key: cord- -gex zvoa authors: abdulkareem, shaheen a.; augustijn, ellen-wien; filatova, tatiana; musial, katarzyna; mustafa, yaseen t. title: risk perception and behavioral change during epidemics: comparing models of individual and collective learning date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: gex zvoa modern societies are exposed to a myriad of risks ranging from disease to natural hazards and technological disruptions. exploring how the awareness of risk spreads and how it triggers a diffusion of coping strategies is prominent in the research agenda of various domains. it requires a deep understanding of how individuals perceive risks and communicate about the effectiveness of protective measures, highlighting learning and social interaction as the core mechanisms driving such processes. methodological approaches that range from purely physics-based diffusion models to data-driven environmental methods rely on agent-based modeling to accommodate context-dependent learning and social interactions in a diffusion process. mixing agent-based modeling with data-driven machine learning has become popularity. however, little attention has been paid to the role of intelligent learning in risk appraisal and protective decisions, whether used in an individual or a collective process. the differences between collective learning and individual learning have not been sufficiently explored in diffusion modeling in general and in agent-based models of socio-environmental systems in particular. to address this research gap, we explored the implications of intelligent learning on the gradient from individual to collective learning, using an agent-based model enhanced by machine learning. our simulation experiments showed that individual intelligent judgement about risks and the selection of coping strategies by groups with majority votes were outperformed by leader-based groups and even individuals deciding alone. social interactions appeared essential for both individual learning and group learning. the choice of how to represent social learning in an agent-based model could be driven by existing cultural and social norms prevalent in a modeled society. a a a a a when facing risks, people go through a complex process of collecting information, deciding what to do, and communicating with others about the effectiveness of their actions. social influence may interfere with personal experiences, making peer groups and group interactions important factors. this is especially important in understanding disease diffusion and the emergence of epidemics, as these phenomena annually take thousands of lives worldwide [ ] . hence, good responsive and preventive strategies at both the individual and government levels are vital for saving lives. a choice of strategy depends on behavioral aspects, complex interactions among people [ ] , and the information available about a disease [ ] . perceiving the risk of an infectious disease may trigger behavioral change, as during the sars epidemic [ ] . gathering information and experience through multiple sources is essential for increasing disease risk awareness about the disease and taking protective measures [ ] . to help prevent epidemics, we need advanced tools that identify the factors that help spread of information about life-threatening diseases and that change individual behavior to curbs the diffusion of disease. various scientific approaches have been developed to tackle this challenge. network science is prominent in studying how epidemics propagate and how different awareness mechanisms can help to prevent the outbreak of disease. some researchers propose a framework with different mechanisms for spreading awareness about a disease as an additional contagion process [ ] . others model populations as multiplex networks where the disease spreads over one layer and awareness spreads over another [ ] . the influence of the perception of risk on the probability of infection also has been studied [ ] . several recent studies have shown how information spreads in complex networks [ , ] . however, a different approach is needed to account for individual heterogeneity (such as income and education levels), the richness of the information on social and spatial distance or media influence. here, a combination of modeling with data-driven machine learning becomes particularly attractive. simulation tools are commonly used to assess the effects of policy impacts in the health domain [ , , ] . among the models for policy-making, agent-based modeling (abm) is recommended as the most promising modeling approach [ ] . abm studies the dynamics of complex systems by simulating an array of heterogeneous individuals that make decisions, interact with each other, and learn from their experiences and the environment. the method is widely used to analyze epidemics [ ] [ ] [ ] [ ] . its advantage is in analyzing the factors that influence the spread of infectious diseases and the actions of individual actors [ ] . as a bottom-up method, abm integrates micro-macro relationships while accommodating agents' heterogeneity and their adaptive behavior. it ensures that the interaction between the spatial environment and the behavior agents can integrate a variety of data inputs including aggregated, disaggregated and qualitative data [ ] [ ] [ ] [ ] . two processes are essential in representing agents' health behavior and disease dynamics, the evolution of risk perception, and selection of a coping strategy. hence, the core of a disease abm lies in defining the learning methods that steer these two processes. sensing of information (global, from the environment, and social, i.e., from other agents), exchanging information (i.e., interactions between agents), and processing of information (i.e., decision making) are critical. machine learning (ml) techniques can support these three elements and offer a more realistic way to adjust agents' behavior in abm [ ] [ ] [ ] [ ] . as more data become available in the analysis of the spread of disease, supporting abm with data-driven approaches becomes a prominent research direction. ml has the potential to enhance abm performance, especially when the number of agents is large (e.g., pandemics) and the decision-making process is complex (e.g., depending on both past experience and new information from the environment and peers). ml approaches in abm can provide agents with the ability to learn by adapting their decision-making process in line with new information. people make decisions both as individuals and as members of a group who imitate the decisions taken by the group or its leader [ ] . information about social networks is becoming increasingly available, e.g., through social media analysis. it may reveal collective behavior in various domains, including health [ ] . for example, people are not entirely rational and imitate others in their views about vaccines [ ] . many abms rely solely on the decisions of individuals, paying little attention to group behavior [ ] . yet, mirroring emotions, beliefs, and intentions in an abm with the collective decision making of crowds affects social contagion in abms [ ] . agents-individuals and groups-may learn in isolation or through interactions with others, such as their neighbors [ ] . in isolated learning, agents learn independently, requiring no interaction with other agents. in interactive learning, several agents are engaged in sensing and processing information and communicating and cooperating to learn effectively. interactive learning can be done in multiple ways, i.e., based on different social learning strategies [ ] . agents might be represented as members of local groups, learning together and mimicking behavior from other group members (i.e., collective learning) [ ] . yet, the impact of different types of interactive learning in groups compared to learning by an individual is an under-explored domain in the development of abms of socio-environmental systems. this article examines the influence of individual vs group learning on a decision-making process in abms enhanced with ml. to illustrate the implications of individual and collective intelligence in abms, we used a spatially explicit disease model of cholera diffusion [ ] as a case study. bayesian networks (bns) steer agents' behavior when judging on risk perception (rp) and coping appraisal (ca). we quantitatively tested the influence of agents' ability to learn-individually or in a group-on the dynamics of disease. the main goal is, therefore, methodological: to introduce ml into a spatial abm with a focus on comparing individual learning to collective learning. the added value of the analysis of alternative implementations of learning in abms goes beyond the domain of disease modeling. it illustrates the effects of individuals learning and collective learning on the field of abms of socio-environmental systems as a whole. therefore, our main objectives are to ( ) simulate the learning processes of agents on a gradient of learning from individual to collective, and ( ) understand how these learning processes reveal the dynamics of social interactions and their emergent features during an epidemic. to address these objectives, the article aims to answer the following research questions: (rq ) what is the impact of social interactions on the perceptions and decisions of intelligent individuals facing a risk? (rq ) how do different implementations of group learning-deciding by majority voting vs by leaders-impact the diffusion process? (rq ) what are the implications of implementing collective learning for risk assessment combined with individual coping strategies? by answering these methodological questions for our case study, we reveal whether individuals perform better than groups at perceiving risks and at coping during epidemics. to explore the implications of intelligent learning on the gradient from individual to collective, we advance the existing cholera abm (cabm) originally developed to study cholera diffusion [ ] . in cabm, mls steer agents' behavior [ , , ] , helping them to adjust risk perception and coping during an epidemic outbreak. for this study, we ran eight abms to test various combinations of individual and group learning, using different information sources-with or without interactions among agents-as factors in the bns. we investigate the extent to which the epidemic spreads, depending on these different learning approaches regarding risk perception and coping decisions. s appendix provides a technical description of the model and the mls. below we briefly outline the processes in cabm essential to understand the performed simulation experiments. nowadays, countries worldwide are labeled as cholera-endemic, with . million cases each year leading to , deaths [ ] . people in urban slums and refugee camps are at high risk of cholera because of limited or no access to clean water and adequate sanitation. cabm is an empirically and theoretically grounded model developed to study the cholera outbreak in kumasi, ghana [ ] . the open-source code for the model code is available online. cabm is grounded in the protection motivation theory (pmt) in psychology [ , ] . the empirically-driven bns model a two-stage decision process of people facing a disease risk: learning to update risk perceptions (threat appraisal, bn in fig ) and making decisions about how to adapt their behavior during the epidemic (coping appraisal, bn in fig ) . according to pmt, threat appraisal depends on individual perceptions of the severity of the disease (evaluating the state of the environment and observing what happens to others) and one's own susceptibility. the coping appraisal is driven by the perceived response efficacy (the belief that the recommended behavior will protect) and one's own self-efficacy (the ability to perform the recommended behavior). cabm simulates individuals who are spatially located in a city. these agents differ by income and education level. individual agents form households and neighborhood groups and are susceptible to cholera at the beginning of the simulation. cabm implements an adjusted seir model [ ] as explained in fig below . instead of going directly from susceptible to exposure, we introduced an awareness component in which agents can assess their risk. options included: no risk perception in which the agent will be exposed (arrow , fig ) ; no risk perception yet no exposure (arrow , fig ) ; and risk perception leading agents to the coping phase (arrow , fig ) . exposure to cholera takes place through the use of unsafe river water. agents can influence their exposure by selecting alternative water sources. these alternative water sources can either reduce their exposure to zero (arrow , fig ) or have no effect on their infection risk (arrow , fig ) . their actions are contingent on income and education levels, as well as on the information that they retrieve from their own experience, information received from others, or observations of the environment. it is not possible to judge by sight whether surface water is infected with cholera, but the agents use other types of visual pollution, e.g., floating garbage, as a proxy. when household agents find the visual pollution level too high, they may decide on an alternative. household agents with high incomes do not take a risk and will buy safe water. in cabm, the risk perception was updated using bn , which depends on the agent memory (me), the visual pollution at the water fetching point (vp), and the evidence of the severity of the epidemic based on communication from the media (m) and potentially with neighbor households (cnh). media broadcast news about cholera starting on day onward (see: ghana news archive). during a simulation, household agents may also interact with their neighbors zero to seven times a day (applied randomly) [ ] . when interactive learning was activated, social interactions among household agents helped to share information on cholera cases that occurred in their communities and on the effectiveness of coping decisions. if risk perception was positive (bn returns a value above . ), household agents activate bn to decide which action (d -d , fig ) to take given their income (i) and education (e) level, the experience of their own household with cholera (oe), and possibly their neighbors' experiences with cholera (ne) [ ] . s appendix provides further details on how the bns are implemented, together with tables of the parameters. sensitivity analysis of the aggregated model dynamics on the bns inputs and training alternatives can be found in [ , ] . a feeling of risk among individuals is fueled by the type of information, the amount of information communicated, and the attention to specific information that may trigger fear and stimulate a learning process regarding a new response strategy [ ] . gained information helps individuals (i) to estimate the severity of the emerging event, (ii) to assess the probability of being exposed to infection, and (iii) to evaluate the efficiency of their coping responses. we used a complex network approach to illustrate the gradual processes from individual to collective learning in cabm (fig ) . each stage is presented as a single network over which a given learning process spreads. each network in fig had the same set of nodes and connections to show how different processes can lead to different outcomes in the same network structure when different information is used to make decisions. in individual learning (fig , process a and process b), agents depend on their prior knowledge (memory, experience, and/or the perceived risk of the environment, such as visual pollution). such learning is the process of gaining skills or knowledge, which an agent pursues individually to support a task [ ] . group learning is the process of acquiring new skills or knowledge that is undertaken collectively in a group of several individual agents and driven by a common goal [ ] . group learning can be realized by making all group members use their own ml algorithms to gather information to perform a specific sub-task (decentralized), and then pool their opinions collectively by making one decision for the entire group (fig , process a and process b). here, we adopt a "majority vote" as the resolution mechanism in the decentralized group decision-making. however, group learning can also be realized by introducing a single agent (leader) who uses ml to learn for the whole group to help it accomplish its group task (centralized). in the centralized group learning, agents in the group copy the decisions of their leader. in both cases, all agents that belong to a group share the same decision, but the information on which this decision is based on varies considerably (fig , process a and process b). both individuals and groups may learn by either by taking information from their social networks (i.e., have it as an additional source of information in their ml algorithms) or not. when individual agents are isolated learners (fig , process a) , they do not have a social network but use only their own information to make a decision in an isolated environment using the information they possess. when individuals learn in an interactively (fig , process b) , https://doi.org/ . /journal.pone. .g they gain new skills or knowledge by perceiving information, experience, and the performance of other agents through their social network. like individual agents, groups can also learn in isolation or interactively. in isolated learning, agents learn independently within their groups, without exchanging any information with each other or with their neighbors (fig , process a and process a). in interactive learning, agents communicate with their neighbors to learn effectively within their groups (fig process b and process b). neighbors could be members of the same group or belong to other income/education groups but live in the same community and share the water collection points. therefore, there might be communication across the groups (fig , process b and process b). groups can be defined in different ways and at different hierarchical levels. this model uses three levels of an organization, the individual agent, groups of agents and communities that comprise several groups. in cabm, household agents living in the same community are grouped based on their income and education level since their coping behavior depends on these factors. agents' behavior in the disease abm also is contingent on their geographic location. hence, all neighbors that share the same water fetching point may contact and exchange information between their groups in cabm. the size and compilation of the groups impact the results of the different learning strategies. when applying interactive learning, a group's decision can be influenced by information retrieved from neighbors inside the group and neighbors outside the group but inside the community. for interactive groups, process b (fig ) shows a situation in which individual household agents make decisions that account for interactions in their social networks (as in process b). then each household conducts a majority vote, allowing it to proceed with the option chosen by the majority of its members. process b (fig ) shows a situation in which the leaders of each group make decisions based on their interactions with others (nodes a, b, and c are leaders of groups g , g , and g respectively in fig ) . the decisions of group leaders are adopted by the household agent of the group. we designed eight simulation scenarios to answer the research questions about the influence of isolated vs interactive individual learning (rq ); centralized vs decentralized learning in processes-during both the risk perception (rp, bn ) and coping appraisal (ca, bn ) processes (rq ); and collective learning about risk perception combined with individual coping appraisal (rq ) on the dynamics of the epidemic and the performance of the model (table ) . we systematically vary cabm settings following the steps in fig to change the gradient of intelligent learning (steps and ) in different cognitive stages corresponding to our decisions of interest: risk and coping appraisal (step ). table shows the setup of the eight scenarios that reflects the three stages shown in fig . the area of the case study captured in cabm is . km and comprises of communities. we assumed that high-income households bought water, so they were excluded from intelligent learning. communities can have up to four groups based on their income and education levels. ten to fifteen percent of the household agents in the case study area usually fetch water from the river. two communities in our dataset (# and # ) hosted only high-income households, so they were excluded from the intelligent learning. hence, we simulated groups spread over communities. each simulation was run for days with a time step equal to one hour. given the inherent randomness of abms, we ran each model for times, generating a new synthetic population every runs. besides the extensive gis data and aggregated data on disease dynamics, we ran a survey via a massive open online course (mooc) geohealth in two rounds ( and ) to gain data on individual behavior. the participants-primarily students from developing countrieswere introduced to the problem of cholera disease, saw pictures of water, and were asked if they would use the water as it is (d in fig ) , walk to a cleaner water point (d ), or use the water after boiling it (d ). the survey data were used to construct and train our bns [ ] . we also used these data to evaluate the results of expert-driven bns in cabm [ ] . table shows that trust in boiled water was much higher than trust in un-boiled water. agents also changed their behavior and began boiling water in the model. to evaluate the impact of individual and social intelligence on agents' learning processes regarding risk perception and coping appraisal and the resulting patterns of disease spread, we used four output measures: disease diffusion, risk perception, spatial patterns, and model performance. these aspects are described in more detail in the odd protocol (s appendix). we also measured the performance of models m -m in terms of run time and the number of intelligent decision steps, i.e., when agents called their bn and/or bn . given the stochastic nature of abms, we ran each of the eight models times. the average and standard deviations of the results of these runs for each output measure were listed in table . behavioral changes can lead to different duration times of the epidemic and reduce the number of infected cases [ ] . this was shown by running cabm with the eight models. models m , m , m , and m recorded a longer duration of active infection during the epidemic ( - days, table ). these results are closer to the real duration of the epidemic in ( days, table ). m , m , and m applied centralized learning, while m applied decentralized learning, but only for the risk perception stage. m , which is individual learning with social interactions, also recorded a shorter duration when compared to the real data of ( days in m ). however, isolated learning and decentralized learning for both risk perception and coping appraisals recorded shorter epidemic duration, with an average difference of - % compared to the empirical data (table ) . all eight scenarios generated more infected cases than the empirical data. this was because infection with cholera bacteria leads to a clinical spectrum that ranges from asymptomatic cases to symptomatic cholera cases. asymptomatic cases are not reported, although they represent roughly half of all cases [ ] . in our simulations, we did not differentiate between symptomatic and asymptomatic cases; we considered all infected cases are considered to be symptomatic cases. therefore, following [ ] , in table , we reported that % of the total infected cases occurred when running the eight models. m , which uses centralized learning for risk perception and individual interactive learning for coping appraisal, reported the fewest infected cases ( , against , in reality). this was followed by m (individual social learning) with , cases and m (individual isolated learning) with , occurrences. these three values reflect the fact that when household agents learned to cope and make decisions individually, they were more efficient than when they were in groups. when these decisions were combined with social interactions, they lead to better protection (m and m ). in general, group behavior had a negative effect, although centralized groups had a less negative impact compared to decentralized ones. finally, in m , where household agents learned risk perception in decentralized groups and learned to cope individually, , infected cases were recorded (table ) . hence, cabm household agents' engagement in decentralized groups for appraising disease risk hindered the perception of risk, lowering agents' motivation to change their behavior to more protective alternatives. the spatial distribution of infected cases (spi) of m reported the closest spi over the communities ( . ) compared to in the empirical data. this was followed by m , with . ( table ). the spatial patterns of the two collective learning models (m and m ) reflected their similarity to the spatial patterns in the empirical data. the correlation between the peak of the epidemic and the peak of risk perception reflects the responsiveness of the household agents' risk perception of the epidemic. scenarios m , m , m , and m were more responsive. that is, the peak of risk perception in m came three days after its epidemic peak, and the peaks in m , m , and m came seven days after their epidemic peaks (table ) . m , m , m and m showed peaks for risk perception near the end of the simulation time. individuals in m were isolated, along with individuals in m ; therefore, they kept following their usual behavior of fetching water and using it as it is. in m and m , household agents depended on majority votes in their groups to make their decisions on risk and to change behavior. more explanations are represented visually in the next sections. table shows the number of steps and the time required to run one simulation of each model. the number of agents that were supposed to go for risk perception daily was % of the total number of household agents (which totaled , ). this percentage was derived from national statistical data from ghana statistical services [ ] . over the days of the epidemic, , agents appraised their risk perception (use their bn ). table also shows the number of steps, during which agents perceived the risk of disease (i.e., risk perception equals ). notably, in m -m , if a group at large assessed the risk perception as zero, then none of its members did the coping appraisal, i.e., the number of steps when bn was activated is zero. in such cases, only the total number of steps with activated bn assessing risk perceptions was included in table . models with centralized learning required the shortest computation times (table ) . for example, m , where only the isolated leaders with the centralized learning consult their bns, had the best performance with the shortest runtime. moreover, m and m recorded the fewest steps across all models. although the average number of agents with risk perception per simulated day was high ( agents), there were only , steps in risk perception and the same number of steps when coping appraisal mls were activated. that is, only leaders activated their bn and bn . this is only % compared to what it would be if agents decided individually. without voting, only one agent per group assessed the situation and made decisions. this made m and m time-efficient. on the opposite end, m recorded the highest computational time because of the intensive calculations required in the individual agents' network and the decentralized group network. among all models, m recorded the longest process time. agents individually perceived risk (bn ) before going back to their groups to negotiate a final decision on risk perception and then repeating the same individual-group sequence for the coping appraisal. in models m , m , and m only one agent per group-a total of leaders-assessed risk perception daily, leading to , steps over the -day epidemic. in m and m only the leaders also went for coping appraisal, while in m , the group members individually assessed the coping appraisal ( , steps in m vs , steps in m and m ). calibration of the original model was conducted in two steps: first the hydrological submodel was calibrated, followed by a calibration of the complete model [ ] . after the calibration, a stability check was performed [ ] . for the current work, the objective of this epidemic model is not to reproduce the real data. it is focusing on the impact of social interactions (present or not, on the level of individual or groups) on both risk perception and coping appraisal of the individual agent. to calibrate a scenario further, one would need risk perception data for that area for the duration of the epidemic. however, such data are very scarce, not only for kumasi but worldwide. hence, risk perception was randomized at initialization. therefore, the eight models cannot be calibrated individually because they need to be comparable at initialization. s appendix shows the statistical analysis that was performed on the output data of the eight models to show and analyze the distribution of the obtained results. when household agents evaluated the risks of getting cholera and made coping decisions individually (m ), they relied only on their own experience. that is, each had individual bn and bn and did not communicate with neighbors. scenario m extends this stylized isolated benchmark case by assuming that while agents continued to make decisions individually, they table risk perception and behavioural change during epidemics did share information with neighbors about the perception of risk and protective behavior. that is, both bn and bn included neighbors' experiences among the information input nodes. fig shows the epidemic curves and the dynamics of risk perception for all scenarios. in the absence of social interactions, more agents became infected with cholera. the peak of the epidemic curve in m (in-i) is higher than m (in-n), leading to % more cases of disease ( fig and table ). overlaying risk perception and epidemic curves suggests that when agents made decisions in isolation (m : in-i), the dynamics of risk perception were hardly realistic (fig a) . namely, when the epidemic was at its peak, household agents in m responded very slowly, with bn delivering a wrong evaluation of risk perception (fig a) . they became aware of the risks very late, so when the epidemic vanished, the number of agents with risk perception = kept increasing. in the absence of communication and experience sharing among peers (in-i), the information about disease spread slowly and there was a significant time-lag between the occurrence of the disease and people's awareness. the small stepwise increase, around day , was because the media started to broadcast information about the epidemic on that day. in m , household agents behaved according to the expected pattern: risk perception became amplified by media coverage and social interactions and then vanished as disease cases became rare (fig b) . only those who experienced cholera infection in their households remained alert. household agents in m after day had more responses to the media's news compared to isolated agents. media supported the agents' social interactions with their risk perception and behavioural change during epidemics neighbors, which led to more agents perceiving risk, especially when the number of infected cases reached their peak (fig b) . even in m , there were limitations of making decisions about risk perceptions individually: risk perception fell too quickly, implying that people stopped worrying about the epidemics although they continued. since household agents in m did not have interactions with other agents, running this model required less time than m (creating a % increase in performance, table ). the interaction between household agents required time to process the information exchanged between agents. in addition, (m : in-i) and (m : in-n) were approximately the same in terms of the realistic spatial distribution of infected cases over the communities, with values of . and . , respectively (table ) . fig presents the spatial distribution of decision types over the study area in both m (in-i) and m (in-n). the household agents in isolated learning were not aware of the cholera-infected cases in their neighbors' household. household agents in m took an unsecured decision and trusted more in using the water fetched from the river as it is (d in fig a) . household agents in m were more rational and mostly boiled the water that they fetched from the river (d in fig b) . in decentralized learning, groups of household agents vote for risk perception and coping appraisal. the final decision of the group is the output of the majority votes. thus, all group members follow the final decision of the group. these groups represent the democratic system, which depends very much on the composition of the group. the decentralized groups with a majority vote can lead to a negative perception of risk. besides, a coping appraisal that depends on a majority vote can lead to inappropriate decisions regarding protection from cholera. when individuals are engaged in social groups, their behaviors are not independent anymore https://doi.org/ . /journal.pone. .g [ ] . this leads to an increase in the randomization of decentralized learning models (m and m ). these two models had higher standard deviations in all measures ( table ) . the qualitative patterns of the three scenarios (m , m , and m ) were the same regardless of the social interactions that added new information to ml (fig ) . for the development of the disease, the voting mechanisms seemed to overwrite individual judgments. the m scenario assumes that household agents were isolated when performing risk perception and coping appraisals. in contrast, m and m allowed household agents to communicate with neighbors during the process of risk perception and before making a coping decision. as a result, m and m generated greater risk perception than m (fig c, d and e ). this suggests that the social interactions still amplify both the awareness of risks and the diffusion of preventive actions. given approximately the same peak heights, the epidemic curves in the three majority voting scenarios reported more infected cases than the other models. among the majority votes, m reported the fewest infected cases, since household agents in their coping appraisal relied on themselves rather than their decentralized groups. overall, it seems that all three models-m , m , and m -got the process of disease risk evaluation wrong. in those cases, risk perception slowly grew in the days when the epidemic was peaking (fig c, d and e) and did not react to the peak in any way, which is unrealistic. moreover, risk perception in the three models continued to grow when the epidemics were almost over. risk perception peaked when there was no longer a risk, i.e., in the last days of the simulation, as shown in table . hence, group voting on risk perception operated with a major time lag: household agents ignored early signals of disease that occurred in just a few households. then they increased their awareness about risk only when most of them were already infected, and they continue to be falsely alerted when the epidemic was over. in m , the small stepwise increase in risk perception represents the response to media, and it is similar to m (in-i) in its development (fig c) . the household agents in their decentralized groups did not have contact with neighbors, therefore, no cases were reported to them from their neighborhoods. as such, they were disconnected from what is happening around them. in m and m , which included social interactions, the development of risk perception seems more responsive, especially after the activation of media on day . nevertheless, their response time was still slow (fig d and e ). in these models, the group decisions were very much dependent on the composition of the group members' opinions. these varied from one another and had different information sources for the final decisions about risk perception (in both m and m ) and coping appraisal (in m ). thus, majority voting led to unsecured decisions. groups in these models were heterogeneous in that household agents had different levels of exposure to the group members with which they voted. decentralized groups with isolated input information (m ) led household agents to vote to use the water fetched from the river (d ) most of the time (fig , map a) . because of their lack of communication with neighbors, household agents missed the opportunity to get information about the infection in their neighborhoods. this explains the higher numbers of infected cases in the majority vote models. social interactions in both m and m helped agents make better decisions, although following the majority still biased their choices. for instance, in m high-income communities (upper communities in maps b and c, fig ) , household agents mostly used the river water as it was even though they were rich enough to boil it before using it (d ) or to buy bottled water (d ). the opposite also occurred when a majority vote forced low-income households to buy bottled water, which is an expensive decision for them. the group voting on the coping appraisal in m might have made individual members uncomfortable when they followed the decisions of their groups even though they might not protect. in reality, household agents sought a balance between preventive behavior and their capability to implement it. moreover, there is always the possibility of routinely changing one's mind based on daily updates of information regarding the epidemic and updates from neighbors. as in m , the household agents in m relied on their decentralized groups for risk perception. this, often led to risk ignorance (fig e) . however, since the agents in m decided on coping appraisals individually, more agents adopted d (fig c) . when they perceived risk during the last days of the epidemic, household agents in the middle-income level switched to boiling water or buying bottled water (d , d in fig c) . those in the low-income level walked to another water fetching point (d ). in centralized groups, one household agent is randomly selected to be the group leader. the leader is responsible for risk perception and the coping appraisal of the group. group members copy the risk perception and disease preventive decisions of their leaders. it is argued that group leaders may improve their group's performance if they model the responses to the situation the group faces [ ] . in this article, we considered two types of leaders: a dictator making top-down decision about risk perception and coping strategy (m and m ), and an opinion leader evaluating risk perception top-down but giving group members the freedom to pursue their own disease coping behavior (m ). the qualitative trends of all three models coincided with what is expected: peaks caused by amplification of risk perception followed by a gradual decrease when epidemics plateau (fig f, g and h) . the centralized group learning on average represented the processes well, as the leader alerted the group members about the disease. however, since no real data are available on risk perception dynamics or the actual coping behaviors that people pursued during the epidemic, we cannot determine which of the models m , m , and m is the best. the following subsections compare models with a leader-dictator (m , and m ) to one with an opinion leader (m ). a dictator-leader decides on behalf of his group regarding disease risk and coping strategies, and both decisions are adopted top-down. a dictator leader learns either in isolation (m ) or in interaction with her/his neighbors (m ). isolated dictators in m are overestimated disease risks (fig f) . for example, if such a leader had his/ her own bad experience with cholera, s/he would keep warning the group. with social interactions (m ), there is less uncertainty in the process of updating the risk perception than in m . for example, compare risk perception assessments around the epidemic peak (fig g) . fig illustrates the impact of social interactions on the dictator's decisions regarding coping appraisal. isolated leaders guided their groups to various types of decisions (fig a) , which were sometimes less secure decisions (e.g., d ). with social interactions, leaders relied on their neighbors and decided more often to walk to a point along the river where the water was cleaner (d ). very few dictators directed their groups to boil the fetched water (d ) or buy bottled water (d ) (fig b) . this shows how centralized decisions making undermines heterogeneity in individual circumstances, such as disease exposure or coping capacity. in m , the leaders in the centralized groups were responsible for evaluating disease risks for their groups, but they interacted with neighbors during the risk perception process. for the coping appraisal, the group members made their own decisions, using the information from their social networks. as a result of this combination of centralized speed alertness about risk perception and individual coping strategies, m generated the fewest infections. the shape of the epidemic curve (except for its height) is very close to the empirical data of , (fig h) . as in m , the uncertainty in the process of risk perception in m , is lower than in m (fig h) . the risk perception curve developed around the epidemic peak followed the dynamics of the epidemic (fig g) . when group members relied on social interaction to learn about the effectiveness of various coping strategies but eventually chose one themselves (m ), there was a diversity of coping strategies. fig c shows the spatial distribution of different types of decisions during the simulation. more household agents went for d and d , which were considered to be the most protective decisions. consequently, communities pursued at least three types of decisions, reflecting the disease coping diversity so important for resilience. the goal of this paper is to perform a systematic comparison of individual vs group learning. the methodological advancements showed that different implementations of individual and collective decision-making in agents' behavior led to different model outcomes. in particular, the stepwise approach of testing how learning (on a gradient from individual learning-without any interactions-to collective-with social networks) affects an abm's dynamics is generic and can be used for other models. to illustrate the subtle difference in implementing learning in abms, we used the example of the spatial empirical abm of cholera diffusion with intelligent agents that employ ml to assess disease risk and decide on protective strategies, which define the dynamics of the epidemic. interactive learning, which assumes that agents share information about risks and potential protective actions, outperformed isolated learning both for individuals and in groups. this underlines the fact that social learning in the decision-making process is very important in abms. while we used disease modeling as a case study, the results may be contingent on the endogenous dynamics of this particular cholera abm. notably, simulation results may differ for abms with other underlying dynamics. this calls for further scrutiny in testing and reporting cases of intelligent social and individual learning in other models. the results indicate that decentralized groups with majority votes are less successful than groups with leaders, whether dictators or opinion leaders. when evaluating current disease risks, majority voting appears to be the worst mechanism for group decisions, often arriving at a wrong decision because of time lags compared to the dynamics of objective disease risks. perceiving risk is a very personal decision-making process [ ] . in contrast, when leaders develop risk perception and propose it to the group, such groups perform better in terms of risk appraisal. moreover, opinion leaders are very effective in helping their group members be alert about disease while giving them the freedom to make coping decisions that accommodate heterogeneity in their socio-economic status and geographical locations. in contrast, dictatorleaders and majority votes that impose a decision that all group members must follow are less effective in reducing the incidence of disease. in our simulation experiments, the structure of the groups is simple and is formed based on the spatial and socio-demographic characteristics of the agents. as grouping seems to have an impact on the spatio-temporal diffusion of the disease, the importance of disease modeling stresses the fact that for this type of model a careful evaluation of the social structures in the case study area should be conducted, to generate trustworthy results. future research should focus on constructing groups based on different variables (family ties, religion, tribes). also, in our abm the leaders had no particular knowledge but were randomly selected and assigned to groups. in reality, this may not be the case. leaders may have access to better information or have already earned the group's trust and respect. in addition, decentralized groups can be improved by giving greater weights to more trusted partners to make wise decisions. the model's performance can be a strong argument when the number of agents is massive, e.g., when simulating a pandemic or epidemics within a very large population is needed to detect a worldwide diffusion mechanism. in that case, social group learning, as described in model m , is a very good alternative to individual interactive behavior. moreover, m shortens the computation time by % while maintaining a good quality model output. the number of contacts each household agent has when they are in their collective learning may impact the diffusion of cholera. however, running a fat tail distribution of the number of contacts would be an interesting topic for future study. different considerations steer the ultimate decision on which type of social behavior to use. besides the technical model performance metrics discussed here, the choice of a particular type of social behavior can also be based on the society that is being modeled. different political systems, the presence of tribes, and different ethnic groups or religious leaders require careful considerations of the social interactions in a model. one should make sure that the actual situation regarding social learning represents the cultural and social norms of the society being modeled. in this article, it was not possible to define, which implementation (m -m ) represented the situation in kumasi most closely. to validate the risk perception-behavior, one would need risk perception data for that area for the duration of the epidemic. however, such data are very scarce, not only for kumasi but worldwide. as we illustrated in this study, many different implementations of social behavior using ml are technically possible, but data are needed to validate alternative implementations. yet, research on risk perception during epidemics is often conducted too late (when the peak is over) or at distance (not in the area where the disease spreads). hence, researches provide little empirical proof of people's behavior and risk perception. more research on risk perception during epidemics, including other variables such as cultural aspects and group behavior, can be very helpful in generating a model that represents a specific society realistically. on a technical note, agent-based modeling software does not always include ml toolkits and libraries. this complicates the implementation of different types of social intelligence. hence, better integration of abm and ml in one software package or linkable libraries could eliminate this problem in the future. finally, an important direction of future research is to implement other ml techniques besides bns, such as decision trees and genetic algorithms. in addition, modeling groups with different ml algorithms may lead to different results since groups will be heterogeneous in terms of members' learning algorithms. several developments in health research drew our attention to the implementation of learning in disease models. one is the impact of fake news on the behavior of people. the other is the fact that human behavior toward vaccination can change radically based on (fake) news it. therefore, including these factors and testing their impact on the behavior of agents may lead to more conclusions for policymakers to consider in their efforts to control epidemics. managing epidemics: key facts about major deadly diseases. world heal organ learning from each other: where health promotion meets infectious diseases modeling infection spread and behavioral change using spatial games severe acute respiratory syndrome epidemic and change of people's health behavior in china the role of risk perception in reducing cholera vulnerability towards a characterization of behavior-disease models dynamical interplay between awareness and epidemic spreading in multiplex networks epidemic spreading and risk perception in multiplex networks: a self-organized percolation method spreading processes in multilayer networks interacting spreading processes in multilayer networks epidemic and intervention modelling-a scientific rationale for policy decisions? lessons from the influenza pandemic wrong, but useful": negotiating uncertainty in infectious disease modelling models for policy-making in sustainable development: the state of the art and perspectives for research using data-driven agent-based models for forecasting emerging infectious diseases out of the net: an agent-based model to study human movements influence on local-scale malaria transmission modelling the transmission and control strategies of varicella among school children in shenzhen a taxonomy for agent-based models in human infectious disease epidemiology an open-data-driven agent-based model to simulate infectious disease outbreaks modeling human decisions in coupled human and natural systems: review of agent-based models spatial agent-based models for socio-ecological systems: challenges and prospects agent-based models global sensitivity/uncertainty analysis for agent-based models intelligent judgements over health risks in a spatial agent-based model a multi-agent based approach for simulating the impact of human behaviours on air pollution simulating exposurerelated behaviors using agent-based models embedded with needs-based artificial intelligence agent-based modeling in supply chain management: a genetic algorithm and fuzzy logic approach evidence for a relation between executive function and pretense representation in preschool children scalable learning of collective behavior based on sparse social dimensions the impact of imitation on vaccination behavior in social contact networks agent based simulation of group emotions evolution and strategy intervention in extreme events modelling collective decision making in groups and crowds: integrating social contagion and interacting emotions, beliefs and intentions learning in multi-agent systems simulate this! an introduction to agent-based models and their power to improve your research practice do groups matter? an agent-based modeling approach to pedestrian egress agent-based modelling of cholera bayesian networks for spatial learning: a workflow on using limited survey data for intelligent learning in spatial agent-based models. geoinformatica the global burden of cholera a comprehensive review of the applications of protection motivation theory in health related behaviors seasonality and period-doubling bifurcations in an epidemic model social contact structures and time use patterns in the manicaland province of zimbabwe cognitive and physiological processes in fear appeals and attitute change: a revised theory of porotection motivation. social psychophysiology: a sourcebook artificial intelligence: a modern approach. third edit integrating spatial intelligence for risk perception in an agent based disease model resilience management during large-scale epidemic outbreaks susceptibility to vibrio cholerae infection in a cohort of household contacts of patients with cholera in behavioral modeling and simulation risk perception and human behaviors in epidemics risk perception it's personal. environmental health perspectives. national institute of environmental health science key: cord- -cgiok ce authors: binjawadagi, basavaraj; dwivedi, varun; manickam, cordelia; ouyang, kang; torrelles, jordi b; renukaradhya, gourapura j title: an innovative approach to induce cross-protective immunity against porcine reproductive and respiratory syndrome virus in the lungs of pigs through adjuvanted nanotechnology-based vaccination date: - - journal: int j nanomedicine doi: . /ijn.s sha: doc_id: cord_uid: cgiok ce porcine reproductive and respiratory syndrome (prrs) is an economically devastating respiratory disease of pigs. the disease is caused by the prrs virus (prrsv), an arterivirus which is a highly mutating rna virus. widely used modified live prrsv vaccines have failed to prevent prrs outbreaks and reinfections; moreover, safety of the live virus vaccines is questionable. though poorly immunogenic, inactivated prrsv vaccine is safe. the prrsv infects primarily the lung macrophages. therefore, we attempted to strengthen the immunogenicity of inactivated/killed prrsv vaccine antigens (kag), especially in the pig respiratory system, through: ) entrapping the kag in biodegradable poly(lactic-co-glycolic acid) nanoparticles (np-kag); ) coupling the np-kag with a potent mucosal adjuvant, whole cell lysate of mycobacterium tuberculosis (m. tb wcl); and ) delivering the vaccine formulation twice intranasally to growing pigs. we have previously shown that a single dose of np-kag partially cleared the challenged heterologous prrsv. recently, we reported that np-kag coupled with unentrapped m. tb wcl significantly cleared the viremia of challenged heterologous prrsv. since prrsv is primarily a lung disease, our goal in this study was to investigate lung viral load and various immune correlates of protection at the lung mucosal surfaces and its parenchyma in vaccinated heterologous prrsv-challenged pigs. our results indicated that out of five different vaccine-adjuvant formulations, the combination of np-kag and unentrapped m. tb wcl significantly cleared detectable replicating infective prrsv with a tenfold reduction in viral rna load in the lungs, associated with substantially reduced gross and microscopic lung pathology. immunologically, strong humoral (enhanced virus neutralization titers by high avidity antibodies) and cell-mediated immune responses (augmented population of interferon-γ secreting cd (+) and cd (+) lymphocytes and reduced secretion of immunosuppressive cytokines) in the lungs were observed. in conclusion, combination of np-kag and soluble m. tb wcl elicits broadly cross-protective anti-prrsv immunity in the pig respiratory system. porcine reproductive and respiratory syndrome (prrs) is an economically devastating disease in pigs causing an estimated direct loss of greater than $ million annually to the us pork industry. prrs is caused by prrs virus (prrsv), an enveloped positive-sense rna virus belongs to the family arteriviridae. there are broadly two distinct prrsv genotypes, the european (type i) and the north american (type ii), dovepress dovepress binjawadagi et al which possess a wide range of intra-and intergenotypic, genetic, and antigenic diversity. therefore, developing preventive measures to control prrs outbreaks has been a challenge to the global swine industry. though both modified live virus (mlv) and inactivated prrsv vaccines have been in use since , control of disease outbreaks has remained unsuccessful. live virus vaccines are successful in reducing the clinical disease, but are invariably implicated in spreading the mutated viruses to susceptible pigs. in contrast, available inactivated prrsv vaccines are safe, but they have failed to elicit protective immunity even against homologous infections. in addition, killed vaccine antigens do not undergo intracellular antigen presentation pathways to induce a strong cytotoxic t-cell (ctl) response, which is necessary for clearance of intracellular pathogens like viruses. [ ] [ ] [ ] thus, research aimed at developing better cross-protective inactivated prrsv vaccines is warranted. therefore, several innovative strategies should be adopted to strengthen potency and efficacy of inactivated/killed prrsv vaccine antigens (kag), with respect to suitable methods of viral inactivation and purification, use of potent adjuvants, route, and efficient delivery of vaccine to protect ags from rapid enzymatic degradation in the body. since prrsv infects primarily the pig respiratory tract and the target cells are lung alveolar and interstitial macrophages, induction of strong local mucosal immunity in the respiratory tract is important. the intranasal route of delivery of vaccines to control primary respiratory infections has shown great promise in induction of protective mucosal (ie, local) as well as systemic immunity. , , poly(lactide-co-glycolide) (plga) is a synthetic biodegradable polymer used successfully in particulate delivery of inactivated vaccines. [ ] [ ] [ ] the adjuvant mycobacterium tuberculosis whole cell lysate (m. tb wcl) was shown to augment immunogenicity of both live prrsv vaccine and plga-nanoparticles entrapped with killed prrsv antigens (np-kag) without causing any side effects in pigs [ ] [ ] [ ] [ ] and with other vaccines in rodents, guinea pigs and rabbits. , unlike complete freund's adjuvant (cfa), m. tb wcl is free from water-insoluble toxic cell wall components of the bacterium, , and it is endotoxin free and contains only water-soluble components. therefore, unlike cfa, m. tb wcl does not cause any toxicity or granulomatous lesions at the site of inoculation. previously, we have shown that a single dose of prrsv kag-entrapped in plga ( : ) nanoparticle (np-kag) elicits both mucosal and systemic immune responses. , recently, np-kag coadministered intranasally twice with m. tb wcl induced cross-protective anti-prrsv immune response in blood to a challenged heterologous prrsv, associated with a significant reduction in viremia. in this report, we made use of various types of the lung samples of that recent study to evaluate viral load and local mucosal immunity both at airway surfaces and in the lung parenchyma, and also microscopic lung histopathology in vaccinated, heterologous prrsv-challenged pigs. killed prrsv vaccine antigens (kag) were prepared as described earlier. briefly, north american prototype prrsv strain vr was grown in marc cells, freeze-thawed three times, and the harvested cell culture supernatant was subjected for clarification followed by ultracentrifugation to pellet the virus. resuspended pellet in sterile phosphate-buffered saline (pbs) was subjected to ultraviolet inactivation ( nm for hour) to prepare kag for use in vaccine preparation. for restimulation experiments, similarly prepared kag of the challenge virus, prrsv strain mn , was used. preparation of whole cell lysate of m. tb m. tb was grown in agar medium and wcl was prepared as described previously. briefly, h rv strain of m. tb was grown in oleic acid-albumine-dextrose-catalase enriched h (difco) agar plates (becton, dickinson and company, franklin lakes, nj, usa). the bacterial cells were harvested by centrifugation of colony scrapings at ×g and washed with pbs (ph . ). live bacterial cells were suspended [ g (wet weight)/ml] in pbs containing mm ethylenediaminetetraacetic acid (edta) (becton, dickinson and company), proteinase inhibitors (emd millipore, billerica, ma, usa), dnase and rnase (sigma-aldrich, st louis, mo, usa), and the bacterial cell wall was disrupted by bead beater until . % cell breakage was obtained (confirmed by acid fast staining). the cell lysate was centrifuged at ×g to pellet unbroken cells and insoluble broken cell wall components. the clear supernatant-containing water soluble fraction of the bacterium was harvested and sterilized through . µm low protein binding membrane filter. further, endotoxin levels in every batch of m. tb wcl was confirmed to be less than the acceptable levels (, . µg/mg conventional large white-duroc crossbred - weeks old weaned pigs were procured from a swine herd seronegative for prrsv, porcine respiratory coro navirus, transmissible gastroenteritis virus, and porcine circo virus -specific antibodies. a total of pigs were randomly divided into one of the ten groups (n= pigs/group) and vaccinated with the indicated vaccine formulation, intranasally ( ml/pig), twice at -week intervals ( table ). all the vaccinated pigs were intranasally challenged on postvaccination day with a virulent heterologous north american prrsv (type ii) strain mn ( × median tissue culture infective dose [tcid ]/pig). adjuvant and vaccine were entrapped separately and combined before administering to pigs, and the dose of adjuvant ( mg/dose/pig) and kag were either (low dose) or (high dose) µg/dose/pig of semipurified viral protein containing ∼ . × or . × tcid of killed prrsv, respectively, either entrapped in nps or unentrapped. the vaccine and adjuvant doses were tested to be efficacious in pigs earlier. , pigs were monitored daily for the respiratory symptoms, and rectal temperatures and body weights were recorded every third day postchallenge (pc); animals were euthanized on day pc as per the approved protocol of the institutional animal care and use committee, the ohio state university, and indicated samples were collected during the necropsy. the lungs were examined for gross lesions in all the lobes. the lung samples collected from the right cranial lobe were fixed in % neutral buffered formalin and sections ( µm) were made and stained with hematoxylin and eosin as described previously. the slides were examined by an unbiased certified veterinary pathologist to score prrsvinduced inflammation. collection of bronchoalveolar lavage fluid, preparation of lung homogenate, and isolation of lung mononuclear cells during necropsy, the lungs were harvested and the bronchoalveolar lavage (bal) fluid was collected by washing the airways using - ml of cold pbs containing antibiotics and edta; the harvested fluid was centrifuged at , ×g for minutes at °c and the clarified bal fluid was aliquoted and stored at - °c. the lung homogenate was prepared as described previously. briefly, gram of lung tissue from the right cranial lobe of every pig was collected in ml ice-cold dulbecco's modified eagle's medium and minced and homogenized using a stomacher laboratory blender (seward limited, worthing, west sussex, uk) for minutes, and the clarified supernatant (lung homogenate/lung lysate) was aliquoted and stored at - °c. the lung mononuclear cells (lmncs) from the individual pig lungs were isolated by treating the perfused and minced lung tissue using collagenase and dnase as described previously. estimation of total immunoglobulin (ig) total isotype specific pig ig levels were estimated by elisa as described previously, with a few modifications. briefly, -well enzyme-linked immunosorbent assay (elisa) plates were coated with pretitrated dilution of ( : , ) of goat the assay was performed as previously described. avidity of the prrsv-specific antibodies in the lungs prrsv-specific antibody avidity was determined as described previously, , with a few modifications. briefly, bal fluid ( : ) and lung homogenate ( : ) samples were added to prrsv-ag-coated and -blocked plates. after hours incubation of test samples at room temperature, washed plates ( ×) were treated with serially twofold diluted ammonium thiocyanate (nh cn) ( µl/well) solution at to . mol concentration and incubated at room temperature for minutes. the plates were washed ( ×) and the remaining steps of elisa carried out as described above. for calculation purpose, od value of the test sample from nh cn-untreated ( m) well was considered as % absorbance (contributed by prrsvspecific antigen-antibody interaction), and the od value of a test sample at different molar concentration of nh cn was used to calculate the percent remained antigen-antibody interaction compared to its % absorbance value. estimation of prrsv-specific igg and igg antibody subtypes total prrsv-specific igg and igg subtypes in the lung homogenate samples were analyzed as described previously, with a few modifications. briefly, kag-coated plates were blocked and a serial tenfold diluted lung homogenate was added; mouse antipig igg or igg (abd serotec, raleigh, nc, usa) ( : dilution) secondary antibody was added to detect virus-specific igg or igg subtype, respectively. further, the washed plate was treated with goat antimouse igg-hrp (sigma-aldrich) ( : , dilution). the reaction was developed using tmb ( , ', , '-tetramethylbenzidine) substrate (kpl, gaithersburg, md, usa), stopped using m phosphoric acid, and the plates were read at od nm . for calculation of the prrsv-specific igg and igg antibody levels of test samples, the od values obtained at : dilution was considered. determination of prrsv-specific inter feron gamma (ifn-γ ) secreting cells by enzyme-linked immunospot (elispot) assay the elispot assay was performed as described previously. adjuvanted plga nanoparticle prrsv vaccine immunity in the pig lungs lated were included as positive and negative controls, respectively. lung homogenates were analyzed for pig cytokines, th (ifn-γ and interleukin [il- ]), proinflammatory (il- ), and immunosuppressive (il- and transforming growth factor beta [tgf-β]) by elisa as described previously. flow-cytometric analyses the phenotypes and frequencies of lymphoid and myeloid cells populations from , events of immunostained lmncs were determined by flow cytometry as described previously. for intracellular ifn-γ staining, monensin (golgiplug, bd biosciences) was added during the last hours of the -hour incubation of lmncs that were unstimulated or stimulated with prrsv mn kag as described above. lmncs were first immunostained using pig lymphocyte-specific monoclonal antibodies (cd ε, cd α, cd α, cd , and tcr n ) conjugated with different fluorochromes. cells were fixed with % paraformaldehyde and permeabilized with a cell-permeabilization buffer ( . % deionized water, % pbs with no ca or mg, % formaldehyde solution, and . % saponin) overnight at °c. cells were washed and stained with a fluorochrome-conjugated antipig ifn-γ or its isotype control monoclonal antibodies (bd biosciences) in . % saponin containing fluorescence activated cell sorting (facs) buffer. immunostained lmncs were acquired using a facs aria ii (bd biosciences) flow cytometer and analyzed using the flowjo software (treestar inc., ashland, or, usa). all the specific immune cell frequencies were presented as the percent of total lymphocytes or myeloid cells. determination of prrsv load, virus-neutralizing antibody titer, and rna copies prrsv titer and virus-neutralizing (vn) titer in bal fluid and lung homogenate samples were analyzed by indirect immunofluorescence assay as previously described. extracted rna was reverse transcribed into complimentary deoxyribonucleic acid (cdna) using quantitect reverse transcription kit (qiagen, venlo, the netherlands). the cdna was subjected to quantitative real-time polymerase chain reaction (qpcr) using primers against prrsv orf in perfecta sybr green fast mix (quanta biosciences, gaithersburg, md, usa) with forward primer (gataac-cacgcatttgtcgtc) and reverse primer (tgccgtt-gttatttggcata). standard curve was generated using serial tenfold dilution of prrsv vr stock virus starting at tcid per µl for viral rna quantification. the data were expressed as the mean ± standard error of mean of three pigs. statistical analyses were performed by one-way analysis of variance followed by tukey's multiple comparison test (or unpaired t-test for figure binjawadagi et al cated that sham or entrapped np particles were spherical with a smooth surface. dynamic light scattering of nps indicated the mean diameter ± standard deviation was ± nm for sham, ± nm for np-kag, and ± nm for np-m. tb wcl, respectively. however, all nps possessed a uniform surface electrostatic potential of - mv. other in vitro studies revealed that the entrapped antigen was pulse-released over a period of several weeks in normal physiological conditions, and was efficiently uptaken by porcine alveolar macrophages. a detailed physical and biological characterization of np-kag vaccine used in this study was published recently. in the serum of all the virus-challenged pigs (groups to ), irrespective of vaccination history at weeks postchallenge, a twofold to threefold increase in total igg amount was observed (data not shown). the total igm and iga amounts in the lung homogenate were comparable in most of the prrsvchallenged pig groups ( figure a and c). however, the levels of igg (both in lung homogenate and bal fluid) ( figure b and e), and igm and iga (in bal fluid) ( figure d and f) in pig groups to were four-to fivefold higher compared to mock enhanced prrsv-specific antibody response in adjuvanted np-kag-vaccinated pigs prrsv-specific iga response was significantly higher both in the bal fluid and lung homogenate of both low ( µg/pig) and high ( µg/pig) doses of adjuvanted np-kag-vaccinated pigs, compared to most of the vaccine trial groups ( figure g and h). in contrast, levels of virusspecific igg were comparable in the bal fluid of all the virus-challenged pig groups ( figure i) . surprisingly, in the lung homogenate, significantly higher levels of virusspecific igg was observed in group and pigs vaccinated with either dose ( figure j ). this suggests that in adjuvanted np-kag-vaccinated pigs (group ), virus-specific iga is the major antibody isotype in the airway surfaces (bal fluid), while both iga and igg isotypes appear to play important roles in the lung parenchyma. the binding strength of heterogeneous antibodies to their cognate ag is defined as avidity. in adjuvanted np-kagvaccinated pigs, increased avidity of virus-specific iga was detected in both bal fluid (both low and high doses) and lung homogenate (only low dose) samples compared to other tested groups (figure a-c) . interestingly, the virus-specific iga avidity in lung homogenate of pigs receiving the highdose vaccine was comparable among all the tested pig groups ( figure d ). comparable levels of avidity of prrsv-specific igg antibody response was observed in lung homogenate of all the tested groups (data not shown). these data suggested that enhanced avidity of prrsv-specific iga antibody persisted for a relatively longer period at the airway surfaces of adjuvanted np-kag-vaccinated pigs. balanced th and th antibody responses in adjuvanted np-kag-vaccinated pigs t helper type (th) -or th -biased immune response is measured by quantifying antigen-specific igg antibody subtypes. in case of pigs, higher levels of igg and igg indicate th and th -biased responses, respectively. our results indicated that in group pigs, comparable levels of both igg and igg subtypes were secreted in lung homogenate ( figure a and c). the ratio of igg :igg , if greater or less than one, indicates th -or th -biased response, respectively. in the lungs of adjuvanted np-kag-vaccinated pigs at day pc a balanced th and th response (ratio close to one) was detected ( figure b and d). in pig groups and , although the ratio was close to one, the detected amount of virus-specific igg and igg subtypes were low ( figure a-d) . enhanced prrsv-neutralizing antibody response in adjuvanted np-kag-vaccinated pigs except group (mock), all the other pigs were challenged using a heterologous prrsv (strain mn ), which is genetically highly divergent (∼ %) compared to the vaccine strain vr . prrsv-specific vn titers were analyzed both in the bal fluid and lung homogenate samples against mn strain, and against another variant type strain, prrsv - - (accession # - ), is genetically distinct from both mn and vr strains. in addition, vn titers were also analyzed against an antigenically highly divergent (∼ %) heterogenotypic (type ) prrsv strain, sd - ( figure e -j). in group pigs, the lung vn titers against mn were significantly higher with mean titers of and with low and high vaccine doses, respectively, compared to other tested groups ( figure e and f). the vn titers against both prrsv - - and sd - strains were significantly greater in group pigs receiving the high-dose vaccine compared to group and group , respectively ( figure h and j). the kag and soluble wcl-vaccinated pigs (group ) also had significantly higher vn titer against only prrsv - - strain compared to group animals ( figure h ). these results indicated that soluble m. tb wcl-adjuvanted np-kag vaccine elicits broadly cross-reactive vn titers. the vn titers observed in bal fluid were low (data not shown). a standard reference for measuring cmi response against prrsv is by determining the frequency of virus-specific iscs by elispot assay. in low-dose vaccinated group pigs, significantly increased iscs in lmncs was detected compared to three other tested groups ( figure a ) and compared to all the tested groups in the high-dose category ( figure g ). the quantity of ifn-γ detected in the lung homogenate was significantly higher in group pigs compared to group (low dose) and groups and (high dose) categories ( figure b and h) . another important th cytokine, il- , was not significantly modulated among the tested pig groups in the high vaccine dose category ( figure j ), but in low-dose groups and , significantly higher levels of il- were detected compared to groups , , and ( figure d ). one of the important proinflammatory cytokines, il- , was significantly reduced in the lungs of all the vaccine trial groups compared to mock-challenged animals ( figure c and i). cytokines il- and tgf-β are immunosuppressive in nature, and they play a vital role in prrsv pathogenesis. , the quantity of tgf-β was significantly reduced in group pigs compared to group ( figure e and k) , and the quantity of il- among all the tested vaccine trial pig groups was comparable ( figure f and l). figure a and b) . the frequencies of intracellular ifn-γ + cells in lmncs either unstimulated or stimulated with mn ags identified the virus-specific memory lymphocyte response. significantly increased prrsvspecific recall ifn-γ response was detected both in cd + and cd + lymphocyte subsets of group pigs vaccinated with a high dose of vaccine ( figure c and d) . these data suggest that both t-helper and ctls were potentially primed in the lungs of only group pigs. when prrsv-specific ifn-γ secreting lymphocyte subsets in only restimulated cells were compared among different vaccine trial groups, only in group animals (both vaccines doses) significantly increased cd + cd -ifn-γ + cells compared to group animals ( figure f and n) , while cd -cd + ifn-γ + cell frequency was significantly enhanced in group pigs were present compared to groups , , and with low vaccine dose and groups to with high vaccine dose ( figure g and o). similarly, cd + cd + ifn-γ + and ifn-γ + γδ t cells were significantly higher in group pigs compared to pigs in groups , , and ( figure h -i, p-q). an increased frequency of activated γδ t cells was detected in group pigs compared to other groups (table a and b) . although there was no significant difference in total natural killer (nk) (cd + ) cell frequency ( figure j and r) , an increase in ifn-γ + nk cell frequency was significant in group pigs compared to other tested groups ( figure k and s) . in addition, macrophage (cd + cd + slaii + ) and dendritic cells (cd + cd c + slaii + ) rich apc populations were significantly higher in group and pigs in the high-dose vaccine category compared to group animals ( figure t and u); in the low-dose category, though a similar trend was detected, the data was not statistically significant ( figure l and m). in the bal fluid of pig groups and (low vaccine dose), detectable replicating prrsv was relatively reduced (but not significant) compared to other vaccine groups ( figure a ); in the same pig groups with the high vaccine dose, detectable replicating virus was absent, and the data was statistically significant compared to pig group ( figure b ). in the lung homogenate of group pigs receiving the low-dose vaccine, detectable replicating virus load was significantly reduced compared to mock-challenged pigs ( figure e) ; detectable virus was absent in the high-dose group pigs, and the data was statistically significant compared to pig groups and ( figure f ). further, prrsv rna copy numbers in bal fluid and lung homogenate were quantified by qpcr. in both the lung sample adjuvanted plga nanoparticle prrsv vaccine immunity in the pig lungs types of group and pigs in the low-dose vaccine category, reduction (but not significant) in viral rna copy numbers was observed compared to other vaccine trial groups ( figure c and g); and in the same pig groups vaccinated with a high dose, a significant reduction ( - fold) in rna load was detected compared to group animals ( figure d and h). gross lung lesions revealed marked consolidation in pig groups , , and , while the group pig lungs were comparable to mock animals and the group pig lungs were in between mock and the group animals. microscopic lmncs isolated on the day of necropsy were unstimulated or stimulated with killed prrsv mn ags and immunostained using a combination of indicated pig lymphocytespecific cell surface markers followed by intracellular ifn-γ and analyzed by flow cytometry. representative histograms showing stimulated total lymphocytes in lmncs with intracellular ifn-γ + (a and b) . the dotted line: isotype control and solid line: ifn-γ + -specific staining. unstimulated (clear bars) or stimulated (black bars) lmncs with killed prrsv mn ags were analyzed for total ifn-γ + cd -, cd -, and cd -expressing lymphocytes (c-e). only stimulated lmncs were compared for indicated ifn-γ + lymphocyte subsets: cd + cd -ifn-γ + (f and n) ; cd -cd + ifn-γ + (g and o); cd + cd + ifn-γ + (h and p); γδ + ifn-γ + (i and q); and total nk (cd + ) (j and r); cd + ifn-γ + cells (k and s). also immunostained for potential apcs; macrophage-rich (cd + cd + sla-ii + ) (l and t) and dendritic cell-rich (cd + cd c + sla-ii + ) (m and u) populations. each bar indicates the average frequency of indicated cells from three pigs ± standard error of mean. asterisk indicates statistically significant (p, . ) difference between the two indicated pig groups. the unpaired t-test was applied to compare the data of only (c-e); for the other data, one-way anova followed by tukey's t-test was used. figure i ii, iii, and v). these data were consistent with the gross lung lesions, especially in pig groups and ; also, these pig groups had irregular fever with reduced feed intake during first week postchallenge. in contrast, the absence of any clinical prrs disease and gross lung lesions in group pigs was associated with the absence of detectable microscopic lung pathology, and the lung architecture was comparable to mock pigs ( figure i vi) . the other pig group which had moderately reduced lung lesions was group (kag + m. tb wcl) ( figure i iv), suggesting the adjuvant mediated protective immune response in pigs. similar but severe lung pathology was observed in pigs receiving the low vaccine dose in groups , , and (data not shown). potent mucosal vaccines against pathogens which predominantly cause disease at mucosal sites have been proven efficacious, with vaccines against influenza, parainfluenza, adjuvanted plga nanoparticle prrsv vaccine immunity in the pig lungs respiratory syncytial virus, rotavirus, and hiv/siv. [ ] [ ] [ ] [ ] [ ] since prrsv primarily infects the lungs of pigs, its effective control appears to be possible by induction of strong respiratory mucosal immunity. thus, development of a novel prrsv mucosal vaccine is warranted. further, among the mucosal routes, intranasal delivery of np-based vaccine elicits a higher and longer duration of igg and iga antibody responses compared to rectal, oral, or intramuscular routes. in the lungs, prrsv infects both alveolar and interstitial macrophages, and greater than % of bal cells are macrophages. we investigated anti-prrsv response both in bal cells and lmncs. cd c + apcs are richly present in the lungs in both bal cells and lmncs, but they differ in their antigen presentation potential. apcs present in the lung mucosal surfaces (represented by bal cells) activate only antigen-primed t-cells, while apcs in the lung parenchyma (represented by lmncs) activate both naïve and antigen-primed t-cells. therefore, our study comprehensively investigated overall immune responses and viral load in the lungs of pigs vaccinated and challenged through the intranasal route. a couple of earlier studies showed hypergammaglobulinemia in the serum of prrsv-infected pigs, indicated by a four-to fivefold increase in total igg levels at - weeks postinfection. , consistent with that observation, in our study, an approximately fourfold increase in total igg amounts was observed both in the serum and lung samples (bal fluid and lung homogenate); however, in the lung homogenate of adjuvanted np-kag-vaccinated pigs, the total igg levels were only twofold more compared to mock animals. these data suggest that adjuvanted np-kag has a strong positive influence on humoral response, further indicated by a significant increase in production of anti-prrsv antibodies and virusspecific high avidity vn antibody titers. inactivated vaccines are safe, but suitable adjuvant and delivery system are critical to boost their efficacy. several unsuccessful attempts were made to develop protective killed prrsv vaccines. , a recent study using uv-or bei-inactivated prrsv ( × tcid per dose) coadministered with either freund's incomplete or suvaxyn oil/water adjuvant elicited the vn titer of greater than associated with partial clearance of homologous viral challenge. in that study, cmi response was not investigated. plga is the food and drug administration (fda)-approved agent, and plga-based intranasal delivery of prrsv vaccine was found safe in pigs. , , one of the strategies to augment uptake of particulate antigens by apcs is by increasing its surface hydrophilic nature of the particles by coating with a nonionic surfactant, polaxamer . , efficient th -immunity-inducing adjuvants are critical to promote a strong cmi response to subunit and inactivated virus vaccines. the water-soluble components of m. tb wcl, such as heat shock protein- and pro-glu/ppe, are potent adjuvants. in addition, four other water-soluble components in m. tb wcl, such as short-and long-chain poly-peptidoglycans, acetylated peptidoglycans, and tetrasaccharide-heptapeptide, have potent adjuvant effects comparable to cfa in inducing production of antibodies in rabbits coadministered with an inactivated influenza virus vaccine. plga-np vaccine coadministered with a potent adjuvant elicits a protective immune response. we demonstrated potent adjuvant effects of m. tb wcl to prrs-mlv, [ ] [ ] [ ] , and also to np-kag, with no side effects. our initial studies using a single dose of np-kag elicited partial cross-protective immune response in pigs. , to potentiate the efficacy of np-kag vaccine, in a recent study np-kag was evaluated by coadministering intranasally twice with either entrapped or unentrapped m. tb wcl. our results suggested that combination of np-kag with unentrapped m. tb wcl significantly cleared the challenged heterologous virus from the circulation, supported with strong humoral and cmi responses in the blood. the enhanced t-and b-cell responses in adjuvanted np-kag-vaccinated pigs were attributed to concerted effects of both plga and m. tb wcl. induction of strong local mucosal immunity and clearance of heterologous prrsv from vaccinated pig lungs is important for effective control of prrs. therefore, in this study we investigated the immune responses exclusively both at mucosal surfaces and parenchyma of pig lungs. our results indicated that adjuvanted np-kag (group pigs) did potentiate anti-prrsv immune response in the lungs, as indicated by the following parameters: ) increased prrsv-specific igg and iga response with enhanced antibody avidity and vn titers, and balanced th and th immune responses; ) upregulated secretion of th (il- and ifn-γ) and downregulated immunosuppressive (tgf-β and il- ) cytokines; ) enhanced frequency of iscs and ifn-γ producing cd + , cd + , cd + cd + t cells, γδ + t cells, and nk cells, and expanded frequency of apcs; and most importantly, ) complete clearance of detectable replicating challenged heterologous prrsv and tenfold reduction in viral rna load in the lungs. further, the microscopic lung lesions ( figure i ) strongly supported the observed virus clearance and immunological responses. in our previous study, in pigs immunized with the adjuvanted np-kag, increased frequency of only cd -cd + ifn-γ + cells in restimulated pbmcs was detected, but in stimulated lmncs, increased populations of both cd + cd -ifn-γ + and cd -cd + ifn-γ + cells was observed, perhaps indicating the induction of both t-helper and ctl memory responses in the lungs. like in pbmcs, increased but comparable frequency of other ifn-γ + lymphocyte subsets in both restimulated and unstimulated cells was observed in lmncs of group pigs, suggesting that other t-effector and nk cells were actively secreting ifn-γ in the lungs to prrsv-challenge infection. due to lack of similar data on ifn-γ + lymphocytes in vaccinated pigs isolated prior to challenge, it is difficult to demarcate the vaccine-alone induced response. np-based delivery of vaccine facilitates affinity maturation and activation of b cells, leading to high avidity antibody production and also cmi response. , avidity of prrsvspecific iga antibody isotype was significantly higher in the bal fluid of adjuvanted np-kag-vaccinated pigs. in the lung homogenates of low-dose (but not high-dose) adjuvanted np-kag-vaccinated pigs, high avidity iga response was observed; the reason for this discrepancy could be the time of lung sample collection. overall, our results suggested that virus-specific functional iga response at mucosal tissues (lungs) was enhanced in adjuvanted np-kag-vaccinated pigs. further, our results indicated that in the lung mucosal surfaces, iga isotype appears to play an important role, while in the lung parenchyma both iga and igg isotypes contribute to protective immune response. vn antibodies against putative neutralizing epitopes on prrsv gp and m glycoproteins play an important role in prrsv clearance. in group pigs, high levels of cross-reactive vn titers were detected against a challenged prrsv mn strain, another heterologous type ii viral strain, and most importantly-even against a highly variant heterogenotypic strain (prrsv sd - ), confirming the broadly cross-protective nature of adjuvanted np-kag vaccine formulation. further, prrsv antibody avidity results were positively correlated with vn titers, in agreement with a previous report. typically, killed vaccines elicit a predominantly th response, but np-based vaccines drive either a balanced or th -biased response, required for efficient clearance of virus. in group pigs, enhanced and balanced th -th humoral and cmi responses were detected. a robust cmi response is essential for complete protection against prrsv. a crucial th cytokine, ifn-γ, is produced by nk cells, γδ t cells, cd + and cd + t cells, and cd + cd + t cells. enhanced secretion of ifn-γ and the presence of increased frequencies of ifn-γ + memory cd + and cd + cells in the lungs of adjuvanted np-kag-vaccinated pigs have confirmed the additive effect of plga-mediated delivery and adjuvanticity of m. tb wcl. a possible mechanism of improved cmi response in group pigs was mediated by cross-presentation of plga-entrapped ags to cd + t cells through mhc class i molecules, of dendritic cells and macrophages. thus, our results were consistent with the previous reports on plga np-based vaccines, which elicited strong effector and memory cmi responses. , in addition, increased levels of another important th cytokine, il- , was detected in the lungs of adjuvanted np-kag-vaccinated pigs, associated with reduced production of immunosuppressive cytokines, il- and tgf-β, which play a vital role in prrsv pathogenesis. the γδ t cells are present in high frequency in pigs and are involved in both innate and adaptive immunity at mucosal tissues. enhanced frequency of activated γδ t cells in the lungs of group pigs was observed. significantly reduced production of il- in group pigs indicated the absence of inflammatory response in the lungs of group pigs. importance of immediate availability of unentrapped potent adjuvant to intranasally delivered np-kag vaccine was critical in our study, because inadequate immune response and incomplete viral clearance was observed in other vaccine formulations pigs received. plga-entrapped hepatitis b subunit vaccine coadministered with an encapsulated adjuvant failed to induce strong antibody response, consistent with our results observed in group pigs (np-kag + np-wcl). further, pigs vaccinated with both adjuvant and kag unentrapped formulation (group ) exhibited th -biased and weak ifn-γ response, associated with partial clearance of replicating prrsv. the presence of - fold fewer prrsv rna copies in the lungs of adjuvanted np-kag-vaccinated pigs and the absence of detectable replicating challenged virus is consistent with a previous report, wherein qpcr failed to differentiate infectious and noninfectious virus, and inactivated prrsv is relatively stable in the environment. further, in samples with low levels of prrsv rna copies, cell culture method has failed to detect the replicating virus. plga-based vaccine delivery is shown to dramatically reduce the required vaccine dose by up to times. plga-np-based vaccine delivery is getting global recognition for effective delivery of subunit/inactivated mucosal vaccines, because their size, contents, and cell targeting properties can be engineered. our study has demonstrated that plga-based adjuvanted np-kag vaccine induced strong anti-prrsv immunity both systemically and locally at the lungs. in conclusion, intranasal coadministration of plga-np-entrapped inactivated prrsv vaccine with a potent adjuvant has the potential to induce superior cross-protective international journal of nanomedicine : submit your manuscript | www.dovepress.com adjuvanted plga nanoparticle prrsv vaccine immunity in the pig lungs immunity in pigs. future studies should aim to fractionate m. tb wcl to identify adjuvant components to np-kag and to identify alternate adjuvants to reduce the cost of vaccine formulation, and perform field trials to validate efficacy of this innovative vaccine delivery approach. our study not only establishes the utility of nanotechnology-based vaccines in large animals, it also envisages its potential application against important human respiratory pathogens. prrs costs industry $ million annually porcine reproductive and respiratory syndrome virus productively infects monocyte-derived dendritic cells and compromises their antigen-presenting ability reversion of a live porcine reproductive and respiratory syndrome virus vaccine investigated by parallel mutations challenges for porcine reproductive and respiratory syndrome virus (prrsv) vaccinology nanotechnology solutions for mucosal immunization role of nanotechnology in pharmaceutical product development vaccine manufacturing: challenges and solutions immunological responses of swine to porcine reproductive and respiratory syndrome virus infection polymeric nano-and microparticle technologies for oral gene delivery is intranasal vaccination a feasible solution for tuberculosis? nanotechnology for the biologist biodegradable nanoparticles for drug and gene delivery to cells and tissue mucosal delivery of vaccines: role of mucoadhesive/biodegradable polymers adjuvanted poly(lactic-co-glycolic) acid nanoparticle-entrapped inactivated porcine reproductive and respiratory syndrome virus vaccine elicits cross-protective immune response in pigs cross-protective immunity to porcine reproductive and respiratory syndrome virus by intranasal delivery of a live virus vaccine with a potent adjuvant intranasal delivery of whole cell lysate of mycobacterium tuberculosis induces protective immune responses to a modified live porcine reproductive and respiratory syndrome virus vaccine in pigs mucosal vaccines to prevent porcine reproductive and respiratory syndrome: a new perspective interaction of heat shock proteins with peptides and antigen presenting cells: chaperoning of the innate and adaptive immune responses adjuvant and immunostimulating activities of water-soluble substances extracted from mycobacterium tuberculosis (var. hominis) symposium on relationship of structure of microorganisms to their immunological properties. ii. host-reactive properties of cell walls and protoplasm from mycobacteria the influence of components of m. tuberculosis and other mycobacteria upon antibody production to ovalbumin biodegradable nanoparticle-entrapped vaccine induces cross-protective immune response against a virulent heterologous respiratory viral infection in pigs plga nanoparticle entrapped killed porcine reproductive and respiratory syndrome virus vaccine helps in viral clearance in pigs effect of genotypic and biotypic differences among prrs viruses on the serologic assessment of pigs for virus infection site of inhibitory action of isoniazid in the synthesis of mycolic acids in mycobacterium tuberculosis altered pathogenesis of porcine respiratory coronavirus in pigs due to immunosuppressive effects of dexamethasone: implications for corticosteroid use in treatment of severe acute respiratory syndrome coronavirus porcine reproductive and respiratory syndrome virus-induced immunosuppression exacerbates the inflammatory response to porcine respiratory coronavirus in pigs measurement of immunoglobulin g, a and m concentrations in boar seminal plasma intranasal administration of cpg oligonucleotides induces mucosal and systemic type immune responses and adjuvant activity to porcine reproductive and respiratory syndrome killed virus vaccine in piglets in vivo antigen-specific b-cell responses to porcine reproductive and respiratory syndrome virus infection maximal adjuvant activity of nasally delivered il- α requires adjuvant-responsive cd c(+) cells and does not correlate with adjuvant-induced in vivo cytokine production the assessment of antibody affinity distribution by thiocyanate elution: a simple dose-response approach protection of pigs against taenia solium cysticercosis using recombinant antigen or in combination with dna vaccine isolation and properties of a macromolecular, water-soluble, immuno-adjuvant fraction from the cell wall of mycobacterium smegmatis cytokine responses in gnotobiotic pigs after infection with virulent or attenuated human rotavirus detection and duration of porcine reproductive and respiratory syndrome virus in semen, serum, peripheral blood mononuclear cells, and tissues from yorkshire, hampshire, and landrace boars restriction fragment length polymorphism of porcine reproductive and respiratory syndrome viruses recovered from ontario farms heterogeneity in nsp of european-like porcine reproductive and respiratory syndrome viruses isolated in the united states porcine reproductive and respiratory syndrome virus induces pronounced immune modulatory responses at mucosal tissues in the parental vaccine strain vr infected pigs certainties, doubts and hypotheses in porcine reproductive and respiratory syndrome virus immunobiology mechanism of nkt cell activation by intranasal coadministration of alpha-galactosylceramide, which can induce cross-protection against influenza viruses combined nkt cell activation and influenza virus vaccination boosts memory ctl generation and protective immunity mucosal immune response to poliovirus vaccines in childhood mucosal immunization of rhesus monkeys against respiratory syncytial virus subgroups a and b and human parainfluenza virus type by using a live cdna-derived vaccine based on a host range-attenuated bovine parainfluenza virus type vector backbone nasal immunization of nonhuman primates with simian immunodeficiency virus p gag and cholera toxin adjuvant induces th /th help for virus-specific immune responses in reproductive tissues enhanced mucosal and systemic immune response with intranasal immunization of mice with hiv peptides entrapped in plg microparticles in combination with ulex europaeus-i lectin as m cell target chronological immunohistochemical detection and localization of porcine reproductive and respiratory syndrome virus in gnotobiotic pigs cellular variables in bronchoalveolar lavage fluids (balf) in selected healthy pigs cd c+ antigen presenting cells from the alveolar space, lung parenchyma and spleen differ in their phenotype and capabilities to activate naïve and antigen-primed t cells polyclonal hypergammaglobulinemia and formation of hydrophobic immune complexes in porcine reproductive and respiratory syndrome virus-infected and uninfected pigs porcine reproductive and respiratory syndrome virus subverts repertoire development by proliferation of germline-encoded b cells of all isotypes bearing hydrophobic heavy chain cdr the assessment of efficacy of porcine reproductive respiratory syndrome virus inactivated vaccine based on the viral quantity and inactivation methods development of an experimental inactivated prrsv vaccine that induces virus-neutralizing antibodies intranasal m cell uptake of nanoparticles is independently influenced by targeting ligands and buffer ionic strength influence of the surfactant concentration on the body distribution of nanoparticles adjuvants and delivery systems in veterinary vaccinology: current state and future developments the adjuvant effects of mycobacterium tuberculosis heat shock protein result from the rapid and prolonged activation of antigen-specific cd + t cells in vivo pe_pgrs antigens of mycobacterium tuberculosis induce maturation and activation of human dendritic cells recent progress in mucosal vaccine development: potential and limitations intranasal delivery of an adjuvanted modified live porcine reproductive and respiratory syndrome virus vaccine reduces ros production evaluation of immune responses to porcine reproductive and respiratory syndrome virus in pigs during early stage of infection under farm conditions mycobacterium tuberculosis whole cell lysate enhances proliferation of cd positive lymphocytes and nitric oxide secretion in the lungs of live porcine respiratory and reproductive syndrome virus vaccinated pigs towards tailored vaccine delivery: needs, challenges and perspectives vaccine delivery: a matter of size, geometry, kinetics and molecular patterns role of neutralizing antibodies in prrsv protective immunity type /type immunity in infectious diseases international-journal-of-nanomedicine-journal the international journal of nanomedicine is an international, peerreviewed journal focusing on the application of nanotechnology in diagnostics, therapeutics, and drug delivery systems throughout the biomedical field role of sustained antigen release from nanoparticle vaccines in shaping the t cell memory phenotype plga nanoparticle-mediated delivery of tumor antigenic peptides elicits effective immune responses debugging how bacteria manipulate the immune response gammadelta lymphocyte response to porcine reproductive and respiratory syndrome virus enhancement of t helper type immune responses against hepatitis b virus core antigen by plga nanoparticle vaccine delivery porcine reproductive and respiratory syndrome virus (porcine arterivirus) porcine reproductive and respiratory syndrome virus: a persistent infection the authors report no conflicts of interest in this work. international journal of nanomedicine : submit your manuscript | www.dovepress.com key: cord- -tkqxb ql authors: toman, miroslav; celer, vladimir; kavanová, lenka; levá, lenka; frolichova, jitka; ondráčková, petra; kudláčková, hana; nechvátalová, kateřina; salat, jiri; faldyna, martin title: dynamics and differences in systemic and local immune responses after vaccination with inactivated and live commercial vaccines and subsequent subclinical infection with prrs virus date: - - journal: front immunol doi: . /fimmu. . sha: doc_id: cord_uid: tkqxb ql the goals of our study were to compare the immune response to different killed and modified live vaccines against prrs virus and to monitor the antibody production and the cell mediated immunity both at the systemic and local level. in the experiment, we immunized four groups of piglets with two commercial inactivated (a —progressis, a —suivac) and two modified live vaccines (b —amervac, b —porcilis). twenty-one days after the final vaccination, all piglets, including the control non-immunized group (c ), were i.n., infected with the lelystad strain of prrs virus. the serum antibody response (igm and igg) was the strongest in group a followed by two mlv (b and b ) groups. locally, we demonstrated the highest level of igg antibodies in bronchoalveolar lavages (balf), and saliva in group a , whereas low iga antibody responses in balf and feces were detected in all groups. we have found virus neutralization antibody at dpv (days post vaccination) and higher levels in all groups including the control at dpi (days post infection). positive antigen specific cell-mediated response in lymphocyte transformation test (ltt) was observed in groups b and b at dpv and in group b at dpv and in all intervals after infection. the ifn-γ producing lymphocytes after antigen stimulation were found in cd (−)cd (+) and cd (+)cd (+) subsets of all immunized groups days after infection. after infection, there were obvious differences in virus excretion. the virus was detected in all groups of piglets in serum, saliva, and occasionally in feces at dpi . significantly lower virus load was found in groups a and b at dpi . negative samples appeared at dpi in b group in saliva. it can be concluded that antibodies after immunization and infection, and the virus after infection can be detected in all the compartments monitored. immunization with inactivated vaccine a —progressis induces high levels of antibodies produced both systemically and locally. immunization with mlv-vaccines (amervac and porcilis) produces sufficient antibody levels and also cell-mediated immunity. after infection virus secretion gradually decreases in group b , indicating tendency to induce sterile immunity. the goals of our study were to compare the immune response to different killed and modified live vaccines against prrs virus and to monitor the antibody production and the cell mediated immunity both at the systemic and local level. in the experiment, we immunized four groups of piglets with two commercial inactivated (a -progressis, a -suivac) and two modified live vaccines (b -amervac, b -porcilis). twenty-one days after the final vaccination, all piglets, including the control non-immunized group (c ), were i.n., infected with the lelystad strain of prrs virus. the serum antibody response (igm and igg) was the strongest in group a followed by two mlv (b and b ) groups. locally, we demonstrated the highest level of igg antibodies in bronchoalveolar lavages (balf), and saliva in group a , whereas low iga antibody responses in balf and feces were detected in all groups. we have found virus neutralization antibody at dpv (days post vaccination) and higher levels in all groups including the control at dpi (days post infection). positive antigen specific cell-mediated response in lymphocyte transformation test (ltt) was observed in groups b and b at dpv and in group b at dpv and in all intervals after infection. the ifn-γ producing lymphocytes after antigen stimulation were found in cd − cd + and cd + cd + subsets of all immunized groups days after infection. after infection, there were obvious differences in virus excretion. the virus was detected in all groups of piglets in serum, saliva, and occasionally in feces at dpi . significantly lower virus load was found in groups a and b at dpi . negative samples appeared at dpi in b group in saliva. it can be concluded that antibodies after immunization and infection, and the virus after infection can be detected in all the compartments monitored. immunization with inactivated vaccine a -progressis porcine reproductive and respiratory syndrome (prrs) is the most economically significant infectious disease currently affecting swine worldwide. typical clinical symptoms of prrs are mild to severe respiratory disease in infected newborn and growing pigs, and reproductive failure in pregnant sows. two genotypes of the prrs virus (prrsv) have been identified: european (type ) and north american (type ). there are considerable genetic and virulence differences between and within prrsv genotypes ( - ) correlated with a lack of cross-protection by vaccines ( ) ( ) ( ) ( ) ( ) . highly pathogenic strains of prrsv (hp-prrsv) have been identified within both genotypes ( ) ( ) ( ) . depending on viral strain and immune status of the host, some swine farms may have pigs subclinically infected, whereas others experience severe reproductive, and/or respiratory disease. infection with both "classical" and highly pathogenic strains is associated with aberrant host immune response ( , ) . swine are the only known natural host of prrsv and the primary target cells for replication of prrsv are porcine alveolar macrophages (pams) ( ) . the first stage is represented by acute infection, resulting in viremia - h post-infection (pi), and lasting for several weeks despite the presence of circulating antibodies. in the second, persistent stage of infection, the virus is no longer detected in blood and lungs, and pigs no longer exhibit signs of clinical disease. in this stage, viral replication is primarily localized in lymphoid organs, including tonsils, and lymph nodes ( ) . infection with prrsv elicit poor innate and adaptive immune responses associated with immune modulation and incomplete viral clearance in most of the pigs, depending on their age, and immune status ( , ( ) ( ) ( ) . infection with certain prrsv strains induced significant suppression of nk cell cytotoxic activity ( ) . the quantity of pro-inflammatory cytokines is significantly lower than in other viral infections and is strain dependent ( ) . prrsv is also a poor inducer of ifn-α. infection with prrsv induces an antibody response (production) by - dpi but with no evidence of protection against prrsv infection; serum neutralizing antibodies appear only later, typically ≥ days pi ( ) . the virus also evades host cell-mediated immunity most likely by the promotion of immunosuppressive cytokines il- and tgf-β resulting in delayed onset of th immune response ( ) . similarly, an immunosuppressive function of prrsv was shown to probably be mediated by the cytokines il- and tgf-β and action of treg ( ) ( ) ( ) . immunosuppression induced by prrsv facilitates other viral and bacterial infections ( , , ) . vaccination is the principal means used to control and treat prrsv infection. several comprehensive review articles have been published recently. they critically evaluate different vaccination approaches against the prrs virus and indicate the main weaknesses of current vaccines and vaccination strategies ( ) ( ) ( ) ( ) . among others the problem are caused by high heterogeneity and occurrence of highly pathogenic strains and therefore efforts have been made to develop vaccines with a broad spectrum of effects ( , , , ( ) ( ) ( ) ( ) . however, the opinion still prevails that vaccination is more cost-beneficial over other health interventions ( ) ( ) ( ) . our study had the following three aims: ) to establish complex immune response characteristics using several methodological approaches; ) to monitor the dynamics in different compartments and in a time-dependent manner after vaccination and the challenging infection; ) to compare the types of immune responses after vaccination with inactivated or live attenuated vaccines and subsequent challenge using a homologous strain. twenty-five weaned piglets aged weeks and weighing - kg of the large white breed from a prrsv negative herd were used. the negative status of the animals was confirmed by serology using commercial elisa kit (idexx labs). the use of animals was approved by the branch commission for animal welfare of ministry of agriculture of the czech republic (approval protocol no. mze- ) as a part of project as a part of project respig (qj ). four commercial vaccines were used. their characteristics are in table . the virus was clarified by centrifugation, and its concentration was determined by plaque assay. the concentration of stock virus used in experiments was × plaque forming units per ml. twenty-five piglets were used in the experiment. the piglets were assigned to five groups of five animals each according to weight and gender. the animals were housed in bsl isolation rooms, keeping animals from only one experimental group in each room. the animals were left to acclimate for days after stocking. all piglets were clinically healthy at the time the experiment started. on day (d ) two groups of piglets (a and a ) were immunized. each animal was administered ml of inactivated vaccine by an intramuscular (i.m.) injection. after days (d ), piglets in these groups were revaccinated with the same dose, and piglets from the other two groups (b and b ) were immunized with ml of a mlv vaccine. the health status of piglets was monitored on a regular basis, including temperature measurements, and samples of blood and other body fluids were taken for respective examinations at preset time intervals. after an additional days (d ), all pigs, including control group (c ), were infected with ml of the live prrs virus. the piglets were monitored for another days and then slaughtered (d ). euthanasia was performed by exsanguination after combined anesthesia with a tkx (telazol-ketamin-xylazin) mixture containing . mg/ml tiletamine and . mg/ml zolazepam (telazol, virbac, carros, france), . mg/ml ketamine (vetoquinol, lure, france), and . mg/ml xylazine (bioveta, ivanovice na hane, czech republic), administered intramuscularly in a final volume of . ml/kg body weight. as well as collection of blood and other body fluids (intestinal contents, bronchoalveolar lavage), an autopsy was performed and organs (lung parenchyma, spleen, lymph nodes,...) were collected for virological examination. blood samples for serum and heparin-treated blood samples were taken from the jugular vein. group saline samples were collected using ropes which were left in the hutch for h. individual fecal samples were collected when handling the animals. bronchoalveolar lavage fluid (balf) sampling was performed for the first time on live animals and for the second time after slaughter. the intravital lavage was performed with the animals under general anesthesia (a mixture of xylazine and ketamin) without the use of an endoscope by a method described earlier ( ) . pigs were positioned in the sternal recumbency. an endotracheal tube was inserted into the trachea and ml of sterile pbs (ph . ) was injected into the distal parts of the airways, toward the bronchus. about % of the infused saline was recovered as balf aspirate and was filtered and centrifuged for min at g. supernatant was stored at − • c prior to serological analyses. total rna from experimental samples of sera, oral fluids, and bal ( µl) was extracted using a nucleospin r rna ii kit (macherey-nagel), in accordance with the manufacturer's instructions (protocol for total rna preparation from biological fluids). the rna obtained was eluted in µl rnase-free water and immediately used for qrt-pcr amplification. remaining rna was frozen at − • c for subsequent use. isolated rna was used for qrt-pcr amplification by ez-prrsv tm mpx . real time rt-pcr kit (tetracore), in accordance with the manufacturer's instructions. quantification of the virus genome copies was based on quantification standards included in the kit. for the evaluation of systemic and local antibody production two elisa methods were used. all swine sera tested were examined by commercially available elisa test ingezim prrs universal (ingenasa), in accordance with the manufacturer's instructions, to examine for the presence of n protein specific igg antibodies. all swine sera, oral fluids, and bal tested were examined by home-made indirect elisa test based on recombinant nucleocapsid protein n of prrs virus (developed previously in our department) for detection of specific igm, igg, and iga antibodies. optimal antigen, serum, and antibodies concentrations were determined by checkerboard titration of positive and negative porcine sera. the cut-off value was determined by defining the upper prediction limit based on the upper tail of the t-distribution of negative control od readings, at a confidence level of . %. positive serum with an absorbance corresponding to the calculated cut-off was included in all test plates. the recombinant n protein diluted in mm bicarbonate-carbonate buffer ph . to a final concentration of . µg/ml was coated on -well-microtiter plates (maxisorp ii r immunoplates, nunc, denmark) overnight at • c. the wells were then blocked with % skimmed milk in pbs for min at • c and then washed with pbs. positive and negative controls were included in each test plate. each sample diluted in % skimmed milk in t-pbs (pbs with . % tween and . m nacl) was added in duplicates on antigen-coated wells with some differences among different types of samples. one hundred microliters of serum samples diluted : (for detection of igm antibodies) or µl of non-diluted samples of bal (for detection of igg and iga antibodies) were incubated for min at • c. two hundred and fifty microliters of oral fluids diluted : were incubated h at • c (for detection of igg antibodies). subsequently the plates were washed three times with t-pbs and antibody binding was detected by incubation for min at • c with µl of anti-pig igm peroxidase conjugate ( : , , bethyl), anti-pig igg peroxidase conjugate ( : , , sigma), or with anti-pig iga peroxidase conjugate ( : , , bethyl) separately (diluted in t-pbs with % skimmed milk). after washing the plates as described above, µl per well of the tmb-complete (test-line) substrate was added. the optical density (od) was measured at nm after an incubation time of - min at room temperature. the virus neutralization test for detection of prrsv neutralization antibodies was performed as follows. samples of sera were diluted : in dmem medium (sigma-aldrich) supplemented with % fbs. then, heat inactivated sera ( • c for min) were diluted -fold serially in flat-bottom -well-microplate (nunc). next, equal volume ( µl) of media containing prrsv pfu (lelystad-capm v- ) was added to each well. following incubation ( min at • c) marc- cells were added to each well ( × per well) in µl media per well. after days of cultivation ( • c, % co ), the cytopathic effect (cpe) of prrsv on marc- was evaluated by optical microscopy. the reciprocal value of the last sera dilution causing % reduction of cpe was defined as virus neutralization antibody titer. the lymphocyte transformation test was performed according to the method published earlier ( ) . peripheral blood mononuclear cells (pbmc) were obtained by gradient centrifugation post infection d ++ ++ + + + + + + -+ + + + + + ++ + + + + + + ++ the end of experiment d + ++ ++ + ++ + + + ± -+ + ++ + frontiers in immunology | www.frontiersin.org (histopaque- , sigma-aldrich). concentration of the cells was adjusted to , cells in µl of rpmi- medium supplemented with % of autologous serum, iu/ml penicillin, µg/ml streptomycin, and µg/ml gentamicin). they were incubated with the µg of optimal concentration of the specific antigen (moi . ) for days at • c in % co . negative controls were incubated with rpmi- medium only. all samples were evaluated in triplicate. h-thymidine was added on the last day of cultivation. subsequently, the cells were harvested (filtermate harvestor, packard bioscience company, usa), and h-thymidine incorporation was measured by a microplate scintillation and luminescence counter (topcount nxt tm , packard bioscience company) in counts per minute (cpm). the results were expressed in terms of stimulation indexes (si), which were calculated as the ratio of cpm in stimulated samples vs. cpm in non-stimulated controls. the number of ifn-γ producing cells was calculated by elispot techniques. commercially available porcine ifn-γ elispot kit ( - hpw- , mabtech) was used in accordance with the manufacturer's instructions. the number of cells used in the test was × /well. prrsv was used for stimulation of the antigen-specific response in multiplicity of infection (moi) . . mitogen cona at a concentration µg/ml was used as a positive control. cells without stimulation were used as a negative control. incubation lasted for h. spots were detected using elispot reader system elro tl (aid, germany). the results were recalculated to the number of cd + lymphocytes. the × of pbmc per well was stimulated with prrs virus in moi . for h. the × of cultured pbmc were pelleted and µl of primary monoclonal antibody cocktail containing anti-cd (igg b, clone - - , wsu, monoclonal antibody center, usa), anti-cd (igg a, clone - - , wsu, usa), and anti-γδ tcr (igg , clone pgbl a, wsu, usa) and µl of heat-inactivated goat serum was added. the cells were incubated for min at • c and then rinsed twice with cell washing solution. then, µl of goat anti-mouse secondary antibody cocktail (anti-igg b: dylight , anti-igg a: alexa fluor , and anti-igg : pe-cy ) was added and the cells were incubated for another min at • c. the cells were rinsed and then µl of anti-cd antibody (igg , clone ppt , southern biotech, pre-stained with alexa fluor dye using zenon antibody labeling kit, invitrogen) was added and the cells were incubated, rinsed twice, and fixation and permeabilization for subsequent intracellular staining was performed by solutions a and b of intra stain kit (dako cytomation, usa) ( ) . finally, µl of rpe-conjugated anti-ifn-γ antibody (clone cc , abd serotec uk) was added and the cells were incubated for min. the cells were measured as soon as possible using bd lsr fortessa flow cytometer (becton-dickinson, usa). at least , events were acquired. the post-acquisition analysis of data was performed using the facs diva software (becton-dickinson, usa). the following lymphocyte subpopulations were identified: (cd + ) γδ + cd + , (cd + ) γδ + cd − , (cd + γδ − ) cd + cd + , (cd + γδ − ) cd − cd + , (cd + γδ − ) cd + cd − , (cd + γδ − ) cd − cd − , and cd − cd + . the percentage of ifn-γ-positive cells was established for each subpopulation. the normality of data distribution were confirmed. experimental groups were compared using non-parametric man-whitney test. data from different dates were compared using non-parametric wilcoxon test for paired samples. after vaccination with inactivated vaccines (a and a ) the first igm in the serum started to appear days after the first dose in some piglets, and days after the second dose in all animals of the a group ( figure a and table ). igg antibodies appeared in all animals of both groups days after the second dose ( figure b) . the level of antibodies in the a group was significantly higher than in the group given the a vaccine. in groups of piglets vaccinated with mlv vaccines (b and b ), both igm and igg antibodies appeared days after vaccination. on day after immunization, their antibody responses were comparable to that of the a group. after infection, we identified a further increase in antibodies in the vaccinated groups. for the a group, a further increase in serum igg antibodies was observed after week and especially at and days after infection, when this antibody level significantly exceeded the values in the mlv immunized groups (b and b ) and the control one (c ). the a group showed a sharp increase on post infection days and , and the level of serum igg antibodies at these intervals was comparable to a . in groups immunized with mlv (b and b ), serum igg levels increased after , , and days post infection, but did not reach the a group values. in the control, non-immunized group, the first igm antibodies appeared days after infection, with a significant increase on day and . igg antibody levels appeared and days after infection but were lower than in the immunized groups. the virus neutralization antibody was detected in sera of animals days after vaccination (figure c) . these antibodies were detected in some animals in the groups a and a only. at the end of experiment (d , days post-infection) the high level of virus neutralization antibodies were detected in all groups except b group, in which significantly lower level was found ( figure c) . local antibodies in the balf performed days post vaccination we detected low levels of iga in all immunized groups (figure a) and igg in a , a , and b (none in b ) with the level in the a group being significantly higher (figure b) . days after infection we detected low levels of iga antibodies in a , b , b , and control group (c ) and low levels of igg antibodies in all immunized groups (none in c ). local antibodies were detected in the saliva of the a group in low concentrations and days after the second vaccination and in all groups after infection with variability in individual intervals and with no statistically significant between-group difference ( figure c) . in the feces, local antibodies (iga) were detected from week after the second immunization dose in groups a and a , and from week after mlv immunization in groups b and b ( figure d ) increased levels of antibody were detected in all groups including control after infection with no statistically significant betweengroup difference. a positive cell-mediated response after lymphocyte stimulation with specific antigen in vitro (stimulation index in ltt above ) was observed in the b group after and days post vaccination and and days post-infection (figure ) . a positive stimulation index was detected in the b group at days post vaccination only as a non-specific basal stimulation occurred from days post vaccination in this group (figure a) . groups immunized with inactivated vaccines a and a showed a marked non-specific stimulation of cells even without using antigen ( figure a ) and, therefore, it was impossible to demonstrate the effect of antigen addition and thus cell-mediated immune response. cell-mediated immune response after challenge infection was positive in all vaccinated groups and in the control group after days post infection, using elispot in pbmc from bronchoalveolar lavages. the results were recalculated to the number of cd + lymphocytes. the differences between individual animals, but no significant differences between groups were detected ( figure d) . we detected ifn-γ producing lymphocytes after prrs antigen stimulation. the most marked differences from control were found in cd − cd + and cd + cd + (and partly also in cd − + and γδ + + ) subsets of all immunized groups days after infection. in the groups vaccinated with live vaccines (b and b ) , the virus load was demonstrated in serum and saliva from day after immunization, in balf days after immunization (the only time point when the lavage was taken), and in feces occasionally days after vaccination, then in all piglets days after immunization (data not shown). no clinical signs were observed in piglets after infection. elevated body temperature was occasionally found in the first days, independent of the experimental group. however, viral shedding was noted, with between-group differences. the virus appeared in serum, saliva, and feces in all groups including the control group days after infection (figures a,b,d) . the virus was detected in balf days after infection in a , a , and c groups (figure c) . virus shedding was decreased in immunized groups and days after infection with the level in the a and b group being significantly lower compared to control group days after infection. negative samples appeared days after infection in saliva (in b group) and in feces (b and b groups). the goals of our study were ( ) to establish comprehensive immune response characteristics using several methodological approaches and monitor the dynamics in different compartments and in a time-dependent manner after vaccination and the challenging infection and ( ) to compare the immune response to different killed and modified live vaccines against prrs using these methodological tools. in order to compare the immune response after vaccination with different vaccines, we used a model of vaccinations of young piglets (beginning at weeks of age) and given vaccination intervals and subsequent infections, regardless of the fact that manufacturers' recommendations were different (especially in progressis). there are only a few papers published providing a comprehensive picture of immune response after vaccination against prrsv ( ) ( ) ( ) ( ) because the majority of the existing studies are based mainly on the evaluation of the vaccination effectiveness by monitoring the immune responses found in the blood ( , , , ( ) ( ) ( ) . our results show that antibodies after immunization and infection, and the virus after infection, can be detected in all the monitored compartments (blood, respiratory tract, intestine). by repeated sampling and simultaneous monitoring of the antibody and cell-mediated immunity and virus shedding systematically and locally, we have managed to get comprehensive information about the dynamics of the immune response after vaccination or prrs virus infection. in practical diagnostics of field samples is an effort to seek simple approaches to obtain tentative information on the epidemiological situation of the herd. one current trend is the monitoring of antibody levels and shedding of the virus in the oral fluid ( ) ( ) ( ) . in our experiment, the antibody detection rate in the oral fluid collected with ropes in pens was sufficient. the levels of antibodies detected after vaccination were low, but they increased after challenge infection. these findings confirms the possibility of using this approach for preliminary characteristics in the herd. it was interesting to observe the dynamics of antibody levels and viral shedding in feces too. this is an approach which is not often used for prrsv infection monitoring but is used in other situations where feces samples are more readily available than samples from other sources ( , ). we were wondering, among other things, to what extent infections occurring systemically, or locally in the respiratory tract occur in this remote compartment. our findings show that fecal samples can also be used for prrsv infection monitoring. detection of both the viruses and antibodies is not entirely consistent, because they appear in individual animals, and cease at later intervals, therefore, it is necessary to consider these findings as approximate. they can be used for herd-or pen-level testing, but not for establishing a diagnosis in individual animals. it appeared to be technically difficult to demonstrate specific cell-mediated immunity. the partial results were provided by each of the three methods used and a comprehensive picture could be obtained by compiling this information. therefore, it was not possible to use only data of ifn-γ production in elispot, although it is currently the most commonly used method for cmi ( , , , , , ) . a positive cell-mediated response after lymphocyte stimulation with specific antigen in vitro (in lymphocyte transformation test) was observed in mlv groups and especially in the b group as a non-specific basal stimulation occurred from days post-vaccination in b group. the strong non-specific stimulation of pbmc without specific antigen were detected in groups a and a immunized with inactive types of vaccine. this non-specific stimulation of cells in vivo masks the overall picture, and thus specific cell-mediated immunity cannot be demonstrated. this effect is attributed to the use of strong adjuvants in inactivated types of vaccines. in the test of ifn-γ production and detection with elispot, which is very often used to identify cmi both in experimental studies ( , ) , and in the field ( , ) , we have shown an increase in both blood and cells acquired by lavage, but the individual variability among the animals was too high and, consequently, there were no differences found between the groups under study. we detected also ifn-γ producing lymphocytes after prrs antigen stimulation in all immunized groups days after infection. the most marked differences from control were found in cd − cd + and cd + cd + (and partly also in cd − cd + and γδ + cd + ) subsets of lymphocytes. the cd − cd + subpopulation belongs to cytotoxic groups of cells, cd + cd + is considered a group of th memory cells ( ) . in another study the expression of cytotoxic cd + cd + and cd + cd − was described which help to recover from prrs infection ( ) . there were qualitative and quantitative differences in the immune responses to the inactivated vaccines and to mlv ones. after immunization with the inactivated vaccine (especially a -progressis), high levels of antibodies were produced generally (serum), which were mostly of the igm, and igg isotypes, and also locally (saliva, balf), both igg and iga. nevertheless it should be noted that we have applied progressis to piglets in our study, while the manufacturers declare the use of this vaccine for gilts and sows. cell-mediated immunity was detected only after infection, high non-specific cell stimulation was detected after vaccination and therefore any specific response could not be demonstrated in these intervals. the antigen specific cell mediated immunity after inactivated vaccine is rarely described ( ) . most work describes low or no cmi after vaccination with inactivated vaccine. after immunization with mlv vaccines, sufficient levels of antibodies in serum and balf (igg) were also produced, but lower than after the inactivated vaccine administration. the levels of iga antibodies in balf were comparable but low. low levels of virus neutralization antibodies after vaccination can be explained by a short interval between vaccination and infection, since neutralizing antibodies after vaccination or prrs infection occur within days ( ) . the dynamics of virus shedding after vaccination and infection is often used for monitoring vaccine efficacy ( , , ) . the decrease in virus secretion was observed days after mlv immunization and disappearance in days ( ) . in another study the excretion of virus was described still for days after vaccination with for porcilis or amervac vaccine ( ) . demonstration of cell-mediated immunity and reduction in viral load correlate with studies by other authors and support the preferred use of mlv vaccines in the control of prrs infection ( , ) . the question is to what extent these results are influenced by the composition of vaccines from different manufacturers and to what extent different types of vaccines (inactivated vs. live attenuated). there was an obvious difference in the quality between the inactivated vaccines, whereas the character of the immune response to both mlv vaccines was similar with only partial differences in the time-related response dynamics. the vaccine b (amervac) showed a more pronounced decrease in virus secretion and a tendency to induce sterile immunity, while b (porcilis) vaccine had a more pronounced of cmi in lymphocyte transformation test. it should be noted that the strain used in porcilis had a higher genetic link with the lelystad strain compared to the strain of amervac ( , ) which, however, probably did not significantly affect the above characteristics. despite the fact that many studies focused on prrs immunoprophylaxis have already been published and many procedures are implemented in the agricultural industry, a universal model does not yet exist ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the use of live attenuated vaccines is generally preferred as was also confirmed in our field study ( ) . in this study, we controlled the infection by a repeated blanket immunization with mlv vaccine (porcilis), followed by targeted immunization of gilts, and sows. the success of the strategy selected and evidence of virus eradication from the given herd were demonstrated by introducing sentinel animals into a fattening herd. based on this result, we believe that control programs can be adopted even in herds with continual throughput housing without interrupting production. however, in this case, vaccination is only one of the necessary preconditions and the introduction of very strict principles of good biosecurity is of no less importance. the use of animals was approved by the branch commission for animal welfare of ministry of agriculture of the czech republic (approval protocol no. mze ) as a part of project as a part of project respig (qj ). mt, vc, js, and mf designed the study. mt, ll, js, and kn performed the experiments. ll, hk, lk, po, and jf performed the lab work and analyzed the data. lk produced the figures and statistical analysis. mt wrote the manuscript. js and mf participated in manuscript preparation. all authors read and approved the final manuscript. the study was supported by projects no. qj , qj , and ro of the ministry of agriculture of the czech republic and by project lo with financial support from the ministry of education, youth, and sports of the czech republic under the npu i program. porcine reproductive and respiratory syndrome virus strains of exceptional diversity in eastern europe support the definition of new genetic subtypes definition of subtypes in the european genotype of porcine reproductive and respiratory syndrome virus: nucleocapsid characteristics and geographical distribution in europe genetic and immunobiological diversities of porcine reproductive and respiratory syndrome genotype i strains strain specificity of the immune response of pigs following vaccination with various strains of porcine reproductive and respiratory syndrome virus evaluation of the efficacy of a new modified live porcine reproductive and respiratory syndrome virus (prrsv) vaccine (fostera prrs) against heterologous prrsv challenge comparison of the efficacy of autogenous inactivated porcine reproductive and respiratory syndrome virus (prrsv) vaccines with that of commercial vaccines against homologous and heterologous challenges comparison of protection provided by type and porcine reproductive and respiratory syndrome field viruses against homologous and heterologous challenge cross efficacy of immune responses to porcine reproductive and respiratory syndrome virus infection aberrant host immune response induced by highly virulent prrsv identified by digital gene expression tag profiling pathogenesis and antigenic characterization of a new east european subtype porcine reproductive and respiratory syndrome virus isolate pathogenesis and control of the chinese highly pathogenic porcine reproductive and respiratory syndrome virus innate and adaptive immunity against porcine reproductive and respiratory syndrome virus effects of origin and state of differentiation and activation of monocytes/macrophages on their susceptibility to porcine reproductive and respiratory syndrome virus (prrsv) porcine reproductive and respiratory syndrome virus: description of persistence in individual pigs upon experimental infection the challenge of prrs imunology immunopathogenesis of porcine reproductive and respiratory syndrome in the respiratory tract of pigs porcine reproductive and respiratory syndrome virus (prrsv): pathogenesis and interaction with the immune system porcine reproductive and respiratory syndrome virus-induced immunosuppression exacerbates the inflammatory response to porcine respiratory coronavirus differential production of proinflammatory cytokines in the pig lung during different respiratory virus infections: correlation with pathogenicity a modified serum neutralization test for the detection of antibody to porcine reproductive and respiratory syndrome virus in swine sera cytokine mrna profiles in bronchoalveolar cells of piglets experimentally infected with porcine reproductive and respiratory syndrome virus: association of sustained expression of ifn-γ and il- after viral clearance upregulation of il- gene expression in peripheral blood mononuclear cells by porcine reproductive and respiratory syndrome virus immune response of pigs after experimental infection with european strain of porcine reproductive and respiratory syndrome virus immune response of porcine alveolar macrophages to a concurrent infection with porcine reproductive and respiratory syndrome virus and haemophilus parasuis in vitro current infection of monocyte-derived macrophages and with porcine reproductive and respiratory syndrome virus and haemophilus parasuis: a role of ifnα in pathogenesis of co-infections challenges for porcine reproductive and respiratory syndrome virus(prrsv) vaccinology. vaccine immunological solutions for treatment and prevention of porcine reproductive and respiratory syndrome (prrs) inactivated and subunit vaccines against porcine reproductive and respiratory syndrome: current status and future direction live porcine reproductive and respiratory syndrome virus vaccines: current status and future direction comparison of different vaccination schedules for sustaining immune response against porcine reproductive and respiratory syndrome virus modified-live prrsv subtype vaccine unistrain prrs provides a partial clinical and virological protection upon challenge with east european subtype prrsv strain lena efficacy and safety of simultaneous vaccination with two modified live virus vaccine against porcine reproductive and respiratory syndrome virus types and in pigs development of a broadly protective modified-live vaccine candidate against porcine reproductive and respiratory syndrome virus economic analysis of vaccination strategies for prrs control review on the transmission porcine reproductive and respiratory syndrome virus between pigs and farms and impact on vaccination cost of porcine reproductive and respiratory syndrome virus at farm level -an economic model significance of different types and levels of antigen-specific immunity to actinobacillus pleuropneumoniae infection in piglets cell-mediated immune response in swine infected with mycobacterium avium subsp intracellular cytokine detection by flow cytometry in pigs: fixation, permeabilization and cell surface staining assessment of the efficacy of commercial porcine reproductive and respiratory syndrome virus (prrsv) vaccines based on measurement of serologic response, frequency of gamma-ifn-producing cells and virological parameters upon challenge comparison of serum and oral fluid antibody responses after vaccination with modified live (mlv) porcine reproductive and respiratory syndrome virus (prrsv) vaccine in prrs endemic farms detection of porcine reproductive and respiratory syndrome virus (prrsv)-specific igm-iga in oral fluid samples reveals prrsv infection in the presence of maternal antibody oral fluid samples used for prrsv acclimatization program and sow performance monitoring in endemic prrs-positive farms ability of elisas to detect antibodies against porcine reproductive and respiratory syndrome virus in serum of pigs after inactivated vaccination and subsequent challenge humoral immune response and viral shedding following vaccination with modified live porcine reproductive and respiratory syndrome virus vaccines long duration of immunity against a type heterologous prrs virus challenge in pigs immunised with novel prrs mlv vaccine: a randomised controlled study new species of torque teno miniviruses infecting gorillas and chimpanzees adenovirus infection in savanna chimpanzees (pan troglodytes schweinfurthii) in the issa valley safety and immune response after intradermal application of porcilis prrs in either neck or the perianal region porcine reproductive and respiratory syndrome (prrs) virus-specific interferon-γ + t-cell responses after prrs virus infection or vaccination with inactivated prrs vaccine t-helper cells from naive to commited pig that recover porcine reproduction and respiratory syndrome virus infection develop cytotoxic cd + cd + and cd + cd − t-cells that kill virus infected cells safety of reproductive and respire syndrome modified live virus (mlv) vaccine strains in a young pig infection model molecular epidemiology of prrsv: a phylogenetic perspective genomic characterization and pathogenicity of a strain of type porcine reproductive and respiratory syndrome virus elimination of prrs virus (eu-type) from farrow-to finish breeding farm by vaccination with ingel-vac r prrs mlv under unfavourable conditions microbial ecology of swine farms and prrs vaccine vaccination strategies development and control of an acute prrs field virus infection in an endemic prrs breeding herd after vaccination with modified live vaccine different porcine reproductive and respiratory syndrome (prrs) vaccine regimes and its effect on pig immunity status at south asia pig farms evaluation of the effect of a porcine reproductive and respiratory syndrome (prrs) modifiedlive virus vaccine on sow reproductive performance in endemic prrs farm successful elimination of prrs virus from an infected farrow-to-finish herd by vaccination key: cord- -nmnssoeb authors: wall, jonathan t.; kaiser, bonnie n.; friis-healy, elsa a.; ayuku, david; puffer, eve s. title: what about lay counselors’ experiences of task-shifting mental health interventions? example from a family-based intervention in kenya date: - - journal: int j ment health syst doi: . /s - - - sha: doc_id: cord_uid: nmnssoeb background: a key focus of health systems strengthening in low- and middle-income countries is increasing reach and access through task-shifting. as such models become more common, it is critical to understand the experiences of lay providers because they are on the forefront for delivering care services. a greater understanding would improve lay provider support and help them provide high-quality care. this is especially the case for those providing mental health services, as providing psychological care may pose unique stressors. we sought to understand experiences of lay counselors, focusing on identity, motivation, self-efficacy, stress, and burnout. the goal was to understand how taking on a new provider role influences their lives beyond simply assuming a new task, which would in turn help identify actionable steps to improve interventions with task-shifting components. methods: semi-structured interviews (n = ) and focus group discussions (n = ) were conducted with three lay counselor groups with varying levels of experience delivering a community-based family therapy intervention in eldoret, kenya. thematic analysis was conducted, including intercoder reliability checks. a stress map was created to visualize stress profiles using free-listing and pile-sorting data collected during interviews and focus group discussions. results: counselors described high intrinsic motivation to become counselors and high self-efficacy after training. they reported positive experiences in the counselor role, with new skills improving their counseling and personal lives. as challenges arose, including client engagement difficulties and balancing many responsibilities, stress and burnout increased, dampening motivation and self-efficacy. in response, counselors described coping strategies, including seeking peer and supervisor support, that restored their motivation to persevere. at case completion, they again experienced high self-efficacy and a desire to continue. conclusions: findings informed suggestions for ways to incorporate support for lay providers into task-shifting interventions at initiation, during training, and throughout implementation. these include acknowledging and preparing counselors for challenges during training, increasing explicit attention to counselor stress in supervision, fostering peer support among lay providers, and ensuring a fair balance between workload and compensation. improving and building an evidence base around practices for supporting lay providers will improve the effectiveness and sustainability of lay provider-delivered interventions. background a major issue facing health systems in low-and middle-income countries (lmics) is improving healthcare accessibility resulting from health care professional shortages, especially for mental healthcare [ , ] . much work advocates for health systems strengthening through task-shifting, or task-sharing, by training non-specialists or non-professionals to provide services [ ] [ ] [ ] . most often, such programs employ community health workers (chws), more broadly referred to as lay providers, who deliver services ranging from hiv-tuberculosis care and management [ ] to mental healthcare, the topic of the current study [ , ] . task-shifting has become the de facto model of much mental healthcare delivery in lowresource settings globally due to the one-million-person shortage of mental health specialists [ , ] . despite the many benefits of task-shifting for increasing healthcare accessibility, a growing body of research points to challenges lay providers face. a key challenge is socioeconomic inequities between lay providers and employed health professionals. this reality is largely driven by interventionists pushing an ethic of volunteerism for lay provider programs [ , ] . some policymakers and community program leaders claim that lay providers are "priceless" and might lose intrinsic motivation to fulfill their responsibilities if paid [ , ] . additionally, many programs emphasize their costeffectiveness in increasing healthcare accessibility, which is premised on not paying lay providers [ , ] . this is a topic of ongoing debate in the field and has important implications for intervention delivery [ , ] . beyond economic impacts, the four most common areas of concern regarding lay provider experiences are motivation, self-efficacy, stress, and burnout ( table ) , any of which can contribute to poor retention among lay providers [ ] . these are concerning from an individual well-being perspective and because they might reduce quality and effectiveness of interventions. these outcomes are even more concerning among lay counselors, a specific type of lay provider focused on mental healthcare, which often requires more time commitment and raises the risk for unique stressors, including compassion fatigue. one proposed root cause of these problems is that lay providers are sometimes treated as a "means to an end, " rather than as individuals who may need support to optimize their services [ ] [ ] [ ] . therefore, some researchers propose fostering a humanistic view of lay providers, encouraging global health actors not to approach lay providers as technocratic solutions, but as people with unique skills, desires, and perspectives [ ] . although past studies have pointed toward workload and socioeconomic inequities as driving problems of demotivation and burnout among lay providers, another possible cause is the stress of taking on the new role itself [ ] . role identity theory provides a useful framing for exploring shifts in identity that lay providers may experience because of taking on a new role, and how these shifts relate to stress or resilience. the theory posits that all people have multiple, hierarchically arranged identities and roles that motivate behaviors [ ] . the roles are thought to be intimately related to each other, often influencing how other roles are performed and shaping the personal meaning of individual identities [ ] . as individuals learn new skills and interact socially, they constantly acquire new roles that add to their "role set, " like adding tools to a toolkit. role shifts are then defined as change or reshaping of a role set because of new relationship interactions, social positions, or duties. for lay providers, such shifts in social roles occur after they receive training and take on new health worker roles. the current study applies this theory with the goal of generating potential avenues for better lay provider support. we used a humanistic approach incorporating role identity theory to examine experiences of lay counselors trained in a family therapy intervention in eldoret, kenya. we aimed to describe how lay counselors experience role shifts and associated outcomes, such as keywords: mental health, lay counselors, task shifting, africa, burnout, motivation, self-efficacy, stress, family therapy, children intrinsic and extrinsic forces, beliefs, and ideals that incline an individual to pursue and maintain their position as a lay counselor [ ] an individual's perceptions and assessments of their capability to be competent and effective in their counseling role [ ] the physical, psychological, emotional, and social consequences that affect a lay counselor due to trying to fulfill the duties and responsibilities expected of them by their clients, supervisors, and communities combination of feelings of workrelated exhaustion, cynicism, and inefficacy due to the daily routine and duties required for a counselor, which can manifest in physical and behavioral changes [ , ] wall et al. int j ment health syst ( ) : motivation and burnout. where relevant, we also aimed to describe any variability in outcomes by comparing counselors with varying degrees of experience in their counseling roles (newly trained, months of experience, and years of experience). our overall goal was to use participant responses to inform strategies to improve counselor experiences, which should improve intervention delivery and quality. because the intervention was designed with the goal of minimizing the added burden for lay providers (described below), it offers a helpful lens and case study for understanding the specific contribution of role shifts in relation to other stressors associated with lay counselor experiences. semi-structured interviews and focus group discussions (fgds) were conducted to explore lay counselor experiences providing a family therapy intervention in eldoret, kenya. lay counselors were recruited from two pilot studies of the intervention in and . data collection occurred july-august . all study procedures were approved by the ethical review boards at duke university and moi university in kenya. written informed consent was obtained for all activities. the study was located in peri-urban communities surrounding the town of eldoret, kenya. eldoret is located in the rift valley province and is the fifth largest kenyan city [ ] . some residents have access to mental health services through moi teaching and referral hospital, which provides limited inpatient and outpatient care. available treatment focuses primarily on adults with serious mental illness and, to some extent, common mental disorders. very little child-or family-specific training or treatment is available, and community-based approaches are uncommon. the research team was composed of two doctoral level clinical psychologists who are co-principal investigators (one us-based, one kenyan-based), graduate students from the us, kenyan masters-level psychologists, and kenyan research assistants. team members collaborated throughout the planning, data collection, and data analysis stages of the project. tuko pamoja (tp, "we are together" in kiswahili) is a family therapy intervention designed to promote family functioning and child or adolescent mental health for families with difficulties in relationships. eligibility for tp is intentionally broad, with content designed to target problems related to family conflict, communication, and organization that occur alongside both internalizing and externalizing child symptoms. related, tp is components-based, tailored to fit the needs of each family, and focuses on generating solutions to influence the family system. it is not time-limited, with families allowed to move at their own pace. a full description of tp is provided in puffer et al. [ ] . for implementation in the pilot studies, lay counselors were recruited through existing social structures, such as religious and community organizations, and chosen because they already naturally engaged in informal helping roles and had shown sustained interest in such activities. none of the counselors in the study had any previous training related to counseling or formal counseling experience; rather, people sought them out for advice, and they reported spending significant time providing advice and listening to people experiencing individual or family problems. at times, this was performed in the context of another helping role, such as pastor, youth group leader, or village community leader (often referred to as "policy maker"). training in the family intervention was intended to augment their current, informal practices with evidence-based strategies. counselors completed approximately h of training. after being trained, counselors were expected to commit the same time to counseling as they dedicated to their advice-giving activities before they were trained, therefore not increasing their workload. this was important, as they were not paid for the counseling. the implementation approach was designed to be sustainable without external resources by integrating into existing volunteer activities and keeping counselors' time commitment the same. however, the lay counselors were paid for their participation in researchrelated activities, such as surveys and interviews. after training, counselors led the process of recruiting families to counsel, mirroring the natural ways they had already been connecting with families for informal counseling. in most cases, families had expressed a need to the counselor previously, but the counselor had not yet addressed the need in depth. the goal was to have counselors recruit from the types of families they were already helping so that the types and severity of problems would be representative of those they would have been expected to address in their day-to-day lives. given this, problems ranged in complexity but were appropriate for the intervention and the counselors, especially with access to support and supervision. counselors received supervision from local kenyan supervisors after each session (in-person or via phone) that included feedback, planning for next steps, and brief refresher training and practicing skills as needed. local supervisors received weekly consultation from clinical psychologists in kenya and the united states [ ] . the tp counseling sessions were held in the homes of the counseled families. in the first pilot trial of tp, counselors held an average of sessions with a mean length of min, totaling an average treatment exposure of contact hours. pilot results are promising for both family-and individual-level outcomes [ ] . lay counselors were included in this study if they completed tp training as part of a pilot study. we categorized them into three groups based on level of supervised tp counseling experience: "moderate" (n = ), "minimal" (n = ), and "training only" (n = ). the moderate experience group included individuals who started tp counseling in and had counseled - families (pilot study ), whereas the minimal group started tp counseling in and had been assigned a single family (pilot study ). the training only group were individuals from both pilot studies who had undergone training but had not yet provided tp for case-specific reasons, including changes in availability or difficulties engaging families. of the eligible counselors, were available, and all participated in this study. of the remaining five, three had moved away, and two had outdated contact information. demographically, the three counselor experience groups were similar (see additional file : appendix s for a detailed demographics table). the overall mean age was , with individual group means ranging between and . of all the counselors, half were women, were currently married, and were widowed. all had some formal education: five had primary-level education (two did not complete primary); six had some secondary education; three completed secondary education; and five had some post-secondary education, with one having a university degree. every counselor except one had a position, either formal or informal, that provided them income. this included four business owners, two casual workers, three policy makers, five farmers, three pastors, a school cook, and a village elder. all except one identified as christian, who identified as muslim. a kenyan research assistant completed all data collection activities following a -day training in study aims, data collection methods, and research ethics. semistructured interviews (n = ) were conducted in kiswahili using a guide developed and piloted collaboratively by the kenyan and us-based researchers. questions focused on lay counselors' approaches to counseling before tp training, changes in identity since becoming a tp counselor, and how tp counseling affected experiences of stress, burnout, motivation, and self-efficacy. for the training only group, questions related to formal counseling experiences were not included. the full interview guide is available in additional file : appendix s . during interviews, participants completed a free-listing activity where they listed current sources of stress, not necessarily associated with the counselor role. the participant then ranked the items from most to least stressful, with the option to rank multiple items at the same level. interviews were audio recorded and transcribed from kiswahili directly into english by a kenyan research assistant fluent in both languages. as each transcript was completed, we conducted preliminary data analysis using close reading of transcripts, memoing, and preliminary code development. this process helped to make iterative adjustments to the interview guide, such as selecting a simpler kiswahili translation or providing a clarifying metaphor. participants were compensated for their time with ksh (~ usd). after all participants from each counselor experience group completed their individual interviews, fgds were conducted for the purpose of member checking-the process of presenting preliminary results to ask participants to provide feedback about whether the interpretations of their responses are accurate. it is also a chance to expand upon their responses or delve deeper into interpretations [ ] . during each session, participants were presented with preliminary results from interviews with tp counselors from their group and asked to clarify, verify the information, and to expand on specific ideas that individuals mentioned. fgd participants also completed a pile sorting activity, a method used to understand how participants categorize items within a domain [ ] . as a group, participants sorted index cards listing the stressors from free lists, placing them into piles with as few or as many stressors as deemed appropriate and labeling the stressor categories. the goal was to consolidate the numerous stressors into higher-level groups to assist with later stress mapping, described below. fgds were conducted primarily in kiswahili, with occasional english. they were audio recorded and transcribed directly into english by a kenyan research assistant. participants were compensated for their time with refreshments and ksh (~ usd). thematic content analysis was used to analyze the data [ ] . all interview and fgd transcripts were first reviewed by the first author through close readings, where emergent themes were extracted and then reviewed with another researcher. themes were organized into a codebook containing parent and child codes, code definitions, examples, and inclusion/exclusion criteria [ ] . most codes reflected research topics on the guide (e.g., identity, stress, burnout, motivation, and self-efficacy), whereas others emerged from the data (e.g., role mixing, burnout resistance). to identify problematic codes and issues with code application, we used an intercoder reliability exercise. transcripts were independently coded one-by-one by two researchers. after each transcript, the researchers discussed discrepancies between coded segments and revised the codebook. this process was repeated until sufficient intercoder reliability was established (kappa coefficient of . and overall agreement percentage of %). all transcripts were then coded by the first author. code summaries were developed to facilitate understanding and interpretation of themes. we determined the data to be thematically saturated, as the final four individual interview transcripts yielded no new themes. this was further supported by the fact that in fgds, no new themes arose; participants only offered examples of previously-identified themes. code summaries were then compared across counselor experience groups to check for patterned differences. primarily, themes did not differ across groups; we indicate in results where they do differ. finally, a concept diagram was devised from data interpretations to provide a visual description of study domain interactions. a stress map was created for each experience group using the ranked lists of stressors from interviews and grouped categories from fgds. the goal of this visualization analysis was to better understand the stressors that were most influential in counselors' lives. methods from participatory risk mapping [ ] were adapted to produce stress maps that visually display relative prevalence and severity of stressors. such quantitative analyses of qualitative data are common with methods such as ranking and pile sorting, with results visually interpreted as reflecting relative rather than absolute values [ ] . the prevalence index was the proportion of a group that listed a stressor category at least once. the prevalence index is therefore ordered between and , with higher values representing stressors named by a higher proportion of group members. the severity index standardized each stressor rank within a participant's list, where each stressor (i) and its rank (r) with total (n) risks identified by each participant (j) was calculated as . if an individual listed multiple items within a category (e.g., daily provisions and school fees within the poverty category), their severity scores were averaged. the severity index is therefore ordered between and , with higher values representing stressors ranked as being more stressful. these individual severity values were then averaged across the group to produce a group severity index value for each stressor category. values were plotted in four quadrants that represent above/ below mean severity and prevalence to help visually identify key stressor clusters within and between groups. to understand counselors' personal expectations in their new formal counseling roles and their perceived counselor identity, participants were asked what they thought it means to be a tp counselor and to discuss key personal qualities of a tp counselor. their developing sense of "professional identity" was important to understand because their new formal role and training were not officially announced to the community but only to the individual families they worked with. across all groups, participants described a tp counselor as someone who is a good listener, empathetic, ready, flexible, has good communication skills, "takes their time, " and is a responsible leader. they noted specifically that a tp counselor differs from community elders in that tp counselors are not judgmental in their advice-giving; instead, they help families identify their own solutions. finally, being a tp counselor was described as being a role model in the community because "nobody will love your work if your actions are not straight" (male, , moderate group). participants described that before tp training, they offered advice and counsel anywhere they went: after church, on the streets, while running errands, or wherever they met someone in need. their advice focused on encouraging or teaching from bible scriptures, drawing from personal experiences, passing along wisdom from elders, praying with others, and giving direct advice on how to solve a specific problem. recipients of their "advising, " as they often called it, were either people who sought their advice directly or those referred to them by someone else. consistent with role identity theory, when counselors began to integrate their new formal counselor role, they experienced some positive role shifts as well as tensions between roles. some described that their new counseling skills generalized in ways that enhanced their performance in related professional or volunteer positions. for instance, "tp has affected me to some extent because i cannot use law enforcement like before; i no longer take people to the police so easily, and i try to solve the disputes" (male, , moderate group). in some cases, counselors described this resulting in increased respect and appreciation from others. on a personal level, counselors described improvements in their roles within their families as they applied the tp skills to their own lives (described below). the majority of tp counselors reported few problems with balancing roles because of the required responsibilities of the counselor role itself, suggesting the counseling role fit with their ongoing routines without significant interruptions. however, there were some cases where taking on the role of tp counselor sometimes conflicted with responsibilities associated with their other roles, especially when logistical challenges, like scheduling problems, required additional time. counselors described "sacrificing time" to engage in counseling, leaving less time to fulfill their many other responsibilities. one pastor described that "one cannot really have time to prepare a sermon, visit members of the congregation, and have time for your own family" (male, , minimal group). though not mentioned frequently, one female counselor described making sure that counseling did not interfere with income-generating activities, saying, "when i am helping others, i should not forget about my own family… since i am the sole provider for my children, if i don't work, what will they eat?" (female, , moderate group). though the tp intervention was designed so that counselors were not spending more total time on counseling, the shift to meeting with the same families on a regular basis restructured time demands in ways that necessitated shifts in how they balanced multiple roles. when asked why they became counselors, participants typically discussed intrinsic motivations first. as expected, every experience group mentioned a general desire to help others: "i was never happy at heart to see people languishing in their sorrows. i could never abandon or neglect them. i had to do something about it" (male, , training only). participants from each experience group also mentioned a deep-rooted calling from god and a passion for counseling and serving people after observing widespread community problems. the belief that they were making a difference and fulfilling god's work was highly motivating. when families engaged in counseling, attended sessions, and showed positive changes or outcomes, the counselors were motivated to continue working. many expressed that receiving training improved motivation to counsel families because they had increased knowledge and new skills to handle a broader set of cases. this in turn increased their sense of self-efficacy and helped sustain them even through challenges or negative feedback. participants also noted increased motivation after seeing the impact of applying some of the skills to their own lives, as described further below. additionally, counselors reported receiving encouragement, respect, and empowerment from supervisors and fellow counselors, as well as from family and community members. these were especially helpful in maintaining motivation when client families were struggling, not progressing, or having problems scheduling sessions. one counselor noted, "i really loved the fact that i wasn't left alone after the training… i got a lot of encouragement to continue" (male, , minimal group). to explore self-efficacy, counselors were asked about their feelings of preparedness and perceived ability to meet expectations. the resounding narrative was that counselors felt empowered in their abilities to fulfill their counselor role after completing tp training. with this improved self-confidence and empowerment from training came a change in how counselors viewed their counselor role. when discussing their counseling approach before, many described their role as "shallow, " "reckless, " and having "no consistency. " now, counselors felt they were more "professional" and were able to meet the expectations of their client families: "before, we were practicing in the dark, unlike now, we are working in the light. tp has given us knowledge, equipped us, and widened our minds" (female, , moderate group). despite overall improvements in self-efficacy, it was tested and often fluctuated based on client family trust, openness, and progress through therapy. though they clearly experienced expanded counseling capacity, the counselors consistently requested that tp continue to provide more trainings. they expressed a persistent desire to improve their counseling abilities to handle an even wider breadth of problems. the stress map (fig. ) helped identify top stress areas for each counselor experience group. as described in the methods, a top stress area is one that has both high prevalence (proportion of group listing the stressor) and severity (rated more stressful overall). for all counselor experience groups, a top stress category was poverty, describing both personal (e.g., acquiring daily provisions, paying school fees) and community (e.g., lack of employment, people not taking children to school) sources. another top category across multiple groups was family, describing both personal (e.g., marriage disputes) and community sources (e.g., homeless individuals, substance abuse). a third category was counseling, describing challenges with being a tp counselor both logistically and emotionally. the specific prevalence and severity of these stressors were different between experience groups. the top stress areas for moderate experience counselors were poverty, family, and poor parenting. for minimal experience counselors, they were counseling, education, poverty, and role balance. for training only counselors, they were family, informal counseling (not tp), and poverty. although participants mentioned a broad range of stressors in free-listing, they focused on a smaller set during individual interviews, as questions aimed to understand counseling-related stressors in depth. participants across groups expressed similar stressors related to therapy scheduling, family attendance and engagement, and perceptions of the family's progress. stress first came from becoming accustomed to their new formal counseling role and logistics, such as providing reports, recording sessions, and making follow-ups. then, family attendance problems were stressful, as family members were sometimes busy with other priorities or avoided counseling when it became difficult. counselors described arriving to empty, padlocked houses or wasting time waiting for family members to show up. at times, they questioned if they had done something wrong to cause a disinterest or avoidance of sessions. during therapy sessions, counselors noted stress if they perceived lack of family engagement, which was essential for conducting the counseling. one counselor noted difficulty "getting them to open up; it takes a lot of time sometimes when none of them believed that their problems will remain confidential" (female, , moderate group). one possibility raised by a counselor was research-specific activities (e.g., recordings and documents) might have made it harder for counselors to build rapport and trust. it was also difficult to maintain engagement and progress when families were undergoing acute hardships, which made it hard for them to focus on longer-term goals during the sessions. examples included losing a job, not having enough money to buy food, or experiencing a medical emergency. participants also noted stress when trying to navigate counseling across gender and age differences, such as a woman counselor advising a man, a younger counselor counseling elders, or a counselor attempting to facilitate inter-generational communication in the family. the interviewer used a "spring metaphor, " developed with the kenyan team during interview guide revisions, to help describe experiences of burnout. counselors were asked to think about any times they felt so compressed or stretched by their tp counseling work, they felt they could not continue working. twelve of the counselors endorsed feeling this way at times, including counselors from all experience groups. when discussing burnout, counselors often described instances where stress piled on continually without relief. this was most commonly discussed in connection to the scheduling and attendance stressors described previously. during times of burnout, counselors experienced pronounced negative thoughts or emotions related to these challenges that interfered with their drive to continue: "you find they are not there; then when you go there again, they tell you they are not ready for you; then it happens again…you feel like you are tired. that is what can make you lose hope" (male, , moderate group). additionally, some counselors experienced burnout when feeling like they could not meet the expectations of their supervisors, which led to hopelessness and the desire to avoid supervision-a required activity for counselors. participants were asked to reflect on how such situations made them feel in their head, heart, and body. all counselor groups expressed physical experiences of fatigue, pain, or feelings of sickness during such instances of overwhelming stress: "[it] makes you feel troubled. you lack peace. you feel even more tired as though you have been digging a shamba [field]" (male, , moderate group). counselors also expressed thoughts related to self-doubt and questioning of their capabilities as a counselor. at the core of the burnout experience was a struggle caused by the sincere desire to help-and belief that they had the skills to help-juxtaposed against families not engaging or making progress. in these situations, counselors noted "questioning myself " as they judged their counseling capabilities. emotionally, participants described an overall lack of peace, loss of hope, and feeling "burdened in my heart. " participants described similar coping mechanisms for dealing with both stress and burnout. for many counselors within all experience groups, stress relief came in the form of religious practices. these included praying, reading the bible because it "makes the burden lighter, " and gospel music because "the songs have encouraging words" or "help me remove my mind from the issues" (male, , moderate group). in addition, counselors invested in personal relationships, including talking to their family, spouse, or friends; playing with children; and "sharing ideas" with others. stress was also relieved by accessing support provided through tp, including information, supervisors, and peers. they described reviewing the therapy manual to reassure themselves they knew what they were doing, calling their supervisor, and meeting with other counselors. some also mentioned that returning to their other roles outside of counseling was helpful as a coping strategy because such actions helped counselors distract and distance themselves from the situation. one counselor said, "they [other tasks] help me to remove my mind from the issues that the family [is] going through and not dwell on it" (male, , moderate group). some counselors also mentioned reframing stressors as a way to cope, alongside reminding themselves that they are likely temporary: "the whole world encounters diverse challenges and stresses; for me, i have decided to take it as a normal thing" (female, , moderate group). in instances of burnout, counselors tended to focus on techniques that renewed their motivation and distracted them. they mentioned reviewing training documents to reassure themselves they were implementing the counseling correctly, as well as their case notes, which often showed some progress had been made. these strategies often restored feelings of self-efficacy. beyond these strategies counselors could perform, burnout also began to resolve if a family finally attended a session or showed progress; this often gave a sense of renewal and relief: "now i am feeling okay. you know when you help a family and they get healed, you feel even much better" for the eight counselors who reported not experiencing burnout, we asked them why they thought they avoided the experience of overwhelming stress. the first protective factor was a strong sense of self-efficacy because of having gone through training, having their capacity widened, and being "built up" in counseling skills. this was connected to intrinsic confidence in one's counseling capabilities. some described a feeling of imperviousness to burnout, with one saying he "never felt that they [a family] could overwhelm me" (male, , moderate group): "no, i didn't feel like that [burnout] . we underwent thorough training where my knowledge and capacity was widened. i have learned how to handle a lot of issues" (male, , moderate group). a second protective factor was supervision, received in person or via phone. these counselors felt they could receive help when needed, and supervision made them feel part of a team and appreciated and recognized for their hard work: "we have all the resources we need to use during the process like the mobile phone. we are also given constant advice on challenges we face. the team is also doing good in checking on us through phone calls" (male, , minimal group). a third protective factor was having a strict schedule for activities so that they could best manage their time. this helped the counselors better balance their multiple responsibilities and roles and perhaps even compartmentalize stress in a positive way: "i always try to ensure that i have a schedule of work so that i don't overstretch myself… there are days i have set for counseling, and there are days that i have set for my own work. " (female, , moderate group). a final protective factor was maintaining motivation based on the potential for overall improvement in a counselor's community, even when dealing with stressors related to a specific family. they took pride in being part of making their community more welcoming and harmonious. all counselor groups described applying tp counseling concepts to their own lives. some saw this as a necessary step for becoming role models and gaining credibility, and the changes they made contributed to positive role shifts on a personal level. counselors most commonly reported changing the ways they interacted with their own families, including their behavior toward their spouses and how they disciplined their children. they described using the problem-solving processes and communication skills taught in tp, which they noticed helped them to control their reactions to negative emotions. several counselors reported this led to positive relationship changes, such as increased love and togetherness in their home because of less quarreling and more open discussions, overall interactions, and time together. one counselor described reductions in marital conflict: another counselor described applying his new counseling skills directly to his spouse and children: in addition to family improvements, a few counselors also noted becoming more approachable, getting along easier, and having stronger bonds within their church and community, and subsequently receiving increased respect, encouragement, and appreciation-again contributing to positive role shifts. we identified a common cycle the counselors reported experiencing over time (fig. ) . following tp training, counselors experience an increase in self-efficacy because of their improved counseling abilities. the tp skills and manual made them feel that they could be more systematic when helping families and that they had an expanded scope of situations with which they could help. this high self-efficacy was accompanied by an increase in motivation to counsel because of a sense of readiness and preparation. after being assigned a family, counselors experienced the first challenges of formal counseling despite their preparations and increased self-efficacy: personal challenges from balancing roles in trying to make time for counseling and therapy-related challenges of engagement and slow (or no) progress in early sessions. for some, these caused stress to increase while motivation and self-efficacy decreased. with persistent challenges, the stress increased and persisted until a counselor could begin to experience burnout. this was driven by even further decreases in motivation and self-efficacy as a counselor questioned the commitment of the family they were counseling and their own capabilities. the struggles related to balancing roles as counselors with other responsibilities also continued, contributing to this negative cycle. when counselors had access to and engaged support and coping strategies, or the counseled family made progress, the negative effects of the challenges could be reduced. this included reduction in stress and burnout and an upswing in motivation and self-efficacy. notably, sometimes this cycle repeated multiple times during the course of counseling for just one family. finally, in most cases, families graduated from counseling, having succeeded in reaching some or all of their counseling goals. at this point, both those who had experienced more support and coping, as well as those who had experienced more prolonged stress, often reported feeling a sense of accomplishment reflected in reduced feelings of stress and burnout and restoration of motivation and self-efficacy. the purpose of this study was to conduct a humanistic examination of lay counselors' experiences of role shifts, in the context of a family therapy intervention in kenya. the lay counselors were already informally advising others in their communities, which provided a unique opportunity to examine changes due to a shift from an informal to formal counseling role. taking on a new formal counseling role produced changes in the lay counselors' lives due to their counseling duties and, more importantly, how their new counseling skills altered their approach to their other roles. this included changes in motivation, stress management techniques, and how they perceived their role in their community and families. results highlight both the positive and negative experiences of lay counselors, and the ways in which these interact. similar to other lay provider populations, counselors expressed clear intrinsic reasons for becoming tp counselors [ ] , and they maintained those foundational motivations throughout their experience. this is not surprising, given that such strong motivational forces have been found in a number of studies [ , ] . tp counselors saw their new role as an outlet to fulfill their intrinsic desires to help the community and achieve fulfillment. most connected this intrinsic motivation explicitly to their religious beliefs and values related to helping others through their abilities as counselors that were now even stronger than before. this idea of using one's talents to benefit others is one that is applicable across many religions and types of spirituality, and religiosity has been associated with more volunteering behaviors [ ] . further, those who perceive their work to be a calling from a higher power may be more involved and invested in their work [ ] . this body of research is small, but available findings resonate with our results and point to the importance of acknowledging the role of faith and the potential benefits of partnering with faith-based organizations in task-shifting efforts. tp counselors also applied the skills to their own lives, which they saw improve their relationships and ability to fulfill other roles, including professional and volunteer roles. this is perhaps related to the "helper therapy principle" described by riesman [ , ] , whereby lay providers who share similar characteristics or problems of their clients receive "helper benefits. " these benefits might promote retention, motivation, and effectiveness of a range of lay provider-delivered interventions [ ] [ ] [ ] . the new tp counselor role was manageable for most, perhaps because they were already engaged in informal counseling, showing a pre-existing interest in spending time on these activities. unlike mlotshaw et al. 's population of lay providers, who described multiple changes in identities and roles, tp counselors seemed to experience less of a role shift both in terms of identity change and adjusting to logistical requirements and maintenance of motivation [ ] . this suggests the model of working with these "natural counselors" might have benefits over models in which lay providers are given multiple new responsibilities related to multiple health needs in which they might lack a specific interest [ ] . in tp, the new roles also led to increased respect and status in the community for many counselors, which is also documented among lay providers in other studies, including those delivering home-based care in south africa [ ] . although tp counselors seemed to experience less of a strained role shift due to their previous informal experience and the positive outcomes they described, the challenges with which they needed to cope are important and informative. first, although entering the role of a formal counselor was positive in many ways and seemingly less disruptive than with other delivery models, the new counseling role did, at times, compete with other roles. some had to shift their schedules to guard against allowing the counseling role to interfere with their other responsibilities. second, counselors were now going beyond providing informal advising to providing more consistent care for families experiencing multiple difficulties in relationships that were often accompanied by unstable living situations, and overall lack of organization in the home that made it difficult for them to keep agreed upon appointments. although it is not surprising that this is a difficult population to engage in therapy, coping with attendance challenges can be defeating for counselors. third, even when families engage, family therapy is, by its nature, a difficult process; conflict is often necessary, clients often experience resistance, and progress can be slow. these clinical challenges lead to stress as counselors cope with the uncertainty about whether families will improve. although some of these stressors are likely unique, other studies have found that chws addressing a variety of health needs also have experienced stress related to caring for people with multiple complex needs that make delivery more difficult and lead to emotional distress, as they are unable to help with all of the presenting needs [ , ] . challenges experienced by counselors were associated clearly with experiences of stress and burnout that were particularly pronounced in the middle of the counseling process with a family, sandwiched between positive experiences. the initial motivation and high self-efficacy experienced at the beginning diminished as challenges persisted over time, leading over half of counselors to experience stress and some to experience burnout. similar to other studies, counselors experienced physical manifestations of stress; they questioned their abilities; and they began to lose hope that the families would ever make progress, feeling that their efforts may be futile [ , ] . their stories emphasize the importance of not only these case-by-case scenarios that caused changes in stress or burnout but the mounting interactions between them. when hitting these low points, counselors identified many effective coping strategies that led to a restoration of a positive perspective. some utilized the behavioral coping skills taught in the therapy for emotion regulation; they reached out to their social networks for emotional support; they met with their counselor peers to provide mutual support; and they used supervision to gain both emotional support alongside problem-solving. more literature on these naturally-occurring coping efforts of lay counselors across contexts and interventions would help in developing interventions that build on existing strengths. integrating counselor supports more intentionally and explicitly within interventions could buffer lay counselors' stress and enhance the benefits of taking on these types of roles. we recommend that lay provider trainings and supervision have more formalized components that discuss potential challenges they might face, allowing them to understand the role more fully and to consider together how to prepare. trainings should then include explicit activities to help counselors prepare for and buffer future stressors, such as forecasting and troubleshooting expected challenges ahead of time, normalizing expected negative emotions, and teaching and practicing coping strategies or problem-solving skills to prevent burnout-including the same skills that are included as part of the intervention itself. counselors in this study certainly applied skills from the intervention to their own lives, and this process could be formalized and facilitated by trainers and supervisors. in ongoing supervision, this process of support in coping and problem-solving should continue, providing structured, frequent opportunities for lay counselors to share their own emotional responses and difficulties that arise throughout the process. this process of implementation support is recognized as an important component of supervision in the training of mental health professionals in high-resource settings [ ] . because supervision efforts are already difficult to scale [ , ] , this can be a brief check-in to provide ongoing support with a mechanism for flagging concerns. additionally, connecting with peers can provide opportunities for mutual support during role transitions, stress, and burnout in a flexible and low-cost way. interventionists should foster a collaborative atmosphere among their workforce and coordinate peer-support strategies. this can be through formal mechanisms, such as in-person meetings and/or through telecommunication for virtual meetings or casual communication (e.g., whatsapp groups). in one tp pilot study, counselors organically developed peer support groups, citing these as important spaces for coping [ ] . in other programs, peer support is likely happening within the context of peer supervision, though their support of one another has not been closely studied. an example of a method to mobilize this organic peer support process was adopted in a study in myanmar through providing workshops for trauma management medics to learn techniques to promote personal and peer mental wellbeing [ ] . by providing lay providers with both the tools and collaborative spaces to work through their issues, such as with peer support groups or targeted workshops, they can become more proactive in dealing with problems that may arise in their work. future task-shifting interventions should carefully consider the demands placed on lay providers related to time, effort, and stress and identify ways to balance those demands with appropriate compensation or incentives. the who has recognized this need in their chw guidelines [ ] as important for promoting high motivation and retention, improving counselor experience, and recognizing that the needs and rights of providers are important in all task-shifting efforts. in our implementation model, the strategy is to lower demand and burden, with a maximum caseload of two families, and to integrate responsibilities into roles counselors had prior to tp training (e.g., informal counselors within their communities). this was not a perfect solution, as counselors met challenges such as requiring additional transport and frustration with participant attendance; at times, counseling demands interrupted their work-related activities, exceeding the anticipated burden. they benefitted from small additional incentives to continue, similar to other settings where training opportunities, certificates, and id cards serve as small, additional benefits [ , ] . even when intended demand on lay providers is relatively low, it is essential to carefully consider demand and value in developing a compensation plan, ideally in collaboration with lay provider input. monetary compensation should always be provided in cases where high workload prohibits the lay provider from meeting family financial demands through other employment avenues [ , ] . if financial resources are not available, it is essential to reduce demand and burden. one specific limitation related to analysis is that we coded the transcripts in english after translation from kiswahili, though the inclusion of member checking with fgds allowed opportunities to get feedback to clarify any questions about translations or interpretations. further, although it is a strength of this study that almost all of the eligible counselors participated, findings are limited by the fact that their experience was related to one specific intervention and geographical location. future work will be valuable in understanding the similarities and differences across contexts, types of mental health interventions, and more diverse groups of counselors. of particular interest is how socioeconomic status of counselors may influence levels of stress and burnout during non-compensated counseling activities-even with implementation strategies designed to minimize burden. in addition, while difference across counselors of different experience groups did not emerge across most domains in this study, future work should examine how counselors' experiences change over time. developing and evaluating lay counselor support strategies is also a clear future direction, as this is the essential step for improving outcomes and minimizing negative consequences for lay providers playing such an integral role in filling the global mental health treatment gap. as global health initiatives continue to involve lay providers, it is important to understand their experiences so they can be adequately supported. counselors in this study reported both positive and challenging aspects of their new roles, with most experiencing initial high motivation and self-efficacy that waned amidst challenges in providing treatment, creating stress and periods of burnout. they also reported effective coping strategies that restored motivation and self-efficacy on which future intervention approaches can build. task-shifting initiatives might improve lay provider experiences and ultimate success of the interventions themselves by providing more formal, intentional support structures. the mental health workforce gap in low-and middle-income countries: a needs-based approach south africa's rural mental health human resource crisis: a situation analysis and call for innovative task-shifting world health organization pu. task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines. geneva: world health organization task-sharing approaches to improve mental health care in rural and other low-resource settings: a systematic review the lancet commission on global mental health and sustainable development integration and task shifting for tb/hiv care and treatment in highly resource-scarce settings: one size may not fit all human resources for mental health care: current situation and strategies for action delivering maternal mental health through peer volunteers: a -year report family-based youth mental health interventions delivered by nonspecialist providers in low-and middle-income countries: a systematic review chapter : task-shifting in global health. global mental health: anthropological perspectives culture, status and context in community health worker pay: pitfalls and opportunities for policy research. a commentary on the female community health volunteer programme in nepal: decision makers' perceptions of volunteerism, payment and other incentives volunteers are not paid because they are priceless": community health worker capacities and values in an aids treatment intervention in urban ethiopia does task shifting yield cost savings and improve efficiency for health systems? a systematic review of evidence from lowincome and middle-income countries barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis should we care what policy makers think? a response to maes, kohrt and closser using theory and formative research to design interventions to improve community health worker motivation, retention and performance in mozambique and uganda volunteers in ethiopia's women's development army are more deprived and distressed than their neighbors: cross-sectional survey data from rural ethiopia the basic support for institutionalizing child survival project (basics ii) for the united states agency for international development becoming and remaining community health workers: perspectives from ethiopia and mozambique community health workers and social change: an introduction community health workers and social change : • fast, convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data, including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research: over m website views per year • at bmc the intrinsic-extrinsic dichotomy: toward conceptual clarity the social psychology of self-efficacy what causes burnout? job burnout in public education: symptoms, causes, and survival skills: teachers college, columbia university staff burn-out predictors of burnout among community therapists in the sustainment phase of a system-driven implementation of multiple evidencebased practices in children's mental health help seeking among helping professionals: a role identity perspective exploring the perceptions and experiences of community health workers using role identity theory county fact sheets: uasin gishu county. commission on revenue allocation development and implementation of a family therapy intervention in kenya: a community-embedded lay provider model research design: qualitative, quantitative, and mixed methods approaches the ethnographic interview using thematic analysis in psychology codebook development for team-based qualitative analysis participatory risk mapping for targeting research and assistance: with an example from east african pastoralists salience counts and so does accuracy: correcting and updating a measure for free-list-item salience religious people, religious congregations, and volunteerism in human services: is there a link? nonprofit volunt sector quart predicting work outcomes from religiosity and perceived calling restructuring help: a human services paradigm for the s helper" therapy principle predictors of activity level and retention among african american lay health advisors (lhas) from the national witness project: implications for the implementation and sustainability of community-based lha programs from a longitudinal study lessons from the research on paraprofessionals for attendant care in children's mental health the design and implementation of a grief support program in a faith-based setting. doctor of nursing practice (dnp) projects motivating and demotivating factors for community health workers engaged in maternal, newborn and child health programs in low and middle-income countries: a systematic review supervision of community peer counsellors for infant feeding in south africa: an exploratory qualitative study a qualitative evaluation of a breastfeeding peer counselor program repercussions of violence on the mental health of workers of the family health program. revista de saúde pública lay health worker involvement in evidence-based treatment delivery: a conceptual model to address disparities in care world health organization. world health organization (who) guideline on health policy and system support to optimize community health worker programmes building capacity in mental health interventions in low resource countries: an apprenticeship model for training local providers trauma and mental health of medics in eastern myanmar's conflict zones: a cross-sectional and mixed methods investigation evaluation of accredited social health activists (asha) springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we conducted this project in collaboration with ampath and moi teaching and referral hospital. we would like to thank joyce jeptum, mark nyalumbe, mercy korir, lydia jelagat, and purity nyangweso for their help with data collection and transcription processes. we also thank wilter rono for her local support in eldoret and savannah johnson for her help with intercoder reliability. supplementary information accompanies this paper at https ://doi. org/ . /s - - - .additional file : appendix s . tp counselor demographics. appendix s . individual interview guide. lmic: low and middle income countries; chw(s): community health worker(s); fgds: focus group discussions; tp: tuko pamoja.authors' contributions jtw: design and analysis of the study and data and the writing of the first draft leading to the final draft. bnk: provided study design assistance and was a major contributor in writing the manuscript. eaf-h: supported design of methodology and study implementation at the field site; provided manuscript editing. da: advised on study conceptualization, design, and implementation at the field site. esp: advised on study design and analysis, and contributed significantly to manuscript writing. all authors read and approved the final manuscript. the author(s) disclosed receipt of the following financial support for the research, authorship, and or publication of this article: the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request ethics approval and consent to participate ethical approval for this study was obtained from duke university's irb ethics committee and the local ampath ethics committee at moi university, eldoret, kenya. informed, written consent was obtained from all participants prior to data collection. consent for publication of any individual person's data was obtained prior to data collection. all data were deidentified before analysis and incorporation in the final manuscript. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. key: cord- -u eb authors: xiong, xiao-li; ding, yan; chen, zhi-lin; wang, yao; liu, pan; qin, huan; zhou, li-shan; zhang, ling-ling; huang, juan; zhao, lei title: emodin rescues intrahepatic cholestasis via stimulating fxr/bsep pathway in promoting the canalicular export of accumulated bile date: - - journal: front pharmacol doi: . /fphar. . sha: doc_id: cord_uid: u eb aim: bile salt export pump (bsep) have been confirmed to play an important role for bile acid canalicular export in the treatment of cholestasis. in this study, we investigated the stimulatory effect of emodin on bsep signaling pathway in cholestasis. methods: cell and animal experiments were given different concentrations of emodin. the bsep upstream molecule farnesoid x receptor was down-regulated by small interfering rna (sirna) technology or guggulsterones and up-regulated by lentivirus or gw . real-time pcr and western blotting was employed to detect the mrna and protein levels of bsep in lo cell, rat primary hepatocytes and liver tissue. immunohistochemistry (ihc) was used to examine the expression of bsep in liver tissues. rat liver function and pathological changes of liver tissue were performed by biochemical test and hematoxylin and eosin (he) staining. results: emodin could increase the mrna and protein expression of bsep and fxr. when down-regulating farnesoid x receptor expression with the sirna or inhibitor guggulsterones, and up-regulating farnesoid x receptor expression with the lentivirus or agonist gw , emodin could increase the mrna level of bsep and fxr and the protein level of bsep, fxr , and fxr . emodin also had a notable effect on rat primary hepatocytes experiment, rat pathological manifestation, bsep, fxr , and fxr positive staining in liver tissues and the test of liver function. conclusion: emodin has a protective effect and a rescue activity on cholestasis via stimulating fxr/bsep pathways in promoting the canalicular export of accumulated bile. intrahepatic cholestasis is characterized by disorders of bile formation, bile acid (ba) detoxification and its transport obstacles that are caused by the impairment of hepatocytes and cholangiocytes (ding et al., ) . as a common liver disease, cholestasis seriously affects the quality of life of patients, and if the disease cannot be effectively controlled, those patients will face liver fibrosis and biliary cirrhosis, and can ultimately die of liver failure (fischler and lamireau, ) . the cause of cholestasis is the bile secretion disorders of hepatocyte or bile duct epithelial cells and bile flow blockage by bile flow formation and excretion barriers, further leading to the retention of ba and other toxic substances, eventually causing liver cell damage and cholestatic liver disease . the common incident parts involve the hepatocyte and intrahepatic bile duct system, and the mechanism is closely associated with the bile components, secretion, detoxification, and transportation (hirschfield and heathcote, ) . at present, the amount of cholestasis treatment drugs is limited, due to a lack of evidence for evidence-based medicine and clinical curative effect. although ursodeoxycholic acid (udca) and s-adenosylmethionine are now supported by more and more evidence, and the clinical studies have confirmed that the two kinds of drugs in the treatment of cholestatic liver disease, such as primary biliary cirrhosis (pbc), primary sclerosing cholangitis and intrahepatic cholestasis of pregnancy, are effective, the drugs are not only expensive but also work slowly (mato and lu, ; corpechot et al., ) . cholestasis as the main clinical manifestation of hepatitis syndrome is difficult to get rapid control of, and the efficacy is not cheap. on the other hand, although there has been evidence of certain clinical efficacy for glucocorticoid (such as dexamethasone, abbreviation for "dxm") and other immunosuppressive agents, the obvious side effects of immunosuppression such as weight gain, hyperglycemia, osteoporosis, cataracts, and increased risk of opportunistic infections limit its clinical application (purohit and cappell, ) . therefore, it is urgent to develop new drugs with quick action and fewer side effects to treat cholestatic hepatitis. emodin ( -methyl- , , -trihydroxyanthraquinone) is extracted from the traditional chinese herb rhubarb as its main active ingredient. the molecular formula is c h o (zhao et al., ) . it has been confirmed that emodin has liver protection (lee et al., ) , anti-inflammation (ding et al., ; zhu et al., ) , anti-virus (ho et al., ) , immune regulation (kuo et al., ) , promotion of gastrointestinal motility (zhang et al., ) , antioxidant and many other pharmacological effects. in the treatment of cholestatic hepatitis, emodin could alleviate the role of liver injury in cholestatic hepatitis caused by concanavalin a and alpha-naphthylisothiocyanate (anit) (ding et al., ; xue et al., ) . more importantly, our previous work revealed that emodin could alleviate intrahepatic cholestasis by promoting the expression of liver farnesoid x receptor (fxr), small heterodimer partner (shp), uridine diphosphate glucuronosyltransferase family polypeptide b (ugt b ), and bile salt export pump (bsep), which are related to the synthesis, detoxification, and transportation process of bas (ding et al., ) . we have demonstrated that emodin played a protective role in intrahepatic cholestasis by promoting fxr signal pathways (ding et al., ) . however, the bsep is the key regulator of ba canalicular export, and the molecular mechanism and target gene on alleviating intrahepatic cholestasis by emodin is still unknown. therefore, the objective of this research was to confirm whether emodin could alleviate cholestasis via the bsep signaling pathway. therefore, this research used the lo cell line and anit-induced rat model to find how emodin interfered with the bsep signaling pathway to alleviate intrahepatic cholestasis. the normal human hepatocyte line lo was purchased from the type culture collection of the chinese academy of sciences, shanghai, china. the human hepatocyte lo cell was maintained in an incubator at • c, % co and saturated humidity in medium supplemented with % fbs (guo et al., a) . the cytotoxic effect of emodin was evaluated by the cck- assay. cell morphology was observed after treatment with emodin for h and the procedure followed the previously published steps (guo et al., b; wang et al., ) . groups were divided into a control group and udca ( . µg/ml), dxm ( . ng/µl) and emodin ( . µg/ml, . µg/ml and . µg/ml) groups. with cells passage in -, -, or -well plates for h and culturing to % density, the supernatants were removed and guggulsterone ( µm) or gw ( µm) was added to the wells, excluding the control group. the cell-culture medium was replaced h later, and the guggulsterone/gw was diluted in medium. after h, the cells were harvested for quantitative real-time pcr and western blotting. the fxr sirna (sense -caagtgacctcgacaacaa- ) for human was synthesized by ribobio co., ltd. (guangzhou, china). lo cells were seeded onto -well plates and transfected with sirna duplexes using lipofectamine (invivogen, san diego, ca, united states) according to manufacturer's instructions. the medium was replaced h later, and then the cells were grown for an additional time up to h. at the time point of h before harvest, the sirna-intervened cells were treated with emodin, udca or dxm. the fxr and negative normal lentiviral vectors were constructed by genechem co., ltd., shanghai, china. gv -fxr/ncenhanced green fluorescent protein (egfp) was transfected into lo cell lines, and viral supernatant was harvested after h ( × transducing units [tu]/ml). lo cells were seeded onto -or -well plates and transfected with lentivirus with a multiplicity of infection of according to manufacturer's instructions. the medium was replaced h later, and then the cells grew for an additional time up to h. then, the lentivirusintervened cells were treated with emodin, udca or dxm for another h. specific pathogen-free neonatal sprague-dawley rats ( - g) were obtained from hubei provincial centers for disease control, including female rats and male rats. all rats were kept under constant housing conditions with • c, % relative humidity, and a -h light/dark cycle and had free access to water and food throughout the experiment du et al., ) . the animal experiment number was scxk (hubei) - . the study was reviewed and approved by the research ethics committee of tongji medical college, huazhong university of science and technology yang et al., ) . after feeding for days for adaptation, rats were equally divided into seven groups, i.e., emodin ( mg/kg), emodin ( mg/kg), emodin ( mg/kg), udca, dxm, model and control groups. each group included six rats with males and females. emodin was prepared to . %, . %, and . % suspensions by sodium carboxymethylcellulose. udca was prepared to . % suspension by water. dexamethasone was dissolved in water with the concentration of . %. anit was dissolved in sesame oil with the concentration of . %. the intervention cycle for the model was days for emodin ( mg/kg, mg/kg, mg/kg), udca ( mg/kg) and dexamethasone ( . mg/kg) groups, and . % anit ( mg/kg) was given to the six groups on the fifth day through administration by gavage. animals were terminated by cervical dislocation after h of anit treatment. during this time, the rats were fasted for the last h and anesthetized for the removal of ml of eyeball blood before their death, and all the rats were anesthetized through intraperitoneal injection with % chloral hydrate ( . ml/ g). the serum was stored at − • c. the right liver was immediately snap frozen in liquid nitrogen and stored at − • c, while the left lobe tissue was fixated in % formaldehyde and embedded in paraffin. adult male sd rats ( - weeks) weighing - g were chose to extract hepatocytes, and we use two-step collagenase digestion method and cultivated according to published steps (klaunig et al., ) . extract hepatocytes was maintained in an incubator at • c, % co and s cultured humidity in medium supplemented with % fbs, we used immunofluorescence to detect ck- protein in cells to identify whether the extracted cells were rat primary hepatocytes (banaudha et al., ) . then, the hepatocytes were planted in -well plates. when the cell cultivated reaching % density after h, they were treated with emodin ( . µg/ml, . µg/ml, and . µg/ml), udca ( . µg/ml), dxm ( . ng/µl). after h, each group of cells was harvested for quantitative real-time pcr and western blotting, respectively. following our previous steps , total rna from liver tissues and cells were isolated using rnaiso plus following the manufacturer's protocol. the cdnas were produced with primescript rt reagent kit and incubated at • c for min and • c for s. real-time pcr reactions were done using a stepone plus device (applied biosystems) at • c for s followed by cycles of • c for s and • c for s according to instruction of the sybr premix ex taq kit. data were analyzed by − ct method. all primers were synthesized by tsingke (wuhan, china). the sequences of all primers are listed in table . abiding by our previous steps (li et al., ) , nucleus protein and total protein were extracted from the liver tissues and hepatocytes, respectively. the protein concentration was determined using bca method. to each tube, an equivalent volume of × sodium dodecyl sulfate (sds) loading buffer ( mm tris-hcl, ph . , % sds, % glycerine, % -mercaptoethanol, and . % bromophenol blue) was added and mixed again. the mixtures were then denatured at • c for min, and approximately mg of the protein mixture was loaded and separated in each well on % sds-polyacrylamide electrophoresis gels. after separation for approximately min, the proteins were transferred to polyvinylidene difluoride (pvdf) membranes, and the membranes were saturated and blocked with % fat-free milk at • c for h. membranes were probed with rabbit polyclonal anti-rat-fxr ( : ), fxr ( : ), bsep ( : ) values are the means ± sd (n = , * p < . compared to the control group; * * p < . compared to the control group, as determined by student's t-test). frontiers in pharmacology | www.frontiersin.org and then with horseradish peroxidase-conjugated secondary immunoglobulin igg ( : ). the membranes were then treated with an enhanced chemiluminescence reagent (amersham, piscataway, nj, united states), and the signals were detected by exposure of the membranes to x-ray films (kodak, rochester, ny, united states). the relative signal intensity was quantified by densitometry with gel pro . image software (media cybernetics, silver spring, md, united states) on an ibmcompatible personal computer. the procedure followed our previous steps (jin et al., ) . the liver tissue specimens were cut into µm sections after dewaxing and hydrating. the sections were incubated in % h o /methanol to eliminate endogenous peroxidase activity. then, the sections were incubated with normal goat serum for min and incubated with fxr ( : ), fxr antibody ( : ) and bsep ( : ) overnight at • c and biotin-conjugated goat anti rabbit igg ( : ) at • c for min. they were rinsed again with pbs and incubated with horseradish peroxidaselabeled streptavidin at • c. the samples were developed with diaminobenzidene (dab) and stained with hematoxylin. after being rinsed with distilled water and dehydrated, the sections were made transparent and mounted for microscope examination. after the immunohistochemical analysis, ipp software (image-pro plus . ) was used to analyze the optical density of the images as described previously. the serum total bilirubin (tbil), direct bilirubin (dbil), alanine aminotransferase (alt), aspartate aminotransferase (ast), alkaline phosphatase (alp), γ-glutamyl transpeptidase (ggt), and total bile acids (tba) were assayed by aeroset fully-auto chemistry analyzer provided by abbott co ltd. values are the means ± sd (n = , * p < . compared to the guggulsterone group; * * p < . compared to the guggulsterone group; # p < . compared to the control group, as determined by student's t-test). frontiers in pharmacology | www.frontiersin.org after fixation in % formaldehyde, tissues were embedded in paraffin and cut in serial sections of µm for hematoxylin and eosin (he) staining as our previous studies . the statistical analyses were conducted with spss . software. data were expressed as the mean ± sem. the comparisons of the measurement data between the groups were performed with oneway anova tests and student's t-tests. statistical significance was defined at p < . (ding et al., ) . based on the cck assay, pretreatment of unstimulated lo cells with prepared solution of emodin at . µg/ml, . µg/ml, and . µg/ml for h did not significantly affect cell viability. therefore, we chose emodin at . µg/ml, . µg/ml, and . µg/ml to treat cells for h. compared with the control group, the mrna expressions of bsep and fxr were significantly elevated in the emodin group (p < . or . ) (figures a,b) . the protein expressions of bsep, fxr and fxr were also significantly increased in the emodin groups (p < . or . ); udca could increase the mrna and protein level of bsep (p < . or p < . ) (figures c-f) . compared with the control group, emodin could notably increase the mrna level of fxr, as well as the protein level of fxr and fxr (p < . ). the lo cells were interfered with using guggulsterones. compared with the control group, the mrna expressions of bsep and fxr were significantly decreased in the guggulsterones values are the means ± sd (n = , * p < . compared to the gw group; * * p < . compared to the gw group; # p < . compared to the control group, as determined by student's t-test). group (p < . ), while compared with the guggulsterones group, the mrna expressions of bsep and fxr were significantly elevated in the emodin groups (p < . or . ) (figures a,b) . the protein expressions of bsep, fxr , and fxr , were also significantly lowered by guggulsterones (p < . ), and compared with the guggulsterones group, the protein expressions of bsep, ugt b , fxr , and fxr were significantly elevated in the emodin groups (p < . or . ) (figures c-f) . the lo cells were interfered with using gw . compared with the control group, the mrna expressions of bsep and fxr were significantly increased in the gw group (p < . ), while compared with the gw group, the mrna expressions of bsep and fxr were significantly elevated in the emodin groups (p < . or . ) (figures a,b) . the protein expressions of fxr and fxr were also significantly elevated in the gw group (p < . ), and compared with the gw group, the protein expressions of fxr and fxr were significantly elevated in the emodin group (p < . ) (figures c-f) . we used sirna to down-regulate the expression of fxr in lo cells for h. then, the cells were treated with emodin ( . , . and . µg/ml), udca or dxm for h. compared with the control group, the mrna expressions of bsep and fxr were significantly decreased in the fxr-sirna group (p < . ) (figure a) , and the protein expressions of bsep, fxr , and fxr were also significantly lowered in the fxr-sirna group (p < . ) (figures b,c) . while compared with the fxr-sirna group, the mrna expressions of bsep, fxr , and fxr were significantly elevated in the emodin groups (p < . or . ) ( figure a ). while compared with the fxr-sirna group, the protein expressions of bsep, fxr , and fxr were also significantly elevated in the emodin groups (p < . or . ) (figures b,c) . we made the fxr lentiviral vector gv and transfected lo cells. gfp (green fluorescent protein) was observed with a fluorescence microscope after h and h (figures a,b) . then, the cells were treated with emodin ( . , . and . µg/ml), udca or dxm for h. compared with the control group, the mrna expressions of bsep and fxr were significantly increased in the lentivirus-up group (p < . ) (figure c) , and the protein expressions of bsep, fxr , and fxr were also significantly elevated in the lentivirus-up group (p < . ) (figures a,b) . compared with the lentivirusup group, the mrna expressions of bsep and fxr were significantly elevated in the emodin groups (p < . or . ) (figure c ), while the protein expressions of bsep, fxr , and values are the means ± sd (n = , # p < . compared to the control group, * * p < . compared to the fxr-sirna group; p < . compared to the fxr-sirna group; * p < . compared to the udca group; p < . compared to the dxm group, as determined by student's t-test). fxr were also significantly elevated in the emodin groups (p < . or . ) (figures a,b) . in this experiment, we set three double ratio concentration mg/kg, mg/kg, and mg/kg. the acute toxicity study figure | the expression of gfp was observed with a fluorescence microscope after lentivirus was introduced into lo cells for h (a) and h (b). the mrna levels of fxr and bsep were detected by rt-pcr (c). (n = , # p < . compared to the control group, * * p < . compared to the lentivirus group; * p < . compared to the lentivirus group; p < . compared to the udca group, as determined by student's t-test). for anthraquinones (emodin) showed ld values of . g/kg and . g/kg in male and female mice, respectively (djimeli et al., ) , which is much higher than the three concentrations in our experiment. indeed, as is showed in table , there is no dose-response in emodin. for alt, ast, dbil, tbil, gtt, and alp, the superior rank was: mg/kg > mg/kg > mg/kg. for tba, the superior rank was: mg/kg > mg/kg > mg/kg. so, the optimum concentration for emodin may be mg/kg and the underlying causes deserve further studies. as shown in table , when compared with the model group, emodin had a significant effect on decreasing alt, ast, tbil, dbil, alp, ggt, and tba levels (p < . or p < . ). on alt, emodin ( mg/kg) and emodin ( mg/kg) had a similar effect with udca. emodin ( mg/kg) was most effective on ast, alp, and dbil (p < . ), which was inferior to udca. emodin ( mg/kg and mg/kg) had a notable effect on tbil (p < . ), and udca showed a similar effect on tbil level as the emodin ( mg/kg) group. it was significant that emodin ( mg/kg, mg/kg, mg/kg) had an effect on ggt (p < . or . ), and emodin ( mg/kg) was markedly more effective (p < . ) than the udca group on ggt. there is no doseresponse in emodin. for alt, ast, dbil, tbil, gtt, and alp, the superior rank was: mg/kg > mg/kg > mg/kg. and for tba, the superior rank was: mg/kg > mg/kg > mg/kg. so, the optimum concentration for emodin may be mg/kg. compared with the control group, the mrna levels of bsep and fxr in the model group were decreased significantly (p < . ). the mrna expression of bsep and fxr was figure | the protein levels of fxr , fxr , and bsep were detected by western blotting (a,b) . values are the means ± sd (n = , # p < . compared to the control group, * * p < . compared to the lentivirus group; * p < . compared to the lentivirus group; p < . compared to the udca group, as determined by student's t-test). affected by emodin treatments when compared with model group (p < . or . ) ( figure a) . compared with the control group, the protein expressions of bsep, fxr , and fxr were significantly decreased in the model group (p < . ). while compared with the model group, the protein expressions of bsep, fxr , and fxr were significantly elevated in the emodin groups (p < . ) (figures b,c) . although udca showed a positive effect on the mrna and protein expression of bsep, fxr , and fxr when compared with model group (p < . or . ), emodin ( mg/kg) and emodin ( mg/kg) groups presented better improvement than that in udca and dxm group (p < . or . ). rat primary hepatocytes were used to study the effects of emodin on cholestasis. to demonstrate whether the extracted cells were rat primary hepatocytes, we used immunofluorescence to detect ck- protein in hepatocytes and observed the red fluorescent molecule dylight in primary hepatocytes by fluorescence microscope (figures a-c) . as shown in figure d , compared with the untreated cells, the emodin group showed significantly elevated mrna levels of fxr and bsep. more importantly, the increases in the mrna levels of fxr in the . µg · ml − emodin group were more significant than those in the udca groups (figures d,e) . the protein expression of fxr and bsep were also significantly increased, and there were no obvious increases in protein expression in the udca groups (figures f,g) . consistent with the results of the lo hepatocyte cell line, the experimental results of primary hepatocytes showed fxr/bsep pathways were markedly up-regulated in the . and . µg · ml − emodin groups in vitro. as shown in figure ( ), the hepatic tissue in the control group showed regular arrangement of hepatic lobules and cells and intact epithelial cells of bile duct. the pathological changes in the model group were typically showing significant swelling of hepatic cells, swelling of cytoplasm, uniformed nucleus and a strongly stained nucleolus. moreover, in the model group, many punctiform or focused necrotic zones were shown in the hepatic tissue and kupffer's cell could also be observed. at the same time, the bile duct showed a narrower canal and bile thrombus and necrotic cells. the pathological impairment in the dxm group appeared more serious in hepatic tissue. however, in emodin groups, the pathological changes were less than the model group emodin ( mg/kg) . ± . * @% . ± . * @% . ± . * # . ± . * @% . ± . * @& . ± . * @% . ± . * @% emodin ( mg/kg) . ± . * @% . ± . * @% . ± . * # . ± . * @% . ± . * @% . ± . * @% . ± . * @% emodin ( mg/kg) . ± . * @& . ± . * @& . ± . * . ± . * @& . ± . * @ . ± . * @& . ± . * @% udca . ± . * @ . ± . * # . ± . * . ± . * @ . ± . * # . ± . * # . ± . * @% dxm . ± . * @ . ± . * . ± . * . ± . * # . ± . * . ± . * # . ± . * @ data were shown as mean ± sd. n = . ( * p < . vs. control group; # p < . , @ p < . vs. model group; & p < . , %p < . vs. dxm group; p < . vs. udca group.) figure | effect of emodin on the shp-bsep signaling pathway in anit-treated rats. the mrna levels of fxr and bsep were measured by real-time pcr (a). the protein levels of fxr , fxr , and bsep were detected by western blotting (b,c). data were expressed as the mean ± sd. n = . ( # p < . compared to the control group, * * p < . compared to the model group; p < . compared to the udca group; p < . compared to the dxm group, as determined by student's t-test). and the manifestations in the udca group were similar to those in emodin ( mg/kg) group. as shown in figures ( )-( ) the rate of bsep, fxr , and fxr positive staining in the model group significantly decreased (p < . ) compared with the control group. with emodin treatment, the rates of bsep-, fxr -, and fxr -positive staining could be increased notably (p < . ). the bsep-, fxr -, and fxr -positive staining rates in udca and dxm groups were higher than that in the model group (p < . ). compared with udca and dxm group, the bsep-, fxr -, and fxr -positive rates in the emodin group were markedly higher (p < . ). as a member of adenosine triphosphate (atp)-binding cassette (abc) transporters, bsep is encoded by the gene abcb (meier et al., ) . it is mainly expressed on the hepatocytes canalicular membranes and utilizes energy that from atp hydrolysis to transport intracellular substrates into the extracellular compartment. so bsep is primarily responsible for the ba excretion (cheng et al., ) and translocates bile salt from hepatocytes into the canaliculus and the multidrug resistance protein (mdr ) translocates phosphatidylcholine from the cytoplasmic to the outer leaflet of the canalicular membrane. bile salt in the canaliculus facilitates the release of phosphatidylcholine from the outer leaflet and forms phosphatidylcholine-bile salt-mixed micelles, which is critical for the solubilization of biliary cholesterol. moreover, phosphatidylcholine-bile salt-mixed micelles reduce the toxic activity of bile salts against the bile ducts. therefore, the proper and coordinated functioning of bsep and mdr is critical for mixed micelle formation and can lead to a decreased solubility of biliary cholesterol and consequently to cholestasis (mahdi et al., ) . recent studies have shown that the nuclear receptor fxr is the central molecule in the metabolism of bas and is currently considered as key target in the treatment of cholestasis (stahl et al., ; sturm et al., ; zhu et al., ) . fxr could not only inhibit bas transportation but could also inhibit the formation of liver fibrosis. the specific mechanism is that fxr can inhibit the synthesis of bas and then further induce bas detoxification and excretion in small bile duct, increasing bile flow and bile phospholipid content of bas (baptissart et al., ; gardes et al., ; matsubara et al., ) . therefore, the nuclear receptor fxr is currently considered to be the hub of cholestasis therapy (kim et al., ) . the heterodimer combined with target genes needs to be translated into proteins and then plays biological functions. more importantly, during the process of ba transport, bsep mainly regulated by fxr plays an important role. bsep can pump univalent bas into the bile duct and ultimately into the gallbladder. as the ba receptor, fxr can regulate the gene expression involved in ba metabolism and up-regulate bsep expression to maintain ba homeostasis in the case of ba overload (mazuy et al., ) . it is worth noting that the bsep promoter contained a response element of fxr (ananthanarayanan et al., ) , and the expression of bsep was significantly decreased in fxr knockout mice (sinal et al., ) , which is suggesting that bsep is a downstream target gene of fxr. thus, the selection of fxr downstream molecules is closely related to ba transportation through excited or inhibited fxr. bas are difficult to separate from the blood and balasubramaniyan et al. ( ) demonstrated that bsep was the target gene of fxr and when fxr was up-regulated or downregulated; bsep was correspondingly increased or decreased with no natural agonists, i.e., bas. so the researchers made efforts to intervene hepatic fxr with chemicals or genetic tools to identify the role of fxr on bsep. the use of fxr agonists, such as gw and -ecdca, can significantly promote figure | effects of emodin on molecules of bsep pathway in rat primary hepatocytes. immunofluorescence was used to detect ck- protein in hepatocytes, and the red fluorescence molecule dylight in primary hepatocytes was observed under a fluorescence microscope (a-c). cytotoxicity of emodin on primary hepatocytes was determined by cck assay (d). the mrna levels of fxr and bsep were detected by qrt-pcr (e). the protein levels of fxr , fxr , and bsep were detected by western blotting (f,g). data are shown as the mean ± sd. n = . ( * p < . compared to the control group; * * p < . compared to the control group). liver cells' uptake of bile salts to reduce cholestasis and then restore bile flow and reduce serum cholestatic indicators (ye et al., ; zollner and trauner, ) . some reports showed that fxr-knockout mice had excessive levels of bas, cholesterol and triglycerides (anakk et al., ) . the fxr antagonist guggulsterones has been proven to exacerbate cholestasis in liver ( ) effect of emodin on bsep expression was examined with ihc at × magnification (a: emodin mg/kg group; b: emodin mg/kg group; c: emodin mg/kg group; d: udca group; e: dex group; f: model group; g: control group. values are the means ± sd. n = , ## p < . compared to the control group, * * p < . compared to the model group; p < . compared to the udca group; p < . compared to the dxm group, as determined by student's t-test). ( ) effect of emodin on fxr expression was (continued) figure | continued examined with ihc at × magnification (a: emodin mg/kg group; b: emodin mg/kg group; c: emodin mg/kg group; d: udca group; e: dxm group; f: model group; g: control group. values are the means ± sd. n = , ## p < . compared to the control group, * * p < . compared to the model group; p < . compared to the udca group; p < . compared to the dxm group, as determined by student's t-test). ( ) effect of emodin on fxr expression was examined with ihc at × magnification (a: emodin mg/kg group; b: emodin mg/kg group; c: emodin mg/kg group; d: udca group; e: dex group; f: model group; g: control group. values are the means ± sd. n = , ## p < . compared to the control group, * * p < . compared to the model group; p < . compared to the udca group; p < . compared to the dxm group, as determined by student's t-test). cells (zhao et al., ) . moreover, the fxr agonist gw can reduce estradiol-induced cholestasis in liver cells (seok et al., ) to increase uptake of bile salts, restore the flow of bile and reduce the levels of serum bile salt. these compounds have been approved for the treatment of pbc and nash (neuschwander-tetri et al., ) . therefore, in order to observe whether emodin could continue to promote the fxr signal pathway in the condition of low and high fxr levels, we chose guggulsterones/sirna and gw /lentivirus to down-or upregulate fxr. there is another natural product, dioscin is also can rescue intrahepatic cholestasis in anit-induced rat model through regulating transporters, apoptosis, and oxidative stress (yao et al., ) and through regulating oatps, mrp , and bsep expression . therefore, in our experiment, we choose bsep as our target gene for fxr and choose the fxr inhibitor guggulsterone (zhao et al., ) and sirna to down-regulate and the fxr agonist gw and lentivirus transfection to up-regulate fxr in our cell experiment. for the lo cell experiment, the mrna and protein expressions of fxr and bsep were significantly elevated in the emodin group compared with control group. then, the lo cells were interfered with guggulsterones or fxr-sirna to inhibit the fxr. when compared with the guggulsterones/fxr-sirna group, the mrna and protein expressions of fxr and bsep were also significantly elevated in the emodin groups. furthermore, to confirm the efficacy of emodin after fxr was up-regulated, we interfered lo cells with gw or lentivirus to activate the fxr. when compared with the gw /lentivirus-up group, the mrna and protein expressions of fxr and bsep were also significantly elevated in the emodin groups. gw can significantly reduce the content of triglyceride, cholesterol and free fatty acid induced by high-fat diet in liver (ma et al., ) . therefore, we speculate that gw could weaken the effect of emodin in promoting the fxr pathway through the degradation of organic solvent that dissolved emodin in this experiment. in vitro experiments, we use the normal, guggulsterone stimulation, gw stimulation and fxr-sirna or lentivirus-up methods to compare the emodin's positive effect on fxr and bsep expression, and the results proved that emodin could increase the level of fxr and bsep, no matter of the basic level of fxr low or high. so it seems like that emodin is an indirect mediator to regulate the expression of fxr. and we verity our idea in rat primary hepatocytes experiment, emodin could also increase the level of fxr and bsep in rat primary hepatocytes. the fxr-bsep pathway was activated in anit-induced cholestasis rats. after model establishment and treatment, the liver pathological changes and the serum tbil, dbil, tba, alp, ggt, alt, and ast were monitored. by emodin intervention, it could be observed that improvement of the hepatic impairment was achieved. the molecules of fxr and bsep decreased significantly in the model group. after treatment of emodin, the fxr pathways in cholestatic hepatitis were markedly activated, and fxr and bsep were promoted to some degree. this study demonstrated that bsep is a viable therapeutic target for ba canalicular export and certified the efficacy of emodin in activating the bsep signaling pathway to alleviate cholestasis in vitro and in vivo, which may help find a new way to prevent and treat intrahepatic cholestasis. bsep, the key target molecules that we study may provide new ideas for future precision medicine accurate treatment of intrahepatic cholestasis. further research is required to demonstrate whether emodin could specifically affect the ba synthesis and detoxification through ntcp (na + /taurocholate co-transporting polypeptide), asbt (apical na + -dependent ba transporter), ost α-β (organic solute transporter α-β), oatps (organic anion transporting polypeptides), mdr (multidrug resistance protein ), shp or ugt b . the study was reviewed and approved by the research ethics committee of tongji medical college, huazhong university of science and technology. combined deletion of fxr and shp in mice induces cyp a and results in juvenile onset cholestasis human bile salt export pump promoter is transactivated by the farnesoid x receptor/bile acid receptor sumoylation of the farnesoid x receptor (fxr) regulates the expression of fxr target genes primary hepatocyte culture supports hepatitis c virus replication: a model for infection-associated hepatocarcinogenesis farnesoid x receptor alpha: a molecular link between bile acids and steroid signaling? in vitro model systems to investigate bile salt export pump (bsep) activity and drug interactions: a review biochemical response to ursodeoxycholic acid and long-term prognosis in primary biliary cirrhosis profiles of responses of immunological factors to different subtypes of kawasaki disease preliminary study on emodin alleviating alpha-naphthylisothiocyanateinduced intrahepatic cholestasis by regulation of liver farnesoid x receptor pathway exploration of emodin to treat alpha-naphthylisothiocyanate-induced cholestatic hepatitis via anti-inflammatory pathway antibacterial activities and toxicological study of the aqueous extract from leaves of alchornea cordifolia (euphorbiaceae) mechanism of corilagin interference with il- /stat signaling pathways in hepatic alternative activation macrophages in schistosomiasis-induced liver fibrosis in mouse model cholestasis in the newborn and infant differential regulation of bile acid and cholesterol metabolism by the farnesoid x receptor in ldlr -/-mice versus hamsters corilagin protects against hsv encephalitis through inhibiting the tlr signaling pathways in vivo and in vitro involvement of tlr and tlr in the anti-inflammatory effects of chlorogenic acid in hsv- -infected microglia cholestasis and cholestatic syndromes emodin blocks the sars coronavirus spike protein and angiotensin-converting enzyme interaction activity of corilagin on post-parasiticide liver fibrosis in schistosomiasis animal model antiinflammatory and anti-oxidative effects of corilagin in a rat model of acute cholestasis pathological features of transplanted tumor established by cd positive tj glioblastoma stem-like cells paeonol exerts anti-angiogenic and anti-metastatic activities through downmodulation of akt activation and inactivation of matrix metalloproteinases mouse liver cell culture. i. hepatocyte isolation regulation of cell proliferation, inflammatory cytokine production and calcium mobilization in primary human t lymphocytes by emodin from polygonum hypoleucum ohwi hepatoprotection of emodin and polygonum multiflorum against ccl( )-induced liver injury emodin ameliorates lipopolysaccharide-induced mastitis in mice by inhibiting activation of nf-kappab and mapks signal pathways corilagin ameliorates schistosomiasis hepatic fibrosis through regulating il- associated signal pathway in vitro and in vivo corilagin ameliorates the extreme inflammatory status in sepsis through tlr signaling pathways synthetic fxr agonist gw prevents diet-induced hepatic steatosis and insulin resistance role of multidrug resistance protein in antifungal-induced cholestasis role of s-adenosyl-l-methionine in liver health and injury fxr signaling in the enterohepatic system nuclear bile acid signaling through the farnesoid x receptor interindividual variability of canalicular atp-bindingcassette (abc)-transporter expression in human liver farnesoid x nuclear receptor ligand obeticholic acid for non-cirrhotic, non-alcoholic steatohepatitis (flint): a multicentre, randomised, placebo-controlled trial primary biliary cirrhosis: pathophysiology, clinical presentation and therapy transcriptional regulation of autophagy by an fxr-creb axis targeted disruption of the nuclear receptor fxr/bar impairs bile acid and lipid homeostasis nuclear hormone receptor-dependent regulation of hepatic transporters and their role in the adaptive response in cholestasis nuclear receptor ligands in therapy of cholestatic liver disease new molecular insights into the mechanisms of cholestasis antischistosomiasis liver fibrosis effects of chlorogenic acid through il- /mir- /smad signaling interactions in vivo and in vitro emodin protects against concanavalin a-induced hepatitis in mice through inhibiting activation of the p mapk-nf-kappab signaling pathway effect of corilagin on the mir- /smad /erk signaling pathway in a schistosomiasisinduced hepatic fibrosis mouse model dioscin protects anitinduced intrahepatic cholestasis through regulating transporters, apoptosis and oxidative stress influence of paeonol on expression of cox- and p in ht- cells dioscin protects against anit-induced cholestasis via regulating oatps, mrp and bsep expression in rats effect of emodin on small intestinal peristalsis of mice and relevant mechanism effects of bile acids and the bile acid receptor fxr agonist on the respiratory rhythm in the in vitro brainstem medulla slice of neonatal sprague-dawley rats investigations of free anthraquinones from rhubarb against alphanaphthylisothiocyanate-induced cholestatic liver injury in rats preliminary exploration on anti-fibrosis effect of kaempferol in mice with schistosoma japonicum infection hepatic bile acids and bile acid-related gene expression in pregnant and lactating rats emodin suppresses lpsinduced inflammation in raw . cells through a ppargamma-dependent pathway nuclear receptors as therapeutic targets in cholestatic liver diseases lz takes responsibility for the integrity of the work as a whole, from inception to published the manuscript. x-lx and yd conceived and designed the experiments. z-lc, yw, and pl performed the experiments. hq analyzed the data. l-sz, l-lz, and jh contributed reagents, materials, and analysis tools. yw, z-lc, and lz wrote the manuscript. lz edited the manuscript. all authors approved the final version of the manuscript. key: cord- -jr hj bs authors: park, hyeong-jun; ko, hae li; won, dong-hoon; hwang, da-bin; shin, yoo-sub; kwak, hye-won; kim, hye-jung; yun, jun-won; nam, jae-hwan title: comprehensive analysis of the safety profile of a single-stranded rna nano-structure adjuvant date: - - journal: pharmaceutics doi: . /pharmaceutics sha: doc_id: cord_uid: jr hj bs adjuvants enhance the efficacy of vaccines by stimulating immune response-related gene expression and pathways. although some adjuvants have been approved for commercial use in human vaccines (e.g., alum, mf , and as ), they might elicit adverse side effects, such as autoimmune diseases. recently, we developed a novel single-stranded rna (ssrna) nano-structure adjuvant, which can stimulate both th and th responses. in this study, we evaluated the safety and toxicological profiles of this ssrna nano-structure adjuvant in vitro and in vivo. mice were intramuscularly immunized with the ssrna nano-structure adjuvant three times, once every weeks. the results indicate no significant differences in hematological and serum biochemistry parameters between the ssrna-treated groups and the control group. from a histopathological perspective, no evidence of tissue damage was found in any group. the levels of ige and anti-nuclear antibodies, which are markers of autoimmune disease, were not different between the ssrna-treated groups and the control group. the findings of this study suggest that the ssrna nano-structure can be used as a safe adjuvant to increase vaccine efficacies. current vaccines are based on various strategies used in an attempt to protect against pathogen infection [ ] [ ] [ ] . among them, formulating vaccines with an adjuvant typically increases vaccine efficiency. the adjuvant can recruit antigen-presenting cells (apcs), such as dendritic cells (dcs) and monocytes, or stabilize the vaccine. recently, newer adjuvants have been developed to increase vaccine efficacy, especially for peptide-based vaccines [ ] [ ] [ ] [ ] . besides, some adjuvants are under development, such as the toll-like receptor (tlr) agonist, which also induces innate immune responses (a prerequisite for an effective vaccine) [ , ] . since the discovery of adjuvants, peptide-based vaccines, subunit vaccines, and conjugated vaccines using protein antigens have been co-administered with adjuvants [ , ] . despite ongoing efforts for more than years, the number of currently approved adjuvants is minimal. in the united states, only five adjuvants have been approved: alum, as , mf , as , and cpg [ , ] . among them, alum was approved as an adjuvant for use in humans and the squalene-based adjuvants mf and as were approved in europe and the usa for use with influenza vaccines [ , [ ] [ ] [ ] . however, alum mainly induces th -type immune responses and does not induce cell-mediated immune responses. mf is an excellent adjuvant for inducing antibody production against antigens, but poorly induces cell-mediated immune responses [ ] [ ] [ ] . moreover, the fact that these adjuvants are "licensed" does not mean that they are entirely safe. in case of the the ssrna nano-structure adjuvant was designed using igr ires and sv late-polyadenylation signal sequences [ ] . because it was designed as expression platform, the ssrna nano-structure adjuvant has four restriction enzyme sequences between the untranslated regions that enable cloning into a multi-cloning site and insertion of various genes. in vitro transcription was performed using the ez t high yield in vitro transcription kit (enzynomics, daejeon, korea), according to the manufacturer's instructions. ssrna purification was performed using licl. the ssrna concentrations were evaluated using a nanodrop spectrophotometer (thermo fisher scientific, ma, usa), and ssrna integrity was analyzed by denaturing gel electrophoresis. brief structure of ssrna adjuvant is shown in figure s . hs cells, derived from human foreskin fibroblast were obtained from korean cell line bank (seoul, korea). hs cells were cultured in dulbecco's modified eagle medium (hyclone™) with % fetal bovine serum (fbs, corning, ny, usa) and % antibiotic-antimycotic (anti-anti, gibco, ca, usa). the cells were cultured in a humidified • c incubator with % co . in vitro cell-viability testing was performed with a -( , -demerthylthiazol- -yl)- , diphenyltetrazolium bromide (mtt) assay. hs cells were seeded in -well plates at densities of × cells/well. after h, the medium without % fetal bovine serum was replaced and then , or µg of the ssrna nano-structure adjuvant or poly i:c was added to each well. cell viabilities were determined at different time points ( , , and h) by performing mtt assays. the viability of cells in each well was measured in terms of the optical density at a wavelength of nm, using a glomax ® microplate reader (promega, wi, usa). six-week-old balb/c mice were purchased from daehan biolink co. (seoul, korea). the mice were quarantined and acclimated for week before initiating the study after evaluating their health status. mice were housed at the catholic university of korea under specific-pathogen-free conditions with a -h light/dark cycle, a temperature of ± • c, and a relative humidity of % ± %. the animals were handled according to protocols approved by the catholic university of korea ( june ). the animal facility at the catholic university of korea is fully accredited by the korean association for laboratory animals. all mice experimental procedures conducted in this study followed the guidelines of the institutional animal care and use committee of the catholic university of korea (approval no. cuk-iacuc- - and cuk-iacuc- - ). the experimental design for the toxicity assessments followed the guideline on the nonclinical evaluation of biopharmaceuticals from the ministry of food and drug safety [ ] . to evaluate the toxicity of the ssrna nano-structure adjuvant, mice ( -week-old) were randomly distributed into six groups ( male and female mice in each group). in this study, we used both sexes in compliance with the guidelines [ ] . a protein-based vaccine candidate is middle east respiratory syndrome coronavirus (mers-cov) spike (s) protein, which was expressed in insect cells [ ] . this mers s protein was obtained from the international vaccine institute (seoul, korea). the six groups involved in this study were treated as follows: group (g ), pbs-control group; group (g ), µg/mouse of mers s protein; group (g ), µg/mouse of ssrna nano-structure adjuvant; group (g ), µg/mouse of mers s protein and µg/mouse of ssrna nano-structure adjuvant as the low-dose group; group (g ), µg/mouse of mers s protein and µg/mouse of ssrna nano-structure adjuvant as the high-dose group; group (g ), µg/mouse of mers s protein and µg/mouse of ssrna nano-structure adjuvant as the recovery group. animals were intramuscularly immunized three times in a volume of µl every weeks, and blood was collected on the day before every immunization. groups - were sacrificed day after the last immunization. also, we investigated group recovery for another weeks after the last immunization to assess long-lasting, delayed, or reversible toxic effects according to the guideline [ ] . the protein and ssrna doses used for immunization were the same or lower than those used in previous studies [ , [ ] [ ] [ ] . the group design and immunization schedules are shown in figure . immunization. groups - were sacrificed day after the last immunization. also, we investigated group recovery for another weeks after the last immunization to assess long-lasting, delayed, or reversible toxic effects according to the guideline [ ] . the protein and ssrna doses used for immunization were the same or lower than those used in previous studies [ , [ ] [ ] [ ] . the group design and immunization schedules are shown in figure . in separate in vivo experiments conducted to analyze immunological responses, the same groups aforementioned were designed (five female mice in each group), but group was immunized weeks earlier than the other groups so that all mice were sacrificed on the same day. the mice in groups - were sacrificed day after the last immunization, and those in group were sacrificed weeks after the last immunization. as a positive control for ige analysis, eight female mice were administered % , -dinitrochlorobenzene (dncb) every other day for weeks and sacrificed at weeks after the last treatment. dncb was dissolved in a : mixture of acetone and olive oil. the hair of all animals was removed the day before dncb was applied to their backs, using a dose of μl/mouse [ ] . animals were monitored for body weight and food intake every week. at the end of the study, the mice were anesthetized with isoflurane ( - %). blood samples were obtained from the abdominal aorta, and the mice were sacrificed. one mouse in group died one day before the first immunization, for unknown reasons. blood samples were collected in tubes containing the anticoagulant, ethylenediaminetetraacetic acid. the following hematological parameters were measured with a procyte dx hematology analyzer (idexx, me, usa): total erythrocyte count (rbc), hemoglobin concentration (hgb), hematocrit (hct), mean cell volume (mcv), mean cell hemoglobin (mch), mean cell hemoglobin concentration (mchc), platelet (plt), total leucocyte count (wbc), and differential wbc (neutrophils, lymphocytes, monocytes, eosinophils, and basophils). serum samples were obtained by centrifuging blood samples at × g for min. the following biochemistry parameters were measured with a mindray bs- chemical analyzer (mindray, shenzhen, china): alanine aminotransferase (alt), aspartate aminotransferase (ast), total cholesterol (t-chol), triglycerides (tg), glucose, high density lipoprotein cholesterol (hdl), low density lipoprotein cholesterol (ldl), blood urea nitrogen (bun), creatinine, total protein (tp), albumin, and the albumin-to-globulin ratio (a/g). in separate in vivo experiments conducted to analyze immunological responses, the same groups aforementioned were designed (five female mice in each group), but group was immunized weeks earlier than the other groups so that all mice were sacrificed on the same day. the mice in groups - were sacrificed day after the last immunization, and those in group were sacrificed weeks after the last immunization. as a positive control for ige analysis, eight female mice were administered % , -dinitrochlorobenzene (dncb) every other day for weeks and sacrificed at weeks after the last treatment. dncb was dissolved in a : mixture of acetone and olive oil. the hair of all animals was removed the day before dncb was applied to their backs, using a dose of µl/mouse [ ] . animals were monitored for body weight and food intake every week. at the end of the study, the mice were anesthetized with isoflurane ( - %). blood samples were obtained from the abdominal aorta, and the mice were sacrificed. one mouse in group died one day before the first immunization, for unknown reasons. blood samples were collected in tubes containing the anticoagulant, ethylenediaminetetraacetic acid. the following hematological parameters were measured with a procyte dx hematology analyzer (idexx, me, usa): total erythrocyte count (rbc), hemoglobin concentration (hgb), hematocrit (hct), mean cell volume (mcv), mean cell hemoglobin (mch), mean cell hemoglobin concentration (mchc), platelet (plt), total leucocyte count (wbc), and differential wbc (neutrophils, lymphocytes, monocytes, eosinophils, and basophils). serum samples were obtained by centrifuging blood samples at × g for min. the following biochemistry parameters were measured with a mindray bs- chemical analyzer (mindray, shenzhen, china): alanine aminotransferase (alt), aspartate aminotransferase (ast), total cholesterol (t-chol), triglycerides (tg), glucose, high density lipoprotein cholesterol (hdl), low density lipoprotein cholesterol (ldl), blood urea nitrogen (bun), creatinine, total protein (tp), albumin, and the albumin-to-globulin ratio (a/g). immediately after the mice were sacrificed, several organs (liver, kidney, spleen, thymus, lung, heart, lymph node, muscle, brain, testis) were removed from the mice, examined macroscopically, and weighed. the organ weights relative to the terminal body weight were then calculated. the organs were fixed in % neutral buffered formalin for histopathological examination. the testis was fixed in bouin's solution. the fixed organs were processed for paraffin embedding. paraffin sections were stained with hematoxylin and eosin (h + e). the microscopic features of the organs from mice in the control (g ) and high-dose groups (g ) were examined by an experienced pathologist, under a light microscope (leica, hamburg, germany). serum samples were prepared by centrifugation ( × g, min) from the last collected blood sample of each group and stored at − • c. the levels of total serum ige were measured using a mouse enzyme-linked immunosorbent assay kit (bethyl laboratory, inc., tx, usa). each step was performed according to the manufacturer's instructions. ige concentrations were determined based on the absorbance at nm, as detected with a glomax ® microplate reader (promega, wi, usa). serum samples were prepared by centrifugation ( × g, min) from the last collected blood sample of each group and stored at − • c. the levels of anti-nuclear antibodies were measured using a mouse anti-nuclear antibody igg elisa kit (mybiosource, inc., ca, usa). each step was performed according to the manufacturer's instructions. serum samples were prepared by centrifugation ( × g, min) from the last collected blood sample of each group and stored at − • c. the concentrations of il- β, il- , il- , il- p , tnf-α, and mcp- were analyzed in each sample, using the magnetic luminex ® screening assay kit (r&d systems, inc., mn, usa) in accordance with the manufacturer's instructions. for surface staining, splenocytes and isolated immune cells from spleen, muscle, and lymph node tissues were stained for min at room temperature with antibodies against the following proteins: cd (clone gk . , ebioscience; clone h . , biolegend, ca, usa), cd (clone - . , bd biosciences; clone - . , invitrogen, ca, usa), cd (clone im , invitrogen), cd l (clone mel , bd biosciences), cd b (clone m / , bio legend), f / (clone bm , invitrogen), cd (clone gl , bd biosciences), and cd c (clone n , ebioscience). cells were fixed with % paraformaldehyde, analyzed using a facs canto ii flow cytometer (bd biosciences, nj, usa), and the data were analyzed using flowjo software (treestar, or, usa). one-way analysis of variance was used to assess significant differences among the treatment groups. for each significant effect identified, tukey's honestly significant difference test and bonferroni were used to compare multiple group means. in addition, all histomorphometric values are expressed as means ± standard deviations (sd). multiple-comparison tests for the different treatment groups were conducted. if significant deviations from variance homogeneity were detected using the levene test, then the non-parametric kruskal-wallis h-test was conducted. when a significant difference was detected by the kruskal-wallis h-test, a mann-whitney u-test was conducted as a post-hoc analysis. statistical analyses were conducted using spss for windows (release . k, spss inc., il, pharmaceutics , , of usa). to assess significant differences between two groups, student's t-test was used. differences were considered significant at p < . . to investigate the toxicity of the ssrna nano-structure adjuvant, we measured the viabilities of treated hepg and a cells, which are liver-and lung-derived tumor cell lines, respectively, [ , ] as well as hs , which is a human skin-derived normal cell line [ ] in mtt assays. previously, we injected mice with µg of ssrna nano-structure adjuvant to increase immune responses [ ] . based on this concentration, we treated the cells with various concentrations of the ssrna nano-structure adjuvant ( - µg/well) for , , or h. the ssrna did not affect cell viability at any concentration tested in tumor cell lines ( figure s a ,b) and normal human cell lines ( figure ). however, poly i:c as positive control showed some toxicity in the normal cell line ( figure ). furthermore, poly i:c induced higher pro-inflammatory cytokines than those of ssrna nano-structure adjuvant in raw . cells, which are a mouse macrophage cell line ( figure s , detailed in supplementary methods), indicating poly i:c may stimulate a stronger inflammation response compared to that of the ssrna nano-structure adjuvant. pharmaceutics , , x for peer review of to investigate the toxicity of the ssrna nano-structure adjuvant, we measured the viabilities of treated hepg and a cells, which are liver-and lung-derived tumor cell lines, respectively, [ , ] as well as hs , which is a human skin-derived normal cell line [ ] in mtt assays. previously, we injected mice with μg of ssrna nano-structure adjuvant to increase immune responses [ ] . based on this concentration, we treated the cells with various concentrations of the ssrna nano-structure adjuvant ( - μg/well) for , , or h. the ssrna did not affect cell viability at any concentration tested in tumor cell lines ( figure s a ,b) and normal human cell lines ( figure ). however, poly i:c as positive control showed some toxicity in the normal cell line ( figure ). furthermore, poly i:c induced higher pro-inflammatory cytokines than those of ssrna nanostructure adjuvant in raw . cells, which are a mouse macrophage cell line ( figure s , detailed in supplementary methods), indicating poly i:c may stimulate a stronger inflammation response compared to that of the ssrna nano-structure adjuvant. we designed an in vivo toxicity test, based on the protocol shown in figure (described in detail in the materials and methods section). after injecting the ssrna nano-structure adjuvant and/or mers s protein, we observed the behavior and symptoms of the treated mice. no specific problems were found in the injected male and female mice compared with healthy control (g ) group (data not shown). the external body weight ( figure a ) and food intake ( figure b ) were measured as critical toxic signs in experimental animals every week, following receipt of the animals. no significant changes were found in the weights and h food intake of the male and female mice among all groups. therefore, no animals administered ssrna nano-structure adjuvant formulated with the mers s protein (even with a high ssrna concentration of μg/mouse) showed any specific toxic symptoms. we designed an in vivo toxicity test, based on the protocol shown in figure (described in detail in the materials and methods section). after injecting the ssrna nano-structure adjuvant and/or mers s protein, we observed the behavior and symptoms of the treated mice. no specific problems were found in the injected male and female mice compared with healthy control (g ) group (data not shown). the external body weight ( figure a ) and food intake ( figure b ) were measured as critical toxic signs in experimental animals every week, following receipt of the animals. no significant changes were found in the weights and h food intake of the male and female mice among all groups. therefore, no animals administered ssrna nano-structure adjuvant formulated with the mers s protein (even with a high ssrna concentration of µg/mouse) showed any specific toxic symptoms. hematological results, including hematopoiesis-and leukopoiesis-associated parameters, are summarized in table . statistically significant changes in the hematological data (e.g., hgb, hct, mcv, mch, mchc, and wbc) in the males and females were of small magnitude within acceptable ranges [ , ] . therefore, these differences were not considered to be related to toxicity of the ssrna nano-structure adjuvant. wbc differential showed that percentages of neutrophils were significantly decreased in g of males and females in comparison with those in g . male mice in g showed significant increase in the percentage of lymphocytes relative to the control value (g ). the percentages of monocytes and eosinophils were significantly increased in g of males, but these returned to normal levels in g . no significant treatment-related changes were found with the other parameters tested in the males and females of groups treated with the ssrna nano-structure adjuvant. hematological results, including hematopoiesis-and leukopoiesis-associated parameters, are summarized in table . statistically significant changes in the hematological data (e.g., hgb, hct, mcv, mch, mchc, and wbc) in the males and females were of small magnitude within acceptable ranges [ , ] . therefore, these differences were not considered to be related to toxicity of the ssrna nano-structure adjuvant. wbc differential showed that percentages of neutrophils were significantly decreased in g of males and females in comparison with those in g . male mice in g showed significant increase in the percentage of lymphocytes relative to the control value (g ). the percentages of monocytes and eosinophils were significantly increased in g of males, but these returned to normal levels in g . no significant treatment-related changes were found with the other parameters tested in the males and females of groups treated with the ssrna nano-structure adjuvant. the serum biochemistry results are summarized in table . serum biochemical analysis revealed that ast levels were significantly decreased of males in g compared to those in g . bun levels were significantly decreased in g of males but increased in g and g of females in comparison with those in g . creatinine levels in g were lower compared to those in g in both sexes. small but significant changes in tp, albumin, a/g ratio, glucose, and ldl were observed only in one sex. hdl levels were high in male mice and low in female mice of group g , which were considered to reflect transient changes and not a concentration-dependent phenomenon. tg levels were significantly changed in both males and females compared to those of respective control groups. the data for absolute and relative organ weights are summarized in tables and . absolute liver weights of males in g and females in g and g were significantly higher than those of their respective control groups. relative liver weights were significantly decreased in males of g but increased in females of g and g in comparison with those in the respective control groups. absolute and relative spleen weights of males in g and females in g were significantly higher compared to those of g . absolute lung weights in females of g and g were higher compared to those in g . furthermore, relative lung weights were significantly decreased in males of g but increased in females of g in comparison with those in g . meanwhile, kidney weights in males of g and females of g , g , and g were higher than those of g . additionally, small and sporadic weight changes in brain, heart, and testis were found in males, and no significant weight changes in these organs were found in females. interestingly, absolute and relative thymus weights of males in g , g , g , and g were significantly lower compared to those of respective control groups, whereas no significant differences were found in the thymus weight among groups in females. although these findings were regarded as toxicologically irrelevant because of the lack of remarkable histopathological correlation, further study is necessary to confirm them and to understand the mechanisms underlying the sex-related differences in thymus weight. not only the liver, which is a typical organ studied to assess toxicity, but also the lungs, kidneys, injection sites, and immune-related organs (spleen and thymus) were stained with h + e to observe local and systemic toxicity, including cellular damage and inflammatory cell infiltration, associated with the ssrna nano-structure adjuvant (figure ). in both males and females, no significant dose-related damages in the liver and lung were apparent in the high-dose group (g , µg mers s protein and µg ssrna adjuvant) compared with g . renal involvement is relatively common in autoimmune diseases [ ] . in this study, we did not observe any histological changes involved in the kidney damage in both sexes. the intramuscular-injection sites were also regular in appearance. importantly, the thymus and spleen (which serve as immunological organs) did not show any treatment-related toxicity. the data shown are expressed as the mean ± sd. *p < . , relative to group . not only the liver, which is a typical organ studied to assess toxicity, but also the lungs, kidneys, injection sites, and immune-related organs (spleen and thymus) were stained with h + e to observe local and systemic toxicity, including cellular damage and inflammatory cell infiltration, associated with the ssrna nano-structure adjuvant (figure ). in both males and females, no significant doserelated damages in the liver and lung were apparent in the high-dose group (g , μg mers s protein and μg ssrna adjuvant) compared with g . renal involvement is relatively common in autoimmune diseases [ ] . in this study, we did not observe any histological changes involved in the kidney damage in both sexes. the intramuscular-injection sites were also regular in appearance. importantly, the thymus and spleen (which serve as immunological organs) did not show any treatment-related toxicity. to identify the involvement of the ssrna nano-structure adjuvant in autoimmunity, serum levels of ige [ ] and anti-nuclear antibodies [ , ] were measured in mice after immunization with the ssrna nano-structure adjuvant. serum ige antibodies in mice were examined using a mouse ige elisa kit ( figure a ). as a positive control group, dncb was used to induce allergy in mice [ ] . as a result, robust ige antibody production was not detected in any group, except for the dncb group. the serum concentrations of anti-nuclear antibodies in treated mice were also examined using an anti-nuclear antibody igg elisa kit. no significant inductions in anti-nuclear antibody production were observed in groups (g -g ) treated with the ssrna nano-structure adjuvant compared with the pbs-treated control group (g ; figure b ). associated with the ssrna nano-structure adjuvant. the pictures show almost the same morphology among control (g ) and high-dose group (g ) in both male and female. g , pbs-control group; g , μg mers s protein and μg ssrna adjuvant. to identify the involvement of the ssrna nano-structure adjuvant in autoimmunity, serum levels of ige [ ] and anti-nuclear antibodies [ , ] were measured in mice after immunization with the ssrna nano-structure adjuvant. serum ige antibodies in mice were examined using a mouse ige elisa kit ( figure a ). as a positive control group, dncb was used to induce allergy in mice [ ] . as a result, robust ige antibody production was not detected in any group, except for the dncb group. the serum concentrations of anti-nuclear antibodies in treated mice were also examined using an anti-nuclear antibody igg elisa kit. no significant inductions in anti-nuclear antibody production were observed in groups (g -g ) treated with the ssrna nano-structure adjuvant compared with the pbs-treated control group (g ; figure b ). we further measured the levels of inflammation-associated cytokines, such as mcp- , tnf-α, il- β, il- , il p , and il- [ ] . no significant differences were found in the levels of the proinflammatory cytokines mcp- , tnf-α, il- β, il- , and il p in any groups examined in this study ( figure s a-e) . interestingly, production of the anti-inflammatory cytokine il- [ ] was slightly higher in the ssrna-treated group (g -g ) than in the other groups ( figure ). however, the il- levels in the recovery group (g ), which were sacrificed two weeks later, had decreased to comparable levels found in g . we further measured the levels of inflammation-associated cytokines, such as mcp- , tnf-α, il- β, il- , il p , and il- [ ] . no significant differences were found in the levels of the pro-inflammatory cytokines mcp- , tnf-α, il- β, il- , and il p in any groups examined in this study ( figure s a-e) . interestingly, production of the anti-inflammatory cytokine il- [ ] was slightly higher in the ssrna-treated group (g -g ) than in the other groups ( figure ). however, the il- levels in the recovery group (g ), which were sacrificed two weeks later, had decreased to comparable levels found in g . to assess immune cell activation by the ssrna nano-structure adjuvant, flow cytometric analysis was performed using splenocytes from immunized mice. cd hi /cd l lo cd t cells and cd hi /cd l lo cd t cells indicate effector memory t cells, which can rapidly differentiate into effector t cells after re-exposure to the antigen [ ] . the splenocytes did not show any statistically significant differences in cd and cd t cells between any group ( figure a,b) . the slightly higher cd t cell frequency in g versus the other groups suggested that the mice were primed for the next antigen exposure. in contrast, the ssrna nano-structure adjuvant appeared to activate apcs, including dcs and macrophages ( figure c,d) . to assess immune cell activation by the ssrna nano-structure adjuvant, flow cytometric analysis was performed using splenocytes from immunized mice. cd hi /cd l lo cd t cells and cd hi /cd l lo cd t cells indicate effector memory t cells, which can rapidly differentiate into effector t cells after re-exposure to the antigen [ ] . the splenocytes did not show any statistically significant differences in cd and cd t cells between any group ( figure a,b) . the slightly higher cd t cell frequency in g versus the other groups suggested that the mice were primed for the next antigen exposure. in contrast, the ssrna nano-structure adjuvant appeared to activate apcs, including dcs and macrophages ( figure c ,d). to assess immune cell activation by the ssrna nano-structure adjuvant, flow cytometric analysis was performed using splenocytes from immunized mice. cd hi /cd l lo cd t cells and cd hi /cd l lo cd t cells indicate effector memory t cells, which can rapidly differentiate into effector t cells after re-exposure to the antigen [ ] . the splenocytes did not show any statistically significant differences in cd and cd t cells between any group ( figure a ,b). the slightly higher cd t cell frequency in g versus the other groups suggested that the mice were primed for the next antigen exposure. in contrast, the ssrna nano-structure adjuvant appeared to activate apcs, including dcs and macrophages ( figure c ,d). recently, we developed an ssrna nano-structure adjuvant using crpv igr ires-derived rna and found its function as an immune stimulator [ , ] in that, it stimulated a balanced th and th response with mers s protein. moreover, ssrna nano-structure adjuvant showed a synergistic effect with alum to increase humoral and cellular immune responses [ ] . although alum is popularly used as an adjuvant for human clinical vaccines, it usually induces a profound th response (humoral immune response) along with producing antibody, whereas it cannot stimulate th response (cellular immune response) and sometimes triggers autoimmune response [ , ] . these previous results proved that crpv igr ires-derived ssrna nano-structure adjuvant could function as an ideal vaccine adjuvant to support the weakness of alum. nonetheless, its safety has not been well investigated yet. therefore, the objective of the present study was to perform a comprehensive investigation for the general toxicity profile and immunological-toxicity results on the ssrna nano-structure adjuvant. for an in vitro cytotoxicity study, we used liver-and lung-derived cell lines to test toxicity because they represent target organs and portals of entry for toxicants and because the liver is a detoxification site [ , ] . moreover, we also used human normal cell lines to test toxicity because of the toxin resistance of tumor cell lines. as a result, the ssrna nano-structure adjuvant did not elicit cellular toxicity in all tested cell lines, even with increasing ssrna concentrations of up to -fold higher than we used to increase immune responses previously ( µg/mouse) [ ] . to overcome the limitation of the in vitro study, we confirmed the general toxicity and immunological toxicity of ssrna nano-structure adjuvant in vivo. our data indicate that the ssrna nano-structure adjuvant formulated with the mers s protein did not cause any treatment-related significant alteration in clinical condition, growth, or food intake. since a broad range of toxic injuries beginning with indolent, often asymptomatic, features can progress to organ failure [ ] , we additionally performed hematological and histological tests to indicate systemic adverse effects of the test materials. following necropsy, the hematological analysis showed that the decrease of neutrophils and the increase of lymphocytes seen in the recovery group of both males and females seemed to be a typical immune response, reflecting an increase of b cells and t cells because these are typical vaccine immunization-derived responses [ ] [ ] [ ] . in other hematological parameters, all treatment groups showed no significant changes within physiologically normal ranges. it indicates that the ssrna nano-structure adjuvant did not affect hematopoiesis and leukopoiesis. in addition, no dose-related significant changes were observed in all serum biochemical parameters tested. no noticeable increases in alt and ast levels, which are representative of liver toxicity [ ] , were found among the groups in both males and females. bun and creatinine levels, which are related to renal function [ ] , showed little changes in both sexes. a significant difference in a fatty liver marker tg [ ] was not considered to be related to its toxicity because this observed change was within acceptable ranges [ , ] . the changes in other markers were sporadic with no concentration-dependency, so these were not considered to reflect toxic changes due to the ssrna nano-structure adjuvant. importantly, organ weights and histological examinations of major organs such as liver, kidney, lung, spleen, thymus, and intramuscular-injection site did not cause any toxicologically significant changes involved in treatment of the ssrna nano-structure adjuvant. collectively, in contrast to poly i:c, which causes severe damage to the kidney and spleen [ ] , the ssrna nano-structure adjuvant did not induce any organ injury in both males and females. alum, a commonly used adjuvant in the clinical vaccine field, sometimes induces high ige levels, which are associated with macrophagic myofascitis, granuloma formation, and allergic reactions [ , ] . ige is also highly elevated in systemic lupus erythematosus and other autoimmune diseases [ ] . also, anti-nuclear antibodies recognize the self as non-self and can bind the nucleus of one's own cells, unlike conventional antibodies that bind foreign antigens, such as viral or bacterial antigens [ ] . most vertebrates commonly express anti-nuclear antibodies at very low levels [ , ] whereas a relatively high concentration of anti-nuclear antibodies indicates the induction of autoimmune disease [ , ] . in this study, the ssrna nano-structure adjuvant caused no significant inductions in serum ige and anti-nuclear antibodies, indicating that the ssrna nano-structure adjuvant did not pose a risk for autoimmunity. inflammation-associated cytokines include mcp- , tnf-α, il- β, il- , il p , and il- [ ] . mcp- , which is monocyte chemoattractant protein- , recruit monocytes during infection to induce inflammation [ ] . tnf-α induces inflammation and activates lymphocytes and leukocytes [ ] . il- β is produced by monocytes and macrophages and plays an important role in inflammatory regulation [ ] . il- promotes the synthesis of acute-phase proteins, such as crp, and is produced at the site of inflammation [ ] . overexpression of these pro-inflammatory cytokines may cause excessive inflammation or autoimmune diseases [ ] . in this study, there were no statistically significant differences in the levels of the pro-inflammatory cytokines mcp- , tnf-α, il- β, and il- among groups. in particular, the levels of il- , which has been associated with autoimmunity [ ] , were not higher in the ssrna-treated group than in the pbs-treated group ( figure s e ), supporting the possibility that the ssrna nano-structure adjuvant did not induce autoimmunity, consistent with the data on serum levels of ige and anti-nuclear antibodies shown in figure . interestingly, il- levels of ssrna nano-structure adjuvant groups (g to g ) compared with g as a control group and g as a recovery group was slightly increased ( figure ). it may be counteracted to the induction of proinflammatory cytokines, regardless of no significant increases at day after ssrna treatment. however, we need further study to reveal the complicated relationship between pro-and anti-inflammatory cytokines after treatment of ssrna non-structure adjuvant. taken together, not only were no significant differences found in pro-inflammatory cytokine levels among the groups, but also the il- levels returned to normal levels in the recovery group. these indicate that the ssrna nano-structure adjuvant had no immunological toxicity. no statistically significant differences in cd and cd t cells were found in the splenocytes between any group. in contrast, as has been observed with other adjuvants [ ] , the dc frequencies of the ssrna nano-structure adjuvant-treated groups were higher than those in the control in the spleen, at least partly through the association with higher neutrophil levels in the hematological analysis in vivo toxicity study ( table ). the increased dc activations found only in the g -g compared with g as control group ( figure c ) were accordance with previous data [ ] , which showed that ssrna nano-structure adjuvant transiently triggered dc activation in the injected site. this may have been caused by sacrificing the mice on the first day after the last immunization because dc activation is an early event after vaccine injection [ , ] . the frequencies of dcs in the recovery group returned to levels found in the control group ( figure c ). since a short immune duration was observed without toxicological differences in organ weights or histopathology, it is considered that our ssrna nano-structure adjuvant did not elicit immunological toxicity. moreover, in draining lymph nodes, no significant difference occurred between groups in terms of both dcs and macrophages (data not shown). these data indicated that our ssrna nano-structure adjuvant performed successfully as safe adjuvant. previously, the ssrna nano-structure adjuvant tested in this study was shown to effectively elicit immune enhancement in mice and non-human primates, based on balanced th and th responses [ , ] . in this study, we showed that the adjuvant did not cause weight loss or abnormal behavior in mice after immunization, even at high doses. moreover, it did not increase any hematological and biochemical parameters and did not change the histopathological patterns compared with the control group. in addition, the ssrna nano-structure adjuvant did not promote sustained pro-inflammatory cytokines and excess immune cell activation for a long time, as these indicators quickly disappeared after immunization. instead, our results appeared to reflect an effective 'hit-and-run' strategy for stimulating immune responses. therefore, the ssrna nano-structure can function as a safe adjuvant with high vaccine efficacy. the following are available online at http://www.mdpi.com/ - / / / /s , figure s : brief structure of crpv igr ires-derived ssrna nano-structure adjuvant. figure s : dose-dependent cell viabilities of various cell lines treated with the ssrna nano-structure adjuvant, using mtt assays. relative viabilities of (a) a cells and (b) hepg cells were compared to negative control ( concentration of ssrna nano-structure adjuvant) from h to h, based on the ssrna concentration. figure s : pro-inflammatory cytokine induction in raw . cells after treatment with poly i:c and ssrna nano-structure adjuvant. supplementary method: real-time pcr for proinflammatory cytokine in raw . cells after treatment with poly i:c and ssrna nano-structure adjuvant. figure s : serum levels of mcp- , tnf-α, il- β, il- , and il p . sera from mice in groups - were collected day after the last immunization, and sera from mice in group were collected weeks after the last immunization. vaccines against dangerous pathogens nanoparticle vaccines against infectious diseases immunological mechanisms of vaccination old and new adjuvants vaccine adjuvants: why and how. hum vaccines immunother correlates of adjuvanticity: a review on adjuvants in licensed vaccines peptide-based vaccines use of defined tlr ligands as adjuvants within human vaccines from to and beyond. vaccines alum adjuvant: some of the tricks of the oldest adjuvant advances in aluminum hydroxide-based adjuvant research and its mechanism. hum vaccines immunother oil-in-water emulsion mf increases germinal center b cell differentiation and persistence in response to vaccination autoimmune/ inflammatory syndrome induced by adjuvants (asia) : unveiling the pathogenic, clinical and diagnostic aspects the endogenous adjuvant squalene can induce a chronic t-cell-mediated arthritis in rats induction of lupus autoantibodies by adjuvants toll-like receptors control activation of adaptive immune responses modulating th /th responses with microbes, dendritic cells, and pathogen recognition receptors tlr and tlr ligands regulate antigen presentation by macrophages tlr-based immune adjuvants enhanced resistance of mice to virulent japanese b encephalitis virus following inactivated vaccine and poly i:c particulate formulations for the delivery of poly(i:c) as vaccine adjuvant phase i-ii trials of poly ic stabilized with poly-l-lysine intranasal poly-ic treatment exacerbates tuberculosis in mice through the pulmonary recruitment of a pathogen-permissive monocyte/macrophage population viral double-stranded rna aggravates lupus nephritis through toll-like receptor on glomerular mesangial cells and antigen-presenting cells length of dsrna (poly i:c) drives distinct innate immune responses, depending on the cell type innate antiviral responses by means of tlr -mediated recognition of single-stranded rna a new rna-based adjuvant enhances virus-specific vaccine responses by locally triggering tlr-and rlh-dependent effects double stranded rna in human seminal plasma structure, stability and specificity of the binding of ssdna and ssrna with proteins toll-like receptor-dependent activation of several human blood cell types by protaminecondensed mrna messenger rna-based vaccines with dual activity induce balanced tlr- dependent adaptive immune responses and provide antitumor activity fotin-mleczek, m. a novel, disruptive vaccination technology: self-adjuvanted rnactive( ® ) vaccines. hum. vaccines immunother rna-based adjuvant cv enhances the immunogenicity of a licensed rabies vaccine in a first-in-human trial post-pegylated and crosslinked polymeric ssrna nanocomplexes as adjuvants targeting lymph nodes with increased cytolytic t cell inducing properties adjuvant effects of a sequence-engineered mrna vaccine: translational profiling demonstrates similar human and murine innate response a novel rna-based adjuvant combines strong immunostimulatory capacities with a favorable safety profile development of an rna expression platform controlled by viral internal ribosome entry sites application of rna transcribed from viral internal ribosome entry site control as an adjuvant: utilization of vaccine development for middle east respiratory syndrome coronavirus cricket paralysis virus internal ribosome entry site-derived rna promotes conventional vaccine efficacy by enhancing a balanced th /th response cricket paralysis virus internal ribosome entry site-derived rna for humoral immunity to middle east respiratory syndrome coronavirus spike protein in non-human primate guideline on nonclinical evaluation of biopharmaceuticals. available online evaluation of recombinant multi-epitope outer membrane protein-based klebsiella pneumoniae subunit vaccine in mouse model targeting poly(i:c) to the tlr -independent pathway boosts effector cd t cell differentiation through ifnα/β optimisation of prime-boost immunization in mice using novel protein-based and recombinant vaccinia (tiantan)-based hbv vaccine a novel mouse model of atopic dermatitis that is t helper (th )-polarized by an epicutaneous allergen cell line a : a model system for the study of alveolar type ii cell function use of hepg cell line for evaluation of toxic and metabolic antipsychotic action -kda microspherule protein (msp ) is novel brahma-related gene (brg )-associated protein that modulates p /p senescence pathway hematological and biochemical reference values for c bl/ , swiss webster and balb/c mice hematological and serum biochemical values in specific pathogen-free balb/c and c bl/ mice kidney damage in autoimmune diseases role of ige in autoimmunity antinuclear antibodies defining autoimmunity pathways american college of rheumatology ad hoc committee on immunologic testing guidelines. evidence-based guidelines for the use of immunologic tests; antinuclear antibody testing the clinical importance of a cytokine network in the acute phase of sepsis role of interleukin transcriptional regulation in inflammation and autoimmune disease memory, and dysfunctional cd + t cell fates in the antitumor immune response a lung/liver-on-a-chip platform for acute and chronic toxicity studies detoxification pathways in the liver comparative analysis of experimental mouse model for blood hematology and chemistry efficacy and safety of immunological adjuvants. where is the cut-off? recent advances on the crosstalk between neutrophils and b or t lymphocytes fundamentals of vaccine immunology comparative levels of alt, ast, alp and ggt in liver associated diseases overview of urea and creatinine triglyceride is strongly associated with nonalcoholic fatty liver disease among markers of hyperlipidemia and diabetes acute toxicity evaluation of ethanol extract of red algae, osmundaria obtusiloba, in balb/c mice adjuvant activity of alum in inducing antigen specific ige antibodies in balb/c mice: a reevaluation antinucler antibodies: marker of diagnosis and evolution in autoimmune diseases antinuclear antibodies in healthy people and non-rheumatic diseases-diagnostic and clinical implications chemoattractant with a role beyond immunity: a review signal transduction by tumor necrosis factor and its relatives different regulation of interleukin- production and activity in monocytes and macrophages: innate memory as an endogenous mechanism of il- inhibition rethinking il- and crp: why they are more than inflammatory biomarkers, and why it matters cytokines in autoimmunity: role in induction, regulation, and treatment il- ) family cytokines-role in immune pathogenesis and treatment of cns autoimmune disease mechanisms of action of adjuvants tailoring inorganic nanoadjuvants towards next-generation vaccines this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflict of interest. key: cord- - x deimg authors: xu, jing-xiu; zhang, cong; cao, chang-yu; zhu, shi-yong; li, hui; sun, yan-chun; li, jin-long title: dietary selenium status regulates the transcriptions of selenoproteome and activities of selenoenzymes in chicken kidney at low or super-nutritional levels date: - - journal: biol trace elem res doi: . /s - - - sha: doc_id: cord_uid: x deimg to determine dietary selenium (se) status regulates the transcriptions of selenoproteome and activities of selenoenzymes in chicken kidney, -day-old chickens received low se ( . mg se per kg of diet) or super-nutritional se ( . or . mg se per kg of diet) in their diets for weeks. it was observed that dietary low or super-nutritional se did not make renal appearance pathological changes in chicken. low se significantly reduced total antioxidant capability (t-aoc), glutathione (gsh) content, but malondialdehyde (mda) content in the kidney increased and decreased glutathione peroxidase (gpx) and thioredoxin reductase (trxr) activity with changes in their mrna levels. super-nutritional se ( . mg/kg) increased t-aoc and gsh contents then made them reduce, but it reduced mda content significantly, elevated then reduced gpx activity, and decreased trxr activity with changes in their mrna levels. dietary low se downregulated the mrna expressions of gpx - , txnrd , sepn , selw, sepx , selh, and sepsecs. at super-nutritional se, most selenoproteins were upregulated in chicken kidney, but sepp and sep was only upregulated in se excess ( . mg/kg) bird. these results indicated that dietary se status stabilizes normal renal physiology function via regulation of the selenoprotemic transcriptions and selenoenzyme activities in avian. electronic supplementary material: the online version of this article (doi: . /s - - - ) contains supplementary material, which is available to authorized users. selenium (se) is an obligatory nutritional trace element and participates in many aspects of health such as chemoprevention, neurobiology [ , ] , immune function [ , ] , reproduction [ ] , aging [ ] , carcinogenesis [ ] , and muscle metabolism [ , ] . poultry is sensitive to se content of diet [ ] . se deficiency manifested as deformation and necrosis [ ] in sheep, cattle, horses, and chickens [ ] . the kidney can be ruled out as a product of metabolism in the organism and maintain electrolyte balance. it could also be influenced by se deficiency or excess, such as predominant pathological changes were convoluted tubule necroses. concentration of free se is the greatest in the renal cortex [ ] . se could protect the renal antioxidant function from oxidative damage [ ] , and se deficiency or excess causes a lot of selenoprotein resultant metabolic disorders in pig kidney [ ] . evidence of cellular damage (i.e., histopathologic and physiologic, including oxidative stress) was found in kidney systems of young snowy egrets [ ] . se can protect against oxidative damage which leads to the overproduction of free radicals that exert deleterious effects on the kidney [ ] . se is regulated in the body to maintain vital selenoproteins and to avoid toxicity, and it exerts its biological effects mainly through its direct incorporation into selenoproteins as the amino acid, selenocysteine (sec) [ ] ( fig. s a) . the mrna for a selenoprotein has two distinctive properties: uga in the open reading frame (orf) and a specialized stem-loop structure in the ′ untranslated region ( 'utr) . the stem-loop structure is known as a selenocysteine insertion sequence (secis) element [ ] .three unique trans-acting factors are vital for selenoprotein synthesis. trna[ser]sec has the anticodon for uga. it is initially charged with serine, which is then phosphorylated by o-phosphoseryl-trna[ser]sec kinase [ ] . the phosphoserine attached to trna[ser]sec is converted to selenocysteine by selenocysteine synthase, using monoselenophosphate as the se donor [ ] . selenocysteyl-trna[ser]sec binds to another vital trans-acting factor, the specific elongation factor efsec [ ] . efsec binds to the third vital trans-acting factor, secis-binding protein (sbp ). in addition to binding efsec, sbp has binding si tes for the secis element and t he ribosome. selenoproteins play an important role in the kidney function. there are intriguing relationships between se physiology and several derangements associated with acute and chronic kidney disease. selenoproteins and selenoenzyme can protect the normal function of the kidney [ ] . however, effects of dietary se on selenoproteome in chicken kidney are yet unclear. selenoproteome is a set of selenoproteins in eukaryotes and prokaryotes. avian selenoproteome consists of selenoproteins. several selenoproteins have been characterized as antioxidant enzymes, serving to alleviate damage caused by reactive oxygen species (ros) [ ] . some antioxidant enzymes contain se called selenoenzymes; the most important metabolic roles of se in cells are due to its function in the active site of these enzymes, for example glutathione peroxidase (gpx) and thioredoxin reductase (trxr) [ ] . gpx activity is essential for avoiding peroxide-generated oxidative damage and is provided by different families of enzymes, namely selenoglutathione peroxidases (gpx; ec . . . ; glutathione: hydrogen-peroxide oxidoreductase) [ ] . the thioredoxin (trx) system catalyzes the reduction of protein disulfides such as in ribonucleotide reductase, an enzyme essential for dna synthesis [ ] ; thioredoxin peroxidases (peroxiredoxins), critical enzymes in the defense against oxidative stress [ ] ; and protein disulfide isomerase (pdi). most selenoproteins in the kidney are intracellular enzymes with their activities relying upon a single selenocysteine residue in their main structures [ ] . although - selenoprotein genes were identified in mammals [ ] , only a few studies have determined collective responses of these genes to dietary se concentrations ranging from deficiency to moderately high levels in chicken kidney [ , ] . the transcriptional response of se is dependent selenoprotein genes. thus, systematic data are needed to link selenoprotein and relationship between se, selenoproteins, selenoenzymatic, and antioxidant function in the kidney, and associated study on poultry is still a vacancy. here, we tested gpx, total antioxidant capability (t-aoc), malondialdehyde (mda) content, selenoproteins, and related genes (table s ) . our results will describe changes for selenoproteome related to dietary se at low or supernutritional levels and the resultant metabolic disorders in chicken kidney which have yet to be determined before. expt. chickens (hy-line variety white, n = , day old) were fed four different diets, each holding chickens (cocks and hens were randomly distributed). all the groups were feed basal diet (table s ) except se. four experimental diets were prepared as . mg/kg se (low), . mg/kg se (standard), . mg/kg se (excess i), and . mg/kg se (excess ii). feed (corn and soybean meal) was from longjiang county, heilongjiang province, which is a typically se-deficient area in china. all other environmental conditions were maintained in accordance with existing norms for the facility. two identical feed troughs were attached side by side to each cage front. on the seventh day, inoculate newcastle disease virus and infectious bronchitis vaccines were given; on the th day, ibd vaccine; and on the st day, newcastle disease vaccine. mental state, diet condition, feathers, feces, and other ten indicators were observed with eye viewing and recorded. at the end of the second, fourth, sixth, and eighth week, experimental chickens were fasted for h before weighting and sacrificing. kidney samples were collected for analysis. frozen chicken kidney samples were homogenized, the homogenized samples were centrifuged, and the supernatant was transferred to fresh tubes. expt. chickens (n = , day old) were treated as expt. . at the end of the eighth week, chickens were sacrificed. the removed kidney tissue is stored in the locker as an extracted rna sample (cat , beijing tiandz, inc., p.r. china). chicks were fasted for h before weighting and sacrificing. every weeks, we randomly selected ten chickens in order to record their kidneys observing the changes with eye viewing and pathological tissue slice. kidney will be cut into small pieces on the ice packs and were fixed in % formaldehyde and embedded in paraffin for microscopic examination. sections ( μm thick) were cut and stained with hematoxylin and eosin (h&e). the pathological changes were observed under a microscope. se was determined in feed using inductively coupled plasma mass spectrometry (icp-ms, agilent cs-octopole reaction cell, agilent technologies, usa). the concentrations of se in the kidneys were determined with the calibration curve method and compared among the non-, h , and d reaction modes. the protein content was measured with a protein quantitative detection kit (a - , nanjing jiancheng bioengineering institute, p.r. china). bovine serum albumin (bsa) was used to construct the standard curve. the glutathione (gsh) content was measured with a gsh detection kit (a - , nanjing jiancheng bioengineering institute, p.r. china) according to the manufacturer's protocol. by measuring dihydronicotinamide adenine dinucleotide phosphate (nadph) oxidation in the presence of oxidized glutathione, and we used tert-butyl hydroperoxide as the peroxide substrate. the t-aoc was measured with a t-aoc detection kit (a , nanjing jiancheng bioengineering institute, p.r. china) according to the manufacturer's protocol by converting fe + into fe + , whereas the latter forms complexes with phenanthroline substances, which can be measured by a spectrophotometer. the content of mda in kidney was carried out with a mda detection kit (a - , nanjing jiancheng bioengineering institute, p.r. china) according to the manufacturer's protocol. by using the thiobarbituric acid method in which mda, the degradation product of lipid peroxidation, condenses with penthiobarbital and generates a red product with measurable absorbance by a spectrophotometer. the gpx activity was measured with a gpx detection kit (a , nanjing jiancheng bioengineering institute, p.r. china) according to the manufacturer's protocol. gpx catalyzed gsh into gssg, and glutathione reductase can use nadph to catalyze gssg into gsh; reduction of nadph can be calculated through testing the vitality of glutathione peroxidase level. trxr catalyzed nadph and made , ′-dithiobis ( nitrobenzoic acid) (dtnb) into trinitrobenzene (tnb). by measuring the increase of tnb at nm, activity of trxr can be calculated [ ] . total rna was isolated from the kidneys using the rnaout reagent (cat: , beijing tiandz inc., p.r. china) according to the manufacturer's protocol. the dried rna pellets were resuspended in μl water that was diethylpyrocarbonate treated. the content and purity of the total rna were determined spectrophotometrically at / nm. the total rna was immediately used to synthesize cdna. first-strand cdna was synthesized from μg of total rna using oligo(dt) primers and transcript reverse transcriptase (beijing transgen biotech co. ltd., p.r. china) according to the manufacturer's instructions. synthesized cdna was diluted ten times with sterile water and stored at − °c before use. primer analysis software (oligo . , molecular biology insights, inc. usa) designs specific primers (table s ). the relative mrna expressions of selenoproteins and factors associated with the regulation of the selenoprotein synthesis genes were assayed by qpcr array. to perform the qpcr array, gotaq® qpcr master mix (a , promega, usa), primers, template, and nuclease-free water (promega, usa) were added to form the reaction mixture (final volumes μl) in one plate according to the manufacturer's instructions. the qpcr array was performed on a real-time pcr system (applied biosystems, usa). four internal reference comparisons (β-actin (actb), glyceraldehyde -phosphate dehydrogenase (gadph), s ribosomal rna ( srrna), ribosomal protein l (rpl )) were designed (table s ). all data were normalized to the four internal control genes, and the relative expression levels were calculated using the −ΔΔct method [ ] . when the software analyzes the data, it uses the mean value of ct value of the selected four internal control genes to make the baseline correction. data analysis of mrna expression was analyzed using the genecopoeia-fulengen qpcr array data analysis system online (http://www.genecopoeia.com/product/qpcr/ analyse /index.php). the data were analyzed statistically using graphpad prism . (graphpad software inc., usa). one-way analysis of variance (anova) and the least significant difference (lsd) post hoc test were used to analyze the data. differences between the means of data were analyzed by the paired t test which was utilized to determine the effects of se supplementation. the results were expressed as mean ± s.d. of different groups. the significant differences of all data were showed by anova of each experiment. p < . is considered significant unless otherwise stated. as can be seen in fig. , the weight of chicken in the low se group was smaller than that in the standard group which was reported in previous paper [ ] and its feather was fluffy and messy. in se excess groups ( . and . se mg/kg), the size of chickens can be seen a little bigger than those in the standard group. dietary se content did not affect kidney performance, no significant differences observed in appearance, symptoms and pathological changes compared with the standard group with the other three groups. from the observation of pathological tissue section, kidney glomerulus, tubule, and interstitial showed no lesions (fig. ) . the levels of se greatly influence antioxidant defense. renal gsh contents in the low se, excess i, and excess ii groups were all significantly reduced compared with that in the standard group at the eighth week (p < . ) ( table ). however, lowered t-aoc activity can be seen significantly in the low se group compared with that in the standard group (p < . ), and it increased then decreased significantly in the excess i and the excess ii groups compared with that in the standard group (p < . ) ( table ) . meanwhile, the mda content showed the rising trend in the low se, the excess i, and the excess ii groups at the eighth week compared with that in the standard group (p < . ) ( table ) . the activity of gpx in the low-se group decreased significantly compared with that in the standard group all the weeks (p < . ). in the excess i group, it decreased significantly at the eighth week (p < . ). in the excess ii group, it decreased significantly at the eighth week (p < . ) ( table ) . gpx - mrna levels significantly increased in the excess i group (p < . ) and decreased significantly in the low-se and excess ii groups (p < . ) (fig. ) . the trxr activity decreased significantly in response to low se at the eighth week compared with that in the standard group (p < . ). in the excess i group, it went up significantly in the second week and eighth week compared with that in the standard group (p < . ), yet from the fourth week to sixth week it decreased significantly compared with that in the standard group (p < . ) ( table ) . txn mrna level increased significantly in all the groups compared with that in the standard group (p < . ) (fig. ) . meanwhile, txnrd and txnrd mrna levels all increased significantly in the low-se and the excess i groups (p < . ) compared with that in the standard group, whereas decreased significantly in the excess ii group (p < . ); nonetheless, txnrd mrna level has no significant changes in the low-se and excess i groups compared with that in the standard group; in se excess ii group, it decreased significantly (p < . ) (fig. ) . the effects of low and super-nutritional se on selenoprotein mrna abundance were determined by qpcr in chicken kidney. the levels of se greatly regulate the expression of several selenoproteins. all data for mrna expression of chicken renal selenoproteome was shown in table s , and the classifications of histogram were shown in figs. , , , . two kinds of trends can be seen: one was that iodothyronine deiodinases (dio , dio , dio ) mrna levels all increased significantly in the low-se and the excess i groups (p < . ) compared with that in the standard group, but decreased significantly in the excess ii group (p < . ), whereas dio mrna levels in the low-se group changed more obviously than that of dio and dio , over ten times (fig. ) . selenoprotein k (selk), selenoprotein u (selu), and selenoprotein p (sepp ) mrna levels showed the same trend with dios, and selk and selu altered more significantly than sepp (p < . ) (fig. ) . the other trend was that selenoprotein n (sepn ) and selenoprotein w (selw) mrna levels' variation was similar with each other in chicken kidney and decreased significantly in the low-se and the excess ii groups (p < . ) but increased significantly in the excess i group (p < . ) (fig. ) . the effects of low se and super-nutritional se on selenoprotein synthesis-related transcription factors were determined by qpcr in chicken kidney. seven selenoprotein synthesis-related transcription factors were studied (fig. ) . the trna selenocysteine-associated protein (secp ), phosphoseryl-trna kinase (pstk), and seryl-trna synthetase (sars) mrna levels were upregulated significantly under low-se condition (p < . ), whereas sep (ophosphoserine) trna:sec (selenocysteine) trna synthase (sepsecs) mrna had no expression. eukaryotic elongation factor, selenocysteine-trna-specific (efsec), sepsecs, secp , pstk, selenophosphate synthetase (sephs ), secis-binding protein (secisbp ), sars mrna levels were upregulated significantly in the excess i group (p < . ) (fig. ) . pstk, sephs , and secisbp mrna levels were downregulated significantly in the excess ii group (p < . ), and sepsecs mrna had no expression (fig. ) . we saw that secp and pstk altered more obviously, then sars, and finally efsec, sephs , and secisbp . we used selenoproteomic expression spectrum to indicate all selenoproteins and selenoprotein synthesis-related transcription factors [ ] . according to different colors, changes of low and super-nutritional se regulation of the selenoproteomic mrna expressions were demonstrated (fig. ) . partial avian selenoproteins including sepx , selo, selt, sels, sep , seli, selm, and selh mrna levels changed differently. sepx mrna level was downregulated significantly in the low-se and se excess i groups (p < . ). however, seli mrna has no expression in low-se and se excess ii groups; selo was the same with seli in se excess ii group (p < . ). meanwhile, in selt and sep , mrna levels were upregulated with low-se and se excess ( . mg/kg). moreover, sels mrna level was upregulated in se excess ( . mg/kg) but downregulated in se excess ( . mg/kg) (p < . ). in addition, selh and selm mrna levels were all downregulated with se excess ( . and . mg/kg), and this can also be observed on selh in low-se group (p < . ) (fig. ). in the present study, we observed that kidneys of chickens fed with low or super-nutritional se diet evidenced no appearance changes and the renal pathological section did not show differences among the four groups. the nutritional antioxidant se ameliorated oxidative stress and loss of cellular antioxidants and suggested that se efficiently protected the kidneys [ ] . it is reported that se can protect the kidney antioxidant defense system [ ] . se influences selenoproteins' and selenoenzymes' activity which is closely related to renal function [ ] . so we tested the antioxidant function of the kidney to find how se affected the organism. gsh and associated antioxidant enzymes are major combatants of oxidative stress that influence redox status [ ] . gsh also works as a specific substrate for the enzyme gpx [ ] . se supplementation was protective of kidney by providing substantial elevations of gsh levels [ ] . supernutritional se enhanced the endogenous antioxidant capacity, increasing gsh content. however, the lack of thiol response in the kidney might indicate that the redox cycling between the se compounds and the reduced intracellular gsh in tench did not occur or other cellular defenses against oxidative stress were induced to prevent oxidative damage [ ] , and gsh act both as a scavenger of various undesired compounds and their toxic metabolites [ ] . suitable content of se greatly improved t-aoc and decreased mda concentration in the kidney [ ] . our result is consistent with previous research. at low or super-nutritional se levels, chickens increased kidney content of mda, whereas decreased t-aoc. gsh level increased at first and then decreased. our results indicated that low or super-nutritional se increased mda content, which fig. the appearance of the chicken and histopathological examination. the pathology slices of kidney tissue of chicken at the eighth week by a microscope (× , he) caused an organism's gsh to protect itself from oxidative stress and in turn prevents it from being damaged in detoxification reactions. measurement of gpx activity has been used as a marker of adequacy of intake because activity of the enzyme is proportional to dietary intake [ ] . some studies previously indicated that low se can result in inactivation of gpx and development of oxidative stress in the kidneys [ ] , and induced gpx activity in the kidney of juvenile carp fed mg se/kg diet for days was the result of the enhanced detoxification ability [ ] . in this study, compared with those fed with a normal se diet, chicken fed with a low or super-nutritional se diet display significant decreases in renal gpx activities. it is interesting that gpx - mrna levels increased in excess i group, whereas gpx activity decreased. we suppose that super-nutritional se ( . mg/kg) could enhance mrna levels, but regulation of mrna translation can be affected by many factors, such as micrornas, or the precursor protein translation requires some modification and activation, and this process requires effects of other selenoproteins. trxr is a selenocysteine-containing enzyme which catalyzes the nadph-dependent reduction of trx and therefore plays a regulatory role in its metabolic activity [ ] . our results indicated that low or super-nutritional se made chicken renal trxr activity decrease. it may be because dietary insufficient se influences trxr directly or . and . mg/kg se excess indirectly as a result of damaging er. trxr is much more vulnerable to oxidative damage than gpx [ ] ; hence, its changes were different from gpx. txnrd and txnrd had different trends maybe because txnrd and are mostly cytoplasmic and mostly mitochondrial, respectively. txnrd is involved in sperm maturation [ ] . it is intriguing that txnrd , txnrd , and txn mrnas increased, whereas trxr activity decreased. it may be caused by the same reason as those of gpx we mentioned above. up to now, selenoproteins were identified in chicken. in this study, to obtain whether low or super-nutritional se would affect the renal selenoprotein transcription, mrna expressions of all avian selenoproteins were analyzed in chicken kidney. it reported that selenoprotein mrnas in mice kidney were identified, including gpx , selh, sepw , selm, txnrd , dio , sep , and sels that were significantly downregulated in se-deficient kidney. in this study, dio , dio , dio , selk, selu, and sepp had the same trend that increased significantly in low se and . mg/kg se excess but decreased significantly in . mg/kg se excess. these results suggested that dietary se status influenced the expressions of selenoprotein mrnas in chicken kidney. in low se diet, these selenoprotein mrnas' levels increased significantly but selenoenzyme activity and antioxidant capacity decreased. one possible explanation could be the mobilization of the se from the liver to the kidney [ ] . a selenoprotein hierarchy is when se supply is insufficient to support full expressions of all l stands for low-se group whose dietary se content was . mg/kg, s stands for standard group whose dietary se content was . mg/kg, ei stands for excess i group whose dietary se content was . mg/kg, and eii stands for excess ii group whose dietary se content was . the selenoproteins, the synthesis of some of them is downregulated so that others can be expressed more fully. moreover, we suggest although se deficiency made selenoprotein mrnas' expression higher, these selenoproteins did not exert function or too many selenoproteins accumulating in the kidney competed with each other leading to selenoproteins not used rationally in the kidney. a . mg/kg se excess can increase kidney function and promoted selenoprotein mrnas' expression; however, . mg/kg se excess might become a harmful accumulation, decrease selenoprotein mrna level, and then damage antioxidative function. we also suggest that too much se could cause organism disorder and lead to cell autophagy. even more noteworthy is sepp is a biomarker of se status, the kidney is dependent on hepatically derived sepp protein as a se source, and selu could potentially be a molecular biomarker of se status too. both of them may be near the top of the abundance hierarchy, so their mrna levels increased in low se diet. however, it needs to be further validated. we found the effects of dietary se status on avian sepn and selw expression were similar in chicken kidney, decreased significantly in low se and . mg/kg se excess, and increased significantly in . mg/kg se excess. gpx and selw regulation was in agreement with a previous study in rat's kidney that these two selenoproteins were highly regulated by se [ , ] ; selw downregulated by dietary low se was also associated with our research [ , ] . insufficient se influenced organism antioxidant capacity that decreased these selenoprotein mrna levels. se status on mrna regulation occurs at post-transcription; organism can reduce some selenoprotein mrnas to save more important selenoproteins in chicken kidney because of hierarchy. we noticed that . mg/kg se excess could improve kidney function and increase enzyme activity, as selenoprotein mrna levels increased. however, . mg/kg se excess might burden the kidneys, which caused decreased levels of selenoprotein mrna in chicken. some studies found that most selenoprotein mrna expressions were not significantly regulated by se status in mice. in rats' kidney, dio , dio , dio , gpx , gpx , seli, selm, selo, sepp , sels, selt, sep , txnrd , and txnrd were expressed but not regulated by dietary se levels. however, the authors disagree with these findings. in chicken kidney, sepx , txnrd , sels, and selt mrna expressions differed from one another. it was discovered that low or . mg/kg se excess levels did not affect selo or seli. sepp mrna levels kept on increasing in low-se and . mg/kg se excess groups. selh decreased all the time in low or super-nutritional se, and selm decreased in se excess. these results may be due to different selenoproteins in different animal disaffinity. insufficient se resulted in selenoenzyme activity decrease, but mrnas were not reduced in the meantime; . mg/kg se excess causes selenoenzyme activity decrease with mrnas decreasing. se deficiency may not decrease some mrna transcription, b u t p r e v e n t m r n a s ' t r a n s l a t i o n i n t o s o m e o f selenoproteins, and se excess directly affects the expression of mrnas. ultimately, it results in the decrease of selenoenzyme activity. these discrepancies from observation let us begin to further analyze on synthesis factors related to selenoprotein. selenoprotein synthesis requires translational recoding of the uga codon from a stop signal to a secis. any of these gene mrnas' change may influence selenoprotein expression. what we can see in our research is that dietary low se made pstk, secp , sps , and sar mrna levels increase significantly. all these gene mrna levels increased significantly in . mg/kg se excess. they, rows represent the probe sets. rna gene expression is shown using the indicated pseudo color scale from green (− ) to red (+ ) relative to values. green squares represent increased significantly (p < . ), red squares represent decreased significantly (p < . ), and gray squares represent no significant difference (p > . ) however, decreased in the . mg/kg se excess samples. some selenoproteins seemed to change as the same trend of these genes. the amounts of selenoprotein expression changes were not fully consistent with these factors. some selenoproteins could be expressed in other ways and this conjecture should be further discussed. it reported that sbp is potentially reduced by the thioredoxin and glutaredoxin systems, facilitating its relocation to the ribosomes and reinitiation of selenoprotein translation [ ] . secp plays a role in the formation or stabilization of the efsec-sbp -sec trna [ser]sec complex and promotes the formation and subcellular localization of the sps /sla/secp complex. secp may also assist in the decoding of multiple uga-sec codons in selenoprotein and in preventing degradation of selenoprotein mrnas by the nonsense-mediated-decay pathway [ ] . some genes can directly affect the function of selenoenzyme, resulting in kidney function to reduce, and these genes might influence each other, all linked with one another. one of these factors damaged cause of selenoprotein synthesis interruption, other related factors accumulated. we can also suggest that in low-se diet, description of selenoprotein synthesis regulation occurs at or before the beginning of the translation for polyclonal antibody protein or uga encoding selenocysteine terminal polypeptide; description of selenoprotein synthesis regulation occurs at or before the beginning of translation. numerous researches suggested that variational se intake regulated the expression of some selenoproteins more than others. from this observation, the concept of a selenoprotein hierarchy developed. in the present study, it was observed that dietary low or super-nutritional se did not make renal appearance pathological changes in chicken. however, dietary low se downregulated the mrna expressions of gpx - , txnrd , sepn , selw, sepx , selh, and sepsecs. at super-nutritional se, most selenoproteins were upregulated in chicken kidney, but selm and selh were downregulated. these results indicated that dietary se status stabilizes normal physiology function via regulation of the selenoprotemic transcriptions. we hypothesize that hierarchy of regulation of the transcriptions of selenoproteome makes an important role for renal se metabolism and transport in avian. an analysis of cancer prevention by selenium testicular toxicity induced by dietary cadmium in cocks and ameliorative effect by selenium the importance of selenium to human health the influence of selenium on immune responses effect of selenium-induced oxidative stress on the cell kinetics in testis and reproductive ability of male mice selenium metabolism in drosophila: selenoproteins, selenoprotein mrna expression, fertility, and mortality targeting selenium metabolism and selenoproteins: novel avenues for drug discovery skeletal muscle disorders associated with selenium deficiency in humans influence of organic selenium on hsp response of heat-stressed and enteropathogenic escherichia coli-challenged broiler chickens (gallus gallus) effects on liver hydrogen peroxide metabolism induced by dietary selenium deficiency or excess in chickens effect of oxygen free radicals and nitric oxide on apoptosis of immune organ induced by selenium deficiency in chickens selenium and selenoproteins in health and disease content of non-mercury-associated selenium in human tissues oxidative stress response of forster's terns (sterna forsteri) and caspian terns (hydroprogne caspia) to mercury and selenium bioaccumulation in liver, kidney, and brain prolonged dietary selenium deficiency or excess does not globally affect selenoprotein gene expression and/or protein production in various tissues of pigs mercury and drought along the lower carson river, nevada: iii. effects on blood and organ biochemistry and histopathology of snowy egrets and black-crowned night-herons on lahontan reservoir specific antioxidant selenoproteins are induced in the heart during hypertrophy selective up-regulation of human selenoproteins in response to oxidative stress identification and characterization of phosphoseryl-trna[ser]sec kinase biosynthesis of selenocysteine on its trna in eukaryotes decoding apparatus for eukaryotic selenocysteine insertion sex-specific transcriptional responses of the zebrafish (danio rerio) brain selenoproteome to acute sodium selenite supplementation selenium status highly regulates selenoprotein mrna levels for only a subset of the selenoproteins in the selenoproteome detoxifying response in juvenile tench fed by selenium diet comparison of different forms of dietary selenium supplementation on growth performance, meat quality, selenium deposition, and antioxidant property in broilers selenium, selenoproteins and human health: a review selenium inhibits renal oxidation and inflammation but not acute kidney injury in an animal model of rhabdomyolysis megalin mediates selenoprotein p uptake by kidney proximal tubule epithelial cells characterization of mammalian selenoproteomes the selenium deficiency disease exudative diathesis in chicks is associated with downregulation of seven common selenoprotein genes in liver and muscle transcript analysis of the selenoproteome indicates that dietary selenium requirements of rats based on selenium-regulated selenoprotein mrna levels are uniformly less than those based on glutathione peroxidase activity selenium regulation of the selenoprotein and nonselenoprotein transcriptomes in rodents marginal selenium deficiency down-regulates inflammation-related genes in splenic leukocytes of the mouse lipid peroxidative damage on cisplatin exposure and alterations in antioxidant defense system in rat kidneys: a possible protective effect of selenium effects of acute in vivo cisplatin and selenium treatment on hematological and oxidative stress parameters in red blood cells of rats regulation of selenium metabolism and transport selenium concentrations and enzyme activities of glutathione metabolism in wild long-tailed ducks and common eiders prevention of cadmium induced lipid peroxidation, depletion of some antioxidative enzymes and glutathione by a series of novel organoselenocyanates di( -ethylhexyl)phthalateinduced renal oxidative stress in rats and protective effect of selenium combined administration of oxalic acid, succimer and its analogue for the reversal of gallium arsenide-induced oxidative stress in rats biomarkers of selenium status effects of selenium diets on growth, accumulation and antioxidant response in juvenile carp the subcellular location of selenoproteins and the impact on their function mercury and selenium interaction in vivo: effects on thioredoxin reductase and glutathione peroxidase selenium as a feed supplement for heat-stressed poultry: a review the thioredoxin system protects ribosomes against stress-induced aggregation supramolecular complexes mediate selenocysteine incorporation in vivo acknowledgments this study was supported by the program for new century excellent talents in university (grant no. nect- - ), the program for new century excellent talents in heilongjiang provincial university (grant no. -ncet- ), and the doctor initial funding of northeast agricultural university (grant no. rbc ). we also acknowledge the valuable help provided by prof. shi-wen xu in northeast agricultural university and all involved workers. key: cord- - uok wb authors: lin, chun-yu; lu, cheng-hui; lee, hsiu-an; see, lai-chu; wu, meng-yu; han, yi; tseng, chi-nan; su, i-li; li, han-yan; tsai, feng-chun title: elderly versus non-elderly patients undergoing surgery for left-sided native valve infective endocarditis: a -year institutional experience date: - - journal: sci rep doi: . /s - - - sha: doc_id: cord_uid: uok wb this retrospective study aimed to clarify the short- and mid-term outcomes of elderly patients who underwent surgery to treat left-sided native valve infective endocarditis (lsnie). between july and september , patients underwent surgical treatment for active lsnie at a single institution. patients were classified into two groups: ≥ years (elderly group) and < years (non-elderly group). clinical features, surgical information, postoperative complications, and three-year survival rates were compared. the average ages were . ± . and . ± . years in the elderly and non-elderly groups, respectively. the elderly group had a higher predicted mortality rate and a lower incidence of preoperative septic emboli-related complications. echocardiographic assessments of infected valves were generally homogenous between the groups. the elderly patients had a higher in-hospital mortality rate than the non-elderly patients ( . % vs. . %, p = . ). for patients who survived to discharge, the three-year cumulative survival rates were . % ± . % and . % ± . % in the elderly and non-elderly groups, respectively (p = . ). in conclusion, elderly patients are at a higher risk of in-hospital mortality after surgery for lsnie. however, once elderly patients are stabilized by surgical treatment and survive to discharge, the mid-term outcomes are promising. each patient fulfilled the modified duke criteria for ie , and surgical treatment was indicated based on published guidelines prior to , . general cardiac function, valvular destruction severity, and vegetation size/location were assessed by an experienced cardiovascular physician using transthoracic or transoesophageal echocardiography. active endocarditis was defined as definitive ie requiring intravenous antibiotic therapy until surgery . after excluding patients with sub-acute ie that resolved after a complete antibiotic treatment course and underwent delayed surgery due to residual valvular insufficiency found by follow-up echocardiography, and with prosthetic valve ie, patients were included. the patients were classified into two age groups: ≥ years (elderly group, n = , . %) and < years (non-elderly group, n = , . %) according to previous definitions of elderly , . preoperative septic emboli-related complications were diagnosed according to clinical symptoms and image studies, including computed tomography and magnetic resonance imaging, which were interpreted by experienced radiologists. if the vegetations were located in the aortic valve, preoperative coronary angiography was avoided to prevent new systemic embolic events. for patients with unstable haemodynamics or cardiopulmonary failure, depending on the inotropic agents and ventilator support, surgery was performed on an emergency basis. surgical management. intraoperative transoesophageal echocardiography was performed by specialized cardiovascular anaesthesiologists to confirm the preoperative diagnosis and extent of the valvular lesion. using a standard sternotomy approach, cardiopulmonary bypass (cpb) was established via cannulation of the ascending aorta and right atrium or the venae cavae. cardiac arrest was induced by a single dose of histidine-tryptophanketoglutarate solution or intermittent cold-blood cardioplegic solution through the coronary orifice. the diseased valves were carefully inspected, and the feasibility of valvular repair was considered after complete debridement of the infected tissues. the decision of valve repair or replacement was dependent on the surgeon's discretion regarding the degree of valvular destruction and patient characteristics, including heart function, comorbidities, and preoperative haemodynamics. for infected mitral valves that were repairable, the carpentier principle was applied , and ring annuloplasty was used to ensure the long-term durability of repair. in regards to infected aortic valves that were repairable, a pericardium patch was usually used for reconstructing the valvular defects following debridement. if valve replacement was necessary due to limited healthy tissue, the prosthetic choice was based on the patient's individual preference after a detailed discussion before surgery. before patients were weaned off cpb, haemostasis and good competency of the treated valve were confirmed, and a global assessment of cardiac function was performed. postoperative care and interventions. after undergoing surgery for endocarditis, all patients were transferred to a specialized cardiovascular intensive care unit (icu) for further treatment and observation. at hours post-surgery, a ventilator-weaning protocol was initiated if there was no active bleeding, unstable haemodynamics, persistent arrhythmia, or signs of organ malperfusion. renal replacement therapy was applied if acute renal failure developed after surgery, according to the acute kidney injury network criteria . further survey imaging, endovascular intervention, and surgical exploration for bleeding or malperfusion were performed, if indicated. statistical analyses. statistical analyses were performed using spss for windows (version . , ibm corp., armonk, ny). the shapiro-wilk test was used to test whether the continuous variables were normally distributed. data were presented as means ± standard deviation for normally distributed variables, whereas medians and interquartile ranges were used to describe non-normally distributed data. the independent t test was performed for comparison of normally distributed data and the mann-whitney u-test was used for non-normally distributed data between the two study groups. dichotomous variables are presented as numbers (n) and percentages (%). univariate analyses of categorical variables were performed using the chi-square test, or fisher's exact test to determine inter-group differences, where appropriate. preoperative and surgical variables found to be significant in the univariate analysis of in-hospital mortality were included in a multivariate logistic regression analysis to identify the independent predictors of in-hospital mortality. numbers of events (in-hospital mortality) per covariate fell below four or five in the present study; therefore, we used penalization through data augmentation to perform multivariate logistic regression to avoid sparse data bias , . the hosmer-lemeshow test was used to evaluate the goodness-of-fit for the multivariate logistic regression model . the kaplan-meier method was used to estimate -year cumulative survival, which was compared using the log-rank test. for all analyses, statistical significance was set at p < . . patient demographics. table shows the clinical demographics, comorbidities, preoperative conditions, and clinical presentation of the elderly and non-elderly groups. the average ages were . ± . and . ± . years in the elderly and non-elderly groups, respectively. overall, . % of patients were female, and diabetes mellitus was the most prevalent comorbidity, accounting for > % of cases in both age groups, followed by hypertension and end-stage renal disease (esrd). the average european system for cardiac operative risk evaluation (euroscore) ii estimated that mortality risk was higher in the elderly group ( . % [ . - . %] vs. . % [ . - . %]; p = . ) than in the non-elderly group. bacteraemia was the most prevalent clinical finding, followed by fever and septic emboli-related complications in both the elderly and non-elderly groups. the elderly group had a lower incidence of septic emboli-related complications ( . % vs. . %; p = . ). there were no differences in the antibiotic courses and length of hospital stays before surgery between the elderly and non-elderly groups. the epidemiology of pathogens was generally similar, and streptococci accounted for > % in both groups (fig. ). preoperative echocardiographic assessment and surgical information. table provides detailed information regarding preoperative echocardiographic assessment and surgical variables. in general, there were no differences in the location of the diseased valves, size/number of vegetations, and occurrence of periannular abscess between the groups. overall, . % of the patients underwent emergency surgery. regarding the valvular procedures, the rates of repair and replacement were similar in the elderly and non-elderly groups. however, more patients in the non-elderly group underwent mechanical valve replacement for both the aortic and mitral valve. the time span of cpb, aortic cross-clamp, and rate of histidine-tryptophan-ketoglutarate cardioplegic solution usage did not differ between the two groups. in total, . % of patients underwent extracorporeal membrane oxygenation installation in the operating room due to intraoperative myocardial failure. postoperative complications. as shown in table , a significantly higher in-hospital mortality rate was observed in the elderly group compared to the non-elderly group ( . % vs. . %; p = . ). moreover, the elderly group showed a higher incidence of complications, including new cerebral infarction, prolonged ventilator dependence, and prolonged icu course. the median hospital stays were . ( . - . ) and . ( . - . ) days in the elderly and non-elderly groups, respectively. an increasing number of elderly patients suffer from cardiovascular diseases, including ie, which can be life-threatening [ ] [ ] [ ] . however, elderly patients tend to receive a more conservative treatment course due to concerns regarding surgical complications , . in this single-centre study, a comparative cohort of patients who underwent surgical treatment for active lsnie is presented, which includes elderly patients aged > years. in-hospital mortality rates and postoperative complication rates were higher in this population than in non-elderly patients. however, the mid-term outcomes were still satisfactory for elderly patients who survived to hospital discharge. due to the increase in average life expectancy and the higher incidence of cardiovascular disease with advancing age, more elderly patients nowadays present for cardiac surgery . however, advanced age is considered a predictor of adverse outcomes following cardiac surgery , . an increased but acceptable surgical mortality rate has been previously observed among elderly patients with ie , , which was also observed in our study. therefore, surgery may be justified as a treatment option for elderly patients with lsnie and should be considered in selected patients. thorough consultation between the medical and surgical teams is essential to make this a reliable strategy. traditional surgery with cpb remains the standard treatment option for ie. however, the aging process is associated with structural and functional changes in various organ systems, possibly reducing the tolerance for haemodynamic fluctuation, and increasing coagulopathy and the systemic inflammatory response induced by cpb. therefore, higher in-hospital mortality and complication rates are expected in this population. in the present study, the elderly group demonstrated a higher euroscore ii-estimated risk, which also addresses the inferior short-term outcome. the aging process is associated with numerous ionic, molecular and biochemical www.nature.com/scientificreports www.nature.com/scientificreports/ changes in the heart , . these age-related changes can affect cardiac morphology and reduce the physiologic function. therefore, cardiac aging results in decreased mechanical and contractile efficiency, and may increase the rate of cardiomyocyte apoptosis after cardiac surgery. in our study, approximately % of elderly patients required mechanical support following surgery, and > % of the mortality in the elderly group was associated with postoperative myocardial failure. although the rates of postoperative mechanical support were similar in the two groups, the aging heart may exhibit inferior recovery compared with younger hearts. septic emboli-related complications occur in - % of patients with ie, especially when the diseased valve is on the left side , . the central nervous system is the most common destination of embolism, followed by the spleen, kidneys, lungs, and liver. in our study, the elderly group had a relatively lower incidence of preoperative septic emboli-related complications than the non-elderly group. we suggest several reasons for this finding. first, contrast-enhanced imaging may have been arranged more conservatively for patients in the elderly group due to the lower reserved renal function. second, the symptoms and presentations of emboli-related complications in the elderly may not be apparent and, therefore, could have been overlooked. when the emboli-related complications have progressed to a serious stage, the timing of surgical treatment may be delayed, and the outcome is compromised. finally, no patients in the elderly group experienced preoperative intracranial haemorrhage or cerebral mycotic aneurysm. these two cerebral complications could increase the surgical risk and induce permanent neurologic deficits. according to previous studies , , % of hospital mortality and % of postoperative cardiac and cerebrovascular complications were reported in this high-risk subgroup. as these complications are extremely serious and life-threatening, elderly patients with these conditions may be reluctant to undergo surgery. the elderly population is associated with a high incidence of comorbidities, including chronic kidney disease (ckd), and relative risk factors, including hypertension and diabetes, which predispose them to ckd . according to a previous multicentre study , patients with ckd had an increased perioperative mortality rate and reduced long-term survival after cardiac surgery. in our study, the elderly group showed worse renal function compared to the non-elderly group before surgery ( . ( . - . ) vs. . ( . - . ) ml/min/ . m ; p = . ). furthermore, esrd was one of the independent predictors of in-hospital mortality for the elderly www.nature.com/scientificreports www.nature.com/scientificreports/ these influences can be magnified. therefore, we suggest that elderly patients with ckd who present with clinical signs of ie should undergo early assessments and receive careful surgical management to optimize the outcomes. elderly patients who underwent surgery for ie were associated with higher in-hospital mortality and morbidity rates owing to their comorbid conditions and delayed timing of surgery. however, the late surgical outcomes are rarely reported. similar short-term results were presented in our study. furthermore, elderly patients who survived to discharge could have a comparable -year survival to that of the non-elderly group. therefore, we suggest that a guideline-directed surgical strategy according to the presence of complications, which include embolism events, large vegetation, heart failure, or uncontrolled infection, would be beneficial to improve the mid-term outcomes of elderly patients with lsnie. limitations of this study. our study had several important limitations. first, because the study used a retrospective and nonrandomized control design with a small sample size, bias might exist that influenced the homogeneity of the study groups and the stability of the multivariate logistic regression model. second, as this cohort spanned a period of > years, the technology of cpb and myocardial protection, as well as strategies for epidemiology, characteristics, and outcome of infective endocarditis in italy: the italian study on endocarditis contemporary epidemiology and prognosis of septic shock in infective endocarditis esc guidelines for the management of infective endocarditis: the task force for the management of infective endocarditis of the european society of cardiology (esc) early surgery versus conventional treatment for infective endocarditis early operation for endocarditis complicated by preoperative cerebral emboli is not associated with worsened outcomes ageing populations: the challenges ahead influence of referral bias on the apparent clinical spectrum of infective endocarditis changing epidemiology of infective endocarditis: a retrospective survey of cases, - . eur infective endocarditis: an analysis based on strict case definitions current features of infective endocarditis in elderly patients: results of the international collaboration on endocarditis prospective cohort study age-dependent profile of left-sided infective endocarditis: a -center experience proposed modifications to the duke criteria for the diagnosis of infective endocarditis infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the committee on rheumatic fever, endocarditis, and kawasaki disease, council on cardiovascular disease in the young, and the councils on clinical cardiology, stroke, and cardiovascular surgery and anesthesia aha/acc guideline for the management of patients with valvular heart disease: executive summary: a report of the american college of cardiology/american heart association task force on practice guidelines valve surgery in active endocarditis patients complicated by intracranial haemorrhage: the influence of the timing of surgery on neurological outcomes native valve infective endocarditis in elderly and younger patients: comparison of clinical features and outcomes with use of duke criteria and the duke endocarditis database carpentier's reonstructive valve surgery acute kidney injury network: report of an initiative to improve outcomes in acute kidney injury a simulation study of the number of events per variable in logistic regression analysis sparse data bias: a problem hiding in plain sight a goodness-of-fit test for the multiple logistic regression model the evolution of cardiovascular surgery in elderly patient: a review of current options and outcomes early and late predictors of mortality following on-pump coronary artery bypass graft surgery in the elderly as compared to a younger population outcomes in nonagenarians after heart valve replacement operation infective endocarditis in elderly patients: clinical characteristics and outcome physiology of cardiovascular aging the changing clinical aspects of infective endocarditis: descriptive review of episodes in a french teaching hospital and risk factors for death risk of embolism and death in infective endocarditis: prognostic value of echocardiography, a prospective multicenter study optimal timing of surgery for active infective endocarditis with cerebral complications: a japanese multicentre study chronic kidney disease in the elderly: evaluation and management outcomes of cardiac surgery in chronic kidney disease we thank tao-hsin tung, department of medical research and education, cheng-hsin general hospital, for statistical assistance. c.y. lin had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. study concept and design: the authors declare no competing interests. correspondence and requests for materials should be addressed to c.-y.l.reprints and permissions information is available at www.nature.com/reprints.publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons license, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this license, visit http://creativecommons.org/licenses/by/ . /. key: cord- -wv wc ct authors: stevens, d. l. title: invasive streptococcal infections date: journal: j infect chemother doi: . /s sha: doc_id: cord_uid: wv wc ct nan in the years since the first description of the streptococcal toxic shock syndrome (streptss), reports have documented the presence of these invasive infections in all corners of the world, in all races, sexes, and age groups. the strains responsible for these infections have been similar, suggesting a global spread of infection. as might be expected, identical strains have also accounted for less serious infections, such as cellulitis, pharyngitis, and even asymptomatic carriage. thus, host factors and co-morbid conditions must account for the different diseases caused by identical strains. the most prevalent m-type associated with streptss has been, and continues to be, m-type . interestingly, mtype strains have always been in second place and, together, m-types and account for approximately % of cases. recent studies in the netherlands found m- and m- strains each accounted for % of cases of invasive group a streptococcal infection. in some geographical areas, m- strains have accounted for % of invasive infections. in contrast, in the epidemic that occurred in wannamingo, minnesota, % of the strains were m- . other strains less commonly associated with streptss include m-types , , , , , and non-typeable strains (reviewed in ). in most geographical settings, a mixture of strains is responsible for sporadic cases. as remarkable as the emergence of invasive group a streptococcal infections has been, the persistence of such infections worldwide is equally unusual. the increased incidence of severe group a streptococcal infections during the later part of the s suggests that the prevalent strains, largely m- and m- strains, have the ability to persist in the human environment for indefinite periods. in fact, these strains have been widely distributed for decades as causes of simple pharyngitis and asymptomatic carriage. thus, much of the world's population has been exposed to these strains, likely on numerous occasions. despite this exposure and the type-specific immunity that should be generated, the increasing prevalence of m- strains in certain regions is troubling. for example, in norway and sweden, the recent prevalence of m- strains among invasive streptococcal infections, as well as pharyngeal isolates, has increased to greater than %. from the theoretical perspective, the high prevalence and persistence of such strains could be due to an absence of protective immunity in a significant portion of the human population, or could be due to changes in protective epitopes in the organism analogous to antigenic drift among influenza viruses. there is some data supporting the latter hypothesis. although restriction fragment length polymorphism (rflp) patterns of m-type strains suggest that these strains have remained identical over a year period, biophysical studies imply that this may not be the case. for example, de malmanche and martin, using functional studies of opsonophagocytosis, demonstrated that immunity may only be strain, and not m-type, specific. in some of these strains, marked differences in the amino acid sequence of m- strains was apparent, despite the fact that these strains were serologically typed as m- . in addition, villasenor has demonstrated that, among strains of m- group a streptococci, susceptibility to opsonophagocytosis in the presence of a single polyclonal anti-m- sera followed a normal distribution curve, and that some m-type strains were no better opsonized than heterologous, non-m- strains. representative strains, selected on the basis of their susceptibility to phagocytosis, had differences in the sequence of m-protein in both the hypervariable region and the a-repeat regions of the molecule. clearly, these changes did not affect the structure enough to alter the serologic m-type, but were sufficient to affect opsonization with convalescent sera. thus, subtle differences in the surface structure of m- protein render some strains resistant to immune sera, suggesting that antigenic drift could account for the high prevalence and persistence of m- strains for the past years. the increased incidence of invasive group a streptococcal infections also suggests a change in the virulence of the organism. m-protein, streptolysin o (slo), and streptococcal pyrogenic exotoxins a and b (spea, speb) have been implicated as important virulence factors. however, none of these has been associated with all invasive cases. for example, although m-types and have been most common, m-types , , and non-typeable strains have been also associated with invasive streptococcal infection. similarly, in the united states, m-type strains containing the gene for spea have been commonly associated with streptss; however, only about % of these strains produce spea. thus, no single surface component or extracellular toxin has, thus far, been identified that correlates with the recent increase in virulence in group a streptococcus. in , we reported a strong association between isolates from invasive disease, regardless of m-type, and the production of nicotinamide adenine dinucleotide glycohydrolase (nadase). in contrast, isolates that are most commonly associated with rheumatic fever, i.e., mtypes and , did not produce nadase. throat isolates associated with uncomplicated symptomatic pharyngitis were most commonly m-types , , and , and % of these isolates from the early s to the present time were nadase producers. this is not surprising, because the source of bacteria in invasive streptococcal infections is frequently the throat. it is of special interest that m-type strains isolated from recent (circa ) invasive cases were nadase producers, because, historically, m-type group a streptococci have been characteristically non-nadase producers. , this observed shift in nadase production has also been reported by karasawa et al. among m-type isolates in japan, and most recently by ajdic et al., at the university of oklahoma, where the group a streptococcal genome has been elucidated. our genetic analysis demonstrated that all strains of group a streptococci, regardless of their ability to produce nadase, possess the nadase gene, nga, and that all isolates examined were more than % identical in nga and upstream regulatory sequences. further, because nadasenegative strains did not produce any immunoreactive protein or peptide fragment, we concluded that additional regulatory element(s) control nadase production. taken together, these findings suggest that, in the early s, serotype m- underwent a stable genetic change, resulting in the ability to produce nadase. further, acquisition of this trait occurred in temporal association with the emergence of m-type group a streptococcus as the predominant serotype associated with severe invasive infections. , , nadase's role in pathogenesis is currently under study. until recently, group a streptococcal bacteremia occurred most commonly in the very young and the elderly. among children, predisposing factors included burns, varicella, malignant neoplasm, immunosuppression, and age less than years. patients with septic scarlet fever had complications, such as extension of infection into the sinuses, peritonsillar tissue, or mastoids, yet, bacteremia was uncommon. among the children with varicella studied by bullowa and wishik in , group a streptococcal bacteremia occurred in only approximately . % of patients. in contrast, recently, doctor et al. found a % incidence of group a streptococcal bacteremia in patients hospitalized with varicella. in elderly patients, the source of group a streptococcal infection is invariably the skin and is associated with cellulitis or erysipelas. group a streptococcal sepsis in the elderly (mean age, - years) has also been associated with diabetes, peripheral vascular disease, malignancy, and corticosteroid use. not surprisingly, mortalities of %- % have been described in this patient population. in the united states and europe during the s, the occurrence of group a streptococcal bacteremia was rare in individuals - years of age, and was primarily associated with puerperal sepsis. recently however, intravenous drug abuse has emerged as a leading cause of group a streptococcal bacteremia in this age group. martin and hoiby have comprehensively demonstrated that the prevalence of group a streptococcal bacteremia in norway in the late s increased in all age groups, but the greatest increase ( %- %) was in adolescents and young adults. thus, the demographics of invasive group a streptococcal infections, with bacteremia as a marker, have changed dramatically in the past two decades. lymphangitis occurs most commonly during the course of an acute infection of the skin, usually cellulitis. it is most common following hemolytic streptococcal infections caused by groups a, c, and g streptococci. red streaks beginning at the margin of skin infection and extending proximally are easily recognized and may extend several inches per hour. thus, lymphangitis associated with a softtissue infection is likely a marker for a more aggressive strain of streptococci, and its recognition should prompt aggressive antibiotic therapy and close observation for evidence of bacteremia. attributed to streptococci, other organisms, including anaerobic and aerobic mouth flora, commonly contribute. still, the group a streptococcus was found alone or in combination with other organisms in % of tonsils removed from different children. in some cases, extension of infection from the tonsil to adjacent cervical nodes, the peritonsillar soft tissues of the neck, or the retropharyngeal space results in necrotizing infections or abscess, which require surgical drainage or debridement. peritonsillar abscesses are readily cured with penicillin plus needle aspiration. like streptococcal pharyngitis, retropharyngeal abscess is most common in children less than years to age. these infections may be caused by group a streptococcus, bacteroides, peptostreptococcus, or staphylococcus aureus. aggressive imaging of the neck, with computerized axial tomography (ct) or magnetic resonance imaging (mri), and emergent surgical consultation, are critically important because of the likelihood of upper airway obstruction, bacteremia, and extension of infection along complex fascial planes. group a streptococcal infections can reach the mediastinum via lymphatics from head and neck infections or soft tissue infection of the thorax, from contiguous spread from pneumonia, empyema, or parapharyngeal infection, or hematogenously from bloodstream infection. mediastinal infections caused by group a streptococcus have a high mortality caused, in part, by the potency of toxins produced, the difficulty in making an early diagnosis, and finally, the difficulty in adequately draining the site of infection because of the abundance of vital structures in this anatomical site. although uncommon among community-acquired infections, pneumonia caused by group a streptococcus is unique for two reasons. first, empyema develops in nearly % of cases, and second, pleural fluid accumulates rapidly, and may be as much as several liters per day. in the past, the greatest challenges for physicians treating patients with this infection were adequate drainage of loculated empyema fluid and the management of restrictive lung disease that developed subsequent to fibrosis of pleural surfaces. shock and organ failure were uncommon. in contrast, recent cases of group a streptococcal pneumonia and empyema have been associated with the streptss (author's observations). puerperal sepsis occurs during pregnancy or abortion, when group a streptococcus colonizing the patient invades the endometrium and surrounding structures, as well as the lymphatics and bloodstream. the result is acute endometri-tis and bacteremia complicated by pelvic thrombophlebitis and peritonitis. puerperal sepsis reached epidemic proportions in europe and the united states during the mid- s, largely as the result of contamination of women by attending physicians. a small number of cases attributed to group b streptococcus was reported during this time, and this organism remains an uncommon cause of puerperal sepsis. from to , improvements in infection control practices and the advent of antibiotics significantly reduced the incidence of this infection. in contrast, currently in the united states, , europe, [ ] [ ] [ ] and japan, there has been a re-emergence of group a streptococcal puerperal sepsis associated with streptss. while most of these cases have been sporadic, secondary cases associated with rectal or vaginal carriage of group a streptococcus by health-care workers have been reported. clearly, if more than one case occurs in a health facility, searches for a common source infection should be carried out. necrotizing fasciitis is a deep-seated infection of the subcutaneous tissue that results in progressive destruction of fascia and fat, but with sparing of the skin itself. historically, pfanner is credited with the first description of what he called necrotizing erysipelas. several years later, meleney described patients with hemolytic streptococcal gangrene in china, and he argued that this entity was different from erysipelas and should have a different name. these cases were probably caused by group a streptococci as we now know them, although at that time they only characterized the organism as hemolytic streptococci. subsequently, "necrotizing fasciitis" has become the term that is preferred, because bacteria other than streptococci, such as clostridium perfringens, clostridium septicum, staphylococcus aureus, and mixed aerobic-anaerobic bacteria can produce a similar pathologic process. meleney's descriptions of the progression are clinically useful and are summarized as follows: characteristically streptococcal gangrene begins at the site of trivial or inapparent trauma. within hours of the initial lesion, there is aggressive development of swelling, heat, erythema and tenderness with rapid spreading proximally and distally from the original focus. during the next - hours, the erythema darkens, changing from red to purple and then to blue, and blisters and bullae form which contain clear yellow fluid. on the fourth or fifth day, the purple areas become frankly gangrenous. from the seventh to tenth day, the line of demarcation becomes sharply defined and the dead skin begins to separate at the margins revealing extensive necrosis of the subcutaneous tissue. up until this time, the patient continues to be febrile, prostration increases and the patient becomes more emaciated. in more severe cases, the process advances rapidly until several large areas of skin have become gangrenous, and the intoxication renders the patient dull, unresponsive, mentally cloudy or even delirious. subsequently, the patient may develop metastatic abscesses, bronchopneumonia or lung abscess. (adapted from reference in should be remembered that meleney's description of hemolytic streptococcal gangrene was published in well before the advent of antibiotics. in fact, he was the first to advocate aggressive "bear scratch" fasciotomy and debridement. using this approach, as well as dakan's solution for irrigation, mortalities of as low as % were achieved. in contrast, more modern series suggest that mortalities of %- % are common, even with antibiotics and aggressive surgical debridement. in addition, the progression of modern group a streptococcal infections is much more rapid than meleney described, and frequently patients may die within - h of the onset of symptoms. further, these necrotizing processes are more likely to destroy skin, subcutaneous fat, fascia, and underlying muscle. for example, in one study, myonecrosis was present in about % of patients who had necrotizing fasciitis. these data suggest that modern strains are more virulent. group a streptococcal myositis has been an extremely uncommon infection. adams et al. documented only cases that had been reported from to , and svane found only cases among over autopsies. in our series of patients with invasive group a streptococcal infection, had myositis alone, had myositis as well as necrotizing fasciitis, and had necrotizing fasciitis alone. recently, deep soft-tissue infections, such as necrotizing fasciitis and myositis, have also been described in reports from norway, sweden, and canada. although group a streptococci can infect viable muscle via a direct penetrating injury or surgical incision, in approximately % of cases there is no history of such an event. these cases develop spontaneously, or secondary to very minor blunt trauma or muscle strain, and most patients deny antecedent symptomatic pharyngitis or tonsillitis. , , [ ] [ ] [ ] , thus, translocation of group a streptococci likely occurs from the colonized pharynx to the site of muscle injury via hematogenous or lymphatic spread. severe pain may be the only presenting symptom, and physical findings early may demonstrate only swelling and erythema, although patients may rapidly develop muscle compartment syndromes. , , [ ] [ ] [ ] [ ] [ ] [ ] in most cases, a single muscle group may be involved; however, because patients are frequently bacteremic, multiple sites of myositis can occur. , distinguishing streptococcal myositis from spontaneous gas gangrene caused by clostridium perfringens or clostridium septicum may be difficult, although the presence of crepitus or gas in the tissue would favor clostridial infection. distinguishing necrotizing fasciitis from myositis is easily done anatomically from surgical exploration or incisional biopsy. in streptococcal cases, many patients may have evidence of both necrotizing fasciitis and myositis. , in published series, the case fatality rate for necrotizing fasciitis is between % and %, whereas group a streptococcal myositis has a fatality rate between % and %. , [ ] [ ] [ ] , , aggressive surgical debridement is of extreme importance, because of the poor efficacy of penicillin that has been described in human cases, , , , , as well as in experimental streptococcal models of myositis , (see section on antibiotic efficacy). of note, the term "myositis" connotes "inflammation" of muscle; however, in most cases of streptococcal myositis, frank necrosis is present, with only a paucity of infiltrating inflammatory cells. thus, a better term would be "myonecrosis". epidemiology several population-based studies of streptss have documented the annual incidence of - cases per popu- with most cases being sporadic in nature; however, larger epidemics of invasive group a streptococcal infections have also been described in some settings. in , an epidemic of related invasive infections occurred in wannamingo, minnesota, with an annualized prevalence of cases per population. in missoula, montana in , the incidence of invasive infections reached cases per population. in addition to community-based infections, invasive group a streptococcal infections have also been described in hospitals, convalescent centers, and among hospital employees and family contacts of patients with invasive infections. , , some of these studies have documented the same m-type and identical rflp patterns in strains from primary and index cases. , [ ] [ ] [ ] in addition, carriage of group a streptococcus by healthcare personnel has been associated with the spread of life-threatening group a streptococcal infections in the obstetrics/gynecology and ear-nose-throat wards of american hospitals. such infections have also originated in outpatient surgical settings and within the home environment. it has been estimated that the risk of secondary cases may be approximately times greater than the risk among the general population. there is ample data from studies conducted over several decades that group a streptococcus is quickly and efficiently transmitted from index cases to susceptible individuals, and that transmission may result in colonization, pharyngitis, scarlet fever, rheumatic fever, or invasive group a streptococcal infections. the risk for secondary cases is likely related to close or intimate contact and crowding, as well as host factors such as: ( ) active viral infections such as varicella or influenza; ( ) recent surgical wounds and childbirth (author's unpublished observations); ( ) absence of type specific opsonic antibody against the group a streptococcus causing the index case; and ( ) absence of neutralizing antibody against pyrogenic exotoxin a or b. the portals of entry for streptococci are the vagina, pharynx, mucosa, and skin in % of cases. interestingly, a portal cannot be defined in the remaining %. rarely, patients with symptomatic pharyngitis develop streptss. surgical procedures, such as suction lipectomy, hysterectomy, vaginal delivery, bunionectomy, and bone pinning provide a portal of entry in some cases. numerous cases have developed within - h of minor nonpenetrating trauma resulting in hematoma, deep bruise to the calf, or even following muscle strain. virus infections such as varicella and influenza have provided portals in other cases. in some cases, the use of nonsteroidal anti-inflammatory agents may have either masked the presenting symptoms or predisposed to more severe streptococcal infection and shock. most cases of streptss occur sporadically, although outbreaks of severe group a streptococcal infections have been described in closed environments, such as nursing homes, , and hospital environments. , symptoms and signs twenty percent of patients have an influenza-like syndrome, characterized by fever, chills, myalgia, nausea, vomiting, and diarrhea. fever is the most common presenting sign, although hypothermia may be present in patients with shock. confusion is present in % of patients, and in some, coma or combativeness are manifest. pain -the most common initial symptom of streptss -is abrupt in onset, severe, and usually precedes tenderness or physical findings. the pain usually involves an extremity, but may also mimic peritonitis, pelvic inflammatory disease, pneumonia, acute myocardial infarction, or pericarditis. eighty percent of patients have clinical signs of soft-tissue infection, such as localized swelling and erythema, which progresses to necrotizing fasciitis or myositis in % of cases, requiring surgical debridement, fasciotomy, or amputation. of the % of cases without soft-tissue findings, a variety of clinical presentations were observed, including endophthalmitis, myositis, perihepatitis, peritonitis, myocarditis, and overwhelming sepsis. a diffuse, scarlatinalike erythema is uncommon, occurring in only % of cases. the serum creatinine phosphokinase (cpk) level is useful in detecting the presence of deeper soft-tissue infections, and when the level is elevated or rising, there is a good correlation with necrotizing fasciitis or myositis. although the initial laboratory studies may demonstrate only mild leukocytosis, the mean percentage of immature neutrophils (including band forms, metamyelocytes, and myelocytes) is striking, reaching %- %. the presence of hemoglobinuria and elevated serum creatinine values is evidence of renal involvement. it is important to note that renal impairment precedes hypotension in %- % of cases. hypoalbuminemia and hypocalcemia occur early, and become profound within - h of admission. the rapidity with which shock and multi-organ failure can progress is impressive, and many patients may die within - h of hospitalization. shock was apparent at the time of admission or within - h in virtually all patients. in only % of patients did systolic blood pressure became normal - h after the administration of antibiotics, albumin, and electrolyte solutions containing salts or dopamine; in all other patients shock persisted. interestingly, renal dysfunction preceded shock in many cases and was apparent on admission in most patients. renal failure progressed or persisted in all patients for - h, and several patients required dialysis for - days. in patients who survived, serum creatinine values returned to normal within - weeks. acute respiratory distress syndrome (ards) occurred in % of patients and generally developed after the onset of hypotension. the severity of ards was such that supplemental oxygen, intubation, and mechanical ventilation was necessary in % who developed this syndrome. mortality rates have varied from % to %; , , however, morbidity is also high; of patients in one series underwent major surgical procedures, which included fasciotomy, surgical debridement, exploratory laparotomy, intraocular aspiration, amputation, or hysterectomy. characteristics of clinical isolates of group a streptococci many different characteristics have been associated with streptss; however, m-types , , , , and account for the majority of isolates. , recently, % of strains in sweden from all types of group a streptococcal infection have been m-type . pyrogenic exotoxin a (spea) and/ or b (speb) were found in the majority of cases of severe infection. in the united states, spea is most frequently associated with these infections, , , , [ ] [ ] [ ] while in sweden and the united kingdom, speb has been most common. , recently, streptococcal superantigen (ssa), a novel pyrogenic exotoxin, has been isolated from an m- strain, albeit in small concentrations. in addition, mitogenic factor (mf) has been demonstrated in many different m-types of group a streptococcus. , pathogenic mechanisms the role of adherence and penetration of pharyngeal epithelial cells has been the subject of intense research recently to determine which surface components of the group a streptococcus are involved, and to determine if penetration of such cells correlates with the ability of a strain to cause invasive infection. lapenta et al. demonstrated that m- strains were efficient at adherence and penetration of respiratory epithelial cells. dombeck et al. then demonstrated that a clonal variant of m- group a streptococcus linked to invasive infections (designated m invϩ) demonstrated high frequency internalization of cultured hela cells, and that this was dependent upon m-protein. in contrast, others have demonstrated that m- strains adhered to and invaded epithelial cells less efficiently than other m-types. , in addition, molinari and chhatwal have demonstrated that, regardless of m-type, strains isolated from invasive cases (blood isolates) exhibited poorer attachment and internalization of epithelial cells than strains isolated from throat or skin. kawabata et al. demonstrated that hyaluronic acid capsule decreased the invasion efficiency. tsai et al. investigated the role of speb in the invasion of respiratory epithelial cells (a- ) and found that speb knockout strains demonstrated reduced ability to invade cells, and that exogenous addition of speb increased invasion by the speb knockout mutants. in other studies, speb knockout mutants did not demonstrate reduced invasion of epithelial cells. this discrepancy could, in part, be explained by the recent work of woischnik, buttaro, and podbielski, who demonstrated that inactivation of the speb structural gene (speb) decreased hyaluronic acid capsule production, but did not affect other virulence factors. these findings demonstrate that interpretation of data from experiments using isogenic mutants may not always be straightforward. talay et al. and hanski et al. demonstrated that streptococcal fibronectin binding protein i (sfbi) mediated the binding of group a streptococcus to epithelial cells in the presence of fibronectin. subsequently, okada et al., using strains lacking the prtf gene, have conclusively demonstrated that protein f, a fibronectin binding protein (sfbi), mediates the attachment of group a streptococcus to hela cells. molinari and chhatwal demonstrated that the distribution of sfbi was lowest among blood isolates ( %) and highest ( %) among skin and throat isolates. these authors concluded that reduced sfbi expression was responsible for the reduced invasiveness of blood isolates. as described under the discussion on bacterial adherence and penetration, m-protein may serve as a ligand in specific strains of group a streptococcus. recent studies by jadoun et al. suggest that both m-protein (m- ) and sfbi may participate in the adherence and invasion of epithelial cells. this is supported by the observation that type-specific siga and igg antibody prevented the adherence and invasion, respectively, of human pharyngeal cells challenged with m- strains. in summary, the adherence and penetration of epithelial cells by group a streptococcus is a very complex process, and it is dependent upon the cell type, state of differentiation (e.g., keratinocyte), strain of group a streptococcus, the immune status of the host, and the inflammatory milieu of the host environment. the importance of these latter points is substantiated by the observation that tumor necrosis factor (tnf) and interleukin- (il- ) reduce the adherence of group a streptococcus to keratinocytes, and by the demonstration that sfbi-vaccinated animals showed % and % protection against homologous and heterologous intranasal challenge with viable group a streptococcus. finally, sfbi and sfbii were found in % and % of strains in the northern territory in australia, and high levels of igg antibody were found in the sera of subjects with defined streptococcal infections. mechanisms of shock pyrogenic exotoxins induce fever in humans and animals, and also participate in shock by lowering the threshold to exogenous endotoxin. streptococcal pyrogenic exotoxins a and b induce human mononuclear cells to synthesize not only tnfα but also il- and il- , [ ] [ ] [ ] suggesting that tnf could mediate the fever, shock, and organ failure observed in patients with streptss. pyrogenic exotoxin c has been associated with mild cases of scarlet fever in the united states (author's observations) and in england. the roles of newly described pyrogenic exotoxins, such as ssa and mf, in the pathogenesis of streptss have not been elucidated. there is strong evidence suggesting that spea, speb, and spec, as well as a number of staphylococcal toxins (tsst- , and staphylococcal enterotoxins a, b, and c) act as superantigens and stimulate t-cell responses through their ability to bind to both the class ii mhc complex of antigen-presenting cells and the v region of the t-cell receptor. the net effect is induction of t-cell proliferation (via an il- mechanism), with the concomitant production of cytokines (e.g., il- , tnfα, tnf , il- , and interferon [ifn]γ) that mediate shock and tissue injury. recently, hackett and stevens demonstrated that spea induced both tnfα and tnf from mixed cultures of monocytes and lymphocytes, supporting the role of lymphokines (tnf ) in shock associated with strains producing spea. kotb et al. have shown that a digest of m-protein type can also stimulate t-cell responses by this mechanism. interestingly, quantitation of such v t-cell subsets in patients with acute streptss demonstrated deletion rather than expansion, suggesting that perhaps the lifespan of the expanded subset was shortened by a process of apoptosis. in addition, the subsets deleted were not specific for spea, speb, spec, or mf, suggesting that perhaps an as yet undefined superantigen may play a role in streptss. cytokine production by less exotic mechanisms may also contribute to the genesis of shock and organ failure. peptidoglycan, lipoteichoic acid, and killed organisms , are capable of inducing tnfα production by mononuclear cells in vitro. , , exotoxins such as slo are also potent inducers of tnfα and il- . speb, a proteinase precursor, has the ability to cleave pre-il- to release preformed il- . finally, slo and spea together have additive effects in the induction of il- by human mononuclear cells. whatever the mechanisms, the induction of cytokines in vivo is likely the cause of shock, and slo, spea, speb, and spec, as well as cell wall components, etc., are potent inducers of tnf and il- . finally, a cysteine protease formed from the cleavage of speb may play an important role in pathogenesis by the release of bradykinin from endogenous kininogen and by activating metalloproteases involved in coagulation. the mere presence of virulence factors, such as mprotein or pyrogenic exotoxins, may be less important in streptss than the dynamics of their production in vivo. for example, chaussee et al. have demonstrated that, among strains from patients with necrotizing fasciitis and streptss, approximately % and around % produced spea or speb, respectively. in addition, the quantity of spea, but not of speb, was higher for strains from streptss patients compared to with patients with findings in non-invasive disease. recently, cleary et al. have proposed a regulon in group a streptococcus that controls the expression of a group of virulence genes coding for virulence factors such as m-protein and c a-peptidase. using dna fingerprinting, cleary et al. showed differences in m- strains isolated from patients with invasive disease compared with m- strains from patients with non-invasive group a streptococcal infections. such strains of group a streptococci could acquire genetic information coding for spea via a specific bacteriophage. multi-locus enzyme electrophoresis demonstrates two patterns, which correspond to m- and m- type organisms that produce pyrogenic exotoxin a, a finding that fits epidemiologic studies implicating these strains in invasive group a streptococcal infections in the united states. numerous studies have demonstrated that spea potentiates the action of lipopolysaccharide (lps) in inducing shock. interestingly, this effect is largely the result of tcell activation, and the "potentiating activity" can be passively transferred to rabbits by infusing supernatants from spea-stimulated lymphocytes, and is likely mediated by ifn-γ and tnf . in contrast, the timing of pre-treatment with spea is crucial, because, as shown by stevens et al., the pretreatment of mice with spea h prior to lps challenge resulted in protection from lps-induced shock, probably due to the production of immunosuppressive cytokines such as il- . finally, sriskandan et al. have demonstrated that animals immunized with recombinant spea have a higher mortality when challenged with a spea-producing strain of group a streptococcus than animals that are sham immunized. further sriskandan et al. have demonstrated that animals challenged with a spea knockout strain of group a streptococcus had greater mortality and greater tissue destruction than animals challenged with the wild-type parent strain. thus, the roles of the pyrogenic exotoxins in the pathogenesis of severe group a streptococcal infections are complex and remain to be fully elucidated. however, the importance of cytokine induction in group a streptococcal infections cannot be denied. hackett et al. have shown that cell wall components from killed invasive and noninvasive strains of group a streptococci elicit significant tnfα production by mononuclear cells, exceeding that elicited by spea, speb, or slo. further, viable slodeficient, but not viable wild-type, group a streptococci stimulated high levels of tnfα, suggesting that slo suppresses the induction of this cytokine, perhaps, in part, because of its cytotoxic effects on host cells. cytokine induction by cell wall components of the group a streptococcus has also been demonstrated by muller-alouf et al. an important role for tnfα in the shock associated with severe group a streptococcal infections is also suggested by the remarkable efficacy of a neutralizing monoclonal antibody against tnfα in an experimental streptococcal bacteremia model in non-human primates. the survival of animals was increased by %, and markers of organ failure, such as serum creatinine and lactate, were also significantly improved. other mechanisms of shock and organ failure recently, chatellier and kotb demonstrated that the cg rich motifs of emm functioned as superantigens and induced t-cell proliferation. sriskandan et al. have also demonstrated that inducible nitric oxide (inos) may play a role in the shock associated with a group a streptococcal necrotizing soft-tissue infection. in that model, nmonomethyl-l-arginine (l-nmma) administration reduced nitrate levels in serum, but did not reduce mortality. the role of streptokinase in invasive group a streptococcal infections has not been extensively studied; however, recent studies demonstrate that certain alleles of streptokinase (ska ) have three energetic folding units which change the tertiary structure of ska into a more lipophilic molecule with high affinity for glomeruli. only ska isogenic mutants are capable of causing kidney lesions with polymorphonuclear lencocyte (pmnl) influx into the glomeruli, as well as deposition of c . streptolysin s (sls) has been known for a long time to be a potent cytotoxin for many different cell types, although it has only recently been implicated as a significant virulence factor. betschel et al. have demonstrated that insertional activation of the gene controlling sls resulted in reduced virulence in a mouse model. recently, nizet et al. have demonstrated that sls production is controlled by a contiguous nine-gene locus, saga to sagi, and that the sls gene product likely has a structure similar to the bacteriocin family of microbial toxins. antibiotic therapy -importance of the mechanism of action streptococcus pyogenes remains exquisitely susceptible to -lactam antibiotics, and penicillin has excellent efficacy in the treatment of erysipelas, impetigo, and cellulitis, as well as in the prevention of acute rheumatic fever. nonetheless, clinical failures of penicillin treatment of streptococcal infection do occur, and penicillin fails to eradicate bacteria from the pharynx of patients with documented streptococcal pharyngitis in %- % of patients. [ ] [ ] [ ] finally, more aggressive group a streptococcal infections (such as necrotizing fasciitis, empyema, burn wound sepsis, subcutaneous gangrene, and myositis) respond less well to penicillin and continue to be associated with high mortality and extensive morbidity. , , , , , , for example, a recent report of cases of streptococcal myositis reported an overall mortality of % despite penicillin therapy. studies in experimental infection have demonstrated that penicillin fails when large numbers of organisms are present. , for example, in a mouse model of myositis caused by s. pyogenes, penicillin was ineffective when treatment was delayed for h or more after initiation of infection. mice receiving clindamycin, however, had survival rates of %, %, %, and % when treatment was delayed , , , and . h, respectively. , eagle suggested that penicillin failed in this type of infection because of the "physiologic state of the organism." this phenomenon has recently been attributed to inoculum effects, both in vitro and in vivo. , it has also been observed that penicillin and other -lactam antibiotics are most efficacious against rapidly growing bacteria. early in the stages of infection, or in mild infections, organisms grow rapidly in vivo but are present in rather small numbers. with delays in treatment, higher concentrations of group a streptococci accumulate, and growth begins to slow to a stationary phase. that high concentration of s. pyogenes accumulate in deep-seated infection is supported by the data from eagle. why should penicillin lose its efficacy when large numbers of group a streptococci are present or when they are making the transition from logarithmic to stationary growth? because penicillin mediates its antibacterial action against group a streptococci by intimately interacting with the expressed penicillin-binding proteins (pbps), we compared the pbp patterns from membrane proteins of group a streptococci isolated from different stages of growth, i.e., mid-log-phase and stationary-phase. the binding of radiolabeled penicillin by all pbps was decreased in stationary cells. in fact, pbps and were undetectable at h. thus, the loss of certain pbps during stationary-phase growth in vitro may be responsible for the inoculum effect observed in vivo, and may account for the failure of penicillin in both experimental and human cases of severe streptococcal infection. the greater efficacy of clindamycin in severe group a streptococcal infections is due to many factors. first, its efficacy is not affected by inoculum size or stage of growth. , secondly, clindamycin suppresses bacterial toxin synthesis. , third, clindamycin facilitates the phagocytosis of s. pyogenes by inhibiting m-protein synthesis. fourth, clindamycin suppresses the synthesis of pbps which, in addition to being targets for penicillin, are also enzymes involved in cell wall synthesis and degradation. fifth, clindamycin has a longer post-antibiotic effect thanlactams such as penicillin. lastly, we have recently shown that clindamycin suppresses lps-induced monocyte synthesis of tnfα. thus, clindamycin's efficacy may also be related to its ability to modulate the immune response to group a streptococcal infection. interestingly, in a recent retrospective analysis of streptss cases, zimbelman et al. demonstrated significantly improved survival in patients receiving clindamycin compared with survival in those treated with -lactam antibiotics. prompt and aggressive exploration and debridement of suspected deep-seated s. pyogenes infection is crucial to limit complications, as well as to prevent extension to vital areas that may be impossible to debride (i.e., the head and neck, thorax, or abdomen). because definite cutaneous evidence of necrotizing fasciitis and myositis may not appear until late in the course, the index of suspicion should be high in patients with fever, excruciating pain, and systemic toxicity. radiographs and ct and mri scans in patients with streptss show soft-tissue swelling and an absence of gas, thus providing clues to the site of the deep infection. prompt surgical exploration through a small incision, with visualization of muscle and fascia, and timely gram stain of surgically obtained material provide the earliest and most definitive etiologic diagnosis. because of intractable hypotension and diffuse capillary leak, massive amounts of intravenous fluids ( - l/day) are often necessary, and about % of patients have significant clinical improvement. pressors such as dopamine are used frequently, although no controlled trials have been performed in streptss. in patients with intractable hypotension, vasoconstrictors such as epinephrine have been used, but frequently, symmetrical gangrene of digits results (author's unpublished observations). loss of all digits on both hands and feet, or loss of both arms and legs has occurred in this setting. in these cases it is difficult to determine whether the symmetrical gangrene is caused by the pressors or by the infection, or by both. neutralization of circulating toxins would be a desirable therapeutic modality, yet appropriate antibodies are not commercially available in the united states or europe. case reports, , and one non-randomized clinical trial, report that commercial intravenous gamma globulin (ivig) has been useful for treating streptss. a doubleblind study using ivig is currently underway in northern europe. because cytokines are important mediators of shock in streptss, strategies to inhibit or neutralize their effects may provide useful treatments. recently, a monoclonal antibody against tnfα showed promising efficacy in a baboon model of streptss. finally, anecdotal reports suggest that hyperbaric oxygen may be helpful; however, no controlled studies are underway, nor is it clear if this treatment is useful. currently, several group a streptococcal virulence factors are being investigated as potential vaccine candidates. these include: group a polysaccharide, c a peptidase, speb, spea, the conserved segment of the m-protein molecule, and a cassette of peptides representing the hypervariable regions of m-protein from strains commonly encountered. at the present time, none have been studied in humans. the risk of secondary cases of streptss must be low, based on the low prevalence of this disease despite a high prevalence of "virulent strains of group a streptococci" in the population at large. yet, clusters of group a streptococcal invasive infections have been described in nursing homes , , in healthcare workers, , and among family members. , finally, patients may acquire group a streptococci from hospital personnel, and this was best demonstrated historically by semmelweis, in vienna, and holmes, in the united states, although even in modern times such transmission is well documented. , , epidemiologic investigation of clusters of cases is important, and treatment of contacts may be necessary despite the low risk of secondary invasive infection. primary care physicians must consider the extent of exposure, the type of exposure, and the risk factors of the contact. for example, a contact of a case of streptss with risk factors such as chicken pox, leukemia, burns, or recent surgery, or any open skin lesion, should receive prophylaxis with penicillin, erythromycin, or clindamycin. invasive group a streptococcal disease in the netherlands: evidence for a protective role of antiexotoxin a antibodies an outbreak of invasive group a streptococcal disease associated with high carriage rates of the invasive clone among school-aged children streptococcal toxic shock syndrome: spectrum of disease, pathogenesis and new concepts in treatment streptococcal serogroup a epidemic in norway - invasive group a streptococcal infections: t mi isolates expressing pyrogenic exotoxins a and b in combination with selective lack of toxinneutralizing antibodies are associated with increased risk of streptococcal toxic shock syndrome protective immunity to the group a streptococcus may be only strain specific hetereogeneous opsonic activity of convalescence serum against m- strains of group a streptococci (gas) epidemiologic analysis of group a streptococcal serotypes associated with severe systemic infections, rheumatic fever, or uncomplicated pharyngitis genetic and phenotypic diversity among isolates of streptococcus pyogenes from invasive infections production of nadase in clinical isolates of streptococcus pyogenes diphosphopyridine nucleotidase as an extracellular product of streptococcal growth and its possible relationship to leukotoxicity application of a new method for detecting streptococcal nicotinamide adenine dinucleotide glycohydrolase to various m types of streptococcus pyogenes nadϩ-glycohydrolase productivity of haemolytic streptococci assayed by a simple fluorescent method and its relation to t serotype the nad-glycohydrolase (nga) gene of streptococcus pyogenes mole-cular epidemiology of nga and nad glycohydrolase/adp-ribosyltransferase activity among streptococcus pyogenes causing streptococcal toxic shock syndrome reappearance of scarlet fever toxin a among streptococci in the rocky mountain west: severe group a streptococcal infections associated with a toxic shock-like syndrome invasive group a streptococcus infections complications of varicella i. their occurrence among patients group a beta-hemolytic streptococcal bacteremia: historical overview, changing incidence, and recent association with varicella treatment of patients with a history of recurrent tonsillitis due to group a -hemolytic streptococci peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines human endothelial cells in culture produce platelet-activating factor ( -alkyl- -acetyl-sn-glycero- -phosphocholine) when stimulated with thrombin the writings of oliver wendell holmes fatal infections by haemolytic streptococcus group b the return of lifethreatening puerperal sepsis caused by group a streptococci an epidemic of "childbed fever life-threatening puerperal sepsis caused by group a streptococci puerperal sepsis due to infected episiotomy wound puerperal sepsis caused by streptococcus group a with a severe form of progression like "toxic shock-like syndrome a new type of fulminant group a streptococcal infection in obstetric patients: report of two cases nosocomial group a streptococcal infections associated with asymptomatic health-care workers -maryland and california zur kenntnis und behandlung des nekrotisierenden erysipels hemolytic streptococcus gangrene streptococcal myositis peracute spontaneous streptococcal myositis. a report on two fatal cases with review of literature aspects of pathogenesis of serious group a streptococcal infections in sweden, - severe invasive group a streptococcal infections in streptococcal necrotizing myositis -a rare entity: a report of two cases spontaneous gangrenous myositis induced by streptococcus pyogenes: case report and review of the literature streptococcal infections in skin and soft tissues spontaneous, nontraumatic gangrene due to clostridium septicum experimental approach to the problem of treatment failure with penicillin. i. group a streptococcal infection in mice the eagle effect revisited: efficacy of clindamycin, erythromycin, and penicillin in the treatment of streptococcal myositis changing epidemiology of group a streptococcal infection in the usa familial transmission of a serious disease-producing group a streptococcus clone: case reports and review spread of serious disease-producing m clones of group a streptococcus among family members and health care workers transmission of streptococcus pyogenes causing toxic shock-like syndrome among family members and confirmation by dna macrorestriction analysis invasive group a streptococcal infections in ontario outbreak of invasive group a streptococcal infections in a nursing home. lessons on prevention and control invasive group a streptococcal (gas) serotype m- outbreak in a long-term care facility (ltcf) with mortality septic shock induced by group a streptococcal infections: clinical and therapeutic aspects association of exotoxin-producing group a streptococci and severe disease in children molecular analysis of pyrogenic exotoxins from streptococcus pyogenes isolates associated with toxic shock-like syndrome streptococcus pyogenes causing toxic-shock-like syndrome and other invasive diseases: clonal diversity and pyrogenic exotoxin expression correspondence: group a streptococcal infections and a toxic shock-like syndrome a novel superantigen isolated from pathogenic strains of streptococcus pyogenes with aminoterminal homology to staphylococcal enterotoxins b and c cloning, characterization and overexpression of a streptococcus pyogenes gene encoding a new type of mitogenic factor superantigenic properties of the group a streptococcal exotoxin spef (mf) group a streptococci efficiently invade human respiratory epithelial cells high-frequency intracellular invasion of epithelial cells by serotype m group a streptococci: m protein-mediated invasion and cytoskeletal rearrangements invasion and survival of streptococcus pyogenes in eukaryotic cells correlates with the source of clinical isolates comparison of adherence to and penetration of a human laryngeal epithelial cell line by group a streptococci of various m protein types capsular hyaluronic acid of group a streptococci hampers their invasion into human pharyngeal epithelial cells effect of group a streptococcal cysteine protease on invasion of epithelial cells role of group a streptococcal virulence factors in adherence to keratinocytes inactivation of the cysteine protease speb affects hyaluronic acid capsule expression in group a streptococci fibronectin-binding protein of streptococcus pyogenes: sequence of the binding domain involved in adherence of streptococci to epithelial cells protein f, a fibronectin-binding protein, is an adhesin of the group a streptococcus streptococcus pyogenes streptococcus pyogenes protein f promotes invasion of hela cells protein f is required for efficient entry of streptococcus pyogenes into epithelial cells immunoglobulins to group a streptococcal surface molecules decrease adherence to and invasion of human pharyngeal cells tumor necrosis factoralpha and interleukin- alpha decrease the adherence of streptococcus pyogenes to cultured keratinocytes protective immune response against streptococcus pyogenes in mice after intranasal vaccination with the fibronectin-binding protein sfbi distribution and antigenicity of fibronectin binding proteins (sfbi and sfbii) of streptococcus pyogenes clinical isolates from the northern territory, australia toxic shock syndromeassociated staphylococcal and streptococcal pyrogenic toxins are potent inducers of tumor necrosis factor production cytokine production by human mononuclear cells in response to streptococcal exotoxins similar cytokine induction profiles of a novel streptococcal exotoxin, mf, and pyrogenic exotoxins a and b cytokine production by murine cells activated by erythrogenic toxin type a superantigen of streptococcus pyogenes the production of pyrogenic exotoxins by group a streptococci characterization of a superantigen from a pathogenic strain of streptococcus pyogenes (abstract) streptococcal toxic shock syndrome: synthesis of tumor necrosis factor and interleukin- by monocytes stimulated with pyrogenic exotoxin a and streptolysin o cellular and biochemical responses of human t lymphocytes stimulated with streptococcal m protein selective depletion of v -bearing t cells in patients with severe invasive group a streptococcal infections and streptococcal toxic shock syndrome gram-positive shock cytokine induction by viable group a streptococci: suppression by streptolysin o comparative study of cytokine release by human peripheral blood mononuclear cells stimulated with streptococcus pyogenes superantigenic erythrogenic toxins, heat-killed streptococci and lipopolysaccharide superantigens associated with staphylococcal and streptococcal toxic shock syndromes are potent inducers of tumor necrosis factor beta synthesis cleavage of interleukin (il- ) precursor to produce active il- by a conserved extracellular cysteine protease from streptococcus pyogenes activation of a -kilodalton human endothelial cell matrix metalloprotease by streptococcus pyogenes extracellular cysteine protease a virulence regulon in streptococcus pyogenes clonal basis for resurgence of serious streptococcus pyogenes disease in the s group a streptococcal pyrogenic exotoxin: pyrogenicity, alteration of blood-brain barrier, and separation of sites for pyrogenicity, and enhancement of lethal endotoxin shock macrophage hyperreactivity to endotoxin induced by streptococcal pyrogenic exotoxin in rabbits pretreatment with either endotoxin (lps), tumor necrosis factor α (tnfα) or streptococcal pyrogenic exotoxin a (spea) protects mice from lethal streptococcal infection streptococcal pyrogenic exotoxin a release, distribution, and role in a murine model of fasciitis and multiorgan failure due to streptococcus pyogenes streptococcal pyrogenic exotoxin a (spe a) can augment neutrophil recruitment to sites of inflammation group a streptococcal bacteremia: the role of tumor necrosis factor in shock and organ failure identification of dna cpg sequence motifs in group a streptococcal virulent genes that preferentially stimulate human lymphocytes: evidence for differential host reponsiveness the role of nitric oxide in experimental murine sepsis due to pyrogenic exotoxin a-producing streptococcus pyogenes allele substitution of the streptokinase gene reduces the nephritogenic capacity of group a streptococcal strain nz reduced virulence of group a streptococcal tn mutants that do not produce streptolysin s genetic locus for streptolysin s production by group a streptococcus association of penicillin tolerance with failure to eradicate group a streptococci from patients with pharyngitis failure of penicillin to eradicate group a streptococci during an outbreak of pharyngitis role of beta-lactamase-producing bacteria in the failure of penicillin to eradicate group a streptococci streptococcal toxic shock syndrome streptococcus pyogenes and the toxic shock syndrome invasive group a streptococcal infection: new concepts in antibiotic treatment penicillin binding protein expression at different growth stages determines penicillin efficacy in vitro and in vivo: an explanation for the inoculum effect the in vitro antibacterial activity of ceftriaxone against streptococcus pyogenes is unrelated to penicillin-binding protein persistent acylation of highmolecular weight penicillin binding proteins by penicillin induces the post antibiotic effect in streptococcus pyogenes effect of antibiotics on toxin production and viability of clostridium perfringens potentiation of opsonization and phagocytosis of streptococcus pyogenes following growth in the presence of clindamycin antibiotic effects on bacterial viability, toxin production, and host response improved outcome of clindamycin compared with beta-lactam antibiotic treatment for invasive streptococcus pyogenes infection intravenous immunoglobulin therapy for toxic shock syndrome necrotising fasciitis (letter) intravenous immunoglobulin therapy for streptococcal toxic shock syndrome. a comparative observational study clusters of invasive group a streptococcal infections in family, hospital, and nursing home settings transmission of 'toxic strep' syndrome from an infected child to a firefighter during cpr wound infections due to group a streptococcus traced to a vaginal carrier the working group on prevention of invasive group a streptococcal infections. prevention of invasive group a streptococcal diseases among household contacts of case-patients: is prophylaxis warranted? acknowledgments this material is based upon work supported by the office of research and development, medical research service, department of veterans affairs. key: cord- - f evh authors: nunes, márcio roberto teixeira; de souza, william marciel; acrani, gustavo olszanski; cardoso, jedson ferreira; da silva, sandro patroca; badra, soraya jabur; figueiredo, luiz tadeu moraes; vasconcelos, pedro fernando da costa title: revalidation and genetic characterization of new members of group c (orthobunyavirus genus, peribunyaviridae family) isolated in the americas date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: f evh group c serogroup includes members of the orthobunyavirus genus (family peribunyaviridae) and comprises arboviruses that can be associated with febrile illness in humans. although previous studies described the genome characterization of group c orthobunyavirus, there is a gap in genomic information about the other viruses in this group. therefore, in this study, complete genomes of members of group c serogroup were sequenced or re-sequenced and used for genetic characterization, as well as to understand their phylogenetic and evolutionary aspects. thus, our study reported the genomes of three new members in group c virus (apeu strain bean , itaqui strain bean and nepuyo strain bean ), as well as re-sequencing of original strains of five members: caraparu (strain bean ), madrid (strain bt ), murucutu (strain bean ), oriboca (strain bean ), and marituba (strain bean ). these viruses presented a typical genomic organization related to members of the orthobunyavirus genus. interestingly, all viruses of this serogroup showed an open reading frame (orf) that encodes the putative nonstructural nss protein that precedes the nucleoprotein orf, an unprecedented fact in group c virus. also, we confirmed the presence of natural reassortment events. this study expands the genomic information of group c viruses, as well as revalidates the genomic organization of viruses that were previously reported. introduction group c viruses are antigenically characterized into the genus orthobunyavirus, family peribunyaviridae, order bunyavirales [ ] . this name is historically based on their serological characteristics, which makes them distinct from members of group a (alphaviruses genus of the family togaviridae) and group b (flavivirus genus of the family flaviviridae) antigenic groups [ ] . currently, the group c serogroup is composed of distinct viruses isolated from humans, wild animals (mainly rodents, monkeys, marsupials, and bats), and mosquitoes. these viruses are present in tropical and subtropical areas of the americas, including the united states, mexico, panama, honduras, guatemala, trinidad, brazil, peru, ecuador, venezuela, and french guiana [ , , ] . clinically, the human infections caused by group c viruses are asymptomatic or characterized by unspecific febrile illness [ , , ] . the percentage of asymptomatic group c viruses infections are unknown, and apparently, the prevalence of antibodies against group c viruses is directly related to people living nearby or maintaining close contact to forest or ecological niches in tropical areas [ ] . the genomes of members of group c viruses presents the typical organization of other orthobunyaviruses, which are a tri-segmented negative-sense rna named small (srna), medium (mrna) and large (lrna) segments. the srna encodes a nucleocapsid protein (n protein) and a non-structural protein (nss), while the mrna encodes a polyprotein precursor that after a post-cleavage process gives rise to two envelope glycoproteins (gc and gn) and a non-structural protein (nsm). lrna segment encodes a large rna-dependent rna polymerase (rdrp) [ ] . so far, previous studies have described the genomic characteristics s and m rna segments of members of group c viruses, but many sequences generated by sanger sequencing approach were divergent, despite using the same strains of group c viruses [ , [ ] [ ] [ ] . therefore, in this study, we combined high-throughput sequencing (hts), rapid amplifica- viruses strains used in this study were propagated into vero cells (atcc ccl- ™), as previously described [ ] . the infected cells were incubated for to days until visualization of viral cytopathic effect. table provides the names, strains, year, sources and local of isolation, as well as the genbank accession numbers. viral rnas were extracted from the supernatant of infected vero cells using the purelink viral rna mini kit (invitrogen, usa) following the manufactures instructions. then, the strands of the rna synthesis were performed using the kit cdna synthesis system and μm roche "random" primer according to the manufacturer's instructions. the cdnas were prepared for hts on a gs flx+ pyrosequencer (roche, life sciences) at the center for technological innovation at the evandro chagas institute, ministry of health, brazil. the de novo assembling strategy applied to obtain the genomes was used with program newbler v. . [ ] . additionally, sequences for terminal untranslated regions (utrs) were determined by '/ ' rapid amplification of cdna ends (race) sequencing (s table) [ ] . virus genomes were evaluated regarding it sizes, annotations of putative open reading frame (orf), ' and ' non-coding regions (ncrs) and conserved motifs with geneious . . (biomatters, new zealand), for identification of transmembrane regions and signal peptide we used the topcons web server [ ] and for identification of n-glycosylation sites we used netnglyc . server (http://www.cbs.dtu.dk/services/netnglyc/). the annotations of protein domains were performed with interpro . [ ] . the presence of potential characteristic motifs for orthobunyaviruses were identified on multiple sequence alignments (msa) based on amino acids sequences, which were carried out using muscle v. . [ ] , and visualized in geneious . . (biomatters, new zealand). maximum likelihood (ml) phylogenetic trees were constructed using nucleotide and amino acids sequences of viruses reported in our study and additional sequences of members of group c viruses with complete coding sequences (s, m, and l) available in the genbank database (http://www.ncbi.nlm.nih.gov/) until th of april of . the msas were carried out using muscle v. . [ ] . the phylogenies were inferred by iq-tree version . . software using the best-fit model based on bayesian information criterion, and the gtr+i+g nucleotide substitution model was used to all rna segments, and lg+g , lg+i+g , and lg+g amino acids substitution model to s, m, and l, respectively. statistical supports for individual nodes were estimated using the bootstrap value using , replicates [ ] . the phylogenetic trees were visualized using the figtree software v. . . . in addition, the nucleotides and amino acid distances among viruses of group c were estimated with segment s, m, and l using the p-distance values. standard error estimations were calculated by bootstrapping method ( , replicates) using the mega v. program [ ] . potential reassortment events were analyzed by distinct phylogenetic topologies based on the depicted trees at the nucleotide level. in addition, all genes were concatenated in a single sequence, and an msa was performed using the program muscle . [ ] . potential reassortment events were then analyzed using the rdp, geneconv, bootscan, maxchi, chimaera, siscan and seq methods implemented in rdp [ ] . common program settings for all methods were used to perceive sequences as linear, to require phylogenetic evidence, to refine breakpoints and to check alignment consistency. the highest acceptable p-value was set as . , after considering bonferroni correction for multiple comparisons. all method-specific program settings remained at their default values. our results showed that the complete srna segments of group c viruses ranged from , to , nucleotides (nt) and presents the open reading frame (orf) of the nucleocapsid (n) protein, with a conserved size of amino acids (aa) and . to . kda for all viruses (fig ) . the second orf in the s segment in these viruses encodes a putative non-structural protein (nss). interestingly, the orf to nss gene starts at an atg codon - nucleotides downstream of the n orf start codon, which potentially encodes an nss protein of nt ( aa) with a molecular mass of~ . kda (fig ) . the nss protein is common in most orthobunyaviruses that have been isolated from vertebrates, such as the members of group c viruses [ ] . previously studies have been reported that caraparu and madrid from group c viruses encode an nss protein with amino acids, and also a aa nss, predicted to be truncated in the n-terminus of marituba and oriboca viruses, and consequently, could not be expressed [ , , ] . indeed, our analysis demonstrates that possibly the members of group c viruses present a pre-n coding strategy, as recently described for the brazoran and enseada orthobunyaviruses [ , ] . therefore, some s segment sequences previously reported for group c viruses are possibly incomplete, as shown in fig . whereas that nss protein has been demonstrated to play crucial roles in virulence and pathogenesis of orhobunyaviruses [ ] , further studies using reverse genetics may elucidate the biological importance of nss protein found in viruses of group c. the complete mrna segments ranged from , to , nt in length, which encodes the glycoprotein precursor (gpc), ranging from , to , aa in length ( . to . kda) with a similar topology to other members of the orthobunyavirus genus (fig ) . the gpc is proteolytically cleaved to yield two structural glycoproteins, gn ( to aa and . to . kda) and gc ( to aa and . to . kda), and a nonstructural protein (nsm) with or nt ( . to . kda) (fig ) . the gpc contains the specific n-terminal signal peptide that is common to all members of the genus, which is responsible for delivering the nascent polypeptide to the endoplasmic reticulum [ ] . the conserved zinc finger region (amino acids position to ) and fusion peptide (amino acids position to ) in the gpc protein were also identified, which is an important rna binding site and is probably involved in viral assembly [ ] . furthermore, the gpc was predicted to contain five transmembrane regions (tmds): a single tmd in gn (close to the c-terminus); three tmds in nsm; and a single one, close to the c-terminus in gc (fig ) . the tmds in gn and gc have been shown to play crucial roles in membrane fusion, assembly, and morphogenesis [ ] . the complete lrna segments ranged from , to , nt in length, with an orf that encodes an rna-dependent rna polymerase (rdrp) of , aa, with a predicted molecular weight of . to . kda. the unique exception is nepuyo virus strain bean with a rdrp of , aa. this protein contains the conserved polymerase activity domains consisting of pre-motif a and motifs a through e in position to aa, as well as the n-terminal endonuclease motifs h, pd, and dxk (fig ) . these domains are highly conserved in negative sense rna viral polymerases as well as other members of the bunyavirales order and are directly involved in the polymerase function activity [ ] . in addition, we observed two mismatches in the th and th nucleotide of the s segments, and another mismatch in the th nucleotide of the l segments, but we did not found mismatches in the utr of m segments (s fig). murv strain bean , oriv strain bean , mtbv strain bean , carv strain bean and madv strain bt viruses present . to % nucleotide identities with the corresponding partial genomic sequences that were previously reported (fig d- f and parts d-f of s fig) [ , , ]. on the other hand, the new viruses that we have been sequenced the complete coding sequences shared higher nucleotide identify with partial genomes, such as apeu strain bean , which shared % nucleotide identify in all segments with partial sequences of same strains previously described [ ] . in addition, the amino acid substitutions were observed as follow: carv strain bean (s p and k n) on gpc. mtbv strain bean (q r); (l q); (q k) and (k r) on rdrp and (g r and d n) in gpc. murv strain bean (f s) in rdrp. however, we did not observe any amino acid substitutions in the nucleoprotein sequence of the viruses that were submitted to the resequencing protocol. on the other hand, the identified amino acids substitutions observed in gpc and rdrp of our results compared with previously sequences reported to same strains. therefore, we suspected that this fact is probably due to serial passages in cultured cells [ ] . collectively, our results are consistent with the same viral strains sequenced previously [ , [ ] [ ] [ ] , but the results of segment s suggested that some complete coding sequences previously reported for group c viruses are possibly are incomplete. to better understand the genetic relationships among group c viruses, we conducted the ml trees based on the complete coding sequences in nucleotide and amino acids level for all segments (fig and s fig) . these viruses were clustered in a unique monophyletic clade with different topologies for each segment. the s and l segments present two major clades, namely of clade a and b (fig a- c ). the clade a was subdivided in three: subclade ia, composed by murv, oriv, and restan (resv); subclade iia, with mtbv and apeuv; subclade iiia comprised by nepv, gumbo limbo (glv). the clade b was split into two subclades: subclade ib, represented by carv strains, itqv, itaya (ityv) strain iqt and fsl and madv and the subclade iiib with bruconha virus (bruv) (fig a- c) . the topology of the ml tree for the m segment reveals four phylogenetic groups that were well supported (bootstrap > %). these groups were named following previous serological classifications based on complement fixation, neutralization, and hemagglutination inhibition tests: marituba, caraparu, madrid and oriboca complexes (fig b) [ , ] . the caraparu complex includes carv, apeuv and bruv, madrid complex comprises madv and ityv, marituba complex comprises mtbv, murv, resv, nepv and glv, and the oriboca complex was composed by oriv and itqv [ ] . unfortunately, there are no complete sequences available to vinces and ossa viruses, but probably these viruses will be clustered into caraparu complex as previously showed by serological assays [ ] . possibly, the concordance observed between the phylogeny of the m segment and the serological classification occurs because the m segment encodes the glycoproteins, which are the primary antigenic determinants recognized by the neutralization and hemagglutination inhibition tests [ , ] . reassortment is an important evolutionary mechanism of segmented rna viruses in which co-infection of a host cell with multiple viruses may result in the shuffling of genomic segments [ ] . this fact has been shown to be involved in virus emergence and interspecies transmission, which include schmallenberg and oropouche virus [ ] [ ] [ ] . in group c viruses, a classic and informative study using standard antigenic tests showed cross-reactivity in marituba and murutucu by hemagglutination-inhibition and neutralization, murutucu and oriboca by complement-fixation, oriboca and itaqui by hemagglutination-inhibition and neutralization, itaqui and caraparu by complement-fixation, caraparu and apeu by hemagglutination-inhibition and neutralization and apeu and marituba by complement-fixation [ ] . however, some these viruses cross-reacted completely by one test, but not by another test and still are related. thus, these and other data indicated that the group c viruses include many natural reassortants [ ] . to elucidate this point, we compared the topology of both s and l trees with the phylogenetic tree generated using the m segment sequences and observed some discrepancies, which were supported by higher bootstrap values and significantly different likelihood scores, which suggested natural reassortment. also, after combining these branching inconsistencies in the phylogenetic trees with rdp analyses of concatenated segments, we confirmed four reassortment events with different genome segment organization than previously described [ , ] . the first reassortment event was identified in apeuv strain bean contains s and l segments from mtbv strain bean and an m segment that is probably unique. also, itqv strain bean has s and l segments from carv strain bean and a possibly unique m segment. interestingly, based on the classification of international committee on taxonomy of viruses (ictv), the reassortment events described in this study occurs between different viral species, as the apeu virus that is classified into caraparu orthobunyavirus, but the s and l this virus is from marituba orthobunyavirus. also, the itaqui and oriboca viruses are classified into oriboca orthobunyavirus, but the s and l segments of both viruses are from viruses of caraparu orthobunyavirus. despite, previous studies based on serological tests and partial genome sequences indicated that apeuv and itqv are potential reassortments, the first complete coding sequences for three segments were reported in this study [ , , , ] . the other reassortment event was observed in oriv strain bean , which possesses the s and l segments from murv strain bean , and a unique m segment (fig ) . interestingly, all reassortments observed in this study have been reported cross-reactions only by the complement-fixation method [ ] . this fact, suggests that cross-reactivity observed by complement-fixation test was determined by s segment because serologic makers identified by the l segment remains unidentified, as well as hemagglutination-inhibition, and neutralization assay that is determined by m segment, therefore, these viruses probably are unique [ ] . also, we confirmed the reassortments in ityv identified in amazon region of peru in , both strains of this virus have s and l segments from caraparu virus and a unique m segment [ ] . on the other hand, murv and resv were previously reported to be reassortments, but we did not find any evidence to support this phenomenon [ ] . additional studies, as well as other strains of group c viruses, may help to clarify this point. in summary, our study provides a better understanding and clarifies the genome sequences, genomic characterization and reassortment events, as well as the evolutionary relationship of group c serogroup. thus, our results may be helpful to better understand the evolution and diversity of these viruses, as well as can be used in further molecular epidemiological, evolutionary studies, and development of molecular methods to diagnostic of infection by group c viruses. nucleotide sequence accession number. the nucleotide sequence determined in this study have been deposited in genbank under the accession number mg to mg . molecular epidemiology of group c viruses (bunyaviridae, orthobunyavirus) isolated in the americas group c, a new serological group of hitherto undescribed arthropod-borne viruses. immunological studies. the american journal of tropical medicine and hygiene the first isolations of eastern encephalitis, group c, and guama group arboviruses from the peruvian amazon region of western south america itaya virus, a novel orthobunyavirus associated with human febrile illness, peru. emerging infectious diseases arboviral zoonoses in south america arboviral etiologies of acute febrile illnesses in western south america genomic characterization of group c orthobunyavirus reference strains and recent south american clinical isolates group c orthobunyavirus genomic sequences require validation biological characteristics and viral susceptibility of an african green monkey kidney cell line (vero) assembly algorithms for next-generation sequencing data rapid amplification of ' complementary dna ends ( ' race) the topcons web server for consensus prediction of membrane protein topology and signal peptides the interpro protein families database: the classification resource after years muscle: multiple sequence alignment with high accuracy and high throughput iq-tree: a fast and effective stochastic algorithm for estimating maximum-likelihood phylogenies. molecular biology and evolution mega : molecular evolutionary genetics analysis version . . molecular biology and evolution rdp : detection and analysis of recombination patterns in virus genomes viral rna silencing suppression: the enigma of bunyavirus nss proteins isolation of a novel orthobunyavirus (brazoran virus) with a . kb s segment that encodes a unique nucleocapsid protein possessing two putative functional domains molecular characterization of capim and enseada orthobunyaviruses. infection, genetics and evolution: journal of molecular epidemiology and evolutionary genetics in infectious diseases bunyamwera orthobunyavirus glycoprotein precursor is processed by cellular signal peptidase and signal peptide peptidase mutagenesis of the la crosse virus glycoprotein supports a role for gc ( - ) as the fusion peptide. virology role of the cytoplasmic tail domains of bunyamwera orthobunyavirus glycoproteins gn and gc in virus assembly and morphogenesis bunyaviridae rna polymerases (l-protein) have an n-terminal, influenza-like endonuclease domain, essential for viral cap-dependent transcription acquisition of cell-cell fusion activity by amino acid substitutions in spike protein determines the infectivity of a coronavirus in cultured cells further studies on the serological relationships of group c arthropod-borne viruses and the application of these relationships to rapid identification of types. the american journal of tropical medicine and hygiene identification of hitherto unrecognized arboviruses from ecuador: members of serogroups b, c, bunyamwera, patois, and minatitlan. the american journal of tropical medicine and hygiene characterization of the candiru antigenic complex (bunyaviridae: phlebovirus), a highly diverse and reassorting group of viruses affecting humans in tropical america rna virus reassortment: an evolutionary mechanism for host jumps and immune evasion genetic reassortment between sathuperi and shamonda viruses of the genus orthobunyavirus in nature: implications for their genetic relationship to schmallenberg virus oropouche virus: clinical, epidemiological, and molecular aspects of a neglected orthobunyavirus. the american journal of tropical medicine and hygiene iquitos virus: a novel reassortant orthobunyavirus associated with human illness in peru viruses of the family bunyaviridae: are all available isolates reassortants? key: cord- -azb nie authors: qvarnstrom, yvonne; nerad, thomas a.; visvesvara, govinda s. title: characterization of a new pathogenic acanthamoeba species, a. byersi n. sp., isolated from a human with fatal amoebic encephalitis date: - - journal: j eukaryot microbiol doi: . /jeu. sha: doc_id: cord_uid: azb nie acanthamoeba spp. are free‐living amoebae that are ubiquitous in natural environments. they can cause cutaneous, nasopharyngeal, and disseminated infection, leading to granulomatous amebic encephalitis (gae) in immunocompromised individuals. in addition, they can cause amoebic keratitis in contact lens wearers. acanthamoeba gae is almost always fatal because of difficulty and delay in diagnosis and lack of optimal antimicrobial therapy. here, we report the description of an unusual strain isolated from skin and brain of a gae patient. the amoebae displayed large trophozoites and star‐shaped cysts, characteristics for acanthamoebas belonging to morphology group . however, its unique morphology and growth characteristics differentiated this new strain from other group species. dna sequence analysis, secondary structure prediction, and phylogenetic analysis of the s rrna gene confirmed that this new strain belonged to group , but that it was distinct from the other sequence types within that group. thus, we hereby propose the establishment of a new species, acanthamoeba byersi n. sp. as well as a new sequence type, t , for this new strain. to our knowledge, this is the first report of a group acanthamoeba that is indisputably pathogenic in humans. acanthamoeba spp. are free-living amoebae that are ubiquitous in natural environments, such as soil and freshwaters, but are also found in a wide range of environments including dust particles in the air, bottled water, chlorinated pools, water taps and sink drains, flowerpots, aquariums, sewage, and brackish and marine waters. they have also been isolated from hydrotherapy baths, dental irrigation equipment, humidifiers, cooling systems, ventilators, and intensive care units (marciano-cabral and cabral ; schuster and visvesvara ) . acanthamoeba may enter the body via a break in the skin or inhalation of wind-blown cysts and may cause cutaneous, nasopharyngeal, and disseminated infection and subsequently spread hematogenously to the central nervous system (cns), where it can lead to granulomatous amebic encephalitis (gae) . acanthamoeba gae most often occurs in immunocompromised individuals, including hiv/aids patients, organ transplant recipients and debilitated persons. acanthamoeba gae has a worldwide distribution and often begins as a subclinical infection without any specific symptoms, making it difficult to diagnose. symptoms are vague and may mimic neurocysticercosis, tuberculoma, or brain tumor. it is frequently identified in biopsy specimens of brain lesions during late stage of the disease process or at autopsy. although a few cases have survived, acanthamoeba gae is almost always fatal because of difficulty and delay in diagnosis and lack of optimal antimicrobial therapy. acanthamoeba also causes a sight-threatening infection, acanthamoeba keratitis (ak), in contact lens wearers or eye trauma patients (visvesvara et al. ) . acanthamoebas are classified into three main groups based on distinct morphological differences in the cysts (pussard and pons ; visvesvara ) . group acanthamoebas are characterized by large trophozoites measuring - lm and cysts greater than lm in size. group acanthamoebas are mostly environmental and have not convincingly been associated with infections in humans or animals. groups and acanthamoebas have smaller trophozoites compared to group and cysts smaller than lm in size. amoebae belonging to group cause the majority of reported human infections (both ak and acanthamoeba gae) and also constitute the majority of the strains isolated from the environment. several of the group species have been shown to be pathogenic as well (booton et al. ; maciver et al. ) . cyst morphology has also been used to define species within the three main groups. however, identification at the species level is problematic as species-specific morphologic features are ambiguous and may vary with culture conditions (visvesvara ) . group is generally considered to include five species, group as many as different species, and group up to five species, but several of them may be synonyms and some strains are likely to have been assigned to the wrong species due to ambiguous identification. as a complement to the morphologic classification, molecular analyses using nuclear small subunit ribosomal rna ( s rrna) gene sequences have divided acanthamoeba into sequence types (designated t -t , also called ribotypes or genotypes) (corsaro and venditti ; gast ; gast et al. ; hewett et al. ; horn et al. ; nuprasert et al. ; stothard et al. ) . in some cases, the ribosomal sequence types correlate very well with the morphologically derived species designations (e.g. the association of sequence type t with acanthamoeba lenticulata) while other species, especially the ones belonging to group , are polyphyletic (stothard et al. ) . here, we describe the characterization of a novel species of acanthamoeba, isolated from the skin and brain of an immunosuppressed patient that died of meningoencephalitis (d'auria et al. ) . morphologic features and ribosomal sequence typing placed this new species within group acanthamoeba. a detailed case report has been published elsewhere (d' auria et al. ) . briefly, a -yr-old male received a double lung transplant in october . in mid-december, he developed skin lesions on his chest wall and posterior right lower extremity. at the end of january , he was admitted to the hospital because of suspected rejection. a punch biopsy of the right chest lesion showed large mononuclear cells with prominent, centrally located nucleoli, consistent with amoebae. one week into his hospitalization, the patient became increasingly altered and agitated. ct and mri scans revealed brain lesions consistent with meningoencephalitis. granulomatous amebic encephalitis caused either by balamuthia mandrillaris or acanthamoeba species was suspected and the patient was started on a broad range of antimicrobials. despite intensive treatment, the patient deteriorated and was declared brain dead in early february, . samples of the punch biopsy of the skin, a csf sample collected wk before death, and skin and brain tissue samples obtained at autopsy were forwarded to cdc and processed for culture, immunofluorescent antibody (ifa) staining, and real-time pcr. immunofluorescent antibody staining of the punch biopsy was positive for acanthamoeba. dna extracted from all types of specimens tested positive for acanthamoeba in a triplex real-time pcr assay that detects acanthamoeba spp., b. mandrillaris, and naegleria fowleri. fresh unfixed skin and brain tissues were separately minced with about . ml of amoeba saline and inoculated on non-nutrient agar plates coated with escherichia coli and into human lung fibroblast (hlf) cultures along with lg/ml gentamicin and incubated at °c, °c, and °c. amoebae that grew on agar plates were allowed to encyst, and those that grew in hlf cell culture were inoculated into proteose peptone yeast extract glucose medium containing % fetal bovine serum (pygs) as described previously (schuster ; visvesvara and balamuth ) . cultured acanthamoeba trophozoites were harvested from agar plates and dna was extracted using the dneasy tissue and blood kit (qiagen, valencia, ca) following the instructions for nucleated cells. three sets of pcr primers were used to amplify the full-length or partial s rrna gene. pcr primers jdp plus jdp (schroeder et al. ) amplified a base pair fragment; jdp plus b (gast ) amplified a , base pair fragment; and crn (schroeder et al. ) plus b amplified the fulllength gene. all pcr reactions were performed in a lm total volume using . lm of each primer, ll of the extracted dna, and the platinum blue pcr supermix (life technologies, grand island, ny). pcr was performed in a geneamp thermocycler (life technologies) with a cycling structure of min initial incubation at °c followed by cycles of °c for s, °c for s, and °c for min and s. pcr products were separated on % agarose gel electrophoresis and purified using the qiaquick pcr purification kit (qiagen). the pcr products were cloned into pcr . topo vectors using the topoisomerase method as described in the kit manual (life technologies). plasmid preparations of recombinant clones were purified from bacterial cultures using the qia-gen miniprep method. sequencing was performed using the bigdye v . chemistry on an abi prism sequence analyzer (life technologies) using the amplification primers and internal s rrna gene sequencing primers described elsewhere (schroeder et al. ; weekers et al. ). full-length s rrna gene sequences from the new isolate were aligned with full-length ribosomal gene sequences from other acanthamoeba strains and isolates using clustalw v. . (thompson et al. ) in the gen-estudio pro v. . . . software package (genestudio inc., suwanee, ga). included sequences were (with genbank accession numbers): acanthamoeba astronyxis atcc (af ), a. astronyxis etw (dq ), acanthamoeba tubiashi atcc (af ), acanthamoeba comandoni atcc (af ), a. comandoni pj (dq ), a. comandoni psh (dq ), acanthamoeba sp. e (gu -gu ), acanthamoeba sp. e (gu -gu ), acanthamoeba sp. e (gu -gu ), and acanthamoeba castellanii atcc (u ). after flush trimming the ends and removing alignment columns containing ambiguous nucleotides, a phylogenetic analysis was performed on the alignment using the tree-puzzle program v. . (schmidt et al. ) with a. castellanii as an outgroup. the resulting phylogenetic tree was visualized with treeview v. . . (page ) . the phylogeny program package phylip v. . (felsenstein ) was used to confirm the tree topology using parsimony and distance methods. the secondary structure of the s rrna gene was based upon the model proposed by wuyts et al. ( ) with slight modifications. the program mfold v. . was used to determine optimal foldings of stems and loops (zuker ) . the sequences from the clones were aligned using the program biolign v. . . (ibis biosciences, carlsbad, ca) and the base positions where variation occurred were noted. the final structure was drawn using the program adobe illustrator cs . both skin and brain specimens were positive for large acanthamoeba trophozoites when inoculated onto agar plates coated with e. coli as well as in hlf cell cultures. amoebae grew on the agar plate, ingested bacteria, and multiplied. in about a week, when all the bacteria were gone, the amoebae differentiated into double-walled cysts. the amoebae grew well on the hlf cell culture and destroyed the monolayer within a week. it produced cytopathic effect (cpe) beginning on day of inoculation. the cpe consisted of shrinkage of cell cytoplasm, nuclear pycnosis, and discontinuity of cell sheet resulting in the complete destruction of the cell sheet in about a week. the amoebae grew well at °c and °c in the pygs medium. the amoebae could also grow at °c on agar plate coated with bacteria, indicating that they are thermotolerant and have the ability to survive high fever that may occur in patients with gae. the amoebae when examined under a phase contrast microscope measured - lm and exhibited large blunt thorn-like processes, acanthopodia ( fig. ) , from the surface of the body, a feature that is characteristic of acanthamoeba. the cysts measured - lm with a smooth, almost round outer wall, the ectocyst, and a thicker, inner cyst wall, the endocyst. the endocysts were mostly star-shaped with five to eight arms or rays, although polygonal endocysts were occasionally seen (fig. ) . the endocyst was widely separated from the ectocyst except at points where the rays contacted the ectocyst at different planes. the tips of the rays at the contact point appeared to be thick and crescent-shaped and seemed to plug a pore, the ostiole. the crescent-shaped plug, the operculum, was removed when the amoeba exited the cyst (fig. ) . on the basis of these features, the amoebae were identified as acanthamoeba sp. group and designated as cdc:v . genetic characterization of the acanthamoeba isolate (cdc:v ) was attempted using the established pcr primers jdp and jdp , as well as by amplifying larger fragments of the s rrna gene. however, the resulting electropherograms were of bad quality with overlapping peaks resulting in ambiguous base calling. the full-length s rrna pcr product was therefore cloned to obtain interpretable dna sequences. ten recombinant clones figure acanthamoeba cdc:v trophozoites exhibiting varying sizes measuring from to lm. the trophozoites feature single (a-c) or double (d) nuclei or donut-shaped nucleus (a, b). all trophozoites feature acanthopodia that are characteristically blunt at the tip, contractile vacuole, food vacuole, and a contractile vacuole. the large trophozoite is binucleate, indicating that it has completed karyokinesis and is awaiting cytokinesis. bar = lm. were analyzed, each one displaying a unique sequence. the sequence differences between the clones consisted mostly of insertions/deletions and transitions; only three transversions were detected. the length of the s rrna gene was between , and , base pairs (primer sequences not included). eight of the clones were very similar with just two to nine differences scattered throughout the sequence, whereas clones and exhibited more divergence with on average and sequence differences as compared to the other clones. the difference in sequences between the clones is noted in fig. . despite the sequence variability among the clones, similarity searches via the genbank server produced the same results for all the clones: the highest similarity (approximately %) to acanthamoeba strains e and e , belonging to the newly described t sequence type, followed by a. tubiashi strain atcc ( % similarity) and a. comandoni isolates ( - % similarity). phylogenetic analysis using full-length s rrna sequences unambiguously placed cdc:v among the other group species a. tubiashi, a. astronyxis, and a. comandoni. the clones of cdc:v formed a single clade separated from the other group acanthamoeba sequences (fig. ) . the t strains formed a sister group to cdc:v , illustrating that cdc:v and the t strains are closely related but genetically distinct. the dna sequence difference in pair-wise alignments between the t strains and cdc:v ranged between . % and . %. the secondary structure of the complete s rrna of cdc:v is depicted in fig. . when analyzing this structure, it became evident that this amoeba had hyper development of the e - through e - region with a bifurcated e - stem not previously identified in groups and acanthamoebas. it also displayed a unique fairly long stem, e - - , inserted in the loop between the e - and e - helices. the size of the insert varied from to bases in the various clones of cdc:v , with the stem containing base pairs. in addition, the e - stem in cdc:v was bifurcated. partial reconstruction of the secondary structures of these regions in other acanthamoebas revealed that the unique features found in cdc:v were characteristics for group acanthamoebas. the genus acanthamoeba consists of several species of free-living amoebae that are ubiquitous in the environment. the amoeba described in this study initially caused skin lesions unresponsive to empiric treatment and subsequently disseminated to the cns, causing a fatal gae. balamuthia mandrillaris, another free-living amoeba, can also cause skin infections and gae. acanthamoeba and balamuthia appear similar in tissue sections and both produce cysts in the tissues. to distinguish these two amoebae in clinical specimens, electron microscopy, immunostaining of tissue sections, or molecular analysis have to be performed. the acanthamoeba infection in our patient was identified by immunofluorescence testing using rabbit antibodies to acanthamoeba as well as real-time pcr performed on tissues (d'auria et al. ) . culture isolation of the amoeba from skin and brain tissues was successful and yielded an acanthamoeba strain designated cdc:v . this new strain exhibited large trophozoites and cysts characteristic for the group acanthamoeba. molecular and structural analysis of the s rrna gene concluded that it is genetically most similar to the other group species within the acanthamoeba genus, confirming the description of cdc:v as a new acanthamoeba group i strain. acanthamoeba-specific pcr primers were used to amplify the s rrna gene from cdc:v ; although single bands of the expected size could be seen on agarose gels following amplification, direct dna sequencing of obtained pcr products failed due to overlapping peaks in the sequence electropherogram. this is a typical result when there is a mixture of two or more distinct pcr products in the amplified reaction. as discussed in a previous publication, the most likely explanation for this is the sequence variability among the many copies of the ribosomal gene within individual amoebae (stothard et al. ) . acanthamoeba castellanii neff strain appears to have copies of the s rrna gene in its genome (byers et al. ) and it is reasonable that other acanthamoeba contain numerous copies as well. the presence of micro-heterogeneity at the s rrna gene level has been detected in strains from all three morphology groups, including group (nuprasert et al. ; stothard et al. ). an alternative explanation for the sequence difference between the clones, errors produced by the taq polymerase, may have contributed to some of the point mutations seen in the clones but cannot account for the majority of sequence variation, especially in clones and . thus, we conclude that cdc:v has several distinct alleles of the s rrna gene. the greatest sequence difference observed between the clones was . %. most of the differences were represented as deletions, insertions, or transitions; only three transversions occurred, of which two were in stem . variations between alleles of ribosomal rna genes in amoebae can be quite substantial. for example, in the amoeba vannella epipetala the difference between clones was as high as . % (amaral-zettler et al. ) . previous studies using dna sequencing analysis of the s rrna gene have identified sequence types and these are designated t -t . based on phylogenetic analysis of strains belonging to morphology groups and , gast et al. ( ) divided the strains into four sequence types (t -t ) and defined a sequence type as sequences with at least % difference from members of the other sequence types. a subsequent study including more sequences from all three morphology groups established the presence of eight additional sequence types (t -t ) and adjusted the sequence difference threshold between the sequence types to % (stothard et al. ). this arbi- trary number of % dissimilarity has since been used to create five additional sequence types (t -t ) (corsaro and venditti ; gast ; hewett et al. ; horn et al. ; nuprasert et al. ) . the vast majority of acanthamoeba isolates from the environment as well as isolates associated with human infections belong to sequence type t (booton et al. ; maciver et al. ) . in contrast, isolation of acanthamoeba with group morphological features is rare. three species of group acanthamoeba, namely a. astronyxis, a. tubiashi, and a. comandoni, belong to sequence types t , t , and t , respectively. the fourth species classified as group , acanthamoeba echinulata, has not yet been associated with a sequence type as no s rrna gene sequence from that species is available in public databases. recently, two environmental isolates were found to exhibit group morphology, but as their s rrna genes differed more than % from all known acanthamoeba sequences, a new sequence type, designated t , was created for them and added to group (nuprasert et al. ) . the dna sequences obtained from the amoebae cdc:v were approximately . % dissimilar from the t strains. although this is slightly lower than % sequence divergence, the phylogenetic analysis clearly distinguishes cdc:v as a separate lineage with an evolutionary distance of . % from the t strains. therefore, we consider cdc:v as a new and unique sequence type and identified it as sequence type t . the proposed secondary structure of the s rrna molecule from cdc:v presents some unique features, especially the new stem identified between stems e - and e - . an extra stem in this region has previously been identified in another amoeba, corallomyxa tenera, and was given the designation e - - (tekle et al. - base pairs. in contrast, acanthamoeba belonging to groups and have either no or a considerably smaller e - - stem, containing less than bases. in addition, the cdc:v amoeba had extra stems and bifurcated stems in other regions of the ribosomal rna molecule similar to other group acanthamoebas and distinct from groups and acanthamoebas. thus, the secondary structure prediction of the s rrna provides additional support for the placement of cdc:v in group acanthamoeba. to our knowledge, this is the first description of a group acanthamoeba that is indisputably pathogenic in humans. acanthamoeba astronyxis has been suggested to have caused human infections in one case where it was cultured from the csf of a patient with encephalitic syndrome, but the patient recovered without any anti-acanthamoeba medication (callicott ) . it is believed that the isolation was probably due to contamination (martinez ). the acanthamoeba isolate described here, however, caused a devastating cutaneous and cns infection leading to the death of the patient. in conclusion, cdc:v is unusual for several reasons and differs from other group acanthamoeba in its morphological, physiological, and genetic features: ( ) its ability to grow on mammalian cell cultures at higher temperature ( °c) with an optimum temperature of growth of °c, ( ) large size with measurements of - lm, and ( ) substantial differences in its s rrna gene from the other species included in group acanthamoeba. therefore, we establish cdc:v as a new species, and propose its diagnosis as follows. super group: amoebozoa luhe, , emend. cavalier-smith, [eumycetozoa zopf , emend olive • description. the amoeboid stage is flattened with prominent subpseudopodia that are flexible and thorn like with blunt tips, acanthopodia. trophozoite with or without a uroid, the cyst is large, bounded by a double wall with an outer smooth, almost round ectocyst and an inner mostly stellate endocyst with five to eight arms in different planes touching the ectocyst. flagellate stage not seen even after suspending in distilled water for h. growth in vitro. grows well on agar plate coated with a gram-negative bacterium such as e. coli at °c, °c and °c. also grows well in axenic medium supplemented with fetal bovine serum, known to support growth of other acanthamoeba strains, at °c and °c. also grows well on mammalian tissue cultures (e.g., hlf cell monolayer) at °c and °c. the optimal growth temperature is °c. the amoeba produces cpes on monolayers of hlf cells. the normal habitat of the amoeba is not known although the amoeba was isolated from the brain and skin tissues of a patient with typical symptoms of granulomatous amoebic encephalitis. species genotypes associated with nonkeratitis infections genes of acanthamoeba: dna, rna and protein sequences (a review) amebic meningoencephalitis due to freeliving amebas of the hartmannella (acanthamoeba)-naegleria group phylogenetic evidence for a new genotype of acanthamoeba (amoebozoa, acanthamoebida) cutaneous acanthamoebiasis with cns involvement post-transplantation: implication for differential diagnosis of skin lesions in immunocompromised patients phylip: phylogenetic inference package (version . ) development of an acanthamoeba-specific reverse dot-blot and the discovery of a new ribotype subgenus systematics of acanthamoeba: four nuclear s rdna sequence types identification of a new acanthamoeba s rrna gene sequence type, corresponding to the species acanthamoeba jacobsi sawyer, nerad and visvesvara, (lobosea: acanthamoebidae) novel bacterial endosymbionts of acanthamoeba spp. related to the paramecium caudatum symbiont caedibacter caryophilus a systematic analysis of acanthamoeba genotype frequency correlated with source and pathogenicity: t is confirmed as a pathogen-rich genotype acanthamoeba spp. as agents of disease in humans is acanthamoeba encephalitis an opportunistic infection? neurology identification of a novel t genotype of acanthamoeba from environmental isolates and t genotype causing keratitis in thailand treeview: an application to display phylogenetic trees on personal computers morphologie de la paroi kystique et taxonomie du genre acanthamoeba (protozoa: amoebida) tree-puzzle: maximum likelihood phylogenetic analysis using quartets and parallel computing use of subgenic s ribosomal dna pcr and sequencing for genus and genotype identification of acanthamoebae from humans with keratitis and from sewage sludge cultivation of pathogenic and opportunistic free-living amebas free-living amoebae as opportunistic and non-opportunistic pathogens of humans and animals the evolutionary history of the genus acanthamoeba and the identification of eight new s rrna gene sequence types a multigene analysis of corallomyxa tenera sp. nov. suggests its membership in a clade that includes gromia clustal w: improving the sensitivity of progressive multiple sequence alignment through sequence weighting, position-specific gap penalties and weight matrix choice classification of acanthamoeba comparative studies on related free-living and pathogenic amebae with special reference to acanthamoeba pathogenic and opportunistic free-living amebae: acanthamoeba spp., balamuthia mandrillaris, naegleria fowleri, and sappinia pedata sequence variations in small-subunit ribosomal rnas of hartmannella vermiformis and their phylogenetic implications comparative analysis of more than sequences reveals the existence of two pseudoknots in area v of eukaryotic small subunit ribosomal rna mfold web server for nucleic acid folding and hybridization prediction this article is a u.s. government work and is in the public domain in the usa etymology. the new species of acanthamoeba is named a. byersi in recognition of the extensive molecular work performed on acanthamoeba spp. by the late dr thomas j. byers ( byers ( - , professor of molecular, cellular and developmental biology program at the ohio state university, columbus, ohio. dr byers was an active member and a tireless worker for the international society of protozoologists (now international society of protistologists) and responsible for proposing a the new name of the journal of eukaryotic microbiology, for the previously named journal of protozoology, to attract new interest and provide additional support for the flagging journal of protozoology. dr byers was responsible for organizing the first acanthamoeba conference in at the ohio state university in columbus, ohio as at that time the first few cases of ak were described. now the conference is known as the international meeting on the biology and pathogenicity of free-living amoebae and includes all pathogenic free-living amoebae. dr byers was instrumental for using both nuclear and mitochondrial ribosomal genes as targets for taxonomic classification and phylogenetic relationships of the genus acanthamoeba. dr byers was a gifted teacher and a tireless research worker, a generous collaborator and a helpful friend of one of the authors (g.s.v.). type species. acanthamoeba byersi, n. sp. deposition of type material. type culture has been deposited at the american type culture collection. gene sequence data. the s rrna gene sequences are deposited in genbank under accession numbers kc -kc . we are indebted to drs jamie lin and andrea d'auria for providing us with the patient specimens and relevant history of the case. dr norman j. pieniazek assisted with the phylogenetic analysis. key: cord- -tpqsjjet authors: nan title: section ii: poster sessions date: - - journal: j urban health doi: . /jurban/jti sha: doc_id: cord_uid: tpqsjjet nan food and nutrition programs in large urban areas have not traditionally followed a systems approach towards mitigating food related health issues, and instead have relied upon specific issue interventions char deal with downstream indicators of illness and disease. in june of , the san francisco food alliance, a group of city agencies, community based organizations and residents, initiated a collahorarive indicator project called rhe san francisco food and agriculture assessment. in order to attend to root causes of food related illnesses and diseases, the purpose of the assessment is to provide a holistic, systemic view of san francisco\'s food system with a focus on three main areas that have a profound affect on urban public health: food assistance, urban agriculture, and food retailing. using participatory, consensus methods, the san francisco food alliance jointly developed a sec of indicators to assess the state of the local food system and co set benchmarks for future analysis. members collected data from various city and stare departments as well as community based organizations. through the use of geographic information systems software, a series of maps were created to illustrate the assets and limitations within the food system in different neighborhoods and throughout the city as a whole. this participatory assessment process illustrates how to more effectively attend to structural food systems issues in large urban areas by ( t) focusing on prevention rather than crisis management, ( ) emphasizing collaboration to ensure institutional and structural changes, and ( ) aptly translating data into meaningful community driven prevention activities. to ~xplore the strategies to overcome barriers to population sample, we examined the data from three rapid surveys conducted at los angeles county (lac). the surveys were community-based partic· patory surveys utilizing a modified two-stage cluster survey method. the field modifications of the method resulted in better design effect than conventional cluster sample survey (design effect dose to that if the survey was done as simple random sample survey of the same size). the surveys were con· ducte~ among parents of hispanic and african american children in lac. geographic area was selected and d .v ded int.o small c~usters. in the first stage, clusters were selected with probability proportionate to estimated size of children from the census data. these clusters were enumerated to identify and develop a list of households with eligible children from where a random sample was withdrawn. data collectmn for consented respondents involved - minutes in-home interview and abstraction of infor· ma~ion from vaccine record card. the survey staff had implemented community outreach activities designed to fost~r an~ maintain community trust and cooperation. the successful strategies included: developing re.lat on .w. th local community organizations; recruitment of community personnel and pro· vide them with training to conduct the enumeration and interview; teaming the trained community introduction: though much research has been done on the health and social benefits of pet ownership for many groups, there have been no explorations of what pet ownership can mean to adults who are marginalized, living on fixed incomes or on the street in canada. we are a community group of researchers from downtown toronto. made up of front line staff and community members, we believe that community research is important so that our concerns, visions, views and values are presented by us. we also believe that research can and should lead to social change. method: using qualitative and exploratory methods, we have investigated how pet ownership enriched and challenged the lives of homeless and transitionally housed people. our research team photographed and conducted one-on-one interviews with pet owners who have experienced home· lessncss and live on fixed incomes. we had community participation in the research through a partnership with the fred vicror centre camera club. many of the fred victor centre camera club members have experienced homelessness and being marginalized because of poverty. the members of the dub took the photos and assisted in developing the photos. they also participated in the presenta· tion of our project. results: we found that pet ownership brings important health and social benefits to our partici· pants. in one of the most poignant statements, one participant said that pet ownership " ... stops you from being invisible." another commented that "well, he taught me to slow down, cut down the heavy drugs .. " we also found that pet ownership brings challenges that can at times be difficult when one is liv· ing on a fixed income. we found that the most difficult thing for most of the pet owners was finding affordable vet care for their animals. conclusion: as a group, we decided that research should only be done if we try to make some cha.nges about what we have learned. we continue the project through exploring means of affecting social change--for example, ~eti.tions and informing others about the result of our project. we would like to present our ~mdmgs and experience with community-based participatory action resea.rch m an oral. presentarton at yo~r conference in october. our presentation will include com· mumty representation ~f. both front-hne staff and people with lived experience of marginalization and homdessness. if this is not accepted as an oral presentation, we are willing to present the project m poster format. introduction the concept of a healthy city was adopted by the world health organization some time ago and it includes strong support for local involvement in problem solving and implementation of solutions. while aimed at improving social, economic or environmental conditions in a given community, more significantly the process is considered to be a building block for poliq reform and larger scale 'hange, i.e. "acting locally while thinking globally." neighbourhood planning can he the entry point for citizens to hegin engaging with neighbours on issues of the greater common good. methods: this presentation will outline how two community driven projects have unfolded to address air pollution. the first was an uphill push to create bike lanes where car lanes previously existed and the second is an ongoing, multi-sectoral round table focused on pollution and planning. both dt•monstrate the importance of having support with the process and a health focus. borrowing from traditions of "technical aid"• and community development the health promoter /planner has incorporated a range of "determinants of health" into neighbourhood planning discussions. as in most urban conditions the physical environment is linked to a range of health stressors such as social isolation, crowding, noise, lack of open space /recreation, mobility and safety. however typical planning processes do not hring in a health perspective. health as a focus for neighbourhood planning is a powerful starti_ng point when discussing transportation planning or changing land-uses. by raising awareness on determmants of health, citizens can begin to better understand how to engage in a process and affect change. often local level politics are involved and citizens witness policy change in action. the environmental liaison committee and the dundas east hike lanes project resulted from local level initiatives aimed at finding solutions to air pollution -a priority identified hy the community. srchc supported the process with facilitation and technical aid. _the processs had tangible results that ultimately improve living conditions and health. •tn the united kmgdom plannm in the 's established "technical aid" offices much like our present day legal aid system to provide professional support and advocacy for communities undergoing change. p - (c) integrating community based research: the experience of street health, a community service agency i.aura cowan and jacqueline wood street health began offering services to homeless men and women in east downtown ~oronto in . nursing stations at drop-in centres and shelters were fo~lowed by hiv/aids prevent ~, harm reduction and mental health outreach, hepatitis c support, sleeping bag exchange, and personal tdennfication replacement and storage programs. as street health's progi;ams expanded, so to~ did the agency:s recognition that more nee~ed t~ be done to. address the underl~ing causes of, th~ soct~l and economic exclusion experienced by its clients. knowing t.h~t. a~voca~y ts. helped by . evtd~nce , street he.alt~ embarked on a community-based research (cbr) initiative to dent fy commumty-dnven research priorities within the homeless and underhoused population. methods: five focus groups were conducted with homeless people, asking participants to identify positive and negative forces in their lives, and which topics were important to take action on and learn more about. findings were validated through a validation meeting with participants. results: participants identified several important positive and negative forces in their lives. key positive forces included caring and respectful service delivery, hopefulness and peer networks. key negative forces included lack of access to adequate housing and income security, poor service delivery and negative perceptions of homeless people. five topics for future research emerged from the process, focusing on funding to address homelessness and housing; use of community services for homeless people; the daily survival needs of homeless people and barriers to transitioning out of homelessness; new approaches to service delivery that foster empowerment; and policy makers' understanding of poverty and homelessness. conclusions: although participants expressed numerous issues and provided much valuable insight, definitive research ideas and action areas were not clearly identified by participants. however, engagement in a cbr process led to some important lessons and benefits for street health. we learned that the community involvement of homeless people and front-line staff is critical to ensuring relevance and validity for a research project; that existing strong relationships with community parmers are essential to the successful implementation of a project involving marginalized groups; and that an action approach focusing on positive change can make research relevant to directly affected people and community agency staff. street health benefited from using a cbr approach, as the research process facilitated capacity building among staff and within the organization as a whole. p - (c) a collaborative process to achieve access to primary health care for black women and women of colour: a model of community based participartory research notisha massaquoi, charmaine williams, amoaba gooden, and tulika agerwal in the current healthcare environment, a significant number of black women and women of color face barriers to accessing effective, high quality services. research has identified several issues that contribute to decreased access to primary health care for this population however racism has emerged as an overarching determinant of health and healthcare access. this is further amplified by simultaneous membership in multiple groups that experience discrimination and barriers to healthcare for example those affected by sexism, homelessness, poverty, homophobia and heterosexism, disability and hiv infection. the collaborative process to achieve access to primary health care for black women and women of colour project was developed with the university of toronto faculty of social work and five community partners using a collaborative methodology to address a pressing need within the community ro increase access to primary health care for black women and women of colour. women's health in women's hands community health centre, sistering, parkdale community health centre, rexdale community health centre and planed parenthood of toronto developed this community-based participatory-action research project to collaboratively barriers affecting these women, and to develop a model of care that will increase their access to health services. this framework was developed using a process which ensured that community members from the target population and service providers working in multiculrural clinical settings, were a part of the research process. they were given the opportunity to shape the course of action, from the design of the project to the evaluation and dissemination phase. empowerment is a goal of the participatory action process, therefore, the research process has deliberately prioritized _ro enabling women to increase control over their health and well-being. in this session, the presenters will explore community-based participatory research and how such a model can be useful for understanding and contextualizing the experiences of black women and women of colour. they will address. the development and use of community parmerships, design and implementation of the research prorect, challenges encountered, lessons learnt and action outcomes. they will examine how the results from a collaborative community-based research project can be used as an action strategy to poster sessions v address che social determinants of women health. finally the session will provide tools for service providers and researchers to explore ways to increase partnerships and to integrate strategies to meet the needs of che target population who face multiple barriers to accessing services. lynn scruby and rachel rapaport beck the purpose of this project was ro bring traditionally disenfranchised winnipeg and surrounding area women into decision-making roles. the researchers have built upon the relationships and information gachered from a pilot project and enhanced the role of input from participants on their policy prioriries. the project is guided by an advisory committee consisting of program providers and community representatives, as well as the researchers. participants included program users at four family resource cencres, two in winnipeg and two located rurally, where they participated in focus groups. the participants answered a series of questions relating to their contact with government services and then provided inpuc as to their perceptions for needed changes within government policy. following data analysis, the researchers will return to the four centres to share the information and continue che discussion on methods for advocating for change. recommendations for program planning and policy development and implementation will be discussed and have relevance to all participants in the research program. women's health vera lefranc, louise hara, denise darrell, sonya boyce, and colleen reid women's experiences with paid and unpaid work, and with the formal and informal economies, have shifted over the last years. in british columbia, women's employability is affected by government legislation, federal and provincial policy changes, and local practices. two years ago we formed the coalition ior women's economic advancement to explore ways of dealing with women's worsening economic situations. since the formation of the coalition we have discussed the need for research into women's employabilicy and how women were coping and surviving. we also identified how the need to document the nature of women's employability and reliance on the informal economy bore significanc mechodological and ethical challenges. inherent in our approach is a social model of women's health that recognizes health as containing social, economic, and environmental determinants. we aim to examine the social contexc of women's healch by exploring and legitimizing women's own experiences, challenging medical dominance in understandings of health, and explaining women's health in terms of their subordination and marginalizacion. through using a feminist action research (far) methodology we will explore the relationship between women's employability and health in communities that represent bricish columbia's social, economic, cultural/ethnic, and geographic diversities: skidegate, fort st . .john, lumhy, and surrey. over the course of our year project, in each community we will establish and work with advisory committees, hire and train local researchers, conduct far (including a range of qualitative methods), and support action and advocacy. since the selected communities are diverse, the ways that the research unfolds will ·ary between communities. expected outcomes, such as the provision of a written report and resources, the establishment of a website for networking among the communities, and a video do.:umentary, are aimed at supporting the research participants, coalition members, and advisory conuniuces in their action efforts. p t (c) health & housing: assessing the impact of transitional housing for people living with hiv i aids currently, there is a dearth of available literature which examines supporrive housing for phas in the canadian context. using qualitative, one-on-one interviews we investigace the impact of transitional housing for phaswho have lived in the up to nine month long hastings program. our post<'r pr<·senta-t on will highlight research findings, as well as an examination of transitional housing and th<· imp;kt it has on the everyday lives of phas in canada. this research is one of two ground breaking undertakings within the province of ontario in which fife house is involved. p - (c) eating our way to justice: widening grassroots approaches to food security, the stop community food centre as a working model charles l.evkoe food hanks in north america have come co play a central role as the widespread response to growing rates of hunger. originally thought to be a short term-solution, over the last years, they have v poster sessions be · · · · d wi'thi'n society by filling the gaps in the social safety net while relieving govemcome mst tut ona ze . . . t f the ir responsibilities. dependent on corporate donations and sngmauzmg to users, food banks men so th' . · i i . are incapable of addressing the structural cause~ of ~u~ger. s pres~ntation w e~~ ore a ternanve approaches to addressing urban food security while bmldmg more sustamabl.e c~mmumt es. i:nrough the f t h st p community food centre, a toronto-based grassroots orgamzanon, a model is presented case e h'l k' b 'id · b that both responds to the emergency food needs of communities w e wor mg to. u ~ sustama le and just food system. termed, the community food centre model. (cfc), ~he s~op is worki?g to widen its approach to issues of food insecurity by combining respectful ~ rect service wit~ com~~mty ~evelop ment, social justice and environmental sustainability. through this approach, various critical discourses around hunger converge with different strategic and varied implications for a~ion. as a plac~-based organization, the stop is rooted within a geographical space and connected directly to a neighbourhood. through working to increase access to healthy food, it is active in maintaining people's dignity, building a strong and democratic community and educating for social change. connected to coalitions and alliances, the stop is also active in organizing across scales in connection with the global food justice movement. inner city shelter vicky stergiopoulos, carolyn dewa, katherine rouleau, shawn yoder, and lorne tugg introduction: in the city of toronto there are more than , hostel users each year, many with mental health and addiction issues. although shelters have responded in various ways to the health needs of their clients, evidence on the effectiveness of programs delivering mental health services to the home· less in canada has been scant. the objective of this community based research was to provide a forma· tive evaluation of a multi-agency collaborative care team providing comprehensive care for high needs clients at toronto's largest shelter for homeless men. methods: a logic model provided the framework for analysis. a chart review of clients referred over a nine month period was completed. demographic data were collected, and process and outcome indicators were identified for which data was obtained and analyzed. the two main outcome measures were mental status and housing status months after referral to the program. improvement or lack of improvement in mental status was established by chart review and team consensus. housing outcomes were determined by chart review and the hostel databases. results: of the clients referred % were single and % were unemployed. forty four percent had a psychiatric hospitalization within the previous two years. the prevalence of severe and persistent men· tal illness, alcohol and substance use disorders were %, % and % respectively. six months after referral to the program % of clients had improved mental status and % were housed. logistic regression controlling for the number of general practitioner and psychiatrist visits, presence of person· ality or substance use disorder and treatment non adherence identified two variables significantly associ· ated mental status improvement: the number of psychiatric visits (or, . ; % ci, . - . ) and treatment non adherence (or, . ; % ci, . - . ). the same two variables were associated with housing outcomes. history of forensic involvement, the presence of a personality or substance use disorder and the number of visits with a family physician were not significantly associated with either outcome. conclusions: despite the limitations in sample sire and study design, this study can yield useful informa· tion to program planners. our results suggest that strategies to improve treatment adherence and access to mental health specialists can improve outcomes for this population. although within primary care teams the appropriate collaborative care model for this population remains to be established, access to psychiatric follow up, in addition to psychiatric assessment services, may be an important component of a successful program. mount sinai hospital (msh) has become one of the pre-eminent hospitals in the world by contributing to the development of innovative approaches to effective health care and disease prevention. recently, the hospital has dedicated resources towards the development of a strategy aimed at enhancing the hospital's integration with its community partners. this approach will better serve the hospital in the current health care environment where local health integration networks have been struck to enhance and support local capacity to plan, coordinate and integrate service delivery. msh has had early success with developing partnerships. these alliances have been linked to programs serving key target populations with _estabhshe~. points of access to msh. recognizing the need to build upon these achievements to remain compe~mve, the hospital has developed a community integration strategy. at the forefront of this strategy is c.a.r.e (community advisory reference engine): the hospital's compendium of poster sessions v community partners. as a single point of access to community partner information, c.a.r.e. is more than a database. c.a.r.e. serves as the foundation for community-focused forecasting and a vehicle for inter and intra-organizational knowledge transfer. information gleaned from the catalog of community parmers can be used to prepare strategic, long-term partnership plans aimed at ensuring that a comprehensive array of services can be provided to the hospital community. c.a.r.e. also houses a permanent record of the hospital's alliances. this prevents administrative duplication and facilitates the formation of new alliances that best serve both the patient and the hospital. c.a.r.e. is not a stand-alone tool and is most powerful when combined with other aspects of the hospital's community integration strategy. it iscxpected that data from the hospital's community advisory committees and performance measurement department will also be stored alongside stakeholder details. this information can then be used to drive discussions at senior management and the board, ensuring congruence between stakeholder, patient and hospital objectives. the patient stands to benefit from this strategy. the unique, distinct point of reference to a wide array of community services provides case managers and discharge planners with the information they need to connect patients with appropriate community services. creating these linkages enhances the patient's capacity to convalesce in their homes or places of residence and fosters long-term connections to neighborhood supports. these connections can be used to assist with identifying patients' ongoing health care needs and potentially prevent readmission to hospital. introduction: recruiting high-risk drug users and sex workers for hiv-prevention research has often been hampered by limited access to hard to reach, socially stigmatized individuals. our recruitment effom have deployed ethnographic methodology to identify and target risk pockets. in particular, ethnographers have modeled their research on a street-outreach model, walking around with hiv-prevention materials and engaging in informal and structured conversations with local residents, and service providers, as well as self-identified drug users and sex workers. while such a methodology identifies people who feel comfortable engaging with outreach workers, it risks missing key connections with those who occupy the margins of even this marginal culture. methods: ethnographers formed a women's laundry group at a laundromat that had a central role as community switchboard and had previously functioned as a party location for the target population. the new manager helped the ethnographers invite women at high risk for hiv back into the space, this time as customers. during weekly laundry sessions, women initiated discussions about hiv-prevention, sexual health, and eventually, the vaccine research for which the center would be recruiting women. ra.its: the benefits of the group included reintroducing women to a familiar locale, this time as customers rather than unwelcome intruders; creating a span of time (wash and dry) to discuss issues important to me women and to gather data for future recruitment efforts; creating a location to meet women encountered during more traditional outreach research; establishing the site as a place for potential retention efforts; and supporting a local business. women who participated in the group completed a necessary household task while learning information that they could then bring back to the community, empowering them to be experts on hiv-prevention and vaccine research. some of these women now assist recruitment efforts. the challenges included keeping the group women-only, especially after lunch was provided, keeping the membership of the group focused on women at risk for hiv, and keeping the women in the group while they did their laundry. conclusion: public health educators and researchers can benefit from identifying alternate congregation sites within risk pockets to provide a comfortable space to discuss hiv prevention issues with high-risk community members. in our presentation, we will describe the context necessary for similar research, document the method's pitfalls and successes, and argue that the laundry group constitutes an ethical, respectful, community-based method for recruitment in an hiv-prevention vaccine trial. p - t (c) upgrading inner city infrastructure and services for improved environmental hygiene and health: a case of mirzapur in u.p. india madhusree mazumdar in urgency for agricultural and industrial progress to promote economic d.evelopment follo_wing independence, the government of india had neglected health promotion and given less emphasis on infrastructure to promote public health for enhanced human pro uct v_ity. ong wit r~p m astrucrure development, which has become essential if citie~ are to. act ~s harbmger.s of econ~nuc ~owth, especially after the adoption of the economic liberalization policy, importance _is a_lso ~emg g ve.n to foster environmental hygiene for preventive healthcare. the world health orga~ sat ~ is also trj:' ! g to help the government to build a lobby at the local level for the purpose by off~rmg to mrroduce_ its heal.thy city concept to improve public health conditions, so as to reduce th_e disease burden. this pape~ s a report of the efforts being made towards such a goal: the paper descr~bes ~ c~se study ?f ~ small city of india called mirzapur, located on the banks of the nver ganga, a ma or lifeline of india, m the eastern part of the state of uttar pradesh, where action for improvement began by building better sanitation and environmental infrastructure as per the ganga action plan, but continued with an effort to promote pre· ventive healthcare for overall social development through community participation in and around the city. asthma physician visits in toronto, canada tara burra, rahim moineddin, mohammad agha, and richard glazier introduction: air pollution and socio-economic status are both known to be associated with asthma in concentrated urban settings but little is known about the relationship between these factors. this study investigates socio-economic variation in ambulatory physician consultations for asthma and assesses possible effect modification of socio-economic status on the association between physician visits and ambient air pollution levels for children aged to and adults aged to in toronto, canada between and . methods: generalized additive models were used to estimate the adjusted relative risk of asthma physician visits associated with an interquartile range increase in sulphur dioxide, nitrogen dioxide, pm . , and ozone, respectively. results: a consistent socio-economic gradient in the number of physician visits was observed among children and adults and both sexes. positive associations between ambient concentrations of sul· phur dioxide, nitrogen dioxide and pm . and physician visits were observed across age and sex strata, whereas the associations with ozone were negative. the relative risk estimates for the low socio-«onomic group were not significantly greater than those for the high socio-economic group. conclusions: these findings suggest that increased ambulatory physician visits represent another component of the public health impact of exposure to urban air pollution. further, these results did not identify an age, sex, or socio-economic subgroup in which the association between physician visits and air pollution was significantly stronger than in any other population subgroup. eco-life-center (ela) in albania supports a holistic approach to justice, recognizing the environ· mental justice, social justice and economic justice depend upon and support each other. low income cit· izens and minorities suffer disproportionately from environmental hazards in the workplace, at home, and in their communities. inadequate laws, lax enforcement of existing environmental regulations, and ~ea.k penalties for infractions undermine environmental protection. in the last decade, the environmental ust ce m~ve~ent in tirana metropolis has provided a framework for identifying and exposing the links ~tween irrational development practices, disproportionate siting of toxic facilities, economic depres· s on, and a diminished quality of life in low-income communities and communities of color. the envi· ~onmental justice agenda has always been rooted in economic, racial, and social justice. tirana and the issues su.rroun~ing brow~fields redevelopment are crucial points of advocacy and activism for creating ~ubstantia~ social chan~~ m low-income communities and communities of color. we engaging intensively m prevcnnng co'.' mumnes, especially low income or minority communities, from being coerced by gov· ernmenta~ age_nc es or companies into siting hazardous materials, or accepting environmentally hazard· ous_ practices m order to create jobs. although environmental regulations do now exist to address the environmental, health, and social impacts of undesirable land uses, these regulations are difficult to poster sessions v enforce because many of these sites have been toxic-ridden for many years and investigation and cleanup of these sites can be expensive. removing health risks must be the main priority of all brown fields action plans. environmental health hazards are disproportionately concentrated in low-income communities of color. policy requirements and enforcement mechanisms to safeguard environmental health should be strengthened for all brownfields projects located in these communities. if sites are potentially endangering the health of the community, all efforts should be made for site remediation to be carried out to the highest cleanup standards possible towards the removal of this risk. the assurance of the health of the community should take precedence over any other benefits, economic or otherwise, expected to result from brownfields redevelopment. it's important to require from companies to observe a "good neighbor" policy that includes on-site visitations by a community watchdog committee, and the appointment of a neighborhood environmentalist to their board of directors in accordance with the environmental principles. vancouver - michael buzzelli, jason su, and nhu le this is the second paper of research programme concerned with the geographical patterning of environmental and population health at the urban neighbourhood scale. based on the vancouver metropolitan region, the aim is to better understand the role of neighbourhoods as epidemiological spaces where environmental and social characteristics combine as health processes and outcomes at the community and individual levels. this paper builds a cohort of commensurate neighbourhoods across all six censuses periods from to , assembles neighbourhood air pollution data (several criterion/health effects pollutants), and providing an analysis to demonstrate how air pollution systematically and consistently maps onto neighbourhood socioeconomic markers, in this case low education and lone-parent families. we conclude with a discussion of how the neighbourhood cohort can be further developed to address emergent priorities in the population and environmental health literatures, namely the need for temporally matched data, a lifecourse approach, and analyses that control for spatial scale effects. solid waste management and environment in mumbai (india) by uttam jakoji sonkamble and bairam paswan abstract: mumbi is the individual financial capital of india. the population of greater mumbai is , , and sq. km. area. the density of population , per sq. km. the dayto-day administration and rendering of public services within gr. mumbai is provided by the brihan mumbai mahanagar palika (mumbai corporation of gr. mumbai) that is a body of elected councilors on a -year team. mumcial corporation provides varies conservancy services such as street sweeping, collection of solid waste, removal and transportation, disposal of solid waste, disposal of dead bodies of animals, construction, maintance and cleaning of urinals and public sanitary conveniences. the solid waste becoming complicated due to increase in unplanned urbanization and industrialization, the environment has deteriorated significantly due to inter, intra and international migration stream to mumbai. the volume of inter state migration to mumbai is considerably high i.e. . lakh and international migrant . lakh have migrated to mumbai. present paper gives the view on solid waste management and its implications to environment and health. pollution from a wide varity of emission, such as from automobiles and industrial activities, has reached critical level in mumbai, causing respiratory, ocular, water born diseases and other health problems. sources of generation of waste are -household waste, commercial waste, institutional waste, street sweeping, silt removed from drain/nallah/cleanings. disposal of solid waste in gr. mumbai done under incineration . processing to produce organic manure. . vermi-composting . landfill the study shows that the quantity of waste disposal of through processing and conversion to organic ~anure is about - m.t. per day. the processing is done by a private agency m/s excel industries ltd. who had set up a plant at the chincholi dumping ground in western mumbai for this purpose. the corporation is also disposal a plant of its waste mainly market waste through the environment friendly, natural pro-ces~ known as vermi-composing about m.t. of market waste is disposed of in this manner at the various sites. there are four land fill sites are available and percent of the waste matter generated m mumbai is disposed of through landfill. continuous flow of migrant and increa~e in slum population is a complex barrier in the solid waste management whenever community pamc pat on work strongly than only we can achieved eco-friendly environment in mumbai. persons exposed to residential craffic have elevated races of respiratory morbidity an~ ~ortality. since poverty is an important determinant of ill-health, some h~ve argued that t~es~ assoc at ons may relate to che lower socioeconomic status of those living along ma or roads. our ob ect ve was to evaluate the association between traffic intensity at home and hospital admissions for respiratory diagnoses among montreal residents older than years. morning peak traffic estimates from the emmej montreal traffic model (motrem ) were used as an indicator of exposure to road traffic outside the homes of those hospitalised. the influence of socioeconomic status on the relationship between traffic intensity and hospital admissions for respiratory diagnoses was explored through assessment of confounding by lodging value, expressed as the dollar average over road segments. this indicator of socioeconomic status, as calculated from the montreal property assessment database, is available at a finer geographic scale than socioeconomic information accessible from the canadian census. there was an inverse relationship between traffic intensity estimates and lodging values for those hospitalised (rho - . , p vehicles during che hour morning peak), even after adjustment for lodging value (crude or . , cl % . - . ; adjusted or . , cl % . - . ). in montreal, elderly persons living along major roads are at higher risk of being hospitalised for respiratory illnesses, which appears not simply to reflect the fact that those living along major roads are at relative economic disadvantage. the paper argues that human beings ought to be at the centre of the concern for sustainable development. while acknowledging the importance of protecting natural resources and the ecosystem in order to secure long term global sustainability, the paper maintain that the proper starting point in the quest for urban sustainability in africa is the 'brown agenda' to improve che living and working environment of che people, especially che urban poor who face a more immediate environmental threat to their health and well-being. as the un-habitat has rightly observed, it is absolutely essential "to ensure that all people have a sufficient stake in the present to motivate them to take part in the struggle to secure the future for humanity.~ the human development approach calls for rethinking and broadening the narrow technical focus of conventional town planning and urban management in order to incorporate the emerging new ideas and principles of urban health and sustainability. i will examine how cities in sub-saharan africa have developed over the last fifty years; the extent to which government policies and programmes have facilitated or constrained urban growth, and the strategies needed to achieve better functioning, safer and more inclusive cities. in this regard i will explore insights from the united nations conferences of the s, especially local agenda of the rio summit, and the istanbul declaration/habitat agenda, paying particular attention to the principles of enablement, decentralization and partnership canvassed by these movements. also, i will consider the contributions of the various global initiatives especially the cities alliance for cities without slums sponsored by the world bank and other partners; che sustainable cities programme, the global campaigns for good governance and for secure tenure canvassed by unhabit at, the healthy cities programme promoted by who, and so on. the concluding section will reflect on the future of the african city; what form it will take, and how to bring about the changes needed to make the cities healthier, more productive and equitable, and better able to meet people's needs. heather jones-otazo, john clarke, donald cole, and miriam diamond urban areas, as centers of population and resource consumption, have elevated emissions and concentrations of a wide range of chemical contaminants. we have developed a modeling framework in which we first ~stimate the emissions and transport of contaminants in a city and second, use these estimates along with measured contaminant concentrations in food, to estimate the potential health risk posed by these che.micals. the latter is accomplished using risk assessment. we applied our modeling framework to consider two groups of chemical contaminants, polycyclic aromatic hydrocarbons (pah) a.nd the flame re~ardants polybrominated diphenyl ethers (pbde). pah originate from vehicles and stationary combustion sources. ~veral pah are potent carcinogens and some compounds also cause noncancer effects. pbdes are additive flame retardants used in polyurethane foams (e.g., car seats, furniture) fer sessions v and cl~ equipm~nt (e.g., compute~~· televisio~s). two out of three pbdes formulations are being voluntarily phased by mdustry due to rmng levels m human tissues and their world-wide distribution. pbdes have been .related to adv.erse neurological, developmental and reproductive effects in laboratory ijlimals. we apphed our modelmg framework to the city of toronto where we considered the southcattral area of by km that has a population of . million. for pah, local vehicle traffic and area sources contribute at least half of total pah in toronto. local contributions to pbdes range from - %, depending on the assumptions made. air concentrations of both compounds are about times higher downtown than km north of toronto. although measured pah concentrations in food date to the s, we estimate that the greatest exposure and contribution to lifetime cancer risk comes from ingestion of infant formula, which is consistent with toxicological evidence. the next greatest exposure and cancer risk are attributable to eating animal products (e.g. milk, eggs, fish). breathing downtown air contributes an additional percent to one's lifetime cancer risk. eating vegetables from a home garden localed downtown contributes negligibly to exposure and risk. for pbdes, the greatest lifetime exposure comes through breast milk (we did not have data for infant formula), followed by ingestion of dust by the toddler and infant. these results suggest strategies to mitigate exposure and health risk. p - (a) immigration and socioeconomic inequalities in cervical cancer screening in toronto, canada aisha lofters, rahim moineddin, maria creatore, mohammad agha, and richard glazier llltroduction: pap smears are recommended for cervical cancer screening from the onset of sexual activity to age . socioeconomic and ethnoracial gradients in self-reported cervical cancer screening have been documented in north america but there have been few direct measures of pap smear use among immigrants or other socially disadvantaged groups. our purpose was to investigate whether immigration and socioeconomic factors are related to cervical cancer screening in toronto, canada. methods: pap smears were identified using fee codes and laboratory codes in ontario physician service claims (ohip) for three years starting in for women age - and - . all women with any health system contact during the three years were used as the denominator. social and economic factors were derived from the canadian census for census tracts and divided into quintiles of roughly equal population. recent registrants, over % of whom are expected to be recent immigrants to canada, were identified as women who first registered for health coverage in ontario after january , . results: among , women age - and , women age - , . % and . %, rtspcctively, had pap smears within three years. low income, low education, recent immigration, visible minority and non-english language were all associated with lower rates (least advantaged quintile:most advantaged quintile rate ratios were . , . , . , . , . , respectively, p < . for all). similar gradients were found in both age groups. recent registrants comprised . % of women and had mm;h lower pap smear rates than non-recent registrants ( . % versus . % for women age - and . % versus . % for women age - ). conclnsions: pap smear rates in toronto fall well below those dictated by evidence-based practice. at the area level, immigration, visible minority, language and socioeconomic characteristics are associated with pap smear rates. recent registrants, representing a largely immigrant group, have particularly low rates. efforts to improve coverage of cervical cancer screening need to be directed to all ~omen, their providers and the health system but with special emphasis on women who recently arrived m ontario and those with social and economic disadvantage. challeges faced: a) most of the resources are now being ~pent in ~reventing the sprea.d of hiv/ aids and maintaining the lives of those already affected. b) skilled medical ~rs~nal are dymg under· mining the capacity to provide the required health care services. ~) th.e comphcat o~s of hiv/aids has complicated the treatment of other diseases e.g. tbs d) the ep dem c has led. to mcrease number of h n requiring care and support. this has further stretched the resources available for health care. orp a s d db . . i methods used on our research: . a simple community survey con ucte y our orgamzat on vo · unteers in three urban centres members of the community, workers and health care prov~ders were interviewed ... . meeting/discussions were organized in hospitals, commun.ity centre a~d with government officials ... . written questionnaires to health workers, doctors and pohcy makers m th.e health sectors. lessors learning: • the biggest-health bigger-go towards hiv/aids prevention • aids are spreading faster in those families which are poor and without education. •women are the most affected. •all health facilities are usually overcrowded with hiv/aids patients. actions needed:• community education oh how to prevent the spread of hiv/aids • hiv/aids testing need to be encouraged to detect early infections for proper medical cover. • people to eat healthy • people should avoid drugs. implications of our research: community members and civic society-introduction of home based care programs to take care of the sick who cannot get a space in the overcrowded public hospitals. prl-v a te sector private sector has established programs to support and care for the staff already affected. government provision of support to care-givers, in terms of resources and finances. training more health workers. introduction: australian prisons contain in excess of , prisoners. as in most other western countries, reliance on 'deprivation of liberty' is increasing. prisoner numbers are increasing at % per annum; incarceration of women has doubled in the last ten years. the impacts on the community are great - % of children have a parent in custody before their th birthday. for aboriginal communities, the harm is greater -aboriginal and/or torres strait islanders are incarcerated at a rate ten times higher than other australians. % of their children have a parent in custody before their th birthday. australian prisons operate under state and territory jurisdictions, there being no federal prison system. eight independent health systems, supporting the eight custodial systems, have evolved. this variability provides an unique opportunity to assess the capacity of these health providers in addressing the very high service needs of prisoners. results: five models of health service provision are identified -four of which operate in one form or another in australia: • provided by the custodial authority (queensland and western australia)• pro· vided by the health ministry through a secondary agent (south australia, the australian capital territory and tasmania) • provided through tendered contract by a private organization (victoria and northern territory) • provided by an independent health authority (new south wales) • (provided by medics as an integral component of the custodial enterprise) since the model of the independent health authority has developed in new south wales. the health needs of the prisoner population have been quantified, and attempts are being made to quantify specific health risks /benefits of incarceration. specific enquiry has been conducted into prisoner attitudes to their health care, including issues such as client information confidentiality and access to health services. specific reference will be made to: • two inmate health surveys • two inmate access surveys, and • two service demand studies. conclusions: the model of care provision, with legislative, ethical, funding and operational independence would seem provide the best opportunity to define and then respond to the health needs of prisoners. this model is being adopted in the united kingdom. better health outcomes in this high-risk group, could translate into healthier families and their communities. p - (a) lnregrated ethnic-specific health care systems: their development and role in increasing access to and quality of care for marginalized ethnic minorities joshua yang introduction: changing demographics in urban areas globally have resulted in urban health systems that are racially and ethnically homogenous relative to the patient populations they aim to serve. the resultant disparities in access to and quality of health care experienced by ethnic minority groups have been addressed by short-term, instirutional level strategies. noticeably absent, however, have been structural approaches to reducing culturally-rooted disparities in health care. the development of ethnic-specific h~alth car~ systems i~ a structural, long-term approach to reducing barriers to quality health care for eth· me mmonty populations. methods: this work is based on a qualitative study on the health care experiences of san francisco chinatown in the united states, an ethnic community with a model ethnic-specific health care infrastrucrure. using snowball sampling, interviews were conducted with key stakeholders and archival research was conducted to trace and model the developmental process that led to the current ethnic-specific health care system available to the chinese in san francisco. grounded theory was the methodology ijltd to analysis of qualitative data. the result of the study is four-stage developmental model of ethnic-specific health infrastrueture development that emerged from the data. the first stage of development is the creation of the human capital resources needed for an ethnic-specific health infrastructure, with emphasis on a bilingual and bicultural health care workforce. the second stage is the effective organization of health care resources for maximal access by constituents. the third is the strengthening and stability of those institutional forms through increased organizational capacity. integration of the ethnic-specific health care system into the mainstream health care infrastructure is the final stage of development for an ethnic-specific infrastructure. conclusion: integrated ethnic-specific health care systems are an effective, long-term strategy to address the linguistic and cultural barriers that are being faced by the spectrum of ethnic populations in urban areas, acting as culturally appropriate points of access to the mainstream health care system. the model presented is a roadmap to empower ethnic communities to act on the constraints of their health and political environments to improve their health care experiences. at a policy level, ethnic-specific health care organizations are an effective long-term strategy to increase access to care and improve qualiiy of care for marginalized ethnic groups. each stage of the model serves as a target area for policy interventions to address the access and care issues faced by culturally and linguistically diverse populations. users in baltimore md: - noya galai, gregory lucas, peter o'driscoll, david celentano, david vlahov, gregory kirk, and shruti mehta introduction: frequent use of emergency rooms (er) and hospitalizations among injection drug users (idus) has been reported and has often been attributed to lack of access to primary health care. however, there is little longitudinal data which examine health care utilization over individual drug use careers. we examined factors associated with hospitalizations, er and outpatient (op) visits among idus over years of follow-up. methods: idus were recruited through community outreach into the aids link to lntravenous experience (alive) study and followed semi-annually. , who had at least follow-up visits were included in this analysis. outcomes were self-reported episodes of hospitalizations and er/op visits in the prior six months. poisson regression was used accounting for intra-person correlation with generalized estimation equations. hits: at enrollment, % were male, % were african-american, % were hiv positive, median age was years, and median duration of drug use was years. over a total of , visits, mean individual rates of utilization were per person years (py) for hospitalizations and per py for er/op visits. adjusting for age and duration of drug use, factors significantly associated with higher rates of hospitalization included hiv infection (relative incidence [ri(, . ), female gender (ri, . ), homelessness (ri, . ), as well as not being employed, injecting at least daily, snorting heroin, havmg a regular source of health care, having health insurance and being in methadone mainte.nance treatment (mmt). similar associations were observed for er/op visits except for mmt which was not associated with er/op visits. additional factors associated with lower er/op visits were use of alcohol, crack, injecting at least daily and trading sex for drugs. % of the cohort accounted for % of total er/op visits, while % of the cohort never reported an op visit during follow-up. . . . lgbt) populations. we hypothesized that prov dmg .appomtments .for p~t ~nts w thm hours would ensure timely care, increase patient satisfaction, and improve practice eff c ency. further, we anticipated that the greatest change would occur amongst our homeless patients.. . methods: we tested an experimental introduction of advanced access scheduling (usmg a hour rule) in the primary care medical clinic. we tracked variables inclu~ing waiting ti~e fo~ next available appointment; number of patients seen; and no-show rates, for an eight week penod pnor to and post introduction of the new scheduling system. both patient and provider satisfaction were assessed using a brief survey ( questions rated on a -pt scale). results and conclusion: preliminary analyses demonstrated shorter waiting times for appointments across the clinic, decreased no-show rates, and increased clinic capacity. introduction of the advanced access scheduling also increased both patient and provider satisfaction. the new scheduling was initiated in july . quantitative analyses to measure initial and sustained changes, and to look at differential responses across populations within our clinic, are currently underway. introduction: there are three recognized approaches to linking socio-economic factors and health: use of census data, gis-based measures of accessibility/availability, and resident self-reported opinion on neighborhood conditions. this research project is primarily concerned with residents' views about their neighborhoods, identifying problems, and proposing policy changes to address them. the other two techniques will be used in future research to build a more comprehensive image of neighborhood depri· vation and health. methods: a telephone survey of london, ontario residents is currently being conducted to assess: a) community resource availability, quality, access and use, b) participation in neighborhood activities, c) perceived quality of neighborhood, d) neighborhood problems, and e) neighborhood cohesion. the survey instrument is composed of indices and scales previously validated and adapted to reflect london specifically. thirty city planning districts are used to define neighborhoods. the sample size for each neighborhood reflects the size of the planning district. responses will be compared within and across neighborhoods. data will be linked with census information to study variation across socio-eco· nomic and demographic groups. linear and gis-based methods will be used for analysis. preliminary results: the survey follows a qualitative study providing a first look at how experts involved in community resource planning and administration and city residents perceive the availability, accessibility, and quality of community resources linked to neighborhood health and wellbeing, and what are the most immediate needs that should be addressed. key-informant interviews and focus groups were used. the survey was pre-tested to ensure that the language and content reflects real experiences of city residents. the qualitative research confirmed our hypothesis that planning districts are an acceptable surrogate for neighborhood, and that the language and content of the survey is appropriate for imple· mentation in london. scales and indices showed good to excellent reliability and validity during the pre· test (cronbach's alpha from . - . ). preliminary results of the survey will be detailed at the conference. conclusions: this study will help assess where community resources are lacking or need improve· ment, thus contributing to a more effective allocation of public funds. it is also hypothesized that engaged neighborhoods with a well-developed sense of community are more likely to respond to health programs and interventions. it is hoped that this study will allow london residents to better understand the needs and problems of their neighborhoods and provide a research foundation to support local understandmg of community improvement with the goal of promoting healthy neighborhoods. p - (a) hiv positive in new york city and no outpatient care: who and why? hannah wolfe and victoria sharp introduction: there are approximately million hiv positive individuals living in the united sta!es. about. % of these know their hiy status and are enrolled in outpatient care. of the remaining yo, approx~mately half do not know their status; the other group frequently know their status but are not enrolled m any .sys~em of outpatient care. this group primarily accesses care through emergency departments. when md cated, they are admitted to hospitals, receive acute care services and then, upon poster sessions v di 'harge, disappear from the health care system until a new crisis occurs, when they return to the emergency department. as a large urban hiv center, caring for over individuals with hiv we have an active inpatient service ".'ith appr~xi~.ately discharges annually. we decided to survey our inpatients to better charactenze those md v duals who were not enrolled in any system of outpatient care. results: % of inpatients were not enrolled in regular outpatient care: % at roosevelt hospital and % at st.luke\'s hospital. substance abuse and homelessness were highly prevalent in the cohort of patients not enrolled in regular outpatient care. % of patients not in care (vs. % of those in care) were deemed in need of substance use treatment by the inpatient social worker. % of those not in care were homeless (vs. % of those in care.) patients not in care did not differ significantly from those in me in terms of age, race, or gender. patients not in care were asked "why not:" the two most frequent responses were: "i haven't really been sick before" and "i'd rather not think about my health. conclusions: this study suggests that there is an opportunity to engage these patients during their stay on the inpatient units and attempt to enroll them in outpatient care. simple referral to an hiv clinic is insufficient, particularly given the burden of homelessness and substance use in this population. efforts are currently underway to design an intervention to focus efforts on this group of patients. p .q (a) healthcare availability and accessibility in an urban area: the case of ibadan city, nigeria in oder to cater for the healthcare need of the populace, for many years after nigeria's politicl independence, empphasis was laid on the construction of teaching, general, and specialist hospital all of which were located in the urban centres. the realisation of the inadequacies of this approach in adequately meeting the healthcare needs of the people made the country to change and adopt the primary health care (phc) system in . the primary health care system which is in line with the alma ata declaration of of , wsa aimed at making health care available to as many people as possible on the basis of of equity and social justice. thus, close to two decades, nigeria has operated primary health care system as a strategy for providing health care for rural and urban dwellers. this study focusing on urban area, examimes the availabilty and accessibility of health care in one of nigeria's urban centre, ibadan city to be specific. this is done within the contest of the country's national heath policy of which pimary health care is the main thrust. the study also offers necessary suggestion for policy consideration. in spite of the accessibility to services provided by educated and trained midwifes in many parts of fars province (iran) there are still some deliveries conducted by untrained traditional birth attendants in rural parts of the province. as a result, a considerable proportion of deliveries are conducted under a higher risk due to unauthorised and uneducated attendants. this study has conducted to reveal the pro· portion of deliveries with un-authorized attendants and some spatial and social factors affecting the selection of delivery attendants. method: this study using a case control design compared some potentially effective parameters indud· ing: spatial, social and educational factors of mothers with deliveries attended by traditional midwifes (n= ) with those assisted by educated and trained midwifes (n= ). the mothers interviewed in our study were selected from rural areas using a cluster sampling method considering each village as a cluster. results: more than % of deliveries in the rural area were assisted by traditional midwifes. there are significant direct relationship between asking a traditional birth attendant for delivery and mother age, the number of previous deliveries and distance to a health facility provided for delivery. significant inverse relationships were found between mother's education and ability to use a vehicle to get to the facilities. conclusion: despite the accessibility of mothers to educated birth attendants and health facilities (according to the government health standards), some mothers still tend to ask traditional birth attendants for help. this is partly because of unrealistic definition of accessibility. the other considerable point is the preference of the traditional attendants for older and less educated mothers showing the necessity of changing theirs knowledge and attitude to understand the risks of deliveries attended by traditional and un-educated midwifes. p - (a) identification and optimization of service patterns provided by assertive community treatment teams in a major urban setting: preliminary findings &om toronto, canada jonathan weyman, peter gozdyra, margaret gehrs, daniela sota, and richard glazier objective: assertive community treatment (act) teams are financed by the ontario ministry of health and long-term care (mohltc) and are mandated to provide treatment, rehabilitation and support services in the community to people with severe and persistent mental illness. there are such teams located in various regions across the city of toronto conducting home visits - times per week to each of their approximately respective clients. each team consists of multidisciplinary health professionals who assist clients to identify their needs, establish goals and work toward them. due to complex referral patterns, the need for service continuity and the locations of supportive housing, clients of any one team are often found scattered across the city which increases home visit travel times and decreases efficiency of service provision. this project examines the locations of clients in relation to the home bases of all act teams and identifies options for overcoming the geographical challenges which arise in a large urban setting. methods: using geographic information systems (gis) we geocoded all client and act agency addresses and depicted them on location maps. at a later stage using spatial methods of network analysis we plan to calculate average travel rimes for each act team, propose optimization of catchment areas and assess potential travel time savings. resnlts: initial results show a substantial scattering of clients from several act teams and substan· rial overlap of visit travel routes for most teams. conclusions: reallocation of catchment areas and optimization of act teams' travel patterns should lead to substantial savings in travel times, increased service efficiency and better utilization of resourc_~· ~e l'<!tenri~i modifications to catchment areas must be conducted with appropriate attention to specific clients servtce needs, service continuity and applicable regulations by the mohl tc. venice lido is a popular island within and outside italy because it hosts the international cinema festival yearly. only few people remember the island for its hospital, which, in the fifties, was one of the most important hospitals in italy and in europe, being a modern center for wind-, sun-and thermal-therapy. since the sixties, its fame became to drop away, since its structure was no longer adequate for the evolving medicine science. at the end of the seventies all the wards were moved into a new big building in the same area. at present the hospital is made up by about forty 'pavilions' (mostly partially used or empty) and a big building, disseminated in a hectares area, on the sea front, on the m long beach. the aim of my research is to suggest a realistic solution, sustainable on the functional use of the area according to basic local needs and economically realizable. i used a philological and multi-disciplinary method, more in detail: -from historical documents, i found what was the very first call of the property and how it adapted to the needs of the demographic development and the sanitary supply over time; -by contacting some operators from different fields, i realized which functions were suitable to the buildings in existence, to the population's needs and to the present sanitary supply. moreover the planning idea considers: -the debate going on between local people who strongly want to preserve the property, and die ones who want to renew it by different new opportunities; and -the regional sanitary politics, aiming at rationalizing the regional hospitals dislocation, and the budget needs. this plan analyzes and proposes some new alternative solutions to satisfy different needs. the different activities will be dealt out and the environmental fall will be limited as much as possible. after having analyzed its basic call, considered its environmental peculiarities and its position, verified the emerging needs of the local population, the plan proposes different activities: the hospital; the social-rehabilitation center; the elderly house; the thermal center; the residential center; and other activities. such a plan wants to share in the solution of a basic problem by giving architectonic and functional dignity to an historical completely degraded area and by starting again a social-economical broken off process, by bringing in venice lido some fresh necessary elements for its so wished new throw. p - (c) dilemma of free health care in spokane, wa david bunting introduction: the paper reports on the activities of project access spokane [pas], a physician sponsored initiative to provide uncompensated health care to low income, uninsured residents of spokane county wa. program providers included all county hospitals, over physicians, other medical professionals, and specialized clinics. each prescription requires only a $ co-payment. sponsored and administered by the county medical society, pas is funded by local and national foundations, private corporations, municipalities, civic organizations and individuals. method: the paper is based on a first year assessment report funded by pas, using hcfa [health care financing administration] insurance claim data documenting utilization rates, disease categories and donated charge information and patient cares [centralized applications, referrals and enrollment status) data. results: while essentially free for enrollees, the program involved real costs. an administrative organization to refer over patients to any of over providers had to be developed and staffed, using both paid and unpaid personnel. methods to identify potential patients and veri.fy eligibility. had to ~devised. patient appointments and transportation had to be scheduled and monitored. pu~hc relanons, provider solicitations and fundraising activities were continuous. information requirements regarding program operation were also significant. data reporting the volume. ~nd value of dona~ed medical services were necessary to demonstrate accomplishments and attr~ct addmon~l support. providers required assurances their contributions were both significant and eqmtable. funding sources sought evidence that their support had important consequences. however, generating this ~~ta proved difficult. many providers failed to submit appropriate insurance claims forms because .of a~dmonal donated effort and administrative cost, thereby not only reducing their own apparent conmbut ons but also the overall significance of the program. conclusions: during its initial year, the estimated cost to deliver free health care was ~bout per enrollee. the lesson is that without an elaborate administrative structure and record keeping s.yst~~· efforts to provide free health care probably will fail. eligible enrollees c~n not be ~parated from in~hgi ble ones, care will not be accessed or delivered in an efficient manner, neither fundmg nor ~upport "". be offered without evidence of tangible benefits, and providers will withdraw if they perceive mequ table tteannent. v p - s (c) mobility in prostitution and the impact of health therese van der helm and henk sulman poster sessions introduction: many of the estimated . commer~ial ~ex wor~ers (c~w)in a'.' ~terdam ~~me from developing countries and eastern europe. to gain ins~ght mto their workmg and_ hvmg condinons the intermediary project (ip) at the municipal health serv ~e _contacts these women via ?utreach work on regular basis. since the new brothel law in october s ~troduc~d, ~sw ~rom outside the eu and who have no dutch residence permit are not allowed to work m prost tut n. smee then, many of these csw therefore have gone "underground." the consequences of the new law in the netherlands will be discussed with regard to the accessibility of csw and their risk for stl/hiv acquisition and unplanned pregnancies. methods: topics during outreach work are the interventions to increase the knowledge of safe sex and birth control for csw. written information is handed out in relevant languages and with addresses of health and social services. in conversations with the women, it appeared that many are not aware of these services. to provide easier access to health care for women, staff of the ip carries out free sti control csw working places, in windows brothels and sex houses. also, women are offered vaccination against hepatitis b (hbv). results: from january till july we approached csw for first contact. one third was dutch; others were from developing countries, other eu countries and eastern europe. sti consul· rations were done among non-iv drug using sex workers, of whom % was dutch. of these, % was diagnosed with syphilis, % with gonorrhea, and % with chlamydia. of women tested for hiv, none were infected. due to the high turnover of csw in .brothels, most wnmen were tested only once. among csw tested for hbv -of whom one third is dutch - % had antibodies for hbv, were carrier of hbv, most of whom came from hbv endemic areas. conclusions: sti control and hbv vaccination in brothels is an important support in health care. our findings suggest that csw do not play an important role in the transmission of sti. many csw are highly mobile and often not aware of the existing health and social services. continuous outreach is important to remain in contact with this mobile population. regulations in the new brothel law should not hamper contacts with (illegal) csw. heart disease (cho) is projected to become the leading cause of death. studies conducted in europe and the united states have proven a higher rate of cho in south asians who have migrated from south asia, most notably india, pakistan and bangladesh. approximately % of all heart attacks among south asian men occur under the age of ; % of them occur under the age of -unheard of in any other population. associated risk factors such as diabetes, high blood pressure and cholesterol are also com· mon in this group. the population of south asians residing in nyc has more than doubled over the past decade to over , , the majority being young, working-class and with limited health care access. many south asian men are employed as taxi drivers ( out of nyc taxi drivers are from south asial, working daily hour plus shifts. methods: acknowledging that this vulnerable, at-risk group was unavailable for outreach through conventional venues, three of the hospitals of the new york city health and hospital corporation, (elmhurst, queens and bellevue) conducted a one day outreach effort at nyc's jfk international air· ~rt's taxi holdin~ ar~a, ~here over one thousand taxis regularly assemble. bringing an outreach event directly to the taxi dnvers workplace, a tent was set up where cardiovascular-related health screenings, in~luding bl~ pressure, sugar, cholesterol, body mass index (bmi), were provided. results were shared with and explamed to the drivers and each participant received a south asian health education brochure. a total of taxi drivers who identified as south asian were involved. rau/ts: participants were all male, ranging from to years; mean age, . . screenings revealed % hypertensive; % had cholesterols over ; % blood glucose over ; % had a bmi greater than . conc~on: a unique outreach activity, adapting to logistical, occupational limitations, is pre· se~ted. on-site f~back and explanation of results, reiterating and reinforcing the concern that south asia~. men are at mcreased danger for early coronary heart disease, and the dissemination of a culturally sensmve and r~levant brochure, may heighten awareness of prevailing cardiac risk factors in this immi· grant community. p - (c) the community-hospital integration program framework: community-hospital panoenhips to improve the population's health john stevenson, richard blickstead, ann-marie marcolin, and sandi kendal v introduction: st. josephs health centre is a catholic community teaching hospital located in the heart of southwest toronto. st. joseph\'s was founded from a community-expressed need for hospital services, and since then has stayed committed to fostering a healthy community through collaboration and parmership. st. joseph's has developed an innovative model, the community-hospital integration program (chip), to strengthen st. joseph's partnerships with community stakeholders, and facilitates the building of links between community needs, service provision, and public policy outcomes to improve the health and wellness of the diverse neighbourhoods they together serve. methods: development of the chip framework st. joseph's health centre developed the chip framework through a multidisciplinary approach that included extensive international literature reviews, consultations, and key informant interviews with community service agencies and academics. to ensure active community voice, st. joseph's has hosted a number of community consultations including a community outreach forum attended by over ninety representatives from community partners. results: the chip framework the chip framework aims to improve the health and wellness of the urban communities served by st. josephs health centre through four intersecting pillars: • raising community voices provides an infrastructure and process that supports community stakeholder input into health care service planning, decision-making, and delivery by the hospital and across the continuum of care; • sharing reciprocal capacity promotes healthy communities through the sharing of our intellectual and physical capacity with our community partners; • cultivating integration initiatives facilitates vertical, horizontal, and intersectoral integration initiatives in support of community-identified needs and gaps; and • facilitating healthy exchange develops best practices in community integration through community-based research, and facilitates community voice in informing public policy. the chip framework drives the complex inter-relationships between community-hospital engagement, reciprocal capacity-building, integration initiatives, and community-based research and evaluation, to create an interconnected network of health care services. the fluidity and simplicity of this framework, and its dedication to balancing community needs and hospital mandate, posits the st. josephs health centre's chip model as an integral component in building healthy and thriving communities. p - (c) home based care promotion: improving acess to quality services and livelihood in the face of aids home based care is a service provided to persons affected/living with hiv/aids, a menu of care/support services at home/community. it is a prominent alternative approach. in uganda, hospital bed ocupacny is high, patient health care worker ratio deteriorating. empowering communities offers solutions to the problems; adressing cost, effectiveness of care. hiv/aids demands changes in attitudes, behaviour, approaches which is enhanced in home/community settings. for example art requires high levels of adherecnce, which medical workers have vety little opportunity to enforce. it also demands other support mechanisims in terms of nutrition, personal displine, etc which work best in stigma free environments. hence the relevance of home based care. this paper highlights the gaps that call for increased action in terms of home based care, examples of whre it has worked key challenges and recommendations for the future. p - (c) health care for one ... health care for alli katharina kovacs burns introduction: at the surface, it appears that every person in canada _has. ~ccess to a publicly funded health care system. those living in urban centers should have the best ava l~b hty, chmce, and access to a variety of health care services because of the distribution of health care services, fac lmes, and health professionals in concentrated in urban centers. this is not true for everyone -people with low income or who are homeless experience the challenges of social exclusion and being marginalized: there are many factors at play making it difficult for the latter group of people to access health care. service they need,.when they need them. health care is not as accessible or inclusive as intended. the quesuon to be explore.cl ~: if health care is available and accessible to one person, what makes it not available to all people? the ~ gmfic~nce of having marginalized people accessing health care and other services includes e~hanced quality of hfe and decreased risks associated with being homeless, and cost savings in ion~ ter~ w rh acute health care. methodology: community-based participatory research is applied m a case study on health care access and challenges experienced by low income and homeless people in one urban centre, edmonton, edmonton, and their challenges. the data is being gathered and ana_lyzed usmg basic m x~d methods. results: the results will focus on how services can be more mtegrated and accessible to all people with low income and who are homeless. there will also be discussion about specific perceptions of not only the service providers but also of people with low income an~ who are homeless~ and vario~s decision makers. the results will be compared to the literature regardmg health care services access mother urban centers in canada and elsewhere. conclusions: recommendations will need to address social exclusion and other factors which can make health care and other services more available to all people in the community. the implications for health care will also be discussed. additional information will be gathered in the next phases of the study to develop a community services access model. p - (c) availability and access exemplified: a case study beth hayhoe and ruth ewert introduction: access to health care in canada requires either the correct documentation or money. street youth have neither. in addition, health services in canada are designed by adults for adults. youth in general are often wary of having trust in adults with respect to their health concerns and frequently feel misunderstood. street youth are even more mistrustful of adults and public organizations, making their contact with health care professionals minimal. this combined with their risky behaviours and dangerous environment creates a population at risk for numerous health issues but with no place to have them investi· gated. at our non-government, not for profit health service designed specifically to provide a broad range of health care to street youth, professional services are provided almost entirely by volunteers. methods: using a retrospective analysis of the years of data gathered from this organization and reviewing the initial reasons gathered from youth about their needs, the success of the health centre was examined. results: all the things youth had listed as being important in a health centre have been implemented, and even more things have been added to improve the breadth and quality of services offered. the use of the health centre has increased by more than six times since its opening in . in addition, tens of thousands of visits have been paid to the health centre, costing the government and taxpayers nothing. as far as we know there is nothing else in canada that offers so many diverse and innovative services to youth in need. conclusion: it is clear from this case, that health care targeted at the needs of specific disadvan· taged populations can successfully provide them with appropriate health care. a model of accessible health care for marginalized populations can easily be developed for high impact and low cost from this successful case. toronto is one of the most ethno-racially diverse cities in the world of the estimated , , toronto residents, % ( , ) live in scarborough population growth in scarborough is faster than toronto. scarborough's population increased by % from to while toronto increased only by %. toronto's population is projected to increase by % ( ) in while scarbor· ough's will increase by %. (census canada ) low income, pove;ty, seniors, hidden homeless, new~omers to canada, the uninsured, are just a few of the issues concerning health care in our community. health care needs in scarborough are greatly impacted by diversity of ethnic and racial groups, poverty and settlement issues. this paper will share how the scarborough hospital (tsh) an urb~n communir_y hospital cares f~~ it~ community. tsh recognizes: •the changing community• b_arriers t~ accessing care • lnequalmes m health care the hospital in caring for its community pro· v ~es services that '!'e~e cu~turally, racially, and linguistically sensitive to our community. the paper will share the hospitals unique program on access and equity. the paper will share the needs in scar· borough and tsh's response to these needs: working in partnership with the local health committee, i:ne scarborough homeless co.mminee, the scarborough network of immigrant services organiza· nons a~d others. :' e paper will also share the many initiatives this urban community hospital has taken viz. community and home programs in service areas such as mental health, haemodialysis day care, t~~ home oxyg~n program, the palliative at-home program, and above all support for the volunteer clinic for the uninsured. j"'" tllu:lion: in canada's universal health care system it is generally assumed that everyone has equal access to health care. however, some immigrant groups in canada have historically been uninswed. these groups include failed refugee claimants, those overstaying their visas, and new immigrants in transition who are waiting to become eligible for health insurance. some estimates have suggested that at the present time there may be as many as one hundred thousand undocumented and thus uninsured immigrants in toronto alone. understandably, information on the characteristics of this marginalized population is very limited, since undocumented immigrants tend to have little contact with formal institutions. knowledge of the demographic characteristics of this population may aid in the development of health and social programs to better identify and meet the needs of undocumented immigrants in toronto. we conducted a review of all undocumented, uninsured patients, years of age or older at access alliance multicultural community health centre (aamchc) between and . demographic information such as age, gender, preferred language, length of time living in canada, selfreported education level and household income were recorded. rmdts: % of all adult patients at access alliance were undocumented and uninsured. % were under years of age (with a median age of years), % were women and only % spoke english. this group lived in canada for an average period of . years before they were first seen at aamchc. % of undocumented clients reported having completed at least a secondary or post-secondary education. % had self-reported household incomes of less than , $/year, while % of households reported earning less than $ , /year. the mean income per person in an average household was $/month. conchuions: uninsured individuals at aamchc were predominantly young females with limited knowledge of the english language. despite having attained a high level of education most were living well below the poverty line. recognition of these characteristics may assist in the development of health and social programs that are better adapted to meet the needs of undocumented immigrants. p - (c) sharing expertise: a role for the hospital lactation consultant in the community. badrgrmuul: st. michael's hospital is a tertiary care hospital that serves a large inner city population in downtown toronto. in order to provide care to this population, the hospital has developed a number of unique outreach roles. one such role was developed to work with pregnant and breastfeeding women living in regent park, a social housing complex located near the hospital. the population of regent park includes new immigrants, refugees and the socially disadvantaged. approach: the outreach lactation consultant provides care, as part of the canada prenatal nutrition program, in the community prenatally, in the hospital during their inpatient stay and postnatally when they return to the community. the continuity of care enhances the probability of long term successful breastfeeding. aside from the health benefits of breastmilk, breastfeeding is especially important for women who are financially needy and must depend on food banks for formula. . . lason learned: aher two years of partnership, the relationship between the an-hospital ~stpar tum experience for breastfeeding mothers and the community postpartum support, the breastfeeding rate ~thin this community is high. the professional support and visibility of the : ctation consultant, both m the hospital and in the community, contributes to the support of breastfee~m~.. . in light of ongoing funding constraints, this ha son between hospital and community could be at risk and discontinued. in light of the benefits to the mother/baby dyad, the lactation consultant as a community partner in the canada prenatal nutrition program should be safeguarded. . lldpodiu:tion: although the importance of adequate health care in pregna~cy is well recognised, ethnic disparities in utilization of prenatal care still exist in many western coun~~es. a fun~amental factor in these disparities may be language proficiency, as it influences women's ab hty. to ob~m and understand health information, to find the way in the health care system and to communicate with health care v poster sessions providers. we investigated the role of language proficiency in use and knowledge of folic acid as aspect of prenatal care in an urban multi-ethnic pregnancy c?hort. . . design: prospective cohort study. setting and parnc pants: amsterdam ~regnant women attending obstetric care providers for their first antenatal visit (n= ). country of birth defined ethnicity: the netherlands, surinam, antilles, turkey, morocco, ghana, other non-~est~m (nw) and other western (w) country. main outcome measures: knowledge about and use of.fohc a~d (fa) supplements in pregnancy, and determinants of these in diffe~~t ethnic ~~ups. deterrrunants mcl~ded age, ed~ tion, parity, pregnancy intention and dutch prof c ency. stansncs: ~ to co~p~re e~c groups, stranfied logistic regression (forward stepwise method) to explore determmants "'.'thm ethmc groups .. use of fa supplements was significantly lower among ghanaian, moroccan, turkish and other nw women ( %to %) than among dutch ( %) or other w women ( %). use amongsurinames and antillean women was intermediate ( %and %). ethnic differences in fa knowledge were similar. knowledge was the strongest determinant of use in all ethnic groups, with odds ratios (ors) ranging from . to . . language proficiency was the strongest determi~a~t of kno~ledge in ethnic groups with a mother tongue different from dutch (ors good vs. low proficiency ranging from . ro . ). educational level had a modifying role, as shown by an interaction effect between education and language proficiency in the nw group. here, the odds of having fa knowledge given a high education and good dutch proficiency was times the odds given a good proficiency but low education. conclusions: appropriate periconceptional use of folic acid supplements in non-western ethnic groups is low, reflecting an absence of knowledge that is largely determined by the inability to speak and understand the language of the habitual country. tailored interventions using communication channels most likely to address (pregnant) women from ethnic minority groups are necessary. apan from specific interventions, our results are in support of strong incentives on language education despite current political debate. introduction: recent research suggests living in an economically disadvantaged neighborhood is asso· ciated with decreased likelihood of undergoing mammography and increased risk of late-stage breast can· cer diagnosis. long distances and travel times to facilities offering low-or no-cost mammography may be imponant barriers to adherence to mammography screening recommendations for residents of economically disadvantaged neighborhoods. the purpose of this study was to examine whether facilities providing low-and no-cost screening mammography were less spatially accessible in low-income neighborhoods in chicago, and the extent to which the relationship between neighborhood income and the spatial accessibility of facilities varied by the proponion of african-american residents in the neighborhood. methods: the sample consisted of chicago neighborhoods. for each neighborhood, we con· structed three measures of the spatial accessibility of facilities: street network distance to the nearest facility, public transportation travel time to the nearest facility, and shortest automobile travel time to a facility. using decennial census data, we characterized the neighborhoods according to proportion of residents with incomes below the poverty line, proportion of residents in each of four raciavethnic groups (african-american, latino, white, and other), and population density. we used ordinary least squares (ols) and spatial exogenous lag regression to examine relationships. model estimated the relationship between neighborhood poverty and the spatial accessibility of facilities, adjusting for raciaveth· nic composition and population density. model added a multiplicative interaction term between neighborhood poverty and african-american. restllts: we identified deven facilities that provided low-or no-cost screening mammography to chicago residents in . we found that the distance and travel times via automobile and public trans· portation to facilities generally decreased as neighborhood poveny increased. however, we also found that the ~egative associations between neighborhood poverty and two of the spatial accessibility mea· sures -distance and public transportation travel time -were less strong in neighborhoods with the highest proponions of african-american residents. among neighborhoods in the highest tertile for poveny, th~ mean distance and mean public transportation travel time to facilities were over twice as long in neighborhoods in the highest tertile than in those in the lowest tenile of african-american residents. . ~ persistent socioeconomic and racial/ethnic disparities in breast cancer stage at diagno-s ~nd su~ val suggest that ensuring an equitable distribution of affordable mammography is a worth-w~e policy .goal. the ~~dy sugges~ that ~ture investigations should consider both neighborhood soc oecono d c charactensbes and rac avethmc composition when examining the spatial distribution of health resources. , ) . epidemiological data suggest tha~ hiv prevalence among msm is over % in some metropolitan cities, such .as beijing (ibid.). due to widespread homophobia in chinese society, however, this population remains invisible within current health/social services. lack of research on sexuality, specifically homosexuality, has impaired our understanding of health and health practices of chinese msm. focusing on the illness experiences of chinese msm with hiv/aids, this paper explores the socio-cultural impacts of hiv/ aids on this group. the data used for this paper were collected through semi-constructed in-depth face-toiace interviews with adult plwhas (including msm) in beijing, china. with the permission of the participants, the interviews were audio-taped or recorded in notes. the transcribed interviews and interview notes were analyzed by using n-vivo, a software program for qualitative data analysis. this phenomenological study aimed to understand the experiences chinese plwhas (including msm) from their own perspectives. results: it is found that the illness experiences of chinese msm with hiv/aids are profoundly shaped by the socio-cultural meanings of homosexuality, which are further complicated by the dominant discourses on hiv/aids in china. at a macro level, homophobia in the larger society has decreased the capability of this group to respond to this epidemic in a more efficient way. at a meso level, aids-phobia within the chinese msm circuits has prevented this group from openly confronting this disease and offering support to those who are already affected by it. at a micro level, however, these hiv-infected/ affected msm have tried their best to locate spaces to live and to construct hope for their future lives despite various barriers within family, community, and the larger society. this study suggests that facilitating chinese msm's response to the aids crisis urgently requires bridging awareness, commitment, knowledge and resources both within and without this group. it also illustrates the importance of understanding homosexuality in the local context of hiv i aids, which will be helpful for developing culturally sensitive hiv/aids programs for this population on the community, national and international levels. introduction: having a regular family doctor (rfd) is known to be positively correlated with a good medical follow up, including access to preventive and/or chronic care. inversely, a lack of primary care may lead to high rates of avoidable hospitalizations, especially among poor people and/or in underserved neighbourhoods. in such a matter, a recent comparative study showed that paris was better ranged than other cities, such as nyc, tokyo or london. nevertheless, despite a quasi universal health insurance and a high density of general practitioners, a noticeable fraction of the paris population does not have any regular physician and we aimed to understand who they are and for what reasons rhey don't have any rfd. mdbods: cross sectional population survey among a random sample of households in ~nderpriv ileged neighbourhoods in paris inner city, performed in , using a face-to-face quest nna re collecr- ng more than social and health characteristics. ruults: a quarter ( . %) of rhe study popularion did not have any rfd. this proporrion was iignificantly higher among male (or= . , %ci = [ . - . ), younger (e.g. or - /> .s l _= ._oo, " .ci = ( . - . )), and/or unemployed (or = . , %ci = ij . - . _ people. in multtvanate analysis, after a full adjustment on gender, age, health status, health insura~ce, income, occupat n and tducation level, we observed significant associations between having no rfd and: ~arrtal and_ pare~t hood status (e.g. or single no kids/in couple+kids = . , %ci = ( . - . ()~ quality of relattonsh ps with neighbours (or bad/good= . , %ci = [ . - . )), and length of residence m the neighbourhood (with a dose/effect statistical relationship). . co clusion: gender, age, employment status, mariral and parenthood stat~s as well as ~e gh bourhood anchorage seem to be major predictors of having a rfd, even when um.versa! health i~sur ance has reduced most of financial barriers. in urban contexts, where residential migrattons and single lift (or family ruptures) are frequent, specific information may be conducted to encourage people to ket rfd. :tu~y tries to assess the health effects and costs and also analyse the availability and accessibility to health care for poor. . methods: data for this study was collected by a survey on households of the local community living near the factories and households where radiation hazard w~s n?~ present. ~~art from mor· bidity status and health expenditure, data was collected ~n access, a~ail~b .hty and eff c ency of healrh care. a discriminant analysis was done to identify the vanables that d scnmmate between the study and control group households in terms of health care pattern. a contingent valuation survey was also undertaken among the study group to find out the factors affecting their willingness to pay for health insurance and was analysed using logit model. results: the health costs and indebtedness in families of the study group was high as compared to control group households and this was mainly due to high health expenditure. the discriminant analysis showed that expenditure incurred by private hospital inpatient and outpatient expenditure were significant variables, which discriminated between the two types of households. the logit analysis showed !hat variables like indebtedness of households, better health care and presence of radiation induced illnesses were significant factors influencing willingness to pay for health insurance. the study showed that study group households were dependent on private sector to get better health care and there were problems with access and availability at the public sector. conclusion: the study found out that the quality of life of the local community is poor due to health effects of radiation and the burden of radiation induced illnesses are so high for them. there is an urgent need for government intervention in this matter. there is also a need for the public sector to be efficient to cater to the needs of the poor. a health insurance or other forms of support to these households will improve the quality for health care services, better and fast access to health care facilities and reduces the financial burden of the local fishing community. the prevalence of substance abuse is an increasing problem among low-income urban women in puerto rico. latina access to treatment may play an important role in remission from substance abuse. little is known, however, about latinas' access to drug treatment. further, the role of social capital in substance abuse treatment utilization is unknown. this study examines the relative roles of social capital and other factors in obtaining substance abuse treatment, in a three-wave longitudinal study of women ages - living in high-risk urban areas of puerto rico, the inner city latina drug using study (icldus). social capital is measured at the individual level and includes variables from social support and networks, familism, physical environment, and religion instruments of the icdus. the study also elucidates the role of treatment received during the study in bringing about changes in social capital. the theoretical framework used in exploring the utilization of substance abuse treatment is the social support approach to social capital. the research addresses three main questions: ( t) does social capital predict parti~ipating in treatment programs? ( ) does participation in drug treatment programs increase social capital?, and ( ) is there a significant difference among treatment modalities in affecting change in ~ial capital? the findings revealed no significant association between levels of social capital and gettmg treatment. also, women who received drug treatment did not increase their levels of social capital. the findings, however, revealed a number of significant predictors of social capital and receiving drug ~buse treatment. predictors of social capital at wave iii include employment status, total monthly mcoi:rie, and baseline social capital. predictors of receiving drug abuse treatment include perception of physical health and total amount of money spent on drugs. other different variables were associated to treatment receipt prior to the icldus study. no significant difference in changes of social capital was found among users of different treatment modalities. this research represents an initial attempt to elucidate the two-way relationship between social capital and substance abuse treatment. more work is necessary to unden~nd. ~e role of political forces that promote social inequalities in creating drug abuse problems and ava lab hty of treatment; the relationship between the benefits provided by current treatment poster sessions v sctrings and treatment-seeking behaviors; the paths of recovery; and the efficacy and effectiveness of the trtaanent. and alejandro jadad health professionals in urban centres must meet the challenge of providing equitable care to a population with diverse needs and abilities to access and use available services. within the canadian health care system, providers are time-pressured and ill-equipped to deal with patients who face barriers of poverty, literacy, language, culture and social isolation. directing patients to needed supportive care services is even more difficult than providing them with appropriate technical care. a large proportion of the population do not have equitable access to services and face major problems navigating complex systems. new approaches are needed to bridge across diverse populations and reach out to underserved patients most in need. the objective of this project was to develop an innovative program to help underserved cancer patients access, understand and use needed health and social services. it implemented and evaluated, a pilot intervention employing trained 'personal health coaches' to assist underserved patients from a variety of ethno-linguistic, socio economic and educational backgrounds to meet their supportive cancer care needs. the intervention was tested with a group of underserved cancer patients at the princess margaret hospital, toronto. personal coaches helped patients identify needs, access information, and use supportive care services. triangulation was used to compare and contrast multiple sources of quantitative and qualitative evaluation data provided by patients, personal health coaches, and health care providers to assess needs, barriers and the effectiveness of the coach program. many patients faced multiple barriers and had complex unmet needs. barriers of poverty and language were the easiest to detect. a formal, systematic method to identify and meet supportive care needs was not in place at the hospital. however, when patients were referred to the program, an overwhelming majority of participants were highly satisfied with the intervention. the service also appeared to have important implications for improved technical health care by ensuring attendance at appointments, arranging transportation and translation services, encouraging adherence to therapy and mitigating financial hardship -using existing community services. this intervention identified a new approach that was effective in helping very needy patients navigate health and social services systems. such programs hold potential to improve both emotional and physical health out· comes. since assistance from a coach at the right time can prevent crises, it can create efficiencies in the health system. the successful use of individuals who were not licensed health professionals for this purpose has implications for health manpower planning. needle exchange programs (neps) have been distributing harm reduction materials in toronto since . counterfit harm reduction program is a small project operated out of a community health centre in south-east toronto. the project is operated by a single full-time coordinator, one pan-rime mobile outreach worker and two peers who work a few hours each week. all of counterfit's staff, peers, and volunteers identify themselves as active illicit drug users. yet the program dis~rib utes more needles and safer crack using kits and serves more illicit drug u~rs t~an the comb ~e~ number of all neps in toronto. this presentation will discuss the reasons behind this success, .s~ f cally the extended hours of operation, delivery models, and the inclusion of an. extremely marg ~ahzed community in all aspects of program design, implementation and eva.luat ?n. ~ounterfit was recently evaluated by drs. peggy milson and carol strike, two leading ep dem olog st and researchers in the hiv and nep fields in toronto and below are some of their findings: "the program has experienced considerable success in delivering a high quality, accessible and well-used program .... the pro· gram has allowed (service users) to become active participants in providing. services to others and has resulted in true community development in the best sense. " ... counterf t has ~~n verr succe~sful attracting and retaining clients, developing an effective peer-based model an.d assisting chen~s ~ th a vast range of issues .... the program has become a model for harm red~ctmn progr~ms withm the province of ontario and beyond." in june , the association of ?ntano co~mumty heal~~ <:en· ires recognized counterfit's acheivements with the excellence m community health initiatives award. in kenya, health outcomes and the performance of government health service~ have det~riorated since the late s, trends which coincide with a period of severe resource constramts necessitated by macro-economic stabilization measures after the extreme neo-liberalism of the s. when the govern· ment withdrew from direct service provision as reform trends and donor advocacy suggested, how does it perform its new indirect role of managing relations with new direct health services providers in terms of regulating, enabling, and managing relations with these health services providers? in this paper therefore, we seek to investigate how healthcare access and availability in the slums of nairobi has been impacted upon by the government's withdrawal from direct health care provision. the methodology involved col· leering primary data by conducting field visits to health institutions located in the slum areas of kibera and korogocho in nairobi. purposive random sampling was utilized in this study because this sampling technique allowed the researcher(s) to select those health care seekers and providers who had the required information with respect to the objectives of the study. in-depth interviews using a semi-structured ques· tionnaire were administered ro key informants in health care institutions. this sought to explore ways in which the government and the private sector had responded and addressed in practical terms to new demands of health care provision following the structural adjustment programmes of the s. this was complemented by secondary literature review of publications and records of key governmental, bilateral and multilateral development partners in nairobi. the study notes a number of weaknesses especially of kenya's ministry of health to perform its expected roles such as managing user fee revenue and financial sustainability of health insurance systems. this changing face of health services provision in kenya there· fore creates a complex situation, which demands greater understanding of the roles of competition and choice, regulatory structures and models of financing in shaving the evolution of health services. we rec· ommend that the introduction of user fees, decentralization of service provision and contracting-out of non-clinical to private and voluntary agencies require a new management culture, and new and clear insri· tutional relationships. experience with private sector involvement in health projects underlines the need not only for innovative financial structures to deal with a multitude of contractual, political, market and risks, but also building credible structures to ensure that health services projects are environmentally responsive, socially sensitive, economically viable, and politically feasible. purpose: the purpose of this study is to examine the status of mammography screening utilization and its predictors among muslim women living in southern california. methods: we conducted a cross-sectional study that included women aged ::!: years. we col· leered data using a questionnaire in the primary language of the subjects. the questionnaire included questions on demography; practices of breast self-examination (bse) and clinical breast examination (cbe); utilization of mammography; and family history of breast cancer. bivariate and multiple logistic regression analyses were performed to estimate the odds ratios of mammography use as a function of demographic and other predictor variables. . results: among the women, % were married, % were - years old, and % had family h story of breast cancer. thirty-two percent of the participating women never practiced bse and % had not undergone cbe during the past two years. the data indicated that % of the women did not have mammography in the last two years. logistic regression analysis showed that age ( r= . , % confi· dcnc~ interval (cl)=l. - . ), having clinical breast examination ( r= . , % cl= . - . ), and practtce of self-breast examination ( r= . , % cl= . - . ), were strong predictors of mammography use . . conclusions: the data point to the need for intervention targeting muslim women to inform and motivate th.cm a~ut practices for early detection of breast cancer and screening. further studies are needed to investigate the factors associated with low utilization of mammography among muslim women population in california. we conducted a review of the scientific literature and° government documents to describe ditnational health care program "barrio adentro" (inside the neighborhood). we also conducted qualiurivt interviews with members of the local health committees in urban settings to descrihe the comm unity participation component of the program. rtsmlts: until recently, the venezuelan public health system was characterized by a lack or limited access w health care ( % of the population) and long waiting lists that amounted to denial of service. moit than half of the mds worked in the five wealthiest metropolitan areas of the country. jn the spring oi , a pilot program hired cuban mds to live in the slums of caracas to provide health care to piople who had previously been marginalized from social programs. the program underwent a massive expansion and in only two years , cuban and , venezuelan health care providers were working acmss the country. they provide a daily average of - medical consultations and home visits, c lly out neighborhood rounds, and deliver health prevention initiatives, including immunization programs. they also provide generic medicines at no cost to patients, which treat % of presenting ill-ij!m, barrio adentro aims to build , clinics (primary care), , diagnostic and rehabilitation ctnrres (secondary care), and upgrade the current hospital infrastructure (tertiary care). local health committees survey the community to identify needs and organize a variety of lobby groups to improve dit material conditions of the community. last year, barrio adentro conducted . times the medical visits conducted by the ministry of health. the philosophy of care follows an integrated approach where btalrh is related to housing, education, employment, sports, environment, and food security. conclusions: barrio adentro is a unique collaboration between low-middle income countries to provide health care to people who have been traditionally excluded from social programs. this program shows that it is possible to develop an effective international collaboration based on participatory democracy. low-income americans are at the greatest risk of being uninsured and often face multiple health concerns. this evaluation of the neighborhood health initiative (nh!), an organization which uses multiple programmatic approaches to meet the multiple health needs of clients, reflected the program's many activities and the clients' many service needs. nh! serves low-income, underserved, and hard-to-reach residents in the des moines enterprise community. multiple approaches (fourth-generation evaluation, grounded theory, strengths-and needs-based) and methods (staff and client interviews, concept mapping, observations, qualitative and quantitative analysis) were used to achieve that reflection. results indicate good targeting of residents in the zip code and positive findings in the way of health insurance coverage and reported unmet health needs of clients. program activities were found to match client nttds, validating the organization\'s assessment of clients. important components of nhi were the staff composition and that the organization had become part of both the formal and informal networks. nhi positioned as a link between the target population and local health and social sc:rvice agencies, working to connect residents with services and information as well as aid local agencies in reaching this underserved population. p - (c) welfare: definition by new york city maribeth gregory for an individual who resides in new york city, to obtain health insurance under the medicaid policy one must fall under certain criteria .. (new york city's welfare programs ) if the individual _is on ssi or earns equal to or less than $ per month, he is entitled to receive no more than $ , m resources. a family the size of two would need to earn less than $ per month to qualify for no greater than ss, worth of medicaid benefits. a family of three would qualify for $ , is they earned less than $ per month and so on. introduction: the vancouver gay communiry has a significant number of asian descendan!l. because of their double minority status of being gay and asian, many asian men who have sex with men (msm) are struggling with unique issues. dealing with racism in both mainstream society and the gay communiry, cultural differences, traditional family relations, and language challenges can be some of their everyday srruggles. however, culturally, sexually, and linguistically specific services for asian msm are very limited. a lack of availability and accessibiliry of culturally appropriate sexual health services isolates asian msm from mainstream society, the gay community, and their own cultural communities, deprives them of self-esteem, and endangers their sexual well-being. this research focuses on the qualita· tive narrative voices of asian msm who express their issues related to their sexualiry and the challenges of asking for help. by listening to their voices, practitioners can get ideas of what we are missing and how we need to intervene in order to reach asian msm and ensure their sexual health. methods: since many asian msm are very discreet, it is crucial to build up trust relationships between the researcher and asian msm in order to collect qualitative data. for this reason, a community based participatory research model was adopted by forming a six week discussion group for asian msm. in each group session, the researcher tape recorded the discussion, observed interactions among the participants, and analyzed the data by focusing on participants' personal thoughts, experiences, and emotions for given discussion topics. ra lts: many asian msm share challenges such as coping with a language barrier, cultural differ· ences for interpreting issues and problems, and westerncentrism when they approach existing sexual health services. moreover, because of their fear of being disclosed in their small ethnic communities, a lot of asian msm feel insecure about seeking sexual health services when their issues are related to their sexual orientation. conclflsion: sexual health services should contain multilingual and multicultural capacities to meet minority clients' needs. for asian msm, outreach may be a more effective way to provide them with accessible sexual health services since many asian msm are closeted and are therefore reluctant to approach the services. building a communiry for asian msm is also a significant step toward including them in healthcare services. a communiry-based panicipatory approach can help to build a community for asian msm since it creates a rrust relationship between a worker and clients. p - (c) identifying key techniques to sustain interpretation services for assisting newcomers isolated by linguistic and cultural barriers from accessing health services s. gopi krishna lntrodaetion: the greater toronto area (gta) is home to many newcomer immigrants and other vulnerable groups who can't access health resources due to linguistic, cultural and systemic barriers. linguistic and cultural issues are of special concern to suburbs like scarborough, which is home to thousands of newcomer immigrants and refugees lacking fluency in english. multilingual community ~nterpreter. service~ (mcis) is a non-profit social service organization mandated to provide high quality mterpretanon services. to help newcomers access health services, mcis partnered with the scarborough network of immigrant serving organizations (sniso) to recruit and train volunteer interpreters to accompany clienrs lacking fluency in english and interpret for them to access health services at various locati?ns, incl~~ing communiry ~c:-lth centres/social service agencies and hospitals. the model envisioned agencies recruin~ and mcis ~.mm.g and creating an online database of pooled interpreter resources. this da.tabase, acces& bl~ to all pama~~g ?rganization is to be maintained through administrative/member · ship fees to. be ~ d by each parnapanng organization. this paper analyzes the results of the project, defines and identifies suc:cases before providing a detailed analysis for the reasons for the success . . methods:. this ~per~ q~ntitative (i.e. client numben) and qualitative analysis (i.e. results of key •~ormant m~rv ews with semce ~sers and interpreters) to analyze the project development, training and mplementanon phases of the project. it then identifies the successes and failures through the afore· mentioned analysis. poster sessions vss resljts: the results of the analysis can be summarized as: • the program saw modest success both ia l?lllls of numbers of clients served as well as sustainability at various locations, except in the hospital iririog. o the success of the program rests strongly on the commitment of not just the volunteer interprmr, but on service users acknowledgments through providing transponation allowance, small honororia, letter of reference etc. • the hospital sustained the program better at the hospital due to the iolume and nature of the need, as well as innate capacity for managing and acknowledging volunceers. collc/llsion: it is possible to facilitate and sustain vulnerable newcomer immigrants access to health !ul'ices through the training and commitment of an interpreter volunteer core. acknowledging volunteer commitment is key to the sustenance of the project. this finding is important to immigration and health policy given the significant numbers of newcomer immigrants arriving in canada's urban communities. nity program was established in to provide support to people dying at home, especially those who were waiting for admission to the resi<lential hospice. with the advent of haart and corresponding challenges for people living with hiv/aids in the community, the community program has developed a unique case management approach. this model features an interdisciplinary team providing a clientdrivcn service. the case manager provides continuity of care to clients in a variety of settings both within and outside of the health care system. a case study is used to demonstrate how formal and informal networks of support facilitate efficient and appropriate resource utilization to promote client health. this case study demonstrates the value of consistent coordination with a client who has complex physical, spiritual, substance use and mental health needs. the authors will show how they liaised with the housing authority, police, social services as well as the family physician, clinic staff and a hospital emergtncy room to ensure this client did not fall between the cracks. tarek hussain recognition of the importance of community involvement and sectoral cooperation in health and !ocial services, formalized in alma-ata declaration in , was reinforced at riga meeting held at the mid·point between alma-ata and the year . then at the th anniversary of alma-ata declaration, ir was declared that 'primary health care is everybody's business'. health does not exist in isolation. health cannot be defined only as an outcome of 'medical care' but also as one of 'social action'; the responsibility of disease prevention and health promotion rests not only on governments, but also with don·govemmentorgan izations, the community, and individuals. the major accomplishment to date may be that rhere is growing realization in the health sector that community involvement is more than a political right-it is absolute necessary. lessons have learned during the implementation of disease-specific l'cltical programmes, such as cdd, ari, and epi; first, integrated and holistic approaches to childcare art needed, and second, the need for community involvement has become evident. imc! is a broad inte-gra ed strategy with an overall objective contributing to reducing child morbidity and mortality in developing countries. and one of the imci components, 'community !mci', which is now broadening ~s an entry point for child-focused community development initiatives. community jmcl/c~ ld health is ~n mtcgrated approach to the promotion of key family and community practices that have impact on: child growth and development, disease prevention, home care for sick, malnourished child~en, a.nd care-seekmg behavior and compliance with advice and treatment. the presentation addres~es, m brief, the ~evel opinent of community !mci, operational aspect of community/im cl, key strategies and tools ava la~le for implementation of c/imci. the paper draws some successful programme examples on working logether for imc! with the community in various countries which had substantial benefns on programme outcomes. p - t (c) healthy child screening: an innovative service initiative ann-marie marcolin and joyce allen . introduction: with mounting attention for creative and integrated models of c~re .that are populallon and community focused, the healthy child screening initiative achiev.es t~ese pnncipl~s and more! . • parkdale high park rotary (sponsorship) the heal~h ~h ld scree? ?g is a ~opl~-centred model of care. agency and professional sector-specific silos are ehmmated, ~rov dmg f~~ hes wit~ one-sto~ access to primary prevention services in a local school gym! children at nsk are rece vmg early mtervent n and appropriate referrals to the right care provider, at the right time a~d in t~e right place. further, with a complimentary focus on prevention, the program serves to keep at nsk children healthy. healthy child screening results: the service model is developed around four distinct phases: ) planned outreach; ) coordinated intake and registration; ) interdisciplinary screening; and ) targeted referral. since the fall and through six collaborative healthy child screenings children ranging in age from to have benefited from this unique service model of care. conclusion: the presentation will provide practical information on the development and implementation of the model. there will also be a focus on lessons learned in building community service provider-hospital relationships. according to statistics canada ( ) % of the toronto population was born outside of canada and % were new immigrants. immigrants often arrive in canada in superior health compared to the canadian born population, but they lose this health advantage over time. changes in immigrant health status over time may be attributed to a variety of factors including barriers to accessing and receiving care as well as limitations in the mainstream health service organizations and their approaches to health care delivery (hyman, ) . for example, immigrant women are less likely to receive pap tests, which places them at a greater risk for developing cervical cancer. similarly, immigrant women receive less mammography screening than their canadian counterparts. the immigrant women's health centre mobile health unit (mhu) was created as an alternative care delivery model to address the need for increased accessibility as well as culturally and linguistically appropriate reproductive health care. toronto western hospital and the immigrant women's health centre have formed a collaborative partnership which incorporates a primary care nurse practitioner and lay ethnocultural counselors providing care on the mhu. currently, a qualitative ethnonursing study is underway to understand the unique experiences of women using the mhu for their reproductive health care as well as the perspectives of the mhu health care providers. based on a literature review and preliminary findings from provider and participant interviews, the proposed presentation will address the themes of health status for immigrant and refugee women, accessibility issues as well strategies to improve their reproductive health care. we will discuss benefits as well as limitations to health care provision using this alternative service delivery model. michael carden, brian edlin, andrew talal, elizabeth getter, and marla shu lntrod.ction: to date most active drug users have not had access to treatment for hepatitis c virus (hcv) infection and substantial barriers continue to exist that interfere with treatment availability for this population. methods: active illicit drug users interested in pursuing hcv care and treatment were recruited in partnership w~th co~munity-based organizations (cbo's) in new york city. baseline data were collected on quahty of hfe, substance use patterns, depression, health care utilization, hcv health beliefs and other relev.ant variables. medical evaluations were conducted, including liver biopsy when indicated, an~ treatment ts ~ffered when no contraindications are present. participants also receive psychiatric evaluahons to determme the appropriateness of interferon treatment. renlts: fifteen individuals have been recruited to date and received an initial medical evaluation. the mean age was years and _the average age of initial heroin or cocaine use was . . eight ( %) ha~ been homeless at least once m the last months and s ( %) were homeless for most or all of this penod. fourteen ( %) had a history of injection drug use with the mean age at first injection being s frsewons v ,an. elrven persc.!ns ( %) reported inje~~ng .heroin or cocaine within the last days while the .wing four ( l'o) reported regular non-m ect on use of cocaine and street-obtained benzodiazepines. sijiy seven percent of the sample (n= ) reported ever being referred to hcv treatment while ( t % ) ftponeddiattreann~nt had been offered by~ ~e.dical provider. none had ever received a liver biopsy or araanent. most believed that hcv was a s gmf cant threat to their health ( %) and that there was a pm)dchance they would eventually die if their hepatitis c was not treated ( %). though individuals % believed that there was no cure for hcv, ( %) reported that they would initiate treatment if i was recommended by their doctor. thirteen ( %) had a current psychiatric diagnosis including «pmsion, anxiety disorder, schizophrenia, schizoaffective disorder, and borderline and antisocial persooaliry disorders. among eight individuals who had the beck depression inventory administered, the mean score was . . attendance rates were % ( / ) at scheduled medical and psychiatric ppointments and % ( / ) at liver biopsy. <andtuions: active drug users, despite experiencing multiple psycho-social problems, can be mgaged in hcv care using a multidisciplinary approach, but require intensive follow-up support. hcv aunnent of active drug users should not be dismissed. n- (c) antiretroviral therapy in mv infected infants: when to initiate therapy an african experience kingsley okonkwo, ademola adeyemo, israel sokeye, and nwaife umeike /""°""ction: as technology for early diagnosis of human immunodeficiency virus [hiv] improves, m to commence highly active antiretroviral therapy [haarn is yet to be fully evaluated. this prospective study describes our initial experience with early haart in hiv infected nigerian infants and rqions the outcome. we also analyzed the socioeconomic implications of early haart therapy in infants in the african setting. method: hiv infected infants were started on haart before months and followed up at mkly intervals.we monitored baseline and monthly cd . conclusion: initial results suggest early haart before months resulted. in improv~d out~ome in african children. treatment appears to be as effective as in developed counmes. in. a~nca as. m most developing countries with limited resources it is possible and effective to use haart m ~~ants if p~oper llloniroring facilities are available. however the occurrence of long-term drug related tox c ty and mk of emergence of resistant viral strains create need for further evaluation of haart in infants. background: most risk factors for cardiovascular disease (cvd) can be mitigated through ~th clinical interventions and lifestyle change. we used data from a telephone survey of new york city (nyc) adults to characterize health care access and healthy behavior among those with three or more cvd risk factors. methods: the study population included respondents to the nyc community health survey (n= , ) self-reporting~ of the following: smoking, diabetes, high cholesterol level, high blood pres· sure, body mass index > , and age > (males) or > (females) (n= , ). results: based on self-report, an estimated . , ( %) of nyc adults have~ or more cvd risk factors. this population is % male, % white, % black, and % with s years of education. most report good access to health care, indicated by having health insurance ( %), regular doctor ( %), their blood pressure checked within last months ( %), and their choles· terol checked within the past year ( % ). only % reported getting at least minutes of exercise ~ times per week and only % eating ~ servings of fruits and vegetables the previous day. among current smokers, % attempted to quit in past months, but only % used medication or counseling. implications: these data suggest that most nyc adults known to be at high risk for cvd have access to regular health care, but most do not engage in healthy lifestyle or, if they smoke, attempt effective quit strategies. more clinic-based and population-level interventions are needed to support lifestyle change among those at high risk of cvd. introduction: recently, much interest has been directed at "obesogenic" (obesity-promoting) (swinburn, egger & raza, ) built environments, and at geographic information systems (gis) as a tool for their exploration. a major geographical concept is accessibility, or the ease of moving from an origin to a destination point, which has been recently explored in several health promotion-related stud· ies. there are several methods of calculating accessibility to an urban feature, each with its own strengths, drawbacks and level of precision that can be applied to various health promotion research issues. the purpose of this paper is to describe, compare and contrast four common methods of calculating accessibility to urban amenities in terms of their utility to obesity-related health promotion research. practical and conceptual issues surrounding these methods are introduced and discussed with the intent of providing health promotion researchers with information useful for selecting the most appropria e accessibility method for their research goal~ ~ethod: this paper describes methodological insights from two studies, both of which assessed the neighbourhood-level accessibility of fast-food establishments in edmonton, canada -one which used a relatively simple coverage method and one which used a more complex minimum cos method. res.its: both methods of calculating accessibility revealed similar patterns of high and low access to fast-food outlets. however, a major drawback of both methods is that they assume the characteristics of the a~e~ities and of the populations using them are all the same, and are static. the gravity potential method is introduced as an alternative, since it is ·capable of factoring in measures of quality and choice. a n~mber of conceptual and pr~ctical iss~es, illustrated by the example of situational influences on food choice, make the use of the gravity potential model unwieldy for health promotion research into sociallydetermined conditions such as obesity. co.nclusions: i~ ~ommended that geographical approaches be used in partnership with, or as a foun~ation for, ~admonal exploratory methodologies such as group interviews or other forms of commumty consultation that are more inclusive and representative of the populations of interest. qilhl in los angeles county ,,..ia shaheen, richard casey, fernando cardenas, holman arthurs, and richard baker ~the retinomax autorefractor has been used for vision screening of preschool age childien. ir bas been suggested to be used and test school age children but not been validated in this age poup. ob;taiw: to compare the results of retinomax autorefractor with findings from a comprehensive i!' examination using wet retinoscopy for refractive error. mllhods: children - years old recruited from elementary schools at los angeles county were iaml with snellen's chart and the retinomax autorefractor and bad comprehensive eye examination with dilation. the proportion of children with abnormal eye examination as well as diesensitiviry and specificity of the screening tools using retinomax autorefractor alone and in combinalion wirh snellen's chart. results of the children enrolled in the study (average age= . ± . years; age range, - years), ?% had abnormal eye examination using retinoscopy with dilation. for the lerinomax, the sensitivity was % ( % confidence interval [ci] %- %), and the specificity was % ( % ci, %- o/o). simultaneous testing using snellen's chart and retinomax resulted in gain in sitiviry ( %, % cl= , ), and loss in specificity ( %, % cl= %- %). the study showed that screening school age children with retinomax autorefractor could identify most cases with abnormal vision but would be associated with many false-positive results. simuhaneous resting using snellen's chart and retinomax maximize the case finding but with very low specificiry. mdhotjs: a language-stratified, random sample of members of the college of family physicians of canada received a confidential survey. the questionnaire collected data on socio-demographic characteristics, medical training, practice type, setting and hcv-related care practices. the self-adminisratd questionnaire was also made available to participants for completion on the internet. batdti: response proportion was %. median age was years ( % female) and the proporlionoffrench questionnaires was %. approximately % had completed family medicine residency lllining in canada; median year of training completion was . sixty-seven percent, % and % work in private offices/clinics, community hospitals and emergency departments, respectively. regarding ~practices, % had ever requested a hcv test and % of physicians had screened for hcv iafrction in rhe past months· median number of tests was . while % reported having no hcv-uaed patients in their practic~, % had - hcv-infected patients. regarding the level of hcv care provided, . % provide ongoing advanced hcv care including treatment and dose monitoring for ctmduions: in this sample of canadian family physicians, most had pro~ided hcv screening. to •least one patient in the past year. less than half had - hcv-infected patients and % provide ~:relared care the role of socio-demographic factors, medical training as wel_i as hcv ca~e percep-lldas rhe provision of appropriate hcv screening will be examined and described at the time of the canference. ' - (c) healthcare services: the context of nepal meen poudyal chhetri """ tl.ction healthcare service is related with the human rights and fundamental righ~ of the ci~ ciaaiuntry. however, the growing demand foi health care services, quality heal~care service, accessib b~ id die mass population and paucity of funds are the different but interrelated issues to .be ~ddressed. m nepat. n view of this context, public health sector in nepal is among other sectors, which is struggling -.i for scarce resources. . . . nepal, the problems in the field of healthcare servic~s do not bnut ~o the. paucity of faads and resources only, but there are other problems like: rural -urban imbalance, regional unbalance, poster sessio~ f the ll ·m ·ted resources poor healthcare services, inequity and inaccessibility of the poor management o , . poor people of the rural, remote and hilly areas for the healthcare services and so on.. . . . · . i f ct the best resource allocation is the one that max m zes t e sum o m ivi ua s u · ea t services. n a , · h d' ·b · · · h . ·t effi.ciency and efficient management are correlated. it might be t e re istn utmn of mes. ence, equi y, . . . . . income or redistribution of services. moreover, maximizanon of available resources, qua tty healthcare services and efficient management of them are the very important and necessary tools and techmques to meet the growing demand and quality healthcare services in nepal. p - (a) an jn-depth analysis of medical detox clients to assist in evidence based decision making xin li, huiying sun, ajay puri, david marsh, and aslam anis introduction: problematic substance use represents an ever-increasing public health challenge. in the vancouver coastal health (vch) region, there are more than , individuals having some probability of drug or alcohol dependence. to accommodate this potential demand for addiction related services, vch provides various services and treatment, including four levels of withdrawal management services (wms). clients seeking wms are screened and referred to appropriate services through a central telephone intake service (access i). the present study seeks to rigorously evaluate one of the services, vancouver detox, a medically monitored -bed residential detox facility, and its clients. doing so will allow decision makers to utilize evidence based decision-making in order to improve the accessibility and efficiency of wms, and therefore, the health of these clients. methods: we extract one-year data (october , -september , from an efficient and comprehensive database. the occupancy rate of the detox centre along with the clients' wait time for service and length of stay (los) are calculated. in addition, the effect of seasonality on these variables and the impact of the once per month welfare check issuance on the occupancy rate are also evaluated. results: among the clients (median age , % male) who were referred by access! to vancouver detox over the one-year period, were admitted. the majority ( %) of those who are not admitted are either lost to follow up (i.e., clients not having a fixed address or telephone) or declined service at time of callback. the median wait time was day [q -ql: - ], the median los was days iq -qt: - ], and the average bed occupancy rate was %. however, during the threeday welfare check issue period the occupancy rate was lower compared to the other days of the year % vs. %, p conclusion: our analysis indicates that there was a relatively short wait time at vancouver detox, however % of the potential clients were not served. in addition, the occupancy rate declined during the welfare check issuance period and during the summer. this suggests that accessibility and efficiency at vancouver detox could be improved by specifically addressing these factors. background: intimate partner violence (ipv) is associated with acute and chronic physical and men· tal health outcomes for women resulting in greater use of health services. yet, a vast literature attests to cultural variations in perceptions of health and help-seeking behaviour. fewer studies have examined differences in perceptions of ipv among women from ethnocultural communities. the recognition, definition, and understanding of ipv, as well as the language used to describe these experiences, may be different in these communities. as such, a woman's response, including whether or not to disclose or seek help, may vary according to her understanding of the problem. methods: this pilot study explores the influence of cultural factors on perceptions of and responses to ipv among canadian born and immigrant young women. in-depth focus group interviews were con· ducted with women, aged to years, living in toronto. open-ended and semi-structured interview questions were designed to elicit information regarding how young women socially construct jpv and where they would go to receive help. interviews were transcribed, then read and independently coded by the research team. codes were compared and disagreements resolved. qualitative software qsr n was used to assist with data management. . ruu~ts_: res~nses_abo~t what constitutes ipv were similar across the study groups. when considering specific ab.us ve ~ tuanons and types of relationships, participants held fairly relativistic views about ipv, especially with regard to help-seeking behaviour. cultural differences in beliefs about normaive m;ile/femal~ relations. familial.roles, and customs governing acceptable behaviours influenced partictpants perceptions about what n ght be helpful to abused women. interview data highlight the social l ter srnfons v suucrural _impact these factors ha:e on you?g women and provide details regarding the dynamics of cibnocultur~ m~uences on help-~eekmg behav ur: t~e ro~e of such factors such as gender inequality within rtlaoo?sh ps and t_he ~erce ved degree of ~oc al solat on and support nerworks are highlighted. collc~ the~ findmgs unde~score the _ mporta_nc_e of understanding cultural variations in percrprions of ipv ~ relanon to ~elp-seekmg beha~ ':'ur. th s_mformation is critical for health professionals iodiey may connnue developmg culturally sensmve practices, including screening guidelines and protorol s. ln addition, _this study demonstr~tes that focus group interviews are valuable for engaging young romen in discussions about ipv, helpmg them to 'name' their experiences, and consider sources of help when warranted. p -s (a) health problems and health care use of young drug users in amsterdam .wieke krol, evelien van geffen, angela buchholz, esther welp, erik van ameijden, and maria prins / trod ction: recent advances in health care and drug treatment have improved the health of populations with special social and health care needs, such as drug users. however, still a substantial number dots not have access to the type of services required to improve their health status. in the netherlands, tspccially young adult drug users (yad) whose primary drug is cocaine might have limited access to drugrreatment services. in this study we examined the history and current use of (drug associated) treatmmt services, the determinants for loss of contact, and the current health care needs in the young drug mm amsterdam study (yodam). methods: yodam started in and is embedded in the amsterdam cohort study among drug mm. data were derived from y ad aged < years who had used cocaine, heroin, ampheramines and i or methadone at least days a week during the months prior to enrolment. res lts:of yao, median age was years (range: - years), % was male and % had dutch nationality at enrolment. nearly all participants ( %) reported a history of contact with drug llt.lnnent services (methadone maintenance, rehabilitation clinics and judicial treatment), mental health car? (ambulant mental care and psychiatric hospital) or general treatment services (day-care, night-care, hdp for living arrangements, work and finance). however, only % reported contact in the past six l!xlllths. this figure was similar in the first and second follow-up visit. among y ad who reported no current contact with the health care system, % would like to have contact with general treatment serl' icts. among participants who have never had contact with drug treatment services, % used primarily cocaine compared with % and % among those who reported past or current contact, respectively. saied on the addiction severity index, % reported at least one mental health problem in the past days, but only % had current contact with mental health services. concl sion: results from this study among young adult drug users show that despite a high contact rm with health care providers, the health care system seems to lose contact with yao. since % indicatt the need of general treatment services, especially for arranging house and living conditions, health m services that effectively integrate general health care with drug treatment services and mental health care might be more successful to keep contact with young cocaine users. mtthods: respondents included adults aged and over who met dsm-iv diagn?snc criteria for an anxiety or depressive disorder in the past months. we performed two sets of logisnc regressmns. thtdichotomous dependent variables for each of the regressions indicated whether rhe respondenr_vis-ud a psychiatrist, psychologist, family physician or social worker in the _past_ months. no relationship for income. there was no significant interaction between educatmn an mco~:· r: ::or respondents with at least a high school education to seek help ~rom any of the four servic p were almost twice that for respondents who had not completed high school. th . d ec of analyses found che associacion becween educacion and use of md-provided care e secon s · · be d · · ·f· ly ·n che low income group for non-md care, the assoc anon cween e ucatlon and was s gm icant on -· . . . . use of social workers was significant in both income groups, but significant only for use of psychologists in che high-income group. . . . conclusion: we found differences in healch service use by education level. ind v duals who have nor compleced high school appeared co use less mental he~lt~ servi~es provided ~y psyc~iatrists, psycholo· gists, family physicians and social workers. we found limited e.v dence _suggesting the influence of educa· tion on service use varies according to income and type of service provider. results suggesc there may be a need to develop and evaluate progr~ms.designe~ to deliver targeted services to consumers who have noc completed high school. further quahtanve studies about the expen· ence of individuals with low education are needed to clarify whether education's relationship with ser· vice use is provider or consumer driven, and to disentangle the interrelated influences of income and education. system for homeless, hiv-infected patients in nyc? nancy sahler, chinazo cunningham, and kathryn anastos introduction: racial/ethnic disparities in access to health care have been consistently documented. one potential reason for disparities is that the cultural distance between minority patients and their providers discourage chese patients from seeking and continuing care. many institucions have incorporated cultural compecency craining and culturally sensicive models of health care delivery, hoping co encourage better relacionships becween patients and providers, more posicive views about the health care system, and, ulcimacely, improved health outcomes for minority patients. the current scudy tests whether cultural distance between physicians and patients, measured by racial discordance, predicts poorer patient attitudes about their providers and the health care system in a severely disadvantaged hiv-infected population in new york city that typically reports inconsistent patterns of health care. methods: we collected data from unscably housed black and latino/a people with hiv who reported having a regular health care provider. we asked them to report on their attitudes about their provider and the health care system using validated instruments. subjects were categorized as being racially "concordant" or "discordant" with their providers, and attitudes of these two groups were compared. results: the sample consisted of ( %) black and ( %) latino/a people, who reported having ( %) black physicians, ( %) latino/a physicians, ( %) white physicians, and ( %) physicians of another/unknown race/ethnicity. overall, ( %) subjects had physicians of a different race/ethnicity than their own. racial discordance did not predict negative attitudes about rela· tionship with providers: the mean rating of a i-item trust in provider scale (lo=high and o=low) was . for both concordant and discordant groups, and the mean score in -icem relationship with provider scale ( =high and !=low) was . for both groups. however discordance was significantly associated with distrust in che health care syscem: che mean score on a -icem scale ( =high discrust and l=low distrust) was . for discordant group and . for che concordant group (t= . , p= . ). we further explored these patterns separacely in black and lacino/a subgroups, and using different strategies ro conceptualize racial/ethic discordance. conclusions: in this sample of unscably housed black and latino/a people who receive hiv care in new york city, having a physician from the same racial/ethnic background may be less important for developing a positive doctor-patient relationship than for helping the patients to dispel fear and distrust about the health care system as a whole. we discuss the policy implications of these findings. ilene hyman and samuel noh . .abstract objectiw: this study examines patterns of mental healthcare utilization among ethiopian mm grants living in toronto. methods: a probability sample of ethiopian adults ( years and older) completed structured face-to-face interviews. variables ... define, especially who are non-health care providers. plan of analysis. results: approximately % of respondents received memal health services from mainstream healthcare providers and % consulted non-healthcare professionals. of those who sought mental health services from mainstream healthcare providers, . % saw family physicians, . % visited a psychiatrist. and . % consulted other healthcare providers. compared with males, a significantly higher proportion gsfer sessions v ri ftlnales consulted non-healthcare_ professionals for emotional or mental health problems (p< . ). tlbile ethiopian's overall use of mamstream healthcare services for emotional problems ( %) did not prlydiffer from the rate ( %) of the general population of ontario, only a small proportion ( . %) rjerhiopians with mental health needs used services from mainstream healthcare providers. of these, !oj% received family physicians' services, . % visited a psychiatrist, and . % consulted other healthll/c providers. our data also suggested that ethiopian immigrants were more likely to consult tradioooal healers than health professionals for emotional or mental health problems ( . % vs. . % ). our bivariate analyses found the number of somatic symptoms and stressful life events to be associated with an increased use of medical services and the presence of a mental disorder to be associated with a dfcreased use of medical services for emotional problems. however, using multivariate methods, only die number of somatic symptoms remained significantly associated with use of medical services for emooonal problems. diu#ssion: study findings suggest that there is a need for ethnic-specific and culturally-appropriate mrcrvention programs to help ethiopian immigrants and refugees with mental health needs. since there ~a strong association between somatic symptoms and the use family physicians' services, there appears robe a critical role for community-based family physicians to detect potential mental health problems among their ethiopian patients, and to provide appropriate treatment and/or referral. the authors acknowledge the centre of excellence for research in immigration and settlement (ceris) in toronto and canadian heritage who provided funding for the study. we also acknowledge linn clark whose editorial work has improved significantly the quality of this manuscript. we want to thank all the participants of the study, and the ethiopian community leaders without whose honest contributions the present study would have not been possible. this paper addresses the impact of the rationalization of health-care services on the clinical decision-making of emergency physicians in two urban hospital emergency departments in atlantic canada. using the combined strategies of observational analysis and in-depth interviewing, this study provides a qualitative understanding of how physicians and, by extension, patients are impacred by the increasing ancmpts to make health-care both more efficient and cost-effective. such attempts have resulted in significantly compromised access to primary care within the community. as a consequence, patients are, out of necessity, inappropriately relying upon emergency departments for primary care services as well as access to specialty services. within the hospital, rationalization has resulted in bed closures and severely rmricted access to in-patient services. emergency physicians and their patients are in a tenuous position having many needs but few resources. furthermore, in response to demands for greater accountability, physicians have also adopted rationality in the form of evidence-based medicine. ultimately, ho~ever, rationality whether imposed upon, or adopted by, the profession significantly undermines physu.: ans' ability to make decisions in the best interests of their patients. johnjasek, gretchen van wye, and bonnie kerker introduction: hispanics comprise an increasing proportion of th.e new york city (nyc) populanon !currently about %). like males in the general population, h spamc males (hm) have a lower prrval,nce of healthcare utilization than females. however, they face additional access barriers such as bnguage differences and high rates of uninsurance. they also bear a heavy burden of health problems lllehasobesity and hiv/aids. this paper examines patterns of healthcare access and ut hzat on by hm compared to other nyc adults and identifies key areas for intervention. . . . and older are significantly lower than the nhm popu anon . v. . , p<. ), though hi\' screening and immunizations are comparable between the two groups. conclusion: findings suggest that hm have less access t? healthcare than hf or nhm. hown r, hm ble to obtain certain discrete medical services as easily as other groups, perhapsdueto!rtor are a hm. i i . subsidized programs. for other services, utilization among s ower. mprovmg acc~tocareinthis group will help ensure routine, quality care, which can lead to a greater use of prevennve services iii! thus bener health outcomes. introduction: cancer registry is considered as one of the most important issues in cancer epidemiology and prevention. bias or under-reporting of cancer cases can affect the accuracy of the results of epidemiological studies and control programs. the aim of this study was to assess the reliability of the regional cancer report in a relatively small province (yasuj) with almost all facilities needed for c llcll diagnosis and treatment. methods: finding the total number of cancer cases we reviewed records of all patients diagnoicd with cancer (icd - ) and registered in any hospital or pathology centre from until i n yasuj and all ( ) surrounding provinces. results: of patients who were originally residents of yasui province, . % wereaccoulll!d for yasuj province. the proportion varies according to the type of cancer, for exarnplecancetsofdiglstive system, skin and breast were more frequently reported by yasuj's health facilities whereas cancmoi blood, brain and bone were mostly reported by neighbouring provinces. the remaining cases ( . % were diagnosed, treated and recorded by neighbouring provinces as their incident cases. this is partly because of the fact that patients seek medical services from other provinces as they believed that the facil. ities are offered by more experienced and higher quality stuffs and their relative's or temporary acooiii' modation addresses were reported as their place of residence. conclusion: measuring the spatial incidence of cancer according to the location of report ortht current address affected the spatial statistics of cancer. to correct this problem recording the permanm! address of diagnosed cases is important. p - (c). providing primary healthcare to a disadvantaged population at a university-run commumty healthcare facility tracey rickards the. c:ommuni~y .h~alth ~linic (chc) is a university sponsored nurse-managed primary bealthwt (p~c:l clime. the clm c is an innovative model of healthcare delivery in canada that has integrated tht principles of phc ser · · h' . vices wit ma community development framework. it serves to provide access to phc services for members of th · · illi · dru is ii be . . e community, particularly the poor and those who use or gs, we mg a service-learning facil'ty f d · · · · · · d rionll h . . .,m.:. · t · . meet c ient nee s. chmc nursing and social work staff and srudents r·--· ipa em various phc activities and h .l.hont" less i . f . outreac services in the local shelters and on the streels to'"" popu auon o fredericton as well th chc · model iii fosterin an on oi : . • e promotes and supports a harm reduction . · local d!or an~ h ng ~art:ersh p with aids new brunswick and their needle exchange program, w tha ing condoms and :xu:t h:~~~e e~aint~nance therapy clients, and with the clie~ts themselves ~_r; benefits of receiving health f ucation, a place to shower, and a small clothing and food oai~· care rom a nurse p · · d d · --""~'i"· are evidenced in th r research that involved needsaans mvo ves clients, staff, and students. to date the chc has unacn- · sessment/enviro i . d ; •• '"""" ll eva uanon. the clinic has also e . d nmenta scan, cost-benefit analysis, an on-go...,, "".'i'~ facility and compassionate lea x~mme the model of care delivery' focusing on nursing roles wi~ cj rmng among students. finally, the clinic strives to share the resu•p v . -arch with the community in which it provides service by distributing a bi-monthly newsletter, and plllicipating in in-services and educational sessions in a variety of situations. the plan for the future is coolinued research and the use of evidence-based practice in order to guide the staff in choosing how much n~ primary healthcare services to marginalized populations will be provided. n- (c) tuming up the volume: marginalized women's health concerns tckla hendrickson and betty jane richmond bdrotbu:tion: the marginalization of urban women due to socio-economic status and other determinants negatively affects their health and that of their families. this undermines the overall vitaliry of urban communities. for example, regarding access to primary health care, women of lower economic surus and education levels are less likely to be screened for breast and cervical cancer. what is not as widely reported is how marginalized urban women in ontario understand and articulate their lack of access to health care, how they attribute this, and the solutions that they offer. this paper reports on the rnults of the ontario women's health network (owhn) focus group project highlighting urban women's concerns and suggestions regarding access to health care. it also raises larger issues about urban health, dual-purpose focus group design, community-based research and health planning processes. mdhods: focus group methodology was used to facilitate a total of discussions with urban and rural women across ontario from to . the women were invited to participate by local women's and health agencies and represented a range of ages, incomes, and access issues. discussions focussed on women's current health concerns, access to health care, and information needs. results were analyzed using grounded theory. the focus groups departed from traditional focus group research goals and had two purposes: ) data collection and dissemination (representation of women's voices), and ) fostering closer social ties between women, local agencies, and owhn. the paper provides a discussion and rationale for a dual approach. rax/ts: the results confirm current research on women's health access in women's own voices: urban women report difficulty finding responsive doctors, accessing helpful information such as visual aids in doctors' offices, and prohibitive prescription costs, in contrast with rural women's key concern of finding a family doctor. the research suggests that women's health focus groups can address access issues by helping women to network and initiate collective solutions. the study shows that marginalized urban women are articulate about their health conctrns and those of their families, often understanding them in larger socio-economic frameworks; howtver, women need greater access to primary care and women-friendly information in more languages and in places that they go for other purposes. it is crucial that urban health planning processes consult directly with women as key health care managers, and turn up the volume on marginalized women's voices. women: an evaluation of awareness, attitudes and beliefs introduction: nigeria has one of the highest rates of human immunodeficiency virus ihivi seroprrvalence in the world. as in most developing countries vertical transmission from mother to child account for most hiv infection in nigerian children. the purpose of this study was ro. determine the awareness, attitudes and beliefs of pregnant nigerian women towards voluntary counseling and testing ivct! for hiv. mnbod: a pre-tested questionnaire was used to survey a cross section '.>f. pregnant women ~t (lrlleral antenatal clinics in awka, nigeria. data was reviewed based on willingness to ~c~ept or re ect vct and the reasons for disapproval. knowledge of hiv infection, routes of hiv transm ssmn and ant rnroviral therapy iart) was evaluated. hsults: % of the women had good knowledge of hiv, i % had fair knowledge while . % had poor knowledge of hiv infection. % of the women were not aware of the association of hreast milk feeding and transmission of hiv to their babies. majority of the women % approved v~t while % disapproved vct, % of those who approved said it was because vct could ~educe risk of rransmission of hiv to their babies. all respondents, % who accepted vc.i ~ere willing to be tnted if results are kept confidential only % accepted to be tested if vc.t results w. be s~ared w .th pinner and relatives % attributed their refusal to the effect it may have on their marriage whale '-gave the social 'and cultural stigmatization associated with hiv infection for their r~fusal.s % wall accept vct if they will be tested at the same time with their partners. ~ of ~omen wall pref~r to breast feed even if they tested positive to hiv. women with a higher education diploma were times v more likely to accept vct. knowledge of art for hiv infected pregnant women as a means of pre. vention of maternal to child transmission [pmtct) was generally poor, % of respondents wm aware of art in pregnancy. conclusion: the acceptance of vct by pregnant women seems to depend on their understanding that vct has proven benefits for their unborn child. socio-cultur al factors such as stigmatizationof hiv positive individuals appears to be the maj_or impedi~ent towards widespread acceptanee of ycr in nigeria. involvemen t of male partners may mpro~e attitudes t~wa~ds vct:the developmentofm novative health education strategies is essential to provide women with mformanon as regards the benefits of vct and other means of pmtct. p - (c) ethnic health care advisors in information centers on health care and welfare in four districts of amsterdam arlette hesselink, karien stronks, and arnoud verhoeff introduction : in amsterdam, migrants report a "worse actual health and a lower use of health care services than the native dutch population. this difference might be partly caused by problems migrants have with the dutch language and health care and welfare system. to support migrants finding their way through this system, in four districts in amsterdam information centers on health care and welfare were developed in which ethnic health care advisors were employed. their main task is to provide infor· mation to individuals or groups in order to bridge the gap between migrants and health care providers. methods: the implementat ion of the centers is evaluated using a process evaluation in order to give inside in the factors hampering and promoting the implementat ion. information is gathered using reports, attending meetings of local steering groups, and by semi-structu red interviews with persons (in)directly involved in the implementat ion of the centers. in addition, all individual and groupcontaets of the health care advisors are registered extensively. results: since four information centers, employing ethnic health care advisors, are implemented. the ethnicity of the health care advisors corresponds to the main migrant groups in the different districts (e.g. moroccan, turkeys, surinamese and african). depending on the local steering groups, the focus of the activities of the health care advisors in the centers varies. in total, around individual and group educational sessions have been registered since the start. most participants were positive about the individual and group sessions. the number of clients and type of questions asked depend highly on the location of the centers (e.g. as part of a welfare centre or as part of a housing corporation). in all districts implementa tion was hampered by lack of ongoing commitment of parties involved (e.g. health care providers, migrant organization s) and lack of integration with existing health care and welfare facilities. discussion: the migrant health advisors seem to have an important role in providing information on health and welfare to migrant clients, and therefore contribute in bridging the gap between migrants and professionals in health care and welfare. however, the lack of integration of the centers with the existing health care and welfare facilities in the different districts hampers further implementation . therefore, in most districts the information centres will be closed down as independent facilicities in the near future, and efforts are made to better connect the position of migrant health advisor in existing facilities. the who report ranks the philippines as ninth among countries with a high tb prevalence. about a fourth of the country's population is infected, with majority of cases coming from the lower socioeconomic segments of the community. metro manila is not only the economic and political capital of the philippines but also the site of major universities and educational institutions. initial interviews with the school's clinicians have established the need to come up with treatment guidelines and protocols for students and personnel when tb is diagnosed. these cases are often identified during annual physical examinations as part of the school's requirements. in many instances, students and personnel diagnosed with tb are referred to private physicians where they are often lost to follow-up and may have failure of treatment due to un monitored self-administered therapy. this practice ignores the school clinic's great potential as a tb treatment partner. through its single practice network (spn) initiative, the philippine tuberculosis initiatives for the private sector (philippine tips), has established a model wherein school clinics serve as satellite treatment partners of larger clinics in the delivery of the directly observed treatment, short course (dots) protocol. this "treatment at the source" allows school-based patients to get their free government-suppl ied tb medicines from the clinic each day. it also cancels out the difficulty in accessing medicines through the old model where the patient has to go to the larger clinic outside his/her school to get treatment. the model also enables the clinic to monitor the treatment progress of the student and assumes more responsibility over their health. this experience illustrates how social justice in health could be achieved from means other than fund generation. the harnessing of existing health service providers in urban communities through standardized models of treatment delivery increases the probability of treatment success, not only for tb but for other conditions as well. p - (c) voices for vulnerable populations: communalities across cbpr using qualitative methods martha ann carey, aja lesh, jo-ellen asbury, and mickey smith introduction: providing an opportunity to include, in all stages of health studies, the perspectives and experiences of vulnerable and marginalized populations is increasingly being recognized as a necessary component in uncovering new solutions to issues in health care. qualitative methods, especially focus groups, have been used to understand the perspectives and needs of community members and clinical staff in the development of program theory, process evaluation and refinement of interventions, and for understanding and interpreting results. however, little guidance is available for the optimal use of such information. methods: this presentation will draw on diverse experiences with children and their families in an asthma program in california, a preschool latino population in southern california, a small city afterschool prevention program for children in ohio, hiv/aids military personnel across all branches of the service in the united states, and methadone clinic clients in the south bronx in new york city. focus groups were used to elicit information from community members who would not usually have input into problem definitions and solutions. using a fairly common approach, thematic analysis as adapted from grounded theory, was used to identify concerns in each study. next we looked across these studies, in a meta-synthesis approach, to examine communalities in what was learned and in how information was used in program development and refinement. results: while the purposes and populations were diverse, and the type of concerns and the reporting of results varied, the conceptual framework that guided the planning and implementation of each study was similar, which led to a similar data analysis approach. we will briefly present the results of each study, and in more depth we will describe the communalities and how they were generated. conclusions: while some useful guidance for planning future studies of community based research was gained by looking across these diverse studies, it would be useful to pursue a broader examination of the range of populations and purposes to more fully develop guidance. background: the majority of studies examining the relationship between residential environments and cardiovascular disease have used census derived measures of neighborhood ses. there is a need to identify specific features of neighborhoods relevant to cardiovascular disease risk. we aim to ) develop methods· data on neighborhood conditions were collected from a telephone survey of s, fesi· dents in balth:.ore, md; forsyth county, nc; and new york, ny. a sample of of the i.ni~~l l'elpondents was re-interviewed - weeks after the initial interview t~ measure the tes~-~etest rebab ~ ty of ~e neighborhood scales. information was collected across seven ~e ghborho~ cond ~ons (aesth~~ ~uah~, walking environment, availability of healthy foods, safety, violence, social cohesion, and acnvmes with neighbors). neighborhoods were defined as census tracts or homogen~us census tra~ clusters. ~sycho metric properties.of the neighborhood scales were accessed by ca~cu~~.ng chronba~h s alpha~ (mtemal consistency) and intraclass correlation coefficients (test-r~test reliabilmes) .. pear~n s .corre~anons were calculated to test for associations between indicators of neighborhood ses (tncludmg d mens ons of race/ ethnic composition, family structure, housing, area crowding, residential stability, education, employment, occupation, and income/wealth) and our seven neighborhood scales. . chronbach's alphas ranged from . (walking environment) to . (violence). intraclass correlations ranged from . (waling environment) to . (safety) and wer~ high~~~ . ~ for ~urout of the seven neighborhood dimensions. our neighborhood scales (excluding achv hes with neighbors) were consistently correlated with commonly used census derived indicators of neighborhood ses. the results suggest that neighborhood attributes can be reliably measured. further development of such scales will improve our understanding of neighborhood conditions and their importance to health. childhood to young adulthood in a national u.s. sample jen jen chang lntrodfldion: prior studies indicate higher risk of substance use in children of depressed mothers, but no prior studies have followed up the offspring from childhood into adulthood to obtain more precise estimates of risk. this study aimed to examine the association between early exposure to maternal depl'elsive symptoms (mds) and offspring substance use across time in childhood, adolescence, and young adulthood. methods: data were obtained from the national longitudinal survey of youth. the study sample includes , mother-child/young adult dyads interviewed biennially between and with children aged to years old at baseline. data were gathered using a computer-assisted personal interview method. mds were measured in using the center for epidemiologic studies depression scale. offspring substance use was assessed biennially between and . logistic and passion regression models with generalized estimation equation approach was used for parameter estimates to account for possible correlations among repeated measures in a longitudinal study. rnlllta: most mothers in the study sample were whites ( %), urban residents ( %), had a mean age of years with at least a high school degree ( %). the mean child age at baseline was years old. offspring cigarette and alcohol use increased monotonically across childhood, adolescence, and young adulthood. differential risk of substance use by gender was observed. early exposure to mds was associated with increased risk of cigarette (adjusted odds ratio (aor) = . , % confidence interval ( ): . , . ) and marijuana use (aor = . , % ci: . , . ), but not with alcohol use across childhood, adolescence, and young adulthood, controlling for a child's characteristics, socioeconomic status, ~ligiosity, maternal drug use, and father's involvement. among the covariates, higher levels of father's mvolvement condluion: results from this study confirm previous suggestions that maternal depressive symptoms are associated with adverse child development. findings from the present study on early life experi-e~ce have the potential to inform valuable prevention programs for problem substance use before disturbances become severe and therefore, typically, much more difficult to ameliorate effectively. the ~act (~r-city men~ health study predicting filv/aids, club and other drug transi-b~) study a multi-level study aimed at determining the association between features of the urban enyjronment mental health, drug use, and risky sexual behaviors. the study is randomly sampling foster sessions v neighborhood residents and assessing the relations between characteristics of ethnographically defined urban neighborhoods and the health outcomes of interest. a limitation of existing systematic methods for evaluating the physical and social environments of urban neighborhoods is that they are expensive and time-consuming, therefore limiting the number of times such assessments can be conducted. this is particularly problematic for multi-year studies, where neighborhoods may change as a result of seasonality, gentrification, municipal projects, immigration and the like. therefore, we developed a simpler neighborhood assessment scale that systematically assessed the physical and social environment of urban neighborhoods. the impact neighborhood evaluation scale was developed based on existing and validated instruments, including the new york city housing and vacancy survey which is performed by the u.s. census bureau, and the nyc mayor's office of operations scorecard cleanliness program, and modified through pilot testing and cognitive testing with neighborhood residents. aspects of the physical environment assessed in the scale included physical decay, vacancy and construction, municipal investment and green space. aspects of the social environment measured include social disorder, social trust, affluence and formal and informal street economy. the scale assesses features of the neighborhood environment that are determined by personal (e.g., presence of dog feces), community (e.g., presence of a community garden), and municipal (e.g., street cleanliness) factors. the scale is administered systematically block-by-block in a neighborhood. trained research staff start at the northeast corner of an intersection and walk around the blocks in a clockwise direction. staff complete the scale for each street of the block, only evaluating the right side of the street. thus for each block, three or more assessments are completed. we are in the process of assessing psychometric properties of the instrument, including inter-rater reliability and internal consistency, and determining the minimum number of blocks or street segments that need to be assessed in order to provide an accurate estimate of the neighborhood environment. these data will be presented at the conference. obj«tive: to describe and analyze the perceptions of longterm injection drug users (idus) about their initiation into injecting. toronto. purposive sampling was used to seek out an ethnoculturally diverse sample of idus of both genders and from all areas of the city, through recruitment from harm reduction services and from referral by other study participants. interviews asked about drug use history including first use and first injecting, as well as questions about health issues, service utilization and needs. thematic analysis was used to examine initiation of drug use and of injection. results: two conditions appeared necessary for initiation of injection. one was a developed conception of drugs and their (desirable) effects, as suggested by the work of becker for marijuana. thus virtually all panicipants had used drugs by other routes prior to injecting, and had developed expectations about effects they considered pleasureable or beneficial. the second condition was a group and social context in which such use arose. no participants perceived their initiation to injecting as involving peer pressure. rather they suggested that they sought out peers with a similar social situation and interest in using drugs. observing injection by others often served as a means to initiate injection. injection served symbolic purposes for some participants, enhancing their status in their group and marking a transition to a different social world. concl ion: better understanding of social and contextual factors motivating drug users who initiate injection can assist in prevention efforts. ma!onty of them had higher educational level ( %-highschool or higher).about . yo adffiltted to have history of alcohol & another . % had history of smoking. only . % people were on hrt & . % were receiving steroid. majority of them ( . ) did not have history of osteoporosis. . % have difficulty in ambulating. only . % had family history of osteoporosis. bmd measurements as me~sured by dual xray absorptiometry (dexa) were used for the analysis. bmd results were compare~ w ~ rbc folate & serum vitamin b levels. no statistical significance found between bmd & serum v taffiln b level but high levels of folate level is associated with normal bmd in bivariate and multivariate analysis. conclusion: in the studied elderly population, there was no relationship between bmd and vitamin b ; but there was a significant association between folate levels & bmd. introduction: adolescence is a critical period for identity formation. western studies have investigated the relationship of identity to adolescent well-being. special emphasis has been placed on the influence of ethnic identity on health, especially among forced migrants in different foreign countries. methodology: this study asses by the means of an open ended question identity categorization among youth in three economically disadvantaged urban communities in beirut, the capital of lebanon. these three communities have different histories of displacement and different socio-demographic makeup. however, they share a history of displacement due to war. results and conclusion: the results indicated that nationality was the major category of identification in all three communities followed by origin and religion. however, the percentages that self-identify by particular identity categories were significantly different among youth in the three communities, perhaps reflecting different context in which they have grown up. mechanical heart valve replacement amanda hu, chi-ming chow, diem dao, lee errett, and mary keith introduction: patients with mechanical heart valves must follow lifelong warfarin therapy. war· farin, however, is a difficult drug to take because it has a narrow therapeutic window with potential seri· ous side effects. successful anticoagulation therapy is dependent upon the patient's knowledge of this drug; however, little is known regarding the determinants of such knowledge. the purpose of this study was to determine the influence of socioeconomic status on patients' knowledge of warfarin therapy. methods: a telephone survey was conducted among patients to months following mechan· ical heart valve replacement. a previously validated -item questionnaire was used to measure the patient's knowledge of warfarin, its side effects, and vitamin k food sources. demographic information, socioeconomic status data, and medical education information were also collected. results: sixty-one percent of participants had scores indicative of insufficient knowledge of warfarin therapy (score :s; %). age was negatively related to warfarin knowledge scores (r= . , p = . ). in univariate analysis, patients with family incomes greater than $ , , who had greater. than a grade education and who were employed or self employed had significantly higher warfarm knowledge scores (p= . , p= . and p= . respectively). gender, ethnicity, and warfar~n therapy prior to surgery were not related to warfarin knowledge scores. furthermore, none of t~e. m-hospital tea~hing practices significantly influenced warfarin knowledge scores. however, panic ~ants who _rece v~d post discharge co~unity counseling had significantly higher knowledge scores tn comp~r son with those who did not (p= . ). multivariate regression analysis revealed that und~r~tandmg the ~oncept of ?ternational normalized ratio (inr), knowing the acronym, age and receiving ~ommum !' counseling after discharge were the strongest predictors of warfarin kn~wledge. s~ oeconom c status was not an important predictor of knowledge scores on the multivanate analysis. poster sessions v ~the majority of patients at our institution have insufficient knowledge of warfarin therapy.post-discharge counseling, not socioeconomic status, was found to be an important predictor of warfarin knowledge. since improved knowledge has been associated with improved compliance and control, our findings support the need to develop a comprehensive post-discharge education program or, at least, to ensure that patients have access to a community counselor to compliment the in-hospital educatiop program. brenda stade, tony barozzino, lorna bartholomew, and michael sgro lnttotl#ction: due to the paucity of prospective studies conducted and the inconsistency of results, the effects of prenatal cocaine exposure on functional abilities during childhood remain unclear. unlike the diagnosis of fetal alcohol spectrum disorder, a presentation of prenatal cocaine exposure and developmental and cognitive disabilities does not meet the criteria for specialized services. implications for public policy and services are substantial. objective: to describe the characteristics of children exposed to cocaine during gestation who present to an inner city specialty clinic. mnbods: prospective cohort research design. sample and setting: children ages to years old, referred to an inner city prenatal substance exposure clinic since november, . data collection: data on consecutive children seen in the clinic were collected over an month period. instrument: a thirteen ( ) page intake and diagnostic form, and a detailed physical examination were used to collect data on prenatal substance history, school history, behavioral problems, neuro-psychological profile, growth and physical health of each of the participants. data analysis: content analysis of the data obtained was conducted. results: twenty children aged to years (mean= . years) participated in the study. all participants had a significant history of cocaine exposure and none had maternal history or laboratory (urine, meconium or hair) exposure to alcohol or other substances. none met the criteria of fetal alcohol spectrum disorder. all were greater than the tenth percentile on height, weight, and head circumference, and were physically healthy. twelve of the children had iqs at the th percentile or less. for all of the children, keeping up with age appropriate peers was an ongoing challenge because of problems in attention, motivation, motor control, sensory integration and expressive language. seventy-four percent of participants had significant behavioral and/or psychological problems including aggressiveness, hyperactivity, lying, poor peer relationships, extreme anxiety, phobias, and poor self-esteem. conclusion: pilot study results demonstrated that children prenatally exposed to cocaine have significant learning, behavioural, and social problems. further research focusing on the characteristics of children prenatally exposed to cocaine has the potential for changing policy and improving services for this population. methods: trained interviewers conducted anonymous quantitative surveys with a random sample (n= ) of female detainees upon providing informed consent. the survey focused on: sociodemographic background; health status; housing and neighborhood stability and social resource availability upon release. results: participants were % african-american, % white, % mixed race and % native american. participants' median age was , the reported median income was <s , year, and % reported receiving a high school diploma or equivalent. women reported a number of health conditions rypical of underserved populations, including asthma ( %), sexually transmitted infections ( %), high blood pressure ( %), hcv ( %), diabetes ( %) and hiv ( %). nearly half ( %) did not anticipate having a place to stay for at least days upon release. factors significantly associated housing stability upon release were: high family support score (adjusted odds ratio [aor) . ; % confidence interval ( % cl) . , . ), high neighborhood stability score (aor . ; % cl . , . ), wanting a commercial sex worker (csw) support group (aor . ; % cl . , . ); and identifying as bisexual (aor . ; % cl . , . ). women desired employment ( %), housing ( %), education ( %), drug treattnent ( %), help with custody of children ( %), childcare ( %), and domestic violence suppon ( %) services. conclusions: female detainees represent one of urban centers' most marginalized pcjpwatioos. short periods of detention represent a unique opportunity for _interven?~ns bri~ co~s and public health institutions. service providers should collaborate ~ th local ~ails to .p~de a con uwnof care for female detainees upon release that includes transportation , housing, residential drug treallllcnt, employment, education, family reunification, childcare and domestic viol~nce su~rt. ~pecial attenlion is warranted to lesbian and bisexual women and csws, who may be especially margmalized &om family and service-based support networks. introduction: "health care and ethnic minority immigrants" examines how health care policy dil· ferences between canada and the united states impact the health-related hardships, access and use of preventative care, and health outcomes of urban ethnic minority immigrants in both countries. methods: the findings of this paper build on the results of my qualitative comparative study of hotel workers in vancouver, bc and seattle, wa that revealed greater health related hardships for similarly matched employees in seattle compared to vancouver. in this paper, i examine the generalizability of these findings at the cross-national level for similar ethnic minority immigrant groups. i compare the impact of health care policy differences on specific groups that have emigrated to cities in both canada and the united states. these include immigrants from china, viemam, philippines, west indies, africa, sri lanka, pakistan, and latin america. comparative statistical analysis -utilizing rel· evant data from statistics canada and the u.s. census -reveal the extent to which health policy differ· ences help explain how current health policy in the united states disadvantages urban ethnic minority immigrants. results: many ethnic minority immigrants are a part of the working poor, a group which disproportionately lacks health insurance coverage in the united states. their position in the labour market makes them most vulnerable to exclusion from health care services. the data reveals how current u.s. health policy creates barriers for recently arrived ethnic minority immigrants to access health insurance and care. it remains difficult to ascribe health outcome differences directly to policy differences because of the challenge in disentangling the complex interacting interventing variables, including income inequality, that determine health outcomes. yer suggestive evidence suggests that health policy in the united states is harming the health of urban ethnic minority immigrants. the current health policy regime in the united states harms the health access, care, and outcomes of urban ethnic minority immigrants. comparing the fortunes of similar immigrants in cana· dian and u.s. cities reveals these patterns of disadvantage and some of their consequences. these barriers are an understudied factor in the sociological literature on "segmented assimilation" and social exclu· sion. the paper ends with policy recommendatio ns to improve access to health care among ethnic minor· ity immigrants in both countries, with the goal of reducing health related hardships, and improving health outcomes. mass index deyu pan, richard baker, and keith norris badtgrou~ over the past decades, there has been dramatic increase in prevalence of obesity in the us population. however, the relationship between obesity and the prevalence of cardiovascular dis· ease (cv~) risk factors in different race/ethnic groups over time is not well known. . ik~rgn: _we use cross-sectional , nationally representative surveys: national health and nutri· t nal examination survey (nhanes iii - (n= ) and nhanes nhanes - , including white, black, and hispa~ic races who were no~preg~ant, aged to years. res lt : the preval~nce of high cholesterol level (~ mg/dl), untreated high blood pressure ( : l / mm hg) an~ diabetes were calculated according to bmi group (lean, < ; overweight, - ; and obese, : ) for different race/ethnicity groups. over the approximately years period (from l ~ ~o [ ] [ ] [ ] [ ] , reducrion in cvd risk factors in non-hispanic white has been observed. for mmonty race/~hnicity groups, black and hispanic, there had been increases in prevalence in high blood fa pressure and diabetes. the lean group experienced larger increase in prevalence of those cvd risk ctors. . fo~~ the prevalence in cvd risk factors over time had reduced in most of the bmi ca egoes r t e w ~~e population. however, for black and hispanic, prevalence of of cvd risk factors ave generauy uncreased, especially in overweight and obese groups. methods: strategies identified to achieve these goals include: developing meaningful neighbourhood and district boundaries for comparing health information, providing free access to neighbourhood health profiles (including relevant data at the smallest level for which valid rates could be calculated); mapping relationships of inequality at a variety of nested levels; providing a range of formats (maps, tables) to meet the needs of users; providing technical support; seeking user input to advance and improve the site; and conducting workshops to foster access and use of data for decision-making , advocacy and collaboration. an evaluation strategy is being developed to assess the efforts and impact of these strategies. a preliminary assessment of the results of the first six months of activity will be completed in october . results: significant differences in health are shown at all the geographic levels indicating success in developing the boundaries. results tabulated for the first six months use of the site include: site visits; media use; reference/acknow ledgement of the site in other documents; number of contacts through presentations and workshops; feedback from users identifying strengths and limitations; and, response from health decision makers. members of the partnership are identifying additional tools and services to further support actions that reduce health inequalities. the assessment will be used to develop more specific goals, targets and monitoring mechanisms. conclusions: our experience with paper-based health profiles indicates that they have been used extensively for program planning and advocacy. the greater availability of information in a publiclyavailable web-based format is expected to translate into even greater usefulness and wider application. the web site has had considerable usage to date, extensive media coverage. site users and workshop participants have provided positive feedback and suggestions for next steps. the six month review will be available in october . in india, more than and a half people are hiv-positive and half a million have aids. india currently has the largest number of positive people in the world, oumumbering south africa and accounting for nearly one tenth of the global hiv/aids prevalence. the world bank predicts that by , there will be million hiv/aids cases in india. the central challenge facing hiv prevention efforts in south asia today is learning how to respond to the societal determinants of vulnerability to hiv. hiv/aids is an issue largely engulfed by social stigma. stigma and discrimination are often considered the foremost barriers to effective poster sess ns v prevention and care initiatives. stigma can make a person afraid of disclosing their status~ ~yone el se, and may make them feel depressed or alone. stigma can .also le~d to poor adherence to medicanon, ~ likelihood to access health and social services, and less desire to hve. hiv+ men and women may beafraidtotd! their co-workers that they have hiv for fear of their reactions or for fear of losing their jobs. in a study conducted of people living with hiv/aids in delhi, india ov~r. -~, many respo~ts shared their experiences of discrimination in their families, in their communmes, an~ m health ~e settmgs. these findings will be shared in the workshop, and will be compa~ed to m~ ex~nences workmg as an ~ co~l~ at the center for aids prevention studies in san francisco, cahforma and congreso de lannos unidos m philadelphia, pennsylvania. the workshop will include an overview of hiv/aids in urban contexts in tht united states (los angeles, san francisco, new york, philadelphia) and south asia (delhi, hyderabad, chennai). differences in methods for outreach, prevention and treatment efforts between devdoped world and developing world contexts will be discussed. a large portion of the workshop will be centered on discussion. participants will engage in an exercise to categorize their ideas of stigma. the workshop will also include a powerpoint presentation on the quantitative data gathered from the survey. the number of homeless and runaway youth is increasing in toronto, which is currently home to out of youth in the gt a who live alone, and it is the preferred locale for the street-involved and homeless youth. the city's youth population is expected to grow by nearly % by , the school dropout rate is rising, and there are is a paucity of empirical data on what works with these at-risk youth. over a two-year period, ( ) ( ) ( ) , youthlink-inner city, conducted an evaluation of the impact of a harm reduction program aimed at reducing street youth's risk of contracting/infecting others with the hep c virus, which has both short-term and long-term deleterious effects. demographic data from street-youth, along with resources/services used, employment methods, type and frequency of drug use, health status, police contacts, and their views of program impact were analyzed using a standardized sur· vey. additionally, focus groups with youth, agency staff and community key informants were conducted, as well as in-depth interviews with three youth, over a sixth-month period. this paper details study results, which both inform both practice and future study about what works, why it works, and how best to work with these vulnerable youth. sho~ed .that the wasteland in this area was contaminated by as cd zn pb cu simultaneously. the con-ta~matton of as ~d was quit significant. the contamination problems and environmental issues in this region are very. serious. the awareness on environmental and health issues was investigated by spot survey and analysis. overall awareness among the residents in the region is very poor. the measures must be taken to assu~e t~e .sustainable economy development by local and central gorvernments. keywords nandan guangx ; mmmg area; environmental awareness. concern like, epileptic fits, vision problems, earache, cough of more than weeks and urinary problems. ninety-five subjects did not take bath regularly and were exposed to sex. the health problems identified are only of a particular point of time and it may be difficult to interpret the depth of "iceberg" of the street children's world also draw the health-illness continuum. periodic interaction and follow-up is very difficult as they generally disappear from the research setting due to their frequent mobility for survival measures. as per the prediction of the iceberg theory, only some problems may have been identified, larger problems in respect to their health may not have been identified. in spite of various limitations, this attempt had proven that, it is possible to enter the street children world, explore the iceberg of illnesses, and establish data of health-illness continuum through an effective nursing agency. it is recommended to deworm these children, provide nutritional education, establish "condom corners" and "street children help line" in the city and urban slum areas and undertake action research on their health. malnutrition is a serious problem in developing countries like bangladesh. malnutrition causes a great deal of child suffering. malnutrition is one of the major causes of morbidity and mortality among the child. the aim of present study was to investigate the nutritional status and its relation to socioeconomic conditions of urban disadvantaged child of under five years age. nutritional status was determined by anthropoemetric measurement(heig ht, weight, mid-arm circumference etc.). determination of total protein and serum albumin were done for biochemical examination. haematological examination was done by blood haemoglobin profile estimation by cynmethhaemoglob in method and determination of haematocrit value or packed cell volume (pcv). stool examination for ova of hook worm, round worm, trichuris species and other species were also done. relevant information on socioeconomic characteristics was recorded by interviewing the house hold head using pretested questionnaire. our study demonstrated that nutritional status of the children are positively correlated with family income, parents level of formal education and negatively related to the family size. the effect of family income on the nutritional status, haematological and biochemical indices of urban disadvantaged child under five will be discussed in detail which will help us to determine proper way of utilization of health care facilities exists in developing countries. introduction: with the increase in morbidity and reduction in mortality and with the introduction of highly active antiretroviral therapy (haart), there is increasing focus on the determinants of healthrelated quality of life (hrqol) in hiv-infection. the focus on the present study is to examine the relationship between social support, depression, and hiv disease severity, and the extent to which these variables impact on hrqol in adult men with hiv-infection. methods: as part of a larger ongoing natural history study focusing on the neurobehavioural complications of hiv and aids, we administered questionnaires to assess depression (beck depression inventory), social support, and hrqol (mos-hiv) to adult men with hiv-infection. a structured interview was used to collect health information and data on hiv disease severity. physical and mental health summary scores (phs and mhs) were derived through principal components analysis. participants were grouped according to level of social support: "well supported" (n= ), "moderately supported" (n= ), "little or ineffective support" (n= ). analysis of variance was conducted to assess the effects of three levels of perceived social support, depression status (present vs absent), and hiv disease severity (aids vs non-aids) on mental and physical health dimensions of hrqol. potential interaction effects were also evaluated. results: social support was found to have a significant effect on both mhs and phs. presence of depression was found to have a significant effect on mhs but not phs. hiv disease severity (presence of aids diagnosis) was found to have a significant effect on phs but not mhs. manov a analyses revealed no significant interactions effects. conclusions and implications: level of social support, presence of depression and hiv disease severity were shown to have independent effects on hrqol. feeling "well supported" appears to have significant benefits for mental and physical health. biological indicators of hiv disease appear to have a selective impact on physical health while presence of depression is related to significant reductions in mental health. the development and evaluation of behavioural interventions to improve perceived social support network and depression will likely result in significant improvements in health outcomes of adults with hiv and aids. introduction: ongoing medical advances have greatly enhanced the longevity of penons living with aids (plwa). however, for certain subgroups living with hiv/aids, including, members of minority groups, women and the economically underprivilege d, aids outcomes have not changed so favorably. one obvious factor to consider when explaining disparities in aids outcomes is the environ· ment within which an individual resides. few studies of aids outcomes have focused on how commu· nity setting influences the effectiveness of care delivery. the principle research questions were: ) what is the relationship between the locations of areas with concentrations of pl wa and the distribution of both primary and ancillary service providers? ) how has the widespread availability of haart (after ) impacted aids outcomes at the community level? ) how do aids mortality and fatality rates vary when related community characteristics, such as household income, ethnic mix, and geographic access to primary and ancillary hiv/aids services are considered? we examine this issue across residential communities in the los angeles area. methods: los angeles county's comprehensive aids service providers database (compiled and maintained by aids project los angeles) was geo-referenced and distances between weighted mean population centers and the nearest hiv/aids service providers were calculated to provide a measure of access which was then merged with aids diagnosis and mortality data along with relevant socioeconomic and population indicators and for analysis using bivariate and multivariate statistics at the zip code level. results: there is a growing disparity in hiv/aids outcomes between low-income minority areas and affluent non-minority areas in the post-haart era (p = . ). ancillary aids services such as case management and counseling and testing are located near the places where low income hiv/aids service consumers are likely to live (p =. ). in spite of having more access to ancillary services low income areas continue to be associated with smaller decreases post-haart aids mortality rates (p= . ). conclusions: given the increasing disparities in aids outcomes between lower and upper income communities in the post -haart era, more specific research into the capacities of aids services providers and the efficiency of their interventions is required. although it is clear that ancillary services are operating in the areas of greatest need, their effectiveness remains limited. understanding the reasons for t~is, be they lack of adequate resources for inner city service providers, failure to reach target popula· tmns or other causes, requires additional research. in ? , y.out~ who were able to speak either french or english and had been absent from their parent's/ c~regivers ~es. dence for at least three consecutive nights took part in the survey which consisted of inter· viewer-adm ms tered question~aires. p.arti~i~an~s were recruited from drop in centres in cities across <?-nada.y~uth self-report as either using in ect on or non-injection drugs. statistical analyses were car· r ed out using sas version . the 'home' is a contested site for many women living in urban areas. women living in poverty and using illicit drugs are largely excluded from participation in dominant 'home-base' gender roles of wife and mother because of economic disadvantage. they thus 'make home' in ways that are specific to their everyday experiences. while research has established links between housing, health and drug use, this literature does not tend to consider the meanings that home may have within the lives of women who lack access to adequate tenured living spaces. this presentation reports the findings of my master's thesis work. using grounded theory methodology within a poststructuralist feminist conceptual framework, i conducted in-depth, open-ended interviews with women living in the toronto area. the women were recruited from within the community through posters at different social service agencies (e.g., drop-in centres, community health centres). they were asked to describe their housing experiences and what home meant to them over the course of their lives. through the data analysis process, a substantive theory of 'making home' for women living in poverty and using illicit drugs emerged. the central concept of making home is a continual process of learning about and interacting with the environment. the process of making home entails different subprocesses: finding home (knowing what is available and accessible, and accessing home), adaptation, and leaving home. the different meanings of home that women developed from their experiences and knowledge emerged as critical components for the process of making home. the women i interviewed were very mobile and experienced constant change with regards to home. home was not considered only in relation to physical living space. home could be made within a relationship or with regards to a possession. while dominant meanings of home relation to tenured living spaces are generally positive, my research indicated that home could also be a negative context. the presentation will describe my research process and findings as well as the theoretical and policy implications of my results. in the western democracies, social citizenship bundles the right to social provision (defined as a share of the social good, not necessarily proportionate to the market value of a citizen's contribution) with participation in the paid labour force. for this reason, social citizenship rights, which usually involve some kind of redistributive measures, are a key mechanism by which states ensure economic equality, or at least, economic equality of opportunity, but are also a mechanism of social exclusion. social rights are inscribed around a single kind of relationship, that which exists between a male family breadwinner and the paid labor market; those who make economic contributions that fall outside this relationship -such as unpaid care-work, or, work that occurs in shadow or underground economiesare to a greater or lesser degree barred from accessing citizen-based social provisions. furthermore, social provision that occurs outside of the breadwinner/market-eco nomy dyad is very often meanstested and is accompanied by regulatory state apparatuses (this includes a range of social services, from welfare payments, to child-care subsidies, to disability pensions). social citizenship is thus stratified; the legal relationship that is at the heart of social citizenship acts as a form of social closure against claims for a share of the social good made by those who are 'lesser' citizens than others. of particular interest in this paper is how citizenship inequalities translate into inequalities in the social provisions that emerge from economic participation: the right to safety on the job, protection from employer harassment, protection from the vagaries of the market as well the right to adequate, comprehensive, and appropriate health services. drawing on mixed methods, longitudinal data from adult sex workers (n= ) located in two research sites with different social welfare regimes -one in canada and one in the u.s. -we examine the consequences of working in a "shadow" or "underground" economy on various facets of health and access to health services, taking into consideration the mediating role that citizenship constructs and social welfare regimes play in accessing other key social and economic determinants of health. methods: the study population included methadone patients (re)admitted at the mhs in the period from / / to / / , born in the netherlands, morocco, surinam, dutch antilles or turkye, and officially registered in the population register of amsterdam. the population register was used to ascer· rain the vital status. causes of death were provided by the central bureau of statistics. mortality was categorised as hiv related, directly drug related (overdose) and other.mortality. results: the methadone patients had the following characteristics: years of age at entry; % male; % ethnic minority; % ever injected. in total, personyear (py) of observation time and deaths ( % hiv related, % overdose; % other) were observed. hence, the crude mortality rate was / py ( % ci - / py). the percentage of (ever) injectors was higher among the native dutch than among the ethnic minorities, % and % respectively. higher rates were observed among native dutch drug users compared to those belonging to an ethnic minority (age adjusted hazard ratio (hr) . ( % ci . - . ). the age adjusted hr of (ever) injecting drug users versus non injecting users was . ( % cl . - . ). after additional adjustment for route of administration a non significant difference between the dutch and ethnic minorities remained (hr . , % cl . - . , p-value . . conclusion: the mortality rate among the heroin users in amsterdam is strongly affected by the high prevalence of non-injecting drug use. moreover, this study confirms that differences in mortality between the native dutch and the ethnic minorities is related to differences in route of administration. the ongoing reduction of injecting drug use (due tot selctieve mortality, and switching route ofadministration and popularity of crack cocaine) may lead to a further reduction of mortality rates among heroin users in amsterdam. interventions preventing the initiation of injecting should be encouraged. . introduction: food insecurity is an inequality that is central in the lives of many low-income cana· d ans. people lack food security when regular access to nutritious food is limited or variable due to high prices'. low income, lack of transportation or inadequate food distribution, or they become disadvan· taged m other w~ys through the acquisition of food. a group comprising academics, health profession· als, and commumty workers who have experience in food insecurity, developed a pilot study in ottawa that sought to und~rstand the lived experience of food insecurity. the study also used the united states department of agriculture (usda) community food security module. methods: a series of group meetings determined the best research approaches; questionnaires and consent forms were developed by a working group. twenty-three self-identified food insecure respon· dents were interviewed. the data were analysed using frequency distributions· the food security module was coded according to the usda coding guide, and open-ended responses w~re coded using a grounded approach. renlts: preliminary results from our pilot study have given the research team cause for considerable concern. out of households without children, experienced food insecurity with hunger; ~ere at the severe l~vel. out of households with children, experienced food insecurity with hunger. ~•rst person reflecnons commonly featured feelings of depression low self-esteem and despair. participants' account tha d . an cu ty gettmg to the store, severely limited putting knowledge and skills mto practice. l'oster sessions v conclusion: based on these early findings, our research team is looking to challenge what appear to be assumptions about poverty and food insecurity and for best ways to use this information. some policy approaches and interventions that encourage people to eat better and exercise more, may be missing the mark for low-income individuals, and may serve to maintain food insecurity. future research will build on this pilot. with methods augmentation, and a comprehensive knowledge dissemination plan, we hope co contribute to research and policy frameworks at all levels. ps- (a) mental health and the corrections system: population-based analyses in urban, semi-urban, and rural settings julian somers, robert watts, and michelle patterson introduction: according to recent epidemiological research, rates of mental disorders vary considerably across countries and across regions within countries. nevertheless, rates of mental disorders (including substance use disorders) are consistently higher in populations involved in the corrections sys- em. courts have long recognized the heavy burden of mental illness within their purview, and have developed innovative programs to better manage the needs of such individuals. the majority of these innovations (e.g., specialized courts) exist in urban settings. however, few studies have examined the degree of variability in rates of different mental disorders between courts in urban and other settings (e.g., semi-urban, rural). variability between courts in different settings, if present, holds implications for needs-based resource planning. the present study was conducted as part of a long-term inter-ministerial collaboration in british columbia (bc). analyses were conducted on linked administrative data regarding population health and correctional services. a database was constructed including all individuals sentenced in bc in a single year (n= , ). corrections records were matched to records of health services utilization (hospital and outpatient services) for mental disorders and substance use disorders in the years preceding sentencing. services for mental health and substance-related problems were aggregated into three groups: severe mental illness (smi); less-severe mental illness (lsmi); alcohol/other drug (ad). courts were grouped, based on their annual volumes, inro three categories: "urban"; "semi-urban" and "rural." rates of service use for mental disorders were compared between groups for -year and -years preceding sentencing. results: there were significant differences in the rates of mental disorders in courts of different size (urban, semi-urban, rural) . however, differences between the rates of disorders within each of these groups exceeded the discrepancies between groups. comparatively high and low rates of disorders were observed in courts of each size. moreover, the courts with the highest rates of certain disorders (e.g., ad) did not have the highest rates of other types of mental disorders (e.g., smi). conclusions: rates of mental disorders differed significantly among the annual populations sentenced across courts in bc. urban courts (which process comparatively large numbers of people) have implemented services to address the needs of the mentally ill. the present analyses strongly suggest that program development should be closely linked to the demonstration of need. the results caution that a uniform approach to court programs for the mentally ill is likely to be inefficient, over-supplying services in some settings and underestimating need in others. results: public settings used for injection are characterized by highly unhygienic conditions, the presence of unsafely disposed syringes, limited availability of sterile syringes and a lack of sterile water for injecting. a number of unsafe injection practices observed were common among public injectors. the presence of police officers nearby and the potential of assault by street predators fostered rushed injecting among those consuming drugs in public spaces. the ecological features of these environments encourage unhygienic and unsafe injecting practices, heighten risk for overdose and the transmission of blood borne viruses. introduction: approximately % of women experience depression in the first weeks or months after giving birth. although it has been argued that postpartum depression (ppd) is a culture-bound p~ nomenon, experienced only in western, industrialized countries, recent international research studies have confirmed that the prevalence of ppd is similar around the world. however, little is known about variables that may influence the experience of ppd in women from diverse cultures and immigrant women. research is needed to identify the role culture may play in the presentation of ppd (i.e., types of symptoms most commonly reported), how women from various racial, ethnic and cultural backgrounds perceive and attribute their symptoms of ppd, and finally, how culture can be appropriately addressed in ppd treatment programs. method: to examine the role of culture in ppd, semi-structured interviews and self-report question· naires were administered to clients of the women's health centre of st. joseph's health centre, tor· onto. participants were identified as either first generation canadians (relative newcomen) (n= ) or second generation canadian (parents were immigrants to canada) (n= ). data were collected qd these two groups of women based on: severity of depression, symptom presentation, perceived role of social supports and culturally-specific traditions, and barriers and responses to treatment. the interview data were analyzed using qualitative methods (thematic content analysis), and the following themes were identified: ) stress about passing on their culture to their children, ) lack of social support and feelings of isolation, ) perceived importance or lack of importance of cultural based tra· ditions, ) conflicts with family members. about cultural traditions and beliefs, ) mental health stigma within ethnic communities and beyond, ) race-and sex-based discrimination, and ) language barriers. conclrllion: identifying the role culture plays in the presentation of ppd, and how women from diverse backgrounds perceive and attribute their symptoms of ppd, is critical in order to establishcultur· ally appropriate guidelines for treatment options. furthermore, information gathered from this study can be used to develop policies and resources for delivering culturally competent care for newcomer wo~ who are dealing with ppd as well as the issues around acculturation (i.e., language barriers, racism). llus is of particular importance for urban health centers which provide postpartum care to diverse groups of women, and particularly recent immigrants or newcomers. ps-~ (al. contaminated 'therapeutic landscape': perceptions of the aamjiwnaang fint nation keyln smith and isaac luginaah . in~: this. paper pres;ents the findings of an ongoing study among the aamjiwnaang f!rst nanon. aam wnaang is located m the heart of samia's 'chemical valley', surrounded by cherrucal ~(ants such as esso, imperial oil, shell, suncor energy, and canada's largest hazardous waste disposal sate. safety kleen. this fint nation community is located within the st. clair river •area of concem'. as destgna~ by health canada for the population of samia and the surrounding region. although this comm_umty, by way of. its proximity to the numerous chemical plants is already exposed to high levels pollu~on, recent che?ucal dumping in ~mjiwnaang, as well as a failed proposal for another ethanol plant m the community, only helped to mtensify community concerns about potential health impacts of exposure. research on the cultural beliefs and traditions of first nation communities has established that th~ ~isting rel~tionship between first nations people and 'mother earth' is not only physical, but also_ spmtual. in this study we explore how the complex relationship between the aamjiwnaang first naaon and 'mother earth' be ha · · · i .. may c ngmg a contammated 'therapeutic' landscape. the study a so ~lores h?w aam wnaang residents are coping with these changes and with the probable conramina· boa of their community. ra!jts: aamjiwnaang residents acknowledge that they are living in a contaminated environment and are being impacted by emissions from the surrounding 'chemical valley' especially for future generations, and have expressed concerns that members of the community and mother earth are 'sick' as a result of this exposure. while moving from that 'place' has been discussed, residents have strong personal and generational connections to the land and insist however, that aamjiwnaang is their 'home' and will remain that way despite growing community concerns about the impact from industry. the contribution of this study lies in the direct involvement of community leadership in designing and conducting this research and distributing the results to further local policy development regarding community concerns on the reserve. background: truck driver are at very high risk for drug abuse because the factor contributing to drug abuse among driver are multiple. it is important to gain an understanding of the key factors that contributing to drug abuse among truck drivers. methods: seventy-truck driver aged - years were conveniently selected from the population. all the participants were male. an interview schedule was developed in the light of literature data and data were collected by personal interview with informed consent in selected urban area of eastern part of nepal. results: a considerable percentage of truck driver have less knowledge about drug abuse, its effect on body and their complication. majority of the participants ( %) explained that lack of education, financial crisis were leading factors of drug abuse. the average numbers of respondents were believed that lack of meaning in life, marital disharmony. friendship with drug abuser, stress, tiredness, modernization of life pattern and freedom from the home pressure were the influencing risk factors to drug abuse. conchuion: this study reveals those truck drivers are at risk in urban area for developing drugs abuse, mostly influenced by social and environmental factors. hence, these groups should undergo certain educational programme to prevent not only drug abuse, but also prevent transmission of infectious disease among these groups. introduction: food insecurity is an inequality that is central in the lives of many low-income canadians. our group of university researchers, health professionals, and community developers conducted a study in ottawa with community workers who work with people identified as food insecure. the purpose of the study was to understand the nature of their work, and their perspectives, perceptions and experiences of the causes and consequences of food insecurity. (a parallel study was conducted with food insecure participants). methods: sampling was through local knowledge of organizations involved in the provision of food to community members. written permission for the researchers to contact workers in confidence was obtained from each organization. thirteen in-depth interviews were conducted. the interviews consisted of a number of open-ended questions. the data were collated, and analysed using a grounded approach. results: workers interviewed represented organizations that offered diverse programming and methods of food distribution intended to address the needs of the community. the provision of food was seen as a necessary response to address hunger that arose for the majority from poverty caused by low income, or levels of government income support and safety nets that were insufficient to support food requirements. workers reported that food requirements varied according to different. ethnic backgrounds, ages of recipients and family configurations, and with food preferences, and d'.etary (health) requirements. workers' observations of the effects of insufficient food on adults and children such as depression, low energy and non-participation or social disengagement matched those of food insecure respondents. food insecurity was cited as "another srressor among the mountain of problems." overall, workers presented a picture of a silent, stigmatized, poor population including children, and a lack of advocacy to address the issues. be tha th · ·ty the results suggest that workers and organizations, like the commuruty mem rs t ey msecun • · · · · f ilab'l' f food · t d ·n thei·r ab 'l 'ty to address food insecurity. l m tanons m terms o ava ty o , serve, are restnc e . . funding, and donations appeared to set the para? eters of pr~g:am r.espon~ to commuruty food msecurity. workers were concerned with program des g": and a~m mstranon that m general addr~d hunger on an emergency short-term basis, although food msecunty was long-ter_m for ~any. sustainable solutions that include knowledge translation strategies, and health and social pohcy responses were suggested and will be explored in future research that hopes to build on this pilot. background: socioeconomic deprivation as well as low levels of soc!al s.uppoi:r have .been associated with poor outcomes following cardiac surgery. pre-operative depression m ~anents with coron~ry artery disease awaiting cabg ranges from - % and is an independent predictor of post-operanve mortality. since st. michael's hospital has a large inner city population, this study was designed to determine the both the prevalence of depressive symptomatology (ds) in patients awaiting cabg as well as its relationship with socioeconomic status (ses) and social support. methods: consecutive patients referred for isolated cabg were invited to complete the centre for epidemiological studies depression scale (ces-d) as well as a social support scale and a life stressors inventory. a ces-d score of : represents mild ds and a score of : represents moderate to severe ds. participants also recorded information on functional status, perceived progression of heart failure, demographic and ses variables. all participants with ces-d scores : were considered to have ds. results: of the patients ( %) who returned the survey, ( . %) of participants had a ces-d score : with ( . %) of those having scores suggestive of severe depression. females and those with ongoing medical concerns tended to have more ds (p= . and p= . respectively). age was not related to ds. perceived worsening of symptoms and increased ccs angina class were significantly related to the presence of ds (p= . and p= . respectively) but not the number of diseased heart vessels. satisfaction with personal relationships including having someone to confide in (p= . ), feeling lonely (p= . ) and not having a partner (p= . ) were significantly related to ds. being very upset by a recent breakup in the immediate family was also significantly related to ds (p= . ). having greater than a grade education was the only ses variable related to ds (p= . ). multivariate logistic regression suggested that not being partnered and having low education were the most significant predictors of ds. conclnsion: pre-operative depression is present in at least one quarter of patients referred for cabg. since ds is related to poor outcomes following cabg, single patients with few social supports and low education should be considered at high risk for ds. these findings support the need for the development of supportive interventions in patients at risk in order to decrease post-operative morbidity. this study examines the relationship between childhood sexual abuse, sexual assault during adolescence, and hiv-risk-related behaviours in a sample of homeless youths. over the past decade, there has been increasing research devoted to the impact of childhood sexual abuse. some studies have suggested that the experience of childhood sexual abuse is associated with substance use and abuse, at· risk sexual behaviour and subsequent higher rates of hiv infection (ompad et al., ; cinq-mars et al., ; brown et al., ) . other studies have found that childhood abuse, especially sexual abuse, is c_o~n among stree~ youth (noell et al. ). this study compares sexually abused males and females livtng on the street ~th non-sexually abused street youth, with regards to unsafe sexual behaviours and e~ures to potmnal t:dv sources (e.g., tattooing, body piercing and injection drug use). the hypothe-sis oft~ ~nt study is that the prevalence of hn-risk-related behaviours will be higher among street youth vtctuns of sexual abuse than those who have not been sexually abused. the sample includes youths aged to who met specific criteria's for itinerancy ( male and female, with a mean ~of . y· and a standard deviation of . ). they were recruited through five organisations working ~th~ you~ and were~ of an ongoing cohort study. all youth completed a to minute ques· ~onnaue on their sexual behaviours, use of drugs and alcohol and other hiv risk behaviours. oral spec· unens for hiv testing were. also collected. a total of ( . %) youth reported at least one incident of ~i •~use/assault ( ~ girls ( . % of all the girls) and boys ( . % of all the boys]). preliminary descnpnve analyses pomt to sexually abused/assaulted youth showing the highest prevalence of sexual poster sessions v at-risk behaviours. for example, . % of sexual abuse/assault victims have engaged in prostitution in their lives compared with . % in the non-sexually abused/assaulted group. in addition, . % of sexual abuse/assault victims reported having injected drugs, compared with . % in the non-sexually abused/assaulted group. more statistical analyses will bring other significant factors to light, especially when we analyze separately those victim of childhood sexual abuse as compare to those victim of sexual assault after childhood. elucidating the risk factors for getting involved in hiv-risk-related behaviours is important for the development of comprehensive and appropriate prevention and treatment intervention strategies. introduction: new immigrants and refugees to canada frequently emigrate from regions of the world where intestinal parasitic infections with worms are endemic. of note, some of these parasites area capable of surviving for years to decades within a given host and can have life threatening consequences many years after initial infection. thus, early diagnosis and treatment of intestinal parasitic worms is considered important in high risk immigrant populations, however there remains a lack of consensus regarding the best method of accomplishing this. diagnosing worm infections through stool examinations is costly and has limited sensitivity, while presumptive treatment of all immigrants, although advocated by some, is expensive and results in healthy individuals being unnecessarily treated. herein, we examine the utility of a hematologic marker (i.e. peripheral blood eosinophilia) as a screening instrument to identify parasitic worm infections in new immigrants to toronto. we identified adults, years of age or older, who were screened for intestinal parasitic infections by stool examination as part of a recently developed screening protocol at a downtown toronto community health centre. we examined the prevalence of infections with worms and subsequently evaluated the impact of several demographic factors on the presence of worm infections. we also determined the sensitivity and specificity of peripheral blood eosinophilia (defined as greater than eosinophils per ml) as a marker for intestinal parasitic worm infections. results: overall, % of the immigrants tested had evidence of at least one worm infection on a single stool examination, while % of such individuals bad infections with multiple worms concurrently. age did not appear to be associated with the presence of worms, however % of males had evidence of worm infections compared with % of females (p= . ). immigrants from asia, sub-saharan africa, and central america had the highest burden of overall infection. the sensitivity and specificity of peripheral blood eosinophilia for worm infections was % and % respectively. conclusions: one in five recent immigrants presenting to a community health centre in downtown toronto had evidence of at least one intestinal parasitic worm infection. the highest burden of illness was in men and in those emigrating from less developed regions of the world. peripheral blood eosinophilia is a poor screening test for worm infections however its presence is highly suggestive of the existence of worms in new immigrants. more than a decade ago, the journal of american college health recommended that a national study be conducted to measure the health status of african american college students, 'both health disparities and [their] positive healthful behaviors' (fennell, ) . it was later decided that when exploring the level of health risk behaviors for african american students, gender is an important variable and should be included in the research (fennell, ) . at historically black college and universities (hbcus) college health researchers must tackle gender disparities through highly-effective health promotion and disease prevention programs. the purpose of this review is to examine the literature that addresses the overarching health behaviors (i.e. risky sexual behavior, poor diet, smoking, physical inactivity, etc.) of african american men who attend hbcus. despite the various social, cultural, and academic benefits of african american students who attend hbcus, the number of research studies that adequately address their health and health behaviors is limited. studies indicate that african american men who attend hbcus are actively engaged in poor health behaviors. compared to females at hbcus, african american men are more likely to behave in ways that could result in injuries and the use tobacco, alcohol, and ~ther dru~. the city of toronto has recently proposed to conduct a street count of the homeless. like proposals that have come before, this most recent proposal is controversial among many homeless advocates and service providers because it is perceived as intrusive, likely to undercount the target population, and unnecessary for addressing the problem. advocates of the count view it as necessary to gauge the scope of the problem and advise city leaders about how to most effectively direct resources ro.the various homeless services. this paper first reviews the history of efforts to count homeless populat ns m toronto, describing the motivations and arguments of people on both sides of the issue. second, the paper reviews the methodological complexities of counting homeless populations, describing approaches that use shelter-counts, administrative data and street observations. those interested in counts for toronto and elsewhere can benefit from this review of approaches that have been proposed and carried out in other municipalities. third, the paper proposes a new community-base d strategy that joins the skills of methodologists, local experts, and service providers to ensure a fair and accurate count. the method of systematic social observation avoids some of the problems of early counts by utilizing a repeated identification approach to minimize undercount bias. the method also has the advantage of involving and compensating homeless individuals for assisting with the street count estimates. the estimation approach can be implemented on a rolling basis throughout the year. drug transitions) is a multi-level study aimed at examining the associations between features of the urban environment and mental health, drug use, and risky sexual behaviors. research participants are being recruited in new york city (nyc) neighborhoods. an essential first step in the implementation of this study was to delineate boundaries for each target neighborhood that could then be used to establish sampling frames and as key units of analytic interest. although many neighborhood studies rely on pre-established definitions (e.g. those used for the census or administrative purposes), such definitions do not always reflect contemporary settlement patterns. we felt that street level observations were a neces· sary component of the definition process. methods: the procedures used to delineate neighborhoods were: ( ) development of census block maps of targeted areas; ( ) review of land use maps and census tract data to ensure, prior to going into the field, tha.t particular blocks are residential and likely to have sufficient population for recruitment purposes; and ( ) field vislts and observation in each of the targeted areas. field observations focused on: housing characteristics, including housing type and condition; characteristics of commercial areas, such as likely customer base (e.g. local or no~, socio-economic status and ethnicity of customers); pedestrian volume (including con· gregauons of people m parks and outside stores or residences); obstructions to pedestrian traffic (e.g. ma or thoroughfares, multi-block industry or institutions); and maintenance and use of open spaces. results: in making the final decisions regarding neighborhood boundaries and the inclusion or exclusion of particular. blocks, we considered a broad range of factors including evidence of homogeneity an~ heterogeneity (socmeconomic, ethnic, housing type, environmental) across blocks within and blocks ad acent to a nei.ghborhood, and across the sample neighborhoods; the potential for efficient recruit· ment of appropriate particip.ants (i.e. sufficient local pedestrian traffic); and boundaries used in reporting census data (s? that population data can be used in our analysis). . altho~gh utilization of field observations for neighborhood definitions is relatively time consuming (ap~~ox mately hours for a block area, with more diverse neighborhoods taking even longer), we annc p~t~ that it will substantially improve the quality and consistency of our data gath· ~rmg ~nd analyse~. spec f c e?'amples from neighborhoods defined through this process will be given dur· m~ this presentatmn. we will also discuss the merits and limitations of characterizing neighborhoods usmg street level observations. has been no consideration for how social networks are associated with sse. the objective of this study was to identify personal and social network characteristics associated with being a recipient of sse. in this cross-sectional study, idus who injected in the past months were recruited from syringe exchange programs in montreal, canada, between april and january . information on each participant and on the persons with whom contact had occurred in the past month were elicited using a structured, interviewer-administe red questionnaire. participants provided detailed demographic and drug use information on up to idu members with whom drugs or injecting materials were shared. using logistic regression, personal and network characteristics were examined in relation to receipt of sterile syringes. res.its: of idus, % reported receiving sterile syringes in the past month from another idu. the sample mean age was years (range - ), % male, % caucasian, and % cocaine injectors. in multivariate analyses adjusted for age and gender, recipients of sterile syringes were more likely than non-recipients to share drugs after preparation ( r= . ( . - . )), to require help or to have helped inject another idu (or= . ( . - . )), to have asked someone to get sterile syringes from a syringe exchange program (or= . [ . - . )), to lend syringes (or= . [ . - . ) ) and to use drug preparation water that was previously used by another iou ( r= . ( . - . ) ) during the past months. recipients also had a higher rate of change (p= . ) of idus in their drug injecting network during the past month. with respect to social networks, % ( / ) of idu network members were providers of sterile syringes and were more likely than non-providers to inject everyday (or= . ( . - . )). when stratified by their role as a sexual partner or as someone who provides support (e.g. friend, family member), further risk behaviours were observed in relation to sharing injecting materials with the participant. conclusion: recipients of sterile syringes and their idu network members had several high-risk behaviours for infection with bloodborne diseases. sse may afford an opportunity for the dissemination of other salutary behaviours such as information sharing on safe injecting practices between recipients and distributors. furthermore, drug injecting networks may be an avenue to reach idus who may not otherwise be exposed to preventive measures. there are numerous sources of stigma and labelling of mental and physical illness. first, the sociocultural dimension to stigma and labelling clearly influences patients, families, health care professionals and society's perception and treatment of illness. this creates multiple challenges related to illness identification and recovery, particularly in culturally diverse societies. second, the media is a major source of stigma and stereotyping with regard to a variety of mental and physical illnesses. despite increased public knowledge of many illnesses, studies have shown that stigma has intensified over the years in certain cases. a third element of stigma and labels appears with the use of diagnosis as a solution to human problems with the result that difficult to treat patients are repudiated and social issues are unaddressed. this presentation will serve to outline the development of stigma, various expressions of stigma, and consequences of stigma. it will provide some practical recommendations for the reduction of stigma related to mental and physical illness. purpose: to assess the knowledge, attitude, and practice about immunization for parent of - years old hispanic and african american children in los angeles county (lac). methods: we conducted two cluster surveys in lac. the sample was selected with probability proportionate to estimated size at the first stage and simple random sample of children at the second stage. data were collected through interview. we absuacted vaccine coverage data from immunization record card (irc) at home or from clinic records. the participation was % in hispanics and % in african americans populations. irc was not available at home for % of african american and % of hispanic children. results: all parents perceived their children got all necessary vaccine~. fa~orable attitudes to.w~rd immunization were reported by % of african american and % of h s?amc parents. '.he m~ ority of the parents ( % african american and % hispanic) agreed that vaccines prevent senous d se~ses among children. regarding vaccine safety, significantly more hispanic parents ( %) than african american parents ( %) mentioned that vaccines are safe. introduction: cervical cancer has been shown to be preventable by papanicolau tests in heterosexual women; however, the utility of papanicolau test in lesbians is controversial. cervical cancer is caused by the human papillomavirus (hpv) which is transmitted by sexual _intercourse; howev_er, its' transmission by homosexual intercourse is also controversial. the goal of this study was to review the evidence for papanicolau tests in lesbians. methods: a pub med, ovid ( ovid ( to , and cochrane library search was performed using the mesh headings "homosexuality , female," "vaginal smears," and "papillomavirus, human." in pub med, the clinical queries feature was used with "diagnosis" and "broad, sensitive" filters. a google advanced search of the internet was conducted with the terms "lesbian," "cervical cancer," and "pap rest." the url was limited to ".ca," ".edu," or ".gov." results: the search yielded original articles and reviews, but no cochrane reviews. none of the publications were canadian. website hits were found and selected websites were reviewed. studies showed that lesbians have fewer papanicolau tests than heterosexual women; however, many reported risk factors for cervical cancer, including multiple past or current sexual partners (male and female), early age of first coitus, history of sexually transmitted diseases, and cigarette smoking. hpv has been detected in - % of lesbians and - % of lesbians who have never had sex with men. case studies of abnormal papanicolau tests in lesbians who have never had sex with men have also been reponed. sexual transmission of hpv among lesbians can be explained by several factors: ) - % of lesbians have had sex with men and - % of lesbians continue to have sex with men. ) hpv may be transmitted by sexual behaviours among women, like digital-vaginal sex, digital-anal sex, oral sex, and the use of insertive sex toys. ) hpv transmission requires only skin-to-skin contact. genital hpv has been identified on human fingers. some professional organizations, like the society of obstetricians and gynecologists of canada and the american cancer society, recognize the need for papanicolau tests in lesbians. other organizations, like the canadian cancer society, do not have official policy statements. the current ontario cervical screening program does not specifically address lesbians. conclusion: although the data was limited, most studies recommended that lesbians should receive papanicolau tests. the frequency of these tests was controversial. policy makers and professional organizations should address the needs of this special population and make specific recommendations . monique chaaya, ahia sibai, hiam chemaitelly, and zana el roueiheb . literature concerning the mental and physical effect of work at an old age is contradictory. in addinon, urban environments are physically and socially harsh with reduced potential for income generation and employment and increased potential for depression. the present paper is an attempt to study how do work, or lack of work, link to the experience of depression among older adults in underprivileged lebanese urban communities. the data comes from a cross-sectional survey, where elderly residing in underprivileged communities in beirut, including a palestinian refugee camp, were successfully inter-v ewed through face-to-face interviews. logistic regression was performed to assess the effect of work on depression ad_justing for many other covariates. data showed that . % of people aged years and more were still workmg. there was a highly protective effect of work on depression in elderly males (or= . , % cl= . - . ). the current study is the first of its kind in the arab region and more work shou_ld be _don_e in this area. it is important for the lebanese government to consider elderly rights for social mclus n m terms of employment opportunities. amam nuru-jeter, nancy adler, and burton singer . l~u~on:_ the socioeconomic gradient is perhaps the most persistent and significant finding in social epidem ological research. the insistent nature of the ses effect is evidenced by its significance after acc?untmg for ~umerous confounds. the significance and magnitude of the effect, however, varies by ::•al group. evidence_ o_f the relative effect of race and ses is inconclusive. further, less attention has f ~ ptid to the specific interactions of race and ses than to examinations of which is a better predictor d ~ th. ~sues are further complicated by the explanatory complexity of the various measures of ses anl . owht ey relate to the health of various social groups. understanding the specific nature of these re a ons ips s necessary for guiding he ith d · i · · h a an soc a po mes and programs aimed at improving t e poster sessions v health of our most disadvantaged groups, and therefore population health, overall. this study examines the synergistic effects of ses with both race and gender in predicting group differences in mortality. methods: analyses use data from the national longitudinal mortality survey (n= , ) for the years , , and - ; and were linked to the national death index for deaths occurring through . results were confirmed using data from the national mortality followback survey for people who died in (n= , ) and the national health interview survey (denominator). we used correlation analysis and the standardized mortality ratio to examine ses (education and income), race, and gender as predictors of group differences in changes in mortality. results: for the total population, analyses support the income gradient showing significant declines in mortality ratios from low to high income along the income strata. education shows a significant drop in mortality with completion of high school and completion of college, exhibiting a threshold rather than a gradient effect. compared to whites, blacks receive diminishing health returns for each subsequent level of income and education; with whites closely mirroring the total population in ses thresholds. similarly, compared to men, women do not experience the same health gains at comparable ses levels. for education, black men and women only show significant mortality declines upon completion of high school. the ses gradient operates differently among race and gender subgroups. threshold effects suggest resource gains in life opportunities at particular milestones along the ses gradient. further, ses matters less for blacks and women compared to whites and men suggesting differing implications for health and social policy aimed at reducing disparities. objective: we assessed the impact of diabetes in a large puerto rican community of chicago by measuring the prevalence of diagnosed diabetes and calculating the diabetes mortality rate. methods: we analyzed data from a comprehensive health survey conducted in randomly selected households in community areas. questions on diagnosed diabetes and selected risk factors were asked. in addition, mortality data were analyzed in order to calculate the age-adjusted diabetes mortality rate. when possible, rates were compared to those found in other studies. results: the diabetes prevalence located in this community ( . %: % cl= . %- . %) is one of the highest ever reported for puerto ricans. for instance, it is more than three times higher than the prevalence for the us ( . %) and twice the prevalence for puerto ricans in new york ( . %) and puerto rico ( . %- . %). diagnosed diabetes was found to be significantly associated with obesity (p= . ). the prevalence was particularly high among older people, females, those horn in the us, and those with a family history. the diabetes mortality rate ( . per , population) was more than twice the rate for all of chicago ( . ) and the us ( . ). conclusions: understanding why the diabetes and mortality rates for puerto ricans in this commu· nity are so much higher than those of other communities is imperative. collaboration between researchers, service providers and community members can help address the issues of diabetes education, early screening and diagnosis and effective treatment needed in this community. introduction: sars is a respiratory illness that is spread from person to person through dose contact. this infectious disease outbreak was unusual due to the high rate of infection among health care workers. the aim of the study is to explore the demographic and attitudinal determinants of psychological distress due to sars among health care workers of a toronto hospital. methods: a total of adult participants completed questionnaires co assess psychological distress (impact of event scale -jes) and attitudes to sars. of these, participants completed the questionnaire during the sars i outbreak, and participants completed the questionnaire during the sars ii outbreak. participants also provided information on demographic variables, including occupation and exposure to sars. principal components analysis was used to derive eight attitudinal scales: fear: system, protection, prevention, job stress, stigma, instrumental coping, and psychological copm~. l ear regression analyses were applied to evaluate the associations of the demographic and amtudmal variables, as well as time, with psychological distress. . . regression analyses showed that time and higher scores on fear, ob stress, stigma'. and instrumental coping were associated with a higher total ies score: (r =. ). contrary to expectations, none of the demographic variables was associated with total ies score. conclusion: the presence of psychological distress in health care workers is indicative of intrusive or avoidant responses to thoughts, feelings, and memories associated with the sars outbreak. this study shows that ( ) fear for one's health and the he~lth of.others, ( ) ex~erien~in~ job stress, ( )_tbe per· ception of stigma, ( ) usage of instrumental copmg skills, ~n~ ( ) t m_e s grufi~an~ly c~nmb~te to increased psychological distress in health care workers. potential mterventmns during mfecttous diseaie outbreaks in health care settings should be targeted to minimize the impact of these factors. purpose: the purpose of this study was to expand knowledge regarding feeding practices, know!· edge and nutritional beliefs of mothers currently residing in the dominican republic (dr). the rising incidence of obesity in children is a major national health concern and obesity in first and second-generation immigrant children also continues to rise. we know that parents (particularly mothers) shape children's early diet patterns and that immigrant mothers experience additional challenges related to acculturation and assimilation into a new culture, however there is a paucity of literature concerning the effect of immigrant adaptation to american culture on the nutrition of children. in addition, new immigrant knowledge about the causes of obesity and the resulting health implications for childhood obesity has not been assessed and reported. this qualitative study used focus group methodology to discuss views and practices related to the introduction of food for infants and feeding practices for young children, along with a discussion on knowledge and beliefs related to the causes and health implications of child· hood obesity. ten dominican mothers' of young children (birth to years old) who reside in a small town in the western frontier area of the dr were participants in the focus group. results from this srudy will be compared to results from an identical study that will be conducted in fall with new immi· grant mothers from the dr to the boston area. we will compare feeding practices, beliefs and knowledge about nutrition for young children between these two groups. methods: using participatory principles, a focus group design was used to interview a group of mothers in the dr. the investigator along with a bilingual translator conducted the focus group. the session was tape recorded and is currently in the process of being transcribed and translated. transcribed data will be systematically analyzed themes will be identified. a qualitative data analysis software will be used to organize and code the data according to the specific aims of the study. supporting quotations will be selected to substrate each theme. lmpli~tions for urban health practice: an ultimate goal of this study is to lay a foundation for understanding the process of acculturation on feeding practices of mothers when they immigrate to the us. understanding beliefs, knowledge and feeding practices that mothers use with young children will help m ~he ~evelopment of culturally and linguistically appropriate educational strategies and materials for use m primary prevention of pediatric obesity. in canada more than seventy-five percent of immigrants choose to stay in three major urban centers of toronto, montreal and vancouver. approximately fifty percent of the immigrants eventually set· tie m ~~e greater tor<_>nto area. there is mounting evidence that the increasing immigrant population has a_ sigmfic~nt health disadvantage over canadian-born residents. this health disadvantage manifests particularly m the ma "ority of "mm "gr t h h d be · · h . . . . an s w o a en m canada for longer than ten years. this group as ~n associ~te~ with higher risk of chronic disease such as cardiovascular diseases. this disparity twccb n ma onty of the immigrant population and the canadian-born population is of great importance to ur an health providers d" · i i · b as isproporttonate y arge immigrant population has settled in the ma or ur an centers. generally the health stat f · · · · · · h h been . us most mm grants s dynamic. recent mm grants w o av_e ant •;ffca~ada _for less ~han ~en years are known to have a health advantage known as 'healthy imm • ~ants r::r · ~:s eff~ ~ defined by the observed superior health of both male and female recent immi- immigrant participation in canadian society particularly the labour market. a new explanation of the loss of 'healthy immigrant effect' is given with the help of additional factors. lt appears that the effects of social exclusion from the labour market leading to social inequalities first experienced by recent immigrant has been responsible for the loss of healthy immigrant effect. this loss results in the subsequent health disadvantage observed in the older immigrant population. a study on patients perspectives regarding tuberculosis treatment by s.j.chander, community health cell, bangalore, india. introduction: the national tuberculosis control programme was in place over three decades; still tuberculosis control remains a challenge unmet. every day about people die of tuberculosis in india. tuberculosis affects the poor more and the poor seek help from more than one place due to various reasons. this adversely affects the treatment outcome and the patient's pocket. many tuberculosis patients become non-adherence to treatment due to many reasons. the goal of the study was to understand the patient's perspective regarding tuberculois treatment provided by the bangalore city corporation. (bmc) under the rntcp (revised national tuberculosis control programme) using dots (directly observed treatment, short course) approach. bmc were identified. the information was collected using an in-depth interview technique. they were both male and female aged between - years suffering from pulmonary and extra pulmonary tuberculosis. all patients were from the poor socio economic background. results: most patients who first sought help from private practitioners were not diagnosed and treated correctly. they sought help form them as they were easily accessible and available but they. most patients sought help later than four weeks as they lacked awareness. a few of patients sought help from traditional healers and magicians, as it did not help they turned to allopathic practitioners. the patients interviewed were inadequately informed about various aspect of the disease due to fear of stigma. the patient's family members were generally supportive during the treatment period there was no report of negative attitude of neighbours who were aware of tuberculosis patients instead sympathetic attitude was reported. there exists many myth and misconception associated with marriage and sexual relationship while one suffers from tuberculosis. patients who visited referral hospitals reported that money was demanded for providing services. most patients had to borrow money for treatment. patients want health centres to be clean and be opened on time. they don't like the staff shouting at them to cover their mouth while coughing. conclusion: community education would lead to seek help early and to take preventive measures. adequate patient education would remove all myth and conception and help the patients adhere to treatment. since tb thrives among the poor, poverty eradiation measures need to be given more emphasis. mere treatment approach would not help control tuberculosis. lntrod#ction: the main causative factor in cervical cancer is the presence of oncogenic human papillomavitus (hpv). several factors have been identified in the acquisition of hpv infection and cervical cancer and include early coitarche, large number of lifetime sexual partners, tobacco smoking, poor diet, and concomitant sexually transmitted diseases. it is known that street youth are at much higher risk for these factors and are therefore at higher risk of acquiring hpv infection and cervical cancer. thus, we endeavoured to determine the prevalence of oncogenic hpv infection, and pap test abnormalities, in street youth. ~tbods: this quantitative study uses data collected from a non governmental, not for profit dropin centre for street youth in canada. over one hundred females between the ages of sixteen and twentyfour were enrolled in the study. of these females, all underwent pap testing about those with a previous history of an abnormal pap test, or an abnormal-appearing cervix on clinical examination, underwent hpv-deoxyribonucleic (dna) testing with the digene hybrid capture ii. results: data analysis is underway. the following results will be presented: ) number of positive hpv-dna results, ) pap test results in this group, ) recommended follow-up. . the results of this study will provide information about the prevalence of oncogemc hpv-dna infection and pap test abnormalities in a population of street youth. the practice implic~ tions related to our research include the potential for improved gynecologic care of street youth. in addition, our recommendations on the usefulness of hpv testing in this population will be addressed. methods: a health promotion and disease prevention tool was developed over a period of several years to meet the health needs of recent immigrants and refugees seen at access alliance multicultural community health centre (aamchc), an inner city community health centre in downtown toronto. this instrument was derived from the anecdotal experience of health care providers, a review of medical literature, and con· sultations with experts in migration health. herein we present the individual components of this instrument, aimed at promoting health and preventing disease in new immigrants and refugees to toronto. results: the health promotion and disease prevention tool for immigrants focuses on three primary health related areas: ) globally important infectious diseases including tuberculosis (tb), hiv/aids, syphilis, viral hepatitis, intestinal parasites, and vaccine preventable diseases (vpd), ) cancers caused by infectious diseases or those endemic to developing regions of the world, and ) mental illnesses includiog those developing among survivors of torture. the health needs of new immigrants and refugees are complex, heterogeneous, and ohen reflect conditions found in the immigrant's country of origin. ideally, the management of all new immigrants should be adapted to their experiences prior to migration, however the scale and complexity of this strategy prohibits its general use by healthcare providers in industrialized countries. an immigrant specific disease prevention instrument could help quickly identify and potentially prevent the spread of dangerous infectious diseases, detect cancers at earlier stages of development, and inform health care providers and decision makers about the most effective and efficient strategies to prevent serious illness in new immigrants and refugees. lntrodmction: as poverty continues to grip pakistan, the number of urban street children grows and has now reached alarming proportions, demanding far greater action than presently offered. urbanization, natural catastrophe, drought, disease, war and internal conflict, economic breakdown causing unemployment, and homelessness have forced families and children in search of a "better life," often putting children at risk of abuse and exploitation. objectives: to reduce drug use on the streets in particular injectable drug use and to prevent the transmission of stds/hiv/aids among vulnerable youth. methodology: baseline study and situation assessment of health problems particularly hiv and stds among street children of quetta, pakistan. the program launched a peer education program, including: awareness o_f self and body protection focusing on child sexual abuse, stds/hiv/aids , life skills, gender and sexual rights awareness, preventive health measures, and care at work. it also opened care and counseling center for these working and street children ar.d handed these centers over to local communities. relationships among aids-related knowledge and bt:liefs and sexual behavior of young adults were determined. rea.sons for unsafe sex included: misconception about disease etiology, conflicting cultural values, risk demal, partner pressur~, trust and partner significance, accusation of promiscuity, lack of community endorsement of protecnve measures, and barriers to condom access. in addition socio-economic pressure, physiological issues, poor community participation and anitudes and low ~ducation level limited the effectiveness of existing aids prevention education. according to 'the baseline study the male children are ex~ to ~owledge of safe sex through peers, hakims, and blue films. working children found sexual mfor~anon through older children and their teachers (ustad). recommendation s: it was found that working children are highly vulnerable to stds/hiv/aids, as they lack protective meas":res in sexual abuse and are unaware of safe sexual practices. conclusion: non-fatal overdose was a common occurrence for idu in vancouver, and was associated with several factors considered including crystal methamphetamine use. these findings indicate a need for structural interventions that seek to modify the social and contextual risks for overdose, increased access to treatment programs, and trials of novel interventions such as take-home naloxone programs. background: injection drug users (idus) are at elevated risk for involvement in the criminal justice system due to possession of illicit drugs and participation in drug sales or markets. the criminalization of drug use may produce significant social, economic and health consequences for urban poor drug users. injection-related risks have also been associated with criminal justice involvement or risk of such involvement. previous research has identified racial differences in drug-related arrests and incarceration in the general population. we assess whether criminal justice system involvement differs by race/ethnicity among a community sample of idus. we analyzed data collected from idus (n = , ) who were recruited in san francisco, and interviewed and tested for hiv. criminal justice system involvement was measured by arrest, incarceration, drug felony, and loss/denial of social services associated with the possession of a drug felony. multivariate analyses compared measures of criminal justice involvement and race/ethnicity after adjusting for socio-demographic and drug-use behaviors including drug preference, years of injection drug use, injection frequency, age, housing status, and gender. the six-month prevalence of arrest was highest for whites ( %), compared to african americans ( %) and latinos ( % ), in addition to the mean number of weeks spent in jail in the past months ( . vs. . and . weeks). these differences did not remain statistically significant in multivariate analyses. latinos reported the highest prevalence of a lifetime drug felony conviction ( %) and mean years of lifetime incarceration in prison ( . years), compared to african americans ( %, . years) and whites ( %, . years). being african american was independently associated with having a felony conviction and years of incarceration in prison as compared to whites. the history of involvement in the criminal justice system is widespread in this sample. when looking at racial/ethnic differences over a lifetime including total years of incarceration and drug felony conviction, the involvement of african americans in the criminal justice system is higher as compared to whites. more rigorous examination of these data and others on how criminal justice involvement varies by race, as well as the implications for the health and well-being of idus, is warranted. homelessness is a major social concern that has great im~act on th~se living.in urban commu?ities. metro manila, the capital of the philippines is a highly urbanized ar~ w. t~ the h gh~st concentration of urban poor population-an estimated , families or , , md v duals. this exploratory study v is the first definitive study done in manila that explores the needs and concerns of street dwdlent\omc. less. it aims to establish the demographic profile, lifestyle patterns and needs of the streetdwdlersindit six districts city of manila to establish a database for planning health and other related interventions. based on protocol-guid ed field interviews of street dwellers, the data is useful as a template for ref!!. ence in analyzing urban homelessness in asian developing country contexts. results of the study show that generally, the state of homelessness reflects a feeling of discontent, disenfranchisem ent and pow!!· lessness that contribute to their difficulty in getting out of the streets. the perceived problems andlar dangers in living on the streets are generally associated with their exposure to extreme weather condirioll! and their status of being vagrants making them prone to harassment by the police. the health needs of the street dweller respondents established in this study indicate that the existing health related servias for the homeless poor is ineffective. the street dweller respondents have little or no access to social and health services, if any. some respondents claimed that although they were able to get service from heallh centers or government hospitals, the medicines required for treatment are not usually free and are beyond their means. this group of homeless people needs well-planned interventions to hdp them improve their current situations and support their daily living. the expressed social needs of the sucet dweller respondents were significantly concentrated on the economic aspect, which is, having a perma· nent source of income to afford food, shelter, clothing and education. these reflect the street dweller' s need for personal upliftment and safety. in short, most of their expressed need is a combination of socioeconomic resources that would provide long-term options that are better than the choice of living on the streets. the suggested interventions based on the findings will be discussed. . methods: idu~ aged i and older who injected drugs within the prior month were recruited in usmg rds which relies on referral networks to generate unbiased prevalence estimates. a diverse and mon· vated g~o~p of idu "seeds." were given three uniquely coded coupons and encouraged to refer up to three other ehgibl~ idu~, for which they received $ usd per recruit. all subjects provided informed consent, an anonymous ~t erv ew and a venous blood sample for serologic testing of hiv, hcv and syphilis anti~!· results. a total of idus were recruited in tijuana and in juarez, of whom the maion!)' were .male < .l. % and . %) and median age was . melhotls: using the data from a multi-site survey on health and well being of a random sample of older chinese in seven canadian cities, this paper examined the effects of size of the chinese community and the health status of the aging chinese. the sample (n= , ) consisted of aging chinese aged years and older. physical and mental status of the participants was measured by a chinese version medical outcome study short form sf- . one-way analysis of variance and post-hoc scheffe test were used to test the differences in health status between the participants residing in cities representing three different sizes of the chinese community. regression analysis was also used to examine the contribution of size of the chinese community to physical and mental health status. rmdts: in general, aging chinese who resided in cities with a smaller chinese population were healthier than those who resided in cities with a larger chinese population. the size of the chinese community was significant in predicting both physical and mental health status of the participants. the findings also indicated the potential underlying effects of the variations in country of origin, access barriers, and socio-economic status of the aging chinese in communities with different chinese population size. the study concluded that size of an ethnic community affected the health status of the aging population from the same ethnic community. the intra-group diversity within the aging chinese identified in this study helped to demonstrate the different socio-cultural and structural challenges facing the aging population in different urban settings. urban health and demographic surveillance system, which is implemented by the african population & health research center (aphrc) in two slum settlements of nairobi city. this study focuses on common child illnesses including diarrhea, fever, cough, common cold and malaria, as well as on curative health care service utilization. measures of ses were created using information collected at the household level. other variables of interest included are maternal demographic and cultural factors, and child characteristics. statistical methods appropriate for clustered data were used to identify correlates of child morbidity. preliminary ratdts: morbidity was reported for , ( . %) out of , children accounting for a total of , illness episodes. cough, diarrhoea, runny nose/common cold, abdominal pains, malaria and fever made up the top six forms of morbidity. the only factors that had a significant associ· ation with morbidity were the child's age, ethnicity and type of toilet facility. however, all measures of socioeconomic status (mother's education, socioeconomic status, and mother's work status) had a significant effect on seeking outside care. age of child, severity of illness, type of illness and survival of father and mother were also significantly associated with seeking health care outside home. the results of this study have highlighted the need to address environmental conditions, basic amenities, and livelihood circumstances to improve child health in poor communities. the fact that socioeconomic indicators did not have a significant effect on prevalence of morbidity but were significant for health seeking behavior, indicate that while economic resources may have limited effect in preventing child illnesses when children are living in poor environmental conditions, being enlightened and having greater economic resources would mitigate the impact of the poor environmental conditions and reduce child mortality through better treatment of sick children. inequality in human life chances is about the most visible character of the third world urban space. f.conomic variability and social efficiency have often been fingered to justify such inequalities. within this separation households exist that share similar characteristics and are found to inhabit a given spatial unit of the 'city. the residential geography of cities in the third world is thus characterized by native areas whose core is made up of deteriorated slum property, poor living conditions and a decayed environment; features which personify deprivation in its unimaginable ma~t~de. there are .eviden~es that these conditions are manifested through disturbingly high levels of morbidity and mortality. ban · h h d-and a host of other factors (corrupt n, msens t ve leaders p, poor ur ty on t e one an , . · f · · · th t ) that suggest cracks in the levels and adherence to the prmc p es o socta usnce. ese governance, e c . . . . . ps £factors combine to reinforce the impacts of depnvat n and perpetuate these unpacts. by den· grou o . · "id . . bothh tifying health problems that are caused or driven by either matena _or soc a e~nvanon or , t e paper concludes that deprivation need not be accepted as a way. of hfe a~d a deliberate effon must be made to stem the tide of the on going levels of abject poverty m the third world. to the extent that income related poverty is about the most important of all ramifications of po~erty, efforts n_iu_st include fiscal empowerment of the poor in deprived areas like the inner c~ty. this will ~p~ove ~he willingness of such people to use facilities of care because they are able to effectively demand t, smce m real sense there is no such thing as free medical services. ). there were men with hiv-infection included in the present study (mean age and education of . (sd= . ) and . (sd= . ), respectively). a series of multiple regressions were used to examine the unique contributions of symptom burden (depression, cognitive, pain, fatigue), neuropsychologic al impairment (psychomotor efficiency), demographics (age and education) and hiv disease (cdc- staging) on iirs total score and jirs subscores: ( ) activities of daily living (work, recreation, diet, health, finances); ( ) psychosocial functioning (e.g., self-expression, community involvement); and ( ) intimacy (sex life and relationship with partner). resnlts: total iirs score (r " . ) was associated with aids diagnosis (ii= . , p < . ) and symptoms of pain (ii= - . , p < . ), fatigue (ji = - . , p < . ) and cognitive difficulties (p = . , p < . ). for the three dimensions of the iirs, multiple regression results revealed: ( ) activities of daily living (r = . ) were associated with aids diagnosis (ii = . , p < . ) and symptoms of pain <p =- j , p < . ), fatigue (ji = - . , p < . ) and cognitive difficulties (ji = . , p < . ); ( ) psychosocial functioning (r = . ) was associated with was associated with symptoms of fatigue (ii= - . , p < . ) and cognitive difficulties <ii = . , p < . ); and ( ) intimacy (r = . ) was related to was associated with symptoms of fatigue (ij = - . , p < . ) and cognitive difficulties (ii= . , p < . ). methods: the sif evaluation methodology involves a comprehensive database located at the sif, a randomly selected p~o.spective coh~rt of sif users, and two pre-existing external control cohorts. . . ~ts: in addmon to reporting process data and descriptions of the sif users, we report on data indicating that the establishment of the sif has been independently associated with reductions in public ~':°g ~ (p <?. ), and syringe sharing (aor = . [ %ci: . _ . ); p = . ) and other unsafe m ecnon pract _ces_ (p ~ . ), and increased uptake of detox services (log-rank p = . ). as well, we report on da~ md cat ng that the sif has not prompted adverse changes in community drug use patterns. the vancouver sif has been well accepted by the target population, and while adve~ events s~c~ as overdoses have occurred, these events have been successfully managed. externally compiled data indicate that the sif has been associated with substantial declines in public disorder !'oster sessions v associated with injection drug use, syringe sharing, and increased uptake of detox services. as well, the establishment of the sif has not exacerbated community drug use patterns. ongoing evaluation activities wiu involve assessing the impact of the sif on a variety of outcomes, including infectious disease transmission, fatal overdose, and utilization of health and social services. city, brazil, - maria cristina almeida, waleska caiaffa, renato assum;iio, and fernando proietti dengue cases were described according to time, space, intensity, age, gender, onset of symptoms, residence address and census tract. spatial distribution of two groups (children and women over years old and men aged - ) were compared, under assumption that they have distinct behaviors regarding their displacement around the city. analysis included local moran index, ripley\\'s k function and recurrence of census areas over time. about , cases were identified in seven epidemic waves. concentration of cases in small areas, followed by a spread either in space or time suggested endemic patterns. regarding age-gender groups, distinct patterns suggested that residence might not be a good proxy in determining the local of infection for men aged - . dengue is shifting to endemic pattern in this city and transmission may not be sole related to home environment, suggesting that additional spatial information must be couected aiming efficient control measures. murukan kandamuthan and subodh kandamuthan lnl uduction: illness or disablement of a child may affect the economic functioning of a family as it alters the employment pattern and earnings of parents this paper tries to assess the health status and the quality of life of disabled children, and how generally, severe disablement in a child affected their fami-lies\' finances, and to quantify any such effects the problems faced by children in their home and to provide information relevant to the formation of criteria for new or increased cash support. methods: a case-control study was done in the thiruvananthapuram district, capital city of kerala by selecting a random sample of families with severely disabled children below years and a random sample of normal children matched for age and occupation of the parents. comparative and subjective data were collected. money spent on children\'s medical care, loss of earnings of the parents, and other economic burden to the family due to the disability of the child in the family. a discriminant analysis along with univariate analysis was done to assess the factors that mostly differentiate the disabled and normal children. the mean expenditure of the families with a disabled child was rs. /-per month, which is significantly higher than the corresponding expenditure of rs. /-per month of families with normal child, (t= . , p <. ). of the disabled children, % were not getting any social security payments and % had no special concessions for medical and other educational purposes. the analysis of income and expenditure pattern indicated that financial impact of disablement in a child on the family is significant. the discriminant model results revealed that medical expenditure was a significant variable that differentiated the disabled and normal child. the study found that the health status and quality of life of the disabled children were far from satisfactory. this in fact affected the economic status of the disabled children. in addition to reduced earnings, there are extra costs for disabled children for travel, domestic help, medical care, and health care expenditures (hospital care, physician services, dentistry, drugs and others) for disabled individuals. a strong case can be made for their long-term care by improving the financial support to such families possibly through the introduction of an allowance specially to compensate for the earnings lost by parents due to the disability of their children. widows in india are considered disadvantage group of population. because they are characterized by pangs of separation from spouse, and consequently they go through mental agony, social ~s?lation, and economic dislocation. in addition to these, poverty, landlessness, homelessness, malnutr non etc. endure serious deterioration of their health. according to census , there are million women are widowed and one fourth live in urban areas. there is a noticeable increase of urban widows from the previous census (almost half). the paper examines the type of disability and chronic ailment borne among elderly widows ( years and above). fifty second round of national sample survey aske~ the individuals three sets of questions regarding their health: their status of health, whether they are physically poster sessions v immobile, and whether or not they have had any specific chronic illnesses. although health infrastruc- · ble ·n urban setting in india as compared to rural counterpart, prevalence of tures are arge y ava a . . . . . h · · · h h"gher "n urban areas analysis shows omt problems m old age qmte common c romc ness is muc • . . and nearly percent elderly widows are suffering from this ail'. ent in urban areas. one-fifth of widows are suffering from high/low bp. heart disease, diabetes and urinary problems are much ~ore pre~alent in urban areas though disabilities is comparatively lower in urban areas. however, the d~fference is not statistically significant. disability with respect to vision is more pronounced and one third_ of the total respondents have problems regarding eyesight. one fifths ofdderly widows are _ha.rd of hearing. though disability increases with age, similar trend is not observed with respect to chr~mc illness. the percepnon of self-health among elderly becomes poorer as their age increases. the perceived health status need not be always corrected to objective indicators of health. it is noted that around per~en~ of those perceived their health as "excellenr" or "very good" are found to be suffering from chrome disease of omts and percent have visual disability. to conclude an elderly widow living in urban areas have similar health problems as she jives in rural areas. this can be easily explained, as they were not made aware to seek treatment from health facility. in addition, the study shows that the economic conditions are deterrent factors for their illness. it is essential that intervention should be taken up improving their economic conditions so that wellbeing of this most vulnerable group of the society can be taken care of. heart failure is a disease that affects nearly million people world wide. the united states alone accounts for one third of this population. blacks are stricken with heart failure twice as often as whites. men are more likely to develop chf than women, however since the majority of the chf population are seniors, there are actually more women than men. congestive heart failure (chf) has become a pandemic. as the baby boomer generation ages, the number of chf cases will rise dramatically. (young, j. & mills, r., ). after the age of , each proceeding decade doubles the incidence level of chf. the average person has a in chance of developing heart failure within their lifespan according to the framingham study (nih.gov). individuals aging or older compose over half of the entire documented heart failure population. in this age group, chf is the leading cause of hospitalization. many patients are continuously readmitted. it is estimated that the chf population will increase by one million within the next years. mortality was at % for a two year period and % for five years (young, j. & mills, r., ). data from: aha as technology evolves, the understanding of the nature of heart failure has become clearer. in the beginning of the th century heart failure was diagnosed as a condition that presented with edema (swelling) in the extremities caused by water retention. treatment in the beginning of the past cenrury was limited to abdominal drainage and diuretics. the discovery of the heart's insufficient pumping ability in heart failure patients lead to new surgeries and devices such as heart transplants and ventricular assist devices (bridge until transplant is available). ventricular hypertrophy often occurs before the development of heart failure. hypertrophy is the term given for cardiac remodeling. cardiac remodeling also includes chamber dilation (young, j. & mills, r., ) . chf financial burden the us healthcare financing administration has ranked chf as the highest cost illness in the diagnose-related area. direct costs related to chf in the us for were nearly $ billion. these costs included hospital admissions, physician fees, home health aids and medications. indirect costs were over $ billion in . loss of jobs or death due to chf was the criteria for this category (young, j. & mills, r., ). . introduction: the injection drug user quality of life scale (iduqol) is a relatively new scale ~es gned to capture the unique and individual circumstances that determine quality of life among injection drug users (idus). the life areas comprising the instrument were based on the research literature an~ ~ocus group discussions with idus. the purpose of the present study was to evaluate the content validity of t.h~ iduqol using judgmental methods based on subject matter experts' (smes) ratings. content vah~ ty refers to the de~ee to which elements of an assessment tool are representative of the construct of interest and appropnate for a given population. methods: data were obtained from six smes, from the field of idu research and practice, who ~ere. asked t.o evaluate various aspects of the iduqol, including the title of the instrument, administraon instruchons, clarity of the names and descriptions of each life area, response format, scoring instruc-no~s and examples, record form and whether each life area should be included in the instrument. sme ratings were made using either or point scales. sm es were also given the opportunity to comment on poster sessions v each section and to suggest whether important life areas had been overlooked, were redundant, not relevant, or in need of revision. (cvi) and the ~v.erage ~eviation index (ad) were used to evaluate smes' agreement on ratings of the content vahd ty vanables. both measures provided support for the content validity of various aspects of the iduqol, although results from the stricter ad index noted some areas of disagreement, including the description of particular life areas (e.g., being useful, drugs, sex), the inclusion of some life areas (e.g., drug treatment, education, independence and free choice), and the ease of the scoring instructions. the findings from this study provide (a) content validity evidence to support the use of the iduqol as well as (b) recommendations to suengthen both the instrument (e.g., improved descriptions for some items) and the accompanying administration and scoring manual (e.g., an easier scoring template). changes made to the instrument and its manual make the iduqol even easier for researchers, practitioners, and program evaluators to use as a way of assessing, and tracking changes over time or as a result of interventions in, quality of life in injection drug users. introduction: strict adherence to prescribed regimens is required to derive maximal benefit from highly active antireuoviral therapy (haart) in persons living with hiv/aids (phas). adherence is a key determinant of the degree and durability of viral suppression. adherence is also essential in reducing the spread of hiv and ensuring that today's treatments remain effective for as long as possible. the objective of this study is to conduct a systematic review of the research literature on the effectiveness of education and patient support strategies for improving adherence to haart. methods: a systematic search of the core databases was performed from january until may . randomized controlled trials examining the effectiveness of education and patient support interventions to improve the adherence to haart were considered for inclusion. only those studies that measured adherence at a minimum of six weeks were included. study selection, quality assessments, and data abstraction were performed independently by two reviewers. results: study heterogeneity with respect to differing populations, interventions, outcomes, and length of follow-up did not allow for meta-analysis. we included studies involving , ph as. sample sizes ranged from to . study duration ranged from a single session to a variable number of sessions delivered over one year. many of the interventions involved the provision of an educational component to improve adherence and often addressed strategies to overcome barriers to adherence and the development of problem-solving skills. they ranged from simple interventions (e.g., the provision of reminder devices) to complex interventions (e.g., cognitive-behavioural therapy delivered by licensed psychologists). eleven of the studies demonstrated a statistically significant advantage associated with the described adherence intervention. the advantage associated with adherence outcomes does not seem to translate into the more clinically relevant outcome of viral suppression. only out of studies that reported virological or immunological results found a significant effect associated with the intervention. the studies had several methodological shortcomings. conclusions: there is a need for standardization and methodological rigour in the conduct of adherence trials. some interventions may have a significant impact on improving adherence. further research is required before any specific adherence improving strategy can confidently be incorporated into standard clinical practice. focus groups were used to collect data from a purposive sample of treatmentexperienced participants. focus group data were analyzed using a grou~ded t~eory appr~ach. i:ne themes identified from the interviews were used to identify the effects of ant rerrov rals on quality of hfe. the content of the mos-hiv was appraised against the themes identified from our analysis. participants also completed the mos-hiv survey and were asked whether the survey covered all important aspects of quality of life on antiretroviral medications. results: five key informant interviews and five focus groups with participants were used to identify effects on quality of life that are not directly ~aptu~ed by_ the mos-hiv health survey. our~~ showed that our participants described quality of hfe as mvol~mg_ a set of ~rsonal trad~ffs ~stay alive. in most cases, worsened quality of life was traded-off for gams ~ longevlty from ~~canon use. these eff~'ts or tradeoffs included: ( ) downstream consequences of side effects and toxlanes; ( ) loss of lrufe. pende~t decision-making privileges, ( ) having to choose drugs over ~areer; (~)burden of medication-taking responsibilities; and ( ) living life under a pretense and havmg to hide-the net effect of the tradeoffs, or "prices" to pay led to what was described as "longevity with hn without hope and future~. conclusion: our study highlights five major themes summarizing the impact of haart on quality on life, and suggests that currently used scales for measuring quality of life do not a~atd~ cap~e these findings and the associated consequences. the conceptual framework for measuring quality of bfe in hiv should be reconsidered in order to better capture the important effects of the medications on quality of life. this may involve widening the boundaries of the definition of health-related quality oflife to include aspects such as finances, employment, and housing. we should further consider the development of a haart adverse effect specific instrument, using a broad definition of adverse effect in order to capture all types of adverse impacts of hiv treatments on quality of life. introduction: measles (rubeola) is the most contagious vaccine preventable disease of humans. while cases of measles are uncommon in canada today, the disease continues to be a leading cause of morbidity and death in the developing world. as a result of human migration, measles cases still occur in canada, primari~ among immigrants, returning travelers, and other susceptible groups. canada's national advisory council on immunizations (naci) recommends that immigrants without records of measles immunization be considered for vac:cination since these individuals may not have been appropriately vaccinated in their native country. on rhe other hand, natural immunity to measles in immigrants is likely to be high given the high incidence of disease in developing parts of rhe world. thus it remains unclear if the most efficient strategy to achieve high levels of measles immunity in immigrants should entail initial serologic screening followed by vaccination of susceptible individuals or preemptive vaccination of all persons lacking immunization records. understanding the epidemiology of measles immunity in immigrant populations could help guide such decisions. . methods: we identified adults, years of age or older, who were screened for serologtc immunity to measles as part of a recently developed screening protocol at a downtown toronto community health centre. we subsequently determined if these individuals had any immunization records from their native country or from within canada. we then examined the relationship between several demographic factors and immunity to measles. results: % of immigrants had no prior immunization records. overall, % of the immigrants rested for immunity to measles were found to be immune; % of those under the age of , % of those between and years of age, % of those between and years of age, and % of those years of age or older. gender, education status, household income, and immigration status were nor ~ssoc ated wirh immunity to measles. immunity to measles was lowest among immigrants from eastern europe ( ~%), whil~ immigrants from other regions of the globe had greater than % immunity. c~lusrons: immigrants and refugees appear to have reasonably high levels of immunity to mea· sics, possibly related to natural infection wirh the measles virus. immigrants from eastern europe appear to have slightly. lower l~vel~ of immunity to the measles virus. universal screening for immunity to meales or preemptive vac:cmauon may both be inefficient public health strategies, however further research is needed to corroborate these findings. nancy r~ss, stephane tremblay, saeeda khan, daniel crouse, mark tremblay, and jean-marie berrhelor o~ve: the speed of the rise in obesity in places like canada suggests that rather than a shift in the gcncnc_ com~sirion of the population, the root of the obesity pandemic is an environment that suprrs ~besity. this paper examines the influence of neighbourhood and metropolitan characteristics. bour~lts:. while accounting. for individual socio-demographics and behaviours, residents of neighs with a large proportmn of poorly educated individuals had higher bmis than those living in poster sessions v neighbourhoods with more highly educated individuals (p <. ). residing in a neighbourhood with a high proportion of recent immigrants was associated with lower bmi for men (p<. ), but not women. neighbourhood dwelling density, a proxy for walkability, was not associated with bm! for either sex. metropolitan sprawl was associated with higher male bmi (p=. ) but the effect was negligible for women (p=. ). bmi was significantly lower for women (p<. ) living in a city in the province of quebec, even after accounting for the influence of individual and neighbourhood covariates. conclusions: bm! was strongly patterned by individual-level social position in urban canada. the incremental influence on bmi of neighbourhood related to the neighbourhood's social conditions and not to their physical form. metropolitan sprawl was associated with higher bm! for men, a group with longer car-dependent commutes than women. the findings suggest that both individuals and their environments (both social and physical) influence the distribution of bmi in urban populations. introduction: urban environments have been linked to a range of human health issues. in singapore, prevalence of end stage renal disease (esrd) is predicted to rise ( in to in , kidney international, vol. , . the clinical and economic burden of esrd has promoted development of strategies aimed at preventing the development and progression of chronic kidney disease. these include population based screening programs such as the national kidney foundation, sin-gapore\'s (nkfs) "partnership for prevention."the program, aims to reduce incidence of esrd through comprehensive intervention and screening for early detection of urinary abnormalities, blood pressure (bp), and random blood glucose (rbg). objective of this study is to examine gender, race and age wise prevalence of elevated bp, rbg and proteinuria. methodology: this current analysis includes , subjects, age to years, who underwent screening during september and december . participants were asked to give demographic information and the history of diseases. tests were given to get clinical information such as proteinuria, blood glucose, sbp, and dbp. blood pressure abnormalities were defined according to ]nc vi criteria. proteinuria was defined as the presence of plus or greater protein (equivalent to> mg/di) on dipstick analysis. results: there were , ( . %) males. racial distribution was chinese ( . % ), malay ( . % ), indians ( . %) and others ( . % ).among participants, who were apparently "healthy" (asymptomatic and without history of dm, ht, or kd), gender and race wise % prevalence of elevated (bp> / ), rbg (> mg/di) and positive urine dipstick for protein was as follows male: ( . ; . ; . ) female:( . ; . ; . ) chinese:( . ; . ; ) malay: ( . ; . ; . ) indian:( . ; . ; . ) others: ( . ; . ; . ) total:(l . , . , . ). percentage of participants with more than one abnormality were as follows. those with bp> / mmhg, % also had rbg> mg/dl and . % had proteinuria> i. those with rbg> mgldl, % also had proteinuria> and % had bp> / mmhg. those with proteinuria> , % also had rbg> mg/dl, and % had bp> / mmhg. conclusion: we conclude that sub clinical abnormalities in urinalysis, bp and rbg readings are prevalent across all genders and racial groups in the adult population. the overlap of abnormalities, point towards the high risk for esrd as well as cardiovascular disease. this indicates the urgent need for population based programs aimed at creating awareness, and initiatives to control and retard progression of disease. introduction: various theories have been proposed that link differential psychological vulnerability to health outcomes, including developmental theories about attachment, separation, and the formation of psychopathology. research in the area of psychosomatic medicine suggests an association between attachment style and physical illness, with stress as a mediator. there are two main hypotheses explored in the present study: ( t) that individuals living with hiv who were upsychologically vulne~able" at study entry would be more likely to experience symptoms of depression, anxiety and phys ca! illness over. the course of the -month study period; and ( ) life stressors and social support would mediate the relat nship between psychological vulnerability and the psychological ~nd physical outcomes. . (rsles), state-trait anxiety inventory (stai), beck depr~ssi~n lnvento~ (bdi), and~ _ -item pbys~i symptoms inventory. we characterized participants as havmg psychological vulnerability and low resilience" as scoring above on the raas (insecure attachment) or above on the das (negative expectations about oneself). . . . . . " . . ,, . results: at baseline, % of parnc pants were classified as havmg low resilience. focusmg on anxiety, the average cumulative stai score of the low-resilience group was significandy hi~e~ than that of the high-resilience group ( . sd= . versus . sd= . ; f(l, )= . , p <. ). similar results were obtained for bdi and physical symptoms (f( , )= . , p<. and f( , )= . , p<. , respec· tively). after controlling for resilience, the effects of variance in life stres".°rs averaged over time wa~ a_sig· nificant predictor of depressive and physical symptoms, but not of anxiety. ho~e_ver, these assooan~s became non-significant when four participants with high values were removed. s id larly, after controlling for resilience, the effects of variance in social support averaged over time became insignificant. conclusion: not only did "low resilience" predict poor psychological and physical outcomes, it was also predictive of life events and social support; that is, individuals who were low in resilience were more likely to experience more life events and poorer social support than individuals who were resilient. for individuals with vulnerability to physical, psychological, and social outcomes, there is need to develop and test interventions to improve health outcomes in this group. rajat kapoor, ruby gupta, and jugal kishore introduction: young people in india represent almost one-fourth of the total population. they face significant risks related to sexual and reproductive health. many lack the information and skills neces· sary to make informed sexual and reproductive health choices. objective: to study the level of awareness about contraceptives among youth residing in urban and rural areas of delhi. method: a sample of youths was selected from barwala (rural; n= ) and balmiki basti (urban slums; n= ) the field practice areas of the department of community medicine, maulana azad medical college, in delhi. a pre-tested questionnaire was used to collect the information. when/(calen· dar time), by , fisher exact and t were appliedxwhom (authors?). statistical tests such as as appropriate. result: nearly out of ( . %) youth had heard of at least one type of contraceptive and majority ( . %) had heard about condoms. however, awareness regarding usage of contraceptives was as low as . % for terminal methods to . % for condom. condom was the best technique before and after marriage and also after childbirth. the difference in rural and urban groups was statistically signif· icant (p=. , give confidence interval too, if you provide the exact p value). youth knew that contra· ceptives were easily available ( %), mainly at dispensary ( . %) and chemist shops ( . %). only . % knew about emergency contraception. only advantage of contraceptives cited was population con· trol ( . %); however, . % believed that they could also control hiv transmission. awareness of side effects was poor among both the groups but the differences were statistically significant for pills (p= . ). media was the main source of information ( %). majority of youth was willing to discuss a~ut contraceptive with their spouse ( . %), but not with others. . % youth believed that people in their age group use contraceptives. % of youth accepted that they had used contraceptives at least once. % felt children in family is appropriate, but only . % believed in year spacing. . conclusion: awareness about contraceptives is vital for youth to protect their sexual and reproduc· tive health .. knowledge about terminal methods, emergency contraception, and side effects of various contraceptives need to be strengthened in mass media and contraceptive awareness campaigns. mdbot:ls: elderly aged + were interviewed in poor communities in beirut the capital of f:ebanon, ~e of which is a palestinia~. refugee camp. depression was assessed using the i -item geriat· nc depressi~n score (~l?s- ). specific q~estions relating to the aspects of religiosity were asked as well as questions perta rung to demographic, psychosocial and health-related variables. results: depression was prevalent in % of the interviewed elderly with the highest proportion being in the palestinian refugee camp ( %). mosque attendance significantly reduced the odds of being depressed only for the palestinian respondents. depression was further associated, in particular communities, with low satisfaction with income, functional disability, and illness during last year. condiuion: religious practice, which was only related to depression among the refugee population, is discussed as more of an indicator of social cohesion, solidarity than an aspect of religiosity. furthermore, it has been suggested that minority groups rely on religious stratagems to cope with their pain more than other groups. implications of findings are discussed with particular relevance to the populations studied. nearly thirty percent of india's population lives in urban areas. the outcome of urbanization has resulted in rapid growth of urban slums. in a mega-city chennai, the slum populations ( . percent) face greater health hazards due to overcrowding, poor sanitation, lack of access to safe drinking water and environmental pollution. amongst the slum population the health of women and children are most neglected, resulting in burden of both communicable and non-communicable diseases. the focus of the paper is to present the epidemiology profile of children (below years) in slums of chennai, their health status, hygiene and nutritional factors, the social response to health, the trends in child health and urbanization over a decade, the health accessibility factors, the role of gender in health care and assessment impact of health education to children. the available data prove that child health in slums is worse than rural areas. though the slum population is decreasing there is a need to explore the program intervention and carry out surveys for collecting data on some specific health implications of the slum children. objective: during the summer of there was a heat wave in central europe, producing an excess number of deaths in many countries including spain. the city of barcelona was one of the places in spain where temperatures often surpassed the excess heat threshold related with an increase in mortality. the objective of the study was to determine whether the excess of mortality which occurred in barcelona was dependent on age, gender or educational level, important but often neglected dimensions of heat wave-related studies. methods: barcelona, the second largest city in spain ( , , inhabitants in ) , is located on the north eastern coast. we included all deaths of residents of barcelona older than years that occurred in the city during the months of june, july and august of and also during the same months during the preceding years. all the analyses were performed for each sex separately. the daily number of deaths in the year was compared with the mean daily number of deaths for the period - for each educational level. poisson regression models were fitted to obtain the rr of death in with respect to the period - for each educational level and age group. results: the excess of mortality during that summer was more important for women than for men and among older ages. although the increase was observed in all educational groups, in some age-groups the increase was larger for people with less than primary education. for example, for women in the group aged - , the rr of dying for compared to - for women with no education was . ( %ci: . - - ) and for women with primary education or higher was . ( %ci: . - . ). when we consider the number of excess deaths, for total mortality (>= years) the excess numbers were higher for those with no education ( . for women and . for men) and those with less than primary education ( . for women and - for men) than those with more than primary edm:ation ( . for women and - . for men). conclusion: age, gender and educational level were important in the barcelona heat wave. it is necessary to implement response plans to reduce heat morbidity and mortality. policies should he addressed to all population but also focusing particularly to the oldest population of low educational level. introduction: recently there has been much public discourse on homelessness and its imp~ct on health. measures have intensified to get people off the street into permanent housing. for maximum v poster sessions success it is important to first determine the needs of those to be housed. their views on housing and support requirements have to be considered, as th~y ar~ the ones affected. as few res.earch studies mclude the perspectives of homeless people themselves, httle is known on ho~ they e~penence the mpacrs on their health and what kinds of supports they believe they need to obtain housing and stay housed. the purpose of this study was to add the perspectives of homeless people to the discourse, based in the assumption that they are the experts on their own situations and needs. housing is seen as a major deter· minant of health. the research questions were: what are the effects of homelessness on health? what kind of supports are needed for homeless people to get off the street? both questions sought the views of homeless individuals on these issues. methods: this study is qualitative, descriptive, exploratory. semi-structured interviews were conducted with homeless persons on street corners, in parks and drop-ins. subsequently a thematic analysis was carried out on the data. results: the findings show that individuals' experiences of homelessness deeply affect their health. apart from physical impacts all talked about how their emotional health and self-esteem are affected. the system itself, rather than being useful, was often perceived as disabling and dehumanizing, resulting in hopelessness and resignation to life on the street. neither welfare nor minimum wage jobs are sufficient to live and pay rent. educational upgrading and job training, rather than enforced idleness, are desired by most initially. in general, the longer persons were homeless, the more they fell into patterned cycles of shelter /street life, temporary employment /unemployment, sometimes addictions and often unsuccessful housing episodes. conclusions: participants believe that resources should be put into training and education for acquisition of job skills and confidence to avoid homelessness or minimize its duration. to afford housing low-income people and welfare recipients need subsidies. early interventions, 'housing first', more humane and efficient processes for negotiating the welfare system, respectful treatment by service providers and some extra financial support in crisis initially, were suggested as helpful for avoiding homelessness altogether or helping most homeless people to leave the street. this study is a national homelessness initiative funded analysis examining the experiences and perceptions of street youth vis-a-vis their health/wellness status. through in-depth interviews with street youth in halifax, montreal, toronto, calgary, ottawa and vancouver, this paper explores healthy and not-so healthy practices of young people living on the street. qualitative interviews with health/ social service providers complement the analysis. more specifically, the investigation uncovers how street youth understand health and wellness; how they define good and bad health; and their experiences in accessing diverse health services. findings suggest that living on the street impacts physical, emotional and spiritual well·being, leading to cycles of despair, anger and helplessness. the majority of street youth services act as "brokers" for young people who desire health care services yet refuse to approach formal heal~h care organizational structures. as such, this study also provides case examples of promising youth services across canada who are emerging as critical spaces for street youth to heal from the ravages of ~treet cultur~. as young people increasingly make up a substantial proportion of the homeless population in canada, it becomes urgent to explore the multiple ways in which we can support them to regain a sense of wellbeing and "citizenship." p - (c) health and livelihood implications of marginalization of slum dwellers in provision of water and sanitation services in nairobi city elizabeth kimani, eliya zulu, and chi-chi undie . ~ntrodfldion: un-habitat estimates that % of urban residents in kenya live in slums; yet due to their illegal status, they are not provided with basic services such as water sanitation and health care. ~nseque~tly, the services are provided by vendors who typically provide' poor services at exorbitant prices .. this paper investigates how the inequality in provision of basic services affects health and livelihood circumstances of the poor residents of nairobi slums . . methods: this study uses qualitative and quantitative data collected through the ongoing longitudmal .health and demographic study conducted by the african population and health research center m slum communities in n ·rob" w d · · · · ai . e use escnpnve analytical and qualitative techmques to assess h~w concerns relating to water supply and environmental sanitation services rank among the c~mmumty's general and health needs/concerns, and how this context affect their health and livelihood circumstances. results: water ( %) and sanitation ( %) were the most commonly reported health needs and also key among general needs (after unemployment) among slum dwellers. water and sanitation services are mainly provided by exploitative vendors who operate without any regulatory mechanism and charge exorbitantly for their poor services. for instance slum residents pay about times more for water than non-slum households. water supply is irregular and residents often go for a week without water; prices are hiked and hygiene is compromised during such shortages. most houses do not have toilets and residents have to use commercial toilets or adopt unorthodox means such as disposing of their excreta in the nearby bushes or plastic bags that they throw in the open. as a direct result of the poor environmental conditions and inaccessible health services, slum residents are not only sicker, they are also less likely to utilise health services and consequently, more likely to die than non-slum residents. for instance, the prevalence of diarrhoea among children in the slums was % compared to % in nairobi as a whole and % in rural areas, while under-five mortality rates were / , / and / respectively. the results demonstrate the need for change in governments' policies that deprive the rapidly expanding urban poor population of basic services and regulatory mechanisms that would protect them from exploitation. the poor environmental sanitation and lack of basic services compound slum residents' poverty since they pay much more for the relatively poor services than their non-slum counterparts, and also increase their vulnerability to infectious diseases and mortality. since iepas've been working in harm reduction becoming the pioneer in latin america that brought this methodology for brazil. nowadays the main goal is to expand this strategy in the region and strive to change the drug policy in brazil. in this way harm reduction: health and citizenship program work in two areas to promote the citizenship of !du and for people living with hiv/aids offering law assistance for this population and outreach work for needle exchange to reduce damages and dissemination of hiv/aids/hepatit is. the methodology used in outreach work is peer education, needle exchange, condoms and folders distribution to reduce damages and the dissemination of diseases like hiv/aids/hepatitis besides counseling to search for basic health and rights are activities in this program. law attendance for the target population at iepas headquarters every week in order to provide law assistance that includes only supply people with correct law information or file a lawsuit. presentations in harm reduction and drug policy to expand these subjects for police chiefs and governmental in the last year attended !du and nidu reached and . needles and syringes exchanged. in law assistance ( people living with aids, drug users, inject drug users, were not in profile) people attended. lawsuits filed lawsuits in current activity. broadcasting of the harm reduction strategies by the press helps to move the public opinion, gather supporters and diminish controversies regarding such actions. a majority number of police officer doesn't know the existence of this policy. it's still polemic discuss this subject in this part of population. women remain one of the most under seviced segments of the nigerian populationand a focus on their health and other needs is of special importance.the singular focus of the nigerian family welfare program is mostly on demographic targets by seeking to increase contraceptive prevalence.this has meant the neglect of many areas of of women's reproductive health. reproductive health is affected by a variety of socio-cultural and biological factors on on e hand and the quality of the service delivery system and its responsiveness on the other.a woman's based approach is one which responds to the needs of the adult woman and adolescent girls in a culturally sensitive manner.women's unequal access to resources including health care is well known in nigeria in which stark gender disparities are a reality .maternal health activities are unbalanced,focusi ng on immunisation and provision of iron and folic acid,rather than on sustained care of women or on the detection and referral of high risk cases. a cross-sectional study of a municipal government -owned hospitalfrom each of the geo-political regions in igeria was carried out (atotal of ce~ters) .. as _part ~f t~e re.search, the h~spital records were uesd as a background in addition to a -week mtens ve mvesuganon m the obstemc and gynecology departments. . . . : little is known for example of the extent of gynecological morbtdtty among women; the little known suggest that teh majority suffer from one or more reproductive tr~ct infect~ons. although abortion is widespread, it continues to be performed under ilegal and unsafe condmons. with the growing v poster sessions hiv pandemic, while high riskgroups such ascomn;iercial sex workers and their clients have been studied, little has been accomplished in the large populat ns, and particularly among women, regardmgstd an hiv education. . . conclusions: programs of various governmentalor non-governmental agen,c es to mvolve strategies to broaden the narrow focus of services, and more importan~, to put wo~en s reproducnve health services and information needs in the forefront are urgently required. there is a n~d to reonent commuication and education activities to incorprate a wider interpretation of reproducnve health, to focus on the varying information needs of women, men, and youth and to the media most suitable to convey information to these diverse groups on reproductive health. introduction: it is estimated that there are - youths living on the streets, on their own with the assistance of social services or in poverty with a parent in ottawa. this population is under-serviced in many areas including health care. many of these adolescents are uncomfortable or unable to access the health care system through conventional methods and have been treated in walk-in clinics and emergency rooms without ongoing follow up. in march , the ontario government provided the ct lamont institute with a grant to open an interdisciplinary and teaching medical/dental clinic for street youth in a drop-in center in downtown ottawa. bringing community organizations together to provide primary medical care and dental hygiene to the streetyouths of ottawa ages - , it is staffed by a family physician, family medicine residents, a nurse practitioner, public health nurses, a dental hygienist, dental hygiene students and a chiropodist who link to social services already provided at the centre including housing, life skills programs and counselling. project objectives: . to improve the health of high risk youth by providing accessible, coordinated, comprehensive health and dental care to vulnerable adolescents. . to model and teach interdisciplinary adolescent care to undergraduate medical students, family medicine residents and dental hygiene students. methods: non-randomized, mixed method design involving a process and impact evaluation. data collection-qualitative:a) semi-structured interviews b) focus groups with youth quantitative:a) electronic medical records for months b) records (budget, photos, project information). results: in progress-results from first months available in august . early results suggest that locating the clinic in a safe and familiar environment is a key factor in attracting the over youths the clinic has seen to date. other findings include the prevalence of preventative interventions including vaccinations, std testing and prenatal care. the poster presentation will present these and other impacts that the clinic has had on the health of the youth in the first year of the study. conclusions: ) the clinic has improved the health of ottawa streetyouth and will continue beyond the initial pilot project phase. ) this project demonstrates that with strong community partnerships, it is possible meet make healthcare more accessible for urban youth. right to health care campaign by s.j.chander, community health cell, bangalore, india. introduction: the people's health movement in india launched a campaign known as 'right to health care' during the silver jubilee year of the alma ata declaration of 'health for all' by ad in collahoration with the national human rights commission (nhrc). the aim of the campaign was to establish the 'right to health care' as a basic human right and to address structural deficiencies in the pubic health care system and unregulated private sector . . methods: as part of the campaign a public hearing was organized in a slum in bangalore. former chairman of the nhrc chaired the hearing panel, consisting of a senior health official and other eminent people in the city. detailed documentation of individual case studies on 'denial of access to health care' in different parts of the city was carried out using a specific format. the focus was on cases where denial of health services has led to loss of life, physical damage or severe financial losses to the patient. results: _fourte_en people, except one who had accessed a private clinic, presented their testimonies of their experiences m accessing the public health care services in government health centres. all the people, e_xcept_ one person who spontaneously shared her testimony, were identified by the organizations worki_ng with the slum dwellers. corruption and ill treatment were the main issues of concern to the people. five of the fourteen testimonies presented resulted in death due to negligence. the public health cen· n:s not only demand money for the supposedly free services but also ill-treats them with verbal abuse. five of these fourteen case studies were presented before the national human right commission. the poster sessions v nhrc has asked the government health officials to look into the cases that were presented and to rectify the anomalies in the system. as a result of the public hearing held in the slum, the nhrc identified urban health as one of key areas for focus during the national public hearing. cond#sion: a campaign is necessary to check the corrupted public health care system and a covetous private health care system. it helps people to understand the structure and functioning of public health care system and to assert their right to assess heath care. the public hearings or people's tribunals held during the campaign are an instrument in making the public health system accountable. ps- (a) violence among women who inject drugs nadia fairbairn, jo-anne stoltz, evan wood, kathy li, julio montaner, and thomas kerr background/object ives: violence is a major cause of morbidity and mortality among women living in urban settings. though it is widely recognized that violence is endemic to inner-city illicit drug markets, little is known about violence experienced by women injection drug users (!du). therefore, the present analyses were conducted to evaluate the prevalence of, and characteristics associated with, experiencing violence among a cohort of female idu in vancouver. methods: we evaluated factors associated with violence among female participants enrolled in the vancouver injection drug user study (vidus) using univariate analyses. we also examined self-reported relationships with the perpetrator of the attack and the nature of the violent attack. results: of the active iou followed between december , and may , , ( . %) had experienced violence during the last six months. variables positively associated with experiencing violence included: homelessness (or= . , % ci: . - . , p < . ), public injecting (or= . , % ci: . - . , p < . ), frequent crack use (or= . , % ci: . - . , p < . ), recent incarceration (or = . , % cl: . - . , p < . ), receiving help injecting (or = . , % cl: . - . , p < . ), shooting gallery attendance (or = . , % ci: . - . , p < . ), sex trade work (or = . , % cl: . - . , p < . ), frequent heroin injection (or= . , % cl: . - . , p < . ), and residence in the downtown eastside (odds ratio [or] = . , % ci: . - . , p < . ). variables negatively associated with experiencing violence included: being married or common-law (or = . . % ci: . - . , p < . ) and being in methadone treatment (or = . , % ci: . - . , p < . ). the most common perpetrators of the attack were acquaintances ( . %), strangers ( . %), police ( . %), or dealers ( . %). attacks were most frequently in the form of beatings ( . %), robberies ( . %), and assault with a weapon ( . %). conclusion: violence was a common experience among women !du in this cohort. being the victim of violence was associated with various factors, including homelessness and public injecting. these findings indicate the need for targeted prevention and support services, such as supportive housing programs and safer injection facilities, for women iou. introduction: although research on determinants of tobacco use among arab youth has been carried out at several ecologic levels, such research has included conceptual models and has compared the two different types of tobacco that are most commonly used among the lebanese youth, namely cigarette and argileh. this study uses the ecological model to investigate differences between the genders as related to the determinants of both cigarette and argileh use among youth. methodology: quantitative data was collected from youth in economically disadvantaged urban communities in beirut, the capital of lebanon. results: the results indicated that there are differences by gender at a variety of ecological levels of influence on smoking behavior. for cigarettes, gender differences were found in knowledge, peer, family, and community influences. for argileh, gender differences were found at the peer, family, and community l.evels. the differential prevalence of cigarette and argileh smoking between boys and girls s therefore understandable and partially explained by the variation in the interpersonal and community envi.ronment which surrounds them. interventions therefore need to be tailored to the specific needs of boys and girls. introduction: the objective of this study was to assess the relationship between parents' employment status and children' health among professional immigrant families in vancouver. our target communmes v poster sessions included immigrants from five ethnicity groups: south korean, indian, chine~e, ~ussian, and irani~ with professional degrees (i.e., mds, lawyers, engineers, ma?~ger~, and uru~ers ty professors) w h no relevant job to their professions and those who had been hvmg m the studied area at least for months. methodology: the participants were recruited by collaboration from three local community agencies and were interviewed individually during the fall of . ra#lts: totally, complete interviews were analyzed: from south-east asia, from south asia, from russia and other eastern europe. overall, . % were employed, . % were underemployed, % indicated they were unemployed. overall, . % were not satisfied with their current job. russians and other eastern europeans were most likely satisfied with their current job, while south-east asians were most satisfied from their life in canada. about % indicated that their spouses were not satisfied with their life in canada, while % believed that their children are very satisfied from their life in canada. in addition, around % said they were not satisfied from their family relationship in canada. while most of the responders ranked their own and their spouses' health status as either poor or very poor, jut % indicated that their first child's health was very poor. in most cases they ranked their children's health as excellent or very good. the results of this pilot study show that there is a need to create culturally specific child health and behavioral scales when conducting research in immigrant communities. for instance, in many asian cultures, it is customary for a parent either to praise their children profusely, or to condemn them. this cultural practice, called "saving face," can affect research results, as it might have affected the present study. necessary steps, therefore, are needed to revise the current standard health and behavioral scales for further studies by developing a new scale that is more relevant and culturally sensitive to the targeted immigrant families. metboda: database: national health survey (ministry of health www.msc.es). two thousand interviews were performed among madrid population ( . % of the whole); corresponded to older adults ( . % of the . million aged years and over). study sample constitutes . % ( out of ) of those older adults, who live in urban areas. demographic structure (by age and gender) of this population in relation to health services use (medical consultations, dentist visits, emergence services, hospitalisation) was studied using general linear model univariate procedure. a p . ), while age was associated with emergence services use ( % of the population: %, % and % of each age group) and hos~italisation ( % .oft~~ population: %, % and %, of each age ~oup) (p . ) was fou~d with respect to dennst v s ts ( % vs %), medical consultations ( % vs %), and emergence services use ( % vs %), while an association (p= . ) was found according to hospitalisation ( % vs %). age. an~ g~der interaction effect on health services use was not found (p> . ), but a trend towards bosp tal sanon (p= . ) could be considered. concl.uions: demographic structure of urban older adults is associated with two of the four health se~ices use studi~. a relation.ship ber_ween age. and hospital services use (emergence units and hospitalisanon), but not with ~ut-hosp tal sei:vices (medical and dentist consultations), was found. in addition ro age, gender also contnbutes to explam hospitalisation. . sexua experiences. we exammed the prevalence expenences relation to ethnic origin and other sociodemographic variables as wc i as y j die relation between unwanted sexual experiences, depression and agreuion. we did so for boys and prts separately. mdhods: data on unwanted sexual expcric:nces, depressive symptoms (ce.s-d), aggrc:uion (bohi-di and sociodemographic facron were collected by self-report quescionnairc:s administettd to students in the: nd grade (aged - ) of secondary schools in amsterdam, the netherlands. data on the nature ol unwanted sexual experiences were collected during penonal interviews by trained schoolnursn. ltaijtj: overall prevalences of unwanted sexual experiences for boys and girls were . % and . % respectively. unwanted sexual experiences were more often ttported by turkish ( . %), moroc· an ( . %) and surinamese/anrillian boys ( . %) than by dutch boys ( . %). moroccan and turkish girls, however, reported fewer unwanted sexual experiences (respectively . and . %) than durch girls did ( . %). depressive symptoms(or= . , cl= . - . ) covert agression ( r• . , cl• . - . ) and cmrt aggression (or= . , cl• . - . ) were more common in girls with an unwanted sexual experi· met. boys with an unwanted sexual experience reported more depressive symptoms (or= . ; cl• i . .l· . ) and oven agression (or= . , cl= . - . ) . of the reported unwanted sexual experiences rnpec· timy . % and . % were confirmed by male and female adolescents during a personal interview. cond sion: we ..:an conclude that the prevalence of unwanted sexual experiences among turkish and moroccan boys is disturbing. it is possible that unwanted sexual experiences are more reported hy boys who belong to a religion or culture where the virginity of girls is a maner of family honour and talking about sexuality is taboo. more boys than girls did not confirm their initial disdosurc of an lllwalltc:d sexual experience. the low rates of disclosure among boys suggcsu a necd to educ.:atc hcahh care providen and others who work with migrant boys in the recognition and repomng of exu.il ... iction. viramin a aupplc:tmntation i at .h'yo, till far from tafl'eted %. feedinit pracn~:n panku· lerty for new born earn demand lot of educatton ernpha a• cxdu ve hrealt fecdtnit for dnared rcnoj of months was observtd in only .s% of childrrn thoulh colckturm w. givm n rn% of mwly horn ct.ildrm. the proportion of children hclow- waz (malnounshrdl .con" a• h!jh •• . % anj "rt'i· acimy tc.. compared to data. mother's ~alth: from all is womm in ttprod~uvr •ill' poup, % were married and among marned w~ .\ % only w\"rt' u mic wmr cnntr.-:cruve mt h· odl % were married bdorc thc •ar of yean and % had thnr ftnc prcicnancy hcftitt dlt' •icr nf yean. the lt'f'vicn are not uutfactory or they arc adequate but nae unh ed opumally. of thote' l'h mothen who had deliverrd in last one year, % had nailed ntmaral eum nat on ira" oncc, .~o-... bad matt rhan four ttmn and ma ortty had heir tetanus toxotd tnin,"t or"'" nlht "'"'"· ljn r ned rn· win ronductrd . % dchvcnn and % had home deh\'t'oc'i. ~md~: the tervtcn unbud or u led are !tu than dnarame. the wr· l'kft provided are inadequate and on dechm reprcwnttng a looun t ~p of h hnto good coytti\#' ol wr· ncn. l!.ckground chanpng pnoriry cannoc be ruled out u °"" of thc coatnbutory bc f. ps-ii ia) dcpn:wioa aad anuccy ia mip'mu ia awccr._ many de wn, witco tui~bmjer. jack dekker, aart·jan lttkman, wim gonmc:n. and amoud verhoeff ~ a dutch commumry-bucd icudy thawed -moarh•·prc:yalm«i al . ' . kw anx · ay daorden and . % foi' dqrasion m anmttdam. nm .. p tficantly hlllhn than dwwhrft .. dw ~thew diffamca m pttyalcnca att probably rdarcd to tlk' largr populanoa of napaan ..\mturdam. <turkish %, moroccan %, and surinam % . lndttd. ic'wt'll ltudla hatt ~ ~ high prevalena rata among migrant poupi in rbe ncdwrlands. howc'ytt au ttlluchn iuffenod from wry low raporne rara, or med screnung talel thac lack a ~y yabdarcd ~ in order to study the prevalence of depression and anxiety, and the (barriers to) use of mental health care among the different ethnic groups the following study was recently conducted: . the study consisted of a two-step approach. the first step was mcl~ded m the ~ h ith survey of (ahs), and consisted of three screening scales for depression and aruaety (klo, g::q- and mhl- ). in this survey all respondents were asked_ permission for~ second app~ :' t consisted of a structured interview containing the cidi for aruaety and depression, and questtollllalres on health care seeking, amongst others. all respondents who gave permission for a second approachwere invited by jetter for a suuctured interview with multilingual interviewers at home at a preset date and time in the following week. . in total, dutch, turkish, moroccan and surinam respondents took part in the ahs and gave permission for a second approach. in the second step, fo~ ~ tur~h, m~roc can surinamese and dutch respondents, information from the extensive interview was available (res~nse rates between and % ). since the data collection was completed only recently (june ), prevalence estimates can be presented at the conference for the first time. we have shown that with this approach it is feasible to achieve an acceptable response rate in a study on mental health among migrants. therefore we expect that this study will provide reli· able estimates of depression and anxiety in the turkish, moroccan and surinam migrants in amstw! ~· for the first time. in addition, insight into mechanisms underlying the differences between and within ethnic groups and into barriers to mental health care will provide pretexts for the improvement of pre· vention and mental health care for migrant groups. this study aimed to determine spatial patterns of mortality and morbidity of five major health problems in an urban environment: homicides, pregnancy among adolescents ((< years old), asthma hospitalization among young children(< years old) and two mosquito-borne diseasesdengue and visceral leishmaniasis, during - . all events were obtained through the city health database and, subsequently, geoproccsscd using the address of residence and the geographical and administrative division of the municipality, composed by unit of planning (up), which in tum were formed, each one, by census tract units. two research questions were investigated: are there spatial patterns to the events dis· tribution, and moreover, are these patterns overlapping across space? we use thematic maps, index of comparative mortality/morbidity by up and the overlapped rank of the th worse up rates for each event. a spatial pattern of high rates of homicides, proportion of young mothers and hospitalization of asthma were overlapping in areas social and economically disadvantaged. for mosquito-borne diseases, high rates with great dispersion were found in unprivileged areas in contrast with very low rares among privileged ones. these results pointed toward a coexistence of heavier burden of diseases for those living in areas of the city where misery, poverty, lack of political public health may be modulating social health problems. a possible environmental intervention in one mosquito•bome disease might be playing a role in the occurrence of other. although with limitations, this study may provide useful information for a joint urban planning under the public perspective, articulated for use in health impact assessment. jalil safaei bdrod#aion: the association of socioeconomic status (ses), usually measured by income, and health status is an established result in bcalth studies. the poor and low income individuals have lower health sta· tus then_ those with higher incomes. in general. such finding has been usually obtained from sample surveys on speafic populations. a problem with many sample survey$ is that their results are not comparable aaoss ~ndaries as they may use different sampling methods, ask different questions, categorize the answers differently, or define groups differently. moreover, the sample data need to be standardized using the demographic: katurea of a ~ population. this study, however, uses the national population health survey (nphs) cycle public use mictodata files which is based on a common survey template ·~~three~ area in canada, namely montreal, toronto, and vancouver. it also utili .es the built-m stanclatdizaaon of the nphs data which accounts for its complex survey design. . ~:the stu~ usc:s two well-known measures of health inequalitythe relative index of meqaality and die concentranon indexto capture the extent of income related health inequality among poster sessions v urban female and male populations in each of the three metropolitan areas. personal income is classified into ten groups by the nphs with "no income" as the first group and "more than $ , " as the last. health status is measured by three variables -having a chronic condition (chc), self assessed health (sah), and health utility index (hui) -using appropriate indices. alternative formulations are used to calculate the standard deviations of the estimated or calculated measures. the findings of the study suggest that the measured health inequality depends on the health measure used. for chc and hui the measured inequality indices do indicate poorer health for lower income individulas, however, they are not statistically insignificant. health inequalities are more pronounced when health is measured by sah. the results do not support any systematic ranking of the three metropolitan areas in terms of health inequalities. they do not reveal any systematic pattern of inequality between men and women, either. conclusions: despite the use of highly aggregated nphs data, income related health disparities are observed in the three metropolitan areas in canada. this is more the case with self perceived (sah) health. such disparities are preventable and call for broader health policies that address poverty and low income among other social determinants of health. introduction: the analysis of health indicators under the spatial perspective is configured as an important instrument in the detection of intra-urban differentials. this study aimed to examine the spatial distribution of the births occurred in belo horizonte, in , analyzing the presence of spatial clusters of health indicators for newborns (rn) and their mothers, using data from the information system on live birth database (sinasc). method: for each covered area of the basic units of health (ubs), we calculated the proportion of: adolescent mothers, mothers with less than years of schooling, first pregnancy, mothers with four or more pregnancies, dead babies born on previous pregnancies, stillbirths, cesarean section, less than four prenatal care attendance, moderate and severe hypoxemia in the st and th minutes of life, low or very low birth weight. we used empiric bayesian methods for smoothing the estimates. for spatial analysis, the indicators obtained from the global moran (i) index and local indicators of spatial association (lisa) were used. maps were built to allow the visualization of the spatial clusters. in all analysis, significance statistics was considered p~ . . results: a total of , births of residents in belo horizonte were registered in i. the estimated bayesian proportions for the entire municipality was close to the one observed for all variables. analysis using lisa showed the presence of relevant spatial clusters for adolescent and low educated mothers, dead babies form previous pregnancies, cesarean section, low attendance to the prenatal care especially in area with low socio-demographic characteristics. three areas presented consistent clusters, with important spatial auto-correlation for almost all studied indicators. conclusion: the used methodology was configured as a great instrument of detection risk areas where clustering occurs. it can easily be incorporated in any surveillance system as a mechanism for controlling events related to births in the municipality. moreover, it can be applied to discriminate target areas for prompt public health interventions, such as improving health services access and the consolidation of better obstetric practices. introduction: gentrification, the displacement of low income and non-majority people out of longtime neighborhoods and residences is a global phenomenon. it has been identified as occurring in both developed and less developed countries and as inequality persists or increases, many communities are vulnerable to disruption and loss. while there may be some benefits to gentrification, these benefits are less likely to impact those who have been forced to move out of a gentrifying community or those who remain but economically stressed. . . . . this paper lays out a theoretical framework for dent fymg and ~ddressm~. the_ health consequences of gentrification on residents living in a community prior .to o.r durmg gent~ ~ cat. n. by drawing on the literature of housing, sociology, health and urban plannmg, t places genmf catt~n and neighborhood change into the context of other forces affecting th~ .hea.lth of vulnerable populations. it then proposes solutions to prevent or mitigate the impacts of genmf cat on. results: four main categories of consequences potentiallr re~ult from ~entr~fica~~n: !'°°r housing· related issues, spatial effects, mental health impacts and contr bunons to racial ~spanttes m heal~. the housing issues include increased susceptibility to asthma, lead exposure, allergiesl~topy an~. acetdents/ injuries. spatial effects include reduced access to health ~are, reduce~ access to obslttadinonal food sources, decreased physical activity, and increased obesity. the __ pnmary mental health effects_ :ire increased stress increased risk of depression and disruption of trad t onal support networks. in addinon to the above he~lth issues, gentrification has the potential to increase racial disparities in health by reduc· ing access to long term and multi-culturally experienced health care provide~s. conclusions: public health practice provides a framework for addressmg the health consequences of gentrification. in this context primary prevention would involve preventing gentrification in the first place along with a renewed commitment to helping distressed communities a~~ im_proving the quality ~f life for long term residents. the next layer of meeting the challenges of gentrification would be to assjst long rime residents to stay in a community and thus potentially allowing them to participate in the bene~ts of gentrification (such as better public services). only if all these efforts fail -and these other prevennon strategies must be a priority, public policy should then work to help people and instirutions move to other communities through grants and the provision of alternative safe affordable housing and neighborhoods. sarah romans, marsha cohen, and tonia forte lnh'odlletion: there has been sustained interest in urban rural (ur) differences in mental health over the last years of epidemiological research, with most studies reporting higher urban rates of mor· bidity, particularly when psychotic disorders have been studied. most recently, in britain, urban rates of non-psychotic disorder were greater than rural and semi-rural rates, both before and after the more adverse circumstances of urban dwellers were considered (paykel et al ) . surprisingly, there were no ur differences in help seeking. in canada, wang ( ) found greater urban rates for major depression only after he controlled for the confounding effects of race, immigration, employment and marital status, a result reminiscent of work from the us (blazer et ) . rural participants were less likely to have sought help for their mental health problems. in this study, we sought to examine urban/rural differences in rates of depression and help seeking in canada. method; data came from the canadian community health survey . , a community survey conducted by statistics canada of people aged and older, with the total sample size of , respon· dents, % response. analyses used weighted data; differences were assessed by chi-squared. ra.its: bivariate cross-tabulations showed a modest increase in month depression rates for urban ( . %) over rural ( . %, p= . ) dwellers; there were no ur differences when the sample was examined separately by gender and age group ( - , - , - ) . in general, more urban ( . %) than rural people ( . %, p= . ) had sought mental health treatment in the past year. there was no ur difference in helping seeking amongst those with depression (u . %, r . % ns). amongst the whole population, helping seeking was gendered with more urban men accessing help ( . %) than rural men ( . %, p= . ); this did not apply for women ( . % vs . % p= . ). ~ons: the urban-rural demographic continues to generate intriguing findings, even recently when internal migration is common and people can seek out the environment most conducive to their health, ~th physical and mental. people with depression are a disadvantaged, frequently stigmatized group, with ~r quality of life a_nd often impaired function. unlike many other factors associated wi~h urban or rural hfe per se, depression can be treated. the low help seeking rates is a cause for concern, m both the ur~n and_ rural populations. it behooves researchers, policy makers and service planners to ensutt effective services are available for both humane and economic reasons. methods: using united states census income data, we assigned the manhattan community districts to two major socioeconomic groups, manhattan i and ii. manhattan i is composed of community districts with average household incomes above the median for new york city; manhattan ii is those below. with public new york city department of health death records and us census data, we calculated a "standard" new york city population and estimated mortality rate distributions for manhattan i and ii. we then compared these age-adjusted actual mortality distributions with a standard t-test. results: we explored premature deaths using several cut-off points (before the ages of , , and ), and with subcomparisons for males and females. every comparison showed the wealthier area, manhattan i, to have significantly lower premature mortality rates than the lower income manhattan ii. further, we compared age-adjusted mortality rates among the city's five boroughs, and found no significant differences based on local geography alone. conclusions: these findings suggest that in manhattan, characterized by its extremes of wealth and poverty, health status, as measured by premature mortality, does vary significantly with the local income level. in manhattan, the relative average income by community district varies as much as : . this ratio is greater than that found in the other cities we have studied: for example, the range among tokyo's kus is half that in manhattan, or about : . paris has shown the longest life expectancy and changing premature mortality rates. from our preliminary work, we expect to find less variation in premature mortality rates in comparable cities. this study will continue to explore the relationship of premature mortality rates and life expectancy to income levels and different health systems among wcp cities with a view to measuring health policy options. introduction: according to the world health organization (who), smoking-related illness is currently the world's second major cause of death, currently responsible for one out of ten adult deaths worldwide. the who's framework convention on tobacco control (fctc) aims to reduce tobaccorelated disease and deaths by changing national public policies. mexico, which, according to the who, had smoking prevalences of % among adults in and % among health care providers (hcps) in , ratified the fctc in . objective: to examine knowledge of and attitudes towards cigarette smoking and smoking cessation among hcps, and clinical practices regarding smoking cessation. methods: in june , a convenience sample of hcps from one public clinic in urban oaxaca, mexico, part of mexico's national network of public health care clinics, were interviewed in spanish using a verbally administered questionnaire that was standard among all participants. during primary care outpatient visits, hcps were observed treating patients to assess the relative importance of smoking cessation as a health care priority. results: of the hcps interviewed, including ten physicians, three nurses, and five medical students, % reported smoking regularly. all hcps reported assessing patients' history of smoking, knowledge of the health risks associated with smoking, and feeling qualified to discuss these risks with patients. all hcps reported counseling patients who currently smoked to quit. all hcps reported recommending nicotine replacement therapy (eg., patch and/or gum) and/or behavioral therapy (eg., psychologist, support groups) to patients who smoked. all hcps reported that there was no government funding for smoking cessation, and that all costs associated with smoking cessation were patients' out-of-pocket expenses. observation of hcp interaction with patients revealed that hcps always inquired about smoking history with new patients and rarely inquired about smoking history with returning patients. hcps were not observed counseling patients who reported current smoking on smoking cessation methods and its benefits. observation of the clinical environment suggested a focus on preventative child health (eg., immunization, water-borne illnesses), family planning, and chronic diseases (eg., diabetes, hypertension). conclusions: while the mexican government has made smoking cessation a public health priority and hcps report addressing smoking cessation, observation of hcps suggests: ) smoking status is assessed only in new patients; and ) smoking cessation methods are not addresse~. observ_atio~ of hcps and the clinical environment in a public clinic in oaxaca suggests that smoking cessation s of lower priority than other heath care issues. p - (a) urban agriculture and food and nutrition security in kampala, uganda fiona yeudall, renee sebastian, abdelrahman lubowa, selahadin ibrahim, and donald cole introduction: urban agriculture is an important livelihood strategy contributing to household food security by increasing access and availability to food in urban settings (koc et al., ) . the purpose of poster sessions v rhis study was to examine relationships between child nutritional securiry outcomes, household food security, and urban agriculture activiries in kampala, uga~da. . . questionnaires assessing socio-demographic, farmmg and household food secunry (hfsi characreristics were administered to households. food diversiry was ~lculate~ from ~e number of foods consumed over hours for one child ( - years) per household. heigh~ weight,. nud-upper·ann· circumference (muac) and tricep skinfolds (tsf) were measured for the mdex child. z-sc.ores for height-for·age (haz), weighr-for-age (waz) and body mass index (zbmi) were ~~ulated usmg cen· rres for disease control and prevenrion reference data. z-scores for body composition measures were calculated using nhanes i and ii data for african americans. the lms method was used to c~.t for skewed z·score indices. all dara was checked for normaliry and univariable and backward mulnvanablc linear regression analysis conducted. ruwlts: household food securiry was significantly associated with wealth (b= . , p< 'a acre were more dependenr on assets for hfs. although sex of head of household was ~ot related to j-:ifs, it modi· fied relationships in rhar female headed households had greater food securtry when fai:mmg less than , acre compared ro male headed households, and vice versa. hfs was significantly associated with food diversiry (s= . , p). urbanization, especially in developing countries, has substantially increased the vulnerability of rhe mass of low-income urban dwellers. the livelihoods and quality of life for many of the poor espe· cially in larin america, asia, and africa, have deteriorated significantly over the years. urban areas are increasingly unable to provide for their populations, resulting in poverry, massive unemploymenr, job cuts, poor housing, lack of or poor public services, and a compromised health status. botswana, a country rhat lies in the sourhern parr of africa, has had its share of urban problems such as rhe mush· rooming of squarters and low-income urban sertlements. despite efforts to address the substandard living conditions in low-income urban areas, these problems have continued to grow. these living con· diuons are porenrially stressful to rhe residenrs and likely affects their health. the primary aim of the udy wa to examine the complex relationship between communiry-level stressors and interveners and health-related quality of life among residents of low-income neighborhoods in francistown, botswana. u i"" a croa -icctional quantitative design (both descriptive and explanatory) and using primarily cloae-mded interview• with a random sample of residents, this study examined the role of chrome life trnson and environmental quality on overall health status qualiry of life) and the physical, psy· chological and level of independence domains of health. the major hypothesis of the study was that community-levrl stre sor would influence health-related quality of life and that social capital would moderate these relationships. findings indicate that neighborhood quality is a powerful predictor of healrh tatu rhan socioeconomic status and individual life stressors. social capital was also found to he a ificant positive predictor of healrh and also moderator of structural factors. social capital moderated the effects of low environmental quality on level of indrpendence and on physical health outcomn, but nor on psychological and global health outcomes. these findings suggest that as the environment get betttr. stresson are reduced, hence promoting berter health outcomes. the study ends with implication• for social justice, public health and social work practice, and research, focusing mostly on the ~ole of social capital and the environmental quality in predicting health outcomes. spt· cafically • anenhon should be focused on political and civic society's commitment for social justice and poveny alleviation, ~uction of the threat of insecuriry and violence; cultivating social capital and good governance; and improving the health and social environments, especially housing and environ· mental aiutanon to name a few. urban and other uprisings by non-elites that lead to transitions, can disrupt sexual and injection "risk" networks that transmit infectious diseases by changing mixing patterns. they can also weaken urban social networks, their associated protective norms and their informal social control mechanisms which can lead to increased sexual and drug risk behaviors and violence (fullilove ; wallace & wallace , aral , friedman & reid hankins et al ) . for example, the revolution and transition to theocratic rule, and subsequent urban and national conflicts, have been followed by many urban youth in iran engaging in clandestine high-risk sexual and drug behaviors. in palestine, conflicts and restrictions on movement have led to increased fatalities from chronic diseases due to limited access to hospitals and modern medical facilities (union of palestinian medical relief committees); and heroin use and violence-related blood exposure have also increased. social movements "from below" that are rooted both in urban social network dynamics and in underlying patterns of injustice can have both protective and risky effects. for example, the social movements that led to the collapse of the ussr and its dependent governments in other countries-with subsequent increases in sex trade, alcoholism, drug use, tuberculosis, hiv, stis, and mortality in many localities-were based originally on such city-based movements in eastern europe. their impacts on health were mediated by urban social dynamics and structures. some urban social movements have improved health by prevent· ing the spread of hiv, hepatitis and other diseases. examples include movements of (a) gays and lesbians and (b) drug users. these have been rooted in social networks that overlap with risk networks. theories of urban health should include social conflict as a core concept. mechanisms that generate conflicts and the pathways by which conflicts affect health should be a major part of urban health research agendas. p - (c) demographic characteristics of people seen with tuberculosis in lagos state university teaching hospital (lasuth) chest clinic john bako, adewale akeredolu, and wale alabi tuberculosis has become a resurgent public health problem in recent times in the world. because resources are limited, control programmes frequently must target population at greatest risk. the purpose of this study was to study the demographic characteristics of people seen with tuberculosis in lagos state university teaching hospital. a total of patients who have been both radiologically and bacteriologically confirmed tuberculosis patients were used for this study between january and march. ( %) were males, while ( %) were females. notable risk factors among patients with tuberculosis were overcrowding ( . % ), homelessness ( . %) cigarette smoking ( . % ), alcoholism ( . %), non vaccination ( %), secondary contact ( . %) and poor knowledge ( . l 'x,). man· agement history patterns among the patients were herbs ( . 'yo), orthodox medicine ( .h . .l'x.). intervention targeting early-identified groups may be an effective way to reduce the incidence of tuber· culosis. such intervention should focus on health education, modification of life style and improvement of standard of living. p - (c) profiles in urban health in cities of the americas in the countries of the americas, there is an increasing migration of national and international populations to urban centers. this presentation will focus on some of the issues created by this influx of populations, the ways that cities in countries are dealing with them, and the efforts to promote local participation and solutions in management and decision-making. the methodology used to collect this information has been to draw upon and analyze information produced by the mayor's and ministry of health and development offices in each of the cities under consideration. an analysis of the impact of urbanization on health and health determinants will be presented. the information covers issues such as health status by geographic areas within the cities, highlighting issues such as marginality, barriers and physical, economic and cultural constructs and inequities in the delivery of and access to essential services (such as health, education, water, and basic sanitation). issues of governance and citizen participation will be highlighted to provide insight in~o the balance of power and mechanisms for decision-making at the local level. part of the analysis will show the relationship between democratic processes and social participation. public ~olicies will be reviewed to indicate those that are most beneficial in promoting health and overcoming barriers to it, as well as ways of capitalizing on local assets and resources. final~y, evidence of effectiveness of various strategies will be indicated. the presentation will conclude wuh suggesuons for future strategic directions to improve the quality of life and the promotion of health in large urban centers of the americas. introduction: much of the illicit drug in mexico is concentrated in northern border areas. the mile border between the u.s. and mexico is also characterized by migration; the border crossing between tijuana, baja california, mexico and san diego, california, u.s.a. is rep~rt~dl~ the busiest land border crossing in the world. we attempt to describe the migration scene among m ect on drug users (idus) m tijuana and investigate service needs. methods: migration trends were investigated in a cross-sectional study conducted from february to june among idus in tijuana. enrollment criteria included informed consent, being years or older, and having injected drugs within the prior month. subjects were recruited by respondent-dnven sampling and were administered a quantitative survey and serology for hiv, hcv, and syphilis. logistic regression was used to compare idus who had migrated to the u.s. versus those who had not. results: of idus enrolled, % were male and median age and age at first injection were and , respectively. drug combinations injected most frequently in the past months were heroin ( % and crystal methamphetamine mixed with heroin ( %). of those enrolled, responded to quesnons on migration and drug treatment and were included in this analysis. although % had resided in tijuana for at least years, % of users were born outside of baja california. working outside of mexico was common, with % working abroad in the last years ( % in u.s.), and % in the past year. in the last months, % of idus had crossed the border to the u.s., with % crossing at least once per month. those working outside of mexico in the past year were less likely to have ever received substance abuse treatment, [ % vs. %, or . , ] and were marginally less likely to have received drug treatment in the past months [ % vs. %, or . , % ci ( . - . )]. drug use patterns, age and gender did not differ between migrants and non-migrants, although migrants were more likely to report being in need of substance abuse treatment ( % vs. %, respectively). conclusions: migration is common among idus in tijuana. maintaining drug treatment regimens and determining how to best target education and services to a highly mobile population pose challenges to officials on both sides of the border. these data underscore the need to develop coordinated binational prevention and treatment efforts. introduction: despite the expanding literature on the important role public policy plays in influencing the broader determinants of the public\'s health, profound differences exist among jurisdictions in rhe attention placed upon such activities. we take an international perspective on health by examining rhe d?minant public _health paradigms of canada, usa, uk, and sweden and exploring how these paradigms shape public health practice. _method: we carefully analyze governmental and public health agencies documents to discern ~he dommant para~igms driving public health approaches and practices. we also consider the unique paht · cal and economic contexts within each nation and consider how these contexts drive public health pahcy and approaches. . . ~u~: the canadian and usa public health communities -with some exceptions --focus upon m~ividuahzed approaches to risk management. in contrast, the uk and swedish public health scenes are oriented toward broader approaches to health determinants. we find that the extent to which govern· ments, public health agencies and public health workers concern themselves with public policy approaches £<_> ~ddress ~ro.ad~r .determinants of health depends upon the particular health parad'.~ adhered. ~o withm each urisd ctton. and whether a paradigm is adopted depends upon the ideologi~a and pol~ncal context of each nation. nations such as sweden that have a long tradition of public policies promonng social jus~ce an~ equity are naturally receptive to evolving population health concepts. '[he usa represen~ a ~bey en~ro~~t where such is~ues are clear!~ subordinate. ., our findings mdicate that there s a strong political component that influences pubh ~ealth a~proaches and practi~ within the jurisdictions examined. the implications are that those seek· m~ to raise the broader detennmants of the public's health should work in coalition to raise these issues with non-health organizations and age · ca d d th · - badrgrollnd: in developed countries, social inequalities in health have endured or even worsened comparatively throughout different social groups since the s. in france, a country where access to medical and surgical care is theoretically affordable for everyone, health inequalities are among the high· est in western europe. in developing countries, health and access to care have remained critical issues. in madagascar, poverty has even increased in recent years, since the country wenr through political crisis and structural adjustment policies. objectives. we aimed to estimate and compare the impact of socio· economic status but also psychosocial characteristics (social integration, health beliefs, expectations and representation, and psychological characteristics) on the risk of having forgone healthcare in these dif· fercnt contexts. methods: population surveys conducted among random samples of households in some under· served paris neighbourhoods (n= ) and in the whole antananarivo city (n= ) in , using a common individual questionnaire in french and malagasy. reslllts: as expected, the impact of socioeconomic status is stronger in antananarivo than in paris. but, after making adjustments for numerous individual socio-economic and health characteristics, we observed in both cities a higher (and statically significant) occurrence of reponed forgone healthcare among people who have experienced childhood and/or adulthood difficulties (with relative risks up to and .s respectively in paris and antananarivo) and who complained about unhealthy living conditions. in paris, it is also correlated with a lack of trust in health services. coneluions: aside from purely financial hurdles, other individual factors play a role in the non-use of healthcare services. health insurance or free healthcare seems to be necessary hut not sufficienr to achieve an equitable access to care. therefore, health policies must not only focus on the reduction of the financial barriers to healthcare, but also must be supplemented by programmes (e.g. outreach care ser· vices, health education, health promotion programmes) and discretionary local policies tailored to the needs of those with poor health concern .. acknowledgments. this project was supported by the mal>io project and the national institute of statistics (instat) in madagascar, and hy the development research institute (ird) and the avenir programme of the national institute of health and medical research (inserm) in france. for the cities of developing countries, poverty is often described in terms of the living standard~ of slum populations, and there is good reason to believe that the health risks facing these populations are even greater, in some instances, than those facing rural villagers. yet much remains to be learned ahour the connections between urban poverty and health. it is not known what percentage of all urban poor live in slums, that is, in communities of concentrated poverty; neither is it known what proportion of slum residents are, in fact, poor. funhermore, no quantitative accounting is yet available that would sep· arare the health risks of slum life into those due to a househoid•s own poverty and those stemminic from poveny in the surrounding neighborhood. if urban health interventions are to be effectively targeted in developing countries, substantial progress must be made in addressing these cenrral issues. this paper examines poverty and children's health and survival using two large surveys, one a demographic and health survey fielded in urban egypt (with an oversampling of slums) and the other a survey of the slums of allahabad, india. using multivariate statistical methods. we find, in both settings: ( substan· rial evidence of living standards heterogeneity within the slums; ( strong evidence indicating that household-level poverty is an imponant influence on health; and ( ) staristically significant (though less strong) evidence that with household living standards held constant, neighborhood levels of poverty adversely affect health. the paper doses with a discussion of the implications of these findings for the targeting of health and poverty program interventions. p - (a) urban environment and the changing epidemiological surfacr. the cardiovascular ~ &om dorin, nigeria the emergence of cardiovascular diseases had been explained through the concomitants o_f the demographic transition wherein the prevalent causes of morbidity and monality ~hangr pr~mmant infectious diseases to diseases of lifestyle or chronic disease (see deck, ) . a ma or frustration m the v poster sessions case of cvd is its multifactural nature. it is acknowledged that the environment, however defined is the d · f · t' b tween agents and hosts such that chronic disease pathogenesis also reqmre a me an o mterac ion e . spatio-temporal coincidence of these two parties. what is not clear is which among ~ever~( potennal fac· · h b pace exacerbate cvd risk more· and to what extent does the ep dem olog cal trans · tors m t e ur an s ' . . . . tion h othesis relevant in the explanation of urban disease outlook even the developmg cities like nigeri~: thesis paper explorer these within a traditional city in nigeria. . . . the data for the study were obtained from two tertiary level hospitals m the metropolis for years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the data contain reported cases of cvd in the two facilities for the period. adopting a series of parametric and non-parametric statistics, we draw inferences between the observed cases of cvds and various demographic and locational variables of the patients. findings: about % of rhe cases occurred in years ( ) ( ) ( ) coinciding with the last year of military rule with great instability. . % occurred among male. . % also occurred among people aged - years. these are groups who are also likely to engage in most stressful life patterns. ~e study also shows that % of all cases occurred in the frontier wards with minor city areas also havmg their •fair' share. our result conformed with many empirical observation on the elusive nature of causation of cvd. this multifactoral nature had precluded the production of a map of hypertension that would be consistent with ideas of spatial prediction. cvd -cardiovascular diseases. mumbai is the commercial capital of india. as the hub of a rapidly transiting economy, mumbai provides an interesting case study into the health of urban populations in a developing country. with high-rise multimillion-dollar construction projects and crowded slums next to each other, mumbai presents a con· trast in development. there are a host of hi-tech hospitals which provide high quality care to the many who can afford it (including many westerners eager to jump the queue in their healthcare systems-'medical tour· ism'), at the same time there is a overcrowded and strained public healthcare system for those who cannot afford to pay. voluntary organizations are engaged in service provision as well as advocacy. the paper will outline role of the voluntary sector in the context of the development of the healthcare system in mumbai. mumbai has distinct upper, middle and lower economic classes, and the health needs and problems of all three have similarities and differences. these will be showcased, and the response of the healthcare system to these will be documented. a rising hiv prevalence rate, among the highest in india, is a challenge to the mumbai public healthcare system. the role of the voluntary sector in service provision, advocacy, and empowerment of local populations with regards to urban health has been paramount. the emergence of the voluntary sector as a major player in the puzzle of urban mumbai health, and it being visualized as voices of civil society or communiry representatives has advantages as well as pitfalls. this paper will be a unique attempt at examining urban health in india as a complex web of players. the influence of everyday socio·polirical-cultural and economic reality of the urban mumbai population will be a cross cutting theme in the analysis. the paper will thus help in filling a critical void in this context. the paper will thus map out issues of social justice, gender, equiry, effect of environment, through the lens of the role of the voluntary sector to construct a quilt of the realiry of healthcare in mumbai. the successes and failures of a long tradi· tion of the active advocacy and participation of the voluntary sector in trying to achieve social justice in the urban mumbai community will be analyzed. this will help in a better understanding of global urban health, and m how the voluntary sector/ngos fir into the larger picture. ba~und: o~er. half _of n~irobi's . million inhabitants live in illegal informal settlements that compose yo of the city s res dent al land area. the majority of slum residents lack access to proper san· iranon and a clean and adequate water supply. this research was designed to gain a clearer understand· mg of what kappr · · · h f . . opnate samtanon means or the urban poor, to determine the linkages between gender, hvehhoods, and access to water and sanitation, and to assess the ability of community sanitation blocks to meet water and sanitation needs in urban areas. m~tbojs_: _a household survey, gender specific focus groups and key informant interviews were conducted m maih saba, a peri-urban informal settlement. qualitative and quantitative research tools were u~ to asses~ the impact and effectiveness of community sanitation blocks in two informal settlements. results ropna e samtarmn me u es not only safe and clean latrines, but also provision ° adequate drainage and access to water supply for cleaning of clothes and homes. safety and cleanliness poster sessions v were priorities for women in latrines. levels of poverty within the informal settlements were identified and access to water and sanitation services improved with increased income. environmental health problems related to inadequate water and sanitation remain a problem for all residents. community sanitation blocks have improved the overall local environment and usage is far greater than envisioned in the design phase. women and children use the blocks less than men. this is a result of financial, social, and safety constraints. the results highlight the importance a need to expand participatory approaches for the design of water and sanitation interventions for the urban poor. plans need to recognize "appropriate sanitation" goes beyond provision of latrines and gender and socioeconomic differences must be taken into account. lessons and resources from pilot projects must be learned from, shared and leveraged so that solutions can be scaled up. underlying all the challenges facing improving water and sanitation for the urban poor are issues of land tenure. p - (c) integrating tqm (total quality management), good governance and social mobilization principles in health promotion leadership training programmes for new urban settings in countries/ areas: the prolead experience susan mercado, faren abdelaziz, and dorjursen bayarsaikhan introduction: globalization and urbanization have resulted in "new urban settings" characterized by a radical process of change with positive and negative effects, increased inequities, greater environmental impacts, expanding metropolitan areas and fast-growing slums and vulnerable populations. the key role of municipal health governance in mitigating and modulating these processes cannot be overemphasized. new and more effective ways of working with a wide variety of stakeholders is an underpinning theme for good governance in new urban settings. in relation to this, organizing and sustaining infrastructure and financing to promote health in cities through better governance is of paramount importance. there is a wealth of information on how health promotion can be enhanced in cities. despite this, appropriate capacity building programmes to enable municipal players to effectively respond to the challenges and impacts on health of globalization, urbanization and increasing inequity in new urban settings are deficient. the who kobe centre, (funded by the kobe group( and in collaboration with regional offices (emro, searo, wpro) with initial support from the japan voluntary contribution, developed a health promotion leadership training programme called "prolead" that focuses on new and autonomous structures and sustainable financing for health promotion in the context of new urban settings. methodology: country and/or city-level teams from areas, (china, fiji, india, japan, lebanon, malaysia, mongolia, oman, philippines, republic of korea, tonga and viet nam) worked on projects to advance health promotion infrastructure and financing in their areas over a month period. tools were provided to integrate principles of total quality management, good governance and social mobili .ation. results: six countries/areas have commenced projects on earmarking of tobacco and alcohol taxes for health, moblization of sports and arts organizations, integration of health promotion and social health insurance, organizational reforms, training in advocacy and lobbying, private sector and corporate mobilization and community mobilization. results from the other six areas will be reported in ..;obcr. conclusions: total quality management, good governance and social mobilization principles and skills are useful and relevant for helping municipal teams focus on strategic interventions to address complex and overwhelming determinants of health at the municipal level. the prolead training programmes hopes to inform other processes for building health promotion leadership capacity for new urban settings. the impact of city living and urbanization on the health of citizens in developing countries has received increasing attention in recent years. urban areas contribute largely to national economies. however, rapid and unplanned urban growth is often associated with poverty, environmental degradation and population demands that outstrip service capacity which conditions place human health at risk. local and national governments as well as multi national organizations are all grappling with the challenges of urbanization. with limited data and information available, urban health characteristics, including the types, quantities, locations and sources in kampala, are largely unknown. moreover, there is n? basis for assessing the impact of the resultant initiatives to improve health ~onditions amo~g ~o": ": um ties settled in unplanned areas. since urban areas are more than the aggregation ?f ~?pie w~th md_ v dual risk factors and health care needs, this paper argues that factors beyond the md v dual, mcludmg the poster sessions v · i d h · i · ment and systems of health and social services are determinants of the health soc a an p ys ca environ . of urban populations. however, as part of an ongoing study? ~s pape~ .addresses the basic concerns of urban health in kampala city. while applying the "urban hvmg conditions and the urban heal~ pen· alty" frameworks, this paper use aggregated urban health d~ta t~ explore the role of place an~ st tu· tions in shaping health and well-being of the population m kampala by understanding how characteristics of the urban environment and specific features of the city are causally related to health of invisible and forgotten urban poor population: results i~dica~e that a .range o~ urb~n he~l~h hazards m the city of kampala include substandard housing, crowdmg, mdoor air poll.ut on, msuff c ent a~d con· taminated water, inadequate sanitation and solid waste management services, vector borne .diseases, industrial waste increased motor vehicle traffic among others. the impact of these on the envtronment and community.health are mutually reinforcing. arising out of the withdra"'.al of city pl~nning systems and service delivery systems or just planning failure, thousands of people part cularl~ low-mc~me groups have been pushed to the most undesirable sections of the city where they are faced with ~ va_r ety ~f envj· ronmental insults. the number of initiatives to improve urban health is, however, growing mvolvjng the interaction of many sectors (health, environment, housing, energy, transportation and urban planning) and stakeholders (local government, non governmental organizations, aid donors and local community groups). key words: urban health governance, health risks, kampala. introduction: the viability of urban communities is dependent upon reliable and affordable mass transit. in particular, subway systems play an especially important role in the mass transit network, since they provide service to vast numbers of ridersseven of the subway systems worldwide report over one billion passenger rides each year. surprisingly, given the large number of people potentially affected, very little is known about the health and safety hazards that could affect both passengers and transit workers; these include physical (e.g., noise, vibration, accidents, electrified sources, temperature extremes), biological (e.g., transmission of infectious diseases, either through person-to-person spread or vector-borne, for example, through rodents), chemical (e.g., exposure to toxic and irritant chemicals and metals, gas emissions, fumes), electro-magnetic radiation, and psychosocial (e.g., violence, workstress). more recently, we need to consider the threat of terrorism, which could take the form of a mass casualty event (e.g., resulting from conventional incendiary devices), radiological attack (e.g., "dirty bomb"), chemical terrorist attack (e.g., sarin gas), or bioterrorist attack (e.g., weapons grade anthrax). given the large number of riders and workers potentially at risk, the public health implications are considerable. methods: to assess the hazards associated with subways, a structured review of the (english) litera· ture was conducted. ruults: based on our review, non-violent crime, followed by accidents, and violent crimes are most prevalent. compared to all other forms of mass transit, subways present greater health and safety risks. however, the rate of subway associated fatalities is much lower than the fatality rate associated with automobile travel ( . vs. . per million passenger miles), and cities with high subway ridership rates have a % lower per capita rate of transportation related fatalities than low ridership cities ( . versus . annual deaths per , residents). available data also suggest that subway noise levels and levels of air pollutants may exceed recommended levels. . ~: there is a paucity of published research examining the health and safety hazards associated with subways. most of the available data came from government agencies, who rely on passively reported data. research is warranted on this topic for a number of reasons, not only to address important knowled~ gaps, but also because the population at potential risk is large. importantly, from an urban perspecnve, the benefits of mass transit are optimized by high ridership ratesand these could be adversely affu:ted by unsafe conditions and health and safety concerns. veena joshi, jeremy lim. and benjamin chua ~ ~rban health issues have moved beyond infectious diseases and now centre largely on chrome diseases. diabetes is one of the most prevalent non-communicable diseases globally. % of adult ¥ benefit in providing splash pads in more parks. given the high temperature and humidity of london summers, this is an important aspect and asset of parks. interviewed parents claimed to visit city parks anywhere between to days per week. corrduion: given that the vast majority of canadian children are insufficiently active to gain health benefits, identifying effective qualities of local parks, that may support and foster physical activity is essential. strategies to promote activity within children's environments are an important health initiative. the results from this study have implications for city planners and policy makers; parents' opinions of, and use of city parks provides feedback as to the state current local parks, and modifications that should be made for new ones being developed. this study may also provide important feedback for health promoters trying to advocate for physical activity among children. introdt clion: a rapidly increasing proportion of urban dwellers in africa live below the poverty line in overcrowded slums characterized by uncollected garbage, unsafe water, and deficient sanitation and overflowing sewers. this growth of urban poverty challenges the commonly held assumption that urban populations enjoy better health than their rural counterparts. the objectives of this study are (i) to compare the vaccination status, and morbidity and mortality outcomes among children in the slums of nairobi with rural kenya, and (ii) to examine the factors associated with poor child health in the slums. we use data from demographic and health survey representative of all slum settlements in nairobi city carried out in by the african population & health research center. a total of , women aged - from , households were interviewed. our sample consists of , children aged - months. the comparison data are from the kenya demographic and health survey. the outcomes of interest include child vaccination status, morbidity (diarrhea, fever and cough) and mortality, all dichotomized. socioeconomic, environmental, demographic, and behavioral factors, as well as child and mother characteristics, are included in the multivariate analyses. multilevel logistic regression models are used. l'nlimin ry rest lts: about % of children in the slums had diarrhea in the two weeks prior to the survey, compared to % of rural children. these disparities between the urban poor anj the rural residents are also observed for fever ( % against %), cough ( % versus %), infant mortality ( / against / ), and complete vaccination ( % against %). preliminary multivariate results indicate that health service utilization and maternal education have the strongest predictive power on child morbidity and mortality in the slums, and that household wealth has only minor, statistically insignificant effects. conclruion: the superiority of health of urban children, compared with their rural counterparts, masks significant disparities within urban areas. compared to rural residents, children of slum dwellers in nairobi are sicker, are less likely to utilize health services when sick, and stand greater risk to die. our results suggest policies and programs contributing to the attainment of the millennium development goal on child health should pay particular attention to the urban poor. the insignificance of socioeconomic status suggests that poor health outcomes in these communities are compounded by poor environmental sanitation and behavioral factors that could partly be improved through female education and behavior change communication. introduction: historic trade city surat with its industrial and political peace has remained a center of attraction for people from all the comers of india resulting in to pop.ulatio~ explosio~ a~d stressed social and service infrastructure. the topography,dimate and demographic profile of the city s threat to the healthy environment. aim of this analysis is to review the impact of managemt'nt reform on health indicators. method: this paper is an analysis of the changing profile of population, sanitary infr~s~rucrure, local self government management and public health service reform, secondary health stat st cs data, health indicator and process monitoring of years. . . health of entire city and challenge to the management system. plague outbr~ak ( ) was the turning point in the history of civic service management including p~blic ~e~lth service management. ~ocal self government management system was revitalized by reg~lar_ field v s ts o~ al~ cadre~, _decentraltzanon of power and responsibility, equity, regular vigilant momtormg, commumcanon facility, ream_approach and people participation. reform in public health service management was throu_gh stan~~rd zed intervention protocol, innovative intervention, public private partnership, community part c panon, academic and service institute collaboration and research. sanitation service coverage have reached nearer to universal. area covered by safe water supply reached to %( ) from % ( ) and underground drainage to % ( ) from % ( ) the overhauling of the system have reflected on health indicators of vector and water born disease. malaria spr declined to . ( ) from . 'yo(! ) and diarrhea case report declined to ( ) from ( ). except dengue fever in no major disease outbreaks are reported after . city is recipient of international/national awards/ranking for these achievements. the health department have developed an evidence and experience based intervention and monitoring system and protocol for routine as well as disaster situation. the health service and management structure of surat city have emerged as an urban health model for the country. introduction: the center for healthy communities (chc) in the department of family and com· munity medicine at the medical college of wisconsin developed a pilot project to: ) assess the know· ledge, attitudes, and behaviors of female milwaukee public housing residents related to breast cancer; develop culturally and literacy appropriate education and screening modules; ) implement the developed modules; ) evaluate the modules; and ) provide follow-up services. using a community-based participatory research model the chc worked collaboratively with on-site nurse case management to meet these objectives. methods: a "breast health kick off event" was held at four separate milwaukee public housing sites for elderly and disabled adults. female residents were invited to complete a -item breast health survey, designed to accommodate various literacy levels. responses were anonymous and voluntary. the survey asked women about their previous physical exams for breast health, and then presented a series of state· ments about breast cancer to determine any existing myths. the final part gathered information about personal risk for breast cancer, the highest level of education completed, and whether the respondents h;td ever used hormone replacement therapy and/or consumed alcohol. responses were collected for descriptive analysis. results: a total of surveys (representing % of the total female population in the four sites) were completed and analyzed. % reported that they had a physical exam in the previous rwo years. % of respondents indicated they never had been diagnosed with breast cancer. % reported having had a mammogram and % having had a clinical breast exam. those that never had a mammogram reported a fear of what the provider would discover or there were not any current breast problems ro warrant an exam. % agreed that finding breast cancer early could lower the chance of dying of cancer. over % reported that mammograms were helpful in finding cancer. however, % believed that hav· ing a mammogram actually prevents breast cancer. % indicated that mammograms actually cause cancer and % reported that a woman should get a mammogram only if there is breast cancer in her family. conclusion: this survey indicates that current information about the importance of mammograms and clinical breast exams is reaching traditionally underserved women. yet there are still critical oppor· tunities to provide valuable education on breast health. this pilot study can serve as a tool for shaping future studies of health education messages for underserved populations. located in a yourh serv· ~ng agency m downtow~ ottawa, the clinic brings together community partners to provide primary medical care. and dent~i hygiene t? the street youths of ottawa aged - . the primary goal of the project is to provide accessible, coordinated, comprehensive health and dental care to vulnerable adolescents. these efforts respond to the pre-existing body of evidence suggesting that the principle barrier in accessing such care for these youths are feelings of intimidation and vulnerability in the face of a complex healthcare system. the bruyere fhn satellite clinic is located in the basement of a downtown drop-in and brings together a family medicine physician and her residents, a dental hygienist and her nd year students, a nurse practitioner, a chiropodist and public health nurses to provide primary care. the clinic has been extremely busy and well received by the youth. this workshop will demonstrate how five community organizations have come together to meet the needs of high risk youths in ottawa. this presentation will showcase the development of the clinic from its inception through its first year including reaction of the youths, partnerships and lessons learned. it will also focus on its sustainability without continued funding. we hope to have developed a model of service delivery that could be reproduced and sustained in other large cities with faculties of medicine. methods: non-randomized, mixed method design involving a process and impact evaluation. data collection-qualitative-a) semi structured interviews with providers & partners b)focus groups with youth quantitative a)electronic medical records for months records (budget, photos, project information). results: ) successfully built and opened a medicaudental clinic which will celebrate its year anniversary in august. ) over youths have been seen, and we have had over visits. conclusion: ) the clinic will continue to operate beyond the month project funding. ) the health of high risk youth in ottawa will continue to improve due to increased access to medical services. p - (a) health services -for the citizens of bangalore -past, present and future savita sathyagala, girish rao, thandavamurthy shetty, and subhash chandra bangalore city, the capital of karnataka with . million is the th most populous city in india; supporting % of the urban population of karnataka, it is considered as one of the fastest growing cities in india. known as the 'silicon valley of india', bangalore is nearly years old. bangalore city corporation (bmp), is a local self government and has the statutory commitment to provide to the citizens of bangalore: good roads, sanitation, street lighting, safe drinking water apart from other social obligations, cultural development and poverty alleviation activities. providing preventive and promotive heahh services is also a specific component. the objective of this study was to review the planning process with respect to health care services in the period since india independence; the specific research questions being what has been the strategies adopted by the city planners to address to the growing needs of the population amidst the background of the different strategies adopted by the country as a whole. three broad rime ranges have been considered for analysis: the s, s and the s. the salient results are: major area of focus has been on the maternal and child care with activities ranging from day-care to in-patient-care; though the number of institutions have grown from to the current day , their distribution has been far from satisfactory; obtaining support from the india population projects and major upgradarions have been undertaken in terms of infrastructure; over the years, in addition to the dispensaries of modern system of medicine, local traditional systems have also been initiated; the city has partnered with the healthy cities campaign with mixed success; disease surveillance, addressing the problems related to the emerging non-communicable diseases including mental health and road traffic injuries are still in its infancy. isolated attempts have been made to address the risks groups of elderly care and adolescent care. what stands out remarkably amongst the cities achievements is its ability to elicit participation from ngos, cbos and neighbourhood groups. however, the harnessing of this ability into the health sector cannot be said totally successful. the moot question in all the above observed development are: has the city rationally addressed it planning needs? the progress made so far can be considered as stuttered. the analysis and its presentation would identify the key posirive elements in the growth of banglore city and spell a framework for the new public health. introduction: anaemia associated with pregnancy is a major public health problem all over the world. different studies in different parts of india shown prevalence of anaemia between - %. anaemia remains a serious health problem in pregnancy despite of strong action taken by the government of india through national programmes. in the present study we identified th~ social beha~iors, responsible for low compliance of if a tablets consumption in pregnancy at community level and intervention was given with new modified behaviors on trial bases. . in vadodara urban. anganwadies out of were selected from the list by random sampling for tips (trials of improved practices) study. . . participants: pregnant women ( , intervention group+ , control. group) registered m the above anganwadies. study was conducted in to three phases: phase: . formative research and baseline survey (frbs). data was collected from all pregnant women to identify behaviors that are responsible for low compliance of ifa tablets. both qualitative and quantitative data were collected. haemoglobin was estimated of all pregnant women by haemo-cue. phase: . phase of tips. behaviors were identified both social & clinical for low compliance of ifa tablets consumption in pregnancy from frbs and against those, modified behaviors were proposed to pregnant women in the intervention group on trial bases by health education. trial period of weeks was given for trial of new behaviors to pregnant women in the interven· tion group. phase: . in this phase, feedbacks on behaviors tried or not tried were taken from pregnant women in intervention group. haemoglobin estimation was carried out again in all pregnant women. at the end of the study, messages were formulated on the bases of feedbacks from the pregnant women. results: all pregnant women in the intervention group had given positive feedback on new modified behaviors after intervention. mean haemoglobin concentration was higher in intervention group ( . ± . gm%) than control group ( . ± . gm%). ifa tablets compliance was improved in intervention group ( . %) than control group ( . %). conclusion: all pregnant women got benefits after trial of new modified behaviors in the intervention group. messages were formulated from the new modified behaviors, which can be used for longterm strategies for anaemia control in the community. introduction: in order to develop a comprehensive mch handbook for pregnant women and to assess its effect among them, a pilot study was carried out at the maternal and child health training institute (mchti), in dhaka, bangladesh. methods: from mchti a sample of pregnant women was selected and all subjects were women who were attending the first visit of their current pregnancy by using a random sampling method. of the subjects, women were given the mch handbook as case and women were not given the handbook as control. data on pre and post intervention of the handbook from the cases and controls were taken from data recording forms between the st of november and st of october, and data was analysed by using a multilevel analysis approach. this was a hospital-based action (case-control) research, and was applied in order to measure the outcome of pre and post intervention following the introduction of the handbook. data was used to assess the effects of utilisation of the handbook on women's knowledge, practice and utilisation of mch services. results: this study showed that the change of knowledge about antenatal care visits was . % among case mothers. knowledge of danger signs improved . %, breast feeding results . %, vaccination . % and family planning results improved . % among case. results showed some positive changes in women's attitudes among case mothers and study showed the change of practice in antenatal care visits was .u. % in the case. other notable changes were: change of practice in case mother's tetanus toxoid (ti), . %; and family planning . %. in addition, handbook assessment study indicated that most women brought the handbook on subsequent visits ( . %), the handbook was highly utilised (i.e. it was read by . %, filled-in by . %, and was used as a health education tool by . %). most women kept the handbook ( . %) and found it highly useful ( . %) with a high client satisfaction rate of . %. conclusion: pregnant women in the case group had higher knowledge, better practices, and higher utilisation of mch services than mothers in the control groups who used alternative health cards. if the handbook is developed with a focus on utilising a problem-oriented approach and involving the recomendations .of end~users, it is anticipated that the mch handbook will contribute significantly to ensuring the quahry of hfe of women and their children in bangladesh. after several meetmgs to identify the needs of the community, a faso clinic was opened at ncfs. health care professionals from smh joined with developmental and social service workers from ncfs to implement the faso diagnostic process and to provide culturally appropriate after-care. the clinic is unique in that its focus is the high risk urban aboriginal population of toronto. it accepts referrals of not only children and youth, but also of adults. lessons learned: response to the faso clinic at native child and family services has been overwhelming. aboriginal children with f asd are receiving timely diagnosis and interventions. aboriginal youth and adults who have been struggling with poveny, substance abuse, and homelessness are more willing to enter the ncfs centre for diagnosis and treatment. aboriginal infants prenatally exposed to alcohol born at st. michael's hospital or referred by other centres have access to the developmental programs located in both of the partnering agencies. the presentation will describe the clinic's development, and will detail the outcomes described, including interventions unique to the aboriginal culture. p - (c) seeds, soil, and stories: an exploration of community gardening in southeast toronto carolin taran, sarah wakefield, jennifer reynolds, and fiona yeudall introduction: community gardens are increasingly seen as a mechanism for improving nutrition and increasing food security in urban neighbourhoods, but the evidence available to support these claims is limited. in order to begin to address this gap in a way that is respectful of community knowledge and needs, the urban gardening research opportunities workgroup (ugrow) project explored the benefits and potential risks of community gardening in southeast toronto. the project used a community-based research (cbr) model to assess community gardens as a means of improving local health. the research process included interviews, focus groups, and participant observation (documented in field notes). we also directly engaged the community in the research process, through co-learning activities and community events which allowed participants to express their views and comment on emerging results. most of the research was conducted by a community-based research associate, herself a community gardener. key results were derived from these various sources through line-by-line coding of interview transcripts and field note review, an interactive and iterative process which involved both academic and community partners. results: these various data sources all suggest that enhanced health and access to fresh produce are important components of the gardening experience. they also highlight the central importance of empowering and community-building aspects of gardening to gardeners. community gardens were thought to play a role in developing friendships and social support, sharing food and other resources, appreciating cultural diversity, learning together, enhancing local place attachment and stewardship, and mobilizing to solve local problems (both inside and outside the garden). potential challenges to community gardens as a mechanism for communiry development include bureaucratic resistance to gardens, insecure land tenure and access, concerns about soil contamination, and a lack of awareness and under· standing by community members and decision-makers of all kinds. conclusion: the results highlight many health and broader social benefits experienced by commu· nity gardeners. they also point to the need for greater support for community gardening programs, par· ticularly ongoing the ongoing provision of resources and education programs to support gardens in their many roles. this research project is supported by the wellesley central health corporation and the centre for urban health initiatives, a cihr funded centre for research development hased at the univer· sity of toronto. p - (c) developing resiliency in children living in disadvantaged neighbourhoods sarah farrell, lorna weigand, and wayne hammond the traditional idea of targeting risk reduction by focusing on the development of eff~ctive coping strategies and educational programs has merit in light of the research reportmg_ that_ ~ lupl.e forms of problem behaviour consistently appear to be predicted by increasing exposure to den_uf able risk factors. as a result, many of the disadvantaged child and youth studies have focused on trymg to better _unde.r· stand the multiple risk factors that increase the likelihood of the development of at nsk behaviour m ch ldren/youth and the potential implications for prevention. this in turn has led t_o. the conclus on that community and health programs need to focus on risk reduction by helpm~ md v duals develop more effective coping strategies and a better understanding of the limitations of cenam pathologies, problematic v poster sessions coping behaviours and risk factors potentially inheren~ in high needs co~unities. ~owever, another ai:ea of research has proposed that preventative interventions should cons de~ .~rotecnve fa~ors alo~~ with reducing risk factors. as opposed to just emphasizing problems, vulnerab ht es, and deficits, a res liencybased perspective holds the belief that children, youth and their families. have strengths, reso~ce.s and the ability to cope with significant adversity in ways that are not only effective, but tend to result m mcreased ability to constructively respond to future adversity. with this in mind, a participatory research project sponsored by the united way of greater toronto was initiated to evaluate and determine the resiliency profiles of children - years (n = ) of recent immigrant families living in significantly disadvantaged communities in the toronto area. the presentation will provide an overview of the identified protective factors (both intrinsic and extrinsic) and resiliency profiles in an aggregated format as well as a summary of how the children and their parents interpreted and explained these strength-based results. as part of the focus groups, current community programs and services were examined by the participants as to what might be best practices for supporting the development and maintaining of resiliency in children, families and communities. it was proposed that the community model of assessing resiliency and protective factors as well as proposed best strength-based practice could serve as a guide for all in the community sector who provide services and programs to those in disadvantaged neighbourhoods. p - (c) naloxone by prescription in san francisco, ca and new york, ny emalie huriaux the harm reduction coalition's overdose project works to reduce the number of fatal overdoses to zero. located in new york, ny and san francisco, ca, the overdose project provides overdose education for social service providers, single-room occupancy hotel (sro) residents, and syringe exchange participants. the project also conducts an innovative naloxone prescription program, providing naloxone, an opiate antagonist traditionally administered by paramedics to temporarily reverse the effects of opiate overdose, to injection drug users (idus). we will describe how naloxone distribution became a reality in new york and san francisco, how the project works, and our results. the naloxone prescription program utilizes multiple models to reach idus, including sro-and street-based trainings, and office-based trainings at syringe exchange sites. trainings include information on overdose prevention, recognition, and response. a clinician conducts a medical intake with participants and provides them with pre-filled units of naloxone. in new york, funding was initially provided by tides foundation. new york city council provides current funding. new york department of mental health and hygiene provides program oversight. while the new york project was initiated in june , over half the trainings have been since march . in san francisco, california endowment, tides foundation, and san francisco department of public health (sfdph) provide funding. in addition, sfdph purchases naloxone and provides clinicians who conduct medical intakes with participants. trainings have been conducted since november . to date, nearly individuals have been trained and provided with naloxone. approximately of them have returned for refills and reported that they used naloxone to reverse an opiate-related overdose. limited episodes of adverse effects have been reported, including vomiting, seizure, and "loss of friendship." in new york, individuals have been trained and provided with naloxone. over overdose reversals have been reported. over half of the participants in new york have been trained in the south bronx, the area of new york with the highest rate of overdose fatalities. in san francisco, individuals have been trained and provided with naloxone. over overdose reversals have been reported. the majority of the participants in san francisco have been trained in the tenderloin, th street corridor, and mission, areas with the highest rates of overdose fatalities. the experience of the overdose project in both cities indicates that providing idus low-threshold access to naloxone and overdose information is a cost-effective, efficient, and safe intervention to prevent accidental death in this population. p - (c) successful strategies to regulate nuisance liquor stores using community mobilization, law enforcement, city council, merchants and researchers tahra goraya presenta~ion _will discuss ~uccessful environmental and public policy strategies employed in one southen: cahf?rmna commumty to remedy problems associated with nuisance liquor stores. participants ~ be given tools to understand the importance of utilizing various substance abuse prevention str~tegi~ to change local policies and the importance of involving various sectors in the community to a~_ st with and advocate for community-wide policy changes. recent policy successes from the commultles of pa~ad~na and altad~na will highlight the collaborative process by which the community mobilized resulnng m several ordmances, how local law enforcement was given more authority to monitor poster sessions v nonconforming liquor stores, how collaborative efforts with liquor store owners helped to remove high alcohol content alcohol products from their establishments and how a community-based organiz,uion worked with local legislators to introduce statewide legislation regarding the regulation of nuisance liquor outlets. p - (c) "dialogue on sex and life": a reliable health promotion tool among street-involved youth beth hayhoe and tracey methven introduction: street involved youth are a marginalized population that participate in extremely risky behaviours and have multiple health issues. unfortunately, because of previous abuses and negative experiences, they also have an extreme distrust of the adults who could help them. in , toronto public health granted funding to a non governmental, nor for profit drop-in centre for street youth aged - , to educate them about how to decrease rhe risk of acquiring hiv. since then the funding has been renewed yearly and the program has evolved as needed in order to target the maximum number of youth and provide them with vital information in a candid and enjoyable atmosphere. methods: using a retrospective analysis of the six years of data gathered from the "dialogue on sex and life" program, the researchers examined the number of youth involved, the kinds of things discussed, and the number of youth trained as peer leaders. also reviewed, was written feedback from the weekly logs, and anecdotal outcomes noted by the facilitators and other staff in the organization. results: over the five year period of this program, many of youth have participated in one hour sessions of candid discussion regarding a wide range of topics including sexual health, drug use, harm reduction, relationship issues, parenting, street culture, safety and life skills. many were new youth who had not participated in the program before and were often new to the street. some of the youth were given specific training regarding facilitation skills, sexual anatomy and physiology, birth control, sexually transmitted infections, hiv, substance use/abuse, harm reduction, relationships and discussion of their next steps/future plans following completion of the training. feedback has been overwhelmingly positive and stories of life changing decisions have been reported. conclusion: clearly, this program is a successful tool to reach street involved youth who may otherwise be wary of adults and their beliefs. based on data from the evaluation, recommendations have been made to public health to expand the funding and the training for peer leaders in order ro target between - new youth per year, increase the total numbers of youth reached and to increase the level of knowledge among the peer leaders. p - (c) access to identification and services jane kali replacing identification has become increasingly more complex as rhe government identification issuing offices introduce new requirements rhar create significant barriers for homeless people to replace their id. new forms of identification have also been introduced that art' not accessible to homekss peoplt-(e.g. the permanent resident card). ar rhe same time, many service providers continue to require identifi· cation ro access supports such as income, housing, food, health care, employment and employmt·nt training programs. street health, as well as a number of other agencies and community health centres, h, , been assisting with identification replacement for homeless peoplt· for a number of years. the rnrrt·nr challenges inherent within new replacement requirements, as well as the introduction of new forn ' of identification, have resulted in further barriers homeless people encounter when rrring to access t:ssential services. street health has been highlighting these issues to government identification issuing offices, as well as policy makers, in an effort to ensure rhar people who are homeless and marginalized have ac'ess to needed essential services. bandar is a somali word for •·a safe place." the bandar research project is the product of the regent park community health centre. the research looks ar the increasing number of somali and afri· can men in the homeless and precariously house population in the inner city core of down~own toronto. in the first phase of the pilot project, a needs assessment was conducted to dennfy barners and issues faced by rhe somali and other african men who are homeless and have add cr ns issues. th_e second phase of rhe research project was to identify long rerm resources and service delivery mechamsms that v poster sessions would enhance the abiity of this population to better access detox, treatment, and post treatment ser· vices. the final phase of the project was to facilitate the development of a conceptual model of seamless continual services and supports from the streets to detox to treatment to long term rehabilitation to housing. "between the pestle and mortar" -safe place. p - (c) successful methods for studying transient populations while improving public health beth hayhoe, ruth ewert, eileen mcmahon, and dan jang introduction: street youth are a group that do not regularly access healthcare because of their mis· trust of adults. when they do access health care, it is usually for issues severe enough for hospitalization or for episodic care in community clinics. health promotion and illness prevention is rarely a part of their thinking. thus, standard public health measures implemented in a more stable population do not work in this group. for example, pap tests, which have dearly been shown to decrease prevalence of cer· vical cancer, are rarely done and when they are, rarely followed up. methods to meet the health care needs and increase the health of this population are frequently being sought. methods: a drop-in centre for street youth in canada has participated in several studies investigating sexual health in both men and women. we required the sponsoring agencies to pay the youth for their rime, even though the testing they were undergoing was necessary according to public health stan· dards. we surmised that this would increase both initial participation and return. results: many results requiring intervention have been detected. given the transient nature of this population, return rates have been encouraging so far. conclusion: it seems evident that even a small incentive for this population increases participation in needed health examinations and studies. it is possible that matching the initial and follow-up incentives would increase the return rate even further. the fact that the youth were recruited on site, and not from any external advertising, indicates that studies done where youth trust the staff, are more likely to be successful. the presentation will share the results of the "empowering stroke prevention project" which incor· porated self-help mutual aids strategies as a health promotion methodology. the presentation will include project's theoretical basis, methodology, outcomes and evaluation results. self-help methodology has proven successful in consumer involvement and behaviour modification in "at risk," "marginalized" settings. self-help is a process of learning with and from each other which provides participants oppor· tunities for support in dealing with a problem, issue, condition or need. self-help groups are mechanisms for the participants to investigate existing solutions and discover alternatives, empowering themselves in this process. learning dynamic in self-help groups is similar to that of cooperative learning and peertraining, has proven successful, effective and efficient (haller et al, ) . the mutual support provided by participation in these groups is documented as contributory factor in the improved health of those involved. cognizant of the above theoretical basis, in the self-help resource centre initiated the "empowering stroke prevention project." the project was implemented after the input from health organizations, a scan of more than resources and an in-depth analysis of risk-factor-specific stroke prevention materials indicated the need for such a program. the project objectives were:• to develop a holistic and empowering health promotion model for stroke prevention that incorporates selfhelp and peer support strategies. • to develop educational materials that place modifiable risk factors and lifestyle information in a relevant context that validates project participants' life experiences and perspectives.• to educate members of at-risk communities about the modifiable risk factors associated with stroke, and promote healthy living. to achieve the above, a diverse group of community members were engaged as "co-editors" in the development of stroke prevention education materials which reflected and validated their life experiences. these community members received training to become lay health promoters (trained volunteer peer facilitators). in collaboration with local health organizations, these trained lay health promoters were then supported in organizing their own community-based stroke prevention activities. in addition, an educational booklet written in plain language, entitled healthy ways to prevent stroke: a guide for you, and a companion guide called healthy ways to pre· vent stroke: a facilitator's guide were produced. the presentation will include the results of a tw<>tiered evaluation of the program methodology, educational materials and the use of the materials beyond the life of the project. this poster presentation will focus on the development and structure of an innovative street outreach service that assists individuals who struggle mental illness/addictions and are experiencing homelessness. the mental health/outreach team at public health and community services (phcs) of hamilton, ontario assists individuals in reconnecting with health and social services. each worker brings to the ream his or her own skills-set, rendering it extremely effective at addressing the multidimensional and complex needs of clients. using a capacity building framework, each ream member is employed under a service contract between public health and community services and a local grassroots agency. there are public health nurses (phn), two of whom run a street health centre and one of canada's oldest and most successful needle exchange programs, mental health workers, housing specialists, a harm reduction worker, youth workers, and a united church minister, to name a few. a community advisory board, composed of consumers and professionals, advises the program quarterly. the program is featured on raising the roors 'shared learnings on homelessness' website at www.sharedlearnings.ca. through our poster presentation participants will learn how to create effective partnerships between government and grassroots agencies using a capacity building model that builds on existing programs. this study aims to assess the effects of broadcasting a series of documentary and drama videos, intended to provide information about the bc healthguide program in farsi, on the awareness about and the patterns of the service usage among farsi-speaking communities in the greater vancouver area. the major goals of the present study were twofold; ( ) to compare two methods of communications (direct vs. indirect messages) on the attitudes and perceptions of the viewers regarding the credibility of messengers and the relevance of the information provided in the videos, and ( ) to compare and contrast the impact of providing health information (i.e., the produced videos) via local tvs with the same materials when presented in group sessions (using vcr) on participants' attitudes and perceptions cowards the bc healrhguide services. results: through a telephone survey, farsi-speaking adults were interviewed in november and december . the preliminary findings show that % of the participants had seen the aired videos, from which, % watched at least one of the 'drama' clips, % watched only 'documentary' clip, and % watched both types of video. in addition, % of the respondents claimed that they were aware about the program before watching the aired videos, while % said they leaned about the services only after watching the videos. from this group, % said they called the bchg for their own or their "hildren's health problems in the past month. % also indicated that they would use the services in the future whenever it would be needed. % considered the videos as "very good" and thought they rnuld deliver relevant messages and % expressed their wish to increase the variety of subjects (produ\:e more videos) and increase the frequency of video dips. conclusion: the results of this study will assist public health specialists in bc who want to choose the best medium for disseminating information and apply communication interventions in multi\:ultural communities. introduction: many theorists and practitioners in community-based research (cbr) and knowledge transfer (kt) strongly advocate for involvement of potential users of research in the development of research projects, yet few examples of such involvement exist for urban workplace health interventions. we describe the process of developing a collaborative research program. methods: four different sets of stakeholders were identified as potential contributors to and users of the research: workplace health policy makers, employers, trade unions, and health and safety associations. representatives of these stakeholders formed an advisory committee which met quarterly. over the month research development period, an additional meetings were held between resc:ar~h~rs and stakeholders. in keeping with participant observation approaches, field notes of group and md v ~ ual meetings were kept by the two co-authors. emails and telephone calls were also documented. qu~h tative approaches to textual analysis were used, with particular attention paid to collaborattve v poster sessions relationships established (as per cbr), indicators of stakeholders' knowledge utilization (as per kt), and transformations of the proposed research (as per cbr). results: despite initial strong differences of opinion both among stakeho~ders .an~ between stakeholders and researchers, goodwill was noted among all involved. acts of rec~proc ty included mu.rual sharing of assessment tools, guidance on data utilization to stakeho~der orga~ zat ns, and suggestions on workplace recruitment to researchers. stakeholders demonstrated mcreases m concep~ual. un~erstand ing of workplace health e.g. they more commonly discussed more complex,. psychosocial md cators of organizational health. stakeholders made instrumental use of shared materials based on research e.g. adapting their consulting model to more sophisticated dat~ analysis. sta~ehol?~rs recogni_zed the strategic use of their alliance with researchers e.g., transformational leadership trainmg as a~ inducement to improve health and safety among small service franchises. stakeholders helped re-define the research questions, dramatically changed the method of recruitment from researcher cold call to stakeholderbased recruitment, and strongly influenced pilot research designs. owing a great deal to the elaborate joint development process, the four collaboratively developed pilot project submissions which were all successfully funded. conclusion: the intensive process of collaborative development of a research program among stakeholders and researchers was not a smooth process and was time consuming. nevertheless, the result of the collaborative process was a set of projects that were more responsive to stakeholder needs, more feasible for implementation, and more broadly applicable to relevant workplace health problems. introduction: environmental groups, municipal public health authorities and, increasingly, the general public are advocating for reductions in pesticide use in urban areas, primarily because of concern around potential adverse health impacts in vulnerable populations. however, limited evidence of the relative merits of different intervention strategies in different contexts exists. in a pilot research project, we sought to explore the options for evaluating pesticide reduction interventions across ontario municipalities. methods: the project team and a multi-stakeholder project advisory committee (pac), generated a list of potential key informants (kl) and an open ended interview guide. thirteen ki from municipal government, industry, health care, and environmental organizations completed face to face or telephone interviews lasting - minutes. in a parallel process, a workshop involving similar representatives and health researchers was held to discuss the role of pesticide exposure monitoring. minutes from pac meetings, field notes taken during ki interviews, and workshop proceedings were synthesized to generate potential evaluation methods and indicators. results: current evaluation activities were limited but all kls supported greater evaluation effons beginning with fuller indicator monitoring. indicators of education and outreach services were imponant for industry representatives changing applicator practices as well as most public health units and environmental organizations. lndictors based on bylaw enforcement were only applicable in the two cities with bylaws, though changing attitudes toward legal approaches were being assessed in many communities. the public health rapid risk factor surveillance system could use historical baseline data to assess changes in community behaviour through reported pesticide uses and practices, though it had limited penetration in immigrant communities not comfortable in english. pesticide sales (economic) data were only available in regional aggregates not useful for city specific change documentation. testing for watercourse or environmental contamination might be helpful, but it is sporadic and expensive. human exposure monitoring was fraught with ethical issues, floor effects from low levels of exposure, and prohibitive costs. clinical episodes of pesticide exposure reported to the regional poison centre (all ages) or the mother risk program (pregnant or breastfeeding women) are likely substantial underestimates that would be need to be supplemented with sentinel practice surveillance. focus on special clinical populations e.g., multiple chemical sensitivity would require additional data collection efforts . . conc~ons: broad support for evaluation and multiple indicators were proposed, though con-s~raints associate~ with access, coverage, sensitivity and feasibility were all raised, demonstrating the difficulty of evaluating such urban primary prevention initiatives. interventionists. an important aim of the youth monitor is to learn more about the health development of children and adolescents and the factors that can influence this development. special attention is paid to emo· tional and behavioural problems. the youth monitor identifies high-risk groups and factors that are associated with health problems. at various stages, the youth monitor chancrs the course of life of a child. the sources of informa· tion and methods of research are different for each age group. the results arc used to generate various kinds of repons: for children and young persons, parents, schools, neighbourhoods, boroughs and the municipality of rotterdam and its environs. any problems can be spotted early, at borough and neigh· bourhood level, based on the type of school or among the young persons and children themselves. together with schools, parents, youngsters and various organisations in the area, the municipal health service aims to really address these problems. on request, an overview is offered of potentially suitable interventions. the authors will present the philosophy, working method, preliminary effects and future developments of this instrument, which serves as the backbone for the rotterdam local youth policy. social workers to be leaders in response to aging urban populations: the practicum partnership program sarah sisco, alissa yarkony, and patricia volland "'" tliu:tion: across the us, . % of those over live in urban areas. these aging urban popu· lations, including the baby boomers, have already begun encounter a range of heahh and mental hcahh conditions. to compound these effects, health and social service delivery fluciuates in cities, whit:h arc increasingly diverse both in their recipients and their systems. common to other disciplines (medicine, nursing, psychology, etc.) the social work profession faces a shortage of workers who are well-equipped to navigate the many systems, services, and requisite care that this vast population requires. in the next two decades, it is projected that nearly , social workers will be required to provide suppon to our older urban populations. social workers must be prepared to be aging-savvy leaders in their field, whether they specialize in gerontology or work across the life span. mllhotu: in , a study conducted at the new york academy of medicine d<> :umcntcd the need for improved synchroniciry in two aspects of social work education, classroom instruction and the field experience. with suppon from the john a. hanford foundation, our team created a pilot proj~"t entitled the practicum pannership program (ppp) in master's level schools of social work, to improvt" aginr exposure in field and classroom content through use of the following: i) community-university partnrr· ships, ) increased, diverse student field rotations, ll infusion of competcn ."}'·drivm coursework, enhancement of field instructors' roles, and ) concentrated student recruitment. we conductt"d a prr· and post-test survey into students' knowledge, skills. and satisfaction. icarlja: surveys of over graduates and field inltnk."tors rcflected increased numlk-n of . rrm:y· univmity panncrships, as well as in students placed in aging agencin for field placements. there wa marked increase in student commitments to an aging specialization. onr year por.t·gradu:nion rcvealrd that % of those surveyed were gainfully employed, with % employed in the field of aginic. by com· bining curricular enhancement with real-world experiences the ppp instilled a broad exposurr for llu· dents who worked with aging populations in multiple urban settings. coltdtuion: increased exposure to a range of levels of practicr, including clinical, policy/ajvocaq, and community-based can potentially improve service delivery for older adulh who live in elfin, and potentially improve national policy. the hanford foundation has now elected to uppon cxpantion of the ppp to schools nationwide (urban and rural) to complement other domntic initiatives to cnhalk"c" holistic services for older adults across the aging spectrum. bodrgnn.ntl: we arc a team of rcscarcbcn and community panncn working tcj c(her to develop an in"itepth understanding of the mental health needs of homeless youth ~ages to ) (using qualiutivc and quantitative methods ' panicipatory rncarch methods). it is readily apparmt that '-neless youth cxpcricnce a range of mental health problems. for youth living on the street, menul illnew may be either a major risk factor for homelessnal or may frequently emcsge in response to coping with rhe multitudinous stressors associated with homclcslllcsi including exposure to violence, prasutt to pamaplte in v poster sessions survival sex and/or drug use. the most frequent psychiatric diagnoses amongst the homeless gencrally include: depression, anxiety and psychosis. . . . the ultimate ob ective of the pr~am of rei:e~ is to ~evelop a plan for intervention to meet the mental health needs of street youth. prior t_o pl~nnmg mtervenbons, .it is necessary to undertake a comprehensive assessment ~f mental health needs m this ~lnerable populanon. thus, the immediate objective of this research study is to undertake a comprehensive assessment of men· tal health needs. . . melbotlology: a mixed methodology triangulating qualitative, participatory acnon and quantitative methods will capture the data related to mental health needs of homeless youth. a purposive sample of approximately - subjecrs. ages to , is currently being ~ted ~participate from the commu.nity agencies covenant house, evergreen centre fo~ srrc;et youth, turning p? ?t and street ~ serv~. youth living on the street or in short -term residennal programs for a mmimum of month pnor to their participation; ages to and able to give infonned consent will be invited to participate in the study. o..tcomes: the expected outcome of this initial survey will be an increased understanding of mental health needs of street youth that will be used to develop effective interventions. it is anticipated that results from this study will contribute to the development of mental health policy, as well as future programs that are relevant to the mental health needs of street youth. note: it is anticipated that preliminary quantitative data ( subjects) and qualitative data will be available for the conference. the authors intend to present the identification of the research focus, the formation of our community-based team, relevance for policy, as well as preliminary results. p - (a) the need for developing a firm health policy for urban informal worken: the case of despite their critical role in producing food for urban in kenya, urban farmers have largely been ignored by government planners and policymakers. their activity is at best dismissed as peripheral eveo, inappropriate retention of peasant culture in cities and at worst illegal and often some-times criminal· ized. urban agriculture is also condemned for its presumed negative health impact. a myth that contin· ues despite proof to the contrary is that malarial mosquitoes breed in maize grown in east african towns. however, potential health risks are insignificant compared with the benefits of urban food production. recent studies too rightly do point to the commercial value of food produced in the urban area while underscoring the importance of urban farming as a survival strategy among the urban poor, especially women-headed households. since the millennium declaration, health has emerged as one of the most serious casualties consequent on the poverty, social exclusion, marginalisation and lack of sustain· able development in africa. hiv/aids epidemic poses an unprecedented challenge, while malaria, tuber· culosis, communicable diseases of childhood all add to the untenable burden. malnutrition underpins much ill-health and is linked to more than per cent of all childhood deaths. kenya's urban poor people ~ace ~ h~ge burde~ of preventable and treatable health problems, measured by any social and bi~ medical md cator, which not only cause unnecessary death and suffering, but also undermine econonuc development and damage the country's social fabric. the burden is in spite of the availability of suitable tools and re:c=hnology for prevention and treatment and is largely rooted in poverty and in weak healah •rstems. this pa~ therefore challenges development planners who perceive a dichotomy instead of con· tmuum between informal and formal urban wage earners in so far as access to health services is con· cemed. it i~ this gap that calls for a need to developing and building sustainable health systems among the urban mformal ~wellers. we recommend a focus on an urban health policy that can build and strengthen the capacity of urban dwellers to access health services that is cost-effective and sustainable. such ~ health poli<=>: must strive for equity for the urban poor, displaced or marginalized; mobilise and effect ~ely use sufficient sustainable resources in order to build secure health systems and services. special anenti_on. should ~ afforded hiv/aids in view of the unprecedented challenge that this epidemic poses to africa s economic and social development and to health services on the continent. methods: a review of the literature led us to construct three simple models and a composite model of exposure to traffic. the data were collected with the help of a daily diary of travel activities using a sample of cyclists who went to or come back from work or study. to calculate the distance, the length of journey, and the number of intersections crossed by a cyclist different geographic information systems (gis) were operated. statistical analysis was used to determine the significance between a measure of exposure on the one hand, and the sociodemographic characteristics of the panicipants or their geographic location on the other hand. restlltj: our results indicate that cyclists were significantly exposed to road accidents, no matter of where they live or what are their sociodemographic characteristics. we also stress the point that the fact of having been involved in a road accident was significantly related to the helmet use, but did not reduce the propensity of the cyclists to expose themselves to the road hazards. condlllion: the efforts of the various authorities as regards road safety should not be directed towards the reduction of the exposure of the vulnerable users, but rather towards the reduction of the dangers to which they could face. keywords: cyclist, daily diary of activities, measures of exposure to traffic, island of montreal. p - (a) intra urban disparities and environmental health: some salient features of nigerian residential neighbourhoods olumuyiwa akinbamijo intra urban disparities and environmental health: some salient features of nigerian residential neighbourhoods abstract urbanization panicularly in nigerian cities, ponends unprecedented crises of grave dimensions. from physical and demographic viewpoints, city growth rates are staggering coupled with gross inabilities to cope with the consequences. environmental and social ills associated with unguarded rapid urbanization characterize nigerian cities and threaten urban existence. this paper repons the findings of a recent study of the relationship between environmental health across inrraurban residential communities of akure, south west nigeria. it discuses the typical urbanization process of nigerian cities and its dynamic spatial-temporal characteristics. physical and socio-demographic attributes as well as the levels and effectiveness of urban infrastructural services are examined across the core residential districts and the elite residential layouts in the town. the incidence rate of cenain environmentally induced tropical diseases across residential neighborhoods and communes is examined. salient environmental variables that are germane to health procurement in the residential districts, incidence of diseases and diseases parasitology, diseases prevention and control were studied. field data were subjected to analysis ranging from the univariate and bivariate analysis. inferential statistics using the chi-square test were done to establish the truthfulness of the guiding hypothesis. given the above, the study affirms that there is strong independence in the studied communities, between the environment and incidence of diseases hence health of residents of the town. this assertion, tested statistically at the district levels revealed that residents of the core districts have very strong independence between the environment and incidences of diseases. the strength of this relationship however thins out towards the city peripheral districts. the study therefore concludes that since most of the city dwellers live in urban deprivation, urban health sensitive policies must be evolved. this is to cater for the urban dwellers who occupy fringe peripheral sites where the extension of facilities often times are illegally done. urban infrastructural facilities and services need be provided as a matter of public good for which there is no exclusive consumption or access even for the poorest of the urban poor. many suffer from low-self esteem, shame and guilt about their drug use. in addition, they often lack suppon or encounter opposition from their panners, family and friends in seeking treatment. these personal barriers are compounded by fragmented addiction, prenatal and social care services, inflexible intake systems and poor communication among sectors. the experience of accessing adequate care between services can be overwhelming and too demanding. the toronto centre for substance use in pregnancy (t-cup) is a unique program developed to minimize barriers by providing kone-stop" comprehensive healthcare. t-cup is a primary care based program located in the department of family medicine at st. joseph\'s health centre, a community teaching hospital in toronto. the interdisciplinary staff provides prenatal and addiction services, case management, as well as care of newborns affected by substance use. regular care plan meetings are held between t-cup, labour and delivery nurses and social workers in the y poster sessions maternity and child care program. t-cup also connects "'.omen with. inpatient treatment programs and community agencies such as breaking the cycle, an on-site counselmg group for pregnant substance users. · f · d d h ith method: retrospective chart review, qualitative patient ~ans action stu ~· an ea care provider surveys are used to determine outcomes. primary outcomes mclude changes m maternal su~tance use, psychosocial status and obstetrical complications (e.g. pre-rupture of membrane, pre-eclampsia, placen· ral abruption and hemorrhage). neonatal measures ~~nsisted of .bir~h pa_rame~ers, length of h~spital st.ay and complications (e.g. feral distress, meconium stammg, resuscitation, aund ce, hypoglycemia, seventy of withdrawal and treatment length). chart review consisted of all t-cup patients who met clinical cri· reria for alcohol or drug dependence and received prenatal and intra-partum care at st. joseph's from october to june . participants in the qualitative study included former and current t-cup patients. provider surveys were distributed on-site and to a local community hospital. raulb: preliminary evaluation has demonstrated positive results. treatment retention and satisfaction rates were high, maternal substance use was markedly reduced and neonatal outcomes have shown to be above those reported in literature. conclusion: this comprehensive, primary care model has shown to be optimal in the management of substance use in pregnancy and for improving neonatal outcomes. future research will focus on how this inexpensive program can be replicated in other health care settings. t-cup may prove to be the optimal model for providing care to pregnant substance users in canada. lntrod ction: cigarette smoking is one of the most serious health problems in taiwan. the prevalence of smoking in is . % in males . % in females aged years and older. although the government of taiwan passed a tobacco hazards control act in , it has not been strongly enforced in many places. therefore, community residents have often reported exposure of second hand smoke. the purpose of the study was to establish a device to build up more smoke-free environments in the city of tainan. methods: unique from traditional intervention studies, the study used a healthy city approach to help build up smoke-free environments. the major concept of the approach is to build up a healthy city platform, including organizing a steering committee, setting up policies and indicators, creating intersectoral collaboration, and increasing community participation. first, more than enthusiastic researchers, experts, governmental officers, city counselors and community leaders in tainan were invited in the healthy city committee. second, smoke-free policies, indicators for smoke-free environments, and mechanisms for inter-departmen· tal inspections were set up. third, community volunteers were recruited and trained for persuading related stakeholders. lastly, both penalties and rewards were used for help build up the environments. raults: aher two-year ( aher two-year ( - execution of the project, the results qualitatively showed that smoke-free environments in tainan were widely accepted and established, including smoke-free schools, smoke-free workpla~es, smoke-free households, smoke-free internet shops, and smoke-free restaurants. smoke~s were. effectively educated not to smoke in public places. community residents including adults and children m the smoke-free communities clearly understand the adverse effects of environmental tobacco smoke and actively participated anti-smoking activities. conclruions: healthy city platform is effective to conquer the barrier of limited anti-smoking rc:sources. nor. only can it enlar:ge community actions for anti-smoking campaigns, but also it can provide par_merships for collaboratjon. by establishing related policies and indicators the effects of smoke· free environments can be susta ·ned a d th · · · ' · n e progression can be monitored m a commuruty. these issues are used ~· oi::c it~ goals, weuha identifies issues that put people's health at risk. presently, team com~u:c: ran ee~tion !earns. (iats) that design integrative solutions ~tesj'°~ g om six to fifteen members. methods in order to establish wo-poster sessions v projects for weuha, the following approach was undertaken: i. a project-polling template was created and sent to all members of the alliance for their input. each member was asked to identify thdr top two population groups, and to suggest a project on which to focus over a - month period for each identified population. . there was a % response to the poll and the top three population groups were identified. data from the toronto community health profile database were utilized to contextualize the information supplied for these populations. a presentation was made to the steering committee and three population-based projects were selected, leaders identified and iats formed. three population-based projects: the population-based projects and health care issues identified are: newcomer prenatal uninsured women; this project will address the challenges faced by providers to a growing number of non-insured prenatal women seeking care. a service model where the barrier of "catchments" is removed to allow enhanced access and improved and co-ordinated service delivery will be pilot-tested. children/obesity/diab etes: using a health promotion model this team will focus on screening, intervention, and promoting healthy lifestyles (physical activity and nutrition) for families as well as for overweight and obese children. seniors health promotion and circle of discharge: this team will develop an early intervention model to assist seniors/family unit/caregivers in accessing information and receiving treatment/care in the community. the circle of discharge initiative will address ways of utilizing community supports to keep seniors in the community and minimize readmissions to acute care facilities. results/expected outcomes: coordinated and enhanced service delivery to identified populations, leading to improved access, improved quality of life, and health care for these targeted populations. introduction: basic human rights are often denied to high-risk populations and people living with hiv/aids. their rights to work and social security, health, privacy, non discrimination, liberty and freedom of movement, marriage and having a family have been compromised due to their sero-positive status and risk of being positive. the spread of hiv/aids has been accelerating due to the lack of general human rights among vulnerable groups. to formulate and implement effective responses needs dialogue and to prevent the epidemic to go underground barriers like stigma need to be overcome. objective: how to reduce the situation of stigma, discrimination and human rights violations experienced by people living with hiv/aids and those who are vulnerable to hiv/aids. methodology and findings: consultation meetings were strm.-rured around presentations, field visits, community meetings and group work to formulate recommendations on how govt and ngos/cbos should move forward based on objective. pakistan being a low prevalence country, the whole sense of compl;u:enc.:y that individuals are not subject to situations of vulnerable to hiv is the major threat to an explosion in th•· epidemic, therefore urgent measures are needed to integrate human rights issues from the very start of the response. the protection and promotion of human rights in an integral component of ;tll responses to the hiv/aids epidemic. it has been recognized that the response to hiv/aios must he multi sectoral and multi faceted, with each group contributing its particular expertise. for this to occur along with other knowlcdg<" more information is required in human rights abuses related to hiv/ aids in a particular scenario. the ~·on sultarion meetings on hiv/aids and human rights were an exemplary effort to achieve the same ohj<..:tivc. recommendations: the need for a comprehensive, integrated and a multi-sectoral appro;u.:h in addressing the issue of hiv/aids was highlighted. the need social, cultural and religious asp•·ct' to he: prominently addressed were identified. it was thought imperative measures even in low prevalence countries. education has a key role to play, there is a need for a code of ethics for media people and h<"alth care providers and violations should be closely monitored and follow up action taken. p - (c) how can community-based funding programs contribute to building community capacity and how can we measure this elusive goal? mary frances maclellan-wright, brenda cantin, mary jane buchanan, and tammy simpson community capacity building is recognized by the public health agency of canada (phac) as an important strategy for improving the overall health of communities by enabling communities to addre~s priority issues such as social and economic determinants of health. in / phac.:, alberta/nwf region's population health fund (phf) supported community-based projects to build community capacity on or across the determinants of health. specifically, this included creating accessible and sup· portive social and physical environments as well as creating tools and processes necessary for healthy policy development and implementation. the objective of this presentation is to highlight how the community capacity building tool, developed by phac ab/nwf region, can demonstrate gains in v poster sessions · · the course of a pror· ect and be used as a reflective tool for project planning and community capacity over . . . . i · a art of their reporting requirements, pro ect sites completed the community caparny eva uanon. s p . . th t i ii i'd d . building tool at the beginning and end of their ~ne-year prorect. e oo ~o ects va an reliable data in the context of community-based health prorects. developed through a vigorous ~nd collabora ve research process, the tool uses plain languag~ to expl~re nine key f~atures o~ commuruty cap~city with 't ch with a section for contextual information, of which also mdude a four-pomt raong ems, ea f fu d · scale. results show an increase in community capacity over the course o the nde prorects. pre and post aggregate data from the one-year projects measure~ statistic.ally si~n~ficant changes for of the scaled items. projects identified key areas of commumty capacity bmldmg that needed strengthemng, such as increasing participation, particularly among people with low incomes; engaging community members in identifying root causes; and linking with community groups. in completing the tool, projects examined root causes of the social and economic determinants of health, thereby exploring social justice issues related to the health of their community. results of the tool also served as a reflec· cion on the process of community capacity building; that is, how the project outcomes were achieved. projects also reported that the tool helped identify gaps and future directions, and was useful as a project planning, needs assessment and evaluation tool. community capacity building is a strategy that can be measured. the community capacity building tool provides a practical means to demonstrate gains in community capacity building. strengthening the elements of community capacity building through community-based funding can serve as building blocks for addressing other community issues. needs of marginalized crack users lorraine barnaby, victoria okazawa, barb panter, alan simpson, and bo yee thom background: the safer crack use coalition of toronto (scuc) was formed in in response to the growing concern for the health and well-being of marginalized crack users. a central concern was the alarm· ing hepatitis c rate ( %) amongst crack smokers and the lack of connection to prevention and health ser· vices. scuc is an innovative grassroots coalition comprised of front-line workers, crack users, researcher! and advocates. despite opposition and without funding, scuc has grown into the largest crack specific harm reduction coalition in canada and developed a nationally recognized sarer crack kit distribution program (involving community-based agencies that provide outreach to users). the success of our coalition derives from our dedication to the issue and from the involvement of those directly affected by crack use. setting: scuc's primary service region is greater toronto, a diverse, large urban centre. much ofour work is done in areas where homeless people, sex trade workers and drug users tend to congregate. recently, scuc has reached out to regional and national stakeholders to provide leadership and education. mandate: our mandate is to advocate for marginalized crack users and support the devdopmentof a com.p.rehensive harm reduction model that addresses the health and social needs facing crack users; and to fac htare the exchange of information between crack users, service providers, researchers, and policy developers across canada. owrview: the proposed workshop will provide participants with an overview of the devdopment of scuc, our current projects (including research, education, direct intervention and consultation), our challenge~ and s~ccesses and the role of community development and advocacy within the coalition. pre-senter~ will consist of community members who have personal crack use experience and front-line work· ers-, sc.uc conducted a community-based research project (toronto crack users perspectives, ) , in w~ich s focus groups with marginalized crack users across toronto were conducted. participants iden· t f ed health and social issues affecti h b · · · d " red . . ng t em, arrsers to needed services, personal strategies, an oue recommendations for improved services. presenters will share the methodology, results and recommen· datmns resulting from the research project. conc/usio": research, field observations and consultations with stakeholders have shown that cradck shmoke~s are at an. increased risk for sexually transmitted infections hiv/aids hepatitis c, tb an ot er serious health issues health · ff, · ' ' · · . · issues a ectmg crack users are due to high risk behavmurs, socio· economic factors, such as homeless d. · · · · d · . . ness, scrsmmat on, unemployment, violence incarceraoons, an soc a so at on, and a lack of comprehe · h i h · ' ns ve ea t and social services targeting crack users. · · sinct · s, owever arge remains a gross underesurnaoon. poster sessions v these are hospital-based reports and many known cases go unreported. however teh case, young age at first intercourse, inconsistent condom use and multiple partnersplace adolescents at high risks for a diverse array of stls, including hiv. about % of female nigerian secondary school students report initiating sexual intercourse before age years. % of nigerian female secondary school students report not using a condom the last time they had sexual intercourse. more than % of urban nigerian teens report inconsistent condom use. methods: adolescents were studied, ages to , from benin city in edo state. the models used were mother-daughter( ), mother -son( ), father -son ( ), and father-daughter( ). the effect of parent-child sexual communicationat baseline on child\'s report of sexual behavior, to months later were studied. greater amounts of sexual risk communication were asociated with markedly fewer episodes of unprotected sexual intercourse, reduced number of sexual partners and fewer episodes of unprotected sexual intercourse. results: this study proved that parents can exert more influence on the sexual knowledge attitudes and practise of their adolescent children through desired practises or rolemodeling, reiterating their values and appropriate monitoring of the adolescents\' behavior. they also stand to provide information about sexuality and various sexual topics. parental-child sexual communication has been found to be particularly influential and has been associated with later onset of sexual initiation among adolescents, less sexual activity, more responsible sexual attitudes including greater condom use, self efficacy and lower self -reported incidence of stis. conclusions: parents need to be trained to relate more effectively with their children/wards about issues related to sex and sexuality. family -based programs to reduce sexual risk-taking need to be developed. there is also the need to carry out cross-ethnicaland cross-cultural studies to identify how parent-child influences on adolescent sexual risk behavior may vary in different regions or countries, especially inthis era of the hiv pandemic. introduction: public health interventions to identify and eliminate health disparities require evidence-based policy and adequate model specification, which includes individuals within a socioecological context, and requires the integration of biosociomedical information. multiple public and private data sources need to be linked to apportion variation in health disparities ro individual risk factors, the health delivery system, and the geosocial environment. multilevel mapping of health disparities furthers the development of evidence-based interventions through the growth of the public health information network (phin-cdc) by linking clinical and population health data. clinical encounter data, administrative hospital data, population socioenvironmental data, and local health policy were examined in a three-level geocoded multilevel model to establish a tracking system for health disparities. nj has a long established political tradition of "home rule" based in elected municipal governments, which are responsible for the well-being of their populations. municipalities are contained within counties as defined by the us census, and health data are linked mostly at the municipality level. marika schwandt community organizers from the ontario coaliti~n again~t pove~, .along ":ith ~edical practitioners who have endorsed the campaign and have been mvolved m prescnbmg special diet needs for ow and odsp recipients, will discuss the raise the rates campaign. the organizati~n has used a special diet needs supplement as a political tool, meeting the urgent needs o.f .poor ~ople m toront~ while raising the issues of poverty as a primary determinant of health and nutrtnous diet as a preventative health mea· sure. health professionals carry the responsibility to ensure that they use all means available to them to improve the health of the individuals that they serve, and to prevent future disease and health conditions. most health practitioners know that those on social assistance are not able to afford nutritious foods or even sufficient amounts of food, but many are not aware of the extra dietary funds that are available aher consideration by a health practitioner. responsible nurse practitioners and physicians cannot, in good conscience, ignore the special needs diet supplement that is available to all recipients of welfare and disabiliry (ow and odsp). a number of toronto physicians have taken the position that all clients can justifiably benefit from vitamins, organic foods and high fiber diets as a preventative health measure. we know that income is one of the greatest predictors of poor health. the special needs diet is a health promotion intervention which will prevent numerous future health conditions, including chronic conditions such as cardiovascular disease, cancer, diabetes and osteoporosis. many communiry health centres and other providers have chosen to hold clinics to allow many patients to get signed up for the supplement at one time. initiated by the ontario coalition against poverty, these clinics have brought together commu· niry organizers, community health centers, health practitioners, and individuals, who believe that poverty is the primary determinant of poor health. we believe that rates must be increased to address the health problems of all people on social assistance, kids, elders, people with hiv/aids -everyone. even in the context of understaffing, it could be considered a priority activity that has potentially important health promotion benefits. many clients can be processed in a two hour clinic. most providers find it a very interesting, rewarding undertaking. in the ontario coalition for social justice found that a toronto family with two adults and two kids receives $ , . this is $ , below the poverty line. p - (c) the health of street youth compared to similar aged youth beth hayhoe and ruth ewert . lntrod~on: street youth are at an age normally associated with good health, but due to their risky ~hav ours and th~ conditions in which they live, they experience health conditions unlike their peer~ an more stable env r~nments. in addition, the majority of street youth have experienced significant physical, sexual ~nd em.ot onal abuse as younger children, directly impacting many of the choices they make around their physical and emotional health. we examined how different their health really is. . , methodl: using a retrospective analysis of the years of data gathered from yonge street mis· ~ • evergreen health centre, the top conditions of youth were examined and compared with national tren~s for similar aged youth. based on knowledge of the risk factors present in the group, rea· sons for the difference were examined. d' ~its: street youth experience more illness than other youth their age and their illnesses can bt . irect t ·~kc~ to the. conditions in which they live. long-term impacts of abus~ contribute to such signif· ~~nt t e t d~slpl air that youth may voluntarily engage in behaviours or lack of self care in the hope at t cir ve~ w perhaps come to a quicker end. concl non: although it has ion b k h th' dy clearly shows d'fi . h g ee~ no~n t at poverty negatively affects health, ~siu be used to make ; erence m t .e health of this particular marginalized population. the infonnanon can relates to th . ecommendatio.ns around public policy that affects children and youth, especially as it e r access to appropriate health care and follow up. p - (cl why do urban children · b gt . tarek hussain an adesh die: how to save our children? the traditional belief that urban child alid. a recent study (dhs d fr r~n are better off than rural children might be no longer v urban migrants are highata th om h c~untn~s i demonstrates that the child survival prospects of rural· er an t ose m their r j · · ·grants. in bangladesh, currently million ~r~ ~ gm and lower than those of urban non-idi million. health of the urban ~ p~e are hvmg m urban area and by the year , it would be so the popu at on s a key a eals that urban poor have the worse h h . concern. recent study on the urban poor rev ea t situation than the nation as a whole. this study shows that infant poster sessions v mortality among the urban poor as per thousand, which are above the rural and national level estimates. the mortality levels of the dhaka poor are well above those of the rest of the city's population but much of the difference in death rates is explained by the experience of children, especially infants. analyzing demographic surveillance data from a large zone of the city containing all sectors of the population, research showed that the one-fifth of the households with the least possessions exhibited u child mortality almost three times as high as that recorded by the rest of the population. why children die in bangladesh? because their parents are too poor to provide them with enough food, clean water and other basic needs to help them avoid infection and recover from illness. researchers believed that girls are more at risk than boys, as mothers regularly feed boys first. this reflects the different value placed on girls and boys, as well as resources which may not stretch far enough to provide for everyone. many studies show that housing conditions such as household construction materials and access to safe drinking water and hygienic toilet facilities are the most critical determinants of child survival in urban areas of developing countries. the present situation stressed on the need for renewed emphasis on maternal and child healthcare and child nutrition programs. mapping path for progress to save our children would need be done strategically. we have the policies on hand, we have the means, to change the world so that every child will survive and has the opportunity to develop himself fully as a healthy human being. we need the political will--courage and determination to make that a reality. p - (c) sherbourne health centre: innovation in healthcare for the transgendered community james read introduction: sherbourne health centre (shc), a primary health care centre located in downtown toronto, was established to address health service gaps in the local community. its mission is to reduce barriers to health by working with the people of its diverse urban communities to promote wellness and provide innovative primary health services. in addition to the local communities there are three populations of focus: the lesbian, gay, bisexual, transgendered and transexual communities (lgbtt); people who are homeless or underhoused; and newcomers to canada. shc is dedicated to providing health services in an interdisciplinary manner and its health providers include nurses, a nurse practitioner, mental health counsellors, health promoters, client-resource workers, and physicians. in january shc began offering medical care. among the challenges faced was how to provide responsive, respectful services to the trans community. providers had considerable expertise in the area of counselling and community work, but little in the area of hormone therapy -a key health service for those who want to transition from one gender to another. method: in preparing to offer community-based health care to the trans community it was clear that shc was being welcomed but also being watched with a critical eye. trans people have traditionally experienced significant barriers in accessing medical care. to respond to this challenge a working group of members of the trans community and health providers was created to develop an overall approach to care and specific protocols for hormone therapy. the group met over a one year period and their work culminated in the development of medical protocols for the provision of hormone therapy to trans individuals. results: shc is currently providing health care to registered clients who identify as trans individuals (march ) through primary care and mental health programs. in an audit of shc medical charts (january to september ) female-to-male (ftm) and male-to-female (mtf) clients were identified. less than half of the ftm group and just over two-thirds of the mtf group presented specifically for the provision of hormones. based on this chart audit and ongoing experience shc continues to update and refine these protocols to ensure delivery of quality care. conclusion: this program is an example of innovative community-based health delivery to a population who have traditionally faced barriers. shc services also include counselling, health promotion, outreach and education. p - (c) healthy cities for canadian women: a national consultation sandra kerr, kimberly walker, and gail lush on march , the national network on environment and women's health held a pan-canadian consultation to identify opportunities for health research, policy change, and action. this consultation also worked to facilitate information sharing and networking between canadian women working as urban planners, policy makers, researchers, and service workers on issues pertaining to the health of women living in canadian cities. methods: for this research project, participants included front-line service workers, policy workers, researchers, and advocates from coast to coast, including francophone women, women with disabilities, racialized women, and other marginalized groups. the following key areas were selected as topics for du.bnes i alto kading .:auk of end·sugr ieaal clileue ia singapore, accounting for more than so% of new can singapore (nkfs) to embark on a prevention program (pp) empo~r d ahc j u f dieir condition bttter, emphasizing education and disease sdf·managemen lkilla a. essennal camponenn of good glycaemic control. we sought explore the effects of a pecialijed edu.:a on pro· pun od glycacmic conuol, as indicated by, serum hba ic values budine serum hba ic values were determined before un<k-rgmng the education progr ;am, which couisted of comprehensive dietary advice, ideal weight goals, and improving lipid profiln. serum hbaic values were obtained ar , , months later to determine impact of the program. analy • wu done uling paired !·tests significant reduction in hba le levels from ro month• was observed in females, chinese race, older age group(> so yean). ohew-ibmi ~ .nwm , wai hip ratio> l),up to primary and above secondary level education and those having om urine iclt showed that increasing hbalc levels ( ) had increasing urmary protein ( .± ; . ±i ih so± ) and crearinine (s .s ± s ± ; ioi± s) levels fbg rnults showed that the management nf d abetn m the nkfs preven· tion programme is effec;rive. results also indicated har hba le leve have a linnr trend wnh unnary protein and creatinine which are imponant determinants of renal diseate tal family-focused cinical palbway promoce politivc outcollln for ua inner city canu allicy ipmai jerrnjm care llctivirits in preparation for an infanr'' dilchargr honlr, and art m endnl lo improve effi.:k'fl.:tn of c.are. lere i paucity of tttran:h, and inconsi trncy of rnulta on ht-•m!*- of f m ly·fc"-'uw d nm a: to determinr whrthrr implrmentation of family.focuted c:pt n ntnn.tt.tl unit w"n mg an inner city ;ommunity drcl't'aki leftarh of lf•y (i.osi and rromclll'i family uo•fkllon and rt. j nest for dikhargr. md odt: family-focuk"d cpi data wm coll«ted for all infant• horn btrwttn and wft"k• t"lal mi atr who wrtt . dm ed to the ntonatal unit lmgdl of -.y . n. . day'o p c o.osi ind pma . d•mr., ho.nr . t . n. . ± i. i wb, p < o.os) wett n« fiamly f.lfrt n the pre.(]' poup. ~ .fxtmon icofn for famihn wrre high. and families noctd thc:y wnr mott prepued to ah thrar t..lby "'-· thett was .a cosi uving of s , (cdn) per patient d teharpd home n the pmi-cp poap c.-pated the p"''lfoup· cortclaion· lmplrmrnr.rion of family·foanrd c:p. in a nrona . i umt tc"fyidi an nnn an com· muniry decre.ned length of'"'" mft with a high dcgrft of family uujamon, and wrre coll~nt at least % percent of the kathmandu population lives in slum like conditions with poor access to basic health services. in these disadvantaged areas, a large proportion of children do not receive treatment due to inaccessibility to medical services. in these areas, diarrhea, pneumonia, and measles, are the key determinants of infant mortality. protein energy malnutrition and vitamin a deficiency persists and communicable diseases are compounded by the emergence of diseases like hiv/aids. while the health challenges for disadvantaged populations in kathmandu are substantial, the city has also experienced various forms of innovative and effective community development health programs. for example, there are community primary health centers established by the kathmandu municipality to deliver essential health services to targeted communities. these centers not only provide equal access to health services to the people through an effective management system but also educate them hy organizing health related awareness programs. this program is considered one of the most effective urban health programs. the paper/presentation this paper will review large, innovative, and effective urhan health programs that are operating in kathmandu. most of these programs are currently run by international and national ngos a) early detection of emerging diseases in urban settings through syndromic surveillance: data pilot study kate bassil of community resources, and without adequate follow-up. in november shelter pr.oviders ~et with hospital social workers and ccac to strike a working group to address some of th~ issues by mcre.asing knowledge among hospital staff of issues surrounding homelessness, and to build a stro?g workmg relationship between both systems in hamilton. to date the hswg has conducted four w~lkmg to~ of downtown shelters for hospital staff and local politicians. recently the hswg launched its ·~ool.k t for staff working with patients who are homeless', which contains community resources and gu dehnes to help with effective discharge plans. a scpi proposal has been submitted to incre~se the capacity of the hswg to address education gaps and opportunities with both shelters and hospitals around homelessness and healthcare. the purpose of this poster presentation is to share hamilton's experience and learnings with communities who are experiencing similar issues. it will provide for intera~tion around shared experiences and a chance to network with practitioners across canada re: best practices. introduction and objectives: canadians view health as the biggest priority for the federal government, where health policies are often based on models that rely on abstract definitions of health that provide little assistance in the policy and analytical arena. the main objectives of this paper are to provide a functional definition of health, to create a didactic model for devising policies and determining forms of intervention, to aid health professionals and analysts to strategize and prioritize policy objectives via cost benefit analysis, and to prompt readers to view health in terms of capacity measures as opposed to status measures. this paper provides a different perspective on health, which can be applied to various applications of health such as strategies of aid and poverty reduction, and measuring the health of an individual/ community/country. this paper aims to discuss theoretical, conceptual, methodological, and applied implications associated with different health policies and strategies, which can be extended to urban communities. essentially, our paper touches on the following two main themes of this conference: •health status of disadvantaged populations; and •interventions to improve the health of urban communities.methodology: we initially surveyed other models on this topic, and extrapolated key aspects into our conceptual framework. we then devised a theoretical framework that parallels simple theories of physkal energy, where health is viewed in terms of personal/societal health capacities and effort components.after establishing a theoretical model, we constructed a graphical representation of our model using selfrated health status and life expectancy measures. ultimately, we formulated a new definition of health, and a rudimentary method of conducting cost benefit analysis on policy initiatives. we end the paper with an application example discussing the issues surrounding the introduction of a seniors program.results: this paper provides both a conceptual and theoretical model that outlines how one can go about conducting a cost-benefit analysis when implementing a program. it also devises a new definition and model for health barred on our concept of individual and societal capacities. by devising a definition for health that links with a conceptual and theoretical framework, strategies can be more logically constructed where the repercussions on the general population are minimized. equally important, our model also sets itself up nicely for future microsimulation modeling and analysis.implications: this research enhances one's ability to conduct community-based cost-benefit analysis, and acts as a pedagogical tool when identifying which strategies provide the best outcome. p - (a) good playgrounds are hard to find: parents' perceptions of neighbourhood parks patricia tucker, martin holmes, jennifer irwin, and jason gilliland introduction: neighbourhood opportunities, including public parks and physical activity or sports fields hav~ been. iden.tified as correlates to physical activity among youth. increasingly, physical activity among children s bemg acknowledged as a vital component of children's lives as it is a modifiable determinant of childh~d obesity. children's use of parks is mainly under the influence of parents; therefore, the purpose of this study was to assess parents' perspectives of city parks, using london ontario as a case study.m~~: this qualitative study targeted a heterogeneous sample of parents of children using local parks w thm london. parents with children using the parks were asked for minutes of their time and if willing, a s.hort interview was conducted. the interview guide asked parents for their opinion 'of city parks, particularly the one they were currently using. a sample size of parents is expected by the end of the summer.results: preliminary findings are identifying parents concern with the current jack of shade in local parks. most parents have identified this as a limitation of existing parks, and when asked what would make the parks better, parents agree that shade is vital. additionally, some parents are recognizing the v poster sessions focused discussions during the consultation: . women in _poverty . women with disability . immi· grant and racialized women . the built and _physica_l environment. . . . . r its· participants voiced the need for integration of the following issues withm the research and policy :::na; t) the intersectional nature of urban women's health i~sues wh~ch reflects the reality of women's complex lives ) the multisectional aspect of urban wo_m~n s health, ss~es, which reflects the diversity within women's lives ) the interse~roral _dynamics within _womens hves and urban health issues. these concepts span multiple sectors -mdudmg health, educat n, and economics -when leveraging community, research, and policy support, and engaging all levels of government.policy jmplicatiom: jn order to work towards health equity for women, plans for gender equity must be incorporated nationally and internationally within urban development initiatives: • reintroduce "women" and "gender" as distinct sectors for research, analysis, advocacy, and action. •integrate the multisectional, intersectional, and intersecroral aspects of women's lives within the framework of research and policy development, as well as in the development of action strategies. • develop a strategic framework to house the consultation priorities for future health research and policy development (for example, advocacy, relationship building, evidence-based policy-relevant research, priority initiatives}.note: research conducted by nnewh has been made possible through a financial contribution from health canada. the views expressed herein do not necessarily represent the views of health canada.p - (c) drugs, culture and disadvantaged populations leticia folgar and cecilia rado lntroducci n: a partir de un proyecto de reducci n de daiios en una comunidad urbana en situ· aci n de extrema vulnerahilidad surge la reflexion sobre el lugar prioritario de los elementos sociocuhurales en el acceso a los servicios de salud de diferentes colectivos urbanos. las "formas de hacer, pensar y sentir" orientan las acciones y delimitan las posibilidades que tienen los individuos de definir que algo es o no problema, asf como tambien los mecanismos de pedido de ayuda. el analisis permanenre del campo de "las culturas cotidianas" de los llamados "usuarios de drogas" aporta a la comprension de la complejidad del tema en sus escenarios reales, y colabora en los diseiios contextualizados de politicas y propuestas socio-sanitarias de intervenci n, tornandolas mas efectivas.mitodos: esta experiencia de investigaci n-acci n que utiliza el merodo emografico identifica elementos socio estructurales, patrones de consumo y profundiza en los elementos socio-simb icos que estructuran los discursos de los usuarios, caracterizandolos y diferenciandolos en tanto constitutivos de identidades socia les que condicionan la implementaci n del programas de reduccion de daiios.resultados: los resultados que presentaremos dan cuenta de las caracteristicas diferenciadas v relaciones particulares ~ntre los consumidores de drogas en este contexto espedfico. a partir de este e~tudio de caso se mtentara co ? enzar a responder preguntas que entendemos significativas a la hora de pensar intcrvcnciones a la med da de poblaciones que comparten ciertas caracteristicas socio-culturales. (cuales serian las .motivaciones para el cambio en estas comunidades?, cque elementos comunitarios nos ayudan a i:nnstnur dema~~a? • cque tenemos para aprender de las "soluciones" que ellos mismos encuenrran a los usos problemat cos? methods: our study was conducted by a team of two researchers at three different sites. the mapping consisted of filling in a chart of observable neighbourhood features such as graffiti, litter, and boarded housing, and the presence or absence of each feature was noted for each city block. qualitative observations were also recorded throughout the process. researchers analyzed the compiled quantitative and qualitative neighbourhood data and then analyzed the process of data collection itself.results: this study reveals the need for further research into the effects of physical environments on individual health and sense of well-being, and perception of investment in neighbourhoods. the process reveals that perceptions of health and safety are not easily quantified. we make specific recommendations about the mapping methodology including the importance of considering how factors such as researcher social location may impact the experience of neighbourhoods and how similar neighbourhood characteristics are experienced differently in various spaces. further, we discuss some of the practical considerations around the mapping exercise such as recording of findings, time of day, temperature, and researcher safety.conclusion: this study revealed the importance of exploring conceptions of health and well-being beyond basic physical wellness. it suggests the importance of considering one's environment and one's own perception of health, safety, and well-being in determining health. this conclusion suggests that attention needs to be paid to the connection between the workplace and the external environment it is situated in. the individual's workday experience does not start and stop at the front door of their workplace, but rather extends into the neighbourhood and environment around them. our procedural observations and recommendations will allow other researchers interested in the effect of urban environments on health to consider using this innovative methodology. introduction: responding ro protests against poor medical attention for sexually assaulted women and deplorable conviction rates for sex offenders, in the late s, the ontario government established what would become over hospital-based sexual assault care and treatment centres (sactcs) across the province. these centres, staffed around the clock with specially trained heath care providers, have become the centralized locations for the simultaneous health care treatment of and forensic evidence collection from sexually assaulted women for the purpose of facilitating positive social and legal outcomes. since the introduction of these centres, very little evaluative research has been conducted to determine the impact of this intervention. the purpose of our study was to investigate it from the perspectives of sexually assaulted women who have undergone forensic medical examinations at these centres.method: women were referred to our study by sactc coordinators across ontario. we developed an interview schedule composed of both closed and open-ended questions. twenty-two women were interviewed, face-to-face. these interviews were approximately one-to-two hours in length, and were transcribed verbatim. to date, have been analyzed for key themes.results: preliminary findings indicate that most women interviewed were canadian born ( 'yo), and ranged in age from to years. a substantial proportion self-identified as a visible minority ( 'x.). approximately half were single or never married ( %) and living with a spouse or family of origin ( %). most were either students or not employed ( %). two-thirds ( %) had completed high school and onethird ( %) was from a lower socio-economic stratum. almost two-fifths ( %) of women perceived the medical forensic examination as revictimizing citing, for example, the internal examination and having blood drawn. the other two-thirds ( %) indicated that it was an empowering experience, as it gave them a sense of control at a time when they described feeling otherwise powerless. most ( %) women stated that they had presented to a centre due to health care concerns and were very satisfied ( % ) with their experiences and interactions with staff. almost all ( %) women felt supported and understood.conclusions: this research has important implications for clinical practice and for appropriately addressing the needs of sexually assaulted women. what is apparent is that continued high-quality medical attention administered in the milieu of specialized hospital-based services is essential. at the same time, we would suggest that some forensic evidence collection procedures warrant reevaluation. the study will take an experiential, approach by chroruclmg the impa~ of the transition f m the streets to stabilization in a managed alcohol program through the techruque of narrative i~:uiry. in keeping with the shift in thinking in the mental health fie!~ ~his stu~y is based on a paradigm of recovery rather than one of pathology. the "inner views of part c pants hves as they portray their worlds, experiences and observations" will be presented (charm~z, , ~· ~)-"i?e p~ of the study is to: identify barriers to recovery. it will explore the exj?cnence of ~n~t zanon pnor to entry into the program; and following entry will: explore the meanmg ~nd defirutto~s of r~overy ~~d the impact of the new environment and highlight what supports were instrumental m movmg pan apants along the recovery paradigm.p -st (a) treating the "untreatable": the politics of public health in vancouver's inner city introdudion: this paper explores the everyday practices of therapeutic programs in the treadnent of hiv in vancouver's inner city. as anthropologists have shown elsewhere, therapeutic programs do not siinply treat physical ailments but they shape, regulate and manage social lives. in vancouver's inner city, there are few therapeutic options available for the treatment of -ilv. public health initiatives in the inner city have instead largely focused on prevention and harm reduction strategies such as needle exchange programs, safe injection sites, and safer-sex education. epidemiological reports suggest that less than a quarter of those living with hiv in the downtown eastside (dtes) are taking antiretroviral therapies raising critical questions regarding the therapeutic economy of antiretrovirals and rights to health care for the urban poor.methods: this paper is drawn from ethnographic fieldwork in vancouver's otes neighborhood focusing on therapeutic programs for hiv treatment among "hard-to-reach" populations. the research includes participant-observation at inner city health clinics specializing in the treatment of hiv; semi· structured interviews with hiv positive participants, health care professionals providing hiv treatment, and administraton working in the field of inner city public health; and, lastly, observation at public meetings and conferences surrounding hiv treatment.r.awlts: hiv prevention and treatment is a central concern in the lives of many residents living in the inner city -although it is just one of many health priorities afflicting the community. concerns about drug resistance, cost of antiretrovirals, and illicit drug use means that hiv therapy for most is characterized by the daily observation of their medicine ingestion at health clinics or pharmacies. daily observed treatment (dot) is increasingly being adopted as a strategy in the therapeutic management of "untreatable" populations. dot programs demand a particular type of subject -one who is "compliant" to the rules and regimes of public health. over emphasis on "risky practices," "chaotic lives," and "~dh~rence" preve~ts the public health system from meaningful engagement with the health of the marginalized who continue to suffer from multiple and serious health conditions and who continue to experience considerable disparities in health.~ the ~ffec~s of hiv in the inner city are compounded by poverty, laclc of safe and affordable houamg, vanous llegal underground economies increased rates of violence and outbreaks of ~~~·~ly tr~nsmitted infections, hepatitis, and tuberculosi: but this research suggests 'that public health uunauves aimed at reducing health disparities may be failing the most vulnerable and marginal of citiztl s. margaret malone ~ vi~lence that occurs in families and in intimate relationships is a significant urban, ~unity, and pu~hc health problem. it has major consequences and far-reaching effects for women, ~~--renho, you~ sen on, and families. violence also has significant effects for those who provide and ukllc w receive health care violence · · i · · . all lasses, · is a soc a act mvolvmg a senous abuse of power. it crosses : ' : ' ~ s;nden, ag~ ~ti~, cultures, sexualities, abilities, and religions. societal responseshali ra y oc:used on identificatton, crisis intervention and services for families and individuajs.promoten are only "-"--:-g to add h · ' · i in intimate relationshi with"-~"'.". ress t e issues of violence against women and vjoence lenga to consider i~ m families. in thi_s p~per, i analyze issues, propose strategies, and note c~· cannot be full -...l'-~ whork towards erad canng violence, while arguing that social justice and equity y -. ucvcu w en thett are people wh mnhod: critical social theory, an analysis that addresses culturally and ethnically diverse communities, together with a population health promotion perspective frame this analysis. social determinants of health are used to highlight the extent of the problem of violence and the social and health care costs.the ottawa charter is integrated to focus on strategies for developing personal skills, strengthening community action, creating supportive environments, devdoping healthy public policies, and re-orientating health and social services. attention is directed to approaches for working with individuals, families, groups, communities, populations, and society.ratdts: this analysis demonstrates that a comprehensive interdisciplinary, multisectoral, and multifaceted approach within an overall health promoting perspective helps to focus on the relevant issues, aitical analysis, and strategies required for action. it also illuminates a number of interacting, intersecting, and interconnecting factors related to violence. attention, which is often focused on individuals who are blamed for the problem of violence, is redirected to the expertise of non-health professionals and to community-based solutions. the challenge for health promoters working in the area of violence in families and in intimate relationships is to work to empower ourselves and the communities with whom we work to create health-promoting urban environments. social justice, equiry, and emancipatory possibilities are positioned in relation to recommendations for future community-based participatory research, pedagogical practices for health care practitioners, and policy development in relation to violence and urban health. the mid-main community health center, located in vancouver british columbia (bc), has a diverse patient base reflecting various cultures, languages, abilities, and socio-economic statuses. due to these differences, some mid-main patients experience greater digital divide barriers in accessing computers and reputable, government produced consumer health information (chi) websites, such as the bc healthguide and canadian health network. inequitable access is problematic because patient empowerment is the basis of many government produced chi websites. an internet terminal was introduced at mid-main in the summer of , as part of an action research project to attempt to bridge the digital divide and make government produced chi resources useful to a broad array of patients. multi-level interventions in co-operation with patients, with the clinic and eventually government ministries were envisioned to meet this goal. the idea of implementing multi-level interventions was adopted to counter the tendency in interactive design to implement a universal solution for the 'ideal' end-user [ ), which discounts diversity. to design and execute the interventions, various action-oriented and ethnographic methods were employed before and during the implementation of the internet terminal. upon the introduction of the internet terminal, participant observation and interviews were conducted using a motion capture software program to record a digital video and audio track of patients' internet sessions. this research provided insight into the spectrum of patients' capacities to use technology to fulfil their health information needs and become empowered. at the mid-main clinic it is noteworthy that the most significant intervention to enhance the usefulness of chi websites for patients appeared to be a human rather than a technological presence. as demonstrated in other ethnographic research of community internet access, technical support and capacity building is a significant component of empowerment ( ). the mid-main wired waiting room project indicates that medical practitioners, medical administrators, and human intermediaries remain integral to making chi websites useful to patients and their potential empowerment. ( ) over the past years the environmental yo~th alliance has been of~ering a.youth as~t. mappin~ program which trains young people in community research and evaluation. wh ~st the positive expenenc~ and relationships that have developed over this time attest to the success of this program, no evaluations has yet been undertaken to find out what works for t.he youth, what ~ould be changed, and what long term outcomes this approach offers for the youth, their local community, and urban governance. these topics will be shared and discussed to help other community disorganizing and uncials governments build better, youth-driven structures in the places they live.p - (a) the world trade center health registry: a unique resource for urban health researchers deborah walker, lorna thorpe, mark farfel, erin gregg, and robert brackbill introduction: the world trade center health registry (wfchr) was developed as a public health response to document and evaluate the long-term physical and mental health effects of the / disaster on a large, diverse population. over , people completed a wfchr enrollment baseline survey, creating the largest u.s. health registry. while studies have begun to characterize / bealth impacts, questions on long-term impacts remain that require additional studies involving carefully selected populations, long-term follow-up and appropriate physical exams and laboratory tests. wtchr provides an exposed population directory valuable for such studies with features that make ita unique resource: (a) a large diverse population of residents, school children/staff, people in lower man· hattan on / including occupants of damaged/destroyed buildings, and rescue/recovery/cleanup work· ers; (b) consent by % of enrollees to receive information about / -related health studies; (c) represenration of many groups not well-studied by other researchers; (c) email addresses of % of enrollees; (d) % of enrollees recruited from lists with denominator estimates; and (e) available com· parison data for nyc residents. wfchr strives to maintain up-to-date contact information for all enrollees, an interested pool of potential study participants. follow-up surveys are planned.methods: to promote the wtchr as a public health resource, guidelines for external researcher.; were developed and posted on (www.wtcregistry.org) which include a short application form, a twopage proposal and documentation of irb approval. proposals are limited to medical, public health, or other scientific research. researchers can request de-identified baseline data or have dohmh send information about their studies to selected wfchr enrollees via mail or email. applications are scored by the wtchr review committee, comprised of representatives from dohmh, the agency for toxic subst~nces and disease registry, and wtchr's scientific, community and labor advisory committees. a data file users manual will be available in early fall .~suits: three external applications have been approved in , including one &om a non-u.s. ~esearcher, all requesting information to be sent to selected wtchr enrollees. the one completed mail· mg~~ wtchr enrollee~ (o , wfc tower evacuees) generated a positive survey response rate. three additional researchers mtend to submit applications in . wfchr encourages collaborations between researchers and labor and community leaders.conclusion: studies involving wtchr enrollees will provide vital information about the long· term health consequences of / . wtchr-related research can inform communities, researcher.;, policy makers, health care providers and public health officials examining and reacting to and other disasters. t .,. dp'"f'osed: thi is presentation will discuss the findings of attitudes toward the repeat male client iden· ie as su e a and substance us'n p · · · · i · 'd . . - g. articipants will learn about some identified effective strategies or service prov ers to assist this group of i · f men are oft · d bl men. n emergency care settings, studies show that this group en viewe as pro emaric patient d i r for mental health p bl h h an are more ikely to be discharged without an assessmen !) ea rofr ems t. an or er, more cooperative patients (forster and wu · hickey er al., · r y resu ts om this study suggest th · · ' ' l · d tel' mining how best to h . d at negative amtudes towards patients, difficu nes e · as well pathways l_e_ p patientsblan ~ck of conrinuity of care influence pathways to mental health care. • uc\:ome pro emat c when p ti k · che system. m a ems present repeatedly and become "get stuc id methods: semi-structured intervie d . · (n= ), ed nurses (n= ) other ed ;s were con ucted with male ed patients (n= ), ed phys oans ' sta (n= ) and family physicians (n= ). patients also completed a poster sessions v diagnostic interview. interviews were tape-recorded, transcribed verbatim and managed using n . transcripts were coded using an iterative process and memos prepared capture emergent themes. ethics approval was obtained and all participants signed a detailed informed consent form.introduction: urban settings are particularly susceptible to the emergence and rapid spread of nt•w or rare diseases. the emergence of infectious diseases such as sars and increasing concerns over the next influenza pandemic has heightened interest in developing and using a surveillance systt·m which detects emerging public health problems early. syndromic surveillance systems, which use data b, scd on symptoms rather than disease, offer substantial potential for this by providing near-real-rime data which are linked to an automated warning system. in toronto, we are piloting syndromic data from the · emergency medical services (ems) database to examine how this information can be used on an ongoing basis for the early detection of syndromes including heat-related illness (hri), and influenza-like-illness (ill). this presentation will provide an outline of the planned desi_gn of this system and proposed evaluation. for one year, call codes which reflect heat-related illness or influenza-like-illness will be selected and searched for daily using software with a multifactorial algorithm. calls will he stratified by call code, extracted from the -ems database and transferred electronically to toronto public health. the data will be analyzed for clusters and aberrations from the expected with the realtime outbreak and disease surveillance (rods) system, a computer-based public health tool for the early detection of disease outbreaks. this -ems surveillance system will be assessed in terms of its specificity and sensitivity through comparisons with the well-established tracking systems already in place for hr! and ill. others sources of data including paramedic ambulance call reports of signs and . this study will introduce complementary data sources t~ the ed ch e~ complamt an~ o~~rthe-counter pharmacy sales syndromic surveillance data currently bemg evaluated m ~ther ontar~o cltles. . syndromic surveillance is a unique approach to proactive(~ dete~tmg early c.hangesm the health status of urban communities. the proposed study aims to provide evidence of differential effectiveness through investigating the use of -ems call data as a source of syndromic surveillance information for hr! and ili in toronto. introduction: there is strong evidence that primary care interventions, including screening, brief advi<:e, treatment referral and pharmacotherapy are effective in reducing morbidity and mortality caused by substance abuse. yet physicians are poor at intervening with substance users, in part because of lack of time, training and support. this study examines the hypothesis that shared care in addictions will result in decreased substance use and improved health status of patients, as well as increased use of primary care interventions by primary care practitioners (pcps). methods: the addiction medicine service (ams) at st. joseph's health centre's family medicine department is in the process of being transformed from its current structure as a traditional consult service into a shared care model called addiction shared care (asc). the program will have three components: education, office systems and clinical shared care. as opposed to a traditional consult service, the patient will be booked with both a primary care liaison worker (pcl) and addictions physician. patients referred from community physicians, the emergency department and inpatient medical and psychiatric wards will be recruited for the study as well as pcps from the surrounding community. the target sample size is - physicians and a similar number of patients. after initial consult, patient will be recruited into the study with their consent. the shared-case model underlines the interaction and collaboration with the patient's main pcp. asc will provide them with telephone consults, advice, support and re-assessment for their patients, as well as educational sessions and materials such as newsletters and informational kits.results: the impact of this transition on our patient care and on pcp's satisfaction with the asc model is currently being evaluated through a grant provided by the ministry of health & long term care. a retrospective chart review will be conducted using information on the patient's substance use, er/clinic visits, and their health/mood status. pcp satisfaction with the program will be measured through surveys and focus groups. our cost-effectiveness analysis will calculate the overall cost of the program per patient..conclusion: this low-cost service holds promise to serve as an optimal model and strategy to improve outcomes and reduce health care utilization in addict patients. the inner city public health project introduction the inner city public health project (icphp) was desi.gned to explore new an~ innovative ways to reach marginalized inner city populations that par-t c pate m high health-nsk beha~ ors. much of this population struggles with poverty, addictions, mental illness and homelessness, creatmg barriers to accessing health services and receiving follow-up. this pro ect was de~igned to evaluat~ .~e success of offering clinics in the community for testing and followup of communicable diseases uuhzmg an aboriginal outreach worker to build relationships with individuals and agencies. v n(demographics~ history ~f testi~g ~nd immunization and participation in various health-risk behaviors), records of tesnng and mmumzat ons, and mterviews with partner agency and project staff after one year.. results: t~e chr ~as i~strumental in building relationships with individuals and partner agencies ' .° the c~mmun_ ~ re_sultmg m req~ests for on-site outreach clinics from many of the agencies. the increase m parnc pat n, the chr mvolvement in the community, and the positive feedback from the agen? staff de~onstrated that.the project was successfully creating partnerships and becoming increasingly integrated m the community. data collected from clients at the initial visit indicated that the project was reaching its target populations and highlighted the unique health needs of clients, the large unmet need for health services and the barriers that exist to accessing those services. ~usion: the outreach clinics were successful at providing services to target populations of high health-nsk groups and had great support from the community agencies. the role of the chr was critical to the success of the project and proved the value of this category of health care worker in an urban aboriginal population. the unmet health needs of this disadvantaged population support the need for more dedicated resources with an emphasis on reducing access barriers. building a caring community old strathcona's whyte avenue, a district in edmonton, brought concern about increases in the population of panhandlers, street people and homeless persons to the attention of all levels of government. the issue was not only the problems of homelessness and related issues, but feelings of insecurity and disempowerment by the neighbourhood residents and businesses. their concerns were acknowledged, and civic support was offered, but it was up to the community itself to solve the problem. within a year of those meetings, an adult outreach worker program was created. the outreach worker, meets people in their own environments, including river valley camps. she provides wrap-around services rooted in harm reduction and health promotion principles. her relationship-based practice establishes the trust for helping clients with appropriate housing, physical and/or mental health issues, who have little or no income and family support to transition from homelessness. the program is an excellent example of collaboration that has been established with the businesses, community residents, community associations, churches, municiple services, and inner-city agencies such as boyle street community services. statistics are tracked using the canadian outcomes research institute homes database, and feedback from participants, including people who are street involved. this includes an annual general meeting for community and people who are homeless. the program's holistic approach to serving the homeless population has been integral, both in creating community awareness and equipping residents and businesses to effectively interact with people who are homeless. through this community development work, the outreach worker engages old strathcona in meeting the financial and material needs of the marginalized community. the success of this program has been surprising -the fact is that homeless people's lives are being changed; one person at a time and the community has been changed in how they view and treat those without homes. over two years, the program has successfully connected with approximately seventy-five individuals who call old strathcona home, but are homeless. thirty-six individuals are now in homes, while numerous others have been assisted in obtaining a healthier and safer lifestyles by becoming connected with other social/health agencies. the program highlights the roots of homelessness, barriers to change and requirements for success. it has been a thriving program and a model that works by showing how a caring community has rallied together to achieve prosperous outcomes. the spn has created models of tb service delivery to be used m part~ers~ p with phannaceunca compa-. · · -. t' ns cooperatives and health maintenance orgamzanons (hmos). for example, the mes, c v c orgamza , . · b tb d' · spn has established a system with pharmaceutical companies that help patients to uy me cmes at a special discounted rate. this scheme also allows patients to get a free one-_month's worth of~ dru_g supply if they purchase the first months of their regimen. the sy_s~e~s were ~es gned to be cm~pattble with existing policies for recording and documentation of the ph hppme national tuberculosis program (ntp). aside from that, stakeholders were also encouraged to be dots-enabled through the use of m~nual~ and on-line training courses. the spn initiative offers an alternative in easing the burden of tb sc:rv ce delivery from rhe public sector through the harnessing of existing private-sector (dsos). the learnmgs from the spn experience would benefit groups from other locales that _work no~ only on ~ but other health concerns as well. the spn experience showcases how well-coordinated private sector involvements help promote social justice in health delivery in urban communities.p - (c) young people in control; doing it safe. the safe sex comedy juan walter and pepijn v. empelen introduction: high prevalence of chlamydia and gonorrhoea have been reported among migrants youth in amsterdam, originating from the dutch antilles, suriname and sub-sahara africa. in addition, these groups also have high rates of teenage-pregnancy (stuart, ) and abortions (rademakers ), indicating unsafe sexual behaviour of these young people. young people (aged - ) from the so· called urban scene (young trendsetters in r&b/hip hop music and lifestyle) in amsterdam have been approached by the municipal health service (mhs) to collaborate on a safe sex project. their input was to use comedy as vehicle to get the message a cross. for the mhs this collaboration was a valuable opportunity to reach a hard-to-reach group.mdhods: first we conducted a need assessment by means of a online survey to assess basic knowledge and to similtaneously examine issues of interest concerning sex, sexuality, safer sex and the opposite sex. second, a small literature study was conducted about elements and essential conditions for succesful entertainment & education (e&e) (bouman ), with as most important condition to ensure that the message is realistic (buckingham & bragg, ) . third a program plan was developed aiming at enhancing the stl/hiv and sexuality knowledge of the young people and addressing communication and educational skills, by means of drama. subsequently a safe sex comedy show was developed, with as main topics: being in love, sexuality, empowerment, stigma, sti, hivand safer sex. the messages where carried by a mix of video presentation, stand up comedy, spoken word, rap and dance.results: there have been two safe sex comedy shows. the attendance was good; the group was divers' with an age range between and year, with the majority being younger than year. more women than men attended the show. the story lines were considered realistic and most of the audients recognised the situations displayed. eighty percent of the audients found the show entertaining and % found it edm:arional. from this %, one third considers the information as new. almost all respondents pointed our that they would promote this show to their friends.con.clusion: the s.h<_>w reached the hard-to-reach group of young people out of the urban scene and was cons d_ered entert~mmg, educational and realistic. in addition, the program was able in addressing important issues, and impacted on the percieved personal risk of acquiring an sti when not using condoms, as well as on basic knowledge about stl's. introduction: modernity has contributed mightily to the marginality of adults who live with mental illnesses and the subsequent denial of opportunities to them. limited access to social, vocational, educational, and residential opportunities exacerbates their disenfranchisement, strengthening the stigma that has been associated with mental illness in western society, and resulting in the denial of their basic human rights and their exclusion from active participation in civil society. the clubhouse approach tn recovery has led to the reduction of both marginality and stigma in every locale in which it has been implemented judiciously. its elucidation via the prism of social justice principles will lead to a deeper appreciation of its efficacy and relevance to an array of settings. methods: a review of the literature on social justice and mental health was conducted to determine core principles and relationships between the concepts. in particular, fondacaro and weinberg's ( ) conceptualization of social justice in community psychology suggests the desirability of the clubhouse approach in community mental health practice. a review of clubhouse philosophy and practice has led to the inescapable conclusion that there is a strong connection between clubhouse philosophy-which represents a unique approach co recovery--and social justice principles. placing this highly effective model of community mental health practice within the context of these principles is long overdue. via textual analysis, we will glean the principles of social justice inherent in the rich trove of clubhouse literature, particularly the international standards of clubhouse development.results: fondacarao and weinberg highlight three primary social justice themes within their community psychology framework: prevention and health promotion; empowerment, and a critical pnsp<"<·tive. utilizing the prescriptive principles that inform every detail of clubhouse development and th<" movement toward recovery for individuals at a fully-realized clubhouse, this presentation asserts that both clubhouse philosophy and practice embody these social justice themes, promote human rights, and empower clubhouse members, individuals who live with mental illnesses, to achieve a level of wdl-heing and productivity previously unimagined.conclusion: a social justice framework is critical to and enhances an understanding of the clubhouse model. this model creates inclusive communities that lead to opportunities for full partic pil!ion civil society of a previously marginalized group. the implication is that clubhouses that an· based on the international standards for clubhouse programs offer an effective intervention strategy to guarantee the human rights of a sizable, worthy, and earnest group of citizens. to a drastic increase in school enrollment from . million in to . million in .s. however, while gross enrollment rates increased to °/., in the whole country after the introduction of fpe, it remained conspicuously low at % in the capital city, nairobi. nairobi city's enrollment rate is lower .than thatof all regions in the country except the nomadic north-eastern province. !h.e.d sadvantage of children bas_ed in the capital city was also noted in uganda after the introduction of fpe m the late s_-many_ education experts in kenya attribute the city's poor performance to the high propornon of children hvmg m slums, which are grossly underserved as far as social services are concerned. this paper ~xammes the impact of fpe and explores reasons for poor enrollment in informal settlements m na rob city. methods: the study utilizes quantitative and qualitative schooling data from the longitudinal health and demographic study being implemented by the african population and health research center in two informal settlements in nairobi. descriptive statistics are used to depict trends in enrollment rates for children aged - years in slum settlements for the period - . results: the results show that school enrollment has surprisingly steadily declined for children aged - while it increased marginally for those aged - . the number of new enrollments (among those aged years) did not change much between and while it declined consistently among those aged - since . these results show that the underlying reasons for poor school attendance in poverty-stricken populations go far beyond the lack of school fees. indeed, the results show that lack of finances (for uniform, transportation, and scholastic materials) has continued to be a key barrier to schooling for many children in slums. furthermore, slum children have not benefited from fpe because they mostly attend informal schools since they do not have access to government schools where the policy is being implemented.conclusion: the results show the need for equity considerations in the design and implementation of the fpe program in kenya. without paying particular attention to the schooling needs of the urban poor children, the millennium development goal aimed at achieving universal primary education will remain but a pipe dream for the rapidly increasing number of children living in poor urban neighborhoods.ps- (c) programing for hiv/aids in the urban workplace: issues and insights joseph kamoga hiv/aids has had a major effect on the workforce. according to !lo million persons who are engaged in some form of production are affectefd by hiv/aids. the working class mises out on programs that take place in communities, yet in a number of jobs, there are high risks to hiv infection. working persons sopend much of their active life time in workplaces and that is where they start getting involved in risky behaviour putting entire families at risk. and when they are infected with hiv, working people face high levels of seclusion, stigmatisation and some miss out on benefits especially in countries where there are no strong workplace programs. adressing hiv/aids in the workplace is key for sucessfull responses. this paper presents a case for workplace programing; the needs, issues and recommendations especially for urban places in developing countries where the private sector workers face major challenges. key: cord- - mdie v authors: valle, denis; albuquerque, pedro; zhao, qing; barberan, albert; fletcher, robert j. title: extending the latent dirichlet allocation model to presence/absence data: a case study on north american breeding birds and biogeographical shifts expected from climate change date: - - journal: glob chang biol doi: . /gcb. sha: doc_id: cord_uid: mdie v understanding how species composition varies across space and time is fundamental to ecology. while multiple methods having been created to characterize this variation through the identification of groups of species that tend to co‐occur, most of these methods unfortunately are not able to represent gradual variation in species composition. the latent dirichlet allocation (lda) model is a mixed‐membership method that can represent gradual changes in community structure by delineating overlapping groups of species, but its use has been limited because it requires abundance data and requires users to a priori set the number of groups. we substantially extend lda to accommodate widely available presence/absence data and to simultaneously determine the optimal number of groups. using simulated data, we show that this model is able to accurately determine the true number of groups, estimate the underlying parameters, and fit with the data. we illustrate this method with data from the north american breeding bird survey (bbs). overall, our model identified main bird groups, revealing striking spatial patterns for each group, many of which were closely associated with temperature and precipitation gradients. furthermore, by comparing the estimated proportion of each group for two time periods ( – and – ), our results indicate that nine (of ) breeding bird groups exhibited an expansion northward and contraction southward of their ranges, revealing subtle but important community‐level biodiversity changes at a continental scale that are consistent with those expected under climate change. our proposed method is likely to find multiple uses in ecology, being a valuable addition to the toolkit of ecologists. occur in space and time. for example, in a spatial context, these approaches have attempted to identify geographic areas with similar taxa, areas that have been variously called "biogeographical regions" (gonzales-orozco, thornhill, knerr, laffan, & miller, ) , "bioregions" (bloomfield et al., ) , or "biogeographical modules" (carstensen et al., ) . such bioregions have been argued to be important for understanding the role of history on community assemblages (carstensen et al., (carstensen et al., , , interpreting ecological dynamics (economo et al., ) , and developing broad-scale conservation strategies (vilhena & antonelli, ) . the latent dirichlet allocation (lda; not to be confused with linear discriminant analysis) model is a powerful model-based method to decompose species assemblage data into groups of species that tend to co-occur in space and/or time. the benefits of using this model include the ability to adequately represent uncertainty, accommodate missing data, and, perhaps most importantly, to describe sampling units as comprised of multiple groups (i.e., mixedmembership [mm] units) (valle, baiser, woodall, & chazdon, ) . conceptually, the ability to describe sampling units as comprised of multiple groups has rarely been considered in previous methods (i.e., prior approaches are typically based on "hard" partitions) but may better honor community dynamics and may better characterize impacts of environmental change. for instance, biome transition zones, ecotones, and habitat edges are locations that are often comprised of a mix of species groups, providing sources for potentially novel species interactions (gosz, ; ries, fletcher, battin, & sisk, ) . similarly, climate change is predicted to cause geographic shifts in species and communities, leading to the hypothesis of novel assemblages arising across space as climate and habitat changes (urban et al., ; williams & jackson, ) . in addition, most partitioning methods that delineate biogeographical regions or modules based on hard boundaries can lead to high uncertainty in boundary delineation-an issue that can be rectified by allowing groups to overlap. it is important to note that lda allows for overlapping groups, but it does not require it to be present (i.e., if data do not support overlap, no overlap is estimated). it is unfortunate that the lda model, as currently developed, has been restricted to abundance data, which are often not available because accurate quantification of abundance can be very challenging and costly. in the absence of abundance data, researchers often have to rely on presence/absence data to understand species distributions and biodiversity patterns (jones, ; joseph, field, wilcox, & possingham, ) . another limitation of the lda model is that the number of groups has to be prespecified, requiring researchers to run lda multiple times to then use some criterion (e.g., aic) to choose the optimal number of groups (e.g., valle et al., ) , an approach that often can be computationally costly. in this article, we substantially develop the lda model to be able to fit the much more commonly available presence/absence data and to automatically determine the optimal number of groups. we start by describing our statistical model. then, using simulated data, we show how our method automatically detects the optimal number of groups in the data, reliably estimates the underlying parameters, and better fits the data, outperforming other approaches. at last, we illustrate the novel insights gained using our method by analyzing a long-term dataset collected on breeding birds in the united states and canada (breeding bird survey [bbs]; pardieck, ziolkowski, lutmerding, campbell, & hudson, ) to determine how environmental variables influence bird assemblages across the continent and how these assemblages are changing through time. the overall goal of our method is to identify the major patterns of species co-occurrence in the data, each of which we define to be a distinct species group. we adopt the term species group (instead of "bioregion" or other related terms) because these major co-occurrence patterns do not have to have a strong spatial pattern (although they often do), these groups can overlap in space, and proportion of groups can change through time. more specifically, our method characterizes each sampling unit l in terms of the proportion of the different groups (parameter vector θ l ) and characterizes each group k in terms of the probability of the different species (parameter vector ϕ k ). for example, θ l ¼ : ; : ; : ; ½ indicates that the second group dominates unit l and that the fourth group is absent. this example also illustrates that a given sampling unit can be comprised of multiple groups, which explains why these types of models are called mixed-membership models. in the same way, ϕ k ¼ ; : ; : ½ indicates that species and (but not species ) are important species of group k. note that a given species can have a high probability in more than one group. a more formal description of the statistical model is given below. the data consist of a matrix filled with binary variables x isl (i.e., equal to one if species s was present in observation i and unit l and equal to zero otherwise). notice that we assume that multiple observations might have been made for each species s and unit l, possibly due to temporally repeated measures or because multiple subsamples were measured within each unit l (e.g., a forest plot comprised of four subplots). each of these binary variables has an associated latent group membership status z isl . this variable indicates to which group species s in sampling unit l during observation i comes from. we assume that each observation x isl comes from the following distribution, given that species s in unit l during observation i comes where ϕ sk is the probability of observing species s if this species came from group k. notice that z isl influences the distribution for x isl by determining the k subscript of the parameter ϕ. next, we assume that the latent variable z isl comes from a multinomial distribution: where θ l is a vector of probabilities that sum to one, and each element θ lk consists of the probability of a species in unit l to have come from group k. in relation to the priors for our parameters, we adopt a conjugate beta prior for ϕ sk : throughout this article, we assume vague priors by setting a and b to . building on the work of dunson ( ) and valle et al. ( ) , we adopt a truncated stick-breaking prior for θ l . this prior assumes that: for k = ,…,k− and γ > . we set the parameter for the last group to (i.e., v lk ¼ ). with these parameters, we calculate θ lk using the under this prior, θ lk is a priori stochastically exponentially decreasing as long as γ < and smaller γ tend to enforce greater sparseness (i.e., the existence of fewer groups). for most of the examples in this article, γ was set to . , which we have found to work well for multiple datasets. more details regarding this prior can be found in supporting information appendix s . the benefit of this prior is that, if the data support fewer groups than specified by the user, it will tend to force these superfluous additional groups to be empty or to have very few latent variables z isl assigned to them, as illustrated in the simulation section below. this prior also helps to avoid label switching, a common problem in mixed-membership and mixture models. bayesian markov chain monte carlo (mcmc) algorithms applied to these types of models sometimes mix poorly and can lead to nonsensical results if posterior distributions of parameters are summarized by their averages (stephens, ) . the label switching problem refers to the fact that the labels of the different groups can change (e.g., groups and can become groups and , respectively) without changing the likelihood (i.e., the group labels are unidentifiable). our truncated stick-breaking prior helps to avoid the label switching problem by enforcing an ordering of the groups according to their overall proportions. we fit the lda using a gibbs sampler. a more complete description of this model and the derivation of the full conditional distributions used within this gibbs sampler are provided in supporting information appendix s . supporting information appendix s contains a short tutorial describing how to fit the model using the code that we make publicly available, reproducing some of the simulated data results. there are three important points regarding lda that need to be emphasized. first, the proposed model can accommodate negative and positive correlations between species. to illustrate this, assume that there are just two species groups and two species, s and s'. negative correlation between these species is captured by our . these parameter estimates indicate that, whenever a site has a high proportion of group , species s will have a high probability of occurring, whereas species s' will tend to be absent. in the same way, whenever a site has a high proportion of group , species s' will have a high probability of occurring but species s will tend to be absent, resulting in negative correlation. positive correlation between these species is captured by our model if, for example,φ s ¼ : : ! and ϕ s ¼ : : ! . these parameter estimates imply that, whenever a site has a high proportion of group , both species s and s' will have a high probability of occurring. in the same way, whenever a site has a high proportion of group , both species s and s' will have a high probability of being absent, inducing positive correlation. second, hard clustering methods that group locations with similar species composition (e.g., kreft & jetz, ) correspond in our model to vectors θ l comprised of zeroes except for a single element which is equal to . in the same way, hard clustering methods that group species that tend to co-occur (e.g., azeria et al., ) from a species composition perspective. this is due to the fact that the probability of observing species s for two locations p and q is (see supporting information appendix s for details). in this scenario, the algorithm might determine that a single species group dominates all locations instead of distinguishing the different species groups. we simulate data to evaluate the performance of the proposed model and to compare its results to those from other clustering methods. to avoid the identifiability problems described above, we generate parameters for all simulations such that each group completely dominates at least one location and that each group has at least one species that is never present in the other groups (ensuring distinct species composition of these groups). we illustrate with simulated data how the truncated stick-breaking prior can identify the optimal number of groups and how our algorithm can retrieve the true parameter values under a wide range of conditions. more specifically, the true number of groups k* was set to and ; the number of sampling units (i.e., locations) was set to and ; the number of species was set to and ; and the number of observations per location was set to . parameters were drawn randomly (i.e., ϕ sk ∼ beta : ; : ð Þ and θ l ∼ dirichlet : ð Þ), and the identifiability assumptions described above were then imposed. we adopted a beta : ; : ð Þdistribution for ϕ sk because this distribution is likely to generate species groups that are more dissimilar in terms of species composition given that it is a u-shaped symmetric distribution. we generated datasets for each combination of these settings, totaling datasets. to fit these data, we assume a maximum of groups (k = ) and estimate the true number of groups k* by determining the number of groups that are not superfluous. superfluous groups are defined to be those groups that are very uncommon across the entire region (i.e., θ lk < : for % of the locations, where θ lk is the mean of the posterior distribution). at last, we test the sensitivity of the modeling results to the prior by fitting these data with γ set to . and . we also compare lda to other methods using simulated data. in these simulations, we assume data are available on species over , locations, with five repeated observations per location. furthermore, , , and groups were used to generate these data. because the goal is to compare inference from different methods, we set the parameters θ lk in such a way that it allows for a straightforward visual appraisal of the advantages and limitations of the different methods. on the other hand, the parameters ϕ ks were randomly drawn from beta : ; : ð Þ ; and subsequently, the assumption regarding groups with distinct species composition was imposed. when fitting lda, we set the maximum number of groups to and rely on the truncated stick-breaking prior with γ ¼ : to uncover the correct number of groups. we compare and contrast inference from our model to that from competing approaches, including traditional hard clustering methods (i.e., hierarchical and kmean clustering) and mixture models (i.e., region of common profile (rcp) model; foster et al., ; lyons, foster, & keith, to determine whether these breeding bird groups have been shifting their spatial distribution over time, we divided our study period into two -year periods: - and - . each route × period combination resulted in a distinct "sampling unit" (i.e., distinct row in our data matrix), and data from individual years within each time period were treated as repeated observations. to relate the spatial distribution of the identified groups to potential environmental drivers, we relied on freely available precipitation and temperature data from worldclim version (available at http://worldclim.org/version ) (fick & hijmans, ) . these data consist of the -years average climate information (from to ) for the month of june, covering the entire world. in an era of global change, an important feature of our method is that it is able to detect relatively subtle temporal changes in species composition. more specifically, we assessed whether group ranges had expanded north and contracted south. these are the patterns we a priori expected given warming temperatures and the strong influence of temperature on the spatial distribution of a range of taxonomic groups, including birds (chen, hill, ohlemuller, roy, & thomas, ; hitch & leberg, ; moritz et al., ; parmesan & yohe, ) . to detect these patterns, we fit the model once to data from both time periods (instead of fitting the model separately for each time period we set the maximum number of groups to for our case study. to interpolate the estimates of the proportion of different groups to unsampled areas, we relied on the inverse distance weighted (idw) algorithm implemented in the package "gstat" (graler, pebesma, & heuvelink, ; pebesma, ) . interpolations were restricted to locations within one degree of a bbs route. finally, our algorithm was programmed using a combination of c++ (through the rcpp package; eddelbuettel & francois, ) and r code (r core team ). we provide a tutorial in the supporting information appendix s for fitting this model. despite assuming the potential existence of a much higher number of groups (k = ), our results reveal that the proposed model was generally able to estimate well the true number of groups (boxplots in figure ) , except for datasets with few species and locations but many groups (i.e., locations, species, and groups; figure f) . we also find a good correspondence between the true and estimated parameter values for most of the scenarios explored (scatterplots in figure ) , with a slightly worse performance for data with few species but many groups (i.e., species and groups; figure g,h) . taken together, these results suggest that, when the ratio of the number of species to the number of groups is small, there is likely to be less distinction between groups from a species composition perspective, making it a harder task to untangle these groups. finally, in relation to the prior, we find that our results are broadly similar for γ ¼ : and γ ¼ . the main difference is that parameter estimates tended to be slightly worse when the true number of groups is and γ ¼ and when the true number of groups is and γ ¼ : (results not shown), agreeing with our expectations. because smaller γ values induce greater sparseness, parameters are better estimated with γ ¼ : when simulations are based on sparse assumptions (i.e., simulations with three groups) versus when this is not true (i.e., simulations with groups). our results reveal that the algorithm accurately estimates the proportion of the different groups in each location, regardless if mm units are present or not (left most and right most panels, respectively, in figure ). these results corroborate the observation that lda encompasses hard clustering of sites and/or species as special cases. on the other hand, figure clearly reveals that hard clustering methods cannot represent these mm locations (k-means and hierarchical clustering [hc] panels in figure ). mixture model approaches such as rcp are sometimes perceived to be able to represent these gradual changes in the proportion of groups. however, f i g u r e the latent dirichlet allocation (lda) estimates well the true number of groups (boxplots) and the θ lk parameter values (scatterplots). results from all datasets in each simulation setting are displayed simultaneously, based on lda with γ set to . . top and bottom panels display results for three and groups, respectively. boxplots in panels (a) and (f) show the estimated number of groups (i.e., the number of groups deemed not to be superfluous), revealing that lda can estimate well the true number of groups (k*) except for datasets with few locations (l), few species (s) but many groups (i.e., l s k*). scatterplots (panels b-e and g-j) reveal that the θ lk parameters can also be well estimated but there is considerable noise for datasets with few species but many groups (panels g and h). a : line and a linear regression line were added for reference (blue and red lines, respectively) [colour figure can be viewed at wileyonlinelibrary.com] our results reveal that, when applied to our simulated data, rcp tended to give transition regions that were too narrow (rcp panels in figure ). these model comparison results are particularly striking given that lda was fitted assuming potential groups, whereas results for the other methods were based on the assumption that the true number of groups was known. notice that these figures illustrate how lda can capture gradual changes in species composition associated with global change phenomena depending on what is being represented in the x-axis. for instance, the x-axis can represent a spatial gradient of anthropogenic forest disturbance (e.g., timber logging intensity or distance to forest edge) or can represent time (i.e., the same location sampled repeatedly through time, perhaps revealing the impact of climate change on species composition). recall that the simulated data were generated with , , and groups, but that the maximum number of groups when fitting lda was set to . our results suggest that the truncated stick-breaking prior was able to correctly estimate the underlying true number of groups (boxplots in figure ) given that the estimated θ lk 's were shrunk toward zero for the superfluous groups (red boxes in figure ) . we also find that all the other alternative methods required a much greater number of groups to fit the data as well as lda when mm locations are present (line graphs in figure ). these results reveal that lda achieves a much sparser representation of the data (based on the number of groups) without losing the ability to represent the inherent variability in the data. although these results are expected, given the larger number of parameters in lda, the ability to fit the data well with fewer groups is highly desirable from the user's perspective as the primary role of these methods is to reduce the dimensionality of biodiversity data. it is important to note that even in the absence of mm sampling units, lda can still estimate well the true number of groups and has similar fit to the data as the other clustering approaches (results not shown). finally, although overall, we identified main breeding bird groups (of a maximum of ) after eliminating groups that were very uncommon throughout the region (defined here as those for which θ lk was smaller than . for % of the locations, where θ lk denotes the posterior mean). an important test for any unsupervised method is if it is able to retrieve patterns that are widely acknowledged to exist by experts. using the estimated group proportion for each location for the - period, we find striking spatial patterns (maps in figure ) . importantly, these spatial patterns generally agree well with other maps of bird communities (e.g., bird conservation (figure a ). we find that the species that best f i g u r e the extended latent dirichlet allocation (lda) method identifies the true number of groups (left panels) and fits the data better than other clustering approaches for data with mm locations (right panels). results are shown separately for simulated data with , , and groups (top to bottom). boxplots depict the estimated proportion θ lk of each group k for all locations l = ,…,l. these boxplots emphasize how θ lk for the irrelevant extra groups (red boxes) are shrunk to zero for all locations. line graphs show the log likelihood, a measure of model fit for which larger values indicate better fit. these graphs reveal how other clustering approaches require a much greater number of groups to fit the data as well as lda with fewer groups. model fit results for lda correspond to the posterior mean of the log likelihood. lda results are shown with a single symbol because, differently from the other methods that were fitted multiple times with different number of groups, lda was fitted just once using a maximum of groups and the true number of groups was estimated (see corresponding boxplots). details regarding how the log likelihood was calculated for the different methods are provided in supporting find that group identifies species associated with desert environments (e.g., cactus wren and ash-throated flycatcher), while group identifies a mixture of short-grass prairie birds (e.g., dickcissel) and species associated with open country environments with scattered trees and shrubs (e.g., eastern phoebe). besides these biogeographical patterns, we also highlight the ability of our algorithm in depicting how environmental gradients are linked to the proportion of each group. for instance, we display how the main east coast groups (groups , , , , , and ) are , , , , , and along the east coast. (c) displays the spatial pattern of groups and . in both (a) and (c), higher proportion of individual groups is depicted using more opaque (i.e., less transparent) colors and different groups are depicted with different colors. (b, d) reveals that average june temperature and precipitation gradients seem to strongly constrain the spatial distribution of these breeding bird groups, respectively. circles represent the estimated proportion for each location and group while lines depict suitability envelopes. these envelopes were created by first defining equally spaced intervals on the x-axis and then calculating the median x value and the % percentile of y within each interval and connecting these results. notice that the same color scheme is used for right and left panels the latent dirichlet allocation (lda) model is a useful model for ecologists because it can more faithfully represent community dynamics and the impact of environmental change through the estimation of mixed-membership sites (valle et al., ) . the standard lda requires abundance data but, for many taxa, reliably estimating abundance is often very hard and costly (ashelford, chuzhanova, fry, jones, & weightman, ; joseph et al., ; kembel, wu, eisen, & green, ; royle, ; schloss, gevers, & westcott, ) . for these reasons, presence/absence data are typically much more ubiquitous than abundance data, often enabling analysis at f i g u r e species groups with a statistically significant association between latitude and change in group proportion using the breeding bird survey (bbs) dataset as a case study, we have shown how our method is able to uncover striking spatial and temporal patterns in bird groups. for example, we illustrate how these groups gradually change along a temperature gradient in the east coast and a precipitation gradient in texas. it has long been known that many bird species have strong relationships with abiotic gradients (bowen, ) , but how these gradients can explain entire groups of species has remained elusive. furthermore, we find subtle but pervasive changes in bird group proportions, changes which follow the expected patterns based on climate change (e.g., parmesan & yohe, ) . half of the species groups (nine of ) have expanded their northern range and shrunken their southern range. this pattern is consistent with species-specific models of changes in bird distribution with climate change in the united states (e.g., hitch & leberg, ; la sorte & thompson, ) . our results expand on these findings by illustrating how entire groups are shifting their spatial distribution. nevertheless, a more formal test that accounts for the multiple factors that influence the spatial distribution of birds will be required to ultimately confirm whether climate change is driving the spatial distribution shifts that we have detected. an important limitation of the method that we have presented is that the identified groups do not change over time, even though their spatial distribution may vary. in other words, θ lk may change with time but ϕ ks does not. this is particularly relevant in the context of climate change, where it is possible that the species composition of the groups themselves might be changing (lurgi, lopez, & montoya, ; stralberg et al., ; urban et al., ) . another important limitation in this study is that the proposed model does not take into account imperfect detection, a pervasive issue for wildlife sampling (mackenzie et al., ; royle, ) . this shortcoming can be partially attributed to inherent limitations in the bbs dataset, given that the estimation of detection probabilities requires very specific data types (e.g., repeated visits in occupancy models). it is also critical to highlight the importance of repeated observations per location given the relatively low information content in binary presence/absence data. determining all the parameters in the proposed model, including the optimal number of groups, can be challenging in the absence of these repeated observations. finally, although important broad-scale patterns can be identified and novel insights gained from post hoc analysis of lda model parameters, as illustrated with our case study, these results rely on a two-stage analysis that does not take into uncertainty in the estimated parameters. our ongoing work is focused on extending lda to accommodate covariates through regression models built-in to lda so that uncertainty can be coherently propagated when performing more formal statistical tests and when making spatial and temporal predictions. community ecologists have traditionally relied on fitting clustering models with different numbers of clusters and choosing the optimal number of clusters using metrics such as aic and bic (fraley & raftery, ; xu & wunsch, ) . using simulated data, we have shown how the truncated stick-breaking prior can aid the determination of the true number of groups. we acknowledge, however, that the modeler still has to specify the hyperparameter γ and the maximum number of groups k. using simulated data, we have found that setting γ to . often works well and that our model often identifies k groups if the true number of groups is equal or larger than k. while this may be seen as an indication that k has to be increased when using real data, an extremely large number of groups defeats the purpose of dimension reduction, making it increasingly harder to visualize and interpret model outputs. ultimately, we believe that the decision regarding the maximum number of groups k is a balance between what the data suggest and pragmatic considerations regarding how the results will be displayed and interpreted. our empirical example focused on large-scale biogeographical patterns. nevertheless, this method could also be applied in a landscape-scale context, identifying spatial variation in community structure within general habitat types and across patches, or to analyze long-term temporal changes in time-series data of species composition (e.g., christensen, harris, & ernest, ) . given the ubiquity of presence/absence data in community ecology, we believe that the extension of the latent dirichlet allocation model developed here will see a much wider use, becoming an important addition to the toolkit of community ecologists. we thank the numerous comments provided by ben baiser, daijiang http://orcid.org/ - - - robert j. fletcher jr. http://orcid.org/ - - - new screening software shows that most recent large s rrna gene clone libraries contain chimeras. applied and environmental microbiology using null model analysis of species co-occurrences to deconstruct biodiversity patterns and select indicator species. diversity and distributions a comparison of network and clustering methods to detect biogeographical regions african bird distribution in relation to temperature and rainfall care and feeding of topic models: problems, diagnostics, and improvements biogeographical modules and island roles: a comparison of wallacea and the west indies the functional biogeography of species: biogeographical species roles in wallacea and the west indies rapid range shifts of species associated with high levels of climate warming long-term community change through multiple rapid transitions in a desert rodent community nonparametric bayes applications to biostatistics breaking out of biogeographical modules: range expansion and taxon cycles in the hyperdiverse ant genus pheidole rcpp: seamless r and c++ integration worldclim : new -km spatial resolution climate surfaces for global land areas ecological grouping of survey sites when sampling artefacts are present model-based methods of classification: using the mclust software in chemometrics biogeographical regions and phytogeography of the eucalypts ecotone hierarchies spatio-temporal interpolation using gstat breeding distributions of north american bird species moving north as a result of climate change monitoring species abundance and distribution at the landscape scale presence-absence versus abundance data for monitoring threatened species incorporating s gene copy number information improves estimates of microbial diversity and abundance a framework for delineating biogeographical regions based on species distributions poleward shifts in winter ranges of north american birds numerical ecology novel communities from climate change simultaneous vegetation classification and mapping at large spatial scales estimating site occupancy rates when detection probabilities are less than one impact of a century of climate change on smallmammal communities in yosemite national park north american breeding bird survey dataset a globally coherent fingerprint of climate change impacts across natural systems multivariable geostatistics in s: the gstat package r: a language and environment for statistical computing ecological responses to habitat edges: mechanisms, models, and variability explained n-mixture models for estimating population size from spatially replicated counts reducing the effects of pcr amplification and sequencing artifacts on s rrna-based studies dealing with label switching in mixture models re-shuffling of species with climate disruption: a no-analog future for california birds improving the forecast for biodiversity under climate change decomposing biodiversity data using the latent dirichlet allocation model, a probabilistic multivariate statistical method individual movement strategies revealed through novel clustering of emergent movement patterns a network approach for identifying and delimiting biogeographical regions novel climates, no-analog communities, and ecological surprises survey of clustering algorithms extending the latent dirichlet allocation model to presence/absence data: a case study on north american breeding birds and biogeographical shifts expected from climate change key: cord- -qwh ei authors: knopf, harry l.s.; hierholzer, john c. title: clinical and immunologic responses in patients with viral keratoconjunctivitis date: - - journal: am j ophthalmol doi: . / - ( ) - sha: doc_id: cord_uid: qwh ei nan ocular viral infections manifest them selves in a variety of clinical pictures. most commonly, the clinician finds follicular con junctivitis, with or without accompanying keratitis. epithelial and subepithelial corneal infiltrates are frequently observed with adenovrrus mwnons. hut -also occur with hprppg simpw and nfhpr sriraijnduced kerajilis-ia&ctions. ' in addition to keratoconjunctivitis, viruses can (directly or in directly) cause deep ocular involvement, in cluding uveitis and optic nerve inflamma tion. in an effort to learn more about the etiolo gies of ocular viral infections and the pathogenesis of viral keratitis, we studied two groups of patients with epidemic and nonepidemic viral infections. all of them had follicular conjunctivitis, and many suffered from keratitis during at least one stage of their illness. we had three major goals: to determine the rate of viral recovery from cases of nonepidemic acute or subacute follicular conjunc tivitis; to compare the accuracy of clinical diagnoses with that achieved by culture or serologic studies, or both; and to explore the possible role of serum antibody in the forma tion and maintenance of corneal subepithelial infiltrates. we examined one group of patients who were involved in an epidemic caused by a single viral agent, and a second group of patients who were infected with many differ ent viruses. our results indicate that a variety of agents can cause similar illness patterns, and that clinical observation cannot always distinguish one from another. furthermore, serologic tests are a more accurate diagnostic method than clinical course in ocular viral illness, as is the case in systemic viral illnesses. finally, viral anti body titers may correlate directly with spe cific clinical changes in adenovirus-induced keratoconjunctivitis. patients-we studied two groups of pa tients by the following methods. the first was a population of industrial employees who had epidemic keratoconjunctivitis. these patients were described in detail elsewhere, but the data concerning their ocular findings were not presented. the second group of patients comprised a heterogeneous population seen during an -month period. the only criterion for se lection was follicular conjunctivitis. all but nine patients were seen in the emergency room, clinic, or staff offices at barnes hos pital from november to december . the other nine were followed at the national eye institute from july to june . one of us (h.l.s.k.) saw every patient during the acute or subacute phase of the illness and followed them until signs and symptoms abated. there were males and females, ranging in age from to years old (mean, . years). twenty-nine patients were black, were white, and two were orientals. all were ambulatory and in good health. collection of virus culture specimens-fifty-eight of the nonepidemic patients had viral cultures. a cotton swab was rolled in the inferior cul-de-sac and transferred to a carrier medium (sodium chloride, potas sium chloride, dipotassium phosphate, char coal, and agar, ph . ). the contents of this tube were either stored at - °c for a short period or immediately transferred to tissue culture tubes of human diploid fibroblast, primary human embryo kidney cell, or human epidermoid carcinoma. stan dard culture methods have been described previously.* all viruses isolated in this initial attempt were passed and compared to ref erence prototype virus strains for indication of atypicality. the methods for viral culture in the epidemic keratoconjunctivitis patients have been described elsewhere. a single patient was cultured for trachoma inclusion con junctivitis (tric) agent by other meth ods. serologic studies-of the original study patients, did not return for a convalescent serum. therefore these serologic results are based on patients. we collected sera dur ing the acute phase and once or twice during the convalescent phase. there were two family groups in which a specimen from one uninf ected member was considered acute and another infected member's specimen was considered convalescent. we took a con valescent specimen from of the pa tients within days of the initial visit; within days; and three patients had speci mens that were separated by more than days. the sera were tested for antibodies to the prototype strains of many respiratory and other viruses in order to survey all of the likely causes of follicular conjunctivitis (table ) . complement-fixation, hemagglutination-inhibition, indirect hemagglutination, or serum neutralization tests were employed as appropriate for each particular virus. the sera were heat-inactivated ( °c, minutes) for all serologic tests. antibodies to influenza a, b, and c, parainfluenza , , and , mumps virus "viral antigen," rubeola, respiratory syncytial virus (rs v), coronavirus oc- and e, herpes simplex , varicella, mycoplasma pneumoniae, bedsonia (tric agent), cytomegalovirus, and adeno virus group-specific hexon-antigen were as sayed by the standardized complement-fixa tion test with overnight fixation of units of complement. ' antibodies to influenza a and b, parainfluenza , , , a, and b, newcastle disease virus, mumps virus, rubeola, coronavirus oc- , vaccinia, and adenovirus types to were assayed by the standardized hemagglutination-inhibition test with . m phosphate-buffered saline diluent and spectrophotometrically standard ized . % mammalian or . % avian red blood cells. antibodies to coronavirus e were additionally measured by an indirect hemagglutination test. neutralizing anti bodies to rubeola, rs v, selected adenoviruses, the six coxsackie b viruses, echovirus types and , and coxsackievirus a- were assayed by serum neutralization tests in human epidermoid carcinoma or monkey kidney tissue culture.' neutralizing vol. , no. viral keratoconjunctivitis antibody titers to vaccinia, herpes, coxsackievirus a- , a- , and a- , and four strains of acute hemorrhagic conjunctivitis virus were similarly assayed by serum neutraliza tion tests in human diploid fibroblast tissue culture. serum neutralization antibodies in coxsackievirus a- and a- were assayed in suckling mouse brain. for diagnostic purposes a fourfold titer change (either rise or fall) was consid ered significant for any of the serologic tests. in addition a stable titer of > : in any serologic test (hemagglutination-inhibition, serum neutralization, or complement-fixa tion) suggested infection with that agent if the clinical course and other serologic tests were confirmatory. when serologic comparisons were carried out, as with the adenovirus groups described below, all of the testing was done in a stan dardized manner. we used only the hemag glutination-inhibition test, with . m phos phate-buffered saline and standardized mam malian or avian red blood cells, to compare adenovirus types. antigens for types to were maintained at the center for disease control and were used for similar serologic studies in the past. other serologic test re sults did not enter into the calculations for significance of titer levels. we tested all sera simultaneously and in duplicate with the same cell lots whenever possible so that test ing conditions and results would be equiv alent. clinical examinations-those patients who had epidemic keratoconjunctivitis were ex amined during the initial phase of their ill ness and approximately one month after res olution of all symptoms. visual acuity was re corded and, by slit-lamp microscopy, we made a determination of presence or absence of subepithelial infiltrates. there was no at tempt to quantitate these or to judge sever ity. the patients in the nonepidemic group were treated in a different manner. all pa tients were seen at least twice for evaluation of subjective and objective evidence of ocu lar illness. during each examination, we at tempted to document severity of symptoms, visual acuity, the presence of pre-auricular nodes (or other adenopathy), and the appear ance of the conjunctiva, cornea, and anterior chamber by slit-lamp microscopy. detailed drawings of the cornea were made in keratitis cases, but the exact number of lesions was not recorded. instead, we attempted to depict accurately the areas of cornea in volved for future evaluation. each patient was followed until keratitis showed signs of stability or actual regression. when possible, those patients with persistent lesions were followed for a longer time period. at the end of the study period, all of the drawings were re-examined. for each pa tient we estimated the percentage of cornea involved with infiltrates during the peak phase of the illness. we assigned values be fore the serologic data were available. when all of the serologies were complete, the adeno virus groups were investigated separately. we calculated the severity of keratitis vs. sero logic titer by hemagglutination-inhibition test values and the percentage of corneal involve ment arrived at previously. therapeutic regimen-almost all of the patients were treated with topical antibiotics, compresses, or astringents. two of the pa tients in the adenovirus group received « corticosteroids after cessation of the acute phase and when visual acuity decreased. pa tients in the herpes group were given various antiviral preparations. although these were generally effective in controlling the acute disease, we did not attempt statistical corre lations to determine efficacy. ancillary studies-we took swabs for rou tine bacterial cultures in nonepidemic pa tients simultaneously with the viral cultures. although most of these were taken at ran dom, occasionally patients presented with signs and symptoms suggestive of bacterial conjunctivitis complicating the viral illness; these patients were cultured specifically to identify possible infectious agents. in addi tion, conjunctival scrapings were examined american journal of ophthalmology october, s in patients. these were processed with giemsa or gram stains, or both. tear studies-tears were collected from ten patients with acute and chronic, nonepidemic viral infections or chronic noninfectious conjunctivitis. the details for collect ing, processing, and quantitating immunoglobulins in tears have been described pre viously. ' the viral serologic studies on the tear specimens were similar to those done on the sera from these individuals, but the tear specimens were not heat-inactivated and were diluted starting at : instead of : . (other studies involving the epidemic keratoconjunctivitis group have been de scribed previously. ) although more than % of the infected eyes were cultured, the yield of positive viral cul tures was low. table * shows the difference between the number of positive isolates ob tained by culturing before or after the eighth * all of the data for the epidemic keratoconjunc tivitis group were published elsewhere, except for the corneal quantitative material in clinical studies.' day of illness. culturable virus tended to dis appear after the first week of illness in most of the virus groups examined. adenovirus isolates (types , a, , and ) were typical prototype-like strains but three of the adenovirus type a viruses were not; these were neutralized or inhibited less well with prototype reference antisera than with the patient's own convalescent serum. this was not clinically significant. serologic studies (nonepidemic patients)-since positive viral cultures were sparse, the restrospective study of acute and convales cent sera constituted the major means of diag nosis. if cultures were positive or if clinical evidence pointed to a specific diagnosis-the presence of herpetic dendrites-the total bat tery of serologic tests (table ) was not al ways carried out. we compared the clinical and serologic diagnoses in the patients whose sera we examined (table ). all patients with posi tive cultures showed the expected serologic changes. two patients appeared to have ex perienced infections with two agents, either simultaneously or in close temporal proxim ity. in one patient, the hemagglutination-inhibition titer to adenovirus type was stable at : , indicating a recent infection; at the same time, the culture for tric agent was positive. the second patient had an ill ness characterized by initial upper respiratory infection and secondary chronic uniocular keratitis, with comeal ulceration and recur rences. over the three months of observation during the chronic phase, he developed a gradual fourfold rise in adenovirus type hemagglutination-inhibition antibody ( : to : ). almost eight months after his initial illness he demonstrated signs of an terior uveitis after an upper respiratory ill ness (nonspecific) and increased his herpes simplex antibody titer fourfold ( : to : ) in both complement-fixation and serum neutralization tests. these data sup port a premise of double infections in both patients. five additional patients demonstrated sero-vol. , no. viral keratoconjunctivitis logic changes suggestive of either sequential or simultaneous infection with two or three agents. however, in these patients we could not differentiate clinically among the various agents. therefore, the serology that best fitted the clinical picture and time sequence of infection was chosen as the final diagnosis. most of the clinical misdiagnoses were made in the cases of presumed epidemic keratoconjunctivitis. adenovirus type was the most prominent masquerader, and herpes simplex passed for epidemic keratoconjunctivitis in one case. we listed the geometric mean titers for the major adenovirus groups encountered in this study in table . although the average fold-rise in geometric mean titers was simi lar, the final absolute titers were different by more than twofold. this difference was sta tistically significant. in an attempt to explain the higher final titer of the group adenovirus-infected pa tients, we looked at two different factors. the first was a consideration of a possible differ ence in the acute and convalescent phase se rum samples ( table ). the two groups were similar in makeup in that nine of group patients and ten of group were examined during the acute phase of their illness: they showed a fourfold rise in their titer to the infecting adenovirus. there was a moderate disparity between patient history and the serologic data. three group patients (cases , , and ) claimed they were ill for a few days, but their titer reflected a long-term illness (> initial or no change with time, or both). we ob served one patient (case ) with an un changing : titer throughout his illness, and we could not explain the lack of change in titer. this disparity was less evident in group (case ). the difference in acute phase geometric titer for each group was nearly significant . < p < . ). however, when we con sidered only patients proven to be in the acute phase, the difference was not signifi cant ( . vs. . ; p > . ). there was a difference in the number of days between acute and convalescent samples for the two groups. overall, the mean num ber of days was for group and for group (not significant). however, if only the patients in the acute phase were again considered, the averages were days and days, respectively (p <. ; t = . ; df, ). (from these data, a higher titer should have been expected for group be cause of the longer interval between acute phase and serum peak.) thus, neither the titer of acute phase sera nor the sampling time of convalescent phase sera seemed to ac count for the difference in final antibody levels. we also considered the degree of upper respiratory or generalized illness among pa tients in both groups. of the patients with serologic evidence of group infection, only gave accurate histories; nine of these reported an associated upper respiratory in fection with conjunctivitis. in contrast, one (with adenovirus type ) of the patients in group exhibited signs or symptoms of upper respiratory infection. this differ ence was again significant (p < . , \ test). thus, those with group nonepidemic adenovirus infection were afflicted with more upper respiratory infections, but these in- fections were not necessarily responsible for the significantly higher serologic titers. in fact, there was no significant relationship be tween the presence of an upper respiratory infection and a serologic response that equaled or exceeded : (table ). this negative correlation held true for changes in both homologous and heterologous virus titers. therefore, the explanation for the higher serum titers in patients with group infections may not be related directly to the concomitant upper respiratory infections. we compared the sensitivity of the two most commonly employed serologic tests (table ) . hemagglutination-inhibition tests demonstrated fourfold rises in many cases where complement-fixation tests failed to show significant changes. hence, primary de pendence on the usual complement-fixation hexon-antigen test would have resulted in fewer positive diagnoses, even in acute infec tions. ancillary laboratory studies (nonepidemic patients)-we microscopically examined conjunctival smears from patients, and routine bacterial cultures were taken from of these patients plus ten other individuals. cultures from five patients showed coagulasepositive staphylococci; these patients had various diagnoses: adenovirus type epi demic keratoconjunctivitis, adenovirus type pharyngoconjunctival fever, herpes sim plex keratitis, and a case of chronic "fac titious" conjunctivitis. the smears were helpful only in cases of herpetic infections. in three patients with herpes simplex and one with herpes zoster, twenty-eight patients showed signs of keratitis during their illness and had chronic subepithelial infiltrates when examined one month after resolution of their illness ( of these experienced some degree of decreased visual acuity as well). the remaining patients, who were also infected during the first wave of the epidemic were seen at the same time and had no subepithelial infiltrates. the peak geometric mean hemagglutination-inhibition titer of the for mer group with residual infiltrates was : . (range : to : ). the data for the un affected group were : . geometric mean titer (range : to : ). this difference was significant (p < . ). (the collection of sera and intervals between examinations were similar for patients because they were part of an epidemic group. the serologic tests were exactly the same as those carried out in the nonepidemic group, and often were done simultaneously t estimated maximum percent of cornea with epithelial or subepithelial infiltrates. * titers did not change significantly (> fourfold) during the observation period (compare with table ) analysis of corneal disease. group was composed of five patients with adenovirus type and patients with adenovirus type infections. group contained patients with adenovirus type and one each with adenovirus type and adenovirus . the data concerning the corneal involve ment and antibody levels of both groups were compiled (table , compare with table ). analysis by x testing showed several sig nificant correlations. first, the number of eyes involved with corneal changes differed significantly in the two groups. in group , there were five patients with no involve ment, seven with one eye, and four with both eyes affected. group had only one patient without corneal changes, three pa tients with a single eye involved, and nine patients with both eyes involved (x = . ; df, ; ps . ). when this same factor vol. , no. (number of eyes) was used, and the antibody levels were compared for all adenovirus infections (groups and ) , a more signifi cant difference was noted. at a level of : , there were doubly involved patients, four with one eye, and three with no corneal in volvement. at a level of : , only one pa tient showed infiltrates in both eyes, six had single eye involvement, and three had no ocu lar involvement. the difference between the number of patients in these three categories proved to be statistically significant (x = . ;df, ;p<. ). correlations of the degree of corneal in volvement with antibody level were also car ried out. there was no difference between the two groups in the number of patients with central lesions vs. peripheral lesions of the cornea. this was reflected in the patients with decreased visual acuity (table ) . we devised a comparison of the two groups in terms of fold-rise in antibody titer (fig ure) . (the fold-rise was a reflection of the rate of antibody production as well as the amount of antibody.) as evidenced by the graph, the responses of the two groups were almost diametrically opposed. for each foldrise in titer, the group patients had pro gressively less corneal involvement. for the same change in titer, the group patients showed progressively more corneal infiltra tion. however, the final level of antibody achieved was lower in group (compare with table ). a similar difference in the two groups was noted at the % level of corneal infiltration. only two patients (of ) in group had infiltrates that involved > % of the corneal surface area. in group , six of patients were affected in the same way ( x = . ; df, ; p<. ). finally, age was not a factor differentiat ing the two groups. the average age of group patients was . years; group patients averaged . years. the difference was not statistically significant (t = . ; df, ). a comparison of the percent corneal involvement with fold-rise in antibody titer among patients infected with group (av ) and (av ) adenoviruses. r represents the correlation coefficient of the least-squares line calculated to fit the data. only patients with at least a fourfold rise are included. group)-rises in titers to heterologous vi ruses were observed in groups and infec tions. thus, in patients infected with adeno virus type (group ), a significant change in titer to this agent occurred, as well as smaller changes to such related types as , , and (table ). however, rises in heterologous titers were more consistently seen in patients with group infections. for example, adenovirus type infections produced rises to related viral types in the group series. this was reflected in the higher heterologous average titers (table ). in particular, we noted a tendency for heterologous responders within family groups. in one of these families, all of the blood relatives showed changes in titer to several other group subtypes after adeno virus type infection. however, the spouse of one member, exposed to the same virus, had a serologic change to adenovirus type alone (homologous responder). american journal of ophthalmology october, we observed patients with keratoconjunctivitis from other causes during this study (table ) , but only adenovirus patients formed homogenous groups that lent them selves to statistical analysis. the herpes group was large (eight herpes simplex, two herpes zoster, two possible mixed herpes simplex-zoster, and three presumed cytomegalovirus), but heterogenous in terms of acute and chronic illness, treatment with var ious antiviral drugs or corticosteroids, and poor serologic responses. variability in his tory, follow-up, and other factors occurred among the patients with adenovirus so the number of patients who met the criteria for various analyses often differed from one test to another. in terms of treatment, however, almost all of the patients with adenovirus required only therapy with topical vasocon strictors or antibiotics, or both. only two patients (one each from groups and ) required corticosteroids for symptomatic re lief, and this was instituted after achieving maximum corneal scores. analysis of tears-ocular external secre tions (tears) were analyzed in ten patients. in general, there were low antibody titers. four patients with serologic diagnoses of herpetic infection represented chronic, re current keratoconjunctivitis or kerato-uveitis. only one patient with disci form keratitis and uveitis had detectable tear-borne neutralizing antibody to herpes simplex. his serum titer, however, was not greater than : in a simul taneous neutralization test. one other patient showed tear antibody to herpes zoster and se rologic changes consistent with simplex. whether this represented true simultaneous infection or the presence of cross reaction was not determined. two patients had high titers ( : , : ) to coronavirus oc- in their external secretions. upper respiratory infection has produced antibody in tears and this may represent that kind of relationship. the predominant immunoglobulin species in the tears was iga, in agreement with pre vious work. ' however, we made no at tempt to prove that the measurable hemagglutination-inhibition or serum neutralization antibodies were unique to iga. discussion because all patients in the second part of this study were seen during a nonepidemic time period, the cases of keratitis were varied in their etiologies (table ). this observa tion agrees with previous studies that de scribed a similar variety of viral agents re sponsible for epidemic keratoconjunctivitis keratitis. " the behavior of the individual viral infec tions also conformed to expected patterns. thus, group adenoviruses caused more upper respiratory and generalized illness, but less keratitis, than group infections. ' - [ ] [ ] [ ] herpes viruses caused more severe keratitis and kerato-uveitis, but clinical illnesses cor related poorly with serologic changes in anti body titer. ' we also encountered difficulty in culturing any virus after seven to ten days of symptoms. this has been reported before for epidemic keratoconjunctivitis, but it is probably true for many other viral syndromes. , - we, like others, also found the hemagglutination-inhibition test to be supe rior to complement-fixation as a serum diag nostic procedure in adenovirus infection. no procedure gave consistent results with tears. there were differences in the extent of corneal involvement observed in group and infections. the correlations indicate that group viruses produced a lower level of specific antibody titer (despite a longer time interval between the collection of acute and convalescent sera), and induced more corneal disease in the affected indi viduals. these data suggest that the higher anti body titer in group protected the cornea, supported by examination of the keratocon junctivitis epidemic of adenovirus type , a group virus. in the latter patients, a range of antibody was observed that was somewhat higher than that of the nonepidemic group . (the reason for this difference is not readily apparent, but does not lie in testing differences, since both sets of sera were ex amined under identical conditions and often simultaneously.) what is more important, however, is the range of corneal involve ment with this single viral agent. once again, the patients with higher antibody titer ex perienced less corneal involvement with this usually virulent agent. ' the corneal infiltrates may only represent a pattern of infection and the antibody re sponse to it. certainly more than one viral type can cause this pattern, as shown in the nonepidemic group. also, the same virus can cause different degrees of involvement (epi demic study), perhaps depending on the level of antibody illicited by the infection. since delayed hypersensitivity was not spe cifically assayed, the elevated humoral anti body in epidemic group or nonepidemic group patients may reflect a higher degree oi overall immunity, and cellular immunity may be the chief deterrent of corneal dis ease. however, systemic antibody alone may protect the cornea (and even the fellow eye) from severe involvement. whether it was humoral or cellular, or both, the nonepidemic and epidemic groups of patients displayed a reasonably similar pattern of protection that correlated with high antibody titer. we only speculate about the pathogenesis of the subepithelial infiltrates. in studies of immune-complex disease, for instance, rheu matoid arthritis and aleutian mink disease, antigen-antibody complexes in blood vessel walls can attract complement and inflamma tory cells that cause the damage. ' these complexes are made to persist by maintain ing a low titer antibody, and the disease may be completely eliminated by raising the titer. the cornea is similar to the collagenous tis sue in the walls of blood vessels, and these tissues can absorb certain antigens. ' therefore, it seems feasible that viral par ticles might be bound to the stromal collagen, form complexes with low levels of antibody diffusing within the cornea, and thereby act as a nidus for inflammation. the subsequent fixation of complement and attraction of in flammatory cells completes the subepithelial infiltrate seen by slit-lamp microscopy. corticosteroids would disrupt the inflammatory response, but it would not remove the com plexes. hence, discontinuation of the drug would allow inflammatory cells to reappear. a similar set of circumstances was proposed in the pathogenesis of stromal disease in herpes simplex keratitis. based on these suppositions, one may con clude that the sometimes permanent visual damage observed in epidemic keratoconjunctivitis might be decreased or eliminated by enhancing the immune response of the in fected patient, perhaps during the acute in fection. of individuals suffering from follicular conjunctivitis, with or without keratitis, had epidemic keratoconiunctivitis caused by adenovirus type . the remaining pa tients had keratoconjunctivitis produced by several different viruses, including herpes simplex, adenoviruses types , , , , , and , and others. positive viral cultures were difficult to obtain after the first week of illness in most viral infections. serologic tests were far more successful in identifying causative agents. hemagglutination-inhibition tests in adenovirus infections proved to be fast, accurate, and more sensitive than other serologic tests. among the epidemic and nonepidemic adenovirus groups, the de gree of corneal involvement in the infections appeared to be correlated with the level anti body against the infectious agent. patients with low antibody titers had more severe keratitis than those with high titers. this correlation was true for both the epidemic and nonepidemic patients. microbiology of the eye adenovirus type keratoconjunctivitis in the united states. . epidemiologic, clini cal and microbiological features epidemic keratoconjunctivitis. a severe industrial outbreak of adenovirus type adenoviruses simplified irradiated mccoy cell culture for iso lation of chlamydia standardized diagnostic com plement fixation method and adaptation to micro test, no. standardized viral hemagglutination and hemagglutination-inhibition tests. . description and statistical evaluation detection of coronavirus e antibody by indirect hemagglutination antibody in tears following intranasal vaccination with in activated virus. . enhancement of tear antibody production by the use of polyinosinic: polycytidilic acid (poly i:c) epidemic keratoconjunctivitis on taiwan. etiological and clinical studies adenovirus type infections in the united states adenovirus infection of the conjunctiva and cornea association of adenovirus type with epidemic keratoconjunctivitis diagnosis of adenovirus infections by use of fluorescent antibody technique corneal im mune response to herpes simplex virus antigens the pathogenesis of chronic inflam mation in experimental antigen induced arthritis. . preferential binding of antigen antibody complexes to collagenous tissues the patho genesis of corneal inflammation due to herpes sim plex virus key: cord- -lc hp o authors: nenna, raffaella; frassanito, antonella; petrarca, laura; di mattia, greta; midulla, fabio title: age limit in bronchiolitis diagnosis: or months? date: - - journal: front pediatr doi: . /fped. . sha: doc_id: cord_uid: lc hp o aim: the most frequent cause of lower respiratory tract infection in infants is bronchiolitis. up to now there is no agreement on the upper limit age of bronchiolitis. our aim was to identify if there are clinical differences in infants hospitalized for bronchiolitis between – months and – months of age. a secondary aim was to establish whether there was differences in terms of recurrent wheezing at , , and months of follow-up. methods: we retrospectively analyzed clinical and virological records of infants hospitalized for bronchiolitis during consecutive epidemic seasons. from each infant at admission to the hospital nasopharyngeal washing was collected, clinical severity was assessed and clinical data were extracted from a structured questionnaire. at – – months after discharge, parents were interviewed seeking information on recurrent wheezing. results: a total of infants (group ) were ≤ months of age, while were > months (group ). no differences between family history for atopy and passive smoking exposure were observed between the two groups. respiratory syncyzial virus was detected more frequently in group and human bocavirus in group . the clinical severity score (p = . ) and the use of intravenous fluids (p = . ) were higher in group with respect to group infants. at months follow-up / ( . %) group and / group infants experienced recurrent wheezing (p = . ). conclusion: we demonstrated that - months old infants bronchiolitis differs from > months bronchiolitis. bronchiolitis is a common cause of lower respiratory tract infection in infants and the major responsible factor of hospitalization under the age of one year, with the highest incidence occurring between december to march. respiratory syncytial virus (rsv) is major involved virus, but also other respiratory viruses are able to cause bronchiolitis ( ) . some infants that require hospital admission for bronchiolitis will present recurrent wheezing episodes later in life ( ) . up to now, there has not been an agreement on bronchiolitis definition concerning the upper age limit, which varies between and months ( , ) . growing evidences suggest that the upper age limit should be restricted to months ( ) . we retrospectively analyzed clinical differences between - months and - months old infants, among our cohort of infants hospitalized for bronchiolitis at the pediatric emergency department, "sapienza" university of rome, during eleven epidemic seasons. among our cohort of full-term previously healthy infants hospitalized for bronchiolitis during consecutive epidemic seasons, ( . %) were - months of age and ( . %) were - months old. bronchiolitis was defined as the first episode of acute lower airway infection, characterized by a history of upper respiratory tract infection followed by acute onset of respiratory distress with cough, tachypnoea, retraction, and diffuse crackles on auscultation. exclusion criteria were prematurity and underlying chronic diseases, such as immunodeficiency, hemodynamically significant congenital heart disease, and pulmonary chronic diseases, such as cystic fibrosis and interstitial lung disease. in line with confidentiality requirements, the database was anonymized and the ethic committees approved the study after infants' parents have released their informed consent. nasopharyngeal washing (npw) was collected from each infant within h. samples were delivered within - h to the virology laboratory and vortexed with beads to dissolve mucus, if needed. rsv was detected using a panel of reverse transcription pcr or nested pcr assays, as reported ( ) . at admission to the hospital, clinical severity was assessed using a score ranging from to , as described ( ) . clinical data were extracted from a structured questionnaire and clinical medical records. at - - months after discharge, parents were interviewed using a standardized telephone procedure with a structured questionnaire seeking information on recurrent wheezing (two or more physician verified episodes of wheezing / year for three consecutive years). a standard statistical package was used for comparisons between groups (spss version . , chicago, il). χ test was used to compare frequency distributions obtained from the two groups. statistical means, medians, standard deviations and interquartile range were computed as well as mann-whitney utest was performed, in order to compare groups. a binary logistic regression analysis was performed to evaluate the odds ratio. a two-tailed p < . was considered significant. a total of infants (group : median age: . months, range: . - . months; males: . %) were ≤ months of age, while were > months (group : median age: . months, range: . - . months; males: . %). a family history of asthma ( . vs. . %) and atopy ( . vs. . %) was similar between the groups. group infants had slightly less frequently tobacco smoking exposure (p = . ) than group . the hospitalization for bronchiolitis occurred over the period december-march in the . % of group and . % of group infants (p = . ). a virus was identified from the nasal washing of . % group and . % of group infants. among virus positive infants, rsv was the most frequently detected virus ( . vs. . %, p = . ), followed by human rhinovirus (hrv: . vs. . %), abbreviations: hbov, human bocavirus; hmpv, human metapneumovirus; hrv, human rhinovirus; npw, nasopharyngeal washing; pcr, polymerase chain reaction; rsv, respiratory syncytial virus. table ) . at months' followup / ( . %) group ( . % of rsv and . % of hrv infants) and / ( . %) group ( rsv and % of hrv) infants experienced recurrent wheezing (p = . ). the bivariate logistic regression designed to investigate the possible confounding factors (sex, clinical severity score, days of hospitalization and exposure to passive smoking, rsv, hbov, and iv fluid) showed that the - months group had an odds ratio of hbov detected at the npa of . ( % ci . - . ) and the need of iv fluid of . ( % ci . - . ). this study analyzed the clinical differences among infants hospitalized with bronchiolitis divided according to the age: ≤ months and > months. younger infants had more frequently rsv infection and a more severe disease. on the contrary, older infants had slightly more tobacco smoking exposure and slightly higher recurrent wheezing after the hospitalization. the hbov has been identified almost entirely in infants older than months. a distinct characteristic of our cohort is the adherence to strict inclusion criteria in bronchiolitis diagnosis, such as age < year, infants at the first episode of lower respiratory infection and the presence of crackles. this large series of bronchiolitis infants collected during consecutive epidemic seasons allows an accurate evaluation of the age limit. the definition of bronchiolitis as the first episode of acute viral wheeze occurring in infants less than two years, likely overlaps the early presentation of asthma or bronchial hyper-responsiveness ( ) . moreover, bronchiolitis is a frequent and costly disease with mainly supportive treatment. many studies have been made with the aim of finding other therapies, with controversial results ( ) . a single definition of bronchiolitis will allow analyzing homogeneously disease's pathogenesis and the possible role of new therapeutic strategies. although it has been already demonstrated that clinical presentation of bronchiolitis can vary over different epidemic years ( , ) , the inclusion of full term infants, without any comorbidities over consecutive epidemic seasons in our study should ensure that this variability is overcome. according to our data, the two age groups differ for the etiology. in fact, rsv remains the most important etiological agent causing bronchiolitis ( ), particularly in - months old infants, while hbov was almost exclusively detected in older infants. interestingly, hbov is an emerging virus frequently identified in wheezing children ( ) . moreover, hmpv was detected only in younger children. some authors indicated that hmpv may cause an illness similar to rsv and follows the same epidemiology ( ) . older infants were slightly more frequently undergone to tobacco smoking exposure. secondhand tobacco smoke in children causes decreased lung function and increased airway responsiveness and consequently it may predispose infants to more severe infections ( ) . passive smoking might be considered as risk factors in this age group. we could conclude that, while bronchiolitis affects independently younger infants, in > months' infants it causes hospitalization particularly when risk factors are present, such as tobacco smoking exposure. the finding of a more severe disease reflects the different characteristic of younger infants with bronchiolitis, who present with retractions, feeding difficulties, and diffuse crackles and, because of the age are predisposed to a more severe disease. in fact, the leading risk factor for severe bronchiolitis is the young age ( ) . in addition, - months old infants had a longer hospital stay. it may be explained because of the more severe illness in this age group. the multivariate analysis showed that the need of iv fluid was higher in the group aged - months, reflecting a higher severity of presentation in this age group. according to our findings of a higher occurrence within the epidemic season and of the slightly higher frequency of recurrent wheezing at months' follow-up, infants > months seems represent a different group of patients hospitalized for bronchiolitis, who are more predisposed to childhood asthma. further studies are needed to clarify the pathogenesis the described difference. in conclusion, we demonstrated that - months old infants' bronchiolitis differs from > months' bronchiolitis. consequently, we believe that is time to reach an agreement on the definition of bronchiolitis, as the first episode of acute lower airways infection, characterized by acute onset of respiratory distress with cough, tachypnea, retraction, and diffuse crackles on auscultation in infants < months, or even months of age. • bronchiolitis is a common cause of lower respiratory tract infection in infants and the major responsible factor of hospitalization under the age of one year. • respiratory syncytial virus is major involved virus in bronchiolitis • infants younger than months had more frequently respiratory syncytial virus infection and a more severe disease. • infants older than months had slightly more tobacco smoking exposure and slightly higher recurrent wheezing after the hospitalization. • the human bocavirus has been identified almost entirely in infants older than months. the datasets generated for this study are available on request to the corresponding author. the study was reviewed and approved by the institutional review board at policlinico umberto i (ref: / ). written informed consent was obtained from the parents/legal guardians. respiratory syncytial virus, human bocavirus and rhinovirus bronchiolitis in infants rhinovirus bronchiolitis and recurrent wheezing: -year follow-up bronchiolitis: diagnosis and management of bronchiolitis in children. london: national institute for health and care excellence american academy of pediatrics subcommittee on diagnosis and management of bronchiolitis. diagnosis and management of bronchiolitis virus-induced wheezing in infants aged - months and bronchiolitis in infants under months are different clinical entities from bronchiolitis guideline to practice: a critical care perspective bronchiolitis hospitalizations in the united states analysis of consecutive epidemic seasons role of emerging respiratory viruses in children with severe acute wheezing clinical disease and viral load in children infected with respiratory syncytial virus or human metapneumovirus association of tobacco smoke exposure and respiratory syncitial virus infection with airways reactivity in early childhood incidence and predisposing factors for severe disease in previously healthy term infants experiencing their first episode of bronchiolitis rn: analysis performance, interpretation of data for the work and drafting the work. af, lp, and gd: acquisition of the data. fm: conception and design of the work. the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © nenna, frassanito, petrarca, di mattia and midulla. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord- -kd xvsg authors: zenetos, argyro; papathanassiou, evangelos; aartsen, jacobus j. van title: analysis of benthic communities in the cyclades plateau (aegean sea) using ecological and paleoecological data sets date: - - journal: mar ecol (berl) doi: . /j. - . .tb .x sha: doc_id: cord_uid: kd xvsg abstract. in the cyclades plateau (aegean sea), a qualitative and quantitative analysis of macro‐benthic fauna was carried out in . standard multivariate analysis techniques were applied to both ecological (living benthic fauna) and paleoecological data sets in order to distinguish distribution patterns. results showed that caution must prevail in drawing conclusions from a limited data set. the clearest classification was obtained using total living fauna, while the dead molluscan fauna gave a similar pattern; this indicates similar response to the environmental conditions of the area. in the analysis of the living molluscan fauna, the groups failed to show any clusters, probably as an effect of some impoverished sites. in the two groups delineated, depth seems to be the major factor in the distribution of species. the fact that two distinct data sets (subfossil assemblages and living communities), when treated separately, produce similar grouping indicates that the subfossil assemblages could be reliably used as a first approach for determination of the living communities' distribution patterns. similar pattern; this indicates similar response to the environmental conditions of the area. in the analysis of the living molluscan fauna, the groups failed to show any clusters, probably as an effect of some impoverished sites. in the two groups delineated, depth seems to be the major factor in the distribution of species. the fact that two distinct data sets (subfossil assemblages and living communities), when treated separately, produce similar grouping indicates that the subfossil assemblages could be reliably used as a first approach for determination of the living communities' distribution patterns. recognizing that our knowledge of the benthic communities of the aegean sea is poor (pbres & picard, ; jacquoite, ; vamvakas, ) , a largescale project was initiated by the national centre for marine research. it aimed at examining the structure of deeper benthic communities as well as mapping their distribution over the aegean sea. ecological surveys usually result in complex bodies of biotic and environmental data from which patterns and relationships need to be extracted. numerical taxonomy is "the numerical evaluation of the affinity or similarity between taxonomic units and the ordering of these units into taxa on the basis of their affinities" (sokal & sneath, ). in ecological studies the "taxonomic u. s. copyright clearance center code statement: - / / - $ . / units" are ecological units (stations) and the taxa are biotopes (q-mode analysis), or respectively the taxonomic units are species and the taxa are benthic communities or "biocoenosis" (r-mode analysis). in paleoecological studies the taxonomic units are species and the taxa are biofacies. a review of the multivariate analysis techniques applied to a variety of ecological data is given in clifford & stephenson ( ) , while an outline of the successfully employed methods for analysing multispecies distribution patterns is presented in field et al. ( ) and gray et al. ( ) . regarding macrobenthic fauna, the above-mentioned classification techniques have been mpst commonly used either taking into account the total number of species encountered in a survey (stephenson & williams, ; stephenson er al., ; reys, ; field el at., ; k n o~ et al., ; hruby, ; gray et at., ; weston, ) or a certain group only, e.g., molluscs (robert, ; coleman & cuff, ) , copepods (sarvala, ) . on the other hand, paleontologists have applied the same techniques in order to define biotopes and biofacies based on a single group. thus, we have biofacies and biotopes of ostracods (maddocks, ) , of foraminiferans (kaesler, ; michie, ), or molluscs (zenetos, . in this study an attempt is made to recognize biotopes using standard multivariate analysis techniques but based separately on a) ecological data and b) paleoecological data. the validity of the various data sets in delimiting biotopes is discussed. benthic samples were taken at stations in the cyclades plateau (fig. i ). with the r n "aigaio" in july . four replicate samples were collected at every station with a . m smith-mcintyre grab. all samples were washed on a mm mesh sieve and the animals removed and preserved in a % formalin solution with rose bengal stain. in the laboratory. macrofaunal organisms sorted from the samples were preserved in % isopropanol, identified to the species level, and counted. the four replicates from each station were lumped and the total number of individuals per m for each species was calculated. the dead molluscan fauna was identified to species level. the water depth at the sampling sites ranged from to . depth. sediment characteristics. and exact location of the sampling sites are given in table . three sets of data: a) total living macrofauna species (numerical abundance), b) living molluscan species (numerical abundance), and c) dead molluscan species (presenceabsence), were treated separately in order to define zones of faunal similarity (biotope analysis). from the species list of each station. margalef's species diversity index was calculated: margalef. ) in n where s = the number of species and n = the total number of individuals. correlations were sought between the biotic parameters (number of species, number of specimens, diversity index) with the abiotic ones (sampling depth. substrate type) using spearman's nonparametric rank correlation coefficient (siegel. ). , ) . in seeking the "best map of the results derived by classification" (field n ul.. ), ordination techniques (mds: multidimensional scaling) were applied. other non-parametric statistics were applied where appropriate using the software package statgraphics. finally, r-mode analysis was used in order to define which species are responsible for the grouping of the q-mode analysis. classification and ordination were carried out using the program primer of the plymouth marine laboratory. a total of specimens belonging to taxa were identified from the living macrofauna and molluscan species from the dead material. among the species of living macrofauna, were molfmca; here clustering was performed separately. the species richness, abundance, and diversity per station is given in table : the number of species ranged from (station a ) to (station a ), and the number of specimens from -m- (station a ) to .m- (station a the dendrograms can be truncated at any level, but the areal presentation derived with mds based on the total living fauna (fig. a) indicated that the more justified separation in terms of ecological sense was at the groups level ( % similarity) (two dimensional stress = . ). the same separation was evident when environmental parameters were superimposed (fig. b) . taking into account: a) in siru observations, b) the faunal composition of each site, and c) the type of the substrate it is clear that the best classification is obtained with the first data set ( taxonomic units). the grouping of the second set ( taxonomic units) was not well defined and thus not mappable. finally, the third data set led to a classification somewhat similar to the first one ( ' taxonomic units). two of the groups were single site groups (stations a and a ). the other two groups delineated with the dendrogram of fig. are presented in fig. . these are: group , composed of stations located in the middle of the study area with substrate ranging from coastal detritic mud to coarse gravel, rich in detritus. this corresponds to the biotope of the de (muddy detritic assemblages) as defined by picard ( ). stations of group were the most coarse grained in the study area, with coralligenous substrates in their typical aspect along with the soft algae peyssonnelia and numerous bryozoa on concretions produced by organisms. the coralligenous assemblage is very well defined by p q r~ ( ) . the groups delimited with the dendrogram of fig. b are roughly the same as those of fig. . the only difference is that station a m , otherwise clustered in group , was not clustered here but remained as a single site group. similarly, stations a and a , north and south of milos island, remained as single site groups in both cases. the r-mode analysis, when total living fauna was considered, produced clusters of species (table ) table . species groups distinguished by inverse (r-type) analysis. the groups are based on the dendrogram of fig. table shows the results of the spearman rank correlation coefficient between the biotic parameters (number of macrofaunal species, number of specimens, and species diversity) and depth and sediment type. the ranking of sediment type was arbitrary, with rank for the coarser sediments (coralligenous with peyssonnefia) and rank for the finer ones (mud with detritus). tied observations were taken into account and the appropriate formula (siegel, ) applied. fig. on the other hand the correlation is rather weak (not significant statistically), but still positive as might be expected due to the sediment type. the coarser mixed sediments (coralligenous substrate with peyssonneliu, coralligenous + detritus) had a higher species diversity than the fine sediments (e. g., mud with detritus), a correlation well known from the literature (gray, the mann-whitney u-test applied between groups and , for all biotic and abiotic parameters (table ) , indicated significant differences for most of the parameters tested. thus, the average number of species and species diversity were significantly greater in the coralligenous assemblage (group l), where the depth was significantly shallower and the sediment coarser. differences in the mean number of individuals between the groups were not significant. species distribution may be seen as a response to varying effects of certain primary gradients such as depth, latitude, and current speed (pearson & rosenberg, ) . further it is affected by another suite of factors dependent on the primary gradients (e. g., physical factors) or independent of these (e. g., vulcanicity, pollution, biotic interactions). o n the cyclades plateau, a strong negative correlation (p < . ) was found between the biotic parameters (species richness, abundance, and diversity) and sampling depth. unfortunately facilities for obtaining critical hydrographic data were not available, so the interpretation of results is based largely on personal observations on board. the substrate description is also subjective since no sediment grain size analyses were performed. a weak correlation exists between the biotic parameters and sediment type. multivariate classification methods have been widely used in the last decade in order to distinguish distribution patterns in benthic ecology and paleoecology (ormerod, ; warzocha, ) . the results of this study, where standard multivariate classification methods were applied to various data sets from the same area, showed that caution must prevail in drawing conclusions from a limited set of data. the clearest separation into station groups was obtained by using total living fauna ( taxonomic units), the least clear using the living molluscan fauna ( taxonomic units). the classification derived from the dead mollusca ( taxonomic units) also gave clear station groups. in the analysis of the living molluscan data the groups failed to show any clusters. this is probably due to the effect of the impoverished sites such as stations a and a with and living mollusc species, respectively. on the other hand, the dead molluscs gave a pattern similar to that of the total fauna and showed a similar response to the environmental conditions of the area. according to powell er al. ( ) , death assemblages provide two distinct types of data: a) data on recent recruitment and mortality and b) data on long-term events provided by the accumulation of remains buried beneath the surface zone and indefinitely preserved. the clusters in the dendrograms of figs. and can be converted into patterns on the locality map. these distinct non-overlapping areas are biotopes that can be described in physical terms. indeed, the primary division is into depth groups. stations of group are all in depths below loom, while group consists of the three shallower stations above (range: -wm). at the same time, considering the traditional p~r & ( ) classification, two main biotopes can be distinguished in the cyclades plateau area: group , corresponding to the biotope of the muddy detritic assemblages (de) and group , representing the biotope of the coralligenous assemblage (c). usually, station grouping can be interpreted largely by sedimentary characteristics such as median grain size. this information is missing in our case, but sampling depth is no doubt a major factor in the distribution of species. the species clusters (table ) responsible for the grouping of stations do not consist of species characteristic of the above biocoenoses. amphiura filiformis, hyalinoecia bilineara, and notomastus larericeus, all found in high densities, are cosmopolitan species (table ) . on the other hand, species with a fidelity to groups were all encountered in low numbers. such species for the group stations are: asychb biceps, golfngia vulgaris, arnpelisca tenuicornis, nephthys incisa, polymnia nesidensis, nucula nucleus, and cidaris cidaris, with an average density of indiv. * m . group occupied a relatively small geographical area. the species characteristic of the coralligenous assemblage are: catapaguroides timidus as well as the bryozoa setosella vuherata and several species of scrupocellaria. the fact that two distinct data sets (subfossil assemblages and living communities) produce similar groupings when treated separately, leads to the hypothesis that the death assemblages form directly from the living communities. however, in the cyclades plateau, the living mollusc data alone ( species), taken in one sampling cruise, represent a poor data set as indicated by the results of the classical (bray-curtis / group average) classification. given that post-mortem transportation is negligible, then the death assemblage is an important source of data on the living community prior to sampling or when facilities for sampling and analysing living fauna are not available. proper use of these data requires knowledge of how death assemblages form from living communities. a quantitative analysis of the benthic fauna was carried out at stations in the cyclades plateau (aegean sea). taxa were identified from the living fauna and molluscan species form the dead material. a biotic parameters (n, s , d) were strongly related to sampling depth (p < . ), yet only a weak correlation was calculated between the biotic parameters and sediment type. the coarser sediments had a higher species diversity than the fine ones. multivariate analysis techniques were applied separately for the ecological and paleoecological data sets. the dendrogram based on total living fauna using bray-curtk / group average led to a satisfactory classification at the two group level. the same group division was delineated with the dead molluscan fauna. the least clear classification was derived from the living molluscan fauna. the two groups distinguished correspond to depth groups, i . e., the primary division is into stations below m (group ) and stations shallower than m (group ). considering the faunal composition of the stations, group corresponds to the biotope of the de benthic assemblage and group to that of the coralligenous assemblage according to the pbrbs ( ) classification. an ordination of the upland forest communities of southern wisconsin an introduction to numerical classification the abundance distribution and diversity of the molluscs of : a practical strategy for analysing multispecies distribution patterns a similarity measure sensitive to the contribution of rare species and its use in investigation of variation in marine benthic communities analysis of community attributes of the benthic macrofauna of frierfjord langesundfjord, and in a mesocosm experiment using similarity measures in benthic impact assessments quantitative re-evaluation of ecology and distribution of recent foraminifera and ostracoda of todos santos bay macrobenthos of sandy beach and nearshore environments at murrells inlet : distribution patterns of living and subfossil podocopid ostracodes in the nosy be area data manipulation in cluster analysis and the concept of zero presence the influence of habitat and seasonal regimes on the ordination and classification of macroinvertebrate assemblages in the catchment of the river wye feast and famine: structuring factors in marine benthic communities. ih symp nouveau manuel de bionomie benthique de la mer mediterranee. recl. trav. stn. mar. endoume recherches qualitatives sur les biocoenoses marines des substrats meubles effect of a large larval settlement and catastrophic mortality on the ecological record of the community in the death assemblage les peuplements benthiques (zoobenthos) de la region marseillaire: un essai d'analyse multivarite benthic molluscan fauna of the st. lawrence estuary and its ecology as assessed by numerical methods patterns of benthic copepod assemblages in an oligotrophic lake principles of numerical taxonomy new guinea. using numerical analysis benthic macrofaunal assemblages of slope habitats in the southern california borderland. occasional papers of the allan hancock foundation peuplements benthiques des substrats meubles du sud dc la mer egee. tethys classification and community structure of the macrofauna in the southern baltic. ices council meeting (collected papers). ices. copenhaven (denmark) macrobenthos-sediment relationships on the continental shelf off cape hatteras animal-sediment relationships in intertidal marine benthic habitats: some determinants of deposit feeding species diversity molluscan populations of the eden estuary. fife and the usc of numerical taxonomy methods to determine their distribution patterns key: cord- - hf vyhz authors: abass, ahmed o; kamel, nancy n; khalifa, walaa h; gouda, g f; el-manylawi, m a f; mehaisen, gamal m k; mashaly, magdi m title: propolis supplementation attenuates the negative effects of oxidative stress induced by paraquat injection on productive performance and immune function in turkey poults date: - - journal: poult sci doi: . /ps/pex sha: doc_id: cord_uid: hf vyhz paraquat (pq) is used as a herbicide in agriculture and causes oxidative and inflammatory damage to animal tissues. the current study was conducted to investigate the positive effects of dietary propolis (pr), as a potent naturally produced antioxidant, on growth performance and immune function of turkey poults exposed to oxidative stress induced by pq injection. native male turkey poults (n = , -d-old) were randomly assigned into groups: poults received a basal diet with a daily subcutaneous pq injection of mg/kg bw for consecutive days (pq group), an experimental diet containing g/kg pr with a daily subcutaneous pq injection for days (pr+pq group), or received the experimental pr diet with a daily subcutaneous injection of . ml sterile saline for days (pr group); while the control poults received a basal diet with a daily subcutaneous saline injection for consecutive days (c group). the productive performance in the pq group showed a significant (p < . ) reduction in the weight gain (wg) and feed intake (fi), and impaired feed conversion ratio (fcr). propolis supplementation in the pr+pq group significantly ameliorated the pq effects on wg and fcr. turkey poults of the pq and pr+pq groups had a significant augmentation in the blood malondialdehyde (mda), tumor necrosis factor-α (tnfα), and corticosterone levels, and in contrast, a significant reduction in the triiodothyronine (t( )), when compared to the c group. while propolis significantly reduced the mda and corticosterone, and increased the t( ) levels in the pr+pq group compared to the pq group. furthermore, the dietary pr supplementation significantly limited the pq-suppressive effects on cell- and humoral-mediated immunity and lymphocyte proliferation of turkey poults. in addition, propolis supplementation in the pr and pr+pq groups markedly reversed the pq-induced dna fragmentation and heat shock protein (hsp ) over-expression in blood cells. it can be concluded that pr could improve turkey immunity and performance, particularly under inflammation and oxidative stress induced by pq exposure. oxidative stress develops when the generation of reactive oxygen species (ros) in a system exceeds the system's ability to neutralize and eliminate them. the imbalance can result either from a lack of antioxidant capacity caused by disturbance in production, distribution, or by an over-abundance of ros from an environmental or behavioral stressor (boelsterli, ) . ros could be produced by several agents and stres-that induced-oxidative stress in broiler chickens leads to proteolysis and gluconeogenesis (lin et al., ) , several pathologies incidence (fellenberg and speisky, ) , dna damage (huang et al., ) , and depression of immune function and growth performance with a high mortality rate (kamel et al., ; mehaisen et al., ) . depending on the severity of the oxidative harm, the consequence of these modulations can vary from modifying cell function to cell death, which negatively affects poultry flocks. paraquat (pq; , -dimethyl- , -bipyridium dichloride) is widely used in agriculture as a non-selective contact herbicide with redox activity. pq is known to exert its toxic effects via oxidative stress mechanisms (ray et al., ) . the potential mechanism of pq toxicity is the cyclic single-electron redox reaction that depletes cellular nicotinamide adenine dinucleotide phosphate (nadph) and generates superoxide anion. superoxide ions may form hydrogen peroxide and hydroxyl radicals; the latter being an extremely potent oxidant that may damage nucleic acids, proteins, and polysaccharides (tukmechi et al., ) . moreover, trace amounts of pq can be detected in more than crops such as corn, tomatoes, olives, field beans, and fruits (prasad et al., ) . pq effects in rodent models showed that prolonged exposure leads to accumulation and persistent damage in the brain, lung, and liver tissues (ortiz et al., ) . a study on paraquat toxicity in turkeys reported that all injected birds were affected at the dose of . mg/kg bw while the lethal dose was about mg/kg and mg/kg by intravenous and intraperitoneal injection, respectively (smalley, ) . propolis (pr) is an adhesive resinous material made by honey bees and it contains a variety of chemical compounds such as poly-phenols (flavonoid aglycones, phenolic acids and their esters, phenolic aldehydes, alcohols, and ketones), terpenoids, steroids, amino acids, and inorganic compounds (newairy and abdou, ) . flavonoid and phenolic compounds in propolis have been appeared to be capable of scavenging free radicals and thereby defending lipids and other compounds from being oxidized or destroyed during oxidative damage (seven et al., ). in addition, propolis is thought to be responsible for many biological and pharmacological activities including anticancer, antiinflammatory, anti-bacterial, antifungal, antiviral, antioxidant, hepato-protective, and immuno-stimulating activities (haščík et al., ) . many previous reports indicated that the inclusion of propolis in the poultry diet has a positive effect on the humoral immunity of laying hens (cetin et al., ; freitas et al., ) , on the hatchability and performance of quail chicks (aygun et al., ) , and on the hemoglobin concentrations and eosinophil count of blue-fronted parrots (silva et al., ) . based on pq actions, it is a good and welldocumented agent to induce oxidative stress when there is a need to provide a better understanding of this type of stress on poultry production. on the other hand, much research is focused on the ability of propolis to improve production performance, enhance immune function, and inhibit inflammatory response, which is very critical for poultry industry. however, it is not clear whether propolis supplementation could also reverse the inflammatory status and the negative effects of oxidative stress induced by paraquat treatment. thus, the current study was designed to investigate the effects of propolis supplementation on controlling the oxidative stress induced by paraquat injection to turkeys. the oxidative stress was determined as the level of mda, which is an important and significant biomarker of oxidative stress, in the blood. in addition, the inflammation status and immune function were evaluated in turkey poults after propolis supplementation with or without paraquat injection. furthermore, dna fragmentation test and stressed-related protein expression of heat shock protein (hsp ) were analyzed in the blood. in addition, growth performance of turkey birds was obtained under propolis supplementation in order to test whether it has the ability to reverse the negative effects of oxidative stress induced by paraquat. one hundred and twenty, -d-old, male baladi turkey poults were used in this investigation. baladi turkey is an egyptian native breed that is characterized by low growth performance and high immune response. the turkey poults were reared in an opened-house with feed and water ad libitum. a basal diet was formulated according to the recommendations of the regional center for food and feed in egypt to meet the local needs and was used as a control diet in the present study. the composition and the calculation analysis of the basal diet are presented in table . propolis was mixed into the basal diet to produce experimental diet containing . % propolis ( g propolis/kg diet). the experimental protocols were approved and carried out according to the regulation and guidelines set by cairo university ethics committee for the care and use of experimental animals in education and scientific research (cu-iacuc). propolis was collected from an apiary located at the faculty of agriculture, cairo university (giza province, egypt). the collected propolis was kept in a clean, dark bottle at • c until use in the experiment. phenolic acids and flavonoid contents were analyzed in a propolis sample using high-performance liquid chromatography (hplc). hplc was achieved on an agilent infinity hlpc series (agilent, santa clara, ca) equipped with quaternary pump, zorbax eclipse plus c column mm × . mm internal diameters, μm particle (agilent), operated at • c. the separation was achieved using a ternary linear elution gradient with hlpc grade water . % h po (v/v), methanol and acetonitrile. the injected volume was μl and the variable wavelength detector (vwd) was set at nm (ivanauskas et al., ) . the free radical scavenging activity of propolis samples was measured according to methods described by oktay et al. ( ) . briefly, the propolis was added to a solution of . mm of , diphenyl- -picryl-hydrazil (dpph) in methanol at different concentrations ( to μg/ml). the mixtures were shaken vigorously and allowed to stand at room temperature for min. then, the absorbance of reactions was measured using an automatic scanning spectrophotometer at nm. the chemical characteristics of propolis used in this experiment are presented in table . at d of age, turkey poults were randomly allocated into one of experimental groups (three pens per group × poults in each pen). the first group of poults served as a control, received the control diet and a single dose of . ml sterile saline per day for consecutive days through subcutaneous route (c group). the second group received the control diet and a single subcutaneously injected of paraquat (sigma aldrich, st. louis, mo), mg/kg body weight, per day for consecutive days (pq group). the third group received the experimental diet containing propolis and a daily subcutaneous injection of paraquat for a pe-riod of days (pr+pq group). the fourth group received the experimental propolis diet and a daily subcutaneous injection of saline for a period of days (pr group). at d of age, blood samples were collected from the brachial vein of the birds in each treatment using heparinized syringes and the physiological parameters were assayed ( samples from each pen for each parameter; n = ), including the mda and tumor necrosis factor-α (tnfα) levels in the peripheral blood mononuclear cells (pbmcs) isolated from blood, as well as the corticosterone and triiodothyronine (t ) hormone concentration in the plasma. the immune function of turkey poults in each group was determined by analyzing total white blood cells (wbcs), heterophil to lymphocyte (h/l) ratio, toe web swelling in response to phytohemagglutinin-p (pha-p) injection as an indicator for the cell-mediated immunity, antibody response to sheep red blood cells (anti-srbcs ab) injection as an indicator of the humoral-mediated immunity, and the stimulation index of peripheral tlymphocyte proliferation. furthermore, the dna fragmentation and blotting expression of hsp were analyzed in pbmcs isolated from blood samples in each group. in addition, the productive performance was obtained for each treatment group as will be mentioned later. the initial and final body weights were recorded individually at the beginning and at the end of the experiment ( and d of age). the entire weight gain was determined for each group. average daily feed intake was measured for each treatment group. the feed conversion ratio was calculated for each group. at d of age, blood samples from different birds (n = ) were collected from each treatment. pbmcs were isolated using histopaque- (sigma aldrich, st. louis, mo) as previously described . the cells were washed twice using roswell park memorial institute (rpmi) medium (gibco tm , thermo fisher scientific, waltham, ma), then re-suspended with pbs (ph . ), and the numbers were adjusted to be cells/ml. a mlcell suspension was centrifuged at , × g for min at • c. the pellets were collected and stored at − • c until processing. the cells were re-suspended with ml pbs, kept on ice for sec, and then sonicated for min. the homogenates were centrifuged at , × g for min at • c and supernatants were collected to determine mda and tnfα levels. the level of mda in the supernatant was determined by the thiobarbituric acid reaction method using a commercial assay (nanjing jiancheng bioengineering institute, nanjing, china). the level of tnfα in the supernatant was measured using chicken elisa commercial diagnostic kit (cat# wac- , wkea med supplies corp, changchun, china). the standard curves and calculations were performed following the kits protocol for each analysis. plasma corticosterone and t hormone assay at d of age, blood samples from each group were collected (n = ), centrifuged at , × g for min at • c, and then plasma was separated and stored at − • c. plasma corticosterone and t concentrations were determined in duplicates using chicken elisa kits (cat# mbs for corticosterone and cat# mbs for t ; mybiosource, san diego, ca). the intra-and inter-assay coefficient of variations was < % and < %, respectively for corticosterone, and was < % for t . the dynamic range of the assay was . to and . to ng/ml for corticosterone and t , respectively. total wbc count total leukocytes were performed manually in samples per group as described by gehad et al. ( ) . briefly, μl of brilliant cresyl blue dye was mixed with μl whole blood samples, and the total leukocytes were counted using a hemocytometer. h/l ratio h/l ratio was determined manually according to zhang et al. ( ) . in brief, blood smears ( slides per group) were fixed and stained using hema- (cat# - , , fisher scientific, pittsburg, pa). the differential leukocyte counts were performed for a total of leukocytes in each slide using light microscope and the h/l ratios were then calculated. toe web swelling the cell-mediated immune response was assessed using the swelling of toe web that induced by intradermal mitogen injection of pha-p. at d of age, the left foot of six turkey poults from each group was injected with μg of pha-p dissolved in . ml of sterile pbs buffer into the toe web between the third and fourth digits. the thickness of toe web was measured before injection and h after injection. the toe web swelling response was expressed in mm as the difference between the thickness before and after injection (loa et al., ) . anti-srbcs ab. the humoral-mediated immune response was assessed by evaluating the antibody production against srbcs. six turkey poults from each group were injected intravenously with ml of % saline suspension of srbcs at d of age. one wk following the injection (d ), blood samples was collected and the antibody production against srbcs was determined by microhemagglutination technique (loa et al., ) . antibody values were expressed as log of the reciprocal of the highest dilution where visible agglutination was observed. peripheral t-lymphocyte proliferation the pbmcs layer were carefully isolated from heparinized blood samples obtained from each group according to the method described by mehaisen et al. ( ) . after washing in rpmi culture medium, the viable lymphocytes were detected using trypan blue dye and plated in triplicate wells ( -well plate) at × cells per well. then, μl of concanavalin-a (sigma aldrich) at μg/ml was added to selected wells to induce the proliferation of t lymphocyte; while control wells received μl of rpmi- medium. after cells' incubation ( • c and % co for h), μl of mg/ml -[ , -dimethylthiazol]- , -diphenyltetrazolium bromide (sigma aldrich) was added to each well and incubated for another h. subsequently, μl of % sodium dodecyl sulfate dissolved in . m hcl solution was added to each well, then the plates were read using an automated elisa reader (model microplate reader, bio-rad laboratories, inc., hercules, ca) at nm. the stimulation index for t-lymphocyte proliferation was calculated as the optical density ratio of experimental group to blank control. the pbmcs were collected from blood samples ( samples for each group) as mentioned previously. the dna isolation was performed using the cells/tissue genomic dna extraction kit (cat# gk , generay biotech co., ltd., shanghai, china), according to the manufacturer's instructions. dna fragmentation was analyzed by % agarose gel (sigma-aldrich) electrophoresis for h at v. visualization of dna was analyzed by ethidium bromide fluorescence using a uvp ec imaging system (uvp inc., upland, ca) with visionworksls image acquisition and analysis software (version . . ; uvp inc., upland, ca). the expression of hsp in the collected pbmcs ( samples per group) was analyzed by western blot technique. the total protein ( μg) was loaded and separated on % polyacrylamide gel containing sodium dodecyl sulphate (sds-page). separated proteins were then transferred to poly-vinylidene difluoride membranes using a tank transfer for h at ma in trisglycine buffer containing % methanol. membranes were blocked with % skim milk for h and incubated overnight at • c with diluted primary anti-rabbit igg polyclonal antibody against hsp ( : , ; cell signaling technology, inc., danvers, ma), followed by a horse radish peroxidase conjugated secondary antibody against rabbit igg ( : , ; santa cruz biotechnology, inc., dallas, texas). to verify equal loading of samples, the membrane was incubated with monoclonal β-actin antibody ( : , ; santa cruz biotechnology, inc.), followed by a horse radish peroxidase conjugated goat anti-mouse igg ( : , ; santa cruz biotechnology, inc.). hsp was detected using the ecl chemiluminescence kit (ge healthcare life sciences, amersham place, little chalfont, buckinghamshire, uk). . ± . a . ± . b . ± . c a-d means within the same row with different letters are significantly different (p < . ). treatment groups: c, control group; pq, the group received a basal diet and a consecutive day injection of paraquat; pq+pr, the group received a consecutive day injection of paraquat and a diet supplemented with propolis; and pr, the group received a basal diet supplemented with propolis. treatment groups (n = number of birds per group): c, control group; pq, the group received a basal diet and a consecutive day injection of paraquat; pq+pr, the group received a consecutive day injection of paraquat and a diet supplemented with propolis; and pr, the group received a basal diet supplemented with propolis. a general linear model was performed using sas software (sas institute inc., ) to determine statistical differences between treatment groups (c, pq, pr+pq, and pr) for the productive traits, physiological parameters, and immunological parameters. significant treatment effects were detected by duncan's multiple range tests. results are expressed as lsm ± se and the significance level was set at p < . . the results reveal that turkey poults in the pq group had significantly (p < . ) reduced weight gain and feed intake compared to turkey poults in the c group (table ). in addition, the feed conversion ratio also in the pq group was impaired significantly (p < . ) compared to the c group. in contrast, the dietary propolis supplementation alleviated these reductions in weight gain and feed intake in the pr+pq group when compared to the pr group. furthermore, administration of propolis to the diets of the pr group significantly (p < . ) enhanced the weight gain compared to the c group. even though, the feed conversion ratio tended to be improved when propolis was supplemented to the diets of both pr+pq and pr groups; the differences were not significant (p > . ) when compared to the c group (table ) . the change in mda and tnfα levels in pbmcs as well as the plasma corticosterone and t concentra-tions after paraquat injection with or without dietary propolis supplementation in turkey poults are shown in table . compared with the control group, pq injection significantly (p < . ) increased the mda, tnfα, and the plasma corticosterone levels in both pq and pr+pq groups. however, adding propolis to the basal diet minimized (p < . ) the mda level and corticosterone concentration in the pr+pq group compared to the pq group. in contrast, the plasma t concentration was significantly (p < . ) lower in the pq group and higher in the pr group when compared to the c group. moreover, dietary propolis supplementation successfully alleviated the negative effect of pq injection and significantly (p < . ) raised the value of plasma t concentration in the pr+pq group, however, it remained lower than that of the c group (table ) . the effects of dietary propolis and paraquat injection on the immune function are presented in table . total wbcs were significantly (p < . ) lower in the pq group than in the c group. meanwhile, dietary propolis supplementation significantly (p < . ) increased the total wbcs in the pr group compared to the c group. not only that, but it also reversed the negative effect of pq injection by significantly (p < . ) raising the total wbcs in the pr+pq group as compared to the pq group. furthermore, the h/l ratio was significantly (p < . ) increased in response to oxidative stress induced by paraquat injection in the pq group compared to the c group. nevertheless, propolis supplementation significantly (p < . ) limited the increasing rate of h/l ratio due to pq injection in the pr+pq group compared to the c group (table ). in addition, oxidative stress induced by paraquat injection treatment groups (n = number of birds per group): c, control group; pq, the group received a basal diet and a consecutive day injection of paraquat; pq+pr, the group received a consecutive day injection of paraquat and a diet supplemented with propolis; and pr, the group received a basal diet supplemented with propolis. significantly (p < . ) reduced the toe web swelling in response to pha injection, antibody titers to srbcs, and t-lymphocyte proliferation in the pq group poults compared to the c group poults (table ). in contrast, adding propolis to the basal diet significantly (p < . ) alleviated the negative effect of paraquat injection on the previous immune parameters in the pr+pq group compared to the c group. moreover, supplementing the basal diet with propolis in the pr group significantly (p < . ) enhanced the t-lymphocyte proliferation compared to the c group (table ) . dna fragmentation test showed appearance of short dna fragments in response to pq injection ( figure ) . meanwhile, the dietary propolis supplementation to the turkey poults reduced the dna fragmentation in either the pr+pq or the pr group to a normal level similar to the control group. furthermore, hsp blotting level was influenced by the pq injection and dietary propolis supplementation (figure ). an overexpression of hsp was observed in the turkey poults of the pq group compared to the c group. however, data of hsp expression in both the pr and pr+pq groups show that propolis supplementation to the diets of turkey poults normalized the hsp expression to similar levels of the c group. paraquat is widely used as an herbicide in agriculture and may cause chronic health problems to animals and humans if it is absorbed through the skin or gastrointestinal and respiratory tracts (ortiz et al., ) . the deleterious effects of pq are mainly attributed to the extreme redox activity that, in turn, induces extensive damage for several organs and tissues, leading to high mortality rates in human (lin et al., ; kang et al., ) and animal populations (ray et al., ; tukmechi et al., ) . on the contrary, propolis, due to its antioxidation and anti-inflammation properties, has been recently used in poultry feeds as an alternative and practical way to alleviate deleterious effects of rearing under abnormal and stress conditions (seven et al., (seven et al., , . so far, the research regarding pq and pr effects on growth performance and immune function in animal science is very limited and the available discussion remains insufficient to understand such effects. in the present study, it was found that pq significantly suppressed weight gain and feed intake, and impaired feed conversion ratio by %, %, and %, respectively, compared to the control poults. a similar low growth performance was obtained by feeding paraquat to fish (babatunde and oladimeji, ) or rats (kimura et al., ) . the low performance after paraquat treatment is attributed to the oxidative stress that may have been due to active oxygen species formed by the action of paraquat. previous reports attributed the low performance in oxidative stressed-broilers to the reduction in associated metabolic and endocrine responses (lin et al., ) or the down-regulation of all sugar, peptide, and amino acid transporter genes in the small intestine (ebrahimi et al., ) . on the other hand, dietary propolis ameliorated the suppression of weight gain, feed intake, and feed conversion in turkey poults that were exposed to pq injection. furthermore, administration of propolis to the diets of the turkey poults without pq stress enhanced the weight gain by % compared to the control poults. this enhancement may probably be due to the ability of propolis to improve nutrients digestibility and absorption as a result of improving saccharase, amylase, and phosphatase activities (mutsaers et al., ) . additionally, shalmany and shivazad ( ) reported that the increase in feed intake could be linked to the palatable substances in propolis like resin, wax, honey, and vanillin. furthermore, kačániová et al. ( ) found that flavonoids in propolis have antibacterial activity and prevent the ability of pathogenic bacteria to attach to the intestinal epithelium (parkar et al., ) ; thus improving intestinal health, and consequently, enhance digestion and nutrient absorption (denli et al., ) . mda is one of the final products of lipid peroxidation and could be used as a direct indicator of oxidative stress induced by potential oxidants like paraquat in the present study. the significant increase in mda levels upon treatment with pq in turkey poults indicates the oxidative damages occurred to pbmcs. these results are consistent with the finding that various concentrations of pq increase the cellular peroxidation . when propolis was supplemented to the diets of turkey poults, a reduction in mda level was obtained in the pr+pq group compared to the pq group. previous studies reported that the supplemental antioxidants extracted from propolis, such as flavonoids and caffeic acid phenethyl ester, block ros production and protect cell membranes against oxidants (seven et al., ) . it was also suggested that polyphenols of propolis can reduce the negative effects of oxidative stress either by chelation of iron or by free radical trapping (thirugnanasampandan et al., ) . it was reported that tnfα is one of the cytokines involved in the early inflammatory phase of pq poisoning (amirshahrokhi, ) through the ros pathway. pq-induced ros accumulation could promote the production of tnfα to trigger the tissue injury; and reversely, increased tnfα concentration could promote further ros generation (edwards et al., ) . results of the present study demonstrate that tnfα concentration in the pbmc's was higher in the pq and pr+pq groups compared to the c group. the positive effect of propolis was not statistically significant in this study, however, it is well documented that propolis supplementation may attenuate the adverse effects of environmental stress and stress induced tissue damage by modulating the levels of cytokines such as tnfα (fitzpatrick et al., ; hu et al., ) . in addition to the increase in the tnfα concentration in the pbmc's, pq injection also induced a significant high plasma corticosterone concentration. this high corticosterone levels probably decreased feed intake and reduced intestinal absorptive surface area as reported by hu et al. ( ) . furthermore, the release of corticosterone and inflammatory cytokines exerted catabolic effects on proteins and lipids (siegel, ) . these findings may be responsible for the lower body weight gain in the pq poults as previously reported in the present study. in addition, the thyrotrophic [triiodothyronine (t ) and thyroxine (t )] axis is considered to be prerequisites for normal growth and development (decuypere et al., ) . it is shown in the current study that turkey poults of pq group had significant reduction in the plasma t concentration compared to the c group. steenland et al. ( ) reported an increased hypothyroidism in the people intoxicated with paraquat herbicide and found detectable levels of paraquat in their thyroid glands. goldner et al. ( ) observed thyroid adenomas in rats exposed to paraquat and suggested that the thyroid could be susceptible to the effects of paraquat. in contrast, the plasma t was significantly higher in the pr group than in the c group. the positive effects of propolis on t /t ratio was previously reported in broilers reared under heat stress condition (amen et al., ) , reflecting improvement in thyroid hormones secretions and higher conversion rate to the active form of thyroid hormone which is responsible for metabolism. the current study also demonstrates that dietary propolis supplementation significantly increased plasma t concentration in the pr+pq group compared to pq group which, consequently, alleviated the negative effect of paraquat injection on the growth performance of turkey poults. the immunological data obtained in the current work show that pq injection impaired the overall immune function of turkey poults. in pq group, the h/l ratio was increased, while the total wbcs, the toe web swelling in response to pha injection, antibody titers to srbcs, and t-lymphocyte proliferation were significantly decreased compared to the c group. these results are consistent with the data presented by riahi et al. ( ) who concluded that paraquat administration at high dose (intra-peritoneal injection of mg/kg bw for d) in mice has an inhibitory effect on the cell-mediated and humoral immunity; including higher neutrophil cells number, and lower hemagglutination antibody titer and lymphocyte proliferation. the increase in h/l ratio in the pq group may be due to the inflammation (dinis-oliveira et al., ) , which was represented by corticosterone and tnfα elevation in the same group. in a recent study, mehaisen et al. ( ) reported that corticosterone treatment has immunosuppressive effect in broiler chickens. in addition, free radicals are known to attack unsaturated fatty acid side chains of phospholipids, causing a substantial decrease of the membrane integrity and fluidity of immune cells (smith and heath, ) . it is possible that free oxygen radicals generated by paraquat could inhibit t cell proliferation via membrane lipids peroxidation (riahi et al., ) . in contrast, dietary propolis supplementation enhanced the total wbcs and t-lymphocyte proliferation in the pr group compared to the c group. not only that, but it also reversed the negative effect of paraquat injection on the immune function in the pr+pq group. these positive effects of pr and its ability to alleviate the pq effects on immunity may be due to the stimulation of intracellular antioxidants, which are important in lymphocyte activation and proliferation (annunziata and iorio, ) . paraquat was found to affect the animal cell through oxidative damage in cellular macromolecules including dna (lascano et al., ) . in the present study, the dna fragmentation test showed an appearance of short dna fragments in response to pq injection. the paraquat toxicity may be due to the excessive release of ros which, in turn, initiate lipid peroxidation, particularly in the polyunsaturated lipid compound of cell membranes (hayes and laws, ) . furthermore, the paraquat toxicity involves depletion of cellular reduction agent of nadph which is used as a cofactor for lipid and nucleic acid synthesis (kelner and bagnell, ) . these events induced by pq-oxidative stress may increase the dna damage at the cellular level (ribas et al., ) , and consequently, the dna fragmentation occurred in the pbmcs lead to the impaired immune function of the turkey poults that were injected with pq in the current study. on the other hand, hsp , which is classified as a constitutive protein synthesized to protect cells from stress (al-aqil et al., ) , was also analyzed in the pbmcs of turkey poults in the present study. the hsp was over blotted in the pq group compared with the c group. in accordance with our results, previous reports demonstrated higher expressions of hsp in rats (crum et al., ) and mice (nakanishi and yasumoto, ) that received pq compound in comparison with the controls. these findings show that pq administration appeared to activate oxidative degradation in the cell, and consequently, increased the level of oxidized proteins, which stimulate self-defense mechanism of the cell to increase the level of hsp . the dietary propolis supplementation to the turkey poults reduced the dna fragmentation and the over expression of hsp in the pr+pq and the pr groups to normal levels similar to the c group. phenolic acids and flavonoids are known as the basic compounds of propolis according to its quality and type (kurek-górecka et al., ) , and these compounds have a powerful antioxidative activity (gülçin, ) . it was demonstrated that such compounds inhibit the activity of participated enzymes in the ros creation such as camp phosphodiesterase, protein kinase c, ascorbic acid oxidase, lipoxygenase and na + /k + atpase (pietta, ) . moreover, the antioxidant compounds of propolis decrease the activity of xanthine oxidase, an oxidase of nadph, which is responsible for the appearance of superoxide anion radical (harborne and williams, ) . in addition, propolis could activate the cu/znsuperoxide dismutase, one of the most important antioxidant enzymes (de sá et al., ) . these antioxidative characteristics of propolis may participate in the mechanism of inhibiting the dna damage and hsp over-expression in pbmcs of turkey treated with pq, and then finally these birds can express a normal immune function. in conclusion, the pq injection in turkey poults induces an oxidative stress status and impairs the growth performance and immune function in treated poults. the negative effects of pq could be justified by the high levels of mda and tnfα in pbmc's, and the high corticosterone with low t concentrations in the plasma. furthermore, the dna fragmentation and hsp expression in the pbmcs explain the malfunction of these cells and the low immunity in the pq-treated poults. in contrast, the dietary propolis supplementation can alleviate the negative effects of pq-induced oxidative stress on the productive, physiological, and immunological parameters of turkey poults. the positive effects of antioxidative compounds in the propolis can decrease the mda, tnfα, corticosterone, dna fragments, and hsp levels. therefore, the addition of propolis at a rate of g/kg to the diet of turkey poults could be recommended as a potential nutritional strategy in order to improve their immunity and performance, especially under oxidative stress conditions by herbicides like paraquat. this study was funded by the general scientific research department at cairo university (gsrd-cu) under activities carried out by the project of rapid climate change in poultry cellular and molecular physiology (rcc-pcmp). ahmed o. abass (associate professor of poultry physiology, cairo university) was the principal investigator and research team leader of the project. the authors would like to thank abdel-rahman m. m. atta (professor of poultry immunology, cairo university) for his technical support during this study. the authors are very grateful to all the personnel from the poultry biotechnology lab and members of poultry services center at faculty of agriculture, cairo university, for their assistance in sample preparation and monitoring of birds throughout the experimental period. the effects of the hot, humid tropical climate and early age feed restriction on stress and fear responses, and performance in broiler chickens the effect of brazilian propolis on serum thyroid hormones in broilers reared under chronic heat stress. page p (abstract) in international poultry scientific forum anti-inflammatory effect of thalidomide in paraquat-induced pulmonary injury in mice the levels of glutathione and hemoglobin in sheep erythrocytes as a function of age effects of propolis on eggshell microbial activity, hatchability, and chick performance in japanese quail (coturnix coturnix japonica) eggs effects of paraquat on the growth and behaviour of oreochromis niloticus mechanistic toxicology: the molecular basis of how chemicals disrupt biological targets effects of diets containing different concentrations of propolis on hematological and immunological variables in laying hens neuroendocrine profile in a rat model of psychosocial stress: relation to oxidative stress heat shock protein responses to aging and proteotoxicity in the olfactory bulb effects of glucocorticoids on circulating concentrations of thyroxine (t ) and triiodothyronine (t ) and on peripheral monodeiodination in pre-and post-hatching chickens effect of dietary addition of turkish propolis on the growth performance, carcass characteristics and serum variables of quail (coturnix coturnix japonica). asian-australasian paraquat poisonings: mechanisms of lung toxicity, clinical features, and treatment effect of dietary lead on intestinal nutrient transporters mrna expression in broiler chickens antioxidants: their effects on broiler oxidative stress and its meat oxidative stability caffeic acid phenethyl ester, an inhibitor of nuclear factor-kappab, attenuates bacterial peptidoglycan polysaccharide-induced colitis in rats the effects of propolis on antibody production by laying hens the role of light program and melatonin on alleviation of inflammation induced by lipopolysaccharide injection in broiler chickens antioxidant activity of caffeic acid ( , -dihydroxycinnamic acid) upsides and downsides of reactive oxygen species for cancer: the roles of reactive oxygen species in tumorigenesis, prevention, and therapy advances in flavonoid research since the influence of propolis as supplement diet on broiler meat growth performance, carcass body weight, chemical composition and lipid oxidation stability handbook of pesticide toxicology biological markers of oxidative stress: applications to cardiovascular research and practice effect of corticosterone administration on small intestinal weight and expression of small intestinal nutrient transporter mrna of broiler chickens effects of ethanol and water extracts of propolis (bee glue) on acute inflammatory animal models heat stress impairs mitochondria functions and induces oxidative injury in broiler chickens evaluation of phenolic acids and phenylpropanoids in the crude drugs in vitro and in vivo antimicrobial activity of propolis on the microbiota from gastrointestinal tract of chickens depression of leukocyte protein synthesis, immune function and growth performance induced by high environmental temperature in broiler chickens absolute lymphocyte count as a predictor of mortality in emergency department patients with paraquat poisoning paraquat resistance associated with reduced nadph reductase in an energy-dependent paraquat-accumulating cell line protective effects of dietary nasunin on paraquat-induced oxidative stress in rats structure and antioxidant activity of polyphenols derived from propolis paraquat: an oxidative stress inducer. pages - in herbicides -properties, synthesis and control of weeds.hasaneen, mohammed nagib oxidative stress induced by corticosterone administration in broiler chickens (gallus gallus domesticus): . chronic exposure repeated pulse of methylprednisolone and cyclophosphamide with continuous dexamethasone therapy for patients with severe paraquat poisoning humoral and cellular immune responses in turkey poults infected with turkey coronavirus comprehensive growth performance, immune function, plasma biochemistry, gene expressions and cell death morphology responses to a daily corticosterone injection course in broiler chickens (r van den bos bee products (properties, processing and marketing) (marieke mutsaers induction after administering paraquat of heme oxygenase- and heat shock protein in the liver of senescence-accelerated mice effect of propolis consumption on hepatotoxicity and brain damage in male rats exposed to chlorpyrifos determination of in vitro antioxidant activity of fennel (foeniculum vulgare) seed extracts effects of antioxidant n-acetylcysteine against paraquat-induced oxidative stress in vital tissues of mice the potential influence of fruit polyphenols on colonic microflora and human gut health flavonoids as antioxidants toxicokinetics and toxicodynamics of paraquat accumulation in mouse brain effects of paraquat on antioxidant system in rats immunotoxicity of paraquat after subacute exposure to mice herbicide-induced dna damage in human lymphocytes evaluated by the single-cell gel electrophoresis (scge) assay. mutat brazilian propolis protects saccharomyces cerevisiae cells against oxidative stress the effects of propolis on biochemical parameters and activity of antioxidant enzymes in broilers exposed to lead-induced oxidative stress effects of propolis on selected blood indicators and antioxidant enzyme activities in broilers under heat stress the effect of diet propolis supplementation on ross broiler chicks performance action of brazilian propolis on hematological and serum biochemical parameters of bluefronted amazons (amazona aestiva, linnaeus, ) in captivity toxicity and hazard of the herbicide, paraquat, in turkeys paraquat lung: a reappraisal thyroid hormones and cytogenetic outcomes in backpack sprayers using ethylenebis(dithiocarbamate) (ebdc) fungicides in mexico analysis of chemical composition and bioactive property evaluation of indian propolis effect of acute and chronic toxicity of paraquat on immune system and growth performance in rainbow trout, oncorhynchus mykiss evaluation of models using corticosterone and adrenocorticotropin to induce conditions mimicking physiological stress in commercial broilers effects of corticosterone and dietary energy on immune function of broiler chickens antioxidant attenuation of ros-involved cytotoxicity induced by paraquat on hl- cells. health (irvine. calif) transport stress in broilers: i. blood metabolism, glycolytic potential, and meat quality key: cord- -xw i k authors: dederichs, melina; weber, jeannette; muth, thomas; angerer, peter; loerbroks, adrian title: students’ perspectives on interventions to reduce stress in medical school: a qualitative study date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: xw i k the mental health of medical students remains to be a matter of concern. numerous setting-based and individual-based interventions for student mental health have been proposed in the literature. however, the student perspective on those interventions has been largely neglected. this study aims to explore how medical students perceive different interventions and if they desire any additional changes with regard to their studies. eight focus groups with participants were conducted at a large german medical school. focus groups were recorded, transcribed and content-analyzed using maxqda . we found that medical students prefer setting-based interventions. most proposed interventions were on a setting-based level. for instance, students asked for more information on the university’s psychosocial counseling services and for better information management regarding contact persons. interventions proposed in the literature received mixed reactions: several participants did not favour a pass/fail grading system. students considered a peer-to-peer mentoring program for freshmen very helpful. students had diverse attitudes towards balint groups. they approved of several self-management courses, most of them being related to time or stress management. interestingly, the most urgently wanted interventions appear to be rather easy to implement (e.g. a mentoring program). this study explored the medical student perspective on student mental health interventions. additionally, our study illustrates the benefit and feasibility of involving students early on in the conception of interventions. further research with a representative sample is needed to obtain broader information on the acceptance of the suggested interventions. medical students show a high prevalence of mental illnesses worldwide, such as high levels of depression and depressive symptoms [ ] .to address medical students' poor mental health, setting-based and individual-based interventions have been proposed [ ] [ ] [ ] [ ] . setting-based interventions aim to improve health by modifying environmental factors, e.g. curricular changes in medical schools [ , , ] . individual-based approaches, by contrast, seek a change in the individual, e.g., by providing skills that help to cope with stress [ , ] . although some interventions different perspectives. we therefore conducted a qualitative study with focus groups to gather insights and specific explanations for why students deemed specific interventions useful or not. our study aims to answer the following questions: . what interventions do medical students themselves suggest and wish for? . how do medical students perceive interventions that have been described in the literature (pass/fail grading, a peer-to-peer mentoring program, balint groups, and self-management courses)? participants were recruited through social media or advertisement on campus of heinrich-heine-university of düsseldorf in germany. the only criteria for participation were to be currently enrolled as medical student and not having participated at our previous focus groups [ ] . participants of one focus group were recruited through a stress-management seminar. participation was explicitly on a voluntary basis. all participants gave their informed consent. students were compensated for their participation with two cinema tickets and one cinema discount card. focus groups were conducted until data saturation was reached. students were grouped into focus groups according to their period of study. this maximised the likelihood that participants could relate to each other in terms of experience regarding classes and exams. four groups included students in the preclinical part of their studies (year to ) and four groups included students both from the clinical part (year to ) as well as students in their clinical internship year (after the second state examination). the focus groups took place in june and july at the medical faculty of heinrich-heine-university düsseldorf. in , the medical faculty introduced a new curriculum. traditionally, medical students take one final exam organised by the state (state-examination) for each of the three periods of study: the first after the preclinical phase (after year ), the second after the clinical phase (after year ) and the last one after one year of practical internship at a hospital. with the new curriculum, the first state examination takes place after the first two years. permission to conduct this study was given by the ethics committee of the medical faculty of heinrich-heine-university of düsseldorf. after provision of written informed consent, participants were asked to fill out a questionnaire covering demographic data. the focus groups were conducted by tm, a faculty member and psychologist by training, while md, a junior researcher and trained psychologist, took notes. the focus groups followed a topic guide developed by md and tm (s file). both facilitators provide lectures for medical students and are involved in research on medical students' wellbeing. participants were informed about the facilitators' research focus. first, participants were asked about their experience in medical school so far and in which situations they had encountered obstacles or experienced stress. secondly, students were asked about potential changes and interventions that could contribute to stress reduction in medical school. previous research at our faculty already pointed out high stress levels and specific stressors of our medical students [ , ] . to answer the second research question (how the students perceived literature-based interventions), we discussed interventions proposed in the literature with medical students. the topic guide contained a list of the interventions (see introduction section), which were explained by the facilitator and then discussed by the students one after the other. if necessary, the facilitator asked follow-up questions to further explore students' views. every single participant was encouraged to contribute to discussions at an early stage. all focus groups were audio-recorded, transcribed and content analyzed by md and jw according to mayring [ ] using maxqda . jw is experienced with occupational health and qualitative research [ ] . research questions were transformed into deductive main categories (students' suggestions, interventions from literature). during analysis these categories were further broken down into sub-categories by inductive category formation. after md completed the first coding round of % of the data, al, an experienced qualitative researcher [ , , , ] , reviewed the coding scheme. the coding scheme was then adapted and a second coding round was performed by md. jw coded the data of four groups independently. both versions were compared and discrepancies resolved. after that, md recoded the remaining four groups and transferred changes made to the coding system in the previous discussion with jw. finally, jw and md discussed the focus groups once more. there was no need for further recoding since there were only minor differences between the analyses of md and jw. due to logistic constraints, corrections and feedback on transcripts and research findings were not obtained from study participants. the completed checklist of consolidated criteria for reporting qualitative research (coreq; [ ] ) can be found in s file. eight focus groups consisting of to medical students were conducted. focus groups lasted between and minutes. in total, medical students ( women) participated. with n = medical students being enrolled at the medical faculty in the summer semester of , we included . % of the population in our focus groups. participant age ranged between and years (mean = . ; sd = . ). all participants engaged in a comprehensive discussion about what they would like to change in medical school to improve student wellbeing. in the following, we will present their proposed starting points for interventions. regulations for absence of lecturers. students reported that especially in the clinical study phase, many lecturers did not show up for teaching. students asked for a substitution or at least a designated contact person. attendance. attendance rules were perceived to be too strict. according to the study regulations, an attendance of at least % presence per subject is required. however, if one subject consists of three appointments for example, all three seminars have to be attended. by attending only two of them, the presence would be %, thus below %. students therefore requested that if one misses class due to sickness or death of a family member, an exception should be granted. according to the participating students, there should also be the option to complete a compensatory task, for instance, holding a presentation on the subject that was missed. as another solution for not missing a mandatory event, participants suggested switching groups with their peers for the required event only. due to the high number of mandatory classes during the preclinical phase, students wished for less mandatory attendance during this phase. coordination of practical and theoretical phases. the düsseldorf medical curriculum combines phases of theoretical studying (lectures) and practical experience (clinical traineeship). students wished that the curriculum is adapted so that theoretical and practical lectures as well as corresponding tutorials are better aligned and deal with the same subjects. this was believed to increase their learning effect. students noted that the workload between theoretical and practical phases fluctuates significantly with high workload during theoretical phases and low workload during practical phases. therefore, they wished for shorter practical phases to distribute the workload more evenly. often, the lecture-free week takes place after the clinical traineeship. however, students would rather have a week off for studying after completing the theoretical lectures when they find to have more content to repeat and memorize. counseling. participants pointed out that they would benefit from a broader psychological support system. regarding the on-campus counseling service, students wished for longer opening hours as well as opening hours that are compatible with their schedules. free of cost confidential counseling services were perceived as useful for reaching out to students to address mental health issues. overall, students wished for more information regarding mental health problems and interventions. possible solutions students brought up were for instance a mandatory lecture about stress related to medical school, coping strategies and support contacts. additionally, students suggested that a newsletter should be emailed close to the first state examination to present information on emergency contacts and counseling services. registration processes for elective subjects. students explained that when they want to register for a subject, they have to log in to an online portal. there they would have to wait until midnight until the registration process opens. they further explained that registrations are allocated on a first come, first serve basis. therefore, students stated that without access to a fast and reliable internet connection at that time they would not be able to take the class they prefer. students would like this procedure be replaced by a selection based on preference. in this procedure, students could indicate their preference within a certain period. then they would be matched according to their choice. if there is no personnel to do this task, some students suggested that at least the first come-first serve procedure was opened during daytime. information management. students reported a lack of information management in medical school. they requested a comprehensive online portal containing information on classes and exams. moreover, students expressed that they would benefit from an introductory lecture for each new topic block that contains all relevant administrative information, e.g. on how to register for an exam. a faq that addresses most urgent questions concerning the first state examination was considered useful. online lectures. many students raised the topic of online lectures. they perceived online lectures as an efficient measure to reduce stress and improve flexibility. especially commuters were thought to profit significantly from it. online lectures were thought to be a great learning tool and aid with the preparation of future seminars. one student requested a contact person in case any questions arise during a session. "i think it would be great to have this opportunity. i personally learn at night. in the morning, i don't pick up much, but at night i am really diligent. and it were a lot easier to combine family, job and university. that would be a huge advantage." refresher courses. students stated that they would benefit from refresher courses before the second state examination. "i believe it would be pretty fair, for instance, to have courses that prepare you for the state examination in practical terms during the semester. that would be, i think, not bad." examinations. students reported that their exams cover several subjects at once. students asked for a restricted number of subjects within the same exam. they reported that this could be achieved if exams included more questions on the same subject per exam instead of the same subject posing only a few questions per exam over several exams. "now for instance [ they also suggested grades acquired in seminars should be added to the exam score and act as a buffer. it was discussed whether more open-ended questions instead of multiple-choice questions would be beneficial. some students stated that they could explain their knowledge better in open-ended questions. moreover, it would motivate them to learn more details. others preferred the existing multiple-choice format. teaching content. participants made a range of suggestions to improve the quality of teaching. for instance, students wished for a contact person to report verbal harassment of students like depreciative comments by teaching staff. exact teaching guidelines containing learning goals for every subject were considered potentially helpful. they also wished for more covering of content relevant for the second state examination. a perceived lack of interest and skill of teaching staff was thought to be solved through employing senior students or external referents. they asked for more interactive and clinically orientated teaching. elective subjects. in total, elective subjects have to be completed over the course of five years at the medical school in düsseldorf. some of the subjects are graded. participants raised the idea to reduce the total number of required courses to reduce stress and provide more time for state exam preparation. "it is good that we have elective subjects. but there are too many. and it is stressful, to have eight elective subjects here and another six elective subjects there. it would be great if we had less." alternatively, additional credit for scientific projects, clinical lectures or extracurricular activities was suggested. clinical traineeship. students asked to move the clinical traineeships towards the end of the medical curriculum, because students felt that they are often confronted with medical conditions for which they are not prepared yet and often clinicians presuppose content they have not dealt with yet. students reported frequent difficulties in their clinical traineeships. for instance, clinicians that are supposed to teach them are often not available and, if they are present, students felt that they do not take time to teach them adequately. more available contact persons or a central complaints office that assists them were mentioned as a possible solution to this issue. preparation for the second state examination. students wished for lecture free and exam free time for preparation before the second state examination. they requested to have at least days to dedicate completely to studying. this way they stated they could follow the learning schedule they wanted to use (so called " -day study plan" which is well-known and widely used by medical students in germany). "it is a question of planning. then, if you have these one hundred days, i think that would help a lot. and it would be nice if it wasn't exactly one hundred days but a couple of days more because maybe you don't study seven days a week." participants had many ideas on how to provide more time to study. participants proposed shortening clinical trainings, or to move them towards the end of the medical curriculum to avoid that students have to pass other exams right before the second state examination. students were willing to complete their clinical training during semester break or to begin the semester early to provide more preparation time for the second state examination. measures proposed in the literature pass-fail system. there was no consensus among the students in our focus groups related to the usefulness of pass-fail systems. some were in favour of eliminating grades because it would reduce pressure and stop demotivation through bad grades. others in favour of the pass-fail system argued grades did not have any informative value regarding their ability as a physician anyway and were thus of no importance. students opposing the pass-fail system reported to appreciate the incentive they received from good grades and to appreciate the feedback to better understand whether they had learned enough. students depending on a scholarship or on receiving particularly good grades raised concerns regarding their ability to compete and prove their performance. scholarship holders among the students reported that in order to keep their scholarship, they had to prove to belong to the top students in their semester. without grades, this might be difficult to prove and students from other universities might have an advantage. in düsseldorf, the final grade for the first state examination is calculated as a cumulative sum score of grades from the first to the third year and of the performance on the day of the state examination. students argued that this way they did not solely depend on one's day performance and therefore the stress on the day of the first state examination was reduced. some preferred keeping grades to maintain this system. however, students suggested alterations of the pass-fail system. they were in favour of eliminating grades from some subjects to reduce stress but maintain the current system of collecting grades for the first state examination. mentoring. almost all participants were in favour of a mentoring program. they appreciated it for its easy access and voluntary nature. the idea of having a permanent contact person that provides not only informational and emotional support but also further networking opportunities to higher semesters was welcomed. the personal experience and organizational knowledge of a senior student was thought to reduce stress significantly. "i would have liked having someone who told me 'everything is fine, this is normal. i experienced it too.' especially at the beginning of medical school. . . i had just moved here. . . and everything was new. having someone who can answer questions related to studying or simply help you." many students in senior semesters expressed the desire to become a mentor themselves. those who did not want a mentoring program stated they already established such a contact to a senior student by themselves. there were many suggestions regarding the design of a mentoring program. a pool with volunteers, possibly on an online-based platform was proposed. students further proposed that mentors should receive some form of compensation, either monetary or in a non-monetary form, like an honorary position. students argued that their willingness to participate in a mentoring program also depended on the mentor's personality. they feared that overly performance-driven students might be a bad role model in terms of stress management. students who would not want to participate in a balint group stated that they preferred being mentored by their peers or supervising physicians. they reported to rely on their own social networks for emotional support. some students expressed fear of stigmatisation due to participation in a balint group. they worried about talking freely about unpleasant experiences and being stigmatized by their peers. therefore, they would not want to participate. self-management courses. students were interested in learning self-management strategies or competences to strengthen their resilience. in this context, they wished for subjects on stress-management and relaxation techniques. moreover, students wished for a time-management course and more capacities in an existing elective subject deals with mind-body-medicine. participants stated they would benefit from courses that covered efficient learning strategies and presentation skills. there was little consensus among participants regarding the question when and how those classes should be implemented in their curriculum. in general, students perceived lack of time as a barrier to participate in a non-obligatory class. some students suggested that it should be an ongoing offer over a long period of time where students could decide for themselves every week whether they wanted to participate or not. students preferred to schedule such courses at the beginning of medical school and shortly before the first state examination. general dissatisfaction with already existing self-management courses on campus was expressed. students either perceived lack of information about those classes, lack of quality of available classes or limited capacity to enroll all interested students. the aim of the present study was to explore which interventions students suggest to improve their mental health and to discuss interventions suggested in the literature. in our eight focus groups, students suggested specific solutions to their perceived obstacles in medical school. interventions that students proposed most frequently pertained to setting-based aspects such as curricular changes, improved information management and new regulations concerning absence of teaching staff and students. many of the suggested interventions, such as online lectures, appear rather easy to implement. due to the current covid- pandemic (time of publication; [ ] ), our faculty addressed the wish for more online lectures by creating new digital learning opportunities and structures. eventually these structures will persist after the university switches to conventional lectures once again. it is also striking that many of the suggested interventions might not only reduce stress, but also improve several aspects of teaching (e.g. the coordination of practical and theoretical phases). this suggests that improvement of well-being and improvement of academic outcomes go into the same direction. in contrast to students' wish for setting-based interventions, most interventions being proposed in the literature focus on the individual [ ] . however, such interventions are believed to not tackle the root of the problem [ ] . it is argued that instead of teaching students how to cope with stress, the causes for stress need to be addressed [ ] . some individual-based interventions (e.g. stress-management courses) might even have the opposite effect by being an addition to existing classes and workload. it is further of interest that we observed that a significant number of our participants did not favor the interventions suggested by the literature. for instance, several students did not prefer a switch to a pass/fail grading system. these students perceived grades as helpful, were concerned that the absence of grades would have a negative impact on their academic performance, or would cause increased stress at the first state examination. however, this latter concern is not supported by the data [ , ] . it is possible that the idea of a pass/fail grading system elicits discomfort among our students because it is rather uncommon in germany. when the pass/fail system was first introduced in the us similar concerns were raised [ ] . a shift to a pass/fail system was perceived as a disadvantage for students and students coming from a university with pass/fail grading were thought to experience difficulties finding a residency placement. therefore, the authors did not recommend such a transition [ ] . however, a recent study showed that a pass/fail grading does not curtail career prospects [ ] . specifically, there were no differences in residency placement (receiving a placement at all and percentage of students that receive top specialty choices) and overall academic performance between pass/fail and tiered grading system cohorts [ ] . besides pass/fail grading being uncommon in germany, it would also require a change of the persisting score calculation for the first state examination. additionally, it would require a cultural shift towards a non-competitive environment among all students in order to be successful. therefore, instead of fully switching to pass/fail grading only, a mixed approach might be more feasible in which pass/fail grading could be adopted in some subjects while other subject are still graded. in this approach, grades still contribute to the result of the state examination. this would address medical students' preference to accumulate marks and thereby reduce stress during the first state examination without a prompt change that requires time for adaptation. possible mentoring programs by senior students were well received by the participants in our study. more advanced students were believed to provide invaluable informational and emotional support. since such a program has relatively low costs and was also favored by potential mentors, we propose starting a peer-to-peer mentoring program at our university as recommended by others [ ] . balint groups received mixed reactions. this is in line with previous research suggesting indifferent to mildly positive student attitudes towards balint groups [ , ] . a qualitative study from finland reported a more positive evaluation of balint groups [ ] . here, students reported being satisfied with their participation and benefiting from the groups [ ] . in our present study, especially those students who had already encountered a difficult situation with a patient stated that they would be grateful for this kind of opportunity and support. therefore, the implementation of a balint group with voluntary participation on request as suggested by students could be considered. it could build on already established peer-support-programs such as the programs at brigham and women's hospital in boston, which has repeatedly served as a model for peer-support-programs [ ] . students themselves requested a variety of self-management courses. most were interested in learning relaxation techniques and how to deal with stress. they stated that existing offers, like a time management class, are less attractive because their study curriculum does not allow for the implementation of taught strategies in this class. overall, they expressed the wish that classes to improve resilience should be accessible to everyone. some stress management courses (e.g. "stress management" or "mind-body-medicine") are only offered as elective subjects and are therefore only available for a fraction of the students. we suggest that all students receive a basic stress-management training and psychoeducation, preferably at the beginning of the curriculum. at some universities, such as the monash university medical school in australia, mindfulness and stress management have been part of the curriculum for many years [ ] . since some studies found reliable short-term effects [ , ] , students could benefit from it in most stressful times without the concern of losing time to study. for the latter reason we also suggest that more classes that address mental health are offered. in addition to face-toface training, e-mental-health-solutions could be made accessible for students for quick support. students' wish for e-learning opportunities suggests that they are open to digital formats that grant them more independence in terms of time and location of use. furthermore, information on specific counseling opportunities should be made more accessible. it is possible that raising awareness of medical students' mental health will reduce fear of stigmatization by peers which was mentioned as a concern in the context of balint groups. overall, we find that students proposed more setting-based interventions than individualbased interventions. this is in sharp contrast with the persistent emphasis on individual-based interventions in medical schools [ ] [ ] [ ] ] . importantly, while setting-based interventions are sometimes considered expensive or difficult to implement [ ] , most ideas in the focus groups (e.g. attendance rules, a new course selection procedure, teaching guidelines) seem easily feasible and resource-friendly and will not only improve wellbeing, but also academic performance. a strength of this study is its rich data, which were collected among as much as students from a broad range of semesters in eight focus groups until data saturation was reached. however, the generalizability of our findings may be limited since only students from the medical school at the university of düsseldorf were included in this study. our findings might be specific to issues and obstacles encountered at universities in germany and therefore only somewhat transferable to universities in other countries. when we asked the participants about their opinions on a pass/fail grading system, we did not clarify in detail whether they would still like feedback on their performance if a pass/fail grading system was implemented. thus, we do not know to what extent students perceive a pass/fail grading system and feedback on their performances mutually exclusive. further, we cannot rule out selection bias. one might argue that only those students suffering from stress or those who are especially dissatisfied with medical school attended the focus groups. on the other hand, one might assume that those students experiencing a high level of stress choose not to participate because of the additional workload. the fact that focus group facilitators were members of the teaching staff and that one focus group was held within a class on stress management could also have affected the observations. md's and tm's position as a teaching staff member might have elicited a social desirability bias and reduced willingness to share sensitive topics. however, also in this seminar, we felt that students spoke very openly about their issues. the contents of this focus group did not differ thematically from the other focus groups. this study explored which type of interventions students consider acceptable and useful. based on our data we are however unable to evaluate the feasibility and effectiveness of proposed interventions. however, we believe that only interventions that are favored by students and address their specific needs will be successful. in contrast to interventions to improve medical students' mental health that are proposed in the literature, we find that medical students mostly proposed interventions on a setting level rather than on an individual level. importantly, many interventions suggested by the students are low-cost and easy to implement. we believe that considering the student perspective is a key factor in designing mental health interventions. further research with a representative sample is needed to obtain more generalizable information on the acceptance of the proposed interventions and to test them in terms of feasibility and effectiveness by using both qualitative and quantitative approaches. prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis medical student mental health: culture, environment, and the need for change medical student mental health . : improving student wellness through curricular changes. academic medicine: journal of the association of american medical colleges medical school strategies to address student well-being: a national survey. academic medicine: journal of the association of academic psychiatry: the journal of the american association of directors of psychiatric residency training and the association for academic psychiatry holistic and sustainable health improvement: the contribution of the settings-based approach to health promotion setting-based interventions to promote mental health at the university: a systematic review effectiveness of universal programmes for the prevention of suicidal ideation, behaviour and mental ill health in medical students: a systematic review and meta-analysis. evidence-based mental health mindfulness interventions in medical education: a systematic review of their impact on medical student stress, depression, fatigue and burnout association between learning environment interventions and medical student well-being: a systematic review the benefits of pass-fail grading on stress, mood, and group cohesion in medical students impact of pass/fail grading on medical students' well-being and academic outcomes differences in medical students' academic performance between a pass/fail and tiered grading system a systematic review of the literature describing the outcomes of nearpeer mentoring programs for first year medical students introducing first-year students to medical school: experiences at the faculty of medicine of erasmus university students helping students: vertical peer mentoring to enhance the medical school experience the doctor, his patient and the illness research on balint groups: a literature review the impact of a physician awareness group and the first year of training on hematology-oncology fellows stressors perceived by the para-clinical undergraduate medical students teaching the clinical encounter in psychiatry: a trial of balint groups for medical students reflecting on our practice: an evaluation of balint groups for medical students in psychiatry a qualitative analysis of student balint groups in medical education: contexts and triggers of case presentations and discussion themes. patient education and counseling self-management education: history, definition, outcomes, and mechanisms. annals of behavioral medicine user involvement: a review of the benefits and challenges. behaviour & information technology acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. bmc health services research helping medical students develop lifelong strategies to cope with stress a comprehensive medical student wellness program-design and implementation at vanderbilt school of medicine. academic medicine: journal of the association of american medical colleges stressors and resources related to academic studies and improvements suggested by medical students: a qualitative study medical students' perceptions of stress due to academic studies and its interrelationships with other domains of life: a qualitative study qualitative content analysis: theoretical foundation, basic procedures and software solution what are the perceived influences on asthma self-management at the workplace? a qualitative study psychosocial working conditions and diabetes self-management at work: a qualitative study consolidated criteria for reporting qualitative research (coreq): a -item checklist for interviews and focus groups meeting between federal chancellor merkel and the minister-presidents of the lä nder to discuss the coronavirus-press release medical student perspective on stress: tackling the problem at the root evaluating a grading change at ucsd school of medicine: pass/fail grading is associated with decreased performance on preclinical exams but unchanged performance on usmle step scores pass fail grading-a disadvantage for students applying for residency stressors and starting points for health-promoting interventions in medical school from the students' perspective: a qualitative study peer support for clinicians: a programmatic approach the health enhancement program at monash university medical school enhancing the health of medical students: outcomes of an integrated mindfulness and lifestyle program academic psychiatry: the journal of the american association of directors of psychiatric residency training and the association for academic psychiatry we would like to thank johanna schwerdt for her invaluable help understanding the medical school curriculum and putting the students' perspectives into the right context. loerbroks. key: cord- -x r rlm authors: yokhana, j. s.; parkinson, g.; frankel, t. l. title: effect of insoluble fiber supplementation applied at different ages on digestive organ weight and digestive enzymes of layer-strain poultry date: - - journal: poult sci doi: . /ps/pev sha: doc_id: cord_uid: x r rlm two experiments were conducted to study effects of dietary insoluble fiber (if) on digestive enzyme function in layer poultry. in experiment , wk old pullets were fed a control diet (group c) or a diet (group if) supplemented with % if (arbocel rc). after wk, pullets per group were killed and organ samples collected. the remaining pullets in group c were divided into two groups: half were fed the control diet (group c) and half were given the if diet (group c-if). similarly, half the pullets in group if continued on the if diet (group if) and half on the control diet (group if-c). at wk, organ samples were collected. bw at wk (if, . g; c, . g) and wk (if, . g; if-c, . g; c-if, . g; c, . g) were not different. at wk , the relative proventricular weight ( . g/ g bw) and activities of pepsin ( . pepsin units/g proventriculus/min) and pancreatic general proteolytic activity (gp) ( . μmol tyrosine produced/g tissue) were greater (p < . ) than those of group c (proventricular relative weight, . ; pepsin activity, . ; gp activity, . ). at wk , relative weights of liver and gizzard of group if were heavier (p < . ) than other treatments; activities of pepsin, gp, trypsin and chymotrypsin of if pullets were significantly greater than other treatments as was mrna expression for pepsinogens a ( . vs. . ) and c ( . vs. . ). in experiment , wk old hens were fed a control diet or a diet containing . % if (arbocel rc) for wk. final bw after wk was not different (if, . g; c, . g). pancreatic gp activity was greater (p < . ) in group if hens than group c at wk ( . vs. . μmol tyrosine released/min/g tissue)) as was relative gizzard weight ( . vs . g/ g bw). the significantly improved digestive organ weights and enzyme activities in if pullets may contribute to an improvement in feed utilization. growth and development in layer pullets during rearing and early lay are important to the commercial poultry industry because of their influence on long-term production efficiency (summers and leeson, ) . incharoen and maneechote ( ) showed that dietary insoluble fiber (if) such as whole rice hulls (wrh) at g/kg diet can be used to enhance growth and uniformity of pullets and improve egg production of laying hens. the inclusion in the diet of if from oat hulls, at levels between to % improves the growth performance of broilers fed low-fiber diets and dietary inclusion of % inulin or cellulose (arbocel fd ) as an if source has been shown to reduce feed intake and improved egg production of broiler breeder hens from to wk of age (mohiti-asli et al., the potential benefits of fiber are dependent to a great extent on the physicochemical characteristics of the fiber source. the inclusion of various if products as feed additives in the diets of growing or productive broiler-and layer-strains of poultry have been shown to induce positive changes on digestive physiology (e.g., hetland et al., hetland et al., , mateos et al., ; lim et al., ) . transit time (retention time) of ingested food from the crop to the gizzard and gizzard activity can be increased by if and these physiological effects can improve mixing of feed particles with digestive secretions and hence improve digestion and absorption of nutrients . digestive enzymes secreted by specific organs and regions of the digestive tract such as proventriculus, pancreas, and small intestines are responsible for the hydrolysis of dietary nutrients and play vital roles in the efficient absorption of the products of digestion. adding if in the form of oat hulls and wood shavings to broiler and layer diets has been shown to benefit nutrient digestion (hetland et al., (hetland et al., , possibly as a result of an increased amylase concentration in the chyme of the jejunum (hetland et al., ) . the majority of experiments examining the effects of if on the functioning of digestive enzymes have examined the effects on pancreatic or intestinal lipases, amylases and peptidases (hetland et al., ; taylor and jones, ; sarikhan et al., ; svihus, ) . there has been very little systematic work on the effects of if on proteolytic enzymes of the different supply organs of the digestive tract (proventriculus, pancreas and small intestine) of layer-strain poultry. enhanced activity of such enzymes may improve the supply of amino acids for body and reproductive organ growth, which continue after supply organs have developed, and may thus contribute to improve egg production. despite pepsin digestion being the first stage in the enzymatic digestion of protein, there has been very little investigation into dietary stimulation of pepsin function or enhancement of synthesis of pepsinogens in poultry. pepsinogens are the zymogen precursors of the active enzyme pepsin, and they are synthesized in poultry in the oxyntic cells of the proventriculus that also secrete hydrochloric acid (hirschowitz, ) . in adult poultry, two pepsinogens have been detected, pepsinogen a (cpga) and pepsinogen c (cpgc). pepsinogen a is secreted in greater amounts than cpgc (donta and van vunakis, ; sakamoto et al., ) . the first experiment was designed to determine whether the addition of a commercial if product (arbocel rc, jrs co. inc., rosenberg, germany) in the diets of young layer-strain pullets between the ages of and wk influenced supply organ growth and proteolytic enzyme activities in the proventriculus, pancreas, and small intestine. in addition, the experiment was designed to determine whether there was a residual effect of if on the supply organs and enzyme activities wk after it was removed from the diet. the effect of starting the if feed at a later age, wk, was also determined. concentration of pepsin in proventricular tissue can be affected by hormones such as neurotensin and food in the gut (degolier et al., ) . on the other hand, pepsinogen mrna activity is unlikely to be affected by short-term effects on pepsinogen secretion from oxyntic cells. we therefore wished to determine whether there was a correlation between pepsin activity and mrna in proventricular tissue so as to provide an alternate means of measuring the effects of dietary changes on digestive function. the second experiment was to determine the effect of the commercial if product arbocel rc on enzyme activities of layer hens kept under commercial conditions from point of lay at to wk of age through early egg production to wk of age. in experiment , -week-old hy-line brown pullets were obtained from a commercial supplier in melbourne, victoria. all pullets were kept in the one house containing pens ( . × . × . m, w × l × h) with slatted floors, two experimental diets were used: a control diet (table , ridley agriproducts pty ltd. , pakenham, , australia) without additives (diet c) and the if diet consisting of the control diet plus % if (arbocel rc fine, jrs co. inc., rosenberg, germany which contains (manufacturer's analyses) % crude fiber and % acid detergent lignin). the analyzed concentrations of crude fiber in the two diets were . % and . % for diet c and diet if, respectively (feedtest, agrifood technology pty ltd, werribee, vic., australia). feed and water were provided ad libitum. in experiment , hy-line brown hens between the ages of and wk old were obtained from a commercial egg producer (country lane poultry farm, tynong north, victoria australia). the company was testing, for their own information, whether addition of . % arbocel rc to the feed they normally used, would increase egg productivity, decrease cannibalism and decrease water content of the manure. they agreed to let us collect hens from their feeding trial. two diets were formulated for the company by ridley agriproducts pty ltd. the control diet (table ) was fed to half the hens in the layer house (group c) and the other diet containing . % arbocel was fed to hens in the other half of the layer house (group if). the concentrations of crude fiber in the two treatments diets were analyzed by the company and were . % for the control diet and . % for the if diet. the layer house held , hens and had fully automated temperature and humidity control with temperature sensors placed throughout the house to monitor conditions and adjust ventilation accordingly. there were cages per tier of the -tier a-frame units; hens were housed five per cage and cage floor area was cm per bird. hens were placed in the house at to wk of age. the control diet was fed to hens in one half of the house and the if diet was fed to hens in the other half of the house. feed and water was provided at all times. experiment on the day of arrival leg-bands were placed on all pullets and they were weighed. fortyeight pullets were allocated randomly to pens, four birds per pen. pullets in six pens were fed the control diet (group c) for the first wk and those in the remaining six pens were fed the % if diet (group if). pen treatments were randomized within the house. after wk, when the pullets were wk of age, six pullets (one per pen) were randomly selected from each treatment and killed with an intravenous overdose of pentobarbitone sodium (lethabarb, virbac animal health, milperra, nsw, australia). within min of the absence of a detectable palpebral reflex, the liver, gizzard, proventriculus, pancreas, small intestine and ceca were removed. the gizzard was cleaned of contents and both it and the liver weighed. whole proventriculus and pancreas were rinsed with cold . % saline, blotted dry, weighed and stored at - • c for later analysis of enzyme activities. the contents of the small intestines (jejunum and ileum) were washed out with . % saline then the tract was divided into three equal lengths (proximal, medial and distal sections) and cm segments from the middle of each section were collected, weighed separately and stored at - • c for later analysis of enzyme activities. the contents of the ceca were washed out with saline. at wk the remaining pullets in group c were divided so that eight pullets continued on the control diet (group c) and eight were given the if diet (group c-if). eight of the pullets from group if continued to be fed the if diet (group if) and eight were given the control diet (group if-c). the pullets were housed in three pens per treatment with two pens of three and one of two pullets. after a further wk ( wk after the start of the experiment) when the pullets were wk of age, they were killed and samples collected as before. in addition, tissues samples from the proventriculi of pullets in groups c and if were taken and stored in rnalater r (cat. no. r , sigma-aldrich, castle hill, nsw, australia) at - • c for later analysis of pepsinogen gene expression. the experiment was conducted in accordance with the principles and specific guidelines of la trobe university animal ethics committee (ltu-aec) project number aec - . experiment because we had no control of the experimental layout of the layer house with hens in one half of the house being fed the control ration (group c), and hens in the other half of the house being fed the ration containing . % if (group if), it was decided that hens from the middle tiers of the two central rows in the house would be taken for sample collection. by doing so, samples would be taken from hens that were kept under as similar environmental conditions (but not feed and water delivery) as possible. at , , , and wk after the start of the feeding trial, eight hens from group c and eight from group if were randomly collected, one hen per cage. the hens were collected from cages along the length of a row of cages. the hens were then transported by road (approximately h) to the university campus and weighed, killed, and tissue samples (excluding small intestines) were collected as in experiment . the experiment was conducted in accordance with the principles and specific guidelines of ltu-aec, project number aec - . proventricular pepsin activity the assay for pepsin activity was based on the method of anson ( ) as modified by susbilla et al. ( ) and delia ( ) . the whole proventriculus was thawed and homogenized on ice with a polytron homogenizer (kinematica ag, lucerne, switzerland) in a . m sodium buffer, ph . the homogenized samples were centrifuged and an aliquot of diluted supernatant was added to a test tube containing . % acidified bovine hemoglobin (cat. no. h , sigma-aldrich) substrate, ph . . the samples were incubated at • c in a shaking water bath (julabo sw, west germany) for min and the reaction stopped with % trichloroacetic acid (tca) solution. the sample was filtered and neutralized with . m sodium bicarbonate solution. free tyrosine released through hydrolysis of hemoglobin was measured with folin-ciocalteu's phenol reagent (cat. no. f , sigma-aldrich) and absorbance measured at nm in a spectrophotometer (model u- spectrophotometer, hitachi, japan). a tyrosine standard curve (cat. no. t , sigma-aldrich) was prepared from standard solutions ranging in concentration from to mm. porcine stomach mucosal pepsin (pepsin a, ec . . . , cat. no. p , sigma-aldrich) was used to convert tyrosine released to pepsin units. pepsin was dissolved in . m sodium phosphate buffer, ph and standards of to μg/ml produced. tyrosine released from hemoglobin by pepsin was measured as for the proventricular tissue. one unit of pepsin activity was defined as μmol of tyrosine released/min/g proventricular tissue. pancreatic general proteolytic (gp) activity the method of susbilla et al. ( ) with slight modification by delia ( ) was used to determine the general proteolytic activity of the pancreas. whole pancreas was homogenized in ringer's solution, ph . . the tissue extract was activated for h on ice, with enterokinase (from porcine intestine, cat. no. e , sigma-aldrich) in tris-hcl solution, ph . . the substrate ( % casein, cat. no. c , sigma-aldrich in a . m sodium phosphate buffer, ph ) was then added to a test tube containing tissue extract. after incubating in a shaking water bath at • c for min, the reaction was stopped with % tca (wt/vol) and the solution filtered through whatman no. filter paper. after addition of . m na co , free tyrosine in the solution was measured with folin-ciocalteu's solution. the absorbance was read at nm and amount of tyrosine released from casein was determined from a tyrosine standard curve in . m sodium phosphate buffer, ph . the gp activity was expressed as μmol of free tyrosine released from casein/min/g pancreatic tissue. pancreatic trypsin and chymotrypsin activities these were measured by the method of erlanger et al. ( ) as modified by caviedes-vidal and karasov ( ) . pancreatic homogenate plus enterokinase solution was incubated for h in a shaking water bath at • c. trypsin activity was then determined with a mm nα-benzoyl-dl-arginine -nitroanilide hydrochloride (dl-bapna, cat. no. b , sigma-aldrich) solution, ph . and chymotrypsin activity with mm n-glutaryl-l-phenylalanine -nitroanilide (gpna, cat. no. g , sigma-aldrich) solution, ph . . samples for trypsin and chymotrypsin determinations were incubated in a shaking water bath at • c for min. the reaction was stopped with % acetic acid and the absorbance was read at nm. the amount of -nitroaniline released from a substrate was obtained from a standard curve of -nitroaniline (cat. no. n , sigma-aldrich) in . m tris-hcl buffer, ph . , for trypsin activity and ph . for chymotrypsin activity. trypsin (ec . . . ) from bovine pancreas, (t , sigma-aldrich) was used to convert -nitroanaline concentration to trypsin units (delia, ) . standard concentrations of trypsin were incubated with mm dl-bapna solution, ph . and -nitroaniline measured as for the pancreatic tissue. one unit of trypsin activity was defined as μmol of -nitroanaline released/min/g pancreatic tissue. to convert -nitroanaline concentration to chymotrypsin units, standards of αchymotrypsin (ec . . . , type ii from bovine pancreas, cat. no. c , sigma-aldrich) were prepared in a mm hcl and incubated with mm gpna solution, ph . , as for pancreatic tissue. one unit of chymotrypsin activity was defined as μmol of nitroanaline released/min/g pancreatic tissue. small intestinal dipeptidase and aminopeptidase activities the dipeptidase activity in each of the three intestinal segments (proximal, medial, and distal) was measured according to the method described by delia ( ) . homogenates of each segment were incubated for min with the substrate, mm glycyl-lleucine (ec . . , cat. no. g , sigma-aldrich) in ringer's solution, ph . , in a shaking water bath at • c. after filtering through whatman no. paper, the absorbance was measured at nm. the amount of glycyl-l-leucine hydrolyzed by the activity of dipeptidase in the small intestine was determined by calculating the decrease in absorbance. dipeptidase activity per g intestinal tissue (nmol of glycyl-l-leucine hydrolyzed per g of jejunal plus ileal tissue/min) was calculated from the sum of the average activities determined for proximal, medial and distal sections. the method of caviedes-vidal and karasov ( ) was used to determine aminopeptidase-n activity. homogenates of each segment were incubated with mm l-alanine- -nitroanilide hydrochloride (cat. no. a , sigma-aldrich) in a . m sodium phosphate buffer, ph , at • c for min in a shaking water bath. the absorbance was read at nm and concentration of -nitroaniline formed was calculated from a nitroaniline standard curve in . m sodium phosphate buffer, ph , at concentrations ranging from to . mm. the activity of aminopeptidase in the small intestine (jejunum and ileum) was calculated as for dipeptidase activity and was expressed as μmol of free nitroaniline released from l-alanine- -nitroanilide per g jejunal plus ileal tissue/min. the protein concentrations in the homogenate extracts of the tissues were measured using the method of lowry et al. ( ) . bovine serum albumen (cat. no. a , sigma-aldrich) was used as standard. for the proventriculus, albumen was prepared in . m phosphate buffer, ph . , while for pancreas and small intestine it was prepared in ringer's solution, ph . . after incubation, tyrosine concentration was measured using folin-ciocalteu's solution. total mrna was extracted from proventricular tissues ( mg) using ml of trizol reagent (invitrogen, life technologies, australia) according to the manufacturer's instructions. a nano drop nd- spectrophotometer (thermofisher scientific, scoresby vic., australia) was used to quantify the extracted mrna. only samples with an absorbance a / ratio of . to . were used. extracted mrna was further purified with ambion x turbo dnase buffer (cat. no. am , life technologies) according to the manufacture's instructions and stored at - • c. the synthesis of cdna from extracted mrna was carried out with a dynamo tm cdna synthesis kit (cat. no. f- l, thermofisher scientific, australia) as recommended by the manufacturer. a thermal cycler (stratagene mx p qpcr system, agilent technologies, santa clara, ca), was used to convert the mrna into cdna. primers for target and reference genes were, pepsinogen a (ab ) forward gggtgccctctatc-tattgc, reverse cagtgtcatagcccaggatg; pepsinogen c (ab ) forward ggtgtcctact-gtgcctgtg, reverse cctggtttgtgatgg agatg; β-actin (nm˙ ) forward atggctc-cggtatgtgcaa, reverse tgtctttctggcc-cataccaa (grommen et al., ) ; glyceraldehyde- -phosphate dehydrogenase (gapdh) forward gccatcacagccacacaga and reverse tttcc-ccacagccttagca (azzam et al., ) . simplex real-time qpcr analysis (rt-qpcr) was conducted using sensimix sybr low-rox kit (cat. no. qt - , bioline australia pty ltd) in a stratagene mx p qpcr system (agilent technologies, santa clara, ca). each well of a -well plate contained the same volume of both forward and reverse primer of either a target or a housekeeping gene along with template cdna (or dnase-free water for no template controls) and reagents according to the manufacturer's instructions for the kit. for each sample a mixture of all reagents was added to a sterile . -ml microcentrifuge tube and mixed well. the first two wells of a -well plate contained buffer instead of the cdna template and were used as a control. from each . -ml microcentrifuge tube that contained a -μl reaction mixture a -μl was aliquot added to each well ( replicates per sample). agarose gel ( % agarose powder (cat. no. bio- , bioline (aust) pty. ltd., alexandria, nsw, australia) electrophoresis was carried out to confirm the purity and size of the bands of the pcr products. the pcr reaction composed of taq buffer, dntps, forward and reverse primers, taq dna polymerase, cdna template and nuclease-free water (nfw) according to the manufacturer's instructions (qiagen-australia, doncaster, australia). calculation of gene expression primer efficiency of the target genes was tested using five dilutions of cdna in duplicate. complementary deoxyribonucleic acid (cdna) was used and diluted as neat (no dilution), : , : , : and : in nfw. efficiency of pcr was determined for both the target and endogenous control genes from the standard curves generated with different dilutions of the cdna synthesized from the chicken proventriculus using the formula pcr efficiency = (− /slope). the slope values were calculated from standard curves and used in the following formula (harrison et al., ; gopinath et al., ) to obtain the corrected cycle time (ct): where ct is the mean cycle time of the target gene ct, nt is the mean ct of housekeeping genes of all the experimental samples, ct is the mean ct of housekeeping gene of the particular sample, s is the target gene slope, andŚ is the endogenous control slope. homogeneity of variances and normality of data were all test using ibm spss statistics version . for windows (ibm corporation, armonk, ny) before analysis of significance between treatments was carried out. for experiment , significance between treatments of pullets sampled wk after the start of the experiment were analyzed with an independent t-test (spss . for windows) with six pen replicates. for samples collected wk after the start, the three pen replicates per treatment were analyzed by one-way anova; when a significant difference between means was observed, post hoc significance between treatment means was determined using the bonferroni test. linear regression of pepsinogen a and pepsin activity was determined with spss. for experiment , each hen was an experimental unit as no cage of five hens was sampled more than once. differences between means were analyzed with an independent t-test. a value of p < . was considered statistically significant. table . experiment live body weights (g) and relative weights (g/ g live-weight) of internal organs of wk old hy-line brown layer strain pullets given a control diet † (c) or a diet supplemented with %, insoluble fiber † (if) for wk then either diet c or diet if for a further wk (mean, pooled sem). ‡ weight ranges for hy-line brown layer-strain, wk - g; wk - g (hy-line international, ) n = (pen replicate) at wk, n = (pen replicate) at wk. * means at wk within the same row are significantly different (p < . ). a,b means at wk within the same row with different superscript letters differ, p < . . c = control diet (no added if) from to wk. if = insoluble fiber (if) diet containing % arbocel rc fine, from to wk. c-if = control diet from to wk; if diet from to wk. if-co = if diet from to wk; diet c from to wk. inc., rosenberg, germany. ‡ normal weight ranges for hy-line brown layer-strain, wk , - , g; wk , - , g; wk , - , g; wk , - , g (hy-line international, ) . * means within the same row at same time point differ (p < . ). the presence of % if in the diet of pullets for five (groups c-if and if-c) or wk (group if) resulted in heavier bw than controls (group c, table ) but there was no significant difference among the treatments. in experiment , the bw of hens in group if were also not significantly different from control hens ( table ). the inclusion of if in the diets had no detrimental effect on bw of the pullets or laying hens as, in all treatments in experiment (table ) , mean bw was heavier than the normal ranges for hy-line brown pullets and in experiment the bw of both treatment groups (table ) was within the normal ranges (hy-line international, ) . others have shown that if can improve bw gain in both layer-strain and broiler birds, and it is possible that weight gain may be affected by age or developmental age at which if is given or by the strain of poultry used. incharoen and manee-chote ( ) showed that if supplied as whole rice hulls to younger pullets and of a different strain than used here, -to -week-old hn nick brown layer-strain pullets, resulted in a significant increase in bw. gonzález-alvarado et al. ( ) showed that bw gain in broiler chicks was significantly improved by increased fiber content of the diet from -to -day-old but was not affected in younger birds and bogus lawska-tryk ( ) showed that feeding broiler chickens from to d of age with arbocel bww- at four different levels (the final amounts added to the finisher ration being (control), . %, . %, and . %) led to significantly increased bw at the lowest and highest levels when compared with controls. feeding the if diet for or wk in experiment did result in significant increases in the relative weights of some organs (table ) . after being fed the if diet for wk the relative weight of the proventriculus in wk old pullets (experiment , table ) was significantly greater than that of the pullets on the control diet. feeding the if diet for a further wk to wk of age resulted in significantly greater relative weights of the liver and gizzard (but not proventriculus) compared to the weights in the control (group c) and other two treatments in which if was fed for a shorter period (table ) . a significant difference among relative weights of the small intestines was seen between those of group if and group c-if pullets (table ) although those from group if were heavier than small intestines in the other two groups (groups c and if-c). no other significant differences were found among relative weights of organs in experiment . insoluble fiber has been shown to affect the weights of supply organs and can affect functioning of the git, digestibility of feed and feed conversion of poultry (e.g., hetland et al., hetland et al., , mateos et al., ) . addition of pea fiber, wheat bran and oat bran either at low ( g/kg) or high levels ( g/kg) in broiler diets was shown by jørgensen et al. ( ) to cause a significant increase in the weight of the git tract which is similar to the results of experiment in pullets given the if diet for wk. the effects of if on gizzard and proventricular weights shown here are similar to those in an experiment by gonzález-alvarado et al. ( ) , in which if was included in the diets of broiler chicks from to d of age: the if was included either as % oat hulls or % soy hulls, in low-fiber diets (crude fiber . %). oat hulls caused a significant increase in gizzard weight: proventricular weight was only significantly increased with soy hulls (gonzález-alvarado et al., ) . thus source of if (and therefore proportions of the different fiber components) can influence organ development differently. similar to the experiment reported here using arbocel rc, bogus lawska-tryk ( ) also reported no effect of the if source, arbocel bww- , on pancreas weight. adding if to poultry feeds has been shown to change the weight and length of the git (siri, ; viveros et al., ; jørgensen et al., ; smits et al., ) which supports the results obtained in experiment . taylor and jones ( ) suggested that increased gizzard size could be a reason for the reduction in weight of the small intestine they found and may reflect an adaptation of the gut to increased availability of nutrients as a result of feeding a diet containing increased fiber concentration. a welldeveloped gizzard can positively enhance digestion as food is retained for a longer time in the upper digestive tract (proventriculus and gizzard) and this may activate digestive secretions from specific organs and result in more efficient nutrient assimilation (jones and taylor, ) . gonzález-alvarado et al. ( ) showed that fiber improved total tract apparent retention of feed and feed conversion and it also caused a decrease in the ph in the gizzard. fewer experiments using if have been carried out on layer-strain poultry than broilers; however, freitas et al. ( ) showed that wk old hy-line brown pullets given increased dietary neutral detergent fiber (ndf) for wk had significantly increased liver and intestinal weights but gizzard weight, unlike that in experiment , was reduced. in the adult hens in experiment only the gizzard at wk and liver at , , and wk after the start of the trial showed significantly higher relative weights. others have reported on the effects of if on organ weights in adult hens: the weights of gizzard and pancreas in -week-old leghorn hens (hetland et al., ) were similar to those of the hy-line brown hens in experiment and the authors reported an increase in relative gizzard weight with increased if intake. the authors (hetland et al., ) also showed there to be a significant increase in the relative weights of the gizzards in -week-old leghorn pullets supplemented with if as wood shavings for wk when compared with unsupplemented controls. the effect of if on concentrations of protein in proventriculus and pancreas differed between the two experiments reported here. the only significant difference in protein contents of the proventriculus were seen between groups if and c after wk in experiment (table ). however in the laying hens in experiment (table ) significantly higher protein contents were seen in pancreatic tissue at , , and wk after the start of the experiment in group if hens compared with those in group c. overall, the results of the experiments reported here show that organ weights can be increased by the addition of if to diets of growing pullets and in hens after the start of egg-laying. such effects may help to contribute to improved feed utilization as has been reported by others. besides the effects of if on live-weights and supply organ weights the experiments reported here show significant effects of if supplementation on the activities of proteases required at the different stages for digestion of dietary protein. five wk after the start of experiment , proventricular pepsin and pancreatic gp and chymotrypsin activities (table ) , were higher (p < . ) in group if pullets than those in group c. after wk on those diets (table ) , activities of pepsin, pancreatic gp, trypsin and chymotrypsin were significantly higher in group if than group c pullets. this may suggest that a longer time of feeding if is required to induce a significant response. feeding the if diet to the older pullets ( to wk of age) for wk (group c-if) had no significant effect (compared to controls) on activities of pepsin or the three pancreatic enzymes measured (table ). although activities of pepsin and pancreatic gp, trypsin and chymotrypsin in pullets fed first the if and then the control diets from to wk of age (group if-c) were always higher than those of controls (table ) significant differences in enzyme activities in the pancreatic enzymes were only table . experiment enzyme activities (per min/ g tissue) and protein content (mg/ g tissue) of wk old hy-line brown layer-strain pullets given a control diet † (c) and the control diet supplemented with % insoluble fiber † (if) for wk then either diet c or diet if for a further wk (mean, pooled sem). n = (pen replicate) at wk, n = (pen replicate) at wk. * means after wk on experimental diets within the same row are significantly different (p < . ). a-c means at wk within the same row with different superscript letters differ p < . . for definitions of c, if, c-if and if-c, see table . pepsin = pepsin activity in proventriculus, pepsin units μmol tyrosine produced/ min/g proventricular tissue. gp-pancreas = general proteolytic activity, μmol free tyrosine released from casein substrate/ min/g pancreas. chymotrypsin = chymotrypsin units of -nitroaniline released from n-glutaryl-l-phenylalanine -nitroanilide (gpna)/ min/g pancreas. trypsin = trypsin units of -nitroaniline released from nα-benzoyl-dl-arginine -nitroanilide (dl-bapna)/min/g pancreas. dipeptidase = μmol glycyl-l-leucine hydrolyzed/min/g tissue. aminopeptidase = nmol -nitroaniline released l alanine-p-nitroanalide/min/g tissue. for units of activity and abbreviations see table . seen for gp activity when compared with that of group c but trypsin activity was significantly greater than activities in groups c and c-if (table ). for small intestinal dipeptidase and aminopeptidase activities in experiment no significant differences were observed among treatments after or wk on the experimental diets (table ). in the laying hens (experiment ), the significant effects of if were less than in the younger pullets in experiment , and this could have been due the lower concentration of if used in the second experiment ( . versus . %). pepsin activities (table ) increased gradually with age from to wk of age in both treatment groups however pepsin activity in group if hens was significantly higher after wk compared with those in the control group. pancreatic gp activity in group c hens (table ) appeared to decrease with age while at all collection times ( , , , and wk) gp activities were significantly higher in in group if hens than those of hens in group c. for trypsin activities of the pancreas (table ) the only significant difference between treatments was seen at wk, with group if having higher activities. chymotrypsin activities (table ) in pancreatic tissues were significantly higher in group if compared with those of the control group at nine and wk after the start of the feeding trial. the mrna expression in proventricular tissues of week-old pullets was greater for cpga than for cpgc in both treatment groups. pullets in group if had significantly greater expression of both pepsinogen a (corrected ct . ± . ) and c (corrected ct . ± . ) compared to those in group c where corrected ct for cpga mrna was . ± . and that for cpgc, . ± . . there was a positive correlation (p < . ) between cpga mrna activity and pepsin activity (y = . x + . , r = . , n = ). because of the significant increase of both proventricular pepsin activity and mrna pepsinogen expression in if pullets (experiment ), it is unlikely that the higher levels of pepsin activity that were measured here were due to reduced secretion of pepsin (gabriel et al., ) into the proventricular lumen. decreased pepsinogen release would contribute to a higher retention of pepsinogen in the tissues (gabriel et al., ) . the significantly greater mrna expression of pepsinogens a and c in the pullets given if reflects the higher pepsin activities determined in proventricular homogenates and probably reflects an increase in production of the zymogens of pepsin enzymes. the similarity in increase between mrna of pepsinogen a and that of pepsinogen c suggests that the mechanism of stimulation of the two zymogens was similar and could have been caused by physical effects on the oxyntic (or oxynticopeptic) cells of the proventriculus or by one or more of the following that have been shown to influence pepsinogen production: increased production of cholecystokinin (cck), decreased ph in the proventriculus and increased reflux of bile from the small intestine via the gizzard (sommer and kasper, ; duke, ; li and owyang, ; sacranie et al., ; jiménez-moreno et al., ; svihus, ; sacranie et al., ) . pepsin activity is stimulated by low ph and possibly through an increase in solubility of mineral salts (incharoen and maneechote, ) and others have reported on the decrease in proventricular and gizzard ph caused by if (e.g., hetland et al., ; svihus, ) . the results obtained here on increased trypsin and chymotrypsin activities in the group if pullets after wk on if (experiment ), confirm those of bogus lawska-tryk ( ) who showed that trypsin and chymotrypsin activities were increased relative to controls in -day-old broilers fed if as arbocel bww- . regulation of the production of pancreatic enzymes is through hormones such as cck, secretin and gastrin produced in the digestive tract (sommer and kasper, ; li and owyang, ; owyang and logsdon, ; wang and cui, ) . hormone production in the intestinal mucosa of pullets fed if could have been increased through increased intestinal tissue production (table ) , and this in turn could lead to increased production of zymogens of the pancreatic enzymes and thus to measurement of an increased activity of the enzymes. significant increases in pancreatic gp and chymotrypsin activities were seen in both experiments reported here when if was added to diets of layer-strain pullets or hens but trypsin activity was only significantly increased in pullets in experiment . these different responses could have been due to the stage of maturity of the birds or to the differences in fiber concentration of the diets fed to the poultry in the two different experiments. the effects of increased enzyme activity in if supplemented poultry may have contributed to the observed increase in weights of supply organs in both experiments but it is not possible to identify the specific components of the if that caused such effects. the commercial product, arbocel rc, used in these experiments contained % crude fiber with % lignin (manufacturer's data) and is probably very different in composition from sources of if used by other research workers. the results of these experiments showing increased proteolytic digestive enzyme activities in the proventriculus and pancreas and in growth of supply organs may explain in part the improvements in protein digestibility reported by others following if supplementation in poultry (e.g., jaroni et al., ; jiménez-moreno et al., ) . however, in order to be able to understand mechanisms by which if can alter enzyme activities and or organ growth and to be able to understand why different if sources produce different effects, it will be necessary to identify more accurately the different types and proportions of the constituents making up the if sources used in poultry feeds. the estimation of pepsin, trypsin, papain, and cathepsin with haemoglobin effect of supplemental l-threonine on mucin gene expression and intestine mucosal immune and digestive enzymes activities of laying hens in environments with high temperature and humidity effect of different levels of cellulose in the diet on the proteolytic activity of the pancreas in broiler chickens developmental changes in digestive physiology of nestling house sparrows, passer domesticus neurotensin decreases pepsin output and gastrointestinal motility in chickens protein requirements, digestion and taste preferences of two lorikeet species chicken pepsinogens and pepsins. their isolation and properties gastrointestinal motility and its regulation the preparation and properties of two new chromogenic substrates of trypsin fiber level for laying hens during the growing phase differences in the digestive tract characteristics of broiler chickens fed on complete pelleted diet or on whole wheat added to pelleted protein concentrate effect of type of cereal, heat processing of the cereal, and inclusion of fiber in the diet on productive performance and digestive traits of broilers rapid detection of newcastle disease virus replication in embryonated chicken eggs using quantitative real time polymerase chain reaction identification of unique thyrotropin receptor (tshr) splice variants in the chicken: the chicken tshr gene revisited lithium chloride inhibits the coronavirus infectious bronchitis virus in cell culture effects of oat hulls and wood shavings on digestion in broilers and layers fed diets based on whole or ground wheat role of insoluble fiber on gizzard activity in layers role of insoluble nonstarch polysaccharides in poultry nutrition hy-line brown management guide -commercial layers control of pepsinogen secretion the effects of dietary whole rice hull as insoluble fiber on the flock uniformity of pullets and on the egg performance and intestinal mucosa of laying hens the effect of dietary wheat middlings and enzyme supplementation ii: apparent nutrient digestibility, digestive tract size, gut viscosity, and gut morphology in two strains of leghorn hens effects of source of fibre on the development and ph of the gastrointestinal tract of broilers the incorporation of whole grain into pelleted broiler chicken diets: production and physiological responses the influence of dietary fiber source and level on the development of the gastrointestinal tract, digestibility and energy metabolism in broiler chickens vagal afferent pathway mediates physiological action of cholecystokinin on pancreatic enzyme secretion beneficial effects of insoluble raw fiber concentrate addition to layer diet protein measurement with the folin phenol reagent poultry response to high levels of dietary fiber sources varying in physical and chemical characteristics effects of feeding regimen, fiber inclusion, and crude protein content of the diet on performance and egg quality and hatchability of eggs of broiler breeder hens new insights into neurohormonal regulation of pancreatic secretion the effect of insoluble fiber and intermittent feeding on gizzard development, gut motility, and performance of broiler chickens reflux of digesta and its implications for nutrient digestion and bird health analysis of temporal expression pattern and cis-regulatory sequences of chicken pepsinogen a and c effects of insoluble fiber on serum biochemical characteristics in broiler effects of dietary cellulose level on nutrient utilization in chickens. asian-aus dietary carboxymethylcellulose with high instead of low viscosity reduces macronutrient digestion in broiler chickens effect of acetylcholine, gastrin, and glucagon alone and in combination with secretin and cholecystokinin on the secretion of the isolated perfused rat pancreas laying hen performance as influenced by protein intake to sixteen weeks of age and body weight at point of lay quantitative feed restriction or meal-feeding of broiler chicks alter functional development of enzymes for protein digestion the gizzard: function, influence of diet structure and effects on nutrient availability the incorporation of whole grain into pelleted broiler chicken diets. ii. gastrointestinal and digesta characteristics effect of enzyme supplementation of a diet based on barley, and autoclave treatment, on apparent digestibility, growth performance and gut morphology of broilers how does cholecystokinin stimulate exocrine pancreatic secretion? from birds, rodents, to humans the ministry of higher education and scientific research-iraq (moher) provided scholarship for johnny yokhana. chris rowell from hy-line company and peter cransberg from ridley agriproducts pty ltd. and also to farm pride at tynong north, victoria provided assistance in acquiring birds and diet formulations. colleagues, diana delia, samuel armoo and vignesh rathinasamy provided information and assisted with lab work. the central animal house staff and in particular, rob evans and eva suric, helped with care of pullets. key: cord- -k opc authors: stjernquist‐desatnik, anna; orrling, arne title: pharyngotonsillitis date: - - journal: periodontol doi: . /j. - . . .x sha: doc_id: cord_uid: k opc nan grouping of streptococci identification of bacterial strains constitutes the basic tool in studies of the epidemiology and treatment outcome of pharyngotonsillitis. the streptococcal group of organisms are classified into lancefieldÕs serological groups a-u according to carbohydrate antigens in the cell wall. based on the presence of t antigen, beta-hemolytic group a streptococci are divided into about t types ( ) . further subdivision of group a streptococci is made on the basis of the m-protein ( ) . dna technologies of the past decade has resulted in the classification of the m-type of beta-hemolytic group a streptococci based upon the sequence of the m-type gene emm, and more than emm-sequence types have been identified ( ) . beta-hemolytic group a streptococci possess a multitude of extracellular and cell-bound virulence factors, which aid in various stages of tissue invasion and are responsible for different disease manifestations. the cell wall m-protein, an extended alpha-helical protein with anticomplementary and antiphagocytic properties, is considered as the main virulence determinant of beta-hemolytic group a streptococci. m-proteins, by interacting with plasma proteins such as immunoglobulin g, fibrinogen and c -binding protein, are able to interfere with innate and adaptive host immune responses ( ) . as recognized for decades, only type-specific antibodies directed towards the n-terminal part of the m-protein will be opsonic and protect against beta-hemolytic group a streptococcal disease ( ) . the hyaluronic capsule, although poorly expressed in vitro, is a second antiphagocytic factor of betahemolytic group a streptococci ( ) . the t-protein, previously not implicated as biologically important, was recently shown to be present in fimbriae-like structures in beta-hemolytic group a streptococci and probably plays a role in tissue adhesion ( ) . pyrogenic exotoxins (erythrogenic toxins) are superantigens capable of triggering t lymphocytes to release massive amounts of cytokines and interleukins, thereby generating severe symptoms such as fever, the scarlatiniform rash, tissue necrosis, hypotension and organ failure ( ) . the cysteine protease (identical to exotoxin speb) according to experimental work may be essential for circulatory shock and lung damage ( , ) . this enzyme, and a second cysteine protease of beta-hemolytic group a streptococci, may cleave immunoglobulin g, thereby interfering with immune opsonization of betahemolytic group a streptococci. streptolysins s and o are capable of lysing erythrocytes as well as leukocytes and platelets ( , ) . streptokinase, which converts plasminogen to plasmin, may significantly contribute to a rapid spread of beta-hemolytic group a streptococci within infected tissue by lysing blood clots ( ) . the ability of beta-hemolytic group a streptococci, especially in the stationary phase, to invade respiratory epithelial cells was recently demonstrated ( , ) . beta-hemolytic group a streptococci are mainly extracellular bacteria, but by specifically binding fibronectin, a protein that exists in human blood plasma and in the extracellular matrix, beta-hemolytic group a streptococci may be efficiently internalized into human mucosal cells. the fibronectin bound to the bacterial surface thereby acts like a bridging molecule with host cell integrins, which in turn initiate the uptake process that leads to internalization ( ) . sela & barzilai ( ) found that beta-hemolytic group a streptococcal strains were able to survive for - days inside cultured epithelial cells. they also found that beta-hemolytic group a streptococcal strains from patients with treatment failure harboured an internalization-associated gene in higher prevalence than strains recovered from patients in whom the streptococcal strains had been successfully eradicated. it is not known if internalization into host cells can influence the severity of beta-hemolytic group a streptococcal infections. strains of streptococci show varying capacity to internalize ( , ) , and internalized beta-hemolytic group a streptococci have been found in asymptomatic carriers as well as in patients with pharyngotonsillitis ( ) . strains from patients with treatment failure exhibit a significantly increased ability to survive intracellularly in cultured epithelial cells compared with strains from successfully treated patients ( ) . on the other hand, a betahemolytic group a streptococcal strain that was able to internalize in an animal model was less able to cause serious disease than beta-hemolytic group a streptococci without the internalizing capacity ( ) . beta-hemolytic group a streptococci are strict human pathogens giving rise to a wide range of infectious diseases. impetigo, pharyngotonsillitis and erysipelas may be comparatively mild and are effectively treated with antibiotics. however, since the late s, a rising number of life-threatening invasive betahemolytic group a streptococcal infections have been encountered, such as necrotizing fasciitis and streptococcal toxic shock syndrome ( , ) . streptococci in these diseases are often restricted to certain m-types, in particular m , and produce powerful superantigens, such as the pyrogenic exotoxin a, spea. surgical intervention is often needed in the case of necrotizing fasciitis. however, in spite of antibiotics and intensive care, the mortality is high for patients with necrotizing fasciitis or streptococcal toxic shock syndrome ( , ) . acute rheumatic fever, the most serious nonsuppurative complication of beta-hemolytic group a streptococcal pharyngotonsillitis, is the leading cause of acquired heart disease among children in developing countries ( ) . although no longer a significant health problem in most socioeconomically advanced countries, limited outbreaks of acute rheumatic fever occurred in the usa in the s ( ) . acute poststreptococcal glomerulonephritis, a major cause of child renal failure, occurs after throat and skin infections with beta-hemolytic group a streptococci ( ) . large epidemics are still occurring in developing countries, compared with sporadic cases in the developed world. signs and symptoms of acute pharyngotonsillitis include fever, throat angina, redness of the tonsils and pharynx, tonsillar exudate, enlarged and tender cervical lymph nodes, dysphagia and headache. concurrent symptoms from the respiratory tract (e.g. cough or rhinorrhea) indicate a viral origin of the disease. established beta-hemolytic group a streptococcal throat and skin infections in close surroundings of the patient such as at home, or in school or daycare centres, increases the probability of a betahemolytic group a streptococcal origin of the infection. certain symptoms are more pronounced in pharyngotonsillitis of a beta-hemolytic group a streptococcal origin than in pharyngotonsillitis of another etiology. thus, a high degree of redness in the throat ( ), fever ( ) and a shorter duration of symptoms before seeking medical care ( ) correlate significantly with a beta-hemolytic group a streptococci etiology. the so-called centor criteria have been widely used to implicate beta-hemolytic group a streptococci in adult patients and these are as follows: tonsillar exudates, tender anterior cervical adenopathy, fever by history and absence of cough. if three of these criteria are met, the positive predictive value for a beta-hemolytic group a streptococcal infection is - % ( ) . the findings are, however, inconsistent and although the clinical picture may be of some guidance, it is seldom sufficient for establishing a reliable etiological diagnosis. as there are no pathognomonic signs or symptoms that can provide a definite diagnosis of beta-hemolytic group a streptococcal pharyngotonsillitis, the diagnosis depends on the identification of the bac-terium. bacterial identification can be performed by obtaining a throat culture or by a rapid antigen detection test. a good view of the pharynx and obtaining proper sampling technique are essential to achieve a representative sample. the specimen should be obtained from the tonsillar surface because beta-hemolytic group a streptococci in pharyngotonsillitis are predominantly localized on the tonsils and on the posterior oropharyngeal wall ( ) . the rapid antigen test requires more bacteria than required for culture. the quantity of sample material thus influences the sensitivity and specificity of the rapid tests, which are currently reported as being - % and - %, respectively ( , ) . an asymptomatic carriage stage of beta-hemolytic group a streptococci is reported to occur in about % of adults and % of children during the winter season, although the estimates vary considerably ( ) . during large outbreaks of beta-hemolytic group a streptococcal pharyngotonsillitis, the carrier rate can be as high as % ( ) . a -year longitudinal study of - -year-old schoolchildren found that the period during which a child carried beta-hemolytic group a streptococci of the same emm type averaged . weeks (range: - weeks). many children, however, experienced several periods of carriage during the study and frequently exhibited switches in emm type ( ) . the risk of becoming a carrier of beta-hemolytic group a streptococci, as well as of contracting pharyngotonsillitis, is related to the period of time spent in close contact with a patient during the week preceding the onset of illness ( , ) . the reason why some individuals become carriers is unknown, but the carrier state appears to be a relatively harmless condition because it probably does not result in a clinical infection ( ) and the streptococci are present in low numbers ( ) , which probably does not support a person-to-person transmission of the organism ( ) . however, problems arise if a carrier of beta-hemolytic group a streptococci acquires viral pharyngitis, because a positive test for beta-hemolytic group a streptococci raises the issue of antibiotic treatment. this example highlights the importance of a careful evaluation of symptoms in order to avoid unnecessary antibiotic treatment. a correlation with leukocytosis ( , ) or an increased level of c-reactive protein and beta-hemolytic group a streptococcal pharyngotonsillitis has been reported ( ) , whereas other investigators have failed to verify such relationships ( , ) . serological tests of anti-streptolysin o and anti-dnase b are of no diagnostic value in acute pharyngotonsillitis, but may be useful in the investigation of complications of the disease, such as rheumatic fever ( ) . beta-hemolytic group a streptococcal pharyngotonsillitis is a self-limiting disease and the routine use of penicillin v has therefore been questioned ( ) . however, beta-hemolytic group a streptococci are amongst the most virulent human pathogens, and patients with pharyngotonsillitis caused by infection with this bacterium can be seriously affected with high fever, dysphagia and severe pain. although a majority of patients become free of symptoms within a week, irrespective of therapy, antibiotic treatment of pharyngotonsillitis caused by beta-hemolytic group a streptococci can significantly shorten the duration of symptoms ( , ) . antibiotic treatment may also, to some extent, reduce the risk of purulent complications, such as peritonsillitis, otitis and sinusitis ( , , ) . in acute rheumatic fever, it is claimed that a majority of the patients have a history of pharyngotonsillitis. the decline of acute rheumatic fever in the developed world may indeed be the result of routine antibiotic use for beta-hemolytic group a streptococcal pharyngotonsillitis, supporting the present principles of treatment. rheumatic fever is still a major health problem in many developing countries, and beta-hemolytic group a streptococci have been estimated to be the eighth most common source of global mortality caused by a single pathogen ( ) . in necrotizing fasciitis and streptococcal toxic shock syndrome, however, the port of entry of beta-hemolytic group a streptococci is seldom reported to be pharyngotonsillitis ( , ) . in sum, the reasons for antibiotic treatment of beta-hemolytic group a streptococcal pharyngotonsillitis are: (i) more rapid alleviation of symptoms; (ii) reducing the spread of beta-hemolytic group a streptococci; and (iii) reducing the risk of suppurative and nonsuppurative complications. it is generally agreed that the benefits of antibiotic treatment outweigh the disadvantages ( , , ) . penicillin v perorally for days ( . mg ⁄ kg, two to four times daily) is currently the antibiotic therapy of choice for beta-hemolytic group a streptococcal pharyngotonsillitis. despite over years of use of penicillin, no penicillin-resistant beta-hemolytic group a streptococcal strains have so far been encountered. a possible explanation for this is that penicillin resistance in this species is not compatible with a virulent phenotype ( ) . in penicillin v treatment of beta-hemolytic group a streptococcal pharyngotonsillitis, a treatment period of at least days should be imposed in order to achieve an acceptably low recurrence rate ( , , , ) . despite the absence of penicillin resistance, treatment failure of beta-hemolytic group a streptococcal pharyngotonsillitis is as high as - % ( ) . a second course of penicillin v treatment is followed by still higher failure rates ( ) , in some cases necessitating tonsillectomy. cephalosporins have been shown to be more effective than penicillin v in treating primary betahemolytic group a streptococcal pharyngotonsillitis ( , , ) . cephalosporins may enable shorter treatment regimens than penicillin v, and some patients may only need to be dosed once daily ( ) . cephalosporins are less susceptible to the b-lactamases produced by oral bacteria and probably exert a lesser impact on bacteriocinproducing alpha-hemolytic streptococci in the throat ( , ) . treatment of recurrent beta-hemolytic group a streptococcal pharyngotonsillitis with clindamycin instead of penicillin v seems to produce a significantly better clinical outcome ( , ) . this may be a result of the intracellular accumulation and a high concentration of clindamycin in tonsillar surface fluid ( ) . penicillin v, as a result of its narrow antimicrobial spectrum and the absence of penicillin resistance among beta-hemolytic group a streptococci, is still regarded as the drug of choice for primary betahemolytic group a streptococcal pharyngotonsillitis. cephalosporins or clindamycin appear to be appropriate alternatives for patients experiencing recurrence of pharyngotonsillitis after penicillin v treatment. the problem of frequent recurrence of betahemolytic group a streptococcal pharyngotonsillitis in patients is sometimes resolved by performing tonsillectomy, although opinions differ as to the benefit and risks of this treatment ( , , ) . in a cochrane review from , no studies fulfilled the inclusion criteria for evaluating the effectiveness of tonsillectomy in adults with chronic ⁄ recurrent acute pharyngotonsillitis. only two studies fulfilled the criteria assessing the benefit of tonsillectomy in children with chronic ⁄ recurrent acute pharyngotonsillitis, and only limited conclusions could be drawn from these studies ( ) . further studies are needed to evaluate the effectiveness of tonsillectomy in relation to pharyngotonsillitis. possible factors that may lead to recurrence after penicillin v treatment of pharyngotonsillitis include low patient compliance, re-infection from the environment, eradication of alfa-hemolytic streptococci with inhibitory effects on beta-hemolytic group a streptococci, an increase in beta-lactamaseproducing bacteria inactivating the drug, penicillintolerant streptococci, a low antibiotic concentration at the site of infection and intracellular betahemolytic group a streptococci surviving therapy ( table ) . treatment of beta-hemolytic group a streptococcal pharyngotonsillitis with penicillin v results in rapid recovery ( , ) . as the patient is often free of symptoms after - days of treatment, they may consider further medication as unnecessary and prematurely discontinue the antibiotic treatment, raising the odds of treatment failure. as family members and other close contacts of patients with beta-hemolytic group a streptococcus pharyngotonsillitis are often infected with the same strain, recurrence may be caused by re-infection from other individuals ( ) . some alpha-hemolytic streptococci produce bacteriocins with inhibitory activity against betahemolytic group a streptococci. eradication of alpha-hemolytic streptococci by penicillin v will theoretically reduce bacterial interference and thus increase the risk of treatment failure ( ) . however, some investigations have failed to show that lack of bacterial interference was related to bacterial treatment failure in beta-hemolytic group a streptococcal pharyngotonsillitis ( ) . on the other hand, administration of alpha-hemolytic streptococci into the throat following b-lactam treatment of beta-hemolytic group a streptococcal pharyngotonsillitis has been able to reduce the recurrence rate ( , ) . however, replacement treatment with alpha-hemolytic streptococci is not yet commercially available. increase in b-lactamase-producing bacteria inactivating the drug treatment with penicillin v will promote selection of bacterial species producing b-lactamase, conceivably accounting for the inactivation of penicillin v ( , ) . however, studies on penicillin v vs. amoxicillin ⁄ clavulanic acid in the treatment of pharyngotonsillitis have been inconclusive ( , ) . gerber et al. ( ) studied penicillin v and cefadroxil in the treatment of primary beta-hemolytic group a streptococcus pharyngotonsillitis and found no evidence that b-lactamases produced by the normal pharyngeal flora were related to bacterial treatment failure. the role of b-lactamases in treatment failure thus remains unclear. tolerance to b-lactam antibiotics is a known phenomenon in some medically important species, such as enterococcus faecalis, streptococcus pneumoniae and various alpha-hemolytic streptococci ( ) , and appears to account for the failure of penicillin therapy of arcanobacterium haemolyticum infections ( ) . penicillin tolerance of beta-hemolytic group a streptococci has been suggested to account for the failure in penicillin v treatment of beta-hemolytic group a streptococcal pharyngotonsillitis, but reports have been contradictory, conceivably because of the variability in the definition of ÔtoleranceÕ as well as the technical pitfalls of the methods used ( , , , , ) . the existence of penicillin tolerance in beta-hemolytic group a streptococci has also been questioned ( ) . the beta-hemolytic group a streptococci causing acute pharyngotonsillitis are mainly present in the secretion on the tonsillar surface and in the crypts rather than in the parenchyma ( , ) . penicillin v was detected in tonsillar surface fluid in a majority of patients on the first day of treatment of acute beta-hemolytic group a streptococcus pharyngotonsillitis, but despite a high concentration in serum, was rarely present on the th day or in healthy, treated subjects ( ) . insufficient concentrations of antibiotics in tonsillar surface fluid may contribute to treatment failure of betahemolytic group a streptococcal pharyngotonsillitis ( ) . beta-hemolytic group a streptococci may reside in epithelial cells of pharyngotonsillitis lesions, and may not be reached by penicillin v. Ö sterlund et al. ( ) found that beta-hemolytic group a streptococci, which were internalized in human respiratory epithelial cells and grown in an antibiotic supplemented medium, were externalized as soon as the extracellular antibiotic was removed and an extracellular infection developed rapidly thereafter. thus, respiratory epithelial cells may act as a reservoir for internalized beta-hemolytic group a streptococci and have the potential to cause infection after termination of a penicillin v treatment. the extent to which epithelial cell-embedded beta-hemolytic group a streptococci cause recurrence of pharyngotonsillitis after penicillin v treatment remains to be determined. group c and group g streptococci may cause pharyngotonsillitis, especially in older children and adults ( ) . rapid tests for detecting these streptococcal groups are not available and thus bacterial culture is needed for diagnosis. evidence suggests that group c and group g streptococci can cause acute poststreptococcal glomerulonephritis, but not rheumatic fever. a. hemolyticum is an uncommon cause of pharyngotonsillitis and is often associated with a rash that may mimic scarlatina ( ) . the disease is found most commonly in individuals of the - years age-group and the incidence is about . % among patients with pharyngotonsillitis in this age group ( ) . the organism must be cultured on specific media and is not sensitive to penicillin but is sensitive to macrolides. a. hemolyticum-related pharyngotonsillitis is self-limiting with no known complications. pharyngotonsillitis caused by to c. diphtheriae was relatively common during world war ii, but has rapidly declined in europe since that time. in a vaccinated population the disease is very rare. however, c. diphtheriae-related pharyngotonsillitis is not uncommon in the former soviet union countries where its incidence is probably under-reported. the pharyngotonsillitis caused by c. diphtheriae is characterized by grey membranes in the throat, larynx and around the nostrils. bleeding occurs if attempts are made to remove the membranes. the bacteria produce an exotoxin that gives rise to myocarditis and neurological complications with paralysis and polyneuropathia. treatment with parenteral antibiotics and specific immunoglobulin should be started immediately and even before the microbiological diagnosis in cases of a high suspicion of c. diphtheriae-related pharyngotonsillitis. vincentÕs angina is an uncommon infection presenting with unilateral necrotizing tonsillitis, caused by a mixed anerobic and aerobic flora of spirochetes, bacteroides, streptococci and fusiform bacteria. penicillin is the drug of choice. the patient must be followed-up after a couple of weeks to rule out malignancy, because carcinoma of the tonsils can show a similar clinical picture. n. gonorrhoeae may be a cause of pharyngotonsillitis in individuals practising oral sex. a study of patients with sore throats in a general medical practice found the prevalence of n. gonorrhoeae to be about % ( ) . about % of patients with genital gonorrhoea have throat cultures positive for n. gonorrhoeae and are often asymptomatic. n. gonorrhoeae must be grown on specific media. antibiotic treatment is needed to prevent transmission as well as further dissemination of the organism and the disease. pharyngotonsillitis involving m. pneumoniae or c. pneumoniae is frequently accompanied by bronchitis. infections with these two bacteria often affect children and young adults. most individuals become infected with epstein-barr virus during childhood and will only experience a subclinical infection or mild pharyngitis. however, about one-third of individuals who become infected during adolescence develop the mononucleosis syndrome. infectious mononucleosis is a systemic disease characterized by pharyngotonsillitis, nodular fever and septicemia. patients show prominent exudate and swelling of the tonsils, cervical adenopathy, hepatomegaly and often splenomegaly. mononucleosis patients with beta-hemolytic group a streptococcal pharyngotonsillitis show a prolonged course of pharyngotonsillitis, fever, fatigue and tender cervical adenopathy. heterophile antibodies are not detectable until several weeks after the onset of mononucleosis, but immunoglobulin m specific antibodies against capsid and early epstein-barr virus antigens can be helpful for early diagnosis. mononucleosis in most patients will resolve without special treatment. some patients having difficulty with swallowing and breathing will need hospital care. cytomegalovirus causes about % of mononucleosis cases, and hepatitis is more evident than with epstein-barr virus-related disease. testing for specific cytomegalovirus antibodies are of diagnostic importance. the clinical presentation of a primary human immunodeficiency virus (hiv) infection may mimic that of epstein-barr virus mononucleosis. the incubation period is about - weeks. the acute hiv syndrome presents with pharyngotonsillitis, weight loss, fever, adenopathy, rash and splenomegaly. laboratory tests often show lymphopenia and increased transaminase levels ( ) . tests for anti-hiv immunoglobulins are often negative in the early disease stages but detection of hiv rna by polymerase chain reaction is helpful in providing a diagnosis. it is important to establish the hiv diagnosis as early as possible to initiate an appropriate antiviral therapy. pharyngotonsillitis caused by influenza virus is often exudative. the disease usually occurs in major outbreaks and is often associated with myalgias, fever, tracheitis and headache. rapid tests for the detection of influenza a and b viruses may be useful, and antiviral therapy may reduce the illness duration by about h but is seldom advocated. adenovirus is a common cause of pharyngotonsillitis. pharyngotonsillitis caused by adenovirus often presents as pharyngoconjunctival fever ( ) . the disease is otherwise difficult to distinguish from pharyngotonsillitis caused by other pathogens. pharyngotonsillitis caused by herpes simplex virus often appears with vesicles and ulcerative lesions of the mouth and gingiva, and the disease occurs most frequently in children. the throat pain can be very severe, and hospitalization and parenteral nutrition may be indicated. herpes simplex virus type is by far the most common cause of the disease, but herpes simplex virus type can present similar clinical manifestations. this coxsackie a enterovirus can give rise to pharyngotonsillitis that is characterized by small vesicles surrounded by a red halo in the posterior palate. the disease is virtually always seen in children. agranulocytosis and leukaemia might occasionally start as a severe pharyngotonsillitis that does not respond to antibiotics. laboratory blood tests are needed to confirm the diagnosis. periodic fever syndrome characterized by repeated episodes of pharyngotonsillitis with cervical adenopathy, fever, headache, nausea, reduced general condition and elevated c-reactive protein can occur in children with no proven etiological pathogen. there is no evidence-based treatment, but tonsillectomy is considered to have an effect ( ) . acute pharyngotonsillitis is a common illness with the highest incidence occurring during the winter season. viruses account for more than half of the cases of pharyngotonsillitis. beta-hemolytic group a streptococci are the etiological agents in - % of cases, with higher figures observed during the winter months. beta-hemolytic group a streptococci are virulent human pathogens, which may cause suppurative and nonsuppurative complications, and sometimes life-threatening diseases such as necrotizing fasciitis and streptococcal toxic shock syndrome. signs and symptoms of a beta-hemolytic group a streptococcal infection include tonsillar exudate, tender anterior cervical adenopathy, a history of fever and absence of a cough, but the findings are rather inconsistent. identification of the bacterium by culture or by a rapid antigen test is needed to establish a definite diagnosis. penicillin v for days is the drug of choice in primary beta-hemolytic group a streptococcal pharyngotonsillitis. although penicillin resistance is not recorded in beta-hemolytic group a streptococci, penicillin v treatment fails in as many as - % of the patients, and higher failure rates can occur after a second course of penicillin v treatment, sometimes necessitating tonsillectomy. factors potentially contributing to antibiotic treatment failure include low compliance rate, reinfection from the environment, eradication of alfahemolytic streptococci with an inhibitory effect on beta-hemolytic group a streptococci, an increase in beta-lactamase-producing bacteria inactivating the drug, penicillin-tolerant streptococci, low antibiotic concentration at the site of infection, and intracellular beta-hemolytic group a streptococci surviving therapy. treatment with cephalosporins or clindamycin has been reported to result in a less frequent recurrence of beta-hemolytic group a streptococcal pharyngotonsillitis and is advocated in patients with beta-hemolytic group a streptococcus pharyngotonsillitis not responding to penicillin v treatment. tonsillitis and rash associated with corynebacterium haemolyticum acute pharyngitis acute pharyngitis. etiology and diagnosis. pediatrics molecular basis of group a streptococcal virulence group a streptococcal infections and acute rheumatic fever treatment of patients with a history of recurrent tonsillitis due to group a b-hemolytic streptococci. a prospective randomized study comparing penicillin, erythromycin, and clindamycin role of b-lactamase-producing bacteria in the failure of penicillin to eradicate group a streptococci tonsillectomy versus non-surgical treatment for chronic ⁄ recurrent acute tonsillitis human fibrinogen bound to streptococcus pyogenes m protein inhibits complement deposition via the classical pathway the global burden of group a streptococcal diseases the diagnosis of strep throat in adults in the emergency room clinical and bacteriologic observations of a toxic shock-like syndrome due to streptococcus pyogenes do patients with sore throat benefit from penicillin? a randomized double-blind placebo-controlled clinical trial with penicillin v in general practice br invasive group a streptococcal infections in ontario, canada. ontario group a streptococcal study group antibiotics for sore throat effect of penicillin on the clinical course of streptococcal pharyngitis in general practice acute pharyngotonsillitis is an infection restricted to the crypt and surface secretion invasive group a streptococcus carriage in a child care centre after a fatal case epidemiological and clinical aspects of invasive group a streptococcal infections and the streptococcal toxic shock syndrome extension of the lancefield classification for group a streptococci by addition of new m protein gene sequence types from clinical isolates: emm to emm outbreak of group a streptococcal infection in a day-care center the role of household contacts in the transmission of group a streptococci tolerance and efficacy of interfering alpha-streptococci in recurrence of streptococcal pharyngotonsillitis: a placebo-controlled study streptococcal m protein: molecular design and biological behaviour guidelines for diagnosis and treatment of sore throat combined contributions of streptolysin o and streptolysin s to the virulence of serotype m streptococcus pyogenes strain manfredo potential mechanisms for failure to eradicate group a streptococci from the pharynx group a streptococci, mycoplasmas, and viruses associated with acute pharyngitis penicillin-resistant and penicillintolerant mutants of group a streptococci sore throat. principles of diagnosis and treatment activation of the contact-phase system on bacterial surfaces -a clue to serious complications in infectious diseases m protein, a classical bacterial virulence determinant, forms complexes with fibrinogen that induce vascular leakage does near-to-patient testing contribute to the diagnosis of streptococcal pharyngitis in adults? scand j prim health care prevalence of nongroup a beta-hemolytic streptococci in childhood pharyngitis effect of antibiotics on symptoms and complications of sore throat. comments on a metaanalysis from the cochrane collaboration the changing epidemiology of invasive group a streptococcal infections and the emergence of streptococcal toxic shock-like syndrome. a retrospective population-based study a randomized study of treatment of streptococcal pharyngotonsillitis with cefadroxil or phenoxymethylpenicillin (penicillin v) current concepts. acute human immunodeficiency virus type infection the role of carrier in treatment failures after antibiotic for group a streptococci in the upper respiratory tract c-reactive protein in streptococcal pharyngitis eradication of group a streptococci from the upper respiratory tract by amoxicillin with clavulanate after oral penicillin v treatment failure association of penicillin tolerance with failure to eradicate group a streptococci from patients with pharyngitis prevalence of pharyngeal gonorrhea in general medical patients with sore throats penicillin tolerant group a streptococci the intracellular status of streptococcus pyogenes: role of extracellular matrix-binding proteins and their regulation the antigenic complex of streptococcus haemolyticus. i. demonstration of a type-specific substance in extracts of streptococcus haemolyticus group a streptococci efficiently invade human respiratory epithelial cells selective attachment of b-haemolytic streptococci group a to oropharyngeal epithelium in health and disease hjortdahl p. which is the best method to trace group a streptococci in sore throat patients: culture or gas antigen test? antibiotic treatment of adults with sore throat by community primary care physicians: a national survey capturing host plasmin(ogen): a common mechanism for invasive pathogens incidence and pathogenicity of arcanobacterium haemolyticum during a -year study in ottawa intracellular survival of persistent group a streptococci in cultured epithelial cells group a streptococci among school-aged children: clinical characteristics and the carrier state cefadroxil versus penicillin in the treatment of streptococcal tonsillopharyngitis group a streptococcus produce pilus-like structures containing protective antigens and lancefield t antigens pharyngoconjunctival fever caused by adenovirus type are current rapid detection tests for group a streptococci sensitive enough? evaluation of commercial kits interactions with fibronectin attenuate the virulence of streptococcus pyogenes penicillin tolerance in arcanobacterium haemolyticum penicillin v, loracarbef and clindamycin in tonsillar surface fluid during acute group a streptococcal pharyngotonsillitis clindamycin in recurrent group a streptococcal pharyngotonsillitis -an alternative to tonsillectomy? treatment failure in streptococcal pharyngotonsillitis. an attempt to identify penicillin tolerant streptococcus pyogenes penicillin v, loracarbef and clindamycin in tonsillar surface fluid during acute group a streptococcal pharyngotonsillitis efficacy of tonsillectomy for recurrent throat infection in severely affected children. results of parallel randomized and nonrandomized clinical trials tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children randomized, single-blind evaluation of cefadroxil and phenoxymethyl penicillin in the treatment of streptococcal pharyngitis effective short-course treatment of acute group a b-haemolytic streptococcal tonsillopharyngitis. ten days of penicillin v vs days or days of cefpodoxime therapy in children anti-streptolysin and anti-dnase b test. in: isenberg hd editor. clinical microbiology procedures handbook c-reactive protein in the differentiation of adenoviral, epstein-barr viral and streptococcal tonsillitis in children the diagnostic value of symptoms and signs in acute tonsillitis in children over the age of and in adults norwegian guidelines for ''sore throats'' nothing for swedish throats! läkartidn interfering alpha-streptococci as a protection against recurrent streptococcal tonsillitis in children bacterial interference: effects of oral antibiotics on the normal throat flora and its ability to interfere with group a streptococci penicillin v for group a streptococcal pharyngotonsillitis. a randomized trial of seven vs ten daysÕ therapy who do we fail with penicillin in the treatment of group a streptococcus infections cytotoxic effects of streptolysin o and streptolysin s enhance the virulence of poorly encapsulated group a streptococci efficacy of b-lactamase resistant penicillin and influence of penicillin tolerance in eradicating streptococci from the pharynx after failure of penicillin therapy for group a streptococcal pharyngitis clinical and laboratory findings in patients with acute tonsillitis penicillin tolerance in group a streptococci and treatment failure in streptococcal tonsillitis penetration of penicillin v tonsillar surface fluid in healthy individuals and in patients with acute tonsillitis five versus ten days treatment of group a streptococcal pharyngotonsillitis: a randomized controlled clinical trial with phenoxymethylpenicillin and cefradroxil lack of influence of b-lactamase-producing flora on recovery of group a streptococci after treatment of acute pharyngitis emergence of b-lactamase producing anaerobic bacteria in the tonsils during penicillin treatment antibiotic tolerance among clinical isolates of bacteria perplexity and precision in the diagnosis of streptococcal pharyngitis differences between streptococcal infections of the throat and of the skin resurgence of acute rheumatic fever in the intermountain area of the united states group a streptococcus carriage among close contacts of patients with invasive infection hyaluronic acid capsule is a virulence factor for mucoid group a streptococci penicillin tolerance in b-streptococci microbiology of infectious diseases of waldeyerÕs ring penicillin for acute sore throat: randomized double blind trial of seven days versus three days treatment of placebo in adults intracellular penetration and survival of streptococcus pyogenes in respiratory epithelial cells in vitro intracellular reservoir of streptococcus pyogenes in vivo: a possible explanation for recurrent pharyngo-tonsillitis periodic fever syndrome in children key: cord- -w ir e authors: moura, hercules; wallace, sara; visvesvara, govinda s. title: acanthamoeba healyi n. sp. and the isoenzyme and immunoblot profiles of acanthamoeba spp., groups and date: - - journal: j protozool doi: . /j. - . .tb .x sha: doc_id: cord_uid: w ir e abstract two strains of acanthamoeba isolated from human brain tissue and a strain of acanthamoeba isolated from a fish were compared with species of acanthamoeba belonging to groups , and based on their isoenzyme profiles and antigenic characteristics. a total of enzymes were studied. the isoenzymes and antigens were electrophoretically separated on polyacrylamide gradient gels, and the patterns obtained were compared after appropriate staining for particular enzymes and reactivities with homologous and heterologous rabbit anti‐acanthamoeba antisera. one of the human strains (cdc: :v ) was identified as a. healyi n. sp. because of its unique isoenzyme profiles for of the enzymes tested. the other human isolate was reidentified as a. culbertsoni because its isoenzyme profiles for of enzymes resembled those of a. culbertsoni, lilly a‐ strain. since the isoenzyme profiles and the antigenic patterns of the fish isolate as well were remarkably similar to those of a. royreba, it was considered as a strain of a. royreba. polyacrylamide gradient gel electrophoresis appears to be a powerful technique for the study of isoenzymes and antigens of acanthamoeba. m water and soil amebae that occur world-wide. during the last decade, these amebae have been isolated with increasing frequency from contact lens paraphernalia as well as from human tissue such as corneal scrapings and the central nervous system [ , ] . acanthamoeba can be readily recognized because of the striking morphologic characteristics of the trophozoites and cysts. based on the size and morphologic features of cysts, pussard & pons [ established species and placed them in three groups. group now consists offour species (a. astronyxis, a. comandoni, a. echinulata, and a. tubiashi) characterized by large trophozoites and cysts ( pm) [ , . species in groups and are smaller ( pm) but can be separated from each other on the basis of cyst morphology. group [ , . although cyst characteristics make genus identification easy, differentiation to the species level is difficult. this is especially true for members of groups and which cannot always be identified by species on a morphologic basis alone. as a result, the most recent identification attempts have been based on both morphologic and biochemical criteria such as isoenzymes, antigens, protein profiles, and restriction fragment-length polymorphism analysis of dna resolved by electrophoretic methods [ , , , . cladistic analysis of the data has also been used to elucidate the affinities of the various species of acanthamoeba [ ] . this paper presents the methods used to isolate acanthamoeba from the cns of humans and identify them to the species level based on morphologic characteristics and isoenzyme and antigenic profiles. we also describe the usefulness of polyacrylamide gradient gel electrophoresis (pagge) in the resolution of isoenzymes and antigens of groups and acanthamoeba spp. and its applicability to the taxonomy of this protozoan. materials a n d methods case . a -year-old girl from barbados with headache, weakness of the right upper and lower extremities, several episodes of vomiting, and positive babinski sign on the right was admitted to the hospital. computed tomography (ct) showed i to whom correspondence should be addressed. a large mass in the left parietal area. a craniotomy was performed, and histopathology of the excised tumor-like mass revealed amebic trophozoites [ . a small piece of the biopsied brain tissue was frozen and sent to the centers for disease control, where acanthamoeba (cdc: :v ) was isolated on non-nutrient agar plates seeded with escherichia coli and mrc human lung cell culture [ . based on cyst morphology and reactivities of the amebae in the brain sections with the rabbit anti-a. palestinensis serum in the indirect immunofluorescence (iif) test, the amebae were identified at that time as a. palestinensis [ . case . a -year-old man with aids was admitted to the hospital with numerous painful, widely distributed skin lesions, hemiparesis of the right side, and clonic movement of the right arm [ ] . a ct scan showed three walnut-sized, lucent lesions in the left cerebral cortex. histopathology of the biopsied left frontal brain revealed acute necrotizing encephalitis but no microorganisms. the patient died the next day. at autopsy, amebic trophozoites and cysts were seen in the brain as well as in the skin lesions [ ] . amebic organisms from brain tissue were isolated in human embryonic kidney (hek) cell culture and identified as a. culbertsoni (cdc: :v ) on the basis of morphology and reactivities of the amebae in the tissue sections with rabbit antiserum to a. culbertsoni in the iif assay [ ] . acanthamoeba strains. the strains ofacanthamoeba used in this study are listed in table , along with the history of their isolation and growth temperature. they include the five species belonging to group ; four species belonging to group ; a. castellanii, a representative of group ; two strains of amebae (cdc: :vo and cdc: :v ) isolated from the brain tissue of patients with acantharnoeba encephalitis; and a strain of ameba (cdc-fish-sk) with a history of isolation from a fish in south korea. this isolate was submitted to one of us (gsv) by dr. james yang on agar plate with e. coli and subsequently axenized at the centers for disease control. all strains o f amebae were grown initially on non-nutrient agar plates with e . coli and then axenically grown in a proteose peptone-yeast extractglucose medium as described previously [ ] , except for the addition of % fetal bovine serum, in -cmz falcon plastic tissue culture flasks. preparation of cell pellets. trophozoites in log-phase ofgrowth were harvested after days of axenic culture at the optimum temperature ( table ). the supernatants were discarded, and ml of wb saline [ ] was added to the flasks containing attached trophozoites. after the flasks were chilled on ice for - min, the solution was transferred to -ml falcon plastic obtained from dr. marc pussard. obtained from dr. james yang. tubes, which were then centrifuged at g for rnin at " c. the cells were washed twice as above and counted using a hemocytometer. to every x lo cells, . ml ofenzyme-stabilizing solution containing mm each ofdithiothreitol, -amino caproic acid, and disodium edta [ was added, and the pellets were stored in liquid nitrogen until used. extract preparation and sds-treatment. acantharnoeba cell pellets were retrieved from liquid nitrogen and processed. for enzymatic studies, amebae were lysed by three cycles of freezing and thawing, rnin per cycle, in a dry ice-methanol slurry and a " c water bath. the suspension was centrifuged at , g for min at " c, and the water-soluble supernatant containing native proteins was aliquoted and stored in liquid nitrogen. for antigenic studies, the pellets were sonicated using a w- sonifier (heat systems-ultrasonics inc., plainview, ny) at % power, % duty cycle, pulse mode, for rnin at " c in a solution (tbe) containing . mm tris(hydroxymethy ) aminomethane (tris), mm boric acid, and . mm edta. the sonicated extracts were centrifuged at , g for rnin to remove particulate matter and cell debris. the supernatants were collected, aliquoted, and stored in liquid nitrogen. a protein determination was done for each extract using the method of bradford [ . the dye reagent was purchased from bio-rad laboratories (richmond, ca), and a suspension of albumin and globulin from sigma (st. louis, mo) was used as protein standard. for isoenzyme analysis, equal volumes of a solution containing pg bromophenol blue in % sucrose were added to each extract of native proteins just before electrophoresis. for silver staining and immunoblots, the extracts were treated with a solution containing % sodium dodecyl sulphate (sds), m urea, and . m tris hydrochloride, ph , to obtain a final concentration of . % sds, . m urea, and pg ofprotein/pl. tracking dye solution ( mg bromophenol blue, ml glycerol, ml . m tris hydrochloride, ph . , and ml deionized water) was used in a % concentration after the samples were heated for rnin at " c in a water bath. high-resolution pagge and buffer systems. all pagge reagents were purchased from bio-rad, except where noted. conditions for pagge were as previously reported [ , , with some modifications. briefly, for isoenzyme electerophoresis we used - % gradient gels with a % stacking gel; the gels measured x x . mm. for silver staining and immunoblot procedures, we used - °/o gradient gels with a % stacking gel; the gels measured x x . mm. a continuous and a discontinuous buffer system were used in the study. the continuous system, tbe, was used for enzymes. the discontinuous system, used for sds-treated proteins, consisted of tbe in the lower chamber and a freshly prepared solution of mm tris, mm boric acid, and . % (w/v) sds in the upper chamber. a pharmacia vertical electrophoresis apparatus ge- / ls (pharmacia lkb biotechnology, piscataway, nj) was used for isoenzyme electrophoresis, which was performed at least four times for each strain using extracts prepared from different harvests to check for fidelity and reproducibility of the patterns. optimum concentration of proteins necessary for the visualization of particular enzymes was also determined. for enzyme separation, the gels were pre-electrophoresed for min at v constant. constant amounts ofprotein for each enzyme ( table ) were loaded and electrophoresed at v maximum. after rnin the voltage was increased to v maximum. the power was turned off after h, when the blue tracking dye could no longer be seen at the bottom of the gel. in the discontinuous system, the sds-treated proteins were loaded at a concentration of . pg/mm of lane width for silver stain and . pg/mm lane width for immunoblot. unstained molecular weight standards, a :l mixture of high molecular weight standards (bio-rad) and low molecular weight standards (pharmacia) were used to calibrate relative molecular weights of the resolved bands. for immunoblots, . pl/mm of prestained protein standards (bethesda research laboratories, gaithersburg, md) was also used. a constant current of . ma per gel was applied during the first rnin and then increased to ma per gel. voltage was allowed to float, and the wattage was limited to w per gel. the power was turned off after h and rnin of electrophoresis, rnin after the tracking dye migrated away from the gel. a constant temperature of " c for enzymes and " c for sds-treated proteins was maintained during electrophoresis. developing solutions for enzymes. all reagents used for isoenzyme study were purchased from sigma, except where noted. the enzymes used in this study are listed in table along with the amount of protein loaded and details for developing solutions [ , , i]. all enzymes except es were developed in the dark at " c. after enzyme development, the gels were immersed in a solution of % methanol and % acetic acid and photographed immediately using a polaroid camera, model . substrate control gels for each enzyme tested were immersed in the same developing solution, but substrate was omitted. silver stain and immunoblot assays. separated sds-treated proteins were either silver stained [ or electrophoretically transferred to immobilon membranes with a . -pm pore size (millipore corporation, bedford, ma). electrophoresis was performed using a trans-blot cell and a power supply model / . (bio-rad) at a constant voltage of v for h and min. the current increased from . a at the beginning to . a at the end of electrophoresis and the buffer temperature increased from " c at the beginning to " c at the end [ ] . after a. astronyxis, a . comandoni, a. castellanii, a. culbertsoni, a . palestinensis, a. royreba, a . lenticulata, and cdc: :vo ) were produced in rabbits by multiple intravenous injections of washed trophozoites and cysts from culture as described previously [ ] . isolation of ameba from brain tissue. agar plates inoculated with thawed and minced brain tissue from case revealed growth of amebae within h and the amebae began to differentiate into cysts after days. however, in the mrc lung cell culture, amebic growth became noticeable only after days of brain tissue incubation, when foci of cleared plaques began to appear in the monolayer. the cell culture was totally destroyed within days, resulting in a monolayer of amebae and cysts. morphologic analysis of the trophozoites and cysts indicated that the amebae belonged to group . the trophozoites (fig. a ) measured . pm long (mean, . fim) and . - pm wide (mean, . pm) when grown on an agar plate. feeding form was variable in shape and size, with a wide, clear, hyaline anterior zone of protoplasm. cysts (fig. b) were oval to round, with a relatively thick, gently rippled ectocyst and a well-developed round or irregular endocyst. the cysts ranged from . to . pm (mean, . pm) in diameter. isoenzymes. isoenzyme profiles for of the enzymes studied are shown in fig. and , and the corresponding lane number for each species is given in table . all substrate control gels (not shown) showed no visible enzymatic activity except where noted for mdh (fig. d ). all isozyme patterns were consistent in all runs. among the four species ofgroup , a. astronyxis, a. comandoni. and a. tubiashi exhibited distinctly different patterns for all enzymes. acanthamoeba echinulata also had unique profiles for eight isoenzymes: es, pgm, acp, gd, me, idh (fig. , ) , gpi and alp (not shown) but resembled a. comandoni in the hk, mdh (fig. , ) , lap, and adh (not shown) patterns. all five species included in group showed unique es, pgm, acp, gd, lap, alp, and me patterns (fig. , ) . acanthamoeha culbertsoni, a. palestinensis, and a. pustulosa had unique hk profiles, but the hk profiles for a. ienticulata and a. royreba were similar (fig. ) . acanthamoeba culbertsoni, a. lenticulata, and a. royreba had unique idh, mdh, adh, and gpi isozyme profiles that differed not only from one another but also from those of a. palestinensis and a. pustulosa. whose idh, mdh (fig. ) , adh, and gpi (not shown) patterns were similar. cdc: :vo , which was originally identified as a. palestinensis [ , exhibited unique isoenzyme patterns for all the tested enzymes except mdh (fig. , ) . however, it resembled a. lenticulata in its mdh isoenzyme patterns. based on its trophic and cyst morphology and isoenzyme patterns, cdc: :v was named a. healyi in honor of dr. george r. healy, chief (retired), protozoal diseases branch, division of parastitc diseases, centers for disease control. the hk, acp, gd, mdh, and gpi enzyme patterns of cdc: :v were very similar to those of a. culbertsoni. though slight differences were noticed in the pgm, idh, alp, and lap profiles of the two strains, the overall patterns of these enzymes were similar. however, the me and es isoenzyme patterns of cdc: :v were distinctly different from those of a . culbertsoni. based on these observations, cdc: :v l is being considered a. culbertsoni pending further studies, isoenzyme patterns of cdc-fish-sk were similar to those of a. royreba for all the enzymes tested (not shown). cdc-fish-sk was also morphologically very similar to a. royreba. sds-pagge of acunthamoebu polypeptides. sds-pagge and silver staining of proteins extracted from whole trophozoites revealed very complex profiles, with multiple major bands ranging from . to kda for each of the strains examined (fig. a) . despite the overall similarity noticed in the protein profiles of the strains, members of group could be easily distinguished from those of the other two groups. for example, members of groups and had a dense, dark staining band at about - kda which was either absent or faint in group organisms. further, group as well as a. castellanii had multiple dark staining bands in the region between and kda that were either faint or not present in group species. the most similar silver-stained protein profiles were those for a. palestinensis-a. pustulosa. those for a. royreba and cdc-fish-sk in group and those for a. tubiashi-a. comandoni-a. echinulata in group . acanthamoeba astronyxis (group ) and a. castellani (group ) each presented remarkably unique profiles. a careful analysis ofthe silver-stained gel revealed that many of the strains possessed unique bands, e.g. a. healyi at . immunoblot assays. figure b- show the immunoblot patterns obtained when the separated acanthamoeba polypeptides were reacted with rabbit antisera to a. palestinensis (fig. b) , ' . culbertsoni (fig. a) , a . royreba (fig. sb) , a. healyi n. sp. (fig. a) , a. astronyxis (fig. b) , a. castellanii (fig. a) , and a. comandoni (fig. b) . hyperimmune rabbit antisera reacted extensively with the polypeptides of each of the strains studied; however, the reactivity was most prominent in the homologous extracts. major antigens were detected between and . kda. in these homologous reactions, the staining intensity was so great that some individual bands could not be easily distinguished in the photographs (fig. - ) . it is obvious from these studies that sera made against the group species reacted extensively with the polypeptides of group organisms, whereas they reacted moderately with those of a. castellanii (lane ) and very little with the polypeptides of group species. only a. astronyxis (lane ), among the group species, appeared to react moderately with the group and group antisera. conversely, sera made against group species reacted prominantly with the antigens of group organisms and sparsely with those of group and group organisms. all four species of group produced a characteristic dense, dark staining band at about kda when reacted with the anti-a. astronyxis and anti-a . comandoni sera. anti-a. castellanii serum reacted much more . as a result, etiologic agents are being isolated with increasing frequency. since it is not always possible to identify the infective agent to the species level by morphologic criteria alone, other nonmorphologic criteria need to be used. isoenzyme electrophoresis is one such nonrnorphologic trait that has been used by others [ , , . we have found that, for native proteins, high-resolution pagge appears to be a useful technique for the differences we observed in the separated proteins strongly support the existence of the three morphologic groups, as reported before [ , , . further, the immunoblot profiles clearly indicate that group species share only a few antigens with those of group and group species and hence are distinctly different from them. however, a. castellanii, a representative of group , shares a considerable number of antigens with those of group species (fig. b- a ) but few with those of group species (fig. a , b) indicating closer relationship with the group strains rather than group species. an acanthamoeba species (cdc: :vo ) isolated from a brain biopsy specimen had been previously identified as a . palestinensis based on its morphologic characteristics and reactivity of the amebae in tissue sections with anti-a. palestinensis serum [ ] . our more detailed study involving morphologic, enzymatic, and antigenic parameters clearly indicates that although this strain bears some morphologic resemblance to a. palestinensis, it is nevertheless very different from a. palesti-nensis and from all other species of acanthamoeba. hence it has been designated a. healyi, a new species. cdc: :v , the human brain isolate that was previously identified as a. culbertsoni [ ] , has been confirmed as a. cul- fig. . immunoblot profiles of sds-treated pagge separated proteins of acunthamoeba strains. numbers in the horizontal axis and molecular mass markers (mw) are the same as those in fig. . the proteins were transferred to immobilon membranes and treated with a : , dilution of a) rabbit anti-cdc: :vo (a. heulyi n. sp.) and b) antid. astronyxis sera. bertsonibecause of its morphologic, enzymic, and antigenic similarity to the lilly a- strain of a. culbertsoni. we believe this is the first report of the isoenzyme make-up and antigenic characteristics of a . tubiashi which had not been cultivated axenically before. our studies confirm the uniqueness of a . tubiashi, not only at the morphologic level, as noted previously [s], but also with regard to its isoenzyme patterns and antigenic profile. this is also the first time that axenically cultivated a . echinulata has been used to examine its isoenzyme and antigenic profiles. by unequivocally demonstrating the unique isoenzyme and protein profiles ofa. echinulata and clearly showing its differences from those of a . comandoni, our results support the existence of four species in group rather than three as reported previously [ , . fig. . immunoblot profiles of sds-treated pagge separated proteins of acanthamoebu strains. numbers in the horizontal axis and molecular mass markers (mw) are the same as those in fig. . the proteins were transferred to immobilon membranes and treated with a : , dilution of a) rabbit anti-a. custellanii and b) a. comandoni sera. in group , a. culbertsoni, a. palestinensis, a. lenticulata, and a. royreba have been well characterized on the basis of morphologic [ , , isoenzyme [ , , , and immunoprecipitation [ ] studies. however, a. pustulosa has been identified as an invalid synonym ofa. palestinensis, based on their lack ofpathogenicity to mice, morphologic similarity and identity of bands obtained for lap, mdh, gpi, pgm, pe, and adh [ , . however, in our studies, a. pustulosa and a. palestinensis could be easily distinguished based on their hk, es, pgm, acp, gd, and me profiles even though they had similar mdh, adh, idh, and gpi profiles. costas and griffiths [ ] also differentiated the two based on their es and acp profiles. further, in reactions with the anti a. palestinensis serum in the immunoblot assay (fig. b ) distinct differences were noted in the antigenic pattern of a. pustulosa from that of a. paleststinensis. w e therefore believe that a. pustulosa is a valid species. a careful review of the isozyme data on groups and acanthamoeba suggests that members of these groups can easily be differentiated from one another based only o n hk, acp, and es profiles, which will reduce the investigator's time, effort, materials, and expense. if, however, numerical analysis of data is planned or other strains are isolated in the future that cannot be differentiated by these three enzymes, then other enzymes such as pgm, me, and gd m a y be used. profiles of sds-treated and silver-stained polypeptides of acanthamoeba species belonging t o group a n d to group exhibited great within-group similarity, as evidenced by a large number of comigrating bands. nevertheless, unique bands detected for each species allowed them to be differentiated, even though the unique bands were neither numerous nor prominent. o u r results confirm the differences reported previously in the protein profiles of acanthamoeba using agarose isoelectric focusing [ ]. when probed with seven different polyclonal rabbit sera, immobilon membranes containing the electrotransfer peptides also confirmed the antigenic similarity among the species, as has been reported before for six different species of acanthamoeba [ ] based on immunoelectrophoresis patterns. however, we were able to recognize unique bands for each strain examined by probing with different antisera. with pagge, a powerful technique for the separation of enzymes and antigens, the bands resolved are sharp and clear a n d thus facilitate the comparison of strains. i n conclusion, we have used this technique to resolve the unique isoenzyme and antigenic patterns of two strains ofkanthamoeba isolated from human brain tissues and classify one as a. healyi n. sp. and the other as a. culbertsoni. a rapid and sensitive method for the quantitation of microgram quantities of protein utilizing the principle of protein-dye binding analysis of mitochondria dna variation as an approach to systematic relationships in the genus acanthamoeba the esterases and acid-phosphatases of acanthamoeba (amoebida, acanthamoebidae). protistologica a molecular approach to the phylogeny of acanthamoeba isoenzvme datterns ofdathoeenic and . dejonckheere, j. f. . isoenzyme and total protein analysis by agarose isoelectric focusing, and taxonomy of the genus acanthamoeba amphizoic amoebae: human pathology. piccin nuova libraria a new species of fresh-water amoebida naegleria and acanthamoeba infections: review isoelectnc focusing of some enzymes from echinococcus granulosus (horse and sheep strains) and e. multilocularis high-resolution polyacrylamide gradient gel electrophoresis (pgge) of isoenzymes from five naegleria species isoenzyme analysis of babesia microti infections in humans granulomatous brain tumor caused by acanthamoeba. case report a new key to freshwater and soil amoebae morphologie de la paroi kystique et taxonomic du genre acanthamoeba (protozoa, amoebida) electrophoretic isoenzyme patterns of the pathogenic and nonpathogenic intestinal amoebae of man the enzyme-linked immunoelectrotransfer blot enzyme-linked immunoelectrotransfer blot technique (western blot) for human t-lymphotropic virus type iii/lymphadenopathy-associated virus (htlv-i ii/ lav) antibodies. immunology series no. i procedural guide. us. department of health and human services comparative studies on related free-living and pathogenic amebae with special reference to acanthamoeba leptomyxid ameba, a new agent of amebic meningoencephalitis in humans and animals acanthamoeba meningoencephalitis in a patient with aids acanthamoeha royreba sp. n. from a human tumor cell culture non-pathogenic naegleria spp. using agarose isoelectric focusing the authors thank d. m. moss, centers for disease control, for helpful suggestions; dr. marc pussard, station d e recherche sur la faune du sol, dijon cedex, france, for providing a. pustulosa (ge a) and a. echinulata ( ); and dr. james yang, toronto general hospital, toronto, ontario, for providing the cdc-fish-sk strain. dr. hercules moura is a recipient of a scholarship from conselho nacional de desenvolvimento cientifico e tecnologico (cnpq), brazil. key: cord- - v di authors: el-ghandour, mamdouh; hammad, bahaa; ghanem, mohamed; antonios, manal a. m. title: efficacy of milrinone plus sildenafil in the treatment of neonates with persistent pulmonary hypertension in resource-limited settings: results of a randomized, double-blind trial date: - - journal: paediatr drugs doi: . /s - - - sha: doc_id: cord_uid: v di background: the management of severe persistent pulmonary hypertension (pphn) can be very challenging in many resource-limited centers without access to inhaled nitric oxide or extracorporeal membrane oxygenation. objectives: the current study aimed to investigate the efficacy of oral sildenafil and intravenous milrinone infusion and compare the effects of these drugs in combination versus as monotherapy in neonates with pphn. methods: a double-blind randomized controlled trial was conducted in which neonates with pphn were divided into three groups of patients each: group received oral sildenafil starting at . mg/kg every h to a target maintenance dose of mg/kg every h; group received intravenous milrinone . μg/kg/min as a continuous infusion; and group received both oral sildenafil and intravenous milrinone. results: post-treatment pulmonary artery systolic pressure was significantly lower in group than in groups and , which both received monotherapy (p = . ). the oxygenation index also decreased significantly in the dual-therapy group (p = . ) compared with the monotherapy groups. combined use of both drugs demonstrated a beneficial synergistic effect with better outcomes and reduced mortality. conclusion: dual therapy using sildenafil and milrinone was superior to monotherapy with either drug in neonates with severe pphn and is recommended for use in resource-constrained settings. registration: pan african clinical trial registry identifier number pactr . in newborn care units lacking this gold standard therapy for pphn, treatment comprises pulmonary vasodilators such as oral sildenafil or continuous intravenous infusion of milrinone. in the current randomized controlled trial, sildenafil combined with milrinone was more effective at normalizing pulmonary artery pressure and improving survival rates than treatment with either of the two drugs as monotherapy. a series of circulatory events takes place at birth to ensure a smooth transition from fetal to extrauterine life. clamping of the umbilical cord removes low-resistance placental circulation and increases systemic arterial pressure. simultaneously, various mechanisms operate to rapidly reduce pulmonary arterial pressure and increase pulmonary blood flow. s ultrasound machine with a mhz probe. m-mode, d, and color doppler mode, with pulsed and continuous waves, were used to evaluate pulmonary artery pressure using the modified bernoulli equation: pulmonary artery systolic pressure (pasp) = tricuspid regurgitation gradient + right atrial pressure (rap), pasp = (v max × ) + rap. neonates with pphn were those with pasp > mmhg [ ] . tricuspid regurgitation was graded as mild, moderate, or severe, according to go et al. [ ] . we excluded neonates with any congenital heart disease, congenital diaphragmatic hernia, or lung anomalies and candidates for major surgical interventions. the study population was randomized into the following three groups in a double-blind manner: group received oral sildenafil starting at . mg/kg every h with increments of . mg/kg/dose and a target maintenance dose of mg/kg every h; group received intravenous milrinone . μg/ kg/min as a continuous infusion; group received both oral sildenafil and intravenous milrinone. block randomization was conducted using web-based software [ ] to assign a patient to one of the three groups in a : : ratio and using sequentially numbered sealed envelopes. drug therapy was administered for days. the primary endpoint was improvement of pasp after h of treatment. doppler echocardiography examination was done on day (first h) for all neonates included in this study. follow-up doppler echocardiography was performed after receiving medical therapy on the following schedule: • within h from the start of treatment • as soon as possible for any case showing progressive respiratory distress and/or increased oxygen requirements • follow-up was continued for months according to the clinical condition of the case until clinical and echocardiographic improvement or death. the secondary outcome was clinical improvement and fate during and until the end of the study duration. a sample size of patients per group (total sample size ) was estimated as sufficient to provide statistical significance with % power and at a significance level of % (accepted α error = . ) [ ] . we used spss (statistical package for the social sciences) version for statistical analysis. since the kolmogorov-smirnov test of normality of these, the most important stimuli appear to be ventilation of the lungs and increased oxygen tension [ ] . failure of the pulmonary circulation to undergo the normal transition after birth leads to persistent pulmonary hypertension (pphn), which is characterized by an elevated pulmonary/systemic vascular resistance ratio resulting from either vasoconstriction, structural remodeling of the pulmonary vasculature, intravascular obstruction, or lung hypoplasia. right-to-left shunting of blood across the foramen ovale and ductus arteriosus results in hypoxemia and labile oxygen saturations [ ] . the use of inhaled nitric oxide (ino) therapy to obtain a sustained oxygenation response has a high failure rate, which has led to a search for other targets to enhance pulmonary vasodilatation. two of the most promising therapies are oral sildenafil to stop cyclic guanosine monophosphate (cgmp) from degrading phosphodiesterase and the use of intravenous milrinone to stop cyclic adenosine monophosphate (camp) from degrading phosphodiesterase [ ] . in developing countries, the high cost of ino renders it unavailable; advanced ventilator support such as extracorporeal membrane oxygenation (ecmo) is also unavailable. this has necessitated a search for less expensive but effective therapies to allow the stabilization of neonates with pphn [ ] . because many patients do not respond to monotherapy with milrinone or sildenafil, the current study aimed to investigate the efficacy of combined therapy. a double-blind randomized controlled trial (rct) was conducted in the neonatal intensive care unit of alexandria university children's hospital, a tertiary care hospital. the study was registered in the pan african clinical trial registry database [ ] (identification number: pactr ) and was approved by the institutional review board of the faculty of medicine, alexandria university. written informed consent was obtained from the legal guardian of all patients enrolled in the study. all newborn cases aged between and days, diagnosed with pphn by echocardiography, and indicated for treatment were recruited for the study. a pediatric echocardiographer with years of experience was blinded to the clinical trial groups and performed echocardiography using a ge vivid revealed significance in the distribution of some variables, we adopted nonparametric statistics. comparisons were conducted between independent subgroups with nonnormal distribution using the mann-whitney u test. the kruskal-wallis test was used if more than two independent subgroups were studied. when the kruskal-wallis test was significant, post hoc pairwise comparisons were carried out using the dunn-sidak test for multiple comparisons. pearson's correlation and point-biserial correlation were performed. the chi squared test was used to test the association between qualitative variables. monte carlo corrections were carried out when indicated. figure shows the process used for the recruitment of the study population and the outcomes of the three groups studied in this clinical trial. no statistically significant differences were found among the three groups in terms of weight, stage of maturity, and sex. group (dual therapy) took longer to normalize pasp (p = . ) and had the lowest incidence of mortality (n = [ %]), although this was not statistically significant ( table ) . the number of patients with patent ductus arteriosus (pda) decreased through the course of management, but the size of ductus that remained patent at the end of management was not affected by the treatment received in the three groups (table ) . although group had significantly more severe cases of tricuspid regurgitation (p = . ), there was no statistical difference between the three groups at day and at the end of management (p = . and p = . , respectively) ( table ) . assessment of left ventricular functions and mitral valve revealed that all cases in all three groups (n = ) were completely normal at the beginning of the study, at day , and at the end of management. interestingly, pasp was significantly higher in group at day before the start of therapy (p = . ) but significantly lower than that in the two groups receiving monotherapy (p = . ) ( table ). the pairwise comparison of the effect of sildenafil was not statistically significant early in the course of therapy (from day to day ; p = . ), but at the end of management there was a statistically significant decrease in pasp (from day to the end of management; p = . ) (fig. a) . the pairwise comparison of the effect of milrinone showed a statistical decrease of the pasp early in the course of therapy (from day to day ; p = . ), but milrinone was not significantly effective in the later part of the trial (from day to the end of management; p = . ) (fig. b) . the pairwise comparison in the dual therapy group showed statistically significant improvement of pasp in both the early and the later phase of therapy (from day to day [p = . ], from day to end of management [p = . ], and from day to end of management [p < . ]) (fig. c) . the oxygenation index statistically decreased among the sildenafil group and the dual therapy group (p = . and p = . , respectively), but the decrease was not statistically proven among the milrinone group (table ) . systolic and diastolic blood pressure before and after treatment did not differ in any of the groups (table ). the current study aimed to evaluate the effect of oral sildenafil plus intravenous milrinone infusion in newborns with pphn compared with the use of monotherapy with either of these agents. results from the current study showed that the combination of oral sildenafil and intravenous milrinone resulted in improved clinical outcomes, reflected by reduced mortality and a significant decrease in pasp. in group (sildenafil only), there was no significant change in pasp from day to day , with the difference only appearing at the end of management. this may be because sildenafil needs a longer treatment duration to induce a therapeutic effect. for group (milrinone only), there was a significant decrease in pasp from day to day but no significant change in pasp from day to the end of management. this may reflect that milrinone induced its therapeutic effect rapidly, but some sort of tolerance arose with continuing management as no further beneficial effect was seen. group (combined therapy) had a significant decrease in pasp from day to day and from day to the end of management, suggesting that the dual therapy had a rapid therapeutic effect, and pasp continued to improve until normalization with no apparent tolerance arising. the use of milrinone in combination with sildenafil in a resource-limited setting has demonstrated a beneficial synergistic effect with better outcomes, especially in severe pphn. to the best of our knowledge, only a few studies have assessed the combined effect of sildenafil and milrinone in humans for the treatment of pphn. an experimental study evaluated sildenafil and milrinone in combination after inducing pulmonary hypertension in adult swines. this study demonstrated a statistically significant decline in pulmonary vascular resistance and improved cardiac output in the group that received the combination therapy. we conclude that milrinone and sildenafil are effective pulmonary vasodilators with independent actions and an additive effect [ ] . in a retrospective study, khorana et al. [ ] examined infants with pphn. all infants received standard therapy with mechanical ventilation, sedation, and inotropic drugs: received oral sildenafil, and of these responded to the drug. three of the five nonresponders showed an improvement in their oxygenation when their treatment was combined with another pulmonary vasodilator such as milrinone. a cochrane meta-analysis from included two eligible trials from resource-limited settings and showed significant improvement in oxygenation in those receiving sildenafil compared with those receiving placebo [ ] . prithviraj et al. [ ] conducted a prospective observational study to evaluate the use of oral sildenafil in neonates with pphn and demonstrated improvement in oxygenation index and a decrease in pasp. milrinone has also shown effectiveness in reducing pulmonary vascular resistance and pasp in experimental models of pulmonary hypertension in adult humans and neonates [ ] [ ] [ ] . managing severe pphn without the use of ino or ecmo is challenging. in such situations, dual therapy using oral sildenafil and intravenous milrinone infusion might be a suitable option. importantly, no significant side effects were found with this combination of drugs; in particular, no decrease in systolic or diastolic blood pressure was observed in any recipients. this has also been observed in other studies [ , , ] . therefore, all available data indicate that dual this study was not without limitations. first, the study was conducted in one center, and results were dependent on the type of supportive care provided in this center so results are not generalizable. a second limitation is the relatively small sample size even though we calculated it to give % power for the statistical analysis. for more robust results, the study should be repeated in a larger population and in multiple settings. third, the clinical trial was designed to compare the effects of the drugs without the gold standard therapy for severe pphn (ino and ecmo) being used as a comparator. however, these results remain crucial for developing countries without access to the gold standard therapy. lastly, the relatively short duration of follow-up for patients in this study did not allow a comparison of the neurodevelopmental outcomes of the three treatment groups. combined therapy with oral sildenafil and intravenous milrinone had significantly better outcomes than monotherapy with either agent in neonates with pphn. the combination delivered added therapeutic effect with no additional side effects over the study duration of months. future trials with longer durations and more patients are needed to confirm the benefits and evaluate the neurodevelopmental effects of the different treatment modalities in these patients. funding this study was funded by the department of pediatrics, faculty of medicine, alexandria university, egypt. mamdouh el-ghandour, bahaa hammad, mohamed ghanem, and manal antonios have no potential conflicts of interest that might be relevant to the contents of this manuscript. ethics approval all procedures performed in this study involving human participants were in accordance with the ethical standards of the national research committee and with the helsinki declaration and its later amendments. the university ethical committee approved the study design. informed consent informed consent was obtained from all patients and caregivers for participation in the study and publication. consent to participate all studied cases were asked a written consent after full explanation of the study. availability of data and material all the raw data and master table of the studied cases are available at the corresponding author who is ready to share it with any researcher. pulmonary vascular biology during neonatal transition update on pphn: mechanisms and treatment severe persistent pulmonary hypertension of the newborn in a setting where limited resources exclude the use of inhaled nitric oxide: successful treatment with sildenafil pan african clinical trial registry identifier number pactr revisiting the simplified bernoulli equation the conundrum of tricuspid regurgitation grading how to do random allocation (randomization) power : a flexible statistical power analysis program for the social, behavioral, and biomedical sciences treatment with phosphodiesterase inhibitors type iii and v: milrinone and sildenafil is an effective combination during thromboxane-induced acute pulmonary hypertension outcome of oral sildenafil therapy on persistent pulmonary hypertension of the newborn at queen sirikit national institute of child health bosentan as adjunctive therapy for persistent pulmonary hypertension of the newborn: results of the randomized multicenter placebo-controlled exploratory trial oral sildenafil in persistent pulmonary hypertension of the newborn in invasive and non-invasive ventilated babies-its effect on oxygenation indices milrinone decreases both pulmonary arterial and venous resistances in the hypoxic dog milrinone: systemic and pulmonary hemodynamic effects in neonates after cardiac surgery hemodynamic and inotropic effects of milrinone after heart transplantation in the setting of recipient pulmonary hypertension oral sildenafil in infants with persistent pulmonary hypertension of the newborn: a pilot randomized blinded study the use of sildenafil in persistent pulmonary hypertension of the newborn authors' contributions dr. mamdouh el-ghandour invented the idea of this clinical trial and performed the ecchocardiographic assessment of the studied cases blindly. dr. bahaa hammad screened the cases as neonatologist and followed them clinically blindly. dr. mohamed ghanem collected the cases and supervised the double blind technique. dr. manal a. m. antonios supervised data collection, statistical assessment, interpretation and manuscript preparation for publication. key: cord- -t qsjyfi authors: norris, s.; collins, c.; hegarty, j.; o’farrelly, c.; carton, j.; madrigal, l.; o’donoghue, d. p.; o’farrelly, c.; holloway, h.; fielding, j. f.; mullins, w.; hone, s. w.; donnelly, m.; powell, f.; blayney, a. w.; cahill, e. a.; daly, s. f.; turner, m. j.; sullivan, p. a.; mcloughlin, m.; skelly, m. m.; mulcahy, h. e.; connell, t.; o’donoghue, d. p.; duggan, c.; duffy, m. j.; troy, a.; sheahan, k.; whelan, a.; herra, c. m.; keane, c. t.; johnson, h.; lee, b.; doherty, e.; mcdonnell, t.; mulherin, d.; fitzgerald, o.; bresnihan, b.; hassett, h. m.; boyce, a.; greig, v.; o’herlihy, c.; smyth, p. p. a.; roche, e. f.; mccormack, i.; tempany, e.; cullen, m. j.; smith, d. f.; smyth, p. p. a.; mcbrinn, y.; murray, b.; freaney, r.; keating, d.; mckenna, m. j.; o’hare, j. a.; alam, h.; raza, q.; geoghegan, m.; killalea, s.; hall, m.; feely, j.; kyne, l.; o’hara, b.; cullen, m.; rea, i. m.; donnelly, j. p.; stout, r. w.; lacey, p.; donnelly, m. j.; mcgrath, j.; hennessy, t. p.; timon, c. v. i.; hyde, d.; xia, h. x.; keane, c. t.; buckley, m.; o’morain, c.; buckley, m.; keating, s.; xia, h.; hyde, d.; o’morain, c.; mcgrath, j. p.; stuart, r. c.; lawlor, p.; byrne, p. j.; walsh, t. n.; hennessy, t. p. j.; skelly, m. m.; mulcahy, h. e.; connell, t.; o’donoghue, d. p.; duggan, c.; duffy, m.; troy, a.; sheahan, k.; norris, s.; tubridy, m.; redmond, j.; hegarty, j.; holloway, h.; fielding, j. f.; mullins, w.; monahan, k.; murphy, r. p.; headon, d. r.; o’gorman, t.; o’reilly, f. m.; darby, c.; fielding, j. f.; murphy, g. m.; murphy, a.; codd, m.; powell, f.; dervan, p.; lawlor, d.; loughlin, s. o.; flanagan, n.; watson, r.; barnes, l.; flanagan, n.; watson, r.; kilgallen, c.; sweeney, e.; mynes, a.; mooney, d.; donoghue, i.; browne, o.; kirrane, j. a.; murphy, g. m.; mckenna, d.; young, m.; mckenna, d.; young, m.; o’toole, e.; young, m.; o’briain, s.; srinivasan, u.; feighery, c.; leonard, n.; jones, e.; o’farrelly, c.; moloney, m. a.; o’farrelly, c.; weir, d. g.; lawler, m.; o’neill, a.; gowing, h.; pamphilon, d.; mccann, s. r.; o’toole, g.; orren, a.; seifer, c. m.; crowley, d. c.; sheehan, g. j.; deignan, t.; kelly, j.; o’farrelly, c.; tormey, v. j.; faul, j.; leonard, c.; burke, c. m.; poulter, l. w.; collins, c.; lynch, s.; madrigal, l.; norris, s.; mcentee, g.; traynor, o.; hegarty, j.; o’farrelly, c.; barry, e.; collins, c.; costello, p.; keavney, a.; o’donoghue, d. p.; o’farrelly, c.; willoughby, r.; feighery, c.; o’donnell, c.; cahill, m.; earley, a.; eustace, p.; osborne, r.; cahill, m.; saidlear, c.; holmes, b.; early, a.; eustace, p.; moran, a. p.; neisser, a.; polt, r. j.; bernheimer, h.; kainz, m.; schwerer, b.; gallagher, l.; cahill, m.; saidlear, c.; early, a.; firth, r.; eustace, p.; kennedy, n.; mcgilloway, e.; redmond, j.; mcgilloway, e.; kennedy, n.; tubridy, n.; shields, k.; cullen, w. k.; rowan, m. j.; moore, a. r.; rowan, m.; feely, j.; coakley, d.; lawlor, b.; swanwick, g.; al-naeemi, r.; redmond, j.; murphy, r.; feely, j.; codd, n. m.; goggins, m.; kennedy, n. p.; mallon, b. l.; kennedy, n. p.; mulherin, d.; fitzgerald, o.; bresnihan, b.; mulcahy, h.; skelly, m.; donoghue, d. o.; mccarthy, d.; saunders, a.; mulherin, d.; bresnihan, b.; fitzgerald, o.; veale, d. j.; belch, j. j. f.; mulherin, d.; bresnihan, b.; fitzgerald, o.; veale, d. j.; belch, j. j. f.; mulherin, d.; fitzgerald, o.; bresnihan, b.; costello, p.; breathnach, d.; murphy, e.; mulherin, d.; fitzgerald, o.; bresnihan, b.; breathnach, d.; costello, p.; mulherin, d.; bresnihan, b.; fitzgerald, o.; breathnach, d.; mulherin, d.; costello, p.; bresnihan, b.; fitzgerald, o.; kernohan, g.; gibson, k.; wilson, a. g.; duff, g. w.; de vries, n.; van de putte, l. b. a.; donoghue, j.; o’kelly, f.; johnson, z.; maher, t.; kyne, l.; moran, a.; keane, c.; o’neill, d.; horgan, n.; barragry, j. m.; o’neill, d.; o’herlihy, c.; campbell, d. m.; behan, m.; o’connell, p. r.; donnelly, v. s.; crowley, d.; geary, m.; boylan, p.; geary, m.; fanagan, m.; boylan, p.; hickey, k.; teoh, t.; doyle, m.; harrison, r.; hickey, k.; lyons, d.; shenouda, y.; coughlan, m.; mckenna, p.; hickey, k.; shenouda, y.; lyons, d.; mckenna, p.; coughlan, m.; lenehan, p.; foley, m.; kelehan, p.; ravichandran, p.; kelly, m.; conroy, a.; fitzpatrick, c.; egan, d.; regan, c. l.; mcadam, b. v.; mcparland, p.; boylan, p.; fitzgerald, g. a.; fitzgerald, d. j.; sharma, s. c.; foran, k.; barry-kinsella, c.; harrison, r. f.; gillespie, f. j.; o’mahony, p.; boyle, m.; white, m. j.; donohoe, f.; birrane, y.; naughton, m.; tempany, e.; fitzsimons, r. b.; piracha, m.; mcconkey, s.; griffin, e.; hayes, e.; clarke, t.; parfrey, n.; butler, k.; fitzpatrick, c.; malone, a. j.; kearney, p. j.; duggan, p. f.; lane, a.; keville, r.; turner, m.; barry, s.; sloan, d.; gallagher, s.; darby, m.; galligan, p.; stack, j.; walsh, n.; o’sullivan, m.; fitzgerald, m.; o’sullivan, m.; meagher, d.; sloan, d.; browne, s.; meagher, d.; larkin, c.; lane, a.; casey, p.; o’callaghan, e.; walsh, n.; rooney, s.; walsh, e.; morris, m.; lane, a.; burke, t.; larkin, c.; o’callaghan, e.; browne, s.; roe, m.; lane, a.; larkin, c.; o’callaghan, e.; maher, c.; wrigley, m.; gill, m.; burgess, m.; corcoran, e.; walsh, d.; gilmer, b.; johnson, h.; hayes, c. b.; thornton, l.; fogarty, j.; lyons, r.; o’connor, m.; delaney, v.; buckley, k.; johnson, z.; johnson, z.; lillis, d.; delany, v.; hayes, c.; dack, p.; igoe, d.; gilmer, b.; o’neill, h. j.; johnson, h.; igoe, d.; delaney, v.; johnson, z.; kelly, p.; mckeown, d.; clancy, l.; varghese, g.; hennessy, s.; codd, m.; gilmartin, j. j.; birthistle, k.; carrington, d.; maguire, h.; atkinson, p.; foley-nolan, c.; lynch, m.; cryan, b.; whyte, d.; cryan, b.; conlon, c.; foley-nolan, c.; johnson, z.; hayes, c.; delany, v.; kucinskas, v.; usinskiene, u.; sakalyte, i.; johnson, z.; hayes, c.; delaney, v.; dack, p.; gill, m.; dawson, e.; molloy, k.; goulden, n.; lawler, m.; mccann, s. r.; doyle, j.; lawlor, e.; lawler, m.; harrington, m. g.; el-nageh, n.; nolan, m. -l.; el-nageh, n.; nolan, m. -l.; harrington, m. g.; lawlor, e.; o’riordan, j.; mccann, s. r.; judge, g.; crotty, g.; finch, t.; borton, m.; barnes, t.; gilligan, o.; lee, g.; limmer, r.; madden, m.; whyte, d.; cryan, b.; bergin, c.; o’leary, a.; keating, s.; mulcahy, f.; wallis, f.; glennon, m.; cormican, m.; niriain, u.; heiginbothom, m.; gannon, f.; smith, t.; o’sullivan, c.; hone, r.; orren, a.; caugant, d. a.; fijen, c. a. p.; van schalkwyk, e. j.; coetzee, g. j.; lynch, m.; cryan, b.; riain, u. ni; cormican, m. g.; park, l.; flynn, j.; glennon, m.; o’connor, m.; regazzoli, v.; o’connor, m.; hayes, m.; nicholson, g.; higgins, p.; niriain, u.; flynn, n.; corbett-feeney, g.; conway, d. j.; sheahan, k.; o’higgins, n. j.; smyth, p. p. a.; rajendiran, s.; byrne, j.; kilfeather, e.; dingle, p.; hunter, m.; kelehan, p.; al-ghazal, s. k.; stanley, p.; palmer, j.; hong, a.; al-ghazal, s. k.; saxby, p.; al-ghazal, s. k.; saxby, p.; mcconkey, s.; sheehan, d.; regan, i.; o’mullane, j.; chaoimh, m. ni; leahy, m.; heffron, j. j.; lehane, m.; keohane, c.; o’leary, n.; sheehan, m.; renny-walsh, e.; whelton, m. j.; doyle, c. t.; webster, j.; benjamin, n.; lyons, d.; fitzgerald, s.; chadha, j. s.; fitzgerald, m. g.; fitzgerald, g. r.; hemeryck, l.; mcgettigan, p.; feely, j.; mcgettigan, p.; feely, j.; mcgettigan, p.; golden, j.; feely, j.; arthur, n.; wen, s. y.; killalea, s.; deegan, p.; mcgettigan, p.; feely, j.; cooke, t.; adebayo, g. i.; feely, j.; gaffney, p.; sinnot, m.; o’riordan, d.; hayes, t.; o’connor, c. m.; fitzgerald, m. x.; costello, c.; finlay, g.; hayes, j.; o’connor, c.; fitzgerald, m. x.; mcmahon, k.; o’farrelly, c.; o’connor, c.; fitzgerald, m. x.; donnelly, m. j.; hone, s.; robertson, j.; coakley, r.; o’neill, s.; walsh, m.; mccarthy, j.; lannon, d.; wood, a. e.; sharkey, r.; mulloy, e.; long, m.; kilgallen, i.; o’neill, s.; faul, j.; tormey, v.; leonard, c.; burke, c. m.; poulter, l. w.; horne, s.; tormey, v. j.; faul, j.; leonard, c.; burke, c. m.; feeney, t.; muiré, Ó. Ó; gilmartin, j. j.; griffin, m. j.; hughes, d.; knaggs, a.; magee, d.; donnelly, m.; mccrory, c.; march, b.; hone, r.; phelan, d.; white, m.; fabry, j.; lynch, m.; buggy, d.; cooney, c.; hughes, d.; mccrory, c.; aziz, e.; o’herlihy, c.; kelly, j.; o’keefe, d.; mcshane, a. j.; boylan, j.; tobin, e.; smith, t.; motherway, c.; colreavy, f.; denish, n.; dwyer, r.; bergin, a.; o’brien, k.; macsullivan, r.; carson, k. d.; blunnie, w. p.; moriarty, d. c.; carson, k. d.; blunnie, w. p.; moriarty, d. c.; kinirons, b.; lyons, b.; cregg, n.; casey, w.; moore, k. p.; colbert, s. a.; ecoffey, c.; o’gorman, d.; fitzgerald, j.; phelan, d.; diamond, p.; codd, m. b.; sugrue, d. d.; kellett, j.; tighe, m.; mckenna, c. j.; galvin, j.; mccann, h. a.; sugrue, d. d.; mckenna, c. j.; codd, m. b.; mccann, h. a.; sugrue, d. d.; scallon, a.; buckley, m.; fraser, a.; norton, m.; tomkin, g.; graham, i.; byrne, a.; maher, m.; moran, n.; fitzgerald, d.; o’callaghan, d.; coyle, d.; nugent, a. g.; mcgurk, c.; johnston, g. d.; mcgurk, c.; nugent, a.; silke, b.; nugent, a. g.; johnston, g. d.; murphy, n.; jennings, l.; pratico, d.; doyle, c.; fitzgerald, d.; hennessy, t.; mccann, h.; sugrue, d.; hennessy, t.; codd, m.; donnelly, s.; hennessy, a.; hartigan, c.; mccann, h.; sugrue, d.; hennessy, t.; codd, m.; donnelly, s.; hennessy, a.; hartigan, c.; mccann, h.; sugrue, d.; hennessy, t.; macdonald, d.; blake, s.; mccann, h.; sugrue, d.; hennessy, t.; sugrue, d.; mccann, h.; hennessy, t.; mccann, h.; sugrue, d.; hennessy, t.; mcdonald, d.; blake, s.; dominque, d.; sugrue, d.; mcmechan, s. r.; mackenzie, g.; allen, j.; wright, g. t.; dempsey, g. j.; crawley, m.; anderson, j.; adgey, a. a. j.; harbinson, m. t.; campbell, n. p. s.; wilson, c. m.; ellis, p. k.; mcilrath, e. m.; freaney, r.; mcshane, a.; keaveny, t. v.; mckenna, m. j.; rabenstein, k.; scheller, f.; pfeiffer, d.; urban, c.; moser, i.; jobst, g.; manz, a.; verpoorte, s.; dempsey, f.; diamond, d.; smyth, m.; rabenstein, k.; dempsey, e.; mcshane, a.; keaveny, t. v.; mckenna, m. j.; freaney, r.; hamilton, v.; dwyer, r.; twomey, j.; crowley, r.; fenelon, l.; walsh, f.; mccann, j.; mcdonagh, p.; white, m.; mcgovern, e.; luke, d.; phelan, d.; mccrory, c.; crowley, k.; lyons, b.; mannion, d.; wood, a. e.; casey, w.; murphy, d.; clarkson, k.; carton, e.; higgins, p.; leonard, i.; o’toole, d.; staunton, m.; phelan, d.; srinivasan, u.; leonard, n.; jones, e.; moloney, m. a.; weir, d. g.; o’farrelly, c.; feighery, c.; griffin, m.; owens, d.; collins, p.; johnson, a.; tomkin, g. h.; herity, n. a.; allen, j. d.; silke, b.; adgey, a. a. j.; o’reilly, f. m.; darby, c.; o’moore, r.; fielding, j. f.; murphy, g. m.; crotty, g. m.; judge, g.; mccann, s. r.; dearce, m.; nugent, a. g.; mcgurk, c.; johnston, g. d.; nikookam, k.; keenan, p.; cregan, d.; firth, r.; o’meara, n.; forman, s.; cusack, d. a.; farrell, b. title: national scientific medical meeting abstracts: oral presentations date: journal: ir j med sci doi: . /bf sha: doc_id: cord_uid: t qsjyfi nan activated t lymphocytes may play a significant role in the pathogenesis of coeliac disease. identification and quantification of t cell populations in subcompartments of the small intestine is now possible using flow cytometry. the aim of this study was to examine phenotype and class ii expression of cd + lymphocytes from the lamina propria and intraepithelial sub-compartments in patients with active coeliac disease. small intestinal biopsies were taken from patients, active coeliacs and controls. a single cell suspension was obtained from the epithelial layer (el), using chelating and reducing agents; the lamina propria (lp) was digested using collagenase. cells were stained with antibodies specific for cd , cd , cd ,~/stcr and hla-dr molecules and analyzed using flow cytometry. class ii antigen expression was detected on a significant percentage of lymphocytes from normal small intestinal el (mean . %; range . - . ) and lp (mean . %, range . - . ). a significant increase was seen (mean . %; range . - . ) in el lymphocytes from active coeliacs when compared with controls. class ii antigen expression was similarly increased on lamina propria lymphocytes (mean . %; range . - . ) when compared with controls. t cell phenotypic studies showed an increase (mean . %; range . - . ) in the cd + y tcr+ population in the el when compared with control patients (mean . %; range - . ). the y infiltrate into the lp of coeliac patients was much less marked (mean . %; range - . ; controls: mean . %; range - . ). the significant change in the cd :cd ratio seen in the coeliac epithelium (ratio : ; control epithelium, ratiol: ) was not mirrored in the lp ( . : in coeliac preparations and . : in controls). high class ii antigen expression by coeliac intestinal t cells was common to both lp and el. the increase in the y tcr+ and cd + populations, however, was significantly more marked in the el than in the lp suggesting that these features may be independent. tonsillitis due to beta haemolytic streptococci is a well recognised triggering factor for both guttate and palmoplanter psoriasis. between and percent of patients with psoriasis experience worsening of their skin condition after an attack of tonsillitis. we reviewed patients with recalcitrant psoriasis exacerbated by recurrent tonsillitis who underwent tonsillectomy over four years, there were females and one male with a mean age of years, - . six patients had guttate psoriasis and seven patients plaque psoriasis. patients were followed by chart review and postal questionnaire full follow up was available on all patients. psoriasis cleared completely after tonsillectomy in patients, improved in patients and was unchanged in patients the guttate group did better than the plaque psoriasis group. we discuss the rational and indications for tonsillectomy in the psoriatic patient. before drug management of hypertension comprised the "stepped care" approach, i.e. start with a diuretic (d), add a beta blocker (b), then a vasodilator (v) and/or neuronal blocker depending on the bp response. of late ace inhibitors (acei) and calcium blockers (cb) are among the most prescribed lowering drugs. this study compares the management of unselected patients in a hypertension clinic between and ( patients) and to ( patients). other than age ( vs yrs, p< . ) both groups had similar sex distribution, duration of follow-up (i vs months). b-baseline. f-follow-up. cholesterol and potassium-mmol/ . creatinineumol/l. *p < . i, **p< . i. wt. (kg) chol. ** ** $ . "* drug management of hypertension has not improved in the past years despite an inflation adjusted cost increase of more than two fold. a specific role for folate in the prevention of both recurrence and first occurrence of neural tube defects has been established ~ ). all women planning a pregnancy are advised to increase their folic acid intake by lag/day over and above their current intake by increasing consumption of folate rich foods, by increasing consumption of folate fortified foods or by taking a folic acid supplement. eighty non-pregnant females were assessed for dietary folate intake using the diet history method. red cell folate was analysed to measure folate stores. the mean total dietary folate intake was ( ) ~tg/day. the mean red cell folate was ( ) i~g/ . analysis of the dietary folate intakes divided into quintiles shows increasing folate stores from the lowest quintile of dietary folate with a mean of ag/d ( % ci, red cell folate ag/ i to ~tg/ ) to the highest quintile of dietary folate with a mean of ag/d ( % ci, red cell folate ag/ to lag/i). these findings are of relevance given the recommendations for periconceptional folic acid intake. in agreement with czeizel et al/ ~, we conclude that based on present dietary patterns, it is unlikely that females can achieve an extra ~g/day of folic acid from food folates alone. as the only two independent prognostic features studied. conclusion: upa antigen measurment may be a useful marker of colorectal cancer aggressiveness, and is capable of predicting prognosis independent of other clinical and pathological features. despite appropriate antimicrobial chemotherapy, the mortality rates associated with severe bacterial infections remain high. to improve prognosis, prompt diagnosis and treatment are essential. thus, the development of early detection methods would be advantageous. since igg antibody binding receptors (fctri fctrii and fctriii) are important mediators of phagocytosis, measurement of these receptors could be useful in the early detection of infection t~). in this study fc~r expression was measured on the neutrophils and monocytes of patients suspected of systemic infection and compared to fctr expression in healthy blood donors. of the patients tested, were blood culture positive, were blood culture negative but had severe bacterial infection at localised sites and the remaining had no cultural evidence of infection. fctr expression was measured using flow cytometry. there was no significant difference in the expression of fcyri on neutrophils or monocytes in patients with systemic vs localised infection, (p= . , p= . ) respectively. fc~,ri expression was, however, significantly increased in both these infected groups, compared to patients without evidence of infection for neutrophils (p= . , p= . ) and monocytes (p= . , p= . ) and compared to controls, p< . , in all cases. the expression of fctrii did not differ significantly between the patient groups, although patients with systemic or localised infection were significantly different to controls for both neutrophils (p= . , p= . ) and monocytes (p= . , p= . ). measurement of fcyriii was not useful in distinguishing the different patient groups from controls. this data suggests that increased fctri expression on neutrophils or monocytes may be a useful rapid indicator of bacterial infection. the efficacy and scheduling of bcg and its potential to interfere with the interpretation of the tuberculin test as a screening tool are debated. counties without neonatal bcg have been shown to be associated with a higher rate of tb hospitalisation in the - year age group (relative risk . , c . - . , p< . )~. this study examines the impact of neonatal bcg on the tuberculin sensitivity in tb contacts. tuberculin (ppd rt ) sensitivity using the mantoux test ( tu) was studied in relationship to bcg status in tb contacts attending a tb clinic in dublin. a bcg scar was used as the indicator of vaccination. data on contacts of cases of tb were examined. the mean age of the contacts was years. ( %) contacts had bcg scars from neonatal vaccination. %, % and % of the contacts had mantoux results of - (negative), - (positive), + mm (strongly positive) induration respectively. tuberculin sensitivity increased sharply between - years of age, declining after years. contacts of sputum positive cases had larger tuberculin reactions. the presence of a bcg scar was not found to significantly influence the degree of tuberculin sensitivity (p< . ) in any age group. studies have shown that bcg given at older ages is associated with larger tuberculin reactions . these data suggest that the optimum age for bcg may be at birth as it significantly reduces the incidence of childhood tb without interfering with tuberculin sensitivity in the contact tracing process using themantoux test. the contribution of individual synovial cell populations to articular destruction in rheumatoid arthritis (ra) is controversial. patients with ra were studied prospectively by measuring disease activity and radiological articular destruction at entry and at review (mean) (range - ) years later. in addition, synovial cell populations were quantified in detail at review. correlations were sought between synovial cell populations and radiological course. mean radiological score deteriorated from at entry to at review (p= . ) despite improvement in all measures of disease activity. significant correlations were identified between both lining layer (ll) depth (r= . ) and sublining layer (sll) macrophage count (r= . ) and the extent of radiological destruction at review and also with radiological progression during the study (r= . and r= . respectively). in contrast, no lymphocyte subpopulation correlated with radiological course. detailed analysis of patients demonstrated reduced cd expression compared to cd expression in the ll (p= . ), unlike in the sll, where expression of cd and cd were equivalent. since ll depth reflects ll macrophage accumulation, this study dearly demonstrated that macrophages throughout the synovium correlated with progressive articular destruction in ra. in addition, ll macrophages differ in their phenotype from those in the sll, and may represent a distinct macrophage subpopulation which plays an important role in progressive articular destruction. these findings have important implications for the development of new therapies for patients with ra. college and national maternity hospital, dublin. hyperemesis gravidarum (heg) has frequently been associated with thyroid hyperfunction. in the present study the prevalence of thyrotrophin receptor antibodies (trab) in whole serum and igg concentrates prepared in serum from patients with heg was compared with those obtained from "well" patients studied during the first trimester of pregnancy (t ) and in non-pregnant controls. trab was measured using using a radioreceptor assay. sera and igg concentrates which produced inhibition of e i tsh binding to thyroid membranes > . % were termed positive. trab were positive in / ( . %) of patients requiring hospitalisation for heg. of "'well" t pregnancy patients, one ( . %) was trab positive. similarly only / ( . %) of non-pregnant female controls was trab positive. when igg concentrates were prepared from sera by peg ( %) precipitation, positivity increased to / ( . %) in heg and a / ( . %) in "well" t pregnancy. in order to investigate a possible role for hcg in influencing trab positivity in pregnancy, known concentrations of hcg ( . - x iu/l) were added to an incubation mixture containing trab negative serum. inhibition of ~ i tsh binding increased from . %- . % with increasing hcg. the results suggest the presence of a non-hcg tsh binding inhibitor in sera from patients with heg. they also emphasise the need to exert caution in interpreting results of trab investigations, particularly in igg concentrates prepared from pregnancy sera. we present a most unusual case of neonatal thyrotoxicosis in premature twins. the mother of the twins has graves disease, was thyrotoxic for two years, becoming hypothyroid one and a half years prior to delivery during which time she was maintained on l-thyroxine. during pregnancy she developed rising levels of thyrotrophin receptor antibodies (trab) which had been absent in early pregnancy rising to % inhibition of j -i labelled tsh binding at weeks gestation. twin boys were delivered vaginally at weeks + days gestation. both boys were significantly hyperactive. twin developed intermittent tachycardia which resolved spontaneously, he displayed no inability,-persistently fed well and had good weight gain. peak trab on day was . %. twin developed tachycardia from day which became increasingly severe necessitating treatment with propranolol. weight gain was also poor despite adequate intake. the twins, now nine months of age remain under followup. at review both twins are thriving and propranolol treatment has been discontinued for twin two. these findings demonstrate the importance of thyrotrophin receptor antibodies (trab) in monitoring neonatal thyrotoxicosis. the report outlines the course of neonatal thyrotoxicosis and demonstrates the need for careful evaluation of offspring born to mothers with thyroid disease. a large number of publications have reported a high prevalence of hypovitaminosis d in elderly subjects. secondary hyperparathyroidism in association with hypovitaminosis d is now being diagnosed with increasing frequency probably due to the advent of more sensitive assays for intact parathyroid hormone. the effect of high dose vitamin d supplementation in correcting shpt in a patient with stress fractures is presented; serum pth decreasing from . - . pmol/l as serum (oh)d increased from - nmol/l. the concentration of serum ( h)d necessary for restoration of serum pth to the adult reference range may be as high as nmol/l in patients who have developed shpt. (e ) -see p. hyperinsulinaemia and dyslipidaemia may be contributory factors. we looked at the lipid profiles, risk factors and incidence of macrovascular disease in non-insulin-dependent diabetics attending a diabetic outpatient clinic. patients ( %), male and female were active smokers. patients ( %) had hypertension. % of all patients had elevated cholesterol levels (> . l mmot/ ), % had elevated non-fasting triglyceride levels (> . mmol/l) and % had low hdl-cholesterol levels (< . mmol/ ). approximately % of patients had evidence of macrovascular disease with more than two thirds of these having coronary heart disease. these patients were more likely to be male, to have hypertension and to have a family history of hypertension or ischaemic heart disease. this group also had a statistically higher mean cholesterol and ldl-cholesterol thar/ the group as a whole. only one patient was on lipid-lowering therapy in this group. in view of current opinion advocating treatment of significant dyslipidaemia in high risk subjects or those with coronary heart disease, a number of these patients may require more active intervention. in this prospective study over a two year period, patients presenting with acute food bolus impaction were investigated. all patients, where possible, had full oesophageal investigation including barium swallow, hour ambulatory ph monitoring and oesophageal motility studies. of these patients % demonstrated oesophageal pathology. over % showed evidence of gastroesophageal reflux, while almost half had abnormal oesophageal motility patterns. % had previous food bolus impaction but only two of these had any definitive treatment in the past. the results of this study suggest that underlying oesophageal pathology as a cause of acute food bolus impaction is evident in the vast majority of patients. it appears that such disorders have been underdiagnosed in the past due to inadequate investigation. we recommend that all patients presenting with acute food bolus impaction should be thoroughly investigated so that appropriate definitive treatment can be advocated and recurrences prevented. the queen's university of belfast lipoprotein lp(a) is a variant of low-density lipoprotein and subjects with values > mg/dl have greatly increased risk of coronary heart disease. lp(a) levels are strongly influenced by genetic factors. it was of interest to measure lp(a) levels in very elderly subjects, who as survivors of their peer group, might be expected to show a predominance of lower values of lp(a) consistent with a reduced risk profile for atherosclerosis. in this preliminary study, elderly subjects, who were apparently well and living in the community, were enlisted - subjects > years of age, subjects > years of age and subjects - years of age. lp(a) was measured by standard immunoassay methods (immunozym). lp(a) levels were asymetrically distributed with median values in > , > and - year age groups of . , . , . mg/dl respectively. there were % of subjects in the > year old group who had values of lp(a) > mg/dl with . % in the > year old group and . % for the - year old group compared with % within the entire group. lp(a) values, in the 'at risk' range for atherosclerosis, are present in a higher percentage of well nonagenanan subjects, than are present in 'younger' old groups. this finding is surprising in view of the expectation that risk factors for coronary heart-disease might be reduced in nonagenarian subjects who by virtue of their age have survived premature heart disease. helicobacter pylori is associated with a wide range of gastroduodenal pathology from asymptomatic carriage through gastritis and/or peptic ulcer disease to gastric cancer. the aim of this study was to assess whether h. pylori-related diseases are associated with specific strains using randomly amplified polymorphic dna (rapd) fingerprinting technique. h. pylori stain was isolated from each of individuals including patients with duodenal ulcer, gastric ulcer, non-ulcer dyspepsia and five asymptomatic volunteers. the organisms were subcultured on chocolate agar for - days and the cells of each strain were harvested. h. pylori dna was extracted by the phenol/chloroform method and amplified using the polymerase chain reaction-based rapd with a combination of two -nt primers. electrophoresis of rapd products on % agarose gel yielded dna profiles (fingerprints) of dna of each strain. the fingerprints of strains were compared with their corresponding clinical gastroduodenal disease status. rapd fingerprinting with a combination of the two primers yielded - main bands on the agarose gels. the profiles of the pcr products of dna from all the strains were different from each other. there were no specific bands that associated with the clinical outcome of gastroduodenal pathology. in conclusion, the strains ofh. pylori may not be disease specific and the host response to the infection may determine the clinical outcome. the aim of this study was to compare the efficacy of omeprazole in combination with one and two antibiotics. subjects with h. pylori gastritis • d.u., who had not received previous eradication therapy were enrolled. h. pylori status was assessed by histology, culture and a rapid urease test. subjects were allocated to one of the following regimes; group : om. mgs daily + am mgs t.i.d, for / group : om. mgs b.i.d. + am. igm b.i.d, for / group : om. mg daily + clarithromycin mg b.i.d. + metronidazole mgs b.i.d, for / . subjects were recruited (mean age, . years, range - year, male). eradication rates were as follows: group ; / ( %), group ; / ( . %), and group / ( %). in group , all patients who failed to eradicate had primary metronidazole reistance and had primary clarithroycin resistance. triple therapy with omeprazole is efficacious ( % eradication) and superior to dual therapy. protease which promotes degradation of extracellular matrix. the aim was to quantitate u-pa antigen in normal and malignant large bowel tissue, and to study the relationship between neoplastic progression and changes in u-pa profiles. freshfrozen tissue specimens from patients, adenocarcinomas (n= ), adenomatous polyps (n= ), and normal colorectal mucosa remote from the tumour site (n= ). levels of the u-pa antigen were measured on detergent extracted tissue using a sandwich elisa assay (american diagnostica). results are expressed as mean values (rig/rag protein) with % confidence intervals (c.i.). mean u-pa expression was unaffected by gender (p= . ), or age (p-- . ). u-pa expression was greater in colonic than rectal mucosa (p-- . ). there was a fold increase in u-pa antigen level between control and malignant tisstte. of patients who underwent olt, developed cpm days - post surgery heralded by the onset of coma in patients with subsequent seizures and spastic quadraparesis; the third patient experienced the 'locked-in' syndrome, with apraxia, hypertonicity and extensor planter responses. two female patients underwent elective surgery for pbc [age and yrs] and one male for aih [age yrs]. all patients experienced slurred speech, ataxic gait, and shorterm memory loss. ct brain scan was normal in all patients, but mri confirmed changes in the pons consistent with demyelination. the sna concentration did not exceed meq/l in any patient during the peri-and hr postoperative period, and metabolic parameters were within normal limits prior to the development of neurological signs. conclusion: cpm occured in . % of patients transplanted and had no demonstrable relationship to sna flux. the purpose of the present study was two fold: a) to determine the relationship between clinical assessment of activity by two clinicians with four previously published indices, the crohn's disease activity index (cdai), the van hees activity index (ai), the simple index of harvey and bradshaw (si), and the fielding index, and b) for the first time, to study the internal correlation between these four indices. a hundred and ninety four assessments were performed on patients with crohn's disease. following each clinical assessment, the indices were calculated. a good relationship was observed between the median indicial values and clinical gradings for all four indices. the best relationship was demonstrated with the ai with no overlap in % values with increasing grades of disease activity. all four indices demonstrated a good correlation with each other (p< . ). the best correlation was observed between more objective indices the ai and the fielding index (r= . ) for first assessments only. conclusion: the van hee's ai is a reliable measure of inflammatory activity in crohn's disease and would be useful in multicentre therapeutic trials. hospital, galway. we have been studying the molecular genetics of a family with an inherited autosomal dominant predisposition to colorectal cancer. this family has a phenotype atypical of familial adenomatous polyposis (fap), with an average age of diagnosis at years, (later than classical fap) but it falls within the range of hereditary non-polyposis colorectal carcinoma (hnpcc). however, some family members contain up to colonic polyps, more than the usual number for hnpcc. there is a possibility that an attenuated form of fap -attenuated adenomatous polyposis coli (aapc) -is involved. this phenotype, represented by a later age of onset and fewer polyps than classical fap, is due to less deleterious germline mutations in the apc gene. attempting to elucidate the nature of this kindred's form of colorectal cancer, we have proceeded with genetic analysis. the results indicate that previously identified conserved and nonconserved single base-pair changes have been shown not to be responsible by single strand conformational polymorphism and heteroduplex analysis. thus, we have undertaken linkage analysis of the apc gene on chromosome (the disease locus for fap), using highly informative polymorphic markers flanking the apc gene to determine if alterations in this gene are responsible for the condition. melanoma is the most lethal of cutaneous malignancies accounting for % of skin cancer related deaths. the aim of this study was to assess survival and identify prognostic indicators in all melanoma patients treated at a single institution over a year period. patients ( females, males) mean age years (range - years) were treated. all had stage disease at presentation, lower limb ( %) was the most frequently affected site in females and trunk ( %) in males. % of the melanomas were invasive, % nodular and % superficial spreading. survival curves were calculated using the kaplan meier methodology and the overall year survival was found to be %, with the majority of deaths occurring within years of diagnosis. multivariate analysis using a logistic regression model identified breslow thickness as being the only independent statistically significant determinant of prognosis, emphasising the importance of early diagnosis and prompt referral in this disease. (e ) bullous erythema ab igne n. flanagan, r. watson, l. barnes. department of dermatology, st. james's hospital, dublin. the clinical manifestations of erythema ab igne are well described and consist of a rectangular red or brown macular dermatosis occurring most commonly on the lower limbs and backs of women. it occurs most commonly after prolonged exposure to infra red radiation at a level lower than that which produces an acute thermal burn. reports of bullae formation in erythema ab igne are very rare. we report three cases of bullous erythema ab igne that presented to our clinics over a two year period. histologically the split occurred at the level of the dermo-epidermal junction similar to that seen in seconddegree thermal burns. direct immunofluorescence of perilesional skin was normal in two patients. we have found only two previous cases of erythema ab igne associated with bullae formation in the literature ' . in one of these cases the histology suggested a coexistent lichen planus. in our three cases, there was no evidence of lichen planus. we propose that thermal injury in erythema ab !gne may result in bullae formation, and that erythema ab igne is more frequently associated with sub-epidermal bullae than is hitherto reported. vasculitis may have many causes. immunoglobulin deposition may be a non specific finding but iga deposition is thought to be mainly associated with henoch schonlein purpura (hsp) and may convey a greater risk of renal disease. we studied all patients diagnosed over the past seven years with vasculitis characterised by iga deposits in the blood vessel walls. patients were identified retrospectively from laboratory records and clinical details obtained from hospital notes. twenty-seven patients (age range - years) with iga vasculitis were identified, females and males. the diagnosis and associated findings are summarized in the pxe is a rare, hereditary clinically heterogenous disease of connective tissue. it may be inherited in an autosomal recessive or dominant (ad) manner. the incidence of ad inheritance is controversial. we report an irish family in which of members showed evidence of pxe on electron microscopy (em) examination of the skin. the index case initially presented with visual loss and angoid streaks were detected on fundoscopy. skin examination was normal on initial presentation. biopsies of flexural skin revealed elastic fibre abnormalities on em confirming a diagnosis of pxe. his asymptomatic parents and siblings (n= ) were similarly assessed. cutaneous examination was normal in all cases. one sibling demonstrated swollen fragmented elastic fibres with elastic van gieson stain. em examination showed evidence of the characteristic elastic fibre abnormality in these cases and also in their asymptomatic year old mother. the pedigree pattern clearly supports an ad pattern of inheritance. we propose that em examination of clinically normal flexural skin is a useful tool in the detection of pxe or of the asymptomatic carrier state. we present epidemiological data on patients with psoriasis vulgaris (probands) attending a dermatology clinic, directly questioned about age of onset and family history of the disease. ( . %) were male, ( . %) female, mean age was . sd _+ . , mean age of onset . sd • . . ( . %) presented before , m:f : . , ( . %) before , m:f ratio l:l . age of onset declined steadily for men after , in women a greater number still developed the disease. ( %) of probands had an affected ~ relative, ( . %) a ~ relative. probands with earlier age of onset had a higher % of affected relatives, . % between - , . % between - , suggesting stronger genetic influence with earlier onset. ( . %) of probands had neither parent affected, ( . %) had parent and ( . %) both parents. ( . %) probands with neither parent involved, had another sibling affected. these results do not favour simple autosomal dominant or x-linked recessive or dominant inheritance. an autosomal recessive pattern with a lower than expected frequency due to delayed age of onset could account for our figure of . %. dublin. dermatophyte nail infection is regarded as rare in children with a reported prevalence of . %, as compared to between - % in adults, rising with the age of population studied. we document its occurrence in the paediatric age group with case reports of tinea unguium occurring in healthy children, ages ranging from to years from different families, presenting over a month period. all were asymptomatic but presented because of the distressing and dystrophic appearance of their nails. all cultured trichophyton rubrum species and only one had an associated tinea pedis. we show carriage of asymptomatic t.rubrum on clinically normal toe-nails of other family members in of the cases, which may act as a reservoir for transmission of infection. we suggest that the prevalence of onychomycosis in children may be increasing and that certain subpopulations of young children are more at risk. we speculate as regards the lower prevalence in children, compared to adults but stress the importance of correct diagnosis at presentation by appropriate mycological assessment. mutant p & bcl- inhibit apoptosis and allow tumour proliferation. in malignant melanoma bcl- expression is most prominent in the radial growth phase. in this study we compared bcl- expression in nodular and acrallentiginous malignant melanomas and looked at ki- expression, a known proliferative marker and determined any relationship with prognostic variables. mean bcl- staining score in the acral lentiginous group was . compared to a score of . in nodular variant (p< . ). bcl- protein expression was not associated significantly with mitosis, breslow thickness or survival. percentage of positive ki- cells varied considerably and did not correlate with mitotic index and survival. the novel observation of markedly increased bcl- expression in the acral-lentiginous group of melanoma suggests that this variant of malignant melanoma is biologically different from nodular malignant melanoma. we hypothesise that the acrallentiginous variant of malignant melanoma is protected intrinsically from stresses that induce cellular apoptosis, for example ionising radiation and chemotherapy. irish journal of medical science controversial and was investigated in this study. biopsy-proven coeliac patients in clinical and histological remission were challenged with g of oats daily for a month period. clinical, laboratory, histological and immunological markers of coeliac disease activation were evaluated. all patients remained asymptomatic throughout the challenge period and no laboratory evidence of malabsorption was found. there was no mucosal damage seen on routine histological examinaton of post challenge duodenal biopsies. surface enterocyte height remained unchanged and intraepithelial lymphocyte counts were also unaltered following challenge. furthermore, oats did not cause immunological activation since no rise in alpha gliadin or endomysial antibodies or in mhc class ii staining of enterocytes was evident. this study demonstrates that oats is neither toxic nor immunogenic in coeliac disease and oats does not appear to contain the putative toxic peptide sequence found in the other cereals. erasmus university rotterdam, holland; regional transfusion centre, bristol, u.k a major complication of bone marrow transplantation (bmt) is graft versus host disease (gvhd) which is mediated by donor t cells. abrogation of gvhd while preserving stem cell repopulating ability might allow an increase in the donor panel for bmt. in vitro evidence suggests that ultraviolet b light(uv-b) can inhibit t cell reactivity. a prospective study of time to engraftment, chimerism kinetics and long term repopulating ability (ltra) of uv-b treated marrow precursors was performed in a murine bmt model. irradiated animals were rescued with an inoculum of donor cells treated with varying doses of uv-b. animals were sampled at weeks - , , , , , and assessed by pcr of short tandem repeat sequences. in semi allogeneic bmt, animals were studied. at low uv-b doses (< , j/m ) donor engraftment was delayed, whereas doses of , j/m or more never resulted in donor chimerism. there was no significant gvhd in control or uv-b treated animals. in the more immuno-aggressive allogeneic bmt animals were studied. / control animals died of gvhd. at j/m , there was no significant gvhd and / animals were long term donor chimeras. at , j/m there was no evidence of gvhd but no animal became a donor chimera. these results indicate: . high doses of uv-b may affect stem cell function (semi-allogeneic studies). . there may be an optimal dose of uv-b that prevents development of gvhd while preserving ltra of stem cells (allogeneic studies). complement deficiencies are best detected using haemolytic assays because these assays allow for screening for activity in all components. haemolytic assays have been developed that allow determination of both functional activity and identification of the missing component, when late acting complement component deficiencies (lccd) exist. we have further developed this assay system to include activity of certain classical components such as c , because c deficiency is the most common complement deficiency, but difficult to detect by antigenic assays. we applied these assays in studies in two irish families. in one family a year old girl from co. tipperary presented with a third episode of severe meningococcal septicaemia and meningitis. testing revealed that she and a younger sibling have complete deficiency of the eighth complement component (c d) whereas three other siblings, and the parents, have normal c activity. the other index case was a woman from dublin with a history of recurrent meningoccal disease. she and two sisters were found to have complete c deficiency (c q ) (one sister was tested in the usa) and both these sisters have a history of meningococcal disease. of three other siblings with no history of infection, one was tested and found to be complement sufficient, as were all the children of the index case and one affected sister. several approaches to prophylaxis for these cases can be considered. they include counselling, the use of the quadrivalent meningococcal vaccine (which gives limited protection) and long term penicillin prophylaxis. gastrointestinal (gi) infection is a common cause of morbidity in young animals. evidence is emerging that oral immunisation of the gastrointestinal tract with specific immunoglobulin (ig) provides protection against intestinal pathogens. hens immunised against such organisms lay eggs containing large amounts of specific ig. the aim of this study was to determine the usefulness of specific hen egg ig against salmonella in preventing infection, using the young calf as an animal model. twelve isa brown hens were immunised with salmonella. specific ig levels reached a peak at days post immunisation. these ig laden eggs were collected, the yolks harvested and pooled. an animal model of salmonella induced gastroenteritis was developed using young calves. forty five animals weredivided into three groups. two of these groups acted as controls, one receiving no egg yolk supplement, while the other received normal egg yolk from non-immunised hens as a supplement. the third group received a supplement of ig rich egg yolk from immunised hens. all animals were orally challenged after five days with live salmonella. in the groups of control animals, / animals given no egg supplement, and / animals fed normal egg, succumbed to infection within three days of challenge. however, in the group fed ig rich eggs, only / animals succumbed to infection after challenge. therefore, specific hen egg ig has a potential use in passive oral immunisation against gi infections. in asthma, dysregulation of bronchial t cell reactivity is associated with an imbalance within functionally distinct macrophage populations. il- inhibits cytokine productionby activated macrophages and also reduces antigen-specific proliferation of human t cells. we investigated the effect of il- on the phenotype of cultured peripheral blood mononuclear cells. monocytes from six healthy volunteers were grown in culture for days. il- was added on day to the differentiating macrophages; negative control and irrelevant cytokine (il- ) control experiments were also performed. double immunoftuoresence studies were performed on macrophage cytospins using the monoclonal antibodies rfd and rfd to show the relative proportions of rfdi+ rfd antigen presenting cells, rfd -rfd + mature phagocytes, and rfdi+ rfd + suppressive cells. the production of the inhibitory cytokine tgfi in the culture supernatant was measured by lymphokinespecific elisa. il- reduced the relative proportion of antigen presenting cells (from % to % of total macrophages) (p< . ) and increased the proportion of mature macrophages ( % to %) (p< . ) and suppressive ( % to %) (p ns) macrophages. the concentration of tgfgl in the supernatant remained unchanged following the'addition of !l- . in conclusion il- may suppress antigen specific immunity and hence bronchial wall inflammation, therefore forming the cellular basis for new therapeutic approaches to asthma. success of engraftment in recipients of orthotopic liver transplantation has been reported to exceed that in recipients of other solid organ transplantation. these individuals seem to adopt a greater degree of tolerance to their hepatic graft, facilitating a reduction in immunosuppressive therapy. such an observation suggests a possible functional role for the liver in the generation of graft tolerance. it is our hypothesis that the liver is a site of extrathymic t cell differentiation and that tolerance to the hepatic graft arises when recipient stem cells mature and differentiate in the donor liver and emerge tolerant of donor antigen. expression of recombination activating genes & (rag l& ) during t cell maturation is essential for rearrangement of gene segments that code for the t cell receptor (tcr). in this study rt-pcr was used to detect rag specific mrna from liver tissue, cdna synthesis was carried out using random hexamers. primers for first round and nested pcr of rag and rag were used. bone marrow mrna was used as a positive control for the reaction. rag and rag expression was not detected in peripheral blood. using this approach rag serum endomysial antibodies (ema) have been used as an aid to the diagnosis of coeliac disease. this method involves the use of distal monkey oesophagus as substrate tissue, % specificity has been reported although sensitivity remains questionable. it has recently been suggested tl) that human umbilical cord might provide an alternative to monkey oesophagus. this study was carried out to compare the specficity andsensitivity of ema estimation using human umbilical cord tissue (huct) and monkey oesophagus (mo) as target tissue. huct was obtained after normal delivery and the cord vessels were dissected out, placed in oct and snap frozen in liquid nitrogen. sections were cut and stored at - c. a modified immunofluorescence procedure was performed. a bright honeycomb fluorescence pattern indicated ema positivity. sera from adult patients being investigated for coeliac disease were studied. histologically, patients had active coeliac disease; of these were ema positive using huct and using mo. of patients showing histological and clinical improvement on a gluten-free diet, were ema positive and were ema negative on both huct and mo. patients had normal small intestinal histology; none of these had detectable ema using either substrate tissue. patients had other noncoeliac conditions and these patients were all ema negative on both uct and mo. in summary, ema estimation using huct is % specific and % sensitive and using mo is % specific and % sensitive. these results indicate the potential usefulness of huct as a screening test for coeliac disease. previous studies have demonstrated the changes seen in early open angle glaucoma using goldmann penmetry to be general constriction of the visual field, arcuate scotoma in the visual field and the nasal step. another study has shown that the nasal visual field can be enlarged by rotating the head by degrees in the direction opposite to that of the eye being tested in normal subjects with no ocular disease. we examined the visual fields in two groups of subjects. the first group (the study group, n= ) consisted of patients attending ophthalmic clinics with a diagnosis of early open angle glaucoma who are on medical treatment with good control of intraocular pressure, evidence of optic disc cupping and no field loss on kowa fields. the second group (the control group, n--- ) consisted of age matched individuals with no evidence of optic nerve disease or any other ocular condition which could result in visual field changes. after ocular examination, each subject had the visual field of each eye plotted with the head in two positions -namely straight ahead and rotated through degrees in the direction opposite to that of the eye being tested. the two sets of fields in each subject were then compared for the presence (or otherwise) of nasal expansion and nasal scotoma. of the eyes examined in the study group ( eyes were unsuitable), fields showed nasal expansion, showed nasal reduction and showed no change. the changes appeared thus: nasally expanded fields: range = . we investigated temporal contrast sensitivity (tcs) in patients with early glaucoma, in order to ascertain the possible clinical value of this test in the early diagnosis of chronic open angle glaucoma (coag), and as a margin screening procedure for coag. the study comprised of patient eyes (group l) and control; eyes (group ). of group almost half had a history of treatment for coag, or were receiving treatment at the time of testing. the control subjects had intra ocular pressure (iop) < mmhg, normal snellen acuity and normal visual fields. the following tests were carried out on both groups: . visual acuity -snellen chart; . iop -goldmann applanation tonometer, assessment of vertical cup: disc ratio -direct ophthalmoscopy; . visual fields -hensen field analysis; . tcs: modulation transfer functions were obtained using a sinusoidal flickering stimulus viewed with central fixation and plotted at frequencies from to hz. the modulation threshold transfer function (mttf) is a plot of log sensitivity versus log temporal frequency (hz) for a given mean luminance and subject. the mttf of group confirms published findings ~, indicating that the sensitivity is greatest within the frequency range - hz and falls offat higher and lower frequency. no statistical difference was found between the two groups which could be considered useful for diagnostic purposes. however, on average the control group did consistently score a higher sensitivity (approx. ), than the glaucomatous group (approx. ) in the temporal trequency range - hz, previous studies indicated that this test could be used to assess contrast sensitivity function in order to diagnose coag. our study to date has not correlated with this finding. it has been well documented that autonomic neuropathy frequently develops in diabetes mellitus. anatomically the iris consists of two muscle groups which control pupil size, innervation is exclusively by the sympathetic and parasympathetic parts ,of the autonomic nervous system. by measuring pupillary reflexes to a light stimulus quantification of the autonomic reflex is achieved in a simple non-invasive manner. previous studies have indicated that the autonomic nervous system may be affected-by diabetes before symptoms and signs of diabetic neuropathy become evident. this suggests irish journal of medical science that altered pupillary reflexes portray early autonomic neuropathy. the pupillary light reflexes were measured in three groups of patients; age and sex matched control subjects (group a), diabetic patients with no symptoms or signs of autonomic neuropathy (group b) and diabetic patients with a diagnosis of autonomic neuropathy (group c). a dynamic binocular infrared light reflex pupillographic method called irls was used. this method is simple, fast and easy to operate in contrast to previous techniques, such as, ohrt's cinematographic technique and friedman et al's use of electronic infrared pupillography. iris also measures the consensual pupillary reaction and provides response measurements with larger amplitudes and time resolutions than previous methods. the basis of this study was to investigate the ability of the iris technique to detect changes in the autonomic reflexes associated with diabetes mellitus. the mean values of the constriction latency (cl) were, in group a ms, group b ms and in group c . ms, while the mean peak constriction velocity latency (mpcvl) values were, in group a ms, group b ms and in group c ms. these results suggest a prolonged latency of the constriction reaction in both diabetic groups, and portray increasing latency values correlating with the development of autonomic neuropathy. the aim was to ascertain the prevalence of neurological symptoms and signs associated with b deficiency seen in st. james' hospital between jan. ' and dec. ' . a retrospective study was performed reviewing the records of all patients with b levels < ng/l. those without full neurological assessment and with pre-existing neurological disease were excluded. patients were studied. % ( ) had no neurological symptoms or signs whereas % ( ) were symptomatic. of those with neurological manifestations peripheral neuropathy was the most common finding ( ) %. % ( ) presented with distal paraesthesia alone. absent ankle jerks were noted in % ( ) and absent knee jerks in % ( ). posterior columns were often affected with reduced vibration sense noted in % ( ), position sense in % ( ) and soft touch % ( ). ataxia secondary to posterior column disturbance was noted in % ( ). spinal cord changes were rare with only % ( ) developing spastic paraparesis. one patient complained of increased irritability and emotional liability and one of worsening short term memory. no visual or spincter changes were noted. in summary posterior column changes and absent reflexes were most commonly noted in cases of b deficiency. spinal cord or central changes were rare. we could find no correlation between the degree of symptoms and the measured deficiency. we present the case of n.h., a year old university student with a three month history of frontotemporal seizures and cognitive deterioration. n.h. experienced episodes of disorientation, paranoid psychosis, speech disturbance and marked deterioration in short and long term memory. over the course of three months, she exhibited fluctuating neuropsychiatric symptoms and required assistance in dressing and feeding. neuropsychological testing revealed an overall decline in cognitive ability with predominantly right hemispheric dysfunction. investigations included: serum vasculitis screen, csf and serum virology including hiv, porphyria screen, toxicology screen, amino acid screen, repeated csf analysis, eeg (interictal), mri brain with gadolinium, vascular screen. these tests revealed persistently elevated csf protein but no other abnormalities. following a further deterioration she had a repeat eeg showing diffuse slow-wave activity. she underwent biopsy of non-dominant frontal lobe and meninges. histological findings were abnormal suggesting a diagnosis of subcortical gliosis. this diagnosis is uncommon in this age group and is often confused with schizophrenia or organic psychosis. the clinical manifestations and the extensive differential diagnosis of progressive frontal dementia and seizures in a young adult will be discussed. abnormalities of the autonomic nervous system in alzheimer's disease have been suggested by previous studies of the cardiovascular response to standing. in this study, outpatients having dementia of the alzheimer type (clinical dementia rating, score ~ ; mean age _+ sem, + years) were continuously monitored using finapress and their responses to the valsalva manoeuvre and positional change were compared with age matched ( _+ years) healthy elderly controls. mean resting supine blood pressure and heart rate were not different between the two groups. although both groups had the predicted tachycardia during the valsalva manoeuvre, on opening the glottis only the controls showed the typical bradycardia (- . +_ . versus + . _+ . beats per minute, b.p.m., for the patients, p< . ). when the subjects stood, there was a similar increase in systolic blood presure for both groups. in contrast, whereas controls had a robust tachycardia (+ . _+ b.p.m.) this was not the case for the alzheimer's patients (+ . _+ . b.p.m., p< . ). this indicates diminished baroreceptor cardiac reflexes in mild alzheimer's disease. b/a amyloid is thought to be responsible for much of the pathology observed in alzheimer's disease. we studied its ability to induce neurodegeneration following intrahippocampal injection in rats. male wistar rats received "injections of: a) soluble b/a ( - , . lag) and n-methyl d-aspartate ( . lag), b) aggregated b/a and nmda, c) aggregated b/a , d) vehicle (water), intrahippocampally (ca -ca ) via an indwelling cannula over a week period. the hippocampal lesion, cannula tract areas and numbers of cell bodies within the pyramidal cell layer were measured in lam sections (week ). all injections produced localised tissue destruction, neuronal loss and reactive gliosis. the relative damage was expressed as the ratio of total damage versus cannula damage. we found that aggregated b/ a appeared to be substantially more damaging than soluble amyloid, while the vehicle alone had little effect. nmda appeared to potentiate the toxic effect of the aggregated b/a . this suggests that b/a is indeed neurotoxic, especially when aggregated and with co activation of nmda receptors. success with long term prophylactic therapy requires patient compliance and education. we reviewed case records and questioned consecutive outpatients with grand mal epilepsy concerning their medication . patients were receiving largely mono-therapy carbamezepine ( ), phenytoin ( ) and sodium valproate ( ). the mean age was years (range - ); were female. almost half ( %) were fit free during the previous year. most knew the name and dose ( %), some ( %) name only and % knew neither. about half reported drowsiness and tiredness with their medication and % claimed it caused hair loss. only ( %) did not attribute any side effect to their medication. patients, including on warfarin, were unaware of potential drug interactions, and almost % were unaware of possible problems with driving, drinking, alcohol or pregnancy despite prescribers advising on these topics when initiating therapy. on the other hand almost all knew what to do if a dose was missed, attended for therapeutic drug monitoring, and requested more information about medication. additional education including written information and reminders concerning therapy could be valuable and would be appreciated by patients with epilepsy. this study was carried out to assess patients' understanding of the prescribed diet and of the importance of adhering to it. a questionnaire was posted to patients with biopsyproven coetiac disease who attended the coeliac clinic in st james's hospital, dublin. an % response rate was obtained and all questions were answered by all respondents. the majority ( %) felt that the gluten-free diet should never be relaxed, although some felt that they could relax the diet during social occasions ( %), when away from home ( %) or when asymptomatic ( %). nevertheless, many patients ( %) admitted deviating from their prescribed diet ( % "often included gluten"). the consequences of poor compliance were not always appreciated, most realising that diarrhoea could result ( %), fewer being aware of weight loss ( %), anaemia ( %), food malabsorption ( %) or metabolic bone disease ( %). factors contributing to difficulty in adhering to the diet included cost ( %), problems during social occasions ( %) and difficulty obtaining gluten-free products ( %). neither time since diagnosis nor socioeconomic group were significant factors in determining difficulty with dietary adherence. poor dietary compliance appeared to be a considerable problem in this population of adult coeliac patients. contributing factors may have included insufficient patient education and infrequent dietetic follow-up as well as insufficient availability of gluten-free products, cost and inconvenience of the glutenfree diet. nutrition plays an essential role in health and in the practice of medicine. general practitioners (gps) receive little nutrition training despite their potentially important role in promoting healthy eating and in using therapeutic nutrition strategies in patient management. a postal survey of gps in the eastern health board area, randomly selected from the irish college of general practitioners' register, was carried out. a good response rate was obtained to the questionnaire ( %) and most of the questions ( of ) were answered by all respondents. awareness of nutrition-related societies ranged from % (european society for parenteral and enteral nutrition) to % (the nutrition society). almost all ( %) felt that nutrition was important in preventative health care, % believing it to be important in general practice. this contrasted with infrequent assessment of patients diets ( % once weekly, % once monthly) where only % reported having access to dietetic services. although % believed that doctors should know more about nutrition, % felt their knowledge of nutrition was adequate ( % were unhappy with their nutrition knowledge and % were undecided). further nutrition education was of interest to %, % stating their willingness to attend lectures and seminars. the topics of greatest appeal were obesity ( %), diabetes mellitus ( %), cardiovascular disease ( %), nutrition in the elderly ( %) and nutrition in infants ( %). if the substantial interest in nutrition expressed by the respondent gps is representative, efforts to promote awareness of nutritional issues and to improve the nutrition knowledge of gps would be well received. anaemia of chronic disease (acd) is a common feature in rheumatoid arthritis (ra) but iron deficiency anaemia (ida) also occurs and may be difficult to identify. a marrow sample demonstrating absent iron stores confirms ida but is invasive, time-consuming and expensive. this aim of this study was to identify simple laboratory measure which either separately or in combination were reliably predictive of absent marrow iron stores, thereby avoiding the need for marrow sampling. forty seven anaemic ra patients (males with haemoglobin (hgb) < . g/dl, females < . g/dl) who were not taking iron supplements underwent a bone marrow aspirate and/or biopsy in addition to a full blood count, serum ferritin (ferr) and iron saturation measurements. mean (range) age was ( - ) yrs and disease duration ( - ) yrs, an evaluable marrow sample was obtained in patients: had ida (no marrow iron stores identified) and had acd (iron stores present). a diagnostic algorithm was developed using the results of the'blood samples measured. patients with serum ferr < ag/l were diagnosed ida; of the remaining patients, those with a mean corpuscular volume (mcv) > fl were diagnosed acd; of those still remaining, patients with serum iron saturation < % were diagnosed ida, and those % as acd. this algorithm had % sensitivity and % validity for the differentiation of ida from acd in patients with ra. this study demonstrates that ida can be reliably identified by measuring serum ferr, mcv and iron saturation in many ra patients, thereby avoiding the expense and trauma of a bone marrow biopsy. influenced by factors other than ra. in addition, the relationship of synovial membrane (sm) to serum (srm) and synovial fluid (sf) am levels has not been examined. sm, sf and srm were obtained from t patients with untreated inflammatory arthritis: mean (range) age ( - ) yrs, disease duration ( - ) mths and ritchie index (ri) ( - ). sm am expression was assessed by routine immunohistology. paired srm/sf soluble am (sam) levels were measured by elisa. mean srm and sf slcam- correlated (tau (t)= . ). lining layer (ll) icam- expression was greater in those with more sub-ll (sll) icam- expression (p= . ) and both ll and sll icam- was greater in those with higher sf slcam- levels (p< . ). srm slcam- levels correlated with both esr (t= . ) and ri (t= . ) and r was higher in those with greatest sll icam- expression (p= . ). mean srm seselectin correlated with sf se-selectin levels (t- . ) and was higher in patients with disease duration mths (p= . ). extent of sll e-selectin expression correlated negatively with ri (t=- . ). sll vcam- extent correlated negatively with ll thickness (t=- . ). no other correlations were seen between sm, sf or srm levels of either vcam- or e-selectin. this study found that srm slcam- levels reflect icam- expression in sm and sf and also disease activity. in contrast, this pattern was not seen with either e-selectin or vcam- . for these reasons, srm slcam- levels may represent a useful marker for the disease process in inflammatory arthritis. and serum (srm) adhesion molecule (am) levels in untreated inflammatory arthritis has not previously been systematically examined. matched sm, sf and srm samples were obtained from patients ( with ra) with inflammatory arthritis: disease duration - mths, no previous steroid or disease modifying therapy. sm icam- and e-selectin expression was assessed by routine immunohistology. srm and sf soluble am (sam) levels were measured by elisa. a consistent inverse relationship was seen between e-selectin and icam- levels in sm, sf and srm. the number of e-selectin positive vessels per mm inversely correlated with the % icam- + lining layer cells (tau (t)=- . ) and was significantly lower in those with more intense sublining layer icam- staining (p= . ). the % e-selectin positive vessels (as a % of all blood vessels) inversely correlated with serum sicam- levels (t=- . ). serum se-selectin inversely correlated with the extent of icam- expression in the sublining layer (t=- . ). sf slcam- levels tended to be lower in those with more intense expression e-selectin in the synovial membrane. finally, synovial vascularity (von willebrand factor expression) was significantly less in those with more intense sublining layer icam- staining (p= . ). these results indicate, an unexpected but consistent inverse relationship between e-selectin and icam- levels in previously untreated inflammatory arthritis. this suggests that the accumulation within the synovium of cells expressing icam- is accompanied by a down-regulation of e-selectin expression by endothelial cells. cohort studies in rheumatoid arthritis (ra) have noted progressive radiological deterioration despite improvement in clinical measures of disease activity. clearly, many of these routine measures are not sensitive to radiological progression. we sought to identify those clinical measures which best correlated with radiological course. serial clinical and radiological data were recorded in patients with active ra enrolled in a prospective study and reviewed a mean (range) . ( - ) yrs later. all clinical measures of disease activity improved, including morning stiffness (p = . ), pain score (p = . ), grip strength, ritchie articular index (rai), esr and hemoglobin (hgb) (all p = . ). overall, % had improvement in or more measures of disease activity and esr improved in %. in contrast, mean larsen score (ls) deteriorated significantly from to (p = . ). cd + cells were significantly higher (p< . ) and cd + cells lower (p< . ) in psa pb and sf compared to ra. the ratio of cd to cd cells seen in psa pb was significantly less than in ra pb (p= . ). the ratio of cd to cd was also less in psa se with cd + cells predominating, as compared to ra where the ratio was : (p= . ). cd counts were significantly less. and cd counts greater, in sf compared to pb in both psa (p= . ) and also in ra (p= . ). in view of the association of psa with class i hla antigens, the predominance of cd + cells in psa sf provides further evidence for a different pathogenetic basis in psa as compared to ra. cutaneous lymphocyte antigen (cla), expressed by - % cutaneous t-lymphocytes in psoriasis, may be involved in lymphocyte homing to skin. it has been proposed that cla+ tlymphocytes may also traffic to synovium in psoriatic arthritis (psa) where they may play a pathogenetic role. cla expression was measured in matched psa peripheral blood (pb) and synovial fluid (sf) and also normal and disease controls. thirty subjects were studied: active psoriasis, psa ( paired pb/sf samples), rheumatoid arthritis (ra) ( paired) and healthy controls. fresh heparinised pb and sf were examined by dual flourescence flow cytometry to measure tlymphocytic cla expression using heca- (gift from dr. louis picker, dallas). in psa, sf %cla+ lymphocytes were higher than pb in four of five paired samples studied but the difference did not reach statistical significance ( . % v . %, p= . ). this pattern was not specific to psa and in ra, sf %cla+ lymphocytes were also higher than pb in all six paired samples ( . % v . , p= . ). there was no significant difference between mean %cla+ sf lymphocytes in psa compared to ra ( . % v . %, p= . ). mean pb %cla+ lymphocytes tended to be lower in psoriasis than in psa ( . v . , p= . ) but there was no significant difference between mean pb %cla+ lymphocytes in psa, ra and normal healthy controls ( . %, . % and . % respectively). these data do not support the hypothesis that cla+ lymphocytes selectively traffic to psa synovium since similar numbers are seen in ra sf. increased numbers of cla+ lymphocytes in sf in both ra and psa may reflect non-specific accumulation of activated cla+ t-lymphocytes at sites of inflammation. hml-l antigen is an adhesion molecule member of the f~ integrin family expressed by over % intraepithelial and % lamina propria lymphocytes but rarely expressed outside these settings. it may be involved in lymphocyte homing to the gut. since a gut-derived antigen may play an aetiological role in rheumatoid arthritis (ra), hml-i+ t-lymphocytes might be expected to traffic to and accumulate in ra synovium. in this study, hml- expression was measured in matched ra peripheral blood (pb) and synovial fluid (sf) samples and also in normal and disease controls. twenty four subjects were studied: ra ( paired pb/sf samples), psoriatic arthritis (psa) ( paired) and healthy controls. fresh heparinised pb and sf were examined by dual flourescence flow cytometry to measure t-lymphocytic hml- expression. in ra, sf %hml-i+ lymphocytes were higher than pb in all (sf>pbx in four of six) paired samples studied ( . % v . %, p= . ). this pattern was not specific to ra and in psa, sf %hml-i+ lymphocytes were also higher than pb in four of five paired samples ( . % v . %, p= . ). there was no significant difference between mean %hml-i+ sf lymphocytes in ra compared to psa ( . % v . %, p= . ). there was no significant difference between mean pb %hml- + lymphocytes in ra, psa and normal healthy controls ( . %, . % and . % respectively). these data do not support the hypothesis that hml- + lymphocytes selectively traffic to ra synovium since similar numbers are seen in psa sf. increased numbers of hml-i+ lymphocytes in both ra and psa sf may reflect non-specific accumulation of activated hml-i+ t-lymphocytes at sites of inflammation. precise, powerful and sometimes subtle in their effects, lasers are increasingly important medical tools which have yet to find any major application in orthopaedic surgery. in one area, the increasing numbers of re-operations carried out on total hip replacement patients cause considerable difficulty for orthopaedic surgeons. one particular problem lies in the removal of the bone cement inserted during the primary operation, without causing damage to the bone. in order to develop a method for differentiating between polymethyl methacrylate bone cement and bone during laser ablation, the laser-induced fluorescence from bone cement has been studied and compared to that from the bone. an oriel multispec spectrometer was used to analyse and record the radiation emitted in the range - nm during nm excimer laser ablation. there was very high intensity fluorescence from bone relative to that from bone cement and several peaks occurred in the spectrum of bone which were absent from that of bone cement. monitoring of this emission has enabled controlled laser ablation of bone cement in contact with bone to be achieved in vitro with no damage to the naked eye. this has shown the potential of controlling the power of laser surgery to solve the problem of cement removal. the aetiology of rheumatoid arthritis (ra) is believed to involve both environmental and genetic factors. a large part of the inherited component is associated with a shared epitope (se) found in several drb alleles. tumour necrosis factor alpha (tnfc~) both because of its chromosomal localisation in the major histocompatibility complex and biological effects, is a candidate gene underlying the genetic association of the mhc with susceptibility to, or severity of, rheumatoid arthritis. we have recently described the first known polymorphism in the tnfot gene and shown that the rare allele (tnf ) lies on the extended haplotype a -b -dr -dq . we have therefore examined the genetic contribution of this polymorphism in ra. unrelated adult caucasian patients and healthy controls were studied. disease activity was assessed clinic~tlly and radiologically at presentation and at three years and no association there was no association with any measurement and tnf genotype. although there was no overall association of tnf with ra we are now studying a larger group to see if it contributes to ra independently of the se. the objective of this study was to quantify the effect of smoking on the cost of drugs prescribed in specific patient age groups under the general medical services (gms) scheme. details of i n g r e d i e n t cost for one month for each pharmaceutical item dispensed by pharmacist~ under the gms scheme with respect to patients attending one large inner city practice were linked to patients' age and to smoking status derived from practice records. age specific costs in year groups were calculated for current, ex-and non-smokers. smoking status was available on % of the , persons aged and over. of these . % were smokers, % were exsmokers and . were non-smokers. average expenditure per patient for current smokers was s vs s for ex-smokers and s for non-smokers. these differences were significant when the effects of age and sex were taken into account (p< . ). expenditure for smokers was higher than for ex-and nonsmokers up to the - age group, but from - upwards expenditure was much greater for ex-smokers than for current and non-smokers. the demonstration that ever smokers cost considerably more in terms of prescribing than non-smokers should provide a double incentive for gps to educate their patients with regard to smoking, and to assist smokers to stop before incurring permanent damage to their health. this study compared non-drug treatment to standard drug therapy for hypertensives in general practice. patients (n = ) with controlled hypertension for at least months (a bp < / mmhg) were randomised to continued medication (c) (n = ) or withdrawal (w) (n = ). drug therapy was recommended if bp exceeded / mmhg on any visit. both groups were counselled regarding lifestyle by their gp and reviewed at least monthly for months. both groups were initially similar for bp, heart rate, age, duration of therapy, total cholesterol and body mass index. subjects ( from the w and from the c group) did not complete monitoring. there were no cardiovascular events. % of w subjects remained off drug therapy at months ( of ) with mean bp of / mmhg (w) and / mmhg (c). no significant differences were observed in mean systolic or diastolic bp, heart rate, or body mass index between the two groups after months (manova). the w group h~td a % reduction in body mass index after months. successful w group patients had lower baseline diastolic bp than u n s u c c e s s f u l subjects (p< . ). on multivariate analysis, physical activity level at months was the best predictor of change in systolic (r = . ) and diastolic bp (r = . ) over the study. a proportion of motivated hypertensive patients can cease drug therapy and be adequately maintained by lifestyle advice from their gp for at least months. cessation of drug therapy may be an important motivating factor for lifestyle change. diarrhoea is a significant cause of morbidity, particularly in the elderly. it may result in increased hospital stay, risk of malnutrition and dehydration and is associated with an increased susceptibility to other nosocomial infections. we undertook a prospective study of patients admitted to a general hospital in a month period to determine the causes of hospital acquired diarrhoea and risk factors for acquisition. cases out of admissions were identified, of these were over the age of years. cases were secondary to clostridium difficile; of these were over years and the other were young debilitated adults. all cases had barthel scores less than / and many shared the same commode or were nursed in the same ward. cases were caused by medications -laxatives accounting for cases, the remainder caused by antibiotics, nsaids or other medications. the overall incidence of hospital-acquired diarrhoea is . cases per admissions. most cases are iatrogenic or caused by clostridium difficile. elderly debilitated patients are particularly susceptible. more careful attention to appropriate prescribing of laxatives in the elderly and rigorous attention to infection control policies by hospital personnel may prevent many cases. however, the prevalence and type of cognitive impairment in older diabetics has not been quantified. in this study diabetic out-patients aged from to years and age-matched nondiabetic out-patients were screened for cognitive impairment using the standardised mini-mental state examination (smmse). smmse scores suggested cognitive impairment in almost in diabetics. on statistical analysis however, no significant difference was found between the two patient groups in mean smmse scores or in the proportion with smmse scores of or below. in the diabetic group lower smmse scores were related to patient age, school-leaving age, depressive mood and living alone. cognitive performance was not related to hb alc~ or frequency of blood or urine glucose monitoring by patients. conventional methods of assessment of the anal sphincters primarily provide functional rather than anatomical information. anal endosonography is the only modality providing direct visualisation of the sphincters. the aim of this study is to evaluate the use of the ~ sector scanner (more widely available than the ~ transducer previously described) in the identification of anal sphincter defects. women were examined in the left lateral and prone positions by a toshiba pvl s sector scanner. neither the patients' symptoms nor the results of anal manometry and pudendal nerve terminal latencies were known to the ultrasound operator and the examinations were assessed by two independent observers. % (n= ) had abnormal transanal ultrasound. of these % (n=l l) had defects of the internal sphincter; % (n= ) had external sphincter defects; ( %) had defects of both. all patients had abnormal manometry. we conclude that endosonography using a ~ sector scanner provides a reliable and well tolerated adjunct to conventional methods for assessing the anal sphincters. effects of cigarette smoking in pregnancy are well known. maternal exposure to other people's cigarette smoke i.e. maternal passive smoking has been less well-defined and the effects are more subtle. the objectives of this study were to document the incidence of maternal passive smoking as well as active smoking in a pregnant population attending a public clinic. this information was collected by self-administered questionnaire. a presenting sample was taken. the total number of women studied was . the response rate was %. % smoked during pregnancy. % never smoked. % were ex-smokers, of whom % stopped just before or during the current pregnancy. the incidence of~passi,ve and active smoking was higher in unemployed women compared to employed and housewife groups. it was also higher in single compared to married women. of those who worked, % were exposed to passive smoking in the workplace. % of smokers received advice about risks of smoking during their~cu~rent pregnancy. conclusions: maternal passive smoking is very common in pregnancy. its effects, which may be subtle, should be studied formally. antenatal adx, ice should refer to its potential hazards. data on maternal satisfaction with care in labour and maternal preference for mode of delivery were gathered by anonymous questionnaire, distributed on the day of postnatal discharge to all women delivered in a six week period during the months of february and march . women whose babies had a congenital malformation or perinatal death were excluded~ women completed the questionnaire (a % response rate). parity, health plan status, antenatal class attendance, awareness of delivery types, analgesia and labour length were studied. visual analogue scores (vas) were recorded for satisfaction with pain relief during and after labour and for care during labour. the majority of women ( % vas or >) were satisfied with care in labour. factors significantlyassociated with such satisfaction were good analgesia during labour (specifically epidural), vaginal delivery, adequate preparation for labour and if personal concerns were listened to by staff. . % had hoped for a vaginal delivery (vd) and . % for caesarean section (cs) -(actual rates - % vd, % cs, % operative vd). % felt they had been adequately listened to by staff. such results may help influence and shape future care of women in labour. the purpose of this study was to determine the incidence of contralateral corpus luteum in ectopic pregnancy and its relationship to clinical presentation and known risk factors. a prospective study of all ectopic pregnancies presenting to an urban maternity unit over a month period. clinical details were recorded. laparotomy findings were noted: site and condition of ectopic pregnancy, side of corpus luteum, evidence of pelvic pathology. statistical analysis of data was by chisquare d test and fisher's exact test. p< . was considered significant. there were ectopic pregnancies: ovarian, tubal, of which had ruptured. a corpus luteum was identified at laparotomy in . the site of ovulation relative to the tubal pregnancy was ipsilateral in ( %), and contralateral in ( %). the mean duration of amenorrhoea, the bleeding pattern at presentation, and the incidence of tubal rupture were no different when transmigration of the ovum had occurred. there was no association between the laterality of the corpus luteum and the presence of risk factors for ectopic pregnancy. conclusion: these data suggest that the contralateral corpus luteum is not an aetiological factor in ectopic pregnancy. the aim of the study was to determine the incidence of cervical dysplasia in patients presenting with condylomata. setting: a sexually transmitted disease clinic. a prospective observational study on all first attenders with condylomata accumminata. patient details included risk factors for cervical dysplasia: age of first coitus, previous partners, contraceptive use, and cigarette smoking. all but women had a cervical smear taken. new patients with genital warts attended the clinic in months. ( . %) had negative cervical smears. ( . %) patients had cervical dysplasia: mild ( ), moderate ( ), severe ( ). results were analysed using chi-squared tests. age of st coitus, previous sexual history, cigzrette smoking, oral contraceptive use, and distribution of genital warts had no significant influence on the likelihood of cervical dysplasia in these patients (p> . ). conclusion: a significant number of patients presenting for the first time with genital warts have cervical dysplasia. coital activity, cigarette smoking, and wart distribution appear to have little effect on the risk of abnormal cervical cytology in these patients. mater misericordiae hospital, dublin. the aim of the study was to detect vaginal and cervical pathogens among patients presenting with condylomata accumminata. setting: a sexually transmitted disease clinic. a prospective observational study on female patients presenting with genital warts. details were recorded of gynaecological symptoms, coital and contraceptive history,and partner's genito-urinary symptoms. a cervical smear and full pelvic inflammatory screen were performed. specific swabs were cultured for candida, trichomonas, chlamydia, and gonococcus. of new patients with genital warts, were screened. patients ( . %) had negative pelvic inflammatory disease screens. pathogens detected on swab culture were as follows: candida , gardnerella , chlamydia , bacteroides , trichomonas , gonococcus . only of the patients ( %) with positive cultures reported vaginal discharge on questioning. conclusion: over half of these patients presenting with genital warts had vaginal or cervical pathogens. most were asymptomatic, and hence screening for genital infection is worth considering in all patients with genital warts. there was a notable absence of trichomonal and gonococcal infection. in recent years, a variety of endometrial sampling devices are reported as alternatives to disgnostic curettage (d&c), for obtaining tissue for morphological assessment. these devices do not require anaesthesia, can be used in an out-patient department and can be easily repeated. in this study, consecutive endometrial samples obtained by the pipelle device were assessed morphologically. (the method of sample collection is illustrated.) . % of the samples yielded either very scanty material or showed fragments of shedding endometrium, and therefore were unsuited for full evaluation. . % of samples showed small fragments of endometrial tissue from the functional layer, with well preserved architecture. of these, % showed proliferative pattern, % secretory pattern, % interval phase, % atrophic pattern, one case ( %) each of adenocarcinoma, atypical hyperplasia, cystic glandular hyperplasia (simple hyperplasia) and a placental site nodule. we believe that the pipelle endometrial sampler is an effective alternative to d&c, and it yields adequate material for morphological assessment in most cases. recent reports call for regular monitoring of breast cancer patients on tamoxifen therapy for endometrial lesions. we think that the pipelle endometrial sampler in combination with transvaginal ultra sound or hysteroscopy would be very useful in this setting. the purpose of study was to review the obstetrical and perinatal outcome of irish travelling women by retropsective chart review of consecutive women delivering in this unit between jan. and august . the mean age was years (range: - ); < and > years. the mean parity was (range: - ); were nulliparae; were > para . thirty-four had a history of miscarriage and of neonatal death. forty-two had a family history of inherited disorder and of diabetes mellitus. fifty-seven consumed alcohol and smoked during pregnancy. sixty two booked at > weeks. seven had a booking hb < g/dl. labour was induced in ; had caesarean sections. the mean birth weight was . kg; (twins) were < . kg; were > kg. there were no perinatal deaths but infants had serious problems. no mother breastfed. a health education programme is required to meet the special needs of this section of our community. the risk of thrombosis is increased in pregnancy and thromboembolism is the commonest cause of maternal death. thrombosis may also play a pathogenic role in preeclampsia, in which placental infarction and ischaemia impairs fetal growth. in this study, we examined for evidence of increased platelet activation in pregnant subjects by determining the in vivo formation of thromboxane (tx) a r txa~ is the major cyclooxygenase product in platelets and is generated in response to platelet activation. moreover, txa itself is a potent platelet activator acting to amplify the original signal. txa formation in vivo was determined non-invasively by measuring the urinary excretion of its major enzymatic metabolite, -dehydro-thromboxane b z (tx-m). urinary tx-m was markedly elevated in pregnancy ( _+ , n= ; normal < pg/mg creatinine). to address if this was derived from platelets, aspirin was administered in low dose either as regular oral aspirin mg/day (ra) or a controlled release preparation (ca) which has been shown to be highly selective for platelet cyclooxygenase. both preparations significantly suppressed platelet cyclooxygenase, determined as serum thromboxane b ex vivo ( _+ to . _+ . ng/ml, n= for ca; _+ to . _+ . ng/ml n=l for ra). to determine whether this effect was selective for platelets, prostacyclin formation was measured as the urinary excretion of its metabolite, , -dinor- -keto-pgf w in pregnant subjects, excretion of pgi-m was elevated ( _+ , n= ; normal < pg/mg creatinine) when measured on two separate days. neither aspirin preparation altered prostacyclin generation. in contrast, urinary tx-m decreased by more than % following days of treatment with either preparation. conclusions: thromboxane formation is increased in pregnancy and this derives largely from platelets. these data demonstrate in a non-invasive fashion that platelet activation is increased in pregnancy. this in turn may contribute to the risk of thrombosis. although negative attitudes toward acquired immune deficiency syndrome (aids) patients have been reported ~, the quality of care delivered has been inadequately addressed. therefore, the aims were, to measure: ). nurses' expressed comfort with aids care, ). behavioural intention toward aids patients, ). knowledge of aids, and ). attitudes towards aids. a random sample of both psychiatric and general nurses were surveyed, using an -item questionnaire comprising a). demographic details, b). a -item nursing care expressed comfort scale which included behavioural sub-scales measuring: willingness, avoidance, refusal intention and caution, c). attitude items measuring: stress, prejudice, and risk perception d). a -item knowledge scale. a response rate of % (n= ) was obtained. while % ( ) were willing to nurse an hiv/aids patient, % ( ) would be uncomfortable with being assignmed to an aids ward and % uncomfortable with nursing an aids patient. all respondents expressed some level of avoidance with regard some aspects of aids care. five percent ( ) were tested for hiv after an occupational injury. in the case of those who would be uncomfortable, the findings imply that the care aids patients receive may be less than desirable. the question then, is if voluntary allocation to aids care may be of more benefit to all parties involved. the:health service is one of the leading employers in ireland and great britain. its occupational health (oh) services vary enormously or are absent in health boards and voluntary hospitals in ireland. health service employees are exposed to numerous hazards -for example needlestick injuries -so adequat e use of their oh department is important. this project investigated i) the knowledge and attitude of health care workers within the united kingdom national health service (nhs) regarding their oh department, and ii) their awareness of policy for needlestick injuries. a questionnaire was sent to nhs employees: the response rate following a second mailing was %. the results highlight deficiencies in employees' knowledge of their oh department, its staffing and the facilities available: % did not know its location, % had never visited it and % did not know by whom it was staffed. staff were reluctant to attend their oh department for anything other than preemployment assessment and vaccination. although over % of staff had experienced a needlestick injury within the last months, % of staff remain unvaccinated against hepatitis b. nearly three-quarters of respondents felt that they had never had any training in the subject and over % of respondents are unaware of the procedure following needlestick injury. these findings have significance for the content and format ot newly developing oh services in irish hospitals. kilogrammes in weight with improved exercise tolerance observed. we conclude that rhdnase is well tolerated by irish paediatric cf patients, with a statistically significant increase in fev , there was an increase also in fvc that failed to reach statistical significance. further follow up studies are indicated to ascertain potential long term benefits of rhdnase therapy in this age group. thirty seven out of a total of infants with congenital pyloric stenosis (ps) over the last l years had measurements of head circumference (hc) and weight at birth and diagnosis. thirty one ( %) were male. a control group of healthy infants was drawn from hospital and private clinics ( % male). a "thriving index" was derived for hc and weight: growth from birth (g or cm) x birth weight (g) or birth head circumference (cm) divided by the age in weeks and expressed as % per weekhead index (hi) and weight index (wi). because these indices varied by age and sex, males only were compared at - weeks, - weeks, - weeks and - weeks. the pyloric male infants had a significantly lower hi at - weeks but more so from weeks on: ( recombinant human dnase hydrolyses dna, present in large quantities in infected cf sputum, so reducing the sputum viscosity. paediatric patients ( male, female) aged - years were selected. criteria for selection were age > years, a positive sweat test and fvc on spirometry between - % of predicted. the study was an open trial with both clinician and patient aware of treatment. all patients received a once daily aerosolised dose of . mgs rhdnase (pulmozyme) for a period of i weeks. baseline spirometry (fvc, fev ) was performed on day , prior to starting therapy and repeated day and day . patients were asked to keep a daily diary of their respiratory symptoms, infections and their concomitant drug therapy during the study. serial weights were recorded for each patient also. spirometry: average fvc for the group increased from . l (sd . l) . % predicted (sd . %) to . this study presents the demographics and clinical manifestations of hiv infection in children in ireland. it is a retrospective/prospective study. children were identfied at birth when maternal seropositivity was known (early), or if symptomatic (late) or at time of hiv diagnosis (dx) in a relative (late). all were monitored prospectively from dx, but for those identfied late, data was also gathered from medical records prior to dx. between ' and ' , infected children ( f, m) born to mothers were identified. hiv was acquired vertically in %. risk factors included maternal ivdu ( %), maternal partner hiv+ ( %), country of origin ( %) and unknown ( % liaison child psychiatry involves a partnership between child psychiatry and paediatrics, to provide integrated medical and psychological care for children. a number of recent publications have described mladels of liaison child psychiatry service provision, but the actual work of such a service has not been described. the present study reviews the work of a liaison child psychiatry service in a -bedded paediatric hospital from january to december . the service which was provided by three consultant child psychiatrists included two components, a) weekly psychosocial ward rounds with specialist paediatric teams, b) direct referrals from paediatrics to child psychiatry. two hundred and thirty three young people were referred, representing . % of all adaissions during the same period. reasons for referral included for clarification of the role of emotional factors in paediatric presentations in cases ( %), and for assessment of deliberate self harm, anxiety or depression in cases ( %). rates of referral increased with age of the child, most being in the - year age range, with equal numbers of boys and girls being referred. referral rates were much higher from paediatricians than from paediatric surgeons, although rates of emotional and behavioural disorder are equally common in children attending these services. increasing awareness of the importance of psychological factors in the management of both acute and chronic paediatric disorders is focusing attention on the development and efficacy of liaison child psychiatry services. lactase enzyme reduces the lactose content of milks, and is available as "lactaid" an "over the counter" preparation. we studied the rate of the reaction of lactaid on milk lactose to determine if the recommended incubation time of hours could be reduced to lessen the risk of infection. four different formulas were reconstituted according to the manufacturers' instructions. osmolality was measured by the fiske os osmometer over hours without added enzyme, and with different concentrations of lactaid. the osmolalities of the same formula brand, reconstituted by paediatric nurses, ranged from to mosm/kg and were higher than the manufacturer's quoted osmolality. there was a slight spontaneous change in milk osmolality over hours. at hours, osmolality ranged from to mosm/kg with one drop of added lactaid; and from to mosm/kg with four drops. the rate of change of osmolality was maximum in the first four hours, and lactaid exerted the majority of its effect within the first hours. lactaid incubation time can be reduced to less than hours. however the osmolalities achieved after incubation exceeded both the mrc and conapp guidelines for infant formulas. there is a wide variation in the osmolality of formulas reconstituted from powder. postpartum depression is well recognised. however, the occurrence of elation or hypomania in the postpartum period and the effect that childbirth has on partners is less understood. over a six week period mothers and their partners were asked to complete the edinburgh postnatal depression scale (epds) and the 'highs' scale and % (n= ) took part. at six weeks postpartum, % (n= ) of mothers scored on the epds; higher scores were associated with bottle feeding (p= . ), unemployment (p= . ), failure to attend ante-natal care (p= . ), babies that were difficult to manage (p< . ), and maternal health problems (p< . ). only . % (n= ) of partners scored on the epds; higher scores were associated with fewer years in formal education (p= . ) and unemployment (p= . ). using the cut-off of on the highs scale, at six weeks, . % (n= ) of mothers and . % (n= ) of partners were classified as 'cases'. maternal 'highs' scores were associated with bottle feeding (p= . ), fewer years in formal education (p= . ), unemployment (p= . ), and failure to attend for antenatal care (p= . ). partners' 'highs' scores related only to partner age (p= . ). depression and elation scores were strongly associated with one another in both the mother and partner groups (p= . ). these findings suggest a complex and not mutually exclusive relationship between depression and elation in the postpartum period and identify possible predictors of mood disturbance in both mothers and their partners that may impact on treatment strategies. we describe the case of a year old female who developed the classical features of dsm-iiir an within a year of her developing and receiving treatment for sle. liking reasons for an association between these two disorders are discussed. conclusions: there was no evidence either clinically or using magnetic resonance imaging to suggest that the emergence of an eating disorder in this patient was a manifestation of cerebral lupus. this study looks at rates of suicidal ideation and acts of self-harm among and year old school children in our catchment area of eest dublin. classes in single sex secondary schools in east dublin were chosen randomly, male and female. an initial agreement questionnaire was given following parental permission. all those with suicidal ideation at some time, and % of those with none were followed up with a detailed home interview. children participated - . % of total class population. home interviews suggest . % "suicidal ideation ever", . % self-harm rate - % of those interviewed felt suicide was a right under adverse circumstances. only . % would advise professional help to a friend with suicidal ideas. conclusion: this survey found lower levels of suicidal ideation than most north american studies. however, there is widespread acceptance of suicide as a desperate problem-solving exercise. professional services need a higher profile among this group. ( . %). the low number of assaults in locked ward setting ( %) reflects the community orientation of the service. vincent's hospital, elm park. the attitude of medical students towards psychiatry has relevance in the planning and structuring of medical curricula, and for patient management at the level of primary care. it is unclear from previous studies as to whether the clinical clerkship carl influence the attitudes of medical students towards psychiatry. final year medical students attached to u.c.d. (n= ) were administered a series of three attitudinal questionnaires, before and after their eight week psychiatry clerkship. anonymity was guaranteed. data was coded and analysed using spss. % (n= ) of the class completed the questionnaires. there were males and females. the average age of the sample was years sd ( . ). there was a significant increase in the mean score on the atp (attitude towards psychiatry questionnaire) post clerkship (p= . ). significantly more students expressed a wish to have a career in psychiatry post clerkship (p= . ). overall positive attitudes were expressed towards psychiatry, psychiatric treatment, and the need for psychiatric skills in general practice. conclusion: the eight week clinical clerkship in psychiatry would appear to have a positive effect upon the students' attitudes. it remains to be seen if this change will be transient or whether it will endure. we intend to follow this group prospectively and measure their attitudes towards psychiatry upon graduation and one year post-graduation. a postal questionnaire was sent to psychiatrists and trainees providing a service to the eastern health board in the dublin area. replied ( . % response rate). had been assaulted ( . %), had been injured as a result ( . %). the only distinguishing characteristic between those assaulted and those not, was that general adult psychiatrists were more likely (p= . ) to be assaulted and child psychiatrists less so (p= . ). data were collected regarding % assaults. . assailants were male, % were known to the assaulted doctor, % were psychotic at the time of the assault and % were intoxicated. weapons were used on occasions including incidents with knives and one with an iron bar. assailants were from broad diagnostic groupings -personality disorder the most numerous group at . %. conclusions: assault rates approximate those of previous surveys in north america - . %. injury rates are lower ~.as thyroid di~sease has been documented to be of a higher prevalence in individuals with down's syndrome, an audit was set up to assess the thyroid status of individuals with down's syndrome in the community and individuals who were residentially based. in the residential sample, % (n= ) showed evidence of a thyroid disorder. . % (n= ) had an established history of hypothyroidism and newly diagnosed cases accounted for . % (n= ) of the sample. in the community based sample, % (n= ) showed evidence of a thyroid disease. there was one established case of hypothyroidism, and new cases identified with evidence of a thyroid disorder. the results from the audit emphasise the need to monitor the thyroid status in individuals with down's syndrome. the average age in the residential sample was years and in the community based sample, it was . this would indicate a youthful sample and as the incidence of thyroid disease has been found to increase over the age of years, it again highlights the need for ongoing monitoring of thyroid status, regardless of age. many studies suggest that brain structure in patients with schizophrenia and that these patients also display a variety of cognitive deficits. this cognitive dysfunction may be influenced by factors such as gender or handedness. patients with schizophrenia (dsm-iii-r) were assessed on a complex neuropsychological battery devised to test a variety of functions. all tests were correlated with equivalent percentile norms to indicate the degree of impairment on each task. patients were also administered a modified annett handedness questionnaire and demographic information collected. cognitive performance of patients was impaired, when compared with equivalent percentile norms. dysfunction of the frontotemporal region was evident, although impairment of the parietal lobe was equivocal. further exploration of the data provided no evidence that this cognitive dysfunction may be influenced by gender. however, there is some evidence to suggest that the pattern of left-and right-handed individuals may differ. this study was supported by the health research board. previous studies of emergency ambulance calls suggest that up to % are inappropriate. however, there is no data in the literature concerning repeated or "nuisance" callers. we describe three cases of repeated ambulance calling in elderly people in which the behaviour was directly related to an underlying psychiatric disorder, the effects of which were compounded by lonliness. prior to psychiatric assessment these patients made up to calls over a weekend. on each occasion the patients were transported to hospital, assessed and, in the absence of any physical findings, discharged home. this pattern persisted for several months in each case until they were referred for psychiatric assessment. the three patients, two women and one man, were diagnosed as having depression with mild dementia, alzheimer's disease, and late onset schizophrenia with associated alcohol abuse respectively. following appropriate intervention the calls stopped in two cases, and diminished significantly in the other. the three case histories show that disturbed behaviour such as repeated ambulance calling in the elderly should raise the possibility of an underlying psychiatric disorder. early identification and treatment can reduce patient disti'ess and prevent the behaviour becoming habitual. the associated loneliness contributory to the behaviour can be tackled by maximising community support, and so more appropriate helpseeking behaviour can be introduced. there is growing interest in asssessing measures of deficit symptoms in studies of the course of schizophrenia. it is postulated that although overlapping, negative and deficit symptoms are not co-extensive. the quality of life scale (qls) is a item scale, based on a semi-structured interview designed to assess deficit symptoms. each item is scored on a point scale providing separate subscale scores and a total qls score (maximum score is ). randomly selected patients with schizophrenia (dsm- l-r) who attended a rehabilitation centre were assessed using the qls and the schedules for assessment of positive and negative symptoms of schizophrenia (saps and sans). there were males and females with a mean age of . years (sd . ) and mean duration of illness of . years (sd . ). the mean qls score was . (sd . and range to ) indicating moderate to severe impairment of functioning. total sans and all the individual sans subscores were strongly negatively correlated with total qls score (p< . ) as was duration of illness (p< . ). educational attainment was associated with better quality of life. age at diagnosis and gender were not correlated with qls score. these findings suggest that premorbid functioning, duration of illness and negative symptoms adversely impact on the outcome of schizophrenia. recurrent nightmares occur in up to % of the population and are associated with insomnia, irritability, tiredness, anxiety and depression. nightmares resemble phobias in that stereotyped cues trigger anxiety and result in avoidance behaviour. several case reports and treatment trials support the value of behavioral treatment in recurrent nightmares. we have conducted a treatment trial to focus on the exposure method (also known rehearsal relief). suitable subjects were recruited following an advertisement in the media. they suffered weekly nightmares for at least a year and were randomised into one of three groups, exposure, relaxation or waiting list. the complete trial was administered by post including measures, diaries and treatments. exposure treatment reduced the average frequency of nightmares by %; significantly better than relaxation treatment and waiting list control. other measures including depression and anxiety diminished significantly in the exposure treatment group. there was an average deaths per year in psychiatric inpatients accounting for % of all suicides per annum. the rate of suicide in short stay inpatients (stay less than one year) was / , . the rate for long stay (stay more than year) per , . the suicide rate for all inpatients increased fourfold in a years while the rate in the general population rose by a factor of eight. % of suicides were - years. ( %) had depression and ( %) schizophrenia. % made previous suicide attempt. the risk of suicide was higher the shorter the time interval after admission. ( %) suicides in those registered as psychiatric inpatients occurred while patient was away from the hospital. ( % ) were absent without leave. -conclusion: the high rate of suicide immediately after admission and the number who leave hospital emphasises the importance of careful management of patients at risk of suicide in a safe secure environment. the person year method is appropriate for monitoring changes in suicide rates. lifestyle plays a key role in determining both the duration and quality of life. personal advice from health professionals can exert a powerful influence on health behaviour of patients. we examined indicators of health behaviour in parents with young children in routine contact with the health service. a cross-sectional study design was used. from oct. ' -jan. ' , parents bringing their child for a routine developmental examination (at mths approx., service uptake %) at health board clinics in a dublin community care area, including inner city and suburbia, were asked to respond to an area medical officer administered questionnaire. data on parents of children are shown in the the table below. mother not on folic acid supplements in early pregnancy % either parent currently smoking %* baby breast fed no %* for up to month % for up to months % no smoke alarm in the house %* an open chip pan is used in the kitchen %* baby sometimes put to sleep in the prone position % child not vaccinated against pertussis % *significantly associated with younger mothers and lower social class (x , p< . ) these data suggest that parents are responding to many health promotion initiatives. however, there remain opportunities at child screening clinics to further influence the health behaviour of families with young children. the study suggests that a broad range of topics should be addressed, and prioritised in line with the targets of the national health strategy. information on survival was sought from multiple sources. follow-up was attempted for each case until death or or until the date last known to be alive. kaplan-meier survival curves were calculated for the total cohort and for children born within the two time periods - and - . other prognostic factors studied included: maternal age, sex, mother's county of residence, season of birth and presence or absence of other congenital anomalies, specifically congenital heart disease (chd) and gastro-intestinal anomalies. a multivariate analysis was carried out using cox's proportional-hazards regression model. the overall year survival was % with no difference for the two time periods studied. presence of chd reduced year survival to % (p< . ). this effect was largely due to the presence of atrio-ventricular canal defects. other congenital anomalies and additional factors studied were not associated with decreased survival. these findings have relevance for service planning for children with down syndrome. long-term follow-up of children with congenital anomalies is clearly useful, however there is a need for simpler methods of establishing outcomes. we conducted a descriptive epidemiological study of down syndrome (ds) in the irish counties covered by eurocat registries of congenital malformations for the years - (dublin, kildare, wicklow and galway). all ds cases born between t/ / and / / to mothers resident in the counties were identified. crude birth prevalence rates and maternal age-standardised rates (sprs) were calculated for each county and for each year in the study period. the crude birth prevalence for the counties was . / , . there was a fall in the total number of ds births over the decade, but less change in the crude birth prevalence due to an increase in the proportion of mothers aged +. galway had the highest crude birth prevalence of ds ( . / , ) but the spr was within average for the counties as a whole - . , % confidence interval . - . the risk of having a ds child increased seventy fold from : at age - to : at years or older. nearly half of all ds cases ( . %) had at least one additional anomaly. the parts of ireland covered by eurocat have a high birth prevalence of ds births as compared with some other countries, but the maternal age-specific rates are not substantially different from those in large international studies. b causes erythema infantiosum (slapped cheeks syndrome). in childhood this is usually a mild self limiting infection. if contracted in pregnancy it may cause non-immune hydrops foetalis and foetal death in up to %. we describe the first outbreak of b infection in this country. in december, , a cluster of pupils with typical "slapped cheeks" rash occurred in a dublin primary school and the diagnosis was laboratory confirmed using serology. information leaflets on the infection were circulated to parents and management guidelines to physicians. in june, , the parents of all pupils were asked whether their child had the suggested symptoms during the previous months. % of pupils had such symptoms. of these, % had slapped cheeks, % had rash elsewhere. the rash was evanescent (i.e. waxed and waned) in %. the mean duration of symptoms was days. % reported spread to family members. % were aware of the illness which may have been due to the information campaign mounted at the time of the initial outbreak. % had not seen a similar rash before. none of the teachers had clinical symptoms. six months after the initial outbreak, parvovirus lgg antibody was detected in salivary samples of % of the pupils, a level higher than that usually detected in the adult population. these data suggest that subclinical infection is common in primary school aged children. irish journal i of medical science , in to . / , in . . % ( ) were livebirths and . % ( ) were stillbirths. % ( ) were male and % ( ) were female. there was one twin pregnancy and singleton pregnancies. the mean birth weight was . (sd ; range to ). the mean length of gestation was . weeks. cad was associated with other major congenital anomalies in . %. the mean age of the mother at delivery was years (sd . years; to years). it was the first pregnancy in . % of mothers. . % ( ) had had a previous stillbirth. using population based data that includes live and still births leads to more accurate descriptio n of the epidemiology of cad. we examined the incidence of tb in the republic of.lreland and northern ireland in . we showed that there is a significant difference between the incidences of tb with tile republic having relatively more cases. this study was undertaken to describe the epidemiology of cad in the eastern health board region, using data from the dublin registry of the eurocat database of congenital malformations. congenital anomalies of diaphragm comprise mainly congenital diaphragmatic hernia and also include a small number of eventrations or absence of diaphragm. the sas programme was used for statistical analysis. from to , cases of cad were identified. the overall prevalence for to was . / , live and still births. the annual prevalence has, however, risen from . / , in , to . / mortality from asthma in ireland for the period - was examined using vital statistics reports, and compared with similar data for the uk. average age-(in -year intervals) and gender-specific rates were derived for three time periods ( - , - ,. - ) . for comparison between countries crude rates were adjusted to a european standard population by the direct standardisation method. age-specific mortality from asthma is < / , under years. this was consistent over the year period. there is some suggestion of decline in mortality in the - age group. the highest mortality occurs in elderly patients, with no indication of a temporal trend. age-standardised rates suggest that the overall mortality from asthma has not changed over the period covered by the study. comparing age-standardised rates between countries shows that for each time period asthma mortality is highest in ireland, with northern ireland second, followed by england/wales and scotland. it also appears that the trend in asthma mortality in the uk is downward at present, whilst that in ireland remains static. to what extent this is real, or related to inaccuracies in death certification in ireland or in the other countries is impossible to say from this study. the aim of this study was to audit the hiv requests in a large teaching hospital. we analysed the number, source and risk category stated on the hiv request forms over the twelve month period, from may through april, . all available information was entered onto an 'epi-info' database for subsequent analysis. we assessed age, sex, the actual source of requests, the rate of positivity by source, and the rates of positivity by age group. in one year we performed , hiv tests, with positives ( %). there was a slight male preponderance ( . %), over female ( . %). the bulk of requests came from the gum clinic ( %), while % came from the fertility clinic, and % from the drug dependency unit. most people were in the - age group. of note was the lack of requests from the antenatal clinic and termination of pregnancy service. positivity rates varied from . % through %, depending upon the source of the specimen. the rate of positivity also varied by the risk category indicated, with the highest rate ( %) among ivdu's. based upon known seropositivity rates among certain populations (e.g. patients undergoing pregnancy termination), it appears that this teaching hospital may not be reaching certain risk groups. staphylococcus aureus is a common organism found on skin and in the anterior part of the nose in % of the population. it is usually susceptible to semi-synthetic penicillins such as methicillin or flucloxacillin. methicillin is used in laboratory susceptibility tests and resistant staphylococci are referred to as methicillin resistant staphylococcus aureus (mrsa). mrsa organisms were first isolated in the s and numbers have increased dramatically since then. they are predominantly a hospital problem and can easily be spread from patient to patient and patient to staff members. in diagnosis of hepatitis a illness in a centre is based on detection of igm antibody to hepatitis a virus in serum. this presentation will display results of surveillance in the southern health board area over a period of ten years, - , and give detailed description of the most recent epidemic where over cases were diagnosed. monthly case notification varied from one to forty-nine cases over the years - . age frequency and geographical distribution will be characterised. from this data we can monitor the ongoing cyclical nature of hepatitis a illness and predict the next possible peak of the cycle. preventative strategies will also be presented. the nw section of n cork cca was chosen for this prospective observational study over the / school year. data was collected by completion of questionnaire by the pupils' teacher following injury. the study involved pupils in national schools. response rate was . %. a total of accidents occurred resulting in injuries, giving an accidentrate of . per hundred student-years;~ one accident per . pupils per year. peak incidence was the - age group. falls were the commonest cause of injury ( . %). / of accidents occurred in the playground. . % ( ) of accidents resulted in fracture. of . % (ll) of accidents which resulted in open wounds, gloves were used in one case when administering firstaid. . % ( ) of schools had an accident-recording policy. . % ( ) had a qualified first-aider on the premises and . % ( ) stocked disposable gloves. % ( ) of schools had a safety statement and one school had legal proceedings pending following accident-occurence. mandatory reporting of school accidents is required. school boards and health boards have a responsibility to understand the reasons for and nature of accidents in schools. however, the real issue is that of helping children to understand the nature of risk by exploring the safety of their own environment. ireland and lithuania are small countries at the periphery of europe with similar land area, population ( . million, . million) and number of births per year ( , ). the objective of this study is to compare the birth prevalence and mortality from major congenital anomalies between ireland and lithuania using the dublin eurocat register and the lithuanian national birth defect registry (lireca). both registries are population based and use multiple sources for case ascertainment. the dublin register covers approx. , births per year and because it contains years of data it can provide trend analyses. lireca is larger and covers the whole of lithuania (approx. , births per year) but it only began in . dublin eurocat had a high birth prevalence of neural tube defects in ( / , births), but by the s this had fallen to a level similar to that found in lireca ( . / , births). dublin eurocat had a higher birth prevalence of chromosomal anomalies . / , births compared to: lireca ( . / , births). lireca had a higher birth prevalence of cleft lip and/or palate ( . / , ) vs. . for dublin. congenital anomalies caused % of infant deaths in lithuania vs. % in ireland in . this collaboration will allow both registries to learn from each other with regard to case ascertainment methods, and where important differences in birth defect prevalence are discovered in depth analysis will be done to try to identify aetiological factors. irish journal of medical science registries, dublin had the third highest prevalences of down syndrome among live births ( . / , ), and the second highest number of liveborn down children ( ). registry data has been used for a number of specific research projects, including a study of survival of liveborn down children. the dublin eurocat register provides valuable baseline and trend data on the birth prevalence of all major congenital anomalies. it is also a potentially valuable resource for further aetiologic and clinical research, epidemiological and neuropathological studies suggest that abnormalities of brain development play a role in the aetiology of schizophrenia. it follows that trophic factors, such as neurotrophin (nt- ), known to have a role in brain development are candidate genes for this disorder. a recent japanese study presented evidence of an allelic association between a dinucliotide repeat polymorphism in the promoter region of the nt gene and schizophrenia in a population of schizophrenics compared with controlled. we have examined the frequency of the alleles at this polymorphism in caucasian schizophrenic patients and control subjects. in a test of all alleles together the patients and controls did not differ significantly in allele frequencies. however the male schizophrenics were more likely to have the allele previously found to be associated. eurocat consists of a network of population-based regional birth defect registries throughout europe, the objective of which is the epidemiological surveillance of congenital anomalies in europe. the dublin registry which is the third largest in europe, began in and covers all births in dublin, wicklow and kildare using multiple sources of ascertainment for birth defects. these include birth notification forms, death certificates, hipe and karyotyping records. from - , births were surveyed, including , stillbirths and , babies/fetuses with congenital anomalies were registered giving a prevalence rate of . per , births. of all the eurocat registries, dublin had the highest birth prevalence of neural tube defects for the period - ( . / , ), but this fell from almost / , to / , over the ll year period. of all the eurocat although the majority of children with acute lymphoblastic leukaemia (all) are cured following chemotherapy, the prognosis for patients in nd or subsequent clinical remissions (cr) remains poor. allogeneic bmt is associated with a % disease free survival but is often limited due to,lack of a hla identical sibling donor. this study was undertaken to investigate hemopoietic chimerism following mud bmt for all in nd or subsequent cr. clinical outcome was unknown at time of study. chimerism post bmt was assessed by amplification of polymorphic short tandem repeats using pcr.. patients have been evaluated from - months post bmt. patients exhibited donor chimerism (dc); in of these patients, dc persisted at all times post bmt and these patients remained in cr. in patients dc evolved to mixed chimerism (mc) and was predictive of subsequent relapse. patients exhibited stable low level mc (level of recipient cells <i%) and all remain in cr. patients showed initially high or progressive mc post bmt. although all can be treated with chemotherapy/bmt, this may only result in reduction of disease burden without eradication of the leukemic clone. persistence of low numbers of leukemia cells in patients in "apparent" clinical remission is termed minimal residual disease (mrd) and may allow relapse prediction. culture based studies were used to detect leukemic precursors in all patients. initial studies focussed on two semi solid assays. cells from patients with b precursor all at diagnosis were grown using either assay system but leukemic blast cell colonies were only detected for % of diagnostic samples. this prompted a change to a system with allogeneic stroma as a feeder layer to prevent apoptotic death of all precursors, stromal layers were grown from normal donor marrow in cm cell culture flasks. intrinsic stromal hemopoiesis was abrogated by removing all non-adherent cells after hours. when a confluent layer was obtained ( - weeks), it was detached and replated into wells of a -well culture dish. bone marrow cells from patients with all (diagnosis/remission) were cultured on stroma for days. contents of the wells were removed and stained with an anti-cdl antibody. subsequent analysis on a facscan (becton dickinson) allowed percentage recovery of b cells from the system to be calculated. samples have been cultured in this system and % cd + cell recovery evaluated. culture of further samples is required to test efficacy in the growth of all cells, particularly from remission samples. to elucidate the mechanism of inhibition of platelet aggregation by pyridoxal- '-phosphate(plp). platelet aggregation was determined using the chronolog aggregometer. phospholipids were extracted by the method of bligh & dyer ~ , separated by t.l.c., located by iodine vapour and extracted and analysed for phosphate (bartlett~ ~), plp ( ram) luas shown to inhibit aggregation of platelet rich plasma and of platelets resuspended in tyrode solution. analysis of the phospholipid fractions showed that aggregation caused a decrease in phosphatidyl choline, phosphatidyl ethanolamine and phosphatidic acid with concomitant increase in the lysophosphatidyl choline and lysophosphatidyl ethanolamine and in the combined phosphoinositide/phosphatidylserine fraction. inhibition of the aggregation by plp was associated with inhibition of these changes in phospholipid components. these results point to the direct effect of plp on phospholipase a ; an effect on phospholipase c is less clear and requires further study. ionised calcium plays a key role in platelet function "~. pyridoxal- '-phosphate (plp) inhibits platelet aggregation ~ ~. this study was carried out to detect an effect of plp on ca § mobilisation in human platelets. aggregation was determined on the chronolog aggregometer. ca § was determined using fluo- indicator. plp( mm) inhibited both platelet aggregation and ca § mobilisation induced by rdp or thrombin, pointing to a direct effect of plp on a receptor-mediated pathway for intracellular ca § mobilisation associated with platelet aggregation. plp( mm) potentiated both platelet aggregation and ca + mobilisation induced by the ca +-ionophore, bromo-r . this potentiation was not observed in the absence of extracellular ca +. here plp may exert its effect through direct or indirect inhibition of na+/h § exchange, leading to cytosolic acidification, which in the presence of extracellular ca + would facilitate exchange of h + for ca § mediated by the ionophore. since the establishment of the irish unrelated bone marrow registry, donors have donated, in , in and in for patients in ireland ( ), europe ( ) and u.s. ( ). ten have donated bone marrow and donated peripheral blood stem cells (pbsc). the volume of marrow harvested under g.a. varied from mls - , mls (mean mls/depending on patient weight). engraftment occurred in / marrow harvests and in the pbsc harvest. one patient who failed to engraft subsequently engrafted with pbsc from the same donor. six of the eleven patients are alive and well - months after transplantation. the most common complication suffered by donors was prolonged discomfort delaying return to work ( female). one of the two donors who donated pbsc following gcsf developed moderate thrombocytopenia which resolved spontaneously. all but one of the marrow donors indicated their willingness to donate again if requested, but the complications of this procedure suggest that pbsc collection with gcsf may be a more acceptable method of harvest for donors. however, the effects of gcsf need to be carefully monitored as experience in normal donors is limited. the lymphocyte homing receptor (cd ) is involved in lymphocyte adhesion to endothelial cells of high endothelial venules and lymphocyte exit from the blood. there is considerable evidence that it may be involved in haematogenous dissemination of malignant lymphoma. cd expression was determined in a series of consecutive patients with primary gastro-intestinal non hodgkins lymphoma who have been followed up for a period of up to ten years. the value of cd expression as a prognostic monitor was assessed and compared to staging, histology and other indices of prognosis. % of this series were cd positive. there was a significantly higher expression of cd ( %) among small bowel cases, compared with gastric lymphoma patients ( % for concern with an increase in the penicillin resistant s.pneumoniae to % in . sample size varied from to over the four years. continued surveillance of resistance rates for antibiotics used against respiratory pathogens is essential to determine probable efficacy for general practitioners and hospital clinicians. these data are provided annually by infoscan in its quarterly bulletin. the need for longterm in-dwellinq right atrial catheters (rac) in the management of patients with hiv infection is common. previously the insertion of rac's required admission to hospital with the procedure taking place in theatre. more recently the insertion of these lines in radiology units in both hiv+ and patients has been reported. we review our experience of rac insertion in aids patients on an outpatient basis in our radiology unit. all patients requirinq rac's between jan. ' and june ' were referred. patients' age, risk qroup, sex, cdc staginq, cd count, indication for insertion and past medical history were recorded. patients were followed up for immediate and delayed complication rates, disease progression, presence of neutropenia and duration of line insertion. patient tolerability was assessed informally by simple questionnaire. all nine catheters were inserted successfully in right atrium within hrs of request. there were no malpositions as can occur with blind insertion in theatre. all patients were outpatients and were discharged on the same day as the procedure was performed. there were no immediate complications in this series and infection rates were comparable with previous surgical series. there is reduced risk exposure to anaesthetic and surgical staff as previously, line insertion required blind direct cut down (venotomy). this initial review supports the advent of this day case intervention service for immunocompromised patients. unit, university hospital, wales. mycobacterium malmoense was first described in . it is now recognised as an opportunistic human pathogen which can be difficult to identify using standard-methods. in this study the nucleotide sequence of the s/ s ribosomal intergenic spacer region from five clinical isolates of m. malmoense has been determined, in order to develop a pcr based dna probe assay to facilitate the early identification of this organism. the dna sequence generated was compared with the intergenic spacer sequences of related organisms and a high degree of sequence homology was observed with mycobacterium avium. an oligonucleotide probe that specifically detects m. malmoense was designed and the ability of the dna probe to detect geographically distinct m. malmoense isolates was investigated. antibiotic audit of in-patients in the mmh is undertaken to evaluate both existing practices and the trends in treatment of infection. information on the influence of microbiology reports on choice of therapy is also recorded. the audit is undertaken by examining patient's records on the wards, and consulting relevant nursing personnel and medical staff. three hundred and forty four and three hundred and eight five patients were audited in and respectively. % received antibiotics in compared to % in . % of surgical patients received antibiotics for prophylaxis in and this rose to % in . the commonest infections treated were respiratory and urinary. duration of therapy for urinary infections fell from eight to five days and for respiratory infections an increase from six to eight days was noted. there was a % increase in switch from iv to oral antibiotics over the period. choice of antimicrobial agent was seen to be appropriate in the majority of cases. neisseria meningitidis isolates can be characterized by the use of epidemiological tools such as polysaccharide capsule serogrouping, class and outer-membrane protein serosubtyping, and multi-locus enzyme electrophoresis. we used these assays to study case isolates from individuals with deficiency of the late acting complement components (lccd). these individuals have increased susceptibility to recurrent meningococcal disease, but some disease manifestations may be less severe in the absence of complement activity. alternatively deficient subjects may become infected with less virulent organisms. sixteen n. meningitidis strains were recovered from cases with known lccd (all c deficiency) and were compared with routine case isolates (obtained from the same area, during the same time period). common serogroups, particularly b, predominated in both patient groups. however, rare serogroups were significantly more prevalent in deficient patients. sero-subtyping showed no significant differences. multilocus enzyme electrophoresis revealed the same genetic diversity in isolates from both groups. however, the et- complex (which is associated with epidemic disease) was found in % of the routine clinical isolates but in none from the lccd subjects. moreover, a highly significant finding we investigated antibodies to hev in sera from antenatal patients and consecutive samples sent to our laboratory for serological diagnosis of viral hepatitis. antenatal samples are readily available, and represent the seroprevalence of hev in the general population in ireland. the viral hepatitis screens were negative for hepatitis a and b. antibodies to hepatitis c were detected in of the samples. two ( . %) of the antenatal patients were igg anti-hev positive. four ( %) of the samples sent for viral hepatitis screens had antibodies to hepatitis e. our results indicate a low prevalence of hepatitis e in ireland with figures similar to those in other european countries. a study was undertaken to confirm the reliability of random amplification of polymorphic dna (rapd) as a fingerprinting method for the gram negative organism, enterobacter cloacae. previously, a group of seven e. cloacae isolates, collected from an intensive care outbreak of infection with this organism, and two control strains, had been investigated with rapd. the pcrbased fingerprinting method was readily applied to this organism providing sufficient discrimination to permit differentiation between strains with identical biochemical profiles and antibiograms. subsequently these isolates have been further characterised by a second well established genotypic fingerprinting method -pulsed-field gel electrophoresis (pfge). the bacterial strain to strain differentiation established by rapd analsis was independently confirmed using pfge, thus establishing the reliability of rapd as a fingerprinting method for e. cloacae. bovine herpes mammillitis (bhm) is an ulcerative disease of the teats and udder which usually occurs in recently calved heifers and cows. it is caused by bovine herpesvirus which is more closely related to human herpes simplex virus than to any bovid herpesvirus. to assess the usefulness of serology as a diagnostic/confirmatory method, , sera from unaffected cattle and samples from outbreaks of bhm were examined for antibodies using a serum neutralisation test incubated at ~ the presence of specific igm in paired samples was detected by titre elevation in the presence of complement. low titred antibody (gmt ) was detected in % of the national herd. by contrast, in investigating the outbreaks, high titred antibody (gmt ) was detected in / single samples and in all herds examined. much higher antibody titres (gmt ) were present in cattle with bhm compared to their unaffected herd-mates (gmt ). high igm and total antibody titres were detected in the first of paired samples (gmt : ), demonstrating that antibody concentrations had peaked early and had began to decline quickly (gmt in second samples). the results demonstrate that a clinical diagnosis of bhm can be corroborated by the detection of high titred total antibody or igm, often in the earliest samples collected. fungal infections are a major cause of morbidity in critically ill surgical patients? we assessed the incidence of candidiasis in a general surgical itu, the characteristics common to patients with postoperative candidiasis 'and the efficacy of regular surveillance cultures in providing early detection. all surgical patients who remained in itu for more than hours were included in the study. the presence of established risk factors for the development of candidiasis was noted. twice weekly urinary surveillance cultures were taken. blood cultures were performed where clinically indicated patients were studied. patients developed urinary candidiasis ( %), of these developed a candida septicaemia. distinguishing candidiasis patients from those with bacterial' sepsis is a difficult clinical problem. long hospitalisation and parenteral nutrition, multiple operations and antibiotics are well known predisposing factors to candidiasis. similar predisposing factors were found to be significant in the present study also. regular urinary surveillance cultures may be useful in the early detection and management of these patients. classical swine fever (csf) is a peracute to chronic disease of domestic pigs and wild boar which continues to occur in extensive outbreaks in the eu. ireland is at risk of importation of csf virus (csfv) via live pigs or meat products. isolation of csfv is currently performed in cell cultures grown cn flying coverslips, followed by virus detection using fluorescent antibody staining. however, this method is unsuitable for examining large numbers of samples at multiple dilutions, as is required when investigating a suspected outbreak of a notifiable disease. a method using microtitre cell cultures and immunoperoxidase staining was developed. this was evaluated by spiking normal porcine organ homogenates and serum with csfv and measuring virus recovery. virus was detected hours after cell culture inoculation, with peak titres being reached in hours. virus concentrations recovered from spiked serum were almost as high as from control samples, but a hundredfold ( log~o) loss of virus activity occurred in the spiked organ samples. the presence of intracellular lipid or lipoprotein inhibitors of measles, dengue, herpes simplex and rabies virus has been reported previously. it is possible that these substances are widespread in nature and adversely affect attempts at virus isolation. breast carcinoma is a leading cause of death in women. endometrial cancer is the commonest genital tract cancer with a lower mortality especially because it can be diagnosed at an earlier stage. tamoxifen, a synthetic non-steroidal, anti oestrogenic drug is widely used as adjuvant therapy for breast cancer in post menopausal women with positive oestrogen receptors. current trials are exploring the use of tamoxifen as a prophylactic agent in women at high risk of developing breast cancer. lately there has been an accumulation of reports suggesting a possible association between tamoxifen treatment and induction of endometrial pathologies such as endometrial hyperplasia, polyps and carcinoma. this presentation is part of our study, aiming to evaluate the oestrogen and progesterone receptor status by using microwave antigen retrieval technique and subsequent avidin -biotin peroxidase complex method in these endometrial lesions, and the possibility, if any, of predicting which of the tamaxifen treated patients will develop such an endometrial pathology. we carried out the receptor assay in cases, of which had a history of tamoxifen therapy. in our short study, the receptor status in the endometrial lesions does not show any relationship with the history of tamoxifen therapy, but status was related to grade of tumour in all cases. assess: the incidence of radionecrosis, natural history of the process of radionecrosis and results of surgical intervention by various reconstructive techniques. a total of patients were studied and the natural history of the process of radionecrosis showed two clinical patterns; immediate (primary) radionecrosis and late (secondary) radionecrosis. the incidence of primary radionecrosis corresponded well to reported levels of approximately %. the incidence of secondary (late) radionecrosis however showed an incidence approaching %. reconstruction with split skin grafts were universally unsuccessful and our experience showed the effectiveness of fasciocutaneous flaps in the surgical management of this difficult condition. an early combined audit between our departments has stopped the practice of radiotheray to the lower leg for common skin malignancies. breast cancer is the most commen malignancy in women, affecting one out of every nine women some time in their lifetime. the most effective treatment for breast cancer today is surgery, either alone or in combination with chemotherapy, radiotherapy or both. restoring a natural appearing breast with few scars and minimal secondary deformity of the donor site is a challenge. tram flap is popular today because it adds bulk to the chest wall and is autologous. reconstruction with free tram flap compared with the pedicle conventional tram flap is more reliable. a year old women who had had bilateral mastectomies in the past, and was on the waiting list for breast reconstruction, on arrival was found to have bilateral local recurrences. she underwent wide excision of both mastectomy scars, followed by bilateral free tram flap operation for chest wall reconstruction. the case and the result will be discussed. all.patients receiving radiotherapy for lower leg lesions between and in exeter following recalibration of radioactive sources, were studied for a period of - years to be confused with basalioma, spinocellular epithelioma, and malignant melanoma. a histologic diagnosis also may prove difficult because of a similarity to certain forms of malignant lymphoma, metastatic pulmonary small cell carcinoma, malignant melanoma and primary extraskeletal ewing's sarcoma of the dermis. this report reviewed three clinical cases treated in this department, with a view towards obtaining early diagnosis and better prognosis. lady's hospital for sick children, crumlin, dublin. the aim of this retrospective study is to review causes and outcome of acute abdomens in a rural hospital in sierra leone where facilities were limited. the surgical service was provided by western trained physicians without postgraduate surgical training and by experienced theatre nurse aids with little formal training. all cases of acute abdomen hospitalised from oct ' until oct ' who required surgery were identified by review of theatre books, ward records and patients notes. epi-info was used as a database and for statistical analysis. cases, % male, %< yrs, were identified. operative diagnoses included; ectopic pregnancy (n ), strangulated hernia (n ) of whom required bowel resection, incarcerated hernia (n ) appendicitis (n ), normal appendix (n ), uterine rupture (n ), perforated ulcer (n ), pelvic or tubal abscess (n ), volvulus (n ), primary bacterial peritonitis (n ), obstruction due to adhesions (n ), traumatic bowel injury (n ), intussusception (n ), and other miscellaneous. % survived to discharge after a median post operative stay of . days (range - ). of deaths % occurred in the first days. predictors of poor outcome included ileal perforation, usually due to typhoid, and resection of bowel in strangulated hernia. these results show that acute abdominal surgery can be done at district level in poor countries using limited facilities even by staff without extensive surgical training. the range and nature of pathology differ from western series in the high incidence of ectopic pregnancies and strangulated hernia maltings, prospect row, cork, ireland. *department of biomedical sciences, regional technical college, rossa ave., bishopstown, cork, ireland. measurements of serum enzyme patterns are important diagnostic indicators of liver damage: enzyme measurements most commonly used in this way include alkaline phosphatase, alanine and aspartate aminotranferases and y-glutamyl transpeptidase. it has been suggested that glutathione stransferase (gst) may be a better diagnostic enzyme for liver damage in a variety of clinical conditions. ~ ) in this present study, we have studied the levels and isoenzyme patterns from groups of patients diagnosed as suffering from chronic active hepatitis (group , n= ), cholestasis (group , n= ) and cholestasis complicated by active cell damage (group , n= ) . although the standard liver test enzymes are elevated in the second group, gst activity is within the reference interval for this enzyme ( . u/mg, n• while significantly elevated in ihe other groups. hepkit tm elisa assays indicate that alpha class gsts are the predominant isoenzymes in these samples. mu class isoenzymes were detected using a qualitative mukit tm elisa assay in % group and ~ group samples while no group samples gave positive results for these enzymes. alpha class gsts were expressed in % group , % group and % group . these results probably reflect gst polymorphisms in the human population. based on these measurements, we suggest that low levels of gst, accompanied by elevation in the standard liver test enzymes may help to distinguish cholestasis from cholestasis complicated by active cell damage. malignant hyperthermia (mh) is a serious disorder, dominantly inherited, which results in muscle contracture and hyperthermia, provoked by volatile agents and muscle relaxants commonly used in anaesthesia. there are few reports of muscle biopsy findings in patients undergoing investigation for mh. whether a specific "mh myopathy" recognisable by histological criteria exists remains uncertain. we studied muscle biopsies from patients undergoing investigation for possible mh for histological/histochemical abnormalities~ seventy eight biopsies were normal, showed some myopathic features. when compared with results of muscle contraeture tests using caffeine and halothane, there was no direct relationship between contracture test results and histological findings. however, a higher incidence of myopathic features was found in mh probands i.e those who had experienced a clinical episode of hyperpyrexia, probably reflecting prior muscle damage. a few biopsies showed other muscle pathology e.g. mitochondrial myopathy, thomsen's disease. eight large kindreds within the group were studied in detail. specific histological features tended to be found within individual families e.g mitochondrial excess, fibre type distribution patterns. the results suggest that there are no specific "malignant hyperthermia myopathy" biopsy features, but that biopsy is often abnormal in probands and may be useful in indicating other muscle disease. university hospital, cork, ireland. type lb hepatitis c virus (hcv) is said to be associated with more severe progressive liver damage than infections with other types. we have studied bile duct epithelium in a cohort of women with longstanding hcv infection. needle biopsy (menghine) of the liver was performed under ultrasound control. specimens were stained with haematoxylin and eosin, haematoxylin and van gieson, periodic acid-schiff and peri's prussian blue stains. histological features were assessed independently by two histopathologists (m.s., c.d.). immunohistochemistry using ae /ae anti cytokeratin monoclonal antibodies (icn immunobiochemicals) by the avidin/biotin horse radish peroxidase method was carried out in of the biopsies. normal control liver biopsies were used. antimitochondrial antibodies were absent in all cases. the ratio of bile ducts to hepatic arteries were significantly higher ( . + . ) in the hcv group compared to normal controls. absolute bile duct epithelial cell proliferation was present involving single bile duct epithelial cells, cords of cells and formed bile ducts within portal tracts, along limiting plates and hepatic septa. bile duct damage was not a consistent finding in the study. conclusions. this study shows conclusively that bile duct epithelial proliferation is a significant feature of type ib hcv hepatitis. while bile duct damage is a feature of hcv infection a more significant finding in this study was bile duct epithelial proliferation. the response was compared to that seen with a ii infused during nitroprusside administration at a dose designed to give a similar dilator response to phentolamine. a ii ( . , & pmol/min) was infused alone and then together with sodium nitroprusside ( ag/min) and phentolamine ( ag/min) in eight healthy volunteers. forearm blood flow was measured by strain gauge plethysmography. the percentage reduction in forearm blood flow produced by all pmol/min in the phentolamine pre dilated vascular bed was significantly lower than that seen in the sodium nitroprusside pre dilated forearm bed ( . _+ . v . _+ . %; p= . ). comparison of the rate of change of blood flow in response to quadrupling doses of a ii during blockade of ct irish journal of medical science receptors with phentolamine and during n i t r o p r u s s i d e administration was calculated from the mean slope of the dose response curves. the mean slope during n i t r o p r u s s i d e administration (- . • was significantly greater than that during blockade with phentolamine (- . -- . ) (p= . ). conclusions. we conclude that a significant part of the vasoconstrictive action of exogenous a ii on forearm resistance vessels in man is sympathetically mediated. initially, ( / ), admission hypokalemia was associated with diuretic therapy ~(ratio, diuretic-associated to non-diuretic = . : ) admission with diuretic-associated hypokalemia (dah) was caused or precipitated by hypokalemia (h) in %. a prescribers' education programme emphasising use of frusemideamiloride reduced significantly h admissions within two years (p=< . ). this new situation indicates highly significant changes in dah/non dah admissions with h: most h admissions are not now related to diuretics; in dah, frusemideamiloride admissions have higher k levels ( . vs . mmol/ ) and less morbidity from equal k levels; other drugs e.g. corticosteriods, bronchodilators are key precipitants in % of admissions with frusemide-amiloride dah; admissions with frusemide-amiloride dah are no longer caused by h alone. we conclude that frusemide-amiloride has led to beneficial chanqes in incidence and profile of dah in hospital admissions. we ~ ) have shown that oral antibiotic therapy has advantages over intravenous in terms of duration of hospital stay, ease of administration and cost in the treatment of mild to moderate community acquired lower respiratory tract infections (lrti). however the vast majority of patients admitted to our hospital with this diagnosis receive intravenous antibiotics. we sent all doctors a copy of our previous report t~ with the recommendation that oral antibiotics be used for lrti except in severely ill, immunocompromised or patients unable to tolerate oral therapy. we compared the use of intravenous to oral antibiotics pre and post-distribution of the recommendations. no. while initially our recommendations produced a significant (p < . ) increase in the use of oral antibiotics, over time, there was a drift back towards baseline levels. additional methods of continuous intervention are required to achieve long term effects. the general medical services (gms) scheme provides medicines free of any charge to approximately % of our population. we looked at prescribing of ulcer-healing agents and analgesics between and to determine if the reintroduction in of alginates/antacids and certain analgesics had any impact on histamine h antagonist/omeprazole and nonsteroidal anti-inflammatory (nsaid) prescribing respectively. data was obtained from the gms lists of top drugs each year. post re-instatement, alginates/antacids were used extensively - , of , ( %) ulcer-healing items in ; , of , ( %) by -but histamine h antagonist prescribing continued to rise, implying no substitution occurred, and fell only in when prescribing incentives were introduced. omeprazole use rose from , items in to , in , possibly indicating consultant/hospital influence"~. prior to the re-introduction of paracetamol, its combinations and dextroproxyphene in , the alternative analgesics were nsaid's, dihydrocodeine or morphine. nsaid's comprised . m ( %) of . m analgesic items dispensed in and rose to . m items in , before falling to . m in ( % of . m items). the less expensive reintroduced agents accounted for the rise in total analgesic use. prescribing changes were temporally more related to introduction of budgetary incentives than to the re-introduction of therapeutic alternatives and prescribers appear to use such items in addition to, not instead of more expensive options until there is good incentive to change. spontaneous reporting of adverse drug reactions (adr's) by yellow cards is the most widely used surveillance system for the safety of drugs in clinical practice, however, fewer than % of adr's are reported. we surveyed hospital doctors and of respondents, over half ( %) had never reported and of reporters, % had just one adr. just % of respondents knew all the ndab reporting criteria. seriousness of the reaction was the most important reason for reporting while unavailability of yellow cards was considered the most important deterrent. having previously identified unavailability of yellow cards as a constraint to reporting ~ ~, we made yellow cards prominently available in wards and clinics and for three months inserted one upon admission into patients' charts. prescribers were reminded regularly of their availability. during the three months of interventionalactivity, the ndab received adr reports from this hospital compared with in the preceding three months. cessation of visual and verbal reminding was followed by a drop to reports in the next five months despite continued availability of yellow cards. clinicians appreciate that adr's should be reported but have poor knowledge of reporting criteria. they are responsive to intensive intervention but availability of yellow cards alone is insufficient to ensure reporting. the ndab must enhance awareness of the need to report and educate doctors regarding reporting criteria while the profession must participate actively in ensuring the safety of medicines. vol. , supplement no. irish journal ~) medical science study now shows higher levels ( . _+ . vs . _+ . umol/ l, mean _+ sd, p < . ) in patients on single drug therapy (n = ) as opposed to combined (n = ). as several antihypertensive drugs had been shown to protect low-density lipoprotein (ldl) against oxidation promoted by copper ions in vitro, we investigated the relationship of antihypertensive drug therapy to copper-induced oxidation of ldl in patients with essential hypertension. we compared two groups (n = ) of sex and age matched patients treated either by combined antihypertensive drugs or by a single antihypertensive drug. the major natural antioxidants such as plasma vitamin c and e, vitamin e in isolated ldl, erythrocyte vitamin e and erythrocyte glutathione were measured and there was no significant difference in respect of these factors between the two groups. the onset and progression of copper induced ldl oxidation was assessed by measuring the lag phase of production of conjugated dienes in an isolated ldl solution with continuous monitoring spectrophotometry at nm through hours. in patients on combined antihypertensive drug therapy, there was a significantly increased lag phase when compared with single antihypertensive drug treated patients ( . _+ . vs . _+ . minutes, mean _+ sd, p < . ) indicating the increased resistance of ldl to oxidation. our data suggests that in hypertensive patients, there may be less oxidative damage and increased resistance to further damage in those on combined drug therapy. high activity of erythrocyte sodium-lithium countertransport (slc) system is associated with essential hypertension. it is a genetically-determined trait and has been reported to be stable over prolonged periods in individuals. however, it is becoming increasingly evident that the transport system is susceptible to modulation, both acutely and chronically, by various factors. in this study, we observed temporal variatio s in slc over a period of ten hours ( . - . h) in healthy volunteers. the activity of the transporter in ram sodium chloride at mid-day was . + . mmol/l cell. h (mean _ s.e.) and was higher than that in the morning ( . _+ . ; p < . ). kinetic characterisation of the transporter indicated that its affinity for external sodium, km, was unaltered during the experimental period. however vmax was maximum ( . _ . mmol/ cell h; p < . ). its value in the evening ( . + . mmol/ cell h) was lower than at mid-day (p < . ) but higher than in the morning (p < . ). changes in slc vmax correlated with neither the correspondung changes in plasma cortisol nor that in aldosterone. however, they correlated significantly with those in plasma renin activity (p < . ); although the regression analyses data indicate that changes in renin activity do not wholly account for the observed changes in the vmax of the transporter (r = . ). we conclude that changes in slc activity occur during the day in healthy volunteers and is partly due to associated changes in plasma renin activity. lung disease is the major cause of morbidity and mortality in cystic fibrosis (cf). lung destruction results from chronic pulmonary inflammation, characterised by a massive influx of neutrophils from the bloodstream. recently, hyper-expression of the b -integrin (cd ) adhesion molecules on circulating neutrophils has been observed in patients with adult respiratotf distress syndrome (ards). it is suggested that this may contribute to the excessive influx of neutrophils to the lung observed in ards. to assess whether similar mechanisms might be operating in cf, we compared su]'face expression of cd on circulating neutrophils from cf patients and control subjects of similar age and sex. peripheral blood leukocytes were labelled with fitc-conjugated antibody to cd and analysed by flow cytometry. results were calculated as the mean fluorescence intensity (mfi) of cd -labelled neutrophils. no difference in surface -integrin expression on circulating neutrophils between cf patients (mfi = . • and control subjects (mfi = . _+ . ) was observed. only one cf patient displayed an mfi value above normal range (i.e. > mean control value + sd). thus, in cf, over-expression of b -integrins on circulating neutrophils does not seem to contribute to the excessive accumulation of neutrophils in the lung. this work was supported by the cystic fibrosis association of ireland. week treatment period (pre-treatment: . • mg/ml; posttreatment: . • mg/ml, p< . ). this was not accompanied by a similar decrease in sputum levels of either il- or ne activity, although a downward trend in ne activity was noted (pre-treatment: • launits; post-treatment: • launits, p= . ). these results indicate that short-term treatment with nebulised dnase has little effect in attenuating underlying inflammation in ce this work was supported by the cystic fibrosis association of ireland. extrinisic allergic alveolitis (eaa) and sarcoidosis are two granulomatous lung diseases characterised by an expansion of lung t-cells. in active sarcoidosis an increase in cd relative to cd t-cells is seen, resulting in a raised cd /cd ratio. in eaa the increase in both cd and cd t-cells is similar. recent studies indicate that interleukin- can induce the transformation of cd to cd t-cells via a cd +cds+ intermediate. by assessing bal samples from eaa and sarcoidosis patients for the presence of cd +cd + t-cells, this study set out to examine whether a difference in the level of cd to cd transformation might contribute to the different pattern of t-cell expansion observed in these two diseases. bal cells recovered from eaa (n= ) and sarcoidosis (n= ) patients were double labelled with fluorescent anti-cd and anti-cd antibodies and analysed by flow cytometry. paired samples were labelled with anti-cd (pan t-cell) antibody and the percentage of cd + cells that were cd +, cd + and cd +cd + calculated. the percentage of cd +cds+ cells was found to be significantly higher in the eaa group compared to the sarcoidosis group (eaa = . • sarcoidosis = . • p< . ). these results suggest that differences in the level of transformation of cd + to cd + cells might indeed contribute to the differential t-cell expansion observed in eaa and sarcoidosis. although inhaled corticosteriod therapy is of undoubted benefit in the management of asthma, dysphonia is a recognised sequela. this study was designed to examine longitudinally the effect of inhaled steroids on the voice and vocal cords of newly diagnosed and previously untreated asthmatics. twelve subjects were recruited and underwent voice and vocal cord assessment prior to and months after starting inhaled steroid treatment. each. patient acted as their own control. the assessment consisted of ) rating dysphonia using a visual analogue scale, ) acoustical analysis of the voice and ) videostroboscopic examination of vocal cord activity. five subjects have been fully assessed. before treatment had normal voices and was mildly hoarse. vocal cord pathology was noted in subjects. after months of inhaled steroids dysphonia was noted in subject, no voice changes in subjects and an improvement in the voice of the other subject were seen. vocal cord bowing was found in subjects, improvement of vocal cord pathology and no vocal cord changes were seen in and subjects respectively. the significance of these findings and the results from other subjects will be discussed. video-assisted thoracic surgery appears to be a viable alternative to conventional thoracotomy when surgical management of spontaneous pneumothorax is required. apical pleurectomy and bullectomy can be performed with this approach thus sparing the patient the morbidity associated with formal thoracotomy. using video-assisted techniques, we have performed procedures on patients, between january and january , including patients with spontaneous pneumothorax. the male : female ratio was . : . age ranged from to (mean . ). the tw o main therapeutic strategies were apical pleurectomy in all patients ( ) and blebectomy/ bullectomy in ( %). there was one hospital death (hospital mortality = %) in an elderly patient who developed multiorgan failure post bullectomy and persistent air leak. one patient ( %) required conversion to formal thoracotomy. mean postoperative chest tube drainage was . days and mean postoperative hospital stay was . days. there has been no recurrence of pneumothorax in this series. our evidence indicates an expanding role for video-assisted thoracic surgery which is now an option in the management of patients with spontaneous pneumothorax. renal functional reserve (rfr) is the normal increase in renal blood flow (rbf) in response to a protein load, which may be diminished in severe copd. we investigated this using duplex ultrasonography in stable hypoxaernic copd pts: and mild copd controls. mean (sd) pao was . ( . ), paco . ( . )kpa, fevi . ( . ) in the hypoxaernics, and pao . ( . ), paco . ( . ) and fevi . ( . ) in controls. i / pts. were hypercapnic. the pulsatility index (p ) (an index of rbf) was measured with an acuson scanner at baseline and , , and rains, after a g steak. the pi should decrease with increasing rbe results: the pi fell normally in the controls, was unchanged in the normocapnic pts., and rose in hypercapnics. we conclude that there is evidence of sub-clinical renal impairment in pts. with severe copd, which is more marked in hypercapnics. we investigated the immunopathological profile of the proximal airways in five patients ( female, male) who died from severe asthma. blocks of tissue from the second generation right middle lobe bronchus were obtained within hours of death and flash-frozen in liquid nitrogen. double immunofluoresence and immunoperoxidase techniques were performed using monoclonal antibodies directed against cd , cd , cd , rfd , rfd , eg and eg surface markers. frozen biopsy sections of human palatine tonsil served as positive controls. each section had a negative control (buffered saline) and an irrelevant control (monoclonal antibody to b cells). airway inflammation was characterised by an epithelial mononuclear cell infiltrate on h&e staining. there were significant increases in macrophages (predominantly of the rfdi+, rfd -antigen presenting cell subset), t cells (the majority expressing cd : suppressor/ memory cells) and eosinophils with equal eg and eg expression. we conclude that: fatal asthma is associated with increased numbers of suppressor/memory t-cells, antigen presenting macrophages and activated eosinophils present in the bronchial wall; fatal asthma results from uncontrolled peribronchial inflammation. it has been suggested that regular inhaled beta agonists may be harmful in asthma. we studied patients with asthma in a prospective, randomised single-blind, single-dummy, threeperiod crossover trial comparing placebo ( puffs tds), salbutamol ( mcg tds) and oxitropium bromide ( mcg tds) for days each. computerised spirometry.and bronchial reactivity to histamine were obtained on entry and after each treatment period. symptom scores, use of rescue bronchodilator and peak expiratory flow rates were recorded daily. there were no significant differences in bronchial hyperresponsiveness during salbutamol, oxitropium or placebo treatment periods. there were no significant differences in baseline fev , symptom scores or morning and evening pefr between treatment groups. the use of rescue bronchodilator was significantly less in the salbutamol period compared to placebo. in conclusion, regular treatment with inhaled salbutamol or oxitropium bromide is not associated with deterioration in asthma control in patients on concommitant inhaled irish journal of medical science corticosteroid therapy. our data suggest that although current concerns about inhaled beta agonists may be misplaced in these patients, regular bronchodilator use does not confer any advantage over intermittent therapy. since the publication of international guidelines for asthma management there has been considerable interest in audit in asthma. to date there has been no community audit of asthma management in ireland. the asthma society of ireland therefore undertook a community based survey through irish pharmacies over days beginning th may . pharmacies were selected to represent the national demographic profile. all prescriptions for asthma medicines were eligible for inclusion. questions were delivered by the pharmacist to define patient details and overall management of disease in the previous year. to assess their understanding of the different types of treatment, patients were asked to identify "reliever" or "preventer" from a series of photos. of patients had complete data. the high loss was due to a surprising % of prescriptions being collected on behalf of patients. % of patients held medical cards. % of patients were managed by their gp alone with % having combined gp/specialist care. % were taking preventative therapy. whereas % of patients had taken inhaled steroids in the past year, an amazing % had at least one crash course or oral steroids over the same period and % were on regular oral steroids. % of patients had their peak flow measured at some time but had never had their inhaler technique assessed. of those on preventative therapy misidentified a reliever as a preventer. of the patients overusing beta-agonists, only were not on regular preventative therapy. % were using a nebuliser regularly. % of all patients missed weeks off work or school. % of patients were happy with their understanding of their illness. in conclusion, patients were generally well informed but had fears about inhaled steroids. a high proportion of patients were taking oral steroids indicating sub optimal control. beta-agonist overuse was relatively uncommon. it was disappointing that so few patients had their technique checked. strategies to deal with these deficiencies will be discussed. we investigated the pre-emptive effect of high dose systemic opiates over a hour postoperative period. asa patients undergoing abdominal hysterectomy, using standardised premed. and ga, were studied. a randomised double-blind design was employed -group a received alfentanil ug/kg over ten minutes beginning minutes before incision; group b received alfentanil ug/kg over minutes beginning minutes after incision. in recovery mg iv boluses ot morphine were administered every minutes until comfortable. pca delivered iv morphine was used for postoperative analgesia. vas pain rating at rest and on movement and morphine consumption were recorded at , , , & hours. vas pain scores and pca morphine consumption were analysed using -way anova. demographic data was similar in both groups.the vasr scores were similar throughout. the vas m scores were higher in group a at and hours. the results demonstrate similar morphine consumption over the initial hours. group a demonstrate less morphine consumption between - hours than group b conclusion: this survey provides authorative figures on the incidence and mortality of nosocomial pneumonia in irish i.c.u.s and these results concur closely with european data. gram positive and polymicrobial infection may be commoner than traditionally believed. despite the difference in utilization of sdd the incidence of pneumonia is the same. * european nosocomial infection survey. ambulation r evaluation of detailed, clinical neurological recovery after spinal anaesthesia has not been reported. we examined men (mean age years, range - ), undergoing transurethral resection of the prostate (turp). each patient had a full clinical neurological examination of the lower limbs pre-operatively, and at minutes, , , , , and hours postoperatively, by the same abserver. all patients received mls plain bupivacaine ( . %) via a spinal needleat l / or l / . median time (hours, interquartile range) to recovery of motor power sufficient for walking ( . ( . - . )) was longer than for complete recovery of proprioreception ( . ( . - . , vibration sense ( . ( . - . )) and spinothalamic sensory ( . ( . - . )) modalities. these results suggest that elderly males may safely be allowed to ambulate after spinal anaesthesia, when lower limb motor function has fully recovered. the contrasting outcome in epidural studies may be related to endocrine and age-related factors. a prototype electrotransdermal device was employed in a clinical setting, examining delivery of hydromorphone. patients were women following surgery receiving analgesic medication by patient-controlled analgesia. a randomised double blind placebo controlled study examined the reduction in pca morphine use by electrotransdermally administered hydromorphone. hydromorphone was delivered from a circular gel of area cm , containing mg hydromorphone hydrochloride. the current was . ma/cm for hour followed by . a/cm for hours. the patch was removed and replaced by a fresh one at hours. followi'ng a log of about six hours, hydromorphone administered by this method caused a significant reduction in morphine use. the mean total amount of morphine was reduced by % by the concomitant administration of hydromorphone. tolerability was good. one patient in the active group had erythema under both the active and the passive gels at hours. the results support a clear morphone-sparing effect of concomitantly administered hydromorphone. the application of a small electric current can considerably enhance transdermal delivery of opoid analgesics: initially resulting in rapid delivery, thereafter providing sustained delivery until patch removal, whereupon there is a rapid cessation of delivery and a rapid fall in blood concentrations there is growing acceptance of spinal anaesthesia for ambulatory surgery. recently, ambutatory epidural analgesia was associated with significant proprioreception impairment, even with normal motor power, possibly undermining safe (nmb) drugs and peripheral nerve stimulators (pns), post anaesthesia residual paralysis remains a problem ~ we studied the genesis of this problem. following ethics committee approval and informed consent, we studied patients having general anaesthesia involving the nmb drug atracurium. the myograph was used and response to continuous train-of-four (tof) stimulation at the ulnar nerve recorded. residual paralysis at extubation, defined as tof < . , was determined. also, interval from last atracurium to reversal, duration of surgery and whether a pns was used by the responsible anaesthetist. the responsible anaesthetist was blinded to the myograph recording and routine anaesthesia care was independent of the research. mann-whitney u test was used for statistical purposes. residual paralysis was found in % at extubation. adequate reversal was significantly associated with a greater duration of surgery, a longer interval from last atracurium to reversal and spontaneous recovery at the time of reversal. use of a pns was inversely associated with years of anaesthetic experience and had no effect on the incidence of residual paralysis. the authors acknowledge support from the health research board. chronic alcohol intake may increase the induction dose of propofol ~'. the clinical endpoints and electroencephalographic (eeg) changes during induction of anaesthesia are well knowfi ~ , ). the aim of this study was to compare the induction dose of propofol between drinkers and non-drinkers using clinical and eeg endpoints of anaesthesia. we studied male patients before surgery. patients were divided into drinkers (> units alcohol/week,) and non-drinkers ( units/week,). anaesthesia was induced by propofol at a rate of mls/hour. the dose requirements of propofol to achieve loss of verbal contact, loss of eyelash reflex, and loss of ability to hold a ml. syringe were noted. the eeg was monitored (lifescan, diatex, california), and the dose of propofol and blood propofol concentrations required to achieve burst suppression was recorded. data were analysed by analysis of variance and dunnetts test. baclofen is an effective antispasmodic agent, structurally similar to the inhibitory transmitter gaba. it functions by binding to gaba receptors in the spinal cord and thalamus, inhibiting mono and polysynaptic reflexes. this suppresses the abnormal response to muscle stretching or cutaneous stimulation that leads.to spasticity, lntrathecal baclofen has been used for relief of spasticity associated with disseminated sclerosis and spinal injury. a previously healthy year old male sustained accidental hypoxic brain damage. he developed severe spasticity in all iimbs. minimal stimulation caused paraoxysmal increase in flexor tone, causing total body rigidity. in adolescence he developed marked kyphosioliosis. the degree of spasticity precluded surgical correction due to the risk of rod extrusion. a trial of intrathecal baclofen reduced spasticity sufficiently to allow surgical intervention. spinal fusion was performed from t to l . lntra-operatively an intrathecal catheter was implanted, tunnelled and connected to a medtronic implantable infusion pump. an intrathecal baclofen infusion was increased from an initial rate of . mg/ hours to . mg/ hrs. over a day period. spasticity and range of movement markedly improved, with total cessation of the intermittent paroxysmal body rigidity. baclofen therapy will be continued indefinitely conclusion: continous baclofen infusion via an implantable pump is not only useful in treatment of intractable spasticity, but also permitted corrective orthopaedic surgery, thus halting progression of the skeletal deformity and preventing development of respiratory compromise. pre-oxygenation prior to induction of anaesthesia, a time associated with stress ") , is becoming routine in many hospitals. it is no longer used solely prior to rapid sequence induction. clear pvc anaesthesia masks, some scented, are available as an alternative to the traditional rubber mask. the aim of this study was to assess and quantify patient preference for the type of face mask used for preoxygenation. in the induction room, prior to induction of anaesthesia after baseline monitoring and intravenous access had been established, asa class i-iii patients aged - years were randomly allocated to preoxygenation using a bains circuit with either a standard black rubber face mask or a king systems' "fresh scent" clear pvc mask. after two minutes they were asked to assess the acceptability of the procedure using a mm visual analogue scale (vas). the process was then repeated using the second mask. patients were then asked if they had a preference for the type of mask used. patients preferred the "fresh scent" while preferred the black rubber face mask. overall from the vas patients found patients undergoing cardiac surgery are often awake on arrival in the anaesthetic room. prior to induction of anaesthesia they are pre-oxygenated. this is recognised as a time of increased stress. stress should be avoided thus preventing increased myocardial work and oxygen demand with possible risk of ischaemia t~). the aim of this study was to determine whether patients undergoing open cardiac surgery had a preference for the type of face mask to be used for pre-oxygenation and during induction of anaesthesia. patients, asa ii-iv, aged - yrs scheduled for cardiac surgery were visited pre operatively. the practice ifi the anaesthetic room was explained and that we were studying face mask preference. the patients were presented with a black rubber mask, a kings systems' clear pvc "fresh scent" (mint) and strawberry scented masks. a brief description of each mask was given in random order. patients were asked to breathe through the masks and express any preference. results were analysed using x test. male female totals % patients preferred the pvc masks (p< . ), but with no significant difference between the scents. use of the pvc masks, which patients preferred, may reduce stress and help prevent the risk of cardiac ischaemia. complications, fasiculation score and the incidence of post operative myalgia (pom). intubating conditions were significantly better (p< . ) and anaesthetic time reduced (p< . ) in the group who received suxamethonium. the incidence of myalgia was low in both groups (one patient in each group). this study shows that when suxamethonium is administered as part of a standard anaesthetic regimen, it does not appear to increase the frequency of pom in children. the use of suxamethonium optimises intubating conditions while reducing anaesthetic time. the incidence of suxamethonium myalgia in children is reported to be low ~, but has not been previously assessed in a randomised fashion. children undergoing adenotonsillectomy were randomised to receive either deep inhalational anaesthesia with halothane (n= ), or suxamethonium lmg.kg- (n= ) for intubation following induction with thiopentone mg.kg- . variables recorded included intubating conditions, respiratory a high dependency unit (hdu) is defined as an area for patients that require more intensive observation, treatment and nursing care than can be provided on a general ward. the economics, the improved nurse/patient ratio and the rationalisation of intensive care utilisation justify the need for such a facility o~. in a bedded hospital with a complement of intensive care beds, we present a month audit of a newly opened bed hdu. we review the demands of the various specialities in terms of utilisation and percentage occupancy. the outcome of consecutive patients (mean age . +_ . years) with confirmed myocardial infarction was audited using a predictive instrument for mortality (t) seventeen patients ( %) died within weeks of admission: the predictive instrument predicted an overall mortality of . _+ . %. none of the patients ( %) predicted to have a mortality below % died. those who died did not present later than survivors ( . +_ . vs. . +- . hours), but were older ( . _+ . vs . _+ . years, p < . )~ forty six patients ( . %) were given thrombolytic therapy. these patients presented earlier ( . +/- . vs. . +/- . hours, p< . ) and were younger ( . _+ . vs. . _+ . years, p< . ) than the patients not given thrombolytics. there was a mean delay of +- minutes between admission and thrombolytic administration. only of the who died received thrombolytics. the actual mortality rate of those not given thrombolysis was % compared with a predicted rate of . _+ . %: both higher than th predicted ( . _+ . %, p< . ) and actual ( . %) mortality rate of those given thrombolytics. there may be a bias against giving thrombolytics to severely ill patients, since all patients with shock were not treated. of the rest not treated only had an absolute contraindication; other reasons were: non-diagnostic ecg changes ( patients), late presentation ( patients), bleeding risk ( patients), age ( patients), hypertension ( patients), no reason ( patients). conclusion: the predictive instrument identified those most likely to die from acute infarction and, hence, those most likely to benefit from thrombolysis. four hundred and ten consecutive patients attending a special anticoagulation clinic over a one year period were asked to complete a questionnaire concerning their warfarin treatment. the total number of patient years on warfarin was . of the patients, ( %) admitted to bleeding episodes, of which / ( %) required admission to hospital or to casualty for treatment and / ( %) required only a lowering or temporary cessation of warfarin therapy. the annual rate of non-fatal bleeding requiring attendance at hospital for treatment was . %. the annual total non-fatal bleeding rate was %. conclusion: the calculated annual non-fatal bleeding rate of % and the . % annual rate of major bleeding requiring attendance at hospital are similar to those reported in randomised clinical trials of anticoagulation for stroke prevention in atrial fibrillation. thus, oral anticoagulation is as safe in an ordinary medical setting as in a closely supervised trial setting and more extensive use of longterm oral anticoagulation for stroke prevention in atrial fibrillation should not lead to an unacceptably high rate of anticoagulant-related haemorrhage. indeed, there is only one recorded case of retinal haemorrhage after thrombolysis. however, the british national formulary states that diabetic retinopathy is a contraindication to thrombolysis. the aim was to assess the influence of retinopathy on the administration of thrombolysis to diabetic patients with mi. an audit using a retrospective chart review was carried out on all casualty admissions with dm and mi. data collected included; demographic details, symptom duration, if fundoscopy was performed, mydriatic usage, thrombolysis and contraindications, if not given. patients were admitted with dm and mi ( m, f). the mean age was . years (range - ). the mean symptom duration before admission was . hours (range . - ). . % ( / ) received thrombolytics. . % ( / ) had fundoscopy documented, mydriatic usage was not recorded in any chart. . % ( / ) had documented retinopathy and all four did not receive thrombolysis. four further cases did not receive thrombolysis; one had cpr, two had delayed diagnoses and one had no reason recorded. conclusion: all diabetic patients with mi were considered for thrombolysis. % of diabetics had fundoscopy to exclude retinopathy. diabetic retinopathy is a practised contraindication to thrombolysis in this hospital. ptatelet aggregation and adhesion is mediated through glyc protein (gp)iib/iiia: an adhesion receptor the primary ligand is fibrinogen which binds via the sequence arg-gly-asp(rgd). hence rgd-containing peptides are antagonists at the receptor. however peptide antagonists induce an active conformation of the receptor and the appearance of novel epitopes: ligand induced binding sites(libs). the function of libs is unclear but they may be involved in cell activation and thus indicate partial agonist activity. we examined a novel nonpeptide gpiib/[iiia antagonist (npa), which binds to the rgd recognition site, in patients with stable angina. platelet aggregation was assessed in response to thrombin related agonist peptide(trap) alone and in combination with collagen (agonist pathways unaffected by aspirin). libs expression was measured by flow cytometric analysis. the npa dose dependently suppressed platelet aggregation to trap ( . + . %, mean+sem) and trap/collagen ( . _+ . %) and prolonged bleeding time in all patients (> mins in / cases). in contrast to previously described peptide antagonists,libs expression was not induced. aspirin is a weak inhibitor of platelet aggregation and adhesion. in contrast this npa shows marked antiplatelet activity. this class of drug offers a novel and alternative approach to antithrombic therapy which is more potent than aspirin. serotonin has been reported to stimulate prostacyclin release ~ . in , blaise et al reported that inhibitors of cyclooxygenase augment serotonergic responsiveness in canine coronary arteriest v serotonin produces a biphasic response on the forearm resistance vessels of healthy volunteers, at low dose vasodilatation occurs and at high dose there is a constrictor response. we have investigated the role of cyclooxygenase in the forearm vascular responses to serotonin in healthy volunteers. ten healthy volunteers aged - years were studied. serotonin was infused into the brachial artery in incremental doses . - ug/min for munutes each. forearm blood flow was measured at baseline and following each dose using venous occlusion plethysmography. indomethacin ( mg) was then administered orally and after minutes the serotonin infusions were repeated. results were analysed using paired t-tests and dunnett's test of multiple comparisons. vasodilatation occurred at doses . to ug min and vasoconstriction at the highest dose ( ug/min). there were no significant differences in the vascular responses to serotonin following indomethacin, indicating that products of cyclooxygenase are not involved. .o the rzo sphygmomanometer, a widely used modified mercury device with a variable 'zero' correction, has been reported to be inaccurate. four recently serviced rzo machines were compared with a standard mercury device under static conditions. a cuff connected to a standard and rzo machine, was placed around a glass jar. an unblinded controller set a random pressure on the standard whilst two independent blinded observers recorded the mercury level on the rzo. residual pressure was then released through the hand valve and through a rapid release technique and the zero level on the rzo was noted. one hundred measurements using each method were made for each rzo. a pressure decay curve was constructed using the hand valve. the rzo underestimated pressure compared with the standard sphygmomanometer using both methods. the modified technique consistently reduced the size of the error (p< . ) with a mean reduction from . to . mmhg. the pressure-time curves can be described by the biphasic log linear curve ae-~t+be-bt. in conclusion, overestimation of the zero in the rzo caused by a residual pressure tail in the system contributes to the machine's inaccuracy. rapid pressure release improves this. in robert furchgott discovered the obligatory role of the vascular endothelium in the vasodilatory response to acetylcholine "~. acetylcholine is now known to stimulate muscarinic receptors on the endothelial cell surface, resulting in production of nitric oxide. local infusion of acetylcholine and measurement of vascular response is now a widely used technique for assessing the function of the vascular endothelium in vivo. l-nmma, a stereospecific inhibitor of nitric oxide, has been found to only partially inhibit vasodilation to acetylcholine~ l this suggests that another vasodilator substance such as a cyclooxygenase product may be involved. ten healthy volunteers (age - years) underwent brachial artery cannulation. forearm blood flow was measured at baseline and following local drug infusions using venous occlusion plethysmography. acetylcholune was infused at , , and nmo/min for minutes each. indomethacin ( ) mg was then administered orally and after a period of minutes the infusions were repeated. results were analysed using paired t-tests and dunnett's test of multiple comparisons. acetylcholine caused a dose-dependent increase in blood flow. there was no significant change in basal or stimulated flow following indomethacin. in conclusion, cyclooxygenase products do not influence forearm vascular responses to acetylcholune in healthy volunteers. fig. the purpose of this study was to determine the value of dobutamine stress echocardiography (dse) in the detection of angiographically significant coronary disease (> % reduction in coronary luminal diameter). dse and angiographic studies were performed in patients of whom ( %) had significant ischaemic heart disease (ihd). the overall sensitivity and specificity of dse for ihd was % and % respectively. the sensitivity was % ( of ) for multivessel disease. sensitivity for detection of those with double vessel disease was % ( of ) while for single vessel disease it was % ( of ). no patient had a symptomatic arrhythmia or complications from induced ischaemia. conclusion: dse is a safe technique. it predicts the presence of significant ihd. the value of dse in detecting angiographically significant ihd in a low risk population remains to be determined. the role of percutaneous transvenous mitral commissurotomy (ptmc) in treating patients with mitral stenosis remains to be clarified. we report our initial experience with the transseptal flow directed inoue ptmc technique in patients. the mean age was _+ years. pre-procedure assessment included transoesophageal echocardiography with detailed anatomic and functional analysis of mitral valve pathophysiology. all patients were new york heart association (nyha) functional class iii or iv. the procedure was successful (mitral valve area > . cm , improvement in functional class and no complications) in patients, ie a % procedural success rate. mitral valve area increased from . _+ . to . _+ . cm (mean • sd). transmittal pressure gradient fell from _+ to _+ mmhg (mean + sd) while nyeha functional class improved by > grade in all patients, falling from . • . pre to . • . post procedure. there were no major complications. in patients mitral regurgitation increased by a single angiographic grade. conclusion: in this initial experience, ptmc was a safe and effective alternative to surgical mitral valvotomy in selected cases. -maternal ( . %) ( . %) -foetal ( . %) ( . %) *mhd = maternal heart disease. conclusions: ( ) most maternal heart disease has a benign outcome and can be managed conservatively. ( ) the prevalence of maternal heart disease complicating pregnancy has declined. ( ) there has been a decline in the prevalence of rheumatic heart disease complicating pregnancy with a relative increase in congenital and miscellaneous conditions. the purpose of this study was to evaluate an algorithm for the detection of acute myocardial infarction, based on body surface mapping. a portable mapping system incorporating a self adhesive electrode harness which can be applied rapidly to the chest was used to map healthy control subjects and patients with acute mi. at each of the electrode sites qrs and st-t iso-integrals, and other features of the qrst segment are measured. in addition new variables are derived which describe the -dimensional geometric surface of the map. using a training set of maps recorded on controls and patients with mi, variables were identified which correctly classified / of the controls (specificity = . %) and / of the mis (sensitivity = . %). the algorithm based on these variables was applied prospectively to a further control subjects and patients with mi ( anterior, inferior, inferoposterior, posterior, lateral, inferior with right bundle branch block and anterior non-q wave mi). all control subjects (specificity = %) and / of the mis (sensitivity = . %) were correctly classified. this algorithm demonstrates a high level of sensitivity and specificity for the early detection of mi. it will be applied to patients with atypical ecg changes such as st segment depression only and it is hoped that it will improve detection of m in such patients thus enabling the appropriate administration of thrombolysis. irish journal of medical science carotid artery disease. patients underwent both selective carotid arteriography and duplex scanning with colour flow mapping. the two examinations were performed within a few days of each other in all cases. angiographic stenosis measurements were recorded in each patient using a digital subtraction technique and dedicated equipment. measurements were similarly obtained using duplex ultrasound scanning and colour flow mapping. measurements obtained from the patients were placed in recognised groups of severity. in % of cases arteries demonstrated to be sonographically normal were confirmed normal on angiography. however, in patients with higher grade sten ses (greater than %) agreement was rather less at %. overall agreement between the two modalities occurred in % of cases. conclusion: we have demonstrated that duplex sonography can reliably identify normal and minimally diseased vessels. however, in higher grade stenoses we would recommend the greater sensitivity of angiography as a standard part of the imaging protocol. consecutive patients completed a questionnaire stating why and for how long they expected to take warfarin and if they were aware of certain problems with long term anticoagulation. the clinic doctor then correlated this with the information on each patient's anticoagulant card, which should include indication for anticoagulation, target international normalised ratio (inr) and expected duration of treatment. the indication for anticoagulation was stated on the card in % of cases, known by % of patients and unknown in %. these indications included valvular heart disease and atrial fibrillation ( %) and complications of ischaemic heart disease ( %). the expected duration of treatment was given on the card in % and known by the patient in %. it was assumed to be lifelong in a further % as the indication in these cases was valve replacement. the inr target range was stated in only % of cases. patients indicated that they were aware of the potential for drug interactions and the possibility of bleeding after surgery or dental work in %, % and % of cases respectively. this audit reveals shortcomings in the completion of anticoagulant cards with basic details such as duration and target anticoagulation range often omitted. the study also revealed that continuing patient education is needed as knowledge of long term risks of anticoagulation was poor. +project co-ordinator the concept of total chemical analysis system (tas) which encompasses automatic sampling, sample transport, preparation and detection and which transforms chemical information into electronic information was first proposed by manz. ~). the ultimate objective of this project is to produce a functional model of a miniaturized total chemical analysis system (/atas) suitable for application in real-time monitoring of clinically important analytes particularly lactate and glucose. equipment miniaturization would increase speed of analysis and reduce consumption of reagents which may be epensive and harmful to the environment. details on two aspects of the project will be presented - ) the improved performance obtained with amperometric enzyme membrane electrodes using lactate oidase/glucose oxidase sandwich membranes in combination with flow injection analysis (fia). the linear lactate concentration increased from . mm to mm by combination with ea using a volume injection of . al. ) the fabrication and performance parametrs of integrated thin film lactate and glucose sensors. the relative effects of potential interferents in clinical application were studied and show that ascorbic acid and uric acid interference is negligible. paracetamol at a concentration times the therapeutic concentration causes a reading error less than . mm/l for glucose. probes for continuous monitoring of blood pressure, temperature and oxygen status of blood in the critical care of patients have been developed. the application on a total chemical analysis system for continuous monitoring of analytes is under development. the sample for analysis could be withdrawn through a microdialysis probe inserted subcutaneously or directly in blood. microdialysis is a diffusion based method by which small molecules can be removed from living tissue for analysis. the sample obtained is free from macromolecules (mainly proteins) and may be introduced directly into microanalytical systems without further purification. the aims of this presentation are to report the effects of perfusion flow rate, temperature and dialysis membrane size on microdialysis efficiency as judged by relative recovery of lactate and glucose in in-vitro studies. relative recovery of lactate and glucose decreased from % to % as perfusion flow rate increased from . to pl/min. dialysis efficiency was not significantly altered by temperature change within the physiological range -effciency altered by . % and . % per degree celsius for lactate and glucose respectively in in-vitro experiments. the relative recovery of lactate increased from % to % as microdialysis membrane surface area increased from mm to mm . we measured the incidence of subclinical liver damage in intensive care (icu) patients by measuring serum levels of r glutathione s-transferase (gst), a marker of acute liver damage . patients had serial gst levels measured (on admission to icu, + hrs, + hrs, + hrs, and once daily thereafter) by radioimmunoassay. routine physiological parameters were noted. % of patients had abnormal gst - % of this group had increases in ast or alt subsequently. patients with increased gst had a higher apache ii (illness severity) score on admission (p< . , unpaired t-test). no physiological variables predicted increases in gst. use of inotropes was associated with increased gst. of the patients with no increase in gst had elevated ast or alt on admission to icu; in these ast and alt decreased after admission. no patients developed liver failure. we conclude that gst has a place in the detection of acute liver damage in critically ill patients. it could allow more sensitive monitoring of ongoing liver damage, earlier clinical intervention, and earlier detection of recovery. vincent's hospital, dublin. hypothesis: that "closed" suction of the trachea (where the suction catheter is within a plastic sheath) contaminates the hands of carets and the air less than "open" method (where the carer holds the catheter through a sterile glove). studies were performed on patients with tracheal tubes or tracheostomies. each study involved performing "open" and "closed" suction once, separated by two hours. the hands of carets were imprinted on culture plates before and after each treatment; two plates assessed airborne contamination. inadequate tissue perfusion occurs during routine cardiac surgery. shibutani has suggested that the critical level of oxygen delivery (crit do ) in cardiac surgery is - ml/min/m . dopexamine improves oxygen delivery. this study prospectively analysed the effect of prophylactic dopexamine on oxygen delivery in low risk patients undergoing elective coronary artery bypass graft (cabg) surgery. consenting elective patients without ventricular dysfunction were enrolled in a double blind, placebo-controlled study. they received either a prophylactic infusion of dopexarnine at ug/kg/min (n-- ) or saline (n=ll). serial oxygen delivery (d ) and oxygen consumption (vo ) were measured at pre-determined intervals. crit do was calculated using split linear regression~analysis from grouped measurements in early ( - hr) post operative and late ( - hr) post-operative periods. the number of do s in each group falling below the crit do were compared. the crit do for the early period was ml/min/m and ml/min/m for the late period. . % of all do measurements fell below the crit do in the early post-operative period compared to . % in the late period. analysis of the mean do for each patient in each time period shows some evidence that dopexamine augments oxygen delivery in the early ( - hr) post operative penod (p= . ). the crit do results correspond with those of shibutani. . % of measured do s fell below the calculated crit do in the early post cpb period. in this period a smaller proportion of the do s (dopexamine group) fell below the crit do relative to controls. despite absence of ventricular dysfunction failure to reach crit do in the post-operative period was common. the objective was to describe the incidence, pre-operative findings, post-operative findings, diagnostic methods and outcome of patients going from the icu for a repeat laparotomy in search of abdominai sepsis. methods: retrospective review of medical notes. fifteen patients age - years were included. mortality was %. in cases clinical examination was abnormal as was the relaparotomy. in one case clinical examination and ultrasound scan were negative but relaparotomy was still undertaken which also proved negative and the patient died. radiology was employed in cases and concurred with clinical examination. a previous study has indicated that down's syndrome may adversely effect mortality rates after surgical correction of certain defects. the paediatric risk of mortality (prism) score is a validated illness severity score used to predict patient outcome in a paediatric intensive care unit (picu) setting. the aim of this study was to assess whether the presence of down's syndrome contributed to morbidity and mortality in the picu in children undergoing cardiac surgery, using the prism score as a guide to likely outcome. the data from consecutive patients entering the picu following cardiac surgery was prospectively collected, and the prism score and predicted mortality rate calculated. ( %) of the patients had down's syndrome of whom died. of the remaining patients also died. the mortality rates were correctly predicted for both groups by the prism score. morbidity was higher in the down's syndrome group with a significantly longer period of ventilation (p-- . ) and duration of stay in picu (p= . ). to assess whether this was related to a difference in procedures, or to down's syndrome a homogenous group of patients undergoing tetralogy of fallot repair was assessed. the prism score again correctly predicted mortality rates, but patients with down's syndrome had twice the duration of ventilation and picu stay (p= . ). in conclusion down's syndrome appears to influence morbidity but not mortality following, cardiac surgery. homocystinuria is an autosomal recessive metabolic disorder, usually involving beta cystathionine synthase deficiency. untreated patients develop a marfan-like syndrome and have a propensity to thromboembolic phenomena t~. a year old male with homocystinuria and marfinoid features presented to a/e with a / history of malaise, cough, haemopytsis and petechial rash. he sustained a respiratory arrest and following resuscitation, developed a septic syndrome. frank pulmonary haemorrhage was noted. differential diagnosis was of either meningococcal septicaemia or bronchopneumonia.the sepsis syndrome resolved over three days. no definite pathogen was identified. apart from pulmonary failure, organ function remained normal. appropriate nutritional support was maintained from the outset. aspirin and dipyridamole therapy were continued as prophylaxis against thrombosis. pulmonary haemorrhage (> ml/day) remained significant, requiring regularblood transfusions over a three week period. systemic vasculites were excluded. a pulmonary arteriogram failed to demonstrate eil~her vessel occlusion or arteriogram malformation. an arch aortogram to demonstrate bronchial arterial supply was normal. barotrauma with recurrent pneumothoraces and interstitial mediastinal emphysema occured over his five week ventilatory period. life threatening pulmonary haemorrhage and recurrent pneumothoraces have not previously been reported in patients with homocystinuria. nine and sixteen year old brothers presented to casualty comatose. both had been previously well and no history suggestive of substance ingestion or exposure was given. at presentation the brothers had glasgow coma scales of and respectively the younger brother showed seizure activity. arterial blood gas estimation revealed metabolic acidosis. toxicology screen was negative. both patients were intubated, ventilation controlled and intensive care monitoring undertaken. carboxyhaemoglobin analysis (requested empirically) revealed toxic levels of % in the yr. old and % in the yr. old. both patients were managed with hyperbaric oxygen treatment at atmospheres for minutes on two occasions. carboxyhaemoglobin levels reduced in the yr. old from %-- %-- % post treatment and levels in the yr. old reduced from %--- . %-- . % post treatment. despite better clinical condition at presentation the yr. old had a more prolonged recovery. vol. , irish journal of supplement no. medical science these cases highlight: ( ) the importance of suspecting a diagnosis of carbon monoxide poisoning in circumstances of coma of unknown origin. ( ) initial clinical status did not correlate with initial measured levels of carboxyhaemoglobin. ( ) despite evidence of severe poisoning at presentation longterm sequelae were minimal following prompt hyperbaric. routine supplementation of trace elements is common in patients receiving total parenteral nutrition. this practice may be both unnecessary and unsafe. for many trace elements, only severe prolonged deficiency will lead to clinical symptoms . on the other hand, routine supplementation may give rise to toxic effects. the proprietary preparaffon addamel| has been discontinued following reports of manganese toxicity. as manganese is excreted primarily in the bile, this is most likely to occur in patients with cholestasis . monitoring of serum manganese levels is an attractive option but may be impractical because of long delays in obtaining results. for these reasons, it has been our practice not to give addamel| or additrace| to patients receiving short term parenteral nutrition (less than weeks). we do, however, give zinc to all patients as zinc deficiency is common in the critically ilp. we have reviewed the nutrition records of patients. patients ( %) received addamel| and patients ( %) recelved additrace| but only after weeks of feeding. this was not associated with adverse effects. in contrast, patients ( %) received zinc (average lamol daily). we conclude that routine manganese supplementation is unnecessary during short term parenteral nutrition. vascular overproduction of the vasodilator nitric oxide (no) causes pathological vasodilatation in endotoxic shock (es). thus no synthase inhibitors including ng-nitro-l-arginine methyl ester (l-name) have been administered to endotoxaemic patients. this treatment restores blood pressure but reduces cardiac output (co). in healthy pigs we have shown that co is restored by the selective arterial vasodilator nicardipine indicating that reduced co is due to increased afterload. to establish whether these findings could be applied to an appropriate pathological situation, we aimed to optimise an existing porcine model of es and to assess the effects of l-name and of subsequent vasodilatation with nicardipine on co in this model. in three groups of six pigs es was induced by administration of e. coli lipopolysaccharide endotoxin (lps lag kg as a minute infusion) with concomitantly inhaled no to attenuate pulmonary vasoconstriction and intravenous fluids to maintain preload. systemic and pulmonary vascular resistances (svr, pvr) and co (thermodilution) were measured at minute intervals. this protocol produced an appropriate model of es minutes after the start of the lps infusion (svr to kpa -~ sec; pvr to kpa - scc; co . to . minl). in two groups l-name ( mg kg q between and minutes after the start of lps infusion) increased svr (to kpa -~ sec) but increased pvr (to kpa - sec and reduced co (to . min- ). one of these groups subsequently received nicardipine ( lag kg ~ between and minutes) which reduced svr (to kpa j sec) and pvr (to kpa - sec), temporarily restoring co (to . rain-l). it may be possible to coadminister vasoconstrictors and vasodilators in es in doses titrated to restore svr without increasing pvr or reducing co. hepatitis c infection (hcv) has been suggested as a triggering factor for porphyria cutanea tarda (pct). patients with pct have been found to have a hundred fold increase in hcv antibody prevalence compared with blood donors, ranging from % of pct patients in ireland to % in spain. there are at least four patients in ireland who have been diagnosed with both hcv and pct. in addition, hiv infection has also been associated with significantly abnormal porphyrin metabolism. however, the role of hcv infection alone in precipitating pct is unclear. we therefore studied porphyrin metabolism in groups of patients with hcv infection. group comprised rhesus negative women immunised with anti-d immunoglobutin (mean age yrs, range - ). group , all hiv negative drug abusers (ivda), included hcv positive patients, male, female. the mean age was yrs with an age range of - yrs. haemoglobin, serum ferritin, liver function tests, hepatitis a and b status were assessed. plasma porphyrins, urinary uroporphyrins, coproporphyrins, aminolevulinic acid and porphobilinogen were measured. a liver biopsy was performed on all patients in group and one in group . one patient in group was on oestrogen therapy. three patients in group abused alcohol. porphyrin excretion was normal in group . in group , however, ( %) had elevated free erythrocyte protoporphyrin, ranging from - ng/ml (normal < ). liver function tests were abnormal in ( . %) in group and ( %) in group . ferritin levels were elevated in ( . %) at ng/ml and ng/ml (normal: - ) in group alone. in our two separate population groups with hcv infection alone we found no evidence of pct. however, had evidence of porphyrin metabolic derangement. hepatitis c infection alone is not sufficient to cause pct. additional co-factors such as genetic susceptibility, iron overload, alcohol abuse and oestrogen therapy appear necessary for induction of pct, as all patients with pct had such additional risk factors. the natural history of chronic myeloid leukaemia (cml) is unaffected by standard chemotherapy. treatment with interferon-or produces cytogenetic remission in only a few patients. allogeneic bone marrow transplantation is curative, but only a small minority of patients are suitable because of age or lack of donors. for these reasons, attention ha s recently focussed on autologous transplantatio n. although the bone marrow of patients with cml appears % philadelphia chromosome (ph') positive, there is evidence that patients have some residual ph'-negative progenitors. carella and others have selectively harvested these cells after myelosuppressive chemotherapy. we have mobilised peripheral blood progenitor cells (pbpc) from patients with cml in first chronic phase with idarubicin mg/m on days and and cytosine arabinoside mg/m bd on days - followed by g-csf until the end of pbpc harvesting. short term cultures indicated an adequate yield of pbpc in patients. in evaluable patients pbpc were predominantly ph'-negative ( / , / , / metaphases ph' positive). one patient has been given high-dose chemotherapy and a pbpc infusion and has engrafted well with predominantly ph'-negative haemopoiesis. we conclude that ph' negative pbsc can be mobilised from patients in first chronic phase cml. serotonin produces a biphasic response in the forearm vascular resistance bed of healthy volunteers, vasodilatation occurring at low dose and vasoconstriction at high dose. in vitro studies have shown that the vascular relation to serotonin is endothelium-dependent . age-related impairment of flow mediatedendothelium-dependent vasodilatation in the human forearm circulation has recently been reportedt l we have studied forearm arteriolar responses to serotonin in young and older non-smoking healthy volunteers. nine young subjects (age range - years) and eight older subjects (age range - years) underwent cannulation of the brachial artery for the local infusion of drugs. forearm blood flow was measured at baseline and following each drug infusion using venous occlusion plethysmography. serotonin was infused in incremental doses . - lag/min for minutes each. results were expressed as change in forearm blood flow (ml/ ml/min) and analysed using multivariate analysis of variance and dunnett's test of multiple comparisons. serotonin produced a biphasic response in both groups with vasodilatation occurring at low doses and vasoconstriction at the highest dose (fig ) . in the older group however, vasodilatation was significantly impaired when compared with the younger group. there was no difference irish journal of between groups in the vasoconstrictor responses at the highest dose of serotonin. in conclusion, there is impaired vasodilatation to serotonin in older subjects. this may be due to age-related impairment of vascular endothelial function. macrovascular disease is the major cause of morbidity and mortality in niddm. although its aetiology is multifactorial, it has been suggested that therapies used in the treatment of niddm may increase the risk of atherosclerosis in this patient population. to evaluate the effects of diabetes treatment on the macrovascular complications, the prevalence of ischaemic heart disease (ihd), cerebrovascular disease (cvd), and peripheral vascular disease (pvd) was evaluated in groups of niddm patients treated with diet alone (group a, n = ), oral hypoglycaemic agents (group b, n = ) and insulin (group c, n= ). the prevalence of angiopathies was as follows: pvd ihd cvd group a . % . % . % group b . % . % . % group c . % . % . % hypertension, hypercholesterolaemia or smoking prevalence did not differ between groups. however, the prevalence of patients with proteinuria was significantly higher in group c ( . %) in comparison with groups b ( . %) and a ( . %) respectively (p< . ). thus, insulin treated niddm patients have a reduced prevalence of ihd and have higher prevalence rates of pvd. the increased occurrence of the latter might partly be explained by the increased prevalence of proteinuria in this group. this study was a retrospective review of the , inquests held in accordance with the coroner's act in the dublin city coroner's court over the period to with particular reference to death by suicide. the study aimed to assess the correlation between the number of verdicts of suicide returned by the coroner or jury and the number suggested by the clinical case records. only in the final six months of the period studied was it permissible in law to return a verdict of suicide following its decriminalisation in july . the study also examined the age, sex, marital status and psychiatric history of the suicide victims and the methods employed. the results show a difference between the clinical number of suicides and suicide verdicts returned in accordance with the legal standard of proof. suicide accounted for deaths ( %). the male to female ratio was : and the incidence was highest in the - year age group. the majority were single. almost / had a psychiatric history. the most common methods in males and females were hanging and drug overdose respectively. the study identified candidates most vulnerable to suicide where prevention may be possible. amendment of the law to allow the coroner return a clinical verdict for central statistics purposes should be considered. mrc vitamin study group prevention of neural tube defects: results of the mrc vitamin study prevention of congenital abnormalities by periconceptional multivitamin supplementation the pupillary light reflex in diabetes mellitus: evaluation of a newly developed infrared light rcflection method stimulation and recording of dynamic pupillary reflex: the iris technique, part invasive candida infections; evolution of a fungal pathogen ketoconazole prevents candida sepsis in critically ill surgical patients oxidative stress in hypertension and increased resistance to ldl oxidation in patients on combined therapy department of therapeutics, trinity centre for health sciences, st. james's hospital, dublin and *department of biological sciences we t~ reported increased plasma lipid peroxidation, measured as malondialdehyde (mda) in hypertensive patients department of clinical cardiology h - . (e ) the hawksley random-zero sphygmomanometer department of therapeutics and pharmacology ) partial agonist activity of platelet glycoprotein lib/ilia antagonists detected as an increase in txa formation in such changes may represent partial agonist activity. the functional relevance of libs was examined in a canine model of coronary thrombolysis induced by t-pa . the gp lib/ilia antagonists miniaturised total chemical analysis systems; a novel concept for chemical sensing current concepts on trace element requirements in nutrition manganese levels in a jaundiced long term total parenteral nutrition patient: potentiation of haloperidol toxicity?: case report and literature review nutrition in the critically ill -hydroxytryptamine can mediate endotheliam-dependent relaxations of coronary arteries aging is associated with endothelial dysfunction in healthy men years before the age-related decline in women macrovascular disease in non-insulin-dependent diabetes mellitus (niddm): a preliminary report from the mater hospital diabetes database the pathogenesis of coeliac disease appears to involve an immunological response to the ingestion of specific cereal proteins in wheat, barley and rye. the issue of oats toxicity is controversial and was investigated in this study. biopsy-proven coeliac patients in clinical and histological remission were challenged with g of oats daily for a month period. clinical, laboratory, histological and immunological markers of coeliac disease activation were evaluated. all patients remained asymptomatic throughout the challenge period and no laboratory evidence of malabsorption was found. there was no mucosal damage seen on routine histological examinaton of post challenge duodenal biopsies. surface enterocyte height remained unchanged and intraepithelial lymphocyte counts were also unaltered following challenge. furthermore, oats did not cause immunological activation since no rise in alpha gliadin or endomysial antibodies or in mhc class ii staining of enterocytes was evident. this study demonstrates that oats is neither toxic nor immunogenic in coeliac disease and oats does not appear to contain the putative toxic peptide sequence found in the other cereals. we examined postprandial endogenous cellular cholesterol synthesis in obese subjects before and after enrolling in a weight reducing program. obese insulin resistant subjects were studied for _+ months. blood was drawn fasting, at minutes and at hours after consuming a carbohydrate rich meal. lymphocytes were isolated and incubated with ~ c acetate to measure de novo cholesterol synthesis. insulin resistance was determined from the fasting insulin to glucose ratio while the ratio of the change in insulin from to minutes to the change in glucose over the same time yielded a index of insulin secretion. weight and bmi fell from . + . to . -+ kg{p< . } and from . _+ . to . _+ . kg/m {p< . } respectively. fasting lipids did not change. there was a decrease in insulin resistance from . + to . -+ . (p=n/s} and in insulin secretion from . _+ . to . -+ {p< . }. at baseline there was a rise in cholesterol synthesis postprandially from . _+ . to . -+ . pg/mg cell protein {p< . } but after weight loss key: cord- - whf md authors: sun, hengchang; shang, mei; tang, zeli; jiang, hongye; dong, huimin; zhou, xinyi; lin, zhipeng; shi, cunbin; ren, pengli; zhao, lu; shi, mengchen; zhou, lina; pan, houjun; chang, ouqin; li, xuerong; huang, yan; yu, xinbing title: oral delivery of bacillus subtilis spores expressing clonorchis sinensis paramyosin protects grass carp from cercaria infection date: - - journal: appl microbiol biotechnol doi: . /s - - - sha: doc_id: cord_uid: whf md clonorchis sinensis (c. sinensis), an important fishborne zoonotic parasite threatening public health, is of major socioeconomic importance in epidemic areas. effective strategies are still urgently expected to prevent against c. sinensis infection. in the present study, paramyosin of c. sinensis (cspmy) was stably and abundantly expressed on the surface of bacillus subtilis spores. the recombinant spores (b.s-cotc-cspmy) were incorporated in the basal pellets diet in three different dosages ( × ( ), × ( ), × ( ) cfu/g pellets) and orally administrated to grass carp (ctenopharyngodon idella). the immune responses and intestinal microbiota in the treated grass carp were investigated. results showed that specific anti-cspmy igm levels in sera, skin mucus, bile, and intestinal mucus, as well as mrna levels of igm and igz in the spleen and head kidney, were significantly increased in b.s-cotc-cspmy- ( ) group. besides, transcripts levels of il- and tnf-αin the spleen and head kidney were also significantly elevated than the control groups. moreover, mrna levels of tight junction proteins in the intestines of b.s-cotc-cspmy- ( ) group increased. potential pathogenetic bacteria with lower abundance and higher abundances of candidate probiotics and bacteria associated with digestion in × ( ) cfu/g b.s-cotc-cspmy spores administrated fishes could be detected compared with control group. the amount of metacercaria in per gram fish flesh was statistically decreased in × ( ) cfu/g b.s-cotc-cspmy spores orally immunized group. our work demonstrated that b. subtilis spores presenting cspmy on the surface could be a promising effective, safe, and needle-free candidate vaccine against c. sinensis infection for grass carp. electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. clonorchis sinensis (c. sinensis), an important fishborne zoonotic trematodes parasite, is prevalent in asian countries and regions including china, south korea, northern vietnam, and russia. adult worms of c. sinensis live in the intrahepatic bile duct of definitive host. in addition to human beings, various other kinds of mammals can be definitive hosts of c. sinensis, such as cat, dog, pig, rabbits, etc. as reported, the average prevalences of c. sinensis infection in dogs and cats were . % and . % in the pearl river delta region which is the most important endemic area in guangdong province (lin et al., ) . and nearly million people are estimated to be infected with c. sinensis globally, of whom approximately million are in china (lai et al. ; qian et al. ; tang et al. b ) and bring a series of diseases like indigestion, biliary inflammation, bile duct obstruction, even liver cirrhosis, and hepatic carcinoma (tang et al. b) . accumulating evidence demonstrated that there is an aetiological relation between clonorchiasis and cholangiocarcinoma in human beings (lun et al. ; machicado and marcos ; zheng et al. ). however, we still lack effective strategy to completely prevent the spread of c. sinensis at present (tang et al. b) . human beings or other definitive hosts get infected by ingesting raw or undercooked fishes (the second intermediate hosts) containing live metacercaria (lun et al. ). on the one hand, in epidemic areas wild animals served as the definitive hosts (reservoir hosts) for c. sinensis (qian et al. ) which could be infectious source. for example, in southern china, a large number of dogs and cats roam freely in rural settings, and the presence of these animals in proximity with people may represent a risk of parasitic zoonoses including c. sinensis (fang et al. ; nguyen et al. ). on the other hand, eating raw fish has been deeply rooted in culture of the area. in previous, most vaccine trials focused on the definitive host of c. sinensis instead of the intermediate hosts including freshwater fishes or snails (the first intermediate hosts). protein-based or nucleic acid-based vaccine trials have been conducted on the rat model, but none of the vaccine candidates brought a protective effection (worm reduction rate) of more than % (qian et al. ; tang et al. b ). freshwater fishes (e.g., ctenopharyngodon idellus, carassius auratus, and hypophthalmichthys nobilis) serve as the second intermediate host for c. sinensis. hence, we speculate that cutting off the life cycle of c. sinensis by preventing the cercaria invasion or metacercariae formation in freshwater fish might be an efficacious tactic to control the prevalence of c. sinensis. vaccine has been the most effective method for combating infectious disease in aquaculture industry (gudding and van muiswinkel ; plant and lapatra ) . compared with other immunization routes (injection and immersion route), oral vaccine is a preferable route as it is needle-free, no size limitation, lower cost, and more convenient for farmer operation (plant and lapatra ) . however, oral immunization suffers from antigen degradation in the gastrointestinal tract of fish, which will affect the protective effect (quentel and vigneulle ) . a considerable amount of investigations have proved that spores of bacillus subtilis (b. subtilis) were a potent antigen delivery platform for oral vaccine rosales-mendoza and angulo ; tavares batista et al. ) . because b. subtilis spores can survive extreme environment in the gastrointestinal tract, thus protect the antigens from digestion and degradation (duc le et al. ) . besides, b. subtilis were widely employed as probiotic additives as it enhances the growth performance, digestive enzyme activities, immune responses, and disease resistance of fishes or shrimps (liu et al. ; sanchez-ortiz et al. ; truong thy et al. ; wang et al. ) . b. subtilis spores were widely investigated as a delivery vehicle for the oral vaccine in aquaculture industry (fu et al. ; valdez et al. ) . in our previous work, an oral delivery system based on b. subtilis spore has been successfully established and confirmed to be valid and feasible tang et al. ; zhou et al. ) . enolase and cysteine protease of c. sinensis (cseno and cscp) were expressed on the surface of b. subtilis spore, and the recombinant spores elicited both humoral and mucosal immune response in grass carp by oral immunization tang et al. ) . but the protect effect against c.sinensis and the safety of spores need further study. paramyosin (pmy), an invertebrate muscle-associated multifunctional protein, has emerged as a promising vaccine candidate for various kinds of parasites (e.g., schistosoma mansoni, schistosoma japonicum, taenia solium, fasciola gigantica, etc.) (abou-elhakam et al. ; jiz et al. ; vazquez-talavera et al. ) . paramyosin of c. sinensis (cspmy, accession number: jq . ) was found to be highly expressed at the stage of adult worm, metacercariae, and cercaria. both prokaryotic expressed protein and dna vaccine of cspmy brought encouraging protect effect in rat models. furthermore, cspmy was confirmed to be an important component of cyst wall of metacercariae, which suggested us that cspmy may play a vital role in metacercariae formation in freshwater fishes ). in the present study, we aimed to explore whether oral administration with b. subtilis spores expressing cspmy on the surface would be an effective and safe measure to protect grass carp from c. sinensis infection. cspmy were fusion expressed on the surface of b. subtilis spores with cotc, a coat proteins of b. subtilis spores, and the immune response and protect effect in grass carp elicited by oral administration with the recombinant spores were evaluated. besides, its influence on intestines and the intestinal microbiota of immunized grass carp were also investigated by using qrt-pcr and miseq high-throughput sequencing, respectively. fishes and recombinant b. subtilis spores healthy grass carp weighing - g were acquired from seedling production base of pearl river fisheries institute (guangzhou, china) and kept in the laboratory for acclimation for weeks. subsequently, fishes were divided into several tanks with the same volume of water ( fishes per tank) and fed daily. before experiments, fishes were randomly sampled for metacercaria detection according to the methods described previously (liang et al. ) to confirm negative infection. b. subtilis spore fusion expressing cotc-cspmy (b.s-cotc-cspmy) and b. subtilis spore expressing cotc (b.s-cotc) as the control were obtained by our previous study and preserved in our lab (sun et al. ). extraction of coat protein of spores b. subtilis wb strains with b.s-cotc-cspmy or b.s-cotc was cultured in difco sporulation medium (dsm, bd, franklin lakes, usa) for h as described. spores were harvested and washed with m nacl, m kcl and distilled water in turn (nicholson wl ) . finally, spores were resuspended in distilled water and treated in °c for h to kill residue vegetative cell. they were counted and stored in − °c prior to use. to extract the coat proteins of spores, spores were resuspended with sodium dodecyl sulfate (sds)-dithiothreitol (dtt) extraction buffer ( . % sds, . m dtt, . m nacl) and incubated at °c for h (tang et al. a) . followed by six times wash with m tris-hcl buffer (ph . ), the spores were suspended in ml broken buffer ( mm tris-hcl, . mm edta, mm pmsf) and ultrasonicated for min. after centrifugation, the coat proteins were collected from the sediment, and the supernatant was preserved for further analysis as well (tang et al. a; zhou et al. ) . b.s-cotc-cspmy spores were analyzed by % sds-page. the corresponding expression band of cotc-cspmy in the polyacrylamide gel was digested with trypsin as described before (katayama et al. ) . the peptides were analyzed through liquid chromatography coupled with tandem mass spectrometry (lc-ms/ms) with an ltq orbitrap velos pro mass spectrometer (thermo finnigan, usa). mascot v . search engine (matrix science, london, uk) was applied for protein identification using the following search parameters: clonorchis sinensis database; two missed cleavage site; fixed modifications of carbamidomethyl (c); partial modifications of acetyl (protein n-term), deamidated (nq), deoxidation (w), oxidation (m); and ± ppm for precursor ion tolerance and ± . da for fragment ion tolerance. the basal diet was a commercial pellet (taifeng, foshan, china, with the chemical composition of crude protein ≥ . %, crude fat ≥ . %, ash ≤ . %, crude cellulose ≤ . %, lysine ≥ . %, and total phosphorus ≥ . %). five experimental diets were prepared in accordance with the methods described before tang et al. ) . naïve group was treated with basal feed without spores. the control group (b.s-cotc- group) was administrated with basal feed plus b.s-cotc spores ( × cfu/g). experimental groups were managed with × cfu/g, × cfu/g, or × cfu/g of b.s-cotc-cspmy spores. to avoid dispersion of the spores in water, spores and basal feed were coated with an equal volume of cod liver oil . the diets were dried and stored at − °c until use. for oral immunization, fishes in each group were hand-fed with % of their initial body weight twice per day (at : am and : pm) for weeks. thereafter, fishes were fed with basal diet till the end of the experiment. five fishes were randomly sampled from each group at week , , and after the beginning of the immunization. grass carp was euthanized with overdose of eugenol mixture, and then skin mucus, blood, gallbladder, intestinal mucus, head kidney, and spleen were collected as described method (guo et al. ) . briefly, skin mucus was gently scraped with a glass slide, then diluted with . ml sterile pbs, centrifuge at °c, rpm for min, and stored in − °c ). blood was collected from the caudal vein using a ml injector, clotted in the room temperature for h, and then sera were separated by centrifugation ( °c, rpm for min) and stored in − °c until use . the intestine was aseptically isolated, lavaged with . ml sterile pbs for several times, and centrifugated ( °c, rpm for min). the supernatant of the lavage fluid was stored at − °c. the spleen and head kidney of each fish was dissected and preserved in sample protector (takara bio, otsu, japan) in − °c. about weeks after the beginning of administration, another three fishes in each group were sampled and euthanized, and the whole intestines of the three fishes were aseptically excised for gut microbiota analysis. indirect enzyme-linked immunosorbent assay (elisa) was employed to analyze the specific antibody levels against cspmy in samples including skin mucus, sera, bile, and intestinal mucus. in brief, the -well microtiter plates were coated with ml per well of μg/ml rcspmy carbonatebicarbonate buffer ( . m, ph . ) in °c overnight. after washing with pbst three times, the plates were blocked with blocking buffer containing % skimmed milk for h at °c. meanwhile, sera, bile, skin mucus, and intestinal mucus was diluted with % bsa in pbst at a dilution of : , : , : , : , respectively. then . ml of diluted samples were added to each well as primary antibody and incubated for h at °c. after three times washing, . ml of hrp-conjugated rabbit anti-grass carp igm (diluted at : ) was added and incubated at °c for h. the plates were washed for times again, . ml of tetramethylbenzidine (tmb, bd, usa) was added and reacted at rt for min. finally, the reaction was terminated by adding μl of m h so , and the optical density value at nm was detected by a microplate reader. mrna levels of immune-related molecules and tight junction proteins by quantitative real-time polymerase chain reaction (qrt-pcr) about weeks after the beginning of oral administration, total rna was extracted from the head kidney, spleen, foregut, midgut, or hindgut tissues of grass carp with trizol reagent (transgen biotech, beijing, china) and was reverse transcribed into the first strand of cdna by using an all-in-one first-strand cdna synthesis supermix kit (transgen biotech, beijing, china). mrna levels of immunoglobulin m (igm), immunoglobulin z (igz), tumor necrosis factor α (tnf-α), and interleukin (il- ) in the head kidney and spleen were analyzed by qrt-pcr. additionally, transcription levels of gene encoding tight junction proteins including zo- , occludin, claudin b, and claudin c were also detected. βactin was used as an internal reference gene . the specific primers were designed according to the published grass carp sequences and were listed in table s . the qrt-pcr procedure was carried out by the process described ). data were analyzed by the -ΔΔct method with cfx manager software. the whole intestines of the three fishes were aseptically excised and opened and rinsed with sterilized pbs to remove the contents. intestines from three fishes in the same group were collected into one sterile centrifuge tube. the intestinal samples were homogenized with sterilized pbs. the genomic dna was extracted using omega d bacterial dna kit (omega, usa) according to manufacturer's protocols. the v -v regions of s ribosomal dna of bacteria were amplified, purified, and pooled in equimolar and paired-end sequenced ( × bp) on an illumina miseq platform (oe biotech, shanghai, china). data was demultiplexed, quality filtered, and analyzed with qiime(v . . ) and uchime (v . ) (caporaso et al. ; edgar et al. ) . operational taxonomic units (otus) were generated using vsearch (v . . ) software with % similarity cutoff. all representative reads were annotated and blasted against silva database (v ) using rdp classifier (v . ) with the confidence threshold of % (hao et al. a ). bias-corrected chao richness estimator (chao ) was applied to evaluate the community richness. shannon-wiener index (shannon) and simpson's diversity index (simpson) was used for diversity evaluation for each sample. the structures of the microbial community in different samples were compared based on the column diagram, heat map analysis, and principal-component analysis (pca) (hao et al. a ). the bacterial abundance was analyzed among the groups. all the illumina sequencing data has been deposited in the ncbi sequence read archive database (http://www.ncbi.nlm.nih.gov/sra/), and the accession n u m b e r s w e r e s r r / s r r / srr /srr /srr . parafossarulus striatulus, the first intermediate host of c. sinensis, were captured from yangshan county, guangdong province, china, and were elaborately cultivated in our laboratory. after weeks acclimation, the parafossarulus striatulus were fed with c. sinensis eggs. ninety days later, snails were checked every day for cercariae release (liang et al. ). water with living cercariae was collected every day and was equally divided into each tank to infect fishes in the naïve group (n = ), b.s-cotc- group (n = ), and b.s-cotc-cspmy- group (n = ). challenge infection lasted for days. four weeks post the challenge infection, all fishes were sacrificed. the flesh was weighted, cut into pieces, and separately digested with artificial gastric juice for c.sinensis metacercaria detection. the number of metacercaria in per gram flesh of fish was calculated. data in experiments were expressed as the mean ± sd values. student's t test was applied to analyze statistical differences in mrna levels and number of metacercaria in per gram flesh among different groups using graphpad prism software (version . for windows). one-way analysis of variance (anova) with tukey tests were used to analyze statistical differences of antibody levels with graphpad prism software (version . for windows). the difference was considered as statistically significant if the p value < . . sds-page and western blotting by using anti-cspmy antibody showed that cotc-cspmy expressed in coat proteins extracted from the recombinant b. subtilis spores (fig. a, b) . flow cytometry showed that . % of b.s-cotc-cspmy spores exhibited a strong fluorescence intensity ranging from to by anti-cspmy serum as a primary antibody (fig. c) . lc-ms/ms confirmed the protein band with kda as cspmy ( fig. d and table s ). specific igm levels in sera, skin mucus, intestinal mucus, and bile compared with naïve groups and b.s-cotc groups, specific anti-cspmy igm levels in sera, skin mucus, intestinal mucus, and bile samples from fishes of b.s-cotc-cspmy groups raised since week and went on rising till week ( fig. ) . in the skin mucus, igm level significantly elevated from week ( fig. b) , which raised later than those in sera, intestinal mucus, and bile samples ( fig. a, c, d) . compare with the dosage group, and dosage groups elicited higher igm level. the highest one was dosage group (fig. ) . mrna levels of igm and igz in the head kidney and spleen compared with naïve groups, the mrna levels of igm and igz in middle dosage ( × cfu/g b.s-cotc-cspmy spores) and high dosage ( × cfu/g b.s-cotc -cspmy spores) were significantly increased both in the head kidney and spleen. the mrna levels of igm and igz in × cfu/g groups were the highest. there was no significant difference in mrna levels of igm and igz in the head kidney and spleen between naïve group and b.s-cotc group. compared with naïve group, there was no statistical increase of mrna levels of igm and igz in × cfu/g group except igz mrna level in the head kidney (fig. ). in the head kidney, tnf-α mrna level of × cfu/g b.s-cotc-cspmy group were significantly higher than those in naïve group and b.s-cotc group (fig. s a ), while no significant differences were detected between those in × and × cfu/g b.s-cotc-cspmy groups. il- mrna level was significantly raised compared with both naïve group and b.s-cotc group. in spleen, mrna levels of tnf-αand the paramyosin from c. sinensis was identified in coat proteins il- significantly increased in × and × cfu/g b.s-cotc-cspmy groups compared with those in naïve group (fig. s b ). no differences were detected between b.s-cotc and naïve group (fig. s ). to investigate the influences of oral administration of spores on the integrality of intestines mucosa, transcriptional levels of genes encoding tight junction proteins (zo- , occludin, claudin b, claudin c) in foregut, midgut, and hindgut of grass carp were analyzed. in the foregut, transcriptional levels of zo- , occludin, claudin b, and claudin c were the highest in fishes fed with × cfu/g b.s-cotc-cspmy spores, which were significantly increased compared with those in fishes from naïve or b.s-cotc groups (fig. s a) . the zo- mrna level in the midgut and hindgut were not dominantly affected by spores administration (fig. s b-a, c-a) . transcriptional levels of occludin, claudin b, claudin c in midgut, and hindgut of grass carp from × b.s-cotc-cspmy spores group were obviously elevated compared with those of other groups (fig. s b, c) . in total, otus were generated from the samples through illumina miseq sequencing, and these otus belong to different phyla. good's nonparametric coverage estimator (good's coverage) of each sample tend to approach ( fig. aa) . chao index was used to estimate microbial community richness of the intestinal microbiota. the chao value in × cfu/g b.s-cotc-cspmy spores (bh) group was the highest compared with those of other groups ( fig. a-b) . shannon index and simpson index were calculated to evaluate microbial community diversity. shannon and simpson index value of bh group was the highest among the groups. diversity index of b.s-cotc spores fed group (bc), × / / cfu/g b.s-cotc-cspmy spores treated groups (bl, bm, bh) were higher than that of control group (nc) (fig. a-c, d) . the shared and unique outs among the samples were investigated and showed in the venn diagram. a total of otus were shared by all the groups, and unique outs were detected in bh group, which was the largest number among groups (fig. b) . principal components analysis (pca) with weighted unifrac method was applied to analyze the relationships between bacterial communities from different groups. the score plot of pca revealed that microbial communities from bc, bl, bm, and nc groups were gathered at left-hand side of the plot along the second principal component axis (pc ), which accounts for . % of the total variations. however, bh group was on right side of the graph along pc . bl group was separated from the other groups along pc , which represented . % of the total variations. in general, the two axes (pc and pc ) explained . % (fig. c ). in addition, the b.s-cotc- : basal diet plus × cfu/g b.s-cotc spores. b.s-cotc-cspmy- , , , basal diet plus , , cfu/g b.s-cotc-cspmy spores, respectively. data were represented as mean ± sd. statistical significance was analyzed by the dunnett's test. *p < . , **p < . , ***p < . differences among the groups were also observed in the heatmap, which showed the bacteria ranking top in the abundance. (fig. d) . proteobacteria, fusobacteria, firmicutes, and spirochaetae were main bacteria phyla in all grass carp, accounting for more than % of bacteria. firmicutes were the most predominant phylum in bh group ( . %), followed by fusobacteria ( . %). in nc, bc, and bm groups, proteobacteria had the highest abundance accounted for . %, . %, and . %, respectively (table ) . the abundance of potential pathogenetic bacteria such as pseudomonas and flavobacterium were detected in samples. the amount of sequences related to pseudomonas in bh group decreased compared with that in nc group. flavobacterium with lower abundance was found in nc and bl groups but not in bh, bc, and bm groups. (table ) . candidate probiotics including lactobacillus, streptococcus, and micrococcus were also detected and analyzed. higherabundance lactobacillus and streptococcus genus were found in bh group compared with nc group. micrococcus could not be detected in all samples (table ). in addition, sequences related to bacteria associated with digestion were also investigated. the abundance of rikenellaceae, ruminococcaceae, and lachnospiraceae (at family level) varied in different groups, but they were dramatically increased in bh group compared with other groups ( table ). the abundances of odoribacter, desulfovibrio, and alistipes were higher in bh group than those in nc, bl, and bm groups. after the challenge infection with living cercaria (fig. a) , c. sinensis metacercaria (fig. b ) was found in all treated fishes. the average amount of metacercaria per gram fish flesh in the naïve group, b.s-cotc- group, and b.s-cotc-cspmy- group was . , . and . , respectively (fig. c ). in the current study, we orally administrated grass carp with × , × or × cfu/g b. subtilis spores surface displaying cspmy. the results showed that specific anti-cspmy igm levels in sera, skin mucus, intestinal mucus, and bile samples from fishes in b.s-cotc-cspmy spores orally treated groups dominantly increased. in × cfu/g b.s-cotc-cspmy spores administrated fishes, mrna levels of fig. the relative mrna levels of igm and igz in the head kidney and spleen. the mrna levels of igm and igz were analyzed by qrt-pcr at weeks after the beginning of the immunization. (a) igm mrna level in the head kidney; (b) igz mrna level in the head kidney; (c) igm mrna level in the spleen; (d) igz mrna level in the spleen. naïve, basal diet group; b.s-cotc- : basal diet plus × cfu/g b.s-cotc spores. b.s-cotc-cspmy- , , , basal diet plus , , cfu/g b.s-cotc-cspmy spores, respectively. *p < . , **p < . (compared with naïve group); #p < . , ## p < . (compared with b.s-cotc- group) igm, igz, tnf-α, and il- significantly elevated in the head kidney and spleen, and transciptional levels of tight-junction proteins in foregut, midgut, and hindgut of grass carp obviously increased too. gut microbiome indicated that potential pathogenetic bacteria with lower abundance and higher abundances of candidate probiotics and bacteria associated with digestion in × cfu/g b.s-cotc-cspmy spores administrated fishes were detected. the amount of metacercaria in per gram fish flesh were statistically decreased in × cfu/g b.s-cotc-cspmy spores orally immunized group. in the past years, the prevention and management of the c. sinensis mainly relied on an integrated control strategy including chemotherapy of infected patients, management or numbers represent the relative abundance of the predominant bacterial phyla. nc, fishes were fed with basal diet; bc, fishes were fed with pellets covered with b.s-cotc spores ( × cfu g − pellets); bl, bm, bh, fishes were fed with pellets covered with dosages of × , × , × cfu g − pellets of b.s-cotc-cspmy spores, respectively sterilization of feces, implementation of education campaigns, etc. lun et al. ; qian et al. ). this strategy helped to reduce the infection rate of c. sinensis in human beings to a certain degree (qian et al. ), but surveys showed that, in some epidemic areas, the prevalence of c.sinensis has been increasing over the years (lun et al. ). hence, vaccine or more effective drugs are urgently expected to control the spread of c. sinensis. a lot of research works had explored vaccine against c.sinensis in recent years, but almost of them were focused on vaccine for the final host (tang et al. b ). to our knowledge, eating raw or undercooked fish flesh harboring living metacercaria is the only route for human being or animals to get infected with c. sinensis. in view of this status, we speculated that cutting off the life cycle of c. sinensis by interfering the metacercariae formation in freshwater fish might be a potential strategy. in our previous work, oral vaccines based on b. subtilis spore expressing enolase or cysteine protease of c. sinensis has already been tested on grass carp and proved to be able to induce both system and local mucosal immune response of fish tang et al. ) . but immune protect effect elicited from vaccine candidates besides the two molecules still needs further evaluation and confirmation . cspmy, as a multifunctional molecular and important component of cyst wall of c. sinensis metacercaria, has been well characterized as a vaccine candidate ). in the current study, cspmy was displayed on the surface of b. subtilis spores by using a coat protein (cotc) as an anchor. sds-page, western blotting, flow cytometry, and lc-ms/ms verified the successful expression of cspmy (fig. ) . recombinant b. subtilis spores are firstly took in by the m cells in intestinal mucosa and transported into peyer's patches. antigens presented on the surface of spores interact with mucosa-associated lymphoid tissues (malts) and other systemic lymphoid tissues, resulting in a series of immune responses including secretion of immune globulins (rosales-mendoza and angulo ; tang et al. a; tavares batista et al. ) . in bony fishes, as there are a lot of lymphoid cells, macrophages, eosinophilic, neutrophilic granulocytes, and other secretory cells in skin, it is also a main tissue-producing mucosal immune response besides intestinal mucosa (salinas ) . antigen-specific immune globulins (e.g., igm and igz) were secreted from intestinal mucus and skin mucus when they were stimulated by heterogeneous antigens so that they serve as the first line of immunological barriers against pathogenic invasion (zhu et al. ). well-studied igm is the main kind of immune globulins in grass carp. igz, analogous to mammalian iga, also plays a specialized role in mucosal immune responses of fish (xu et al. ). in the present study, the specific igm antibody levels in serum, bile, intestinal mucus, and skin mucus of grass carp orally administrated with different dosages of spores (b.s-cotc-cspmy) were significantly increased with dosedependent from the nd week after the beginning of the immunization till to weeks (fig. ) . our results were coincident with the former reports about immune response in grass carp induced by oral immunization with spore expressing enolase or cysteine protease of c. sinensis tang et al. ) . moreover, mrna levels of igm and igz were up-regulated in the head kidney and spleen of fishes from b.s-cotc-cspmy spores orally treated groups (fig. ) . the results verified that cspmy on the spore surface could be recognized by immune system in intestinal mucosa and obviously elicit strong systemic and local mucosal immune response in grass carp by oral administration, especially treated with high dosage (b.s-cotc-cspmy- ). the numbers represent the total abundance of bacteria genus presented in the community. nc, fishes were fed with basal diet; bc, fishes were fed with pellets covered with b.s-cotc spores ( × cfu g − pellets); bl, bm, bh, fishes were fed with pellets covered with dosages of × , × , × cfu g − pellets b.s-cotc-cspmy spores, respectively # at family level *at genus level the numbers represent the total abundance of bacteria genus presented in the community. nc, fishes were fed with basal diet; bc, fishes were fed with pellets covered with b.s-cotc spores ( × cfu g − pellets); bl, bm, bh, fishes were fed with pellets covered with dosages of × , × , × cfu g − pellets b.s-cotc-cspmy spores, respectively * represent the potential pathogenetic bacteria # the candidate probiotics the specific igm levels in the intestinal mucus and bile of grass carp increased more early than that in sera or skin mucus in b.s-cotc-cspmy groups (fig. ) . it might due to that orally delivered antigen (cspmy) interacted with the local immune system on the intestinal mucosa first and later triggered the systemic immune reaction. it has been documented that immune status of grass carp was closely related to expression of cytokines (secombes et al. ). il- was considered to be one of the most important proinflammatory cytokines in grass carp (wang et al. ) . il- expresses in immune-related tissues in grass carp such as the head kidney, spleen, gill, and so on. il- level would increase when grass carp was stimulated by heterologous antigens or pathogens resulting in attraction of other immunerelated cells for fighting against the pathogens (wang et al. ) . tnf-α was also proved to be a crucial cytokine involved in immune regulation and mediates the inflammatory responses in grass carp zhu et al. ). in the current study, mrna levels of tnf-α and il- in the head kidney and spleen in b.s-cotc-cspmy- and groups were significantly up-regulated at week ( fig. s ). it demonstrated that oral administration of the recombinant spores activated the innate immunity and might invoke specific adaptive immune responses . additionally, the tnf-αlevel had no significant difference in b.s-cotc-cspmy × and × group in the head kidney. the possible reason might be that the spore dosages ( × and × cfu/g) were not enough to induce tnf-αsecretion in the head kidney because a certain amount of the spores might be excreted from the intestine with the intestinal movement (leser et al. ) . studies showed that the structural integrity of intestinal mucosa was crucial to vaccinated fishes . tight junction proteins play vital roles in tight junction among epithelial cells of intestine which maintains intestinal integrity resulting in the foundation of mechanical barrier (chen et al. ) . evidences indicated that expressions of tight junction proteins such as zo- , occludin, claudin b, or claudin c would be down-regulated when intestinal mucosa was damaged by inflammation (chen et al. ; feng et al. ; gong et al. ) . our results showed that oral administration with or cfu/g − b. subtilis spores up-regulated mrna levels of occludin, claudin b, and claudin c in foregut, midgut, and hindgut. mrna levels of zo- increased in the foregut (fig. s ) . it was previously mentioned that b. subtilis could promote epithelial tight junctions of mice with inflammatory bowel disease (gong et al. ) , indicating that b. subtilis spores were beneficial to maintenance of structural integrity of intestinal mucosa in grass carp. the gastrointestinal microflora is a complex ecosystem harboring a variety of bacterial communities and plays an imperative role in immune regulation and nutrition consumption of the host (han et al. ; hao et al. a; hao et al. b) . variation in the diversity and abundance of bacteria in intestine seriously impairs the immune development and function (nayak ) . it has been verified that probiotic additive (e.g., b. subtilis) enhance certain innate immune response, thus improve disease resistance of the host (hao et al. a; li et al. ; liu et al. ) . in addition, probiotic supplement in the diets improves growth performance by positively improving the composition of intestinal microbial community (hao et al. a) . we analyzed intestinal microbiota by using s rrna sequencing. our results indicated that proteobacteria, firmicutes, and fusobacteria were the dominant phyla in each group (table ), suggesting that dietary supplement of b. subtilis spores did not affect the primary phyla constitution of grass carp. compared with naïve group, both the diversity and richness indices of bacteria in intestines of spores administrated grass carp were elevated, especially in b.s-cotc-cspmy- group. the results of pca, venn, and heatmap also verified that the intestinal microbiota in b.s-cotc-cspmy- group was dramatically different from the other groups (fig. ) . previous studies reported that b. subtilis ch and b. subtilis cgmcc . strains could increase probiotics but decrease pathogenetic bacteria in intestinal of grass carp or broilers (hao et al. a; li et al. ) . streptococcus, lactobacillus, and micrococcus have been widely used as probiotics in aquaculture and brought positive effects on the host including improvement of the immune status and inhibiting pathogen infection in the intestines (balcazar et al. ; hai ) . in our present study, the abundance of streptococcus and lactobacillus in high-dosage spores-treated group was dramatically higher than those in other groups (table ) , while lactobacillus was not detected in intestine of b. subtilis treated fish (hao et al. a) . considering that culture condition and feed may affect intestinal microbiota of fish (han et al. ; wu et al. ) , it might due to the different culture condition and diet in different experiments. some strains from flavobacterium and pseudomonas genera were considered to be potential pathogens to grass carp, as they might induce columnaris disease, white head-mouth disease, and red skin disease (hao et al. a) . lower abundance of flavobacterium was found in naïve group but not in b. subtilis treated groups. dramatically lower abundance of pseudomonas in b.s-cotc-cspmy- group was detected compared with naïve group ( table ) . the results demonstrated that oral administration with probiotics might reduce potential pathogenic bacteria in grass carp intestine (hao et al. a; liu et al. ) . a possible explanation might be that probiotics generate antibiotics, bacteriocins, hydrogen peroxide, and lysozyme, etc., thus inhibit the adherence or proliferation of pathogens in intestinal mucosa (hai ; sugita et al. ). in addition, rikenellaceae, ruminococcaceae, and lachnospiraceae were dramatically increased in b.s-cotc-cspmy- group. at genus level, higher abundance of alistipes, odoribacter, and desulfovibrio in the high-dosage group were presented (table ) . rikenellaceae were considered as intestine beneficial bacteria, as alistipes genus belong to the family can produce fibrinolysin, digest gelatin, and ferment carbohydrate resulting in enhancement of digestion in fishes . odoribacter can produce short-chain fatty acids (scfas) such as acetic acid, succinic acid, or butyric acid, which are beneficial to both microbial and epithelial cell growth of host (meehan and beiko ) . desulfovibrio has also been proved to be beneficial to the microbial community and able to improve energy recovery from food . lachnospiraceae are a butyrate-producing superfamily, which can produce an enzyme to break down a wide variety of complex carbohydrates found in plants (hao et al. b) . hence, higher abundances of these bacteria found in the intestines would probably be helpful to digestion function of grass carp and promote their growth performance. compared with naïve group, abundances of bacteria mentioned above were not obviously changed in bc, bl, and bm group (b.s-cotc- , b.s-cotc-cspmy- / groups) (tables , , ) . it might because that lower dosage of b. subtilis spores accompanied by less colonized b. subtilis spores in intestine of grass carp (hao et al. a) . after oral immunization, the fishes were infected with c. sinensis cercaria for a week. compared with naïve group, metacercaria intensities in b.s-cotc-cspmy- spore treated grass carp were significantly decreased (fig. c ). we conjectured that immune responses induced by the recombinant spores (b.s-cotc-cspmy) played roles in protecting against adherence or invasion of cercaria to grass carp. it needed further study to illuminate the involved mechanisms. when grass carp was orally administrated with b.s-cotc-cscp spore ( dosages), no metacercariae were observed . we speculated that might be due to two reasons: firstly, the function and immunogenicity of cspmy were different from those of cscp (tang et al. a; wang et al. ) resulting in different protect effect. secondly, the methods used for metacercariae detection were different. in the former study, metacercariae were checked by direct compression method by randomly picking fish flesh from different positions in one fish , which might lead to missed detection when the infection intensity was low. while in our present study, we checked by digestion method with high detection rate. that is, the fishes were totally digested with artificial gastric juice, so that every metacercariae could be detected. in conclusion, oral administration with b.s-cotc-cspmy spores could induced both systemic and local mucosal immune responses without bad effects on intestinal structural integrity and elicited promising protective effect in grass carp. additionally, oral treatment of the spores in grass carp could reduce the abundance of potentially pathogenic bacteria (e.g., flavobacterium) and enhance the abundance of probiotics (e.g., streptococcus, lactobacillus) or bacteria associated with digestion. our work suggested that b. subtilis spore presenting cspmy on the surface is a promising effect, safe, and needlefree oral vaccine candidate for prevention of c. sinensis infection in grass carp. our study established the cornerstone for the prevention of c. sinensis infection in both human and mammalian reservoir hosts by using fish vaccine to cut off its life cycle. this work also shed light on the vaccine development for other zoonosis. conflict of interest the authors declares that they have no conflict of interest. ethical approval all applicable international, national, and/or institutional guidelines for the care and use of animals were followed. protection against fasciola gigantica using paramyosin antigen as a candidate for vaccine production the role of probiotics in aquaculture qiime allows analysis of high-throughput community sequencing data intestinal immune function, antioxidant status and tight junction proteins mrna expression in young grass carp (ctenopharyngodon idella) fed riboflavin deficient diet germination of the spore in the gastrointestinal tract provides a novel route for heterologous antigen delivery uchime improves sensitivity and speed of chimera detection zoonotic helminths parasites in the digestive tract of feral dogs and cats in guangxi dietary phenylalanine-improved intestinal barrier health in young grass carp (ctenopharyngodon idella) is associated with increased immune status and regulated gene expression of cytokines, tight junction proteins, antioxidant enzymes and related signalling molecules immune responses of fenneropenaeus chinensis against white spot syndrome virus after oral delivery of vp using bacillus subtilis as vehicles effects of bacillus subtilis on epithelial tight junctions of mice with inflammatory bowel disease a history of fish vaccination: science-based disease prevention in aquaculture identification and characterization of bacillus subtilis from grass carp (ctenopharynodon idellus) for use as probiotic additives in aquatic feed the use of probiotics in aquaculture analysis of bacterial diversity in the intestine of grass carp (ctenopharyngodon idellus) based on s rdna gene sequences effects of dietary administration of shewanella xiamenensis a- , aeromonas veronii a- , and bacillus subtilis, single or combined, on the grass carp (ctenopharyngodon idella) intestinal microbiota impacts of diet on hindgut microbiota and short-chain fatty acids in grass carp (ctenopharyngodon idellus) an integrated control strategy takes clonorchis sinensis under control in an endemic area in south china. vector borne zoonot immune response induced by oral delivery of bacillus subtilis spores expressing enolase of clonorchis sinensis in grass carps (ctenopharyngodon idellus) development of paramyosin as a vaccine candidate for schistosomiasis improvement of in-gel digestion protocol for peptide mass fingerprinting by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry current status of clonorchis sinensis and clonorchiasis in china germination and outgrowth of bacillus subtilis and bacillus licheniformis spores in the gastrointestinal tract of pigs effect of bacillus subtilis cgmcc . on the growth performance and intestinal microbiota of broilers experimental establishment of life cycle of clonorchis sinensis prevalence of clonorchis sinensis infection in dogs and cats in subtropical southern china effect of a new recombinant aeromonas hydrophila vaccine on the grass carp intestinal microbiota and correlations with immunological responses dietary administration of bacillus subtilis hainup enhances growth, digestive enzyme activities, innate immune responses and disease resistance of tilapia clonorchiasis: a key foodborne zoonosis in china carcinogenesis associated with parasites other than schistosoma, opisthorchis and clonorchis: a systematic review a phylogenomic view of ecological specialization in the lachnospiraceae, a family of digestive tractassociated bacteria role of gastrointestinal microbiota in fish infections by hepatic trematodes in cats from slaughterhouses in vietnam sporulation, germination and outgrowth advances in fish vaccine delivery antigen uptake and immune responses after oral vaccination mucosal vaccine delivery by non-recombinant spores of bacillus subtilis bacillus subtilis comes of age as a vaccine production host and delivery vehicle the mucosal immune system of teleost fish effect of mixed-bacillus spp isolated from pustulose ark anadara tuberculosa on growth, survival, viral prevalence and immune-related gene expression in shrimp litopenaeus vannamei cytokines and innate immunity of fish production of the antibacterial substance by bacillus sp. strain nm , an intestinal bacterium of japanese coastal fish bacillus subtilis spore with surface display of paramyosin from clonorchis sinensis potentializes a promising oral vaccine candidate the immunological characteristics and probiotic function of recombinant bacillus subtilis spore expressing clonorchis sinensis cysteine protease current status and perspectives of clonorchis sinensis and clonorchiasis: epidemiology, pathogenesis, omics, prevention and control oral delivery of bacillus subtilis spores expressing cysteine protease of clonorchis sinensis to grass carp (ctenopharyngodon idellus): induces immune responses and has no damage on liver and intestine function gut adhesive bacillus subtilis spores as a platform for mucosal delivery of antigens effects of the dietary supplementation of mixed probiotic spores of bacillus amyloliquefaciens a, and bacillus pumilus b on growth, innate immunity and stress responses of striped catfish first litopenaeus vannamei wssv % oral vaccination protection using cotc::vp fusion protein displayed on bacillus subtilis spores surface characterization and protective potential of the immune response to taenia solium paramyosin in a murine model of cysticercosis immunostimulatory activities of bacillus simplex dr- to carp (cyprinus carpio) identification and characterization of paramyosin from cyst wall of metacercariae implicated protective efficacy against clonorchis sinensis infection molecular characterization, expression analysis, and biological effects of interleukin- in grass carp ctenopharyngodon idellus composition, diversity, and origin of the bacterial community in grass carp intestine teleost skin, an ancient mucosal surface that elicits gut-like immune responses functional characterization of tnf-alpha in grass carp head kidney leukocytes: induction and involvement in the regulation of nf-kappab signaling liver fluke infection and cholangiocarcinoma: a review oral administration of a bacillus subtilis sporebased vaccine expressing clonorchis sinensis tegumental protein . kda confers protection against clonorchis sinensis advances in research of fish immune-relevant genes: a comparative overview of innate and adaptive immunity in teleosts publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -kg uvpi authors: vita, s.; dalessandri, a.; alfonzetti, t.; britti, d.; boari, a. title: evaluation of total proteins and serum protein fractions in cats naturally infected by leishmania infantum–a preliminary study date: journal: vet res commun doi: . /s - - - sha: doc_id: cord_uid: kg uvpi nan in canine leishmaniosis, laboratory parameters such as serum total proteins (tps), albuminto-globulin (a/g) ratio, and single serum protein fractions have been proposed for their particular diagnostic significance and for monitoring the progress of the disease (ceci and petazzi, ; bizzetti, ; ciaramella and de luna, ) . during the course of canine leishmaniosis, tps may be mildly or remarkably increased or they may remain within normal ranges, depending on the degree of decrease in the serum albumin level. this decrease is often associated with βand γ-globulin increase, due to the activation of b-lymphocytes (bungener and mehlitz, ) , resulting in a reduction of the a/g ratio. hypoalbuminemia may be the consequence of increased albumin loss secondary to glomerular or small bowel disorders (ceci and petazzi, ) , or decreased albumin synthesis because of chronic hepatic insufficiency (bizzetti, ) . in canine leishmaniosis the electrophoretic pattern is often characterized by increased βand γ-globulin concentration. during the progress of feline leishmaniosis, some authors have observed increased serum tps associated with hyper-γ-globulinemia and hypoalbuminemia with inversion of the a/g ratio and changes in the α-globulin fractions (laurelle-magalon and toga, hervas et al., ; ozon et al., ; pennisi, ; poli et al., ) . according to other authors, serum protein concentration may be normal or only mildly changed in cats with leishmaniosis (athias, ; merchant and taboada, ) . to the best of our knowledge, the evaluation of serum protein changes has only been reported once for a group of fiv infected cats positive to pcr assay for leishmania infantum (pennisi et al., ) . the objective of this study was to evaluate serum tps and some protein fractions in cats positive to leishmania. the study was performed on domestic shorthair cats (group a), females and males, with an age ranging between months and years. all cats were positive to the indirect immunofluorescent antibody test (ifat) for anti-l. infantum antibodies at the following titres: : (no. ); : (no. ); : (no. ) and : (no. ). a titre ≥ : was considered positive. all cats were also positive using a qualitative pcr assay for l. infantum on blood samples. some cats were clinically asymptomatic (no. ), while others showed moderate lymphadenomegaly (no. ), anorexia and weight loss (no. ), clinical signs related to chronic renal failure (no. ), respiratory disorders (no. ), chronic intestinal inflammatory disease (no. ), and flea-bite hypersensitivity (no. ). the control group included cats (group b) of different breeds, females and males, with an age ranging between months and years. these were clinically healthy and negative to the ifat for l. infantum. total proteins, albumin levels, a/g ratio, and protein electrophoresis were analysed on serum samples of both groups. total proteins and serum albumin concentration were measured with an automated chemistry analyser (olympus au ), and electrophoresis and relative protein fractions were measured with an automatic instrument (amplimedical esprime ). cats of both groups were also tested with an elisa assay (snap combo plus r ) for the detection of fiv antibodies and felv antigens, and with an ifat for coronavirus antibodies. results are expressed as mean ± sd and the % confidence interval ( %ci) was calculated for each parameter. the student's t test for unpaired data (software graphpad prism . ) was employed to compare data observed in the two groups of cats. furthermore, additional statistical comparison was made between seronegative cats (group b) and subjects of group a with equal titres of ifat ( : and : ) for leishmania, and between cats of group b and clinically asymptomatic subjects of group a . significance was set at p < . . cats belonging to both group a and b were negative to fiv, felv and coronavirus with the exception of cats ( %) of group a that tested positive for fiv and, therefore, were excluded from successive statistical analysis. results of tps, a/g ratio, and serum protein fractions, expressed as mean ± sd and %ci, are shown in table i . albumin concentration and a/g ratio were significantly lower (p < . ), and γ-globulin concentration was significantly higher (p < . ) for positive cats when compared to cats of the control group. the statistical comparison between the values of the subjects positive to titre : and those of group b showed the same level of significance observed between the entire group a and group b. the comparison between the subjects positive to titre : and the values of group b, resulted in statistically significant differences for the following: a/g (p < . ), albumin (p < . ), α -globulins (p = . ), α -globulins (p = . ) and γ-globulins (p < . ). furthermore, comparing the values of group b with those of the clinically asymptomatic subjects of group a (no. ), statistically significant differences were obtained for the following parameters: a/g (p < . ), γ-globulins (p < . ), and albumins (p < . ). our results showed that the modifications in tps, a/g ratio, and serum protein electrophoresis in cats naturally infected with l. infantum, are similar to those observed in dogs with leishmaniosis (bizzetti, ; ceci and petazzi, ; ciaramella and de luna, ) . furthermore, seropositivity in cats seems to be associated with a decrease in the a/g ratio secondary to both hypoalbuminemia and hyper-γ-globulinemia. this finding is particularly relevant because it has also been observed in asymptomatic seropositive cats. the comparison among seronegative cats and cats of group a with different ifi titres showed that subjects with a titre of : had the same statistical significance of the entire group a, whereas subjects with a titre : also had a higher level of both α -globulins and α globulins when compared to the control group. since the increase in α-globulin fraction is usually associated with an acute inflammation (kaneko, ) , the variations found in subjects with different antibody titres may be due to a different stage of the infection, even though the subdivision of group a on the basis of a single dilution could seem arbitrary. by recruiting a higher number of seropositive cats more definitive data could be obtained. in addition, it will be necessary to collect follow-up data for these subjects to be able to assess the relationship between the modifications of the considered parameters and the course of the infection. in conclusion, the evaluation of different laboratory parameters has emerged as useful tool for addressing the diagnostic suspicion of l. infantum infection also in the cat, especially in areas endemic for leishmaniosis. la sieroelettroforesi per il controllo nel cane della leishmaniosi atypical course of leishmania donovani infections in dogs. histopathological findings aspetti immunoelettroforetici della leishmaniosi canina leishmaniosi nel cane: aspetti clinicodiagnostici. obiettivi e documenti veterinari two cases of feline visceral and cutaneous leishmaniosis in spain serum proteins and the dysproteinemias un cas de leishmaniose fèline systemic diseases with cutaneous manifestations. the veterinary clinics of north america small animal practice disseminated feline leishmaniosis due to leishmania infantum in southern france high prevalence of feline leishmaniasis in southern italy studio dell'infezione da leishmania mediante pcr in gatti che vivono in zona endemica feline leishmaniosis due to leishmania infantum in italy key: cord- -esnsa u authors: nan title: abstracts (th) tripartite meeting salzburg/austria, september – , date: journal: langenbecks arch chir doi: . /bf sha: doc_id: cord_uid: esnsa u nan the gastric secretion capacity increases during the first year after all types of vagotomy which is assumed to be important for the development of recurrent ulceration. however, the cause of this reestablishment of the preoperative gastric function is not adequately explained. the purpose of this study was to investigate the vagal innervation of the parietal cell mass in dogs / year after truncal vagotomy (tv), selective gastric vagotomy (sgv) and parietal cell vagotomy (pcv). material and methods: mongrel dogs supplied with a gastric fistula were used. the groups comprised dogs with tv, dogs with sgv and dogs with pcv. the acid secretion was measured before and one month and one year after vagotomy following insulin and pentagastrin stimulations. operative technique: a gastroduodenostomy was performed in addition to the gastric fistula operation in the dogs randomised for either tv or sgv. the vagotomy operations were performed after the prevagotomy secretion experiments. tv by a cm resection of the main truncs through a left side thoracotomy and sgv as described by amdrup [ ] . the pcv dogs had no gastroduodenostomy added but the technique at the lower esophagus was identical with the sgv and the dissection of the lesser curvature was extended cm distal of the sharp physiological and histologically determined borderline between the fundus and the antrum. about / year after the vagotomy the dogs were sacrificed by an acute experiment. the persistent or the regenerated vagal innervation of the parietal cell area was mapped out by neutral red excretion elicited by electrical stimulation of either the thoracic or the cervical vagal nerves [ ] . results: one year after vagotomy no increase in insulin response could be demonstrated in the tv and sgv groups, but a gradual increase to about % of prevagotomy output occured in all pcv dogs. reliable neutral red experiments were performed in tv, sgv and pcv dogs. the stimmulated neutral red excretion was scanty to the same extent at the cardia region in all three groups, but a distinct antralfundic border was outlined in all pcv dogs. the border was, however, only suggested in one of the sgv dogs. conclusion: pcv including denervation of cm distal of the antral-fundic border do not prevent a functional important reinnervation of the distal part of the parietal cell area. no important reinnervation seems to occur at the cardia region after any of the three vagotomy procedures. and insulin ( . ugkg - ) i.v. bolus; after uni-and then bilateral truncal vagotomy. each study was minutes and blood was taken at , , , and then min intervals. gastric acid was measured by autobiuret titration. plasma was stored at - °c until assayed for pp by ria using an antibody sensitive to fmol ml- . results are expressed as mean total increment _+ se. significance: p < . ". bombesin-stimulated gastric acid secretion was not significantly altered by vagotomy (p < . ), whereas that stimulated by insulin was significantly inhibited by bilateral truncal vagotomy (p < . ). bilateral and right hemi-vagotomy significantly inhibited pp release by bombesin ( < . ), however; only bilateral truncal vagotomy significantly inhibited pp release by insulin (p < . ). these results suggest that the measurement of pp release by insulin or bombesin is a sensitive index of vagal integrity and that bombesin-released pp may specifically delineate the integrity of the right vagus. since the measurement of gastric acid secretion after operation is both uncomfortable and often difficult to interpret, the value of a simple blood test to determine vagal integrity may be of considerable clinical relevance. glucose (g) or oleate (o) empty more slowly from the stomach than . m nac (s). this chemoregulation may be achieved by resistance beyond the proximal stomach [ ] . we sougth to define the site of this resistance. expt. : gastric emptying of s and mm g was measured in dogs with intestinal cannulas cm distal to the pylorus while gastric pressure was maintained at , or cm h with a barostat. the dogs were studied either with an uninterrupted intestinal stream or with duodenal effluent diverted through a second barostat prior to its return downstream. since the latter ensured a constant pressure at the ligament of treitz, any observed effects on emptying could not be due to resistance further distally. expt. : emptying of s, g, and mm oleate emulsion was measurd in dogs without cannulas after control antroduodenal transection and after antrectomy while gastric pressure was controlled at , and cm h . emptying rates expressed as the average of the volumes emptied at the pressures. under both conditions in expt. emptying rose with pressure yet s emptied faster than g. thus a major site of chemoselective resistance to emptying of liquids lies proximal to the ligament of treitz. after antrectomy s and o emptied faster than before, however, the differences between saline and nutrients were maintained. resistance, therefore, does not reside in the antrum or pylorus and clearly the duodenum is implicated. gastric emptying of liquids may be abnormally rapid in du. this abnormality my be due to a selective loss of inhibition in response to acid since previous studies [ ] have demonstrated rapid emptying of acid solutions but normal emptying of glucose and fat. previous investigations, however, used meals of only one concentration, so differences between dus and normals (n) may have been minimized by selection of a supra-maximal inhibitory dose. furthermore intragastric ph was not maintained constant so emptying could have been slowed by higher rates of acidification in du. we therefore studied emptying of graded concentrations of citric acid, glucose and oleate in ml meals. gastric volumes were measured by the george technique in dus and n at rain intervals for min after ingestion. gastric ph was maintained constant by intragastric titration ( . for acid; . for nutrients). subjects received one type of meal on separate days and the doses were randomly administered. dose dependent inhibition of emptying in response to acid and nutrients occured in n and du, but emptying was faster in du (p< . ). with glucose and acid the difference occured within - min whereas with fat the difference occurred between - min. thus ( ) dus do not have a selective loss of inhibition of emptying in response to acid, and ( ) the mechanisms which control emptying of fat and which are disturbed in du differ from those which control emptying of glucose and acid. gross ra, isenberg ji, hogan d, samloff im ( ) the effect of fat on meal-stimulated duodenal acid load, duodenal pepsin load and serum gastrin in duodenal ulcer and normal subjects. a means of reducing the requirement for postoperative nasogastric intubation would be advantageous. we report the effect of cimetidine on postoperative nasogastric aspirates. thirty patients undergoing elective abdominal aortic surgery or colonic resection were entered into a double blind randomised study, receiving cimetidine mg hourly or placebo (saline) by continuous intravenous infusion from the morning of the first postoperative day. volumes of hourly aspirates were recorded and ph and (h ÷) of samples measured. nasogastric tube removal accorded to standard clinical practice. it has been shown, that the duodenum has a better ability to resist acid than jejunum or ileum. this resistance was attributed to alkaline secretion (a.s.) of the mucosa, because pancreatic and bile secretion were excluded. recent in vitro studies demonstrated an energy dependent hco -transport (flemstroem am j physiol g : ). we were interested in studying the role of blood flow (bf) in the production of alkali in an in vivo preparation. min. three groups of animals were studied: i) controis with normovolemia for min. ii) normovolemia for min, thereafter min of shock induced by bleeding to mmhg mean arterial blood pressure. iii) min normovolemia and min vasopressin ( . i. u./kg/min) under normovolemia. in controls a small decrease in bfand a.s. as well was observed. both shock and vasopressin induced a significant reduction in a.s. and bf. the relation ofbf to a.s. was found to be exponential (y = . + . x- . x r= . ; p< . ). the reduction in a.s. during shock was much less, when shock induced acidosis was compensated by i.v.-infusion of hco ( . ,uequ/kg/min). conclusion: the alkaline secretion of the proximal duodenum is dependent on blood flow and the arterial [hco~. there has been considerable controversy as to the nature of the offending agent in the etiology in reflux oesophagitis in man. in rat studies, surgically induced reflux oesophagitis was shown to be correlated with the presence of active trypsin in the reflucting juice. reflux of bile and gastric juice with a ph of did not induce oesophagitis. even short periods of oesophagitis ( - weeks) showed an increasing amount ofpanmural fibrosis which even further increased after a reflux abolishing roux-y operation. the pattern of the collagen content of the full thikkness oesophageal wall was similar to that found in human reflux oesophagitis. the hypothesis that active trypsin is also in man responsible for reflux oesophagitis prompted to the following investigation. patients with typical gastrooesophageal reflux symptoms and control patients were endoscopically examined. on entering the stomach with the endoscope samples of gastric juice were taken for ph and active trypsin determinations. trypsin activity was determined with a kinetic method using s- (kabi vitrum b.v. amsterdam) as substrate. results: in all patients some trypsin could be detected in the gastric juice. in those patients with endoscopically erosive and/or ulcerative changes (n = ) the trypsin content was significantly elevated compared to the controls (/ < . wilcoxon). conclusions: the composition of gastric juice is determined by gastric secretion and duodenogastric reflux. duodenogastric reflux is increased in patients with symptoms of reflux oesophagitis [ ] . trypsin in gastric juice (ph . - ) will stable and partly active over prolonged periods [ ] . so from our study in man one may conclude that the high concentration of trypsin in the gastric juice in patients with reflux oesophagitis, may well be the etiological factor of the oesophagitis. disinfection, using artificial contamination of hands with escherichia coil and 'surgical' disinfection directed against the resident microflora of the hands. the authors who developed the procedure have reported unexpectedly high potency for n-propanol compared to iso-propanol, and, in turn, for iso-propanol compared to povidone-iodine and chlorhexidine preparations [ ] . however, using the same procedure we have been unable to find any significant differences in activity between these agents. we have identified several potential sources of error including the method of applying e. coliand its spontaneous loss of viability, the use of neutralizers before disinfection, the differing surfactant effects of the agents, and the absence both of a control untreated area and of a cross-over of disinfectants studied sequentially. in our parallel tests using an excision-sample technique [ ] which is considerably more sensitive than the dghm procedure, we have observed the following mean reductions in the counts of accessible bacteria: iodine in ethanol, %; povidone-iodine, %; chlorhexidine in ethanol, %; iso-propanol, the purpose of this study was to compare radiation injury in guinea pig small bowel ( ) devoid of contents ( ) containing bile ( ) containing pancreatic juice. one group was intact control animals not radiated. another was intact animals radiated. in group a roux y cholecystojejunostomy was constructed and the bile duct ligated. thus one limb contained bile, the other pancreatic juice. in group a blind roux y was constructed such that one limb was empty of contents and the other contained both bile and pancreatic juice. each animal was subjected to a single dose of rads via an abdominal port and sacrificed four days later. the severity of injury was judged by counting the number of surviving crypts per circumference. damage was further evaluated by histologic criteria -mucosal loss, edema, inflammation, hypervascularity and loss of mucus. the maximum histologlc grading score on this scale was . the microscopist was ,,blinded" as to the origin of each tissue section. for histologic grading all radiated groups were significantly different from control (p< . ) and from one another (/r< . ) except pancreatic juice vs. empty. intestine devoid of contents sustains a mild, but significant radiation injury. the presence of pancreatic juice enhances the damage. pure bile makes for yet more severe injury but still significantly less than normal whole intestinal contents which contain both bile and pancreatic juice. the main problem facing patients with ulcerative colitis after mucosal proctectomy and ileo-anal anastomosis is severe frequency of bowel action. our hypothesis was that either an artificial valve [ ] or reversed ileal loop might improve intestinal absorption and slow transit. we tested it in dogs after colectomy and low ileo-rectal anastomosis (ira). body weight, xylose absorption, serum albumin, folate, vitamin b , calcium, urea and electrolytes, full blood count, faecal weight and mouth to anus transit time [ ] were measured before operation. the dogs then randomly underwent either ira alone (control, c, n = ), ira with a cm reversed loop (ira + rl, n = ) or ira with an artifical valve (ira + v, n = ). body weight, haematological estimations and faecal chemistry were measured weekly for months post operatively. xylose absorption and transit time were measured a minimum of months after operation. body weight decreased significantly after each type of operation. there was no difference however, between (ira + rl) and c or (ira + v) and c. likewise, haematological and faecal measurements after both test operations did not differ significantly from c or from pre-op, measurements. the grosfeld valve prevented the reduction in transit time that occurred after the control operation, whereas the reversed loop did not. use of such a valve in combination with mucosal proctectomy might slow transit, but is unlikely to improve absorption. it seems worthy of further study. histologic grading___ sem crypt count-+-sem we have examined the effects of changes in intestinal blood flow induced by hypovolaemia, the mesenteric vasoconstrictors somatostatin and vasopressin and the mesenteric vasodilator prostaglandin e (pge ), on intestinal absorption, electrical activity and volume. in each of dogs a cm jejunal segment was isolated and serosal electrodes attached. in absorption experiments the segments were perfused at . ml/ rain with a solution of retool/ sodium and retool/ glucose. to measure segment volume, a solution of . g/ mannitol was perfused. this solution shows zero net absorption but does not alter electrical activity. intestinal motility and absolute volume were monitored by gamma camera. experiments were performed after a steady state was reached. absorption and transit time were measured using non-absorbable markers. electrical fast wave activity was reduced by (a) intravenous somatostatin . mcg/kg/h ( + . to _+ . ; mean_+sem/ rain) and abolished by (b) intravenous vasopressin . u/kg/h (p< . ). motility was inhibited and mean transit time was prolonged (a) . to . rain and (b) . to . rain (/r< . ). intestinal volume rose by (a) . ___ . ml and (b) . -+ . ml (p< , ). absorption was unchanged by somatostatin and fell with vasopressin ( . --- . to . -+ . ml/ min). acute blood loss sufficient to lower the central venous pressure by cm of water produced identical changes to somatostatin. pge produced no alteration in electrical activity or absorption. intestinal absorption is resistant to changes in intestinal blood flow whilst electrical activity is depressed and intestinal volume increased by mesentric vasoconstriction. the accepted views on the pathogenesis of amoebic lesions in complicated amoebic colitis are that amoebae produce a toxin resulting in cytolysis and necrosis. this concept may adversely affect the management of patients with complicated amoebic colitis by implying that once the amoebae are killed, the disease process is arrested and colonic perforation is unlikely. we present an alternative hypothesis that 'complicated amoebic colitis is the result of vascular compromise'. transmural disease is caused by amoebic invasion of vessels supplying a segment of the colon with subsequent thrombosis and ischaemic necrosis of the affected area. the ischaemic nature of the necrosis is suggested by its shape, and the demonstration of vascular thrombosis on dissection ofresected colons which have perforated. amoebic invasion of blood vessels can be demonstrated histologically. the ischaemic nature of the lesions can be confirmed by angiographic examination of the resected colon. vascular occlusion can be demonstrated pre-operatively with the use of selective mesenteric angiography, which clearly delineates the ischaemic segment of the colon. selective rnesenteric angiography in patients with fulminating amoebic colitis aided the preoperative diagnosis of colonic infarction before signs of visceral perforation had developed and permitted life saving surgical intervention. there is accurate correlation between angiographic and operative findings. in postdysenteric colitits associated with amoebic strictures of the colon, mesenteric angiography will demonstrate the ischaemic nature of the stricture and accurately define the extent of resection. after ca. the mean age at operation was and years respectively. anal canal length was . ___ . cm (mean + s.e.m.) after ia and . ___ . cm after ca. a resting tone of ___ cm water after ia and ----- cm water after cawas recorded. squeeze pressure was ___ cm water after ia and ----- cm water after ca. the recto-anal reflex was present in % of the ia patients and in % of the ca patients. a mean daily bowel frequency of . ___ . followed ia and +_ after ca. these findings show that after ia anal pressures are within the normal reference range for our laboratory [ ] . lower pressures were found after ca, probably due to the older age of the patients in this group [ ] . normal anal canal length, the integritiy of the striated sphincter and in most cases preservation of the recto-anal reflex contribute to satisfactory continence following peranal anastomoses. perineal descent is found in patients with idiopathic faecal incontinence (ifi) and patients presenting with symptoms of the descending perineum syndrome (dps), who have no incontinence. manometric, radiological and neurophysiological studies were performed in patients with ifi, all of whom leaked during rectal infusion of ml saline, patients with dps, who were continent of rectally infused saline, and matched controls. both patient groups exhibited similar degrees of perineal descent below the pubococcygeal line of straining (ifi, - . ___ . cm; dps, - . + . cm) compared with controis (- . __+ . cm;p< . in both cases), and similar prolongation of both the latency of the cutaneoanal reflex (ifi, ___ ms; dps, + ms; controls, + ms;/,< . in both cases), and motor unit potential duration (ifi, . ___ . ms; dps, . ___ . ms, control, . + . ms; p< . in both cases). moreover, both groups had an abnormal ano-rectal angle (/,< . ), though this was more obtuse in ifi than dps ( ___ ° vs ___ °;p< . ). however, while patients with ifi had lower sphincter pressures than normal (basal; ___ vs ___ cm water; / < . ; squeeze, ___ vs ___ cm water; / < . ), and required a lower rectal volume to inhibit sphincter tone for more than one minute ( + vs ___ ml; p< . l), these values were normal in patients with dps (basal; ___ cm water; squeeze, _+ cm water; rectal volume, ___ ml). these findings suggest that perineal descent and neuropathy are not necessarily associated with incontinence if sphincter pressures remain normal. aminoacids administered either enterally or intravenously stimulate gastric secretion in both dog and man. it has been suggested that absorption of amino acids from the gut into the circulation might contribute to the intestinal phase of gastric secretion. the mechanism of this stimulation by amino acids remains uncertain but in an earlier communication we reported the direct action on the parietal cell of phenylalanine, glutamine and alanine [ ] . in the present study using ( c) aminopyrine uptake as an index of dispersed parietal cell secretory function, the interaction between histamine and individual amino acids and the effect of the histamine h -receptor blocker ranitidine ( - molar) on these interactions have been examined. results (percentage of maximal stimulation produced by - molar histamine) results (percentage of maximal stimulation produced by - molar histamine) methionine glutamine alanine amino acids only ( - molar) amino acids and histamine ( - molar) - amino acids and ranitidine ( - molar) histamine and ranitidine -complete inhibition - . the response to the combination of amino acids and histamine was greater than the sum of the maximal responses to each of these agents alone. . the histamine h -receptor antagonist ranitidine completely inhibited the histamine stimulated response but only partially inhibited secretion stimulated by amino acids. we conclude that amino acids act directly on the parietal cell by a mechanism which is not solely dependent on histamine. sex related differences in gastric acid secretion have been documented (lilja et al, ) . it has been also reported that male rats have a significantly higher serum gastrin concentration than females and that oophorectomy increases serum gastrin to male levels (lichtenberger et al., ) . estimation of serum gastrin levels after administration of androgens has not been reported. aim. the aim of this study was to investigate the serum gastrin levels before and after oophorectomy and administration of estrogens and testosterone in female guinea pigs. method. groups of guinea pigs were used for this study, animals as controls, were given estrogens for weeks, were given testosterone for weeks and underwent oophorectomy. results. the mean serum (-+sem) gastrin value in controls was found + . pg/ml, after estrogens . -+ . pg/ml, after testosterone _+ . pg/ ml, after oophorectomy -+ . pg/ml. conclusion. it is concluded that estrogens decrease the serum gastrin, and that the increase of serum gastrin after administration of androgens and oophorectomy is statistically significant (/r< . ). the mechanism by which the ovarian hormones influence gastrin levels may be a sex-dependent change in the synthesis or secretion of gastrin. the reported inhibitory influence of estrogen on food consumption may be also the predominant factor in serum gastrin alterations. mean caloric intake was --+ kcal/day. moderate to severe dumping occurred in one patient. faecal fat was normal in while patients had greater than grams fat loss per day. weight loss was . _+ . % of recall weight. muscle mass measured by arm muscle circumference ( . _+ . cm) and creatinine heigth index ( ___ %) was normal for our patients but triceps skin fold was % less than normal ( . _+ . mm) indicating that in these patients fat stores were reduced. in six patients haemoglobin was less than grams per cent but serum iron, iron binding capacity and serum folate were normal. red cell folate was depressed in six patients whose haemoglobin values were normal. it is concluded that with this reconstruction total gastrectomy produces satisfactory digestive and "nutritional results. examination of factors affecting faecal fat loss and folate metabolism may help improve the nutritional status of these patients. in order to assess the optimal conditions for segmental pancreatic graft viability the following experiment was conducted. the duct obliterated splenic lobe of the canine pancreas was autotransplanted by end to side fashion to the femoral vessels (n = ). the graft was lodged in a subcutaneous pocket. a month later total pancreatectomy was completed. the dogs were supplemented with pancreatic enzymes (viokase). mean survival was ___ days. deaths were due to hyperglycemia when grafts lysed from local infection and thrombosis. in the second experimental group (n= ) the autografts were anastomosed to the iliac vessels and placed intraperitoneally followed by total pancreatectomy one month later. construction of a distal splenic arterio-venous fistula increased blood flow from . cc/min to cc/min. the pancreatic duct was obliterated with neoprene (n= ) silastic (n= ) or left open (n= ). three dogs died one month to four months due to graft fibrosis and failure. seven dogs had been followed from four months up to seven months when sacrificed. all were normoglycemic. mean k values for ivgtt were . . the normoglycemic dogs had mean plasma concentrations of amino acids similar to healthy controls. a two to threefold elevation was observed in pancreatectomized diabetic dogs for plasma leucine, isoleucine and valine. immunoreactivity of pancreatic polypeptide was measured by radioimmunoassay with an antibody raised against the human hormone by re. chance, lilly research laboratories. mean plasma levels rose form --+ s.e. pg/ml to over pg/ml following protein meal ( g ground lean beef/kg) in all normal control dogs (n= ), and to levels in the range of to over pg/ml in the same dogs following infusion ofbombesin ( pg/kg/ h) for min. mean basal levels were lower ( ___ . s.e. pg/ml) in dogs with autotransplants and did not increase significantly during any stimulatory test. the levels of pancreatic polypeptide did not distinguish between viable and failing grafts. in successful grafts histology showed fibrosis of the exocrine component. transmission electron microscopy revealed the presence of clusters of functional islet cells in the six-month implants. a and b cells were common. d cells were much less frequent. release of secretion granules into the perivascular connective tissue space was observed. the results indicate that vascularized segmental pancreatic graft comprising % to % of the pancreatic mass maintains normal carbohydrate and amino acid metabolism. graft survival was extended by intraperitoneal location and creation od distal splenic a-v fistula, but chronic graft fibrosis occurred regardless of the method of pancreatic duct treatment. the results further suggest the necessity of an intact vagal innervation for the physiological or pharmacological stimulation of pancreatic polypeptide release from thendocrine pancreas which is otherwise apparently functional. besides, these considerations rule out pancreatic polypeptide levels as a useful marker for evaluation of pancreas graft. polyisoprene ductal occlusion allows segmental pancreatic transplantation in man with satisfactory early islet cell function. however acute rejection remains a problem as the diagnosis, based on hyperglycaemia and glycosuria, represents a late manifestation of rejection. although llqndiumlabelled platelets have been used in the diagnosis of renal rejection [ ] , their use in pancreas transplants has not been studied. ~ in patients, autologous llqn-labelled platelets were injected on the second, sixth and tenth days following combined renal and pancreatic transplantation. graft radioactivity was expressed as the ratio of counts from the pancreas over a reference area on daily gamma images for days. one patient developed hyperglycaemia coinciding with renal rejection on day . over the previous h pancreas radioactivity had increased by %. in a further patient whose pancreas continued to function, a perigraft haematoma was recognised on the gamma image. the remaining patients had good pancreatic function and no xin-platelet accumulation: mean (_s.c. mean) pancreatic radioactivity was . + . on the third postoperative day and . _+ . at the end of study. these results demonstrate that ductal occlusion with polyisoprene does not cause significant platelet accumulation. hence min-platelets may potentially be used for the earlier diagnosis of pancreatic rejection. isograft models of pancreatic transplantation, methods involving closure of the duct system result in severe inflammatory changes and eventual fibrosis [ ] . these changes can be avoided by formal drainage of the duct into the bowel of urinary tract. inflammatory changes initiated by duct closure may contribute to and enhance allograft rejection. pancreas transplants were performed in rats using lewis (rt ) donors and streptozotocin-induced dia- betic da(rt a) recipients, using duct-ligation, open duct and ureteric duct drainage. cyclophosphamide produced significant prolongation ofnormoglycaemia in all groups and although there was a tendency towards longer function in the unligated groups there was not statistical difference (wilcoxon's unpaired test) between the methods of duct management. management of the pancreatic duct did not seem to have any immunological consequences for graft survival but septic complications, associated with the normoglycaemic deaths, were more common in immunosuppressed animals with draining ducts. between july , and march , combined pancreatic and kidney transplantation was performed in patients with type i diabetes who had all been on insulin therapy for at least years. age at the time of transplantation was to years. the pancreatic segment used for transplantation consisted of body and tail of the organ based on a vascular pedicle of the celiac axis and the splenic vein. imediately prior to intraperitoneal transplantation to the iliac vessels the ductal system was filled with to ml of prolamine, a rapidly solidifying alcoholic protein solution. simultaneous kidney transplantation was performed through a separate incision. five pancreas transplants were lost for non-immunological reasons. four of them never had any useful endocrine function, one graft was lost of venous thrombosis after hours of excellent function. in none of these patients did failure of the graft lead to any substantial complication. in the remaining patients initial graft function was excellent with plasma glucose normalizing within hours and subsequent normoglycemia on a regular diet without exogenous insulin administration. plasma glucose did not rise spontaneously during rejection episodes of the kidney and eleva-tions due antirejection treatment were promptly; reversed as high dose prednisolone was discontinued. in oral glucose tolerance test (ogtt) performed at to weeks in patients median glucose rose from a basal . mmol/l to . mmol/ and was back in normal range ( . mmol/ ) at h. basal insulin was - pmol/ and also returned to the normal range after h after a peak of - pmol/ at - rain. c-peptide showed a significant peaked rise over basal values ( , pmol/ ) in patients while all values were above pmol/l in the third. two of these patients have since rejected both organs. two tranplants still function very well after and months, respectively. in one of these patients the ogtt after months is even slightly better than the above -mentioned first test, and he shows a norreal insulin and c-peptide response. in the fourth patient an ivgtt performed at months and an ogtt at sixteen months were normal with insulin peaking at pmol/ and a c-peptide peak of pmol/ at min in the latter. -results at and months, respectively, will be presented. three problems persist in clinical organ preservation. these are failure of current systems to replenish the ischemically injured organ, to reliably extend the period of organ preservation and to definitely determine organ viability. previous studies have documented the value of electrochemical redox control in rejuvenation of the ischemically injured kidney during perfusion preservation. this study was undertaken to develop the cost effective technique applicable to current organ preservation systems, to test the reliability of redox measurement in prediction of organ viability and to determine the ability ofredox maintenance to safely extend the period of organ preservation. a disposable cell has been developed using reticulated vitreous carbon as an electrode which is driven by a potentiostat powered by a nine volt transistor battery. short term preservation studies using ischemically injured dog kidneys ( rain in-situ warm ischemia) were auto transplanted after h of pulsatile preservation to determine the optimum redox level of the hypothermic kidney. this was determined to be a - mv vs the standard calomel electrode. twenty-one adult mongrel dogs were equally divided into three groups. pulsatile perfusion preservation was extended to four days in group a with redox level monitored only. group b was treated with electrochemical reduction for four days and group c for six days. three of seven dogs survived in group a following auto transplantation and immediate contralateral nephrectomy. the kidneys of all survivors were able to bring perfusate redox potential under control and maintain this level throughout the preservation period. six of seven dogs in group b survived with a mean posttransplant peak serum creatinine of . rag/ ml. in group c four of seven kidneys supported life immediately. all redox controlled kidneys made copious amounts of urine. our data indicate that perfusate potential may be either monitored as a reliable index of organ viability or controlled to allow extended safe preservation. antithymocyte globulin (atg) has been shown to be an effective agent in combination with increased doses of steroids in reversing renal allograft rejection. since it is frequently undesirable to employ raised doses of steroids, the following study evaluated the effect of - i.v. daily doses of horse atg alone without additional steroids, on nd- th rejection episodes in recipients of cadaveric renal allografts ( rejections: biopsy-proven) detected within - mos. of transplantation. of rejection episodes, were successfully reversed, with return of serum creatinine to pre-rejection levels in episodes ( patients). three patients had primarily humoral rejections and returned to dialysis - mos. after treatment of the last rejection. levels of circulating horse immunoglobulins were obtained in all patients during and follwing administration of atg. recurrent rejections ( rd- th) following last treatment with atg ( - mos.) were seen in / patients. all patients had rapid immune eliminiation of atg ( / life - days) as compared to the patients who had no more than rejection episodes ( / life - days). atg without additional steroids is an effective agent for reversal of multiple renal allograft rejections which by biopsy are primarily cell-mediated. to be effective, heterologous atg must be given in adequate total doses and/or from appropriate heterologous source, to prevent rapid immune elimination by the recipient. the use of atg alone for treatment of recurrent allograft rejections is particularly recommended for its steroidsparing effect in treatment of multiple rejections and for those patients at high risk from steroid side effects. the significance of the monocyte crossmatch in lrd recipients of hla identical kidney grafts j. cerilli, l. brasile and s. rogers ohio state university hospitals, columbus, ohio, usa in a preliminary study from our transplant center, the presence of pre-formed antibody in recipient sera directed against monocytes from their respective living-related donors correlated with a poor clinical course. a poor prognosis for graft survival was found regardless of the hla match grade. to minimize the role of the hla system, only those living-related recipient/donor pairs who were hla identical at the a, b, c, d and dr antigen loci, and who exhibited severe immunological types of rejection were evaluated. due to the small numbers found in this category at any one center, this abstract represents an international study from different transplant centers. patients who met the criteria were studied for the presence of antibody directed against their respective donor's monocytes both pre-and posttransplant. in eighteen of these patients, cytotoxic antibody against their donor's monocytes was found in their pre-transplant sera. there was no detectable cytotoxic activity against their donor's t or b lymphocytes. two additional transplant recipients exhibited this antibody in post-transplant sera. again, no t or b lymphocyte cytotoxicity was detected. a control group of hla identically matched siblings who incurred no or minimal rejection demonstrated no anti-donor monocyte antibody. the results of this international study points towards a correlation between a high incidence of graft rejection and the presence of antibody directed against their respective donor's monocytes. therefore, in our view, the presence of anti-monocyte antibody to the prospective donor pre-transplant is a contraindication to transplantation. in patients with different liver diseases the reduced concentration of the peripheral blood t-cells and altered immune response were observed. the purpose of our studies was to investigate the mechanism of the immunological modification of the lymphoid system in the hepatic injury. studies were carried out in groups: ) lew rates were treated with dimethylnitrosamine (dmna), mg/kg b.w., i.v. for acute liver necrosis induction, ) cc ( . ml/ g b.w., i.v.) twice weekly, over weeks for chronic liver damage, ) ccl over weeks for liver cirrhosis (histologically examined). serum and thymus, spleen, mesenteric lymph nodes (ln) were removed and days after dmna treatment and and days after last cc injection. the total number of thymocytes and spleen cells was counted and the reactivity to pha and cona was measured. normal liver perfusate (lp) was prepared h after removing ( °c) by times perfusion in rain intervals (flow rate ml/g/min with ml/g of ringer). the effect oflp, sera, dmna and cc on the viability and pha response of normal thymocytes was tested in vitro. liver enzymes were evaluated, we found the decreased total number of thymocytes immediately after the stopping of medication (group : , ___ , %, group : , ___ %, group : less than % of control). proliferative response of the remaining cells in thymus to pha was much higher than normal thymocytes (group : ± % group : ___ %, group : nd). the total number of spleen cells was not changed but their response to cona was altered in the all groups and to pha only in group . pha response of ln-cells was decreased in the all groups. liver perfusate was cytotoxic ( ___ % of viable cells) and suppressive for pha response of thymocytes ( _+ % of control). the sera of rats with the hepatic damage showed an enhanced suppressive activity. cc and dmna did not have any effect on thymocyte in vitro. one month after last medication we observed the recovery of thymus involution (total i in the acute and partial in the chronic hepatic damage and cirrhosis). our results suggest that the liver origin cytotoxic and immunosuppressiv e factor(s) can be released from the damaged liver into the circulation (like to lp) and can destroy the thymus leading to the secondary changes in the other lymphoid organs. the grade of thymus alteration is dependent on the degree and the duration of hepatic damage and is reversable. the hepatic factor (s) showed the similar effect on the cortical population of thymocytes like the steroid immunosuppressants. liver grafts in the rat are in certain strain combinations not rejected and in this situation there is evidence for spontaneous donor specific tolerance [ ] . we have developed a model of auxiliary liver transplantation which would allow us to study the immunosuppressive properties apparently produced by a liver allograft. the portal vein is anastomosed to the left renal artery, the i.v.c. to the renal vein and the bile duct to the ureter. simultaneous kidney or heart allografts were performed. conclusions:auxiliary liver grafts are rejected. survival of heart or kidney grafts is not influenced by a simultaneous kidney or heart allograft. heart and kidney grafts are prolonged by simultaneous auxiliary liver grafts. [ ] . the role of suppressor cells in the initiation and propagation of malignant tumours in man, is less clearly defined. the present study, using in vitro mitogen assays (pha, cona, pwm) and various rosetting assays [ ] with specific monoclonal antibodies to lymphocytic helper (okt ) and suppressor (okt ) cells, has revealed the presence of such suppressor lymphocytes in women with clinically localised (breast and axilla) mammary carcinoma. lymplaocyte hyporeactivity to mitogens was found in % of lymphocyte preparations from blood and axillary lymph nodes of patients with breast cancer. in % of patients nodal lymphocytes were totally anergic. the most profound hyporeactivity, however, was detected in the lymphocyte subsets (< %) of specimens isolated from the breast carcinomas by collagenase digestion and sephadex g- column passage [ ] . the lymphocyte preparative techniques were not responsible for the low levels of responses detected. also, in situ prostaglandin synthesis and release did not appear to be involved in depressing lymphocyte reactivity [ ] . comparable percentages of suppressor cells (okt +) were detected within these different lymphocyte preparations. suppressor cells were not found in the lymphocyte preparations from the blood and lymph nodes of appropriate controls. from clinical and experimental studies it is known that blood transfusions may have immunosupressive as well as immunostimulating consequences. the effect of transfusions on graft survival has been extensively studied by our group in the bn to wag rat model. in this donor-host combination it was found that a donor specific pre-transplant blood transfusion could lead to a marked prolongation of heart and kidney graft survival, whereas the similar pretreatment resulted in accelerated rejection of bn skin allografts. this specific model was used to investigate the influence of a single bn transfusion on the growth of different syngeneic transplantable tumors in wag rats. the first tumor was a radiation induced basal cell carcinoma of the skin (t ), the second tumor was a chemically induced adenocarcinoma of the duodenum (t ). the antigenicity of both tumors was assessed in vivo, using classical challenge-protection experiments. it was observed that t i exhibited strong immunogenetic properties, whereas t was only weakly immunogenic. the doubling time oft i was . days, the doubling-time of the adenocarcinoma was days. intravenous inoculation of isolated t cells led to development of lung nodules which could be counted after days. wag rats were injected i.e. with ml of bn blood or syngeneic blood (controls) at - days before tumor challenge. t l was given in two different ways: a) sc. implantation of+ x mm pieces, b) i.e. injection of isolated tumor cells. t was implanted sc. only. each experimental group consisted of animals. for t it was found that allogeneic blood transfusions caused a slight (but not significant) inhibition of subcutaneous tumor growth. however, in the t lung-metastasis model it was observed that a single bn blood transfusion led to a % reduction of nodules, counted at weeks after inoculation. this reduction in number and size of nodules was highly significant (p< . ). for tumor t , the bn blood transfusions evoked a strong inhibitory effect on the growth of the sc. implanted tumor. at weeks after implantation all tumors in the control group had grown to a diameter of - rnm (average diameter . ram). in the group pretreated with bn blood, only of tumors were palpable at that time (average diamter mm). for t it was further investigated whether a single bn transfusion, given one week after i.e. tumor cell inoculation, would have any influence on tumor growth. no significant effect on number or size of the lung nodules could be noticed, if anything, the transfusion appeared to have a stimulatory effect. the results indicate that allogeneic transfusions can lead to a substantial modification of tumor growth, depending on tumor type and site of implantation. this observation may have important clinical implications. we report here the serial study of circulating immune complexes (cic) in two human tumor systems, colorectal cancer and gestational trophoblastic neoplasia (gtn). cic were assayed by antigen nonspecific insolubilization induced by . % polyethylene glycol (peg) and monitored as a od o changes by spectrophotometry. all of the serially studied colorectal cancer patients presented with elevated cic levels (mean = + zt od ) as compared to our standard cic level for pooled normal human sera ( --+_ aod , p< . ). initial values in these patients range from to a od with no correlation to tumor load, site of presentation, or subsequent clinical course. in / patients who underwent ,,curative" resection of primary or metastatic colorectal cancers, serial cic elevations occured only when antigen excess (measured by simultaneous carci-noembryonic antigen [cea] assay) decreased. immunoglobulin components of fractionated cic showed predominantly iga subclass. in gtn patients followed with serial cic and simultaneous human chorionic gonadotropin (hcg) assay, only those patients documented to enter hcg remission after molar evacuation showed significant elevation of cic. chromatographic fractionation of peak cic in one such patient defined three irnmunoglobulin containing fractions showing immunoreactivity to one of four paternal hla haplotypes (aw ). one ,,antigen" fraction (< . mw) from this complex completely inhibited reference anti-aw binding. as in the colorectal cancer patients, these data show that cic rise only when antigen excess decreases (reflected in the gtn patients by hcg normalization). in addition, some gtn patients may react to immunogenic paternal hla haplotypes as part of their response to molar pregnancy. dfmo, an enzyme-activated irreversible inhibitor of ornithine decarboxylase (odc), reduces tumor polyamine levels, inhibits growth of emt sarcomas and hepatomas in experimental animals, and induces remission in human leukemia. a renal adenocarcinoma (ra) cell suspension, or a mm segment ofwilms' (wm) tumor was transplanted intrarenally into balb/c mice (n-- ) or subcutaneously into wistar-furth rats (n= ) respectively. dfmo ( %) in drinking water was administered to half the animals in each group throughout the experiment. at days ra tumors in dfmo-fed mice weighed % less than tumors in control animals (p< . ); wm tumor weight at days was not affected by dfmo feeding. the mean number of lung metastases in dfmo-fed r.a-bearing mice was . and in ra-bearing control mice was . (p< . ). dfmo caused - % inactivation of tumor odc, reduced ra putrescine levels by /o (p< . ), reduced wm putrescine levels by % (d < . ), reduced wm spermidine levels by % (p< . ) and increased wm spermine levels by % (p< . ). dfmo feeding did not alter dna content of ra or wm tumors. although final carcass weight was similar in all animals, dfmo feeding progressively reduced total body weight (tbw) of mice, but not rats, until at day the tbw of dfmo-fed mice was . % less than tumor-bearing control mice (p< . ). dfmo-fed mice bearing ra tumors survived . -t- . days longer than control mice (p< . ). reduction of polyamine levels in wilms' tumors does not affect tumor growth. lowering of renal ade-nocarcinoma putrescine levels by continuous feeding of dfmo to tumor-bearing animals decreases tumor growth, reduces lung metastases, and increases host survival. we have previously demonstrated that vagal nerve stimulation releases -ht into the lumen of the feline gut. this study was initiated to: . determine if substance p (sp) and motilin (mt), other enterochromaffin cell products, are released simultaneously, . to evaluate if this release is under cholinergic or adrenergic control. in cats, cm isolated in situ segments of proximal jejunum were perfused with saline at ml/min ( ~c). perfusate samples were evaluated at rain intervals and concentrations of -ht, sp, motilin were measured by ria's developed in our laboratory. after two -min basal periods, the supradiaphragmatic sectioned vagus nerves were stimulated electrically ( v, m s, hz). the output from the loop in ng/ min ( -ht) and pg/ rain (sp and mt) was: introduced into the jejunum of conscious dogs through an external small bowel fistula. the gut was perfused at ml min- with a physiological electrolyte solution containing the non-absorbable marker polyethylene glycol (mol. wt. ; g - ); water and electrolyte absorption and transit time (tt) were measured during intravenous (i.v.) administration of each peptide, and during preceding and succeeding i.v. control infusions of . m naci. separate studies showed jejunal absorption and tt to be constant over prolonged periods during i.v. nac administration. bombesin ( pmol kg-lmin- ) and neurotensin ( pmol kg-~min ) significantly reduced jejunal water absorption; bombesin and enkephalin ( . nmol kag- rain- ) significantly prolonged tt; and enkephalin encreased water absorption (/ < . in all cases). measurement of plasma neurotensin during i.v. infusion indicated that physiological blood levels were not exceeded during these studies. conclusion: a number of peptides may be involved in the regulation of small bowel function. the effect of neurotensin on jejunal water transport provides a possible mechanism linking raised blood neurotensin levels with intestinal intraluminal fluid accumulation in the dumping syndrome. in order to establish whether this release was under adrenergic control, cats had cervical ganglionectomies. using the same electrical paramenters, stimulation of the cut cervical vagus nerves resulted in identical -ht responses as above. in additional cats atropine administration (lmg/kg iv) totally abolished the -ht responses to vagal nerve stimulation. the paralled release of -ht, sp, and mt following vagal nerve stimulation, strongly suggest that the ec cell is the source of these luminal hormones. this release appears to be under cholinergic control. since diabetes mellitus is markedly improved immediately after jejunoileal bypass before significant weight loss, but only gradually and often incompletely changed after gastric bypass, it seemed appropriate to investigate the effects of intestinal exclusion on experimental diabetes. studies were performed on alloxan diabetic sprague-dawley rats. two days after jejunal exclusion (je) in rats (resection of proximal / of small intestine), fasting blood sugars (fbs) decreased , from to mg/dl, and averaged mg/dl at weeks. after ileal exclusion (ie) in rats (resection of distal / of small intestine), fbs fell % in days, from to mg/dl, but increased % above preoperative levels to mg/ dl at weeks. sham operated rats responded similarly to ie rats. after alloxan and operations, all groups lost weight, but only je rats began to increase weight at a normal rate. increased water intake, polyuria ( ml/ h), and glycosuria ( rag/all), were present in ie rats; je rats were normal (urinary output < ml/ h, and urinary glucose mg/dl). oral glucose tolerance tests (gtt) were extremely abnormal in ie rats, similar to those in non-operated alloxan rats, while gtt curves in je rats were similar to normal animals, with some elevation at , and min. serum insulin levels remained low in all alloxan treated rats after jejunal exclusion. possible mechanisms, currently under study, relate to carbohydrate malabsorption and changes in enteric chemical mediators. the purpose of the present study was to investigate the changes in somatostatin release and somatostatin-containing cells of the pancreas and stomach of the streptozotocin (stz) -induced diabetic rat after the amelioration of diabetes by whole pancreatic transplantation. highly inbred lewis rats were divided into three groups: ( ) normal rats, ( ) stzinduced diabetic rats and ( ) transplanted rats. diabetes was induced by the administration of stz ( mg/kg). on the seventh day after stz treatment, pancreatic transplantation was performed. four weeks after the transplantation, in vivo and in vitro, studies were performed. pancreatic d cells and gastric somatostatin-containing cells were stained with antibody enzyme method. studies in vivo showed marked improvement of the impaired arginine-induced insulin release by the transplantation. studies in vitro employing isolated perfused rat pancreas and stomach revealed following results: mean basal pancreatic somatostatin release in normal, diabetic and transplanted rats were ___ , -t- , and __+ pg/ml, respectively. total amount of pancreatic somatostatin release in each group during arginine stimulation ( . . mm) were --+ , ___ , and -+ pg/ min, respectively. significantly higher somatostatin release was obtained from the diabetic pancreas, which was, however, reduced to normal after the whole pancreatic transplantation. on the other hand, insulin release from the diabetic pancreas was severly impaired and pancreatic transplantation had not effect on insulin release from the host pancreas in the transplanted rats. as to the glucagon release, there was not significant difference among them. mean basal gastric somatostatin release in normal, diabetic and transplanted rats were -t- , ___ , and + pg/ml, respectively. there was no significant difference between normal and diabetic rats, though the significant decreased value was obtained in the transplanted rats. (vs. normal;/ < . , and diabetes; / < . ). on the other hand, glucagon-stimulated peak values in these groups were _ , ___ , and + pg/ml, respectively. glucagon-stimulated gastric somatostatin release in diabetic rats was significantly increased, but reduced to normal value by pancreatic transplantation. also, a number of pancreatic d cells and gastric somatostatin-containing cells were markedly increased on the diabetic rats. on the other hand, a number of these cells in the transplanted rats were descreased to normal levels. in summary, enhanced pancreatic and gastric somatostatin release and cells in the diabetic rats were both normalized after the amelioration of diabetes by the whole pancreatic transplantation. from these results, it is suggested that pancreatic and gastric somatostation are regulated by circulation and/or metablic of nutrients. doppler velocity recordings are widely used for the non-invasive diagnosis of carotid arterial disease. although detailed analysis of carotid doppler spectral information has been suggested as a method for improving diagnostic sensitivity, the accuracy of the relationship between the doppler recording and the true instantaneous velocity profile has not been established. the purpose of this study is to determine if a cw doppler velocitymeter can accurately transduce the true instantaneous blood flow velocity information. methods: a pulsatile flow model has been constructed in which it is possible to record the instantaneous doppler spectrum and simultaneously photograph and measure the true velocity profile. a computer controlled pump generates a carotid waveform in tubes without stenoses and with, symmetrical stenoses. flow is visualized using the photochromic dye tracer technique. a short burst of uv light from a laser is passed across the tube. a narrow band of the fluid turns blue, its movement is photographed, and the instantaneous velocity profile determined every msec throughout the pulse cycle. at the same time, the instantaneous doppler spectral information is recorded by a frequency analyzer. the results follow. for pulsatile laminar flow, the doppler spectrum correctly recorded the true velocity spectrum, including the instant/~neous maximum velocity and mean velocity. for disturbed flow, it was not possible to show the same direct relationship between the doppler spectral recordings and the blood flow velocity. in conclusion doppler velocitymeters accurately transduce velocity information when flow is laminar but when flow is disturbed there is not a direct relationship between doppler recordings and the true velocity profile. consequently, one should be cautious in attempting to relate doppler measurements of disturbed flow directly to the true changes in the velocity pattern. early failure of arterial reconstruction may originate in poor patient selection. in aorto-iliac stenosis (ais) selection for operation relies upon clinical examination of the femoral pulse and radiology. since single plane arteriography is inadequate for accurate definition ofiliac stenosis [ , ] , this paper compares clinical examination, doppler ankle systolic pressure (aspi) and femoral signal analysis (laplace transform damping, ltd, and pulsatility index, pi) [ ] with biplanar contrast studies. i at biplanar angiography of ischaemic lower limbs had ais with diameter reduction from - %, of the remainder, were normal (< % stenosis) and were ,,occluded" ('_-- / ). nearly two thirds ( %) of limbs with a clinically normal femoral pulse had identifiable arteriographic stenosis (~-__. / ), upstream abnormality was predicted incorrectly in % and the overall accuracy of clinical examination was %, both for detecting stenosis and predicting its severtiy. aspi (median . ; % confidence ,limits . - . ) and pi ( . ; . - . ) although correlated with stenosis (aspir = . ; p = . , pir = . ; p= . variance analysis for linear regression), did not aid the clinician further (accuracy %). however ltd ( . ; . - . ) was well correlated (r= . , p= . ) and did improve assessment ofiliac stenosis (accuracy %). the need for biplanar arteriography is reiterated and its use with doppler signal analysis should improve the evaluation of aorto-iliac disease. in the absence ofa non-invasive method for estimating volume flow in an individual artery, local blood pressure measurement has proved, with certain limitations, useful in assessing the cardiovascular system. now ultrasound technology has progressed to enable blood flow in an artery to be measured noninvasively. we report the results o four evaluation ofa mhz, computerized, channel, pulsed doppler vessel imaging and flow measuring instrument in in-vivo experiments. computed blood flow was compared to actual blood flow (calculated by timed collection) in anaesthetised dogs. correlation between computed and actual blood flow was stronger in the larger abdominal aorta than in the smaller common carotid arteries. from the regression plot, the coefficients of determination, p, were: . (exposed aorta scans); . (transcutaneous carotid scans); and . (exposed carotid scans). stepwise regression analysis showed the computed flow values to be independent of probevessel angle, depth and lumen diameter for vessels greater than . mm in diameter. these results suggest that this pulsed doppler instrument has the versatility and accuracy essential for diagnostic flow measurements in the main conducting arteries of the neck and limbs and in vascular bypass grafts. in the assessment of patients undergoing carotid artery surgery, many laboratory methods are available in addition to angiography. in a series of patients experience has been gained with the use of eeg, tc m isotope scanning, opg, ct scanning and doppler. in a year follow up over % of patients had a satisfactory outcome. an early mortality of % in the beginning of the series has been eliminated due to improved selection. in this report the application of multi-gated pulsed doppler techniques is reported. this allows a non invasive measurement of mean volume flow in the common carotid artery with a method reproducibility of + %. mean volume flow in undiseased arteries ( subjects mean age years) was found to be ± (s.d.) ml/min. from this a lower range for normal flow of ml per minute ( x s.d.) was selected. patients were investigated before surgery and a follow up examination was performed at a mean interval of v months post operatively. groups were defined. group a > ml/min; group b - ml/min; group c < ml/min, of arteries in group a before surgery, remained in the group and dropped to group b. in group b, of arteries, go to group a, remain and dropped to group c. in group c, out of arteries moved to group a and to group b. thus of arteries with below normal volume flow before surgery, were returned to normal range and further improved. remain unchanged and disimproved. of the arteries examined ;/ months after surgery, are in the normal range and a further improved. remain unchanged and disimproved. of the arteries examined / months after surgery, are in the normal range in flow values and a further remain unchanged. the non-invasive and isotope techniques have a valuable and practical application in assessment of carotid artery surgery. timing is influenced by the finding fo infarction on ct or isotope scanning. doppler techniques are useful not only in defining severity of diseas and sub-radiological plaques, but valuable flow information can be obtained by pulsed doppler pre and post operatively. this may help in identifying patients who need further medical or surgical treatment. stepwise logistic regression-amodel for predicing success of femorai-popliteal bypass grafts the objectives of this study were to identify the preoperative factors that influenced postoperative patency of femoral-popliteal grafts and to develop a model that could be used prospectively to determine the probability of successful outcome. data base material consisting of history, physical examination, laboratory data, angiography, and operative findings in patients undergoing femoral-popliteal bypass grafting was entered into a computer programmed for stepwise logistic regression analysis. the computer identified and ranked factors that influenced outcome. the top five factors (other than technical problems) included quantity of runoff, previous ipsilateral femoral-popliteal bypass, preoperative prediction of potential amputation level, concurrent proximal vascular reconstruction, and the location for distal graft anastomosis. having established the computer data base, it is now possible to enter information from new patients into the computer which will weigh all factors and indicate the likelihood of surgical success. in addition, tables can be generated which will look at simple combinations of variables to predict patency. for example, in a patient about to undergo a primary femoral-popliteal bypass with no anticipated technical problems, the likelihood of success as a function of runoff and preoperative amputation level is as follows: irreversibility of shock and ischemic injury is generally considered a consequence of extensive cellular injury. to study the role of intravascular coagulation in shock, rats were bled to a mean arterial pressure of mm hg for hrs or % uptake of shed blood, whichever occured first. return of shed blood with these data provide the patient and the surgeon with a quantitative prediction for success and permit an informed decision when considering therapeutic alternatives. potential cytoprotection by heparin was studied by similarly bleeding additional rats; controls were only cannulated. twenty pairs were heparinized (h); were not (nh). paired-bled and control rats were sacrificed following hemorrhage, liver (l) and kidney (k) mitochondria were isolated, and the isolates were studied by the polarographic technic with glutamate and succinate to determine the respiratory control index (rci) as a measure of cellular injury. results were: an equal volume of isotonic saline resulted in a % survival; % uptake of blood during shock allowed prediction of survival. an additional rats were then randomized (coin toss) to heparinization versus no heparin prior to shock, and were similarly bled and resuscitated. significantly improved survival (p< . ) was seen in heparinized ( / ; / ) versus nonheparinized rats ( / ; %). uncoupling and inhibition of mitochondrail function were noted in both h and nh rats with rci being significantly reduced from control. however, there was no difference between h and nh compared to each other. heparin does not provide cytoprotection during shock; improved survival with heparin may rather be a consequence of improved reperfusion of tissues following the shock episode. fl-endorphin (b-end) has been postulated to play a role in the pathogenesis of shock because the opiate "antagonist naloxone improves the macrohemodynamics in various shock models [ ] . however, plasma levels ofopioid peptides have not been determined as yet. the aime of our study was to measure the plasma concentrations of various peptides and to evaluate the influence of naloxone particularly on the plasma concentration of r-end. in anesthetized foxhounds, the adrenolumbar vein was cannulated and hemorrhagic shock (map = mm hg for h) was induced according to wiggerstechnique. the plasma levels offl-end, methioninenkephalin (m-enk), and leucine-enkephaline (l-enk) were simultaneously determined in c.v. and/ or adrenal venous blood by a specific ria. crossreactivity of r-end withfl-lipotropin was about %. the enk-antibodies crossreacted with less than %. five dogs received an i.v. bolus of naloxone ( mg/ kg) and a subsequent naloxone infusion of mg/kg/ h after h of hypovolemia. eleven dogs served as control and received equivalent volumes ( mg/kg per h) of ringer solution. hemorrhage resulted in a sharp rise of central venous plasma levels particularly of m-enk and l-enic this effect was even more pronounced in the adrenal's effluent system.fl-endorphin levels remain elevated whereas the enk secretion began to decrease h after hemorrhage. naloxone treatment inhibited any spontaneous fall of adrenal enkephalin release during the shock phase and the values remained elevated - fold. volume substitution with autologous blood resulted in a normalization of all peptide levels. these data demonstrate that hemorrhagic shock will cause stimulation of endogenous opioid peptides. the high levels of enkephalins in the adrenolumbar vein indicate that the adrenal gland is the main source of these peptides in the circulation. in addition toil-end, the enk seem to play a role in the pathogenesis of shock as well. at our present state of knowledge, however, it is difficult to design a coherent concept of mechanisms involved. this shows that cp treated cells bound nearly as much [ t]-acth analog as control cells but there was very little specific binding to sp treated cells. low concentrations of acth effectively displaced the acth analog whereas exposure of adrenocortical cells to sp resulted in a significant decrease in acth receptors. this suggests that sp has a factor(s) that binds to acth receptors of adrenocortical ceils which may adversely affect the stress response of shock. f- has been proposed as superior to other asanguinous fluids due to increased oxygen carrying capacity. evaluation to date has been largely uncontrolled and at extremes of hemodilution (hct. < %) rarely seen clinically. near infrared spectrophotometric monitoring of brain cytochrome a, a redox state, a sensitive indicator ofintramitochondrial oxygen availability, offers a unique opportunity to contrast f- with balanced salt-albumin (bsa) and whole blood saline (wbs) as a resuscitative regimen in a clinically relevant model. fifteen rats were subjected to minutes of hypoxia (fio = , %) and hemorrhagic hypotension (map = mmhc), then randomly allocated to one of three groups and resuscitated by fio = % and infusion of either f- , bsa, or wbs. cytochrome a, a redox state was monitored continuously at run. thirty additional rats were sacrificed at baseline, end shock and and minutes post resuscitation for cerebral cortical atp and lactate assay. despite hematocrits as low as % in the bsa and f- groups, there were no significant differences / < . between groups in the parameters of oxygen sufficiency; atp, lactate, and cytochrome a, a redox state. we assume differences in cardiac output compensated for differences in arterial oxygen content. on this basis we suggest perfluorochemical utilization should be limited to situations in which hematocrits are < % and when cardiac reserve is limited. metabolites of the prostaglandin endoperoxide h (pgh ) affect both vascular tone and platelet aggregation and thereby may influence blood flow. we, therefore, determined the metabolites formed from pgh by microsomes isolated from human saphenous vein used for aortocoronary bypass surgery. in the absence of reduced glutathione (gsh), the enzymatic metabolism of c-pgh produced only prostacyclin (pgi ) as measured by the formation of its stable breakdown product -keto-pgfla. the amount of pgi formed varied from - % of the substrate depending upon the microsomal protein and pgh concentrations. in addition, the nonenzymatic breakdown of pgh resulted in the formation of pgf a, pge , pgd and heptadecatrienoic acid (hht). there was no formation of thromboxane a (txa ) as measured by the absence of its stable breakdown product txb . in the presence ofgsh, a required cofactor for microsomal pge isomerase activity, the formation of pge was augmented fold (up to % of the substrate) indicating enzymatic for-mation of pge . the gsh either did not alter or augmented (less than fold) the formation of pgi . the increased formation of pge in the presence of gsh was at the expense of decreased nonenzymatic breakdown of pgh to pgf a, pgd and hht. these data suggest that prostacyclin synthetase activity may serve to protect the vessel graft from platelet aggregation and/or vessel spasms and may possibly serve as an indicator of graft viability. thrombosis is a frequent cause of early arterial bypass graft failure and platelets are known to be major determinants ofthrombus formation on arterial surfaces. pgi and flbriolytic activators from the vascular wall counteract intravascular thrombosis. the aim of this work was to study the effect of arterial grafting on the aforementioned mechanisms. cm lengths of tanned human umbilical vein grafts (huvg) with an internal diameter of mm were interposed end-to-end in the carotid arteries (c.a.) and jugular veins (j.v.) of sheep. placed in the c.a.'s, grafts with restricted flow ( cc/min) were removed on the th postoperative day (group i); grafts with unrestricted flow ( ___ cc/min after placement) were taken out days later (group ii) and grafts placed in the j.v.'s were removed days after surgery (group iii). upon removal, the grafts were checked for patency and sections from the proximal and distal anastomoses and midgraft were obtained for determination of pgi production (ria) fibrinolysis activators activity (histochemical method) and for light and scanning electron microscopy. sections from the femoral arteries were also obtained. the results of pgi generation are expressed in ng/ml/cm% all grafts showed fibrinolytic activity in the adventitia but grafts in group ii also showed fibrinolytic activity in the intima. early neointimal fibrous hyperplasia (nfh) characterized by proliferation of smooth muscle cells was present in group ii. the, occluded grafts showed organizing thrombus material and inflammatory cells and the patent ones showed fibrin and scattered inflammatory cells. in groups i and iii, sem revealed numerous platelets and rbc's incorporated into a proteinaceous material overlying the anastomoses and in some specimens obvious thrombus material was present. in group ii, the anastomotic areas were covered with large endothelial cells, nonetheless, some areas were denuded and small thrombi were occasionally noticed. in conclusion: . anastomotic sites create a strong stimulus for thrombus formation despite a high production of pgi . this suggests that antithrombotic therapy may be necessary to prevent early failures. . huvg develop the capacity to produce pgi and fibrinolytic activators and . although the etiology of nfh remains obscure, the decreased levels of pgi in group ii suggest that exhaustion of pgi generation from the endothelium might occur leading to proliferation of smooth muscle cells (nfh). these cells will in turn supply pgi if a persistent stimulus exists. permeability of intestinal capillaries to fibrinolytic products d. manwaring and p. william curreri department of surgery, university of south alabama college of medicine, usa fibrin/fibrinogen degradation product d (fdp-d) is significantly elevated in the serum of patients after trauma or sepsis. purified fdp-d infused into nontraumatized rabbits precipitates thrombocytopenia, complement depletion, pulmonary dysfunction and increased permeability of lung capillaries to i s-albu -composite fibrin plate assay size oflytic zones (mmx) after h incubation at °c rain. in order to determin of products of fibrinolysis alter fluid filtration or permeability, either purified fdp-d or fdp-e were tested in an isolated, autoperfused cat ileum preparation. steady-state lymphatic: plasma protein concentration ratio (cl/cp) and lymph flows (ql) were measured at a venous outflow pressure of mmhg. data was analyzed for each animal group by the paired student t test for ql, cl/cp and protein clearance (ql x cl/cp). in cats which received fdp-d (n= ), ql and clearance increased five-fold (p< . ), but cl/cpwas not altered, which suggests a permeability change. ileal mucosal biopsies prepared for histology had villi that were de-epithelialized and platelet clots in blood vessels. fdp-e (n= ) provoked a slight increase in ql (p< . ), but not in cl/cp or clearance. histology was normal. (fdp-e causes no pathological lung change in awake rabbits). fdp-d may contribute to various organ pathologies after trauma. the effect of aspirin on the fibrinolytic activity of viable granulocytes r.c. franz, w.j.c. goetzee, b. rotunno and r. anderson department of surgery, university of pretoria, rsa although several influential authors have suggested that low dose ( rag) acetyl salicylic acid (asa) represents a balanced daily antithrombotic regimen probably by both inactivating thromboxane a production and enhancing prostacyclin synthesis little is known about the effect of aspirin on the fibrinolytic activity of live granulocytes [ ] . the present study was designed to evaluate this effect in vivo. methods: granulocytes from fasting samples of heparinized venous blood taken from male volunteers were separated from monomuclear cells and platelets by density gradient centrifugation (ficoll: sodium metrizoate). viable granulocyte suspensions and plasma samples were placed as drops on a coin- before aspirin after aspirin p = [ ] . the experiment was repeated h after each subject had ingested . g of aspirin. the results are summarized in table . . there appears to be a significant increase in granulocyte fibrinolytic activity h after the ingestion of .sg of aspirin. . this increment is insufficient to overcome the resting inhibitor potential of plasma on granulocyte fibrinolysis. . aspirin does not evoke a significant increase in plasminogen activator-(urokinase) induced flbrinolysis in platelet free plasma or in the combined system of granulocyte-plasma mictures. . the optimal dosage of aspirin as a fibrinolytic agent requires further study. the terminal vascular bed of malignant tumors is characterized by a lack of organization, differentiation and sufficient developement of nutritional capillaries. as a result, malignant tumors reveal consistently small regions of low or even no perfusion. pre-vious data in a melanoma indicate that due to the rarefication of capillaries, the full impact of tumor treatment ±st diminished by an elevated microvascu lar resistance, which could significantly affect the impact of tumor therapy. since the improvement of the blood's fluidity has been shown as one therapeutic modality to increase significantly the capillary blood flow, it was assumed that this measure might enhance the accessibility of tumor tissue for bloodborne drugs. this study was aimed to investigate the effects of the improvement,of microcirculatory flow on tumor growth and tissue oxygenation. moreover, the response of the melanoma to chemotherapy was evaluated when isovolemic hemodilution was employed in conjunction with chemotherapy. a transparent chamber technique, intravital microscopy, a platinum multiwire electrode (local po measurement) and quantitative television image analysis (capillary blood cell velocity and diameter) were employed to study the microvasculature in the amelanotic melanoma a-mel- of hamsters in the event of hemodilution without and in conjunction with chemotherapy ( mg/m dtic, dimethyl-triazeno-imidazol-carboxamid). permanent indwelling catheters in carotid artery and jugular vein served for measuring systemicpressures, heart rate, for withdrawing blood and the infusion of dtic and/or dextran . after inoculation of x cells of the amelanotic hamster melanoma a-mel- into s.c. tissue in the preparation, this tumor re~ched a diameter of approx mm within five days. the reduction of systemic hematocrit from . to . ( . ± . ml blood vs dextran , animals) at a tumor diameter of mm increased the growth rate of the melanoma by about % while enhancing significantly the volume flow through capillaries and the mean local po . table control hemodilution capillary velocity (ram/s) . _ . . ± . capillary blood flow (ml/min x - ) . ± . . ± . mean local po (mmhg) . ( - ) . ( - ) the frequency distribution of local po on the tumor's surface showed a distinct shift toward higher po values with still some hypoxic regions remaining. intravital microscopy, however, revealed petechial bleeding and localized, interstitial edema which compressed a small number of capillaries. by contrast, the tumor's diameter remained at app. mm for a period of ten days with chemotherapy alone ( animals). in one of the animals, a complete stop in the melanoma microcirculation was seen within four hours after infusion of dtic followed by a significant decrease of tumor diameter. when chemotherapy was initiated in hemodiluted animals, neither retardation of tumor developement nor vascular obstruction was observed ( animals). conclusion: capillary blood flow of the melanoma can be enhanced by hemodilution thus diminishing tissue hypoxia. this measure, however, was associat-ed with an increase in melanoma diameter of %. at the present, we investigate whether, in hemodiluted animals, a reduction of tumor size can be obtained with a higher dose of dtic. ). however, the etiology of stress hyperglucagonemia in the immobilized rat is only poorly defined. since during restraint stress, catecholamines (ca) are elevated and stimulation ofglucagon by ca is accepted (woods sc d jr [ ] physiol rev. : ), we decided to study by surgical means the the relative contribution to glucagonemia of different sources of ca, i.e. peripheral sympathetic nervous system and adrenal medulla. methods: male sprague-dawley gastric fistula rats (n= ), weight approx. g, were subjected to either sham-op or various sympathectomies [microsurgical splanchnicotomy = s-sx; chemical sympathectomy = c-sx ( mg/kg -oh-dopamine ip two days prior to the experiment); adrenal demedullation = amx; combinations: s-sx + amx; c-sx + amx]. gastric acid secretory trials (duration h), preceded by a h fasting period were carried out - days following the operation. at the start of the experiment an intraperitoneal polyethylene tube, was inserted into the abdominal cavity of the rats, allowing a constant infusion of physiological saline ( ml/ kg/h). in addition, stress was performed by pairwise restraint of the extremities and small electric shock waves applied by a tail electrode. at the end of the experiment, blood was drawn from the vena portae and the abdominal aorta for plasma and serum. hormones (glucagon, insulin) were measured by radioimmunoassay, glucose enzymatically, volume was read to the next . ml, acidity by microtitration. results (see table) : volume and acidity are not changed by the various sympathectomies, when compared to the sham group. the same is true for acid secretion, except in s-sx + amx, where it is elevated. glucagon in peripheral plasma is elevated in c-sx, amx and c-sx + amx. in the portal vein, glucagon is dccreased in s-sx + amx ( ___ pg/ ml) and elevated in c-sx + amx ( ___ pg/ml) when compared with sham rats ( --. pg/ml). the portal/aortal glucagon ratio is significantly decreased only in c-sx and amx ( . --+ . , . --. . , resp.) when compared with sham ( . --_ . ). insulin is increased only in amx, glucose decreased in amx, s-sx + amx and c-sx + amx, insulin and glucose are unchanged in the other groups. conclusion: . stress hyperglucagonemia in the rat is confirmed (levels during zero stress - pg/ml) and also the rise in insulin following removal ofadrenomedullary ca (but not other sympathectomy); . the blood glucose fall (amx; s-sx + amx; c-sx + amx) is not uniformly paralleled by hyperglucagonemia, but in the case of amx it may be secondary to relative stress hypoglycemia owing to removal of adrenal medullary ca or reactive insulin release; . mechanism underlying the increased systemic glucagon despite partial (c-sx; amx) or total (c-sx + amx) sympathectomy are yet unknown. . during stress the enterogastrone component of hyperglucagonemia may be of minor importance. evlw showed good agreement with gravimetric lung water determinations. significant lung water accumulation was produced by pressure elevations over mmhg. reductions in plasma oncotic pressure significantly increased transvascular fluxes at each level of pressure elevation. however, fluid accumulation was not significantly greater during hypoproteinemia. we conclude that a - % reduction in plasma oncotic pressure does not contribute to increased high pressure edema because the lymphatic safety factor is augmented. this phenomenon may explain the well tolerated state of hypoproteinemia in patients after hemorrhagic shock. computerized gamma scintigraphy is a new technique for the analysis of albumin flux in the acute respiratory distress syndrome (ards). the objectives of this study were to obtain normal control values and to determine the method's validity in patients with cardiogenic vs. permeability pulmonary edema. methods: following mci mtechnetium-human serum albumin, lung :heart radioactivity ratios were determined. this ratio remains constant unless there is a leak o falbumin, when a rising ratio is seen, called the ,,slope index" (si). si's were determined in control individuals who had :> % left ventricular ej ection fraction and < s pulmonary circulation. thirtythree studies were obtained in patients using a portable gamma camera. fourteen patients had clinical evidence of ards. results: studies were considered positive if the si was s.d. > control mean ( - . ___ . x - units/ min). among positive studies, all had diffuse air space disease on chest radiographs. their average pulmonary capillary wedge pressure (pcwp) was . _+ . mmhg. the average artertial: alveolar oxygen tension ratio (a/a)o was . +-- . on . cm h peep, which were both significantly (p< . ) different from patients with normal si's. positive si's were present from hours to days following the apparent onset of ards in patients. recovery of gas exchange was associated with normal si's on repeat studies in patients. of patients with cardiogenic pulmonary edema, had negative studies ( - mmhg pcwp) and i a positive study ( mmhg pcwp). conclusion: gamma scintigraphy was a sensitive, non-invasive tool for the detection of a pathological increase in pulmonary protein flux, which was usually normal in cardiogenic pulmonary edema. positive scintigraphy was associated with significantly impaired gas exchange. the method documented that the leak of albumin in ards may last for days but resolves with recovery. cancellous bone thermocoagulation ph. dumontier, r. benichoux and a. vidrequin institut de recheres chirurgicales -c.h.u. de brabois vandoeuvre les nancy cedex, france electrocoagulation can not stop bleeding from the cancellous part of a sectioned bone. therefore we tested the efficiency ofthermocoagulation by hot air. the hot air generator delivers a flow, of non illtercd air, at - /min at a fixed temperature of °c measured at the exit of a mm diameter pipe and °c at the site of bleeding. the generator sustains usual steam sterilization. dogs were operated on both patellae, femoral short segments and iliac crests giving different site of cancellous bone. in vitro sterility studies: the conduit of hot air was applied at various distances, from cm to meters, above a petri plate containing culture material. thus the turbulence in the atmosphere around the zone of thermocoagulation has been bacteriologically controlled and a particle counter used. in vivo thermocoagulation: three sites of cancellous bone were used in anesthetized dogs, using a sterile procedure: the iliac crest, a small segment of the femoral bone and the divided patella. . five iliac crests were divided and bleeding measured after thermocoagulation. . the segmental femoral resections were thermocoagulated. . the patellae were vertically divided and each section submitted separately either to thermo or electrocoagulation. the pipe of thermo- coagulation was directed to the bleeding surface at a cm distane, sweeping it during to seconds. the bleeding was compared by photography and the two fragments were approximated by a wire synthesis to provide a bone fusion. in few cases both sides were thermocoagulated. results: in vitro: no contamination was found in the atmosphere, up to a distance of meters. there was a significant decrease of particles around the operating site ( % less, at cm and % less, at meters). in vivo: the bleeding was weighted around % less than with conventional coagulation. thermocoagulation did not delay or disturb the healing of the patella after wire synthesis. the in vitro nucleation time of cholesterol crystals from gallbladder bile of patients with gallstones is more rapid than that from normal persons, (holan rt [ ] gastroenterology : ). this study determined whether this was due to a gallbladder or liver defect and wether the defect was the addition of a nucleating factor or the deletion of an antinucleating factor. hepatic and gallbladder bile were gathered at surgery in stone patients and gallbladder bile in patients with a normal biliary tract. after ultracentrifugation, the isotropic phase was observed daily by polarizing microscopy until cholesterol crystals appeared. in gallstone patients, the nucleation time of gallbladder bile was significantly more rapid, . days+ . sem, than that of hepatic bile . + . days, although hepatic bile was significantly more saturated with cholesterol [cholesterol saturation index (csi), . _+ . ], than gallbladder bile, (csi, . _+ . ). thus the characteristic short nucleation time of stone formers is due to an alteration in bile after it enters the gallbladder. to determine whether the gallbladder defect was due to addition of a nucleating factor or the deletion of an antinucleating factor, isotropic phases of normal gallbladder bile and that from stone formers were mixed and nucleation time determined. mixtures of up to % normal bile had pathological nucleation times demonstrating that the defect is the addition of a nucleating factor by the gallbladder, and that this factor is potent. the rate of formation ofgaustone precursor crystals in bile, although faster in gallstone patients than in controls, is unrelated to the degree of cholesterol supersaturation [ ] , implying that other factors are involved. two competing factors seem likely; (a) secondary seed crystals in bile may trigger and accelerate gallstone crystal formation from supersaturated solution; (b) "poisons" in bile may retard or inhibit crystal growth. because of the complexity of bile itself, experiments were performed in highly purified mixtures of bile salt, lecithin and cholesterol, in concentrations closely resembling those of gallbladder bile. (a) lipid solutions were seeded with calcium carbonate, hydroxy-apatite, calcium bilirubinate and biliary mucus, all of which are found in gallstones [ ] . cholesterol crystal formation was significantly faster in_ the presence of all of the seed compounds tested (x= . /~g ml-lh- ) than in unseeded controls ( . /ag ml-~h- ) (/ < . ). (b) substances with "crystal-poisoning" properties included heparin, chondroitin sulphate and bile salt. these and changes in ph altered the quantitiy ( - % decrease) and rate of calcium carbonate and calcium phosphate crystal formation. we suggest that gallstone precursor crystal formation may be affected by a subtle balance between crystal seeding and crystal growth-inhibition, both due to the presence of other compounds in bile. at the last tripartite meeting we reported experimental data on a new method to destroy concrements of the kidney in situ by shockwaves allowing for spontaneous excretion via the urinary tract [ ] . the shockwaves are generated externally by underwater discharge of a condensor with sparking electrodes which are localized in a focus o fan elliptic cavity. for treatment the renal concrement must be positioned exactly in the second, virtual focus opposite to the elliptic cavity. since then, altogether patients were subjected to this form of treatment in our institute by the colleagues of the department of urology at the university of munich. % of the patients got rid of their concrements within a few days, in . % small remnants remained in the renal pelvis, and in . % ( cases) additional surgery became necessary. meanwhile this technique is employed on a routine basis in the department of urology of the university of munich [ ] . the experimental as well as clinical results were considered encouraging enough to extend the technique for the treatment of biliary concrements. for this purpose, human gallbladder concrements of different composition (bilirubin, cholesterol) were implanted into the gallbladder of dogs for exposure to shockwave treatment after wound healing. under in vitro-conditions the biliary concrements could be crushed into any size desired, irrespective of their composition, while only in out of experiments this was accomplished under in vivo-conditions. blockage of the biliaiy duct after shockwave exposure was never observed. concrements which were experimentally implanted into the bile duct could be visualized without difficulties by contrast medium. here, destruction by shockwaves was accomplished as well. currently experiments are conducted to dissolve remnants of biliary concrements after treatment by administration of desoxycholic acid. precise positioning of the gallbladder concrements in the second virtual focus is a problem which has not been satisfactorily solved so far, because the concrements cannot be visualized by conventional x-ray techniques. alternatively it is attempted to employ ultrasound, or visualization by retrograde injection of xray contrast medium through a catheter. in experimental animals, we leave a t-formed drain in the gallbladder for injection of contrast medium. in animal experiments conducted so far, histological or clinical evidence for tissue damage has not been obtained, as is the case with shockwave treatment of kidney stones. we are convinced that treatment of biliary concrements by shockwave exposure can be employed under clinical conditions in the near future. exploration of the common bile duct (cbd) for calculi, particularly in the presence of obstructive jaundice, is a procedure with considerable mortality and morbidity. to avoid the problem of retained stones, choledochoduodenostomy and transduodenal sphincteroplasty have been recommended, but have their own complications. this morbidity might be reduced by removal of cbd calculi prior to surgery. endoscopic sphincterotomy (es) allows this. a review of cases of es performed for calculi indicated that this was a safe (complications % no deaths) and reliable procedure ( % success rate). a study was conducted of patients with known cbd stones who had either preliminary es followed by operation at a later date (group i) or operation alone (group ii). this study showed a lower morbidity in group i. a prospective randomised controlled study has begun on the basis of these findings and the data from both studies are shown in the table. these results suggest that pre-operative endoscopic sphincterotomy my reduce the morbidity of cbd stones. group ii n = two controversies regarding the physiology of the biliary sphincter (bs) concern its functional independence from the duodenum [ ] and those aspects of its acitivity which control bile flow [ ] . the rabbit was chosen as the experimental animal as it has an easily identifiable sphincter. during anaesthesia induced by intravenous pentobarbital sodium, recordings of the electrical and mechanical activity of the bs and duodenum were made from (a) starved, (b) fed and (c) starved animals during administration of cholecystokinin, pentagastrin, secretin and glucagon. spike complexes (sc) were ordinarily associated with mechanical acitivity of the sphincter and duode-num. of . sphincter sc, recorded in animals, ( %) were not associated with duodenal acitivity, whereas . of ( . %) duodenal sc were accompanied by synchronous bs activity. this supports the hypothesis that the rabbit's bs can contract independently of the duodenum but that duodenal contraction is usually accompanied by simultaneous contraction of the bs. sphincter scs correspond to its phasic acitivity. food and cholecystokinin increased the number of sc without altering the baseline pressure of the perfused common bile duct. pentagastrin produced a transitory increase in sphincter activity whereas :secretin and glucagon were without effect. phasic activity of the spincter may influence bile flow through the choledochoduodenal junction. natural blood coagulation finally results in the formation of fibrin, which is one of the most important components of hemostasis in the human organism and thus provides the basis of all reparative procedures that are part of wound healing. it stands to reason to utilize the properties of fibrin for hemostasis during surgery and for joining severed tissue. first attempts of this kind were made at the beginning of this century. but only after greater insight had been gained into the coagulation proc- ess and the manufacturing techniques of blood derivatives had become more sophisticated, the essential breakthrough was made. a biological adhesive system has been developed, which consists of highly concentrated fibrinogen, thrombin and clotting factor xiii. this tissue sealant is completely resorbable and of high adhesive property. further advantages are elasticity of consistence and excellent tissue compatibility. after extensive animal experimentation, first clinical experience was made in . in the meantime the fibrin-adhesive-system (fas) has been introduced into numerous surgical disciplines with excellent results. the outstanding properties are: atraumatic tissue synthesis; enhancement of fibroblast proliferation and promotion of rapid wound healing; obtaining of local hemostasis by sealing bleeding surfaces, which is of special importance in the treatment of patients suffering from hemophilia or during operations under heparinization. the authors experience in using the fas within the last years is reported and a review over indications, techniques and advantages of this method is given. bile salts have been shown to enhance the stability and prolong the activity of intraluminal pancreatic enzymes and may therefore influence the effects of impaired exocrine secretion in patients with pancreatitis [ ] . individual bile salts in the peak min collection of duodenal fluid following cck/secretin administration have been quantitated by high performance liquid chromatography in patients without pancreatic or hepatic impairment (group c), patients with acute pancreatitis (group ap) and patients with chronic pancreatitis (group cp) all with functioning gallbladders, and patients with gallstone related acute pancreatitis (group gs). the peak total bile salt output in moles and the trihydroxy: dihydroxy (tri:di), primary:secondary (p:s) and glycine:taurine (g:t) bile salt ratios are shown below (mean___ sem). the duodenal aspirates contained detectable amounts of taurine and glycine conjugates of cholate, chenodeoxycholate, deoxycholate and ursodeoxycholate but not lithocholate or free bile salts. the low total bile salt output in groups cp and gs were due to decreased levels of all the individual bile salts. although the bile salt pattern in groups c and ap were similar, the relative proportions of trihydfoxy and secondary bile salts were higher in groups cp and gs respectively. these results indicate that patients with chronic pancreatitis without obvious large bile duct obstruction have an impaired bile salt output into the duodenum and this may exacerbate the effects of pancreatic exocrine insufficiency. an elevated amylase creatinine clearance ratio (accr) was considered a specific test for the diagnosis of acute pancreatitis (ap). however, it has been found elevated in other diseases as well as after surgery. the aim of this study was to evaluate prospectively the accr levels in patients with ap and in several groups of surgical patients. we studied subjects divided into groups: group a: acute pancreatitis (n= ). group b: patients undergoing biliary tract surgery (n= ). group c: peptid ulcer patients undergoing gastric surgery (n= ). group e: patients undergoing cardiac surgery under extracorporeal circulation (n = ). group f: control group of healthy subjects (n = ). the accr was determinated using the levitt method. in the surgical groups the accr was measured before and after the operation. amylase was determinated by the phadebas amylase test. ap was diagnosed on the basis of both clinical and radiological findings and the presence of high serum amylase levels. this diagnosis was confirmed through laparotomy in cases ( %). the accr was . + . % (mean___ sd) in group f, control group, and . + . % in group a, acute pancreatitits p< . . accr values below % were found in cases of acute pancreatitis ( %). among those patients whose ap diagnosis was confirmed through surgery the accr was . + . % (mean_+sd), higher than in the rest of the ap patients, . ± . % (p< , ). in groups b,c,d and e (surgical groups) the accr before the operation was . ± . %, . ± . %, . + . % and . + . % (mean___ sd), respectively. after the operation it was: . + . %, . + %, . ± . % and . + . %, respectively. on the average, we found an increase in the accr levels after the operation in the biliary tract group (p< . ), but not in the other surgical groups. in patients ( %), the accr after operation was above the upper limit of normal. none of these patients had symptoms compatible with clinical pancreatitis. in conclusion: . the accr increase in acute pancreatitis (sensitivity: o/ ) . the average accr increase after biliary tract surgery, but not after either gastric or thyroid surgery or after cardiac surgery under extracorporeal circulation. however, it is possible to find isolated cases with high accr after any type of surgery without any symptoms of pancreatitis, suggesting that an increase of accr may be an unspecific finding in postoperative patients which require further investigations. out of patients with acute pancreatitis developed a fulminant type. were males and females, mean age years (range - years). all patients were primarily treated by peritoneal lavage applied at laparotomy. indication for laparotomy was sudden deterioration with ( ) or without ( ) organ failure. a necrotic or hemorrhagic pancreas was found in every patient. the pancreas was exposed and soft and large catheters were placed close to the pancreas. mean duration of lavage (ll/h) was days. due to secondary deterioration a pancreas resection was performed - days later in nine patients. patients with acute fulminant pancreatitis died, a mortality of . %. all patients with the mild type of acute pancreatitis survived, thus the overall mortality was . %. none treated by peritoneal lavage only developed diabetes mellitus, whereas out of surviving patients with an additional pancreas resection had this complication. patients with acute fulminant pancreatitis displayed or more ranson criteria [ ] and six died. however, no less than of those with a mild type of acute pancreatitis fulfilled or more of these criteria and they all survived. a laparotomy -not a laboratory test -is necessary to confirm the diagnosis of acute fulminant pancreatitis. the indication for laparotomy is mainly clinical and therefore such a patient should preferably be handled by surgeons or physicians experienced in this disease. after confirmation of a correct diagnosis peritoneal lavage is one of the methods by which the mortality of acute fulminant pancreatits -which by conservative means is - % -can be reduced. coincidences ofhyperparathyroidism and pancreatitis have been given up by different author varying between % and %. frequently a causal relationship has been defended. recently, however, any causality has been queried [ ] . we analysed our own series of patients with surgically and histopathologically confirmed primary hyperparathyroidism (phpt) (n= ) and found a coincidence with a coexisting or prior pancreatitis of . % (n = ). from this a causal relationship cannot be concluded. however, out of these patients (i.e. . %) had an acute onset or exacerbation of a pancreatitis immediately following the parathyroidectomy, which is strikingly more than one would expect after an operation without any anatomical relation to the pancreas (< . %) [ ] . none of these patients had another cause of the pancreatitis such as cholelithiasis or alcohol abuse. hence a causal relationship cannot be excluded. it is imaginable that excessive amounts of parathyroid hormone are released during the surgical manipulation of the pathologically altered parathyroids. the postoperative pancreatitis may be caused by the acute elevation of parathyroid hormone levels in the presence of hypercalcemia. in our series the parathyroidectomy was combined with a partial or total thyroidectomy in patients. in another patients a thyroid operation was performed prior to the parathyroidectomy. although calcitonin has been employed as a possible therapy in patients with acute pancreatitis (ap), the normal levels of this substance in ap are not well documented and have not been correlated with pth. furthermore no definitive role in human calcium homeostasis is accepted for calcitonin, whereas high pth levels have previously been correlated with hypocalcaemia [ ] . in patients with ap the mean serum calcitonin on admission was ng/ , and the peak level mean lag/ (upper limit of normal ng/ ). calcitonin levels were higher in severe than mild ap, and of patients with levels > ng/ , were objectively graded as severe ap [ ] . in the hypocalcaemic patients, with corrected serum calcium < . mmol/ all recorded calcitonin levels > ng/ and had elevated pth. nine of the patients had significantly elevated pth ('> rig/l) and of these only did not have an associated elevation in calcitonin. the high calcitonin levels in patients with ap suggest that supplementary calcitonin intended to inhibit pancreatic secretion is unnecessary. at present it is merely speculative to suggest a role for calcitonin in ap but intriguing to report a tendency to parallel the elevations of pth. nuclide labelled microspheres were used to measure pancreatic and other visceral blood flow in two groups of conscious dogs before and after intravenous alcohol infusion. blood alcohol concentrations at the time of blood flow measurements were similar to those encountered in intoxicated humans. thus dogs (groups a) were given a somewhat low dose of alcohol to produce a mean blood alcohol level of . gm d - , while dogs (group b), received substantially greater doses of alcohol, and reached a mean blood alcohol of . gm dl- . wilcoxon matched pairs signed rank test confirmed a biphasic, concentration-related, response of pancreatic blood flow after alcohol infusion; no such response was found in blood flow to other viscera. moderate alcohol levels (group a) were associated with a decrease in pancreatic blood flow (p< . ), while high blood alcohol concentrations resulted in increased pancreatic blood flow (p'< . ). colonic blood flow increased in both groups a and b, but blood flow to the gallbladder, small intestine and the parotid gland increased in group b only. gastric, duodenal, renal, hepatic (arterial) and cerebral perfusion did not change. in addition, direct observations of the surface of the pancreas showed occasional haemorrhagic areas and mottling. these findlings however could not be confirmed by objective attempts to measure blood flow in such discrete areas in conclusion pancreatic blood flow shows a biphasic, concentration-related, response shortly after intoxication. this response appears to be peculiar to the pancreas and does not occur in other viscera. we recently showed that acute ethanol (e) and/or aspirin (a) ingestion increased the permeability of the pancreatic duct to large molecules, this suggested that pancreatic enzymes might leak from the duct into the parenchyma, causing pancreatic disease. this is a new concept in the study ot he pathophysiology of this organ (to be presented at aga, may, , plenary session). in the present experiments wie studied the effects of chronic e/a ingestion on pancreatic function in dogs. methods: dogs were fitted with duodenal and gastric cannulas. after recovery, baseline secretory sutdies were performed by cannulating the pancreatic duct and collecting pancreatic juice during secretin infusion ( . (submax) or . u/kg-hr. (maximal) iv). at least studies were performed in each dog at each dose. after baseline studies, dogs (group e) were given daily intragastric ethanol ( gm/kg-day). dogs (group a/e) were given e and a ( mg/kgday). after - weeks, secretory studies were repeated. results: all dogs gained weight (x = . kg). the pancreases appeared normal by light microscopy. drug treatment increased volume and hco output by and %, respectively, in group e, submax secretin, but decreased them by and % in group a/e animals. (p= . vs. predrug values and group e vs. a/e values). drug treatment decreased volume and hco output in both groups by - °/c (p= . ) after maximal secretin stimulus. (manova test for all statistical analyses). conclusions: consumption of e alone increased volume and hco output after submaximal and decreased them after a maximal secretin stimulus. this confirms the work of sarles. consumption of e and a reduced volume an i-ico output after secretin at both doses. thus chronic a ingestion further impaired pancreatic function in these animals. since only a small proportion of chronic alcoholics develop clinically significant pancreatic disease, an aggravating "cofactor" may be operating in this group. chronic asa ingestion, not uncommon in alcoholics, may represent such a cofactor. the development of diabetes mellitus in pancreatic cancer is well known but the standard oral glucose tolerance test is not recognised as a useful diagnostic indicator. glucose homeostasis, insulin and c-peptide secretion in response to intravenous glucagon were studied prospectively in patients with suspected pancreatic cancer and assessed as to their diagnostic value. fasting patients were given glucagon, m.g., i.v., and serial measurements of blood glucose, plasma insulin and c-peptide concentrations made for min. subsequently it was shown that patients had pancreatic cancer and the remainder constituted a control group. there was not significant difference in the rise in blood glucose between the groups after glucagon. the mean plasma insulin concentrations rose rapidly in both groups peaking between and rain but the values were sginificantly lower in the pancreatic cancer group (p< . at min: p< . at min: p< . at min). a similar pattern was observed with c-peptide. in patients with obstructive jaundice the plasma insulin response was a better discriminator of pancreatic cancer. we conclude that abnormal pancreatic beta cell funktion exists in patients with pancreatic carcinoma, detectable before any change in glucose homeostasis, particularly in patients with obstructive jaundice. the glucagon stimulation test may have a useful role in the diagnosis of pancreatic cancer. t-suppressor cells (t~) have previously been implicated as mediators of graft surival in baboons tolerant to their renal grafts [ ] . in addition, it seems that t-helper cells (th) are also affected by totallymphoid irradiation in that they are unable to provide help in mitogen-induced t-cell responses or pokeweed mitogen induced immunoglobulin synthesis in bcells. in this study the evolution of t~ and th is followed in baboons undergoing graft rejection at different rates. peripheral blood was collected from the animals at weekly intervals after renal transplantation, defibrinated and the lymphoid cells isolated by flotation on ficol hypaque. the t-lymphocyte fraction was purified by filtration through a column packed with nylon wool. th, ts and total t-cells were enumerated using monoclonal antibodies okt , and respectively (ortho). the th/ts rations reported were taken immediately before a rapid rise in serum creatinine occurred. in longlived baboons who maintained normal creatinine values, a mean of the ratios over the last month was used. b rats are produced by sublethal ( rad) x-irradiation of thymectomized animals, reconstituted with bone marrow from syngeneic, thymectomized, thoracic duct drained donors. in these lew rats, (lew x bn)f cardiac allografts survice indefinitely (> days); unmodified lew rats acutely reject such allografts ( -+ days). in this study, we have tried to restore the processes of acute rejection in b recipients. graft survival appeared independent of blocking factors or suppressor cells, as transfer of serum or lymphocytes from b recipients into syngeneic normal animals failed to increase survival of test allografts, placed subsequently. similarly, immunogenicity of long surviving grafts was unchanged; such grafts functioning > days and retransplanted into normal animals were rejected acutely. adoptive transfer of unseparated spleen cells (sl) from nonimmune syngeneic animals produced slow rejection ( --+ days) in b rats; sensitized slwas somewhat more effective ( _+ day). transfer of x syngeneic peritoneal exudate (pe) cells plus sensitized sl caused acute rejection in % orb recipients ( _ days), the remainder experiencing rejection at c weeks. pe cells harvested from rats injected ip with thioglycollate days previously, were primarily macrophages/adherent cells, as the cells used were that fraction sticking to plastic dishes and removed with lidocaine (purity > %). in vitro, b rat macrophages were abnormal, having only % of capacity of normal macrophages to promote production of interleukin (il ) when co-cultured with purified t lymphocytes. however, b recipients experienced acute graft rejection ( -+ days) after transfer of sensitized sl plus semipurified il , thus bypassing the above defect. addition ofll to the t cell (purity > °/ ) equivalent of sl (purified over degalan bead columns coated with rabbit antirat lgg, nonadherent fraction) failed to reestablish acute rejection ( -+ days), while further addition of b lymphocytes (degalan bead adherent fraction, purity > %) or macrophages was uninfluential ( ___ days and ___ days, respectively). transfer of il- alone never produced rejection. acute rejection can be re-established, however, by increasing the number oft lymphocytes ( , transferred concomitantly with il ). thus, the state of unresponsiveness in b rats can be reversed in vivo by adoptive transfer of particular cellular elements in the presence of growth factors; increased graft survival seems dependent ultimately upon il- production by sensitized t cells, presumably t helper cells. the relative inability of b rat macrophages to promote production of il- by t cells may be primarily responsible for the immunological deficit of the b rat. one of the most intriguing findings ofcyclosporin a (cya) immunosuppression is that in some species a short course of treatment will produce very prolonged allograft survival. we have tested the ability of cya to prolong the survival ofvascularized heart, kidney and pancreas allografts by direct comparison in a da (rt a) to lew (rt ~) rat allograft model. accessory abdominal heart and orthotopic left kidney transplantation were performed using standard microsurgical techniques. in renal transplantation the left kidney was removed at the time of transplantation, the remaining right kidney days thereaf- ter. streptozotocin-diabetic animals received ductligated pancreas whole organ grafts isolated on the portal vein and a segment of the aorta giving offthe coeliac axis and the superior mesenteric artery. rejection was taken as complete stop of palpable pulsations in heart transplantation, the day of death in renal transplantation and recurrance of hyperglycemia above mmol/ in pancreas transplantation, respectively. cyclosporin a mg/kg body weight, dissolved in olive oil, was administered intramuscularly for days starting with the day of transplantation. in all instances functional demonstration of rejection was confirmed by histological examination. cyclosporin a is effective to prolong the survival of vascularized heart, kidney and pancreas allografts. while cya is administered none of the grafts has been rejected. however, following withdrawal of the drug pancreas grafts are rejected within days and heart grafts within days. none of the kidney grafts has been rejected so far. the differential susceptibility of vascularized heart, kidney and pancreas allografts to cya immunosuppression may be caused by differences in immunogenicity due to organ specific alloantigens or a differential representation of spezialized antigen presenting cells. it may also reflect different patterns of rejection of the various organs. during cya administration all rejection processes are effectively suppressed. in the maintaince phase after withdrawal of cya such immune responses may prevail and ultimately lead to rejection of pancreas and to a lesser degree of heart allografts. the venous allograft still remains an attractive alternative for the reconstruction of small caliber vessels. however, when the venous graft is introduced to a non-histocompatible host, rejection and early occlusion is the rule. this study evaluates the use of cyclosporin a (cya) as a graft pretreatment, or systemic immunosuppressant for venous allografts. in addi-tion, cryopreservation techniques for pretreated venous allografts was investigated. adult mongrel dogs, weighing between and kg, were used as recipients for donor jugular vein segments ( - cm) which had been excised and flushed with cc of plasma protein fraction (ppf) at °c. these venous allografts were anastamosed end-to-end into a carotid artery of the recipients. the animals were divided into five groups as follows: group i (n= ) received untreated venous allografts without subsequent immunosuppression, group ii (n = ) was the same as group i with minimal immunosuppression (azathioprine . mg/kg/day). in group iii (n= ) the animals were transplanted with venous grafts stored in cc of plasma protein fraction (ppf) containing cy a ( mg/ ) at ° c for hours, immunosuppression was as in group ii. in group v (n= ) the animals received allografts that had been cryopreserved in a % dmso solution at - ° c for - days and then the animals had azathioprine as in group ii. in group v (n= ) venous allografts recipients were treated with systemic cya ( mg/kg/day x weeks, followed by mg/kg/day x weeks) as the only immunosuppression. the patency of the allografts was evaluated at , , , and weeks post transplantation. patency results at one month showed that azathioprine alone failed to improve the patency rate (gr. i and ii = % patency). cya graft pretreatment, however, significantly improved the one month patency (gr. iii = %). in addition, cryopreservation appeared to enhance the graft pretreatment effect of cya (gr. iv; one month patency = . %) of the allografts. finally, systemic cya proved very effective in preventing rejection and occlusion (gr. v; one month patency = %). grafts that remained patent for a initial critical period of - weeks, all showed long term patency. the effect of cya in preventing graft rejection was further documented by histiological studies of the allografts which showed a marked cellular infiltration and degenerative changes in all the grafts of the control group as compared to minimal or no cell infiltration in the patent grafts of the treatment groups. in summary, it appears that cya used as a graft pretreatment with minimal immunosuppression of the recipient, in conjunction with cryopreservation or given systemically as the sole immunosuppressant can significantly improve the survival of venous allografts. in our previous reports, it was shown that isolated hepatocytes transplanted into the splenic parenchyma of syngeneic rats, proliferated markedly and recomposed the hepatic tissue. this experimental system provided a new model to elucidate the mechanism of hepatic regeneration which could not be obtained in in vitro cell culture experiments. in the present paper, fetal hepatic tissue instead of isolated adult rat hepatocytes were transplanted into the rat spleen. we document briefly long-term morphological observations on the transplanted fetal hepatic tissue with special reference to proliferation of the hepatocytes and bile ducts. materials andmethods:wistar rats were mated in our laboratory for a fetal liver source. gestation day was when a plug or sperm were observed in the vaginal smear. fetuses used were of to days gestation. about ten fetal livers which were obtained from one maternal rat, were minced with scissors. the liver fragments were washed three times with saline solution. transplantation was carried out by direct injection into the spleens of syngeneic adult rats using a gauge needle. half of the liver fragments obtained from one maternal rat were innoculated into the spleen of one animal. a total of approximately rats with transplanted liver fragments were killed , , , and days and then every two to three months until one year after transplantation. the spleens removed were stained by h.e., pas and silver nitrate for histological examination. results: fetal livers exhibited no lobular architecture or hepatic cord structure. the very sparse cytoplasm of the hepatocytes and many hemopoetic cells among the hepatocytes were characteristically found only in the fetuses. one week after transplantation, the survived hepatocytes revealed almost the same morphological features as in fetal liver except for the presence of several proliferated bile ducts around the hepatocytes. two weeks later, the hepatocytes formed apparent hepatic cord structures and the extoplasm of each hepatocyte increased abunduntly and became acidophilic as seen in normal neonatal hepatocytes. hemopoetic cells disappeared. four weeks later, hepatocytes began to proliferate sporadically among the markedly proliferated bile ducts, groups of survived hepatocytes with cord structure were very similar to a neonatal liver except for the lack of the glisson's area. two or three months later, proliferation of the hepatocytes became prominent. there seemed to be no interrelationship between proliferated hepatocytes and bile ducts. one year after transplantation, a white nodule was observed on the spleen macroscopically and it consisted of numerous bile ducts and hepatocytes with or without cord structure on histology. summary: . fetal hepatocytes transplanted into the spleen, differentiated to almost normal neonatal hepatocytes two weeks after transplantation. . hepatocytes began to proliferate about weeks after transplantation. . three days after transplantation, proliferation of bile ducts was already observed independent of the transplanted hepatic tissue. . when comparing the difference in proliferation between fetal hepatic tissue and isolated hepatocyte transplantation, marked proliferation of the bile ducts in fetal hepatic tissue was observed and fetal hepatocytes proliferated more rapidly, while there were no proliferated bile ducts in isolated hepatocyte transplantation. pretransplant splenectomy (sx) has been of disputed benefit since its introduction two decades ago. of patients with first cadaver transplants treated at our institution between dec. and dec. have had pretransplant sx. at six monts, sx patients had % better kidney survival, but this benefit was lost shortly after year and by and years was % and % worse in sx patients. patient survival for sx and no sx was identical for the first year but was % and % worse by and years respectively in sx patients. thus, the early improvement in kidney survival was more than offset by a late high mortality. a rational basis for selecting patients who might benefit most from pretansplant splenectomy is urgently needed. since july, , patients ages - have received first cadaver transplants after having been tested for reactivity to dncb. nine of dncb negative patients had splenectomy as did of dncb positive patients. kidney survival at year for dncb negative patients without sx was %; for dncb negative with sx, %; for dncb positive without sx, %; for dncb positive with sx, %. rejection was the sole cause for kidneyloss in dncb positive patients without sx. however, of dncb negative patients with splenectomy died, primarily of septic complications. since survival of sx patients has been % compared to % in non sx patients (p< . ). sx appears to be beneficial in dncb positive patients but has an adverse effect in dncb negative patients because of an increased susceptibility to fatal infections. prior blood transfusion improves renal graft survival [ ] . plasma from uraemic patients suppresses the in vitro responses of normal lymphocytes to antigen (plasma suppressive activity, psa) and this effect is mainly attributable to the plasma protein macroglobulin (a m) [ ] . the aims of the present study were: a) to identify changes in psa and a m concentration in uraemic subjects following primary blood transfusion. b) to correlate the psa of transfused renal transplant recipients with subsequent graft survival. a) ten potential transplant recipients were studied before and after their first blood transfusion. following blood transfusions the psa increased significantly (p< . ) reaching a maximum at two months. there was no significant change in the plasma a m concentration over the same period. b) the plasma of consecutive chronic renal failure patients was tested for psa prior to renal transplantation and before institution of immunosuppressive therapy. all but two patients had received previous blood transfusions. after transplantation patients were followed for a minimum of months and a maximum of months. grafts failed for non-immunological reasons and were excluded from the study group. patients were divided into two groups according to the degree of suppressive activity of their plasma. a volume of /t , producing a % inhibition of normal lymphocytes was used as a treshold to differentiate those with a high or low suppressive activity. graft survival in the first three months was significantly better, % (/ < . ) for those recipients with a high psa as compared to % for those with a low psa. we conclude that blood transfusion causes a significant increase in psa although not a m concentration and that patients with high psa have a better graft survival. the effect of in vitro steroid on antibody dependent cellular cytotoxicity (adcc) was studied in patients awaiting renal allotransplantation and the results were correlated with transplant outcome. recipients of primary cadaveric allografts were classified as steroidsensitive or steroid-resistant from the degree of adcc suppression induced in vitro by methylprednisolone, patients being steroid-sensitive and steroid-resistant. following transplantation patients received azathioprine and prednisone, and rejection crises were treated with bolus doses of methyl-prednisolone. graft failure occured in of the steroid-sensitive patients, and in of the steroid-resistant patients. the observed one year graft survival rate was . % for the whole group, . % for the patients with steroid-sensitive adcc and . % for those with steroid-resistant adcc, the difference between the two groups being highly significant (xz= . ). a high incidence of early graft failure was seen in steroid-resistant adcc patients, . % of grafts being lost in the three months after transplantation, as compared with only of graft failures in the steroid-sensitive adcc group in the same period. analysis of hla-a, hla-b and hla-dr incompatibilities showed no significant difference between the groups, and since all patients had received deliberate pregraft blood transfusion, the difference in survival rates between the two groups appears to be independent of these two variables. these findings confirm our preliminary observation that pregraft assay of adcc response to in vitro steroids identifies those patients who are unlikely to respond to steroid therapy in the treatment of rejection, and in whom alternative forms of therapy may be appropriate. post-operative dxt, whilst not influencing survival, protected patients from loco-regional recurrence < . , hazard ratio (hr) = . ). interestingly it was found to be most effective against axiallary node recurrence (p< . , hr = . ), reasonably effective against chest wall recurrence (/ < . , hr= . ) but conferred no protection against supraclavicular node recurrence (hr = . ) in spite of a supraclavicular field being routinely employed in the radiotherapy technique. with such large numbers involved, this trial has facilitated the study of the prognostic significance of sub-groups of patients with different patterns oflocoregional recurrence as first evidence of treatment failure (see table) . of those patients developing loco-regional recurrence who have since died ( out of in wp group; out of in dxt group) % in the wp group and % in the dxt group did so with evidence of persistent loco-reglonal disease. however, the incidence of uncontrolled local disease at death was higher in the wp group overall. stress as well as dietary fatty acids have been shown to prolong allograft survival in rats [ ] . poly unsaturated fatty acids (linoleic acid, arachnoidic acid) have been reported to depress immune response [ ] . depressed immune response was suggested to correlate with a higher incidence of spontaneous tumor [ ] as well as with an increased growth rate of inoculated tumors [ ] . the objective of this study was to elucidate the effect of two environmental factors i.e. chronic stress (change in light/dark pattern) and diets low and high in linoleic acid on immune response and growth of transplantable tumors in bn rats. immune response: four experimental groups (n > ) were used in immune response studies. group i: high linoleic acid dietl; group i : low linoleic diet , group iii: l/d shift weekly, normal diet and group iv: controls on normal diet, normal lighting. seven weeks after the start of the experiment the immune response was measured. the results showed that corticosterone levels were slightly increased in all experimental groups, although only the high linoleic group showed statistic significant difference with the control group. cellular immune response (con a stimulation and popliteal node assay) was decreased in all experimental groups compaired to controls. transplantable tumors: x leukemia cells were injected i.v. and pieces of mm of an spontaneous adrenal cortical carcinoma, a urethral squamous cell carcinoma and a round cell cervix sarcoma were implanted subcutaneously. all tumors were inoculated in groups of animals each. spleen weight as a measure of leukemia growth was high in the control group and low in the experimental group. the same pattern was seen in the growth of the subcutaneously implanted adrenal cortical carcinomas. both the urethral squamous cell carcinoma and the round cell cervix sarcoma, being non-immunogenic, did not show any difference in growth. so far, it can be concluded, that the immunosuppression as induced by mild chronic stress or dietary fatty acids does not lead to enhanced tumor growth. in contrary, the results of both leukemia and adrenal cortical carcinoma show a possible reserve effect. little is known of the derivation or content of human breast cysts. recent reports have shown wide variations in the content of steroid hormones, particularly dehydroepiandrosterone sulphate (dhas) [ , ] . no explanation for this is apparent. to confirm the large variation in dhas concentrations and to further define the contents of cyst fluids, cysts from patients have been analysed for dhas, sodium and potassium. dhas concentrations ranged from . - pmol/ . both sodium and potassium content also varied widely (sodium - pmol/ and potassium - ~umol/ ). there was a significant direct correlation between the content of potassium and dhas in cyst fluid (p< . ) and a significant negative correlation with sodium content (/ < . ). three separate subpopulations of cysts could be identified according to the sodium and potassium content and these were, predominantly potassium cysts ( ), predominantly sodium cysts ( ) and mixed cationic cysts ( ). the median dhas concentration of the potassium cysts was pmol/ similar to the levels found in human breast secretions [ ]. in contrast the median concentration of dhas in the predominantly sodium cysts was pmol/ and significantly different (p< . ), with many of these cysts having dhas concentrations in the same range as those found in plasma. the remaining mixed cysts had a median dhas concentration intermediate between the two main groups. it may be that the variation in cationic content and dhas concentration in these two major subpopula-tions of human breast cysts represents either, derivation from two different sources, namely breast secretions and plasma or marked differences in the secretory activity of the epithelium lining these two groups of cysts. there is no uniform agreement on the correct management of patients with invasive lobular carcinoma (ilc). it is widely considered that in ilc there is an increased risk of developing a contra-lateral carcinoma and the major controversy surrounds the management of the second breast. the survival of patients with ilc was significantly better than that of idc fp<: . ). six patients had bilateral carcinomata at diagnosis and a further developed a contra-lateral carcinoma during the period of follow-up ( to years). survival data showed poor survival for patients with simultaneous bilateral disease, but no difference in survival for patients with metachronous bilateral or unilateral disease. this suggests that the later development of a second carcinoma does not necessarily reduce the probability of survival for patients with ilc. the major factor predicting patients at risk of developing a contralateral carcinoma was histologi- cal type. of patients with a particular histological pattern of ilc [ ] with a classical pattern of spread but showing nuclear pleomorphism and cellular cohesion, developed a contralateral carcinome, compared with a further in the remaining patients (p< . ). if bilateral mastectomy is justified it ought to be restricted to patients with this histological type of ilc. both the anti-oestrogen tamoxifen and cyclical combined chemotherapy will provide significant palliation in advanced breast cancer. the optimal use of these agents requires further evaluation and thus this trial was designed to compare a combination ofcytotoxic therapy and tamoxifen, against cytotoxics alone in patients with advanced breast cancer. post-menopausal patients presenting with metastatic breast cancer, locally advanced cancer extending beyond the breast and regional nodes, or with tumor recurrence following primary local treatment were allocated to the treatment arms via sequential manner. doxorubicin, cyclophosphamide, -fluouracil, and vincristine were given intravenously once every weeks. tamoxifen was prescribed in a dose of mg. b.d. on failure or relapse from one of the single modality arms, a crossover of those arms occurred. the combination consisted of both the above therapies. assessment of therapies was made in terms of objective response (uicc criteria), duration of response, and survival. we have previously reported that the combination results in a significantly greater response rate [ ] . as a result of stenosis reducing flow or by platelet embolisation [ ] . as neither aniography nor ultrasound can identify thrombotic activity we have evaluated gamma camera neck imaging using n indium platelets. labelled platelets on endarterectomy specimens were also measured and the activities found were then examined in a theoretical model. twentyfive patients with tia received rain platelets and sequential gamma images were interpreted by two observers, carotid endarterectomy in patients allowed measurement of specimen radioactivities. angiography and doppler spectral analysis [ ] were also performed. all endarterectomy specimens contained labelled platelet deposits with the most active equivalent to platelets from . ml of blood. this activity level was at the threshold of resolution in the theoretical model. both observers agreed that of the carotid bifurcations showed platelet accumulation on imaging. of the atheromatous ulcers demonstrated by angiography were visualised, but only of stenoses greater than per cent were detectable~ since ultrasound identified all stenoses only one angiographically diseased carotid was not detected by combining doppler and platelet imaging. diseased carotids accumulate rain platelets with the more thrombogenic ulcerated plaques identified more frequently than stenoses. long term follow-up is required to establish the clinical relevance of platelet deposition. major problem in vascular endoscopy is the existence of blood which prevents clear visualization. we devised a new technique using a combination of balloon catheter and slender fiberoptic endoscope, by which clear visualization was obtained experimentally and clinically. three to four pairs of orifices of intercostal arteries were also visualized in one visual field. in some dogs, acute aortic dissection was experimentally created by means of blanton's method. the entry, which was located at the descending aorta just distal to the left subclavian artery, was clearly identified. complete occlusion of blood flow and clear visualization could be obtained when balloon pressure exceeded systemic blood pressure. clinical study: in six patients requiring major vascular reconstruction of the aorta (abdominal aneurysm , leriche's syndrome , dissecting aneurysm ), vascular endoscopy was performed intraoperatively. in five patients, balloon catheter was introduced through the one of the limbs of y graft after proximal anastomosis. in each case, orifices of the major abdominal aortic branches were clearly observed. irregular orifices and atheromatous plaque of the aortic intima which were not expected from aortogram, were also identified in all patients. intimal tears by vascular claps were more extensive than expected and anastomotic suture lines were able to be checked from inside. in a case of dissecting aneurysm, balloon catheter was advanced through the mm graft which was sutured to the common femoral artery with finding the entry just above the left renal artery. using fiberoptic endoscope and balloon catheter was useful to observe orifices of the major aortic branches, unexpected intimal tears by vascular clamps and atheromatus plaques. it was particularly usbful to check the anastomotic suture line from inside of the aorta and to identify the exact location of the entry in dissecting aneurysm. vascular endoscopy could be one of the invaluable methods to examine, diagnose and treat the patients requiring aortic, caval and other major vascular surgery. ( ) produced endothelial injury and a local increase in shear stress in cynomolgus monkeys by suture plicating and constricting the aorta and then feeding an atherogenic diet for months. our findings reveal that carotid plaques localize on the outer wall of the internal carotid (plaque thickness . --+ . mm) which is an area of low flow velocity ( - ___ cm/s at re ) and shear stress ( -+ dynes/cm ) and not at the flow divider (thickness . ___ . mm, p< . ) which is an area of high flow velocity ( --- cm/s) and shear ( -+ dynes/cm ). distal to the carotid bulb, velocity and shear increased on the outer wall and little or no plaque was observed. in experimental coarctations, no endothelial damage was observed (sem and tem) within the high-shear coarct channel and the channel was noted to be free ofatherosclerotic plaque despite the development of extensive diet-induced lesions proximally and distally. thus, high flow velocity and shear stress do not appear to produce endothelial damage in vivo. in addition, plaques were minimal in high shear areas in the human carotid bifurcation and high shear appears to have an inhibitory effect on experimental plaque formation. these data contradict previous investigations implicating high shear stress in plaque pathogenesis. in contrast, host aortic endothelium (ae) fails to cover large vp by pannus ingrowth even over much longer times. to see if iaes succeeds because of inherent differences in growth potential between ae and ve, we used ae to seed cm x mm diameter dacron velour infrarenal vp in dogs. an average of x cells obtained by trypsin/collagenase digestion of the bypassed aortic segment was used to seed each vp by a step preclotting method. the identity of ae was confirmed by stains for factor viii antigen. viability of seeded ae was verified by growth of subaliquots in tissue culture. six weeks after surgery central segments of aeseeded (n = ) and control unseeded (n = ) vp were compared by light and scanning electron microscopy using an endothelial coverage score range of - (for fibrin/platelet thrombi) to + (for confluent endothelial coverage). ae-seeded vp had a score of+ . ___ . (mean___ sd) versus. - . ___ . for controls (p< . ). in addition to endothelial coverage, the subluminal smooth muscle and intramural vasa vasorum previously reported in ve-seeded vp were also seen in ae-seeded vp. since ae and ve seeding give identical results, the success of iaes with ve cannot be due to inherent biological differences in mitotic potential between ae and ve. iaes must instead achieve additional endothelial growth either through a) the action of the proteolytic enzymes used for cell harvest or b) mitogenic stimuli to nonconfluent cells at the edges of seeded cell clusters on the vp. further improvement of the efficiency of iaes to allow use of less harvested vein per cm of vp should come from enhancing one or both of these effects. pyrolytic carbon is a crystalline form of carbon that has been extensively used in the construction of cardiac and bone prostheses. since it has also been suggested that pyrolytic carbon will prevent thrombosis from occuring in vascular prostheses, the aim of the present study performed in dogs was to test the immediate blood compatibility of this material and to evaluate its biocompatibility when inserted as vascular substitute. after pryolysis of a gazeous hydrocarbon, the carbone crystalite was deposited on a knitted textile surface or tube. its surface examined by scanning electron microscopy (sem) was rough and porous to a depth of p. this material was tested °) for immediate hemocompatibility as inserts within the vascular lumen (aorta and inferior vena cava). the specimens were examined sequentially by sem and histology at , , , s and min after reestablishment of the blood flow, ° ) for long term biocompatibility as vascular cylinders ( mm id) inserted either in the aorta or inferior vena cava or as intraatrial (left or right) implants. patency of vascular cylinders was tested during postoperative month by doppler ultrasound investigations, specimens were examined by histology, electron microscopy (scanning transmission) at , and days following implantation. satellite lymph nodes were examined by histology. already s after establishement of the blood flow, platelet adhesion and limited fibrin mesh with few erythrocytes developed on the material. platelet aggregates of limited extent were only observed on intravenous implants. plasmatic protein deposition, an early event on polymeric vascular material was not observed. after s a fibrino-erythrocytic membrane recovers completely the material. except in the case of intravenous insert, no thrombosis developed at the contact of intraarterial or intracardiac implant. after days it was completely recovered by a - fibrocellular layer consisting of large myofibroblasts with microfilaments, newly synthetized collagen and elastin. the blood interface was of fibrous nature. at one month by sem, endotheliallike cells developed in a mosaic-like pattern, characterized by transmission e.m., by microvillous projections, numerous pinocytic vesicles and intercellular tight junctions. this endothelial-like cell lining was complete months after implantation. their immunocytochemical properties are now under investigation using specific anti-dog factor viii-rag sera. although preliminary, the present results suggest that among the numerous vascular biomaterials tested, pyrolytic carbon may represent a unique feature of rapid cell development and differentiation of endothelial lining at the blood material interface. department of connective tissue biology, institute of anatomy, university of aarhus, aarhus, denmark in the surgical clinic a significant number of patients report that their incision wound has burst, even though the scar appears to be intact. by mechanical testing of strips from skin wounds we have noticed a breaking pattern, in which the deepest layer of the wound ruptures earlier than the superficial part. therefore, we have investigated the strength and extensibility of rat skin wounds at different levels (superficial-deep) of the epidermis ( . mm), dermis ( . - . mm) and m. panniculus carneous ( . - . mm), average thickness is indicated. , and day old standardized skin wounds from the dorsal region of rats have been used. strips were punched out at right angle to the wound line and mounted in a materials testing machine. the strips were stretched until rupture and load-strain curves registered continuously. simultaneously, the strips were transluminated and the breaking pattern was studied by taking photographs of the wound specimens during the mechanical testing ( - photographs of each specimen). the photographs were marked on the load-strain curve by means of a connection between camera and x-y-recorder. from the load-strain curves the maximum load and the failure energy were calculated. the breaking patterns of , and day old wounds were found to be similar. the deep part of the wounds ruptured first. the force required to break the deep part was less than that required to break the superficial part of the wounds. the musculus panniculus carneous was very extensible and did not break. however, it possessed only minimal strength. quantitative measurements of the strength of the combined superficial-deep layers were performed on mm wound strips. specimens contained the superficial . , . and . mm of the wound area and were produced by cutting off the deep layer parallel to the skin surface. specimens containing the total wound area down to the musculus panniculus carneous were produced by cutting off the muscular tissue. these specimens were mechanically tested as described above. the present studies demonstrate the mechanical inhomogeneity of incision wounds. a new method for testing the mechanical properties of the tissue of incision wounds at various levels (superficial-deep) is presented. the superficial layer of an incision wound contributes a major part of the strength of the wound and is more extensible than the deep layers. these results may explain the clinical observations. the effect on wound healing of different kinds of vitamins is worth investigating, since the efficiency of vitamin c has been dearly demonstrated. the possible action of vitamin bs-whose trophic effect on skin is well known -has been experimentally studied on skin and aponeurosis healing after a standard laparotomy. materials and methods: experiments were carried out on five months old rabbits which were randomly divided into three groups: in group i, animals served as controls ( animals in sequence of days from the th to the th post-operative day), group ii, animals injected with vit b ( mg/kg of body weight/ h) and group iii, animals injected with a placebo ( animals in sequence of days for each group). in each case four samples were tested of skin and aponeurosis for determinating tensile strength, directly recorded with an original technic [ ] : this new apparatus allowed us to obtain simultaneously two dynamic parameters, the healing tensile strength and stretching of the scar. results: . no significant difference was found between controls (group i) and the placebo group (group iii) both for resistance of skin and the aponeurosis. . as far as vitamin b treated animals were concerned (group ii) there was no significant difference regarding skin resistance when compared with the other two groups. . inversely aponeurosis resistance become significantly greater when measured on the th (p< . ), th (/r< . ) and th (p< . ) post-operative day. in mongrel dogs ( x cm cranial based rectus abdominis) mc and corresponding rp flaps were raised. in group i ( dogs) skin bf was determined from the clearance curve for ~ xenon injected intradermally and measured with a computer-linked gamma camera. in group ii ( dogs) subcutaneous pro was determined by a recently developed method using a silastic tonometer, subcutaneously implanted. the pro inside the tonometer was measured in infused saline, by a platinum oxygen needle electrode and a silver/silver chloride reference electrode. b f and pto were measured before and after the flaps were raised and on postoperative days (pod) , , and . pto were taken at various inspiratoric oxygen levels (f~o ) ranging from % (air) to % oxygen. intact areas lateral to the flaps and in flap regions prior to surgery served as controls. immediately after surgery bf in the mc increased while in the rp flaps was %, % and % of the flow in the mc flaps, in lateral intact area and in the preoperative areas (p< . ). during pod - bf in the rp flaps increased to the preoperative level, but not to the increased levels found in the mc flaps and the lateral intact areas. by pod there were no differences in bf between the two types of flaps and the lateral areas, but all were higher than corresponding preoperative values (/'< . ). tissue oxygen tension showed a dramatic fall pod , and in the rp flaps for all fio , and for all days the values were lower than the preoperative level (p< . ). one rp developed pod distal necrosis and the pro was then even with a fio of %. the mc flap showed an increased pro on the operative day but at pod the values were slightly lower than the preoperative level, but pod , and the values for all fio were higher than for rp flaps (p< , ). at pod the pro reached preoperative level for rp as well as mc flaps. lateral intact areas showed comparable changes to that observed in the mc flaps. it is concluded that the mc flap demonstrates superior bf as well as pro when compared to the rp flap. early postoperative pro in the distal part of the rp flaps is critically low despite of increasing f~o to % and increasing bf. differences in bf and pto may be the biologic factors responsible for the superior healing characteristics of the mc flap. ( ) atp~adp + pi (inorganic phosphate) ( ) pcr + adp~atp the net result ofreaotjoxas and is a fall in pcr and a rise in pi while atp ~'emains relatively constant. all of the phosphorus metabolites are easily measured in gastrocnemiaas muscle using pnmr spectroscopy. normal volunteers and patients with angiographically documented arterial occlusions were studied in a / " bore oxford research systems tmr- spectrometer at rest and after exercising each limb separately. normal resting values ofpcr/p iwere > and the nmr index = p/(p~+pcr) was . _+ . (s.d.). limbs with femoral arterial occlusions whose ankle systolic pressure index was < . had nmr index which was significantly elevated above norreals ( . + . p< . ) indicating a failure of metabolic compensation for reduced bloodflow and oxygen delivery, although atp concentration was norreal. exercise produced a five-fold rise in nmr index in both normal and diseased legs. spectra were taken over one minute intervals during the recovery period and in normal limbs returned to resting values within rain. the recovery period was considerably slower in the diseased limbs indicating abnormal mitochondrial oxygen delivery and impaired mitochondrial formation of atp. these data demonstrate the feasibility of using pnmr to non-invasively probe the biochemical abnormalities of energy metabolism in patients with peripheral vascular disease. the incidence of urinary calculous disease (ucd) in the south african black population is very low in comparison with the white population group. no biochemical differences in serum nor urine account for this discrepancy and no other measurable parameters have demonstrated any difference between the two groups. urinary particulate activity measurements have demonstrated differences between normal persons and those with ucd who are otherwise biochemically similar, and it would therefore seem rational to expect such measurements to demonstrate differences between the two population groups. urinary particulate activity was measured in the urin of normal whites and normal blacks, the two groups being matched for age, height and weight, and monitored under normal dietary hydrational and environmental conditions. the three parameters of particulate nucleation, growth and aggregation were measured and the two groups compared. particulate nucleation demonstrated the most significant contrast between the two groups with the production of new particles through nucleation being far greater in the white group than that which occurred in the black group (p< . ). particulate growth occurred at similar rates in the two groups although at slightly higher rates in the white group. particulate aggregation occurred at a greater rate in the white group but the difference between the two groups was not statistically significant. the differences between the two groups are shown to occur as a consequence of differing rates of particulate nucleation although the rates of particulate growth and aggregation are parallel. whilst the factors responsible for the low nucleation rate in black person remain unknown their effect can now be measured quantitatively through the parameters of urinary particulate activity. blood levels of ketone bodies appear to determine skeletal muscle amino acid release; high levels conserve protein and attenuate gluconeogenesis. starvation indt/ced ketosis is suppressed by infection [ ] . to determine if the relative hypoketonaemia following sepsi s in turn contributes to increased glucogenesis, arterial substrates and glucose production (constant infusion - h(n)-glucose) were measured before and after infusion of na-dl-./ -hydroxybutyrate (/ oh) to raise levels three-to fourfold in fed (n= ), in fasted (n = ) and in fasted-infected (n= ) animals. in fasted-infected animals before infusion ketosis did not occur (/ oh . ± . mm/ fasted; . ± . fasted-infected) and basal glucose turnover was increased ( . ± . /tm/kg/min fasted; . ± . fastedinfected). with infusion of glucose and alanine concentrations decreased as expected in fed and fasted animals but not in fasted-infected (glucose . ± . ram/ befor; . + . mm/ after). glucose production also fell significantly in the fed ( . ± . /~m/kg/min before; . ± . after) and fasted ( . ± . v. . ± . ) groups but was unaffected by infusion in the fasted-infected group ( . +- . v. . + . ). the accelerated rate of gluconeogenesis in infection is thus not a consequence of hypoketonaemia. the usual reciprocal relationship between glucose and ketone utilisation during feeding and fasting has not been demonstrated~in sepsis. preliminary experiments in a hindlimb model support the hypothesis that during infection amino acid release from muscle is not affected by ketone levels. we have developed a technique for measuring the total body carbon of the living subject which is suitable for measuring the critically-ill as well as the ambulatory patient. by combining this measurement with that of total body nitrogen and calcium [ ] an estimate of total body fat is derived. measurement at the beginning and end of a given period enables the changes in total body protein and fat to be obtained, as well as the patient's energy expenditure if energy intake is also known. the method is a radiation technique. the supine patient is irradiated laterally with a horizontal beam of fast neutrons and the resulting gamma rays from the body are detected by a radiation detector placed unterneath the subject. the nuclear reaction employed is the inelastic scattering of fast neutrons by the carbon nuclei of the body with the emitted gamma rays having an energy of . mevi in the initial application, measures of total body fat obtained using the technique were compared with those derived from skinfold thicknesses in six volunteers: there was no significant differences between the two measurements, (see table) . the method is being employed in studying the changes in total body protein and fat, and the energy requirements of surgical patients receiving nutrition. in order to investigate the mechanism of this effect, normal monocytes were incubated at °c for min (with intralipid /a/ml) and their function assessed by three different techniques (chemotaxis, phagocytosis and chemiluminescence). all three methods showed impairment of function following exposure to intralipid. in order to try and prevent this potentially damaging effect, heparin was added to the various in vitro tests and found to cause marked impairment of phagocytosis. (p< . ) to assess its effect in vivo, volunteers were given , units of subcutaneous heparin h prior to intravenous intralipid (as above). although the use of heparin did not affect either immunological function, it completely prevented the fall of monocyte chemotaxis following intralipid alone. these findings suggest that monocyte function may be impaired by the presence ofintracellular lipid particles. the use of s.c. heparin may help to alleviate this problem and could, therefore, be beneficial to ill and often septic patients requiring intravenous nutrition. to investigate the effect of elevated glucocorticoids of stress and trauma on peripheral glutamine metabolism, . mg/kg bw dexamethasone was injected daily intramuscularely in adult mongroel dogs over a period of weeks. at least weeks prior to the experiments catheters were placed into the animal's abdominal aorta ( ) and caval vein ( ) in order to measure a-v differences and hindquarter blood flow. during dexamethasone treatment nitrogen balances were negative, - . - - g n per day, whereas slightly positive n-balances were observed during the control period ( . +__ . g n/day). muscle glutarnine concentrations declined constantly from . + . mmol/ intracellular water to . - - . by % within two weeks. whole blood arterial and venous plasma concentrations remained constant. to test the hypothesis of increased peripheral glutamine utilisation or decreased glutamine formation, the activities of glutaminase and glutamine synthetase were measured in a muscle homogenate obtained before and days after dexamethasone treatment. both enzyme activities were found to be unchanged. hindquarter glutamine efflux increased from . + . pmol/min in the control state to . + . during dexamethasone treatment indicating a fold muscle glutamine output. this increased glutamine output was enirely due to increased a-v differences and despite decreased hindquaarter blood flow during dexamethasone. it is concluded that dexamethasone reproduces the metabolic response of trauma and sepsis in terms of negative nitrogen balance and muscle glutamine depletion. muscle glutamine is shifted from peripheral tissues to visceral organs with muscle compensating for visceral demands rather than skeletal muscle being the primary target of corticoid action. it has been suggested that there is abnormal glucose utilisation in malnourished patients and that this may explain the adverse clinical sequelae of high rates of glucose infusion during intravenous feeding. we have investigated the hypothesis that there is a depression of the key enzymes of glucose oxidation in the muscle of malnourished patients which is due to an alteration of muscle fibre type proportions. malnourished patients (p) ( m, f + yrs) our results demonstrate that there is a positive correlation between preoperative cp and stage of cancer ' = . +- . x; r= . ;/ < . ). nevertheless before surgery there is no difference between cp values in the two groups considered (g.c.= . ___ . mg %;p.u. = . ---- . mg%), but after surgical trauma cp presents a positive response in patients with p.u. (mean increase + . %), whereas it acts as a negative ap protein in g.c. patients (mean decrease - / ) (p< . ). moreover malnourished g.c. patients present a reduction of cp values ( - %) which is greater than g.c. patients with albumin > . g% ( - . %); this difference is not statistically significant. cancer patients undergoing palliative (n= ) or radical surgical procedure (n= ) show parallel decrease of preoperative cp ( - %), the first group presenting higher preoperative values in relation to the tumor diffusion. in conclusion our results demonstrate that cp is not only a positive ap protein, but in some circumstances it may act as a negative pa protein depending on the underlying disease and the preoperative nutritional status. in this study the free aa concentration in liver tissue of non septic patients (cholecystectomy) were compared with those of septic patients (abdominal sepsis). the liver specimens were taken intraoperatively..the nature and possible risk involved in this study were explained to the patients and their consent obtained. the data presented in this abstract are part of a metabolic screening program of septic patients including the determination of aa (plasma, muscle), hormones (insulin, glucagon, cortisol), nutritional parameters (prealbumin, retinol-binding protein, transferrin), and of energy metabolism (atp, adp, glucose, free fatty acids). for the determination of the free aa the intra-and extracellular water content (chlorid method) and of fat content of the liver specimen were analysed. a membrane potential o f - mv was assumed. the aa analysis were performed with an automatic aa analyser (kontron, svitzerland) by means of an ionexchange resin (durrum dc- ) and a lithium buffer system (durrum-pico buffers). conclusions: . this study reveals decreased concentrations of nearly all aa in liver tissue of septic patients (exception: phenylalanine, tyrosine, cystathionine). . the significantly decreased concentrations of the gluconeogenetic aa (thr, ser, ala) indicate that the gluconeogenetic capacity of the liver is not exhausted through an increased uptake of those aa as shown earlier by wilmore et al. [ ] . an increased administration of gluconeogenetic and basic aa (lys, his) may normalise the aa pattern in the liver of septic patients. the liver is being increasingly recognized as a critical organ in postoperative multiple organ failure. the principle factors precipitating postoperative multiple organ failure were sepsis, hypotension and injury to the liver. previous studies from our laboratory have shown that hepatic failure, which has a high mortality rate, is linked to the marked decrease in energy charge. in order to evaluate the possible presence of metabolic blocks, the changes in the ratio of acetoacetate to fl-hydroxybutyrate (ketone body ratio), which reflects the hepatic mitochondrial redox potential, were analyzed in relation to energy charge in hepatectomized, jaundiced, hemorrhagic-shokked and septic animals, as well as patients with postoperative multiple organ failure. experimental: . in hepatectomized rabbits, mitochondrial phosphorylative activity increased to % of the control and the energy charge level decreased from the normal level of . to . at h after hepatectomy (/ < . ). afterward, these values returned to preoperative levels within a week. the ketone body ratio in arterial blood was positively correlated with hepatic energy charge (r= . , p~ . ). . in jaundiced rabbits, the hepatic energy charge decreased rapidly after the bile duct ligation along with the decrease of mitochondrial pbospborylative activity. the hepatic energy charge fell from . to . at h postoperatively with a maximum incidence of mortality. moreover, changes in the blood ketone body ratio were positively correlated with the hepatic energy charge (r= . ,/~ . ). the decrease in the blood ketone body ratio was attributed to the restricted mitochondrial reoxidation of nadh due to an inhibition of oxidative phosphorylation. . in hemorrhagic-shocked rabbit with a mean arterial blood pressure of mmhg, the changes in the blood ketone body ratio were correlated with hepatic energy charge (r= . , p< . ). . in septic pigs subjected to the ligation and perforation of the cecum, the hepatic energy charge level decreased gradually from . to . and the mitochondrial phosphorylative activity was enhanced to % of controls in the hyperdynamic state. in the hypodynamic state, the hepatic energy charge level fell drastically . concomitant with the decrease in mitochondrial phosphorylative activity and blood ketone body ratio. from these results, the blood ketone body ratio may be regarded as a reliable indicator for assessing the degree of decreased energy charge. clinical: changes in the blood ketone body ratio were measured in patients who underwent major surgery such as hepatectomy. these patients were classified into groups according to the postoperative changes in blood ketone body ratio: group a without decrease to below . , group b with transient decrease to . , group c with progressive decrease to below . and group d with terminal decrease to below . . all group a and b patients tolerated the operation well. by contrast, the group c patients showed multiple organ failure with % mortality rate, which involved pulmonary failure ( %), hepatic failure ( %), gastrointestinal bleeding ( %), renal failure ( / ), cerebral failure ( %) and coagulopathy ( %). all patients who transitioned to the terminal stage of group d died of cardiogenic decompensation. in patients of group c, the decreased blood ketone body ratio was restored with the amelioration of clinical symptoms after ex vivo pig or baboon liver crosshemodialysis and patients of them were later discharged. evidence presented indicates that the decreased blood ketone body ratio has a direct bearing on multiple organ failure. conclusion: sepsis, hypotension or injury to the liver are a metabolic burden to the liver mitochondria which can result in mitochondrial impairment leading to a marked decrease in hepatic energy charge. such impairment ultimately leads to multiple organ failure as a result of the critically decreased energy and substrate store and the reduced protein synthesis relative to demand in the various organs. in interferon-treated cells, the '- 'a synthetase, activated by double stranded rna, polymerizes atp into a series of oligonucleotides characterized by '- ' phosphodiester bonds and collectively designated '- 'a. these activate an endoribonuclease which cleaves rna. other regulatory functions of this enzyme may be expected because of its wide occurence in mammalian cells (untreated with interferon), where its activity appears, in vitro, to be dependent on the growth conditions, hormone responses regenerating liver after partial hepatectomy is often used as a model for the study of control growth and cell proliferation in vivo. in order to evaluate the role of the '- 'a synthetase in the processes leading to initiation of cell division, we measured this enzymatic activity in the rat liver during the first h after partial hepatectomy. partial hepatectomy ( rats) was performed under neuroleptanalgesia by removing the median and the left lateral lobes of the liver according to the method of higgins and anderson. control animals ( rats) were subjected to a sham operation. after selected time intervals, the animals were sacrificed and the enzymatic activity in the regenerated liver was measured. the '- 'a synthetase activity present in the two first removed lobes was defined as %. we observe a very rapid decrease of enzymatic activity which reaches % already h after partial hepatectomy. the lower level of enzymatic activity ( %) is measured between and h after partial hepatectomy. this minimum is followed by a slow restoration of the activity (at h: %). during this early phase of liver regeneration, a maximal incorporation of tritiated thymidine in dna takes place h after surgery. so well differentiated liver cells have elevated levels of '- 'a synthetase. but, after partial hepatec-tomy, the '- 'a synthetase activity decreases dramatically before the first wave of cell mitosis. these observations clearly illustrate the relationship between '- 'a synthetase activity and the growth status. moreover, this drop of enzymatic activity may be a trigger for the initiation of cell division. the primary event or events setting in motion the process of liver regeneration after partial hepatectomy (ph) remain unsettled. regarding the so called hepatotrophic factors, i.e. insulin, glucagon and recently egf, present evidence suggests that they would play mainly a promoting rather than a initiating role. early changes such as glycogen breakdown, fat infiltration and changes in adenine nucleotides and mitochondrial phosphorylative activity are usually, at least the first two, ascribed to metabolic overload of the remaining liver (bucher et al ( ) johns hopkins med, j, : ). so far, however, little attention has been paid to a possible involvement of this phenomenon in the initiation of liver regeneration. attempts were therefore made to modify metabolic overload through early changes in energy metabolism in order to study their influence on the pattern of dna synthesis. fed or h fffsting male wistar rats weighing + g were examined after ph at , , , , and h for adenine nucleotides, oxidative phosphorylation and dna synthesis, based on the rate of~h thymidine incorporation. fasting animals received continuous infusion of % dextrose for h at the rate of . ml/ g/h. in addition to the above mentionned parameters hepatic glycogen and fatty acids were measured. within h partial hepatectomy caused a decrease in hepatic atp which was maximal at h (from . ___ . to . + . /~ moles/g p< . ); in energy charge (atp + . adp/atp + adp + amp) from . -+ . to . ___ . (p< . ) and increase in phosphorylation potential which was maximal at h (from + to _ p< . ). dna synthesis began at h reaching a peak by h. glucose infusion to ph rats suppressed the decrease of hepatic atp, . ___ . / mole/g at h vs . _ . in the control group, prevented glycogen depletion (histochemical estimation) and the increase in fatty acids (two folds increase in ffa and triglycerides (tg) at h vs folds in ffa and folds in tg in the control group),with little effect on mitochondrial activity. the initiation of dna synthesis was delayed and the whole pattern was considerably modified. cessation of glucose infusion restored the usual rate of h thymidine incorporation after a late fall of hepatic atp. in conclusion, glucose infusion was shown by one of us to modify the hormonal response to ph, but insulin and glucagon administration to glucose treated animals failed to normalize the pattern of dna synthesis. it is suggested that metabolic overload as estimated on the basis of early changes in energy matabolism may account for one of the events involved in the initiation of dna synthesis after ph. infusion on liver cell regeneration after partial hepatectomy in the rat b. de hemptinne, j.f. ngala and l. lambotte university of louvain, laboratory of experimental surgery ucl , brussels, belgium after partial hepatectomy (ph) the portal and the peripheral blood serum concentration of immunoreactive insulin suffers a drastic fall and levels ofglucagon show a rapid increase which is maximal h after the liver resection. as these changes appear closely correlated to the blood glucose levels which show a % decrease at h and progressive restoration towards normal values up to h, attempts have been made to alter the insulin/glucagon ratio by glucose infusion after ph and study its relation to liver regeneration. the purpose of this work is thus to determine after ph and hypertonic ( %) glucose infusion: . the effect of glucose on insulin and glucagon blood levels over h; . the repercussion of the insulin/glucagon modified ratio on dna synthesis; . the possible improvement of dna synthesis by extensive glucagon infusion. male fisher rats underwent a standard % ph. a % glucose solution or isotonic salin was infused at a constant rate of . ml/h through a cannula placed in the iliac vein. the rats were sacrified at , , , , and h. ( h) thymidyne ( .. /~ci/mmol) was injected h prior to sacrifice and the liver caudate lobes removed for analysis of ( h) thymidine uptake into nuclear dna. blood samples were withdrawn from the portal vein, the inferior vena cava and the aorta for glucose, insulin and glucagon assays. compared to the salin treated group, the infusion of glucose while keeping a normal steady blood glycemia was responsible of a marked increase of insulin ( . --+ . ng vs . _+ . ng,/ < . ) and decrease of glucagon ( . -+ . ng vs . + . ng, p< . ), with a major switch of the insulin/glucagon ratio at h after ph (from . to . ). dna synthesis started at h in both series, but was very significantly impaired at h in the glucose infused group ( -+ cpm/mg dna vs + cpm/mg dna, p< . ). infusion of increasing doses of glucagon (from . to mg/kg/day could not restore the impaired dna synthesis. only a slight improvement was recorded at . mg/kg/day as the insulin/glucagon ratio tended to approach that of the control group. fractionation of various doses of glucagon over the h perfusion time, in such a way that the changes in concentration of glucagon after partial hepatectomy was imitated, remained unsuccessful to improve thymidine incorporation. in conclusion: . the infusion of hypertonic glucose which impairs dna synthesis after ph, modifies markedly the insulin and glucagon secretion. . if a specific insulin/glucagon ratio after ph is important to sustain normal regeneration, its modification does not seem to be the major factor contributing to the blunted dna synthesis response in the hypertonic glucose infusion model. operative mortality of emergency shunt operations or esophageal transection during acute hemorrhage from ruptured esophageal varices in cirrhotic patients (child's category c) has been intolerably high. hence, the emergency operations in these patients should be avoided when the bleeding could be stopped by non-operative measures. when the emergency operation eventually becomes inevitable, the operative procedures should be simple and of short duration. in , we have introduced the endoscopic balloon tamponade method for the management of esophageal variceal bleeding. the new balloon tube used in this method has essentially the similar structure as the sengstaken-blakemore tube, but is made of translucent plastic materials, and has a larger internal diameter so that a small caliber optic fiberscope (ex. bronchofiberscope) can be passed through the tube. by this method, the endoscopic observation of the esophagus is possible through the translucent balloon tube during tamponade of the ruptured varices. it is possible to know directly whether the bleeding from varices has been successfully stopped or not, which seems to be an advantage over the blind tamponade method using the sengstaken-blakemore tube. this endoscopic tamponade method has been used for emergency hemostasis of acute bleeding from ruptured esophageal varices in patients. the mean initial tamponade pressure by the esophageal balloon necessary to stop bleeding was _+ mrnhg and the average duration of tamponade was h. the location of the ruptured v~ices observed by this method was in the lower esophagus within cm of the esophagocardiac junction in % of the cases. the bleeding has been stopped in occasions ( . %) by this method. no significant complications other than atelectasis in patients have been observed. in patients, the bleeding was initially stopped by the new translucent balloon tube, but recurred within h after decompression of the esophageal balloon. tamponade was repeated for several times since these patients were in the category c of the child's classification, however, the emergency operation eventually became necessary. transthoracic esophageal transection was performed using autosu-ture apparatus, eea, in these patients. one patient died of liver failure in the th postoperative day, but others survived the operation and recovered. the use of eea in transthoracic esophageal transection simplifies the esophageal anastomosis, and shortens the duration of operation by rain. we have so far used the autosuture apparatus, eea ( mm cartridge) in elective esophageal transection of patients. neither anastomotic bleeding or insufficiency has been encountered. acute variceal bleeding in category c patients should be treated initially by endoscopic balloon tamponade, when emergency operation is inevitable, transthoracic esophageal transection using eea is the operation of choice. arterialisation of the portal vein in conjunction with an end-to-side portacaval shunt has been proposed as a method of improving survival following shunting [ ] . however, there is little experimental evidence to support this suggestion and so we have examined the effects of arterialisation of the portal stump in cirrhotic rats. rats with dimenthylnitrosamine-induced cirrhosis were used in this study. of the rats received an end-to-side portacaval shunt, had a portacaval shunt and the portal stump arterialised with the left gastric artery, eight were sham-operated. liver blood flow (lbf) and wedged hepatic venous pressure (whvp) were measured before and after shunting. three weeks after surgery lbf and whvp measurements were repeated, the animals bled and the liver removed and weighed. an end-to-side portacaval shunt led to an immediate fall in lbf ( . _+ . to . _+ . mls/min/ g-~) and whvp ( . _+ . to . -+ . mmhg). however, if the portal stump was arterialised lbf ( . -+ . to . + . ) and whvp ( . _+ . to . _+ . ) did not change significantly. no further changes in lbf and whvp were observed three weeks after operation in any group of animals. arterialisation of the portal stump prevented the loss in body weight, loss in liver weight deterioration of liver function tests and hyperammonemia observed in animals with a portacaval shunt alone. these findings suggest that arterialisation of the portal stump may prevent some of the deleterious effects after shunting. departments of surgery and pathology, university of virginia hospital, charlottesville, virginia , usa we have hadexperience with operative restoration ofhepatopedal portal blood flow in five patients intolerant of total splanchnic shunting. hepatopedal flow was reestablished by takedown of the total shunt and construction of a selective, distal splenorenal shunt, or by isolation and arterialization of the hepatic limb of the shunted portal vein. in two patients, shunt revision was undertaken electively for chronic encephalopathy, unresponsive to low protein diet, intestinal antibiosis and oral lactulose. each individual had been hospitalized more than eight times for encephalopathy or coma. nine and months postoperatively, both patients have had no encephalopathy on unrestricted protein intake, and work. actively as homemakers. serial liver needle biopsies have shown bilobed nuclei and enhanced mitotic activity suggesting hepatocyte regeneration. in three patients, shunt conversion or arterialization was undertaken in desperate circumstances, characterized by liver failure (bilirubin > mg/dl, albumin < . girl, prothrombin time > " s)~ coma and respirator dependency. although two patients showed immediate, marked improvement in mentation, all three died of intraabdominal hemorrhage in the first few postoperative days in spite of prolonged attempts to achieve hemostasis and maximum blood product support. three conclusions can be drawn from this limited experience: . total shunt procedures which are anatomically suitable for subsequent conversion to a selective configuration or for hepatic limb arterialization should be favored over those not offering such potential; . at a time of election, restoration of hepatopedal portal flow can be accomplished in patients with side-to-side portacaval or hemodynamically equivalent shunts with considerable benefit; and . similar procedures in patients with fulminant liver failure are unlikely to succeed. peritoneal-venous (leveen) shunts are associated with a significant incidence of disseminated intravascular coagulation (d.i.c.). this study identifies a site of origin, a pathogenic mechanism, and the hemostatic pathway which accounts for the thrombogenicity of human ascites. ml of peritoneal fluid were removed percutaneously from individuals with malignant and cirrhotic ascites. ficoll-hypaque column chromatography and ultracentrifugation were utilized to prepare four fractions: cellular; a low speed cell-free fluid; a high speed supernatant; and the precipitate from the high speed centrifugation. the cellular fraction from both types demonstrated an ability to shorten a one stage clotting time by % relative to saline and endotoxin controls. similarly, low speed cell-free fluid shortened the clotting time of pooled normal plasma by %; was also effective in factor viii (required for intrinsic pathway of coagulation) deficient plasma; but had no effect on factor vii (required for extrinsic pathway of coagulation) deficient plasma or platelet aggregation and release. the high speed supernatant was demonstrably less thrombogenic. the resuspended precipitate shortened the clotting time of pooled normal plasman by % and of factor viii deficient plasma from infinity to s. in contrast, this material was ineffective on factor vii deficient plasma. we conclude that the thrombotic potential of human ascites derives from peritoneal cells, either leucocytes or malignant cells. consistently, the thrombotic factor exists in suspension and is thromboplastin-like in its behavior, operating through the extrinsic pathway of coagulation. thus, a site of origin and a pathway of activity for the thrombotic agent in human ascites is identified. the effect of somatostatin in hepatic haemodynamics in the cirrhotic rat s. jenkins, p. devitt and r. shields department of surgery, university of liverpool, liverpool, u.k. although somatostatin has been suggested as an alternative treatment to vasopressin in the emergency control ofbleeding oesophageal varices [ ] , recent studies on its effect on wedged hepatic venous pressure in cirrhotic patients have provided conflicting results [ , ] . therefore we have examined the effect of somatostatin on hepatic heamodynamics in cirrhotic rats. rats with dimethylnitrosamine-induced cirrhosis received a bolus injection of , or pg/kg body weight of somatostatin followed by a min infusion of either , or pg/h/kg body weight. control rats received saline only. portal venous flow (pvp) portal pressure (pp), liver blood flow (lbf) and wedged hepatic venous pressure (whvp) were measured before, during and after somatostatin infusion. at the lowest rate of somatostatin administration (bolus injection of pg/kg body weight followed by an infusion of pg/h/kg body weight)there was a rapid decrease in pp ( . + . to . --+ . mmhg), whvp ( . ___ . to . --- . mmhg) and pvf ( . ___ . to . ___ . ml/min). rain after the start of the infusion pp, whvp and pvf were still signaflcantly lower than preinfusion levels. at higher rates of somatostatin infusion there was no furhter decrease in pp, whvp and pvf. lbf was significantly reduced at all the doses of somatostatin. the highest rate of infusion of somatostatin ( pg) produced a significantly greater reduction in lbf than either or pg. these data suggest that somatostatin may have a role in the management of portal hypertension, but that higher doses may have a detrimental effect on lbf. er positive breast cancers preferentially metastasize to bone ( ) prostaglandin e (pgez) is synthesized by breast cancers and potentiates bone resorption in vitro ( ) . this study investigates the relationship between er status and pge synthesis in breast cancer cells. pge was measured by radioimmunoassay in primary breast cancers: a) after ethanol inhibition of further prostaglandin (pg) production -,,basal pg" b) after stimulating pg production with excess arachidonic acid -,,total pg". ,,total" minus ,,basal" = ,,synthesized pg". in order to relate pg production to breast cancer cells, measured pge values have been corrected for the epithelial cellularity of each tumour. pge x corrected pge = actual (%) cellularity cellularity was evaluated by a proportional count of cancer cells expressed as a percentage against non cellular material in all fields of - histological sections at x magnification. we conclude that er positive tumour cells synthesize greater amonts pge than er negative cells. this may account for the greater tendency of er positive cancers to recur in bone. oestrogen receptor activity (er) is of prognostic value in breast cancer [ ] . however, the chosen cutoff between er-negative and -positive is arbitrary and likely to affect its prognostic value. in patients with invasive breast cancer treated by mastectomy, tumour er was determined [ ] and the patients were followed up until first recurrence. using a computer program to perform repeated logrank analysis, the effect of varying the cut-off on prognostic value of erwas studied between and fmol/mg protein. er levels were higher in postmenopausal patients ( - , median , n= ) than in pre-menopausal patients ( - , median , n= ). for the whole group, optimal prognostic discrimination was achieved with a cut-off fmol/mg protein. in premenopausal patients, the effect of varying cut-off was complex, leading to an optimum of fmol/mg protein, whilst in post-menopausal patients the optimum was fmol/mg protein. these findings were unexpected and may relate to the relationship of er to tumour cellularity [ ] . it is concluded that: . the failure of some centres to relate er to prognosis may be due to the inappropriate cut-off point chosen; . in our patients, the optimal cut-off was fmol, which agrees with the level suggested by the british breast group [ ], though it differed between pre-and post-menopausal patients; . optimal cut-off for prognosis may differ from that for predicting response to endocrine therapy. previous studies have reported that the use of adjuvant chemotherapy improves relapse free survival following mastectomy. the effect on overall survival is less certain. patients with histologically confirmed axillary node metastases were randomised to receive postoperative radiotherapy (rt), chemoterapy (cmf) or radiotherapy plus chemotherapy (rt + cmf). patients have now been followed for between months and years. patients initially treated with rt received chemotherapy on failure where possible. of patients receiving rt alone, have developed distant recurrence and have died. of receiving cmf alone have developed distant recurrence and have died (see table) . although the use of adjuvant chemotherapy significantly prolongs the relaps free interval there is no corresponding improvement in overall survival. a sample of patients with histologically proven prostatic carcinoma underwent transrectal find needle aspiration at six month intervals, for a mean follow-up of months, as an out-patient procedure, without significant side effects. patients were followed from time of initial diagnosis. the others had been on treatment for a mean period of months before the study commenced. in of the new patients, cytology was positive at the time of histological diagnosis, and correlated with the histological grade. there were no false positives. repeat cytology on patients after months showed positive and in of these the disease was progressing, and in one it was stable. of the who were negative, were stable and one progressing. of the patients already on therapy had positive cytology at their initial aspiration - showing progressive disease and being stable. patients whose cytology was initially negative became positive months later and all had disease progression at this time_ patients had negative cytology on or more occasions and in only cases was there evidence of disease progression. cytology showed evidence of squamous metaplasia on follow-up in of the patients whose condition was stable. the prognosis for all patients was assessed on the basis of gleeson's score and aspiration biopsy has been shown to be a safe and useful procedure for monitoring disease activity and response to treatment. the optimum method of restoring the ability to swallow in patients with unresectable carcinoma of the oesophagus remains controversial. this study evaluates the palliative potential of pulsion intubation versus retrostemal gastric bypass of the excluded oesophagus in unresectable carcinoma of the upper thoracic segment ( - cm from the incisor teeth). patients and methods: patients were prospectively randomised for treatment by pulsion intubation ( patients) or gastric bypass ( patients). non-resectability was indicated by ( ) tumour lengths greater than cm, ( ) tracheal or bronchial invasion, ( ) disrant dissemination, ( ) mediastinal invasion. the operative mortality, morbidity, palliation of dysphagia and postoperative nutritional status was compared in the two groups. results: mortality: intubation resulted in deaths, a mortality rate of , %. gastric bypass resulted in deaths, a mortality rate of , %. complications: intubation was complicated by respiratory infection ( ), tube migration ( ), respiratory obstruction ( ), oesophageal perforation ( ), bleeding ( ). gastric bypass was complicated by chest infection ( ), pneumothorax ( ), wound infection ( ), subphrenic abscess ( ), anastomotic leak ( ), pulmonary embolism ( ), purulent neck discharge ( ). ability to swallow: palliation of dysphagia was achieved in % of patients following intubation and % of patients following bypass. postoperative nutritional status: improvement in nutritional status was more rapid following intubation. conclusion: pulsion intubation is the preferred palliative procedure because of fewer complications and lesser degree of postoperative catabolism. the current technique for investigating the response of vascular prosthetic materials to infection is by challenge with a sub-lethal dose of bacteria, usually an intravenous infusion of organisms in an animal model. this large bacterial innoculum, however, obscures any difference in the infectibility of prostheses that may be inherent in the material, its incorporation into host tissues, or its resistance to infection. we have developed a sensitive method for determining the susceptibility to infection of vascular prostheses based on calculation of the number of bacteria required to infect a specific prosthesis in % of trials (ids ). following implantation of the prosthesis to be tested in the canine infra-renal aorta, a dose-response curve was generated by the intravenous injection of known innocula of s. aureus (at log intervals from to bacteria). at six weeks the prosthesis was harvested and cultured to document infection with s. aureus. a characteristic sigmoid curve resulted from which the ids was determined. to test this method, a comparison was made between commercial human umbilical vein grafts (huvg) and huvg impregnated with silver sulfadiazine in dogs. although both prostheses were infected by the standard innoculum, a greater than tenfold increase in the resistance to infection by the treated huvg (< to ) was demonstrated in the dose-response curves. since the number of bacteria in a postimplant bacteremia rarely exceeds organisms/ml, such differences in infectibility are clinically significant. ids determination provides a sensitive, reproducible method for quantitating resistance to infection in vascular protheses. prosthetic infection following reconstructive vascular operations is an infrequent but often fatal complication which generally persists until the graft is removed. it is accepted that infection arises from operative contamination, bacteraemic seeding and abscesses or viscus eroding into the graft. this study investigates the role played by distal sepsis on groin grafts. ten dogs had a specific strain of staphyloccocus aureus inoculated onto a surgical wound in the right foot pad. five days later interposition mm dacron grafts were implanted into the ipsilateral and contralateral groin in continuity with the superficial femoral artery. ten days following this the grafts were removed for bacteriological and histological examination. blood cultures and lymphnode cultures were also taken at this time. in seven dogs the specific staph, aureus, was grown from both grafts. two dogs failed to grow the specific staph, aureus from either graft. these results are significant at the % level using fischer's exact test. blood cultures grew staph, aureus from only one dog. ipsilateral lymphnode cultures yielded the specific staph, aureus in seven dogs. we believe that distal sepsis plays an important role in the estabishment of graft sepsis. the mechanism of spread would appear to be via the lymphatics. the influence of tumor growth on wound healing p.w. de graaf and a. zwaveling laboratory experimental surgery, state university, leyden, the netherlands leakage of a colonic anastomosis is a complication each surgeon fears, because it usually leads to a prolonged hospital stay and is accompanied by a high mortality. carcinoma as an indication for operation and preoperative malnutrition are considered to be high risk factors. the subject of this study was to measure the influence of malignant tumor growth at a distant site on woundhealing in colon and skin, and to find a correlation between the influence of the nutritional state of the experimental animal, and the influence of malignant tumorgrowth on woundhealing. we also tried to find ways to compensate the possible unfavourable influence a malignant tumor might have on woundhealing. the study was performed in rats, the tumor used was a rhabdomyosarcoma, transplanted subcutaneously in the rats right flank. parameters for woundhealing were tensile strength of the skin-incision, and bursting pressure of a colonic anastomosis. six groups of rats were studied, each rat undergoing a standardized colonic operation after two or four weeks. the groups consisted of: control animals ( ); tumorbearing animals ( ), without tumor removal; malnutrltioned animals ( ); tumorbearing animals receiving intravenous hyperalimentation ( ), without tumor removal; animals undergoing tumor removal and colonic operation in one session ( ); animals undergoing the colonic operation two weeks after tumor removal ( ). woundhealing was negatively influenced in an early stage of tumorgrowth (f< . ). four weeks of tumor growth did not impair woundhealing to a greater degree than two weeks. laboratory determinations showed no deviations. malnutrition, leading to less weight gain than in control and tumor bearing animals took much longer to influence woundhealing than tumor pearing. this is in accordance with publications by irvin and hunt ( ), devereux et al ( ) and garattini and guaitani ( ) , which led us to the conclusion that the negative effect of tumor bearing on woundhealing was not solely the result of anorexia. hyperalimentation in tumorbearing rats resulted in undisturbed woundhealing, despite the fact that hyperalimentation as practised by us (with amino-acids and carbohydrates) stimulated tumorgrowth. we concluded from these experiments that tumorgrowth caused a metabolic chaos in the animal, which in turn led to a disturbance in woundhealing. intravenous hyperalimentation could apparently compensate this. woundhealing in rats operated in one session was significantly more disturbed than woundhealing in rats operated in one session was significantly more disturbed than woundhealing in rats operated in two sessions (p< . ). irvin an hunt ( ) have demonstrated however that extraabdominal trauma had no influence on colonic healing. this led to the conclusion that the diminished woundhealing found in rats operated in one session was an effect of the tumor. obviously this influence is not instantly removed with tumor excision. this study offers a theoretical foundation for the clinical observation that in operations for colonic carcinoma with a substantial operative trauma, the anastomosis needs extra protection and/or needs to be performed in a second session. the aorta of the blotchy mouse undergoes dilatation during adult life, resulting in the formation of fusiform aortic aneurysms. the mutation is x-linked, so only the males are affected. we have found a shift in the fluorescent spectrum of insoluble, hydrolyzed, dermal collagen in these mice; suggesting the presence of an abnormal crosslinkage compound. the purpose of this report is to describe additional studies carried out on the soluble collagen fraction in these animals, which lend support to the hypothesis of a crosslinkage abnormality. dermal collagen was prepared from one-monthold mutant mice and their normal male littermates by sequential extractions in salt solution, acetic acid, and urea. amino acid analyis and sds gel electrophoreses of the salt-soluble fractions revealed similar profiles of amino acids and collagen-chain types, suggesting that there is no abnormality of the basic building blocks of collagen in the mutants. fluorescent spectroscopy of the acid hydrolysates of these fractions also demonstrated similar absorption and emission peaks. however, reduction with sodium porohydride abolished fluorescence in the collagen fraction from the mutants. results ( emission m a x ± sem): normal blotchy before reduction . ± . . ----- . after reduction . + . none sodium borohydride is used experimentally to stabilize labile collagen cross-linkages. the present studies indicate that the salt-soluble collagen from the blotchy mice is borohydride-reactive and is thus chemically ,,unstable". these studies suggest a rational for developing probes based on these fluorescent croperties of investigate collagen from human subjects affected with aneurysms. one third of testes are removed after torsion ( , ) because of delay in presentation and diagnosis. in a retrospective study of patients with torsion our salvage rate was %. nineteen percent were misdiagnosed as epididymitis by a junior doctor and % by a surgical registrar. doctors could not distinguish between torsion of the testis and its appendages. in the literature, eight factors have been reported to be of discriminant value (table ) . a computer program, using these parameters and bayes' theorem, was written to calculate the most likely diagnosis. data from the patients with torsion and patients with acute epididymitis were analysed by this program ( table ) . the program correctly diagnosed all cases of epididymitis. of patients with torsion of the testis . in this study we determined the critical ischemic time for the development of an arrhythmogenic potential. egg and bipolar electrograms were recorded from the his bundle, ventricular endocardium and epicardium in twelve anesthetized dogs. short bursts ofventricular pacing ( beats; - beats/min) were used to induce ventricular arrhythmias before and after lidocaine administration ( , , mg/kg). previously, lidocaine has been shown to exacerbate conduction delay in ischemic myocardium leading to reentrant ventricular arrhythmias. in the control state, ventricular pacing with or without lidocaine induced either no response or single or repetitive ventricular responses. sustained ventricular tachycardia was never evoked in the control studies. in six dogs, after min of left anterior descending coronary artery ligation and reperfusion, ventricular pacing with and without lidocaine produced sustained ventricular tachycardia in one animal. in another six dogs, after rain ofligation and reperfusion, one dog showed sustained vertricular tachycardia in response to ventricular pacing alone. the other showed sustaine~l vertricular tachycardia after ventricular pacing with lidocaine. sustained ventricular tachycardia averaged /min and degenerated into ventricular fibrillation within - rain. in conclusion - min of ischemia appears to be the critical period for development of malignant arrhythmogenic potential in the canine heart. administration of lidocaine during this critical period enhances the inducibility of cardiac arrhythmias, which may have clinical relevance in the management of acute myocardial infarction. untreated coronary artery air embolism in the experiments without ecc (group i) resulted in a transmural myocardial ischemia with a mortality rate of % in contrast there were no death in the experiment when extracorporeal circulation was used (group ii to v). the best therapeutic effect with regard to the reversibility of temporary myocard ischemia following coronary artery air embolism was achieved by increasc of the postembolic perfusion pressure (group v), a finding being significantly different (p< . ) to groups i through iv. also volume depletion of the left ventricle on ecc (group ii) resulted in a faster regression of the left ventricular hypothermic area compared to group i (p<: . ). the application of dipyridamole (group iii) and st.thomas cardioplegic solution (group iv) was not able to produce a significant therapeutic effect. the increase of perfusion pressure following coronary artery air embolism has demonstrated to be the most effective procedure to achieve reversibility of myocardial ischemia. to transfer these experimental findings into clinical application is suggested because of its practicability and convenience. transmural biopsies were obtained before and , , , , , min after acc for biochemical and structural analysis. myocardial temperature (t) ph (mph), and pco ) were measured continously with a thermistor, a new ph electrode, and a mass spectrometer respectively. in group i (n= ) acc was under normothermia. in group ii mean t was reduced to °c by the administration of cold potassium cardioplegia immediately after acc and consecutively every min. mph at the end of acc reached . -t- . group i) and . ___ . (group ii) (/ < . ); pmco rose from ___ to _+ mmhg in group i and did not change in group ii. tissue content of atp decreases by % group i) and by °/ (group ii) (f< . ); tissue creatine phosphate fell by % (group i) and by % (group ii) (p< . ). changes in atp and creatine phosphate as well as in tissue glucose and glycogen related ton concomitant changes in ph. the degree of ischemic damage assessed histologically by a mean ischemic score was . +-- . in group i and . _+ . in grup ii (p< . ). irreversible structural demage assessed by electron microscopy occurred in group i - min after acc and was associated with a mph below . . no such damage was observed in group ii. we conclude: . irreversible damage during normothermic arrest occurs considerably later than has been reported for regional ischemia in the beating heart; . during h of acc cold potassium cardioplegia does not completely protect against id when mean t is °c; and . on-line oaeasurement of mph reflects the inadequacy of' mp more accurately than do either pmco or t and thus, provides a useful potential method for intraoperative monitoring of mp. in rabbits, infusion cardioplegia was installed at , , and °c respectively. the infusate contained na , k , , , or , ca , or mmol/ , and varying amounts of glucose. measured osmolality varied from to mosmol/kg. the hearts were excised at the end of a rain infusion period; one half was immediately frozen, the other half was incubated for varying periods of time. specimens of left ventricular myocardium were analyzed for metabolite and electrolyte contents. at termination of the cardiplegic perfusion, total adenine nucleotides (tan) and total creatine (tcr) were within control ranges under all conditions. however, atp and ecp = (atp + . adp)/tan as well as creatine phosphate (crp) and the ratio crp/tcr decreased significantly with increasing dosages of k and ca and higher temperatures. there were corresponding increases in adp, amp, and free creatine. at °c, there were no such changes except in hearts perfused with retool/ k and mmol/ ca. on the contrary, crp and the ratio crp/ tcr were elevated above the control values in hearts perfused with ca-free solutions containing between and mmol/ k. the decrease in atp served as the parameter of the ischemia-induced metabolic alterations and the energy deficit developing during cardiac arrest. at °c, it averaged . and . /zmol/g (p< . ) after min of arrest induced by and mmol/l k respectively. ca, or retool/ respectively, significantly increased the atp-decay to . and more than . pmol/g/lo min respectively (/ < . and p< . ). hypothermia of °c reduced the rate of metabolic deterioration and suspended the influence of the k-dosage. however, the ca-effect was still visible: induction of cardiac arrest by and mmol/l k without/with ca decreased atp by . / . pmol/g (p< . ) and . / . pmol/g (n.s.) respectively within rain. at °c, the rate of metabolic alterations was further reduced. the effects of k-dosage and of ca were completely abolished. the atp-decreased . pmol/g during min of arrest. although higher concentrated k-solutions for infusion cardioplegia do not enhance the ischemiainduced myocardial metabolic alterations in deep hypothermia, they are not recommended for practi-despite the advantages of cbk carrdioplegia, the severely impaired myocardium and/or long ischemia time continue to be a challenge. because of the association of ca ~ with cell injury and death the use of ca ~ channel blockers is logical. investigation of cbd revealied no advantages over cbk. the combination of k and d is appropriate because of their different mechanisms of action. ten dogs had one hour of myocardial ischemia (mi) with topical ice (temp ___ °c) after coronary perfusion with ml cb ( ___ l___c) containing k, meq/l and d, pg/kg. eight dogs had two hours of mi after perfusion with ml cb containing k, meq/l and d, /zg/kg. six dogs received the same treatment as the previous group except that d was increased to /zg/kg for all four perfusions. baseline studies were repeated after min ofreperfusion without the use of ca ~ or inotropic agents. heart rate, peak systolic pressure, vc¢, v~,~x, peak + dp/dt, peak -dp/dt, dp/dt over common peak isovolumic pressure, left ventricular compliance, stiffness and elasticity and great water were unchanged from control. coronary vascular resistance was unchanged in groups one and two but declined in group . creatine phosphate returned to control but atp, adp and the adenosine pool were depressed. ultrastructure was well preserved. in / dogs defibrillation was not required whereas / dogs with cbk and / with cbd required defibrillation. these data suggest that d is a worthwhile addition to cbk. early one-stage repair of some congenital vascular anomalies might be accompleshed readily if the material used for grafts grew along with the reconstructed tissues. we have evaluated the capacity of tubular grafts constructed from anterior rectus sheath to serve as growing segmental replacements of the descending thoracic aorta of puppies (age weeks). grafts measuring cm in length were placed in animals; were implanted with attention to tissue preservation (live grafts) while received grafts subjected to prior freezing and thawing in order to kill the donor tissue cells (devitalized grafts). grafts were measured initially and at sacrifice , or months later. each months animals with live grafts and with devitalized grafts were sacrificed. no aneurysmal dilatations or grafts ruptures were observed in any of the specimens. by months, the live grafts had increased . - - % in length and . ___ % in diameter, while length and diameter of the devitalized grafts showed minimal growth ( . ___ /o and . ___ o/o respectively). during the same period the length of the thoracic aorta increased . ___ % in the live graft group and . ___ % in the devitalized graft group. grafts were lined by endothelium and organized into transmural zones. the thickness of each zone in the live grafts remained static from to months, whereas thickness of the middle and outer zones in the devitalized grafts increased to fold. in living grafts the layers consisted principally of newly formed fibrocellular tissue; the rectus sheath was reduced to a atrophic fibrous band. by contrast, the rectus sheath remained prominent in the devitalized graft specimens. cellularity (cells/field) of the live grafts was much greater than that of the devitalized grafts (ratio . ___ : . ----- ). a newly formed, fibrocellular layered structure replaces the rectus sheath in the live grafts. these findings indicate that rectus sheath grafts are capable of growth in the young animal, providing that at implantation the tissue is well preserved. it is well known that durability of valvular bioprostheses (vbp) depends mainly on the structure of constituent biomaterial and long-term preservation of the collagen network. to our knowledge, no studies on ultrastructure of tissues currently used for vbp has been reported so far after a long time of chemical preservation. the presentation of a new anysotropic tissue, xenogenic cervical duramater (xcd), with a collagen tridimensional network, and a comparative study of scanning (sem) and transmission (tem) electron microscopy of bovine pericardium (bp), human duramater (hd) and procine aortic-cusp (pao) represent the purpose of the present communication. samples of the tissues were obtained in semisterile fashion, rinsed and fixed in karnovsky medium at °c for h. materials were then minced on paraphine plates and washed with . m cachodylate buffer for h and dehydrated in increasing concentrations of ethanol ( %- %) and intermediate exposure to % uranyl acetate for the in-bloc contrasts. were conducted, and results are exposed in table . as a general rule, histologic evaluation was by far, more satisfactory for tissues preserved with . % glutaraldehyde (xcd, pap) than those with % glycerol (hd) and % formaldehyde (bp) in combination. it is concluded that the new anysotropic tissue herein presented, xcd, can be appropriately preserved with . % glutaraldehyde as collagen preservation is concerned, and it's anysotropic and ultrastructural features, maintained for as long as months as assessed by sem and tem. albeit, clinical use of this new biomaterial is subjected to further experimental and animal trials. tetralogy of fallot and absent pulmonary valve (tapv) is associated with massively dilated pulmonary arteries which cause tracheobronchial compression in the newborn and heart failure and cyanosis in older patients. corrective operations have been attended by mortality rates exceeding % due to pulmonary insufficiency causing right heart failure (rhf) and pulmonary complications. pulmonic valve insertion (pvi) with complete repair has resulted in improved survival. the purpose of this paper is to assess the results of total correction and pvi in ten patients. during the last five years, patients with tetralogy were corrected. of these, ten patients (ages days to years) had absent pulmonary valve. one patient ( days) present with severe rhf and pul-monary insufficiency and nine patients presented with mild rhf and cyanosis. chest roentgenographs showed increased cardiothoracic ratio and pulmonary prominence in all. arteriography revealed massively enlarged pulmonary arteries with a mean right pulmonary artery to aorta size ratio of . to . associated pulmonic stenosis and insufficiency was present in all. seven patients underwent closure of ventricular septal defect (vsd) and pvi. of these, three had pvi ( tissue and prosthetic) with outflow patch and four had right ventricle to pulmonary artery (rv-pa) tissue valved conduits. two patients had repair without pvi, and one had repair with a monocusp pericardial valve patch. nine patients have done well with no episodes of thromboembolism or infection. death occurred in a day old infant who had vsd closure and relief of pulmonic stenosis. pulmonary valve insertion seems indicated in these patients at it lowers peak pulmonary artery pressure and thus reduces compression effects on the trachea and bronchi. as well, when pvi was used right heart failure was not noted postoperatively. although in experimental acute myocardial ischemia intraaortic balloon pumping (iabp) appears to increase regional contractility of ischemic segments of the left ventricle by increasing the collateral flow, evidence for this effect of iabp in patients with refreactory myocardial ischemia is not available. this study was done to analyze the effect of labp on global and segmental left ventricular performance in patients with refractory, acute myocardial ischemia using gated blood pool scanning with tc- albium tracer. eight patients were studied on-and-off iabp prior to and following coronary bypass surgery. left ventricular (lv) wall motion analysis was undertaken and both cardiac output (co) and left ventricular filling pressure (lvfp) were determined from thermistor-tipped pulmonary artery catheters. when placed on iabp, mean preoperative global ejection fraction (gef) increased ( . - . (off) to . - . (on); p< . ) abut no changes in co or lvfp were observed. when comparisons were made praend postoperatively, co increased after operation (p< . ), due chiefly to an increase in heart rate ( - to - beats/rain; p< . ), but gef was unchanged whether or not iabp was on. only segmental wall motion analysis pre-and postoperatively revealed that iabp increased regional ejection fraction (ref) and contraction velocity by % (mean) in the angiographically determined regions of myocardial ischemia and these regional changes were maximal during the last one-third of the lv contraction cycle. it appears that ref is a more sensitive indicator of changes in lv performance than co and gef in these patients. further, this study indicates that iabp does increase the regional wall contracility in the ischemic areas of the myocardium in man. the use of aspirin (asa) to inhibit platelet thromboxane synthesis (tbx ) in patients undergoing coronary artery bypass grafting (cabg) has been advocated to reduce the potential for graft occlusion. however, asa in conventional doses also inhibits the venous synthesis of prostacyclin (pgi ) a potent anti-thrombotic factor, and may contribute to excessive surgical bleeding. to investigate the relationship between asa dose, blood loss and inhibition of venous synthesis of pgi , patients undergoing cabg were studied. control patients (no asa) were compared to those receiving or mg. asa as a single dose - hours prior to surgery. production of pgi by saphenous vein specimens removed at the time of surgery was measured by radioimmunoassay (ria) of -keto pgf~a following incubation with um na arachidonate. blood loss was assessed by chest tube drainage and transfusion requirement in the perioperative period. serum tbx was measured by ria following asa ingestion. transfusion (units), drainage (cc), vein pgi (pg/mg tissue) and serum tbx (ng/ml) were (mean -sem): therefore, asa mg or mg did not increase blood loss during cabg. however, asa mg, significantly reduced saphenous vein pgi synthesis (/ < . ) while the lower dose asa mg spared the production of pgi . asa is both doses inhibited tbx (p< . ) and blocked platelet aggregation. low dose asa deserves further investigation as an anti-thrombotic agent since it does not appear to increase operative bleeding or significantly inhibit venous pgi production. transfusion postoperatively, igg increased progressively in patients in group a, reaching preoperative levels on the th or th day, whereas in patients in group b, igg remained at lower than preoperative levels during the first week. the number of patients with abnormally low lavels of igg during the whole po period was significantly higher in group b (p"~. ). no significant differences were found in the others studied variables. one patient in group a had infection. three patients in group b had infections. conclusion: high doses of fab igg administered during ohs and the first po days are effective in lessening the po decrease oflgg and thus may be beneficial in preventing po infection. a water insoluble but very hygroscopic polyvinyl alcohol powder, zy- ", is capable of significantly stimulating the cicatrization of open, contaminated skin wounds in rats. when it is compared to other substances in clinical use such as powders containing antibiotics, antiseptics, amino-acids, enzymes or a dextranomer, no other agent tested was capable of producing a similar beneficial effect. these excellent experimental result justified pilot clinical trials on patients: varicose vein ulcers, atherosclerotic leg ulcers, infected traumatic wounds and infected postoperative wounds. whether in rats or in patients, zy- powder removed secretion, bacteria and tissue debris; it produced an early and increased proliferation of fibroblasts with the appearance of dense granulation tissue; it reduced wound size after less than three applications permitting very early grafting of the wound of eventually, cicatrization advanced to complete epithellzation. regardless of whether the treatments were applied daily in the hospital bed or every other day in outpatients, there were not complaints of unpleasant sensations such as itching, burning or pain. few studies have dealt with long term healing in stomach and none is available for duodenum. this study evaluates morphology and development of mechanical strength and collagen concentration in and adjacent to wounds after to ]g days of healing. incisions were made in the non-glandular (rumen) and in the glandular oxyntic (corpus) part of the stomach and in duodenum of male wistar rats, intact rat served as controls. the wounds were dosed with - polypropylene sutures using a single sutur technique. after , and days of healing complete load deformation curves were determined on strips perpendicular to the incision line after the sutures were cut. collagen distribution was measured as hydroxyproline in strips parallel to the incision line. wound tissue continued to gain strength up to days of healing (breaking energy significantly increased in all tissues from to days of healing). no such increase was found for wounds tested togetherwith adjacent tissue, because the "point of maximum weakness" had moved laterally from the incision line with healing time. wound collagen concentration increased in corpus and duodenum between and days of healing, but was unchanged between and days. the biochemical active zone around the incision line was unchanged - mm on each side from day to . conclusion: while the wound tissue itself continues to gain strength during the days ofheaiing studied, the increase seen after days does hot,enhance the functional properties of the organ as a'whole. the "point of maximum weakness" has at that time moved to the borderline of the biochemically active zone, which lies outside the tissue area enclosed by sutures. myocutaneous flaps based on either the inferior or superior epigastric artery may be used to cover extensive soft tissue defects from the mid thigh to the clavicle. we report our experience with rectus abdominis flaps, based on the superior epigastric artery and based on the ingerior epigastric artery. the flap is easily elevated, no skin loss has occurred and primary closure of the donor defect has been achieved in every case. in a follow-up period of between month and months no patient has developed an incisional hernia. the flaps have been used to cover extensive chest wall resection for recurrent carcinoma of the breast ( patients), extensive radionecrosis of the chest wall ( case) as part of a primary breast reconstructive procedure ( patients) and to replace soft tissue overlying the femoral vessels after radical dissection of the groin for metastatic tumour ( patients). of the patients undergoing primary reconstruction required additional subpectoral prosthesis but in adequate bulk was provided by the flap itself. primary healing occurred in all cases. this easily raised and reliable flap will shorten hospital stay after major ablative surgery for recurrent disease and provides a useful addition to methods of breast reconstruction. a. watson department of surgery, royal lancester in girmary, lancaster, u.k. occult gastro-intenstinal bleeding which defies readiological and endoscopic diagnosis provides one of the greatest diagnostic challenges in surgery. lesions producing this clinical situation are often very small by definition and not infrequently mucosal angiodysplastic lesions, localisation of which may be extremely difficult pre-operatively and indeed at laparotomy. various methods have been described in an attempt to improve pre-operative localisation of such lesions. string tests an dthe detection of sicr labelled red cells in the faeces are notoriously inaccurate. arterioghraphy is invasive and usually necessitates a bleeding rate in excess of ml per day. scintiscanning after red cell tagging with mtc gastro-intestinal blood loss, but localisation is difficult. a method oflocalisation of such lesions using slcr labelled red cells and intestinal intubation is described. after labelling of the red cells, a miller-abbot intestinal tube with the balloon inflated and rendered radio-opaque is passed and samples of gastrointestinal secretions aspirated at each cm during passage down the gastro-intestinal tract. samples are counted on a well scintillator counter and when a sample of high radioactivity is obtained, localisation is assessed both by the length of tube passed and by instilling dilute barium down the miller-abbot tube underfluoroscopic control. this method has been used successfully in five patients which were subsequently treated surgically with localised resection resulting in cessation of bleeding. case histories together with photographs of the method and respected specimens will be presented in poster form. postoperative sepsis is tlae most frequent complication of surgery and is the commponest cause ofprolungation of hospital stay. purpose of the study is to prospectively evaluate incidence predisposing factors, bacteriology and costs of postoperative infections. consecutive surgical patients admitted to our institute from may to july were studied. patients undergoing minor surgical procedures (wound less than cm) were excluded from the study. patients were evaluated daily during hospital stay for onset of infection and results recorded in a data sheet. hemocultures in septic patients and free plasma, activated partial thromboplastin time, prothrombin time, and thrombin time, ristocetin test for soluble monomer complexes and fibrin degradation products (fdp, welco test) euglobulin lysis time (elt) and platelet counts. conclusion: . thrombocytopenia is not a typical feature of boomslang coagulopathy. . the demonstration of soluble monomer complexes is blood samples (positive ristocetin test) appears to be an early and consistent indication of intravascular coagulation. . despite unequivocal evidence of advanced consumption, platelet function seems to be maintained, thus preventing complete heamostatic failure. . support for this view is found in the clinical observation that bleeding is essentially mild and late in onset. . thrombelastographic hyperretractility the "spinning top" appearance is a constant feature and is probably mediated via the platelets. . although d. (vpus venom is extremely potent and often fatal, the antivenom is rapidly effective despite advanced consumption. this mechanism which may involve the platelet release reaction has not been fully elucidated and deserves detailed study. in most cases artificial ventricles are driven pneumatically with the advantage of easy handling and the disadvantages of regulation problems, high weight and volume of the driving units and the danger of air embolism in the case of membrane rupture. the driving unit developed at innsbruck universiy consists of a microprocessor-controlled electromagnet driving a pump that functions as a safety chamber (sk). force transmission to the artificial ventricle (ellipsoid heart-eh) is effected hydraulically. thus there is a fixed connection between armature stroke and membrane movement in the eh. the armature position is measured by the microprocessor by means of a position sensor with programmable switch-over points determining the change from systole to diastole so that idling and beat volumes, respectively, of the eh can be programmed. the sk is a newly designed double rolling membrane pump for pressure and suction with very low compliance. pressure and suction are determined by the armature force which is proportional to the microprocessor-controlled current in the solenoids. thus a very positive control of the pumping action is possible. in mock circulation experiments with the hydraulic safety driving unit the cardiac output (co) was between /min and /min at beat frequencies of to bpm. with constant piston-stroke a direct relation between frequency and co was observed. the influence of preload (starling's law) and afterload decreases with increasing armature force (decreasing periods of systole and diastole, respectively) which is due to friction in the hydraulic transmission system. improvements in the geometry of the next system should reduce these losses. in vivo experiments confirmed the hemodynamic efficiency of the system. applied as lvad the system proved to relieve the beating heart considerably. in the case of heart fibrilation the circulation could be maintained by the safety driving unit. the variable height differences between driving unit and eh as they occur in long-term experiments (animal lying or standing) affect only the ratio systole/diastole periods with the co remaining constant. mechanically assisted circulation is indicated in patients with cardiac failure after open heart operations. the clinical experiments show that left ventricular assist devices are capable only in a few cases to maintain full circulation. the limiting factor is the additional right heart failure syndrome. in patients with postoperative cardiac failure, a distinction must be made between isolated left heart failure and total heart failure. in patients with total heart failurebased on diffuse coronary sclerosis or on an increased pulmonary resistance -left ventricular assistance alone is not effective and right ventricular support is desired. therefore, a simple, quick and safe biventricular assist device is necessary. with the biventricular bypass it is possible to maintain complete circulation in cases of cardiac insufficiency. for a successful outcome in patients with low cardiac output after cardiopulmonary bypass, the e-bvad was evaluated in animal experiments (with calves in acute and survival experiments) in cardiac failure situations. the cannulas for the inflow are put into the left and right ventricle, the outflow tracts into the descending aorta and the pulmonary artery. both parts are connected with the ellipsoid hearts. with the e-bvad it is possible to have a replacement of the heart -a total heart assistance similar to the total artificial heart. in cases of clinical emergency this device can be recommended because of the satisfactory hemodynamic effects achieved and the small degree of traumatic hemolysis ( , mg% free hemoglobin). it represents an easy and quick implantable system for total functional heart replacement. the realtionship between acute pancreatitis (ap) and the enzyme and hormone level in blood and gastric and duodenal juices is the factor that had driven us to do this experiment that would complete the study of the physiopathology of this illness. material and methods. we used eight -year-old dogs. a) production of two antiperistaltic fistula in the mann and bullman way; one gastric and the other duodenal (first part). . blockage of the gastric and duodenal compartments: by the gastric fstula we introduced one foley's bucket with closed point and inflatable globe to block the pylorus. by means of the duodenal fistula we introduced another foley's bucket into the duodenum. once inflated, the ball blocks the first duodenal portion. . juice extraction: by adjacent openings in the gastric bucket blocking the pylorum, we extracted the gastric juice separately. with another thin foley's bucket, that was introduced by the duodenal fistula near the already blocked one, to block the third part of duodenum when the globes inflates. b) production of ap: days after the first surgical operation, by the morandeira method with intraparenchymal injection of a mixture of autologous bile and olive oil. results. one of the animals died on the fifth day after the first operation. + no animal died spontaneously after the second operation. they were killed on the th day. in each one acute necrotizing pancreatitis could be verified. + the radiograph showed that the gastric and duodenal compartments were sealed. -it was easy to separately extract blood and gastric and duodenal juices. conclusion. we believe that this method is complete, simple, with good results and very useful for the study of the physiopathology of ap. liver samples were taken form patients operated for cholelithiasis and common bile duct obstruction by gallstones or pancreatic tumour. early evident histoenzymatic deficiency was found even without jaundice or liver structural lesions. in the bilio-obstructive jaundice, the histochemical methods revealed more marked liver impairment, as compared to the histological picture. the degree of the enzymatic depression could explain the occurence of the postoperative liver failure in some patients. experimentally, the effect of common bile duct ligation was studied in rats. group i = healthy controls. group ii = aspartate ( ml % sol.) was injected i.p. in rats daily, for a week. group iii = the common bile duct was ligated under other anes-thesia, in rats h before killing, and group iv=in another rats days before killing. group iv =in rats aspartate was administered h before an twice after choledocus ligation, and group vi = in another rats aspartate was injected daily for a week after surgery. the liver slices frozen in liquid nitrogen were cut in a slee-type cryostat and the histochemical reactions were performed according to arnold, chayen-bitensky and lojda-gossrau-schiebler's methods. the biochemical reactions were performed using merckotests and merz-dade test-kits. after h, and still more after days, very severe structural, histochemical and enzymatic lesions developed. the liver cell glycogen and rna, as well as the "marker" enzymes of infrastructures markedly diminished: nach -tetrazolium reductase - . %, glucose- -phosphatase - . %, alphanaphthylacetat esterase - . %, atp-ase - . %, '-nucleotidase - . %, pas-reaction - . %, mgp-staining - . %. aspartate treatment seems to exert a protecting effect against the noxious action of retained bilirubin and conjugated bile salts upon the liver cells: nadh -tetrazolium reductase + . %, gsp-ase + . %, esterase + . %, atp-ase + . %, 'n-ase + . %, pas + . %, mgp + . % and lipids - . %. but it does not influence the biochemical signs ofcholestasis: bilirubinemia, alkaline phosphatase, leucinearylamidase, gamma-glutamyltransferase, lactate dehydrogenase. aspartate prevented partially but significantly only the increase of cytolysis enzymes: asat - . % and alat - . %. the histochemical and enzymatic results are in agreement with the severity ofmorphologic changes. therefore, aspartate treatment might be adequate for the preoperative improvement of the liver function in cases of obstructive-jaundice, in order to reduce the incidence of liver failure, without influencing cholestasis. oral glucose tolerance tests (ogtt) y. yamoaka, a. sugitani, ic kimura, ic ozawa and y. tobe department of surgery, kyoto university medical school, sakyo-ku, kyoto, japan two patients with cholecystographic evidence of septate gallbladder underwent dynamic hepatobiliary radionuclide scanning with mtc-ehida. when a steady state of emission had been reached from both gallbladder lobes, cholecystokinin was infused incrementally in four doses ( . , . , . and . ivy-dog-units kg-lmin - ) and counts from the gallbladder analysed by computer. in each an obvious functional difference was revealed between the lobes: both distal lobes ceased emptying abruptly during the third hormone infusion whereas the proximal lobes continued to empty predictably [ ] . in one case, histology revealed the septum to be a well-developed smooth muscle ring with cholecystitis glandularis proliferans confined to the distal lobe; the other case awaits surgery. the cause of the difference in response was probably contraction of the muscle in the septum acting as a sphincter. this study provides indirect confirmation that pain in septate gallbladder is due to septum contraction and raised distal intralobe pressure. it is known that the gallbladder stone passes into the common bile duct. furthermore, common bile duct stones pass to the duodenum. these gallstone movements were analysed in cases during the past six years. the phenomenon in which gallbladder stones pass through the cystic duct down to the common bile duct are seen in cases where stones are small and numerous, the cystic duct is wide and connected with the common bile duct angularly or in parallel. in . % of our cases common bile duct stones passed into the duodenum. there were neither inflammatory stenosis of the terminal choledouchous, high grade pappilitis nor severe obstruction of the common bile duct in these cases. it appears that the movement of gall stone is related to size and number of stone and morphological variations in the biliary system. the study was conducted in order to investigate whether intraoperative mano~etry of the bile ducts could be of additional valtie in diagnosis of afflictions of biliary tract or of the papilla. in contrast to current methods of water manometry it seemed important to the authors to use a simple and safe method which could deliver precise results. method: electromanometrics studies were carried out with a cannula placed in the common duct. three manometric parameters were obtained for evaluation. . resting pressure (rp); . pressure increase after injection of ml saline (lml/s) (pi); . time in seconds needed for return of initial pressure (bile flow) (tr). for pressure measurements a pressure transducer with a recorder was used. results: (table) manometry results in patients with calculi in the common duct or with organic stenosis of the papillawere significantly changed as compared with normal findings in the bile ducts. false positive results (proven by cholangiography and biopsies of the papilla) were found in . % of cases, false negatives in % % of all patients with patho-histological changes in the papilla had pathological bile pres-. sures. although false positive and negative results were mainly caused by methodical errors, the described method delivers a high percentage of correct results in agreement with the final diagnosis. it is avery sensitive method in indicating impaired and reduced bile flow and discovers early pathological changes in the papilla as proven by histological examinations. a functional anhepatic state in experimental animals for biochemical studies and as a model for treatment of acute liver failure can be achieved by different surgical procedures like portocaval shunt and complete arterial devascularization or by replacement of the liver with vascular prosthesis and protocaval shunt. we developed a simple hepatectomy procedure using t/ inch silastic tubing, carbon-y-connector and specially designed "vascular spirales" to restore normal portal and caval blood flow. this model was used for auxiliary liver perfusion studies in heparinized animals; the operation takes min, requires no surgical skill, vascular occlusion is less than min, no signs ofsplanchic hypertension are present and blood loss in fully heparinized animals over h is insignificant. one of the main problems in atypical and anatomical liver resections consists of achieving appropriate hemostasis. also because bile capillaries are opened when liver tissue is separated there is the danger of infection and subphrenic or parahepatic abscesses. the authors have used the human fibrinogen clue to seal the surface of the resected liver in cases ( hemihepatectomies and resections). even in anatomical resections exists, in the majority of cases, a diffuse bleeding or oozing of the resected area. this can be completely controlled by sealing the surface with the fihrinogen adhesive. also one of the main advantages of the fibrinogen consists of having the possibility to avoid the insertion of numerous tubes for drainage. all our cases were drained by a single silicon tube. the postoperative courses were uneventful in all cases no major complications were observed. liver regeneration is thought to be stimulated by changes in portal blood constituents, or flow or by a substance in the hepatocytes. rice et al. have documented increases in total hepatic perfusion in rats during liver regeneration. this study has measured the portal and arterial components sequentially in large animals. young pigs ( - weeks) were subjected to shamoperation or % partial hepatectomy (ph). blood flow in the portal vein or hepatic artery were measured pre-operatively and at intervals of h postoperatively using cuff probes of an s.e.m. electromagnetic flowmeter; these were positioned daily under light anaesthesia. systemic arterial and portal venous pressures were measured via indwelling catheters. previous studies have shown that the peak of regenerative response occurs in pigs to days after ph. the mean pre-operative total liver blood flow increased from . + . (s.e.m.) ml.g-lmin- to a peak of + % on day . thereafter flow declined towards normal by day . the pre-operative portal component was ___ %; this increased to + . % on day and returned to normal level within to days. it seems that both total hepatic flow and the portal component increase markedly just preceding the peak of regeneration. this response may stimulate regeneration, or merely accompany it, or may be proyoked by similar stimulators. the analysis of individual bile acids is relevant to several clinical investigations although established techniques have a number of disadvantages. to overcome these we have developed a simple hplc method using a waters associates rcm radial compression module with a radial-pak c , ,u, mm id, reverse-phase cartridge (column). bile acids were eluted from the column at a flow of . ml min- with a mobile phase of methanol:water ( : v/v) containing . % (v/v) acetic acid and adjusted to ph . with m naoh. a mixture of standards of cholic, chenodeoxycholic, deoxycholic, lithocholic and ursodeoxycholic acids and their glycine and taurine conjugates were resolved, while the conjugates alone were completely separated in under rain. the technique has been applied to the study of human bile from the common duct, gallbladder, tube and duodenal fluid, and serum from patients with hepatobiliary disorders. bile acids in these samples were rapidly extracted using a sep-pak c cartridge before being applied ( /a to pl) to the hplc system, although bile could be analysed directly without extraction. quantitation (~mol ml- sample) of separated bile acids was achieved by comparison with standards using an on-line integrating computer and less than nmol could be detected using a refractive index detector. acute hepatic failure induced by total liver devascularization in pigs -amino acid uptake by combined charcoal -resin hemoperfusion support system where losses averaged %. jib patients had progressively greater losses with increasing preoperative weight (/ lbs- %, - lbs- %, - lbs- %, - lbs- %, lbs- %). weight loss in patients dbs was statistically and clinically greater with jib. . diabetics, especially insulin-dependent, were rapidly cured after jib. normal plasma glucoses, serum insulins, and oral glucose tolerance curves were usually seen within l postoperative mouth, unrelated to weight loss. all patients requiring insulin or oral medication preoperatively could discontinue mediation usuallywithin a weekpostoperatively. improvement after gb was gradual, appeared related to weight loss, and was often incomplete. . hypercholesterolemic patients had % decreases, from to mg/dl, after jib, but only % decreases after gb. all serum cholesterols were normal after jib, but % remained elevated after gb. because of complications after jib, some needed reoperation and conversion to gb. fortunately, most benefits were retained after conversion to gb. we suggest considering jib for "superobese", diabetic and hypercholesterolemic patients. in the past years jenunoileal bypass procedures were performed. the most common complications and side effects were frequent abdominal pain, or discomfort and flatulence in almost half of the cases. in addition kidney stones, blind loop invagination, electrolyte and liver dysfunction problems could be observed. the over all complication rate was %, the postoperative mortality rate %. to eliminate the blind loop of the small intestine, to maintain enterohepatic circulation of bile, and to diminish undesirable side effects in the conventional jejunoileal bypass, biliointestinal bypass was introduced in . twenty patients with a mean weight of kg were subjected to primary biliointestinal bypass within the last two and a half years. three additional patients had secondary biliointestinal bypass due to side effects, especially diarrhea and flatulence, of jejunoileal bypass, performed two to four years previously. the surgical procedure entailed establishment of an end-to-side jejunoileostomy. cm of the jejunum and cm of the ileum were left in the continuity. the blind loop of the jejunum was anastomosed to a functioning gallbladder. so far the above mentioned complications of conventional jejunoileal bypass could be remarkebly diminished. there have been no deaths in this material and no metabolic side effects. frequent diarrhea is avoided by reduced bile spill-over to the colon. the weight reduction has been satisfactory. in summary: due to a lesser complication rate biliointestinal bypass seems to be superior to the simple jejunoileostomy in the treatment of morbid obesity. hyperplasia or neoplasia g.w. geelhoed, c.j. schaeffer and p. daudu department of surgery, george washington university medical center, washington, usa patients with various thyroid disorders who were undergoing thyroid operation were studied for the presence of absence of estradiol and progesteronebinding proteins in thyroid tissue. steroid receptor assays were carried out using similar techniques and standards as those routinely employed for study of breast cancer specimens. quantitative data were collected by coded specimen number by an observer unaware of the patients' clinical diagnoses, and diagnostic correltions were drawn following de-coding. there was no correlation with age or sex and the presence or quantitative value of steroid-binding site. specimens with the histologic diagnosis of follicular adenoma had estradiol binding sites, and had them at high levels ( . to . ) femtomoles/mg cystosol protein). patients with the histologic diagnosis of thyroid hyperplasia had marginally positive estradiol-binding and lacked progesterone binding. patients with adenocarcinoma of the thyroid exhibited neither estradiol nor progesterone-binding in significant quantity. presence or absence of steroid binding sites in thyroid tissue appears independent of sex or age, but correlates with benign neoplasia of the thyroid, suggesting a possible etiologic association for thyroid adenomas. patients with esophageal cancer underwent resection and primary reconstruction of the esophagus by posterior invagination esophagogastrostomy which we devised. the anastomosis was made in the cervical level in cases and in the left thoracic cavity in cases. functions of stomach placed in the posterior mediastinum were examined in patients surviving more than years and in patients surviving less than years. within one year postoperatively, the absorption ofvitamine b decreased markedly. one and a half year after operation, however, the secretion of castle's instrinsic factor recovered and it showed normal values in patients surviving over years. in secretion of gastric acid by tetragastrin, both total acidity and free hydrochloric acid increased in the progress of the postoperative period and showed normal values in all patients surviving over years. this fact was also confirmed by endoscopic observation of color development by congo-red in the gastric mucosa; its coloring area was scattered in patients surviving years, but extended to the whole surface in patients surviving over years. roentgenographycally in head-down position, the surgically created fornix with a sharp angle of his was effective in preventing gastroesophageal reflux completely. the strain combination of donor and recipients. the nature of the mechanisms determing the different fate of allografts remains obscure and all interpretations of the above findings must be speculative. however, the long-term acceptance of hepatic allografts in the rat appears to be similar to that in other species and emphasizes the role of the liver as an immunologically favoured organ. footnote: part of the work (intrahepatic bile duct proliferation!) contained in this abstract will be presented at the xvii essr meeting . peoples' friendship university, tamojenii pr. , department of operative surgery, moscow, ussr a transplanted kidney, besides tissue incompatibility reaction, is influenced by non-specific injuring factors, including decentralisation. for normal functioning of a kidney transplant over a long period of time we carried out an experimental study. the purpose of the study was the investigation of operative reinnervation possibilities and its influence upon the functional state of a transplanted kidney. for the kidney reinnervation kirpatovski's method for suturing perivascular fascial tissue flaps of anastomosed vessels with branches of vegetative plexus nervosus on them was used. experiments were carried out on mongrel dogs, both male and female. in the first group of experiments a kidney was transplanted into the pelvis while the opposite kidney was preserved or ablated. in the second group the kidney autotransplanted into pelvis was reirmerved by the described method with preserving the contralateral kidney in part of the animals and ablating the kidney in the rest of them. the third, fourth and fifth were control groups. in the third group the kidney was denerved, in the fourth it was denerved and reinnerved by the mentioned method, in the fifth group unilateral nephrectomy was performed. after the operation the animals, in different periods of time (from days to years), were studied by isotopic renography and by scanning kidney's by jbl-hippuran and neohydrin-hg ° intravenous injections. results of the isotopic renography were estimated qualitatively and quantitatively by universal renographic index (hirakawa-corcoran, ). results of the experiments indicate that autotransplantation and denervation of a kidney without its reinnervation were followed by lowering of a kidney vascularisation and its secretory and excretory functions. during the first or months after the operation a tendency to improvement of the kidney function took place; later those functions gradually oppressed and the renographic index lowered down to . +__ . , . +--. . (p< . ) respectively according to the groups. after operative reirmervation of a kidney autotransplant and denervation of a kidney without its transplantation gradual improvement of separate functions of the kidney took place: in or months the kidney circulation was restored; in or , and in or months respectively, secretory and excretory functions of the kidney restored; renographic index reached its norm after or months and remained stable during years (according to the groups . +___ . , . - - . , p> . respectively). thus, the operative reirmervation of a kidney prevented depression of its functions and provided its normal functioning during a long period of time. introduction of fine needle aspiration cytology in renal transplantation gives the possibility not only to distinguish acute tabular necrosis, arterial and venous obstruction and viral infection from acute rejection, fnc also seems to allow judgement of the effectiveness of various types ofimmunosuppressive therapy during rejection episodes. method: after sterile fine needle biopsy the cytological evaluation of the aspirate was performed on cytocentrifuged smears after staining the cells by the method of may-grtinwald-giemsa. thus normal and "activated" mononuclear cell populations as well as parenchymal cells such as tabular and endothelial cells and their pathological changes could easily be recognized. the white blood cell types in fnc were compared with those of the peripheral blood. the difference in number due to the graft invading cells was expressed as "increment". the findings of fnc were correlated with clinical signs and serum creatinine values. results: fnc allows to judge the in situ inflammation in the rejecting kidneys within h. non-rejection grafts show cell counts comparable to peripheral blood. with onset of rejection (grade ) t-and bblasts and monocytes appear in the graft. with sever-ity of the rejection (grade ) monocytes and lymphocytes as well as blood cells increase in numbers. acute rejection (grade ) is heralded by high numbers of monocytes and macrophages. acute tubular necrosis (atn) and virus infections can be distinguished from rejection episodes to be treated. in all cortisone and azathioprine resistant cases where alg was used in order to suppress inflammation during rejection episodes it reduced not only the peripheral white blood cells, but also within h after start of alg therapy the number of in situ cells. beside reduction of inflammatory cells typical changes in shape of the nucleus and density of chromatine in up to % of the lymphocytes and granulocytes could be detected. these changes look closest to what has been described as apoptoses. conclusion: cortisone and azathioprine resistant rejection episodes could be monitored within - h using fine needle aspiration cytology. this method is safe, cheep, and it provides good information about the in situ situation of the graft, it allows to distinguish acute rejection from atn and other situations where higher immuno-suppressive therapy, especially with cortisone, could only be harmful for the patient. criteria of the border of normothermic ischemic tolerance in dog kidneys are first normal pah-and exogenic creatinine-clearances compared with unilateral nephrectomized dogs in neuroleptic analgesia under excessive water and sodium load and second perfectly normal kidneys after two weeks in pathological examination. the protective solution htk ® by bretschneider has a superior buffering capacity compared to euro-collins-solution ® , which, by itself, enhances anaerobic glycolysis by substrate stimulation (glucose) especially between ° and °c. without preservation in normothermia oligo-anuric arf is observed at the border of ischemic tolerance ( - min; °c). the obligo-anuric arf is dependend on ischemia which will result in necrosis of the kidney after rain and °c ischemic temperature. the border ofischemic tolerance corresponds to an intrarenal ph of less than . (outer stripe of medulla), and medullary lactate levels of to pmol/gdw. substrate stimulation of anaerobic glycolysis limits the effectiveness of euro-collins-solution ® above °c earlier than anaerobic glycolysis in pure ischemia. after warm ischemia (>--__.. °c; min) all kidneys protected with euro-collins-solution ® show anuric arf, whereas all htk®-protected kidneys ( to min of warm ischemia; °c) are having polyuric arf. under these conditions, renal ph will not increase above nmol/ h+-concentra -tion. the border of ischemic tolerance for htk ®protection ofkidneys is rain- °c and seems to be limited by a transitory secondary postischemic oliguria ( - h). in summary: intrarenal anaerobic glycolysis limits tolerance of pure warm ischemia by inducing anuric arf. in contrast polyuric renal failure is observed at the border ofischemic tolerance by using the protective procedure with the htk®-solution mentioned above. at least % of unrelated pigs respond to liver allografting with a rejection episode which they overcome without immunosuppression; kidney transplants are rejected uniformly within to days. in this study, mlc responses were measured at weekly intervals in such animals. non-litter mate pigs were subjected to autograft, exchange liver allograft, or exchange renal allograft. blood from mlc responses were taken from unaesthetised pigs before and at weekly intervals after operemained the same for each pair of transplants. in of pairs of liver allografts, mlc responses were depressed up to fold for weeks post-operatively. in all these pigs, the mlc responses were initially high. in pairs where the mlc response was initially low, there was no change after the transplant, and in one pair with a low pre-operative response, there was a marked increase post-operatively. in pairs of kidney allografted pigs, there was a similar depression in the single post-operative sample available. in liver autografted pigs, there was a slight post-operative rise in mlc response. it appears that liver and kidney transplantation but not hepatic autografting, markedly depress sequential post-operative mlc responses. the process of ischaemic kidney degeneration was estimated by measuring the adenine nucleotide (atp)levels and the effect of inosine and naftidrofuryl (praxilene) was assessed. min ischaemia was induced on both dissected kidneys of wistar male rats. then, either both clamps were removed and the right kidney was excised after i rain reperfusion the role of mononuclear phagocytes in various disease states has been extensively studied by phagocytosis, fc and complement receptor sites, and enzyme content. chemotaxis of peripheral blood mononuclear phagocytes, however, has not been studied to any great extent. we have therefore investigated a method for quantifying chemotaxis by mononuclear phagocytes. mononuclear phagocytes were purified from peripheral blood by centrifugation over ficoll-hypaque and a discontinuous percol gradient. chemotaxis was quantified by the 'under-agarose method'. mononuclear phagocytes were allowed to migrate towards the chemotactic agent zymosan activated serum (zas), and the control non-chemotactic agent eagles medium. the distance of cell migration was measured after hours incubation at °c in % co with the aid of a microscope eyepiece graftcule. using non-sepcific esterase staining the purity of mononuclear phagocytes obtained was %___ % and the viability by trypan blue dye exclusion was at least % preliminary results have shown selective migration by purified human peripheral mononuclear phagocytes towards zas. this method may therefore represent a means of investigating an important role of these cells in disease states. the intrathoracic pressure rises when a person exhales into a manometer to such an extent that finally the venous blood-flow to the heart stops. it is supposed that this venous stop flow pressure (vsfp), measured by an ultrasound device, is equal to the central venous pressure. in a prospective clinical trial by two independant examiners in % of the cases (n= ) the correlation was within cm h . therefore, the central venous pressure (cvp) can be measured non-invasively with an ultrasound device. we have previously reported that opiate receptor blockade with naloxone (nal) significantly improves cardiovascular function and survival in canine hemorrhagic shock [ , ] . since species differences do exist, we investigated the effects of nal in cynomulgus monkeys anesthetized with n /o . blood was withdrawn to achieve a mean arterial pressure (map) of mmhg (t--- ) which was maintained until t= h when the reservoir was clamped and the animals treated with either nal at mg/kg bolus plus mg/kg.h infusion i.v. or . % nac in equivalent volumes. there were no significant differences between nal (n= ) and con (n= ) in map, left ventricular contractility (lv dp/dt max, mmhg. vs), and survival; the nal animals, however, were acidotic (pha . ----- . ) and colder ( . - . °c) than con ( . +__ . , . -+- . ). map responses to nal were proportional to ph a complications of vascular bypass grafts, especiallyin the femoro-popliteal region are common. the most frequent of these by far is occlusion. other late complications iclude leaking and false aneurysm formation at the anastomotic site, dilatation of the graft material and stenosis ofanastomotic sites. the most commonly employed non-invasive studies render little information of value in the diagnosis of these complications. we have recently undertaken a study to evaluate arterial grafts at various intervals after implantation with the use of a duplex ultrasonic scanner. imaging of graft material with this system ist excellent and patency of the lumen can easily be established. graft diameter can be measured and accumulation of material within the lumen can be measured and quantitated. although anastomoses are not always clearly visualised they are often seen satisfactorily for diagnostic purposes. graft dilatation, false aneurysm formation and occlusions can be accurately diagnosed with this method. we have also studied the behaviour of femoro-popliteal grafts across the knee joint using the duplex scanner. as a non-invasive technique scanning with a duplex system has many advantages enabling frequent investigations and therefore early recognition of complications where synthetic material vascular grafts have been used for arterial bypass. an experimental model for dissecting aortic aneurysm has been designed to obtain much better understanding of the disease, leading to more effective methods of surgical treatment. dissection of the descending thoracic aorta was successfully performed by modified blanton's prodedure in % of more than mongrel dogs. fals lumens ruptured distally into true lumens to form a doublebarreled aorta in % of the dogs. the method of surgical treatment performed were ( ) closure of entry by direct suture, ( ) closure of entry by inserting dacron vascular prosthesis with a stainless steel ring, and ( ) bypass grafting with vascular prosthesis and ligation of the thoracic aorta. in dogs treated by methods ( ) or ( ) at the time of performing the dissection, cine angiography revealed that false lumens hat thrombosed within month and dissection was found to have completely healed on autopsy. in chronic cases treated by methods ( ) or ( ), false lumens were all patent with various degrees of formation of mural thrombi at observation of to months after surgical treatment. these results indicate that closure of entry for acute dissecting aneurysm should be a curative procedure. studies are now continuing on chronic dissecting aneurysm. the lack of controlled trials not rarely resulted in the incorrect acceptance o fan ineffective operation as an effective one igation of internal mammary arteries for relief of angina pectoris, for example). this failure also explains the non-stop controversies over the appropriate operation (and whether the question operate at all) for various myocardial revascularization procedures, over the thymectomy for myasthenia gravis, the limited vs radical mastectomy for breast cancer etc. several clinicians and surgeons assert that controlled clinical trials for new operations are unrealistic and naive because of some important differences between operations and drugs. compared with medical trials surgical ones are often really more difficult to be carded out. they are subject to more restrictions, ethical, statistical and practical, and may require longer or even remarkably long times. in any case, patients must nevertheless be sheltered from harmful and ineffective surgical operations since luckily not all the undoubted difficulties are unsurmountable, and prospective controlled trials of surgery, including random allocation of patients, are quite feasible. comparison between surgical and non-surgical treatment is a really particularly suitable field for these studies. comparison of effectiveness of two operations of the same type or of different types can also be carried out, but only on certain conditions and using suitable and appropriate expedients. also the doubleblind approach may be feasible, although remarkable restrictions and adequate cooperation are necessary. acceptance in trials of surgery as placebo is objectively very difficult, and obviously it has to be considered only when an effective operation for the considered disease does not exist. the ethical sound of this delicate aspect of clinical research can be minimized enough only if ( ) there are substantial doubts about the effectiveness of the intended operation and ( ) requested placebo-surgery is of very slight importance. posters for scientific meetings mary evans and a.v. pollock scarborough hospital, north yorkshire y ql , u.k. the display of information in posters antecedes even the,art of writing. they have been used to advertise, to educate and to inform and their function is to disseminate information to a wide audience quickly, simply and effectively. in medicine they have been used since the thirteenth century for the promotion of health education. in recent years poster sessions have been introduced into scientific meetings as an alternative to the spoken paper for the presentation of original work. following this experimental procedure hepatic coma supervenes in - h and animals die after ca. h. five male pigs, aged - months, weighing - kg were studied ca. h after operation. the detoxifying system consisted of activated charcoal (norit ¢ (lmm x ram) and ionexchange resin (dowex lx ), subsequently inserted in an extracorporeal circulation. plasma amino acids were determined serially ( , , , rain) in and out the detoxifying system. plasma extraction of individual amino acids (means_ se in/zmol/min) is reported in the table a remarkable extraction was present in the first rain and chiefly involved aromatic amino acids and tryptophan which did not further increase. during hemoperfusion, the molar ratios between neutral amino acids improved. the ratio of branched-chain to aromatic amino acids increased from late hepatic effects of small intestinal bypass (sibp) for obesity plasmafl-endorphin (/ -end, pg/ml, by ria) was related to t:fl-end = (t- ) + , r= . , p< . . when acid-base balance and temperature were maintained, nal (n= ) significantly (*p< . ) improved map and lv dp pg/ml in nal and + pg/ml in con). r-end is released in and contributes to the cardiovascular depression of primate hemorrhagic shock. nal reverses this depression and improves survival but only when arterial ph and core temperature samples of exudates at site of infection were taken wherever possible for aerobic and anaerobic cultures. in following infections were recorded: wound, respiratory tract, thrombophlebitis, indwelling intravenous catheter, unidentified origin fever (> °c lasting more than days) (fuo) and miscellaneous. incidences: patients ( %) had postoperative septic complications. wound infection was recorded in patients ( . %), respiratory tract infection in ( %), urinary tract infection in ( %), fuo in ( . %) thrombophlebitis in ( . %) and miscellaneous infections in ( . o/ ). predisposing factors: wound infections were / ( . %) in clean operations, / ( . %) in potentially contaminated, / ( %) in contaminated and / ( . o/ ) in dirty.wound infections were diagnosed later (mean th day) in clean than in dirty operations (mean th day) (p< . ). a statistically significant correlation was found between wound infection and leght of preoperative hospital stay: from . % in patients operated on within - days to . % for patients operated after days or more (p< . ). no correlation was found between wound infection and age. urinary infections were more frequent when the patients were catheterized at least once in the postoperative period ( % vs %). a statistically significant correlation was found between the incidence of respiratory infections and duration of anaesthesia ( . %----< min, / > < min, / > min;/~ . ). bacterology: out of cultures gave positive results ( %): aerobes were isolated in samples ( / ); mixed aerobes and anaerobe in ( . o/ ); anaerobes in ( . %). bacteroides fr. was the commonest isolated anaerobe in all types of sample except hemocultures were propionibacterium aches was the most frequent. a statistically significant correlation was found between the incidence of recvery of anaerobes and intraoperative contamination ( . % in clean operations, . % in potentially contaminated, . % in contaminated and . % in dirty; p< . ).in wound infections the most frequent aerobes were staphylococcus in clean and e. coli in contaiminated operations. costs: mean postoperative hospital stay of patients with septic complications was days, whereas patients with no postoperative sepsis were discharged after an average of days (p< . ). mean daily cost in our hospital was extimated $ ; accordingly, the mean postoperative hospital stay of patients with sepsis costs $ vs $ of that o~ the patients without postoperative infections. overwhelming postsplenectomy sepsis/infection has been accepted the highest risk with more than percent mortality due to pneumococcus species. however, e. coli, pseudomonas and staph. aureus have been reported a deadful threat to the splenectomized individual also. pneumococcal challenge after splenectomy in animal experiment and after partial salvage has been well examined. staph. aureus-challenge has not been tried after splenic repair, so far. material and method: a total of nmri-mice ( - g) have been subjected to: sham-operation, splenectomy, peritoneal splenosis, controls as non-operated group.the technique was similar to the one performed in rabbits, prior reported. weeks postoperatively, the mice were exposed to intraperitoneal injection of staph.aureus concentrations of °c/ml down to c/ml. the peritoneal cavity of mice has a high resistance to staph.aureus, as only no. proved lethal. results: whereas the macroscopic view post mortem seemed promissing, showing almost total salvage of the splenic particles weeks postoperatively bacterial challenge with staph.aureus was contradictory: x s c/ml was survived by all splenectomized mice, by only percent of the splenosis micecand by none of the sham and nonoperated mice. due to the small number of only mice within this mice-pathologenic staph. aureus species, we may not draw definite conclusions. as for one, the intraperitoneal application may not be the natural way of septicemia. on the other hand, splenic remnants may not be as effective in the protection of staph.aureus-sepsis as in a pneumococcal challenge. therefore, further studies with staph.aureus species in other animals and by other application route will be needed! studies of the coagulant effects of boomslang (dispholidus typus) venom have indicated that the coagulant effect was mainly due to its ability to activate prothrombin. it also activates prethrombin i, factor x and possible factor ix as well [ ] . although boomslang envenomation is said to represent a classic model of disseminated intravascular coagulation, certain features are worthy of critical thought. the coagulation profile of a nine year old lad, who was admitted to the h.f. verwoerd-hospital, h after a reputed boomslang bite, provided the impetus to explore the in vivo effect ofcurde. d. typusvenom on the thrombelastographic and other haemostatic changes in the chacma beboon. methods: . mg, . rag and . mg respectively of crude. d. typus venom were injected subcutaneously in adult baboons. serial determinations of the flow parameters were done over - days. thrombelastography on whole blood an platelet this report presents the ten year survey of liver mitochondria analized in patients. . two mechanisms were of major importance in the augmentation of mitochondrial ability to synthesize atp: a) the enhancement of atp-generating capacity per unit of respiratory assemblies and b) the increase in respiratory enzyme contents. those compensatory mechanisms were functional within a certain range of contents in cytochrome a ( . - . nmol/mg protein, normal; . ). hepatic insufficiency was observed in patients with cytochrome a contents less than . or more than . . . in all patients with cytochrome a of . - . nmol/mg, the blood glucose level after an oral glucose load ( g) returned toward normal within h (parabolic pattern). in patients with cytochrome a of more than . , the blood glucose level did not return toward normal within h (linear pattern). parabolic and linear patterns were intermingled in the patients with cytochrome a form . to . .in this report, we will emphasize the importance of preoperative ogtt and measurement of cytochrome a contents during operation for the prediction of operative prognosis, better than any other currently used index of liver function, in the patients receiving major surgery such as hepatectomy or operation for esophageal varices in severe cirrhosis. the reticulo-endothelial system (res) has largely been ignored in studies of liver regeneration. in this study, the res was "blocked" with colloidal carbon, or was stimulated with olive oil or with glucan. indices of liver regeneration were the thymidine kinase acitivtiy (tk) and the number of mitotic figures (mi) in liver biopsies. fibronectin was measured as a putative index of kupffer cell function.four animals in each group were sacrified at , , , , , and h after sham-operation or % partial hepatectomy (ph). group : carbon suspension (pelikan ink, wagner) mg/ g rat single injection pre-operative; group : olive oil ( % in % dextrose water + . % tween ) . ml/ g rat single injection pre-operative; group : as group given at intervals of h; group : glucan . rag/ g rat pre-op, and at intervals of h.results: glucan or a single dose of oil increased tk in ph and sham-operated rats but did not influence m.i. carbon inhibited mi but did not influence tk. fibronectin levels were increased in sham-operated and ph rats after daily oil or glucan.in conclusion, no administration enhanced both tk and mi but stimulation of the res with glucan or oil did increase fibronectin levels in both sham and ph rats. it appears that the res does not have a role in liver regeneration as assessed above, but fibronectin appears to have been an indicator of res activity. anatomical abnormalities of the gallbladder include multiseptate and bilobed organs, and the more common transverse septate variant. patients with the latter type often have typical biliary symptoms which are thought to be caused initially by raised intracystic pressure and subsequently by inflammation and calculi formation in the distal lobe [ ] .this study evaluate~ the long term effects of sibp on hepatic lipid and fibrous tissue accumulation. liver was obtained at the time of abdominal operation from normal weight patients, morbidly obese patients (mean body weight + kg) and patients or more years (mean -+ months) postoperative from sibp. from wedge liver biopsies hepatic total lipid, triglyceride, cholesterol, phospholipid and protein contents were determined as well as the activities of acetyl coa carboxylase and fatty acid synthetase. histologic evaluation of needle biopsies of the liver was used to quantitatively estimate the amount of hepatic steatosis and fibrosis present.there was also a significant histopathologic increase in hepatic fibrosis present in the liver tissue from sibp patients when compared to hepatic fibrosis in liver from obese patients as well as when compared to liver specimens obtained from the sibp patients at the time of their sibp. the effect of reversal of the sibp on hepatic fat content and fibrosis was determined by transcutaneous liver biopsy - mos. following take down of sibp. post-reversal histologic quantitation of hepatic fibrosis and inflammation was significantly decreased from pre-reversal values and the improvement was greater in patients who lost weight. patients year after sibp have persistent hepatic steatosis with hepatic fibrosis and inflammation. improvement in these parameters may be anticipated following reconstruction of the intestinal tract particularly if weight loss is maintained. the aim of this paper is to study the metabolic effects of gastric bypass in dogs. we used dogs weighing between and kg. the animals were divided into three groups: a) five dogs without surgical operation (control); b) six dogs with a fundoj ejunal bypass, and c) six dogs with a gastroplasty. in group b and c the exclusion was / of the stomach. in all of the animals and groups were determined: cholesterol , live r function tests, calcium, magnesium-and electrolyte levels, the body weight evolution and the apparent-digestibility coefficient (adc) of fat, protein, minerals and glucosides for a type of diet. the composition of this diet in dry substance was: fat . %, protein . %, glucosides . % and minerals . %. these analyses were determined five times during the twelve months of control. the animals were kept in individual metabolism cages which allow feces and urine to be gathered separately as well as the food consumed to be controlled. the cages were housed in a room thermoregulated at °c± . the cholesterol, calcium, magnesium and electrolyte levels were normal during the twelve months of control in the three groups. the liver function tests were normal in all groups with the exception of serum aspartate transaminase initially deteriored in group b. the body weight evolution was significantly diminished in groups b and c compared with the control group (p< . and p< . ). the results of adc expressed in % ± sd were.by roviding a functional gastric capacity of less than ml and consequently a forced reduction in food intake the gastric bypass produces an effective loss of weigth. our results suggest that the gastric bypass can be considered as an effective and safe alternative to intestinal bypass for treatment of morbidly obese subjects who have failed nonsurgical treatment; however, a great and deeper research is necessary to discover the possible side effects of gastric bypass surgery; then its ultimate benefits will be fully understood. there was no operative mortality. the percent of the excess weight lost following the two operations is shown and compared with weight lost following gastric bypass. it is concluded that: . complications occured more often following gastroplasty, . % compared with . % of the patients treated by gastrogastrostomy. . the amount of excess weith lost was greater after gastroplasty, a mean of % for patients followed for two years, than after gastrogastrostomy, a mean of % for patients followed for two years. . because of the incidence of stomal obstruction requiring reoperation following gastroplasty, . % compared with . % after gastrogastrostomy, is our preferred operation. . to improve weight loss after gastrogastrostomy the ta- is now used instead of the ta- stapling instrument. the proximal gastric pouch is reduced in size to - ml and the stoma made smaller to ram. an artifical esophagus was made of silicone rubber tube covered with a dacron mesh. a segment of thoracic esophagus of dogs was replaced with this graft using three different types ofamastomosis, i.e., overlayer end-to-end anastomosis, two layer end-toend anastomosis both using a flanged tube, and monolayer end-to-end anastomosis with noflange tube. seven of dogs ( %) survived more than months without complications, and of them more than years. in of of the prolonged survivors, extrusion of the graft was recognized in the rd to th month after operation. esophageal stenosis increased slightly up to the th month after extrusion of the graft, but it did not further advance until sacrifice. in these dogs, mucosal regeneration of the neoesophagus was complete with muscle layers and mucous glands in the submucosa recognized microscopically. proximal esophagus from the replaced portion was apparently dilatated more than that of the distal portion. there was no definite difference between the anastomotic techniques with regard to complication or prognosis. these results suggest a possibility for clinical trials. paper withdrawn attempts to reduce nephrovascular hypertension by surgical techniques deviating renal venous blood and renin directly to the hepatic filter are at present discouraging. experimental data with portocaval transposition are contradictory, due mostly to the use of heterogeneous biological models (mongrel dogs) and collateral circulation developement. renal to portal vein end-to-side (ets) and end-to-end (ete) anastomoses in the rat were therefore tested as possible experimental models. we observed that even after right kidney decapsulation, collateral vein circulation develops through the periureteral plexus, particularly after ets shunts, one month after surgery. nevertheless, collateral cirulation in the male rat can be prevented by ligature and cutting offthis plexus near the kidney. in the female rat instead, collateral circulation is still possible. in fact, newly formed pericapsular veins join the right kidney to the right ovaric vein and therefore preventive ligature and eradication of these vessels is also necessary. in conclusion, both models (ete-ets shunt) appear feasible in the rat, and reliable for studies dealing with nephrovascular hypertension and hepatic metabolism of renin. the handling of the exocrine system is one of the main problems inpancreas transplantation. one trial to overcome this problem consists of the occlusion of the pancreatic duct system. a the theoretical disadvantage is the induction of a secretion oedema which may lead to blood flow disturbance followed by venous thrombosis. the aim of the present experiments was to study the effect of an anti-oedematous drug (cumarin and rutin sulphate (venalot ®) on the blood flow of autologous segmental pancreatic transplantation was tested by chosing the cervical region of the dog as the site of grafting. material and methods: dogs weighting - kg were used. these dogs were divided into two groups (control group, n= ; treated group, n= , venalot ® dose: rag, cumarin/kg/b.w.). the body and the left limb of the pancreas was removed, perfusion with eurocollins was started wia the splenic artery and the duct system was injected with prolamine. a distal a. v. fistula of the splenic vessels was performed. this conditioned graft was transplanted at the neck of the same dog, performing the anastomoses between the carotid and the splenic vessels. the blood flow of the pancreatic graft was measured with radioactively labelled microsperes of /~m immediately after, as well as days after grafting. the developing oedema of the graft was estimated by weight gain, histological and electron microscopic investigation. residual exocrine function of the graft was measured by determining the serum lipase and amylase levels.results: the autotransplantation of an segmental pancreatic graft to the neck of a dog is a feasable and technically easy surgical procedure, without major venalot -treated dogs local complications. in the ® there was a higher weight increase of the graft in comparison to the controls. as tested so far there was no difference in the behaviour of the i~lood flow of the grafts in both experimental groups. there was a significant increase of serum amylase and lipase values in the venalot®-trea'ted group. conclusion: the technique of cervical segmental pancreatic transplantation in dogs is recommended in cases where immunological monitoring (aspiration cytology, biopsies) is the aim of the study (good access to needles). the technique of microspheres injection is a useful method for the examination of the blood flow in segmental pancreatic grafts in dogs. the prolamine-induced secretion-oedema of ductoccluded pancreatic grafts is resistant to venalot ®treatment. graft pretreatment has been used in various organs to prolong auograft survival. we have recently demonstrated that graft pretreatment of canine renal allografts with cyclosporin a (ca a) led to improved animal and graft survival. our present study assesses the effect ofcy a as a graft pretreatment on pancreatic islet cell allografts. pancreases were removed from unrelated donor mongrel dogs and placed in iced saline ( °c) after the collagenase digestion. the tissue fragments were washed once more and then another mg cy a was added to the preparation prior to intrasplenic injection of the islet cell allografts. three groups were studied: group i (n= ) served as pancreatectomized non-transplanted controls, group ii (n = ) received a non-pretreated islet cell allograft after total pancreatectomy and group iii (n= ) received a cy a graft pretreated islet cell transplant after total pancreatectomy. all animals were given minimal immunosuppression with azathioprine ( rng/kg/day x , followed by , mg/kg/ day). blood glucose values were monitored to determine engraftment and subsequent rejection. hyperglycemia was considered when plasma glucose values rose above mg/dl. all pancreatectomized controls (group i) became hyperglycemic by the first post-operative day. non-pretreated islet cell allografts in group ii had variable function and became hyperglycemic between one and nine days after transplantation. only five of ten animals in group iii, receiving cy a pretreated islet cells, became hyperglycemic levels greater than days and one died of unknown causes immediately after transplantation. the following table presents the animal survival data for the day follow-up period.although the exact mechanism of action is not known, this study indicates that cy a graft pretreatmerit can be beneficial in prolonging pancreatic islet cell allograft survival, further studies will optimize the use ofcy a in this application and hopefully contribute to the improvement of pancreatic islet cell transplantation. grafting of vascularised organs has become a standard procedure in surgical research. however, only few data of the fate oforthotopicliver transplantation in the rat are available, probably because of the difficult ~iargery involved. this communication gives an account of the outcome of liver allografts and liver isografts in four inbred strains of rat. the following groups of allo and isografts are formed; the survival time is given in days postoperatively.the technical details of the operative procedure of orthotopic liver transplantation in the rat are described elsewhere (eur surg res : ( ). the distribution of death among allallograft groups show blocks of survivors. the first block includes animals surviving up to days. acute rejection and infection are the diagnosed causes of death in this compartment. the second block includes animals surviving up to days. in the grafts, which belong to this compartment a intrahepatic bile duct proliferation is a frequent and dominant histological feature. because of the development of identical lesions in isograft surviving the same periode and the induction of this lesions by common bile duct ligation experiments, chronic rejection is excludet as the cause of death. the third block includes all so called long-term survivors, in which the structure of the grafts are remarkably well preserved and very few abnormalities are present. the occurence of fatal acute rejection and long-term survival in each allograft group demonstrates, that the fate of the orthotopically transplanted livers in not dependent upon key: cord- - rvfsx p authors: nan title: ps - date: - - journal: intensive care med doi: . /s - - - sha: doc_id: cord_uid: rvfsx p nan as a base line, we retrospectively reviewed patient characteristics (time ventilated and icu mortality) of all patients ventilated > days over months. over the following months, we determined the impact of the long term care plans on patients ventilated > days. those who failed > weaning attempts from mechanical ventilation were assessed by the mdt for suitability for long term weaning plans. not all were accepted by the mdt team due to resource limitations. both groups were similar with regard to age, gender and apache ii. in the second group, patients adhered mdt weaning plans; all survived to icu discharge. the introduction of the mdt plan was associated with a significant reduction in mortality for all patients ventilated > days (p< . ), with the most significant difference seen in those patients ventilated > days (p< . ). the duration of mechanical ventilation was greater following the introduction of the long term plans. conclusion. we demonstrated the feasibility of applying a long term mdt weaning approach to patients receiving prolonged mechanical ventilation across different consultant weeks. our preliminary data suggests that this approach did not lead to harm and was in fact associated with a significant reduction in icu mortality. the increase in median time to wean requires further investigation. multidisciplinary team involvement with this difficult patient group was essential to enable a change in practice to occur and led to a culture shift within the unit. conclusion. the inclusion of plasmatic levels of transthyretin as an a additional variable improves the predictive ability of the severity scales and indicators of organ failure. . early administration of aas in the acute coronary syndrome, during the months of the study we diagnosed a total of patients with acs, all of them received aas in the first hours which results in a % compliance for this indicator. . semi-upright positioning of patients with invasive mechanical ventilation (imv), during the period of monitoring we attended patients with imv > hours, which made a total of days of imv, we complied to the indicator of semi-upright position % . prevention of tromboembolic events, in the days of monitoring we attended to a total of patients with a stay over hours and we achieved profylaxis of deep venous thrombosis in , which leads to a compliance of %. . pneumonia associated with mechanical ventilation, during the months of monitoring we recorded a total of days of imv in a total of patients and pneumonias associated with imv, which comes down to a total of per episodes. . profylaxis of gastrointestinal hemorrhage in patients with invasive mechanical ventilation, during the days of the study we attended a total of patients with imv > hours with a compliance to the indicator of %. conclusion. discussion. in our unit the indicators have a high percentage of compliance, the only divergence being the pneumonia associated with mechanical ventilation which is due to the small number of patients with imv. due to the characteristics of our unit, with the private setting and the high number of admissions of post surgical patients ( %), imv > hours constitudes a low percentage of our patients. we also have to stress the fact that there where non-labour days during the time of the study. conclusions. in our unit the indicators of quality of the critical patient have a high compliance rate. the use of imv > hours in our unit has a low occurance rate. grant acknowledgement. work group of quality indicators of the semicyuc. drug-drug interactions can cause adverse drug events (ades) and affect icu patient care. a pharmacist on rounds decreases the number of preventable order-writing ades and positively impacts patient safety, outcome and drug costs. the aim of this study is to describe the frequency of drug-drug interactions and its implications on patient outcome. from august to february our clinical pharmacist, present on daily rounds, conducted an active screening of all icu physician orders searching for drug-drug interactions (epocrates rx ® drug reference). these interactions were classified in seven different groups according to potential adverse effects: neurological, cardiovascular, gastrointestinal, renal / metabolic, pharmacokinetic, hematological and others. once an interaction was identified the icu team was warned to detect and report any possible ade and the pharmacist could make interventions judged necessary like a recommendation of an alternative therapy or dose adjustments. physicians , acceptance rate of these interventions and incidence of ades were recorded. we analyzed orders with prescribed items. there were drug-drug interactions identified ( interaction per prescribed items) and these interactions were present in orders ( %). neurological was the leading group with . % (n= ) followed by cardiovascular . % (n= ), gastrointestinal . % (n= ), renal/metabolic . % (n= ), pharmacokinetic . % (n= ), hematological . % (n= ) and others . % (n= ). a great variety of therapies was involved in these interactions. the clinical pharmacist made interventions in order to change the prescribed drug therapy and acceptance rate was %. the incidence of order-writing ades was . per patient days. there was not ades-associated mortality rate during the study period. conclusion. drug-drug interactions are frequent and involve the majority of routinely prescribed items in icu environment. neurological and cardiovascular are the most common affected systems. these interactions can adversely affect patient outcome and a clinical pharmacist integrating the multiprofessional icu team can help to identify and minimize its effects. patients with severe and persistent bleeding have high mortality rates despite standard therapy. recombinant activated factor vii (rfviia) must be considered as a pharmacological complementary treatment for critical ill patients suffering from acute bleeding (acbl). the aim of this report is to evaluate the role of rfviia in the management of severe bleeding refractory to other treatments following a regular protocol for its administration in our icu. during a one year period (february -february ) a protocol of rfviia was applied to patients who were admitted with acbl diagnosis in our icu. the protocol was developed by a commission of experts according to the recommendations of use of rfviia indicated by martinowitz et al ( ). indication: any salvageable patient suffering from massive uncontrolled bleeding that fails to respond to appropiate surgical measures and blood component therapy. preconditions: fibrinogen > mg/dl, platelets > xmm , ph > , , no hypothermia. results. patients with acbl fulfilled the criteria of the protocol. etiology of the bleeding: surgical and obstetric. the average of age was . mean apacheii was . in all cases only one dose of rfviia of mcgr/kg was given. transfusion requirements: red blood concentrates (rbc), fresh frozen plasma (ffp), cryoprecipitate (cry) and platelets (plt) decreased significantly. in addition, prothrombin time (pt) and activated partial thromboplastin time (aptt) improved. patients survived and were discharged from hospital, one patient died due to nosocomial pneumonia. there were no adverse events. before an after rfviia administration before-after pt (s) case . - . - . - . following an agreed protocol model, the use of rfviia may have an important role in achievement of an adequate hemostasis, reduces blood requirements and the adverse events in patients with acbl. intensive care units (icus) provide intensive observation and treatment for critically ill patients, but the total hospital mortality is high at . %. this is according to statistics from the intensive care national audit and research centre (icnarc) case mix programme database. most of the deaths occur in icu itself ( . %), rather than after discharge from icu ( . %). the purpose of this study was to see if the deaths in the lister hospital icu were related to the initial clinical insult or caused by a complication that developed during the icu stay. methods. this retrospective study included all patients admitted to the lister hospital icu over a -year period from april to march . for all patients who died in icu, an icu consultant classified the cause of death into the following three categories: ( ) initial reason for admission; ( ) co-morbidity -e.g. myocardial infarction that occurred after icu admission on a background of ischaemic heart disease in a patient who was admitted after having had major surgery; or ( ) complication that developed because the patient was in icu -e.g. line sepsis or ventilator-associated pneumonia. results. there were admissions to lister icu over the -year period. some were repeat admissions, leaving individual patients to study. the total hospital mortality was . %. patients ( . %) died in icu, patients ( . %) died after discharge from icu but prior to hospital discharge and patients ( . %) survived to hospital discharge.we were able to obtain medical notes for of the patients who died in icu. of these patients, patients ( . %) died due to initial reason for admission, patients ( . %) died due to co-morbidity, and patients ( . %) died due to a complication that developed because the patient was in icu. of the patients for whom we could not obtain medical notes, patients stayed in icu for day, patients stayed for days and patient stayed for days before dying in icu. the short lengths of stay for these patients suggest that they died due to initial reason for admission. our study reveals that most of the deaths in icu were related to the initial clinical insult for which they were admitted. less than a third of the deaths were related to a complication that developed during their icu stay, whether the complication was related to co-morbidity or being in the icu environment. this is surprising, as icu admissions are for patients who suffer an acute deterioration that is potentially recoverable. therefore, deaths that occur in icu should be related to complications that subsequently develop rather than the initial clinical insult. our finding that the converse is true could imply that we may be too unrealistic in our assessment of whether the acute clinical problem is potentially recoverable or not. the practise of withdrawal of treatment varies from unit to unit. if it is carried out properly it could decrease the amount of suffering the patients and the relatives undergo and it would also save valuable resources, which could be utilised more constructively. there was a relative's complaint on unnecessary prolongation of treatment and this lead to this prospective study. we proposed to study the frequency, reasons, documentation, delays and the process of withdrawal of treatment. the study was carried out at the new cross hospital, wolverhampton uk over a period of months may and june . the critical care unit has itu and hdu beds. a proforma was prepared after obtaining the suggestions from the consultants and the nursing staff working in this critical care unit. i was contacted when a decision to withdraw treatment was made. i went through the notes and the monitoring charts to fill in the details in my proforma. the patients were followed up from this point. . treatment was withdrawn on patients and there were admissions during the audit period. the commonest reason was 'unfavourable response in spite of aggressive treatment' followed by 'poor neurological condition'. out of patients suffered from multi organ failure while patients suffered irreversible neurological damage. the decision to withdraw was made by a single itu consultant in majority of the cases. withdrawal decision to death time ranged from minutes to hours. the commonest mode of withdrawal was by extubation. dnar forms were filled for patients only. quality of documentation varied from short and concise to long notes lacking relevant information. there was no documentation in one case. the documentation by the trainees was found to be sub standard. conclusion. partial withdrawal was associated with delay in death. complete withdrawal was associated with quicker death. documentation was sub optimal. inadequate information was provided when trainees did the documentation. majority of the patients suffered from multi organ failure. identification of variables correlated with predisposition p is an initial step. subsequent studies would then be needed to test the clinical efficacy of piro scoring system in the diagnosis and management of sepsis. grant acknowledgement. we acknowledge elililly for the access to the databases. we declare no financial support. to identify genetic markers of proc and proc c loci that may be associated with the susceptibility to develop sepsis, which may adversely affect the prognosis of patients. in the group of patients with severe sepsis and/or septic shock, there were statistically significant differences (p = . ) for the mean apache ii score in genotype cc of snps of proc c, without significant differences for the remaining variables (sofa h, prothrombin time, partial thromboplastin time). snp type groups or subgroups or % ci-p rs cases vs controls . . - . * . rs presence of shock . . - . . rs presence of mof . . - . . † or: odds ratio, ci: confidence interval, mof: multiple organ failure, *sasieni test, †homozygous test conclusion. genotype aa + ga vs gg of the proc gene (snps ) was found to be involved in a higher susceptibility to develop sepsis, genotype cc (snps ) to present multiple organ failure, and genotype gc to develop shock. genotype cc of proc c was related to a higher apache ii score. none of the snps studied seemed to affect the prognosis of patients. patients with sepsis, particularly those in septic shock often develop atrial fibrillation (af) ( , ). interestingly, incidence and prognostic impact of af in septic shock have scarcly been examined so far. the aim of the present study was to answer the following questions: . what is the incidence of newly diagnosed af on a surgical intensive care unit (icu)? . which percentage of patients suffering a septic shock eventually does develop af? . what is the impact of newly diagnosed af on mortality and length of icu stay in patients with septic shock? we prospectively recorded data of all patients who were newly diagnosed with af and all those with a septic shock on a surgical icu (no cardiac surgery) during a one year period according to the requirements of the local ethical committee. during the observation period patients were admitted to the icu. patients ( , %) newly developed af during their stay on the icu. patients ( , %) had a septic shock. of the patients with septic shock had chronic af. of the remaining septic patients, ( %) were newly diagnosed with af. those patients with septic shock who developed af, had a higher mortality as compared to septic patients without af ( % versus %). moreover the median length of stay in the icu of surviving patients was significantly longer in patients with newly diagnosed af as compared to those without af ( versus days). conclusion. according to our data, more than % of patients with septic shock develop af. those patients who do develop af during septic shock seem to have a considerably poorer prognosis compared to those without af. af is a clinically important complication in septic patients and might be a useful criterion in assessing the prognosis of patients with septic shock. to our knowledge this is the first study to describe the incidence and prognostic relevance of newly diagnosed af in septic shock. a. socias* , a. rodríguez salgado , l. gutiérrez , r. morales , a. villoslada , b. comas , m. borges intensive care unit, surgery department, internal medicine, emergency department, h. son llàtzer, palma de mallorca, spain our objective was to evaluate the utility of seriated lactate measurement as a part of a cpims to predict outcome in patients with sepsis. prospective study, conducted in a teaching hospital in patients with sepsis included in a cpims. it automatically produces an annotation on the medical chart and a serie of analytics forms when activated. plasmatic lactate levels were determined at the moment of activation and after and h. clinical and analitical variables, as well as severity scores were also collected. patients have been included fron january to january . statistical tests: chi-square, mann-whitney, anova, kruskal-wallis, spearman, logistic regression. roc curves were traced for all seriated lactate determinations and for lactate clearance at h [ ] . results. patients were included, ( %) had sepsis, ( , %) severe sepsis and ( , %) septic shock. eighty-five ( , %) patients deceased, of whom ( %) had sepsis, ( , %) severe sepsis and ( , %) septic shock at the moment of activation. mean lactate levels were , ( , ) mmol/l, , ( , ) mmol/l and , ( , ) mmol/l at the activation moment, at and a hour respectively. patients with septic shock had significantly higher lactate levels at every moment (p< , ). moreover those levels correlated with the number of organ failure (nof) for the first d (table ) and the sofa score for the first days (p< , ). using roc curves we established a cutoff of mmol/l for lactate levels and of % for lactate clearance. pacients with initial lactate > (p< , ), at h (p , ) or at h (p < , ) and those with a lactate clearance at h < % (p , ) had higher mortality. recently it was suggested that critically ill patients can tolerate hemoglobin levels as low as g/dl and a more "liberal" red blood cell (rbc) transfusion strategy may in fact lead to worse clinical outcomes. objective: to study the rbc transfusion practice in critically ill patients and to examine the relationship of rbc transfusion to clinical outcomes. prospective observational study of patients admitted in the icu between / / and / / . we excluded patients with active haemorrhage. data on demographics, comorbidities, length of icu stay and icu mortality were collected. . patients were enrolled. ( . %) were transfused. pre-transfusion hemoglobin was . ± . g/dl. related factors to transfusion in multivariate analysis (od (ic)): uci los . ( . - . ). mv . ( . - . ). rr ( . [ ] [ ] [ ] [ ] [ ] [ ] [ ] . chronic anemia ( - ). transfused patients had higher icu mortality ( % vs %, p < . ). however, in a multivariate analysis including saps , mv, rr and transfusion, only saps was significantly related to outcome. conclusion. our transfusional trigger was approximately gr/dl. rbc transfusion was related to chronic anemia (prior to icu admittance), the use of invasive supports and the icu los. in our group of patients, rbc transfusion was not related to icu mortality. w. huber* , m. neudeck , a. umgelter , w. reindl , m. franzen , c. lampart , m. hennig , r. schmid nd medical department, institute for medical statistics and epidemiology, klinikum rechts der isar,technical university of munich, munich, germany introduction. np still has a high mortality and the outcome is hard to predict in the individual patient. while in the last years non-surgical therapy of sterile necroses has become the standard of care, infected necroses are currently treated surgically in most centres. we here present the data of consecutive patients with np treated non-surgically regardless of the infection of the necroses. it was the aim of our study to find prognostic factors relevant for the outcome of patients with conservative therapy of np focussing on the relevance of the infection of pancreatic necrosis. methods. data analysis of consecutive patients with np proven by contrast-enhanced ct-scan admitted to a medical icu. patients were treated with with imipenem as first line antibiosis and ct-guided puncture or drainage if appropriate. surgery was restricted to complications of the puncture or fluid collections not accessible to radiological drainage (n= ). hemodynamic monitoring using picco or pac and monitoring of intra-abdominal pressure if appropriate. statistics: multiple regression analysis (backward selection); chi-square-test (comparison of survival); sas software. patients characteristics: n= ; female; male; age . +/- . years, maximum crp . +/- . mg/dl, max. apache-ii-score . +/- . , max. lipase +/- u/l; max. ldh +/- u/l. / ( %) of the patients required mechanical ventilation and / ( %) dialysis/hemofiltration. .) prognosis: the only independent risk factors at admission to the icu for an unfavourable outcome were the level of serum creatinine (p= . ) and old age (p= . ). the following parameters were not predictive: etiology of pancreatitis, blood/serum levels of lipase, calcium, glucose, leukocytes and hematocrit as well as the presence of a cullen-and/or a grey-turnersign. .) mortality: the overall mortality was / ( %). in patients puncture and drainage of the necroses was performed. the mortality of these patients ( / ; %) was not different compared to the patients without puncture/drainage ( / ; %). in / ( %) of the patients with puncture bacteria and/or fungi were cultured in the aspirates. the mortality of these patients ( / ; %) was not different compared to the patients with sterile necrosis ( / ; %). conclusion. .) the overall mortality of % was low with regard to the severity of np. .) infection of the necroses had no impact on the outcome. therefore, the presence of infected necrosis is no contraindication to conservative management of np. .) the most important predictors for the outcome were serum creatinine levels and old age. x. schmit*, j. vincent intensive care, erasme university hospital, brussels, belgium sepsis remains an increasingly common killer. although there are a lot of studies about sepsis, it is a clinical syndrome and uncertainties will remain in its clinical course. the patient populations are very heterogeneous. some patients will respond well to initial empirical antibiotic therapy while others do not improve and need an adaptation or even a procedure in order to contol the infection. our study addresses for the first time the value of a dynamic evaluation of blood crp concentrations in an icu heterogeneous population of septic patients. clinical an other biological variables were also studied. in critically ill patients with sepsis, enrolled in a prospective observational multicenter study, crp levels and standard clinical and biological variables were measured daily from the day of identification of sepsis until death, transfer to the regular floor, or the th day, whatever came first. patients were divided into three groups according to their clinical course: group -patients with a favourable response to the initial antibiotic therapy; group patients who required a change in antibiotic therapy (shift to or addition of another antibiotic class); group -patients who needed surgery or drainage to control the infection. the studied population, from two large institutions was similar to those found in most of the icu's, with a median age of years, a majority of male patients and the lungs as the most common infectious site, and about % of positive cultures. we found that an increase in crp of at least . mg/dl in the first hours was associated with an inadequate response to therapy with a sensitivity of % and a specificity of %. crp concentrations decreased more rapidly and more significantly in group than in group (p= . ). there is quite a significant variability in baseline crp levels but we show that the time course during therapy is meaningful. in contrast, no correlation was found between crp levels and any of the clinical or other biological studied variables. these variables may also vary in numerous other situations than sepsis. conclusion. changes in crp over the first hours of therapy can help to evaluate the response to therapy in septic patients. the daily dosage of crp is easily accessible, inexpensive to perform, and offers much information, aiding in the clinical course of sepsis and early adequate therapeutic attitudes. is it not our rescuer? in septic patients scoring systems such as acute physiology and chronic health evaluation ii (apache ii) as well as sequential organ failure assessment (sofa) on admission and during treatment quantify the disease severity and therefore stratify the risk of adverse outcome. predictive roles of certain in-hospital parameters such as hypoalbuminemia, increased serum creatinine, c-reactive protein (crp), lactate and serum blood glucose were studied in some prospective clinical studies, however, their independent predictive roles of outcome in septic patients remain uncertain. our aim was to evaluate the predictive role of admission apache ii, admission and total maximum sofa score, hypoalbuminemia, increased serum creatinine, c-reactive protein, lactate, and serum blood glucose for the -day mortality of septic patients admitted to medical icu. included were all consecutive patients admitted to our medical icu in with criteria for sepsis according to sccm/esicm/accp/ats/sis international sepsis definitions conference. the data were collected retrospectively and the predictive roles of variables were tested by univariate and multivariate regressional statistical method. in patients (mean age . +/- . years, . % men) mean admission apache ii was . +/- . , mean admission sofa score . +/- . and total maximum sofa score . +/- . . -day mortality was present in %. we observed significant differences between nonsurvivors and survivors in mean apache ii ( . +/- . versus . +/- . , p = . ), peak blood glucose ( +/- . mmol/l vs . +/- . mmol/l, p = . ) peak serum lactate ( . +/- . mmol/l vs . +/- . mmol/l, p < . ), minimum serum albumin ( . +/- . g/l vs . +/- . g/l, p < . ), peak serum creatinine ( . +/- . micromol/l vs . +/- . micromol/l, p < . ), admission sofa score ( . +/- . vs . +/- . , p < . ) and total maximum sofa score ( . +/- vs . +/- . , p < . ). according to regressional statistical analysis, minimal serum albumin level was the most significant independent predictor of the -day mortality of septic patients in medical icu (or . , hi-square . , p = . , % ci . to . ). serum hypoalbuminemia was the most significant independent predictor of the -day mortality in septic patients. conclusion. the early decrease in mhla-dr expression is related with mortality, but after the severity adjustment, it does not predict outcome globally or in septic subgroups. a flat trend curve of mhla-dr expression is associated with a high risk of ni, which increases the icu length of stay. reference(s). ( )v caille, shock ;( )monneret g icm grant acknowledgement. university paris (ea ), all investigators introduction. intravenous fluid therapy is a cornerstone in the management of severe sepsis and septic shock but the effects of rapid boluses of either crystalloids or colloids on septic-induced microcirculatory alterations are not well defined. we hypothesized that fluid administration may improve the microcirculation in the early phase of severe sepsis and septic shock. we used a sidestream dark-field (sdf) imaging device (microvision medical, amsterdam, the netherlands) to evaluate the sublingual microcirculation in patients with severe sepsis or septic shock during the first hours of resuscitation, in whom fluid challenge was indicated to improve tissue perfusion. hemodynamic and microcirculatory measurements were obtained before and after a fluid challenge with either ml of a % albumin solution or ml of crystalloid over min. at each assessment, sequences of seconds each were recorded and stored under a random number. an investigator blinded to the patient's clinical course and sequence order, analyzed the images semi-quantitatively. the vessels were separated into large and small using a cut-off value of µm in diameter and two microcirculatory variables were evaluated: percentage of perfused vessels and percentage of perfused small vessels. a student t-test was used and data are presented as mean ± sd. a p< . was considered as significant. while arterial pressure and vasopressor use remained unchanged, microcirculatory perfusion increased and lactate levels decreased during fluid challenge (table ) . before after p mean art p, mmhg , ± , , ± , , card outp, l/min (n) , ± , ( ) , ± , ( ) , scvo , % , ± , , ± , , lactate, mmol/l , ± , , ± , , % total perfus vessel , ± , , ± , < , % small perfus vessel , ± , , ± , < , these results suggest that fluid resuscitation can improve the sublingual microcirculation in the early phase of severe sepsis. sdf monitoring may become a new tool to guide fluid therapy in critically ill patients. the study was held in a bed multidisciplinary icu of a tertiary hospital. twenty four norepinephrine dependent (> . γ/kg/min) patients, fulfilling the criteria of septic shock, were enrolled in the study. patients were divided in groups according to the continuous administration of mg hydrocortisone for > days (group a: pts) or conventional treatment (group b: pts). end points of the study were, the within days vasopressors weaning, evolution of mods and -day as well as -day survival. mods was described by sofa score. statistics : statistical analysis was computed by using paired t-test and linear regression analysis. groups were similar regarding demographics ( + vs + y), initial sofa score ( + vs , + ), initial norepinephrine dose ( . + . vs . + . γ/kg/min) and mean elapsed time from the onset of shock ( . + . vs . + . days). an early and significant decrease in norepinephrine dose (p< . ), was observed in all group a pts, while no difference was detected in group b pts. this decrease was associated with hemodynamic stability. on days and mean abp was significantly higher in group a pts (p< . , p< . ). weaning from vasopressors within days was achieved in pts in group a ( . %) and pts in group b ( . %). seven day mortality was . % in group a vs % in group b while -day mortality was % and % respectively. in the treatment group a positive correlation between the within days shock reversal and survival (cor coeff = . , r = . , p= . ) was found. there was no relation between the time elapsed from the onset of shock to the steroid administration and survival (p= . ). oxygenation parameters (fio /po ), sofa score and creatinine did not differ between groups. wbc in group a pts were significantly higher (p< . ) only on day . no significant adverse effects were detected. in late septic shock patients with mods the administration of low doses of hydrocortisone is associated with decreased vasopressors requirements, hemodynamic improvement and beneficial effect on survival. the within days shock reversal was a good predictor of survival. prolonged sepsis is associated with the development of immunoparesis, a down-regulation of the immune system, the degree of which is associated with a poor outcome. little is known about its evolution during the septic process (including the recovery phase), particularly in terms of functionality of the different leukocyte populations. below are preliminary data from an ongoing study. after appropriate consent was obtained, ml blood samples were drawn from previously healthy patients with septic shock (n= ). associated demographic and clinical data (eg sofa score, steroid use etc) were also collected plus icu and hospital outcomes. samples from healthy volunteers acted as controls (n= ). total and differential counts were performed by coulter counter. flow cytometry was used to assess viability (dual staining annexin v/ propidium iodide to determine apoptosis and necrosis), and characterization of populations (surface molecule expression of characterising lymphocytes, monocytes, and neutrophils). functional assays were performed on the phagocyte cell population using phagotest (phagocytic activity assessed as % ingestion of opsonized fitc-labeled bacteria) and phagoburst (measure of oxidative burst activity in response to opsonized e coli, pma and the chemotactic peptide fmlp expressed as % positive cells vs non-stimulated controls, and the increase in median fluorescence intensity [mfi]) (kits from orpegen pharma). compared to controls, septic shock samples taken on icu day showed a wide range of functional responses with some having a reduced number of functionally phagocytic phagocytes while others retained their phagocytic capacity. changes in phagocytic capacity were not related to the respiratory burst. respiratory burst was generally suppressed in septic patients. the viability of the phagocytic population ranged between - % in all septic patients. the proportion of neutrophils of total leukocytes remained constant ( - %) whereas the monocyte population was more variable ( - %) . conclusion. phagocytic populations of septic patients differ from healthy controls. variable effects were seen in phagocytic activity and/or respiratory burst in different septic shock patients on day of admission. this may possibly relate to previous priming or to as yet unexplained immunoparetic mechanisms. further work will assess the evolution of leukocyte number and functionality, and any relationship to outcome. it has been established that raised procalcitonin (pct) levels > ng/ml in critical care patients are associated with an elevation of infection-related mortality risk . we have performed a study to assess the effect of drotrecogin alfa (activated)(daa) on outcome in patients with severe sepsis and very high procalcitonin levels > ng/ml. we examined the outcome data for consecutive patients with severe sepsis and two or more organ failures who had procalcitonin levels greater than ng/ml at the time of critical care admission. pct was measured using the brahms pct-q immunochromatographic test. patients were divided into groups depending on whether or not they received drotrecogin alfa (activated). for all patients we recorded age, sex, apache ii score, and outcome at days. risk of death and standardised mortality ratio (smr) were then calculated. between july and november a total of patients with severe sepsis and multiple organ failure had pct > ng/ml. fourty-seven were not given daa because of or more contraindication or because their prognosis was so poor. the results are shown in the table. the smr was lower in the group not given daa. in patients with very high pct > ng/ml there was no reduction in mortality associated with the administration of daa. it is known that mortality increases with elevated pct > ng/ml and there may be a point at which the physiological derangement is so severe that daa is less effective. given that this drug is expensive and has significant side effects it would be prudent to avoid its use under such circumstances. pct may be useful in selecting patients for this treatment if our results are repeated in a larger study. since adrenergic stress and catecholamine-induced myocardial stunning may contribute to the pathogenesis of septic cardiomyopathy we evaluated the effects of beta blockers in patients with septic cardiomyopathy and shock. twenty patients with septic shock requiring milrinone therapy who were treated with enteral metoprolol after stabilization of cardiovascular function and within hours after onset of shock were included into the retrospective study protocol. hemodynamic, laboratory and clnical data documentation was performed immediately before, , , , , , and hours after the first metoprolol dosage. the incidence of the following adverse events was evaluated during metoprolol therapy: symptomatic or asymptomatic bradycardia, decrease in mean arterial blood pressure, cardiac or stroke volume index, central venous oxygen saturation, and hypoglycemia. descriptive methods and a linear mixed effects model was used for statistical analysis. metoprolol therapy was started after cardiovascular function had been stabilized ( . ± . hrs after onset of shock) and was targeted to reduce heart rate to - bpm. hemodynamic data and laboratory parameters were documented immediately before, , , , , , and hours after the first metoprolol dosage. a linear mixed effects model was used for statistical analysis. heart rate (p< . ), central venous pressure (p= . ), norepinephrine (p< . ) and milrinone dosages (p= . ) significantly decreased during beta blocker therapy. cardiac, stroke volume and cardiac power index remained unchanged. metoprolol was discontinued in two patients because of asymptomatic bradycardia. norepinephrine and milrinone dosages had to be increased in seven and four patients, respectively. in none of the four patients with a decrease in cardiac index a decrease in central venous oxygen saturation occurred. arterial lactate levels (p< . ) and c-reactive protein serum concentrations (p= . ) decreased during the observation period. enteral metoprolol therapy in combination with phosphodiesterase inhibitors seems to be safe and may be beneficial in patients with septic cardiomyopathy and shock. further studies on the use of beta blockers for septic cardiomyopathy are warranted. septic shock represents the leading cause of mortality in critically ill patients worldwide. the cornerstone of therapy continues to be early recognition and prompt initiation of antibiotic plus hemodynamic support measures. continuous renal replacement therapies (crrt) seem to play an important role in the early management of septic patients with acute renal failure, based on classical depuration properties and mediator clearance capacity. different crrt include: -convection techniques as high-volume hemofiltration (hvhf). -adsorption techniques as coupled plasma filtration adsorption (cpfa); introduced in recent years,it's a technique that separates plasma from the blood by means of a plasma filter. the plasma is then passed through a synthetic resin cartridge and returned to the blood. a second blood filter is used to remove excess fluid and small molecular weight toxins. the aim of this prospective and not randomized study was to analyze and compare the hemodynamic effects of both techniques(hvhf and cpfa). we studied twelve patients (n= ) with septic shock and acute renal failure. we initiated either of the two crrt when patients fullfilled renal depuration criteria. we analyzed the clinical effects by measuring main hemodynamic parameters and vasoactive drugs requirements during the first twelve hours. we started cpfa in four patients (mean age was years, % were male, and mean apache ii was ), and hvhf in eight patients (mean age was years, % were male, and mean apache ii was ). in table we represent the variation percentages in main hemodynamic parameters and norepinephrine requirements after the first twelve hours of crrt. no adverse effects due to crrt were registered. (up to %) . the aim of this study was to analyze the clinical presentation and to evaluate mortality associated factors (timing and accurancy of diagnosis, timing of surgery, severity score and organ failure, surgical and medical treatments). this study retrospectively investigated the medical records of patients (pts) diagnosed and treated for nf who were admitted to a -bed general icu from to . the pt characteristics are shown in table . the mean delay from onset of symptoms and hospital admission was . ± days. the provisional clinical diagnosis was incorrect in % pts. eighty % of pts was admitted with clinical signs of septic shock (ss). the mean time from diagnosis until surgery was ± , hrs. all pts underwent a mean of ± , surgical procedures related to necrotic tissue debridement. the wounds were sealed with a vacuum-assisted closure device which was exchanged every days until second intention healing. only pt required above-knee amputation. after surgery % of pts were submitted to hyperbaric oxygen therapy (n= - /pt). all pts received broad-spectrum antibiotics therapy which was changed according to the results of culture and sensitivity. mechanical ventilation was performed in all pts for respiratory failure (mean time= , ± days). two pts required surgical tracheostomy at admission for airways obstruction due to nf. all pts were in ss requiring vasopressor therapy for , ± days. thirty % of pts showed renal dysfunction (rifle class injury) and % were treated with high volume hemofiltration for anuric renal failure. disseminated intravascular coagulation was diagnosed in % of pts. low dose steroids were prescribed in % of pts and pts were treated with apc. the average lenght of icu and hospital stay were respectively of , ± and , ± days. overall mortality in our series was %. two pts died of severe ss and mof. in one case hyperkaliemia of unknown origin (after ss resolution) was fatal. sepsis is a common source of morbidity and mortality among critically ill patients. targeting measures to reduce the incidence and promote early recognition and treatment of sepsis is at the forefront of many critical care initiatives. advances in the management of severe sepsis have evolved over recent years in an attempt to combat the spiraling mortality trends. the "surviving sepsis campaign" (ssc) is a worldwide initiative promoting the evidence-based treatment of sepsis, with the explicit goal of reducing both the morbidity and mortality associated with sepsis. protocol watch (pw) was developed as a tool to assist clinicians at the bedside with the implementation and compliance of the ssc guidelines. participants were critically ill patients in -bed intensive care unit in a large university-affiliated teaching hospital in the northwestern united states. prior to the installation of pw, implementation of the ssc was done using a paper-based system of standing orders. base line data on compliance with the ssc guidelines were collected. protocol watch, which offers an electronic version of the guidelines and is resident on the bedside patient monitor, was then installed in all critical care beds. the post pw installation data collection is currently being completed. preliminary results show a significant improvement in both the early identification of sepsis as well as compliance with the ssc guidelines. in addition, the feedback from the clinical users has been extremely positive. if the final data analysis supports the preliminary findings, pw could emerge as an important method for assisting in the implementation of the ssc guidelines, thus making a valuable contribution in the care of critically ill patients with sepsis. hyperglycemia during acute brain injury such as ischemic stroke, cerebral hemorrhage, or head trauma is frequent and is associated with increased morbidity and mortality [ ] . there is also a profound increase in glucose utilization (hyperglycolysis) that can persist for up to one week after traumatic brain injury (tbi). however, little is known about the optimal glycolytic rate and about the influence of intensive insulin therapy on the tbi-induced changes in glucose metabolism [ ] . this study was designed to estimate the safety of routine versus intensive insulin therapy on the basis of hypoglycemic episodes defined as blood glucose concentration < . mmol/l (< mg/dl), in patients admitted to intensive care unit (icu) after severe tbi. in this prospective, single-blind, randomized clinical trial patients admitted after severe tbi, were enrolled and randomly assigned to one of two groups on the basis of the targeted levels of glycemia. insulin infusion was administered either at conventional rates, to maintain glycemia at . - . mmol/l ( - mg/dl), or intensive rates, to maintain glycemia at . - . mmol/l ( - mg/dl). hypoglycemic episodes, duration of icu stay, infections rate, mortality and neurologic outcome measured using the glasgow outcome scale (gos) at months follow-up, were recorded. in patients receiving intensive insulin therapy, hypoglycemic episodes were significantly higher ( . % vs . %, p< . ), duration of icu stay shorter ( . vs . days; p< . ), and infections rate lower ( . % vs. . %, p< . ) than in patients treated with conventional insulin therapy. mean gos and overall mortality at months were similar in the two groups ( . % vs. . %). intensive insulin therapy significantly increased the risk of hypoglycemic episodes. despite the shorter icu stay and lower infection rates, no differences were observed at months follow-up mortality and neurologic outcome. therefore, in tbi patients receiving intensive insulin infusion, whether to avoid episodes of hypoglycemia either with a stricter blood glucose monitoring or with a wider target blood glucose level needs further investigation. severe head injuries are a frequently encountered problem in intensive care medicine, and a cause of significant mortality and long term morbidity. various clinical features related to the initial trauma and secondary brain injuries are associated with adverse outcomes. [ ] we developed a head injury database, and investigated the management and outcome of head injured patients in our department, with particular emphasis on ventilation and haemodynamics in the pre-hospital and resuscitation phases. in this observational cohort study we collected data on head injured patients admitted to the icu at the royal london hospital (rlh) between march and november . demographic, clinical and outcome data was extracted from the patient notes and the icnarc database and then entered in a data collection proforma and subsequently in a ms excel spreadsheet for analysis. outcome measures were primarily mortality, and for survivors, the length of stay both in intensive care and in hospital were recorded. data was collected on head injured patients. the group of patients that died tended to be older, to have a lower gcs at the scene, a higher systolic blood pressure both at the scene and in the emergency department, and a lower pao in the emergency department although these results were still in the physiological range for the majority of patients. of the patients that had abg results recorded, only % had an initial paco < . in the emergency department. the lowest mortality ( . %) was associated with an initial a&e paco in the range . - . kpa. the mortality rate for patients brought directly to rlh was . % compared with . % for patients transported from other hospitals. ( , ) . we evaluated the association between bnp and the presence of sah, intracranial hypertension, hyponatremia, csws as well as water and salts balance in patients with severe traumatic brain injury (tbi). we examined patients with severe tbi coming from emergency ward. serum bnp was measured five times: t ( ˚- ˚day), t ( ˚- ˚day), t ( ˚- ˚day), t ( ˚- ˚day), t ( ˚- ˚day). daily and cumulative balance of water, sodium and potassium were calculated for all the patients. the presence of hyponatremic events, csws, intracranial hypertension episodes, sah (tc evidence) and the use of cathecolamines were notified, as well. seventeen male patients were included in the study (with a total of days of monitoring in icu and samplings of bnp). no association between bnp and the other observed variables (hyponatremia, csws, sah, the use of cathecolamines and intracranial hypertension) was observed. on the other hand, positive correlations between bnp levels and cumulative sodium balance (r= , ; p< , ) as well as between bnp and water balance (r= , ; p< , ) were observed. bnp level was higher in patients with positive cumulative sodium balance than in patients with negative balance: mean (sd) , ( ) pg/ml vs ( ) pg/ml (p= , ), respectively. bnp levels were also higher in patients with positive cumulative water balance: mean (sd) , ( , ) vs , ( , ) pg/ml (p= , ), respectively. our study does not confirm the role of bnp in the genesis of hyponatremia and csws. moreover, observing higher bnp levels in patients with positive sodium and water balance, we conclude that bnp in patients with severe tbi has a physiological role in the regulation of water and salts balance in order to avoid the excessive expansion of extracellular compartment. brain tissue oxygen monitoring plays important role in prevention of secondary brain injury. values of partial brain oxygen pressure (pbto ) in first hours after severe brain trauma should predict final patient's outcome. aim of this study is to analyze relationship between early values of brain oxygen in severe head trauma and the patient's outcome one year after this traumatic accident. study follows up our previous observation. we analyzed data of consecutive adult patients treated in our icu during time period of month for severe head trauma with glasgow coma scale (gcs) and less and with monitoring of intracranial pressure (icp) and partial brain oxygen pressure (pbto ). we placed sensor for pbto monitoring at the same time as icp sensor. all patients were treated according standard therapeutical protocol used in our department. target of our treatment was to avoid icp hypertension, to maintain cerebral perfussion pressure above mmhg and to reach optimal pbto levels. we compared data of first hours of the treatment in icu with neurological status using glasgow outcome scale (gos) in time intervals , and months after trauma in all patients. all this studied patients were already not at these times treated in our hospital. group with gos at the time of leaving icu had patients and initial values of pbto in first hours of treatment , mmhg (mean). group with gos had patients and initial valus of pbto , mmhg (mean). from this group patients died a one improved to gos . group with gos had patients, initial values of pbto , mmhg. from this group patients improved to gos and patients to gos , both in months. there were no changes in neurological status between and month after injury. group with gos had no patients. group with gos had patients and initial values of pbto , mmhg at a time of leaving icu. conclusion. there were found in our study no clear relationship between initial values of brain tissue oxygen and long term outcome. patients in vegetative state at a time of leaving of icu had in our group bad prognosis. all patient with severe dissability improved. values of brain tissue oxygen were in this group below mmhg. group with gos had values also relative low. we have no database of patients treated without brain tissue oxygen monitoring to make direct comparation and to evaluate real benefit of brain tissue oxygen monitoring. can protein s predict neurological deterioration after moderate or minor traumatic brain injury? p. bouzat* , p. jaffres , p. declety , j. brun , g. francony , j. c. renversez , a. kaddour , c. jacquot , j. f. payen department of anaesthesiology and critical care medicine, department of biochemistry, department of emergency medicine, albert michallon hospital, grenoble, france serum protein s "eta (ps ) is believed to reflect brain damage following traumatic brain injury (tbi). since patients with moderate tbi (glasgow coma scale, gcs, score - ) or minor tbi (gcs - ) may be at risk for subsequent neurological deterioration, we wondered whether the determination of serum ps on admission could be associated with the neurological outcome. methods. patients with moderate or minor tbi were prospectively studied. they had normal or moderate ct scan (trauma coma data bank, tcdb, classification i or ii, respectively) on admission. serum ps dosages were performed on admission within hours post-injury using a commercially available kit (elecsys s roche, detection limit . mathrmµg/l). neurological outcome was assessed up to days after trauma. secondary neurological deterioration was defined as a decrease in gcs score of points or more from the initial gsc score, or any treatment for neurological deterioration. two groups of patients were defined : group (absence of secondary neurological deterioration) and group (presence of neurological deterioration). data are expressed as median and range. univariate analysis (non parametric mann-whitney test, chi test) was used to identify factors related to the neurological outcome. . patients had a secondary neurological deterioration days after trauma (group ). they had significant higher gcs score and more injuries on ct than group . however, serum ps were not different between the groups (table) . ( - ) serum ps (µ µ µg/l) . ( . - . ) . ( . - . ) tcdb classification i/ii (n) / / ** gcs score on admission ( - ) ( - )** **p< . conclusion. serum ps cannot be viewed as a biological marker for detecting patients at risk for neurological deterioration after minor or moderate tbi. the contribution of this blood sampling is not as informative as a ct scan or the gcs. methods. seventy patients with traumatic brain injury (tbi) and stroke with glasgow coma scale (gsc) < were evaluated. thirty-degree head-up position was used during the study. icp was monitored during the following procedures: chest compression, vibration associated to chest compression, unilateral continuous chest compression, tracheal suction with open circuit and closed circuit, passive mobilization of arms and legs, hip rotation, scapular mobilization in lateral decubitus and lateral flexion of the lower trunk. wilcoxon test was used to evaluate changes on icp during the procedures. algorithm of intracranial hypertension (ich) therapy in patients with tbi should be modified on the base of the level of cerebral autoregulation (ca) impairment. the aim of the study was the application of the pressure reactivity index (prx) monitoring in the treatment of tbi patients. tbi patients with gcs< underwent the monitoring of the arterial blood pressure (abp), icp, prx. analog outputs from the monitors abp and icp were connected to the analog-to-digital converter (dt , data translation) installed into a laptop computer. data were sampled, digitized, and stored on the hard disk with the software for the waveform recording. digital signals were processed with software (icm plus, england). the therapeutic strategy modified on the base of results clinical evaluation and prx, abp and icp. all the patients were divided into two groups. patients had preserved ca with prx [- ; , ], gcs , +/- , ; icp , +/- ;cpp , +/- mmhg. in patients gos was favorable ( -with good recovery; -moderate disability) and unfavorable in patients ( -severe disability; -vegetative state). in this group we used iv infusion of colloids and vasopressors for cpp-protocol. in patients were determined "optimal" levels of cpp: in it was - mmhg, in - - mmhg, and in - - mmhg. in patients developed ca failure on the day after brain trauma and uncontrolled intracranial hypertension demanded decompressive craniotomy. second group included patients with impaired ca -prx [ , ;+ ], gcs , icp , +/- , , cpp , +/- mmhg. gos: both patient had unfavorable outcome (one-severe disability, other-vegetative state). conclusion. the monitoring of prx added to routine measuring of the abp and icp in tbi patients is helpful in choice of the best therapeutic strategy. grant acknowledgement. we thank dr. marek czosnyka and peter smielevski for their scientific support. a. raigal*, g. hernandez, l. marina intensive care unit, hospital virgen de la salud, toledo, spain severe traumatic brain injury (tbi) defined with a glasgow coma score (gcs) ≤ with normal or near normal craneal ct at hospital admission (type i-ii traumatic coma data bank classification) represents a common clinical dilemma about the real severity of cerebral lesions and neurological prognosis. the aim of the study was to relate some clinical factors with a higher probability of developing neurological complications (intracraneal hypertension) and bad neurological function on icu discharge defined as the presence of a motor component of gcs≤ . retrospective series of patients consecutively admitted for severe tbi in the general -bed icu of a tertiary trauma center during one year. we study patients with craneal ct admission classified as tcdb i-ii, after excluding those with another non traumatic cause of the coma and encephalic death on admission. after the admission ct the radiologic study was repeated in the first hours posterior to the trauma. icp was monitorised in all patients with tcdb> in the second ct or type i and confirmed gcs ≤ after transitory withdrawal of any sedative agent. the radiologic study was repeated after hours, on the th day and if the clinical evolution or icp required it. epidemiological, clinical and radiologic associated variables were also analysed and the gcs at icu discharge. a multivariant study was done adjusted by age, genre, initial gcs, radiologic lesion, associated trauma lesions and vital signs during the early phase of the traumatic injury (arterial oxygenation, blood pressure, etc). five patients ( %) had a poor gsc on discharge (m≤ ). those five patients showed an early damage of tcdb type at second ct and hypericp during icu admission. a sixth patient showed unfavorable outcome of the second ct with normal icp and gcs= on discharge. of the left over patients with a favorable neurologic evolution, showed hemodynamic and/or respiratory deterioration. the multivariant study displayed a relation between the early progression of lesions in the second craneal ct (or . , % ci: . - . ) with increase of icp or a poor gcs on icu discharge. also, the presence of systemic factors associated to admission was related to a good gcs on discharge (or . , % ci: . - . ). conclusion. . the early progression of type tcdb is related to hypericp and bad neurologic prognosis on icu discharge. . systemic factors in the initial phase of trauma (hypotension, hypoxia, etc) are related in these patients with a good final neurologic outcome, absence of both radiologic deterioration and intracraneal hypertension. the glasgow coma score on hospital admission has been shown to be correlated with outcome in patients with traumatic brain injury( ). however many patients who arrive at a neurosurgical referral centre have been sedated and intubated some time prior to transfer and so their glasgow coma score cannot be accurately recorded. an option in these cases is to use the last recorded score prior to sedation and intubation. this may be the glasgow coma score recorded in the accident and emergency department of the referring hospital, or in some cases that recorded on the ward after deterioration. in some cases the only available score is that recorded at the scene of the injury. in our study we examined the degree of correlation between these various glasgow coma scores and outcome at one year in order to assess the validity of using a surrogate for the admission glasgow coma score when this is not available. data were collected prospectively on all patients admitted to the queens medical centre from to with a recorded glasgow coma score of or less within hours of a traumatic brain injury. three glasgow coma score groups were identified. patients in group (certainty factor ) had a glasgow coma score recorded on admission to the queens medical centre. group (certainty factor ) was made up of patients in whom the last pre sedation and intubation glasgow coma scores was recorded at the referring hospital. in group (certainty factor ) the glasgow coma scores were recorded at the injury scene. for each group we looked at the strength of the association between the glasgow coma score and glasgow outcome score using linear regression analysis. results. data were available on patients. mean age years (range - ), % male and % victims of road traffic accidents. linear regression between the glasgow coma score and glasgow outcome score was highly significant in all three groups (p = < . for all three groups). the strength of the association was similar for groups and and superior to group (r = . for group , r = . for group , r = . for group ). we found a good correlation between the glasgow coma scores and outcome for all three groups. the best predictor of outcome is the glasgow coma score actually recorded on admission to the referral centre, but the pre-intubation glasgow coma score at the referring hospital provides an acceptable alternative. head injury remains a common cause of hospital admission, morbidity and mortality. uk recommendations are that all head injuries are managed either in the emergency department or the regional neurosciences centre. many patients are managed in local hospitals despite evidence that outcomes are improved by specialist care. we reviewed outcome data for all head-injured patients admitted to a regional centre over a -month period (sept -aug ). consecutive adult patients (> years) were studied prospectively. gcs following resuscitation, demographic data and surgical intervention were recorded. glasgow outcome scores were determined at discharge from the regional centre, and at and months following injury. whilst at the regional centre, patients were managed according to locally established protocols. . patients were admitted ( m, f). gcs following resuscitation was - in patients, - in , and < in . patients were aged - years, were - years and > years. patients had evacuation of an extradural haemorrhage, had evacuation of a subdural haemorrhage, had contusionectomies and patients required decompressive craniectomy. gos data were available for all patients at discharge, at months and at months (table ) . for patients with initial gcs < , gos was available for at discharge, at months and at months ( table ). mortality from head injury was % with only / patients with severe head injury dying. patients were discharged in a vegetative state with only remaining so at months. a bolus infusion of . % saline in % hydroxyethyl starch / . (hs) attenuates mean intracranial pressure (icp) in patients suffering from spontaneous subarachnoid hemorrhage (sah) ( ). it has been suggested that intracranial pulse pressure is more useful for prediction of intracranial compliance than mean icp alone ( ) . in this study, the effect of an infusion of hs on the parameter mean icp wave amplitude (i.e. intracranial pulse pressure) is compared with the effect on mean icp. prospectively collected data was retrospectively analyzed. all patients included were sedated and mechanically ventilated patients suffering from spontaneous sah. nine patients received infusions of hs, mean . (range . to . ) ml/kg. mean values of a minute period just prior to the infusion were compared with a -minute period after maximum effect was reached. results. the mean icp wave amplitude decreased . mmhg ( % confidence interval - . to - . ) from a baseline of . (sd . ) mmhg, p = . . mean icp decreased . mmhg ( % confidence interval - . to - . ) from . (sd . ) mmhg, p <. . comparing mean icp and mean icp wave amplitude, there was no statistically significant correlation for baseline values or change (table ). there was a stronger correlation between baseline values and change for mean icp wave amplitude than for mean icp (table ) . this study documents an effect of osmotherapy on intracranial pulsatility; mean icp wave amplitude was attenuated after infusion of hs. this reduction was strongly correlated to baseline mean icp wave amplitude. however, regarding the association between mean icp wave amplitude and mean icp, we found neither any correlation for baseline values nor for change after hs infusion. hence, monitoring of one parameter can not substitute the other. the value of mean icp wave amplitude in clinical practice should be further evaluated. hyponatraemia is an important electrolyte dysbalance in acute brain diseases. there are two known syndromes: the more frequent cerebral salt wasting (csw) syndrome due to natriuresis, and the less common syndrome of inappropriate secretion of antidiuretic hormone (siadh) caused by free water retention. differentiation between them can be made using renal function parameters, and is essential because each syndrome requires different therapy. we retrospectively analysed all patients (pts) with acute brain diseases admitted to our neurologic-neurosurgical care unit (nnicu) over a period of five years who developed hyponatraemia (serum sodium < ). first we divided them according to measured serum osmolality (normal values - mmol/kg) and then we evaluated the group with hypoosmolality (s osm < mmol/kg). the type of hyponatraemia was diagnosed using renal function parameters established in clinical practice in our nnicu. there were pts (mean age +/- yrs, m ) with days of hyponatraemia. the majority of pts had normal serum osmolality ( pts, days), some had hyperosmolality ( pts, days) and only pts ( days) had low plasma osmolality. osmolality was not measured for the remainder. pts in the hypoosmolal group (mean age +/- yrs, m ) were with the following diagnoses: subarachnoid haemorrhage , intracerebral haemorrhage , ischemic stroke , tumour , trauma , infection and others . the mean gcs at the start of hyponatraemia was . (range - ), the mean discharge gos was . (range - ). hyponatraemia lasted from to days (mean . days) and in patients was already present on the day of admisson. the mean value of hyponatraemie was . mmol/l (range - mmol/l, p< . ) and the mean value of serum osmolality was . mmol/kg (range - mmol/kg, p< . ). the mean increase of natraemia over hours was . mmol/l (range - mmol). no patients had central pontine myelinolysis. renal function parameters were examined in patients ( %), of whom patients were diagnosed csw syndrome (diuresis +/- ml/day; fu na+ . +/- . mmol/day, p< . ; c osm . +/- . ml/s, p< . ; c el . +/- . ml/s, p< . ; c na+ . +/- . ml/s, p< . ; ewc - . +/- . ml/s, p< . ; fe na+ . +/- . , p< . ), patients had other causes of hyponatraemia and no one siadh. renal function parameters are very useful to diagnose the type of hyponatraemia and available to put into clinical practice. hyponatraemia with hypoosmolality is not so frequent, and csw syndrome is more prevelant then siadh. microbial colonization of the respiratory and gastrointestinal tract (rt and gt) of a critically ill patient is an early event in the chain leading to invasive infection. systematic colonization surveillance permits monitoring of transmission dynamics, early detection of epidemics in the icu and possibly guidance for adequate empiric antimicrobial treatment in infectious episodes. we retrospectively analyzed the ability of colonization surveillance to predict microbial etiology of subsequent infections and permit adequate empiric therpay in septic episodes. the study was performed in a -bed general icu from november to december . infection control policy included weekly surveillance cultures of bronchial secretion and stool samples. all cases of ventilator-associated pneumonias (vap) and bloodstream infections (bsi) during the study period were recorded and the relationship between infectious etiology and most recent colonization was analyzed, based on species, antimicrobial susceptibility patterns and molecular typing by rep-pcr of selected isolates. in cases of new septic episodes, empiric treatment was determined, among other risk factors, by the antimicrobial susceptibility of most recent colonizers in either the rt or gt. during the three years of the study, we recorded vap and bsi cases ( catheter-related). pathogens isolated from vap cases correlated with bronchial or stool colonizers in %, with prior rt colonization being most important. in bsi cases, gram-negative pathogens were recent colonizers in % associated with both the gt and rt. no relationship was observed between gram-positive colonization and subsequent infection. rep-pcr techniques confirmed pathogen and colonizer concordance in all cases tested. systematic colonization surveillance use to determine empiric antimicrobial treatment in new vap episodes permitted % adequacy, compared to only % if the hellenic society of intensive care vap guidelines were used. empiric treatment for bsi cases was adequate % of the time. conclusion. rt and gt colonization is strongly related to microbial etiology of subsequent infection. systematic weekly colonization surveillance of rt and gt specimens could be helpful in implementing adequate antimicrobial therapy, especially for multidrug resistant gram (-) pathogens, in the icu. s. barbadillo* , m. olsina , a. leon intensive care unit, microbiology, capio hospital general de cataluña, sant cugat del vallés, spain production of extended-spectrum beta-lactamases (esbl) by enterobacteria is an important resistance mechanism against antimicrobial beta-lactamics. klebsiella pneumoniae and escherichia coli (esbls) strains had mostly been described but infection due to enterobacter producing extended-spectrum beta-lactamases (esbls) is a relatively uncommon clinical entity. this study was performed to investigate the risk factors associated with the acquisition of enterobacter-esbls strais infections in an intensive care unit (icu). this case-control study took place at a tertiary spanish hospital with a polyvalent icu beds from january to december . demographic data, underlying diseases, risk factors, length of icu stay and hospitalization and antimicrobial treatment were investigated by comparing infections due to enterobacter esbl-positive to cases due to esbl-negative strains. enterobacter were tested for esbl production by double disc diffusion synergy test (ddst) as well as by the mic reduction test. thirty-six enterobacter infections over a period of years were collected. ventilator associated pneumonia was the most frequent infection ( %). nine cases ( %) of esbl-producing eneterobacter isolates were compared to those infections with enterobacter non-esbl. days of mechanical ventilation, length of icu stay, tracheotomy, peripherical venous catheter and administration of cephalospin were all associated with esbl-enterobacter infections in the univariate analysis. there was not differences for sex, age, prognostic scores and mortaliy between groups. the multivariate analysis revealed the administration of broadspectrum cephalosporin as the unique risk factor for the presence of esbl-producing strains [odds ratio (or) . ; % confidence intervals (ci) . - . ; p= . ]. use of cephalosporines was associated with enterobacter esbl-positive isolates. thus, rational antimicrobial administration and antibiotic protocol regimens appears to be critical for control emergence of esbl production. to evaluate and characterize the ni in two intensive care units (icu) of a central portuguese hospital. a retrospective study of patients with ni, hospitalized in two icu (one medical and other surgical)between / / and / / identified by a computer-based program vigi@ct (biomerieux) and confirmed after. in the surgical icu we found episodes of ni. of this ( . %) were respiratory infections; ( . %) were surgical site infections and ( . %) bacteriemias. in the respiratory infections the most frequent agents were acinetobacter baumannii ( - . %) and pseudomonas aeruginosa ( - . %). enterococcus faecalis ( - . %) was the most frequent in surgical site. staphylococcus epidermidis ( - %) and acinetobacter baumannii ( - . %) the most frequent agents in bacteriemias. among all microrganisms . % of acinetobacter baumannii; . % of pseudomonas aeruginosa and . % of klebsiella pneumoniae were multiresistent bacteria (mrb). in the medical icu we found episodes of ni. half of these were due to respiratory infections ( - %), ( . %) were bacteriemia and ( . %) were urinary infections. pseudomonas aeruginosa was the most frequent microrganism ( - . %) among respiratory infections. in the bacteriemias coagulase negative staphylococcus (cns) (staphylococcus epidermidis and staphylococcus hominis) were the agents most frequently found ( - . %). escherichia coli was the bacteria most isolated in urinary infections ( - %). in medical icu we found mrb, among these were pseudomonas aeruginosa ( . %); were staphylococcus epidermidis ( . %) and ( . %) were acinetobacter baumannii. conclusion. ni is a significant problem in our icu's. we found more ni episodes in the surgical icu than in the medical. respiratory infection were the most common ni in both icu. as expected surgical site infection is also a serious occurence in the surgical icu as well bacteriemia. in the medical icu bacteriemia was also a considerable issue. gram negative bacteria and cns were predominat in this ni. acinetobacter baumannii was the most frequent mrb. we study retrospectively icu pts, men ( %), women ( %) who developed bacteremia. all had been operated at least once under general anaestesia. mean age: . ± . years, length of stay (los): . ± . days. all were mechanically ventilated and were divided in groups according to their age: group a ( . %) < and group b ( . %) ≥ years. in groups a and b we had respectively: mean age: . ± . and . ± . years. los: . ± . and . ± . days. underlying diseases: multiple trauma ( . %) and ( . %), complicated surgery ( . %) and ( . %), other ( . %) and ( . %). in groups a and b respectively: site of infection: pneumonia ( . %) and ( . %), intra-abdominal infection ( %) and ( . %), central venous catheter-related infections (cvc-ri) ( . %) and ( . %), other ( . %) and ( . %). invading microorganisms in single strain bacteremia: ps. aeruginosa ( . %) and ( . %), ac. baumannii ( . %) and ( . %), st. aureus ( . %) and ( . %), kl. pneumoniae ( . %) and ( . %), st. epidermidis ( . %) and ( . %), other and ( . %). mods occurred in ( . %) and ( . %). mortality rates (mr): / ( . %) and / ( . %). global mr: / ( . %). conclusion. ) cvc-ri appeared more frequently in elderly (p< . ), while all other sites of infection did not differ. ) invading organisms were similar in both groups except ac. baumannii which was isolated much more frequently in younger pts and very rarely in the elderly (p< . ). the resistance was similar in both groups. ) los was smaller in elderly (p< . ). ) elderly developed more frequently mods (p< . ) and had higher mr (p< . ), while the outcome of the infection was independent of the type of invading organism and its resistance. j. pavleas , a. skiada* , g. thomopoulos , i. stefanou , n. kouna , b. kaitanidi , a. salvari , p. tassiopoulou , a. papadopoulou , e. christofilou intensive care medicine, laikon general hospital, research laboratory for infectious diseases "g.l. daikos", athens university, microbiology laboratory, laikon general hospital, athens, greece nosocomial catheter-related bloodstream infections (cr-bsi) have been associated with increased morbidity and possibly increased mortality in critically ill patients. the aim of this study was to analyze the epidemiology of cr-bsis in our intensive care unit. prospective epidemiological study, in a mixed icu of a tertiary care hospital, of the incidence of cr-bsis, the responsible bacteria and the outcome of the episodes of bacteremia. the demographic and clinical characteristics of all patients admitted in the icu were recorded. each bacteremia recorded was classified as primary, catheter-related or secondary. the study took place in a tertiary care hospital, mixed icu, during a thirty-two months period. three hundred and thirty patients were admitted. their mean age was years and % of them were male. mean apache score was and the mean duration of stay in the icu was days. the total number of bloodstream infections (recorded in patients) was . of these, % were catheter-related. specifically, sixty-five cr-bsis occurred in catheter days ( . per catheter days). sixteen cr-bsis were due to gram-positive ( methicillin-resistant staphylococcus aureus, coagulase-negative staphylococci and enterococcus spp.) and to gram-negative bacteria ( acinetobacter baumanii, pseudomonas aeruginosa, klebsiella pneumoniae and one each of morganella morganii, enterobacter cloacae and serratia marcescens). of the gram-negative bacteria, % were multi-drug resistant, while % of the enterococci were vancomycin resistant. a positive outcome was noted in % of the catheter-related and in % of the other bacteremias. although cr-bsis have a better prognosis than the other bacteremias, they are still a serious cause of morbidity and mortality in the icu. since these infections are preventable, appropriate measures should be meticulously applied. opportunistic invasive aspergillosis in an immune compromised patient is being increasingly reported. however, this condition is thought to be rather rare in an immune competent host and therefore often unrecognized. we report two cases of invasive aspergillosis in patients without previous medical history of conditions leading to immune compromised status admitted to our intensive care unit. first case concerns a -year old woman who underwent an exploratory laparotomy because of acute abdomen without any significant findings. in the postoperative period, the patient developed sepsis with multiorgan failure necessitating ventilation, vasopressive and inotropic support and hemofiltration. early microbiologic analysis of the sputum showed an aspergillus fumigatus and patient was treated with voriconazol. the further evolution was unfavorable with hemodynamic instability and the patient died after two months of treatment. the autopsy revealed a severe tracheobronchitis and aspergillus endocarditis. the second patient, a -year old man admitted to our intensive care unit due to recurring arterial embolism and fever was diagnosed culture-negative endocarditis of the native mitralis valve on the transoesophageal echocardiography. subsequently, patient underwent a successful valve replacement. the culture of explanted valve revealed an aspergillus fumigatus infection and appropriate antimycotic treatment was started. in the postoperative period, the course was complicated by a sudden neurological condition with altered consciousness and patient eventually died of cerebral aspergillosis. in both patients, an exogenous infection possibly took place. the first patient was admitted to our hospital during the reconstruction work next to the intensive care unit. this may have led to her exposure to increased pathogen load during the early postoperative period. the second patient probably contracted the infection during the reconstruction work he was executing himself at his house before the admission to the hospital. invasive aspergillosis is a severe condition which is not only limited to patients with immune compromised status. alertness of the physicians ensuing in early diagnosis may be crucial for determining the individual patient prognosis. k. clabault* , f. soulis , m. tavolacci , g. beduneau , f. tamion , g. bonmarchand , j. richard medical intensive care unit, epidemiology and public health, rouen university hospital, rouen, france introduction. surgical hand rubbing (sr) has been proved to be an efficient alternative to traditional hand scrubbing. we tested an educational program based on continuous direct observing practice in order to implement this technique in a medical icu. residents and medical students benefit from an educational program included a ten minutes video demonstration of the sr presented by the infection control practionner. results of each observation was immediatly feed back to residents. medical students were encouraged to complete a form for each sr occuring h activity. data collection were due to sr (in emergency or not), duration of sr procedure, quantity of alcohol hand based (ahr) rub used. two successive groups of residents and groups of students participated to the study. two hundred and twenty-five observations were performed during a month period. the mean of the procedure time was s (sd . ). time expected according to the institutionnal protocol was s. . % of sr was inferior to mn , . % between mn and mn , . % superior to mn . time of sr did not differ between emergency or planned procedure ( s vs s, p= . ). cumulative volume of ahr was significantly correlated with duration of the procedure (r= . ,p< - ). our study suggest that implement of a new procedure of surgical hand disinfection in a icu is feasible on result on good adhesion of educated residents. the original method based on a audit performed by medical students may allow both hand hygiene education and adherence to an infection control program of future practionnners. infection surveillance: it is based in the unit not in the patient, using the envin-helics tool. this information from the patients was gathered: age, diagnosis on admission, apache ii, exposure and use to invasive devices (mechanical ventilation, central venous and urinary catheter). a multidisciplinary team from microbiology, preventive and intensive care units composed the team. the criteria for infection diagnosis were those from the cdc. incidence rates were calculated. handwashing surveillance: it was recorded in two periods: january-march (p ) and october-december (p ); each observation period lasted minutes. we observed the opportunity, defined as every time in which an indication for handwashing exists. . patients were enrolled, , % male, mean age ± ; more frequence of patients with medical pathology ( , %) with a media ± standard deviation of , ± , . apache ii . ± , . overall mortality rate was , %. a greater incidence of infections were found in the traumatic group. there is a large number of central venous catheter (use rate , %, , %:coronary patients). infections were detected as acquired in our unit ( , % and , %o patient-day). the respiratory tract infections and bactraemias were the most frequent localizations, with ventilator-associated pneumonia (vap) as the predominant nosocomial infection ( . % over total infections; , % in intubated patients, an incidence rate of , %o). there were two outbreaks of methicillin resistant staphylococcus aureus (mrsa). thus, the most frequent were pseudomona aeruginosa ( , %), escherichia coli ( , %) and staphylococcus aureus ( , %); acinetobacter baumanii and methicillin resistant staphylococcus aureus were quite very infrequent ( , % and , % repectively). opportunities of handwashing were detected (p : , p : ). the compliance increased from , % in p to , % in p . conclusion. )nosocomial infections affected to one out of five of the admitted patients. the vap was the most frequent infection. )we had a large rate of vap but similar to spanish standard ( , / days of use of mechanical ventilation). )the microbiology was similar to other critical care units, with a predominance of pseudomona aeruginosa. there were two outbreaks by mrsa. ) despite an increase in handwashing compliance, the rate of vap did not was lowered. m. karvouniaris* , s. xitsas , p. kasviki , d. lagonidis , m. stougianni , a. tefas icu, microbiology lab, general hospital of giannitsa, giannitsa, greece introduction. icu physicians are nowadays faced with the formidable task of dealing with bacteria that can hardly treat. multidrug resistant gram(-) bacteria are usually isolated from brocheal aspirates and associated with the development of vap , while their presence increases the risk of death. sometimes the only option for treating them is colistin , which was until recently an obsolete antibiotic of questionable efficacy. methods. patients with at least a -day stay in our icu had the following characteristics : men ( . %) , median age years ( interquartile range years) , median icu stay days (interquartile range days) , a mean apache ii score of . ( % confidence interval . - . ) these patients where retrospectively divided in two groups. the first one included patients with at least one brocheal culture positive for panresistant gram ( -) bacteria and the second one consisted of patients carrying bacteria sensitive to colistin only. a comparison was made according to days of stay in the icu , survival in months , age and apache ii score. statistical analysis was made using mann-witney analysis and a kaplan-maier analysis for survival. the patients in the group with the panresistant bacteria spend more days in the icu (p< . ) , while tended to live longer ( mantel-cox pairwise , p< . ). multidrug resistant bacteria are poorly responsive to colistin which failed to make an impact in survival. introduction. aids is a increasing chronic disease , with a great impact in medical costs. objective: to analyze incidence and epidemiological factors and outcome in aids patients (with previous or actual diagnosis) admitted to a general adult icu, comparing them with non-aids patients. retrospective cohort comparative study made in a general adult -bed icu of a university hospital, in a -month period. it were analyzed all patients admitted during this period. it was made descriptive statistics, analysis of variance and t-test. during studied period, there were patients admitted with a previous or actual diagnosis of aids. most common admission cause in these patients was sepsis by community pneumonia ( patients) and neurological diseases ( cases). there were patients with association with pulmonary tuberculosis, and patient with coexistent pulmonary paracoccidioidomycosis. among most frequent complications, ( . %) had acute renal failure (arf), ( . %) plaquetopenia (of these, had associated leucopenia), and ( . %) ards (all secondary to pneumonia). conclusion. in this study, aids patients admitted to icu were younger, mainly male, more severe and with a higher icu and hospital mortality. systemic complications were frequent, and commonest admission cause was community pneumonia with sepsis. it is emphasized the association with tuberculosis and paracoccidioidomycosis. grant acknowledgement. this study was not supported by any companies. th esicm annual congress -berlin, germany - - october a. sencan* , t. adanir , h. er , m. aksun , g. aran , n. karahan anesthesiology and icu, infection deseases, anesthesiology, izmir ataturk training and research hospital, izmir, turkey acinetobacter baumanii is a gram-negative coccobacillus that is normally a commensal pathogen but can be a nosocomial pathogen which is responsible for severe icuacquired infection, mainly pneumonia and bacteraemia. the aim of this study was to determine the risk factors and mortality rate of acinetobacter baumanii infections in icu patients. in this retrospective study, we analyzed acinetobacter baumanii infections developing in all patients who were admitted into our icu between january , and december , . a comparison of data was collected from the patients' record cards. age, gender, mortality ratio, apache ii and sofa values, length of mechanic ventilation (lomv) and length of icu stay (loicus) up to determination of infection, total length of mechanical ventilation (tlomv) and icu stay (tloicus), region of culture from which the infectious agent was obtained, existence of another microorganism together with acinetobacter baumanii (eamo), tracheotomy, intubation tube, central catheter, urinary catheter and nasogastric tube days up to the determination of infection and the feeding route were evaluated. these characteristics were compared between living and dead patients. during that time period, cases of acinetobacter infection were found in our clinic. the mortality ratio was %. the comparison of living and deceased cases is shown in the following table. we observed that this nosocomial infection was seen in the - year-old age group and in the first week of mechanical ventilation. mortality was greater in patients with high sofa scores and the infection prolonged the length of total icu stay. if the infection was located in the lungs, the mortality rate could be higher. there were cases of a baumanii nosocomial pneumonia and of them died. in addition, the rate of female patients dying was greater ( of female patients died). r. e. farah* , a. kondratov , r. michelis , n. makhoul internal medicine, intensive care unit, eliachar research laboratory, nahariya hospital, nahariya, israel community-acquired pneumonia, that requires hospitalization, is a severe illness with high mortality rates, especially, in the cases of delay of appropriate treatment. at times, the correct diagnosis of the disease is difficult due to equivocal clinical picture or chest film, accompanying diseases that could mask or simulate the pneumonia. the aims of our study were: .follow-up levels of scd and oxidized fibrinogen (of) throughout hospitalization in the group of patients admitted to the hospital due to pneumonia and pulmonary edema of non-infectious origin; .an estimation opportunity using them as possible new markers for diagnosis of pneumonia and for following response to treatment. three groups of patients were studied: a group of patients admitted due to pneumonia, a group of patients admitted due to pulmonary edema, and a control group - healthy subjects. the blood samples for white blood cells count, erythrocyte sedimentation rates, levels of fibrinogen, c-reactive protein, albumin, scd , oxidized fibrinogen were taken for each patient on admission, and hours following admission and on discharge day. the received dates were compared using student t-test. the levels of scd were higher, but still in the normal ranges, on admission in the patients with pneumonia and pulmonary edema in comparison with control group (p< . for both groups), with gradual declining throughout hospitalization period (p> . for both groups in discharge day). the comparison of scd levels between groups of patients with pneumonia and pulmonary edema did not reveal statistically significant results (p> . ). the rates of oxidized fibrinogen were in the normal ranges (< . nmol/mg) throughout hospitalization period in both groups of patients, but surprisingly higher in the control group (p< . ). oxidized fibrinogen and scd can't be used as reliable markers neither for primary diagnosing of pneumonia or differential diagnosis from pulmonary edema, nor for patient follow-up throughout hospitalization period. the finding of elevated levels of of in the group of healthy persons demands additional studies for discovering other factors that cause changes in fibrinogen oxidation rates. appearance of myocardial infarction and stroke during the same hospitalization is rare and has great mortality ratio. it was expected these events to take place more often during winter and in connection with infection. we have retrospectively analyzed data of patients with diagnose of acute myocardial infarction and stroke during the same hospitalization, treated in our internal intensive care unit from january to december . none of these patients were subjugated to thrombolytic therapy, percutaneus coronary intervention or coronary artery bypass graft. all included were caucasians (who were maked . % of total number of hospitalised patients during that period), ( %) males,and ( %) females. age of patiens was between and years, mean ± . (ci - ). six patients have survived ( %), and died ( %) ( males and females). the average age of deceased males was ± . years (ci - ), and females was ± . (ci - ). mean apache ii score was ± (ci - ), and mean gcs was ± (ci - ). most of the patients ( patients or %) were admitted during the winter, six in autumn ( %), five in spring ( %) and in summer only one patient ( %). in patients ( %) ( males and females) we found connection between current state with recent infection (within last month) or signs of infection on admission in icu. respiratory infection was found in patients, urinary infection in , and in cases we have found some other source of infection. also we found significant connection between current state (myocardial infarction and stroke during same hospitalization) and infection during winter (p= . ) and positive correlation between infection and mortality of these patients (r= . , p< . ). although exact mechanisms are still unknown. we can expect these events more often during winter period when are respiratory infection are more frequent. introduction. vap is the most frequently occurring nosocomial infection among patients requiring mechanical ventilation in the icu and is associated with increased morbidity and mortality. the major route of acquiring vap is oropharyngeal colonization by the endogenous flora or by pathogens acquired from the icu environment. oral decontamination with hexetidine , % reduces the risk for vap according the results of many reported studies and is the most common oral antiseptic in greek icus. our aim was to determinate the effect of oral decontamination with hexexidine , % on development of oropharyngeal colonization and vap. methods. patients admitted to the icu and received mechanical ventilation for more than days. were males ( , %) and ( , %) females. mean apache ii score on admission was , ± , . we excluded patients with multiple icu admissions. only the first admission was considered for analysis. we excluded also all patients with a diagnosis of pneumonia on or before the first day of mechanical ventilation, so that the sample would include only patients who had hospital-acquired pneumonia develop while receiving mechanical ventilation. all patients were randomized to hexetidine . % applied every hrs into the mouth, beginning hrs after admission. oropharyngeal sample cultures were obtained on admission on the nd and on the th day of hospitalisation and analyzed for gram positive, gram negative microorganisms and fungi. all patients were examined daily for the presence of vap with clinical criteria and chest x-rays. the most common isolates were: pseudomonas aeruginosa , %,klebsiella pneumoniae , %,s.aureus %,enterococcus faecium % ,acinetobacter %,e.coli , %,proteas mirabilis , % and candida species , %. coupled plasma filtration adsorption (cpfa), using a sorbent once the separation between plasma and blood has been obtained with a plasma filter, has been designed to non-selectively remove inflammatory mediators released in sepsis and septic shock. the aim of this study was to test whether cpfa is beneficial in septic shock. fourteen h-fasted, anesthetized, invasively monitored, mechanically ventilated female sheep ( . ± . kg) received . g/kg body weight of feces s lactate (rl)+ hydroxyethyl into the abdominal cavity to induce sepsis. ringer starch (voluven) (volume ratio= : ) was titrated to maintain cardiac filling pressures at baseline levels throughout the experimental period. four hours after feces injection, animals were randomized to two groups: cpfa treatment (n= ) or control (n= ). a four-pump hemofiltration machine (lynda, bellco, mirandola, italy) was used for the study. although mean arterial pressure and cardiac index were significantly lower in the cpfa group compared to the control group (p= . and p= . , respectively) and blood lactate concentrations tended to be higher in the cpfa treated group (p= . ), survival time tended to be longer in the cpfa than in the control group ( . ± . vs . ± . hours, log rank p= . ). in this clinically relevant septic shock model, cpfa treatment tended to prolong survival time. acute severe liver failure (alf) is a clinical syndrome that results from rapid loss of the major liver functions. despite improvements in the treatment of these patients, including liver transplantation, mortality rates remains high. a liver support system capable of removing endogenous toxins may be useful in alf patient's management. the aim of this study was to assess the efficacy of the extracorporeal liver assist device mars ® (molecular adsorbent recirculating system) in patients with alf unresponsive to intensive medical therapy. the study was performed in a medical-surgical intensive care unit of a tertiary referral hospital with multi-organ transplant program. a prospective clinical case-control study was designed. patients with severe alf of any etiology admitted to icu were included if mods was present and an indication for liver transplantation was done. standard treatment measures were applied in all cases according to patient's clinical condition. patients received mars ® treatment after this therapy was introduced in our icu. patients without mars treatment were the control group. outcome parameters were the main variables for comparison between groups. complications related with mars treatment were also analyzed. methods. in a previously-described test set-up, a l jar serving as a dummy lung was ventilated through a heated water-filled reservoir placed on a weighing scales so that gain or loss of water from it could be detected. the ventilator was a viasys sensormedics b using a fisher/paykel mr humidifier the ventilator was set to maximum power at a frequency of hz. three investigations were performed with humidifier temperatures of . ˚c, . ˚c and . ˚c. weight gain or loss over - hours was recorded and calculated in g/h. four measurements were made at . ˚c, four at . ˚c and two at . ˚c. previous spirometry studies suggested - % tracheal stenosis following percutaneous tracheostomy(pt) based on techniques that involved either the original ciaglia serial dilatation or griggs modified forceps blunt dilatation of the trachea. subjective voice changes and hoarseness has been reported at an incidence of % following pt by the blue rhino single dilator technique. aim of this study was to assess upper airway narrowing effects based on spirometry and symptoms following pt by blue rhino technique. invitations were sent to patients(identified from the liver database) who underwent pt during their intensive care stay and were attending liver clinic beyond months after the procedure. all participants underwent formal pulmonary function tests and filled in a standardized questionnaire on symptoms (pain, dysphonia, dyspnoea, cough, throat tightness, dysphagia) and scar appearance. flow volume loops were recorded using a jaegar master-lab . pneumotachograph, and best values for forced vital capacity(fvc),forced expiratory volumes at . and second(fev . ,fev ),peak expiratory flow rate(pefr),forced inspiratory flow at %vital capacity(fif ),forced expiratory flow at %vital capacity(fef )and peak inspiratory flow(pif) recorded. values for fev /pefr,fef /fif and fev /fev . ratios were then calculated. during august to january , patients underwent pt, of whom survived. of the outpatient attendants participated in the study. median age was . years ( - y) and m:f ratio was : . of the current or past smokers had obstructive airway disease based on fev /fvc ratio. median interval between pt and review was months ( - mth,n= ; - mth,n= ; - mth,n= , beyond y,n= ). median apache ii score on day of pt procedure day was . nine patients had failed extubation, and one patient underwent pt procedures during the same hospital stay. median duration of translaryngeal intubation prior to pt and from pt placement to decannulation were days ( - d) and days ( - d) respectively. moderate/severe dyspnoea was reported by patients (mild,n= ) and cough by patients (mild,n= ). patients reported voice changes and patient with hoarseness. assessment of scars at the time of review showed patient with keloid scar and patient with an ugly indurated scar (at and months respectively); all others were good to barely visible. satisfactory flow-volume loops were obtained for patients. patients had evidence of extrathoracic tracheomalacia based on the fef /fif ratio > ( with symptoms), however fev /pefr ratio did not suggest obstruction in any of them. dyspnoea and cough were the most common symptoms, notably in smokers. late complications were uncommon, other than one patient with indurated scar, hoarseness and possible tracheomalacia. leonard rc. chest fikkers bg. anaesthesia j. dellamonica*, a. lyazidi, f. vargas, l. brochard medical icu, henri mondor hospital, creteil, france high frequency percussive ventilation (hfpv) is a technique that delivers small bursts of gas with frequency higher than hz (usually - hz). intrapulmonary percussive ventilation using hfpv has been used during spontaneous breathing, but is also proposed superimposed to conventional ventilation (cv). airway humidification during hfpv has not been studied, however, and is generally provided with an aerosol. a poor airway humidification could lead to secretion thickening and atelectasis. we therefore performed a bench study to assess hygrometry provided by different devices when hfpv is added to cv. methods. circuits have been tested: . a heater humidifier (hh) (fisher & paykel mr ) placed on the inspiratory line of the cv. .& . heat and moisture exchanger (hme) and active hme (ahme) were tested placed at the y piece. for these circuits, hfpv was connected to a branches y piece with inspiratory and expiratory lines of the cv. . hh was connected between hfpv and y piece. all circuits were tested with the aerosol provided by the manufacturer. hygrometry (relative and absolute humidity rh and ah) was measured using psychometric method at y piece. hygrometry provided was compared with non parametric test. p< , was considered significant. conclusion. the minimal level of humidity recommended during prolonged mechanical ventilation is mgh o /l, and the fourth circuit was the only one to provide sufficient ah. temperature drop due to gas acceleration and large admission of gas during hfpv may explain the lack of efficacy of the other devices. coagulation abnormalities are very frequent in critical illness. these, often secondary to sepsis and dic, significantly contribute to mortality in the intensive care unit (icu). thrombelastography (teg ® ), a cell-based whole blood analysis, enables global evaluation of the haemostatic system and the purpose of the present study was to evaluate whether the haemostatic competence on admission to the icu, evaluated by teg ® was associated with mortality in critical ill patients. blood samples were prospectively obtained upon arrival from consecutive patients admitted to a multidisciplinary tertiary icu. teg ® analysis was performed (teg ® haemostasis analyzer, haemoscope corporation, niles il, usa), measuring clot formation,stability and degradation in whole blood. the teg ® parameters r time, angle, and the maximal amplitude ma were evaluated. the r time represents the initiation of the coagulation process (normal reference - min), the ma represents maximal clot strength mainly dependent on the platelet function (normal reference - mm), and angle represents the clot build up, involving fibrinogen function (normal reference - ˚). the primary endpoint of the study was defined as death within days. data are presented as mean (sd). mann-whitney's u-test and fischer's exact test were applied with a p value < . considered statistically significant. the age was . ( ) years in a cohort of . % medical (n= ) and surgical (n= ) patients of whom were male ( . %). length of stay in the icu was . ( . ) days and the apache ii score was . ( . ). thirty-one patients died ( . %). r time ( . ( . ) min vs. . ( . ), respectively; p= . ), ma ( . ( . ) mm vs. . ( . ), respectively; p= . ) and angle was significantly lower in non-survivors than in survivors ( . ( . )v s. . ( . ), respectively; p= . ). patients with a normal teg did receive less cvvhdf ( . % vs. . % (p< . )and had a lower mortality rate ( . % vs. . (p< . ) than patients with not-normal teg. a compromised haemostatic competence on admission to the icu as evaluated by the teg ® r time, angle, and ma are associated with increased -day mortality in un-selected critically ill patients. this finding is consistent with the hypothesis that a dysfunctional haemostatic system could be a central part of developing organ failure and, hence, mortality. this prognostic tool may be useful as a rapid, point-of-care assessment. the possibility of goal-directed haemostatic intervention should be investigated in a randomized controlled trial. n. komitopoulos* , a. kanavou , a. giakoumaki , i. ioannidis , a. komitopoulou , e. varsamis nd internal medicine dpt, biochemistry lab, konstantopoulion general hospital, athens, greece introduction. brain natriuretic peptide (bnp) is a -amino-acid polypeptide mainly secreted by the ventricles of the heart in response to excessive stretching of myocytes. cardiac dysfunction, characterized by reduced ejection fraction, biventricular dilatation and decreased response to resuscitation with fluids, is often present in patients with sepsis. the myocardial depression is probably due to tumour necrosis factor-α and interleukin- β acting in synergy. the aim of the study was to determine whether bnp levels in elderly septic patients are related to the severity of the disease. in patients ( males) with sepsis of various origin, aged ± years, hospitalized in the internal medicine department, bnp serum levels (direct immunochemiluminescence, centaur, bayer) and apache ii score were measured within hours after hospital admission. sepsis was determined according to the criteria of the consensus of the american college of chest physicians and the society of critical care medicine ( ) . patients with acute myocardial infarction were excluded from the study. the mean bnp value (pg/ml) in our subjects was ( - ). the bnp levels in the subgroup of individuals with chronic heart failure (n: ) were higher than those of the rest of the patients [ ( - ) vs ( - ), p= . , mann-whitney test]. a statistical significant difference was also found in bnp levels of the patients with apache ii score ≥ as compared to those of lower score [ ( - ) vs ( - ), p= . , mann-whitney test]. patients who succumbed (n: , %) had extremely high bnp levels [mean: ( - ) ]. a positive correlation was observed between bnp values and apache ii score (linear regression analysis , r= . , p< . ). in conclusion, brain natriuretic peptide was found to be correlated with the severity of sepsis in elderly patients and thus it might be used as a useful prognostic marker in septic process. prometheus ® is a newly developed extracorporeal liver support that combines fractionated plasma separation and adsorption (fpsa) with high-flux hemodialysis. clearance of albumin-bind and water-soluble toxins are achieved in several steps. here we present our results in applications. thirteen patients ( patients with viral hepatitis acute on chronic liver failure, three mushroom intoxication, one liver failure after metastatectomy and one cittrullinemi) have undergone ( . ± . [ - ] ) times fpsa with high flux hemodialysis between june till march in our icu. inclusion criteria were hyperbilirubinemia (total bilirubin > mg/dl), or hepatic encephalopathy (grade ), or inr > . during a six-hours period of application, a variety of clinical and biochemical parameters were assessed; and data before and after the procedure were recorded. seven of the patients survived. one patient has undergone liver transplantation; six survived without liver transplantation. there was a decrease of ± % in total bilirubin per application (from . ± , mg/dl to . ± . mg/dl; p< . ), blood urea nitrogen (bun) was decreased from ± gr /dl, to , ± , gr/dl (p< . ), white blood cell (wbc) increased from , ± , mm to ± , mm (p< . ), albumin decreased from , ± , gr/dl to , ± , gr/dl (p< . ). consequent applications have led to additional decreases in bilirubin. regarding the hemodynamic parameters, there were no significant changes during the procedure. conclusion. fpsa obtained decreases in bilirubin and bun (but also in albumin levels). there can be an increase in white blood cell count. this procedure can be considered a bridge therapy for liver transplantation: it can increase the tolerance time until the liver transplantation or can improve the clinical status achieving a treatment without an organ donation. at present orthotopic liver transplantation is the only treatment modality that provides significant improvement in outcome of hepatic liver failure; but the availability of transplantation is hindered by organ shortage resulting in extended wainting list. extracorporeal liver support devices are effective therapies to overcome periods of descompensation or to bridge until transplantation. although its main therapeutic indication is hepatic failure, the possibility of removing metabolits opens new therapeutics options for other entities. we reports clinical cases where patients were treated with prometheus as a bridge to transplant or to treat refractory pruritus. several analytics results like bilirubin, platelets, creatinine, urea were measured before and after each treatment. extracorporeal liver support devices have recently attracted increasing interest. although its role in liver failure and other conditions with toxin accumulation is yet to be better characterized, we believe that its use may be advantageous and life saving in selected patients. thrombocytopenia is a common problem in the icu and cardiovascular patients. it has been considered to play a role in worsening the prognosis of icu patients. especially patients submitted to cardiac surgery may be exposed to high dose of unfractionated heparin (ufh) infusions, mainly during extra-corporeal circulation. after open-heart surgery, as opposed to other surgical procedures, the platelet count falls, primarily due to platelet damage and destruction in the bypass circuit and hemodilution. heparin is the most common drug to be implicated in thrombocytopenia in icu patients. determining the etiology for the low platelet count is important for the implementation of appropriate management. the use of a direct thrombin inhibitor in treatment should be considered early (< hours) if a diagnosis of heparin-induced thrombocytopenia is possible( ). the aim of the study is to present one case of heparin-induced thrombocytopenia after a mitral valve replacement surgery and to compare the rotational thromboelastometry (rotem) and coagulation tests before and after argatroban administration. an -year-old female patient was hospitalized because of acute mitral regurgitation secondary to chordal rupture and submitted to a mitral valve replacement. past medical history included hypertension, diabetes, chronic atrial fibrillation and mild renal failure. before the surgery, a coronary angiography was performed and revealed normal coronary arteries and a normal left function. after four days using ufh, the platelet count dropped % and the anticoagulation was changed from ufh to low molecular weight heparin. postoperatively, the patient presented in shock, acute renal failure and signs of peripheral hypo perfusion and increased abdominal pressure. seven days after the surgery, the suspicion of hit was confirmed by elisa test for pf -heparin antibodies. heparin was stopped and argatroban was initiated. the patient died from multiple organ failure week later. we evaluate the rotem and coagulation tests (platelets; ptt; tat; pai; ptn-c; fibrinogen; d-dimer and antithrombin-iii) before and after the argatroban use. conclusion. comments: in this case the roteg was as good as a wide coagulation profile test to evaluate the effects of anticoagulation using argatroban in a hit patient. the objective of this study is to evaluate the efficacy and safety of this technique in a multidisciplinary icu environment following a procedures' protocol. it was created a fiberoptic bronchoscopy protocol to implement in a routine basis, and we are testing it in this study. we applied it, in a prospective manner, in every patient undergoing fiberoptic bronchoscopy from january to march , to evaluate the indications, risk factors, the use of drugs (sedatives, analgesics and muscle relaxants) and monitoring (ecg, bp, spo , etco , plateau pressure and blood gas analysis), complications and results of this technique. our sample included patients (medical, surgical and trauma patients), with a median saps ii of ( - ). ten patients had criteria of severe respiratory failure (pao /fio < ). twenty four fbo were done in the study period; for diagnostic reasons ( pulmonary infiltrates, hemoptysis and stridor), for therapeutic reasons (bronchial toilet) and to assist percutaneus tracheostomy. seventeen of our patients had risk factors for this procedure (bronchodilator therapy in patients, pao /fio < in patients, peep > cmh o in patient, platelet count < /mm in patient and altered coagulation screen in another). all exams were successfully concluded. the median procedure time was minutes ( - minutes). beyond sedation, exams were done with topical anaesthesia and with muscle relaxants. concerning safety, the exam was interrupted due to hypoxemia in one patient and due to episodic tachycardia in another patient, both concluded without major problems. two patients showed new pulmonary infiltrates in x-ray evaluation hours after the technique. no significant variation of the pao and paco were noticed during the first hour after the procedure. concerning efficacy, from broncho-alveolar lavage samples, were microbiology positive. one small-cell lung carcinoma was diagnosed by a bronchial biopsy. all these findings have therapeutic relevance. full pulmonary reexpansion was achieved after fbo in cases of lobar atelectasis. conclusion. implementation of a protocol and an individual risk assessment policy may improve safety of bfo in ventilated patients in icu. fbo contributes to valuable diagnostic information and is useful for therapeutic purposes. n. markou* , p. malamos , p. myrianthefs , i. alamanos icu-b, athens university school of nursing icu, kat hospital, athens, greece there is a scarcity of data on the effects on oxygenation of the position of the mixing tube relative to the t-piece and the venturi mask. some data show that while a mixing chamber positioned between the venturi mask and the t-piece is associated with improved oxygenation, positioning of the t-piece between the mixing chamber and the venturi mask has no effect on patients' pao ( ). yet there are no data on an alternative arrangement, with two mixing chambers, one at each end of the t-piece. we relate our experience with this arrangement. we studied critically ill patients who were either intubated or on tracheostomy and who although clinically stable and spontaneously breathing on a t-piece for at least hours could not be extubated. the patients initially (t- ) had one mixing chamber that was positioned between the t-piece and the venturi mask. after sampling of arterial blood gases, a second mixing chamber was inserted at the other limb of the t-piece and arterial blood gases measured again after a further minutes (t- ). patients in whom interruption of these arrangements (for administration of nebulized drugs or for endotracheal suction) was needed at the time period starting at minutes before t- and up to t- , were excluded from the study. during this time period fio for all patients was , . in all patients ( intubated and on tracheostomy) were studied. results are expressed as median and interquartile range. statistical analysis was performed with wilcoxon signed-rank test. there was a significant increase in pao from t- (median mmhg, %- % range - mmhg) to t- (median mmhg, %- % range - mmhg) (p = , ), with no significant change in paco , breathing frequency, arterial blood pressure or heart rate. a second mixing chamber adjusted to the limb of the t-piece opposite to the venturi mask is associated with significant improvements in oxygenation. presumably the second mixing chamber acts as a reservoir with high-content oxygen mixture, and this might be beneficial, especially in patients with higher peak inspiratory flows. percutaneous dilatational tracheotomy (pdt) is one of the procedures more frequently performed at the patient bedside in icu. airway control is usually maintained through an endotracheal tube (ett) but a laryngeal mask airway (lma) can be successfully used as well ( , ). lma ensures a high quality fiberoptic view of laryngotracheal structures; furthermore mechanical ventilation is easier and more uniform with lma than with an ett withheld at vocal folds level. potential disadvantages of lma are the risk of inhalation and a failed ventilation in case of oedematous airway. methods. icu patients were scheduled for pdt in the last three years. all pts were admitted to pdt after a - hours fast time from enteral nutrition. predictive anatomic and anthropometric parameters or history of difficult airway were considered. in case of suspected difficulties in airway management, an evaluation laryngoscopy was made. if tube removal was considered possible, a lma, proportional to body weight, was positioned. the following parameters were registered: • classification of fiberoptic laryngeal view through lma • uniformity of inspired/expired tidal volumes during mechanical ventilation • trends of pco and po during whole procedure by seriated blood gas analysis • need of lma repositioning or its substitution with an ett during the procedure • suspect or clinical evidence of airway inhalation • chest x-ray after pdt results. in patients lma positioning was unsuccessful; in patients lma did not allow an adequate ventilation due to a increasing laryngeal oedema evident at fob endoscopy. in these cases the ett was soon repositioned. in other patients ventilation was maintained thorough lma but an increase in pco higher than % was registered during procedure. in all the other patients we had no problem neither in lma positioning nor in mechanical ventilation. in all our population we did not have any difficulty in airway management. no cases of airway inhalation were registered. conclusion. in our experience lma is an effective and successful ventilatory device during pdt. it improves the quality of endoscopic view, makes easier tracheal puncture and allows a more uniform ventilation. it is important to remember that, before removing ett, we must always evaluate the risks related to full stomach and to the presence of a difficult airway. single dilator technique is increasingly used for percutaneous tracheostomy ( ). although complications have shown a decreasing trend, there remains a concern that the posterior tracheal wall damage can occur during tracheostomy tube placement over a loading dilator. the lip between the loading dilator and the tracheostomy tube tip often causes an obstruction requiring greater force which may be responsible for posterior tracheal wall damage. the percutan tracheostomy set ( tracoe medical, gmbh, frankfurt) claims to overcome this problem by having a tracheostomy tube-loading dilator assembly with a collapsible silicone sleeve covering the tip of the tracheostomy tube. we were interested to evaluate this in practice. a total of patients scheduled for elective pdt were enrolled in this open prospective observational clinical trial. assent was obtained from the immediate relatives. patients were excluded if they had unidentifiable anatomy, severe coagulopathy, a history of difficult tracheal intubation or required significant levels of ventilatory support ( fio > . or peep > cmh o). experienced operators conversant with pdt techniques performed the procedures whilst the airway and bronchoscopy were maintained by an anaesthertist. the trachea was punctured in all cases between the nd and rd tracheal rings and dilated using the percutan single rhino dilator. the tracheostomy tube-loading dilator assembly was then inserted. the ease of tracheostomy tube insertion was graded by the operator on a scale of - , being extremely difficult and extremely easy. all complications were recorded during the procedure. a total male and female patients aged ± years (mean±sd) were enrolled. patients were ventilated for . ± . days (range - days) before tracheostomy. the operating time was . ± . minutes (range - minutes). stoma dilatation and placement of a size tracheostomy tube was successful patients. other two cases required a second dilatation before tracheostomy tube placement. average grade of tracheostomy tube placement was median (range - ). the operators stated that the force required to place the tracheostomy tube was less than that required with other single dilator manufacturers kit. there were no serious perioperative complications and blood loss was estimated for all cases between - ml except in one patient surgical ligation of a venous bleed was required. no significant difference was seen in pre and post tracheostomy arterial blood gases. this study suggests that the percutan tracheostomy set allows a single step dilation of tracheal stoma and relatively easier placement of tracheostomy tube. further randomised controlled trials are warranted to assess its advantages over the other singe dilator techniques. nebulizers designed for use with oxygen or air require high flows of heliox to create aerosol in the respirable range. this aerosol is not well characterized for standard nebulizers and the high flow of heliox is costly. the objective of this study was to characterize the performance of a new breath enhanced nebulizer designed for use with heliox ( / ) gas and compare it to an industry standard breath enhanced nebulizer. using a malvern spraytec laser difractor we measured the aerosol particle size (vmd), total output rate (tor), respiratory fraction (rf) and calculated the respiratory drug delivery rate (rddr = tor x rf). heliox flows of and lpm were used and normal saline was nebulized. we performed trials with each flow. a pari lc plus reusuable breath enhanced nebulizer was used for comparison at lpm source gas flow. table . a novel active humidification system has been developed which can heat and humidify dry therapeutic gases during mechanical ventilation. this study measures the ability of this in-line humidification device (pari hydrate , pari respiratory equipment, midlothian, va, usa) to heat and humidify gas during mechanical ventilation. the new technology (c-force ; pari respiratory equipment) produces water vapor from an in-line, small device placed proximal to the circuit 'wye' in the inspiratory line. a controller allows precise water vaporization and heating directed into the gas flow. this study was performed to determine the performance of this humidification device for mechanical ventilation. we used a puritan bennett mechanical ventilator under various settings to produce minute ventilation volumes of , , , . , and . litres. our test lung (quick lung, ingmar medical, pittsburg, pa, usa) was set to normal lung settings to simulate cp= . l/cm h o and ra= cm h o/l/s. the disposable c-force was inserted into the ventilator circuit inches proximal to the patient wye. gas temp and relative humidity (rh) were recorded at the patient wye using an electronic thermometer and hygrometer. the source gas was dry medical air; measured at % rh and oc. ambient temperature was . oc and relative humidity was . %. although the amount of water and the temperature are adjustable with this device we used a constant temperature setting of oc and the calculated water setting that would saturate the volume of gas using minute ventilation. no attempt was made to optimize the temperature and humidification of the gas beyond these settings. patients were similar in terms of demographics,type of admission and reason for intubation. the overall incidence of severe life-threatening complications was significantly lower in the after group than in the before group ( % vs. , p< . ) (fig ). the implementation of eti management protocol permitted to decrease the incidence of severe life-threatening complications in icu patients. ( , ) . the aim of this study was to review the tracheostomy practice and to determine if either technique was associated with better outcomes in the setting of an inner city general hospital. we identified patients who had had tracheostomies over a / year period (may -dec ) by using our institution's icnarc (intensive care national audit and research centre) database. the case notes of these patients were examined in detail. we divided the patients into two groups (st and pt) depending on method of tracheostomy insertion. patient age, sex, weight and apache score were recorded. we collected figures on icu length of stay (los) and icu & hospital mortality. we also compared the following data: duration from intubation to tracheostomy, time from clinical decision to actual procedure, size of tracheostomy tube inserted and number of tracheostomy days. high flow gas therapy is a new therapy which has been shown to reduce intubations, ventilator days and non-invasive ventilation. the purpose of this study is to determine the efficacy of a novel humidification device (pari hydrate tm g) for high flow gas therapy and compare it to current high flow oxygen humidification devices. we compared aquinox (smiths medical ), mr (fisher & paykel), i (vapotherm) and pari hydrate (pari respiratory equipment). each device was setup as per manufacturer's instructions to heat and humidify medical air at flow of lpm. temperature settings were adjusted to c. we recorded warm-up time from "on" to highest stable temperature when set at c, exiting gas temperature, maximum device surface temperature, and water condensate. water condensate was obtained from a condensation tube connected to outlet side of the devices and measured after minutes. temperature of the condensate tube water was set at c. ( ) suggest that, in patients liberated from mechanical ventilation (mv), the persistence of the tracheostomy tube at discharge from icu to the ward may increase the post-icu mortality rate. our objective was the confirmation of this hypothesis with close attention to selection biases as confounding by indication, patients characteristics and the prognosis at icu-discharge ( ). prospective observational study in the general -bed icu of a tertiary hospital without a step-down unit. inclusion criteria: patients tracheostomized in our icu during a -month period without neurological damage. exclusion criteria: patients tracheostomized before icu-admission, tracheostomies for difficult to control airway, and patients with "do-not-resucitate" orders. data collection: age, gender, comorbidities, severity of illness at icu admission, admission category, indication for tracheostomy, length of icu and hospital stays, length of mv, need for aspiration and characteristics of respiratory secretions, and glasgow coma scale (gcs) at icu-discharge. patients with tracheostomy tube were discharged only to wards with specific "tracheostomy care protocols" with a nurse-to-patient ratio of : - . statistical analysis: multivariate logistic regression analysis adjusted for age, gender, body-mass index (bmi), severity of illness and diagnosis at icu-admission, indication for tracheostomy, duration of mv, glasgow coma scale, need for aspiration and characteristics of respiratory secretions at icu-discharge. lung recruitment (rm) can be considered as an adyuvant for lung protection in the ventilatory support of ards patients. the recruitment pressures needed to achieve full lung recruitment in these patients are generally above cmh o. however little is known about the hemodynamic effects of the brief application of pressures beyond this level in ards patients when using a sequential cycling recruitment maneuver. we , ) that were± mmhg; lis , ±present six ards patients (pao /fio managed with a global lung protective ventilation (lpv) strategy. we used trans-esophageal echocardiography (tee) to assess the effects of a rm using increasing levels of pressure. after confirming hemodynamic stability with predefined criteria, patients were submitted to a cycling sequential rm in pressure controlled ventilation that included three consecutive pip/peep levels of / , / and / cmh o each one of them maintained for min and followed by a min period of pressure reduction to / cmh o before the next pressure level was explored ( ). data were collected during the second minute of each recrutiment step. after rm, lpv was reinstituted: vt - ml/kg and a peep level adjusted to a level immediately above maximum dynamic compliance obtained during a decremental peep trial after recruitment ( ). all patients could be mmhg). no significant decreases in mean±fully recruited (pao + paco systemic arterial pressure (less than % during maximal intrathoracic pressure) and in heart rate were observed. tee measured left (lv) and right (rv) cardiac output (co) and systolic volume (sv) decreased significantly only at rm pressures of and cmh o (around and % respectively). recovery to baseline levels occurred within minutes after reducing the airway pressures (table) . central venous pressure increased progressively to a maximum of % of the baseline value at maximal rm pressures. we hypothesized that patients in acute (arf) on chronic respiratory failure (crf) have complex acid-base disorders and that stewart's quantitative approach may be useful to make the situation clearer. in this approach, plasma ph is dependent on independent variables: strong ion dissociation (sid), total weak acid negative charge (atot) and paco . in a prospective observational study, arterial plasma from consecutive patients with crf, obstructive and restrictive, admitted to our medical icu in arf between november , and april , were studied. they were compared with those from patients with ards admitted to our icu in the same period. in addition, values in patients were compared with those in normal subjects from the literature( ). the plasma values were taken from the samples obtained at icu admission (d ), d and d . arterial blood gas, electrolytes, lactate and albumin were measured and the following variables computed: sid = hco − + albuminate (alb-) + phosphate (pi-)) from reference ( ), strong ion gap (sig) computed from reference ( ), atot= (alb-)+(pi-). the values (mean±sd) were compared using anova (table ) . there was no effect of time on the variables and, therefore, the values in table correspond to icu admission. for statistical similar ph between crf and ards, paco was higher in obstructive crf than ards. sid was not different between crf and normal subjects but greater in crf than in ards, as was sig. atot was lower in ards than in obstructive crf. in crf patients, low ph mostly resulted from hypercapnia without metabolic alkalosis on average. in ards patients, acidemia is mostly metabolic. the positive sig expresses accumulation of unmeasured anions. ( ) open lung approach has been based on a lower inflection point (lip) and an upper inflection point (uip) of the pressure-volume (p-v) curve. but we cannot always find out them, so we examined the method to get maximal compliance point in stead of uip and lip from static compliance curve. in ten patients with ards(ards group) and twelve non-ards patients (control group), we found a maximal compliance point by the static compliance curve induced by differentiation of the pressure volume curve led by polynomial approximation of scattergram of plateau pressure and tidal volume. in the ards group the compliance at the range from to cmh o were smaller than that of the control group (p< . ). but there was no difference between the maximal compliance point of the ards group and that of the control group ( . ml/cmh o at . cmh o vs. . ml/cmh o at . cmh o). we conclude that maximal compliance points were detected in all patients by this method and there was difference of the compliance between the ards group and the control group in low pressure range. p. kopterides* , i. i. siempos , a. armaganidis critical care department, attikon university hospital, department of experimental surgery, "evangelismos" hospital, critical care department, "attikon" university hospital, athens, greece prone positioning is increasingly used to improve oxygenation in patients with hypoxemic respiratory failure, especially those with acute respiratory distress syndromeacute lung injury. however, its benefits in regard to clinical outcomes are uncertain. we performed a systematic review and meta-analysis of the pertinent randomized controlled clinical trials to assess at what extent prone positioning has an effect on mortality and various clinical outcomes in patients with hrf. we conducted a systematic literature search of medline, current contents, and cochrane central register of controlled trials (from inception to january ). we included only rcts(in which prone positioning was the applied intervention and supine positioning the control treatment) that reported clinical outcomes in patients with hrf. there were no language restrictions. four trials met our inclusion criteria, including patients randomized to prone and patients to supine ventilation. data were extracted independently to assess intention to treat intensive care unit (icu) and hospital mortality, days of mechanical ventilation, length of stay, incidence of ventilator-associated pneumonia and pneumothorax, and associated complications of the implemented intervention. data were also collected to assess the quality of the included studies. the pooled odds ratio (or) for the icu mortality in the intention-to-treat analysis was . (confidence interval . - . ), for the comparison between prone and supine ventilated patients. interestingly, the pooled or for the icu mortality in the selected group of the more severely ill patients favored prone positioning (or . ; ci . - . ). the duration of mechanical ventilation and the incidence of pneumothorax were not different between the two groups. the incidence of ventilator-associated pneumonia was lower, but not statistically significant, in patients treated prone compared with patients treated supine (or . ; ci, . - . ). however, prone positioning was associated with a higher risk for development of pressure sores (or . ; ci, . - . ) and a trend for more complications related to the endotracheal tube (or . ; ci, . - . ). despite the limitations of the meta-analysis (ie the included studies were heterogeneous in terms of design, case mix, report of outcomes etc), the available evidence suggests that prone positioning has no discernible effect on mortality in the general population of patients with hypoxemic respiratory failure. it may decrease the incidence of ventilatorassociated pneumonia at the expense of more pressure sores and complications related to the endotracheal tube. however, some data imply that the more severely ill patients may benefit most from the intervention and await confirmation from adequately powered and designed clinical trials. in severe acute respiratory distress syndrome (ards), short-term high frequency oscillation (hfo) and tracheal gas insufflation (tgi) improves oxygenation relative to both standard hfo and ards network conventional mechanical ventilation (cmv)( ). we hypothesized that hfo-tgi may improve pulmonary function indices relative to cmv, if repeatedly employed on a daily basis. thirty adult patients with severe ards {pao /inspired o fraction (fio ) < mm hg at peep > cm h o}were randomized to receive either low tidal volume cmv ( - ml/kg predicted body weight) alone or in combination with daily, - -h-lasting hfo-tgi until resolution of severe ards or death. primary end-points were the time courses of gas exchange, respiratory mechanics, and hemodynamics. survival to days following randomization was also evaluated. data from all patients were analyzed. patient clinical profiles were similar. median hfo-tgi use was h/day for days. within the first eight days following randomization, study (hfo-tgi) group patients vs. controls had higher pao /fio ( . - . ± . - . mm hg vs. . - . ± . - . mm hg; p < . - . ) and quasistatic respiratory system compliance, and lower oxygenation index ( . - . ± . - . vs. . - . ± . - . ; p < . - . ), shunt fraction, and plateau and mean airway pressures. hemodynamics were not significantly affected by hfo-tgi. there was a trend toward improved -day survival in the study group vs. control ( / vs. / , p = . by fisher's exact test). in severe ards, the systematic daily use of hfo-tgi substantially improves gas exchange and respiratory mechanics. pressure-volume (pv) curve could help knowing which patient can benefit from a recruitment manoeuvre (rm). this study has been design to compare the hys of the quasi-static pv curve and the volume recruited by a rm. after ethical approval and relatives informed consent, early onset (< h) ards patients were investigated (igs ii = [ - ], lis = , [ , [ ] [ ] [ ] ] ). patients were sedated and paralyzed throughout the study. a to cmh o pv curve (pv tool, hamilton medical) was realized to measure hys i.e. the surface between the inflation and deflation curve measured between and cmh o. after min of ventilation, a rm consisting of a seconds pause at cmh o was realized using the pv tool. the volume recruited during the seconds/ cmh o rm was obtained by integration of the flow signal necessary to maintain the pressure of cmh o. no correlation was found between the lower/upper inflection points and the point of de-recruitment on the deflation limb of the pv curve. the volume recruited during a pause at the end of the inflation curve was well correlated with hys (r = , ; p = , ) (figure). in the early course of ards, the hys of the pv curve may be an indicator of how much the lung can be recruited by a seconds/ cmh o rm. treating acute respiratory failure (ali/ards) in the icu often requires mechanical ventilation, which carries a risk of vili. it is now commonly accepted that these patients should be ventilated "gently", i.e. reducing transpulmonary pressure fluctuations during ventilation. it is however still much debated as to how peep should be applied. methods to identify "best peep" are based upon descriptions of respiratory mechanics. however, only little is known as to how changes in peep modify pulmonary gas exchange. pulmonary gas exchange is usually described by arterial blood gas analysis or over-simplifying models such as the pao /fio ratio, the alveolar-arterial oxygen difference or the effective shunt. we describe the use of a more complex two-parameter model ( ) describing the effects of a peep-change using routine icu equipment. this method has potential for non-invasive use and may be incorporated in standard respiratory monitoring. eleven adult patients with acute respiratory failure on mechanical ventilation were included in the study. the patients were studied at two different levels of peep, i.e. either increasing or decreasing peep with cmh o. on each occasion the fio was varied in - steps to achieve values of sao ranging from - %. at each fio level measurements were taken of ventilation and arterial acid base and oxygenation status. these data were then used to estimate pulmonary shunt (shunt) and a measure of ventilation/perfusion mismatch, i.e. deltapo . upon increasing peep shunt decreased significantly by % (median) in patients, whereas deltapo improved in patients by kpa (median). as assessed by the p/f ratio oxygenation improved in patients by kpa (median). the increase in p/f ratio was, however, in cases explained by decreased deltapo not shunt. in patients where p/f-ratio was unchanged the value of shunt decreased significantly. the results suggest that by describing gas exchange by shunt and deltapo additional information can be obtained. these information may enable improved assessment of potential for recruitment and/or peep optimization. further studies are warranted. optimal peep avoids ventilator induced lung injury. this study determined the value of the elimination time-constant for co (tau-co ) to assess optimal peep. methods. pigs received lung lavage and hrs of injurious mechanical ventilation. a recruitment maneuver (rm) was performed for ' at / cmh o of peep/plateau pressure. the open lung peep (ol-peep) was defined as the level of peep after rm that kept the lung free from collapse. ol-peep was determined by respiratory dynamic compliance (cdyn), during a peep titration trial using the open lung tool ® (maquet, sweden), which was performed in vcv at a vt of ml/kg while decreasing peep from to cmh o in steps of cmh o every ' ( ). thereafter, we randomly assigned six ' periods at diff. peeps: ol-peep and peep either cmh o above or below it both, in recruited and non-recruited conditions. baseline ventilation was applied between study periods. we recorded dynamic lung mechanics and volumetric capnography data on a breath-by-breath basis (nico, respironics, usa). abg data were collected at the end of each period. paco was added to volumetric capnography to perform a complete dead space analysis using the standard bohr-enghoff formula. tau-co was calculated multiplying the respiratory time constant (cdyn x raw) by the amount of co eliminated per breath (vtco ,br). lung mechanics and gas exchange were best at ol-peep after rm. tau-co was longest at this moment due to an increase in both, cdyn and vtco ,br. the increase in cdyn and the decrement in raw slowed down peak expiratory flow during ol-peep ventilation. a reduction in vdalv/vtalv after rm and ol-peep indicated an increased ventilatory efficiency ( ) . vdalv/vtalv was more sensitive for determining ventilatory efficiency than the classical vd/vt. positive pressure ventilation in patients suffering from acute lung injury (ali) affects both, the distribution of ventilation (v) and perfusion (q) within the lungs. the aim of this work was to study the effect of lung recruitment and peep on v/q as assessed by multiple inert gas elimination technique (miget). a recruitment maneuver (rm) was performed for ' at / cmh o of peep/plateau pressure. the open lung peep (ol-peep) was defined as the level of peep after rm that kept the lung free from collapse. ol-peep was determined by respiratory dynamic compliance (cdyn), during a peep titration trial using the open lung tool ® (maquet, sweden), which was performed in volume control at a vt of ml/kg while decreasing peep from to cmh o in steps of cmh o every ' ( ). thereafter, we randomly assigned six 'periods at diff. peep levels: ol-peep and peep either cmh o above or below it both, in recruited and non-recruited conditions. baseline ventilation was applied between study periods to standardize lung volume history. we recorded dynamic lung mechanics on a breath-by-breath basis. hemodynamic data were recorded continuously and discont. by the picco monitor (pulsion, munich, germany). miget and abg data were collected at the end of each study period. ventilation at ol-peep after a rm resulted in better oxygenation and lung mechanics, lower shunt and lower amounts of areas with a high v/q as compared to the other periods studied (table) . recruited lungs ventilated at ol-peep showed better gas exchange and ventilatory condition than any other condition studied. these findings show that rm in conjunction with ol-peep make ventilation and perfusion more homogeneously distributed within the lungs and lead to an adequate matching of both. the onset mechanism of ali/ards and subsequent tissue injury are considered to be associated with neutrophil elastase, and the main two causes( direct lung injury: group d. and indirect lung injury: group i) of ali/ards are considered to be pneumonia ( bacterial, fungal, viral et al), aspiration pneumonia and sepsis. in japan, sivelestat sodium hydrate, a selective elastase inhibitor, was approved in for ali/ards accompanied by sirs, and this medicine has been evaluated in clinical situation. in this study, we performed a retrospective comparison of the sivelestat sodium hydrate administration between two groups of patients: group d, consisting of patients ( males and females, aged ± years old) , and group i, consisting of patients ( males and females, aged ± years old) with ali/ards accompanied by sirs who were treated with sivelestat sodium hydrate at a dose of . mg/kg/hour for hours or more in the icu. il- , il- , elam- (endothelial leukocyte adhesion melucule- ), pai- (plasminogen activator inhibitor- ) and pct (procalcitonin) were measured every hours. elisa and eia methods were used for the measurement of il- , pai- and elam- , respectively, and icl method was used for pct. the apache ?scores of group d and group i were ± and ± , and the lung injury score(lis) were . ± . and . ± . , respectively, with no significant differences between the groups. sofa scores of group d and group i were ± and ± , which was significantly higher than that of group d (p< . ). the pao /fio ratios under mechanical ventilation management , and hours after the beginning of drug administration were ± , ± , and ± mmhg in group d, and ± , ± , and ± mmhg in group i. furthermore, the survival rate after days was significantly higher in group d than in group i (group d: . %, group i: . %, p< . ). these results suggest that sivelestat sodium hydrate is a good option as a treatment strategy for neutrophil elastase-associated direct lung injuries accompanied by sirs. grant acknowledgement. no disclosure pulmonary edema significantly contributes to ventilation-perfusion mismatching and hypoxemia in ards. while inhaled nitric oxide (ino) has been shown to lower pulmonary pressures and edema accumulation in experimental acute lung injury (ali)( ), its clinical use has been questioned because of a lack of improvement in outcome, rebound phenomena and potential toxicity. we investigated the effects of aerosolized iloprost, a stable prostacyclin analogue, compared to ino on pulmonary pressures and lung edema in oleic acid lung injury. the most effective dose of iloprost in this setting was determined in healthy animals prior to the experiment. the anesthetized and ventilated sheep received a central venous oleic acid infusion ( . ml/kg) and were continuously infused with ringer's lactate to achieve a positive fluid balance ( ml/kg/h). in the ino group (n= ), inhaled nitric oxide ( ppm) was then administered continuously for hours, while animals in the iloprost group (n= ) received aerosolized iloprost ( µg every hours). animals in the control group (n= ) had no further intervention. pulmonary edema was measured by transpulmonary thermodilution (extravascular lung water). oleic acid infusion was associated with impaired oxygenation, pulmonary hypertension, and lung edema in all groups. while ino significantly decreased pulmonary vascular resistance index (pvri), effective pulmonary capillary pressure (pceff), and extravascular lung water index (evlwi), both parameters were unaffected by iloprost. oxygenation index (pao /fio ) increased significantly both during no and iloprost inhalation but also tended to improve in the control group over time. conclusion. this is the first study directly comparing the effects of inhaled nitric oxide and aerosolized iloprost on pulmonary hemodynamics and lung edema in experimental lung injury. in contrast to ino, µg iloprost inhaled every hours was ineffective to reduce pulmonary pressures and extravascular lung water. these findings partly contradict previous investigations, and may be best explained by dissolution of the highly water soluble iloprost in alveolar edema, which is a common finding in oleic acid lung injury. much higher doses of iloprost may thus be required to achieve a reduction of pulmonary pressures and fluid filtration when alveolar edema is present. while inhaled nitric oxide (ino) may be used in the management of ards, data would suggest that its benefits pertain to a short-term improvement in oxygenation with no significant beneficial effect on mortality . we performed a retrospective audit on the use of ino in our mixed medical and surgical intensive care unit. the following data were collected; age, apache ii score, length of icu stay, duration and cost of ino therapy, percentage change in pao /fio ratio, icu mortality. patients were sub-divided into responders/non-responders and survivors/non-survivors. a response to ino was defined as > % increase in pao /fio ratio . results are displayed in the table below. five responders survived to icu discharge ( . %), while non-responders survived ( . %). this difference did not reach statistical significance (p = . , chi-square). the total group costs of ino for responders, non-responders, survivors and non-survivors were £ , , £ , , £ , and £ , respectively. responders only accounted for % of the total ino expenditure in our icu. conclusion. ino is an expensive therapy. in this small retrospective audit we were unable to show any significant benefit of ino on outcome. the use of ino within our icu needs to be reappraised, especially in those ards patients classified as non-responders. the pvm tool of the respirator was easy to use. we observed no clinically evident haemodynamic complication. as a consequence of the pvm peep was increased in patients from ± to ± cm h o and decreased in patients from ± to ± cm h o. peep was not changed in two patients. there was a significant increase in pao /fi o ratio from ± to ± (p= . ) ( figure) while the change in paco was not significant ( ± versus ± ; p= . ). changes in peep did not correlate with changes in paco (r = . ; p= . ). after the implementation of the pvm into commercially available respirators, this manoeuvre can be performed safely and quickly. the setting of peep according to the results of the pvm lead to an improved oxygenation of the patients. we conclude that patients with ali/ards may profit from a routinely performed pvm. introduction. ards is a common syndrome with a high mortality rate in intensive care units. several pharmacological therapies have been proposed but none of them improved survival up to now. pulmonary hypertension occurs already in early stages of the disease and its magnitude has been shown to be associated with poor outcome. the phosphodiesterase type inhibitor sildenafil selectively dilates pulmonary vessels and has been approved for treatment of pulmonary arterial hypertension.. we investigated the effects of oral sildenafil in combination with inhaled prostacyclins in five patients with ards and septic shock. five patients with severe ards were investigated. underlying diseases were: copd (n= ), small airway disease (n= ), idiopathic fibrosing alveolitis (n= ), as well as cardiac insufficiency (n= ). four patients showed severe obesity, mean bmi was , ( ± , ). all patients fulfilled criteria of septic shock, three of them developed acute renal failure requiring continuous venovenous hemofiltration. all patients were monitored by a pulmonary artery catheter. mechanical ventilation was carried out according to recommendations of the ards-network. prone positioning (at intervals of hours) was instituted if possible. inhaled prostacylins (iloprost) were given times daily (max. concentration µg/d). if no persistent improvement of oxygenation could be achieved, sildenafil was added per os ( x mg/d). the combination of oral sildenafil ( x mg/d) and inhaled prostacylins resulted in a significant decrease of the mean pulmonary arterial pressure (pap-m). on the third day of therapy pulmonary arterial pressure was reduced by about % of the initial value (table ) . within a week a % improvement of the horowitz indices could be achieved. administration of sildenafil was continued in four patients until they could successfully be weaned from mechanical ventilation. these four patients left hospital alive. one patient died because of cardiogenic shock. , ± , * * significant difference from day (p < , ) conclusion. sildenafil in combination with inhaled prostacyclins causes significant reduction of pulmonary arterial hypertension as well as significant improvement of oxygenation in patients with ards and septic shock. increasingly the mouse has become the experimental animal of choice in immunological research because of the large set of immunological tools that is available. this is of particular interest in the area of inflammatory and immunological response to mechanical ventilation. most available rodent ventilators only ventilate one mouse at a time. in order to expedite the results of interventions, larger series of mice must be ventilated in a short period of time. therefore, we developed a method to ventilate mice simultaneously using a conventional ventilator. twelve mice were anesthetised, tracheotomised and subsequently connected to a servo ventilator c with a distribution system allowing simultaneous ventilation of six mice. a canula was inserted into the carotid artery for bloodsampling. for consecutive hours the mice were ventilated in a pressure-controlled, time-cycled mode, pip cm h o, peep cm h o, i/e ratio of : , fio . and a frequency of /min. during the hours of ventilation, arterial bloodgasses were collected after various periods of ventilation, with a maximum of bloodsamples per individual mouse. (n= ) not only demonstrated normocapnia (paco . ± . ) but also a normal ph (ph . ± . ) and adequate oxygenation (pao . ± . ). six mice can be ventilated simultaneously using a servo ventilator c with a distribution system, thereby decreasing the number of days spent to the experimental procedure and expediting experimental time. pulmonary vascular permeability increases in response to lung overstretching. phosphoinositide -kinase gamma (pi k gamma) is activated by mechanical stretch. akt, a major downstream signal molecule of pi k gamma, induces nitric oxide (no) production. we investigated the contribution of pi k gamma to acute alveolar edema formation by mechanical stretch. in wild type (wt) and knock-out (ko) pi k gamma mice, lungs were ventilated and perfused with two settings: eip - cmh o and eep cmh o (stress) or eip - cmh o and eep - cmh o (no stress). at the end of each experiment histological alveolar edema, lung elastance, pulmonary expression of erk, akt, enos, nitrate/nitrite (nox) on pulmonary perfusate were measured. see table . data are mean ± sd. during high stress ventilation vascular permeability changes were pi kgamma, akt, enos mediated. the lack of pi k gamma activity protected from alveolar edema increases. recent experimental data suggest that intrapulmonary cxc chemokine release, neutrophil infiltration and myeloperoxidase activity is considerably increased in aged individuals [ ] . years represented the best age threshold value that discriminated survival in mechanically ventilated patients [ ] and, we speculated that inflammatory responses may differ considering this age threshold. in patients bronchoalveolar lavage (bal) was performed with aliquots of ml . % saline on initial hospital presentation within hours after multiple trauma. cytokines were quantified using a sandwich immunoassay and neutrophil secretion products were determined with immunoluminometric assays. bal-phospholipids were determined with electrospray ionization mass spectrometric analysis. we compared older (> years, n= ) with younger patients (< pg/ml) (n= ) using the mann-whitnes-u-test or fisher's exact test and used the spearman rank correlation to assess relations between inflammatory parameters and age. older patients (mean±sd, . ± . years) had similar injury severity scores, thoraxtrauma severity and pao /fio -values as compared to younger patients ( . ± . years) (p> . ). of the older and of the younger patients developed ards (p> . ). only one patient died days after trauma. he was years old and developed ards due to sepsis weeks after trauma. intraalveolar il- release and both pulmonary and systemic neutrophil activation as reflected by myeloperoxidase and lactoferrin concentrations were reduced in older compared to younger patients (p< . ). pulmonary inflammatory parameters decreased significantly with increasing age: bal-neutrophils (rho=- . , p= . ), the inflammatory cell membrane phospholipid phosphatitylinositol : / : (rho=- , , p= . ), bal-lactoferrin (rho=- . , p= . ) and bal-il- (rho=- . , p< . ). in contrast to experimental data proinflammatory responses were reduced in aged individuals. it is tending to speculate that reduced immune competence instead of exacerbated inflammation may contribute to worse prognosis seen in the aged given an inflammatory insult. design: prospective, randomized controlled study. setting: medical and surgical intensive care units in a university tertiary care centerpatients: a total of patients with localized ards ready for recruitment maneuver (rm) were included. intervention: patients were randomized to receive mechanical ventilation (mv) in supine (smv, control group) or in prone position (ppmv, study group). both groups were ventilated with protective lung strategy (tidal volume to ml/kg). an rm was applied using a pressure control mode (pcv) with a cm h o and a cm h o peep for s. peep was subsequently reduced by cm h o increments until a decrease in compliance was observed. a second rm was then performed and peep was set one step above the level at which compliance declined. pcv level was kept at cm h o during the determination of optimal peep. results: bronchoalveolar lavages (bal) and blood samples were collected before randomization and at hours to determine the concentrations of interleukine (il- ), interleukine (il- ), interleukine (il- ) and tumor necrotic factor (tnf-±), pao / fio . pao /fio was improved and paco was lower in ppmv when compared with smv with statistic significance. at hours after rm, il- ( p = . ), il- ( p = . ) and il- ( p = . ) in bal was lower in the ppmv group than smv group. the serum level of il- ( p = . ) and tnf-± ( p = . ) were reduced with statistic significance and il- was reduced also (p = . ) for the ppmv group. conclusion. ppmv may improve oxygenation and reduce pco than in the smv position in patients with the localized ards during rm. the pro-inflammatory cytokines can be reduced during ppmv, which indicates attenuation of vili during pcv with peep recruitment maneuver for these patients. grant acknowledgement. this research is sponsored by the grants of vghnsu - . inflammatory cytokines have been found to be elevated in bronchoalveolar lavage fluids (balf) of ards patients. mediators formed from n- fatty acids (fa) and those developed from n- fa have opposite influences upon inflammatory processes. the aim of this study was to investigate whether n- fa may modulate inflammatory cytokines release in a cell culture of human pneumocytes exposed to balf of ards patients. thirty-one patients ( males, ± yr, sapsii ± ) with ards (as defined by the american-european consensus conference) requiring mechanical ventilation were included in the study. the p. were divided into those with pulmonary ards [ardsp, pneumonia (pn) n= ], and those with extrapulmonary ards (ardsexp, sepsis n= ; other n= ) without pn. all p. were examined by bal for clinical purposes within h after intubation. tnf-alpha, il- beta, il- and il- levels were measured in balf. we exposed a cells, a human pulmonary cell line with type ii pneumocyte properties, to the collected balf. after h, fa were added as docosahexaenoic acid (n- ) and arachidonic acid (n- ) in two different n- /n- ratios ( : and : ). h later, culture supernatants were collected to evaluate cytokine and prostaglandin (pg)e release. the fa percentage content was determined in phospholipids of a cells. level of peroxisome proliferator-activated receptor (ppar)gamma and nf-kb binding activity were determined. cytokine levels in balf were found higher in ardsp than ardsexp (p<. ). the baseline n- /n- fa ratio of : in a cell phospholipids approximately dropped to : and raised to : after : n- /n- ratio and : ratio incubation, respectively. we found that pge levels were significantly lower in a cells treated with the : ratio than those with : (p<. ). the release of cytokines from a cells was reduced by the : ratio (p<. ), but increased by the : (p<. ). nf-kb activity was induced in a cells by balf. addition of : ratio to the cells resulted in an increased expression of ppargamma, whereas nf-kb activity was more inhibited compared to : (p<. ). our results showed that increasing the n- share in n- /n- fa ratio induces a significant reduction of pro-inflammatory mediator (cytokines,pge ) release in stimulated a cells, whereas the administration of an n- fa predominance increases their release. although different cytokine levels in ardsp vs. ardsexp, the cause of ards did not influence the effect of n- addition. fa are ligands for ppargamma. our results suggested that n- fa might exert their anti-inflammatory effects through direct actions on the intracellular signaling pathways which lead to activation of ppargamma and inhibition of nf-kb activity. inflammatory response in a cells exposed to balf can be modulated by n- fa, due to their incorporation into membrane phospholipid pools that modifies lipid-related intracellular signaling events. th esicm annual congress -berlin, germany - - october s type plasminogen activator inhibitor (pai- ) is one of the primary regulators of fibrinolysis in vivo. a - g- g sequence polymorphism in the promoter of the pai- gene has been described as response polymorphism, since its release is regulated by various inflammatory factors. elevation of pai- levels after stressful events is much more pronounced in patients with the g allele. thus, the formation of microthrombi is no longer counteracted by the fibrinolytic system, resulting in impaired microcirculation, multiple organ dysfunction and poor outcome. our aim was to study the impact of the g allele on the survival rate of ali-ards patients. methods. ali-ards ( ali) due to sepsis ( ), pneumonia( ), aspiration ( ), severe trauma ( ), cardiac surgery ( ), pancreatitis ( ) and pulmonary embolism ( ) were studied. the mean apache ii score was ± . identification of the g- g polymorphism was based on polymerase chain reaction and reverse-hybridization. the comparison of the death rates between the two polymorphism groups ( g g versus non- g g group) was done by means of a logistic regression model, with survival as the dependent variable and the polymorphism, as well as the apache score, as the independent variables. . patients died (mortality . %). patients had a genotype g- g, patients were g- g heterozygous, while were g- g homozygous. apache scores were not significantly different between subgroups. the death rate among the g- g patients was %, while in the non- g- g patients was %. the univariate analysis showed that the g- g patients had % higher odds of dying compared to the non- g- g patients (odds ratio = . , % ci: . to . , p-value= . ). in the multivariate analysis the g- g patients had approximately . times higher odds of dying compared to the non- g- g patients (odds ratio = . , % ci: . to . , p-value= . ). however results were not statistically significant. our findings suggest a negative effect of this polymorphism on the survival odds of ali-ards patients. however, the small number of patients limited our power to detect a statistically significant difference regarding its influence on the prognosis of ali-ards patients with disorders triggering the coagulation cascade. our data might support further research on the relation between g- g polymorphism and outcome of ali-ards patients. excessive production of nitric oxide by neuronal nitric oxide synthase (nnos, nos- ) is one major factor in the pathogenesis of acute lung injury and systemic inflammation after burn and smoke inhalation injury. we hypothesized that the use of the selective nnos inhibitor -nitroindazole ( -ni) will block molecular mechanisms in ovine acute lung injury. adult ewes (n= ) were chronically instrumented to determine cardiopulmonary hemodynamics and pulmonary transvascular fluid flux. after seven days of recovery, sheep were randomly allocated to either an injured untreated control group (n= ), or an injury group treated with -ni (n= ). the injury consisted of a % total body surface area flame burn and breaths of cotton smoke. -ni ( mg/kg/h) was continuously infused from h post injury to the end of the -h study period. this double hit injury was associated with oxidative stress, severe pulmonary derangements and systemic inflammation, as evidenced by a . -fold increase in plasma nitrite/nitrate (nox) levels, as well as -fold, -fold, -fold and -fold increases in interleukin- (il- ), myeloperoxidase (mpo), malondialdehyde (mda) and poly-adp-ribose-polymerase (parp) lung tissue concentrations, respectively. compared to untreated controls, -ni significantly reduced nox plasma levels ( . ± vs. ± µmol/l) and decreased il- , mpo ( . ± . vs. . ± . u/g tissue), mda ( . ± . vs. . ± . nmol/mg protein) and parp lung tissue content ( . ± . vs. . ± . ), thereby decreasing pulmonary obstruction ( . ± . vs. . ± . obstruction score) and increasing pao /fio ratio ( ± vs. ± , each p< . ). these data show that nnos-derived no plays a pivotal role in the pathophysiology of combined burn and smoke inhalation injury and suggest selective nnos inhibition as a useful approach to attenuate pulmonary injury. h. qiu*, p. li, y. yang department of critical care medicine, nanjing zhong-da hospital, nanjing, china hpmecs were cultured, and used lps with a gradient concentration ( ng/ml, ng/ml, ng/ml, and ng/ml) to stimulate the cells for h, h, h, and h. subsequently, the experiments below were carried out. total ribonucleic acid was extracted from the cells for reverse transcription polymerase chain reaction (rt-pcr) to identify the expression level of angii receptor mrna. the total protein was extracted from the adhere cells for western blot to identify the protein expression of the at receptor. radioreceptor assay (rra) was used to obverse the affinity (kd) and maximum receptor binding (bmax) of angii with its receptor after lps stimulation. rt-pcr demonstrated that angiotensinii type (at ) receptor mrna level escalated after varying concentrations lps stimulating in h, h, h and h. there was obvious time-dependent increase in ng/ml group. the level of the at receptor mrna in ng/ml and ng/ml groups have not time-dependent increase. irrespective of lps stimulating or not, hpmecs didn't express mrna of angiotensinii type receptor (at ). western bolt presented that the protein level of at receptor had a predominant increase followed the lps treat compared with control group ( ng/ml). after stimulated for h, the level of at receptor protein reached to the peak value in ng/ml group, and no notable difference was defined at every time after that. the significant dose-dependence was showed in every stimulating time, but the time-dependence was defined just in ng/ml and ng/ml groups. rra was confirmed that there was no striking statistics difference between each group for kd. as far as bmax is concerned, bmax of the three groups ( ng/ml, ng/ml, and ng/ml) had a significant increase compared with the control group. the groups of ng/ml and ng/ml had peak value at h and h respectively, and had a significant decrease after respective peak value time. the bmax of the ng/ml group escalated to the peak value and demonstrated a notable time-dependence. lung ischemia and reperfusion in the pulmonary vascular compartment is an unavoidable consequence of transplantation. it is associated with release of inflammatory mediators promoting chemotaxis and adherence of neutrophils, which finally disrupt endothelial cell layer and increase permeability, possibly leading to acute lung injury ( ). rare data exist about similar mechanisms in the upper and lower respiratory compartment with tracheobronchial (tbec) and alveolar epithelial cells (aec). purpose of this study was to evaluate the effect of hypoxia/re-oxygenation (h/r) regarding the inflammatory response in the respiratory compartment. aec and tbec were placed in a hypoxic incubator with % oxygen for hours and re-oxygenated at % oxygen during , , and hours. for each time point, control cells were left at % oxygen. supernatants were analyzed performing a sandwich enzymelinked immunosorbent assay (elisa) for mcp- and cinc- (pharmingen, san diego, ca). caspase- and ldh measurements were performed. statistical significance was assessed by student's t-test. (values: mean ±sem). protein expression of mcp- and cinc- in aec was decreased upon h/r: at h hypoxia with h re-oxygenation mcp- decreased fromm ± pg/ml to ± pg/ml (p< . ), cinc- from ± pg/ml to ± pg/ml (p< . ). at h/ h h/r no difference in mcp- and cinc- expression could be observed in comparison to control cells. interestingly, inflammatory mediators released from tbec did not show any differences upon stimulation compared to control cells. caspase- activity in stimulated and unstimulated aec was similar. in tbec, however, caspase- activity was decreased by % at h/ h h/r, at h/ h by %, and at h/ h by % (p< . ). ldh values did not differ in stimulated and unstimulated aec and tbec, indicating that no process of necrosis is involved. upon h/r the lower respiratory compartment with aec reacts with decreased production of inflammatory mediators, while the upper compartment with tbec shows diminished apoptosis rate. biological significance of this attenuation of epithelial injury upon h/r has to be further investigated. , . : - grant acknowledgement. société suisse d'anesthésiologie et de réanimation schweizerische gesellschaft für anästhesiologie und reanimation: ssar/sgar methods. ards was induced in healthy pigs ( ± kg) by repeated saline lung lavage until pao decreased to less than mmhg. after a stabilisation period, the animals were randomly assigned to two groups: cmv: fio = . , vt = ml/kg, and hfov/av-ecla: fio = . , frequency = - hz. after lung recruitment, the peep in the cmv group and the mean airway pressure (mpaw) in the hfov/av-ecla group was set cmh o above the lower inflection point (lip) of the p/v-curve. gas exchange and hemodynamic data were determined hourly. after h, mrna expression of tnf-alpha, il- -beta, il- , il- and il- in lung tissue was quantified by real time pcr. histopathologic analysis from the lungs was performed using a four point semi-quantitative severity based scoring system. ( ). h s also exerts a variety of cytoprotective effects in vitro and in vivo ( ) . therefore, we tested the potential cytoprotective effect of infusing the h s-donor nahs during porcine thoracic aortic occlusion-induced ischemia/reperfusion(i/r)-injury. methods. after random assignment to either nahs (n= ); mg/kgxh started h before and continued until h after aortic occlusion) or vehicle (n= ) anesthetized, ventilated and instrumented pigs underwent min of aortic occlusion using inflatable balloons placed immediately downstream the a.subclavia and upstream the aortic bifurcation. during aortic occlusion, mean arterial pressure (map) was maintained between - % of the baseline levels using continuous i.v. esmolol, nitroglycerine and atp. during the reperfusion continuous i.v. noradrenaline (na) was titrated to maintain map> % of the baseline level. dna damage in blood samples was evaluated with single cell gel electrophoresis (tail moment in the comet assay). data are median (range), within group effects over time were analyzed using a friedman anova on ranks, intergroup differences with an unpaired rank sum test. results. infusing nahs resulted in significantly lower heart rate and cardiac output, while map and stroke volume remained unchanged. nahs significantly reduced the na requirements needed to achieve the hemodynamic targets, significantly decreased glucose turnover, and completely blunted the i/r-induced dna damage (see septic shock is associated with increased oxidative stress, which in turn depresses mitochondrial activity. the key antioxidant enzyme superoxide dismutase (sod) was reported to restore mitochondrial function ( ). since glucose oxidation represents the most effective energy generating process, we investigated the effect of genetic cuzn-superoxide dismutase overexpression on glucose oxidation in a clinically relevant model of murine septic shock ( ) . h after sepsis induction by cecal ligation and puncture (clp) or sham-operation heterozygous (he), homozygous (ho) sod overexpressing and wildtype (wt) mice were anesthetized, mechanically ventilated and instrumented. in the clp groups normotensive, hyperdynamic hemodynamics were achieved with colloid fluid resuscitation and intravenous noradrenaline (na) titrated to maintain mean arterial pressure (map) > mmhg. glucose oxidation rate was calculated from simultaneous determination of co enrichment and co concentration (gas chromatography/mass spectrometry) in the expired gas during continuous i.v. stable-isotope , , , , , - c -glucose infusion. measurements were recorded , and h after clp. within group effects over time were analyzed using a friedman anova on ranks, intergroup differences with an unpaired rank sum test. all parameters of gut and liver macro-and microcirculatory perfusion and oxygenation were well maintained. na infusion rates did not differ between clp groups. glucose oxidation (percentage of the infused c -glucose) did not differ between groups nor over time. liver sod-activity prior to anesthesia and surgery was . -fold and -fold higher in he and ho mice, respectively. while it decreased by about % in the septic he and ho mice, sod activity was not significantly affected in the wt animals. given the comparable parameters of macro-and microcirculatory perfusion and oxygenation, the lacking na-induced increase in glucose oxidation rate confirms the sepsis-related defect in energy metabolism. the higher tissue sod-activity did not restore the impaired carbohydrate utilisation, possibly due to a sepsis-related loss of tissue sod and/or catalase activity. anemia is frequent in icu and involved both functional and true iron deficiency due to inflammation and blood loss. hepcidin (hepc) is a negative regulator of iron recycling by macrophages. its synthesis is highly inducible by inflammation and repressed by iron deficiency and stimulation of erythropoiesis. we explored iron metabolism and hepc gene expression in this complex situation of icu anemia. we developed a model of inflammation in c bl/ mice, by ip injections of zymosan (z), combined or not with repeated blood withdrawals (w). we followed blood numeration and tissue iron concentrations. using qrt-pcr, we quantified hepc and il- mrna in the liver as well as erythropoietin (epo) mrna in the kidney (normalised to s mrna and expressed as a ratio to controls (c)). hepatic ferroportin protein concentrations were assessed by western-blot. kruskal-wallis or anova were used for comparisons of mean±sd. p< . significant. anemia was found already days after zymosan injection, and was more severe blood withdrawals, either alone (w) or following z (z+w). at day , epo mrna expression was stimulated in both w ( . ± ) and z+w ( ± . ), as compared to c( ± . ) or z ( . ± . )(p< . ). as expected, z injection induced il- mrna expression ( . ± . for z; . ± . for z+w). interestingly, hepc mrna was induced following z injection ( ± . ) but the combination of inflammation and w repressed hepc mrna expression ( . ± . ). to confirm that it was due to erythropoiesis stimulation, we injected epo on consecutive days following z and found that it prevented activation of hepc mrna( . ± . ). in mice undergoing w or epo injections, spleen iron was reduced, as opposed to c and z ( ± , ± , ± , ± vs ± and ± µg/g for z+w, w, z+epo, epo, c and z). ferroportin was reduced in z and increased by w and epo (western-blot). conclusion. in this mouse model of inflammation, induction of hepc gene expression is prevented by repeated w or epo ip. it seems that the signalling pathway which represses hepc expression in response to activation of erythropoiesis dominates over the pro-inflammatory signal. furthermore iron exporter ferroportin is also induced. these results raise the possibility that iron supplementation might be proposed for critical care patients' anemia. studies examining the effect of glutamine supplementation in critical illness have demonstrated significant beneficial effects in animals and man although the mechanisms by which this protection occurs are not understood. we aimed to examine the effect of various glutamine concentrations on the ability of c c myoblasts to differentiate and its effect on heat shock protein expression (hsp). methods. c c myoblasts were raised under standard conditions. differentiation to multinuclear myotubes was induced by replacing fcs with % horse serum. cells were supplemented with glutamine at concentrations between and mm throughout and this was replaced every other day. photographs were taken at day of differentiation. hsp content of cells was determined using western blotting as described previously (maglara et al, ) . at low levels of glutamine ( - mm), cell survival was greatly impaired and differentiation was reduced. however hsp content of cells grown in media of . m and m glutamine showed an increased hsp response compared with cells grown and differentiated in physiological glutamine concentrations. no effect of higher glutamine concentrations (between . - mm) on cell viability or hsc and hsp content was evident. conclusion. glutamine supplementation affects heat shock protein (hsp) expression in various cell types. several authors have suggested that exposure of cells to relatively high concentrations of glutamine results in increased hsp expression and an enhanced cell survival (wischmeyer et al. ) skeletal muscle degeneration occurs following a number of insults and muscle repair is reliant upon activation and differentiation of stem cells or myoblasts to form mature multinucleated muscle. transgenic studies in our laboratory have demonstrated that the ability of skeletal muscle cells to produce hsps during stress and development is crucial to the correct maturation and functioning of these cells (mcardle et al, ) . our data suggests that the glutamine concentration for optimal myoblast proliferation and differentiation is ∼ mm. reduction below this value resulted in reduced cell viability and modified hsp although levels higher than physiological had little effect on cell growth and differentiation. this might suggest that reduced glutamine concentrations in it self acts as a stressful stimulus. further reduction however renders the cell unable to respond at all. in addition g regulation might be linked to other stress hormones, such as cortisol (c) and prolactin, in rats and humans in physiological conditions. our aim is to study the circadian variations of cortisol and ghrelin plasma levels in patients with acute coronary syndrome (acs) admitted to the intensive care unit. eight male ( ± years old) patients with acs were studied. seven showing non-st-elevation and one with st-elevation. within the first hours of admission, blood samples were taken every hours (nine samples) in all acs patients. patients were kept nothing per os during the sample drawing period. eight patients admitted in the department of internal medicine in a stable clinical situation were studied on the day before being discharge, as control group. g and c levels were measured in all samples using specific ria (phoenix pharm. usa). control subjects showed a cortisol circadian rhythm with peak values at : a.m. ( , ± , mcg/dl) and nadir values around : p.m. ( , ± , mcg/dl). in this patients g levels also present circadian variations, with peak values at : a.m. ( , ± , pg/ml) and nadir values at : p.m. ( ± , pg/ml). in contrast, patients with acs showed a very demised c circadian rhythm, and the amplitude of the circadian variations of g levels is markedly reduced, showing a shift of the peak values to : p.m.( , ± , pg/ml ) and nadir values around : a.m. ( , ± , pg/ml). there is a circadian rhythm of ghrelin with a peak ranging from : a.m. to : a.m. in hospitalized subjects. those variations are o shifted in phase respect to cortisol rhythm. opposite, in patients with acs the circadian variations of ghrelin levels are lost. the results of lft of patients admitted to the general intensive care unit of a large teaching hospital in south london, between st december and th february were obtained from the chemical pathology department. mortality statistics were obtained from the hospital electronic patient record. lft of patients who were readmitted were excluded. a total of patients had a first admission to the general icu during the three months studied. the average age was . yrs (sd . ), % were male and the mean length of stay was . days (range - ). mortality rate at days was % ( / ). at the time of admission only ( %) patients had entirely normal lft. patients with cholestatic lft above the normal range on admission were more likely to be female (akp odds ratio: . ( . - . ), gammagt or: . ( . - . )). abnormalities in alt, akp and gammagt on admission, were associated with a higher likelihood of death at days (table). average length of stay was greater in those with abnormal lft but only reached statistical significance with akp above the normal range (table) . conclusion. abnormality of liver function tests is common in the critically ill patient admitted to the general intensive care unit. even relatively minor elevations of lft are associated with an increased risk of death within days. the cause of these abnormalities is likely to be multifactorial and further studies are needed to elucidate the cause. myxedema coma with extreme hypothermia: a case report e. brands* intensive care, academisch ziekenhuis maastricht, maastricht, netherlands a patient is presented with an undiagnosed hypothyroidism which progressed to myxedema coma with extreme hypothermia, bradycardia, anaemia and somnolence. a year old male patient, with a history of hypertension and a cerebral vascular accident, was admitted to the emergency room after a collapse. during several months he showed progressive disability due to fatigue, unstable gait and chilliness. the last weeks his condition worsened leading to muscle weakness, dysarthria, dysphagia, cognitive dysfunction and somnolence. upon physical examination we saw a somnolent patient with a gcs (glasgow coma scale) of - - , with hyporeflexia and pareses of the lower extremities. respiratory rate of per minute. blood pressure was / with a heart rate of beats per minute. the patients temperature was . oc. the patients gcs decreased to - - upon which an endotracheal tube was placed and mechanical ventilation instituted. laboratory tests showed a haemoglobin . normal adrenal function test. one day after thyroid hormone substitution ( µgr t intravenously on day one, followed by µgr t once a day, µgr t orally every hours on day one only), the patients regained consciousness. his heart rate increased to beats per minute after normalisation of body temperature. gastroscopical evaluation showed an ulcus duodeni. despite of a ventilator associated pneumonia the patient recovered well. hypothyroidism may lead to a variety of symptoms ranging from malaise and fatigue to specific organ related complaints. especially in the elderly the symptoms may be mistakenly attributed to the physiological aging process, psychiatric, neurological illnesses or even dementia. numerous precipitating factors can evolve untreated hypothyroidism to myxedema coma. in our patient infection, cold exposure, gastro intestinal bleeding or iron deficiency could have played a role. the elderly patient is already prone to hypothermia due to physiological changes, in myxedema this may lead to an extreme low temperature. myxedema in its classical, full clinical presentation is a rare occurence in present times. especially in the elderly patient it can cause pronounced hypothermia. according with surviving sepsis guidelines we must control blood glucose levels to a less than mg/dl after h of admission to an icu. objectives: to evaluate the results obtain with the use of an intensive insulin treatment (iit) in a polyvalent intensive care unit. we conducted a prospective cohort study in a -bed polyvalent icu in a portuguese university hospital. adult patients who were assumed to require at least days of intensive care were eligible for inclusion. the study was carried out during months. capillary blood glucose (cbg) levels were measured on admission and subsequently every two or four hours in all patients during days. with the iit, insulin infusion was started when the blood glucose level exceeded mg per decilitre. we enrolled patients, age: , ± , ( , ), sapsii: , ± , ( , ), sofa: , ± , ( , ), length of stay in icu: , ± , ( , ), mortality rate: . %. , % of the patients were diabetes. incidence of hypoglycemia - , %. to examine the effect of central venous catheter (cvc)location on the incidence of catheter related blood stream infection (crbsi) in a total parenteral nutrition (tpn) population over a -year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . . bed university hospital. tpn population includes all medical and surgical patients hospital-wide referred for tpn. service based in intensive care. tpn committee meets quarterly to examine prospectively collected data. . cvcs were included. we compared incidence in different anatomical locations(figure). femoral cvcs were rarely used for tpn and so were excluded. subclavian cvc insertion was associated with a peak incidence of crbsi of per cvc days in which dropped to in . peak incidence of crbsi in internal jugular cvcs was per cvc days in , per cvc days in . this study prospectively examines the effect of anatomical location on crbsi. crbsi in subclavian cvcs remains almost consistently lower than internal jugular throughout study. this correlates with published data in the literature and cdc recommendations for use of subclavian site in preference for cvc insertion . patients after urgent abdominal surgery require adequate nutritional support. we aimed to assess the effectiveness of parenteral nutrition (pn) by "all-in-one" system with adding of glutamine to eliminate metabolic disturbances in patients after small bowel obstruction surgery. methods. patients after small bowel obstruction surgery (mean age . ± . years) was divided into groups. control group (n= ) received standard basic intensive therapy including pn by "all-in-one" system "oliclinomel" in first hours after an operation. glutamine group patients (n= ) received additional glutamine (dipeptiven - ml/kg/day). plasma whole protein and its fractions, amino acids spectrum, transferrin concentration, glucose and insulin levels, as well as standard laboratory and instrumental data were assessed before, at rd and th day of pn. in all patients metabolic disturbances with protein status shifts was revealed. dynamic analysis of data showed faster compensation of these disturbances in glutamine group. in both groups whole protein and albumin/protein ratio decreased gradually while amino acid sum, essential and nonessential amino acid concentration, glucose and insulin levels remained normal. by th day glutamine group showed faster increasing of transferrin concentration ( . ± . g/l vs. . ± . g/l) and fisher index ( restoration of metabolic activities confirms adequate nutritional support in both groups but glutamine adding provides faster improvement of protein disturbances and helps to avoid glutamine deficiency. y. kang* , h. jiang , x. qiang , x. jin , q. yi icu, general surgery, respiratory, west china hospital of sichuan university, chengdu, china to investigate the effect of supplementation with alanyl-glutamine dipeptide on insulin resistance and outcome in critically ill copd and respiratory failure patients. prospective, randomized and controlled study. patients who were admitted to west china hospital icu between jan and feb were selected and randomized into two groups which were given the similitude nutrition support protocol. two groups' nonprotein calorie were kcal/kgd, % were provided by fat emulsion. the nitrogen supply were . g/kg in each group. in treatment group %- % of nitrogen was given from the parenteral nutrition by the alanyl-glutamine dipeptide, the rest was the equilibrium amino acids. in the rd and th day, blood glucose clamp were performed in both groups, and blood glucose was rigidly controlled between . to . mmol/l. daily blood gas, glucose and insulin dosage and th day mortality , length of stay (los) in hospital and in icu, duration of mechanical ventilation (dmv) and the costs of icu and hospital were measured respectively. . patients completed the research. there was no difference in blood gas between two groups, but pao rose gradually. compared with control group, the five day's blood glucose level have a decreasing trend in treatment group. during the five days, the average insulin dosage have an obviously decreasing in treatment group. there were no difference between two groups in th day mortality, los in hospital and the costs of hospital. but the los in icu and dmv have a decreasing trend in treatment group. alanyl-glutamine dipeptide have not improved pulmonary function in critically ill patients with copd and respiratory failure. however, alanyl-glutamine dipeptide have contained certain function at attenuated insulin resistance and stabilized the level of blood glucose. alanyl-glutamine dipeptide did not reveal the effect of improving outcome in critically ill patients with copd and respiratory failure, the th day mortality, los in hospital and the costs of hospital. but the the los in icu and dmv have a decreasing trend in treatment group. adrenocortical dysfunction is a common finding in severe illness. however, it remains currently unclear whether adrenocortical responses predict outcome in acute critically ill patients. to investigate this, ( men) acute critically ill patients, with a median age of years were studied. admission diagnoses included multiple trauma (n= ), medical (n= ) or surgical (n= ) critical conditions. within hours of icu admission, a morning blood sample was obtained to measure baseline cortisol, corticotropin (acth), and dehydropiandrosterone sulphate (dheas). subsequently, a low-dose ( mcg) acth test was performed to determine stimulated cortisol. the incremental rise in cortisol was defined as stimulated -baseline cortisol. overall, patients survived and patients died. non-survivors were older and in a more severe critical state, as reflected by the higher sofa and apache ii scores. furthermore, non-survivors had a lower incremental rise in cortisol ( . vs. . mcg/dl, p< . ) along with lower dheas than survivors ( vs. ng/ml, p= . ). the two groups had similar baseline and stimulated cortisol. multivariate logistic regression analysis revealed that age (odds ratio= . , % c.i. . - . , p= . ), sofa score (odds ratio= . , % c.i. . - . , p< . ), and the incremental rise in cortisol (odds ratio= . , % c.i. . - . , p= . ) were independent outcome predictors. in mixed critically ill patients a blunted cortisol response to acth within hours of icu admission is an independent predictor for poor outcome. in contrast, baseline cortisol or adrenal androgens are not of prognostic significance. teicoplanin is a gycopeptitide antibiotic for treatment of highly resistant gram-positive bacteria such as methicillin resistant staphylococci and enterococcus faecalis. it is eliminated unchanged by the kidneys. in renal impairment the maintenance dose has to be reduced. data on pharmacokinetics of teicoplanin in patients requiring continuous veno-venous haemofiltration (cvvh) are sparse. therefore teicoplanin pharmacokinetics was assessed in critically ill patients during on cvvh. teicoplanin serum levels were measured in adult critically ill patients requiring cvvh for acute renal failure after the first dose and at approximate steady state conditions (day - of therapy). cvvh was performed using . m polyetersulfone membranes; blood flow was ml/min and the ultrafiltration rate amounted ml/kg body weight. a loading dose of , mg of teicoplanin was administered (infusion time h). subsequently the dosage was guided by serum levels and reduced to an average daily dose of ± mg per day. samples were drawn , , , , and h after start of infusion. teicoplanin was measured by a fluorescence polarisation immunoassay in serum and ultrafiltrate. pharmacokinetics was calculated using a non-compartmental model by kinetica . concentration time profiles of patients were determined after the first dose and of patients during steady state. the teicoplanin peak concentration was . ± . µg/ml (mean sd) after the first dose and . ± . µg/ml at steady state. trough levels amounted . ± . µg/ml and . ± . µg/ml, respectively. the half-life increased from . ± . h after the first dose to . ± . h at steady state, whereas the clearance declined from . ± . l/h to . ± . l/h. the apparent volume of distribution decreased from ± to ± l. the sieving coefficient of teicoplanin amounted . after the first dose and . after repeated administration. a loading dose of , mg of teicoplanin followed by a maintenance dose of about , mg per day appears to result in adequate serum levels in a majority adult critically ill patients on cvvh. however, because of a considerable variability of teicoplanin pharmacokinetics in this group of patients, therapeutic drug monitoring is recommended to warrant safety and efficacy of treatment. although heparin is the most frequently used anticoagulant in cvvh, alternatives to heparin are needed in case of heparin induced thrombocytopenia (hit). argatroban, a direct thrombin inhibitor approved for hit is primarily metabolized by the liver, thus, should not accumulate in renal failure. however, there is only limited data regarding its use in continuous venovenous hemofiltration (cvvh). we report a patient with acute renal failure where anticoagulation by argatroban appears to be influenced by cvvh. a years old woman was admitted to the icu department with septic shock and acute renal failure. bilateral infected crural ulcers could be identified as focus and therefore both calves had to be amputated. after days of cvvh with heparin as anticoagulant a rapid drop in platelet count of more than % occurred, a suspected hit was confirmed by heparin-pf antibodies (elisa). although there was no hepatic failure argatroban was started at mg/h ( , µg/kg/min) because of cholestatic cholecystitis and severe sepsis. results. aptt increased from to seconds after hours of argatroban infusion and further to sec after hours (figure ). at the same time pt fell from % to %. therefore argatroban dose was reduced by % to , mg/h. after h cvvh had to be stopped for h. after discontinuation of argatroban a decrease in aptt from to sec, as well as an increase in pt from to % was observed. h after argatroban was restarted at , mg/h, cvvh was stopped again for , hours without discontinuing argatroban. shortly after cvvh was halted aptt increased from to sec and pt decreased from to % within hours. this trend continued even after stepwise reduction of the dose of argatroban to , mg/h. the trend could not be reversed until the dose was further reduced to , mg/h and argatroban was stopped. after restarting cvvh without argatroban infusion a further decline in aptt as well as an increase in pt was observed. conclusion. this case demonstrates that argatroban may be influenced by cvvh and that dose may have to be substantially reduced in these patients. regional citrate anticoagulation (rca) is the recommended strategy when risk of bleeding is increased in continuous venovenous hemofiltration. we evaluated the feasibility and the safety of this method in high volume hemofiltration (hvhf) in critically ill patients with severe coagulopathy. methods. patients ( ± years, saps ii ± , sofa . ± . , septic shocks and sirs) have been retrospectively studied between january, and december, . continuous renal replacement therapy, daily limited to hours, was performed with a frésénius hdftm generator. blood flow was ml/min. the generated replacement fluid, calcium free, was used in pre-dilution. a citrate solution (acdar-fréséniustm) was infused to target a prefilter ionised calcium level below . mmol/l whereas systemic calcium perfusion maintained normal plasmatic calcium level. hemofiltration characteristics, filters lifetime and metabolic complications were the main collected data. . hfhv days ( filters needed) were analysed. mean hemofiltration volume was ml/kg per hour (about l per hour or l per day). percent of the prescribed hfhv dose could be carried out. mean filters lifetime was . hours. percent of them prematurely clotted. citrate and calcium perfusion flow respectively needed to be modified an average of and , time per day. metabolic alkalosis (ph> . ), hypocalcemia (ca++< . mmol/l), hypercalcemia (ca++> . mmol/l), hypernatremia (na+> mmol/l) and one citrate intoxication (total to ionised calcium ratio> , ) occurred. none of these events lead us to modify the anticoagulation strategy. prefilter ionised calcium level in non clotting filters was , ± , mmol/l versus , ± , mmol/l in clotting filters (p= , ). % of the patients died in hospital whereas predicted mortality was %. conclusion. rca is a reliable and simple method for hvhf with high hemorrhagic risk patients. frequent minor metabolic complications require a narrow biological monitoring. to improve our practices, prefilter ionized calcium levels should be decreased. continuous venovenous hemofiltration(cvvh) or hemodiafiltration (cvvhd) are the commonest renal replacement therapies(rrt) prescribed to the patients with the septic shock having renal failure. each cvvh session for hours costs around e in india as against intermittent hemodialysis(ihd),which costs around e per to hour session. hence ihd is still the commonest form of rrt in indian icus. major concern of ihd in septic shock patients is hemodynamic instability. whether stringent hemodynamic monitoring and maintaining preset goals would reduce these instabilities & deliver optimal rrt is not clear. we undertook a prospective study to evaluate this concept. we attempted to achieve preset goals of keeping mean arterial pressure (map) > mm, cardiac output (co) > lit./min & cardiac index (ci) > . lit./min/m throughout the session by following the protocol in the given sequence-: ) fluid boluses ) increase in vasopressor or inotrope dose ) adjustment in ultra filtration rate between - ml/hr and )adjustment in blood flow rate between - ml/min on hemodialysis machine. dopamine, norepinephrine, vasopressin and dobutamine were used alone or in combination to achieve these goals. hemodynamic monitoring & data collection was done with flotrac-vigileo monitoring systemtm (edwards lifesciences,irvine,ca,usa) and intellivue mp (philips,germany). . ihd sessions of patients with septic shock needing vasopressor were monitored and managed in icu. base line apache ii score was . ± . and all patients had at least organ failure. average duration of ihd was . ± . hrs and net negative fluid balance achieved per ihd session was . ± . ml. table showing hemodynamic parameters before ihd and during ihd preset goals were maintained without any intervention in sessions, with fluids alone in sessions, fluids and escalation of vasopressor in sessions and fluid bolus plus vasopressor escalation plus reduction in ultra filtration & blood flow in sessions. only / sessions were terminated at & min. due to development of new myocardial infarction in one and persistent hypotension in the other. additional cost of c. o. and c.i. monitoring was aboute per session. continuous veno-venous haemofiltration (cvvh) clears solutes and improves acidosis in critically ill patients with renal failure and sepsis. we studied solute clearance and filtration quantity prospectively in the first hours of patients requiring cvvh on two teaching hospital intensive care units. data collected included demographic data, reason for starting cvvh, blood biochemistry prior and after starting cvvh as well as duration of cvvh, including reasons for any interruptions. blood tests were collected once in a -hour period. data was collected for the entire period that patients required cvvh. solute clearance on cvvh within the first hours was expressed as a percentage change of urea and creatinine levels compared with levels prior to cvvh. quantity of haemofiltration was calculated over the interval between the first two blood tests and expressed in relation to bodyweight. data from patients is presented ( patients died before blood samples on cvvh was taken). the main indication for commencing cvvh was sepsis/acidosis in patients and renal failure in patients. the values for urea and creatinine on admission differed considerably between both groups. patients with sepsis/acidosis received a median cvvh-dose of . mls/kg/hr, whereas patients with renal failure were treated with a median cvvh-dose of . mls/kg/hr. table shows the respective median values for urea and creatinine prior to cvvh and from the first sample on cvvh, as well as the median (interquartile range;iqr) cvvh dose delivered in the period between the two samples. ( ) . we therefore studied the effect of anticoagulation on cvvh delivery. over a four month period data from patients across adult intensive care units was recorded. the number and reasons of interruptions and subsequent time lost as well as the type of anticoagulation was documented. infusion of heparin into the circuit was the primary form of anti-coagulation. heparin was started at units/kg/hr and adjusted according to local protocol to achieve a target heparin ratio (aptr) of . - . . aptrs taken from the circuit within the previous hours were defined to represent the degree of heparinisation at the time of a filter clotting off. a total of . patient hours of cvvh was delivered. filter clotting was implicated in of interruptions ( %). table shows the various forms of anticoagulants used, the number of interruptions and total time lost due to filter clotting. in the heparin group, aptrs were recorded. only % of these were therapeutic and % were sub-therapeutic. aptrs were recorded within the hours prior to filter clotting, representing % of all clotting events occurring on heparin. clotting events occurred with a therapeutic aptr, with recorded subtherapeutic ratios (relative risk . ), and event with an aptr > . filter clotting is by far the most common cause for interruptions in cvvh delivery ( %). adequate anticoagulation of cvvh circuits with heparin is problematic and failure to achieve the terget aptr carries a considerable risk of filter clotting. % of ap-trs were subtherapeutic despite use of a written protocol, suggesting that many patients are exposed to an increased risk of filter clotting regardless of other causative factors. whilst we recognise that the aetiology behind filter clotting is multifactorial, reducing these interruptions with adequate anticoagulation is important and may have positive effects on patient outcome. during continuous renal replacement therapy (crrt) anticoagulation of the extracorporeal circuit is generally required to prevent clotting of the circuit, preserve filter performance, optimize circuit survival, and prevent blood loss due to circuit clotting. unfractionated heparin (ufh) and low molecular weight heparin (lmwh) are generally used to perform this strategy. however, this anticoagulation may cause dangerous bleeding especially in acute renal critical patients. in these patients, it's very difficult to predict bleeding or thrombosis correctly during crrt. to asses the safety and efficacy of the use of an enoxiparin dose protocol based on anti-xa activity in crrt. methods. consecutive patients with acs was admitted to a coronary care unit of terciary hospital between [ ] [ ] patients presented heart failure during their hospitalization. clinical, ecg, echocardiographic, features were prospectively investigated. we also took blood samples in the first hours of their admittance to the ccu for a complete hemogram, levels of total cholesterol, hdl cholesterol, ldl cholesterol, triglycerides, creatinine, clearance of creatinine (mdrd equation), glucose, hbac , high sensibility-c reactive protein (hs-crp) and a follow up of levels of troponine, ck and ck-mb. we determined the presence of microalbuminuria (ma) (> mg/dl in a -hour urine sample). all patients were submitted to a coronary angiography in the first hours. we defined rd if the clearance of creatinine < ml/min/ . m . non-st segment elevation myocardial infarct (nstemi) was the most frequent cause of heart failure ( . %). the rd was present % of hf. the patients of this group was oldest, more diabetes mellitus, more previous myocardial infarct more anterior descendent occlusion. moreover, the patients with hf and rd had a lowest hematocrit ( % vs %), troponin i peak concentration ( . ng/ml vs ng/ml) and had higher of creatinine ( . mg/ml vs . mg/ml), ma, admission glycemia ( mg/dl vs mg/dl), nt probnp ( pg/ml vs pg/ml) and cystatin c ( . vs . ). both group present similar reduced ejection fraction ( % vs %). this group presented higher incidence of post infarct angina ( %; p= . ). in-hospital mortality was in patients with hf and rd % vs % in hf without rd (p= . ). in the follow-up (median days) the mortality of patients with hf and rd was % (p= . ). the mortality of the group with rd and treatment with ace-inhibitors was % vs % without ace-inhibitors (p= . ). the multivariate analysis identified the rd was a independent predictor of mortality in the patients with heart failure ( . ; p= . ) and the impact negative of rd was reduced by ace-inhibitors (or= . , ci % . - . ; p= . ). conclusion. the rd is common and a strong predictor of mortality in patients with hf complicating acute coronary syndrome. it is associated with a worse risk profile. ace-inhibitors improve the prognosis this group of patients. acute renal failure is a very frequent problem in the critically ill patients and contributes to their high mortality. the most frequent cause is sepsis,usually in the context of multiple organ dysfunction. the more prevalent admission cause in our arf patient were medical illness and pos-operative urgent surgery. the arf patients presented higher saps ii and initial sofa scores. the most common risk factor was shock;other factors frequently seen were sepsis,mod and rhabdomyolysis. the mortality rate measured was lower than that referred in the literature. following a needs-assesment, realistic acute-care simulations were designed using a modified delphi approach. didactic instruction was given regarding crm strategies including "the three c's of communication": clear instructions, citing names, closing the loop (eliciting feedback following instructions). teams of four: two physicians (a leader and an assistant);a pre-briefed critical-care nurse (rn) and critical-care respiratory therapist(rt), then responded to standardized simulation scenarios, delivered using a laerdal high-fidelity mannequin in a working critical care unit. we found insufficient crm skills on the first simulation (suggesting poor retention from didactic instruction alone) with gradual improvement following the three simulations (suggesting simulation offers a supplementary technique but may still be insufficient). we therefore made the team perform a fourth resuscitation, but with the physician-leader blindfolded. we found immediate/marked improvement in crm skills: physicians elicited help sooner and ensured instructions were completed. other members were quicker to volunteer changes in vital signs. debriefing confirmed that this novel approach was well received and participants reported enhanced understanding of the importance of teamwork. in the early stages of undifferentiated shock we are essentially "blind" to the diagnosis, and hence must rely on others. this strategy is also useful for trainees whose first language is not english: blindfolding forces them to focus on communication, with the result of increasing their confidence and reassuring supervisors. this technique allowed us to emphasize crm principles. we now expectat senior trainees to perform at least one blindfolded simulated-resuscitation. it is no longer an exaggeration to say our teams are "good enough to resuscitate blindfolded"! in current spanish population around % of people are over years of age. in our country, life expectancy is years. it is obvius that this population aging has modified some approachs in organs donation and transplantation process, forcing to include older people in waiting lists. the increase in the organs demand for transplantation has conditionated changes in the donor profile, therefore the evaluation, acceptance and rejection criteria of donors have been changing. the acceptance for older donors with associated comorbidity provide transplantations with acceptable results getting to reduce tranplant waiting lists and mortality. the consequence that arise from it is the concept of expanded criteria donor (ecd). we studied retrospectively donors from a hospital with no neurosurgery service from january to december , comparing donation potential between over and under years of age donors. . four of the donors younger than years (n: ) were not appropriate ( , %) whereas older than years (n: ) were ( , %) (p-ns). donors older than years provided kidneys and livers available for transplantation ( , % and , % of total organs, respectively) whereas younger than years group obtained kidneys and livers available ( , % and , % of total organs, respectively). number of useful organs per donors was , and , for younger and older than years donors, respectively (p: , ). conclusion. in our serie, age was not a predictor variable for hepatic usefulness whereas it was for renal usefulness. nowadays dce are indispensable and age can not be an exclusive factor in this donors evaluation. pct has many indications in icu patients, mainly prolonged mechanical ventilation / weaning difficulties and airway protection in comatose patients. the consensus conference on artificial airways in patients receiving mechanical ventilation recommended translaryngeal intubation for an anticipated need of up to days and a tracheostomy if an artificial airway for more than days is anticipated. however this decision should be individualized. the aim of this study is to analyse the indications and timing pct in our icu patients, and icu and hospital survival. we conducted a retrospective study, analysing patients submitted to pct, in months: since the technique was implemented in our icu in december , until march . we reviewed their age, gender, apache ii score, length of icu stay, ventilation time before and after pct, icu and hospital survival. patients were stratified in groups, based on the indication for the pct: prolonged mechanical ventilation (n= ) and airway protection in comatose patients (n= ). data was treated in spss programme, using the mann whitney test. the results presented are in mean values. conclusion. )the indications for pct in our icu were prolonged mechanical ventilation (n= ) and airway protection in comatose patients (n= ), a reduced sample size to analyse. )there was no significant difference in age ( years), gender, apache ii ( , ) and saps ii ( , ) scores. )comatose patients submitted to pct for airway protection had less ventilation days prior ( , vs , p= , ) and after ( , vs , p= , ) tracheostomy. their length in icu was shorter ( , vs , p= , ) . they had a lower hospital survival rate ( % vs , % p= , ), although there was no significant difference in icu survival. ) , % of patients submitted to pct due to prolonged mechanical ventilation were discharged alive from our icu, but only , % were discharged alive from hospital. recent literature suggests that early pct (in - days) could have had an influence on this high mortality hospital rate. )overall icu survival rate is %, but hospital survival is only % -a high mortality rate is seen after discharge from icu, in hospital wards. t. van galen*, o. p. groenendijk recovery room -high care, vu university medical center, amsterdam, netherlands introduction. the vu university medical centre (vumc) has chosen to integrate competence management (cm) within the human resource structure. functioning as an health care professional is not only about performing medical or nursing interventions. cm explicates not only knowledge and skills, but also attitude. cm contributes in developing abilities to cope with complex medical and nursing situations. cm is about managing professional behavior for reaching personal and organizational objectives. cm also contributes to an organization wide understanding of achieving the mission statement objectives. after introducing cm to the high care (hc) nursing staff, the set of (chosen) competences was integrated within the unit's mission statement (september ) . during team sessions competences were described to fit into the daily organizational and professional practice (october ) . personalizing cm is performed during an (competence based) assessment (december ) . strengths and weaknesses are determined. personal objectives are integrated within a defined educational and development structure guided by the clinical supervisor educator. although cm is relatively new in our organization and the return on investment is hard to determine, some results are clear. with cm observable behaviors were defined and thereby manageable, next to the set of nursing skills definitions (already defined as part of the primary training course and daily practice). increased employee responsibilities led to % more (non mandatory) training course attendance. during the hc nurse attended full training course hours. in the training course attendance increased to full hours for each hc nurse. with cm the relation between organizational and individual performance objectives is more clear. a prismant survey proclaimed decreasing sickness absence when cm is implemented. this result was confirmed on our ward. sickness absence decreased from > % to < %. because most of the personal development targets were easy to combine, the educational/training course budget was not exceeded. cm provides more different development levels, thereby individual talents are easier to discriminate. the employee satisfaction with cm is growing. conclusion. cm was successfully implemented on our hc unit within a month period. starting with a manageable package of competences the rollout strategy was easy to cope with for the hc supervisor and nursing staff. there are a few conditions the organization has to facilitate. cm must be integrated in the organization mission statement and adopted by hospital management. nursing supervising staff, including the clinical supervisor educator, must be capable to apply and practice cm. span of control and educational/training budgets must be fitted for applying cm. cm is a well manageable and applicable tool to increase and improve nursing outcomes. [ ] have shown immune modulatory effects. the alpha agonist dexmedetomidine produces sedation more analogous to nrem sleep compared to traditional agents [ ] . obstructive sleep apnoea and depression are known to alter both sleep architecture and immune function. we postulated that immune modulation could be produced by pharmacologically altered sleep pathways. methods. pvg hooded lister rats (harlan)were randomly allocated to midazolam, dexmedetomidine or sham infusions. all animals were instrumented with implanted telemetry week, and jugular lines day prior to the infusions. infusion rates were targeted to maintain deep sedation, mg/kg/hr for midazolam and . - mcg/kg/min for dexmedetomidine. infusions were commenced at am, and continued for hrs during the sleep phase, and recommenced hours later for a further hrs. animals were then given mg/kg ultrapure e.coli lps at am the following day. blood was taken every mins for facs and cytokine analysis. at mins post lps animals were sacrificed and their brains and lungs harvested. lungs were macerated and the samples were stained for ox and cd b and analysed by facs. there was no statistical significance difference between the groups at any time points for serum tnf,il- ,il- , crp, total blood pmn and monocytes, platelet-leukocyte aggregates. there was a non-significant trend to lower monocyte/neutrophil margination into the lung bed in the dexmedetomidine group. conclusion. in this underpowered study pharmacological manipulation of sleep does not produce immunoparesis in a rat model of icu sedation and sub-lethal endotoxaemia. from these data animals in each group would be required to detect a true difference. gut microbiota is a stable community with high biodiversity index and plays a key role in maintenance of health status. several factors of gut ecology alteration occur during the critical patients(pts) care:luminal hypoxia/hypercarbia, gastric-secretions inhibitors, vasoactive, sedation, nutrient/fiber scarcity, antibiotics, sepsis/injury, digestive surgery. ecological balance disruption of gut microbial community often results in reduced protection against pathogens,including opportunistic ones. we studied faecal microbiota changes in critical pts during icu stay. consecutive pts expected to need mechanical ventilation (mv) for> days were enrolled. exclusion criteria: hospital stay and/or antibiotic treatment before icu admission, opportunistic/autoimmune diseases, cancer/steroid therapy. faeces were collected at icu admission(t ) then weekly(t ,t ,t ). pts were excluded if t or t samples could not be harvested. total bacterial dna pattern analysis was performed by denaturing gradient gel electrophoresis (dgge). the % of similarity between the t -dgge profile and the following ones in each pt was used as index of microbiota modification. a similarity value > median at t versus t was defined as index of microbiota biodiversity preservation. new dominant dna bands were analyzed to identify bacteria species. . pts ( peritonitis, lung infections, cellulitis, meningitis, trauma) were enrolled. pts ( alive) were discharged before t , pts ( alive) before t , and pts ( alive methods. rfviia was used in adult patients aged between - (mean ± ) years average bmi . ± . underwent massive perioperative haemorrhage. all patients were admitted to icu with the diagnosis of sepsis or severe sepsis. all septic patients has been received da therapy within - hrs of icu admission. the following diseases were diagnosed: post abdominal surgery bleeding (severe sepsis after surgery: laparoscopic cholecystecomy, laparotomy due to peritonitis) - pts, gastrointestinal bleeding (severe sepsis in acute pancreatitis ) - pts, postpartum bleeding (septic shock in the course pyelonephritis and right hydronephrosis) - pts, intracranial bleeding (septic shock in pregnancy) - pts. we used the questioners of novo nordisk to asses the indications and effectiveness of treatment. we compared haemoglobin level, haematocrit, number of platelets and laboratory coagulation profile parameters before treatment, hours and hours after treatment. the dosage of rfviia was . ± . µg/kg. continuous iv mg infusion is effective for spasticity due to tetanus. compared to previous reports, our case series contributes meaningful additional data, as mg therapy was applied effectively for up to days without major toxicity, and all pts had good outcome. iv mg therapy has been proposed as first-line treatment for tetanus ( ), but the optimal dose and maximum duration of therapy are unknown. we believe that iv mg is a promising treatment option but, until more data are available, it should be reserved for carefully selected tetanus cases. observational, prospective, multicenter study in which patients admitted to the icu during the periods of the envin study for the years and were included. the following rates as markers of quality were defined: ) rate of amc use, ) rate of directed treatments, ) overall rate of changes in the amc used for therapy, ) rate of amc change due to inappropriate treatment, ) rate of amc change due to adjustment of treatment or deescalating therapy, ) rates of use of selective digestive decontamination (sdd), and ) duration of prophylaxis of cefazolin, amoxicillin-clavulanate, and cefuroxime. data of all variables in and are compared. high rate of use of antimicrobials in the icu. twenty-five percent of antimicrobial agents were used as directed therapies and in % of cases, antimicrobials were changed. changes for inappropriate treatment decreased, whereas changes for adjustment of treatment increased. there was an increase in the use of sdd. duration of prophylaxis with antimicrobials was is longer than the length of days prescribed. [ , ] . our goal was to evaluate this marker in critically ill patients with severe sepsis and sirs. methods. patients with severe sepsis and patients after coronary artery bypass grafting (cabg) have been included in this pilot study. plasma samples have been collected daily in the sepsis group or on day after surgery in the cabg-group. bg was measured with the turbidometric assay (wako pure chemical ind.) with a cut-off of pg/ml. results. bg levels were elevated after uncomplicated cabg and differed to the sepsis group. median concentrations were in the normal range in sepsis patients but fraction of elevated beta-glucan levels tend to increase with length of stay and were higher in nonsurvivors. this first observational study demonstrated consistent results of higher bg levels in different populations of critically ill patients. while bacterial translocation has been suspected as reason for sirs after cabg, this has never been associated with fungemia. this finding and higher bg levels in nonsurvivors with sepsis warrants further research. reference(s a prospective, observational and multicenter study in which an analysis was made of antimicrobials used in patients admitted to the spanish icu during the time periods of the envin study. the present report includes data for the years to . reasons for the use of antimicrobials included community-acquired infection, extra-icu nosocomial infection, and as a prophylactic measure. empirical or directed treatments were also differentiated. the antimicrobial drugs most frequently used for each indication as well as the mode of therapy are described. rate of antimicrobial use is expressed as percentage of patients in which one or more drugs were administered. descriptive statistics are presented. of a total of , patients admitted to the icu during the study period, , ( %) received , antimicrobials. changes in the number of antimicrobials and rates of antibiotic use are shown in table . table shows the distribution of antimicrobials according to reasons of prescription and modes of use antimicrobial agents most frequently used in the -year study period were amoxicillin-clavulanic acid, piperacillin-tazobactam, cefazolin, and vancomycin. data of the drugs most frequently used in each category are available. candidemia is a major cause of morbidity and mortality in modern icus. candidemia rates and patterns in icu appear to be changing over time. non-albicans spp, especially c. tropicalis and c. glabrata may be associated with higher mortality ( ). we describe the epidemiology and outcome of candidemia caused by candida albicans and non-albicans spp. from to , consecutive cases of candidemia in a general medical-surgical icu were identified from the computerized microbiology database. apache ii scores, demographic and clinical data were abstracted from clinical records. antibiotic usage was retrieved from the pharmacy database. . cases of candedemia were identified, giving an incidence of ( %ci - ) per patient-days. candidemia rates (per patient days) increased, with non-albicans making up a greater proportion over time ( fig. ). antibiotic use did not change significantly over time. non-albicans species made up % of isolates -c. tropicalis ( . %), c. glabrata ( . %), c. parapsilosis ( %), c. krusei ( . %), c. guillermondi ( . %). risk factors more commonly present in non-albicans species were: haematological neoplasm (p= . ) and neutropenia (p= . ). c. albicans was associated with diabetes (p= . ) and male sex (p= . ). baseline apache ii scores for non-albicans vs c. albicans (median, iqr , ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) were similar, however patients with non-albicans had a higher icu mortality ( % vs %, p= . ), and a trend towards higher hospital mortality ( % vs %, p= . ). despite stable antibiotic usage, candidemia rates are progressively increasing over time, with non-albicans making up a higher proportion of cases. mortality rates were higher than generally reported, but may be partly related to the high baseline illness severity. the comparatively higher mortality of non-albicans candidemia may be related to the high incidence of c. tropicalis and c. glabrata, which made up > % of non-albicans spp. risk factors associated non-albicans were identified and could help guide early empiric therapy in this group. previous studies have investigated the role of diabetes mellitus(dm) as risk factor for infections. tight glycemic control has recently been proved to reduce morbidity in icu patients. the aim of our study was to assess the association of prior dm history with bsi in icu patients. we prospectively studied medical patients admitted to a -bed general icu, during a -month period. history of dm, age and apache ii at admission were recorded. all patients were under tight glycemic control and were followed up for the development of bsi during icu stay. cox proportional hazards regression models were fitted for each consecutive bsi episode. statistical significance was set at p< . . although myocardial systolic dysfunction is common in sepsis/sirs, its time course over longer periods in severely ill patients is not well investigated. the aim of this project is to investigate the time course of left ventricular (lv) systolic function over a period of days in patients with severe sepsis/sirs using transthoracic echocardiography (tte), and to evaluate the adequacy of different tte methods. methods. patients with severe sepsis/sirs with circulatory failure despite adequate fluid resuscitation were included. tte examinations were performed daily for a total of days. lv systolic function was assessed by eyeballing ejection fraction (eb), simpson's biplane method in the chamber view, atrioventricular plane displacement (avpd) with m-mode in the septal, lateral, anterior and inferior view, tissue velocity imaging (tvi) in the mitral annulus and stroke volume in the left ventricular outflow tract (sv-lvot). data were analysed for differences over time using anova. systolic function was impaired and there were statistically significant changes with time in the measured parameters except tvi. table . avpd, eb, tvi, sv-lvot and simpson's were obtained in %, %, %, % and % respectively of all possible measurements. conclusion. lv systolic function was impaired in this heterogeneous group of patients as expected . all parameters improved significantly throughout the observation period reaching normal values by day . simpson's biplane method was difficult to perform due to poor imaging quality. the eb method was inconclusive in several patients due to hyperdynamic status. the fact that tvi was not significantly improved was unexpected and may be due to small sample size, wall filter settings and variations in sampling volume. the avpd method was easy to obtain and seemed the most consistent marker of systolic function in this group of patients. the small sample size of this study precludes subgroup analysis however it would be relevant to study differences, eg. between survivors and non-survivors. in view of the adverse consequence of af "chronic or paroxysmal" comprising hemodynamic deterioration, risk of thromboembolic complications, and the intolerable fast palpitation, etc., cardioverting af to sinus rhythm seems an ideal goal. there had been some controversy concerning the effects of af on atrial and ventricular dimensions as well as functions. the present work addresses the latter issue through trial of cardioverting patients( females and males) with a mean age of . years (range from to years). underlying cardiac examination revealed rheumatic heart disease in pts, hypertension in , ischemic heart disease in , and lone af in pts. only one pt had cardiomyopathy and one pt had thyrotoxicosis. prior to cardioversion, all pts were subjected to clinical evaluation, and transthoracic echocardiography (tte). transesophageal echocardiography (tee) was done only in cases with heparin or warfarin anticoagulation for at least days. standard m-mode, cross sectional and pulsed doppler echocardiography were obtained using hewlett-packard sonos echocardiograph. echo parameters measured before cardioversion comprised left ventricular end diastolic diameter (lvedd), left ventricular end systolic diameter (lvesd), fractional shortening (fs), and left atrial dimensions (length, diameter and volume by planimetry). left atrial function after cardioversion was expressed as atrial ejection force (aef) and doppler a-wave, with aef defined as the force that the atrium exerts to propel blood into the lv and expressed as aef= . *mitral orifice area*(peak a velocity) . effective mechanical atrial function (emaf) was defined as a-wave more . m/s. the presences of la thrombus or spontaneous echo contrast (sec) were studied by tte or tee. measures were recorded weeks after cardioversion to avoid la stunning. a questionnaire was sent to the lead clinicians of itus in germany inviting them to describe their current practice for the management of new-onset af. the questionnaire sought to establish the type of hospital and unit in which the intensivist practiced, whether there was a protocol in place for the management of af, satisfaction with current management strategies, and opinions about the immediate goals of treatment. in addition, colleagues were asked to identify and rank their choice of medical treatment. there were responses, with describing their units as mixed medical-surgical, as medical, surgical and cardiothoracic. thirty were teaching hospitals, district hospitals, and the remainder specialist or unstated. sixty-seven had no protocol for treatment of af in itu patients, but only expressed dissatisfaction with their current approach. those who did use a guideline cited the european society of cardiology guideline most commonly. for reversion to sinus rhythm was the goal of treatment, whilst for ventricular rate control was satisfactory. for hemodynamically unstable af in the itu, considered electrical cardioversion to sinus rhythm to be optimal treatment, would use medication with the aim of reversion to sinus rhythm, and for ventricular rate control with medication was sufficient. when medication was thought appropriate, the ranked choice of drugs is given in the table (findings for uk practice are given in parentheses, and percentages are used for easier comparison). conclusion. the lack of a uniform approach to the management of new-onset atrial fibrillation in the itu is common to both uk and germany. however, both consider amiodarone to be the first choice drug, while β-blockers and calcium channel blockers feature more prominently in germany. the use of magnesium appears to be far more emphasised in the uk. we suggest a pan-european consensus to manage this prevalent problem. atrial fibrillation is a common problem in the intensive care population, with a reported incidence between % and %. it is associated with an increased mortality, but there is some question whether this represents a true mortality increase, or whether it occurs in a group with a higher risk of dying. few studies have defined the extent of the problem in the mixed medical-surgical intensive care population. all patients admitted to our intensive care unit for more than hours were enrolled into the study over a six month period, with the exclusion of children and those who had an existent or treated tachyarrhythmia. they were then followed up prospectively for days, with various parameters recorded, including the development of atrial fibrillation, the presence of sepsis, apache ii score, treatments and interventions, and outcome at days. the population studied were divided into those who developed new-onset atrial fibrillation (new-onset af) and those that did not (no af). data from the two groups were then compared to determine any significant associations. two hundred and twenty-eight patients were admitted over a six month period, with one hundred and twenty-two meeting the inclusion criteria (excluded were for duration of stay less than hours; who already had af or a pacemaker; and who were children). twenty-eight patients developed new-onset af ( %). of the patients who had sepsis, ( %) developed af, as opposed to out of ( %) in the non-septic group. the af group tended to be older (mean age vs ) and more ill (mean apache vs ), with a higher mortality rate ( % vs %). when the mortality rate was standardised (observed/predicted mortality), the af group still appeared to have a worse outcome (smr . vs . ). this result is in contrast with a recent finding that showed smr to be similar in the two groups . our study found no association with low serum potassium or magnesium levels. findings are summarised in the table. conclusion. the rate of new-onset af in our mixed medical-surgical intensive care unit is %. there is a strong association with sepsis, with over one third of septic patients developing af ( %). our findings of older age and greater degree of illness being independent risk factors for af concur with other studies, but we have also shown an increased standardised mortality rate associated with af, suggesting that the arrhythmia confers a higher risk of death. after myocardial infarction, venous lactate levels as determined in the central laboratory are known to be increased. the relationship between systemic lactate levels and hemodynamic parameters at presentation is largely unknown. we hypothesized that arterial lactate immediately measured in the catheterization laboratory provides optimal information to study this relation. we determined arterial lactate with a point-of-care analyzer (poc) in patients with st-elevation myocardial infarction (stemi) prior to primary percutaneous intervention (pci), and investigated if lactate was related with blood flow in the involved coronary vessel. we prospectively measured arterial lactate levels (reference values , - , mmol/l) in patients with stemi directly before treatment with primary pci. patients on mechanical ventilation were excluded. all blood samples were analyzed within minutes from sampling. thrombolysis in myocardial infarction (timi-)flow in the infarct-related vessel at first angiogram was recorded for all cases and dichotomized as timi - (inadequate) and - (adequate). additional data was taken from the medical chart. lactate levels were analyzed after lognormal transformation. . with multivariate analysis, shock, body mass index, tachycardia, smoking and especially timi-flow were independently related with lactate levels. the relation of timi-flow with lactate was more pronounced than the relation of timi-flow with heart rate and blood pressure. in patients with myocardial infarction, systemic arterial lactate measured before revascularisation with a poc-device allowed detection of a strong relation between poor timi-flow and elevated arterial lactate levels. there are few echocardiographic investigations of myocardial dysfunction in sirs and sepsis. the aim of this project was to investigate left ventricular diastolic function over a period of days in patients with sirs/sepsis and circulatory shock using transthoracic echocardiography (tte). methods. patients with severe sepsis/sirs were included. tte examinations were performed daily for days. diastolic function was assessed by transmitral pulsed doppler with e/a ratio, deceleration time(dt), and tissue velocity imaging (tvi) in the mitral annulus. patients were subdivided into < and > years of age. changes in these parameters over time were analyzed using anova. median values for dt, e/a, e/É andÉ for all patients were calculated. there were no differences with time for all parameters exceptÉ (table ). in patients < y.o., subnormal values for e/É andÉ were seen ( table ) . reliable continuous hemodynamic monitoring of critically ill patients is essential for effective volume management and adequate administration of vasoactive drugs. the picco-system (pulsion, germany) allows continuous measurement of cardiac index (ci) using arterial pulse contour analysis. calibration of this system by transpulmonary thermodilution is recommended every hours. in this study we examined the reliability of the continuous measurement of the cardiac index using the arterial pulse contour analysis (cipc) compared to the cardiac index acquired by the transpulmonary thermodilution (citd) when calibrating the system. our study includes measurements in critically ill patients ( male, female, age - years, mean . ± . ) requiring hemodynamic monitoring with the picco-system. patients had an infection, hepatorenal syndrome, gastrointestinal bleeding, acute pancreatitis and were admitted to the icu for other reasons. first the cipc was recorded immediately before the next calibration and afterwards the citd was measured times what resulted in a simultaneous calibration of the pulse contour algorithm of the picco-system. we performed a mean of . ± . measurements per patient ( - ). the time-lag between the measurements was h min ± h min ( min- h min). the comparison of cipc immediately before calibration and the calibration-derived citd resulted in a correlation coefficient of . with a p-value of < . . in mean the aberration between cipc and citd was . ± . l/min*m . in the bland-altman-analysis the cipc was in mean . l/min/m lower than the mean of citd and cipc. the standard deviation was . l/min/m . there was no correlation of the time-lag between the calibrations and the difference of cipc and citd (r= . ; p= . ). there was an increase of the aberration of cipc and citd in low and high cipc values. reliable cipc values with an aberration from citd less than . l/min*m can be obtained with a cipc in-between and l/min*m . ) the picco-system allows a reliable continuous measurement of the ci using the pulse contour analysis. ) in our study we could not find an increased difference of cipc and citd even with longer time periods in-between the calibrations using transpulmonary thermodilution. ) reliable ci values using the pulse contour analysis can be obtained in-between and l/min*m . ) because calibration is easy to achieve and additional data for the intrathoracic blood volume and the extravascular lung water are obtained a - hours period in-between the calibrations is reasonable. n. zoremba* , g. schälte , j. bickenbach , b. krauss , r. rossaint , r. kuhlen intensive care medicine, anaesthesiology, university hospital rwth aachen, aachen, intensive care medicine, helios klinikum, berlin-buch, germany cardiac function monitoring in patients at risk for cardiac failure is a very useful tool to recognize and treat cardiac dysfunctions. the objective of this study was to compare a new method of non-invasive determination of cardiac output (ev-co) based on electrical velocimetry with invasive cardiac output measurements performed with a pulmonary artery catheter (pa-co). methods. twenty-five patients ( male, female) were included into the study during a three month period. the non-invasive measurements of cardiac output (co) were obtained with a new cardiovascular monitor (aesculon eletrical velocimetry, osypka medical gmbh, berlin, germany). simultaneous invasive measurements of co were made by injection of iced . % saline and the recording of thermodilution curves with a pulmonary artery catheter (baxter swan-ganz catheter, . french, edwards life sciences, irvine, usa). the analysis of the data was performed based on statistical methods recommended by bland and altman for evaluation studies( ). in all patients invasive and non-invasive co values could be obtained. the analysis of co showed a strong linear correlation (r= . ) between ev-co and pa-co (fig. a) . the mean difference between ev-co and pa-co was - . ± . litre*min − (mean±sd). the lower and upper limits of agreement for the comparison of ev-co with pa-co were - . litre*min- and . litre*min − and are defined as the mean difference± sd (fig. b) . the percentage error between ev-co and pa-co was . %. in this present study we found a good correlation between the haemodynamic values measured by electrical velocimetry and those obtained from pulmonary artery catheter measurements. therefore, electrical velocimetry, a new icg algorithm, is a suitable method to evaluate haemodynamic parameters with clinically acceptable accuracy. reference(s). ) bland jm, altman dg: statistical methods for assessing agreement between two methods of clinical measurement. the pulmonary artery catheter (pac) is still used to assess the hemodynamic status in cardiac patients, because it allows the measurement of pulmonary artery occluded pressure (paop), an indirect marker of left ventricular function. we studied the relationship between the cardiac function variables derived from pac and those provided by the transpulmonary thermodilution technique (picco) in patients with acute heart failure (hf) and severe sepsis or septic shock. twenty-one patients with circulatory failure requiring invasive hemodynamic monitoring were included. icu diagnosis was hf in and severe sepsis or septic shock in patients. all patients were monitored with a pac (edwards lifesciences, usa) and a picco catheter (pulsion medical system, germany). the following parameters were simultaneously assessed during the first day in each patient: cardiac index by either method (ci-pac, ci-picco), paop, cardiac function index (cfi), global ejection fraction (gef), and global end-diastolic volume index (gedvi). pearson correlation, bland-altman analysis and nonparametric mann-whitney u test were performed, as appropriate. results are given as median (interquartile range, iqr). a total of simultaneous measurements were performed during the first hours after icu admission ( measurements in each patient). the overall correlation showed a pearson correlation coefficient between ci-picco and ci-pac of . (p< . ). bland-altman analysis showed a mean bias of . l/min/m and limits of agreement (± two standard deviations) - . to + . l/min/m . using the pac the median (iqr) ci in hf and septic patients was . ( . - . ) and . ( . - . ) l/min/m (p< . ), respectively. the paop was ( - ) in hf and ( - ) mmhg in septic patients (p= . ). the gedvi in hf and septic patients was ( - ) and ( - ) ml/m (p= . ), respectively. in hf patients the cfi was . ( . - . ) and in those with sepsis . ( . - . ) min- (p< . ), and the gef was ( - ) versus ( - ) % (p< . ), respectively. in critically ill medical patients, assessment of cardiac function using transpulmonary thermodilution technique is a valuable alternative to the more invasive pulmonary artery catheter. cardiac output and cardiac function index better discriminate between patients with and without impaired cardiac function than pulmonary artery occluded pressure. endotoxin (lipopolysaccharide, lps) tolerance is characterized by a reduced sensitivity to subsequent challenge of lps. in animal models lps tolerance is closely associated with marked, unbalanced production of pro-and anti-inflammatory cytokines as several animal studies have shown a decrease in proinflammatory cytokines and an increase in il- (anti-inflammatory cytokine). the presence and mechanism of lps tolerance in humans is unclear. the aim of this study was to test whether -day administration of endotoxin leads to lps tolerance by an enhanced anti-inflammatory response and a suppressed proinflammatory response. methods. healthy volunteers received iv bolus injections of ng/kg escherichia coli lps on consecutive days. blood samples (tnfα, il- , il- β, ifnγ and il- ) were drawn before (t= ) and after (t= , , min, , , and hrs) administration of lps on day and and on t= hrs on day till . symptom scores were obtained including nausea, vomiting, headache, muscleache, backache and shivering. the volunteers were asked to score above mentioned complaints ranging from 'nihil' (score ) up to 'severe'(score ) every half hour after administration of lps on five consecutive days. both tnfα (proinflammatory cytokine) and il- (anti-inflammatory cytokine) showed a peak level the first day which was almost completely abolished on the fifth day (anova repeated measures between day and : p< . , figure ). all volunteers experienced the expected and transient influenza-like symptoms on the first day, at t= . hrs after the administration of±maximum clinical symptom score . . (p±lps. the symptom score on day was . < . )(figure ). conclusion. endotoxin tolerance developed after consecutive days of lps administration as demonstrated by the attenuated release of proinflammatory cytokines on the fifth day. in contrast to animal studies, the attenuated cytokine response was not limited to the proinflammatory response, but also the anti-inflammatory response was diminished. this human endotoxin tolerance model appears to be useful in exploring the possible beneficial effects of endotoxin tolerance, for example, in ischemia-reperfusion damage. t. eduardo* , f. alvarez , j. gomez-hererras , s. florez , s. soria , c. lajo anaesthesiology and reanimation, university hospital, pharmacology and therapeutics, faculty of medicine, university of valladolid, valladolid, spain systemic inflammatory response occurs frequently after coronary artery bypass surgery, and it is strongly correlated with the risk of postoperative morbidity and mortality. we have analysed the effects of gelatin priming versus ringer's lactate priming on cytokine release and during the inflammatory state following coronary artery bypass surgery with cardiopulmonary bypass. a prospective, randomized study was designed. forty four patients undergoing elective coronary artery bypass grafting were allocated randomly to one of two groups: patients with ringer's lactate prime and patients with gelatine containing prime during coronary artery bypass surgery. the study protocol was approved by the ethics committee of the 'clinico' hospital of valladolid. written informed consent was obtained from each patient. plasma levels of interleukin il- , il- , tnf-alpha, c-reactive protein (crp), complement (c ), and sris score were measured along the surgery and within the first postoperative hours at various time points. cytokine levels were measured by enzyme-linked immunosorbent assay from plasma sample obtained. the spss program (version ) was used for the statistical analysis of the data. differences from baseline and between the groups were evaluated by two-way analysis of variance for repeated measurements (anova, followed by scheffe's test). correlation analysis between variables was calculated using pearson's correlation coefficient. a probability value of p < . was considered significant. there were no significant differences between the groups regarding pre-operative data. patients were similar with regard to type of procedure, bypass time, aortic cross-clamp time and number of grafts. in both groups the serum levels of the proinflamatory cytokines (il- , il- , tnf-alpha), sris score, c , crp, and leukocytes increased significantly over baseline, with no difference between either the colloid or crystalloid group. the operation time, blood loss, need for inotropic support, extubation time, and length of intensive care unit stay did not differ significantly between the two groups. priming with gelatin versus ringer's lactate produces no significant differences in the inflammatory response in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. a prerequisite to evaluate resuscitation from hemorrhagic shock is a reproducible experimental model, which leads to a predictable outcome. in order to evaluate the best predictor of death, blood lactate was compared to mean arterial pressure in hypotensive animals submitted to severe controlled hemorrhage. forty immature pigs were anesthetized with ketamine, atropine and halothane, intubated and maintained breathing spontaneously with atmospheric air and halothane. pulmonary, femoral and jugular vein catheters, were inserted in order to measure cardiac output, mean arterial pressure (map), blood gases and blood lactate. group i (n= ) was hemorrhaged to a map of mmhg breathing room air with halothane . %. group ii (n= ) remained as control of group i, breathing room air with halothane . % and no bleeding. group iii (n= ) was hemorrhaged to a map of mmhg breathing room air with . % halothane. finally, group iv (n= ) remained as control of group iii breathing room air with halothane . % and no bleeding. variables were recorded every ten minutes with no further intervention for minutes, when anesthesia was discontinued in the surviving animals. death of the animals was registered up to twenty four hours after the experiment. all animals in group i died. all animals in group iii survived, despite the fact that both groups had equal degree of hypotension (map = mmhg). however, only group i exhibited high levels of blood lactate. receiver operating characteristic (roc) curve analysis with death of the animals as the variable of interest, demonstrated that only blood lactate exhibited % sensitivity, % specificity and a roc curve area of . . mean arterial pressure was less accurate in predicting the death of the animals. tissue oxygen tension (tpo ) represents the balance between local supply and demand and may be a useful monitoring modality. we previously reported that lipopolysaccharide infusion produced different responses in four organ beds studied ( ). in the present study we sought to compare peripheral tpo measurements (bladder, muscle) against those measured in more vital organs (liver, renal cortex) during acute hypoxaemia. under isoflurane anaesthesia, male wistar rats (approx g weight) underwent left common carotid and right jugular venous cannulation for blood sampling/bp monitoring and fluid administration, respectively. flow in the descending aorta (abf) and left renal artery (rbf) were monitored by ultrasonic flow probes (transonic systems, usa). arterial po was measured using a blood gas analyser (radiometer, copenhagen, denmark). tissue po was determined using oxylite probes (oxford optronix, uk) placed in thigh muscle, between the right and left lobes of the liver, in the left renal cortex and within the bladder lumen. after a -min stabilisation period, fluid-resuscitated rats ( ml/kg/h, n-saline) were subjected to progressive increases in hypoxaemia ( , . and % inspired oxygen). comparisons were made to time-matched controls breathing room air. statistics were performed using two-way rm-anova and post-hoc tukey's test. results. data shown as mean (± se), *p< . between control (c; n= ) & hypoxaemia (h; n= ); $ p< . between timepoint & baseline. ( ) ( ) conclusion. patients with erd have higher severity and more frequently immunodepression and medical pathology. they needed more invasive procedures and antibiotic therapy so infection rates and resistance patterns are superior to the rest of icu patients. conclusion. an improvement of the methods of regulation and of the monitoring of treatments are essential if we take into account the increasing bacterial resistance. if glycopeptides are still the initial standard treatment of serious infections, new therapeutic strategies should be emerging, depending on the confirmation of presented innovations. prospective observational cohort study, performed in a -bed icu. all copd patients with ae who required intubation and mechanical ventilation were eligible. at icu admission, information on endotracheal aspirate purulence, and hyperthermia was collected. in all patients, gram stain and quantitative endotracheal aspirate culture (positive at cfu/ml) were performed. in addition, leucocytes count, c-reactive protein (crp), and procalcitonin (pct) levels were measured. univariate and multivariate analyses were used to determine variables associated with bacterial severe aecopd. positive predictive value and negative predictive value were calculated for variables independently associated with bacterial severe aecopd. . severe aecopd were diagnosed in patients. bacteria were isolated at significant threshold in exacerbations. s. pneumoniae ( %), methicillin-sensitive s. aureus ( %), and h. influenzae ( %) were the most frequently isolated bacteria. age ( ± vs ± ), male gender ( % vs %), saps ii ( ± vs ± ), duration of mechanical ventilation ( ± vs ± d), and mortality ( % vs %) were similar in patients with bacterial severe aecopd and those with nonbacterial severe aecopd. rate of patients who received prior antibiotic treatment was significantly lower in patients with bacterial severe aecopd than in patients with nonbacterial severe aecopd ( % vs %, p = . ). no significant difference was found in rates of patients with hyperthermia ( % vs %), purulent endotracheal aspirate ( % vs %), and leucocytosis ( % vs %) between the two groups. although leucocytes, crp and pct levels were similar in the two groups, rates of patients with pct > . ng/ml ( % vs %, p = . ), and patients with positive gram stain of endotracheal aspirate ( % vs %, p< . ) were higher in patients with bacterial severe aecopd than in patients with nonbactrerial severe aecopd. pct > . ng/ml (or [ % ci] = . [ . - ], p = . ), and positive gram stain of endotracheal aspirate ( [ - ], p < . ) were independently associated with bacterial severe aecopd. conclusion. positive gram stain of endotracheal aspirate, and pct > . ng/ml are independently associated with bacterial severe aecopd. these results could be helpful for future interventional studies aiming at reducing antibiotic use in these patients. systemic inflammatory response (sir) in patients with infection clearly influences outcome. the aims were to study the sir in icu-acquired infection (i-icu) according to the source and etiology and evaluate outcome impact. multicentre prospective study from april to july in ucis of hospitals. the number of patients admitted to icu> h until icu discharge or a -day period. i-icu diagnosed according to the cdc's criteria, source, etiology and sir were analyzed. conclusion. % of the i-icu worsen in sepsis severe/septic shock. vap and bacteriemias had more severe sirs and uti less frequent. septic shock presented a high mortality (> %) without significant differences in infection sites. c albicans, a baumannii and p aeruginosa developed the worst sir. conclusion. this analysis confirms that a small percentage of long stay patients occupy a large proportion of icu patient-days. the mortality is higher in this group than the overall unit, but the survival rate of . % could justify the extra resources required to treat these patients. age does not appear to influence length of stay in this study. the patients who are most likely to have a prolonged length of stay are re-admissions, patients who are peri-transplant or have ventricular assist devices. editorial: safe use of cricoid pressure cricoid pressure: knowledge and performance amongst anaesthetic assistants assessment of the ml syringe as a simple training aid in the application of cricoid pressure reference(s). possum and portsmouth-possum for predicting mortality possum scoring for patients with fractured neck of femur this study would not have been possible without the contribution of all icu team and the following people: wagner fontes, marilia calipo ferreira and ivy dantas gangiredddy ch admission of older patients to intensive care units is a controversial issue. the outcome of elderly patients with critical illness in india has not been previously studied. retrospective chart review of males > years & female > years from may till november . data collected included age, gender, disease category, comorbidities, mechanical ventilation days, length of stay in icu and hospital, apache ii, sofa, premorbid functional state and mortality. in admissions to micu, were critically ill elderly [ ( . %) males, ( . %) females]. premorbid functional state assessment showed: independent ( . %), partially dependent ( . %) and wholly dependent ( . %). at admission, organ involvement was respiratory [ ( . %) ], renal [ ( . %)], neurology ( . %), metabolic ( . %) and cardiac ( . %). mean apache ii and sofa scores were . + . (median ). and . + . (median . ) respectively. mean length of stay (los) in icu was . days + . and . days + . in hospital. mean icu stay was . + . & in hospital was . + . in - year age group, vs . + . and . + . in the over group [ . ] . total mechanical ventilation days were (range - ). died ( %) of which [ / ( %) ] were in - yrs and / ( . %) in > yrs [ns] . decisions to limit life support were taken in / cases ( . %), dnr in ( %) and withholding in ( %). apache score > correlated with mortality ( deaths in score> ; death in score < (chi square test . ). there was no correlation between premorbid functional status and mortality. respiratory involvement was the predominant cause of admission. the hospital mortality for the elderly was only %. apache ii score correlated with mortality. the sample size was too small to detect any significant differences between age groups in terms of los and mv days. % of the deaths were preceded by eol decisions. introduction. the phenomenon of increased intra-abdominal pressure and the resultant physiologic compromise were first described in the late s. acs has been defined as the cardiovascular, pulmonary, renal, splanchic, abdominal wall and intracranial disturbances resulting from elevated iap. korn and associates first used the term acs in . malbrain et al found during one day point prevalence study in icus had . % of patients has acs. intra abdominal pressure (iap) was measured in consecutive patients (age range - ; males: females) who were admitted to the micu with diverse clinical problems. iap was routinely measured using the transurethral measurement of urinary bladder pressure using a foley's catheter. abdominal compartment syndrome (defined as > cm h o) was found in patients (age range - , males; females). of these patients had primary acs, had secondary and had recurrent acs. the mean apache ii score was and sofa score was . in the acs group; the apache ii score was . the sofa score was . the group without acs. ( p value not significant) out of , patient with acs had a surgical intervention to reduce iap (pd catheter in , decompressive celiotomy in ). the indications for intervention were unexplained respiratory deterioration seen as in increase in plateau pressure or fio , fall in urine output despite adequate map and fluid resuscitation and iap> cm of water. / in the intervention group died ( . %). patients in the raised iap group managed conservatively with fluid restriction and diuretics. the mortality in the patients without acs was . %. in addition, increased iap alone gave a clue to the need for surgical intervention in / patients; these would have otherwise been managed conservatively. our study suggests that routine iap measurement of patients in the icu is beneficial because of the presence of unsuspected acs in a significant proportion of patients ( %) irrespective of the primary disease. acs may cause renal, hemodynamic and respiratory compromise that can be improved by judicious and timely intervention. further, raised iap alone may sometimes give a clue to the need for a surgical intervention, which may beneficially affect the clinical course. a. lorx* , b. szabó , m. hercsuth , z. hantos anesthesiology and intensive therapy, semmelweis university, budapest, medical informatics and engineering, university of szeged, szeged, hungary introduction. the low-frequency respiratory impedance (zrs) has been shown to reflect the respective contributions of the airway and tissue mechanical properties accurately in healthy subjects. little information is available, however, on the values of airway and tissue parameters derived from low-frequency zrs data in ali patients before and after bronchodilator therapy. zrs was measured with small-amplitude forced oscillations between . and hz at three peep levels ( , and hpa) before and after nebulised berodual in mechanically ventilated patients including with severe pneumonia and with postoperative respiratory failure, without any previous pulmonary disease. airway resistance (raw) and inertance (iaw), and constant-phase tissue damping (g) and elastance (h) were estimated from zrs spectra by model fitting. raw decreased with peep, and on the administration of berodual in both groups. in the postoperative patients, g decreased with peep, and g and h decreased following berodual inhalation; this indicates that bronchodilation was accompanied by recruitment of previously closed regions of the lungs. there was no change in iaw and hysteresivity (g/h), suggesting that the peripheral airway inhomogeneity was not markedly affected by the intervention. the decreases in raw reflect the presence of reversibly elevated airway resistance in all patients. the decreasing g/h in the pneumonia patients after berodual indicates improved homogeneity in the mechanical properties of the peripheral lung with consequent improvement in ventilation, although the changes did not reach the level of statistical significance. berodual inhalation results in improved tissue properties of the respiratory system, i.e. decreases in elastance and tissue damping, which is associated with the bronchodilator effect. overall, the low-frequency oscillation technique proves to be an informative and accurate method for bedside monitoring of critically ill patients. dialysis disequilibrium syndrome -report of cases n. shaikh* , m. kettern , y. hanssens anesthesia and intensive care, pharmacy, hamad medical corporation, doha, qatar introduction. dialysis disequilibrium syndrome (dds) is a central nervous system disorder occurring in pts (pt), either during or within hours of dialysis. dds is unknown in pt who are on dialysis for some time and no case had been reported in ventilated pts. report of cases of fatal dds in ventilated pts with acute renal failure (arf) on haemodialysis (hd) for more than a week. case : a year old male pt victim of motor vehicle accident, spleenic and bowel injury. ct head normal, gcs / . he underwent spleenectomy, hartman's procedure and abdominal packing. post-op, he was in dic and haemorrhagic shock. he remained hypotensive, adrenaline and noradrenaline were started. pt was oliguric and developed arf on day , daily hd was started over hours, normal bath and heparin free. on day , pt was trying to obey commands. on day , pt developed sepsis and meropenem was started. on day , pt underwent hd, became unresponsive after hour and pupils fixed-dilated. ct brain showed severe oedema and herniation. eeg was flat and brain stem reflexes absent. diagnosed as brain dead on day and expired same evening. case : a year old male pt fell from height, on arrival gcs was / . he had severe chest trauma and liver laceration,underwent laprotomy, haemostasis and packing of abdominal cavity. on day , pt developed arf, started on slow hd ( - hours) , low sodium, potassium and heparin free. ct brain on day was normal. on day pt developed septic shock, started vancomycin and ciprofloxacin. pt required noradrenaline. on day , during hd (increased potassium, heparin free), pt developed hypotension, pupils became dilated and fixed. hd was stopped, mannitol was given and pt was hyperventilated. ct brain showed severe oedema and herniation of brain. brain stem functions were absent. eeg was flat and heart stopped after hours. tioxidant capacity, as well as the detection of oxidized biological markers. the direct, in vivo quantitative measurement of the production of superoxide radical, an important parameter of the oxidative load, is difficult due to its low concentration and a short half life ( ) . in this study, the effect of h/s and resuscitation on the oxidative state in vital organs (gut, liver, lungs, kidneys) was estimated for the first time by measurement of the production of superoxide radical in vivo, using a new superoxide assay.methods. male wistar rats were divided in two groups (n= ): sham and h/s group. h/s was induced by withdrawal of blood targeting to a mean arterial blood pressure of - mmhg, which was maintained for minutes. at the end of the shock period, rats were resuscitated with re-injection of the removed shed blood volume. tissue samples were collected hours after resuscitation and the oxidative load was assessed by a new superoxide assay which directly measures the production of superoxide radical and an established lipid peroxidation assay which measures the production of organic hydroperoxides. statistical analysis was performed using anova. animals that underwent h/s exhibited a statistically significant increase in the production of organic hydroperoxides in the gut (p< . ), liver (p< . ) and lung (p< . ) tissues, whereas no change was observed in the kidneys. the rate of production of superoxide radical increased more in the gut and the liver (p< . respectively) and to a lesser extent in the lungs (p < . ), while kidneys were not affected as well.conclusion. this study demonstrates an increase in oxidative load in the gut, the liver and the lungs after h/s-resuscitation, which was estimated by two different methods. moreover, and for the first time in a model of h/s, the new superoxide assay directly and more precisely estimates oxidative stress in vivo, since the formation of superoxide radical seems to play a pivotal role in the cataract of reactions that lead to the oxidation of biological structures. these results suggest that predominantly the gut and the liver, and to a lesser extent the lungs, but not the kidneys are the organs primarily affected by h/s in this model. reference(s). . biasi f, et al.: free radic. biol. med. ; : - . . georgiou cd, et al.: anal. biochem. ; : - . g. luckner* , s. jochberger , v. d. mayr , v. wenzel , h. ulmer, in this retrospective analysis, we examined if a low-dose avp infusion ( iu/h) can reverse isolated postoperative vasodilatory hypotension and prolonged vasopressor requirements (> hrs) in fifteen patients under chronic ace inhibitor treatment. hemodynamic and laboratory parameters were recorded , , hrs, and immediately before start of avp therapy, , , , and hrs after start of avp, as well as , , and hrs after cessation of avp infusion. the primary endpoint was to evaluate hemodynamic effects and changes in phenylephrine dosages during avp infusion. the secondary endpoint was to evaluate changes in laboratory parameters during avp. . avp infusion did not show any significant effects on hemodynamic variables. only mild, non-significant effects on map (+ . %, p= . ) and phenylephrine (- . %, p= . ) dosages were observed during the first hrs after avp infusion. there were no changes in laboratory parameters during avp infusion. a supplementary, low-dose avp infusion proved to be ineffective to improve hemodynamic function and reverse vasopressor dependency in patients with chronic ace inhibitor therapy and prolonged postoperative hypotension. results. drotaa was administered in patients [ ± years old, simplified acute physiology score (sapsii): ± ]. a community acquired infection was the causal infection in % of cases. patients had > organ failures before the drotaa onset (hemodynamic failure in patients,respiratory in ). all patients received hydrocortisone (started ± hours before the onset of drotaa) and patients received hemofiltration (started ± hours before the onset of drotaa). serious bleeding events occurred in patients. interestingly, the icu mortality was % while mortality predicted from saps ii was %. we observed a significant improvement in the pao /fio ratio and in the blood lactate level after the onset of drotaa (h ) ( table ). in patients treated with norepinephrine (n= ), we also observed a rapid decrease in the vasopressor dose after drotaa onset while the mean arterial pressure was maintained stable in the same period ( figure) . in this observational study, we evidenced significant improvement in the hemodynamic and respiratory failures and a decrease in blood lactate after the onset of drotaa administration. in the past few years new insights in the role of microcirculatory alterations during sepsis have been elucidated by means of orthogonal polarization spectral (ops) imaging. persistent alterations appeared to have prognostic value. several other techniques, such as near infra red spectroscopy, laser doppler and peripheral temperature have been used to asses peripheral circulation. however there is unclarity about relation between peripheral and microcirculation during sepsis. aim of this study was to evaluate the relation between peripheral and microcirculatory alterations during sepsis. we performed a single centre observational study in patients with < h severe sepsis/septic shock. ops imaging of the sublingual region and semi-quantitative analysis were performed as described in detail elsewhere . skin perfusion was measured as central-to-toe temperature difference (deltat). non-parametric rank correlation is expressed as spearman's rho(rs). , ( , - , ) , ( , - , ) , serratia marcescens (n= ) , ( , - , ) , ( , - , ) , acinetobacter baum (n= ) , ( , - , ) , ( , - , ) , klebsiella pneumoniae (n= ) , ( , - , ) , ( , - , ) , all pathogens (n= ) , ( , - , ) , ( , - , ) , msc -meropenem serum concentration, mic -minimum inhibitory concentration conclusion. we conclude that continuous infusion of meropenem in dose g per hours in critically ill patients provides reliable serum meropenem concentrations in relation to mics of meropenem sensitive pathogens. grant acknowledgement. this study is supported by the czech ministry of education (project msm ) s. boyes* , g. l. thomas speech and language therapy, salford primary care trust, intensive care unit, hope hospital, salford, united kingdom although several key documents recommend that slt should be integral to the multidisciplinary care of critically ill patients , , , these services are often not funded. without this input there is increased risk of nosocomial pneumonia, malnutrition and dehydration. antibiotic prescription and length of stay may increase with higher dependency and a slower transition through levels of care. communication difficulties may also impact on the patient experience. as per royal college of speech & language therapists guidelines our project explored unmet need and defined the potential role of slt at hope hospital, a regional neuroscience centre. slt provided daily input to critical care patients for a month period. prospective data were collected detailing referrals and slt management, and were compared with retrospective data from months prior to the project. stakeholder evaluation was carried out using pre and post project staff questionnaires, and by collecting anecdotal evidence from patients and staff.results. referrals to slt increased by % ( pre-project versus during the project). pre project, % referrals( ) were inappropriate and % ( ) transferred before asessment. % referrals ( ) during the project were appropriate and assessed. % of pre-project referrals were seen on the day of referral compared to % during the project. pre-project slt intervention focused on assessment and advice alone. the project promoted earlier identification of needs, early management of clinical risk and contributed to multidisciplinary care. major training and education needs were identified. stakeholder evaluation was overwhelmingly positive, demonstrating slt contribution to multidisciplinary care and the patient experience.conclusion. dedicated slt input in critical care increased referrals to slt. the number of inappropriate referrals and the time to slt assessment decreased. input promoted the identification of clinical risk, facilitating early intervention and rehabilitation. training needs and additional roles for slt (weaning, decannulation and risk management) were identified. stakeholder evaluation demonstrated improved patient experience. these findings form the basis of a business case to expand slt resources in critical care. whereas several studies established cefotaxime, or other rd generation cephalosporins, amoxicillin/clavulanic acid and oral quinolones as effective first-line antibiotic regimens in community-acquired cases, little is known about the spectrum of antimicrobial resistance, impact of an effective initial antibiotic regimen on survival and the spectrum of causative micro-organisms in hospital acquired cases. all cases of sbp diagnosed in a university hospital between january and august were retrospectively analysed. . cases ( m, f) were retrieved. mean (± sd) age was (± ) years. meld-score was . (± . ) at the time of the diagnostic tap. in patients the infection was community acquired, in patients hospital acquired. patients ( . %) died in the hospital. the initial antibiotic regimen was a third generation cephalosporin in , an ampicillin/sulbactam in and a quinolone in cases. cases (all hospital-acquired infections) were initially treated with a carbapenem and vancomycin had been added in cases. in patients the antibiotic regimen had to be changed during the course of treatment. survival was not worse in hospital-acquired cases than in community-acquired cases, but hospital-acquired cases were more often treated with broader antibiotic regimens at the onset of therapy. patients in whom the initial antibiotic treatment had to be modified had a higher mortality than patients in whom the initial treatment was continued ( % vs. %; p= . ). in patients with positive culture results, an effective first-line antibiotic regimen was associated with lower mortality ( % vs. %; p= . ). binary logistic regression analysis found meld-score at diagnosis (p= . , % confidence interval (ci) . - . ), ascitic fluid cell count (tsd) (p= . , % ci . - . ) and an escalation of antibiotic therapy (p= . , % ci . - . ) to be independently associated with mortality. the most commonly cultured micro-organism was e. coli (n= ), followed by enterococcus faecium (n= ). among culture positive cases the causative micro-organism was resistant to ceftriaxone in ( %), to ampicillin/sulbactam in ( %) and to ciprofloxacin in ( %).conclusion. the incidence of resistance to one of the recommended standard regimens is high in hospital-acquired and community-acquired cases of sbp. failure of the initial antibiotic regimen is associated with higher mortality. broader antibiotic regimens should be considered as initial approach. the multidrug-resistance (mdr) of gram (-) strains in the icu is a severely growing problem, so colistin has been recently reintroduced in clinical practice. colistin had fallen out of favour after due to nephrotoxicity, neurotoxicity and poor pharmacokinetics in lung tissue. the aim of this clinical trial is to study the efficacy and safety of colistin in mdr gram (-) nosocomial infections (ni) in the icu during the last months. we enrolled retrospectively icu patients (pts), men ( %) and women ( %), who developed a mdr gram (-) ni. mean age: . ± . years, mean stay: . ± . days. underlying diseases: multiple trauma , complicated surgery , other . the pts were treated ( courses) with intravenous (iv) colistin . . iu x daily (adjusted for creatinine clearance) in combination with carbapenems or b-lactamase inhibitors. in pts aerosolized colistin ( . iu x daily) was added to iv colistin. the ni treated were: pneumonia ( . %), central venous catheter-related infection ( %), peritonitis ( %), central nervous system infection (cnsi) ( . %). pts with cnsi additionally received colistin intrathecally. the responsible bacteria were: ac. baumannii ( . %), ps. aeruginosa ( . %) and kl. pneumoniae ( . %), with double pathogen in episodes of ni. clinical success (important lessening of the signs and symptoms of ni) occurred in ni ( . %); microbiological success (eradication of the pathogen in cultures of blood, peritoneal fluid, bronchial secretions or celebrospinal fluid) was obtained in ( . %). nephrotoxicity was observed in pts ( . %); it was reversible. mortality rates: / = . %.conclusion. ) colistin in combination with other antibiotics is an effective treatment of severe mdr gram (-) ni in the icu. ) the incidence of adverse events is low; a close surveillance of renal function is needed. ) when aerosolized colistin was included in treatment, microbiological success was accelerated (p< . ). ) pneumonia was the ni best corresponded to colistin than other sites of ni, but not statistically significantly (p< . ). ) prognosis was independent of type of invading gram (-) microorganism. introduction. the biggest concern in infection epidemiology in intensive care is the emergence of multidrug-resistant gram-negative (pseudomonas aeruginosa, klebsiella pneumoniae and acinetobacter baumannii) and gram-positive (staphylococcus aureus) organisms. two periods of six months were analyzed for each icu: in the first six months (from mar/ to aug/ ) no infectious disease advice was given in any; in the following six months (sep/ the fev/ ) infectious disease consultation was given in icu when requested, as opposed to icu , where it was continuously provided by an infectious disease consultant with degree in intensive care. the number of multi-resistant organisms grown was then compared. a t-test for two independent samples was used in statistics. the species distribution of the pathogens evaluated in icu is summarized in table . there was reduction in the occurrence of p.aeruginosa % ( - , %), a.baumannii % ( , - %) and s.aureus % ( , - , %), with significant p value for p.aeruginosa, the most common microorganism.* k.pneumoniae percentage of increase = , %. table summarizes the results in icu , where the decrease in growth of the multi-resistant stains was higher: % for p.aeruginosa ( , - , %), , %for k.pneumoniae ( , %- , %) and % for s.aureus ( , - %) also with significant p value for p.aeruginosa. introduction. intravascular catheter related infections are very critical in icu environment, with elevated morbi-mortality and impact on costs. in our unit, according to a quality political, it had established standards on prevention, diagnosis and treatment of nosocomial infections, with a periodic review of the ours rates. we will describe the managerial model chosen when we noticed an increase of the catheter related infections incidence: outcome management. in december it was created a multi-professional work group ( doctors, nurses and respiratory therapists) who performed a weekly meeting with the brainstorm technique. all the infections data were reviewed. the group identified main risk factors related to the problem using a diagram cause-effect. then, it had established corrective measures, deadlines and ways for execution. measures chosen: team for catheter insertion; using full-barrier precautions for insertion of central venous catheters; using of semipermeable and transparent dressings; avoiding the jugular and the femoral sites; routine replacement of the catheters after ten days insertion; removal of the unnecessary catheters. target was return of catheter related infection rate to level of the previous year. in the first three months after the intervention, we noticed a reduction of the median rate of catheter-related bloodstream infection per catheter-days: , infections to , . catheter-related bloodstream infection is the nosocomial infection par excellence: costly, common, and frequently fatal. efforts to improve patient safety must focus on simple and inexpensive interventions and prevention measures. the managerial tool showed us main causes of the problem and caused the adhesion of all staff around the catheter related infections and the correct measures to solve it. limited data suggest that vancomycin when given by intermittent injection may not be as affective as linezolid for the treatment of ventilator acquired pneumonia and this inferiority may be negated by administering vancomycin by continuous infusion ( ). administration in this fashion may improve the drug's tissue penetration and is easier to control but a double blind randomised controlled trial has not been carried out. the way in which vancomycin was administered in our icus was changed in may so that any patient with central venous access was given vancomycin by continuous infusion according to a strict protocol ( ) . data from our electronic prescribing system was correlated with icnarc data for mortality. we conducted a retrospective audit from december to october comparing icu outcome in patients who were treated with one agent only. patients who received both linezolid and vancomycin or were on a bd and infusion regiment were excluded. . patients were treated with vancomycin infusion, of whom . % died. this was not significantly different from the mortality for vancomycin when given by intermittent injection of . %. interestingly the mortality for those treated with linezolid in an unmatched group of patients was . % (p< . ). conclusion. contrary to previous audits, our data suggest that vancomycin is not inferior to linezolid for icu mortality. the mode by which vancomycin is administered does not affect mortality. the increased mortality found in patients treated with linezolid has yet to be explained. further analysis is required. there are recommendations for control and prevention of methicillin-resistant staphylococcus aureus (mrsa) ( ); surveillance reduction in antibiotics use, screening, nasal and skin decolonization, handwashing, isolation, decontamination of clinical areas, adequate staffing. these recommendations however, are frequently based on large series and case reports rather than randomised trials ( ) . of those recommendations, only two (handwashing and adequate staffing) are reliably carried out in our icu. even conventional 'deep cleaning' has been shown to be unreliable ( ). all patients admitted to itu at university hospital birmingham between june and may were retrospectively studied so that any microbiological sample that was positive for mrsa was correlated with the date of icu admission. conclusion. there has been a steady decline in the number of primary mrsa infection occurring in our icu whilst the number of cases admitted has remained constant. colonisation pressure from patients admitted to icu is independent of mrsa acquisition. the reasons for our decline in mrsa infection remain unclear as full recommendations to inhibit mrsa spread can not be implemented. in our tertiary surgical icu, antibiotic policy restricts prescription of meropenem to ) the empirical treatment of suspected bacterial severe sepsis in patients with risk factors for antimicrobial resistance or with documented colonisation with multiresistant gram negative (mrgn) organisms, or ) the directed treatment of infections caused by mrgn organisms. to evaluate compliance with these restrictions, the indications for meropenem use were reviewed, and the feasibility of a de-escalation strategy in case of empirical meropenem prescription was evaluated. we performed a retrospective study of all meropenem prescriptions in the surgical icu from / / to / / . patients who received more than one dose of meropenem were included in the analysis. age, apache ii, prior length of stay, duration of meropenem administration, antibiotic prescription other than meropenem, microbial etiology and site of infection were recorded. the presence of risk factors for antimicrobial resistance, i.e. either previous exposure to broad spectrum antibiotics or a hospital stay for longer than days prior to infection were documented. data are presented as mean (standard deviation). data from hundred and thirteen meropenem prescriptions were available for analysis. mean age of the patients was ( . ), and the mean apache ii score was ( . ). pulmonary ( %) and intraabdominal ( %) infections were the most frequent sites of infection. meropenem was prescribed according to the restricted indications in / patients ( %). in patients it was initiated empirically with both risk factors for antimicrobial resistance present, and in patients it was used because of documented colonisation with mrgn organisms prior to the current infection; in cases it was used after identification of a mrgn organism as the causative organism of the infection. in the other patients (n= ), meropenem was started empirically with no or only risk factor for resistance and without documented colonisation with mrgn organisms. empirical prescription of meropenem was de-escalated in patients ( %). reasons for not de-escalating were the identification of mrgn organisms or uncontrolled polymicrobial infections. compliance with the restricted indications for meropenem in our icu was high. empirical prescription of meropenem was de-escalated upon culture results in half of the cases. d. r. goldhill , a. badasconyi* , a. a. goldhill , c. waldmann anaesthetic department, the royal national orthopaedic hospital, stanmore, anaesthetic department, the whittington hospital, medical school, kings college london, london, anaesthetic department, the royal berkshire hospital, reading, united kingdom patient position in icu is important for preventing complications such as pneumonia [ ] . two hourly turning is a common standard of care [ ] . evidence suggests that patients may not be turned this frequently [ ] . we therefore conducted a prospective observational study of patient position and turning in icu and the factors that may affect the frequency of turns. forty eight of uk icus contacted agreed to participate in this study. the position of each icu patient was recorded every hour over two hour periods, one midweek and one weekend. the patient age, gender, estimated height and weight, diagnosis, whether intubated and ventilated, hourly sedation score, nurse:patient ratio and number of patients on the unit were also recorded. patients could be on their back, front, left or right side. a turn was defined as a change from one of these positions to another. the degree of rotation and whether patients were flat, head down or head up was also noted. analysis of the relationship between the average time between turns and factors that may be associated with this was performed using multiple regression on the log transformed dependent variables. . sets of observations were analysed. patients were prone at some time. other positions are in the table. the average time between turns was . hours, median . (range . - ; interquartile range - . ). there was no significant association between the average time between turns and age, gender, respiratory tract-related diagnosis, intubated and ventilated, sedation score, day of week or nurse:patient ratio. there were significant differences between hospitals in the frequency with which they turned patients on their unit. patients are rarely nursed flat. some patients go for prolonged periods without a change in their position. there was no association between the average frequency of turns and the patient and organisational factors we examined. however there are differences between hospitals in the practice of turning patients. introduction. this study compares the incidence of vap in traumatic patients receiving mechanical ventilation for > hours with a endotrachealtube with a dorsal lumen for intermitent drainage of subglotic secretions with others that received mechanical ventilation with a conventional endotracheal tube. traumatic patients admitted to the reanimation unit of the complexo hospitalario de ourense from march to august that received mechanical ventilation for at least hours were eligible for study. the follow-up period consisted of the patients remaining stay in the reanimation unit. demographic and clinical characteristics of patients were collected on admission. vap was suspectted in patients with a clinical pulmonary infection score or more. the diagnosis was done by tracheal aspiration and protected specimen brush. the bacteriologic examination was done by cuantitative and cualitative methods. patients were included inthe study ( that received intermitent drainage of subglotic secretions and in group control). there were not early-onset pneumonia on patients with intermitent drainage of subglotic secretions. there were not significative stadistycal differencies in incidence, duration of ventilation, reanimation length of stay or mortality.conclusion. this study didn't find statystical differences between the two groups because of the short number of patients; but it is important that inthe group wich received intermitent drainage of subglotic secretions there weren't eppisodies of early-onset pneumonia. f. lambiotte* , t. levent , x. lemaire , m. castro , l. gaybor , w. joos , t. ngheim intensive care, chsa, maubeuge, infectious disease, tourcoing, france to analyze the indications and the quality of the prescription of glycopeptides (gp) in an intensive care unit of beds. a -months retrospective study. the treatment was indicated if it answered the recommendations were selected. it was correct if:correct initial dose,corrects glycopeptides concentrations,serum dose obtained with fixed levels, antibiogram justifying the prescription of a gp in the event of bacteriological documentation. . saps ii , (± , ), age years (± , ),gender (m/f) , . , % of the patients presented a renal insufficiency. treated pathology: pneumoniae( %), septic shock( %), intra-abdominal infections ( %), blood stream infections, hyperthermia of unknown origin ( %), infections of the skin ( %), pyelonephritis ( %). frequency of organism recovery was: coag-neg staphylococci (including oxa-r), staphylococci aureus (including mrsa), entérococcus (including ampi-r),others : . the indications of regulation were largely respected but the methods of use of the gp were failing. even when the regulation was correct (n= ), the fixed serum rate was reached only in % of the cases. there is no difference between this patients in septic shock and other patients. taking into account the profile of the patients of intensive care unit, it seems difficult to predict that a treatment will be effective and that sub-inhibiting serum concentrations will be avoided even if the recommendations were respected. the situation becomes more and more delicate because of the increasing bacterial resistance. nosocomial pneumonia (np) continues to be an important cause of morbidity and mortality in the icu. the type of icu (medical, md or surgical, sg) has been described as an important factor to influence their etiology. prospective, observational study conducted between / and / in specialized icus of a tertiary hospital. all patienst who fulfilled clinical criteria ( of ) of np were included. epidemiological and microbiological features were registered. the patients were grouped according their origin from a md or sg icu. we included patients (md, n= and sg n= ). age ± yrs. icu admisión apache ii . ± . the distribution of infections between icus was for md and sg respectively: ventilator-associated pneumonia (vap) % vs %, ventilator-associated tracheobronchitis (vat) % vs %, and np % vs %. we could not find significant differences in epidemiological characteristics (except age ± vs ± , p= . ), risk factors for nn and blood test between the groups. patients ( %) had microbiological diagnosis (md= vs sg= ). the most frequent microorganism producing pneumonia in these patients were mrsa and mssa (same distribution: , % vs , %, p= . ), followed by p. aeruginosa ( , % vs %, p= . ). the inadequate initial ab therapy was slightly higher in sg patients ( % vs %, p= . ) and the mortality rate was not influenced by this variable. the icu and hospital los were alike and hospital mortality rate was significant higher in md than sg icu patients ( , % vs , %, p= . ). for a predicted mortality of % and %. we find some differences in this small cohort of md and sg icu patients with np. the microbiology profile showed important differences between the groups. the main limitation of this study is the small sample size. renal insufficiency is a frequent complication of septic shock. aminoglycosides are highly potent bactericidal antibiotics that together with beta-lactam antibiotics will result in a broad antibacterial coverage. yet, the use of these antibiotics in the treatment of early gram-negative septic shock has been hampered by the assumption that aminoglycosides may be nephrotoxic even in short term therapy. as this is very difficult to investigate in the clinical setting, an experimental study was set up, the aim of which was to evaluate whether the addition of tobramycin further deteriorates kidney function in pigs with endotoxin-induced renal damage. the animals were anaesthetised, catheterized, mechanically ventilated and randomised to groups. groups i (n= ) and ii (n= ) received endotoxin infusion in a dose of mcg x kg- x h- for h, whereas groups iii (n= ) and iv (n= ) received corresponding amounts of saline. groups i and iii received a -min infusion of tobramycin sulphate in a dose of mg x kg- starting minutes after the initiation of the endotoxin infusion, whereas groups ii and iv received corresponding amounts of saline. in parallel with the tobramycin/saline infusions, a cefuroxime infusion in a dose of mg x kg- was given to all pigs. renal function was evaluated by cefuroxime clearance, creatinine clearance, plasma cystatin c, plasma urea, urine output and urine nag (n-acetyl-beta-d-glucoaminidase) excretion. there was no significant difference in physiological baseline variables between the groups of pigs. the elimination rate of cefuroxime - h decreased in both endotoxemic groups whereas it was constant in the non-endotoxemic groups. at h cefuroxime concentration and cystatin c were higher in endotoxemic vs. non-endotoxemic pigs (p< . and p< . , respectively), whereas urine output and creatinine clearance were lower (p< . for both). however, there were no differences between groups i and ii or iii and iv in cefuroxime elimination, urine production, cystatin c or creatinine clearance. plasma urea and urine nag did not differ between any of the groups. endotoxin in the dose administered caused a significant renal dysfunction in this porcine model. the results indicate that the addition of a high single dose of tobramycin seems not to further aggravate the endotoxin-induced renal injury.grant acknowledgement. this work was financed by grants from the nielsen-olinder foundation. the overall nosocomial infection rate was decreased in the chx-treated patients by % ( / vs / ; p< . ). we also noted a % reduction in the incidence of total respiratory tract infections in the chx-treated group ( / vs / ; p< . ). gram-negative organisms were involved in significantly less (p< . ) of the nosocomial infections and total respiratory tract infections by % and %, respectively. no change in bacterial antibiotic resistance patterns in either group was observed. a reduction in mortality in the chx-treated group was also noted ( / : . % vs / : . %). inexpensive and easily applied oropharyngeal decontamination with chx oral rinse reduces the total nosocomial respiratory infection rate in patients undergoing off pump cabg surgery. this results in significant cost savings for those patients. staphylococcus aureus (mrsa) has sparked development of alternative anti-microbial strategies. one such approach involves the use of light-activated antimicrobial agents (photosensitisers), termed photodynamic therapy (pdt). following excitation of the photosensitiser by light of an appropriate wavelength, singlet oxygen and free radicals are generated locally which directly attack the plasma membrane and lead to bacteriolysis. although pdt is well established as an oncological treatment, its use in the treatment of wound infections, in particular those involving resistant strains of bacteria, has yet to be established. after anaesthesia and depilation, week old female c black mice received either a single excisional wound or a superficial scarified wound that were immediately inoculated with an emrsa- bacterial suspension ( cfu/wound) and treated after hour with pdt using methylene blue (mb) as the photosensitiser and laser light with a wavelength of nm to a dose of j.cm − per wound. at the end of treatment, the wounds were excised and processed to assess the total number of viable bacteria per wound. two further experiments investigated the heating effect of pdt and possible collateral damage caused by pdt. three control groups were used to sequentially test the effect of mb alone, light alone and an untreated group which received neither mb nor light illumination. pdt treatment resulted in at least a log reduction (p< . mann whitney-u test) in the number of viable bacteria isolated from the wounds (figure) . there were no obvious histological differences between pdt-treated and untreated wounds. the temperature of the treated wounds rose by an average of . ˚c (± . ˚c) at the end of the treatment.conclusion. pdt is effective in reducing the total number of viable mrsa in an inoculated wound and this effect is not due to local heat generation. there were no gross histological changes apparent between pdt-treated and untreated inoculated wounds. candida species have become the third most common nosocomial bloodstream isolates worldwide. an early adequate treatment is undoubtedly a major prognostic factor. on the basis of efficacy and cost considerations, the empirical treatment often consists in fluconazole administration. yet, given the ever increasing incidence of potentially azoleresistant species such as candida glabrata (which currently accounts for one fourth of cases), this therapeutic option may be ineffective and result in subsequent poor prognosis. moreover, definite identification of candida glabrata may take up to five days, thus delaying modification of initial antifungal therapy and further impairing prognosis. the purpose of this study was to identify early risk factors for candida glabrata candidemia, likely to guide and improve the efficacy of the empirical treatment. all non neutropenic patients with blood culture-confirmed candidemia were included in this prospective study, performed in five french icus. for each patient, baseline characteristics and potential risk factors for candida glabrata candidemia available at candidemia diagnosis were collected. comparisons between patients with and those without candida glabrata candidemia were based on student's t-tests or chi-square tests, as appropriate.variables with a p value < . were entered into a multiple logistic regression model to determine independent risk factors for candida glabrata candidemia. of the patients included over a -year period, had a candida glabrata candidemia. independent risk factors for candida glabrata candidemia were: age > yrs (odds ratio -or- . , p < . ), recent abdominal surgery (or . , p < . ), recent use of cephalosporins (or . , p < . ), solid tumor (or . , p = . ), and diabetes mellitus (or . , p = . ). the model showed satisfying goodness of fit (hosmer-lemeshow statistic = . ) and discrimination (auc = . ). we found early available and easy-to-identify risk factors for candida glabrata candidemia. when these factors are present, alternatives to fluconazole for the empirical treatment should be considered. ventilator-associated pneumonia (vap) is an airways infection that must have developed more than hours after the patient was intubated. vap is the leading cause of death amongst hospital-acquired infections, exceeding the rate of death due to central line infections, severe sepsis, and respiratory tract infections in the non-intubated patient. hospital mortality of ventilated patients who develop vap is percent compared to percent for ventilated patients who do not develop vap.[ ] reducing mortality due to ventilator-associated pneumonia requires an organized process that guarantees early recognition of pneumonia and consistent application of the best evidence-based practices. the ventilator bundle is a series of interventions related to ventilator care that, when implemented together, will achieve significantly better outcomes than when implemented individually. to evaluate the implementation effect of a vap bundle in a general intensive care unit (icu), with the utilization of a software house made designed for this goal.(http://www.bundles.com.br) in a bed general icu, implementation of the bundle was done over months beginning on january . the key components of vap bundle are: elevation of the head of the bed; daily "sedation vacations"; ventilation tube with subglotic aspiration system; peptic ulcer disease prophylaxis; deep venous thrombosis prophylaxis; oral feeding tube instead of nasal feeding tube and oral hygiene with chlorexidine twice a day. we compared the incidence density rate from april to december to the same period in (software stata . ). the vap incidence rate reduced from , / to , / mechanical ventilation days (p< , ) -incidence rate ratio , (ci: % , - , ). after months, the rate of vap was zero. this period was the lowest incidence of vap ever registered in the icu. the incidence of multi-resistant gram-negative bacteria infections was also the lower than before bundle implementation. after five months of a vap bundle implementation with the aid of software house-made to help clinicians follow the results in daily basis, has demonstrated an important reduction in the incidence of vap in our icu. the impact of this system implementation for longer period should be followed. amphotericin b desoxycholate (ampho b) has been nebulized in transplant patients to prevent aspergillus infections, but also as part of selective digestive decontamination (sdd) to decrease fungal colonization and infection in critically ill patients. severe adverse effects of ampho b after systemic administration, particularly nephrotoxicity, led to its substitution by less toxic antimycotics. however, it is still unknown whether even small amounts of ampho b found systemically after inhalation therapy ( ) may be associated with organ dysfunction and increased mortality in critically ill patients subjected to sdd prophylaxis. topical (polymyxin, tobramycin, ampho b) and systemic (cefotaxime for days) antimicrobial chemotherapeutics were routinely administered to ventilated surgical patients who were expected to remain in the icu for more than hrs. a prospective observational study was conducted to accompany the change in sdd regimen ( months of data collection with nebulization of ampho b ( mg every hrs) and months without). conclusion. the use of nebulised amphotericin b as part of a sdd prophylaxis was associated with an increased incidence of renal failure and increased mortality in this study. in the view of the nephrotoxic properties of ampho b, this finding may be potentially explained by systemic effects after prolonged drug inhalation in predisposed critically ill patients. however, in the ampho b group, there were a slightly higher percentage of patients suffering from pre-existing diabetes and renal insufficiency, and potentially nephrotoxic antibiotic regimens were administered more frequently in the study period. drainage for septic focus is the most important process in the management for severe sepsis and septic shock. however, there is no reliable evidence concerning the drainage technique, because the condition is usually so complexed and various that there can not be managed with the uniform standard technique. we have preferred double luminal drain with continuous high pressure aspiration method (dld-chpa) in patients with these conditions. the aim of this study is to clarify the effectiveness and safetiness of dld-chpa by clinical experience.methods. dld-chpa was performed for septic foci. the effectiveness of drainage was examined before and after dld-chpa. the structure of dld is same as that of aspiration device used during surgery which consists of outer tube with multiple pore and inner tube directly connected with high pressure aspirating central vacuum system. the aim of dld-chpa is rapid and continuous removing of discharge and pus, to maintaining dry condition of the abscess and fistula, and stimulating granulation; which leads (a) to quickening the closure of the abscess and fistula and (b) prevention of worsening of local condition of localized abscess and leaking point of injured intestine until definitive surgery. mean grade of discharge soaking in gauze, a wash recovered in intermittent lavage, local inflammation of skin surrounding drain (dld) improved after dld-chpa. mean volume of discharge from wound and drain other than dld was depressed after dld-chpa. the sum of volume of discharge and aspirated material after dld-chpa is smaller than before dld-chpa. the frequency of dressing change was decreased. in all cases, we could perform definitive surgery without worsening of local inflammation, especially inflammation of skin around drain. there was no complication with dld-chpa.conclusion. dld-chpa is useful and safe procedure for managing septic foci by draining mucinous purulent fluid effectively, which can prevent worsening of local condition of localized abscess, and keeping the local condition good until definitive surgery, if definitive surgery is necessary. to evaluate pre-dialysis full-dose aminoglycoside administration in septic anuric critically ill patients. in a prospective observational study, all septic patients with anuria received fulldose gentamycin (g), tobramycin (t) or amikacin (a) consisting in a mg/kg (g/t) or mg/kg (a) dose, infused hours before daily dialysis. the pharmacokinetic study of serum dosages was compared to that of septic patients with normal renal function. dosages were compared to that of patients with normal renal function who received infusions and served as controls. anuric patients' demographic data were as follow: mean age [iqr - ], mean saps ii [iqr - ], former renal failure %, respiratory tract infection %, nosocomial infection %, icu mortality %. pre-determinated aminoglycoside peak concentration targets for g/t ( - mg/l) and a ( - mg/l) were achieved in respectively % and . % of anuric patients versus and % of controls. compared to target (theoretically non-toxic) trough mg/l for a), trough concentrations in≤ mg/l for g/t and ≤concentrations ( anuric patients were higher (g/t : median . mg/l; a: median . mg/l) than in normorenal patients (g/t : median . mg/l; a: median . mg/l). with aminoglycoside clearance due to intensive dialysis (median kt/v . / session), delay in aminoglycoside infusion was reduced to hours with an observed half-life of . hours.conclusion. this pilot study supports the feasibility of a new aminoglycoside dosing schedule consistent with full-dose administration three hours before dialysis in anuric septic critically ill patients. the prerequisite is that hemodialysis should be performed daily, using high efficacy membranes. further randomised controlled trials are needed to confirm these results. conclusion. mortality in gram negative nosocomial infection remains high but the impact is greatest for nf-gnb due to their intrinsic resistance to many antibioitics, making selection and optimal therapy difficult. in our population, bsi due to nf-gnb was not associated with significantly increased mortality. this could be explained by older age in f-gnb cf nf-gnb. our study highlights the importance of risk stratification to identify patients at risk. empirical combination antimicrobial therapy (ecat) has been recommended for bacteraemia due to gram positive microorganisms during many years, especially for streptococcus pneumoniae, although its use still remains controversial. the aims of this study were to determine the prevalence of ecat in icu patients with gram positive bacteremia (gpb), to describe the main clinical, epidemiological and microbiological features of such patients comparing with monotherapy treatment and to know the impact of this strategy on related mortality to gpb in critically ill patients. during a ten years and a half period, from to , icu-patients with gpb were prospectively evaluated. empirically antibiotic combination or monotherapy regimen was administrated until the agent of infection was identified following the patient's physician criteria. the administration of two or more antibiotic with activity against gram positive microorganism was defined as ecat. clinical and microbiological variables were recorded. logistic regression analysis was performed to deterrmine the impact of this strategy on related mortality to gpb. there is evidence that current practice could be improved. to achieve this, teaching and assessment techniques that are acceptable to both consultants and trainees must be developed. in other specialities video is used to teach communication skills, although its application to intensive care training has not been widely studied. after obtaining ethics approval, specialists in intensive care at general hospitals in the north-east of england were invited to take part in the study. participants were given a written scenario describing the admission to the icu of an elderly woman with pneumonia. data was included which suggested deterioration despite treatment and progression toward multi-organ failure. the consultants were then videoed conducting an initial meeting with the patient's closest relative (played by an actress). questionnaires were used to record previous experience of communication skills training and reaction to the video exercise. . consultants gave written, informed consent to take part. only half of the participants had previous, limited experience of audio or video recording to teach communication skills. none felt 'significantly experienced' in this area or had used the technique with trainees. most had developed their communication skills by sitting-in as an observer when colleagues were talking to relatives. participants stated they had never had any formal teaching in communication skills either through lectures, workshops or role-play. the plausibility of the scenario and actress were rated highly by all the participants. despite individuals choosing to agree with the statement 'i was anxious and uncomfortable throughout the video exercise', none of the respondents disagreed with the statement 'i managed to settle into the normal style i use when speaking to relatives'. only participants did not support the statement 'overall i feel happy with the way the consultation went'. of the participants disagreed or strongly disagreed with the statement 'i feel the video does not represent my normal practice of speaking to relatives.'conclusion. this study shows that video techniques can be used to reproduce realistic intensive care scenarios. the format was well received by a majority of specialists and despite no previous experience of being filmed, participants felt that the simulation closely replicated their normal practice. teaching-training would be required to introduce these techniques as current specialists have received little formal training in communication skills. during a two-month period, consecutive adult icu patients (sapsii score: ± ; ventilated patients) requiring a transthoracic echocardiography were prospectively studied. after a curriculum including a -hour training course and hours of hands-on, one of noncardiologist residents and an intensivist experienced in ultrasound subsequently performed hand-held echocardiography (hhe), independently and in random order. assessable "rule in, rule out" clinical questions were purposely limited to easily identifiable conditions by the sole use of two-dimensional imaging. cricoid pressure should be applied lightly ( n) before induction of anaesthesia and while the patient is still awake. once the patient is unconscious the force should be increased to n (vanner & asai, ) . a simple training aid using an air filled, capped ml syringe has been described (ruth et al., ) , but a lack of knowledge and poor technique amongst anaesthetic assistants has already been highlighted (meek et al., ) . the aim of this study was to investigate knowledge and skills of a group of intensive care unit nurses in performing cricoid pressure, using a structured interview questionnaire and simple practical test. we asked intensive care nurses from queen elizabeth hospital, birmingham uk to participate in a structured interview. volunteers were asked about their own experience, training and knowledge of cricoid pressure in a questionnaire conducted by one of the authors. each subject was then asked to apply the force that they would normally use in clinical practice to the plunger of a plastipak (b-d) ml syringe filled with air. the destination of the plunger was recorded (ml). the subjects were then informed of the recommendations stated above and allowed to practice the application of n on the syringe ( . ml standard destination). they were than asked if they thought a simulator would be useful for training. . % respondents (n= ) were staff nurse with to years experience, and % performed cricoid pressure less than monthly. only % nurses had formal training and % described their training as 'totally inadequate'. . - % nurses applied and released cricoid pressure only on instruction by anaesthetist and . % respondents did not know the optimum force to use. on simulation, the mean force applied was nearer n than n (mean plunger destination . ml, less than . ml standard. s.d = +/- . , variance = . ). of ( . %) respondents thought simulation training would be useful. intensive care nurses perform this procedure infrequently and become deskilled. this study also highlights the inadequacy of training they receive. using a readily available training aid such as a ml syringe is reliable and may improve staff confidence, performance and patient safety. j. m. boles* , g. prat , a. berthouloux , b. seys , a. renault réanimation médicale, hôpital de la cavale blanche -chu, psychothérapie, société civile alternatives, brest, france the policy of our -bed medical icu includes helping members of the staff to cope with the burden of job stress. our university hospital agreed to finance a focus group to help staff relieve their stress. we performed an evaluation months after. a first non-anonymous survey was conducted in / amongst the staff to know who was willing to attend a focus group. an independant family therapy psychologist was selected out of candidates. a focus group was set up in / open to any volunteer; -hour monthly reunions were conducted by the psychologist. an anonymous questionnaire was sent to all staff members in / . initial survey: mds/ , daytime nurses/ ( night nurses/ ), / auxiliary nurses,the secretary and the chief nurses agreed to attend = , % of the daytime staff. the group held reunions, attended respectively by , , and members of the staff. the group was then suspended. anonymous evaluation: / staff members answered = , %. conclusion. ) in a two hour icu oriëntation in the undergraduate curriculum the icu nursing staff was as successful as the medical staff in improving understanding of the icu organization as well as in improving the ability to recognize vital organ functions and principles of the monitoring of critically ill patiënts. this study suggests that icu nursing staff can enhance learning the basic practical monitoring of undergraduates and can be successfully integrated into undergraduate medical education. in meeting the needs of increasing numbers of medical students there is a potential for this role to be to developed. ) interest to qualify as an intensivist increased significantly when the intensivist was the teacher. guidelines for cpr teach us to do chest compression per minute and to ventilate for a minimum time. however, paramedics tended to do chest compression more quickly and to do ventilation more slowly. in japan, prehospital cpr has been performed by emergency life support techniciens (elst), who belongs to the fire department. in this study, we tried to clarify the actual condition concerning prehospital cpr. japanese elsts are licensed after hours of lecture and , hours of experience, and they are trained repeatedly. in yokohama, one supporting medical doctors is working in the central operation center of the fire department. they can detect the frequency of chest compression and ventilation during cpr in the ambulance. we recorded these frequency for and evaluate the quality of cpr by elst.results. in our system, elst performed chest compression times per . sec, that meant times per minute. they perfom ventilations for . sec. we should train elsts more frequently and repeatedly and should use metronome, voice guide or aed with voice guide during cpr in the ambulance. tracheostomy is often required in icu patients to prevent the consequences of long term translaryngeal intubation, indicated in prolonged mechanical ventilation and long term airway maintenance. it has lots of benefits like increasing patient comfort, less need for sedation, improving oral and bronchial hygiene, allowing oral nutrition, and ease the process of weaning from mechanical ventilation. percutaneous tracheostomy (pct) as opposed to surgical tracheostomy (st) has many advantages: it can be made at bedside (and be performed immediately once the decision is made), being safe and easy, with less operative time, and less intra and early postoperative complications (reduced stomal bleeding and infection, due to the tamponade effect of the tightly fitting tracheostomy tube). it is also associated with lower costs and has better cosmetic results than st. the aim of this study is to compare the timing and outcomes of tracheostomies in our icu, and hospital mortality of these patients. we conducted a retrospective comparative study in distinct periods: and , when all patients in our icu were submitted to st (n= ); and and when patients were preferentially submitted to pct (n= ). we reviewed their indications for tracheostomy, age, gender, apache ii and saps ii score, days to tracheostomy, length of icu stay, ventilation time before and after tracheostomy, icu and hospital mortality. the results presented are in mean values. conclusion. )there was no significant difference in indications for tracheostomy (prolonged mechanical ventilation and airway protection in comatose patients), age( ), gender, mean ventilation days prior to( , ) and after ( , ) tracheostomy. )pct was performed sooner ( , vs , day), and these patients had a sooner icu discharge ( , vs days). )patients submitted to st had higher apache ii( , vs , ) and sapsii( , vs , )scores; higher icu( % vs , %) and hospital mortality ( % vs , %). reported here. the study was carried out in finland. the expert panel was formed of intensive and critical care nurses and physicians of five university hospitals and four central hospitals. altogether (=n) experts participated in first round. the experts completed a questionnaire which consisted of demographics and one essee question. text were analysed according to research questions by content analysis. competence requirements in intensive and critical care nursing can be described as five main domains: specific ) knowledge base, ) skill base, ) attitude and value base and ) experience base of intensive and critical care nursing. additionally competence can be described as several ) personal attributes of competent intensive care nurse. competence requirements can be divided into clinical and professional competence requirements. the sub domains of clinical competence requirements are implementation of principles of nursing care, implementation of clinical guidelines and implementation of nursing interventions. the sub domains of professional competence requirements are then ethical activity, decision making, development work and collaboration.conclusion. competent nurse in intensive and critical care nursing has to have specific knowledge base, skill base, attitude and value base and experience base that differs from overall competence in nursing. additionally competent intensive and critical care nurse has to have spesific personal attributes.grant acknowledgement. we would like to thank the experts of university and central hospitals who participated in this study. to define examine catheter related bloodstream infections (crbsi) over a -year period ( - ) , and compare three expressions of incidence.methods. -bed tertiary referral centre. hospital-wide, total parenteral nutrition(tpn) service based at department of intensive care. quarterly meetings of tpn committee analyse prospectively collected data to examine crbsi incidence. effect of introduction of education protocols and appointment of dedicated tpn nurse were assessed. . patients, cvcs were included. a consistent decline in incidence was observed, % of patients in to % in (figure) . incidence may also be expressed as percentage of cvcs infected, decreasing from % of cvcs to % . finally, incidence is expressed per cvc days which peaked at / cvc days dropping to / cvc days .conclusion. crbsi occurs commonly in tpn populations, but published data remains limited. irrespective of means of expression, our data demonstrates a falling incidence in crbsi, which we attribute to the appointment of a tpn nurse, ongoing education protocols regarding cvc insertion and maintenance. this data supports the pronovost paper that an intervention may result in a sustained decline in the incidence of crbsi. dimension and course of cognitive ability change after elective coronary bypass (cabg) or valvular replacement (vr) interventions are discussed controversely. the aim of our study was ( ) to measure the difference of cognitive abilities concerning attention, memory and fluid intelligence before and after cardiosurgery, ( ) to investigate the outcome difference between cabg-and vr-patients and ( ) to investigate the relevance of duration of bypass-and aortic-clamping as well as duration of anesthesia as predictors of cognitive outcome. subjects: consecutive patients; cabg, vr; timepoints of measurement: t : - days before intervention, t : days and t : - days after intervention: cognitive assessment instruments: d -test (selective attention), rbmt (memory), cft- (fluid intelligence). a significant decline of all measured cognitive functions at t compared to t could be demonstrated for the cabg-(d : p< . ; cft : p< . ; rbmt: p< . ) as well as for the vr-sample (d : p< . ; cft and rbmt: p< . ). both groups showed a remission at t concerning memory and intelligence scores, only vr-patients had persistent deficits in selective attention (p< . ). there were no significant differences between cabgand vr-samples at any time of measurement. no parameter of surgery reached significance as predictor for cognitive outcome in regression analysis. in the early postacute phase ( days) after cabg-and vr-surgery we could show deficits in various areas (attention, memory, fluid intelligence) of cognitive performance as well as rapid remission within one week. despite expectations there were no significant differences between cabg-and vr-samples. abdominal complications in postoperative cardiac population are not frequent but may be catastrophic. non-occlusive mesenteric ischemia appears when there is a mismatch between perfusion and metabolic demands. the symptoms and signs are not incontrovertible and the suspicion of this complication may improve prognosis. indocyanine green plasma disappearance rate (icg-pdr) has been proposed as a tool for the assessment of liver perfusion and function ( , ) so that it may help in diagnosis and to optimize treatment. a prospective study was conducted in cardiac surgery patients. icg-pdr values were measured hours and hours after icu admission transcutaneously by a commercially available system (limon; pulsion medical systems, munich, germany). icg-pdr values and other postoperative data were compared between patients suffering and not suffering from abdominal complications. mann-whitney and wilcoxon tests were applied for statistics. significance was considered when p < . . . patients were analysed but we did not find major abdominal complications. minor abdominal complications were suspected in because they suffer abdominal pain, ileus and higher serum amylase values. this group of patients were older ( ± vs ± , p= . ) and suffer from more hypertension (p= , ). their preoperative risk (numeric eu-roscore) was higher(es num ± vs ± , p= . ) and so was the apache ii score ( ± vs ± , p= , ). twelve hours after icu admission icg-pdr values were lower ( . ± vs ± ,p= . ) and normalized at hours. length of stay (los) was longer (icu-los was ± vs ± , p= . and hosp-los was ± vs ± , p= . ). they had associated more complications : cardiovascular (p= . ), renal (p= . ), neurolgical disorders (p= . ) and infectious (p= . ). procalcitonine (pct) values were also higher(p= . ). they suffer from higher preoperative pulmonary hypertension (pap de ± vs ± , p= . ). cardiac index values were lower hours after admission (ic- . ± . vs ± . , p= . ). serum amylase values were higher in first postoperative day (amy- was ± vs ± , p= . and amy- was ± vs ± , p= . ). and so were aspartate amino-transpherasa (ast) values hours after admission (p= . ). the incidence of gastrointestinal hemorrhage was also higher (p= . ).conclusion. . patients suffering from minor abdominal complications had worse icg-pdr values hours after admission. . they were were older and their preoperative risk and apache ii score were higher. . they suffer more complications and their los was longer. . serum amylase, ast, pct, pap and cardiac index values were worse in these patients. deployment of an intraaortic balloon pump is a technique that is used and recommended in high-risk surgical patients. this group includes patients with haemodynamically significant stenosis of the left coronary artery trunk and ejection fraction minor %, preoperative unstable angina, and intraoperative and postoperative cardiogenic shock. we examined the pre-and post-operative use of an intraaortic balloon pump in our surgical series and its association with morbidity and survival. we undertook a prospective, observational, cohort study of patients who underwent cardiac surgery with extracorporeal circulation between january -june who were admitted to the polyvalent intensive care unit of our third-level hospital. the data collected were analysed statistically with spss . . the study included patients, with a mean age of . ± . years and % were men. the incidence of iabp were: preoperative . %, intraoperative . %, postoperative . %, technically imposible . % and no need of iabp . %. % had some degree of surgical morbidity (including atrial fibrillation). the overall mortality was % and the mean stay was . ± . days (range, - days). the indication were: ejection fraction %, unstable angina %, vessel disease %. after an univariate analysis iabp and postoperative complications there was relation with low output or shock (the indication of iabp, p< . ). the others postoperative complications (mechanical ventilation > h, kidney failure, important haemorrhage and perioperative infarction) were no relationed and has the same incidence as the moderate-low risk interventions.conclusion. the intraaortic balloon pump is a commonly used technique in high-risk patients, reducing the incidence of postoperative complications to the limits of those in moderateor low-risk patients. mecc is a new approach to cardio-pulmonary bypass (cpb). the system differs from conventional bypass (cpb) as follows: minimal priming volume (< ml); no venous reservoir (closed system); active venous drainage; no cardiotomy suction; heparin coating (tip-tip). practical advantages of mecc include: minimal haemodilution; no blood-air interface; reduced foreign-body contact; less haemolysis; reduced heparin given. potential improvements in clinical outcome in icu as a result include: reduced requirement for inotropes; fewer blood transfusions; less systemic inflammation; reduced coagulopathy; improved endorgan function. these factors combine [ ] to significantly reduce prbc transfusion (u/patient) requirements with mecc ( . ± . ) compared with cpb ( . ± . ), or opcab surgery ( . ± . ). mecc has recently been introduced in the swcc for routine cabg surgery. intraoperative data were collected for quality control purposes (n= ), compared with historical controls (same surgeon and anaesthetist) but with cpb (n= ). conclusion. an improved haematological profile (seen here with hb, but theoretically reflected in other blood components) with mecc may reduce postoperative coagulopathy, costs and risks associated with blood and other blood product transfusion, and improved oxygen delivery and therefore end-organ function. g. satkurunath*, p. wilton intensive care and anaesthesia, harefield hospital, harefield, united kingdom cardiothoracic units have high usage of intensive care unit (icu) beds and patient flow-through affects their continued productivity and cost-effectiveness. prolonged icu stay patients are a small percentage but consume a disproportionate amount of resources and have a higher mortality. our aim was to determine the type and the outcome of icu patients requiring prolonged stays at our institution to determine if resources were used appropriately on patients with a reasonable chance of survival. our institution is a cardiothoracic hospital specializing in adult cardiothoracic surgery and transplantation. a retrospective analysis of the institution icu database was performed and all admissions with a duration ≥ days from april to march were identified. the medical records of these patients were reviewed to determine individual risk factors for prolonged icu stay. this data was compared to the overall icu outcome audit data for that year. there were a total of icu admissions of which ( . %, patients) were ≥ days. the median icu length of stay in the study group was . days (range - ). the patients had a cumulative total of bed days which was . % of the total icu bed days ( ). icu mortality was . times greater than the overall unit mortality ( . % versus . %). mean and median age was similar to that of the overall unit. the percentage of readmissions in the study group was . times greater than the overall percentage ( . % versus . %). in the prolonged stay group patients ( . %) survived the hospital admission: were discharged home and were transferred to another hospital for further rehabilitation. cardiac surgery necessitating cardiopulmonary bypass involves periods of ischaemia followed by reperfusion. reperfusion of previously ischaemic tissue may itself result in tissue damage through the activation of neutrophils, production of oxygen free radicals and endothelial damage. this phenomenon has been termed ischaemia reperfusion injury (iri). the consequences of iri may be observed locally in the form of reversible cellular dysfunction or more remotely with effects observed in the lung, liver and cardiovascular system. ultimately, a systemic inflammatory response syndrome (sirs) may develop with the potential to progress to multiple organ failure in the most extreme cases. remote ischaemic preconditioning (ripc) is a technique which provides protection against experimental iri in humans. we performed a randomised controlled trial to investigate the effect of ripc on patients with triple vessel coronary artery disease undergoing cabg surgery (n = ). ripc was induced by cycles of minutes of inflation ( mmhg) and deflation of a blood pressure cuff around the upper arm hours prior to surgery. patients were assessed post operatively for the development of sirs. blood samples were collected up to hours post operatively. myeloperoxidase (mpo), interleukin- (il- ), c-reactive protein (crp), and von willebrand factor (vwf) were measured as biochemical markers of neutrophil activation and endothelial damage.results. sirs developed in % of patients who had undergone ripc compared to % in the control group (p = . ). mpo, il- , (table ) crp, and vwf (table ) were elevated post operatively but no protection was observed in patients pre-treated with ripc. of note, the study was not powered to measure these variables as the primary outcome and thus it is possible that a protective effect may be observed in a larger study population. gender differences in the coronary bypass surgery have been the focus of numerous publications in recent years. compared to men, women undergoing coronary artery bypass grafting appear to have a higher morbidity and mortality, particular in the perioperative period. the aim of this study was to analyze which clinical parameter and laboratories data effect on gender differences in postoperative course. . to the end of december .,all patients on whom were performed elective coronary bypass surgery were included in this retrospective study. age,ef,euroscore,numbers of days in jil,total numbers of day in hospital stay, troponin t (t - hours after addmision,t - hours after addmision in jil),lactate (l ,l ),cardiac output,cardiac index were observed. for all variables was made descriptive statistics. we used student-t test and mann-whitney u test. . patients ( m and f)were observed. analyzing age, ef,euroscore,cardiac output and cardiac index we did not find statistical important differences man versus female. analyzing troponin t, level of lactate (particulary l )we found statisticaly important higher levels in women group. women needed longer support with inotropes and are more likely to spend longer time in the hospital. fortunately, the last decade has produced a surge of public interest and scientific research in womens health, including gender issues related to cabg. it is now well accepted that there are major differences in the risk profile of man compared to the profile of woman undergoing cabg procedures. even when both genders share a common risk factors, the relative impact of risk factor is often quite different in man as compared to woman. w. baulig* , v. hinselmann , m. lachat , k. rentsch , e. schmid devision of cardiac anaesthesia, department of cardiac surgery, institute of clinical chemics, university hospital zurich, zurich, switzerland reports regarding the benefit of continuous local analgesia after various surgical procedures are conflicting ( ). the aim of this prospective, randomized, double-blind study was to investigate the efficacy of continuous local anaesthesia using the pain relief system (i-flow corp, usa) in patients after abdominal aortic surgery. after closing the peritoneum, two multi-hole catheters (length cm) were placed in the opposite direction of the skin incision. following skin closure, both catheters were connected to the elastomeric pump filled with ml of an unknown solution (either sodium chloride [nacl] . % or ropivacaine . %) and a continuous infusion of ml.h- was started through each catheter. every hours until h after surgery combined visual analog pain scale (vas) and numeric rating scale (nrs), partial oxygen (pao ) and partial carbon dioxide pressure (paco ), arterial oxygen saturation (sao ), pulse rate, and mean arterial pressure were recorded. the serum concentration of ropivacaine, free ropivacaine and alpha- -acid glucoprotein were measured daily. the total amount of intravenous morphine sulphate and nonsteroidal analgetics, ventilation time, length of stay in the icu, and the condition of the removed catheters were documented. sixteen patients were enrolled, but one patient had to be excluded because of accidental catheter removal at icu arrival. demographic and surgical data were not different between groups. ropivacaine was applied in , nacl . % in patients. vas/nrs was lower in the ropivacaine group during the first postoperative hours ( . ± . ) than in the control group ( . ± . ), but this difference did not reach statistical significance. no significant intergroup differences were found with regard to morphine sulphate, metamizole and paracetamole consumption, pao , paco , sao , ventilation time and length of stay in the icu. serum concentrations of free ropivacaine ( . ± . µmol/l) were well below toxic levels ( . ± . µmol/l). in two thirds of the removed catheters > % of the holes were closed. . ± . . ± . metamizole (g) . ± . . ± . continuous infusion of ropivacaine . % ml.h- using two multi-hole catheters at the surgical site in patients after abdominal aortic surgery did not reduce the consumption of intravenous morphine and nonsteroidal analgetic drugs. introduction. prognostic scores have been developed for assessing patients's risk of complications or death and are useful to identify high risk patients allowing specific interventions. surgical scores have been developed but it is still not clear if they offer any benefit compared to general icu scores. the aim of this study was to compare the accuracy of the scores apache ii, apache iii and p-possum in a brazilian surgical intensive care unit. consecutive surgical patients admitted in the surgical unit were included prospectively from august to march . cardiac and neurosurgery, age < and length of stay in the icu < h were excluded. after exclusion, the scores were applied in patients. we compared actual in-hospital mortality with those predicted by the apache ii, apache iii and p-possum scoring systems applying receiver operating characteristic (roc) curve analysis by integrated methods using r-system . . . the physiological parameters of p-possum score were obtained in the postoperative period. the operative parameters in orthopedic surgery were adapted. the most common surgeries were: abdominal surgery ( . %), orthopedic ( . %), urologic ( . %), vascular ( . %), bariatric ( %) and thoracic ( . %). procedures done before h of hospital admission were and before h of admission were . the average number of days in icu was . (+- . ) and the mean number of postoperative days before discharge was . (+- . ). the rate of icu readmission in days was . %. the median age was years. overall hospital mortality was . %. the mean absolute values of apache ii, apache iii and p-possum were . (+- . ), . (+- . ), . (+- . ) and mean predicted in-hospital mortality were . %, . % and . %. respectively. the area under the curve from receiver operator characteristic curve analysis for apache ii was . , for apache iii was . and for p-possum was . . these data suggest that p-possum may provide a better estimate of the risk of mortality than apache ii and is at least as accurate as apache iii. p-possum requires fewer individual patient parameters to be calculated and is thus easier than apache iii to be generated. preeclampsia is a multisistemic disease that may occur in pregnancy or in the immediate post-partum period. the incidence of pregnancy induced hypertensive disease is observed in . % in spain. we analise the mortality and the clinical profile of this entity in our icu. the study comprise prospectively women admitted in icu with the diagnose of severe gestosis, from january to october . we define preeclampsia, eclampsia and hellp syndrome as used by the american college of obstetric and gynecology. we consider hellp as a different disease as its mortality rises up to a %. cualitative variables are shown as percentage and cuantitative variables as mean ± standard deviation or median and range in asymmetric variables. we used chi square test, t-test and multivariant testing for statistical analysis of the data. we report data from women admitted in icu in the period january . we didn't find significant difference on systolic pressure between preeclampsia, eclampsia or hellp nor in uric acid levels. there were significant differences in aminotransferase enzymes and platelet count between preeclampsia-eclampsia and hellp. gestational age was significantly lower in preeclampsia than in eclampsia or hellp (p< , ) and, additionally, the weight of newborn were significantly lower in preeclampsia versus eclampsia and hellp. fetal death is associated with a birth weight below gr (p< . ), or . , ci % ( . - . )). maternal death is associated with renal failure, heart failure or coagulopathy (p< . ) or . (ci % . - . ). multivariant analysis show that primiparity appears as a protection versus mortality, p< . or . (ci % . - . ) and pulmonary oedema as a risk factor p< . or . (ci % . - . ). fetal mortality is associated in multivariant analysis with gestational age and consequently with low weight (p< . ) and (p< . ) respectively, or . , ci % . - . and or . ci % ci . - . respectively. women admitted to the icu are mostly years old, in the week gestational age of their first pregnancy. in our environment, delivery mostly occurs in the following to days of admission. maternal mortality is low but not so fetal mortality that rises up to , %. maternal mortality is associated with multiparity and complications such as pulmonary oedema, and fetal mortality mostly with gestational age and low birth weight. in order to reduce postoperative morbidity and mortality following liver resection due to hepatic failure it is important to carefully monitor liver function. as lactate is mainly cleared by the liver, it has the potential to be a good indicator of liver performance. many factors may determine liver function, such as the extent of the liver resection, pre-existent liver conditions, the amount of blood loss, and other patient and operation characteristics. we assessed the value of fast and inexpensive point-of-care lactate measurements as an indicator for liver function next to prothrombin time which is the current standard. in a retrospective observational study we included all patients admitted to the surgical icu after liver resection between april and march . lactate levels were frequently measured in arterial blood with a point-of-care device (abl radiometer). maximal lactate during the first hours after icu admission were determined. extent of liver resection, preoperative liver condition and red blood cell transfusions were recorded. . patients were studied ( males, females) with a median age of years (range - ). abnormal liver parenchyma was present in ( %) patients. in patients, more than % of the liver was resected (major resection). red blood cells were administered in patients with a mean of . (± . ) packed cells. lactate measurements were performed during the first postoperative day. multivariate analysis with the parameters volume percentage resected, peri-operative blood loss, age, gender, preexistent liver condition, showed that the extent of liver resection was significantly associated with lactate levels (p= . ). mean lactate levels were respectively . for major resections and . for minor resections. blood lactate levels were significantly correlated to pt (pearson's r= . ; p< . ).conclusion. the extent of liver resection was an independent predictor of lactate levels. age, gender, amount of blood loss and preexistent liver disease were not associated with lactate levels. lactate levels were clearly correlated with prothrombin time. phaeochromocytoma is a rare chromaffin cell tumour predominantly arising in the adrenal medulla. following pharmacological control, elective surgical excision is performed ( ). postoperative admission to itu is standard as cardio-respiratory, renal and metabolic complications (hypertension, hypotension, pulmonary oedema and hypoglycaemia) may occur ( ) . the aim of this study was to identify postoperative complications following adrenalectomy, requiring critical care support. the data collected would allow us to evaluate the statement that, 'not every patient following adrenalectomy for phaeochromocytoma requires itu admission'. over years, adrenalectomy patients with a clinical, laboratory and histological diagnosis of phaeochromocytoma, were studied retrospectively. twenty three patients were identified from clinical databases and data collection followed a review of the perioperative records.results. % of the adrenalectomies were open, the remainder were laparoscopic ( were converted to open). multiple anaesthetic techniques were used by four anaesthetists. % arrived on itu intubated, but extubation followed within to hours. with a map between and mmhg, % received postoperative inotropic support (noradrenaline . to . mg/h) for to hours. one patient ( %) required inotropic support for hours and remained intubated for hours. six developed postoperative respiratory infections ( % were open adrenalectomies); one of which required reintubation, ventilation and inotropic support. all of those that developed respiratory infections had morphine infusions or pca for analgesia. although the difference between the preinduction and peak intraoperative blood pressures (systolic and mean) were smaller in those receiving remifentanil, it was not statistically significant.conclusion. ) following adrenalectomy for phaeochromocytoma, few patients experienced significant perioperative morbidity and the traditional practice of electively admitting all patients to the itu, should be reviewed. ) an experienced team approach ( ) is more likely to limit perioperative complications than using surgical duration, tumour size and urinary catecholamine concentration to predict postoperative complications ( ). ) standardising the anaesthetic technique could increase the 'in theatre' extubation rate. ) the routine use of epidural analgesia may reduce the incidence of postoperative respiratory infections and may influence the incidence of reintubation. ) the role of remifentanil requires further investigation but prior to venous ligation of the tumour, it appears to improve intraoperative haemodynamic stability. thoracoabdominal aortic aneurysm (t(a)aa) repair is associated with major blood loss exceeding the intravascular volume and complex perioperative coagulopathies requiring transfusion of blood products. there have been three reports evaluating bloodproducts needs in t(a)aa repair. the combination of surgery induced tissue damage and massive blood products transfusion may enhance post operative organ dysfunction and infections. mortality in cabg surgery is associated with number of bloodproduct transfusions. in t(a)aa surgery this relation has not been studied. this question might be of clinical importance as elective t(a)aa repair is associated with considerable mortality ( - %) and morbidity (e.g. respiratory failure - %). in this retrospective single centre study we identified all consecutive patients with taa(a) surgery during the period - . patients records in an icu database and transfusion database were combined and evaluated. baseline characteristics, apache ii score, respiratory failure (ventilator support > hours), transfusion and mortality data were collected. association between variables was determined with multivariate regression analysis. in all patients cellsaver was used. results. patients underwent t(a)aa surgery in the study period. patients ( ( . %) male and ( . %) female) were identified in both databases. the mean age was . ± . years. in hospital mortality was . %. mean apache ii score in the first hours was ± . rbc transfusion results in an significantly increased mortality risk (or . ( %ci . - . )). rbc transfusion was significantly associated with respiratory failure (or . ( %ci . - . )). increased post operative apache ii score results in significantly more rbc infusion (p< . ). these findings could not be demonstrated for ffp and platelets infusion. we did not find a significant difference in blood transfusions and extent of aneurysm, as found by others. our quantity of blood transfusion is much less than reported previously (with and without cellsaver use). conclusion. large volume of blood transfusion may be necessary during and after t(a)aa surgery. rbc transfusion is associated with increased mortality rates. as apache ii score is related to rbc transfusions, peri operative optimalisation might contribute to less blood transfusions. blood transfusion in our population is less than reported previously. cardiac surgery is occasionally complicated by refractory postcardiotomy bleeding, leading to increased mortality and morbidity. recombinant activated factor vii is being increasingly used as rescue therapy in such cases. we report our experience with the use of rfviia in our -bed csicu. all patients who received rfviia as rescue therapy for intractable bleeding during or after cardiac surgery over a -year period was analyzed. we assessed and compared the use of blood products (rbc, ffp, plt), coagulation indicators (international normalized patio [inr] , activated partial thromboplastin [aptt], and fibrinogen), and platelet levels before and after rfviia administration. results. patients (mean age, , +/- , years) received a single dose of rfviia ( , +/- , microg/kg). surgical procedures were aortic surgery (n= ), double valve operation (n= ) and left ventricular assist device (n= ). the men time between icu admission and rfviia administration was hours while patient received it intraoperatively. the mean blood product usage prior and after the administration of rfviia was the following: packed rbc, , versus , u; ffp, , versus u; platelets versus , u; bleeding stopped in all cases and no patient needed reoperation. the mean coagulation results were ptt, , +/- . versus , +/- , seconds; p= , ; inr, , +/- , versus , +/- , ; p< , . in all cases, blood loss decreased considerably after rfviia administration almost eliminating the need for additional blood products, and the prolonged prothrombin time normalized. no side effects of rfviia treatment were noted. there were no thrombotic complications, cardiac ischemic events or deaths. our results support the use of rfviia as rescue therapy in severe, uncontrollable, nonsurgical, postoperative hemorrhage after cardiac surgery as efficacious and safe. however the data are still limited, and further studies are necessary to determine the safety and efficacy of this new hemostatic agent. coumarin oral anticoagulants are widely used to prevent thromboembolic complications in patients at risk for such events. rapid reversal of anticoagulant effects may be required in cases of severe bleeding or emergency surgery and the use of prothrombin complex concentrate (pcc) is recommended. as a surrogate marker international normalised ratio (inr) is used to evaluate the effective use of treatment with pcc. however, a clear correlation between correction of inr and improved haemostasis has not yet been established. this study intended to validate the correlation between the correction of inr, shortening of time to haemostasis, and reduction of blood loss in anticoagulated rats. four groups of female wistar rats were used in the study. rats in groups to were anticoagulated with . mg/kg body mass of phenprocoumon on occasions ( and hours), group , the control group, received isotonic saline. approximately hours after the second treatment, ml/kg body mass isotonic saline was administered intravenously (iv) in groups and . groups and received and iu octaplex ® /kg body mass. fifteen minutes after treatment blood samples were taken. the tail tip was cut off and the tail immersed in isotonic saline at + ˚c. bleeding time and haemoglobin concentration in the saline were measured subsequently. mean bleeding time in group was ± s. in groups and , the maximum observation time of minutes was recorded (except of one which died after minutes). in group mean bleeding time was ± s, complete cessation of bleeding was observed in out of animals. one animal died before minutes and in the remaining clotting was noted with markedly reduced bleeding. haemoglobin concentrations in groups and ( , µg/ml and , µg/ml) were significantly higher (p < . ) than in group ( µg/ml). no statistically significant difference was found between group ( µg/ml) and group . pulmonary thromboembolism (pe) is a critical complication after general surgery with an incidence ranging between , % and % and a mortality rate up to %. systemic thombolytic therapy is the core treatment of submassive and massive pe but may be associated with severe bleeding complications after major surgery. we report a case series of four postoperative patients with suspected (n= ) or proven (n= ) massive, life threatening pulmonary thromboembolism. diagnostic and therapeutic measures as well as decision-finding pro and contra thrombolytic therapy are discussed. one female and three male patients (age to years) presented with acute hypoxemia and severe cardiogenic shock (n= ) or cardiac arrest (n= ) on postoperative day to day following major surgery. pe was suspected in all cases and confirmed by a computer tomography pulmonary angiography (ctpa) in two patients. thrombolytic therapy with mg alteplase (actilyse ® ) was indicated in one patient under cardiopulmonary resuscitation and in two patients by severely impaired right ventricular ejection fraction, and was waived in one patient with moderately impaired right ventricular function. immediate thrombolysis lead to successful resuscitation and to a marked improvement in right heart function and gas exchange within min after administration. bleeding complications following alteplase injection occurred in all patients within the following hours requiring transfusion of - units packed red cells as well as minor surgical revision in two patients. three patients survived in good conditions and one patient died from progressive therapy-refractory right heart failure. we carried out a single-centre, prospective, randomized, double-blind trial with the aim of assessing the efficacy of postoperative prophylactic treatment. this prospective study examines the relationship of haemoviscoelastography (hvg) mednord (ukraine co analyser), a viscoelastic test, measures clot formation and includes information on the cellular, as well as the plasmatic coagulation, system and serum anti-xa concentration in patients treated with enoxaparin. patients scheduled for open prostatectomy using epidural anesthesia were enrolled. epidural catheters were removed the morning after surgery before the commencement of subcutaneous enoxaparin mg once daily. venous blood samples were obtained at: ) the induction of anesthesia (baseline), ) immediately before the third dose of enoxaparin operatively; ) h after the third dose postoperatively, and ) immediately before the fifth dose postoperatively. whole blood samples were obtained for haemoviscoelasthgraphy (hvg), activated clotting time, and anti-xa level analyses at each of the four time intervals. at the four sample intervals, the r time (mean ± sem) ( , ± , ; , ± , ; , ± , min) and the κ time ( , ± , ; , ± , ; ± , ± , min) of the hvg were significantly correlated with the expected peak and trough levels of lmwh and serum anti-xa levels (p < . ). after fifth dose immediately, hvg r times exceeded the normal range in of patients ( %). prolongation of r time and κ time on postoperative day may indicate an exaggerated response to lmwh. lowfrequency haemoviscoelastography is a test that could potentially correlate with the degree of anticoagulation produced by low molecular weight heparin enoxaparin. lowfrequency haemoviscoelastography mednord (ukraine co analyser), a viscoelastic test, measures clot formation and includes information on the cellular, as well as the plasmatic coagulation system is a test that could potentially correlate with the degree of anticoagulation produced by lmwh. the r time from the haemoviscogram correlates with serum anti-xa concentration. hvg is a convenient test to measure the degree of anticoagulation from lmwh. despite the evidence of perioperative hypercoagulability in cancer patients, there are no consistent data evaluating the extent, duration, and specific contribution of platelets and procoagulatory proteins by in vitro testing. this study compared efficacy of haemoviscoelastography versus thromboelasthgraphy for monitoring of coagulation imbalance. patients undergoing open surgery for abdominal cancer received mednord (ukraine co analyser) analysis (hvg), a viscoelastic test, measures clot formation and includes information on the cellular, as well as the plasmatic coagulation system. we examined the efficacy of a variety of coagulation tests. a complete coagulation screen, activated clotting time (act), thromboelasthgraphy (teg) and haemoviscoelastography (hvg) were performed before surgery, at the end of surgery, and enoxaparin anticoagulation monitoring on postoperative days , , , and . there were analyzed for the reaction time and the maximal amplitude (ma). we calculated the elastic shear modulus of standard ma (gt) and hvg ma (gh), which reflect total clot strength and procoagulatory protein component, respectively. the difference was an estimate of the platelet component (gp). there was a % perioperative increase of standard ma, corresponding to a % increase of gt (p < . ) and an %- % contribution of the calculated gp to gt. we conclude that serial standard thromboelas-tography and hvg viscoelastic test may reveal the independent contribution of platelets and procoagulatory proteins to clot strength. using multiple linear regression, all coagulation, teg and hvg variabities were used to model postoperative hypercoagulation. results showed that some components of the teg failed to identify hypercoagulation (r < . , p > . ). however, three components of the routine coagulation assay, including bleeding time, prothrombin time, and platelet count could be modeled to show prolonged postoperative hypercoagulability (p < . ). we conclude that all components of the hvg test reflect postoperative coagulopaties, these results suggests that it may be usefull in determining the coagulation status of cancer patients perioperatively. postoperative hypercoagulability, occurring for at least week after major cancer abdominal surgery, may be demonstrated hvg viscoelastotest. hypercoagulability is not reflected completely by standard coagulation monitoring and teg and seems to be predominantly caused by increased platelet reactivity. hvg provides a fast and easy to perform bedside test to quantify in vitro coagulation, may be usefull in determining the coagulation status of cancer patients perioperatively. in the epidural anaesthesia group (n = ), haemoviscoelasthography (hvg) was performed after crystalloid preloading and during the immediate postanaesthesia course. in the general anaesthesia group (n = ) hvg was performed before induction and during the immediate postanaesthesia course. hvg were repeated postoperativly at , and h. [kk] in the preanaesthesia period were similar in both groups. intraoperative blood loss was not significantly different between between the epidural and general anesthesia groups. there was no significant difference in measured coagulation variables between both groups, but there were significant differences in postoperative r, t and f variables (p < , ). in the postanaesthesia period r and t significantly decreased (p < , ), and ar and f increased (p < , ) in general anaesthesia group. the total blood loss after open prostatectomy was correlated (r = , ; p < , ) with the prostatic tissue weight. when the tissue weight resected exceeded g, blood loss was in excess of the linea correlation shown with the weight of resected prostatic tissue. ( , %) patients has significantly increased f (fibrinilytic activity) and h postoperatively. thromboelastography (teg) provides information on patients' coagulation status within minutes. the value of the teg has not been established in general icu patients. we present cases of critically ill patients with bleeding tendency in whom clinical decisions based on conventional laboratory results were modified by teg. we started implementing routine use of teg (haemoscope,usa). we describe patients in whom teg results changed clinical decisions that were taken before information from teg was available. case - y. o parturient admitted with massive pulmonary hemorrhage of unknown etiology. because of concern of a bronchial tear and bronchial arterial source bleeding, angiography with embolization was performed. despite this, bleeding recurred. there were no coagulation abnormalities and the patient was not thrombocytopenic. teg showed significant early thrombolysis and therefore treatment with tranexamic acid begun. within few hours bleeding stopped and did not recur. case - y. o man with autoimmune vasculitis presented with acute on chronic renal failure and epistaxis. after dialysis which was performed without heparin,the patient became hemodynamic unstable,was intubated and ventilated due to massive pulmonary hemorrhage. blood samples showed inr . ,prolonged ptt,normal fibrinogen level,thrombocytopenia and hemoglobin . g/dl. teg showed no primary fibrinolysis. repeated teg with heparinase showed normalization of the teg tracing. it thus evident that the patient did receive heparin during dialysis and the diagnosis of dic was negated. the patient was treated with packed red cells only,and further bleeding was not demonstrated. case - y.o man with status epilepticus due to an a-v malformation and brain edema,developed left arm compartment syndrome secondary to thrombophlebitis. the patient's platelet count was , . he was operated uneventfully without correcting the thrombocytopenia. a few hours later there was bleeding from the operative site. a teg test showed normal parameters. therefore,despite an initial assessment by the surgical team that the reason for bleeding is a coagulopathy,the patient was taken for a re-exploration of the wound. an arterial bleeder was found which was coagulated.conclusion. laboratory abnormalities are critical for making decisions in critically ill patients. occasionally, the clinical setting of bleeding with mild coagulation and platelet count abnormalities, preclude the patient from receiving invasive procedures prior to correction of the abnormality. thromboelastography can identify alteration in platelet number and function and abnormalities in the coagulation system. in our cases teg tracings were performed in addition to other coagulation tests. we found that in some patients as demonstrated here, the information provided by teg is different from that derived from conventional coagulation tests and leads to a change in clinical decisions. candida airway colonization is common in mechanically ventilated icu patients but the implications of this finding are not well appreciated. fluconazole prophylaxis is a reasonable approach to decrease fungal infections in critically ill surgical patients and is routinely administered in all of our cardiac surgery patients that stay in sicu for more than days. the present study was undertaken to evaluate the incidence and clinical significance of positive bronchial secretion cultures (bsc) for candida in mechanically ventilated cardiac surgery patients, who were febrile (t> c) after the first h in sicu. positive bsc for candida developed in . % of our general sicu population ( . % after cabg, . % after vr, . % after cabg+vr and % in others). the average time for candida airway colonization of sputum was . ± d. the vast majority ( %) of patients developed positive bsc prior to initiation of fluconazole prophylaxis ( pts within - d, pts within - d and pts after d of sicu stay). the icu stay ( ± d), hospital stay ( ± d) and mortality ( %) were significantly higher in patients with positive bsc for candida, compared to the general sicu population (icu stay . ± . d, hospital stay . ± d, mortality . %). candida airway colonization of febrile cardiac surgery patients after the first h in sicu is associated with a grave prognosis and could be a marker of compromised immune response. this colonization appears early in the course of icu stay and therefore the initiation of earlier fluconazole prophylaxis may be necessary. the current incidence of ie is estimated as cases per . population per year and continues to increase. the prognosis is significantly influenced by proper diagnosis and adequate therapy. cardiac surgery for active ie is established as a cornerstone therapy as it is required in % of patients but remains a challenging and high-risk procedure. the purpose of this study was to analyze the clinical characteristics of the patients underwent cardiac surgery for active ie in our center for a -month period. to evaluate principal indications for cardiac surgery and assess the major causes of surgical morbidity and mortality in ie patients. retrospective review of ie cases who underwent cardiac surgery from december to november in our -bed csicu. we collected age, gender, site of endocarditis, native or prosthetic, microbiological agent, indication of surgery, postoperative complications, icu stay and mortality. . patients with ie underwent surgical intervention in acute phase of infection. their ages ranged from to years (mean , ) and % were males. the causative agents were: streptococci-enterococci ( %), staphylococci ( %), candida spp ( %), pseudomonas aeruginosa ( %). the principal indications for cardiac surgery were development of heart failure due to severe heart valve defects or prosthetic valve dysfunction and intracardiac abscess. all patients had positive blood culture endocarditis but only two were still positive before operation. cases of aortic valve involvement were the most frequent, followed by cases of mitral valve endocarditis. native valve endocarditis prevailed over the prosthetic ones versus . surgery was performed using a mechanical prosthesis of the infected valve. in patients the procedure was complemented with tricuspid valve annuloplasty. patients underwent bentall procedure. the mean icu stay was , days (range to ). thirty-days mortality of patients undergone surgery for ie was %, patients died in the icu. operation for active ie carries a relatively higher mortality in comparison with elective surgery. an indication of surgery depends on several clinical variables but the main indication remains heart failure due to severe heart valve defect or prosthetic valve dysfunction. a high degree of clinical suspicion, at an early diagnosis, and indication of surgical treatment prior to deterioration of ventricular function and installation of generalized sepsis may improve prognosis. severe sepsis is a major cause of morbidity and mortality following major surgery. factors that are associated with an increased risk of sepsis following surgery include emergency surgery, patient comorbidities and degree of surgical insult. the risk of developing severe sepsis following major surgery for cancer has been shown to relate to the charlson comorbidity score , with a higher score predicting a greater risk of developing severe sepsis .we conducted a prospective observational study in order to investigate whether the charlson score could be correlated to the risk of developing sepsis following elective major general surgery in patients without cancer. we collected data on patients undergoing elective major surgery in a large teaching hospital. the charlson comorbidity index was calculated preoperatively for each patient. the patients were followed up for days postoperatively, and signs of the systemic inflammatory response syndrome (sirs), sepsis and septic shock were documented each day. the source of sepsis was recorded, if present. admission to critical care bed was also documented. . data was complete on patients, ( . %) were male, and ( . %) had cancer. the median age of the patients was years. mean operation time was hours, and mean transfusion requirement intraoperatively was . units. the median charlson score was . ( . %) patients were admitted to a critical care bed for reasons other than routine postoperative care. ( . %) patients developed sirs postoperatively. ( . %) patients developed sepsis postoperatively, and ( . %) of these went on to develop septic shock. there was a progressive, but non-significant difference in charlson score in those patients who developed septic shock or sepsis and those who did not. those patients who developed septic shock had a mean charlson score of . , while those with sepsis had a mean charlson score of . . those patients who did not develop sepsis had a mean charlson score of . . sepsis and septic shock are common after elective major surgery, but the charlson comorbidity index was not a useful predictor of the likelihood of developing sepsis in our population of cancer and non-cancer patients. rate of neurological complications after central nerve blockade is < . % ( ) and spinal epidural abscess vary from : to : ( ) . we audited the complications following epidural analgesia in postoperative patients admitted to our critical care unit with sepsis. we performed a retrospective case note review of all septic patients who had epidural analgesia for postoperative pain relief or for weaning from mechanical ventilation. all patients who had a major laparotomy and sepsis were included. we looked into the complications of epidural during insertion, usage and after removal of epidural catheter. patients were followed up by the critical care outreach and acute pain teams on discharge from the critical care unit. data are presented as mean and standard deviation. in a year period there were septic patients who had epidural analgesia. of these were commenced immediately prior to the laparotomy and were inserted in itu to enable weaning from mechanical ventilation. the male: female ratio was : with an average age of . ( . ). there were patients with or more organ failure. only ( . %) patients had positive blood cultures during the period of epidural analgesia. multiple attempts at epidural insertion were found in patients. mean duration of epidural catheter was . ( . ) there were survivors and non-survivors in this group. of the nonsurvivors died during the period epidural analgesia. the other nonsurvivors were followed up for an average period of . days and a median duration of days after the epidural catheter was removed. none of the patients developed any complications attributable to the epidural. the serious complications of epidural analgesia like epidural abscess and nerve injuries, although rare, are reported in case series( ). we did not note any adverse complications of epidural analgesia in this high risk group of septic patients admitted to the critical care unit. key: cord- - aei kaz authors: ruzauskas, modestas; bartkiene, elena; stankevicius, arunas; bernatoniene, jurga; zadeike, daiva; lele, vita; starkute, vytaute; zavistanaviciute, paulina; grigas, juozas; zokaityte, egle; pautienius, arnoldas; juodeikiene, grazina; jakstas, valdas title: the influence of essential oils on gut microbial profiles in pigs date: - - journal: animals (basel) doi: . /ani sha: doc_id: cord_uid: aei kaz simple summary: in recent years, the intake of ultra-processed foods has increased dramatically worldwide. missing natural foods in the diet raise the need of biologically active food components that could compensate for this deficiency and help maintain proper immune status. in this study, the microbial changes in pigs as experimental animals were assessed as influenced by consumption of oregano extract combination with peppermint and thyme essential oils. the results demonstrated that the combination of plant extracts had a positive effect on the gastrointestinal tract of animals by increasing the number of probiotic bacteria. based on the results obtained it may be outlined that the combination of oregano extract and peppermint and thyme essential oils can be promising ingredient as a functional component for the development of the new nutraceutical preparation. abstract: in recent years, the intake of ultra-processed foods has increased dramatically worldwide. missing natural foods in the diet raise the need of biologically active food components that could compensate for this deficiency and help maintain proper immune status. this study used pigs as an animal model for the assessment of the impact of consumption of origanum vulgare plant extract combined with mentha piperita and thymus vulgaris essential oils on microbial profile in intestines. a single group of weaned pigs received basal diet, while the other group basal diet supplemented with plant extract and two essential oils in the form of bilayer tablets prepared using “liquid/solid” phase technology. metagenomic sequencing was performed with the aim to investigate changes of microbial communities in ileum, caecum, and colon. the results demonstrated that the combination of essential oils was non cytotoxic, and had a positive effect on the microbial composition in the large intestine of pigs due to significant increase in the number of probiotic bacteria. the amount of lactobacillus was . times and bifidobacterium . times higher in the animal group fed with supplement. the combination, however, had some negative impact on the variety of minor species in the distal part of the ileum. additional studies need to be performed to obtain knowledge on how combinations of essential oils can change bacterial variety in the proximal part of the gastrointestinal tract. recent advances in next generation sequencing allow us to explore microbial communities very efficiently, compared with investigations based on classical microbiological methods. as there is still a lack of information how do eos acts on the human metabolism and microbial composition, many studies have been performed using animals and particularly pigs as experimental model. the pig model is one of the best preclinical animal models for investigating the gastrointestinal system and its functions in humans and it is widely used for in vivo experiments searching for healthier foods [ , ] . the possibility to feed animals with supplementation of eos is also promising from few perspectives including economic reasons and reducing of antimicrobial usage. there are data that the cinnamaldehyde and thymol ( mg/kg) can significantly improve digestibility of dry matter, crude protein, and energy in piglets [ , ] . the apparent ileal digestibility of crude protein and most amino acids were improved by the cocktail of eos ( mg/kg) with menthol as the primary component [ ] . the mechanism of action of eos is not very clear, but according to some studies, the improved digestibility can be attributed to the enhanced secretion of bile and enzymes [ ] and to the decreased endogenous losses of nutrients [ ] . eos can also modify intestinal microbial composition in weaned piglets and therefore can enrich biosynthesis of proteins and to activate metabolism of lipids [ ] . eos have also been shown to regulate intestinal contraction, and thereby to influence the transit of digesta and the resultant interaction between feed and the endogenous enzymes. in pigs the active substances of eos were found to be absorbed nearly completely in the stomach and the proximal small intestine within h after oral administration [ ] . this means that the absorption of eos in the foregut protects the possibility of active substances to reach large intestines and directly act on the microbial communities. it is known that microbial changes in the large intestines appear after supplementing of feed by unprotected eos [ ] . this means that there are other pathways to active substances of eos interacts with gut microbial communities. however, for the different drug relaxation in the gastrointestinal tract (git) different types of pharmaceutical coatings are used. the "liquid/solid" coating technique is capable addition toward such an aim for solubility enhancement and dissolution improvement, thereby increasing the bioavailability. it contains liquid medications in powdered form. this technique is an efficient method for formulating water insoluble and water soluble drugs [ ] . it is known that eos can act on the gut microbiota selectively. for instance, a cocktail of carvacrol, cinnamaldehyde, and capsicum oleoresin increased the population of lactobacilli and the ratio of lactobacilli to enterobacteriaceae in the jejunum and cecum of early-weaned piglets [ ] . the way eos active substances can modify microbial composition is very important as it is known that the microbiota plays a fundamental role in the induction, training, and functioning of the host immune system [ ] . it also actively participates in the digestion process. bacteria belonging to phylum firmicutes are able to digest long-chain carbohydrates and thus provide the host with additional sources of nutrients [ ] . in addition to its positive role, microbiota has a potential in the development of irritable bowel disease and some other diseases, as well as obesity [ ] . it may also elaborate toxic products from food residues such as genotoxic hydrogen sulphide [ ] . as the microbiota has the potential to play different roles in the gut of the host, it is very important to explore the key elements influencing the domination of beneficial bacteria over the pathogenic ones or those that may have a negative impact on health. different eos have been investigated regarding their antimicrobial and functional properties. the previous investigations proved that the potential of activity of different eos is not equal [ ] ; therefore, the selection of an appropriate eos with the aim to obtain the most active (or optimal) composition is very important. oregano (origanum vulgare) is a worldwide herb that is extensively used due to its medicinal activities against respiratory, digestive, and urinary disorders in addition to dental caries and rheumatoid arthritis [ ] . this plant also has strong antioxidative properties [ ] . the aforementioned pharmacological properties of origanum vulgare are attributed to its high content in carvacrol and other phenolic compounds [ ] . peppermint (mentha piperita) is another widespread plant recognized for their special qualities such as anti-bacterial, stimulative, diaphoretic, stomachic, and anti-spasmodic. it reliefs against cold, flu, fever, anorexia, nausea, motion sickness, food poisoning, esophagus and sinus illnesses [ ] [ ] [ ] . thyme (thymus vulgaris), which belongs to the lamiaceae family, is rich source of phytochemicals and bioactive compounds. [ ] . thyme eo also inhibits growth of pathogenic bacteria and is known as an anti-fungal animals , , of agent [ ] . among this, thymus possesses antispasmodic, diaphoretic, antiseptic, disinfectant, carminative, sedative, and expectorant properties that are due to thymol and carvacrol [ ] . as aforementioned, herbs have wide spectrum of activity the composition of herbs and their eos are expected to have even wider spectrum of activity including their ability to act on microorganisms and therefore to modify microbiota within the gut. the possibility to reduce the dose of a single essential oil and the usage of a cocktail of eos can be important to reduce the toxicity of a single active substance as the main active substances from eos such as thymol and carvacrol are known as toxic at least for plants and insects [ , ] . the necessity to explore eos influence on the microbial communities in the gut is actual for both humans and animals. with the aim to develop nutraceuticals we have explored different active ingredients including bovine colostrum, probiotics and various plant by-products. here we have investigated the mix of eos with possibility to include the selected composition as ingredient into the nutraceutical formulation. the aim of this study was to evaluate the cytotoxicity of origanum vulgare plant extract, mentha piperita, and thymus vulgaris eos and to evaluate microbial changes in the guts of pigs as experimental model by supplementing their diet with a combination of the aforementioned plant extract and two essential oils (eeos) given in the form of bilayer coating tablets. dried origanum vulgare herb was obtained from "zolynu namai" (vilnius, lithuania). voucher specimens (no. l ) were deposited at the herbarium of the department of drug technology and social pharmacy, lithuanian university of health sciences, lithuania. oregano herb was ground in a cross beater mill ika a basic grinder (ika works, guangzhou, china) and sieved using a vibratory sieve shaker as basic (retch, united kingdom) equipped with mint (mentha piperita) essential oil and thyme (thymus vulgaris) essential oil purchased from sigma-aldrich (st. louis, mo, usa). dried powdered plant material ( g) has been extracted with ml of % ethanol + % glycerol (purity %) in a round bottom flask by heat-reflux extraction performed in a water bath for h at • c. the extract has been passed through a vacuum filter. the innovative technology in the "liquid/solid" phase of the system has been used to improve the bioavailability of sparingly water-soluble active compounds (thyme and mint essential oils) and has been used for powder production. in the "liquid/solid" phase of the system, the technology was carried out: using a simple mixing method, where the solution of active ingredients and excipients were mixed until the formation of suitable powder properties. magnesium aluminum metasilicate was chosen as the carrier for powder production in the "liquid/solid" phase. the carrier and the mixture of ethanolic oregano extract and mint and thyme essential oils were mixed together in a mortar, sieved through a mm sieve and homogenized for min in a mixer. the prepared mixture was placed in an oven at • c for h, the procedure being repeated until all the solution has been used. the prepared mixture was placed in a ventilated dryer at • c for h. after drying, a free-flowing, yellowish powder was obtained. chromatographic analysis showed that the amounts of the main biologically active compounds, thymol, carvacrol and menthol, were not significantly reduced in the powder formulations. the liquid/solid powder was further used in the tableting process. the resulting bulk and high-quality powder was tableted into mini-tablets, which are coated with a bilayer coating for different relaxation in the git. the eeos combination was prepared from the oregano (origanum vulgare) extract, which contained at least . g/l of carvacrol, peppermint (mentha piperita) essential oil, which contained at least g/l of animals , , of menthol, and thyme (thymus vulgaris) essential oil, which contained at least g/l of thymol and . g/l of carvacrol. the ratio of oils in the prepared combination was : . : . , respectively. the suspension obtained was used for tablet production with neusilin (fuji chemical industries, toyama, japan) as adsorbent. mg tablets were produced using the single punch eccentric tablet press erweka rtp-d (langen, germany). the tablets were coated with an erweka ar apparatus with a drilling rig d . coated with a % shellac solution containing . oleic acid and ml of a % ammonia solution in a % ethanol solution. the weight of the coating is % of the weight of the tablet. the tablets were manufactured using an erweka rtp-d eccentric press. press speed pcs, compression force n. tablet weight mg. the obtained results are shown in table . the following cell lines were used: pig kidney cells (pk- atcc no. ccl- ) and monkey kidney cells (marc- atcc no. crl- ; vero atcc no. ccl- ). all cell lines were cultured in minimum essential medium (mem; gibco) with additional % heat-inactivated fetal bovine serum (fbs; gibco), u ml − penicillin and µg ml − streptomycin. cells were grown at • c in humidified % co and % air mixture. monolayers of cells were trypsinized, diluted ( : dilutions for pk- cells and : for marc- and vero cell lines, respectively) in growth medium and transferred to cm tissue culture flasks (tpp techno plastic products ag, trasadingen, switzerland). the extract of oregano and the mint essential oil and thyme essential oil were evaluated on pig kidney cells (pk- ) and monkey kidney cells (marc- , vero) in order to examine their cytotoxic effects against normal cells. the cells were seeded on -well plates ( × cells/well) and incubated at • c with % co . after h incubation, the cells were treated with the extracts (from µl/ml to µl/ml) for h and h at • c. the essential oil extracts were dissolved in mem. following the removal of the extracts from the wells, the cells were washed in phosphate buffered saline. cell viability was determined by mtt assay. the cytotoxicity of essential oil extracts was estimated against pk- , marc- and vero cells using mtt assay [ ] . each extract was tested in triplicate. after h mtt reagent ( µl, mg/ml, sigma-aldrich) was added and incubated for h at • c. then, µl dimethyl sulphoxide (dmso) (carl roth, germany) was added into each well, and the plates were placed on the shaker for min. the absorbance of each well was measured at nm in a microplate reader (multiskan™ fc microplate photometer, thermo fisher scientific oy, ratastie, finland), and the percentage of cell survival was calculated. viability was defined as the ratio (expressed as a percentage) of absorbance of treated cells to that of untreated control cells. the composition analysis of essential oils and tablets was performed using a shimadzu gc- gas chromatograph (shimadzu, tokyo, japan) equipped with a shimadzu autoinjector aoc- is (shimadzu, tokyo, japan). the operational conditions for essential oils analysis (thyme and mint) were as follows: temperature program from • c to • c ( min), from • c to • c ( min) at • c/min, and then from • c increased to • c ( min) at • c/min, pressure . in vivo experiment was performed using weaned-off - kg lithuanian white breed -day-old pigs in september . pigs were bred and delivered from the large capacity pig breeding farm to the biological research centre of lithuanian university of health sciences keeping requirements of animal welfare. animals were selected from the same two related litters, with the aim to obtain individuals with more similar physiological parameters including body weight. all animal procedures were conducted according to the eu directive of the european parliament and of council from september [ ] on the protection of animals used for scientific purposes and requirements for the keeping, maintenance, and use of animals intended for science and education purposes ( / /eu), approved by the order of the director of the lithuanian state food and veterinary service [ ] . the number of permission for this study is g - . the animals were divided into two groups (control group and experimental group), eight pigs (four males and four females) in each group in separate pens within the same room. all animals were fed regular animal feed, which was prepared according to the standard recipes. regular feed consisted of barley ( . %), wheat ( %), soybean meal ( . %), whey powder ( . %), corn ( %), soybean protein ( %), sugar beet pulp ( %), and potato protein ( %). before experiment, the animals were kept in pens for days for adaptation. all animals in the experimental group additionally received~ g of the preparation ( tablets) daily, during the morning feeding until the end of the experiment. this corresponds to mg of oregano extract, mg of peppermint essential oil and mg thyme essential oil. the preparation was added to the feed ensuring that it was consumed by each animal. duration of the experiment was days. twenty-four hours before the experiment, fecal content from the rectum was taken for microbiome studies for the comparison of microbial variety among the groups. on the th day, the experiment was finished, and animals were sedated and euthanized according to the requirements laid down in the directive. / /eu. the content ( g) from the distal part of the ileum, caecum and the central part of the colon was taken into sterile dnase and rnase free tubes, delivered to the institute of microbiology and virology, where specimens were preserved using dna/rna shield (zymo research, irvine, usa) and stored at − • c. the material was used for microbiome studies in experimental and control animal groups. the dna from each sample was purified using a fecal dna miniprep kit (d , zymo research, irvine, ca, usa) according to manufacturer's instructions. the obtained dna then was purified using a dna clean & concentrator- kit (zymo research, irvine, ca, usa) to produce about ng/µl of dna. the same amount of dna from each group of animals was pooled into one sample per group representing one sample per intestine i.e., three samples were obtained from each group representing samples from ileum, caecum and colon. in total, six samples were obtained representing three intestines from both animal groups. partial s rrna genes (v -v ) were pcr amplified followed by barcoding and library preparation of the resulting pcr products in a secondary pcr. metagenomic libraries were prepared, sequenced, quality controlled, and assembled in an independent service laboratory (baseclear, the netherlands). short paired sequence reads were generated using the illumina miseq system (illumina, il, usa) and converted into fastq files using the bcl fastq pipeline software, version . . (illumina, il, usa). subsequently, reads containing phix control signal were removed using an in-house filtering protocol. in addition, reads containing (partial) adapters were clipped (up to a minimum read length of bp). the second quality assessment was based on the remaining reads using the fastqc quality control tool version . . . subsequently, the illumina paired reads were merged into single reads (so-called "pseudoreads") through sequence overlap. chimeric pseudoreads were removed, and the remaining reads were aligned to a combination of the greengenes and rdp s gene databases. based on the alignment scores of the pseudoreads, the taxonomic classes were assigned by associating each pseudoread to the best matching operational taxonomic unit (otu). the results of the taxonomic classification were presented on the interactive online platform. the number of probiotic bacteria was recorded and the relative number of probiotics from all bacteria detected was counted in all intestines tested as an average number per group. the bacterial genera considered as probiotic bacteria was based on literature analysis [ ] [ ] [ ] and included lactobacillus, bifidobacterium, bacillus, faecalibacterium, streptococcus, enterococcus, and escherichia. moreover, all the bacterial genera detected in the amount of ≥ %, irrespective of the animal group, were checked as to whether they were not mentioned as probiotic bacteria in scientific manuscripts. differences of microbial profile between the groups were assessed using z score calculator for two population proportions (https://www.socscistatistics.com/) [ ] evaluating the proportion of total number of otu and otu of separate taxonomic units prevalence, all of which was compared in the experimental and control animal groups. the kruskal-wallis test was used for multigroup comparisons of tested cytotoxicity. the results were considered statistically significant at p < . . the volatile compounds obtained from thyme essential oil were beta-myrcene, p-cymene, gamma-terpinene, linalool, terpinen- -ol, thymol, and carvacrol ( figure a) . thymol was the predominant compound of the thyme essential oil composition ( . %). the volatile compounds obtained from mint essential oil were menthone, pulegone, piperitone, and menthyl acetate ( figure b) . the predominant compound in this composition was menthone ( . %). according to the results of the gas chromatography-mass spectrometry (gc-ms) analysis the main compounds in the tablets were obtained. the predominant compounds of the tablets were d-menthol, thymol, and carvacrol ( figure c ). aligned to a combination of the greengenes and rdp s gene databases. based on the alignment scores of the pseudoreads, the taxonomic classes were assigned by associating each pseudoread to the best matching operational taxonomic unit (otu). the results of the taxonomic classification were presented on the interactive online platform. the number of probiotic bacteria was recorded and the relative number of probiotics from all bacteria detected was counted in all intestines tested as an average number per group. the bacterial genera considered as probiotic bacteria was based on literature analysis [ ] [ ] [ ] and included lactobacillus, bifidobacterium, bacillus, faecalibacterium, streptococcus, enterococcus, and escherichia. moreover, all the bacterial genera detected in the amount of ≥ %, irrespective of the animal group, were checked as to whether they were not mentioned as probiotic bacteria in scientific manuscripts. differences of microbial profile between the groups were assessed using z score calculator for two population proportions (https://www.socscistatistics.com/) [ ] evaluating the proportion of total number of otu and otu of separate taxonomic units prevalence, all of which was compared in the experimental and control animal groups. the kruskal-wallis test was used for multigroup comparisons of tested cytotoxicity. the results were considered statistically significant at p < . . the volatile compounds obtained from thyme essential oil were beta-myrcene, p-cymene, gamma-terpinene, linalool, terpinen- -ol, thymol, and carvacrol ( figure a) . thymol was the predominant compound of the thyme essential oil composition ( . %). the volatile compounds obtained from mint essential oil were menthone, pulegone, piperitone, and menthyl acetate ( figure b ). the predominant compound in this composition was menthone ( . %). according to the results of the gas chromatography-mass spectrometry (gc-ms) analysis the main compounds in the tablets were obtained. the predominant compounds of the tablets were d-menthol, thymol, and carvacrol ( figure c ). the results of cell cultures viability tests obtained using different bioactive compounds and their mixtures, demonstrated that the oregano extract, mint essential oil, thyme essential oil, and the mixtures of all the tested compounds in concentrations of - µl/ml did not show any cytotoxic effect after h in marc- , pk- and vero cell lines. cytotoxic effects of the extracts on the viability of cell cultures are summarized in figure . for pk- cell line, where the exposure to μl/ml of oregano extract, mint essential oil ( figure e) , and the mixture of all components ( figure h ) resulted in cell viability of around %, cell viability did not fall below % in the μl/ml exposure group. in the μl/ml exposure group, only marc- cells exposed to thyme essential oil showed cell viability lower than % ( figure c) . interestingly, while cell viability in all tested cell lines did not fall below % in the μl/ml exposure group, in the μl/ml exposure group, a μl/ml difference resulted in cell viability falling below % in marc- cells exposed to the mixture of all components ( figure d ), vero cells exposed to oregano extract ( figure i ) and pk- cells exposed to oregano extract ( figure e ). while the cell viability of the majority tested cell lines did not fall below % at μl/ml exposure concentrations, marc- cells exposed to oregano extract (figure a ) reached cell viability of . % (ci % . - . ), vero cells exposed to mint essential oil ( figure j ) reached cell viability of . % (ci % . - . ), while pk- cells exposed to thyme essential oil ( figure g ) and the mixture of all compounds ( figure h ) reached cell viability of . % (ci % . - . ) and . % (ci % . - . ), respectively. cell viability in all tested cell lines did not fall below % in the µl/ml exposure group. except for pk- cell line, where the exposure to µl/ml of oregano extract, mint essential oil ( figure e ), and the mixture of all components ( figure h ) resulted in cell viability of around %, cell viability did not fall below % in the µl/ml exposure group. in the µl/ml exposure group, only marc- cells exposed to thyme essential oil showed cell viability lower than % ( figure c) . interestingly, while cell viability in all tested cell lines did not fall below % in the µl/ml exposure group, in the µl/ml exposure group, a µl/ml difference resulted in cell viability falling below % in marc- cells exposed to the mixture of all components ( figure d ), vero cells exposed to oregano extract ( figure i ) and pk- cells exposed to oregano extract ( figure e ). while the cell viability of the majority tested cell lines did not fall below % at µl/ml exposure concentrations, marc- cells exposed to oregano extract (figure a ) reached cell viability of . % (ci % . - . ), vero cells exposed to mint essential oil ( figure j ) reached cell viability of . % (ci % . - . ), while pk- cells exposed to thyme essential oil ( figure g ) and the mixture of all compounds ( figure h ) reached cell viability of . % (ci % . - . ) and . % (ci % . - . ), respectively. before experiment, the most prevalent bacterial classes in pig faces were bacteroidia and clostridia, whose general prevalence varied from . % to . % in all microbiota in the experimental and control animals , , of groups. the other frequently detected classes were negativicutes, bacilli, and gammaproteobacteria. the composition of microbiota at a class level was similar among the groups. the most prevalent bacteria at the genus level in both groups of pigs were prevotella, clostridium, barnesiella, streptococcus, and megasphaera (figure ). lactobacillus and bifidobacterium were also detected with the prevalence from . % to . % (lactobacillus) and from . % to . % (bifodobacterium). the overall genus variety and the number of predominant bacteria were similar among the groups with the highest difference found in the number of prevotella, which was higher ( . % vs. . %) in the control animal group (p < . ). animals , , x for peer review of before experiment, the most prevalent bacterial classes in pig faces were bacteroidia and clostridia, whose general prevalence varied from . % to . % in all microbiota in the experimental and control groups. the other frequently detected classes were negativicutes, bacilli, and gammaproteobacteria. the composition of microbiota at a class level was similar among the groups. the most prevalent bacteria at the genus level in both groups of pigs were prevotella, clostridium, barnesiella, streptococcus, and megasphaera (figure ). lactobacillus and bifidobacterium were also detected with the prevalence from . % to . % (lactobacillus) and from . % to . % (bifodobacterium). the overall genus variety and the number of predominant bacteria were similar among the groups with the highest difference found in the number of prevotella, which was higher ( . % vs. . %) in the control animal group (p < . ). at the end of the experiment, the variety of species in large intestines was similar in both groups. the number of species in the caecum in both groups was , including unclassified species with the prevalence of at least . % from all bacterial reads. the number of bacterial species was very similar in the colon as well ( and species in the control and experimental groups, respectively). statistically significant differences were detected in the terminal ileum, where the number of species was much higher in the control group ( vs. species) of pigs. microbial profiles at the genus level in different intestines at the end of the experiment are presented in figure . when comparing bacterial composition in the ileum, high differences were observed between the groups. in the control group, the highest amount of bacteria was observed in populations of clostridium ( . %), escherichia ( . %), alloprevotella ( . %), and actinobacillus ( . %), while the distribution of genera was quite equal ( figure a ). in the experimental group, the bacterial amount of four genera was much higher, compared with the numbers of microorganisms of other genera detected in the ileum content. in this case, the most prevalent genera were escherichia ( . %), lactobacillus ( . %), clostridium ( . %), and terrisporobacter ( %). the prevalence of those four genera was . % of all bacterial loads. bacterial composition in the caecum content was more similar between the groups, compared with other intestines. prevotella, denitrobacterium, barnesiella, gemmiger, alloprevotella, streptococcus, and collinsella were among the most prevalent genera in both groups. the biggest difference was observed in the amount of barnesiella, which was more than times higher in the control group, while in the experimental group prevotella was the most abundant genus. the other genera with a higher prevalence in the experimental group were streptococcus ( % vs. . %) and collinsella ( . % vs. %), while in the control group, higher numbers were observed in denitrobacterium ( . % vs. %) and gemmiger ( . % vs. . %) ( figure b ). there were no statistically significant differences in the number at the end of the experiment, the variety of species in large intestines was similar in both groups. the number of species in the caecum in both groups was , including unclassified species with the prevalence of at least . % from all bacterial reads. the number of bacterial species was very similar in the colon as well ( and species in the control and experimental groups, respectively). statistically significant differences were detected in the terminal ileum, where the number of species was much higher in the control group ( vs. species) of pigs. microbial profiles at the genus level in different intestines at the end of the experiment are presented in figure . of lactobacillus in the caecum content between the groups ( . % vs. . %, p > . ). significant differences were detected among the predominant genera in the content of colon between the groups ( figure c ). in the control group, the most prevalent genera were streptococcus, prevotella, clostridium and barnesiella, whose amount was more than a half of all bacterial loads within this part of the git. the amount of streptococcus was very high ( . %), compared with the other genera in this group. in the experimental group, the most prevalent genus was prevotella ( . %), followed by barnesiella species distribution among the groups is presented in figure . the data represents the species whose prevalence was at least % in any of the animal groups. when comparing bacterial composition in the ileum, high differences were observed between the groups. in the control group, the highest amount of bacteria was observed in populations of clostridium ( . %), escherichia ( . %), alloprevotella ( . %), and actinobacillus ( . %), while the distribution of genera was quite equal ( figure a ). in the experimental group, the bacterial amount of four genera was much higher, compared with the numbers of microorganisms of other genera detected in the ileum content. in this case, the most prevalent genera were escherichia ( . %), lactobacillus ( . %), clostridium ( . %), and terrisporobacter ( %). the prevalence of those four genera was . % of all bacterial loads. bacterial composition in the caecum content was more similar between the groups, compared with other intestines. prevotella, denitrobacterium, barnesiella, gemmiger, alloprevotella, streptococcus, and collinsella were among the most prevalent genera in both groups. the biggest difference was observed in the amount of barnesiella, which was more than times higher in the control group, while in the experimental group prevotella was the most abundant genus. the other genera with a higher prevalence in the experimental group were streptococcus ( % vs. . %) and collinsella ( . % vs. %), while in the control group, higher numbers were observed in denitrobacterium ( . % vs. %) and gemmiger ( . % vs. . %) ( figure b ). there were no statistically significant differences in the number of lactobacillus in the caecum content between the groups ( . % vs. . %, p > . ). significant differences were detected among the predominant genera in the content of colon between the groups ( figure c ). in the control group, the most prevalent genera were streptococcus, prevotella, clostridium and barnesiella, whose amount was more than a half of all bacterial loads within this part of the git. the amount of streptococcus was very high ( . %), compared with the other genera in this group. in the experimental group, the most prevalent genus was prevotella ( . %), followed by barnesiella ( . %) and alloprevotella ( . %). the highest differences were detected among the numbers of streptococcus ( . % vs. . %), prevotella ( . % vs. . %), clostridium ( . % vs. . %), alloprevotella ( . % vs. . %), and oligosphaera ( . % vs. . %) in the control and experimental groups, respectively. species distribution among the groups is presented in figure . the data represents the species whose prevalence was at least % in any of the animal groups. the amount of predominant bacterial species in the ileum of the control group was quite equally distributed ( figure a ). the highest number of a single species (escherichia coli) in this group was . %, while the numbers of other prevalent species differed only slightly. in the experimental group, figure . microbial profiles at the species level in ileum (a), caecum (b), and colon (c) content after the experiment (species with the prevalence of ≥ %). * means significant differences between the groups (p ≤ . ). the amount of predominant bacterial species in the ileum of the control group was quite equally distributed ( figure a ). the highest number of a single species (escherichia coli) in this group was . %, while the numbers of other prevalent species differed only slightly. in the experimental group, on the contrary, there were two species whose numbers were much higher, compared with the rest. the highly predominant species in this group were escherichia coli, with the prevalence of %, and lactobacillus amylovorus, with the prevalence of %. despite that, the amounts of separate bacterial species were different between the groups, the general variety of species was quite similar, except for few species (alloprevotella rava, prevotella stercorea, and bacteroides stercoris), which were absent in the experimental group. in the caecum, like in the ileum, the bacterial number of separate species changed in a gradually decreasing manner in the control but not experimental group ( figure b ). the most prevalent species in the groups were the same; however, their numbers differed, particularly regarding the amount of prevotella copri, whose prevalence was . % and . % in the control and experimental groups, respectively. the control group had significantly higher amount of barnesiella intestinihominis, compared with the experimental group, with the prevalence of . % and . %, respectively. in the colon, the variety of species among the groups was similar, whereas the amount of separate species was unequally distributed. in the control group, the high number of streptococcus lutetiensis ( . %) was recorded and followed by the other streptococcal species-s. gallolyticus ( . %) ( figure c ). in the experimental group, the highest prevalence had prevotella copri ( . %) and barnesiella intestinihominis ( . %). figure represents the number of bacterial genera which are considered as probiotic bacteria. on average, the number of probiotic bacteria in all three intestines as a part of the total amount of bacterial load was . % and . % in the control and experimental groups, respectively (p < . ). in the control group, the higher prevalence had streptococcus and enterococcus, while the rest of the genera, including lactobacillus and bifidobacterium, were significantly more abundant in the intestinal content of the experimental group. the only faecalibacterium prausnitzii was equally distributed among the groups. we studied the influence of the composition of eos to microbial profiles in different intestines using pig model. two animal groups used in this experiment came from the same litters, they had similar microbial profiles at the beginning of the experiment. at that period of age, the most prevalent bacterial classes in piglet faces were bacteroidia (phylum bacteroidetes) and clostridia (phylum firmicutes), whose prevalence varied from . % to . % depending on the animal group, and this on average, the number of probiotic bacteria in all three intestines as a part of the total amount of bacterial load was . % and . % in the control and experimental groups, respectively (p < . ). in the control group, the higher prevalence had streptococcus and enterococcus, while the rest of the genera, including lactobacillus and bifidobacterium, were significantly more abundant in the intestinal content of the experimental group. the only faecalibacterium prausnitzii was equally distributed among the groups. we studied the influence of the composition of eos to microbial profiles in different intestines using pig model. two animal groups used in this experiment came from the same litters, they had similar microbial profiles at the beginning of the experiment. at that period of age, the most prevalent bacterial classes in piglet faces were bacteroidia (phylum bacteroidetes) and clostridia (phylum firmicutes), whose prevalence varied from . % to . % depending on the animal group, and this is in coincidence with data obtained by other authors [ , ] . the main genera included prevotella, clostridium, barnesiella, and streptococcus, i.e., normal microbiota usually found in healthy pigs [ ] . at the end of the experiment, microbial profiles were examined is separate intestines, as bacteria of different genera unevenly prevail in different parts of the gut [ ] . significant changes were detected regarding bacterial composition in the ileum. although taxonomical composition was similar in both groups, the amounts of separate genera were unequally distributed in the intestines of experimental group. the main changes were associated with an increase of escherichia (almost three times) and lactobacillus (five times) and a decrease of prevotella ( times) in the experimental group, compared with control pigs. both escherichia and lactobacillus are considered as probiotic bacteria [ ] ; therefore, eos obviously had a positive effect on the numbers of those genera; however, escherichia is also a possible pathogen and can be unwanted microorganism, depending on its pathogenicity. while virulence factors of e. coli were not investigated in this study, it should be taken into account that it could be investigated in forthcoming trials. although prevotella is usually found in pig gi tract in large amounts [ ] , there is a lack of information about the importance of this genus in pigs. there are suggestions that prevotella may play important roles to combat post-weaning diarrhoea and that it may contribute to nutrient transport and uptake in the pig gut ecosystem [ ] . it is unclear, however, in which part of the gi tract prevotella has the most important role, but according to the study performed previously, this bacterium is mostly distributed in the colon [ ] . in our study, we found the highest amount of prevotella present in the caecum, where it was the most predominant genus in both groups of pigs. moreover, the amount of prevotella in the caecum of experimental animals was significantly higher than in the control group; therefore, the total number of this genus in gi did not decrease in pigs fed with eeos supplement. the species whose prevalence increased in the ileum of control animals were escherichia coli and lactobacillus amylovorus. the number of l. amylovorus increased times and made % of total bacterial count from the jejuni. this species has adhesive and significant pathogen inhibitory efficacy and is recognized as potential candidate to be used as probiotic feed supplement [ ] . changes in the caecum content were mostly associated with an increase of prevotella and streptococcus and a decrease of barnesiella and denitrobacterium, compared with the control group. the amount of barnesiella, however, was more than eight times less in the experimental group and was probably replaced by prevotella and streptococcus. although barnesiella has been found in many other studies investigating pig microbiome, there is still no clear information regarding its functions and significance. denitrobacterium has a single species-d. detoxificans, which is better known as ruminant species and its significance in porcine gi is also still under-investigated. the increased genera in the caeca of experimental pigs therefore are considered as positive or even probiotic (streptococcus) microbiota. the most prevalent species in the caeca of the experimental group of pigs was prevotella copri, whose prevalence was . %, and that is . times higher than in the control group. the role of this species in pigs is not known yet, but p. copri is a common human gut microorganism that is both positively and negatively associated with host health [ ] . the role of p. copri in human health is debatable [ ] . in a recent study, de filippis et al. have detected distinct strains of p. copri by metagenome studies and showed that the diet might select distinctive p. copri populations [ ] , but there is still no data about this in pigs. the most prevalent bacterial species in the caeca in the control group was barnesiella intestinihominis, followed by p. copri. b. intestinihominis was also more prevalent in the colon content of experimental animals; therefore, there were no big differences in this species between the groups. b. intestinihominis has been better described in humans than in pigs and has also been mentioned in a study were this species together with enterococcus hirae had a positive effect on the efficacy of cyclophosphamide used for cancer treatment in mice. the prevalence in healthy pigs of species that were previously associated with human microbiota, demonstrates the similarity between human and porcine microbiota. this fact is important as pig model can gain more knowledge about the pathogenesis of different human diseases. variety of the rest of the species in the caecum content was similar in both groups demonstrating that eeos did not have a selective inhibitory effect on the main species normally inhabiting the gi of pigs. such variety similarities were also observed in other large intestines. the amount of some genera and species, however, differed significantly. in the colon, these differences were also noticeable: while in the control group the most prevalent genus was streptococcus, in the experimental group predominated prevotella. among streptococci the most prevalent species were s. lutetiensis and s. gallolyticus, whose prevalence reached almost %. those species were also detected in the experimental group but only in a small amount ( . %). it is not clear yet if these species of streptococci are widely distributed in pigs, but they are frequently encountered in blood cultures of humans with bacteremia, sepsis, and endocarditis [ ] . recently, piva et al. described the first case of isolation of s. lutetiensis from a diseased cat [ ] . s. lutetiensis and s. gallolyticus belong to the group of s. bovis from which they were separated into separate species [ ] . while s. lutetiensis is well known as pathogenic species in humans, particularly in patients with reduced immunity, s. gallolyticus is recognized as an inhabitant of the alimentary tract of cattle, sheep, and other ruminants [ ] . this study revealed that both streptococcus species can be abundant in the intestinal tract of pigs and proves that pigs are carriers of streptococcal species pathogenic to humans. for this reason, s. gallolyticus and, particularly, s. lutetiensis can be considered as zoonotic bacteria. on the other hand, this is not certain for types or strains that might differ between the hosts, thus more studies in this direction should be performed. s. gallolyticus is known to be transmitted either directly or indirectly between animals and humans [ ] . it is also important to note that s. gallolyticus is genetically close to the other species-s. suis-which is known as a normal inhabitant of the oral cavity of pigs [ ] . there are data that it is sometimes difficult to correctly identify s. suis, and even molecular methods, including pcr, have a risk of misidentifying s. gallolyticus as s. suis [ , ] . as in this study s. suis was detected in very low amounts, taxonomic distribution of streptococcus species should be further studied for more accurate identification. the rest of the species in the colon were more equally distributed by their variety and numbers in both groups of pigs, although big differences were also observed regarding clostridium cellulovorans, which had a higher prevalence in the control group, and different species of prevotella, which were more prevalent in the experimental group. c. cellulovorans is known as widely distributed bacteria, which is also found in porcine respiratory tract; however, there is no clear information about its role in pigs. differences between microbial changes within the same animal group at the beginning and at the end of the experiment were recorded. while the main prevalent bacterial genera in both groups at the beginning of the experiment were prevotella, clostridium, barnesiella, and streptococcus, at the end of the experiment the most prevalent genera were clostridium, escherichia, lactobacillus, and terrisporobacter in the content of jejuni. in the large intestine, such differences were unequal: in caecum of the control group, prevotella and barnesiella predominated, whereas in the experimental group, the most prevalent were prevotella and streptococcus. in the colon, the most prevalent genera were streptococcus, prevotella, clostridium, and barnesiella in the control group and prevotella, barnesiella, and oligosphaera in the experimental group. in spite of the fact that certain differences were determined between the groups at the end of the experiment, the same genera were detected in both groups only with different proportional count. one of the most important questions raised in this study was to evaluate the influence of eeos on the amount of probiotic bacteria in the gi tract of pigs. the data demonstrated that pigs receiving eeos supplements had a higher amount of bacteria that are considered as probiotics, including lactobacillus, bacillus, bifidobacterium, and escherichia. only streptococcus and enterococcus, which are also probiotic species, were more numerous in the control group of pigs. the overall number of probiotic bacteria in the experimental group was . times higher compared to controls and accounted for % of the total amount of bacterial reads in the gut of pigs. the number of lactobacillus was . times higher, while the number of bifidobacterium was . times higher in the experimental group. the amount of streptococcus, however, was four times higher in the control group. as the lactic acid bacteria, including lactobacillus and bifidobacterium, are among the better described probiotic bacteria, the role of streptococci for the host is less investigated. this genus is mostly known as a pathogenic for pigs causing different diseases and, particularly, s. suis infections via skin injuries, which manifest as meningitis and other clinical expressions. there are data that natural probiotics can be a promising tool in cancer prevention and therapy for humans [ ] ; therefore, the obtained results can be important from the perspective of the usage of nutraceutical preparations containing eeos. moreover, lactobacillus and bifidobacterium are the genera already known as suppressors of cell proliferation in tumors; their action is associated with oxidative stress [ , ] . although eos anticancer potential is known by acting by multiple pathways and mechanisms, involving apoptosis, cell cycle arrest, antimetastatic and antiangiogenic action, increased levels of reactive oxygen and nitrogen species (ros/rns), and dna repair modulation [ ] -this study reveals that they can also act indirectly, by increasing populations of probiotic bacteria in the host. our previous experiments with separate ingredients and intended for development of nutraceutical formulations have demonstrated good results in vitro, regarding antimicrobial activity of lactic acid bacteria, berries/fruit-by-products and eos, which demonstrated bacteriostatic or bactericidal effect against wide spectrum of field pathogens [ , , ] . ultrasonication and fermentation of bovine colostrum allowed us to obtain decontaminated colostrum with increased functionality and reduced amount of cadaverine, histamine, and tyramine [ ] . a new delivery system based on apple pomace-pectin gels ensured the viability of antimicrobial strains [ ] . current experiment in vivo demonstrated a positive effect of eeos on the microbiota of the gi tract without reducing variety of species in the large intestine and increasing the number of probiotic bacteria. the study also demonstrated that eeos combination has no cytotoxic effect at high concentrations (up to µl/ml). the minimum inhibitory concentrations of eos on different pathogenic strains in our previous study were lower [ ] than concentrations which had no cytotoxic effect established in the present study. as there was a decrease of some probiotic bacteria, in particular, gram-positive cocci, more data are required about the possible action of the current eeos combination on this group of bacteria and about the role of streptococcus spp. in the gut of vertebrates. moreover, as the eeos had a certain negative impact on species variety in the ileum, studies on the role of minor species of bacteria in small intestine should be further studied. origanum vulgare plant extract and mentha piperita and thymus vulgaris essential oils, alone and in combination, had no cytotoxic effect at concentrations up to µl/ml after h in marc- , pk- , and vero cell lines. the combination of these essential oils given to pigs orally in a form of tablet with bilayer coating, prepared by "liquid/solid" phase technology, resulted in the increase of probiotic bacteria in jejunum, caecum and colon using an experimental pig model. immune function and micronutrient requirements change over the life course animals diet and immune function the role of dietary polyphenols in tumor necrosis factor-related apoptosis inducing ligand (trail)-induced apoptosis for cancer chemoprevention nutritional modulation of immune function: analysis of evidence, mechanisms, and clinical relevance development of antimicrobial gummy candies with addition of bovine colostrum, essential oils and probiotics fermented, ultrasonicated, and dehydrated bovine colostrum: changes in antimicrobial properties and immunoglobulin content plants and lactic acid bacteria combination for new antimicrobial and antioxidant properties product development in a sustainable manner the essential oil and hydrolats from myristica fragrans seeds with magnesium aluminometasilicate as excipient: antioxidant, antibacterial, and antiinflammatory activity sources of essential oils review: chinese herbs as alternatives to antibiotics in feed for swine and poultry production: potential and challenges in application. can essential oil eugenol: sources, extraction techniques and nutraceutical perspectives immunomodulatory activity of geranial, geranial acetate, gingerol and eugenol essential oils: evidence for humoral and cell-mediated responses in vitro activity of essential oils against gram-positive and gram-negative clinical isolates, including carbepenem-resistant enterobacteriaceae essential oils as antiviral agents, potential of essential oils to treat sars-cov- infection: an in-silico investigation much more than a pleasant scent: a review on essential oils supporting the immune system immunomodulatory activities of selected essential oils the relative antioxidant activities of plant-derived polyphenolic flavonoids antioxidant activity and phenolic compounds in selected herbs enrichment of animal diets with essential oils-a great perspective on improving animal performance and quality characteristics of the derived products porcine models of digestive disease: the future of large animal translational research in vivo effects of einkorn wheat (triticum monococcum) bread on the intestinal microbiota, metabolome, and on the glycemic and insulinemic response in the pig model effects of adding essential oil to the diet of weaned pigs on performance, nutrient utilization, immune response and intestinal health. asian-aust effects of essential oil supplementation of a low-energy diet on performance, intestinal morphology and microflora, immune properties and antioxidant activities in weaned pigs studies on the effects of essential-oil-based feed additives on performance, ileal nutrient digestibility, and selected bacterial groups in the gastrointestinal tract of piglets digestive stimulant action of spices: a myth or reality? intestinal microbiome-metabolome responses to essential oils in piglets in vitro degradation and in vivo passage kinetics of carvacrol, thymol, eugenol and trans-cinnamaldehyde along the gastrointestinal tract of piglets novel drug delivery system: liquid/solid compacts potential of essential oils for poultry and pigs role of the microbiota in immunity and inflammation microbiota in the gastrointestinal tract intestinal microbiota: it's role in digestive diseases nutrition and colonic health: the critical role of the microbiota antimicrobial, antioxidant, and immunomodulatory properties of essential oils: a systematic review carvacrol-induced [ca + ] i rise and apoptosis in human glioblastoma cells antioxidative characteristics and inhibition of α-melanocyte-stimulating hormone-stimulated melanogenesis of vanillin and vanillic acid from origanum vulgare the bioactivity and toxicological actions of carvacrol characterization of microwave vacuum drying and hot air drying of mint leaves (mentha cordifolia opiz ex fresen) drying of mint leaves in a solar dryer and under open sun: modelling, performance analyses drying and testing of mint (mentha piperita) by a hybrid photovoltaic-thermal (pvt)-based greenhouse dryer antioxidant capacity of spice extracts and characterization of their phenolic constituents evaluation of the antifungal activity of the iranian thyme essential oils on the postharvest pathogens of strawberry fruits chemical composition and fungicidal activity of the essential oil of thymus vulgaris against alternaria citri toxicity of thymol, carvacrol and their respective phenoxyacetic acids in lactuca sativa and sorghum bicolor insecticidal toxicities of carvacrol and thymol derived from thymus vulgaris lin rapid colorimetric assay for cellular growth and survival: application to proliferation and cytotoxicity assays lithuanian director of the state food and veterinary service. b - dėl mokslo ir mokymo tikslais naudojamų gyvūnų laikymo, priežiūros ir naudojimo reikalavimų patvirtinimo microorganisms with claimed probiotic properties: an overview of recent literature #:~{}:text=most% probiotic% products% contain% bacteria,have% been% developed% as% probiotic functional characterization of novel faecalibacterium prausnitzii strains isolated from healthy volunteers: a step forward in the use of f. prausnitzii as a next-generation probiotic assessment of fecal bacterial diversity among healthy piglets during the weaning transition longitudinal investigation of the swine gut microbiome from birth to market reveals stage and growth performance associated bacteria meta-analysis to define a core microbiota in the swine gut characterization of bacterial microbiota compositions along the intestinal tract in pigs and their interactions and functions using probiotics to improve swine gut health and nutrient utilization the dynamics of the piglet gut microbiome during the weaning transition in association with health and nutrition structure and function of the fecal microbiota in diarrheic neonatal piglets functional characterization of probiotic surface layer protein-carrying lactobacillus amylovorus strains the prevotella copri complex comprises four distinct clades underrepresented in westernized populations distinct genetic and functional traits of human intestinal prevotella copri strains are associated with different habitual diets first case of streptococcus lutetiensis bacteremia involving a clindamycin-resistant isolate carrying the lnub gene first description of streptococcus lutetiensis from a diseased cat characterization of streptococcus bovis from the rumen of the dromedary camel and rusa deer potential transmission pathways of streptococcus gallolyticus subsp streptococcus suis, an important pig pathogen and emerging zoonotic agent-an update on the worldwide distribution based on serotyping and sequence typing characterization of streptococcus suis isolates recovered between phenotypic and pcr-based identification of bacterial strains isolated from patients with suspected streptococcus suis infection in northern thailand probiotic bacteria: a promising tool in cancer prevention and therapy effects of lactobacillus strains on cancer cell proliferation and oxidative stress in vitro essential oils and their constituents as anticancer agents: a mechanistic view improvement of the antimicrobial activity of lactic acid bacteria in combination with berries/fruits and dairy industry by-products the effects of ultrasonication, fermentation with lactobacillus sp., and dehydration on the chemical composition and microbial contamination of bovine colostrum a new delivery system based on apple pomace-pectin gels to encourage the viability of antimicrobials strains this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflict of interest. key: cord- -e zhty authors: tassier, troy; polgreen, philip; segre, alberto title: network position and health care worker infections date: - - journal: j econ interact coord doi: . /s - - - sha: doc_id: cord_uid: e zhty we use a newly collected data set coupled with an agent-based model to study the spread of infectious disease in hospitals. we estimate the average and marginal infections created by various worker groups in a hospital as a function of their network position in order to identify groups most crucial in a hospital-based epidemic. surprisingly, we find that many groups with primary patient care responsibilities play a small role in spreading an infectious disease within our hospital data set. we also demonstrate that the effect of different network positions can be as important as the effect of different transmission rates for some categories of workers. vaccines are a primary way to stop or slow the spread of many infectious diseases, perhaps most notably, influenza. the lack of appropriate vaccination levels is a major health problem. for instance, influenza is a major cause of morbidity and mortality throughout the world despite the availability of a highly effective and inexpensive vaccine. in the us alone, influenza causes an estimated , deaths and , hospitalizations annually yet only around / of healthcare workers are vaccinated each year (thompson et al. ) . efficient provision of vaccinations poses a difficult problem in that the positive externality associated with a vaccination is the product of the probability of infection, the cost of the infection, and the marginal infections generated by an agent if infected (all of which may vary across agents). there is great concern over the spread of infectious diseases in hospitals, but little knowledge is available to identify healthcare workers who are most likely to acquire and transmit infectious diseases in hospitals. the problem is especially difficult because the transmission of many infectious diseases is not observable. for instance if someone in your household acquires influenza, you likely do not know which of the potentially hundreds of people you come in contact with each day that may have caused the infection. further if a vaccine is available for an infectious disease and the vaccine is in short supply or is expensive, it is imperative to know which individuals should have the highest priority in vaccine campaigns. in this paper we use a newly collected data set on hospital worker contacts in order to identify hospital worker groups that have the potential to create the largest number of infections based on their location in a hospital contact network. to achieve this goal, we have collected person-to-person contact information on individuals belonging to one of types of healthcare workers at the university of iowa hospitals and clinics (uihc). the data contain information on the contacts between healthcare workers and patients and between healthcare workers and other healthcare workers at the hospital. with this information we develop a network model describing the spread of an infectious disease in a hospital. we estimate, using an agent-based model, the effect of network position of different hospital worker groups on the spread of infectious diseases in a hospital. through this model we are able to identify the hospital worker groups that create the largest externality if removed from the network (perhaps through a vaccination or a quarantine). we argue that methods such as those used in this paper can help hospitals, health care professionals, and epidemiologists to design efficient programs for healthcare worker vaccinations. of importance, we note that we only study the externality in terms of network position within the hospital. in this paper we do not consider other potential heterogeneity among agents such as differences in transmission rates across workers, or differences in behavior outside the hospital that may play a role. while these effects are also important, the large differences across classes of workers shown below are worthy of independent study. this is the first paper to use specific micro-level contact data within a hospital that can be used to help guide policy makers and public health officials in the problem of efficiently allocating vaccines within hospitals. the data used in this paper is unique and detailed in comparison to other studies. the data consists of shadow data (where a research assistant follows a specific, randomly chosen hospital worker for an entire shift) for the major groups of healthcare workers at the uihc, a -bed major medical center. this results in over h of direct hospital worker observations and the notation of over specific worker to worker or worker to patient contacts throughout the hospital. to the best of our knowledge, the data that we have collected comprises the most detailed micro-level healthcare worker contact data set in existence. as a comparison, ueno and masuda ( ) collect data on contacts between doctors, nurses, and patients. their data is based on two calendar days from a small, room, community hospital in tokyo. they model contacts between nurses, physicians and patients. their data does not consider contacts with and between other healthcare worker groups (other than nurses and doctors). based on our data at the uihc, these assumptions would ignore over % of hospital staff, including most of the groups we identify as most crucial to the spread of an infection disease. we begin by discussing the background and motivation for our study and then move to develop a simple model of infectious disease transmission. in the model, we initially assume homogeneous contacts as in traditional epidemiological models. we then discuss a similar model with heterogeneous contacts and discuss the difficulties of achieving efficient vaccination levels. following the theoretical discussion, we use our newly collected data on healthcare worker and patient contacts to model the spread of an infectious disease in a hospital setting. the model allows us to identify the healthcare worker groups that would be expected to play the largest role in the spread of infectious diseases, in terms of network position, in this hospital setting. traditionally, epidemiology research has focused on well-mixed (randomly mixed) populations where agent contacts are homogeneous. in these models, every agent in a population may "bump into" any other agent with equal probability, much as a gas molecule may bump into any other gas molecule with an equal probability over a fixed time period. only recently have epidemiologists and other researchers begun to study the heterogeneous contact structures between people over which infectious diseases spread (early studies include comins et al. ; grenfell and harwood ; wallinga et al. ) . we focus this study on healthcare workers and a particular class of infectious disease, of which influenza is an example. healthcare workers are at especially high risk of contracting influenza. one study of healthcare workers with a low rate of influenza vaccination demonstrated that % of healthcare workers had evidence of influenza infection during a single influenza season (elder et al. ) . two features of influenza make its spread difficult to control in hospitals. first, people with influenza are infectious - days before the onset of symptoms. thus, they can spread the virus when they are still feeling well and are unaware of their own infectious state. second, only about % of infected persons develop classic influenza symptoms (cdc (cdc , consequently, restricting healthcare workers with influenza-like symptoms from the workplace will not completely prevent transmission of influenza because healthcare workers with atypical symptoms could continue working and spreading the virus. furthermore, studies show that healthcare workers are more likely than other workers to return to work early or to keep working when they have influenza-related symptoms (weingarten et al. ) . because of the ease with which influenza may be contracted and spread by healthcare workers, the centers for disease control and prevention (cdc) have, for the past two decades, recommended influenza vaccination for all healthcare workers. yet, in the us, only % of workers who have direct patient contact are immunized against influenza annually (smith and bresee ) . outside of concerns about traditional influenza, there are additional reasons to study the spread of infectious diseases in hospitals. first, healthcare-associated infections affect about million patients in us hospitals each year (jarvis ). second, there is a growing fear that hospitals could become a breeding ground for new strains of influenza such as the recent h n influenza outbreak, the potential emergence of person-to-person transmission of avian flu, or other "new viruses." much as sars spread widely in hospitals to begin the sars epidemic in toronto (chowell et al. ) , person-to-person transmission of avian flu may start in hospitals as well, and, if a more lethal version of h n were to develop, hospitals again could be a breeding ground for new infections. this last point is of particular salience. with the recent h n outbreak and the subsequent work to develop a vaccine, controversies arose concerning which individuals to vaccinate first. healthcare workers were high on the list. but, as we show below, not all healthcare workers are equal in terms of their importance in spreading infectious diseases. thus, one primary focus of this paper is identifying the individual hospital workers who are most important to vaccinate should a similar outbreak occur again. there is a growing literature in economics on the vaccination choices of individuals and of the externalities associated with vaccinations. but scant attention is paid to the network effects determined by heterogeneous contacts that we focus on in this paper. for example, francis ( ) solves for the optimal tax/subsidy policy for influenza in an sir model with a constant contact rate and random mixing among the population. geoffard and philipson ( ) examine how the individual incentives for vaccination decrease as disease incidence decreases and thereby argue that relying exclusively on private markets is unlikely to lead to disease eradication. boulier et al. ( ) , the most similar paper to ours, investigate the magnitude of the externality associated with a vaccination as a function of the number of vaccinations in the population, the transmission rate of the disease, and the efficacy of the vaccination. they find nonmontonic relationships between each of these items and the magnitude of the vaccine externality. more specifically, the externality and the number of infections prevented per vaccination initially increases before eventually decreasing. however, like francis, they do not consider the case of heterogenous contact number or heterogenous sorting among the population. finally, much of the recent literature on the economics of infectious disease is summarized in philipson et al. ( ) . we begin by describing a simple model where agents in a population have contacts with each other with a uniform probability. this is the traditional random mixing model in epidemiology pioneered by kermack and mckenrick ( ) . the important results in this paper describe exceptions to this homogeneous contact assumption, but we use the simplified model to develop intuition before describing a richer model with heterogeneous contacts. in this simple model, we assume that all agents are homogeneous in that all agents have the same number of contacts with other agents and that these contacts are randomly drawn with uniform probability from the population at large. suppose that agents are assigned to one of three states: susceptible (s), infected (i), or recovered (r). a susceptible agent can transition to being infected with probability α if she is in contact with an infected agent. once infected, an agent transitions to the recovered state according to a parameter κ. once recovered, the agent is immune to the possibility of future infection. this is a classic susceptible-infected-recovered (sir) model for infectious diseases such as influenza (kermack and mckenrick ) . the description and parameters yield the following differential equations describing the flows of agents among the various states, assuming a constant population of size n and contact rate of γ . each equation describes the rate of growth for one of the three populations in the sir model. equation describes how susceptible agents contact γ other agents in the population, of which i t /n are infected, and how, of these contacts with infected agents, a percentage α cause the susceptible agent to transition to being infected. equation describes the previously mentioned flows from susceptible into infected and that each infected agent moves to being recovered at rate κ. finally, eq. describes the flows from infected to recovered. we can write these equations in terms of population shares by dividing each of the above equations by the population size n and using lower case letters to denote these population shares, s t = s t /n , i t = i t /n , and r t = r t /n , yielding the following population share equations: the number of infected agents will increase in the population if the flows into the infected state from the susceptible state exceed the flows out of the infected state into the recovered state, di t dt > . this condition is equivalent to αγ s t > κ or s t > κ αγ . if this inequality holds then we say that the population is above the epidemic threshold. note that we cannot remain above the epidemic threshold forever without an introduction of new susceptible agents since ds t dt < : eventually the population will run out of susceptible agents to infect unless the susceptible population is replenished at a sufficient rate. one goal of healthcare policy is to attempt to place a population below the epidemic threshold so that the number of infectious agents in a population does not grow subject to some cost constraint. a population is most vulnerable to being above the epidemic threshold when the infectious disease first enters a population because s t ≈ . this implies that each infected agent infects approximately αγ κ new agents in the population. this fraction is sometimes referred to as the initial reproduction number in the population and is commonly denoted as r ≡ αγ κ . without new individuals entering a population in the susceptible state this reproduction number can only decline as the infectious disease spreads. a successful vaccination moves an agent from state s to state r without incurring the costs of infection. if we reduce the initial population of susceptible individuals, s , by enough we can push the population below the epidemic threshold. specifically, if s < κ αγ then the infectious disease dies out of its own accord without further action. thus an epidemic is prevented whenever s < κ αγ which occurs when ( − κ αγ )n agents are successfully vaccinated. vaccinating enough agents to produce this effect is called herd immunity (smith ) ; once enough people are vaccinated, the entire population (herd) is effectively protected without everyone being vaccinated. the question then becomes, given a cost of vaccination, c(v), what is the efficient level of vaccinations to provide in a population and how do we obtain this efficient level? we begin to approach this question by introducing standard value function notation. in this initial model, once an agent enters state r she remains there forever. thus the value of being in state r is simply the lifetime discounted utility received in state r. we also introduce the possibility of having heterogenous contacts at this stage by indexing agent j's contacts (γ j ) and other terms that we allow to vary across agents. where u j ( ) = utility of agent j from the specified state and β is the discount rate. if an agent is in state i, she will remain in state i for /κ periods, on average, until recovered and then enter state r. if an agent is in state s, she receives the same utility as she would if she was recovered, unless she becomes infected. the value to an agent of being in state s is the value of being in state r less the product of the probability that the agent becomes infected and the cost of the infected period. where π(γ j , α, i) is the probability of becoming infected over the course of the epidemic as a function of the contacts of the agent and the transmission rate of the infectious disease. the cost of being infected is the difference in utility between states s and i during the time spent in state i , with the value functions specified we can now specify the vaccination problem for the individual and the social planner. to simplify the vaccination choice of individuals we assume that an agent can only be vaccinated at time period . at this time the agent will choose to be vaccinated if the value of being in the recovered state less the cost of the vaccination is greater than the value of being in the susceptible state. thus the agent will choose to be vaccinated if which implies the agent will choose to be vaccinated if c(v) < π(γ j , α, i)c j . the social planner's vaccination problem is more difficult than the individual vaccination problem. essentially, the social planner's problem is to vaccinate agent j if the cost of the vaccination is less than the expected dis-utility of the increase in infections created by agent j if agent j is infected weighted by the probability that agent j is infected. we define the term "marginal infections" of agent j to be the additional infections that occur if j is infected that would not occur if j was not infected. note that this is not simply the number of infections that agent j creates. as an example, agent k maybe infected by agent j. but, if k would have been infected by another agent had she not been infected by j then this would not be a "marginal infection" of agent j. k will be infected regardless of the vaccination choice of agent j. along these lines of thinking, measuring marginal infections is a difficult problem for epidemiologists for at least three reasons: . as mentioned earlier, many infectious disease transmissions are not observable. thus it is not easily known how many infections a given agent causes. . even if transmissions are observable, the marginal infections created by agent j are not simply the number of other agents that j infects. this is because some agents that j infects may get infected by agents other than j even if j does not infect them herself. further one needs to know how many additional agents are infected by those that j infects and any additional infections created by these agents and so forth. thus one needs to know information on the dynamics of the entire epidemic to measure the true marginal infections of a given agent. . the marginal value of vaccinating an agent depends on the behavior and vaccination choices of other agents. it eventually must be decreasing in the number of other vaccinations that are performed. in the extreme, if there are enough vaccinations in the population to produce herd immunity the marginal value of vaccinating an additional agent only involves the probability that the agent is infected from outside the agent population. in effect, the only value is preventing a single agent from infection because she will not, on average, infect anyone else. because of these difficulties we use a simulation approach to help us measure the average and marginal effects of individuals belonging to different worker groups in our hospital contact data. with simulations one can monitor the various infections that occur and also perform controlled experiments to sort out the effects of various groups on potential hospital epidemics. define m j (γ j , α, κ, i, v) as the true marginal infections created by agent j if infected, where v is the number of agents vaccinated in the population. for the majority of the paper we will suppress the notation that does not differ across agents and simply refer to marginal infections as m j (γ j ) since the primary focus of the paper will be on the effect of heterogeneous contacts on the spread of infectious diseases. as shown in boulier et al. marginal infections may be increasing in v for sufficiently small v. but, marginal infections must eventually decrease in v; at the extreme, marginal infections are for any level of v above the point at which herd immunity is reached. thus marginal infections may be increasing or decreasing in the number of vaccinations depending on the specifics of disease transmission, contact patterns, and the number of vaccinations performed. we can now state the social planner's vaccination problem. vaccinate agent j if: note that the individual and social planner's vaccination problems differ by the term π(γ j , α, i)m j (γ j )c j (i). this is the positive externality created by a vaccination when a vaccinated agent j protects other agents which he contacts from acquiring the disease from him. the key terms to investigate in this externality are the probability agent j gets infected, and the marginal infections created by agent j if infected. note that if these marginal infections, m j (γ j ), go to , the social planner's problem and the individual problem converge, and the externality is removed. similarly the externality is removed if enough vaccinations are performed to reach herd immunity, again because m j (γ j ) = when herd immunity is achieved because the epidemic never occurs. the main focus of this paper concerns the network position of hospital workers. as such, we assume throughout the paper that the cost of an infection is equal across all agents, c j (i) = c k (i) for all j and k. further, without loss of generality, we can normalize c j (i) = . thus the externality above is the product of the probability of infection and the marginal infections produced by the agent if infected. one question then emerges: how are π(γ j ) and m(γ j ) related? at a simple level, if contacts only vary in degree, that is if the only difference in contacts between two agents is the number of contacts and not other, qualitative, aspects of the contacts, then you would expect π(γ j ) and m(γ j ) to be highly correlated. if an agent has a high likelihood of being infected because he has many contacts then he also has many contacts to pass on the infection. suppose that each agent pair is connected with a fixed probability. then, by chance, some agents will have a higher than average number of contacts and some a lower than average number of contacts. in this case, any agent who has a large number of contacts will also generate a large number of secondary infections since there is a lack of structure within the network population. thus any agent with a high probability of infection, π(γ j ) will also be expected to generate a high level of marginal infections m(γ j ). example one is fairly direct. however, various relationships are possible as we show below. in this case each agent in a population is directly connected to every other agent in the population. if this is the case, then any agent that becomes infected is directly tied to all other agents and can infect anyone in the population. thus once someone is infected each agent has a high probability of becoming infected (either from the original agent or from secondary infections). but, since the first agent contacts everyone in the population, and many agents will be infected from him, the other agents in the population may have a low m(γ j ). thus it is possible to have a high probability of infection π(γ j ) and low marginal infections generated m(γ j ) from the same agent. imagine that there are three groups of agents in a population. two of these groups, call them a and b, are separate fully connected graphs containing equal numbers of agents, who do not have any connections to the other group. in other words an agent a ∈ a is connected to every agent a ∈ a but no agent a ∈ a is connected to any agent b ∈ b. suppose that group b is formed in a similar manner. the third group is composed of one agent, j. agent j has only two contacts: one to agent x ∈ a and one to agent y ∈ b. in this example it may be unlikely that agent j gets infected, especially if there is a low transmission rate, because he only has two contacts in the populations. but, if agent j is infected, he may be integral to spreading the disease to the second fully-connected group. suppose an agent in a becomes infected and subsequently infects agent x (or any of the other agents in a) as well as several other agents in a. agents in group b are safe from infection as long as agent j is not infected. but, if j becomes infected, then it is possible that a large fraction of agents in b may become infected as well. thus agent j may have a low probability of being infected, π(γ j ), but create a large number of marginal infections, m(γ j ), if he does become infected. note that each of these three examples offer different implications for public policy approaches to encouraging vaccinations. in the first example, each agent has a probability of being infected that is in line with the number of marginal infections generated. in the other two examples, the infection rate and the number of marginal infections generated may not have a simple relationship with each other. this is an important observation if one considers using subsidies or other means to encourage increased vaccination rates. in the remaining portion of the paper we examine a data set on contacts of and between healthcare workers and patients in a large hospital on the university of iowa campus. we discuss the data and use agent-based models to identify the healthcare workers whose position in the hospital contact network has the potential to create large numbers of infections in the hospital. observational data on contacts between healthcare workers and patients was collected during the winter and early spring of - (the - "flu season") at the university of iowa hospitals and clinics (uihc). the uihc is a -bed comprehensive academic medical center and regional referral center in iowa city. data were collected by randomly selecting uihc employees from each of job classifications (specified below) and then using research assistants to "shadow" the selected employees. the research assistants manually recorded every human contact of the subjects (within approximately three feet) over a work shift. note that these observed contacts include anyone contacted within the hospital, not just with the other workers in the shadow sample. this resulted in a total of recorded contacts over h of observation. additionally, the ra recorded the worker or patient group category for each observed contact (patient or category of healthcare worker) in our data set, and the location in the hospital where the contact occurred. the job categories and number of observed subjects in the data set are as follows: floor nurse ( ), food service ( ), housekeeper ( ), intensive care nurse ( ), nurse assistant ( ), pharmacist ( ), phlebotomist ( ), physical/occupational therapist ( ), resident/fellow/ medical student ( ), respiratory therapist ( ), social worker ( ), staff physician ( ), transporter ( ), unit clerk ( ), and x-ray technician ( ). the data for each group contain approximately h of shadowing. the data were summarized into tallies of contacts over -min intervals and then aggregated into contacts per h shift by the authors. table lists the average number of non-repeated contacts per h that occur between the various worker (and patient) categories. note that we were not allowed to choose patients as subjects in our shadow data directly because of privacy concerns. we were only able to observe patient contacts as a result of shadowing other members of the hospital. thus they do not appear as a row in the table. we use this contact data to model the spread of an infectious disease across the uihc hospital. with this data we create a probabilistic contact network for the hospital worker groups. the network is constructed to match the distribution of worker groups at the university of iowa hospitals and clinics. this totals employees. the distribution of workers across the categories is given in table . we create a contact network among these agents. in the model, each worker in a given group connects to other workers according to the rates observed in our shadowed subjects given in table . as an example, all floor nurses in the model create contacts to other randomly selected floor nurses on average, contacts to food service workers, etc. we assume that the contacts are symmetric in our model, that is, a contact from a given floor nurse to a given housekeeper is also a contact from the housekeeper to the floor nurse. there are at least two reasons for this assumption. first, if our subject is in close enough proximity to pass on the influenza virus to a second agent, the second agent is also within close enough proximity to pass on the influenza virus to our subject. thus the ability to acquire or to pass on virus is a symmetric relationship. second, the reader may note in the table that the matrix of observed contacts is not symmetric because of randomness in the observation of subjects. for instance one notices that the subject floor nurses were not observed to contact food service workers, but a small number of food service worker to floor nurse contacts were observed. thus by assuming that all contacts that occur in the matrix are undirected, we create a symmetric contact matrix where the total number of contacts from a member of group x to group y (and from group y to group x) is one-half the sum of the observed average contacts from group x to group y and from group y to group x. we create the contacts in a uniform random manner within groups. let ρ i j be the ratio of the average contacts between a member of group i and j (taken from table ) to the total number of group j employees (taken from table ). we then take each pair of employees across each group and create a contact with probability ρ i j . specifically, let agent a be a member of group i and agent b be a member of group j. then the probability that a and b are connected is average number of contacts observed between members of groups i and j and n j is the number of employees belonging to group j. before moving to the computational model, we mention two limitations of our data set. human contact networks frequently have a small number of individuals with a much larger than average number of contacts, perhaps differing by orders of magnitude. these individuals are often called hubs. these hubs have the potential to significantly influence disease transmission because they are highly likely to be infected, and if so, to pass on infections to a large number of individuals. because our sample includes approximately . % of the hospital worker population, we may be missing hubs in our sample if they exist in this setting. however, we note two things in relation to this: first, the relatively homogeneous workday responsibilities of workers within categories, likely limit the variation of contacts within a category. for instance two physicians or two floor nurses are likely constrained to see a relatively similar number of patients each day. this is unlike many other social network data sets, (such as general friendship or online networks) where there are not these work responsibility constraints on individual contacts. thus the possibility of hubs with orders of magnitude differences in numbers of contacts is more limited in our data context. second, our data set is more comprehensive than any other within hospital contact data set in existence in terms of the worker categories included. recall from earlier in the paper that the ueno and masuda data set only includes physicians, nurses, and patients in a hospital much smaller than is studied here. our results below suggest that many of the most important groups in the hospital are not included in their study. thus, at a minimum, our study highlights the importance of funding for studies that aim to collect even more comprehensive data sets that include individuals with nonpatient care responsibilities and more comprehensively cover a larger share of hospital workers. in addition, we note that we consider all contacts in our data set to be equivalent, or "equally weighted." there may be some concern that not all contacts are created equal in our context. for instance, a contact between a physician and a patient that occurs during a physical examination, may be more likely to spread an infectious disease than other contacts in our data set. we attempt to control for this possibility later in the paper when we consider heterogeneous transmission rates and repeated contacts. as mentioned above, transmissions of infectious disease are not usually observable. thus studying infectious disease transmission using an agent-based model can be a useful tool. in the remainder of the paper we model the spread of an infectious disease across the simulated hospital contact networks described above. once created, we use the contact network in a model of the spread of an infectious disease in the hospital as follows: agents can be in one of three states, susceptible to being infected (s), infected and able to infect others (i), or recovered (and therefore immune) (r). we assume that each infected agent recovers after periods which is in-line with the infectious period for influenza. once recovered the agent enters state r and is therefore immune to further transitions to the infected state. initially, all agents in the model are in state s. agents may be vaccinated against infection. vaccinations occur only in the initial period of the model. once vaccinated, an agent moves immediately from state s to state r and is thus immune for the remainder of the model. in the initial period of the model, each agent in state s (all agents that have not been vaccinated) is subject to infection with probability α = . . these are the agents of our model that seed the potential epidemic. once these initial infections occur we assume that each contact in our network occurs once in each subsequent period of the model. if a contact occurs between a state i and a state s agent, the state s agent transitions to state i with probability α, which we vary across experiments. we continue the model until no agents remain in state i. in each period of the model we calculate the fraction of agents in each worker category in each state (s, i, or r). for each of the results reported below we run replications of each parameter set or computational experiment reported. the results reported are averages over these replications. in addition to the results reported below, we have studied a wide range of parameters for our model and find the results reported below to be robust to changes in all of the parameters within reasonable bounds. the purpose of the model is to estimate m(γ j ) and the externality generated for the network of contacts in the uihc shadow data and, in turn, to identify the classes of workers most important to vaccinate. this is a two step process. first we perform a series of base-line models as described above with none of the healthcare workers and patients vaccinated. from this baseline, we observe the rate of infection for each class of agents in the hospital population ( worker groups and patients for a total of groups). we denote the infection rate of group k in the base model as a function of the transmission rate α as π k b (α) and the overall infection rate in the entire population as a function of α as π b (α). second, we want to calculate the average and marginal infections generated by each group. to do so, we change the vaccination rate for each group, one group at a time, and re-run the model. as an example, we run the model with all floor nurses vaccinated and no other vaccinations and observe π (α). then we run the model with all housekeepers vaccinated and no one else and observe π (α) and so on for each group. we then compare the change in the average number of infections between the models, δ(b, k) = (π b (α)−π k (α))n , which is the difference between the overall infection rate in the base model with no vaccinations and the overall infection rate in the model with all of group k vaccinated, multiplied by the total population size n . now, using the notation described above, the change in the number of infections δ(b, k) is equal to the change in number of people vaccinated, n k , multiplied by the probability that each of these agents becomes infected if not vaccinated, multiplied by the number of additional infections each infected agent would generate. simplifying, if we assume each agent infects the same number of individuals, we can write the average number of secondary infections generated per infected person in group k, as a k and write: one can then find an estimate of the average secondary infections per infected person as: effectively, this process removes each group from the hospital, one at a time. we then can observe the effect of each individual worker group on the size of the modeled epidemic. instead of vaccinating all agents of a group at once, we can vaccinate a fraction of a group. as we change this fraction at intervals n k we can view the effect of increases in vaccination rates for each group (one at a time). we then have an estimate of the marginal infections prevented per vaccination as: we now proceed in two steps. first we investigate the effect of each group in total on the epidemic process by vaccinating an entire group one at a time and calculatinĝ a k for each group. we then choose a sample of interesting groups and study the details of the epidemic process as we vary the number of vaccinations performed in each of these groups, at specified intervals between and %. interestingly, as we vary the percent of each group vaccinated, we will see that there are different outcomes across these different groups in terms of marginal infections generated, probability of infection and the overall effect of a vaccination (in terms of reducing the number of infections). we begin by varying the transmission rate, α, over the range [ . , . ] and observing the base infection rate π b (α). the results are displayed in fig. . as one can see in the figure, a sufficiently large transmission rate is needed to generate an epidemic of reasonable size. further, as expected, the number of infections generated monotonically increases as a function of the transmission rate, α. our primary interest is in intermediate ranges of epidemic outbreaks. if the transmission rate is too high then almost everyone in a population needs to be vaccinated in order to reach herd immunity. and, if the transmission rate is too low, then there is not a large need to worry about vaccine priority. thus, we concentrate on two intermediate levels of the transmission rate α = . and α = . . with no vaccinations, these levels yield an epidemic where between one-third and one-half of the population is infected over the course of the epidemic. we now find the average effect of vaccinations across the hospital worker groups using the procedure described above for α = . and α = . . we present results for the average "secondary infections" generated per infected person, k , and the product of average infections and probability of infection, which yields the "decrease in infections per vaccination," δ(b,k) n k in tables and . from the decrease in infections per vaccination we have an indication of how much the vaccination of an individual group member is contributing to preventing the spread of an epidemic. the results of this experiment suggest where efforts should be directed in the event of an influenza vaccine shortage or in the event of the development of new disease for which a vaccine may be developed (e.g., avian flu, swine flu, etc.) but is initially in short supply until mass quantities may be made available. note that some of the groups have vaccinations that prevent less than one infection per vaccination. this occurs because these groups have a low probability of infection and sufficiently low number of average infections that each member generates if infected. groups with large decreases in infections per vaccination are the ones to prioritize in times of a vaccine shortage, assuming equal costs of infection. in these experiments we see three clear groups that stand above the others in terms of the effect of vaccinations. for the parameters of the experiments, each vaccination of a unit clerk, social worker, and phlebotomist, results in a decrease of . infections or more on average for α = . and of . or more for α = . . in addition vaccinating unit clerks is extremely effective; each unit clerk vaccination results in a decrease of over infections for α = . and over infections for α = . . somewhat surprisingly, some of the groups that are seen as central to the functioning of a hospital play a very small or moderate role in spreading an infectious disease. vaccinating staff physicians results in a lower than average decrease in infections. we revisit this result in our discussion of transmission rates later in the paper. also of note, as one would expect, as the transmission rate increases, the probability of infection increases. but, this has the effect of making individual vaccinations less beneficial on average. note that k is smaller for each group for a higher transmission rate. this has the effect of lowering the variance of average infections. for the α = . case above the standard deviation is . , and for the α = . case, the standard deviation is . . as the transmission rate increases, a larger fraction of individuals are infected throughout the population. thus there are more opportunities for each individual to be infected if she has not already been infected. vaccinating a given person in the population will only prevent one of these multiple channels for infection. so, as the infection rate increases, the effectiveness of a vaccination becomes more uniform across the groups. this has direct policy applications. an infectious disease that is highly contagious could best be met with a uniform vaccination strategy since each individual in the population will create a similar level of infections on average. but an infectious disease with a low level of contagiousness could most effectively be met with a targeted vaccination campaign (bansal and pourbohloul ) . we next look at the marginal effect of a vaccination as the number of vaccinations increase. we present results in figs. , , , , and for five interesting worker group categories for the same two transmission rates discussed above. unit clerks, social workers and phlebotomists are chosen because of their large number of secondary infections generated. we also choose floor nurses and staff physicians because of interest in the effect of worker groups with primary patient care responsibilities. in fig. we plot the marginal infections prevented per vaccination as a function of the number of vaccinations performed for the five groups. recall that the number of marginal infections is the additional number of infections that an agent generates if the agent becomes infected. in fig. we plot the probability of infection for the five groups. and, in fig. we plot the product of marginal infections and probability of infection which yields the total number of infections prevented per vaccination. these figures all consider a transmission rate of . . figures , , and plot the same relationships for a transmission rate of . . we begin with marginal infections. recall that marginal infections may be increasing or decreasing in the number of vaccinations performed for small numbers of vaccinations (boulier et al. ). (here the number of vaccinations performed is small relative to the entire population as we are only vaccinating some members of one of the groups. so, even if we vaccinate an entire group, this is a small number relative to the entire population.) here, we see two interesting outcomes. first, we see that marginal infections for both unit clerks and floor nurses increase as more vaccinations are performed. for these two groups, each additional vaccination prevents a larger and larger number of infections. this is particularly extreme for a transmission rate of . and the case of unit clerks where a small number of vaccinations results the product of the two previously discussed statistics yields the number of infections prevented per vaccination. again, unit clerks display a unique relationship in that the number of infections prevented per vaccination dramatically increases in the number of vaccinations performed. the other four groups result in much flatter plots. thus again there is little difference between the marginal and the average for these groups. there are two interesting points to be made from these results. the first is that the effect of vaccinating unit clerks in our data is most important both from a marginal and an average perspective regardless of how many vaccinations have been performed. particularly, the marginal effect of vaccinating a unit clerk increases at a greater rate than the probability of infection for a non-vaccinated unit clerk falls. thus, it is always more beneficial to vaccinate one more unit clerk as opposed to a worker from another group (assuming transmission rates are equal). the second is that there is little difference between the average and the marginal effect of a vaccination for the other groups considered here. this second point can be interpreted as good news from a policy making perspective in the sense that the optimal allocation of vaccinations does not switch as more of a group is vaccinated. in other words it is not the case that group a is the optimal group to target up to some vaccination percentage, after which group b should be targeted. switching such as that would indicate a much more complicated solution to the optimal vaccine allocation problem. here, because there is little difference between the marginal and the average effect of a vaccination for most groups, one can pragmatically target the groups with the largest average effect of a vaccination. we now move to discuss the important features of the contact network that creates the externality. as we will see below, it is not just the number of contacts that an agent has but also which specific agents and groups the agent contacts, as well as who the agent's contacts connect to in turn. we begin by looking at some basic statistics of the contacts in our data in table . for each group, the table displays the total number of contacts, the percentage of total contacts that are with members of an agent's own group, and the number of patient contacts. total contacts and contacts with patients could be directly correlated with the likelihood of being infected and with passing on infections. the percentage of contacts within one's own group can indicate how varied one's network is and how widespread one's connections are. for instance having few contacts within one's own group provides the possibility of introducing an infection to other groups within the hospital. in addition the table also contains a common network characteristic measure, betweenness centrality, which we discuss below. on a network, the geodesic distance, g a,b , between nodes a and b is the length of the shortest path between the two nodes that traverses connections on the network measured as the number of connections traversed (or "hops" required) to reach node b from node a. as one measure of the centrality of a node on a graph one can calculate the average distance to all other nodes on the graph. thus if a graph g is composed of n nodes, average distance for node a is calculated as: a short average distance indicates that a node is close to other nodes on average an thus may be likely to be infected and to pass on infections. thus it is sometimes considered a measure of the centrality or importance of a node in a network. betweenness is another measure of the centrality of a node in a network. let c i jk be the proportion of all geodesics linking node j and node k which pass through node i. let c i be the sum of all c i jk for i = j = k. letc i be the maximum possible value for c i . (normalized) betweenness for node i, b i is then: betweenness for node i is therefore a measure of the proportion of shortest paths between nodes that go through node i. in the the table below we report group level values for betweenness centrality. the values are created in the following manner. first we create a network using the same methods as described above. second, we then calculate the betweenness centrality measurement for each agent in the simulated network. third, we calculate the average value for each hospital worker group and report the result in the table below. this network variable is likely to be an indicator of importance for disease transmission in the network. if a hospital worker group has a high average betweenness value, then the nodes in this group are potentially important in passing infections on to other nodes as it plays a crucial role in location along many of the shortest paths between nodes in a network. as such, this measure should be closely related to the marginal infections that a group generates. what is most interesting in table is the lack of a clear relationship between any of the variables in the first three columns and our previously-listed most important groups (highlighted in bold). the only measure that consistently aligns well is the betweenness measure. for a moment concentrate on the values in the first three columns. each of these three plausibly important characteristics fail to display a meaningful relationship with the average or marginal infections generated. if we concentrate on the top three most important groups, some have relatively large numbers of contacts (unit clerks), although not the largest, while others have contacts significantly below the average (phlebotomists). some have large numbers of patient contacts (phlebotomists) while others have some of the smallest number of patient contacts (unit clerks and social workers). one interesting thing that appears in the table is that phlebotomists have almost all of their contacts with patients and other phlebotomists. thus the network position of phlebotomists, is in some sense, very similar to that of patients. overall, what these observations imply is that there is not likely to be a simple relationship (or a small set of simple relationships) indicating which individuals are most important to vaccinate by looking at easily observed worker interaction patterns. instead the relationship depends on the intricate and complex web of relationships that make up the entire contact network of the hospital. this is what is captured in the betweenness centrality measure. betweenness measures the percentage of shortest paths in the entire network on which an agent is located. if we remove agents with high betweenness measures (by vaccinations) from the disease propagation network, we disrupt the flow of an epidemic. for concreteness, the correlation between the betweeness measure and the average infections generated is about . for both α = . and α = . . as mentioned above, the primary focus of this paper concerns the effect of network position on the marginal infections generated within a hospital. here, we consider two robustness checks to the results presented above. first, we discuss a comparison of the magnitude of the above described network effects and the effect of transmission rates on marginal infections for an interesting example group, staff physicians. second, we do an additional set of experiments using an additional data set that includes observed repeated contacts. we perform these robustness checks for two main reasons: first, because of the job responsibilities of different worker groups, the different worker groups may have different transmission rates, durations of contacts, or frequency of contacts creating another source of heterogeneity in infections. as a few examples, a staff physician may be more likely to transmit an infection over the course of a patient exam that includes a series of physical contacts, compared to a nurse who has a brief arm's-length conversation with a hospital transporter. a floor nurse may have multiple interactions with the same patient during the course of the day. we begin this analysis by varying the transmission rate of staff physicians. (recall that staff physicians created a lower than average number of infections in our earlier model.) again, this is primarily to account for the fact that physicians may have longer duration contacts with patients and the contacts may more frequently involve physical touch. we now assign a special transmission rate to staff physicians that we denote as α p . this will be the transmission rate for any contact between a physician and another agent where one of the agents is infected. we use α = . for all other contacts in the population and vary α p from α p = . and α p = . . as we do this we again measure average infections as described earlier and show the resulting average infections for unit clerks and staff physicians in fig. . before we present the results we note that there are alternative ways to model this scenario. for instance, we could re-weight our contact matrix. if we knew, for instance, that physician to patient contacts lasted twice as long as other pairs of contacts in the hospital worker population, we could re-weight each physician to patient contact by a factor of two. but note that, on average, this is equivalent to increasing the transmission probability by a factor of two because the expected number of new infections is the number of susceptible to infected contacts in a period multiplied by the transmission rate. a doubling of the number of contacts is equivalent to a doubling of the transmission rate. recall from our results above that when the transmission rates are equal the average secondary infections created by unit clerks are slightly greater than and slightly greater than . for staff physicians. as we increase the transmission rate for staff physicians we see several things: first, as you would expect, the average infections for staff physicians increases. but the change is not large. for α p = . the average secondary infections created by staff physicians is . , slightly less than a two-fold increase and still well below the level of average infections noted for unit clerks when the transmission rates are equal. for unit clerks, as α p increases, the average infections of unit clerks drops rapidly. this occurs for at least two reasons: one is that unit clerks become less important relative to staff physicians as α p increases. another is that, as α p increases, the overall infection rates increase, and as we reported earlier, this causes average infections to become more uniform across groups. overall, the level of average infections between these two groups does not become similar until the α p increases to about . , a five-fold increase in the staff physician transmission rate. and, the average infections of staff physicians does not become greater than that of unit clerks until α p = . . most interesting about these results is the magnitude of the network effects relative to the magnitude of the transmission rates. in the case of staff physicians and unit clerks it takes a - times increase in the transmission rate of staff physicians to "make up" the difference in network position. this suggests that the network effect differences in average infections are very important in understanding overall transmission patterns. as a second robustness check we use an additional cut of our data that includes observed repeated contacts. in some instances members of the hospital population were observed to have come in contact more than once during the observation period. we use this data as one way to include the weighting of contacts mentioned above into the analysis. table displays the observed contacts that were observed and had occurred previously in our data. as you see in the table many of these contacts involved repeated interactions with patients (often by members of the nursing staff). we re-perform the analysis above with these additional contacts added into the data. the only additional change is that we modify the transmission rate to α = . so that the total number of infections in the population remains nearly constant compared to the non-repeat contact data. (recall from earlier in the paper that a larger epidemic smooths out differences in the population groups and makes the average and marginal values more similar across groups. thus we control for epidemic size by varying the transmission rate.) we present the results in table . you will notice in the table that most of the groups that previously had the largest effect still do. unit clerks are still the most important group to vaccinate, but the difference in magnitude between unit clerks and other important groups is less than in the the previous model. further, as one would expect, groups that have more repeated contacts, such as all types of nurses, become more important. the important point though, is that the relative ranking of most of the groups changes very little. of course this is partially due to there being relatively few repeated contacts in the data set. taking these two robustness checks in combination, they demonstrate two important things. first, network structure is at least as important as transmission rate in determining the course of an epidemic in our data set. second, while the data we have collected is not perfect in terms of comprehensiveness, the relative ranking of group importance appears relatively robust to alternative measures of network structure. a a minimum, taken in combination, these results suggest a need for a greater emphasis on network based data collection in order to better understand both micro level and macro level epidemiology. we now make a small shift in focus. generally, a hospital's primary goal is to restore or improve patient health. thus prioritizing healthcare worker vaccinations so as to best protect patients may be a legitimate goal of a hospital. in other words hospital administrators may care about protecting patients from infection as much, or more, than they do about protecting the entire hospital population from infection. of course these may be closely related goals. in addition, in a large scale epidemic, it may be of great importance to have a healthy staff of physicians to treat patients. thus protecting physicians may be another important goal in vaccine priority within a hospital. in tables and we display the same relationships as displayed in our initial results section above but this time only with regard to patient infections generated and staff physician infections generated, not infections in the entire hospital. in this analysis we see very similar results to the overall population results. beginning with patients, the four groups (unit clerk, social worker, physical and occupational therapist, and phlebotomist) that played the most important role in transmitting to the hospital population as a whole also play an important role in their effect on patients specifically. however, we see some difference in the two groups of models. first, groups that have more direct patient contacts increase in importance. for instance, phlebotomists replace unit clerks as the most important group. second new groups emerge as important for transmitting to patients. for instance, hospital transporters are among the top four groups in transmitting to patients but are significantly below the average in terms of transmissions to the general population. with this in mind it seems that giving vaccination priority to health care workers with direct patient contacts is more important for protecting patients than it is for protecting the general population, as one would expect. but still, some of the groups with the largest impact on infecting patients have few direct patient contacts (unit clerks and social workers, for example). for staff physicians we see similar results. again, the four most important groups remain important, but other groups such as floor nurses increase in importance when considering staff physicians specifically. to summarize the results of this section, the same groups that create infections in the general population also create infections in the patient and staff physician population. but, groups that have direct patient or staff physician contacts have increased importance. still, one should not ignore other groups central to the network of the hos- pital that have only few direct patient or staff physician contacts (e.g., social workers and unit clerks). we utilize a newly collected data set on contacts of health care workers at a large university hospital to estimate network effects for infectious disease transmission. interestingly the most important groups to vaccinate tend to have heterogeneous contacts throughout the hospital. groups such as social workers and unit clerks are very important to vaccinate even though they have been given low priority in past vaccine campaigns because of their relatively limited number of patient contacts. for instance, the cdc recommended in their interim influenza vaccination recommendations in - that influenza vaccine priority be given to "health-care workers involved in direct patient care" and further stated, "persons who are not included in one of the priority groups described above should be informed about the urgent vaccine supply situation and asked to forego or defer vaccination." this mismatch of scientific results and past policy decisions suggests that future research in this area is warranted especially when one considers the public health dangers associated with the emergence of avian flu, a more lethal version of swine flu, or recent dangers such as sars. with that stated, we want to be careful to recognize that one reason to vaccinate primary care providers is to assure individuals are available to care for the sick. this important incentive is outside the scope of our model. the results of this paper lead to important public policy considerations. specifically, hospital workers with a low probability of infection may be likely to ignore recommendations for vaccination even if they are central to the spread of an infectious disease. one way to increase the overall vaccination level is with a subsidy program. but, as the results in this paper show, not all hospital workers are equal in terms of the positive externality generated by a vaccination. because of the heterogeneous contacts throughout the hospital, some workers are more important to the spread of an infectious disease than others. thus if hospitals and other public health organizations want to efficiently distribute vaccines they need to target specific worker groups, perhaps by allocating subsidies, on the basis of discrepancies in probability of infection and marginal infections generated. this paper is the first to use specific micro-level contact data within a hospital to guide policy makers and public health officials in this endeavor. to be clear, these results are not meant to be specifically calibrated to measure the exact effect of vaccinations in these groups. instead our hope is that the orderings of the hospital worker groups (which are robust across the parameters that we have explored) indicate where public health officials can effectively intervene in order to prevent widespread epidemics within hospitals. and these experiments reveal interesting and surprising groupings. prior to this study, as quoted above, it had been argued that groups like unit clerks be excluded from influenza vaccine campaigns, in times of vaccine shortages, because of their minimal patient contacts. the results of this study suggest that decisions such as these need to be more fully explored. a comparative analysis of influenza vaccination programs article cdc ( ) epidemiology and prevention of vaccine-preventable diseases, th edn. public health foundation prevention and control of influenza: recommendations of the advisory committee on immunization practice (acip) model parameters and outbreak control for sars the spatial dynamics of host parasitoid systems incidence and recall of influenza in a cohort of glasgow healthcare workers during the - epidemic: results of serum testing and questionnaire optimal tax/subsidy combinations for flu season disease eradication: private versus public vaccination meta)population dynamics of infectious diseases selected aspects of the socioeconomic impact of nosocomial infections: morbidity mortality, cost, and prevention a contibution to the mathematical theory of epidemics epidemiology economic, diseases infectious prospects of the control of disease prevention and control of influenza: recommendations of the advisory committee on immunization practices, morbidity and mortality weekly report mortality associated with influenza and respiratory syncytial virus in the united states controlling nosocomial infection based on the structure of hospital social networks perspective: human contact patter ns and the spread of airborne infectious diseases barriers to influenza vaccination acceptance. a survey of physicians and nurses key: cord- -ln qfg authors: bertolesi, gabriel e.; zhang, john zhijia; mcfarlane, sarah title: plasticity for colour adaptation in vertebrates explained by the evolution of the genes pomc, pmch and pmchl date: - - journal: pigment cell melanoma res doi: . /pcmr. sha: doc_id: cord_uid: ln qfg different camouflages work best with some background matching colour. our understanding of the evolution of skin colour is based mainly on the genetics of pigmentation (“background matching”), with little known about the evolution of the neuroendocrine systems that facilitate “background adaptation” through colour phenotypic plasticity. to address the latter, we studied the evolution in vertebrates of three genes, pomc, pmch and pmchl, that code for α‐msh and two melanin‐concentrating hormones (mch and mchl). these hormones induce either dispersion/aggregation or the synthesis of pigments. we find that α‐msh is highly conserved during evolution, as is its role in dispersing/synthesizing pigments. also conserved is the three‐exon pmch gene that encodes mch, which participates in feeding behaviours. in contrast, pmchl (known previously as pmch), is a teleost‐specific intron‐less gene. our data indicate that in zebrafish, pmchl‐expressing neurons extend axons to the pituitary, supportive of an mchl hormonal role, whereas zebrafish and xenopus pmch+ neurons send axons dorsally in the brain. the evolution of these genes and acquisition of hormonal status for mchl explain different mechanisms used by vertebrates to background‐adapt. different types of camouflage (i.e., masquerade, disruptive and distractive coloration, surface disruption and countershading) are generated by a combination of skin patterns and colours selected through evolution in many prey and predator species as a means to reduce the likelihood of detection (crypsis) (skelhorn & rowe, ) . in general, they are not mutually exclusive and work best when several of their components match the background colour (eterovick et al., ) . the matching of skin pigmentation to background colour can be genetically determined (defined here as "background matching"), or induced by physiological plasticity through differential secretion of hormones by neuroendocrine systems ("background adaptation") (baker & bird, ; hoekstra, ). an example of genetically based background matching are mutations that produced a hyperactive melanocortin receptor (mc r), the main receptor for α-melanocyte-stimulating hormone (α-msh) (robbins et al., ) . the emergence of genetic polymorphisms in mc r expressed by pigment cells, and the selection of standing genetic variations, resulted in adaptive evolution of background matching in populations of reptiles, birds and mammals (linnen et al., ; price & bontrager, ; rosenblum, hoekstra, & nachman, ) . in contrast, background adaptation is plastic, with colour change mediated by pigment cell receptors activated by hormones secreted after eye photoperception of surface colour. although background adaptation occurs in many species, differences exist in the mechanisms between species that are not well understood. here, the evolutionary analysis of three critical genes involved in background increase in organisms with a black background de rijk, jenks, & wendelaar bonga, ; jenks, overbeeke, & mcstay, ) . the existence of a second hormone secreted from the pars nervosa of the pituitary, with opposite effects on background adaptation to α-msh, was suggested initially by hogben and slome ( ) in their "dual-hormonal control" theory. mch is processed from the c-terminal end of the preprohormone pmch ( figure ). in fish, an "mch" peptide is produced in the hypothalamus and transported down axons to be secreted from the neurohypophysis upon stimulation (baker & bird, ; enami, ; kawauchi, ; kawauchi, kawazoe, tsubokawa, kishida, & baker, ) (figure ). the ability to adapt to a white background by aggregating melanosomes associates with the synthesis and secretion of an "mch" in several teleost species (gröneveld, balm, martens, & wendelaar bonga, a; kishida, baker, & eberle, ; mizusawa et al., ; sugimoto, f i g u r e zebrafish and xenopus both background-adapt but only in zebrafish do mchl+ neurons project axons to the pituitary. (a) schematic of the genomic structure of the three-exon pmch and one-exon pmchl genes, the mrnas, the prehormones and the aligned a.a. sequence of mch and mchl. the two cysteines involved in the disulphide bonds in mch and mchl are indicated in red, and a.a. identity in green, while the predicted dibasic peptide at the cleavage site (rr) is underlined. (b) quantification of the pigmentation index (left) and dorsal pictures of the head (right) from zebrafish and frog larvae developed for days with a white (wb) or a black (bb) background. bars indicate average (normalized to wb) from two independent experiments (n = ; n = ; ±se; *p < . , anova). bottom right panels are enlargements of the red squares. (c) fish against pmch and pmchl followed by immunohistochemistry against mch/mchl. transverse brain sections ( µm) processed for fish (red; white arrows) and with a polyclonal anti-human mch antibody (green) that recognizes both mch and mchl. note mch immunoreactivity surrounding the pituitary (p) in zebrafish but not xenopus. pmchl+ neurons project their axons to the pituitary in fish (yellow arrows), while the axons of pmch+ neurons from both species project dorsally and are restricted to the brain (hypothalamus areas) nagamori, yasui, & oshima, ) . thus, a dual-hormonal control of regulation by α-msh and an mch with "hormonal status" may exist in fish. mch can also act as a neurotransmitter or neuromodulator to regulate physiological processes associated with feeding and energy homoeostasis (amano & takahashi, ; ludwig et al., ; matsuda et al., ) . the fish mch system differs from that in mammals with regard to the hormonal status of mch and the presence of two genes, pmch and pmchl, with distinct genetic structures (berman, skariah, maro, mignot, & mourrain, ). the single pmch gene of mammals and birds contains three exons and encodes a prohormone that generates an mch that acts as a neurotransmitter (breton, presse, hervieu, & nahon, ; cui et al., ; nahon, presse, bittencourt, sawchenko, & vale, ) . zebrafish have this gene, named originally pmch (renamed here pcmh), but also possess a one-exon gene that ultimately produces a peptide with "melaninconcentrating activity" (berman et al., ; ono, wada, oikawa, kawazoe, & kawauchi, ; takayama, wada, kawauchi, & ono, ) (figure ). the mammalian mch, encoded by the three-exon gene, is almost identical to the -a.a. fish "mch," encoded by the single-exon gene (berman et al., ; kawauchi, ; kawauchi et al., ; nahon et al., ; ono et al., ) . because rat mch was characterized after the fish peptide, both received the same name (nahon et al., ) . synteny analysis indicates, however, that the mammalian and zebrafish three-exon genes are linked evolutionarily, and higher similarity exists between the mch peptides encoded by the three-exon genes than that by the one-exon gene (named hereafter pmchl) (figure a ) (berman et al., ) . a few studies have compared the expression of the pmch genes in fish adapted to different backgrounds (berman et al., ; kang & kim, ; mizusawa et al., ; zhang et al., ) , but it is unclear whether it is mch or mchl that mediates teleost background adaptation. moreover, an evolutionary analysis of pmch and pmchl genes is lacking. our data indicate that pmchl-expressing cells extend "mchl"positive axons to the zebrafish pituitary, while the pmch-expressing neurons extend "mch"-positive axons dorsally in the brain, suggesting that mchl rather than mch has the hormonal role. we used the phylogeny of chordates to analyse the evolution of pomc, pmch and pmchl genes. we suggest an explanation for the differences in the mechanisms that evolved to regulate background adaptation by inferring ancestral relationships, and assessing associations with plastic colour change, the ability of α-msh, mch and mchl peptides to be synthesized and secreted and to work as neuroendocrine hormones, as well as their effects on skin pigmentation. we propose that the evolution of background adaptation relates mainly to key changes in the pmch genes, with the topological structure of the pomc gene and the α-msh a.a sequence both conserved during evolution. we show that the intron-less pmchl gene appears only in the teleostei lineage, possibly as a result of an ancestral retroposition or during the teleost-specific genome duplication (tsd). based on our analyses, we suggest renaming the intron-less gene, originally named pmch in several fish (kawauchi, ; ono et al., ; takayama et al., ) , as pmchl, which is in concordance with the current zebrafish nomenclature convention and reflects its evolutionary origin. pmchl gained "hormonal status" and is found only in teleosts, while the three-exon pmch peptide product was conserved as a brain neurotransmitter that regulates feeding behaviour. to be consistent with the evolutionary origin of both genes, in this paper we call the mammalian and fish three-exon gene, and the prehormone and the peptide generated, as pmch, pmch and mch, respectively, and the fish intron-less gene, pmchl, and its corresponding peptides pcmhl and mchl. of note, special care should be taken with the literature, as a different nomenclature was used. physiological skin pigmentation indices were measured on -dayold embryos at the middle of the light cycle period ( hr on), as described previously (bertolesi, hehr, & mcfarlane, ) . briefly, pictures of the dorsal head of tadpoles were taken with identical conditions of light, time exposure and diaphragm aperture, and converted to binary white/black images using nih imagej (u. s. national institutes of health, bethesda, md) public domain software. the areas of ten dorsal head melanophores/fish were measured (n = fish; n = experiments), while in xenopus (n = ; n = ) the pigmentation present within an area of the dorsal head between the eyes was used for quantification, since melanophore processes overlap. statistical differences were determined by anova (*p < . ). pmch and pmchl from zebrafish were amplified by reverse transcriptase pcr (rt-pcr) from single-strand cdna generated from zebrafish embryos at days post-fertilization (dpf) using superscript™ ii rnase h reverse transcriptase (invitrogen) according to the manufacturer's instructions. pcr amplifications were carried out in a total volume of μl using fermentas pcr mix (thermo fisher scientific inc., ottawa, ontario). pcr amplification products were cloned into the pcrii-topo vector and sequenced at the dna services facility, u. calgary. pcrii-topo-pmch-zf and pcrii-topo-pmchl-zf amplified by pcr produced sequences with % identity to those deposited previously in the genbank database [fj . between nucleotides and (pmch) and fj . between nucleotides and (pmchl), respectively). a pcmv sport plasmid, containing the full-length cdna encoding x. laevis pmch obtained from an image clone (open biosystems image clone number ic ; pcmv-sport -pmch-xl), was used to generate pmch probes. antisense and sense riboprobes were synthesized from linearized plasmid using sp or t rna polymerases (roche) and digoxigenin (dig) (roche, montreal, qc, canada)-labelled nucleotides and stored at − °c. fish was performed on -µm cryostat sections obtained from embryos at dpf. hybridized probes were detected using anti-dig antibody ( : ; roche) conjugated to horseradish peroxidase. the staining process was carried out with a tsa cyanine (red) system kit (perkin elmer, usa), according to the manufacturer's instructions. immunohistochemistry was performed on sections after fish using standard procedures. briefly, the fish reaction was stopped with several washes of tn-t ( mm tris ph . , mm nacl, . % bovine serum albumin (sigma), and . % tween- (bdh)) before addition of primary antibody (anti-mch rabbit polyclonal m ; / dilution; sigma-aldrich) in blocking buffer ( . % blocking f i g u r e schematic diagram of related taxa (classes or orders) of vertebrates with a similar state of evolution and/or mechanism for background adaptation. extant species divided (see materials and methods) into groups corresponding with taxonomic classes (top rectangles) or taxonomic orders. evolutionary years (millions) dividing different era are indicated on the left. whole-genome duplication events ( r; teleost-specific duplication [tsd r] and salmonid-specific duplication [ss r]) are indicated in yellow, while blue circles denote the age of the oldest preserved fossils with fur or feathers with insulation capacity. homoeotherms (birds and mammals) are in grey boxes. background adaptation is indicated with a white/black circle. group : cyclostome (agnathans: hagfish and lamprey); group : chondrichthyes (cartilaginous fish; sharks); group : cladistei (polypteriformes; bichir); group : chondrostei (sturgeon); group : holostei (bowfin; gar); group : teleostei; group : euteleostei and neoteleostei; group : acanthomorpha (see taxonomic orders for groups , and in table s ); group : coelacanthi and dipnoi (lungfish); group : anura (frogs); group : caudata (salamanders); group : squamata (lizard and snakes); group : testudine (turtles); group : crocodilia (crocodiles, alligators); group : aves (birds); and group : mammalian (mammals). not included in the analysis are the taxonomic orders from amphibian gymnophiona (caecilians) and from reptile rhynchocephalia (tuatara) (grey circle) reagent fp in tn-t; perkin elmer). alexa fluor-tagged secondary antibodies (green; nm emission, anti-rabbit) diluted : , were used to detect the primary antibody. a variety of organisms from agnathans and gnathostomes with readily available protein reference sequence were used to probe for pmch, pmchl and pomc. homologues were identified using zebrafish pmch, pmchl and pomc as queries with a cut-off expect (e) value for positive candidates set at . . the organisms selected are listed in tables s and s (pmch and pmchl) and (pomc). the genetic-structural analysis of pmch and pmchl was performed from organisms listed in the ncbi gene database that contained the exonintron structure and gene identification number, as referred to in the organism list. although organisms with fully sequenced genomes were chosen wherever possible, some organisms in key lineages with unpublished or incomplete genomes were also included. in a few cases, for example, for organisms that are used as model systems for background adaptation (i.e., oncorhynchus keta and verasper moseri), we included nucleotide sequence obtained from cdna rather than derived from genomic sequences. different species were chosen to represent a broad range of organisms in sixteen clades (taxonomic classes or orders) as referred to in figure . vertebrates were divided into sixteen clades. group contains species in the infraphylum agnathan (cyclostomes, represented by two taxonomic classes, myxini and cephalaspidomorphi, which includes the hagfish and lamprey, respectively). groups - correspond to extant gnathostomes. group contains the cartilaginous fish (sharks; taxonomic class, chondrichthyes), while the ray-fin fish (actinopterygii) were divided into six groups representing taxonomic classes or orders (groups - ). the taxonomic classes cladistei, chondrostei and holostei were maintained as independent groups (groups , and , respectively), while the clade teleostei was divided into three groups based on the taxonomic orders and differences in their background adaptation response (see results and table s ). the taxonomic orders in teleostei were divided as follows: group (teleostei) contains taxa, group (euteleostei plus neoteleostei) contains taxa, and group (acanthomorpha plus percomorpha) contains taxa (table s ) . lobe-fin fish (sarcopterygii) were group . the amphibians were grouped into their three taxonomic orders: anura (frogs; group ), caudata (salamanders; group ) and gymnophiona (caecilians, not analysed because of lack of information on pomc, pmch and pmchl). reptiles were also grouped according to their taxonomic order: squamata (lizards and snakes; group ); testudine (turtles; group ); crocodilia (crocodiles; group ); and rhynchocephalia (tuataras), with the latter not considered because only one living species (sphenodon punctatus) exists and genetic information is lacking. finally, groups and correspond to the clade aves (birds) and mammals, respectively. validated sequences were aligned using muscle (multiple sequence alignment) and used to build a hidden markov model (hmm) by using a maximum-likelihood architecture construction algorithm. all phylogenetic analysis and alignments were performed by using the public domain mega x software (www.megasoftware.net) (kumar, stecher, li, knyaz, & tamura, ) . detailed descriptions and statistics are indicated in the figure legends. mch and mchl show a similar a.a. sequence (figure a ), and both bind cultured mammalian hek cells that overexpress mch r and mch r (mizusawa et al., ) . the data are more convincing, however, for mchl having "hormonal status." at physiological concentrations (< nm), mchl induces greater melanosome aggregation in cultured skin melanophores and xanthophores than mch (mizusawa et al., ) . further, mchl is the "factor" with melanin-concentrating capacity that was shown initially to be secreted by the pituitary of catfish (parasilurus asotus) (enami, ) , and was then purified from the pituitary of chum salmon (o. keta) ( figure a ) (enami, ; kawauchi et al., ) . finally, pmchl mrna is upregulated in organisms with a white background (berman et al., ; kang & kim, ; mizusawa et al., ; zhang et al., ) , and pmchl overexpression in medaka (oryzias latipes) increases mchl plasma levels and lightens the skin, but leaves feeding behaviours unchanged (kinoshita et al., ) . these data argue that mchl has hormonal status. whether the related mch is also secreted into the circulation blood to induce melanosome aggregation is unclear. in order to answer this question, we used two experimental models: zebrafish (danio rerio) and the african clawed frog (x. laevis), which possess mch/mchl and only mch, respectively ( figure a ). of note, studies have defined the hormonal status of an mch in fish based on the immunohistochemical detection of mch+ axon fibres that project to the neurohypophysis (baker, ; baker & bird, ; powell & baker, ) and/or the biochemical detection of mch peptides in blood kishida et al., ) . those studies, however, were performed before it was known that two pmch genes exist, and used polyclonal antibodies raised against either mammalian mch (human or rat) or salmonid mchl (coho salmon), which likely cross-react in that mch and mchl a.a. sequences are almost identical ( figure a ). in order to compare the background adaptation response between the two model systems, we grew three-dayold zebrafish and xenopus larvae for days with a white or a black background, and then measured skin pigmentation (bertolesi et al., ) . both species showed melanosome aggregation and a light skin colour with a white background ( figure b ). next, we asked whether the pmch+ and pmchl+ neurons in zebrafish and the pmch+ neurons of xenopus are present in the hypothalamus, and project axons to the neurohypophysis. of note, in zebrafish pmch and pmchl are expressed by different neurons (berman et al., ) our experimental data suggest mchl possesses hormonal status in zebrafish, while mch may act as a brain neurotransmitter. together with the presence of two pmch genes in fish and one in mammals, these observations led us to hypothesize that the uni-hormonal or dual-hormonal theories of background adaptation in vertebrates might be explained by the evolution of the pomc, pmch and pmchl genes. to address this possibility, we assessed in species across evolution first the presence of a physiological background adaptation response, via an analysis of the literature, and, second, the structure and sequences of the pomc, pmch and pmchl genes and their corresponding peptides. thus, the evolution of the physiological background adaptation response was inferred by comparison of extant organisms grouped in clades (taxonomic classes or orders) as referred to by the integrated taxonomic information system (https://www.itis.gov/) (figure ). we focused our evolutionary analysis on two assemblages in the phylum chordata that emerged over the past million years: the agnathans (bilateral organisms with an internal support system but that lack a hinged jaw; cyclostome; group ) and the gnathostomes (bilateral organisms with an internal cartilaginous or bony skeleton, and a hinged jaw; groups - ). the protochordata (organisms that lack an internal cartilaginous or bony skeleton) were not considered in this study, since the mechanisms to change skin colour differ from those in chordata (umbers, fabricant, gawryszewski, seago, & herberstein, ) , and the pomc gene is not detected (sundström, dreborg, & larhammar, ) . cyclostomes (group ) change skin colour in response to environmental light (dark/light) through melatonin secreted by the pineal gland (joss, ) ; however, we are unaware of reports of quick physiological skin adaptation prompted by changing the surface colour (figure , circle with a red cross). background adaptation does occur in extant gnathostomes starting in group (cartilaginous fish; chondrichthyes) with sharks altering their skin pigmentation to adapt to the "background" colour generated by deep and shallow water (lowe & goodman-lowe, ) , and continuing through to mammals (beltran, burns, & breed, ; zimova et al., ) (figure , black and white circles; see additional references in table s ). the ray-finned bony fish (groups - ; actinopterygii) constitute the largest clade of living vertebrates and distribute over cladistei, chondrostei, holostei and teleostei taxa ( figure ). here, we maintained three of the four taxonomic classes (cladistei, chondrostei and holostei, with , and living species, respectively) as independent groups (groups , and , respectively), with all containing species that background-adapt ( figure and table s ). the fourth actinopterygii taxonomic class, teleostei, contains more than , species. we divided this clade into three groups that reflect different evolutionary lineages based on recent molecular and genomic data (groups - ) (betancur-r et al., ; betancur-r et al., ; near et al., ) . cypriniforme zebrafish (d. rerio) and the anguilliforme eel (anguilla anguilla) with a dual-hormonal mechanism (figure , tables s and s ). group contains the euteleostei plus neoteleostei ( figure and table s ). background adaptation occurs in the esociform esox lucius, as well as in several species of salmonids, including oncorhynchus mykiss, and the chum salmon (o. keta) from which an mch peptide (we call mchl) was originally purified (kawauchi et al., ) . studies in salmon helped reveal the dual-hormonal mechanism, in that circulating mch/mchl and α-msh levels increase with a white and black background, respectively kishida et al., ) (figure and table s ). finally, group , acanthomorpha, are collectively known as the spiny-rayed fish ( figure ) . percomorphas, the clade that encompasses most of the diversity of modern acanthomorpha, is the major evolutionary lineage at the top of the teleost tree ( figure and table s ). organisms of this group backgroundadapt and include the important models beloniforme medaka (oryzias latipes), tetraodontiforme fugu (takifugu rubripes) and the pleuronectiforme flounder (verasper moseri) (klovins et al., ; mizusawa, kobayashi, yamanome, saito, & takahashi, ; sugimoto et al., ) . interestingly, several species in this group lack the dual-hormonal mechanism, in that mch/mchl plasma levels but not α-msh vary with background adaptation, including flounders (verasper moseri and platichthys flesus) (gilham & baker, ; kang & kim, ; mizusawa et al., ) and tilapias from the genus oreochromis (nile and mozambique) (gröneveld, balm, martens et al., a; gröneveld, balm, & wendelaar bonga, b; van der salm, metz, wendelaar bonga, & flik, ) . group consists of the coelacanthi and dipnoi lobe-finned fish (lung fish), with only eight living species (figure ) . captive dipnoi adapt their skin colour to the background (smith & coates, ) , while no information is available for coelacanths. to best characterize evolutionary changes in pomc and pmch, we grouped the species in the taxonomic classes amphibia and reptilia according to their taxonomic orders (figure ): the amphibian frogs (anura; group ), salamanders (caudata; group ) and caecilians (gymnophiona; not analysed, grey circle), and the reptilia squamata (lizards and snakes; group ), testudine (turtles; group ), crocodilia (crocodiles; group ) and rhynchocephalia (tuataras not analysed, grey circle) (figure ) . although colour skin pigmentation of several species of caecilians mimics the above-ground soil where they move (wollenberg & measey, ) , is not clear if it is a genetically mediated process (background matching) or driven by physiological colour plasticity. therefore, caecilians were not grouped for further analysis. in contrast, background adaptation in amphibian frogs and salamanders is well documented (table s ) and appears to be driven by a uni-humoral mechanism, since mch/mchl do not trigger melanosome aggregation (ferroni & castrucci, ; wilkes et al., ) . background adaptation is also present in species in the clade reptilia ( figure and table s ). finally, the homoeotherms of the taxonomic classes aves (birds; group ) and mammals (group ) we next performed an evolutionary analysis of the mch and mchl peptides and genes. we focused first on the gene structure of pmch, analysing mainly organisms whose genome was fully sequenced and listed in the ncbi gene database with the exon-intron structure and gene identification number (table s ). the three-exon gene appears conserved during evolution, as it is present in all groups in which we were able to find the gene, from chondrichthyes (group ) to mammals (group ). in contrast, the intron-less gene is present only in teleost fish (groups - ; figure and table s ). teleosts possess ~ % more pigmentation-related genes than tetrapods, most of which were duplicated and retained during the tsd and are involved in specification and differentiation of pigment cells (braasch, brunet, volff, & schartl, ; lorin, brunet, laudet, & volff, ) . thus, the idea that pmchl was retained in teleostei by evolutionary pressure selection on a gene with a key role in pigmentation regulation (e.g., background adaptation) is tempting. (minth, qiu, akil, watson, & dixon, ) and o. kisutch (mch ) (nahon, presset, schoepfer, & vale, ) . we find four variants in the arctic char (salvelinus alpinus) and the atlantic salmon (salmo salar), which express the mrnas (leong et al., ) ( figure and table s ). phylogenetic analysis of the predicted proteins of the group salmonids and the esociform esox lucius shows that pmcha and b, and pmchla and pmchlb are related to pmch and pmchl from esox lucius, respectively, but appeared more recently in evolution ( figure ). this result, together with the ab- (courseaux & nahon, ) . we next analysed pmch and pmchl at the a.a. level. both pmch and pmchl contain a predicted mch and mchl sequence able to generate a cyclic ring with a.a. between two internal cysteines that mediate a disulphide bond essential for receptor binding (audinot et al., ; matsunaga, hruby, lebl, castrucci, & hadley, ) , as well as two consecutive basic residues (e.g., arg -arg in mammals and rodents) critical for cleavage and release (viale et al., ) ( figures a and ) . mch peptides are at least two a.a. longer ( - a.a. / species) than mchl ( a.a. / species in groups - ). the latter is highly conserved (> % identity, / a.a.) in all species of groups - (figure and table s ). also, highly conserved in f i g u r e carboxy-end amino acid sequence of the evolutionary conserved pmch and the teleost-specific pmchl. structure (top) and alignment of the carboxy-end region of pmch and pmchl of several species grouped as indicated in figure . the putative peptides processed from pmch include mch and neuropeptide glutamic acid-isoleucine (nei), and from pmchl include mchl, neuropeptide glutamic acid-valine (nev) and mch gene-related peptide (mgrp). the length of the a.a. sequences and the number of exons (ex; red) that contribute to the open reading frame are indicated on the right. note three (or more) exons and one exon contribute to pmch and pmchl, respectively. multiple protein sequence alignments were performed by using muscle and correspond to pmch from group mchl is a valine inside the ring ( / species from groups - ). in mch, the a.a. at this site is isoleucine or leucine, except for in two group species, d. rerio and paramormyrops kingsleyae, in which valine is present (figure ) . we next analysed the presence of other putative peptides in the pmch and pmchl prohormones. in mammals, pmch is processed to mch and neuropeptide glutamic acid-isoleucine (nei) (viale et al., ) , a -a.a. peptide that affects the hypothalamic-gonadal axis (bittencourt & celis, ; fujimoto, fukuda, sakamoto, takata, & sawamura, ) . conserved sequence for the mammalian nei is present in amphibians and reptiles (groups - ), while several a.a. are absent from group species and missing completely from group and species (figure ) . these data suggest that nei has no biological function in teleosts. similarly, in birds (group ), the predicted nei peptide is highly modified, and the loss of the k/r r site for cleavage in chicken and japanese quail (figure ) suggests that the peptide is not processed and released. thus, nei is conserved in land organisms, but not aquatic organisms or birds. interestingly, a arginine-valine (nev) neuropeptide from the rainbow trout sequence was suggested as a homologue of the mammalian nei, based mainly on the topological position and the presence of a dibasic rr motif nahon et al., ) . our analysis shows that nev is predicted to be processed from pmchl but not pmch, and in species from groups and , but not group (figure ). an additional putative peptide, named mch gene-related peptide (mgrp) (figure ) , is present in nile tilapia, but does not participate in background adaptation (gröneveld, balm, & wendelaar bonga, c) . (hu et al., ; takahashi et al., ) . thus, the three-exon gene is translated to pmch, which then releases mch after processing. in mammals, and probably in fish (berman et al., ; mizusawa et al., ) , mch acts as a neurotransmitter to regulate feeding. the paralogue pmchl intron-less gene (originally named pmch), and the mchl peptide to which it gives rise, appears only in teleostei. its existence, coupled with the potential of mchl to reach the circulation, associates with the dualhormonal mechanism for background adaptation in teleosts. with α-msh as a key regulator of background adaptation, and data which suggest that pomc and mcr in chordates are linked evolutionarily (dores & baron, ; dores et al., ) , we next analysed the a.a. sequences of pomc, α-msh and acth. acth and α-msh arise from processing of pomc in the anterior pituitary and pars intermedia pituitary, respectively, and are utilized in distinct neuroendocrine circuits (zhou, bloomquist, & mains, ) (figure a ). β-, γ-and δ-msh are also processed from pomc, but have no known role in f i g u r e topological organization of pomc and amino acid sequence alignment of acth/α-msh. (a) schematic representation of pomc with the positioning of the different processed peptides. γ-msh, β-msh, acth (green) and α-msh (red), which is at the amino-end of acth, are indicated and positioned based on the presence of the conserved hfrw sequence. β-endorphin is located at the carboxy-end. the a.a. length and the position of the first a.a. of hfrw are indicated on the right and inside the acth/α-msh domain, respectively. note that δ-msh is exclusive to group (sharks) and γ-msh is not present in teleosts (groups , and ), cyclostomes (group ) and the lineage from which arose the snakes (group ), but is present in lizards (half blue rectangle). also indicated are mutations in hfrw in groups and species. in lamprey, acth and α-msh are encoded by different genes, named pom and poc, respectively (heinig et al., ; takahashi et al., ) . (b) aligned sequences of acth and α-msh (green and red box, respectively). amino acids in α-msh are coloured. note similarity between groups to . topological organization and sequence alignment were performed by using the following pomc prohormones (species, genbank acc. background adaptation (gilham & baker, ; sumpter & lowry, ) . for group cyclostomes, we analysed the peptides that would arise from two genes with homology to pomc, pom (pro-opiomelanotropin) and poc (pro-opiocortin), which contain the acth and the α-msh sequences, respectively (heinig, keeley, robson, sower, & youson, ; takahashi et al., ) . common to acth and all three msh peptides is the presence of a his-phe-arg-trp (hfrw) sequence, critical for binding and activation of mcrs (dores et al., ; schwyzer, ) . we used this motif to align the various pomc peptides of the different taxonomic groups (figure a ). the comparison of msh peptides between groups supported our taxonomic grouping of phylogenetic clusters. first, in agreement with previously described differences (dores, cameron, lecaude, & danielson, ; takahashi, amemiya, nozaki, sower, & kawauchi, ) , the δ-msh sequence is detected only in species of group ( / species) (figure a and table s ). second, γ-msh exists in cartilaginous fish and tetrapods, but is absent in the agnathan poc and pom (amemiya, takahashi, suzuki, sasayama, & kawauchi, ) ( figure a and table s ). in agreement with previous studies (dores & baron, ; kitahara et al., ) , we found γ-msh is also absent from groups , and . novel is that γ-msh in squamata is missing in the lineage giving rise to snakes ( / species), but is present in lineages from which lizards and geckos arose ( / species) ( figure a and table s ). further, we find mutations in the functionally relevant hfrw motif of γ-msh in species from groups and [e.g., hfhw ( / species) and hfrs ( / species), respectively) ( figure a and table s ), which may result in non-functional peptides. together, our analysis suggests that while γ-msh was lost in teleosts and snakes, it may already have become non-functional earlier in evolution (chondrostei and holostei lineages). the analysis of acth/α-msh sequences between the agnathan poc/pom and gnathostome pomc indicates an association with the ability to background-adapt. the α-msh sequence is similar in length ( a.a.) and homology (identity between % and %; / and / a.a., respectively) only between groups that background-adapt (groups to ), but is remarkably different in cyclostomes (figure b ). these differences in cyclostome α-msh may explain the lack of background adaptation in lamprey. first, while the α-msh peptide predicted from the pom gene is identical to the msh-b peptide isolated from the pituitary glands of the sea lamprey petromyzon marinus , it is longer than gnathostome α-msh, with additional a.a. located near two amino terminal basic a.a. essential for endopeptidase cleavage ( figure b) . second, the homology in the region surrounding hfrw is low in agnathans ( %; / a.a. as compared to more than % in gnathostomes) (figure b) . finally, the affinity of α-msh to the lamprey mcr is , times lower than to the human receptor (haitina et al., ; schiöth, petersson, muceniece, szardenings, & wikberg, ) . the fact that α-msh and acth bind to the lamprey receptor with similar affinities, while the affinity of α-msh for the human mcr is times higher than that of acth (haitina et al., ; schiöth et al., ) , suggests that acth may be the biological and the "ancestral" ligand for the mcr in agnathans. interestingly, the localization of α-msh and acth to the intermedia and anterior pituitary, respectively, is nonetheless conserved between agnathans and gnathostomes , as is the tetrapeptide hfrw required to bind mcr (figure b ) (costa et al., ; schwyzer, ) . as mentioned, species of groups to all show background adaptation. the literature supports the idea that this pigmentation response associates with the conservation of α-msh sequence between these groups. particularly relevant in this regard, given their evolutionary separation from mammals, are group species, which also lack mchl. the dogfish squalus acanthias α-msh (figure b ) (lowry, bennett, & mcmartin, ) is almost identical to that of human (identity / a.a; figure b ). interestingly, in sharks, background adaptation is reversed by intravenous administration of α-msh antibodies (rodrigues & sumpter, ) , and the marine elasmobranch and mammalian α-msh both induce melanosome dispersion after intravenous injection (sumpter & lowry, ) . indeed, α-msh regulates pigmentation in species from groups (potamotrygon reticulatus) (visconti & de l. castrucci, ) to group (abdel-malek et al., ) , suggesting a conserved role (supporting references in table s ). of note, while α-msh functions in background adaptation in homoeotherms (groups - ), the peptide source may differ in key ways from that in groups - . in birds, α-msh is likely produced in a paracrine manner in the integument, and not from the pars intermedia pituitary, which birds lack (boswell & takeuchi, ) . in mammals, α-msh levels change seasonally, rising during spring/summer and decreasing in autumn/winter (altmeyer, stöhr, & holzmann, ; lincoln & baker, ; mcfarlane et al., ) , but the mechanisms and the source of α-msh are unknown. a possible explanation for the differences with groups - is that species therein require rapid colour plasticity for thermoregulation (fan, stuart-fox, & cadena, ; tattersall, eterovick, & andrade, ) , a need minimized in birds and mammals with an "insulated" integument. in summary, our analysis reveals that α-msh (and β-msh) was conserved during evolution, while γ-msh and δ-msh were not. interestingly, the differences in α-msh a.a. sequence between agnathans and gnathostomes associate with the capacity to background-adapt. in ectotherms, background adaptation (and thermoregulation) is regulated by α-msh secreted from the pars intermedia pituitary. in homoeotherms, however, a role of a pituitary-derived α-msh in background adaptation is unclear. we used both the structure and presence of pomc, pmch and pmchl as a "genetic basis," alongside mch/mchl "hormonal status," to explain differences in the physiological mechanisms for background adaptation over evolution. the genetic basis includes a conserved α-msh sequence and function between groups and , but not group (figure ) . a conserved three-exon pmch gene, whose function appears conserved and relates to feeding behaviours and energy homoeostasis, is present in species of all groups. a pmchl gene appears in teleosts (groups - ) and associates with hormonal status for mchl ( figure ) and axon projections from pmchl+, but not pmch+, neurons to the hypophysis. therefore, we suggest mchl arose evolutionarily in the teleostei lineage, acquiring hormonal status and a new role in skin pigmentation. finally, the "genetic basis" and the "hormonal status" together explain the following differences in the mechanisms that regulate background adaptation in vertebrates (figure ; conclusions): . group : no significant role for α-msh and mch. the absence of a background adaptation response in cyclostomes likely reflects the inability of mch and α-msh to regulate skin pigment dispersion or aggregation, with a distinct α-msh sequence and affinity to mcr from that in gnathostomes. lamprey skin does not respond to synthetic salmon mchl (baker & bird, ) , and a "melanophore-aggregating factor" is detected in hypothalamic but not pituitary extracts (baker & rance, ) , suggesting that mch does not possess hormonal status. additionally, mchl is not present in cyclostomes (figure ). groups - : α-msh but not mch regulates background adaptation. mchl is not detected in these groups, and mch does not appear to have hormonal status. for instance, a shark mch antibody detects cells in the hypothalamus, but not the pituitary gland, of sphyrna lewini (group ) (mizusawa et al., ) . additionally, neither human mch ( % identity to shark mch; / a.a.), nor synthetic mchl, produce aggregation in triakis scyllium and potamotrygon reticulatus (group ) (mizusawa et al., ; visconti & de l. castrucci, ). yet, pituitary-derived α-msh regulates background adaptation in several shark species (visconti & de l. castrucci, ) (figure ; supporting references in table s ). interestingly, skin melanophores from erpetoichthys calabaricus (group ), and acipenser stellate and polyodon spathula (group ), do not respond to synthetic mch and mchl, and mch antibodies fail to label fibres in the posterior pituitary (baker & bird, ; sherbrooke & hadley, ) , arguing against hormonal status for mch in groups and . background adaptation in species from these groups, however, requires a functional pituitary and involves α-msh-induced dispersion of melanosomes, pointing to α-msh, but not mch, as the key regulator of skin pigmentation (figure and additional references in table s ). group : hormonal status and skin response to mch appears. in holosteans, mch+ fibres extend to the pituitary in lepisosteus osseus and amia calva, and mchl causes melanosome aggregation (baker & bird, ; sherbrooke & hadley, ) . therefore, a dual hormonal role of α-msh and mch in regulating skin pigmentation is possible. whether mchl is responsible is unclear, in that we were unable to find pcmhl in any holostean genome, including that of the fully sequenced lepisosteus oculatus (figure ). thus, it is possible that the dualhormonal system was present in the common ancestor of holosteans and teleosts. a key question that needs to be addressed is what selective advantage, if any, was provided by the duplicated genes of teleosts? evolutionary selection of pmchl may be explained as a case of subfunctionalization, with essentially no functional change before and after the duplication in holosteans. groups - : a dual control mechanism at the bottom of the teleostei lineage (groups and ), and a single main regulator, likely mchl, at the top (group ). we suggest pcmhl appears early in the teleost lineage by retroposition or during the tsd, with mchl-expressing neurons then selected over evolution to extend f i g u r e genetics and the hormonal status of mchl explain the different mechanisms for background adaptation. groups able to background-adapt are indicated with a white/black circle. the genetic basis corresponds to the presence of a highly conserved -a.a. α-msh (red square), a three-exon pmch gene (three yellow bars) or a one-exon pmchl gene (yellow square), while hormonal status indicates the capacity of an mch to be released into the bloodstream. a teleost-specific pmchl gene encodes mchl, which acts as a hormone in background adaptation, while the conserved pmch gene encodes mch, which we suggest acts as a neurotransmitter to regulate energy homoeostasis and food intake. the six different mechanisms for background adaptation include the following: (a) group : no significant role for α-msh and mch; (b) groups to : α-msh but not mch participates; (c) group : hormonal status appears with a dual role of α-msh and mch in regulating skin pigmentation; (d) groups - : a "dual control theory" mechanism for background adaptation at the bottom of teleostei lineage (groups and ) and a single main regulator, likely mchl, at the top (group ); (e) group : α-msh but not mch regulates background adaptation; (f) groups - : a uni-humoral α-msh system that also is involved in thermoregulation; and (g) groups and : α-msh and mch roles changed in homoeotherms as insulation systems (fur and feathers) appear during the evolution of endothermy their axons to the pituitary. in this manner, function was split between neurotransmitter (mch) and hormonal (mchl) roles. in support of the dual control theory in groups and , physiological changes in both α-msh (black background) and mchl (white background) are produced when background is altered. for example, in the eel (group ), mch induces melanosome aggregation, and a salmon mchl antibody labels secretory granules in neurons with fibres that terminate on neurohypophysial blood vessels, whose density varies between white and black adapted organisms (gilham & baker, ; powell & baker, ) . plasma α-msh levels increase in eels with a black background . in zebrafish, in addition to the hormonal status for mchl suggested by our expression analysis (figure ) , a white background increases pmchl mrna levels, while fasting increases the expression of pmch (berman et al., ) . a black background in zebrafish triggers melanosome dispersion via α-msh interaction with mcr expressed by melanophores (richardson et al., ) . in two group species, starry flounder (platichthys stellatus (kang & kim, ) ) and barfin flounder (verasper moseri (mizusawa et al., ) ), pmch and pmchl mrnas increase in white backgroundadapted organisms, although most robustly for pmchl. because mchl, but not pomc mrna/α-msh, levels change with background in several group species at the top of the teleostei lineage, it is possible that during evolution the balance between α-msh and mch changed from α-msh»mch in groups - , to a dual mechanism in groups and (α-msh = mch ), to α-msh«mchl in group species (figure ) . group : α-msh but not mch regulates background adaptation. mch+ nerve fibres are absent from the neural lobe of the pituitary of protopterus annectens, and synthetic salmonid mchl does not influence skin cells of lepidosiren paradoxa (dipnoi) (baker, ; visconti & de l. castrucci, ) , suggesting that mch does not have hormonal status and plays no role in skin pigmentation ( figure ). . groups - : a uni-humoral α-msh control system for background adaptation and thermoregulation. mchl is not present in amphibians and reptiles, and mch appears to lack hormonal status ( figure ) . indeed, while the hypothalamus contains mch-expressing cells in frogs (rana esculenta; group ), squamata (podarcis muralis and natrix natrix; group ) and turtles (trachemys scripta; group ), their axons do not project to the posterior pituitary (cardot et al., ; lázár et al., ) . thus, α-msh is the main regulator of background adaptation and may also be important for temperature regulation of ectotherms though colour plasticity (fernandez & bagnara, ) . groups and : new roles for α-msh and mch. in birds and mammals, mchl does not exist, mch+ cells do not extend axons to the pituitary (cardot et al., ; cortés et al., ) , and the pars intermedia pituitary disappears in birds, arguing against a hormonal status for mch (figure ) . birds rely on carotenoid ingestion for background adaptation, while in mammals α-msh possibly associates with seasonal colour moulting. thus, while colour plasticity is important for thermoregulation in ectotherms, in feather/hair covered homoeotherms, skin pigment cells changed with regard to cell type (only melanocytes in birds and mammals), pigment type (eumelanin and pheomelanin) and properties (pigment secretion vs. dispersion/aggregation). together, our experimental data and comparison of evolutionary studies suggest that mchl but not mch has hormonal status in teleosts. a conserved α-msh peptide and the presence of mch or mchl constitute the "genetic basis" for background adaptation that together with the "hormonal status" for mchl explains the different background adaptation mechanisms observed in vertebrates. the authors declare no conflict of interest. geb designed the experiments. geb and jzz performed the experiments and analysed the data. geb and sm wrote the paper. https://orcid.org/ - - - mitogenic and melanogenic stimulation of normal human melanocytes by melanotropic peptides seasonal rhythm of the plasma level of alpha-melanocyte stimulating hormone melanin-concentrating hormone: a neuropeptide hormone affecting the relationship between photic environment and fish with special reference to background color and food intake regulation a newly characterized melanotropin in proopiomelanocortin in pituitaries of an elasmobranch, squalus acanthias structure-activity relationship studies of melanin-concentrating hormone (mch)-related peptide ligands at slc- , the human mch receptor zur chromatischen hautfunktion der amphibien. pflüger, archiv für die gesammte physiologie des menschen und der thiere melanin-concentrating hormone: a general vertebrate neuropeptide the role of melanin-concentrating hormone in color change neuronal organization of the melanin-concentrating hormone system in primitive actinopterygians: evolutionary changes leading to teleosts cloning and expression of melanin-concentrating hormone genes in the rainbow trout brain further observations on the distribution and properties of teleost melanin concentrating hormone changes in pituitary and plasma levels of msh in teleosts during physiological colour change convergence of biannual moulting strategies across birds and mammals characterization of two melanin-concentrating hormone genes in zebrafish reveals evolutionary and physiological links with the mammalian mch system melanopsin photoreception in the eye regulates light-induced skin colour changes through the production of α-msh in the pituitary gland seeing the light to change colour: an evolutionary perspective on the role of melanopsin in neuroendocrine circuits regulating light-mediated skin pigmentation the tree of life and a new classification of bony fishes phylogenetic classification of bony fishes anatomy, function and regulation of neuropeptide ei (nei) recent developments in our understanding of the avian melanocortin system: its involvement in the regulation of pigmentation and energy homeostasis pigmentation pathway evolution after whole-genome duplication in fish structure and regulation of the mouse melanin-concentrating hormone mrna and gene melanin-concentrating hormone-producing neurons in reptiles melaninconcentrating hormone-producing neurons in birds evolution of the melanocortin system mutational analysis of evolutionarily conserved acth residues birth of two chimeric genes in the hominidae lineage characterization of melanin-concentrating hormone (mch) and its receptor in s: tissue expression, functional analysis, and fasting-induced up-regulation of hypothalamic mch expression morphology of the pars intermedia and the melanophore-stimulating cells in xenopus laevis in relation to background adaptation evolution of pomc: origin, phylogeny, posttranslational processing, and the melanocortins presence of the delta-msh sequence in a proopiomelanocortin cdna cloned from the pituitary of the galeoid shark, heterodontus portusjacksoni years of pomc: melanocortin receptors: evolution of ligand selectivity for melanocortin peptides melanophore-contracting hormone (mch) of possible hypothalamic origin in the catfish tadpoles respond to background colour under threat cyclic colour change in the bearded dragon pogona vitticeps under different photoperiods effect of background color and low temperature on skin color and circulating alpha-msh in two species of leopard frog alpha-msh (melanocyte stimulating hormone) and mch (melanin concentrating hormone) actions in bufo ictericus ictericus melanophores neuropeptide glutamic acid-isoleucine (nei)-induced paradoxical sleep in rats evidence for the participation of a melanin-concentrating hormone in physiological colour change in the eel differential melanin-concentrating hormone gene expression in two hypothalamic nuclei of the teleost tilapia in response to environmental changes biphasic effect of mch on alpha-msh release from the tilapia (oreochromis mossambicus) pituitary identification, cellular localization and in vitro release of a novel teleost melanin-concentrating hormone gene-related peptide functional characterization of two melanocortin (mc) receptors in lamprey showing orthology to the mc and mc receptor subtypes the appearance of proopiomelanocortin early in vertebrate evolution: cloning and sequencing of pomc from a lamprey pituitary cdna library phylogenetic timing of the fish-specific genome duplication correlates with the diversification of teleost fish genetics, development and evolution of adaptive pigmentation in vertebrates the pigmentary effector system. viii. the dual receptive mechanism of the amphibian background response identification of prohormones and pituitary neuropeptides in the african cichlid synthesis, storage, and release of msh in the pars intermedia of the pituitary gland of xenopus laevis during background adaptation a swimming mammaliaform from the middle jurassic and ecomorphological diversification of early mammals the pineal complex, melatonin, and color change in the lamprey lampetra functional characterization of two melanin-concentrating hormone genes in the color camouflage, hypermelanosis, and appetite of starry flounder functions of melanin-concentrating hormone in fish characterization of melanin-concentrating hormone in chum salmon pituitaries transgenic medaka overexpressing a melanin-concentrating hormone exhibit lightened body color but no remarkable abnormality the measurement of melanin-concentrating hormone in trout blood solid-phase absence of a gamma-melanocyte-stimulating hormone sequence in proopiomelanocortin mrna of chum salmon oncorhynchus keta the melanocortin system in fugu: determination of pomc/agrp/mcr gene repertoire and synteny, as well as pharmacology and anatomical distribution of the mcrs mega x: molecular evolutionary genetics analysis across computing platforms distribution of melanin-concentrating hormone-like immunoreactivity in the central nervous system of rana esculenta salmo salar and esox lucius full-length cdna sequences reveal changes in evolutionary pressures on a post-tetraploidization genome evolution of melanocortin receptors in cartilaginous fish: melanocortin receptors and the stress axis in elasmobranches the atlantic salmon genome provides insights into rediploidization topology of feather melanocyte progenitor niche allows complex pigment patterns to emerge seasonal and photoperiod-induced changes in the secretion of a-melanocyte-stimulating hormone in soay sheep: temporal relationship with changes in b-endorphin, prolactin, follicle-stimulating hormone, activity of the gonads and growth of wool and horns adaptive evolution of multiple traits through multiple mutations at a single gene teleost fish-specific preferential retention of pigmentation gene-containing families after whole genome duplications in vertebrates a phenology of the evolution of endothermy in birds and mammals suntanning in hammerhead sharks the isolation and amino acid sequence of an adrenocorticotrophin from the pars distalis and a corticotrophin-like intermediate-lobe peptide from the neurointermediate lobe of the pituitary of the dogfish squalus acanthias melanin-concentrating hormone overexpression in transgenic mice leads to obesity and insulin resistance feeding-induced changes of melanin-concentrating hormone (mch)-like immunoreactivity in goldfish brain synthesis and bioactivity studies of two isosteric acyclic analogues of melanin concentrating hormone the effect of geographic location, breed, and pituitary dysfunction on seasonal adrenocorticotropin and α-melanocyte-stimulating hormone plasma concentrations in horses two precursors of melanin-concentrating hormone: dna sequence analysis and in situ immunochemical localization identification of mrnas coding for mammalian-type melanin-concentrating hormone and its receptors in the scalloped hammerhead shark sphyrna lewini involvement of melanin-concentrating hormone in background color adaptation of barfin flounder verasper moseri inhibiting roles of melanin-concentrating hormone for skin pigment dispersion in barfin flounder, verasper moseri interrelation between melanocyte-stimulating hormone and melanin-concentrating hormone in physiological body color change: roles emerging from barfin flounder verasper moseri the rat melanin-concentrating hormone messenger ribonucleic acid encodes multiple putative neuropeptides coexpressed in the dorsolateral hypothalamus identification of a single melanin-concentrating hormone messenger ribonucleic acid in coho salmon: structural relatedness with sl ribonucleic acid resolution of ray-finned fish phylogeny and timing of diversification distribution of lamprey adrenocorticotropin and melanotropins in the pituitary of the adult sea lamprey, petromyzon marinus neuroendocrine control of physiological color change in chameleo gracilis structures of two kinds of mrna encoding the chum salmon melanin-concentrating hormone origin of adult pigmentation: diversity of pigment stem cell lineages and implications for pattern evolution structural studies of nerve terminals containing melanin-concentrating hormone in the eel, anguilla anguilla evolutionary genetics: the evolution of plumage patterns the evolutionary origin and diversification of feathers mc r pathway regulation of zebrafish melanosome dispersion pigmentation phenotypes of variant extension locus alleles result from point mutations that alter msh receptor function effects of background adaptation on the pituitary and plasma concentrations of some pro-opiomelanocortin-related peptides in the rainbow trout (salmo gairdneri) adaptive reptile color variation and the evolution of the mc r gene genetics of colouration in birds deletions of the n-terminal regions of the human melanocortin receptors acth: a short introductory review exploring the evolutionary history of melanin-concentrating and melanin-stimulating hormone receptors on melanophores: neopterygian (holostean) and chondrostean fishes cognition and the evolution of camouflage cutaneous melanosis in lungfishes (lepidosirenidae) mass spectrometric map of neuropeptide expression and analysis of the gamma-prepro-tachykinin gene expression in the medaka (oryzias latipes) brain regulation of melanophore responsiveness in the background-adapted medaka, oryzias latipes: change in the intracellular signaling system the involvement of melanotrophins in physiological in the dogfish scyliorhinus canicula colour change concomitant duplications of opioid peptide and receptor genes before the origin of jawed vertebrates desalle r isolation and characterization of melanotropins from lamprey pituitary glands evolutionary significance of proopiomelanocortin in agnatha and chondrichthyes possible involvement of melanin-concentrating hormone in food intake in a teleost fish, barfin flounder structures of two genes coding for melanin-concentrating hormone of chum salmon tribute to r. g. boutilier: skin colour and body temperature changes in basking bokermannohyla alvarengai (bokermann ) reversible colour change in arthropoda alpha-msh, the melanocortin- receptor and background adaptation in the mozambique tilapia cellular localization and role of prohormone convertases in the processing of pro-melanin concentrating hormone in mammals melanotropin receptors in the cartilaginous fish, potamotrygon reticulatus and in the lungfish, lepidosiren paradoxa synthesis of a cyclic melanotropic peptide exhibiting both melaninconcentrating and -dispersing activities why colour in subterranean vertebrates? exploring the evolution of colour patterns in caecilian amphibians pineal-specific agouti protein regulates teleost background adaptation the prohormone convertases pc and pc mediate distinct endoproteolytic cleavages in a strict temporal order during proopiomelanocortin biosynthetic processing function and underlying mechanisms of seasonal colour moulting in mammals and birds: what keeps them changing in a warming world key: cord- -z c zgp authors: garden, jenni g.; mcalpine, clive a.; possingham, hugh p.; jones, darryl n. title: habitat structure is more important than vegetation composition for local‐level management of native terrestrial reptile and small mammal species living in urban remnants: a case study from brisbane, australia date: - - journal: austral ecol doi: . /j. - . . .x sha: doc_id: cord_uid: z c zgp abstract as urban areas continue to expand and replace natural and agricultural landscapes, the ability to manage and conserve native wildlife within urban environments is becoming increasingly important. to do so we first need to understand species' responses to local‐level habitat attributes in order to inform the decision‐making process and on‐ground conservation actions. patterns in the occurrence of native terrestrial reptile and small mammal species in sites located in remnant urban habitat fragments of brisbane city were assessed against local‐level environmental characteristics of each site. cluster analysis, multidimensional scaling ordination, and principal axis correlation were used to investigate relationships between species' occurrences and environmental characteristics. native reptiles were most strongly associated with the presence of termite mounds, a high amount of fallen woody material, and a moderate amount of weed cover. native small mammals were most strongly associated with the presence of grass trees (xanthorrhoea spp.), and both reptiles and small mammals were negatively influenced by increased soil compaction. significant floristic characteristics were considered to be important as structural, rather than compositional, habitat elements. therefore, habitat structure, rather than vegetation composition, appears to be most important for determining native, terrestrial reptile and small mammal species assemblages in urban forest fragments. we discuss the management implications in relation to human disturbances and local‐level management of urban remnants. over the past years, habitat loss and fragmentation have had the greatest influence on terrestrial ecosystems and biodiversity worldwide (sala et al. ; millennium ecosystem assessment ) . agricultural land use has previously been regarded as the primary cause of habitat loss and fragmentation, yet as areas of suitable arable land are exhausted, agricultural expansion is declining (millennium ecosystem assessment ) . comparatively, urban development is expanding rapidly, encroaching on agricultural and natural, non-arable, landscapes (levia & page ; lugo ) . it therefore seems likely that urban development will surpass agricultural land use as the primary anthropogenic driver of land use change and habitat loss and fragmentation. areas deemed suitable for urban development often coincide with those areas that also support high native species richness and endemism (lugo ) . the impacts of urbanization on fauna populations are multicausal and multiscaled, altering the in situ structure and composition of habitat fragments, as well as their spatial patterning within the landscape context. these habitat modifications potentially have important consequences for concomitant fauna assemblages, with significant differences being apparent between urban and preurban assemblages (jones & wieneke ; van der ree ; tait et al. ) . within the urban matrix, introduced species and a handful of native generalist species tend to dominate, while habitat and dietary specialists and migratory species tend to decline in numbers or become locally extinct (how & dell , white & burgin ; tait et al. ). this problem is particularly pertinent to australia, where more than % of the human population currently resides in urban areas (united nations ) . for native fauna assemblages, native terrestrial reptile and small mammal species are considered to be the fauna groups most sensitive to urbanization and its associated disturbances (how & dell , van der ree ; white & burgin ; tait et al. ) . although many native mammals and reptiles are negatively influenced by urban development, some native mammal and reptile species, such as the common brush-tail possum (trichosurus vulpecula), blue-tongue lizard (tiliqua scincoides), and fence skink (cryptoblepharus virgatus) may adapt, and even thrive, within the built environment (koenig et al. ; matthews et al. ; garden et al. ) . in contrast, urban-sensitive species (e.g. dunnarts, sminthopsis spp., antechinus, antechinus spp., geckos, and large reptiles) face significant dispersal, predator avoidance and, resource adaptation challenges within the human-dominated urban matrix. consequently, these urban-sensitive species are restricted to the often isolated, remnant native vegetation patches that occur within the urban matrix or in the fringing peri-urban landscapes (how & dell tait et al. ; garden et al. ) . effective conservation in urban remnants requires scientific knowledge underpinning management decisions and on-ground actions. much of the current available scientific knowledge is based on non-urban ecological research (garden et al. ) . in non-urban environments there is a strong global consensus that, regardless of the disturbance pressure, many native reptile and small mammal species depend more on structurally complex habitats, than compositionally diverse floristics (e.g. bennett ; southgate et al. ; flemming & loveridge ; lenders & daamen ; spencer et al. ; kanowski et al. ) . similar findings have also been reported for native species within australian urban landscapes (e.g. dufty ; jellinek et al. ; white & burgin ) . although, fischer et al. ( ) and jellinek et al. ( ) found that vegetation composition, in addition to structure, was important for reptile species in grazed and urban affected habitats. in contrast, wilson et al. ( ) reported that within coastal heathlands of victoria, several native rodent and dasyurid species displayed no floristic or vegetation structural preferences. such discrepancies in research findings, coupled with the distinct lack of urban-based ecological research (garden et al. ) , limit our ability to make generalizations about the habitat requirements of urban reptiles and small mammals, and hence management recommendations. this limitation is further compounded by differences in the type, rate and intensity of disturbances within urban landscapes compared with non-urban landscapes. a further complication is the large variation in habitat requirements among species (e.g. jellinek et al. ; monamy & fox ), but also within species according to age. for example, although fischer et al. ( ) found that four-fingered skinks (carlia tetradactyla) responded to habitat structure and composition in grazing-affected landscapes, they also found that the relative importance of different attributes varied between juveniles and adults. consequently, australian urban conservation managers face significant uncertainty regarding the most appropriate management strategies for achieving long-term conservation outcomes for a diversity of native fauna species. if native fauna diversity is to be conserved in the face of rapid urban expansion, it is vital that we understand the habitat requirements and sensitivities of species living within urban remnants. this requires understanding how both species' composition and species' richness are influenced by local-level habitat factors. however, local-level habitat management is often focused on maintaining overall species' diversity within the landscape by managing habitat patches so that current concomitant assemblages of native fauna are conserved before they become locally extinct, thereby avoiding the need for expensive reintroduction programs. conserving native fauna in urban landscapes first requires understanding what local or in situ factors are important for maintaining diverse assemblages of native fauna. this knowledge may then by used to inform urban conservation managers and planners about priority habitat management decisions and activities so that native fauna occupying urban habitat fragments are adequately conserved. this was the focus of our study. this paper investigated correlations between the composition of native terrestrial reptile and small mammal fauna within urban habitat fragments and local-level (< ha) habitat factors such as habitat structure, vegetation composition, fire and human disturbances. these habitat factors were considered ecologically important for the target species and also can be manipulated and managed by conservation managers. investigations were based in urban habitat fragments located within the brisbane city council (bcc) local government area, where local government is responsible for setting within-patch management priorities and actions.we applied cluster analysis, multidimensional scaling and principal axis correlation to identify significant habitat attributes and examine their importance for reptile and small mammal assemblages. mammal and reptile assemblages were analysed separately. based on our findings, we discuss the implications for conservation management within brisbane city. the study focused on queensland's capital city, brisbane ( ° ′s, °e; area km , population approximately million) (fig. ). brisbane has a subtropical climate and is australia's third largest and most rapidly growing capital city (commonwealth of australia ). as european settlement in the early s approximately two-thirds of the original woody vegetation has been cleared for agricultural, industrial and/or urban development purposes (brisbane city council ) . more than % of this clearing was of lowland forests (< m from sea level) resulting in the current, highly fragmented and isolated lowland remnant vegetation patches that vary in their internal condition and disturbance and management histories (catterall & kingston ; brisbane city council ) . of the remaining % remnant vegetation cover, about % is protected for conservation purposes, yet much of this area is concentrated in contiguous forest on the city's outskirts, particularly in the d'aguilar ranges to the west (brisbane city council ). contemporary urban growth has concentrated along major transport networks to the north, south and south-west, with coastal wetlands and moreton bay to the east and mountain ranges to the west constraining urban expansion in these directions. accord-ingly, the highest concentration of urban development pressure currently occurs in the lowland outer suburbs to brisbane's south and south-east (brisbane city council ) . despite recent rapid urban expansion and subsequent habitat destruction and modification, brisbane still supports high floristic and faunal diversity and endemism, boasting the highest diversity of native vertebrate species of any of australia's capital cities (queensland museum ) . however, in the face of rapid urbanization, the continued persistence of this species' diversity is uncertain. our study focused on lowland remnant habitat fragments situated within - km of brisbane's central business district, in the southern (karawatha) and southeastern (burbank) suburbs (fig. ) . we selected sites located within regional ecosystem (re) type . - . , which is dominated by scribbly gum (eucalyptus racemosa) woodland located on sedimentary rocks and sandy soils (young & dillewaard ) . although classified as 'not of concern' by the queensland environmental protection agency (queensland environmental protection agency ), this re is extensively cleared and fragmented within brisbane city (young & dillewaard ) . bcc spatial data and satellite imagery were used to select sites located on private and council owned land. potential site locations were ground-truthed to assess their suitability. site locations were considered unsuitable if they were: (i) difficult to access; (ii) had been largely cleared or disturbed; (iii) patches were too small to fit a survey site; or, (iv) had a high likelihood of human interference to fauna survey equipment. survey sites measured m ¥ m and consisted of three parallel transects m apart, along which fauna traps were placed and habitat assessments were conducted. where possible, sites were positioned perpendicular to the landscape slope and a minimum of m from patch edges. this distance was selected to concentrate on interior rather than edge and matrix habitats. sites were also located at least m from designated walking tracks and recreational areas. wildlife surveys were conducted over three consecutive nights, during fine weather conditions in the spring and summer of . initial surveys ( were conducted at all sites, yet repeat surveys ( ) occurred at only sites, as nine sites were abandoned owing to recent fire or substantial human interference. native reptile and small mammal species were identified at each site using a combination of live-trapping, direct observation and trace survey methods, to maximize the probability of detecting the range of target species. each site was surveyed using: eight cage traps, elliott traps (two sizes: ¥ ¥ mm; ¥ ¥ mm), five dry pitfall traps ( l buckets) and three hair funnels. opportunistic species identifications from scats, visual observations and vocalizations were also recorded. cage traps, elliott traps and hair funnels were baited with the standard australian native small mammal bait mixture (menkhorst & knight ) . pitfall traps were unbaited. the dense vegetation and fallen woody debris at several sites prevented the use of drift-fences, which have previously been used with pitfall traps to improve capture success (e.g. mengak & guynn ; crosswhite et al. ; menkhorst & knight ) . cage and elliott traps were set and baited each afternoon, checked for captures each morning and closed during the day. pitfall traps remained open for the entire trap cycle ( days and nights) and were checked for captures each morning and afternoon. hair funnels were set at the beginning of a trap cycle and left undisturbed until collection at the end of the trap cycle. scat collection, direct observations and vocalization records occurred opportunistically throughout each site visit. at the point of capture, animals were identified to species-level using a relevant field guide (menkhorst & knight ; wilson ) , photographed, weighed, sexed (if possible) and immediately released. scat and hair samples were identified ex situ by one of two independent experts (initial surveys analysed by michiala bowen; repeat survey samples analysed by barbara triggs ) . habitat assessments were conducted at all sites between the initial and repeat wildlife survey periods. twenty-three habitat variables (table ) were measured at each site, following a protocol similar to that detailed by eyre et al. ( ) .the number of large trees (d.b.h. Ն cm) within the site perimeter was visually counted from the centre of each site, and the total basal area was recorded using the bitterlich variable radius method (sensu mueller-dombois & ellenberg ). a visual appraisal of the total number of termite mounds, approximate weed cover and, the presence or absence of fire (e.g. tree scars, charcoal, ash) and human disturbances (e.g. litter, garden waste, sawn logs) were recorded over the duration of each site assessment. the remaining habitat variables were measured along each of the three transects and the measurements either totalled or averaged for the whole site. the total number of acacia spp., allocasuarina spp., banksia spp., pteridium esculentum, callistemon spp., xanthorrhoea spp., and melaleuca spp. within m of the transect lines were recorded. similarly, all fallen woody material within m of each transect line was tallied and categorized into five diameter classes (< cm, - cm, - cm, - cm, > cm), eight decay classes (recently felled, sound, bark peeling off, to % decay, - % decay, - % decay, > % decay, debris), and three complexity classes (simple, complex, stump). these records were later used to calculate the relative volume (m ) of fallen woody material for each site.the total number of pieces of fallen wood that contained hollows was also recorded. the presence of canopy, mid-storey, and understorey cover was recorded every m along each transect using a gimballed sighting tube. understorey density was also measured every m using an adaptation of methods described by macarthur and macarthur ( ) and haering and fox ( ) . this involved a m screen, divided into cm grid cells, viewed at waist height from a -m distance. three understorey measurements were recorded: (i) the total number of grid cells obscured by vegetation; (ii) the highest grid row obscured by vegetation ( cm- cm); and (iii) the highest grid row with at least one grid cell Ն % obscured by vegetation. these six stratum records were later averaged to provide measures of average per cent cover for each stratum and average understorey density at each site. the per cent of ground cover, number of ground cover types (e.g. coarse leaf litter, casuarina needles, rocks, herbs), ground cover depth, and soil compaction were recorded every m within a ¥ m quadrat along each transect. per cent and types of ground cover were assessed visually. a -cm ruler was used to record ground cover depth. soil compaction was measured using a penetrometer (e.g. fox et al. ) and counting the number of hits taken (up to hits) to drive a weighted probe mm into the soil. for both ground cover depth and soil compaction, six measurements were made every m. the records of per cent ground cover, ground cover depth and soil compaction were later averaged for each site. analyses were based on the species detected and habitat variables recorded at each site. total species occurrence data were derived by combining the species detected from each wildlife survey method and during both survey periods.the overall species' occurrence data were divided into two separate data sets: (i) native reptile species; and (ii) native mammal species. exotic species were not included in the data analysis. continuous habitat variables were initially compared using the spearman rank correlation test in r version . . (the the r development core team ). a correlation coefficient > . was chosen to identify highly correlated habitat variables.where variables were highly correlated, one variable was removed from the data set. the remaining variables were used for subsequent statistical analyses. we applied a multivariate statistical approach using patn version . . for windows (belbin ) to examine the relationships between species' occurrence and site habitat characteristics. similarities between sites in terms of species' composition were first investigated using the bray & curtis index (bray & curtis ) . clusters were derived from the data set using the flexible unweighted pair group using arithmetic averaging method (upgma) with a beta (b) value of - . . the upgma clustering method is considered superior as it considers more than one species at any fusion (wardell-johnson & williams ; podani & schmera ) . at a beta value of - . , the upgma clustering method is space-dilating (cf. spacecontracting), thereby creating even-sized groups and preventing the formation of a single large group (belbin ; wardell-johnson & williams ) . we examined the acceptability of the resulting site groups and patterns using semi-strong hybrid multidimensional scaling ordination. the ordination was considered in conjunction with the minimum spanning tree (mst) and dendogram.the mst represents pairwise associations between group objects. its use is comple-mentary to ordination and may be used practically to confirm or deny close relationships or identify trends in the data (belbin ) . the dendogram schematically displays the hierarchical clustering of groups.the number of site groups was adjusted until maximum congruence was obtained between the ordination, mst and dendogram, thereby indicating that the most robust site groupings had been attained. relationships between the intrinsic species occurrence and the ordination groups were examined using principal component correlation (pcc) with permutations. pcc uses multiple linear regression to fit selected variables to the ordination space, showing the direction of best fit and the correlation with that direction (r ) (belbin ) . monte-carlo attributes in ordination (mcao) procedure with iterations was then used to test the reliability of these correlations with the ordination space by calculating the proportion of r values that exceed the true r in a given number of iterations (belbin ). an mcao value less than % was considered significant. variables identified as having significant correlations with the species groups were then overlaid on the ordination space. this analysis procedure was repeated to investigate relationships between the extrinsic habitat variables and the ordination groups. species and habitat variables that were found to be highly correlated with the ordination were examined further using the kruskal-wallis statistic function in patn to determine how well each variable discriminated between the ordination groups. the larger the kruskal-wallis statistic for a variable, the more significant that variable's contribution was to the differentiation of ordination groups. significant variables according to the kruskal-wallis statistic (p < . ) were compared with mcao values in order to test the strength of the relationships. we recognize, however, that the reliability of the kruskal-wallis statistic is proportional to the number of objects in the smallest group (belbin ) . as such, the kruskal-wallis statistic results are included, based on expert advice, as a comparative value to investigate the strength of mcao results, but these values should be treated with caution. a total of native species (eight mammals, nineteen reptiles) were identified from trap nights (table ). an additional native mammal (melomys sp.) was identified at two sites from scat and hair samples, but positive identification to the species level was not possible. instead, the genus was included in the analysis of the mammal data set. in total, these represented native family groups. the most common mammal species was the common brushtail possum identified in of the sites ( %). however, it was considered a predominantly arboreal species (how & kerle ) and was not included in further analysis.the common dunnart (sminthopsis murina) and the northern brown bandicoot (isoodon macrourus) were the most commonly detected terrestrial mammal species (n = sites each). detections of the common planigale (planigale maculata), common dunnart, and the yellow-footed antechinus (antechinus flavipes) were of particular interest as these dasyurids are relatively uncommon in brisbane's lowland habitats and are classified as significant species within the local government area (brisbane city council ).the fence skink (c. virgatus) and garden skink (lampropholis delicata) were the two most common reptile species (n = and n = sites, respectively). larger-bodied and more cryptic reptile species such as snakes, lace monitors (varanus varius), and dragons (e.g. bearded dragon, pogona barbata, and eastern water dragon, physignathus lesuerii) were identified at significantly fewer sites than small-bodied skink species (table ) . correlation analysis revealed the three measures of understorey density were strongly correlated (> . ). we eliminated two variables and retained total understorey density. although not highly correlated with other variables, average ground cover was also removed from the data set as it showed very little variation between sites with sites having an average cover > %. each species' common name and the total number of sites at which they were detected are also shown. for reptiles, four groups of sites (fig. a ) yielded the lowest ordination stress level (stress = . ) and maximum congruence between the ordination, mst and dendogram. the two most commonly captured reptile species, c. virgatus and l. delicata, dominated group sites (n = ), being identified at % and % of sites, respectively (fig. a) .this indicates a high degree of overlap in the distribution of these species within group . however, these skink species showed little or no overlap in the and sites that, respectively, comprised groups and . group sites were characterized by the ubiquitous presence of l. delicata (detected in all sites) and the absence of c. virgatus (fig. a) . the presence of c. virgatus rather than l. delicata dominated group ( % and %, respectively) (fig. a) . species' richness also varied between groups, with group containing the highest overall native species richness ( species), more than % greater species richness than group (fig. a) . group represented the fewest sites (n = ) and was characterized by a total absence of native reptile species. mcao reported eight native reptile species that were highly correlated with the ordination of reptile groups: carlia foliorum, carlia vivax, cryptoblepharus virgatus, dendrelaphis punctulata, diporiphora australis, l. delicata, carlia pectoralis, and v. varius (fig. b) . of these species, the presence of c. virgatus, l. delicata, and c. vivax explained the largest amount of variation in the ordination (r = . , . and . , respectively) and were highly significant at p < . (table ) . c. foliorum, and d. australis were less significant (p < . ). although c. pectoralis, d. punctulata, and v. varius were highly correlated with the ordination, these species were not found to be statistically significant (table ). the results further suggest that calyptotis scutirostrum and lampropholis amicula discriminate well between the groups (p < . and p < . , respectively), yet mcao indicated these species had a low correlation with the ordination groups (table ) . four habitat variables: soil compaction, total number of termite mounds, wood volume and weed cover ( - %) were significantly correlated with reptile groups (fig. c) . of these variables, only soil compaction and weed cover ( - %) discriminated well between the groups according to the kruskal-wallis statistic (table ) . three statistical groups of native mammal species (fig. d) produced the best ordination fit (stress = . ) and maximum congruence between the ordination, mst and dendogram. group was comprised of the sites at which no native mammals species were detected, indicating that native mammal species were undetected at the majority of the sites. comparatively, groups and were dominated by the dasyuridae and peramelidae families, respectively. native rodent species (family: muridae) were represented in group and group (fig. b ). all native mammal species were correlated with the ordination (fig. e) and, with the exception of northern brown bandicoots, explained between % and % of the group variation (table ) . northern brown bandicoots explained more than % of the group variation (r = . ), being found at all sites comprising group (fig. b) . the statistical significance of all but one species (long-nosed bandicoot, perameles nasuta) was supported by the kruskal-wallis statistic (table ) . both northern brown bandicoots and common dunnarts had the highest discrimination between groups (p < . ). the number of grass trees (xanthorrhoea spp.) and soil compaction were the only habitat variables that were significantly correlated with the mammal ordination (fig. f) . however, the associated kruskal-wallis values indicated that neither of these variables discriminated well between the groups (table ) . this study considered a range of local-level environmental factors and their correlation with native terrestrial reptile and small mammal species' compositions within fragmented urban bushland habitats. our results initially appear to imply that both vegetation composition (weed cover and grass trees) and habitat structure (termite mounds, wood volume and soil compaction) are important for native reptile and small mammal species. however, when previous research and species' behaviours and life history traits are examined, it seems likely that species in this study were responding to the structural role fulfilled by weed cover and grass trees rather than the compositional or floristic role. therefore, we conclude that at the local-level, habitat structural complexity is more important than vegetation composition for the occurrence of terrestrial, native reptile and small mammal species in brisbane's lowland remnant habitat fragments. this overall result is consistent with several other studies of various fauna species (including birds, reptiles and mammals) living within natural and disturbed (non-urban) habitats (e.g. grover & slater ; catterall et al. ; scott et al. ; webb & shine ; tait et al. ; vesk & macnally ). many of these and similar studies indicate distinct speciesspecific responses to particular habitat attributes, yet it was not possible in our study to identify speciesspecific relationships because of the low detection rate of many species in several sites. the low detection of several species may potentially be explained by localized species' declines owing to urbanization and its associated disturbances and/or, owing to the cryptic nature of habitat use, dietary preferences and seasonal population fluctuations resulting in a high degree of false-absences. additional surveys conducted over a longer time period are likely to have improved detection rates, added certainty to our results and, provided more information on the habitat preferences of individual species. however, such long-term surveys were not possible in this study owing to time and resource constraints. consequently, our analysis focused on the influence of habitat characteristics on native reptile and small mammal species' compositions rather than individual species' occurrences. reptile captures were dominated by two main species, l. delicata and c. virgatus. both species are also found throughout the urban matrix, although c. virgatus apparently more so than l. delicata (j. garden, pers. obs. garden, pers. obs. - . the recorded dominance of these species during fauna surveys played a significant role in determining the subsequent reptile groups in the patn analysis, indicating that these skink species may influence the composition of skink assemblages within urban patches. similar reptile inter-species interactions were reported by fischer et al. ( ) who found that c. tetradactyla more frequently inhabited sites occupied by at least two other small reptile species. other small reptile species and l. delicata and/or c. virgatus is a hypothesis that warrants further investigation in order to clearly delineate existing relationships and examine the influence of inter-species interactions relative to habitat suitability. the significance of termite mounds and fallen woody material is likely explained by the habitat and resource requirements of reptiles. reptiles are ectothermic and ) , mcao (%) and chi-squared (derived from kw statistic) are shown. significant mcao variables and values are indicated in bold font. chi-squared significance is indicated by: * . > p > . ; ** . > p > . ; ***p < . ; n/s, not significant. the ordination group with which each species and habitat variable was most highly correlated is also shown. so are dependent on habitat attributes that enable them to regulate their body temperature to achieve optimal performance, which is essential for foraging, breeding and predator-avoidance behaviours (huey ; bauwens et al. ; vitt et al. ; burrow et al. ; singh et al. ; lenders & daamen ) . termite mounds and fallen woody material both provide suitable basking locations, habitats for prey species and, numerous nesting and refuge niches. it is not surprising therefore that these structural attributes were most strongly associated with sites dominated by the presence of sun-loving reptile species such as c. vivax, ctenotus taeniolatus and, d. australis (group ). the association of reptiles with termite mounds is consistent with previous studies, both in australia and elsewhere. for example, a lizard species (metroles cuneirostris) from the namib desert of coastal namibia, was found to commonly utilize newly formed termite mounds as foraging locations (murray & schramm ) .the use and importance of termite mounds as refuge locations has also been reported for different reptile species, such as inactive monitors (varanus bengalensis) in sri lanka (wikramanayake & dryden ) and frillneck lizards (chlamydosaurus kingii) in australia's northern territory (griffiths & christian ) . griffiths and christian ( ) particularly demonstrated the importance of termite mounds as refuges by showing that c. kingii individuals who utilized termite mounds to avoid high intensity fires had a % survival rate, compared with the increased mortality and injury of individuals that sought refuge in tree canopies. as supported by previous research, the significance of fallen woody material is likely to provide similar resources as termite mounds for a suite of smallbodied, reptile species (e.g. smith et al. ; fischer et al. ; jellinek et al. ) . other ground-level structural attributes, such as ground cover/leaf litter (e.g. burrow et al. ; singh et al. ) and bushrocks (e.g. schlesinger & shine ; webb & shine ; white & burgin ) have also been reported to provide suitable basking, shelter and foraging opportunities for various native terrestrial reptile species (e.g. snakes, skinks, agamids and geckos). these structures are naturally occurring yet, in degraded urban remnants, human-introduced materials such as discarded metal and wood, and even old car bodies may work equally well (j. garden, pers. obs. ) . the occurrence of native reptiles was positively associated with a moderate amount of weed cover ( - %). weediness was particularly associated with group which was characterized by comparatively 'secretive' reptile species such as l. delicata, l. amicula and burton's snake-lizard (lialis burtonis). although all species require habitats that facilitate thermoregulation, group species appear to tolerate of a moderate amount of certain habitat disturbances (as indicated by weediness), so long as adequate vegetation cover is available either to facilitate thermoregulation or to provide rapid refuge from predators.this is consistent with bragg et al. ( ) who found that l. delicata was more likely to inhabit forested areas, which had more leaf litter, ground and shrub cover than the adjoining open habitat of regenerating minedisturbed areas. furthermore, in our study l. delicata, unlike c. virgatus, were more likely identified from pitfall captures than direct observations, a trend that is indicative of the more cryptic nature of l. delicata. similar capture trends were noted by singh et al. ( ) for l. delicata and c. virgatus surveyed in contiguous forest near brisbane. l. burtonis and pseudechis porphyriacus were also identified from direct observations as pitfall traps were not large enough to trap these larger-bodied species. however, upon detection, these species were observed to actively seek refuge within relatively dense thickets of lower-stratum vegetation. the positive association therefore between the occurrence of certain reptile species and a moderate amount of weed cover is most likely owing to the shelter provided by low, weedy vegetation rather than the weed species' composition per se. these findings support those of fischer et al. ( ) who noted that juvenile and some adult c. tetradactyla were found in moderate to highly weed-infested habitats, concluding that these species are able to tolerate a certain degree of habitat disturbance and potentially benefit from the associated structural changes. other researchers have similarly commented on the importance of lowerstratum vegetation cover for supporting important reptile prey species and also for the safe shelter provided from predators while foraging and dispersing (e.g. burrow et al. ; fischer et al. ) . although it appears that some reptile species respond positively to a certain degree of weed cover, hadden and westbrooke ( ) and jellinek et al. ( ) reported that overall reptile species' richness was negatively associated with increased weediness. our results provide some agreement with these previous findings. moderate weed cover was most associated with group which, compared with groups and , also had the lowest overall native species richness. further, the highest amount of weed cover ( - %), although not significantly correlated with the ordination, appeared to be associated with group (no reptiles detected). jellinek et al. ( ) discuss the possible influence of weediness and time since isolation, commenting on smaller and older remnants being more likely to be dominated by weeds than larger and younger remnants. this may potentially be critical for effectively managing reptile species' compositions investigated in the current study. as weed invasions are indicative of disturbed habitats, it seems likely that, as highlighted by jellinek et al. ( ) and suggested by the current study's findings, certain reptile species are sensitive to habitat disturbances and so will respond negatively to even a low amount of weed cover. conversely, some reptile species are able to tolerate a certain degree of habitat disturbance and may even benefit from the cover provided. it is therefore difficult to make generalizations of the importance of weeds for all reptiles. increased soil compaction was characteristic of habitats in which few or no native reptile species were detected, with the hardest soils occurring at sites at which no native reptile species were detected (group ). there are two possible explanations for this finding. the first directly implicates soil compaction and considers its impact on species' behaviours, whereas the second considers indirect implications of soil compaction, its associated disturbances on vegetation structure, and the resulting influence on reptile species. soil compaction was least associated with group , indicating that reptiles in this group occur more frequently in habitats with soft soils. this is consistent with the two fossorial skink species identified, c. scutirostrum and anomalopus verreauxii, which were found only at sites within this group. owing to their burrowing behaviour, these species do no inhabit or persist in areas with hardened soils where burrowing is difficult. soil compaction also has a significant influence on vegetation growth and regenerative ability (amrein et al. ; bassett et al. ) . increased soil compaction is often a result and a consequence of decreased vegetation cover (e.g. groves & keller ; hadden & westbrooke ) . this cyclic condition is intensified by external disturbances which directly compact the soil and destroy ground cover vegetation. hence, habitats with compacted soils are also likely to be indicative of highly disturbed habitats. inappropriate fire regimes (including arson fires) and aesthetic clearing which decrease vegetation cover and do not promote vegetation regeneration are likely to increase soil compaction and, in turn, make it more difficult for plant species to regenerate (amrein et al. ) . as a result, the habitat structure and soil condition degrades, negatively impacting on various reptile species dependent on structurally complex habitats. similarly, off-track trampling within urban bushland habitats compacts soil and destroys or degrades ground cover vegetation, making these habitats less suitable for reptiles. mammal species were found to be influenced primarily by habitat structure rather than vegetation composition. this is consistent with previous studies (e.g. bennett ; haering & fox ; monjeau et al. ; vernes ; monamy & fox ) which concluded that vegetation structure, rather than vegetation composition, was more important for small mammal occurrence, although species-specific responses to various aspects of structure were evident. for instance, small-bodied mammals, such as dasyurids, are likely to be more capable of moving rapidly through dense undergrowth, whereas largebodied mammals such as kangaroos are impeded by dense midstorey cover, but are less likely to be affected by dense understorey and ground cover. comparatively, large areas of dense undergrowth may present a significant locomotor (and escape) obstacle for medium-bodied mammals, such as bandicoots, and may also inhibit bipedal vigilance behaviours (garden ) . vernes ( ) found that northern bettongs (bettongia tropicana) avoided areas of dense ground cover, particularly dense cover within . m above ground, which approximates the height of an adult bettong. keiper and johnson ( ) similarly reported that short-nosed bandicoots (isoodon obesulus peninsulae) in north queensland forests avoided habitats with a tall, dense grass understorey. such a response is also likely to be true for bandicoots in urban landscapes and so these animals may actively select habitats that are structurally complex, yet are not vegetatively dense. therefore, as suggested by previous bandicoot studies (e.g. dufty ; scott et al. ; chambers & dickman ) , optimal habitats for peramelidae are structurally complex and encapsulate a mosaic of open foraging areas and denser shelter sites that are not so dense as to impede locomotor ability. grass trees also appear to be an important factor for the occurrence of native mammal species. this finding supports previous studies that have identified grass trees as important structural elements for several australian small terrestrial mammal species. vernes and pope ( ) , for instance, found that prior to fires, almost half the number of b. tropicana nests were located in dense vegetation cover such as the skirts of grass trees. spencer et al. ( ) similarly found that native bush rats (rattus fuscipes) responded negatively to the decrease in grass tree cover following fires. likewise, lunney ( ) commented that 'cover-seeking' r. fuscipes prefer habitats with dense ground and understorey cover -a structural requirement that would be partially filled by the presence of grass trees in the understorey layer. grass trees have also been documented as providing important nesting habitats for small dasyurid species such as the common dunnart (fox ) and the yellow-footed antechinus (marchesan & carthew ) . our results support these previous findings, in that the presence of grass trees was most strongly associated with group , which was dominated by dasyurids and r. fuscipes. soil compaction, as for reptiles, was also associated with mammal species occurrences. like reptiles, mammal species also appear to avoid habitats with very hard soils and the reasons may be similar. first, certain mammal species such as some dasyurids may nest in terrestrial burrows (woolley ; j. garden, pers. obs. ) and harder soils would inhibit their ability to burrow. however, unlike the reptile results, certain mammal species appear to respond positively to compacted soils. mammal group was most strongly associated with moderately compacted soils rather than very hard soils. this group was dominated by the peramelidae (bandicoot species). bandicoots are omnivorous and most commonly feed on subterranean invertebrate prey and plant structures such as roots and hypogeal fungi (vernes ; keiper & johnson ) , a behaviour that is obvious from the conical diggings left from foraging (triggs ; j. garden, pers. obs. j. garden, pers. obs. - . their ability to obtain these food resources is possible owing to specialized strong claws on their forefeet which make them powerful diggers. this morphological trait may provide them with an advantage over other species in enabling them to penetrate into harder soils and therefore utilize habitats with increased soil compaction. however, if soils become too hard, vegetation cover decreases (amrein et al. ) , resulting in decreased soil moisture and microbial activity, and hence less food availability and increased energy output (for foraging). structurally complex habitats are likely to occur where there is low to moderately compacted soils influencing vegetation floristics and cover. in addition, although bandicoots appear to prefer structurally open habitats for foraging, they have also been reported to require structurally dense habitats for diurnal shelter (e.g. dufty ; southgate et al. ; chambers & dickman ; vernes ) . therefore, as soils harden and vegetation cover decreases, important food resources decrease as does critical vegetation cover. however, in the urban landscape, dufty ( ) reported that the easternbarred bandicoot (perameles gunii) used a range of natural and artificial structures as shelter sites, implying a certain degree of disturbance tolerance, including moderately compacted soils. although it is important to understand the habitat requirements of individual fauna species, when the goal is conserving, restoring or increasing native fauna diversity, habitats must not be managed based on the requirements of a single species. this is often difficult owing to the variety of species-specific responses and the cryptic nature of many native australian terrestrial fauna. a potential way to address this challenge and facilitate effective management of habitats for multiple species is to construct ecological species profiles (opdam et al. ) . such profiles enable various species to be categorized based on similarities in their habitat requirements and disturbance responses. the resulting ecological species profiles may then be used to guide habitat management decisions, such as priority areas, actions and funding allocation, and facilitate the long-term conservation of multiple species. in addition, long-term monitoring of remnant habitat fragments, and associated adaptive management strategies, is recommended in order to minimize inherent problems of short-term studies such as false-absence records and seasonal fluctuations in species diversity and abundance. disturbance of suburban fagus forests by recreational activities: effects on soil characteristics, above-ground vegetation and seed bank consequences of soil compaction for seedling establishment: implications for natural regeneration and restoration thermoregulation in a lacertid lizard: the relative contributions of distinct behavioural mechanisms patn pattern analysis package:technical reference. csiro division of wildlife and ecology patn. pattern analysis package. csiro division of wildlife and ecology microhabitat use by the long-nosed potoroo, potorous tridactylus, and other small mammals in remnant forest vegetation of south-western victoria distributions of lizard species across edges delimiting open-forest and sand-mined areas an ordination of the upland forest communities of southern wisconsin brisbane city plan microhabitat selection by texas horned lizards in southern texas remnant bushland of south east queensland in the s: its distribution, loss, ecological consequences and future prospects deforestation, urbanisation and seasonality: interacting effects on bird assemblages habitat selection of the long-nosed bandicoot, perameles nasuta (mammalia, peramelidae), in a patchy urban environment comparison of methods for monitoring reptiles and amphibians in upland forests of the ouachita mountains habitat and spatial requirements of the eastern barred bandicoot forest condition and habitat assessment in queensland: standards for forest assessment habitat models for the four-fingered skink (carlia tetradactyla) at the microhabitat and landscape scale the challenge of managing multiple species at multiple scales: reptiles in an australian grazing landscape miombo woodland termite mounds: resource islands for small vertebrates? common dunnart, sminthopsis murina comparison of regeneration following burning, clearing or mineral sand mining at tomago, nsw. i. structure and growth of the vegetation locomotion and energetics of the northern brown bandicoot review of the ecology of australian urban fauna: a focus on spatially explicit processes the effects of fire on the frillneck lizard (chlamydosaurus kingii) in northern australia conservation value to birds of remnants of melaleuca forest in suburban brisbane ecological characteristics of small mammals on a radioactive waste disposal area in southeastern idaho habitat relationships of the herpetofauna of remnant buloke woodlands of the wimmera plains habitat utilization patterns of sympatric populations of pseudomys gracilicaudatus and rattus lutreolus in coastal heathland: a multivariate analysis australian institute of urban studies, greening western australia, department of conservation and land management, and the tree society ground vertebrate fauna of perth's vegetation remnants: impact of years of urbanization common brushtail possum, trichosurus vulpecula physiological consequences of habitat selection environmental and vegetation variables have a greater influence than habitat fragmentation in structuring lizard communities in remnant urban bushland the suburban bird community of townsville revisited: changes over years factors affecting the use of reforested sites by reptiles in cleared rainforest landscapes in tropical and subtropical diet and habitat preference of the cape york short-nosed bandicoot (isoodon obesulus peninsulae) in north-east queensland the dangers of life in the city: patterns of activity, injury and mortality in suburban lizards (tiliqua scincoides) habitat management for the sand lizard at the meinweg national park long-term effects of large scale sod-cutting and burning. natuurhistorisch maandblad the use of cluster analysis in distinguishing farmland prone to residential development: a case study of sterling can we manage tropical landscapes? an answer from the caribbean perspective bush rat, rattus fuscipes on bird species diversity autoecology of the yellow-footed antechinus (antechinus flavipes) in a fragmented landscape in southern australia brushtail possums: 'champion of the suburbs' or 'our tormentors'? pitfalls and snap traps for sampling small mammals and herpetofauna a field guide to the mammals of australia differential habitat use by a local population of subadult common dunnarts, sminthopsis murina, following wildfire in coastal wet heath plants, small mammals, and the hierarchical landscape classifications of patagonia aims and methods of vegetation ecology a comparative study of the diet of the wedge-snouted sand lizard meroles cuneirostris (strauch), and the sand diving lizard aporosaura achietae (bocage), (lacertidae), in the namib desert bridging the gap between ecology and spatial planning in ecology on dendogram-based measures of functional diversity regional ecosystems: . - . . queensland government global biodiversity scenarios for the year choosing a rock: perspectives of a bush-rock collector and a saxicolous lizard ecology and population biology of long-nosed bandicoots (perameles nasuta) at north head effect of control burn on lizards and their structural environment in a eucalypt open-forest the effect of habitat fragmentation and livestock grazing on animal communities in remnants of gimlet eucalyptus sulabris woodland in the western australia wheatbelt population and habitat characteristics of the golden bandicoot (isoodon auratus) on marchinbar island adult free zones in small mammal populations: response of australian native rodents to reduced cover changes in species assemblages within the adelaide metropolitan area, australia r: the r project for statistical computing (v . . ) [freeware] language and environment copyright tracks, scats and other traces the impact of urbanisation on the mammals of melbourne -do atlas records tell the whole story of just some of the chapters? fine-scale habitat preferences and habitat partitioning by three mycophagous mammals in tropical wet sclerophyll forest, north-eastern australia stability of nest range, home range and movement of the northern bettong (bettongia tropica) following moderate-intensity fire in a tropical woodland, north-eastern queensland the clock is ticking: revegetation and habitat for birds and arboreal mammals in rural landscapes of southern australia the impact of individual tree harvesting on thermal environments of lizards in amazonian rain forest a floristic survey of the tingle mosaic, south-western australia: applications in land use planning and management paving the way for habitat restoration: can artificial rocks restore degraded habitats of endangered reptiles? current status and future prospects of reptiles and frogs in sydney's urban-impacted bushland reserves thermal ecology of habitat and microhabitat use by sympatric varanus bengalensis and v. salvator in sri lanka a field guide to reptiles of queensland ecology of small mammals in coastal heathland at anglesea, victoria. aust nest location by spool-and-line tracking of dasyurid marsupials in new guinea southeast queensland this research was a collaborative project between the university of queensland and brisbane city council. financial support was provided by brisbane city council and a uq postgraduate research scholarship. fauna surveys were conducted under uq aec permit, gsp/ / /bcc/uqgs, and queensland government epa scientific purposes permit, wisp . we thank private and council land owners for kindly allowing access to their properties. thanks also to the volunteers who helped establish survey sites and, to the project's two research assistants, michelle walton and alison howes. we gratefully acknowledge valuable statistical advice and comments provided by the uq patn-users group, particularly dr grant wardell-johnson, dr ben lawson and hussein bashir. we thank the editor for useful comments provided on the manuscript. key: cord- -lcgeingz authors: nan title: th international symposium on intensive care and emergency medicine: brussels, belgium, - march date: - - journal: crit care doi: . /s - - - sha: doc_id: cord_uid: lcgeingz nan introduction: increasing evidence supports a central role for "immunosuppression" in sepsis. it is necessary to develop biomarkers of immune dysfunction that could help to identify patients at risk of poor outcomes [ ] . the decreased expression of human leucocyte antigen (hla)-dra is proposed as a major feature of immunodepression and its persistent decrease is associated with mortality in sepsis [ ] . in a previous study, we evidenced that fcer a (fc fragment of ige receptor ia) is the gene showing the lowest expression levels of the entire transcriptome in sepsis [ ] . here we studied the association between fcer a expression and mortality in infected surgical patients. methods: fcer a and hla-dra expression levels were quantified by droplet digital pcr in blood of infected surgical patients. patients died within days ( . %). spearman test was used to evaluate the association between gene expression and the sequential organ failure assessment (sofa) score. areas under receiver operating curves (auroc) were used to determine the gene expression cut-off values predicting mortality. kaplan-meier survival curves were obtained and differences in survival between groups were evaluated using the log rank test. cox regression was employed to assess mortality risk at days. results: gene expression levels of fcer a and hla-dra correlated inversely with patients' severity (r: - . p< . ; r: - . , p< . respectively). both genes showed significant aurocs to predict survival, but fcer a showed the best accuracy (fig. ) . patients with introduction: severe pulmonary and renal conditions such as acute respiratory distress syndrome (ards), respiratory failure, and deterioration in kidney function often occur in patients with nosocomial pneumonia (np). the emergence and course of infection is genetically determined, hence host genetic landscape may influence an ability to resist infection. methods: variants for genotyping were selected using the phewas catalog which presents genotypic data for caucasian patients, phenotypes and single nucleotide polymorphisms (snps) with p < . [ ] . snps with the lowest p-values for phenotypes with both, respiratory and renal manifestations were selected: intergenic variants rs and rs , rs (edil ) and rs (cyp a ). cyp a gene was associated with pneumonia and ards in our previous investigations, so we included in our analysis three sites of cyp a gene (rs , rs and rs ) studied on a smaller sample. genotyping was performed on sites for a sample results: allele rs -g of the cyp a gene was protective against ards and an increase in creatinine level (fig. ) . the rs -g allele was associated with lung complications and with the development of severe respiratory insufficiency (fig. ) . conclusions: the snps rs and rs can influence the aggravation of pulmonary and renal symptoms through genetically mediated response to infection. introduction: an uncontrolled inflammatory response plays a major role in the sepsis related organ dysfunction. mesenchymal stem cells(mscs) can improve survival of sepsis experimental models by modulating the inflammatory response. macrophages have been considered as important immune effector cells and their polarization imbalance aggravates the disordered inflammation reaction. the project aims to identify the effects of mscs on macrophages polarization against dysregulated inflammatory response. methods: raw . cells were plated in the lower chambers of transwell system in the presence or absence of lipopolysaccharide (lps). then, mscs were seeded in the upper chambers and incubation for different time. finally, transforming growth factor beta (tgfβ) receptor (tgf-βr) inhibitor was added in transwell system. the phenotype of raw . cells were analyzed by flow cytometry, the levels of inflammatory cytokines were detected by enzyme-linked immunosorbent assay (elisa). results: our data showed that lps increased the level of interleukin (il)- in raw . cells (p< . ) (fig. ). in line with il- expression, lps induced the expression of m macrophage (p< . ). moreover, lps stimulated raw . cells co-culture with mscs in transwell system, mscs inhibited the expression of il- and m macrophages, while increased m macrophages (p< . ). compared with lps group, the concentration of tgf-Β was obviously increased in mscs treatment groups (p< . ), furthermore, there were no significantly difference between mscs directed and indicted groups. more significantly, tgf-βr inhibitor abolished the impact of mscs on lps stimulated raw . cells (p< . ) (fig. ) . conclusions: mscs polarized m macrophages into m macrophages and decreased pro-inflammatory cytokine levels by paracrining tgf-β. introduction: sepsis is dysregulated response to an infection, which can lead to progressive microcirculatory dysfunction, release of reactive oxygen intermediates (roi) and life-threatening organ dysfunction. our aim was to investigate the relationship between organ damage -characterized by the sequential organ failure assessment (sofa) scores, microcirculatory failure and roi production, in a large animal model of experimental sepsis. methods: fecal peritonitis was induced in anesthetized minipigs (n= ; . g/kg autfeces containing - x cfu bacteria i.p.), control animals (n= ) received sterile saline i.p. invasive hemodynamic monitoring and blood gas analyses were performed between - hrs, the signs for failure of circulatory, respiratory and urinary systems were evaluated in accordance with the sofa score. the microcirculatory perfusion rate in the sublingual region was measured by orthogonal polarization spectral imaging technique (cytoscan a/r). the leukocyte-origin roi production was determined by lucigenine (mostly o -. ) and luminol-based (h o ) chemiluminescence methods. results: between - hrs after induction the sofa score indicated moderate organ failure in animals (m: . ; p: . , p: . ) and the change was statistically significantly higher in pigs, suggesting severe organ dysfunction (m: . ; p: . , p: . ). the microcirculation was significantly deteriorated in all cases, independently of sofa score data. the h o production was significantly lower in septic animals as compared to controls, while the lucigenine enhanced roi production correlated with the sofa score-indicated moderate and severe organ dysfunction. conclusions: sublingual microcirculatory parameters are not correlating with the severity of sofa score-indicated organ dysfunction in abdominal sepsis. the measurement of roi production of the whole blood seems to be better biomarker for the detection of the progression of events from moderate to severe organ damages. introduction: the purpose of this study was to characterize differences in sepsis management in patients with and without left ventricular (lv) dysfunction. septic patients with lv dysfunction have higher mortality, and limited guidance exists for sepsis management of patients with lv dysfunction. the possibility exists that the cornerstones of sepsis management may contribute to these poor outcomes. methods: a retrospective chart review was conducted from may -january at two centers. adult patients who had a diagnosis of sepsis, were treated with vasopressors for > hours, and had an echocardiogram within months were included. patients were divided into two groups: reduced ejection fraction (ef) of < % and preserved ef defined as ef ≥ %. information about patient outcomes and sepsis management were collected. the primary outcome was the need for mechanical ventilation (mv). categorical and continuous data were analyzed using the chi-squared and mann-whitney u tests, respectively. the irb has approved this project. results: a total of patients with ef < % and patients with ef ≥ % were included. no significant differences in fluid management, vasoactive agent maximum rate or duration, or steroid use were observed. net fluid balance between low and preserved ef was positive . liters vs. . liters (p = . ), respectively. the number of patients that needed mv was higher in the low ef cohort ( % vs. %, p = . ), and this cohort had fewer mv-free days ( , iqr - vs. (iqr - ), p= . . conclusions: no significant differences were observed with regard to sepsis management, reflecting current guidelines. the significantly increased need for mv is a provocative result. a potential mechanism is the inability of a patient with reduced lv dysfunction to maintain appropriate cardiac and respiratory function in the face of fluid overload. prospective analysis of the role of fluid balance in septic patients with lv dysfunction is warranted. introduction: the relationship between myocardial injury and systemic inflammation in sepsis response is not well understood [ ] . it´s proposed to evaluate the association between myocardial injury biomarkers, high-sensitive troponin t (hs-ctnt) and n-terminal pro-brain natriuretic peptide (nt-probnp), with inflammatory mediators (il- , il- Β , il- , il- , il- / il- p , il a, il- and tnf-α ) and biomarkers, c protein reactive (cpr) and procalcitonin (pct), in septic patients methods: this was a prospective cohort study performed in three intensive care units, from september to september enrolling patients with sepsis (infection associated with organ dysfunction), and septic shock (hypotension refractory by fluids infusion requiring vasopressor). blood samples were collected up to h after the development of first organ dysfunction (d ) and on the th day after inclusion in the study (d ) results: ninety-five patients were enrolled, with median age years (interquatile? - ), apache ii: median ( - ), sofa: median ( - ); . % were admitted in icu with sepsis and . % with septic shock. hospital mortality was . %. in d , nt-probnp correlated with il- (r = . , p < . ) and il- (r = . , p < . ). in d , hs-ctnt and nt-probnp correlated with pct (r = . , p < . and r = . , p < . ; respectively). nt-probnp d was higher in nonsurvivors than in survivors on mortality in seventh day (p = . ) and in-hospital mortality (p = . ). hs-ctnt d (p = . ) and nt-probnp d (p < . ) were significantly higher in non-survivors on in-hospital mortality. nt-probnp d (or . ; ic % . - . , p= , ) and hs-ctnt d (or , ; ic % . - . , p= , ) were independently associated with in-hospital mortality conclusions: nt-probnp plasma levels at d correlated with il- and il- , and both nt-probnp and hs-ctnt at d correlated with pct. in addition, nt-probnp has been shown to be an important predictor of mortality introduction: heparin-binding protein (hbp) acts proinflammatory on immune cells and induces vascular leakage through cytoskeletal rearrangement and cell contraction in the endothelium and is a promising novel prognostic biomarker in sepsis and septic shock. however, studies on repeated measures of hbp are lacking. our objective was to describe the kinetics of plasma hbp during septic shock and correlate it to hemodynamic parameters. methods: we included patients with septic shock (sepsis- ) on admission to helsingborg hospital's intensive care unit (icu) during september to february . patients were sampled from icu admission and every hours for hours or until death or icu discharge. the plasma samples were analyzed for hbp and converted using the natural log (lnhbp) for normality. lnhbp was then evaluated against mean arterial pressure (map) as primary analysis and against systemic vascular resistance index (svri) as a secondary analysis, using mixed-effects linear regression models, treating patient id as a random intercept and adjusting for hemodynamic parameters. results: a total of patients were included with median age years, females ( %), surgical admissions ( %), median sofa-score points on day one and deaths from all causes within days ( %). plasma hbp ranged from to ng/ml with a median of ng/ml (lnhbp range . to . , median: . ). an increase lnhbp was significantly associated with a decrease in map (coef. - . mmhg, % ci: - . to - . , p= . , n= ), when adjusting for heart rate (hr), noradrenaline (na), vasopressin (vp), dobutamine (dbt) and levosimendan (ls). in a secondary subgroup analysis, an increase in lnhbp was also significantly associated with a decrease in svri (coef. - . dyne*s*cm- *m- , % ci: - . to - . , p= . , n= ), when adjusting for map, hr, na, vp, dbt, ls and cardiac index. conclusions: repeated measures of plasma hbp during septic shock were correlated with important hemodynamic parameters in this small pilot study. introduction: mid-regional pro-adrenomedullin (mr-proadm) comes from the synthesis of the hormone adrenomedullin (adm), which is overexpressed during inflammation and progression from sepsis to septic shock. thus, mr-proadm can be a useful biomarker for the clinical management of septic patients [ ] . the aim of our study was to understand the ability of mr-proadm to predict -day ( -d) mortality and to find a correlation between mr-proadm and sequential organ failure assessment (sofa) score in the first hours from intensive care unit (icu) admission. methods: we evaluated consecutive septic shock patients according to sepsis iii definitions. clinical data from the medical records included demographics, comorbidities, laboratories, microbiology and biomarker levels. whole blood samples for biomarker profiling were collected at , and hours from icu admission. mr-proadm measurement was detected in edta plasma using a sandwich immunoassay by trace® (time resolved amplified cryptate emission) technology (kryptor thermo fischer scientific brahms). results: overall -d mortality rate was . %. mr-proadm [odds ratio (or) = . ], sofa score (or = . ) and lactate (lac) levels (or = . ) in the first hours were associated with -d mortality in univariate logistic analysis (p value < . , table ). -d mortality rate was not associated with procalcitonin (pct) levels (or = . ). further linear regression analysis showed significant correlation between mr-proadm and sofa score at hours from icu admission (p value< . , fig. , table ). conclusions: mr-proadm demonstrated superior accuracy to predict -d mortality compared to pct levels and is directly linked to sofa score at hours from admission. mr-proadm may aid early identification of poor prognosis septic patients who could benefit a more intensive management. introduction: study of the expression of cell free dna (cfdna) in the search for new biomarkers for infection, sepsis and septic shock. methods: the population studied was all patients included in the sepsis protocol from march to january , hospitalized patients of a federal public hospital. plasma samples were collected for quantification of cfdna, which after centrifugation were stored at - °c and then thawed and analyzed by fluorescence using a varioskan flash fluorometer). cfdna values were expressed as ng/ml. the patients were divided into groups: infection and sepsis/septic shock. we analyzed mortality, sequential organ failure assessment score (sofa score), qsofa (quick sofa), comorbidities, cfdna and laboratory parameters of patients. results: among the patients, % were classified as infection and % sepsis/septic shock. overall lethality was %, infection . %, and sepsis/septic shock . % (p< . ). the mean of cfdna, sofa and lactate was higher according to the classification of infection and sepsis/septic shock: cfdna ( . ± . and . ± . , p= . ), sofa ( . ± . and . ± . , p< . ), qsofa (positive in % and %, lactate ( . ± . and . ± . , p< . ). we analyzed leukocytes, creatinine, crp (c reactive protein), inr (international normalized ratio), as predictors of severity and only crp showed no association with disease severity (p= . ). levels of cfdna and qsofa showed worse prognostic utility as a predictor of sepsis / septic shock when compared to lactate and sofa: or . ( % ci . - . ), p= . for cfdna, or . ( % ci . - . ), p= . for sofa and or . ( % ci . - . ), p= . for lactate. negelkerke r square was , for cfdna. in addition, area under the curve for cfdna mortality was . ( % ci . - . ) and sofa . ci % . - . ). conclusions: our study suggests that cfdna and qsofa have worse prognostic accuracy when compared to lactate and sofa, variables already used in clinical practice and easily measured. introduction: the aim of this study is to develop a "molecular equivalent" to sequential organ failure assessment (sofa) score, which could identify organ failure in an easier, faster and more objective manner, based on the evaluation of lipocalin- (lcn /ngal) expression levels by using droplet digital pcr (ddpcr). sepsis has been classically defined as the exuberant, harmful, pro-inflammatory response to infection. this concept is changing [ ] and the presence of a life-threatening organ dysfunction caused by a dysregulated host response to infection is now considered a central event in the pathogenesis of sepsis [ ] . methods: lcn expression levels were quantified by ddpcr in blood of a total of surgical patients with a diagnosis of infection. spearman analysis was used to evaluate if lcn correlated in a significant manner with sofa score. area under the receiver operating curve (auroc) analysis and multivariate regression analysis were employed to test the ability of lcn to identify organ failure and mortality risk. results: spearman analysis showed that there was a positive, significant correlation between lcn expression levels and sofa score (fig. ) . aurocs analysis showed that lcn presents a good diagnostic accuracy to detect organ failure and mortality risk (fig ) . in the multivariate regression analysis, patients showing lcn expression levels over the optimal operating points (oops) identified in the aurocs showed a higher risk of developing organ failure (table ) and a higher mortality risk (table ) . conclusions: quantifying lcn expression levels by ddpcr is a promising approach to improve organ failure detection and mortality risk in surgical patients with infection. introduction: sepsis is an inflammatory state due to an exacerbated immune response against infection. in cancer patients, sepsis presents a -fold higher mortality than in general population and leads to longer intensive care unit (icu) and hospital lengths of stay. it has been shown that reduced levels of circulating immunoglobulins (ig) might be a surrogate marker of unfavorable outcome in sepsis [ ] . the aim of this study was to evaluate the association between ig levels in plasma and -day mortality rate in cancer patients with septic shock. methods: from december to november , we conducted a prospective study in the intensive care unit (icu) of cancer institute of state of sao paulo, an -bed icu linked to university of sao paulo. patients ≥ years old with cancer and septic shock were enrolled. descriptive statistics were computed for demographic and outcome variables. laboratory data and ig levels were collected at icu admission and at days , and . a multivariate analysis was performed to evaluate predictors of -day mortality. results: a total of patients were included in the study. the -day and -day mortality were . % and . %, respectively. no significant differences in igm and igg levels were observed between survivors and non-survivors. in both groups, the median igm levels were low and the median igg levels were normal. in the multivariate analysis for -day mortality, a favorable status performance measured by the eastern cooperative oncology group (ecog) was associated with better survival; metastatic disease, higher sequential organ failure assessment (sofa) score at admission and higher levels of initial lactate were associated with increased mortality. conclusions: low levels of serum endogenous immunoglobulins are not predictors of -day mortality in cancer patients with septic shock. introduction: cytovale has developed a rapid biophysical assay of the host immune response which can serve as a rapid and reliable indicator of sepsis. neutrophils and monocytes undergo characteristic structural and morphologic changes in response to infection. one type of response is the generation of neutrophil extracellular traps (nets), these have been proposed as potential mediators for widespread tissue damage. during netosis there is a fundamental reorganization of a cell's chromatin structurea signal that we have shown is sensitively measured by the cytovale cytometer. we hypothesized that quantification of plasticity (deformability) of leukocytes in the peripheral blood provides an early indicator of sepsis. the cytovale assay uses microfluidic cytometry to measure the plasticity of up to , white blood cells from edta-anticoagulated, peripherally-collected whole blood and provides a result in minutes. methods: in two prospective studies conducted in two academic medical centers in baton rouge, la, the cytovale test was performed on peripheral blood samples obtained from patients who presented to the emergency department with signs or symptoms suggestive of infection. the two studies included high acuity patients ( patient study) and low acuity patients ( patient study). an adjudicated reference diagnosis of sepsis or no sepsis was established for each subject, using consensus definitions, by review of the complete medical records. results: the receiver operator curve (roc) performance of the cytovale assay for both studies demonstrated an area under the curve (auc) greater than . (fig. ) . conclusions: measurement of neutrophil and monocyte plasticity by a novel assay provides an accurate and rapid indication of sepsis in patients who present to an emergency room with signs or symptoms of infection. plasma hepatocyte growth factor in sepsis and its association with mortality: a prospective observational study introduction: sepsis and septic shock are commonly associated with endothelial cell injury. hepatocyte growth factor (hgf) is a multifunctional protein involved in endothelial cell injury and plays a pivotal role in sepsis. this study assesses its correlation with relevant endothelial cell injury parameters and prognostic value in patients with sepsis. methods: a prospective, observational cohort study was conducted in patients with sepsis admitted to the department of critical care medicine at the zhongda hospital from november to march . the plasma hgf level was collected on the first h after admission (day ) and day , then was measured by enzyme-linked immunosorbent assay. the primary endpoint was defined as all-cause -day mortality. furthermore, we analyzed the correlation of hgf with relevant endothelial cell injury markers. results: eighty-six patients admitted with sepsis were included. hgf levels of non-survivors were elevated upon day ( . ± . pg/ml vs. . ± . pg/ml; p = . ) and day ( . ± . pg/ml vs. . ± . pg/ml; p = . ) compared with that in survivors, and showed a strong correlation with von willebrand factor (r = . , p < . ), lactate (r = . , p = . ), pulmonary vascular permeability index (r = . , p = . ), first h fluid administration (r = . , p < . ) and sequential organ failure assessment score (r = . , p = . ) (fig. ) . plasma levels were able to discriminate prognostic significantly on day (auc: . , %ci: . - . ) and day (auc: . , %ci: . - . ) (fig. ) . conclusions: hgf levels are associated with sepsis and are correlated with established markers of endothelial cell injury. elevated hgf level in sepsis patients is a predictor of mortality. methods: adult patients with septic shock by the sepsis- classification due to lung infection or primary bacteremia or acute cholangitis are screened using two consecutive measurements of ferritin and of hla-dr/cd co-expression for mals (ferritin above , ng/ml) or immunosuppression (hla-dr/cd less than %) and randomized into immunotherapy with either anakinra (targeting mals) or recombinant ifnγ (targeting immunosuppression) and into placebo treatment. main exclusion criteria are primary and secondary immunodeficiencies and solid and hematologic malignancies. results: patients have been screened so far. most common infections are community-acquired pneumonia ( . %), hospitalacquired pneumonia ( . %) and primary bacteremia ( . %). mean +/-sd sofa score is . +/- . and charlson's comorbidity index . +/- . ; patients have mals ( . %); two immunosuppression ( %); the majority remain unclassified for immune state. conclusions: current screening suggests greater frequency of mals than recognized so far in a setting of septic shock due to lung infection or primary bacteremia or acute cholangitis. development of an algorithm to predict mortality in patients with sepsis and coagulopathy d hoppensteadt , a walborn , m rondina , j fareed study was to develop an equation incorporating biomarker levels at icu admission to predict mortality in patients with sepsis, to test the hypothesis that using a combination of biomarkers of multiple systems would improve predictive value. methods: plasma samples were collected from patients with sepsis at the time of icu admission. biomarker levels were measured using commercially available, elisa methods. clinical data, including the isth dic score, sofa score, and apache ii score were also collected. -day mortality was used as the primary endpoint. stepwise linear regression modeling was performed to generate a predictive equation for mortality. results: differences in biomarker levels between survivors were quantified and using the mann-whitney test and the area under the receiver operating curve (auc) was used to describe predictive ability. significant differences (p< . ) were observed between survivors and non-survivors for pai- (auc= . ), procalcitonin (auc= . ), hmgb- (auc= . ), il- (auc= . ), il- (auc= . ), protein c (auc= . ), angiopoietin- (auc= . ), endocan (auc= . ), and platelet factor (auc= . ). a predictive equation for mortality was generated using stepwise linear regression modeling. this model incorporated procalcitonin, vegf, the il- :il- ratio, endocan, and pf , and demonstrated a better predictive value for patient outcome than any individual biomarker (auc= . ). conclusions: the use of a mathematical modeling approach resulted in the development of a predictive equation for sepsis-associated mortality with performance than any individual biomarker or clinical scoring system. furthermore, this equation incorporated biomarkers representative of multiple physiological systems that are involved in the pathogenesis of sepsis. the effects of biomarker clearances as markers of improvement of severity in abdominal septic shock during blood purification t taniguchi , k sato , m okajima introduction: sepsis associated coagulopathy (sac) is commonly seen in patients which leads to dysfunctional hemostasis. the purpose of this study is to determine the thrombin generation potential of baseline blood samples obtained from sac patients and demonstrate their relevance to thrombin generation markers. methods: baseline citrated blood samples were prospectively collected from patients with sac at the university of utah clinic. citrated normal controls (n= ) were obtained from george king biomedical (overland park, ks). thrombin generation studies were carried out using a flourogenic substrate method. tat and f . were measured using elisa methods (seimens, indianapolis, in). functional antithrombin levels were measured using a chromogenic substrate method. results: the peak thrombin levels were lower ( ± nm) in the dic patients in comparison to higher levels observed in the normal plasma ( ± nm). the auc was lower ( ± ) in the dic group in comparison to the normals ( ± ). the dic group showed much longer lag time ( . ± . ) in comparison to the normal group ( . ± . ). wide variations in the results were observed in these parameters in the dic group. the f . levels in the dic group were much higher ( ± pmol) in comparison to the normal ( ± pmol). the tat levels also increased in the dic group ( . ± . ng/ml) in comparison to the normal ( . ± . ng/ml). the functional antithrombin levels were decreased in the dic group ( ± %). conclusions: these results validate that thrombin generation such as f . and tat are elevated in patients with dic. however thrombin generation parameters are significantly decreased in this group in comparison to normals. this may be due to the consumption of prothrombin due to the activation of the coagulation system. the decreased functional at levels observed in the dic group are due to the formation of the complex between generated thrombin and antithrombin. introduction: sepsis-associated disseminated intravascular coagulation (dic) is a complex clinical scenario involving derangement of many processes, including hemostasis. assessment of markers including inflammation, endothelial function, and endogenous anticoagulants may provide insight into dic pathophysiology and lead to improved methods for assessment of patient condition and response to treatment. methods: citrated plasma samples were collected from patients with sepsis and suspected dic at icu admission and on days and . dic score was determined using the isth scoring algorithm (e.g. platelet count, pt/inr, fibrinogen and d-dimer). cd ligand (cd l), plasminogen inhibitor (pai- ), nucleosomes, procalcitonin (pct), microparticle tissue factor (mp-tf) and prothrombin . (f . ) were measured using commercially available elisa kits. protein c activity was measured using a clot-based assay. interleukin (il- ), interleukin (il- ), interleukin (il- ), tumor necrosis factor alpha (tnfα), and monocyte chemoattractant protein (mcp- ) were measured using biochip technology. results: significant differences in levels of protein c (p= . ), pct (p= . ), il- (p= . ), il- (p= . ), pai- (p= . ), were observed between survivors and non-survivors. significant variation of protein c (p= . ), nucleosomes (p= . ), pct (p< . ), il- (p= . ), il- (p= . ), il- (p= . ), tnfα (p= . ) and mcp- (p= . ) were observed based on severity of dic score. conclusions: markers from multiple systems perturbed in dic were associated with mortality, suggesting that while these systems may not be routinely evaluated in the normal course of patient care, dysfunction of these systems contributes significantly to mortality. in addition, numerous inflammatory cytokines showed an association with dic score. this suggests that the measurement of additional markers in sepsis-associated dic may be of value in the prediction of mortality and may be helpful in guiding treatment for these patients. introduction: the endotoxin activity assay (eaa) is a rapid immunodiagnostic test based on chemiluminescence. it was approved by the fda in as a diagnostic reagent for risk assessment of severe sepsis in the icu. ascertaining endotoxin levels in the bloodstream is important in targeting patients and determining the appropriate timing for initiation of treatment. it has high sensitivity and specificity for endotoxin, and is considered to be useful in predicting clinical symptoms and determining prognosis. the usefulness of the eaa has yet to be fully clarified. methods: a total of patients admitted to the icu between january and june with suspected sepsis or sepsis were enrolled. the eaa was conducted within hr after admission. patient characteristics were determined, together with levels of il- , procalcitonin, presepsin, and pao /fio . thereafter, the patients were classified into groups depending on their eaa value: ) < . ; ) from ≤ . to < . ; ) from ≤ . to < . ; ) from ≤ . to < . ; and ) ≤ . ). the transition of various markers was also examined. the spearman rank correlation, wilcoxon rank sum test, and a nonrepeated anova were used for the statistical analysis. a p-value of < . was considered statistically significant. the eaa values showed a positive correlation with both the apache ii (r= . ) and sofa scores (r= . )(p< . ), although that with the latter was stronger. a significant correlation was also observed with levels of procalcitonin (r= . ) and presepsin (r= . early diagnosis is important to allow early intervention. the current clinical methods are insufficient for early detection. we hypothesized that intraperitoneal microdialysis allows detection of peritonitis prior to changes in standard clinical parameters in a pig model. methods: bacterial peritonitis was induced in pigs by bowel perforation and intraperitoneal fecal instillation, one pig underwent sham surgery. intraperitoneal microdialysis catheters were placed in each abdominal quadrant. the observation time was hours. results: in peritonitis pigs the intraperitoneal lactate increased during the first two hours and remained elevated throughout the observation time (table ) , whereas the arterial lactate remained within reference range (< . mm). intraperitoneal glucose decreased significantly. hemodynamics were hardly influenced during the first two hours, and decreased thereafter. sham surgery did not influence in any of the parameters. conclusions: a rapid and pronounced increase in intraperitoneal lactate and decrease in intraperitoneal glucose was observed after instillation of intraabdominal feces. systemic lactate increase was absent, and the hemodynamic response was delayed. postoperative intraperitoneal microdialysis is applicable in detecting peritonitis earlier than standard clinical monitoring and should be evaluated in a clinical study in order to explore if early intervention based on md data will reduce icu length of stay, morbidity and mortality. introduction: procalcitonin (pct) is a serum biomarker suggested by the surviving sepsis campaign to aid in determination of the appropriate duration of therapy in septic patients. trauma patients have a high prevalence of septic complications, often difficult to distinguish from inflammatory response. pct values typically declined after h from trauma and increased only during secondary systemic bacterial infections. the aims of the study are to evaluate reliability and usefulness of pct serum concentration in trauma. methods: we retrospectively analyzed data from trauma patients admitted to icu at bufalini hospital -cesena, from july to august . we collected data about antimicrobial therapy, injury severity score (iss), first arterial lactate in emergency room, sofa score and sepsis severity. plasma pct concentration was measured using an automate analyzer (modular e-brahms) on st day of antimicrobial therapy and every h hours. antimicrobial therapy was stopped according to a local protocol; however medical judgment was considered the overriding point for therapeutic decision. results: median iss of patients was . , inter quartile range (iqr) . . pct mean concentration at the starting of antimicrobial treatment was . μg/l (d.s . ), median . (iqr . ). no significative correlation (spearman´s rho test) was found between pct at day of antimicrobial therapy and iss (rho - . ), between first arterial lactate in er and pct (rho . ). daily course of pct was not related to distance from trauma (rho - . ). in of patients ( . %) pct measurement led physician to save days of antimicrobial therapy compared with standard clinical practice. we couldn´t find any cut off value. conclusions: our experience suggests that pct could help physician to optimize duration of antimicrobial therapy in trauma patients. no standard approach can be recommended at present. introduction: long duration of antimicrobial treatment may predispose to colonization and subsequent infections by multidrugresistant organisms (mdro) and clostridium difficile. progress (clinicaltrials.gov registration nct ) is an on-going trial aiming to use pct for the restraining of this calamity. methods: adult patients with sepsis by the sepsis- classification and any of five infections (pneumonia community-acquired; hospital-acquired or ventilator-associated; acute pyelonephritis; primary bacteremia) are randomized to pct-guided treatment or standard of care (soc) treatment. in the pct arm antibiotics are discontinued when pct on or after day is decreased by more than % of the baseline or remains below . ng/ml; in the soc arm antibiotics are discontinued at the discretion of the attending physician. patients are followed for six months. primary endpoint is the rate of infections by mdro and/or c.difficile or death. serial stool samples are cultured for mdro and screened for glutamate dehydrogenase antigen and toxins of c.difficile. results: patients have been enrolled so far. mean ± sd sofa score is . ± . . most common diagnoses are community-acquired the progress trial is the first trial assessing the probable benefit from pct guidance to reduce ecological sequelae from long-term antibiotic exposure. analysis of baseline patient characteristics indicates that progress is a real-world trial so that results can have major clinical impact. prospective multi-site validation of -gene host response signature for influenza diagnosis s thair , s schaffert , m shojaei , t sweeney there are no blood-based diagnostics able to identify influenza infection and distinguish it from other infections. we have previously described a blood-based -gene influenza meta-signature (ims) score to differentiate influenza from bacterial and other viral respiratory infections. methods: we prospectively validated the ims in a multi-site validation study by recruiting individuals ( patients with suspected influenza, healthy controls) in community or hospital clinics across australia. we assayed the ims and genes from viral genome of influenza strains to generate the blood flu score (bfs) as a measure of viremia using nanostring from whole blood rna. results: using clinically determined phenotypes, the ims score distinguished patients with influenza from healthy (auc= . ), non-infected (auc= . ), bacterial (auc= . ), other viruses (auc= . ) ( figure a) . interestingly, probes of bfs were found in all phenotypic groups (non-infected, bacterial, and other viral infections) to varying degrees, and positively correlate with the ims score (r= . ). ims aurocs improve when the bfs is used to inform the phenotypic groups: healthy (auc= . ), non-infected (auc= . ), bacterial (auc= . ), other viruses (auc= . ) ( figure b ). patients who were clinically influenza negative but had a high ims and bfs were admitted less often, yet had~ -fold higher mortality than those who were clinically influenza negative with low ims and no bfs (table ) . conclusions: collectively, our prospective multi-center validation of the ims demonstrates its potential in diagnosis of influenza infections. introduction: previous findings of our group suggest that patients with gram-negative hospital-acquired severe sepsis have better prognosis when sepsis is developing after recent multiple trauma through stimulation of favorable interleukin (il)- responses [ ] . under a similar rationale, we investigated if preceding osteomyelitis may affect experimental osteomyelitis. methods: sham or experimental osteomyelitis was induced in male new zealand white rabbits after drilling a hole at the upper metaphysis of the left tibia and implementing diluent or log of staphylococcus aureus using foreign body. after three weeks, the foreign body was removed and experimental pyelonephritis or sham surgery was induced after ligation of the right pelvo-ureteral junction and instillation of log of escherichia coli in the renal pelvis. survival was recorded and circulating mononuclear cells were isolated and stimulated for the production of tumour necrosis factor-alpha (tnfa) and il- . at death or sacrifice, tissue outgrowth and myeloperoxidase (mpo) were measured. results: four sham-operated rabbits (s), rabbits subject to sham surgery and then pyelonephritis (sp) and rabbits subject to osteomyelitis and then pyelonephritis (op) were studied. survival after days of group sp was . % and of group op % (log-rank . ; p: . ). lab findings are shown in figure . il- production was blunted. negative correlation between e. coli outgrowth and tissue mpo was found at the right kidney of the op group (rs: - . , p: . ) but not of the sp group (rs: - . , p: . ). conclusions: preceding staphylococcal osteomyelitis provides survival benefit to subsequent experimental osteomyelitis through downregulation of innate immune responses leading to efficient phagocytosis. introduction: activation of neutrophils is a mandatory step and a sensitive marker of a systemic inflammatory response syndrome (sirs) which is closely related to development of multiple organ failure. the search for drugs that can prevent sirs and reduce mortality in critically ill patients remains significant. the aim of this study was to study the anti-inflammatory effect of the synthetic analogue of leu-enkephalin (dalargin) on human neutrophils. methods: the study was conducted on isolated from the blood of healthy donors neutrophils. their activation was assessed by fluorescent antibodies to markers of degranulation cd b and cd b (sd b-fitc and cd b-alexafluor (bd biosciences, usa). as inductors of inflammation lipopolysaccharide (lps) and the peptide formyl met-leu-pro (fmlp) were used. mkm fmlp and dalargin in concentrations of and μ g / ml were added to neutrophils at a concentration of ppm / ml and incubated for min at °c; then antibodies were added and incubated for min on ice; then fluorescence was assessed by flow cyto flow meter beckman-coulter fc . non-parametric criteria were used; data were presented as a median and %- % interquartile intervals. the statistical significance was estimated using mann-whitney test. the difference was considered statistically significant at p< . results: synthetic analogue of leu-enkephalin in various concentrations has an anti-inflammatory effect on both intact and preactivated with bacterial components neutrophils, reducing their activation and degranulation in a dose-dependent manner (figs. , ) . conclusions: synthetic analogue of leu-enkephalin prevents neutrophil activation by bacterial compounds. this has a potential of translation into clinical practice for sepsis treatment. introduction: the endothelin system plays important roles in circulatory regulation through vasoconstrictor et-a and et-b receptors and vasodilator et-b receptors (etar; etbr, respectively). tissue hypoxia during the progression of sepsis is associated with microcirculatory and mitochondrial disturbances. our aim was to investigate the possible influence of etar antagonist, etbr agonist or combined treatments on oxygen dynamics, microcirculatory and mitochondrial respiration parameters in experimental sepsis. methods: male sprague-dawley rats (n= /group) were subjected to faecal peritonitis ( . g/kg faeces ip) or sham-operation. septic animals were treated with sterile saline solution, or received the etar antagonist etr-p /fl peptide ( nmol/kg iv), etbr agonist irl- ( . nmol/kg iv) or same doses as combination therapy, hr after sepsis induction. invasive hemodynamic monitoring and blood gas analyses were performed during a -min observational window. introduction: sepsis often induces immunosuppression, which is associated with high mortality rates. nivolumab is a human igg- antibody directed against the programmed cell death (pd- ) immunecheckpoint inhibitor, which disrupts pd- -mediated signaling and restores antitumor immunity. nivolumab is an approved anti-cancer drug that may have the potential to improve sepsis-induced immunosuppression. methods: this multicenter, open-label study investigated the safety, pharmacokinetics and pharmacodynamics of a single intravenous infusion of or mg nivolumab in japanese patients with immunosuppressive sepsis (lymphocytes ≤ /μl). the dosing of nivolumab was set using the predicted steady state concentration of nivolumab at mg/kg every weeks (q w), which was the approved dosage for cancer patients at the time of planning. results: five and eight patients were assigned to the and mg groups, respectively. the mean (standard deviation) peak serum drug concentration in the mg group was comparable to the predicted median concentration ( % pi [prediction (figures and ). adverse events (aes) were observed in four patients in each group. drug related-aes were observed in only one patient in the mg group (table ) . no deaths related to nivolumab occurred. conclusions: a single dose of mg nivolumab appeared to be well tolerated and sufficient to maintain nivolumab blood concentration in patients with sepsis. results suggest both and mg nivolumab therapy could improve relevant immune indices. introduction: the systemic inflammatory response syndrome (sirs) accompanies tissue trauma and infection and, when severe or dysregulated, contributes to multiple organ failure and critical illness. observational studies in man and animal have shown that low-dose acetyl-salicylic acid promotes resolution of inflammation and might attenuate excessive inflammation by increasing the synthesis of specialised pro-resolving lipid mediators (spms). methods: we randomly assigned patients with sirs who were expected to stay in icu for more than hours to receive enteral aspirin ( mg per day) or placebo for days or until death or discharge from the icu, whichever came first. the primary outcome was il- serum concentration at h after randomisation. the secondary outcomes included safety and feasibility outcomes. in one center, additional blood samples were taken during the first three days for exploratory analysis of spms using reversed-phase highperformance liquid chromatography -tandem mass spectrometry (rp-hplc-ms/ms). results: from march through december a total of patients across four general icus in australia underwent randomization (table ) . compared to placebo patients, il- serum concentration after h in aspirin-treated patients was not significantly lower ( [ - ] pg/ml vs [ . - ] pg/ml; p= . ). there were no significant differences for control vs. aspirin-treated patients in the change of pro-resolving/anti-inflammatory lipids between the time points (figure , ). there were no between-group differences with respect to icu or hospital mortality, number of bleeding episodes or requirements for red cell transfusions (table ) . conclusions: in patients admitted to the icu with sirs, low-dose aspirin did not result in a decreased concentration of inflammatory biomarkers compared with placebo. introduction: sepsis is associated with excessive ros production, nf-kb, inos and inflammatory mediators overexpression. vitamin c is a cellular antioxidant, it increases enos and decreases nf-kb; it has several immune-enhancing effects and is crucial for endogenous vasopressors synthesis. vitamin c reserves in sepsis are often as poor as in scurvy [ ] . in recent studies, intravenous high vitamin c dose seems to reduce organ failure and improve outcome in septic shock. methods: we treated all septic shock patients admitted to our icu in months (from / to / ) with intravenous vitamin c . g/ h and thiamine mg/ h (for its synergistic effects) [ ] as adjunctive therapy for consecutive days and we compared data to septic shock patients admitted in the previous months period. we enrolled patients: received vitamins supplementation, standard of care. we analysed -days mortality, sofa at and hours, pct variation from baseline in first days, vasoactive therapy length and daf (days alive and free from vasopressors, mechanical ventilation and rrt in days follow up). patients with end stage kidney disease were ruled out. we analysed data with mann-whitney and wilcoxon tests. results: vit c group showed lower -days mortality ( % vs . %: ns); sofa improvement at (- . ± . vs - . ± . : p= . ) and hours (- . ± vs - . ± : p< . ) was higher in vit c group; vit c patients had faster pct reduction without statistical significance. mean vasoactive therapy length was quite similar. daf was . (± . ) days in vit c group and . (± . ) in controls (p= . ). control patients needed rrt, none in vit c group. conclusions: despite small study size, we found that vit c has positive effects on survival and improves sofa score (fig. ) and daf (fig. ) in septic shock. no vit c patient developed oxalate nephropathy nor worsened renal function. introduction: toxin-producing gram-positive organisms cause some of the most severe forms of septic shock [ , ] . adjunctive therapies such as intravenous immunoglobulins (ivig) have been proposed for these patients [ , ] . however, at patient presentation, the presence of a toxin-producing organism is most often unknown. methods: we reviewed the use of ivig in our patients requiring extracorporeal membrane oxygenation (ecmo) in a -year period between february and march . results: in % ( / ) of the patients that received ivig for presumed toxin-mediated shock, group a streptococcus or panton-valentine leukocidin producing s. aureus was isolated, but the clinical characteristics of these patients were not significantly different from the ones with other final diagnoses, except for a predisposing influenza infection and the presence of an often very high procalcitonin level. these patients were extremely unwell at presentation with a sofa score of ± , high lactate levels ( . ± . mmol/l) and need for vasopressors (equivalent norepinephrine dose of . ± . μ g/kg/min). they had very high inflammatory parameters with a procalcitonin ≥ ng/ml in more than half of patients ( / ). ivig use in these patients was generally safe, with only possible transfusion reaction. the mortality of % ( / ) was lower than predicted based on the sofa scores. conclusions: ivig administration can be considered in a selected group of patients presenting with acute and very severe septic shock, as part of a multimodal approach [ ] . introduction: extra corporeal treatments are used in septic patients to decrease the inflammatory mediators, but definitive conclusions are lacking . more over in many studies the effect of aki isn't evaluated and this may be an important bias. . the aim of this study is to evaluate in septic patients with aki: the effect of the adsorbing membrane oxiris on the immunological response -the different response in survivors and non survivors methods: from our local data base we analyzed retrospectively septic shock patients with aki (kdigo classification) submitted to crrt with the adsorbing membrane oxiris (baxter, usa ) . at basal time ( t ) and at the end of the treatment ( t ) we evaluated the following variables: il il procalcitonin endotoxin (eaa). all data are expressed as mean ±sd or median and iqr. student t test or mann-whitney was used to compare values changes. p < . was considered statistically significant. results: thirty patients with sepsis /septic shock and aki were enrolled in this study. patients had aki , patients aki , patients aki . the duration of treatment was ± hours. patients had citrate as anticoagulation and heparine continous ev. at table are shown the main results of this study in all the patients. survivors vs non survivors had a significant decrease of il , procalcitonin and eaa. conclusions: data of this study confirm on clinical ground previous study "in vitro" [ ] that the adsorbing membrane oxiris has important immunological effect during septic shock with aki. this must be confirmed in a rct. introduction: sepsis is common and often fatal, representing a major public health problem. hemoadsorption (cytosorb) therapy aims to reduce cytokines and stabilise the overall immune response in septic shock patients. methods: a prospective, multi-centre, investigator initiated study to evaluate hemoadsorption (cytosorb) therapy in septic shock patients admitted to a tertiary icu's in india during to . all centres followed a common protocol and received ethics committee approval. results: a total of patients were administered cytosorb in addition to standard of care. a total of patients ( %) survived out of patients. among survival group, patients ( %) were administered cytosorb within hours of icu admission resulting in significant reduction in sepsis scores, apache ii ( . vs . ) and sofa ( . vs . ) post cytosorb therapy. also there was reduction in inflammatory markers like cytokines il in most of the patients. all patients in survivor group showed a significant improvement in map ( . vs . ) and reduction in vasopressors (epinephrine . to . mcg/kg/min, nor-epinephrine . to . mcg/kg/min) after cytosorb therapy. no device related adverse effect was observed in any of the patients. among the non-survivor group, ( patients, %) we observed that cytosorb was administered after hours of icu admission. although a few patients showed improvement in sofa score, majority did not show a significant improvement with map ( . vs . mm of hg) and required increased demand in vasopressors. conclusions: in this multi-centered prospective iis study, we could observe clinical benefits of hemoadsorption (cytosorb) therapy in septic shock patients if the therapy was initiated early. larger randomised study are required to establish the above clinical benefits in larger patient population. a single centre experience with hemoadsorption (cytosorb) in varied causes of sepsis and mods y mehta , c mehta , a kumar , j george , a gupta , s nanda , g kochar , a raizada introduction: sepsis and the multiorgan failure is a leading cause of mortality in the intensive care unit. promising new therapies continue to be investigated for the management of septic shock. we tried to evaluate a novel hemoadsorption therapy (cytosorb) through a retrospective evaluation of patient's data in our centre. we used it as an adjuvant therapy in our patients with sepsis due to varied causes. methods: we retrospectively analysed data of introduction: septic shock is a life-threatening multiple organ dysfunction that has high morbidity and mortality in critically ill patients, due to a dysregulated host response to infection. the aim of this study was to evaluate the efficacy of therapeutic cytokine removal (cytosorb®) in the management of patients with septic shock. methods: we retrospectively analyzed patients admitted to icu with septic shock between june and november . patients included in the study were diagnosed according to the third international consensus definitions for sepsis and septic shock (sepsis- ), received maximal supportive care including continuous veno-venous hemodiafiltration (cvvhdf) for acute kidney injury and cytosorb® haemoadsorption column was added to return limb of the cvvhdf circuit. demographic data, procalcitonin and leukocyte levels before and after therapeutic cytokine removal and duration of cytosorb® haemoadsorption column application and apache ii scores were recorded. results: the mean age of patients included in the study was ± . years ( % male) and the mean body mass index was . ± . . the mean apache ii score was . with an expected and actual mortality rates of % and %, respectively. % of the patients were admitted with sepsis and % of them with septic shock. . % (n= ) of the cases were solid organ transplant recipients. cvvhdf was applied in all patients during therapeutic cytokine removal. treatment was combined with ecmo in patients. while the mean duration of cvvhdf was . hours, the duration of cytosorb® haemoadsorption column application was . ± . hours. procalcitonin ( . ± ng/ml vs ± ng/ml) and leucocyte levels ( ± / mm vs ± mm ) after therapeutic cytokine removal were found significantly lower than the pretreatment values (respectively p= . , p= . ). conclusions: therapeutic cytokine removal applied with cvvhdf in septic shock patients have positive contributions to biochemical parameters and provide survival advantage. introduction: recent studies have focused on demonstrating the potential benefits of immunomodulation in the management of septic patients. the aim of our study was to assess the effects of a hemoadsorption column (cytosorb®) in critical ill septic patients. methods: after ethical approval was obtained, we prospectively included patients admitted to the general icu of fundeni clinical institute. three consecutive sessions of renal replacement therapy (continuous venovenous hemodiafiltration) in combination with cytosorb® were applied after icu admission. clinical (heart rate, arterial pressure, temperature, glasgow coma scale) and paraclinical data (pao , serum bilirubin and creatinine, platelet count, white blood cell count, ph, c-reactive protein and procalcitonine), vasopressor support and need for mechanical ventilation were recorded before and after the three sessions. results: the mean age in the study group was ± years. median number of organ dysfunction at the time of icu admission was [ ] [ ] [ ] [ ] [ ] and the mean sofa score was . ± . . the use of cytosorb® was associated with a non-significant increase in pao /fio ratio from ± to ± (p= , ) and creatinine levels from . ± . to . ± . mg/dl (p= . ). although we observed a non-significant increase in c-reactive protein levels from ± mg/l to ± mg/ l (p= . ), we noted a significant decrease in procalcitonine levels from a median of . [ . , . ] ng/dl to a median of . [ . , . ] ng/dl (p= . ). a significant decrease in platelet count was also noted from ± /mm to ± /mm (p= . ). mean sofa score decreased non-significantly from . ± . to . ± . (p= . ). conclusions: the use of cytosorb was associated with a slight nonsignificant improvement in organ function and a decrease of procalcitonine levels. thrombocytopenia remains one of the most important complications of renal replacement therapy. introduction: circulating cell-free neutrophil extracellular traps (nets) would induce a microcirculatory disturbance of sepsis. the removal of nets remnants from the circulation could reduce nets-dependent tissue injury. to address this issue, we evaluated the effect of hemoperfusion with a polymyxin b cartridge (pmx-dhp; toray, japan), which was originally developed for the treatment in patients with gram-negative bacterial infection, on circulating cell-free nets in patients with septic shock and in phorbol myristate acetate (pma)-stimulated neutrophils obtained from healthy volunteer. methods: ex vivo closed loop hemoperfusion was performed through a circuit formed by connecting the small pmx module to a tube and a peristalsis pump. whole blood from healthy volunteers incubated with or without pma or from septic shock patients were applied to circuit and perfused. blood was collected at , and hr after perfusion. circulating cell-free nets were assessed by myeloperoxidase (mpo)-, neutrophil elastase (ne)-, and cell free (cf)-dna. results: plasma mpo-dna, ne-dna and cf-dna levels were significantly increased at hr after pma stimulation when compared with plasma levels without pma. when either blood from septic shock patients or pma-stimulated neutrophils obtained from volunteers were applied to circuit, circulating mpo-dna, ne-dna and cf-dna were significantly reduced in perfusion with pmx filter than in perfusion without pmx filter at times and hr. conclusions: in the ex vivo experiments, mpo-dna, ne-dna and cf-dna were found to decrease after ex vivo perfusion through pmx filters. selective removal of circulating components of nets may improve the remote organ damage in patients with septic shock. a retrospective study of septic shock patients who were treated with direct hemoperfusion with polymyxin b-immobilized fibers based on the levels of endotoxin activity assay s sekine, h imaizumi, i saiki, a okita, h uchino tokyo medical university, anesthesiology/icu, tokyo, japan critical care , (suppl ):p introduction: the purpose of this study was to evaluate the outcomes for septic shock patients with direct hemoperfusion with polymyxin b-immobilized fibers (pmx-dhp) and endotoxin activity assay (eaa). methods: according to the levels of eaa, patients were classified for three groups (low group (gl); eaa < . , intermediate group (gm); eaa > . or eaa < . , high group (gh); eaa > . ). in order to evaluate the severity of illness, acute physiology and chronic health eva-luationii (apache ii) score, the sequential organ failure assessment (sofa) score, catecholamine index (cai) were recorded. and the presence of pmx-dhp treatments were also recorded. blood samples were obtained to measure eaa levels, inflammatory markers (procalcitonin (pct), c-reactive protein (crp), and white blood cell count (wbc)), serum lactate level as an indicator of tissue hypoxia, and for blood culture. apache ii score, sofa score, cai, inflammatory markers, serum lactate levels (lac) and blood culture results were examined for diagnosis of septic shock and prognosis of -days mortality. each values were also compared to eaa levels. results: septic shock patients were included (gl/ gm/ gh: / / ). in gh, apache ii and sofa score was significantly higher than that in gl (p< . ). eaa levels were significantly increased in gramnegative bacteremia patients compared to the patients with grampositive bacteremia or fungemia. there was no relationship between eaa levels and other inflammation markers, cai, and lac. in gm, days mortality in patient with pmx-dhp treatments was lower than that of without pmx-dhp treatments ( . ( / ) vs . ( / ), p= . ). in gh, -days mortality in patient with pmx-dhp treatments was same as that of without pmx-dhp treatments ( . ( / ) vs . ( / ), p= . ). conclusions: these results of this study suggest pmx-dhp treatment may improve the outcome of septic shock patients with intermediate eaa levels. introduction: numerous inconclusive randomized clinical trials (rcts) in sepsis in the past years suggest a need to re-think trial design to improve resource allocation and facilitate policy adoption decisions. the inclass study (clinicaltrials.gov nct: ) is an ongoing rct evaluating clarithromycin as an immune modulator in high-risk septic patients with clinical and cost-effectiveness outcomes. we aim to compare the original one-shot trial with an alternative sequential design that balances trial costs and value of information. methods: adult patients with sepsis, respiratory failure and total sofa score of at least , are randomized to receive intravenous clarithromycin or placebo adjunctive to standard-of-care therapy. for the cost-effectiveness study, efficacy is measured in quality-adjusted life years (qalys) by eq- d- l questionnaire at days. the endpoint is the incremental net monetary benefit (inmb) of clarithromycin compared to placebo, defined as wtp x (increment in qaly) -(increment in costs), where wtp is willingness to pay per qaly gained. fixed and variable costs of trial execution (including administrative, insurance, supplies, tests) are calculated; hospitalization cost is extracted from patient records; medical care beyond day is recorded; cost of adoption in the general population is estimated. previous data from rcts using clarithromycin are used to form a prior belief about the inmb. known incidence of sepsis with respiratory failure allows estimation of the population to benefit from trial decision. a bayesian model is used to determine the sequential design that maximizes trial value. results: we will compare the performance of the sequential trial design with the one-shot design of inclass trial in terms of sample size, cost, social-welfare, and probability of correctly identifying the best treatment. conclusions: in this protocol we validate a bayesian model for sequential clinical trials and assess the benefits for the patient population and health care system. the effect on the outcome of critically ill patients with catecholamine resistant septic shock and acute renal failure through implementation of adsorption therapy g schittek introduction: cytosorb-adsorption has been described as an effective way for hemodynamic stabilisation in septic shock [ ] . aim of this study was to examine whether the adsorption-therapy could influence patient-outcome with catecholamine resistant septic shock (crss) and acute renal failure(arv). furhtermore we tried to identify clinical constellations that would predict an effective use of adsorbers [ , ] . initial il- in patients with catecholamine-reduction through adsorption was non-significantly different to those with no reduction ( ng/l [ , ] vs. ng/l [ , ]). mortality did not differ significantly between the groups ( % vs %). length of intensive care unit stay (los) did differ significantly ( days [ , ] vs days [ , ] ). conclusions: il- can be reduced with adsorption. patients with catecholamine-reduction did not differ in regard to their initial il- . los was shorter for patients treated with adsorption. according to our experience adsorption can be taken into consideration when crss is beginning. introduction: in our intensive care unit (icu), we have already started expanded application to the contact precautions. applied patients are; ) emergency admission, ) patients who had already had bacteria* that are required to contact precautions, ) scheduled surgical patients with prolonged icu stay, although we have not yet decided the started period of expanded application exactly. *detected bacteria(db);mrsa, cd, mdrp, esbl, pseudomonas a, pisp, prsp, vrsa. the aim of this study was to determine the adequate starting period of expanded application to the contact precautions in the scheduled surgical patients in the mixed icu. methods: we performed retrospective observational study on patients who were admitted to our icu after planed surgery from may to dec. . we detected the patients who acquired bd newly and investigated the relation to the length of icu stay. the relationship between detection rate and categorized date was also analyzed using logistic regression adjusted for age, gender, apache , and sofa score. using youden´s index and roc curve, we also calculated cutoff point of the duration of icu stay related to detection rate. finally, we made the logistic regression model of each cutoff day(day to ) and compared odds ratio(or) and auc of each models using stata. results: category day or more, especially day or more had significantly higher detection rate of db compared to day ( results: pao /fio was lower than mmhg in ( %) patients. compared to patients in group , patients in group were less severely ill at admission but presented a higher sofa and cpis score and a greater incidence of ards and shock at pneumonia onset (fig ) . ( %) patients in group had a microbiological diagnosis of pneumonia, compared to patients ( %) in group (p= . ). pao /fio ≤ mmhg was associated with less probability of having microbiological diagnosis of pneumonia (or . , % ci . to . , p= . ). when adjusted for other variables significantly associated with positive microbiology, pao /fio ≤ mmhg remained significantly associated with less probability of a microbiological diagnosis (adjusted or . , % ci . to . , p= . ). hospital mortality was significantly higher in patients in group compared to group ( % vs %, p= . ). however, no difference was found in non-response to treatment, icu and hospital stay, icu mortality (table ) and -days survival (fig ) . conclusions: a significant higher number of patients with vap didn't have a definitive etiological diagnosis when using the proposed threshold criteria of pao /fio ≤ mmhg. pao /fio ratio does not seem a good predictor of etiology in patients with vap. introduction: immunological dysfunction is common in critically ill patients but the optimal method to measure it and its clinical significance are unknown. levels of tumor necrosis factor alpha (tnf-α) after ex-vivo whole blood stimulation with lipopolysaccharide has been proposed as a possible method to quantitate immunological function. we hypothesized that patients with a lower post-stimulation tnf-α level would have increased rates of nosocomial infections (nis) and worse clinical outcomes. methods: a secondary analysis of a phase randomized, multicentre, double-blinded placebo controlled trial [ ] . there were no differences in allocation groups; all the patients were analyzed as one cohort. on enrolment, whole blood was incubated with lps ex-vivo and tnf-α level was measured. patients were grouped in tertiles according to delta and peak tnf-α level. the primary outcome was the development of nis; secondary outcomes included -day mortality. results: data was available for patients. baseline characteristics and outcomes are reported in tables and . patients in the highest tertile for post lps stimulation delta tnf-α compared to the lowest tertile were younger, had a lower acuity of illness and had lower baseline tnf-α. when grouped according to peak post-stimulation tnf-α levels, patients in the highest tertile had higher serum tnf-α at baseline. both comparisons showed no difference between nis and clinical outcomes between tertiles. in multi-variate analysis peak or delta tnf-α were not associated with the occurrence of nis. conclusions: admission ex-vivo stimulated tnf-a level is not associated with the occurrence of nis or clinical outcomes. further study is required to evaluate the ability of this assay to quantify immune function over the course of critical illness. results: sanitary and epidemiological examination revealed the connection between infection and intravenous infusion of dexamethasone performed concurrently with chemotherapy. in patients fever with chills and hypertension developed within hours after infusion of the infected drug; empirical intravenous antibiotic therapy started immediately after collecting blood culture. in patients fever appeared after - days outpatiently, so they received antibiotics per os. all these patients had permanent vascular access, and bsi was detected either the next chemotherapy course when fever reappeared ( pts) while using vascular access, or as a result of a specific examination ( pts). in all cases empirical antibiotic therapy started on the first day of fever, drug correction was performed in patients according to results of bacteriological research. septic shock developed in patient, pneumonia in patients. permanent vascular access was preserved only in case. all patients were cured and continued to receive antitumor treatment. conclusions: detection of more than case of b. cenocepacia bsi should be the reason for sanitary and epidemiological examination. a favorable outcome of bsi treatment is associated with the early start of antibiotic therapy and its correction after microbiological examination. emerging conclusions: implementation of asp in hospital allows to decrease incidence of eskape-bacteremia and candidemia, which may lead to improved clinical outcomes in icu's patients (fig ) . association of multi-drug resistant (mdr), extended-drug resistant (xdr) and pan-drug resistant (pdr) gram negative bacteria and mortality in an intensive care unit(icu) s chatterjee , s sinha , a bhakta , t bera , t chatterjee , s introduction: colistin-resistant klebsiella pneumoniae (cr-kp) is increasingly reported around the world. it is worrying to note emergence of resistance to last line of defence against mdr gram negative infections in regions endemic to carbapenem resistance. we report the first outbreak of cr-kp co-producing carbapenemases in an adult intensive care unit (icu) from south india. methods: retrospective analysis of all patients with carbapenem resistant klebsiella pneumoniae blood stream infection (bsi) was done between january and december . microbiological and clinical variables along with outcomes were analysed. results: seven patients had cr-kp with no prior exposure to colistin. all seven were modified hodge test (mht) negative making probability of blakpc unlikely. in resource limited setting, analysis beyond mht could only be performed for cr-kp samples. / samples belonging to cr-kp isolates produced the blandm- whilst / cr-kp isolates did not produce either blakpc or blandm carbapenemases prompting hypothesis of blaoxa- or blavim as the causative factor. compared to carbapenem resistance only group, cr-kp group had higher apache ii, icu length of stay and mechanical ventilation duration. day mortality was noted to be . % for carbapenem resistant and % for cr-kp groups. aggressive infection control measures were undertaken with successful containment of cr-kp strains along with reduction in overall bsi. conclusions: infection control measures form the backbone of patient care in centres showing endemicity for carbapenem resistant klebsiella to prevent colistin resistance and also to reduce occurrence of overall blood stream infections. rapid diagnosis of carbapenem resistance: experience of a tertiary care cancer center with multiplex pcr s mukherjee tata medical center, critical care medicine, kolkata, india critical care , (suppl ):p introduction: sepsis due to carbapenem resistant organisms has high mortality; inappropriate empirical antibiotic is one of the main causes of this poor outcome. on the contrary, "too much" broad spectrum empiric antibiotics will increase drug resistance, even in community, because of selection pressure. so, early diagnosis of resistance pattern (carbapenemase genes) is crucial. aim of this study is to compare rapid diagnostic test like polymerase chain reaction (pcr) with conventional culture sensitivity (c/s) to identify carbapenem resistance. methods: this is a prospective observational study done in tata medical center, kolkata, india. real time multiplex pcr technique has been developed "in house" in our microbiology lab and can identify ndm, ndm , kpc, oxa - , oxa - , oxa - & vim carbapenemase genes. blood cultures were sent as per clinical & laboratory diagnosis of sepsis in icu patients. culture positive samples had been used for conventional c/s by vitek system along with pcr study to identify carbapenemase genes. result of pcr technique was been compared with conventional c/s method. results: multiplex pcr results were available within - hours of positive blood culture compared to conventional c/s method that takes - days. among positive blood cultures, samples were positive for carbapenemase genes. most common gene identified was oxa - ( %), followed by ndm ( %). our pcr technique has very high sensitivity, specificity, positive & negative predictive value ( . %, . %, . % & . % respectively) while comparing with final c/s report by vitek system (table ) . there was only one false negative diagnosis for carbapenem resistance. conclusions: real time multiplex pcr for carbapenemase gene can be helpful for early diagnosis of carbapenem resistance and can help us to choose / modify antibiotics or to use 'targeted therapy'. it is more practical to "rule -in" infection rather than "rule -out" by this technique. carbapenemase producing enterobacteriaceae colonization in an icu: risk factors and clinical outcomes m miranda, jp baptista, j janeiro, p martins centro hospitalar e universitário de coimbra, intensive care unit, coimbra, portugal critical care , (suppl ):p introduction: carbapenemase-producing enterobacteriaceae (cpe) colonization has been increasingly reported in intensive care units (icus) since their first identification more than years ago. colonization with cpe seems to constitute a risk factor for mortality. the aim of our study was to identify associated risk factors and clinical outcomes among patients with fecal colonization by cpe admitted to a portuguese tertiary hospital icu. methods: a -year retrospective study was performed in patients with previous unknown cpe status (colonization or infection), admitted to our icu. rectal swabs were performed and analyzed using real-time polymerase chain reaction testing. clinical records were reviewed to obtain demographic and clinical data. results: of patients admitted, ( . %) harbored cpe, ( . %) were colonized at admission and ( . %) acquired cpe colonization during icu stay. the most frequent carbapenemase genes detected were kpc ( . %) and vim ( . %). cpe carriers had high rates of hospitalization (previous or ongoing), invasive procedures (mainly intraabdominal surgery), malignancy (hematopoietic or solid tumor), introduction: gram-negative pathogens-particularly pseudomonas aeruginosa and enterobacteriaceae-predominate in nosocomial pneumonia (np) and ciai both. these infections are becoming difficult to treat with available treatment options due to growing antimicrobial resistance in india. ceftazidimeavibactam has in-vitro activity against gram-negative organisms producing class a, class c and some class d beta-lactamases. we carried out a qualitative analysis to assess the safety and efficacy outcomes of the indian population cohorts involved in the re-prove and reclaim trials. methods: in line with the global reprove protocol, indian patients enrolled in the study with np, were randomly assigned ( : ) to mg ceftazidime and mg avibactam or mg meropenem. in the reclaim study, indian patients with a diagnosis of ciai were enrolled in the study and were randomly assigned ( : ) to receive either ceftazidime-avibactam ( mg of ceftazidime and mg of avibactam) followed by metronidazole ( mg); or meropenem ( mg). the primary efficacy outcome measure in the reprove and reclaim studies was clinical cure rate of caz-avi compared with that of meropenem at toc (test-of-cure) visit in pre-defined analysis sets. in both studies, non-inferiority was concluded if the lower limit of the twosided % ci for the treatment difference was greater than - · % in the primary analysis sets. as the indian subset study was not statistically powered to detect a difference in the subgroup, we descriptively analysed the efficacy results in the indian population and compared them with the overall results in the global trial. in addition, the study also analysed the safety of caz-avi in the indian patients by monitoring the number and severity of adverse events. introduction: early administration of effective intravenous antimicrobials is recommended for the management of the patients with sepsis. although meropenem (mepm) is one of the first-line drugs in patients with sepsis because of its broad spectrum, the optimal dose in the critical care settings especially during continuous renal replacement therapy (crrt) has not been established since therapeutic drug monitoring of mepm has not been popular. methods: eighteen critically ill patients who received crrt were enrolled in this study. one gram of mepm was administered over hour, every hours, and blood samples at , , , and hours after administration were collected on day , and . all samples were stored at - °c until analysis. the measurement of the blood concentration of mepm was performed using high performance liquid chromatography with ultraviolet detection (hplc-uv introduction: meningitis is one of the complications of severe traumatic brain injury, and it is often associated with encephalitis (incidence from . - . % to - %). the aim of the investigation was to study the dynamics of the concentration of meropenem in serum and cerebrospinal fluid (csf) with intravenous and intrathecal administration of meropenem. methods: in eight patients with bacterial meningoencephalitis blood serum and csf were studied prior to the administration of meropenem and - min, , . and hrs after it. antibiotic regimen: mg of vancomycin ( mg bid) and meropenem ( mg tid diluted in ml of saline iv + mg bid diluted in ml of saline bolus slowly intrathecally). meropenem infusion was carried out for minutes, mins after it ml of blood and ml of csf were sampled. prior to antibiotics administration blood and csf were taken for microbiological examination. to determine the concentration of antibiotics iquid chromatography/mass spectrometry was used. the samples were analyzed on an agilent infinity liquid chromatograph coupled to a sciex qtrap mass detector (sciex, us introduction: the prophylactic use of probiotics has emerged as a promising alternative to current strategies viewing to control nosocomial infections in a critically-ill setting. however, their beneficial role in vap prevention remains inconclusive. our aim was to delineate the efficacy of probiotics for both vap prophylaxis and restriction of icu-acquired infections in multi-trauma patients. methods: randomized, placebo-controlled study enrolling multitrauma patients, requiring mechanical ventilation for > days. participants were randomly assigned to receive either probiotic (n= ) or placebo (n= ) treatment. a four-probiotic formula was applied and each patient received two capsules per day from day to day post icu admission. the content of one capsule was given as an aqueous suspension by nasogastric tube, while the other one was spread to the oropharynx after being mixed up with water-based lubricant. the follow-up period was days, while icu stay and mortality were also assessed. ], while no difference in -day mortality rate was identified between groups ( . % probiotics vs . % placebo). conclusions: the prophylactic administration of probiotics exerted a positive effect on the incidence of vap or other icu-acquired infections and icu stay in a critically-ill subpopulation being notorious for its high susceptibility to infections, namely multi-trauma patients. use of a c-reactive protein-based protocol to guide the duration of antibiotic therapy in critically ill patients: a randomized controlled trial i borges introduction: the rational use of antibiotics is one of the main strategies to limit the development of bacterial resistance. in this study we aimed to evaluate the effectiveness of a c reactive protein (crp) based protocol in reducing antibiotic treatment time in critically ill patients. methods: an open randomized clinical trial was conducted in two adult intensive care units of a university hospital in brazil (clini-caltrials.gov: nct ). patients were randomly allocated to: i) intervention -duration of antibiotic therapy guided by crp levels, and ii) control -duration of therapy based on best in the intention to treat analysis, the median (q -q ) duration of antibiotic therapy for the index infection episode was . ( . - . ) days in the crp group and . ( . - . ) days in the control group (p= . ). in the cumulative suspension curve of antibiotics, a significant difference in the exposure time between the two groups was identified, with less exposure in the crp group (p= . ). in the pre-specified per protocol analysis, with patients allocated in each group, the median duration of antibiotics was . ( . - . ) days in the crp group and . ( . - . ) days in the control group (p= . ). mortality and relapse rates were similar between groups. conclusions: daily levels of crp may aid in reducing the time of antibiotic therapy in critically ill patients, even in a scenario of judicious use of these drugs. introduction: the macrophage activation syndrome (mas) or hemophagocytic lymphohistiocytosis(hlh) is a life threatening complication characterized by pancytopenia, liver failure, coagulopathy and neurologic symptoms and is thought to be caused by the activation and uncontrolled proliferation of t lymphocytes and well differentiated macrophages, leading to widespread hemophagocytosis and cytokine overproduction [ , ] .the etiology is unknown, but is considered to have an infectious trigger.the aim of our study is to evaluate the impact of hlh in our beds infectious diseases icu, during months period ( - ). methods: a retrospective study based on electronic databases, including all patients admitted in our icu, that have matched at least out of criteria for hlh diagnosis ( ):fever; hepatosplenomegaly; > cytopenia (hb < g/dl, plt</dl, pmn -n< /mmc); hypertriglyceridemia> mg/dl, fibrinogen< mg/dl; hemophagocytosis-bone marrow, spleen, and/or lymphnodes; nk activity reduced/ absent; ferritin level> ui/l; cd > . we have evaluated the etiology established with cultures, serology, and molecular methods, treatment with corticosteroids, iv immunoglobuline, cyclosporine, etoposide and outcome ( ) . results: patients were admitted to icu, patients( . %) met the criteria for hlh. the average length of stay in icu was days; patients died ( %) without relation with the followed treatment. conclusions: hlh is not a rare condition in infectious diseases icu. the etiology is more frequent established compared with literature data. treatment (corticosteroids, immunoglobuline, cyclosporine, etoposide) is not associated with increased survival forecasting hemorrhagic shock using patterns of physiologic response to routine pre-operative blood draws introduction: irreversible hemorrhagic shock (ihs), a critical condition associated with significant blood loss and poor response to fluid resuscitation, can induce multiple organ failures and rapid death [ ] . determining the patients who are likely to develop ihs in surgeries could greatly help preoperative assessment of patient outcomes and allocation of clinical resources. methods: machine learning model of ihs is developed and validated via porcine induced bleed experiment. healthy sedated yorkshire pigs first had one ml rapid blood draw during a stable period, and then were bled at ml/min to mean arterial pressure (map) of mmhg. subjects had ihs defined as map< mmhg. arterial, central venous and airway pressures collected at hz during the blood draw [ fig ] were used to extract characteristic sequential patterns using graphs of temporal constraints (gtc) methodology [ ] , and a decision forest (df) model was trained on these patterns to determine subjects at high risk of impending ihs. results: in a leave-one-subject-out cross-validation, our method confidently identifies % ( % ci [ . %, . %]) of the subjects who are likely to experience ihs when subject to substantial bleeding, while only giving on average false alarm in , such predictions. this method outperforms logistic regression and random forest models trained on statistically featurized data [tab , fig ] . conclusions: our results suggest that by leveraging sequential patterns in hemodynamic waveform data observed in preoperative blood draws, it is possible to predict who are prone to develop ihs resulting from blood loss in the course of surgery. future work includes validating the proposed method on data collected from human subjects, and developing a clinically useful screening tool with our investigations. work partially funded by nih gm . introduction: the h s and oxytocin(oxy) systems are reported to interact with one another [ ] . h s plays a major role in the hypothalamic control of oxy release during hemorrhage [ ] . there is scarce information about oxy receptor(oxyr) expression in the brain in general and what is there is ambivalent. oxyr has been immunohistochemically(ihc) detected in the human hypothalamus but not in the hippocampus, in contrast to rodents [ ] , which underscores the need for additional characterization in relevant animal models. thus the aim of this study is to map the expression of the oxy and h s systems in the porcine brain in a clinically relevant model of hemorrhagic shock (hs). methods: anesthesized atherosclerotic pigs (n= ) underwent h of hs (map +/- mmhg) [ ] , followed by h resuscitation. ihc detection of oxy, oxyr, the h s producing enzymes cystathionine-γ -lyase (cse) and cystathionine-β -synthase(cbs) was performed on formalin fixed brain paraffin sections. results: oxy, oxyr, cse and cbs were localized in the porcine brain. proteins were differentially expressed in the hypothalamus (fig ) , parietal cortex and cerebellum (fig ) . cell types positively identified were: magnocellular neurons of the hypothalamus, cerebellar purkinje cells and granular neurons, and hippocampal pyramidal and granular neurons of the dentate fascia. arteries and microvasculature were also positive for oxyr and cse. conclusions: our results confirm the presence of oxy and oxyr in the hypothalamus similarly to the human brain. novel findings were: oxyr in the cerebellum and cse expression in the hypothalamus and cerebellum. the coexpression of oxyr and cse may link and help better understand neurochemical systems and physiological coping in hemorrhagic shock. funding: crc introduction: septic shock is one of the main causes of intensive care unit (icu) admission, leading to mortality up to % of patients. acute kidney injury (aki) frequently occurs and is associated to great morbidity and mortality. hemodynamic optimization may reduce the incidence of aki, but the use of vasopressors to increase mean arterial pressure (map) could have deleterious effect on renal perfusion. we aimed at investigating the effect of map and norepinephrine (ne) on the incidence of aki in septic shock patients methods: retrospective study based on prospectively collected data on digital medical records (digistat) at our icu. introduction: in patients with distributive shock, increasing mean arterial pressure (map) to a target of > mmhg can improve tissue perfusion. patients unable to achieve the target map of > mmhg despite adequate fluid resuscitation as well as catecholamines and vasopressin standard care (sc), may benefit from the noncatecholamine vasopressor angiotensin ii to increase map. this posthoc analysis examined whether patients from the athos- study with a baseline (bl) map < mmhg and treated with sc plus either angiotensin ii (ang ii) or placebo achieved a map of > mmhg for consecutive hours, without increasing the dose of sc therapy. methods: patients were assigned in a : ratio to receive ang ii or placebo, plus sc. randomization was stratified according to map (< or > mmhg) at screening. in patients with bl map < mmhg, we evaluated whether patients achieved a map of > mmhg for the first hours after initiation (map measurements taken at hours , , and ), without an increase in the dose of sc. results: among treated patients, had bl map < mmhg (ang ii, ; placebo, ). median bl map (iqr) was ( - ) and ( - ) mmhg for placebo and ang ii groups, respectively. patients with bl map < mmhg who were treated with ang ii were more likely to achieve map ≥ mmhg for consecutive hours after initiation without an increase in sc dose ( %, %ci - ), compared with placebo-treated patients ( %, %ci - , or= . , p< . ). conclusions: in this post-hoc analysis of patients with bl map < mmhg, patients receiving ang ii plus sc were significantly more likely to achieve a map > mmhg for the first consecutive hours after initiation than patients receiving sc only. this suggests that administering ang ii may help patients with catecholamine-resistant distributive shock to achieve the consensus standard target map. norepinephrine synergistically increases the efficacy of volume expansion on venous return in septic shock i adda, c lai, jl teboul, l guerin, f gavelli, c richard, x monnet hôpitaux universitaires paris-sud, hôpital de bicêtre, aphp, service de médecine intensive-réanimation, le kremlin-bicêtre, france critical care , (suppl ):p introduction: through reduction in venous capacitance, norepinephrine (ne) increases the mean systemic pressure (psm) and increases cardiac preload. this effect may be added to the ones of fluids when both are administered in septic shock. nevertheless, it could be imagined that ne potentiates in a synergetic way the efficacy of volume expansion on venous return by reducing venous capacitance, reducing the distribution volume of fluids and enhancing the induced increase in stressed blood volume. the purpose of this study was to test if the increase in psm induced by a preload challenge were enhanced by ne. methods: this prospective study had included septic shock adults. to reversibly reproduce a volume expansion and preload increase at different doses of ne, we mimicked fluid infusion through a passive leg raising (plr). in patients in which the decrease of ne was planned, we estimated psm (using respiratory occlusions) at baseline and during a plr test (plr high ). the dose of ne was then decreased and psm was estimated again before and during a second plr (plr low ). . the increase in cardiac index induced by plr low was significantly greater than that induced by plr high (p< . ). Δ psmhigh -Δ psmlow was moderately correlated with the diastolic arterial pressure at baseline-high (p= . , r= . ) and with the ne-induced change in mean arterial pressure (p= . , r= . ). conclusions: ne enhances the increase in psm induced by a plr, which mimics a fluid infusion. this suggests that it may potentiate the effects of fluid in a synergetic way in septic shock patients. this may decrease the amount of administered fluids and contribute to decrease the cumulative fluid balance. introduction: arginine vasopressin (avp) can be used in addition to norepinephrine (ne) for ne-resistant septic shock. however, a subgroup who will response to avp is unknown. the purpose of this study was to determine factors which could predict the response to avp in patients with ne-resistant hypotension. methods: this was a single-center, retrospective analysis of patients who administered avp for ne-resistant hypotension in our intensive care units (icus). eligible patients were adult patients who administered avp in addition to ne due to hypotension (mean arterial pressure (map) < ) in our icus between august and december . we divided all patients into two groups by response to avp; responders and non-responders. the responders were defined as an increase of map ≥ mmhg at h after avp initiation. we conducted univariate and multivariate logistic regression analysis to evaluate the effect of variables on avp response. results: a total of patients were included; responders ( %), non-responders ( %). there was no significant difference for map at the time of avp initiation ( vs mmhg; p = . ), initiation dose of avp ( . vs . u/min; p = . ), and dose of ne at the time of avp initiation ( . vs . μ g/kg/min; p = . ). map at h after avp initiation was significantly higher in responders than non-responders ( vs mmhg; p < . ). responders were older ( vs ; p = . ) and had lower heart rate (hr) ( vs. ; p = . ) and lactate ( . vs. . mmol/l; p = . ) at the time of avp initiation. the multivariate logistic analysis revealed that hr ≤ (or . , % ci . - . , p < . ), lactate ≤ (or . , % ci . - . , p < . ) and age ≥ (or . , % ci . - . , p = . ) were significantly associated with the response to avp. conclusions: hr, lactate levels and age before avp initiation can predict the response to avp in icu patients with ne-resistant hypotension. the maximum norepinephrine dosage of initial hours predicts early death in septic shock d kasugai , a hirakawa , n jinguji , k uenishi nagoya university gtaduate school of medicine, department of emergency and critical care, nagoya, aichi, japan; fujita health university, department of disaster and traumatology, fujita health university, toyoake, japan; fujita health university hospital, department of emergency and general internal medicine, fujita health university hospital, toyoake, japan critical care , (suppl ):p introduction: the mortality of septic shock refractory to norepinephrine remains high. to improve the management of this subgroup, the knowledge of early indicator is needed. we hypothesize that maximum norepinephrine dosage on the initial day of treatment is useful to predict early death in septic shock. methods: in this retrospective single-center observational study, septic shock patients admitted to the emergency intensive care unit (icu) of an academic medical center between april and march were included. cardiac arrest before icu admission and those with do-not-resuscitate orders before admission were excluded. the maximum dosage of norepinephrine initial hours of icu admission (md ) was used to assess -day mortality. results: one-hundred-fifty-two patients were included in this study. median sofa score was ( - ), and median md was . ( . - . ) mcg/kg/min. vasopressin and steroid were administered in ( %) and ( %) cases. nineteen patients ( %) died within a week. non-survivors had higher md , higher sofa score, and higher rate of vasopressin use. the higher md predicted -day mortality (area under curve . , threshold . mcg/kg/min, sensitivity %, specificity %). after adjustment of inverse probability of treatment weighing method using propensity scoring, md higher than . mcg/kg/min was independently associated with -day mortality (or: . , %ci: . - . , p < . ). conclusions: the maximum dosage of norepinephrine higher than . mcg/kg/min initial hours was significantly associated with day mortality in septic shock, and may be useful in the selection of higher severity subgroup. the impact of norepinephrine on right ventricular function and pulmonary haemodynamics in patients with septic shock -a strain echocardiography study k dalla sahlgrenska university hospital mölndal, göteborg, sweden critical care , (suppl ):p introduction: septic shock is characterized by myocardial depression and severe vasoplegia. right ventricle performance could be impaired in sepsis. the effects of norepinephrine on rv performance and afterload in septic shock are not immediately evident. the aim of the present study was to investigate the effects of norepinephrine on rv systolic function, rv afterload and pulmonary haemodynamics. methods: eleven, volume-resuscitated and mechanically ventilated patients with norepinephrine-dependent septic shock were included. infusion of norepinephrine was randomly and sequentially titrated to target mean arterial pressures (map) of , and mmhg. at each target map, strain-and conventional echocardiographic were performed. the pulmonary haemodynamic variables were measured by using a pulmonary artery thermodilution catheter. the rv afterload was assessed by calculating the effective pulmonary arterial elastance (epa) and pulmonary vascular resistance index (pvri). results: the norepinephrine-induced elevation of map increased central venous pressure ( %, p< . ), stroke volume index ( %, p< ), mean pulmonary artery pressure ( %, p< . ) and rv stroke work ( %, p= . ), while neither pulmonary vascular resistance index nor epa was affected. increasing doses of norepinephrine improved rv free wall strain from - % to - % ( %, p= . ), tricuspid annular plane systolic excursion ( %, p= . ) and tricuspid annular systolic velocity ( %, p= . ). there was a trend for an increase in cardiac index assessed by both thermodilution (p= . ) and echocardiography (p= . ). conclusions: the rv function was improved by increasing doses of norepinephrine, as assessed both by strain-and conventional echocardiography. this is explained by an increase of rv preload. pulmonary vascular resistance is not affected by increased doses of norepinephrine. peripheral perfusion versus lactate-targeted fluid resuscitation in septic shock: the andromeda shock physiology study. preliminary report g hernandez , r castro , l alegría , s bravo , d soto , e valenzuela , m vera , v oviedo , c santis , g ferri , m cid , b astudillo , p riquelme , r pairumani , g ospina- tascón table . conclusions: this preliminary results suggest that using crt as a target for fr in septic shock appears to be feasible, and not associated with impairment of tissue perfusion-related parameters as compared to lactate-targeted fr. grant fondecyt chile introduction: shock patients often become resistant to catecholamines which often require the addition of a non-catecholamine vasopressor. preclinical studies suggest that in the presence of aadrenoceptor antagonism, the renin-angiotensin aldosterone system exerts the major vasopressor influence. we sought to determine the effects of angii or lypressin (lyp [porcine vasopressin]) on blood pressure in a norepinephrine (ne)-resistant hypotension pig model. methods: phentolamine (phn), a reversible α-blocker that antagonizes the vasoconstriction by ne, was continuously infused to induce hypotension. after ne-resistant hypotension was established, lyp or angii was then co-infused with phn. mean arterial pressure (map) and heart rate were continuously recorded (fig. ) . results: as shown in fig. conclusions: in a background of α-adrenoceptor blockade, at clinically comparable doses, the vasopressor effect of ang ii was maintained while those of ne and lyp were attenuated. these data suggest that the blood pressure effect of vasopressin-like peptides may require a functioning α-adrenoceptor. patients with shock who are resistant to increasing doses of catecholamines may also have vasopressin resistance potentially making angiotensin ii a preferred vasopressor for these patients. introduction: resuscitative endovascular balloon occlusion of the aorta (reboa) has been increasingly used for the management of both traumatic and non-traumatic hemorrhagic shock. however, there is limited evidence for its use in gastrointestinal bleeding (gib), especially in the icu setting. we successfully treated a patient with massive gib using reboa in the icu. we will discuss the difficulty performing the procedure and its countermeasure. methods: a case report. results: an -year-old woman was transferred to our hospital with shock. coffee grounds material was found in a nasogastric aspirate after intubation and upper gastrointestinal endoscopy identified a pulsating large duodenum ulcer without active bleeding, for which an elective procedure was planned. she was admitted to our icu, responded to initial resuscitation, and thereafter extubated. her systolic blood pressure (sbp) suddenly dropped to mmhg with massive hematochezia at that night, and did not increase despite resuscitation with blood products, crystalloid and norepinephrine. to buy time until measures for stop bleeding, we planned to place reboa in the icu. following the placement of a sheath in the left femoral artery, we tried to place a fr intra-aortic balloon occlusion catheter, which unintentionally and repeatedly went into the right common iliac artery because her left femoral artery was tortuous. after compressing the right lower abdomen, we managed to introduce reboa in zone . it took approximately minutes to successfully place the catheter. the patient's sbp increased immediately after the balloon inflation and bleeding was endoscopically controlled. introduction: the natural components of the pomegranate fruit may provide additional benefits for endothelial function and microcirculation. we hypothesized that chronic supplementation with pomegranate extract might improve glycocalyx properties and microcirculation during anaerobic condition. methods: eighteen healthy and physically active male volunteers aged - years were recruited randomly to the pomegranate and control groups ( in each group). the pomegranate group was supplemented with pomegranate extract for two weeks. at the beginning and end of the experiment, the participants completed a high intensity sprint interval cycling-exercise (anaerobic exercise) protocol. the systemic hemodynamics, microcirculation flow and density parameters, glycocalyx markers, and lactate and glucose levels were evaluated before and after the two exercise bouts. results: no significant differences in the microcirculation or glycocalyx were found over the course of the study. the lactate levels were significantly higher in both groups after the first and repeated exercise bouts, and were significantly higher in the pomegranate group relative to the control group after the repeated bout: . ( . - . ) vs. . ( . - . ) mmol/l, p = . . conclusions: chronic supplementation with pomegranate extract has no impact on changes to the microcirculation and glycocalyx during anaerobic exercise, although an unexplained increase in blood lactate concentration was observed. introduction: extracorporeal membrane oxygenation in adults in accompanied by high mortality. our ability to predict who will benefit from ecmo based on currently available clinical and laboratory measures is limited. the advent of single cell sequencing approaches has created the opportunity to identify cell populations and pathophysiological pathways that are associated with mortality without bias from a priori cell type classifications. identification of such cell populations would provide both an important prognostic markers and key insight into immune response mechanisms and therefore a possibility for advanced drug matching that may impact clinical response to ecmo in these patients. methods: whole genome transcriptomic profiles were generated from a total of , peripheral blood monocytes obtained from patients at the time of cannulation for ecmo (fig ) . differential gene expression analysis was performed with the monocle package for the r statistical analysis framework. time-to-event data were analyzed in a survival analysis with a log-rank test for differences. results: genes encoding several members of the heat shock family of proteins were up-regulated in cells from non-survivors. notably, these genes were expressed by a small fraction of cells ( . % on average). nevertheless, the proportion of cells expressing these genes was a significant predictor of survival to days (p = . by log rank test), with a particularly pronounced effect in the first days after initiation of ecmo support (fig ) . conclusions: the proportion of cells expressing genes encoding members of the heat shock proteins is predictive of survival on ecmo. majority of pt ( %) had no known predisposing conditions, followed by immobility ( %) and cancer ( %). in ecg analysis tachycardia and v -v t wave inversion were the most common findings whereas hypoxemia± hypocapnia were the most prominent features in abg analysis. pt ( %) had bleeding complications (none intracranial), ( . %) during rtpa, ( . %) in the first h and only pt required transfusion. mortality rate was %: % directly due to pe (all during cpr) and % due to late complications (newly diagnosed cancer and infections). conclusions: in our experience, fibrinolytic therapy is safe and effective but in submassive pe should be applied after thorough assessment of risks and benefits on individual basis aiming to patient tailored precision medicine. [ ] trials evaluated the role of levosimendan in preventing low cardiac output syndrome in patients undergoing cardiac surgery. the studies were similar in their design and recruited patients with preoperatively low lvef undergoing either isolated cabg or valve surgery combined with cabg (table ). in both, a -hour levosimendan infusion was started at induction of anesthesia. neither study met the primary efficacy composite enpoints, but both showed a clear tendency for better outcome in patients undergoing a cabg compared to a valve procedure. we are currently evaluating the solidity of a co-analysis based on shared end-points. we are planning a shared analysed of the data related to the cabg settings and analyze the aggregated mortality data for both studies at and months by cochran-mantel-haenszel odds ratio. data from individual studies would be analysed as fixed effect and breslow-day test was used to evaluate homogeneity of the odds ratios results: in the placebo groups of the two studies, the mortality is similar; . % ( / ) in levo-cts and . % ( / ) in licorn, corroborating the working hypothesis that the two studies can be coanalysed. in a preliminary combined analysis (fig ) , -day mortality was . % ( / ) in the placebo group and . % ( / ) in the levosimendan group. odds ratio was significantly in favor of levosimendan ( . ; % confidence interval . - . ; p= . , fig. ) conclusions: the levo-cts and licorn trials can be co-analysed in their sub-setting of patients requiring isolated cabg surgery for mortality at and months. a preliminary analysis on mortality reinforce the hypothesis that, in isolated cabg surgery, levosimendan lowers post-operative mortality significantly both at and months, when started at the induction of anesthesia introduction: emergency medical system (ems) -based st elevation myocardial infarction (stemi) networks allows not only stemi diagnosis in the pre-hospital phase but also reduces treatment delays; treat your fatal complications and the immediate activation of the catheterization laboratory. the aim of study was to investigate the effect of out-of-hospital by mobile intensive care (micu) versus hospital beginning treatment in hospitalization length and survival of patients with stemi diagnosis introduction: contrast induced nephropathy (cin) is a complex acute renal failure syndrome, which can occur after primary percutaneous coronary intervention (pci) and is an important cause of morbidity and mortality in this subgroup of patients. the aim of our study was to establish the incidence and predictors of cin after primary pci. we performed a retrospective analysis of stemi patients treated with primary pci in the period from january until september of . cin was defined as an absolute increase in baseline serum creatinine of ≥ . mg/dl ( μmol/l) or > % relative rise within hours after primary pci. we analyzed demographic characteristics, risk factors, clinical status at hospital admission, laboratory parameters, left ventricle ejection fraction and data regarding pci procedure. results: the study included patients, with an average age of . ± . years, . % of the patients were males. an average of . ± . ml of contrast medium per patient was utilized. cin developed in ( . %) patients and overall intra-hospital mortality was . %. in multivariate analysis, the independent predictors of cin were age> years ( introduction: left main coronary artery (lmca) disease is a disease of the main coronary branch that gives more than % of blood supply to the left ventricle, it carries high mortality without surgical intervention; [ ] however the influence of lmca surgery on morbidity icu measures needs to be explored. we aim to determine whether lmca is definitive risk factor for prolonged icu stay as a primary outcome and whether lmca is definitive risk factor for early morbidity methods: retrospective descriptive study with purposive sampling analyzing patients underwent isolated coronary artery bypass surgeries (cabg). patients were divided into groups those with lmca disease as group ( patients) and those with coronary arty disease requiring surgery but without lmca disease as group ( patients) then we will correlate with icu outcome parameters including icu stay length, postoperative atrial fibrillation, acute kidney injury, re-exploration, perioperative myocardial infarction, post operative bleeding and early mortality. results: patients with lms had significantly higher diabetes prevalence ( . % vs %, p= . ). however, we did not find a statistical significant difference regarding icu stay, or other morbidity and mortality outcome measures conclusions: diabetes was more prevalent in patients with lms. the latter group showed similar outcome as those without lms in this study these findings may help in guiding decision making for future practice and stratifying the patients care. introduction: multimorbidity in patients admitted for acute myocardial infarction [ami] is associated with higher risk for in-hospital mortality and adverse clinical outcomes. we investigated to what extent an increasing number of comorbidities affects the age-stratified excess risk of death and other clinical outcomes among patients with myocardial infarction. methods: we analyzed nationwide administrative data of ` admissions for an acute myocardial infarction between and . we calculated multivariate regression models to study the association of four comorbidities (chronic kidney disease [ckd], diabetes mellitus, heart failure [hf], and atrial fibrillation) and excess risk of in-hospital mortality, length of hospital stay [los] , and -day readmission and stratified the analysis for different age categories. results: the incidence of admissions for ami increased continuously during the observed decade without an increase in in-hospital mortality, los, and -day readmission. among admitted patients with ami, there was a stepwise increase in risk for adverse outcomes for each comorbidity. compared to patients with no comorbidity, patients with comorbidities had -fold increased risk for mortality (adjusted odds ratio [or] . , % confidence interval [ci] . to . ) and a similar risk for readmission (or . , ci . to . ). the los was . days (ci . to . ) in patients with no comorbidity and increased by . days (ci . to . ) with each additional comorbidity. these associations were stronger in younger compared to older patients. ckd was the strongest predictor of in-hospital mortality and los, while hf was the strongest predictor of -day readmission. conclusions: this study of nationwide admitted patients with ami found a stepwise increase in the risk for adverse outcome with increasing number of comorbidities, particularly in the younger patient population. younger, multimorbid patients may thus have the largest benefits from multidisciplinary treatments. introduction: certified cardiac arrest centers, sophisticated post cardiac arrest care and prehospital ecls teams aim to increase survivor rates with a preferable neurological outcome after cardiac arrest. centers also provide emergency ecls and ecls pick ups for cardiogenic shock patients before arresting. few data answer the question of the long-term quality of life after ecls therapy. methods: in a retrospective single center register we included patients after emergency ecls (ecpr and cardiogenic shock) between / and / discharged alive and performed a follow-up after years on average at / . in our center criteria to initiate ecls therapy in cardiogenic shock or under cardiac arrest are an observed collaps, shockable rhythm, absence of frailty and severe comorbidities. all patients were requested to take part in a telephone interview. thus, we analyzed survival, cpc scores and sf scores. results: patients with hospital survival after ecls were screened. % (n= ) had survived until / ; patients were not accessible; had ceased. survivors (mean±sd; min-max; ± ; - years, women) answered sf questionaires ± ; - months after ecls ( % cardiogenic shock, % ecpr with shockable rhythm in %). the participantsĆ pc scores were in median . the results of the sf were physical functioning ± , physical role functioning ± , bodily pain ± , general health ± , vitality ± , social role functioning ± , emotional role functioning ± and mental health ± . survivors who did not take part at the sf had a cpc score of in median (n= , personally signed refusals, language barriers, vegetative states). conclusions: after emergency ecls therapy and hospital survival % of our patients survived the following years up to over years with a preferable neurological outcome and a general mentally and physically satisfactory quality of life. a vague outcome in % limits the results of our study. introduction: successful weaning from va-ecmo requires the restoration of a sufficient cardiac function to ensure an adequate tissue perfusion. skin blood flow (sbf) is among the first to deteriorate during circulatory shock and the last to be restored after resuscitation. sbf would be a good predictor of successful weaning from va-ecmo. methods: patients with va-ecmo, who required a first weaning attempt, were included. weaning procedure (wp) was performed by a reduction of va-ecmo blood flow to l/min for minutes. the weaning criterion was an aortic velocity-time integral (vti) > cm. successful weaning from va-ecmo was defined as hemodynamic stabilization and without the need to increase the vasopressor dose during the next hours. sbf, assessed by skin laser doppler (peri-flux , perimed, right index finger); perfusion unit: pu), together with global hemodynamic parameters were obtained before and after min of weaning. receiver operating characteristic curves (roc) were generated to assess the ability and reliability of baseline parameters to predict a successful weaning. results: we studied wps in patients with va-ecmo for pulmonary embolism (n = ), post cardiotomy (n = ), acute coronary syndrome (n = ), myocarditis (n = ). these were successful (sw) in and unsuccessful (nsw) in . at baseline, hemodynamic variables, lactate, ecmo blood flow were similar in both groups (table ). sbf was greater in sw than nsw patients (table ). during wp, ci rose from baseline and was similar in sw and nsw (p= . ) ( table ). vtis were higher in sw than nsw ( ( - ) vs ( - ), respectively, p= . ). sbf decreased in sw and remained low in nsw (table ) . from the roc curves analyses, baseline sbf had the highest area under the roc curve with a cut off ≥ pu (sensitivity %, specificity %) (figure ). conclusions: sbf is a good predictor of successful weaning from va-ecmo introduction: postoperative cognitive dysfunction (pocd) is defined as a temporarily decline in cognition associated with surgery. long-term pocd ( months after surgery) occurs in - % of cardiac patients and is associated with a higher morbidity and mortality. endo-cabg is a new minimally invasive endoscopic coronary artery bypass grafting (cabg) technique that requires retrograde arterial perfusion which may be associated with a higher incidence of neurological complications. the aim of this study is to assess the incidence of pocd after endo-cabg. methods: sixty consecutive patients undergoing an endo-cabg were enrolled. pocd was assessed following the recommendations of the " statement of consensus on assessment of neurobehavioral outcomes after cardiac surgery". a comparative group of patients undergoing percutaneous coronary intervention (pci) and a control group of healthy volunteers were also enrolled. additional tests included the digit span test and digit symbol-coding test. patients were tested at baseline and at month follow-up. pocd is defined as a reliable change index (rci) ≤ - . (significance level %), or z-score ≤ - . in at least two different tests. results: after enrolling patients in each group, respectively in the endo-cabg-group, in the pci-group and healthy controls were analysed. patients suffering from a cva within three months after their procedure were automatically classified as having pocd (pci: n= ; endo-cabg: n= ). the total incidence of pocd was not different between groups (pci: n= ; endo-cabg: n= , p= . ). conclusions: our results suggest that the risk of pocd after endo-cabg is low and comparable with the risk of pocd after pci. introduction: rhabdomyolysis ( rml) post aortic surgery probably affects the renal outcome adversely [ , ] . there is no robust data regarding the same in literature. methods: retrospective single center data review; prior approval from institutional review board. patients were divided to two groups group -with rml ( ck above cut off levels u/litre) and group without rml. the determinants of rml and the impact of the same on outcome; predominantly renal function was evaluated. chi-square tests are performed for categorical variables whereas, student t tests (un-paired ) are performed with continuous variables. correlation is performed between creatine kinase and creatinine rise. p value . (two tailed) is considered for statistical significant level. results: out of patients, patients ( . %) developed rhabdomyolysis ( group rml) and did not( group non rml). demographic and intraoperative factors had no significant impact on the incidence of rml. there was a significantly higher incidence of renal complications including new postoperative dialysis in the rml group. other morbidity parameters were also higher in the rml group. conclusions: there is high prevalence of rml after aortic dissection surgery -identification of risk factor and early intervention might help to mitigate the severity of renal failure introduction: we investigate whether central venous pressure (cvp) pressure waveform signal can be informative in detection of slow bleeding in post-surgical patients. we apply a novel machine learning method to analyze cvp datasets to characterize bleeding in a porcine model of fixed rate blood loss. methods: thirty-eight pigs were anesthetized, instrumented with catheters, kept stable for minutes, and bled at a constant rate of ml/min to mean arterial pressure of mmhg. cvp waveforms were extracted from inspiration and expiration phases of respiration and statistically featurized. the proposed machine learning method, canonical least squares (cls) clustering, identifies correlation structures that differ between subsets of observations. we extend it to supervised classification. both clustering and classification methods yield human-interpretable models that reflect distinctive patterns of correlations within cvp waveforms. results: we conducted three experiments to discover structure in the physiological response to bleeding. first, we clustered respiration cycles with full knowledge of blood loss. the color-coded cluster assignments are shown in the figure . they are consistent with escalation of bleeding. second, we deployed clustering on only cvp features without blood loss. temporal structure was complemented with some subject-specific clusters (fig ) . third, we ran cls classification to decide whether an observation came from before or after the onset of bleeding (performance shown in the results: over the last decade, the number of patients with hlhs who underwent norwood has increased. interstage mortality has decreased, and is currently - %. significant morbidity was not seen at a rate higher than in the international literature. discharge planning, and community access to allied health professional services remained a concern. conclusions: the paediatric congenital cardiac surgical service in the united arab emirates is relatively new (compared to some services around the world). interstage mortality in hlhs is improving as a result of programme development, surgical progress and postoperative care. in the interstage period, there is currently no home monitoring programme in place. some patients were found to have had very extended hospital admissions. improved community support may reduce interstage mortality further, as well as improve the social situation of many of these patients. postoperative complications were observed in ( . %) patients. we lined out the prevalence of cardiac complications, such as heart failure and rhythm disturbances, observed in ( . %) and ( . %) patients respectively. hospital mortality rate was . % ( / ). the cause of mortality in all cases was acute heart failure, due to the initial severity of the disease, and in ( . %) cases an acute myocardial infarction was diagnosed. duration of postoperative period was . ± . days. conclusions: off-pump coronary artery bypass grafting can be safely performed with relatively low incidence of mortality and postoperative morbidity. prognostic value of mid-regional pro-adrenomedullin and midregional pro-atrial natriuretic peptide as predictors of multiple organ dysfunction development and icu length of stay after cardiac surgery with cardiopulmonary bypass in adults introduction: one of the most harmful complications after cardiac surgery with cardiopulmonary bypass is a syndrome of multiple organ dysfunction (mods). we consider that mid-regional proadrenomedullin (mr-proadm) and mid-regional pro-atrial natriuretic peptide (mr-proanp) plasma concentrations can be used as predictors of mods development and los in icu. methods: thirty six adult patients (mean age years, male) with cardiovascular diseases undervent cardiac surgery with cardiopulmonary bypass (heart valve(s) replacement - ( . %) patients, aorta and it`s branch surgery - ( . %) patients, valvular surgery and coronary artery grafting - ( . %) patients). nyha heart failure class ii was in ( . %) patients, iiiin ( %) patients, ivin ( . %) patients. in the dynamics levels of mr-proadm and mr-proanp were measured in the venous blood with the kryptor compact plus analyzer (thermo fisher scientific, germany) before day and on the st and th days after surgery. all patients were divided into subgroups according to the lengths of stay in the icu and the development of mod in the postoperative period. the data are shown as median and th and th percentiles. the data were compared by mann-whitney u-test, pvalue of < . was considered statistically significant. results: levels of mr-proanp did not significantly change at the study stages and did not have a significant difference between subgroups. the levels of mr-proadm increased in the first postoperative day and remained elevated for days. this increase was significantly higher in subgroups of increased los in icu and with mods. the data are shown in the table . conclusions: mr-proadm can be used as predictor of mods and los in the icu for adult patients underwent cardiac surgery with cardiopulmonary bypass. introduction: prolonged intensive care unit (icu) stay after cardiac surgery is associated with increased mortality and cost .the aim of this study was to investigate factors influencing prolonged icu stay. methods: consecutive patients who underwent cardiac surgery from june to october in our cardiothoracic department, were retrospectively investigated. group a consisted of pts with prolonged stay defined as more than days and group b the rest of the cohort. the following characteristics and perioperative factors were compared between the groups: smoking, diabetes, copd, redo(re-operation), ejection fraction (ef)< %, emergent procedure, cardiopulmonary bypass time (cpb)> min, low cardiac output syndrome (lcos), acute kidney injury(kdigo) and mortalitychi square test was used for the statistical analysis. introduction: hemorrhagic complications of extracorporeal membrane oxygenation (ecmo) pose a major morbidity and mortality. optimal anticoagulation strategies balancing risks of bleeding and thrombosis in children are poorly understood. we aimed to identify factors associated with non-surgical bleeding in the first ecmo hours. methods: we evaluated all pediatric (< yrs) post-cardiotomy patients requiring ecmo between dec -july stratifying them by presence/absence of surgical bleeding. non-surgical bleeding was defined as chest tube output > cc/kg/hr during the first -hours not requiring reoperation. patient characteristics and coagulation parameters at various time points after ecmo initiation were compared between groups, and receiver operator characteristic (roc) curves were constructed to identify models and thresholds with optimal predictive performance. figure . conclusions: deranged coagulation parameters, particularly kaolin rtime may predict non-operative bleeding in pediatric ecmo patients. these findings may guide therapeutic anticoagulation while avoiding hemorrhagic sequelae in at risk patients. introduction: elevated cardiac troponin (ctn) level in patients (pts) admitted in the intensive care unit (icu) is multifactorial and has been associated with a worse prognosis. the aim of the study was to review the frequency and the main cause of ctn elevation and to calculate a discriminating index. methods: we retrospectively assessed all pts admitted in our eightbed general icu during a -month period with at least one measurement of ctn during their icu stay. we recorded clinical characteristics, the level of ctn on admission, the maximum ctn during icu stay and the possible causes of elevation. variables are expressed as mean ± sd or as median and interquartile ratio (ir), according to the normality of their distribution. student´s Ô test or the mann whitney u tests were used to compare the group of elevated ctn with the group of normal ctn. the prognostic performance of elevated ctn was evaluated by the receiver operating characteristics (roc) curve. statistical analysis was performed using spss version . (spss, inc., chicago, illinois). results: in out of pts that ctn was measured at least once, abnormal levels (> . pg/ml) were found in ( %) of them, and the maximum ctn value was ( . ) pg/ml. the clinical characteristics of the pts are depicted in table . sepsis was the main cause of troponin elevation, which complicated by acute kidney injury (aki) in pts ( %). maximum ctn, aki and the difference of maximum -admission ctn (Äctn) differed significantly between pts who survived and pts who died (p= . and . , respectively). the area under the curve (auc) was . and the optimal prognostic cut-off value of Äctn was pg/ml with a sensitivity of . and a specificity of . conclusions: raised cardiac troponin values is a frequent finding in icu pts and sepsis is the driving cause. aki and the difference between maximum and admission ctn measurements differ significantly between pts who survive and pts who die. an elevation of ctn during icu hospitalization > pg/ml seems to be a threshold indicating poor prognosis regarding both mortality and aki. the prognostic role of nt-pro-bnp in septic patients with elevated troponin t level introduction: sepsis is frequently accompanied with release of cardiac troponin t (tnt) and nt-pro-bnp, but the clinical significance of this myocardial injury and cardiac dysfunction remains unclear [ ] . tnt is known to be an independent predictor of mortality, whereas the prognostic role of nt-pro-bnp is uncertain. methods: here, we report data of va-ecmo-patients, treated with dobutamine, levosimendan, suprarenin or no inotropic agens, in respect of -day survival. all data were collected retrospectively ( / to / ) at a single center, all patients with a survival below hours were excluded. while treatment of va-ecmo patients is strongly guided by standard operation procedures at our institution, no recommendation on positive inotropic therapy could be made. results: a total of va-ecmo patients were evaluated, of which patients were treated with levosimendan within hours after cannulation. day survival in the whole cohort was . %. a total of patients did not receive any positive inotropic therapy at hours after implantation (survival . %). survival was best in the levosimendan plus dobutamine group %, followed by dobutamine mono-therapy . % and levosimendan mono . %. survival with suprarenin mono was . %, suprarenin plus levosimendan . % and suprarenin plus dobutamine , %. pooling data, we found no evidence that levosimendan and/or dobutamine (survival . %, n= , p= . ) improves survival over no inotropic therapy (fig ) . therapy with any combination including suprarenin however resulted in poor survival ( . %, n= , p= . ). adjustment for lactate levels or ecpr did not change the results. conclusions: this retrospective analysis of va-ecmo patients shows no evidence that early inotropic therapy improves outcomes in va-ecmo patients. this conclusion is obviously biased by retrospective design. until randomized data are available, suprarenin however should be avoided. survey of non-resuscitation fluids in septic shock a linden-sonderso introduction: positive fluid balance is associated with poor outcome in septic shock. the objective of the present study was to characterize non-resuscitation fluids in early septic shock. methods: consecutive patients > years of age were screened for inclusion criteria during a -month period in icus in sweden and in canada. inclusion criteria were septic shock per sepsis- definition within hrs of icu admission. a maximum of patients per center were included. type, indication and volume of non-resuscitation fluids were recorded during the first days of admission. fluids other than colloids, blood products and crystalloids given at rate > ml/kg/h were considered to be non-resuscitation fluids. the study was registered on clini-caltrials.gov (nct ). data are presented as median (interquartile range). results: a total of patients were included between march st and june th (see table for demographics). patients received ( - ) milliliters (ml) of non-resuscitation fluids introduction: we aimed to ascertain the extent and make-up of fluid overload in critically ill patients and to identify whether delivery of more concentrated medications could reduce this. positive fluid balance is associated with increased mortality [ ] . a recent study has shown that the predominant component of fluid overload was from iv medications and maintenance fluid [ ] . methods: we reviewed sequential patients admitted to our icu with an apache ii score of greater than and a length of stay (los) greater than hours. the patients' electronic admission summary was interrogated to establish: length of stay (los) fluid balance at hours, total volume administered as iv medications, total volume administered as maintenance fluid and total fluid administered introduction: in children less than kilograms, maintenance fluids are routinely added to the resuscitation requirements calculated using parkland's or other formulae. the contribution of this component for fluid resuscitation in children can add a significant quantity to total estimated fluid requirements. for example, in a child who is kilograms with a % burn, the maintenance fluid requirement is mls per hours and the resuscitation component per parkland's will be x x %= mls. hence, the maintenance requirement can exceed the resuscitation requirement in this child if the burn surface area is less than a % burn. the contribution of maintenance fluids to the total fluid requirements in small children with thermal injuries is under-recognised and not frequently studied. methods: to understand the contribution of maintenance fluids to the total fluid requirements in children less than kilograms who need resuscitation for thermal injuries of different sizes, we numerically simulated . children who had similar weights but different burn sizes and . children with similar burn size but different weights. the results are as shown in fig introduction: accurate quantification of fluid in resuscitation of thermal injuries is important for benchmarking, comparing and improving outcomes. in adults, it is usually expressed as mls/kg/%tbsa. in children, maintenance fluids are added to the resuscitation requirements. this is kept constant and the resuscitation component is titrated to meet pre-defined end points-usually urine output. maintenance fluids are not uniformly stratified across the weight ranges. we propose that quantification of fluids in mls/ kg/%tbsa in children does not accurately capture fluid needs for resuscitation due to the maintenance component of the fluid requirement. methods: we conducted this retrospective study in children admitted to a single-center burns intensive care unit (bicu) between january and december . children ≤ kilograms with tbsa ≥ % admitted within hours of their injury were included. oe (observed to expected ratio) and fluid in mls/kg/% tbsa were calculated as shown in figure . results: there were children in the cohort with half requiring invasive mechanical ventilation in the bitu and nearly a quarter requiring inotropic support. the demographic details are as shown in table . the oe ratio at the end of hours in the cohort was . ( . - . ). the total fluid given was . ( . , ) mls/kg/ % tbsa. the titrated resuscitation component was . ( . , . ) mls/kg/tbsa. total fluid (which included the maintenance fluid) had a poor correlation with oe ratio r = . (fig ) . exclusion of the maintenance fluid had a better correlation with the oe ratio r = . conclusions: to capture differences in the titratable resuscitation component rather than differences in the maintenance requirements, fluid should be quantified in children by excluding the maintenance component when expressed as mls/kg/%tbsa. dynamic arterial elastance for predicting mean arterial pressure responsiveness after fluid challenges in acute respiratory distress syndrome patients p luetrakool , s morakul , v tangsujaritvijit introduction: dynamic arterial elastance (eadyn; pulse pressure variation/stroke volume variation; ppv/svv) is a dynamic parameter of arterial load that can be continuously monitored. previous study proposed that eadyn was able to predict mean arterial pressure (map) responsiveness after fluid challenge [ ] [ ] [ ] [ ] [ ] . the objective of this study was to assess whether the eadyn was able to predict map responsiveness in acute respiratory distress syndrome (ards) patients ventilated with low tidal volume. methods: we performed a prospective study of diagnostic test accuracy in adult ards patients with acute circulatory failure and fluid responsiveness. all patients are continuously monitored blood pressure via arterial line connected with flotrac® transducer and vigileo® monitor. once the attending physicians decided to load intravenous fluid, we recorded ppv/svv and also other hemodynamic parameters before and after fluid bolus. map responsiveness was defined as an increase in map ≥ % from baseline after fluid challenge. results: twenty-three events were included. nine events ( . %) were map-responsive. cardiac output, heart rate and stroke volume were similar in both map-responder and map-nonresponder group. baseline map, diastolic blood pressure (dbp) and pulse pressure (pp) were significantly different after fluid challenge in map-responder group. eadyn of preinfusion phase was failed to predict map conclusions: one of the arterial load parameters such as eadyn derived from non-calibrated pulse contour analysis method was unable to predict map responsiveness in ards patients with low tidal volume ventilation. the our aim is to test the hypothesis that in fr septic shock patients, fluid load will determine a significant increase in pmsf but not in cvp. we prospectively included all mechanically ventilated patients with diagnosis of septic shock with invasive hemodynamic monitoring (transpulmonary thermodilution volumeview-ev ed-wards©). we collected hemodynamic and metabolic data and pmsf with the inspiratory holds technique, before and after a fluid challenge (fc) of ml of ringer lactate in minutes). fr was defined as an increase in cardiac output (co)> %. results: measures were obtained in patients. in case we observed fr. we found a significant increase in pmsf after a fc (mean difference(md) . ± . mmhg, p=. ). cvp increased significantly (md . ± . mmhg, p=. ). pmsf increased significantly in non-fr (md ± mmhg, p=. ) but not in fr while cvp was higher after fc only in fr (md . ± . mmhg, p=. ). venous return gradient (pmsf-cvp) globally increased after fc (md ± mmhg, p=. ), but only in non-fr such increase was significant (md ± mmhg, p=. ). no correlation was found between the variation co and venous return gradient. we did not find any improvement in metabolic parameters after the fluid challenge. conclusions: pmsf and combined cvp variations do not correlate with fr in our cohort of septic shock patients. inspiratory holds may not be adequate to infer pmsf in such context. further studies are warranted to investigate the effect of fc on pmsf in this field. evaluation of pre-load dependence over time in patients with septic shock i douglas , p alapat , k corl , m exline , l forni , a holder , d kaufman , a khan , m levy , g martin , j sahatjian , w self , e seeley , j weingarten , m williams , c winterbottom , d hansell is an effective method to predict fluid responsiveness (fr) or cardiac response to preload expansion. we have previously shown that fluid responsiveness is a dynamic state, changing frequently over a hour monitoring period. methods: fresh is a currently enrolling prospective randomized controlled study, evaluating the incidence of fr and patient centered outcomes in critically ill patients with sepsis or septic shock (nct ). patients randomized to plr guided resuscitation were evaluated every - hours over the first hours of care and classified as fr if the sv increased > % when measured with non-invasive bioreactance (starling sv, cheetah medical). the time of first fr was noted. results: a total of plr assessments were performed in patients over a hour monitoring period. % were female, and the average age was years. plrs were evaluated over time, with time representing initial fluid resuscitation ( figure ). when individual subjects were evaluated over time, % of subjects who became fr only after hours showed evidence of lv/rv dysfunction ( figure ). conclusions: fluid responsiveness or preload dependence frequently changes for septic shock patients over the first hours of care. evidence suggests it is beneficial to periodically perform an assessment of preload responsiveness to guide fluid administration, as preload dependence is a dynamic and changing state. preload dependence provides additional information beyond fluid responsiveness. those patients who remain primarily fluid non-responsive (preload independent) are more likely to demonstrate echo confirmed lv/rv dysfunction, as the delay in return to cardiac function may be related to underlying cardiac deficits. further evaluation may be indicated in preload independent patients. introduction: hydroxyethyl starch (hes), a synthetic colloid, has been used as a volume expander, and is associated with renal impairment in patients with sepsis. however, a small dose of hes ( %, / . ) has sometimes been used in acute ischemic stroke. therefore, we investigated whether a small dose of hes was linked with renal deterioration in patients with acute ischemic stroke. methods: a consecutive patients with acute ischemic stroke within days from onset were included between january and may (fig ) . we collected admission serum creatinine (scr), estimated glomerular filtration rate (egfr), and renal function was assessed using kdigo definition of acute kidney injury on hospital days to as to patient's hospitalization period. is crucial for venous return and volaemic status, and as such it is a useful parameter in physiology and clinical settings alike. we tested whether: near infra-red spectroscopy (nirs) could be effective at measuring msfp both in healthy individuals and in conditions with a rise in interstitial pressures; after an occlusion pressure is relieved, the decrease in venular blood volume could allow calculation of τ (time constant) and thus venous resistances (rv). in order to verify these hypotheses we used a forearm nirs probe on healthy individuals at rest and during different degrees of maximal voluntary contraction (mvc). methods: healthy subjects volunteered in the study that took place at sant'andrea hospital in rome (italy). all subjects had venular pressures and volumes assessed via a nirs probe positioned on the forearm using a pressure-cuff in steps of mmhg from to mmhg, at rest and at % and % mvc. for each patient msfp, unstressed volume (vu) and stressed volume (vs) were measured. a temporary mmhg occlusion was obtained and volume time course was calculated upon release, to derive τ . results: p-v relationship was found to have a -slopes shape reflecting venular network changes. we measured vu, vs, and obtained msfp values of . ± . mmhg, p< . ; during exercise no changes in vu and vs were noted but msfp values rose; value was found to be . ± . sec at rest and . ± . sec after exercise, reflecting a reduction in rv. conclusions: nirs measurements on healthy subject may have implications in the clinical assessment of critical care patients where changes in interstitial pressure are possible. introduction: in the pathogenesis of multiple organ dysfunction syndrome (mods) important role plays the development of hepatic dysfunction. a known method for assessing hepatic blood flow is reohepatography (rhg). however, it requires the analysis of a large number of parameters of the rheogram curve. the aim of this study was to develop a method for assessing arterial hepatic blood flow based on the rhg in patients with mods after abdominal surgery. methods: patients in the department of anesthesiology and intensive care unit were included in a prospective study ( men and women, age . ± . years, weight . ± . kg.). all patients were divided into two groups: group -patients after orthopedic and trauma surgery (n = ), group -patients after abdominal surgery with mods (n = ). patients in the groups did not have statistical differences by sex, age, body weight, height. rhg was carried out using the "reo-spectr" (russian federation). we have compared the rhg indicators between the groups ( table ) . we have developed a method for assessing hepatic arterial blood flow, which consists in determining the area under the arterial part of rhg curve using the simpson's rule. its normal values range from . mΩ *s to . mΩ *s. the method is non-invasive, can be applied at the patient´s bed. its advantage is simplicity, it can be used for rapid diagnosis and monitoring the effectiveness of treatment. area under the rhg curve in the group were . ± . mΩ *s and . ± . mΩ *s in the group (p < . ). conclusions: patients after abdominal surgery with mods have impaired hepatic blood flow, which may be associated with liver pathology caused by main surgical disease (obstructive jaundice) and hemodynamic disorders caused by acute cardiovascular failure. the method we developed allows us to determine disorders of hepatic arterial blood flow in the early stages before signs of liver dysfunction appear. comparison of pulse oximetry hemoglobin with laboratory measurement of arterial and central- results: patients: % male, median years ( - ); p:f ratio ( - ); peep ( - ); apache iii . ( ); median ventilation time days ( - ). fair agreement was seen in subjective assessment vs objective measures with binary assessment of rv size and function. ordinal data analysis showed poor agreement with rvfws ( figure ) and rv dimensions. if onestep disagreement was allowed the agreement was good ( table , ). significant overestimation of severity of abnormalities was seen comparing subjective assessment with rv eda and tapse, s' and fac. there was no difference in agreement values when accounting for clinician echo experience, perceived expertise (at level of cardiologist) or type of qualifications. conclusions: relatively low levels of agreement were seen with subjective assessment vs objective measures of rv size and function assessed by echo. it seems prudent to avoid subjective rv assessment in isolation and a combination of objective and subjective measures should be used. introduction: even short periods of hypotension are associated with increased morbidity and mortality. using high-density numerical physiologic data, we developed a machine learning (ml) model to predict hypotension episodes, and further characterized risk trajectories leading to hypotension. methods: a subset of subjects with / hz physiological data was extracted from mimic , a richly annotated multigranular database. hypotension was defined as > measurements of systolic blood pressure ≤ mmhg and mean arterial pressure ≤ mmhg, within a -minute window. derived features using raw measurements of heart rate, respiratory rate, oxygen saturation, and blood pressure were computed. random forest (rf), k-nearest neighbors (knn), and logistic regression models were trained with -fold cross validation to predict instantaneous risk of hypotension using features extracted from the data leading to the first episode of hypotension (cases) or icu discharge in subjects never experiencing hypotension (controls). for a given subject, risk trajectory was computed from the collation of instantaneous risks. results: from a source population of subjects, subjects met our definition of hypotension, and subjects without hypotension comprised the control group. features were generated from the four vital signs. the area under the curve (auc) for random forest classifier was . , out-performing logistic regression (auc . ) or k-nearest neighbors (auc . ) (fig ) . risk trajectories analysis showed average controls risk scores < . (< % risk of future hypotension), while the hypotension group had a rising risk score ( . to . ) in the hours leading to the first hypotension episode, and significantly higher scores leading into subsequent episodes (fig ) . conclusions: hypotension episodes can be predicted from vital sign time series using supervised ml. subjects developed hypotension have an increased risk compared to controls at least hours prior to the episode. introduction: in critically ill patients or in patients undergoing major surgery, monitoring of co is recommended [ ] [ ] [ ] . less-invasive advanced hemodynamic monitoring with pwa is increasingly used in perioperative and critical care medicine. in this study, we evaluate the measurement performance of an uncalibrated pulse wave analysis (pwa) device (mostcareup, vygon, ecouen, france) compared with cardiac output (co) assessment by pulmonary artery thermodilution (patd) in patients after cardiac surgery. methods: in patients after cardiac surgery, we performed seven sets of patd measurements to assess patd-co. simultaneously, we recorded the pwa-co and compared it to the corresponding patd-co. to describe the agreement between pwa-co and patd-co we used bland-altman analysis showing the mean of the differences and %-limits of agreement and calculated the percentage error. results: we included patients in the analysis. the bias between pwa-co and patd-co was . l*min- . upper and lower % limits of agreement were + . l*min- and - . l*min- . the percentage error was . %. conclusions: pwa-co estimated with using the mostcareup device shows good agreement with pulmonary artery thermodilutionderived co in patients after cardiac surgery. introduction: non-invasive continuous blood pressure monitoring devices have been investigated, however, these devices did not have sufficient accuracy and precision. we developed a continuous monitor using the photoplethysmographic technique and tested the accuracy and precision of this system to ensure it was comparable to conventional continuous monitoring methods used for critically ill patients. methods: the study device was developed to measure blood pressure, pulse rate, respiratory rate, and oxygen saturation, continuously with a single sensor using the photoplethysmographic technique. patients who were monitored with arterial pressure lines in the icu were enrolled. the physiological parameters were measured continuously for minutes at -minute intervals using the study device and the conventional methods. the primary outcome variable was blood pressure. results: pearson fs correlation coefficient between the conventional method and photoplethysmography device were . for systolic blood pressure, . for diastolic blood pressure, . for mean blood pressure, . for pulse rate, . for respiratory rate, and . for oxygen saturation. percent errors for systolic, diastolic and mean blood pressures were . % and . % and . %, respectively. percent errors for pulse rate, respiratory rate and oxygen saturation were . %, . % and . %, respectively. conclusions: the non-invasive, continuous, multi-parameter monitoring device presented high level of agreement with the invasive arterial blood pressure monitoring, along with sufficient accuracy and precision in the measurements of pulse rate, respiratory rate, and oxygen saturation. conclusions: stroke volume measurement using bioreactance technique had strong correlation with odm while pwtt had moderate correlation. both devices had small bias with wide limits of agreement and percentage error compared with odm. therefore, these devices are not interchangeable with odm. however, using trends in stroke volume to guide treatment might still be acceptable. introduction: hemorrhage is the most common cause of trauma deaths and the most frequent complication of major surgery. it is difficult to identify until profound blood loss has already occurred. we aim at detecting hemorrhage early and reliably using waveform vital sign data routinely collected before, during, and after surgery. methods: we use waveform vital sign data collected at hz during a controlled transition from a stable (non-bleeding) to a fixed bleeding state of pigs. these vital signs include airway, arterial, central venous and pulmonary arterial pressures, venous oxygen saturation (svo ), pulse oximetry pleth and ecg heartrate, continuous co, and stroke volume variation (lidco). we used gated recurrent units (gru), long short-term memory (lstm) and dilated, causal, one-dimensional convolutional neural (table ) . however, outside of the very low fpr range (cf. rocs in fig. and ), our models appear inferior to a referenced random forest (rf) classifier. conclusions: our work demonstrates the applicability of deep learning models to diagnose hemorrhage based on raw, waveform vital signs. future work will address why the rf classifier can address the greater homogeneity of subjects when they bleed compared to an apparently wide dispersion of their statuses when being stable. this work is partially supported by nih gm . can myocardial perfusion imaging with echo contrast help recognise type acute myocardial infarction in the critically ill? introduction: many instances of significant bleeding may not occur in highly monitored environment, contribution in the delay in recognition and intervention. we therefore proposed a noninvasive monitoring for early bleeding detection using photoplethysmography (ppg). methods: fifty-two yorkshire pigs were anesthetized, stabilized and bled to hemorrhagic shock, and their invasive arterial blood pressure (abp), and ppg data were collected [ ] . time series of vital signs were divided into data frames of minute updated every seconds and beat to beat features were computed. the final feature matrix contained abp features and ppg features. a supervised machine-learning framework using least absolute shrinkage and selection operator regularized logistic regression model was constructed to score the probabilities for hemorrhage of each data frame. data in stabilization was set as negative and data in bleeding was set as positive. model performance was evaluated by receiver operating characteristic (roc) area under the curve (auc) with leave-one-out cross validation, and its precision was assessed with activity monitoring operative characteristic (amoc). results: two different models were proposed using abp and ppg features separately. figure showed the ppg model could classify the hemorrhage with auc = . , where the auc of abp model was . . figure showed the ppg model could detect the hemorrhage on average . minutes (equals to ml blood loss) if the false alarm rate of / was tolerated, whereas the average detection time of abp model were . minutes at same threshold of false alarm rate. conclusions: we proposed a novel non-invasive bleeding detection approach using ppg signals only. this method potentially can improve the identification of hemorrhage with in patients and environments where invasive monitoring is unavailable. table , catheter and procedure characteristics are shown in table . the median angle of bed position was °. no patients were positioned in neutral or tp. all procedures were successful with a mean of . punctures per patient, and a maximum of . the median procedure time was . minutes. no major complications occurred in any of our patients. conclusions: central venous catheterisation in moderate upright position is feasible and can be done safely when using realtime ultrasound by well-trained physicians. we recommend performing clinical assessment and pre-procedural ultrasound to choose the optimal puncture site and position in order to attain an optimal ultrasound visualisation of the vessel and patient comfort. methods: a retrospective analysis of patients presenting to tertiary-care emergency department who required cvc for vasopressor administration was carried out. all central venous cannulation into the right brachiocephalic vein was performed with ultrasound guidance using the high frequency linear probe. right brachiocephalic vein was visualised in its long axis. the needle was positioned just beside the centre of ultrasound probe degrees below the coronal plane and degrees angle to the ultrasound probe and advanced just behind the clavicle. results: the mean puncture time taken to perform this procedure, calculated from the needle piercing the skin until to the aspiration of blood from the brachiocephalic vein through the needle, was ± . s. no procedure-related complications were detected. conclusions: the oblique needle trajectory of right brachiocephalic vein cvc in adult is feasible and able to visualised well the anatomical structure, hence avoid complications. introduction: central venous cannulation, a routine procedure on intensive care units, is associated with a low complication rate. as a consequence, the routine use of chest x-ray (cxr) or ultrasound (us) to assess these complications is under discussion. our aim was to identify risk factors for central venous catheter (cvc) placement associated complications that can help decide whether or not follow-up using cxr and/or us is indicated. methods: multicenter prospective, observational study. consecutive critically ill adult patients who underwent cvc placement. either the internal jugular vein or subclavian vein was cannulated. complication rates were determined. predicting factors were obtained through a questionnaire filled in by physicians after placing a cvc. if the questionnaire was incomplete or data was missing, analyses were performed using the available data. patient characteristics were duplicated if a patient recieved more than one cvc. outcomes were iatrogenic pneumothorax and malposition. pneumothorax was detected using us, whereas cxr was used to determine cvc malposition. table . usguidance, insertion site, and setting were predictive for complications. the overall cvc placement associated complication rate is low and multiple risk factors associated with the occurrence complications were identified. a complication rate this low, strongly suggests that routine post-procedural diagnostics is superfluous. therefore, we suggest, provided that uneventful execution of the procedure is assured, post-procedural diagnostics are only necessary in selected cases with (multiple) risk factors. introduction: the use of ultrasound for subclavian vein cannulation (scv) has developed poorly due to the difficulty of visualizing this vein via the classical infraclavicular approach. we explored the feasibility of ultrasound-guided subclavian vein catheterization via a supraclavicular approach methods: prospective study conducted over six-month period in intensive care unit. after approval of the ethics committee, we included patients over years of age and requiring central venous access. exclusion criteria were: hemostasis disorders, puncture area infections and cervico-thoracic vascular malformations the procedure consisted of catheterization of the vsc with a supraclavicular approach under ultrasound guidance using an ultrasound in plane approach (fig and ). data collection included clinical and ultrasound data: scv depth, diameter and length, catheterization time, number of needle redirection, cannulation success and complications. results: thirty four patients were included. age: ± (mean ± sd), % of whom were male. the success rate of scv catheterization was % (one failure). the depth of the scv was ± . mm and its diameter was ± . mm. the puncturable length of the scv was ± mm and the puncture angle was ± °. the time required to obtain an adequate ultrasound image was ± seconds. the interval between the beginning of the puncture and the insertion of the guidewire into the vein was ± sec. the total catheterization time was ± seconds. the number of needle redirection . +/- . redirects. the quality of the ultrasound image was excellent or good in . % of cases. an arterial puncture was observed in two patients conclusions: this preliminary study demonstrated the feasibility of the subclavian vein cannulation via the supraclavicular approach. more study are required to confirm its safety and to compare this approach to the infraclavicular acces using ultrasound. introduction: lung ultrasound b-lines, a comet-like reverberation artefacts arising from water-thickened interlobular septa, indicate extravascular lung water which is a key variable in heart failure management and prognosis. aim of this study is to measure the correlation between lung ultrasound b-lines and nyha functional classification. methods: this is a months prospective study on congestive heart failure patients conducted in urban emergency departments in malaysia. following enrolment, patients had their functional capacity categorised based on nyha classification, followed by point of care ultrasound (pocus) lung scan using a mhz linear probe. the scanning was performed by trained emergency physicians. the longitudinal scan done at the recommended zones of both left and right lungs and the total number of b-lines identified were summed up as the comet score. comet score of , , and were categorised based on amount of blines of less than , - , - and more than b-lines respectively. results: hundred and twenty-two patients were analysed ( males( . %) and females( . %)) ranging from to years old. comet score of , and were found to be statistically significant with presence of paroxysmal nocturnal dyspnoea, elevated jugular venous pressure, lung crackles, bilateral pitting oedema and chest radiographic findings. a moderate correlation between nyha classes with comet score , and (rs= . (p< . )) was documented. conclusions: our study demonstrated a moderate correlation between nyha classes and lung ultrasound b-lines. lung ultrasound may be a potential tool to objectively determine the functional capacity in patients with congestive heart failure and monitor its changes in response to treatment and disease progression. the introduction: point of care ultrasound (pocus) is a tool of increasing utility in the management of the critically ill patient. guidelines exist for training and accreditation in pocus [ , ] however the widespread use of pocus has been hampered by a lack of mentors. online communication with end-to-end security, such as whatsapp ™ are increasingly used in medicine as a communication aid [ ] . some individuals are using such communications to share pocus images for review-the overall sentiment around these tools is unknown. methods: an online survey of pocus users was conducted via twitter ™. the question was "in situations where an expert opinion on an ultrasound is not immediately available, is it acceptable to get an expert review via an online medium such as whatsapp, and would you be happy to be that expert?" results: votes were received. voters were a mix of pocus users from the usa, europe, and australia. % said the medium was acceptable, and that they would be happy to provide expertise. % voted "no", with % voting "other" (fig ) . conclusions: in this international survey of pocus users, % were happy to provide and receive mentorship using remote software such as whatsapp. distance mentorship for pocus training should be explored. [ ] . a description of the development and refinement of insight -a feasibility and clinical effectiveness randomized controlled trial. methods: a modified delphi exercise was used to select the most beneficial ultrasound windows and imaging questions to ask for each window in scheduled inter-professional ultrasound. nurses, doctors and physiotherapists from critical care were given the same information regarding potential utility of each window. the windows and associated questions were individually ranked; each window and question tested against three further criteria; and filtered by ease of training to level standard; clinical usefulness; time of practical delivery and applicability across an inter-professional group. results: the modified delphi exercises and prioritization exercise ranked ease of adoption by training; feasibility within the time frame and clinical usefulness to develop a core insight scan of domains, each with set binary questions (tables and ) conclusions: we have developed a research intervention that will allow us to test the effectiveness of inter-professional scheduled whole body assessment of critically ill patients by ultrasound. we now plan to conduct a clinical effectiveness trial with an internal pilot to confirm feasibility. to search for optimal pressing time, the plots from the color sensor during nail bed compression were analyzed. we found two phases in the color sensor plots. in the initial part of compression, the plots changes rapidly (rapid phase) and then the slope of plots reduces (slow phase). the pressure release during the rapid phase could destabilize the measurement. the longest period of the rapid phase was . s among all the study subjects. thus, a pressing time of s seems to be needed to obtain stable crt measurements. conclusions: on our study for the investigation of standard pressing time and strength for crt measurements, pressing the nail bed with - n and s appears to be optimal. detection of pancreas ischemia with microdialysis and co sensors in a porcine model introduction: pancreas transplantation is associated with a high rate of early graft thrombosis. current postoperative monitoring lack tools for early detection of ischemia, which could precipitate a graft-saving intervention. we are currently exploring the possibility of ischemia detection with microdialysis and co -sensors in the organ tissue or on the surface in a porcine model. methods: in anesthetized pigs, co -sensors and microdialysis catheters are inserted into the parenchyma or attached to the surface of the pancreas. pco is measured continuously and lactate is sampled with microdialysis every min. ischemia is induced by sequential arterial and venous occlusions for minutes, with minutes of reperfusion in between. results: pco increased and decreased in response to ischemia and reperfusion within minutes. lactate increased and decreased with the same pattern, but with a considerable delay as compared to pco . an example is depicted in figure . the values are presented in introduction: reliable automated handheld vital microscopy (hvm) image sequence analysis is a prerequisite for use of sublingual microcirculation measurements at the point-of care according to the current consensus statement. we aim to validate a recently developed advanced computer vision algorithm [ ] versus manual analysis in a wide spectrum of populations and contexts. methods: our collaborators were invited to contribute raw data of published or ongoing institutional review board approved work. inclusion criteria were use of the cytocam hvm device, manual analysis with the ava software, and image quality as independently assessed by massey score of < in > % of recordings in a random subset of each study. subjects from studies were included, covering clinical and experimental populations, major shock forms and interventions to recruit the microcirculation (table ) . results: , , red blood cells were tracked by the algorithm across , frames in measurements in real time. a good to excellent correlation was found between algorithm-determined and manual capillary density (p< . , r . - . , figure ). capillary perfusion was classified using space-time diagram derived red blood cell velocity (rbcv), yielding good correlation with manual analysis for functional capillary density und proportion of perfused vessels. microcirculatory alterations during disease and interventions were equally detected by the algorithm and manual analysis. change in flow short of severe abnormality was reflected in absolute rbcv but not microcirculatory flow index. conclusions: we demonstrate the validity of automated software for hvm image sequence analysis across broad populations, disease conditions and interventions. thus, microcirculatory assessment at the bedside may finally complement point-of-care evaluation of disease severity and treatment response in critically ill patients and during surgery. introduction: in , naumann et al introduced the poem score as a real-time, point-of-care score to assess sublingual microcirculation [ ] . our study aimed to determine the reproducibility of the poem score. methods: two expert operators used a sidestream darkfield (sdf) videomicroscope (cytocam, braedius, netherlands) to separately acquire four high-quality video clips and assign a poem score to each image in adult mechanically ventilated patients. each operator was blinded to the other's images and analysis. video clip scores and acquisition times were recorded. results: of the patients enrolled in this study, % (n= ) required vasopressors. we categorized poem scores - as "normal" and poem scores - as "impaired." (fig ) . with only one instance of interrater disagreement (i.e., a single image scored as versus ), cohen's kappa ( . ) confirmed a strong correlation between interpreters. the mean time to complete a study session was minutes. conclusions: the present inability to quickly characterize the quality of sublingual microcirculation as either normal or impaired at the point of care limits real-world clinical application of this resuscitative endpoint. the rapidly obtained poem score appears to be reproducible between bedside interpreters. future studies should assess the effect of poem score-guided resuscitation. . sublingual microcirculatory images were obtained using a cytocam-idf device (braedius medical, huizen, the netherlands) and analyzed using standardized published recommendations. results: the median age of participants was years. we found no significant difference in proportions of hemodynamic responders before and after marathon ( % vs %, p= . ). also we did not find differences between plr induced changes of total vessel density (tvd) and proportion of perfused vessels (ppv) of small vessels before and after marathon. correlations between changes of sroke volume and changes of tvd or ppv of small vessels during plr were not significant. conclusions: marathon running did not change microcirculatory responsiveness. introduction: clinical measurement of mitochondrial oxygen tension (mitopo ) has become available with the comet system [ ] . a question with any novel technique is whether it is feasible to use in clinical practice and provides additional information. in elective cardiac surgery patients we measured cutaneous mitopo and tissue oxygenation (sto ). methods: institutional research board approved observational study in patients undergoing cardiopulmonary bypass (cpb). mitopo measurements were performed on the left upper arm (comet, photonics healthcare b.v.) by oxygen-dependent delayed fluorescence of aminolevulinic acid (ala)-induced protoporphyrin ix [ ] . priming of the skin was done with ala (alacare, photonamic gmbh) applied the evening before surgery. sto measurements (invos, medtronic) were done in close proximity to the comet sensor. results: at the time of writing of patients were enrolled and mitopo measurements were feasible in this clinical setting. mitopo appeared sensitive with a high dynamic range. for example, highdose vasopressor therapy decreased mitopo and blood transfusion increased a low mitopo but not a high mitopo . in the example in figure , mitopo is clearly dependent on cpb flow and the restored cardiac circulation is able to maintain good cutaneous oxygenation after cpb even before returning of cellsaver blood. sto had the tendency to provide relatively stable values within a small bandwidth and little response to even major hemodynamic changes. conclusions: mitopo shows the effect of interventions on mitochondrial oxygenation and provides additional information compared to standard monitoring and sto . introduction: traumatic asphyxia is a rare condition in which breathing and venous return is impaired due to a strong compression to the upper abdomen or chest region, and induces swelling, purplish red appearance, and petechiae around the face and neck. to our knowledge, there are no reports describing details of traumatic asphyxia including the clinical course and the therapeutic reactivity from cardiac arrest. we focused on cardiac arrest among all traumatic asphyxia patients treated at our hospital, and investigated their clinical features and therapeutic reactivity. methods: sixteen cases of traumatic asphyxia involved with our hospital between april and march were reviewed by using the pre-hospital activity record, medical record, and hyogo prefectural inspection record. these patients were divided into three groups. the first group had already cardiac arrest at the time of rescue from the trapped place (group a; cases). the second group became cardiac arrest after the rescue (group b; cases). the third group did not experience cardiac arrest (group c; cases). results: all cases had abnormal findings in skin or conjunctiva (table ) . total mortality rate reached %, but among cases of group a and b who resulted in cardiac arrest, there were cases with injury severity score or more and abbreviated injury scale in the chest or more. they had pneumothorax, flail chest, pericardial hematoma. seven of them restored spontaneous circulation, and two cases achieved neurologically full recovery. conclusions: there are some cases of traumatic asphyxia whose therapeutic reactivity is very good even after cardiac arrest, so it is important not to spare efforts for life support in such cases. rhythm and % witnessed arrest, five hundred ten ( %) patients had a good functional outcome at -months. physiological derangements were each negatively associated with outcome in bivariate analysis at the p < . level. a summary score of physiological derangements was included with potential confounders in the final regression model, and was independently associated with outcome with the chance of a good outcome decreasing by % for each increase of one physiologic derangement ( % ci . - . ). conclusions: uncorrected physiological derangements are independently and cumulatively associated with worse outcome after cardiac arrest. although causality cannot be established, it is reasonable to consider that the correction of physiological parameters may be an important step in the chain of survival after resuscitation. characteristics introduction: glan clwyd hospital (gch) was recently designated one of three cardiac arrest centres for wales. it has offered a / percutaneous coronary angiography (pci) service to a geographically dispersed north wales population of approximately , since june . prior to this, urgent coronary angiography was available on a more limited basis to patients requiring pci. the aim of this study was to investigate factors associated with hospital mortality after critical care admission following cardiac arrest. methods: retrospective review of the ward watcher critical care database at gch to identify patients who had undergone cpr in the hours prior to critical care admission in - . patients likely to have sustained ooha of cardiac aetiology (ooha-c) were identified from primary and secondary diagnoses and free text entry. data were subsequently analysed using excel and spss. the project was registered as a service evaluation with gch audit department. results: there were cardiac arrest admissions over this period, increasing from in - to in - . of these were ooha, of which were considered ooha-c. although ooha-c hospital mortality appeared to decrease over the time period ( %% to %), this was not statistically significant (p= . ). factors associated with survival to hospital discharge are presented in the tables below. on logistic regression, only pci and low ph within the first hours of critical care remained statistically significant (p= . and p< . respectively). conclusions: although we have been unable to make a distinction between patients presenting following stemi and nstemi, and appreciating a potential influence of selection bias, the significant association between pci and survival to hospital discharge supports the introduction of clinical pathways enabling pci access following ooha-c [ ] . chest radiography. [ ] here, we aimed to derive and validate rules to estimate p_max.lv using anteroposterior chest radiography (ches-t_ap), which is performed for critically-ill patients urgently needing determination of personalised p_max.lv. methods: a retrospective, cross-sectional study was performed with non-cardiac arrest adults who underwent chest_ap and computed tomography (ct) within h (derivation:validation= : ). on chest_ap, we defined cd (cardiac diameter), rb (distance from right cardiac border to midline) and ch (cardiac height, from carina to uppermost point of left hemi-diaphragm) (fig , ) . [ ] setting p_zero ( , ) at the midpoint of xiphisternal joint and designating leftward and upward directions as positive on x and y axes, we located p_max.lv (x_max.lv, y_max.lv). the coefficients of the following mathematically-inferred rules were sought: x_max.lv=a *cd-rb; y_max.lv=ß *ch+γ . (a : mean of (x_max.lv+rb)/cd; ß , γ : representative coefficient and constant of linear regression model, respectively ) . conclusions: evaluable echocardiographic records were reached in most of the patients. etco positively correlated with all parameters under consideration, while the strongest correlation was found between cimax and etco . therefore, cimax is a candidate parameter for real-time monitoring of haemodynamic efficacy of chest compressions during cpr. introduction: the uk resuscitation council has set out guidelines for management of patients post cardiac arrest [ ] . this is in line with european resuscitation council guideline. we set out to find if we are following the guideline. methods: we did a retrospective audit over the course of years looking at the data of patients who had in hospital and/or out of hospital cardiac arrest and after the return of spontaneous circulation were admitted to the intensive care unit (icu). we focused on whether the care they received was as per the standards set by the uk resuscitation council. results: we had in the hospital and out of hospital cardiac arrests; patients had less than minutes of cpr, had more than minutes cpr and patients the data was not recorded; patients needed more than minutes to reach from the site of arrest to the icu. the partial pressure of carbon dioxide was > . kpa in patients at two or more occasions. target map was not documented in patients; blood sugar target was not documented in patients and was not maintained within limits in patients. target temperature was not documented in patients. the withdrawal of treatment was not delayed for hours in patient out of . in patients neurological tests were not documented. multimodal assessment tools were not used in patient. electroencephalography and serum neuron specific enolase were not used to diagnose brain deaths as they were not available at our trust. patients were discharged, died in the icu and died in hospital after discharge from icu. conclusions: the audit reflected our local practice and showed that our mortality was in line with the acceptable limits; poor documentation of plan of care which posed problems in analyzing the care that these patients received; some of the parameters were not being maintained as set by uk resuscitation guideline. introduction: high-quality chest compressions (cc) with minimized interruptions are one of the most essential prerequisites for an optimal outcome of resuscitation. therapy of reversible causes of cardiac arrest often requires intra-hospital transportation (iht) during ongoing cpr. the present study investigated cc quality during transportation depending on the position of the provider. methods: paramedics were enrolled into a manikin study with four groups: a reference group with the provider kneeling beside manikin on the floor (group ), and groups performing cc during a simulated iht of meters: walking next to the bed (group ), kneeling beside the patient in bed (group , fig. ) or squatting above the patient in bed (group , figure ). indicators of cc quality were measured as defined in the erc guidelines (pressure point and depth, compression frequency, complete relief, sufficient pressure depth) [ ] . all paramedics performed cc during each scenario (group - ). results: there were no statistical differences in quality of cc between groups , and . notably, group performed significantly worse in respect to the proportion of cc with correct pressure point (p = . vs group ), correct cc depth (p= . vs. group , p= . vs. group , p= . vs. group ). the results are shown in table . conclusions: carrying out guideline-compliant cc [ ] during iht is feasible with multiple provider positions. based on the present results, kneeling or squatting position next to the patient ( figure and ) is recommended, whereas "walking next to the bed" while performing cc should be avoided. methods: a retrospective review of clinical notes was undertaken for patients admitted to icu following return of spontaneous circulation but whom remained comatose. this audit encompassed three-month periods before and after introduction of the care bundle in october . audit standards were assigned from target parameters documented in the bundle and reflected guidance from the cheshire and merseyside critical care network. results: patients were included in our audit; admitted prior to and admitted following implementation of the care bundle. in patients whom targeted temperature management was indicated, improved adherence to thermoregulation between - °c was observed ( vs %). significant improvements were since in the observance to target values for oxygen saturation ( vs . %, p= . ) and mean arterial pressure ( vs . %, p< . ) following the introduction of the care bundle. improved observance of ventilation targets was also seen; maintenance of p a co > . kpa ( vs %, p= . ) and tidal volumes < ml/kg ideal body weight ( to . %, p= . ). conclusions: the introduction of a post-cardiac arrest care bundle in our icu has improved care by providing discrete physiological targets to guide nursing staff and standardising management between clinicians. variations in care are associated with poorer patient outcomes [ ] and introduction of this bundle has reduced disparities in practice. array of cardiac diseases and reported survival rate is low in spite of advances in resuscitation and ems services. methods: single-centre retrospective study analyzed outcomes of ohca patients admitted to cardiac icu between .- . we studied demographic data, initial rhythm, type of cpr, comorbidities and various post admission diagnostic findings in order to identify their impact on survival. results: ohca comprised , % of all admissions. mean los was . days ( - ). mean age was , y ( - ), m: f ratio : and bystander cpr was performed in only % ohca patients. the most common initial rhythm was vf ( . %), followed by vt ( . %), pea was found in , % and asystole in . % of pt more than half of pt received adrenalin ( %) and defibrillation ( %) and only % required a temporary pacemaker. % of pt had an ecg consistent with mi after rosc, % underwent coronary angiography resulting in pci in % of cases. in pt ( %) therapeutic hypothermia protocol was performed. most ohca pt had hypertension ( %) and hyperlipidaemia ( %) as the most common risk factors followed by cardiomyopathy ( %), diabetes ( %) and cad ( %). only % had a preexisting significant valvular disease and the rest were extracardial comorbidities: chronic renal disease ( %), copd ( %) and cerebrovascular disease ( %). patients survived ( %) and gcs on admission was the only significant impact factor on survival along with comorbidities (mean gsc was in survivors vs. in deceased). interestingly, age, initial rhythm, troponin i level, ph and therapeutic hypothermia had no impact on survival. conclusions: our data demonstrate the importance of early onsite resuscitation as the most important factor of neuroprotection and outcome and puts an emphasis on the importance of cpr education for layman population. prediction of acute coronary ischaemia and angiographic findings in patients with out-of-hospital cardiac arrest j higny , a guédès , c hanet , v dangoisse , l gabriel , j jamart introduction: coronary artery disease (cad) is the leading cause of out-of-hospital cardiac arrest (ohca). however, diagnosis of acute coronary ischaemia (aci) remains challenging, particularly in patients without st-segment elevation on the post-resuscitation ecg. in this regard, a consensus statement recommends the implementation of a work-up strategy in the emergency room (er) to exclude noncoronary causes of collapse within hours. methods: retrospective single-centre study performed on consecutive patients with resuscitated ohca who underwent a diagnostic coronary angiography (ca). we present data on coronary angiograms for patients who underwent cardiac catheterization after resuscitation. afterwards, we sought to identify parameters associated with aci. results: st-segment elevation was noted in patients ( %). stsegment depression or t-wave abnormalities were noted in patients ( %). invasive coronary strategy allowed to identify an acute culprit lesion in cases ( %). patients with st-segment elevation underwent an immediate angioplasty for an acute coronary occlusion. patients without st-segment elevation underwent an ad hoc percutaneous coronary intervention for a critical lesion. stable cad was found in cases ( %) and a normal angiogram was found in only cases ( %) (figure ). conclusions: aci was the leading precipitant of collapse. stsegment elevation was highly predictive of coronary occlusion. in addition, a culprit coronary lesion was identified in nearly % of patients undergoing ca despite the lack of stsegment elevation. finally, our findings suggest that the identification of risk criteria may help to improve the recognition of aci after ohca. the prediction of outcome for in-hospital cardiac arrest (pihca) score e piscator , k göransson , s forsberg , m bottai , m ebell , j herlitz , t djärv figure. predictive value for classification into < % likelihood of favorable neurologic survival was . %. false classification into < % likelihood of favorable neurologic survival was . %. the phica score has potential to be used as an aid for objective prearrest assessment of the chance of favorable neurologic survival after ihca, as part of decision making for a dnar order. introduction: prognosis of survival in patients with cardiac arrest remains poor. during and after cardiopulmonary resuscitation, pathophysiological disturbances in relation with a cytokine storm, are described as "post-resuscitation" disease like a combination of cardiogenic and vasodilatory shocks. veno-arterial extracorporeal membrane oxygenation (va ecmo) allows to restore adequate perfusion but little is known about its effect on left ventricular (lv) function and about the role of cytokines. methods: this study was performed in an experimental model of cardiac arrest performed in groups of anesthetized and mechanically ventilated pigs. cardiac arrest was obtained by application of electrical current to epicardium inducing ventricular fibrillation. after a no-flow period of minutes, medical resuscitation with catecholamines and vasopressors was performed in "control" group while va ecmo was started in "ecmo" group and va ecmo in combination with cytosorb (extracorporeal blood purification therapy designed to reduce excessive levels of inflammatory mediators such as cytokines) was started in "ecmo-cyto" group. lv function was assessed with transthoracic echocardiography and arterial pressure with aortic pressure catheter. results: hemodynamic stability was obtained after ± and ± minutes in ecmo and ecmo-cyto groups, respectively. no return of spontaneous circulation was observed in control group. at minutes following cardiac arrest, lv area fractional change on short axis was normalized in ecmo and ecmo-cyto groups ( ± and ± %, respectively). vasopressor requirements were significantly lower in ecmo-cyto group than in ecmo group. conclusions: after cardiac arrest (no-flow) of minutes duration, va ecmo allowed complete lv recovery and hemodynamic stability within minutes of "post-resuscitation" disease. cytosorb added to va ecmo could contribute to reduce post-resuscitation vasodilatation. impact of rapid response car system on ecmo in out-of-hospital cardiac arrest: a retrospective cohort study m nasu , r sato , k takahashi introduction: extracorporeal life support (ecls) has been reported to be more effective than conventional cardio-pulmonary resuscitation (cpr). in ecls, a shorter time from arrival to implantation of extracorporeal membrane oxygenation (ecmo; door-to-ecmo) time has been reported to be associated with better survival rates. this study aimed to examine the impact of the physician-based emergency medical services (p-ems) using a rapid response car (rrc) on door-to-ecmo time in patients with out-of-hospital cardiac arrest (ohca to study the interest and the educational contribution in the short and medium term of medical simulation compared to a classical training. methods: cohort, prospective, observational, single-center, randomized study with control group including residents ( in anesthesia resuscitation and in emergency medicine). all benefited from a theoretical training with a reminder of the latest recommendations on the management of cardiac arrest and anaphylactic shock. they were randomized into groups and received practical training on a high-fidelity simulator for the management of either cardiac arrest (acc group) or anaphylactic shock (ca group). each group was evaluated at weeks (t ) and at months on two scenarios: refractory ventricular fibrillation (fv) scored on points and grade anaphylactic reaction (ra ) scored on points. each group served as the control group for the pathology in which they did not receive specific simulator training. the results are expressed on average with their standard deviations with "p" < . . introduction: simulation is a tool for improving the quality and safety of care, and its recognized as an essential method of evidence-based education. emergency medicine is a discipline in which there is a constant concern for the safety of patients. the emergency physician is often called upon to take charge of critical situations that use knowledge, know-how and knowledge as skills that must be mastered and whose theoretical learning alone is insufficient. methods: it´s a prospective study including residents in emergency medicine performing their specialty courses in emergency services and emergency medical assistance in the region of sousse from january to june . they were randomized into two groups: the one benefiting from a traditional education and the other from an education based on simulation sessions. the chosen scenario was the management of a cardiac arrest. a pre-test and a post-test were performed in both groups. results: we included emergency residents who did not receive specialized training in the management of cardiac arrest, there was a female predominance with an average age of , there was no significant difference regarding the pretest between the two groups with . there was no significant difference with respect to the pre-test score between the two groups . ± . / for the control group versus . ± . / for the simulation group. there was a significant progression after the course with an average posttest score of . ± . in the simulation group while this score was . ± . in the control group with a statistically significant difference (p < . ). conclusions: simulation learning has led to a better acquisition of cognitive knowledge by learners. the simulation is not intended to replace bed-based teaching, nor theoretical or faculty teaching, but it is an essential complement . in tunisia, the simulation must continue its current integration in the initial and continuous training of doctors. introduction: recent studies have shown that obesity and its related metabolic dysfunction exacerbates outcomes of ischemic brain injuries in some brain areas, such as the hippocampus and cerebral cortex when subjected to transient global cerebral ischemia (tgci). however, the impact of obesity in the striatum after tgci has not yet been addressed. the objective of this study was to investigate the effects of obesity on tgci-induced neuronal damage and inflammation in the striatum and to examine the role of mtor which is involved in the pathogenesis of metabolic and neurological diseases. methods: gerbils were fed with a normal diet (nd) or high-fat diet (hfd) for weeks and then subjected to min of tgci. hfd-fed gerbils showed the significant increase in body weight, blood glucose level, serum triglycerides, total cholesterol, and low-density lipoprotein cholesterol without affecting food intake. results: in hfd-fed gerbils, neuronal loss occurred in the dorsolateral striatum days after tgci and increased neuronal loss were observed cholesterol days after tgci; however, no neuronal loss was the in ndfed gerbils after tgci, as assessed by neuronal nuclear antigen immunohistochemistry and fluoro-jade b histofluorescence staining. the hfd-fed gerbils also showed severe activated microglia and further increased immunoreactivities and protein levels of tumor necrosis factor-alpha, interukin- beta, mammalian target of rapamycin (mtor) and phosphorylated-mtor in the striatum during pre-and postischemic conditions compared with the nd-fed gerbils. in addition, we found that treatment with rapamycin, a mtor inhibitor, in the hfd-fed gerbils significantly attenuated hfd-induced striatal neuronal death without changing physiological parameters. conclusions: these findings reveal that chronic hfd-induced obesity results in severe neuroinflammation and significant increase of mtor activation, which could contribute to neuronal death in the stratum following tgci. abnormal mtor activation might play a key role. associations between partial pressure of oxygen and neurological outcome in out-of-hospital cardiac arrest patients introduction: exposure to hyperoxemia and hypoxemia is common in out-of-hospital cardiac arrest (ohca) patients following return of spontaneous circulation (rosc) but its effects on neurological outcome are uncertain and study results are inconsistent. methods: exploratory post-hoc substudy of the target temperature management (ttm) trial [ ] , including patients after ohca with rosc. the association between serial arterial partial pressures of oxygen (pao ) during hours following rosc and neurological outcome at months, evaluated by cerebral performance category (cpc), dichotomized to good (cpc - ) and poor (cpc - ), was investigated. in our analyses, we tested the association of hyperoxemia pao > kpa and hypoxemia pao < kpa, time weighted mean pao , (twm-pao ) (fig ) , maximum pao difference (Δ pao ) and gradually increasing pao levels ( . - . kpa) with poor neurological outcome. a subsequent analysis investigated the association between pao and a biomarker of brain injury, peak serum tau levels. results: patients were eligible for analysis. patients ( %) were exposed to hyperoxemia or hypoxemia after rosc (table ) . our analyses did not reveal a significant association between hyperoxemia, hypoxemia, twm-pao exposure or Δ pao and poor neurological outcome at -month follow-up after correction for co-variates (all analyses p= . - . ) (fig ) . we were not able to define a pao level associated with the onset of poor neurological outcome. peak serum tau levels at either or hours after rosc were not associated with pao . conclusions: hyperoxemia or hypoxemia exposure occurred in one third of the patients during the first hours of hospitalization and was not significantly associated with poor neurological outcome after months or with the peak s-tau levels at either or hours after rosc. introduction: cerebral hypoperfusion may aggravate the developing neurological damage after cardiac arrest. near-infrared spectroscopy (nirs) provides information on cerebral oxygenation but its clinical relevance during post-resuscitation care is undefined. we wanted to assess the possible association between cerebral oxygenation and clinical outcome after out-of-hospital cardiac arrest (ohca). methods: we performed a post hoc analysis of a randomised clinical trial (comacare) where both moderate hyperoxia and high-normal arterial carbon dioxide tension (paco ) increased regional cerebral oxygen saturation (rso ) as compared with normoxia and low-normal paco , respectively. rso was measured from ohca patients with nirs during the first h of intensive care and neurological outcome was assessed using the cerebral performance category (cpc) scale at months after cardiac arrest. we calculated the median rso for patients with good (cpc - ) and poor (cpc - ) outcome and compared the results using the mann-whitney u test. we compared the rso over time with outcome using a generalised mixed model. finally, we added median rso to a binary logistic regression model to control for the effects of possible confounding factors. results: the median (interquartile range [iqr]) rso during the first h of intensive care was . % ( . - . %) in patients with good outcome compared to . % ( . - . %) in patients with poor outcome, p = . . we did not find significant association between rso over time and neurological outcome ( figure ). in the binary logistic regression model rso was not a statistically significant predictor of good outcome (or . , % ci . - . , p = . ). conclusions: we did not find any association between cerebral oxygenation during the first h of post-resuscitation intensive care and neurological outcome at months after cardiac arrest. fig. introduction: near-infrared spectroscopy (nirs) provides a noninvasive means to assess cerebral oxygenation during postresuscitation care but its clinical value is unclear. we determined the possible association between cerebral oxygenation and the magnitude of brain injury assessed with neuron-specific enolase (nse) serum concentration at h after out-of-hospital cardiac arrest (ohca). methods: we performed a post hoc analysis of a randomised clinical trial (comacare) comparing two different levels of carbon dioxide, oxygen and arterial pressure after ohca and successful resuscitation. we measured rso continuously with nirs from patients during the first h of intensive care. we determined the nse concentrations at h after cardiac arrest from serum samples using an electrochemiluminescent immunoassay kit. the samples were tested for haemolysis and all samples with a haemolysis index > mg of free haemoglobin per litre (n = ) were excluded from the analyses. we calculated the median rso for all patients and used a scatterplot and spearman's rank-order correlation to assess the possible relationship between median rso and nse at h. in addition, we compared the nse concentrations at h after cardiac arrest in patients with good (cerebral performance category scale [cpc] - ) and poor (cpc - ) neurological outcome at months using the mann-whitney u test. results: we did not find significant correlation between median rso and serum nse concentration at h after cardiac arrest, rs = - . , p = . (figure ). the median (iqr) nse concentration at h was . ( . - . ) μg/l and . ( . - . ) μg/l in patients with good and poor outcome, respectively, p < . . conclusions: we did not find any association between cerebral oxygenation during the first h of post-resuscitation intensive care and nse serum concentrations at h after cardiac arrest. the association between lactate, cerebral oxygenation and brain damage in post-cardiac arrest patients introduction: patients admitted to the intensive care unit (icu) after being successfully resuscitated from a cardiac arrest (ca) have a large cerebral penumbra at risk for secondary ischemic damage in case of suboptimal brain oxygenation. therefore, resuscitation during icu stay should be guided by parameters that adequately predict cerebral hypoxia. the value of lactate as resuscitation parameter may be questioned in post-ca patients since the brain critically depends on aerobic metabolism. we aimed to investigate the relationship between arterial lactate, cerebral cortex tissue oxygenation (scto ) by near infrared spectroscopy (foresight) and unfavorable neurological outcome at days (cpc score - ) methods: subanalysis from the neuroprotect post-ca trial. lactate values and scto were recorded hourly in post-ca patients during hours ttm and subsequent rewarming. results: in total paired lactate/ scto measurements were analysed. we found no correlation between paired lactate and scto² (fig. ) . moreover, temporary trends in lactate did not correlate with corresponding trends in scto during the same one-hour time interval (r²= . ) (fig ) . if lactate values above . mmol/l are considered to be abnormal, lactate could not adequately detect clinical important brain ischemia (scto < %): sensitivity % and specificity % (table , ). nevertheless, time weighted lactate at h (or . ; p . ), h (or . , p . ), h (or . ; p . ) and h (or . ; p . ) were inversely correlated with unfavorable neurological outcome at days (fig , ) . conclusions: although lactate was a marker of prognosis in post-ca patients, it should not be used to guide resuscitation since lactate values were not correlated with scto and changes in lactate do not correspond with changes in scto during the same time interval. simplified introduction: the aim of the study was to investigate whether simplified continuous eeg monitoring (ceeg) [ ] post-cardiac arrest can be reliably interpreted by icu physicians after a short structured training, and whether acceptable interrater agreement compared to an eeg-expert can be achieved. methods: five icu physicians received training in interpretation of simplified ceeg (fig ) consisting of lectures, hands-on ceeginterpretation, and a video tutorial -total training duration day. the icu physicians then interpreted simplified ceeg recordings. basic eeg background patterns and presence of epileptiform discharges or seizure activity were assessed on -grade rank-ordered scales based on a standardized eeg terminology [ ] . an experienced eeg-expert was used as reference. results: there was substantial agreement (κ . ) for eeg background patterns and moderate agreement (κ . ) for epileptiform discharges between icu physicians and the eeg-expert. sensitivity for detecting seizure activity by the icu physicians was limited ( %), but with high specificity ( %). among icu physicians interrater agreement was substantial (κ . ) for eeg background pattern and moderate (κ . ) for epileptiform discharges. conclusions: after a one-day educational effort clinically relevant agreement was achieved for basic eeg background patterns after cardiac arrest. assessment of epileptiform patterns was less reliable, but bedside screening by the icu physician may still be clinically useful for early detection of seizures. interpretation of simplified ceeg requires awareness of its limitations and support from an eeg-expert when clinically indicated. introduction: hypoxic-ischemic injury on head computed tomography (ct), which manifests with varying degrees of cerebral edema and loss of gray-white matter differentiation, is a poor prognostic sign after resuscitated out-of-hospital cardiac arrest that may influence early clinical decision-making. agreement among physicians on the presence of hypoxic-ischemic injury on early head ct is unknown. methods: we recruited faculty physician participants ( emergency medicine, critical care, neurocritical care, and general radiology; average . years of practice) across academic medical centers each with > admissions for resuscitated out-of-hospital cardiac arrest each year. participants, blinded to clinical context, reviewed unique head cts obtained within hours of cardiac arrest that were randomly selected from a local registry. a blinded neuroradiologist also reviewed all scans (gold standard). participants determined if hypoxic-ischemic injury was present on each ct, and agreement was determined using multi-and dual-rater kappa statistics with % confidence intervals. results: overall agreement among physicians regarding the presence of hypoxic-ischemic injury on head ct was fair (kappa . ; % ci, . - . ) with agreement consistent across most specialties (table ) . when compared to the neuroradiologist, individual physician agreement ranged widely, from poor (kappa . ) to substantial (kappa . ), with of physicians having fair or worse agreement compared to the gold standard interpretation. conclusions: the finding of hypoxic-ischemic injury on early head ct after cardiac arrest had high interobserver variability as interpreted by acute care physicians and general radiologists. pending the development of objective diagnostic criteria, clinicians should bear in mind the subjectivity and subtlety of cerebral edema or loss of graywhite matter differentiation soon after return of spontaneous circulation in these patients. figure ). baseline characteristics and differences between the wlst and no-wlst groups are shown in table . utilization of neuro-prognostication tests is shown in table . while ct and eeg were commonly employed, ssep and mri were used less frequently. basic multimodal neuroprognostication (arbitrarily defined as at least one ct or mri, plus eeg, plus ssep) was performed only in . % of all patients undergoing wlst but the rate increased significantly over six years (p< . ) and was higher in the time period after , compared to the one prior to ( figure ). this association remained significant after adjustment for confounders such as age, arrest rhythm, downtime, targeted temperature management, apache ii score and organ failure in a logistic regression model (p= . ). in an institution with access to a wide range of imaging and neurophysiology tests, mri and ssep remained underutilized but the rate of basic multimodal neuro-prognostication increased significantly over the study period, especially in the period after . introduction: although multiple reports using animal models have confirmed that melatonin appears to promote neuroprotective effects following ischemia/reperfusion-induced brain injury, the relationship between its protective effects and the activation of autophagy in cerebellar purkinje cells following the asphyxial cardiac arrest and cardiopulmonary resuscitation (ca/cpr) remains unclear. methods: rats used in this study were randomly assigned to groups as follows; vehicle-treated sham-operated group, vehicletreated asphyxial ca/cpr-operated group, melatonin-treated shamoperated group, melatonin-treated asphyxial ca/cpr-operated group, melatonin plus (+) p-pdot (the mt melatonin receptor antagonist)-treated sham-operated group and melatonin+ p-pdot-treated asphyxial ca/cpr-operated group. results: our results demonstrate that melatonin ( mg/kg, ip, time before ca and times after ca) significantly improved the survival rates and neurological deficits compared with the vehicle-treated asphyxial ca/cpr rats (survival rates ≥ % vs %). we also demonstrate that melatonin exhibited the protective effect against asphyxial ca/cpr-induced purkinje cell death. the protective effect of melatonin in the purkinje cell death following asphyxial ca/cpr paralleled a dramatic reduction in superoxide anion radical (o ·-), intense enhancements of cuzn superoxide dismutase (sod ) and mnsod (sod ) expressions, as well as a remarkable attenuation of autophagic activation (lc and beclin- ), which is mt melatonin receptor-associated. furthermore, the protective effect of melatonin was notably reversed by treatment with p-pdot. conclusions: this study shows that melatonin conferred neuroprotection against asphyxial ca/cpr-induced cerebellar purkinje cell death by inhibiting autophagic activation by reducing expressions of ros, while increasing of antioxidative enzymes, and suggests that mt is involved in the neuroprotective effect of melatonin in cerebellar purkinje cell death induced by asphyxial ca/cpr. introduction: fucoidan is a sulfated polysaccharide derived from brown algae and possesses various beneficial activities, such as antiinflammatory and antioxidant properties. previous studies have shown that fucoidan displays protective effect against ischemiareperfusion injury in some organs. however, few studies have been reported regarding the protective effect of fucoidan against cerebral ischemic injury and its related mechanisms. methods: therefore, in this study, we examined the neuroprotective effect of fucoidan against cerebral ischemic injury, as well as underlying mechanisms using a gerbil model of transient global cerebral ischemia (tgci) which shows loss of pyramidal neurons in the hippocampal cornu ammonis (ca ) area. fucoidan ( and mg/kg) was intraperitoneally administered once daily for days before tgci. results: pretreatment with mg/kg of fucoidan, not mg/kg fucoidan, attenuated tgci-induced hyperactivity and protected ca pyramidal neurons from ischemic injury following tgci. in addition, pretreatment with mg/kg of fucoidan inhibited activations of resident astrocytes and microglia in the ischemic ca area. furthermore, pretreatment with mg/kg of fucoidan significantly reduced the increased -hydroxy- -noneal and superoxide anion radical production in the ischemic ca area after tgci and significantly increased expressions of superoxide dismutase (sod ) and sod in the ca pyramidal neurons compared with the vehicle-treated-group. we found that treatment with diethyldithiocarbamate (an inhibitor of sods) to the fucoidan-treated-group notably abolished the fucoidanmediated neuroprotection in the ischemic ca area following tgci. conclusions: these results indicate that fucoidan can effectively protect neurons from tgci-induced ischemic injury through attenuation of activated resident glial cells and reduction of oxidative stress following increasing sods. thus, we strongly suggest that fucoidan can be used as a useful preventive agent in cerebral ischemia. the effects of cold fluids for induction of therapeutic hypothermia on reaching target temperature and complications-a sub-study of the tth study a holm , m skrifvars , fs taccone ). there was no difference in early bleeding incidences (fig ) . during late observation, ttm patients had fewer minor bleeding ( . % vs. %) and more intracranial bleeding ( . % vs. %; fig ) . adjusted calculated risk ratio for major bleeding (including intracranial) for ttm was . ( %ci . - . ) at baseline and . ( %ci . - . ) over time. conclusions: bleeding complications were common. although the risk ratio for major bleeding increased over time in ttm patients, residual and unmeasured confounding in addition to selection and detection bias may limit the clinical relevance of this finding. methods: patients with neurological deficit > by nhiss were included. the t°of the brain was recorded non-invasively using radiothermometer rtm- -res (russia). we measured t°in symmetric regions of left & right hemispheres, calculated the average t°of brain, fig. (abstract p ) . temperature of patients given and not given pre-icu fluids (table ) . conclusions: observed moderate brain t°heterogenecity in hp, marked increase brain t°heterogenecity in is & sharp decline of t°h eterogenecity in cci. supposedly, correcting the impairment of cerebral tb (increase or decrease t°) through physical (selective cerebral hypothermia, magnetic stimulation etc.) or pharmacological (sedation) can contribute to positive therapeutic results in is & cci. nonivasive radiothermometry of the brain can be an objective method of patients' condition evaluation & their rehabilitation potential. introduction: basilar artery stroke has a multitude of different presentations and may not be captured on plain computed tomography (ct). it can progress to severe disability, locked in syndrome and death [ ] . with the advent of thrombolytic and endovascular therapies, prompt diagnosis can change the outcome. we present a case of basilar artery stroke, which was heralded by tongue spasticity and dysarthria, indicative of pseudobulbar palsy. methods: case reviewed with consent. a literature search was conducted using pubmed and medline. results: a -year-old presented with pulmonary oedema and hypertension. he was transferred to our intensive care unit for treatment of a suspected anaphylaxis. his marked lingual swelling was associated with dysarthria. glyceryl-trinitrate and labetalol infusions were started for hypertension. he developed left sided weakness and deteriorated over several days to the point that he could only move his right foot (table ) . magnetic resonance imaging (mri) showed midbrain ischaemia and angiogram showed no flow in the basilar artery (fig , ) . conclusions: common presenting features of basilar artery occlusion include dysarthria, vertigo, vomiting, headache and motor defects; these may evolve gradually or be intermittent [ , ] . presentation with pseudobulbar palsy is described in early literature [ ] . delayed recognition of the stroke led to aggressive treatment of hypertension, potentially compromising perfusion to the penumbral area [ , ] . this case highlights the need for a wide index of suspicion with posterior strokes. consent: informed consent to publish has been obtained from the patient prognosis is related to gcs < or = on admission (p = . ) and to malignant cerebral edema (p = . ). conclusions: our study has shown some predictive factors closely related to mortality and morbidity in patients with acute ischemic stroke. gcs at admittance < or = and onset of malignant cerebral edema lead to a worst prognosis at discharge from nicu. coherence analysis of cerebral oxygenation using multichannel functional near-infrared spectroscopy evaluates cerebral perfusion in hemodynamic stroke tj kim table ). in addition, severe stroke patients were more likely to have higher phase coherence in interval iii (p = . ). conclusions: our results demonstrated that the higher phase coherence of oxyhb in myogenic signal, which was originated locally from smooth muscle cells in brain was related to impaired cerebral perfusion. this suggests that monitoring cerebral oxygenation using fnirs could be a useful noninvasive measuring tool for evaluating impaired cerebral autoregulation in stroke patients. is esmolol associated with worse outcome at the acute phase of ischemic stroke that receives thrombolysis? introduction: ischemic stroke patients experienced frequent early neurological deterioration (end) events. since ischemic stroke has also been shown as inflammatory disease, the neutrophil-tolymphocyte ratio (nlr) may associated with end events. however, the direct study regarding this association has not been addressed. poor grade sah, use of vasopressors, mechanical ventilation, intracranial pressure monitoring, external ventricular drainage, blood transfusions and renal replacement therapy were all more frequent among nonsurvivors (all p< . ). mortality was also higher with initial lactate above mmol/l, in those admitted to public hospitals and when admission to icu was delayed more than hours after ictus. after adjusting for common predictors (age, gender and wfns) saps non-neuro, sofa non-neuro, early vasopressor use and admission to a public hospital were independently associated with hospital mortality. moreover, the area under the curve for prediction of mortality with saps , sofa and wfns was . ( figure ). hospital, austria. the association of intensity and duration of intracranial hypertension episodes with -month glasgow outcome score (gos) was visualized using the methodology introduced by güiza et al. [ ] . results: in both cohorts, it could be demonstrated that the combination of duration and intensity defined the tolerance to intracranial hypertension, and that a semi-exponential curve separated episodes associated with better outcomes from those associated with worse outcomes. the association with worse outcomes occurred at a lower pressure-time burden than what has been previously observed in patients with tbi. nevertheless, the percentage of monitoring time spent by every patient in the zone associated with poor gos was independently associated with worse -month neurological outcome, even after correcting for age and fisher score ( introduction: apnea test is an essential component in the clinical determination of brain death, but it may incur a significant risk of complications such as hypotension, hypoxia and even cardiac arrest [ ] . we analyzed the risk factors associated with failed apnea test during brain death assessment in order to predict and avoid these adverse events. methods: medical records of apnea tests performed for brain-dead donor between january and january in our institution, were reviewed retrospectively. age, gender, etiology of brain death, use of catecholamine and results of arterial bleed gas analysis (abga), systolic/diastolic blood pressure (sbp/dbp), mean arterial pressure (map) and central venous pressure (cvp) prior to apnea test initiation were collected as variables. a-a gradient and pao /fio were calculated for more precise assessment of the respiratory system. in total, cases were divided into a group which was completed apnea test and the other which was failed the test. introduction: tunisia has already suffered recurrent outbreaks since . outbreak started relatively earlier this year. we were interpellated by the frequency of neuroinvasive presentation of the disease. methods: we report a case series of patients presented to icu with niwnd. results: we report cases of niwnd with different severe presentations overlapping neurological manifestation including encephalitis (n= / ), meningitis (n= / ) and flaccid paralysis (n= / ). almost all patients live in the locality of sousse. six patients presented a long course of isolated fever before developing neurological signs. cerebrospinal fluid was consistent with encephalitis within the patients. cerebromedullar mri identified brain lesions (n= / ), myelitis (n= / ) and polyradiculoneuritis (n= / ).three patients had electromyography for flaccid paralysis showed diffuse axonal polyneuropathy with motoneuron involvement. ten cases had a positive wnv igm antibody and nine had a positive wnv igg antibody in serum. urine polymerase chain reaction was positive for wnv in / patients. ten patients were mechanically ventilated. all patients were managed symptomatically. two received high doses of methylprednisolone for days, one patient received polyclonal immunoglobulin intravenous and one patient had plasmapheresis. two patients died consecutive to brainstem lesions. two patients recovered significantly and discharged with no complications. five other patients evolved to persistent flaccid paralysis with a minimal consciousness state and weaning difficulties requiring tracheostomy. the last remaining patient is still evolving. conclusions: modification of the regional climatic conditions accounted probably for the early outbreak of niwnd. this initial case series displays the severity and the poor outcomes of niwnd with higher incidence compared to past epidemics. noninvasive estimation of intracranial pressure with transcranial doppler: a prospective multicenter validation study c robba , c fig. ], mean bias was - . mmhg (limits of agreement are ± sd . mmhg). . % measures were outside the limit of agreement in the overall population. however, when icp was high, % of measures were out of the limit of agreement. the auc [ fig. introduction: surgical treatment of aortic aneurysm needs extracorporeal circulation (ecc), aorta clamp and hypothermia, and it is often related to poor systemic perfusion and blood flow velocity. one of the main concerns of intensive care team is to prevent secondary neurological injury after long time without blood flow pulsatility, such as brain edema and seizure. the most common parameters for neuromonitoring would be intracranial pressure and eeg, however, for non-neurological patients this information is unusual and prevents optimal management. methods: we aimed to assess brain compliance and neurological condition of icu patients on immediate post-operative recovery of bentall-de bono procedure and/or other aortic aneurysm surgical treatment using a novel non-invasive intracranial pressure (icp) device. this device uses mechanical displacement sensor capturing extracranial continuous volumetric variation of the skull and this information proportionally reflects intracranial dynamic [ ] . results: twenty patients were included in this study. ecc mean time was minutes for patients and only one did not need it. eleven presented altered icp curves with poor brain compliance (p /p ratio > . ) assessed by icp curve morphology analysis. volemic optimization and neuroprotective measures were taken based on this icp information for acute case management. among these patients with altered icp curves, eight were discharged from icu with good clinical condition and glasgow coma scale of . overall mortality rate was six out of twenty ( %) and three of these had altered icp curves. conclusions: brain monitoring of cardiovascular post-operative patients is important to prevent secondary neurological complications and can be a helpful tool for neuroprotective acute management on icu. the technique supplies electrical current to muscle, combined with passive cycling. prior to a clinical trial, we first investigated the effects of one session of fes in healthy volunteers. methods: healthy male volunteers (n= ) were recruited. the participants had their postural sway assessed on a pressure sensitive board, and measurement of maximal inspiratory pressure (mip). ultrasounds were taken assessing thickness of the quadriceps and rectus abdominis. they performed minutes of supine passive cycling, with fes supplying the lower limbs and abdomen. after a minute rest, the tests were repeated. a further participants performed just the initial baseline tests, to help assess muscular factors affecting balance and sway. results: the current needed for palpable contraction was significantly correlated to weight in the abdomen (r= . , p< . ) and quadriceps (r= . , p< . ). current required to stimulate the abdominal muscles was also correlated to depth of the subcutaneous fat layer (r= . , p< . ) and echogenicity of the muscle (r= . , p= . ). pre-cycling, left and right vastus lateralis thickness inversely correlated to postural sway in the antero-posterior (r=- . , p< . ) plane. compared to pre-cycling, postural sway in the antero-posterior and lateral planes increased significantly after cycling. there was a significant decrease in mip after cycling and greater reductions in mip were found in participants who had thinner rectus abdomni. conclusions: sway at baseline is related to quadriceps thickness, which atrophies during critical illness, and could worsen balance. mip is reduced during fes and the severity of reduction is related to the thickness of the abdominal wall muscles at baseline, suggesting that fes can fatigue the diaphragm and abdominal muscles. in awake healthy volunteers, fes is a safe, comfortable technique. introduction: in most cases postoperative cognitive dysfunction (pocd) is transient, but still some patients suffer from persistent cognitive impairment which is associated with increased length of hospital stay, early withdrawal from labor market and higher mortality. available data on the prevalence of pocd after cardiac surgery is very diverse from % to % upon discharge and up % months after surgery. we aimed to investigate the prevalence of short-term and long-term pocd after off-pump coronary artery bypass grafting (cabg) surgery. methods: psychometric testing was performed in (mean age . ± . ) patients before, days and months after the surgery. we used following tests to assess cognitive capacity: auditory verbal learning test (avlt), digit span test (dst), digit-letter substitution test (dlst), stroop's test and trail making test (tmt). a decline in comparison to preoperative test results for % or more in two or more tests was declared as pocd. results: the prevalence of pocd after days was . % ( patients) and . % ( patients) after months. when comparing patients who developed pocd with those who did not we found the former were older ( . ± . vs . ± . years; p< . ), had lower education level ( . ± . vs . ± . years; p< . ) and had longer surgery duration ( . ± . vs . ± . minutes; p< . ). the most affected cognitive domains were long term memory (avlt) and executive function (tmt) and least affectedworking memory (dst) and selective attention (stroop's test). conclusions: in our prospective study the prevalence of long-term pocd after cardiac surgery was slightly less ( . %) in comparison to available data (from % to %). it might be due differences in psychometric testing and interpretation of its results among authors. advanced age, low cognitive reserve and long duration surgeries are linked with higher incidences of pocd. introduction: postoperative cognitive dysfunction (pocd) is a common and widely described phenomenon in surgical patients. advanced age, major surgery, certain general anesthetics, genetic factors, sleep deprivation and other factors were described as contributing factors to pocd. the hospital stay itself is a major 'social' trauma for patients; social isolation, sleep deprivation and changes in daily regimen may effect neurocognitive behavior of patients. in this trial we tried to assess the link between pocd and the length of hospital stay in cardiac surgery patients. methods: patients who underwent 'off-pump' coronary artery bypass grafting (cabg) surgery selected for this trial. neuropsychological testing was performed prior to the operation and upon discharge. we used auditory verbal learning test (avlt), digit span test (dst), digit-letter substitution test (dlst), stroop test and trail making test (tmt). a % or more decline in two or more tests in comparison to preoperative test results was declared as pocd. patients were allocated into two groups according to the length of hospital stay: the short-stay group (group ) included patients (n= ) who were discharged on the th day after surgery or earlier and the long-stay (group ) group consisted of patients (n= ) who were discharged on the th day after surgery or later. patients received similar anesthesia, postoperative care and were operated by the same surgical team. reasons for prolonged duration of hospital stay were mainly surgical. results: patients ( . %) in group and patients ( . %) in group had pocd upon discharge (p< . ). mean length of hospital stay were ± . and ± . days in group and group patients respectively (p< . ). conclusions: prolonged length of hospital stay increased the prevalence of pocd in our trial. studies with various types of surgical procedures and larger patient populations needed to further understand the effect of length of hospital stay to pocd. the influence of multiple trauma with head trauma on posttraumatic meningitis: a nation-wide study with hospital-based trauma registry in japan introduction: posttraumatic meningitis is one of severe complications and results in increased mortality and longer hospital stay among head trauma patients. however, it remains unclear whether there is a difference in the incidence of post-traumatic meningitis due to single traumatic brain injury (tbi) and multiple trauma including head injury. methods: this study was a retrospective observational study during years we included trauma patients registered in japanese trauma data bank whose head ais score was > in this study. multivariable logistic regression analysis was used to assess potential factors associated with posttraumatic meningitis such as csf fistula, skull base fracture, type of injury that divided into single tbi and multiple trauma. introduction: the aim of this study was to determine if regional cerebral oxygenation (rsco ) can be used as an indicator of tissue perfusion in icu patients with tbi [ , ] , and to determine the prognostic value of cerebral oxygenation rsco in survival prediction. methods: patients were enrolled retrospectively from january through july in the icu of derince kocaeli training hospital. patients with trauma patients and traumatic braine injury patients who were admitted to the icu from the emergency room were included in the study. the sedation levels of the patients were followed up with bis. the rsco , bis was taken as well as blood lactate level, mean arterial blood pressure and cardiac output at baseline time, , , , and hours. results: no significant difference was also detected between the value of rsco in all patients . it was average sco (right) . ± . and average rsco (left) . ± . . conclusions: cerebral regional oxygen saturation might be helpful as one of the perfusion parameters in patients with tbi but it could have no prognostic value in mortality prediction. however, further studies with larger sample size are still needed to validate these results. introduction: tbi in elderly is an increasingly cause of admission in icu. data regarding management and prognosis of these patients are lacking. validated prognostic models refer to younger patients and do not adequately consider the influence of pre-injury functional status, which often compromises with aging. frailty has been defined as a state age-related of increased vulnerability and decline in autonomy of daily life activity. aim of the study is to evaluate the impact of frailty on outcome in tbi elderly patients. methods: moderate and severe tbi patients > years, admitted in neuroicu from january to may , were prospectively enrolled. data of age, comorbidity, glasgow coma scale (gcs), pupils' reactivity, ct scan characteristics, neurosurgical intervention and gose (extended glasgow outcome scale) at -months were collected. frailty status was measured by clinical frailty scale (cfs) [ ] and patients were divided as frail (cfs> ) and not frail (cfs< ). bad outcome was defined as gose< . results: ( %) of the studied patients were frail. frailty was not related to age. frail patients had more comorbidities and worse pupils' reactivity at admission (table ) . other variables did not differ between groups. in univariate analysis neurological diseases, gcs, tsah (traumatic subarachnoid haemorrhage), compressed/absent basal cisterns, non-reactive pupils and cfs were significantly associated to bad outcome. in multivariate analysis only gcs and cfs remained associated to bad outcome ( table ) . conclusions: pre-injury frailty is strongly associated to outcome in tbi elderly patients. the age of the patients was . ± . years. patients were operated on for intracranial traumatic ( cases) and non-traumatic hematomas ( ), brain tumors ( ) and the need for plastic of postoperative skull defects ( ). general endotracheal total intravenous anesthesia with fentanyl, propofol, rocuronium, or tracrium was used. after tracheal intubation, - nerves were blocked (e.g., supraorbital, supratrochlear, zygomaticotemporal, auriculotemporal, great auricular, greater and lesser occipital nerves), depending on the surgical site. . - . % ropivacaine was used. for blockade of one nerve used . - . ml of local anesthetic. fentanyl was applied on section of a periosteum, dura matter and at inefficiency of blockade of nerves. anesthesiology monitoring included hr, ecg, spo , nib, respiratory parameters, eeg (csi), body temperature, blood glucose and lactate levels. in and - hours post-surgery, the intensity of pain was ranked by alert patients using vas. results: the volume of local anesthetic for blockade in one patient was . ± . ml. in ( . %) from patients, an additional fentanyl injection was required to skin incision due to an increase in blood pressure and heart rate by % of the baseline values, and an increase in csi until un. patients available to productive contact in hours post-surgery ranked the pain by vas at ( ; ) point, and in - hours post-surgery ranked it at ( ; ) p. conclusions: at patients with craniotomies scalpe-block with lowvolumes of a ropivacaine showed high efficiency ( . %). were transferred to hospital ward or ( . %) to the center of intensive nursing care; ( . %) went to the surgical recovery room. acute renal failure, hypernatremia and hyperphosphatemia were independent predictors of mortality as described in table . conclusions: hypernatremia and hyperphosphatemia were independent predictors of mortality in critically ill patients. introduction: the strong ion difference (sid) is essential for the assessment of acid-base equilibrium, thus requiring an accurate measurement of plasma electrolytes. currently there is no gold standard for electrolyte measurements and sid computation. differences in electrolyte values obtained with point-of-care (poc) and central laboratory (lab) analyzers have been reported [ , ] . in previous studies [ , ] we have shown that changes in pco induce electrolyte shifts from red blood cells to plasma (and vice versa), yielding variations in sid. aim of the present in-vitro study was to induce sid changes through acute changes in pco and compare values of electrolytes and sid obtained with poc and lab techniques. methods: blood samples from healthy volunteers were tonometered (equilibrator, rna medical) with gas mixtures at fractions of co (fco ) of , , and %. electrolytes were measured quasisimultaneously with a poc analyzer (abl flex, radiometer) and a routine lab method (cobas ise, roche). for both techniques a simplified sid was computed as sodium + potassiumchloride. results: bland-altman analysis of sid calculated with poc and lab showed a proportional bias (slope = . , r = . , p < . ), indicating a variable agreement between methods according to the average sid value (fig. ) . sid values measured with poc and lab at different fco differed significantly (p< . , fig. ) . a similar discrepancy was observed for chloride (p < . , fig. ), while sodium (p= . ) and potassium (p= . ) were similar. conclusions: sid measured with poc and lab differed significantly, mainly due to a variable discrepancy in chloride. our findings suggest that our poc analyzer is superior to the lab in measuring electrolytes and thus compute sid. introduction: this study evaluated the safety of half dose insulin (hdi) versus standard dose insulin (sdi) for the treatment of hyperkalemia in a medical intensive care unit (micu) population with renal insufficiency. recent emergency medicine data demonstrated a lower incidence of hypoglycemia in patients with renal insufficiency when hdi was used for the treatment of hyperkalemia [ ] . there is limited data describing the safety of hdi in a micu population with renal insufficiency. methods: this was a retrospective, chart review of patients admitted to the micu with a diagnosis of aki and/or ckd stage - with a serum potassium ≥ . meq/l from january to september . sdi is defined as units of regular iv insulin and hdi as units. the primary outcome was the incidence of hypoglycemia within hours of insulin administration. secondary outcomes included severe hypoglycemia and change of serum potassium after insulin administration. results: a total of patients were screened and were included for analysis. the incidence of hypoglycemia occurred in / patients ( . %) and / patients ( . %) who received sdi and hdi, respectively. one patient in the sdi group and two patients in the hdi group developed severe hypoglycemia. the mean decrease in serum potassium after insulin administration was . meq/l in both groups. patients in the hdi group who were re-dosed with units of regular insulin did not have any hypoglycemic events. conclusions: in a micu population with renal insufficiency, sdi and hdi regimens appear safe and effective for the treatment of hyperkalemia. introduction: sepsis and septic shock are common causes of admission in the intensive care unit with a high mortality rate [ , ] . hence, electrolyte disturbances are common in this group of patients. acute hypernatremia is one of the multiple features of homeostasis disturbances and available data in the literature suggest that its incidence can reach % [ , ] . (fig , ) . the main source of sepsis was pneumonia with affected patients ( . %). conclusions: hypernatremia is significantly associated with higher mortality in septic patients. (abstract p ) . the outcome versus the sodium levels higher in the group - % vs . % (p= . ). there were no significant differences between the groups in length of stay in the icu. in group , there was an increase of serum phosphorus level and in the group the tendency to decrease. however, statistically significant differences were obtained only on the nd day after surgery . ± . mmol/l (group ) vs . ± . mmol/l (group ) (p= . ). the roc curve was constructed to assess the predictive significance of serum phosphorus levels (fig. ) . auc was . ; % ci . - . ; p= . ; sensitivity . %, specificity . %. the kaplan-meier survival analysis (fig. ) introduction: the rate of extubation failure might be higher in obese patients than in non-obese patients. effect of obesity on mortality is controversial [ , ] (obesity paradox). several pathophysiological changes contribute to an increase of respiratory complications [ ] . we sought to identify incidence of extubation failure in obese and non-obese patients. methods: the primary endpoint of this post-hoc analysis of a prospective, observational, multicenter study [ ] performed in intensive care units was extubation failure, defined as the need for reintubation within hours following extubation. only patients with body mass index (bmi) recorded were included. results: between december , and may , , among the patients with bmi available undergoing extubation, obese patients ( %) and non-obese patients ( %) were enrolled. extubation-failure rate was . % ( / ) in obese patients, and . % ( / ) in non-obese patients (p= . ). delay of reintubation did not differ between obese and nonobese patients (figure ). length of intubation > days was significantly more frequent in obese patients ( / , %) than in non-obese patients ( / , %, p< . ). precautions to anticipate extubation failure were more often taken in obese patients ( / , %) than in non-obese patients ( / , %, p< . ). spontaneous breathing trial (sbt) characteristics differed between obese and non-obese patients (table ) . physiotherapy was more often used in obese patients ( / , %) than in non-obese patients ( / , %, p= . ). conclusions: incidence of extubation failure did not differ between obese and non-obese patients. in obese patients, clinicians anticipate more a possible extubation failure, delaying the moment of extubation, performing more physiotherapy and providing an optimal sbt. introduction: in the acute phase of critical illness, growth hormone (gh) resistance develops, reflected by increased gh and decreased insulin-like growth factor-i (igf-i), mimicking fasting in health. the epanic rct observed fewer complications such as muscle weakness and faster recovery with accepting a macronutrient deficit in the first icu week, as compared with early full feeding [ , ] . we characterized its impact on the gh axis in relation to the risk of acquiring muscle weakness. methods: in this epanic rct sub-analysis, for matched patients per group, and all patients assessed for muscle weakness (n= ), serum gh, igf-i, igf binding protein (igfbp ) and igfbp were measured upon icu admission and at day or the last icu day for patients with shorter icu stay (d /ld). for matched patients per group, gh was quantified every min between pm and am, and deconvolved to estimate gh secretion. groups were compared with wilcoxon test or repeated-measures anova. associations between changes from baseline to d /ld and muscle weakness were assessed with logistic regression analysis, adjusted for baseline risk factors, baseline hormone concentrations and randomization. results: in the fully fed group gh, igf-i and igfbp increased, whereas igfbp decreased from admission to d /ld (all p< . ). accepting an early macronutrient deficit prevented the rise in gh and igf-i and the decrease in igfbp (all p< . ) but did not affect igfbp , whereas basal, but not pulsatile, gh secretion was lowered (p= . ). a stronger rise in gh and igf-i was independently associated with a lower risk of acquiring muscle weakness (or ( %ci) per ng/ml change . ( . - . ) for gh; . ( . - . ) for igf-i). conclusions: accepting an early macronutrient deficit suppressed basal gh secretion and reduced igf-i bioavailability during critical illness, which may counteract its protection against muscle weakness. introduction: aim of the study was to relate hypokalemia (hypok) and hypoglycemia as diabetic ketoacidosis (dka) treatment complications and precocious insulin interruption also use of sodium bicarbonate with length of stay (los) in intensive care unit (icu). methods: analysis of retrospective cohort study data of patient (pt) treated for dka at icu of hospital kaunas clinics of lithuanian university of health sciences during - has been carried out. serum kalemia, glycaemia; rate of episodes of hypok, hypoglycaemia and precocious insulin interruption; use of sodium bicarbonate, in relation with los in icu were analysed. spss . was used for statistic calculations. traits evaluated as significant at p< . . results: at the beginning of dka treatment hypok ( . ± . mmol/l) was recorded in / ( %) pt. due to disregarding of blood ph ( . - . ( . ± . ) kalemia was falsely misinterpreted as "normo-" or "hyperkalemia" . - . ( . ± . mmol/l) in of ( %) pt, as normo-and hyperkalemia thus not treated and complicated by hypok additionally in / ( %) pt. in hypok los in icu was . ± . vs . ± . h, p< . . insulin use has caused hypoglycaemia ( . - . ( . ± . mmol/l)) in / ( %) pt, los in icu . ± . vs . ± . h, p< . . insulin use was interrupted in case of normo -and hypoglycaemia with still persisting ketoacidosis in / ( %) pt, los in icu was found to be . ± . vs . ± . h, p< . . sodium bicarbonate was given for symptomatic treatment of acidosis during the first h of dka in / ( %) pt with stable hemodynamic: hco buffer has increased ( . ± . - . ± . mmol/l), p< . , but ketoacidosis has still persisted, los in icu was . ± . vs . ± . h, p< . . conclusions: hypok ( %), hypoglycemia ( %), precocious interruption of insulin use ( %) have prolonged los in icu almost twice. symptomatic treatment of ketoacidosis with sodium bicarbonate ( / pt) didn't control it and has prolonged los in icu. introduction: cystathionine-γ -lyase (cse), a regulator of glucocorticoid (gc)-induced gluconeogenesis [ ] , correlates with endogenous glucose production in septic shock [ ] . the hyperglycemic stress response to noradrenaline (noa) is mediated by the kidney [ ] and less pronounced with low cse [ ] . gc receptor (gr)-mediated gene expression is differentially regulated: the gr monomer is considered to repress inflammation, and gc side effects are attributed to the gr dimer; recent reports challenge this view [ ] . gc-induced gluconeogenic gene expression is reduced in gr dimerization deficient (grdim) mice [ ] . the aim of this study is to investigate renal cse expression and systemic metabolism in grdim and grwt mice in a resuscitated model of lps-induced endotoxic shock. methods: anesthetized grdim (n= ) and grwt (n= ) mice were surgically instrumented, monitored, resuscitated and challenged with lps. noa was administered to maintain map and c glucose was continuously infused. h after lps, cse expression was determined via immunohistochemistry of formalin-fixed paraffin sections (n= p.gr.). results: grdim required . -fold more noa than grwt and had . fold higher glucose and . -fold higher lactate h after lps. this was concomitant with elevated endogenous glucose production ( -fold), % lower glucose oxidation and . -fold higher renal cse expression in grdim. conclusions: increased cse expression together with higher glucose production (confirming [ , ] ) and glucose levels in grdim mice suggest an association that may link cse to gc signaling. the higher noa administration in grdim mice could contribute to these effects. introduction: to achieve safe glycemic control in critically ill patients frequent blood glucose (bg) measurements and according titration of insulin infusion rates are required. automated systems can help to reduce increased workload associated with diabetes management. this bi-centric pilot study combined for the first time an intraarterial glucose sensor with a decision support system for insulin dosing (sgcplus system) in critically ill patients with hyperglycemia. methods: twenty-two patients ( females, males, with preexisting diabetes mellitus, age . ± . years, bmi . ± . kg/ m , creatinine level . ± . mg/dl, saps (simplified acute physiology score) . ± . , tiss- (therapeutic intervention scoring system) . ± . who were equipped with an arterial line and required iv insulin therapy were managed by the sgcplus system during their medical treatment at the intensive care unit. results: sgcplus-based bg determinations were performed and . ± . sensor calibrations per day were required. sensor glucose readings correlated well with reference bg (figure ). mean treatment duration was . ± . days. time to target was ± min ( - mg/dl) and ± min ( - mg/dl). mean blood glucose was ± mg/dl with seven blood glucose values < mg/dl. mean daily insulin dose was ± u and mean daily carbohydrate intake ± g /day (enteral nutrition) and ± g/day (parenteral nutrition). acceptance of sgcplus suggestions was high (> %). the novel intraarterial glucose sensor demonstrated to be highly accurate. the sgcplus system can be safely applied in critically ill patients with hyperglycemia and enables good glycemic control. introduction: we aimed to assess the effect of frailty as assessed by clinical frailty scale (cfs) and karnofsky performance score (kps) on critical care (cc) and hospital mortality in this group at a nonspecialist tertiary critical care unit. methods: patients admitted to critical care were identified from our electronic database by screening for liver disease or cirrhosis in the admission diagnoses. those with an aetiology of liver disease other than alcoholic liver disease (ald) were excluded. data was collected on patient demographics, length of stay, status at discharge from critical care and hospital and cfs. kps was also calculated where sufficient in-formation was available in the medical record. data was analysed using logistic regression multivariate analysis with stata software. [ ] . results: tg diagnosis criteria and severity grading criteria for acute cholangitis and acute cholecystitis were judged from numerous validation studies as useful indicators in clinical practice and adopted as tg diagnostic criteria and severity grading without any modification. provide initial treatment, such as sufficient fluid replacement, electrolyte compensation, and intravenous administration of analgesics and full-dose antimicrobial agents, as soon as a diagnosis has been made. in new flowchart for the treatment of acute cholecystitis (ac) in the tg , grade iii ac was indicated for gallbladder drainage, but some grade iii ac can be treated by laparoscopic cholecystectomy (lap-c) at advanced centers with specialized surgeons experienced in this procedure and for patients that satisfy certain strict criteria. we also redefine the management bundles for acute cholangitis and cholecystitis. introduction: c-acetate breath tests provide a non-invasive assessment of gastric emptying [ ] and could, hence, be used to judge tolerance to enteral nutrition. result values like t (time for % absorption) correlate with scintigraphic measurements. the data evaluation is based on model equations like the β -exponential function (bex) [ ] . it considers a mono-phasic breath gas response. this may not be the case during critical illness, which could reduce precision too low for a reliable personalized assessment [ ] . methods: we recently developed an evaluation of irregular gastric emptying patterns, which separates absorption from post-absorptive distribution and retention of tracer and from the terminal respiratory release of the oxidized tracer [ ] . using breath test data of icu patients (mean saps +/- ) the precision of this approach was compared with a bex analysis to explore how often an extended analysis is warranted and whether it improves the reliability of estimates. results: patients had a release profile consisting of series of peaks with a periodicity of - min. a first dominant peak carries about % of the released moiety, as reported [ ] for controls. for these patients the precision in t for the bex approach was +/- % of that observed for the new approach. for the other patients, the secondary peaks had a similar periodicity but were more pronounced, indicating persisting peristaltis, which has been linked to tolerance to enteral nutrition [ ] . the bex approach achieved a precision of +/- % relative to the new one, challenging its applicability for these patients. introduction: clinical scoring systems used to prognosticate the severity of acute pancreatitis (ap), such as apache ii, are cumbersome and usually require hours or more after presentation to become accurate, at which time the window for early therapeutic intervention has likely passed. sirs at presentation is sensitive but poorly specific for severe ap. we postulated that sirs and accompanying hypoxemia would specify at presentation patients with ap who have severe inflammation and are at risk for clinically severe disease. methods: patients with ap who had sirs and hypoxemia at presentation were enrolled in an open-label study evaluating the safety and efficacy of cm -ie, a calcium release-activated calcium (crac) channel inhibitor (nct ). hypoxemia was defined as an estimated pao < mm hg calculated using a log-linear equation and the spo on room air at the time of presentation. a contrastenhanced computed tomography (cect) was performed at presentation and a cbc with differential, d-dimer and crp were analyzed daily. the cect was read by a blinded central reader who assessed the degree of inflammation using the balthazar scoring system (table ) . results: patients, seven men and six women, have been randomized in the study. the mean estimated pao at presentation was mm hg. patients had sirs criteria present and the other patients had sirs criteria present. the median value for age was . (iqr - ), initial neutrophil-lymphocyte ratio (nlr) . ( . introduction: to investigate whether circulating immune profiles were able to serve as early biomarkers in predicting persistent organ failure (pof methods: thirty-nine patients with predicted severe acute pancreatitis (psap) and healthy control subjects were prospectively enrolled in our study. we measured the expression of monocytic human leukocyte antigen-dr (mhla-dr), the proportions of dendritic cells (dc) and its subtypes (including myeloid dendritic cell (mdc) and plasmacytoid dendritic cell (pdc)), the different cytokineproducing cd + t helper (th) cells and regular t (treg) cells. plasma crp and several inflammatory mediators levels were measured by elisa. results: compared with healthy controls, there is a significant decrease in the expression of mhla-dr, the frequencies of total circulating dcs and its subsets, and percentage of th cells in patients with psap. however, we found significantly higher frequencies of th cells, higher proportion of treg cells than healthy subjects. of interest, we observed that there was a significant decrease in the positive percentage and mean fluorescence intensity (mfi) of mhla-dr, the proportions of total dcs and pdc, and th cells in patients with pof compared with transient organ failure (tof). besides, there is a significantly higher frequency of th cells in pof than those in tof. area under the receiver-operating characteristic curve analysis showed that disease severity scores had a moderate discriminative power for predicting pof in patients with psap. more importantly, the expression of mhla-dr and the percentage of dcs and pdc had a significantly higher auroc and thus, better predictive ability than disease severity in patients with psap. conclusions: circulating immune profile show multiple aberrations in patients with psap who have developed pof. both the expression of mhla-dr and the percentage of total dc and pdc may be early good biomarkers for predicting risk of pof in patients with psap. introduction: pancreatic fistula (popf) due to anastomosis insufficiency is a common ( - %) complication after pancreaticoduodenectomy and often discovered with delay, causing severe morbidity, icu stay and deaths. microdialysis (md) catheters have been shown to detect inflammation and ischemia in several postoperative conditions and organs. the aim was to investigate if md catheter monitoring could facilitate earlier detection of popf than current standard of care. methods: in a prospective, observational study patients ( to years) were investigated. a md catheter was fixed to the pancreaticojejunal anastomosis. samples for analysis of glucose, lactate, pyruvate and glycerol were acquired hourly during the first hours, then every - hours to discharge. popf was defined according to the international study group of pancreatic fistula update definition. results: patients who developed popf (n= ) had significantly higher glycerol levels (p< . ) in microdialysate than did patients without popf (n= ) during the first h. thereafter, the difference diminished. a glycerol concentration > μmol/l during the first h detected patients who later developed popf with a sensitivity of % and a specificity of %. lactate and lactate to pyruvate ratio were significantly higher (p< . ) and glucose was significantly lower (p< . ) in patients with popf from about h. fig. shows microdialysis measurements in patients with (red lines) and without (blue lines) popf. conclusions: a high level of glycerol in microdialysate is an early (first hours) indicator of popf. glucose, lactate and lactate to pyruvate ratio are indicators of peritonitis caused by the leakage. thus, md monitoring detects popf several days earlier than current methods and may play an important clinical tool in the future. we are currently conducting a rct to explore if md monitoring will improve prognosis in these patients the phenomenon of total impaired of metabolic activity of gut microbiota in critically ill septic patients introduction: during a critical condition, dramatic disturbances occur not only in the change of species diversity, but in gut microbiota metabolism as well, that might lead to nonreversible breakdowns of host homeostasis and death [ ] . metabolic activity of microbes can be assessed by the measurement of the levels of aromatic microbial metabolite (amm) in blood serum, which are associated with the severity and mortality of icu patients. critically ill patients are characterized by the totally different sfs profile than in healthy people, particularly by the absence of phpa; but dominated by p-hphaa and p-hphla [ ] . the purpose of our study is to assess the gut metabolic activity via amm in sepsis. methods: in this study simultaneously serum and fecal samples (sfs) were taken from icu patients: -with sepsis, -chronic critical ill (cci) patients and control - sfs from healthy people. after liquid-liquid extraction from serum and fecal samples, phenylcarboxylic acids (amm) were measured using gc/ms (thermo scientific). results: the sum of the level of most relevant amm in serum samples were higher in patients with sepsis (median - . μm) than in cci patients ( . μm) and healthy people ( . μm). at the same time the opposite pattern was observed in the fecal samples - . , . and . μm, respectively. the ratios of sums amm gut/serum were higher in healthy people than icu patients (fig. ) introduction: the aim of this study is to describe the characteristic of bioelectric impedance vector analysis (biva) and muscular ultrasound during the first week after admission in the icu, and their correlation with indices of metabolic support. biva is a commonly used approach for body composition measurements [ ] . muscular ultrasound represents a valid tool to provide qualitative and quantitative details about muscle disease [ ] . methods: consecutive patients admitted to icu and expected to require mechanical ventilation for at least hours were enrolled in the study. within the first hours of icu admission (t ), patients were evaluated with muscular ultrasonography comprehensive of diaphragm thickness (dth) and rectus femoris cross-sectional area (csa). at the same time, biva and biochemical analysis. all the same measures were repeated at day (t ) and (t ) (figure (table ) . dividing the patients in two groups based on prealbumine changes (t vs t : increase, anabolic vs decrease, catabolic), those in which prealbumine increased had a higher reduction in muscle mass ( figure ). conclusions: this study showed how the pa tends to be reduced in the first week of icu stay. it is correlated with a concomitant introduction: the modified nutrition risk in critically ill (mnutric) has been developed in order to identify critically ill patients who may receive benefit from nutrition support [ ] . several evidences showed the association between the mnutric score and clinical outcomes [ , ] , however there are no data in thai critically ill patients. the purpose of this study was to find the association between mnu-tric score and -day mortality in medical intensive care unit (icu) patients, ramathibodi hospital. methods: we retrospectively reviewed the medical patient records from june to january . a mnutric score of each patient was calculated to evaluate the risk of malnutrition. statistical analysis of the association between mnutric score and -day mortality, length of stay in icu and hospital were performed. results: a total of critically ill patients were included in the study. the -day mortality was . % in patients with high mnutric score ( - ) and . % in patients with low mnutric score ( - ). modified nutric score was significantly correlated with day mortality (r = . , p< . ), length of stay in icu (r = . , p< . ) and length of stay in hospital(r = . , p< . ). in the receiver operating characteristic (roc) curve analysis, the auc of mnutric score and -day mortality was . ( % confidence interval (ci), . - . ) (fig ) . optimal cut-off value of showed sensitivity of . % and specificity of . % in mortality prediction (youden's index, . ). additionally, patients who received adequate nutrition supplement within days was . % for calorie and . % for protein. there was no association between nutrition support and -day mortality. conclusions: in thai medical intensive care population, the mnutric score was associated with -day mortality in critically ill patients. fig. (abstract p ) . within the first hours of icu admission (t ), patients will be evaluated with muscular ultrasonography comprehensive of diaphragm thickness and rectus femoris (medial vastus) cross-sectional area. at the same time, anthropometric measure will be collected (such as body height, ideal body weight, real body weight declared, right arm circumference) as well as biva measure (xc, r, pa, lean body weight and % of extracellular body weight) and biochemical analysis (inclusive albumin, pre-albumin, blood count, lymphocyte count, magnesium, phosphorus, reticulocytes, renal and hepatic function test). the day after, the fluid balance will be calculated as well as the nitrogen balance. all the same measures will be repeated at day (t ) and days (t ) introduction: ultrasonography is an essential imaging modality in critical care to diagnose and guide for therapeutic management of shock, multiple organ failure, etc. enteral tube feed intolerance occurs frequently in hospitalized patients and more so in critically ill patients. in present study, we consider that nursing staff may be able to use bedside ultrasound as an alternative to standard aspiration protocol or radiographic studies to assess gastric volume and nasogastric (ng) tube in patients with enteral feed intolerance. methods: in present prospective, single-center study, we performed ultrasound residual stomach volume and ng tube placement assessments of adult critically ill patients (figure ) compared to standard protocol of stomach volume assessment (routine daily shift -ml syringe aspirations) and ng (nasogastric) tube placement verified by abdominal x ray. we used an abdominal (linear ultrasound transducer) probe ( - mhz). the residual volume was calculated according to formula: gv (ml) = + . x right-lateral csa- . x age). results: hundred simultaneous double (ten critically ill patients) ultrasound measurements sessions were performed by nursing staff of our intensive care (icu) (fig ) . double simultaneous measurements of the ultrasound assessments were compared to standard nurse icu protocol for assessment of residual volume of stomach. the new ultrasound assessment method demonstrated excellent intra-class reliability (icc- . ( . - . , p< . ) and strong correlation with standard residual volume assessment method (icc- . ( . - . , p< . ). ng tube placement was successfully verified by ultrasound measurements in all ten critically ill patients and, thereafter, confirmed by abdominal x-rays. conclusions: preliminary results of our study demonstrated good correlations between both methods of ng tube placement and residual stomach volume: standard icu nurse protocol and ultrasound assessment. evaluating the documentation of nasogastric tube insertion and adherence to safety checking l roberts introduction: enteral feeding into a misplaced nasogastric (ng) tube is recognised by the national patient safety agency as a never event. ng tubes are commonly indicated in level / patients, thus we set out to evaluate current practice in critical care. the aim was to evaluate: documentation of insertion, adherence to safety guidance pertaining to checking safe use, chest x-ray interpretation. methods: this prospective cohort study was based on inpatients in critical care who had insertion of ng tubes over four weeks; there were insertions. data was analysed from patients' medical notes and the hospital's imaging system. results: % of insertions were documented using proformas. . % of proforma documentations included or more details: type of tube, tube length at the nostril, nex measurement, aspirate adequacy, chest x-ray adequacy, whether it was safe to feed. only . % of hand-written documentations included or more details. % of initial aspirates were obtained on insertion, of these, % had an appropriate ph between and . . this led to % of patients having chest x-rays to confirm initial placement of the ng tube. only % of chest x-rays adequately satisfied the four criteria. written documentation in medical notes stating if it was safe to feed was completed in % of cases. conclusions: we found that proformas ensure a higher level of detail and uniformity in the documentation of ng tube insertions. there was a high incidence of chest x-rays performed to confirm correct placement of tubes due to difficulties in obtaining aspirates and failure to follow guidelines. a need for a uniform, ward-specific proforma on ng tube insertion has been identified, as well as a teaching session on chest x-ray interpretation and on techniques to aid obtaining aspirates. we have established critical care's shortcomings in ng tube insertion documentation and tube safety checking. introduction: pressure ulcers(pu) are considered as important types of public health problems, due to high mortality and cost. we aimed to investigate the efficiency of curcumin and fish oil on prevention and treatment of pu using a feasible mice model. methods: mice were randomly divided into control(group ), curcumin(group ), fish oil(group ), curcumin and fish oil(group ) groups. mm skin bridge between two gauss magnets was formed on the back of mice, followed by ischemia reperfusion cycles as hours of rest after hours of magnet placement [ ] . a single dose of curcumin and fish oil was injected intraperitoneally. tissue samples had taken th day of first compression, rates of pu, inflammation, reepithelisation, neovascularisation and granulation were examined histopathologically. the data analyzed by pearson chi-square test. results: third degree pu were observed in all groups.there was no significant difference between groups in terms of inflammation.the formation of reepithelisation showed a significant difference between groups.partial reepithelisation ratios in group and group was elevated.there was significant difference between groups in terms of neovascularisation, the highest rate as % was observed in group .formation of granulation was observed at maximum rate as . % at group . conclusions: depending on positive results of curcumin, fish oil, cur-cumin+fish oil on wound healing it may be advised to use them in treatment of acute pu.after similar rate of pu with control group we consider that it should be beneficial to evaluate the effect of these therapies with more studies by changing the mode of administration, time of initiation and duration of therapy. introduction: inflammation is a key driver of malnutrition during acute illness and has different metabolic effects including insulin resistance and reduction of appetite. whether inflammation influences the response to nutritional therapy in patients with disease-related malnutrition remains undefined. we examined whether the effect of nutritional support on the risk of mortality differs based on the inflammatory status of patients. methods: this is a secondary analysis of a multicentre trial in eight swiss hospitals, where patients with a nutritional risk score (nrs) of ≥ upon hospital admission were randomly assigned to receive protocol-guided individualized nutritional support according to nutrition guidelines (intervention group) or a control group. the inflammatory status was defined based on admission crp levels as low inflammation (cpr < mg/dl), moderate inflammation (crp - mg/dl) and high inflammation (crp > mg/dl). results: we included a total of , patients of which . %, . % and . % had low, moderate and high inflammation levels on admission. while overall there was a significant reduction in day mortality associated with nutritional support (adjusted or in the overall cohort . , %ci . - . ), the subgroup of patients with high inflammation did not show reduced mortality (adjusted or . , %ci . - . , p for interaction = . ). there was no difference in other secondary endpoints when stratified based on inflammation. nutritional support did not affect crp levels over time (kinetics). conclusions: this secondary analysis of a multicentre randomized trial provides evidence, that the inflammatory status of patients influences their response to nutritional support. these findings may help to better individualize nutritional therapy based on patients initial presentation. introduction: low plasma glutamine levels have been associated with unfavourable outcomes in critically ill patients. this study aimed to measure plasma glutamine levels in critically ill patients and to correlate glutamine levels with biomarkers and severity of illness. methods: we enrolled critically ill patients admitted to three icus in south africa, excluding those receiving glutamine supplementation prior to admission. we collected clinical, biochemical and dietary data. plasma glutamine levels were determined within hours of admission, using liquid chromatography mass spectrometry and categorized as low (< μmol/l), normal ( - μmol/l) and high (> μmol/l). results: of the patients (average age . ± . years, % male), % were mechanically ventilated, with a mean apache ii score of . ± . and a mean sofa score of . ± . . plasma glutamine levels were low in . % (median plasma glutamine of . μmol/l). baseline plasma glutamine correlated inversely with crp (r=- . , p< . ) and serum urea (r=- . , p< . ), and positively with serum bilirubin (r= . , p< . ) and serum alt (r= . , p= . ). significantly more patients with low admission glutamine levels required mechanical ventilation (chi = . , p< . ) and had higher apache scores (p= . ), higher sofa scores (p= . ), higher crp values (p< . ), higher serum urea (p= . ), higher serum creatinine (p= . ), lower serum albumin (p< . ) and lower bilirubin levels (p= . ). using multiple logistic regression analysis, apache score (odds ratio, [or] . , p= . ), sofa score (or . , p= . ) and crp (or . , p< . ) were significant predictors of low plasma glutamine levels. roc curve analysis revealed a crp threshold value of . mg/l to be indicative of low plasma glutamine levels (auc . , p< . ). conclusions: . % of critically ill patients had low plasma glutamine levels on admission to icu. this was associated with increased disease severity and higher crp. introduction: the east of england deanery operational delivery network in the united kingdom came together as a group of intensive care units to comply an evidence-based care bundle. one of the branches of this care bundle is on parenteral nutrition and states: 'parenteral nutrition should not be given to adequately nourished, critically ill patients in the first seven days of an icu stay.' this is based on evidence [ ] [ ] [ ] that showed that 'in patients who are adequately nourished prior to icu admission, parental nutrition initiated within the first seven days has been associated with harm, or at best no benefit, in terms of survival and length of stay in icu.´the objective of this second cycle was to assess whether or not we are adhering to the guidelines, last year we were failing to hit targets and after some action i reassessed how we performed in the year compared to . methods: a retrospective audit of the whole year of for all patients admitted to icu who had parenteral nutrition started at any point during their stay. results: there is a significant improvement in the percentage of patients who are being started incorrectly on tpn before days ( % compared to %) (fig , ) . i also found a total reduction in the number of patients prescribed tpn, a reduction in the number of bags being used and a reduction in length of hospital stays. conclusions: as we have recently switched over to an electronic icu programme for all documentation and prescriptions, as part of our plan and act in the pdsa cycle we are organising for several things to be put in place on the new system on prescription: pharmacy authorisation, links to guidelines and alert/justification boxes. i will do a further cycle in another year. jg and mpc contributed equally. introduction: recent rcts revealed clinical benefit of early macronutrient restriction in critical illness, which may be explained by enhanced autophagy, an evolutionary conserved process for intracellular damage elimination [ ] . however, in the absence of specific and safe autophagy-activating drugs, enhancing autophagy through prolonged starvation may produce harmful side effects. a fasting-mimicking diet (fmd) may activate autophagy while avoiding harm of prolonged starvation, which also improved biomarkers of age-related diseases in an experimental study [ ] . we evaluated if short-term interruption of continuous feeding can induce a metabolic fasting response in prolonged critically ill patients. methods: in a randomized cross-over design, prolonged critically ill patients receiving artificial feeding were randomized to be fasted for hours, followed by hours full enteral and/or parenteral feeding, or vice versa. patients were included at day in icu and blood glucose was maintained in the normal range. at the start and after and hours, we quantified total bilirubin, urea, insulin-like growth factor-i (igf-i) and beta-hydroxybutyrate (boh) in arterial blood. insulin requirements were extracted from patient files. changes over time were analyzed by repeated-measures anova after square root transformation. results: as compared to hours of full feeding, hours of fasting decreased bilirubin (- . ± . mg/dl; p= . ) and igf-i (- . ± . ng/ml; p< . ), and increased boh (+ . ± . mmol/l; p< . ), without affecting urea concentrations (fig ) . fasting reduced insulin requirements (- . ± . iu/hour; p< . ). conclusions: short-term fasting induces a metabolic fasting response in prolonged critically ill patients, which provides perspectives for the design of a fmd, aimed at activating autophagy and ultimately at improving outcome of critically ill patients. introduction: recent evidence has led to changed feeding guidelines for critically ill patients, with a shift towards lower feeding targets during the acute phase [ ] . when micronutrients are not provided separately, prolonged hypocaloric feeding could induce micronutrient deficiencies and increase risk of refeeding syndrome once full feeding is restarted, which are both potentially lethal complications [ ] . since there is limited evidence how to optimize micronutrient provision in order to avoid deficiencies, we hypothesized that there is a great variation in current practice. methods: within the men section of the european society of intensive care medicine (esicm), we designed a questionnaire to gain insight in the current practice of micronutrient administration. in email blasts, invitations were sent to all esicm members, with currently more than respondents. the survey will be closed at december , . results: first, we will describe demographic characteristics of the respondents, including geographical location, icu and hospital type, and function. second, we will describe some aspects of the current practice of micronutrient administration. we will identify the proportion of respondents having a protocol, on which evidence such protocol is based and whether it takes into account the stability and daylight sensitivity of micronutrients. next, bearing refeeding syndrome in mind, we will identify whether there are respondents who never measure and/or separately administer micronutrients and phosphate. finally, we will make a top of the most measured and most supplemented micronutrients. conclusions: this survey will deliver more insight in the current practice of micronutrient provision across different types of icus and may identify areas for future research. furthermore, we will evaluate whether there is need to increase awareness for refeeding syndrome. introduction: large gastric residual volumes (grvs) have been used as surrogate markers of delayed gastric motility to define enteral feeding intolerance (efi). recent studies have challenged the definition of efi. study objectives: ) investigate the potential relationship between grvs and clinically outcomes, ) develop an algorithm for early identification of patients at increased risk of mortality due to efi. methods: a retrospective study of inpatient encounters from electronic health record charts within the dascena clinical database. , patients were included in the study; patients had efi. eight vital signs (diastolic/systolic bp, heart rate, temperature, respiratory rate, grv, glasgow coma scale, and feeding rate) and their trends were input to the classifier. machine learning classifiers were created using the xgboost gradient boosted tree method with -fold cross validation. results: rate of change in grv (Δ grv) was measured over a -day period, beginning at the time of efi onset (figure a) . figure b shows a high likelihood of mortality for patients with none or modest grv reduction. patients with an increase in grv over the five-day period after efi onset had the highest mortality likelihood. a stratification algorithm was developed to identify efi patients who died inhospital despite grv reduction at , , and hours in advance of efi onset. area under the receiver operating characteristic (auroc) curves demonstrated high sensitivity and specificity of algorithm predictions of in-hospital death up to hours in advance of efi onset (table ) . conclusions: the analysis suggests an association between grv and mortality, especially in patients with persistent grv increase over the -day period after efi onset and the potential of algorithmic models to predict efi development. prospective validation of these fig. (abstract p ) . changes in metabolic markers of fasting over time for both randomization groups algorithms may assist in clinical trial design to develop treatments for patients at highest risk of experiencing serious outcomes due to efi. a quality improvement project to improve the daily calorific target delivery via the enteral route in critically ill patients in a mixed surgical and medical intensive care unit (icu) b johnston, d long, r wenstone royal liverpool and broadgreen university hospital trust, critical care, liverpool, united kingdom critical care , (suppl ):p introduction: 'iatrogenic underfeeding' is widespread with the calo-ries study reporting only %- % of prescribed daily kcal was actually delivered to patients [ ] . in the present project, quality improvement methodology was utilised with the aim of delivering greater calories by implementing -hour volume-based feeding and allowing increased feeding rates for, 'catch up' of missed daily feed volume. methods: baseline data assessing the percentage of daily kcal delivered to ventilated patients was collected in september . data was presented and new intervention guidelines agreed based upon the pepup protocol [ ] . nurse champions were identified and were responsible for cascade training of the pepup protocol. educational tools to help determine daily calorific requirement and volume of feed required were provided. repeat data was collected at months (cycle ) after pepup implementation. results: ten patients were included in cycle . during cycle the percentage of kcal achieved via enteral feeding was %. following intervention this increased to % (p< . ) during cycle . this increased further to . % of daily kcal when calories obtained from propofol were included. conclusions: a -hour volume-based feeding regimen is a simple and cost-effective method of improving enteral feeding targets. through the use of quality improvement methodology, we demonstrated that this approach is achievable. the success of this project has led to the adoption of the protocol in other icu units in a regional critical care network. effect of non-nutritional calories on the calory/protein ratio in icu patients s jakob, j takala university hospital bern, dept of intensive care medicine, bern, switzerland critical care , (suppl ):p introduction: nutritional diets are composed to match the needs of critically ill patients. while effective calory needs can be measured or calculated, the needs of proteins are more controversial. we aimed to calculate non-nutritional calories and assess how they influence the ratio of calories to protein delivered to the patients. methods: in this retrospective analysis, nutritional and nonnutritional calories and protein delivery were calculated in consecutive icu patients receiving enteral nutrition in . introduction: marked protein catabolism is common in neurocritical patients. optimal nutritional monitoring and protein nutritional adequacy could be associated with outcome in neurointensive care unit (ncu) patients. we aimed to evaluate the impact of monitoring and optimal support of protein using nitrogen balance on outcome in neurocritical patients. methods: a consecutive patients who were admitted to ncu were included between july and february . nitrogen balance was calculated using excreted urine urea nitrogen during icu admission. follow-up nitrogen balance monitoring was performed in patients. we divided patients into two groups based on the results of nitrogen balance (positive balance and negative balance). moreover, we evaluated improvement of nitrogen balance in patients. we assessed the outcome as length of stay in hospital, length of stay in ncu, and in-hospital mortality. we compared the clinical characteristics and outcome according to nitrogen balance. results: among the included patients (age, . ; and male. . %), ( . %) patients had negative nitrogen balance. the negative balance group was more likely to have lower glasgow coma scale (gcs), longer length of stay in hospital, and longer length of stay in ncu. in patients with follow-up nitrogen balance monitoring, improvement of nitrogen balance group had lower in-hospital mortality ( . % vs. . %, p = . ), and received adequate protein intake ( . g/kg/day vs. . g/kg/day, p = . ) compared to no change group (table ) . there was no significant difference in baseline nitrogen balance, baseline body mass index, and gcs between two groups. conclusions: this study demonstrated that critical illness patients in ncu are underfeeding using nitrogen balance, however, adequate provision of protein was associated improvement of nitrogen balance and outcome. this suggests that adequate nutrition monitoring and support could be an important factor for prognosis in neurocritical patients. increased protein delivery within a hypocaloric protocol may be associated with lower -day mortality in critically ill patients introduction: to test the hypothesis, using real world evidence that increasing protein delivery and decreasing carbohydrates (cho) may improve clinical outcomes. methods: retrospective analysis of existing electronic medical records (emr) of patients admitted to the intensive care units (icu) at the geisinger health system. logistic regression analysis was used to determine correlation between protein delivered (which was proportional to the concentration of protein in the formula utilized) and clinical outcomes. results: medical encounters for a total number of , icu days were collected and analyzed. average age was . years ( . % male) and . % were obese and overweight. primary diagnoses included sepsis or septic shock, acute and/or chronic respiratory failure (or illness), cardiovascular diseases, stroke and cerebrovascular diseases among others. median hospital los was . days, . days in the icu, median days of invasive mechanical ventilation of . -day readmission rate among patients discharged alive was . %. patients in the high protein group received lower amounts of chos (data not shown). unadjusted -day post-discharge mortality was inversely proportional to the amount of protein delivered (table ) . conclusions: a significant improvement in mortality is observed with increased protein delivery while decreasing carbohydrate loads. prospective randomized trials are warranted to establish causality. introduction: acute kidney injury (aki) is associated with high mortality. the risk increases with severity of aki. our aim was to identify risk factors for development and subsequent progression of aki in critically ill patients. methods: we analysed patients without end-stage renal disease who were admitted to the icu in a tertiary care centre between january to december and did not have aki on admission. we identified risk factors for development and non-recovery of aki as defined by the kdigo criteria. results: the incidence of new aki in days was % (aki i %, aki ii %, aki iii %). multivariate analysis revealed bmi, sofa score, chronic kidney disease (ckd) and cumulative fluid balance as independent risk factors for development of aki. among patients who developed aki in icu, % had full renal recovery, % partial recovery and % had no recovery of renal function by day . aki patients without renal recovery in days had significantly higher hospital mortality ( %) compared to the other groups. independent risk factors for non-recovery of renal function were ckd, mechanical ventilation, diuretic use and extreme fluid balance before and after first day of aki. (table ) the association between cumulative fluid balance before aki and hours after aki with risk of aki non-recovery are shown in figure and . conclusions: aki is common and mortality is highest in those who do not recover renal function. cumulative fluid accumulation impacts chances of aki development and progression. (table ). all were in r . / ( %) of those with an admission ck> had aki or . all ( %) patients who required crrt for aki associated with rm were at risk for aki regardless of initial ck: vascular surgery ( / ), multi-organ dysfunction ( / ), and/or pre-existing renal disease ( / ). conclusions: raised ck is common in icu but its cause is multi factorial thus an isolated measure > does not require immediate high output treatment for rm aki. aki is more common in patients who have more than ck> on sequential days or those whose first ck was > as rm may be contributing. a single ck> in patients with a clear reason to develop rm should also start treatment. surgical outcomes of end-stage kidney disease patients who underwent major surgery p petchmak , y wongmahisorn , k trongtrakul introduction: acute kidney injury (aki) occurs in more than % of successfully resuscitated out-of-hospital cardiac arrest patients treated with targeted temperature management (ttm) [ ] . the effect of the duration of cooling on aki has not been well studied. in this post-hoc analysis of the tth randomized controlled trial that compared vs -hours of ttm ( °c) after cardiac arrest [ ] , we studied the impact of ttm length on the development of aki. fig. . duration of ttm had a significant impact on the development of creatinine values during the first days in the icu, p< . . this was primarily driven by an increase in creatinine during rewarming on day for the hour and day for the -hour group (fig ) . conclusions: in a trial of vs hours of ttm after out-of-hospital cardiac arrest, the length of ttm did not affect the incidence of aki. fig. (abstract p ) . creatinine over time patients [ ] , but there are no published data on longer-term renal outcomes in adult patients. the purpose of this study was to assess longer-term trends in serum creatinine in this cohort. methods: a retrospective study was conducted of all patients admitted to an adult regional referral centre for ecmo at a uk university hospital between and . those who survived for > months were included. demographics, baseline serum creatinine, presence of aki during icu admission, and serum creatinine at hospital discharge were determined. serum creatinine and dependence on renal replacement therapy (rrt) were assessed at and months post ecmo. results: patients had a complete (or near-complete) data-set available. the mean age was . years, % of whom were male. / had aki during their critical care admission. none were dependent on rrt at or months post ecmo. most patients had lower serum creatinine results at hospital discharge compared to their pre-hospitalisation baseline, but creatinine concentrations at and months post ecmo tended to be higher than at hospital discharge ( figure ) . conclusions: in this cohort of ecmo patients who were discharged from hospital alive, serum creatinine tended to be lower at hospital discharge compared to baseline and rose again in the following months. decreased creatinine production due to deconditioning and muscle wasting may offer a biological rationale for the lower creatinine results at hospital discharge [ ] . therefore, caution should be exercised in the use of serum creatinine at hospital discharge to assess renal dysfunction -further research is warranted. introduction: aki complicates more than half of icu admissions [ , ] and is associated with development of chronic kidney disease (ckd), need for renal replacement therapy (rrt) and increased mortality [ ] . we prospectively evaluated all icu admissions during a one-year period in order to determine incidence, etiology and timing of aki as well relevant clinical outcomes. methods: prospective observational study of all patients admitted from jan to dec to a multidisciplinary icu in greece. patients with end-stage renal disease and anticipated icu stay less than hrs were excluded. aki diagnosis and classification was based on kdigo criteria [ ] . lowest creatinine level within months before admission or first creatinine after icu admission served as reference. (fig ) . conclusions: although aki alert does not include urine output criterion or aki risk factors, it remains a helpful tool to point out patients with aki. education and diagnostic algorithms are still needed to early diagnose and treat aki patients. influence of severity of illness on urinary neutrophil gelatinaseassociated lipocalin in critically ill patients: a prospective observational study c mitaka, c ishibashi, i kawagoe, d satoh, e inada untendo university, anesthesiology and pain medicine, tokyo, japan critical care , (suppl ):p introduction: neutrophil gelatinase-associated lipocalin (ngal) is a diagnostic marker for acute kidney injury (aki). ngal expression is highly induced not only in kidney injury, but also in epithelial inflammation of intestine, bacterial infection, and cancer. however, the relationship between ungal and severity of critically ill patients has not been well understood. the purpose of this study was to elucidate whether ungal is associated with severity of illness and organ failure in critically ill patients. methods: we prospectively enrolled patients with sepsis (n= ) and patients who underwent esophagectomy with gastric reconstruction for esophageal cancer (n= ). sepsis was defined according to sepsis- . ungal levels were measured on icu day , , , and . ungal levels and aki rate in patients with sepsis were compared with those in patients who underwent esophagectomy. aki was defined according to kdigo. acute physiology and chronic health evaluation (apache) ii score and sequential organ failure assessment (sofa) score were calculated. results: median ungal level ( ng/mg creatinine) was significantly higher in patients with sepsis than that ( ng/mg creatinine) in patients who underwent esophagectomy on day . median apache ii score and median sofa score in patients with sepsis were significantly higher than those in patients who underwent esophagectomy. four patients with sepsis developed aki, and out of them underwent continuous renal replacement therapy, whereas no patients who underwent esophagectomy developed aki. ungal levels were positively correlated with apache ii score and sofa score in patients with sepsis. ungal levels were remarkably elevated (> ng/mg creatinine) in urinary tract infection (n= ), loops enteritis (n= ), and obstructive jaundice due to cholangiocarcinoma (n= ). conclusions: these findings suggest that ungal level is associated with severity of illness and organ failure in patients with sepsis. ungal levels might be influenced by severity of illness and inflammation. to assess the quality of the course us renal images had to be evaluated in "post-renal obstruction" (p-ro) or "no p-ro". the rate of correctness (roc farius ) was determined. in we, once again, contacted the students to attend a web-based online "follow-up". this online survey was created with "google formular". new and unknown us images were presented and rated in "p-ro" or "no p-ro" (roc fup introduction: septic-induced kidney injury worsen the patient's prognosis [ ] . renal resistance index (rri) is correlated with an increased mortality in septic patients [ ] . the aim of this study was to describe the evolution of rri in a rat sepsis model. methods: the local ethics committee approved the study (apa-fis# - ). sepsis was induced in -month-old male rats by caecal ligation and puncture (clp) [ ] . the rri was assessed before and h after clp by pulse doppler on the left renal artery (rri=(peak systolic velocityend diastolic peak)/ peak systolic values expressed as % per column. abbreviations in alphabetical order: aki acute kidney injury; akin acute kidney injury network definition; ckd chronic kidney disease. there were statistical differences between subgroups with and without aki for the subgroups of patients with previous ckd (p = . *), sepsis at admission (p = . **), hypotension (p= . ***) fig. (abstract p b) . target comparing accuracy and precision of aki alert and actual aki diagnoses velocity) (fig ) . rri were compared by a paired wilcoxon test (r software v. . . ). a p value < . was considered significant. results: rats were included. hours after sepsis induction, all rats were in septic shock with cardiac dysfunction. the rri increased after sepsis induction compared to baseline ( . ± . vs . ± . , p< . ) and mean renal artery velocity decreased ( . ± . vs . ± . , p< . ) (fig ) . systolic and diastolic peaks velocity of the renal artery were unchanged. conclusions: sepsis induced changes in rri and mean velocity on the left renal artery whereas no changes in systolic or diastolic velocities were seen. these results are consistent with available clinical datas. the rri could be an additional tool to assess renal failure in septic rats. further studies are needed to confirm the validity of this marker during sepsis. kidney failure is one of the most common organ dysfunction during sepsis. the rri could be an additional tool in small animals to assess the effects of potential therapeutic targets on renal function induced by sepsis. (fig ) . the egfr improved more with the heparin group ( % vs %; p= . ) (fig ) . interruptions of the filter circuit were as expected less with the citrate group ( mins vs mins; p= . ). finally, inotropic requirements increased following therapy interruptions, more so with patients receiving citrate ( . % vs . %; p= . ). conclusions: our analysis suggests that using citrate anticoagulation for rrt results in a monitoring cost saving of approximately £ per hours, alongside the other conferred savings previously reported. furthermore, results demonstrate the efficacies of both systems are similar in the initial hours, although there is a suggestion that heparin systems improves renal parameters more quickly. finally, interruptions and 'filter downtime' caused an increase in the patient's inotropic requirements, however results suggestive that this is greater in the citrate group. mmol/l respectively. demographic characteristics of the study group and the main parameters of the procedure were presented in fig . conclusions: regional citrate is a safe and effective anticoagulation method for crrt in children, when it is applied following a protocol. it significantly prolongs circuit survival time and thereby should increase crrt efficiency. we did not find any serious adverse effects of regional citrate anticoagulation. - ) , deceased at year n= ( %). the mdrd trend is more indicative than creatinine of decline of renal function in the post operative period (fig ) . crrt was used in . % ( pts) and was associated to a greater los and mortality (fig ) . preoperative bilirubin, bun and creatinine are among the greatest risk factors for its use ( table . at year follow up n= pts ( . %) were on hemodialysis. conclusions: aki requiring crrt in after lt is associated with higher mortality and los. identify patients at risk and adopt preventive strategies in the perioperative period is mandatory. introduction: we developed a new co removal system, which has a high efficiency of co removal at a low blood flow. to evaluate this system, we conducted in vivo studies using experimental swine model. methods: six anesthetized and mechanically ventilated healthy swine were connected to the new system which is comprised of acid infusion, membrane lung, continuous hemodiafiltration and alkaline infusion. in vivo experiments consist of four protocols of one hour; baseline= hemodiafiltration only (no o gas flow of membrane lung); membrane lung = "baseline" plus o gas flow of membrane lung; "acid infusion" = "membrane lung" plus continuous acid infusion; "final protocol" = "acid infusion" plus continuous alkaline infusion. we provided an interval period of one hour between each protocol. we changed the respiratory rate of the mechanical ventilation to maintain pco at - mmhg during the experiment. results: the amount of co eliminated by the membrane lung (vco ml) significantly increased by . times in the acid infusion protocol and our final protocol compared to the conventional membrane lung protocol, while there was statistically no significant difference observed in the levels of ph, hco -, and base excess between each study protocol. minute ventilation in the "final protocol" significantly decreased by . times compared with the hemodiafiltration only protocol (p < . ), the membrane lung (p= . ) and acid infusion protocol (p= . ). we developed a novel ecco r system which efficiently removed co and is easy-to-setup to permit clinical application. this new system significantly reduced minute ventilation, while maintaining acid-base balance within the normal range. further studies are needed for the clinical application of this easy setup system comprising of the materials typically used in a clinical setting. , and psychomotor agitation ( %) while the most common symptoms of hypertensive emergency were chest pain ( . %), dyspnea ( . %) and neurological deficit ( %). clinical manifestations of hypertensive emergency were cerebral infarction ( . %), acute pulmonary edema ( . %), hypertensive encephalopathy ( . %), acute coronary syndromes ( . %), cerebral hemorrhage ( ,. %), congestive heart failure ( %), aortic dissection ( . %), preeclampsia and eclampsia ( . %). conclusions: hypertensive urgencies were significantly more common than emergencies ( . % vs. . %, p< . ). there was no statistically significant difference in the number of patients with hypertensive urgency and emergency in relation to age, gender, duration of hypertension, except for the - age group, where urgency was statistically significantly higher (p= . ). introduction: emergency department (ed) crowding is a major public health concern. it delays treatment and possible icu admission, which can negatively affect patient outcomes. the aim of this study was to investigate whether ed to icu time (ed-icu time) is associated with icu and hospital mortality. methods: we conducted an observational cohort study using data from the dutch nice registry. adult patients admitted to the icu directly from the ed in academic centers, between and , were eligible for inclusion. for these patients nice data were retrospectively extended with ed admission date and time. ed-icu time was divided in quintiles. the data were analyzed using a logistic regression model. we estimated crude and adjusted (for disease severity; apache iv probability) odds ratios of mortality for ed-icu time. in addition, we assessed whether the apache iv probability (divided into quartiles) modified the effect of ed-icu time on mortality. results: a total of , patients were included. baseline characteristics are shown in table . the median ed-icu time was . [iqr . - . ] hours. icu and hospital mortality were . and . %, respectively. the crude data showed that an increased ed-icu time was associated with a decreased icu and hospital mortality (both p< . , figure a ). however, after adjustment for disease severity, an increased ed-icu time was independently associated with increased hospital mortality (p< . , figure b ). figure shows that only in the sickest patients (apache iv probability > . %), the association between increased ed-icu time and hospital mortality was significant (p= . , figure d ). we found similar results with respect to icu mortality. conclusions: this study shows that a prolonged ed-icu time is associated with increased icu and hospital mortality in patients with higher apache iv probabilities. strategies aiming at rapid identification and transfer of the sickest patients to the icu might reduce inhospital mortality. reliability and validity of the salomon algorithm: -year experience of nurse telephone triage for out-of-hours primary care calls e brasseur, a gilbert, a ghuysen, v d´orio chu liege, emergency departement, liège, belgium critical care , (suppl ):p introduction: due to the persistent primary care physicians (pcp) shortage and their substantial increased workload, the organization of pcp calls during out-of-hours periods has been under debate. the salomon (système algorithmique liégeois d'orientation pour la médecine omnipraticienne nocturne) algorithm is an original nursing telephone triage tool allowing to dispatch patients to the best level of care according to their conditions [ ] . we aimed to test its reliability and validity under real life conditions. methods: this was a -year retrospective study. out-of-hours pc calls were triaged into categories according to the level of care needed: emergency medical services (amu), emergency department visit (maph), urgent pcp visit (upcp), delayed pcp visit (dpcp). data recorded included patients' triage category, resources and potential redirections. more precisely, patients included into the upcp + dpcp cohort were classified under-triaged if they had to be redirected to an emergency department. patients from the amu+maph cohort were considered over-triaged if they did not spend at least resources, emergency specific treatment or any hospitalization. results: calls were actually triaged using the salomon tool, of which . % were classified as amu, . % as maph, . % as upcp and . % as dpcp (fig ) . as concerns the amu+maph cohort, the triage was appropriate in . % of the calls, with an over-triage rate of . %. as concerns the upcp + dpcp cohort, . % of the calls were accurately triaged and only . % were under-triaged. sal-omon sensitivity reached . % and its specificity . %. these results indicate that salomon algorithm is a reliable and valid nurse telephone triage tool that has the potential to improve the organization of pcp out-of-hours work. introduction: inappropriate visits to the emergency department (ed), such as patients manageable by a primary care physician (pcp), have been reported to play some role in the ed crowding [ ] . indeed, non-urgent patients directly managed by pcps could reduce ed workload [ ] . triage and diversion to alternative care facilities, eventually co-located within the ed, could offer a solution [ ] provided fig. (abstract p ) . distribution of different calls, their triage using the salomon algorithm and the inappropriate triages (over and undertriages) based on the preselected criteria the availability of a reliable triage tool for their early identification. we created a new triage algorithm, persee (protocoles d'evaluation pour la réorientation vers un service efficient extrahospitalier) and tested its feasibility, performance and safety. methods: after initial evaluation with a -level ed triage scale [ ] , ambulatory self-referred patients classified as level or below benefited from a simulated triage with persee identifying categories of patients: ed ambulatory patients and primary care (pc) treatable patients. we collected patients data and resources. patients requiring less than resources, no specific emergency treatment and no hospitalization were considered as manageable in a pc facility. results: patients were included in the study of whom . % were self-referred (fig ) . among those self-referrals, . % were triaged as level or below. . % patients were triaged as ambulatory patients of whom % were as pc treatable. we noted a redirection rate of % of the global visits or % of the self-referrals, an error rate of %, a sensitivity of . % and specificity of . %. conclusions: using advanced ed triage algorithm in addition to classical ed triage might offer interesting perspectives to safely divert self-referrals to pc facilities and, potentially, reduce ed workload. introduction: generally, prehospital medical provider should minimize staying prehospital scene to reach the patient to definitive care as soon as possible in prehospital medical activity. in addition, some textbook and report saids that medical provider minimize the number of procedure or limit minimum requirement procedure because unnecessary procedure may extend the staying time in prehospital scene. however, there are few studies evaluating this hypothesis and that this "extension is significant or not. therefore, we perform this study. methods: we evaluated the operated air ambulance(doctor-heli) case from st april to st march , in gifu university hospital using our mission record. we evaluated about time from landing to ready for taking off(activity time), operation doctor, mission category (i.e. trauma), number of procedure in the each activity and work load. we only focused on prehospital care and exclude transportation from hospital to hospital . in addition, we exclude the case which are not suitable for analysis. results: cases were operated in these period. cases were suitable for analysis. average activity time in prehospital scene was . ± . . there was weak correlation between the number of procedure and activity time. (r= . ) the length of the activity time did not depend on mission category. if the doctor perform and over procedures, staying time was minutes longer, this was significantly longer than that of under and under procedures. conclusions: we confirmed that we have to minimize the number of procedure or limit minimum requirement procedure in prehospital scene. and our result suggest we may have to limit appropriate number of procedures. introduction: organ failure is a critical condition, but the prevalence is largely unknown among unselected emergency department (ed) patients. knowledge of demographics and risk factors could improve identification, quality of treatment, and thereby improve the prognosis. the aim was to describe prevalence and all-cause mortality of organ failure upon arrival to the ed. methods: this was a cohort-study at the ed at odense university hospital, denmark, from april , to march , . we included all adult patients, except minor trauma. organ failure was defined as a modified sofa-score > within six possible organ systems: cerebral, circulatory, renal, respiratory, hepatic, and coagulation. the first recorded vital, and laboratory values were extracted from the electronic patient files. primary outcome was prevalence of organ failure; secondary outcomes were - -day and - -day mortality. results: of , contacts . % were female and median age (iqr - ) years. the prevalence of new organ failure was . %, individual organ failures; respiratory . %, circulatory . %, cerebral . %, renal . %, hepatic . %, and coagulation . %. the - -day and - -day all-cause mortality was . % ( % ci: . - . ) and . % ( % ci: . - . ), respectively, if the patient had new organ failures at first contact in the observation period, compared to . % ( % ci: . - . ) and . % ( % ci: . - . ) for patients without. seven-day mortality ranged from hepatic failure, . % ( % ci: . - . ) to cerebral failure, . % ( % ci: . - . ), and the - -day mortality from cerebral failure, . % ( % ci: . - . to renal failure, . % ( % ci: . - . ). conclusions: new organ failure is frequent and serious, with a prevalence of . % and a one-year mortality of % with wide variation according to type of organ failure. results: we proceeded to a descriptive study that showed that % of patients were male and % of them were female with a sex ratio of . .the average age of patients was years old and ranged between and years old.we found that patients of our population had medical background, dominated by diabetes in cases, high blood pressure in cases and asthma in cases.the results also showed that . % of patients had a history of abdominal surgery while % of them had history of other types of surgery.the patients were oriented according to their severity level as following: % care unit of emergency department, . % close monitoring room .the vaspi score was ranged between and with an average of ± . it was higher than in . % of cases.the results of physical examination found an isolated pain in , % of cases, a reactionnal pain syndrom in % of cases, a peritoneal syndrome in % of cases and an occlusive syndrome in % of cases.the final diagnosis was mostly represented by the following causes: . % of gastroenteritis . % of constipation and % of ulcer disease.the final orientation of patients according to the diagnosis led to hospitalization in % of cases and to outpatient clinic in % of cases while % of them did not need any more care. conclusions: appropriate diagnostic evaluation and decision for or against hospitalization is a challenge in the patient who comes to the emergency department with acute abdominal pain it need an adequate evaluation and management. introduction: we assessed patients' impressions of a selfadministrated automated history-taking device (tablet) to gather information concerning emergency department (ed) patients prior to physicians' contact. the quality of communication was compared with the traditional history-taking. methods: the algorithm content was developed by two emergency physicians and two emergency nurses through an iterative process. item-content validity index (i-cvi) was measured by five experts rating the relevance of each item (from : not relevant to : highly relevant) [ ] . next, quality control was realized by research team. to assess the feasibility, we used a computerized randomization. low acuity, ambulatory adult patients presenting to the ed were assigned either to a control group (cg, n= ) beneficiating form a traditional history-taking process or to the experimental group (eg, n= ) assigned to use the tablet with further history-taking by the ed physician. communication was analyzed by the health communication assessment tool [ ] and satisfaction assessed by questionnaires. results: after two rounds, validity was excellent for each item (i-cvi > . ). the universal agreement method was of . . refusals (n= ) to participate were analyzed: they fear using an electronic device or the experimentation. content satisfaction revealed that % of patients understood the questions. % of patients indicated that the device was easy to hold and use. medical communication was not affected by the device (p= . ). we noticed that, among the subsections, physicians significantly introduced themselves better in the eg (p= . ). conclusions: in this feasibility study, patients were highly satisfied. the use of a self-administrated automated history-taking device does not generate miscommunications and allow physicians better introduce themselves. . a positive point we have established is the possibility for the detorsion of a twisted retention ovarian cyst after its transvaginal aspiration. we used this method only in cases when the onset of torsion did not exceed hours. . % of all emergency conditions associated with retention cysts were recurred by conservative therapy, and . % of patients with the retention cysts rupture were successfully treated in this way. conservative management is possible in the case of a small loss of blood (up to . - . ml), hemodynamic stability and the absence of signs of continuing bleeding. the detorsion and resection of the cyst when torsion is not more than °and even longer than hours, in most cases did not reveal necrosis in the appendages. conclusions: improvement of organs of preservation and reproduction in women. criteria for admission to an intensive care unit of a tertiary hospital: analysis of the decisions of the outreach intensivist and day in-hospital mortality introduction: the aim of this study was the analysis of icu admission criteria and evaluation of in-hospital mortality of patients assessed by our critical care outreach team. criteria for admission to the icu should be defined to identify the patients most likely to benefit from icu admission. this triage process is complex, associated with several factors, including clinical characteristics of the patients, but also subjective factors because it depends on the judgment of the intensivist who decides whether to admit or not the patient and is obviously conditioned to the structure and size of the icu. methods: the outreach intensivist records the patient observation in a form with questions (reversibility of acute illness, objective of admission in icu, comorbidities, functional reserve and intuitive prognosis of the doctor). analysis of months (january through june , ) of admission decisions in icu, mean delay, icu mortality, and day in-hospital mortality ( hm). results: the intervention of the intensivist in "outreach" was requested on occasions. the main places of observation were the emergency room ( . %) and the wards ( . %). the hm increased with the degree of comorbidity decompensation. functional reserve also influenced hm, reaching . % in partially dependent patients and . % in totally dependent patients. there was agreement between the mortality and the physician´s intuitive prognosis in % of the cases. conclusions: a larger sample is needed to draw sustainable conclusions, however, the evaluation algorithm correlated well with hospital mortality. decompensated comorbidities and low functional reserve have a negative impact on prognosis, regardless of acute disease. there was agreement between mortality and the physician´s intuitive prognosis. electrochemical methods for diagnosing the severity of patients with multiple trauma introduction: multiple trauma is one of the leading causes of death worldwide [ ] . timely diagnosis and treatment is crucial in this state. one of the promising areas is the use of new electrochemical methods they are simple, flexible, efficient and of low cost. among these methods, attention is paid to the measurement of open circuit potential (ocp) of the platinum electrode and cyclic voltammetry (cva). the ocp is a reflection of the balance of pro-and antioxidants in the body, and the amount of electricity (q) determined by cva is proportional to the antioxidant activity of the biological environment. methods: a total of patients with severe multiple trauma ( . ± . y.o., men and women) were enrolled; apacheii . ± . ; iss . ± . ; blood loss ± ml. blood plasma was collected from patients. measurement of the ocp was carried out according to [ ] , cva analysis -according to the original method on a platinum working electrode. results: a shift in the ocp towards more positive potential values (fig. ) , while the antioxidant activity of blood plasma decreased (fig. ) . a more significant change of ocp, as compared to the q values, may indicate not only a deficiency in the components of the antioxidant defense system of the body, but also an increase in the concentration of prooxidants (e.g., reactive oxygen species), which are involved in oxidative stress. who underwent surgical fixation). information was collected from tarn, icnarc and surgical team databases. our primary outcome was itu resource utilisation (itu los and mechanical ventilation days). our secondary outcomes were morbidity and mortality (hospital los, infection burden, inotrope use and death before discharge). data was collected and analysed in microsoft excel and r. results: patients were included (group = , group = , group = ). mortality was significantly higher when comparing the post groups undergoing conservative ( %, / ) vs. surgical fixation ( %, / ), p-value = . . regarding potential temporal changes, there was no significant difference in mortality between the non surgical groups; pre- (group : / ) and post (group ), p-value . . group patients did spend more time mechanically ventilated (p-value . ) and used more antimicrobials (p-value . ) ( table ) . conclusions: patients undergoing surgical rib fixation at the rlh had significantly improved mortality with more days spent mechanically ventilated. pilot study on ultrasound evaluation of epiglottis thickness in normal adult a osman introduction: as the prevalence of epiglottitis is decreasing due to immunization, the difficulty in early detection remained. the aim of this study is to determine the thickness of epiglottis in normal adult with the utilization of bedside ultrasound. methods: this was a prospective observational study of convenience selection among healthy staff in emergency department, university malaya medical centre. the identification and measurement of epiglottis were performed using a mhz linear transducer by trained emergency physicians and registrars in em. subjects were scanned in either standing or upright seated position with the neck neutral or mildly extended. the epiglottis, thyroid cartilage and vocal cord were visualized and the epiglottis anteroposterior(ap) diameter was measured. difference in categorical parameters were analyzed by independent-sample t-test. the relationship between height, weight and epiglottic size was analyzed using pearson's correlation. results: fifty-six subjects were analyzed with males and females age ranging from to years old. the epiglottis ap diameter ranged from . cm to . cm, with average of . cm. there was significant difference in epiglottic ap diameter between male (m= . cm, sd= . ) and female (m= . cm, sd= . ; t( )= . , p=< . , twotailed). moderate positive correlation between height and epiglottic ap diameter (r= . ) and weight (r= . ) was documented. conclusions: our study demonstrated the identification and visualization of epiglottis was feasible and easy with the use of bedside upper airway ultrasonography. there was a little variation in the ap diameter of epiglottis in adults. indoor vs. outdoor occurrence in mortality of accidental hypothermia in japan y fujimoto , t matsuyama , k takashina introduction: the impact of location of accidental hypothermia (ah) occurrence has not been sufficiently investigated so far. thus we aimed to evaluate the differences between indoor and outdoor occurrence about baselines, occurrence place, mortality, and length of icu stay and hospital stay. methods: this was a multicenter retrospective study of patients with a body temperature ≤ °c taken to the emergency department of hospitals in japan between april and march . we divided the included patients into the following two group according to the location of occurrence of ah (indoor versus outdoor). the primary outcome of this study was in-hospital death. secondary outcomes were the length of icu stay, and hospital stay. results: a total of patients were enrolled in our hypothermia database. there were and patients with the outdoor and indoor occurrence. the indoor group was older ( versus . years-old, p< . ) and worse in adl than the outdoor group. the proportion of in-hospital death was higher in the indoor group than the outdoor group ( . % [ / ] versus . % [ / ], p< . ). the multivariable logistic regression analysis demonstrated that adjusted odds ratio of the indoor group over the outdoor group was . ( %ci; . to . ) ( table ) . as for secondary outcomes, both of the length of icu stay and hospital stay in survivors were longer in the indoor group than the outdoor group. conclusions: our multicenter study indicated that indoor occurrence hypothermia accounts for about % of the total in this study, and the proportion of in-hospital death was higher in the indoor group. we have to raise an alert over the indoor onset accidental hypothermia and need to take countermeasures for prevention and early recognition of ah in indoor location. conclusions: during acute asthmatic attack, arterial hyperlactatemia is frequently present at ed arrival. nevertheless, the plasma lactate level was no significant difference between ed admission and hr after treatment. the introduction: this is a case series of traumatic aortic injury (tai) which was diagnosed by transesophageal echocardiography (tee) in the emergency department. the number of patients with blunt thoracic aorta injury arriving at emergency department is on the rise and survival rate is time-dependent on early diagnosis. tee offers several advantages over transthorasic echocardiography (tte) including reliability, continuous image acquisition and superior image quality. methods: all trauma patients who presented to emergency department from st january until th november at hospital raja permaisuri bainun, perak, malaysia with suspected tai were evaluated with transesophageal echocardiography. over the years period, tee was performed in patients. patients had positive findings suggestive of tai. results: the first case was an old lady who presented after a deceleration injury in a car accident. tee was performed due to hemodynamic instability and found an intimal flap along the ascending aorta. the second case, a stanford type a (figure ) , was complicated with pericardial tamponade. the intimal flap was visualised from the aortic arch extending to the descending aorta by tee. the third case was a case of intramural haematoma involving distal aortic arch extending to the descending aorta which survived until corrective surgery. in the fourth case, tee revealed a motion artefact which mimicked an intimal flap in the ascending aorta. in the fifth case, tee showed intimal flap at aortic isthmus which was not detected by tte. in the last case, a traumatic aortic dissection was complicated by aortic regurgitation (figure ) . conclusions: tee can be a useful point of care tool use by emergency and critical care physicians for early diagnosis of blunt traumatic aorta injury. introduction: reboa is an endovascular intervention intended to preserve central perfusion in the context of shock due to noncompressible torso haemorrhage. more so, it is less invasive than the traditional approach of resuscitative thoracotomy (rt) and aortic crossclamping. though its use dates back to the korean war, it has not been widely adopted in trauma management, as evidence demonstrating clear benefit compared with conventional rt is lacking [ ] . we aimed to evaluate feasibility, outcomes and complications after reboa for haemorrhagic shock and traumatic cardiac arrest. methods: we performed a systematic literature review, searching scopus and pubmed databases using relevant terms (july ). we included studies enrolling patients with haemorrhagic shock or cardiac arrest after civilian trauma who had undergone reboa and reported hospital mortality (our primary outcome). abstract-only studies and single-patient case reports were excluded. we collated and analysed data using review manager v . . the newcastle-ottawa scale was used to assess risk of bias. results: sixteen in-hospital studies met inclusion criteria (n= ). ten were case series and six were cohort studies comparing reboa outcomes with those of rt. there were wide differences between studies' inclusion criteria, case-mix (including cardiac arrest), injury severity, insertion details, and reported outcomes. overall hospital mortality post-reboa was . %. meta-analysis of cohort studies indicated notably lower mortality in patients undergoing reboa (or . , . - . ) than rt with low statistical heterogeneity between studies (i = %), shown in fig . conclusions: whilst our findings are limited by methodological differences and biases in the included studies, almost % of patients undergoing reboa for haemorrhagic shock and/or cardiac arrest survived to discharge. furthermore, reboa appeared to offer a consistent mortality benefit compared with rt. introduction: trauma related coagulopathy remains a primary contributor to mortality on battlefields and in civilian trauma centres. fibrinogen is considered to be the first to drop below critical level and correspondingly compromised coagulation process. however, it is unclear if fibrinogen concentrate at a very early stage is feasible and effective to prevent from coagulopathy. methods: a total of acutely injured patients in austria, germany and czech republic were screened and enrolled in this controlled, prospective randomized placebo controlled double blinded multicentre and multinational trial. upon the completion of randomization, fibrinogen concentrate ( mg/kg, fgtw©, lfb france) or placebo was reconstituted and given to the patients at the scene or during helicopter transportation from the scene to nearby hospitals. blood samples were taken at baseline (scene of accident before study drug administration), at the emergency room, three hours, nine hours and twentyfour hours after admission to the hospital as well as after three and seven days after admission, for measurements of blood gases and coagulation, together with clinical data and outcome records. results: the demographic and injury characteristics and the estimated blood loss, iss, and gcs at the scene were similar in both groups. in the placebo group, fibrinogen concentration dropped from mg/dl at injury site to mg/dl () at er admission and clot stability reduced from . mm ( , mm) to mm (p= . ) (fig ) . fibrinogen concentrate administration prevented the drop of fibrinogen level (baseline of mg/dl to mg/dl and improved clot stability from mm at baseline to mm at er. conclusions: pre-hospital administration of fibrinogen concentrate in traumatic bleeding patients is feasible and effective in preventing the development of coagulopathy. data from this study support the use of fibrinogen to prevent trauma related coagulopathy. fibrinogen concentrate vs cryoprecipitate in pseudomyxoma peritonei surgery: results from a prospective, randomised, controlled phase study results: the per-protocol set included pts (hfc, n= ; cryo, n= ). the mean total intraoperative dose of hfc was . g vs . pools of cryo (containing approx . g of fibrinogen). median duration of surgery was . h. overall haemostatic efficacy of hfc was non-inferior to cryo and was rated excellent or good for % of pts receiving hfc and cryo, with similar blood loss. intraoperatively, only red blood cells were transfused (median: unit). intraoperative efficacy is shown in table . infusions were initiated . h earlier with hfc than cryo due to faster product availability. preemptive hfc led to a greater mean increase vs cryo in fibtem a ( figure ) and plasma fibrinogen (figure ). there were serious adverse events (saes) in the hfc group and in the cryo group, including thromboembolic events (tees; deep vein thromboses, pulmonary embolisms). no aes or saes were deemed related to the study drug. conclusions: hfc was efficacious for treatment of bleeding in pts undergoing surgery for pmp. no related aes and no tees occurred in pts treated with hfc. fig. (abstract p ) . fib mcf t to t with % ci fig. (abstract p ) . fibtem a prior to and following the preemptive dose of hfc/cryoprecipitate introduction: patients in the intensive care unit often suffer from thrombocytopenia. in dealing with this problem, we need to figure out not only the cause of thrombocytopenia but also the risk of bleeding. however, there is no reliable method for evaluating bleeding risk. methods: in this preliminary study, four thrombocytopenic patients who required platelet transfusion before undergoing invasive procedure were enrolled. written informed consent was obtained from all patients for participation in the study. bleeding was graded using the who bleeding scale. thrombogenic activity was evaluated using total thrombus-formation analysis system (t-tas), rotational thromboelastometry (rotem), and multiplate impedance aggregometry. for t-tas analysis, we prepared a novel microchip, named hd chip, which is suited for analyzing low platelet samples rather than those with normal platelet counts. , key patient groups in which it was wasted and the use of standard laboratory tests (slts) to guide its use. the purpose was to assess the potential benefit a point of care viscoelastic haemostatic assay (vha) could have on ffp transfusion and waste. the national blood transfusion committee and nhs blood and transplant committee have published data showing that up to % of ffp is transfused inappropriately [ ] . methods: blood bank data was obtained evaluating haemorrhaging patients in whom ffp was requested across a nine-month period in . patient bleeds were categorised by speciality. the mean time ffp dispensed and wasted was recorded, as were timings of slt requests. where available, the inr result was recorded. results: patients were identified. transfusions were requested. table shows that the highest transfusion requirements are for acute medical emergencies and major trauma. % of transfusion were surgical specialities, it would be expected that these patients would have anaesthetic or critical care input. units were wasted. acute medical emergencies wasted the highest amount of ffp ( units). table demonstrates that . % of transfusions had an inr available one hour prior to ffp being dispensed. conclusions: we conclude that use of slts to guide ffp transfusion is low. this suggests transfusion decisions are being made clinically. a point of care vha could give treating physicians better access to timely haemostatic data. introduction: we developed the process for the out-of-hospital packed red blood cells (prbc) transfusion in the hems of castilla-la mancha clm according to criteria of medical indications, security, monitoring and tracking. haemorrhage is a preventable cause of death among population suffering accidents or bleeding injuries in regions with low population density where health services should reach people in remote areas. hems of clm is the first out-ofhospital emergency service in spain that provides prbc transfusion there where the accident takes place. this program has been developed jointly between hematologists of the center for transfusions ct and the hems team. methods: observational retrospective study with data collected from june to august . the medical helicopter was provided with two prbc o rh(d) negative (fig ) . shock index was selected as indication for transfusion. to achieve feasibility and preservation of the prbc it was established a prospective monitoring and microbiological culture for both groups: case group for the prbc kept in the hems and control group in the hospital (fig ) . controls and comparison of hematologic analysis were performed immediately and days after collection. statistics used spss . (signification p< . ). results: prbc were evaluated, case - control. analyses were tested days and after collection. hemolysis was not observed. all cultures were negative. results obtained of the prbc after days transported in the hems related to monitoring parameters were not different than those observed on prbc conserved in the ct. prbc were transfused to patients in out-of-hospital assistance. neither post-transfusional reactions or undesirable events have been registered. prbc units are changed every days. conclusions: the process designed (collection, conservation, tracking and tests) to make prbc available in the medical helicopter has demonstrated to keep the standard conditions and properties to be transfused in critically ill patients out-of-hospital. outcomes in patients with a haematological malignancy admitted to a general intensive care unit a corner east sussex healthcare nhs trust, intensive care, eastbourne, united kingdom critical care , (suppl ):p introduction: recent published data have challenged the view that critically ill patients with a haematological malignancy have a poor prognosis [ ] . reports have largely originated from tertiary centres. the aim of this audit was to evaluate the intensive care unit (icu), in hospital and one year mortality for a cohort of patients admitted to a mixed medical and surgical icu in a district general hospital. methods: details were obtained for all patients with a haematological malignancy admitted to eastbourne and hastings icu between march and august . patient characteristics, type of malignancy, reason for admission, degree of organ support and survival rates at icu discharge, hospital discharge and year postadmission were collected. results: patients, % male, were identified. median (interquartile range, iqr) age was ( - ) years. % had neutropenia. the commonest malignancies were acute leukaemia %, lymphoma % and myeloma %. reasons for admission were respiratory %, cardiac % and renal %. organ supports used were noradrenaline %, intubation and mechanical ventilation %, renal replacement therapy (rrt) % and dobutamine %. overall survival rates are shown in figure . patients were discharged from hospital following a period of mechanical ventilation. for these patients, median (range) age was ( - ) years. all were male. median (iqr) time in hospital prior to admission was ( - ) days, / patients required vasoactive support, / required rrt, median icu length of stay was ( - ) days. / were admitted following surgery for an unrelated condition. to date, only / patient has survived years post icu admission. conclusions: although survival rates were disappointing, particularly in those patients requiring mechanical ventilation, selected patients have the potential for a good outcome. these results outcomes have been presented to our haematology department to aid patient counselling. analyses. cox regression was used for the survival analysis. organ failure was defined as the occurrence of renal failure based on acute kidney injury network (akin)-creatinine or need for; vasopressors, invasive ventilation or continuous renal replacement therapy (crrt) the first days after admission. length of stay was only analysed in survivors. results: the study included unique patients. prolonged aptt was associated with mortality with a % confidence interval (ci) of hazard ratio . - . . prolonged aptt correlated also with the occurrence of renal failure and the need for vasopressor and crrt with % ci of odds ratio (or) . - . , . - . and . - . (fig ) . increased pt-inr was associated with the need for vasopressors and invasive ventilation with % ci of or . - . and . - . . both aptt and pt-inr correlated with length of stay with % ci of or . - . and . - . . conclusions: activated partial thromboplastin time on admission to the icu is independently associated with mortality. both aptt and pt-inr are independently associated with length of stay and the need of organ support. all regression models were adjusted for saps score which means that aptt prolongation and pt-inr increase on admission represent morbidity that is not accounted for in saps . introduction: the goal was to assess if daily venous thromboembolism (vte) assessment was being done in our critical care (cc) unit, and if not, what changes could be made. a mortality review showed the need for a dynamic vte assessment in cc patients, who are subject to daily changes influencing vte risk. a daily risk assessment was introduced, and a 'tab' on our clinical information system, metavision(r)(mv) was created. recently published national institute for health and care excellence guidelines on vte risk assessment in cc provided us cause to assess our compliance [ ] . methods: data was collected from mv. review of daily vte assessment was made and a percentage completion of daily vteassessments was calculated per patient.interventions were done using standard improvement methods through pdsa cycles. results: baseline data, of patients, was collected in july, .compliance with daily vte assessment was %. the results were presented at the clinical governance forum(cgf), and posters were displayed in cc. the second cycle, of patients, was collected in october. compliance had increased to %.following discussion from presenting results at the cgf, the vte tool was appropriately modified.the responsibility of vte assessment was also shifted to becoming more shared, including all clinical staff, rather than mainly consultants. the third cycle, of patients, was collected in november. compliance had increased to %.introducing a nursing care bundle with vte is in progress. conclusions: despite the identification of a risk in our clinical practice and the development of an appropriate it tool to facilitate improved practice, the advent of new national guidance revealed poor compliance with agreed standards. this shows the difficulties with achieving practice change in complex multiprofessional clinical environments. a sustained effort is required focusing on dissemination and engagement across the whole team. introduction: we describe the changes in anti factor xa (afxa) activity, thrombin generation and thromboelastography (teg) in critically ill patients with and without acute kidney injury (aki) following routine administration of tinzaparin as part of venous thromboembolism (vte) prophylaxis. methods: pilot prospective observational study. patients divided into those with and without aki were administered tinzaparin by subcutaneous injection as per established local guidelines. patients who did not receive tinzaparin were recruited as a 'control'. plasma afxa activity and thrombin generation were measured at intervals over a hour period. teg parameters were collected at t and t . results: afxa activity: results are shown in figure . / patients failed to achieve a prophylactic afxa level of > . at any point. / patients achieved a level of > . however in all cases this was at the lower end of the prophylactic range and was achieved for only a short time (median . hours). / achieved a level of > . for the whole h period. there was no difference between the aki and no aki groups. endogenous thrombin generation: there is no significant difference in thrombin generation between the aki and no aki groups. there is a significant decrease in thrombin generation between h and h (p< . ) and a significant increase between h and h (p< . ) (figure ). there is no significant difference between h and h (p= . ). teg: all teg parameters for all patients were within normal range conclusions: standard vte prophylactic dose tinzaparin rarely achieves an afxa range that has been suggested for vte prophylaxis. however, as assessed by thrombin generation, a hypo-coagulable state is generated in response to lmwh. there is no difference between critically ill patients with or without aki that would suggest the need for dose reduction in this context. (abstract p ) . thrombin generation at h, h and h. t = time of tinzaparin administration, with the sample taken just prior to administration. patients from aki group shown with dotted line and from no aki shown with solid line % which takes the third place between cpb-associated complications . current data demonstrates the importance of researching of changes in haemostatic system in paediatric patiens after cpb. provided below data is an intermediate result of our research. methods: patients in age up to mohth days (median age - , months, youngest age - days after birth, oldest - months days), who underwent cardiac surgery with cpb to treat congenital heart diseases, were enrolled in this study. all patients were divided into two groups: stwithout tc, ndwith tc. protein c (pc) and fibrin-monomer (fm) plasma levels were assessed in there points: before surgery, -hours and hours after surgery. thrombotic cases were provided by doppler ultrasound or mri. results: thrombotic complications were diagnosed in chidren ( %). between all tc ischemic strokes were diagnosed in % ( cases), arterial thrombosis in % ( cases), intracardiac thrombus in % ( cases). in group with tc fm-mean values in points , and respectively were . ; and mcg/ml, meamwhile in group without thrombosis - . ; . and . mcg/ml .pc-mean value in st groupwere ; and %, in the nd group - ; and % respectively in the points , and . statistically significant differences between groups in rd point (p< . ) and correlation between pc and fm (r=- . ; p< . ) were detected. conclusions: cpb causes hypercoagulation with increasing of pc consumtion and fm level. moreover, cp associated with a high risk of tc on the rd day after cardiac surgery. further studies to investigate prognostic values of fm and pc in thrombosis are required. these studies would help to asses fm and pc as markers of tc and possibility of pc-prescribing for prevention and treatment of these complications. introduction: thrombocytopenia is a common condition in critically ill patients and an independent predictor of mortality. the relevance of a supranormal platelet count remains unclear. septic patients with disseminated intravascular coagulation (dic) are also known to have a high mortality, but the influence of sepsis on mortality rates in coagulopathic patients is less well characterised. our objectives were to: ) evaluate mortality amongst patients with sepsis and nonsepsis associated dic. ) assess incidence of dic during the first days of admission. ) assess the relationship between platelet count and mortality. methods: records of adult critical care patients admitted to the royal liverpool university hospital between - were retrospectively reviewed. the presence of sepsis (using the definition of sirs with infection), coagulopathy, degree of thrombocytopenia and day mortality were noted. modified isth dic score was used to define dic. results: the overall mortality rate was %. patients were identified as having sepsis ( %) and non septic patients ( %). mortality rates of patients with sepsis were significantly higher than without sepsis ( % vs % respectively, p< . ). in patients with dic, their dic scores tended to be 'positive' for the first days of admission. fibrin-related markers were often not available for dic scoring. mortality rates amongst patients with sepsis-associated dic were greater than patients with non-sepsis related dic. thrombocytopenia severity was associated with mortality, and patients with platelets above the upper limit of normal had lower mortality rates ( % when platelets > x ^ /l, % when platelets < x ^ /l). conclusions: sepsis-associated coagulopathy is associated with a higher mortality rate than non-sepsis associated coagulopathy. supranormal platelet counts may be associated with a mortality benefit. introduction: deep vein thrombosis (dvt) is a major problem in icu and affects overall lethality. dvt is widespread complication in icu, especially in elderly patients, when early activisation may not be achieved. aim of this study is comparison of haemostatic potential and analgesia methods of elderly patients who underwent major urological surgery during their stay in icu. methods: a cross-sectional study was employed. participants were ≥ y.o., underwent major urological surgery, have had normal initial hemocoagulation data (thromboelastography was performed to all of them), had received analgesia with epidural catheter or iv by opioids use and were treated in icu > days due to non-coagulopathy states, were included. data were collected from october till october . the patients were examined with thromboelastograph "mednord" for thromboelastogramm (teg) and with esaote usg for thrombi occurrence in lower limb deep veins. the anticoagulants were prescribed under the esa guidelines . results: participants (n= ) were divided in two groups -non-opioid analgesia with epidural catheter (n= ) and opioid analgesia (n= ). we received moderate decrease in anticoagulants dosage to the patients with epidural analgesia with the same teg goals compared to the patients with opioid analgesia. other factors as comorbidities may provoke dvt events, but was not evaluated in this study. the dvt events were monitored by expert with the use of usg to locate thrombi in the vein. conclusions: use of epidural catheter analgesia provides moderate decrease of anticoagulants dosage compared to opioid analgesia patients; however strict control of teg data must be presented. comorbidity need to be monitored for early detection and prevention of dvt events. introduction: patients with morbid obesity (mo) have a high risk of thromboembolic events. in patients with a bmi > , the hypercoagulable state is due to impairment of all parts of the blood coagulation as well as anticoagulation mechanisms by obesity. methods: the hemostasis system was studied in patients with a bmi> kg/m with various pathologies that were admitted to icu. all patients were divided into groups depending on the type of therapy: group (n= ) received monotherapy with enoxaparin sodium . % . ml sc times a day every h; group (n= ) received combination therapy with enoxaparin sodium . % . ml sc times a day every h and pentoxifylline mg times a day every h. to study the hemostasis system, we used lpteg immediately after hospitalization, on , , days. results: in both groups, prior to treatment: contact coagulation intensity (icc) was increased by . %, intensity of coagulation drive (icd) -by more than . %, clot maximum density (ma) -by . %, index of retraction and clot lysis (ircl) - . % above normal. patients of the st group: icc increased by . %, icd was close to normal values, ma increased by . %, ircl was increased by . %. patients of the nd group on the th day: icc decreased by . % compared with the norm; the coagulation and fibrinolysis parameters were close to normal values and the decrease in fibrinolysis activity reaches to normal. conclusions: combined therapy of thromboembolic complications in patients with obesity sodium enoxaparin sodium and pentoxifylline is more effective than enoxaparin sodium monotherapy because it affects all parts of the hemostatic system. introduction: a laryngeal injury secondary to blunt neck trauma can lead to life-threatening upper airway obstruction [ , ] . ultrasound enables us to identify important sonoanatomy of the upper airway [ ] . the purpose of this report is to discuss role of pocus airway in blunt neck trauma and to determine airway management based on standard schaefer subgroups classification. methods: three cases of blunt neck trauma presented to our centre with either subtle or significant clinical signs and symptoms. standard airway management was performed prior to pocus airway using mhz linear transducer and it findings were later compared to flexible fibreoptic laryngoscopy and computed tomography (ct). results: pocus airway had identified one out of cases to have schaefer and the remaining as schaefer . all pocus airway findings were confirmed with flexible fibreoptic laryngoscopy and ct scan (figs , ) . based on schaefer, supportive care and early steroid administration are advisable for group and . for groups to , immediate open surgical repair is deemed necessary due to extension of injuries.all cases were intubated using glidescope.all including those presented with schaefer were managed conservatively and discharge well with proper follow-up. conclusions: upper airway ultrasound is a valuable, non-invasive and portable for evaluation of airway management even in anatomy distorted by pathology or trauma. an organised approach using pocus airway as an adjunct can expedite care and prevent early and long term complications in facilities without flexible laryngoscope and ct. introduction: high-flow nasal oxygen (hfno) and helmet noninvasive ventilation (hniv) are increasingly used for the early management of acute hypoxemic respiratory failure (ahrf). we compared the physiological effects of hfno and hniv during ahrf. methods: in this randomized cross-over study, we enrolled patients with acute-onset (< days), non-cardiogenic respiratory distress (respiratory rate> /min), pulmonary infiltrates at the chest-x-ray and hypoxemia (spo < % while breathing on room air). all patients received hniv (peep cmh o, pressure support adjusted to achieve a peak inspiratory flow of l/min) and hfno (flow l/min) for one hour each, in a randomized cross-over manner. at the end of each period, arterial blood gases, inspiratory effort (esophageal pressure) and respiratory rate were recorded. self-assessment of dyspnea and device-related discomfort ( [ ] [ ] [ ] [ ] [ ] ). conclusions: as compared to hfno among critically ill patients with ahrf, hniv ameliorates oxygenation, limits inspiratory effort and relieves dyspnea, without affecting paco , respiratory rate and comfort. introduction: pre-intubation hypoxemia is a predictor of negative patient outcomes including in-hospital mortality. while successful first intubation attempt is also an important factor of patient outcomes, little is known about whether physicians achieve successful first intubation attempt for the hypoxemic patients in the emergency department (ed). the aim of this study is to investigate the first-pass success for patients with pre-intubation hypoxemia in the ed. methods: this is an analysis of the data from the second japanese emergency airway network study (jean- study)a multicenter, prospective, observational study of eds in japan. we included all patients who underwent intubation in the ed from through . we excluded patients ) aged < years and ) patients who underwent intubation for cardiac arrest. we grouped pre-intubation hypoxemia as follows: non-hypoxemia (oxygen saturation [spo ], ≥ %), moderate-hypoxemia (spo , %- %), and severehypoxemia (spo , < %). primary outcome was the first-pass success rate. to demonstrate the association between pre-intubation hypoxemia and the first-pass success in the real-world setting, we fit two unadjusted logistic regression models ) using grouped preintubation hypoxemia as a categorical variable and ) using the preintubation spo as a continuous variable. results: among , patients who underwent intubation in the ed (capture rate, %), , patients were eligible for the analysis. compared to the non-hypoxemia, the first-pass success rate was low in moderate-hypoxemia ( % vs %; or= . [ %ci, . - . ]) and severe-hypoxemia ( % vs %, or= . [ %ci, . - . ]). additionally, there was a linear association between pre-spo and lower first-pass success rate (or for the success, per one pre-spo decrease, . [ %ci, . - . ]). conclusions: based on the large, multicenter data, the first-pass success rate was low in hypoxemic patients compared to nonhypoxemic patients in the ed. introduction of rapid-sequence induction guideline to reduce drug-associated hypotension in critically unwell patients introduction: the aim of this project was to assess whether the introduction of a rapid sequence induction (rsi) agent guideline changed drug choice and the incidence of peri-intubation vasopressor use at st john's hospital, livingston. it is well documented that emergency airway management in the critically ill can be a source of significant morbidity and mortality [ , ] and the choice of induction agent matters [ ] . methods: an rsi agent guideline was instituted for all critically ill patients being intubated in icu and the ed [ figure ]. following this, we set up an intubation registry to collect data from all intubation events. this data was then compared to a previous audit of intubations completed in . results: the choice of agent used pre-and post-intervention are summarized in figure . forty-five intubation events were included in the initial audit in , of which, ( %) required vasopressor support immediately following intubation. of the intubation events following the guideline's introduction, ( %) required vasopressors. ketamine use changed from % to %, propofol use from % to % and midazolam from % to %. thirty-eight of these intubation events ( %) were compliant with the guideline. conclusions: the introduction of the rsi guideline dramatically affected the choice of induction agent and reduced the incidence of significant hypotension requiring vasopressors ( % versus %). overall compliance with the guideline was excellent ( %). introduction: the purpose is to test the feasibility of using the i-gel® device for airway maintenance during bronchoscopic-guided percutaneous dilatational tracheostomy (pdt). usually pdt is accomplished via the tracheal tube. failure to position the endotracheal tube correctly can result in further complications during the procedure. the alternative implies extubation and reinsertion of an i-gel® airway device. methods: the pdt was performed using the blue dolphin method in patients in intensive care unit. before undertaking bronchoscopicguided percutaneous dilatational tracheostomy (pdt), the patient's tracheal tube (et) was exchanged for i-gel®, as a ventilatory device for airway maintenance. the insertion of the i-gel®, the quality of ventilation, the blood gas values, the view of the tracheal puncture site, and the view of the balloon dilatation were rated as follows: very good ( ), good ( ), barely acceptable ( ), poor ( ), and very poor ( ) [ ] . results: the i-gel® successfully maintained the airway and allowed adequate ventilation during percutaneous tracheostomy in all patients. the ratings were or in % of cases with regards to ventilation and to blood gas analysis, for identification of relevant structures and tracheal puncture site, and for the view inside the trachea during pdt. conclusions: the i-gel® successfully maintained the airway and allowed adequate ventilation during percutaneous tracheostomy in all patients. the ratings were or in % of cases with regards to ventilation and to blood gas analysis, for identification of relevant structures and tracheal puncture site, and for the view inside the trachea during pdt. no damages to the bronchoscope, reports of gastric aspiration or technical problems were detected. the bronchoscopic view obtained via an i-gel® seems to be better than that obtained through an endotracheal tube (et) or through traditional laryngeal mask [ ] . introduction: the purpose of this study was to investigate the efficiency of nasal airway inserted in the oral airway (on airway) in securing the airway patency during mask ventilation [ ] (fig ) . methods: fifty eight patients undergoing general anesthesia were randomly assigned to either oral airway group (group o) or on airway group (group n). in both group, mg/kg of propofol was infused intravenously and mask ventilation was performed in the sniffing position without head extension or jaw thrust. the patients were ventilated with a volume-controlled ventilator with o flow of l/min, tidal volume of ml/kg (ibw), and respiratory rate of /min. before the start of mask ventilation, airway was placed in the oral cavity. oral airway was used in group o and on airway was used in group n. peak inspiratory pressure (pip), tidal volume and etco were compared between the two groups. the location of airway tip was graded by fiberoptic bronchoscope as; : airway obstructed by tongue, : epiglottis visible, : airway touches epiglottis tip, : airway passes beyond epiglottis tip [ ] . methods: a prospective uncontrolled observational study in - in ukrainian hospitals. sma-pts from - mo were involved. all pts. ready for extubation: afebrile, no infiltrations on chest x-ray, normal wbc. however, each sma-pts. failed sbt (t-tube or psv). we evaluated: extubation success (no reintubation in hours), icu los, one year survival. three pts. were excluded: two pts. by staff decision, family have choosen tracheostomy. sma-pts. included. a cuff leakage test performed -with a negative, dexamethazone mg iv was administered. after extubation niv was started by ventilogik ls in st mode via nasal mask giraffe. the epap and ipap settings were titrated to reach the chest excursion and target levels of spo ( - %) and etco ( - mmhg). a sputum was draining by mechanical insufflation-excuflation (mie) and aspirator results: all pts, were extubated successful. the mean icu los was . days ( - days), one year survival rate was %, respiratory failure fully compensated by niv, there was no icu admission. every sma-pts. are in good condition, gaining weight introduction: aerosol delivery has previously been assessed during simulated adult hfnt, delivered by various stand-alone humidification systems [ ] . the objective of this study was to evaluate aerosol delivery during simulated hfnt delivered by a mechanical ventilator, across three clinically relevant gas flow rates. methods: ml of mg/ml salbutamol was nebulised using an aerogen solo nebuliser (aerogen, ireland). an adult head model was connected to a breathing simulator (asl , ingmar, us), vt ml, bpm and i: e, : (fig ) . hfnt was supplied via the servo-u ventilator (maquet, getinge, sweden), using the integrated nebulisation option. tracheal dose was recorded at two nebuliser positions; a (after the humidification chamber) or b (before of the cannula), at three gas flow rates ( lpm, lpm and lpm) (n= ). the mass of drug captured on a filter placed distal to the trachea (tracheal dose) was quantified using uv spectroscopy at nm. results: presented in table . conclusions: to our knowledge, this is the first study to successfully demonstrate aerosol delivery during simulated hfnt, delivered by a mechanical ventilator. increasing gas flow rate was associated with a reduced tracheal dose (p= < . ). at lpm, a significantly greater tracheal dose was observed when the nebuliser was positioned before the nasal cannula (p= < . ). at lpm, a greater tracheal dose was yielded when the nebuliser was positioned after the humidifier (p= < . ). introduction: tracheotomies are often performed in critically ill patients who are in need of prolonged mechanical ventilation and respiratory care. our aim was to evaluate the possible effect of percutaneous and surgical tracheotomies on thyroid hormone levels. methods: eighty seven adult patients were included in our study from january to september . patients were in need of prolonged mechanical ventilation and tracheotomies were performed after consent was taken. we have excluded patients with preexisting thyroid diseases. forty five patients were undergone percutaneous tracheotomies and forty two patients were undergone for surgical. thirty eight female patients and forty nine male, age range - . we studied tsh, t and ft serum levels using chemiluminescence immunoassay method before either procedure and hours post each procedure.: statistical analysis was performed using spss . significance was estimated at the level of p< . results: tsh levels were increased in surgical group compared to percutaneous group at hours post procedure but the difference was not found statistically significant (p> . ). the rise in post operative levels of t compared to preoperative was found statistically significant for surgical tracheotomy group (p< . ).elevated ft levels for both groups have shown statistically significant difference between preoperative and postoperative period for the surgical tracheotomy group (p< . ) conclusions: we analyzed the effect of surgical versus percutaneous tracheotomy on thyroid hormones and it was found that both introduction: insertion of a tracheostomy for weaning purposes is associated with prolonged critical length of stay (los) and several adverse patient outcomes [ ] . previous work has suggested that protocolised weaning may reduce weaning times [ ] . we aimed to assess the impact of protocolised weaning on los following introduction of a standardised weaning protocol in . conclusions: introduction of a standardised weaning protocol for patients with a tracheostomy in our unit has had a beneficial effect on several patient outcomes, notably duration of weaning and length of critical care admission. introduction: delirium is a relatively frequent neurologic complication in liver transplantation (lt) recipients, which is an important cause of increased morbidity, mortality, extended icu stay, and increased cost of medical care. extubation of the endotracheal tube at an appropriate timing is an essential part of intensive care after lt, suggested to improve graft perfusion and systemic oxygenation, and thus decrease intensive care unit (icu) stay and positively affect prognosis. the aim of this study was to compare the incidence of delirium between early and late extubation groups after lt. methods: medical records from patients who received lt from january to july in a single university hospital were retrospectively reviewed. patients were divided into groups: those who underwent early extubation after lt (group e, n = ) and those who underwent extubation within few hours of icu admission after surgery (group c, n = ). the data of patients´demographics, perioperative management, and postoperative complications were collected. early extubation was defined as performing extubation in the operating room after lt. a propensity score matching analysis was performed to minimize the effects of selection bias. results: postoperative delirium occurred in / ( . %) in group e and / ( . %) in group c, respectively (p = . ). after propensity score matching, there was no difference in icu stay (p = . ), time to discharge after surgery (p = . ), and incidence of delirium between groups (p = . ). conclusions: although this study is retrospective in nature, limited by small sample size, early extubation did not affect the incidence of delirium after lt. further prospective studies on this area are required. weight estimation and its impact on mechanical ventilation settings in queen elizabeth hospital intensive care unit a nasr, a iasniuk, a roshdy queen elizabeth hospital, icu, london, united kingdom critical care , (suppl ):p introduction: documented weight in the intensive care unit (icu) can be the total, ideal, adjusted or predicted body weight (pbw). lung protective ventilation depends on tidal volume (vt) delivery which is based on accurate calculation of patients´weight [ ] . the weight is most probably documented on admission to the icu using estimation or one of many available equations. the aim of this study is to assess the documented versus the pbw and its impact on tidal volume delivery for mechanically ventilated patients in queen elizabeth hospital icu. methods: data was collected prospectively from all ventilated patients over a period of weeks in june . vt delivered in the first hour was calculated for each patient. documented body weight and height of each patient was obtained from the nursing chart. pbw was calculated and compared with the documented weight. the difference in vt attributable to the difference in weight has been subsequently calculated. results: ventilated patients were included ( males). the mean tidal volume delivered according to the documented body weight was . ml/kg versus . ml/kg based on pbw. vt more than ml/ kg was delivered in % of patients based on documented weight versus % when correcting the weight according to the pbw equation. conclusions: inaccuracy in documenting weight on patients´admission to the icu is a potential cause of delivering unsafe tidal volume [ ] . the harm can extend to drug dosage, nutrition provision and renal replacement therapy. introduction: ventilator-associated pneumonia (vap) is the leading cause of death among mechanically ventilated critically ill patients [ ] . chest radiography (cxr) is essential in the diagnosis of vap. in the past decade lung ultrasonography has proven to be a valuable tool in the diagnosis and monitoring of lung diseases. the aim of the study is to assess sensitivity and correlation between cxr, lung ultrasound and clinical pulmonary infection score (cpis). methods: in this retrospective, non-randomized study seven patients with proved vap were enrolled. in all patients cpis and lung ultrasound score (lus) [ ] were assessed. comparison of patients that had lus≥ and cpis≥ points was performed. the correlation between lus and cxr was done using the pearson model. results: we found significant difference between positive cxr patients with lus≥ and cpis≥ ( % vs %, p< . ). there is a very high correlation between cxr and lus. these results render lung ultrasound as a highly sensitive tool in the diagnosis of vap. conclusions: our study shows that lung ultrasonography could be used as a reliable supplementary method in the diagnosis of vap. the benefits of lung ultrasound include the ability to perform it at the patient´s bed without need for transportation, no radiation exposure and repeatability. the high correlation between cxr and lung ultrasound makes echography a valuable adjunct in the diagnosis of vap. color introduction: it is difficult to differentiate between pneumonia and atelectasis as cause of lung consolidation in intensive care unit patients. tools like the clinical pulmonary infection score are of little help (sensitivity % and specificity % for detecting pneumonia) [ ] . the objective of this study was to determine the accuracy of ultrasound assessed vascular flow within the consolidation to distinguish these causes. methods: adult patients with pulmonary symptoms and lung consolidation on lung ultrasound that were scheduled for chest-ct were included. vascular flow was analyzed with color doppler imaging (flow velocity scale was chosen at . m/sec.). the final diagnosis made by the treating physician was regarded as the gold standard. results: patients were included of which nine ( %) were diagnosed with pneumonia. vascular flow in the consolidation was present in seven ( %) out of nine patients with pneumonia, compared to three out of ( %) patients with atelectasis (p = . ). the diagnostic accuracy in differentiating between pneumonia and atelectasis was %. the sensitivity and specificity were % and % respectively. the positive predictive value was % while the negative predictive value was %. conclusions: vascular flow in lung consolidations assessed by lung ultrasound in icu patients aids in differentiating between pneumonia and atelectasis. it outperforms the frequently used clinical pulmonary infection score. methods: three intubated patients for various causes of respiratory distress undergoing mechanical ventilation were subjected to tee. at the level of mid-esophagus, the descending aorta short-axis view ( °) the imaging plane is directed through the transverse axis of the descending aorta. sector depth was increased to image the left pleural space beneath the aorta. for the right lung, the tee is rotated to the right at the level of atria until lung is seen or until the image of the liver is seen and the probe was withdrawn until the right lung is seen. recruitment manoeuvres were performed after identifying pbl atelectasis. atelectatic lungs were visually observed to open up during and after the recruitment manoeuvres. results: the time to acquire the image of pbl atelectasis from the time of insertion by tee is short. the images of posterior lung and the effect of lung recruitments is successfully viewed (fig ) . no immediate complication seen. conclusions: tee provides an excellent view of pbl atelectasis and able to directly monitor the success and failures of recruitment manoeuvres. introduction: high respiratory driving pressure (Δ prs) is strongly associated with increased risk of lung injury and increased mortality during mechanical ventilation. Δ prs consists of the pressure required to distend the lung the transpulmonary driving pressure (Δ pl) and the pressure required to distend the chest wall. Δ pl is the pressure that increases the risk of lung injury. data on Δ pl is limited because its measurement requires an esophageal catheter. we aimed to assess changes in Δ prs and Δ pl during proportional assist ventilation (pav+) at different experimental conditions. methods: we retrospectively analyzed patients ventilated with pav+ who had esophageal pressure measurements before and after dead space or chest load addition. we calculated end-inspiratory plateau pressure (pplateau), Δ prs, respiratory system compliance (crs) and Δ pl during occluded breaths in pav+ (figure ). data were compared with wilcoxon signed rank test and p value< . was considered significant. results: patients were analyzed. dead space increase ( patients) did not affect the studied parameters. chest load ( patients) significantly increased pplateau (p= . ) and Δ prs (p= . ) and decreased crs (p= . ) but Δ pl remained the same (p= . ). median (iqr) changes were . ml/cmh o ( . - . ) for crs, . cmh o ( . - . ) introduction: particle flow in exhaled air from mechanically ventilated patient's mirrors the opening and closing of small airways and can be detect by optical particle counter [ ] . we hypothesized that this particle flow is affected by cardiac function. methods: exhaled air from mechanically ventilated patients was analyzed using a customized optical particle counter pexa, figure . introduction: we assessed the diagnostic accuracy of mechanical power (mp) and driving pressure (dp) alone and combined with stress index (si) to identify ventilator settings likely to produce ventilator induced lung injury caused by tidal hyperinflation [ ] [ ] [ ] . methods: secondary analysis of a previous database of ards patients [ ] . computerized tomography markers of tidal hyperinflation (were used as a "reference standard". analysis of the area under the receiver-operating characteristics curve (auc) was used using a two-fold cross-validation. results: in a cluster of patients, a "training set" of not hyperinflated patients was compared with a "validation set" of hyperinflated patients. (figure - ) . conclusions: si seems to be more accurate than mp and dp in identifying tidal hyperinflation in patients with ards. specificity and sensibility were not improved combining si with mp or dp. the introduction: the pao /fio (p/f) ratio is widely used to assess the severity of lung injury. conceptually, the p/f ratio should be independent of the fio and solely depend on the pulmonary condition. however, effect of fio modulation on the p/f ratio has not been well characterized in ventilated intensive care (icu) patients. the purpose of the present study was to investigate the relationship between fio and the p/f ratio in icu patients on mechanical ventilation. methods: in a prospective, interventional study patients with a swan ganz catheter in situ were included. the p/f ratio was calculated at fio levels ranging from . to . with minute intervals. during the study other ventilator settings were not modulated. to understand the physiological effects of fio modulation on gas exchange and hemodynamics, mixed venous oxygen saturation and cardiac output were assessed. shunt fraction was calculated as described by west [ ] . results: patient characteristics and ventilator settings are reported in table . all patients were admitted to the icu after elective cardiac surgery. modulation of fio did have a significant effect on the p/f ratio, following a u-shaped pattern (p < . ) (figure ). the shunt fraction varied with altering fio levels, also exhibiting a u-shaped pattern (p < . ) (figure ). cardiac output was not affected by fio . conclusions: in contrast to current thinking, the p/f ratio varied substantially with altering fio levels in mechanically ventilated icu patients. this is an important novel physiological observation. in addition, it demonstrates that the assessment of the severity of respiratory failure by using the p/f ratio should be standardized to a fixed fio level. conclusions: in patients undergoing prolonged mechanical ventilation, we must take into account all the factors that may affect our patients. the assessment of diaphragmatic dysfunction is key to preventing weaning failure. an optimal level of consciousness as well as a good management of secretions are key to a successful weaning. prognostic value of the minute ventilation to co production ratio as a marker of ventilatory inefficiency in the icu r lopez , r pérez , Á salazar , i caviedes , j graf introduction: ventilatory inefficiency for co clearance may provide better severity stratification in acute respiratory failure than oxygenation [ ] . ventilatory inefficiency (vi) is best assessed by the bohr-enghoff physiological dead space [ ] . we recently reported that the minute ventilation to co production ratio (ve/vco ), a simplified vi index from exercise testing that obviates the paco measurement, correlates better than other vi indices to physiological dead space in mechanically ventilated patients [ ] . here we report the prognostic performance of this index using a survival analysis. mean±sem ve/vco was higher in patients who died than those who survived ( ± vs ± , p< . , figure ). we found a ve/ vco cutoff value of . mortality was higher in patients with high-ve/vco (≥ ) as compared to those with low-ve/vco ( % vs %, p= . ) with an odds ratio of . [ %-ci . - . ]. cumulative mortality was higher in the high-ve/vco than in the low-ve/vco group (log-rank p= . , figure ). conclusions: in this unselected cohort of mechanically ventilated patients an early high ve/vco ratio was associated to -days mortality. the ve/vco ratio may be a simple and non-invasive vi index with prognostic value in this population. introduction: sodium thiosulfate (sts) is a clinically relevant and safe hydrogen sulfide donor that improved acute lung injury (ali) and brain ischemia/reperfusion injury in previous studies [ , ] . methods: in a prospective, controlled, randomized, and doubleblinded trial, twenty adult, anesthetized, mechanically ventilated and surgically instrumented swine with preexisting coronary artery disease [ ] underwent h of hemorrhagic shock (hs; removal of % of the calculated blood volume and subsequent titration of mean arterial pressure to mmhg). post-shock resuscitation ( h) comprised re-transfusion of shed blood, crystalloids, and norepinephrine. animals were randomly assigned to "placebo" or "sts" ( . g·kg - ·h - for h). before, at the end of and every h after shock, hemodynamics, blood gases, and lung function were recorded. results: survival rates did not differ between groups. sts-infusion attenuated the hs-induced impairment of lung mechanics and pulmonary gas exchange (table , ), resulting in a significantly higher horovitz/peep-ratio ( figure ). conclusions: sts during acute resuscitation from hs may protect comorbid swine against hs-induced ali. introduction: alveolar epithelial cell (aec) death is a main mechanism of severe respiratory failure in acute respiratory distress syndrome (ards). classically, cell death is classified into necrosis or apoptosis. recent studies have reported that not only apoptosis but also certain types of necrosis are molecularly regulated and that these regulated necrosis can be therapeutic targets for various diseases. however, the relative contribution of necrosis and apoptosis to aec death in ards has not been elucidated. our study aimed to elucidate which type of cell death is dominant in aec death and to evaluate whether the regulated necrosis is involved in lps-induced experimental ards. methods: we established ards model by instilling μ g of lps intratracheally to mice. to estimate the relative proportion of apoptosis and necrosis in aec death, we measured cytokeratin m level (total cell death marker) and m level (apoptosis maker) in bronchoalveolar lavage fluid (balf) by elisa, and quantified propidium iodide-positive necrotic cells and tunel-positive apoptotic cells in the lung sections. moreover, we performed pathway enrichment analysis of gene expression data from pcr array to evaluate whether regulated necrosis pathway is associated with the ards model. results: both m and m levels were increased in the ards mice. the m /m ratio (an indicator of the proportion of apoptosis to total cell death) in the ards mice was significantly lower than that of healthy controls. moreover, the number of propidium iodidepositive necrotic cells was significantly higher than that of tunelpositive apoptotic cells in ards mice. in the pathway enrichment analysis, the necroptosis pathway, a regulated necrosis pathway, was associated with lps-induced experimental ards. conclusions: aec necrosis is more dominant than apoptosis in lpsinduced ards model. moreover, necroptosis may contribute to ards pathogenesis. aec necrosis including necroptosis is a potential therapeutic target for ards. clinical ards diagnosis is not associated with a unique circulating neutrophil cell surface phenotype t craven , s duncan , s johnston , c haslett , k dhaliwal , t introduction: acute respiratory distress syndrome (ards) is a form of non-cardiogenic oedema due to alveolar injury secondary to an inflammatory process. the clinical diagnosis is defined by the berlin criteria but this may not reflect the underlying biological process. the activated neutrophil is central to the pathogenesis of ards, characterised by altered cell surface markers. methods: three cohorts of seven participants were recruited. the first cohort suffered from mild, moderate or severe ards as defined by the berlin criteria [ ] . the second cohort was composed of ventilated patients on the intensive care unit with acute inflammatory lung disease (diagnosis of clinical suspicion) but did not meet the berlin criteria for ards. a third cohort was composed of age and sex matched healthy volunteers. procurement of human tissue was approved by a regional ethics committee ( /ss/ or /s / or amrec: -hv- ) and with the informed consent of the participant or their personal legal representative. patients were excluded if aged under or over years of age, were expected to survive for less than hours, if the attending physician refused, due to the absence of suitable indwelling vascular catheter, if the haemoglobin concentration was below . g/dl, or if the patient was enrolled in a trial of novel anti-inflammatory agent. whole blood (lysed erytocytes) underwent flow cytometry to determine cd b, , b, , l and . results: a description of the enrolled cohorts can be found in table . there were no significant differences between the mechanically ventilated, critically ill cohorts for any cell surface molecule in the multiplicity adjusted p values (fig ) . the results support the conjecture that clinical diagnostic criteria should not be used as a surrogate to stratify patients according to biological changes, with implications for the testing of biological therapies. introduction: aim of the present study was to compare the global and regional diagnostic accuracy of lung ultrasound (lus) compared to lung computed tomography (ct) scan in patients with the acute respiratory distress syndrome (ards). ards is characterized by a diffuse, inhomogeneous, inflammatory pulmonary edema. lung ct scan is the reference imaging technique, but requires transportation outside the intensive care and exposes patients to x-rays. lung ultrasound (lus) is a promising, inexpensive, radiation-free, tool for bedside imaging. methods: lung ct scan and lus were performed at peep cmh o. lus was performed using a standardized assessment of regions per hemithorax: superior and inferior; anterior, lateral and posterior. each region was classified for the presence of normally aerated, alveolar-interstitial syndrome, consolidation regions and pleural effusion. agreement between the two techniques was calculated, and diagnostic parameters were assessed for lus using lung ct as a reference. both a global and a regional analysis were performed. results: thirty-two sedated and paralyzed ards patients (age ± years, bmi . ± . kg/m and pao /fio ± ) were enrolled. global agreement between lus and ct was . ± . . the overall sensitivity and specificity of lus are shown in table . similar results were found with regional analysis (anterior/lateral/posterior lung regions is a common practice in our icu. during the interruption eit belt was positioned. when the presence of spontaneous breathing activity was evident by clinical assessment and ventilator traces analysis, nmba were administered to reach full paralysis, in accordance with the treating physician. eit tracing were analyzed offline and the change in eeli after nmba bolus, as compared to before nmba administration, was measured. respiratory mechanics and arterial blood gas (abg) data were collected results: we enrolled ards patients, undergoing controlled mechanical ventilation with muscle paralysis. baseline respiratory mechanics and abg data are shown in table . in out of patient the bolus of nmba led to an increase of eeli. in case, the nmb administration led to no changes in eeli. the mean change in eeli was ± ml conclusions: in our small population of ards patients, the administration of a bolus of nmba after the regain of spontaneous breathing activity led to an increase in eeli in out of patients. further study are needed to ) correlate this increase to global and regional respiratory system compliance and ) correlate this increase to the time needed to wean the patient from nmba introduction: to analyze the use of the orthostatic board as an auxiliary device for the treatment of severe ards by assessing its risks and benefits. methods: we selected patients, females and males, hospitalized in a neurological icu, between june and july , in a physiotherapeutic follow-up with diagnosis of severe ards. the patients were submitted to orthotics assisted for to minutes and monitored hr, pam, fr, sato at °and °of inclination and the pao / fio ratio after the procedure. the mean number of sessions per patient was . . all patients were undergoing anticoagulation in rass - , in the treatment of the cause of ards. the mean time of mechanical ventilation was . days. results: among the patients selected, . % presented tachycardia above bpm, requiring intervention in . % and interruption of the procedure in . %. pam arterial hypotension < mmhg was observed in . %, requiring intervention (increase of vasopressor dose and / or change of plank angulation) in % and interruption of the procedure in . %. hypoxemia sato < % was observed in . %, without interruption, but an improvement in pao / fio was observed in only . % of the patients. conclusions: assisted orthostatism as an auxiliary device for the treatment of severe ards was shown to be an alternative, with improvement of pao / fio in . % of the patients, safe and without significant hemodynamic repercussions that could lead to interruption of the procedure. introduction: the eolia trial found that vvecmo compared to conventional mechanical ventilation (cmv) did not improve mortality in patients with severe ards [ ] . the cmv strategy consisted of airway pressures below cmh o. in patients with severe ards higher airway pressures are required to maintain lung aeration. grasso et al. measured the transpulmonary pressure (p l ) in patients with severe ards and increased peep until p l was cmh o, accepting airway pressures above cmh o. fifty percent of patients responded to an increase in airway pressure and did not require vvecmo [ ] . we hypothesized that a p l guided open lung concept (olc) improves oxygenation and prevents conversion to vvecmo in patients with severe ards. methods: a retrospective study was conducted in a tertiary referral icu. the records of patients referred to our icu for advanced medical care were reviewed. inclusion criteria were severe ards according to the berlin definition and the eolia trial inclusion criteria for vvecmo. results: mechanical ventilation was limited to a p l of < cmh o instead of plateau pressures below cmh o. the p l guided olc resulted in an increase in p/f ratio and none of the patients required vvecmo. during the first hours peak airway pressure was increased, but was reduced within hours while peep was maintained ( fig. ). at hours both peak airway pressures and peep were reduced to baseline values while p/f ratio remained stable. only one patient ( . %) died of disseminated invasive aspergillosis. conclusions: the p l guided olc improved oxygenation and none of the patients required vvecmo. these findings support a ventilation strategy guided by transpulmonary pressures instead of plateau pressures in patients with severe ards. introduction: the mortality benefit conferred by early prone positioning in the treatment of acute respiratory distress syndrome (ards) has been well established. we also know that aprv improves oxygenation, and more recently has been shown to reduce ventilator dependent days and icu length of stay [ , ] . however, controlled ventilation remains the mainstay mode of ventilation used during prone position. literature looking at combined aprv and prone positioning is scarce. we aim to explore and report our institutional experience with respect to feasibility and outcomes in combining aprv and prone positioning, and perform a literature review in this area. methods: we undertook a single-centre retrospective cohort study within a surgical icu of a tertiary hospital in singapore between jan -oct . patients with ards who received combined prone positioning and aprv were reviewed retrospectively. a literature review of patients with ards who received combined intervention was also performed. results: adult patients aged - years old diagnosed with ards received a combination of aprv and prone positioning for a duration of - h ( table ). all the patients tolerated aprv with prone positioning well. our patients saw an improvement of p:f ratio ranging from - upon completion of combination therapy. out of patients were extubated within hours of turning supine, was weaned to tracheostomy mask after days and died while on the ventilator. only case report and randomized clinical trial were found on this topic upon literature review, which corroborated our findings. conclusions: in our experience, aprv is a practical and feasible alternative mode of ventilation that can be employed in the prone position, yielding significant p:f ratio improvements. the synergistic effects on improving oxygenation herald potential, especially in the subset of severe ards patients with refractory hypoxemia, where extracorporeal membrane oxygenation is unsuitable or unavailable. introduction: the recirculation during veno-venous extracorporeal membrane oxygenation (vv ecmo) had been a drawback, which could limit sufficient oxygenation. purpose of this study is to compare the short-term oxygenation in acute respiratory distress syndrome (ards) patients under vv ecmo according to their cannula configurations, especially in the national environment of the absence of newly developed double-lumen, single cannula. introduction: vv-ecmo is most commonly used in severe potentially reversible respiratory failure. this report looks at two patients in whom vv-ecmo was used to facilitate surgical airway stenting. methods: case -a -year-old with recurrent respiratory arrests, on a background of neurofibromatosis type and kyphoscoliosis. he had complex airway pathology, including, airway neurofibromas and granulation tissue, tracheobronchomalacia, severe kyphoscoliosis and a permanent tracheostomy tube. rigid bronchoscopy was performed and following debridement of granulation tissue, a trouser-leg stent was deployed. case -a -year-old with progressive stridor due to recurrence of a malignant melanoma, which was causing mid-lower tracheal compression. three tracheal stents were deployed via a rigid bronchoscope. in both cases, percutaneous bi-femoral vv-ecmo was established prior to general anaesthesia and decannulation took place the following day. results: in these cases, vv-ecmo provided stable extracorporeal gas exchange without conventional tracheal intubation. cardiopulmonary bypass and veno-arterial ecmo have been described in patients at risk of compression of the heart and distal airway [ ] . however, if the major threat is airway collapse, vv-ecmo can provide cardio-respiratory support without the problems associated with arterial cannulation and with lower anticoagulation requirements. introduction: ecco r facilitates the use of low tidal volumes during protective or ultraprotective mechanical ventilation when managing patients with acute respiratory distress syndrome (ards); however, the rate of ecco r required to avoid hypercapnia remains unclear. methods: we determined ecco r requirements to maintain arterial partial pressure of carbon dioxide or co (paco ) at clinically desirable levels in ventilated ards patients using a six-compartment mathematical model of co and oxygen (o ) biochemistry [ ] and whole-body transport [ ] with the addition of an ecco r device for extracorporeal veno-venous removal of co . the model assumes steady state conditions and is comprehensive from both biochemical and physiological perspectives. o consumption and co production rates were assumed proportional to predicted body weight (pbw) and adjusted to achieve pao and paco levels at a tidal volume of . ml/(kg of pbw) as reported in lung safe [ ] . clinically desirable paco levels during mechanical ventilation were targeted at mm hg for a ventilation frequency of . /min as previously reported [ ] . results: model simulated paco levels without and with an ecco r device at various tidal volumes are tabulated in tables and , respectively. table shows a substantial increase in paco at a tidal volume of ml/(kg of pbw) that is more pronounced when further reducing the tidal volume. additional simulations showed that predicted ecco r rates were significantly influenced by ventilation frequency. conclusions: the current mathematical model predicts that ecco r rates that achieve clinically acceptable paco levels at tidal volumes of - ml/(kg of pbw) can likely be achieved with current technologies; achieving such paco levels with ultraprotective tidal volumes of - ml/(kg of pbw) may be challenging. figure a ). pulmonary infections for each subtype of immunosuppression are shown in figure b . conclusions: ards vv-ecmo patients with underlying immunosuppression have higher mortality rates and higher rates of ecmo weaning failure. immunosuppressed patients suffer from a different spectrum of pulmonary infections in comparison to not immunosuppressed patients. introduction: acute asthma attack in children is a life-threatening emergency that requires urgent medical intervention. in the present study, we aim to clarify the effect of non-invasive ventilation (niv) on the heart rate (hr), respiratory rate (rr), and fraction of inspired oxygen (fio ) in children with acute severe asthma (asa) who failed to respond to standard medical treatment; and to evaluate the associated complications and length of stay (los) at the pediatric intensive care unit (picu). methods: this is a retrospective descriptive study of prospectively collected data. it was carried at the picu of a tertiary university hospital, saudi arabia. the study included children ≤ years old with asa admitted to the picu from november to november and required niv. outcome measures include the effect of niv on the hr, rr, fio , and los. the study included children with asa and ( %) of them required niv. of those patients, ( %) were excluded due to incomplete data, and ( %) patients were included in the final analysis. they were ( %) male and ( %) female with a mean age of months and a median pediatric index of mortality (pim ) score of . %. of them, ( %) had moderate asthma scores (≥ - ) and ( %) had severe asthma scores (≥ ). the median duration of niv was hours and the median los in the picu was three days. at hours, only rr showed a significant decrease compared to initiation of niv (p-value < . ) (fig ) ; while hr, rr, and fio were significantly improved at hours from initiation of niv (p-value < . ) (fig ) . conclusions: non-invasive ventilation, in association with standard medical treatment, was associated with clinical improvement in children with asa not responding to standard medical treatment alone. niv was not associated with significant complications or side effects. neurally adjusted ventilatory assist (nava) is a partial support ventilatory mode which triggers and tailors the level of assistance delivered by the ventilator to the electrical activity of the diaphragm. the objective of this study was to compare nava and pressure support ventilation (psv) in patients who were difficult to wean. methods: a total of difficult-to-wean patients who were able to sustained psv in the critical care medicine unit (icu) of the zhongda hospital, southeast university were enrolled in the study (fig ) . patients were classified according to the reason for weaning failure and were randomly assigned to receive nava or psv during weaning ( table ). the primary outcome was the duration of weaning. secondary outcomes included the proportion of successful weaning and patient-ventilator asynchrony. results: there were % ( / ) and % ( / ) patients in the psv and in the nava group never weaned from mechanical ventilation (p = . ). the duration of weaning was significantly shorter in the nava group [ . ( . - . ) days], than in that in the psv group [ . ( . - . ) days] (p = . ). the proportion of patients with successful weaning was % (n= / ) in nava group which was much higher than that in psv group ( %, n= / ) ( table ) . compared with psv, nava improved the rate of successful weaning in patients with single reason ( % vs. %, p = . ) but not in patients with multiple reasons for difficult weaning ( % vs. %, p = . ). nava decreased ineffective efforts and improved the trigger and cycling-off delays when compared with psv. mortality was similar in the two groups (fig ) . in patients who were difficult to wean, nava decreased duration of weaning and increased the probability of successful weaning. nava which improved patient-ventilator asynchrony, is safe, feasible and effective over a prolonged period of time during weaning. conclusions: only mrc score is independently associated with sbt failure and difficult or prolonged weaning. hgs is also associated with these two outcomes related to mv weaning and may serve as a simple tool to identify icuamw. introduction: there is evidence to support that in patients with hypoxemic respiratory failure (ahrf) under non invasive ventilation (niv), high tidal volume (tv) and high respiratory rate (rr) are associated with niv failure and possibly poor prognosis. we postulated that high minute ventilation (mv); or tv x rr; is associated with mortality in ahrf, when niv is initiated. methods: single-center, prospective and observational study. we included consecutives ahrf adults requiring niv. ahrf was defined as acute dyspnea with new pulmonary infiltrates on chest radiography and paco below or equal to mmhg. we registered demographic and clinical parameters (including rr, mv, arterial blood gases, heart rate and blood pressure) at baseline and after hours of first session of niv, apache ii score, diagnosis, need for intubation and icu mortality. we performed a multivariate analysis to assess independent factors associated with mortality and roc . ) and (auc = . ; p = . ), respectively for mortality, future exacerbations and readmissions. the optimal cut-off point for the mwt ratio to predict mortality was . and to predict future exacerbations and readmissions was . . the mwt ratio performed at icu discharge reveals interesting discriminative properties to predict early mortality, future exacerbations and readmissions in ae/copd patients. diffuse alveolar haemorrhage in an intensive care unit -search and you will find m matias , e ribeiro , j baptista , p martins introduction: the incidence of diaphragmatic ruptures after thoracoabdominal traumas is . - % [ ] and up to % diaphragmatic hernias present late [ ] when there is a complication. we report two cases of delayed traumatic diaphragm rupture to highlight the diagnostic difficulties. methods: case (image ) presented left diaphragmatic hernia containing the stomach, spleen, bowel and pancreas. the patient reported a motor vehicle accident dating months. he had thoracoabdominal trauma with several broken ribs on the left side. he then reported occasional pain in his left shoulder and occasional dyspnoea. case (image ) showed right diaphragmatic hernia containing right hemicolon, right hepatic lobe and gallbladder, he reported occasional dyspnoea and recent right chest pain. he had a years car accident in which three ribs broke on the right side. results: almost % of the patients with delayed diaphragmatic rupture presented with complications between and months after trauma, singh [ ] reported a diaphragmatic rupture presenting years after the traumatic event. the physical examination is often not helpful. conclusions: those cases emphasizes on the delayed presentation, patients may be asymptomatic or produce only mild, nonspecific symptoms, such as vague abdominal pain, chest pain or recurrent dyspnoea for months or years. the best tool to guide the clinician toward the appropriate diagnosis is a high index of suspicion whenever there is a history of high velocity trauma, regardless of how remote. factors associated with asynchronies in pressure support ventilation (psv), a bench study introduction: critically ill patients frequently have increased risk of ocular surface disorders (osds) due to poor eyelid closure and reduced tear production due to sedation during mechanical ventilation. we conducted a study to look at the incidence of osds in our icu with the current eye care practices and the impact of a protocolised eye care on the incidence and outcome and to determine the correlation of risk factors with the incidence of osds methods: this study was done in our mixed medical surgical icu. it had a prospective cohort design and was done as before and after study in two phases (phase i and phase ii). in phase i existing eye care practices were continued. in phase ii protocolised eye care was implemented and incidence of osds was noted in both phases. introduction: both fentanyl and morphine are known as opioid analgesics, which blocks the brain from receiving pain signals, the route of administration and the adverse effects affect their use. we compare the efficacy of intranasal fentanyl versus intravenous morphine adults population presenting to an emergency department (ed) with acute post traumatic severe pain. methods: we conducted a prospective, randomized, double-blind, placebo-controlled, clinical trial in a tertiary emergency department between october and june . adults with severe post traumatic was included to receive either active intravenous morphine ( mg immediately and then mg every min if persistence of severe pain maximum mg) and intranasal placebo or active intranasal concentrated fentanyl ( μ g /kg maximum μ g) and intravenous placebo. exclusion criteria: significant head injury, allergy to opiates, nasal blockage, or inability to perform pain scoring, pain scores were rated by using a digital scale at , , , and minutes. routine clinical observations and adverse events were recorded. conclusions: iscs were related to k over-use in our bicu. burnt patients are at risk of hepatic injury [ ] , but k related hepatic injury likely occurred. its not clearly understood mechanisms may involve a cumulative dose effect. although involvement of concomitant medications is being investigated, k restriction policy seemed to contain hepatic disorders. introduction: in november , our institution switched from using alfentanil to fentanyl for analgesia and sedation in adult patients receiving ecmo. there is no published evidence comparing the clinical use of alfentanil vs fentanyl for sedation in ecmo patients, although some reported increased fentanyl sequestration into the circuit [ ] . for these reasons, we conducted a retrospective observational study to explore whether there were any significant differences in patient outcome or adjunctive sedation before and after the switch. methods: outcome data and total daily doses of alfentanil or fentanyl as well as adjunctive sedation/analgesia for each patient where obtained from our clinical information system (philips icca®). data was included from ecmo patients who were sedated with alfentanil or fentanyl from / / to / / until ecmo decannulation. patients not requiring either opiate or who were switched between the two during ecmo therapy were excluded. all medicines prescribed for the management of sedation or agitation were included. for each patient an average total daily dose of each drug, was calculated. data was analysed using stata®. results: both groups were found to be statistically equivalent for mode of ecmo, age, apache score and charlson score (p= . ) except for bmi (p= . ). no difference in patient outcomes were found between groups (table ) . patients in the alfentanil group were found to have received significantly higher median average total daily dose of quetiapine and midazolam (table ) . conclusions: no differences in patient outcomes were found between patients sedated with alfentanil compared to fentanyl. we introduction: the european society of intensive care medicine consensus statement recommends that for comatose survivors of cardiac arrest hours without sedation is the minimum acceptable before neurological assessment. they highlighted the need to investigate the pharmacokinetics of opioid drugs in post-cardiac arrest patients, especially those treated with controlled temperature [ ] . methods: following approval by research ethics committee, we measured the blood concentration of fentanyl in post-cardiac arrest patients treated with ttm following cessation of continuous infusion. the fentanyl was discontinued when the patients were rewarmed to a temperature of . degrees celsius and a blood sample taken hours later. the blood was analysed using a commercial elisa kit (neogen corporation). using the total dose of fentanyl administered, the half-life of fentanyl was calculated for each patient. patient physiological data, cyp a and abcb polymorphism and drug history were compared with half-life. results: the median fentanyl concentration at hours was . mcg/l with a very wide range ( . - . mcg/l). the results for calculated half lives are shown in figure . there was no correlation between fentanyl level and bmi, illness severity (saps ll), creatinine clearance, transaminase or lactate level. there was no correlation between co-administration of drugs of metabolised by the cyp a and abcb enzyme systems or genotype. conclusions: there is marked variation in the concentration of fentanyl at hours in patients managed with ttm following cessation of fentanyl infusion. the calculated clearance of fentanyl in some patients is greater than hours and a hour cut off is not safe. introduction: objective of this study was to compare the effects of three analgesic regimens, one opioid and two multimodal ones, on cardiovascular stability and pain intensity in patients undergoing elective surgery under general endotracheal anesthesia during the h postoperative period. methods: sixty elderly patients, asa ii, undergoing elective knee sugary were assigned to receive ) morphine or mg iv q h, depending on body weight, and paracetamol g iv q h (mp group), or multimodal nerve block: ) femoral nerve block, single shot (fnb group) or ) fascia iliaca compartment nerve block single shot (ficnb group). measurement of pain intensity was performed with numerical introduction: opioids are frequently used in the intensive care unit (icu) to relieve pain and facilitate tolerance of life-support technologies. when discontinued abruptly, patients may develop a cluster of symptoms known as opioid-associated iatrogenic withdrawal syndrome (oiws). this phenomenon is poorly described in critically ill adults although it is associated with unfavourable outcomes, such as prolonged icu stay. the objective of this study was to describe the signs and symptoms of oiws in adult icu patients. methods: a prospective observational study was conducted in two tertiary care centres in patients requiring mechanical ventilation and regular opioids for more than hours. after an opioid dose reduction of at least %, patients were assessed daily for signs and symptoms of withdrawal using a standardized form. concomitantly, the presence of oiws was assessed daily by a physician using modified dsm- criteria. all physician evaluations were blinded and performed independently. inter-rater reliability for dsm- evaluations was assessed with the kappa coefficient. results: a total of patients were screened and twenty-nine enrolled. the majority were male ( . %) with a median age of . the median apache ii score was . withdrawal occurred in . % of patient within a median of three days (iqr to days) from opioid weaning. according to investigator assessment, restlessness, agitation, anxiety, hallucinations, insomnia/sleep disturbance, mydriasis and elevated blood pressure were more prevalent in oiws-positive patients. dsm- evaluations identified dysphoric mood, muscle aches, lacrimation/rhinorrhea, pupillary dilation/piloerection/sweating, diarrhea and yawning more frequently in oiws-positive patients. the kappa coefficient showed good agreement ( . ). conclusions: oiws in critically ill adults presents with a large spectrum of signs and symptoms that occur within a median of three days from onset of opioid weaning. further studies are needed to confirm these preliminary findings. withdrawal reactions after discontinuation or rate reduction of fentanyl infusion in ventilated critically ill adults s taesotikul introduction: propofol is a well-known sedative, commonly used in intensive care units (icu s), that on rare occasions has been reported to cause green urine and has also been associated with pink or transient white urine discoloration. it can cause several adverse effects, such as low blood pressure, pain on injection, apnea, hypertriglyceridemia and when administered in high doses it may lead to the "propofol infusion syndrome". methods: we present two examples of interesting urine discolorations observed unexpectedly in our icu in patients under propofol sedation requiring mechanical ventilation. results: dark green urine discoloration as presented in fig. is the result of a phenolic metabolite of propofol that is produced in the liver and is subsequently excreted in the urine, thus changing its color. it is considered a reversible phenomenon that resolves after propofol discontinuation.respectively, pink urine discoloration as presented in fig. can also be the result of propofol infusion. the increase in urine excretion of uric acid caused by propofol, in combination with a low urinary ph can lead to the formation of uric acid crystals and turn the urine pink. discontinuation of propofol and urine alkalization can reverse the phenomenon. conclusions: green or pink urine discoloration due to propofol is generally a benign, reversible condition. its presence should not compel the physician in charge to perform unnecessary testing, although other causes of discoloration should be considered. as far as green urine discoloration is concerned, other factors such as drugs, dyes, certain nutritional supplements or even a pseudomonas urinary tract infection may be at fault. on the other hand, pink urine syndrome due to propofol infusion seems to be even rarer. although its presentation is not alarming, it may well increase the risk of uric acid lithiasis, a fact that the physician in charge should always keep in mind. conclusions: hepatic changes related to propofol are frequently observed and should be systematically monitored to ensure patient safety. fig. (abstract p ) . dark green urine discoloration introduction: clevidipine (clev) and propofol (prop) are lipid-based medications used in the intensive care unit (icu) for hypertension and sedation, respectively. no data exists regarding potential adverse effects of concurrent therapy with this combination. this study aims to evaluate the incidence of hypertriglyceridemia (htg) and pancreatitis in icu patients using concurrent clev and prop. methods: this was a single-center, retrospective chart review in patients utilizing clev and prop concurrently from february to november . patients were included if they were years and older, on clev and prop concurrently for at least hours with no more than hours of interruption at a time, had at least one triglyceride (tg) level during concurrent therapy, and admitted to the medical or surgical icu. the incidence of htg (defined as tg equal to or greater than mg/dl) and pancreatitis (provider assessment based on american college of gastroenterology guidelines) was evaluated. patients with and without htg were compared to identify risk factors for the development of htg. results: of patients screened, patients were included which comprised observations. the incidence of htg was . % with no patients developing pancreatitis. patients with htg had a higher median age compared to without htg ( . vs. ), p= . . in patients with htg the median dose of clev and prop were mg/h and . mcg/kg/min, respectively, which was higher but not statistically significant when compared to patients without htg. cumulative lipid load (g/kg/d) was non-significantly higher in patients with htg ( . vs. . ), p= . . conclusions: the incidence of htg was comparable to what is cited in literature for prop alone. patients with htg were older, had higher median clev and prop doses, and a larger cumulative lipid load compared to patients without htg. introduction: the society of critical care medicine guidelines for pain, agitation and delirium suggested use of nonbenzodiazepine sedatives like dexmedetomidine which is associated with a reduced duration of mechanical ventilation, shorter length of hospital stay and a lower incidence of delirium [ ] . enteral clonidine represents a potentially less costly alternative for agitated patients with prolonged dexmedetomidine infusion. limited literature exists examining this transition for management of agitation [ ] . methods: the critical care management initiated an action plan on the transition of patients with prolonged dexmedetomidine infusion to oral clonidine. a protocol was prepared with clinical pharmacist's assistance. risk factors were assessed and inclusion criteria were applied as per protocol. dexmedetomidine infusion rate was reduced gradually with oral clonidine administration in selected patients. other rescue managements were implemented as per protocol. oral clonidine was then tapered down by reducing frequency of administration over few days. results: post intervention data in showed significant decrease of dispensed doses and cost of the injections compared to . the annual cost saving was % equating to , usd (table , figure ). conclusions: transitioning to clonidine may be safe and less costly method of managing agitated critically ill patients on prolonged dexmedetomidine infusion. more studies are needed to evaluate the efficacy and safety of this practice. incidence of dexmedetomidine associated fever at a level trauma center na beaupre, jt jancik hennepin county medical center, pharmacy department, minneapolis, united states critical care , (suppl ):p introduction: we evaluated the incidence of dexmedetomidine associated fever (daf) in a level trauma center's medical intensive care unit (micu). hypotension and bradycardia are the most commonly reported adverse effects associated with dexmedetomidine (dex) infusion. case reports suggest dex can cause fevers and the clinical trials that led to the approval of dex demonstrated fever rate to be - % [ ] . methods: this was a single-center, retrospective chart review of patients admitted to the micu at hennepin county medical center between march and july of that were started on a dex infusion. patients were included if they were years and older, on a dex infusion for at least hours, and had temperature data available. fever was defined as > . c and other causes of fever including infections, medications, withdrawal, recent surgery, thromboembolic disease, thyroid disorders and seizures were excluded from analysis. results: of the patients screened, were included. the mean age was years and . % were males. of all the patients included, the mean change in temperature after initiation of dex infusion was + . c from baseline. the mean initial dose was . mcg/kg/hr. four of patients ( . %) had a daf. of those that had a daf, the median initial dose was . mcg/kg/hr; the median time of infusion was . hours; and the median cumulative dose was . mcg/kg/hr. the median time to fever after initiation of dex was hours, with a range of to hours. the median time to fever cessation after discontinuation of dex was hours. conclusions: in our population, the incidence of dexmedetomidine associated fever was relatively rare at . % and similar to current literature rates. the results obtained showed a statistically significant fact that fewer points on the test, from to points, received older patients who underwent an urgent surgical procedure, over years of age, of which % . also statistically significant data were obtained that patients who used a higher amount of sedatives during emergency surgery, % had a worse test result than under points due to increased preoperative anxiety. the older population is more susceptible to postoperative delirium, especially in emergency surgery situations, which they carry, unpreparedness for surgery, increased use of medication for fig. (abstract p ) . flowchart of enrolled patients calm, unpredictability of the duration of surgery, and therefore anesthesia as well the use of anticholinergics, which is sometimes impossible to avoid in operative procedures such as gall bladder surgery. the results of the study suggest that in cases of emergency surgery, the use of protocols for postoperative delirium should be planned regularly to prevent or at least mitigate the clinical picture of delirium that can lead to complications postoperatively. introduction: delirium is a serious and often underestimated condition with implications for morbidity, mortality and healthcare costs. as it presents in a wide range of settings from admission to discharge, early prediction and risk assessment are essential. e-pre-deliric is a delirium prediction score which has been validated in itu patients but not in other populations, and we conducted a quality improvement project using this score to assess its utility in other settings. methods: data was gathered from three patient categories: those undergoing elective surgery (es), admissions to the emergency observation unit (eou) in the a&e, and patients with fractured neck of femur (nof). clinical notes were reviewed to collect data to calculate e-pre-deliric score at admission, along with a number of other clinical variables including incidence of delirium, and statistical analysis performed. results: a total of patients were included, with in the es group, in the eou group, and in the nof group respectively, with an overall average e-pre-deliric score of . %. es had a . % average e-pre-deliric score, a mean age of and no cases of delirium. the eou group had an average age of , a . % average e-pre-deliric score and no incidence of delirium. the nof group had a mean age of and an average e-pre-deliric score calculated on admission of . %. this was the only group in which patients developed delirium. a % cut off was demonstrated to be the most accurate to predict delirium in this population with a sensitivity of . and a specificity of . . conclusions: despite the limitation of a small sample size, this project has shown that e-pre-deliric score could be a useful tool to predict patients at high risk of delirium in a non-itu setting, with a % cut off in hip fracture patients. further investigation should be conducted into the potential use of e-pre-deliric in non-itu patients. comparison of long-term mortality between patients with and without delirium during admission in medical intensive care units in a university hospital n kongpolprom king chulalongkorn memorial hospital, pulmonary unit, bangkok, thailand critical care , (suppl ):p that delirium is linked with preoperatory comorbidities. the complexity of surgery has a big influence on the development of delirium, especially in the cases of aortic dissection. delirium was associated with intraoperatory blood transfusions. finally, our data point to a bridge between postoperatory electrolytic disturbances, as well as inflammation as factors potentially triggering delirium onset. introduction: we did a retrospective case note study of mortality due to sepsis of our unit over three months as observational study in which we noted the causes of deaths, origin of sepsis, organism, patient characteristics and icnarc physiology scores and icnarc h model predicted risk of acute hospital mortality percentage. methods: icnarc data base was used to gather the data and coding was used to identify the patients with sepsis for three months. patients mortality attributed to sepsis were identified from mortality list.causes of death were noted from patients notes and death certificates.cyber lab was used to access the data and case note were ordered for review.patients characteristics were noted including dnacpr orders and treatment withdrawal orders. scores (apache scores, icnarc physiology scores, icnarc h predicted risk models of acute hospital mortality percentage) were noted. results: mortality percentage was found to be % as per codig which was reduced to % as % deaths were attributed to other causes. % patient had dnacpr in first hrs. average length of stay was . days with median of . days.median age was yrs in surviving age group and years in other. icnarc physiology score with predicted risk of . %. commonest cause was found pneumonia % followed by urine tract infection. % patients were with no source identification. conclusions: conclusion was made that we do need to improve the coding as significant percentage was mentioned as sepsis as cause of death where clinicians differed. pneumonia was found to be the commonest killer in critical care followed by urine tract infection. it was pointed to be useful to carry out further audit targeting pneumonia .review of icnarc case mix program, development of icnarc physiology score, which provides excellent local use with downside of lacking international comparison was done also. introduction: hospitals vary widely in the quality of care they provide for septic patients. since many septic patients present to their nearest hospital, local variations in care quality may lead to geographic disparities in access to optimal sepsis care. we sought to better understand geographic access to high quality sepsis care, taking advantage of publicly reported data on sepsis management and outcomes in a large us state. methods: we performed a cross-sectional analysis of geographic access to high quality sepsis care, taking advantage of a new york state initiative that mandates public reporting of sepsis quality data to the state government. we linked these data to the locations of hospitals in new york state from the us centers for medicare and medicaid services and population data from the us census bureau for . we defined hospital sepsis performance using self-reported risk-adjusted mortality rates (ramr) and defined high-performing hospitals as those with a ramr < %, which represents the lower end of short-term mortality typically observed in sepsis. we used arcgis to generate drive-time estimates and assess population access to high performing acute care hospitals for sepsis care. results: hospitals publicly reported treating , cases of sepsis from a population of , , persons. overall access to an acute care hospital was excellent at the -minute drive threshold ( . %), good at the -minute threshold ( . %), and marginal at the -minute threshold ( . %). we classified hospitals ( . %) as high-performing based on a ramr < %. high-performing hospitals reported , ( . %) of the total sepsis cases. high-performing hospitals were geographically dispersed across the state, although population access diminished substantially with increasing drive times ( . % at -minutes, . % at -minutes, and . % at minutes; figure ). conclusions: one in six people do not have timely access to a high performing hospital for sepsis care using a -minute threshold. [ ] . this poses a significant safety risk. a previous study found that the implementation of a multidisciplinary medication safety group in intensive care increased reporting of errors and near misses [ ] . the purpose of our work was to set up a multidisciplinary group to provide a forum to review and improve medication safety at all stages of the process. here we discuss some of the initiatives and outcomes implemented in the last months. methods: ccmsg was formed in , under the leadership of the critical care pharmacy team, with representation from medical and nursing disciplines. the group meet fortnightly to analyse trends in medication errors, implement changes to local practice and review outcomes to improve patient safety. the cohesive, multidisciplinary nature of the group allows medication safety initiatives to be delivered in the most effective way. results: on average, ccmsg reviewed medication errors per month. the most common high risk drug classes involved are seen in table . medication safety initiatives implemented were based on these trends and included writing guidelines and policies, bedside education, teaching and training, informatics optimisation and operational changes. examples are seen in table . conclusions: initiation of a ccmsg provides a cohesive approach to facilitate the implementation of targeted safety initiatives, which are proven to reduce some of the most common medication errors in critical care. in addition, these often result in optimisation of operational and financial inefficiencies. introduction: cis/hospital electronic medical records downtime can cause major disruptions to workflow, patient care, key communication and information continuity [ ] . here we describe the consequences of deploying a business continuity plan (bcp) designed to support a critical care clinical informatics system (cis) failure, during an -hour unplanned downtime in a large central london icu. the institutional bcp was developed through an iterative process based on cis provider recommendations and internal workflow knowledge. it consisted of a web offline chart (woc) that is accessible at every computer connected to the network (in the event of a cis server fault), and via hard copy from designated back up computers connected to a printer (in the event of whole network loss). operational and clinical consequences were recorded during informal and formal debrief of the informatics team. the decision making around´drop-to-paper´was reviewed. -the bcp permitted´drop-to-paper´, service continuity and controlled uptime -patchy network loss and lack of a general institutional bcp delayed initial system failure diagnosis (network vs primary server); reduced reliability of´read-only´data and delayedd rop-to-paper-day-to-night handover during downtime led to loss ofḿ emory´of key patient data/events, and should have accelerated decision to´drop-to-paper-transfer of prescriptions was time consuming, distracting (occupied cis team) and prone to error conclusions: previous end-to-end testing of the bcp had not identified many of the observations and recommendations that came from the analysis of an actual period of unplanned downtime. we recommend sharing of similar experiences and scheduled high-fidelity simulated downtime in other institutions to replicate real world conditions, particularly in a critical care setting. . ) were predictors of icu transfer. we developed a simple score to predicting icu transfer from previous variables and performed analysis of auc of roc, which was compared to that of apa-che ii. the result showed the auc of roc of a new score was slightly higher than the apache ii, namely . vs. . respectively. conclusions: the immunocompromised patients take two times higher risk than the immunocompetent ones regarding icu transfer. the other risk factors are lower gcs, lower sbp, and higher rr. a newly developed score may be a promising tool for predicting and triaging site of care in patients who require imcu admission. introduction: this research aims to explore the role of situation awareness in the decision-making of patient discharge from the intensive care unit (icu). the discharge of these patients is a complex and, moreover, a challenging transition of care. readmissions are undesirable given the association with a more extended hospital stay and a possible chance of higher mortality. little is known on how the decision-making process takes place and accordingly, the role of situation awareness of patient discharge from the icu. in order to improve the quality of care of patient discharge from the icu, further research is necessary. methods: this research concerns a qualitative study in which various health care providers, working in an icu adults of a large teaching hospital, were interviewed. through purposive sampling, six nurses, two physician assistants, two intensivists and a physiotherapist were included. on the obtained data a thematic analysis was applied, based on the principles of the grounded theory. results: the discharge decision of icu patients seems mainly based on the team´s situation awareness, with the initiating role of the intensivist and the guiding role of the nurse. furthermore, there is an additional role for the physician-assistant and a consultative role for physiotherapy in the process of the decisionmaking. worries of patients and family seem not to affect the decision-making directly. in the decision-making process, the well-being of the patients and the possibility to provide the most suitable and best possible care were central. organizational factors, such as an urgent demand for icu beds do count but seem not to push the decision to transfer patients from the icu to the regular hospital ward. conclusions: the decision to dismiss icu patients is a complex process with different disciplines and a variety of factors involved. obtained knowledge and insights into the role of situation awareness provide starting points for improving the quality of the discharge process of icu patients. conclusions: despite the fact that older people was more severe illnes, and similar frequency of respiratory failure, the use of mechanical ventilation, the use of central venous catheter and arterial catheter was less frequent. the addition of a simulation fellow within the intensive care team and introduction of in situ simulation n bhalla, d hepburn, g phillips royal gwent hospital, intensive care unit, newport, united kingdom critical care , (suppl ):p introduction: traditionally, simulation based medical education has been carried out in off site simulation centres, however, we trialled the addition of a simulation fellow, within our intensive care team, to run an in situ simulation (iss) program on our intensive care unit over a month period. methods: our multi-disciplinary iss program, led by a simulation fellow, incorporated participants, observers and facilitators including doctors (junior trainees up to consultants of varying medical specialties), nursing staff, healthcare support workers, operating department practitioners, physiotherapists and medical students. we ran simulated emergency scenarios and technical skills sessions. with every scenario, we collected data on participant and observer feedback using the world health organisation participant feedback form and conducted a satisfaction survey at the end of our trial period. results: our results, highlighted in table , show participants found iss led by a simulation fellow realistic, well structured and organised. it was useful for testing and understanding our response systems, fig. (abstract p ) . patient journey of group : those patients discharged home days after step down from critical care identifying strengths and gaps and establishing individual roles/functions within emergencies; overall leaving us feeling better prepared for critical care emergencies. from our satisfaction survey, % of participants found the simulation fellow a useful addition to the intensive care team and expressed the need for more in situ simulation. conclusions: the addition of a simulation fellow allowed for numerous disciplines within the critical care team to be involved in challenging emergency scenarios (fig , ) , with the additional realism of being on the intensive care unit playing the role they would in real life; as well as having opportunity for spontaneous discussion and learning. from this they reported great benefit and satisfaction. following our initial success with this program, we plan to have a simulation fellow as an ongoing role within our critical care team. impact of multidisciplinary team in readmission in a brazilian cardiac intensive care unit c bosso , p introduction: the aim of this study is to determine the importance of the multidisciplinary team at readmission rates in a cardiac intensive care unit (cicu). methods: retrospective study with analysis of patients in a cicu of a medium size brazilian hospital. the years of and represent the reduced team (physician, nurse and physiotherapist) and and the complete multidisciplinary team (additional presence of phonoaudiologist, psychologist, pharmacist, dentist and nutritional professional). the risk of mortality was determined by saps score. in order to compare the teams, it was utilized odd ratio of a logistical sample to the discrete data, and t-student test to the continuous data. the data analysis was executed from the software rstudio ( . . ), and the significance level adopted was %. results: the number of patients was of n= ( from the reduced team and from the multidisciplinary team). the age, sex and bmi didn`t present significant difference between groups. the average age of the sample was ± years old (p= . ). the male sex represented % (p= . ), and the bmi was around . ± . (p= . ). the main diagnoses were similar in both groups -coronary angiography with stent ( %), unstable angina and non st elevation myocardial infarction ( %). table shows the average, standard deviation, p-value to t-student test to saps score and lengh of stay (days), according to both reduced and multidisciplinary teams. table exposes the mortality rate and readmission for both teams. the figure shows the odds ratio and its ic % to the comparison of the mortality, readmission, hours readmission and hours readmission rates between the teams. conclusions: the multidisciplinary team performance reduced the number of hospital readmissions in and hours in a cicu. methods: during the initial audit hours' worth of waste from one itu bed was manually divided into the categories above. results: based on these figures it was estimated that a saving of £ per year would be made (£ . per bed space) over the course of a year should domestic waste bins be placed across the bed icu/hdu. a business case was made, and every bay had a domestic waste bin installed with poster signs for explanation.the reaudit in which all domestic waste across the unit was weighed produced an even greater figure of a saving of £ per bed space (£ ) per year. conclusions: introducing a domestic waste bin may save approximately £ per year per bed. in a typical itu such as lewisham ( itu beds/ hdu beds) that may mean a saving of £ per year (with % capacity). there are also environmental benefits, burning of plastics releases harmful dioxins. the authors wish to make intensive care units and indeed all areas of the hospital aware of the cost and environmental impact associated with disposing of waste in incorrect categories. we hope that our quality improvement project demonstrates how easily money may be saved and environmental footprint reduced. association between resilience and level of experience in intensive care doctors in india j gopaldas, a siyal manipal hospital, bangalore, critical care medicine, bangalore, india critical care , (suppl ):p introduction: attrition of doctors in intensive care unit (icu) is one of the highest amongst all medical specialities globally, and is strongly associated with stress and burn out syndrome (bos). factors that contribute to bos are low pre-morbid resilience and low level of icu experience. studies from india have shown high levels of stress in intensive care doctors (> %), but there are no published studies measuring pre-morbid resilience and risk of burnout in relation to years of experience amongst icu doctors. our main aim was to measure cross sectional resilience levels in icu doctors compared between those with less than years of experience to those with years or more. a secondary aim was to assess the impact of other factors that may contribute to low scores. methods: an anonymised survey was conducted involving doctors in icus across different states in india, using the connor-davidson resilience scale (cd-risc ), which is validated in indian population. results: a statistically significant correlation was found between low levels of resilience in icu doctors with under years of experience . ) , and the significance level adopted was %. a logistic regression model was used to test the difference between the mortality and readmission rates in < and ≥ groups, which enabled the calculation of odds ratios. chi-square test was used to evaluate categorical variables and t-student test to some quantitative variables. the roc curve was constructed to verify the sensitivity of prediction of mortality through different saps scores. results: among the < and ≥ groups, respectively % and % was male (p = . ). mean weight of the> years was ± kg and < years was ± (p < . ). odds values indicated a significant difference only for the mortality rate, which was more than double among ≥ . readmissions in any time, h and h as well the mortality is shown in table and odds in figure . there was a significant difference in saps points between groups ( table ). the ≥ group presented an average of points higher on the severity scale when compared with those in the < group. there was no significant difference in lengh of stay. the highest amount provided by saps scores was % and a specificity of % for hospital mortality not group < years. in ≥ group the highest sensitivity was % and the specificity was %. roc curve for saps is shown in figure . conclusions: the extremely elderly patients of a cicu is more severe, with higher mortality and have the same lengh of stay and readmission rates. introduction: the purpose was to assess the prevalence and impact of non-urgent interruptions (nui) within critical care (cc).a root cause analysis of a never event in our cc discussed nui as a contributory factor, paralleled by learning from serious incidents.the negative impact of nui is well evidenced, resulting in delayed task completion, increased stress, and affecting patient safety. methods: any nui during a consultant ward round (cwr) or invasive procedure (ip), not relating directly to the current clinical episode, was included. qualitative data was collected by a survey, assessing the cc multidisciplinary teams(mdt) perception of nui. results: one third of reviews during the cwr, and %of ips, had a nui. adverse effects included prescription omissions, delayed cwr, near-miss with a cvc, and failed picc insertion. overall, % of staff considered nui a problem; % had experienced nui that led to distraction in train of thought. % felt that nui had led to an error: % of doctors, versus % of nurses. % overall felt nui contributed to stress at work. reasons for interruptions included: feeling overloaded, needing to resolve concerns before forgetting/being distracted, unable to prioritise, and to shift responsibility.lack of leadership or clinical supervision providing a point of contact for problems during shifts was mentioned as contributory. senior staff raised that whilst attempts have been made to level hierarchy, allowing a voice for all to express concerns contributes to interruptions. potential solutions included awareness on impact of nui, jobs book,´sterile cockpitd uring ips, and increased clinical supervision during shifts. conclusions: we have demonstrated the prevalence and consequences of nui within cc is significant.the impact on staff is significant, both for contribution to errors and also the negative impact on stress in the workplace. identified potential solution will be implemented. the impact of an education package on the knowledge, skills and self-rated confidence of medical and nursing staff managing airway & tracheostomy/laryngectomy emergencies in critical care l o´connor , k rimmer , c welsh methods: the factors affecting the delivery of intensive care was elucidated by a comprehensive review of the intensive care literature. a further understanding of intensive care delivery in south africa was obtained by "making sense of the mess" with eight workshops and interviews using a systems approach. systemic intervention served as the meta-methodology and methods and techniques from interactive planning, critical systems heuristics, soft systems methodology and the viable system model were employed. results: making sense of the mess emphasised the complexity of intensive care delivery, on both a situational and a cognitive level. it became clear that a single methodology would not suffice, but that a pluralist methodology was required to guide improvement in intensive care delivery. based on this understanding, nine principles were formulated to guide the development of a framework. systemic intervention was again used as the meta-methodology. interactive planning was identified as the key methodology, incorporating methods and techniques used in the making sense of the mess phase to build a systemic framework for the improvement of intensive care delivery. embedded in the proposed framework are matters relating to systemicity, complexity, flexibility, empowerment, and transformation of intensive care delivery. the proposed framework allows for multiple-perspectives, including that of marginalised stakeholders, the mitigation of multivested interests and power relationships (fig ) . it is both flexible and adaptable to promote learning about the complex problems of intensive care delivery and it accommodates the strengths of various relevant approaches to complex problem solving. conclusions: the proposed framework aims to facilitate sustainable improvement of intensive care delivery and to ensure the "just-use" of resources to foster distributive justice. the perioperative management of adult renal transplantation across the united kingdom: a survey of practice c morkane , j fabes , n banga , p berry , c kirwan introduction: there is a limited evidence base to guide perioperative management of patients undergoing renal transplantation and no national consensus in the uk. we developed an electronic survey to provide an overview of uk-wide renal transplant perioperative practice and determine the need for future guidelines on patient management. methods: a -question survey was developed to encompass the entire renal transplant perioperative pathway with input from clinicians with expertise from renal transplant surgery, anaesthesia, nephrology and intensive care. the survey was sent to lead renal anaesthetists at each of the transplant centres across the uk. results: twenty-two centres ( %) returned complete responses. there was limited evidence of guideline-based approaches to preoperative work-up, with marked variety in modality of preoperative cardiorespiratory function testing performed. questions regarding intraoperative fluid management (fig ) , blood pressure targets and vasopressor administration (fig ) identified a broad range of practice. of note, the routine use of goal-directed fluid therapy based on cardiac-output estimation was reported in six ( %) centres whilst nine centres ( %) continue to target a specific central venous pressure (cvp) intra-operatively. a dedicated renal ward was the most common postoperative destination for renal transplant recipients ( % of centres), whilst a renal or transplant-specific hdu provided postoperative care in ( %) centres. the need for care in an icu setting was decided on a case-by-case basis. conclusions: this questionnaire highlighted a high degree of heterogeneity in current uk practice as regards the perioperative management of renal transplant recipients. development of evidence-based national consensus guidelines to standardise the perioperative care of these patients is recommended. fig. (abstract p ) . framework for the improvement of intensive care delivery introduction: postoperative care of high risk patients in the icu used to be considered the gold standard of care in terms of reducing perioperative mortality [ ] . new evidence comes to question this practice [ ] . the primary objective of our study was to detect any benefit of postoperative icu care after elective surgery in terms of patient's outcome, length of hospital stay, complications and cost. methods: a -month retrospective analysis of high perioperative risk patients who were about to be subjected into an elective operation were included into the study. subsequently they were allocated into two groups. group i patients were those admitted into the icu for postoperative care while those admitted into the standard ward consisted group ii. demographic data, length of hospital stay, outcome, need of mechanical ventilation, complications and total cost were recorded. results: a total of patients were recorded, in each group. there was no statistical difference regarding the demographic data between the two study groups. seven patients died before hospital discharge ( in group i and in group ii, p> . ). there was no impact of icu admission on length of hospital stay (p= . ) which is primarily affected by the need of mechanical ventilation (p= . ) and reoperation (p< . ). the total cost and the postoperative cost of hospital care did not statistically differ among study groups. conclusions: according to our study the need of postoperative care of high risk patients in the icu is rather questionable in terms of perioperative mortality, length of hospital stay and cost of care. introduction: tivap is a preferred vascular access device for patients with solid tumors and radiological-guided insertion is a standard of care. however, many hospitals have no access to interventional radiology service. our study aimed to determine whether it is safe to place tivaps in icu for immediate administration of chemotherapy. methods: we analysed prospectively maintained database of our department and collected data for adult pts with tivaps implanted between / and / . the median age was (range - ) years, % were women. all procedures were performed by trained physicians with experience in ultrasound (us). puncture technique was used and tip location was controlled with electrocardiographic (ecg) and us with subsequent chest x-ray confirmation. pts were followed up for at least days after the procedure for complications, functioning of tivap and surgical wound healing. results: all tivaps were successfully implanted in pts. infraclavicular route was used in cases ( . %). difficulties with indwelling guide wire were observed in ( . %) pts but did not precluded implantation. placement complications included pneumothorax (n = ), catheter malposition (n = ) and artery bleeding (n = ). these complications required additional therapy but were managed successfully and resolved without consequences. in the rest cases internal jugular vein (jv) was used. complications were not observed. ecg and us navigation provided optimal tip location control in these situations. surgical wound healed after - days and chemotherapy initiation did not affect healing. all tivaps had adequate functioning days after placement. conclusions: it is feasible to implant tivaps in icu. these devices can be used on the implantation day without jeopardizing patient safety. jv catheterization seems to be optimal approach and us navigation and ecg are sufficient methods for placement control. introduction: there is increasing use of clinical information systems to improve patient safety and quality of care in critical care. with all these systems, a rigorous business continuity access (bca) plan needs to be in place so patient safety is not compromised [ ] and ensure continuity of care. here we evaluate the types of medication errors that occurred during a period of unscheduled downtime; potential contributory factors [ ] and the number of errors involving critical medicines [ ] were analysed. methods: during the unscheduled downtime, all prescribing and administration of medicines were transferred to a paper based system using the patients' web offline chart (woc -philips healthcare). pharmacists at the time double checked the paper charts that were transcribed, to mitigate errors but this was not consistent due to the timing of the event. we retrospectively compared the paper drug charts against the electronic prescriptions and noted all errors for patients. results: in total medication errors were identified & allergy omission ( table ) . pharmacists double checked % of the paper charts. conclusions: our data highlights the risks associated with unscheduled electronic patient management system downtime and the heterogeneity of the types of errors & potential contributory factors. it underscores the need for robust local bca plan implementation, critical review of the woc document and regular staff training around potential unscheduled system downtime. introduction: the transfer of patient care (toc) between the intensive care unit (icu) and hospital ward is associated with a high risk of medical errors [ ] .according to uk national data between - % of patients have an error or unintentional medication change made when moving between care settings [ ] . currently different prescribing systems without interoperability are used between icu areas & ward settings in our institution, resulting in medications needing to be re-prescribed on transfer. we aimed to evaluate the time delay in medication re-prescribing, number of unintentional omissions of drug doses and reasons, as well as percentage of critical medicines [ ] omitted in the first h following discharge. methods: over a month period, discharged patients ( % of all discharges) from two icu units were included. the icu discharge letter which contained the medication list on transfer was compared against the ward based electronic drug chart to identify all unintentional omitted medication doses during the first hours. the starting time point was when the patient physically left icu. results: / ( %) of patients had their medication prescribed more than hours post discharge. there were a total of / , ( %) unintentional omitted doses (table ) . of these / ( %) were considered critical medicines ( table ) . conclusions: this data confirms the risk associated with toc especially around medicines. the need of interoperable electronic prescribing systems is one solution and could improve patient safety by streamlining the process. introduction: staff perceptions of safety may contribute to workforce stress and be organisationally important [ ] . this study explored the feasibility of capturing perceptions of safety with a bedside professional reported (bpr) shift safety score, and explored relationships between bpr and measures of staffing and workload. methods: uk health research authority approval was obtained (id ). data were collected for consecutive days at imperial college healthcare trust ( general critical care beds on sites).the bpr asked all icu staff to rate each shift as "safe, unsafe, or very unsafe". responses were described and correlated with data on organisational staffing (care hours per patient day chppd) and nursing intensity (total number of organs in failure/ total number of nurses). results: a total of bpr scores were recorded (response rate %). we noted heterogenous responses between sites and days, and within shifts, only % of shifts were unanimously rated. whilst % of shifts were rated by staff as "unsafe" or "very unsafe", organisational metrics recorded only % as 'unsafe'. we did not find a correlation between measures of staffing (chppd) and perceptions of safety ( figure ). preliminary analyses suggest that staff perceptions of safety are not well correlated with nursing intensity (figure ), although these numbers commonly inform staffing metrics. conclusions: completing the bpr tool was feasible and acceptable to staff. responses showed variations in perceptions of safety and a gap between organisational metrics and individual perceptions. introduction: delivery of intensive care (icu) is complex because of multiple stakeholders with varied perspectives and conflicting goals that interact and are interdependent. to inform the development of a framework for the improvement of icu delivery in south africa, it was essential to first understand icu delivery or "make sense of the mess". a systemic approach such as systems thinking is required to holistically explore and understand the complexity of icu. no methodology is perfect and methodological pluralism as proposed by systemic intervention, a systems thinking approach, was used for a more flexible and responsive intervention. the methods used was the making sense of the mess phase of interactive planning, stakeholder analysis as describe by critical systems heuristics, rich pictures from soft systems thinking and viable systems model diagnosis. making sense of the mess was done in phases: first the mess was formulated with rich pictures generated in workshops and interviews. the discussions of the rich pictures by the respective stakeholders were transcribed and analysed using braun and clark's thematic analysis. secondly, based on the data generated from phase a diagnosis of the viability of the icu system was made. results: the data from the phases were very rich and complex and themes emerged (figure ). these themes were interdependent and resulted in disorganised icu delivery with limited opportunities for learning to improve icu delivery with dichotomies that existed at various levels of icu. it was a problem to present the complex data in the traditional linear manner due to the interdependence of the themes. the analysis is presented as stories, a known approach in the complexity discipline, where the themes of the analyses are portrayed. the making-sense-of-the-mess phase confirmed the complexity of icu delivery, at both a situational and a cognitive level and with this understanding a framework for the improvement of icu delivery could be developed. introduction: improving prescribing practice involves changing prescriber behaviour. education is assumed to change behaviour but other approaches may be more effective (figure ) [ ] . changes to the presentation of information and the configuration of choices have potential to rectify common prescribing errors through subtle 'nudges' [ ] . the implementation of clinical information systems (cis), including electronic prescribing, provides an opportunity to deploy strategies such as standard orders, dose limits, and product level prescribing. with an infinite number of configuration options available, clinical leaders need to know which interventions are most effective. we evaluated several of these strategies in a before and after observation study methods: interventions, utilising cis nudges, were chosen to improve four areas of prescribing practice in a tertiary critical care unit using methods matched to the top levels of the hierarchy. data were collected for months before and after interventions to map changes in compliance with a pre-defined standard except for the standardisation intervention where months' data were collected due to low prescription numbers. no education on changes was given during the baseline data collection so any change in performance after the go-live date is entirely attributable to the intervention. results: the change in performance for each level ranks the intervention levels in the order (highest first) forced function, automation and standardisation ( table ). the use of point of prescribing reminders was not associated with a significant difference in performance. conclusions: the effectiveness of intervention levels seen in practice is consistent with that of the model. further studies could be undertaken to strengthen these conclusions but in the meantime the approach to changing practice using cis nudges should focus on standardisation or above. introduction: intensive care unit (icu) sound pressure levels (spl) are persistently above world health organisation recommendations for clinical areas [ ] . this may impact patient recovery. standard spl monitoring records single values for each h period (laeq ). we hypothesise this reporting rate is unsuitable for icu. methods: we measured spl october -may , logging frequency (hz), spl (db), and loudness (perception of sound) every second [ ] . the resulting dataset was of a size that conventional statistics programs would require computational resources not easily obtainable on standard university commodity hardware. we processed the full dataset without sampling by using distributed task dispatching, parallelism and scheduling of a cluster computing framework (apache spark). we created a system consisting of a single workstation ( cores; gb ram) running ubuntu . lts, oracle java . , apache spark . , scala . , r core . , r studio . and sparklyr . . . we utilised the sparklyr library in r studio to run arbitrary r code using the dplyr library. we analysed aggregate data in r core & used ggplot (v ) to create visuals. results: we achieved more complex analysis than standard spl reporting with relatively modest computing resources. specifically we identified lower spl peaks in the early hours & loudness levels considerably higher than parallel spl. conclusions: simple laeq do not facilitate reflection on practice thus impetus for change is limited. loudness data highlight the patient experience of spl in the icu is more intrusive than laeq indicates due to high sensitivity to sounds~ - khz, a common frequency range for alarms. higher fidelity increases understanding of spl which can lead to targeted interventions to reduce patient disturbance. introduction: survivors of critical illness face significant long term impairments in mental and physical function. early mobilisation (em) in the intensive care unit has been suggested to improve functional outcomes and reduce delirium in the icu. we hypothesized that implementing a protocol for em in the icu would improve mobilisation rates while remaining safe. methods: design: prospective non-blinded observational cohort study, based on a quality improvement project. data was collected conclusions: only of variables in boyd criteria were significant associated with morbidity or mortality. the physiologic score and operative score were significant higher in the patient on mortality and morbidity after sicu admission. effects of structural hospital characteristics on risk-adjusted hospital mortality in patients with severe sepsisanalysis of german national administrative data d schwarzkopf introduction: the quick sequential organ failure assessment (qsofa) score is a simple tool used to identify severe patients with infection. as this score is calculated from three variables that can be measured at the scene of trauma-systolic blood pressure, respiratory rate and consciousness-the prehospital qsofa score may also be a good predictor of mortality in trauma patients. so we evaluated the discriminative ability of the prehospital qsofa score in patients with trauma for in-hospital mortality. methods: this is a retrospective multicenter study using the data from nationwide trauma registry in japan. we included patients with trauma aged ≥ years old transferred to hospitals from scene. primary outcome is in-hospital mortality. results: the mean age was . ± . years old and patients ( %) were male. in-hospital mortality occurred in patients ( %). in-hospital mortality in each qsofa score was / ( . %), / ( %), / ( %) and / ( %) in qsofa score , , and , respectively (p< . for trend). area under receiver operating characteristics curve (auroc) of the aqsofa score for inhospital mortality was . ( % confidence interval . - . ). if we use the cutoff ≥ , sensitivity and specificity of the qsofa score were . and . . conclusions: in patients with trauma, the prehospital qsofa score was strongly associated with in-hospital mortality. we can identify patients with very low risk of death by using the cutoff ≥ of the prehospital qsofa score. introduction: only one prospective study is available of the validation of the diagnostic and prognostic role of qsofa (quick sofa score) in the emergency department (ed). a prospective study was conducted in greek eds. methods: the prompt study (clinicaltrials.gov nct ) run in the ed of six hospitals in greece among patients with suspected infection and presence of at least one of fever, hypothermia, tachycardia, tachypnea and chills. clinical data were collected and the -day outcome was recorded. sepsis was defined by the sepsis- criteria. results: the sensitivity and the specificity of at least signs of qsofa for the diagnosis of sepsis was . % and . % respectively and for the prognosis of -day mortality . % and . % respectively. the odds ratio for -day mortality when qsofa was equal to or more than was . among patients with charlson's comorbidity index (cci) equal to or less than ; this was . among patients with cci more than (p: . between the two ors by the breslow-day's test; p: . by the tarone's test). conclusions: data validated the sensitivity of qsofa for the diagnosis of sepsis. cci was an independent predictor of severity. qsofa could better predict unfavorable outcome among patients with low cci. comparative accuracy between two sepsis severity scores in predicting hospital mortality among sepsis patients admitted to intensive care unit n sathaporn, b khwannimit prince of songkla university, internal medicine, hat yai, thailand critical care , (suppl ):p introduction: recently, the new york sepsis severity score (nysss) was developed to predict hospital mortality in sepsis patients. the aim of this study was to compare the accuracy of nysss with the sepsis severity score (sss) and other standard severity scores for predicting hospital mortality in sepsis patients. methods: a retrospective analysis was conducted in a medical intensive care unit of a tertiary university hospital. the performance of severity scores was evaluated by discrimination, calibration, and overall performance. the primary outcome was in-hospital mortality. results: overall , sepsis patients were enrolled, patients ( . %) were classified to septic shock by sepsis- definition. hospital mortality rate was . %. the nysss predicted hospital mortality . +/- . %, which underestimated prediction with smr . ( %ci . - . ) . however, the sss predicted hospital mortality +/- . %, which slightly overestimated mortality prediction with smr . ( %ci . - . ). the nysss had the moderate discrimination with an auc of . ( % ci . - . ), in contrast to the sss presented good discrimination with an auc of . ( %ci . - . ). the auc of sss was statistically higher than that of nysss (p< . ). nevertheless the apache iv and saps ii showed the best discrimination with auc of . . the auc of the nysss and sss was significant lower than that of apache ii, iii, iv, saps ii and saps ( figure ). the calibration of all severity scores was poor with the hosmer-lemeshow goodness-of-fit h test < . . the nysss was the lowest overall performance with brier score . . the apache iv present the best overall performance with brier scores . . conclusions: the sss indicated better discrimination and overall performance than the nysss. however the calibration of both sepsis severity scores and another severity score were poor. furthermore, specific severity score for sepsis mortality prediction needs to be modified or customized to improve the performance. introduction: metabolic markers, especially lactate, have been shown to predict mortality in acutely unwell patients. we hypothesised that early changes in metabolic markers over time would better predict mortality and length of stay, with patients who correct their metabolic derangement having lower risk of death and reduced length of stay (los). methods: single centre, retrospective cohort study in a bed icu. we included all patients who had an arterial measurement of lactate, paco , base excess (be) and ph on admission and at hours after admission to icu between / / and / / . the 'clearance' of these markers was calculated using the equation ((value at admissionvalue at hours)/value at admission). clearance calculations only included those patients with deranged results on admission (lactate> mmol/l, be<- mmol/l, ph< . , paco > . kpa). roc analysis was used to predict in-hospital mortality and length of stay, using both the initial admission values, and using the clearance value, as well as icnarc and apache ii scores for comparison. if a patient was admitted twice in the time period, only the first admission was included. results: patients were included (sex ratio . , mean age . ). table ). none of the values tested had a auc greater than . for predicting length of stay. conclusions: the clearances of metabolic markers over the initial hours after icu admission does not provide better prognostic information than the value at admission. initial lactate level was the best predictor of mortality, but compared poorly to icnarc score. metabolic markers do not accurately predict length of stay. . - . ) vs . (iiq . - . ), p= . ]. the other hemogram parameters did not differ between groups (table ) . when adjusted for severity score, in patients submitted to emergent surgery, the mpv value was still independently associated with mortality (or . ci . - . , p= . ), and its roc curve (auc) was . to mortality (figure ). conclusions: mpv is a cheap and easily accessible marker which can add prognostic value in this specific population. in the future, we will validate it in a larger cohort of cancer pts admitted to intensive care. haematological malignancy in critical care: outcomes and risk factors c denny introduction: about % of patients admitted to hospital with a haematological malignancy will become critically ill [ ] . life expectancy in these patients is poor with a month mortality of % or more in specialist units [ ] . in contrast, patients without critical illness can expect a year survival rate exceeding % for many cancers. this disparity results in differences of opinion on the best strategy for such patients among haematologists and critical care physicians. we conducted a local quality improvement project to quantify mortality and risk factors in critically ill patients with a haematological malignancy in our hospital. methods: patients admitted to the critical care unit of broomfield hospital, a district general hospital with tertiary specialist services, from january to december with haematological malignancy were included in the analysis. patients in remission for more than years and patients admitted following elective surgery were excluded from analysis. death in critical care or in hospital after critical care discharge were the primary outcomes. mortality was correlated with demographic data using simple statistical measures and regression analysis. results: patients were included in the analysis. overall mortality was %(n= ). survivors tended to be younger ( vs years) but had similar clinical frailty scores. early critical care admission (within hours) was associated with better survival ( . vs . %). nonsurvivors had a greater incidence of sepsis and respiratory failure, and required more ventilatory and vasopressor support. mortality was higher in patients requiring more than one organ support. conclusions: the overall mortality in our data is lesser than previously published data but supports the conclusion that mortality is determined primarily by the number of organs supported with the effects of malignancy playing a secondary role. (figure ). increasing levels of frailty were associated with increasing risks of death at year (p< . ) (figure ). frailty significantly increased -year mortality hazards in unadjusted analyses (hr . ; %ci; . - . ; p< . ) and covariate-adjusted analyses (hr . ; %ci . - . ; p= . ) ( table ) . conclusions: frailty was common and associated with greater age, more severe illness and female gender. frailty was significantly associated with heightened mortality risks in both unadjusted and covariateadjusted analyses. frailty scoring may encapsulate variables affecting mortality which are omitted in current predictive systems, making it a promising risk stratification and decision-making tool in icu. fig. (abstract p ) . unadjusted survival curves stratified by frailty status. frail patients were statistically significantly less likely to survive to year plateau at day = , delta peak= and hpr= . . were assigned respectively a point value of , , and to these predictors based on their beta coefficient in the predictive model. the score yielded a roc-auc: (auc= . ; %ci, [ . - . ]; p= . ). using the validation data set (n= ), the score had an roc-auc= . and similar estimated probabilities for mortality. conclusions: the paw-mps seems to demonstrate interesting discriminative properties to predict mortality. what is the role of the pulmonary embolism severity index (pesi) and rv/lv ratio as clinical risk assessment tools for patients undergoing ultrasound-assisted catheter-directed thrombolysis (uacdt)? introduction: to evaluate if the pulmonary embolism severity index (pesi) score correlates with rv/lv ratio, biomarkers of cardiac injury, fibrinogen and length of stay(los). also to evaluate the correlation between rv/lv ratio with biomarkers of cardiac injury, fibrinogen and los for patients who underwent uacdt. methods: a retrospective review of patients with sub-massive pulmonary embolism (pe) who underwent ultrasound-assisted catheterdirected thrombolysis (uacdt) was performed. pesi score, rv/lv ratio, length of stay(los), fibrinogen levels, troponin levesl, and brain natriuretic peptide(bnp) levels, were calculated and collected prior to uacdt. spearman's rank correlation coefficient was calculated for all non-parametric variables. results: patients, males and females, were included in the study. the mean (±sd) age was ± years. the mean pesi score was ± . mean rv/lv ratio was . ± . . a significant correlation between the rv/lv ratio and both fibrinogen and troponin level (p= . , p= . ) was noted. no significant correlation existed between pesi score and rv/lv (p= . ). no significant correlation existed between both rv/lv ratio and pesi score with length of stay (p= . ) after uacdt. there were no noted mortality or complications. conclusions: pesi score is used as a prognostic factor for the patients with pe, however, our study shows that pesi score does not correlate with rv/lv ratio or length of stay after the uacdt. there was inverse correlation between rv/lv ratio and fibrinogen. there was also positive correlation between rv/lv ratio and troponin for patients with and without heart failure. according to our data, there may be limited use of pesi score and rv/lv ratio for risk stratification of pe patients undergoing uacdt. introduction: conventional scores for prediction of risk and outcome, such as sapsii and sofa, have not been validated for patients admitted to level ii critical care units (intermediate level or imcus). we compared the performance of sapsii and sofa scores with the intermediate care unit severity score (imcuss) in a general population admitted to imcu. methods: we conducted a prospective observational cohort study in a -bed level ii-iii icu from a university-affiliated hospital, during a three-month period. we applied sapsii, sofa day one and imcuss to all patients admitted during that period. primary outcome was a composite of hospital mortality and need to increase level of care. additionally, we tested the relevance of each variable within each score to predict the outcome. results: we included patients with a mean age of . ± . years. patients were considered "step-down" (transferred from our level iii beds), and the remaining originated from the emergency conclusions: months after completion, the primary care management intervention had no effect on mental health-related quality of life and physical function among survivors of sepsis. increase in ptsd symptoms in the control group may suggest a possible protective effect of the intervention. introduction: critically ill patients and their families are often confronted with an overwhelming amount of clinical information shortly after hospital admission. their reliance on internet resources for additional information is increasing, particularly for unfamiliar medical terminology. yet, little is known about whether these online resources meet the recommended reading level and complexity appropriate for the average reader. methods: an online search of websites containing four common critical care diagnoses in the icu (respiratory failure, renal failure, sepsis and delirium) was performed. a total of readability formulas were used. the flesch-kincaid grade reading level (grl) and flesch reading ease (fre) were used in the final analysis. document complexity was evaluated using the pmose/ikirsch formula. results: websites on respiratory failure were written at the th grl with fre of . . renal failure resources had a th grl with fre of . . sepsis websites had an th grl with fre of . . delirium websites had a th grl with fre of . . when comparing website types (government, non-profit and private), anova showed a difference in fre across all groups and government websites had a conclusions: online resources used by intensive care unit patients and families tend to be written at higher than the recommended th grl, with government sites better meeting this target than nonprofit and private organizations. online resources should be improved to lower this unfortunate barrier to patient education. introduction: the recent enactment of the data protection act , the general data protection regulations, and a series of data breaches in the healthcare sector, have renewed interest in how our patients' information is collected, used and shared. the complex framework of laws and regulations governing the use and disclosure of personal data may lead to professional and financial consequences if information is disclosed inappropriately. disclosures to the police when they concern incapacitous patients are particularly challenging, as the disclosure may have no direct benefit to the patient and may cause the patient considerable harm. methods: we have reviewed the relevant laws and regulations to identify the circumstances in which doctors must release information regarding incapacitous patients to the police. the laws and regulations are examined to identify the extent of the disclosure required, and any requirements for the disclosure to be lawful. we have also identified laws which confer a power to disclose information about incapacitous patients, and the circumstances in which these powers can be used. results: in conjunction with a local police constabulary we have developed an information request form which makes it easier for those requesting and disclosing information to understand the legal basis of the disclosure. we have also developed guidelines to allow practitioners to understand where a disclosure is obligatory or discretionary. conclusions: the next stage of the project is to audit disclosures of information in the intensive care unit, and identify whether information is being released lawfully and following the correct procedure. introduction: family members are affected both physically and psychologically when their relative is admitted to icu. there is limited knowledge describing their experiences and structured interventions that might support them during their relative's critical illness. the aim of this review is to describe published literature on the needs and experiences of relatives of adult critically ill patients and interventions to improve family satisfaction and psychological well-being. methods: design: scoping review. standardised processes of study identification, data extraction on study design, sample size, sample characteristics and outcomes measured (figure ) . results: from references, studies were identified for inclusion four key themes were identified: ) different perspectives on meeting family needs ) family satisfaction with icu care ) factors impacting on family health and well-being and capacity to cope ) psychosocial interventions conclusions: family members of patients in icu experience unmet information and assurance needs which impacts on their physical and mental health. structured written as well as oral information show some effect in improving satisfaction and reducing psychological burden. icu's who are able to support interventions based on meeting family information needs, in addition to reducing psychological burden and increasing satisfaction will enable each family to provide more support to their relative within the icu. introduction: unmet informational needs lead to dissatisfaction with care and psychological distress. identifying interventions to help meet specific needs is a crucial and necessary step in providing family centred care in icu. we aimed to implement and evaluate the impact of delivering a structured communication strategy on levels of anxiety, uncertainty and satisfaction with care and decision making in families of critically ill adults. methods: a quasi experimental study with pre and post test design. a convenience sample of family members were recruited from july to february . the intervention group (n= ) received both oral and printed information to guide them in preparing for a structured family meeting. the control group (n= ) received usual fig. (abstract p ) . article selection process for scoping review routine care and existing family informational support. anxiety, uncertainty and family satisfaction were measured in the two groups on icu admission and icu discharge. results: mean anxiety, uncertainty and satisfaction with care and decision making scores pre and post intervention were compared. there were no significant differences in mean anxiety, uncertainty or satisfaction scores between the two groups before the intervention (p> . ). mean scores on anxiety ( . vs . ), and uncertainty ( . vs . ) were lower post intervention, but not significantly so ( figure & ). total satisfaction, satisfaction with care and satisfaction with decision making mean scores were similar in both groups before and after the intervention (p. . ). conclusions: providing relatives with a combination of targeted written and oral information delivered by nursing and medical staff reduced anxiety and uncertainty with this reduction being evident through to discharge from icu. although not statistically significant, there was what may be seen as a suggestion of a clinically significant drop in anxiety and uncertainty following the intervention introduction: clinical studies in intensive care unit (icu) patients are warranted in order to improve healthcare. the aim of this study was to analyse barriers and challenges in the process of achieving informed consent from icu patients. methods: we analysed patients considered for inclusion in a prospective observational study of venous thromboembolism in the icu, i.e. the norwegian intensive care unit dalteparin effect (norides) study. data were collected from the screening log, consent forms and associated research notes of the norides study. results: we observed that of ( %) eligible patients according to inclusion and exclusion criteria were omitted from the nor-ides study due to barriers and challenges in the process of receiving informed consent. were categorized as psychiatric diseases consisting of known psychosis or recent suicide attempt, likely or actual treatment withdrawals and due to language barriers among non-norwegians. among the patients included in the norides study, ( %) consents were from patients and ( %) obtained from their next of kind. from the patient consents, ( %) consents were oral and ( %) were written. patients were physically unable to sign, and patients did not recognize their own signature. the study further pointed at some specific challenges in the process of consent, herein questionable competence to give consent, failure to remember being asked/included, inability to separate research from treatment etc. there were also difficulties in evaluating who was next of kin and how to reach them. conclusions: barriers and challenges in obtaining informed consent from icu patients led to exclusion of one fifth of the eligible patients in our study. informed consent directly from patients was obtained from less than half of the included patients. obstacles in the process of achieving informed consent were practical, medical, ethical and/or legal. determinants of end-of-life decision-making in the intensive care unit p eiben, c brathwaite-shirley, s canestrini king´s college hospital nhs foundation trust, london, united kingdom critical care , (suppl ):p introduction: although the majority of intensive care unit (icu) deaths follow the decision to forgo life sustaining treatment (lst), variability in patterns is commonly observed [ , ] . we reviewed end of life (eol) practice at our institution in order to explore: (i) patient characteristics affecting eol decision-making, (ii) communication among surrogate decision-makers, and (iii) eol management. methods: we retrospectively analyzed data from consecutive patients who died in our ten-bed icu over months (study period). patient demographics, apache ii, functional status, diagnosis on admission, icu length of stay (los) were collected; family/next-of-kin (nok) involvement and rationale for lst limitation were recorded ( conclusions: our analysis shows that in our institution eol deliberations follow a shared decision-making process. lack of family/nok involvement and incomplete documentation was exceptional. the significant difference in los between w-group and nw-group, in the face of similar apache ii, warrants further investigation. vae calculator rheumatology review . van der jagt m. crit care consensus on circulatory shock and hemodynamic monitoring. task force of the european society of intensive care medicine cardiac output monitoring: how to choose the optimal method for the individual patient perioperative cardiovascular monitoring of highrisk patients: a consensus of guidelines for nutrition support therapy in the adult critically ill patient references . nice guideline for aki: prevention, detection and management serial creatinine results pre-and post ecmo references . polit et al. research in nursing & health reference . sherliker et al national blood transfusion committee, nhs blood and transplant arch otolaryngol head neck surg fig. (abstract p ). rsi agent guideline references . nuckton tj nejm icm baseline characteristics reference elso guidelines for cardiopulmonary extracorporeal life support s -leitlinie invasive beatmung und einsatz extrakorporaler verfahren bei akuter respiratorischer insuffizienz .auflage p handgrip strength does not predict spontaneous breathing trial failure or difficult or prolonged weaning of critically ill patients g friedman total burn care introduction: we aimed to evaluate safety and efficacy of light sedation with dexmedetomidine (dex-ls) in acute brain injury (abi) patients. methods: retrospective analysis on icu patients with traumatic/medical abi, out of the neuroprotection window and undergoing dex-ls. data of pre-infusion and infusion periods were compared. results: patients (age ± , males . %) were included. traurespectively. conclusions: dex-ls among icu patients affected by abi turned out to be feasible and safe. it enabled discontinuation from mv and maintenance of spontaneous breathing in the majority of cases %) delirious patients and of ( . %) non-delirious patients could be discharged from the hospital. we evaluated the -year mortality in the hospital survivors. results: totally, patients participated in our study. the majority of them ( . %) were male with the median age of [ , . ] years and the median apache ii score on the first day of icu admission of risk of delirium was associated with preoperatory euroscore ii (p= . ) and history of previous cardiac surgery (p= . ). moreover, in the intraoperatory period the risk of delirium was associated with red blood cell transfusion, intervention for aortic dissection (p= . ), hypothermic circulatory arrest (hca) with anterograde cerebral perfusion (acp) (p= . ) (table ). in the postoperatory period risk of delirium was associated with levels of creatinine clearance (p= . ) and c-reactive protein (crp) (p= . ). conclusions: delirium is relatively frequent in the cardiac surgical icu patient journey of group : those patients discharged directly home from critical care unit poor compliance with co-signing in icca ( %, n= ) compared to paper ( %, n= ) (figure ) and the reported difficulty in co-signing ( %, n= ) reveals significant usability concerns and potential safety issues. % (n= ) found icca intuitive, though % (n= ) found navigating the interface difficult and reported concerns with losing saved work ( %, n= ). conclusions: this study highlights important usability issues that may impact staff satisfaction th national audit project of the royal college of anaesthetists and the difficult airway society. major complications of airway management references . guidelines for provision for intensive care services (gpics), version medicines optimisation: the safe and effective use of medicines reducing harm from omitted and delayed medicines. a tool to support local implementation p understanding the delivery of intensive care in south p mobilising ventilated patients early with interdisciplinary teams (move it) singapore general hospital, department of respiratory and critical care p validation of boyd criteria and possum-score on mortality and morbidity in general surgical intensive care unit k chittawatanarat, y chatsrisuwan faculty of medicine pts with central nervous system neoplasms or submitted to elective surgeries were excluded. descriptive analysis and χ test, pearson´s, wilcoxon rank-sum, uni and multivariate logistic regressions were used when appropriate. results: from a total of pts identified, . % (n= ) were admitted after emergent surgery and . % (n= ) for medical reasons. global icu mortality was . % (n= ). in comparison to survivors, the patients that died had a similar age were recorded data regarding demographics, clinical variables, paw (at admission and at day ), high pressure ratio (hpr = number of days with high pressures: peak ≥ and/or plateau ≥ ; and/or driving pressure ≥ ; and/or auto-peep ≥ ; divided by los), trends of paw (paw at day -paw at admission) and outcomes. the patients were divided into two groups: a construction group (n= ) and a validation group(n= ). the paw-mps was developed and validated by analyzing in a multivariate regression model the different paw ± . ; pco , ± mmhg paw were respectively for peak, plateau, driving, and auto-peep at admission: ± , . ± , . ± and three independent mortality risk factors were identified centro hospitalar do porto p five-year mortality and morbidity impact of prolonged icu stay n van aerde , g hermans laboratory of cellular and molecular medicine we investigated differences in mortality and morbidity after short (< days) and prolonged (≥ days) icu-stay. methods: prospective, -year follow-up study of former epanicpatients (clinicaltrials.gov:nct , n= ). mortality was assessed in all. for morbidity analyses, all long-stay and a random sample ( %) of short-stay survivors were contacted. primary outcomes were total and post- -day -year mortality in multivariable cox regression analysis, icu-risk factors comprised hypoglycaemia, corticosteroids, nmba, benzodiazepines, mechanical ventilation, new dialysis, new infection, liver dysfunction, whereas clonidine may be protective. among long-and short-stay -year survivors hgf, mwd and pf sf- were lower in long-stayers mwd: % ( %ci: %- %) vs % ( %ci: %- %) multivariable regression identified associations with benzodiazepines (hgf and pf-sf ), vasopressors (pf-sf ) and opioids ( mwd) ptsd related symptoms were accessed with the post traumatic stress syndrome questions inventory (ptss- ) at the post icu follow up clinic, six months after the acute stress event. the post icu consultation was carry out by an icu doctor and an icu nurse. exclusion criteria: previous severe psiquiatric disorders, not able to respond the questionnaire medical %, surgical % and trauma %. patients ( %) were on imv and the median ventilation days was . ptsd scores ranged from to . delusional memories were conclusions: in this study the rate of ptsd was lower . % and related with a lower saps ii and the presence of memories of the icu stay. no relation was found with delusional memories, imv or superior icu length of stay. patients with lower illness severity and without imv, should be elective to the follow up-clinics. p long-term effects of a sepsis aftercare intervention k schmidt united states; jena university hospital patras general university hospital, intensive care unit, patras, greece; patras general university hospital, division of infectious diseases results: ( . %) patients were readmitted within hours and ( . %) in to days. the two groups didn't differ in age, gender, charlson comorbidity index and length of stay on both admissions. elective surgery was the most common type of admission ( . %) followed by medical ( . %), emergency surgery ( %) and trauma ( . %). the mean time to readmission in the late group was . (± . ) days. patients in the late group had higher apache ii score on their first and second admission, ( . ± . vs . ± . ; p= . ) and ( . ± . vs . ± . ; p= . ) respectively. respiratory insufficiency was the most common cause of readmission in both groups followed by sepsis and cardiac arrest. finally in the early group p introduction: in intensive care units, perceived inappropriate treatments (pit) have been associated with negative impact on caregivers univariate analysis revealed that burn-out, pit and intention to leave were greater in units where nurses´teams included no activity in the icu, compared to "shared" work in icu and idtcu. in multivariate analysis, perception of non beneficial treatment of patients with life support witholding was associated with: bad collaboration with other units p profile of intensive care unit (icu) patients on whom life-sustaining medical treatment were withdrawn or withheld s chatterjee variables collected-age, sex, apa-che iv score, diagnostic-category and co-morbidities. primary outcomes were icu and hospital mortality. secondary outcomes included icu and hospital length of stay(los) female sex, n (%) ( . %) diagnosis on admission: medical, n (%) rrt at time of wlst, n (%) ( . %) dnr order, n (%) ( . %) organ donation services involved, n (%) ( . %) introduction: high flow nasal cannula(hfnc) is a new modality in respiratory failure management [ ] . this study objectively held to compare the physiological outcomes in the non-invasive ventilation(niv) treatment of cardiogenic acute pulmonary oedema(apo) patient in the emergency department(ed) delivered by helmet cpap(hcpap) and hfnc. methods: single-centre randomized controlled trial on patients presenting with cardiogenic apo. primary endpoint was a heart rate reduction.secondary endpoints included: improvement in subjective dyspnoea scales, respiratory rate, blood oxygenation, intubation rate and days mortality rate. results: patients were enrolled and randomized ( patients to hcpap; to hfnc) ( to . ± . ). intubation rate was lower in hcpap ( . % for hcpap versus . % for hfnc) and days mortality rate is lower in hcpap ( . % for hcpap versus . % for hfnc). conclusions: both hcpap and hfnc significantly improved patient condition in patient presenting to the ed with cardiogenic apo. however, hcpap was better than hfnc in improving physiology outcomes, lower intubation rate and mortality rate in patient introduction: the aim of the study was to compare the confusing assessment method of the intensive care unit (cam-icu) and the nursing delirium scoring scale (nu-desc) for assessment of delirium in the icu. furthermore we wanted to test the interpersonal variation of the nu-desc. delirium is proved to be associated with increased mortality [ ] . nu-desc is an observational five-item scale that does not require patient participation and is adapted to the fluctuating nature of delirium. each item can be scored from to . delirium is defined with a score > . the nu-desc has recently been translated into danish (nu-desc dk) but has not been validated.methods: icu patients, who met the inclusion-criteria for the cam-icu were scored with both cam-icu and nu-desc dk. patients were scored of two independent nurses at approximately the same time every day.results: a total of patients were enrolled, and comparisons between cam-icu and nu-desc dk were registered ( figure ).there was agreement between nu-desc and cam-icu in of registrations (hereof registrations were delirium negative). in interpersonal variation, registrations were made. the conclusion was identical in % of registrations, but only % agreed in all scoring-scale items (all negative).conclusions: a high agreement between nu-desc and cam-icu was found however the comparison was based on predominately patients with negative delirium score. the interpersonal variation of nu-desc scoring was substantial. a future validation of the nu-desc dk as a screening tool in the icu requires thorough training and instructions to minimize interpersonal variation. introduction: an increasing number of patients are being discharged directly home from critical care units and this is currently viewed as a negative quality indicator [ ] . the purpose of this audit was to characterise a cohort of patients who can be safely discharged directly home from adult critical care at st thomas´hospital (sth). methods: retrospective observational study of two groups of patients; ) those discharged directly home from critical care, ) those discharged within two days of step down to a ward from critical care (admissions st june- st october ). the clinical notes of these patients were reviewed via online systems. results: baseline demographics of the patients in group and patients in group were similar (mean age of years, versus years, p= . ); average length of stay in critical care was also similar ( . days versus . days respectively p= . ). in group , of icu days were after considered fit for step down versus of days in group , p= . (fig , ) . in group , drug related presentations were more common ( % versus % p= . ), fewer patients had specialist follow up post discharge ( % versus %, p< . ). in group , patients ( %) were readmitted within days, to critical care. in group , patients ( %) were readmitted, to critical care (p= . and . respectively); none of these readmissions were felt to have been preventable.conclusions: there is a cohort of patients suitable for discharge directly home from critical care who did not spend significantly longer in icu awaiting discharge than those who were stepped down to the ward. identifying these patients early, potentially by their diagnosis, and creating a pathway including access to specialist follow up clinic could allow prompt discharge directly from critical care, thus improving patient satisfaction and reducing hospital-acquired morbidity healthcare costs [ ] . the evaluation of the usability of a critical care information system ( introduction: critical care information systems (ccis) support clinical processes by storing and managing data, but poor usability can lead to staff dissatisfaction and increased workload, promoting workarounds that may compromise patient safety [ ] . the purpose of the study was to evaluate the usability of a philips intellispace critical care and anaesthesia (icca) ccis, recently implemented in beds across three critical care units of a large uk teaching hospital. methods: a prospective, mixed method observational study conducted in may , comprising of ( ) an audit assessing the ease of linking bedside devices to icca, ( ) an audit assessing the usability of co-signing medications in icca compared with a non-icca paper factors that commonly drive workforce metrics may not correlate with staff perceptions of safety. the bpr is a pragmatic, staff driven, tool to augment other measures of safety and is applicable to various icu settings. further research is needed to explore staff perceptions in order to understand the importance of this organisationally, and for staff stress. ventilator-free duration in icu, central venous catheter duration, urinary catheter duration, rates of deep vein thrombosis (dvt) and stress ulcer prophylaxis, rates of de-escalation antibiotic therapy, dvt prophylaxis duration, stress ulcer prophylaxis duration, icu and hospital mortality, -day mortality, rate of central venous catheter infection, length of stay in icu and hospital between two groups were analyzed. results: rate and duration of dvt prophylaxis in the intervention group were . % and ( , ) days respectively, in the control group were . % and ( , ) days, the differences between two groups were statistically significant(p< . ) ( table ). there were no differences in ventilator-free duration in icu, central venous catheter duration, urinary catheter duration, rate of stress ulcer prophylaxis, rates of de-escalation antibiotic therapy, stress ulcer prophylaxis duration, icu and hospital mortality, -day mortality, rate of central venous catheter(cvc) infection, length of stay in icu and hospital between two groups ( table ) . conclusions: electronic checklist in ward rounds can increase the rate of dvt prophylaxis and reduce the duration, but it cannot improve the prognosis of critically ill patients. introduction: the goal of the project "i see you" is family-centeredcare based on family meetings that improve the experience of the patient´s family members during hospitalization in the icu. the meetings focus on relaying information, raising knowledge and addressing the social and emotional needs of families. providing support along with information was found to be the strongest predictor of family satisfaction and could lead to improve cooperation between family and staff [ ] .methods: meetings and questionnaire: family meetings consist of a multidisciplinary team, a group facilitator and combined with a multimedia presentation about the unit and equipment. in addition, they focus on social and emotional needs: managing daily routine, sharing problems, fears and anxieties and more. at the end of the session a questionnaire was given to assess the impact of the intervention. sharing data: at the end of the first quarter, the data from meeting was summarized and sent to the staff alongside tools for effective communication.results: the project began in february . to date, family members of patients have attended the sessions. the topics discussed by the participants include: contact with the patient, prevention of infections, procedures, visits, conversations with doctors, medical confidentiality; guardianship; tracheotomy and social issues (fig ) . a sample of questionnaires was transferred to participants report satisfaction at a very high level.conclusions: the meeting received a very positive feedback from the participants. the project has achieved its goals and therefore it has been decided to be continued.introduction: possum score and boyd criteria are used to predict the outcome for high risk surgical patients. the aim of this study was to validation of these two measurement tools on mortality and morbidity in a university-based surgical intensive care unit (sicu) in thailand.methods: nine hundred and fifty two patients were enrolled onto this prospective review. all patients who had been admitted to sicu in a university-based hospital were included. all patients were collected for boyd criteria and possum score and outcomes and morbidity during sicu admission and discharge. introduction: aromatic microbial metabolites (amm), such as phenyllactic (phla), p-hydroxyphenylacetic (p-hphaa), and phydroxyphenyllactic (p-hphla) are involved in the pathogenesis of septic shock and are associated with mortality [ ] . according to previous studies, amm have a high prognostic value in patients with abdominal infection [ , ] . we hypothesize that amm have the prognostic value in patients with pneumonia in icu. methods: data of patients with community-acquired pneumonia was obtained on admission to icu. the levels of amm (phla, p-hphla and p-hphaa) were measured in blood serum using gas chromatography with flame ionization detector and compared in groups of patients: with favorable and with lethal outcome (mann-whitney utest). spearman's correlations between amm and clinical and laboratory data were calculated. using method of logistic regression and roc analysis, we measured the prognostic value of amm. (table ) . it was revealed, that some amm have similar prognostic characteristics in comparison with sofa and curb- scales; high level of amm is associated with high risk of death (roc-analysis - fig. ) .conclusions: serum concentrations of amm can be used as independent and practical criteria for the assessing of prognosis in patients with infection in icu. introduction: frailty in the critically ill is associated with increased morbidity and mortality but the optimal timing of frailty assessment, how to best measure frailty, reasons for adverse outcomes and how critical illness impacts frailty are unknown [ ] . in preparation for a multi-center study designed to address these knowledge gaps, we conducted a pilot study whose aim was to assess feasibility as determined by recruitment rates, ability to assess frailty at icu admission and hospital discharge, ability to measure icu and hospital processes of care and ability to conduct -month assessments. conclusions: a multi-center study is feasible but follow-up losses due to mortality and inability to return for assessment will require sample size adjustment. frailty characterization is method dependent, can be done on hospital discharge but varies with time of assessment. these findings will need to be confirmed in our larger study currently in progress. introduction: given the ageing of the world´s population, the demands of critical care resources for elderly patients has increased during the past decade. however, little is known about quality of life and outcomes of elderly icu survivors. the aim of the study is to assess outcomes of elderly icu survivors at least months after discharge: quality of life and mortality. methods: it is a retrospective study performed in a medical adult icu between january to december . the study included all elderly survivors ( ≥ years) after icu admission. outcomes were assessed by telephone interviews at least months after icu discharge. the primary outcome was assessing the quality of life after icu stay, measured by euro qol d questionnaire. the eq- d descriptive system contains five dimensions (mobility, self-care, usual activities, pain and discomfort, and anxiety and depression). for each dimension, there are five levels (no problems, slight problems, moderate problems, severe problems and unable to/extreme problems figure . conclusions: most elderly survivors patients showed a good health related quality of life using the euroqol d- l after icu discharge. fig. (abstract p ) . quality of life (euroqol d) scores after icu discharge introduction: sepsis survivors face mental and physical sequelae even years after discharge from the intensive care unit (icu). effects of a primary care management intervention in sepsis aftercare were tested. exploratory analyses suggest better functional outcomes within the intervention group compared to the control group at six and months after icu discharge. longer term effects of the intervention have not been reported. methods: a randomized controlled trial was conducted, enrolling patients who survived sepsis (including septic shock), recruited from nine german icus. participants were randomized to usual care (n= ) or to a -months intervention (n= ). the intervention included training of patients and their primary care physicians (pcp) in evidence-based post-sepsis care, case management provided by trained nurses and clinical decision support for pcps by consulting physicians. usual care was provided by pcps in the control group. the primary outcome of the trial was the change in mental healthrelated quality at -months after icu discharge. secondary outcomes included measures of mental and physical health. data were collected by telephone interviews using validated questionnaires at the -months follow-up ( months after the -year intervention).results: [ . %, intervention, control] of patients completed the -months follow-up. unlike the intervention group, the control group showed a significant increase of posttraumatic symptoms (diff. ptss- to baseline, mean (sd) . ( . ) control vs.- . ( . ) intervention; p= . ). there were no significant differences in the mcs and all other secondary outcomes between intervention and control group.introduction: survivors of sepsis often show symptoms of posttraumatic stress disorder (ptsd). only few studies report on courses of more than month after discharge from the icu. the aim of this study was to identify predictors for changes in ptsd symptoms over time up to month. methods: follow-up data of the smooth triala rct to evaluate a primary care management intervention on sepsis survivorswere analyzed. included patients were surveyed by phone for ptsdsymptoms at one, , and months after discharge from icu using the post-traumatic-stress-scale (ptss- ). scores changes between follow-up periods were analyzed using latent-change scores in structural equation models. predictors were clinical and sociodemographic baseline characteristics as well as physical, cognitive and functional sepsis sequelae assessed by validated questionnaires.results: patients were included of which participated in the month follow-up. a decrease of ptsd symptoms between and months was predicted by higher education (b=- . , p= . ), while higher pain intensity at one month predicted an increase (b= . , p= . ). increasing ptsd symptoms between and months were predicted by reporting more than two traumatic memories at one month (b= . , p= . ), more sleep problems (b= . , p= . ) and worse cognitive performance at months (b=- . , p= . ) as well as more neuropathic symptoms at months (b= . , p= . ).conclusions: sepsis patients that suffer from physical, cognitive and functional impairments after icu discharge may be at increased risk for developing late-onset ptsd. these predictors need to be replicated by future studies. early versus late readmission to the intensive care unit: a ten-year retrospective study v karamouzos , n ntoulias , d aretha , a solomou , c sklavou , d logothetis , t vrettos , m papadimitriou-olivgieris , d velissaris , f fligou conclusions: icu patients whose life-sustaining treatment was withdrawn or withheld had higher illness-severity scores, were older, had longer icu los and higher mortality than those in active-treatment group. healthcare introduction: caring for the critically ill patient is a complex task and becomes tougher when a death process takes place. a number of needs and coping strategies emerge from the healthcare providers before these issues but are mostly displayed out of individual skills and intuition. if those approaches are unappropriate and the needs are not met, patients' death process may be burdensome for caregivers. this could affect the quality of care for patients and families during the whole end-of-life care process. the aim of our study was to explore the different needs and coping strategies used by icu healthcare providers when facing patients in the dying process. methods: qualitative and collective case study. ten semi-structured interviews were conducted in icu personnel ( physicians and nursing professionals). a thematic analysis was done using nvivo software. local ethics committee approved the study. results: respondents were % women, had . ± . years-old and . ± . years of icu experience. main needs identified in icu healthcare providers refer to a lack of tools for doing emotional containment when delivering bad news to families, handling personal mourning, the need to perceive consistency regarding end-of-life care management across the icu team, and a wish of having regular training from a psychologist. main identified coping strategies included closing rituals, finding quiet spaces to spend time, and asking for counselling with more expert colleagues. a need for systematic, although basic training on these issues from qualified professionals is demanded. conclusions: usually, basic needs from patients and families in the process of dying are well addressed, but healthcare providers' needs are underrecognized and coping strategies mostly unknown. visibilization of those needs and basic but formal training in emotional containment, self-care and coping strategies are greatly desired. introduction: in the intensive care unit (icu), patients often exhibit cognitive impairments that prevent them from participating in decisions related to therapeutic options at the end of life. consequently, their families are often asked to speak for them when difficult decisions must be made. the main of this study was to determine the frequence in wich family want to share in end of life decisions and factors associated with this desire.methods: a prospective study was conducted in one mixed icu in montevideo. relatives of patients were invited to participate in this study after hours in the icu and completed a survey that included the hospital anxiety and depression scale. results: we analized relatives from patients hospitalized in the intensive care unit. the relationship with the patient was as follows: % spouses, % siblings, % grown children, % parents, and % other family members and friends. of them, . % reported a desire to share in end of life decisions. anxiety and depression symtoms were present in % and % respectively. factors asociated with the desire of involvment in end of life decisions by bivariate analysis were: female sex ( % vs %, p= . ), presence of anxiety ( % vs %, p= . ) and patient ecog - ( % vs %, p= . ). multivariate analysis shows that the presence of anxiety is the only independent factor associated with the desire to participate in end of life decisions (or . , ic % . - . ; p= . ). conclusions: have a loved one in icu is often associated with anxiety and depression after hours of admission. only % of the relatives want to participate in end of life decisions. the presence of anxiety is independently associated with the want to share in decisions making process. introduction: intensive care aims to treat failure of vital organ systems. sometimes, a patient's condition is of such a degree that intensive care is no longer beneficial, and decisions to withdraw or withhold intensive care are made. this means that life-sustaining treatments are terminated or not initiated. we aimed to identify variables that are independent factors for the decision to withdraw or withhold intensive care. methods: registry study using extracted data from a national quality registry the swedish intensive care registry (sir) - . data are delivered to the registry by nurses and doctors daily, during each patients' stay in the intensive care unit (icu). a total of , intensive care cases reported to the sir from - . results: data regarding each patient´s age, sex, diagnoses, condition at admission (expressed as simplified acute physiology score version , saps ), comorbidities and registered decisions to withdraw or withhold intensive care were analyzed. of the , cases reported, . % were women and . % men, and . % were - years old. a total of . % received a decision to withdraw or withhold intensive care, accounting for . % of all women and . % of all men, p< . . independent variables associated with increased odds of receiving a decision to withdraw or withhold intensive care were older age, worse condition at admission, and female sex. female sex was associated with an increased odds of receiving a decision to withdraw or withhold intensive care by % (ci . - . %) after adjustments for condition at admission and age. conclusions: older age, worse condition at admission and female sex was found to be independent variables associated with an increased odds to receive a decision to withdraw or withhold intensive care.publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- -ncrdwtdg authors: nan title: abstractband dog date: - - journal: ophthalmologe doi: . /s - - - sha: doc_id: cord_uid: ncrdwtdg nan glaukom s kornea / konjunktiva s linse s pathologie / anatomie s plastische chirurgie, lider, orbita s refraktive chirurgie s retina / rpe / aderhaut / glaskörper s sehbahn / gehirn / neuro-ophthalmologie s strabologie / kinderophthalmologie s trauma s tumoren, hinterabschnitt s tumoren, vorderabschnitt und sonstige s uvea, iris, pupille, kammerwinkel s verkehrsophthalmologie s versorgungsforschung, gesundheitsökonomie und -politik s die abstracts sind zunächst nach subspezialitäten sortiert und dann alphabetisch nach erstautoren. liegend. beidseits gingen von der papille nach nasal ausgeprägte atrophien und pigmentepithelverdichtungen im sinne von knochenkörperchen aus. in der fundusautofluoreszenz (faf) zeigte sich in diesen bereichen eine ausgeprägt reduzierte faf, umgeben von einem saum erhöhter faf. die sd-oct der makula ergab eine regelrechte foveale senke und struktur, die oct-analyse der papille eine normale retinale nervenfaserschicht. in der kinetischen perimetrie (octopus , fa. haag-streit diagnostics, ° bereich) stellte sich beidseits ein keilförmiges skotom der marke iii nach temporal superior dar, korrespondierend zu der lage und ausdehnung der betroffenen netzhautareale. im multifokalen elektroretinogramm fanden sich normwertige amplituden. im photopischen ganzfeld-elektroretinogramm (erg) waren die a-und b-welle leicht reduziert. flicker und ops waren unauffällig. die skotopischen erg antworten waren vor allem in der b-welle mittelgradig reduziert. schlussfolgerung: das alagille-syndrom kann zu pigmentretinopathien mit gesichtsfelddefekten führen, die einer retinitis pigmentosa ähneln. es handelt sich um den ersten beschriebenen fall eines sektoriellen retinalen befundes, der sich in bemerkenswerter weise spiegelsymmetrisch darstellt. the first examination no correction of ocular magnification was applied. in the second examination the previous focus value (of imaging ) was applied as refraction data in the heyex-software to incorporate ocular magnification. the third examination was performed including anterior corneal curvature (as examined with zeiss iol master ) and objective refraction, the standard parameters in the heyex-software for ocular magnification correction. segmentation of prnfl, bmo and mrw was conducted with heyex-software. intraclass correlation coefficient (icc) were computed. results: twenty eyes of participants were included in this ongoing study. the mean value of se was - . conclusions: our preliminary data with small number of eyes showed that measurement of bmo area should incorporate biometric parameters for ocular magnification correction or at least the focus measurement as se data. in contract, prnfl and mrw measurements showed high agreement between the three measurements (no correction, using focus as se data for ocular magnification correction or the standard method). sessed by patient-reported visual functioning together with relevant clinical parameters and visual field (vf) changes over a longer time period. methods: patients with glaucomatous optic nerve damage were enrolled in this prospective longitudinal observational study. assessment of qol was obtained by patient-reported visual functioning using the rasch-calibrated person estimate glaucoma activity limitation (gal- ) questionnaire at baseline and after eight years together with best-corrected visual acuity (bcva), vf data, and many other parameters. results: bcva of the better eye changed from logmar , ± , to , ± , whereas there was change from , ± , to , ± , on the worse eye. values of gal- changed from - , ± , to - , ± , , according to a gql sum score change from , ± , to , ± , . mean deviation (md) of the better eye changed from average - , ± , to - , ± , (p = , ) while the worse eye changed significantly from - , ± , to - , ± , (p = , ) . the change in pe-gal showed a highly significant correlation with the md at follow-up, especially with the worse eye (r = , ). the impact of the md at follow up on qol could also be well predicted in a regression model. conclusion: qol decreases significantly over time in glaucoma patients. especially the changes of the visual field of the worse eye have a great impact on reported functioning. careful treatment also of the eye with the worse glaucomatous damage is mandatory. long-term iop lowering and relationship to early iop response after a single bimatoprost implant administration in a phase / study klabe k. *, , chen m. , wang k. , liu j. , rivas m. aims: this analysis assessed early iop response in a subset of patients in which a single administration of bim implant managed iop for up to months without use of rescue topical medication. methods: in this prospective, paired-eye phase / study, bim implant was administered in the study eye; the fellow eye received once-daily topical bimatoprost . %. subgroup analysis evaluated early iop in patients without rescue/implant retreatment in the study eye who remained in the study through month (long-term iop responders) vs all other patients. early iop response was defined as iop through weeks (average iop from day through week ) . associations between early iop lowering and long-term iop responder status were explored using logistic regression analysis. results: of enrolled patients, the ( %) long-term iop responders demonstrated early iop lowering after bim implant administration, with mean (sem) iop through weeks of . ( . ) mmhg. patients with rescue/retreatment or early exit (all other pts) had a mean (sem) iop through weeks of . ( . ) mmhg (p < . vs long-term iop responders). baseline mean (sem) iops for long-term iop responders and all other patients were . ( . ) and . ( . ) (or . , > % vs ≤ %). conclusions: early response to treatment can potentially be used to predict later response and guide clinical decision-making. the present phase / study results indicate an association between iop at early timepoints after bim implant administration and long-term iop lowering without additional treatment. cmv und rv au betrifft vorwiegend jüngere und männliche patienten, während vzv und hsv vau hauptsächlich in älteren und weiblichen patienten zu finden ist (p < . ). n = patienten ( %) zeigten eine glaukomatöse schädigung, wovon n = ( % der gesamtkohorte) einen glaukomchirurgischen eingriff bei progression benötigten. es zeigte sich eine signifikante drucksenkung von präoperativ , ± , mmhg auf , ± , mmhg jahre postoperativ (p = , ). in n = patienten ( %, n = migs + n = te) wurde ein zweiter operativer eingriff notwendig. schlussfolgerung: verschiedene virusentitäten der uveitis anterior stellen unterschiedliche spezifische risiken für die entwicklung eines glaukoms sowie notwendige folgeoperationen dar. migs kann als erstbehandlung in individuell ausgewählten fällen eingesetzt werden. das passende verfahren sollte von einem erfahrenen spezialisten sorgfältig ausgewählt werden. eine filtrierende glaukomoperation kann in vau patienten zur augeninnendrucksenkung über einen längeren zeitraum empfohlen werden. intraocular pressure years after repeated anti-vegf treatment for age-related macular degeneration the paediatric glaucoma diagnosing ability of macular segmentation by optical coherence tomography compared to peripapillary retinal nerve fibre layer thickness lever m. *, , halfwassen c. , , unterlauft j. d. , bechrakis n. e. , , manthey a. , , böhm m. , universitätsklinikum essen, essen, germany; achim wessing institute for ophthalmological diagnosic (awio), essen, germany; universitäts-augenklinik, leipzig, germany purpose: the decrease of peripapillary retinal nerve fiber layer (prnfl) and macular layers thickness measured by spectral domain-optical coherence tomography (sd-oct) is well documented in pediatric glaucoma. however, the diagnostic impact of these measurements in children has rarely been investigated. the aim of this study was to compare these measurements in pediatric glaucoma patients and healthy children to evaluate their respective glaucoma diagnosing ability. methods: retrospective observational study including children aged - years (glaucoma: [ . %] , healthy: [ . %]) examined with sd-oct (spectralis®, heidelberg engineering). the thickness of prnfl sectors and of etdrs subfields after automated macular segmentation were compared between diseased and healthy control children. the correlation of those measurements with the presence of glaucoma was evaluated using logistic regression. the glaucoma discriminative capacity of single or combined prnfl and macular areas were calculated using area under the receiver-operating curves (auc). results: prnfl thickness is reduced in glaucoma patients (e. g. total-average-thickness: p < . ). the thickness of the three inner macular layers is reduced in glaucoma patients (e. g., ganglion cell layer [gcl] , outer-inferior subfield: p = . ). prnfl and macular segments' thickness correlate highly with the presence of glaucoma. correspondingly, analyzing these parameters revealed a high auc for the identification of glaucoma (prnfl: . ; gcl: . ). finally, the strongest glaucoma discriminating ability was observed for the combination of selected subfields of all macular segments (auc . ). the measurement of prnfl thickness and of selected macular segments showed a high glaucoma discriminative ability. the strongest diagnostic performance, however, was found combining data from all macular segments. further studies are needed to study more precisely how prnfl and macular thickness measurements using sd-oct could improve the diagnostic possibilities in pediatric glaucoma. pahlitzsch t. , pahlitzsch m. methodik: insgesamt wurden fünfzehn patienten (alter: , ± , jahre) mit moderatem bis fortgeschrittenem primären offenwinkelglaukom (powg) in die studie eingeschlossen. präoperativ, ein tag und drei monate postoperativ einer katarakt-operation wurden folgende untersuchungen durchgeführt: visus, gesichtsfeldprüfung (weiß-weiß-perimetrie octopus ), augendruckmessung (goldmann applanationstonometrie), bestimmung der perfusionssituation mit der oct-angiographie (cirrus hd-oct ), der zentralen kornealen dicke (pentacam) und endothelzelldichte (nidek cem- ) sowie des flarewerts (kowa fm ). ergebnisse: postoperativ verbesserte sich der bestkorrigierte dezimalvisus von , ± , auf , ± , . es zeigte sich eine augeninnendruckreduktion von , ± , auf , ± , mmhg. eine abnahme der kornealen endothelzellzahl von , ± , zellen/mm auf , ± , as to the optical coherence tomography results, the rate of the ganglion cell complex thinning in patients with pxf was . % higher than in patients without this syndrome. conclusions: according to the results of our study, the ganglion cell complex thinning is almost one and a half times higher in patients with openangle glaucoma and pseudoexfoliation syndrome in comparison with the ganglion cell complex thinning in patients with oag. methods: all patients who were admitted in january to our department for anti-vegf treatment and were on anti-vegf therapy (ranibizumab, aflibercept) for years-from january or before, were included in our study. the retrospective study included patients with namd ( eyes). all the patients with glaucoma, ocular hypertension, myopic or diabetic maculopathy, eye trauma, uveitis were excluded from our study. the diabetes with or without diabetic retinopathy was also an exclusion criterion. only the patients with namd without any other ophthalmic pathology were involved. sustained iop was defined as a rise in iop above baseline ≥ mmhg and/ or > mmhg on two or more consecutive visits. untreated eyes were used for control group. results: the average age of our patients was , years (ranging from to ). the majority were women ( , %). except for clinical picture of namd other ophthalmological findings were normal. all patients were treated after "treat and extend" regiment receiving intravitreal ranubizimab (lucentis) or aflibercept (eylea) injections. bilateral manifestation was observed in patients ( eyes). in all eyes a decrease in iop from baseline was observed after years of therapy with a mean reduction of . mmhg in treated eyes compared with an average increase of . mmhg in fellow untreated eyes. the difference was statistically significant. only in , % ( of eyes) iop elevation of and mmhg was observed. none of the patients in treated group experienced iop > mmhg. in control group the elevation of or more mmhg or > than mmhg was not observed. conclusions: our study revealed that repeated intravitreal anti-vegf injections during a period of years or more for namd in otherwise healthy eyes and subjects are not associated with iop elevation. we found a significant difference in iop between treated and untreated eyes with reduction in treated and elevation in untreated eyes. further studies are necessary to confirm our results. purpose: micro-invasive glaucoma surgery (migs) has become an important treatment approach for primary open angle glaucoma, while the long-term efficiency of these procedures remains yet to be substantiated. recently, we published a protocol for the assessment of aqueous humor outflow in vitro using an in rostock developed dedicated oculopressor (rop), which allows analysis of migs efficiency. in the present study the performance of an in house developed valve-controlled microstent was evaluated with regard to drainage capacity and effect on intraocular pressure (iop) using this protocol in rabbits in vivo. methods: six months after migs draining in the subconjunctival tenon space, aqueous humor outflow was assessed utilizing the rop protocol in anaesthetized new zealand white rabbits. a g cannula, connected to a scans (spectralis oct ii, heidelberg, germany) in layers: superficial vascular plexus (svp), intermediate vascular plexus (ivp) , and deep capillary plexus (dcp). the local ethics committee approved the study. results: mean macula vd was significantly reduced in svp ( . ± . vs . ± . ), ivp ( . ± . vs . ± . ), and dcp ( . ± . vs . ± . ) of oht compared to healthy controls (p < . ). additionally, mean macula vd of svp ( . ± . ), ivp ( . ± . ), and dcp ( . ± . ) were significantly reduced in pre-oag patients compared to controls (p < . ). no significant differences were observed between oht and pre-oag patients in ivp, and dcp (p > . ), yet svp differed significantly (p = . ). conclusion: as a significant reduced macula vd was seen in all retinal vascular layers of glaucoma suspects compared to healthy controls, the data of the present study might indicate microvascular changes in the macula region even early in glaucoma pathogenesis. vorstellung eines standardisierten schemas zur glaukomverlaufskontrolle in der augenärztlichen praxis rakitin m. fluid reservoir with buffered saline solution, was injected into the anterior chamber to adjust baseline iop to . ± . mmhg. for iop-measurements a second g cannula, connected to a pressure transducer, was inserted into the anterior chamber. the rop (weight = g) was positioned on the central cornea and held in place for min. iop value dynamics were continuously monitored and compared with the contralateral control eye which had not undergone surgical intervention (n = , each). results: immediately after rop placement iop peak values peaked of . ± . mmhg for control and . ± . mmhg for treated eyes were measured, respectively. iop of control and migs eyes was lowered during the four minutes of oculopression to similar values, . ± . mmhg and . ± . mmhg, respectively. however, iop decrease was significantly steeper in migs eyes compared to the untreated eyes. following rop removal iop levels were . ± . mmhg below adjusted baseline iop. the rop protocol was successfully utilized to evaluate aqueous humor outflow following migs in a standardized manner. the faster iop decrease in treated eyes in comparison to control eyes evidenced in vivo functionality of our proprietary, valve-controlled microstent and its facilitation of aqueous humor outflow six months after implantation. following this proof-of-principle in vivo study in a rabbit model, further investigations will include use of the rop protocol with glaucoma patients, before and after migs, to assess the contribution of the implanted drainage device to aqueous humor outflow. in vitro decrease of extracellular matrix deposition by suppression of the tgf-β pathway by a macrolide antibiotic in ocular fibroblasts sterenczak k. a. * , fuellen g. purpose: a major complication after fistulating glaucoma surgeries are fibrotic processes causing postoperative decrease in the liquid drain. accordingly, the prevention of fibrotic processes represents a key aspect in the development of advanced therapeutic surgical concepts. kitasamycin represents an antibiotic molecule belonging to the group of macrolides and can act as a potential candidate to modulate fibrotic processes. herein we evaluated the antifibrotic potential of kitasamycin in a tgf-β mediated fibrotic human fibroblast in vitro model system. methods: primary ocular fibroblasts from human tenon capsule (htf) were isolated, cultivated and kitasamycin was tested for its highest possible non-toxic dose covering a concentration range from to µm. differentiation of fibroblasts towards myofibroblasts was performed by incubation with ng/ml tgf-β for h. fibroblasts were cultured on coverslips and fixed for immunocytochemical analysis. immunofluorescence was performed using antibodies against ecm-components (α-smooth muscle actin (sma), fibronectin). dapi staining was used for additional nucleic labeling. protein detection of ecm-components (α-sma, β-actin, β-tubulin, collagen i and vi, fibronectin, vimentin) was performed by western blot. results: in htfs exposed to different kitasaymcin concentrations no increase in α-sma and ecm-component expression was detected. tgf-β strongly induced fibrotic marker expression. the addition of kitasamycin inhibited the induced fibrotic marker expression in a concentration dependent manner (up to a highest concentration of µm). conclusions: our study demonstrated a dose-dependent expression inhibition of fibrotic marker in tgf-β stimulated htfs by kitasamycin. these findings demonstrate that kitasamycin impairs the transformation of fibroblasts towards myofibroblasts and the expression of proteins involved in scarring processes. therefore, kitasamycin is a potential agent for the specific prevention of postoperative scarring processes and fibrosis following glaucoma filtration surgery. abstracts pensierte neovaskularisationsglaukom (nvg) bei gematchen patienten mit zentralvenenverschluss (zvv) und proliferativer diabetischer retinopathie (pdr) zu vergleichen. methodik: patienten wurden mit -g-ppv, panretinaler full-scatter-endolaser, transskleraler zyklophotokoagulation ( -nm-diodenlaser, w, s, herde) und intravitrealer bevacizumab-eingabe behandelt. phake augen wurden kombiniert mit katarakt operation versorgt. zvv patienten konnten mit pdr patienten auf iod gematcht werden mit coarsened exact matching (cem). analysiert wurden bestkorrigierter visus (logmar), augeninnendruck (iod, mmhg), medi-score (anzahl der glaukom medikamente) nach , , und monaten (m) , visuelle analoge schmerzskala (vaps, - ), erneute eingriffe und die erfolgsrate (iod ≤ mmhg oder iod-reduktion ≥ %, keine erblindung). ergebnisse: zvv patienten konnten mit pdr patienten mit dem präoperativen iod gematched werden (baseline iod: , ± , mmhg, p = , ) . zvv patienten ( , ± , j) waren älter als pdr patienten ( , ± , j) (p = , ). männer waren in beiden gruppen häufiger betroffen (zvv %, pdr %). der visus zeigte nur in der pdr-gruppe einen signifikanten unterschied zwischen baseline (zvv , ± , ; pdr , ± , ) und m follow up (zvv , ± , ; pdr , ± , ) (p < , ). der gematchte präoperative iod sank in beiden gruppen nach m signifikant (zvv , ± , mmhg; pdr , ± , mmhg). es zeigte sich kein unterschied diesbezüglich zwischen den beiden gruppen (p = , ). der medi-score sank zwischen baseline (zvv , ± , ; pdr , ± , ) und m stärker in der pdr gruppe (zvv , ± , ; pdr , ± , ) (p = , ). alle patienten waren postoperativ schmerzfrei. zvv und pdr augen ( , %) benötigten keine weiteren stationären behandlungen. die erfolgsrate betrug und % in der zvv beziehungsweise pdr-gruppe (p = , ). zusammenfassung: die kombinierte operationsstrategie senkte in beiden gruppen den iod und kontrollierte die schmerzen. in der pdr gruppe verbesserte sich der visus und sanken die drucksenkenden medikamente. % der patienten erfüllten das erfolgskriterium nach einem jahr. kgd/iopstim: , ± , / , ± , . streubreite der ezm: , ± , / , ± , , (t-test: p = , ) intraclass korrelationskoeffizient (ikk) der ezm: , / , . anova der ezm: p = , / , . mrvp kgd minus mrvp iopstim: , ± , . verhältnis mrvp kgd/mrvp iopstim: , ± , . schlussfolgerungen: wie aus dem hohen ikk und dem anova-ergebnis zu schließen ist, werden mit dem iopstim und dem kgd gut reproduzierbare einzelwerte des rvp erhalten, deren streubreiten sich nur gering unterscheiden. der iopstim erscheint somit geeignet für den klinischen einsatz. das neue iopstim verfahren wurde erst einmal bei freiwilligen erprobt. weil bei diesen erwartungsgemäß eine spontane pulsation der zv (svp) vorliegt, musste unter valsalva-bedingungen untersucht werden, um die svp aufzuheben. diese bedingung und die unterschiedliche kraftrichtung bei kgd und iopstim kommen als ursache für den unterschied des mrvp in frage. strzalkowska a. fragestellung: wir benutzten exact matching, um einen ausgewogenen vergleich zwischen der ab-interno-trabekulektomie (ait) mit dem trabektom und der trabekulektomie (trab) mit mitomycin c (mmc) zu erstellen. methodik: patienten, bei denen eine trab durchgeführt wurde, wurden mit ait patienten verglichen. die patienten wurden anhand des augeninnendrucks (iod), der anzahl der glaukommedikamente (medikamente) und der glaukomarten unter verwendung von exact matching und nach dem alter durch nearest-neighbor-matching verglichen. die ergebnisse wurden nach , , , , und monaten analysiert. ergebnis: ait konnten mit trab gematcht werden. der mittlere präoperative iod betrug , ± , mmhg und die grundlinienzahl der glaukommedikamente betrug in beiden gruppen , ± , . nach monaten sank der iod in ait auf , ± , mmhg und in trab auf , ± , mmhg. der iod war bei allen weiteren follow-ups niedriger als der ausgangswert (p < , ) und in trab niedriger als der in ait (p < , ). die anzahl der glaukomtropfen sank bei ait auf , ± , und bei trab auf , ± , . im vergleich zum ausgangswert verwendeten die patienten bei allen follow-ups weniger medikamente (p < , ) und bei trab weniger als bei ait (p < , ). sekundäre chirurgische eingriffe (revisionen oder weitere glaukom-operationen) hatten den größten einfluss auf das Überleben und wurden bei ait-und trab-patienten notwendig. schlussfolgerung: ait und trab führten zu einer verringerung des augeninnendrucks und der medikamente, die bei trab stärker ausgeprägt war, jedoch auf kosten von viermal so vielen sekundären interventionen. subgruppenanalyse nach kombinierter operationsstrategie für das dekompensierte neovaskularisationsglaukom -eine retrospektive coarsened exact matching fallserie strzalkowski p. * , strzalkowska a. , loewen n. uluk y. * , baulig c. in der gruppe ts cya zeigte sich eine iod-senkung von präoperativ im median , mmhg (q mmhg/q mmhg) auf im median mmhg (q mmhg/q , mmhg) (p = , ) nach monaten. die drucksenkenden wirkstoffe konnten im median von (q /q ) auf im median (q /q ) (p = , ) reduziert werden. ein complete success wurde bei % und ein qualified success bei % der patienten erreicht. die durchschnittliche prozentuale drucksenkung lag in beiden gruppen (ts nativ und ts cya) bei % nach monaten. der unterschied zwischen den beiden gruppen war nicht signifikant (p = ). schlussfolgerung: beide gruppen zeigten nach ts erwartungsgemäß eine signifikante senkung des iod, sowie der drucksenkenden wirkstoffe. die anwendung von topischem cya in der postoperativen therapie der ts zeigt keinen vorteil bezogen auf iod oder drucksenkende wirkstoffe. - , %) in der trabekulektomie gruppe und , % ( %-ki: , - , %) in der xen gruppe. es gab keinen signifikanten unterschied zwischen den beiden gruppen hinsichtlich des primären endpunktes ‚kompletter chirurgischer erfolg' nach einem jahr (or = , [ %-ci: , - , ]; p = , ). mittels multivariater logistischer regressionsanalyse konnte kein einfluss auf den kompletten chirurgischen erfolg nach einem jahr für folgende faktoren gefunden werden: geschlecht, alter, präoperativer iod oder die anzahl topischer medikamentenklassen präoperativ. nach einem jahr war die iod reduktion (sekundärer endpunkt) in der trabekulektomie gruppe ( , ± , mmhg) signifikant höher verglichen mit der xen-gruppe ( , ± , mmhg) (p = , ). schlussfolgerung: xen-implantation und trabekulektomie zeigen ähnliche erfolgsraten nach einem jahr bei patienten mit refraktärem offenwinkelglaukom, und sind daher chirurgische optionen für die klinische routine. die trabekulektomie zeigte allerdings eine höhere drucksenkung im vergleich zum xen-stent. eine randomisierte klinische studie fehlt, um einen möglichen unterschied in den langzeitergebnissen zwischen den beiden gruppen zu zeigen. aim: glaucoma is a chronic disease that frequently requires long-term treatment with topical ocular hypotensive eyedrops. dry eye symptoms frequently coexists with glaucoma and may be initiated or exacerbated by topical glaucoma medications. thealoz duo® is a novel artificial tear preparation containing two active ingredients: trehalose, a natural alpha-linked disaccharide with high water retention capabilities and sodium hyaluronate, an anionic glycosaminoglycan polysaccharide found in various connective tissue which has lubricant and water-retaining properties. the aim of this study was to evaluate the efficacy of trehalose/hyaluronate tear substitute (thealoz duo®) in recovering the tear film changes in glaucoma patients with mild to moderate dry eye symptoms. methodology and results: the group of glaucoma patients (n = , males and females) under topical medical treatment and age-matched controls (n = , males and females) were reviewed. the mean age of all patients was (respectively, mean±sd) . ± . years, males and females. age, gender, number of glaucoma medications used, the duration of glaucoma treatment and the presence of dry eye symptoms were recorded. after initial evaluation, patients were instructed to administer thealoz duo® with the regimen of one drop/eye/three times daily. patients were observed in visits: day (baseline) and after one month of treatment (endpoint). tear film quality was measured using tear break-up time (tbut) test. significant changes at endpoint as compared to baseline were found in both groups (p < , ). tbut test results improved in both, glaucoma ( , ± , vs , ± , s) and non-glaucoma ( , ± , vs , ± , s) patients. the improvement in tear film quality (measured by tbut) was shown after application of trehalose/hyaluronate tear substitute for one month in both, glaucoma and control group patients with mild to moderate dry eye symptoms. however, randomized studies are required to truly ascertain the magnitude of their clinical value. vidinova c. n. * , pravoslava g. military medical academy, sofia, bulgaria; eye clinic zrenie, sofia, bulgaria our ability to help patients often depends on technology. oct is essentially used in the diagnosis and treatment of glaucoma. understanding the types of artifacts commonly seen is vital in the clinical practice. purpose: the purpose of our study is to determine the frequency and distribution of oct and oct a errors and imaging artifacts in patients evaluated for glaucoma. to provide examples for the most common mistakes. methods: in our prospective study patients with primary open-angle glaucoma were enrolled. they all underwent a complete ophthalmological examination including va, perimetry and oct-both sd-oct (rtvue, examined patients were divided into groups: the main group included workers ( eyes) who were in direct contact with the petrochemical products; the control group included workers ( eyes) who were not in direct contact with the petrochemical products. results: the mean age of workers in the main and control groups was . ± . and . ± . years, respectively ( . % male). the mean work experience of workers in the main and control groups was . ± . years and . ± . years (p > . ). the eye pathology was revealed in ( . %) workers of modern petrochemical industry. the prevalence of eye pathology in the main and control groups was . ± . % and . %± . , the difference was statistically significant (р < , ). the prevalence of different eye pathologies in the both groups were . ± . % and ± . % for the dry eye syndrome, . ± . % and . ± . %-conjunctival melanosis, . ± . % and . ± . %-blepharoconjunctivitis, . ± . % and . ± . %-pingvecula, . ± . % and . ± . %-conjunctival nevus, . ± . % and . ± . %-pterygium, . ± . % and . ± . %-glaucoma. the mean iop in the main and control groups was . ± . mmhg and . ± . mmhg, the difference was not statistically significant. conclusions: despite the decrease of the harmful factors' influence on the eye due to the use of modern petrochemical industry technologies in azerbaijan they still could cause occupational diseases of the eye. the prevalence of eye pathology in the workers of modern petrochemical industry with direct contact with the petrochemical products is higher than in workers without direct contact. ashikova p. * , oganesyan o. , khandjan a. , getadaryan v. , grdikanyan a. , oganesyan c. the helmholtz moscow institute of eye diseases, moscow, russian federation; the charles university, prague, czech republic introduction: a pterygium is a pinkish, triangular fibrovascular tissue growth on the cornea, which occurs more often from the medial side. in different countries the frequency (incidence?) of the disease varies from . to %. over surgical methods have been offered for the pterygium treatment. however, the rate of recurrence is still relevant and can reach up to %. to decrease the reoccurrence of the pterygium, conjunctival and limbal autografts, amniotic membrane transplantation, beta-irradiation, antimetabolites are used. after any pterygium surgery, there is no bowman layer in intervention area. the bowman layer transplantation can restore not only normal anatomy of cornea, but also intercellular interactions (relationships?) as well. this may reduce the frequency of the reoccurrence of the pterygium. purpose: to describe the feasibility of bl transplantation during pterygium surgery and to study short-term results. methods: two female patients and years old with pterygium (stage ii) were operated. decimal uncorrected visual acuity was . . patients were examined before the surgery, after day, and months after surgery by biomicroscopy, keratotomography, and optical coherence tomography (oct). briefly, the surgery technique was following. after the pterygium excision, a simple conjunctival closure was performed. phototherapeutic keratectomy (ptk) recipient cornea and the stromal surface of bl graft were performed. the bl graft ( . and . mm in diameter) was placed in the postptk bed. a contact lens was placed on the cornea. postoperatively corticosteroids and antibiotics were prescribed times per day for weeks. results: the surgeries and months follow-up were uneventful. the cornea area of intervention are clear, the grafts are in place, and the edges of grafts are fully adapted. the data of visual acuity and central keratometry stay unchanged. according to oct the grafts thickness are and microns months after surgery. clinical efficacy of cypass microstent with months follow-up wörn m. * , hohberger b. , ennen m. , lämmer r. univ.-augenklinik, erlangen, germany propose: minimal invasive glaucoma surgery (migs) offers a good intraocular pressure (iop) lowering effect and high safety profile. as ab interno approach, the stents enable glaucoma surgery without conjunctival dissection. cypass microstent (available / - / ) was the only migs option, draining the aqueous humor suprachoroidally. it was the aim of the present study to investigate efficacy of cypass microstent as stand-alone and combined procedure with cataract surgery with a months follow-up. methods: eighty-four eyes from open-angle glaucoma (oag; female, male) patients received stand-alone cypass microstent implantation (n = ) or combination with cataract surgery (n = ). patients were grouped into cohort with preoperative iop ≥ mmhg (n = ) and cohort with preoperative iop < mmhg (n = ). efficacy outcome included change of mean iop and number of glaucoma medication through months follow-up. results: preoperative iop was . ± . mmhg (cohort ) and . ± . mmhg (cohort ). mean iop was significantly decreased after months ( . ± . mmhg; - . %), months ( . ± . mmhg; - . %), and months ( . ± . mmhg; - . %) compared to preoperative iop for cohort (p < . ). yet, no significant differences were observed for mean iop after months ( . ± . mmhg, - . %), months ( . ± . mmhg, - . %), and months ( . ± . mmhg, - . %) compared to preoperative iop in cohort (p > . ). glaucoma medication was significantly reduced in both cohorts after months (cohort : p < . , cohort : p = . ) and months (cohort : p < . , cohort : p = . ) compared to baseline. at the end of the follow-up number of glaucoma medication was significantly decreased in cohort ( . ± . vs . ± . , p < . ) and slightly in cohort ( . ± . vs . ± . , p = . ) compared to preoperative. surgery procedure of stand-alone implantation or combination with phacoemulsification did not influence outcome of iop or glaucoma medication (p > . ). conclusion: iop reduction after cypass microstent implantation was larger in oag eyes with higher preoperative iop than with preoperative iop< mmhg. number of locally administered medication was significantly reduced in both cohorts. aghayeva f. a. * , ibrahimova s. n. , kasimov e. m. national centre of ophthalmology named after academician zarifa aliyeva, baku, azerbaijan introduction: the petrochemical industry occupies a leading position among the sectors of the azerbaijan economy. thus, health care of the oil industry employees that are exposed to the complex of chemical, physical and psycho-emotional harmful factors is becoming more socially significant. in the s academician zarifa aliyeva conducted research on occupational eye diseases in workers of petrochemical industry. taking into account the use of new modern industry technologies continuation of such type of studies are of great interest. the aim: of this study was to study the prevalence of eye pathology and intraocular pressure (iop) in workers of modern petrochemical industry of azerbaijan. methods: analysis of eye condition and iop was performed in workers ( eyes) of the oil refinery factory named after heydar aliyev. all first results of a prospective multicentre phase i/iia clinical trial on application of purified allogenic abcb + limbal stem cells for treatment of severe limbal stem cell deficiency auffarth g. * , meller d. , cursiefen c. , wasielica-poslednik j. , chodosh j. universitäts-augenklinik heidelberg, heidelberg, germany; universitäts-augenklinik jena, jena, germany; universitäts-augenklinik köln, cologne, germany; universitäts-augenklinik mainz, mainz, germany; department of ophthalmology, harvard university, boston, united states background: limbal stem cell deficiency (lscd) is characterized by a loss or deficiency of limbal stem cells (lscs), which causes a loss of the regeneration potential of the cornea, a loss of the barrier function between conjunctiva and cornea and severely impaired vision up to blindness. methods: in this study purified lscs from cadaveric donors were prepared by using the lsc marker abcb . the aim of this study is to test this lscbased atmp in a first-in-human multicenter phase i/iia clinical trial to evaluate the safety and efficacy of ascending doses of allogeneic abcb + lscs for the treatment of lscd. the lscs are expected to permanently engraft in the limbal stem cell niche, so that the limbal barrier is restored and a transparent cornea is regenerated. the study is planned with lscd patients in ascending dose groups of patients each. the inclusion criteria involve patients with secondary lscd with vessel penetration of at least quadrants with central cornea involvement. cells are topically applied on the entire corneal and limbal area following surgical dissection of conjunctival pannus tissue from the corneal surface. to date, patients have been recently treated with the imp, but as the primary efficacy endpoint is measured after year it is not yet possible to present the primary efficacy endpoints. in preclinical studies, transplantation of abcb + lscs in mice with induced lscd led to normal and transparent human corneas without corneal neovascularization. the inclusion criteria involve patients with secondary lscd with vessel penetration of at least quadrants with central cornea involvement. cells are topically applied on the entire corneal and limbal area following surgical dissection of conjunctival pannus tissue. to date, patients have been recently treated with the imp, but as the primary efficacy endpoint is measured after year it is not yet possible to present the primary efficacy endpoints. in preclinical studies, transplantation of abcb + lscs in mice with induced lscd led to normal and transparent human corneas without corneal neovascularization. discussion: abcb + lscs are a promising new treatment method that could possibly be a permanent cure to patients with lscd, but before any statistically significant statement about efficacy is possible, more patients need to be treated and the already treated patients need to be observed for a longer period. purpose: to assess possible parameters that may affect endothelial cell density (ecd) decrease after descemet membrane endothelial keratoplasty (dmek) by comparing eyes in the low versus high quartile of ecd decrease over a follow-up period of four years. methods: for eyes ( patients) who underwent dmek for fuchs endothelial corneal dystrophy (fecd), donor ecd decrease as compared to preoperative donor ecd was evaluated up to four years after surgery. eyes with a postoperative ecd decrease in the lower quartile at all available follow-up moments were assigned to group (n = ), and those in the upper quartile to group (n = ). multinominal regression was used to assess which covariates were related to the different patterns of ecd decrease (i. e. high versus low ecd decrease). from the retina to the cornea and to increase the in-plane resolution. furthermore, a piezo actuator is implemented to control the focal plane within the cornea. measurements on various corneal layers were performed ex vivo on pig and lamb eyes as well as in vivo on human eyes. results: in general, imaging could be performed at all investigated wavelengths and species. exemplifying the found imaging patterns, the cell borders and nuclei of the human superficial epithelium are shown, which have a stronger reflectance using the blue or green compared to near-infrared light. at deeper layers, almost all cellular structures (nerves, keratocyte nuclei) are comparable, but the image quality decreases with shorter wavelengths due to scattering (not shown here). interestingly, although the endothelium is the deepest layer, the cellular structure could only be resolved by the blue or green light and not by the near-infrared light. conclusions: most differences in image quality can be attributed to depthand wavelength-dependent scattering. however, there are also layers that vary in spectral reflectance of certain cellular structures (e. g. endothelium). this demonstrates the importance of choosing the right wavelength for certain target structures. in order to answer the question of the optimal wavelength, various aspects have to be considered: ( ) corneal target structures (being a compromise between low scatting and high resolution), ( ) light hazard and ( ) glaring the patient. the optimal solution would be a multimodal instrument using different wavelengths. fallbericht: interstitielle keratitis im rahmen einer symptomtrias borgardts k. the filatov institute of eye diseases and tissue therapy nams of ukraine, odessa, ukraine; lviv regional clinical hospital, lviv, ukraine the aim: was to determine the cytological features in conjunctival epithelium in patients with subclinical and manifest hypothyroidism and dry eye materials and methods: the impression cytology of hypothyroid patients ( with subclinical, and -with manifest) and dry eye was performed. all patients underwent ophthalmological investigation: biomicroscopy with fluorescein test, determination of the ocular surface disease index (osdi), tear film stability (test norn) and tear production (schirmer test i), the lipcof test. cytological material was taken using standart method of impression cytology by contact compression of the bulbar conjunctiva with millipore filter (millicell cm). the material was fixed in a mixture of alcohol and ether : with followed staining with hematotoxillin and eosin. were analyzed the following signs: state of a layer of epithelial cells (ec), metaplasia, degree of keratinization, type of ec change nuclei, goblet cells density, presence of the inflammatory cells. in the subclinical hypothyroidism a layer of ec was detected without significant structural changes. a distribution of ec was evenly. the ec were almost the same size without disturbances in intracellular contacts. the cells nuclei were round or oval. the ratio of nucleus to the cytoplasm was : . changes in ec nucleus due to slight karyopicnosis were rarely observed. single cells were seen in a state of keratinization. no evidence of epithelial cells metaplasia and inflammatory cells was observed. the goblet cells density was slightly reduced. cytological features of the manifest hypothyroidism are more pronounced structural changes in the epithelial layer. in all cases, it was not possible to obtain a single layer of epithelial cells. in the epithelial layer focal epithelial hyperplasia, keratinization of ec, disturbance of intracellular contacts were observed. the nuclei of ec had various shapes, from round to rod-shaped. karyopicnosis and snow-like dissociation of ec nuclei were observed frequently. the goblet cells were in a state of degeneration, their density was significantly reduced. conclusion: Сytological examination of the bulbar konjunctiva of patients with hypothyroidism and dry eye revealed degenerative changes in epithelial and goblet cells of various degrees, which depended on the stage of hypothyroidism. the severity of degenerative changes were more pronounced in patients with manifest hypothyroidism. el halabi m. * , seitz b. , quintin a. , suffo s. , flockerzi f. . further studies showed that stimulation of its activity is involved in this process through promoting both keratocyte transdifferentiation into myofibroblasts and extracellular matrix remodeling. based on these findings, the purpose of this study was to investigate whether there is an interplay between trpv and another trp subtype channel such as trp ankyrin (trpa ) cold receptor, which is closely related to trpv . methods: an established hck cell line was used as a cell model for corneal keratocytes. single cell fluorescence calcium imaging was used to measure the intracellular calcium concentration ([ca + ] i ). specifically, the fluorescent dye fura- /am was used to measure a fluorescence ratio (f /f ), which is proportional to [ca + ] i . results: the trpa agonist icilin ( µm) increased the fluorescence ratio f /f from . ± . to . ± . (n = ; p < . ). this increase could be suppressed by the trpa antagonist hc- ( µm) to . ± . (n = ; p < . ). interestingly, icilin was also able to suppress the cap-induced increase of f /f from . ± . (n = ) to . ± . (n = ; p < . ) (both µm). conclusion: for the first time, our studies show a functional expression of the cold receptor trpa and its interplay with trpv in hck. consequently, the use of cold receptor agonists may be an interesting option to modulate stromal scarring through suppressing injury induced intrinsic trpv activity. abstracts bilität der befunde über den beobachtungszeitraum von derzeit monaten. die beschriebene kohorte wird längsschnittlich weiterverfolgt. schayan, f. * , flockerzi e. , hamon l. , langenbucher a. (b) , dünnste pachymetrie (c) und die bestkorrigierte sehschärfe (d) jeweils in den ausprägungsstadien bis . alle werte wurden prä-und monate postoperativ verglichen. ergebnisse: sechs monate postoperativ zeigte sich eine verbesserung sowohl des mittleren sc-visus (logmar) von , ± , auf , ± , (p < , ) als auch des mittleren cc-visus (logmar) von , ± , auf , ± , (p = , ). hinsichtlich der refraktion zeigte sich eine reduktion der sphäre von - , ± , dioptrien (d) auf - , ± , d (p < , ) und des zylinders von - , ± , d auf - , ± , d (p = , gibt es einen zusammenhang zwischen geburtsgewicht und hornhautaberrationen im erwachsenenalter? ergebnisse der bevölkerungsbasierten gutenberg-gesundheitsstudie (ghs) fieß a. * , urschitz m. , nagler m. , nickels s. , münzel t. , wild p. , beutel m. , lackner k. j. , pfeiffer n. astigmatismus (z( ,- ); z( , )), koma (z( ,- ); z( , )), trifoil (z( ,- ); z( , )), sphärische aberration (z( , )) und aberrationen höherer ordnung (hoa) und niederer ordnung (loa). ergebnisse: insgesamt wurden teilnehmer in die vorliegende analyse einbezogen ( frauen; alter: , +/- , jahren). in der multivariablen analyse war ein niedriges gg mit höherer sphärischen aberration (b = - , µm/ g, %-ki: [- , ; - , ]; p < , ) und höheren hoa (b = - , [- , ; - , ] µm/ g; p < , ) assoziiert. horizontales koma (z( , )) zeigte einen möglicherweise schwachen zusammenhang (b = , [- , ; , ] µm/ g; p = , ) wohingegen die anderen aberrationen keinen statistischen zusammenhang aufwiesen (astigmatismus (z( ,- ) p = , ; z( , ) p = , ), koma (z( ,- ) p = , ), trifoil (z( ,- ) p = , ; z( , ) p = , ). schlussfolgerung: unsere ergebnisse zeigen einen zusammenhang zwischen geburtsgewicht und sphärischer aberration bei erwachsenen im alter von bis jahren. dies deutet darauf hin, dass ein niedriges geburtsgewicht möglicherweise einen einfluss auf eine veränderte entwicklung der hornhautform haben könnte, was auf die optische bildqualität auswirkung haben könnte. duces involuntary eye movements and avoids compression artifacts, have proven to increase the image quality and d/ d reconstruction possibilities in all planes. in this study, we examine the clinical usability of the new system and present findings in patients with specific corneal alterations. methods: five patients with brittle corneal syndrome (bcs), mucopolysaccharidosis, small moldering myeloma (smm), schnyder corneal dystrophy and keratitis of unknown origin were examined with the hrtii-rcm . modality. subsequent, dedicated image alignment procedures and stack quality evaluation were conducted. these results were compared with conventional digital slit lamp examinations as well as anterior segment oct. results: the overall investigation time was less than min for each patient. the recorded data was adequate for further analysis in all cases, almost independent of patient compliance. particular findings worth mentioning were observed in all patients. for example in the patient with bcs, an increased level of stromalhaze, alterations such as the elongation of keratocyte nuclei and clustering of cells at the anterior stroma, and dark bands in the posterior stroma were observed. in the patient with smm, confocal microscopy visualized diffuse localized deposits throughout the epithelium and stroma. the highly reflective deposits were intracellular as well as extracellular and were present as deep as anterior to descemet's membrane. this was in line with the slit lamp examination, which showed white dot-like opacities throughout the entire depth of the cornea. the rcm . corneal imaging concept enables reliable recordings of expanded in vivo human corneal image stacks, even in patients with limited compliance. this allows optimal imaging plane selection according to individual clinical questions and offers new insights into cellular processes in vivo. the rcm . enhances the slit lamp imaging concept to a cellular level. the influence of tonebp on lymphatic and electrolytic homeostasis of the cornea hadrian k. *, , bock f. , , cursiefen c. , , eming s. a. , , hos d. objectives: lymphangiogenesis plays an important role in the regulation of various inflammatory processes in the cornea. furthermore, a positive function of lymphatic vessels in the regulation of corneal edema has recently been demonstrated. in addition to their function as mediators of (lymph)angiogenesis, macrophages have been shown to play a crucial role in the regulation of the salt/water balance in the skin. the mechanism underlying these processes involves the activation of tonicity-responsive enhancer binding protein (tonebp). tonebp is an osmosensitive transcription factor and can be induced in macrophages by proinflammatory stimuli. thus, aim of this work was to characterize the role of macrophagederived tonebp in the regulation of corneal inflammation and edema. methods: the role of tonebp in lymphatic and electrolyte homeostasis was investigated in two different corneal injury models in mice. for this purpose, six to eight weeks old wildtype c bl/ n mice and mice with a tamoxifen-inducible tonebp knockout (ubcc-cre tonebp fl/fl) underwent intrastromal suture placement or incision of the central cornea to induce corneal inflammation and/or edema. tonebp expression was evaluated using immunofluorescence as well as qrt-pcr. furthermore, the co-expression pattern of tonebp/f / (macrophages) and tonebp/ cd (leucocytes) in both models was evaluated. in addition, expression of vegf-c, a main regulator of lymphangiogenesis, was evaluated using qrt-pcr. results: tonebp is expressed in both corneal epithelium and stroma. the expression pattern of tonebp differs in the naïve cornea compared to injured corneas: whereas the majority of tonebp positive cells in the naïve corneal stroma are fibroblasts, the majority of tonebp cells in injured corneas are f / as well as cd positive. although the overall expression schulz a. , nickels s. , wild p. , schmidtmann i. , münzel t. , beutel m. , lackner k. j. , pfeiffer n cursiefen c. , pfeiffer n. , , viestenz a. , geerling g. the treatment of acute hydrops in keratoconus: first results from our centre and a preview of a germany-wide registry study händel a. * , siebelmann s. , hos d. , matthaei m. , cursiefen c. , bachmann b. zentrum für augenheilkunde -universitätsklinikum köln, köln, germany purpose: the treatment of acute keratoconus varies considerably from conservative to surgical approaches. thus, aim of this study was to ) obtain national data on treatment modalities of other centres and ) compare two surgical treatment options for acute corneal hydrops in keratoconus (mini-descemet membrane endothelial keratoplasty (mini-dmek) or predescemetal sutures). methods: a germany-wide registry study on acute keratoconus was initiated. in addition, a retrospective analysis of thirteen patients who presented in our clinic with a corneal hydrops treated by mini-dmek (n = , group ) or predescemetal sutures (n = , group ) was conducted. results: ten centres agreed to participate in the registry study. in our retrospective analysis, both groups showed reductions in corneal thickness and increased visual acuity after surgical treatment of acute hydrops. in group (age years (± years)) best corrected visual acuity increased from logmar . (± . ) before mini-dmek to . (± . ) days after mini-dmek (p = . ). corneal thickness significantly decreased from µm (± µm) preoperatively to µm (± µm) days after mini-dmek (p = . ). group (age years (± years)) showed a preoperative corneal thickness of µm (± µm) and a visual acuity of logmar . (± . ). after surgical treatment using predescemetal suturing, there was a reduction in corneal thickness to µm (± µm) (p = . ) and visual acuity increased to logmar . (± . ) (p = . ) respectively after days. there was no relapse of the hydrops and the corneas remained dehydrated to physiological levels. conclusions: both techniques, mini-dmek and predescemetal sutures, are effective treatments for acute hydrops in keratoconus. mini-dmek appears to be beneficial in large dm tears. as the treatment of acute keratoconus is different in many centres in germany, the initiated germanywide registry study on acute keratoconus will combine the results of many centres and lead to larger case numbers. clinical сase early therapeutic deep anterior lamellar keratoplasty following of pseudomonas corneal ulcers with descemetocele associated with contact lenses wearing. in the future we need to perform further antibody validation for the remaining markers to confirm these findings. purpose: the purpose of the study was to analyze mistakes made during surgical treatment for pterygium based on medical records of patients treated at the corneal pathology department of the filatov institute. materials and methods: one hundred and three patients ( eyes) who had been followed up after surgery for ptergygium stage or during the recent two years were involved in this study. postoperative complications were observed in eyes ( . %) of patients after primary pterygium excision. results: some patients seeking care at our institute had undergone - previous surgeries for pterygium in one eye. of the surgical complications, there were frequent recurrences with multiple early repeat surgeries ( to surgeries within a year) with the development of extensive vascular fibrous tissue and decreased vision ( eyes), corneal ulceration and perforation in bilateral pterygium surgery in patients with concomitant autoimmune disorders ( cases), and corneal ulceration and perforation due to deep pterygium excision ( cases). conclusion: first, pterygium should be excised with minimal trauma to the limbus and cornea. special attention should be given to autoimmune disorders, in which a corneal trauma may result in keratomalacia. second, current medicamentous and surgical techniques should be used to prevent pterygium recurrence. third, one should not perform bilateral pterygium surgery or repeat pterygium excision early (≤ months) after primary pterygium surgery. finally, any patient after pterygium excision should be followed by the ophthalmologist to promptly prevent or arrest the recurrence of pterygium. in situ donor keratometry in deceased patients as a new screening technique for eye banking? quintin a. objective: to evaluate the dynamics of biomechanical properties (corneal hysteresis (ch) and corneal resistance factor (crf)), topographical corneal thickness changes and corneal densitometry (corneal optical density (cod) in first-time soft contact lenses (scl) users ( months) and in longterm scl wearers (over years). methods: patients ( eyes) with low and moderate myopia took part in our trial. mean age of the participants was ± years. all patients were divided in groups: i group-first-time scl users ( eyes), ii grouplong-term scl users ( eyes). keratoconic patients were excluded from the study. the participants of both groups underwent corneal pachymetry mapping, corneal densitometry (pentacam, oculus) and corneal biomechanical properties evaluation-ch and crf (ora, reichert technologies). in i group patients were examined before the first time and after months of scl wear. in the group ii the same examinations were held during long-term (over years) scl wear and after ≥ week of scl removal. the i group showed reduction in central cornea thickness (by mkm) and insignificant decrease of peripheral corneal pachymetry (by , mkm, p > , ) during months of scl wear. cod reduced by %. ch and crf were significantly increased compared to baseline by , and , mmhg respectively (p < , ). the ii group showed reduction in central cornea thickness (by , mkm) and in peripheral corneal thickness (by , mkm) during scl wear. cod increased by %. ch and crf were significantly decreased by , and , mmhg respectively compared to the results after ≥ week of scl removal (p < , ). conclusions: long-term scl wear can show morphological corneal changes. we observed the same dynamics of corneal pachymetry in both first-time and long-term groups. increase of ch and crf as well as cod reduction in the i group can show clinically insignificant water content changes in different corneal layers during first months of scl wear. significant ch and crf decrease with cod increase in long-term scl users can point at structural and dystrophic corneal changes. femtosekundenlaser assistierte transplantation der bowman-lamelle: laser assistierte donorpräparation und empfängerkonditionierung parlak m. abstracts the cornea (- . d, - . d, - . d; and - . d, - . d, - . d respectively; p > . ) did differ between groups. conclusions: after penetrating keratoplasty (pkp) with both sutures in place, a smaller graft diameter seems to result in a flatter curvature at the anterior surface of the cornea, but does not affect the astigmatism. this information may be indicative for iol power calculation in relation to graft diameter in a triple pkp procedure, depending of the individual size of the cornea. combined "muraine sutures" and intracameral air tamponade for the management of corneal hydrops in acute keratoconus razafimino s. * , daas l. , quintin a. , seitz b. universitätsklinikum des saarlandes, homburg/saar, germany purpose: typically corneal transplantation in case of acute keratoconus with corneal hydrops has to be postponed for to months until the edema has resolved and a stable scar has formed. the purpose of this study was to analyze the short-term clinical outcomes in patients undergoing combined multiple predescemetal interrupted corneal sutures (so-called "muraine sutures") with intracameral air tamponade in acute corneal hydrops. methods: this retrospective uncontrolled case series enrolled patients with keratoconus who presented with a corneal hydrops of recent onset. all patients underwent combined intracameral air tamponade and to predescemetal - -nylon sutures placed orthogonally to the axis of the rupture of descemet's membrane. a prophylactic o' clock iridotomy was preoperatively performed to avoid acute air-bloc intraocular pressure (iop) elevation. main outcome measures included pre-and postoperative median pachymetry in the center of the hydrops measured by anterior segment optical coherence tomography casia (tomey corp., nagoya, japan) and best-corrected visual acuity (bcva in logmar). the median corneal pachymetry decreased significantly (p = . ) in all our patients. the median preoperative corneal pachymetry was µm (range - µm), which significantly reduced to µm (range - µm) at day and to µm (range - µm) weeks after surgery. bcva improved from . preoperative to . log-mar (p = . ) weeks after surgery. bcva on day was finger counting ( . logmar) due to air fill of the anterior chamber. no acute elevation of the iop occurred. conclusions: our results show a rapid reduction of the corneal thickness and non-significant improvement of bcva after combined intracameral air injection and predescemetal compression sutures. "muraine sutures" seem to be an effective and safe procedure to reduce corneal swelling in acute corneal hydrops, thus allowing quicker readaptation of contact lenses and earlier corneal transplantation if necessary. die kontaktlinsenanpassung beim keratokonus -retrospektive untersuchung des verlaufes der linsenanpassung bei patienten richter k. wir dokumentierten un-measured in situ times repeatedly < h after death using the portable retinomax k-plus (bon, tokyo, japan). the means of the obtained keratometric readings were compared to the routinely measured donor corneas using a mann-whitney u test. the respective values of the whole globes, from which sclerocorneal discs were removed for organ culture in the eye bank, were also compared to those obtained after measuring the same sclerocorneal discs in medium i after ± days using a wilcoxon signed-rank test. the mean standard deviation of the five in situ measurements was . d and . d for the dioptric power (p) at the steep and flat meridian of the cornea, and . d for keratometric astigmatism. p at the steep meridian of in situ corneas ( . d) remained unchanged after preserving sclerocorneal discs in medium i ( . d; p = . ). however, p at the flat meridian of in situ measured corneas ( . d) increased (p < . ) to . d, whereas keratometric astigmatism ( . d) decreased (p < . ) to . d after preservation in medium i. the comparison of the in situ values with the routinely measured different donor corneas in medium ii showed no difference in p at the steep meridian ( . d; p = . ), but again a greater p at the flat meridian ( . d; p < . ) and a smaller keratometric astigmatism ( . d; p < . ). measuring deceased patients' eyes in situ with the portable retinomax k-plus could be, in the absence of an anterior segment optical coherence tomograph (as-oct), an alternative and moderately reproducible screening technique in the eye bank. in comparison to the as-oct, the portable retinomax k-plus estimates a similar power at the steep meridian of the cornea but seems to underestimate the power at the flat meridian and to overestimate the keratometric astigmatism. impact of graft diameter on the relation between sterile donor tomography in the eye bank and graft tomography after penetrating keratoplasty quintin a. background and purpose: sterile donor tomography in the eye bank can be used to avoid refractive surprises after corneal transplantation. the purpose of this study was to assess the impact of graft diameter on the relation between preoperative donor tomography and postoperative graft tomography after penetrating keratoplasty (pkp). patients and methods: this retrospective study enrolled eye bank corneal tissues that underwent elective pkp with application of a double-running suture. donor and recipient trephination were performed using the -nm excimer laser (schwind amaris rs). diameters were . mm ( %), . mm ( %) and . mm ( %), with a graft oversize of . mm. preoperative measurements, taken through the cell culture flask using the anterior segment optical coherence tomograph casia (tomey corp., nagoya, japan), were repeated postoperatively after ± months with all sutures in place. differences between post-and preoperative values (∆) were compared in function of the graft diameter using a mann-whitney u test. results: the ∆ keratometric power (p) at the steep meridian of the anterior surface of the cornea in the . mm grafts (- . d) was significantly smaller than that in the . mm grafts (+ . d; p < . ) and than that in the . mm grafts (+ . d; p < . ). no statistically significant differences occurred for this parameter between the . mm and the . mm grafts (p = . ). at the flat meridian of the anterior surface of the cornea, ∆ p in the . mm grafts (- . d) was significantly greater than that in the . mm grafts (- . d; p = . ) and than that in the . mm grafts (- . d; p < . ). no statistically significant differences occurred for this parameter between the . mm and the . mm grafts (p = . ). neither ∆ astigmatism (+ . purpose: to evaluate ocular symptoms in european non-hospitalized patients with severe acute respiratory syndrome-related coronavirus (sars-cov- ) and to investigate associations with the demographic data as well as general physical symptoms. methods: in this prospective, observational study, non-hospitalized patients with polymerase chain reaction (pcr) confirmed sars-cov- infection not requiring intensive care were asked using a standardized questionnaire regarding disease-associated ocular symptoms, demographic data, and general physical and nasal symptoms. total ocular symptom score (toss) was evaluated during and retrospectively prior to coronavirus disease infection. associations between toss and demographic data as well as general and nasal symptoms were evaluated. results: out of non-hospitalized patients with covid- infection ( %) suffered from ocular symptoms mostly including burning sensations, epiphora, and redness, compatible with conjunctivitis. these symptoms occurred in most cases in the first three days of covid- but were rather mild. toss was significantly higher during than prior to the covid- infection (p < . ). there were no significant associations between toss and demographics, general physical and nasal symptoms. conclusions: ocular involvement in european non-hospitalized patients with covid- seems to be highly underestimated and needs further attention. overall, these ocular symptoms including burning sensations, epiphora and redness seem to be mild. abstracts schlussfolgerung: die bildqualität der µoct scheint ausreichend, um durch quantitative auswertungen diagnostisch relevante aussagen zur sbp treffen zu können. aufgrund der variierenden nervendichte innerhalb der hornhaut ist die aufnahmefläche des µoct von derzeit × mm vorteilhaft, sodass sich zusammen mit der kontaktlosen anwendung des µoct ein klinisch erfolgversprechendes anwendungsfeld ergibt. epithelimplantationszyste der kornea schölles k. the "knights of the blind"-eye banking and lions, a successful cooperation since scholtz s. *, , auffarth g. , hellwinkel o. , kampik d. , maier p. , seitz b. , wegner t. , krogmann f. , rosenbaum k. der prä-zu postoperative ecl in gruppe betrug % (n = ) nach monaten und % nach monaten (n = ). in gruppe lag der ecl bei % (n = ) nach monaten, % (n = ) nach monaten, % (n = ) nach jahren und % (n = ) nach jahren. die postoperative zentrale hornhautdicke nach , und jahren war in gruppe im mittel (± sd) ± µm, ± µm und ± µm beziehungsweise in gruppe ± µm, ± µm und ± µm (p = , p = beziehungsweise p = , ). schlussfolgerung: unsere daten legen nahe, dass die dmek die sehschärfe bei patienten mit endotheldekompensation nach den hier untersuchten glaukomoperationen, gdd-implantation und te, deutlich verbessert. diese augen zeigen jedoch ein erhöhtes risiko zum transplantatversagen mit notwendigkeit zur re-dmek. allerdings besteht hierbei kein signifikanter unterschied zwischen den beiden untersuchten glaukomoperationen. sinicin e. * , bartram m. purpose: to compare the efficacy of epi-off customized corneal crosslinking (cxl) with and without supplementary oxygen. methods: in this prospective study, eyes of patients with documented progressive primary keratoconus were treated either with epi-off customized cxl under a supplementary oxygen environment (o > %, n = ) or with customized cxl under atmospheric oxygen conditions (o = %, n = ) and followed for year. customized irradiation patterns had an irradiance of mw/cm and radiant exposure levels ranging from . j/cm up to j/cm centered on the maximal posterior elevation. analyzed parameters were placido topography, scheimpflug tomography, endothelial cell count, bscva and anterior segment oct. results: kmax showed significant changes after year for both groups with a significantly higher regression in the supplementary oxygen subgroup (- . ± . d vs. - . ± . d). six out of eyes ( %) in the supplementary oxygen group showed a flattering of > d, whereas only out of ( %) did in the atmospheric oxygen group (p < . ). improvement in bscva and reduction in corneal coma were also significantly higher in the supplementary oxygen group, however, sterile infiltrates occurred more frequently, and corneal haze appeared denser. the regularization index (ri) was significantly better in the customized cxl group with supplementary oxygen. endothelial cell count maintained stable in both groups. conclusions: supplementary oxygen enhances the efficacy of epi-off customized cxl with stronger qualitative and quantitative flattening in kmax and corneal regularization. substantial flattening rates of more than d can be achieved in about % of the treated cases. inselspital bern, bern, switzerland; iroc, zürich, switzerland purpose: to measure the oxygen consumption and concentration during corneal crosslinking (cxl) in different depths and compare different protocols with and without supplementary oxygen. methods: in de-epithelialized porcine eyes, a femtosecond-laser generated channel was used to place a fiber-probe in corneal depths of , and microns to measure the local oxygen concentration. after a min imbibition of . % riboflavin the corneas were irradiated at , , and mw/cm while the oxygen concentration was continuously measured. to assess the benefit of supplementary oxygen, all experiments were performed under atmospheric ( % o ) as well as under hyperoxygenic (> % o ) conditions. results: the equilibrium oxygen concentration under atmospheric oxygen conditions at mw/cm was % in microns decreasing to % in microns and % at microns. with , and mw/cm no oxygen was available in microns or deeper. using a hyperoxygenic environment the oxygen concentration was % using mw/cm in microns decreasing to % in microns and % in microns. at mw/cm the concentrations were %, % and % in , and microns, respectively. using and mw/cm all oxygen was depleted during cxl and no equilibrium was established, however, the time until all oxygen was consumed was longer in the mw/cm than in the mw/cm . conclusion: supplementary environmental oxygen increases the stromal oxygen-availability during cxl. in particular at higher irradiances with increased oxygen consumption, supplementary oxygen is beneficial and eliminates the bottleneck of oxygen and, therefore, enhances more crosslinks. steindor f. a. * , borgardts k. the benefits of using the amniotic dry membrane in corneal ulcers stanila d. m. *, , , , , stanila a. epithelial defects of the cornea heal quickly and without incidents. when these defects are not healed in time, defined in the literature in two weeks, they become known as persistent epithelial defects (ped) and sometimes become corneal persistent ulcers. the purpose of this paper is to present using omnigen refrigerated dry amniotic membrane and omnilens in corneal ulcers. we applied omnigen amniotic membrane and omnilens contact lens in eyes with corneal ulcers, eyes with neurotrophic keratopathy and were perforated, eyes with steven-johnson syndrome, eyes with mooren ulcer and were perforated, eye with corneal lattice dystrophy and perforation, eye with corneal transplant. we applied the amniotic membrane after rehydration in cases without suture and cases with suture. at the same time we applied the omnilenz contact lens on ocular surface until membrane was absorbed. omnigen is a transportable biological matrix that can be used as a regenerative therapy for corneal ulcers or other diseases of the ocular surface. the application of the membrane has been made according to the existing lesion. the use of the membrane was like graft with epithelial position up in cases and patch with epithelial position down in cases. the results were good, obtaining the anatomical reconstruction of the ocular surface. in cases we repeated the membrane application. we must speak about unmet needs in our country regarding the treatment of corneal ulcers with or without perforation. because we have not a tissue bank we cannot perform corneal transplant and we resort in urgency to amniotransplant for the tectonic purpose. conclusions: omnigen's amniotic membrane together with the omnilenz therapeutic contact lens can be a solution for the treatment of corneal ulcers with perforated or no perforated cornea. korneale aberrationen höherer ordnung nach superfizieller keratektomie bei phscb walckling m. purpose: implementation of a systematic analytical approach for detection of antigen-presenting cells (apc) in human corneal tissue using facs. methods: to implement facs analysis of apc in the human cornea, we set up a novel protocol for cell harvesting from human corneal tissue. the corneas used were stored in organ culture, they were unsuitable for transplantation and consent for scientific use was available. the harvested cells were analysed by facs; special attention was paid to the detection of inflammatory and regulatory macrophage populations. among the live cells, cd +/cd b+/cd + cells were defined as macrophages. m macrophages were defined as cells expressing cd +/cd +/ hla-dr+/cd + in addition to the markers mentioned above; while m macrophages were defined by their additional expression of cd +/ cd +. subsequently, cell populations were assessed with respect to their response to different stimuli (lps/il- /il- with il- ) as well as dynamics of apc in organ culture. results: facs allowed the identification as well as quantification of innate immune cells in processed human corneal samples. the use of lps as an innate stimulus led to a down-regulation of cd (p > . ), a regulatory maker in apc. co-expression of cd + and cd + is down-regulated by regulatory interleukins like il- (p < . ) and il +il- (p < . ). in addition, hla-dr, as an inflammatory maker, was also down regulated by il- (p < . ). a cell loss over time during organ culture of the corneas was observed in both m and m macrophages (n = , p = . ). in the present study we report on the implementation of a facs protocol for processing and phenotyping human corneal cells. we demonstrate that inflammatory and regulatory macrophage subtypes are present in the cornea and that these cells show a functional response to different interleukins. we also demonstrate for the first time the dynamics of apc cell loss in organ culture. zwingelberg s. questionnaire. moreover, diabetes duration, blood sugar levels, and type of therapy for diabetes were assessed. results: palpebral demodicosis was twice as common in patients with t dm duration more than years as in those with t dm duration less than years (p = . ). our meibography study found changes in meibomian glands in % of diabetics with palpebral demodicosis, with the mean meibograde score of . ± . points, which indicated a predominance of moderate mgd. abstracts skop. dabei wurde das d-system auf das vorhandene mikroskop angepasst, so dass die mikroskop-optik unverändert blieb. in beiden gruppen wurde entweder eine femto-sekunden-laser-assistierte kataraktoperation (flacs) oder eine traditionelle phakoemulsifikation durchgeführt. es wurden retrospektiv komplikationen erfasst und analysiert. ergebnisse: der anteil von flacs betrug in der d gruppe , % und in der d gruppe , %. eine kapselruptur trat bei augen auf ( d: n = ( , %), vordere vitrektomie: n = ; d: n = fällen ( , %), vordere vitrektomie: n = ). ein kurzfristiger irisprolaps trat bei augen auf ( d: n = , d: n = ). in zwei augen kam es zu einer zonulolyse ( d: n = , d: n = ). insgesamt zeigte sich kein statistisch signifikanter unterschied zwischen den beiden gruppen (p > , ). schlussfolgerung: in einer großen serie von augen zeigte sich hinsichtlich des sicherheitsprofils bei katarakt-operationen kein signifikanter unterschied zwischen der d und der d chirurgie. die d-chirurgie ist daher für die katarakt-op ohne zusätzliches risiko einsetzbar. protection of the cornea during cataract phaco (group ) and patients with pes who operated without protection (group ). the average age is . ± . years. visual acuity before surgery . ± . . in group , after capsulorexis was performed using micro-forceps,a soft contact lens (scl) was inserted into the anterior chamber (ac), and then a viscoprotector was introduced into the ac. the viscoprotector was located between the cornea and the lens and in the ac behind the lens. scl was removed after surgery at the iol implantation stage. results and conclusions: on the st day after surgery in ( %) patients of the st group and in patients ( %) of the nd group, diffuse edema of the entire area of the cornea with involvement of the stroma and epithelium was determined, edema of the upper corneal sector with folds of the descemet membrane in patients ( %) of the st group and patients ( . %) of the second group. visual acuity in group on the st day after phaco was also statistically significantly higher than before surgery and in group , averaging . ± . . on the th day- . ± . , on the th day . ± . , and this difference was significantly higher than in group (p < , ). visual acuity in the nd group of patients on the st day after phaco was . ± . , on the th day- . ± . and on the th day- . ± . . our results indicate that the use of scl during phaco helps to improve the postoperative state of the cornea (to reduce the presence of stromal edema), which reduces the risk of intraoperative damage to the corneal endothelium, accelerates the restoration of corneal transparency, and thereby ensures higher indicators of visual acuity after surgery. ergebnis: die vorläufige auswertung in dieser laufenden studie ergab eine wunddehnung von , mm ± , mm (von , ± , mm vor implantation auf , ± , mm nach der implantation) in den mit dem autono-me-injektor behandelten augen und eine wunddehnung von , mm ± , mm (von , ± , mm vor implantation auf , ± , mm nach der implantation) in den mit dem isert-injektor behandelten augen. die licht-und rasterelektronenmikroskopie der injektorspitzen zeigte folgen- learning yamane- tips for a better start -videobeitrag shajari m. comparing the effective lens position and refractive outcome of a novel rhexis-fixated lens to established lens designs shajari m. benefits and new features of modern international internet database "iolcon" for updated and optimized iol constants scholtz s. pre-and three months postoperatively. lens constant optimization was performed. results: seventy eyes of subjects were included. elp for rhexis fixated iol was shortest ( . ± . mm), followed by c-loop haptic ( . ± . mm) and plate-haptic ( . ± . mm) iol. difference in elp was significant between rhexis fixated iol and both plate-haptic (p = . ) and c-loop haptic iol (p = . ). acd adjustment based on lens design showed a significant effect on refraction and iol power predictions for all formulas and lenses (p < . ). for the rhexis fixated iol the differences in refraction ranged from + . d for the hill-rbf to + . d for haigis. the other two lenses showed mean differences in refraction between - . d for hill-rbf. the difference in iol fixation and its resulting position in the capsular bag have a significant effect on the effective lens position and consequently a significant effect on the prediction of postoperative refraction. usov v. y. * , kolomiychuk s. g. , tarik a. t. the problem: age-related cataracts, especially when combined with the development of inflammatory diseases of the cornea-important medical and social problem. imbalance in the prooxidant-antioxidant eye tissues system is the main reason of the progression of pathological changes in the lens and in the cornea during inflammatory and degenerative diseases of the eye. the aim-to study the relationship between the indicators of the prooxidant-antioxidant system and pathological changes in the lens during the inflammatory process in the cornea. methodology: chinchilla breed rabbits with and without modeling bacterial keratitis were modeling a light cataract. the severity of pathological changes in the lens was determined by ophthalmobiomicroscopy. the activity of glutathione peroxidase and catalase, the content of malondialdehyde (mda) and diene conjugates (dc) were measured in the lens, chamber moisture and tear fluid of rabbits. the total antioxidant activity, the content of mda and dc were measured in the tear fluid of patients with keratitis with and without age-related cataract. results: a negative correlation between the indices of lipid peroxidation (mda and dc) and the antioxidant state rabbit eye tissues with cataract with concomitant keratitis was found. the relationship between the lens state and biochemical parameters was evaluated, with the spearman correlation coefficient being: negative for glutathione peroxidase (r = - . ,p < . ) and catalase (r = - . , p < . ), positive for mda (r = . , p < . ) and dc (r = . , p > . ). significant abnormalities in the prooxidant-antioxidant eye tissues system were found to be depended significantly on the severity of pathological changes in the lens of rabbits with light cataracts, especially during the inflammatory process in the cornea. maximal changes in the prooxidant-antioxidant system in the tear fluid were observed in patients with age-related immature cortical, nuclear and posterior capsular cataracts and visual acuity less than . with keratitis. particularly pronounced corneal disorders were observed in patients with cortical and nuclear mature cataracts with visual acuity less than . . the presence of correlation between the indices of lipid peroxidation products and antioxidant activity indicates the important role of these metabolic disorders in the formation of structural and functional changes in the lens of experimental animals and patients during the inflammatory process in the cornea. freiburger ophthalmopathologie im wandel der zeit: - glegola m. purpose: to assess a potential relationship between the location of the maximal extent of parapapillary gamma zone and the location of the foveola. the population-based beijing eye study consisted of subjects (mean age: . ± . years) who underwent a detailed ophthalmological examination including biometry and fundus photography. using fundus photographs we measured the angle between the disc-fovea line and the horizontal, and the location and width of parapapillary gamma zone. the present study consisted of individuals with a mean age of . ± . . years (range: - ) and an axial length of . ± . mm (range: . , . ). the angle between the disc-fovea line and the horizontal increased significantly (i. e., the fovea was located more inferiorly) with increasing width of parapapillary gamma in the inferior sector, and vice versa (disc-fovea angle = . × maximal gamma zone width + . ; standardized regression coefficient beta: . ; p = . ). this relationship was independent of axial length (p = . ). conclusions: an inferior location of gamma zone is spatially correlated with a relatively inferior location of the foveola and vice versa. this spatial relationship between location of gamma zone and fovea location supports the notion of bruch's membrane pushing backward during axial elongation and of a bruch's membrane opening shift parallel to a change in the fovea location. excessive collagen formation) is considered to be crucial for the congenital glaucoma development as well as for the elaboration of pathogenetically based treatment of this disease. peripapillary border tissues of the optic nerve head: associations with gamma zone and delta zone and potential biomechanical importance universität zu köln, cologne, germany; univ.-augenklinik, erlangen, germany purpose: to assess the relationship between the peripapillary border tissue (pbt) of the choroid (pbtc) (jacoby) and of the peripapillary scleral flange (pbts) (elschnig) with the presence and length of parapapillary gamma zone and delta zone. methods: the histomorphometric investigation included histologic sections of enucleated eyes of caucasian patients. using light microscopy, the pbt dimensions were measured. the study included eyes (age: . ± . years) (range: - years). mean axial length was . ± . mm) (range: . - . mm). the length of pbtc was strongly and positively associated with the length parapapillary gamma zone (p < . ; standardized regression coefficient beta: . ) and delta zone (p < . , beta: . ). in contrast, the length of the pbts was strongly and negatively associated with gamma zone length (p = . ; beta: - . ) and delta zone length (p < . ; beta:- . ). the length of the peripapillary border tissues are strongly associated with the width of the parapapillary zones gamma and delta. since the whole inner ocular shell (choroid, bruch's membrane, retina) are connected to the outer shell (i. e., sclera) only through the scleral spur anteriorly and through the pbtc posteriorly, the findings may have importance for the physiology and biomechanics of the eye. optic disc fovea distance and axial length: highly myopic eyes versus non-highly myopic eyes purpose: to assess a relationship between the optic disc center-fovea distance and axial length in eyes divided into highly myopic eyes (axial length ≥ . mm and non-highly myopic eyes. methods: the population-based beijing eye study consisted of subjects (mean age: . ± . years) who underwent a detailed ophthalmological examination including biometry and fundus photography. the optic disc center-fovea distance was measured on the fundus photographs. the present study included fundus images of individuals with a mean refractive error of - . ± . diopters (range:- . , + . ) and an axial length of . ± . mm (range: . , . ) results: the disc-fovea distance increased significantly with longer axial length, with a relatively flat slope in the non-highly myopic eyes (disc-fovea-distance = . × axial length (mm)+ ) and a steeper slope in the highly myopic group (disc-fovea-distance = . × axial length (mm)- ). the increase in the disc-fovea distance was strongly correlated with an increase in the width of parapapillary gamma zone, while the distance between the peripheral gamma zone border and the fovea was not significantly associated with axial length. the disc-fovea distance increases slightly with longer axial length in non-highly myopic eyes, and increases more steeply in highly myopic eyes, with a cut-off value of . mm axial length for the definition of high myopia. the results confirm the notion of bruch's membrane opening (bmo) shifting to the temporal side in non-highly myopic eyes, leading to the development of parapapillary gamma zone and thus an in- the problem of high risk of blindness and disability in a given population by reason of glaucoma dictated the relevance of this research. infringement of eye hydrodynamics plays the main role in glaucoma pathogenesis. purpose of this work was to establish patterns of development and structure of the human eye drainage system in embryogenesis and in postnatal ontogenesis. methodology: the human iris-corneal angles were studied in embryos from to mm of parietal-coccygeal length (pcl) and on the anatomical preparations of heads. the obtained histological sections of iris-corneal angles were stained with hematoxylin and eosin. the iris-corneal angle in embryos mm pcl was represented by the accumulation of mesenchymal cells. it began to be identified in embryos mm pcl when the border between the cornea and sclera started to be determined. in embryos mm pcl the iris and ciliary body were shifting posteriorly and the spaces of schlemm's canal (sc) appeared above the trabecula. on histological sections the transition zone cornea-sclera was located in front of sc. background: jones tube surgery-creating a bypass between the caruncular conjunctiva and the nasal cavity using a glass tube drawing tears-is the gold standard for managing epiphora secondary to upper lacrimal outflow obstructions. however, tube extrusion occurred in up to % of the cases. recently, the stoploss jones tube (sljt) with an internal silicone flange was reported to reduce the risk for tube extrusion. besides, tube insertion requires a bony ostium, which might preexist due to previous failed dacryocystorhinostomy (dcr). however, in patients without previous dcr, an external transcutaneous approach is needed for correct tube placement. purpose: to describe a novel transcaruncular laser-assisted sljt procedure without any skin incision for the treatment of lacrimal canalicular obstructions. methods: under general anesthesia, sharp scissors were used for a -mm caruncular incision and gently advancing dissection in inferomedial direction towards the nasal bone. a laser fiber optic with µm-diameter connected to an µm-wavelength diode laser was inserted into the track and positioned under visual control using nasal endoscopy, so that the aiming beam appeared at the anterior margin of the middle turbinate. subsequently, laser energy created a bony ostium with a -mm diameter, and a specially designed dilator was applied to enlarge the track. after measuring the distance between the caruncle and the nasal mucosa using a sizer, a sljt of the required length was passed down the guidewire until the silicone flange opened within the nasal cavity. the guidewire was removed, and a suture was passed around the neck of the tube and secured to the caruncular conjunctiva. results: twelve consecutive patients ( eyes) with absolute canalicular dacryostenosis were enrolled. eleven eyes were surgically successful. in one case the inserted sljt was too long and had to be replaced by a -mm shorter one. in cases, conjunctival scarring, conjunctival granuloma and tube-associated irritation of the ocular surface required conjunctival revision. there were no cases of tube extrusion or sink-in. conclusions: this novel technique is a promising strategy for the treatment of lacrimal canalicular obstructions. advantages include the lack of skin incisions and visible scars, the less risk of bleeding due to the vaporization method, and the reduced risk of tube migration or extrusion due to the stoploss jones tube with endonasal silicone flange. purpose: currently therapeutic management of patients with graves' orbitopathy (go) relies on clinical assessments and mri scans. however, monitoring of inflammation remains difficult since external inflammatory signs like injection and chemosis do not necessarily represent the orbital disease activity.therefore, we aimed to evaluate the diagnostic value of fdg-pet/mri to assess the inflammation of go patients. methods: patients with new onset of go who were examined in our eu-gogo tertiary referral center were enrolled in this trial. all patients underwent ophthalmological and orthoptic examinations to evaluate the activity and severity of go, as well as an f-fdg-pet/mri (siemens biograph mmrt). a subset of pet parameters including maximum standardized uptake value (suvmax), metabolic target volume (mtv), and total lesion glycolysis (tlg) were obtained separately per-eye and per-extraocular eye muscle (eom). eom thickness was measured on the coregistered mri. subsequently, differences in pet parameters among nospecs classes were compared and statistically analysed, as well as tested for correlation with clinical findings. results: fourteen go patients were enrolled and analyzed. three showed mild, six moderate-to-severe and four sight-threatening go. patients with severe go showed statistically significant higher values for tlg and mtv on the early static images, whereas suvmax did not differ among groups. pet parameters did not show statistically significant differences on the late acquisition images. pet parameters obtained both from early as well as late static images showed no correlation with eom thickness. pet parameters obtained from individual eoms were not correlated with its motility. discussion: tlg and mtv derived from pea of early static images appear to be good discriminators for severe vs. mild to moderate go. our results suggest that in go early static acquisition is superior to late static acquisition. as expected pet parameters of individual eye muscles were not correlated with associated eye motility, since fibrosis is responsible and not inflammation is mainly responsible for motility disorders. in conclusion, f-fdg-pet/mri appears to be a promising modality for the assessment of go severity with the potential to address limitations of the current diagnostic standard procedures. therefore, its diagnostic value should be subject of further studies on larger collectives. purpose: evaluation of the ocular and adnexa pathological signs and the results of their treatment in patients who previously underwent radiation therapy for eyelid skin cancer. material and methods: the study included patients ( men, women, mean age . ± . years) who previously underwent radiation therapy for eyelid skin cancer. follow up period from months to years. all patients suffered from lid cosmetic defect, had different grades of cicatricial lagophthalmos and corneal lesions. lagophthalmos value ranged from to mm (m±m, mm: . ± . ), it was mild-in , moderate-in , severe-in cases. cornea was involved in all cases (keratopathy- , keratoconjunctivitis- , neurotrophic keratitis- , corneal ulcer- cases). dry eye diagnosed in all cases. radiation induced cataract was detected in cases. bcva varied from / to / in patients. results: all patients underwent medical therapy and one or more surgical steps. surgical correction of the eyelids position was performed in all cases. the type of surgical intervention depended on the grade of lagophthalmos: fixing of edges of a cartilage of a lower eyelid to the periosteum or canthoplasty, z-plasty, transposed flaps. in the presence of severe complications of the cornea, the following surgical procedures were performed: transplantation of the amniotic membrane- , autoconjunctival flap- eyes. as a result of the combined treatment, the state of the eye anterior segment has improved in all cases. cataract extraction with iol implantation was performed after stabilization of the cornea. conclusions: radiation therapy for skin cancer of the eyelids can lead not only to a cosmetic defect, but also to severe dry eye and serious complications of the cornea and adnexa. the optimal combination of medical and surgical treatment can achieve a satisfactory position of the eyelids and stabilization of the ocular surface, which significantly improves the quality of life of patients. eine ptosis als wegweiser zur systemerkrankung neumann c. postoperativer astigmatismus nach photorefraktiver keratektomie bei augen mit rein sphärischer myopie ezzeldin m. * , frings a. , , linke s. j. , , steinberg j. , objective: to determine the incidence of tearing in patients after radioiodine therapy (i ), as well as to conduct a correlation analysis of tearing and some clinical and laboratory parameters. material and methods: a questionnaire survey of patients was conducted (average age ± years, median years) who underwent single ( cases) or repeated ( cases, up to times) i therapy in a dose of . to gbq (average , ± . gbq) for thyroid cancer to months ago (average ± months, median months). the severity of tearing was determined in points according to the munk scale. a statistical analysis was performed, including a spearman correlation analysis. the tearing was absent in respondents ( . %), the severity of tearing was point according to the munk scale in cases ( . %), points in cases ( . %), points in cases ( . %), points in cases ( . %). a significant correlation was revealed between the severity of tearing and the frequency of i therapy (p < . , r = . ). the complaints of significant tearing after a single therapy with radioactive iodine ( points) were determined in patients for periods of to months. the incidence of significant tearing ( points) in patients after a single i therapy increased with age (p < . , r = . ), as well as with an increase in the effective radiation dose (p < . , r = . ). conclusion: the significant tearing probably caused by a secondary obliteration of the nasolacrimal duct occurs in . % of cases. the probability of this complication development is dose-dependent and is related to the eines hochviskösen viskoelastikums im rahmen der icl-implantation beziehungsweise des icl-austausches entstehen. bei urrets-zavalia-syndrom nach icl-implantation stellen zwei gegeneinander versetzte aniridie-ringe im kapselsack zur dauerhaften reduktion der blendempfindlichkeit eine praktikable therapieoption dar. hamon l. * , flockerzi e. ( ) preloaded iols ( . d- . d) per treatment group were delivered into the anterior chamber of human cadaver eyes through a . mm (vivinex) or . mm (autonome, ultrasert, and itec) incision size. corneal incision morphology was evaluated using optical coherence tomography (oct) and incision sizes were measured using asico incision gauges before and after iol delivery. differences in mean incision enlargement between delivery devices were evaluated using a paired t-test. results: autonome ( . ± . mm) and ultrasert ( . ± . mm) had the smallest average incision enlargement compared with itec ( . ± . mm) and vivinex ( . ± . mm). vivinex had the largest corneal incision enlargement and was significantly larger than autonome (p = . ), ultrasert (p = . ) and itec (p = . ). representative oct images of pre-and post-implantation incisions (cross sectional images of cornea) showed more incision gaping, corneal stromal damage and distortion for delivery systems with the largest incision enlargement: vivinex and itec. the new autonome preloaded delivery system protects the corneal incision during iol implantation and causes smaller incision enlargement and less corneal stromal damage compared to itec and vivinex. further clinical studies are necessary to confirm the effect of incision enlargement on wound healing and post-operative corneal morphology. lwowski c. m purpose: to assess the morphological and functional outcome of intravitreal aflibercept following treat and extend regime compared to fixed regime for treatment of eyes with neovascular age-related macular degeneration. this retrospective study included eyes with primary onset neovascular age-related macular degeneration followed for months. all eyes were treated with . mg/ . ml aflibercept. all eyes received three aflibercept injections monthly as upload phase. then, we compared two groups of eyes. for group , eyes were treated following treat and extend regime. for group , eyes were treated following fixed regime (fixed -weekly interval). main outcome measures included: best corrected visual acuity (bcva), central macular thickness (cmt) and number of injections. results: bcva (logmar) in group vs group was ( . ± . vs . ± . , p = . ) before treatment and ( . ± . vs . ± . , p = . ) after one year of treatment. the visual improvement was ( . ± . vs . ± . , p = . ). cmt in group vs group was ( ± µm vs ± µm, p = . ) before treatment and ( ± µm vs ± µm, p = . ) after one year of treatment. the decrease in cmt was ( ± µm vs ± µm, p = . ). number of injections/eye in group vs group was ( . ± . vs . ± . , p = . ). in group , six patients ( %) were reverted back to monthly treatment as the treatment interval was extended over weeks. conclusions: eyes treated with aflibercept following treat and extend regime had no significant differences regarding bcva and central macular thickness compared to eyes treated with fixed regime. however, eyes treated following treat and extend regime received a significantly higher number of injections during the first year of treatment. ergebnis: bei augen erfolgte der revisionseingriff nach primärer linsenchirurgie (iol-gruppe: multifokal, monofokal), bei augen war eine hornhautchirurgische operation vorausgegangen (hh-gruppe: femto-lasik, transprk, lasek). die refraktion betrug präoperativ in der iol-gruppe + , ± , dpt (- , bis + , dpt) im sphärischen Äquivalent (sphÄ), in der hh-gruppe - , ± , dpt (- , bis + , dpt). der unkorrigierte visus (ucva) lag präoperativ bei , ± , (iol-gruppe: , ± , ( , bis , ), hh-gruppe: , ± , ( , bis , ). in augen der hh-gruppe wurde eine wellenfrontgeführte ablation durchgeführt. von augen lagen postoperativ im zielbereich von ± , dpt. die ucva betrug monate postoperativ im mittel , ± , ( , bis , ) (iol-gruppe: , ± , ( , bis , ), hh-gruppe: , ± , ( , - , ). in der aberrometrie zeigte sich in der iol-gruppe eine zunahme, in der hh-gruppe eine dezente abnahme der aberrationen höherer ordnung (hoa, bei mm pupille) (iol-gruppe: rms + , µm, coma + , µm, trefoil + , µm, sphab - , µm; hh-gruppe: rms - , µm, coma - , µm, trefoil - , µm, sphab + , µm). in keinem fall kam es zu postoperativen komplikationen, und es waren bei subjektiver patientenzufriedenheit keine weiteren revisionen notwendig. schlussfolgerung: excimer-laser-gestützte revisionseingriffe stellen bei residueller ametropie nach primärer linsen-oder hornhautoperation, speziell im refraktiv-chirurgischen bereich, eine sichere und effektive therapieoption dar, um dem patientenwunsch zu entsprechen. rayamajhi a. objective: the mechanism of the two-photon absorption by photoreceptors and their visual pigment chromophore isomerization lays the ground for a better understanding of how infrared light (ir) triggers color perception in an unaided eye. the association between retinal disease and expected changes in ir-light sensitivity has yet to be investigated, though. this study aimed to measure and compare scotopic eye sensitivity of healthy and diabetic-retinopathy patients using an ir-light microperimeter. method: this research was carried out at the ophthalmology department of the heidelberg university hospital. among included eyes, were healthy, and were diabetic. all participants underwent a comprehensive eye exam, including visual acuity (va) and contrast sensitivity tests, optical coherence tomography and slit-lamp examination. the ir threshold was measured following -min dark-adaptation with a goldman ii size stimulus and the method of adjustment. to this end, we used the ir-light microperimeter with integrated pulsed laser light ( nm) for sensitivity assessment and scanning laser ophthalmoscopy for fundus imaging. the mean age of the diabetic patients ( . ± . years) and the control group ( . ± . years) was not statistically significant (p = . ). the mean logmar va of the diabetic patients ( . ± . ) was worse than in the healthy group (- . ± . ), which was significantly different (p < . ). furthermore, the contrast sensitivity of the diabetic patients was lower than that of the healthy group, especially at and cycles/degree. a statistically significant (p = . ) difference was found in the mean retinal thickness between the diabetic patients ( . ± . µm) and the healthy group ( . ± . µm). the mean retinal sensitivity to ir light in the diabetic patients ( . ± . db) was significantly (p < . ) lower than in the healthy group ( . ± . db). kharkiv national medical university, kharkiv, ukraine background: nowadays phacoemulsification is a standard in the cataract surgery. however, it is impossible to exclude the negative effect of low-frequency ultrasound, cavitation and thermal energy during surgery. changes in the posterior segment of the eye after phacoemulsification require clarification. aim: was to analyze the changes of the macular morphology and posterior vitreous among patients with unchanged posterior segment of the eye after the phacoemulsification of the cataract with and without posterior capsulorhexis. methods: in this prospective study patients with senile cataract and unchanged posterior segment of the eye were included. all patients underwent uncomplicated phacoemulsification. posterior capsulorhexis was not performed to patients of the first group whereas it was applied to patients of the second group because of the opacification of the posterior capsule of the lens. oct was performed to all patients preoperatively and postoperatively on the st day, the st week, and the st, the rd, and the th months. results: there were no significant differences in the macular thickness among patients of the first and the second group before the surgery. significant difference in the macular thickness was detected on the st day (p = . ), the st week (p = . ), and the st month (p = . ). but this difference in both groups became insignificant by the rd and th month of observation. during the st week after the surgery one patient ( . %) of the nd group manifested cystoid macular edema that was resolved by the rd month of the observation. there were no changes of the posterior vitreous among patients of the st group. partial detachment of the posterior hyaloid membrane was observed in patient ( . %) of the nd group one month after the operation. three months later partial detachment of the posterior hyaloid membrane was diagnosed in more patients ( . %) of the nd group. during months of observation partial detachment of the posterior hyaloid membrane did not lead to a significant change in retinal thickness among all patients. summary: potentially, posterior capsulorexis during uncomplicated phacoemulsification leads to a more pronounced effect on the vitreous body and macular zone. however, the morphological changes in the posterior segment of the eye in this case are either reversible or do not lead to gross structural changes that could affect visual function within six months of observation. berlin m. edema-grade-dme study busch c. purpose: to evaluate the proportion of functional and anatomical responders and non-responders to the first dexamethasone (dex) implant in naïve and non-naïve diabetic macular edema (dme); to assess different response patterns; and to propose a grading classification for dme treatment response. methods: retrospective, multicenter, observational study. naïve and nonnaïve dme patients treated with dex, with visual acuity (va) ≥ . log-mar (≤ . decimal) and central subfield thickness (cst) of ≥ µm measured on spectral domain optical coherence tomography (sd-oct). va and cst were recorded at baseline, month and month after first dex treatment. functional and anatomical responses were graded, and different response patterns were analyzed. results: we included eyes from patients, of which % ( eyes) were treatment-naïve. mean baseline va was . ± . logmar and mean cst was . ± . µm. the proportion of very good functional responders (va gain ≥ letters) after and months was and % for naïve eyes, and and % for non-naïve eyes (naïve vs. non-naïve eyes: p < . ). proportion of functional non-responders (va gain < letters) after and months were and % for naïve eyes, and and % for non-naïve eyes (naïve vs. non-naïve eyes: p < . ). anatomical non-responders (cst reduction < % or cst increase) at months were rare in both groups (naïve: %, non-naïve: %, p = . ). naïve eyes usually demonstrated an early and stable functional and anatomical improvement, while in non-naïve eyes a persistent non-response pattern was the visusrelevante prognostische parameter bei fibrovaskulärer umwandlung der cnv unter anti-vegf-therapie bei neovaskulärer amd book m. methods: endothelial cell growth medium (ecgm-mv) and dmem were supplemented with % fetal bovine serum, endothelial cell growth supplement, µg/ml heparin and nm cortisol, and confluent ibrec were exposed to both cell culture media or mixes thereof for - d. the cell index (ci) of confluent cells cultivated gold electrodes was continuously determined to evaluate permeability, cell adhesion or cell viability for which the activities of nad(p)h-dependent oxidoreductases were also measured. we assessed expression and/or subcellular localization of proteins specific for (microvascular) ec and those involved in regulation of paracellular flow and transport. results: the ci dramatically dropped to % within h after exposure of the cells to dmem, slowly recovering to normal values over the following days. expression of tight junction (tj) protein claudin- specific for microvascular ec was significantly lower even after d and barely detectable on day . in contrast, expression of tj-protein claudin- was higher after d, but significantly declined during prolonged cultivation of the cells in dmem. adherens junction protein vecadherin was only slightly affected, but expression of caveolin-involved in transcellular transport-was also significantly lower. in accordance, plasma membrane localization of claudin- or claudin- was reduced and that of vecadherin more diffuse after exposure to dmem for d. the cells then still expressed ec-specific von willebrand factor although to a lesser extent. interestingly, the nad(p)hdependent oxidoreductases were more active. all changes were observed with ibrec cultivated in mixes of ecgm-mv and dmem containing at least % dmem. conclusion: cultivating ibrec in dmem results in a rapid loss of the phenotype and properties typical for microvascular ec. these changes include barrier dysfunction and loss of specific marker proteins. therefore, observations made with (retinal) ec cultivated in dmem have to be evaluated with caution. falahat p. * , wintergerst m. w. m. , holz f. g. , schaefer c. einfluss der wwc-proteine auf die gefäßbildung der netzhaut der maus egbring c. non-adhärenz und non-persistenz in der ivom-therapie -eine systematische literaturrecherche ehlken c. * , ziemssen f. , eter n. , lanzl i. , kaymak h. , lommatzsch a. ex-vivo retinal dystrophy models via blue light induced neurodegeneration fietz a. * , hurst j. , leinwetter m. , schnichels s. universitäts-augenklinik, tübingen, germany background: the hallmark of many retinal diseases like age-related macular degeneration (amd) or retinitis pigmentosa (rp) are neurodegenerative processes in the retina, leading to damaged photoreceptor cells and ultimately blindness. there is strong evidence that photochemical oxidative stress plays a role in amd and rp pathogenesis as well as in several other eye diseases. blue light triggers the production of reactive oxygen species (ros) and might therefore be a promising non-chemical-based inducer of oxidative stress. the aim of this project was to establish a ros based degeneration model on ex vivo porcine cells and retinae. methods: primary porcine retinal cells and organ cultures were exposed to blue light in varying intensities, treatment numbers and periods of time. ros production was measured and the apoptotic state of the retinal cells and cultures was determined. furthermore, the degree of degeneration was analyzed via immunhistology, western blot and qrt-pcr. cell and disease specific, as well as cell death and cellular stress markers were evaluated. results: primary rpe and müller cells were exposed to blue light for h and the ros-level was determined. both exhibited significant ros increase after and h of cultivation ( . - -fold). furthermore, müller, rpe and dissociated retinal cells were exposed for h and the rosamount was measured after and h. the strongest ros-increase was detected after h ( - -fold), proving that blue light irradiation causes oxidative stress in primary retinal cells. to investigate the effect of blue light on retinal explants, specific markers like parp- , hsp , p , caspase , and opsin were analyzed. in blue-light-irradiated retinal explants, a significant increase of parp- and other stress markers was demonstrated, whereas opsin expression was decreased ( -fold). conclusion: we successfully established an oxidative stress based disease model with blue-light-induced neurodegeneration. this model can be used to test novel therapeutic approaches for amd-or rp-treatment exvivo. due to a similar morphology of the pig eye to the human eye, this setting is close to the human condition. the features of vitrectomy and vitreous chamber tamponade in the surgical treatment of severe forms of proliferative diabetic retinopathy golovin a. germany, the netherlands and switzerland. here, we will focus on the dme subgroup. the pacific study is a non-interventional, open label, multicentric study aiming to collect real world evidence regarding the use of ranibizumab. . patients were recruited in sites across germany (ger), the netherlands (nl), and switzerland (ch). we present data of at least months dme treatment with ranibizumab ( naive and pretreated patients-full analysis set) in a real-life setting, with a focus on treatment outcome, supply and therapy schemes applied. the percentage of female patients were . % (ger), . % (nl) and . % (ch). the entire population presented with a mean age of . (ger), . (nl) and . (ch) years. in ger most patients were already pretreated (p-t). mean bcva at baseline was . ± . (ger), . ± . (ch) for treatment-naïve (t-n, no patients nl) and . ± . (ger) . ± . (nl), . ± . (ch) letters for p-t patients. after months ranibizumab treatment, . % more t-n than p-t patients achieved a bcva gain ≥ letters. within months t-n patients received an average of . ± . (ger), . ± . (ch) ranibizumab injections which was comparable to p-t patients ( markova k. , rößler b. , iwersen m. , michel u. , beeke e. , gamael a. , scheffler m. , ter the lesion. number and length of regenerating rgc axons in the distal optic nerve stumps were analyzed one month after the lesion. results: the number of surviving rgcs in retinas treated simultaneously with gdnf and cntf, gdnf only, or cntf only was significantly higher than in retinas that received injections of control nscs at all post-lesion time points. importantly, the simultaneous administration of both neuroprotective factors rescued rgcs more effectively from injury-induced cell death than the separate administration of either gdnf or cntf. haritoglou c. * , conclusions: data indicate that combinatorial neuroprotective approaches represent a promising strategy to effectively rescue rgcs from lesion-induced cell death even when the treatment is started at a time point when a significant fraction of rgcs is already lost. jiang j. * universitätsaugenklinik freiburg, freiburg, germany background: retinopathy of prematurity (rop) is a major cause of blindness in children. hyperoxic insults to the premature retina after birth, followed by a hypoxic phase subsequently, lead to neovascularisation. without timely treatment, retinal detachment ensues. diode laser photocoagulation is the current gold standard treatment but may not be widely available in developing and middle-income countries, where a surge in the incidence of rop has been observed. therefore, trials are ongoing to find time-saving and less invasive alternatives. objectives: this literature review aims to discuss potential treatment options explored recently (from onwards) and to examine how they relate to the pathophysiology of rop. embase and the cochrane database of systematic reviews (cdsr). key words such as "retinopathy of prematurity", "anti-vegf", "igf- " and "beta blockers" were searched using medical subject headings (mesh), free text terms and synonyms. trials published in english and within the last ten years ( - ) were evaluated. results: thirty-five trials were relevant to this literature review and generated findings for the use of anti-vegf, igf- , beta blockers, oxygen saturation targets and postnatal nutrition. the largest body of evidence relates to anti-vegf agents, but their side effect profile and optimal dosages are areas to be addressed before widespread clinical use can be advocated. other promising interventions include beta blockers and fish oil supplementations, which should be further evaluated in large-scale randomised trials. discussion: despite the advantages associated with anti-vegf therapy, more high-quality studies are required and determination of the safety of this class of drugs is paramount. up to date guidelines for ophthalmologists in the treatment of rop are also needed. there is much interest in managing a range of co-morbidities associated with prematurity by means of a single intervention, which has proven to be an ambitious but challenging task. purpose: to address the need for a reduced treatment burden for the management of neovascular age-related macular degeneration (namd), the port delivery system with ranibizumab (pds) was designed as a refillable, indwelling implant providing diffusion-mediated continuous intravitreal delivery of ranibizumab (rbz). the ladder trial (nct ) is evaluating the efficacy and safety of the pds with rbz formulations compared with monthly intravitreal rbz . mg injections for the treatment of namd. the primary study endpoint, defined as time to first required implant refill assessed when the last enrolled patient completed the month visit, has been reached. the phase archway (nct ) is an ongoing randomized clinical trial directly comparing pds mg/ml with fixed -week refills with intravitreal rbz . mg monthly. results: the ladder primary analysis population was patients: , , and patients in the pds , , and mg/ml arms, respectively, and patients in the monthly intravitreal rbz arm. the median time to first refill was . , . , and . months with . %, . %, and . % patients not meeting implant refill criteria until ≥ months for the pds , , and mg/ml arms, respectively. at month , mean change in bcva from baseline was + . , - . , - . , and + . letters for pds , , and mg/ml, and monthly intravitreal rbz arms, respectively. at the time of primary analysis, patients in the pds , , and mg/ml arms had received a mean total of . , . , and . rbz treatments during a mean time on study of . , . , and . months, respectively, compared to a mean total of . rbz treatments received by patients in the monthly intravitreal rbz arm during . month mean time on study. the optimized pds implant insertion surgery and refill procedures were well tolerated. case examples from the ladder study and mechanism of action of continuous delivery will be presented at the meeting. conclusions: with % of patients not needing an implant refill until ≥ months in the pds mg/ml arm and comparable efficacy outcomes between pds mg/ml and monthly intravitreal rbz treatment, ladder results support the archway design of pds mg/ml with fixed -week refills. pds has the potential to reduce high intravitreal treatment burden and improve patient outcomes in clinical practice. hintergrund: beschreibung der klinischen variabilität in augen mit retinitis pigmentosa assoziiert mit pathogenen eys genmutationen. methoden: neun patienten (mittleres alter: , , - jahre bei erstuntersuchung, frauen) mit zwei pathogenen eys genmutation bestätigt durch molekulargenetische diagnostik wurden klinisch untersucht mit s abstracts these patients. faricimab is a first-in-class bispecific monoclonal antibody directed against vegf-a and ang- and designed for intravitreal use. we aimed to assess efficacy and durability of faricimab in patients with dme and namd (boulevard and stairway). methods: boulevard (nct ) analysed treatment-naïve dme patients receiving intravitreal . or . mg faricimab or . mg ranibizumab (rbz), and previously anti-vegf-treated patients . mg faricimab or . mg q w for weeks. stairway (nct ) analysed patients with namd treated intravitreal with . mg faricimab, q w flex or q w after initiation, or with . mg ranibizumab (rbz) q w. we here present the results of both phase studies regarding central subfield thickness (cst), diabetic retinopathy severity score, size of choroidal neovascularisation (cnv) lesions and safety signals. results: cst improved from baseline at week in all dme patients (adj. mean change, microns: . mg faricimab, - . ; . mg faricimab, - . ; . mg rbz, - . ). %, % and % of dme patients experienced a ≥ -step improvement in diabetic retinopathy severity score with . mg faricimab, . mg faricimab or . mg rbz, respectively. more patients treated with . mg faricimab maintained disease stability with stable cst during the off-treatment period at both and weeks after the last dose compared to rbz. % ( / ) of faricimab-treated namd patients had no disease activity at week . q w flex and q w faricimab-treated namd patients showed similar cst and cnv lesion size reductions vs q w rbz. in both studies no new or unexpected safety findings were identified. conclusions: maintenance of disease stability was improved with faricimab in dme patients, and extended faricimab dosing (q w flex and q w) revealed similar outcomes compared to q w rbz in namd patients. these results support further investigation of the efficacy, safety and durability of response, addressing an important unmet need for treatment options for these patients. karzinomassoziierte retinopathie -zwei fallberichte kilic a. purpose: multicentre trials have demonstrated the safety and efficacy of the fac implant in the management of dme over a year period. there are few real-world studies with sufficiently large populations of patients with dme reporting year outcomes. the current study reports the safety and effectiveness findings from the iriss study methods: iriss is a post-authorisation observational open label, registry safety study of the fac implant in dme, conducted in the united kingdom, germany and portugal. the study was designed to collect the data from patients that had been treated with the fac implantation according to the european label. the present analysis focused on only those patients (n = patients/n = eyes) completing years of monitoring post-treatment with the fac implant. safety was assessed in terms of the occurrence of intra-ocular pressure (iop) events and their management. effectiveness was determined from changes best-recorded visual acuity (va), particularly on the percentage of patients maintaining or achieving / ( / or etdrs letters) vision. results: mean age of the patients was . ± . (mean±standard deviation [sd]) years and the duration of dme was . years. the majority ( . %) of eyes treated with the fac implant were pseudophakic. mean iop was . ± . mmhg at baseline and remained below mmhg throughout months of follow up, with a small increase from baseline at month (+ . mmhg, p = . ). topical iop-lowering drops were required in . % of eyes to control elevation in pressure and only . % (n = / ) of eyes requiring iop-lowering surgery. mean va improved/ was maintained in % of eyes at year and % achieved / vision compared to . % at baseline. eyes with a starting va of / had no significant change in va over years. conclusions: these real-life outcomes confirm the long-term safety and effectiveness of the fac implant in the treatment of dme after three years of treatment and in a cohort of patients larger than the eu registration trial population. the results from clinical practice show changes in iop and visual acuity similar to those reported in the pivotal fame trials. these data also show that when patients with good starting va (≥ letters) were treated with the fac implant, vision was stabilised for the full three years of therapy. khoramnia r. * , patel s. , khanani a. m. , sahni j. , sadikhov s. , basu k. , grzeschik s. , szczesny p. purpose: the importance of vegf-a inhibition in the treatment of neurovascular age-related macular degeneration (namd) and diabetic macular edema (dme) has been well demonstrated. still, real-world response rates are not sufficiently satisfying and treatment burdens are high due to high injection frequencies (q w). additional simultaneous inhibition of angiopoietin- (ang- ) might improve treatment efficacy and durability in berlin a. , radun v. , reichel c. augenklinik der lmu münchen, munich, germany; universität ulm, ulm, germany introduction: foveal alterations in asymptomatic patients can be very challenging in order to facilitate a diagnosis. methods: a female -year-old patient was referred to us by a general ophthalmologist to clarify a foveal lesion, that had been observed in a routine fundus examination of the right eye. in addition to her medical history and a standard clinical examination we performed the following examinations: fundus imaging, widefield imaging, heidelberger autofluorescence, oct imaging, fluorescein and icg angiography. the patient presented without any medical or ophthalmological history. the vision was / . the clinical examination of the anterior segment of the eye showed no pathological findings. the posterior segment of the right eye showed a circular central lesion of the fovea. in fundus imaging and widefield imaging this lesion could be documented. heidelberger autofluorescence showed no foveal enhancement. in oct imaging the retinal layers were normal, however, we observed uncommon dilated choroidal vessels. in fluorescein and icg angiography the dilatation and central anastomosis of choroidal vessels were clearly documented. discussion: this is one of the rare examples of an asymptomatic patient who presented with an alterated fovea, which is most likely due to choroidal anastomosis and dilatation. bewertung der eignung des serum vegf spiegels als prognostischer faktor bei einem makulaödem bedingt durch einen venenastverschluss/zentralvenenverschluss unter therapie mit lucentis® (ranibizumab) lang m. purpose: neuronal ceroid lipofuscinosis (ncl) is a clinically and genetically heterogeneous group of neurodegenerative lysosomal storage disorders of mainly childhood. characteristic clinical symptoms of this fatal disorder include cognitive decline, mental deterioration, motor impairment, seizures, vision loss as a result of retinal degeneration, and premature death. enzyme replacement strategies represent promising treatment options for ncl forms caused by dysfunctional lysosomal enzymes. cln disease is caused by mutations in the gene encoding the lysosomal enzyme cathepsin d (ctsd). here, we analyzed the efficacy of two enzyme replacement strategies to attenuate retinal degeneration in a ctsd knockout (ko) mouse. methods: functional murine ctsd was administered to the ctsd ko retina prior to the onset of retinal degeneration by intravitreal injections of either a ctsd-overexpressing neural stem cell (nsc) line or ctsd encoding adeno-associated virus (aav) vectors. the impact of the treatments on accumulation of storage material, reactive astrogliosis and microgliosis, dysregulation of various lysosomal proteins and the loss of different retinal cell types was analyzed at the end-stage of the disease using immunohistochemistry and western blot analyses. results: both treatment strategies resulted in a reduction of storage material and attenuation of reactive microgliosis. treatments also normalized the dysregulated expression of various lysosomal proteins. however, significant attenuation of retinal degeneration was only observed in animals treated with ctsd-encoding aav vectors but not in animals that received injections of ctsd-overexpressing nscs. ctsd levels were significantly higher in aav-treated than in nsc-treated ctsd ko retinas. conclusions: a sustained administration of functional ctsd, either through a cell-or an aav-based approach, resulted in attenuation of the retinal pathology in an animal model of cln disease, the most severe ncl form. however, delivery of therapeutically relevant amounts of the lysosomal enzyme to the ctsd ko retina was only achieved through the gene therapy approach, as indicated by a significant rescue of retinal cell types. bioadhere -maßgeschneiderte bioadhäsiva für epiretinale netzhautstimulatoren okuläre beteiligung bei einer systemischen attr-amyloidose mit einer p.v m mutation lubbad a. verlauf: im labor fielen ein kaliumwert von , mmol/l, sowie . leukozyten mit deutlicher linksverschiebung auf. bei v. a. leukämie erfolgte eine stationäre aufnahme in der hämatoonkologie. mittels zytound molekulargenetischer analyse wurde die translokation t( ; ) (q ;q ) mit nachweis des bcr-abl transkriptes ermittelt und die diagnose einer cml gestellt. daraufhin wurde die zytoreduktive therapie (mit hydroxycarbamid gefolgt von einem tyrosinkinaseinhibitor) eingeleitet. unter der therapie normalisierten sich die blutwerte und funduskopischen veränderungen und der visus stieg beidseits auf , . in der fag zeigten sich die tortuositas und blutungen rückläufig. in der sd-oct kam es beidseits zum rückgang des mÖs unter der cml-therapie. diskussion: bei einem zvv erfolgt die diagnostik meist ohne notfallindikation über den hausarzt. bei bilateralem auftreten und jungen patienten (< jahre) muss eine ursachenabklärung durchgeführt werden, da häufig eine systemische erkrankung assoziiert ist. die sofortige blutuntersuchung sowie die hämatoonkologische therapie sind bei diesen patienten essentiell. ein effekt der systemischen therapie auf das mÖ sollte für bis zu wochen nach symptombeginn abgewartet werden, bevor eine anti-vegf therapie begonnen wird. so könnte in manchen fällen eine anti-vegf therapie eingespart werden. besteht das mÖ ungeachtet der purpose: our increasingly aging society leads to a growing incidence of neurodegenerative diseases. as the pathological mechanisms are inadequately known, the establishment of defined therapies is impeded. additive gene therapeutic approaches for the increased expression of a protective factor are considered as promising treatment modality. our approach relies on the genetic modification of retinal pigment epithelial (rpe) cells. we have already established their transfection to stably overexpress the genes coding for pigment epithelium-derived factor (pedf) and brainderived neurotrophic factor (bdnf), respectively. here, we describe the analysis of the neuroprotective function of the transfected rpe cells using a co-culture model. methods: arpe- cells were transfected with the genes coding for pedf and bdnf using the non-viral sleeping beauty transposon system. pedf and bdnf gene expression were analyzed via quantitative real-time pcr. pedf and bdnf secretion were evaluated by immunoblotting and quantified by elisa. transfected and non-transfected arpe- cells were cocultured with sh-sy y cells, a human neuroblastoma cell line exhibiting neurite outgrowth in the presence of neurotrophic factors. prior to the co-culture, sh-sy y cells were oxidatively stressed with µm h o for h to mimic damaged cells (oxsh-sy y). after and h, the neurites were stained with an anti-neuron-specific β-iii tubulin antibody and visualized by confocal microscopy. neurite outgrowth was analyzed using the software simple neurite tracer. the transfection of arpe- cells resulted in a significant increase in pedf and bdnf gene expression as well as protein secretion. first results indicated that bdnf-transfected arpe- (trarpe- ) cells significantly stimulated neurite outgrowth (p < . ). the neurite length in trarpe- /oxsh-sy y co-cultures was . -fold extended compared to oxsh-sy y cells alone ( . ± . µm vs. . ± . µm), whereas nontransfected arpe- cells showed no significant effect on oxsh-sy y cells ( . ± . µm). however, for pedf, no significant neurite elongation was observed until now. with the establishment of the sh-sy y co-culture model, we were able to analyze the neuroprotective function of a cell-based gene therapy. the next steps include the co-cultivation of sh-sy y cells with transfected primary pigment epithelial cells and the translation of the method to an ex-vivo retinal organ co-culture model. traumatische zyklodialyse -von zyklopexie ab interno bis zur dmek martin c. oct ( , , , , , , , , wochen) auch die mikroperimetrie (maia mikroperimetrie, , , , , wochen) . verglichen wurde der verlauf der fixationsstabillität (p ) und die zunahme und abnahme der retinalen empfindlichkeit an einzelnen punkten der mikroperimetrie. ergebnisse: nach wochen zeigt sich ein anstieg der sehschärfe im mittel von , ± , auf , ± , buchstaben etdrs (p = , ) und eine abnahme der crt von , ± , µm auf , ± , µm (p < , ). p verbesserte sich von , ± , % auf , ± , % (p = , ) . während zu beginn der therapie deutlich mehr punkte eine verbesserung der retinalen empfindlichkeit als eine verschlechterung zeigen (nach wochen: , ± , vs. , ± , (p < , ), gesamtsumme db: , ± , vs. , ± , (p < , ) ; nach wochen: , ± , vs. , ± , (p = , ), gesamtsumme db: , ± , vs. , ± , (p = , ), sind bei der letzten visite verbesserte und reduzierte punkte gleich häufig ( , ± , vs. , ± , (p = , ), gesamtsumme db: , ± , , , ± , (p = , ) . diskussion: unsere ergebnisse zeigen, dass eine eylea-therapie mit fixem schema zu einer kurz-und langfristig signifikanten verbesserung der fixationsstabilität sowie der sensitivität einzelner bereiche der mikroperimetrie führt. es kann also mit einer konsequenten therapie eine langfristige verbesserung des sehens erzielt werden. in all eyes a complete ophthalmic examination, swept source oct and ss-oct a was performed. we measured central retinal thickness (crt), central choroidal thickness (cct) and the area of the fovea avascular zone in superficial (sfaz) and deep retina (dfaz) vessels layer. results: eyes were included into this retrospective analysis. patients were included into the "observation only group". during the months observation period traction spontaneously released in / eyes ( %), and the traction release was statistically significant (p = . ). in this group improvement of visual acuity was noted (from . to . snellen). in mul- müller p. l. *, , treis t. , pfau m. , , esposti s. d. , alsaedi a. , maloca p. , , balaskas k. , webster a. , egan c. mikroperimetrie bei amd patienten während des ersten jahres fixer therapie mit aflibercept (eylea) muto e. s. * , dulz s. , spitzer m. , wagenfeld l. drils at the boundary between the ganglion cell-inner plexiform complex and inner nuclear layer improved in / eyes ( %, p = . ) one month after dex treatment. drils between the inner nuclear layer and outer plexiform layer improved slightly (p = , ). the occurrence of drils at baseline correlate with worse bcva and crt at baseline and one month after dex implantation. furthermore, an improvement of drils could be shown after one month. therefore, dril may serve as a predictive and robust biomarker of visual outcome in uveitic cme treated by dex injection. pauleikhoff l. * , vössing c. , song f. , usman m. , joachimsen l. , reiff c. m. , nelis p. *, , schmidt c. , lehmann f. , ertmer c. , heßler m. oct-based automated vitreous inflammation score: a promising biomarker in dexamethasone implant treated uveitis patients pohlmann d. * , terheyden j. h. , berger m. , ometto g. , montesano g. , neuber f. , langner m. , wintergerst m. w. m. , aslam t. , liu x. , holz f. g. , keane p. a. , crabb d. p. , denniston a. purpose: to objectively detect and evaluate vitreous inflammation before and after dexamethasone implant in patients with uveitis by using a recently developed optical coherence tomography (oct)-based algorithm. methods: in this multicenter, retrospective, cross-sectional study, eyes of uveitis patients were included. clinical and oct data (spectralis; heidelberg engineering inc) of all patients were collected. the inflammation score was obtained using an available automated oct-based algorithm. data of pre and post dexamethasone implantation were compared using a random effects model. results: patients with cystoid macular edema in uveitis anterior (n = eyes), intermediate (n = eyes), posterior (n = eyes), and panuveitis (n = eyes) were treated with a dexamethasone implant. the mean of age was years ± years and a range of to years. we registered follow-ups visits at month (up to months after injection) and followup visits at months (> months to months). the mean inflammation score at baseline was . , and changed significantly to . (p < . ) - months and to . (p < . ) months after dexamethasone injection. correlations with clinical ratings of intraocular inflammation are currently evaluated. conclusion: automated oct-based objective quantification of vitreous inflammation captures the expected decrease in vitreous inflammation following intravitreal dexamethasone implant. thus, the automated octbased quantification of vitreous inflammation may be a promising alternative and a potentially relevant biomarker compared to current subjective clinical estimates of vitreous inflammation in uveitis. dunkeladaptation und skotopische mikroperimetrie bei patienten mit sorsby fundusdystrophie raming k. *, , hess k. , , pfau m. , , birtel j. , , müller p. l. , gliem m. , issa p. c. , holz f. g. , vesselness-basiertes ki-verfahren zur automatischen d-segmentierung der gefäße in der oct-angiographie (octa) rothaus k. * , kuhlmann j. , faatz h. , jiang x. , lommatzsch a. , longitudinale struktur-funktions-analyse bei intermediärer altersabhängiger makuladegeneration saßmannshausen m. *, , zhou j. , , pfau m. , , , thiele s. , , fleckenstein m. , holz f. g. , , a smart phone app for individual risk assessment for progression of diabetic retinopathy scholtz s. * , aspelund t. , einarsson s. , gudmundsdottir a. , jonsdottir s. , steinarsson a. t. , stefansson e schultheiss m. * , wenzel d. a. , kromer r. , poli s. vorstellung der revision-studie zur therapie des nicht arteritischen zentralarterienverschlusses schultheiss m. * , poli s. in-vitro-bewertung von hydrogelen auf alginat-und hyaluronsäurebasis als glaskörperersatz schulz a. *, , rickmann a. , , wahl s. , , germann a. , stanzel b. , , the pachychoroid disease spectrum-and the need for a uniform classification system purpose: introduced in , the term pachychoroid has recently generated worldwide interest explaining disorders associated with a thick choroid. the spectrum of pachychoroid disorders includes pachychoroid pigment epitheliopathy (ppe), central serous chorioretinopathy (csc), pachychoroid neovasculopathy (pnv; defined by cnv), and aneurysmal type cnv (at ). in contrast to these new findings, cnv complicating csc has already been described in a multitude of publications; and, moreover, polypoidal choroidal vasculopathy (pcv) has long been known to present with a thick choroid. currently, it is unclear how ophthalmologists implement the old (csc with cnv, pcv) and new terminology (pnv, at ). the online database pubmed.com was searched for the terms "pachychoroid", "ppe", "csc", "pnv", "pcv", "at " and "cnv". articles published between august st until october th were included. results: in total, articles containing the term "pachychoroid" were identified. using the keyword "ppe", articles were found. in the articles on "csc", only ( . %) also contained the keyword "pachychoroid", while ( . %) also contained the term "cnv". in contrast, articles were found on "pnv". only one article referencing "csc with cnv" and "pnv" as an overlapping disease was found ( . %). reporting the outcomes of anti-vegf in neovascular non-aneurysmatic pachychoroid disease, articles on "csc with cnv", and articles on "pnv" were found. in the articles on "pcv", only ( . %) also contained the keyword "pachychoroid". in contrast, "at " was referred to in articles. of these, all ( %) also referenced "pcv". conclusion: there is a significant amount of overlapping studies reporting similar findings in pachychoroid disease using different names for the disorders involved. most importantly, this involves the seemingly interchangeable use of the terms "csc with cnv" and "pnv". to unify the terminology and to spur validating research on the idea that pachychoroid diseases of the macula represent a continuum, we recommend a new classification system as follows: rod function rescue after gene therapy with voretigene neparvovec: time window for intervention? stingl k. background: voretigene neparvovec is a gene therapeutic agent for treatment of retinal degenerations due to bi-allelic mutations in rpe . rpe is part of the phototransduction cycle in the retinal pigment epithelium. the rescue of rods is the short-term therapy effect of voretigene neparvovec. in the long term it should stop the natural course of retinal degeneration leading to blindness. we analysed the prediction value of patient's age for the short-term rod functional rescue by voretigene neparvovec using three readouts of dark adapted retinal function. methods: six eyes of four patients (age , , and years) have been treated with voretigene neparvovec and followed-up for at least month. the dark adapted threshold was assessed by the full-field stimulation threshold (fst) with chromatic stimuli. the local rod function was assessed by dark adapted chromatic perimetry (dacp) using a new protocol applying test points (cyan and red) in the central ° visual field. additionally, the local rod function was also evaluated objectively by scotopic chromatic pupil campimetry (cpc), a novel test of the local rod function based on pupil contraction analysis following local scotopic stimuli inside of the ° central visual field. all tests have been performed at baseline and one month after the treatment. results: all three methods indicated no measurable rod function before and showed clear improvement in the two younger subjects, and small or no improvements in the older subjects. fst with blue light improved by up to db one month after the treatment, the red-blue thresholds difference improved to normal values ( db) in the youngest subject. corresponding to the treated area, dacp showed an improvement of the retinal sensitivity of up to db. scotopic cpc in that area improved to up to % of normal values indicating functional rescue of % of rod population in the same area. in the oldest subject, readouts improved only minimally after the therapy. all three readouts at one month after the treatment correlated highly with age: r = , for fst blue threshold; r = , for the improvement of dacp hill of vision volume and r = , for the maximal pupil constriction amplitude in the scotopic cpc. conclusions: voretigene neparvovec can restore local rod function, measurable already one month after the treatment. the presented data indicate that the age may be a valid prediction factor for the short term outcome of rod rescue. medical university of plovdiv, plovdiv, bulgaria introduction: age-related macular degeneration (amd) is the leading cause of visual impairment in individuals over the age of years worldwide. wet (exudative, neovascular) amd represents only about % of all amd patients, but it is responsible for % of blindness secondary to amd. choroidal neovascularization (cnv) is the hallmark of neovascular amd. according to the localization of cnv by optical coherence tomography (oct) and oct-angiography (oct-a) it may be classified as cnv (under retinal pigment epithelium-rpe), cnv (above rpe), cnv -retinal angiomatous proliferation (rap), and cnv (mixed, cnv +cnv subtype). objectives: different subtypes of cnv related to amd were established in randomly selected patient population using oct-a. aims: to investigate the frequency distribution and morphological types of the different cnv secondary to wet amd using oct-a. method: a total of eyes ( consecutive patients, mean age ± years (range - ), . % females) with wet amd were enrolled in a prospective study. all patients underwent a complete ophthalmologic examination, including best-corrected visual acuity (bcva) using snellen charts, slit-lamp biomicroscopy, tonometry, fluorescein angiography (fa), and oct-a (cirrus hd-oct, angioplex, carl zeiss meditec, dublin, ca). written informed consent was obtained from all patients. results: all cnvs were confirmed by fa and oct-a. in eyes ( . %) there was late leakage from an undetermined source on fa and a pathologic vascular complex under rpe on oct-a correlating with cnv . in eyes ( . %) there was leakage with a classic pattern on fa and a neovascular membrane into the avascular part of retina on oct-a suspected for cnv . in eyes ( . %) we found cnv (mixed cnv). cnv (rap) was not established in the examined group of patients. three different morphological subtypes of cnv were visualized-"medusa-like" in eyes ( . %), "seafan-like" in eyes ( . %), and cnv with indistinct form in the rest eyes ( . %). the results in this study confirmed the higher incidence of cnv against the other cnv subtypes which correlates with the cited frequency in the literature. in addition, "medusa-like" and "seafan-like" cnv present an active subtype, while cnv with an indistinct form-inactive subtype. oct-a is a reliable and appropriate technique for easily visualizing and localizing different subtypes of cnv in patients with wet amd. oct-a characteristics of neovascular membranes in wet amdpossible correlation to the prognosis vidinova c. n. * , dafina a. a rare case of serous retinal detachment at the posterior pole after high dose intravenous steroids due to renal-graft rejection wiecha c. background: non-adherence (na) continues to be a major challenge in the real-life treatment with anti-vascular endothelial growth factor. however, there is still a gap of sufficient evidence related to the reasons for na in patients treated with intravitreal injection therapy (ivt). furthermore, there is no reliable measure, which can be used in clinical routine to detect potential barriers in time. the aim of this investigation was to develop a questionnaire (adherence barriers questionnaire-ivt: abq-ivt), based on an earlier version of the abq. the existing abq was discussed in an expert panel and revised according to specifications of ivt. initially, the abq-ivt consisted of items formulated as statements ( -point-likert-scale ranging from "strongly agree" to "strongly disagree"). the abq-ivt was applied in a cross-sectional survey of german patients with neoavascular age-related macular degeneration (namd) and diabetic macular edema (dme). evaluation of the questionnaire included an assessment of internal consistency as well as factor analysis. the occurrence of potential barriers in the patient sample investigated was evaluated using descriptive statistics. results: of patients ( %) were able to complete the abq-ivt. on the basis of the answers given and the analysis of their independence, a possibility was used to condense the questionnaire-without reducing its informative value. the final abq-ivt has been reduced within the reliability analysis to -items and demonstrated a good internal consistency (cronbach's alpha = . ). factor analysis showed no evidence for subscales of the questionnaire. nearly half of the patients ( %) reported being affected by at least three different barriers. on average, a patient was affected by . barriers. most reported barriers were "challenge due to time commitment of physician visits" ( % of the patients) followed by "depression" ( %), "travel and opportunity costs" ( %), and "burden for family members" ( %). the prevalence of specific barriers differs by patient characteristics. the items "cost of treatment" and "too old for therapy to be worthwhile" were reported more frequently in older patients compared to younger. the abq-ivt is a practical and reliable instrument for identifying patient-specific barriers of adhering to ivt treatment. in practice, it might be useful to assess, whether individual patients are at higher risk of na due to specific adherence barriers. optical coherence tomography angiography in patients with optic nerve head drusen and anterior ischemic optic neuropathystructural and functional analysis problem: to evaluate the quantitative characteristics of the radial peripapillary capillary (rpc) network in the eyes with anterior ischemic optic neuropathy (aion) in association with optic nerve head drusen (onhd), and age matched healthy eyes using optical coherence tomography angiography (oct-a). to determine correlations between rpc density and structural and functional damage of the retinal nerve fiber layer (rnfl). methodology: eyes (mean . ± . years) with aion caused by onhd (exposed drusen) were enrolled, and also eyes from the same patients with onhd (buried drusen), but without aion. the control group contained eyes (age matched mean . ± . years). foto fundus, fundus autofluorescence and goldmann visual field testing were done in all patients. also peripapillary rnfl and oct a images were acquired using the optovue oct (angiovue; optovue). standard . mm diameter circular scans were used to record disc parameters and average rnfl in sectors, and . × . mm scans of the optic disc were used to record oct-a rpc density (%) in sectors. correlations between main outcome parameters (sectoral rpc density and rnfl thickness, disc area size and visual field index) were determined and compared to the control group. results: both corresponding rpc and rnfl sectoral parameters were significantly lower in eyes affected by aion than in buried drusen group and control group (p < . ). there was no significant difference between these parameters in buried drusen group compared to control group. sectoral rpc density was strongly correlated with corresponding sectoral rnfl (p < . ) and also visual field index (p < . ). no significant correlation was found between disc area size and rpc and rnfl damage. conclusions: this study shows significant peripapillary microvascular damage in eyes with onhd and aion correlating with the same sectorial rnfl reduction and visual field defects. the same patients' eyes with onhd deeply buried without aion and rnfl defects had the same finding of rpc as the age matched control group. our data suggest that disc area size is not an indicative risk factor for aion associated with onhd. oct-a could be a useful method in the analysis of capillary density in patients with onhd. introduction: childhood optic nerve glioma (ong) is typically a slowgrowing tumor that can lead to blindness. the first six years of life constitute the greatest risk of developing the disease. treatment of ong is currently controversial, and involves simple observation, radiation, chemotherapy, and surgical excision. objectives: chemotherapy has emerged as the preferred treatment modality for childhood ong. however, no study has previously analyzed long-term sequelae of chemotherapeutic treatment in children aged - years-old compared to older children, which is the objective of this study. aims: we aim to investigate whether the use of chemotherapy alone in the treatment of childhood optic nerve glioma correlates with different overall survival (os) patterns in infants as compared to its use in treating older children. methods: a retrospective, epidemiological analysis of children with optic nerve glioma was conducted on patient data extracted from the surveillance, epidemiology, and end result (seer) registry. patients were divided into two groups: group included patients - years old while group included patients - years old. survival analysis was performed in patients treated with chemotherapy only. results: ong cases were identified, of which % were in group . patients were white. female:male ratio was : . introduction: carotid cavernous fistula (ccf) is an abnormal communication between the cavernous sinus and the carotid arterial system. ccfs are classified into subtypes based on their communication. these patients may present with signs as conjunctival chemosis, proptosis,exophthalmos, diplopia, ophthalmoplegia, orbital pain etc. case report: a -year-old male patient, presented diplopia and proptosis. his history revealed that he had previously been treated for one month with unspecified drops, after which he was admitted to a local hospital for a month. during that admission, he was given retrobulbar and subconjunctival triamcinolone. the situation with eye improved and he was discharged. an orbital ct scan was performed while in hospital. a few days later, the situation worsened, he developed diplopia, a reddish eye with protrusion. on presentation to our clinical centre, he had bcva . , was hypermetropic. iop re was mmhg and le mmhg. slit-lamp and fundus examination of the right eye showed normal findings, while on the left eye, showed episcleral congestion with corkscrew blood vessels, reddish eye, slightly oedema cornea. fundus showed normal onh with dilated retinal blood vessels. both angles were wide open on gonioscopy, re schaffer , and le schaffer . the right motility was normal and the left was limited in elevation and abduction (hesse lancaster). the optic nerve head and maculae were both normal on oct. a b scan ultrasound showed a vertical hypoechogenic space just behind the optic nerve in the left orbit. the patient was given timolol . % ×, brimonidine ×, acetazolamide tablets and tobramycin/dexamethasone drop. he then underwent ct angiography, as mri was not possible because of a metallic foreign body sustained during the war. ct angiography showed dilated blood vessels crossing over the optic nerve, without much clear detail. the patient was referred to a neurosurgeon and underwent digital subtraction angiography which showed a carotid-cavernous fistula requiring neurosurgical treatment. brimonidine and tobramycin/dexamethasone drops with acetazolamide tablets were continued while he awaits surgery. the eye is quiet, the proptosis and diplopia have resolved. conclusion: many patients with ccf may initially present to an ophthalmologist, who should be able to make a presumptive diagnosis in most cases. an ophthalmologist should properly refer the patient to a neurosurgeon. lhon-therapie mit idebenon -wann beginnen, wie lange therapieren? eine langzeitbeobachtung über jahre schuart c. o augenklinik, universitätsklinikum dresden, dresden, germany aim: uveitis is associated with visual impairment and blindness. in western countries idiopathic inflammation is the most common cause. nonbiologic treatment for autoimmune/idiopathic uveitis is not based on published strong evidence. this study was to evaluate high-dose intravenous methylprednisolone (ivmp) treatment in patients with juvenile autoimmune/idiopathic uveitis. method: a retrospective chart review was conducted in two tertiary referral centres to investigate treatment response to ivmp in children and adolescents with autoimmune uveitis between and . disease activity, outcomes, and additional treatments were documented at , and months after ivmp. purpose: to evaluate the effect of prism adaptation test (pat) on the angle of squint as well as eye muscle surgery dosage in decompensated microesotropia (dekmet) and decompensated esophoria (dekeph). methods: in this single-centre retrospective study we reviewed the medical records of all patients with the diagnosis of dekmet or dekeph, aged at least years, who were treated by strabismus surgery for the first time between and . the maximum angle of squint (aos), pat results before surgery, surgical dosing and aos one day postoperatively were considered. pat included wearing a prism based on the largest angle for over min. results: patients (mean age ± years) were included in the dekmet group, patients (mean age ± years) in the dekeph group. for dekmet, before surgery aos was . ± . pdpt for far (f), . ± . pdpt for near fixation (n). during pat ( . ± . pdpt), the aos increased significantly by . ± . to . pdpt (f) and by . ± . to . pdpt (n). postoperatively, aos was reduced to . ± . pdpt (f) and . ± . pdpt (n) . for dekeph, before surgery aos was . ± . pdpt (f) and . ± . pdpt (n). during pat ( , ± . pdpt), the aos increased significantly by . ± . to . ± . pdpt (f) and by . ± . to . ± . pdpt (n). postoperatively, aos was reduced to . ± . pdpt (f), and . ± . pdpt (n). before pat there was a significant distance-near difference (dnd) in both groups which differed significantly between both groups: mean dnd before pat: dekmet - . ± . pdpt (aos(f) lower than (n)), dekeph + . ± . pdpt (aos(f) higher than (n)). after pat there was still a significant dnd in the dekmet group, but no longer in the dekeph group. considering only eyes with ametropia up to dpt spherical equivalent, the mean dosage applied for combined medial and lateral rectus muscle surgery (referring to the mean of aos (f) and (n) after pat) was significantly different between the groups (dekmet . ± . pdpt/mm, de-keph . ± . pdpt/mm). the mean dose-effect was not significantly different (dekmet . ± . pdpt/mm, dekeph . ± . pdpt/mm). the aos before pat in patients with dekmet showed significant dnd with greater angle of squint at near fixation, in the dekeph group the angle of squint was significantly greater at far fixation. after pat, the difference persisted in dekmet with the near and far angle in-s abstracts , ± , und die normalgeborenen , ± , jahre alt. results: dvd improved significantly (p < . ) in the two groups of the study. in group i, the mean vertical deviation improved from . ± . prism diopter (pd) preoperatively to . ± . pd months after surgery (p < . ), with a mean correction of vertical deviation of . ± . pd and a mean correction of asymmetry of . ± . pd. four patients needed inferior rectus tucking for residual or recurrent manifest dvd. in group ii, the mean vertical deviation improved from . ± . pd preoperatively to . ± . pd months after surgery (p < . ), with a mean correction of vertical deviation of . ± . pd and a mean correction of asymmetry of . ± . pd. five patients needed inferior rectus retucking for residual manifest dvd. conclusion: inferior rectus tucking is as effective as superior rectus recession with posterior fixation sutures for the primary treatment of dvd without inferior oblique overaction. inferior rectus tucking can also be used effectively for the treatment of residual and recurrent dvd; further studies are recommended in this field. do extraocular muscle pulley bands or does retrobulbar fat keep the eye muscles in place, and thereby acts like a pulley? simonsz h. j. * extraocular muscle pulley bands were described by tenon in as "faisceaux tendineux", acting as "poulies de renvoi". sappey described the band's smooth muscle fibers in . in tenon's, sappey's, miller's and demer's pulley concepts, this connective-tissue band between muscle and bony orbital rim limits vertical shift of a horizontal rectus muscle belly in up-and downgaze caused by the muscle's tendency to follow the shortest path from insertion to origin. it thereby redirects muscle force like a pulley. however, the band's attachment to the muscle moves mm sagittally when looking from ° left to ° right, limiting its ability to stabilize the muscle vertically. the band should be elastic to stabilize the muscle vertically while permitting large horizontal eye movements. we measured it after orbital exenteration: it was slack but, once extended, very stiff. in , our research group in amsterdam compared horizontal-rectusmuscle positions in up-gaze with those in down-gaze using ct and found no vertical shift. in primary gaze the muscle path was curved outwards, indicative of retrobulbar pressure resulting from rectus muscles pulling the eye into the orbit and contained by muscles and connective tissue sheets enveloping retrobulbar fat including the intermuscular membrane. the eye ball is held in place with the retrobulbar pressure. later, we repeated the ct study in a crouzon patient whose bony orbital rim was displaced cm posteriorly. the connective tissue band could not attach to bone. nevertheless, no vertical shift of horizontal rectus muscles occurred when the patient looked up or down. the muscles were kept in place by the retrobulbar fat and its enveloping connective tissue sheets including the intermuscular membrane. this mechanism was simulated in a soft-tissue finite-element model of the orbit, the muscles, the fat and the eye ball moving with degrees of freedom. although retrobulbar fat was assigned a low elasticity as found in vivo, it not only kept the eye ball in place, but also horizontal rectus muscle bellies in up-and down-gaze and vertical rectus muscle bellies in left-and right-gaze. the force keeping the muscle in place is delivered either by fat, connective tissue and orbital wall, or by the eye. in the former case, overall muscle force is redirected and pulley action occurs. if both force components contribute equally, listings' law is implemented naturally. "faisceaux tendineux" are likely to be check ligaments. visualisierung von intraokularen fremdkörpern im vorderen augenabschnitt mittels infraroter transillumination (pilotstudie) kogan the incidence of ocular melanoma in germany alfaar a. *, , rehak m. , saad a. introduction: ocular melanoma is the most common ocular malignancy in adults. its reported age-adjusted incidence in usa is . per million. many european countries have reported incidence and showed an increase from per million in south europe to more than per million in northern countries. our aim is to assess the incidence of uveal melanoma in germany between and . methods: data were collected from the german centre for cancer registry data. we have used the icd-o- topography codes c . to c . and histology codes / to / for mining and reporting the data. the tumors were limited to those with malignant behavior. we have compared the incidence between northern and southern states. german states of schleswig-holstein, hamburg, lower saxony, bremen, north rhine-westphalia, berlin, brandenburg, mecklenburg-west pomerania, and saxony-anhalt were grouped as northern while the states of hessen, rhineland-palatinate, baden-württemberg, bavaria, saarland, saxony, and thuringia were grouped as southern states. results: our study included patients diagnosed with melanoma including patients ( . %) with ocular melanoma and with an orbital disease ( . %). the diagnosis was histologically confirmed in . % of the patients, and . % were registered from death certificates only. the die rnfl war in allen quadranten außer dem temporalen signifikant geringer bei frühgeborenen im vergleich zu normalgeborenen. folgende parameter der papille waren signifikant größer bei frühgeborenen im vergleich zu normalgeborenen: die exkavationsfläche ( , ± , vs. , ± , mm , p = , ), das exkavationsvolumen ( , ± , vs. , ± , mm , p = , ), der flächenquotient cdr ( , ± , vs. , ± , , p = , ), die horizontale cdr ( , ± , vs. , ± , , p = , ) und die vertikale cdr ( , ± , vs. , ± , mm, p = , ). die randsaumfläche war signifikant dünner bei den frühgeborenen ( , ± , vs. , ± , mm, p = , ). bei den frühgeborenen zeigte sich eine signifikant positive korrelation des geburtsgewichts und des gestationsalters mit dem superioren quadranten und der gesamtdicke der rnfl. eine negative korrelation fand sich mit der exkavationsfläche, dem exkavationsvolumen und der horizontalen cdr. frühgeborenenretinopathie hatte keinen einfluss, die neurologischen erkrankungen waren hingegen der stärkste prädiktive faktor für eine dünnere rnfl in allen quadranten außer dem temporalen. schlussfolgerung: aufgrund der dünneren rnfl haben die papillen bei frühgeborenen eine dünnere randsaumfläche und eine größere exkavation. insbesondere wird die rnfl durch die neurologischen begleiterkrankungen negativ beeinflusst. diese faktoren sollen berücksichtigt werden, bevor bei einem frühgeborenen kind die diagnose eines glaukoms gestellt wird. results: according to bett closed globe eye injury was observed in cases ( . %), incl. eye contusion in cases and lamellar corneal injury in cases. in cases ( . %) there was open globe injury (with corneal perforating injury and with lens and iris prolapse in one case). left eye was injuried in . %, right- . %. the character of the injury and its incidence was the following: corneal erosion- cases ( , %), corneal edema- ( . %), retinal edema- ( . %), eye hypertension- ( . %), hyphema, accompanied by vitreous hemorrhage- cases ( . %), vitreous opacity- ( . %), subretinal hemorrhage- ( . %). in cases macular hole was observed, in cases-retinal detachment. iris changes was in cases (incl. aniridia in case). in cases ( . %) va was light perception; in cases ( . %)- , - , ; in cases ( . %)- , - , and in cases ( . %)- , - , . in cases ( . %) surgery was necessary and was performed. conclusion: bottles of sparkling wine can cause severe ocular trauma due to the high-impact energy. so, there is evident the necessity of educational work and protective measures among population for the prophylaxis of such eye trauma. the real rate of eye injury due to cork of sparkling wine supposed to be much higher. the bottle must be properly handled (although it is not the guarantee for trauma avoidance). it is advisable to avoid the bottle to undue heat and agitation and to direct cork away from the face when opening the bottle. all bottles of sparkling wine must have warning labels. the consumer can reduce the risk of eye trauma by keeping bottles in a cool place and not to shake it before use. introduction: retinoblastoma (rb) is the most common intraocular pediatric malignancy. many studies have analyzed its epidemiological trends and have shown varying results over the years. objective: the purpose of our study is to analyze the most recent epidemiological trends of retinoblastoma. aims: to analyze the epidemiological trends of retinoblastoma during the years to methodology: a retrospective, population-based analysis was conducted on children younger than years of age. data were extracted from the surveillance, epidemiology, and end results registry from to . incidence data from - were accessed for comparative purposes relative to results from the timeframe of our study. all incidence (ir) data were estimated as cases per million. incidence rate ratios (irr) were calculated in comparison to the entity with the highest value to determine statistical significance. results: cases were identified. % were females. the overall ir was . . incidence rates in male and female subgroups were not statistically different ( . and . per million, respectively [p = . ]). ir was highest in black patients ( . ), but was not significantly different from other races; irr were: non-hispanic white ( . , p = . ), asian/pacific islander ( . , p = . ), and hispanic ( . , p = . ). ir was significantly highest in the st year of life ( . ) and irr for presentation at the nd, rd, th, and th year of lives were: . (p < . ), . (p < . ), . (p < . ), and . (p < . ), respectively. % of patients presented with unilateral (ul) disease. ul disease incidence was significantly higher than that of bilateral (bl) disease ( . and . , respectively p < . epidemiological analysis and comparison of sporadic and inherited retinoblastoma, - mikhael s. * , tadrosse a. , yassa a. , mikhael m. , , eloy j. a. , , lewis ( . ) was significantly higher than that of bl ( . ) [irr . ; p < . ]. no change was noted in ul (apc - . ; p = . ) or bl (apc . ; p = . ) ir from to . stratification by sex showed no difference in ir within either ul or bl. in the ul and bl, there was no statistical significance in ir between non-hispanic white, black, pacific islander or hispanic groups. ir of ul cases were significantly higher than those of bl cases across all races. in the ul, % of cases were diagnosed during the st year of life, overall age-adjusted incidence of ocular melanoma was per million. generally, the incidence of ocular melanoma was higher in males than females consistently across all age groups except the group - years old. the crude incidence in males reached a peak in the age group - while the peak appeared between - in females. about % of the patients were diagnosed at the age of years or older. the choroid was the most common site for intra-ocular melanomas ( . %, n = ) followed by the ciliary body ( . %, n = ). on the other hand, the conjunctiva was the most common site for orbital tumors ( . % of orbital melanomas, n = ) followed by orbital adnexa ( . %, n = ). northern states showed higher age-adjusted per/year incidence rates ( . per million) in comparison to southern states ( . per million). conclusion: the incidence of ocular melanoma followed the european rates and patterns. further studies are required for studying the trends, and the risk factors. kiefer t. * , schlüter s. , bornfeld n. in % der fälle konnte der befund mittels einer lokalen therapie (brachytherapie, laser-und oder kryokoagulation) konsolidiert werden. in % der fälle konnte der bulbus mittels iac, protonentherapie oder systemischer chemotherapie erhalten werden. augen ( %) mussten im mittel nach monaten ( , - monate) enukleiert werden. hiervon waren jedoch nur in fällen die durch ivc behandelten tumore der grund der enukleation. diskussion: in unserem patientenkollektiv zeigte sich ein geringfügiges ansprechen der soliden tumore oder peripheren rezidive auf ivc. in vielen fällen konnte allerdings im weiteren verlauf nach ivc eine konsolidierende therapie mit bulbuserhalt durchgeführt werden. Über die limitierten therapiemöglichkeiten der ivc bei soliden tumoren und die potentiell toxischen nebenwirkungen sind die betroffenen familien aufzuklären. analysis of the epidemiological trends of retinoblastoma during the years to mikhael s. * , tadrosse a. , yassa a. , mikhael m. , , eloy j. a. , , lewis objectives: the expediency of surgical removal of uveal melanoma (um) after its irradiation by various methods, including gamma knife radiosurgery (gkrs), remains debatable. unresolved questions are the indications and timing for um resection. aims: we analyzed the results of eye-conserving treatment of um after gkrs to determine the indications for um resection, as well as the optimal timing of surgery. methods: patients ( male, female) between and years of age were treated using gkrs with a dose of - gy. patients ( . %) with large um (t n m in . % of cases) and widespread secondary retinal detachment (srd) with macula involvement underwent tumor resection after gkrs (transscleral resection- , endoresection- ). the remaining patients ( . %) with medium-sized um (t n m in % of cases) and local srd without macula involvement mainly were treated without surgery. patients of both groups received local adjuvant therapy (lat) -angiogenesis inhibitors and triamcinolone. the timing of operations after gkrs ranged from days to months. last years resection was performed only if there was no effect from lat for - months. follow-up period ranged from to months. results: in the group with um resection, enucleation was performed in one patient ( . %) due to tumor recurrence months after surgery. in which ir ( . ) was significantly higher than that in the nd, th and th years of life (p = . , < . , and < . , respectively). in bl, % of cases were diagnosed during the st year of life; ir ( . ) was significantly higher than that during the nd, rd, th, and th years of life (p < . ). the ir of ul cases were significantly higher than that of bl during all other age groups except during the st year of life. mean survival was not statistically different during - : . months (ul) and . (bl). survival was also not significantly different between both groups based on race, age and sex. regression analysis showed that laterality was not a predictor for survival (hr: . ; p = . ). the incidence of sporadic cases of retinoblastoma is greater than that of hereditary ones, but similar during the st year of life. incidence is not affected by either sex or race. incidence during the st year of life is higher than that during the nd, th, and th years of life in sporadic cases and higher than all other age groups in inherited ones. sporadic and inherited cases of rb share comparable survival patterns. einfluss von papillendosis und bestrahlter optikuslänge bei protonentherapie choroidaler melanome riechardt a. i. * , stroux a. mikhael s. * , tadrosse a. , yassa a. , mikhael m. , , eloy j. a. , , lewis introduction: uveal melanoma is the most common intraocular malignancy in adults. objectives: the purpose of this study is to analyze epidemiological trends in incidence and survival of uveal melanoma specifically arising from the ciliary body. aims: to identify epidemiological and survival trends of ciliary melanoma. methods: a retrospective, population-based analysis was conducted using the surveillance, epidemiology, and end results registry from - . all incidence (ir) data were estimated in cases/million/year. incidence rate ratios (irr) were calculated in comparison to the entity with the highest value to determine statistical significance. treatment data were available only post year . results: cases of ciliary melanoma (cm) were identified. overall ir of cm was . . % of cases were white. ir for the white subgroup ( . ) was significantly higher than that for the black group ( . ) [irr: . , p < . ]. ir was also significantly higher in males ( . ) than in females ( . ) [irr . , p < . ]. patients aged - years had an ir of . , which is statistically higher than that of - , - , and - years intervals [irr = . (p < . ), . (p < . ), and . (p < . ), respectively], but not the - years interval (p = . ). average ir during the years - ( . ) was significantly higher than that for the years - ( . ) [irr = . ; p < . ]. annual percent change (- . ) over the time frame of the study displays a significant decrease in incidence (p < . ). -year overall survival (os) in - ( %) was significantly higher than that in - ( . %) [p = . ]. . % of cm cases received radiotherapy treatment and . % underwent surgery. -yr os in patients with localized malignancy who received only radiotherapy ( . %) was similar to that of those who were treated with surgery alone ( . %) [p = . ]. conclusion: the incidence of ciliary melanoma is highest in the white, male, and elderly population. although overall incidence is decreasing, overall survival patterns are declining, which requires further studies to pinpoint the underlying cause. radiotherapy does not exhibit survival advantage over surgery in the management of localized disease, suggesting that long-term sequelae of radiotherapy can be avoided with tumor excision, while maintaining similar survival rates. okkultes basalzellkarzinom innerhalb einer seborrhoischen keratose des augenlids: ein klinisch-pathologischer fallbericht nüßle s. beutel m. , schmidtmann i. augenzentrum am st franziskus hospital hautklinik -experimentelle dermatologie und immunologie der haut abteilung für nephrologie, immunologie und osteologie am st. franziskus hospital schmidtmann i. , beutel m. die konversion eines retinalen venenverschlusses (rvo) in ein neovaskuläres glaukom (nvg) ist eine visusbedrohende komplikation. unser ziel war es, die umwandlungsrate von rvo in nvg innerhalb einer klinik für augenheilkunde/kath. krankenhaus hagen, hagen, deutschland abstracts anzahl über zwei jahre erreichen. dabei konnten für / der patienten die injektionsintervalle verlängert werden. wir halten unser frühes te-schema für geeignet im anschluss kam ein -punkte-evaluationsbogen unter verwendung von "visual analogue scales" (bereich: - ) zum einsatz. sämtliche nachfolgenden ergebnisse sind als median/interquartilsabstand (iqr) dargestellt. ergebnisse: im rahmen dieser pilotstudie wurden versuchspersonen im alter von / j. untersucht. die sehschärfe der untersuchten augen lag bei , / , . schlussfolgerung: für deutlich überschwellige optotypen lagen sowohl die validität, als auch die retest-reliabilität aller eingabemethoden hoch. die untersuchungsdauer war bei sprachlicher rückmeldung mehr als untersuchungen mit höherer fallzahl sind nötig lauermann p. * , gebest j. , pfeiffer s. , feltgen n. , hoerauf h. ausschlusskriterien waren faktoren, von denen bekannt war, dass sie den iod beeinflussen, wie z. b. die kataraktoperation während der nachsorge, die verlängerte anwendung von steroiden, die kryotherapie und die silikonöl-endotamponade. als primärer endpunkt wurde die relative veränderung des iod (operiertes auge im vergleich zum nachbarauge) [ ] [ ] [ ] [ ] [ ] [ ] [ ] monate nach der operation definiert. sekundäre endpunkte waren die relative Änderung des iod nach - und - monaten. mögliche beeinflussende kofaktoren wurden mittels ancova analysiert. ergebnisse: der primäre endpunkt zeigte keine signifikante iod-reduktion des operierten auges im vergleich zum nachbarauge (p = , , n = ). allerdings war der iod des operierten auges allein nach - und - monaten nach der operation signifikant reduziert (- , ± , und - , ± , mmhg, p = , bzw. , ). der augeninnendruck des nachbarauges war nach - monaten ebenfalls signifikant reduziert (- , ± , mmhg, p = , ). in der subgruppenanalyse war die größe der vitrektomie ein signifikant beeinflussender kofaktor, der zu einem niedrigeren iod nach g im vergleich zur g-vitrektomie führte (p = , ). zusammenfassung: die pars plana vitrektomie bewirkte keine signifikante langfristige iod-reduktion im vergleich zum kontralateralen auge. wir beobachteten jedoch ein iod-senkungspotenzial bei der g-vitrektomie. analyse der choriokapillären flussdichte bei patienten mit systemischem lupus erythematodes -eine optische kohärenztomographie-angiographie-studie leclaire m. d. * , mihailovic n. , brücher v. c. , eter n. universitätsaugenklinik münster, münster, deutschland hintergrund/ziel: kollagenosen wie der systemische lupus erythematodes (sle) können einfluss auf die retinale durchblutung haben. immunofluoreszenz-und elektronenmikroskopisch konnten einlagerungen von immunkomplexen in der choroidea von sle-patienten demonstriert werden. ferner zeigten sich veränderungen der choriokapillaris bei sle-patienten in der konventionellen kohärenztomographie. ziel der vorliegenden studie war die quantitative analyse der retinalen flussdichte (fd) gemessen mittels optischer kohärenztomographie angiographie (oct-a) bei patienten mit sle unter hydroxychloroquin (hcq)-therapie unter besonderer berücksichtigung der choriokapillaris. methoden: es erfolgte eine messung der fd im oberflächlichen und tiefen kapillären plexus sowie der choriokapillaris im makulären × mm oct-angiogramm (rt vue xravanti, optovue inc., fremont, kalifornien, usa) bei patienten mit sle (n = ) und bei gesunden, alters-und geschlechtskorrelierten probanden (n = ). nur patienten ohne hinweis für eine hcq-induzierte retinopathie wurden eingeschlossen. die sle-patienten wurden in eine hochrisiko-(hcq-therapiedauer > jahre) und eine niedrigrisikogruppe (hcq-therapiedauer < jahre) eingeteilt. korrelationskoeffizienten in hinblick auf die fd und die kumulative dosis hcq wurden berechnet. ergebnisse: das mittlere alter der patienten lag bei , ± , jahren, das alter der gesunden kontrollen bei , ± , jahren (p = , ). in beiden inhaltet die gruppe der w -responder alle patienten, die innerhalb von wochen auf die standardtherapie reagiert haben, d. h. dass erstmals kein makulaödem im oct entweder zu visite , oder nachweisbar war und bis visite auch kein rezidiv dokumentiert war. insgesamt zählen patienten ( , %) zu den w -respondern und patienten ( , %) zu den w -non-respondern und patienten ( , %) sind vor visite aus der studie ausgeschieden. bezüglich des primären endpunktes sind somit n = patienten auswertbar. betrachtet man die baselinewerte der einzelnen studienpatienten, so zeigt sich eine deutliche streuungsbreite. der mittelwert liegt bei pg/ml. insgesamt zeigt die gruppe der overall-responder deutlich niedrigere serum-vegf werte als die gruppe der non-responder. was auch, berücksichtigt man die pathophysiologie, zu erwarten war. schlussfolgerung: primäres studienziel war die frage, ob das erneute auftreten eines makulaödems innerhalb von monaten bzw. eine erhöhung eines vorbestehenden makulaödems durch die bestimmung des serum vegf-wertes vorausgesagt werden könnte. hierbei konnten keine signifikanten unterschiede zwischen den respondern und non-respondern in der relativen vegf veränderung festgestellt werden. oct veränderungen der neurosensorischen netzhaut bei zerebraler mikroangiopathie langner s. m. * , terheyden j. h. , geerling c. f. , kindler c. , , keil v. c. , turski c. , turski g. n. , wintergerst m. w. m. , holz f. g. , gabor p. , , finger r. p. universitäts-augenklinik bonn, bonn, deutschland; klinik für neurologie, universitätsklinikum bonn, bonn, deutschland; deutsches zentrum für neurodegenerative erkrankungen (dzne), bonn, deutschland; klinik für radiologie, universitätsklinikum bonn, bonn, deutschland fragestellung: zerebrale mikroangiopathien (zma) sind ein risikofaktor für neurodegenerative erkrankungen. bei letzteren wurden bereits retinale veränderungen in der optischen kohärenztomographie (oct) gezeigt, für die zma gibt es hierzu bislang jedoch keine daten. daher haben wir strukturelle retinale veränderungen bei probanden mit zma untersucht. methodik: probanden wurden rekrutiert. ausschlusskriterien umfassten ophthalmologische vorerkrankungen und höhere myopie (< - dpt). bei allen probanden wurden eine cmrt, eine klinisch-ophthalmologische untersuchung, ein montreal cognitive assessment (moca) test, und ein oct-volumen-scan der makula sowie ein bmo-scan der papille (spectralis, heidelberg engineering) durchgeführt. die einzelnen scans wurden von der software des geräteherstellers vorsegmentiert und manuell korrigiert. probanden mit zma wurden statistisch mit gleichaltrigen kontrollen verglichen. die auswertung erfolgte mit der software spss (chicago, il, usa). ergebnis: probanden ( weiblich, männlich; mittleres alter ± jahre) wurden in die auswertung eingeschlossen. der vergleich von neun probanden mit zma und neun altersangepassten kontrollen (mittleres alter jeweils jahre) ergab einen signifikanten unterschied des ganglienzellschichtvolumens (gcl, p = , ). in einer regressionsanalyse der eingeschlossenen probanden mit zma waren die volumina der äußeren nukleären (onl, p = , ) und äußeren plexiformen schicht (opl, p = , ), das gesamte retinale volumen (p = , ), sowie anteile der retinalen nervenfaserschichtdicken (rnfl: papillomakuläres bündel, p = , , temporal superiore, p = , , temporal inferior, p = , und nasale anteile, p = , ) signifikant mit der läsionslast in der mrt assoziiert. schlussfolgerung: unsere studie zeigt erstmals sowohl veränderungen der neurosensorischen netzhaut in der oct bei zma gegenüber altersgleichen gesunden als auch veränderungen bei erkrankten, die mit der läsionslast in der mrt korrelieren. insbesondere die parameter opl, onl, gcl und rnfl sollten in prospektiven folgestudien weiter hinsichtlich ihrer eignung zur diagnose oder verlaufsbeurteilung bei der zma untersucht werden. neurovascular dysfunction in diabetes mellitus: the relationship between different stages of diabetic retinopathy and diabetic optic neuropathy karliychuk m. * , bezditko p. , pinchuk s. bukovinian state medical university, chernivtsi, ukraine; kharkiv national medical university, kharkiv, ukraine; eye microsurgery center ‚vash zir' , chernivtsi, ukrainediabetes mellitus (dm) causes neurodegenerative changes, and retinal neurodegeneration can be found in early stages of dm, even before the development of clinically detectable microvascular damage. the objective was to analyze the relationship between different stages of diabetic retinopathy (dr) and different types and stages of diabetic optical neuropathy (don). methods: a total of patients ( eyes) aged , ± . years with type dm were analyzed. in addition to routine eye examination, optical coherent tomography of the retina and optic nerve was performed. subclinical stage of chronic axial don was found in . % of eyes ( eyes); initial stage-in . % of eyes ( eyes); advanced stage-in . % ( eyes); dystrophic stage-in . % of eyes ( eyes). diabetic anterior ischemic neuropathy was found in eyes ( . %), diabetic papillopathyin eyes ( . %) of patients. results: frequency of dr in initial stage of axial don was . times, in advanced stage- . times, in dystrophic stage- . times, in anterior ischemic don and in diabetic papillopathy- times higher than in subclinical stage of don (p < , ). in absence of don dr was not detected. the difference in frequency of different stages of dr, depending on type and stage of don was noticed. the incidence of nonproliferative form of dr in initial stage of don was found to be . times, in advanced stage- . times, in dystrophic stage- . times, in anterior ischemic don- . times, in diabetic papillopathy- . times more often than in subclinical stage (p < . ). preproliferative and proliferative stages of dr were found only in advanced and dystrophic stages of axial don, and in anterior ischemic don and diabetic papillopathy, most often-in dystrophic stage of axial don. so, there was a direct correlation between the stage of dr and the type and stage of don (r = . , p < . ). the frequency of preproliferative dr in advanced stage of axial don was . times, in anterior ischemic don- . times, in diabetic papillopathy- . times less than in dystrophic stage of axial don. the frequency of proliferative dr in advanced stage of axial don was times, with ischemic don and diabetic papillopathy- . times less than in dystrophic stage of axial don. so, in dm there was a direct correlation between the frequency and form of dr and the type and stage of don that confirms the close relationship between neuronal and vascular dysfunction in dm. vergleich subjektiver visusangaben mit elektrophysiologischen verfahren zur visusevaluation kitsche m. sakkadenmessung bei phenylketonurie -sinnvoll oder nicht? hopf s. * , nowak c. , hennermann j. b. , schmidtmann i. , pfeiffer n. mehmed b. * , fronius m. , pohl t. , schramm c. , spieth b. inferior rectus tucking versus combined superior rectus recession with posterior fixation suture (faden) for the treatment of dissociated vertical deviation without inferior oblique overaction milisic s. tumor recurrence was observed in patients ( . %) in the group without um resection. other patients ( . %) died from metastatic disease and months after gkrs. the degree of vision loss was more pronounced in the group with um resection. the highest rate of subretinal fluid resorption and regression of even large um was observed in patients with initially local srd on the background of regular lat without resection. the expediency of um resection in the absence of metastases should be determined - months after gkrs on the background of regular lat. complete regression of large um without resection is possible. the indication for um resection is not the size of the tumor only (t n m ), but a combination of several characteristics: lack of regression of the um with preservation of permanent secondary retinal detachment involving the macula after regular lat or the development of ng. the incidence and survival of adult orbital tumors in germany alfaar a. *, , rehak m. , hassan w. , mehanna m. , saad a. , jansen l. der ophthalmologe · suppl · s conclusions: socioeconomic factors play an undeniable role in the disease management process for patients diagnosed with sebaceous adenocarcinoma of the eyelid. our results show that married patients tend to enjoy higher survival rates than unmarried ones. marriage or social union may translate into better compliance to treatments and a greater capability to endure the challenges brought forth by the disease. higher income levels, likewise, have been shown to correlate with better survival patterns. socioeconomic considerations should be a crucial aspect of the treatment process in caring for patients with eyelid sebaceous adenocarcinoma. wolf j. * , schlecht a. lgl and acc patients, respectively. incidence was significantly higher for lgl than acc ( . and . , respectively [p < . ]). acc incidence was highest in the black (bl) and lowest in the american indian (ai) subgroups ( . and . , respectively [p = . ]); incidence for the non-hispanic white (w) and pacific islander (pi) groups were . and . , respectively. the difference between racial groups with the highest and lowest incidence for lgl was not significant, . (w) and . (pi), respectively (p = . ); the ai and bl groups showed an incidence of . and . , respectively. average incidence of lgl based on geographical location was highest in alaska ( . ); the second highest incidence was in california ( . ). alaska showed an lgl incidence spike of cases/million in . acc, contrarily, did not show varying regional incidence. -year overall survival was statistically higher for lgl than acc ( . and . %, respectively [p = . ]). sex, race, and disease stage did not impact survival for either lgl or acc patients. conclusions: females represent most lgl and acc cases. lgl incidence is significantly higher than that of acc. while acc incidence varies by race, lgl's is influenced by geography. alaska witnessed an lgl incidence spike in , which accounts for its overall higher average incidence compared to other regions studied. overall survival in lgl is higher than that in acc.lgl survival considerably improved compared to that documented in previous studies, while acc survival remains similar to recently reported values. introduction: sebaceous adenocarcinoma of the eyelid is a slow-growing tumor. although many studies have analyzed its epidemiology and pathogenesis, no study has investigated the impact of socioeconomic disparities on its prognosis. objectives: to provide the first analysis on the effect of socioeconomic disparities in the management of sebaceous adenocarcinoma of the eyelid. aims: to provide insight on the impact of marital status and income level on survival rates of sebaceous adenocarcinoma of the eyelid using a population-based study. methods: a retrospective, epidemiological analysis of patients with sebaceous adenocarcinoma of the eyelid was conducted on patient data extracted from the surveillance, epidemiology, and end result (seer) registry from to . survival analysis was performed using the kaplan-meier method. we performed data analysis on cases of sebaceous adenocarcinoma of the eyelid. . % were married, . % single, and . % separated/divorced/widowed (sdw). median survival in months were: (married), (single), and (sdw). -year overall survival patterns based on marital status were: . % (married), . % (single), and . % (sdw). married patients showed significantly higher survival than sdw patients (p < . ). univariate cox regression analysis showed that the married group had a significantly lower hazard ratio than the widowed group ( . ; % ci: . - . %; p < . ). -year survival in patients with median annual income between $ , -$ , was significantly higher than that of patients with $ , -$ , income ( . and . %, respectively [p = . ]). in der spa-gruppe war s a gegenüber der jiau-gruppe erhöht (medium, lps, fsl- , pha; p < , ). die t-zell-proliferation unterschied sich nicht signifikant zwischen den gruppen. schlussfolgerungen: die pbmc der jia-und spa-assoziierten uveitispatienten unterschieden sich hinsichtlich der zytokinmuster nach den unterschiedlichen tlr-stimulationen. die jiau-gruppe war durch erhöhte arginase- -, aber niedrige il- -und tnf-a-konzentration gekennzeichnet, während die spa-gruppe durch eine höhere s a -freisetzung charakterisiert war. anti-citrullinated protein/peptide antibodies in convalescence stage may be a marker of autoimmune uveitis panchenko m. * , shevchenko n. single studies showed the existence of netosis in cytokine-induced ocular inflammation in a mouse model and in patients with behcet's disease. (barliya t et al., ; perazzio sf et al., ; safi r et al., ) . according to research data, the serum levels of myeloperoxidase (mpo)-dna complexes (net remnants) in patients with rheumatoid arthritis correlates with the level of anti-citrullinated protein/peptide antibodies. (wang w et al., ) . the aim of the work was to study serum levels of anti-citrullinated protein/ peptide antibodies in patients with uveitis. methodology: patients ( eyes) with idiopathic posterior, intermediate and panuveitis were examined and treated. men and women in the age group from to years were included in the study. the duration of the disease ranged from months to years. the first attack of uveitis was diagnosed in patients, the chronic uveitis was in patients. all the patients underwent standard ophthalmic examinations, including ultrasound biomicroscopy and optical coherence tomography. serum levels of anti-citrullinated protein/peptide antibodies were defined with the help of the enzyme immunoassay using a standard reagent kit. the control group included the serum of healthy donors. results: high serum levels of anti-citrullinated protein/peptide antibodies were identified in patients ( . %) in the active stage of first attack of uveitis and in patients ( . %; p > . ) with chronic uveitis. anti-citrullinated protein/peptide antibodies were detected in the blood serum of . % of patients in the stage of convalescence of uveitis first attack and in . % of patients (p < . ) with chronic uveitis. conclusions: serum anti-citrullinated protein/peptide antibodies in patients with uveitis in the stage of convalescence may be a marker of the autoimmune process. the problem: macular edema (me) during anterior uveitis (au) reduces visual function, leads to dystrophic changes. currently, its pathogenesis has been little studied. objective: to study the frequency of me and the expression features of the icam- and cd- marker in patients with uncomplicated and complicated au. methodology: patients with au were examined. persons had the primary process ( - days) and -had chronic recurrent au ( - days). a control group- healthy volunteers. the absolute (cell/µl) and relative (%) level of expression on the venous blood lymphocytes of the icam- intercellular adhesion molecules marker, which is considered a functional inflammation biomarker, and the apoptosis marker cd- using monoclonal antibodies by the histoimmunocytochemical method were determined. results: monocular au proceeded without complications in . %, and binocular in . % (χ = . ;p = . ). me (diffuse or cystic), which during the au in only one eye was found in % cases, during au in both eyes-in . % (χ = . ;p = . ) cases. the absolute level of icam- me = ; q l-u ( - ) cells/µl with uncomplicated au, and in patients with me-me = ; ( - ) cells/µl, which is . % higher (χ = . ; p = . ). in the control group, the expression of icam- me = . ; q l-u ( - ) cells/µl. so during au, icam- is - . times higher (p < . ). the relative index of icam- during au is ± . %, during au with me is higher by . % (p = . )-equal to . ± . %. in the control group, the relative amount of icam- is . ± . %, which is lower than during au in . and with complication of au- . times (p < . ). absolute level of apoptosis marker cd- for au was me = ; q l-u ( - ) cells/ µl, and for au with me-me = ; q l-u ( - ) cells/µl (p = . ), which does not differ and . times higher (p < . ) than in the control group-me = ; q l-u ( . - . ) cells/µl. the relative level of cd- during au is . ± . % and during au with me is below . ± . % (p = . ). in the control group, cd- is . ± . %. daniel m. application of the pattern electroretinogram in evaluation of the risk of myopia progression grudzińska e. introduction: myopia is an important social problem due to the significant increase in its incidence. myopia, especially of high degree, is associated with the risk of vision-threatening complications such as myopic macular degeneration, retinal detachment, cataract or glaucoma. the current state of knowledge does not allow to determine the early indicators of complications in people without degenerative changes at the eye fundus. the aim of the study was to assess whether the perg may be an independent, objective risk indicator for myopia progression. material and methods: eyes of patients aged . ± . years with myopia of medium degree were qualified to the study. the spherical equivalent of the refractive error was - . ± . d (range - d-- d). the control group consisted of healthy individuals aged - years with refractive error ± d. the following examinations were performed in the study and control group: an interview (in subjects with myopia including known risk factors of myopia onset and progression), assessment of the visual acuity, intraocular pressure, refractive error, assessment of anterior and posterior segment of the eye in a slit lamp, measurement of the axial length, structure and thickness of the macula and optic nerve disc in oct and perg. results: in the group with myopia, the spherical equivalent of refractive error was significantly lower than in the control group. the values of p and n wave amplitudes did not differ significantly between the groups. however, significant differences were observed in the p peak time. it was significantly longer in myopia than in the control group. the analysis of myopia progression risk factors showed a statistically significant positive correlation between the number of hours of physical activity per week and the amplitude of p wave. there was also a statistically significant positive correlation between the peak time of p wave and the amount of time spent on near work. conclusions: it is very possible that the perg may be an early prognostic marker in identifying those patients with myopia who will develop ophthalmic complications in the future. the assessment of p peak time, which correlates with the best known risk factor of myopia progression which is near work, seems particularly valuable. on the other hand, the increase of p wave amplitude may indicate a protective role of physical activity in myopia progression. analyse des stellenwertes von "elearning" in der augenheilkunde und evaluierung einer "elearning-app" grabowski e. published continously up to now. in he founded famous private eye clinic in berlin, where he treated many eye patients and educated many prominent ophthalmologists. at the age of he became associate professor of ophthalmology, the first with such a title in germany. conclusion: albrecht von graefe was founder of modern ophthalmology and separated it from surgery. graefe's contacts, correspondency and meetings at ophthalmological congresses with his teachers, assistants, colleagues also contributed to international co-operation and internationalization in ophthalmology. although albrecht von graefe died before years, he still provokes great admiration and respect in the world of ophthalmology. digitale weitwinkelfotografie bei der früherkennung der diabetischen retinopathie kaya s. ophthalmology service, makarska, croatiaobjective: a short review of the work of a german ophthalmologist albrecht von graefe is given in this presentation, on the occasion of the th anniversary of his death. he is regarded as the greatest ophthalmologist of the th century. modern and scientific ophthalmology owes its beginning to him. methods: extensive literature research is made and contacts with institutions for history of medicine as well as medico-historians in the field of ophthalmology.results: his contributions to ophthalmology were multiple. von graefe was the first to introduce iridectomy in acute glaucoma treatment, initiated visual field testing and developed the first tonometer. he made the first classification of glaucoma. von graefe was the ophthalmologist who created a special knife for cataract surgery. he was also the first to use helmholtz' ophthalmoscope. he founded the first ophthalmological society in the world and the second ophthalmology journal which has been lahme l. * , marchiori e. , mihailovic n. , nelis p. , oberhuber a. der ophthalmologe · suppl · s of postoperative surgical interventions was observed within one year. the outcome was considered to be stable when no further surgical interventions were needed for months before the last follow-up. the mean diameter of the corneal grafts was . ± . mm. the mean corneal thickness after one year of follow-up was ± µm. the bcva increased from . ± . to . ± . , the mean intraocular pressure was . ± . mmhg. three patients ( %) needed no further surgical interventions. four patients ( %) needed amniotic membrane transplantation, three patients ( %) needed cyclophotocoagulation for glaucoma, two patients ( %) needed repeated ppv, one patient needed a repeat pole-to-pole-surgery because of corneal graft failure with panophthalmitis, and two patients were subject to enucleation due to recurrent endophthalmitis. of patients were considered stable during the one year of follow-up. conclusion: pole-to-pole-surgery seems to be a viable option to attempt the salvage of the eye globe suffering simultaneously from severely affected corneal and retinal pathologies, thus preserving an ambulatory vision. ist das u-net zur objektivierung manueller markierungen in phasenkontrastmikroskopbildern geeignet? maßnahmen der hochschulambulanz einer augenklinik während der covid- -pandemie schmid a. purpose: drug delivery to treat ocular diseases still is a challenge in ophthalmology. one way to achieve drug delivery currently investigated topical administration of drug-loaded polymeric nanoparticles (nps) that are able to penetrate ocular barriers. the purpose of this study is optimal preparation of nps made from pseudo-proteins and evaluation of their ability to penetrate ocular tissues. methods: biodegradable nps of various types were prepared by nanoprecipitation of a pseudo-protein composed of l-leucine, , -hexanediol and sebacic acid ( l ). arginine-based cationic polyester amides r and comb-like polyester amides containing lateral peg- chains along with l anchoring fragments in the backbones were used to construct positively charged and pegylated nps. the nps were loaded with fluorescein diacetate (fda) or rhodamine g (rh g) as fluorescent probes. suspensions of the nps were given to cultivated microglial cells and retinal pigment epithelial (rpe) cells as well as topically on eyes of c bl/ mice. penetration of nps into the eyes was checked by fluorescence analysis. results: nps were prepared and their physicochemical properties were characterised. cultured microglial cells and rpe cells took up the nps. after topical administration penetration of nps into the cornea of the eyes could be clearly shown. small amounts of fluorescent dyes were also found in the lens, the retina and the sclera depending on the type of nps. the results show that the new nps penetrate ocular tissues after topical administration and are internalized by the cells. this raises confidence that the nps may be useful carriers of therapeutic agents for ocular delivery. key: cord- -xhx pzhj authors: nan title: nd world congress on pediatric intensive care rotterdam, the netherlands, – june abstracts of oral presentations, posters and nursing programme date: journal: intensive care med doi: . /bf sha: doc_id: cord_uid: xhx pzhj nan we present the results of a prospective population-based audit of paediatric intensive care activity in two comparable communities with markedly different delivery systems. in the trent region of the uk ( . million people), children receive intensive care largely without the supervision of a paediatric intensivist in a variety of hospitals, few of which have designated paediatric intensive care units (picus). critically ill children otherwise receive intensive care in children's wards, special care baby units (scbus) or adult intensive care units. in the australian state of victoria ( . million people), children receive intensive care almost exclusively in one centre -a picu staffed by full time paediatric intensivists. the two regions are otherwise demographically comparable. in both groups, data were collected on all children admitted to an intensive care unit between / / and / / and children who received intensive care (defined by levels of intervention and nurse dependency) in other sites during the same period. values of each variable at first contact with the icu, and the highest and lowest values over the first hours were recorded. the principal outcome was survival to discharge from the intensive care unit. severity of illness was assessed using pim (paediatric index of mortality) and prism. risk-adjusted mortality was compared using flora's z test and logistic regression. the rate of utilisation of intensive care (> admissions in each region) were similar. there was some variation in case mix between the two groups, but crude mortality rates were similar ( . % in trent and . % in victoria). however severity corrected data and other measures of picu performance were dramatically better in' the centralised delivery system. the substantial excess mortality in the trent region provides strong evidence for the benefits of centralisation of paediatric intensive care services. there are considerable difficulties in evaluating the efficiency and effectiveness oflcare in children presenting with respiratory failure during acute medical illness. optimal outcomes for such episodes include survival and the shortest length of stay (los) in intensive care with negligible risk of readmission. we have tried to determine whether or not the time course of acute severe medical illness with respiratory failure is predictable. study i (n= ): a retrospective study of intubated and mechanically ventilated children (> days, < years) with acute severe medical illness. measures: diagnosis, intensive care los in calender days, and survival. results: the underlying diagnosis fell within one of three broad categories: respiratory disease (n= , mortality . %), central nervous system (cns) disease (n= , mortality . %), and systemic inflammation or multisystem (sims) disease (n= , mortality . %. the los in survivors was: respiratory -median (interquartile range) ( - ) days, cns ( - ) days, £p, £ ( -g) days. :i'~'-+cen diag~,~is-rc!ated-grnnp~ (drgs) were identified ( respiratory, cns, sims disease) and each have been characterised by mortality and los. study ii (n= ): a prospective study of patients supported by the hypothesis that los for the above drgs was predictable (compared with study i data). in certain instances attributable causes for variances in los were identified: e.g. disease severity, timing ofdrug therapy, and associated disease. with daily paediatric risk of morality scoring within each drg, four profiles of instability were identified. discussion: the time course of acute severe medical illness with respiratory failure is predictable and variance may be attributable to specific care or diagnostic factors. we are now developing a means of linking drg-specific clinical care pathways with an integrated computerised decision support and education facility at the bedside. the objective of this open, prospective study was to assess the relation between basic patient characteristics as well as effectiveness of treatment on the one hand and resource utilization in pediatric intensive care on the other. as universal, non-monetary indicators of resource utilization we used the therapeutic intervention score system (tiss) and length-ofstay (los), from which indicators for total resource utilization per admission (tisstot) and average daily resource utilization (tiss-mean = tisstot/los) were obtained. overall admissions, totalling days, were included. mortality was . %; non-survivors accounted for . % of overall resource utilization. in non-survivors, both total resource utilization per admission and average daily resource utilization were higher, whereas los was not different from survivors'. severity of illness, surgical status, the presence of substantial chronic comorbidity, emergency admission and transfer from another hospital constituted the major predictive determinants of tisstot (r:= . ) and tissmean (ra= . ) in multiple regression analysis (p< . ). hence these indicators are appropriate non-monetary measures of resource utilization, a considerable proportion of which are determined by a concise set of basic clinical characteristics. subsequently we analysed the relation between effectiveness of care and resource utilization by assessing severity of illness corrected mortality in low, medium and high resource users, respectively. these categories were delineated by percer/tiles of resource utilization (< p , p -ps , > ps ). despite on average long los and high resource utilization in the high risk group, a relatively low standardized mortality was found, probably warranting prolonged intensive treatment in this patient category. summary: objective:the primary purposes of intensive care are to provide treatments to patients with life-threatening physiological dysfunction or to monitor and observe patients perceived to be at significant risk of dying. this collaborative study was performed to describe our patients and their outcome. in order to improve our results we tried to identit~ high risk groups, patients and methods: picus entered the study, the data included all the admissions with > hs. during a days period between the l°june and the th september . the records included: age, sex, weight, mechanical ventilation (mv), post-operative condition (p.op), malnutrition, diagnosis, length of stay, prism score and outcome. student test, mann-whitney or wileoxon were performed for univariate analysis. fisher exact test or chi square for dicotomic variables. risk group analysis was performed by logistic regression, odds ratio and % confidence interval. results: patients entered the study. mean age was . months (ds hh¢# ) and median months. we found significant statistical differences in calculated ,is observed mortality rate comparing malnourished with euthrofic patients; mechanical ventilated (mv) with non mv patients. no differences in ter ~,h of stay or di~ noses were found. effect of the un sanctions on the morbidity rate araong the iraqi small children ( below years old of age ) in bagdad. abdulsamad a.abood / institute of medical technology, bagdad. meningitis is essentially a childhood disease (i). the risk of infection are increased by powerty and overcrowding ( ). the impah'ed immunity may be an important pathogenic factor underlying the susceptibility to infections in undernourished subjects ( ). in general, malnutrition is a man made disease and it begins quite in the womb and ends in the grave (i). small children, below years of age were admitted to the pediatric hospital in washash with meningitis over cold months in i , in contrast to only child admitted with meningitis over the same period in . all of the children who admitted in were frankly undernourished, % of them were infected with enterobacteriae, because they were exposed to faulty hygiene and lack of asepsis. these facts showed precisely that our small children had suffered at most from the un_ sanctions against iraq, because of food, milk and drug shortage, since years which had resulted a severe undernutrition among them, which impaired their immune status. m wells, of riera-fanego, j lipman. baragwanath intensive care unit, university of the witwatersrand, south africa. background the use of prism or other scoring systems in the icu is of great importance for evaluating the efficacy and efficiency of a particular icu, the prism score was developed and validated in the usa and europe but has recently been shown to be inaccurate in a south american population, a south african population as well as several european studies. part of the poor performance of the prism score is as a result of differences in the case mix between the reference population and other paediatric icus. since scoring systems should generally be used only in populations similar to the reference population from which the prediction model was developed, a modification of the prism score is necessary to improve its discriminatory ability in a wide range of patient groups, aim to improve the predictive power of the prism score in a south african paediatdc icu population. patients & methods we analysed prism, demographic and clinical data collected prospectively from consecutive paediatrie icu admissions. the prediction of actual mortality by prism was evaluated by standard statistical methodology (goodness-of-fit test and receiver operating characteristic (roc) analysis), the components of the prism logistic regression equation (prism score, operative status and age) and the physiological variables making up the prism score in addition new variables analysed (nutritional index, the need for inotropes and institution of mechanical ventilation) were subjected to discriminant analysis to determine their association with outcome. results the goodness-of-fit test showed a significant failure of prism to accurately predict mortality over a wide range of expected mortality (chi [ ] = , p = ). prism underpredicted mortality at lower prism scores, but overpredicted mortality in patients with high prisms. similarly roc annysis indicated apoor predic~jve power (az = . ± . ), with an area under the curve significantly less than that for the prism reference population (p = ), prism showed equally poor discriminatory function at all age groups and diagnosfic categories. '~mth the addition of an index of nutrifional status (proportional weight-far-age), and indicators of early respiratory and cardiovascular failure to the logistic regression formula, and a recalibration of the acute physiological score component, the roc can be improved to . ± . , with a good fit described by the goodness-of-fit test (cn ] = , p = . ). discussion the prism score is not accurate in our patient population has been recalibrated in view of the poor discriminatory function that we have shown. part of the inaccuracy derives from the different demographic characteristics of our icu population and a different pattern of diseases. in addition to assessments of acute physiological aberrations, an assessment of nutritional status and early respiratory and cardiovascular failure significantly improve the discriminatory ability of the prism score, these parameters have been devised with a view to improving the accuracy of prism in our population, while not decreasing its accuracy in icus similar to the reference population. in interviewing parents regarding how physicians have communicated bad news, the response i have received is that it has not infrequently been done without appropriate care, understanding and compassion. personal experience and the lessons learned from parents, chaplains and others who deal extensively with these situations have provided me with an approach that has been supportive, compassionate, and caring. an especially difficult communication situation for the intensivist occurs when the parents have to be informed of the death of their child. for the parent, death is the hardest loss of all -the ultimate unalterable loss. circumstances surrounding the death are an important consideration (e.g., a fatal crash caused by a drunken driver, a prolonged illness, a suicide, aids). each produces a different grief reaction. the physician needs to inform parents of their child's death sympathetically coming right out with the news and leaving details until later. allow pauses and time for the paren~ to express sorrow and grief, the best communication may be thoughtful silence and a tender touch. there is disbelief that this happened. it is necessary to repeat oneself. acknowledgment of the parent's "feeling terrible" and the physician's acknowledgment of how terrible he/she feels that the life of the child could not be saved is an important first step in the parent's dealing with this tragic loss. with prolonged resuscitation, it is helpful to have a member of the icu team talk to the parents while the resuscitative efforts are ongoing so that the parents are not left unsupported at this time. a progress report should be delivered in a caring, lucid, and sensitive.manner, indicating that every effort is being made to save the life of their desperately injured child. after a child has died, it is helpful to the family if the physician maintains some contact with them. this should take the form of follow-up telephone calls at approximately , , and months. this can help to screen for depression in the parents. in giving bad news to the family and making every effort to support them through this tragic time, it is necessary to remind oneself that the intensivist has personal needs for dealing with grief and will also require support to pass through this stage. direct evidence that child mortality is lower in specialist pediatric icus comes from studies. a study in oregon (ccm ; : - ) found that mortality adjusted for severity of illness was % of expected in pediatric units and % of expected in general units (p< . ). a study in holland (ccm ; : - ) found that mortality in high risk patients was % of expected in tertiary pediatric units, and % of expected in nontertiary units (p< . ). a third unpublished study, has found that children in victoria (who almost all receive intensive care in a pediatric icu) have a much lower standardised mortality rate than children in the trent region of the uk (where many children receive intensive care in adult icus). there is indirect evidence that icus looking after many children are likely, on average, to perform better than icus looking after few children: numerous studies in many specialities have found that units looking after many cases of a particular disease have better results than units with few cases. see luft hs, "hospital volume, physician volume, and patient outcomes", happ, ; and farley d, medical care ; : - . compared to general icus, medical and nursing staff in pediatric icus are likely to be better at looking ~fter children, and plcu rmos have greater skills in pediatric intubation, ventilation, iv drip insertion and drug doses. picus are more likely to have appropriate equipment to manage children -especially for uncommon but life-threatening situations. icus in pediatric hospitals are more likely to have physicians and surgeons with pediatric expertise available for consultation at all times. the american academy of pediatrics, the society of critical care medicine, the british paediatric association and the australian nh&mrc have all said that children should receive intensive care in'specialist pediatric units. the weight of authoritative opinion, and direct and indirect evidence is strongly in favour of looking after children in dedicated pediatric icus. neurological deficit showed higher cbf values ( . / . ml/ g/ rain.) than the patients with good outcome (mean cbf . sd + . ; cbf . sd _+ . ml/ g/rain}. discussion: in asphyxia decrease of ph is due to reduced tissue oxygenation and indicates the severity of metabolic derangements. co reactivity in newborns with perinatal asphyxia correlates with the lowest ph and therefore may reflect severity of asphyxia. continuous monitoring of cerebral activity is carried out in our unit on all admissions at risk of cerebral dysfunction, a number of monitors are commercially available and we report our experience with the cfam which provides in addition to amplitude integrated eeg analysis, continuous raw eeg display and frequency distribution. bilateral recordings are commenced as soon as possible and continued while clinically indicated. forty one children ranging in ages from weeks to years were monitored for periods from hours to i days, diagnoses included traumatic brain injury ( ), sepsis/meningitis/encephalitis ( t), status epilepticus ( ) and miscellanous others ( ). results are tabulated below. patients status epilepticus * beta activity * background voltage * < i o/zv or more of above * (*z p < , ) asymmetry developed in children, all of whom died. positive predictors of good outcome included a mean background activity of > zzv, the presence of faster frequencies (usually ) in response to sedative drugs and the absence of seizures. all monitoring is performed by the picu staff and increasing expertise in interpretation has resulted in earlier therapeutic and diagnostic interventions. regional it was previously found that histamine, a vasoactive mediator, accumulated in brain compartments (kov~ics et al neurosci lett : ) , and antihistamines prevented brain edema formation (dux et al. neuroscience : ) in asphyxiated newborn pigs. in the present study we investigated the effect of intracarotid histamine injection on the blood-brain barrier (bbb) permeability, left internal carotid artery of newborn pigs ( - h; , - , g; ketamine anesthesia, mg x kg ) was catheterized through the external branch and different doses of histamine ( , - , xi - , - , x , m, respectively, in groups of animals; n= in each) diluted in . ml isotonic saline was injected into the vessel through rain. bbb permeability was determined for a small (sodium fluorescein, sf, da) and a large (evans blue/albumin, eba, kda) tracer ( %, mlxkg , rain circulation time for both dyes) concomitantly in frontal, parietal and occipital cortex, hippocampus, and periventrieular white matter both on left and right sides h after the challenge. then, intravascular dyes were removed by perfusion and bbb permeability for both tracers was quantified by fluorescence spectrophotometry (wavelengths for excitation and emission were nm and nm for sf; and nm and nm for eba, respectively). histamine injection, in doses higher than . m, significantly (p< . ; kruskal-wallis one way anova on ranks followed by dunn's test) increased bbb permeability for both tracers in each brain region. changes in left hemisphere were more intense (p< . ) than those in right one after the doses of xi - and - m in each region, i m histamine administration induced similar edema in both sides. increased intracarotid histamine levels resulted in a dose-dependent vasogenic brain edema formation. histamine might have a pathogenetic role in neonatal hypoxicischemic cerebral injuries. supported by otka f- and h-u.s,-jfno. , $ in coma caused by traumatic brain jnjury, an indication of the likely outcome is provided by the best motor response to pain in the first .$ hours after the insult. in a study in our picu, the proportion of children who died or had a severe disability was % in who had no response to pain, % in with an extensor response, % in with a flexor response, and % in who localized in response to pain. the long term outcome of traumatic brain injury appears to be worse in children < years old. other risk factors in traumatic brain injury are absent basal cisterns, midline shift or subdural haemorrhage on ct scan (or loss of grey-white differentiation in nontraumatic injury); or an intracranial pressure > mmhg despite hyperventilation, mannitol and barbiturate infusion. apart from brain death, there are two findings implying such a poor prognosis that consideration should be given to stopping treatment: first, after traumatic injury, the absence of any motor response to painful stimulus in the cranial nerve distribution (providing drug effects and a post-ictal state have been excluded); and second, in acute brain injury from trauma, infection, hypoxia, or ischaemia, the b{lateral absence of short-latency somatosensory evoked potentials (providing brain stem haemorrhage, subdural and extradural effusions, and decompressive craniectomy have been excluded). in children over months of age, recovery from prolonged coma or a vegetative state is exceedingly rare when more than months have elapsed after traumatic brain injury, and when more than months have elapsed after nontraumatic injury. overproduction of nitric oxide (no) via an inducible isoform of" no synthasc (inos) produces profound vasodilatation in adult septic shock. high nitrate levels have been reported in hypotensive children with sepsis syndrome ]. cardiovascular collapse is a prominent feature of severe meningocoecai disease (mcd). however, systemic vascular resistance (svr) was slightly higher in a group of non-survivors ~ and the rote of no in ivicd remains unclear. children with a presumptive diagnosis of mcd were enrolled. parental consent was obtained. blood was drawn on admission and hrly thereafter. plasma was separated immediately and stored at - °c. the final concentrations reported represent the product of nitrite and nitrate (nox). nox was measured spectrophotometrically using the greiss reaction. children were studied (median age (range); m ( - )). the diagnosis of mcd was confirmed in children, of whom had a glasgow meningococcal score (gms) of" ~ . in this group with severe mcd there were deaths. peak nox was significantly higher (,. ( - ) vs ( - )nmol/ml, median) and systolic btood pressure was significantly lower in children with severe mcd than mild mcd (p< . . wilcoxon rank test). there was a significant correlation between peak nox and gms (spearman's rank correlation r= . (p= . )) and prism (r= . (p: . )). nox production from adm.ission onwards was also higher in the severe mcd group (p: . , kmskal ~wallis). we have demonstrated that plasma nox levels are elevated in children with mcd, correlate directly with the severit ' of disease and are inversly related to systolic blood presssure. similar to hypotensive septic syndrome, mcd appears to be associated with an up-regulation of the l-arginine-no pathway.. non-survivors with mcd have higher svrs and may be relatively hypovolaemic. in our group of severe mcd there was a significantly lower systolic pressure and increased no formation. excess inos expression at different stages in mcd may contribute to the pathology of the disease. the identification of agents which can boost and/or inhibit no reiease may therefore represent different treatment strategies for mcd. u. merz, th. peschgens, g. kusenbach, m. b hle, h. h rnchen in this controlled, prospective study ventilated premature infants with a birth weight < g were randomized to receive treatment with dexamethasone (dex) either on day of life or on day of life. dex was given over days tapering from . mg/kg/day to . mg/kg/day. the infants treated with dex on day of life could be weaned earlier from the ventilator -in median after days (range - ) versus days (range - ) in the [ate treatment group (p = . ). the need for supplemental oxygen was shorter in the early treatment group -in median days (range - ) versus days (range - ) (p = . , ns). the incidence of chronic lung disease was lower in the early treatment group - of infants ( . %) versus of patients ( . %) (ns). to evaluate the long-term efficacy of early dex treatment we performed a respiratory function test in the age of - months using an infant whole body-plethysmograph. the intrathoracic gas volume (itgv), the airway resistance (r.w) and the airway conductance (gaw) were measured and no significant differences could be detected between the groups. the frequency of adverse effects due to dex therapy was found to be without significant differences between the early and the late treatment group. we conclude that early dex treatment had short-term improvements in pulmonary outcome in our study population, long-term efficacy however, remained unproven. several factors contribute to the development of chronic lung disease (cld) in premature infants including structural immaturity of the lung, mechanical ventilation, and oxidative stress. reactive oxygen species are formed during normal cellular metabolism but they are generated in higher concentrations during inflammation or inhalation of high oxygen concentrations. to study the relationship between increased oxidative stress, antioxidants and the development of cld we examined ventilated premature infants with birth weights below t g. infants developed severe chronic lung disease of prematurity (cld), defined by radiological signs of cld and an increased oxygen requirement at a postconceptional age of weeks, and infants had moderate cld with an increased oxygen requirement on day but not at an age of weeks. ventilator settings (fio , peak inspiratory and mean airway pressure) and the incidence of early-onset-sepsis were significantly higher in the severe cld group than in infants with moderate cld or without cld (n= ) during the first week of life. plasma concentrations of the two antioxidative substances bilirubin and uric acid (ua) were comparable in all groups during the first days of life. however, on day seven bilirubin and ua were significantly decreased in the plasma of infants with severe and moderate cld compared to the non cld group (p<o. ). there was no difference between both cld groups. in serially obtained tracheal aspirate fluids (taf) malondialdehyde (mda) was measured by hplc as an indicator of lipid peroxidation reflecting oxygen injury of the lung. ua was found in higher concentrations in taf than bilirubin. ua has been proven to be a potent antioxidant, capable to react especially with hydroxyl radicals and hydrochlerous acid, which play an important role in the induction of lipid peroxidation. infants with severe cld had significantly higher mdnua ratios in taf from day to compared to the non-cld group (p<o. ). mdnua ratios in taf of infants with moderate cld were significantly higher from day on but still lower than in the severe cld group. in addition, the ratio oxidized / reduced glutathione was significantly increased in taf of infants with cld compared to infants without cld between day and . the data support the hypothesis that an imbalance of oxidative stress and antioxidant defense contributs to the onset of cld at the end of the first week of life. introduction. rocuronium bromide (roe), a neuromuscular blocking agent with an onset time dose to that of succinyleholine l'z, has been studied in american society of anesthesiologists' physical status (asa) i or ii pedlatrie patients under non-critical elective conditions. there is a paucity of studies looking at the pharmacodynamics of roc under emergent conditions, involving pediatric patients who are asa iii or iv, without the use of adjuvant inhaled anesthetics ~. methods. with approval of our committee on clinical investigations (irb), roe . mg/kg was administered to asa iii/iv pediatric intensive care patients (age days to months; m:f= : ) on intravenous sedation. the time to reach % a~d % of b~elinc tetanie stimulus response was recorded using a r.elaxogra'ph/qmt- nerve stimulator/recorder (datex, helsiaki). depth of clinical relaxation at the % level was recorded. results. the time from rapid bolus to % was . + . see with a range of - see; and to % was . + . see, with a range of - see. at the % level, excellent clinical relaxation was seen. conduslon. in critically ill children, use of roe at . mg/kg produces rapid onset of neuromuscular blockade and excellent clinical relaxation, such that roe should be considered for rapid sequence intubation. int anesth clin. ; ( ): - . anesthesiology. ; ( ) computed tomography of the chest (ct) in mechanically ventilated adults can detect intrathoracic pathology not appreciated on chest radiographs (cxr) and influence intensive care management. no such data exists for ventilated children. aims: ) to assess if ct provides additional information over cxr regarding extent and nature of intrathoracic disease in ventilated children. ) to determine whether such information alters clinical management, inclusion criteria : ventilated children with cxr changes inconsistent with their respiratory status underwent ct if either a) pao :fio ratio < and/or mean paw> cm h or b) there was an unexplained increase in ventilatory requirement. methods : high resolution ct was performed in patients and spiral ct in patierits, to ensure minimal transport related morbidity, patients were transferred to the ct scanner by a specialised mobile intensive care team. results: in / patients ct demonstrated greater extent of disease than appreciated on cxr but did not significantly alter clinical management. in / patients ct provided additional information regarding the nature of disease present, in / children this involved a further diagnosis and in / children the exclusion of a suspected pathology. new information led to a positive therapeutic intervention in children, prevented inappropriate manoeuvres in , and had no significant effect on acute management in children. conclusions: initial data suggests that in a selected group of mechanically ventilated children chest ct can add to the sensitivity and specificity of intrathoracic diagnosis provided by the chest radiograph and directly influence acute management. case selection criteria and choice of the most appropriate protocol requires further study. pressure control ventilation (pcv) utilizes a decelerating flow pattern which may improve gas distribution and lead to alveolar recruitment. in contrast, volume control ventilation (vcv) employs a constant flow. in children, the effects of pcv as compared to vcv are unclear. the purpose of this study was to determine how these two modes compare in terms of dynamic compliance (cdyn). peak iaspiratory pressure (pip), and mean airway pressure (paw) at equivalent minute ventilation. methods: sixteen infants and pediatric patients ranging in age from day to years were studied. diagnoses included ards ( ), postoperative cardiac surgery ( ), head trauma ( ), and resfrictive lung disease ( ). patients were randomized to pcv ( ) or vcv ( ). initial measurements of gas exchange (abg's) and respiratory mechanics (ventrak, novametrix medical systems) were obtained after a minute stabilizadon period. respiratory mechanics included pip, peep, paw, delivered tidal volume, and cdyn (avolume/apressure). the patients were then crossed over to the alternate mode of ventilation holding delivered tidal volume, peep, inspiratory time, minute ventilation, and fio constant. data were collected after minutes, in each mode the absence of intrinsic peep was confirmed. to assure that the measurements were not affected by changes in clinical status, the patients were returned to the initial mode of ventilation and measurements repeated (final) . patients were ventilated with a siemens c or sv . reselts: data were analyzed using -way analysis of variance with repeated measures. ~ < . vs. vcv) vcv pcv ~ initial ] final ! cdljn . _+ . . _+ . * . _+ . . _+ . i , pip + . l-_t. * _+ , +- , paw . _+ . . i-_ . * . + . . -!-_ . pao _+ +- _+ _+ discussion: at the same minute ventilation, the decelerating flow pattern of pcv resulted in a % increase in cdyn and an % increase in paw while decreasing pip by %. the lack of a significant change in oxygenation may be a result of the limited time in each ventilator mode as well as the inclusion of patients with both normal and abnormal lungs. there was no significant difference in initial and final measurements indicating patient stability. the beneficial effects of iecre~l~iug cdyn and paw while decreasing pip indicate that pcv may be a preferable mode of ventilation in patients with lung injury. further randomized studies examining the effect of pcv on respiratory outcome measures in pediatrics are indicated. prolonged positive pressure ventilation following repair of cdh is associated with a high prevalence of iatrogenic lung injury, in our unit dudng - late deaths after repair of cdh were due to chronic lung disease. since babies requiring assisted ventilation for more than days following surgery were transferred to a cnep chamber to limit lung injury. cnep of - cm of h was combined with positive pressure ventilation via an endotracheal tube dudng the transition phase. immediate reduction of peak inspiratory and positive end pressures were possible and following extubation respiratory support was maintained by cnep v~th appropriate inspired oxygen. overall outcome: [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] n= deaths before surgery (%) ( ecmo during - / who were ventilated for more than days received cnep and there were no deaths and no chronic lung disease in that group. cnep assisted ventilation may be an important management option for babies who require prolonged respiratory support to avoid the adverse effects of chronic positive pressure ventilation, introduction so far modes of liquid ventilation (lv) have been used in experimental animals and, exceptionally, in humans: . total liquid ventilation (tlv)-functional residual capacity (frc) is filled by perfluorocarbons (pfc), and slow tidal volume (tv) breathing is performed by pfc. . partial liquid ve, ti,la~ion (page) -only frc is filled by pfc. gas tv is delivered by conventional mechanical ventilation (cmv), high frequency jet ventilation (hfjv) or high frequency oscillation (hfo). the aim of our study is to present our limited experience with page in newborns and infants. page was used in two groups of infants: , in infants with brain death before disconnection from cmv, because recipients for organ transplantation were not available. these infants have relatively normal lungs (fio~ less than . ). infants stayed on page for hour, during that period no ventdator manipulations were made. after page, infant were switched to cmv for next hours. . very critically diseased infants with ards (rds) - on ecmo more than days, before cannulation for ecmo, on hfo because of intractable respiratory failure, preoxygenated rm (miteni, italy) was used in the doses up to ml/kg intratrachealy. blood gases and parameters of pulmonary mechanics were followed (dynamic compliance -c dyn, airway resistance -raw, bicore monitor). page was combined with no inhalation ( - p.p.m, in infants). in both groups ad hoc an approvement from e local ethical commission and informed parental consent were obtained. in the first qroud with relatively normal lung parameters of oxygenation drops after pfc instilation intratracheally and stayed depressed for - hours. slight pco retention occured in both cases during page. c dyn increased almost double during page period, raw drops transitorily after pfc instilation but in minutes they were identical like in prepage period, parameters of oxygenation (peo /fio ) after - hours after page improved and were better than in prepage period. after that time infants were disconnected and died. in the second group no improvement of oxygenation was seen in one ecmo baby, in spite ()f transient improvement of c dyn. in the second ecmo baby, oxygenation improved and flow of pump could be decreased by more than %. none of these babies, however, survived, improvement was only transient in spite of repeated dosis of pfc. in these babies serious problems were to maintain the adequate frc by liquid, because of severe air leak, in babies on hfo/hfjv with severe ards/rds the improvement of oxygenation were seen in all the cases immediately after pfc instiletion for the period of - hours. after that period, pfc dose had to be repeated. two babies of this group survived. conclusion. page is going steadily from tabs to clinical practice. it is simple, could be performed anywhere, cheaper than tlv. however, because liquivent -perflubren (aliance pharmaceutical) is not available in europe, rm of (mitenti, italy) is the only solution, which could be currently used here. before the widespread use of page in clinics, liquid network among most nicus and picus must be built up, the criteria for page must be defined and ethinal-legal problems resolved as well. after resolution of these particular problems page can be life saving procedure for very special part of critically ill newborns end infants. catherine caronia, peter silver, laura nimkoff, cad quinn, jack gorvoy, and mayer san. division of pediartic critical care, medici,, schneider children's hospital, new hyde park, ny , imroduetiun: cystic fibrosis (cf) patients awaiting lung transplantation present a therapeutic dilenuna when severe respir, aory decompemalion occurs, endotracheal intubation and mechanical ventilation is known to have no long term benefits and is associated with high morbidity and mortality. noninvasive respiratory support appears to be a beneficial alternative. methods: we instituted bipap (respironics, inc,, murrayville, pa) in end-stage cf patients who were admitted to the pediatric icu with severe respiratory decompeusation. all patients were awaiting tung transplantation. after a control period, bipap was applied via a tight fitting nasal or facial mask, using the spo~aneous breathing mode, expiratory pressures were set at - cm hhzo. inspiratory pressures were started at cm ~i o and increased in cm i-i increments until the patient's respiratory comfort was achieved and substantiated by non-invasive monitoring. patients were instructed to use bipap during night sleep and whenever subjectively required, data are reported as mean _+ s.d. results: all patiems utilized nocturnal bipap for - hours/day during a follow-up period of - months. compared to their pre-bipap status, the patiems' oxygen requirement and respiratory rate both oz~ cundusion: bipap tl~rapy improves the respiratory status of decompeusatir!g end-stage cf paacnts. it is well tolerated for long term use at home, and provides an extended period of respiratory comfort and stability for cf patients awaiting lung transplantation. l. bindl*, g. kiihl**, p. lasch***, appel**, j.m er**** and the "arbeitsgemeinschaft ards im kindesalter" background acute respiratory distress syndrome (ards) is a therapeutic challenge in pediatric intensive care in view of the high mortality, in about german paediatlic hospitals founded a working group aiming on collaborative clinical research in this field. aims and methods the aim of both a prospective and retrospective survey conducted in german pediatric intensive care units in was to accumulate data on the epidemiology, risk factors, natural history and treatment strategies in a large group of pediatric ards patients who were treated in the tt~ee year period from to .all patients had acute bilateral alveolar infiltration of noncardiogenic origin and a po ~io ratio < mmhg. the influence of sex, underlying disease and single organ failure was analyzed using the fischer's exact test, the influence of additional organ failure on mortality was tested with the cochran-mantel-haenszet statistics. results patients were reported giving an incidence of cases per admissions to pediatric icus. median age was month. in % of the cases, ards was associated with a pulmonary, in % with a systemic underlying disease. in % immunocompetence was impaired. mortality was % and not dependent on age, sex and triggering event. the number of associated organ failures, however, strongly influenced mortalib,. mortafity in immuno-compromised patients was t %. the analysis of treatment modalifies employed in the patients revealed a lack of uniform therapeutic strategies. on the other hand, the patients were exposed to interventions not yet supported by controlled trials. conclusions the observation of the lack of uniform treatment strategies led to the elaboration of recommendations on ventilator therapy and patient monitoring within the working group. the data gathered in this survey provide the basis for the design of prospective multicenter studies urgently needed to evaluate innovative treatment modafities in pediatric ards. recurrent apnea and respiratory failnre due to severe lower respiratory tract disorders such as bronchiolitis or pneumonia are the most common reasons for mechanical ventilation during respiratory syncytial virus (rsv) infection. acute respiratory distress syndrome (ards) has been described as a complication of severe rsv infectionj in contrast to the low mortality rates associated with rsv infection (< %), mortality rates in the range of - % have been reported in pediatric patients with ards. however, studies on ards are usually lumped in respect to causation and the disease course of rsv induced ards has not been previously studied. we examined the lung function abnormalities of infants with rsv induced respiratory failure requiring assisted ventilation, measurements included respiratory mechanics, maximal expiratory flow-volume curves and lung volumes, ards was defined clinically using the criteria which were recently proposed by the american-european consensus conference on ards~: acute disease onset, pao /fio~ ratio _< mrn hg, bilateral infiltrates on chest radiograph and absence of clinical evidence of left atrial hypertension. we calculated the murray lung injury scores modified for use in pediatric patients from total respiratory system compliance, radiographic findings, ventilator settings and blood gas results. we identified infants with severe restrictive lung disease that fialfilled the clinical criteria fbr classification as ards. all had lung injury scores above . which is the recommended cut-off for a diagnosis of ards, twenty-seven infants had obstructive disease consistent with a clinical diagnosis of bronchiolitis. the ards patients were significantly younger, had a longer time of assisted ventilation (p < . ) and a greater proportion of infants with preexisting illnesses (p= . , odds ratio = . ) when compared to the patients with obstructive disease. with the exception of one immunodeficient patient, none of these infants died. given the low mortality despite a clinical picture of severe lung injury, there is evidence that rsv induced respiratory failure may represent a relatively benign cause of ards in pediatric patients, bachmann an audit of patients with severe acute bypoxic respiratory failure (ahrf) receiving highfrequency oscillatory ventilation (hfov) in our unit ( n= , mortality %) revealed that sub-groups with severe underlying disease (n= , mortality %)and those with mu~pie organ failure ( > systems failing, n= mortality %) accounted for all the deaths beyond the neonatal period. v~ therefore hypothesized that in a modem paedistric intensive care unit (picu): a) children greater than one month of age with ahrf do not die in the absence of severe, pre-existing disease or multi-organ dysfunction syndrome, b) respiratory parameters alone will predict outcome poorly in ahrf. method prospect~/e sty/of all adm~ns to our tertiary picu. data it, citing the respiratory parameters (oxygena~n index [ol] , aiveolar-artedal oxygen tension gradient , pao /fio ratio) were collected hourly from the bedside charts throughout admission. patients were included in the study if ahrf was present at admission either none or in combination with other organ dysfun~on. ahrf was defined as the acute (< hour) onset of respiratory dysfunctk:~l with a pao /fio ratio.< for six consecutive hours dunng the first hours of admission (with no evidence of left anal hypertension), x-ray review defined a sub-group of patients with acute respiratory distress syndrome (ards) by the presence of bilateral interstitial infiltrates. results to date children (ages - months, weight . - kg) have been admitted in ahrf. of these also had ards. the overall mortality was . % ( / ), and greater in the ards group than the non-ards group ( t , . % vs, , . %, p< o. ) . it was not possible to predict survivors from non-survivors on the basis of the seventy of the respiratory failure alone, the a-ado on the day of admission (best in hours) was not significantly different between survivors and non-survivors: (mean, + sd)( mmhg +_ , vs mmhg _+_ ). kdl non-survivors were immunodeficient (n= ), previously extmrnsly premature infants (< ),(n= ) or suffedng fcom chronic metabolic or gastrointestinal disease (n= ). no previously normal child died. conclusion the severity of respiratory failure does not allow predioljon of outcome in our patients. we believe that this reflects that modem picu is so effective at providing respiratory support that pre-existing pathology alone de~ prognosis. this suggests that an abnormally regulated host response or abnormal persistence of a pathogen may be required to induce lung injury of sufficient severity that the resulting respiratory failure cannot be supported in a modem picu. introduction: postural changes (supine to prone) is a therapeutic intervention that could be useful in children with adult respiratory distress syndrome. objective: to determine the effects of postural changes in the oxygenation of young children with ards. method,s: a prospective stud ," was performed in eleven subjects aged to months (mean= ) with the diagnosis of ardsreceiving vendlatory support. (mean peep and fio of and . respectively). postural changes was performed every - hours, during a period of time ranging from to days. arterial blood gases were determined before and - n~n after the postural change, no modification in the mechattical ventilation other that changes in the fio were performed. the oxygenation was determined by the index pao /fi (p/f). to study the differences between the oxygenation mean, before and after the postural changes the wilcoxon test for paired samples was used, results: changes were performed ( from supine to prone and from prone to supine). a % increased p/f ratio was obtained after the change from supine to prune. although, not all the patients receiving postural changes improved their p/f. six of them (group i) showed an improve in the p/f when changed from supine to prone, returning to their base line when positioned from prone to supine. no improvement on the p/f was observed in the remaining subjects (group ii)after postural changes (table ) . during the maneuver no complications were observed. two patients had a pneumothorax, not related with the postural change. conclusions: postural changes (supine to prone) is an easy way to improve oxygenation in some children with ards. change to prone change to supine introduction: the common noninvasive diagnostic efforts to identify possible obstruction of the intrathorucic airway, are of limited value. invasive procedures such as bronchoscopy and bronchography may also be noncontributory and entail risks. we evaluated the usefulness of d-ct in the diagnosis and management of pediatric patients with suspected intrathoracic airway obstruction (itao). methods: we used a diagnostic algorithm (see diagram) in patients with suspected itao resulting in respiratory distress. three-dimensioual imaging of the tracheobronchial tree was reconstructed, following high speed spiral ct scan, by specific computer software (advantage window computer work station, general electric, milwaukee, wisconsin). non-ionic contrast medium was injected, in some patients, to delineate the intrathoracie large vessels.. results: eight patients were studied. in patients the d-ct revealed intrathoracic airway abnormalities. these patients underwent further invesive studies which confirmed the following diagnoses: patients had bronchomalacia, had bronchial stennsis due to a dilated pulmonary artery mad patients had subglottie stenosis extending to the thoracic cavity. three patients had no significant disruption in the configuration of the tracheobronchial tree and thus did not require invasive diagnostic procedures. conclusion: computer reconstruction of three dimensional images of the tracheobronehial tree is a safe and reliable diagnostic tool for itao. ards and ecmo; preliminary data from a randomized clinical trial. j fackler, c steinhart, d nichols, d bohn, m heulitt, t green, l martin, k newth, m klein, j ware. many suggest ecmo be considered experimental for ards and undertaken only with careful data collection and reporting. a mtflticenter pediatric rct is in progress to determine whether ) ecmo and/or ) permissive hypercapnia, offer significant advantage for the treatment of ards. methods: all patients aged wk to yr (without congenital heart disease) are eligible for study. data collection begins when a patient receives at least % oxygen and a peep of cm h for hours (stage t). if the predicted mortality reaches % within days (stage ), eligible patients are asked for written consent for randomization. patients are excluded from randomization with significant chronic lung disease, immune compromise, cardiac disease; or profound acute central nervous system damage. the prime outcome variable is survival. at the studies onset, pts were estimated to be required so that pts were randomized per arm. results: patients are enrolled from centers. data are complete on . patients never reached stage (i.e. % mortality). patients improved and died. of the latter, had randomization exclusion criteria even if stage was reached. patients reached stage . had exclusions from randomization and all died. eight patients ( survivors were eligible for randomization; consent was obtained in no case. two patients received ecmo. overall survival is % ( / ). in patients without randomization exclusions, survival is % ( / ). morbidity m survivors (discharge -admission popc or pcpc score >_ ) was seen in none of the stage surviviors and % ( / ) of those who reached only stage !. conclusion: the rct requires completion. the records of hospital in-patients at king faisal specialist hospital and research center who received external cardiac massage as part of their cardiopulmonary resuscitation were reviewed. success of resuscitation was analyzed as ( ) short term (restoration of spontaneous circulation), and ( ) long term (discharge from hospital). of such patients, ( . %) survived the initial resuscitation, and ( . %) were discharged. success of outcome was not related to age, location of patient, time of day, or rhythm at arrest, including asystole. longer resuscitation time was associated with less chance of restoration of spontaneous circulation (p< . ), but not associated with hospital discharge rate. results for patients with congenital heart disease were similar to those with other medical or surgical conditions. in this series, . % of ward in-patients survived to discharge, compared to two "*;'~r ~r;~' ,.,.'her,, the r-e~ult~ were c/ "'~d ~, ~,°(. overall, % of patients who survived the initial resuscitation were discharged from hospital. where resuscitation continued for more than minutes, . % of patients had tong term survival. outcome from asystole was no worse than for other cardiac rhythms, we believe that previous reports of poor outcome from asystole in pediatric cardiac arrest should noi influence decisions to stop resuscitation for pediatric in-patients prematurely. successful restoration of spontaneous circulation with long term survival can be achieved after prolonged resuscitation. abdelmoniem~ lindsey jahusou~,mariano fiallos, university of florida, prudential drive, suite jacksonville, florida usa central acidosis is well recognized as a marker of inadequate tissue perfusiou, and ventilation. however, obtaining central venous blcod is difficult and fraught with complications in the child undergoing cardiopuimonary resuscitation. intraosseous blood may be used instead of central venous blood to judge ph and pcoz during short durations of cardiopulmonary resuscitation and during hemorrhagic shock. the purpose of this study is to compare the ph and pcoz status of intraosseous and central venous during prolonged cardiopulmonary resuscitation after fluid and drug infusion. we hypotbesized that there would be no difference in ph and pco values of simultanecusly obtained intraosseous and central venous blood samples. eighteen ( ) introduction: cardiopulmonary arrest (cpa) in children is usually preceded by a deterioration of cardiac or respiratory function due to sepsis, dehydration and hypovolemia. early recognition of clinical and laboratory signs followed by immediate intervention are essential for prevention of cpa. the purpose of the present study was to identify factors which contributed to high rates of mortality from cpa in patients admitted to a paediatric intensive care unit (p cu). methods: a prospective study was done of all non-surgical patients with cpa who were admitted to the picu, hospital baca ortiz, quito ecuador from january to october . clinical and laboratory variables before and after admission to the picu, time from hospital admission to picu admission and the pediatric risk of mortality score (prism) were recorded on a questionnaire designed specifically for this study. results: of the non-surgical patients admitted to the picu, ( %) were admitted after developing cpa on the general pediatric wards. mean age was + . months, with of patients under months of age. initial diagnoses upon picu admission included meningitis (n= ), respiratory failure (n= ), congenital heart disease (n= ), severe neurological impairment (n= ), end stage neoplastic disease (n= ), hypovolaemic shock (n=l), peritonitis (n=l) and sepsis (n=l). mean time from hospital admission to p cu admission was _+ . hours. the mean prism score upon hospital admission was + . (score > = > % mortality). % ( / ) of the patients died. one of the three survivors had severe neurologie injury. prior to picu admission, patients experienced tac~,cardia (n= ), hypotension (n= ), neurological deterioration (n= ), respiratory, distress (n= ), oliguria (n= ), bradycardia (n= ), metabolic acidosis (n= ), hyponatremia (n= ), hypokalemia (n= ), hypocalcemia (n= ) and severe hypoglycemia (n= ). there were serious delays from the time of development of clinical and laboratory abnormalities to the time of admission to picu. conclusion: in the critically ill pediatric patient, rapid recognition of clinical and laboratory signs of deterioration, followed by immediate intervention, are required to prevent end stage shock and cpa. we found serious delays in intervention following development of important premonitory clinical and laboratory abnormalities in patients less than months of age on the general pediatric wards, which iikely contributed to the dismal % mortality rate. hospitals throughout ecuador should institute immediate improvements in ctinical supervision, and provide training in paediatric advanced life support (pals) to decrease excessively high rates of and mortality from cpa. intraosscous access is recommended by the american heart association and american academy of pediatries as a means of rapid access to the vascular system for childhood emergencies. bone marrow and fat embolism is a concern and has been reported post intraosseous infusion in stable animals but has never been studied in animals subjected to cardiopuimonary resuscitation. we undertook this study to investigate the incidence and magnitude of lat and bone marrow embolism with the use of intraosseous infusion during prolonged cardiopuhaonary resuscitation and after fluid and drug infusion. we hypothesized that there will be no difference in the magnitude of fat embolism between cardiopulmonary resuscitation only and other cxperirnental conditions. thirty-one ( ) piglets were anesthetized, mechanically ventilated, and instrumented (carotid artery, pulmonary artery and intraosseous earmulas ). the animals then underwent bypoxic cardiac arrest followed by chest compressions with the mechanical thumper (michigan insmunents) and mechanical ventilation for a minimum of minutes. the animals were divided in groups: a (n= ) which had no intraosseous, ~'oup b (n= ) had intraosscous with no infi~ion, and groups c (n= ), d (n= ), e (n= ) had intraosseous with infusion of adrenaline, normal saline and sodium bicarbonate, at cessation ofcardiopulmonary resuscitation, representative lung samples were collected fi'om upper and lower lobes of each lung, embedded in ocp and firozen immediately. ltmg specimens were stained using oil red-o dye and observed for fat globules and bone marrow elements. the amount of emboli present was rated as a percentage in relationship to iung tissue, by a pathologist blinded to the experimental groups. buffy coat specimens were collected before and at cessation of cardiopuimonary resuscitation, stained with oil red-o dye and observed for fat globules. percentage of fat present were compared using analysis of variance. fat globules were seen in the prebronchial blood vessels and in intravascular areas throughout all lung fields. there was no difference in appearance or distribution of fat globules between groups. quantity varied in the different groups[(a) %, (b) %, (c) % (d) %, (e) %], but were not statistically significant (p = . ). fat globules in the buffy coat were few and inconsistent with lung findings. fat and bone marrow emboli were present in all experimental conditions, the use of the intraosseous cannula does not increase the magnitude of embolization during cardiopuimonary resuscitation. the decision to use the intraosscous route should not be influenced by the risk of embolization. tzareva iv/,, md*, nedialkova r, md**, *dept. of pathophysiol, *~dept. of child surg. and icu, emergency medical institute pirogov, sofia, among children with blunt abdominal trauma, treated in emi pirogov during the last five years, children had serious disturbances of the basic vital functions, connected with the trauma, and most often with massive haemorrhage, for this reason being an object of reanimation and intensive care. in the group of children who survived - , predominated the trauma of only one abdominal organ (mainly the spleen, rarely the kidneys, the intestine) and only children had injuries of more than one abdominal organ. in the same group, in children the abdominal trauma was combined with chest or head trauma or bone fractures. in the group of children who died - , a profound combined trauma was present. the haemodynamic parameters in all children showed a characteristically significant tachycardia along with normal or even high blood pressure, while hypotonia was present in only % of the children on the first trauma day. despite the fact that only . % of the children had direct chest injury as well, the gas exchange was considerably disturbed - ' of the children were hypoxemic during the first, and % during the third trauma day -in % significant -below . kpa ( mmhg). together with the markable decrease in haemoglobin levels, this determines the pronounced disturbance in oxygen transport. during the first trauma day all the children were acldo~c, and a metabolic alkalosis was present during the following days. twelve of the children with severe combined trauma died within several hours, with the symptoms of irreversible haemorrhagic shock, or in the next - days, developing multiple organ failure. in conclusion, the intensive therapy of children with severe abdominal and combined trauma, should take in consideration the special haemodynamical trauma answer in children, and requires dynamic monitoring of the most influenced homeostatic parameters -blood gases, acid-base metabolism, haemostasis. introduction: endocrine emergencies, other than diabetic ketoacidosis, are uncommon causes of pediatric intensive care unit (picu) admissions. we report our experience of children diagnosed of adrenal insuficiency (ai) admitted in the picu, during the last four years. subjects: five eases of ai requiring intensive care unit admissions are presented. four females anna male, with ages ranging from days to years, none of them had a previous systemic or endocrine diseases that could suggest al the initial clinical manifestations were: dehydration ( ), vomits ( ), abdominal pain ( ), seizures ( ), lethargy ( ) and hyperpigmentation in the muco-genitat area in a newborn male and ambigna genitalia in a newborn female. the reason for their admission in the p cu were: shock in two subjects; three because of hyperkalemia and hyponatremia (k/na: . / ; / ; , / meq/l); and two with severe hyponatremia (na: ; meq/l). laboratory findings: severe hyponatremia ( ), increased concentration of urinary sodium and chloride ( ); metabolic acidosis ( ); hyperkalemia ( ); increased levels of urea ( ) and hypoglycemia ( ). in all of them, the electrolytes abnormalities did not normalize with replacement and only normalized after the administration of hydrocortisone. tile ai was due to: autoimmtme disease in two subjects, congenital adrenal hypoplasia, congenital adrenal hyperplasia secondary to alia hydroxylase deficiency and in one no etiology was found, at the present time, comments: aiis an uncommon disease in the pediatric age. anearly diagnosis is crucial, as if the treatment is delayed could lead to patients death. in subjects with arterial hypotension and electrolytes abnormalities refractory to the usual treatment, they should be treated with corticosteroids, if no etiology is found. although, previously samples must be obtained to make the diagnosis, : denotes the number of cases. gerbaka b; hakme c; akatcherian c. toxics are frequently involved in domestic accidents during childhood; among non medical products ingestion, carbohydrate poisoning is a serious injury often made possible by inadequate stocking. over years, children aged years and less were examined in the emergency department of hotel-dieu de france hospital for carbohydrate ingestion. , % are boys; age goes from months to years (moan = , years). kerosene is found in , % of cases; all were admitted (mean = , days). , % were symptomatic on first examination but % of all children presented signs of gastric ( %) or respiratory ( , %) irritation sometime during their history; , % had neurological signs and , % presented some fever. leucocytosis is found in % of cases; , % of the children received antibiotics. chest x ray was abnormal in , % of cases: mainly parahilar infiltrates were found, all children survived; , % with a normal course ( , days of hospital stay) whereas those who presented complications (severe pneumonia, coma) stayed in the hospital for days (mean) with short course of assisted ventilation for two of them; long term follow up was not possible. we fonnd nick's criteria for hospital admission to be of value: -symptomatic children with normal x ray } to hours monitoring -asymptomatie children with x ray abnormality } -symptomatic children with x ray abnormality: hospital admission -asymptomatic children with normal x ray : no admission. these criteria would have helped to avoid admission in children and would have allowed a short t hours stay for more. we found chest x ray to be mandatory in carbohydrate ingestion; other tests were not helpful, aside arterial blood gases measurement in case of respiratory involvement; we now also advocate more restriction in antibiotic use. prevention remains efficient and should be stressed on. severe liver failure [slf] is a rare but severe condition in infants. we report our experience. patients: slf was defined as liver insufficiency with hepatic encephalopathy and a decrease in the level of factor v to below %. between and , infants (mean : mo) were admitted for slf (neonates excluded). main causes were metabolic disorders ( . %) (tyrosinemian= , hemochromatosis n= , reye's syndrome n= , other n= ), virus-induced flf ( . %) and hematologic diseases ( . %). in cases, the causes remained undetermined. results: olt was contraindicated in cases because of multiple organ failure (n= ), or underlying disease. all of them died within days after admission. patients had no indications for olt, all but one are alive. ( of them was transplanted later for tyrosinemia and died lately (virus induced-slf). among the t infants who underwent emergency olt, are alive and died because of primary non function of the graft. conclusion: slf in infants admitted before their first birthday is a severe condition with an overall mortality rate reaching %. inherited metabolic disorders are the first cause of slf at this age. contraindications for olt are frequent because of underlying disease or multiple organ failure. a number of children undergo primary graft failure after liver transplantation. it is unknown if there is any increased morbidity or mortality following retransplantation. this study seeks to explore these issues. methods: a pediatric intensive care/iiver transplant database is in formation. records of all liver transplant patients are reviewed and abstracted. this data is then computerized to allow analysis. this data provides the source for this study. statistical analysis was performed via student's t-test where appropriate. results: of the patients who have thus far received at our center orthotopic liver ransplants, the records of who underwent transplants form the basis for this review. twenty-three patients underwent multiple transplants, required one additional, three required organs, and one patient survived after a fourth organ transplant, there was no significant difference in age at first transplant between those who received multiple organs and those who did not ( vs, months, p=ns). the anesthesia time for the procedure did not significantly increase tbr subsequent transplants ( . vs, , hours), nor did time in the intensive care unit (t . vs. . days), nor did time on the ventilator ( . vs. . days) subsequent transplants did not predispose to having more bleeding in the intensive care unit for usage of packed red blood cells or platalets was not significantly altered ( vs ml and vs ml respectively). patients who required retransplantatior~ did receive mere fresh frozen plasma (ffp)daring their first transplant than in the subsequent ones ( vs ec, p < . ). however ffp use was not significantly different than patients who did not require retransplant. patients who underwent retransplant had a markedly increased mortality ( %) than the overall mortality for liver transplants at our center ( %), conclusion: children who require another liver transplant have a markedly increased mortality. bleeding and prolonged icu stay is not significantly different between the first and subsequent transplants, fulminant hepatic failure and ortothopic liver transplantation.dr.sasb n,j;centeno,m;entin,e;acarenza,m;ciocca, m:gofii,j;bianco,g;weller, g;imventarza,o. unidad de cuidados intensivos.hospital de pediatria "dr.j.p. garrahan" .buenos aires.argentina. introduction:fulminant hepatic failure (fhf) is a clinical syndrome, defined by the development of hepatic encefalopathy within weeks from onset of illness in a previously healthy person.by far,the most comun cause of pediatric fhf in all series, is acute viral hepatitis.we report our experiences with the pediatric fhf and ortothopic liver transplantation (olt) as attemative of treatment. patients: childrens with fhf diagnosis were admitted at the picu from / / to / / .symptomatic treatment was given to all children and all were put on list for olt,) following the king's college criterion (protrombina time,age,atiologies,bilirrubin,and encefalopathy state). results:etiologic causes corresponded to the childrens were: , hav ( %); , noa nob ( %); ,autoinmune ( %).the age was mean: years (range: month- years).seventeen patients were transplanted, chidmn were discarded because:no donors: ;withdrow of the list: ,because sepsis in and bleeding of cns ;and no admission at list: because genetic syndrome ,massive intestinal necrosis, ,mitral valvulopathy and sepsis, . patients ( %) had at least one complication dudng the post operative period.the most frequent was the acute renal insufficiency(ari) and patients requiered continuos hemofiltration.the gtobal mortality rate was %.the mortality of patients without olt was % and the mortality of patients with olt was %, patients dayed because sepsis, ( candidiasis) and the others because mof.the actuarial survival at year is % and the follow up of months. conclusions:the fhf is a very severe and frequent disease at picu. supportive treatment only is associated with a very poor prognosis and high mortality rate.the most frequent etiology in our country is the hav. the olt is applicable in this cases and is a valid alternative of treatment (mortality in our series %).the ari is the most frequent complication during the post opeative period.in argentina,due the high prevalence of hav,prevention must be considered the main and only way to avoid this catastrophic illness.- to assess the efficacy of gastric intramucosal ph (phi) for evaluation of tissular perfusion and prediction of hemodynamic complications m critically ill children. patients and methods: thirty critically ill children ( boys and girls) whose age ranged from month and years old were studied. a tonometry catheter was placed in the stomach of all patients at their °admission in pediatric icu. intramucosal ph measures were made at the admission and each - hours during the study: a total of determinations were made. the catheter was removed after extubation and/or checking of hemodyrmmic stability of the patient. the intramucosal ph was derived from application of the henderson-hasselbaeh formula using the pco value from the tonometer and the arterial bicarbonate. values of phi between . and . were considered normal. the relationship between phi and severity of patient measured through prism, presence of major (cardiorespiratory arrest, shock) and minor (hypotension, hypovolemia or arrhytlmtias) hemodynamic complications, mortality and stay in the picu, was analysed. results: the admission value of phi was . -t- . (range . - . ). five patients ( %) had an admission phi < . . no relationship was found between an admission phi < . and a higher incidence of hemodynamic complications. sixteen patients ( %) showed some values of phi < during their evolution. patients with phi < . had a higher number of hemodynanuc complications than the rest (p< . ). every cardiorespiratory arrest (cra) and shock cases were related to a phi < . . patients with major complications (cra and shock) had a phi lower (p= . ), as well as a higher number of measurements of low phi (p= . ) than patients with minor hemodynamie complications. the value of phi lower than presented a % of sensibility and % of specificity with regard to hemodymanic complications. there was no relationship between phi < . and prims score and stay in picu. patients with phi < . presented a prims higher than the rest of patients (p< . ). conclusions: the phi value may be an early sign of presence of hem dyaaimc complications in the critically ill child. we tested the hypothesis that gastric intramural ph (phi) can be used as an early sign of failure m weaning pediatric patients because the blood flow from nonvital areas is diverted to meet the increased demands of respiratory muscles. methods: children (mean age ( . _+ . ) years + sd) who were thought by their physicians to be weanable from mechanical ventilation (mv.). these patients were ventilated on serve c ventilators, receiving ranitidine, and had intestinal tonometer (tonometrics, inc.) minutes before obtaining a sample.. all children were placed on pressure support (ps) at levels judged to overcome the resistance of the endotracheal tube and ventilatory circuit ( em h.,o). a sample of arterial blood and a sample oftonometer were obtained during vm and weaning (ps). phi, hemodynamic and respiratory data were recorded during vm and weaning we did not interfere with the primary caretaker's decisions regarding extubation. patients were considered to be successfully weaned if they were able to sustain spontaneous ventilation for more than hours after extubation. paired t-test were used to compare the values obtained during mechanical ventilation with those obtained during weaning trials. unpaired ttest were used to compare values from the group that was successfully weaned (a=i ) with those from the group that were not (b= ). results: we did not find statistical differences in any of those variables mesured during mv for patients who were successfully weaned(group a) and those who were not (group b). gastric phi was in group a: . + . (vm) and + . (weaning); in group b: . _+ . (vm) and . t _+ . (weaning). discussion: although we did not find differences in gastric phi during vm, the group a had a lower value than group b because of the number of cardiac patients ( %) and transfusion therapy, in fins group. in group b % of patients showed a problem in upper airway (subglottic edema, and enlarged tonsils). we found it after extubation. conclusion: ) gastric phi is a good predictor of risk in critically ill patients but maybe because of the small size of the sample, in our study is not of practical value as a predictor of failure in weaning pediatric patients from vm. ) this test is not a predictor of problems in upper airway~ important etiology of failure weaning in children. objectives: i-to determine the prognostic value of the gastric intramueesal phi in mortality and multiple organ dysfunction (sdmo) in critically ill children. -to compare this value, with the pediatrics risk index mortality score (prims). methods: aprospective study was performed with critically illcbildren, aged from mouth to years. the athnittiug diagnosis was: post-surgery ( neurosurgery, spinal fusion and thoracic or abdominal surgery), sepsis, polytraumatism, adult respiratory distress syndrome and with miscellaneous. all the subjects were monitorized on picu admission and treated for their underlying condition. gastric intramucnsal pt{ was measured following the tonometric method, ou admission and every - hours depending on the patients state. the severity of the clinical condition was evaluated using the the prims, on admission (prims-i) and during the first hours, when the clinical condition deteriorate, the worse score was utilized for the statistical analysis (prims- ). to perform the statistical analysis the subjects were divided in two groups, one with the phi< . and the other with phi> . .aunivariate analysis (student's tand wilcoxon two tailed test, chi-square) and multivariate analysis were used. results: out of the subjects dyed. of children developing multiorgan failure (mof) expired. % of the patients admitted to the picu with sepsis, ards and miscellaneous had a phi < . . in contrast, with % of post-surgical and none of the postqraan~atism. the mortaliry rate, in children with a phi< . was % (ci %: . ; , ) and . % (ci %: , ; . ) in children with phi> . (p= . ). mofwas observed in , % of children withphi< . v.s, . % with phi > . .no relatiouship was observed between the phi and the score of prims-i and . perforating an unconditional logistic regression analysis, two independent variables have mortality predictive value: the phi and the prism- . (table i) following induction of anaesthesia, a laser doppler probe (moorsoft instruments ltd) was inserted cm into the patient's rectum, the probe's special design ensuring that the optical prism lay against the mucosa. continuous monitoring of rectal mucosal perfusion ("flux") was continued throughout the operation. after rain cpb at °c, "steady state" readings of nasopharyngeal temperature, mean femoral arterial pressure (map) and flux were recorded over a further min before cpbinduced core cooling to - °c. steady state was defined as a rain period with no change in core temperatures or map. other rain steady state recordings were taken immediately prior to low flow, immediately prior to rewarming and after rewarming to °c, before initiation of any vasoactive drugs. the cpb flow rate was kept at m l k g - min q, the pcv at _+ %, the p~co at . + . kpa and the pro at + kpa. results: initial warm and rewarm map (both mmhg) were significantly lower ( = . ) than during the cold cpb periods ( & mmhg). the mean cold flux before ( ) and after ( ) low flow were both significantly lower (p= . ) than the mean initial warm cpb flux ( ). the mean rewarm cpb flux ( ) was significantly lower than all other flux values (p= . ). there were no siglaificant correlations between map and flux except at the first warm cpb period (r= , , p= . ). conclusions: although hypothermia significantly reduces rectal mucosal perfusion, rewarming produces an even greater reduction in gut perfusion which, considering that mucosal oxygen constmaption is highest during this time, may prove crucial in the postoperative development of mof. therapy aimed at improving gut perfusion during cpb should be directed at the rewanning period in particular. abstract this work is aimed at establishing a clinical procedure for the diagnosis of enteritis necroticans (en), even at the communal level, and to define criteria for diagnosis able to distinguish between acute forms. subjects and method : cases admitted at the institute for protection of children's health dpch), having characteristic symptoms, were examined clinically, by roentgenography of the abdominal cavity, with the analysis of the blood (total protein, electrolytes, hematocrite) and cultures of intestinal fluid and faeces. through surgical operations, the pathological lesions were observed and recorded. results: common epidemiological features: the average age is - years old ( - ) ; male/female : . ; in % of the cases, the disease occurred after a meal rich in protides. the acute toxic form accounted for % : severe shock appearing early, with very severe dehydration associated with profoundly decreased blood protein concentration and lowered natriemia as well. the lesions of the small intestine were expanded, all of them were necrotic. in the surgical form ( %), the predominant feature was an obstruction -peritonitis syndrome, the peritoneal fluid showed a characteristic inflammatory reaction. for the rest of cases % were the internal form, the shock syndrome was less severe, the abdominal distention was light and disappears gradually, the inflammatory reaction of the peritoneal fluid was not so characteristic. conclusion (ino) is a selective pulmonary vesodilator that is rapidly inactivated compared to intravenous vasodilators. these qualities make ino an attractive agent for the treatment of pulmonary hypertension (pittn). the efficacy of ino has been studied in persistent fetal circulation, acute respiratory distress syndrome (ards), and congenital heart disease (chd). potential adverse effects oflno include: nitrogen dioxide (no toxicity, methemoglobinemia, and platelet dysfimction. our objective was to evaluate the safety of ino in pediatric patients (pts). methods: pediatric pts. with phtn from ards or chd were studied under an established, approved protocol conforming to fda guidelines tbr an investigational new drug. informed consent was obtained for each child prior to treatment. no was sequentially titratad from parts per million (ppm) to , , , and ppm at ten minute intervals. parameters monitored before and during therapy included nitric oxide (no) and no~ concentrations (cone.), mean arterial blood pressure (map), and percent methemoglobin (mhg). no and noz levels were continuously monitored using an inline dr~ger electrochemical detection device. ~,litp was continuously measured with an indwelling arterial catheter. mhg was measured by co-oximetry. a mhg level e % or no cone. ~ ppm were considered adverse effects by study criteria. pretreatment map was compared to map at and ppm ino using paired t-tests. ap value < . was considered statistically significant. results: thirty-two mechanically ventilated children with phtn ( with ards, with chd) were studied. five pts. were treated following cardiopulmonary bypass. methemoglobin (met-hb) levels were routinely measured in two prospective clinical studies on no inhalation in pediatric patients with pulmonary hypertension following heart surgery with extracorporeal circulation and in pediatric and neonatal ards patients, the observed differences between the groups prompted in an in vitro study, red blood cells (rbc) of patients sampled before and after surgery with and without extracorporeal circulation (ecc), respectively, were incubated with ppm no for rain, met-hb, atp, and nadht nadph concentrations were compared, during therapeutic exposure no increased met-hb from . - -_ . to . _+ . % in cardiac surgery patients and from . ± , to . ± . % in ards patients (p < . ). rbc's having undergone ecc were more susceptible to met-hb formation (p< , ) whereas intracellular coenzymes did not differ neither between the groups (table) nor before and after no exposure. ecc predisposes to increased methemoglobinemia upon exposure to no both in vivo and in vitro. our data suggest a reduced activity of met-hb reducing enzymes rather than diminished availability of energetic substrates, variation of the inhaled nitric oxide concentration with the use of a continuous flow ventilator. anne pmc de jaegere ~, frans im jacobs , nico gc laheij , john n van den anker t . dept. of paediatrics ~, central instrumentation , sophia children's hospital, erasmus university rotterdam, rotterdam, the netherlands. objective: to investigate the homogeneity of nitric oxide (no) concentration in a delivery system with a continuous flow ventilator. design: bench study, setting: biomedical laboratory. interventions: a nitrogen/nitric oxide (njno) gas mixture was injected at three different sites in the patient circuit: just before and just behind the humidifier, and centimetres before the y-connector. ventilator flow ( , , l/rain), ventilator rate ( to , increments of ) and compliance of the testlung ( . ; . ; . ml/cm h ) were changed. carbon dioxide (co ) instead of n /no was injected at the same points in the circuit. measurements and main results: a) though the flow ratio of the njno and the ventilator gas were kept constant, the no concentration ([no]) raised with increasing ventilator rates. the increase in [no] was up to % when the n /no injection site was close to the y-connector of the ventilator circuit. minimal changes in [no] were noticed when the n~/no was mixed to the ventilator gas before the humidifier. b) analysis of the ventilator flow pattern showed variations at different places in the ventilator circuit. the magnitude cf the p, ow change depended on the meas~:rement site. the closer to the expiratory valve the highest the flow change was. the duration of the flow change was inversely proportional to the adjusted ventilator flow. c) real time measurements of the co concentration ([coz]) showed variations during tile respiratory cycle. these [co ] variations were higher when the co gas was blended closer to the yconnector. conclusions: the ventilator flow variations in relation to the fixed side flow of the n /no gasmixture result in changes of the inhaled [no] during the respiratory cycle. the no concentration during inspiration is always higher then during expiration. this could not be detected with the available monitoring system. to ensure a constant [no] by blending a njno gas balance in a continuous flow ventilator, the site of injection should be as close as possible to the inspiratory outlet. nitric oxide, a potent and selective pulmonary vasodilator, has recently been successfully used to treat pulmonary hypertension of variable etiology in infants and children. side-effects and complications in infants are so far not well known. we describe here two cases in which prolonged ( and- days respectively) high-dose ( - ppm) nitric oxide was used to treat refractor~¢ pulmonary hypertension. one patient was a newborn infant with pulmonary hypertension secondary to a large leftsided diaphragmatic hernia. nitric oxide was begun under conventional ventilation (babylog ) at hours of life with a slight initial improvement in oxygenation. he was then placed on oscillation with the same nitric oxide concentration due to worsening respiratory failure. he died on th day of life. monitored nitric dioxide concentration never exceeded ppm. the other patient was a months old infant with severe pulmonary hypertension due to a complete atrioventricular septal defect. he required high-dose nitric oxide to come off cardiopulmonary bypass after surgical repair of his heart defect. he slowly improved over the week following surgery but developped suddenly respiratory failure due to massive pulmonary hemorrhage and died. surprisingly, a particular autopsy finding in both infants was a massive acute necrotizing tracheobronchitis. we conclude that nitric oxide is an excellent and sometimes lifesaving treatment of pulmonary hypertension in infants. tracheobronchitis has not yet been reported as a possible complication of nitric oxide administration. we suggest that caution needs to be taken with prolonged high-dose administration and this possible complication to be looked for at autopsy. introduction: permissive hypereapnia (ph) is a beneficial strategy for patients with acute respiratory distress syndrome (ards) to minimize barotrauma by decreasing the peak inspiratory pressure (pip). hypercapnia and hypoxia cause pulmonary vasoconstriction, pulmonary artery (pa) hypertension, and, thus, an increased afterload to the right ventricle. this increased afterload may result in increased right ventricular (rv) work load and subsequent rv dysfunction. one therapeutic approach is the use of inhaled nitric oxide (inn), a selective pa vasodilator. the objectives of this study were to test the hypothesis that in a swine model of ards with ph, inn would improve rv work load and not change intrinsic rv contractility. methods: in swine ( - kg), ards was induced by surfactant depletion. hypercapnia was achieved by decreasing the pip while increasing the peep to maintain a constant mean airway pressure, inn was administered in concentrations of , , and ppm in a random order. pulmonary blood flow (qpa) was determined by an ultrasonic flow probe. rv total power (tp) and stroke work (sw) were calculated by fourier transformation of the pa pressure (ppa) and qpa data. preload recruitable stroke work (prsw), a preload and afterload independent measure of ventriculur contractility, was determined by a shen-subtraction method and vena caval occlusion. respiratory failure with pulmonary hypertension in piglets gerfried zobel*, bernd urlesberger*, drago dacar**, siegfried rtdl*, fritz reiterer* and ingeborg friehs** depamnents of pediatrics* and cardiac surgery**, university of graz,austria objective: to evaluate gas exchange, pulmonary mechanics and bemodynamic data during partial liquid ventilation (plv) combined with inhaled nitric oxide (no) in acute respiratory failure with pulmonary hypertension. design: prospecfive~ randomized, controlled study. setting: university research laboratory. subjects: twelve piglets weighing to kg. interventions: acute respiratory failure with pulmonary hypertension was induced by repented lung lavages and a continuous infusion of the stable endoperoxane analogue of thromboxane. thereafter the animals were randomly assigned either for plv or conventional mechanical ventilation. initially perfhiorocarbon liquid ( ml/kg) was instilled into the endotracheal tube over min followed by - ml/kg~. all animals were treated with different concentrations of no ( - - ppm) inhaled in random order. measurements and results: continuous monitoring included ecg, cvp, mpap, map, san and svo measurements. during plv pao /fio increased significantly from _+ . mmhg to ± mmhg (p< . ) within rain, while pao ]fio remained constant at -+ . mmhg. qs/qt decreased significantly from -+ % to -+ % (p< . ) during plv and did not change during conventional mechanical ventilation. static pulmonary compliance (cstat) increased significantly ff~m . r± . to . _+ . ml/cmh /kg (p< . ) during plv and decreased slightly from . _+ . to . e . ml/cmh /kg during conventional mechanical ventilation. the infusion of the endoperoxane analogue resulted in a sudden decrease of pao /fio from _+ to _+ . mmhg in the plv group and from ± to +_ . mmhg in the control group. inhaled no significandy improved oxygenation in both groups (pao /fio : _+ mmhg during plv and +_. mmhg during conventional mechanical ventilation). during inhalation of no mpap decreased significantly from -+ m ± mmhg (p< . ) in both groups. there was no significant change in oxygenation and mpap during inhalation of and ppm no. conclusions : plv significantly improves oxygenation and pulmonary compliance in acute respiratory failure. the additional application of inhaled no further improves oxygenation and pulmonary hemodynamics when acute respiratory failure is associated with severe pulmonary hypertension. inhaled no is very effective in improving oxygenation and pulmonary blood flow even at low doses. the work was supported in part by grants of the austrian nationalbank nr . as in neonates, severe respiratory failure in infants and children can be aggravated by pulmonary hypertension, resulting in further deterioration of oxygenation due to increasing intrapulmonary shunting. we analysed the influence of inhalational nitric oxide (ino) in treatment, course and outcome of severe ards in a pediatric population. since infants and children (age: - months) with ards and oi > (mean value: . ± ) underwent a trial with ino (concentration: , , , and ppm) to prevent further respiratory failure. patients had a significant improvement of their oxygenation (rise of pa > mm hg) for at least hours (responders); mean best ~fficient no dose: . ppm. the non-responders had only a short-term improvement or ino had no effect. in responders and nonresponders there was no significant difference with regard to age, underlying disease, ards severity, time on mechanical ventilation, blood gases and ventilator settings before notrial, nor was there a different grade of pulmonary hypertension (estimated by echocardiography). the only difference was an higher ol in the group of the non-responders: . ± .i vs. . ~ . , p < . . in the group of the respenders there was a secondary deterioration of lung function after i - days on ino in children (transient responders): in these patients, as well as in the group of the non-responders, alternative modalities of treatment (hfov and/or ecmo) became necessary. children ( %) died: transient respenders and non-responders. in infants and children with ards due to different underlying diseases ino can acutely lead to a significant improvement of oxygenation in about % of the cases. the right selection of patients for no therapy and the influence of ino on the survival rate of ards in childhood has to be evaluated in further studies. and pediatric cardiology, university of graz, a- graz purpose: after fontan procedure cardiac output is critically dependent on the pulmonary vascular resistance. even minor elevations of the pulmonary vascular resistance may significantly decrease cardiac output. inhaled no is an effective, selective pulmonary vasodilator in experimental and clinical situations of pulmonary hypertension. the aim of this study is to evaluate the effects of inhaled no on oxygenation and pulmonm , circulation in children after a bidirectional glenn-anastomosis (n-~) or a fontan-like operation (n= ). material and methods: from june t to january children with a mean age of . +~ . (sem) yrs and a mean body weight of . -+ . (sem) kg were treated with inhaled no after glenn-or fontan-like operations. all but one had complex cardiac malformations with single ventricle. all children were mechanically ventilated with an fin > . . inhaled (no) was applied using a rrdcrdproeessor based system which additionally allowed measurement of no/nox using the chemihimniscence method. methemogtobin concentrations were determined times a day. the major indication for postoperative inhalation of no was a high (> mmhg) transpulmonary pressure gradient (tpg--cvp-lap). severe myocardial dysfunction of the single ventricle was excluded by echocardiography. results: the mean duration of mechanical ventilation was . _+ . (sem) days the. mean dose of inhaled no was . -+ . (sem) ppm, the mean duration of no-inhalation was _+ (sem) hours. the mean methemoglobin concentration was . -+ . (sem)%. hemodynamic data and arterial oxygen saturation before inhaling no and minutes later are given in table acute hypoxaemic respiratory failure (ahrf) in children occurs in a heterogenous group of diseases with pulmonary pathophysiological processes ranging from reversible physiological intrapulmonary shunting to fixed structural lung damage. we hypothesized that inhaled nitric oxide (ino), a selective pulmonary vasodilator, might identify those patients with potentially reversible disease, i,e, large response may indicate a greater likelihood ef reversibility and thus survival. a retrospective review of the early response to ino in infants and children (aged month to years, median months) with severe ahrf( with ards). the mean p(a-a)o , pao / fio , oxygenation index (oi) and acute lung injury (all) score prior to the commencement of ino were +_ . , +_ . , _+ , and . +_ . respectively, the magnitude of response to ino was quantified as the % change in oi occurring within minutes of ppm ino therapy. this response was compared to patient outcome data. results. there was a significant correlation between response to ino and patient outcome, kendall tau b r= , , p< . (table) conclusion. in ahrf response to ino appears te define a subgroup of patients with improved outcome compared to nonresponders. we speculate that response to ino may be useful in selecting patients with potentially reversible lung disease for special support therapies such as ecmo. randomised controlled trials are needed to define the role of ino in paediatric ahrf. between may and december , patients (pts) were treated for mas. treatment groups were: group i only : pts; group i conventional mechanioal ventilation (cmv): pts; group ii hfo: pt; group iv hfo+no: pts. therapy was stepwise intensified until oxygenation improved ( i -) ii -) iii --) iv). "high volume strategy" was used with hfo (mawp - cm h ). the initial no-concentration was - ppm, with rapid reduction down to - ppm once oxygenation improved. results: one pt (group it) died of hypoxic-ischemic encephaiopathy (termination of therapy); all other newborn babies survived. in group iv pt and showed barotrauma prior to hfo. pt , and were treated with additional mgci (max. mg serum concentration . - . mmol/i). following the identification of inhaled nitric oxide "no) as a selective pulmonary vasodilator (frostell et al ) [ .+ , + . data are compared to baseline values within each group. *=p< . , **=p< . , ***=p< . l among patients who fulfilled ecmo criteria, improved with no and did not required extracorporeal life support. tltree out of ecmo patients eventually survived. conclusions: m our study low-dose of irthaled no showed a variable effect on oxygenation in newborns with acute respiratory failure. an acute response to no appeared to be correlated with a better short-term outcome and the avoidance of extracorporeal support in ecmo candidates. differently, lack of acute and/or sustained response was associated with death or need for ecmo. although the nature and severity of the underlying disease or the degree of prematurity may play an important role in these patients, we believe lack of acute response to no may be an early predictor of bad outcome, prompting toward alternative treatments such as ecmo or liquid ventilation. *picea s., °bartuli a.,°dionisi-vici c., *dello strologo l., §villani a., §bianchi r., ^salvatori g.,*rizzoni g, °sabetta g. *div. of nephrology, °div. of metabolism, §intensive care unit, ^div. of neonatology. "bambino gesfl" children research hospital. rome, italy. successful prevention of handicaps or death in newborns with ~ depends on rapidity and efficiency of treatment. poor response to nutritional and/or pharmacological treatment requires extracorporeal removal of nh . efficiency and cardiovascular tolerance are often difficult to obtain with peritoneal or hemodialysis in neonates. we report the results of cavhd in newborns with hc. methods: vascular access: femoral vessels. blood flow: - ml/min, dialysate flow: - ml/h. filter: amicon minifilter plusrm(polysulfone membrane; . sq.m.). no ultrafiltrate(uf) production, patients: case with carbamoytphosphate synthetase deficiency (body weight -bw-: . kg) showed hc at day , a relapse of hc occurred at day due to an infectious event. case and (bw: . and . kg), both affected by propionic aeidemia, showed hc at day and day , respectively. plasma nh (~tg/dl) decrease is shown in the complications: transitory ischemia of arterial cannulation limb and transitory thrombocytopenia occurred in case ; surgical repairing of artery after cavt-id was necessary in case ; no cardiovascular instability was observed during cavhd . outcome,'all patients recovered from hc in less than day: case : alive, mild b)iootonia at mos; case : dead after days from cavhd withdrawal for pulmonary hemorrhage; case : alive, normal development at mos. conclusions: ) in newborns with hc, ca~q-id provides good cardiovascular tolerance,high efficiency and quick removal of nh , even without uf production (i.e. only by diffusion). this allows easier management (no need of fluid and electrolyte balance). ) arterial complications seem frequent in neonates treated by cavhd. venovenous circulation could overcome this problem. vb nguyen, m jokie, c leeaeheux paediatric intensive case service, hospital university centre, avenue c te de nacre, caen cedex, france background, the implication of polymorphonuclear neutrophils (pmns) in the physiopathology of children's haemolytic.uraemie syndrome (hus) becomes more and more evident. the purpose of the present study is to role out their impact among other pronostie elements during the course of the disease. patients and methods. diarrheal prodrome and its duration, patient's age, maximal blood nitrogen level, anuria and dialysis time, extra.renal involvements, white enll and pmn counts and thrombopenia duration have been retrospectively analysed in infants with good outcome and in another children with unfavorable outcome. results. neither diarrhoea or its duration, nor children's age, nor blood nitrogen level, nor anuria or dialysis time had any predictive value for the disease evolution in the acute phase of our patients. adversely, extra-nenal involvements was accompanied by severe and complicated courses of the disease (p< , ). the elevation of white cells and pmns (heyon x /i) and pmns (more than x / ) as well as its persistence beyon a week were most frequently observed in complicated forms (p< , , p< , and p< , , respectively). a transient thrombopenia (less than day@ in patients with elevated counts of white cells may be a filrther obvious sign of an unfavorable course of the disease ( < , ). conclusion. the elevated count of white cells and pmns, either alone or associated to one rapid regeneration of platelets, seems enabled to predict an unfavorable evolution of the hus in children. msud results from an inherited impairement of catabolic pathway of branch chain amino-acids. high leucine blood levels may induce acute brain dysfunction. this dramatic complication led us to propose leucine removal procedures as continuous hemofiltration. patients and methods three newborns in acute msud onset were treated by hf, hdf and hd. extracorporeal circulation was performed through a . fr catheter, a circuit with a blood pump (priming volume = ml). patients and procedures characteristics are summarized below in the sucralfate (an aluminium salt of sucrose octa sulfate) is used to prevent and treat upper gastrointestinal bleeding in critically ill patients. with minimal absorption, the potential for side effects is thought to be limited, though aluminium toxicity has been reported in patients with chronic renal failure. these patients may already have had high body stores of aluminium. we report critically ill children with high serum concentrations of aluminium following sucralfate therapy. all had renal impairment. the normal aluminium level is < . gmol/l and in patients with chronic renal failure < . ].tmol/l. none of these patients had known preexisting chronic renal disease. cpb was conducted under deep hypothermia (t,° °c) and cardiocirculatory arrest (cca) or under hypothermia (t,° °c) and low-flow perfusion. continuous holter-electrocardiograms (h-ecg) were recorded from the ilranediate postoperative (po) period on for hours. h-ecg were also recorded prior to the operation and before discharge. following dr were observed: snpraventricutar (sv) and ventricular (v) extrasystoles (es) (> / h), sv and v tachycardia (svt and vt), accelerated junctional rhythm (ajr) and junctional ectopic tachycardja (jet), and nd and rd degree atrioventricular block (avb and avb ). the incidence of po dr was % in the pre-op h-ecg, % on the st, % on the rid, % on the rd po day and % befbre discharge. compared to the pre-op findings, an increased incidence of sves, ves, svt and avb on the st po day was observed, whereas vt and a jr or jet were exclusively observed po. all types of dr were observed up to the rd po day. ty e of dr before discharge was similar to pre-op findings and there was no definitive avb . considering patient groups according to the most frequent isolated op-procedure, the incidence of dr on the first po day was % after asd ii-closure (n= ), % after stthaortal vsd-closure (n=lg), % after correction of a complete avsd (n= ), % after correction of a tetralogy of fallot (n= ) and % after fontan-operation (n= ). incidence and type of dr were not significantly different between groups. longer cpb-dttration and use of cca were risk factors for po ves and vt (p< , and p< , , respectively) whereas use of cca and degree of hypothermia were risk factors for the development of a jr and jet (p< , and p< , , respectively). -our results indicate that po dr after cpb in children m'e frequent but mainly transient. in our series, specific cpb-related parameters are of greater influence than surgical procedure itseif for the development of dr and are discriminant risk factors for particular types of dr. the course of anp, cgmp/anp (as indicator for atrial natriurefic peptide biological activity), and no and no (as indicator for endogenous nitric oxide (no) synthesis) was investigated in i infants (median age months) undergoing cardiopulmonary bypass (cpb). patients were divided into groups according to whether they had (group , n= ) or not (group , n= ) preoperative heart failure (hf) and pulmonary hypertension (pht). group patients had preoperatively significantly higher levels of anp (p< . ), cgmp (p< . ) and no and no (,p< . ) but had significantly lower cgmp/anp (i < . ) than group patients. during cpb, anp was significantly higher in group patients ~< . ). as compared with prebypass values, cgmp/anp was reduced in both groups during cpb (p< . ). cgmp/anp inversely correlated with duration of cpb and aortic clamping time (p< . , respectively). no and no were significantly higher in group than in group patients (p< . ) without any intraindividual change during cpb. from the early postoperative period on anp, cgmp/anp and no and no were similar in both groups. after cpb, anp correlated in both groups with blood pressure (p< , ) and diuresis (p< . ). no and no inversely correlated with pulmonary arterial pressure immediately after cpb ( < . patients after a fontan-type of procedure have elevated central venous pressures (cvp) leading to congestion in the gastrointestinal system and often ascites. purpose of this study was to evaluate whether this causes a different postoperative gastric mucosal ph (phi). methods: we evaluated a series of patients, who underwent cardiac surgery with cardiopulmonary bypass (age: days to years (mean , yrs), weight: . to kg (mean . kg). a commercially available tonometer (tonometics®) for sigmoidal use in adults was inserted into the stomach after induction of anesthesia. the phi measurements were done according to manufacturer recommendations we compared three groups of patients: ) aeyanotic (n= ), among them p with vsd and p with avsd; ) cyanotic (n= ): tof: p, tga: p; ) cyanotic after a fontan-type procedure (n= ). phi were measured at picu arrival and after h. fudhermore we compared lactat levels at these time points. differences between the groups were evaluated with one way anova on ranks with pairwaise multiple comparisons (dunn's method). the relationship between cvp and phi was investigated by regression analysis. results: the median phi for groups i, and were . , . and . at ardval and . , . and . after h respectively. at picu arrival group was significantly (p< . ) different from groups and . there was no significant difference between the latter two groups, after h group was different from group , there were no other significant differences. the median lactate levels for groups t, and were . , , and . at ardval and . , . and . after h respectively. at ptcu arrival group was significantly (p< . ) different from group , after h there were no significant differences. there was a weak negative correlation between cvp and phi: r= - . ; p< . . conclusion: patients after a fontan-type of procedure have lower phi than patients after other cardiac surgical procedures, however, this is only in part due to the elevated cvp and venous congestion. eleven children were investigated months (median) after postoperative mof. iviof was defined as the failure of at least two vital organ systems (kidney, liver, lung, central nervous system) in addition to cardiac insufficiency and high fever. underlying surgical procedure was repair of tetralogy of fallot (n= ), fontan-(n= ) or seuning procedure (n=l). all patients fulfilled criteria for mof in the first postoperative (po) days. six patients needed peritoneal or hemodialysis for days (median) during the po period. one patient showed cerebral infarction due to thromboembolism in the territory of the right internal carotid artery immediately after the operation. the follow-up protocol consisted of extensive investigations of heart-, renalliver-, and lung functions as well as complete neurological and psychological examinations. all patients had adequate cardiac examination. lung function was normal in all but patients who had an obstructive syndrome. only patient showed an isolated decreased creatinine clearance. abnormalities of the liver ftmction tests were only noticed in patients after fontan procedure. severe neurological sequels such as paraplegia (n = ) and diplegia (n-i) were observed in of the patients. the remaining children presented with a delayed graphomotorical and speech development associated with normal intelligence. -in our series the most frequent and severe sequels after postoperative mof were neurological. -abnormal liver fimction tests are more likely to be a consequence of the fontan hemodynamics than a sequel of mof. the optimal dosing schedule of surfactant therapy for the treatment of neonatal respiratory distress syndrome (rds) remains unclear. goal: surfaetant function and the concentration of phospholipids (pl) in tracheal aspirates are compared in a prospective randomized trial involving neonates with rds who received either two or more ( or ) doses of survanta. methods; ventilated neonates < w with rds were treated with survanta oo mg/kg if fio >_ % or mean airway pressure _> , cm hzo, after h a nd dose was given (same criteria), if the support still exceeded the criteria h after the nd dose, the patient was randomized to no extra dose (two}, or to an extra dose of survanta (morel (and a th dose h later; same criteria), pl was measured in tracheal aspirates and corrected for dilution with the urea method. "active" large aggregates and "non-active" small aggregates of surfactant were separated by centrifugation and quantified. surface tension of the large aggregate fraction was measured by pulsating bubble surfactometer, results: neonates were randomized, x two and x more ( x and x doses), gestational age was , ± , w and birth weight ± g. most patients had severe rds with initial ventilation: rate . _+ , , peak inspiratory pressure (pip) , -+ . cm hzo, fio . ± . %. at randomization: rate . ± . , pip . -+ . cm hzo, fio . ± . %, and h after randomization: rate . ± . , pip . _+ . cm hzo, fio . ± . %, without signif, differences between the groups. there was relapse (again fio _> % within h) in group two and t bpd in group more. in total, tracheal aspirates were analyzed. pl was not signif, different before randomization (two . ± . vs more . ± . /jmol/ml), but neither after randomization (two . -+ . vs more . ± ,o /~mol/ml). there was no difference in the % small aggregates (two . ± . vs more . ± . %), the surface tensions (ran/m) were not signif, different (each time two vs more): before randomization . ± , vs . -+ . , in the h after randomization . ± . vs . -+ , , or - h after randomization . -+ . vs . ± . , or - h after randomization . _+ . vs . -+ . . conclusion: neonates who received more than two doses of survanta did not have higher pl, nor a better surfactant function than neonates who received only two doses of survanta. continuation of the trial is necessary to evaluate clinical outcome. may not indicate need for treatment p.c. clemens s.j. neumann university of hamburg, department of pediatrics, klinikum schwerin, wismarsche str.. , d- schwerin. aim of the study: the finding of elevated tsh and decreased t in the newborn usually is classified as "transient hypothyroidism", thus the elevation of tsh is classified as consequence of the lowered t . but on the other hand several data sets show that tsh elevation as well as low t , one independently of the other one, are associated with different kinds of perinatal stress. each of these laboratory deviations, if not associated with the other value being abnormal too, is generally accepted not to be an indication for treatment. from this we conclude, that more pefinatal stress, as in intensive care neonates, may produce tsh elevation as well as low t , but only coincidentially, not the tsh elevation being the consequence of low t , thus not to be classified as "hypothyroidism", thus not indicating treatment. if this hypothesis is right, we should find an association of increasing pefinatal stress with an increasing number of neonates from tsh and t normal via tsh or t abnormal to high tsh and low t . method: in the newborn screening program in germa w we determine primarily tsh, and only in the neonates with elevated tsh, in addition we determine t . thus in our study we asked whether we find an association of increasing perinatal stress with an increasing number of neonates from tsh normal via tsh abnormal while t normal to high tsh and low t . definitions for this study were: tsh elevation = > mu/ (as usual in the german screening programs), t lowered = < p_g/dl perinatal stress score was or or or in dependency of the neonate having stress in none to all of the following three categories: (a) forceps or vacuum extraction or sectio co) birth weight below g (c) at the th day existence of a relevant neonatal disorder (rds, ictems gravis, infection/sepsis, vitium cordis with hemodynamic relevance, severe malformation). results: our data of neonates show a high significant association (chi = , p < . ) of, on one hand, perinatal stress score with normal tsh, versus, on the other hand, perinatal stress score or with high tsh and low t . discussion: facing the background given above, in the intensive care newborn, the constellation of high tsh and low t may be only a coincidential addition of two independent abnormalities. in tbese cases -the high tsh not being the consequence of low t -the classification as "hypothyroidism" is not justified, thus a therapy not indicated. on the other hand of course there exist rare cases with high tsh as consequence of low t thus with hypothyroidism tlms with indication for therapy. unfortunately we have no criteria, that enable a certain discrimination of these two categories thus in respect to the question of therapy or not. conclusion: further research has to be done to learn how to discriminate the coincidential high tsh and low t from the causal constellation of high tsh and low t . until we have certain discrimination criteria we have to treat both groups of neonates. few studies have focused on fa composition of surfactant pc in preterm infants before and after surfactant therapy. methods: tracheal aspirates were collected in venttlated mfants from birth until extubatlon ( / _ /twk ga, .+ g bw). after lipid extraction, t.l.c,, and methylation, fas of pc were quantified by gaschromatography. intralipid a ( . % linoleic acid, : • ) was started h after birth. results: six infants developed respiratory distress syndrome (rds) and received survanta r i mg/kg (sr), all doses within h after birth (ix s r n=l, x s r~ n= , x s r n= ). one child did not develop rds. in alt patients, the patmitate % in pc was ~ % (before sr<=natural composition), increased to ~ % after s r, and remained > % for i h after lx s a, . .+i . h after x, and . .+ . h after doses. in patients, intubated long enough, the palmitate % decreased with a half-life of . _+ . h to a new plateau which was still higher than baseline after week. linoleic acid % was . _+ . (with rds), decreased after s r~ and returned to baseline due to the decrease in patmitate %. thereafter the linoleic acid % increased linearly with . % per h, in patient even up to . %. other fas did not increase after return to baseline. in neonatal medicine the current parameters, arterial oxygen saturation and arterial oxygen pressure, are poor indicators for oxygen delivery and oxygen demand. the purpose of this study was to obtain venous blood samples from the inferior vena cava in stable neonates with respiratory failure and to determine a parameter that reflects more adequately the balance between oxygen delivery and oxygen demand. "l~e study included neonates requiring mechanical ventilation tbr severe respiratory insufficiency. an umbilical venous and arterial catheter were inserted in the inferior vena cava and in the aorta respectively. paired blood samples were obtained at the time that the patients were hemodynamically stable. fifty paired arterial and mixed venous blood samples were analyzed. jnear regression analysis showed the following correlations: in a neonatal intensive care unit adjacent to a delivery room caring for mothers per year, (with a referral of mostly for preterm delivery), virtually every neonate <ls g was seen by the same ophtalmologist, j.o. the incidence of retinopathy of prematurity (rop) was in - of ii cases ( preterms <ls g with % surviving to discharge, and % rop in survivors; % if less than weeks). in - , cases of rop were diagnosed by the same ophtalmologist. were born at less than weeks, of which ( %) survived to discharge, and among those survivors, rop was present in ( %), with rates varying from % at weeks to % at . objective: to compare a method of teicoplanine (teico) infusion using an electrical syringe-pump with a manual injection. methods: infusion of teico was simulated through a standart neonatal i.v. system. the infusion system consisted of an life care infusion pump (abbo'it lab.) with its i.v. set for maintenance intravenous fluid (flow < mi/h) connected to a -way stopcock. an meter extension tubing (vygon lab.) was placed between the stopcock and a neonatal catheter, an another meter tubing (injection tubing) was connected to the stopcock. the volume of the injection circuit was . ml. simulations were realised for weights ( or kg), with a doses of mg/kg and a injected volume of , ml to ml. our goal was to perform a complete infusion in minutes. we compare one method of infusion with an electrical syringe-pump with manual methods: a: teico was infused with a syringe-pump pilot c (becton & dickinson lab.) according to a protocol using ) a priming before connecting the syringe to the tubing (for immediate starting of infusion), ) a programmed volume injected in minutes (the drug volume was greater than the dose prescribed to avoid loss of teico into the syringe), ) a ml wash out was performed over minutes with the syringe pump. b: teico was manually injected in a few seconds in the tubing followed by a ml wash out over minutes. c: idem as b but a nu site valve (medex) was connected to the proximal end of injection tubing to avoid leakage between removal of the teico syringe and connection of the wash out syringe. during each run, serial samples were collected every ten minutes over a one hour period. the samples were assessed using hplc method. results: the amount of drug delivred at minutes was calculated and expressed as a perventage of the total amount of teico prescribed. results are a mean of to rons. a b c kg . + , % , + . % , -+ . % kg -+ , % -+ , % . -+ % conclusion: with a drug volume injected < circuit volume and a valve, a direct i.v. administration of the drug in the circuit followed by a wash out seems an accurate alternative to drug infusion conbroled by a syringe pump and is easier to perform. doxapram hydrochloride is a central and respiratory stimulant which is used in neonatal intensive care units to treat caffeine-resistant apnoes of the newborn. routinely, doxapram is administered intravenously. oral administration would be much easier but data on bioavailability after oral administration are limited (two studies) and show a large variation. we therefore studied the oral bioavailability of doxapram in preterm infants. doxapram treatment was started with an intravenous loading dose of , mg/kg during minutes, followed by a continuous infusion of mg/kg/h. after h the intravenous administration was changed to continuous oral administration with the same dosage, blood samples were collected h after both the intravenous and oral administration and analyzed by hplc-assay. apnoea rates per hours were listed before and after starting doxapram treatment. the median apnoea rate per hours declined from to after both the intravenous and oral administration. the oral bioavailability of doxapram is between and %, indicating that the oral route can be used effectively in these infants . there were no differences in the decline of the apnoea rate after intravenous versus oral administration of doxapram, infasurf r has been comnared with exosurf r in two studies: one as drodhvlaxis and the other a rescue trial. similar. althouah non-sianificant benefits were found for the natural surfactant. in trials there was a sianificant reduction in dulmonarv air leaks for . : % ci . - . for babies treated with natural comnared to svnthetic surfactants. for trials ( babies~ comdarina natural and synthetic surfactants for rds { comdarina survanta r and exosurf r. and one infasurf r and exesurfr% neonatal mortalitv was sianificantlv reduced (or . : % ci . - . with natural compared to synthetic surfactant treatment. in two further trials different natural surfactant drenarations were compared. reduced oxvaen needs for hours after treatment were found for r r infasurf and curosurf respectively when each was compared to survanta r. andarent lonaer-term benefits from these surfactants were not statisticallv sianificant. further trials will be needed to ascertain differences between various surfactant preparations. introduction bacterial meningitis is a common cause of admission in the paediatric age group, and one which still carries a high morbidity and mortality. these complications are strongly associated with a delay in antibacterial therapy. a significant proportion of these patients require mechanical ventilation; it is in this particular group of patients that survival is greatly diminished. the identification of risk factors for mechanical ventilation associated with bacterial meninges may help improving survival by shortening the delay to icu referral. the paediatdc risk of mortality score (prism) is the most widely used scoring system in the paediatric icu literature; the accuracy of prism on predicting outcome in meningitis has been shown to be poor. aim we aimed to describe our population of patients with bacterial meningitis requiring ventilation, and then to identify predictors of survival. methods this study was conducted at the baragwanath hospital in south africa which is an universityaffiliated institution with end average annual paediathc admission of patients. baragwanath icu admits non-neonatal paediatdc patients per year. a retrospective chart review from january to december of consecutive paedistdc icu admissions with bacterial meningitis was performed. results approximately cases of bacterial meningitis are admitted to the general paediatric wards every year; this constitutes ± % of all admissions. the mortality of these patients is + %. during this time ( m, f) patients ( %) were accepted for icu admission, with a mortality of . %. the median age was months (range days to years). the median delay to hospital admission was hours, and the median delay to icu admission was a further hours. the median duration of tcu stay was hours ( for non-survivors, for survivors). the main presenting features were convulsions ( %), altered mental state ( %), fever ( %), respiratory symptoms ( %), headache ( %), and diarrhoea and vomiting ( %). the most common indications for icu admission were seizures ( %), coma ( %), shock ( %), respiratory failure ( %) and acidosis ( %). in % of patients there was a cardiorespirstory arrest prior to admission. the most common organisms in the csf was pneumococcus ( %), haemophilus influenza ( %) and e coli ( %). the presence of leucopenia (wcc < ), a low platelat count (< ), acidaemia (ph< . ), and the need for inotropic support were strongly associated with nonsurvival. tachycardia and hypotension were not significantly essorjsted with poor outcome, as has been previously reported. discussion early diagnosis of meningitis and prompt institution of antibiotic therapy requires a high level of clinical suspicion. paediatric patients with bacterial meningitis that require mechanical ventilation have a poor prognosis. there is little evidence to suggest that nomsurviva[ can be predicted prior to icu admission, but a rapid deterioration requiring ventilation and inotrepic support with evidence of severe sepsis (low platelet count, leucopenia) is nmost invariably associated with a fatal outcome. the long term functional outcome of these patients make this disease even more devastating; the rote of icu in the management of these patients has yet to be fully estanished. objective and study design: a retrospective study was pertbrmed for all patients diagnosed with hemorrhagic shock and encephalopathy syndrome (hse) during to . soroka medical center is the only medical facility in the southern negev region of israel serving a population of - , residents, consisting primarily of jews and bedouins. results: patients ( bedouins and jews) were diagnosed with hse. main features on arrival included profound shock and coma with con~alsions. active bleeding and/or disturbing coagulation tests with falling heuroglobin levels and thrombocytopenia was noted in every case. all infants developed diarrhea shortly after arrival. elevated urea, creatinine and liver enzymes was noted in all cases. annual incidence tbr inlhnts < year of age was : , for bedouins and . : , for jews. patients ranged in age from - wks and arrived at the hospital late night/early morning ( : am-ll: am), during winter/early spring (november-april). all were healthy prior to admission, with short prodromal symptoms of upper respiratory tract or gastrointestinal infection noted in cases. most infants had markedly elevated body temperature on arrival. a history of overwrapping and/or excessive hearing was obtained in of infants. bacteriological and virological cultures were negative in all infants. one infant died and neurological sequelae were observed in all survivors. the high prevalence of hyperpyrexia during sleep in the presence of negative microbiological results with no evidence of excessive hearing, and the high incidence of rise among a closed, culturally isolated society known to have a high incidence of congenital malformations, may support previous assumptions that hse results from hyqperpyrexia, originating in most cases from a "physiologic" heat induced trigger which starts and peaks during the night in previously healthy infants with susceptible, predisposing genetic underlie. approximately % of hospitalised infants with respiratory syaacytial virus (rsv) infection require mechanical ventilation. our general practice is not to use specific antiviral therapy. we have undertaken studies of rsv-infected mechanically ventilated patients without underlying congenital heart disease or immunodeficiency. study i (n= ): a retrospective review of infants (mean post-conceptual age weeks; median duration of intubation was days (interquartile range - ). blinded review of chest x-rays during the first three days of mechanical ventilation revealed a spectrmn of lower respiratory tract findings from marked diffiase consolidation in all zones without hyper-inflation (n= ) to gross hyperinfiation without consolidation (n= ), with the remaining patients have an intermediate picture (n= ). death occurred only in patients who were at the poles of this continuum ( / consolidation and / hyperinflation). patients at these poles could be differentiated by gender predominance, birth gestation, alveolar-artarial (a-a) oxygen gradient (p< . l), oxygenation index (p< . l), peak inspiratory pressure (p< . ), and intubation days (p< . ). study ii (n= ): prospective audit of infants with the aim of verifying the above differentiation. separating patients based on their early x-rays and a-a gradient we confirmed the above predictable difference in duration of supportive therapy (consolidation v intermediate: ( - ) v ( - ) p< . ). severe lower respiratory tract rsv-infecrion in young infants results in different distinctive partems of disease with characteristic radiological and clinical features, and each has a predictable timecot~se. conflicting reports on special therapy should be interpreted with respect to these observations before making conclusions about the efficacy of any specific treatment. the clinical data of children wich suffered from a severe mycosis between jan. -dac. and wich were treated with amphotericin b in spanish hospitals were collected. mean age was + . years; were mate ( %) and female ( %). the most common underlying diseases were leukemimymphoma ( %) and congenital heart defects ( %). the major pathogens isolated were candida albieans ( %), other candida ( %) and aspergillus ( %). and liposomal amphotericin (la) in ( %). in the ca group, the starting dose was , ~ , mg/kg, reaching a maximal dose of . + , mg/kg after . + days. maintenance time was + days and the cumulative dose: ~ rag. in the la group, the starting dose was . ± mg/kg, reaching a maximal dose of . _+ . mg/kg (p< . ) after + days. maintenance time was ~ days (p< . ) and the cumulative dose _+ mg (p< . ). the reasons for la use were: elective in % of cases, previous renal failure in %, and ca inefficacy in %. hepatic or renal function impairment was two times more frequent in la group than in ca group, the antifungal efficacy was % for ca and % for la. therapeutic failure or toxicity induced withdraw of ca in % of cases, vs, , % for la (p< , ). mortality was not different in both groups ( vs. %), adverse effects were related to ca in events vs, only one in la group (p< , ). the commonest side effects in ca patients were fever ( %), chilis ( %) and nausea ( %). in ca group, cases ( %) developped analitical anormalities related with amphotericin, vs. cases ( %) in la patients (p< . ). in the first group, the commonest serum alterations were hypokaliemia ( %), raised creatinine ( %) and bilirrubin ( %). in the second one, hypokaliemia presented in % of cases (p< . ), raised bilirrubin in % and creatinine in % (p< , ), the antifungal efficacy of la is at least the same of ca. from the clinical and analitical points of view, la is much less toxic than ca. la can be used at a greater dose than ca and is safe in children with renal failure. laurence desplanques -serge gottot -christian dageville d~artement de sant~ publique -facult~ xavier bichat - rue henri huchard paris -france -the french << reaped ~> network was created to implement a nosecomial infections (ni) quality care program in nicu and picu, the first objective was to describe the annual ni incidence rate in each icu population : all patients stayed more than hours in icu. methods : n] criteria were defined by the reaped group according to cdc criteria. all data were collected by a medical and nursing team. all infection data were validated by an external investigator. results : patients were admitted over a months period. % were newborns. ni were identified among patients. the overall ni incidence rate (ir) was . % and . °/ person day (from . to . °/ according to age, lowest rate for newborns). septicemia ( % of ni) and pneumonia ( % of ni) were the two main ni. according to age, the septicemia ir varied from . to . °/oo catheter day (lowest rate for newborns) and the pneumonia ir from . to . °/ ventilator day (lowest rate for newborns). there were very few other infections (uti : %, ir : . °/ catheter day). gram positive cocci were isolated in % of septicemia ( % of them were coagulase negative staphylococcal). gram negative bacilli were isolated in % of pneumonia ( % of them were pseudomonas). % of ni were caused by candida, mostly septicemia. the septicemia and pneumonia ir varied according to unit even after adjustment for age. discussion the aminoglycoside antibiotics are frequently used in newborns for the treatment of severe infection and sepsis due to gram-negative microorganisms. the currently recommended dosage schedule for tobra ( . mg/kg q h) does not take into account differences in gestational or postnatal age during the first weeks of life. we questioned the validity of these recommendations and studied the population kinetics of tobramycin to establish predictive equations that enables the clinician to select the appropriate initial dosing schedule. methods tobra trough (t= ) and peak values (t= ) were taken on day - after birth in newborns. tobra was administered as a -minute intravenous infusion already in an adapted dosage schedule: . mg/kg q h in infants with gas < weeks; . mg/kg q h in infants with gas between - weeks and . mg/kg q h in infants with gas > wks, tobra concentrations were analyzed by tdx-assay, a one-compartment model was assumed and non-linear mixed effect modelling (using nonmem) was applied to the data, a trough level < mg/l and a peak level between and mg/l was required, with the present dosage scheme % of the trough levels were too high and almost % of the peak levels too low. calculations showed that the following dosage schedule should result in optimal levels of tobra. preterm infants gas < wks: mg q h preterm infants gas - wks: . mg q h preterm infants gas > wks: the currently recommended dosage schedules for toeira result in high trough and low peak levels. prolongation of the dosing interval and increasing the amount of drug per dose according to the above scheme will improve tobra level control. since january british clinicians have been conducting a randomized controlled trial of neonatal ecmo. mature infants (>- weeks gestation and birthweight kg) with severe cardiopulmonary failure have been randomized to receive continued care in their referring institution or referral to a designated ecmo centre for further management. we now present the preliminary results which have prompted closure of recruitment to this trial. the final outcome will be assessed as intact survival against death or severe disability at one year of age for all the recruited patients. patients were categorised by diagnosis such as isolated persistent fetal circulation, secondary persistent pulmonary hypertension of the newborn or congenital diaphragmatic hernia and by severity of illness at the point of first contact with the clinical coordinators of the trial -judged primarily by the oxygenation index ( before randomization). patients were randomized ( in each arm). hospital outcome data are reported for all patients and year outcomes on t ( survivors). at this stage of the babies allocated to ecmo are known to have died compared to of those allocated to conventional management (rr . ; % ci . - . ; p= . ). fewer deaths have been obsea-ved amongst ecmo allocated babies in all the diagnostic categories used. a % incidence of disability and impah~nent has been observed amongst survivors. this rate is similar in both groups and the survival advantage is not offset by an increased rate of disability or impairment following allocation to ecmo. we consider that these data combined with those available from other studies provide conclusive evidence that the survival to discharge from hospital is substantially higher in patients allocated to ecmo than in comparable infants not so allocated. therefore recruitment to this trial has been closed whist awaiting complete one year outcome data. sigston pe, goldman ap. #keating j. crook r. ~e dj~. great ormond street hospital for children nhs trust, and ~biochemistry department, kings college hospital, london, united kingdom. isoflurane is a safe and effective means of long term sedation in both children and adults in the intensive care setting. the use of isoflurane, by adding it to the sweep gas allows the use of this volatile anaesthetic agent in patients on ecmo, enabling rapid control and weaning of sedation. a potential problem with the long term use of isoflurane is fluoride ion accumulation with the possibility of renal toxicity, the purpose of this study was to assess plasma fluoride levels in patients receiving prolonged isoflurane on ecmo. method: fifteen infants and children (aged day - years, median weeks) receiving ecmo support for either cardiac or respiratory failure were recruited to this study. the patients were sedated with isoflurane as well as intravenous agents (morphine and midazolam). isoflurane was administered ( % - %) via a calibrated vaporiser to the sweep gas, adjusting the level to maintain adequate sedation. blood samples were obtained on a daily basis for plasma inorganic fluoride assay. the relationship between plasma fluoride and amount of isoflurane administered, as %-hours (vaporiser setting in % x hours) was calculated by linear regression. results: the duration of ecmo ranged from to (mean ) hours, during which the amount of isoflurane administered varied from to (mean ) %-hours. blood samples were anaiysed, demonstrating individual peak plasma fluoride levels of . to . #mol/ , mean , p.molli (toxic threshold = gruel/f). the plasma fluoride positively co;related with the %-hours of isoflurane (r = . , p = < . ). conclusion: this study shows that although there is a dose related accumulation of inorganic fluoride ions in patients sedated with isoflurane on ecmq, the peak fluoride levels are well below the suggested toxic threshold. merzel y, lev a, bar yosef g, halbertal m, lorber a ecmo center, picu, emek medical center, israel. the mortality rate of pediatric patients with acute myocarditis is - % according to the severity of myocardial damage. a month old gzrl presented with high fever, respiratory and cardiac failure. diagnosis of acute myocarditis was made and the patient was ventilated with high pressures and fio of . . she required high doses of inotropes. echocardiography revealed a dilated la and lv with severe mr. lvedd was mm and lvsf %. calculated oxygenation index was . she was resuscitated after a cardiac arrest. she was commenced on ecmo (using biomedicus centrifugal pump and avecor oxygenator) at a flow of ml/kg/mm with immediate improvement of hemodynamlcs, oxygenation and pc . resptratory assistance and vasoactive drugs were reduced. the patient was transported by air, on ecmo, to the ecmo cevter. she developed arf and cvvh-d was performed. cardiac fimction started to improve after days. ecmo was discontinued on day . echo revealed lvedd mm and lvsf %. ippv was discontinued on day . on discharge, a month later, her lvedd was mm and lvsf %. she behaves normally for age without neurologic or other medical sequellae. literature search revealed no case of acute myocarditis, as severe, that was treated successfully. survavors of disease this severe usually suffer dilated cardiomyopathy and permanent disability. the use of ecmo allows myocardial rest which prevents long term myocardial damage. introduction ecmo is increasingly used in the care of critically ill newborns. despite the frequent use of betalactam antibiotics in the treatment of these infants there are no data available on the dispbsition of cefotaxime (ctx) and amoxicilfin (am) d ring ecmo. the purposes of this study were to determine the pharmacokinetics of these two drugs in infants on ecmo and consequently formulate appropriate dosing regimens. we therefore studied the pharmacokinetics of ctx ( mg/kg ql h) and am ( mg/kg q h) in term infants on day after birth, blood samples were taken before (t-o) and . , , , , (am) and t h (ctx) after the intravenous bolus injection and analyzed by hplc-assays. . ctx mg/kg q h results in adequate serum levels of ctx in fullterm infants on ecmo, am mg/kg q h results in very high serum trough levels. recalculation based on the known volume of distribution and elimination serum half-life of these infants resulted in the following dosage recommendation: mg/kg q h. persistent pulmonary hypertension of the new-born (pphn) is characterised by rapid fluctuations in pulmonary artery pressure (pap) and a clinical impression of stifflungs. lung mechanics were measured in term infants, mean age . +_ . days who were paralysed and ventilated within the first three days of life. fourteen infants had pphn with systemic or suprasystemic pap measured by echocardiography. in these patients, the respiratory system resistance was . % higher (p < . ) and compliance . % lower (p = . ) during systemic or suprasystemic pap compared to when the pulmonary hypertension had resolved. in contrast, there were no changes in resistance in the infants with respiratory distress syndrome (rds) and no pulmonary hypertension or in the seven infants with normal lungs, where two readings were taken hours apart. the changes in lung mechanics interfered with mechanical ventilation, resulting in a . mmhg rise in paco (p= . ) during pulmonary hypertension. inhalation of nitric oxide ppm resulted in a % decrease in respiratory system resistance and an improvement in oxygenation. the bronchial and vascular smooth muscle was increased by % in postmortem lung samples from eight infants with pphn compared to six age matched post-mortem controls with normal lungs (p< . ). these findings suggest a co-constriction and co-hypertrophy of bronchial and vascular smooth muscle during pphn. anatomically the pulmonary vasculature and bronchi lie in close proximity to each other. thus mediators such as endothelin- released locally may act on both vascular and bronchial smooth muscle to produce the observed vasoconstriction, bronchoconstriction and smooth muscle hypertrophy. prince of wales children's hospital university of new south wales, randwick, n.s.w. australia. introduction an increasing mortality in asthmatic children has been reported. the increased severity of asthmatic illness leads to an increased demand for icu admission, and a corresponding increased need for mechanical ventilation. geographic end environmental factors are thought to be partly responsible for differences in disease sevedty throughout the wodd. for this reason, epidemiological studies from diverse areas are important, risk factors for icu admission, and for the institution of mechanical ventilation should be identified, to optimise icu admission criteria and to avoid unnecessary delays in admitting at-risk patients. aim to document the clinical characteristics of ventilated and non-ventilated asthmatic patients admitted to icu. methods this is a retrospective study of all paediatric asthma icu admissions from january to december . results there were patients admitted to the icu for acute severe asthma in the study period. the male:female ratio was : , the mean age . • . months, the mean prism . - . %, and the mean duration of admission . hours. there was no seasonal variation in admissions. only % ( / ) patients required mechanical ventilation. in % of all patients this was the first presentation with asthma. there were some significant differences between ventilated and non-ventilated patients (see table) . there was a significantly higher incidence of concomitant and nosocomial pneumonias in the ventilated patients ( . % vs . %) as well as segmental lung collapse ( . % vs . %). there were no deaths. discussion the need of mechanical ventilation significantly increases the morbidity of and duration of icu stay of asthmatic patients. younger asthmatic paediatdc patients have a significantly higher risk of ventilation. the need for ventilation is predicted principally from a worsening pco and respiratory acidaemia, which is often independently interpreted by the clinician as respira ory exhaustion. this study has shown that icu admission is important in the management of young paediatdc patients with acute severe asthma and respiratgry fa!!ure. intravenous salbutamoi in the emergency, department management of severe asthma in children. g.j.browne,a. perma,x. phung,m.soo westmead hospital, sydney, australia. it is postulate that if an initial intravenous loading dose of salbutamol is given in severe asthma, a more rapid clinical response will occur, reducing requirements for continued high doses of nebulised salbutamoi with fewer side effects. this double blinded study was conducted in the emergency department of westmead hospital a university hospital in sydney, australia. all children with severe asthma had initial nebuliser therapy ( rag of salbutamol with ml of saline). if asthma remained severe minutes later, they were given a dose of intravenous hydrocortisone ( mg/kg) and either normal saline or salbutamol microgm/kg intravenously. frequent nebulised salbutamoi therapy continued during the initial first hour if clinically indicated. continuous respiratory and haemodynamic monitoring occurred in the first hours. serum potassium and glucose determinations were made at study commencement and hour after intravenous therapy. salbutamol determination was made at study commencement. children remained clinically monitored for the next hours, with their ongoing treatment determined by clinical response. children with severe asthma months to years of age were studied, with given intravenous salbutamol and given intravenous saline. the intravenous satbutamol group (ivsg) showed rapid reduction in asthma severity scale in the first hours, with reduced need for high frequency nebuliser therapy ( _< hourly), occurring . hours.earlier. no clinically significant side-effects were found in either group, although, tremor more frequent in the [vsg. biochemistry and salbutamol concentrations were similar in both groups. the use of intravenous salbutamol (i microgm/kg) in the management of severe childhood asthma is a safe and effective therapy with no significant side-effects and the potential to abort severe asthma attacks in the emergency department. intravenous terbutaline in picu piva j., amantra s, rosso a., zambonato s, giugno k, maia t. introduction: the admission to a picu of children with respiratory failure secondary to an acute obstructive lower airway disease is a common event, especially during winter seasons. these diseases have several causes, but most of them (especially asthma and chronic airway disease) have a good response to the administration of b -adrenergic drugs. objective: to find the dosis of intravenous terbutaline that is safe, efficient and with minimal adverse effects when used in children admitted to a picu with acute obstructive lower airway disease and respiratory failure. material and methods: we study the records of all children that were admitted to our picu during the winter of . only the patients that had respiratory failure and acute lower airway disease and who needed the use of iv terbutaline were selected. the records were divided in two groups: less than months and more than a year old these two groups were compared in the following aspects: the minimal and maximal dosis, and the length of time of use of iv terbutaline, frequency of tachycardia, hypokalemia, and mechanical ventilation. to establish any difference in the two groups we use the t exact test of fisher and x , with p< . , results: during the period of study were admitted patients to the picu, and ( , %) of them used of iv terbutaline. the mean age was . + . month, used iv terbutaline during . + . days ( . to days), the initial rate was . + . p~g/kg/min, and the means of therapeutic dosis was . +l. ~g/kg/min (ranged from . to . ). twelve ( . %) patients had tachycardia art obstacle to the increases in the rate of use of iv terbutaline during any time. mechanical ventilation was necessary in patients ( . %) and ( . %) patients died. the children under year of age used initial dosis of iv terbutaline lower than the children up of year old ( . p.g/ kghnin x . ~tg &g/rain, p< . ), but without difference in the length of use, the maximal dosis, the rate of mechanical ventilation and tachycardia. the frequency of hypokalemia was most common in the group of children under year of age. acute respiratory failure during status asthmaticus may require mechanical ventilation. current therapy includes paralysis, pressure control ventilation (pcv) and permissive hypercapnia to limit pulmonary barotranma and its hemodynamic consequences. asthmatic children exert a significant amount of respiratory effort during exhalation. with paralysis, this expiratory effort is lost. unloading the inspiratory work of breathing while maintaining the patient's expiratory eftbrt using pressure support ventilation (psv), may be beneficial. methods: children receiving pcv (peak inspiratory pressure (pip) = kpa. rate breaths/min) and pco > kpa were switched to psv. children were initially ventilated with psv . kpa and peep = . kpa (servo c). all children received beta agonist therapy, ipratropium and anesthesia with ketamine or inhalational anesthesia, and were breathing spontaneously. respiratory parameters and blood gases are shown be~bre psv, within minutes (start) and when the ph had normalized (during). data are presented as median and range, * p < . compared to before psv. results: children with hypercarbia during pcv responded to psv, normalizing pcos and ph within hours. the mean respiratory rate decreased from a median of ( - ) to ( - ) while the pip was decreased to . ( . - . ) kpa within hours. the i:e ratio also significantly decreased. conclusion: psv permitted patients to active/y exhale while unloading the inspiratory work of breathing. perhaps this strategy shifts the patient's respiratory effort from inspiration to exhalation, thus permitting the child to meet the excess work of breathing caused by bronchoconstriction. maged z. youssef, peter silver, laura nimkoff, and mayer sagv. division of pediatric critical care medicine, schneider children's hospital, new hyde park, ny . introduction: mechanical vemiladon of patients with severe bronchospasm can be difficult, due to poor chest compliance and increased airway resistance. ketarmne is a cormnonly used anesthetic agent that has been shown to have bronchodilator properties. the purpose of this study was to determine ifa continuous infusion of ketamine had an effect on the oxygenation and chest compliance of children with severe lironchospasm who were mechanically ventilated. methods: a retrospective chart review was conducted of pediatric patients in severe bronchospasm who were mechanically ventilated in our picu and treated with a continuous ketamine infusion. all patients were receiving aggressive bronchodilator therapy and adequate sedation prior to keramine. patients were excluded if any new bronchodilator or sedative agents were started within hours of initiation of ketamine treatment. all patients were simultaneously treated with benzodiazepines. for each patient, the pao /fio ~ ratio and dynamic compliance [tidal volume/(peak imp. pressure -peep)] was determined immediately prior to ketamine, and at , , and hours post-ketsmine initiation. data are presented as mean ± s.d., and were a~yzed using one way anova and the multiple comparison method of bonferroni. patients (age . ± . yrs.) received * p< . ketamine for severe bronchospastu during mechanical ventilation in our picu. both . .xto-* * the pao /fio ratio and dynamic . . -.... . compliance increased significantly following initiation of the ketamine infusion (see figure) . the mean ketamine dose was ± mcg/kg/min, and the -, mean infusion duration was ± too-[/ hours. one patient required glycopyrrotate ~' to control excessive airway secretions, and " one patient required an additional dose of o--j i ~-~ ~/me diazepam to control hallucinations after i cessation of ketamine. all patients were t~n~,mr~ *~am~ successfully weaned off mechanical ~l~s ~,~s~on ventilation and discharged from the picu. conclusion: continuous ketamine infusion to mechanically ventilated pediatric patients with refractory broncliospasm results in a significant improvement in oxygenation and dynamic compliance of the chest. reports of adults with status nsthraaticus document significant morbidity and mortality, whereas studies in children have had more varied results. different centers report mechanical ventilation (mv) in to % of admissions, occurrence of pneumothoraces or paeutuomediastinums in to %, and mortality in up to % of patients ~'t . we retrospectively reviewed status asthmaticus admissions to the pediatric intensive care unit (picu) between january and december . seventy-five of these patients were admitted fr~an the emergency department of chla (er admit). the mean length of stay in the picu was . days and the mean length of stay in the hospital was . days. based on patients who had arterial blood analyses, patients had hyperoapnia (pco > ). all patients received oxygen, inhaled albuterol (alb), and cortieosteroid therapy. ninety-five percent of patients also received methylxanthine (mx) therapy. of the admissions, patients ( %) required mv. only of these patients were admitted through our emergency department, whereas the remaining patients were intuhated at outside facilities. twenty-three cases required intr:wenous beta-agonist therapy, either isoproterenol osop) or terbutaline (terb). h~ff of the ea.~es re~%wed were complicated with hypokalemia (k+< . ). c,', ,~lications ofpoeumothoraces or pneumomediastinums were seen in % of ,'r:u~ported patients, but in only % of er admit patients. only % of these were in mechanic.all, )atients. there were no deaths in the review. respiratory mechanics measurements 'are useful in mechanically ventilated children to optimize ventilator settings. nevertheless, the transducers used to measure flow (f) and pressure (p) remain expensive. objective. to evaluate the performances of piezoelectric p transducers ( us dollar) in measuring f and p. methods. we used a previously described monitoring system measuring respiratory parameters [ ] . in this study f was obtained by a differential piezoelectric p transducer (_+ . cmi-i , honeywell) whose sensitivity has been reduced to +_ cmh by an electronic amplification equipment and p by a piezoelectric p transducer (_+ (). cmhzo, honeywell) connected to a grid pneumotachymeter &nt) ffleisch or ). volume (v) ( to ml) obtained by numeric integration off ( . to l/rnin ) and p ( to cmh ) were respectively delivered through a calibrated seringe and an electronical manometer (pic premier) and calculated by the computer. bland and altman analysis was used for assessment of results bias. coefficient of repeatability (cr) was estimated by the standard deviation of repeated measurements of the parameters as calculated in a oneway analysis of variance. results. mean difference (mdi between injected v ( to ml) and measured v using pnt was . ml, sd = . ml. difference and mean v were not correlated. sd of repeated v measurements were not correlated to v. cr was . ml. mdif between injected v ( to ml) and measured v using pnt was lrd, sd = ml sd of repeated v measurements were not correlated to mean v. cr was ml. mdif between injected p and measured p was . cmi-i , sd . cm h sd of repeated p measurements were not correlated to mean p. cr was . cmh . conclusion. inexpensive piezoelectrical transducers can be used to measure f and p and evaluate respiratory mechanics in ventilated children. previous studies have already shown the problem of the reproducibility of pft in preterm ventilated babies. were studied preterm ventilated babies {mean weight gr) in the first week of life in clinically stable condition, measuring flow, airway pressure and esophageal pressure simultaneously. each baby was studied twice with an interval of one hour and each study was done increasing the rate till to inhibit spontaneous breaths. none sedative has been used. only mechanical breaths were analyzed. compliance and resistence were calculated with a computer system using the linear regression method. we expressed quantitatively the intrapatient variability as the percentage of variation of tidal volume, compliance and resistence between the two studies in each baby. then intraclass correlation coefficient test (icc) was applied to confirm qualitatively our results (total agreement = , good reproducibjtity > . ). we h~£ed, an a eept~ble ~efiabirl¢, ~-~r;= '~ . during mechanical ventilation, an air leak (al) and plateau phase duration (pl) may influence dynamic and static compliance (cdy and cst, respectively). this study evaluated the effect of al and pl on two methods of measuring c.dy and est. methods. intubated, ventilated patients in a pediatric intensive care unit were evaluated after obtaining informed consent. patients were intuhated with a cuffed endotracheal tube and ventilated with a serve ( ventilator. cdy and cst were determined using the serve ands~rmedics . objective: evaluate the repercussion in respiratory mechanics and arterial blood gases and the impact of the ventilator adjustments on the auto-peep magnitude. material and methods: the measurement of the auto-peep was performed using an eletronic-pneumatic controlled device with a oclasion valve installed between endotracheal canutla and the ventilator circuit. the d~'ice was connected to a solenoid to detecte the end of inspiratuo phase and thus, the activation of the oclusion valve. the signs of pressure and flow were monitorized using a diferential transducer and it was processed using a pc computer and tmeumoview® software. the stud were divided in phases: phase a. where the ventilator adjustments was performed using the routine of the unit and phase b, where the targets of mechanical ventilation were to minimize the auto-peep. static compliance (crs) was ineasured by the single-breath occlusion technique, using a mean of ten occlusions for analysis. passive respiratory resistance measurements and the tidal breathing flow-volume loops were also obtained., while the ventilatory settings were siguificantly reduced soon atier ecmo was started. before ecmo crs measured in all patienls was . _+t). ml/cmh /kg (mean_+sem). for each patient the ecmo course was divided into four periods, proportional to the duration of the treatment, and the best ~alue of crs in each period was chosen for analysis. as shown on the figure. crs significantly improved (*p< , ) from the second half of the ecmo course in the group of patient that finally were successfidly weaned from ecmo. no change ill compliance was measured in the group of patients who failed to respond to the extracorporeal hmg support our data suggest that compliance measurements during ecmo can be useful togelher with overall clinical evaluation to predict both outcome and duration of cxtracorporeai support in the neonatal and pediatric population. objectives: brain temperature determines the amount of neuronal damage caused by hypoxic insults. thus measuring brain temperature at standardised conditions is in request. we investigated whether brain temperature of neonates varies with head insulation environmental temperature, body activity and time course. patients and methods: we investigated non-invasive brain temperature analogues in healthy prematures tess than two weeks of age in an incubator (gestational age . + . wks; x + sd, weight + g). we measured nasopharyngeal temperature (tnasoph) by a thermistor placed in the nasopharynx via a feeding tube, zero-heatflux temperature (zht) at the temple by a thermistor and healflux transducer, insulated by two pads, as well as rectal and incubator temperatures. patient activity was documented by video taping. measurements were performed during periods of increased insulation ) by turning the head with its measuring site on to the mattress ( ( ) ( ) - ( ) ( ) ( ) ( ) . ( ) ( ) { ) ( ) ( ) - ( ) ( ) ( )i ( ) ( ) ( ) ( ) . ( ) ( ) t ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) web (lmg/kg) at rain ( ) - ( ) ( ) ( ) ( ) - ( ) the vehicle had no effect. paf caused dose dependent rise in ao and pa pressure and reduction in flow to lpa (up to % like the vascular endothelium, the endocardial endothelium (ee) has a significant impact on adjacent myocytes, and may critically alter myocardial function.~ we have previously shown that ee cells are capable of sensing and responding to hypoxia by the release of prostacyclin (pgl). potassium channels in other cell types have been reported to be oxygen sensitive. to determine whether potassium channels modulate the ee hypoxic response, we investigated the effects of three potassium channel inhibitors on hypoxia-induced pg] release from ee cells. methods: ovine endothelial cells were harvested and passaged onto ,~ microcarriers. cells were constantly perfused with normoxic and hypoxic kreb's solution, and with three potassium channel blockers: glibenclamide (gb, #g/ml), tetraethyl-antmonium (tea, ram) and aminopyridine ( ap, i mm), perfusate was assayed for prostacyclin (ria). data were compared by analysis of variance. * p<. compared to normoxic control; # p< . compared to hypoxic control. adrenaline is extensively used for resuscitation in neonates with rds. however, effects of adrenaline on systemic, pulmonary and cerebral hemodynamics have not been defined in newborns with rds. thirteen anesthetized, and ventilated newborn piglets were subjected to repeated saline lung-lavage series while mean systemic arterial pressure (abp), mean pulmonary arteriat pressure (pap), mean left atrial pressure (lap) and mean central venous pressure (cvp), cardiac output and blood flow in the internal carotid artery (ica) were measured. systemic vascular resistance (s~), pulmonary vascular resistance (pvr) and cardiac index (ci) were calculated. sixty minutes after luug-lavage, the adrenaline group (a) (n= ) received adrenaline as a continuous infusion of . lag/kg/mi, while the control group (c) (n= ) received saline. none of the varlables were changed by saline. however, significant increases in abp (p< . ), pap (p< . ), ci (p< . ) and svr (p< . ) were observed after administration of adrenaline, whiie pvr and ica were not modified. mean±sd for abp/pap (p/a), fvr/svr (p/s) and ci (ml/mirdkg) were: ratios of pap/abp and pvpjsvr significantly increased following infusion of adrenaline. these data suggest: ) the cerebral perfusion is preserved during the infusion of adrenaline; ) effect of the adrenaline infusion on the systemic circulation is more pronounced than its effect on the pulmonary circulation in newborn piglets with surfactant deficiency. s demirak~a, ch knothe, kj hagel, j bauer department of pediatrics, justus-liebig-university giessen, frg inhaled no is a short acting selective pulmonary vasodilator. we studied the effects of ppm no and % oxygen during heart catheterization in children (age - years, median years) with heart defects and elevated pulmonary vascular resistance index (pvri) in order to asses the value of no as a tool of decision making for corrective cardiac surgery. patients were eligible for testing when they were more than one year old and had a pathologically elevated pvri in a previous heart catheterization. intubation, 'anesthesia and muscle paralysis were performed in all patients during testing of pulmonary reagibility. calculations of pulmonary vascular resistance and flow were based on the fick method. response to no was assumed when pvri declined more than %, of the patients were responders to no. effects of no and oxygen on pvri, mean pulmonary arterial pressure (mpap) and pulmonary vascular flow (qp) in all responders are described in the table below. cardiac surgery was offered to all responders, and of them were successfully operated. surgery is planned in another patients and parental consent for surgery was not given in one patient. in ebstein disease, during the first days of life, the ability of right ventricle to propel blood to the pulmonary artery is impaired due to high pulmonary vascular resistances. the flow is mainly directed to left atrium through tricuspid insufficiency, right atrium and foramen ovale. to decrease pulmonary resistances and increase pulmonary blood flow, high frequency oscillations, mechanical ventilation, nitric oxide and prostaglandin are required. after few days, a forward circulation is normally established. we cared two newborns with ebstein disease where this approach was hindered by a large pulmonary valve insufficiency. both of them were diagnosed in utero, showing a large tricuspid insufficiency with a non opened pulmonary valve and a ductal left to right shunt. one fetus was hydropic. at birth, blood stream from the ductus arteriosus was directed to the right ventricle through the pulmonary valve insufficiency then to right atrium, left atrium and ventricle, aorta and ductus arteriosus. a low pulmonary blood flow was demonstrated by low mean velocities ( cm/sec). a high reverse flow was seen in descending aorta with a negative flow in the renal artery. both of these newborns were oliguric because of ductus arteriosus steal. pulmonary blood flow doppler evaluation allowed different strategies of ventilation, switching between hfo and conventional ventilation, modulation of pge doses, inhaled pulmonary vasodilators (nitric oxide) and surfactant. the hydropic baby died, the other survived after weeks of intensive care complicated by supraventricular arythmia (wpw). in conclusion, during neonatal period, in ebstein disease, a large pulmonary insufficiency leads to a vicious circle where lungs are excluded, inducing severe asphyxia and high pulmonary resistances. the blood is backward propeled from the aorta through the ductus arteriosus to the right ventricle and atria, then left cavities to aorta. arec must be considered when pulmonary blood flow does not increase despite optimal therapy. guti~rrez-larraya f*, mandoza a*, velasco jm*, zavaneua ( **, gatindo a ~, s&nchez-andrede r, s&nchez jl***, mellon a***, mar f***. pediatric cardiology*, pediatric cardiac surgery**, pediatric intensive care unit***. hospital de octubre. madrid. background: transesophageal pacing (tp) is effective and sate both for diagnosis and treatment of pediatric arrhythmias. material and methods. eleven consecutive patients are included. a tri or quaddpolar or f temporal transvenous catheter with an interpolar distance of to mm was advanced through the nares and positioned to the point with the largest amplitude of atrial deflection, surface ecg and a bi or monopolar electregram were recorded simultaneously, selecting filters when needed ( to mhz). pacing was performed with a programmable stimulator (medtronic ) beginning with ms and increasing ma to and then increasing up to . ms. narula method was selected to diagnose sinusal node disfunction (snd) and overdrive pacing to treat tachyarrhythmias. results. tp was useful in all the patients and no complications were observed: in patients a snd was diagnosed (one needing a definitive pacemaker), in two patients with atrial ratter (ripe ) sinus rhythm was recovered, in one patient with a postoperative junctional ectopic tachycadia we were able to get atrial synchrony with marked bemodinamic improvement, and patients with paroxysmal supraventricular tachycardia sinus rhythm was easily and quickly restored ( of them recquirad repited episodes of tp until pharmacelogycal levels of antiarrhythmic drugs were raised). mean age and weight were months and . kg (one patient had . kg). there was a close relation between height and depht insertion (r= . ). mean stimulation parameters were , ms and . ma. discussion. in experiencied hands tp is an effective and safe way to treat and diagnose cardiac arrhythmias even in newborns. it should be tried before endovenous pacing is stablished and it is faster than pharmacologycal treatment. bailing g., eicken a., sebening w., vogt m., schumacher g., bl~hlmeyer k.; kinderkardiologie, deutsches herzzentrum m nchen, germany to assess the outcome of balloon valvuloplasty in infants with cardiac failure caused by critical aortic stenosis a retrospective study was performed. between and neonates, aged - days (median d), weight .t - , kg (median , kg) with critical valvar aortic stenosis were dilated by balloon (aovp) as the first line treatment. patients received prostaglandin el, needed inotropic drugs and mechanical ventilation. associated cardiac lesions : persistent ductus arteriosus (pda) in patients (restrictive pda in cases), a mitral regurgitation (mivr) in cases ( severe and moderate or mild mivr), angiographic findings of endocardial fibroelastosis (efe) in patients, mitral stenosis (mivs) in , coarctation of the aorta (coa) in , and finally a small musculary ventricular septum defect (vsd) in i patient. vascular approach for ballooning : a. axitfaris in cases ( %) a. femoralis in t ( %) and v. femoralis in cases ( %). the median ratio between inflated balloon and aortic valve diameter was , . dilatation was achieved in all cases. the peak systolic gradient across the aortic valve (pre aovp) ranged from to mmhg (median mmhg) and was reduced to to mmhg (median ; gradient reduction is significant (p < , )). aortic regurgitation (aovr) was absent or mild in , moderate in and severe in patient after aovp. children survived (actual suwival rate: %; early mortalffy: n = ; late mortality: n = ). mid term follow up ( - , years; mean , years) showed an increase of the systolic peak doppler gradient across the aortic valve (median mmhg) but no increase of aovr. re-interventions (re-aovp: n = , commissurotomy: n = , mitral valve replacement n = , resection of subaortic stenosis: n = , resection of coarctation: n = ,vsd-closura: n = ) were performed in patients. rv contractility and pulmonary vascular mechanics(pvm) in immature animal models are poorly underslood. we developed an acute rv injury model to measure rv contractility and pvm in response to commonly used cateehalamines. ten anesthetized piglets ( - kg) were instrumented with micromanometers in the lv, rv, pa, and la. a pulmonary artery flow probe was placed to measure cardiac output(qpa). ultrasonic dimension crystals were sutured to the myocardium and dynamic chamber volumes estimated using shell subtraction methodology. rv injury was induced with - cryoprobe injuries at - to - °c for - minmes each. da at mg/kg/min, db at mg/kg/min, and ep at . mg/kg/min were infused in random order. rv contractility was evaluated by calculating a load independent measure of contractility, the preload recmitable stroke work(prsw), during vena caval occlusions. to describe pvm, input resistances), characteristic impedance(z ), total pewer(tp), and efficieacy f=qimo"p) were measured. measurements were made pre-and post-injury, during infusions, and between infusions. clyoablation decreased prsw ( . _+ . to . + . , p< . ). at the end of the experiment, prsw remained depressed to this level indicating stability of the model. one factor contributing to organ dysfunction for infants undergoing repair of congenital heart defects (chd) is their "inflammatory response" to cardiopulmonary bypass (cpb). this response is characterized by an increase in cytokine release, complement activation and endothelial injury. modified ultrafiltration (muf) is a method for removing tissue water and inflammatory mediators by rapid ultrafiltration followin~ cpb, muf may acutely improve post-operative end organ function. in this study, we evaluated the effects of muf on the pulmonary and cerebral function of infants undergoing cpb for repair of chd. we prosnecrivety randomized infants (.~ mos) to either muf (n= ) or no muf (n= )(control) following correction for chd. the study intervals were ) before cpb, ) immediately after cpb, and ) minutes after cpb. pulmonary function was evaluated by measuring dynamic compliance (cdyn) and airway resistance (raw). for pts (mue= pts; control= pts) exposed to a period of deep hypothermie circulatory arrest (dhca), cerebral metabolism (cmro ) was calculated at each interval using the xe clearance technique for cerebral blood flow measurements and arterial and jugular bulb saturation measurements to calculate cmro . a reduction in cmro has been consistently demonstrated after dhca. the effects of muf on cdyn and on cmro are shown below: p< . vs pre-cpb; # p< . vs post-cpb • p--o. vs. post-cpb this study demonstrates that immediately following exposure to cpb, muf will improve pulmonary compliance. raw was not different between groups. there was no significant difference in hours of post-op ventilation for either group. in those pts exposed to dhca a trend towards better cerebral metabolic recovery compared to control was demonstrated. this is the first technique applied to infants undergoing dhca where cmro after cpb was greater than precpb measm~s. although this may be beneficial to postoperative hemodynamics, ventilatory management and long-term neurologic recovery, more patients and longer follow up will be necessary to verify such an effect. the effects of conventional mechanical ventilation (cmv) on left ventricular (lv). diastolic filling in neonates are not well established. one approach to improve lv filling is the use of cmv to provide a phasic increase in airway pressure {thoracic augmentation). this phasic increase in airway pressure may result in an increase in lv filling similar to that which occurs with cpr. thoracic augmentation has not been evaluated in neonates with ventricular dysfunction who frequently demonstrate increased heart rates. attempts to maintain low peak airway pressures during cmv may result in a prolonged inspiratory time that occurs over multiple cardiac cycles. this may alter lv filling in the later cardiac cycles. to determine the effects of inspiratory time on lv diastolic filling, infants were examined with doppler echocardiography less than hrs after surgery for the arterial switch procedtme. pulsed doppler recordings of the millal valve (mv) were obtained with the inspiratory time adjusted to occur over cardiac cycles ( sec.). a pressure transducer was placed in line with the ventilator, and the respiratory cycle was recorded superimposed on the doppler tracing to provide accurate determination of inspiration and expiration. doppler recordings were obtained from the apical -chamber view and the following measurements were made: peak e and peak a velocities, eia ratio, and deceleration time. compared to the expiratory phase of cmv, the initial beat during the iuspiratory phase of cmv resulted in an increase in mv peak e (. +-. vs . -+ . m/s, p< . ) and peak a (. + . vs . -+ . m/s, p< . ) velocities with no change in mv deceleration times (p<. ). compared to the initial beat during tile inspiratory phase, the third beat during the inspiratory phase resulted in decreased peak e (. + . vs . + . m/s, p< . ) and peak a (. + . vs . + . m/s, p< . ) velocities with no difference in deceleration times. thus, cmv augments lv filling during the initial phase of inspiration. however, as the increase in airway pressure is distributed over multiple cardiac cycles, lv filling falls below baseline levels. these observations indicate that while thoracic augmentation may be beneficial, to optimize lv filling the inspiratory time of cmv must be < cardiac cycles. energy expenditure in pediatric orthotopic liver tranaplantat~on, to determine the actual calorie requirements of critically ill children and evniuate the correlations between measured, stress-p~lictod and repleted energy exponditttm and the severity of illness. des/gn: a prospective, dinlcal study. se~ng: tertiary care pediatric icu in a university hospital. patients: ten patients aged to months with disorders prompting picu admission, including sepsis, respiratory failure, solid organ transplantation, and cardiovascular surgery. inta~entions: all patients were studied within hrs of major surgery or transplantation, or following acute illness. all patienls were severely stressed clinically and all but two were intubated by cuffed tubes, in three of them, still in a stress state, the study repeated on the third day of the disease, energy expenditure mensurements (mee), as well as illness seventy scoring systems, mtfltisystern organ failure scores and various anthropemetric and clinical indices of nutritional status, the stress-predicted energy expenditure (s-pee), the basal metabufie rote (pbmr), the repleted energy (re) and the recommended dietary allowances (rda) were measured or calculated in each patient. multiple regression analysis was used to analyze the data. measurements and main results: although the mean mee was significantly lower than the mean s-pee ( . + kcal/kg/day vs. . : kcal/kg/day, p<. ), it did not differ significantly from the pbmr (mean difference - . kcal/kg/day, range - . to + . kcal/kg/day). the s-pee/mee ratio ranged from . to . , while the re/rda ratio ( . : kcal/kg/day)/( . : kcal/kg/dny) ranged from only . to . . the prism/tiss ratio was not correlated better with mee than the diagnostic category (r~=. vs.. , respectively). the re was positively correlated withthe mee (rz=. , i)=. ) while negative oarrelatian has been found between mee and age, mid-arm circumference, triceps skinfotd and the use of vaseactive agents (r~. , - , -. , p<. and -. resp~lively). concl.m~: if s-pee is used for caloric repletion in the stressed oritic~ly fll el~d, these patients will be substantially overfed by as much as %. although pbmr appears to approximate the mee by ± %, other clinical and nutritional indices should also be ennsidered. objective: to deter .mine..t.he metabpli.c and.nutritional state of mechanically ventilated intants and children m relatmn wlm severity or msease. patients and methods: mechanically ventilated infants and children, median age months (range days to years), were studied. severity of illness was assessed using prism, prism-ii~ and fiss-scores. oxygen consumption (vo ), energy expenditure (mee) and respiratory quotient (rq) were determmed by mdirect calorimetry. total urinary nitroger(tun) and creatinine excretion, levels of albumin and crp were aetermmed in patients. in these patients daily caloric intake and substrate utilization were assessed. they were categorized in subgroups: a partial feeding (recent admission to p cu); b complete feeding. results: mee of the total group (n= ) a) i=intake g/kg/day (% total intake); u=utilization g/kg/day (% total production). nitrogenba]ance was negative in all patients in group a (mean - . -- : mffkg/day) and positive in all but one patient in group b (.mean . ± .d n~g/..kg/day;p= . ). no significant correlations were round between creatinine height index, crp, albumine, jun vs v u /kg conclusions: the mean measured energy expenditure does not exceed predicted resting energy expenditure, but ~ere is a wide range. in a majority ot patients with complete feeding h.igh carbohydrate intake resulted, in high kq and lipogenesis. in patients witla partial teeding the highly negatwe nitrogen'balance suggests that in the early phase of diseasean higher protein intake should be provided. severity of illness scores ann oiocnemicm markers of physiologic stress correlatedpoorly with oxygen consumption. leite,hp; iglesias, s; faria, c; ikeda, a; albuquerque, mp; carvalho, wb pediatric icu -s~o paulo federal university -s~o paulo, brazil objectives: ) to evaluate patterns of use and monitoring of nutritional support in critically ill children; ) to evaluate an education program in nutrition support given throughout the resident physician training in the pediatric icu. patients and methods: records of patients receiving nutritional support during were reviewed. aider this first phase, knowledge and understanding of the role of nutrition support was conveyed to the residents through didactic lectures. in a second phase thedata were reevaluated in children who were given nutrition support in . results: from a total of days ofthempy, the single parenteral route was utilized in , %, the digestive route (tube feeding or oral route) in , %. of this time. a previous nutr~ional assessment was performed in children; no patient had the nutr~on goals set. the nitrogen to nonprotein calories ratio ranged among : and : . only , % of the patients had their estimated caloric needs supplied and this goal was achieved only in those patients who were on enteral tube feeding. patients did not achieved their goals for vitamins. the supply ofoligonleme~s was adequate except the zinc. nutritional monitoring parameters including weight, serum albumin and serum triglycerides were performed in almost all the patients but without uniformity. the reevaluation ofthase parameters showed adequacy of protein and micronutrients supply; however deficiency in nutritional monitoring and infrequent enteral feeding were still detected. conclusion: there were lacks in the implementation of nutritional support, which were partially corrected in the rid phase of the study, although the training of residents may have contributed to give them cognitive skills, it didn't changed policies and procedures as desired. we recommend reinforcement of the education program concerning basic nutritional aspects, and the organization ofa multidisciplinary team in charge of coordinating the providing of nutritional support. plasme free fatty acids (ffa) are the meier energy source for mast tissues. during fasting ffa are released from the breakdown af triglycefides in edipose lissue (at). lipalysis, le. the rote of release o/ ffa, has been megsured in humans by means of stable isotope techniques using labeled pa or glyeerd as traces. no information is avoilob!e io dale on the ro of la. we infused albumin hound u c-pa and u c-la in critically ill infants, receiving kcel/kg/doy of iv glucose end na oral feeding (weight . ,i., kg;, range . - . ; ego : days, range ) and measured simultaneously the ra of pa and la from (he isotopic enrichment of plasma fea by gas chromatography-mass speclrome|ry ai : , : and : hours from tile shod of the infusion. a subcutaneous gluted at biopsy was obtained far fatty acid (fa) composition. we intended to ( ) in fie infants sbjdied atipa ~'os hi her than attla (~p<o.o )' and ihe ra of pa was higher then thai of la (~p= . §). however the ratio el the re's to the respeclive fa in at was higher for la than far pa (*p= . ). in conclusion the ra af la was higher then expected from ~he fa composition of at. we speculate [hat la is preferentially released during tipolysis and its contributuion to the energy metnbolism of the sick infonl could io !orger than what: is normai!y assumed from ihe fa composilion of at and of plasma fea. preoperative starvation can be prevented in infants undergoing non gi surgery by continuing feeds till as long as it is safe to do so. some gi disorders require withholding of feeds for a long period. for these and for infants already suffering from pem~ parenteral feeds are given preoperatively. peroperatively nutrition is maintained by ensuring adequate glucose supply in the infusion fluid and its smooth metabolism. proper placement of feeding tubes are also carried out peroperatively. postoperative early resumption of oral feeds is ensured by new techniques of anaesthesia and pain relief and methods to ensure early return of peristalsis. enteral feeds of pre digested substances and feeds through transanastomotic tubes and through gastrostomies and jejunostomies can prevent starvation in many situations. parenteral feeding is carried out only when enteral feeding is not possible, for example in necrotising enterocolitis~ gastroschisis, short gut syndrome, high enteric fistula and acute pancreatltls. the artedal ketone body ratio (akbr) is established as a valuable tool in the management of adult patients undergoing surgery for severe liver disease.the redox theory emphasises the central role of the liver in preserving homeostasis and the importance of the hepatic mitochonddal redox potential (nad+/nadh) in monitoring liver function and integrity.the akbr (plasma acetoacetate/ hydroxybutyrate) is a measure of hepatic mitochonddal redox status, reduced ratios associated with poorer outcome. the venous ketone body ratio (vkbr) is influenced by peripheral ketone utilisation and therefore thought unreliable in assessing hepatic redox its use has been dismissed as no correlation with the ratio in hepatic venous blood was found. inspite of this. vkbr is used in the diagnosis of lactic acidoses and respiratory chain defects. the objective of this study was to determine the relationship between the akbr and vkbr in a paediatnc intensive care population. children admitted to the paediatdc intensive care unit, with indwelling arterial and central venous lines as part of their routine care, were recruited for the study. the median (range) age was . years ( - . years) with prism score ( - ), simultaneous akbr and vkbr were measured. suppression of ketogenesis was confirmed using a rapid -hydroxybutyrate strip test (ketofilm, genzyme diagnostics) pdor to sampling. the median vkbr . (range . - . ) was lower than median akbr . (range . - , ), there was good agreement between artedal and venous ratios, bland-altman analysis giving a % confidence interval for relative bias of - . to - . . there was a significant correlation between vkbr and akbr r , , p, . (intercept . , slope , ) conclusions; values for akbr tend to be higher than vkbr, however there is a consistent relationship in critically ill children. in paediatdc patients in whom ketogenesis is suppressed, vkbr may be considered equivalent to akbr. this simple test may prove to be a useful adjunct in predicting mortality in cdt{cally ill children. to understand the present status of pediatric intensive care in china, we conducted a survey between october and december, , involving hospitals in provinces and municipalities. the results showed that there were totally icus for pediatric patients, including pediatric icus (picu), neonatal icus (nicu) and pediatric surgical icus (sicu), with total of beds. the physicians to bed and nurses to bed ratios were : . and : . respectively. the average number of equipment per bed was . ventilator, . multi-fnnction monitor and . infusion pump. very few of the icus had portable x-ray machine, biochemical and blood gas analyzers, and hemodialysis machines. the most frequently treated diseases/conditions were pneumonia, intracraniat infections, post-operation and sepsis in picus, and neonatal pneumonia, hypoxic ischemic encephalopathy and sclerema in nicus. pneumonia and respiratory failure accounted for . % and . % of all the diseases/conditions treated in the icus and the mean case fatality rate of respiratory failure was . %. the results of the survey suggest that there is shortage of tcu beds and modern equipment, and treatment is often delayed due to excessively strict criteria for mechanical ventilation. a set of simple, and nationally acceptable criteria for evaluation of severity and cure of the diseases/conditions is urgently required. the medical reports of children were reviewed and each admission was analysed in terms of age, sex, diagnosis, management within the hosp~al, length of hospital stay and type of poisoning. the youngest age was days and the oldest was years. hundred and twelve ( . %) of the children were girls and ( . %) were boys. the most common ( . %) reason of admission was intoxication among all of the cases and the greatest group ( . %) of the poisoned children had ingested medication which was followed by another group of patients ( . %) who had eaten mushrooms. the peak incidence of drug ingestion was salicylate intoxication ( %). forty drug poisoninigs were accidental while was intentional. the majority ( . %) of the cases that committed suicide was between and t years old, and the main cause of suicide was being unsuccessful at school. we conclude that poisoning -especially salicylate intoxication -is still a major problem in turkey and we believe that emphasis on the need to stere all kinds of drugs in a secure place and re-examination of a chin resistant packaging should help to reduce childhood poisoning significantly which is a preventable condition. included were all patients who died in the hospital, except those treated in the neonatal icu (predominantly premature and sga newborns) and those who died in the emergency room. among a total of hospital admissions (excluding the neonatal icu and emergency room), patients died ( . %). of these patients ( %) died in the pediatric icu, ( %) in the ward and ( %) in the operating room. a chronic underlying disease was present in ( %). withholding or withdrawal of therapy was implemented in ( %) children, ( %) died due to failed cpr, ( %) were brain dead and ( %) died following a dnr order. justification for therapeutic restrictions in the patients of the dnr and w/w groups was imminent death in ( %), lack of future relational potential in ( %) and excessive health burden in ( %). withdrawal or withholding of therapy was carried out by extubation in %, vasoactive drugs were stopped in %, and mechanical ventilation was withdrawn in %, analgetics and sedatives were frequently used (in % and %, respectively). hence decisions concerning restrictions of treatment are common in pediatric practice, mostly due to imminent death. patients in which treatment was restricted were characterised by a longer hospital stay, a worse prognosis, a higher frequency of chronic underlying diseases and a lower acute mortality risk. despite restrictions of intensive therapy, most patients were allowed to die in the pediatric icu. background microalbuminuria (mca), a subclinical increase in urinary albumin, reflects glomerular and overall vascular permeability " . an increase in urinary excretion of albumin occurs after burns and trauma. transcanillary albumin escape rate is also increased in response to elective surgery and in critically ill adult patients . we investigated a possible relationship between urinary albumin levels and clinical instability, as measured by pediatric risk of mortality (prism) scores. method we studied consecutive patients (median age of months, range - ). patients whith nephropathies or any abnormality of urine analysis were excluded from the analysis. prism scores, mca (mg. - ) (immunonepbelometric) and urinary creatinine (cu) (mmol.l -!) (jaffb) ( hour collection sample) were determined within hours from admission to the picu. the mca/cu ratio (mg.mmol. "l) was used to correct for urine output variability. diagnoses included respiratory failure ( ), postoperative ( ), neurologic ( ), sepsis ( ), trauma ( ) and miscellaneous cases ( ). pearson's correlation was performed to correlate data. results and conclusions. mean prism score and mca/cu were . ± . sd and - sd, respectively. a significant correlation was found between mca/cu and prism scores (r= . , p< . ). our observations show that, independently of the initial insult, the paediatric unstable patient may have increased capillary permeability, which is correlated with the degree of physiological derangement, as measured by prism scores. microalbuminuria can be rapidly determined since it is routinely used in the management of diabetic patients, it is inexpensive, simple to measure and blood-spearing. therefore, it might have a role in the clinical assessment of capillary permeability and transcapillary albumin escape worldwide the demand for paediatric intensive care services exceeds the supply. in developing countries sporadic access to such services alters expectation of care and can lead to children being either mechanically or handventilated in general paediatric wards. the outcome of children requiring ventilation in a major teaching hospital in india was reviewed.children were ventilated on an adult intensive care unit (aicu) if a bed was available, otherwise in the general paediatric wards. over a year period children were ventilated on aicu with deaths. yearly mortality rates varied between - %. over a month period patients were ventilated on the paediatric wards. of the p~tients over weeks of age died (chi squared .t >p> . ) reasons for the higher mortality rate on the paediatric ward likely include the higher patient:nurse ratio, and more limited resources. a predictor of mortality based on simple physiological observations without the need for expensive blood tests and including chronic health status would be a useful tool. the establishment of a paediatric intensive care unit is proposed to redress the balance of care. to assess the performance of the pediatric intensive care unit of hospital dona estef~nia by an international standard score, the authors did a prospective study of consecutive admissions to the unit during a period of months. mean age was . _+ . months; mean lengh of stay was . + . days. the effectiveness and efficiency were determined by the admission prism. admission efficiency was defined by two criteria: a) mortality risk > % or b) the administration of at least one intensive care unit-dependent therapy. the cumulative observed mortality was . % and the expected mortality was . %, with a standardized mortality ratio (smr) = . . the overall performance of the prism score-based predictive model was found to be good (goodness-of-fit test x [ ] = . ;p= . ). of patients admitted, combining the two criteria (icudependent therapy and mortality risk) an admission efficiency of ( . %) was found, equating to ( . %) of cu days. conclusion: in our study the assessment of the admission efficiency and of the effectiveness of the unit was possible by using the prism score of admission. there was no significant difference between mean values for otiss and ntiss)in level l patients (p= . paired t-test).for level and patients mean value of ntiss was greater than otiss (p< . ). there was a significant correlation between levels using either ntiss or otiss (mean difference level and , level and , ( p < o.oool). conclusions: a new tiss has been developed and used in a picu. nurses were able to accurately score the interventions on their shift. the assignment of patients to intensive care levels correlates with tiss values allowing a quantitative measure of severity. objective : to compare the rate of cerebral palsy (cp) between monochorionic-twins, dichorionic-twins and singletons born at to weeks' gestation. design : two-year prospective cohort study. setting : geographically defined study (region of franche-comt~., france). main outcome measures : type of plasentation was obtained by anatomopathological, or macroscopic examination of placenta and comparison of twins' blood-groups. neurological assessment was performed at two years of age (uncorrected for gestational age) by family doctor (pediatrician or physician), or neonatologist of the icu at tertiary center. sample : of i survivors aged of two years ( % follow-up rate), born between / / and / . triplets and chromosomic malformation were non included. results : thirteen ( %) of the singletons had cp.vs / ( %) of dichorionic twins and / ( %) of monochorionic twins (p= . ). four of the monochorionic twins ( %), / dichorionic twins ( %) and / ( %) nngletons suffer from quadriplegia (p< . ).in a multivariate approach, monochorionic twin placentation was the strongest risk-factor of cerebral palsy (or= . , ic % = a- , p< . ). others risk-factors of cp were : lack of father's profession (or , p< . ), maternal antecedent of abortion (or . , - , p< . ), vaginal delivery (or . , - , p< . ), hyaline membrane disease (or . , . -t , ~ . ). discussion : this is the first population-based study to uplight the role of monochorial twin-placentation as a strong risk factor of cp for premature infants. cp is more severe in monochodonic twins than in other infants. mecanism of cerebrat deficiency is not clear since none of our infants with cp was survivor of an in utero cotwin's death, and none of these infants was exposed to twin to twin transfusion syndrome. were these monochorionic-twins affected by an undiagnosed neurological structural defect that could lead both to prematurity and handicap remains an open question, a vital role of the intensivist is to ensure that knowledge and practice are imparted to trainees in the icu so that patients receive optimal care. teaching effectiveness varies widely leaving gaps in knowledge and practice in the trainee. being an effective teacher should not be a "gift" of a privileged few. the icu provides a fertile ground for using a variety of methods for teaching, e.g. didactic, at the bedside, emergencies, and in the performance ofproeeaures. in this environment, much can be learned. we have embarked upon a program to facilitate this learning process. i) teaching needs to be recognized as the foundation of good clinical care, i.e., patient related, and in its ability to generate discussion and research investigation. ) teaching structurally has many components including the speaker, audience, varying situations, and the message delivered. ) establishment of a program using these components to enhance teaching abilities at all levels, a) evaluate base-line teaching skills initially, b) individualize interventions to improve teaching skills, e) demonstration of learned skills with re-evaluation. this process is analogous to the analysis of a clinical disorder in a patient which, once recognized, interventions are then instituted and then re-evaluated. ) instill the desire to use these attained skills to teach and interest others to teach. teaching excellence should be recognized through awards, honors, and academic advancement. a major emphasis of this program is to provide participants with skills necessary to teach thought processes, decision-making skills (what to do, what to avoid) and implementing appropriate management during stressful emergency situations common to the picu. introduction: many" e-mail based discussion groups exist on the internet to provide medical professionals with a rapidly responsive medium for the international exchange of ideas relating to patient care. several such lists each serve more than a thousand professionals in more than countries, each distributing a dozen or more messages each day to every subscriber. there is very little known about the time being spent by professionals interacting with these lists, and very little known about the impact of the discussions on patient care. we wished to test the hypothesis that these discussion groups provide infortuation which is being used to change the care of individual patients and the general approach to patient problems. methods: in early january a pilot electronic survey was sent to a small fraction (n= ) of the memberships of e-mail discussion groups, picu@its.mew.edu, and nicu-net@u.washington.edu (the full memberships of both. groups (n=t for nicu-net, n= for picu) will be surveyed in early february of ). participants were asked for demographic information, experience and skill level relating to e-mail, time spent with the discussion groups, perceived usefulness of different types of discussions, and the ways in which the discussions were used clinically. the pilot study was analyzed for construct validity by correlating an overall assessment question with a summary of the specific questions. scale reliability was measured by cronbach's alpha statistic. results: the pilot survey response rate was ( %). the majority of respondents were male physicians, with an average age of +_ years, who had completed subspecialty training in intensive care, and were working at a university-affiliated hospital. most had been using e-malt for more than months, and considered themselves moderately adept in that use. % felt that the list helped weekly to keep them informed about current issues and practices in their field(s), and % felt that, at least monthly, they used information from the list(s) that was not readily available in medical journals. overall, % agreed that the list improved their professional competency. when asked to compare the value of months of membership on an e-mail discussion group with more traditional educational media, % compared it with attending a national conference, and % compared it to a journal subscription. cronbach's alpha was . , construct validity testing yielded coeff=. , p <. . conclusior~: internet-based e-mail discussion groups for health care professionals can be an important part of a strategy for maintaining professional competency. despite the very low cost of this medium for most, the value is felt to be comparable to that of t~r more expensive forums for education. further study will include distribution of the full survey in early february of . fronk shann, tony slater, gale pearson and the pim study group we have developed a new score for predicting the risk of mortality in children admitted to intensive care. the score is calculated from only seven variables collected at the time of admission to icu: mechanical ventilation (yes/no), booked admission after elective surgery (yes/no), the presence of any one of specified underlying conditions, both pupils fixed to light (yes/no), the base excess, the pao divided by the fio , and the systolic blood pressure. most scores used to predict outcome in intensive care require the collection of a large number of variables (so many icus do not calculate them routinely), and they use the worst value of each variable in the first hours in intensive care. this means they appear to be more accurate than they really are (about % of child deaths in icu occur in the first hours -so they are diagnosing these deaths rather than predicting them), and they blurr the differences between traits (a child admitted to a good unit who recovers will have a low score; but the same child who is mismanaged in a bad unit will have a high score -the bad unit's high mortality rate will be incorrectly attributed to its having sicker patients). pim was developed in the picu at the royal children's hospital in melbourne, and has been tested in six other picus in australia and one in the uk. objectives: to study the characteristics of the muhiorgan dysfunction syndrome (mds) in children. methods: a retrospective study with all the children with mds diagnosed from january to june is presented. children fulfilled the wilkinson criteria (i). in all of them the number of organs affected and the prims score were determined during the first hours. several groups were performed according to the clinical diagnosis, the hospital of origin and the order of organs affected. results: the subjects studied were an % of the pediatric intensive care unit admissions. of them expired ( %). no differences in age, sex and weight were observed between the children dying and the survivals. the most common causes of mds were sepsis, both nosocomial ( %) and medingococcal (i %) and acute respiratory failure. sixty-fivepercent of the patients were from the hospital wards and the remaining were directly admitted to the pigu from the emergency room. the systems affected were: respiratory ( %), cardiovascular ( %), hematologic ( %), central nervous system ( %), renal ( %) and (hepatic) liver ( %). the organs initially failing were: heart ( %), tung ( %) and central nervous system ( %). the children dying had a larger number of organs with failure than the survivors ( . v,s. . , p< . ).the prmis score was higher in the children expiring than in the survivors ( . v.s. , p < . ). s.mmary: the mds is a common pathology in picu, with a high mortality, the mortality is higher in children with a larger number of organs affected and a higher prism score. sepsis is the most common etiulogy. methods : from june ist to july th , all patients admitted to the pediatric icu were included. the score was measured at day (d ) and day (d ) and we used variables. for each organ system, we defined categories : dysfunction or failure, which we respectively confered or points. results : patients were admitted : newborns, children. were medical and were surgical patients. ( %) patients had two or more organ failure at the admission, ( , %) patients died, which ( %) in the first hours. the mortality rate was the same for children with two or more organ faiiure at d and d : / ( , %) at d , / ( , %) at d . the mean score is different for children who survived or who died : , versus , at d ; , versus , at . when the score is > , the mortality rate is significant. conclusion : in this study, there is a good correlation between the score of severity and the mortality rate but we have few included patients. we need a prospective multicentric study to assess these results and we must compare this score to other scores of severity used in picu. back.qround: injury to the central nervous system is the cause of death in the majority of pediatric trauma victims, studies have identified a wide range of factors associated with poor outcome from brain injury. however, when single features are analyzed, they are not sufficiently accurate predictors. few studies have used a multivariate analysis of these factors and pediatric outcome, methods: clinical and radiographic features of comatose children after traumatic brain injury were analyzed, clinical parameters, the initial cranial ct scan, and demographic characteristics were analyzed for an association with death or vegetative survival at months. a tree diagram in which risk factors may differ within the study subpopulations was constructed using recursive partitioning. results: chitdren with a motor score _< had an -fold increased risk of poor outcome compared to those with motor scores > . among patients with scores of _< , those with abnormal pupillary reflexes experienced a -fold increased risk of death compared to those with normal pupillary reflexes. among patients with a motor score > , an intracranial diagnosis code (no pathology, mild shift _< mm, swelling, shift > mm, surgical mass lesions, or non-operative mass lesions) was highly predicative of poor outcome at months. children with ct findings other than normal or mild swelling had a -fold increased risk of poor outcome. of children with swelling, shift or mass lesions, the pupillary light reflex was associated with outcome. children with abnormal pupils had a -fold increased risk of poor outcome. discussion: a few clinical and radiographic features stratified comatose children into fairly distinct risk groups. information available early after traumatic brain injury in comatose children provides useful prognostic information on the likelihood of death or devastating injury. a retrospective study of children with the diagnosis of epidural hematoma was made during - period. ages ranged between days and years ( % less than year, % between and years, and % older than years), % of them were admitted at the picu. % of the cases were due to falls, % to road traffic accident and % to other causes. on admission gcs was less than in % of the cases and more than in %. diagnosis was made during first hours in % of patients and delayed more than hours in % of them. neurologic impairment was present at admission in % of patients, and delayed in %. even so, % remained without impairment. radiological findings at first ct were skull fracture ( %); epidural hematoma localization was: in the right side ( %), frontal area ( %), temporoparietal ( %) and occipital (t %). associated lesions were: several ( %) or unilateral ( %) cerebral contusions, diffuse brain oedema ( %), unilateral hemispheric oedema ( %) and % showed shifted middle line. four patients died, half of them during the first hours. fully recovered ( . %) and have sequelae of different nature : were left with severe motor disability ( %); at the follow-up t have some degree of neurodisability. next datas keep correlation with death or neurosurgical impairment: only were significative multiple cerebral contusion (p= . ) and brain oedema (p= . ), gcs less than at the admission (p-- . ), shock (p= . ) and remaining cerebral contusion in control ct correlated with death or diasability at discharge. on the other hand, neither surgical drainage volume nor first or highest levels of icp ( cases),nor pupillary abnormalities ( cases) correlated with worse prognosis. conclusion: gcs equal or less than an shock are main factors related to worse prognosis, also multiple cerebral contusions in ct and diffuse brain oedema. the results of a modified gcs were compared to outcome and intensive therapy in children (mean age , t , years) with head and associated injuries ( , % of all cases) of different causes (traffic accidents, falls). the gcs was regularly used inn the course of intensive therapy. according to our own and other experiences the gcs was divided in stages: stage ( - points), stage ( - points) und stage ( - points) palhuiugy wile sp, tdhlg c~'lcb al blood ~ w. sabgcqucntl}. rhc slat,: rerltncd to t tl, iiltlils. the p st,~pem~v~ b}i~g wij!!,:q ! ,:_a!~p!ica!j n~:. ri~;¢ ill the level of sensibflizatjou lo tile cerebn~ anhgrns up to t. -o was flofcd iu i,alicnts. there wa.~ al~ iuclt~a~e ill cerebral vdociij,. ~m d~;'ati a il~ p¢fiphc~ai re~ista/isc of the large ce~'bral ve~ds. neur h;~c ~:yn'.pt,m~at !a~, (s::mno!en~', _r_uscu!~r l~:pot ni& !ryper*'flema) was nbserwed tu lt~ese pal~enls o. cbruc~l ~ nnds. rile ple~c.ut abse~vafion~ suggesl ihal die ~tttdy at" ihe stale ~f hematocr~chcplm/itic bm~ic~ in ckil&en with on emergensy is of abviou.~ !?ece~sib; in co~.te ctin g severe pa~ lo ~-i~mnediately f u wing ne ,:~per,'~fion. background: reconstruction of the heart by three-dimensional ( d) echocardiography provided new information on anatomy of complex congenital heart defects, we assessed the utility of d ultrasound in detecting morphological changes in cerebral anatomy in newborns before and after cardiac surgery. methods: transfontanel cross-sectional ultrasound, scans were obtained in standardized coronal and median sagittal planes. subsequently, rotational scanning was used to acquire the multiple sequential crosssections of the brain. for rotational scanning, a conventional mhz transducer was rotated degrees.scanning took less than one minute and required no sedation, data was stored in the image processing computer which allowed for off-line three dimensional reconstruction of different brain regions.twelve infants aged - (median ) days were assessed before and after cardiac surgery, results: cavity of lateral ventricle, choroid plexus and the periventricular brain parenchyma could be reconstructed in all. accurate estimation of size and volume of lateral ventricle, aqueduct, and other ultrasonographic visible pathological brain lesions could be performed. reconstruction of various brain areas was accomplished in - minutes. the localisation and extension of severe periventricular hemorrhage which was detected preoperatively in one infants was better visualized than in conventional ultrasonography. epicortical and subarachnoidal space could be reconstructed in all and allowed detection of hemorrhage in one case which was not detected by conventional ultrasound. conclusion: d reconstruction of different areas of the brain may provide additional quantitative information on size and volume of the internal ventricle and choroid plexus, and better understanding of the topographical aspects and the extension of intra-and periventricular hemorrhage than conventional cross-sectional ultrasound. introduction: intracranial cerebral blood has been estimated to be % venous, the invasive measurment of venous blood saturation in the jugular bulb provides quantitative information on cerebral oxygen supply and consumption. however, routine oxymetric measurement of blood saturation in the jugular bulb by insertion of a catheter line into the internal jugtdar vein is an invasive procedure which has limited use especially in infants and young children. thus the aim of this study was to investigate the correlation between the non-invasive spectroscopic measurement of rso and the oxymetric determination of the blood saturation in the jugular bulb in infants and children undergoing routine cardiac catheterization.. methods: during routine cardiac catheterization infants and children (age day- year, median , year) the rso was measured continuously using a two chanel cerebral oxymeter (invos a). the sensor was placed in standardized location at the left temporal head side. after the routine oxymetric blood sampling in the superior vena cava the oxymetric catheter was manupilated into the left jugular bulb. after control of the catheter position simultenuous values of the rso were documented. results: over a range of ( - %) sjo , a significant linear correlation was found between the spectroscopic measurement of rso and the oxymetric determination of venous blood saturation in the jugular bulb (r= , , p< , ) and the superior vena cava (r= , , p< , ). no significant correlation was found between rso and the arterial blood saturation in the descending aorta and as well as to the standared hemodynamic parameters. conclusion: meusurement of rso by mrs may provide continuous non-invasive information on cerebral venous blood saturation and thereby possibly on cerebral oxygen supply and consumption in infants and children. these may be of clinical value particulary during and immediately after heart surgery by means of non-pulsatile cardiopulmonary bypass. information on refractory status epilepticus (rse) from developing countries is scarce. we analysed cases of rse admitted over last yrs. the objective was to study etiology end evaluate efficacy of diezepam infusion. median age of the patients was . years irange . months to t . yrs); % were boys. onset of seizures was -t hours (median hours) prior to hespitalisation. the glasgow coma scale score ranged from . (mean+sd + ). the commonest underlying causes were acute cns infections ( / , %; bacterial meningitis, , encephalitis, ) and epilepsy ( / , %). oiazepam infusion in incremental dose (range . - . mg/kg/min) was used in patients over . _+ . days. seizures were controlled n ( %), mechanical ventilation was required in ( %)only, while none had hypotension; % patients survived. thiopental infusion (holus mg/kg followed by . mglkg/min, and increments of . mg/kg/min till seizure control) was used in patients over . _+ . days; seizure were controlled in all, but five patients needed mechanical ventilation, six developed hypotension needing infusion of vasopressoi drugs, out of ( %) died, overall mortality was %, mainly due to acute cns infections (n- ) and prolonged se. the patient was a -year-old gift di~aosed of dov,~'s s~drom¢, tetralogy of fallot. (t.f.) before admission a vasovagal crisis after coughing and vomiting was seen, and she was taken to the emergency room. mother said she had eyanosis in the mucous membranes of the mouth with exercise.on physical examination, she ~as afebrile, normal fundi and neurologic examination was normal. a harsh systolic murmur was hear~ with decrased intensity during bradycardia. chest rx disclosed a decreased pulmonary vascular markings. ecg: synus rhythm, with bradycardia and nodal escape rhyflmas. she was transferred to our picu because of severe h ,pertomc seizure, lost conciousness, and deeembrate poslamng~ ~t cyancx~is. the episode lasted for ~weral seconds, and ceased v~th diazepam. on admission she was lethargy, and neurologlc exammation showed weakness of left leg without babinski, and normal funduscopic. the patient had two episodes of bradycardia and isoproterenol was begun. during those episodes the patient was cyanotic, and the murmur was heard with the same intensity. act scan disclosed a tight parieto-temporai abscess with midline shift, lnmediately after the diagnostic ct, we administered antibiotics, antiedema treatment and it was drained. the abscess culture was negative. a ct control disclosed air and midlme shift. ~ the next two days she had three episodes of h oxia and c'yauosis ceased with o@gen, morphine and propanolol the patient died during a fourth episode. discussion: arrhytmias are uncommon in patients with tetralogy of fallot before surgery. in our case the first diagnosis was sick sinus syndrome vs bradycardia secondary to cyanotic episodes. the incidence of cerebral abscess in children with congenital heart disease (chd) is approximately %. tetralogy of fallot is the most common associated lesion, and is unusual in children under years of age. conclusion: ) brain abscess is a rare complication of patients with cyanotic chd, but should be suggested in patients with °'apparent" sick sinus syndrome. in patients with down's syndrome, t.f.,with cyanotic episodes, and difficult neurologic exploration, a brain ct scan is recommended. guillain-ba~re syndrome (gbs) is an acute autoimmune reaction, directed primarily toward the myelin encasing the peripheral motor nerves= this reaction causes a delay or block in nerve conduction. the presentation often can be very subtle but is followed by rapid loss of neuromuscular power, leading to acute respiratory distress, resulting from weakness of muscles and aspiration pneumonia. there were boys - , , and i i years old with gbs, treated in our icu. two of them due to the respiratory distress were intubated nasotracheally and ventilated mechanically with servo- ooc (siemens-elema, sweden) ventilator. duration of ventilation was i i and days, respectively. plasma exchange was performed in all cases. the numbers of plasma exchange sessions were - in each case. mean amount of plasma exchanged per session was , ml/kg. plasma was substituted with albumin, plasma or saline. the most important aspect of the management of patients with gbs in the icu involves the airway care, prevention and treatment of aspiration pneumonia and the mechanical ventilation if respiratory distress presents. endotracheal intubation should be performed whenever there is evidence of retention of pulmonary secretions, refractory to chest physical therapy, weakness of protective reflexes of the airway, leading to aspiration pneumonia and (or) atelecr~sis. cardiac arrhithmias too, is a main threat to the circulatory stability in gbs. therapeutic plasmapharesis has been shown to be beneficial, reducing the time for weaning from the ventilator and for achieving independent ambulation. however, plasma exchange is expensive and not without significant risks for the patient. some authors find that plasmapheresis is not effective for patients with fulminant course of gbs and blocking of nerve conduction. recent studies have demonstrated that intravenous high-dose immunoglobulin can be equally effective. there were no significant complications associated with plasma exchange. all presented patients survived without residual disability. tetraparesis associated with long-term paneuronium use in an infant. paneuronium is a muscle relaxant used in ventilatory management of patients with respiratory distress in intensive care unit. after the end of sedation some patients were found to have severe tetraparesis. paresis was accompanied by complete areflexia and diffuse atrophy of alt extremity muscles. this neuromuscular complication is caused by prolonged high-dosage pancuronium treatment. in the last years, numerous reports have linked the use of pancuronium bromide with prolonged paralysis, disuse atrophy and areflexia. this side-effect is well known in adults patients but rare in a pediatric intensive care unit. we describe one pediatric observation of tetraparesis after prolonged pancuronium treatment in a -month-old girl, this female infant developed respiratory distress syndrome and was intubated and mechanically ventilated. to decrease chest wall rigidity pancuronium bromide was administered during days. (she received approximately mg of pancuronium bromide). on day the drug was discontinued and the patient had severe tetraplegia and areflexia with normal head movements. electromyograpliy showed absence of any disorder of neuromuscular transmission. this infant showed a recovely of muscles after months. the other causes of peripheral neuropathies were eliminated. electroencephalograms and head scans were normal. the recovery pattern observed in our patient correspond to the process of regeneration after axonal degeneration. it is suggested that these neuromuscular complications were caused by prolonged high-dosage pancuronium treatment (associated with cortieoid and aminoglucosides). polyneuropathy syndrome in adult lc.u. appeared in literature in and is extremely common in long stay cases. the etiology of these disorders remains elusive. it is tempting to ascribe them to administration of drugs (muscle relaxants, steroids, aminoglycosidea), plolonged immobility, malutrition, sepsis and ischemia associated with reperfusion injury. to our knowledge there is only one case report of similar condition in a children i.c.u. (pascucci ) we present a serie of previously healthy children, aged months to years, who admitted in i.c.u with respiratory failure and who following weaning from m.v, remained in profound diffuse hypotonia with proximal and distal muscle weakness for various length of time, recovery of muscle strength occured in a week or months {the longest i months), all children, except one, - days before admission developed symptoms of either respiratory or upper airway infection with fever. on admission viral and bacterial cultures were positive in cases (haemophilus influenze, herpes virus). during treatment patients became septic. muscle histological and neurophusiological investigations have not been done. considering the multifactorial nature of the aquired nmd in adult critically ill pts, is impossible to attribute the muscle weakness of our pts to any specific cause, in conclusion, our findings suggest the need for further investigation of nmd in critically ill children treated in i.c.u. a van esch, ha van steen~l-m , ir ramtal, g derksen-lubsen, idf habbema. febrile status epilepticus (fse) is a prolonged and serious febrile seizure. little is known about the outcome of fse in neurologically normal children. this survey involved patients between months and years of age who had visited due to their first fse, the sophia children's hospital during the period of january till december . patients with a history of neurologic disorders were excluded. patients were identified, % were male. the cause of the fever remained unknown in % of the cases. in all case the fse was generalized and it most frequently occurred at night ( %). the mean age at fse was t. years ( . - . ), the mean temperature . °c ( . - °c). the mean follow up time was . year. twelve children ( %) had neurologic sequelea. the neurologic sequelae varied from speech deficit ( case mild, v - year delayed; case moderate > year delayed) to severe retardation and epilepsy ( cases). speech deficit was detected after a mean period of months (range - ), age, gender, temperature, family history and time of onset were no significant risk factors for neurologic sequelae. duration of seizure [rr . ( . - . )] and more than two drugs to treat fse (rr . (t. - . ) were related to neurologic sequelae. we recommend that fse children should be followed for at least a year to detect possible speech disorders properly and start early intervention. unusual presentation of myasthenlg gra%qs ibtza e. modesto ,v~ abe~gochea a, sanch]s l all, go l varas k folgado s, garcia e. p. .c.u. la fe, valencia. spain case report: the patient was a -year-o!d gift transferred to our pic because of severe respiratory failure. the patient, convaleseem of ehiekenpox, came into contact with horse manure previous afternoon. in the morning, she was lethargy, and irritability, with poor finding, and ~ an episode of coughing, cyanosis and acute respiratory failure after mucous vomiting when she was drinking milk. on admission she had severe respiratory distress, respiratory acidosis, and the sat was %. she was mtubated without difficulty, and was transferred to our p.i.c.u. physical examination reveals stable hemodynamies, pupils equal, round, reactive to light, normal fandi, and muscle relaxation. crusted vesicles diseminats~d. rhonehi over both lungs. hepatomegaly (+) and splenomegaly (+). ~lhe urine, hematologic, and c.s.f. laboratory findings were normal. c.t. scan of the brain, e.e.g., and ekg. revealed no'abnormalities. rx chest disclosed a retrocardiac atelectasis. speci~ts of stool and blood were obtained for cultures and study of c. botul#num toxins. pending receipt of these results, a broad-speotmm antibiotic and acyctovir was begun. the initial differennal diagnosis consisted of laryngospasm associated with aspiraqlon, botulism, and postmfecfious varicella encephalitis. after hours, weatm~ was begun. the neurologic examination showed a low modified glasgow coma ~ale (mgcs), generalized hypotouia and muscle weakness. these data suggested three diagnoses, posfnfecfious encephalitis, residual neuroumsoaar blockade, and excessive doses of sedative and analgesic drugs. after hours she regained skeletal muscle poxver and ufltlcient respiratory effort, the mcgs was acceptable, and blood gases were normal. she was given n~-tigmine and atropine, and her tr~ma was extubated. an acute respiratory failure ocurrs ram. after. chest radioga'aph disclosed a left inferior lobe atelectasis. after hours weaning begun~and the same episode w~as seen. at this point her mother stated that the girl showed weakness of the eyelids or extraneular muscles. it suggested myasthenic syndrome vs ~-barr syndrome. c. botul#num toxins were negative, chotinesterase level ~as normal. edrofoinum test ~as positive. anti-acetyleholine receptor antibodies were negatives. e.m.g. confirmed myasthenia gravis (congenital vs juvenile serenegative). pyridostigmine was begun and the trachea was extubated without complications. conclusion: din the differential diagnosis of weamng failure we must consider ~c gravis~ )myasthenia gravis could resemble encephalitis, because of low ocs, overall if is triggered by viral infection. )in some diseases (this case) gcs could not he an aemuate index of mental state. a burguet*, a menget*, e monnet**, a gasca-avanzi*, c fromentin*, h allemand**, jy pauchard*, ml dalphin*. * r animation infantile potyvaiente chu st jacques besancon cedex. ** d~padement de sant publique besancon cedex, france, objective : to point out that strabism is) of one-year-old premature is a good predictor of a poor neurological outcome at two years of age. design and setting : two-year prospective cohort study and geographically defined study (region of franche-comte, france). main outcome measures : neurological assessment was performed at one and two years of age (uncorrected for gestationnal age). a mailing questionnaire was sent to the famity and fuu-filled by thefamily doctor (pediatrician or physician), or neonatologist of the icu at tertiary center, s was diagnosed at one year of age by the examinator but s was not used to diagnose cerebral palsy (cp). sample : of survivors ( %) evaluated at one and two years of age. results : correlation of one and two years neurological evaluation is weak (kappa= . ). correlation of s at one year and cp at two year is fair (kappa= , ). the goal of this paper is to review evidence related to hypothesis that the "waiting" axons and cells of the transient subplate zone may participate in the structural plasticity of the human cerebral cortex after perinatai brain damage (kostovic et al, metabot brain res : , t ) and to correlate this phenomenon with different forms and mechanisms of structural plasticity. it is our basic assumption that all lesions occuring during cortical histogenesis will lead to more or less pronounced structural reorganization. here we show that various components of the subplate zone participate in several forms of the structural "plastic" responses in the human cortex: modification of convolutional pattern, changes in size of cytoarchitecturat areas~ columnar reorganization, dendritic and synaptic plasticity. the etiological factors which induce lesions and subsequent plastic changes act via the following pathogenetic mechanisms: * disturbances of radial unit formation (rakic); * changes in ingrowth of afferent fibres; * changes in the rate of normally occuring reorganisational events, depending on the critical period for a given histogenetic event. in the present study developmental lesions (localized perlventricular leukomalacia and haemorrhages) were demonstrated by ultrasound in live-born infants ranging between to weeks of gestation. in younger infants ( - w) who died shortly after birth, examination revealed lesions of the white matter with the preservation of the subplate zone. in infants who died one week of more after the lesion, we have observed localized micropolygyria, cavities, condensed layer vi -subplate zone, and columnations of the cortical plate. these changes are less prominent if the lesion occurs after diminishment of the subplate zone (after w). since in the fetal cortex the subplate zone serves as predominant source of growing fibers, transient neurons, trophic factors and contains cellular substrata for migration, this zone is the most likely candidate for major types of structural plasticity. in conclusion, cerebral cortex of the low -birthweight infants is more susceptible to the various lesions but shows vigorous structural plasticity and conspicuous functional recovery due to the growing, transiently located neuron at elements. the mortality due to meningoccocal sepsis is high in spite of important progress in emergency and intensive care medicine. during the last decade multiple scoring-systems have been developed in order to establish a therapeutic approach and to evaluate the final outcome of a meningococcal infection. different clinical and biological data (shock, ecchymosis, peripheral wbc and platelet count, coagulopathy, acidosis, meningism, etc) are taken into consideration and the importance given to these data depends on the scoring-system used. a review of the different scoring-systems is given and a clinical case is presented. we report the case of a year old male, who was transfered to our icu hours after onset of temperature and skin rash. the parents described a fast deterioration of his condition. the boy presented wide spread ecchymosis, high temperature, no signs of meningism, circulatory insufficiency and shock, coagulopathy and low peripheral wbc and platetet count. disseminated intravascular coagulopathy developed promptly. the glasgow meningococcal septicemia prognostic score (gmss) was used and the obtained score reached the highest level ( / ). this corresponds to a % mortality. the patient required mechanical ventilation for days. at admission he received human albumine, fresh frozen plasma, dexamethason, dopamine, dobutamine and a continuous infusion of adrenaline. antibiotical treatment consisted of ceftdaxone. the evolution was favorable and the infant fully recovered. retrospectively the gmss was compared to other meningococcal scoring scales which gave the same mortality ( %). we conclude that the scoring-systems are important to evaluate the seriousness and to assess the therapeutic approach, but they should be used cautiously even when % mortality is predicted by several risk evaluations scoring-systems. the aim of this study was to assess the haemodynamic status on admission and the critical care management of children presenting with meningococcat infection. this was a retrospective study of the charts of consecutive admissions. mean age was . years (+/- . ). the average duration of symptoms prior to admission was . hours (+/- . ). on admission . % were hypotensive, . % had clinical signs of haemodynamic instability and . % of cases that had a blood gas analysis on admission had a metabolic acidosis (bases excess < - .q): the mortality rate was . %. % of patients that died were hypotensive on admission and all had a metabolic acidosis. of the survivors . % were hypotensive on admission, % had clinical signs of haemodynamic instability, % required invasive pressure monitoring and . % were ventilated and received inotropic support. this study demonstrates that at the time of presentation with meningococcal infection children had a high incidence of established haemodynamic instability. successful management of this infection is dependent on early presentation and initiation of therapy and on aggressive support of the cardiovascular and vital organ systems. dept. of intensive care medicine and dept of infectious diseases, our lady's hospital for sick children, crumlin, dublinl , ireland. jude. pediatric intensive care unit, ch&u, lille-france. more than % of children surviving sip (defined as purpura with shock) have snli. objective. to search for a specific hemostatic profile in children with snli. patients and methods. between may and march , children with sip were admitted to our picu : ( . %) died and ( . %) ranged in age from to months (mean : ) survived, of them ( . %) with snli (defined as the need of a surgical procedure). in survivors, two hemostasis studies (between h and h , and h later) included the determination of coagulation factors (routine tests), protein c (pc : amidolytic activity, biogenic), total protein s (ps : elisa, stago), c b binding protein (c bbp : laurell's technique, stago), antithrombin (at : chomogenic test, stago), and plasminogen activator inhibitorl (pail : chromogenic test, biopool). three severity scores were determined at admission : french group of pediatric intensive care, gedde-dahl, and crp. statistical analysis used the wilcoxon's test. results. at admission (lst sample) severity scores and at , pc, ps, c bbp levels were not different between the group with snli and the group without snli ; quick time ( - % vs ± % ; p = . ), vti+x ( . % vs - % ; p = . i) and pall ( - ui/m! vs . ui/ml ; p = . ) were lower in the group with snli. on the nd sample there was no difference between the two groups. kinetics of hemostatic abnormalities was not different between the two groups. conclusion. in the literature, intravascular coagulation (dic), low fibronectin and at were identified as predictors of snli, and a negative correlation was found between the mean size of the skin lesions and pc activity, at , and total ps. in this series, apart from dic, there were no specific hemostatic abnormalities that support the use of treatments such as pc, at , and pail antibodies administration to prevent snli. further studies including more children are needed. the aim of study was to investigate the efficacy of intravenous immunglobulin with enriched igm content pentaglob/n /biotest/. in our pediatric intensive care unit ten septic children /group i/-their average age , years /sd:o, /, of them with gramm negative and one with gramm positive blood cultures, and two with unindentified bacteria-were treated with basis sepsis therapy and pentaglobin. the application of pentaglobin was as follows: , ml/kg loading dose for one hour, followed by a continuous intravenous infusion , - , ml/kg/hour depending on body temperatura /lanser scheme/ for - hours. another ten septic patients /control-group ii/the mean age , years/sd:o, /, their blood cultures were gramm negative bacteria , positive , and the bacteria was not indentified in two cases -were treated with only the basis therapy. results: the duration of intensive treatment decreased from an average , days /sd: , min -max days/ to , days /sd: , min -max days/ in the group treated wit pentaglobin. the difference was significant /x p< , /. in the group i nobody died, but three in the group ii. conclusion: the pentaglobin therapy can improve the efficacy of the basis therapy of sepsis. sinus bradycardia after an episode of sepsis is a rare symptom complex decribed in children with hematologic malignancies. we present a case of postsepsis bradycardia following severe typhlitis and septic shock in a year old boy with relapse common all. blood and ascitic fluid specimen grew clostridium species and pseudomonas aeruginosa. at surgery there was a necrotic gangrenous terminal ileum and cecum, requiring ileocecal bowel resection with ileostoma. while clinically recovering from sepsis he developed bradycardia for hours. extensive diagnositic procedures was given and the heart rate slowly increased to normal range of age. postsepsis bradycardia in children with hematologic malignancies after an episode of sepsis is self-limiting and after careful differential diagnostics warrants an expectative attitude. nitrate level is known to be enhanced during sepsis. serum nitrate is the stable metabolic end-product of endogenous nitric oxide generation. nitric oxide has demonstrated to be a powerful anti microbial final mediator and also a key molecule driving to the lethality of one of the most common complication of sepsis; the endotoxic shock. such facts prompted us to investigate the possible diagnostic and/or prognostic value of monitoring serum level in high risk, presumptive and confirmed sepsis patients. additionally we have explored the usefulness of this mediator as index of therapeutic response. in our study it is demonstrated that there is an important relationship between nitrate level and the occurrence of neonatal sepsis. septic newborn group showed fold higher nitrate level than that of healthy control group. in addition, the group of patients with high risk of sepsis which finally became septics, exhibited fold higher nitrate level at - hours before the first symptoms appeared, when compare with those who did not develop sepsis. however in the presumptive sepsis group, there was no difference between the patients which finaliy ,&'ere considered septics and those which not. in all septic cases, after days of a successful therapy with antibiotics, the level of nitrate diminish fold. our results suggest the utility of monitoring nitrate as index for the diagnosis of neonatal sepsis. the potential benefits of exchange transfusion, plasma exchange, and haemofiltration have all been described in children with overwhelming sepsis. however, little hard evidence exists to prove the benefits of any of these techniques. i have treated five patients with plasma exchange (pe), having been asked to see all these patients at a point when it was felt death was inevitable. two of the patients had staphylococcal, two meningococcal and one enterococcal septicaemia. all patients showed a dramatic haemodynamic improvement following pe with improvement in blood pressure, reduction in inotrope requirement and improvement in tissue perfusion. three patients survived. one of the patients with staphylococcal sepsis and both of the patients with meningococeal sepsis had developing gangrene of the limbs which showed remarkable reperfusion with pe. in two of the patients measurements of cardiac output (co) and systemic vascular resistance (svr) showed ~a reduction in co and a rise in svr over the course of a pe despite the reduction or cessation of vasoconstricting inotropes. many believe haemofiltration is of value in septic shock. a trial with a no treatment limb is difficult to achieve. i believe we now have enough evidence to justify a controlled trial of haemofiltration versus plasma exchange in patients with septic shock and unstable haemodynamic status whilst on inotropic support. during the next several days, cough and chest pain suggested pulmonary embolism confirmed by radiologic evaluation. echocardiographic examination showed multiple thrombosis of the superior vena cava, right atrium and ventricle and pulmonary artery. estimated protein c level was . % (normal range - %); identical deficiency was found in patient's mother and elder sister. cvc was removed, and alter -month heparin therapy and supstitution of protein c with fresh frozen plasma, there was almost complete thrombolysis of the great vessels and cardiac chambers. we conclude that invasive diagnostic and therapeutic procedures in such patients may result in higher risk for severe thrombosis at unusual sites, and numeuos further complications bronchopulmonary dysptasia (bdp) is a chronic pulmonary disease of preterm and term babies treated with mechanical ventilation for respiratory problems of different origin and requiring oxygen therapy days after birth. bpd is a disease affecting the growth and development of pulmonary tissue. such pulmonary }esions heal by squamous metaplasia leading to scar formation and fibrous tkssue r~growth, the pediatric intensive care unit makes the survival of babies w~h very low birth weight ( - g) possible. with the increase in their aulyival, the number of complications in low birth weight babies increases as well. bdp is a very serious complication. therefore the importance of early diagnosis and treatment of bdp must be stressed in order to reduce the consequences. babies with bdp must be under medical suveillance for at least years as the disease needs at least that long for complete resolution. tn the icu of pediatric department at madbor teaching hospital: during the past two years ( - ) newborns were treated with mechanical ventilation. the neonatal and postnatal death rate of all newborns admitted to our icu was , %o.ln the two years from to , newborns were admitted to our icu ( %~ of all newborn babies at maribor teaching hospital), with birth weight - g. in the icu, the survival of these babies and parallel to it the number of complications is increasing. during the mentioned -year period, babies with very low birth weight ( - g) survived: in and in t . in - %, first or second stage bdp was treated,there was no case of third of fourth stage bdp. the treatment consisted of eary removal from mechanical ventilation, oxygen therapy~ intensive treatment of infection, volume and caloric intake contro}, corticosteroid treatment throught weeks with decreasing doses, diuretic end antioxydant therapy. the children are to be reevaluated at the age of and months and again at i and years. oeure j van der, markhorst do, haasnoot k department of pediatrics, pediatric intensive care unit, free university hospital, amsterdam, the netherlands. case summary a %-month . kg girl of african origin was admitted to the pedfatric irtensive care unit with pneumonia and progressive respiratory irlsuffjderey. she was intubated and ventilated by pressure regulated volume controijed ventilation (servo c, siemens, soma, sweden). maximum conditions were inspiratory minute volume . l, peep cm h~o ahd % ~. chest x-ray showed bilateral interstitial consolidation. material obtained by broncho-alveolar lavage showed preumocystis car}nil htv-serology (elisa and westerll blott) and p -antigerl were positive, confirming the diagnosis of pediatric aids. she was then treated with high dose co-tllmoxazoie, penthamldine, z{(~ovudire and steroids iv. because of thee x-ray features, high need for o ( %, pad mm hg), not responding to elevatiofi of peep (max cm h=o) and pao /fio = < (s ). m acute respiratory distress syhdrome (ards) was diagnosed. because conventional ventilation (cv) failure, hfo-v ( ooa, serisor medics,yorba linda, ca) was initiated. starting mean airway pressure (map) of cm h~o was based or map of the cv, oscillatory pressure amplitude (dp) of was, at ii~itial frequency of . hz, adjusted ur~til chest wall vibrations were visible, it was required to raise map to cm h and dp to before optimal lung volume and ventilation were achieved and need for o reduced within hours, this was monitored by frequent blood-gas analysis and chest x-rays. map and dp could slowly be reduced, after a good response the first day, gradually demand reduced and the patient could be weaned from the ventilation. map, dp, fi and oxygenation index (map x pa ~jfio ) are shown in table i. chest x-ray follow-up showed gradually improving lung features, with marked improvement of aereation. after days hf -v she could be succesfully detubated when a map of cm h was acmeved. results : sianificant increase in ventilato~ rate and mean airway pressure was noticed after the change to savi. no differences in oxygenation, co partial pressure and systolic, diastolic or mean blood pressure between imv and savi periods were noted. in infants however an improvement in pao /p .ol/ and decrease in paco was observed after the switch to savi. these babies had a lower initial a/a oxygen tension ratio and required higher initial ventilator rate /p<o. / in comparison to the rest of the studied patients. conclusion:infants with low a/a po ratio who need high initial ventilator rate are likely to obtain benefit from savi.. fumimare hatori, haruo uchida, masao katayama, and rika muto department of anesthesia and critical care medicine chiba children's hospital, chiba city, japan. purpose: this study was made to find out whether the heat and moisture exchangers (hme) was effective enough to humidify in the respiratory management for children. patients: the study population consisted of patients who were provided with artificial airway. they were divided into the two groups: ii with heated humidifier (a) and i with hme (b). methods: hme could be used for those without pulmonary complication and with less leakage around the endotracheal tube. in both a and b groups, (i) we have measured relative humidity, temperature, and absolute humidity at the endotracheal tube connector. for these measurements, humidity sensor system was utilized. ( ) any troubles and complications caused by the artificial airway were investigated. results: (i) in group a, we confirmed the mean values as the relative humidity of . %, the temperature of . ~c, and the absolute humidity of . mg/l. in group b, they were . %, . °c, and . mg/l respectively. no difference was noted between the two groups as to the relative humidity, but the temperature and absolute humidity were lower in group b with a significant difference (p< . ). ( ) in neither of the groups, any respiratory complications such as obstruction or stenosis of the artificial airway were noted. in pediatric icu, hme can be used without any problems under given conditions. titei: objective: evaluate the precision, reproductibility and aplicability of a new device to measure auto-peep in pediatric patients during mechanical ventilation. material and methods: it's an electromc-pneumatic eontolled device with an oclusion valve and a pressure monitor installed between endotracheal canulla and the ventilator circuit. the measurements were performed with a sollenoid conected with to the ventilator to detect the end of inspiration phase and the actwation of the oclusion valve. the signs of pressure and flow were moniturized using a difere~rtial transducer and it was processed using a pc computer and a pneumoviaw® software. the auto-peep also displayed in the ventilator pressure monitor. results: we submitted children with neuromuscular disease or respiratory distress in this study. the incidence of auto-peep was %, with variability between , to cmh . all the measurements were performed times to verify the precision and the reproduetibility and evaluation of the pressure and flow curves. conclusion: the device is low cost, easy to use and can be used without the pneumotacograph. the auto-peep measurement can be done during mechanical ventilation with time cycled, pressure limited and continuous flow, the most commom ventilator used in pediatric patient. resistance was modeled by endotracheal tube (ett) sizes ( . , , , ), and compliance by test lungs ( and ml/crnh ), for each resistance -compliance arrangement, we measured tidal volume (vt) at various frequencies, peak to peak (p-p) and mean airway pressures. results vt increased when ett size increased with all ventilators in accordance with fredberg results (jap, ; : - ) . the maximum vt delivered was smaller with the hfv-babyiog than with the ohf or the sm a at a given frequency (figure on the left). increasing p-p resulted in a linear increase in vt delivery in the - % range of maximum p-p (figure on the right). hfv-babylog didn't provide significant vt increase when p-p was set above % and vt deliven/decreased when mean airway pressure decreased. --i ~ sm a a number of ventilatory parameters had been analyzed with russia-produced monitor humitemp htm (servisinstrument j,-s. co) in newborn infants with rdsn of t-iv stages on cmv, cppv, imv, and cpap steps using respirators of various kinds (stephan-staxel, bear- , newport rezee, sechrist). parameters investigated were: temperature of inspired mixture (t), relative and absolute humidity (rh and ah, respectively), static compliance (c), expired tidital volume (vte), expired minute volume of ventilation (mve). the monitor read these parameters in following ranges; rh-from to %; ah-up to mg/i; mve-up to . i/mini vte-from to ml; t-accurate to %; c-from . to t ml/cm h . continuous monitoring time ranged from to hours, it was noted, that during this time the monitor and transducers had no malfunctions, and it's using didn't require additional calibration, it was found, that humidifiers mr and mr (fisher, paykel) couldn't maintain parameters t and ah continuously (these values varied from , to . c and from , to . mg/i, respectively, when heating regulator position was unchanged). changes of parameters c depended clearly on cppv conditions and rdsn severity (with rdsn of stages i-ii c value ranged from . to . ml/cm h ; and with stages iit-tv-from . to . ). tn newborn suffering from rdsn of stages ii-ltl and ill-lv with pip> mbar, fi > , , peep= - mber, c-from . to . ml/cm h , effectivity of exosurf therapy was studied. in newborns in - hours of therapy pip decreased to . - . , and c increased to , - . ml/cm h . in newborn infants with aad > mmhg and c from , to . mltcm h positive effects of exosurf on lung compliance were not observed. in newborns the monitor had revealed decreased of c (from . - . to , - . ml/cm h ), manifested clinically by pneumothorax. in general, monitor htm made possible; ), to estimate the adequacy of cmv-parameters and regimes in newborn infants; ). to select optimal t and ah values in the respiratory outline in dependence on lung damage severity and infused volume; ). to reveal rdsn severity; ), to optimize indications and adequacy of surfactaot therapy; ). to diagnostieate the air leakage syndrome; ). to effects to some agents (broncholytics, spasmolytics); ). to obtain objective indications for imv/simv and cpap regimes. albano communication is an important aspect of human development and existence, and an inability to vocalise can be a problem in ventilatordependent patients. we present our experience with speaking aids as a means of enhancing verbal communication in four ventilatordependent children in our paediatric intensive care unit. the age of the children ranged from months to years, and the period of ventilation ranged from months to months via a tracheostnmy. they require continuous flow generated pressure limited or control ventilation at rates of - bpm. the reasons for ventilation include tetraptegia following a shrapnel injury; tetraplegia following congenital cervical spine damage; tetraplegia following atlanto-axial subluxation; and critical illness polyneuropathy following adult respiratory distress syndrome from prolonged ventilation for a severe head injury. the first three patients have passy-mnir one-way speaking valves and the final patient has a bivona foam cuffed tmcheostomy tube with a talk attachment in view of recurrent aspiration. an improvement in quaiity of speech has been shown by independent assessment. we will review the present literature on this subject and discuss the advantages and disadvantages of these two types of speaking aids in the light of our experience. the prognosis of antenatally diagnosed cdh is closely related to the degree of ph. there have been attempts to correlate antenatal or postnatal criteria to mortality: none have been demonstrated to be predictive of lethal ph. the aim of this retrospective study was to determine whether antenatal or early postnatal data could correlate with the findings of post-mortem examinations. patients and methods: between july and july , cdh patients have been antenatally and postnatally managed at our institution. twentythree infants underwent a post-mortem examination. ph was assessed by using the lung weight to body weight ratio (lw/bw) and the radial alveolar count (rac). antenatal results: cdh diagnosis was made at weeks of gestation (wg) ( - ). twenty-eight patients had a left sided cdh, had a right sided cdh, and one had a bilateral cdh. herniated organs were stomach none (n= ), or liver alone (n= ), or both stomach and liver (n= the patient was a -yenr-old girl with chronic renal insufficiency see~ to renal dysptasm, two months before admission a kidney trar~ptant was performed. one morah later she showed acute graft rejection with serum ereafinine (cr) level of . mg%. the rejection was unreslxmsive to an increased steroid dosage, and okt was begun with resolution of the rejection. one week arer, new rejection episode was seen marestxmsive to an increased steroid dosage, and transp~ ~s performed five days before admission to our ptc. hemedialysis and peritoneal dialysis (p.d.) each other day, was indicated (g.r.f.< ml/rnin). four days before admission t ~ rose to °c. "lhe diagnosis of opporttmistic pneumoma was made on the basis of tach ,pr',e~ hypoxi~ and diffuse interstitial infiltrates. senma ~ was positive for cytomegaloviras (cmv), and stool culture for c albicans. pentamidine, ganciclovir (dhpg), arai-cmv gamma globulin, eritromicine and amphotericin b was administered. on admission in our picu, trachea was mmbated, (a-a) o gradient was , paofffio~: , lung injury score > with peep level of cm hzo. she had normal fiver function. during te next days she had fever and developed ards. bal was negative. p.d. was of little efficiency. we adjusted pentanfdine, and dhpg doses for severe renal failure, with supplements after hero, sis, and at~rp.d.. during ~ next days she was afebrile, and the chest became radiologlcally normal. after ten days on menhani~al ventilation (mv.), the patient was extubated. cr. level was . rag%, (a-a) oz gradient was , and paoyfioz was , the patiem was discharged with chronic ambulatory p.d. discussion: opportunistic pneumonia is a major complicalaou in imm~romised children, specially after kidney tvansplaraafion. c m.v. infection can result at~r okt administration. in the treatment dhik} dose must be adapted to the degree of renal insu~cieney, with supplements after hemedialysis, and after pd. pneu~y~tis cann# tmeumov~ is ehemeterized by ventilafion-perfusion mistmaeh, decreased pulmonary compliance, hypoxia arld elevated (a-a) oz gradient, with diffuse interstitial infiltrates. in our ease bal was negative. although we did not find the etiology the prevoclons eombh~ation of arairmcrobiat therapy, along with m.v., and supportive measures were the most effective trealme~. conclusion: ) in patients with severe renal failure and life-threatening infections, we must co~ider drug adjuslments. ) in our patient we gave dhpg supplements at~r pd. with excett~at results, although p.d. was of little effiele~. introduction: endotracheal intubation and mechanical ventilation have become an important treatmem for many diseases accompanied by respiratory failure. with the frequent use of this treatment modality, an increasing number of complications associated with endotracheal intubation have gained clinical significance. material and methods: a transversal study was realized to find the prevalence of pulmonary aspiration with endotracheat tubes in infants and children. aspiration was assessed by applying two dyes (evans blue, er)¢rosine sodic) on the tongue and searching for the dye during suctioning in the endotracheal aspirate. the factors, that potentially have influenced the aspiration, including weight, age, sex, cause of respiratory failure, main pressure airway (map), level of consciousness, presence of swallowing and body position were evaluated. all the variables studied had their association with aspiration tested by chi-square method with relative risk considering a confidence interval of %. the results were adjusted by multivariate analysis. results: the overall prevalence of aspiration was . %. among all children who aspirated, compared to those who did not, there was a statistically significant difference in the presence of swallowing (p= . ). the odds ratio to aspiration in the presence of swallowing was . (t. - c.i. %) and the relative risk . . aspiration was not significantly affected by sex, weight, age, cause of respiratory failure, map, level of consciousness and position of the body during the ventilation. conclusion: the endotracheal intubated children frequently aspirate as intubated adults and that preventive measures are ineffective. the presence of swallowing movements is the main risk factor to aspiration of oropharingeal content in intubated patients. clinical features and shortterm outcome skling, rp gie pneumonia is the second most important cause of death in young south african children. the clinical features, intensive care course and outcome of children being ventilated for pneumonia in the developing world is unreported. aim: to describe the clinical findings, aetiology and shortterm outcome of children younger than months with pneumonia requiring ventilation. the data of all babies under the age of six months with a lower respiratory tract infection admitted to the paediatric icu for ventilation were prospectively collected over a period of months. tracheal aspirates and blood specimens were submitted for viral and bacterial cultures. results: forty-seven babies aged to days were ventilated for pneumonia. twenty-six infants had been born prematurely; t had been ventilated during the neonatal period and had bpd. the median duration of symptoms was day, the most common being cough, tachypnoea, apnoea and cyanosis. five babies ( %) died. the mean duration of ventilation was days (range - days) and of ward stay after icu discharge days (range - days), blood euttures were positive in children ( %). viruses were cultured in children ( %). conclusion: ) fifty-five percent of children below months requiring ventilation for pneumonia were premature infants, of whom % had been ventilated during the neonatal period. ) the median duration of symptoms prior to admission was day. ) ninety percent of the children survived and were discharged from hospital. ) viral pneumonia was responsible for % of the admissions. mechanical ventilation and atrial natriuretic factor release ulloa santamarfa, e, p rez navero jl, ibarra de la rosa i, espino hernladez m, velasco jabalquinto mj, frfas p rez m. picu. reina sofia children's llospital. c rdoba. spain. mechanical ventilation effects on renal function decreased diuresis and natriuresis due several factors including anf. several studies have demostrated anf released due increaasing pressure in right atrium. on the other hand, mechanical ventilation, overall peep modality, inhibits peptide release althougt cvp increased is found. this study was designed to demostrate anf stimulation is due rigth atrium stretch which be higher during mechanical ventilation instead of atrium pressure. we desing a prospective study including patients, age range months- years with congenital heart disease. all of them were admitted at pediatric intensive care unit after extracorporeal surgery and were assisted by mechanical ventilation. hemodinamic state was stabilized in all patients and nor renal neither neurological diseases were found. after hours with mechanical ventilation, plasmatic levels of anf were measurement, pvc, pericardical pressure were assessment; all patient were sedated with midazolan and paralized with neuromuscular blocking agent; mechanical ventilation technique was as follow: imv between and , tidal volume and fi o enough to mantain respiratory parameters in normal range. afterwards, at least twentyfour hours in spontaneous breathing, the study was made again in each patient. atrial stretch was assesssment according to following equation: transmural pressure= cvp -pericardial pressure. cvp were significantly higher with mechanical ventilation than when the patient was breathing by himself. ( . +__ . vs . + . mm hg; p< . ). however, transmural pressure during mechanical ventilation were lower than during spontaneous breathing ( . +__ . vs . +__ . mm hg; p < . ) equal, plasmatic anf levels were lower during mechanical ventilation ( . + . vs . + . pg/rnl; p< . ). in conclusion, anf secretion decreases during mechanical ventilation, even with cvp higher. anf release would depend on atrial stretch meassured by transmural pressure, lower in patients with mechanical ventilation and it would not depend on atrial pressure. the paediatric intensive care unit shaikh zayed hospital, lahore is an acute care area devoted to the care of critically sick children upto the age of years. in a bedded unit with limited equipment, constant care is ensured by the presence of at least one nurse aed one doctor round the clock. in this setup we have the facility to ventilate - children at one time, between sep. and dec. , out of patients admitted to icu, ( . %) were below yr of age, while ( %) were below month of age. life support was discontinued in ( . %). total mortality was ( . %), major mortality was in - month age group ( . %), and month to month ( . %). majority of the patients were of sepsis ( . %), cns disorder ( , %) followed by respiratory problems ( . %). it seems therefore that the major indicatiou for ventilation was overwhelming septicemia leading to multiple organ failure, rather than purely respiratory problems. high frequency oscillation (hfo) in the therapy for ards in pediatric patients requiring aggressive conventional mechanical ventilation (cmv) -routine or experimental mode ef pre ecmo therapy. fedora m., nekvasi~ r, vobruba v., srnsky p,, zapadlo m. dpt. critical care medicine, nicu and ecmo center, university children's hospita! brne, nicu of university hospital prague, czech republic. introduction: pediatric patients ( males, female, average age . months, average body weight , kg) with severe ards ventilated with aggressive regimen of pcv or prvc were connected to hfo (sensormedics ) as the last "rescue" therapy due to uncontrollable respiratory failure before intended ecmo. in the course of hfo of them were given no in the concentrations of - p.p.m., were subjected repeatedly to surfactant replacement therapy (alveofact). results: ecmo was needed in no patient, patients survived, patient was disconnected from the ventilator because of brain death in spite of conspicuous improvement of oxygenation and other parameters, some relevant parameters hours before and hours after starting hfo are given in table ~ in all the cases, the disconnection from hfo was carried out through the simv regimen, never directly to cpap. table : the levels of blood gases, oxygenation index (oi), aado ,map,fio and pao /fio ratio hours before and hours after starting hfo. conclusion: although none of the patient had to be subjected to pediatric ecmo, hfo should be carried out only in workplaces having the immediate possibility of using this method in the case of hfo failure. speculation: should not hfo be used ir pediatric patients with ards earlier than aggressive cmv? can hfo ce considered standard, not experimental method of therapy? refractory hypoxemia in premature patients is characterized in a persistent elevation of pulmonary vascular resistance, with right to left shunt through the ductus arteriosus and or foramen oval. we report the case of a vlbw patient (ga w, bw g) who present a severe hypoxemia related to hyaline membrane disease and a pulmonary and systemic infection to group b streptococcus, refractory to conventional ventilatory support and surfactant therapy, associated to hemodynamic failure falling in ecmo criteria used for term infants. a rescue therapy with hfov (sensor medics a) is decided at h of live, the table resume the patient's evolution before and after hfov. at w of postgestational age the patient present a fio of . with a chest x ray compatible with a cld type l at discharge no oxygen requirements was needed and actually he's doing well. conclusion: hfov, using an adequate alveolar recruitment strategy, was effective in the rescue of a severe hypoxemic respiratory failure with a rapid off of ecmo criteria entry in our vlbw premature patient, during the united nmioffs embargo ~nst yugoslavia the prevalence of the ast}nnafic ~acks in c~dldren aratsed. the mo~t common causes have beem dramm~e worsening of life standard, ecom~c disaster in global community, gr~ number of refugees from the other parts of former yugodavia. it wm obviom that mcio-ecoumnical conditions took a part in the exacerbations of previously known cldldhood asthra~, ~av~ of micro-and m~mclimaflc changes, psychosocis] and emotional cryses, lack of medics-m~nts for p~ve~on and tl~rspy of acute asflanatic attacks. about % of d-dldv~ tmslod in our picu for these year~ exp~dvncod ~vcr~ attack for the flint time iu ~jzeir lifts. it has been cu~ ~%~ children in mspir~ry picu of our hos~mt. the scut~ revere attack (more ~asn ~/o of hight clinical score) was detected in % of all children admitted with respirak~ problems. from tl~ mmlysss we exclu&d: bmncldolifis, ~i anomalies, ~eve~ i~ccqions. concerning our drug supplies (which wc~e reduced), we started our therapy by administration of oxygen, ~ta -ago~dst inhalations (but sometimes we had the solution for jet nebulizcm only for o~e inhalation per p~cnt), mwinophyllin and mefl~ylpr~ini~done in/ravenously. % of ih~ asthmatics needed repea~ doses of muinophyl~n pinch.ally, tnch.,ding the fluids. the bronchodilak)r msponm was poor ~r~cl slow, hospital stay in picu was for days and for days in other units sl~rwsvds. tim ~ of their stable condifio~ was hard at borne (or refugees camps), without p~ventkm, so they came bsvk to hospital for morn than times in % of cases, dtrdng ~e je last motlfl~s file dtustion improved, concerning tim drugs supply for prevention, and we hope that these lifc~restening conditions wouldd~ introduction: the incidence of ards is increasing as survival of critically ill patients is higher. the application of new therapeutic modalities have increased the survival rates in (ards) adult patients. objective: to study the therapeutic efficacy of new tleamlents in children with ards material and methods: a retros~ctive study was conducted from to . children with severe ards, (lung severity score > , ) (r), aged days to years, were included. the diagnosis were as follows: interstitial pneumonitis, non interstitial lung infection, with lung aspiration and with clinical sepsis. patients had different tipes of cancer and to suffer inmunodeficiency disease, the first subjects (group t) were treated with conventional measures. from october of new therapeutic modalities were introduced, including: less agressive ventilatory support, postural changes (prone to supine) in subjects, administration of corticosteroids in patients, rfitric oxide in , pe~ssive hypercapnia and administration of exogeans sarfactant in one, pao /fio , d(a-a)o , oxigenation index (oi) and the score of respirator), severity disease were similar in both groups. the two groups evolntiou was compared. results: -ten patients died, from group i and from group ii ( % v.s. : %,ns). -the evolution time, either to exitus or weaning from ventilatory support was higher in group ii ( . v.s. . days in group i, ns), -the incidence of barotrauma was observed in subjects ( . %), from group i and from ii. of these patients % expired. -during the course of the disease, ( %) patients had more than one damaged organ. only in one subjet mof was considered to be the main cause of death. the majority of the patients expired because of their respiratory disease, although, % of them met criteria of mof. -fifty percent of the subjects were infected at the time of death. stmmry: a trend toward a higher survival rate is observed in the subjects receiving the new modalifies therapeutic intervention (corticosteroides, postural changes and permissive hypercapnia). our results are not significative,probably because of the small number of subjects studied. a new doubleaurae~t two-stage et-tube (dl-ett) was desig~aed and tested in the rabbits with acute king injury under conventional mechanical ~entilation_ ventilation efficiency of dl-ett was emrrpared with that of canveniionally t~sed single lumen et-tube (sl-ett). meth~s: dl-ett was specially made out of two sl-ett. vertical crosssections at the distal end of two et-tube (td _ rmn portax) were adhered with each other to form a tracheal stage lumen wifu id . mm the two remained uncut parts of the tubes corlntithted the oval s~ge with two separate imnens. dl-ett and sl-ett were randomly applied to five adult paralyzed rabbits with acute lung injury (by . nffkg oleic acid. iv). a bird inter vetffttator (bird products corporation) was used for time-cycled pressure-limited ventilation at /min of respiratory rate, ern h of peak i_~piratory pressure, l: of ire ratio, ljmin. of flow rate and . of fich. peak inspirntory pressure, mean mrway pressure, posi ve end-expiratory pressure at tip of et-mbe and bemodynamics were measured and recorded continuously. arterial blood and expired gas were measured ~by avl blood gas analyzer) after each stabilization t.~iod of minntes. _analysis w~as by prated t test. result: dl-ett acaltety improve cos removal at all amman. pa(?oz was decreased by t . +_t. (p< . l) and physiologic dead space fraction (v~zvt) reduced by % +- . % (p< . t), compared with dl-ett. there were no significant change in arterial oxygenation. conelus|on: the double-lumen two-stage et-tabe significantly increases ventilation effmiency with simple operation in rabbits v, ith acute hmg injury, lts availability may influence future clinical management of ~ennated patient~. this ~muly was fimded by the science and technology. commiuee of beijing municipality. analis of hemostasis alterations on different coagulation cascades in children with septic shock has shown that coagulation disorder character is dependent on lung affection rate. the initial manifestation of the respiratory distress-syndrome (rds) are characterized by the obvious activation of blood thrombin potential, moderate coagulopathy and not sharply marked endoteliosis, the witlebrand's factor (wf) increase tot - %. progress in the clinical picture of "shock lung" leads to chronometric and structural hypocoagulation with potential hypercoagulation in "mix-test", high level of firbin derivative, thrombocytopenia with thrombocytopaty and the wf increase to ~ %, terminal stages of the rds, as a rule, are characterized by potential hypercoaguletion absense, depletion of at-lit and plasminogen, prevalence of antithrombin and antiaggregating activity, obvious endoteliosis (the wf to increase - %). the arteriowenous difference according to index of the thromboelastography (teg) in the rds ill-iv rates was , % less than in the - rates, disorder of lung filtering ability in severe rds is confimed also by minimal arterio-venous difference of activated euglobulin lyses (ael) in children with the rds ill-iv rates is only , %, while the patients whit rds i-i rates have the ael-activity in arterial blood , times as much than in venous blood. the use of then allows to determine the potential hypercoagulation rate, the at-ill level and fibrinogen quantity during the anticoagulant therapy and also the character of the x-factor activation and thrombocytic hemostasis. the effective therapy component of septic genesis rds in children is the controled coagulation method with the use of the individual selected heparin doses in according to desagregants, kryoplasma, proteolisis inhibitors and trombolytics. it is necessary to avoid the heparintherapy for children with the rds complicated with producting coagulopaties and termal phases of blood disseminated intravascular coagulation (dic). bronchoseopy has been used for evaluation of the potential problems of the airways and for investigation the bronchial specimens for diagnostic purposes. regent technical advances result in performing this procedure at the bedside manner and in critically ill patients. we have performed hronehoaeopy during last three years on pediatric patients with respiratory problems, in % of cases the opentube hroneh seopy was performed (for diagnostic as well as for therapeutic reasons) and collected secretions or bioptic material were examined. the indieatiuns were: acute upper respiratory problems, chronic wheezing, inspiratory strider, tracheal or bronchial bleeding, chronic eongh, retractable atelectssis, severe pulmonary infections, lymph node perforation in lung tuberculosis and soquells like bronehiectssis and fibrosis. our results were: anatomical malformations in %, mueosal oedema with chronic inflammation and thick secretions in %, easuos masses in %, granulation tissue and purulent secretions in foreign bodies and bronehieetasis in %, and only % of eases were normal finding. our exlxdenees pointed that this invasive procedure in carefully selected patients has important role in establishing the diagnosis and in the- introduction: tbg has been a useful investigation in the management of ventilator-dependent infants in our experience. one ml of contrast was hand ventilated into the respiratory tree via their nasotracheal tubes and their anatomy and dynamics demonstrated on radiological screening. case descriptions: three infants who were difficult to ventilate requiring high airway pressures, high peep and a significant oxygen requirement had tbgs. the ages ranged from to months. two cases were complicated by complex cardiac lesions. in all cases there were frequent episodes of desaturation, where hand ventilation proved difficult and various intermittent lobar collapses occurred. microlaryngobronchoscopies (mlb) performed on the infants by experienced paediatric ent surgeons failed to identify the airway problems. more than one mlb was frequently done. concern about introducing contrast into the airways of infants with limited cardiorespiratory reserve combined with an uncertainty about how much extra intbrmafion would be gained often led to a delay in investigation. when performed these fears proved groundless, the anatomy and pathology of the airways were demonstrated in full and the correct therapeutic plan started. in two cases tracheostomy and peep producing patency of bronchomalacic segments allowed weaning to low levels of ventitatory support. in one case tracheal reconstruction was undertaken and in the cardiac cases the respiratory component of the ventilatory dependence was fully assessed. at the age of months, a baby boy with a history of minor respiratory problems, was admitted to hospital with an upper airway infection and severe dyspnoea. shortly after arrival at the icu he had a total airway obstruction. after intubation there were still difficulties to establish a normal gas exchange, and he was tranferred to the regional picu. ct scan and bronchoscopy verified a congenital tracheal stenosis affecting the whole trachea except the upper mm below the vocal cords. the diameter was estimated to less than ram. an unsuccessful attempt was made to dilate the extremely rigid stenosis with a balloon. after the procedure he had a respiratory and circulatory arrest, and he was put on ecmo as a bridge to surgical correction. after stable days on ecmo, surgery was performed during ecmo with a tracheal homograft transplantation. immediately after surgery, ecmo was discontinued. a silastic dumont type stcnt was inserted inside the homogra~, and a nasotracheal tube was placed inside the stent for assisted intermittent mechanical ventilation. repeated bronchoscopies were performed to remove granulation tissue and secretions. at months of age, the stem was removed with an endoscopic procedure. however, the trachea was still soft and collapsable, and another silicon stent was placed inside the trachea for another months period, after removal he had some respiratory problems and he was treated with nebulized salbutamol, mcemic epinephrine and steroids. he was discharged from the hospital at months of age and his condition is now stable. this is the first procedure of its kind in sweden. it was accomplished by international and multidisciplinary collaboration. ecmo may be a bridge to corrective surgery and long time stenting may be necessary in the postoperative period. post mtubation laryngitis ( pil ) is still a frequent complication, occurmg in l - % of intubated patients. inhaled racemic epinephrine has for long been used as an accepted therapy, but this drug is not always available. the authors undertook a randomized, double-blind, placebo-controlled trial to determine the efficacy of inhaled l-epinephrine(le) in the treatment of plu in the period between july/ and may/ , patients were submitted to endotracheal intubation for ventilatory support. atter the extubation procedure patients were considered for enrollement if they met the following criteria: clinical signs of laryngeal estridor and a downes and rafaelly score for upper respiratory obstruction equal to or higher than patients with primary upper respiratory disease were excluded all patients enrolled reeieved either inhaled l-epinephrine % or normal saline. dexametasene ( , mg/kg/day) was given to all patients in both groups. after inhalations, au patients were monitored for a period of - minutes and monitoring included cardiac and respiratory rate, mean arterial blood pressure, arterial blood gases and the dowries and rafaelly score. statistical analysis included, qui-square with the fisher correction test and the z-test for paired variables. thirty eight patients ( , % ) met the criteria for enrollment, to the le group and to the placebo group.there were no significant differences in both groups in regard to age, sex, initial score ( , x , ) and endotracheal tube diameter. the period of ventilatory support and tracheal intubation was significantly higher in the le group ( , x , , p = , ). the follow-up score showed a significant drop only at minutes after the inhalations (p = , ). re-intubation due to laryngitis, occured in patient of the le group and in of the placebo group with no statistical sxgnificance (p = , ). no difference was observed on the monitored hemodynamic variables during the minutes, except for the mean arterial pressure at minutes, being heighar on the placebo group (p = , ). we concluded that, although the l-epinephrine group showed a trend in better scores post-inhalation and fewer re-intubations due to laryngitis, the results were not statistically significant. we especulate that the period of intubation may have affected our results. similarlly there were no differences in the incidence of adverse effects between both groups. objectives:to evaluate the complications of endotracheal intubation in children with upper airway obstruction due to epiglottitis or croup. methodes: during a year period ( - ) all patients with epiglottifis or croup were reviewed to determine the complications of endotracheal intubation, especially upper airway obstruction due to granulomas. results: patients were reviewed. in children (mean age . years) with epiglottitis the mean duration of intubation was . days ( - ). no complications were seen. in patients (mean age . years) with croup the mean duration of intubation until the first extubation was . days ( - days). elective extubation was performed if an airleak was present or after days without airleak but in the absence of fever and obvious secretion. reintubation was not necessary in children ( . %). in this group the mean duration of intubation was . days ( - ). in patients ( . %) reintubation was necessary because of severe upper airway obstruction due to granulomas. mean duration of intubation until the first extubation was . days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . there seems to be a difference in duration of intubation between these two groups with croup, however it is not significant (p > . ). all the patients with granulomas could be successfully extubated after microlaryngeal surgery, with a mean intubation period of . days ( - ). revealed no complications, where as endotracheal intubation in children suffering from croup showed a high incidence ( . %) of granulomas. however laryngeal steepsis and other serious complications were not sesn~ patients ( days averagely] was obviously seen in ~he peak =one of fl, f resonance and in the zone of high freq,-~ncy :r, ~;~e composition while cases( day~ average;y] :~bowed no abnormality both clinically and isryngoscopica!~y. / patients with catheter placement for more than week~ end p~tie,~ts for less than weeks had t;~ryngeal abnormal change in their larynges,abnormal changes of sound spectrogram were all seen in patients with placement for mope than weeks. our data suggest= ca] the complication of endotracheal intubation was increases with increasing length of time of catheter placsm. entjbut aeriuoa complication is rare i (b] the time limit of pernasal endotraoheal catheter placement is weeks within which the procedure is • comparatively safe and effective means for maintaining e tong term artificial airway. in a -year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) we diagnosed tbm as an apparent dilatation of the trachea and main bronchi ih four premature infants on continued mv for respiratory distress syndrome (rds). the infants were three boys and one girl with gestational age (ga) - weeks and body weight (bw) - g. mv was provided by bourns cub time-cycled and pressure-limited ventilator to attain normal gas tensions. no jet ventilation was used. chest radiographs were reviewed for a complete evaluation, and for the evaluation of the airway. after the intial subjective diagnosis of tbm, the width of the tracheal and main bronchial air column was measured at the lower level of the first and the third thoracic vertebal body it , t ) and near the carina; the width of the main bronchi below the carina was also measured. in all infants, tbm became apparent close to the lh day, that is, after - weeks of mv. therefore, for the time period from birth to the th day the following ventilatory parameters were reviewed and analyzed: ( ) the percentage of total ventilation time when more than % o concentration was required, ( ) the peak inspiratory pressure, ( ) the positive end-expiratory pressure, and ( ) the duration of high frequency ventilation ( - breaths per minute). also noted were the apgar scores ( and min after birth), the duration of hypotension (systolic bp below mmhg) and circulatory instability, the presence of systemic or tracheal conatal or later infection, the duration of mv, and the final clinical outcome. the records were also reviewed for other possible pertinent data. rigid respiratory endoscopy in children fraga j, amant a s, piva j, nogueira a, palombini b. introduction: the respiratory endoscopy is an important procedure to diagnose and treat many airway's diseases in children. although have had advances in radiologic investigation exams and pulmonary function tests, the direct anatomic visualization of airway is important to the management of many respiratory problems. objective: evaluation the respiratory endoscopies performed with a rigid bronchoscope in a pediatric reference hospital. material and methods: we study the records of all children that were submitted to respiratory endoscopy under general anesthesia from march to march . age, sex, clinical to indicate the procedure, diagnosis and complications of endoscopy were registered. results: three hundred and fifty six respiratory endoscopies were performed. the most common indications for endoscopy were strider ( %), suspected foreign body ( %), atelectasis ( %) and difficult tracheal extubation ( %). the most frequent diagnosis were laryngomalacia ( %) and subglottic stenosis ( %) in the glottic and subglottic areas, and foreign body ( %) and tracheomalacia ( %) in the tracheobronchial area. normal endoscopy was performed in ( %) of the children. only three slight complications of the endoscopy were observed. two patients presented bradycardia during the exam, and the third need tracheal intubation due to post-endoscopic subglottic edema. conclusion: the rigid endoscopy in children is efficient and has no serious complications. near drowning; indicators of acute and long term prognosis bernardien t.mj. thunnissen t, reinoud j.b.j. gemke , loes veenhuizer?, krijn haasnoot , a.johannes van vugh department of pediatrics, ~wilhelmina children's hospital, utrecht, sophia hospital, zwolle, and ~free university hospital, amsterdam, the netherlands. in this retrospective study factors that affect short and long term prognosis after submersion were analysed. all patients that were admitted to a tertiary pediatric icu between january i, and january i, were included. of patients, aged - years, died in the icu, one after hospital discharge. survivors and non-survivors showed significant differences with respect to central temperature, pupillary reactions, arterial ph, pediatric risk of mortality (prism) score and therapeutic intervention scoring system (tiss) upon admission (p < . ). non-survivors more frequently required mechanical ventilation, bicarbonate administration and active reheating. ards was seen in patients ( %), invariably within hours after admission. no patients with cardiac arrest on" admission snrvived without sequelae. hypothermia appeared to have no protective effect on hypoxic damage. survivors with persistent sequelae _> months after discharge had significantly higher prism and t ss scores (mean and , respectively) than those with complete recovery (mean and , respectively). long term cognitive problems were present in / survivors ( %) and emotional disturbances in / ( %). in conclusion, a concise number of clinical and laboratory parameters, representing acute severity of illness, are important prognostic indicators for survival and health status of children after submersion. there were ( %) bronchoscopies, and ( %) were oesophagoscopies.the average age was , years for bronchoscopies, and years for oesophagoscopies. the outcome of the patients was good. no complications were observed. extraction is recomended in every symptomatic patient. orphenadrine is an anticholinergic drug mainly used to decrease symptoms of parkinson disease. orphenadrine has a peripheral and central effect and overdose can result in athetoid movements, convulsions, cyanosis, coma, arrhythmias, shock and cardiac arrest. physostigmine is a specific antagonist of the peripheral and central effects and can be a useful antidote. we report the case of a two and a half year old female who was transfered to our icu for general convulsions. the little girl had, three hours before admission, accidently ingested rag of orphenadrinehydrochlodde (disipal®), which was her grandmothers anti-parkinson medication. three hours after ingestion she presented neurological signs: confusion, unstable walking, and periods of aggression. generalized tonic-clonic seizures appeared who were rebel to administration of multiple anti epileptica but ceased after iv administration of diazepam and endotracheal intubation and ventilation. an episode of ventdcular tachycardia responded well to the iv administration of tidocaine. the levels of orphenaddne in the serum were high at admission ( pg/l) and were present in the blood up to hours after ingestion. high serum levels are, in the literature, associated to a high mortality rate. physostigmine was administered three times at a . mg/kg dose in the first hours. we decribe the noted effects of physostigmine on the different symptoms. the patient survived and could leave the icu after one week. in conclusion: orphenadrine poisoning is a very complicated medical problem associated with high mortality. in severe intoxication, the benefit of physostigmine more than counterbalances its side effects. objective: to define the optimal volume of dilution for endotracheal (et) administration of epinephrine (epi) design: prospective, randomized, laboratory comparison of four different volumes of dilution of endotracheal epinephrine ( . , , and ml of saline) setting large animal research facility ofa universi~ medical center subjects and interventions: epinephrine ( . mg/kg) diluted with four different volumes ( , . . and i rot) of normal saline was injected into the et tube of five anesthehzed dogs. each dog served as its own control and received all four volumes in different sequences at ieast one week apart. arterial blood samples for plasma epinephrine concentration and blood gases.were collected before and . , . . . _ . . , . . , . , . , and minutes after drug administration. heart rate and arterial blood pressure were continuously monitored. measurements and main results: higher volumes of diluent ( and i ml) caused a significant decrease of pao , from :!: tort to ±i torr, compared to the tower volumes of diluent ( and ml), from ± torr tu +_ torr (p< . ). these effects persisted for over minutes. mean plasma epinephrine concentrations significantly increased within seconds following administration for all the volumes of diluent. mean plasma epinephrine concentrations, maximal epinephrine concentration (cmax), and the coefficient of absorption (ka) were higher in the ml and ml groups. the time interval to reach maximal concentration (tmax) was shorter in the ml and ml groups. yet these results were not significantly different. heart rate. systolic and diastolic blood pressures did not differ significantly between the groups throughout the study. conclusions: dilution of endotracheal epinephrine into a ml volume with saline optimizes drug uptake and delivery, without adversely affecting oxygenation and ventilation. the aetiology and outcome of paediatric out-of-hospital cardiac arrest was studied during a -year period in southern finland served by physician staffed emergency care units. the files of prehospital patients less than years old without palpable pulse and spontaneous respiration were analysed retrospectively. fifty patients were declared dead on the scene (dos) and resuscitation (cpr) was initiated in patients. the sudden infant death syndrome was the most common cause of arrest ( %) in the dos patients as well as in patients receiving cpr ( %). asystole was the initial cardiac rhythm in % of the patients in whom cpr was attempted. eight of the hospitalised patients were discharged, of them with mild or no disability, with moderate disability and one in vegetative state. in multivariate analysis the short duration of cpr (< minutes) was the only factor significantly associated with better survival. due to various aetiologies the survival rate from prehospital paediatric cardiac arrest is quite low. on the other hand, hypothermic near-drowning victims seem to have a relatively good prognosis. duration of cpr less than minutes was the best predictor of intact survival, our study supports the previous findings of the importance of early and effective resuscitation efforts for establishing ventilation and perfusion on the scene. in our system well trained physician staffed emergency care units are able to provide immediate and effective als on the scene. on the other hand, these units also appear to be able to refrain from resuscitation when the prognosis is pessimistic. objective: to assess the normal ,gastric intramucosal ph ~hi) by tonometry in healthy children patients and methods: twelve healthy children ( males and females) with age rmaged from months to years scheduled for minor plastic or urologic surgery. children were previously medicated with midazolam ( . mg/kg) and atropine ( . mg~) both i.m.. anaesthetic induction was standardized with -n ( %) administered via facial mask and increased halotane concentrations (up to %). all patients got an endotraeheal tube after iv. administration of femanile ( mcg:jkg) and vecuronium ( . mg/kg) or suxametonio ( mg/kg), pmaesthesia was maintained with o -n ( - %) and isofluorane ( . - %). during surgery, children needed mechanical ventilation and the others maintained spontaneous breathing. ekg, heart rate, blood pressure, and pulse oximetry were moniterized. after anaesthesia, a sigmoid tenometry catheter (tonometrics, inc.) was inserted in the stomach of the patients by direct visualization with laryngoscope and magyll clamps. children were all maintained normoventilated and with normal cardiorespiratery variables. cadet's balloon was £~led with . ml of saline. thirty minutes after the insertion rrd was extracted and rejected, just afterwards the remanent . ml was extracted and immediately analyzed. simultaneously an arterial gasometry by puncture was performed. gastric phi was calculated by the henderson-hasselbalch's equation using the pco obtained from the tenometry catheter and the bicarbonate value obtained from the arterial gasometry. results: average gastric phi was . -i- . , range ( . - . ). objective: demons~ating intramucesai ph (phi) alterations during transport of patients from operative room to pediatric intensive care unit (picu), material and methods: phi measurements were performed with gastric tonometer catheter in t patients undergoing cardiac surgery with cardiopulmona d" bypass (cpb), there was mate and female, the average age = yl ra, average weight = , kg, average time of cpb = rain. the measurements were made at the end of the surged' and when the patients had arrived in the picu statistical aualysis: average and ~andart deviation and test "t" student. objetive: to asses the efficacy of gastric iatramucosad ptt (phi) and arterial lactate levels to evaluate splacalc tissular perfusion in an experimental model of intestinal ischemia. suneets ~nd methods: twelve piglets weights t - kgs. undergoing orthot~ie liver trasplantation. the intestinal ischemia was induced by aortic damping. tonometry catheter (tonometrics inc.) w~s placed in the stomach after artaesthesia and ot intubation. phi ~s determined times and lactate levels was determined fi times in stages: i) pre-ae~hepatic stage (twice: before surgery and before aortic clamping ); ii) end anhepatic stage (only phi): iii) reperfusion stage (a , , and minutes). the phi was derived from application of the henderson-hassdbach formula using the pco value from the tonometer and the arterial bic~rbonate. all pipets received raaitidiila before sttrgery. values of phi above , and lactate levels between and mg/dl were considered nortrm. the results were statistically anaj.izated with anova and bonferroni tests. results: the phi was normal on pre anhepatic stage (> , ) and lactate levels were slightly increased ( , +_ , and , ± , mg/dl ns) . in relalion to we-anhepatics values, phi decreased signncatly at the mid of anhevatic stage ( , _+ , vs , _+ , p< , ), phi remain low in stage iii, at rain ( , + , p< , ) and min(g -+o, p< , ). arterial lactate levels increased significatly in relation to levels in stage i, at rain ( , _+ , p< ,o ) arid rain ( , ± , p< , ) of reperfusion stage. there is a slight improvement on phi and lactate ievels at and t rain althought the differences did not reach significance. cnmments: phi and arterial lactate levels propperly reflect hypoperfusion on the experimental model of acute intestinal isdlemia. b~kground : the paediatrie gallbladder diseases generally described are calculous ¢hol~tstitis, cystic duct obstruction, congenital anomaly of the biliary tract, and inflammation. in the neonatal period, noulithogenie gallbladder disease could be also due to erythroblastosis or hyperalimentation. obieetive : we describe an other type of disease affecting the gallbladder in neonates thought to be related to their vascular vulnerability. methods : four patients with abnormal gallbladder ultrasound not related to classical observations were included. we have studied and reviewed the biological and clinical data, the ultrasound findings and their evolutions. results : four patients, to ~.k-old neonates ~ffth a birthweight be~,een , and , kg, were intubated and under total parenteral nutrition for to days. none of them were symptomatic on repeated clinical evaluations. one newborn developped hypotensien on umbilical bleeding at hours of life. in two cases, signs of cholestasis were discovered : the total bilirubin level has risen to mg/dl; the direct bilirubin level was , mg/dl while the urina were dark and the ~o~,ls :mcolour~. the c~mplct~ ~crology as a!! the culvare~ remained negative. the ultrasound explorations were atypical : in the four eases, an initial increasing broad and thickness of the wall of the gallbladder with an hyperecbogenie inside content, which was not sludge, was discovered. in three eases the images resolved in ten to fifteen days. in one ease, an asymptomatie thrombosis of the vena portu which remained patent was discovered. in this case, at one month, the ultrasound showed images encountered in chronic ebolecystitis and, at one year, the gallbladder appeared atrophic. none of them underwent surgery. conelusiou : the gallbladder diseases are multifactorial. besides the prematurity, the infections, the total parenteral nutrition, the premature neonate is exposed to vascular vulnerability affecting also the gallbladder and this may explain our findings. progress in prognosis of pts with b-nhl had followed the use of multimodality chemotherapy (ct). with the prolonged survival, there are comlications due to myetosupression & desease process. the syndrome of neutropenic enterocolitis (ne) is one of the ominous problems because ofpts increased susceptibility to infection & overwhelming sepsis. this material included neutropenic pts ( - years) with the stages iil& iv of b-nhl who were treated with the modifired bfm- (mtx g/m in -h inf.); males, females. seventeen episodes of ne were observed & only after the first courses of ct ( of after tst, %; of after nd, %). the symptoms existed to days. wbc ranged from to in l~tl (median, ). the first signs of ne were directly correlated to the beginning of the neutropenia & the recovery of neutrophils led to the disappearance of abdominal recovery of neutrophils led to the disappearance of abdominal pain. the conservative treatment included gastrointestinal tract decompression, broad spectrum antibiotics initially, volume & electrolyte substitution, nutritional support, correction of acid-base balance, symptomatic treatment. sixteen pts were treated nonoperatively, died. on autopsy the transmural bowel necrosis due to thrombosis of branches of a.mes.sup, was found. the bowel perforation occurred in one patient, he was undergone laparotomy & hemicolonectomy & survived. we conclude that ne is a frequent complication in neutropenic pts with the st. lii& iv of b-nhl. it occurs after the induction courses of ct. close observation by surgeons, oncologists & pediatric intensivists is mandatory. conservative treatment is effective & more preferable until leucopenia resolves. operation is necessary only for those.with perforation. near infrared spectroscopy as a tool for evaluation of intestinal perfusionpresentation of an animal model. c. scheibenpflug, p. buxbaum and a.m. rokitansky the recent development of and investigations in the so called near infrared spectroscopy ( nirs --transcutanous emission and simultaneous registration of intensity of spectralcolours depending upon modulations of tissue perfusion ) enable physicians to measure and qualify organ perfusion and nowadays is mainly used to control cerebral as well as skeleton muscular blood flow in trauma patients at intensive care units ( icu ). today intestinal perfusion, hypoperfusion , cell damage caused by reperfusion injury, bacterial and toxin translocation are serious problems in critically ill patients at an icu. paediatric intensive care physicians put major concern on intestinal perfusion, which for. instance gains more and more importance, especially in the neonatal period for example as an etiologic factor for necrotizing enterocolitis. we established an animal model, in which we measured intestinal perfusion by nirs under various invasive and noninvasive conditions. methods and results will be referred. for preliminary conclusion we propose near infrared spectroscopy ( nirs ) also as a potent diagnostic tool to determine early intestinal malperfusion in order to prevent lethal outcome. fm'ther investigations in animals as well in paediatric iritensive care patients should be done to estimate our efforts. introduction: following the acute phase of necrotising enterocolitis (nec) starvation of the gut for a period up to weeks is a generally accepted treatment modality in many centres. objective criteria to refeed these patients are hardly available. recently the double sugar test has become available as a parameter for (ab)normal gut permeability ~' . aim of the study: to evaluate the changes in permeability of the small bowel in patients with nec and controls before introduction of enteral feeding. methods: a lactulose! rbarrmose (i/r) test was performed in two groups. group was studied - times within a -week period of starvation (n= , mean gest. age , range - weeks). in group seven different control patients were studied (mean gest.age , range - weeks). the test was performed by giving a patient after at least a hour fast ml/kg bodyweight l/r solution and determination of the /r ratio in a -hour urine sample by chromatography. results: objective: to evaluate the prognostic factors in the response to nitric oxide (no) in children with acute respirator/ distress syndrome (ards) and/or pulmonary hypertension (pht). patients and methods: critically ill children received no inhaled for ands and/or pht treatment. patient before and after cardiac surgery ( cardiac transplants), with bronchopneu~onia, multiple trauma, sepsis and cardiorespiratory arrest. patients showed /j~ds and pht, in with associated ards. we analyzed age, sex, diagnosis, pao , pa /fi , oxygenation index, pht, shock, and sepsis as prognostic factors and response factors to n . results : after no administration oxygenation did not improve in patients ( . %) and pht did not diminishe in one children ( %). patients survived ( %), / ( . % with /d%ds) and / ( %) with pht. the four patients with isolated pht survived , and the patients with pht and ards dead. patients after cardiac surgery presented less mortality ( . %) than the rest of patients ( . %). patients with shock presented higher mortality ( . %) than the rest of patients ( . %). there are no differences in response to no in respect of sex, age, diagnosis, shock, and sepsis. survivors showed higher increase of pao /fi . ± . to no than non-survivors . ± . (n.s). patients with pht showed higher increase in pa /fi to no administration ( ± . ) than patients with ards ( . ± . ), (n.s), but patients with ards showed a higher increase in !, ± . , than patients with pht . ± (p < . ). patients with pa /fi < i showed less increase in pa /fi , . ± . , than the rest of patients . ± . (n.s) conclusions: i. mortality of isolated pht treated with no is less than patients with ap~s. patients with shock and those with pht and ards showed higher mortality. . we have not found any clinical or analytical factor to predict clinical response to no administration. patients showed ards, and severe pht after cardiovascular surgery, in with associated ards. we registered respiratory assistance, blood gases, pao /fi , the oxygenation index (oil, and mean pulmonary pressure/ mean systemic pressure (pap/sap) before and after no inhalation. we measured continuous concentration of no and no by electrochemical method (noxbox, bedfont, airliquide). results: no administration improved oxygenation mean pao from ± tm~g to i ± ~g (p < . ), mean pa /fi fr<xa ~ to £± (p < . )and i from ± to ± (p < . ). patients did not improved with no administration. the oxygenation improved in the first five minutes and the best oxygenation was achieved with - ppm. there is no significant change in pac . pap/sap diminished from ± % to ± % ( p< . ), in one patient there is no response. the no administration was maintained between ~ minutes to days. the effect of no on pulmonary pressure and oxygenation was maintained without change during all the time it was administrated. n concentration were always less than ppm y metahemoglobinaemia less than . %. there are no side effects secondary to no administration. patients survived ( %). concluaions:l.administration of no improves oxygenation in children with ~/eds and diminishes pht after cardiac surgery. .no effect is fast and maintained during the evolution. high frequency oscillatory ventilation in combination with inhaled nitric oxide g~thberg sylvia, md, edberg k e md, phi), dept of paediatric intensive care, children's hospital, s- g teborg, sweden background: for man), years severely sick infants with congenital heart malformations or acute lung disorders have died due to pulmonary hypertension, hypoxia and multiple organ failure. today there are several therapeutic facilities coming up for these infants. ecmo progranunes have been introduced in severul centres as well as improved venlllatory techniques, as high frequency oscillatory ventilatior~ (hfov), which provides adequate ventilation with less risk for hmg injury.. in , the endothelium derived relaxing factor was identified as nitric oxide (no), and extensive studies have sho~-a that inhaled no reduces pnimonm o vascular resistance and improves oxygenation in hypoxic infants with pulmona~ hypertension. material.. from july to january , we have treated severely hypoxic children with combined ttfov-no. seven were newborn, with cdh, one with mas, one with irds, one with paediatric ards due to rsv infection and one with poor oxygenation atler open heart surgery. were between month and years and all had ards of differentorigin but one who was hypoxic after open heart surgery. method: hfov was given by means of sensormedics a oscillatory ventilator to patients, and dr~ger babylog was used in one case. mean airway pwssures varied from - cm h . oscillatory pressures varied from - cm h and ventilatory rates from - hz. fi o varied from , - , . no was administered by nomius classic. no and no was measured in the inspiratory limb with an electrcchemieal device. noconcentration varied from to ppm and the no -concentration between - , ppm. methemoglobin was never more than , % (average , ). duration of treatment varied from to days. combined trealment with hfov and inhaled no improved oxygenation and carbon dioxide elimination in out of treated childretl patients died, due to their underlying congenital heart disease, one of asphyxia due to rsv-infection and one of cdh with progressive hypoxia and multiple organ failure. combined treatment with hfov and inhaled no improves oxygenation in severely hypoxic children. treatment should be slarted early to reduce the risk for chronic lung injury following barotranma and high oxygen concentrations. we speculate that the combined hfov-no may reduce the use of ecmo, and that it may improve outcome in ceotres where ecmo programmes are not introduced. apart from its vasodilative properties nitric oxide appears to act also in physiologic immune defense. intracetlular concentrations of no synthesized by macrophages are in the range of above those produced by vascular endothelium. we investigated the bacteriostatic effect of nitric oxide at concentrations used during inhaled therapy for pulmonary vasodilation in neonates. ten different strains of five species were used (staph. anrens, staph. epidermidis, strop. group b [gbs], e. coil and pseudomenas aeruginosa), which are ~e most often tracheally isolated bacteria in mechanically ventilated premature infants and neonates. we compared bacterial growth of cultures applying three different concentrations of nitric oxide ( ppm. ppm, ppm) m the growth of the same strains in room air for a duration of hours. no bacteriostatic effect was demonstrable at no concentratioes of ppm. e. coil showed decreased bacterial growth at ppm and ppm, however without reaching statistical significance (p= . ). at nitric oxide concentrations of i ppm staph. epidermidis and gbs grew significantly less as compared to colonies of the same strains in room air. no effects were found regarding the growth of staph. aureus and pseudomonas aneruginosa. we conclude that nitric oxide has a selective bacteriostatic effect on some of the most often trachealb, isolated bacteria in premature infants and neonates. this effect appears to be dose-dependant and occurs in the upper range of dosages used with inhaled no therapy. further research is required in order to examine the mechanisms of action as well as specific interactions between different strains of bacteria and nitric oxide. the no,box monitor (bedfont, kent, uk) is used to monitor nitric oxide (no) and nitdc dioxide (no ) during no administration in ventilated neonates. according to the manufacturers specifications the monitor can be applied in cases where airway pressures range from to mbar. we investigated in-vitro the accuracy of the no monitor in a range of ventilatory conditions. using a dr~ger babylog we ventilated an artificial lung. no was administered { ppm no in % nitrogen) with a mass flow controller to the inspiratory tube, at a distance of cm from the y-piece. the no target value was set to ppm. the ventilator was operated in both cpap and ippv modes at different settings. the no sampling tube was placed on two different locations; in the inspiratory tube dose to the y-piece; in the expiratory tube haft way between the y-piece and the ventilator. the no-monitor was ca)ibrated with ppm no at mbar. fig. and show the sensitivity of the no-monitor for respectively static pressure (cpap) and pulsatile pressure (ippv) with the sampling tube located in the inspiratory tube. fig. shows the resur for pulsatile pressure with sampling in the expiratory tube. we conclude that the accuracy of the bedfont no-monitor is dependent upon airway pressure and sampling site, the latter possibly caused by incomplete mixing, pressure and no are linearly related when sampling occured further away from the administration site. based on this study we suggest to place the sampling tube in the expiratory tube. during neonatal care the clinician should be aware of varying inaccuracies depending on the respiratory pressures. hypothesis: availability of therapy with inhaled nitric oxide (ino) decreases ecmo use in patients referred .to a tertiary care hospital for treatment of respiratory, failure unresponsive to conventional therapies. background: at children's hospital of wisconsin (chw) treatment for patients who have failed conventional treatment for respiratory failure, sometimes called "rescue" therapy, has included ecmo since and high frequency oscillatory ventilation since . ino has been in experimental use at chw since may of i and has resulted in the perception of a decreased need for ecmo therapy in those patients referred for rescue therapy. this study was designed to tbst the validity of that perception. study type: retrospective cohort. methods: the medical records of all patients referred to chw from /lj to / / for rescue therapy for severe respiratory failure were included in the chart review. data were collected regarding diagnoses, illness severity, hospital course including interventions and complications, and outcomes. exclusion criteria w~ere the finding of structural heart disease or congenital diaphragmatic hernia as the basis for hypoxemia. qualification for ino treatment included an a-ado - or oi ~- for two hours or -> for twelve hours and echocardiographic demonstration of persistent pulmonary hypertension of the newborn. patients were classified into two groups based on the availability of ino at the time of their hospitalization. results: in the time period of the study, patients were referred for possible ecmo therapy. twelve patients greater than weeks old, with congenital diaphragmatic hernia and with congenital heart disease were excluded from this analysis, leaving patients for study, ino availability reduced ecmo use from of ( %) patients in the ~ino unavailable" group to out of ( . %) patients in the "ino available" group, p=& by fisher's exact test. the fact that the two groups were composed of patients of similar severity of illness is reflected by comparable rates of ecmo and ino rescue therapy ( % vs. %). conclusion: by providing an alternative rescue therapy, ino has reduced the need for ecmo in this group of neonates referred for respiratory failure. introduction: true hepatnrenal syndrome (his) is defined an acute renal failure {arf) in the presence of severe liver disease without other known causes of renal failure. hrs is frequently seen in the course of hepatic cirrhosis• in children, cirrhosis is rare; however, arf can be seen in combination with aseites and liver dysfunction• we describe patients with hepatic dysfunction and aseites in combination with ar~ and abnormal sodium-water handling, leading to the diagnosis of hrs. pathophysiology: three factors are considered in the pathogenesis of hr~: i) hepatic dysfunction, ) deranged hemodynamics, including abnormal blood pressure, reduced effective arterial blood volume and abnormal blood flew distribution, and ) neuro-humoral dysrsgulatiom, including elevated levels of aldosteron, renin, angiotensin-ll, ade, vasodilatim nitric oxide and vasoconstrictor peptide endothelin-l. the main pathogenetic feature is decreased cortical renal blood flow, decrease of glomerulur filtration rate (gfr), vastly increased sodium retention, uliguria, and azotemia. treatment: therapy is based on counteracting sodium and fluid retention by highdose aldosteron antagonists and loop diuretics, improving renal perfusion by lowdose dopamin, and strict restriction of fluid and sodium. interventions as paracenteals of aacites or n peritoneo-systemic shunt are associated with high morbidity and poor outcome in children. reversal of hem by conservative measures can only be attained at early stages of hrl liver transplantation is the only definitive treatment that can reverse ere at advanced stages. patients: the described patients developed severe ascites with insidious renal dysfunction and abnormal sodium-water handling during admission at picu and fullfilled clinical criteria fur hrs. treated according to the cited principles, all patients showed improvement of gfr, with increased natriuresis and gradual decrease of ascites. eventually, renal function normalised completly. conclusion: ere deserves greater recogmitimn in the picu population; diagnosis can be suspected on clinical criteria. with this increased awareness, therapy tun be instituted at an early phase, with better prospects for recovery. positive outcome of hem depends on early recognition of the clinical picture, understanding of the pathophysiology, and early institution of consistent treatment. mtx is an antimetatxflite widely used as chemotherapeutic agents. high dose ivitx (i to ~m ) administered as a prolonged intravenous infusion (over - hours), is often used to treat malignant paediatric diseases. major complications of this treatment are myelosuppression, orointestinal mucositis, dermatitis and impairment of anal function. we report two cases of mtx overd~age occurred in two children ( -year-old. month-old) t~ted for acute lymphoblastic leukaemia. they were treated by cavh and the mtx bhk~d levels rapidly decreasedavoiding multisystemic involvement. establishment of alkaline diuresis and monitoring of plasma mtx levels during treatment is essential to prevent nephrotoxicity. however. leuco',cnn rescue may not prevent the development of potentially lethal toxicities in patients with mtx concentrations persistantl} exceeding t mm. in theses cases, em'ly treatment of mtx intoxication may pm~cnt myelosuppression and reducerenal damage. the goal is to lower the concentration to below mmoll, at which time rescue agents aleme would be expected to be cllcctive. respective indications of these remo',at mctny.:is are still discussed : hacmt~ialysis t~ eharc(~l haemoperfusion should be prolx',sed for massive and acute intoxication. however, rebound has been reported after combined hcmodialysis and hemoperfusion. exchange transfusion may be proposed as a treatment for prolonged and moderate intoxication. peritoneal dialysis is an incflbedve method for remo~ al of mtx. cavh was used in our icu. cavh is a simple method for blood purification and n':dy iluid control. use of cavh was never be reported in this indication to our knowledge. simplicity, rap~d application and gco.l clinical tolerance are the main advantages of this technique. the technique presents ~peclal advantages in terms of low priming volume of extracorporeal circuit, low blood flow, low rate heparinisation. our results show a decreaseof plasma mtx concentration and a rapid reduction of halfqite of elimination (t hours over the period of cavh). moreover, we didn't delec~d rebound after stopping prc,xedure. small size of the i:ratients may present sometime special problems, but these technical problems can be overcome, no severe complication (needing, inlection) were observed during filtration, in summary, aggressive intravenous fluid hydration and alkaliniaation of the urine coupled with careful monitoring of renal function and plasma mtx concentrations during and al'tcr infusion along with lem~overin rescue has reduced the inndcace of life-threatening toxicity after highdose mtx. however, some mtx inu>xication still occurred, leading to se~em toxicity, particularly nephrotoxicity. in these cases, we think that cavh (or cavhd) is a reliable, rapid method without rcix~und increase in plasma mtx concentration or important adverses effects compared to other procedure removal. gouyon jb, germain jf, semama d, pr vot a, desgres j preliminary limited data suggested that hemofiltration and hemodiafiltration may be valuable in some neonates with decompensation of maple syrup urine disease (msud). venovenous hemofiltration (vvhf) and hemodiafiltration (vvhdf) were performed with a new neonatal hemo(dia)filter (miniflow , hospal) on anesthetized rabbits infused with branched-chain amino acids (leucine, isoleucine and valine) and c~-keto-isocaproate. the bcaa and aketo-isocaproate blood levels were close to those previously observed in neonates with msud when extracorporeal blood purification was required. vvhf and vvhdf performances were assessed with two different blood flows (qb = . and . ml/min). vvhdf was performed with dialysate flow rates (qd = , , . , . and . l/h). thus, each animal was submitted to successive procedures. within each studied period, clearances of the bcaa were strictly similar. bcaa clearances obtained by vvhf were similar to ultrafiltrate rates (respectively, . - . and . - . ml/min at high and low qb ; p < . ). the ~x-keto-isocaproate clearances obtained by vvhf were . - . and . - . ml/min at low and high qb (not significantly different). whatever qd value, the vvhdf procedures always allowed higher bcaa and c~-keto-isocaproate clearances as compared with the corresponding v'~hf period with similar qb. bcaa clearances obtained by vvhdf with a . l/h dialysate flow, were . - . mljmin and . - . ml/min at iow and high qb, respectively. the concurrent a-keto-isocaproate clearances were . -,. , ml/min and . _+ , ml/min. at both qb regimens, bcaa clearances provided by vvhdf were markedly higher than values previously obtained with peritoneal dialysis in human neonates with msud. the management of renal failure in the newborn is difficult. when dialysis is instituted peritoneal dialysis (pd) is usually the technique of choice. this is can be problematic and impossible in some patients with pre-existing intra-abdominal pathology. continuous arterio-venous haemofiltration (cavh) has been described in infants but sick preterm infants are not able to support the circuit. i have devised a means of having pumped haemofiltration in small/preterm infants (phis/pi) and describe its use in nine patients ranging in size from to gms for periods of to days. vascular access was achieved through or guage cannulae in either a peripheral artery and a central vein or through two central veins. blood was pumped out using an ivac infusion pump and through a gambro fh haemofilter. a second ivac pump was used to remove haemofiltrate from the filter and a third to infuse replacement solution. removal rate was set to give a clearance of mls/min/ . sq.m and blood flow rate set to between and times the removal rate. heparin was infused into the circuit to prevent clotting of the filter. biochemical and fluid balance control was achieved in all infants. guaranteed fluid removal allowed the administration of full nutritional support. four patients died when treatment was withdrawn because of an untreatable underlying problem. one recovered renal function but died some weeks later from unrelated problems, three survived and recovered renal function and one patient is still on treatment. this system allows a secure means of achieving fluid and electrolyte control in the preterm infant. the use of this technique may allow haemofiltration to become as applicable to preterm infants as it is to older children and adults. unibrtunately, children often receive no treatment, or inadequate treatment for pain and painful procedures. this prospective, multicentric study focuses on the efficacy, safety and side effects of novalgin (metamizol sodium) for this indication. patients and method: novalgin was administered to children, aged between - years, with acute, postoperative or procedural pain. novalgin ( - mg/kg) was given - hourly iv or im respectively, in some cases ( ) in combination with opioids (tramadol , piritramid , butorphanol ). the pain relief was assessed by six-step verbal rating scale (vrs) from to , vital signs were monitored, the side effects, that occured were recorded. results: pain relief was good (vrs less ) in children - . % of study patients. novalgin was very well tolerated, only one patient had adverse reaction -hyperpyrexia following intravenous application of the drug. discussion: novalgin (metamizol sodium) is safe and effective drug in the management of acute pain in children with low incidence of side effects. obie~qve: a prostx~tive study comparing simultaneous, indepeadent ratings conducted by intensi~ sts using an american (comfort) and an european chartwig) sedation scale for mechanically ventilated pediatric patients. measurements and results: the study comprised observations in mechanically ventilated pediatric patients (aged days to years) in a pediatric intensive care unit (from march to january . each patient was sedated by his/her managing physician with opiates, benzodiazepines, barbiturates, used isolated or in combination. each observation consisted of a -mid period of oly~ervatien of the patient in his or her pediatric icu bed, after each observation, the comfort (analyses dimensional physiologic and behavioral subscores -range to paints) and hartwig (analyses dimensional behavioral subsenres -range to points) were performed by the intensivist. we established the comfort scores ~ correspanding to adequate (range to ), excessive (range to ), and inadequate (range to ) sedation; and, hartwlg scores z correslxmding to adequate (range to t ), excessive (range to , and inadequate (range to ). statistical mmlysisj: agreement rate (kappa) and p <. was considere d s!l~nificant. comfort ( . %) ( , %/ ( . %) hap, twig , ( . %) ( . %) ( . %) to the comfort score, the average for adequately sedated, inadequately sedated, and too sedated was . +- . , z _+ . , and a.+_l , respectively. and to the ha~twig scorn, the average for adequately sedated, inadequately sedated, and too sedated was . :k-' . , . -&l , and . l- . , respectively. conclnsion: in our study there were no significantly statistical difference when you apply a more complex scale (conff'ort) or a less complex scale (hartwig) to assess the sedation of mechanically vemilated pediatric patients. the application of local and intravenous morphine infusion after surgery of urinary tract eva nemeth , m.d. semmelweis medical university , first oepartment of paediatrics , budapest , hungary in±roduction:continuous analgesia with morphine may be ~egaroed as a safe and effective method of pain relief during postoperative period. subjects and methods: children /mean age . years/ underwent elective ureteroneoimplanta±ion were randomly selected to receive either morphin intravenously of lo ug/kg/h /group one/ or bladder morphineinfusion ug/kg/h /group two/ after surgery. all patients were prospectively evaluated during their s±ay in the postanaesthetic care unit. cardiac and respirafory rates,blood pressure,sa ~,degree of alertness,pain perception and complaints of the paticnto ~cr~ recorded hourly. pruritus,nausea and vomiting,voiding difficul-±ies,sedation,dysphoria were systematically sough and quoted. statistical analysis was performed by chi square test. results:postoperative analgesia was the same in the two groups,but side effects were less in the bladder morphine group,because of the lower se morphine concentration.the differentes weren't significant in two groups. conclusions:the administration of bladder morphine infusion is a safe and effective method in children. objetive: compare the evaluations of sedation level made by physicians and nurses with the visual analog scale (vas) and the comfort scale (cs) in pediatrics patients receiving difforents modes of intravenous sedation. material ~ method." file evaluations were made by an attending physician and nurse with the vas and by another physician (always the same) using the cs. the observations were divided following the sedation mode: one drug (fentanyl or midazolan), two continuous drugs, one continuous and one intermi~ent drug and two intermittent drug (fentanyl and midazolan). the groups were compared using the t-student test. the groups also were compared between the percentual of agreement of the evaluations of sedation level made by physicians and nurses with the cs and vas using the x . results: we didnk find any statistical difference between the observations made by physicians and nurses with the vas in the differmts modes of intravenous sedation, the average of the observations using the cs betwom one drug and two drugs modes didnk exhibit also statistical difference. the observations made by physicians mad nurses using the the vas when compared with the cs didn't show statistical difference between the sedation level. we found statistical difference only in percentual of concordance of sedation level between physicians and nurses when compared the one and two drugs modes of sedation. conclusion: we didn't find differences in the observations made by physicians and nurses in the sedation level, only in concordance pereentua/ of observations when compared two modes of sedation. the observations using the cs (more complex) didnk show differences when compared with the vas. effects of age, concurrent administration of other pharmacologic agents, and disease [cardiac(n= ) & pulmonary(n= )] on the pk & pd of b were evaluated in volume overloaded infants aged days- mo (n= ). single doses of . , . , . , . , . , , , . , . & . mg/kg iv were given over - min after baseline evaluation. age was used as a continuous vadable to determine its effects on the variability in the pk & pd of b. values for pk parameters were compared between patients in cardiac and pulmonary disease groups. hierarchical multiple regression analyses were used to determine the effects of age, disease and other pharmacologic agents on the variability of bumetanide excretion rate (ber) and pd responses, e.g. urine flow rate (ufr) & electrolyte excretion. cit, cir & cinr increased with age (p< . ) while t, decreased markedly in the first monthe of life (p< . ). ber normalized for dose increased with increasing age. patients with pulmonary disease exhibited significantly greater clearance and shorter t~= (p< . ) than those with cardiac disease whereas vd~ was similar in both groups. the administered dose of b was the primary determinant of ber but increasing age also contributed. penicillin antibiotics decreased ber. dose response curves for ufr and electrolyte excretion were similar between disease groups. more of the variability in ber and pd responses could be accounted for in the pulmonary group than the cardiac group but this was not statistically significant. conclusion: the pk of bumetanide were influenced significantly by age and disease. differences in pk between patients with pulmonary and cardiac disease were primarily due to differences in total clearance. age and the administered dose of b were positive determinants of ber and pd responses while penicillin antibiotics had a negative impact on both, once b reached its site of action, no differences in pd responses were detected between disease groups. the pharmacodynamic effects of bumetanide were evaluated in volume overloaded infants (n= ) aged days- months. single doses of . , . , . , . , , , . , . , . & . mg/kg iv were given over - rain. bumetanide concentration in blood (n=l ) & urine (n= ) samples were quantified by hplc. baseline urine samples were collected over - hours prior to drug administration. determinations of urine volume, electrolytes (na ", k +, ci, ca ++ and mg++), creatinine and osmolality were performed before and at - , - , - , - , - and - hours after bumetanide dosing. changes in urine flow rate and electrolyte excretion were plotted as a function of bumetanide excretion rate which was considered the effective dose of the drug. peak bumetanide excretion rate increased linearly with increasing doses of drug and showed no evidence of approaching a maximum. time course patterns for urine flow rate and electrolyte excretion were similar for all dosage groups. urine flow rate and electrolyte excretion increased lineady up to a bumetanide excretion rate of approximately #g/kg/hr and either plateaued (urine flow rate) or declined at bumetanide excretion rates > #g/kg/hr. bumetanide had no detectable effect on serum electrolyte concentrations, conclusion: maximal diuretic responses occurred at a bumetanide excretion rate of about ;~g/kg/hr. higher bumetanide excretion rates produced no increased diuretic effect. peak bumetanide excretion rate of about #g/kg/hr corresponded to bumetanide doses of . - . mg/kg. neonates using an electrical syringe-pump. authors: tr~luyer j.m., sertin a., bastard v., settegrana, c., bourget p., hubert p. background and objective: many problems can be observed with drug administration by i.v. route, especially in neonates. so we evaluate different protocols of teico delivery using an electrical syringe-pump. methods: we simulate infusion of teico with a syrlnge-pump (pilot c, becton & dickinson lab.) trough d standart neonatal i.v. system. for weights ( or kg) we used doses of teico ( mg and mg/kg) and a dose volume _< . ml. our goal was to perform a complete infusion in minutes. the infusion system consisted of an life care infusion pump (abbott lab.) with its lv. set for maintenance intravenous fluid (flow _< ml/h) connected to a -way stopcock. an meter extension tubing was placed between the stopcock and a neonatal catheter. an another meter tubing (injection tubing) connected the teicoplanine syringe to the stopc, ock. the volume of the injection circuit (from the syringe to the distal part of the catheter was . ml methods of injections were assessed: a: injection of the predetermined volume of teico in minutes with no wash out. b: idem as a but the teico was injected in minutes, followed by a wash out ( ml / minutes). c: twice the required volume was introduced in the syringe and the volume to infuse was programed in minutes, followed by a wash out ( ml/ minutes). d: ]dem as c but a priming was performed before connecting theteico syringe to the tubing. during each run, serial samples were collected every ten minutes over a one hour period. the samples were assessed using hplc method. results: the amount of drug delivred at minutes were calculated. the results are a mean of to runs and expressed as the percentage of the total amount of teico prescribed. a , % , % b % , % c a % , % d , % % conclusiom for accurate and reliable intermittent drug infusion with a syringe pump it is mandatory to use a precise protocol of administration and to take in account ) a priming (for immediate starting of infusion), ) a drug volume greater than the dose prescribed and a programmed volume injected, ) a wash out of the tubing (with a volume ~ , x volume of tubing injection) caz is an antibiotic with activity against the major pathogens responsible for neonatal bacterial infections. we previously reported the pharmacokinetics of caz in preterm infants on day of life which showed that the clearance of caz increased with increasing gestationat age (ga). mean serum half-life of infants with gas < wks was . h. we wanted to investigate the effect of postnatal age on caz pharmacokinetics, we therefore studied caz pharmacokinetics on day - of life in preterm infants with gas < wks. caz ( mg/kg) was administered as an intravenous bolus injection. blood samples were coilected before (t = ), and . , , , , and h after the caz dose and analyzed by hplcassay, the pharmacokinetics of caz followed a one-compartment open model. during newborns with complex congenital heart defects requiering either htx or palliative staged single ventricle repair were admitted to our hospital: hlh n= , unbalanced cavsd, tga with hypopl. rv and hypoplastic aoa. tga with hypopl. rv, sas and dextrocardia. /i children had been admitted with cardiogenic shuck and mukiorgan failure due to intermittend closure ofductus arteriosus; in / stabilization failed. parents were informed about the known and unknown risks of the always palliative surgery; in cases parents denied further therapy. one pafiem with hlh underwent orthotopic htx at the age of month after the ducms art. had been stunted in the newborn period. month later he is still in favourable condition and without any sign of acute organ rejection. / underwent first stage of palliative single ventricle repair: norwood -op. ( ) ( n= ), damus-kaye-stansel -procedure ( ). the clue to adequate postoperative management was to archieve a balanced distribution of flow to systemic and pulm circulation, that is to protect the single ventricle from volume overload and to guarantee sufficient oxygenation and pulmonary development as well. with the centralvenous sato at about % provided maintaining the arterial sato at about _+ % is corresponding with a qp/qs of : . using modified bt-shunts of . mm resp. a central anrtopulm, shunt of mm in one case l severe puim. hypertension, surgery at weeks of age ) there was no excessive pulm. blood flow and no need to increase pvr with inspired co . one child ( norwood at weeks, preexisting pnim_ edema ) developed severe pulur hypertension and parenchymal pulm. dysfunction after prolonged bypass and multiple transfusions due to intraoperative bleeding: hypoxemia could be managed successfully by implanting a second shunt of mm hh later and temporarily using prostacyclin and no; at sternum closure dd later the second shtmt was banded to ram. follow-up ranges - month: all children are at home being assigned for second stage operation at about month of age. establishing clinical practice guidelines has become increasingly important in the current health care environment. significant effort has been focused upon development of post-operetive critical care pathways. however, benchmark data upon which such pathways should be based has not been well reported. length of mechanical ventilation (lmv) and length of stay (los) for children following cardiac surgery, for example, is poorly described. we prospectively recorded the lmv and los in patients who underwent cardiothoracic surgery between / / to / / . only patients who belonged in any one of five categories of congenital heart disease (ventricular septal defect _+ other septal defects (vsd), atrioventricular (av) canal, tetralogy of fallot (tof), transposition of great arteries (tga), and single ventricle physiology (fontan)) were included. eight non-survivors were excluded from the analysis. all patients were admitted to an intensive care unit cu) post-operatively where mechanical ventilation was managed by pediatric intensivists. lmv was defined as the period from post-operative admission to planned extubation. length of stay (los) was defined to be from le from the icu. cytokine patterns during and after cardiac surgery in young children. especially in children, cardiac surgery with cardiopulmonary bypass (cpb) can cause a systemic inflammatory response. this process is thought to be mainly a result of inflammation induced by surgery and exposure of blood to an artificial surface, and of reperfusion injury during weaning of bypass. complement activation, degranulation of granulocytes, induction of free oxygen radicals, endotoxemia and release of cytokines, are important contributing factors. we studied cytokine patterns before, during and after cpb in young children admitted for complex surgery or for septal defect correction. in the first group, significant amounts of il- and il-lra could be detected preoperatively. these findings could reflect the already existing hemodynamic dysregutation. in both groups, cpb procedure upregulated the circulating pro-inflammatory cytokines il- / , but not il- b. at the same time, il-lra became detectable. therefore, we suggest that in these patients the production of the anti-inflammatory cytokine il-ira was not induced by the preceding acnvity ot pro-inflammatory cytoidnes. during cpb, we noticed a sharp decline in the capacity of the leucocytes to secrete il- / . the ex-vivo production of il-lra however, was only slightly attenuated. we conclude that there is a differential regulatory pathway for the induction of il- / and il-lra. in addition, we studied the influence of dexamethasone administration on the cytokine pattern. administration delayed the appearance of il- / and il-ira in the plasma, interestingly, it did only interfere with the ex-vivo production of pro-inflammatory cytokines. the latter supports our hypothesis that production of il- / and of il-lra is regulated by two independent pathways, ( %) of pts. % ofpts < months of age developed metabolic alkalosis as compared with % ofpts > months of age.the infants with metabolic alkalosis received more citrated blood products and furosemide. following cardiac pulmonary bypass the highest ph-values and be-values were observed - hours and - hours, respectively. ii. prospective study: metabolic alkalosis was registerd in t children ( %), of those < month ( %) developed metabolic alkalosis and % of those elder than monms.durmg the postoperative course patients younger than months developed the highest ph-and base excess values after and t hours, in the subset of the older patients maximum ph and base excess was found after and hours, respectively. in one case the top level ofph-value exceeded . , the base excess + mvalb. conclusion: children undergoing cardiac surgery with cardiopulmonary bypass often develop metabolic alkalosis.in contrast to previous reports, we did not observe an association between metabolic alkalosis and mortality, nor greater frequency of cardiac arrythmias or prolonged mechanical ventilation. in context with decreasing serum lactate levels, our data show positive correlation of metabolic alkalosis with postoperative improvement of liver function. respirator, mechanics and weaning outcome in children undergoing cardipvascular surgery. vassallo j., cernadas c., saporiti a., landry l., rivello g., buamsha d., rufach d., magliola r. mechanical ventilation (mv) and acute respiratory failure are common events in children unergolg cardiovascular surgery (cvs), the development of new techniques helped to measure some of the main respiratory mechanics (rm) in a non invasive fashion. our goal was to evaluate the predictive value of these measurements in weaning (w) outcome in these patients, patients and methods: we prospectively evaluated children considered clinically to be ready for w with < kg and > hs mv. patients with diaphragm paralysis and those who failed w because of upper airway obstruction were excluded. before patient extubation the following measurements were recorded during spontaneous ventilation (cpap/t piece) using the cp neonatal pulmonary monitor bicore (lrvine, ca): total respiratory system static compliance (cssr) and resistance (rts), rapid shallow breathing index (rsbi). maximal inspiratory negative pressure (pi max) was measured using an unidirectional expiratory valve. threshold values predicting w success (ws) were: cssr > . ml/cm h , rts < cm h /l/sec, rsbi and pi max > - cm t . w failures (wf) -patient reintubation within the following hs, these values were compared between w success and failures using fisher exact test. an apriori level of statistical significance was chosen at p < . . considered, an increase in tnf-a levels is observed after cardiac surgery (p< . ) with a return to previous values after hours (p< . ). hours after cpb, similar values are observed in groups ii and ill, but there is a further increase in serum tnf-a levels in group i when compared with both other groups (p< . ). we found no statistically differences in any other moment. there was a significant correlation between serum tnf-o levels determined hours after surgery and cpb duration (p< , ). conclusions: cpb in childhood provokes a significant increase in serum tnfa levels, in newborns the inflammatory response is maintained hours after surgery. this enhancement of serum tnf-e levels indicates the existence of a relevant inflammatory response in these patients. introduction: cardiac surgery appears to induce a systemic inflammatory response. we have investigated the behaviour of il- i~ and il- before and after cardiac surgery. patients and methods: we studied serum il- and il- levels from children with congenital heart disease ( boys and girls), aged from days to years, undergoing open heart surgery, before cpb (d we found no statistically differences in the il-i levels in the different groups and moments. there is a significant increase in il- immediately after surgery (p< , ) with similar levels hours after cpb and a significant decrease (p< . ) hours after cpb. preoperatory il- levels were higher in the groups i and tl than in group i (p< . ). hours after cpb serum il- levels in group were significantly higher when compared with group (p< . ). conclusions: cpb in childhood induces a significant transient increase in serum il- levels, strongly relevant in newborns. cpb was not associated to a significant modification in serum il- levels. thus, cpb in childhood induces a dissociated behaviour in the proinflammatory il- and il- & pathways. obiective, to evaluate the effects of amg receipt on the clinical condition during the first hours after birth (t ), the morbidity and mortality in immature outborn neonates. methods. we studied outborn neonates with ga to wks, admitted during the years to . eighteen neonates exposed to amg (ga: , +lwks, bw: _+ g) and neonates did not (ga: , _+ wks, bw: _+ g). results. amg-exposed neonates compared to those not exposed had lower incidence of apgar score at min _< ( % vs %, p<. ), lower incidence of ph t < . ( % vs %, p<. ), decrease need of bicarbonate ( % vs %, p<. ), lower fio (fio min> : % vs %, p<. and fio max > : % vs %, p<. ), lower incidence of intubation ( % vs %, p<. ), lower requirements of surfactant ( % vs %, p<. ) and lower mortality ( % vs % p<. ). there were no differences between the two groups for the following parameters: type of delivery, hypothermia hypoglycemia and anemia during admission, hypernatremia, hypotension (map< mmhg), need of dopamine and or plasma , incidences of ptx pda sepsis nec severe rop major ivh (plus pvl) and bpd and duration of intubation. conclusions. the main beneficial effects of amg receipt on the immature outborn neonates were the decrease of mortality and the decrease of surfactant need. there was no effect of amg receipt upon other severe morbidity in this high risk group of neonates. premature babies are very sensitive on homeostatic disturbances, and often develope intracranial haemorrhage (ich). ultrasound scan of the bram shows four grades of ich: -grade i -only periventricular hyperechogenic areas -grade ii -haemorrhage ham the lateral ventricles -grade ili-dilated lateral ventricles -gtrade iv -intracerebral haemorrhage. the purposes of this study were: to show the incidence of ich in premature babies and its correlation with the gestational age, . to determine the severity of ich . to present the outcome &those babies. in the study were included premature babies successively-born at the department of gynecology and obstetrics before gestational week (g.w.) and grouped in three groups: less than g.w., - g.w., - g.w. to all of them was performed ultrasound scan of the brain. results : . the incidence of ich hi premature babies is % and there is ingh level of correlation with the gestational age: -babies born before t~ g.w. have % incidence of ich and graduated : i grade - %, ii grade - %, iii grade - %, iv grade - % -babies old between - g.w. have incidence of % : i grade - %, i[ grade - %, iii grade - %. -babies older than g.w. have incidence of %: i grade - %, ii grade %, iii grade - % . sixty of premature babies have died and it is . % lethality. in all died ilffant was confirmed the grade of ich diagnosed by ultrasotmd scan of the brain. d. maksimo~ c. z.braiko~ic, n.vunjak. p. ivanovski ( ~iversi~, children's hospital. belgrade, yugosla~, ia infantile intracranial hemorrhage is the most frequent and serious manifestation of late hemorrhagic disease of the newborn caused by ,,~tamm k deficiency in earl?,, ti~fancy. in the last two years, we recorded five cases of infantile intracranial hemorrhage due to "dtamin k deficiency, despite routine prophylax~s (intramuscular vitamin k, mg) , with bpieal clinical presentation: age was - days (average days): vomiting, poor feeding, lethar~'irritabiljty, palor, bulging t ntanelle and convatsiones were present in most cases.two patients developed signs of hemorrhagic shock, with hemoglobin level less than g. . in ~ f \qi level was less than % of predicted value. there was no evidence of head trauma or liver disease in none of patients. four inlants were breast fed, while one, who had diarrheal disea.se, was on adapted milk formula. routine therapy wa.s given (including vitamin k and fresh frozen plasma). two patients were discharged with no sequellae, one developed posthemon'hagic hydrocephalus as a complication and two patients died. late hemorrhagic diseo.se of the newborn is sill/ a significant cause of morbidib' and mortality in earl ' infancy, despite different approaches to prophylaxis developed in recent years. background: neonatal hearing screening in at risk newborns can detect % of the children with a congenital hearing loss. automated abr hearing screening (algo- ) has been introduced for healthy newborns. the aim of this study is to test the validity of this algo- screener in at risk newborns in a neonatal intensive care unit. subjects: at risk newborns (median gest.age: . wks, median birthweight g) selected according to the criteria of the american joint committee on infant hearing. interventions: algo-i automated abr-hearing screening at a level of db was performed in the neonatal intensive care unit. when bilaterally referred, further audiologic screening and/or therapeutic intervention took place. when passed uni-or bilaterally, children enrolled in a) a nation wide screening programme (ewlng) at the age of months and b) in a half yearly follow-up programme in which hearing and speech-and language development were observed according to egan an illingworth. results: screening without disturbance from ambient noise or from routine technical equipment was possible in the incubator, even during nasal cpap therapy. ( %) newborns passed algo- screening. ( %) did not pass bilaterally. of with a congenital rubella died shortly after screening.in of bilateral congenital hearing loss of -> db was confirmed. of the newborns passed were still alive at the age of year. ewing screening was performed in of ( , %). / passed, of had passagere conductive hearing loss, in / no further investigation was performed. all children enrolled in the i/ yearly follow-up programme had normal speech-and language development. in this study all at risk newborns with bilateral congeni "tai hearing loss were detected with algo- screening. screening results showed no false negatives at follow-up. the algo- infant hearing screener can be used as an valid automated abr-screener to detect hearing loss in at risk newborns in a neonatal intensive care unit. gancia gp, bruschi l pnlito e, ferrari g, rondini g -divisione di patologia nc~matate e turapia intensiva -irccs policlinico s. mattco -pavia, italy latrogenic esophageal perforations (iep) in preterm and term infants are seldom reported in litteraturc, in association with difficult endotracheal (et) intubation (with or without stylets), insertion of gastric tube, and pharyngeal suctioning with stiff catheters. crieopharyngeal muscle spasm caused by instrumentation may also lead m a narrowing of lumen, with increased risk of local injury. we report iep observed in intubatcd, mechanically ventilated newborn infants ( male, female, all outborn). a common feature of iep was inability to pass a nasogastric (ng) tube into the stomach, mimicking e~)phageal atresia.~se : birth weight (bw) (i g, gestational age (ga) wk, sepsis. before admission to n cu, the baby underwent multiple et inmbations, because of inappropriate securing of et robe. bloody secretions in pharynx were observed. the endoscopy showed a large lesion at the end of proximal third of the esophagus, case : bw g, ga wk, rds. chest x-ray (cxr) showed a retrostcrnal air leak: the ng tube was stopped }~etwcen d and d and soluble contrast was seen in upper mediastinum.case : bw (/g, ga wk, rds. the endo~opy showed an esophageal lesion. cxr showed a paravertebral route of ng tube and a right pneumothorax.case : bw (i g, cz ,.v!:. rd c. ~!,'.::;;: ::':'_'rvt!~' s l" ~k':.rvrx. cwr, d,,,,vs ~,,mr~e, ~n rhe upper mediastinum and abnormal route of ng tube through a false passage. surgical intervention is needed in case of mediastinitis or mediastinal abscess: conservative management included broad spectrum antibiotics, total parenteral nutrition, antireflux therapy and, if necessary, drainage of air leaks. enteral feeding has been stopped lor days and cautiously resumed after radiographic study. [x~cal sequelae and death are uncommon, but iep occur in newborns with high risk of death due to prematurity and other diseases. in our patients, et intubation has been performed by experienced personnel: therefore the lack of skills in resu~itative procedures is not always the main factor of iep. prevention of iep requires appropriate materials (et tubes, laryngoscope blades, suction catheters), and procedures (positioning of the infant with correct neck estension, firm et placement). sedation and pain control may help to prevent the muscle spasm. aggressive treatment has improved the tong-term outcome of extremely low birth weight neonates (elbw) but it has also increased the chances of iatrogenic lesions. reviewing the charts of our neonates we observed a high number of vascular injuries. from to , neonates were admitted to the neonatal intensive care unit (nicu); of them were elbw ( . %). studying the charts of these elbw we observed cases ( m - f) with vascular lesions ( . %). mean gestational age of these patients was . weeks (rain -max ). mean weight at birth was g . mean weight at diagnosis was g ( - ). in the same period patients with vascular injuries were reported in the neonates over g ( . %). the injuries observed in elbw group were: arteriovenous fistula ( bilateral) at femoral,level, carotid lesion and limb ischemic lesions. aetiology was in cases by venipuncture, in one case umbilical catheter and in the case of carotid lesion a wrong surgical maneuver. no general simptoms were observed. the vessels were repaired with microsurgical technique in six cases: the carotid lesion and five arteriovenous fistula; one case was solved with thrombolitic drugs; an amputation at knee level was required in one case after a long period of medical treatment. the last neonate with an arteriovenous fistula was only observed for parent's will. at follow-up (clinical and by ecodoppler) out of neonates presented normal vascular function without sequelae. from our experience elbw neonates have more chances than older neonates to develop iatrogenic vascular lesions. we advocate an aggressive microsurgery and/or medical treatment to obtain good results and prevent late sequelae. a retrospective comparison between natural surfactants l.j.i.zimmermang m.c.m,van oosten. dept. pediatrics, div. neonatofogy, sophia children's hospital/erasmus university, rotterdam, the netherlands. aim: retrospective comparison of alvofact (in ) versus survanta (in ) as rescue treatment for neonatal respiratory distress syndrome (rds). methods: both surfactants were given at an initial dose of mg/kg (except for alvofact mg/kg for mild rds grade mi). repeat doses were attowed (survanta mg/kg, alvofact mg/kg) up to a maximum of mg/kg, all parameters and outcome criteria were strictly defined beforehand. the initial response (good,mild,no response,relapse) to surfactam therapy was defined on the basis of the decrease in fio . results: there were no signif. differences in patient population and initial parameters: ga ( . +_ . vs a _+ , wks), birth weight (t _+ vs -+ g), severity of rds (grade ill-iv: . % vs . %), apgar scores, cord blood gases, initial ventilatory settings. in ' however, the initial surfactant dose was administered earlier than in ' ( . -+ . vs . _+ . hrs postpartum, p= . ). although the average total cumulative dose was equal in ' and ' ( . -+ , vs . _+ . mg/kg), more doses of alvofact were given compared to survanta { . _+ . vs . _+ . , p=o.o ) and more patients in ' received more than two doses than in ' ( % vs % of patients). there was no difference in the incidence of non-putmonarycomplications. aivofact ( there was a better initial response to survanta and a better respiratory outcome in : in the group < g the duration of ventilation was half in , and in the group >~ og the duration of extra o need was half in as compared to . we speculate that the main reason for this difference is the earlier and initially higher dosing used with survanta compared to that used with alvofact which was given in the same total cumulative dose but over a larger time span. background: e×ogerlous sur&ct~t raplacem~t treatmem has become rou~ne k~ the t~eatme~t of respira~"¢ dim'~ syndrome (i~ds) of pr~e~tur~, wh~eas its effica w th odi~ respiratory diseoses is sdi being wader mvesugatio~. objective: "eac~ mt ereat isto report ottr results of prospect/re, non-randomized "re~-o.e" study oe suffact~t replacement in outhom premamae infa~t~ with rds reruirmg me~aical ventilatioa (nfv). p~tien~ and metho .s: from j-aly to june , / ; ( %) out~ ~¢ infaats, at a mesa age of z , horn's ( boys, ~rls; ~ gestafioan age -+ . weeks, mera~ birth weight _+ g, ~ . i" at minutes) with rds, requiring mv, received bov~e-suff~amt (survanta, ros~/aboti, laboratotie~ columbus, ohio) eadotracheally, as was recomm~aded by maaufacturer. as the c,~:ttrol group o~bom premature infants (ot~ of ; %, admitted with rds from euiy to eune ) were saelected ~d who did not receive surfaaam, compared with ~hctant ~'oup they were admitted for treatmeat e~'li~" aft~" daliv~:y (at the age . :: . hours vs. . +- hours), but they did not diff~ in othe~ baseline dam'a~eri~cs at ~ti~ion. entry crkeda for ~¢fa~aut ~hcadou were fractional i~firat o~ oxtgem r~emeats -fio > . - . , ratio au-lerlal to alveolar oxygea pre~are~ao ~ao < , ~ad oxyge~at,~ i~.dex -ol > . primary o~comes were deter~caned by ~hanges m exs'ge~ab, c~ ~r~d vmtilatic~ ~ the following variable~; ( ) fi'aaic~ of i~spired oxtge~ (fio ); ( ) mesa nnvay presmzre (map) ( ) pag ~ao ratio, ( ) oxyge~ion index (oi). commo~ comphcadces of prem,musty ~d con~ol mechamcal v~ati]al~on (pater dumas merios.s, intracr~nlal haemcrn:hage, air leak, br onchop ulmrmm'y dy~pl~a ~d death) were reg~ded as sec~d,~y outcomes. r~suas: in warfactaat group we observed slg~ .c~t improve~aeat (p< . ) in oxygea~thia md veaatilation at hours all~ e~try k~to the m~dy in compari~ion to nons~fa~m" group. compa~on of secondao' outcomes in ~ts with p,.ds showes table l we did not observe ~y major acute hfe fl:u-eattming complicatlola,s m sxlrlhct~mt grou~ tr/lmediately after stu'~actsmt rcplacemev_t therapy. the duramm of mechmucal ven~ation ~ad oxygen lreau~ent m survivals of both groups did not dafter gmficautl y a-ore ead~ other. condusion: l!a premature mthats with rds treated with surfaaaat replacemeaat therapy we observed decrease m mc~de~ce of tme'~m~o~oraces add de~th (p< . and p< . ), whe~e~s m othe~ observed variables thee was uo ,igmfi~t d~=ecce infectious complications during the therapy of respiratory insufficiency in neonates with birth weight less than g in the course of yearsretrospective study. zitek infants on cmv, cppv, and imv were administered exosurf in dose of - mg/kg twice endotracheally (see table) . in newborns ( . %) hours after surfactant admin fi value decreased by . %, and after hours -by . % compared with initial value; pip and peep values decreased by - cm h and - cm h after hours, and by - cm h and - cm h after day, respectively accompanied by mean decrease of aado from , to . mmhg, qs/qt decrease from . to . % (see table) . mean time of cmv, cppv was . days, imv- - hours, cpap - - hours. respiratory therapy in newborns ( . %) was complicated by pneumothorax (bilateral -in infants chorioangioma is a rela~ively rare placentai malformation associated with considerable mortality and morbidity. a chorioangioma can be regarded as an arterio-venous shunt in the circulatory system of the fetus. this causes volume loading eventually resulting in cardiomegaly and high output cardiac failure. a female neonate (gest age wk, birth weight g, - . sd) was born with an apgar score of and after and rain respectively. the placenta showed multiple chorioangioma. ultrasound of the heart showed a hypertrophic cardiomyopathy. she developed severe hypertension ( / mm hg), treated with nitroglycerine and nitropruside. finally blood pressure decreased when enalaprillic acid was given ( . mg.kg ). we measuered the activity of the renin-angiotensinsystem. an elevation in renin-angiotensin system is shown probably to compensate for the low resistance circulation before birth, hypothesis: the instantaneous cut off of a large arteriovenous shunt did not result in a fast downregulation of the renin-angiotensin system resulting in hypertension. hypertension should be added to the list of complications of chorioangioma of the placenta. the authors studied cases of children's septicemia with blood culture yielding staphylocucetts aurens. the age of patients varied from months to years ( , % from years downward), % of the children caught their disease in the hot season (may to october). the deaths also occured in this season: , % ( / ). following were the anatomo-dinical lesions. -skin %, muscle , %, bone , %, joint . %. -viscera : lung %, heart . %, cerebrum . %, kidney . %, fiver , %. -simple lesion skin-muscle-bone joint: %, no death in this group. the concomitant lesions of the soft tissue,bone-joint and viscera : % with one viscera, % with two viscera, % with three viscera and % with four viscera. -bone lesion : mainly on the long bones ( % on the tibia, % on the femur, the remainder being the mandible ( ) and the humerus), inflammation of' the hip joint was the main one. -i,ung lesion had forms pneumatocele ( cases), bronchopneumonia ( cases), pleural effusion ( cases), multimicroabcess bursting into the pleura ( cases), most multimicroabcesses were lethal : / ( , %), -heart: all thethreelay~rs got le@~r~, % had or layers alrected and death ensued. -cerebrum : the meninges had three forms of lesions purulent meningitis ( cases), obturafing embolns of brain vessels ( cases) and cerebral abcess (one case). the characteristic clinical sign was paralysis and meningismus, phlebothrombosis of eavcrnous finus ( cases)was mually ther~sultofalxil vdfi:h burst there were cases of death with lesion of the meninges and cases of obturating embolns of brain vessels. -the main sign of lesion of the kidney was a change in the components of urine: % got proteinuria, % had leucocytes in their urine, % had erythrocytes in their urine, the urea in their blood increased (over rag%) in . % of cases.the lesion of the kidney seemingly had little relation to death. seven cases of ictertts due to an increase of direct bilirubinemia and a decrease of blood-albumin. -the biological characteristics of the pathogen staphylococci showed that all the isolated specimens had positive coagulaza ; the specimens from the dead patients were less semiti~e to, mad ~t to mali~ overag death rate was . % ( / ). the fungal infection to fusariun species in immunocompromissed child have been reported in the literature with a rare, severe and high, mortality rate in spite.of the use of antifungal drugs. we report a case of successful treatment of a severe disseminated fusariun infection in a ll-year-old boy with acute lymphocytic leukemia (lla-l ), after use a chemotherapy followed by absolute granuloeytopenia. the patient developed fever, skin lesions, pneumonia and fungaemia. fusariun species was cultured from the blood, necrotic skin lesions and lung secretion. the child developed multiple organ system disfunctiou in spite of use broad spectrum antibiotcs and antimycotic therapy needing. uci during days. the patient receive suport treatment (mechanical ventilation, inotropie d~.ugs, diuretics, imunestimulants, blood components, a broad spectrum antibiotes and antifungal agents). we absorved a gradual recovery in the white blood cell count and regression on the sites of infection. the association of preeoce diagnostic and the terapentic with increase in the white blood cell count was the most important in a successful treatment. a year old african-american child suffered a severe pulmonary injury in a house fire. initial survey revealed % total body surface burns, soot on the face, and bloody endotracheal secretions. initial chest radiograph revealed diffuse, bilateral infiltrates. severe respiratory failure with an oxygenation ratio of rapidly developed. he developed a pneumomediastinum and subcutaneous emphysema. although transient improvement occurred with inverse i:e ventilation and surfactant, he became more hypoxic (sac as low as %) and acidotic. on day post injury, he was placed on venc~venous extracorporeal life support (ecls). on ecls day he was decannulated. chest radiograph on ecls day showed an opacity in the left chest. ultrasound of the left chest was consistent with atelectasis rather than pleural fluid. flexible bronchoseopy failed to reveal any obstruction in the left lung. a computed tomography (ct) seen of the chest, which was performed after decannulation, revealed a large loculated collection of fluid in the left, anterior chest. under ct guidance, a f cope loop catheter was inserted and cc of thick blood was removed, follow-up ct performed immediately after this procedure revealed minimal change in the size of the fluid cavity. over the next hr, we instilled urokinase , units over minutes every two hours. a minute dwell time was allowed before draining the fluid. repeat ct scan done at the end of the urokinase infusion showed a marked decrease in the size of the fluid cavity. act scan was not performed prior to decarmulation because the ecls circuit tubing was too short to allow appropriate positioning of the child in the ct scanner. after a ct scan revealed loculated pleural fluid, a simple drainage procedure was diagnostic but inadequate treatment. we were able to successfully dissolve the thrombus after hr of urokinase therapy even though the thrombus was > days old. we suggest that large loculated plenral thrombi which develop as a complication of ecls therapy may be successfully managed with urokinase infusion. introduction: haemorrhages, particularly intracranial, are major complications experienced in - % of neonates treated with extracorporeal circulation. an induced thrombocytopenia and impaired platelet function play a key role in the increased bleeding tendency observed in these patients. the aim of the present study was to establish a dose-respons curve for the effect of a synthetic protease inhibiting agent, nafamostat mesilate (fut- ), on platelet membrane glycoprotein density and platelet activation during experimental perfusion. methods: two identical extracorporeal life support (ecls) circuits were primed with fresh, heparinized human blood and circulated for h. four different concentrations of fut- ( . mg/l blood/h; . mg/l/h; . mg/l/h+ % bolus at the start of the perfusion and & mg/l/h+ % bolus) were used in different perfusion experiments. a total of eight paired experiments were performed. platelet count, plasma betathromboglobulin levels and platelet membrane density of glycoprotein ib and lib/ilia were followed as well as plasma concentration of haemoglobin. results: a protective effect of the agent on platelet count, plasma concentration of btg and platelet membrane gpib could be observed during the first hours of the perfusion when a bolus dose was added. no positive effect could be recorded with the two lower doses used. plasma concentration of haemoglobin was higher in all the fut-circuits compared to the control circuits. conclusion: the addition of a bolus dose of fut- at the start of the perfusion seem to induce a protective effect on platelets during the first hours of perfusion. extracorporeal membrane oxygenation (emco) is a form of invasive cardiopulmonary support that can provide imporary physiologic stabilisation in reversible circulatory failure and or respiratory failure. we reviewed our expierence with extra corporeal membrane oxygenetion in children aged day to year between and . two neonates was succesfully decanulated, but died - well after decanulation due to septic complictions. one child years old, one neonates died on day and day" respectively while still on emco. complication which were and encountered were heavy bleeding in case (child), (neonate) and raceway rupture in case (neonate). problems which are specific developing countries like indonisia are: high cost ( . us for days) difficulty in transportation (transporting intubated baby) from the orgin hospital, lack of knowledge and understanding of the primary physician and nm-ses and difficulty organizing in hours emco team. resnratory mon tor/ng in picu z,zjvkovic, s. mihailovic, o, tosev respiratory monitoring in pediatric intensive care unit picu) provide the importartt informations for understanding of the pathophysiology of the clinical signs, aid with the diagnosis, and assist in therapeutic management and predicting prognosis. pien in children's hospital for ~flmonary diseases and tuberentosis remained for the t~s't two end a half years relatively limited for diagnomic tools and therapeutic regimens, mostly because of the poor fmnaeial suptx~rt. the number of children admitted for aurae asthmatic at.lzek~ severe pneumonias, bronehiolitis, complicated pulmonary tuberculosis, foreign bodies and exacerbations of ehronit'. pulatonary diseases was t . for all patients the respirator' monitoring system means: physie~d examination, ehe~ x rays, capillary bltxxl gas mmlyses (vevv few ehiktren experienced itwasive arterial blt~.~'i gases), noninvasive oxyntctry, measuring of the vital capacity in coopo-able patients, as~d capnography. later on, after the imtial critical illness, a complete hmg fimction tests was performed, as well ,~s bronehoscopy in selected eases, (~lr experience revealed that abotrt % of ehil&en heos suecessthl outcome, without s~lllens , instead they had been tremted in limited conditions. ']'he rest of our patients were previously diagnosed ~s ettronie pulmonary patients, with high risk score system ibr having seqnells 'llae mortality rate were , %. the continuous blood gas monitor, pasatrend (biomedical sensors, ltd., high wycombe, bucks, england) has the capability of measuring ph, pco , and po via an indwelling optical absorption optodelclark electrode sensor that is placed through an intra-arterial catheter. we evaluated the accuracy of the sensor in radial and femoral locations in critically ill pediatric patients. methods: the simultaneous values of ph, pcoz, and po recorded from the paratrend monitor were compared to values measured by standard arterial blood gas analyzer (coming , ciba-corning diagnostics, medfield, ma). criteria for the elimination of data points included a core vs. sensor temp. gradient, and sensor pulled back beyond accepted insertion distance. mean time of monitoring per sensor was hours (range . - . hrs). mean time of radial monitoring was hrs (range . - . hrs) and of femoral monitoring was . hrs (range . - . hrs.). linear regression and bland-altman analysis for bias and precision for each parameter were calculated. results: a total of patients (age range weeks to years) had paired samples of ph, pens, and poz made by the sensor and blood g&s analyzer. the range of measurements were ph . - . , pco, . -i . t(n r, and po - torr. the paratrend monitor demonstrated accuracy that is comparable to the accepted standard of blood gas analysis in a group of critically ill pediatric patients manifesting wide variation in ph, pen , and poz..this technique appears m be very useful especially in the extreme values of the parameters measured. funding provided by biomedical sensors. understanding of pulse oximetry d.semple, l.e.wilson. royal hospital for sick children, edinburgh, eh lf, scotland, uk. pulse oximetry is a useful, non-invasive monitor, routinely used on the itu and increasingly often on the general wards. we used a questionnaire incorporating questions on the theory and clinical uses of the pulse oximeter to assess understanding of pulse oximetry in medical and paramedical staff doctors indicated grade, speciality, pulse oximetry tuition and neonatology experience. doctors, itu nurses, t medical students and physiotherapists completed the questionnaire. some confusion existed between the principles of pulse oximetry and transcutaneous oxygen measurement. wide variations in the lowest acceptable saturation in fit children were seen ( - %), with around % of respondents in all groups accepting values of % or less. some potentially serious mistakes were made in the evaluation of oxygen saturations in the clinical scenarios. there were widespread variations in correct responses at all grades of medical staffing. nurses scored well on more clinically-orientated questions but relatively poorly on theory. only % of doctors (mostly senior grades) had received tuition in putse oximetry. neonatology rotations appeared to confer little additional knowledge on pulse oximetry. few doctors and nurses receive tuition in the use of pulse oximetry a significant proportion of nurses and doctors, of all grades, exhibited a lack o{" understanding of the principles of pulse oximetry. this may result in unsafe use of the equipment and put patients at risk. one can see from the table that blood composition in uv and ua differens in some characteristics, and similar in sgp magnitude. venous-asterlal gradients "gas functiomals" between uv and ua represent the measure of difference in this characteristics. the gradient cari be positive, zero -order or negative and change both in value and in sign but not reach apo (positive) and apco (negative) in absolute significance.minimization of "gas functionals" deviations atom the zero is achieved due to"mutual replacement acts" between po and pco in uv and ua blood. we suggest that presented tests can be useful in full evaluation of gas exchange in newborns. (pap) in the context of pulmonary hypertension is oft desired but rarely achieved. inhaled nitric oxide (no) has been shown to produce this desirable effect, but is relatively difficult to administer or monitor. we wondered whether np, chemicaily related to no but more stable in solution, would produce similar physiologic effects when administered in the convenient modality of nebulization. methods: piglets were anesthetized, mechanically ventilated, and surgically instrumented. systemic blood pressure (bp), pap, and cardiac output (co) were monitored continuously. after postoperative stabilization, . % nac} nebulization was begun, and pulmonary hypertensiorr was induced by reducing fio from . to . . the piglets were monitored for minutes during this hypoxic phase, next, without altering fio or ventilator settings, np ( mg/ml, dissolved in . % nacl, flow ipm) was substitued for . % nacl in the nebulizer circuit. np was nebulized for mins. results: during hypoxia, pao fell from to mm hg. pap rose during hypoxia from to torr (p< . ). ,^fhile bp and co did not change significantly. pap fell during nebulized np in each piglet, (mean apap = to torr; p< . ; mean reduction of hypoxia-induced rise in pap = %; range: to %; p < . ). pvr/svr fell by % during np nebulization (p< . ), while bp and co did not fall significantly ( to tort; to mllkg-min), the reduction in pap began within minutes of the onset of nebulized np, and appeared to reach a plateau by minutes. no tachyphylaxis to nebulized np was noted. nebulized np did not significantly affect pap, bp, or co under normoxic conditions. conclusions: ) like no, np selectively reduced hypoxia-induced pulmonary hypertension without altering systemic bp, ) unlike no, np can be administered by nebulizer, a technique familiar to virtually all health-care providers, and potentially adaptable to both intubated and non-intubated patients. } nebulized np may be beneficial in clinical contexts where inhaled no is impractical. dang phuong kiet and nguyen xuan thu examining cases of purulent pericarditis with various clinical forms treated by surgery, the authors drew the following experiences for their diagnosis. t. clinical factors. purulent pericarditis appeared like a cardiac tamponade in a septicemia due to staphylococci with dassieal symptoms: severe dyspnea, tachycardia, faint heartsound, big liver, prominent cervical vein ; rentgenography of the chest showing enlargement of the cardiac silhouette, a diminution of ventricular pulsations, ~i clear lung field. by an emergency operation, ml of diluted blood were drained. purulent pericarditis and pleural effusion appeared at the same time but at first tile symptoms of purulent pericarditis were masked by the predominant symptoms of plearal efihsion. after the pleura was drained, its pus was no more, the general state was relatively stabilized but there still were big liver, dyspnea, enlargement of the cardiac silhouette while central venous pressure increased. purulent pericarditis appeared late. in the first stage (about weeks) there was no suspected sign. later on gradually appeared such symptoms as dyspnea (during serum transfusion for instance). central veinous pressure also raised. the heart chest diametre increased at first (up to - %) then decreased (down to below % ) but the liver kept on swelling together with the particular changes of electroeaediegramme. now the pericardium had no more pus but get fibrous (up to ram) thus constricting the heart and its main arteries ike pick syndrome). . diagnostic values of electrocardiograms : common signs of ecg related of these purulent pericarditis were: a diminution of voltage, a widespread elevation of the st segment, the tf wave flattened and inverted. however, what should be stressed was : the diagnostic values of an electrocardiogram for purulent pericarditis was mainly in the dynamics of their signs: in the first week, the voltage diminished corresponding to a pericardium containing pus, while the st segment went up then seemed parallel to the fibrosis of the epicardium, the liver swelled, the central velnous pressure increased, the heart/chest dimension ratio decreased, the st segment went down, the t wave became more flat and inverted. between and neonates, aged - days (median ), weight , - kg (median , ) with critical valvar pulmonary stenosis were scheduled for balloon dilation (psvp), children ( %) were on pge and ( %) needed mechanical ventilation. after stepwise dilation a final balloon : pulmonary valve (pav) ratio of % ( - ) was achieved, there was a significant correlation (p< , ) between an adequately sized balloon and freedom of reintervention. two valves could not be passed, four neonates underwent surgical procedures (brock n = , commissurotomy n = ), two children ( %) died of sepsis. / patients ( %) were successfully palliated by psvp in the first month of life. the rv : systemic pressure value fell from % ( - ) to % ( - ), complications included transient dysrhythmias, transient hypoxia, vessel occlusions;- right ventricular outflow tract perforation. in / patients follow up data is available. the residual systolic peak doppler gradient over the pav on the last out patient visit ( - months after psvp) was - mmhg (median ). four children needed repea.ted psvp to months after the initial intervention. conclusion: psvp of critically ill newborns is possible. the risk of mortality is relatively low. psvp in neonates with an adequately sized balloon is a challenging alternative to surgical treatment. post hypoxic-ischemic (hi) reperfusion induces the formation of non protein bound iron (npbi), leading to production of the reactive hydroxyl radical. it was investigated if the ironchelator deferoxamine (dfo) could reduce free radical production and improve neonatal myocardial performance after hi. severe hi was produced in newborn lambs and changes from pre-hl values were measured at , and min post-hi for (mean) aortic pressure (mean pao), cardiac output (co) and stroke work (sw). left ventricular (lv) contractility and co were assessed by measuring lv pressure (tip-manometer) and volume (conductance catheter), using inferior caval vein occlusion to obtain slope (ees) and intercept of the end systolic pv relationship (v ). npbi, reduced and oxidized vitamine c ratio (vcred/ox) and lipid peroxidation (mda) were measured from sinus coronarius blood. lambs received dfo ( mg/kg i.v.) immediately post-hi, control lambs (cont) received a placebo. results: mean pao was stable, co and sw decreased up to and % respectively in cont as compared to pre-hi. in both dfo-groups co and sw remained within the normal range. ees and v decreased in all groups post hi, but did not differ between groups. npbi and mda were higher at min post hi (p<o. ), vcred/ox was lower at min post-hi (p<o.o ) in cont as compared to dfo-group, indicating more oxidative stress in cont. conclusions: dfo reduced the oxidative stress of the heart and prevented co and sw to drop, suggesting a positive effect of iron chelation on the myocardium after h{. from we published reports with analysis of performance of the heart as a whole organ.while analysing the heart performance as a whole, we recognize three block in it located intrapericardially: l."atrial"block -left (la) and rigth (ra) atriums; ."aorta-pulmonary" block-aorta 'bulb (a) and pulmonary artery(pa); .ventricular "three-chambered" block (vb) consisting of: -left (lv) and right (rv) myocardial chambers, both frith blood outflow into "aorta-pulmonary" block vessels, and -spongy (venous) myocardial chamber with the blood outflow through coronary sinus (cs) and thebesiau vein (tv) into "atrial" block. the following conceps are introduced for vb functions assessment "common" systole and "common" diastole of "three-chambered" vb. the process of normal "common" vb systole: -begins with blood ejection from vb spongy chamber into the "atrial" block; -continues with blood outflow from rv and lv into "aorta-pulmonary" block wi~ venous minimums -x-coiiapses -~btmation iu "a~riai" block; -completes with "three-chambered" vb general emptying. at this period the following blood volumes are transferring: -two-from rv and lv(their stroke volumes)into"aor~o-pulmonary"block; -two-from "spongy" chamber .into "atrial" block; -two-from systemic and pulmonary veins into "atrial" block during the process of so called "systolic" membrane suction (at pulling atrio-ventricular valves into rv and lv chambers as blood ejects out of them). it appears to be the regulation of blood inflow to "atrial" block by blond outflow from "three-chambered" vb into "aorto-pulmonary" block. objective: to evaluate the efficacy and complications of transpyloric enteral nutrition(ten) in critically ill children patients and methods~ from june to january children (i boys and girls), aged from days to years (mean l. ± . years) were treated with ten. patients were included after cardiac surgery, with acute respiratory failure, and after cerebral surgery. the indication of ten was mechanical ventilation in patients and failure of nasogastric nutrition in patient. children ( %) had previously received parenteral nutrition. and i fg enteral tubes was inserted into duodenus through nasogastric intubation en patients and by endoscopy in patients. rx and ph determination were used as methods to control tube situation. children received adapted formula, caseine hidrolisate, and enteral formulas. (in patients the nutrition formula was changed during ten). patients were supported with mechanical ventilation during ten, received midazolamperfussion(range to mcg/kg/min), fentanyl (i - . mcg/kg/h), and vecuronium ( . - . mg/kg/h). resulte: ten was used during to days (mean . ± . days). mean maximmnvolume ad~iniateredwas ± ml/kg/day (range ) .patients with midazolam, fentanyl and vecuronitml tolerated ten similar than children without sedatives. complications were diarrhoea patient, abdominal distension and/or important gastric fed residuals patients. pulmonary aspiration or respiratory complications were no registered. ten was ended in one patient due to diarrhoea, in due to change to oral or nasogastric nutrition, children continue yet with ten and was discharged of picuwith ten. conolusion: ten is an useful method of nutritional support in critically ill children with mechanical ventilation and/or nasogastric intolerance. introduction: the enteral nutritional support of the critically ill child may reduce the morbidity and mortality by attenuating, the hypermetabolic and catabolic response, decreasing the gut translocation and the septic complications, improving the bowel mucosa integrity and the wound healing. the aim of this study was to show the safety and tolerance of en. methods: we enrolled consecutive patients admitted to our unit from may to december , mean age . years (range imonth to i years). the prism, mechanical ventilation, inotropic use, opiates and other drugs were recorded. the en was delivered by continuous infusion across a polyuretane tube.we kept the patients head elevated °, and we used cisapride routinely. the gap betweeen admission and the en beginning, average time to meet the nutritional objective, en duration, selected formula, patients outcome and complications were recorded. results: prism groups were - = patients; - = ; - = ; - = ; - = . two patients with mof (multiorgan failure) died. % needed mechanical ventilation.the average time elapsed from picu admission to initiation of en was . days (range to ) and the average duration of the en was . days (range to t ). the average time to meet the nutritional objective was days (range to ). the selected formula were: lactose free infant formula in patients, elemental diet in , pediasure in and jevity in . we recorded vomiting in patients, diarrhea in and constipation in . none of them forced the en suspension. we didn't recorded any case of ~spiration or pneumonia. we found no relation between drugs, selected formula and complications. we think that en may be a safe and well tolerated procedure at the picu setting. generation of free radicals in iipid emulsions used in parenterai nutrition (pn) has been described recently. this seems to be due to high polyunsaturated fatty acid content. we studied lipoperoxidation status and antioxidant parameters presurgically and through the postoperative period ( days) in a group of twelve children (ranging from months to years of age), who underwent heart surgery and received nutritional support with pn. malondiaidehyde (mda), an end product of lipid peroxidation was used as a marker of oxidative stress. it was determined by the yagi spectrofluorometric method. antioxidant activity was measured with an assay based on the inhibition of spontaneous autooxidation of a brain homogenate, and vitamin e in serum by the technique of hansen and warick. erythrocyte mda release fonowing incubation in hzo in vitro was used as a functional measure of tissue vitamin e levels. data were compared using one-way variance analysis. there was not significant differences in the plasma mda production among the values obtained before surgery ( :t: . nmol/ml), postoperative pre-pn ( . +_ . nmol/ml) and through the course of pn ( . : . nmol/ml). levels of vitamin e previous to surgery were , : . #g/ml and decreased to . _+ . #g/ml at hours post-surgery before starting pn. while receiving pn, concentrations of vitamin e increased progressively up to + . l #g/ml (p = . ). pre-surgicai plasma antioxidaut activity values ( :i: %) dimiuished in the first postoperative day ( _+ . %) and then showed a clear increasing tendency, directly correlated with that observed in vitamin e levels. the measurements of the maximal percentage of mda release of erythrocytes in vitro, showed an inverse relationship with plasma vitamin e levels and with the plasma antioxidant capacity: preoperative . + . % and postoperative descending from . + % to _+ . %. our results indicate that during surgery and within hours postsurgery, a decline in antioxidant defenses occurs, in the postoperative period, while patients are on pn and taldng into account our obtained data: the unaltered mda values, the rise of plasma vitamin e levels, the recovery of both functional erythrocyte membrane antioxidant protection and the plasma antioxidant activity, they do reflect that during the intravenous administration of lipid infusions, oxidative damage does not occur, probably due to the addition of vitamin e to pn solutions in order to avoid autooxidation of lipid emulsions. garnitine is one of the essential nutrient in the diet of newborn infants. mother's milk represents the natural eamitine source for the newborn infants. we studied enteral earnitine intake in premature infants eutrophic (eu) and hypotrophic (hy), fed with mothers milk trough consecutive days-from fifth to tenth day of life. mean gestational age was (range - ) weeks for eu and (range - ) weeks for hy. birth weight was ranged - g for eu and - g for hy (p < , ). breast milk carnitine concentration was , i.tmol/i in mothers milk delivered eutrophic babies, and singnificant higher mean coenetration , l.tmol/i, of hypotrophic premature infants (p< , ). breast milk earnitine concentration was ranged between , - , ~moi,'l, and daily carnitine excretion was between , - , p.mol/i, mean , +- , i p.molll. the daily mean carnitine intake was from - , mgkg/d, in eutrophic and , - , mg/kg/d, in hypotrophic premature infants, in milk volumene intake from - mllkgld., the results of this study suggest that premature infants should be fed with own mothers mitk in eady neonatal pedod in attempt to prevent camitine deficiency. keto-acids and parenteral lipid admlnistration. castorina m., antuzzi d., ricci r., rendeli c., polidori g. pediatric intensive care unit -catholic university -roma (italy). some metabolic studies have suggested that the administration of mediumchain tltgticerides (mct) might induce a marked increase in ketone body concentrations; the aim of this study is to evaluate the effective ketogenetic risk of infusing mct emulsions in total parenteral nutrition (tpn). two groups of seriously infected children were examined: a- septic infants were given to tpn with a % of long-chain tryglicerides ( lct). b- septic infants, in wich the lipid source in tpn consisted in a - mixture of lct and mct. the children in the different groups showed similar severity and therapeutic scores (prism, tiss, ~, f~ , f~ ); the lipid intake was the same, corresponding to - . g, ckg bodyweight/day. in all patients a sample of urine was taken six times a day for the whole time of tpn the urine samples were screened by the diphenylhydrazone test, and the ketoacids excretion was confirmed by a chromatography. the urinary excretion of -keto-acids equivalent to p-ohphenyl-pymvate (mcg/ml urine) is summarized in the no significant increases in frequence and/or in severity of acid-base disturbances were found in all studied patients in consequence of the lipid infusion. the patients of b-group showed a lower excretion of -ketoacids. the c~-keto-acids excretion was ever unsignificant and seemed to be correlated with the illness severity more than with the lenght of the tryglicerides chain. this observations let us suppose that the mct, at employed doses, can be safely administred also in childen with metabolic acidosis and/or serious illness. reye syndrome cayetano heredia hospital, lima, peru five patients with reye syndrome were studied; included were those diagnosed from january to march and treated at cayetano heredia hospital. the age of presentation varied from z. to months. the syndrome occurred more frequently in males ( / ); the time of illness at the presentation varied from to lo days, and the following features were found: fever ( / ), akeration in mental status ( / ), seizures ( / ), gastrointestinal illnesses (diarrhea) ( / ), and respiratory insufficiency ( / ) --in this case ventilator)-support was needed, in all cases hepatomegaly, intracranial hypertension, hypokalemia hyponatremia, metabolic acidosis, hyperammonemia and elevation of hepatic enzymes were found. coagulation blood tests were abnormal in three patients. cerebrospinal fluid (csf) showed hypocellularity in all cases (less than cells/ram ). the cultives were negative, and the final diagnosis was confirmed by hepatic biopsy. no deaths were due to reye syndrome. a contribuhon to the study of reye's syndrome the aulhors analysed records of patients meeting all the clinical, biochemical and anatomic criteria put forward by hutrealoch~ and samaha ( ) who were ireated at the emergency and resusdlation depammlt tithe ipch in years. the average age of the children was years (the ~umgest monks and the driest year~ most of lhon ( / ) came from lhe countryside to lhe lmfia~ willfin hours of file oulbreak. a few days previously the patients w¢~ld have fever (some of ahem wilh diarrhea or cough) ,,rod vomit then rapidly fidl into coma and c~nvuksien. they ~me to the imtia~ with the signs of typical increased inlracranial pressure ( stages - according to lovejiy for most cases) but the liver was unllkely big. the main biocheafical dmnge of the blood was acute hepatic thilure -the bllod glucose decreased : (ha the aver~ , n~% ( ) ~ not measured in five cases (glucose a"aces). -the blood ammonia ino~ased riven to microg/dl fin lhe average , n = ) -the percentage of p~in was low, in the average , % (n-- ), % at the lowest (a case ofmekaa lasling five days was ctwed with vitamin k). -got and gpt enzymes increased - times (n= ) besides, tht~re was decompcmated addt~is with lhe average valnes ph = . ; pcoz = ~ mmhg and eli = - ~ ~, (n~). the charadaislic dumge in the ¢~'ebrospinal fluid was a low glucose tx~acenwalien h the average of k mg/dl ( cases of glucose it'aces) ; meanwhile protein decreased in the average of mg/dl ( cases below mg/dl). besides ~here was no inflammatory lesion ~tion) : very serious brain oedona and fatty degeneration of live~ scatteredly or parllally.microso~ically (biopsy and necropsy) in file brain appeared bright space around blood arteries and glioma extended v'lrdmw -robin space, with no inflammatory reaction. liver.-the sa~dure was intact there was no " "mtlammal~s ' cell, the kupffer cells did not show hyperplasia but show a heterogenous deg~nerafion~eart: also showed a fatty degencralion in some areas of the myocard eellkidney: the ihtty degenerati~l scattetedly in the tubular cell. pano~as:fatty degeneration scattetedly in file pancreatic cell. two cases of liver biopsy for lhe rid lime (check before leaving file inslitute) found that fatty degeneration was r~tta~ nearty ff~pletely. the exact muse remained unknown. objectives: to analyse whether there exists serum and urine electrolyte disorder in children with respiratory failure, methods: we have made prospective study of children in our icu during a month period, electrolyte concentrations were measured in serum and urine collected during hours (sodium-na, potassium k, chloride-ci, calcium-ca, magnesium-mg and phosphorus-p). results: average values in serum were: na . +/- , (rv: - ) mmol/i, k . +/- . ( . - . )mmol/i), cl . +/- . ( - ) mmol/l, ca .t +/- . ( . . )mm /i), mg . +/- . ( . - . )mmol/i. average electrolyte levels in hours urine were: na . ~/~ . ( - )mmol/day. k . +/- . ( - )mmol/day, ci . +/- . ( - )mmol/day, ca . +/- . ( . - . )mmol/day and p . +/- . ( . - )mmol/day. conclusions: average serum ci and ca levels were decreased in children with respiratory failure. in urine, average k, ci, ca and mg levels were decreased and urine p concentration was increased. we concluded that serum and urine electrolite disbalance may be expected in children with respiratory failure. the nurse is going to kill me! (icu syndrome) anita duvndam ~, sonia v.d,sluis ~dpt. of pediatrics, div. pediatric intensive care, sophia children's hospital, rotterdam dpt. of pediatrics, div. pediatric tntensive care, juliana children's hospital, the hague. content description: this presentation will provide the critical nurse with background information concerning the identification, the prevention and management of the critical ill child who has developed the icu syndrome. the results of a questionnaire concerning the occurrence of icu syndrome on a picu will be presented. behavioral objectives: at the end of this session the participant will be able to: . describe four clinical symptoms of the tcu syndrome, . identify major sources of picu environmental stress, . discuss nursing's unique role in helping the child to cope with the icu syndrome, . discuss nursing's unique role in preventing icu syndrome. content outline: the icu syndrome is a situation in which the individual is not able to deal with changes in observation and interpretation of both quantity and of patterns of sensory perceptions. in other words the borders between the inner and outer world becomes unclear for the person. the exact incidence of the icu syndrome in the critical care setting is unknown, we have limited knowledge of the occurrence of the icu syndrome in critical ill children. yet critical ill children in our hospitals sometimes show the symptoms of icu syndromes. to be able to identify the occurrence of icu syndrome we developed a questionnaire. the thesis of the questionnaire was: does the icu syndrome occur in critical ill children in the age between three and ten, who have been intubated and/or ventilated in a picu? eighteen questionnaires have been send out to parents of critical ill children in two hospitals. the response was percent. conclusions: . most of the children were anxious (n= ), showed regression (n= ) or had sleeping problems (n-lo) during the stay on the picu. . children showed the same problems after discharge. . there is no relationship between environmental factors and symptoms of the tcu syndrome during the stay. . there is no relationship between preexistential behavior and symptoms of the icu syndrome during the stay. because the lack of a scientific definition for the icu syndrome in children and good criteria for diagnosis, we were not able to get an answer to our thesis. more research is needed. continuous veno venous haemofiltration (cvvh) was adopted as a first line renal replacement therapy in our paediatric intensive care unit (picu) some three years ago. ~/he process of introduction and development of cvvh proved to be an exciting challenge for nurses as indeed it was for the whole multidisciplinary team involved. we have successfully used cvvh in the treatment of over infants and children, weighing between - kg. the range of conditions treated is ever increasing. to date we have not only used cvvh for patients in renal failure and fluid overload, but also to gain biochemical control in tumour lysis syndrome-and metabolic disorders. other distinct patient benefits in comparison with more conventional means of renal replacement therapies are that, it is a continuous controlled treatment being extremely effective in creating 'space' for nutrition, which is especially important in the fluid restricted, catabolic patient. of paramount importance in providing this level of service is the education and training necessary to impart the skills and knowledge for nurses to become expert practitioners in this field. we now have a teem of highly advanced practitioners who have developed their nursing skills to provide even more holistic care for their patients. this group are embracing new challenges and responding positively to the developing service whilst expanding their knowledge base. this paper will discuss the advantages and disadvantages of cvvh as we have experienced, relating i t to the wide variety of patients we have treated. we wish to share how cvvh has become an accepted role of the picu nurse and how the service has been successfully implemented. integrated care pathways (icp's) define the optimum course of events in the care of a patient with a specific condition, within a set timescale. aims and methods: icp's and case management (cm) were introduced to evaluate and improve clinical practice. icp's were developed for patients undergoing surgery for atrial septal defect (asd) ventricular septal defect (vsd) and fallots tetralogy. they were based on the median experiences of the last patients. patients have been managed using icp's. results: analysis of variation from the icp's shows a reduction in the following potentially avoidable causes of variation: delay in extubation has been reduced from % to %, and patients ( %) were extubated earlier than the median. prolonged stay on the intensive care unit (icu) has decreased from % to %, and patients ( %) were discharged to the ward a day earlier than the median. the number of patients receiving inadequate post operative analgesia has decreased from % to %. delayed feeding after operation has been reduced from % to %. unavoidable delays in extubation and discharge from icu occurred in patients ( %) because of haemodynamic instability" or lung problems. cm utilising individualised pathways for these patients has reduced variation in care which can improve patient outcomes. pathways have been developed for other conditions and it is anticipated that approximately, % of patients will be treated using an icp revision of icp's results in continuous evaluation and improvement of the care provided, conclusions: the use of icp's and cm has improved patient care and decreased avoidable delays and variations. the future development of other icp's, combined with a case managed model for selected patients, is seen as a viable method of continuously improving patient care. this paper is a retrospective audit of children who received continuous veno venous haemofiltration (cwh) whilst on the paediatrie intensive care unit (picu), data was collected over a month period from may to january . the girls and boys were aged from day to ½ years (median ½ years) and weighed between , and kg (median . kg). length of admission to picu was to days (median days). sepsis syndrome was diagnosed in cases: of these had bowel necrosis and meningoceccal disease. eight patients had an underlying haematological, oncolngical or immune disorder. the remaining children had inborn errors of metabolism ( ), nephrotic syndrome ( ), or cardiac failure ( ). cvvh was instituted for a variety of reasons. muttiorgan dysfunction was present in % of patients, % had acute renal failure, . % tumour lysis syndrome, . % uncontrollable metabolic acidosis with hyperammoneemia and % required fluid management. treatment was continued for between hours and days (median ½ days). haemofiltration was successful in achieving its desired effect in all except one patient. . % of children with haematological, ontological or immune disorders died despite successful haemofiltration. survival was higher in cases of septicaemia ( . %), nephrotic syndrome ( %) and errors of metabolism ( %). overall mortality was . %. this was attributed to the severity of the underlying disease process rather than the effectiveness of cvvh as a renal replacement therapy. asynchronous defibrillation and synchronized cardioversion deliver direct currents of high amplitude through the chest, to stop ventricular fibrillation or to convert life-threatening arrhythmias. since the human body is partially conductant, it should be possible that after a brief delay of time, a derivation of this monophasic defibrillation pulse is measurable in regions of the defibrillated body, other than the traject between anodal ("sternum") and cathodai ("ape~;") paddles. one could also estimate that health care personnel in the immediate environment of defibrillatoty shocks, are always at risk to possible electric injury. accidents might occur when health care personnel do not stand clear from the patient during firing and create an additional electric path from this patient through their own body. most likely, the nonisolated parts creating a transversal eiectric path, will be the hands of the caretaker. since defibrillation generates touch voltages up to v and - a in ved, short delay's ( to millisec), the total body resistance during skin to skin or skin to paddle contact, is calculated to be as [ow as ohm (percentile tank for the entire population). an experimental protocol was developed to evaluate the conducted currents during defibrillation. mature pigs with a weight of up to kg. were used as animal models. the:,, had barbiturate anaesthesia, inotropic support with dobutamine at l micmgrams/kg bodyweight and all had a sinasat rhythm at the begining of the test-rounds. synchronized defibrillation at j (approx. . j/kg) and asynchronized -at j (whenever ventricular fibrillation or ventricular tachycardia occurred), were attempted, through latero-lateral placed and firmly pressed defibrillation paddles and/or adhesive multi-function electrodes. gel pads were choosen as contactmedium to cross the skinpaddle barrier. subdermal electro-myography needle electrodes were put at different parts and regions of the pig's body, but not between the paddles. these electrodes were coupled to a resistance device of ohm and a measuring computer. we measured monophasic and low current pulses up to , a during the defibrillation burst. thus conducted currents are high enough to produce accidental electric shocks when additional electric paths are created by the caretaker. "llaese are usually harmless, but in some "worst case" (wet or transpiring hands, rings,...) or in association with defectuous equipment, peak currents might be harmfull, and can produce pain, bums, apnae or cardiac (transient or persistant) arrhythmias. maria skogbv. karin mellgren, lars-g ran friberg, g sta mellgren, hans wadenvik. g teborg, sweden. bleeding complications in extracorporeal circulation is partly due to perfusion-induced platelet dysfunction. the aim of this study was to evaluate an in vitro model for investigation of platelet function parameters in an extracorporeat system. study: two complete extracorporeal life support systems were perfused with fresh heparinized human blood for hours. piatetet membrane glycoprotein changes, platelet granule release and platelet count were followed. eight paired experiments were performed. one of the circuits was perfused by a roller pump (polystan) and the other by a centrifugal pump (biomecicus), other components were identical. results: a continuous increase in glycoprotein (gp) ib-negative platelets was seen in both circuits. a marked increase of plasma beta-thromboglobulin concentration and a decrease of the intracellular pool of serotonin was observed, indicating a marked release of alpha as well as of dense granules. the plasma concentration of glycocalioin increased in parallel with a reduced platelet surface expression of gpib, suggesting that the loss of gpib is caused by proteolysis rather than by a downregulation of this receptor protein. conclusion: hours of ecls perfusion induces pronounced platelet degranutation and causes changes of important membrane receptors. this is in accordance with clinical studies, suggesting that our in vitro model does mirror the platelet exhaustion observed in a clinical reality. no significant difference was observed between the two pumps. the purpose of this study was to examine signs of distress exhibited by several patients following the discontinuation of opioids and benzodiazepines (o & b) in a -bed pediatric intensive care unit. the authors compiled a list of all cases of possible withdrawal reactions reported by nurses in the study setting over a one-year period. five cases were selected for study in terms of their wide diversity of relevant circumstances. the cases were examined through a retrospective chart review. data pertaining to analgesic and sedative administration, along with nurses' reports of behavioral distress, were transcribed and coded. a remarkable pattern of behavioral distress was clearly associated with discontinuation of o & b. cessation of benzodiazepines was associated with severe distress. these reactions were characterized by various combinations of crying, irritability, tremors, grimacing, gagging, vomiting, or feeding problems. some of these persisted in spite of large amounts of bolus drug administration. these signs were manifested for to days following cessation of o & b. these findings demonstrate that the rapid weaning of o & b infusions, sometimes following short-term therapy, can cause severe withdrawal reactions. the particular course that a specific patient will follow will likely be modulated by underlying manifestations of "icu psychosis" and unresolved pain and emotional distress. hermana tezano mt, pilaf orive j, latorre garcia j, lizarraga azparren ma, lopez bayon j ucip hospital de cruces. bilbao. spain a female child, one year old, was referred to our unit from another hospital because she had ischemic syntomsjn her right forearm wich started three days before. she had ~i downs syndrome and fallot's tetralogy with a systemic-pulmonary by-pass. nine days before the admission in our hospital she was undergone to a cardiac catheterization by arterial and venous femoral punctures with no incidences. on the admission to the picu her forearm was cold and pale with absence of cubital and radial pulses and slow capilary filling. treatment with heparine was started unsucessfully in the firsts hours, so uroquinase was added that later was changed to rtpa plus brachial plexus blockade. by the time me arterial tlux became more and more evident (doppi~) il bccuute aiat) evident a regional aedema witch made necessary a fasciectomy &the wrist. she also developped necrotic delimitted areas that included her first and fifth fingers. she was discharged from the picu after days and a week later she went to the operating room where an amputation of the distal phalange of the fifth finger was made. the etiolgy of this ischemic picture can't be attributed to the catheterization itself, but probably it should be due to some attempts in arterial puncture in its course, attempts that could be guess by the little marks noticed at the elbow flexure when she was admitted. long maintenance of cardiovascular funtion by assisted ventricular device with membrane oxigenator hermana tezanos mt, pilar orive j. latorre garcia j, lizarraga azparren ma lopez bay n j. ucip. hospital de cruces. bilbao. spain a little girl of three and a half years came to the intensive care unit from the operating room. affected of great vessels transposition with a pulmona~' banding corrected vith rastelli technique, it became impossible to discharge her from the by-pass circulation. it was assumed that this factt was due to a transient myocardial disfunction dfter the surgeon x~ent through the technique and found no wrong step in it. at the picu admission she had an ejection fraction belox~ % (echncardiografy), and was manteined on veutricular assistance with a circuit consisting ofa plate's membrane oxigenator, a bio-medicus pump and pvc rubber tubes, with monitoring of pulmonary', right and left atrial pressures. initially she needed a ventncular support of . l/min with dopamine. dobutamine and adrenaline; gradually the ejection fraction rose to % aliowing a decrease in the mechanical and inotropic support. the organic function ,.'.-as preserved but x-ray of the thorax showed images of pulmonary aedema with an increase in the needs until a fi of . . even though she was placed in a transplant program, she was remouved when the ejection fraction rose to % on the lth da of the evolution. there were no signs of infection (profilactic coverage). on the fifhteen postsurgery day. with a good cardiac sound and an ejection fraction of at least %. it was considered the withdrawal of the ventficular support, but unsucessfully despite the increase ofinotropic drugs, so she died. we think that our patient is a good example of the posibiti~ to mantain x~ith ecmo during a prolonged period of time a potential transplant receiver without major complicatios. joan wierema; ma )an mourik. sophia children's hospital, department of pediatric surger,j, rotterdam, the netherlands. the success of an ecmo program is heavily determined by the organizational structure and the daily availability of both well trained nurses and physicians. until now there is no general guideline to determine the optimal training schedule to set up an ecmo program. objective: to evaluate the set-up of an ecmo program in an area without direct availability of perfusionists of cardiothoracic surgeons. description of the progress: during the preparation of the ecmo program which started november , different phases are identified. first phase, acquisition of experience by training abroad of one physician, staff member of the icu, physician acting as a fellow and one icu nurse with theprimary task to serve as an ecmo coordinator and train the nursing start. in the second phase animal experiments were performed by paediatric surgeons, staff physicians, fellows and nurses. third phase, start of the actual ecmo program, priming by one trained nurse and ecmo fellow, daily care of the patient by nurses, icu nurse taking care of the patient related activities, ecmo trained nurse taking care of the circuit. fourth phase, transition of the tasks for priming the system from the ecmo fellow to the ecmo nurse and changing daily care for the ecmo patient now including the circuit by trained icu nurse with special legislation for ecmo. ongoing training of to nurses working for at least half a year in the icu. during an ecmo run direct contact between the ecmo nurse and one of the staff members; patient data: in a year period neonatal ecmo cases were performed with an overall mortality of %, ranging from over % in meconium aspiration to % in congenital diaphragmatic hernia. in other patients pediatric ecmo (age range month - months) mortality was %. conclusions: ecmo can be established without perfusionists or cardio surgical back up once a predetermined training schedule is available, resulting in comparable results with the international ecmo registry both for neonatal as well as for pediatric cases. mechanical ventilation at home makes normal development of the child with chronic respiratory failure possible. the parents must be encouraged to accept the treatment at home; therefore, they should be enabled to take care of their children all by themselves and the continuous professional support has to be offered to them. it must be stressed that the nurse is the link between the diseased child and his family introducing them into the process of the medical care at home. all the equipment needed for the mechanical ventilation of the child at home (ventilator, suction device, pulse oxymeter, oxygen tanks) has to be provided before the child is discharged. it is paid by the national insurance company. the maintainance service workers will make the necessary installations available and they will renew oxygen and compressed air weekly. the ventilation assembly must not interfere with the childs activities. the related dispensary and nursing service should be notified of the child's condition and the list of the required material (suction tubes, cannulas, desinfectants etc.) has to be made. our experience is so far -from the nursing and medical point of view -satisfactory, however the social status of the parents needs further regulations, omphalocele. mourik m, sophia children's hospital, department of pediatric surgery, rotterdam, the netherlands. in patients with (giant) omphalocde operative closure is impossible due to the lack of intra-abdominal space and a variable degree of pulmonary hypoplasia. consequently conservative treatment allowing epithelialization is the treatment of choice with a high risk of infection and/or sepsis due to a sometimes very long stay in the icu. this conservative treatment consists of daily application of an antibiotic containing powder on the cele which is covered by sterile gauzes. furthermore the enteral intake is started as soon possible. objective: to evaluate whether this treatment renders a high risk for serious infections. patient characteristics: in a year period patients with a giant omphalocele were admitted; mean birth weight g ( - g) mean gestational age . ( - weeks). overall mortality ( %). patients had to be ventilated for a median duration of t days ( , - ). results: patients were discharged at the mean of days following birth ( - ) following complete epithelialization of the omphalocele. following the initial stabilisation period parents were involved in daily care of all patients even during artificial ventialation. enteral intake was started at a median of days ( - ). colonization of the omphalocele was observed within - days in all patients. although infectious periods were observed at regular intervals, sepsis was the primarily cause of death in only of the patients who died, in conclusion: nursing care to prevent sepsis in patients with (giant) omphalocele is feasible for a long period of time and can be performed with simple measures, since june , we have been using nasal cpap in the treatment of respiratory disorders in newborn infants (severe apnea syndrom, tachypnea, hyaline membrane disease). in newborns presenting hyaline membrane disease, we have used cpap and administered surfactant therapy to premature babies out of . clinical data were : mean ga : . + weeks. mean bw : + g. mean administration time was hours. before administration, mean fio was . + . , mean pao . + . kpa and mean a/ao ratio . . all babies were intubated for administration of surfactant (curosurf) and were extubated after half an hour to hours after administration. this treatment failed for seven babies and they were ventilated by oscillation ventilation ; all babies survived. complications : we have observed pneumothorax in cases and cerebral hemorrage. mean duration time of nasal cpap was hours for the babies without assisted ventilation. nurses in charge of babies with nasal cpap should be aware of neonatal care, of the possibility of surfactant administration and of complications during this type of treatment. therefore nurses should know very well the use of nasal cpap, the monitoring during this treatment, the fixation of the system on the baby, nursing of the babies during this treatment and finally should take care of the baby physical and psychological well being. as a conclusion, nurses in intensive care neonatal units should know the possibility of treatment of rds by nasal cpap and should be aware of baby-nursing. emco in the postcardiotomy infan_t : a simplified circuit and reduced management grillet lsabelle, bosson christa, goelz andrea, helmer pascale, icu nurses, tschaut rudy perfusianist aldo castaneda institute, clinique de genolier, suisse to improve postoperative survival of infants with repaired cardiac tessions but severe residual cardiopnlmonary dysfunction, emco was used in infants, ranging in age from l days to months and in weight from , kg to , kg. diagnosis included tga / intact ventricular septum ( ) (both subiected to rapid arterial switch operation because of unsuitable lv function) and tga +vsd ( ). "['he emco circuit included a sarns roller ump, a medtronic minimax plus hollow fiber oxygenator and tubing ( / - / inch) with bioactive surfaces, an arterial canula fr., venous canulas : right atrial fr, left atrial fr., an air oxygen mixer and a sarns heater. the act was kept between - sec. after the infant was connected to emco by the surgical team and the perfusion technologist, the patients were being cared for and controlled exclusively by the cu nurse assigned to the patient and the physician on call for the icu, pump flows of - ml / kg / mln were targeted to insure an adequate urine output, a brisk capillary fill and physiologic left and right atrial pressures. sodium nitroprusside was used to control systemic hypertension while all other inotropic drugs were discontinued. inspired oxygen fraction on the ventilator was reduced to , at a respiratory rate of - breaths per minute. body temperature was maintened close to normal. when the heart started to eject again, inspired oxygen was increased to about , . the preparation for weaning from emco was done by the icu nurse: including oxygen fraction and ventilator rate. weaning from emcowas coordinated by the medical / surgical team and the perfusion technologist. the duration of emco in the patients ranged from to days. three patients ( %) were saccessflly weaned from emco. one of the three died within hours from neurologic complications, unrelated to the emco. the other patients ( both with tga + vsd ) are long term survivors and are doing well. neither the survivors nor the patients who died bad hemorrhagic complications, despite the fact that of the were placed on emco because of failure to wean from cardiopulmonary bypass. the simplified emco circuit worked reliably throughout this experience and no complications occurred nor could any shortcoming be ascribed to the use of this reduced, cost effective management team. years of praciical experience wiih exiracorporeal membrane oxygenation (echo) -the viewpoint of the nursing siaef monika schindler in a training program was started for the introduction of echo in the kinderklinik of mannheim/germsny. years later ( ) the first european echo patient, a days old newborn baby, ~as treated successfully in our institution. with echo, more treatment modalities ~ere available after failure of conventional therapy in eases of severe lung diseases like meeonium aspiration syndrome, congenital diaphragmatic hernia, sepsis/pneumonia, primary persistent pulmonary hypertension of the newborn and -in infants and children -ards (acquired respiratory distress syndrome) due to multiple underlying illnesses. in the first ards patient, a years old girl, was treated successfully ~ith ecmo in mannheim. until now patients (age: i day - years) were treated with echo in our institution; additional patients were transferred to us from other institutions for therapy with echo, but could be treated ~ieh alternative moda]ities of therapy like improved conventional ventilatory support, high frequency oscillatory ventilation (hfov) and inhaled nieric oxide (no), unexpectedly the more ~ide-spread use of hfov and no -also in other ~ntensive care units -did not lead to a reduction of the echo frequency in our hospital. due to this long ecmo practice, which is helpful in many critical situations, a certain routine came up in the nursing staff of our intensive care units; but ecmo continues to be a maximum strain for all co-workers and implies an high personnel and material/financial-expense. but in our opinion the improved survival rates in severe respiratory failure-( % in neonates and % in infants and children, estimated survival rates under continued conventional management: < %) by the use of echo justifies this expense, even in times of less financial support for public health. • analyse the differences between each urdt. method : ni criteria were defined by the rt~a ped group according to cdc criteria. all data were collected by a nursing and medical team. data vere dealed with epi info software. all u-dections data were validated by an external mvestigatol : patients who stay more than hours in an icu were included over a months period. % were newborns, % infants and , % children. ni were idenlified among sll patients, the overall ni incidence rates was , % and , person day, septicemia was the first cause of ni ( %). staphylococcus epidermidis were isolated in % of septicemia cases. pneumonia was the other main ni ( %) with gram negatwe bacille isolated m % ( % of them beei,ng fseudomonas) accordmg to age, the septicemia mcidence rate varied from , ~., to . %,, catheter/day and pneumonia incidence rate from , %, to , % ventilation/daywith the lowest rate for newborns. : this survey was possible thanks to the collaboration between laboratories, bacteriologist, physicians and nurses, and allowed each concerned unit to work together in~tead of every one in his own field. 'lhe results of this survey bring changes in attlhades and empower the different team work the next step is to analyse the ditferent nurses procedures of indwelling central venous catheter in each unit ar)d implement a ni quatity care. program in all nicu anti picu. v~,~jl~j~'v~y : new born in~ra-v~ nous drugs ~md lheir pr~taration mcounter a lot of risk ~)f utters, due to inadapted conditionn~ng to podia)eric and minimal amount injec~.~d, th~ study t~ed to evaluate degrees of do.~age er~o~ dye tt) dru~ preparaek, n i~ nc,:,~atol~gy and to come out w~th ~ method of dihttion able to reduce risk to minima (errors _< %) at the ~eme t~me, ¢o~,~x-tueaces on cost were studioj methnd~ : amikacine was choosen because this antibiotic is regularly ~,~l in neonatology unit and its dosage is easily used by standardiaud method, amikacine doses ( , mg doses and , mg doses) were prepared" by nurse~ form mg for m) vial. each dose w'a~ diluted to obtain mi volume, tallowing usual ward method, for each dilution, amikacine con<entrati('m and it,s volume was measured and used equipment for preparation wa~ regi~tred. "first s utj(m" were prepared diluting ~t'~ mg amikacine pouder inn ) ml glucnse solution bag (viaflex baxter bag with transfer cap), from tho~e "first solution" doses at mg and doses of ~ rng were prepared, amik~cine coc, cenir,)tmn for each preparabon and their volume were measured, ai,~n ntttl~,ber of seringe were tounted. first soiuhon staeiiity was conrroieo aher one week conservation at + '>c. amjkacine concentration were measured by fluorescence process (tdx abbott) after sample dilurion. on a mg/l sample, tovhnical reliahility show~ > ~ % of result mpmductlon and < % of variation due to dilutions. results : when amikacine injection werv pro.pared from araikacme /) mg for mt vial > % do~ge, ermr~ were found in / cases ; ~ % in ,t ,to cases. if preparation is done from amikacine "~it'st soltltion", les.--concenvr~tcd, it i~ more preci,,,e and only one dosage error ~ % ( , %} is found in eli studied doses. in add)inn to )hal if doses were wep,m-'d from one "first soiatiol~' bag, the cost economy sl~ouid b~" of fr~, and ii dos~$ were prepared tram the same bag the saving mtmey should be o{ i its .cencluslon : .ur survey shows th~t h' ntu)nato|ogy the u~ of a "first sohation which can be kept fi~r one week is enable to reduce dosage erroes and i~ co,~tsavmg, regarding [,v. admimst'rahon method the survey is still on, introduction: so-called vein of galen m~iformations ale rare in~racranial embryologycal anomalies, repl~senti~g tess than of symptomatic intracranied artefiovenoas l~alform~tions. the spontlneous prognosis is ~s~u~lly fatal, because of cardiac frilure due to left-to-right shunt thrq~ugh the fistula. recent developments of new techniques of treatment of the malformation and its cardiac consequence have led to a revolution in the practical approach of children w~th galen malformation. our fukfose is to contribute, with our persoaal series of s newborns and infal~ts admitted in our unit after endov~,scular embolization, to a better management of these children. such a management requ!res a rnultidisciplinary approach. intensive care are required prior to embollzation for patients with cardiac failure or cardiogenic shock and after cmbolization in order to insure cardiac and cerebral hemodyna.mic stabilities. this overlooking suppose for the nursing team to understand: prior to embolization : heart failure and cardiogenic shock. after cmbolization : evaluation of neurological and hemodynamic consequences of this proccdure, without forgetting the nursing and psychologic aspects, in concl'iision, this last ten yerrs, these new approaches give to the patients and their famitiy a good reason to hope a total recovew, in our exl)erience, the global mortality is % aad % of children #j-e neurologically normal after embolizafion, ii ii~ i ~ii i ii i i l i iiii~ i ~i iii i background: venous oxygen saturation (svo z) reflects the residuai oxygen after tissue oxygen extraction and represents the relation between tissue oxygen supply and demand. we studied svo and arterial lactate during progressive isovolemic anemia to assess the relation between svo and tissue hypoxia. subjects: ten - day old anesthetized ventilated piglets sao and svq were measured continuously by a fiberoptic catheter (oximetrix, abbott lab.) in the carotid and pulmonary a~epy tissue hypoxia was confirmed by a reduced vo, and an increase in lactate. conclusion: svo reflects better a reduced dp obtained by progressive anemia surfactant replacement improves gas exchange in early-stage adult respiratory syndrome (ards) [ , ], but not in late-stage ards [ ] . we report the first case of successfull treatment of ards after repeated instillation of surfactant.a ten year old boy, weighing kg, presented with hemorragic shock. biphasic-positive-airways-pressure ventilation was performed (evita ii, dr~ger, germany). he had recieved nine units of packed red blood cells and underwent surgical exeresis of two bleeding gastric ulcus. post-operatively, a cardiac arrest required cardiopulmonary resuscitation for three minutes. hemodynamic status was subsequently stabilised. the chest-radiograph showed infiltrates of both lungs without signs of cardiac failure. on the third day, the patient became severely hypoxic with a pao /fio ratio of . gas exchange was not improved by high ventilator settings. peak inspiratory pressure (pip) and ventilatory rates were cmh~o and breaths/min respectively. inspiratory:expiratory time was : and the positive end expiratory pressure (peep) cmh . after increasing the peep level to cmh , we instilled over minutes, mg/kg of porcine surfactant (curosurf, serene france), in two equal volumes in both main bronchus,the spo~ rose to % within rain, the fie could be reduced to . . twenty four hours later, gas exchange worsened again (pao /fio ratio ). we increased the peep from to cmh , and instilled a second dose of surfactant ( mg/kg). again, fie could be reduced within minutes (spo ; fie . .). the patient was weaned from the ventilator and extubated on the tenth day. follow-up at four month showed normal lung function.we demonstrate improvement in oxygenation after repeated exogenous surfactant administrations. we assume that in early-stage ards, surfactant may potentiate shunt-reducing effect of peep as it has been demonstrated in experimental model of ards [ ] , and allow decrease in fie . in case of secondary deterioration, we think that a second dose of surfactant should be administered. . weg jg, balk ra, tharratt rs, et al. ,lama : : - . . spragg rg, gillard n, pdchman p, et al. chest t : : - . . haslam pl, hughes da, mcnaughton pd. et al. lancet : - . . huang yc, caimulti sp, fawcett ta, et al. jappl physiol : - % (ref) . the aim of this study was to verify these data: patients/~lethods: all pts admitted to our multidisciplinary nicu/picu in were included if they were in respiratory failure recruiting conventional mechanical ventilation (cmv) with peep >_ and 'fig -: % or high-frequency oscillation ventilation (hfo) with mean airway pressure _> t cm h for or more houm. diagnosis, maximal ventilatory parameters, barotrauma, organ/ system failures, mechanism of death and glasgow oulcome scale (gos) and months after study entry were prospectively collected. results: patients were admitted to the unit, o whom required mechanical ventilation for a mean duration of . days. overall mortality was %, patients fulfilled study criteria. survivors had gos , pts with preexisting neurological impairment survived with gos . neonatal diseases included hyaline membrane disease ( ), meconium aspiration syndrome ( ) and cardiovascular surgery ( ), pediatric diseases included bacterial ( ) and viral ( ) pneumonia, aspiration ( ) and cardiovascular surgery beyond the neonatal period ( ). - ) . patients and methods: cefotaxim was used as a prophylactic agent in patients in life threatening situations (e.g. multitrauma, neurosurgery atc.). more than % children required cefotaxim for the treatment of severe infections (epiglotitis, meningitis, sepsis, pneumonia mainly in immunodeficient and neutropenic patients) in monotherapy or in the combination with the other antimicrobial agents. results: cefotaxim as a prophylactic drug was successful in all cases ( %). the effectivity of treatment of infections was . % ( patients). the change of antibiotic therapy required patients ( . %). patients ( . %) died, but only in of them ( . %) the obduction confirmed infection. conclusion: we conclude that cefotaxim is very effective and safe antibiotic and represents "golden standard" in the treatment of severe infections in childhood. in order to improve nursing quality, we recently adapted nursing care to the "five nursing functions" (activities of daily living, accompagnment in crisis, treatment, prevention and research) as described by the swiss red cross in accordance to the new educational guidelines of the european community, the aim of this study was to document complications of "treatment nursing function".methods: all treatment complications were prospectively collected by the nursing and medical staff. the nursing staff included patient (pt) name, time of occurence and exact description of complication, proposal for prevention and information of parents. the medical staff reported type of complication together with pt information, diagnosis, medication, treatment and interventions, outcome and referral, all complications were discussed in monthly meetings including nursing and medical staff.results: from january until december , pts were admitted to the picu/nicu for nursing days ( % of total bed occupancy). pts needed endotracheal intubation for an average of . days and pts required nasal cpap. complications in pts were noted ( per pi): inadequate check-up of equipment ; accidental extubation ( in intubated pts); bedsores ; false drug dosing ; wrong drug ; umbilical bleeding ; wrong transfusion setup ; nasal septal necrosis ). there was no mortality due to these complications. exact documention of treatment complications and their meticulous discussion within the medical and nursing staff may improve "treatment nursing function". however, documentation and evaluation of nursing within all "five nursing functions" will be nessecary in order to achieve optimal nursing care. cardiac output determination by thermodilution, using iced injectate has been shown to be valid and reliable in pediatric patients. it has been demonstrated in adult patients that there is no difference in cardiac output values when using room temperature injectate as compared to iced temperature injectate. the purpose of this study is to examine the effect of injectate temperature on cardiac output values in pediatric patients. our study consisted of sixteen pediatric patients who had oximetric thermodilution catheters in place after cardiac surgery and who had cardiac output determined using both iced and room temperature injectate. with each patient, cardiac output was measured once on the day of surgery and again the following day. in each case cardiac output was measured using both iced and room temperature injectate. statistical analysis included a two-way, repeated measures analysis of variance for each individual injectate administered and no significant differences were found in cardiac output. no statistically significant differences were found between groups with regard to the order of injectate administration or volume of injectate used (i,e., or cc's). the correlation coefficients between groups for cardiac output measurements at each injectate administration time, and for the average measurements across times, ranged between . to . (p < . ). preliminary data analysis suggests that cardiac output measurements for children are not effected by the temperature of injectate. a lenghty stay at a paediatric intensive care unit will always have sideeffects on a child's well-being and will put a high strain on the parents. in order to minimize the side-effects longterm intensive care unit opened in at the childrens' hospital. admitted children are all ~ongterm-ill and technically-dependent and the ventilatory support can alter from a tracheostoma to cpap or portable volume ventilator. nutritional support is applied by gastrostomies. a homelike atmosphere surrounds the children, they share a dormitory, a living-room and a dining-room the main purpose is to send the child home with or without technical equipment. this can only be implemented by giving structured education (theory and practice) to all categories involved. the multi-disciplinary team consists of one anaesthesiologist, head nurse, clinical specialist, rn nurses, nurses, one habilitation doctor, one social worker and therapists. twenty-four patients have been admitted to licu during these six years. length of stay was from one day to four years. four are presently staying at the trait. the assessment of pain in children ( - yrs) is still difficult, because children of this age have limited language and cognitive skills. to standardize the assessment of postoperative pain and distress in the intensive care unit an observational mstrument was needed that met several criteria. it should be easy to use in daily routine care. be suitable for the i.c. situation, and in children of - hrs of age. the comfort scale, an observational instrument designed to assess distress in infants in i.c. units, met these criteria. to accommodate the use of the comfort scale in the i.c. units and in research, nurses should be trained to use the scale. an additional requirement was that the inter-rater reliability should be sufficiently high, (cohen's kappa > . ). objectives: ) to introduce the comfort scale in the i.c.u.; ) to examine whether this instrument can easily, be incorporated into routine care; ) to investigate the inter-rater retiabtlity. methods: the comfort scale is an -item instrument specifically designed for use in pediatric i,c, units and contains both physiological items (heart rate, blood pressure) and behavioral items (e.g., alertness behavior, calmness/agitation, body movement, facial expression respiratory response, muscle tension). the observation period is minutes. the scale is supplemented with an item on crying tbr children who are not mechanically ventilated. groups of t.c. nurses were trained by means of video's and observations at the wards. after the training, each nurse completed scores with other nurses, after which the cohen's kappa was computed. when the kappa's for the items met or exceeded our . criterium, a new group of nurses was trained. results: to date, nurses have been trained. nurses find the comfort scale easy" to administer and a valuable addition to routine care in the i.c. unit. the cohen's kappa's were higher than . for all items that the inter-rater reliability was high. the comfort scale is feasible in postoperative care in the i.v. and is considered a valuable instrument to improve and maintain high postoperative quality of care in the i.c. unit. introduction:children with neuro-muscular disease are believed to have a higher resting energy expenditure (ree), because of their increasedwork of breathing.the influence of nocturnal nasal mask ventilation on energy metabolism and nutritional state of these children has not been studied so far.objective:l,ls the ree inereased? . s there an influence of nasal mask ventilation on the ree? .what is the nutritional state? .what is the estimated total energy expenditure(ete) in relation to the caloric intake? methods:a pilot study of patients( - years) .the following measurements were performed:l.anthropometry. .bioelectric impedance- .ree was measured by indirect calorimetry during the day (in bed) with and without nasal mask ventuation,ree was compared with predicted ree according to schofield(pee), .caloric-intake and activities were recorded during hour before measurement. .total energy expenditure was calculated as follows:measured ree x estimated activity factor. results:tin all children weight for height was too low, <p . .aii children had a low % of fat. .according to the healthy group, ree is not increased. ,nasal mask ventilation lowered ree in patients, in patient we measured a clear decrease.conclueion:l.anthropometry and indirect calorimetry were helpful in evaluating the nutritional state. .there is no increased ree,in t patient there is clearly effect of nasal mask ventilation. .when caloric intake was related to ree and level of activity patients had too low caloric intake. .the influence of nocturnal nasal mask ventilation and nutritional assessment should be evaluated longitudinally. increasing awareness that the neonate can percept pain and suffer following surgical procedures, has major impact on pain management. in our unit continuous morphine infusion (t /~g/kg/hr) was introduced from january as a standard medicatton following surgical procedures. before morphine was given as a bolus (i.m., i.v., rectal) of /~g/kg up till four times a day. repeated gifts of morphine were only gwen following observation by the nurse that the child experienced pain. aim of the study: to evaluate pain management before and tbllowing introduction of a continuous morphine infusion for postoperative pain in our icu. patients and methods: term born babies with isolated oesophageal atresia and tracheo-oesophageal fistula were included in the study. the total amount of morphine (/~£/kg/ hours); number of days morphine was given; duration of artificial ventilation was evaluated in a case control study. res ults: - - central venous catheters (cvc) have been increasingly used also at our picu, university medical centre ljubljana. besides advantages, the cvc has brought numerous risks of complications; the catheter sepsis occurs most often and can be fatal for the patient. for example, in we dealt with children aged - years or in other words . cvp per a child treated at our picu. a specialized unit for preparing parenteral natrition started to function in the university medical centre pharmacy in . after that we equipped a special room for preparing other necessary infusion mixtures and organized a team of nurses -"catheter nurses".their tasks comprise: managing cvcs, replacing and installing infusion systems and mixtures made at pharmacy, preparing drugs and some necessary infusion mixtures in special room, permanent training and co-operation with related disciplines, pharmacy, epidemiology, microbiology, etc. all registered nurses at picu have been trained for this work. the routine is as follows: in the morningafter the doctor's visit, we first check the cvc and change the dressings; according to the nurse's observations, the doctor decides whether there is a need to remove or replace the cvc. if the catheter site is inflamed, swollen, or purulent, a swab is taken for microbiological culture and the area cleaned. in case of systemic infection signs, cvc has to be replaced, blood culture taken and the infection treated with antibiotics. the dressings are always changed by two tmcatheter nurses together. afterwards the infusion mixtures for the next hours are prepared for each child. the infusion mixtures which will not be used immediately are kept on + °c; before application they are, of course, warmed to at least room temperature. finally the "catheter nurse" supplies the cvc with new infusion mixtures made at our pharmacy. our observations show that such work requires responsibility and is demanding; but our pemanent care lessens the number of complications. thus the described scheme fulfilled our expectations. perl- perative management of neonates with hypoplastic left heart syndrome muir warren, blondel maryse, foltz rhonda, farine martine, icu nurses, the aldo castaneda institute, clinique de genolier, switzerland both the pre-operative and post-operative physiology of patient with hypoplastic left heart syndrome is critically determined by the puhnonary-tosystemic resistance ratio. a high ratio results in minimum volume work for the right ventricle but is at the expense of important hypoxemia. a low ratio is reflected in minimum hypoxemia but an unfavorable increase in excess ventricular volume work. a resistance ratio of approximately results in an arterial oxygen saturation of % - %, a qp/qs of , and ventricular volume work only twice normal. this latter physiology appears best for oxygen delivery and systemic perfusion with tolerable volume work. carbon dioxide (co ) in the inspired gas is known to increase pulmonary vascular resistance without significantly influencing systemic resistance in the range of to tort partial pressure. hyperventilation with no co in inspired gas decreases pulmonary vascular resistance. thus, managing co may be useful to modulate the pulmonary-to-systemic resistance ratio, in the tast months, patients with hypoplastic left heart syndrome were managed by a norwood procedur e. patients with endotracheal entubation pre-operatively had co added to inspired gas to modulate the pulmonary-to-systemic flow ratio. patients had co added to inspired gas post-operatively. all but patient had characteristically large pulmonaary-to-systemic flow ratio with oxygen saturation mean % preoperatively, even in those patients receiving co , co was accompanied by elimination of metabolic acidosis pre-operatively. the most comlnon partial pressure of co added post-operatively was torr. po ranged from mmhg to mmhg. all surviving patients developed a metabolic alkalosis ( mean) when treated with co . there were deaths, one from drug toxicity, one from excessive post-operative hemorrhage, two from sepsis or mocardial insufficiency. only one patient benefited from catecholamine support which can increase systemic resistance unfaborably. in this experience co was felt to be an important adjunct in some patients pre-operatively and most patients postoperatively to faborably modulate the critically important systemic-topulmonary flow ratio, to maximize oxygen delivery and systemic perfusion, while minimizing excessive right vantricular volume work. key: cord- -e g lns authors: nan title: poster sessions - date: - - journal: intensive care med doi: . /s - - - sha: doc_id: cord_uid: e g lns nan the improvement in p/f ratio in the hfov group compared to cmv was statistically significant [at hours (p= . ) and hours (p= . )] and this trend continued through the study period. though the fio was higher in the hfov group at baseline, by , and hours this was significantly lower as compared to cmv group(p< . and p< . and p< . respectively)and again this trend continued over the study period. we studied patients with heatstroke admitted in icu during the august heat wave in france. plasma samples were available at the admission for all patients and during the course of the disease in patients. to assess the extent of the inflammatory response in the patients, plasma concentration of cytokines was studied by elisa. leucocyte activation was evaluated by the expression of eta integrins and l-selectin by flow cytometry using specific moabs; reactive oxygen production (ros) by chemoluminescence and metalloproteases mmp and mmp by gelatin zymography. as markers of cell activation and/or apoptosis, microparticles (mp) isolated from plasma were double-stained with annexinv (av) and cell specific moabs against platelets (cd ) or granulocytes (cd ) and analyzed by flow cytometry. microparticles procoagulant phospholipids were measured by prothrombinase assay. whole blood and microparticles tf was determined by a specific clotting assay. increased levels of il , il and il -ra were observed whereas il , il -eta and tnflpha were normal or undetectable (table) . blood leucocyte activation was demonstrated by:-an up-regulation of eta -integrin expression, -a down-regulation of l-selectin expression, -an increased ros production. moreover, pro-mmp and , possibly released by activated granulocytes were increased in the tested patients with presence of active mmp in three. markers of dic (thrombocytopenia, decreased fvii and fv levels, presence of soluble fibrin and increased levels of tat) were observed in / patients. whole blood tf was increased in all patients ( ± pg/ml, mean ±sd) vs controls (< pg/ml). compared to healthy controls, the number of av positive mps was not increased, but the cellular origin was different, with a significant decrease in platelet mps (p< . ) and a significant increase in granulocyte mps (p< . ). furthermore, mps tf was increased and contributed for a large part to the high procoagulant state. high levels of inflammatory cytokines play a crucial role in leucocyte activation leading to down regulation of l-selectin, ros production and active mmp . our results suggest a major role of mps of granulocyte origin in the tf-dependent procoagulant state that correlates with the severity of the disease. kalenka a , münch e , fiedler f departement of anesthesiology and critical care medicine, faculty of clinical medicine mannheim, university of heidelberg, mannheim, germany introduction: recombinant factor viia (rfviia; novoseven, novo nordisk, agsvaerd, denmark) has been approved for prevention and treatment of bleeding in patients suffering from hemophilia with inhibitors. numerous case reports and retrospective studies submitted to a webbased drug surveillance have been published, that record the sucessfull use of rfviia to treat lifethreatening haemorrhage in patients without pre-existing coagulation disorders. however, it is unknown whether rfviia induces hemostasis in septic patients with disseminated intravascular coagulation. therefore, the objective of this study was to investigate clinical efficacy of rfviia in septic and non-septic patients with bleeding complications methods: between / and / , adult patients with life-threatening haemorrhage without pre-existing coagulopathy were entered into the study retrospectively. out of patients with severe sepsis and dic (known infection and at least organ dysfunction) and non-septic patients with severe bleeding complications due to different reasons, we reviewed coagulation parameters and the amount of transfused blood products prior to and hours after application of rfviia. the patients´s underlying diseases and dosages of administered rfviia are illustrated in table . relevant thromboembolic complications were recorded results: prior to administration of rfviia, . ± . (mean ± standard error of the mean) units of red blood cells (rbc), . ± . units of fresh frozen plasma (ffp) and . ± . units pooled platelets (plt) were substituted to the non-septic patients. after administration of rfviia, significantly less rbc . ± . (p< . ), ffp . ± . (p< . ) and plt . ± . (p< . ) were transfused. coagulation analysis demonstrated normalisation of international normal ratio ( . ± . versus . ± . ; p< . ) and partial thromboplastin time ( ± . s vs. ± . s; p< . ) after administration of rfviia. no differences were detected concerning the platelet count. in the septic-group administration of rfviia neither resulted in a reduction of transfused blood products nor in a reversed coagulopathy. three thromboembolic complications were observed in the non-septic patients. mortality rate was % in the non-septic group vs. % in the septic group (p= . ) marsilia p f , imperatore f , munciello f , scarpelli m , teodori r , de cristofaro m , occhiochiuso l unit of anaesthesia and intensive care, department of emergency, a. cardarelli hospital, naples, italy introduction: acute septic descending mediastinitis (asdm) has been defined as the mediastinum infection which results from the spreading of oropharyngeal infections, or deep neck structures ( ). drotrecogin-alpha (activated) or recombinant human activated protein c (rhapc) is the only biological agent approved for use in severe sepsis syndrome that has demonstrated efficacy in reducing -day all-cause mortality and new data suggests a trend towards longer term survival( ). very few data in literature report the use of rhapc in the treatment of asdm. aim of this study is to report our experience of cases of asdm complicated by a severe sepsis-induced multiple organ failure syndrome (mofs) and successfully treated with the infusion of rhapc. four male and three female patients were admitted to our intensive care unit for asdm due to oropharyngeal infection and complicated by a severe sepsis-induced mofs. all patients were undertaken to combined cervicotomy and thoracotomy surgical operation with toilette and drainage of infection. moreover the infusion of rhapc at gamma/kg/min for hours was given together with all other certain established procedure. respiratory failure was managed with sedation, orotracheal intubation and invasive mechanical ventilation. cardiac failure was managed with invasive arterial and central venous pressure monitoring together with the infusion of catecholamines up to standard doses; while renal failure was managed with continuos venous-venous haemodiafiltration. antibiotics were given first empirically and then according to lab test results. in cardiac surgery, more than in any other type of surgery, in early postoperative period can occur low cardiac output syndromes due to hypovolemia or to myocardial failure. our objective is to evaluate the accuracy of the systolic pressure variations (spv) and of its negative component ∆ down under mechanical ventilation in predicting the response to volume loading and to diagnose hypovolemia. in a group of patients who underwent cabg surgery, in the early postoperative period we monitored: co/ci, cvp, pcwp, bp (s/d/m), vps and ∆ down. the including criteria were: sinus rhythm, ci ≤ . l x min- x m-?, pcp < mm hg. all the patients underwent a fluid challenge ( ml of colloids in min). according to the ci variation the patients were then divided in two groups: group a ( pts) with a raise of ci > %, and group b ( pts) with a ci variation < %. we analyzed the variations of the parameters mentioned above due to fluid loading and the differences between the two groups. in the following table are the data obtained. all parameters are measured in mm hg and are expressed as the average value ± standard deviation (*p< . ).statistical analysis shows significant differences between the two groups regarding only the initial value of spv ( . ± . mm hg in group a, . ± . mm hg in group b, p< . ) and ∆ down ( . ± . mm hg in group a, . ± , mm hg in group b, p< . ). there also significant differences of the values before and after the fluid challenge only in group a and for the same parameters: spv (from . ± . mm hg to . ± . , p < . ) and ∆ down (from . ± . mm hg to . ± . mm hg, p< . ). in predicting a significant raise of ci after volume loading a spv > mm hg the new parameters of preload dependency tend to replace the classic pressure parameters in hemodynamic assessment, being more accurate as predictor of ci response to volume loading and as detector of hypovolemia ( ). the low costs and accuracy of the spv method advocate for using it in critical care settings, even in cardiac surgery. marangoni e , volta c a , alvisi v , bertacchini s , ragazzi r , orlando a , alvisi r anesthesia and intensive care, university of ferrara, ferrara, italy several studies provide compelling evidence on the clinical role played by fluid optimization. till now, the assessment of the intravascular volume has been based on data derived by pulmonary-artery catheter. however, some studies suggest that the use pulmonaryartery catheter is associated with an increased mortality and hence the central venous pressure (cvp) remains the only parameter to be used. nine patients undergoing mechanical ventilation were enrolled. cvp was determined while patients were breathing spontaneously (sb) and during assisted control ventilation (acv) at different peepe levels ( - - - cmh o). patients clinical characteristics are (mean±sd): age (yr) ± ; weight (kg): ± ; tidal volume (ml, acv): ± ; respiratory rate (b.min- , acv): ± ; static compliance of the respiratory system (ml.cmh o- , acv): ± . the following parameters were determined: mean airway pressure (acv), mean systemic blood pressure (map), cvp. the most dramatic increase of cvp was registered when the patients were ventilated in acv compared to spontaneous ventilation ( fig. ) . surprisingly, cvp values were much less influenced by progressive rise of mean airway pressure obtained by different peepe level. moreover, map variations were closely linked to those of cvp. our data shows that cvp monitoring is useful for assessing the intravascular volume in patients requiring high peepe level. however, the cvp values obtained during acv are very different from those calculated during sb and hence, when possible, it is advisable to determine cvp during sb. pottecher j , bouyges s , caron s , moreau x , beydon l dept of anesthesia, hôpital larrey, angers, france routine use of pulmonary artery catheters (pac) measuring continuous cardiac output but not svo is controversial in cardiac surgery. oxygenation derived variables like arteriovenous oxygen difference (avdo ) could better reflect supply-demand balance than cardiac index (ci). moreover, bedside, respiratory changes in arterial pulse pressure (deltapp) are a more reliable indicator of fluid responsiveness than pressures obtained from pac (cvp and pcwp). the goal of our study was to compare two hemodynamic assessment methods: one based on pac derived variables, the other taking avdo and dpp into account. fifty consecutive mechanically ventilated patients emerging from cardiac surgery in a university hospital icu were included without informed consent since pac insertion is systematic in our institution.an independent observer simltaneously recorded pac variables (cvp, pcpw, ci) (first set, s ), avdo and deltadpp (second set, s ). initially, the caring physiscian could get the first set of value, was asked about volemia, inotropism and vasomotor tone and gave a therapeutic option. then he had access to the second set of value, answered the same questions and was able to maintain or to change his opinion. patients were divided in four categories, according to deltapp (< or >= ) and avdo (< or >= ) and discrepancies between the two sets of answers were analysed. based on s data, new drugs or therapeutic were introduced ( % of patients): inotropic drug, fluid loading, diuretic, vasodilatator, vasopressor. after knowing s , in patients ( %) we challenged the initial decision. deltapp did not correlate with cvp nor with pcpw. similarly, ci did not correlate with avdo . according to table: case : therapies decided knowing s challenged by s : all should not have been fluid loaded; case : therapies decided knowing s challenged by s : they should have received a fluid load; case : therapies decided knowing s challenged by s : should not have been fluid loaded and should have received inotropes; case : therapies decided knowing s challenged by s : should have been fluid loaded and should not have received inotropes. deltapp >= (n) deltapp >= (n) avdo < ( ) case ( ) case avdo >= ( ) case ( ) case conclusion: conventional pac measurements do not allow optimal therapeutic guidance, postoperatively in cardiac surgery. indeed, ci does not reflect metabolic requirements at best measured by avdo . also, cvp and pcpw do not reflect hypovolemia contrarily to deltapp. the association all data provided by s albers j , heggemann f , kayhan n , bahner m , vahl c f abt. herzchirurgie, icu, abt. radiodiagnostik, chirurg. universit, heidelberg, germany noninvasive imaging of coronary artery disease (cad) using multidetector computer tomography (mdct) provides theoretically additional information to the classical d coronary angiography. the objective was to determine: ( ) how accurate is the d imaging compared to the d method? ( ) is it feasible to profit from the additional d information in the clinical setting? methods: study population consisted of consecutive patients with diagnosis of -vessel-cad (n = ).every patient underwent both, d coronary angiography and mdct scanning (siemens somatom plus vz, slice thickness . or . mm, pitch . , contrast medium ml). retrospective gating was used. d visualization was performed using raytracing. comparison of d and d imaging was performed in a blinded manner, blinded investigators scored applicability of the coronary segments (cs) for aortocoronary bypass grafting (acb) (necessary/not necessary) and stenosis (stenosis < %/ - %/ - %/ - %). ( ) agreement in applicability for acb was (cs number/% agreement) / . , / . , / . , / . , / . , / . , / . , / . , / . , / . . cs rarely being object to acb, showed poor agreement: / . , / . , / . , / . , / . . agreement in quantification of stenosis was: . % for the right coronary artery, . % for the left anterior descendent and . % for the circumflex coronary artery. ( ) d volume data were acquired in a single breathhold. temporal resolution was ms (reconstruction time min/image) enabling calculation of stroke volume. d visualization showed distribution of coronary calcifications together with non-calcified lesions. severe cad was identified noninvasively in all cases studied. ( ) accuracy of the d method was sufficient for bypass planning purposes. however, quantification of stenosis was not acceptable. ( ) data acquisition was quick, safe and provided additional data superior to conventional d (calcification, soft plaques, d quantification of stroke volume). in conclusion, patients with severe cad can be diagnosed with high accuracy using noninvasive imaging. boulo m , fleyfel m , robin e , lebuffe g , lecoutre h , onimus j , tavernier b , vallet b anesthesiology and intensive care medicine, university hospital, lille, france aortic surgery can be taken as a model of fluid and blood losses leading to volume status variation and hemodynamic impairment. these variations together with aortic clamping may compromise tissue perfusion. in intubated and ventilated operated patients, respiratory pulse pressure variation (∆pp) reflects ventricular preload dependency ( ). ∆pp is a good predicting marker of increase in stroke volume index (svi) after a fluid challenge (fc) ( ). the aim of this study was to evaluate whether preload dependency as assessed by ∆pp measurement was associated with impaired tissue perfusion. after approval from the local ethics committee, patients undergoing aortic surgery were prospectively enrolled. intraoperative hypovolemia was suspected when heart rate increased and/or systolic blood pressure dropped more than % from baseline. a ml colloidal fc was then systematically performed. automated gastric tonometry (tonocap, datex-ohmeda, finland) was used to assess pgco -petco before and after fc (co gap- ,co gap- ) . an increased co gap larger than mmhg can be taken as a threshold value of decreased tissue perfusion. an increased svi larger than % was identified as responder (r) and fc was repeated until svi did not increase more than % again. an increase in svi of less than % was identified as non-responder (nr conclusion: increased production of gut wall lactate was previously shown to be associated with increased leakage of macromolecules across the gut wall due to gut barrier dysfunction ( ). in this study we were able to show that even short and uncomplicated cpb leads to increased gut wall lactate detected by gut luminal microdialysis, indicating gut barrier dysfunction. simultaneous tonometry proved to be insensitive to these changes. we propose that gut luminal microdialysis in the rectum may be a good method to estimate markers of metabolism and gut barrier dysfunction during surgery and in the critically ill patient. matamis d , tsagourias m , vakalos a , synefaki e , kareklas m icu, papageorgiou general hospital, thessaloniki, greece introduction: copd patients are often aged, smokers and may suffer from right ventricular (rv) failure. moreover, they may have smoking and age -related diseases of the left heart, as ischemic heart disease or valvulopathies. left ventricular (lv) failure may induce hypercapnic respiratory failure (hrf) and mimic the clinical picture of copd, especially in patients with heavy smoking history. the aim of our study was to identify, in patients with hrf leading to mechanical ventilation (mv), the prevalence of rv, lv, or biventricular failure, the presence of severe valvulopathies and the impact of the targeted cardiac treatment (according to echo findings) on the mv days and mortality. over a period of seven years patients ( m and f) with a mean age of ± years and a mean apache score of ± included in the study. heart function was assessed with echo within the first hours from intubation. patients were divided in three groups (rv failure, lv failure and normal heart group) according to echo criteria. cardiac treatment was given according to echo findings. respiratory treatment and weaning process was identical in all patients. anova and chi square test were used for statistical analysis. the objective of this study was to measure the cost-effectiveness of an igm enriched immunoglobulin preparation in adult patients treated for severe sepsis and septic shock. we performed a meta-analysis followed by an economic analysis conducted from the hospital perspective in germany. effectiveness data from a meta-analysis of eight randomised trials (n= ) was used to assign probabilities in a decision model to estimate cost-effectiveness of igm enriched immunoglobulin preparation and its comparator standard therapy. analysis of effectiveness data used all cause hospital mortality as the primary outcome and intensive care (icu) length of stay (los) as a secondary outcome. benefit was expressed as lives saved (ls). published icu treatment cost data was applied to assess differences in treatment costs. cost-effectiveness was calculated as the incremental cost per ls. we develop a systematic data collection of all the admitted patients in our icu through a home-made software and database leading to a broad description of the population and activities of the icu during the last five years; this was correlated with the classical scoring systems of icu patients. the system was utilisator friendly made by automatically generating hospitalisation icu reports which guaranteed the use of the database and its completion. at the end of each year and after a data validation period standard reports were generated with classical parameters: mean age of the population, mean length of stay, mortality rate, readmission rate, daily repartition of all the icu admissions ... and correlated with the severity of the icu population. the following observations were noted during this five years period: non significant elevation of the mean age and of the mean icu length of stay, but significant reduction of the global mortality while the mean icu scores remain stable. in the same period the number of icu technical procedures (right catheterisation days, artificial ventilatory days, cvvhdf days...) was also significantly higher but without significant influence on nosocomial infection rate. interesting management data were also available: more than thirty procent of the icu patients were admitted during the night shifts (between pm and am) which can be an important data to discuss the staffing problems (during the night shifts for example). the use of antibiotics was also significantly reduced during the same period. a five years data collection period of standard icu indicators correlated with the use of severity scores can be an interesting icu management tool to promote quality of care (and communication procedures inside and outside the icu) and to reduce mortality and morbidity in icu populations. further studies are necessary to confirm these interesting observations. the national intensive care evaluation (nice) registry (www.stichtingnice.nl) aims to analyse and improve the quality of dutch intensive care. the nice registry contains data items for each patient admitted to one of the participating icus. to support the individual icus in comparing their population and performance to several standards nice has introduced an internet application, nice online. users of nice online compose their own data analyses by selecting a)functions, b)split-elements, c)comparisons, d)subpopulations. figure (left side) shows an example of a request for a graph which presents the mean length of stay (function) for survivors and nonsurvivors (split-element) of the user's own icu and of all participating icus together (comparison). readmissions to the icu are excluded (subpopulation). results of analyses, presented in graphs or tables, can easily be copied, e.g. to management reports. privacy of patients and of icus is ensured by )login and password, )encryption of transferred data, )using a copy of the original nice database without patient-or icu-identifying information, )disabling combinations of functions and comparisons which may lead to identifiable information. in figure transport of the critically ill patient between hospitals or intrahospital remains an hazardous road trip where the patient is exposed to less controlled circumstances outside the icu. to gain more insight in the incidence of complications, circulatory-and respiratory instability (ci/ri) related to intrahospital transport, we investigated transports from our surgical icu. all data concerning transports from the surgical icu to the department of radiology from - were retrospectively reviewed. clinical relevant circulatory instability (ci) was defined as the necessity to start vasoactive medication(vam)or to change the existing dosage of vam during or directly after transport to maintain a map ≥ . clinically relevant respiratory instability (ri) was defined as the need to change the settings of the mechanical ventilator (fio , peep, minute volume) during or directly after transport. we also evaluated the administration additional opiates and sedatives (aos) prior to or during transport and the possible impact of i.v. administration of contrast fluid jopromide (ultravist ®) on renal function. sedation and analgesia are essential components of patient care in the intensive care unit (icu). "bottom up" costing of intensive care is more accurate but more labour intensive and difficult to perform compared to "top down" costing ( ). "bottom up" cost of sedative, analgesic and neuromuscular blockade drugs have not been reported. we therefore performed an audit of the cost of these drugs in our icu using the "bottom up" costing approach. over a month period, we prospectively recorded the daily amount of sedative, analgesic and neuromuscular blockade drugs administered to patients in a -bedded icu and multiplied the amounts by the cost of drug per milligram using pharmacy costing figures. patients were divided into groups that corresponded, roughly, to the length of stay quartile marks. out of patients admitted during the study period, data were collected for ( %). we also collected data for % ( days) of icu patient days. table shows cost of sedation per group, patient and icu day. around % of the cost was on drugs administered to the % of patients who stayed in icu for more than hours. propofol and alfentanil were the commonest drugs used (administered to % and % of patients respectively) and the most expensive ( , and , respectively). total cost was , which was % of the pharmacy ("top down") cost. cost of sedation per group. several medical specialities have conducted surveys among their residents during their training, in order obtain a feed back and assess possible improvement issues. at our knowledge, not such a survey has been conducted in europe. in france, icu specialisation can be obtained by two separate trainings: either specifically in medical icus or jointly to the anaesthesia training which is followed by the majority of future icu practitioners. a shortage in icu doctors is expected, urging raised efforts to make this training as attractive as possible. this inquiry was intended as a first step in this purpose. a question questionnaire was mailed to the first year residents (y ) whereas a question one was sent to the forth year residents (y ) registered to the joint icu-anaesthesia training program (lasting years) in france. anonymity of answers was insured. a total of questionnaires were received ( %) for y and ( %) for y . main y answers were: age: ± year, ( % female). they chose icu for good job opportunities ( %), a clinical ( %) and dynamic ( %) speciality. they had discovered icu-anesthesia during medical studies ( %). night shifts were: not disturbing ( %), are shared by many other specialities ( %), and are more interesting that non-specialised night wards ( %). a % of them hesitated before starting this specialisation. half of them changed geographical region for specialisation. medical english was spoken and red: %. a computer was owned personally: %. main y answers were: ± year, ( % female), their -year training was judged for theory: excellent ( %), good ( %), fair ( %); for practical teaching: excellent ( %), good ( %), fair ( %). medical english was spoken and red: %. only % had a position at the end of their training. they wished to join public institutions: %, private: %. research was a professional issue for %. future practice restricted to icu was aimed by %, whereas % preferred anaesthesia and % emergency medicine and pain clinics. they had published in french at least once during training: %, in english: %. additional degrees (mainly in infectiology and as sub-specialisation in some icu techniques) were obtained by % during specialisation. periods spent in non-academic hospitals (one year) were rated as excellent: %, good: %, fair: %; and medical supervision was judged excellent-good in %. they spent an average euros/year for medical furniture (books, computer). a computer was owned personally: %. finally, % did not regret choosing icu (and anaesthesia) as a speciality. training in icu (and anaesthesia) was judged as good especially for practical aspects by most of residents. about a third aimed at working exclusively in icu. more efforts should be performed to improve formal job offer at the end of the training. conclusion: diagnostic and imaging testing represents a significant amount of hospitalization costs in our icu due to the high number of tests performed per patient per day and especially for abg analysis. thus, a better control of lab tests ordering will result in costs reduction and a cost containment policy is becoming mandatory. kanevetci b n a c i , dosemeci l , y?lmaz m , cengiz m , ramazanoglu a anesthesiology and reanimation, akdeniz university, antalya, turkey the common problem arising in the icu's is the use of the beds for the patients who are expected not to benefit from icu treatment. in this prospective study, we aimed to determine the proportion, costs, length of icu stay and prognosis of those patients who were expected to die according to our clinical experiences. one hundred and forty five patients over year of age admitted to our -bed icu between march and february and expected not to benefit from icu treatment according to the experiences of the physicians working in icu. the apache ii, saps ii and gcs scores were noted and according to those scores, the estimated mortality rates were determined by the formulas. also icu stay, icu beds occupied by those patients, icu and hospital discharge mortality and morbidity and costs were determined. we didn't change the treatment strategies of those patients. the patients who had high risk of mortality but could possibly recover completely after given therapy were not included in the study. the mean age was . ± . . the most common underlying diseases were nontravmatic intracerebral hemorrhage ( % . ), cerebrovascular accident ( % . ), head injury ( % . ), metastatic tumors and vascular diseases of gastro-intestinal tract ( % . ), cardiac arrest ( % . ), lung cancer and end-stage lung diseases ( % . ) and the others ( % . ). the mean gcs, apache ii, saps ii scores were . ± . , . ± . , . this represents a % increase in activity with no change in the number of beds available or alteration to admission criteria. in both time periods bed occupancy was > %.length of icu stay decreased from a mean of . days to . days (p< . )and the length of ventilation decreased from . days to . days (p< . ). this reduction was observed across all specialites excluding neurosurgery. the use of information technology to provide iterative feed back has reinforced the adoption of the ventilator and euglycaemia carebundles making the desired elements of the care bundle the default mode within the intensive care unit. the culture of the icu has changed enabling more reflective practice ready for the adoption of the sepsis care bundle and other packages of evidence based treatment. papadopoulos a c , karakoulas k k , vassilakos d , filippidou m , skourtis c t h , giala m m anaesthesiology and intensive care, ahepa university hospital, aristotle university of thessaloniki, thessaloniki, greece proper heparinization is perhaps the most important aspect of sampling technique for arterial blood gas and ph analysis. ( ) the aim of our study was to evaluate two sampling techniques for arterial blood gases and ph measurements and their possible cost implications. we obtained paired samples from postoperative spontaneously breathing patients in icu having an indwelling arterial line. body temperature and blood hb of patients were within normal ranges. commercially available preheparinized (quik a.b.g.tm, marquest medical products, co, usa) and self-prepared with liquid sodium heparin syringes were used. ( ) the pao , paco and ph values were obtained from the same analyzer within minutes of sampling. the cost of each sampling technique was also estimated. data were analyzed by bland and altman analysis. the mean differences (+/-sd) between the results of the sampling techniques were - . (+/- . ) mmhg for pao , . (+/- . ) mmhg for paco , and - . (+/- . ) for ph. the % confidence interval was . - . for pao , . - . for paco , and . - . for ph. the correlation coeffiecient (r) between measurements from the two syringes was r= . for pao , r= . for paco , and r= . for ph. the cost of each sampling technique was . euros for preheparinized and . euros for self-prepared syringes, per sample. our data demonstrated a relationship between the results of the two sampling techniques, close enough, to justify the use of self-prepared heparinized syringes for arterial blood gas and ph measurements. a significant -fold cost reduction would result by the routine use of this latter technique. we checked the performance degree of the following measures in two stages, pre and post intervention: prophylaxis of pulmonary embolism (pe), elevation of the head of the bed to > degrees, intensive insulin therapy, lower tidal volumes in acute lung injury, daily trial of spontaneous breathing, daily withdrawal of sedation, stress ulcer prophylaxis and use of nimodipine in subarachnoid hemorrhage.the intervention consisted in the handing over of written information and talk on the therapeutics measures to the medical staff and to the nursing. conclusion: with only one diagnose, the system is unable to identifie the complex cases. the stay and most of the icu procedures, do not interfere nor modify the weight of the drg. dias f s , nagel f , wawrzeniak i , fonseca c , guerreiro m , froemming j , canabarro m general icu, hospital são lucas da pucrs, porto alegre, brazil there is no information regarding the impact of the resident in critical care medicine on the outcome of critically ill patients in our environment. we performed a comparative study between two periods in an icu, the first without ccmsp (pi) and the second with ccmsp (pii). we collected prospectively the following data: gender, age, apache ii and mods in days (d ), (d ) and (d ), prevalence of sepsis/septic shock, duration of mechanical ventilation (mv), use or renal replacement therapy and icu survival. between january and june , there were icu admissions, of which in the pi period ( ) ( ) and in the pii ( ) ( ) ( ) ( ) . after the implementation of a ccmsp, despite an increase in organ dysfunction in d and in prevalence of sepsis/septic shock, there was a significant reduction in the utilization of renal replacement therapy and mortality. these findings suggest that, the participation of a ccmsp medical resident was an important factor in the support of septic patients, reduction in renal replacement therapy and mortality. pachl j , haninec p , tencer t , tomas r , mizner p anaesthesiology and ccm, dept. of neurosurgery, charles university, rd school of medicine, prague, czech republic introduction: delayed cerebral ischemia due to vasospasm is a major cause of death and disability in patients after subarachnoidal hemorrhage (sah). the outcomes of several experimental studies designed to investigate an effect of nitric oxide donors on the treatment and prevention of this life-threatening condition appear controversial [ , ] . the purpose of our study was: ) to specify the influence of prophylactic subarachnoidal administration of sodium nitropruside (snp) on the incidence of vasospasm ) to determine the role of brain tissue monitoring-pbtio , pbtico and phbti, measured in the area of high risk of vasospasm, for management of snp administration. prospective observational study on patients with non-traumatic sah (hunt-hess grade i-iv) with secured ruptured aneurysma. in postoperative period all patients underwent triple-h protocol with calcium channel blocker. subarachnoidal preventive snp was administred in initial dose of mg by catheter which was inserted to basal cisterns during neurosurgical procedure. the timing of following dosage (period of or hrs) was directed by the changes of pbtio , pbtico and phbti after snp administration. snp administration did not exceed a period of postoperative days. the brain tissue respiratory values were estimated by codman neurotrend multiparameter sensor®. the blood flow velocity was simultaneously measured on circuit of willis by transcranial doppler sonography (tcd). in case of detected signs of vasospasm the dosage of snp was increased and maintained by monitoring modalities (tcd and values of pbtio , pbtico , phbti). : patients were enrolled. no brain infarction was developed in the studied group. all patients survived. the vasospasm was identified in two patients by tcd and simultaneously by changes of tissue respiratory values.these patients arrived at hospital with delay of several days from the beginning of symptoms. the overall outcome was good in out of patients including patients with vasospasm. preventive subarachnoidal administration of snp controled by tcd and brain tissue multiparameter sensor might increase the effect of triple-h protocol with calcium channel blocker. multimodal brain tissue monitoring could be the way to maintain titratable prophylactic snp administration. the therapeutical intervention requires considerable raise in doses frequency and its effect cannot be evaluated until now. basílio c , rio e , barbosa s , paiva j , mota a department of anesthesiology and critical care, department of neurology, hospital s. joão, porto, portugal the search for drugs to minimize neuronal lesions after prolonged seizures has been the goal of treatment of patients with status epilepticus. topiramate is a new anticonvulsant with multiple mechanisms of action: potenciation of gaba, blockade of glutamate receptors (ampa), inhibition of sodium and calcium channels. recent studies state that topiramate is effective in treating refractory status epilepticus and may reduce post-status epilepticus neuronal lesions. description of two clinical cases of patients, admitted in the icu, with status epilepticus refractory to conventional therapy were treated with topiramate. case : woman, years old, with a history of alcohol abuse and psychiatric disease was admitted with encephalitis and tonic-clonic seizures. the patient was treated during days with hidantin, valproate sodium and thiopental. despite this, the eeg showed a periodic epileptiform activity. topiramate ( mg daily) was added to valproate with clinical improvement and an absence of ictal discharges on eeg after days. case : male, years old, admitted with hematemesis, shock and eventual cardiopulmonary arrest. admitted in the icu for postoperative care of duodenal ulcer surgery. two days later, the patient developed partial status epilepticus. he was treated with midazolam, clonazepam and phenytoin. the eeg showed bilateral periodic epileptiform discharges with no recent cerebral lesions in the cerebral ct scan. pentobarbital coma was induced for seven days. status epilepticus persisted despite appropriate measures and on the th day topiramate ( mg daily) was added to clonazepam. after days, there was clinical improvement and eeg showed periodic generalized slow wave activity with motor response to painful stimulus wich was a prediction for a better outcome. in both cases, topiramate was able to induce clinical improvement and disappearance of ictal discharges in the eeg in case . however, in case the pattern of eeg persisted with signs of better prognostic. it needs further investigation with larger prospective series to better confirm the results. van tulder l , chioléro r , regli l , revelly j , berger m surgical intensive care unit, neurosurgical, university -chuv, lausanne, switzerland hypovolemia is deleterious in patients developing a vasospasm after subarachnoid haemorrhage (sah). fluid resuscitation to induce hypervolemia is considered by many as the cornerstone of management. the efficacy of this approach is however not established.the aim was to assess the effect of fluid resuscitation on blood volume and fluid balance during the initial phase of icu management for cerebral vasospasm after sah retrospective analysis of the database of a clinical information system (metavision, imd soft). patients with the diagnosis of vasospasm after sah (angiography) were studied. cardiac index (ci) and intra-thoracic blood volume (itbv) measured with transthoracic thermodilution (picco, pulsion) were determined as part of the clinical management. fluid supply consisted of isotonic saline. the value of mean arterial pressure (map), ci, itbv, as well as fluid supply and fluid balance at time , , , and hours were analysed (presented as mean±sd). comparisons between these time-points were performed with one-way analysis of variance for repeated measurements. p< . was considered significant. results: ten patients were studied. fluid supply amounted to . ± . l at h, . ± . at h, and . ± . at h (p< . ). initial map was ± mmhg, ci . ± . l/min/m^ , and itbv ± ml/m^ . there was no significant change over time for these variables, although itbv increased to ± at h, and decreased to ± ml/m^ at h. cumulative fluid balance amounted to . ± . l at h, . ± . at h, and minus . ± . at h (not significant), due to a diuresis. despite aggressive volume loading with normal saline, the fluid balance of patients with vasospasm was not significantly altered over the first hours of icu admission. these preliminary data suggest that, these patients may become rapidly resistant to fluid loading due to induced natriuresis. this escape phenomenon, may contribute to the absence of documented benefit of fluid expansion in vasospasm this was a prospective study design. all cases of sah(n= )of ages between to years which were admitted over a period of thirteen monthswere included in this study. aneurysm detection criterion was digital substraction angiography or ct angiography. mean hunt-hess grading in coiling group was , whereas in clipping group it was . .fisher grade was > in all patients clipped and between - in patients coiled. exclusion criteria included cases witha-v malformation, preexisting neurological deficit or where no intervention was done. outcome analysis was done using modified rankins scale (mrs) and world federation of neurologicalsurgeons gradingwfns).stastisticallyanalysed using chi-square and standard error of difference between two means-tests results: % aneurysms (n= ) were coiled and %(n= ) were clipped. there were no significant differences in age race, gender, but there was a significant difference in the hunt-hess grading ( ajderian s stepan , petrov n department of anesthesiology and icu, military medical academy, sofia, bulgaria background: the modulation of the intracranial pressure in patients with head injuries is important precondition in the optimizing of the therapeutic management. the goal of the authors is to study the influence of the hypocapnea over intracranial pressure as a part of complex treatment of the head injuries methods: : there are encompassed patients with head injury ct-scan data for brain contusion and perifocal edema who assessed according glasgow comma scale under pct. all patients had ventricle drainage placed in one of the lateral brain ventricles in order to measure intracranial pressure and received standard therapy. the patients divided in two groups: i -in patients we applied controlled hypocapnea with ???? value between - mm hg and ii group - patients with ???? values between - mm hg. statistical program was used -sd, tcriteria and p-value. we received significantly dropping of the intracranial pressure in patients set at artificial ventilation with moderate hypocapnea. in first group the mean value of intracranial pressure was . mm hg. in this group ( %) patients died. botsis p , litis d , nikolopoulou i , chatzivasiliadis h , ioannidou h icu, kat hospital athens greece, athens, greece acute pancreatitis and acute acalculus cholecystitis are frequent and serious complications in severely head traumatized patients. the aim of this study is to find if the early administration of somatostatin plays a role in the prevention of these complications. methods: brain injured icu patients ( men and women), with no abdominal or thoracic trauma, were entered the study. age +/- , apache ii score ≤ , gc +/- on admission, with no signs of preexisting gallstones in the u/s of the upper abdomen. surgical on conservative therapy for the brain injury, with drugs known not to interfere with the pancreatic and biliary system and early e.n. via nasogastric tube, was performed. after the admission in icu they were divided into two groups: a) at group a ( patients) somatostatin ( ?g/h) was added in the standard therapy for the next days. b) at group b ( patients), the standard therapy was continued, as planned. daily laboratory tests for: temperature, blood type, bilirubin, blood sugar, ca, alkaline phosphatase, serum-urine amylase, serum-lipase and daily clinical examination as well for: pain and tenderness of the abdomen, vomiting, distention, decreased bowel sounds. every second day an u/s of the upper abdomen was performed. at patients of group b ( %) and at patient of group a ( %) acute pancreatitis was developed the th day-of-stay in icu. at patients of group b ( %) and at patients of group a ( %) acute acalculus cholecystitis was developed as well at the same day. diagnosis of both complications was based on clinical and laboratory findings. early administration of somatostatin in brain injured icu patients diminishes the possibility of development of acute pancreatitis, but does not influence the development of acute acalculus cholecystitis in these patients. rijnsburger e r , girbes a r , spijkstra j j , peerdeman s m , polderman k h department of intensive care, department of neurosurgery, vu university medical center, amsterdam, netherlands hypothermia is widely used to improve neurological outcome in various types of neurological injury; however, this has not yet been well studied in patients with subarachnoid haemorrhage (sah), where cooling has been used mainly to prevent or treat vasospasms [ ] . hypothermia has been used to treat refractory intracranial hypertension in patients with tbi and severe stroke; however, its potential to treat cerebral oedema in patients with sah has not been well studied [ ] . only one small feasibility study dealing with this issue has been published, but here various interventions (such as induction of barbiturate coma and mild hypothermia) were applied simultaneously [ ] . thus it remains to be determined whether induction of hypothermia per se can decrease icp in patients with sah. methods: patients admitted with sah and refractory intracranial hypertension (icp> mmhg lasting longer than minutes despite prevention of hypovolemia or induction of hypervolemia, induction of hypertension, and treatment with nimodipine, mannitol and hypertonic saline, and following coiling or clipping of the cerebral aneurysm) were treated with induced hypothermia ( - oc) according to a protocol guided by icp. hypothermia was induced using cooling blankets and infusion of refrigerated fluids. target temperatures were achieved within (range - ) minutes. icp decreased from . ± . to . ± . (normal value: < mmhg). icp< mmhg was achieved in / patients; in / patients icp decreased but remained at levels between - . hypothermia was maintained until normal icp had been observed for hours, after which patients were slowly rewarmed (again guided by icp). hypothermia was maintained for an average of ± hours. no patients died during treatment with hypothermia. two patients ( . %) died in the icu after hypothermia was discontinued; ( . %) died in the subsequent months. good functional outcome at months (glasgow outcome score - ) was achieved in patients ( . %). previous studies had reported a high incidence of side effects such as pneumonia in patients treated with hypothermia. we observed no increase in infectious problems, perhaps because our patients were treated with sdd. conclusion: induced hypothermia can be safely and effectively used to treat refractory intracranial hypertension in patients with sah. vasospasms and intracranial hypertension are thought to be the two key factors in the development of additional brain injury in sah; however, it remains to be determined whether this treatment also improves neurological outcome and survival in these patients. to evaluate the usefulness of magnetic resonance images (mri) in patients suffering from severe brain injury, unfavourable clinical progress and marshall brain scans types i and ii. fifteen patients with severe brain injury were retrospectively studied, considering their age, gender, initial gcs initial head scans and mri upon admission to intensive cares unit (icu), their outcome (gos) at discharge form icu. mri level i was defined as being when the subcortical white matter was affected, mri level ii being level i plus affectation of the corpus callosum, and mri level iii was defined as being mri-ii as well as damage to the brain stem and spinal cord. gos was also evaluated, defining gos i-ii as positive and gos iii, iv and v as negative. the average age of the patients studied was . years old. nine ( %) were males and six ( %) were females. the average gcs on admission was . . five patients ( %) had and initial marshall scan type i and ten ( %) had marshall scan type ii. two patients ( . %) showed mri-i, five ( %) mri-ii and eight ( . %) mri-iii. in the two patients with mri-i their initial gcs was . and both progressed favourably and were discharged from intensive care unit. the five patients with mri-ii had an initial gcs of . three of these ( %) did not progress well. in the eight patients with mri-iii, the initial gcs was . . seven of these ( . %) progressed unfavourably when discharged from intensive care. magnetic resonance images are related to the severity of head damage and have a high diagnostical and prognostical value for use with patients suffering from diffuse axonal lesions. pakulski c , badowicz b , bak p , kwiecieñ k , mikulski k , surudo t department of emergency medicine, pomeranian medical university, szczecin, poland, intensive care unit, regional hospital, pasewalk, germany, traumacentre, pomeranian medical university, szczecin, poland the management of patients with severe head injury should include monitoring of mean arterial pressure (map) and intracranial pressure (icp), cerebral perfusion pressure (cpp) and levels of jugular bulb oxygen saturation (sjo ). the aim of the study is to present the outcome in patients with severe central nervous system injuries treated in the traumacentre, pomeranian medical university. this retrospective study evaluates the methods of treatment in patients with severe brain injury treated between july st, and december st, in the our traumacentre. these patients were admitted to our institution directly from the accident sites or from the referring hospitals during the first post-injury day. glasgow coma score of or less was the inclusion criterion. in all patients map and icp values were monitored, cpp values were calculated, and additionally in patients sjo values were measured. the initial treatment protocol was always the same: analgosedation (fentanyl, midazolam), normoventilation, osmotic diuretics (mannitol , - , g/kg/day in doses and furosemide , - , mg/kg/dose in doses), supine position. the protocol was modified with regard to map, icp and sjo values (brain ischemia or brain hyperemia). the patients with increased icp values resistant to osmotic diuresis were scheduled for unilateral or bilateral decompressive craniectomy. the results of treatment were evaluated with glasgow outcome classification after months following the injury. the mortality in our ample was , % - deaths out of treated patients. isolated brain injury was the cause of death in patients, and in patients-multi-organ injury. sixty seven ( , %) patients were transferred from the trauma icu for further treatment to other wards. out of the patients discharged from the trauma icu patients died -goc ( , %), none of the patients were in the neurovegetative state -goc ( %), patients with persistent aphasia or hemiparesis were classified as goc ( , %), patients with mild neurological deficits that didn't impair their social life were classified as goc ( , %), and finally patients without any neurological sequelae were classified as goc ( , %). out of patients with treatment modified according to sjo values patients survived. brain hyperemia was found in non-survivors and severe brain ischemia was found in non-survivors. the outcomes in our patients treated with the protocol based on monitoring of cpp and sjo are encouraging. monitoring of sjo is a significant element of the modern treatment protocol for patients with brain injury and the best method of diagnosing both hyperemic and ischemic episodes. anastasiou e , tsaousi g , giannakou m , efthimiou k , geka e , albanèse j , boyadjiev i , chaabane w , antonini f , leone m , martin c intensive care and trauma center, hopital nord, marseille, france in severely head-injured patients, it is often needed to add vasopressive amines to maintain adequate cerebral perfusion pressure (cpp). norepinephrine (n) and dopamine ((d) are proposed, but their vasoconstrictive effects may be deleterious for regional circulations.objective is to compare the effects of d and n on cerebral, splanchnic, and renal circulations when used to raise cpp after severe head injury. prospective, randomized, cross-over study including patients with head trauma, requiring intracranial pressure (icp) monitoring and vasopressor therapy. after and min of administration of d or n, were studied : systemic hemodynamics (mean arterial pressure (map), cardiac index (ci), central venous oxygen saturation (svo ), cerebral circulation (icp, cpp, transcranial doppler : mean velocity in the middle cerebral arterey (vmca)), splanchnic circulation (gastric intramucosal ph (phi)), renal circulation (urin flow (uf), creatinine clearance (clcreat) and metabolic data (energy expenditure) (es), oxygen consumption (vo ), and lactate (lac)). the wilcoxon signe test was used with p< . considered significant. they are presented in table . no significant differences were observed in systemic hemodynamics when the two drugs were compared. none of the studied local circulation were altered with any of the studied drugs. vakalos a , doukelis p , kareklas m , setzis d , matamis d i.c.u, papageorgiou general hospital, thessaloniki, greece in patients with severe head injury the main complication is cerebral edema and intracranial hypertension that may cause cerebral ischemia, disability and in certain cases brain death. transcranial doppler (tcd) is a non-invasive, bedside technique which detects the blood flow velocities in the great intracranial arteries. the aim of our study was to investigate if there is a relationship between tcd findings and the outcome of patients with severe head injury. methods: patients with severe head injury (gcs< ) were included in our study. from these patients were males and females. their mean age was . years, with a range from to years. among these patients died in the icu ( . %). in each tcd examination we measured the maximum, mean and the end diastolic velocity (vmax, vmean and vmin respectively), and we calculated the pulsatility index (pi). the patient's outcome was recorded at the disharge from the icu according the glasgow outcome scale as following: good recovery (gr), moderate disability (md), severe disability (sd), persistent vegetative state (pvs) and death. the patient's outcome was compared with the cerebral flow velocities and the pi index. there was a statistically significant difference in the mean values of all velocities between the outcome categories of the patients. we found the stronger difference in the mean values of vmax and vmin between the death and the categories pvs and sd, and in the mean values of vmean between the death and the categories pvs, sd and md. inter-hospital transfers of the critically ill patient raises important medical and ethical dilemmas . in a transfer questionnaire assessed the views of intensivists in scotland, regarding the problem, that when no intensive care bed is available, is it ever acceptable to transfer an existing patient to another facility to create a bed for a new referral . % of scottish consultants would not transfer a stable patients to create space for a new patient under any circumstances. reasons given included no intrinsic benefit to the current patient and that there was a designated transfer team who were experienced in transferring critically ill patients and providing critical care without walls. this time the questionnaire was repeated among intensivists in south thames to determine any regional variation. the questionnaire was sent to consultants in intensive care units (icus). consultants were asked if they would ever consider transfer of an existing patient to another hospital in order to admit a new referral and if so what would they consider the most compelling reasons for doing so.we also asked whether or not formal consent was sought prior to undertaking a transfer and what risks, if any, were explained to the patient and their family. prior knowledge of their wishes regarding this form of therapy is essential in order to preserve their autonomy. objective: to examine the knowledge of copd patients related to the illness, about mechanical ventilation as a potential treatment and their wish to participate in the health care decision-making process and advanced care planning. methods: a qualitative research of an intentional sampling of homogeneous subgroups with copd outpatients (ii and iii by gold score) was performed between november and march in an ambulatory setting by means of semistructurated interviews and later content analysis with a sample size defined by saturation criteria. : male outpatients with copd were interviewed (age range from to years). they feel to be correctly informed and trust their respiratory physician or family doctor, but in most cases there have not been prior discussions with the health care team concerning mv as a potential treatment of their disease. they consider themselves to have a good quality of life although their health is not good. they are interested in participating in the health care decisionmaking process. in case of treatments and cares as mv or admittance to an intensive care unit they accept any option that keeps their usual quality of life at the same level. this sample of copd patients are in favour of advanced care planning and show the aim to shape their own specific advanced directives. conclusion: patients with copd do not have enough information to take autonomous decisions. although mv is a potential treatment for copd patients with acute exacerbations, most of them were unaware of mv as a possible treatment option for them because discussions about this topic occur infrequently between physicians and patients. they are in favour of participating in health care decision-making with physicians and accepting any therapy that makes them able to keep their quality of life. the patients consider advanced directives as an opportunity to express their preferences in order to be considered when they are not able to communicate with the health care team. conclusion: wh/wd in ireland is common ( %) and similar to european practice( %). there was no sdp although the prevalence was % in europe. the increased use of sedation ( %) in association with wd suggests an awareness of patient comfort. despite only one advance directive, patient wishes were known in %. icu physicians were the primary initiators of eol discussion ( %) suggesting their important role in icm practice. the majority ( % v %) of eol decisions were taken during 'office hours'. this is finding warrants further study; it may represent the inexperience of on call personnel or may reflect the complexity of the decision. despite popular opinion extubation is infrequent and comfort measures tend to be continued. an anonymous questionnaire including questions was sent out to all staff mebers including medical staff, nurses and physiotherapists. questions included potential benefits to staff and patients and concerns regarding the use of restraint. of the questionnaires sent out, were returned completed. most respondents ( , %) felt that sedative drugs are used as a form of restraint in care of the patients. most ( , %) thought there is a place for physical restraint in critical care and that it might benefit patients, ( %) believed it might benefit staff but ( %) of responders had concerns regarding the use of physical restraint. a majority ( %) stated that concerns would be answered if undertaken as part of a clear unit policy. responders ( %) would be happy to use physical restraint with sedation to ensure patient's safety, but only ( %) would agree to its use if they were a patient. the majority of responders ( %) felt that some form of physical restraint may be appropriate. practice should be re-examined and consideration given to the use of some physical restraint in addition to sedative drugs. in some patients shock is so severe that extremely high doses are needed to elevate their blood pressures. studies show that % of icu physicians withhold or withdraw vasopressor administration because patients did not respond to "maximal" therapy. however the "maximal" dosage of vasopressors is not defined so each physician has his/her own limit as to the highest dose of adrenaline or noradrenalin that he/she will administer to a patient. many icus physicians order doses of up to mg of adrenaline or noreadrenalin per hour ( mg/kg/hour) we hypothesize that this dose is futile. following helsinki approval, all intensive care charts from were reviewed ( patient charts patient days) patients were found to have received a vasopressor. demographic data as well as apache ii scores, icu days and total hospital days, biochemistry, liver functions, blood gases, diagnoses and secondary complications were recorded. vasopressors, adrenaline and noradrenalin, maximal doses , initial dose, number of days/hours patient received all subsequent doses, and mortality were recorded. the data showed that all patients who received more than microgram per kilogram per minute of adrenaline or noradrenalin died. (p value < . ). the length of time that the patients received vasopressors had no influence on survival. these data showed a direct correlation between the number of days a patient received vasopressors and the length of hospitalization. the length of time a patient received low dose of vasopressors had no significance on mortality, but the vasopressor dose had an indirect association with survival. there was no significance difference in age between survivors and non-survivors. the elderly (over years of age) and the young had the same of survival rates when receiving vasopressors. patients who received more than microgram per kilogram per minute of noreadrenaline or adrenaline died. it thus appears that therapy with such high doses is futile. th annual congress -berlin, germany - - october s ehrmann s , mercier e , bertrand p , dequin p medical intensive care unit, department of biostatistics, bretonneau university hospital, tours, france to carry on indefinite invasive treatments in the intensive care unit for patients with a high probability of death in the short term, is ethically objectionable. on the individual level it extends the agony and suffering of the patient and on the community level it consumes precious limited resources. as there is no tool that can objectively and reliably help the physician to make ethical decisions of therapeutic limitations, we examined whether the absolute change of the lod score between the day of admission to the icu and the third day of unlimited treatment could be predictive of death in the icu. methods: consecutive patients admitted to the icu were prospectively included during a three-month period. for all of these patients the simplified acute physiologic score ii (saps ii) and the lod score (lod ) were calculated on the day of admission. the lod score was calculated again between the nd and the th hour in the icu (lod ) for the remaining patients ( patients left the icu before the nd hour, of whom died) without exclusion criterions ( therapeutic limitations before the nd hour). the endpoint was death in the icu. the performance of the deltalod = lod -lod index to predict death was examined through univariated and multivariated analysis and through calculation of the positive predictive value of death (ppv) for different cut-offs. after hours of unlimited treatment in the icu, deltalod appears to be a good predictor of death in the icu, independent of the initial severity of disease. the ppv is not high enough even for high cut-offs to assist with making individual therapeutic limitation decisions. accordingly to the bayes theorem, the performance of deltalod deserves to be evaluated in a population of patients exhibiting greater severity of disease. developed as an answer to the stressful everyday practice. indeed, in icu, the caregivers are under a great pressure induced by several factors: the explicit urgency to act, the implicit burden to face patients and families in critical situations and the requirement of a high level of technicity. such a creative workshop was set up for physicians and nurses in our unit, in order to give the opportunity to express the "unspoken", to share the experiences, explore the patient's perspectives. methods: sessions of hours were planned. at the first session, the participants were proposed to imagine a situation starting from one of pictures of icu patient. they were invited to write as "i" or "you" in order to take the patient's or the relative's place through their imagination. the written texts were distributed to all participants and discussed at the second session. the workshop was organized and moderated by a senior specialist in intensive care medicine and the person in charge of the medical humanities teaching program. the participation to the workshop was optional. : physicians ( m, f) and nurses (all f) and ( f, m) medical students participated to workshops. one month later, they answered a questionnaire. all participants gave a positive global appreciation and underlined the importance of the discussion which allowed the sharing of their experiences. felt encouraged to adopt the patient's perspective, were reassured about their feelings of their practice. the relevant themes of the texts were the behaviour of the caregivers, the abrupt change of worlds, a strange perception of time, the importance of noises in the icu environment. despite the similarity of the themes, the way the narrators shaped the story was very different. the author's selection of words, details, and literary devices confers the personal touch of his/her experience. none of them considered the writing as an obstacle to their expression, even if they first felt difficult to step in the writing process. all of them were satisfied with the workshop and with the sharing of their experiences. the most important point reported was the awareness that the others, either physician or nurses, had the same preoccupations and feelings. the fact that this workshop did not give any concrete recipe for the resolution of problems induced some frustration among icu caregivers. there have been few studies to investigate how well the results obtained by co rebreeding to assay cardiac output (co) ( - ). a reliable non-invasive co monitor could enhance patient safety and reduce risk. this study evaluates a nico measurement and calculated derived parameters from co. co was based on differential from of the co fick equation. twenty three co measurements with derived parameters were obtained from male patients admitted to a medical intensive care unit, st vincent hospital, medellín, colombia, . the nico monitor (novametrix medical systems inc) was connected between the ventilator circuit and tracheotomy tube. previously, multilumen swan-ganz thermodilution catheters, edwards labs were placed into the external jugular vein via an introducer sheath. co was calculated from pulmonary blood flow by correcting for shunt. the difference between consecutive thermodilution and nico measurements was calculated. also, calculated derived parameters from s-g catheter such as ci, svri, lvswi, rvswi, and svi were compared to measurements derived from nico. on nico measurements, central venous pressure replaces the value of pcwp. correlation between the two methods was determined by pearson´s correlation. a bland-altman analysis was used to compare the bias and precision of the two methods, and a difference > % was considered as a limit of accuracy. significance was assessed at the % confidence interval. twenty-three matched pairs of consecutive changes in co and calculated derived parameters measurements were recorded in three critically ill patients. with a mean (±sd) age of , y. relationship between changes in thermodilution and nico co measurements was significant (r = . , p = . ). none of calculated derived parameters (ci, svri, lvswi, rvswi, and svi) were considered significant. only co and rvswi showed difference between means to compare the degree of agreement measurements (co . % and rvswi . %% respectively). the results of the current study agree with those from previous studies where is suggested that nico monitor would provide a good alternative to invasive co measurements on critically ill patients. however, nico cannot be a substitute to get calculated derived parameters when pulmonary artery occlusion pressure is a necessary value. (std) has been demonstrated to be sufficiently accurate for estimation of intrathoracic blood volume (itbv) and evlw when compared with the clinical standard, i.e., transpulmonary thermo-dye dilution (tdd) [ ] . in this study, we examined the reliability of std for estimation of itbv and evlw with respect to several influencing factors. we retrospectively analyzed data of critically ill patients patients ( male, female; age - , mean ± years) who underwent extended hemodynamic monitoring by the transpulmonary thermo-dye dilution technique. the agreement between itbvstd/ itbvtdd and evlwstd / evlwtdd was determined as mean bias and standard deviation (sd) within different categories (level of peep, pao /fio ratio and evlw). linear regression analysis was applied to compare overall bias between evlwstd and evlwtdd with the different factors. : mean bias ± sd within the different categories are shown in the clinical judgement of an adequate volume status in critically ill patients remains a challenge. current clinical parameters to assess the adequacy of resuscitation often do not adequately reflect the volume status of the patient. therefore additional information about the adequacy of circulating blood volume in critically ill patients could be of great value. on occasions in critically ill patients on a surgical intensive care unit the adequacy of circulating blood volume (bv) was clinically judged by the parameters central venous pressure, mean arterial blood pressure, heart rate, and urine production. clinically estimated blood volume was compared with measured blood volumes using pulse dye densitometry with indocyanine green (ddg- a/k, nihon kohden, japan). obtained bv measurements were categorized in low blood volume (lbv), normal blood volume (nbv), and high blood volume (hbv) using reference values for men and women - ml/kg and - ml/kg respectively( ). clinical judgements led to hypovolemic (hv) versus not hypovolemic (nhv) cases. there was no statically significant relation between the clinical judgement of volume status and measured bv. in hv patients no lbv was measured and in clinically nhv patients lbv as well as hbv were measured. no significant correlation between measured bv and calculated fluid balances was found. conclusion: there seems to be a discrepancy between the clinical judgement of circulating blood volume and the measured circulating blood volume in critically ill icu patients. these results emphasize the difficulty of judging the volume status by current clinical parameters in critically ill patients. schütz n , romand j a , stotz m , gerard i , bendjelid k apsic, geneva university hospitals, geneva- , switzerland we recently demonstrated the accuracy of a new miniaturized transcutaneous sensor (tosca monitor, switzerland) to monitor non invasively paco (tcpco ) in white skinned patients [ ] . the objective of the present study is to analyse the same accuracy in a subgroup of dark skinned patients. eight post operative patients (mean ± ) were included. tcpco sensor was applied at the ear lobe. the simultaneously obtained tcpco and paco values (measured using a blood gas analyser) were compared by linear regression analysis. the difference between paco and tcpco values were compared using the method of bland and altman. : paired measurements were correlated. tcpco correlated with paco (r = . , p< . ) in the paco range . to . kpa. the mean bias between the two methods was . ± . %. our results demonstrate that skin pigmentation affects slightly the accuracy of the sensor. ( ). in critically ill patients it is difficult to gain knowledge of the intravascular volume using the conventional clinical parameters such as mean arterial blood pressure, central venous pressure (cvp), heart rate and urine production. new insights in the assessment of hemodynamics such as central venous saturation (svo ) and blood volume (bv) monitoring may give additional information of a patient's intravascular volume status. methods: blood volume measurements were performed in critically ill icu patients on occasions using pulse dye densitometry with indocyanine green (icg)(ddg- a/k, nihon kohden, japan). blood volume measurements were compared with the parameters svo and cvp in assessing the patient's intravascular volume status. also the relation between bv and albumine and colloid oncotic pressure (cop) was investigated. th annual congress -berlin, germany - - october s hofmann d , sakka s g anesthesiology and intensive care medicine, friedrich schiller university, jena, germany introduction: patient management guided by extravascular lung water (evlw) is associated with reduced mortality of patients with pulmonary edema [ ] . recently, single transpulmonary thermodilution (std) has been demonstrated to be sufficiently accurate for estimation of intrathoracic blood volume (itbv) and evlw when compared with the clinical standard, i.e., transpulmonary thermo-dye dilution (tdd) [ ] . in this study, we examined the reliability of std for estimation of itbv and evlw with respect to several factors of pulmonary function. we retrospectively analyzed data of critically ill patients patients ( male, female; age - , mean ± years) who underwent extended hemodynamic monitoring by the transpulmonary thermo-dye dilution technique. the agreement between itbv std / itbv tdd and evlw std / evlw tdd was determined as mean bias and standard deviation (sd) within different categories (level of peep, pao /fio ratio and evlw). linear regression analysis was applied to compare overall bias between evlw std and evlw tdd with the different factors. mean bias ± sd within the different categories are shown in acute-on-chronic (aoc) liver failure but data on the use of this procedure is yet scarce. we communicate our experience after centralizing all the procedures of our centre in the icu data of all treatments performed in our centre (liver transplant program; icu with continuous renal replacement therapies -crrt-experience; a unique protocol for surgery, hepatology and icu patients and a prospective registry). alf patients stay in the icu but aoc patients are admitted every other day for the procedure. mars is performed with a prisma monitor and sessions are aimed for a length of al least hours if feasible (in alf continuously with h changes). we analysed clearance, metabolic control, tolerability and technical and clinical complications. we used pearson correlation coefficient and linear regression analyses to detect relation between hours of treatment and clearance capabilities electrical impedance tomography (eit) is a promising technique to assess continuously respiratory function with high temporal resolution . changes in thoracic gas volume lead to corresponding changes in thoracic impedance. the aim of this study was to evaluate air distribution during volume controlled mechanical ventilation. five adult patients undergoing elective thoracic surgery with single lung ventilation were included. eit data were collected during ventilation of both lungs (tidal volume (tv): ml), left lung (tv: ml), and right lung (tv: ml), respectively. eit was performed using electrodes placed around the thorax. data are presented as percent of impedance change of both lungs (normalized electrical impedance (nei)). during one lung ventilation nei was reduced to . ± . in right lung and . ± . in left lung compared with both lungs with a clear separation between ventilated and nonventilated lung. in addition we found an imbalance of distribution of ventilation along the vertical axis in favor of the ventral part of the lungs (fig. ) . conclusion: eit seems to be a sensitive non-invasive method for monitoring distribution of ventilation. the use of pet in adults with tma has dramatically improved outcome. resistance to pet, which is observed in / of such patients and may affect mortality, remains however incompletely understood. we retrospectively studied adults with tma treated by pet in our unit to evaluate the short and long term outcome and to identify predictive factors of mortality and of resistance to pet. all records of adults with tma treated by pet between and were reviewed. tma associated with bone marrow transplantation were excluded from the study. age, sex, cause of tma were collected. glasgow and sofa scores were estimated at the admission. clinical data including: neuroligical or pulmonary disorders with mechanical ventilation (mv), renal failure, and therapeutic delay (td) to pet; biological data including: hemoglobinemia, platelet count, and ldh; plasmatic volume exchange per procedure and number of plasmapheresis sessions were also collected. mortality was assessed at one month and at one year follow-up. all data were analyzed and compared between survived/deceaded and between responders/nonresponders (r/nr) patients. : females and males were included. mean age: . ± . yo, mean glasgow coma score: ± , mean sofa score: . ± . . etiologies of tma: post-immunologic , post-infectious , post-neoplastic , drugs associated , idiopathic . two patients were in mv, underwent hemodialysis and had at least two organ dysfunction. the mean td for pet was . ± . days and the mean plasmatic volume exchange per procedure was . ± . ml/kg. patients ( %) partially or fully responded to pet. patients ( %) survived after one month and ( %) after one year follw-up. the comparison between survived and deceaded patients showed that response to pet ( / vs / responders respectively) was the only significant determinant parameter. the comparison between r and nr showed that a longest td ( . ± . vs . ± . ) and neoplastic cause of tma ( / vs / ) were significantly discriminant for a non-response to pet. almost all of the r patients ( %) exhibited a positive response to pet before the tenth plasmapheresis session. in a median follow-up period of , ( - ) months, relapses episodes occured in patients ( %). adults with tma, characterized by a mild to important severity, treated by pet have a relatively good outcome since survival reached % at month and was maintained at % after year follow-up. among the parameters studied, lack of response to pet was the only predictive factor of mortality. two factors were predictive of resistance to pet: neoplastic etiology of tma and a longer td to pet. adult with tma non-responding to pet after the tenth plasmapheresis session could be considered as totally non-responder and should benefit shortly from another therapy. ) . additional in-formation can be gained by visual conditioning of large data sets. we report a novel approach on data inter-pretation by visualizing the gastric tonometry values in a case of necrotizing pancreatitis and septic shock and the correlating clinical events ( ( y., male, apache ii score , measurements, days running). pgco was measured every min. with a gastric tube (trip, ngs catheter) and an automatic gas analyzer (tonocap, finland). we recorded these values continuously and calculated the frequency distribution in an h interval and in an area between and mmhg (increment ). this histogram was displayed as a contour-plot. in that kind of visualization the frequency is displayed as colour in the area and not as third axis in a graph. our form of data processing provides additional information on pathological patterns at an early stage. in context with other parameters, this can be helpful in guiding treatment, e.g. volume substitution, catecholamines or blood transfusion. in this case we can see episodes of normal tonometric values as well as periods of pathological patterns like periods of septic shock (t , t ), daily abdominal lavage in a period of severe sepsis (t ), major abdominal surgery (t ), unsuccessful trials of enteral feeding (t ), successful enteral feeding (t ), weaning period and extubation (t ). the graphical presentation of the frequency distribution of a large number of data easily allows to conceive the information of the data. the aim of future activities has to be the development of a real-time bedside display of the progress of changes in the measurement of pgco -values. our study population consisted of patients undergoing elective cardiac surgery (n= ). blood samples for tnf alpha mrna were taken preoperatively (baseline), hr and hrs postoperatively. total rna was extracted from purified peripheral blood mononuclear cells (rneasy, qiagen). we utilised real time rt-pcr to quantify tnf alpha gene expression after cardiac surgery using abi prism sequence detection system and normalised against an endogenous reference gapdh. the patients were divided into two groups: group a: eighteen patients who developed complications post surgery as defined by i) hypotension requiring inotropes (n= ) ± intra-aortic balloon pump counterpulsation (n= ) and /or ii) lactate > mmol/l (n= ). group b: control group of patients with an uneventful postoperative course (n= ). statistical analysis was performed using the kruskal-wallis test. ischaemia of the colon is a recognised but infrequent complication following cardiac surgery. colonic ischaemia is thought to lead to a disruption in the intestinal barrier and this has been implicated in the progression to the systemic inflammatory response syndrome (sirs) with some patients going on to develop multi-organ dysfunction syndrome (mods). little is known of the early pathophysiological processes occurring in the colon during cardiac surgery. thus, the aim of this study was to investigate the early histological changes within colonic mucosa and cytokine release during cabg surgery. methods: patients undergoing coronary artery bypass surgery ( on-pump, off-pump) were prospectively recruited. mucosal biopsies of the sigmoid colon were obtained after induction of anaesthesia and immediately at the end of the procedure. microscopic examination was performed using haematoxylin and eosin staining. peripheral blood was assayed intraoperatively for cytokines il- and il- and for up to hours post-operatively. on-pump surgery produced a . -fold increase in columnar epithelium apoptosis. no other histological changes occurred. there was a -fold rise in il- in both two groups intraoperatively. post-operatively, il- continued to rise to -times baseline levels in contrast with the off-pump group which remained at intra-operative levels. il- did not change significantly in the off-pump group. in the on-pump group there was a fold increase in il- associated with initiation of cardiopulmonary bypass (p< . student's t-test). post-operatively, il- levels returned to baseline levels. apoptosis of colonic mucosa occurs during on-pump cabg but not in offpump cabg. this precedes the inflammatory process. thus, we identify apoptosis, rather than necrosis, as the principal mode of cell death following on pump cabg surgery. further elucidation of this process may identify targets for pharmaceutical prevention colonic mucosal apoptosis. cabello b , rubio o , delgado m , vera p , mancebo j intensive care, hospital sant pau, barcelona, spain liberation from mechanical ventilation can be interfered by the development of congestive heart failure (chf). this issue has been poorly studied as a cause of weaning failure. we designed a clinical-physiologic study to analize the mangnitude of the problem and its physiological characteristics. during a two months period we daily screened all the intubated mechanically ventilated patients in our -bed icu looking for those who meet usual weaning criteria. these patients went on a t-piece trial (sb) during minutes. patients who presented respiratory distress were studied with esophageal-gastric balloon and a swan-ganz catheter. hemodynamic and respiratory measurements were collected in assist control ventilation (acv), pressure support (ps) of cm h with peep of and again sb. we defined chf when the pulmonary wedge pressure (pcwp)was normal during acv and above mm hg during sb. unsuccessful extubation in copd patients is associated with increased morbidity and hospital mortality, and accurate prediction of post-extubation acute respiratory failure (arf) is potentially important. our hypothesis was that two parameters i.e., the airway occlusion pressure at . s (p . ) and the expiratory flow limitation (efl) determined by applying a negative expiratory pressure (nep) during tidal breathing, both recorded repeatedly after extubation, could be good indicators of postextubation arf in copd patients. copd patients were included prospectively after extubation. a specially devised system (micro ; medisoft , dinan, belgium) was used to measure efl and p . . each patient was placed in half sitting position and breathed spontaneously. after stabilization of the patient, a nep of - cm h o was applied at the beginning of expiration and maintained throughout the ensuing expiration. the test breath was the breath during which the nep was applied, and the preceding expiration served as control. five test breath separated by periods of quiet breathing were recorded. the expiratory flow-volume loops generated with nep were compared by superimposition with those obtained during the immediately preceding breaths. the portion of the tidal expiration over which there was no appreciable change in flow with nep was considered as flow-limited and was expressed as a percentage of the expired control tidal volume (%vt). the module of nep was replaced by that allowing to measure the p . . five measurements of p . were made, spaced by at least seconds. gas exchange, p . and efl under nep were measured at the st , th, th and th hour following extubation. if a limitation of flow was evidenced at a given time, the subsequent measurements were not carried out. post-extubation arf was defined by a respiratory rate of more than per min, a respiratory acidosis with a paco > . mmhg and a ph lower than . without metabolic acidosis. to date, patients have been included. heighteen of them ( %) presented a elf at ± hours following extubation. nine patients presented an arf at ± hours in post extubation. these patients had a elf and a p . significantly higher than those without postextubation arf (respectively . ± . % vs. . ± . %; and . ± . cm h o vs. . ± . cm h o; p < , ). seven patients ( %) did not have elf and did not present arf in post extubation. conclusion: elf by nep and p . are easily measured in the period following extubation in copd patients. this preliminary report seems to demonstrate that p . and efl, measured precociously then repeatedly after extubation, could be good indicators of postextubation arf in copd patients. serebriysky i i , galstian g m , gorodetsky v m . intensive care unit, national centre of hematology, moscow, russian federation acute respiratory failure (arf) is the most frequent and serious complication in patients (pts) with hematological malignancies. respiratory insufficiency in this group of patients can be caused by a combination of increased vascular permeability, heart failure and liquid overload. the aim of this study was to analyze the effects of colloid replacement therapy in pts with hematological malignancies and arf. we examined pts with acute leukemia, complicated by sepsis and arf (bilateral radiographic infiltrates, pao /fio = ± ). three of them had pawp> mmhg, respectively , and mmhg. all the patients received infusions of % albumin (a.). the first infusion of ml was carried out during minutes, later the speed was ml/ min. we measured extravascular lung water index (elwi), pulmonary vascular permeability index (pvpi) by picco-plus (pulsion, germany), central hemodynamics parameters by swan-ganz catheter. in the first group that received a. in doses of . ml/kg ( pts) there were no significant changes in ci, pawp, elwi, pvpi, apart from pt ( st pt, see should critical illness polyneuropathy (cip) itself prolongs mechanical ventilation or whether this prolongation is the effect of concurrent risk factors for weaning failure is a matter of debate. our primary objective was to evaluate the impact of cip on the length of mechanical ventilation after controlling for coexisting risk factors for weaning failure. we also set out to assess the impact of cip on the length of the stay as well as to determine the costs associated with this neurological complication. a prospective cohort study. setting: icu of a tertiary hospital. patients: all patients with severe sepsis or septic shock that required mechanical ventilation for at least days who were considered ready to discontinue mechanical ventilation. patients underwent a neurophysiologic evaluation at onset of weaning from mechanical ventilation. gianesello l , pavoni v , paparella l , gritti g dept. of critical-medical surgical area, section of anaesthesia and intensive care, florence, italy extubation failure (ef) has an important effect on length of icu and hospital stay,icu and hospital mortality( ).ef can occur secondary to upper airway obstruction or to an inability to manage respiratory secretions a cause of laryngeal dysfunction (ld) and ineffective cough.ld can result from depressed mental status or local trauma after intubation.pre-admission functional status can also delay post-estubation swallowing impairment in critically ill elderly patients( ). over a -month period patients who needed reintubation after successful trial of weaning and planned extubation, in a polyvalent intensive care unit (icu) were identified.data including clinical features (age, sex, saps ii on admission, glasgow coma score (gcs) on day of extubation, type of patient, length of intubation and mechanical ventilation (mv) before extubation, length of icu stay (los), icu and hospital mortality) were collected.moreover we considered two parameters that asses airway patency and protection like predictors of ef:cough strength and suctioning frequency after extubation.cough strength on command was measured with a semiobjective scale of to ( = weak cough, = strong cough). ( / )( . %), pulmonary embolism( / )( . %)and severe sepsis( / )( . %).seven of patients who received reintubation a cause of defective airway manage needed at least one suctioning every two hours; moreover the same patients and other three with alteration in neurological function had weak cough (grade to ).the los of ef patients was ± . days, their icu and hospital mortality were . % and . %, respectively, both higher when compared with not reintubated patients.results of logistic regression showed that saps ii is the only independent risk-factor of reintubation (odds ratio . , sig. . ),while age, type of admission,length of intubation and gcs seem to do not influence ef.data were analysed using the spss . for windows. conclusion: ef can depend from defective airway protective mechanisms due to alteration in consciousness or glottic incompetence.this event influences negatively los and outcome.severity of illness is the only independent risk-factor. over a year-period, patients with dild ( males; age: ± years; saps ii: ± ) were retrospectively studied. among them, patients were immunocompromised and patients sustained complications attributable to the procedure: airleak (n= ), pneumothorax (n= ). the median duration of the chest tube drainage was ± days (range: to days). both the pao /fio ratio and mean level of peep were comparable before and hours after the olb (table ) . no patient died in the perioperative period. olb allowed to establish a diagnosis in patients ( %). in patients ( %), the dild was idiopathic (table ) . in patients, histologic diagnoses obtained from olb were not suspected clinically or by radiological investigations: invasive pulmonary aspergillosis, diffuse amyloidosis, methotrexate lung toxicity. ± ± peep level (cm h o) ± ± idiopathic interstitial pneumonia diagnosis uip aip* boop n. of patients *: acute interstitial pneumonia (ards) conclusion: in ventilated patients, olb can be performed with acceptable morbidity at bedside in the icu. in this study, olb established a definite diagnosis in % of patients and corrected the clinical and radiological diagnosis in % of the cases. fonsato v , mariano f , triolo g , camussi g , nederlof b , tetta c laboratory of renal immunopathology, university of turin, unit of nephrology and dialysis, cto hospital, turin, italy, department of research, fresenius medical care, bad homburg, germany introduction: high porosity membranes may enhance cytokine elimination by convection and also diffusion. however, there is need to balance the high permeability between cytokine removal and a clinically acceptable loss of plasma proteins. here,we studied the sieving coefficients (sc)and clearances of different cytokines (tnfa; il- b;, il- , il- , il- ra) and protein permeability profile (albumin, cystatin c, igg)in an ex vivo hemofiltration (hf), hemodiafiltration (hdf)and hemodialysis (hd)circuit of nanostructured high porosity polysulfone membranes with different albumin permeabilities of %(type a)and %(type b). three hundred ml of fresh normal human blood was incubated with endotoxin ( mg, e. coli, sigma, °c, hr and overnight at room temperature). we set up the three circuits under the following conditions: i) post dilutional hf, at three different blood flow rates ( , or ml/min) and with a fixed ( %) ultrafiltration rate (ufr: . , . and . l/hour, respectively). the circuit operated at zero balance. samples for scs and clearances were obtained conventionally at , , , , , and min; ii) hd, at a dialysate flow rate of l/h and l/h; iii) hdf, dialysate flow rate of l/h and l/h included . l/h of ultrafiltrate. both hd and hdf were conducted always at blood flow rate of ml/min. cytokines were determined by commercially available kits, albumin, cystacin c and igg by nephelometry (beckman). median sc was nearly up to for il- b and il- ra, at about . for il- , . for il- and . for tnfa (type a vs b, p > . ). despite similar high cytokine clearance ( and mil/min), permeability profile showed a higher sc for albumin, cystacin c and igg for type b than for type a (p< . ). sc for all cytokines was significantly reduced in hd (at both l/hr and l/hr) as compared with hf and hdf. it was of interest that in hdf sc of il- and il- at l/h were overlapping those obtained in hf. however, sc of il- b, il -ra and tnfa in hdf were about half of those obtained with hf. in addition, increasing dialysate flow (from l/h up to l/h) in hd and hdf at a constant blood flow of ml/min led to decrease sc of il- , il- , tnfa and albumin. albumin clearance was . ± . and . ± . ml/min in hdf and hd, respectively. our data show that high cut-off polysulfone membrane are associated with high clearances of cytokines independently from blood flow rate and ufr. tailoring membrane porosity on the basis not only of cytokine clearances but also on ex vivo plasma protein permeability was instructive to formulate their clinical application in mixed convective-diffusive treatments rather than in pure convective or diffusive modes. nunomiya s , momose k , ohtake k division of intensive care, dept of anesthesiology and intensive care med, jichi medical school, minamikawachi, japan introduction: several clinical and experimental studies have reported recently that direct hemoperfusion using a polymyxin b immobilized fiber column (pmx-dph) is effective for septic ards and improves pulmonary oxygenation. unfortunately, however, little is known about the exact mechanism in such effects. therefore, we studied the role of circulating leukocytes activities in endotoxemic pigs undergoing pmx-dph. eleven anesthetized pigs were received endotoxin infusion (etx) to develop ards state and submitted to either pmx-dph group or ctrl group. ards state was defined when pao /fio ratio decreased to the level less than % compared to the point before etx. extracorporeal circulations (ecc) were done for hours in both groups. blood samples were obtained at points; the time before etx (t- ), ards state (t ), hour (t ) and hours (t ) after the start of ecc. leukocyte activities were measured as the abilities of oxygen radical productions from leukocytes using chemiluminescence assay. one was dead within hour and another was dead within hours after the start of ecc in ctrl group, whereas no animals were dead in pmx-dph group during the study period. time courses of pao /fio ratio and leukocyte activities in both groups are shown in tables. changes in p/f ratio compared to t- cotogni p , muzio g , trombetta a , canuto r , trompeo a , viale a , ranieri m anestesia e rianimazione, patologia generale, university of turin, turin, italy in the early phase of ards, intense inflammatory reactions occur in the alveolar space. in this setting, the balance between pro-and anti-inflammatory cytokines may be a critical component for prognosis. evidence is accumulating that n- /n- polyunsaturated fatty acids (pufa) ratio may influence inflammation, since the eicosanoids formed from n- pufa and those developed from n- pufa have opposite effects upon inflammatory mediators production. in standard artificial nutrition -both in parenteral and in enteral formulas -n- /n- pufa ratio is quite low (between : and : ), since most nutrients are richer in n- than in n- pufa. though, the most favourable n- /n- pufa ratio is not yet defined. our study tested the hypothesis that n- /n- pufa ratio may modulate inflammatory cytokines production in a cell culture of human pneumocytes exposed to lipopolysaccharide (lps). a cells, a human pulmonary cell line with type ii pneumocyte properties, were cultured ( /cm ) in ham f- k medium. in all cultures but in controls, lps was added hours after seeding, to obtain a final concentration of mug/ml. three hours after lps, pufa were added as docosahexaenoic acid (dha) (n- ) and arachidonic acid (aa) (n- ) in different n- /n- ratios. four hours later, all culture supernatants were collected to determine the release of tnfalpha, il- , il- , and il- (elisa). pro-inflammatory cytokines production was significantly reduced by a : ratio of n- /n- pufa, but increased by a : ratio. a higher ratio ( : ) was not associated with further cytokines reduction (table ) . *n- /n- conclusion: in a human pulmonary cell culture stimulated with lps, inflammation can be modulated by pufa, through appropriate changes of n- /n- ratio. high doses of selenium could be a promising way for septic shock treatment. however, selenium (se) toxicity is supposed to be related to oxidative stress through a reaction with thiols. in the situation of an oxidative stress such as severe sepsis, it is to be feared that selenium toxicity could be increase, despite the fact that preliminary results are in favor of two different pathways for lipopolysaccharide (lps) and se toxicity. after approval by the crssa ethical committee, wistar male rats were studied. rats were quarantined for days. then, lipopolysaccharide (lps) followed one hour later by selenium, as sodium selenite (lps-se group) or se alone, as sodium selenite, (se group) were administered intraperitoneally. in ten rat lps-se groups, lps were administered at the dose of mg/kg followed by se at increasing doses from . to mg/kg. in ten rat se groups, se was administered with increasing doses from . to . mg/kg. mortality rate was observed at hours. surviving animals were sacrificed under anesthesia by halothane. blood samples were taken on two surviving rats of each group. plasma selenium concentration was measured using electrothermal atomic absorption. mortality related to se appears for lower doses in lps-se groups than in rats receiving se alone. mortality rate of rats receiving mg/kg lps alone was % ( / ). for doses of more than . , septic rats died in respiratory distress in less than one day. for lps alone or followed by se at the dose of . mg/kg, rats were rapidly sick. they rolled up into a ball. their fur was dull, and stood on end. they were asthenic and had diarrhea. se rats developed an encephalopathy the first day and later recovered, except rats with extremely high doses of se, according to the literature on selenium acute toxicity. mortality related to se (mg/kg) mg/kg . . . . lps-se / / / / / not do se / / / / / / conclusion: in a % mortality non reanimated lps rat model, mortality related to selenium administration appears at lower doses those administred in healthy rats. mortality was related to respiratory distress in lps followed by se rats. doses of . mg/kg, presently considered as the maximum selenium level administration, seems not to modify the spontaneous evolution of sepsis in this model. zimmermann t department of visceral-, thoracic-and vascular surgery, technical university dresden, dresden, germany selenium plays a dual role in the regulation of the inflammatory response in mononuclear blood cells. first, selenium enzymes (gpx , trr) are essentiel for the physiological regulation of the redoxsensitive transcription factor nf-kb (key role in inflammation). second, selenium is capable to inhibit the activity of nf kb. another transcription factor (ap- ) is being specific activated via the subunits (c-jun,c-fos) by means of selenium. the authors investigated patients with severe sepsis within the sic-study (selenium in intensive care). mononuclear blood cells: nf-kb-and ap- binding activity, p /p (nf-kb)-protein concentration in the nucleus and cytoplasm. mrna-expression of ikb, tnf, tissue factor, mif, gpx- and trr (selenoenzymes), intracellular synthesis of mif and ikb. ros in whole blood. blood was taken on the ., ., ., ., ., . day of sepsis. septic patients with supplementation of selenium showed a increase of the nf-kband a strong increase of the ap- binding activity during the course of the sepsis. in the same time a rigorous reduction of the mrna-expression of ikb (inactivator of nf-kb) and mif could be observed. the mrna-expression of the tissue factor and tnf was not influenced. supplementation of selenium lead to a amplified translocation of p /p (nf-kb) within the nucleus, whereas in the placebo group this effect was not shown. in contrary to septic patients, only the nf-kb bindung activity was strongly suppressed in healthy controls. selenium seems to possess a regulatory role in der inflammatory response of mononuclear blood cells. the positive effect of selenium in septic patients could be dependent on the time point of the supplementation, within the inflammatory (anti-or hyperinflammatory) response. this could be one explanation of "non-responders" of selenium supplementation. high dose of selenium (se) could be a promising way for septic shock treatment. however, selenium toxicity is supposed to be related to oxidative stress through a reaction with thiols. in the situation of an oxidative stress such as severe sepsis, it is to be feared that selenium toxicity could be increased. presently human administration of sodium selenite of more than µg per dose must be avoided, outside carefully conducted study. however preliminary results are in favor of two different pathways for lipopolysaccharide (lps) and se toxicity, which leads to think that selenium, especially as sodium selenite, could be a new way of treatment. after approval by the crssa ethical committee, wistar rats were studied. rats were quarantined for days. sixty four rats received mg/kg of lps intraperitoneally, followed one hour later by milliliters of saline water (placebo) (n = ), or . mg/kg selenium as sodium selenite (n= ) corresponding to around mg for a kg man, or . mg/kg selenium as sodium selenite (n= ). mortality rate was observed at hours. videos were performed during the -hour course. surviving animals were sacrificed under anesthesia by halothane. blood samples were taken on two surviving rats of each group. there is a tendency of the mortality decrease in this post-treatment septic rat model. moreover, rats receiving lps alone or supplemented by . mg/kg sodium selenite were rapidly sick. they rolled up into a ball. their fur was dull, and stood on end. they were asthenic and had diarrhea. lps non-surviving rats died in an asthenic syndrome, and surviving lps alone rats remain very asthenic at hours. on opposite, surviving lps followed by se rats were much more dynamic, even quite normal. th annual congress -berlin, germany - - october s kepa l , oczko-grzesik b department of infectious diseases, silesian university medical school, bytom, poland cytokines and neutrophiles play an important role in pathogenesis of bacterial sepsis with purulent meningoencephalitis (bs-pme). experimental studies in animals revealed that pentoxyfiline (pf) exerted inhibitory influence of cytokines on these cells with beneficial outcome of the disease. the aim of the presented study was the estimation of pf influence on clinical course and outcome of bs-pme in adults. between - bs-pme was recognized in patients treated in our centre. neisseria meningitidis and streptococcus pneumoniae were etiological agents in subsequently % and % of cases. in the remaining % of subjects the etiology was not elucidated. all patients were divided at random way into two groups: i - patients (mean age yrs.) treated with antibiotics, symptomatic drugs and pf ( mg/kg/day) beginning from the first day of treatment, ii - patients (mean age yrs.) treated only with antibiotics and symptomatic drugs. cerebrospinal fluid (csf) samples were taken on the st, th and th day of therapy with estimation of pleocytosis and protein, glucose, lactic acid, tnf-alpha, il- beta and crp concentrations. mean periods of consciousness impairment, fever persisting as well as hospitalization were comparable in both groups of patients. faster normalization of csf protein, glucose, lactic acid and crp concentrations were recorded in patients of group i, who survived, compared to subjects of group ii, but the differences were not statistically significant. csf parameters remained abnormal in fatal cases. most frequent sequeles of bs-pme were: partial deafness, deafness, paresis and paralysis. side efects of pf were not observed. death sequels group i ( %) ( %) ( %) group ii ( %) ( %) ( %) conclusion: pentoxyfiline used as adjunctive therapy in adult patients with bacterial sepsis and purulent meningoencephalitis did not reveal evident beneficial influence on clinical course and outcome of the disease. zahorec r , setvak d , cintula d , blaskova a , belovicova c of anesthesia and icu, st. elizabeths cancer institute, bratislava, slovakia sepsis is a common cause of acute renal failure (arf). arf in early phase of severe sepsis occurred in - % septic patients and is associated with significant influence on sepsis mortality. the aim of this observational study was to measure the incidence of arf syndrome and to evaluate the efficacy of noradrenaline and furosemide infusion (martin et al. (martin et al. , for the treatment arf in early phase of severe sepsis. an observational study of consecutive critically ill cancer patients with severe sepsis ( ) and septic shock( ). acute renal injury/arf syndrome was detected according bellomo et al ( ) criteria. the surrogate markers of renal dysfunction involve serum urea, serum creatinine and urine output (diuresis per hour). we measured creatinine clearance and excretion fraction of sodium from collected urine.the severity of severe sepsis was measured by apache ii and sofa score during the first - hrs of icu stay. we monitored in all pts invasive sap,map,cvp,temperature, pulse oximetry, urine flow per hour and per day.blood sampling were done every hrs for wbc counts, platelets count, procalcitonin, crp, urea, creatinine and lactate. : severe septic patients with mods (initial sofa score were , and , p., and apache ii score , and , )received full intensive therapy. severe sepsis was documented by proven infection and high serum levels of procalcitonin (mean , ng/ml) and crp(mean mg/l). acute renal injury ( pts) and arf( pts) syndrome was detected in patients ( %) out of septic cancer pts. we used the combination of noradrenaline infusion ( , - , mcg/kg/min) and furosemide infusion( - mg/hr) for hemodynamic and renal support. we induced polyuria and reverse ari/arf to nonoliguric arf in pts ( %) from severe septic pts. we used no renal replacement therapy.we recorded % hospital mortality. acute renal injury and acute renal failure syndrome occurred in % of severe septic patients. criteria for ari/arf syndrome diagnosis are very simple and useful in early detection of renal dysfunction. renal rescue protocol (combination of noradrenaline and furosemide infusion) seems to be very effective modality in the treatment for ari/arf syndrome in early phase of severe sepsis, when it is instituted very early with low/moderate dosage of noradrenaline and furosemide. the purpose of the present study was to evaluate the effects of intravenous lornoxicam on hemodynamic and biochemical parameters, serum cytokine levels, patients' outcome in humans suffering from severe sepsis methods: patients were included to the study. after applying, lornoxicam mg was administered intravenously every hrs for six doses vs placebo. hemodynamic parameters (heart rate,mean arterial pressure), nasopharyngeal body temperature, arterial blood gas changes (ph, po , pco ), plasma cytokin levels (interleukin -b, interleukin -r, interleukin , interleukin , tumor necrosis factor-a), biochemical parameters (lactat, leucocyt, trombocyt, creatinin, total billirubin, serum glutamat oxalat transaminase), staying time in the intensive care unit, time of mechanical ventilation support, mortality, with the control group were recorded. all measurements were obtained at baseline (before start of the study) and were repeated immediately at th , th and th h. after lornoxicam. no differences were found differences in major cytokines, duration of ventilation and icu stay, and fi / pa intravenous lornoxicam vs placebo (p> . ). we found that the effect of intravenously lornoxicam did not effect hemodynamic and biochemical parameters, or cytokine levels or in patients' outcome in severe sepsis in humans. because of the limited number of patients in our study and the short period of observation, our findings need to be confirmed by larger clinical trials of intravenously lornoxicam in a dose-titrated manner bernard gr, wheeler ap, russell ja, et al: n engl j med , : - . bubenek-turconi s s t , sefu f , stelian e , boros c , miclea i , timofiev l , moldovan h , iliescu v st cardiovascular anaesthesia and intensive care dept., st cardiac surgery dept., institute of cardiovascular diseases c. c. iliescu, bucharest, romania severe systemic inflammation with a vasodilatory syndrome occurs in about one third of all patients after cardiac surgery with cardio-pulmonary bypass (cpb). we studied the effects of early continuous veno-venous hemofiltration (cvvh) on the course and outcome of the patients with severe systemic inflammatory response syndrome (sirs) after cardiac surgery. a group of patients with severe sirs [fulfilling the criteria of accp/sccm consensus committee ( )] in early postoperative period after cardiac surgery with cpb was divided in two subgroups: a - patients receiving conventional therapy and b - patients who received cvvh for a period of h. criteria for receiving cvvh was a severe cardiovascular dysfunction (catcholamine support required in large amounts, norepinephfrine or epinephrine > . ?g x kg- x min- , for maintaining a map > mm hg or a svr > dyne x sec x cm- ). of those patients had also a severe respiratory dysfunction with pao /fio < . there were no significant diferences regarding demographic data and type of surgery between the two groups. the patients from group b had a dramatic improvment of the cardiovascular function, the catecholamine support being tapered off faster than in group a even the initial dose was very much higher in group b. also the patients with respiratory dysfunction from group b were extubated earlier than those from group a, with the same amendament regarding the severity of the dysfunction. the result are sumarized in the following ricci z , salvatori g , bordoni v , bonello m , ratanarat r , d'intini v , ronco c nephrology dialysis and transplantation, ospedale civile s.bortolo, vicenza, italy sepsis and mods are associated with a disruption of normal homeostasis and alteration of biological systems. the accumulation of pro-apoptotic factors in plasma may contribute to organ dysfunction. removal of such factors by extracorporeal blood purification techniques may help to re-establish homeostasis and cell function. we investigated the effect of treatment dose comparing standard and high volume hemofiltration. in a prospective, randomised, cross over study two hemofiltration regimes in two consecutive days were administered to anuric septic patients: we studied hours high volume hemofiltration (hvhf: l/h) followed by hours standard hemofiltration (cvvh: l/h) and viceversa. replacement solution was administered pre filter and performed by m polysulfone membranes. blood flow rate was ml/min. routine laboratory and clinical data were collected including illness severity scores. prefilter plasma and ultrafiltrate were collected at treatment start, at hour, at hour, for each hemofiltration regimen. plasma samples and ultrafiltrate were frozen at - °c. samples were close labelled. samples from normal human blood were used as control. samples were studied for apoptosis using a u monocyte cell line. a quantitative analysis of the apoptotic u cells in culture was carried out by fluorescence microscopy at hours. u cells were also assayed for caspase , activation. during the sequence hvhf/cvvh cell apoptosis significantly decreased after hour of l/h treatment start (p< , ); after hours of l/h treatment apoptosis rate continued to decrease significantly (p< , ). after passing to l/h regime the percentage of apoptosis remained constant. the fold-increase of caspase- measured at hr correlated with the above findings (r= , ). similarly when the inverse sequence (cvvh/hvhf) was studied cell apoptosis did not show a decrement in the first hours, while after switching hemofiltration dose to l/h apoptosis was significantly decreased either at the first and at the fifth hour (p< , ; correlation between apoptosis and caspase- fold increase: r= , ). the results where independent from the administration sequence. conclusion: high hemofiltration rates seem to correlate with a decrease in plasma apoptotic pattern during crrt in anuric septic patients. the clinical relevance of such findings may contribute to explore new therapeutic options in septic patients. epinephrine (e). we conducted a casenote review of patients with septic shock. the unit icnarc/midas database was searched for all patients admitted over a two year period with septic shock. the icu notes and charts were then retrieved and data found on physiology, choice and dose of catecholamine given. : patients were identified, of whom were treated with ne and with e. there were notable differences in outcome between the two vasopressors commonly used. patients receiving either drug were seen to have an increased mortality in association with higher doses used. no patient survived to hospital discharge who was treated with a dose of e above . micrograms/ kg/ min or ne above . micrograms / kg/ min. conclusion: there is an increased mortality seen in patients with septic shock receiving e. whilst they may be older, with worse apache scores and calculated risk of death; this doesn't explain the degree of the problem. some of the answer may lie in their worse glucose metabolism. there was also an increasing mortality seen with increasing dose of vasopressor given. this was independant of apache score and as such may repesent a drug effect rather than a marker of illness severity. (vili) .but positive end expiratory pressure with or without low tidal volume is protective against lung injury. in this study we investigated the effect of different inspiratory times on vili. methods: sprague dawley rats were used. all were started to ventilate on pressure controlled ventilation mode, after anesthetized and tracheostomized, with the parameters of cmh o peak inspiratory pressure (pip), cmh o peep, fio : . , breaths/min and i/e: / . after minutes stabilization period baseline blood samples were taken for blood gas and cytokine analysis, then the rats were randomized into groups due to their peak inspiratory pressure, peep and inspiratory/expiratory ratios as follows: other ventilator settings were kept as baseline values. the rats were ventilated with these parameters for two hours. at the end of experiment before sacrification of rats, blood samples were obtained for blood gas and cytokine analysis. then the lungs were taken out and the left lung was used for measurement of wet weight/dry weight ratio (ww/dw). there were no differences in baseline ph, pao , paco , map values among groups. as compared to baseline values pao decreased in lp / , hp / , / , / groups and hpp / , / groups but significant differences was found only in hp / group(p= . ). at the end of experiment map decreased in all hp groups and hpp / group. ww/dw ratio was found lower in hpp groups when compared to hp groups (p< . ). il- level was found higher in hp groups than lp and hpp groups at end of experiment. high pip caused lung injury with deterioration of oxygenation and increase in ww/dw ratio. while application of peep was protecting lungs from vili changing inspiration expiration ratio did not. dragazis i , mariatou v , kopteridis p , kapetanakis t h , karidis n , balanika m , michalia m , armaganidis a nd critical care department, athens university medical school, athens, greece our purpose was to investigate whether temperature modulates ventilatorinduced lung injury (vili). we perfused (constant flow ml/min) isolated sets of normal rabbit lungs and ventilated them using different perfusate temperatures and two different ventilatory settings ( groups). after initial stabilization all preparations were ventilated for min using pressure controlled ventilation [pcv] with peep cm h o and pcv cm h o above peep. following the results of randomisation the necessary adjustments were made during this period to obtain in the perfusate: ) a ph . with a partial pressure of co mm hg and ) a perfusate temperature of oc, oc or , oc. two groups of preparations were tested at each temperature level: a control or low pressure (lp) group ventilated with peep cm h o and pcv cm h o above peep for min and a high pressure (hp) group, in which a pcv = cm h o above peep (= cm h o) was applied for min. the weight gain (deltawg in g/min) observed in each group during this period, as well as changes in ultrafiltration coefficient (kf in gr/min/ cm h o/ g) were used to assess vili (indexes of pulmonary edema and of vascular permeability respectively). our results are summarized in table . deltawg in hyperthermic isolated, perfused lungs was significantly higher than deltawg in any other group. significant kf changes were observed only in hp groups, with a significantly higher deltakf in the hp_ . group (p= . ). there were no important differences between normothermic and hypothermic preparations. methods: sprague-dawley rats were anaesthetized, paralyzed and mechanically ventilated. rats were ventilated similarly (vt= ml/kg, rr= bpm, fio . ), but were randomized to peep , or cmh o (n= per group). the abdomen was then inflated stepwise with helium up to mmhg of abdominal pressure (iap, intra-peritoneal direct measurement). airway pressure (paw), esophageal (pes) and gastric (pga) pressure were also measured, together with invasive blood pressure. data were simultaneously recorded and digitally stored for subsequent analysis. this allowed to consider end-expiratory (pes exp), mean (pes m) values of pes and the difference between pes at end-inspiration and end-expiration (dpes). data are presented as mean±sd. we conclude that in our study study the closed tracheal suctioning system did not decrease the incidence of ventilator-associated pneumonia, not even the exogenous pneumonias. we believe that the respiratory secretions suction may be done with guarantee with an open tracheal suctioning system if it is performed with suitable asepsis measures. and we think also that it is not necessary the high cost that the routine use of a closed tracheal suctioning system represents. however the closed tracheal suctioning system may be recommended in patients with severe impairment of gaseous exchange. in order to avoid decrease in bacterial count due to empiric ab before sampling, we evaluated the feasability of delaying the cultures of broncho-alveolar lavage (bal) frozen at - °c et - °c for hours. the results from these delayed processing were compared with those from immediate ones. a total of bals were performed on icu patients suspected of nosocomial or community-acquired bacterial pneumonia. each sample was divided in three, one for immediate culture (h ), the nd and rd for a delayed processing after storage at - °c and - °c for hours (h ) respectively. all negative h samples (n= ) were also negative at h except for one sample that yielded and cfu/ml of streptococcus sp on - °and - °h culturing respectively. seventy seven bals yielded one or more microorganisms, with a total of microorganisms in one or both samples. h and h (- °& - °) hájek r , nìmec p , zezula r , fluger i , rù?ièková j cardiac surgery, university hospital, olomouc, czech republic introduction: thrombelastography (teg)is a method frequently used in perioperative assessment of haemostasis in cardiac surgery. this bedside examination can reveal some specific disorders of haemostasis especially hypercoagulation and fibrinolysis. one hundred fourteen consecutive patients with acquired heart desease were assessed. all the patients were operated electively and the cardiopulmonary bypass was used. standard laboratory perioperative assessment of coagulation was performed. these results were compared with teg performed afer indtroduction of anaesthesia, after minutes of cpb and immediately after admission on icu after operation. preoperative anticoagulation therapy, blood loss and the necessity of transfusion were evaluated. only patients nad no anticoagulation medication preoperatively. in laboratory assessment all the patients had normal results preoperatively, patients had coagulation disorder and patients thrombocytopenia postoperatively. teg examination revealed hypercoagulation status in patients and hypocoagulation in patients preoperatively. during operation increased fibrinolysis was found out in , % patients ( , % during operation, , % after operation and , % both during and after operation), only in % of them aprotinin was used because of increased bleeding. thrombocytopatia was revealed in , % patient and only in of them thrombocyte infusion was required. in patients the residual high level of heparin was confirmed. the average blood loss during operation was ml and during first hours was ml. no patient was reoperated because of bleeding. correction of hypocoagulation was made with ffp in average dose tu ( case with normal postoperative teg tracings versus cases with pathological teg). conclusion: teg revealed hypercoagulation status in many patient preoperatively, which was not confirmed by standard laboratory tests. during operation mainly fibrinolysis and thrombocytes dysfunction was present but any specific therapy was usually not necessary. the use of blood products depends more on clinical status of the patient than on the teg results. clinicians are facing the challenge to differentiate between postoperative inflammation a condition considered to be benign and early signs of infection. the aim of our study was to define the timecourse of sirs and severe sirs after cardiac and thoracic surgery. we utilised a structured data mining process to the prospectively collected data within the patient-data-management-system (picis caresuite v. . ) from the cardiothoracic icu of a university hospital between january and may . data from all monitoring device are collected in intervals of minutes, laboratory data and blood gas analysis was done according to institutional standards. in this data mining process we determined in a first step the fulfillment of each individual item of the sirs criteria (accp/sccm consensus conference) during a minimum of one hour. in the second step we identified the first occurrence of simultaneous fullfillmment of at least criteria as the starting point for sirs. severe sirs was defined as sirs with at least two criteria for organ dysfunction as defined in the sofa score. we used three categories sirs, sirs with low blood pressure (sirs low bp) and severe sirs with additinal organ dysfunction (sirs severe). a total of patients were admitted during the observation period. sirs was present in ( . %), sirs with hypotension in ( . %) and sirs with additional signs of organ dysfunction in ( %). the timepoints of first fullfillment are given in the table. the timeprofile with very early fullfillemtn was not changed by censoring the first hours after admission since the identified state persistent for a prolonged period. timepoint of first sirs fullfillment: in this large cohort of patients after cardaic and thoracic surgery we found dystinct profiles for sirs with additional signs of organ dysfunction. in the majority of the patients the three different sirs categories occurred within the first hours. further research is necessary to determine whether any of these categories are indicative of a changed outcome depending on the starting point. th annual congress -berlin, germany - - october s samalavicius r , misiurine i , norkiene i , juozaitis m , urbonas k , bubulis r , baublys a anaesthesiology and intensive care, vilnius university hospital santariskiu clinics, vilnius, lithuania introduction: preoperative risk stratification for predicting mortality and morbidity is widely used in cardiac surgery. the goal of this study was to assess the value of serum lactate level in predicting mortality and morbidity following coronary artery bypass grafting (cabg) procedures. methods: consecutive cabg patients, operated on from . . to . . , were included in this prospective observational study. all patients were operated using cardiopulmonary bypass. serume lactate levels were measured before cardiopulmonary bypass, before declamping of the aorta, after heparin neutralisation and at the icu admission. : lactate level greater than mmol/l was found in . % of patients during cardiopulmonary bypass, in . % of patients shortly after weaning from cpb and in . % of patients at icu admission. mortality rate of patients, with hyperlactemia at icu admission was . % and morbidity . %. mortality rate of patients without hyperlactemia was . % and mobidity - . %. lactate levels on icu admission were raised in non survivors (median . +/- . , range . - . mmol/l)compared with survivors (median . +/- . , range . - . ). conclusion: increased serum lactate levels following coronary artery bypass grafting allows to identify a group of patients with increased risk of postoperative mortality and morbidity. since the year , we have been studying prognosis in cardiac surgery (cs) and noticed the lack of models with similar populations in the literature. the objective this study is create a predictive score (rio score-pre) of in-hospital mortality in patients (pts) undergoing cs based on preoperative variables. classical cohort with data of pts, of whom undergoing valvular surgery (vs) and admitted to intensive care units (icu), public and private, consecutively selected between june and february . all variables were previously defined. the data underwent univariate analysis with the chi-square, student t, mann-whitney, and pearson tests, followed by logistic regression, and stepwise (likelihood ratio), with the chi-square linear tendency test and a classification table. the score created (appendix) allows the following prediction: from to -low risk; from to -medium risk; and from to -high risk. pérez-vela j , renes e , escribá a , alonso m , corres m , garcía a , perales n intensive care unit, hospital de octubre, spain, spain vital parameters monitorization is an usual practice in the management of critically ill patients. cardiac index (ci) is one of more important perfusion parameters used. picco system is a device that offer the quantification of intermittent ci by transpulmonary thermodilution (citp) and in a continuous manner by arterial pulse contour analysis. objective: to compare the agreement between the standard thermodilution monitorization system (citd) with the transpulmonary system. also, we analysed the complications secondary to the picco system. prospective study, in patients in the immediate postoperative period after cardiac surgery with cardiopulmonary bypass. ci by standard themodilution was measured with pulmonary artery catheter abott optiq svo /ccoâ. we made a transpulmonary thermodilution with ml physiologic fluid injection with a temperature less than celsius degrees, through a central venous line, and we analysed the thermodilution in the femoral artery catheter thermistor (a -fr gauge, cm long arterial with a thermistor embedded in its wall: pulsiocath pv l) using the picco system from pulsion medical system (munich; germany). we calculated ci (both methods) after inserting the picco system, one hour later and then, every two hours. also we measured parameters when staff considered appropriate to value the results of a therapeutic attitude. results between techniques were compared by lineal regression analysis and the bland-altman method. we analysed a total of pair of data obtained in patients, male and female, in the immediate postoperative period of valvular replacements ( mitral, aortic and one both), aortic grafts, myocardial revascularizations, mixoma and pericardiectomy. mean age: ± . years, mean citd . ± . and citp . ± . l/m. the range of measured ci: . a . l/m/m . in comparison we obtained a r= . and a bias of - . ± . . in tables we have the realised statistic analysis. we did not have complications attributed to the system. both ci measurement methods are comparable, showing a good agreement between systems, indicating that citp is as reliable and precise as standard thermodilution. this suggests that picco is a monitorization system applicable to clinical routine in critically ill patients. we did not observe complications attributed to the system. gomes r v , rouge a , nogueira p m m , fernandes m a o , olival s a , campos l a a , dohmann h f r , santos m surgical intensive care unit, hospital pró-cardíaco -procep, surgical intensive care unit, instituto nacional cardiologia laranjeiras, rio de janeiro, brazil the left ventricular ejection fraction (lvef) has been extensively studied as a prognostic marker in cardiac surgery (cs); our group, however, has found a correlation between left atrial diameter (lad) and several outcomes in cs. the objectives this study is show the importance of lad as a prognostic marker by assessing the following outcomes: in-hospital mortality (hm), surgical intensive care unit length of stay (siculos), pneumonia (pn), and need for hemodialysis (nhd). compilation of data collected in the databank of several cohorts with patients (pts) of sicu from june/ to february/ . the variables studied underwent uni-and multivariate statistical analysis. the few reports exist about lad on echocardiography as a risk marker for cs; in our studies, however, lad has reached greater significance than the subjective analysis of lv function. the great prevalence of valvular surgery (vs - %) might be another possibility. these findings should be validated in a cohort with other centers. conclusion: amylase level > un/ml and bilirubin concentration of mg/dl in duodenal aspirated fluid has a high positive predictive value. position of the feeding tube within the gastrointestinal tract can be determined objectively by using simple ph and bilirubin reagent strips. webb i , gibbs t , beale r , jones a . department of intensive care medicine, guy's and st thomas' hospital, london, united kingdom septic shock may be accompanied by dysfunction of the hypothalamic-pituitaryadrenal axis (hpa). in a recent multi-center randomized controlled clinical trial, treatment with hydrocortisone and fludrocortisone significantly reduced the risk of death in patients with septic shock and relative adrenal insufficiency (as determined by acth stimulation) but not in patients with an adequate adrenal response ( ). subsequently it has become accepted practice to start corticosteroid replacement in patients with septic shock following an acth stimulation test to determine the presence (non-responder-nr) or absence (responder-r) of "adrenal insufficiency". in those patients with "adequate" adrenal function, corticosteroids are withheld or withdrawn. it is known that in patients who recover, this "adrenal insufficiency" is temporary. however, less is known about the temporal changes in hpa function within the period of critical illness. methods: our clinical information system (carevue, philips medical systems, uk) was interrogated to find all patients with septic shock who underwent repeated acth stimulation ( \mug) testing in an month period. baseline cortisol, nr/r status (\deltacortisol < \mug/dl), vasopressor requirements and use of hydrocortisone were identified. we identified patients who underwent repeated acth stimulation testing within a single episode of septic shock, who received no or limited steroid replacement therapy. in subjects ( , , the recognition that hpa abnormalities exist in sepsis and that exogenous steroids are beneficial in some individuals has changed practice over recent years. however, the best indicator of which patients would benefit from corticosteroid replacement remains unclear. in addition, this preliminary data suggests that an individual patient's response to acth stimulation may change during an episode of septic shock. of particular concern are patients who are initially "responders" who would not recieve beneficial therapy if only single estimates of adrenal dysfunction are used. twenty four neonates with tof were divided into two groups after getting parents consent and local ethical commitee approval into two groups ( each); group i : after general anaesthesia they had continous thoracic paravertebral block with a catheter placed at right fifth space with continous infusion of . ml/kg of . % ropivacaine every minutes to be maintained post operatively in nicu this. group ii :had balanced general anesthesia. measurements: -number of neonates required post operative ventillatory support in both groups. -mean total dose of opioids required for analgesia in both groups. -days of stay in nicu in both groups. -mortality in both groups results: -there was statistically significant less need for ventilatory support in group i ( %) in comparison to group ii ( %). -mean total dose of opioid analgesia was higher in group ii -more days of stay in group ii. -three cases of mortality in group ii ,while one case of mortality in group i. conclusion: picu mortality was relative high, partly due to high prism scores and the high proportion of mv pts. mortality continues to increase up to y and stayed the same thereafter. the majority of our pts reached their preadmission cognitive status (pcpc) at two y. on the other hand they didn't reach their overall functional status (popc) even after two y mainly due to the high proportion of pts with mild disability, popc , which is however compatible with near normal and independent life. s -s . .jalan r, williams r. blood pruif predictors of transfusion requirements for cardiac surgical procedures at a blood conservation center references: maillet jm grant acknowledgement: chris stoutenbeek foundation references: .debra henry fiser ( , ) ( , ) ( , ) ( ) e coli ( , ) ( , ) ( , ) ( , ) s pneum+ ( , ) ( , ) ( , ) ( . ) others**+ ( , ) ( , ) ( , ) ( , ) *p= . g / g ; **p< . g /g ,+all groups conclusion: in our country, late-onset vap showed important variations in aetiology considering th and th days and that should influence antimicrobial prescribing practices. nosocomial pneumonia represents a significant cause of morbidity and mortality in intensive care units (icu). the high incidence of nosocomial pneumonia among icu patients can be attributable to dysregulation of lung immune responses elicited by systemic inflammation. in a previous study with endotoxin-challenged mice, defects of lung adaptive immunity were heralded by reduced numbers of lung-resident cd + t-lymphocytes. the depletion of cd + t-lymphocytes was associated with a higher susceptibility to lung infection caused by staphylococcus aureus in some clinical and experimental studies. the aim of our study was to evaluate the mechanism by which endotoxemia reduces the number of lung-resident cd + t-lymphocytes and increases susceptibility to s. aureus in the lungs. experimental systemic inflammation was initiated in balb/c mice (n= ) with \mug of endotoxin (lps) given intraperitoneally; hrs after this challenge, the animals were anesthetized and x cfu of s. aureus (s.a.) were administered into the trachea. for the control group, mice were challenged only with s. aureus (n= ). mice were sacrificed hrs after the challenge with s. aureus. lung-resident lymphocyte subsets were obtained by enzymatic digestion of lung tissue. lung-derived and circulating total t-(cd +) and b-(cd +) lymphocytes, cd + and cd + t-lymphocytes as well as nk cells were enumerated with monoclonal antibodies, single platform method and cytometric analysis. colony forming units (cfu) of s. aureus were obtained from lung tissue homogenates using a plate dilution method. the differences between groups of animals were evaluated by one-way anova with a level of significance p< . . data are presented as mean standard ± error. results are shown in the table (number of cells is expressed as cellsx /ml for the blood and cellsx lobe for the lung). conclusion: our results demonstrate that mice challenged with endotoxin and s. aureus have reduced recruitment of cd + t-lymphocytes to the lungs when compared to animals infected only with s. aureus. despite this finding, the susceptibility to secondary lung infection due to s. aureus was significantly decreased after endotoxin challenge indicating its protective effect against staphylococcal infection. aranha f g , rouge a , gomes r v , dessen m , nogueira p m m , fernandes m a o , campos l a a , dohmann h f r surgical intensive care unit, hospital pró-cardíaco -procep, rio de janeiro, brazil the need for dialytic support (hd) in the po period of cs relates to a significant increase in costs and length of hospitalization, in addition to high rates of morbidity and mortality.the objective this study is assess the incidence of hd and its association with mortality in adult patients (pts) undergoing cs. historical cohort with data of pts undergoing cs collected from june/ to january/ . the pts were divided into groups as follows: ) group i, pts who did not undergo hd; and group ii, pts who required hd, accounting for . % of the sample. their mean age was . years, . % were males, . % were diabetic, and % of the cs were elective. the mean aha mortality score was . ± . , and the mean euroscore was . ± . . analysis of frequency and the chi-square test were used for comparing mortality. fifty-six ( . %) pts died in the hospital, ( . %) in group i, and ( %) in group ii. thirty-nine ( . %) pts died within days, of whom ( . %) were in group ii. an important statistical significance (p< . ) was observed between both groups. the po intensive care unit length of stay was significantly longer in group ii, in which % of the pts remained hospitalized for more than days (p< . ). the po intensive care unit length of stay and mortality were significantly greater in the group of pts undergoing hd in the po period of cs. a high percentage of patients underwent hd ( . % of the sample), which may be explained by the profile of the population studied. in group ii, in-hospital mortality was %, and mortality in days was . %. in the entire sample, these indices were . % and . %, respectively, and the euroscore predicted a mortality rate greater than . %. the conventional choice for type-b aortic dissection has been medical treatment. surgical repair has been kept for cases presenting complications. both treatments are associated with high mortality rates. endovascular stent-graft placement opens up new perspectives in the controversial treatment of thoracic aorta dissections. the objective of this paper is to describe our experience in the post-operative handling of type b aortic dissections treated with endovascular stent grafting. twelve patients admitted to an all-purpose icu from january to march treated with endovascular stent grafting. ten patients with acute type b dissection and one patient with traumatic rupture of thoracic aorta. the pre-operative study included transesophagic ecography and ct to evaluate the extent of the dissection, the relation with the left subclavian exit, true and false lumen size, and vascular complications. placement of the endovascular stent-graft (talent type) was successful in all cases. three patients died within the first days, two of them in the icu, with a mortality rate of %. complications: one patient had retroperitoneal hematoma, and another presented perioperative ami. two cases were observed of paraplegia, and one case of perioperative acute cerebellar ischemia in relation with type a retrograde dissection of the thoracic aorta. the mean stay in the icu was . days. mean mechanical ventilation time was . days. five patients ( %) presented nosocomial infection: four infections by catheter ( %), one episode of urine infection ( %) and one episode of pneumonia associated with mechanical ventilation ( %). four patients presented acute kidney collapse ( %), without the need for hemodialisis in any case.conclusion: endovascular stent-graft placement can be an alternative to open surgery in the treatment of type b aortic dissection. preliminary results on post-operative morbimortality are promising. randomized and controlled studies are needed to assess the therapeutic potential. durand m , gardelin m , bertet m , tessier gonthier-maurin y , bouzat p , girardet p anaesthesia, chu de grenoble, grenoble, france global tissue hypoxia is associated with a poor outcome after cardiac surgery [ ] . the best predictor of anaerobic metabolism in septic patient seemed to be the ratio of venoarterial co difference (dpco )/arteriovenous o (ca-vo ) content [ ] . the aim of the present study was to verify if this ratio had the same predictive value after cardiac surgery. we performed a retrospective analysis of patients with simultaneous measurements of arterial and venous blood gases and arterial lactate levels during the first hours after surgery. we tested the predictive value of heart rate (hr), cardiac index (ic), mixed venous oxygen saturation (svo ), dpco , ca-vo , dpco /ca-vo and oxygen consumption (vo ) to predict anaerobic metabolism (lactate > mmol/l). the area under roc curves was calculated for the main parameters. results are expressed as mean +/-sd. : results of lactate were below mmo/l (gr ), were above (gr ). dpco (kpa) was significantly higher in gr than in gr ( numerous prospective, randomized studies in critically ill patients indicated that enteral feeding is superior to parenteral feeding and that early enteral feeding, compared with delayed enteral feeding, improves patient outcome as measured by length of stay or complication rates. ideally, tube insertion would be inexpensive and would require minimal time and technical expertise. we inspected a simple bedside technique for positioning the feeding tube. all included patients received a polyurethane feeding tube with a flexible wire stylet ( - silk enteral feeding tube, corpack, wheeling, il).one size cm - fr of feeding tubes was used in this study. feeding tube position was confirmed by an abdominal radiograph. each radiograph was reviewed by a radiologist. equipment to measure ph and bilirubin consisted of color -coded paper (multistic sc bauer corp.usa), amylase and bilirubin (second test) were measured in the central clinical laboratory. successful aspiration of duodenal fluid was performed in ( %) patients. median time for perform bilirubin and ph by color -coded paper (multistic sc bauer corp.usa) -up to seconds. median time for perform bilirubin and amylase analysis in duodenal fluid in central laboratory was . ( + . ) hours. koulenti d , mis m , myrianthefs p , tsigou e , ioannidis c , gavala a , grigoriou p , baltopoulos g icu, kat hospital, athens, greece introduction: liver dysfunction is very common in critically ill patients due to a variety of reasons including trauma, sepsis, congestive heart failure, gall stones, hemorrhagic shock, transfusions, and drug hepatotoxicity. the purpose of the study was to investigate the characteristics of liver dysfunction in icu patients. we prospectively collected data concerning demographic characteristics and liver biochemistry in critically ill patients for a total period of months. liver dysfunction was defined as an increase in liver enzymes by twofold times including sgot, sgpt, alkaline phosphatase, gamma-gt, and bilirubin. during the study period, patients were admitted in our icu. mean age was . ± . , saps ii was . ± . , apache ii was . ± . and mods was . ± . . icu los was . ± . . forty-five patients ( . %) developed liver dysfunction. five of them ( . %) had more than one episodes of liver dysfunction. mean peak values of liver enzymes in patients developing liver dysfunction were sgot . ± . , sgpt . ± . , alp . ± . , gamma-gt . ± . , total bilirubin . ± . , and direct bilirubin . ± . . mean duration of liver dysfunction was . ± . days. mean day of liver dysfunction developed was on . ± . day. confirmed aetiology of liver dysfunction included sepsis ( pts), trauma-rhabdomyolysis ( pts), cholestasis ( pts) and drugs ( pts). we found statistically significant differences (p< . ) between the patients developing liver dysfunction and those who did not concerning los ( . ± . vs. . ± . days), saps ii score ( . ± . vs. . ± . ), apache ii . ± . vs. . ± . and mods score . ± . vs. . ± . . mortality was also significantly higher in patients developing liver dysfunction ( . vs. . %). half of the critically ill patients may develop liver dysfunction during icu hospitalization due to a variety of reasons which may be related to increased los, increased illness severity and other organs dysfunction and worst outcomes. hoeksema m , wester jp , bosman rj , oudemans-van straten hm , van der spoel ji , haak eaf , leyte a , zandstra df intensive care unit, clinical pharmacy, clinical chemistry, olvg, amsterdam, netherlands in critically ill patients with multiple organ dysfunction (mods), thrombocytopenia is frequently observed. heparin-induced thrombocytopenia (hit) accounts for - % of all causes of thrombocytopenia. as hit may be complicated by arterial and venous thrombosis (hitt), alternative anticoagulation is indicated. fondaparinux sodium (arixtra®) is a newly developed synthetic pentasaccharide and acts by selective antithrombin-mediated indirect factor xa inhibition resulting in subsequent thrombin inhibition. fondaparinux sodium has no cross-reactivity to heparin and has not induced an immune-mediated thrombocytopenia in non-icu patients. the elimination is almost exclusively renal. its major drawback is the increased risk of bleeding, to which patients with mods are prone. data on treatment schedules in critically ill patients are non-existent. we describe our experience with fondaparinux anticoagulation in the treatment of hit. we have treated patients with mods and laboratory-proven hit with fondaparinux sodium between december and february . treatment with unfractionated heparin or nadroparin calcium was stopped and laboratory tests for hit were performed with the hit-antibody elisa test. awaiting the test results, fondaparinux sodium (arixtra®, sanofi-synthelabo, the netherlands) was administered as a once daily subcutaneously injection or a continuous infusion of . - . mg/day without loading dose. study endpoints were increase of platelet counts, thrombo-embolic and bleeding complications, and need of transfusion. one female and two male patients, aged between and years, with apache ii scores between and , were diagnosed of hit due to concomitant nadroparin calcium anticoagulation. minimum platelet counts varied from to g/l. hit-antibodies were present in all patients. all patients suffered acute renal failure and were treated with continuous venovenous hemofiltration. treatment with fondaparinux sodium varied from to days. platelet counts improved during fondaparinux sodium. one patient died and autopsy revealed a new myocardial infarction. in another patient recurrent major bleeding resulting in acute tamponade and hematothorax occurred under treatment of both unfractionated heparin and nadroparin as well as under fondaparinux. the third patient suffered a minor bleeding complication. totally, units of erythrocyte concentrates, units of plasma, and units of platelet concentrates were transfused during treatment days.conclusion: treatment with low-dose fondaparinux sodium in patients with mods and hit may be an alternative to treatment with direct thrombin inhibitors. the efficacy and safety need to be determined. caballero zirena a , cortés díaz s , Álvarez terrero a intensive care unit, hospital virgen de la concha, intensive care unit, "virgen de la concha" hospital., zamora, spain introduction: acute pancreatitis is an "acute inflamatory process of the pancreas with variable involvement of other regional tissues or remote organ systems". the definitions of severe pancreatitis accepted generally are: acute physiology and chronic health evaluation (apache ii) score greater than , three or more ranson´s criteria and ct grading system of balthazar. predicting severity of pancreatitis early in the course of disease is very important to prevent and minimize organ dysfunction and complications. from to a total of patients were hospitalized with the diagnosis of acute pancreatitis. of these, patients ( %) were admitted to the intensive care unit. the aim of this study was to compare apache ii score, ranson´s criteria and ct grading system of balthazar for predicting severity and fatal outcome in severe pancreatitis. : patients were identified. there were men and women. the mean age was years (range - ). the most common cause of severe acute pancreatitis were gallstones ( %) and alcoholism ( %). the mean of apache ii score at the admission was , (range - ). most of the patients had higher ct score. all of them had more than three ranson´s criteria. the overall mortality was % ( patients). the intensive care unit length of stay ranged from to days ( mean days). high apache ii or ranson´score at admission significantly determined survival. ranson criterium has the disadvantage of delay. apache ii score is useful in organ failure prediction. balthazar score is superior in predicting pancreatitic necrosis. none of the parameters tested achieved sufficient predictability when used alone. claessens y e , marque s , chiche j d , mira j p , dhainaut j f , cariou a emergency medicine, icu, icu and emergency medicine, cochin hospital, paris, france introduction: saving red pack cell (rpc) transfusion is an important goal in critical care management. the need for rpc transfusion after icu discharge has never been evaluated. prospective monocentric study in critically ill patients admitted between july and december in the medical icu of a teaching hospital. data collected: demographics; saps and lod (d & discharge) ; comorbidity; diagnosis, treatments, icu and hospital lenght of stay ; hb level at icu admission and discharge ; rpc transfusion in icu and during the days following icu discharge with hb threshold and active haemorrhage. information letter was given to patients and families results: population: consecutive pts ( ( ) yrs, saps ( ), (med(sd)). icu mortality %. hb at admission . ( . ) g/dl. . % needed rpc transfusion, threshold . ( . ) g/dl) ; % mortality among rpc transfused pts. , however, with unknown impact on the pituitary-glucocorticoid axis (key mediators: acth / cortisol, affected key metabolite: serum glucose). both, the acth / cortisol system [ ] and blood glucose levels [ ] are increasingly regarded important in intensive care medicine. since the effects of levo on this system may depend on the state of consciousness, we studied respective endocrine effect of levo both in the awake and anesthetized state. we compared respective effects of levo with those of established inotropes, milrinone and dobutamine. awake and anesthetized ( . mac sevoflurane, ventilated) dogs (total: experiments) randomly received levo ( µg/kg plus steps: . - . µg/kg/min), mil ( . µg/kg plus . - µg/kg/min) or dob ( . - µg/kg/min). under steady state conditions (each dose: min) we measured arterial acth-, cortisol-and glucose-levels. statistics: data presented as mean±sem, wilcoxon test, p< . , alpha-adjusted for multiple testing. : levo preserved the levels of acth both in the awake state ( . ± . vs. . ± . pg/ml, baseline and highest drug dose) and during anesthesia ( . ± . to . ± . pg/ml). levo dose-dependently -but insignificantly-increased cortisol under both conditions (awake state: ± , ± , ± and ± ng/ml; anesthesia: ± , ± , ± and ± ng/ml). levo preserved (as did mil and dob) arterial glucose at ~ - mg/dl under all conditions. mil maintained acth in the awake state ( . ± . to . ± . pg/ml) and during anesthesia ( . ± . to . ± . pg/ml), also cortisol ( ± to ± ; ± to ± ng/ml). dob maintained acth in the awake ( . ± to . ± pg/ml) and anesthetized state ( . ± . to . ± . pg/ml), and caused insignificant increases in cortisol ( ± to ± ; ± to ± ng/ml). hfov is an ideal method of ventilation to minimize vili. however, there is limited data regarding outcome in children treated with hfov. we therefore report our experience with hfov at our picu. we retrospectively analysed the chartrecords of all children treated with hfov after failure on cmv between - . the following were recorded: demografic variables, admission diagnosis, pim ii scores, and oi and aado at several timepoints before and after transition to hfov. end points included survival at days post-admission to picu and total number of ventilation days (cmv and hfov). twenty-four children aged day to . years were treated with hfo. seven died and seventeen children survived. non-survivors had a significant higher pim score ( . vs . ), shorter duration of pre-cmv ( vs h). the oi and aado between non-survivors and survivors were . vs . and vs , respectively. both oi and aado did not decrease over time in the non-survivors. total ventilation days were lower in the non-survivors ( vs h).conclusion: hfov was associated with a high survival percentage ( %)in a selected group of children were cmv failed. olsen p , rasmussen m , tønnesen e , zhu w , stefano g deptartment of anaesthesia, Århus university hospital, Århus, denmark, neuroscience research institute, state university of new york, new york, united states exogenously administered morphine has immune modulating effects. the discovery of endogenously synthesised morphine and increased synthesis in response to surgical stress ( , ) and endotoxin infusion imparts a role to endogenous morphine in the immune response. morphine may also affect cancer progression. however, in vitro and xenograft experimental studies illuminating morphine's role in carcinogenesis show conflicting results. the aim of the present study was to analyse human gliomas for the content of endogenous morphine. the study was approved by the regional ethical committee on human research.twelve gliomas were extracted during craniotomy and frozen instantaneously in liquid hydrogen. patients did not receive morphine intra-or postoperatively. pathological analyses confirmed the diagnoses glioma. upon preparation samples were analysed for morphine content with radioimmunoassay (ria) and specificity was confirmed with mass spectrometry. all tumours contained endogenous morphine with concentrations ranging from , ng/g - , ng/g. the identity of morphine was subsequently confirmed by mass spectrometry. the demonstration of endogenous morphine in gliomas suggests its potentially role in carcinogenesis either as an inherent protective measure or as a result of neoplastic transformation. however, it remains to be clarified where the endogenous morphine production takes place. it is also unknown whether the presence of morphine is a pan-cerebral phenomenon or specific to cancerous tissue. the present study revealed a high content of endogenous morphine in human gliomas, providing further support to the idea of potential influence of endogenous morphine in cancer growth. . the majority of infections were exogenous, i.e., the bacterium was introduced into a normally sterile organ, directly from the picu environment. one quarter of the infections were primary endogenous, i.e., the child developed an infection due to a micro-organism present in the admission flora. the death of one child was unrelated to infection. this study shows an infection and mortality rate of % and %, respectively. low level pathogens caused practically all infections which were mainly exogenous following breaches of hygiene. sdd was effective as endogenous infection due to agnb was controlled. scale (gcs),hypotension (systolic blood pressure < mmhg) and hypoxia (cyanosis or pulse oximetry < %)on admission, other traumatisms, head computed tomography (ct) based on marshall's classification (tcdb), intracranial pressure (icp) monitoring,jugular bulb oxygen saturation (sjo ), transcranial doppler (tcd), intracranial hypertension (htic) defined as icp> mmhg.brain edema treatment,length of stay in critical care unit (icu) and hospital,gcs at icu and hospital discharge, and mortality. we also studied hemodinamic and respiratory (pao /fio < ) complications, fever (axilar temperature > , ºc) and electrolytic disorders (sodium < mmol/l or > mmol/l). lewejohann j c , hansen m , zimmermann c , muhl e , bruch h p surgery-icu, universitätsklinikum schleswig-holstein-campus lübeck, lübeck, germany propofol infusion syndrome (pris) is a very rare and often fatal syndrome in critically ill patients undergoing long-term propofol infusion at high doses. until today cases of pris in adults have been described in the literature and of them died. the aim of our representation is to demonstrate the clinical course of a patient with severe rhabdomyolysis subsequent to a multiple trauma and sedation with propofol and to make obvious the importance of this life-threatening syndrome. a year old multiple trauma patient of about kg bodyweight was admitted to our surgical-icu at a university hospital. he had a severe head trauma, a fracture of the cervical vertebra, an ards, multiple rip fractures, severe lower leg fractures with severe vascular damage and the nead of amputation h after admission, fractures of the femora, pericardial effusion and hematoma of the spleen. he received from the beginning on high doses of catecholamnies (norepinephrine, epinephrine), hemofiltration because of renal failure. after resection of his right lower leg one day after admission he received propofol % in a dose range between to ml/h over a time period of days. an initial myoglobin level of µg/l as a result of the multiple trauma on admission decreased to µg/l when the propofol infusion was started with ml/h at first. myoglobin level decreased to µg/l after h. propofol infusion then was increased to ml/h and after h to ml/h. in the following h we saw a dramatic increase of the myoglobin level to a peak level of µg/l. the propofol infusion was stopped then because of the severe rhabdomyolysis and because we thougt about the recently publihed review about the propofol infusion syndrome. soon after removal of propofol myoglobin level decreased rapidly and the patient survived later on. the propofol infusion syndrome is a very rare complication subsequent to propofol use. our patient was severe head injured and received high doses of catecholamines as triggering factors like the patients described in literature. rhabdomyolysis decreased rapidly after stopping the propofol infusion.conclusion: think about the propofol infusion syndrome in patients with severe rhabdomyolysis receiving high dose propofol long-term sedation and consider alternative sedative agents. in northern ireland the process of co-ordinating appropriate and timely therapeutic intervention for severe traumatic brain injury (stbi) is somewhat fragmented. the objectives of the audit were to obtain baseline epidemiological data for stbi in northern ireland and to review current regional critical care management. this was a month prospective audit. stbi patients were identified for inclusion through referrals made to the regional neurosurgical unit (rnsu). during the audit period adult patients were referred to the rnsu. patients were admitted to the regional icu (ricu). % of these patients were male and mostly in the - year age group. % of the injuries were due to falls, . % road traffic accidents and . % assaults. alcohol was detected in % of the patients. icp monitoring was utilised in % of cases, and on day of admission intracranial hypertension (icp > mmhg) was diagnosed in %. this figure fell to % by day . muscle relaxants were used for icp control in % of patients on day and in % on day . over % of individuals developed a ventilator-associated pneumonia (vap) during their ricu stay. this significantly increased the length of stay, but did not increase individual mortality. % of patients required a tracheostomy prior to discharge. there was a high incidence of vap in stbi patients in northern ireland. this may be related to the increased frequency of alcohol intoxication in these patients. heavy reliance on muscle relaxants for icp control may be a further contributing factor. in light of these findings new critical care management guidelines for stbi are being considered.pradl r , chytra i , kasal e , bosman r , ?idková a , ?tepán m dept. of anaesthesia and intensive care medicine, charles university hospital, plzen, czech republic transesophageal doppler was confirmed as useful non-invasive tool for hemodynamic optimisation in group of elective surgery patients. the aim of prospective randomized study was to evaluate the efficacy of early hemodynamic optimisation in multiple trauma patients using transesophageal doppler in comparison with traditionally used basic hemodynamic monitoring (arterial blood pressure, heart rate, central venous pressure). patients with multiple trauma and expected blood loss more than ml admitted and mechanically ventilated on interdisciplinary icu of university hospital in were randomized in protocol group (doppler) and control group (control). hemodynamics of doppler group patients were immediately after admission to icu managed according to the protocol based on data obtained by transesophageal doppler. hemodynamics of control group patients was aimed at generally used resuscitation endpoints -mean arterial pressure (map), central venous pressure, heart rate (hr), urine output and skin perfusion. the age, the apache ii score and injury severity score (iss) were assessed. map, hr and blood lactate level (lact) were evaluated at the time of icu admission (map- , hr- , lact- ) and after hours of icu stay (map- , hr- , lact- ). mann-whitney, wilcoxon, unpaired and paired t-test were used accordingly; p< , was considered statistically significant. a total of patients ( men and women) were enrolled and randomized in doppler (n= ) and control (n= ) group. no differences between doppler and control group in age ( , ± , vs , ± , ), apache ii score ( , ± , vs , ± , ) and iss ( , ± , vs , ± , ) were found. no differences between both groups in map- , map- , hr- , hr- , lact- and lact- were detected, however significant differences between map and blood lactate level at the admission to icu and after hours of icu stay were observed in doppler group (see table) .map- mm hg map- mm hg p lact- mmol/l lact- mmol/l p doppler , ± , , ± , * , ± , , ± , * control , ± , , ± , n.s. , ± , , ± , n.s. n.s. -non-significant, * -p < , conclusion: we conclude that early hemodynamic optimisation by transesophageal doppler in multiple trauma patients can contribute to better tissue perfusion and elimination of oxygen debt. the study is supported by a research grant iga mz cr nd/ - fotouhi ghiam a , abootalebi s , tavana r neurology unit, internal medicine department, al-zahra hospital, bushehr university of medical sciences, bushehr, shiraz university of medical sciences, shiraz ,iran introduction: awareness of the relative prevalence of diseases causing loss of consciousness (loc) in a particular geographic locality could greatly facilitate the approach to patient management. so this study has established to determine the etiologies responsible for nontraumatic loc and hospital outcome in an emergency ward (ew).methods: patients older than twelve years old who present with loc were enrolled in this cross sectional study during the -month period in the ew of the al-zahra teaching hospital. loc was defined as a clinical state manifested by any decrease in level of consciousness ranging from confusion to deep coma. these numbers of patients (accounting for % of the ew patient volume) were identified with a mean age of . years ( . % men). etiology was metabolic in . % , structural in . % and infective in % of patients. it remained unknown in % despite extensive investigation. the most prevalent causes in subgroups were cerebrovascular accidents ( . %) , drug intoxication ( . %), and hypoxic-anoxic conditions ( . %) respectively. the history taking and physical examination were most useful in diagnosis. computed tomography (ct) scan plays an important role in diagnosis of structural causes. lateralizing signs ( %) and nausea/vomiting ( . %) were particularly evident in the presenting symptoms. prognosis is highly dependent on etiology. the admission glasgow coma scale significantly correlated with outcome (p < . ). overall series hospital mortality was . %. most of the patients have been referred to center in less than hours after loc onset. metabolic causes were the commonest overall etiology. the number of undiagnosed cases are significantly higher than other similar domestic and foreign (usa , europe , asia , africa) studies, so emphasis on educating the medical staff to approach to loc and establish cpr committee in ew should be considered. poor outcome was associated with low gcs score. endobronchial blockade represents an alternative to a double-lumen tube (dlt)( ). the wire-guided arndt endobronchial blocker (web, cook inc) can be coupled to a fiberscope and directed as a unit through an endotracheal tube into the area to be blocked. this is of particular interest in patients with a difficult airway in whom intubation with a dlt is contraindicated( ). in contrast to a dlt, that results in complete blockade of either the left or right lung, the web can be positioned in almost any portion of the airway, thereby allowing to isolate a single lobe. we report on the use of the web in a patient with bronchopleural fistula and pulmonary hemorrhage. a yr-old male was admitted after being hit by a truck. orotracheal intubation had been performed at the scene. ct scan revealed fractured ribs, severe bilateral lung contusion, bilateral pneumothorax, pneumomediastinum and -percardium. chest tubes placed in the right thoracic cavity were suggestive of bronchopleural fistula. bronchoscopy revealed a tear in the right lower lobe bronchus and significant bleeding into the airway. due to massive leakage, selective ventilation of the left lung was decided. because of severe mediastinal emphysema, the risk of airway loss during tube exchange seemed high. we decided to perform selective blockade using the web. the web was inserted through the endotracheal tube together with the fiberscope and endoscopically directed into the right lower lobe bronchus with its cuff proximal to the bronchial tear. once the cuff was inflated, the bronchopleural fistula closed, and ventilation improved to normal within minutes. the web was left in place for hrs, and the fistula did not reccur thereafter. the patient's trachea was extubated on day , and he was transferred to a peripheral ward on day in good condition. the web for use in single-lung ventilation with single-lumen intubation proved to be an appropriate tool in an emergency situation caused by severe bronchopleural fistula. intubation with a dlt was considered a high-risk maneuver because of severe mediastinal emphysema and difficult airway. with the web inserted through the endotracheal tube it was possible to isolate the injured right lower lobe from ventilation, to prevent spread of hemorrhage, and to avoid the risk of airway loss during tube exchange. because the web is fixed to the fiberscope with a wire loop, both fiberscope and blocker can be navigated through the tracheobronchial tree as one unit, the web released as soon as in place. our expercience with the web prompts us to recommend this device as a highly practicable alternative to a dlt whenever one-lung ventilation or lobe isolation is required. ( ) campos jh, kernstine kh. anesth analg ; : - .( ) arndt ga, et al., acta anaesthesiol scand ; : - . chaparro m , prieto m , aragonés r , muñoz j , curiel e , arias d , delgado m , ruíz m . intensive care unit, hospital materno-infantil, málaga, spain postpartum haemorrhage is one of the most common causes of maternal morbidity and the primary cause of maternal mortality. only a few case reports have shown that recombinant activated fvii (rfviia) successfully controlled intractable obstetric bleeding ( ). three obstetric patients with massive bleeding and clinical and analytical repercussion, without previous coagulopathy are presented. the use of rfviia in three consecutive obstetric patients with unresponsive lifethreatening haemorrhage admitted to our intensive care unit within the last six months is reported. demographic data, rfviia doses, timing of treatment and diagnosis, among other variables are presented in the floros j , maratheftis n , kolliass , vletsas c , roussos c icu, neurosurgery, evangelismos, athens, greece cerebral microdialysis is a relatively new technique for measuring the levels of brain extracellular chemicals, which to date has predominantly been used as a research tool. there are many reports which emphasize the importance microdialysis to monitor patients with head injury. we describe a significant relation lactate/pyruvate ratio and icp in ten severely head injured patients admitted in the icu in the perioperative period. microdialysis catheters inserted via a bolt fixation device together with the icp catheter. the catheters implanted into the brain to reflect changes in the penumbra of a lesion under computed tomographic control. we used the standardized equipment (cma microdialysis oma ). the lactate/pyruvate ratio is a better marker of ischemia in these patients. there is a strong difference between the values (repeated measured anova) l/p (p< . ) and icp (p< . ) in tracking secondary ischaemic and edema events. the lactate/pyruvate ratio was increased in all ten patients - hours before any change in the ct scan. the lactate/pyruvate ratio is also a better marker of ischemia (p< . ) than lactate alone (p< . ).conclusion: .microdialysis is an effective tool for studying extracellular chemistry and, thus, has great potential for exploring the pathophysiology of secondary brain damage. . the sensitivity and specificity of microdialysis for ischemia and secondary damage are better than icp. . there are data to confirm that microdialysis can be used to direct therapy and influence outcome. moriwaki y , sugiyama m , toyoda h , fujita s , yamagishi s , kanaya k , hasegawa s , kosuge t critical care and emergency center, yokohama city university medical center, yokohama, japan recently, most of trauma patients can be non-operatively treated. one of the most important issues is a few chances of experience of surgery for trauma patients (on-jobtraining). many training courses (off-job-training) for initial trauma care are held frequently, which training course obtain good results in many country. however, it is obvious that on-jobtraining is more effective training method. the objective of this study is to clarify the hourly incidence of trauma patients and surgery for them in one typical urban emergency center and how surgeons are effectively trained for initial care of trauma patients in this center in the education of surgical specialty. our city yokohama is one of the biggest city in japan and has of third level emergency center, including our center, for , people. we examined , of trauma patients treated mainly by surgeons (neck-chest-abdominal trauma cases and polytrauma cases) in our emergency department (ed) including cardiopulmonary arrest (cpa) patients, and of them including cpa who underwent emergency operation. the planning of training in the education of surgical specialty was discussed from a viewpoint of an hourly incidence of trauma patients and surgery for them. trauma patients were mainly transferred during the night shift: . of non-cpa trauma patients ( . %) were transferred during the day shift and . during the night shift per months. surgeries for them were also performed mainly during the night shift: . of non-cpa patients ( . %) and . of all trauma patients (including cpa) underwent surgery during the day shift and . and . patients, respectively, during the night shift per months. we conclude that trainee for surgeon in japan can have adequate opportunity of the initial care and surgery for trauma patients if they belong to the emergency center as an exclusive staff and are on frequent night duty. key: cord- -i q gsu authors: nan title: (th) european congress of trauma and emergency surgery: may – , antalya, turkey date: - - journal: eur j trauma emerg surg doi: . /s - - -z sha: doc_id: cord_uid: i q gsu nan introduction and aims: although liver is well protected by the thoracic cage, it is a frequently injured organ especially by penetrating traumas and also rarely by blunt traumas. retroperitoneally located pancreas and duodenum injury with or without liver injury occur rarely but they are seriously life threatening injuries. for these reasons we aimed to investigate the traumatic liver, duodenum and pancreas injuries as a whole. materials and methods: cases of blunt and penetrating traumas occured in our district are included in this study. in these patients parameters of sex, age, etiology, admission time, stability and physical status on admission, concurrent organ injury, operation type, gradings of injuries, were investigated. results: cases ( , %) suffered from liver injury, while cases ( , %) suffered from hepaticopancreaticoduodenal injury. cases ( %) were caused by penetrating injuries. cases of liver injury group had isolated liver injury whereas cases of the group has additional thoracic injury, cases had great vessel injury, case had orthopedic injury and lastly case had head injury in addition to the liver injury. in the combined hepatic injury group mortality rate was , %. conclusions . in hepatoduodenopancreatic injury group blunt and penetrating injury rates are equal. . duodenum-pancreas injuries occur rarely. liver,with injury rates of cases in this study, is the most frequently injured organ. . mortality rate is higher in the subgroups of patients who admitted to hospital late, and who had concurrent thoracic, orthopedic, and head trauma. background: the incidence of blunt bowel and mesenteric injury (bbmi) has increased recently in blunt abdominal trauma and this is possibly due to an increasing number of high speed motor accidents and the use of seat belts. objective: in this study we sought to identify the factors determining the time of surgical intervention and how they affect the outcome of the patient with bbmi. this was achieved by reviewing our experience as a major victorian trauma service in the management of bowel and mesenteric injuries and how this compares to current literature. methods: a retrospective study reviewing consecutive patients who presented to the alfred trauma centre with blunt bowel and mesenteric injuries over years. results: of the patients with bbmi % were male, % were female. % of the patients underwent a laparotomy, % of patients were treated conservatively and % were diagnosed post-mortem. the times from admission to laparotomy were: - h %, - h %, - h %, - h %, - h %, more than h %, respectively. fast (focused abdominal sonography for trauma) was done in and % of this group had a positive fast. while % of patients had a negative fast and % of patients had an equivocal fast. % overall group did not have a fast. computerised tomography (ct) scans were undertaken preoperatively in % of the patients and showed: free gas ( %), bowel wall thickening ( %), fat and mesenteric stranding or hematoma ( %) and free fluid with no solid organ injury ( %). conclusion: the timing of surgical intervention is mostly determined by the clinical examination and the helical ct scan findings in bbmi. fast lacks in sensitivity and specificity in identifying bowel and mesenteric trauma. delayed diagnosis of more than h has significantly higher bowel related morbidity but not mortality. predictors for the selection of patients for abdominal ct after blunt trauma: a proposal for a diagnostic algorithm introduction and objectives: gastrointestinal and mesenteric injuries (gimi) are not common in trauma, and their diagnosis is frequently delayed. our aims were to determine the reliability of ct scan and to assess the clinical significance of a delayed diagnosis. methods: retrospective analysis of cases confirmed at laparotomy. patients were identified at the severe trauma registry of our hospital, between and . results: we found ( , %) gimi out of patients with abdominal trauma, in a registry with . severe trauma cases included. the mean iss and niss were of and , respectively. mortality was of ( , %) patients, of them unexpected. a ct scan was performed in ( %) cases, and only in were there signs suggestive of a gimi. surgery was delayed for more than h in ( %) patients, the most common reason being a false negative result in the ct scan. there was no significant increase of morbidity or mortality in the delayed diagnosis group. conclusion: the overall incidence of gimi was high in our registry ( % in penetrating and . % in blunt trauma). several factors such as the initial lack of symptoms, a low diagnostic sensitivity of the ct ( % false negatives), and the nonoperative management of solid organ injuries, have contributed to a delayed diagnosis in one of every five patients in our series, but this has not led to a significant increase in septic complications in this group. author to editor: ct scan diagnosis of gastrointestinal injuries continues to be a matter of concern. there is controversy on the clinical significance of a delayed diagnosis of small bowel injuries management of rectal injury: reappraisal of old techniques introduction and objectives: due to immunological functions, conservation of injured spleen following abdominal trauma is very important. for this reason nonoperative management (nom) in the last years has been accepted as the ideal treatment in those patents who are hemodynamically stable and do not require a laparotomy; however in case of multiple abdominal solid organ injuries (soi) nom is controversial. methods: we report on a case of a -years-old patient with spleen and renal injury subsequent to blunt abdominal trauma. ct scan revealed a ois iv injury (third degree in graz classification) and an ois iv renal injury. since chances for successful spleen angioembolization were judged poor by radiologist, a laparotomy and partial spleen resection with preservation of one-third of the spleen was performed. immediately after surgery, angioembolization of the renal injury was successfully performed. results: a contrast enhanced ultrasound (ceus) performed on day and day after trauma revealed a hypertrophy of the residual spleen with diffuse distribution of contrast agent in the spleen parenchyma, confirming functional activity of the organ. morphological and functional evolution of left kidney was normal. conclusions: sequential treatment (surgical preservation of the most injured organ followed by immediate angiographic embolization) could be a valid option in case of multiple abdominal soi; furthermore, ceus is an interesting new tool to determine functional activity of residual spleen. introduction: precise timing of cholecystectomy procedure after biliary pancreatitis is still controversial. the major drawback of interval cholecystectomy is the recurrence of pancreatitis within the interval of - weeks. early cholecystectomy (performed prior to discharge), however, have the disadvantages of increased technical difficulty and conversion rates. methods: we reviewed patients with recurrent biliary pancreatitis among a total number of cases of biliary pancreatitis in-between january and january . results: the mean age was . (range - ), and male-to-female ratio was . ( : ). seventeen patients (% ) had a history of previous cholecystectomy. of these patients, (% ) have had early cholecystectomy, and (% ) have had interval cholecystectomy. the rest of the patients (% , n = ) consists of those who have been scheduled for interval cholecystectomy but have had a recurrent episode during the -week interval (% , n = ) or after the -week interval (% , n = ). conclusion: the majority of patients with biliary pancreatitis do not have any recurrent episodes even if they do not have a surgical or an endoscopic treatment. according to our data, however, an influenced percentage of recurrent pancreatitis develops in patients who do not have early cholecystectomy. therefore, we prefer early cholecystectomy in means of reducing the risk of recurrent pancreatitis during or after the -week interval. introduction and aim: nonoperative management (nom) of splenic injury is currently the most common management strategy in hemodynamically stable trauma patients. aim of this study was to asses if the success rates of - % described, mainly in the north-american literature could be confirmed. methods: we conducted a retrospective study of all patients older than year with blunt splenic injury who were admitted to a level i trauma center. a total of patients were identified with blunt splenic injury during the -year study period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . results: the majority were young men; mean age was years. thirty-three ( %) patients underwent immediate surgical management. sixty-seven ( %) patients were treated with planned nom and ( %) patients underwent angiography and embolization (a&e). we did not encounter early complications following a&e. fourteen patients failed observation due to ongoing bleeding. of these, were treated with splenectomy and three with a&e. the splenic salvage rate after observation was %. the splenic salvage rate after a&e was %. four of the five patients with a rebleeding after initially a&e underwent splenectomy and one patient was treated with reembolization. the overall mortality rate was . %. none of the patients died as a result of splenic injury treatment failure. conclusion: nonoperative management in blunt splenic injuries in our trauma center is a well-tolerated treatment with a success rate of %. the splenic salvage and mortality rate is comparable with the literature which is mainly based on north-american studies. mannheim peritonitis index (mpi) is a scoring system with prognostic significance. we applied mpi to patients with perforative peritonitis (on patients in sri ramachandra medical college) to validate the scoring method. it is a specific score with accuracy and allows prediction of prognosis. aim of the study ( ) to study the incidence and aetiology of perforative peritonitis. ( ) to study the demographics of the study population. ( ) to analyse if mannheim peritonitis index (mpi) is a valid scoring method. p-possum (p < . ) scores in the index surgery. malignancy was the most frequent initial diagnosis in patients with spp and benign diseases in tp. there were no differences on the interval between operations ( ± days tp vs. . ± days spp; p = . ) neither in the number of previous laparotomies (p = . ). tp was associated to emergency index surgery (p = . ) and icu hospitalization (p < . ), mechanical ventilation (p = . ) and vasoactive drugs (p = . ). there were no differences in any of the clinical and biochemical parameters analyzed, neither in sirs (p = . ) or p-possum scores after relaparotomy (p = . ). we found no differences regarding mean hospital stay ( days tp vs. days spp; p = . ) and mortality rate ( % in spp vs. % in tp; p = . ). conclusions: although certain differences exist, the clinical course of postoperative peritonitis seems to depend more on factors other than their secondary or tertiary origin. background and aim: patients with primary acs will often develop a secondary acute respiratory distress syndrome (ards). mechanic pressure is mainly responsibe in pulmonary findings in acs. we aimed the role of aspiration of gastric contents into lower airways in pulmonary complications of acs. methods: the rats were initially divided into five groups (group i-v), and then these groups were divided again into two groups if they are unfed (group ia-va) or fed (group ib-vb). in animals in group i-v intraperitoneal pressure (iap) was applied as follows: , , and cm h o by instillation of isotonic saline solution. results: total scores of lung histopathologic findings were concordant with the degree of iab. when the total scores of histopathologic findings in lungs were compared for each applied iab with control group, the scores were higher in fed animals than unfed animals. histopathologic findings in lungs were observed when increased-iap to mmhg ( cmh o) which was accepted as cut-off value. the comparison of the scores of histopathologic findings in two groups in which the applied iab was lower then the cut-off value were not significantly different from the control group. however comparison of the scores of histopathologic findings equal to or above mmhg were significantly higher then the control group. conclusion: our results show that that pulmonary aspiration related with passive regurgitation in acs has a substantial influence on histopathologic findings seen in this disorder. editor to self: secilmiş bildiri emergency surgery and delayed abdominal closure: results in cases carlos mesquita, marco serô dio, francisco castro-sousa emergency and general surgery departments, coimbra university hospital, coimbra, portugal delayed abdominal closure (dac), in emergency surgery, must be economical, fast to execute and easy to maintain, allowing second look and definitive closure, with minimal prejudices to the abdominal wall. as an alternative to the vacuum closure systems, the aa have been utilising the rotondo and schwab technique (iatsic-dstc course), by the interposition of a plastic towel between abdominal contents and wall. dac has been utilised in patients ( male, female, - ) , median age of ( - ). in five, after abdominopelvic packing for hypovolemic shock conditions. in , after mediastinal and peritoneal decontamination procedures and lavage for septic situations with actual or potential compartment syndrome: three from acute necrotizing pancreatitis, six from dehiscent digestive sutures and two from strangulated hernias. four patients died in the open abdomen situation, one from pancreatitis and three from dehiscent sutures. primary abdominal closure has been possible in : in the cases of packing and in of the of the cases of sepsis. in one case of pancreatitis it has been possible a secondary closure. dac is now accepted like a safe procedure in damage control and compartment syndrome conditions which contributes to ameliorate the results in life threatening situations. than %. this report describes our experience with vacuum assisted closure (vac-)therapy in the management of efs in an oa. materials and methods: nine patients with seventeen high output efs in an oa were treated with vac-therapy from january till january . the abdominal wound was covered with fatty gauzes. small efs were covered with a patch of hydrophilic polyvinylalcohol foam. the entire abdominal wound was covered with polyurethane foam which promotes granulation and seals of the oa preventing further spillage of enteric contents. continuous negative pressure at - mm hg was applied. for large fistulas with protruding mucosa a hole was cut within the polyurethane foam and an ostomy bag was placed over the fistula mouth. surgery with enterectomy was planned - weeks later. results: the vac-dressing was changed every days. three efs closed spontaneously. time between onset of fistulisation and surgery was days (median days). no additional fistulas occured. one patient died postoperatively. conclusions: although previously considered a contraindication to vac-therapy, the oa with efs can be managed with vac-therapy. a taylored application of the foam and a reduced negative pressure seem to allow a safe and reliable way to manage efs. partial enterectomy and abdominall closure is possible after several weeks. introduction: it was the aim of the study to analyze the potential value of microdialysis in the rectus abdominis muscle (ram) compared with conventional monitoring parameters currently in clinical use for the detection of the abdominal compartment syndrome (acs). methods: pigs were anaesthesized, mechanically ventilated and continuously monitored. microdialysis was performed in different abdominal organs, the ram and cervical muscle (distant reference) for glucose, lactate, lactate-pyruvate ratio (lpr) and glycerol. iah was maintained for h. three groups were analysed: control (a), iah mmhg (b) and mmhg (c).cardiopulmonary parameters, urinary output, blood gas analysis and venous lactate were recorded. results: mean arterial pressure and abdominal perfusion pressure remained above clinically defined thresholds during the experiments for groups a and b. in contrast, group c demonstrated a persistent decrease below these thresholds. significant reduction of urinary output was only seen in group c. lactate levels also remained within physiological range in all groups. in contrast, microdialysis revealed a significant increase of lpr in all monitored organs in groups b and c, indicating ischemia and energy failure. of interest, lpr in the ram showed a significant increase already after h of iah in group b. conclusion: microdialysis of the ram detected local metabolic derangements in animals with iah of mmhg while clinically established monitoring tools failed to show organ dysfunction/tissue ischemia. our data suggest that continuous microdialysis in the ram may represent a promising tool for early detecting iah-induced metabolic derangements before manifestation of clinically apparent acs. introduction: to avoid morbidity associated with open abdomen, subcutaneous linea alba fasciotomy (slaf) was introduced for management of abdominal compartment syndrome (acp) in severe acute pancreatitis (sap). we analyzed the efficacy and safety of slaf as a surgical decompressive technique. methods: a retrospective study of a -year period identified patients with sap and acs undergoing slaf. mean age was (range - ) years, were male and had alcohol-induced sap. slaf was performed - days post-admission, in / cases within h. results: the mean (range) preoperative intra-abdominal pressure (iap) was ( - ) mmhg and immediate postoperative iap ( - ) mmhg. the mean decrease was ( - ) mmhg and the decompressive effect was considered sufficient in / cases. two of these developed recurrent acs and required completion laparotomy, as did the with insufficient effect ( - days post-slaf). the mean preoperative sofa score was ( - ) and ( - ) - days postoperatively, the decrease was > in patients with successful slaf. eventually four patients underwent necrosectomy, two following sufficient slaf. the overall mortality and morbidity rates were / and / , no complications were attributed to slaf itself. mean hospital stay was ( - ) days. of the survivors, fascial closure was achieved in two, and planned hernia in four (two with split-thickness skin graft and two with post-slaf hernia). conclusion: slaf is a safe decompressive technique in sap-related acs. it is effective in about - % of cases, but some require completion laparotomy and/or necrosectomy later on. methods: between march and december , patients were managed with vac technique (kci, san antonio). the mean age was . ( - ) , and m/f sex ratio was / . indications were severe abdominal sepsis in patients, mechanical obstruction due to colorectal cancer in patients, pancreatitis in patients, posttraumatic abdominal compartment syndrome patients, evisseration in patients, enterocutaneous fistule in patients. results: as morbidity there were fistulaes and intraabdominal abscess in all patients. four of the patients were died with concomitant disease. there was no mortality related using vac system. thirty five patients ( %) was underwent a delayed primary closure, five underwent secondary healing by granulation, and four underwent split thickness skin grafting. surgical outcomes of severe hepatic injury were retrospectively reviewed. (methods) among patients with hepatic injury treated between and , patients who underwent surgery were included. the study period was divided into early ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , middle ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) and late ( ) ( ) ( ) ( ) ( ) phases, and type of injury, surgical procedure performed and patients' outcome were retrospectively reviewed. (results) ( ) percentage of patients undergoing surgery: % ( / ) underwent surgery in the early phase, % ( / ) in middle and % ( / ) in late phase. ( ) timing of surgery: the numbers of patients underwent laparotomy in er, urgent laparotomy in or, and delayed laparotomy (after h) were ( %), ( %) and ( %) in early phase; ( %), ( %) and ( %) in middle; and ( %), ( %) and in late phase, respectively. ( ) surgical procedures performed: for type iiib (jast grading) cases, hepatectomy was performed in % and hepatorrhaphy was performed in %, giving a mortality rate of % in early phase, . % in middle and % in the late phase. for iiib + ivc/hv cases, hepatectomy was performed in all patients, giving a mortality rate of % in early phase, % in middle and . % in late phase. (discussion) with the increase in nonsurgical management, surgical treatment for hepatic injury is performed preferably in patients requiring immediate response, such as laparotomy in er. the surgical outcome of hepatic injury has been improving, with a survival rate of approximately % for type iiib cases and % for iiib + ivc/hv cases. rifat tokyay, tolga taymaz amerikan hastanesi, istanbul, turkey objective: the aim of this study was to assess the unexpected returns (ur) within month of the adult patients and the pediatric trauma patients initially seen in the _ istanbul american hospital emergency department. design: all urs between . . - . . were recorded. initial diagnosis, final diagnosis, initial treatment, final treatment, reason for readmission, and last medical condition were noted. results: eighty eight urs were recorded. final diagnosis of of these patients were surgical. forty one of these surgical patients had ur due to error in diagnosis and five due to error in treatment. fifty two of these patients returned on the same day or the next day, between nd and rd days, between th and th days and between th and th days. male to female ratio was to . three of the patients were pediatric trauma patients, were between - years, and were over . missed final diagnosis were: acute cholecystitis ( ), acute appendicitis ( ), missed fractures ( ), pneumothorax ( ) liver mass ( ), urethral stone ( ), ectopic pregnancy ( ), diverticulitis ( ), subarachnoid bleeding ( ), others ( ). conclusions: acute cholecystitis, acute appendicitis, and missed fractures were the most frequent surgical causes of urs after emergency department discharges. liberal utilization of abdominal sonography and abdominal ct scan may reduce missed acute abdomen in abdominal pain patients and appropriate radiological imaging and meticulous evaluation of the x-rays may reduce unnoticed spinal, pelvic and facial fractures in trauma patients. editor to self: seçilmiş bildiri olabilir introduction and aim: bacteremia sepsis and septic shock might develop rapidly for the patients with infection in bile path. early diagnosis, surgical treatment and antibiotherapy decrease mortality. in this study, the relation between choledocholithiasis, cholangitis and pancreatitis and treatment methods have been evaluated. method: the demographic features, the treatments, the intensity of the illness and mortality rate of the patients in afyon kocatepe university general surgery clinic between the years background: enterocutaneous fistula continues to be a serious surgical problem. they are related with major electrolyte imbalances, malnutrition and delayed tissue healing. our recent experience with enterocutaneous fistulas is reviewed hereby. methods: we analyzed the charts of all patients with enterocutaneous fistula from january to december . fistulas were assessed for localization, type, output, etiology, use of somatostatin analog and fibrin glue, nutritional support, type of surgical intervention, wound vac, and endoscopic findings. results: we identified patients. fistulas were localized as gastroduodenal in five patients, jejuno-ileal in seven, and colonic in eight. there were enterocutaneous and entero-atmospheric fistulas. endoscopy was performed in patients. output was low (< ml) in , whereas high (> ) in patients. seventeen patients developed fistulas due to iatrogenic reasons, six patients had an underlying malignancy, and three patients developed fistulas after pancreatitis. somatostatin analogs were used in patients. conservative treatment was performed in patients, primary surgical intervention in patients, and secondary surgical intervention in patients. fibrin glue was used in patients and was of benefit to . healing was achieved in patients ( %) after mean . days (range - ). two ( %) patients were died. conclusion: there appears to be no strict rule for treatment of enterocutaneous fistulas. liberal use of endoscopy, fibrin glue as well as restorative surgical intervention all play a major role, and should be employed selectively on an individual basis in the management of enterocutaneous fistulas. aim: in this study we aimed to evaluate the patients whose admitted to neurosurgery and anesthesiology intensive care unit (naicu) between and . matherial and methods: the patients whose admitted to naicu between january and january evaluated retrospectively. diagnosis, age, gender, mortality rate, staying day in icu of the all patients were determined. head traumas were obtained in trauma and multitrauma patients. results: total number of the patients those are admitted to naicu were , and of them because of head trauma ( . %). of the cases were pure head traumas ( . %) or politraumas accompanied with head traumas (ht).the rate of ht was . % of all traumas.there were men, women. mean age of men were . and women were . . staying icu were obtained as . days. the mortality rate was found as . % ( cases). operated cases were ( . %) and the cases followed without any operation were ( . %). mortality rate between operated cases were . % ( ) and nonoperated cases were . % ( ) . ht cases were evaluated by glascow coma scale (gcs) as severe (gcs £ ),intermediate ,moderate (gcs ‡ ).the cases which had gcs £ were ( . %). operated cases were ( . %) and of them dead ( . %). the mortality rate of operated cases ( cases) which had gcs = - were . % ( cases). the number of cases were which had gcs ‡ and the mortality rate of operated cases ( cases) were . % ( cases) at this group. the mortality rate of nonoperated cases ( cases) were . % ( cases). conclusion: the higher rate was ht cases when the trauma patients evaluated and mortality rate of nonoperated trauma patients were higher then operated trauma cases. author to editor: this study send for giving knowledge about traumas which admitted to kocatepe university school fo medicine at a period of months. introduction and aim: this study has been carried out to compare conservative and surgical treatment for the acute pancreatic. method: the treatment processes and radiologic outlook of the patients with acute pancreatitis in afyon kocatepe university general surgery clinic between the years and have been observed retrospectively. results: the average age of the patients with acute pancreatic is and . % of them were women. while conservative treatment was applied on patients, surgical treatment was applied on patients. while the etiologic reason was based on a known source for the . % of the patients, no reason was found for the . % of the patients. ercp was applied for six patients within the scope of conservative treatment. necrotizing pancreatitis existed in five patients. surgical debritment and abdominal washing were applied for four of the patients. acute pancreatitis were diagnosed for the . % of the patients after tomography. one of the patients which had surgical treatment died ( . %). there was no mortality for the patients having conservative treatment. there was not a substantial distinction between the two treatment methods in terms of mortality. ten of the patients had laparoscopic cholecystectomy, ten of the patients had open cholecystectomy (one of the patients with abdominal washing), one of the patients had choledochal exploration with t tube drainage and open abdomen. conclusion: the conservative treatment should be prefered though the treatment ways of acute pancreatitis under discussion. there is not a distinction between the tow methohds in terms of mortality. mü nevver moran, emre gundogdu, ismail bilgiç, hayrettin dizen, mehmet mahir Ö zmen department of surgery, ankara numune teaching and research hospital, ankara, turkey our aim was to compare to efficiancy of different scoring systems as a prognostic indicator in acute pancreatitis. medical records of patients ( female) with mean (range) age of ( - ) years who are diagnosed as acute pancreatitis during years were evaluated according to age, sex, etiologic factors, sirs, apache ii, balthazar scores and ranson scores at admission and at h in order to evaluate the correlation with mortality. the commonest cause was gallstone seen in ( %) cases followed by idiopathic in ( %), alcohol in ( %) and other in ( %). there were ( , %) cases with mortality and ( %) patients underwent operation. in survivors mean (sd) age was ( ) years, sirs score was . ( ) , ranson scores at admission was . ( . ) , ranson scores at h was . ( . ), apache ii score was . ( . ), balthazar scores was . ( . ). in the nonsurvivors group of ( , %) cases, the mean age (sd) was ( ). admission sirs score was . ( . ), apache ii score was ( . ), ranson score was . ( . ), ranson scores at h was . ( . ). when both groups were compared sirs score, apache ii score at the admission and ranson score at h were found to be statistically significant (p < . , p = . , and p = . , respectively), and no differences observed in reference to balthazarscore, hospital stay and icu stay (p > . ). although admission sirs score, apache-score and h ranson score were all found to be important prognostic indicators, sirs seems better and most promising indicator as it is easy to use and not requires sophisticated tests. normal in patients ( %). the appendix was divided by endo-loop in %, intracorporeal suturing in % and endo gia in % of the patients. the meso-appendix division was performed by endoclip ( %), ligasure ( %) and bipolar cautery ( %) . conversion to open procedure rate was ( %). mean operating time was min ( - ). mean hospital stay was . days . major complications were as follows: right iliac artery injury (n = ), bladder injury (n = ), post operative bleeding (n = ), intraabdominal abscess (n = ), appendiceal stump leakage (n = ). minor complications were trocar site infection (n = ) and mechanical bowel obstruction (n = ).there was no mortality. conclusion: la is associated with considerably decreased morbidity and might be considered as the treatment of choice in aa. hakan yanar, cemalettin ertekin, korhan taviloglu, ali fuat kaan gö k, emre sivrikö z, gü lay sarıçam, recep gü loglu trauma and emergency surgery service, istanbul university, istanbul faculty of mediine, istanbul, turkey background: gastrointestinal stenting is increasingly employed to relieve passage. it provides a palliation in inoperable cases or anastomotic strictures. in left-sided colonic and rectal obstruction, it allows decompression for a definitive surgery to be performed. methods: between may and december , patients with acute mechanical intestinal obstruction were treated with endoscopic stenting. localization of malignancy, stenting complications, and surgical interventions were assessed. results: there were a total of patients undergoing gastrointestinal stenting. sixteen patients received gastroscopic stents, four patients with esophageal, eight patients with gastric, four patients with duodenal tumors. stenting failed in five patients ( %), and surgery was required in four patients. nine patients were referred to adjuvant oncologic treatment. fourteen patients received colonoscopic stents; in one patient with a left-colon, in nine patients with sigmoid colon, and in four patients with rectal tumors. stenting failed in seven patients ( %), and six patients were operated emergently with a need for stoma in two patients. ten patients were referred to adjuvant oncologic treatment. no patient was died related with procedure. conclusion: gastrointestinal stenting is a useful adjunct in the treatment of patients presenting with acute mechanical intestinal obstruction for palliation as well as for decompression before definitive surgical therapy. introduction and objectives: internal hernia (ih) is a rare entity which occurs due to the protrusion of an intraabdominal viscus through a normal or abnormal mesenteric or peritoneal aperture. ih can either be acquired through a trauma or surgical procedure, or constitutional and related to congenital peritoneal defects. intestinal obstruction due to ih is very dangerous and lethal because it may be silent, and delay in diagnosis may cause severe abdominal conditions. in this report, we aimed to present patients with ih. methods: seventeen patients who were admitted to our clinic with the diagnosis of ih between january and january were included. patients' demographic data, type of the hernias, type of surgical procedures, length of hospital stay, and prognosis of the patients are evaluated retrospectively. results: there were nine male, eight female patients. mean age of the patients was . years ( - ) . postsurgical ih were seen in eight, paraduodenal in four, transomental in one, sigmoid mesocolon hernia in one patient, and the remaining three hernias were not classified. laparotomy was performed in patients, laparoscopy in and conversion to open surgery in patient. small bowel perforation was found in three patients. seven patients underwent intestinal resection and anastomosis. mean length of postoperative hospital stay was . days ( - ). there was no mortality. conclusion: ih is a rare cause of small bowel obstruction in adults and often present with complications. a high index of suspicion may lead to early surgical intervention and reduce morbidity and mortality. introduction: esophageal perforation is a serious surgical condition in which delay for surgery results in high mortality. application of covered stents is an alternative for emergency surgery. the aim of this study is to analyze the results of esophageal stent application retrospectively. the clinical data and outcome of patients diagnosed and treated for esophageal perforation by endoscopic stent application between february and december were evaluated. results: the mean age of these patients was ( - ) and male to female ratio was / . causes of perforation was mediastinal abscess (n ¼ ), metal stent application (n ¼ ), and balloon dilatation (n ¼ ). stents were applied immediately after perforation in three patients. remained three patients were referred from other institutions and the mean time of delay was h ( - ). perforations were at proximal (n ¼ ) middle (n ¼ ) and distal esophagus (n ¼ ). self expanding covered metal stents were applied in an appropriate position to bridge perforation area in a fashion to cover minimally cm distal and proximal normal esophageal mucosa to all patients under fluoroscopic control. no contrast leak was observed immediately after application and h later. patients were interned and observed under intravenous fluid and antibiotic therapy. except one patient developing transient subcutaneous emphysema no complication was observed. all perforations were closed and the stents were removed at the end of fourth week. conclusion: at the early phase of esophageal perforations covered esophageal stent application can be a better alternative to surgery. introduction: upper gi bleedings are serious conditions which may be life threatening. in seriously bleeding cases the failure of the endoscopic interventions makes surgical intervention necessary. the aim of this study is to present the success rate of endoscopic interventions for upper gi bleeding performed by surgeons. methods: clinical data and the outcome of endoscopic interventions made to of , upper gi bleeding patients admitted to a large community hospitals single surgical endoscopy center between january and september were analyzed retrospectively. results: hemostasis with endoscopic interventions was achieved in ( . %) at initial (n ¼ ) or at second endoscopy (n ¼ ). patients underwent emerging surgery. there was no mortality at the patients treated by endoscopic interventions where as seven patients died after surgery ( . %). conclusion: the outcome of surgery is poor in upper gi bleeding. thus maximum effort should be given to achieve homeostasis by endoscopy. the success rate of endoscopic interventions in this study performed by surgeons is extremely high and satisfying. naomi beks, mariëlle van gameren, sander ten raa, armand van kanten, gert roukema emergency department, maasstad ziekenhuis, rotterdam, the netherlands analgesia use at the emergency department, how evidence-based do we work when dealing with patient with acute abdominal pain? based on a pilot at our emergency department we concluded that it is still common practice to withheld a patient with acute abdominal pain from analgesia till examined by a surgeon or resident. this in contrary to evidence presented in literature which show no negative effect of analgesia use on accuracy of diagnosis in patients with acute abdominal pain. a total of inquiries were send to nurses, physicians and surgeons working at the emergency department of teaching hospitals in the netherlands. we questioned their standard policy on analgesia use in acute abdominal pain. a total of completed inquiries were retrieved, resulting in a response rate of %. there is a difference between the response of nurses and doctors, versus %, respectively. compared to nurses, doctors are more optimistic about the moment analgesia is given. remarkable is the result that % of patients do not receive any analgesia even after examination by a surgical resident and % of the patients have to wait till they are examined by a surgeon is outshining. patients are still withheld from analgesia till a resident or surgeon examines them even though this is not evidence-based medicine. there is no consensus in the netherlands on analgesia use in patients with acute abdominal pain in the emergency department setting. a national guideline for patients with acute abdominal pain is recommended. introduction and objectives: the benefits of laparoscopic appendectomy remain debated in literature. methods: this is a monocentric, retrospective study to evaluate the differences between open and laparoscopic appendectomy for length of hospital stay, wound infection, major complications. retrospective surgical site infection rate evaluation has been possible only for in hospital stay, no further clinical data has been collected regarding outpatient follow-up. results: from january to october we reviewed patients undergoing surgery for acute appendicitis. patients underwent laparoscopic appendectomy ( . %) (group a), patients open appendectomy ( . %) (group b). two different surgical teams, one for laparoscopy and one for laparotomy, performed the procedures. complicated (perforated or gangrenous) appendicitis were in group a ( . %) and in group b ( . %). mean hospital stay group a was . days, . (p = n.s.) group b. mean hospital stay in complicated appendicitis group (a + b) was . days, in uncomplicated (a + b) was . days (p < . ). laparoscopic appendectomy was associated with lower wound infection rate (group a . % vs. group b . %) (p < . ). infection rate in complicated appendicitis (a + b) was . %, in uncomplicated cases (a + b) was . % (p < . ). no mortality in both groups has been observed. one conversion in laparoscopic group was reported. no cases of deep surgical site infection have been observed. conclusions: laparoscopic appendectomy seems to be associated to a lower rate of wound infection. length of hospital stay and rate of major complication seems to be related to gangrenous or perforated appendicitis and not to the surgical technique. significantly lower on postoperative third and seventh day, respectively. conclusions: in this model of general peritonitis, mb significantly reduced adhesion formation. mb is blocking the tnf alpha early postoperative days. early blocking of the activity of tnf-alpha after peritonitis resulted in lower rates of adhesion formation macroscopically. the tnf-alpha can be an important factor for postoperative adhesion formation. results: laparoscopic surgery was performed in patients due to peptic ulcer perforation. seventy-five patients ( %) underwent laparoscopic repair alone or laparoscopic repair with omentoplasty. in the remaining patients ( %), the procedure was converted to laparotomy. amongst ( men / women) patients who were included into the study, the mean age was . ( - ) . in patients ( %, / ) preoperative diagnosis was unclear and the patients were taken to operating theater due to acute abdomen. in all patients, but one, the duodenal defect was repaired by primary suturing; in one patient, simply intra-abdominal lavage and drainage were performed because the omentum was found to seal the defect. omentoplasty was performed in ( %) patients. one and two abdominal drains were used in ( %) and ( %), respectively. mean hospital stay was . ( - ) days. morbidity was % (n = ). early morbidity included bile leakage in three patients, postoperative intra-abdominal bleeding in one. one patient had trocar site hernia. one patient ( -year-old female) died on postoperative day due to sepsis in the intensive care unit. conclusion: laparoscopic primary repair is a safe and efficient method in peptic ulcer perforation. akın tarım, sedat yıldırım, cem aydogan, gö khan moray, mehmet haberal department of general surgery, baş kent university, ankara, turkey introduction: approximately % of multiple trauma patients sustain concomitant burns. complicated management issues arise in these patients as burn and trauma care often conflict. the purpose of this study was to describe the different types of burn injuries seen in burn patients with additional forms of trauma, and to report the survival rate for this patient group. methods: in this retrospective study, patients were admitted to our center with concomitant burns and trauma from - . this study retrospectively analyzed the types of burn injury, extent of burns, types of other trauma associated with the burns, and outcomes. results: of this study group, were male. average age was . ± . . mechanisms included motor vehicle collisions, electrocutions with subsequent falls, one plane crashes, lpg or oxygen tube explosions and other type of explosions. average burn size was . ± . %. the most common traumatic injury was fracture and head injury ( ). management of fractures in burn patients and resuscitation in head injured burn patient represented the most common conflicts in patient care. there were deaths in this series. conclusion: burns are a rare but significant complication in the trauma patient. outcomes are dependent on rapid trauma evaluation as well as effective resuscitation and wound management. given the complexities of their problems, these patients necessitate a balanced multidisciplinary approach to maximize their potential for full recovery. thoughtful compromise between trauma and burn priorities is frequently necessary. introduction: fournier's gangrene (fg) is a rapidly progressive, polymicrobial, synergistic necrotizing fasciitis. in this study we aimed to determine the risk factors effective on the prognosis of the disease. methods: the files of consecutive patients operated for fg during - were investigated retrospectively. the surviving and mortal groups of patients were compared for demographic data, etiological factors and treatment modality besides length of hospital stay and treatment cost. results: the mean age of the patients was . years and female/ male ratio was / . mortality was seen in ( . ) patients and significantly high in female ( . %) (p = . ). the most frequent comorbid disease was diabetes ( . %), etiological factor was perianal abscess ( . %) and etiological source was anorectal region ( . %); and they did not affect the mortality. the most frequent cultivated microorganism e.coli ( . %) was significantly high in the mortal group (p = . ). imipenem was the antibiotic used in all of the patients. the mean number of debridements was , and intestinal diversion was utilized for . % of the patients. fecal decontamination ( . %) of the patients was performed by surgical ( ) and nonsurgical ( ) methods. the length of hospital stay in surviving group ( . days) was higher than the mortal group ( . days) (p = . ). there was no difference between two groups of patients for the length of hospital stay (p > . ). conclusion: female gender, duration of complaint prior to treatment, fournier gangrene severity point and cultivated microorganism (e.coli) were the factors affecting the mortality. aim: post-traumatic coronary aneurysms (ptca) are extremely rare. we report an asymptomatic ptca in a young patient. case: -year-old male, with no significant previous history. admitted intubated and ventilated after a car runover. he had cerebral, thoracic, abdominal, pelvic and lower extremity trauma. initial assessment disclosed eight left fractured ribs with associated pneumothorax; fast was negative, head ct normal. thoracic ct reveled small bilateral hemothoraces and pulmonary contusion, with no evidence of vascular lesions. he also had a fibular, clavicle, and pelvis fracture. control angio-ct at day showed pleural and pericardial effusions and raised the suspicion of left descending ptca, subsequently confirmed with mri. the patient remained asymptomatic with normal ekg and cardiac enzymes throughout this period. a coronariogram confirmed the ptca, that had undergone spontaneous thrombosis, with no further treatment required. discussion: coronary aneurysms (true or false) may occur after blunt thoracic trauma. ptca normally result from controlled rupture post myocardial infarction or cardiac contusion, with gradual wall rupture. although in this patient the diagnosis was made without any clinical manifestation, suspicion is the main key for diagnosis. aneurysms must be considered as a differential diagnosis in patients with thoracic trauma history associated with arterial emboli, congestive heart failure, arrhythmia, chest pain or dyspnea. conclusion: every trauma victim must be exhaustively evaluated. in any case a careful follow-up must be made in thoracic and abdominal trauma victims to decrease the possibility of missing injuries. aim: acute mesenteric ischemia (aim) continues to be highly morbid cause of emergency. early diagnosis and treatment may reduce severity of the disease. the aim of this study is to investigate causes for morbidity and mortality in ami patients. materials and methods: this retrospective study has patients of ami. the patients were classified according to their age, sex, clinical and laboratory findings, comorbidity, etiology, operative procedures, complications. and effect of these causes on mortality and survival was investigated. the results were statistically evaluated. results: of patients were male and were female. mean age was . for females and . for males. the most common symptom was abdominal pain. only one third of patients had diagnosed correctly before operation. amylase was high in % of patients. plain abdominal graphy showed air-fluid levels in all patients. mortality rate was high in patients aging over years (p < . ). there were no relationship between mortality and gender. the patients those who had massive small bowel and colon resection developed high mortality rates ( %). resection of ileocaecal valve also increased the mortality. five patients all of whom developed perforation died. majority of survivors had surgical intervention during first h of ischemic attack. the patients those died due to perforation had delayed surgical intervention. • there is no benefit of routine laboratory findings in early diagnosis of ami. • massive intestinal resection, absence of ileocaecal valve and stomal procedure increased mortality rate. • delay in diagnosis and treatment also caused high mortality. cem aydogan , yahya ekici , ebru sakallıoglu , sedat belli , mahir kırnap , emin tü rk , mehmet haberal department of generel surgery, baş kent university, ankra, turkey institute of burn, fire and natural disaster, baş kent university, ankara, turkey introduction: more than % of all burn patients can be managed on an ambulatory basis. appropriate management of minor burns minimizes further damage. methods: the epidemiology, demographics, and outcomes of ambulatory acute burn patients were reviewed at our center between and . patients who were in aba referral criteria were excluded from the study. results: the patients' mean age was . ± . years (range, - years) . the percentage of patients whose first admission was to our center was . %; the percentage of those referred from another center was . %. scald burns were the most frequently reported cause of burns ( . %). the house was the most frequently reported place at which the burns occurred ( . %). the percentage of stoverelated burns was . %. the upper extremities ( %) and lower extremities ( %) were the most frequently reported places on which the burns occurred. mean tbsa affected and superficial partial thickness burned area were . ± . % and . ± . %. the mean follow-up and the mean number of dressings applied to the burns were . ± . days (range - days) and . ± . (range - ). four patients ( . %) needed skin grafting, and two patients ( . %) were hospitalized for debridement without grafting. conclusions: close follow-up is important in minor burns to minimize further damage. burn centers must play an active role in the care of all burns. the devastating effects of burns can be prevented and decreased by educational programs. stove-related burns remain a problem in turkey. results: mean age was . ± . years. the percentage of the male patients was . %. the mean tbsa affected was . ± . %. the percentages of high voltage electricity injury, lightning injury, and lowvoltage current injury were . , . , and . %, respectively. place of employments ( . %) and outdoors ( . %) were the most frequently reported places at which the burns occurred. the burns mostly occurred in urban areas ( . %).upper and lower extremities were the most frequently affected regions. the percentages of the patients who underwent debridement, grafting, amputation and fasciotomy were . , . , . , and , %, respectively. the percentage of patients who had additional trauma other than electric burn injury was . %. mean hospital stay of patients was . ± . days. the mortality rate was . %. majority of the patients died from septic complications ( . %) conclusion: aggressive multidisciplinary treatment modalities and early debridment, grafting and/or flaps are very important. special considerations are required for public education about electricity and its hazardous effects. governmental supports are needed both in prevention and in therapy. ahmet erkilic, harun analay, sabri mehmet barazi, halil Ç eliksö z, bayram rü zgar burn center, av.cengiz gö kçek general hospital, gaziantep, turkey early staged excision and autogenous skin grafting or temporarily wound coverage with biologic dressing or allograft until autogenous donor sites are available is now conventional treatment for fullthickness burns. typically, tangential excision is performed with a handheld knife thus it may be difficult to control bleeding from the wound bed and difficult to assess the suitability of underlying for accepting a graft. a hydrosurgery system -versajet Ò is available that can be used for tangential burn wound excision. this device offers an easy and more precise way of excising eschar and is particularly useful excising nonviable tissue from the concave surfaces of hands and feet, as well as the eyelids and ears. totally, hydrosurgical tangential excision (hte) were performed for patients with burn, in our burn center in one and half year. several times performing were needed . % of patients (n = ). wounds of patients with - % total burned body surface were covered autogenous skin grafts subsequent to hte. more extensive wounds were covered with biologic dressings temporarily and wounds as soon as suitable autogenous skin grafting was performed. at this interval, burn wounds were shrunk average - % and donor skin poverty was increased. frequently, delaying to excision and coverage of burn wounds may be awful. early excision and early coverage of the burn wounds must be a golden standard for the current treatment of the burns. also hte is becoming a candidate to golden standard at burn treatment. introduction: in our previous study, we examined the treatment results of burn patients older than years, and found a significant increase in mortality with increasing age groups. the aim of the present study was to reevaluate this patient group and also compare these results with the previous study period of to . patients and methods: one-hundred and fifteen patients older than years were admitted to our burn unit during the last years. these patients were divided to three groups with respect to their ages (group a: - years, group b: - years, and group c: older than years). demographic properties of patients, etiology, and extend of burn injury, co-morbidity, length of hospital stay, and mortality rates were recorded. results: during the last years, demographic properties and etiology of burn injury did not changed significantly. however overall survival rate increased from . to % and ld values for burn injury are significantly increased in all age groups. length of hospital stay is significantly decreased in all age groups, especially in group b (from . to . days). co-morbidities did not change over time and sepsis is the leading cause of death in patients ( %). conclusion: in our burn unit, treatment results in patients older than years showed a significant improvement during the last years. introduction and objectives: patients who has weakness of mental and motor functions are under more risk than normal burned injured population. we would like to focus on burn injured cases that have co-exiting morbidities. methods: comorbid patients who applied to burn unit due to burn between january and july were taken into evaluation. comorbid etiologies were seizures ( case), mental retardation ( case) and down syndrome ( case), respectively. results: during follow-up period, one of the cases had aggrevated petit mal convulsion due to devastating effect of burn injury. in one case there was grade pressure sore and urethral infection who was paraplegic patient. weight loss was observed on a geriatric case that had seizure due to insufficient nutrition. conclusion: burn injured cases that have comorbidity, special care, and additional measures should be taken. psychological, neurological or geriatric causes are the factors that affect the recovery of burn defects and success of operation. detailed evaluation of coexisting disorder and additional care are the key points of the comorbid burn patient. aim: the present study was aimed to evaluate the gender differences of burned children in clinical course and outcome. methods: children (aged - ) admitted to our burn center between august and january were retrospectively evaluated. total burn surface area (tbsa), levels of some acute phase markers, grafting need, and hospitalization time were analyzed. results: sixty three patients [ ( . %) males, ( . %) females] were included in this study. the mean age was respectively . ± . years and . ± . years in males and females (p = . ). the mean tbsa burned respectively . ± . % and . ± . % in males and females (p = . ). the mean wbc count in admission was significantly higher in males than females ( . ± . x - /l vs. . ± . x - /l, p < . ), but there was not any significant difference between females and males in crp count. (p = . ). skin graft operation was performed in ( . %) of males and in ( . %) of females (p = . ) and also, we did not find any significant difference between males and females in hospitalization time ( . ± . days vs. . ± . days, p = . ). conclusion: although many studies have showed that critically ill females have a better outcome than critically ill males, any significant difference was not observed between burned male children and burned female children in most of the clinical parameters, except white blood cell counts. introduction and objectives: the goal of our study was to evaluate the preparedness of hospital physicians, emergency physicians and paramedics in the eu and the usa for a mass casualty incident. methods: an online survey which contained questions was sent to the head of the department of trauma-surgery, emergency medicine and to paramedics by e-mail. among other things we questioned: existence of a hospital emergency-and disaster plan and the yearly exercise of the plan. coordination with the local rescue service as well as existence of decontamination facilities were asked for. replies were analysed statistically with the one-way analysis of variance (anova) test and the turkey-kramer multiple comparisons test. results: altogether, assistant and emergency doctors as well as paramedics answered. % were not conscious of the details of the disaster plan of her hospital while % did not know the plan at all. % of the interviewed doctors did not know her area of responsibility in the case of an internal emergency. % of the interviewed know what to do in case of an mci. % of the interviewed doctors and % of the paramedics did not know her area of responsibility at the treatment of patients contaminated chemically, nuclearly or biologically. conclusions: the preparedness for doctors and paramedics in hospitals and in the preclinical rescue service in the eu and the usa on a mci (mass casualty incident) are insufficient. the emergency medical education of doctors and paramedics should be adapted to the terrorist threats disaster preparedness of chief physicians and hospitals in germany, the eu and the usa for a mass casualty incident introduction and objectives: the goal of our study was to evaluate the preparedness of hospitals in the eu and the usa for a mass casualty incident. methods: an online survey which contained questions was sent to the chief physician of hospitals by e-mail. things we questioned: existence of a hospital disaster plan and the yearly exercise. coordination with the local rescue service as well as existence of decontamination facilities. replies were analysed statistically. results: altogether, senior consultants, of this senior consultants from germany as well as senior consultants from the usa and the eu, answered. all people claimed to have a hospital disaster plan. % of the german hospitals made an exercise of the plan with tabletop exercises. however, % of chief physicians in the usa and the eu made an exercise of the plan regularly with table top exercises. % of the hospitals in the brd did not have any decontamination possibility of nbc (nuclear, biological, chemical) contaminated patients, while % of the hospitals had this possibility on the spot in the eu and the usa. conclusions: the exercise of the hospital disaster plan in germany is insufficient, compared with the hospitals in the eu and the usa. furthermore the german hospitals are badly equipped in the worldwide comparison to decontaminate patients on the spot. we demand for an increase of the ''exercises'' of the hospital disaster plan (also by tabletop exercises) as well as an improved equipment for the decontamination of the injured. in the two big earthquakes that occurred in the north-west of turkey in in short intervals within less than months there were approximately , cases of death and around , were injured. there were several other deadly earthquakes in the whole world the same year. main survival factors in the post-disaster period are prevention from injuries as well as detecting the location of the survivors and the rescued. the reality of the situation of persons who lost their lives in such traps, the severely injured, and the ones who survived must be analyzed. rational prevention methods against possible crush injuries due to collapsing buildings have been con-sidered in the light of the field and simulation experience we gained and suggestions have been presented to reduce mortality and morbidity. our work has been conducted with the aid of medicine based on proof, appropriate observation as well as sampling and experimental methods. a global approach concerning worst case scenario led by earthquakes has been proposed taking into consideration the different models of behavior in different countries and societies to increase the chance of survival to a maximum and to reduce injuries to a minimum level. due to unlimited possibilities of travelling nowadays, it is not possible to estimate the place, the country or the circumstances under which a person could experience a disaster. carlos alberto godinho cordeiro mesquita ordem dos mé dicos, colé gio de competê ncia em emergê ncia mé dica, lisbon, portugal in portugal there are three official ways to differentiate: specialty (vertical), subspecialty (vertical) and competence (transversal). doctors may access to a subspecialty or a competence as a second step, after a specialty. portuguese medical association (ordem dos mé dicos, om) is the official entity that regulates all the medical and surgical activities in portugal, being his duty to protect the public interest. doctors must be registered with to practise medicine or surgery. om also sets the standards and outcomes for basic medical education. after graduating from medical school and completing their foundation training, doctors usually complete a third and even a fourth stage of postgraduate training, whose standards are set by the colleges. these are responsible for promoting the development of postgraduate medical education and training for all, establishing standards and requirements and making sure they are met across the country. emergency medicine exists as a competence since and goes behind the prehospital acute care. this college is strongly interested in the development of an autonomous college of competence on emergency surgery (trauma surgery included) and it exists, since , an official national working group on emergency surgery education (grupo de trabalho para a formaçã o específica em cirurgia de emergê ncia), with representatives of general surgery ( ), neurosurgery ( ), orthopaedics ( ), thoracic ( ), vascular ( ) , urological ( ) and paediatric surgery ( ) . the general surgeons, iatsic members and dstc instructors, also integrate and lead the national steering committee for dstc, after a recently signed memorandum of understanding. author to editor: the point of the situation, from an organisational point of view, about trauma and emergency surgery education in portugal and the importance for the relationship with portuguese speaking doctors around the world introduction and objectives: practical training in emergency medicine should be an important part of undergraduate education, as every physician should be able to handle medical emergencies. however, adequate practical training is time and personal consuming. this work seeks to determine whether medical students (peer to peer education) can be trained as course instructors in emergency medicine training and if there are differences in the training outcome. methods: the undergraduate training consists of both basic life support (bls) and advanced cardiac life support (acls) courses. after both courses, students have to pass a multiple choice test and have to complete a course evaluation. during the instructor training, all candidates, students and physicians were trained together with theoretical and practical training and were furthermore supervised during their first courses. results: until now, bls and acls trainings were conducted of which % (bls) and % (acls) were run by medical students. there were no significant differences in the written examinations nor in the course evaluations ( = very good to = unsatisfactory) between courses by staff ( . for bls and . for acls) or medical students as trainers ( . for bls and . for acls, respectively). conclusions: peer to peer education can be a useful tool in the manpower consuming practical training in emergency medicine without influencing the learning outcomes or the evaluation. background: non-invasive pelvic ring stabilization (pelvic binding, pb) in shocked patients is recommended by state and institutional guidelines regardless the fracture pattern. the purpose of this study was to determine the adherence to the guidelines, radiological efficacy of the technique, and identification of potential adverse effects associated. methods: analysis of the prospective database of a level trauma center on high-energy unstable pelvic fractures. collected data included patient demographics, physiology, fracture classification, application, and timing of pb, associated injuries and outcomes. pre and post-pb radiographs were compared to evaluate the changes in fracture position. the potential effects of pb on soft tissue complications were assessed by independent experts. results: during the -month study period a total of pb was performed on patients with high-energy unstable pelvic ring injuries. stable patients were less likely to get pb ( %) than shocked patients ( %). the adherence to guidelines was %. analyzing fracture types (ao/ota classification) of shocked patients the adherence was: b %, b %, b %, c %, c %, c %. better radiological appearance was detected in b %, c %, c %, c % types. one femoral artery, four bladder and three rectum injuries were identified in patients with pb applied. there were no association between the complications and the pb. introduction and objectives: in our country, the vast majority of circumsicion is stil not done by physicians. in this study, we evaluated the patients who treated for circumsicion complications in our clinic. methods: a total of children who treated for cicumsicion complication in our clinic between and were evaluated. results: mean age during circumsicion was . months ( - years). out of had not been circumsiced by physicians. complication was bleeding in patients, burred penis in , complete glanular amputation in , and urethral fistula in patient. one suture was enough to control bleeding for the majority of patients with this complications, while general anesthesia required for treating other complications. conclusions: significant number of children still undergo circumsicion between and years old (fallic period) in our country. the vast majority of complications occur when circumsicion is not done by physicians; significant number of these complications require revision under general anesthesia. as a result, circumsicion is still a challenging both public and social problem in our country, and results in high morbidity because the majority is not done by experienced hand. arda demirkan , salih ekinci , onur polat , serdar gü rler , mü ge gü nalp , semih baskan department of emergency, ankara university, ankara, turkey department of general surgery, ankara university, ankara, turkey objective: multiple trauma involves at least two systems of body which abdomen, extremities, chest and head-neck. the aim of this study is to show relationship between the severity of injury and electrolyte changes in multiple trauma patients. method: this is a prospective study which adult multiple trauma patients ( male and female) were studied. the median age was . (range - ) . in all cases, serum sodium, potassium and calcium levels and injury severity score (iss) were obtained on admission to emergency department after trauma. severity of injury was estimated with iss. degree of association between variables was evaluated by spearman's correlation coefficient test. results: the mean sodium levels was . mmol/l, the mean potassium levels was . mmol/l, the mean calcium levels was mg/ dl. there was a negative correlation between calcium and iss, and this is statistically significant (p = . ). while other serum electrolytes (sodium and potassium) did not change according to iss. conclusion: electrolyte abnormalities often occurs in critical ill patients, this imbalance has a prognostic importance particularly in multiple trauma patients. electrolyte changes determinated in early period and appropriate resuscitation is indispensable. we suggest that low calcium levels can be considered for the severe injury. this condition may be related to interrupted calcium mechanism in critical trauma patients. introduction and objectives: preparation is essential to meet the challenge of optimal care for a sudden unexpected surge of casualties due to a major incident. by definition, requirements exceed standard care facilities in qualitative and or quantitative respect and interfere with regular patient care. to meet the growing demand for disasterpreparedness a permanent facility to provide structured, prepared relief in such situations was developed. we describe this facility. objectives: the aim of this study is to find out the effects of melatonin on the erythrocyte and kidney malodyaldehyde (mda) and superoxide dismutase (sod) levels in radiocontrast nephropathy. methods: in this study, new zealand type rabbits were included. the test subjects were divided into four groups six rabbits in each (control, sham, hydration and melatonin groups). blood samples of all subjects were taken in beginning of study. renal tissue was obtained in the control group. the rest received ml diatrizoat sodium intravenously. hydration group was given ml/kg/day iv bolus . % nacl. melatonin group was given mg/kg iv melatonin four times with the same dose isotonic. it was blood and renal tissue samples were taken at the th and nd hours. mda levels were determined with ohkawa method, sod enzyme activity was studied with ransod (randox,uk) superoxide dismutase assay kit. results: the mean renal sod value of the melatonin group ( . ± . nmol/g) was significantly higher than in the sham ( . ± . nmol/g), control ( . ± . nmol/g) and hydration groups ( . ± . nmol/g) (respectively p = . , . , . ). the mean renal mda value of melatonin group ( . ± . nmol/g) was significantly lower than sham ( . ± . nmol/g) and hydration groups ( . ± . nmol/g) (p = . , . respectively). conclusion: melatonin has a curative effect on the lipid peroxidation caused by the contrast substance in the kidney. in preventing nephropathy resulting from contrast substance, giving melatonin together with hydration can be more effective than giving hydration alone in the clinic. in addition, all datasets entered with voice recognition were complete and available in the system as soon as the patient left the trauma bay. compared to the retrospective cohort % of the patients had incomplete data concerning the vital parameters. conclusion: the introduction of voice recognition technology real time produces more accurate data more quickly. we are convinced that high tech technology will increasingly assist the trauma surgeon and if we are correct it looks like the prediction of don trunkey will come true viz: ''the current possibilities for using digital resources within medical care are merely limited by our own imagination'' introduction and aims: despite the improvements in the diagnosis and treatment, mortality rates are still high following urgent operation for perforated peptic ulcer (ppu). in this study, we analyzed the factors affecting the survival of the patients operated for ppu. materials and methods: the records of the patients operated due to ppu between january and january were analyzed. age, sex, american society of anesthesiology (asa) score, alcohol consumption, smoking, nonsteroidal antiinflammatory drug (nsaid) usage, the time passed from the onset of symptoms to operation, history of previous peptic ulcer disease, diameter and localisation of the ulcer, surgical technique, length of stay, postoperative complications and mortality rates were determined. results: the mean age was and asa score was . primary suture and omentoplasty was the selected procedure in patients while gastrostomy was added to primary suture to another patients. twenty nine patients received primary suture, truncal vagotomy and gastroenterostomy and seven underwent resection. the mean length of stay was days. three patients suffered from atelectasis and pneumonia, one from empyema, eight from surgical site infection and four from leakage. twenty three of the patients experienced respiratory failure and died of multi organ deficiency ( . %). age and asa score were found as factors significantly affecting survival. abdominal cocoon (idiopatic sclerosing encapsulating peritonitis) is a rare disease of the peritoneum which refers to a condition where there is a total or partial encasement of the small bowel by a dense fibrous membrane. the abdominal cocoon is probably a developmental abnormality, largely asymptomatic, and is found incidentally at laparotomy or autopsy. it is an unusual cause of intestinal obstruction. pre-operative diagnosis cannot be often made correctly. complete recovery is expected after removal of the membrane surgically. a -year-old man presented with abdominal pain, swelling and vomiting of two day's duration. there was no history of peritonitis, abdominal surgery or tuberculosis. physical examination of the abdomen revealed a distended abdomen, hypoactive bowel sounds, tenderness and rigidity in the whole abdomen. a tender lump was palpated in the right lower quadrant. routine laboratory workup revealed a total leukocyte count of cells/ml, and normal serum chemistry. pa x-ray of the chest normal. plain abdominal x-ray showed few air-fluid levels. contrast-enhanced abdomen-pelvis computed tomography showed a dilatation up to . cm in small intestine. emergency laparotomy was performed through a right paramedian incision. in exploration, small bowel was observed to be dilated, its mesentery was edematous and the whole small and large bowel was covered by a dense whitish and approximately mm thick membrane. the membrane was partially removed, and adhesiolisis of the intestinal loops was performed without bowel resection. after surgery, the patient was tolerated diet without any complication and was discharged, on hospital day . methods: the data of al-ain hospital trauma registry were prospectively collected over a period of years ( ) ( ) ( ) ( ) . all trauma patients who were admitted to intensive care unit (icu) were included in the study. univariate analysis was used to compare gender, age, nationality, mechanism of injury, systolic blood pressure and gcs on arrival, the need for ventilation, presence of head or chest injuries, ais for both the chest and head injuries and the iss. significant factors were then entered into a direct logistic regression. results: there were patients ( males). mean (range) age was year. . % were uae nationals. the two most common mechanisms of injury were road traffic collisions ( . %) followed by fall from height ( . %). the median (range) iss was . the mean (sd) icu stay was . ( . ) days while the mean (sd) hospital stay was . ( ). the overall mortality was . %. significant factors that have affected mortality included gcs (p < . ), mechanism of injury (p = . ), age (p = . ) and iss (p = . ). the best gcs that predicted mortality was . while the best iss that predicted mortality was . conclusions: rta is the most common cause of serious trauma in uae followed by falls. gcs is the most significant factor that predicted mortality in icu trauma patients. introduction: glutamine is an antioxidant which enhance glutathione levels. in this study our goal is to assess the safety and efficacy of parenteral glutamine on antioxidant capacity and organ dysfunction in septic patients. methods: prospective, randomized study of the septic patients admitted to the surgical intensive care unit (icu). patients were randomized to receive either glutamine (group glu, n = ) or glutamine + n-acetylcysteine (group nac, n = ) or a control supplement-placebo (group pla, n = ) parenterally up to days. organ dysfunction and clinical outcomes were assessed by daily total sequential organ failure assessment (sofa) score over the -day study period. serum total antioxidant capacity (tac) was measured by cuprac method. also we evaluated procalcitonin (prc) and c-reactive protein (crp) levels as infection markers on days , , , and . results: there was no significant differences between the patients' ages, apache ii, sofa scores and infection markers on the day of admission. group glu and nac showed a significant decline of daily total sofa score (glu: p < . , nac: p < . , pla: p = . ) and crp levels (glu: p < . , nac: p < . , pla: p < . ). but prc levels decreased significantly over time just in group glu (glu: p < . , nac: p = . , pla: p = . ). on the other hand, serum tac measurements were not significant. the mean icu length of stay were glu: ± . , nac: . ± . , pla: . ± . (glu/nac: p < . , glu/pla: p < . ), but in group glu the overall mortality was significantly lower than nac and pla groups (glu: %, nac: %, pla: %). conclusion: in septic patients, parenteral supplementation with glutamine results in significantly better recovery of organ function compared with nac and pla. we coud not find any significant relationship between tac levels and clinical outcomes. background: acute renal failure (arf) requiring renal replacement therapy in icu setting is related to high mortality. the purpose of the study is to assess any indicators of improved survival. materıal and methods: retrospective study of trauma patients, who underwent haemodialysis over a period of years (patients with penetrating, blunt trauma and burns). information on pre-hospital and in-hospital resuscitation, trauma scores and physiological scores and daily icu records were collected. the majority of patients were initially dialysed with cvvhd and later on with sled. results: of the patients, died and overall mortality was . %. this was highest in the group of burn patients ( %). survival in all patients irrespective of mechanism of injury was unrelated to rts, iss, apache ii and triss. the duration of haemodialysis be-tween the three different trauma mechanism groups was not significantly different. age is not a significant predictor of survival. patients with polyuria at time of initiation of haemodialysis had not a better outcome than those who were oliguric/anuric/normouric. conclusions: arf in trauma patients has a low survival rate. controversial conclusions have been presented in the literature. in our study, none of the parameters reported in previous publications to affect survival was proven as correct, although our number of patients was comparable to that of other studies. as we are still at an early stage of understanding the predictors and the behaviour of renal failure in the trauma patients there is a need for the planning multicentric prospective studies. weaning from mechanical ventilation constitutes a dynamic process, and represents one of the most challenging decisions in the management of critically ill patients. success of weaning depends on multiple factors, and wrong decisions result either in prolonged mechanical ventilation, or reintubation and nosocomial pneumonia. many mathematical indexes have been described and used for decision making with varying successes. we have developed a multiparameter fuzzy-logic decision support system for prediction of success of weaning from mechanical ventilator. after fuzzifying relevant numerical variables, this system evaluates the appropriateness of perfusion, arterial blood gases, mechanical properties, and gas exchange, and converts these to a weaning probability. system has been designed using jfuzzylogic package and uses mamdani center of gravity algorithm for defuzzification. after optimization system has been tested over a software that creates random clinical scenarios within a range that can represent challenging patients. for each scenario jabour' weaning index, rapid shallow breathing index (rsbi) and pressure time index have also been calculated and compared with fuzzy-logic system. results indicate that currently used indexes and especially rsbi, disregard many important parameters and shown a potential to fail in many critical scenarios (in % of simulations). additionally we would like to discuss the potential of fuzzy-logic in clinical decision support, and design and optimization issues. trauma scoring systems used for uniform reporting and evaluation of trauma outcomes include physiologic, anatomic and combined systems. these systems have already been evaluated and shown to have accurate performance. we proposed a possible effect of response to resuscitation on the performance of trauma scoring. data necessary for calculation of iss, rts, triss and ascot systems have been retrospectively collected from the records of last consecutive trauma patients admitted to our surgical critical care unit. score and mortality prediction calculations have been performed over a software developed in our department, at three time points, at admission to er, after h of resuscitation, and at icu admission. additionally a fuzzy-logic inference system which uses physiologic variables as input has been designed for trauma related mortality prediction and applied to the same dataset. performances of scoring systems and fuzzy-logic inference system have been evaluated. results indicated that all systems have good discrimination, but variable calibration characteristics. for all systems evaluated response to resuscitation has effected system performance and scores and predicted mortality values calculated after resuscitation have shown better discrimination. fuzzy-logic inference system designed has shown discrimination characteristics comparable but not better then the other systems, which indicate the importance of inclusion of specific organ injuries in trauma scoring and mortality prediction. daily monitoring of immune/inflammatory status is a fundamental procedure in the icu. in small animal disease models such a surveillance is challenging given the limited blood volume available. to validate a new method for daily immuno-inflammatory monitoring in critically ill (septic) mice, we followed their short/longterm survival, organ function and inflammatory status. furthermore, the reliability of complete blood count (cbc) differential was tested in re-suspended blood cell pellet. female of- and cd- mice were subjected to cecal ligation and puncture (clp). ll blood samples were collected (facial vein puncture) from half of each strain daily for days or on day only. additionally, ll (diluted : ) volume was collected (of- only) and divided to compare cbcs in whole versus resuspended blood. there were no differences in / -day clp mortality. for both strains, changes in circulating interleukin- and chemical parameters (alt, ldh, bun, glucose) were comparable between sampled subgroups. ll sampling in of- mice caused a decrease of % in rbc and % in hb (both p < . ). in cd- animals, both rbc and hb showed a similar decrease of % (p > . ). platelet and wbc counts were unaffected. cbc comparison displayed a high correlation for all cell types (r > . , slope > . ) except lymphocytes (r > . ,slope > . ). this was reproduced in non-clp mice. the results indicate the minimal biological effect of daily sampling upon septic mice. cbc differential from resuspended pellet is highly reliable. this newly validated facial vein punture sampling protocol allows multi-directional monitoring in mouse models of critical illness such as acute peritonitis. introduction: a comparison of the amount of procalcitonin (pct) with that of c-reactive protein (crp) during various types of and severities of multiple trauma., and their relation to trauma-related complications, was performed. the aim of this study was to describe the amount of and the time course of pct and crp induction in patients with various types of and severities of high-velocity trauma. background: to provide a score to predict the risk of early mortality after single craniocerebral gunshot wound (gsw) based on three clinical parameters. methods: all patients admitted to baragwanath hospital, johannesburg, south africa, between october and may for an isolated single craniocerebral gsw were retrospectively evaluated for the documentation of (a) blood pressure on admission, (b) inspection of the bullet entry and exit site, and (c) initial consciousness (n = ). results: conscious gsw victims had an early mortality risk of . %, unconscious patients a more than fourfold higher risk ( . %). patients with a systolic blood pressure between and mmhg had a . % risk of mortality. hypotension (< mmhg) doubled this risk ( . %) and severe hypertension ( mmhg) was associated with an even higher mortality rate of . %. patients without brain spilling out of the wound (''non-oozer'') exhibited a mortality of . %, whereas it was twice as high ( . %) in patients with brain spill (''oozer''). by logistic regression a prognostic index (pi) for each variant of the evaluated parameters could be established: non-oozer: , oozer: , conscious: , unconscious: , £rrsys < mmhg: , rrsys < mmhg: , rrsys mmhg: . this resulted in a score ( - ), by which the individual risk of early mortality after gsw can be anticipated. conclusions: three immediately obtainable clinical parameters were evaluated and a score for predicting the risk of early mortality after a single craniocerebral gsw was established. gunshot wounds to the head are associated with poor outcome. we reviewed data to identify prognostic factors. we performed a retrospective study of all patients admitted to a level trauma center with isolated gunshot injury to the head during six and half years. data collected included demographics, mechanism of injury, prehospital and resuscitation room data, and initial ct scan characteristics. the primary outcome measure was the glasgow outcome scale (gos). seventy-two patients with isolated gunshot wounds to the head were admitted. overall mortality was %. the mortality for patients with an initial gcs of < was versus % for those with initial gcs > (p < . ). fifty percent had pupillary abnormalities on arrival at the emergency department. mortality in this group was versus % in those with normal pupillary reflexes (p = . ). elevated plasma lactate was associated with nonsurvival. thirteen percent of survivors were assessed as able to live independently after their injury. civilian gunshot injury to the head is related to high mortality. indicators of outcome are the admission gcs score, pupillary abnormality, metabolic acidosis, and ct pattern of severe injury. introduction and objectives: the aim of this study is to compare the effects of the mannitol and melatonin on the levels of blood and brain malondialdehyde (mda). methods: in the study, new zealand type rabbits were used. the test subjects were divided into four groups; sham (n = ), control (n = ), mannitol (n = ) and melatonin (n = ) groups. blood cerebrum tissue samples were taken to research for mda in the control group. head trauma was applied with feeney method to the rabbits in the other groups. venose blood samples were taken before and after trauma to observe mda. mg/kg melatonin was given to the melatonin group, and g/kg mannitol was given to mannitol ( %), between and in ( . %), and between and in patients ( . %). mortality rate was % (n = ). patients who died had significantly higher iss (p < . ), lower gcs, (p < . ), and higher head ais (p < . ). conclusions: road traffic collision is the leading cause of head injury in our setting. in this study population, head injury was severe, more than one fifth of the cases were admitted to the icu, and gcs was below in %. patients who died had significantly higher iss, lower gcs, and higher head ais. backgrounds and objectives: benefits of emergency burr-hole craniotomy (or evacuation) for patients with critical head trauma remained unclear. our study objective is to compare the effectiveness of burr-hole craniotomy to decompressive craniotomy using data from a large-scaled, multicenter and nationwide registry of hospitalized trauma patients in japan. materials and methods: among a total of records registered in japan trauma data bank, we selected patients with critical head trauma which were scored as ais (critical injury on the abbreviated injury scale) on head and underwent either of burr-hole craniotomy or decompressive craniotomy. parameters of the trauma injury severity score (triss) were used to adjust the baseline trauma severity. univariate analysis and multivariate logistic regression analysis estimated the relative risk of inhospital death. results: a total of zygomatic and/or orbital fractures were identified with subtarsal ( %), subciliary ( %), transconjunctival ( %) incisions, and laceration ( %). the risk of ectropion was highest in subciliary incisions ( . %, p = . ), however, only one case required operative management. entropion was found in two cases after transconjunctival incisions (p = . ); both required operative management. lid edema was present in . % of subtarsal and . % of subciliary incisions (p = . ). one hypertrophic scar was seen with the subtarsal and two cases with the subciliary approach (p = . ). conclusions: lower eyelid malposition occurs after any lower eyelid incisions for facial fracture repair. ectropion is most commonly seen in subciliary incisions, while entropion is rare. a subtarsal incision has a low risk of malposition, however is associated with hypertrophic scars. although choice of incision can be based on surgeon preference, a thorough patient discussion must include potential complications with each approach. in traumatology things happen quickly, data are often incomplete and therefore misleading and there is also pressure for quick decision. in dealing with the matter we distinct among wrong decisions based on insufficient data and errors due to systemic faults or individual incompetence or negligence. possible systemic faults are at every level of treatment: taking history, clinical examination, diagnostics, decision making, treatment procedures and even rehabilitation. most analysed errors occured when patient was handed over to another team or another level of treatment. haste and insufficient or inadequate report leads to wrong assumptions and -if that is not discovered in time -to wrong treatment. on personal level usual mistake was being satisfied when one injury was found and others were missed to insufficient exam or diagnostics. dealing with unfamiliar drugs lead to overdosage and sometimes death of the patient. to avoid such disasters extra training was added to medical school and medical students systematically approach the subject. at the emergency department adherence to protocols is encouraged, especially in cases of unresponsive patients. on hospital level enough time should be provided for attending physicians to make thorough rounds. this should provide much needed redundancy in the age of maximum efficiency. unfortunately we feel it is still not possible to implement measures of self-reporting as known by the airline industry due to inadequate law regulation! author to editor: measures for preventing medical errors in trauma department is showed. background and aim: missed injuries adversely affect patient outcome and damage physician, as well as institutional, credibility. autopsies are useful in uncovering missed injuries or undiagnosed conditions that contribute to death after injury. the aim of this paper is to analyze and compare medical documentation and autopsies findings in searching for missing injuries in trauma fatalities treated in our hospital. patients and methods: we analyzed data for patients died after trauma in years period (january st, -december st, introduction: immune suppression is a compensatory mechanism in acute inflammation e.g. following trauma. multiple mechanisms underlying this phenomenon include decreased cytokine production, shifts in cytokine balance and unresponsive adaptive immunity. we show in a model of acute inflammation that neutrophils, apart from their established pro-inflammatory characteristics, possess multiple mechanisms mediating immune suppression. methods: healthy male volunteers were given ng/kg e. coli lipopolysaccharides intravenously. blood was taken at various time points. neutrophils were stained with antibodies and isolated by facs. neutrophil receptor-expression, phagocytosis and oxidase were measured. lymphocytes were cultured in the presence of neutrophil subsets and cd /cd or pha. proliferation was measured by incorporation of h. results: distinct neutrophil subsets were identified. - h after administration of lps % of neutrophils displayed a two to threefold decreased expression in innate immune receptors, decreased phagocytosis and oxidase production. another neutrophil subset ( %) inhibited lymphocyte proliferation by % (in the presence of cd /cd or pha) in a : ratio independent of il- , tgfb, arginase or indoleamine - . instead direct delivery of h o appeared to be the mechanism of immune suppression. conclusion: in acute inflammation neutrophils utilize multiple mechanisms mediating immune suppression. firstly refractory neutrophils appear in the circulation. secondly another population of circulating neutrophils effectively suppresses adaptive immunity. these observations dictate an important role for neutrophil-mediated immune suppression following conditions such as trauma, contributing to the susceptibility to infections seen in these patients. sham-group) received a single intraperitoneal injection of either zinc protoporphyrin (znpp), an ho inhibitor, hemin, an ho- inducer, or vehicle. h later, rats were anesthetized and subjected to hts, including bleeding, laparatomy, and reperfusion (inadequate and adequate phase) and were sacrificed h later. ho- mrna was determined by real-time pcr and ho activity was determined in liver homogenate. free iron was measured by electron paramagnetic resonance spectroscopy in nonhomogenized liver tissue. ho- mrna was elevated only in the hts-group pretreated with znpp versus the sham-group. ho activity was increased in all hts groups compared to sham groups, with the most distinctive increase seen in the hemin pretreated groups. plasma bilirubin values showed a similar increase in the groups pretreated with hemin. no significant difference was found in free iron concentration among all groups. our data show that changes of ho activity prior to hts are not associated with elevated free iron, late after reperfusion, suggesting that free iron released from ho is efficiently deactivated. introduction: cells of the innate immune system are essential in the development of inflammatory complications. the activation status of this system can be determined by analyzing expression activation markers on neutrophils in peripheral blood. our research group previously showed that a combination of these receptors, the 'priming score', reflected the inflammatory status of individual patients. hypothesis: systemic activation of the innate immune system attracts functional neutrophils into damaged tissues. dysfunctional neutrophils stay behind in the circulation, causing a paralyzed innate immune system and increased susceptibility to late onset sepsis (> days objectives: our study objective is to stratify risk factors of the second (within hours) and third peak (within days) of trauma death independently. materials and methods: , records from japan trauma data bank were retrospectively analyzed. as outcomes for the analysis, we defined the early and delayed death as deaths within days and those after days, respectively. based on the framework of trauma injury severity score (triss), coded glasgow coma scale (cgcs), coded systolic blood pressure (csbp), coded respiratory rate (crr), injury severity score (iss) and coded age (cage) were used as independent variables to determine the outcomes using proportional hazard analysis. conclusions: in our observation, statistically-significant risk factors of early and delayed trauma death differed. physiological severity largely affected the second peak. in contrast, the third peak mainly correlated to anatomical severity and elderly in age compared to risk for the second peak. especially, an initial hypotension might no longer affect the third peak of trauma death independently. regression analysis including all the parameters of rts as explanatory variables showed the odds ratios of categorical sbp variables predicting the inhospital death. results: a total of , records matched the inclusion criteria. score- , , , , a and b in sbp subcategory consisted of , , , , , , and patients, respectively. inhospital mortality of score- , , , , a and b were , , , , and %, respectively. after adjustment for rts, the odds ratios for the inhospital death of score- , , , , a and b were . , . , . , . , . (reference) and . , respectively. isolated head trauma were more frequent in score- b compared to score- a ( vs. %, p < . ). conclusion: a trauma patient with systolic hypertension ‡ mmhg is scored points in sbp category under rts rule, however, exposed to higher mortality rate similar to patients with points in sbp subcategory and maybe related to isolated head trauma. author to editor: to whom it may concern: we have received a e-mail replied from abstractagent.com which alert the exceed in limitations of abstract submission. the e-mail noticed us, the presenting author of this abstract (akira endo) posted or more abstract as a presenting author, however, the authors of ''increased mortality in trauma patients with systolic hypertension'' believed that akira endo in department of accdm, tmdu, japan surely posted this abstract only. the name ''akira endo'' is common in japan. we suppose that ''akira endo'' of the other institutes were doublecounted. editor to self: seçilmiş bildiri background: the united arab emirates (uae) is developing rapidly, with many foreign construction, farm, and industrial workers at risk of injury. aims: to assess external causes, risk factors, severity, and anatomical region of work-related injuries using a trauma registry. methods: surgical admissions / to / were recorded in the registry at the main trauma hospital in al-ain region, population , . prevention-related variables were analyzed using spss and severity quantified by injury severity scores (iss). results: there were work-related injury hospitalisations, equating to an incidence of about / , workers/year. males accounted for %, ages - years %, and nonnationals %, with % of workers from the indian sub-continent. external causes included falls %, falling objects %, powered machines %, animals %, burns %, and other %. at least % of falls were from relatively high levels. median iss was for all six main external causes. extremities were most frequently injured. mean hospitalisation was . days. % (n = ) were admitted to the intensive care unit and % (n = ) died after admission. conclusions: main external causes were proportionately much more frequent than in industrialised countries, and admissions prolonged. priorities include effective countermeasures for falls from height and falling objects, and for machinery injuries. improved work injury data, access to occupational health services, specific regulations and frequent inspections at all construction sites, workshops, and farms, together with appropriate penalties for safety violations, are essential to reduce incidence and severity of occupational injury among vulnerable migrant workers in the uae. introduction and objectives: immobilization of the spine in trauma patients at risk of spinal damage is performed using a rigid long spineboard or vacuum mattress both during pre-hospital and inhospital care. however, disadvantages of these immobilization devices in terms of discomfort and tissue-interface pressures have guided the development of a new soft-layered long spineboard. we compared tissue-interface pressure and degree of comfort during immobilization on a rigid spineboard, a vacuum mattress and a newly developed soft-layered long spineboard. methods: in this randomized cross-over trial, volunteers were immobilized sequentially on all three devices for min per device. tissue-interface pressures were measured using an xsensor pressure mapping device, including the peak pressure and the peak pressure index (ppi). comfort was rated on a visual analogue scale (vas) after min and after min of immobilization. results: tissue-interface pressures were significantly higher on the standard long spineboard and the vacuum mattress than on the softlayered long spineboard. ppi for the sacrum on the soft-layered long spineboard was significantly lower than on both other devices, with an average ppi close to normal diastolic blood pressures. the participants reported significantly more comfort on the soft-layered long spineboard compared to the rigid long spineboard, both after and min (p < . ). conclusion: using the soft-layered long spineboard, which imposes less pressure on the tissue and provides better comfort than the standard long spineboard and the vacuum mattress, means buying time to optimize the patient's treatment while minimizing tissue damage. background: trauma and emergency surgery models differ all across europe. no definitive model was accepted and work and surgical emergency load are different in each region. we performed a cohort study to analyze the impact of emergency (including trauma) surgery in the general surgical practice at a portuguese university hospital. methods: data on emergency surgical cases and admissions to the surgical service over a -month period were collected and analyzed; this included patient demographics, referral sources, diagnosis, operation, and length of stay (los conclusion: emergency workload represents a significant part of the work for the general surgeons. the emergency surgical cases and admissions had a significant impact in the mortality rates of the general surgery admissions. resource planning and training should be based on more comprehensive, prospective data such as these. background: the long-term health outcomes and costs of helicopter emergency medical services (hems) assistance remain uncertain. the aim of this study was to investigate the cost-effectiveness of hems assistance versus emergency medical services (ems). methods: a prospective cohort study was performed at a level i trauma centre. quality of life measurements were obtained at year after trauma, using the euroqol- d as generic measure. health outcomes and costs were combined into costs per quality-adjusted life year (qaly). results: the study population receiving hems assistance was more severely injured than that receiving ems assistance only. the incremental costs for intramural care were e , for hems treated patients compared with patients treated by ems only, which was mainly determined by the costs of the intensive care stay and the used diagnostics. finally, the costs for hems assistance instead of ems assistance were e , per qaly. the sensitivity analysis showed a cost-effectiveness ratio between e , and e , . conclusion: the costs per qaly for helicopter emergency medical services in the netherlands remain below the acceptance threshold. therefore, hems should be considered as cost-effective. author to editor: this study describes the long-term health outcomes and costs of helicopter emergency medical services (hems) assistance. it investigates the cost-effectiveness of hems assistance versus emergency medical services (ems), and may serve as a reference for future quality of life and cost-effectiveness studies on the subject of hems and severely injured patients introduction: in usual multi-trauma care (utc) each partner has its own ''autonomous'' treatment perspective. clinical evidence, however, suggests that an integrated multi-trauma rehabilitation approach ('supported fast-track multi-trauma rehabilitation service': sftrs), featuring earlier transfer to a specialised trauma rehabilitation unit; earlier start of 'non-weight-bearing' training and multidisciplinary treatment; early individual goal-setting; co-ordination of treatment between trauma-surgeon and physiatrist, may be more (cost-)effective. the feasibility of a multi-centre trial examining the (cost-)effectiveness of sftrs was assessed. methods: data from multi-trauma patients (iss ‡ , complex multiple extremity injuries or complex pelvic fractures) were inventoried. patient characteristics, trauma severity, quality of life, health status, anxiety and depression, and cognitive functioning were assessed in two dutch trauma centres providing utc or sftrs. results: no differences in patient characteristics', trauma severity or discharge destination were found between sftrs and utc. discharge destination was 'home' ( . %), 'rehabilitation clinic' ( . %), 'nursing home' ( . %), 'other hospital' ( . %), 'unknown' ( . %). . % of patients died. however, hospital length-of-stay differed: . (sd: . ) days (sftrs) and . (sd: . ) days (utc). conclusion: adequate patient numbers may be recruited, baseline patient characteristics did not differ between collaborating centres, hospital length-of-stay was reduced in sftrs and adequate patient follow-up is possible. based hereupon, a nonrandomised multi-centre clinical trial started. (isrctn ). the trauma-region of north-west netherlands has consensus criteria for mobile medical team (mmt) scene dispatch. the mmt can be dispatched by the ems-dispatch centre or by the on-scene ambulance crew and is transported by helicopter or ground transport. although much attention has been paid to improve the dispatch criteria, the mmt is often cancelled after being dispatched. the aim of this study was to assess the cancellation rate and the noncompliant dispatches of our mmt, and to identify factors associated with this form of primary overtriage. methods: we conducted a retrospective case review of consecutive mmt-dispatches during a months period. by means of chart review, data pertinent to prehospital triage, patient's condition onscene and hospital course were collected and analyzed. all dispatches were evaluated by using the mmt-dispatch and mission appropriateness criteria results: median age was . years and . % of the patients was male. of these, patients were trauma victims ( . % blunt trauma). after being dispatched, the mmt was cancelled times ( . %). statistically significant differences between assists and cancellations were found for overall mortality, mean rts, gcs, and iss, mean hospitalization and amount of icu admissions (p < . ). almost % of all dispatches were neither appropriate, nor met the dispatch criteria. fourteen ( %) missions were appropriate, but did not meet the dispatch criteria. conclusions: nearly a half of mmt-dispatches were cancelled and almost % did not meet the dispatch criteria. dispatch criteria for the mobile medical team in our trauma-region need further refinement and compliance. the ''traumax Ò '' hip screw plate is a new device that allows the treatment the fractures both of the neck and the trochanteric area of the femur, expected subtrochanteric area. this plate conserves the characteristics of a dynamic hip screw (compression of the fracture site, good positioning of the pieces of bone, integrity of gluteus muscles) more specific characteristics: this device is modular, allows to choose the length of the barrel adapted to the length of the head screw, the diaphysal screws are locked by a tech nut according to the patented ''surfix'' system. the locked screw gives a good stability even if the bone has a poor density and allows to use a short plate that preserves the piercing lateral vessels of the femur. this short modular screw plate can be implanted by a cm minimal invasive approach using a particular instrumental pipe. during the presentation we will report the results of a prospective study colligating cases of ten french hospitals. a preliminary study of consecutives cases gives prominence to a few blooding with an average of ml, a operative time of an average of mn, a xr exposing time of an average of s. healing bone has been obtained in all cases. the head screw has been placed at the center or just below in %. no complication dues to the plate has been reported; in all cases only one approach has been used. aim: to assess moderate-term outcomes of silastic joint replacements of the first metatarsophalangeal joint. methods: the patients ( feet) that had silastic implants inserted were reviewed at an average of years and months (ranging months to years and months). the mean patient age was years. these patients answered a subjective questionnaire, had their feet examined clinically and radiographically and a pre-operative and post-operative aofas score was calculated for each. results: the questionnaire revealed that every patient described that their pain had decreased after surgery and feet ( %) were completely pain free. there was a significant improvement in patients' subjective pain scores after surgery (t value £ . ). preoperatively, the mean pain score for all feet was . , whereas post-operative the mean pain score was . . the mean aofas score before surgery was . . this increased to a mean score of . after surgery (p £ . ). this again is a significant improvement. no patient was dissatisfied with the outcome with their surgery. conclusion: these moderate term results are encouraging, with good subjective and objective results. however, long-term follow-up will be required to assess the longevity of this implant • theatre staff should be trained for proper application and cleaning of the exsanguinators • alcohol wipes are good alternative to current practice and should be used for decontamination • we must wash our hands before and after its use • we should use plastic bag over the limb first before using the exsanguinators it is presented one new minimally invasive method for closed fracture reduction and one extramedullary selfdynamisable internal fixator developed by the author. there is no contact between bone and internal fixator in fracture area. it has been widely investigated biomechanically. in clinical use it has been applied to , patients in treatment of femoral fractures. the age of patients was from to years. this internal fixator is applied by two small incisions. reduction is achieved using standard traction table or using special reduction device. this reduction device provides possibility of reduction with minimal using of fluoroscopy or even, after more experience without using of any imaging technique as fluoroscopy, ultrasound or computer navigation. received clinical results are promising, as it has been shown early callus formation and radiological union within the - months. it has been allowed to patients early full weight bearing. during the treatment it has been confirmed working of self-dynamisation concept, which probably all together with d configuration resulted in unexpectedly quick fracture healing. follow up was months ( - ). according to results obtained, it can bee concluded that new biological internal fixator is suitable for minimally invasive technique, without opening of fracture site. it can be used as primary method or soon after external fixation if damaging control concept used. ( ) ( ) ( ) ( ) ( ) and followed-up for a minimum of years formed the study population. a retrospective review of data from electronic patient record (epr), clinical coding, clinic and gp letters was made. age, residential placement, garden's classification of fracture, mode of injury, associated comorbidities, pre-admission mobilisation status, allergies, addictions and anticoagulation status details were collected. an indepth study was conducted to look into delays for surgery, length of stay in hospital, complications and treatment of these complications. reasons for re-admissions, re-operations and comorbidities developing as a result of these interventions was critically analysed. results: the mean age of patients was years (range - years). the incidence of non-union was % and avascular necrosis at year was %. revision surgery was performed in ( %) cases. complications were more principally in patients who had end-stage renal failure ( %), diabetes mellitus ( %), osteoporosis ( %), and steroid use ( %). conclusion: the complications and revision surgery rate was high in patients with particular co-morbidities despite being undisplaced. comorbidities and patient's age were also strong predictors of healing in addition to fracture configuration. outcome of hip fractures is influenced by complex interplay of multiple factors and not only by radiographic appearance. methods: this is a -year of retrospective study. we had included patients to our study ( females and males) with the average age of . . we used bryan and morrey classification system and included type i and type iii fractures. results: there were type i and three type iii fractures. associated injuries were two dislocations with one mcl injury and two radial nerve symptoms. all the patients had orif with screw and two patients had supplementation of fixation with wires. most patients were mobilized early in weeks time. nine of them treated with miniacutrak screw fixation, four with herbert screws and one lag screw (ao miniscrew). the approach was mainly postero-lateral but for five patients, it was antero-lateral. all patients were clinically and radiologically assessed. average time for radiological union was weeks. on the other hand, one patient had revision fixation because of failure of metalwork. additionally, one patient had capsular release for contraction and another one had removal of screw for prominence of metalwork. average follow-up was . months ( - months). mayo elbow score was excellent for seven patients, good for three patients, and fair for three patients. one patient could not be fully scored due to learning difficulties. we recommend open reduction and internal fixation for all type and type fractures so that function can be regained early. objectives: to report the outcome and comparison of calcaneum fracture managements for intra-articular fractures. methods: a prospective study of the patients with intra-articular calcaneum fractures in the foot&ankle unit of a busy trauma hospital. all the patients were followed up with the calcaneal fracture score. we compared the outcome of surgical management sanders type (group a) and type (group b) fractures with conservative treatment (group c) at years and assessed the medium term outcomes of groups a and b. group c were a consecutive series of patients recruited to the study later than a and b, hence the smaller number in that group. results: patients were included in our study. there were in group a, in group b, and in group c. mean follow-ups for the groups were a = years, b = . years, and c = . years. mean -year scores for the groups were a = . , b = . , and c = . , with statistically significant differences between groups a and c (p = . ), and between groups b and c (p = . ), but no significant difference between groups a and b. at medium-term follow-up (> years), the scores for group a and b were . and . , respectively. there were deep, superficial infections and metalwork removals in total. conclusion: on comparing the medium term outcome to the -year one, group a showed some improvement and group b stayed the same. in this series, contrary to published articles, there was a better outcome at years with surgical treatment than conservative treatment. author to editor: all the authors have agreed with content of the abstract. there was not any conflict of interest for this study. objective: to assess the effectiveness of mobile angiography with a digital subtraction angiography (dsa) technology directly into the emergency room (er) for blunt trauma patients with pelvic injury. materials-methods: this is a retrospective review of a cohort of blunt trauma patients with pelvic injury treated after the direct availability of mobile angiography by trained trauma surgeons into the er for resuscitation. data was collected including demographics, hemodynamic variables, resuscitation intervals form admission through completion of hemostasis, metabolic factors (ph and body core temperature), mortality and transcatheter arterial embolization (tae) related complications. results: twenty-nine patients underwent tae in the er. mean age, shock index, and injury severity score were ± years old, . ± . , and ± , respectively. the interval from the decision to perform tae through initiation of tae and the interval from the decision to perform tae through completion of tae were ± min and ± min, respectively. the mean dbody core temperature (bt) from admission through completion of tae was - . ± . °c. and the mean dph from admission through completion of tae was . ± . . there were clinically significant correlations between dbt and resuscitation interval, and between dph and resuscitation interval. tae was successfully performed in all cases and mortality was %. no tae-related complications were observed. conclusion: immediate availability of mobile angiography into the er by trained trauma surgeons was effective to shorten the time required to restore normal physiology of trauma patients with pelvic injury without leaving the er for resuscitation. introduction: tgf-b is a regulatory protein, involved in fracture healing. the purpose of this study was to investigate the role of tgf-b in human fracture healing, and to verify whether tgf-b is a reliable marker of nonunion. methods: serum samples of patients with long bone fractures were collected over a period of months. patients were assigned to groups: first group contained patients with physiological fracture healing. eleven patients with nonunions formed the second group. healthy volunteers served as controls. results: in patients with physiological healing serum concentrations were initially high. serum concentrations then decreased rapidly after weeks and reached a plateau between weeks and . thereafter, another continuous slight increase of the concentrations was observed between weeks and . in patients with impaired fracture healing tgf-b serum concentrations were initially similar to those with normal healing. a significant increase of the concentration was observed between weeks and , followed by a continuous decline of the serum levels for the remainder of the observation period. significant differences between the concentrations in both groups were observed at weeks and . tgf-b as marker would have detected patients with nonunions at weeks after fracture with a sensitivity of % and a specificity of %. distal metaphyseal radial fractures are extremely common fractures in children (% , ). high rates of displacement occurs during conservative treatment. the aim of this study was to determine the effect of kirschner wire application after closed reduction of radial metaphyseal fractures with high risk of redisplacement. in this retrospective study cases were studied in two groups. in group (n = ), k-wire applied after closed reduction. in group (n = ), only cast was applied following closed reduction. the mean follow-up was months. the compared clinical and radiological parameters were; pain, limb deformity, range of motion of the wrist, angulation of the fracture site, radial distal epiphyseal angle and severity of translation. redisplacement rate was % in group and % in group . this shows, kirschner wire fixation had a positive effect in continuity of the initial reduction (p = . ). age (p = . ), gender (p = . ), reduction quality (p = . ) had no effect on redisplacement. concerning the severity of translation, the risk of redisplacement increases in stage ( - %) and stage (> %) fractures (p = . ). concomitant complete ulnar fracture had also redisplacement risk (p = . ). redisplacement risk increases when the distance of fracture line to epiphyseal line was between and mm (p = . ). there was no significant difference between two groups after last evaluation based on radiological parameters and clinical results (p > . ). as a conclusion; this study shows that kirschner wire fixation prevents redisplacement in early follow-up of first weeks but there is no superiority after months follow-up in distal metaphyseal fractures of children. patients in group c showed the best functional results, the greatest ankle range of motion, the fastest full bearing, the fastest walking on toes and heels, and the shortest duration of physical limitations (walking on uneven ground and sports activities) (p < . for all). in group b, there were two reruptures, in group c one, and in group a there were no reruptures. good functional results and a relatively small number of postsurgical complications advocate the usage of surgical techniques. the best and fastest functional recovery was attained in the group treated with the original technique of percutaneous fixation with two embracing and crossed loops. open surgical reconstruction is indicated only in the case of rerupture after percutaneous suturing. introduction: there are different techniques for arthrodesis of endstage arthrosis of the ankle-joint. internal fixation is the favoured method in many institutions. we retrospectively examined the technique and clinical results of external fixation in a triangular frame. patients/methods: from to a consecutive series of patients with end-stage arthritis of the ankle joint was treated. mean age at the index-procedure was . years, patients were male ( . %). via a bilateral approach the malleoli and the joint-surfaces were resected. an ao-fixator was applied with steinmann-nails. follow-up examination at mean . years included a standardised questionnaire and a clinical examination including the criteria of the aofas-score and radiographs. results: in two cases, due to contracture a pes equinus position had to be accepted. in two cases a further bone transplant was performed at and weeks for unsatisfactory bony union. after mean . weeks, radiographs confirmed satisfactory union and the fixator was removed. in four patients a nonunion of the anklearthrodesis developed ( . %). the mean aofas score improved from . to . points. statistical analysis of the insurance status showed that patients insured under a workers injury compensation scheme had a mean score of . compared to . for the remaining (p = . ). discussion: nonunion rates and clinical results of arthrodesis by triangular external fixation of the ankle joint do not differ to internal fixation methods in literature comparison. the complication rate and the reduced patient comfort reserve this method mainly for infected arthritis and complicated soft tissue situations. implants with multidirectional locked screws have theoretical advantages in the treatment of periprosthetic fractures. in osteoporotic bone they provide a high stability. we concluded a retrospective study of a consecutive series of the outcome of vancouver b and c femoral injuries using two specific locked-implants. from to we treated patients with a periprosthetic fracture of the femur with a locked plate. the mean age at the index procedure was . years, patients were female ( %). in cases ( . %) we saw a hip endoprosthesis, in cases ( . %) a knee endoprosthesis and in cases both ( . %). outcome measures were intra-and postoperative complications, bony union, degree of mobility and social status, barthel-mobility-index and ''stand-up&go'' test. union occurred in cases ( . %) after the index procedure. twice the implant failed, we saw four general complications. the mean duration until full weight bearing status in these patients was . weeks. at follow-up patients ( %) had maintained the same social status as before the fracture. regarding the mobility status patients ( %) had regained their previous level, patients walking without aid before now required a cane and patients a walking frame. the mean barthel-index was points of . the mean stand-up&go time was measured as seconds. conclusion: overall failure rates of osteosynthesis after periprosthetic fractures of up to % are reported ( ). with . % implant related failures and % general complications, the presented methods achieve bony union and mobility in a high percentage of cases. arthroscopic-assisted percutaneous figure introduction: we describe a new arthroscopic-assisted reduction and percutaneous tension band wiring technique for patella fractures that combines the advantages of minimally invasive surgery and stable internal fixation. surgical technique: we reduce the fracture percutaneously by towel clips with the patient in the supine position. we insert two . mm kirschner (k) wires in a caudocranial direction under arthroscopic control. we do four stab incisions to assign the inferolateral (il) and inferomedial (im), superolateral (sl) and superomedial (sm) portals besides the k wire tips. we insert a trocar with its cannula from sl portal to sm portal under the k wires. we take the trocar out and leave the cannula inside. we run -gauge cerclage wire through the cannula in sl to sm direction. we take out the cannula. we perform exactly the same steps directed from sm portal to il portal, from il portal to im portal, and from im portal to sl portal, respectively. finally near the sl portal, wires are secured with a single knot. we check the fixation by c scope. results: radiographic consolidation was achieved in all five patients at an average of months. all patients returned to the activity level previous to fracture. conclusion: this technique presents advantages over open techniques. it is minimally invasive and cosmetically pleasing, permits visualization of reduction and stability, allows concomitant intraarticular pathology to be exposed, and facilitates early rehabilitation. although we did not attempted yet, we believe that even comminuted fractures can be fixed with this technique. ( ) timing of the procedure, ( ) accurate technique, ( ) stable implants for early mobilisation. in this study we present our experience in the treatment of ftp with locking plates trying to define the role of a medial plate. materials and methods: from to we treated patients with a ao c ftp by orif with locking plates. indications for a medial plate were: involvement of the medial joint surface, coronal fracture of the medial plateau and irreducible dislocated medial condyle. all the patients have been followed up clinically with the lysholm and rasmussen scores and radiographically until consolidation. results: all fractures united. one patient underwent knee amputation for septic complication. the mean lysholm score was ''fair'' while the rasmussen score was ''good'', that means that the subjective result was worse than the objective one. patients treated by double plating had a worse clinical result that was not dependent on the quality of reduction. we had three cases of malalignment, one rsd, two superficial infections, two transient nerve palsy. conclusion: complications in our series were frequent and the clinical results not particularly good. the right timing and an accurate surgical technique are essential for a good reduction, newer implants control effectively the fragments but the high energy of the trauma remains the major determinant of the bad outcome of these fractures. introduction: the high percentage of failure of fixation systems in periprosthetic fractures depends on the technical difficulty of the procedure, the presence of the cement mantle and the poor quality of the remaining bone. the lcp system offers an enhanced stability that reduce the implant mobilization, and preserves the bone vascularity, fastening the healing time. we present our results in the treatment of periprosthetic fractures with lcp. materials and methods: consecutive patients with vancouver b fractures were operated on using . lcp. a standard open reduction of the fracture through a lateral approach was used. patients were evaluated clinically and radiologically for a mean follow up time of . months. results: all the fractures united except two where a narrow . plate and too many cerclage wires around the fracture were used. all the patients showed at fu an hhs over points. the anatomical reduction of the fracture led to a faster healing. conclusions: the effect of the position of screws and cerclages in relation to the plate and fracture are discussed. the authors conclude that lcp system, has to be considered the golden standard in the osteosynthesis of vancouver type b periprosthetic hip fractures, permitting early weight bearing and healing in physiological time. it is better to avoid narrow . plates and cerclages at the fracture site. suggestions on the plate length and screw and cerclages position are given depending on the fracture type and length. the role of the anatomical prosthesis in the treatment of proximal humeral fractures ló ránt bardó cz, jános csotye pá ndy ká lmá n county hospital, gyula, hungary, traumatology introduction and objectives: we would like to present the results of the treatment of proximal humeral fractures with endoprosthesis. methods: between and we operated patients with endoprosthesis for proximal humeral fractures. were delta prosthesis, the results of these operations are the subject of an other presentation. patients were treated with anatomical shoulder prosthesis. the results of these were controlled by personal examination (constant score, x-ray) and by the base of the clinical documentation. was hemi-and total endoprosthesis. in cases the operation was acute and in cases for chronic cases. the average follow up time was . month. we categorized our patients in different groups, based on the fracture type and the time of the surgery. results: we compared the cs of the operated shoulder with the contralateral one in each patient group. we have to accentuate the importance of patient cathegorization, because the results can be analyzed properly only on base of these. on the x-rays the prosthesis were in good place, we found no evidence of losening. conclusions: when the indication is good, the prosthetic procedure is the choice for acute or chronic fractures of the proximal hunerus, and the results are good. we confirmed the statistically significancy of the efficacy of the treatment methods between the same analyzed groups. aim: to discover if how often lateral x-ray change the management of fracture neck of femur fractures as an adjunct to the standard ap film. method: orthopaedic consultants and registrar grade orthopaedic surgeons were asked to decide the management of neck of femur fracture solely from an ap film. at a second sitting the same films were shown in a different order in conjunction with the associated lateral hip x-ray. the surgeons were asked to comment on the adequacy of the lateral x-ray and their choice of management using the both films to make a decision. results: less than half of the lateral hip x-ray were adequate when reviewed on the monitors and very few operative decisions were changed with the addition of the lateral x-ray. conclusion: a standard ap film is usually sufficient to plan management in a fractured neck of femur fracture and the additional time, money, and discomfort of obtaining lateral films does not seem justified in these circumstances. an sermon, stefaan nijs, barbara bosch, paul broos department of traumatology, university hospitals gasthuisberg, leuven, belgium introduction: humeral head fractures extending into the shaft often are a challenge to the surgeon. although they are a rather rare entity, they often occur in osteoporotic bone and are difficult to stabilize. however, because of their intra-articular extension, a perfect reduction and stable osteosynthesis is needed. methods: between august and august , patients with a combined shaft and humeral head fracture were operated in our department. a long philos plate was used in all cases through an extended deltopectoral approach. postoperatively, immediate mobilization was allowed. mean follow-up time was months. results: there were three preoperatively existing radial nerve palsies of which two completely and one partially recuperated postoperatively. there occurred no radial nerve palsies which did not exist preoperatively. revision surgery was necessary in two patients because of hardware failure and secondary fracture displacement within the first week after surgery. in both cases, again a long philos plate was used. all fractures were radiographically healed within months; there were no cases of avascular necrosis of the humeral head. most of the patients were subjectively satisfied with the functional result although mobilization of the shoulder was only moderate in nearly half of the cases. conclusion: in conclusion we can say the use of long philos-plates for the treatment of combined shaft and humeral head fractures gives good results when carried out by experienced hands. osteosynthesis with the use of locked nails is an efficacious method for the treatment of long bone fractures and nonunions of extremities. however, it is contraindicated in case of infection. one way to obviate this problem is to coat implants with antibiotic-loaded bone cement. the objective of this work was to evaluate the efficiency of antibiotic cement-coated interlocking nails for osteosynthesis of long bones in case of infection (infected nonunions) or at high risk of its development (severe open fractures). in - , nails with antibacterial cement coating were used to treat patients including ones with severe open long bone fractures (gustilo-anderson type iiia-iiib). these fixators were employed both at admittance of the patients (with an isolated injury) and within - days after it (in case of polytrauma). patients of this group underwent one-step surgery combining osteosynthesis and the closure of soft-tissue defects with local muscular flaps. in patients with infected nonunions of long bones, osteosynthesis was performed after seeding fistula discharge for microflora. none of the patients in the group with severe bone fractures suffered deep suppuration and all achieved consolidation of fractures. one case of recurrent infection associated with extensive necrosis of bone was documented in the group of patients with infected nonunions. the remaining patients had resolution of signs of infectious process, and their nonunions consolidated. the use of antibiotic cementcoated interlocking nails is a promising method for osteosynthesis of long bones in case of infection and at high risk of its development. author to editor: severe open fractures and infected nonunions are one of the most difficult problems in trauma orthopedic surgery. we had only one treatment option for this pathology down to resent times. it was an external fixator, but it has many disadvantages. in we start using antibiotic cement-coated interlocking nail, and we have promising first results. this results we would like to present in eurotrauma . hawar akrawi, david gordon hargreaves department of trauma and orthopaedics, southampton university hospitals nhs trust, southampton, the united kingdom introduction: we describe our clinical experience with a new posterior approach for reconstruction of distal intercondylar fractures of humerus. the maserati approach comprises of a midline proximal triceps split in conjunction with elevation of medial and lateral edges of triceps from the condylar ridges. this approach gives adequate access for accurate reduction and internal fixation of distal and intraarticular humeral fractures. methods: a single consultant series of patients with distal humerus fractures (ao grade -a to -c) were treated using the maserati approach and distal humeral locking plates over -year period at level trauma centre. all cases were reviewed. there were female and male patients with age range from to year. average follow-up was months. these patients were assessed for: . accuracy of reduction of fracture fragments. . complications i.e. infection, triceps weakness, triceps lag and fracture union. . elbow function as per the mayo elbow performance score (meps). results: nine patients had anatomical reduction. no cases of infection or nonunion. one case of delayed union. none of the patients exhibited triceps lag or weakness. the meps was - (mean ). discussion: the maserati approach is a safe approach that provides good access to the articular surface of elbow without compromising the triceps muscle. triceps continuity is preserved, allowing early rehabilitation without the possible co-morbidities associated with other posterior elbow approaches (non-union of olecranon, triceps weakness or triceps lag). author to editor: dear sir/madam, i will be very grateful if you could offer me the opportunity to give a podium presentation about this innovative approach. patients with distal humeral fractures are difficult to manage and with oral presentation, i will be able to demonstrate clearly, with media presentation, the full advantage of this new approach. results: improvement of the neurological deficit was observed in cases. ct control at least of years follow up shows good bone integration of the iliac crest bone in majority of the cases. two patients experienced temporary neurological symptoms, which showed complete remission. the endoscopic procedure for reconstruction of the anterior load-bearing spinal column developed to a standard concept in trauma management. the minimal morbidity of the operative approach, good visualisation of the operative field and angle stable implant make it possible to restore the anterior column on a safe technique. full weight bearing (painless) ranged (un) - (ø ) and (rn) - (ø ) weeks. x-ray healing ranged (un) - (ø ) and (rn) - (ø ) weeks. there was one patient with delay union( weeks) in un group. there were any infection; loss of reduction; re-operation and nonunion in both groups. discussion: we started this study because many studies before preferred reamed nailing but we have long term experience with undreamed nail with the comparable results (retrospective analyze). our hypothesis is that the biological advantages of undreamed nail should display if the perfect technical performance is done. conclusion: there are no significant differences between un and rn groups in our study in this time. we expect recruiting more than patients by the year end and during next years we will be able evidence the data completely. this work was supported by the research project moofvz septic arthritis following acl reconstruction péter frö hlich zentralinstitution for sportsmedicine, budapest, hungary infection after arthroscopic anterior cruciate ligament reconstruction is an uncommon complication, which could be a danger not only for joint function, but also for the joint integrity. we have to differentiate by the clinical recognition of this complication from swelling caused by other conditions (for example suffusion). there is no standardized opinion and method in the field of arthroscopic or open procedure, or necessity of aggressive graft removing. from a consecutive case series of , patients, who underwent anterior cruciate ligament reconstruction between and . we report on patients with postoperative septic complication. of these were extraarticular, and intraarticular manifestation. our protocol is based on infection severity classification modified by gä chter. reliability and significance level of diagnostic criteria (clinical evaluation, laboratory tests, synovial fluid analysis, and bacterial culture) were analyzed. the outcome was determined by early recognition and consequent treatment. there is only one patient, whose acl tendon graft has to be removed. the ikdc score shows the following result: a: , b: , c: , d: , it proved to be similar to the multicenter studies. in the last years we have no more postoperative infection following acl reconstruction by the application our protocol. we will review this protocol. introduction: early fixation of long bone fractures in the multiple injured patient has been recognized as beneficial in minimizing secondary lung and remote organ failure. although early fracture fixation is expedient in px with multiple injury etc may be associated with post-traumatic systemic complication. in this study all pz from a consecutive series of trauma patients with truama team activation admitted between / and / to department of emergency of niguarda hospital in milan were included when they fulfilled all of the following criteria: directly admitted, iss of more than , and survival of more than h. patients with fracture of long bones and/or pelvis with a clear indication for operative treatment and the necessity of immediate fracture stabilization where treat according with dco. all other patients fulfilling the inclusion criteria with minor fracture or thus not requiring immediate fixation formed the control group. iss, rts and ps was calculated at the admission and reevaluated later by the trauma leader. all injury was classified with ao and gustilo classification conclusion: the goals of dco include stopping ongoing injury including local soft-tissue injury and remote organ injury secondary to local release of inflammatory mediators further thought to prevent pulmonary complications by allowing patients to avoid the enforced supine position. this study was conducted retrospectively to evacuate the effectiveness of the trauma team organization and to evaluate the concept of dco by immediate external fracture fixation and consecutive conversion osteosynthesis with regards to time saving, effectiveness and safety. introduction: injury of the soft tissue results in a release of numerous cytokines, which activate fibroblasts of the surrounding tissue to proliferate and to undergo a phenotypic transdifferentiation into contractile myofibroblasts (mfs). in this study we analyzed the hypothesis, that human joint capsule mfs are specifically regulated by the cytokine ifn-c via the modulation of alpha-smooth muscle actin (a-sma) which is responsible for the contractile phenotype. methods: joint capsules were obtained from patients undergoing orthopaedic surgeries. to investigate the functional effect of ifn-c, we cultured mfs in a three-dimensional ( d)-collagen gel contraction model. an alamarblue assay in combination with the collagen gels was established to analyze the viability and the proliferative capacity of mfs upon ifn-c treatment. the effect of ifn-c stimulation on the gene expression levels of the specific mf markers a-sma and collagen i is going to be determined by real-time pcr (rt-pcr). this part of the study is in progress. results: mfs cultured in the presence of ifn-c show a reduced proliferative capacity. moreover, the addition of ifn-c reveals a dose-dependent decrease of collagen gel contraction. these effects were specifically blocked by a neutralizing ifn-c antibody. first results of rt-pcr analysis show an inhibition of a-sma and collagen i gene expression by ifn-c. conclusions: ifn-c reduces mf viability and contractility in a dosedependent way, presumably by down-regulating mf specific genes. this study suggests that ifn-c might be effective in attenuating the contraction of soft tissue in fibrocontractive disorders. with an average age of . years old were included and a retrospective database study was performed. the outcome parameters we analysed were the radiological outcome, the functional outcome and the prevalence of complications. results: the fracture healed in an accurate anatomical position in all patients treated with esin ( %). seven patients ( , %) suffered from irritation around the entrance opening and in four patients ( . %) the pen migrated medially. in eight cases ( , %), this resulted in a reoperation, consisting of remodelling, reposition or removal of the pen. in two cases we saw a refracture after removing the pen. the overall complication rate was . %. dash scores showed an average functional outcome of . points (range: - ) at . months follow-up. conclusion: operative treatment with esin in dislocated midclavicular fractures offers good mid-term radiological results and a good dash score. the overall prevalence of complications was . % and in . % a re-operation was required. the results found in the available literature showed a re-intervention rate of %. prospective randomised research is required in order to determine the right surgical indications and to find out what the long-term results of this relatively new method of fixation are. aim: our main aim was to find out whether there is a place for nonoperative treatment as a definitive primary option in patients with significant medical co-morbidity. methods: we did this audit in collating information on , hip fracture patients across nhs hospitals in england. out of , ( . %) patients were treated conservatively. results: there were males and females patients managed conservatively in our study. during hospitalisation, became bedridden and died. among these patients, were deemed physically unfit for surgery by anaesthetists and by medical consultants. the decision was made by orthopaedic consultants in ten cases and by multidisciplinary team in four cases. five patients refused surgery and five patients were palliative due to terminal illnesses. patients who did not proceed to surgery had significantly higher mortality rates (overall mortality rate %) suggesting that they were physiologically much worse group of patients. conclusion: as the average life span of our population increases, some hip fractures are now treated nonoperatively because of the possibility of severe or fatal complications due to surgery. often, refusal of surgery by the patient or the patients' family obligates the need for nonoperative treatment. it might be acceptable not to opt for the surgery if the patients are medically very high risk because of these reasons (e.g. acute cardiac event, severe aortic stenosis, multiorgan failure etc). the burden of patients with pubic rami fractures seems to be increasing. more patients with pubic rami fractures are admitted to hospital due to the absolute increase in the number of elderly people. although pubic ramus fractures are generally considered a benign fracture for its inherent stability experience indicated that this fracture is accompanied with a high morbidity and mortality. in a case-control study patients aged over years old with an isolated single fracture of the pubic rami admitted to the hospital were compared for morbidity and mortality to age-and gender matched hospitalized patients without fractures. data was acquired by the patient files. during years patients, with a median age of . (range: - ) years, were admitted with a median length of stay of days (range: - ). the mortality rates of patients with isolated pubic rami fractures at , , and years were significantly higher in the patient group compared to our control group, being: . , . and . %, respectively (p < . ). one third of the mortality is explained by cardiovascular events. during hospital admission a complication rate of . % was found, which was mainly caused by infectious diseases, including urinary tract infection and pneumonia. thirty-three percent of the patients (temporarily) went to a nursing home, because of the incapability to mobilise independently. in conclusion, patients admitted to the hospital for an isolated pubic ramus fracture have significant morbidity and mortality both during hospital admission and during -year follow-up. purpose: comminute fractures of the radial head are challenging to treat with open reduction and internal fixation. radial head arthroplasty is an alternative treatment. the purpose of this study was evaluating our results of a closely followed cohort of patients in whom an unreconstructible radial head fracture had been treated with modular pyrocarbon/metallic prosthesis. methods: from may to september , patients were operated for traumatic injuries in elbow. there were female and male with mean age ( - years). the follow-up was a mean of months ( - months). fractures of the radial head have been classified by mason with a subsequent modification by johnston. the indication for a radial head replacement are comminuted type iii fractures in cases, type iv in cases, and monteggia variant with olecranon and radial head fractures in cases. results: by using the mayo elbow score, patients had good/ excellent results, with fair and poor outcomes. patients showed an average arc of motion from - º to º. complications were three implant dislocations, needed to remove the implant. asymptomatic radiographic heterotopic ossification in elbow was showed in one case and bone lucencies were found in seven cases. we had not seen persistent instability, infection, synostosis, loosening, severe degenerative changes or impingement. conclusion: the treatment of unreconstructible comminute radial head fracture with noncemented pyrocarbon radial head implant usually gives an optimal result depending on the severity of the initial injury and the presence of associated injuries. methods: this retrospective clinical study is a follow-up examination of bony avulsion fractures of the intercondyloid eminence in adults and adolescents treated in our hospital in the last years. after the medical history was recorded, the course of the accident and type of injury was documented (classification according to meyers and mckeever) . also the type of treatment (conservative, arthroscopic surgery or open surgery) and accompanying injuries were analysed. the clinical follow-up examination took place after more than months after the trauma. during the face-to-face interview, physical and radiological examination, the knee function, and especially the stability of the knee-joint were assessed. furthermore the clinical outcome was determined using the lachmann-test and the lysholm-knee-score. results: the patient group consisted of male and female patients aged - years. the patients showed subjective and functionally predominant good to very good results. despite subjective stability and absence of pain, in some patients remained a mild hyperlaxity of the anterior cruciate ligament. conclusion: fractures of the intercondyloid eminence are a rare but serious injury of the knee. the correct diagnosis, classification, and curative treatment of the fracture is indispensable for the flawless function and stability. an individual approach is necessary in every patient. distal radius fractures are typical and frequent fracture of elderly woman with reduced bone density. the angle stable plate, often also multidirectional is today the most common stabilisation device. because of the introduction of bulky and bended implants as the micronail or targon dr we decided to test the xs radius nail witch is a , mm or , mm straight nail and witch is introduced after guide wire placement and over drilling with a cannulated drill of the same diameter. it is locked parallel to the joint in different directions with angular stability with threaded wires. methods: radius sawbones were osteotomised corresponding to a a fracture and stabilised with a angle stable plate ( ) and xs nail ( ). , alternating load cycles from - n were performed and the deformation was registered. also a fe analysis with the msc patran/marc software were performed. both types of osteosynthesis showed good stability. the deformation of the xs group however was % lower. also the calculated deformation in the fe study was % lower. also deformation amplitude was lower with . mm compared to . mm in the plate group. the differences however were not significant. both devices show good biomechanical results. the xs nail has the advantage of mainly intraosseus position, simple operation technique with introduction over a guide wire from the proc. styloideus radii and over drilling with a cannulated drill of the same size. the exposure of the n rad.superf. must be performed. first clinical evaluation is presented. angioembolization in severe pelvic fractures: experience of a tertiary centre in united arab emirates results: twelve patients (all males) having a median (range) age of ( - ) years were studied. five were vehicle drivers, four passengers, two pedestrians, and one fall from height. seven had abdominal tenderness while four had abdominal guarding. median (range) systolic blood pressure before angioembolization was ( - ) mmhg and ( - ) mmhg after embolization. nine patients had unilateral internal iliac artery embolization, one had embolization of the pubic bone artery, one had pudendal artery embolization, and one had bilateral iliac embolization and liver embolization. six patients had external fixation of the pelvis after the angioembolization. three patients had a laparotomy, the first had intraperitoneal urinary bladder rupture which was repaired, the second had pelvic packing and diverting colostomy for a severe perineal wound, the third had a liver injury and died on the table. one patient had a thoracotomy with interposition aortic thoracic graft. eleven were admitted to the icu having a median (range) icu stay of ( - ) days. the overall median (range) hospital stay was ( - ) days. only one patient died ( . %). conclusions: angioembolization of severe pelvic fractures with haemorrhage was successful in % of cases and played an important role in the initial management of severe pelvic fractures with haemorrhage. there were nine female and eight male patients passed with a mean age of . years. the knees were assessed at regular intervals and the mean follow-up period was . months (range - ). after initial assessment to confirm absence of trochlear dysplasia, the technique involves plication of the medial retinaculum with a nonabsorbable suture passed percutaneously using a long curved needle under arthroscopic vision and a small incision to bury the knot from the plication. post operative rehabilitation was done with flexion restricted to °for the first weeks followed by a gradual return to normal range of movements with vastus medialis obliquus strengthening exercises. results: patients reported good outcomes with no further episodes of dislocations. one patient who had persistent patellar instability requiring further distal bony-realignment procedure to achieve stability. none of the patients had major complications. conclusion: we report good results with this relatively simple technique of medial retinacular plication and would advocate it as an effectiveless invasive surgical option for patients with recurrent patellar instability in the absence of major trochlear abnormality or significant mal alignment. in a lateral (group a) and in a prone position (group b) with no significant difference in age ( . / . years) as well as pre-and insurgery parameters; no patients were excluded. the complication rate was analyzed by medical records, the radiographic outcome by plain x-rays and ct scans after an average of months postoperatively. comparison of the two patient groups utilized t-tests or chisquare testing of pearson as determined by number of data points for each variable assessed. results: the adequacy of fracture reduction had significantly poorer findings according to matta in a (p = . ), resulting in a significantly higher post-traumatic arthrosis rate (p = . ) defined as helfet iii or iv. no revision surgery was needed; no infection was detected in any group whereas iatrogenic nerve damages ( temporary, persistent) were found only in a. there was no significant difference concerning extensive blood loss, femoral head necrosis, epstein grades, heterotopic ossification classified by brooker and secondary surgery needed. conclusions: due to gravity the femoral head in the lateral position may constrain reduction leading to an inferior radiographic outcome. purpose: the incidence of fracture neck of femur (nof) has been increasing worldwide, due to an aging population. the commonest forms of analgesia are opioids and in some units regional blockade. but regional block is skill dependent and opiates are known to have many side effects. paracetamol is an analgesia that is safe and has an excellent side-effect profile within standard doses. intravenous paracetamol has a far higher predictable bio-availability than oral, within standard dosage. this study is to assess the suitability of using intravenous paracetamol as an alternative. method: prospective study: a change in protocol resulted in all nof's admitted under the care of the senior author being prescribed regular intra-venous paracetamol within standard dosage. prn opioids were available for breakthrough pain. nof's admitted under the care of other consultants remained on the established protocol. opioid usage and pain scores ( - ) were measured. results: results of patients were collected, in intravenous paracetamol group and in the original protocol group. there is a % reduction in opiate usage in the intravenous paracetamol group (p value = . ). there is only a . difference in average pain score between groups (p value = . ). conclusion: the use of regular intra-venous paracetamol results in a significant reduction in the need for opioid analgesia. the pain relief within this group was comparable to that in the control group. a simple change in analgesia protocol to a safer, more predictive agent can result in an improved pre/postoperative period. author to editor: funding: the study received no funding from any source. external fixation has already became on the end of last century as routine temporarily method of fracture bone fixation, especially in the light of damage control. but out of damage control, external fixation has been accepted in many developed countries as routine temporarily method in treatment of complex articular fractures (knee, ankle, elbow). the main reason was absence (night time, weekend) of experienced surgeon who can treat these complex particular fractures, as during the night. sometimes, the skin problem can prolong such fixation for three or more weeks. however, external fixation of tibia and distal radius can be method of choose for definitive treatment not only in open but in closed fractures as well. it becomes justified when high mobile and relatively simple external fixation devices have been developed allowing addition correction of reduction. in this paper, we want to present possibility of using already applied, external fixation device as temporarily method. about week after external fixation done (on femur or tibia) we developed technique existing external fixator to be used as a reduction device. once, desirable fracture reduction achieved, internal fixation is very easy and we do not need fluoroscopy control for reduction, just for internal device fixation by minimally invasive method. using this method, we already treated patients with femur fractures and with tibia fractures. from results obtained it can be concluded that external fixator developed by mitkovic is suitable to function as accurate fracture reduction device providing condition for simple minimally invasive internal fixation. results: with the antegrade nailing technique the mean postoperative constant score was . (flexion . °m abduction . °, pain . ). the elbow extension was free in . %. a correct axial alignment was found in %, in % we found a varus deviation of °- °. in % the nail perforated. in complications there was one prolonged bone healing, one pseudarthrosis and one infection. two thirds of the patients were very satisfied with the outcome. in the retrograde nailing technique the mean postoperative constant score was . (flexion . °, abduction . °, pain . ). the elbow extension was free in . %. only % of the patients showed a mild discomfort at the operative approach at the elbow. a correct axial alignment was found in %, in % we found a varus deviation of °- °. in % patients showed a postoperatively detected fracture in the supracondyle region. . % of the patients were very satisfied with their outcome. conclusion: the retrograde nailing technique is a save and sufficient method for treating humeral shaft fractures, especially because the rotator cuff is not disturbed. introduction and objectives: the bony bankart lesion is an avulsion fracture of the glenoid that usually occurs after anterior shoulder dislocation. this injury is frequently missed and often creates shoulder instability. therefore, open reduction and internal fixation (orif) of the fragment is recommended. in this study we looked at shoulder function, instability and pain after this operation. postoperative x-rays were reviewed on anatomical reduction. patients and methods: between and , bankart fractures were operated. they were classified according to ideberg. sixteen patients had an ideberg type b fracture and three a type . these patients received questionnaires with a number of validated scoring systems. we used the ases, rowe shoulder score and the dash questionnaire. results: the response was %. all respondents did get a stable shoulder after surgery. two patients regularly experience mild pain. the average rowe score was . (range - ). the average ases score for adl was (maximum score , adl unlimited). the median dash score on the quality of life was . (where means no loss of quality of life). there was a clear positive relationship between the radiological postoperative congruency of the joint, the shoulder function and quality of life. introduction: traumatic dislocation is the most severe form of ligament injury of knee.the purpose of this study is to report our cases in past years. methods: between and , knees in men and women; patients were treated for traumatic knee dislocation in our trauma center. the mean age was ( - ) years at the time of injury. the mechanism of injury were motor vehicle accident in , fall from high in and industrial accidents in patients. patients had additional extremity trauma. vascular injury detected in knees who required immediate reconstruction by vascular surgeons. the orthopaedic stabilization of the initial injury was bridging external fixation in knees included all vascular injuries. patients had fibular nerve palsy. in knees medial collateral ligament, in knees lateral collateral ligament, in knees anterior cruciate ligament, in knees posterior cruciate ligament and in knees posterol ateral corner lesions were diagnosed. one had tuberositas tibia avulsion. multiligament reconstruction was performed on a delayed basis in patients for a minimum of ( - ) month after the injury all patients had functional rehabilitation for a mean ( - ) weeks. results: at an average follow-up of . ( - ) years they were examined for stability and range of motion. all knees having multiligament reconstruction and of the patients in whom nonsurgical treatment was undertaken were stable. patients having multiligament reconstruction had slightly lower knee range of motion hypothesis: computed tomography (ct) is more accurate than bone scintigraphy for diagnosis of a radiographically occult scaphoid fracture. methods: in a study period of year, consecutive patients with a suspected scaphoid fracture but no fracture on scaphoid radiographs were evaluated with ct within h of injury and bone scintigraphy between and days after injury. the reference standard for a true (radiographic occult) scaphoid fracture was either ( ) diagnosis of fracture on both ct and bone scintigraphy, or ( ) in case of discrepancy, clinical and/or radiographic evidence of a fracture. results: ct showed scaphoid and other fractures. bone scintigraphy showed scaphoid and other fractures. according to the reference standard there were nine scaphoid fractures. the prevalence of true scaphoid fractures among suspected fractures was therefore %. ct had a sensitivity of %, specificity of %, accuracy of %, a positive predictive value (ppv) of % and a negative predictive value (npv) of %. the prevalence corrected ppv was % and the prevalence corrected npv was %. bone scintigraphy had a sensitivity of %, specificity of %, accuracy of %, a positive predictive value of % and a negative predictive value of %. the prevalence corrected ppv was % and the prevalence corrected npv was %. summary: this study could not confirm that early ct imaging is superior to bone scintigraphy for suspected scaphoid fractures. bone scintigraphy remains a highly sensitive and reasonably specific study for the diagnosis of an occult scaphoid fracture introduction: the therapeutic management of scaphoid fractures is still surrounded by controversy. immobilisation for non-or minimal displaced scaphoid fractures results in a union rate of more than %. functional outcome is often measured using clinical examination and radiological consolidation. however, the indication of how successful the treatment has been is the functional outcome of the patient. functional outcome of upper-extremity fractures can be measured reliably using the dash (disabilities of the arm shoulder and hand) outcome measure. materials-methods: consecutive patients with non-or minimally displaced scaphoid fractures, treated conservatively, were included. the trauma mechanism, treatment modality, diagnostic modalities, duration of cast immobilization and complications were analysed for all patients. functional outcome was measured using the dash outcome measure. results: patients showed good clinical and radiologic outcome after weeks of cast immobilization with a mean dash of . . six patients consolidated within weeks with a mean dash of . . three patients with four fractures took more than weeks to achieve clinical and radiologic consolidation and had a mean dash of . . the dash questionnaires showed statistically significant differences between patient age, fracture location and duration of cast immobilization. conclusion: conservative treatment of non-or minimally displaced scaphoid fractures results in good functional outcome after weeks of cast immobilization, particularly in young patients with distal or waist scaphoid fractures. objective: pedicle screw instrumentation is the most common procedure in stabilizing fractures of the throracolumbar spine, but yields an immanent potential for iatrogenic damage due to malpositioned pedicle screws. methods-materials: patients undergoing posterior instrumentations were included. preoparative ct scans were used to determine fracture level and classification. postoperative ct scan were evaluated for screw positions of all pedicle screws. cobb angles were compared to calculate the degree of reduction. the position of all pedicle screws was determined according to the classification proposed by zdichavsky. results: pedicle screws were assessed. pedicle screws were classified as optimal (ia, %), ib, iia, iib, iiia and iiib. malpositions were more often the more cranial pedicle instrumentation was performed ( % increase per level, p < . ). malpositions (ib-iiib) occurred more often on the right side of the patient (p < . ). the mean reduction was °. discussion: this study confirms the hitherto felt but unproven suspicion that malpositioning occurs more often in the upper thoracic spine. even more remarkably is the side-dependency in malpositioning. we attribute the higher rate of malpositioned screws on the right side of the patient to the circumstance that the surgeon usually stands on the left side of the patient and visual control of the direction of the pedicle screw during insertion is probably more difficult on the opponent side. we recommend envisioning this fact and -if navigation is not used -changing the position during the procedure. background: u-shaped sacral fractures are rare and highly unstable pelvic ring injuries. surgical stabilization may facilitate early mobilization and reduce mortality. however, limited evidence has prevented the development of a standard treatment algorithm. furthermore, little is known about the quality of life in these patients. purpose: to assess the injury characteristics, choice of treatment and quality of life of patients with u-shaped sacral fractures. methods: eight patients with u-shaped sacral fractures were identified over a -year period. neurological outcome was classified by gibbons' criteria. quality of life was evaluated using the euroqol- d questionnaire. results: there were five women and three men; the median age was years. the injury severity score ranged from to . definitive internal fixation was established after to days. percutaneous iliosacral screws were used in two patients with relatively stable fractures. transsacral plate osteosynthesis was used in one patient with minor displacement. triangular osteosynthesis with transsacral plating was used in four patients with multilevel sacral fractures, highly unstable fractures or traumatic spondylolysis l -s . one patient with an associated l fracture received a triangular osteosynthesis without transsacral plating. early partial weight bearing was encouraged whenever possible. follow-up ranged from to months (median months). four patients kept severe bowel and/ or bladder dysfunction. in the euroqol- d, pain, mood disorders and mobility problems prevailed. conclusion: u-shaped sacral fractures are rare and complex injuries. operative stabilization is tailor-made on the individual fracture characteristics. outcome is dominated by neurological deficits, pain, mood disorders and mobility problems. background: traumatic amputations are important causes of acute stress disorder and post-traumatic stress disorder. in this study, we aimed to present traumatic amputated patients needed more psychiatric support than the other trauma patients during the hospitalization period in the orthopaedics and traumatology clinic and in the later periods more post-traumatic stress disorder could be observed in this patient group. patients and methods: twenty-two traumatic amputated patients who have been treated in our clinic were evaluated retrospectively. during the early post-traumatic period, between the nd and th day, it was observed whether they needed any psychiatric support treatment. after the th month of the trauma, the patients were referred to the psychiatry department, and it was evaluated whether they needed any psychiatric support treatment by measuring the 'post-traumatic stress disorder scale' (tssb-Ö ). results: twenty-one (% . ) of twenty-two patients were male, one (% . ) of them was female. introduction: intramedullary nailing is challenging in proximal tibia fractures, associated with high rates of malalignment. to date, no studies report the potential of lateral tibia nail insertion to correct primary valgus malalignment, commonly seen in proximal quarter fractures. materials and methods: fresh-frozen cadaver lower extremities were used to simulate an ao/ota -a fracture. six nails (expert tibial nailing system, synthes, salzburg, austria) were inserted at the lateral third, six nails at the middle third and six nails at the medial third of the lateral tibia plateau. after nail insertion, alignment in the coronal plane was recorded. results: mean varus malalignment was dependent on the entry point at the lateral tibia plateau. mean varus malalignment was °if nails were inserted at the lateral third, °at the middle third and °after nail insertion at the medial third. if nails were inserted from the medial third, valgus malalignment was recorded in two specimens. discussion: the effect of correction of coronal malalignment in proximal tibia fractures is dependent on the point of nail entry at the lateral plateau. primary valgus deformation up to °can be corrected by inserting tibia nails at the lateral third of the lateral tibia plateau. surgeons should be aware of possible varus deformity and valgus malalignment despite lateral nail insertion. introduction: treatment of patients with distal radial fractures is primarily based on radiologic parameters. however, correlation between these parameters and functional outcome is questionable. objective: determine the value of radiological parameters for the appropriate treatment of patients with distal radial fractures. methods: a retrospective analysis was performed for a consecutive series of patients with conservatively treated distal radial fractures. axial radial shortening, radial displacement, radial angle, dorsal angle, and dorsal displacement were measured on the postero-anterior and lateral x-rays. functional outcome was measured using the quick dash-score (qds). minimal follow up was months. the radiological findings of patients who met the criteria for conservative treatment were compared to those of patients that met the current criteria for operative treatment (dorsal angulation > °, radial angle > °, radial displacement > mm, radial shortening > mm and step off > mm) but who had been treated conservatively instead. results: in a -year period patients were treated conservatively for a distal radial fracture. the qds was performed in ( %) patients. male female ratio was : , the average age was years (range - ). the mean qds was (sd ± ; range - ). age and female sex associated negatively with the qds. none of the radiologic findings was associated with the qds. half of the patients met the current criteria for operative treatment. the qds of this group corresponded however with that of the correctly conservatively treated patients. introduction: conservative treatment is generally preferred for simple elbow dislocations. in this study, the clinical and radiological results of conservative treatment are retrospectively evaluated. the patients were treated with closed reduction, plaster splint and brace. methods: dislocations of all patients were towards posterior and the average length of immobilization was . days ( - days) after closed reduction. the patients were assessed clinically for range of motion, instability, and atrophy after . months of mean follow up. mayo elbow performance score (meps) was used to evaluate functional outcome. standard elbow x-rays were evaluated for degeneration, heterotopic ossification, and concentric reduction. results: the average age of the patients was . ( - ) years. none of the patients had muscular atrophy. four patients ( . %) reported mild pain with heavy activity. six patients ( . %) had neurological complaints related with ulnar nerve. the average flexion arc and average rotational arc were °and °, respectively. the differences between the contralateral elbow motions were . °for flexion arc and . °for rotational arc. four patients ( %) had minimal residual instability. three patients ( . %) had mild radiographic signs of arthrosis and patients ( . %) showed minimal-mild degree of heterotopic ossification. an average score of . was obtained using meps. only four patients ( %) considered themselves fully recovered. conclusion: closed reduction and immobilization is a universal method for simple elbow dislocations. however, although functional scores were excellent, most of the patients did not consider themselves fully recovered. anterior odontoid screw fixation (aosf) is a valuable treatment after of, reported union rates in the elderly vary between and % when assessed on plain radiographs. in this study union-rates in of treated with aosf in patients aged ‡ years were revisited and risk factors for non-union analyzed. retrospective data review of a prospectively gathered c -fracture patients treated with aosf for of and age ‡ years were included for study. asides demographics and common injury characteristics, injury radiographs and ct-scans were assessed for fracture displacement, type, atlantodental osteoarthritis and particularly focussing on the square surface of of. follow-up ct-scans were assessed for technical failures, odontoid union, number of screws in aosf, square surface of screws used and the related healing surface. there were male ( . %) and female ( . %) patients with a mean age of . ± . years at injury ( - y). mean follow-up with ct-scans was . ± . months ( . - . mo). intervall injury to aosf was . ± . days ( - days). mean square surface of fractures was . ± . mm ( . - . mm ) and mean osseus healing surface was . ± . % ( . - . %). ct-based analysis revealed osseus union in nine ( %), while the remaining nine patients ( %) revealed non-union. in two patients, symptomatic non-union indicated posterior fusion of c - . union-rate significantly correlated with increased fracture surface (p = . ). observable was the trend that using two screws for aosf correlated with increased fusion-rate compared to one screw (p = . ). lifethreathening hemorrhage is often seen in pelvic ring fractures. efficient treatment of this hemorrhage is critical for survival in these patients. the purpose was to analyse the causes of death in hemodynamically unstable patients with a pelvic ring fracture and to determine if standardized treatment will reduce mortality. retrospectively, all data were reviewed of hemodynamically unstable patients with a pelvic ring fracture in the period / / till / / . of all patients, the pathway of treatment was analysed and compared with the standardized treatment protocol in our clinic. all injuries were categorized in injuries in airway, breathing, circulation and disability according to atls Ò principles. death was classified as directly related to the pelvic fracture if the patient required massive transfusions, died within h after admission and had no other body area injury with ais ‡ responsible for persistent hemorrhagic shock. we reviewed the data of patients. / patients died ( %). these patients were significant older and had a significant higher iss and shock class than survivors. two patients died of pulmonary trauma ( %), patients ( %) died of exsanguination(c) and patients ( %) died due to major head trauma. in patients ( %) there was a combination of injuries, which caused death. thus, overall hypovolemic shock contributed to mortality in cases. only in three patients death could be directly related to hemorrhage from the pelvis. two nonsurviving patients ( %) were not treated according to our standardized treatment protocol. in the survivor group this was only one patient. there is no consensus on the treatment of the acute total achilles tendon rupture. treatment modality is chosen on the basis of patient characteristics or the preference of the attending surgeon. using ultrasound, the distance between the two tendon ends in equinus position can be measured. this could form the basis for decision making between conservative-and surgical treatment. this cohort study consists of consecutive patients, between january and january . using ultrasound, patients were assigned to a surgicalor conservative treatment group. a gap of more than mm in maximal equines position was an indication for surgical treatment. seventy-two patients, men and women, received a conservative treatment. in patients the achilles tendon was primarily sutured. in the surgical group the post operative treatment was identical to the conservative treatment. the male-female ratio did not differ significantly (p = . ). the average age was years. sports caused % (n = ) of all injuries. the surgical group showed six re-ruptures versus nine in the conservative group (p = . ). on average, a rerupture occurs after days. no significant difference in major and minor complications (p = . ). outpatient treatment was needed days for the surgical treatment group versus days for the conservative treatment group (p = . ). ultrasound measured distance between the two ends of the achilles tendon in equinus in an acute total rupture can be used as a selection method in making a decision between surgical and conservative treatment. introduction: missile wounds induced by aviation bomb splinters pertain to grave injuries, due to large wound area and high risk of complications. material-methods: patients with large defects, in of casescombined with long bone fractures caused by missile injuries were treated by us in the period of august-november in . every cases were subjected to radical primary debridement with complete drainage. after relevant preparation for soft tissue plastic repair (involving primary radical debridement, primary external fixation, complex drug therapy and repetitive regular debridement) the following repair procedures were undertaken: in four cases, soft tissue defects were covered via rotation of local flaps. in three cases, defects were covered through transplantation of free skin grafts. in four cases, large soft tissue defects were overlayed by vascularized thoraco-dorsal (ld flap). in two of these, bone defect repair was simultaneously performed applying avascular graft taken from hip bone crista. results: in seven cases, transplanted flaps adhered perfectly, without trophic or infective complications. in one case, rotated local flap necrotized due to interrupted perfusion, which was subsequently replaced by free skin transplant. in five cases, fracture consolidation was completed in - months. in remaining two cases (after bone defect repair), consolidation process still proceeds with satisfying rate. conclusion: transplantation of vascularized thoraco-dorsal flap is especially effective for covering large soft tissular defects. soft tissular plastic repair has the double advantage of defect reconstructive ability and prevention from secondary infections, with additional stimulation of bone tissue regeneration. introduction: shoulder arthroplasty remains a valuable treatment for complex fractures of the proximal humerus. however the success of anatomical arthroplasty is mainly dependent of anatomical healing of the tuberosities. even with specific prostheses and fixation techniques in - % of cases anatomical healing is not achieved. using a nonfracture specific trauma prosthesis we achieved better elevation and abduction; however endorotation, exorotation, subjective shoulder rating and complication rate did score poorer than in anatomical arthroplasty. we assumed that the impossibility to refixate the lesser and greater tuberosity fragment, and subsequently the subscapularis and infraspinatus-teres minor tendons, are the main cause for this observation material-methods: we developed a fracture specific reversed shoulder prosthesis allowing for anatomical refixation of the tuberosities. we included patients in the reversed fracture arthroplasty group. function is scored using the constant murley-score. radiographically we evaluate for evidence of scapular notching. complications are recorded. we compare our results to an historical series of delta iii prostheses. results: at months the mean constant score is . points. there was no case of notching. there was one complication, an early infect. the mean constant score in the delta group was points. there was notching present in % of cases. in the delta group there were five reoperations in three patients because of dislocation. conclusion: there is a strong trend to better functional outcome using the fracture specific design. there are less complications and less notching. the possibility to refixate the tuberosities leads to better results. introduction: as fractures of the femur are severe injuries and patients mostly suffer from extensive pain they quickly attract the physician's attention in the emergency room. the literature has shown that injuries to the ipsilateral knee can occur accompanying such injuries. in most cases, these injuries though were diagnosed on delay. excluding cases in which a knee injury was apparent already on admission, we sought to investigate the number and severity of initially undetected lesions to the knee accompanying a femoral shaft fracture and give an overview of the literature. methods: charts and x-rays of patients treated for a femoral shaft fracture from january until december were reviewed. patients, in whom any other injury of the affected limb apart from a midshaft femoral fracture was initially diagnosed, were excluded. also patients, in whom an injury to the knee had been diagnosed on admission, were excluded. results: fifty-three patients with midshaft femoral fractures were available for analysis. an injury to the knee was diagnosed in cases ( %). there was one partial tear of the posterior cruciate ligament and two grade lesions of the medial meniscus. all lesions were conservatively treated. the shoulder is the most mobile joint of the human body. it has a great range of movement that takes place in all three cartesian planes. this is a complex phenomenon. there is considerable controversy over an ideal method for the functional assessment of shoulder joint complex. various methods have been used but they are often inaccurate and unreliable. thus, a better technique, that is reliable as well as repeatable, is required to measure the movements. the aim of this study is to assess the shoulder movement by fastrak Ò and vicon Ò systems and to compare their repeatability. methods-materials: the functional movement of the shoulder joint was assessed by fastrak Ò and vicon Ò systems. a difference between the two systems was determined and a comparison of repeatability was carried out. a population of healthy male volunteers were asked to perform six different tasks that covered all the movements occurring at the shoulder. these tasks were repeated twice on each side on two different days. the measurements were recorded and a custom-made programme, prepared for each system separately, calculated the angles. results: the recorded data was analysed using repeated measure analysis of variance. it was found that the coefficient of repeatability of fastrak Ò was better than the vicon Ò system for each task and there was no significant difference (p < . ) between the two sides. conclusion: the fastrak Ò system is better than the vicon Ò system for assessing shoulder movements. it can be used in clinical practice. ( - ). we applied sarmiento cast without any padding or little padding immediately. we encouraged the patients moving their arms. the treatment ends upon the presence of a bone callus and absence of pain at the fracture site. during the whole therapy the skin condition is monitored and emphasis is put on the prevention of reflex sympathetic dystrophy. we evaluate the result of the treatment with a focus on the any restriction of the range of motion of joints and the presenting any angulation of the humeral shaft. average follow up time was months ( - ). all fractures were healed without any major problem and we did not face any nonunion and no major angulations axis of the humerus. average union time was months ( - ). the results of nonsurgical treatment of the humerus mid and distal thirds shaft fractures are reported as a less complicated way and have a higher rate of union. this method is practical, efficient, cheap, and safe, if a good cooperation with patients is established and close observation is done. ( ). the aim of this study is to evaluate the surgical anatomical aspects of the minimally invasive hip surgery procedure in cadavers. methods: the mis approach was performed on four specially embalmed cadavers. all cadavers had a normal 'range of motion' of the hip joint. the difference in muscle length and work space were measured in all leg positions. additionally the difference in muscle tension in anterior and posterior luxation was compared with regard to the accessibility of the femoral shaft. results: the length of the medial-and minimal gluteal muscles is reduced in abduction. a difference of more than cm was found between °to °abduction and full abduction. the working space ( . · cm), is limited in the maximum ( °) abduction position. posterior luxation gives a better femoral shaft approach and less/ none muscle tension/damage compared to anterior luxation. the optimal approach to the femoral neck during mis of the hip is achieved during °- °abduction of the ipsilateral leg combined with °retroflexion. the best femoral shaft approach for prosthesis insertion is the posterior luxation. no additional damage, excluding the skin and fascia incision, was seen during posterior luxation. posterior luxation and exorotation of the leg enables straight and direct access to the femoral shaft compared to the access obtained during anterior leg luxation. background: it has been stated that acromial morphology plays an important role in the etiology of rotator cuff pathology. the system most widely used to describe the morphology is the bigliani classification. recently nyfeller introduced the acromial index. we wanted to examine whether there is a correlation between these two parameters and the presence of a rotator cuff tear or an impingement syndrome. methods: we assessed both parameters in four groups of patients each. the first group consisted of patients with operatively treated rotator cuff tears (average age . years) and the second group of patients known with impingement syndrome but documented intact rotator cuff (average age . ). for both groups, an age and gender matched control group was constructed. results: type three acromions were significantly more prevalent in the rotator cuff tear group than in the control group (p < . ). the average acromial index was . + . in the rotator cuff tear group and . + . in the rotator cuff control group, which is not statistically significant (p = . ). in the impingement group, the acromial index was . + . and . + . in the impingement control group. this difference was found to be statistically significant (p < . ). conclusions: patients with a rotator cuff tear appear to have more frequently bigliani type three acromion than age and gender matched, asymptomatic patients. there is no correlation between acromial index and acromial type or age. objective: extracorporeal membrane oxygenation (ecmo) is rarely used successfully in trauma. transfusion related acute lung injury (trali) is also rare in plasma containing blood product transfusion. methods: this is a case report of a trauma patient with life-threatening trali following trauma that was rescued successfully using ecmo. a year old patient was struck by an automobile and suffered a grade ii splenic injury, grade iv-v right renal injury as well as multiple orthopedic injuries. an attempt at angiographic embolization failed as the patient required multiple transfusions and became progressively hypotensive. the patient underwent emergent nephrectomy but rapidly became hypoxic with the pao becoming less than mmhg for over an hour. despite aggressive attempts at ventilation and oxygenation, the endotracheal tube was filled with fluid and hypoxia pursued despite low right heart filling volumes. rescue ecmo was instituted with successful oxygenation. after h the patient recovered from trali and was able to have ecmo discontinued. the patient was weaned off the ventilator within days and the patient had full recovery. the patient did not suffer any hypoxic brain insult. conclusions: although it is often thought that ecmo is unsuccessful in trauma patients, this case demonstrates its potential use in trauma patients. author to editor: will also present as poster findings: a total number of patients (all male; . ± . ) were found. injuries were resulting from gun shot fires (n = ; . %) or stab wounds (n = ; . %). injury sites within the heart were the right atrium (n = ; . %), the right ventricle (n = ; . %), the left atrium (n = ; . %), and the left ventricle (n = ; . %) (more than one site was observed in patients). the accompanying injuries were observed in the spleen (n = ; . %), the lung (n = ; . %), the liver (n = ; . %), and the stomach (n = ; . %). in ( . %) patients emergent thoracotomy was clinically decided with suspicious findings of hypovolemic shock or cardiac injury including low blood pressure, jugular fullness, deeply heard heart sounds, filiform pulse, narrowing of pulse pressure. the rest patients (n = ; . %) were operated after major blood drainage from tube thoracostomy. all the injuries were repaired with sutures, and pericardial fenestration was done in all. mortality was observed in two cases ( . %). patients with penetrating regional wounds should be suspected for penetrating cardiac injuries, since immediate surgical intervention may decrease the risk of mortality. introduction: the use of ''pan-ct'' is discouraged in settings of high imaging demand. this study compared clinical and plain chest film findings to determine need for, and results of, chest ct. methods: during recent month period, patients sustained blunt chest injury either isolated or in setting of multisystem trauma. data was tabulated by a combination of prospective and retrospective analysis. initial injury assessment followed atls protocol. supine chest film, followed by chest ct, were performed in all patients and compared with clinical findings. results: significant clinical findings were defined as tachypnea, decreased air entry, chest wall tenderness and initial oxygen saturation less than %. the presence of two or more of these clinical findings occurred in patients ( %). ct findings in this group included multiple rib fractures ± flail chest, sternal fractures, pneumothoraces, hemthoraces, and pulmonary contusions. higher ais and need for interventions occurred in this group. the co-existence of tachypnea and desaturation correlated with the need for tube thoracostomy in / patients( %) - pre-ct, post ct. conclusions: in patients with blunt chest injury, the presence of two or more of the clinical signs -tachypnea, decreased air entry, chest wall tenderness, oxygen saturation < % -is associated with: ( ) significant chest injury demonstrated on chest ct; ( ) higher correlation with ct findings than plain films alone; and ( ) introduction: complex regional pain syndrome (crps) sustained after trauma has a great negative impact on rehabilitation and activities of daily living. treatment is most often unrewarding. aim: to analyze prospectively the efficacy of endoscopic thoracic sympathectomy (ets) in reducing pain and disability associated with crps. patient and methods: over a -year period, patients ( females and males; mean age . ± . ) with posttraumatic crps underwent unilateral ets. the median duration of crps symptoms before ets was . months (range: . - ) . the sympathetic chain was resected from the second to fifth rib. mean postoperative follow-up was . ± . months (range: - . ). pain was assessed, at rest (passive) and during movement (active), using a visual analogue scale (vas) from to . results: one patient ( . %) had a hydrothorax and three patients ( %) complained about contralateral compensatory hyperhydrosis. at month (n = ), months (n = ), months (n = ) and year (n = ) after ets, there was a significant decrease in passive and active vas (p < . ). ten out of patients ( , %) needed less analgesics after surgery, and seven ( %) did not need analgesics at all. the mean sleep duration improved significant from . ± . h preoperatively to . ± . h postoperatively (p < . ). overall, patient satisfaction was % ( out of patients). conclusion: ets is efficient for decreasing pain and improving quality of life, and therefore should be considered in the treatment of crps. author to editor: complex regional pain syndrome (also known as sudeck or reflex sympathetic dystrophy) is a complex disease that trauma surgeons frequently encounter in the post-traumatic period. endoscopic thoracic sympathectomy is not well known among trauma surgeon, although it is an good option in relieving the pain and improving the quality of life. monitoring is accomplished with chest x-ray (cxr), but ultrasound (us) is nowadays established as more sensitive than cxr in detection of ptx. patients and methods: from october , thoracic views for detection of ptx are systematically included in the efast protocol during primary survey for every trauma patients (pts) admitted to our level i trauma center. among hospitalized pts, a selective usguided aspiration for small ptx was applied in three pts (two with a slow reabsorption time, one in a pt requiring hyperbaric oxygen therapy for a soft tissue infection of the leg). in supine position, delimitation of the area of anterior ptx was done with a linear probe, searching for lung points in adjacent intercostal spaces. under local anesthesia, a fr catheter was inserted in the ptx and aspiration monitored in real time by us, until restoration of sliding lung. the day after, after confirmation of normal gliding lung, two pts were discharged and one deemed suitable for hyperbaric oxygen therapy. discussion: small traumatic ptx is generally monitored without treatment. in some pts, drainage is however required, but the procedure is blind if performed on the basis of cxr findings. us allows to precisely define the site and the limits of ptx, insert a small catheter in the right area, monitoring reexpansion of the lung and complete aspiration of ptx and shortening recovery. background and objectives: occult diaphragmatic injuries are associated with significant mortality, if the diagnosis is delayed. we report our experience in diagnostic and therapeutic thoracoscopy in a selected group of patients with penetrating thoracoabdominal injuries. methods: the patients who underwent thoracoscopic management of thoracoabdominal stab injuries between june and june were included into the study. the data were retrospectively analyzed. results: eighteen selected patients with thoracoabdominal stab injuries were managed by thoracoscopy. the procedures were performed under general (n = ) or local anesthesia (n = ). diaphragmatic injuries were repaired by intracorporeal sutures in seven cases and bleeding was controlled in another two cases by electrocautery coagulation. the procedures were simply diagnostic in nine patients. the mean operating time and hospital stay were . min and . days, respectively. there was neither intraoperative or early postoperative complication, nor mortality. in a patient who had intra thoracic adhesions due to prior tuberculosis, unmentioned by the patient preoperatively, adequate exploration could not be achieved during thoracoscopy. the procedure was converted to laparoscopy and laparoscopic gastric and diaphragmatic repairs were performed. conclusion: thoracoscopy seems to be a safe, quick and efficient method in the diagnosis and treatment of diaphragmatic wounds, due to thoracoabdominal penetrating injuries. the nonoperative management is gradually more used in abdominal stab injuries and surgeons can resort to thoracoscopy and laparoscopy as a minimally invasive, diagnostic and therapeutic tool. trauma surgeons should be aware of the benefits of thoracoscopy and must have sufficient skills to carry out this technique. summary: generating acute lung injury by smoke inhalation and analyzing a method to pursuit standardized smoke. methods: a standardized glass, measures of cm width, cm length and cm height used as a closed area. we established a valf system under the glass which allows air inside but does not let it outside. with a hole above the glass, we attached the system to pomp with a hose. and the pomp was attached to a cm radial length balloon by another hose. we put a four ampere electricity owen in to glass and put g cotton to the oven. we burned the cotton for s in the closed area and we fullfilled the balloon with smoke by the pomp in s. rabbits were entubated after being anestesized. we waited seconds for the smoke to reduce down to room tempe rature to avoid thermal damage. after that, we seperated the balloon from the pomp and put it right through rabbits by ambulant air flow and inhalated in min.this procedure repeated for each rabbit. after the procedure ended,the entubation tubes were pulled away and the rabbits were left to spontaneous respiration. rabbits were allowed to standart rabbit bait and water at the th hour. results: we think we used a standardized smoke inhalation model in this study. methods: ten wistar rats were anesthetized and heparinised before the femoral artery was pierced to initiate bleeding. rats were than randomized to control and study groups. mph was poured into the bleeding site and a mass was placed on it. after s, the mass was removed and assessment of hemostasis was done. if bleeding ceased the test was scored as ''passed at s''. if not, additional dose of mph and compression was reapplied for an additional s. if bleeding has stopped after the second application, the test was scored as ''passed at s''. if not, the same procedure was repeated for the last additional s. if bleeding stopped now test was scored as passed at s. similar sequence of trials was done in the control group but without mph. the difference between bleeding periods in two groups was observed. results: application of mph resulted in complete cessation of bleeding in four of five and one of five rats at and s, respectively. in the control group hemostasis could not be achieved in all five rats, even at s. the statistical difference between the groups was significant (p < . ( . - . year) with supracondylar humeral fractures were treated operatively. according to gartland ( %) were type-ii, ( %) were type-iii. at the time of arrival at emergency department, four ( %) children sustained vascular impairment with pink pulseless extremity persisting after reduction. in three cases, a cubital approach was performed. two arteries showed a major lesion (one direct suture, one saphenus vein graft), and one artery showed an entrapment. all lesions showed a normal postoperative pulsation. another three ( %) children sustained a complete paralysis of the radial nerve. these cases were conservatively treated with complete neural restitution. conclusions: urgent anatomical reduction and fixation are crucial. in persisting vascular impairment after reduction, surgical exploration for the restoration of arterial patency should be performed, even in the presence of a pink hand. conversion to open surgical repair was needed in one case due to retroperitoneal bleeding from the iliac arteries. early postoperative mortality was observed in ( %) patients; due to massive coagulation disorder and hemodynamic instabiliy in postop st day and th day. mean follow-up was months (range - months). late mortality was not observed. overall reintervention rate was % (n = ); proksimal re-stenting was needed due to type endoleak in one patient. embolectomy for crossfemoral bypass was needed in one other patient after stenting for aneurysmal abdominal aortic rupture, this patient underwent re-crossfemoral bypass surgery later on. introduction: dislocations of and fractures around the knee are accompanied by injuries of the regional vessels to a certain extent. in any case of suspicion at the scene of accident an immediate transport to an adequate trauma center is the precondition for successful limb salvage. methods: between and , patients with arterial injury after dislocation of or fractures around the knee have been treated. retrospective analysis was performed in order to acquire epidemiologic data. furthermore we investigated the sufficiency of preoperative management and diagnostics. we explored peri-and postoperative complications, such as compartment syndrome, secondary thrombosis, infection and number of revision surgeries and related the data to the final follow up after and months. results: arterial injury was found in four cases of knee dislocation, in seven cases of proximal tibial fracture, and in nine cases of distal femur fracture. seven patients underwent acute angiography, since the year all patients were assessed with cta. seventeen cases were treated with venous interposition, one with a venous patch, and two with direct suture. fasciotomy was performed in all cases. limb salvage was successful in cases. in seven cases secondary amputation was necessary, six of these patients were polytraumatized. discussion: sufficient time management is crucial for the survival of vessel injured extremities, as the time of ischaemia must not exceed h. perfect interdisciplinary coordination and the establishment of specific algorithms are needed in order to decrease the risk of complications and amputations of lower extremities. the survey on the epidemiology of car-motor related accidents in children in kashan, iran iman ghaffarpasand, maneli dorudian tehrani department of surgery, kashan medical university, kashan, iran introduction: the most common cause of death in children is accident and reinforced a lot of taxes on the society. kashan has the second position in trauma ranking of iran so we studied this important issue in the children. methods and material: in this descriptive study, data has been gathered by trained hospital nurses during month in traumatic patients refered to -bed teaching hospital, kashan. the main method is questionnaire filling by direct interviewing. findings: among cases of trauna ( . %) of them was children below years old that cases ( . %) were due to car accident, cases ( . %) were due to motor accident and rest of them ( . %) were pedestrian accident. boys involved . times as girls the most injuries happened was head-injury ( . %). conclusion: these finding suggest that we have to pay more attention to this age group specially - because of the high rate of their involvement. finally as you see the last but not the least, these findings emphasise on protective cap wearing for every persons. managing blunt splenic injury in a level ii trauma center: the laparoscopic option background: the past decades treatment modality of blunt splenic trauma was a point of discussion. where nowadays explorative laparotomy remains the standard of care for hemodynamic unstable patients, treatment of hemodynamic stable patients is less uniform. in this stable population maximum conservative approach seems preferable, though level evidence is still absent. failure of the conservative pathway is backed up by percutanous angioembolisation or laparoscopic salvation. the evolution to minimal invasive access makes laparotomy as a primary care for hemodynamic stable isolated splenic injury superfluous. methods: this paper discusses the initiation of explorative laparoscopy and successive splenectomy in two patients scoring a grade iii posttraumatic splenic injury. grading was based on ct scan imaging using the spleen injury scale defined by the american association for the surgery of trauma (aast). conservative treatment was abandoned because of moderate hemoperitoneum and continuing need for transfusion. results: an uncomplicated laparoscopic splenectomy was performed in both patients. perioperative spleen preserving measures failed because of the extent of the parenchymal lesion. conclusion: performing laparoscopic splenectomy seems a good procedure when conservative treatment for splenic injury fails. this accounts for a rural level ii trauma center where the accommodation to perform safe angioembolisation is missing, knowing that laparoscopic splenectomy is not a straight forward procedure but is made easier because of the growing skills of our surgeons. hepatic portal venous gas (hpvg) is often associated with serious intra-abdominal pathology like ischaemic bowel disease and necrotizing enterocolitis, with reported mortality rates above %, with most requiring urgent operation. however, hpvg has been reported seen on ultrasound or computed tomography (ct) scans immediately after blunt trauma, followed by spontaneous resolution. gastric pneumatosis (gp) has rarely been reported as a trauma-related entity. the combination of hpvg and gp after blunt trauma has been described in very few patients. we report the case of a -year-old woman who presented with an edh requiring craniotomy and an initial abdominal ct scan showing only an ois grade liver injury. a transient increase in serum amylase combined with abdominal distension led to a repeat abdominal ct scan h post injury to rule out pancreatic and duodenal injuries, revealing gp and hpvg. endoscopy demonstrated mucosal erythema of the posterior gastric wall from the fundus to the pylorus. however, the clinical status of the patient was benign, and did not mandate surgical intervention. the patient was treated nonoperatively with nasogastric decompression and antibiotic coverage, and underwent a successful recovery with no abdominal complications. to our knowledge, only one other adult patient has been described with hpvg and gp occurring after an initial normal abdominal ct scan. a gastric resection was performed, and operative treatment was recommended for this combination of entities in trauma patients. our patient shows that treatment strategies in these cases probably should be guided by the clinical status of the patient. introduction and aims: while the number of colorectal injuries due to penetrating trauma are increasing, increased traffic accident rates also cause the number of blunt rectal injuries associated with trauma in traffic accidents to be increased. rectal injuries occur rarely. because of post operative septic complications, morbidity and mortality rates are high. early admission, stability, operation type all play important roles in the fate of the patient. we aimed to investigate these criteria in our patients who have colorectal injuries. material-method: cases who had penetrating or blunt trauma in our district during last years were included in this study. aim of this study is to present three cases with torsion of omentum, that often resemble acute cholecystitis or appendicitis, and the diagnosis is made at the time of exploratory laparotomy. case description: the first case, a -year-old men, presented with a -day history of right hypocondrial abdominal pain, fever and vomiting. the pain increasing in severity while the patient is standing and relieved in supine position. laboratory findings were normal, except for mild leucocytosis ( , /cc). the patient underwent u/s examination, which showed an encysted mass in the right abdomen. a mass, originating from the omentum, was revealed after laparotomy. the mass was excised and an appendectomy was also performed. the second patient, a -year-old female, was admitted in our department with abdominal pain, associated with vomitus. a mild leucocytosis ( , /cc) was observed. an u/s was carried out, which revealed a mass · cm lying besides a stone-free gallbladder. the patient underwent diagnostic laparoscopy and a cystic mass, which was twisted, was resected using bipolar forceps. sixteen of all laparotomies did not reveal any internal organ lesion. of these laparotomies with negative findings, had been operated for stabbing injury and had been operated for gunshot injury. twenty-one cases had single organ injury; whereas, multiple organs were affected in cases. frequencies of organ injuries were as follows: small intestine, colon, stomach, liver, diaphragm, spleen, kidney, and pancreas. the mean duration of hospitalization was . ± days. after surgery, four cases needed intensive care unit; therefore, they were referred to a higher-level healthcare center. among cases whom the treatment was completed in our institution, had complication. conclusion: penetrating abdominal injuries mostly occurred in young males and stabbing injuries were more common. most penetrating injuries can be treated at secondary care centers. however, they should be referred to a higher-level institution after the initial intervention, when necessary. background: both nonoperative management (nom) of blunt hepatic trauma and the damage control laparotomy are significant advances in the management of massively injured trauma victims. methods: this study is a retrospective evaluation of patients admitted with liver trauma during . of them required early surgical procedures, damage control surgery and followed nom. patients were stratified by age, mechanism of injury, ais, initial blood pressure, heart rates, and blood transfusion volume. initial outcome data included major complications, intensive care unit and hospital length of stay, and mortality. readmission data including the number of admissions, surgical procedures, and hospital length of stay were then analyzed. the average age of the study group was , years. almost all of these patients were males ( , %) and car crash was the main mechanism involved ( , %). liver injuries were frequently an element of multiple trauma and was associated with cranio-cerebral trauma ( , %) and spleen lesion ( , %). the overall mortality during the first admission was , %, yet . % attributable to the liver trauma and only . % after damage control. conclusions: damage control surgery offers a simple effective alternative to the traditional surgical management of complex or multiple injuries. phase i can be done at a local hospital before transfer to a major trauma center for resuscitation and definitive repair. reasonable surgical procedures based on classification of liver injuries and damage control principles increase the survival rate of severe liver trauma. background: at our department, a simple scoring system based on three criteria (blood pressure below , be below - . and body temperature below °c) has been used to determine the suitability of individual patients as candidates for dcs. objectives: the present study was undertaken to establish a valid strategy for the treatment of severe pancreatic injury and to test the validity of the scoring system used at our department for identifying suitable candidates for dcs. subjects and methods: the subjects of the study were patients with the grater and equal of grade iii (organ injury scale (ois))pancreatic injury treated surgically (type iii in cases and iv or v in cases). results: resection of the pancreatic body and tail was performed in both the groups to treat type iii injury, and all of the cases with type iii injury had favorable outcomes. among the cases with type iv or v injury, all of those patients satisfying two or fewer than two of the criteria of the dcs scoring system survived dcs, while two patients satisfying all the three criteria of the dcs scoring system died after dcs. the two patients who underwent pancreatic duct-forming surgery needed prolonged hospitalization. discussion: our results suggest that dcs should be selected in cases where at least one of the three criteria of the dcs scoring system is satisfied. as a procedure for radical operation, resection of the distal pancreas may be recommended for type iii, and pancreatoduodenectomy for type iv or v. author to editor: our results suggest that dcs should be selected in cases where at least one of the three criteria (systolic pressure below , severe hypothermia with body temperature below °c, and acidosis with be below - . ) of the dcs scoring system is satisfied. this dcs score is accords with the score of another abstract (abs ref ). we did not show the details of the score in another abstract ( ). please refer in our another abstract (ref iatrogenic and traumatic lesions involving common hepatic duct and duodenum can be treated with a primary and contemporary reconstruction, at the condition of hemodynamic stability. we propose a technique which include the following steps: cholecystectomy with intraoperative cholangiography; transection of the common bile duct above the tear, oversewing its distal part; kocherization of the duodenum; a cm long roux-en-y jejunal loop is constructed and brought up retrocolically in the right sub-hepatic space, orientating its antimesenteric side towards the corresponding duodenal wall; termino-lateral hepatico-jejunostomy with a transanastomotic temporary stent in case of small biliary duct's size; a side-to-side jejuno-duodenostomy performed cm distally; a feeding jejunostomy. we remark the following advantages of this procedure: ( ) the rouxen-y biliary diversion reduces the risks of stenosis and cholangitis, frequent after a direct repair of the common bile duct; ( ) an adequate distance between the biliary and duodenal anastomosis prevent entero-biliary reflux; ( ) the duodeno-jejunal anastomosis appears more appropriate, considering the complications after direct repair of large duodenal tears. more aggressive options, such as duodeno-cephalo-pancreatectomy, pancreas-preserving-duodenectomy and segmental duodenal resection, must be considered more risk solutions. introduction: the liver is the most commonly affected organ in abdominal trauma. in our department, the majority of traumatic liver injuries are treated conservatively. this option involves the monitoring of possible complications, such as late rupture, hemobilia, arterio-venous fistula, pseudo-aneurysm, biloma and abscess formation. case: a year-old patient was admitted after a m fall. established diagnoses were: multiple facial fractures, right pneumothorax with pulmonary contusion, right renal artery thrombosis and grade hepatic laceration. the patient was discharged on the st post-trauma day (ptd), after an uneventful course. on the st ptd, he was readmitted for abdominal pain. thoracoabdominal ct revealed an intra-hepatic arterio-venous fistula. angiographic superselective embolization was performed, and the patient was discharged following a control abdominal ct scan that showed resolution of the fistula. he was again readmitted on the th ptd, with abdominal pain, jaundice and gastrointestinal bleeding. an abdominal ultrasound raised the possibility of hemobilia, confirmed by upper endoscopy. a new angiography did not reveal any active bleeding, and an abdominal ct showed satisfactory evolution of the liver lesion. the patient was discharged on the th ptd, asymptomatic. at month follow-up, the patient presents no complaints, other than a new-onset arterial hypertension of renovascular origin. conclusion: arteriovenous fistulae and hemobilia are relatively uncommon sequelae of abdominal trauma. however, these diagnoses should be actively sought in the presence of abdominal pain, especially when associated with jaundice and gastrointestinal bleeding. a multidisciplinary approach is essential for a successful treatment. diaphragmatic hernias constitute frequent complications after thoracic and abdominal trauma ( . - %), especially on the left side ( %) and the diagnosis is frequently delayed. clinical presentation is variable and may include respiratory distress and abdominal pain, frequently attributed to intestinal obstruction, pancreatitis, biliary colic or peptic disease. the authors present a case report of a right diaphragmatic hernia diagnosed years after a thoracoabdominal blunt trauma. the male patient, years old, was admitted in the emergency room with epigastric pain, bloating, slight abdominal distension with months of evolution and recent worsening. he suffered a previous thoracoabdominal trauma years ago, consecutive to a downfall of about eight meters high with lumbar vertebrae fracture (l ) and was submitted to conservative treatment in an orthopaedic ward; x-ray signs of diaphragmatic hernia were unrecognized. actual chest x-ray revealed an elevated right hemidiaphragm and presence of abdominal content in the right hemithorax. mr demonstrated a right hemidiaphragmatic rupture and the presence of abdominal content in the thoracic cavity. patient was operated by laparoscopic approach; a diaphragmatic hernia grade iii (a.a.s.t. classification) was observed and submitted to prosthetic repair. postoperative period was uneventful. patient remains asymptomatic with no signs of recurrence after years. this case is paradigmatic of the difficulty of immediate diagnosis of diaphragmatic hernias, especially at the right hemidiaphragm. high index of clinical suspicion is needed for its early recognition in context of blunt trauma. laparoscopic treatment revealed to be safe and efficient, with the known advantages of minimally invasive procedures. results: their ages were between and , were male and were female. the type of injury was penetrating in , blunt in and blunt and penetrating in patient. in patients, the left kidney was injured, in the injury was at right kidney and in injuries was bilateral. the average transport time to hospital was min ( min- days). one hundred and seventeen out of patients were explored immediately as they hemodynamically unstable position. remaining patients were evaluated with ultrasonography, intravenous urography and computerised tomography. sixty four of these patients were followed conservatively. the injuries in patients followed conservatively were in patient's grade , in grade , in grade . renal units of patients were operated. nephrectomy was done in , nephropathy was done in and renal artery repairing was done in patient. conclusion: nephrectomy and mortality were high because of the long transport time, frequent high grade and high rate of associated organ injuries. rojnoveanu gheorghe sigmoid volvulus is seen more frequently at elderly ages and early diagnosis and treatment decreases its mortality and morbidity rate. we reviewed sigmoid volvulus cases treated in our clinic. patients hospitalized and treated due to diagnosis ofsigmoid colonic volvulus in dr. lü tfi kırdar kartal education and training hospital during - were analysed. treatment modalities, morbidity and mortality rates were analysed. patients were male, were female. mean age was ( - ). sigmoid colon resection and end colostomy was done to patients, sigmoid colon resection and end to end anastomosis was done to patients and nonoperative colonoskopic decompression was applied to patients with sistemic illness and they were prepared for elective sigmoid colon resection and end to end anastomosis. in one patient with anastomosis, anastomotic leakage was detected and end colostomy was applied. two emergently operated patients with sistemic illness died. mortality rate was% . in conclusion, sigmoid volvulus patients with sistemic illness should be prepared to elective surgery with colonic decompression. we think that the best treatment for early diagnosed cases is sigmoid colonic resection and end to end anastomosis. introduction: onset of world war ii, the report concerning diverting colostomy declared reduced mortality rates for colon injury, compared to world war i. in spite that nearly years has passed away, although all therapeutic options, this method -used for the management for colon injury -still include some controversial points. methods: ninety-five patient's characteristics were compared in two groups (patients with or without diverting stoma). clinical findings and patient's characteristics, injury mechanism, localisation of the wound, blood transfusion requirements, fecal contamination, colon injury score (cis), penetrating abdominal trauma index (pati score), evidence of shock, morbidity rate, mean hospital stay, main and additional surgical procedures of patients who admitted to our clinic from to were reviewed retrospectively. results: we have no mortality in both groups, except the first postoperative h. diversion colostomy was performed in patients and primary repair in patients. median hospital stay for primary repair and diversion groups were and days, respectively, (p < . ). respiratory system, septic complications, clinical anastamosis leakage and other complications were similar in both groups. conclusions: although all articles that prompt primary repair, this approach includes some inconvenient points. it is acceptable in military or war originated injuries. diversion mostly is necessary in wounds, related to highly potent and energic fragments. nevertheless, nearly all of the civilian colonic injuries can be treatment with primary repair without diversion since the mechanism of the wound is different than war injuries. dogan gö nü llü , oguz Ç atal , nilü fer yazgan yıldırım , tayfun yucel , ferda nihat kö ksoy taksim trainig and research hospital, _ istanbul, turkey background: the management of haemodynamic stable penetrating injuries of the flank has not been well defined; laparoscopic exploration, closed abdominal examination and triple contrast computed tomography (ct) are alternative modalities. our aims are to explain our experiences in these cases. methods: we reviewed the patients with isolated penetrating flank trauma admitted between and . the flank was defined as area between the anterior and posterior axillary lines, inferior to the fifth intercostal space superior to the iliac crest. results: there were haemodynamic stable patients ( gunshot and stab injuries). there were three patient groups: laparotomy (g ) (n = ), laparoscopy (g ) (n = ) and only closed clinical observation with triple contrast ct scan (g ) (n = ). patients in the g were gunshot injuries; the other two gunshot injuries were tangential and were included in the g . in the g there were four left diaphragmatic injuries, all repaired laparoscopically. one patient with splenic laceration and another with small bowel injury were converted to an open exploration. there were eight negative laparoscopies ( / ).two patients of g ( / ) with negative tomography were submitted to laparotomy after day of closed observation. the mean length of hospitalization in the groups was respectively . , . and . days. introduction: intra and retro abdominal hemorrhage are common following blind and penetrating abdominal trauma. liver, spleen and kidneys are known to be prone to injury and to bleed after an abdominal trauma. hepatocellular carcinoma is a well known disease. however, a renal mass from a primary origin in the liver is rare. this paper presents a patient, who was treated with right nephrectomy for traumatic bleeding from a ruptured renal mass. end diagnosis was metastatic hepatocellular carcinoma. case: the patient was -years-old man. he had no positive medical and surgical history, and no complaint. he was referred to emergency service after traffic accident. during his initial assessment abdominal rigidity and tenderness were found, which were accompanied with tachycardia and hypotension even after fluid resuscitation. fast revealed that there was free fluid in his abdomen, so we decided to operate him. at laparotomy we observed a bleeding tumoral mass in the right kidney and in his liver. he was treated with right nephrectomy and irregular hepatectomy. pathologic examination demonstrated a metastatic hepatocellular carcinoma. conclusion: hepatocellular carcinoma is a well known disease with its common acute complications such as rupture and bleeding. in this case, we observed hcc metastasis to the right kidney although the patient had no medical and surgical history including hcc. bleeding was induced after a blind trauma, was treated with resection. gall bladder (gb) injuries either following penetrating or blunt abdominal trauma is a rare entity and usually misdiagnosed with a delay in diagnosis. the incidence of gb injury is reported to range between . and . % among the surgically treated patients following abdominal trauma. cholecystectomy is the definitive treatment even in severe contusion of a nonperforated gb. simple suture repair or cholecystostomy are also advocated as alternative surgical interventions by some authors. gb is afforded significant anatomic protection from external trauma, since it is partially embedded in the relatively massive liver parenchyme, cushioned by the surrounding omentum and intestines, and shielded by ribcage. clinical symptoms may be minimal or nil initially but gradual clinical deterioration, related to spillage of bile into the peritoneal cavity, can follow. bilous fluid taken by paracentesis or diagnostic peritoneal lavage can only be helpful after a delay as abdominal computed tomography. an year-old male was admitted to our emergency department for the fifth time because of penetrating abdominal trauma of at the right upper quadrant by a knife in a -day-period. he was hospitalized in three of them and operated on at last, because of acute abdomen, since paracentesis revealed bile coloured free abdominal fluid in addition to abdominal guarding, leucocytosis( , /mm ), and fever.the ultimate ultrasonography and computed tomography revealed large amount of free fluid (bile) and minimal intrahepatic hematoma. at laparotomy; full-cut hepatic and cholecystic perforation (both anterior and posterior surfaces) resulted in cholecystectomy. he was discharged on the fourth postoperative day. since almost all reports about the delayed rupture of gb are usually unrecognized gb perforations,a diagnostic delay can only be avoided by a high clinical index of suspicion. sixty-three patients were treated conservatively, whereas patients had laparotomy and patients underwent angiography. of patients transported by ambulance or helicopter, % arrived at the emergency unit within min after prehospital alert. in % the time on scene were longer than min. in this group only % were diagnosed by ct within min after arrival to the emergency unit. conclusion: low volume in trauma care results in substandard handling time. in hospitals with a low volume exposure to trauma, the prehospital response teams and surgeons achieves limited experience, especially in penetrating trauma. exchange programs must be emphasised. author to editor: this study describes the complete workload in primary handled trauma patients in a typical nothern european universtyhospital with very low incidence of penetrating trauma and low volume of blunt trauma. our trauma registry covers % of patients admitted to the hosptial. it is the only hospital in the area, and patients do not bypass the system and are treated elsewhere. the study will point out that prehosptial responsetime and inhosptial procedures are is acceptable, but emergencyroom handlingtime is to long, due to lack of practice. national or european exchange programs for surgical trauma care must be practiced. introduction: explosives create and energize particles that act as projectiles prone to further fragmentation in the body. these fragments may result in secondary injuries. this has been repeatedly described in the orthopedic and neurosurgical literature. in this paper we demonstrate that such a process is also possible for abdominal injuries during or after fascial penetration. material-method: in all abdominal wall injuries, despite negative physical examination of conscious and alert patients we used local wound exploration as a standard approach. finding a full thickness fascial defect, we assumed an intraperitoneal injury and performed laparotomy. result: using this method, we found hollow organ injuries in of ( . %) patients. in ( . %) of these patients at laparotomy, we found multiple, projectile induced injuries in a sprayed distribution. these injuries were found far from the trajectory, in the absence of bone fragmentation. the mean number of peritoneal defects was . , however, for each peritoneal defect, we found an average of . intraabdominal injuries when through and through injuries were excluded. conclusion: local wound exploration is an accurate indicator of possible intraabdominal injuries. although fragments of projectiles would be expected to be distributed along the trajectory, meticulous exploration of abdomen is mandatory because this is not always true. despite a single peritoneal defect, there may be multiple intraperitoneal injuries due to further fragmentation of the projectile. introduction and objectives: nonoperative management of penetrating abdominal stab wounds has been established as standard care recently. it decreased negative laparotomy rate without any increase in morbidity and mortality. in this study we evaluated the outcome of patients managed due to penetrating abdominal stab wounds. intraabdominal injury due to blunt abdominal trauma usually presents acutely. in the absence of peritoneal irritation findings or shock the patients may be treated conservatively. delayed small bowel obstruction after blunt trauma is very rare clinical entity. it may be caused by subclinical bowel perforation, localized bowel ischemia or mesenteric vascular injury. we present a years old man of blunt abdominal trauma that was treated nonoperatively. despite the success medical treatment, months later, the patient presented with abdominal pain and vomiting. the radiologic studies suggested a mechanical intestinal obstruction. at the operation a conglomerated terminal ileal segment causing obstruction was found and the patient is treated by a resection and primary anastomosis. the operative findings may be explained by a subclinical perforation at the time of the trauma. this kind of complication should be suspected in patients with post traumatic patients which presents with signs of intestinal obstruction in weeks after the trauma. nevin kanan, ayfer Ö zbaş department of surgical nursing, istanbul university, florence nightingale school of nursing, ankara, turkey with traumatic injury, kidneys can be thrust against the lower ribs, resulting in contusion and rupture. up to % of patients with renal trauma have associated injuries of other internal organs. injuries may be blunt (automobile and motorcycle crashes, falls) or penetrating (gunshot wounds). approximately - % of all renal trauma cases are blunt trauma injuries; penetrating renal trauma accounts for the remaining - %. blunt renal trauma is classified into one of four groups which are contusion, minö r laceration, majö r laceration and vascular injury. • with a contusion of kidney, healing may take place with conservative measures (i.e. bed rest) • if minö r laceration is present, the patient is hospitalized and kept on bed rest until the hematuria clears. • depending on the patient's condition and the nature of the injury, major lacerations may be treated through surgical intervention or conservatively (bed rest, no surgery) • vascular injuries require immediate exploratory surgery because of the high incidence of involvement of other organ systems and the serious complications that may result if these injuries are untreated. the patient is often in shock and requires aggressive fluid resuscitation. for the management of patient with renal trauma, nursing diagnoses are: • inefective tissue perfusion (renal) related to interruption of arterial flow • anxiety related to physical injury • acute pain related to physical injury • impaired urinary elimination related to renal damage and shock background: penetrating abdominal buckshot wounds are believed to necessitate emergent laparotomy to rule out any hollow or solid organ injury. recently, nonoperative management has been suggested in selected patients. this paper aims to present two cases with penetrating abdominal buckshot wounds, treated nonoperatively. materials-methods: a chart review has been conducted for patients operated in our institution for abdominal buckshot wounds. demographics, evaluation tools and follow-up parameters has been analyzed and documented. results: a total number of two patients (both male; and years old) were found. both were shot on their left thoracolumbar regions. left and bilateral chest tubes were necessitated after initial examinations, but both denied any abdominal tenderness, although computed tomography showed multiple abdominally located pellets. gastroscopy (n = ), echocardiography (n = ), intravenous pyelography (n = ) were necessitated for further evaluation, but showed no abnormality. the patients were followed up with routine abdominal examinations, vital signs and routine laboratory tests and discharged from the hospital on days and after uneventful recovery periods. discussion: patients with penetrating abdominal buckshot wounds may be followed with nonoperative management instead of routine laparotomy. objective: treatment procedures in cases who were operated due to colon injuries were investigated in this study. material-methods: thirty-two cases who were operated due to colon injuries in our clinic between and were investigated retrospectively. cases were investigated with regard to age, sex, type of trauma, hemodynamic condition, interval between injury and surgery, additional organ injury, transfusion volume, injury site and severity, faecal contamination, surgical procedures, postoperational complications and mortality and factors affecting morbidity and mortality were determined. colonic injury severity scale (ciss), abdominal trauma index (ati) and flint classification were used for evaluating severity of colon injury,severity of additional organ injury and faecal contamination, respectively. systolic blood pressure less than mmhg on admission was referred to as ''shock''. results: males comprised out of cases and mean age was . (range: - ) years. twenty-five cases were injured due to penetrating trauma and left colon injury was the most common ( cases) type of injury. additional intraabdominal organ injury and extraabdominal injury were observed in and cases, respectively. mean interval between injury and surgery was . (range . - ) h. fifteen cases received blood transfusion. five cases had shock on admission. seven cases received stoma surgery while all cases with flint grade more than iii or ati score higher than received colostomy. only cases with high ciss score received resection and anastomosis surgery. complications were observed in cases while mortality occurred in two cases due to hemorrhagic shock. conclusion: routine primary repair cannot always be performed in colon injuries since many factors affect the decision for type of surgery. primary repair may be performed safely in hemodynamicallystable cases with ati score less than and flint grade i-ii. seat belt syndrome is defined as a seatbelt sign associated with lumber spine fracture and bowel perforation. an isolated rectal perforation due to seatbelt syndrome is extremely rare. there is only one case reported in the danish literature and non in the english literature. hereby, we report a -years old male who was a front seat restrained passenger involved in a head-on collision. he has presented with lower abdominal and back pain. seat belt mark was seen transversely across the lower abdomen. initial trauma ct scan was normal except for burst fracture of l vertebra which was operated by internal fixation on the same day of admission. the patient continued to have abdominal pain and distention which became clear on the third day. repeated abdominal ct scan on the third day has shown free intraperitoneal air. exploratory laparotomy has revealed a perforation of the proximal part of the rectum below the recto sigmoid junction. hartmann's procedure was performed with end colostomy. the abdomen was left open and temporarily closed using saline iv bags sandwiched between layers of steri-drape. peritoneal toileting was performed four times under general anesthesia with gradual closure of the abdominal fascia over a period of weeks. postoperatively, the patient had urinary retention due to a quada equina injury although he could walk. the presence of seat belt sign and a lumber fracture should rise to the possibility of a bowel injury. author to editor: seat belt syndrome is defined as a seatbelt sign associated with lumber spine fracture and bowel perforation. an isolated rectal perforation due to seatbelt syndrome is extremely rare. there is only one case reported in the danish literature and non in the english literature. hereby, we report such a case. fuat ipekçi, muharrem karaoglan, hü seyin toptay, hasan Ş ahin department of general surgery, tepecik education hospital, izmir, turkey introduction and aims: meckel's diverticulum results from incomplete degeneration of omphalomesenteric duct. it is usually diagnosed incidentally during appendectomy; however, sometimes perforation or bleeding may lead the surgeon to the diagnosis. we aimed to investigate the frequency of meckel's diverticulum during emergency laparotomy performed for acute appendicitis and clinical and pathological characteristics of the patients with meckel's diverticulitis and appendicitis. material-method: the material consisted of , patients who admitted to our hospital and treated by appendectomy during a -year interval between the years and . of these patients ( , %) were male and remaining ( , %) were female. all patients were investigated for meckel's diverticulum weather they have acute appendicitis or not. results: meckel's diverticulum was found during out of , appendectomies ( . %). of the cases, were asymptomatic but four patients were symptomatic with inflamed diverticulitis. of these four patients two have normal appendix and other two have secondary appendicitis due to meckel's diverticulitis. all four symptomatic cases were treated by diverticulectomy and appendectomy. all asymptomatic cases were treated by appendectomy alone. no mortality or major morbidity was detected. conclusions: despite of its rarity ( . % in our appendectomy series), meckel's diverticulum must be searched weather the appendix is normal or inflamed. introduction: illegal drug smuggling is a widespread problem. drug packs carried inside body cavities may leak its contents and be dissolved inside the body and signs of toxicity (aka. body packer syndrome) become evident. this case was reported to represent the very first proven patient in turkey. case: a year-old man were brought in the emergency department (ed) from the airport because of severe tremor, palpitation, restlessness associated with hypertension and tachycardia. the patient was cooperative and oriented. on examination, his blood pressure (bp) was / mmhg, pulse rate /bpm, whereas other systems were unremarkable. he was put on cardiac monitor and infusion of glycerol trinitrate was instituted ( mcg/min). urinary toxicologic screen was positive for cocaine and benzodiazepine. after admission to the ed he complained of epigastric distension and abdominal pain and admitted that he had swallowed cocaine packs. his abdominal xrays showed gas-fluid levels and opaque round-shaped mass images. a nasogastric catheter was inserted and gastric contents (approximately , ml) were drained. he was consulted with surgery clinic with a diagnosis of an ileus due to swallowed packs. he was hospitalized in the surgical ward. after supportive treatment and repeated enema applications he excreted cocaine packs in days. he was discharged following clinical stabilization and abdominal x-rays were repeatedly normal. conclusion: toxicologic analysis must be employed in patients who are suspected to have intoxication, to identify life-threatening drugs and vasoactive substances. advanced imaging methods must be exercised to exclude bowel obstruction in these patients. background: pseudoaneurysm is a well recognized complication of pancreatitis. angioembolization is considered to be the first option of treatment. to our knowledge, the case we hereby report is the first one with successful re-angioembolization. case: a -year-old man, with aids, history of cns toxoplasmosis, chronic pancreatitis with pseudocyst secondary to alcohol abuse, was hospitalized for pneumonia. during his hospitalization, he developed abdominal pain and hypotension. after resuscitation, ct angiogram of the abdomen revealed active bleeding into a pseudo-aneurysm, near the head of the pancreas, measuring . x . cm and arising from superior and inferior pancreaticoduodenal arteries. this was confirmed by angiogram. angioembolization distal and proximal to the bleeding area was performed using coils. eight days later, the patient became hypotensive and dropped his hemoglobin again. he was taken for an emergency laparotomy which revealed a cm pancreatic pseudocyst with hemorrhage. the pseudocyst was opened through the medial wall of the duodenum, ligation of the bleeding intracystic vessels, and cysto-doudenostomy were performed. his postoperative course was uneventful and he was discharged home on postoperative day . five days later he was readmitted with hematemsis and anemia. celiac angiogram revealed bleeding from the gastrodoudenal artery which was embolized. he died months later due to hiv nephropathy without any evidence of re-bleeding. objectives: any sort of discomfort in the abdominal cavity that lasts less than week is defined as acute abdominal pain. the purpose of the study was to evaluate the outcome of hospitalized patients with unspecified acute abdominal pain following initial clinical and laboratory evaluation. method: from january to december , patients with acute unspecified abdominal pain were admitted to surgery department. gender, age, definite diagnosis, time from hospitalization to surgery and hospital length of stay were retrospectively reviewed. results: fifty-six of the patients with acute unspecified abdominal pain were females ( %) and were males ( %), median age was years (range - ). while definite diagnosis was confirmed in patients ( %), the initial diagnosis was not changed in patients ( %). distribution of new diagnoses were appendicitis (n = ), gastroenteritis (n = ), genitourinary disorder (n = ), familial mediterranean fever (n = ), inflammatory bowel disease (n = ), mesenteric adenitis (n = ), peptic ulcus perforation (n = ), constipation (n = ), diverticular disease (n = ), pneumatosis intestinalis (n = ), hepatobilier disease (n = ) and intra abdominal tumor (n = ). depending on the cause of abdominal discomfort, patients ( %) required surgical intervention. median time from hospitalization to surgery was h (range - the use of temporary skin substitutes (tss) is a useful technique in the treatment of full-and partial thickness burn wounds affecting a large body surface area. early excision of the eschar is mandatory. but if we cannot find sufficient donor site, tss using seems to best choice. the ideal tss must be has some properties: adherence, control of water loss, safety, flexibility, stability on wound surfaces, bacterial barrier, and ease of application, ease storage and cost effectiveness. case report: a -year-old girl was admitted to our burn center with deep flame burns affecting face, thorax, upper and lower extremity ( %). she underwent an early burn excision on day post-burn day. the whole area excised with hydrosurgically was covered with biobrane Ò and compressive dressing. seven days after we removed biobrane from the upper and lower extremities and grafted the wound bed. face healed spontaneously under the tss and tss covering the thorax was rest intact. after days thoracic tss was removed and grafted and we covered the thorax with biobrane Ò over the grafts again. after days a second grafting was needed. patient was discharged from the hospital th post-burn day. the use of biobrane Ò as a tss after burn wound excision was satisfactory, because it enabled us to delay auto grafting until we were sure of good conditions in the wound bed. also it proved to be a good dressing over the meshed autografts. it reduces the healing time and improved the quality of grafts. introduction: endoscopic examination of the colon during the diagnostic or treatment purposes, perforation incidence is reported between . and . %. determination of risk factors may decrease the incidence with early recognition of the serious complications of surgery may reduce interference. method: we have examined retrospectively the patients in whom colon perforation appeared due to endoscopic analysis of colon carried out at endoscopy unit between january and december . results: total colonoscopy and rectosigmoidoscopy were applied to , patients. in patients ( . %) perforation was observed. the median age was . ( - ), m/f: / . all colonoscopys were made for diagnosis; anemia in two, hemorrhodial disease in one, subileus in two, anal prolapsus in one, right colon tumor suspation in one patients. one sigmoid polypectomy was applied, diverticulosis disease of the colon in two patients, dolichocolon in one, one previous pelvic surgery were observed. perforation zone was observed in sigmoid colon in all patients. four patients were diagnosed in the process of colonoscopy ( . %), were diagnosed in - h ( . %), was diagnosed days later. laparotomy was applied to all patients. perforation zones of patients were fixed primarily and these patients were discharged as cured. one patient who was applied to diversionary ostomy was reoperated due to abdomen collection. no mortality was observed. conclusion: colonoscopic perforation is a rare, serious complication. sigmoid colon is the location where the perforations are mostly observed. although primary fixation is generally efficient in cases of early diagnosis, morbidity increases seriously due to late diagnosis. with more than one stomas. eleven patients were discharged with planned ventral hernias. primary abdominal closure succeeded in four patients. fasciitis due to severe peritonitis and stomas prevented primary closure. eighteen of patient died during treatment, were discharged. sixteen of patients with more than one bag were died, five survived (mortality . %). conclusions: morbidity and mortality were higher in patients with more than one stoma than patients with single stoma. second stoma has a negative effect on primary fascial closure. fasciitis due to severe peritonitis also prevents fascial closure. acute diaphragmatic hernia after minimally invasive esophagectomy the aim of this study was to evaluate the disease profile and mortality ratio of patients presenting with acute abdomen. four hundred fifty eight patients who underwent surgery with the diagnosis of acute abdomen were analyzed retrospectively. the effects of age, sex, american society of anesthesiology (asa) class, accompany disease, admission time after the onset of the symptoms, follow up interval before the operation on mortality and length of hospital stay were evaluated. male/female ratio was . , and mean age was . . main causes were biliary system disease ( . %), intestinal obstruction ( . %), peptic ulcer perforation ( %) and acute appendicitis ( . %). median asa class was and . % of the patients had at least one preexisting disease. mortality ratio was . %. asa class, age, preexisting diseases other than malignity, period between the onset of symptoms and admission, follow-up time was significantly effective on mortality. background: resveratrol is a strong antioxidant with antiinflammatory effects. we aimed to investigate the effects of resveratrol on oxidative injury, histopathology and bacterial translocation in induced i/r injury in rats. methods: female wistar-albino rats were randomly allocated into four groups; sham-operated group(laparotomy without i/r injury), i/ r group (laparotomy plus min of ischemia followed by min of reperfusion), alcohol group (only . % ethyl alcohole . ml/day intraperitoneally for both days before surgery and min before ischemia), resveratrol group ( mg/kg resveratrol intraperitoneally both days before surgery and min before ischemia. intestinal tissue samples were obtained for investigation of tissue levels of malondialdehyde (mda), nitric oxide (no), superoxide dismutase (sod), myeloperoxidase (mpo) and histopathologic evaluation bacteriological translocation (bt) in mesenteric lymph node (mln), liver and spleen was also studied. results: resveratrol significantly decreased mda, no and mpo levels in i/r injury (p < . ). sod activity of resveratrol-treated group was significantly lower than sham group and significantly higher than i/r and i/r + alcohol groups (p < . ). histopathologically, the median intestinal injury score in i/r and i/r + alcohol groups was significantly higher than in sham and resveratrol-treatment groups (p < . and p < . , respectively). the incidence of bt differred between the groups i/r and i/r + alcohol in mlm, spleen and liver (p < . ). nevertheless, the treatment with resveratrol reduced bt to mln, spleen and liver, compared to other i/ r groups (p < . gastrointestinal stromal tumors (gists) represent rare neoplasms of the gastrointestinal tract. here we describe a case with gist and thrombocytosis presenting as an acute abdomen. our knowledge, the co-existence of gist and thrombocytosis has not been reported so far. case: a -year old female was admitted to the emergency room with epigastric pain and vomiting over duration of days. physical examination showed abdominal distension, rebound tenderness, and a palpable rlq mass. the laboratory findings were, wbc: . /l, plt · - /l and c-reactive protein . mg/l. a computed tomography scan of the abdomen showed conglomerate of small bowel. the abdominal exploration showed that a · · cm mass was located on small intestine. the mass was completely resected and enteroenterostomy was performed. the histological examination demonstrated whirling sheets of spindle cells which were stained positively for cd (c-kit) and cd , mitotic index > / hpf, while smooth muscle actin and vimentin were focally positive, and keratine, desmin, s- protein were negative. this specific immunophenotype characterized gist. during the post operative follow up, platelets were above normal levels · - /l. therefore, bone marrow biopsy was performed. hiperplasia in megakaryocytes were found. the patient was negative for bcr-abl and philadelphia chromosome. discussion: here we describe a case with gist and thrombocytosis presenting as an acute abdomen. ten percent to % of these tumors are biologically aggressive; signs of malignant potential are metastases and invasion. the current treatment for localized disease is surgical resection. co-existence of thrombocytosis and gist has never been reported. laboratory tests showed no abnormality except white blood cell count of /ll.plain abdominal x-ray and ct did not show any abnormal findings including free air (fig. ) . endoscopic examination of the stomach revealed an ingested toothpick protruding from the prepyloric antrum (fig. ) . the toothpick was deeply fixed into the antral wall. the whole toothpick . cm in length was removed using a loop without damage to the gastrointestinal wall, bleeding or any other complication. after endoscopic removal of the toothpick, her epigastralgia resolved. on the second hospital day, the patient was asymptomatic. medical therapy with proton pump inhibitor was stopped and she was discharged on the third hospital day. conclusion: accidental ingestion of foreign bodies is common and in general harmless. a perforation of the gastrointestinal tract by ingested foreign bodies is rare, occurring in less than % of ingested bodies like toothpicks are involved in less than . %. occasionally, the passage of the swallowed item may stop at one of the anatomic bottlenecks of the gastrointestinal tract, which may lead to perforations that may require operative or endoscopic interventions. results: we analyzed the number, causes and rates of emergency operations. the total number of emergency operations was , and , , for the first and second groups, respectively. we observed an % decrease in number of emergency operations for the second group. we also observed that the cause of majority ( % for the first group, % for the second) of the emergency operations was acute abdomen and the rate between the groups did not change. lower extremity amputation and strangulation hernia operations decreased and %, respectively. the number of operations which are caused by ileus and acute cholecystitis increased and %, respectively. conclusions: difference in distribution of emergency operations between two groups was statistically insignificant. however, we observed both an increase and a decrease in small numbers of some subgroups. it is believed that this is related to the change in patient profile and technological improvements in surgery. aim: we hypothesized that one of the most widely used anesthetic agents, propofol, may reduce inflammatory processes, and organ injury induced with cecal and ligation puncture study design: bacterial peritonitis was induced in rats by cecal ligation and puncture. the rats were randomly assigned to three groups. group (n = ) received propofol, group (n = ) received intralipid, group (n = ) was control, which did not receive any injection. all animals were killed days later so we could assess the adhesion score. tissue antioxidant levels were measured in -g tissue samples taken from the abdominal wall. results: the adhesion score was significantly lower in the propofol group than in the control group (p < . ). the catalase levels were higher in the intralipid and control groups than the propofol groups. conclusions: intraperitoneal propofol reduced the formation of postoperative intra-abdominal adhesions without compromising wound healing in this bacterial peritonitis rat model. propofol also decreased the oxidative stress during peritonitis approximately, min after the onset of the operation, a sudden decrease in end-tidal carbon dioxide from to mmhg was noticed. soon after, both systolic arterial pressure and heart rate decreased dramatically. arterial blood gas measurements showed that pco was mmhg at that moment. surgery and insufflation of gas was stopped, ephedrine mg was given intravenously and ventilation with % o was started. trendelenburg position was achieved immediately. a catheter was introduced through the right juguler vein to the right atrium rapidly and - ml gas bubble was withdrawn. soon, hemodynamic measures were recovered. since substantial amount of blood in the peritoneum was noticed, conversion to laparotomy with subcostal incision was performed. at exploration, through and through tear of mm in inferior vena cava was detected. the defect was sutured with / polypropylene. anesthesiologist and surgeon must be aware of this dangerous complication. the emphasis is given to the prevention and prompt recognition of this event to the use of available tools in the management of cardiovascular complications. aim: obstructive jaundice, develops accompanied with high morbidity and mortality rates. the absence of bile in bowels leads to bacterial translocation and ultimately to endotoxemia and septice-mia. _ in our study, observing changes on bowel level during obstructive jaundice and examining its contribution to bacterial translocation have been aimed. material-methods: the study has been carried out at _ istanbul university _ istanbul faculty of medicine experimental medical research center (detam) with approval of _ istanbul university _ istanbul faculty of medicine ethical board for animals. two groups out of male wistar albino rats have been formed. one hour after injecting d-xylose to first group the rats were put to sleep (anesthetized) and specimens of tissue (liver, spleen, mesenteric lymph nodes) and blood were taken for microbiological and biochemical examinations. in the second group an obstructive jaundice has been established by ligation of common bile ducts. the same specimens were obtained after days. findings: in the first group no proliferation on tissue and blood cultures were detected. an obstructive jaundice has been shown in biochemical investigation of blood. d-xylose was found to be . ± . mg/dl. in the second group, proliferation, of mainly e. coli, were detected on cultures and d-xylose was found to be . ± . mg/dl. statistically significant increases were assigned between groups, between tissue and blood cultures (p < . ) and d-xylose values (p < . ). results: detecting statistically significant increases in d-xylose levels in the second group leads to the conclusion that increases in bowel permeability plays an important role in bacterial translocation. conclusions: while wound infections were higher in open appendectomy procedure group, surgical time was higher in laparoscopic procedure group. the achievement of optimal results will be based on increasing surgical laparoscopic experience. objectives: intraabdominal hypertension (iht) in intensive care units is a common problem. investigation of the effects of dexmedetomidine on respiratory system in rats with iht was aimed. patients and methods: adult wistar-albino male rats were anaesthetized by rata ''ksalazin/ketamin'' combination. experimental model of iht( - mmhg) was induced via pressure cuff. rats were left to spontaneous respiration for h prior to randomly division into four groups. the first group underwent no process (control group). in sf group; cc of . % nacl,in the third group; . lg/kg dxmt and in the last, . lg/kg dxmt were intravenously administered. thereafter min passed to observe the effects of dxmt. the rats were killed via cervical dislocation prior to surgery. lung tissues were fixed in % formalin and stained with he. whereas the other cross sections were stained with tunel method,the rest were stained with anti-caspase , , and anti-fas/fasl antibodies for immunohistochemical analysis. results: histological changes in group were the less. there were no atalectatic changes in the same group. pnl infiltration and interalveolar thickness were higher in the . lg/kg dxmt group than others. in indirect immunohistochemical studies, in the . lg/kg dxmt group, immunoreactivity of caspase and were increased. however, the caspase- immunoreactivity was less than caspase- . these results supported that . lg/kg dxmt administration led apoptosis, even though to be delayed, to start and showed that extrinsic pathways was used through apoptotic pathways. it was concluded that low dose of dxmt caused to delay in apoptosis in the lungs. results: a total of microorganisms were responsible for the cris, of which ( . %) were gram-positive bacteria, ( , %) were gram-negative bacteria and ( . %) were candida species. isolated from the microorganisms were: klebsiella pneumoniae ( %), acinetobacter ( . %), enterobacter ( . %), rroteas mirabilis ( . %) pseudomonas aeroginosa ( %), staphylococcus ( . %). patients ( . %) developed crbsis and in patients with positive blood cultures cris were negative. in our study, femoral venous access was associated with a significantly higher incidence of cri and crbsi than jugular and subclavian access; and jugular access was associated with a significantly higher incidence of cri and crbsi than subclavian access conclusion our results suggest that the order for punction, to minimize the cvc-related infection risk, should be subclavian (first order), jugular (second) and femoral vein (third). introduction and objectives: undescended testis is a risk factor for the testicular carcinoma, especially a seminoma. seminoma can be seen at any age, but it is considerably rare in elderly patients. we describe a patient who presented with acute abdomen secondary to an ileum perforation due to the involvement of seminoma. case: a year-old man complaining with right lower abdominal pain and a palpabl mass with a -week history was evaluated. an abdominal computed tomography was showed a large, solid, welldefined intraabdominal mass, measured about · ·x cm in right quadrant of lower abdomen. an exploratory laparotomy was adjudged to perform. whilst the preoperative investigations for surgery were continued, the patient admitted to the emergency service with acute abdomen symptoms, which was started suddenly. he had peritoneal irritation signs. he underwent an urgent laparotomy and a large mass located on terminal ileum mesenter through the retroperiton was detected. dilated ileum segments with omentum wrapped along the antimesenteric border of the distal ileum was found. on separating omentum from ileum, perforation along the antimesenteric border was noted. extended right hemicolectomy and an end ileostomy was performed. histopathologic examination revealed a classical seminoma with extensive tumor necrosis and showed evidence of vascular invasion. conclusions: undescended testes should be considered in men with an intraabdominal groin mass and should be aware of its potential complications. department with diagnosis of acute cholecystitis and on exploration giant gallbladder with giant stone and gallbladder adenocarcinoma. case: a years old female was applied to emergency department with abdominal pain, nausea and vomiting. on physical examination, right upper quadrant tenderness and defence were detected. murphy sing was positive and gallbladder was palpable on subcostal space. in laboratory tests, white blood cell count was , /mm , glucose was mg/dl and liver function tests were minimally elevated. in hepatobiliary ultrasonography, the gallbladder was hidropic ( · cm) and there was a stone ( cm in diameter) and a mass ( · cm) in the gallbladder.cholecystectomy operation was performed. acute cholecystitis + cholelithiasis + adenocarcinoma were reported in the histopathological evaluation. conclusion: the carcinomas of the gallbladder were associated with gall stones in - % of the patients. we concluded that the presence of the symptoms in our patient was delayed due to the magnitude of the gallstone and the excessive size of the gallbladder. perforation of the gallbladder by trans-gastric migration of a sewing needle _ ingestion of foreign bodies is a common problem, especially in the elderly, pediatric, and psychiatric population, but fortunately, most of them pass spontaneously and uneventfully within week.the perforation and migration of ingested foreign objects into the abdominal cavity is very rare and usually leads to a laparotomy. perforation of the stomach by sewing needle with migration to the gallbladder is extremely rare, and none cases have been reported in the literature. a -year-old woman was admitted because of abdominal pain and a history of a swallowed sewing needle month ago. she had been followed-up at her local hospital and referred to our hospital because of the failure of progression of the foreign body. physical examination showed right upper quadrant tenderness, guarding, and a positive murphy's sign. blood analysis showed increased white blood count. she was submitted to abdominal plain x-rays, which revealed a radio-opaque objects in the liver area with the form of the sewing needles. the patient was clinically stable, and a semi-urgent laparotomy was planned. at laparotomy the needle was in the gallbladder and that the end of the needle could be palpated and the site of gastric perforation. removal of the intra gallbladder needle did not cause any problem. we was performed cholecystectomy and primary gastroraphy. the postoperative period was uneventful and the patient was discharged on seventh day of the operation. if there is a history of sewing needle ingestion and failure of progression and also signs of an acute abdomen, the surgeon must carefully evaluate gallbladder. introduction: sigmoid volvulus is an unusual intestinal obstruction form ( ) . it is most common in the middle aged, elderly, institutionalized or neuropsychiatric patients ( ). patients and methods: twenty-one sigmoid volvulus patients were reviewed retrospectively between and .the recorded data were age,gender,admission symptoms,physical examination,radiological, and operative findings, surgical procedure, postoperative complications, mortality, and hospital stay.there were male and female patients. the mean ages of the patients was . years ( - ).the most common symptoms in acute abdomen patients were pain, and tenderness. abdominal distension were the most recorded sign in patient without peritonitis. the mean admission time was . days ( - ). five patients had a history of sigmoid volvulus ( %). leukocytosis and high fever were found in ( %) patients. radiological evaluation of the patients revealed sign of intestinal obstruction (n = , %),frimann-dahl sign (n = , %) and bilateral free air under diaphragm due to perforation of the twisted sigmoid colon (n = , . %). no patient underwent contrast enema examination of the colon. the mean hospital stay was . days ( - days) . two patients without signs of peritonitis were treated by sigmoidoscopy and operated on elective course.patients with signs of acute abdomen were operated urgently. the patients had several associated diseases such as atherosclerotic heart disease, diabetes mellitus, hypertansion, chronic obstructive pulmonary disease, cerebrovascular disease. eight patients ( %) died due to sepsis. morbidity rate was %. wound infection, evisseration pneumonia, and acute renal failure were found in ( %) patients. the principal strategy in treatment of sigmoid volvulus is early nonoperative detorsion followed by elective surgery consist of colectomy and anastomosis on well-hydrated patient. urgent laparotomy is indicated in case of peritonitis. sigmoidopexy is an alternative option but it is usually ineffective and has high recurrence rate. results: ten men and four (six) female were enrolled in the study. mean age was years (range - ). e.coli and acinetobacter were the common organisms cultured. all patients were treated with a common approach of resuscitation, broad spectrum antibiotics, and wide surgical excision. objectıves: acute appendicitis is one of the most common nonobstetric surgical pathology. clinical symptoms and findings are masked due to anatomical and physiological changes of peregnancy, so diagnose and treatment of acute appendicitis in pregnancy generally late. the curent study reported the cases which were diagnosed acute appendicitis in pregnancy and promptly operated in our general surgery clinic. material-methods: we evaluated sixteen cases' data between october and october who admitted to emergencey department with abdominal pain, vomiting, nausea and anorexia complaints and diagnosed as acute appendicitis in pregnancy and operated. results: the average of the cases were . (range - ) and thirteen of them were second, two of them were third and one of them was in the first trimester. the time interval between the onset of the complaints and operation was . (range - ) days. upon physical examination, there were rebound tenderness present in cases, muscular rigitide in three cases, right lower quadrant pain in nine cases and widely irration of all abdominal guadrant in four cases. there were not any maternal mortality and morbity after operation, however in only one case fetal mortality was observed inevitable abortion due to vaginal bleeding. conclusion: in our cases acute appendicitis was diagnosed frequently in the second of the pregnancy with abdominal pain symptoms and rebound tenderness findings. recognition is important because early diagnose and prompt surgical intervention can reduce maternal and fetal mortality and morbity in acute appendicitis. introduction and objectives: conservative management of penetrating trauma has been mainly advocated in centres with a high incidence and large experience with those injuries. our aim was to assess the preventable death rate in our patient population, and the failure rate of conservative management. introduction and objectives: the data about role of amelogenin that is an extracellular matrix protein, during the healing process of the gastrointestinal anastomosis is lacking. in this study, the effects of amelogenin treatment on normal and ischemic colon anastomosis were evaluated. methods: adult male wistar albino rats weighing - g, were divided into four weight-matched groups: normal colon anastomosis group (n = ); amelogenin treated normal colon anastomosis group (n = ); ischemic colon anastomosis group (n = ); amelogenin treated ischemic colon anstomosis group (n = ). sufficient equal volume of amelogenin to entirely cover the anastomosis area had been applied. all animals were killed on postoperative day . bursting pressure levels were measured. peri anastomotic colon tissue hydroxyproline, catalase (cat), cu-zn superoxide dismutase (sod), glutathione (gsh), malondialdehyde (mda) and nitric oxide (no) levels were assessed to evaluate oxidative stress. results: bursting pressure levels of the ischemic colon anastomosis group is significantly lower than the normal colon anastomosis, the amelogenin treated normal colon anastomosis and the amelogenin treated ischemic colon anastomosis groups respectively (p = . , p = . , p = . ). hydroxyproline level of the amelogenin treated normal colon anastomosis group is significantly lower than the normal colon anastomosis and the ischemic colon anastomosis groups respectively (p = . , p = . ). gsh level of the ischemic colon anastomosis significantly lower than the amelogenin treated normal colon anastomosis group and the amelogenin treated ischemic colon anstomosis group respectively (p = . , p = . ). conclusions: amelogenin treatment could support the physical strength of ischemic colon anastomosis and effect oxidant/antioxidant response positively. introduction: meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract, occuring in - % of the population. in the majority of patients, meckel's diverticulum is asymptomatic. we report our experience with the management of complicated meckel's diverticulum in adults. methods: between april and january , the data of seven patients ( males and females) aged - years who underwent surgery due to complications of mechel's diverticulum was retrospectively evaluated. results: of the seven patients, three presented with acute surgical abdomen, two had abdominal pain mimicking acute appendicitis, one had incarcerated incissional hernia, and one had intussusception. intraoperative diagnoses were as follows; littre's hernia in one, ileoileal intussusception due to meckel's diveticulum in one, diverticulitis in two, perforation of the diverticulum in three patients. while diverticulectomies were performed in five patients, two had small bowel resections. in addition to, appendectomy was performed in four patient. all the patient had an uneventful recovery except one, who experienced a postoperative wound infection. the hospital stay was - days. ectopic gastric mucosa was found in two cases. in one case, neuroendocrine tumor was detected in the appendix. conclusions: meckel's diverticulum is an uncommon cause of acute abdominal disease in adults. meckel's diverticulum presents distinctive challenges to a clinician, as it is prone to varied complications such as intestinal obstruction, diverticulitis, perforation. the diagnosis of meckel's diverticulum is difficult to establish preoperatively, and index of suspicion is necessary in patients with an acute abdominal illness. introduction: pneumatosis cystoides intestinalis is a pathologhy which is rarely incidentally seen and is characterised with submucosal or subserosal air cysts. there is no surgical indication in asymptomatic cases. surgical treatment is needed in the development of complication or the possibility of risk. a patient who is hospitalized with diagnosis of pyloric stenosis and is detected pneumatosis cystoides intestinalis incidentally at the operation is presented. case: year old male was admitted our emergency department with vomiting weight loss complaints. pyloric stenosis was diagnosed by radiologic and endoscopic examination. he was hospitalized and acute abdominal signs developed. free air was detected in radiologic examination. surgery was performed. pyloric stenosis and pneumotosis cystoides intestinalis in jejenum were diagnosed. biopsy specimen was obtained from the cysts in jejunal serosa. subtotal gastrectomy, gastrojejunostomy and bilateral truncal vagotomy were performed for the pyloric stenosis. result and discussion: there is no surgical indication in asymptomatic cases. pneumotosis cystoides intestinalis commonly accompony pyloric stenosis and perforation of the cysts may bring out acute abdominal symptoms. knowing this pathology, we may avoid unnecessary emercent laparotomies. aim: in urgent surgical procedures for peptic ulcer perforation, there is considerable postoperative morbidity and mortality. this study aimed to describe and analyze the risk factors that determine beforehand morbidity and mortality in cases with perforated peptic ulcer. materıals-methods: age, sex, co-morbid diseases, symptom duration, abdominal air, amount of intra-abdominal liquid, location and diameter of perforation, operation, and the mannheim peritonitis index (mpi) score were prospectively analyzed in cases. significant risk factors that cause morbidity and mortality were determined through a statistical study. results: the study sample consisted of a total of cases ( males and females) with a mean age of (range - ). duodenum and stomach perforations were detected in and . % of the cases. in cases ( . %), a total of complications were detected. the mortality rate was . %. statistical analyses revealed significant relationships between morbidity and > age (p = . ), co-morbid disease (p = . ), perforation location (p = . ), type of operation (p = . ), and mpi score (p = . ). the factors significant for mortality included > age (p = . ), co-morbid disease (p = . ), > h of symptom duration (p = . ), > cc intra-abdominal liquid (p = . ), a perforation diameter of > . cm (p = . ), omentopexy (p = . ), and a mpi score of > (p = . ). conclusion: factors such as age, co-morbid disease, prolonged perforation duration, amount of intra-abdominal liquid, perforation diameter, type of surgical operation, and mpi score were significant for mortality. the present study found that primary suture is a safe procedure for cases with peptic ulcer perforation. introduction: the presence of foreign objects in the rectum is a rare encountered situation. these objects are usually inserted transanally or swallowed as foreign objects. this study was conducted to investigate the results of patients admitted to our clinic with a rectal foreign body. methods: data of patients who admitted to our clinic between and were evaluated retrospectively results: mean age of the population was . . the foreign object was taken out in the proctological position in patients. in patients these methods failed and laparatomy was performed and the objects were taken out transanally without colotomy. in three patients symptoms and signs of peritonitis were significant at admission and all of them were lost because of rectum perforation followed by septic shock. distribution of foreign objects was: six deodorant lids, five glass bottles, two aubergine, a glass, a salt cellar, a piece of plastic pipe, a vibrator, a plastic cover, a chocolate cover, a chicken bone, a fish bone, needles, a spiral, coins and key, a piece of thermometer, teeth prosthesis and soap. mortality was seen in three patients. the presence of foreign objects in the rectum is a rare encountered situation which should always be kept in mind for differential diagnosis. most of these objects can be taken out transanally. if this fails, all efforts must be shown to take it out without opening the colonic lumen. because of potential complications, the surgeon must be careful during intervention. median age of the alive was . median leukocyte number at the moment of appliance was . , median debridement . and median inpatient stay were determined as days. median age of the dead . median leukocyte number at the moment of appliance was . , median debridement . and median inpatient stay were determined as days. the most common reason of the aetiology was determined as perinal abscess. diversionary ostomy was applied to six patients. chronic kidney failure, and type diabetes was exist in four patients of dead-group. in addition, in one patient type diabetes and hypertension was observed. conclusion: chronic kidney failure related to hemodialysis and high level of lekucyte number at the moment of appliance are the important prognastic factors of deaths related to fg. computed tomography (ct) has become the mainstream of evaluating all hemodynamically stable patients with acute problems when the attending doctor, is urging for diagnosis. basing a diagnosis solely on radiological data sometimes ignoring medical history and physical examination may lead to unexpected errors. wrong interpretation of radiological images or images with equivocal findings which may delude the radiologist and technical errors (artifacts) are all potential sources of mistakes. the aim of this study is to draw attention to the danger of the modern imaging diagnostic modalities to misguide the treatment of patients who need emergency care. we present some cases we faced in our clinic where radiological images showed pathologic entities which in fact did not exist (false positive errors) but forced us to inappropriate treatment. two patients underwent negative laparatomies with imaging diagnosis of a ruptured gallbladder in one case and free air under the diaphragm in the other. a patient with a severe head injury and a ct scanning showing pneumocephalous was transferred to a tertiary centre to be proved on repeated images that initial diagnosis was mistaken due to a wrong calibration of the gantry. imaging findings do not necessarily represent reality. almost always surgeons rely on ct scans for treatment decisions. it is a hard task for a surgeon to question or ignore the pictures to treat a patient based on medical history and physical examination. experience of radiologist is essential and close cooperation with the attending surgeon is needed to avoid radiological misfindings in emergency cases. author to editor: to be presented as a poster. a full text is available on demand. intentional own insertion of rectal foreign bodies in a married, claimed to be straight male, using antidepressive medicaments because of sexual orientation disorder, resulted in resurgery with the same reason of mechanical intestinal obstruction after years in the same surgery clinic by the same surgery team as an emergency intervention. failure of the nonoperative measures under local, spinal and general anesthesia led to the surgical treatment of the -year-old patient in and , who is now years old during the second event. large bottles were removed through laparotomies and colotomies followed by primary repair to reverse the ongoing ileus, which resolved on the th postoperative days in both events. a surgeon who is called to see a patient with retained foreign body should answer whether the patient had rectal perforation and whether the foreign body could be removed transanally without regional or general anesthesia with or without surgical intervention. in case of children; habitually self inserting objects in her vagina or sexually aggressive behaviour with others, e.g. for a boy ''humping'' toys in sexual positions can be a behavioural indicator of child sexual abuse or assault. hence message is: if in a patient perforation of sigmoid colon or rectum history after anal insertion of foreign body in an otherwise healthy adult becomes habitual,the patient should be send to psychiatric counselling. discussion of the nonoperative measures to remove rectally inserted objects is also an utmost important opportunity constituting the largest part of the report of the present case. necrotizing fasciitis is a highly morbid and mortal condition. as a result of aggressive debridement, wide tissue defects occur. wound cleaning from infective material, granulation process and grafting of wound requires a long time. recently, a vacuum assisted therapy system has begun to use for this kind of wounds. this study discuss the treatment result of vacuum assisted therapy (vac Ò therapy tm ) in two patients with giant abdominal wall defect in view of current literature. case : a years old man had an operation because of an accident on railway. at the time of admission there was a wide defect with necrotizing fasciitis on the right lombar region and anterior abdominal wall. there was a full thickness defect about · cm after an aggressive debridement. it was successfully treated with vac and the patient has been discharged after tissue grafting on the postoperative day . case : a years old man had an operation because of an accident. he was admitted at postoperative day . he underwent an aggressive debridement because of necrotizing fasciitis. the skin, rectus abdominus, transversus abdominus, internal and external oblique muscles and some part of quadriceps femoris on the left side was excised. the sacroiliac joint was also broken and pubis was separated. vac abdomen has been applied on two different sites and the wound has become available for grafting after days of therapy. as a conclusion, vacuum assisted therapy provides safe and accelerated wound healing, improves proper tissue granulation in patients with giant abdominal defect. introduction: bogota bag (bb) is a device used for the temporary closure of the abdominal wall (aw). despite its potential benefits, their use is not widespread and remains controversial in the present. aım: to describe our experience in its management for the temporary closure of the aw in emergency situations. methods: for a period of years, bb has been used in patients (pts), with an average age of . years. six had a secondary peritonitis, one tertiary peritonitis, two haemoperitoneum and one a compartment syndrome established. the technique consisted of the placement of a bag of sterile serum, stitched to the skin with nonabsorbable material. results: the average of bags placed by year was . . no morbidity was associated with the placement and/or replacement of bb. the average time of hospitalization was . days and the average time of income in the icu was . days. in pts, the bag was replacement one or more times. the average number of surgical interventions by patient during the income was . . the average time of permanence of the patient with the bag was . days. sixty percent of patients are alive today. objectıves: the aim of the current study is to assess the role of ultrasonography in the management of acute appendicitis. methods: ultrasonography was performed to patients with acute appendicitis suspicion between and . appendectomy was performed to patients with acute appendicitis diagnosis according to clinical examination after ultrasonography. patients who had a diagnosis different from acute appendicitis with clinical examination were observed. the histopathological findings of patients with appendectomy were compared with their usg findings. results: of patients had acute appendicitis diagnosis by ultrasonography. hystopathological examination showed acute appendicitis in of these patients. patients did not have acute appendicitis. usg showed that patients did not have acute appendicitis. ten of these patients showed gynecological pathology, and six of them showed urinary pathology, and they were all treated appropriately. in eight patients the appendicitis findings became evident in clinical observation; resulting in appendectomy, and histopathological examination showed acute appendicitis. forty patients showed improvement at follow up. no spesific treatment was needed. misdiagnosis rate was determined as . %. the sensitivity, specificity, positive predictive value, negative predictive value and accuracy percentage of ultrasonography in the diagnosis of acute appendicitis was . , . , . , . and . %, respectively. conclusion: ultrasonography has a high degree of accuracy in the diagnosis of acute appendicitis. however, we also conclude that ultrasonography results should always be interpreted in combination with clinical findings. background: hydatid cyst disease is frequent in some regions of the world, including our country turkey, and is most commonly located in the liver and lungs. the hydatid cysts may rupture spontaneously or as a result of trauma. herein, we describe a rare case of retrovesical hydatid cyst which was resulted from rupture of spontaneous rupture of liver hydatic cyst intraperitoneally. case: fifty-four years old male was admitted to emergency department with complaints of frequent urination and abdominal pain lasting for days. there was general abdominal tenderness on physical examination. there was no history of trauma or operation. in his abdominal ultrasonography and tomography there were primary cyst ( · cm), ruptured cyst ( · cm) and retrovesically located cyst ( · cm). indirect hemagglutination test was positive for echinococcus granulosus ( / , ) . laparotomy was performed and all the cysts were excised by partial cystectomy. there was no postoperative complication. the patient was externalized on postoperative th day with albendazol treatment. conclusion: retrovesical localization of hydatic cyst is a very rare. these cysts mostly occur as a result of surgical inoculation caused by inadequate surgery or free intraperitoneal rupture of primary hydatic cyst. in endemic regions, possibility of hydatic cyst should be kept in mind in differential diagnosis of intrapelvic cysts and masses. background: wegener's granulomatosis (wg) is a systemic necrotizing vasculitis of unknown etiology characterized mainly by involvement of the upper airways, lungs, kidneys and may rarely involve the gastrointestinal tract. intestinal involvement may be asymptomatic. we herein report a wg with massive lower gastrointestinal hemorrhage due to colonic involvement. case: the patient complained of dyspnea which started months ago, fatigue, generalized arthralgia and myalgia together with loss of sensation on right upper extremity was applied to emergency and hospitalized by internal medicine department. physical examination revealed a very ill-looking patient, there were positive lung findings for wg and c-anca was positive. we consulted the patient because of hematochesia with abrupt drop of hemoglobin and platelet count. on colonoscopy whole mucosa was full with fresh blood from sigmoid to anal canal. on angiography multiple foci of bleeding were demonstrated on descending and sigmoid colon. embolectomy was not performed because of multiple foci. hemoglobin decrease continued and his clinical condition deteriorated; an explorative laparotomy and total left colectomy was performed. his melena persisted for days but hemoglobin was maintained at after units transfusion after operation. conclusion: we herein report a case with clinical wg who developed a gastrointestinal hemorrhage and treated by surgery. the uremic state and cytotoxic agents given to patients may detoriated the gastrointestinal bleeding. immunosuppressive therapy might exacerbate gastrointestinal complications. the clinicians should be aware of this situation, therefore treatment of these must be performed in centers where angiography and endoscopy are available. background: the aim of this study is to determine the strength and proceeded efficiency of mda, sod, and catalase levels that are indicators of oxidative stress in generalized peritonitis. material-methods: this study was conducted as prospective and randomized with patients who applied at dicle university, department of general surgery between march-september . patients were composed as group (n = ); generalized peritonitis, group (n = ); laparotomy under elective conditions and not present peritonitis; group (n = ) as control group. in order to measure limits of mda, sod, crp and catalase, blood samples were drawn from the patients in group and group on before operation day (bod), st and rd days. the mda values of group on before operation day, st and rd days were compared to group and , the difference were found statistically meaningful. statistical differences noticed between group and mda values on bod, st and rd days. statistical differences were noticed between catalase values measured bod and rd days when group and values compared to group . the sod values of group and group on day were compared to group , meaningful statistical difference was found. statistically meaningful difference was found between the sod values group and on st day. conclusion: values of sod, mda and catalase were noticed usable parameters for the following and detection of severity of generalized peritonitis sinan cumhur karakoç, gü rkan yetkin, _ ismail ethem akgü n, mehmet uludag, bü lent Ç itgez, hamdi Ö zş ahin, cabbar kartal general surgery departmet, Ş iş li etfal training hospital, istanbul, turkey objectıve: we aimed to evaluate the effects of early cholecystectomy on morbidity and patient comfort in patients with acute biliary pancreatitis. methods: patients who underwent cholecystectomy for acute biliary pancreatitis in our clinic between and were evaluated retrospectively. the patients were divided into three groups as early, late and elective cholecystectomy cases. fındıngs: patients who had undergone cholecystectomy operation in the first days until the administration to hospital were classified as the first group (early cholecystectomy). patients who had undergone cholecystectomy between the nd and th weeks until the administration to hospital were classified as the second group (late cholecystectomy). patients who had undergone cholecystectomy after weeks were classified as the third group (elective cholecystectomy). in group , no patient had pancreatitis attacks; of patients in group had recurrent pancreatitis attack in the preoperative period and treated in our clinic. in order of these data, age, height, weight, gender, sgot, sgpt, amylase, bilirubin and the time for waiting for the operation were compared and evaluated statistically. the time for waiting for the operation was found to be p > . , and it was shown to be significant. results: there is a tendency to perform cholecystectomy in patients with acute biliary pancreatitis, after the acute attack is resolved. we believe that the early cholecystectomy prevents the patient from the additional morbidity in patients with acute biliary pancreatitis, by showing this with a statistically significant result in our study. traumatic right sided diaphragmatic hernia is clinically rare and may present with complications in a later period. on the right side presence of liver is thought to be a protective factor for both development of diaphragmatic injury itself and for its complications. we present a case of right sided diaphragmatic hernia due to blunt trauma, which was asymptomatic for years and has been presented with intestinal obstruction. the patient, years of male, has presented with intestinal obstruction and abdominal pain which has been relieved after nasogastric decompression. despite conservative treatment patient has not shown further improvement and has been operated on a semi-elective basis. significant part of small and large bowel, distal portion of stomach, and almost whole of liver had been herniated and reduced by right thoracoabdominal approach. cm wide defect in diaphragm has been repaired with prolene mesh, laparotomy has not been closed and bogota bag has been applied. in the early postoperative period transaminase levels have increased , u, and ct-angiography has revealed patchy areas of low per-fusion in both lobes of liver. after therapeutic anticoagulation liver function has recovered completely, abdomen is closed and oral feeding commenced. at the th postoperative day respiratory insufficiency has occured after witnessed aspiration of gastric contents, followed by multiple organ failure. this case represents a quite late presentation of right sided traumatic diaphragmatic hernia, for which treatment was complicated. this case clearly shows the importance of detailed evaluation and timely treatment of all traumatic diaphragmatic hernias. cem ibis, dogan albayrak, fedayi calta, eren taskin, mehmet ali yagci, ahmet hatipoglu, irfan coskun department of general surgery, medical faculty, trakya university edirne, turkey introduction: amyand hernia is first described by claduis amyand in london in an year old male. it is a rare condition and described as appendix vermiformis in the hernia sac. we present a case of an incarcerated inguinal hernia with appendix vermiformis inside. case: sixty nine years old male with bulging and pain in the right inguinal region is evaluated. right inguinal hernia was detected. after opening the hernia sac, the appendix and ceacum were observed. lichtenstein procedure was performed. the patient was discharged in the second postoperative day. discussion: although the incidence of appendix vermiformis in the hernia sac is . - %, the incidence of acute appendicitis in the hernia sac is . - . % in various reports. the treatment of amyand hernia is related to the appendix found inside. the application of appendectomy to normal appendix in routine hernia repair procedure is controversial due to infection risk. we do not routinely perform prophylactic appendectomy in such patients. we thought that a patient tailored approach is more acceptable. introduction and objectives: hydatid disease is typically asymptomatic. it can become symptomatic due to expansion, rupture or pyogenic infection. rupture of the cyst is the most common complication, followed by secondary infection, jaundice, and anaphylaxis. methods: in this study, we analyzed demographic and clinical characteristics of the cyst hydatic patients who admitted the emergency service due to complications of the cyst hydatic. the medical records of patients, with a final diagnosis of complicated cyst hydatic were reviewed for demographic information, admission symptoms, laboratory findings, evaluation techniques, and outcome. results: ten patients ( men, women) with final diagnosis of complicated ce (cystic echinococcosis) included the study. all of the patients had abdominal pain. while the pain was diffuse in the entire abdomen in seven patients, it was located in the right upper quadrant in three patients. patient's complaints were nausea, vomiting, jaundice, ileus and urticaria. the clinical signs and symptoms of hc rupture are not always severe, but hydatid fluid can irritate, which can cause peritonitis as occurred in our series of patients, all of whom had acute abdominal signs. in this study, % of the patients with ruptured ce had abdominal pain. thus, the clinical presentation of ce rupture is not always silent. the severe clinical presentation and infrequency of ce perforation has been held partially responsible for the misdiagnosis by the surgeon. conclusion: in conclusion; complicated hc may be admitted to emergency service with different clinical pictures especially in endemic regions and must be considered in differential diagnosis. background: to evalute the changes in the pattern of iatrogenıc bılıary injury and consequentıal effects on treatment strategy and outcome. methods: seventy-three patıents treated for iatrogenıc bılıary injury (ibi) between july and november at a tertıary care center in izmir, turkey were retrospectıvely analysed. results: underlyıng diseases were; missed tumor (n: , . %), biliary surgery (n: , %) and hydatıc dısease (n: , , %). in recent years wıth a gradual increase in the avaılabılıty of endoscopıc and radiologial expertise the majorıty of patıents underwent extensıve preoperatıve diagnostic and therapeutıc procodures includıng endoscopıc retrograd panceratography for cases( . %) and percutaneus transhepatıc cholangıography for cases( %). defınıtıve surgery was performed in all patıents except ( . %) of them. roux-en-y hepatıco-jejunostomy was the primary reconstructıon technıque and performed for cases ( %). there was only one ( . %) hospıtal mortalıty. restenosıs developed in ( . %) cases and was reoperated. percutaneus baloon dilatation was faıled in three patıents as a fırst treatment optıon. none of patıents died of dısease related causes durıng the follow-up perıod. conclusion: increased experınece in laparoscopıc biliary surgery might be caused to attempt more challengıng cases and increased bılary tract injurıes. tolga kafadar, ercan gedik, sadullah girgin, bilsel baç, _ ibrahim halil taçyıldız department of general surgery, dicle university, diyarbakir, turkey the aim our study was to determine the independent risk factors affecting patients with upper gastrointestinal hemorrhage who underwent surgery. materials and methods: the medical records of patients with upper gastrointestinal hemorrhage who underwent operation were reviewed for variables including age, gender, shock, association with co-morbidity, pulse rate, hemoglobin levels, white blood cell count, serum urea, creatinine, sodium and potassium levels, time of opera-tion, number unit of blood transfusion, rockall risk score and length of hospital stay. in order to determine the independent risk factors mortality and morbidity, we carried out entered logistic regression analysis. results: morbidity and mortality rate were . % ( patients) and . % ( patients), respectively. the independent risk factors affecting morbidity were serum albumin level [odds ratio (or) = . , % confidence interval (ci) = . - . , p = . ] and rockall score ‡ (or = . , ci = . - . , p = . ), and the independent risk factors affecting mortality were advanced age (or = . , ci = . - . , p = . ), and high rockall score (or = . , ci = . - . , p = . ). conclusion: to decrease the postoperative morbidity and mortality rates in patients with ugih requiring surgery, patients preoperative risk factors should be demonstrated. we believe that establishment of interventional indication on time and evaluation of intraoperative surgical region and technique in combination with the patient-and disease-related factors in patients requiring surgery would help reduce morbidity and mortality rates. blunt thoracic trauma leads to various clinical conditions, such as hemothorax, pneumothorax, pulmonary contusion, and respiratory tract hemorrhage. especially, respiratory tract hemorrhage resulting from pulmonary contusion is so critical to require a clinical challenge. of our experienced survivors, trauma victims (male / , - years old) with blunt thoracic trauma associated with motorcycle accident were transferred to our emergency departments. they similarly suffered respiratory failure (average respiratory rate of ) and hypotension (average shock index of . ) on arrival. immediate after the rapid-developing respiratory failure in relation to lung contusion and endobronchial bleeding, bronchial blockade device and extracorporeal membrane oxygenation (ecmo) were urgently introduced at an average of and min, respectively, and achieved rapid resolution of their respiratory crisis. all of them withdraw from ecmo within days. pulmonary contusion sometimes follows fatal progress, and we consider that quick bronchus blockade and ecmo introduction is the key of survival. emergency departments (ed) in greece are incorporated to the departments of the hospital and are divided in two major areas: one for internal medicine and one for general surgery. every patient has free access to the (ed). the workload and the conditions treated in ed in greece are geographically and social -economically depended. the national health system is represented by one hospital for each prefecture. the general hospital of trikala, is categorized as an urban hospital, with beds, and is covering a population of approximately , people, living in the town and in villages situated in the surrounding mountain area. the department of general surgery is stuffed by general surgeon specialists and seven residences. during , , patients were examined in the surgical ed. in this study we analyze the characteristics of the patients, the number and causes of admissions in the various departments of our hospital and also the transferals to a tertiary center. aim: pneumotosis cystoides intestinalis is a rare entity, and may be associated with pyloric stenosis. materıals-methods: data of a patient operated for pyloric stenosis and pneumotosis cystoides intestinalis in our institution are presented. results: patient was a year-old addicted male, and his body mass index was . kg/m . he had been suffering from nausea/vomiting, bloating and constipation for a few months. a gastroscopic examination revealed atonic gastric dilatation, duodenal ulcer and related pyloric stenosis, and positive serology for helicobacter pylori. an eradication treatment in conjunction with long term proton pomp inhibitors were given, however the patient readmitted to our department with worsening symptoms including vomiting, pain and weight loss after months. repeated gastroscopies and gastric meal x-ray examination revealed pyloric stenosis and the patient decided to have an operation instead of repeated medical treatment. during laparotomy, subserosal foamy air bubbles were observed on the serosal wall of ileum. a partial resection of ileum was necessitated for the suspicion of perforation. vagotomy with finney pyloroplasty was performed in order to cure the pyloric stenosis. the postoperative period was uneventful and the patient was discharged from the hospital on day . the patient has not have a recurrence, gained weight and have no problem since years postoperatively. conclusion: pneumocytosis cystoides intestinalis may be observed in the presence of a pyloric stenosis and necessitates resection if any doubt for perforation is present. granulosus. in this study, a rare appearance of the disease is presented as an abscess located in the retroperitoneal space. results: the patient was years-old male with several comorbidities admitted to our emergency department with fever and left lumbar pain. he had had operated for hepatic hydatid disease years before the admission. physical examination revealed local tenderness and slight hyperemia on his left lumbar region. his laboratory findings showed leucocytosis, and a computed tomography demonstrated a huge retroperitoneal abscess located between spleen and pelvic entrance and denied any pathological finding regarding to the left kidney or adrenal gland. since the general condition of the patient did not allow an operation under general anesthesia, the abscess was drained through a cm long incision located on the hyperemic area under local anesthesia. after complete removal of the abscess and daughter cysts, a drain was left behind, and removed on day . the patient was discharged out of hospital on day , after an uneventful recovery period. discussion: to best to our knowledge, this is the first hydatid disease case presented as a retroperitoneal abscess in the literature. hydatid disease may be kept in mind as a differential diagnosis in the presence of a cystic retroperitoneal mass in endemic regions. ali uzunkö y , zekeriya sayın harran university school of medicine department of general surgery, sanliurfa, turkey osm ortadogu hospital, sanliurfa, turkey introduction and objectives: giant true splenic artery aneurism is rare lesions. these aneurisms have risk of rupture and bleeding. we have performed a giant true splenic artery aneurism. case: the case is a year old female patient. she applied to hospital with complaints of abdominal pain. at the physical examination, there were a moderate splenomegaly and a pulsatile mass in the left upper abdomen. it was shown a giant splenic aneurism at the abdominal computed tomography and colour doppler ultrasonography. colour-doppler abdominal ultrasonography showed about mm splenic artery aneurism. computed abdominal tomography showed a hypo dense mass situated anterior and superior to the pancreas tall and corpus extending up to the splenic helium. the diagnosis was confirmed by ct angiography. the patient was performed with general anaesthesia and left subcostal incision. at the exploration, splenic arterial dilatation and aneurismal sac was shown and aneurysmectomy with splenectomy was performed. there was no complication intraoperatively and postoperatively. the patient was discharged at the postoperative fifth day. there was no complaint at the control examination at the fifteenth day after discharging. conclusions: although giant splenic artery aneurism is rare, but they have risk of rupture and bleeding. there are two options for treatment of these lesions. one of them is aneurysmectomy. it is frequently performed with splenectomy. other option is embolisation. in our opinion, surgery for giant splenic artery aneurism is performed successfully without important complication. author to editor: saved by lookus introduction: an association between the administration of paracetamol and relative hypotension in critically ill patients has been reported by the staff working in the surgical and trauma intensive care unit of istanbul faculty of medicine. methods: a prospective, observational study was undertaken to investigate the effect of paracetamol on systemic blood pressure in two groups of critically ill patients. a dose of mg of paracetamol was administered intravenously to both groups in min time. blood pressure, heart rate were recorded at baseline, at the end of infusion and then at , , min after administration. the differences occured over the observation period was measured by friedman analyse. results: twenty-eight patients with sepsis, were enrolled to group- (anti-pyretic effect) and postoperative patients were enrolled to group- (analgesic effect). analysis of data from all patients showed that systolic arterial pressure (sap) and mean arterial pressure (map) were reduced significantly over the observation period in both groups (sap:p < . for both, map:group- p < . , group- p < . ). sap and map in group- and group- decreased by an average of approximately and % respectively. however, no significant decrease in dap was noted in group- . conclusions: utilization of the intravenous paracetamol for febrile and/or postoperative patients caused a significant decrease in systemic blood pressure after administration. this drug-induced hypotension was clinically relevant to control the required blood pressure. thus, clinicians should be aware of this potential effect, especially in critically ill patients. yazile sayın faculty of health, surgical nursing division, cumhuriyet university, sivas, turkey background: pain is considered one of the most important symptoms which guide diagnosis, treatment and nursing care in the emergency departments. aım: to discuss pain evaluation by nurses in emergency departments and to attract attention towards nurses' responsibility for pain evaluation. methods: qualitative and quantitative data from studies on pain evaluation by nurses were evaluated. results: all studies reviewed showed that about three fourths of the nurses in the emergency departments did not make pain evaluation based on the standards (using pain rating scales, reporting the conditions likely to affect pain evaluation etc.). the nurses included in studies assigned significantly lower scores for pain than the researchers(p < . ;p < . ). all studies revealed the following reasons why triage nurses did not play an effective role in pain evaluation: insufficient knowledge, the idea that doctors are responsible for pain evaluation, doctors not appreciating the value of pain data provided by nurses, insufficient cooperation among members of the health staff, work overload, time constraints, errors in reporting data on pain evaluation and conflicting attitudes and beliefs concerning pain evaluation. it has been reported that only - % of the patients presenting with pain to emergency departments received effective pain management. the most important reason for this low rate has been shown to be deficiencies in pain evaluation due to insufficient multidisciplinary cooperation. conclusion: it can be concluded that nurses in emergency departments are not efficient enough to use interventions which help to evaluate pain for effective pain management. introduction: diverticulosis of the colon is a common condition. complications of diverticulitis often require surgery. perforated diverticulitis may rarely present with spreading superficial sepsis. case: male, years, history of chronic depression. admitted in the emergency department after a -day history of abdominal pain in the left lower quadrant (llq), associated with asthenia, anorexia and weight loss, without diarrhea, constipation or fever. the patient examination showed edema and thickening of the abdominal wall with swelling and redness in the llq. blood chemistry revealed leukocytosis with neutrophilia and elevated c-reactive protein. a diabetic ketoacidosis was diagnosed. the abdominal ct confirmed abdominal necrotizing fasciitis with an abscess, without other intra-abdominal changes. the patient was then submitted to emergency surgery with debridement of the necrotising fasciitis and drainage of the abscess. he was admitted to the icu. further debridement was necessary h later. at d , fecal contamination of the wound was detected, leading to a subsequent laparotomy with identification of a sigmoid inflammatory mass attached to the site of the fistula's external orifice. a hartmannprocedure was performed (histology confirmed the diagnosis of perforated diverticulitis). the patient developed a sirs complicated with a right-side necrotizing pneumonia requiring multiple antibiotic treatment and pulmonary decortication. death occurred at the th hospitalization day. conclusion: necrotising fasciitis as a consequence of perforated diverticulitis is an uncommon but potentially lethal condition requiring prompt surgical intervention. when accessing an abdominal necrotising fasciitis without recognisable source, an elevated index of suspicion is necessary to link it to complicated diverticulitis. fatih baş ak, kü rş ad Ö ztü rk tc sb bozkir community hospital introduction: care of trauma patients may be difficult in small community hospitals. these hospitals are usually staffed by a small number of general practitioners and, perhaps, a general surgeon, and a significant number of trauma cases are brought to them. the records of minor and major trauma patients who admitted to bozkir community hospital between june and december were evaluated. mortality and transfer rate were recorded. general surgeon was not present in first months. the rates of last months when general surgeon has been present were calculated separately. results: trauma patients were admitted in first months ( . %) of these were transferred to larger centers. treatment of remaining ( . %) patients continued in our hospital. mortality rate of first months was . %. three patients requiring immediate surgery died because of absence of general surgeon. patients were admitted in last months. ( . %) of these were transferred to larger centers. mortality rate of last months was . %. three gunshot wound and one penetrating cardiac wound patients were saved with emergent surgery. conclusions: regardless of the sophisticated techniques for dealing with trauma that exist in larger centers, it is the staff of smaller hospitals that often shoulder the initial burden of trauma care. transfer rate is between and % of all trauma cases. our hospital is . h away from larger centers. presence of general surgeon in last months mainly affected the care of patients that requiring immediate surgical attention. metin kement, hakan acar, ilhami soykan barlas, uygar dü zci, cem gezen burn center, kartal education and research hospital, istanbul, turkey aim: fecal contamination which may result in septicemia, graft loss and wound healing delay is the most serious problem for burns in perineal, gluteal and upper thigh regions. temporary fecal containment devices can be used for diverting feaces from burned area. the aim of this study was to evaluate early results of using of these devices in our burn center. methods: twelve patients, who were applied temporary fecal containment devices in our burn center, were retrospectively evaluated in this study. results: ( . %) of the patients were male.the mean age was . ± . year.the mean tbsa burned was . ± . %. ( %) of the patients had burn in all three regions (perine, gluteus and upper thigh). three ( %) of the patients had burn in upper thigh. and ( %) of the patients had burn in gluteal region. the devices were placed intra-rectally on the first admission days of all patients.the mean application time was . ± . days. except minimal fecal leakage in ( . %) patients, any complication was not observed in our cases. local infection confirmed by tissue culture was observed in ( . %) patients including two patients with fecal leakage. besides, in one of these four patients, septicemia was developed and managed successfully with antibiotics and supportive treatment in intensive care unit of our center.one patient with % burn was died on days of application due to multiple organ failure. conclusion: temporary fecal containment devices aim to protect patients' wounds from fecal contamination by diverting feaces. if the safety of these device is proved in further studies, they may reduce the necessities of diverting stoma operation in burn patient. metin kement, ilhami soykan barlas, uygar dü zci, hakan acar, cem fazlı gezen burn center, kartal education and research hospital, istanbul, turkey aım: reactive thrombocytosis which develops secondary to infection, trauma, malignancy or surgery is the most common ethiology of thrombocytosis. although thrombocytosis is a benign and self-limiting condition in most cases, it may result in some thrombotic and hemorrhagic complications. the aim of this study was to evaluate the reactive thorombocytosis in burn patients. material: thrombocyte counts was retrospectively evaluated in consequent burn patients admitted to our burn center between august and january . the correlations between thrombocyte counts and demographic data, total body surface area burned (tbsa), hospitalization time and levels of some acute phase markers also analysed. results: the mean thrombocyte counts were respectively . ± . /mm , . ± . /mm on admission day and second day (p < . ). the number of patients with thrombocytosis was ( . %) in admission, ( %) of them were children. the rate of thrombocytosis was / ( . %) in children,whereas the rate of thrombocytosis was only / ( . %) in adults (p < . ). the mean thrombocyte counts in children and adults were respectively . ± . /mm , . ± . /mm in admission (p < . ). the mean wbc count was significantly higher in patients with thrombocytosis than patients with normal thrombocyte count (p < . ), but there was not any significant difference in crp count (p = . ). and also,we did not find any significant difference between patients with thrombocytosis and patients with normal thrombocyte count in tbsa and hospitalization time (p = . and . , respectively) conclusion: reactive thrombocytosis is seen more frequently in burned children than burned adults and mostly unrelated to degree of burn. background: electrical injuries are related with multiple organ dysfunction as well as high morbidity and mortality. pulmonary compromise is rare, if compared to other organ dysfunctions related with electrical injuries. in this study, we presented a case with pulmonary hemorrhage associated with electrical injury. case: a -year-old previously health man was brought to our emergency department (ed), h following the accident, with electrical injury. initial examination findings were blood pressure / mmhg, heart rate /min, respiratory rate breath /min. glasgow coma score was . decreased breath sounds, bilateral rales and wheezing were determined. there were small necrotic wounds (typical contact injury) on the first finger of left hand and under the right foot of patient. there was no trauma in thoracic wall. blood gas analysis revealed respiratory and metabolic acidosis. the inr and platelet levels were normal. when chest radiograph and thoracic computed tomography were assessed, air bronchograms and symmetric consolidations were determined in the both lungs. patient was intubated and fresh blood was aspirated from endotracheal tube. mechanical ventilatory support was performed the patient due to lung hemorrhage and respiratory failure. patient died after h of admission in the ed. conclusion: multiple organ dysfunction and necrotic skin lesions could be occurred in electrical injuries. electrical injuries on the chest may cause lung infarction because of the direct effect of the electrical current and vascular embolism. possibility of lung injury should be investigated after electrical injury especially in patients with respiratory failure. nebahat yıldız , aysel gü rkan , _ imren aş ar , ayş e hale uysal trauma and emergency surgery service,istanbul university, istanbul faculty of mediine, istanbul, turkey health science of faculty marmara universty, istanbul, turkey introduction and objectıve: the outcome of burn treatment is measured not only by mortality and morbidity, but also by post-burn psychological factors. the purpose of this study was to investigate whether difference in length of hospitalization exist between burn patients with and without mental health problems and if so, why. methods: the descriptive study was retrospective review of patient with burn injuries who had received care at one burn unit in the istanbul from october to december . socio-demographic features of patients, burn criteria (kind, depth, size, location), duration of hospital stay, and psychological problems were tabulated. results: psychological impairment was found in of hospitalized burn patient. there were acute stress disorder in fifteen patient, anxiety in nine, adjustment disorder together with anxiety in eight, depression in seven, post-traumatic stress disorder in six patient. fortyone ( . %) patient had burns which were between i and ii degree and ( . %) patient had burns which were between ii and iii degree. in patient, burned area has been % or more. patients with psychologocal impairment were longer hospital stay and intensive care unit than patients without psychologocal impairment. sixty-four ( . %) patients with psychologocal impairment had been discharge either getting better or recovering completely but unfortunately ( . %) patients died. conclusion: the presence of psychological problems in burn patients have an impact on their burn care. psychological interventions can contribute towards successful outcomes. introduction and objectives: major burns can cause disseminated intravascular coagulation (dic) and is a serious clinical problem. we would like to present dic cases whose burn rate is % according to total body surface area (tbsa) which developed after late postoperative period. methods: two cases over %, nd and rd degree burn injury admitted to our facility. first case who was year old female developed s. aureus and second case was years old female developed p. aeruginosa sepsis which was confirmed by blood culture. in first case dic developed at postburn day and in second case at postburn day. in both cases dic developed after postsurgery day . results: on patients, bleeding points, as leaking, were detected on all over burn areas. at the same period thrombocyte values decreased sharply ( . k/ul). increase in prothrombin time (pt) ( . second) and active partial thromboplastin time (aptt) ( second) values, decrease in fibrinogen levels was observed. cases were discharged from hospital in th day, without any problem. patient was taken for iu erythrocyte suspension and iu platelet suspension in this time totally. conclusion: dic occurs in early period of burning; but it can be formed in later periods, even after defects were recovered by operation. rapid establishment of dic table just before the discharging term from hospital is an unusual and interesting situation. the patients in our study can be accepted as an example of the necessity of observing coagulation parameters in every periods of burn damage. methods: sphere project handbook reviewed by experts in the field of each section, the terms of our country's adaptation has been made. within the framework of the project dissemination, sphere workshops have been organized in various provinces. the ppt slides were adapted to turkey's needs. the project's outcomes have been observed through the pre-post tests and the workshop evaluation forms. results: expert review and the end of the first study, with a high risk of disaster in our country, the handbook was understood to be necessary and useful. in addition to this, the control lists in details but useful and also, the summary tables are useful to take a decision in emergencies. it is also understood that preliminary results from the project is compatible with literatur data. conclusions: developed in each country is adapting to the local experience of the sphere, significant experience with disasters in our country the right to contribute are welcome. indeed, the first application of the new approach by the sphere project's coordination center is monitored with interest. introduction: ( ) initial assessment of trauma patients is a period with a high frequency of treatment protocol deviations and an elevated number of avoidable complications. ( ) the majority of medical errors are diagnostic or cognitive, whereas operative technical complications accounted for less than %, and ( ) general surgery residents (gsr) do not feel well-trained on the management of major trauma patients. aim: describe initial experience with one approach to foster quality improvement in trauma care modifying the method by which we train surgeons. methods: we integrated in the gsr program, simulation based training sessions with other educational tools as lectures and workshops. the scenario objectives were based on research data indicating major deficiencies in trauma care (tc). we incorporated team training and crisis resource management sessions. to review trauma life support diagnostic and therapeutic standardized protocols we run scenarios to train initial assessment, and head, thoracic and abdominal trauma. after every clinical case, residents participated in a video assisted debriefing session leaded by a specialized instructor. an evaluation interview was made after the course. results: all resident viewed the experience as a ''very good'' training modality. many of them felt their time was better spent in the simulator session than in the operating room, and wanted to do it more often or in a scheduled way. some of them complained about evaluating the mannequin and the equipment when compared to the one in their actual work setting. conclusions: integrating patient simulation with traditional surgical training may strength the approach to tc education. introduction: pulmonary embolism is a life-threatening condition and its diagnosis is generally based on clinical suspicion. case: a years old male had been admitted to another hospital with acute dyspnea and syncope and after initial evaluation he had immediately been undergone an operation due to epidural hematoma. he was referred to our emergency department with early diagnosis of acute coronary syndrome after operation because intraoperative and postoperative tachycardia could not be controlled. in his physical examination gcs: , arterial blood pressure / mmhg, heart rate /min and breath rate /min. ecg, echocardiogram and thorax ct findings complied with pulmonary embolism. venous doppler ultrasonograpy findings complied with chronic deep venous thrombosis. thrombolytic or antiaggregant medication could not be started because of epidural hematoma operation. at postoperative h low molecular weight heparin and at h warfarin was administered. in follow-up period his symptoms regressed and there was no complication due to epidural hematoma surgery. he discharged from hospital at day . conclusion: in trauma patients, one of the important issues that have to be considered during clinical evaluation is the primary reason leading to trauma. in this case, the investigation for syncope etiology revealed the haemorrhage and thrombus diagnosis concomitantly. these two diagnoses have opposite treatment strategies and due to this condition we had difficulty in management of the patient. although there are intracranial haemorrhage cases due to pulmonary embolism treatment (thrombolytic or antiaggregant), a similar case report cannot be found in the available literature. introduction and objectives: different societies have different type of snake bites. _ in our actually series, two patient from u.k. and seven patients from south-eastern part of turkey presented with lıke compartment syndrome result of was bitten by a snake to their fingers. methods: four of nine patients applied to our clinic at the day of event, the other five were referred to us after the emergency treatments have been done. all bites were over or distally to the pip joint. after being bitten by snake, patients admitted to our accident and emergency department because they had like as compartment syndrome on the forearm. two of the patients were referred to us very late stage and one of them had partial necrosis and the other had total necrosis already. none of patients had signs of systemic envenoming. results: two patients with local swelling and no other symptoms were discharged. coverage of the defects were performed with full thickness skin grafting in two patients, cross-finger flap in one patient, reverse dorsal digital arter flap in one patient and dorsal interosseous metacarpal flap in two patients. one patient had amputation. none of patients had fasciotomy. conclusions: this study represents the clinical effects and current approaches for the treatment of snake bites to distal finger. all patients presented with compartment syndrome like symptoms on the hand or forearm. these patients should be followed-up very closely. final wounds should be closed either with skin grafts or local flaps. simultaneously, systemic envenoming should be considered. the aim was to evaluate the geriatric patient with abdominal pain in emergency department (ed). methods: the preliminary retrospective study included the period between january and june , , ankara. data were achieved from registration notebooks, manually. the patients separated within age to three groups as - , - , and over. the finalization of management, hospitalization, operation rate, mortality were studied. results: there were ( . %, annually) patients. the mean age was . ± . ( - ), the mean hospitalization duration was days ( - ). the sex and the age of patients can be seen in table . . % (n = ) of them discharged from ed. abdominal ct and usg usage were . % (n = ), . % (n = ) in ed. . % (n = ) patients had both ct and usg. abdominal ct and usg results are showed in tables , . finalization of patient management was demonstrated in table . the operation rate for all patients was . % (n = ). general surgery hospitalization and operation rate were . and . % (n = , n = ). the mortality rate was . % (n = ) in admission. there were not any significant difference between the groups of - and - according to sex, finalization, ct, usg utilization, operation rate (p = . , p = . , p = . , p = . , p = . ) with spss x test, while the number of advanced geriatrics was unsuitable for statistics. conclusions: females and the - age group were common with a complaint of abdominal pain in ed. most of them had hospitalization indications and the primary yard was general surgery with brid ileus. mortality rate was lower than % introduction: nontraumatic epigastric and left upper caudran pain is a common complaint in emergency department. it can include lifethreatened various reasons as cardiac, respiratory, and serious gastrointestinal problems, rarely. case: a year old man had an emesis with recurrent epigastric and left upper caudran pain admitted as second turn to ed in h. physical examination except a slight epigastric sensitiveness, ekg, urine test and biochemical tests, complet abdominal ultrasonography, x-rays were nonspesific on the first day. wbc was . on cbc. his complaints relieved with semptomatic treatment with an mg ranitidine, mg metoclopramide, serum sale on his observation and discharged with suggestions. in second admission with nonspecific physical examination findings, computerized tomography (ct) revealed splenic unenhanced parenchymal areas consistent with splenic infarcts. computerized tomography angiography (cta) showed a small aneurysm of the celiac trunk, a characteristic pattern of caliber irregularities and arterial wall thickening of the splanchnic arteriesincluding splenic artery, common hepatic, right and left hepatic arteries-, suggesting splanchnic arterial mediolysis (figures and are presented with permission of patient's written consent). he was hospitalized to general surgery and started low molecular weight heparin. as clinical and radiologic findings were degrated, he was discharged without an operation. conclusions: splanchnic (segmental) arterial mediolysis is a rare noninflammatory vascular disease of the abdominal splanchnic arteries with slight symptoms. ct for vasculary and internal organs should be performed to diagnose in recurrent complaints beside observing the physical findings. introduction: it is well documented that healing of peptic ulcer perforation (pup) is possible with conservative therapy in selected cases. thus a spontaneously closed pup diagnosed at exploration may not require surgical repair. methods: study included three patients in which diagnostic laparoscopy suggested spontaneously closed pup between and . suggestion criteria were; fibrin cloth on duodenum with or without subhepatic fluid collection, no visible perforation, otherwise normal exploratory findings. omentum minus was dissected and cautiously observed. the stomach was filled with ml diluted methylene blue fluid via nasogastric tube, operation table was tilted to right and up, a gentle pressure on the stomach was made with the shaft of laparoscopic irrigator to fasciculate the passage while the descending section of duodenum was compressed with the shaft of a grasper. duodenum was cautiously observed for min to detect dye leakage in all patients. if no leak was observed, operation was terminated after abdominal irrigation and inserting a catheter to the subhepatic area. therapy for pup was given postoperatively. results: all patients were male and the mean age was ( - ), no leak of dye was observed at operation. nasogastric tube was removed and food intake was allowed at postoperative second day. all patients were discharged on third day. conclusion: although the perforation site is almost always identified at operation, to meet a spontaneously closed pup is also possible. irrigation and drainage alone may be sufficient for these cases after blue dye test as described in this study. the complicated appendix with/without abscess was delivered through the umbilical incision for an open technique safely. this gave our patients the maximum benefits of the minimally invasive surgery with better visualization, reducing equipment needs, less postoperative pain, rapid discharge, no postoperative infections, and excellent cosmetic results. all patients were quite satisfied during follow-up. conclusions: it is concluded that hybrid appendectomy seems to be feasible and reliable for children with complicated appendicitis not suitable for conventional laparoscopic technique. vata was successfully accomplished with obvious advantages, and avoided conversion to the open fashion. background: appendicectomy remains the most frequent emergency operation. the management of these patients varies between surgeons and hospitals. at our centre, it was a routine to review post operative children at months. aims: is to evaluate the need for a routine follow up in children who had appendicectomy. methods: it is a retrospective observational study for consecutive patients between and . a parallel questionnaire was sent to the parents of all the children. results: the average age was . years. % of the patients were found to have normal appendices. % of the patients were discharged within days. % of the patient had intravenous antibiotics for day and % were discharged with oral antibiotics. % had a routine follow up appointment in months time. in % of cases there was no change in the management. on the questionnaire % of the parents thought they were given enough information regarding the procedure. in terms of routine follow ups, % of the parents found it very useful while % found it a little or not useful. conclusion: this study shows that there is no change of the management or a clinical need for the routine follow up. however the patients and their families like to keep a follow up appointment. it is more convenient for the patients and their family to arrange other sorts of follow up like a phone call conversation or a general practitioner follow up. yavuz savaş koca, mustafa ugur, celal Ç erçi, recep Ç etin department of general surgery, sü leyman demirel university, isparta,turkey the aim of this study was to evaluate the disease profile and mortality ratio of patients presenting with acute abdomen. four hundred fifty eight patients who underwent surgery with the diagnosis of acute abdomen were analyzed retrospectively. the effects of age, sex, american society of anesthesiology (asa) class, accompany disease, admission time after the onset of the symptoms, follow up interval before the operation on mortality and length of hospital stay were evaluated. male/female ratio was . , and mean age was . . main causes were biliary system disease ( . %), intestinal obstruction ( . %), peptic ulcer perforation ( %) and acute appendicitis ( . %). median asa class was and . % of the patients had at least one preexisting disease. mortality ratio was . %. asa class, age, preexisting diseases other than malignity, period between the onset of symptoms and admission, follow-up time was significantly efective on mortality. reliability of ultrasonography for diagnosing acute appendicitis aylin hande gö kçe , acar aren , feridun suat gö kçe , hakan Ö zkan , alper dursun Ş agban , _ ibrahim aydın , gü rhan Ç elik , gü rol kö roglu s.b. _ istanbul eg itim ve araş tırma hastanesi, istanbul, turkey balıklı rum hastanesi, istanbul, turkey purpose: abdominal ultrasonography is the most commonly used diagnostic tool for diagnosing acute appendicitis,which is one of the most common causes of acute surgical abdomen. _ in this study, we examined the reliability of ultrasonography for diagnosing acute appendicitis. in this prospective study we performed abdominal ultrasonography on patients admitted to our surgical emergency department and diagnosed as acute surgical abdomen according to the physical examination and laboratory findings during . these patients were surgically treated by appendectomy and the materials were pathologically examined. results: patients were admitted to this study. of these patients ( . %) were diagnosed as acute appendicitis, and ( . %) of them diagnosed differently. ( . %) of patients diagnosed as acute appendicitis on ultrasonography examinations were reported as acute appendicitis on histopatological examination. ( . %) of patients diagnosed differently on ultrasonography examination were reported as acute appendicitis on histopathological examination. conclusion: the sensivity of abdominal ultrasonography for diagnosing acute appendicitis is high ( %), but the specificity is low (p = . ). we calculated that the specificity is . , positive predictive value is . , negative predictive value . , accuracy is . . abdominal ultrasonography is a helpful diagnostic tool for diagnosing acute appendicitis.however, it should not be seen superior to anamnesis and physical examination findings. poisoning: a case report background: mushroom poisoning is an important clinical problem which may cause serious complications and death. acute pancreatitis is a rare complication of mushroom poisoning. in this study, we presented a case that developed liver damage and acute pancreatitis following wild mushroom ingestion. case: sixty-six years old women admitted to emergency department with complaints of nausea, vomiting and abdominal pain. it was learned that patient was ingested wild mushroom before h of admittance and her complaints were started after - h of ingestion. in initial examination, general appearance and vital signs of patients were normal and there was epigastric discomfort. laboratory findings were leukocyte , /ll ( . - . ), aspartate aminotransferase u/l ( - ), alanine aminotransferase u/l ( - ), amylase u/l ( - ), lipase , u/l ( - ) on admission. liver and pancreas was determined as normal in abdomen ultrasonographic examination. computerized tomography of the abdomen showed minimal peripancreatic fluid. the patient was observed in emergency intensive care unit and symptomatic therapy was performed. hepatic transaminases and pancreatic enzymes were decreased progressively during the observation. the patient was discharged from the hospital after days clinical course, without complication. conclusion: mushroom poisoning and acute pancreatitis have similar gastrointestinal symptoms and sings. therefore, possibility of acute pancreatitis as well as other organ dysfunctions should be investi-gated in patients with mushroom poisoning. early recognition and appropriate therapy for acute pancreatitis and mushroom poisoning may lead to an improved prognosis and complications. mehmet mustafa altıntaş , , ayhan Ç evik , , yekin Ö zcabı , , gü lay dalkılıç , , hü seyin ekinci , , nejdet bildik , dr. lü tfi kırdar kartal education and training hospital, istanbul, turkey general surgery clinic, istanbul, turkey diagnostic emergency laparoscopy is very helpful in diagnosing acute abdomen and evaluating abdominal trauma. parallel to developments in laparoscopic techniques, its emergency applications are increasing. we reviewed our diagnostic emergency laparoscopy procedures applied to patients with acute abdomen and could not be diagnosed after h of follow-up. we applied diagnostic emergency laparoscopy to patients in dr. lü tfi kırdar kartal education and training hospital during - . in patients laparoscopy indication was undiagnosed acute abdomen. there were four acute appendicitis, two peptic ulcus perforation, two small bowel necrosis, one perforated hepatic hydatid cysts, one iatrogenic urinary bladder perforation, one postlaparoscopic cholecystectomy bile fistula and non-surgical adnexial pathologies. diagnostic emergency laparoscopy was performed in five patients with penetrating abdominal injury. there were small bowel injury in two patients, colonic injury in two patients and no injury in one patient. diagnostic emergency laparoscopy was performed in four patients with blunt abdominal injury. there were grade splenic laceration in two patients, grade liver injury in one patients and intraabdominal bleeding in one patient. in conclusion, diagnostic emergency laparoscopy is a suitable technique in undiagnosed acute abdomen patients which could not be diagnosed after physical examination, laboratory, radiology and follow-up and helps surgeon to diagnose the disease. also diagnostic emergency laparoscopy performed by experienced surgeons prevents negative laparotomy especially in abdominal trauma patients. mehmet ali yagcı, atakan sezer, ahmet rahmi hatipoglu, irfan coskun, zeki hoscoskun, aydın altan department of general surgery, trakya university school of medicine, edirne, turkey introduction: appendectomy is known as the most common nonobstetrical operative procedure in pregnant women with an estimated frequency of / , of all pregnancies.pregnancy continues to obscure the accurate diagnosis of acute appendicitis due to gestational physiological changes.diagnostic delay increases the incidence of perforation, hence increasing maternal and fetal morbidity and mortality. patients and results: four patients of appendicitis during pregnancy were concluded in study between to may ( table ). the mean age was (range - ). three patients presented during three trimester and one in first trimester.the mean time interval of symptoms to the admission is h (range - ).abdominal pain, vomiting, and nausea are the most common complaints.rebound was the main sign observed in all patients.fever was noted in two patients. mean value of wbc count was , per l (range , - , ). ultrasonographic examination was performed to all patients with the diagnosis of acute appendicitis.three patients were operated under general anesthesia and one under regional anesthesia. paramedian incision was applied to three patients and mcburney to the other one. the exploration findings were two perforated, one phlegmonous appendicitis and a normal appendix. no maternal or fetal mortality occured. cesarean section was performed on -week pregnancy during appendectomy due to early onset contractions. adhesiolysis was performed in same case because of postoperative ileus. conclusion: the accurate diagnosis of appendicitis during pregnancy requires a high level of suspicion and clinical skills. delay of operation correlates to more inflammatory changes in the appendix and to higher maternal and fetal complication rates. early laparotomy with appropriate preoperative diagnosis will reduce the fetal and maternal morbidity and mortality. introduction: paraesophageal hernias occur most commonly in elderly and account for % in all hiatal hernias [ ] . although the fundus or corpus of the stomach are most commonly the contents of a paraesophageal hernia, we reported a case in which the gastric fundus and corpus incarcerated in the paraesophageal space, followed by perforation. case: -year-old woman admitted to state hospital following sudden onset of abdominal pain.previously she was diagnosed as esophageal hiatal hernia. on physical examination, abdominal distension with mild tenderness was recognized. pulse rate and blood pressure were per min and / mmhg. the initial laboratory investigations revealed wbc , per ml, urea mg/ dl, creatinine . mg/dl. chest graphy revealed unusual gas shadow in the left thorax (fig. ) . ct demonstrated intraperitoneal free air, ascites, and the prolapsed stomach in the left thorax (fig. ). an urgent laparotomy was performed revealing dirty ascites.the gastric fundus and corpus were incarcerated in paraesophageal space (fig. ) . a perforation mm in size was recognized in the fundus. the perforation was sutured primary and cruroraphy was performed. the patient required respiratory support and died on the th postoperative day due to multiple organ failure and septic shock. conclusion: the contents of paraesophageal hernia commonly include the gastric fundus or corpus. paraesophageal hernias can cause lethal complications, including gastric obstruction, strangulation, perforation, and hemorrhage. paraesophageal hernias can usually be repaired easily, even using the most recent laparoscopic technique ( ). thus, because of the very serious potential complications inherent in cases such as ours that can result from an untreated paraesophageal hernia, we recommend that elective repair be carried out, even in asymptomatic patients. introduction and objectives: the solitary fibrous tumor (sft) of peritoneum, especially arising in lesser omentum is extremely rare. we report a case of lesser omentum soliter fibrous tumor, causing pain and abdominal fullness with its mass effect. case: a -year-old male was admitted to our hospital, due to an intraabdominal mass lesion, epigastric pain, abdominal fullness and vomiting episodes. on physical examination, a hard, non-tender mass was palpated in the epigastric region. computed tomography (ct) showed, an approximate . · . · . cm sized solid mass with fibrous capsula between left liver lobe and stomach. at laparotomy, a yellowish brown solid tumor with hard consistency was found on the lesser omentum. the tumor was not adhered to the adjacent structures and could be resected completely. postoperative course was uneventful and no recurrence was determined during follow up. results: histopathologic examination diagnosed the mass as a sft. the tumoral cells were spindle-shaped and did not present mitotic activity or atipies and showed very low proliferation index with ki (< %) and immunohistochemical positivity for cd and negativity for c-kit (cd ), actin, and s- . conclusion: although sft are rare, especially in the abdomen of adults, are generally benign but malignant cases have been reported. in our case, the tumor has a benign character shows neither mitotic activity nor nuclear atypical. this is the third case of soliter fibrous tumor of the lesser omentum described in the english literature. introduction and aims: a single hamartomatous adenoma of stomach is rare. gastric hamartomatous polyps are usually multiple, familial and assosciated with other syndromes. they are also associated with chronic helicobacter pylori infection, acid hypersecretion and predisposition to gastric cancer. this is the first case of gastric hamartoma which is coexistent with duodenal ulcer perforation. case: a -year old male admitted to our hospital with complaints of stomach ache, nausea and vomitting. because there was free air under right subdiaphragmatic surface on chest x-ray, an emergency operation was performed. there was a perforated ulcer on the first part of duodenum and a large quantity of bile mixed with blood in the abdominal cavity. on further exploration a tumoral mass which was about cm in diameter was found on the stomach corpus. because of possibility of malignancy, a subtotal gastrectomy including the perforation zone was performed. histologically the tumor was well circumscribed and it consisted of uniform, clear cells. at first, it was thought to be metastatic lesion from kidneys or other organs. in this context, all body was scanned however no pathology has been identified. later on, the tumor was approved to be hamartomatous adenoma and helicobacter pylori was positive. postoperative course was entirely uneventful. objectıve: the aim of this work is to determine the level of apoptosis, which is believed to hold an important role in septicemia process that affects mortality and morbidity in obstructive jaundice, in lingers of rats that were experimentally subjected to obstructive jaundice. materials and methods: the experimentals were separated into two goups of eight. choledoch was isolated in each group and while surgery was ended at this level in the control group, choledoch was tied with - silk from two different places and cut between ligatures full fold. experiment animals were operated for the second time in the postoperative seventh day for liver sampling and sacrificationaimed histological analysis through the old incision with anaesthesia provided. to exhibit the p expression immunohistochemically, anti-p clone do- was used as the primer antibody and hrp as the secondary antibody. samples taken for the determination of apoptosis were painted by the tunel method. fındıngs: in the evaluation of apoptotic cells in liver cells, apoptotic cells were observed to widely exist in the liver tissue and it was determined that they exhibited dense accumulation in some regions. in the immunohistochemical evaluation made for evaluation of p expression in hepatocytes, p -positive hepatocytes were determined to exist quite widely in the tissue samples taken from the livers of rats in the experiment group. result: consequently, in this study we determined that in the obstructive jaundice group, both apoptotic index and, as a result of the immunohistochemical studies, p expression increases in the liver. introduction: the risk of leakage from an anastomosis is higher in large intestine. in emergent colon operations primary anastomosis is avoided especially on the left colon, and multi-step procedures are preferred if there is a dirty abdomen. the aim of this experimental study was to compare different suture materials in left colonic anastomosis in presence of peritonitis. metods: this study was conducted on wistar-albino rats by dividing them in groups of equal numbers. after median laparotomy, the whole layer of left colon was cut cm over the pelvic peritoneum and fecal contamination was performed. one day later, the abdomen was opened again under general anesthesia. the abdomen was washed with sf before starting colonic anastomosis. for colonic anastomosis; vicryl + silk was used in the st group rats, pds was used in the nd group rats, and coated vicryl plus antibacterial suture and silk was used in the rd group rats. results: tissue hydroksiproline, anastomosis bursting pressures and histopathologic findings on the anastomosis line were evaluated on the th postoperative day. the highest anastomosis bursting pressure was found in group iii (p < . ). the highest tissue hydroksiproline level was found in group iii (p < . group i-iii, group ii-iii). when histopathologic findings were evaluated by comparing three groups, the healing of the intestine tissue score was found to be highest in group iii (p < . , groups i-iii). conclusion: consequently, it was observed that using antibacterial suture increased resection safety in the presence of peritonitis and anastomosis safety in primary anastomosis. introduction and objectives: the chance of finding the vermiform appendix within an inguinal hernia occurs in approximately one percent of the cases, and is known as amyand's hernia. appendicitis within an inguinal hernial sac is rare. materials and methods: we present two amyand's hernia cases: one with a vermiform appendix and one with a perforated appendicitis. case : an -years-old man presented with a years history of bilateral inguinal mass. ultrasound examination described a hernia which contains mobile bowel segments inside, on the right side. the appendix was obsereved edematous and hyperemic in the hernial sac. an appendicectomy was done. further exploration of the bowels revealed a meckel diverticulitis which was managed by a wedge resection. case : a -years-old woman presented with one week history of an inguinal mass, pain and anorexia. abdominal computerized tomography demonstrated an incarcerated right-sided inguinal hernia.the hernia sac was filled with the perforated appendix. appendicectomy was carried out. results: postoperative recovery was uncomplicated, the patients were discharged without any complication. discussion: acute appendicitis or perforation of the appendix within the hernia sac simulates perforation of the intestine, and does not have specific symptoms or signs. preoperative clinical diagnosis is very difficult and the diagnosis is made intraoperatively. since the absence of any pathognomonic radiological features, the value of preoperative computed tomography is limited. treatment of hernial appendicitis is an appendicectomy with suture hernial repair. the management of a non-inflamed appendix is debatable. the usual practice covers reduction of the appendix, and mesh repair. in the immediate post-operative period the patient had a high output jejunostomy and was dependent on total parenteral nutritional support. a bishop-koop procedure was performed on day and by day , the patient was completely independent of any adjuvant nutritional therapy. five months from primary surgery colostomy was closed. introduction and objectives: the management of pancreatic pseudocysts which occur after blunt abdominal trauma in children is still controversial. in this study, we present our experience therapeutic approach of pancreatic pseudocysts that occur after trauma. methods: we evaluated patients with traumatic pancreatic pseudocysts who admitted to our clinic between and . we performed ultrasonography, computerize tomography (ct) and blood amylase level for all patients. results: there were eight males and one female. the average age was . years (range - years). the mechanism of injury was bicycle handle bar injury in four, falls in three, assault in one and motor vehicle accident in one patient. abdominal pain was the most common symptom. the median size of cysts was . cm (range - cm). the time interval between trauma and pancreatic pseudocysts was days (range - days). of the nine patients, four ( . %) occurred in less than weeks. all patients were initially followed up conservatively. three patients ( %) were successfully treated conservatively, while patients ( %) required intervention either by percutaneous radiological drainage ( ), cystogastrostomy ( ) and external drainage with laparotomy ( ). complication developed in two patients (septic shock, persistent hyperamylasemia). no patient died. conclusion: traumatic pancreatic pseudocysts may occur short after traumatic injury in children. all patients with traumatic pancreatic pseudocysts should be managed by conservative approach initially. however, if the cyst is cause of gastric outlet obstruction or the size of cyst is bigger than cm, interventional management may be required. introduction: splenic abscess is a rare entity,with a frequency of . - . % in autopsy series.mortality rate is still high, up to %, and can potentially reach % among patients who do not receive antibiotic treatment. case : year-old woman presented with fever and left upper abdominal pain for days. hepatomegaly and tender splenomegaly were present.ct of the abdomen revealed · cm hypoechoic lesion in the spleen (fig. ) . initial laparoscopic approach was performed but failed due to inappropriate anatomy. conventional splenectomy was done and at exploration there was · cm abscess in spleen. the patient was dischared on the eighth day of operation. case : yearold woman admitted with femoral artery thrombosis.thromboembolectomy and leg amputation was performed by cardiovascular surgeons.she was consultated with fever and left upper abdominal pain on the second day of operation. ct of the abdomen revealed a · cm mass with air fluid levels in the spleen (fig. ) . splenectomy was performed and a · cm abscess was observed in spleen.the patient died on the second day of operation due to sepsis. a proximal stoma after resection of the perforated small bowel and colon, closure of the distal stump in case of severe generalized peritonitis without the possibility to perform a primary anastomosis. a loop ileostomy to prevent bacterial translocation in case of pancreatitis. retrospective analysis of clinical data of patients admitted between and for emergency operation requiring laparotomy and the construction of one or more small-bowel stomas. patients had ileostomies created for temporary fecal diversion after emergency surgery including bowel obstruction was the most frequent cause of peritonitis ( cases),followed by anastomotic leakage and peritonitis ( ), acute mesenteric infarction ( cases), intestinal perforation ( cases), strangulated incisional hernia ( cases), acute abdomen of crohn disease ( cases), peritonitis carcinomatosa and frosen pelvis ( cases), mean age was . years (range - ), being males and females. overall mortality was % ( patients). patients died on the first days postoperatively. indications, morbidity, mortality and problems involving the ileostomies in emergency abdominal surgery urgency are herein discussed. in the majority of patients with acute abdomen doing ileostomies,lacking of vital capacity of bowel wall as well as insufficiency of previously laid sutures were revealed, which forced a surgeon to resort to resection; in such cases the method of choice for decompression should be the application of ileostomy. postoperative jaundice is often multifactorial. a precipitating or causative factor may be identified but seldom can a specific therapy be offered. the late complications were mainly presented by the biliary ducts cicatricial stricture, the jaundice and cholangitis recurrency. in this report, we described an extremely rare case of a -year-old woman presenting with pain in the right upper quadrant, jaundice, and weight loss in whom a whipple procedure was performed. usg and mr cholangiography showed that dilatation of intrahepatic and extrahepatic bile ducts and hepaticojejunostomy line. mrcp also showed that, there was a closed jejunal loop related with hepaticojejunostomy. obstruction by local tumor recurrence and infiltration of the efferent jejunal conduit between the proximal hepaticojejunostomy and the duodenojejunostomy led to closed loop syndrome and jaundice. frozen sections by direct incisional biopsy revealed a recurrent tumor invasion. a previously unreported late complication after whipple resection of the head of the pancreas was recognized as ''closed efferent loop syndrome'' mimicking obstructive jaundice. the case was accepted as inoperable because of tumor invasion to the jejunum, transverse colon, and surrounding tissue. roux-en y type jejunojejunostomy was performed. the patient had an uneventful postoperative course. introduction: the form of mechanical asphyxia where respiration is prevented by the external pressure on the body: a large weight compressing the chest or abdomen, wedging of the body within a narrow space death in large crowds is traumatic asphyxia. case: a -year-old man was found compressed by a motorboat in the garage while he was working for installation of the boat. the face, neck and upper part of the chest were congested and many petechiae were observed on the conjunctivae. ecchymotic bruises were observed on the right cervical, lower chest, upper abdominal regions and open fracture of the right humerus, ecchymotic abrasion on right anterior superior iliac spine line were detected. subcutaneous haemorrhages in the chest wall and bleeding without subcutaneous haemorrhage in the inferior part of the right sternocleidomastoid region were observed during the internal examination. fractures of the right third and fifth ribs which were accompanied by bleeding in the surrounding soft tissues and muscles, and ecchymoses over the right sixth rib without any fracture were also observed. macroscopic examination of the lungs revealed congestion, subpleural superficial bleeding areas and histopathological examination showed hemorrhagic alveolar oedema. all the internal organs and big vessels were intact. there was no hemorrhage in the thoracal and abdominal cavity. toxicological analysis was negative. conclusions: in the presented case, the impact cause of the chest compression was distinctly determined by the autopsy and criminal investigation. death was reported as asphyxia by the thorax compression without other lethal factors. purpose: the purpose of this prospective study was to evaluate safety of early surgical interventions in the repairment of animal bites with tissue injuries. materials and methods: tissue repairment and/or reconstruction were done, total in patients. of them were dogs', of them were horses' or donkeys' biting between the years - . wound sterilization and debridement were made before repairment. rabies and tetanus prophylaxis were done for all patients. tissue repairments after animal biting were made early and promptly. patients having animal injuries, apart from biting were not included in the study. results: of the patients were male and of them were female. the minimum age of the patient was . and the maximum was , and the average age was . in cases head-neck, in eight cases extremities and in two cases body were biting areas. horses' or donkeys' bitings were seen particulary in ears. in these animals' biting tissue lose was emphased. we prefered primary saturation in cases, skin greft in ten cases and repairment with flap in five cases. finger amputation was required in one of the patients. total ear reconstruction was done gradually in a patient. no infections observed in patients after the surgical interventions. conclusion: we concluded that, early tissue repairments may done after wound sterilization and debridement, safely. treatment plan. multidetector computed tomography (mdct) imaging is an improving and being a widely used method recently in many areas of medicine. it is possible to evaluate the peripheric vascular structures, anatomic variations or vascular pathologies with mdct angiography (mdcta). methods: the arcuate foramen is an anatomical variant of the atlas vertebra: anterior and posterior osseous bridges or ponticles can arch over the vertebral artery, to a greater or lesser degree, transforming the arterial groove into a canal. dissection of the vertebral artery leading to thrombotic occlusion or ischaemia from narrowing of the arterial lumen has been described in trauma. there are fistula between a dural branch of the spinal ramus of a radicular artery and an intradural medullary vein in spinal vascular malformations. mdct angiography is feasible and is an alternative technique in diagnosis spinal vaskü ler malformations. the craniovertebral junction (cvj) is a funnel-shaped structure comprised of the clivus and foramen magnum and the upper two cervical vertebrae. the most frequent neoplastic lesions of the craniovertebral junction are meningiomas, neurinomas, chordomas, paragangliomas, epidermoids, dermoids and chondrosarcomas. conclusion: in this presentation, pathologies seen in craniocervical junction (congenital variation, trauma, vascular malformation and tumor) were discussed with figures and compared with the literature. introduction and objectıves:small bowel obstruction (sbo) is very rare. although the diagnosis is straightforward, some patients with intermittant and low-degree symptoms could be misdiagnosed as psychiatric disease. we presented here a patient with intermittant symptoms of ileus treated as psychiatric disease case: a year old male patient was referred from phsyiciatry clinic to our department with complaints of weight loss, nausea and malnutrition. his medical history revealed a laparoscopic appendectomy months ago. he emphasized that his complaints started shortly after the operation and increasingly got worse. he was admitted to hospital days after operation with symptoms of ileus and managed conservatively. the intermittant abdominal pain and nausea continued. since the pain was intensified after meals, patient refused eating. during the period of months he lost kg of weight. after numerous radiological and endoscopic investigations patient was referred to psychiatry due to persistent anorexia. after short psychiatric medication, he was referred to our surgical unit. multislice abdominal computerized tomography and and enteroclysis of small bowel clearly demonstrated an obstruction in the jejunal segment of the intestine. at laparotomy, small bowel obstruction was detected and segmental resection was performed. postoperative period was uneventful and patient was discharged from hospital on postoperative day . conclusions: the diagnosis of anorexia and nausea due to sbo is relatively difficult. the patients were sometimes misdiagndosed as having psychiatric disease. before starting psychiatric medication, they must be reevaluated for all putative causes of sbo. introduction: endoscopically placed biliary stents are a well-established procedure for the treatment of benign and malignant biliary disease. duodenal perforation may occur at the time of insertion of a biliary endoprosthesis or following endoscopic manipulation of such a stent. methods: we report a case of duodenal perforation complicating stenting for biliary fistula in surgery for hepatic hydatid cyst. case: a -year-old man was admitted to a local hospital following the sudden onset of abdominal pain,distension with nausea and vomiting. he developed a biliary fistula after surgery for hepatic hydatid cyst months ago. endoscopically placed biliary stent was performed for the treatment of biliary fistula at the same hospital months ago.on examination, marked abdominal distension with mild tenderness was recognized. his pulse rate and blood pressure were /min and / mmhg, respectively. abdominal x-ray showed two foreign body images and subdiaphragmatic free air. emergency laparotomy revealed dirty ascites and perforation of the third portion of the duodenum by the plastic stents. the second stent was found at pericecal area. after extraction the plastic stents and irrigation with isotonic sodium chloride solution, the site of perforation in the duodenum was primary reparing and triple tube placement performed. conclusion: endoscopic retrograde cholangiopancreatography (ercp) is considered to be the most difficult endoscopic procedure in gastrointestinal endoscopy, and is associated with potentially severe and sometimes life-threatening complications such as duodenal perforation. surgical statistics indicate the importance of early diagnosis and treatment for duodenal perforation. introduction and objectives: ticks play an important role in transmitting several infectious agents, such as viruses, bacteria, spirochetes, rickettsia, and parasites. in this study, we analysed the demographic and clinic characteristics of the patients who admitted to emergency service due to tick bite. methods: in this study, patients were selected from cases of tick bite admitted to the department of emergency medicine of ankara numune hospital during the - periods. detailed histories and some blood tests of patients were taken, and the body of the tick grasped gently avoiding to inject more salivary toxins. results: totally patients admitted to hospital in this period. the most frequent symptoms at administration were malaise, myalgia, and fatigue. hemorrhagic manifestations were observed in patients and bleeding was from multiple sites in patients. other symptoms were watery diarrhoea, skin eruption, macular rash, and petechia-ecchymosis. in the comparison of the clinical features and laboratory results of the surviving and the patients who died, we found that the rates of fever during hospitalization, confusion, neck stiffness, bleeding from multiple sites and presence of petechia/ecchymosis were higher in the patients who died than in the surviving ones. additionally, the mean values of alt, ast, lhd, ck, ptt, international normalized ratio (inr), and urea were also higher and mean plt counts were lower in the patients who died. conclusion: the acute tick-bite reactions show special histologic features, which are unquestionably related to the particular morphology and physiology of the mouthparts of these arthropods. results: totally patients ( men and women) were evaluated. the mean age was . ( - ) years and the mean follow up period was ( - ) months. the localization of the hernias were as follows: inguinal hernias, seven femoral hernias, two umblical hernias, two paraumblical hernias, one epigastric hernia and one inguinal + femoral hernia. all of these strangulated hernias were treated with prosthetic graft repairing. in addition to these hernia repairs, in the same operation sessions three hydrocele repairs, three omentum resections, two partial small intestine resection and anastomosis, one lymphadenectomy, one orchiectomy and one laparotomy were done when necessary. in the early post operative period four patients died because of other diseases not related with the surgical procedures or hernia itself. wound infections were observed in three patients and they were treated with antibiotics and anti inflammatory drugs. we report a rare case of ileal perforation caused by an ingested cm long fork. a -year-old man presented to the emergency department with exhaustion, weight loss and abdominal pain. he had been having pain in the abdomen, nausea and vomiting for the previous days. the patient had received psychiatric treatment, and started to experience weight loss and exhaustion - months previously. no conclusions could be drawn from physical examination for abdominal tenderness and defence. direct x-ray showed an appearance conforming to a fork in the intestine and subdiaphragmatic free gas. the patient was sent for emergency surgery, with a diagnosis of ileal perforation and foreign-body ingestion. most of the ingested foreign bodies that reach the stomach pass through the alimentary tract without complication. perforation occurs in, % of all cases of foreign-body ingestion, usually in the oesophagus. other sites where perforation can occur are the pylorus, the duodenum, the duodenojejunal flexure, the ileocaecal region and any site of congenital anomalies. long, thin or sharp objects, as seen in our case causing ileal perforation. foreign-body ingestion is a possibility to be borne in mind at presentations to the emergency department, especially those with symptoms described in psychiatric cases. appendicectomy is a common emergency operation, its major complications are uncommon. most complications of appendicectomy occur in the early postoperative period and easy amenable to treatment with conservative medical therapy. appendicitis, usually a benign disease, can have its prognosis worsened in case of postoperative fistula. the latter occurs rarely after open appendicectomy but accounts for % of the morbidity rate. schloffer tumor (inflamatory granuloma or abscess in the abdominal wall at the operative scar) is rare complication that usually develop months to years postoperatively and late postoperative enterocutaneous fistula has been described in literature as a rare complication of acute appendicitis. we describe one such case where the patient presented with a tender mass under the incision site six months later after appendicectomy. findings of computed tomography were demonstrated thickening in the abdominal wall and abdominal wall abscess like schloffer tumor. abscess was drained. there were not produced any microorganisms in the wound culture. after conservative therapy healing was completed in a short period. one year later, the patient was admitted with complaints. on the examination, passage of undigested food particles through a sore in the appendicectomy incision site. computed tomography were demonstrated fistula tract extending from appendicectomy site to skin. enterocutanous fistula was occured at the appendicectomy incision year later after operation and successfully treated with en-block fistulectomy and right hemicolectomy. postoperative course was uneventfull. patient discharged from hospital at seventh day after operation. objective: vascular insufficiency may lead to hypoxic injury in intestines. the lesions in the colon are called ischemic colitis. mesenteric ischemia is more prevalent in patients getting hemodialysis. in this study we report hemodialysis patients admitted to the emergency department because of acute abdominal symptoms. case year old woman was chronic hemodialysis patient admitted to the emergency room with acute onset abdominal pain.the initial diagnosis was acute appendicitis and she underwent laparotomy. peroperatively isolated cecum necrosis was seen. right hemicolectomy and ileotransversostomy was performed. she died days after surgery because of sepsis. case year old man was chronic hemodialsysis patient admitted to the er because of abdominal pain persisting for h. with an initial diagnosis of acute abdomen a median incision was performed. peropertively widespread peritoneal adherences and isolated cecum necrosis were seen. cecum was resected and side to end ileocolostomy was performed.he died days after his first operation. case year old man was chronic hemodialysis patient admitted to the er with pain localizing to right inferior abdomen. with an initial diagnosis of acute appendicitis laporotomy through a mc burney incision was performed. there was · cm cecum necrosis. cecum resection and end colostomy and ileostomy was performed. the patient was discharged days after the operation without any problem. discussion: ischemic necrosis of cecum is a rare variant of ischemic colitis. in hemodialysis patients requiring colon resection due to ischemic colitis, primary anastamosis should be avoided, diversion stomies should be preferred. agitation is a non-specific constellation of comparatively unrelated behaviours that possess a risk to the safety of the patient or caregiver, impedes the process of care giving or impairs a person's function. the management of agitated trauma patient contains hospital, prehospital, in emergency department and inside of the hospital transports. the reasons of the agitation hypoxia, hypoglycemia, hypovolemia, pain, traumatic brain injury, anxiety disorder, drug and alcohol abuse, psychiatric disorders. pain management has had a limited role in the management of trauma patients, primarily because of the concern that side effects (decreased ventilatory drive and vasodilatation) of narcotics may aggravate preexisting hypoxia and hypotension. health professionals should monitor pulse oxymetry and serial vital signs if any narcotics are administered to a trauma patient. small doses of benzodiazapine sedatives should be titrated cautiously because of the potential side effects of hypotension and ventilatory depression. to control agitated patients with traumatic brain injury include haloperidol, midazolam, and propofol. in the emergency setting, they are most often indicated to control agitated or psychotic behavior that constitutes an imminent danger to the patient or others. to control agitated patients should be a part of the trauma management. we present a protocol for trauma team. there were males ( . %) and females ( . ). eighty percent of the patients were between and years of age. the overall mortality was . % ( patients). eighty percent of deaths occured in comatose patients (p < . ). comatose state, precence of focal motor signs, respiratory irregularities and hypertansion-bradycardia, pupillary changes were determined as the bad prognostic factors. a midline shift greater than mm, hematoma volume greater than ml, accompanying intracerebral and extracranial traumatic pathologies significantly increased the mortality rate. there was no significant statistical correlation between the outcome and the age, sex of the patient, trauma-to-operation interval, thickness, localization and origin of edh and aetiology. results: the primary factor on outcome is glasgow coma scale scores of the patients at the time of surgery. therefore early surgery is crucial in the management of edh which is a dynamic process. introduction: in this study, we have evaluated the incidence and clinical characteristics of the patients for traumatic brain injury (tbi)-associated coagulopathy after tbi retrospectively. methods: retrospective study of all patients admitted to the trauma and emergency surgery intensive care unit (icu) from january through december with tbi. criteria for tbi-coagulopathy (tbi-c) included a clinical condition consistent with coagulopathy in conjunction with a platelet count < , mm and/or international normalized ratio (inr) > . and/or activated partial thromboplastin time (aptt) > s and/or prothrombin time (pt) > . s. the following potential risk factors were included to identify independent risk factors for tbi-c and its association with mortality, age, mechanism of injury (blunt (b) or penetrating (p)), glasgow coma scale (gcs), injury severity scale (iss), presence of polytrauma, icu length of stay (icu-los). results: a total of patients met study criteria. tbi-c occured in . % (n: ) of all patients (b: . %, p: . %). in patients with tbi-c, mean age was . ± . years. the averages of gcs was . ± . , iss was . ± . , icu-los was . ± . days, polytrauma was considered . % (n: ) and the overall mortality was . %(n: ) in patients with tbi-c. conclusions: in our study, tbi-c occured more frequently among patients sustaining blunt versus penetrating injuries. to our knowledge, tbi patients are at considerable risk of developing coagulopathy and anesthesiologists should be aware of this life-threatening syndrome, especially in tbi patients with blunt injuries. erythropoietin (epo), glycoprotein hormone, is a mainly produced by the kidney that stimulates proliferation, growth and differentiation of erythroid precursors in the bone marrow. recently, anti-inflammatory, neuroprotective, antiapopitotic, angiogenic and vasodilatator effects of epo have been also determinated. the purpose of this study was to investigate the effects of rhuepo in reducing the severity of experimental spinal cord injury (sci). ninety adult sprague-dowley rats weighted g (± ) were used for the study. through a dorsal incision, t - laminectomies performed in prone position and clip compression had made for ischemic injury as tator method. the rats divided in three groups. systemic l ( , u/kg) rhuepo had given h before the trauma in the first group, min. later after the injury in the second group and the third was the control group. the rats were killed with high dose intraperitoneal ketamin h later after the injury. the histological examination of injured spinal cord specimens for the potential neuroprotective effects of rhuepo was done. further more the axial spine sections stained with ttc (triphenyl tetrazolium chloride). the ischemic areas were evaluated with a imaging calculation program. we use wet-dry method for determination of ischemic tissue edema. we concluded that administrating a single dose rhuepo ( , u/ kg) has potential neuroprotective effect on experimental spine injury by reducing severity of inflammation and tissue edema in the secondary ischemic area. it has known both early surgery and high dose steroid treatment prevents the neurological function and viability caused of the traumatic secondary spine injury. we present surgically treated a traumatic rotation-compression spinal cord injury caused by a motor vehicle accident. the patient referred to our clinic h after the injury. at the time of admission, he had a localized pain at the thoracic - vertebrae level, loss motor and sensorial function under the level t classified as asia grade a. he was incontinent. in the radiological evaluation we found loss of height at the thoracic th and th vertebrae body, serious spinal column injury include t - burst fracture, laminas and facet joints fractures with three colon damage (denis f). we detected the spinal instability criteria in . we did not see penetrating injury or primary spinal cord injury signs but spinal canal tightness for percent in ct and mri scans. we took the patient to surgery in unusual classical surgery timing. first, decompressing surgery applied to the t - laminas and posterior stabilization with transpedicular screw-rot system. one day after the first operation, t and t corpectomy applied for anterior stabilization with cage-screw system. mega dose steroid had given also before the first surgery. postoperatively early neurological evaluation, he had asia grade c, after second month asia grade d without incontinence. in our opinion the decompressing surgery that applied in h in the patients without complete primary spine injury, has a positive neurological feedback. introduction: it is a rare occurrence with the rate of % in the subjects with spinal infestation cyst hydatic echinococcus granulosus. intradural hydatic cyst is relatively rare when compared with other spinal hydatic cysts. we are presenting here a -year-old female case who applied to emergency service with backache and paralysed legs and was diagnosed with spinal intradural extramedullary hydatic cyst. case: a -year-old female patient applied to emergency service with complaints of a backache started two days ago, paralyses in both legs and being unable to walk. in her neurological examination, a complete motor power loss in the lower extremities and bilateral sensation loss compatible with t dermatoma were detected. in the torako-lomber spinal magnetic resonance imaging (mri), multiple cystic characterized nodular lesions having peripheral contrast with regular contour including right neural foramen and paravertebral zone at the level of t -t and l in the intradural distance were determined. the patient was diagnosed with common spinal intradural extramedullary hydatic cyst exhibiting bone involvement. as the lesion was very broad had paraplegia, we did not consider operation. conclusions: hydatic cyst infestation is a benign disease. if it is not diagnosed early and treated when it involves in some systems rarely as it did in this study, the results can be serious. diagnosis should be confirmed quickly with increasingly common advanced radiological diagnosis methods. the aim in these cases is to eradicate the cysts surgically, however, chemo-therapy and percutaneous drain methods have become more significant recently. introductıon: several guidelines advocate multiple chest radiographs during primary resuscitation of trauma patients. several local hospital protocols include a repeat radiograph before leaving the trauma resuscitation room (tr). the purpose of this study was to determine the value of routine repeat radiograph. methods: one year data of all radiological imaging in our tr were prospectively collected for all patients presented to the tr of the hospital. we counted and assessed the radiographs and classified our findings as either 'new injury detected', 'presence of intervention equipment', or 'deterioration of previously detected injury'. results: in total, patients were included. more than % had two radiographs. eight ( . %) new injuries without clinical relevance were found on the repeat radiograph after an initial normal radiograph. in total patients ( %), had a repeat radiograph to verify the effect of an intervention or position of equipment. in patients ( %) with two abnormal radiographs, newly diagnosed injuries (n = ) or deterioration of known injuries (n = ) were found. in patients ( %) the results of the repeat radiograph had no clinical consequences. conclusıon: our study supports a strategy of omitting a routine repeat radiograph in trauma patients whose initial radiograph is normal. introduction and objective: the neck region is affected in only about - % of all trauma cases, and isolated neck injuries, especially from a blunt mechanism, is even more rare. our objective was to assess the incidence, disability from spinal cord injuries, and preventable deaths in our patients with isolated neck trauma. material and methods: patients were identified at the severe trauma registry of our hospital, between and . the triss method was used to assess preventable deaths. results: we found ( . %) patients with neck injuries out of . patients included in our registry, ( %) from blunt (bnt) and ( %) from penetrating trauma (pnt). only ( %) bnt and ( %) pnt were isolated. the mean iss of the bnt and pnt groups was of ± and ± . , respectively. in the bnt group, ( %) patients had spinal fractures (with spinal cord injuries with permanent disability), had airway injuries and a vascular injury. in the pnt group, patient had a spinal fracture, had vascular injuries and airway injuries. overall mortality was of ( %) patients, in each group, and only one of them was deemed preventable. conclusions: isolated neck trauma is a rare cause of disability and preventable death in our area. most penetrating injuries have a lowto-moderate degree of anatomic severity (ais £ ). for each group. however about applications increased gradually with a peak at o'clock in all groups. patients treated at ed were mostly stricken ( . %) and the busy period was between - h with two peaks at and o'clock. totally, patients were hospitalized mostly in group iii ( . %) regardless of cause (p < . ). patients referred to another hospital were frequently in group iii ( . %) and also in group iv ( . %). mortality was slightly high in group iii. however higher rate ( . %) was seen among patients in group ii. conclusion: midnight hours seemed safe in terms of mortality and severity of trauma. whether the reason for a higher transportation rate at night hours is the severity of trauma or sedation of ed staff is not clear. introductıon: in this study we aimed to investigate and compare the features of child and adult injuries due to bicycle accidents admitted to our emergency department. patients and methods: the study was carried out retrospectively by searching the files of patients admitted to the emergency department due to bicycle accidents, in the emergency department and archive records between the dates of january and december . the patients were divided into two groups as adults and children. age and sex of patients, season or month of injuries, place and mechanism of injury, injury site of the body, diagnosis and treatment modalities, discharge and hospitalization rates were evaluated. results: totally patients were included in the study. % of the patients were in child age group, % were adults. it was determined that number of accidents increased especially in the summer months. . % of accidents concerning children and all of adult accidents occurred in the streets. falling down from the bicycle was the most common injury mechanism in children ( %) and adults ( %). head and neck region was the most common body site subjected to the injury both in children ( %) and adults ( %). % of child patients and % of adult patients were discharged after emergency department follow up and treatment. there was a significant difference between two groups with respect to injury severity. conclusıon: as a conclusion most of the injuries due to bicycle accidents happen in children, in the streets, in summer months and school vacations. conclusıons: road traffic collision is a major cause of trauma and death in al-ain city. seatbelt compliance is alarmingly low and should be enforced. introduction and objectives: the controversy between the ''scoop and run'' versus the ''stay and play'' approach in severely injured trauma patients has been an ongoing issue for decades. the present study was undertaken to investigate whether changes in prehospital care for patients with severe traumatic brain injury in the netherlands, have improved outcome. methods: in this retrospective study, files were analysed for all patients admitted to one of six hospitals in the limburg region in the netherlands with a gcs < on admittance over the period january -december . all patients had proven traumatic brain damage on ct or mri. relevant prehospital and clinical data from a similar study conducted years ago were compared to data from the present cohort. the main outcome was mortality. results: the two research groups had similar characteristics. in the historic cohort, basic life support (bls) and the 'scoop and run' method in patients with major traumatic brain injury (tbi) was common, with an average time on scene of . min. nowadays, prehospital care is performed mainly on the level of prehospital advanced life support (als), with average time on scene about four times as long as in the historic cohort. however, the overall mortality rate for the current cohort compared to years ago has not decreased. conclusion: despite more on-site als in major tbi nowadays, there was no reduction in mortality. the team is provided to be ready all the time by making monthly and yearly national education exercises. these exercises are planned with two methods: ( ) as demonstration during education ( ) by creating extraordinary condition simulations aim: _ interpret the support of exercises plans on umke operational agility and to accomplish next plans through this way. material -method: umke teams are divided into two parts after geting their basic educations. first group is planned to exercise in education room with demonstrations. the second is planned to exercise the extraordinary situation simulations in which people(not from the groups) made up and acted as injured and moulage is also used in this group. after the exercises, results are compared according to the criteria for assessment. in the first group's demonstrations it is worked by giving roles to team members in the education atmosphere with existing equipments (chair, table, ladder…). in the second group, worked with the moulaged volunteers and extraordinary situation simulations just like the real(wreck, avalanche, fire…) the results are considered statistically by t test. findings: according to the assessment criterias the first group's average point is . and the second is found as . . (p < . ). discussion and result: exercises in a form of extraordinary situations effected team's performance, operational success and involvement positively. planning the exercises with this data will increase the quality of the educations which planned in the future. nurhan babaoglu, tayfun cucioglu, gö khan akbulut national medical rescue team, ministery of health, afyonkarahisar, turkey entry: umke designed as serving medical rescue in extraordinary circumstances. they carries their approaching skills to the top by managing regional and national exercises. the teams in different cities coordinate and share their knowledge and agility by this exercises. aim: after the workshop oriented educations, criteria are needed to improve and decide the affect of the exercises as numerical which supplies standardization of the teams. material-method: teams are evaluated according to criteria and graded from to . after the exercises, results and the importance of criteria shared with teams. month later same teams evaluated again in exercises. criteria: ( ) equipment ( ) team accordance and work discipline ( ) security and to define work risks ( ) approach to the injured ( ) evaluate the injured people ( ) convert the theory to practise ( ) usage of materials correctly and in proper place ( ) packaging ( ) taking out the injured safely ( ) cleanness of the materials and control of medical bag findings: after antalya umke basic education, team's evaluated and average score was . . this results shared with teams and in next exercises in isparta mean score founded as . . (p < . ) discussion and result: when the evaluation criteria and results shared with the teams, it is confirmed that the teams react better in ongoing situations. it is considered that it will also increase the quality and effectiveness of the education. the criteria for evaluation going to help standardization which can be used by all medical rescue teams will provide a common manner between the groups. hasan Ç elik, gö khan akbulut, nurhan babaoglu, tayfun cucioglu national medical rescue team, ministry of health, afyonkarahisar, turkey umke teams are established in in cities in order to act in disasters and extraordinary circumstances as a medical rescue team. members are chosen among the volunteered medical crew. the team's mission is to support the search and rescue teams medically in extraordinary circumstances. team starts with the first intervention and maintain the stabilization of the injured person before the transport so that prevents the second insult. working principles was not obvious during the establishment phase and this caused chaos at the beginning. by designating the teams responsibilities work distribution reached to the standard. national medical rescue team is consisting of medical personnel who are named as leader, logistic, pigeon, squirrel and courier. the team leader who is chosen from doctors who has experienced in disaster medicine and have knowledge about leadership, provides a common manner and motivation among the team. also directs the intervention to the injured person and coordinates with search and rescue teams just after the fast arrive in extraordinary circumstances. squirrel communicates with injured at first and starts his intervention with the direction of the leader. logistic is responsible for all equipment (spin board, medical bags…). courier provides the equipment transportation between logistic and squirrel. pigeon is responsible for photographing, recording and communicating with the center. this organization type performed in regional and national practises from to and also in train accident in kü tahya. _ it helped maintaining standardization and acquired successful results. author to editor: bu yazıyı ulusal medikal kurtarma ekiplerini (umke) tanıtmak amacıyla hazırladık. eg er uygun gö rü rseniz, umke yi tanıtıcı bir stand açıp medikal çantamızı ve dig er kullandıg ımız malzemeleri tanıtabiliriz. ayrıca bu gü ne kadar katıldıg ımız (pakistan depremi, isparta uçak kazası, kü tahya tren kazası) afet, tatbikat ve eg itimlerimizi(ameliyathane konteynırımızı) power point olarak sunabiliriz. helicopter use as a part of trauma care introductıon: rapid transport and persistence of prehospital care is crucial to decrease the mortalities and morbidities of combat related injuries. hence, helicopters are effectively used by the military although they are austere environments that offer limited space, equipment and resources for the crew and requires higher level of skills for prehospital trauma care. materıal-method: the data were collected from consequent casualties, by the helicopter medical team (a surgeon, anesthesiology technician and a paramedic). during the flight, we triaged the casualties according to wound characteristics (severity, mechanism, location), physiological parameters, and provided basic life support stated by trauma resuscitation course (trk). we transmitted these findings to the military trauma center to provide hospital preparedness. result: injury mechanisms were % explosives and % highvelocity weapons. time to hospital admittance was < min after the injury. most frequent sites of injury (ais - ) were extremities ( %) and thorax ( . %); the frequency of ‡ anatomical site injury was %. capillary refill rates were; < seconds . %, > seconds . %. mean sao , gcs, hr, respiratory rate values were . ± . , . ± . , . ± . , . ± . , respectively. during uninterrupted care, ( %) intubations were performed and % of casualties were operated upon admittance without any onboard mortalities. conclusion: the high energy and lethality of the wounding agents in combat render the helicopter evacuations indispensible. additionally, civilian major trauma patients may benefit from expeditious transport to the closest trauma centers or from rural inaccessible areas within the 'golden hour of trauma'. the most important steps for the treatment of the combat injury causalities are to stop or reduce bleeding and to start fluid resuscitation. peripheral intravenous (iv) line placement is one of the most important procedure in the battlefield conditions. most of the time, fluid resuscitation would be the only available medical treatment for the injured combatant because of the prolonged evacuation period in the battlefield. also, this procedure would be very difficult and time consuming especially under hostile gunfire. excessive blood loss and hypotension may cause the peripheral venous collapse and makes the procedure more difficult. here we described a simple method to make this procedure easier. we offer the forward medical team personal to perform the upper extremity peripheral venous mapping of the combatant before the operation. the medical providers (doctor or paramedic) who would perform the first medical intervention would examine the upper extremities of baddy just before the operation. the medical care provider should determine the suitable situations for the iv line placement. then he should remark the both site of the appropriate vein by camouflage paintings, leaving the probable angiocath insertion sites non-painted. we believe that this method would make the peripheral iv line placement easier and faster for the forward medical team personal in the war conditions. one probable disadvantages of this method is the negative psychological effect on the combatant that makes them to estimate the risk of wounded in a few hours. introduction and objectives: ambulance and emergency care technicians are the key personnel for pre-hospital care of trauma. this study reviews the work anxiety states of some of the students in ambulance and emergency care technicians department, vocational school of health services, marmara university by comparing it with those of the students in radiology department of the same school. methods: this study was developed as a sectional type of study and was conducted on volunteer students from the above mentioned departments. the data were analyzed using the spss . software and employing the frequency distribution, t-test for individual groups, and unidirectional variance analysis methods. results: the study group of subjects was . % female and . % male. . % of the subjects expressed anxiety over their employment in the future; . % of them expressed no work anxiety. the work anxiety points of the subjects were compared in terms of their genders, academic years and departments, and said comparison did not reveal any statistically significant difference (p > . ). conclusions: the work anxiety state is one of the major factors having an impact on professional success, and is a negative state having an impact on one's performance, success and, in turn, psychological state. it would be proper to study the issue of work anxiety by obtaining psychological support, and to cooperate with the actors in this sector to develop solutions. it is concluded that further studies should be conducted on work anxiety and its reasons. in general, emergency patients should be transported to the closest appropriate hospital. if the emergency medical services have identified a specific hospital with better resources to treat seriously injured patients, the patient should be transported to that institution, bypassing closer hospitals. the cooperation is expected between the hospitals, and the development of formal transfer agreements, describing all of the legal, economic, and medical aspects of the relationship are encouraged. ideally, the entire trauma system in a city should be designed on the basis of need and existing resources, with all affected parties involved in the planning, development, and implementation. the goal of the system is to match the needs of an injured patient to the resources of the available facilities so that optimal and cost-effective care is achieved. we conduct six essential questions for the preparation of trauma. is there a legal authority to formally designate hospital's trauma response in your city? what sources were used as a basis for standards of the trauma response in your service area? were the number of hospitals identified for your service area limited based on the results of needs assessment? what type of transport practice occurs in your service area when a field assessment identifies a trauma patient with severe injuries that threaten loss of life or limb? is a trauma registry present in your service area? is there a designated trauma advisory committee that evaluates the performance of trauma care delivery within your service area? we evaluated the role of primary hip arthroplasty (consisting of both total hip replacements and hemiarthroplasty) in these comminuted, osteoporotic or neglected fractures. these patients at-risk were in need of a single definitive surgical plan for early ambulation and preventing complications. typically these patients were elderly with poor mobility and had multiple other medical condition to be able to withstand multiple surgeries. there was a need to obtain the best results with the single, rapid procedure for pain relief and early ambulation. excellent to very good results were obtained in about % of these patients. good results were obtained in about % of these patients and poor results in about %. most of the poor results were the outcomes of complicated medical conditions rather than the failure of the orthopaedic procedure itself. we advocate arthroplasty in neglected, osteoporotic or severely comminuted per-trochanteric fractures for immediate mobilization and optimising outcomes. the role of intra-articular steroids or hyaluronic acid injections in early arthritis may be warranted and perhaps safe. but for patients waiting for a knee replacement these can prove positively dangerous. a meta-analysis has revealed that intra-articular injections given in patients waiting for a knee replacement procedure is fraught with dangers. apart from a high risk of post-operative infection and failure of the procedure, several other side-effects or complications make this risky. there is a higher-than-average chance of quadriceps tendon rupture, delayed wound healing, superficial infections and slower rehabilitation. in comparison hyaluronic injections have been found efficacious in the short term and do not contribute to complications normally attributed to steroids. thus intra-articular injections should be used with caution, repeated injections are best avoided and are certainly contraindicated if a procedure is anticipated to be performed within six months. introduction: pediatric forearm fractures are common. the majority has satisfactory outcome. but poor results do occur and malunion can compromise rotation. we belief that the angulation of the fracture depends on the action of the body and that we can reduce the fracture by completing the action. this way we can perceive a stable anatomic reduction without internal fixation. methods: we undertook a prospective study of distal forearm fractures in children. we included children with a non-displaced angulated metaphyseal distal forearm fracture. the angulation was between °and °.we all reduced them by completing the action of the body. this means a volar angulated fracture is reduced by pronation of the hand and a dorsal angulated fracture is reduced by supination. after the reduction they were casted in an upper-arm cast in pronation or supination depending of the reduction manoeuvre. afterwards the all received weeks of upper-arm cast and weeks of lower-arm cast. results: they all healed without loss of reduction and without further treatment. they all had full recovery of function. conclusıon: non-displaced angulated metaphyseal distal forearm fractures in children can be treated conservatively by closed reduction and plaster cast. background: vascular endothelial growth factor (vegf) plays an important role in the bone repair process as a potent mediator of angiogenesis and influences directly the osteoblast differentiation. inhibiting vegf suppresses angiogenesis and callus mineralization in animals. however, no data exist on systemic expression of vegf with regard to delayed or failed fracture healing in humans so far. methods: one hundred fourteen patients with long bone fractures were included into the study. serum samples were collected over a period of months following a standardized time schedule. vegf serum concentrations were measured. patients were assigned to groups according to their course of fracture healing. the first group contained patients with physiological fracture healing. eleven patients with delayed-or non-unions formed the second group of the study. in addition, healthy volunteers served as controls. results: an increase of vegf serum concentration within the first weeks after fracture in both groups with a following decrease within months after trauma was observed. serum vegf concentrations in patients with impaired fracture healing were higher compared to the patients with physiological healing during the entire observation period. however, statistically significant differences were not observed at any time point between both groups. vegf concentrations in both groups were significantly higher than those in controls. conclusıon: the present results show significantly elevated serum concentrations of vegf in patients after fracture of long bones especially at the initial healing phase indicating the importance of vegf in the process of fracture healing in humans. first, dsbls is applied to . cm proximal to most prominent point of medial malleol of tibia. the dsbls was inserted parallel to the joint surface in frontal and horizontal plane. after the dsbls is applied the selected nail is inserted. reamed imn is used for the tibias with narrow isthmus ( ). the success of di is checked following the insertion of nail with set screw on the dslbs. the unsuccessful attempts are repeated after the reason is removed. the di of tibias were successful and were unsuccessful at the first attempt. in unsuccessful cases, the nails were at the posterior ( ), anterior ( ) and lateral ( ) collum femoris fractures accounts . - % of all fractures. however it is very rare in children ( %). in this study we evaluated pediatric patients who were operated due to collum femoris fracture in terms of avascular necrosis and functional outcome. age of the patients ranged from to . there were seven girls and five boys. two of the patients were admitted to the emergency department due to a fall from height, therefore they had multi system trauma. the remaining ten patients had isolated collum femoris fracture. fractures was classified according to delbet classificaion; seven transcervical and five cervicothrochanteric. locking plate-screw fixation was applied to one patient, other fractures were fixed with two or three cannulated screws. open reduction was applied to four patients and closed reduction to eight. five of the cases were operated in the first h of the fracture, however the remaining seven patients were operated after the first h ( - days) due to late admission. range of motion of the hip joint was limited in only one patient who had polytrauma and operated after the first h. there were three avascular necrosis as acomplication. all of them operated after the first h and all the fracture types were cervicotrochanteric. open reduction was applied to two patients and closed reduction to one. pediatric collum femoris fractures are rarely seen in children but treatment is challenging and open to complications. fracture type, surgical methods, did not effect the outcome, but timing of surgery did. author to editor: in this study we discussed the outcome of pediatric collum femoris fractures, which is a very rare fracture in orthopaedic experience. surgical management of humerus shaft fractures is an increasing interest nowadays. we want to discuss the outcome of conservative, open reduction and internal plate fixation (or _ if) and intramedullary nailing (imn) methods in adults ( - years old). patients had conservative treatment with modified custom made sarmiento brace and of them had union with °- °of malunion. none of the nine have complains and the avarage union duration is weeks ( - ). one patients did not tolerate bracing and undergone surgery. patients had or _ if and had gone second operation for nonunion and had elonged wound drainage. all the fractures healed eventually with in weeks ( - ). no neurovascular complication was observed. patients had imn treatment and had delayed union up to months, had undergone reoperation with or _ if for non-union, had intraoperative fracture of elbow and had shoulder problems with impingement and rotatory cuff problems. avarage union duration was found weeks ( - ). surgical treatment is getting more popular for long bones nowadays. early return of work and social life, anatomic reduction, using no sling or such devices and easy follow up protocols are the facts that popularising the surgical management. but in our series, we had seen multiple types complications that are as high as they are mentioned in literature. with the experience of those patients that had been treated with in this year, conservative treatment methods have to be conserned firstly in suitable and tolerable patients for us. intoduction and objectives: correction of sagittal deformity is important in thoracolumbar burst fractures. the clinical maneuvers needed for reduction and the assessment of correction of the fractured vertebra is not well described. in this prospective series we used the length of the interspinous ligaments as reduction parameter. our aim was to evaluate the efficacy of this assessment technique in achieving good correction. methods: from to patients (m/f / , mean age . ) with unstable thoracolumbar burst fractures were treated by posterior fusion with a standard construct by a single surgeon. all patients were treated with segmental posterior instrumentation with two levels above and two levels below the fracture level fixation by means of pre-contoured rods and distraction technique. with these maneuvers the length of the injured level was tried to be equalized to the mean of upper and lower levels. anterior column was assessed by radioscopy. preoperative and postoperative radiographs were analyzed and local kyphosis (lk), farcy's sagittal index (fsi) and compression percentage (cp) were measured. results: the preoperative lk decreased from . °to . °, fsi decreased from . °to . °and cp decreased from to . . after a minimum follow-up time of years all patients continue to do well with no statistically significant decrease in these parameters. conclusions: assessment of thoracolumbar burst fracture reduction with pre-contoured rods and distraction technique can be made safely by intraoperative measurement of the length of the interspinous ligaments. case: an -year old lady was admitted in our emergency department with a neer -part fracture of the right proximal humerus caused by a fall. she was operated on and received a shoulder hemiarthroplasty. during cementation of the stem the patient became bradycard and acute respiratory arrest occurred. she was resuscitated, but eventually died h postoperatively. postmortem examination revealed embolic bone marrow occluding the pulmonary capillaries. comment: pulmonary embolus after upper extremity surgery is a rare complication. fatal pulmonary embolus is even more rare. when reviewing literature there is no previous case of fatal pulmonary embolus caused by fat emboli described. fat embolism syndrome was first described by zenker in , but its frequency today is still unclear. usually it presents as a multisystem disorder. the most often and most seriously affected organs are the lung, brain, cardiovascular system and skin. it is a self-limiting disease, therefore treatment should be mainly supportive. purpose: lack of knee flexion is a possible complication in severe femur fractures. two different techniques for the treatment of this problem were applied. materıals-methods: from to , patients with severely arthrofibrotic knees were managed with two different operative techniques. the mean age of the patients at the time of the operation was years. we recorded the clinical outcome of patient using judet quadricepsplasty with a follow-up of months, and of two patients using extra-articular mini-invasive quadricepsplasty and intra-articular arthroscopic lysis of adhesions during the same anesthesia session with a mean follow-up of months. all patients were evaluated according to the criteria of judet and the hospital for special surgery knee-rating system. results: the average maximum degree of flexion increased from °p reoperatively to °at the time of the most recent follow-up. according to the criteria of judet, the result was good for knees, and fair for one. the average hospital for special surgery knee score improved from points preoperatively to points at the time of the most recent follow-up. a superficial wound infection occured in one patient. conclusions: if you select the appropriate cases, the judet procedure and mini-invasive operation for the severely arthrofibrotic knee can be used to increase the range of motion and enhance functional outcome. purpose: floating knee and elbow injuries are complex injuries. the types of fractures, soft tissue and associated injuries make this a challenging problem to manage. we present the outcome of these injuries after surgical management. materials and methods: two patients with floating knee injuries(classified by blake and mcbryde) and one patient with floating elbow injuries were managed over an average of months. both fractures of the floating knee injury and the three fractures of the elbow injury were surgically fixed using different modalities. the associated injuries were managed appropriately. assessment of the end result used the karlströ m criteria after bony union. results: mechanism of injury was road traffic accidents in two patients (floating knee) and falling from height for one patient (floating elbow). there were associated injuries, patient was tipiia, patient was tipiib. both these patients had intramedullary nailing for femur fractures. patient had ilizarov external fixation for segmenter tibia fractures, patient had a proximal medial plate for proximal tibia fracture. patient had plates afıxed to all fractures.complications were knee stiffness and delayed union of femur in a patient (second operation required). the bony union time average from weeks for femur fractures, weeks for tibia, weeks for upper extremities. according to the karlstom criteria the end results was acceptable. the average elbow score was / (good). patients with tibial bio-screw fixation there is insufficient evidence from randomized trials to determine the optimal intervention in patients with displaced four-part fractures of the proximal humerus: head preserving surgery with problem to obtain and maintain reduction until bone healing, implant failure, avn of the head, ha with > % tuberosities related complications-resorption, displacement, rsa with high complication rate, moderate function due to restricted rotation and insufficient long-time follow-up. in our presentation we will discuss: • new rsa designs, which improve function and lessen complication rates • question of tuberosities fixation to rsa in proximal humeral fractures • literature overlook of rsa in proximal humeral fractures the goal of rsa is to minimize shoulder immobilization and to start functional rehabilitation immediately. indications are same as for ha + tuberosity osteoporosis and comminution + week or absent rc. decision for if, ha or rsa is often intraoperative. tuberosities fixation is debatable (prolonged immobilization, prosthesis dislocation). functional results are more consistent than in ha, but complication rate is higher (it may be lowered by new prosthesis designs). frequent ct scanning due to incomplete -view x-ray imaging of the cervical spine background: conventional c-spine imaging is still widely used, despite increasing replacement by ct scanning. the aim of this study was to analyze the frequency of incomplete c-spine x-rays ( -view series) in blunt trauma patients. methods: during a -year period we analyzed the frequency and value of -view series of the c-spine. secondary we assessed the reasons for subsequent ct scanning after the -view series according to the following classification: inevaluability, incomplete -view series, evaluation of findings on -view series or for unexplained, persistent clinical symptoms. furthermore we evaluated predictors for incompleteness. results: c-spine injuries were diagnosed in blunt trauma patients ( . %). patients ( %) had their c-spine cleared based on the nexus criteria. patients were primarily evaluated with view series and patients primarily with ct scanning. within the population with primarily -view series ( %) were repeatedly incomplete and ( %) were inevaluable. in the major part of the incomplete -view series no apparent reason could be determined. however, the presence of clavicular fractures (resulting in incomplete radiographs in vs. % without a fracture; p < . ) and rib fractures ( vs. %; p = . ) were associated with incomplete -view series. conclusion: in more than a third of the patients primarily assessed with -view series, the results are incomplete or inevaluable necessitating ct scanning. therefore, the diagnostic value of -view series is questionable. in patients with clavicular and rib fractures -view series can be omitted and primary ct scanning is advised. the treatment of open distal tibia fractures is still discussed controversially and they are a great challenge for surgeons. it is still not clear if there should be initial stabilization with an external fixator or primary osteosynthesis with an intramedullary nail or plate. we retrospectively examined patients with ii°and iiia°open distal tibia fractures which were treated during the last years in our level one trauma center. we treated male and female patients with an average age of years. ten patients were treated with an external fixator and patients were treated with an intramedullary nail or plate osteosynthesis in acute surgery. the patients, firstly treated with an external fixator, were stabilized with reamed intramedullary nailing in eight cases and with locked plating in two cases after wound closure. there was no difference in the duration until bony union in any groups. fewer unplaned revisions (n = ) and no deep osseous infections were found in those patients treated with an external fixator in the acute phase of the injury. patients treated with a definitive osteosynthesis underwent unplaned revisions in six cases and developed deep osseous wound infections in four cases. we therefore recommend that initial treatment with an external fixator should be preferred and after consolidation of the soft tissue, the definitive stabilization should be done with a stabile osteosynthesis system. author to editor: this topic remains of a high interest among trauma surgeons, especially now, that angle stable intramedullary fixation systems run the market. fractures of the clavicle shaft are common and have been typically addressed to nonoperative treatment. but favorable results with the precontured anatomic plates are facilitating surgeons for primary surgical treatment. this study reports the surgical results of adult clavicle shaft fractured patients (age range - ) that had been operated with in last months. all fractures were displaced and none of them was open nor had neurovascular injury. avarege healing time was found weeks ( - weeks). all patients had anatomic reduction postoperatively. of the patients fracture site was grafted with dbm. of patients had sterile wound drainage which was lasted for weeks postoperatively (all were grafted with dbm), of them re-operated ( of them for early implant failure and early implant removal for plate disturbance) and one patient was operated for times ( of them was in another center) for early implant failure, nonunion,wound problems and neurovascular complications. of was healed eventually. of patients were satisfied with the treatment and had a full range of motion at final follow-up and were able to return to pre-injury occupational and activity levels. nonoperative treatment of displaced shaft fractures may be associated with a higher rate of nonunion and functional deficits. however, our study shows that surgical treatment also has high complication rates. there is currently considerable debate about the benefits of primary operative treatment of these injuries because it remains difficult to predict which patients will have these complications. platelet rich plasma (prp) is applied in orthopaedic, maxillofacial and plastic surgery with variable outcome. different growth factors and cytokines are stored in platelets, including platelet derived growth factor (pdgf), contributing to the potential positive effects of prp. the aim of our study was to investigate the properties of pdgf administered locally in a rat femoral non-union model. in our experiment a critical sized osteotomy was performed in the rat femur, which was filled with a spacer, inhibiting bone formation for a period of weeks. in a second operation this spacer was removed and the test item was applied into the defect. we compared the pdgf group (d = ng, c = lg/ml of pdgf in fibrin matrix) with the fibrin alone and blank control groups. four weeks after the second operation, specimens were analysed by x-ray, lct imaging and histology. in group pdgf we found a lct confirmed union in of specimens and the lct evaluated bone volume was median . mm (q = . / q = . ). in the control groups there was a bony bridge in of fibrin and in of blank specimens. the bone volumes were median . mm (q = . /q = . ) fibrin and median . mm (q = . /q = . ) blank, respectively. we did not find a strong tendency for new bone formation in the group treated with pdgf. in our model we observed even a tendency to inhibit bone regeneration for pdgf. introduction and objectıves: hand traumas are one of the most common encountered complex traumas. closing the defects on either dorsal or palmar side of the hand is sometime difficult because of limited local tissue and to provide a tissue the tendon glides underneath. in spite of high risk of donor side morbidity and sacrificing a major artery of the hand, radial forearm flap is the most frequent choice to close the defects at this region. method: in a year time, five patients with severe hand traumas who admitted to our clinic, treated with perforator based three radial artery and two ulnar artery adipose-fascial forearm flaps. the adipose-fascial island flap was raised on one or two of these perforators without sacrificing a major vessel.the flap was transposed to defect region and covered with stsg. in all five patients' donor side was closed primarily. results: the biggest flap size was · cm. there was no flap loss except one patient who had partial flap necrosis and it healed secondarily. the donor side was healed uneventfully in all the patients. there was no tendon adhesion. conclusıon: perforator based radial or ulnar artery adipose-fascial flap is a safe and reliable method for closing defects on the hand. it has both less donor side deformity and fascial component of the flap provides better tendon gliding and less tendon adhesion. however, it requires more experience to raise adipose-fascial flap. introduction and objectıves: one of the most common causes of the lower extremity defect in adult is a road traffic accident. the most challenging issues is to close the defect on the / of lower extremity because local tissue is very limited and mostly damaged due to high energy injury. we investigated the difficulties of how we close the defect on one third of the lower extremity particularly in children, in our unit. method: in a year time, patients under years old admitted to our unit. all patients had gustillo iiib injury and the biggest size of the defect was · cm. one patient had different lesions on the heel the other was on the anterior aspect of tibia. after radical debridement, the wound closed with alt free flap with in first week of admission. different defects on a lower extremity were closed with alt and vastus lateralis muscle free flap with a single pedicle. result: the biggest flap size was · cm. an average pedicule length was . cm and the diameter of the vessel was . cm the average operation time was h min. one flap had partial necrosis and healed secondarily. they had uneventful recovery and discharged on average postoperative days. conclusıon: in children even less than years age, one of the good and suitable options for closing the defect on the one third of the lower extremity is alt as a free flap. stable odontoid fractures can be treated with external immobilization using, e.g., a philadelphia collar (pc) or a halo thoracic vest (htv). it is important to delineate the capacity of both orthoses, halo and philly, for immobilization of the atlantoaxial complex (aac), e.g., for their use in odontoid fracture care. in this in-vivo biomechanical comparison volunteers (mean age = . ± . ) were subjected to flexion-extension radiographs immobilized in a modified htv and a pc. radiographs were analyzed for the segmental rotation angle of c - in sagittal plane (sra c - ) and the absolute rotation angle of c - (ara c - ). separation angles (rsra c - and rara c - ) were calculated from flexion-extension views. concerning restriction of subaxial sagittal plane motion, the htv was more effective than the pc. the difference for the rara c - between the pc (mean . °) and htv (mean . °) yielded significance (p = . ). but, concerning restriction of flexion-extension at the aac, there was no statistical significant difference for the rsra c - between the pc and htv (p = . ). pc (mean . °) was superior to the htv (mean . °) in restricting sagittal motion at c - . in comparison to normals atlantoaxial motion was restricted by . % (pc) and . % (htv). the current study demonstrated that there was no significant difference in restriction of sagittal motion at c - between the pc and htv. in light of the current biomechanical data and a selected review of literature it is concluded that the use of a pc is sufficient for the treatment of stable odontoid fractures. introductıon: although most ankle injuries are associated ligamentous structures, some types of fractures mimic to ligamentous sprain and misdiagnosed as well. most of the ankle sprains undergo radiographic examination and some of type fractures easily are missed even x-ray. the aim of this study is to evaluate the missed talar neck fractures and to emphasize the missed fractures. materıals-methods: misdiagnosed cases were included in the study. average age at the time of trauma was ( - ). all cases evaluated prospectively. if the patients had ankle sprain and their initial x-rays show no evident of fracture, they were involved in the study. the diagnosis of the fracture was figured out by control x-ray, ct scan and mri (except case). all patients were evaluated by the scoring system of american orthopaedic foot and ankle society (aofas introductıon and objectıves: treatment of proximal humeral fractures remains controversial, because of complexity of this kind of fractures. the purpose of this study is to present our first experience using angular stable fixation in and part proximal humeral fractures method: in last mounts we treated patients with this method, men and women (mean age ). anterior approach was performed in every case (mis technique in two cases), and every patients underwent to early rehabilitation. periodical clinical and radiographic control were performed. results: short term results are good with satisfaction of the patient, no pain and acceptable range of motion. we have case of deep infection that need revision surgery and antibiotic treatment. preoperative diagnosis of appendiceal diverticulitis is rare. the incidence of appendiceal diverticulitis ranges from . to . %. % of the diverticulitis of colon cases appear above years of age, and they are mostly in the left colon. case: a year-old male, who had a -year history of episodic right lower quadrant abdominal pain was admitted to the surgical emergency department for worsening of his complaints. the physical examination was only notable for right lower quadrant abdominal tenderness. laboratory findings was normal. on ultrasonography examination signs of acute appendicitis was noted. as the radiological findings did not match with the clinical status of the patient, he was followed up. later, acute abdominal symptoms appeared, and the patient was admitted to the operating theatre. two cm long nodules were seen on the appendix preoperatively. appendectomy was done. the patient was discharged on the first postoperative day. the histopatological examination revealed acute appendicitis signs and two mm long diverticula one of which is inflamed in the middle and the other in the distal part of the specimen were reported. conclusıon: the most common cause of acute appendicitis in adult population is fecaloid. lymphoid hyperplasia, carsinoid tumors, mucosel, parasites, fruit and vegetable seeds are other causes. although appendiceal diverticulitis is rare, clinicians should be aware of its occurrence and tendency for appendiceal perforation. introduction and objective: traumatic intracranial hematoma is the most common complication of the head injury requiring emergency intervention. as most of them are located supratentorially, they can be seen less frequently in the posterior fossa. this study aims to evaluates the clinical, radiological and surgical aspects of traumatic posterior fossa hematomas in patients who were treated at our center. methods: the records of patients with of traumatic posterior fossa hematomas that had been treated at our center between and were reviewed. results: of the cases, had cerebellar hematomas and had epidural hematomas. fall was the most common cause, followed by animal kick, assault and traffic accident. diagnosis and management decisions were determined by cranial computed tomography scans. surgical intervention was performed in cases. the outcome was good in patients. three patients died who had low gcs at admission and additional cranial lesion. conclusions: patients with occipital trauma should be evaluated immediately using cranial computed tomography scans. early diagnosis of traumatic hematomas and prompt surgical intervention in those having mass effect provide good results. introduction: transcranial stab wounds made with a knife mostly produce a classic slot skull fracture and underlying tract hematoma, and often cause severe neurological deficits. an unusual case with combined pareses of oculomotor and trochlear nerves due to penetrating stab wound to the brain is presented. methods: a -year-old boy was admitted to our clinic after an altercation that resulted in the patient sustaining stub wound to his head. results: he was conscious. neuro-ophthalmic examination showed that the left eye had limited adduction, supraduction, and infraduction, incomplete convergence and left sided ptosis with dilated pupil. an emergency computed tomographic scan of his brain was obtained, which revealed a left slot fracture at the squamous portion of the temporal bone of the anterior cranial fossa and a frontotemporal intracerebral stub tract hematoma. he underwent emergent surgery. fractured bone pieces and lacerated brain tissue were removed. neurological deficits remained unchanged at months follow-up. conclusions: cranial nerve injury related to the knife wound to the brain is very rare. the penetration site, depth of penetration and trajectory of the object are important in occurring of this injury. prognosis seems to be poor in these cases. introductıon: large number of knee x-rays are done incidentally for patients presenting with knee trauma in accident and emergency. using only one lateral view knee x-ray as a screening tool would reduce the cost by % as per a. verma et al., an interesting proposition. method: we investigated the validity of lateral view knee x-rays alone as a screening tool for detecting fractures around the knee in acute knee trauma. randomly picked x-rays were reviewed. the ap and lateral views were interpreted by a consultant radiologist and the findings used as gold standard for the study. the lateral views alone were independently interpreted on two different occasions by the (a) radiographer (b) emergency nurse practitioner accident & emergency (c) middle grade doctor accident and emergency (d) consultant orthopaedic surgeon. results: there was significant inter observer variation in sensitivity which ranged from to % with the highest sensitivity being achieved by the radiographer. the specificity was generally high with a range from to %. though there was a high validity in the case of the radiographer the sensitivity for the other observers was low. conclusıon: though there could be a significant saving in terms of resources and unnecessary radiation by doing lateral views alone as opposed to the routine ap & lateral views as first line x-rays, we do not recommend using the lateral views alone as a safe screening tool in knee trauma because of high inter observer variation in sensitivity. tk gullett, charalambous p. charalambous, ajay sahu, matt j. ravenscroft stepping hill hospital, stockport, uk introductıon: in distal biceps tendon ruptures, re-attachment to the radial tuberosity should ensure an adequate tendon to bone surface contact to achieve a sound repair and fast tendon to bone healing. method and technique: we are describing a l-configuration reattachment of distal biceps tendon rupture, using a single anterior transverse incision at the cubital fossa crease. each pair of sutures from the most distal anchor is passed through the distal part of the tendon. one strand of each pair is passed in a zig zag fashion through the tendon whilst the other strand is simply passed straight through the tendon in a posterior to anterior direction. the four strands of the proximal anchor are passed so that they form two mattress sutures through the proximal part of the tendon. tightening is then performed in a specific sequence with initially pulling on strand a and b to bring the tendon down to bone and then tightening these to the corresponding suture strand of their pair. the two pairs of sutures are then tied to each other. this second anchor tightening ensures that the tendon is brought down onto the bone in an l configuration increasing the contact surface area between tendon and bone. results: we have used this technique in patients till now with excellent results and no re-ruptures. discussion: our technique is simple to perform and provides a sound repair with a large surface area of contact between tendon and bone. results: out of a % (n = ) response rate, respondents ( male, female) were included in the study. we excluded people with previous hip, knee or back problems. in our study, the symptom scores that is lysholm, oxford and visual analogue scale for pain and function did not show any significant decline with age. on the other hand, the scores measuring activity levels that is tegner and ucla scales declined significantly with increasing age. our normal scores were far ahead of age-matched post operative scores following total knee replacement. there was no difference between males and females. the symptom scores declined with increase in medical problems. conclusıon: our age matched scores were superior to post operative total knee replacement (tkr) scores from the njr. this furthered our motive to create a set of reference knee scores in the normal population which could be used by other studies to compare their results and help improve postoperative outcomes. mesenchymal stem cells (mscs) are multipotent stromal cells that have extensive proliferative potential and the ability to undergo multilineage differentiation. traditionally, osteogenic differentiation of mesenchymal stem cells has been studied in cells isolated from bone marrow and iliac crest. however, these harvest techniques are associated with several problems, including donor morbidity, pain, and limited amount of cells. only a few years ago, adipose tissue has been identified as another source of mulitpotent mscs, which are referred to as adipose derived stem cells (adscs). the aim of our study was to provide a comparative analysis of primary osteoblasts from the iliac crest and osteogenic differentiated mscs from adipose tissue, using osteoblast-specific protein expression. in patients the cells were differentiated into the osteoblast lineage using osteogenic medium (adobs). primary osteoblasts were isolated from iliac crest specimens in patients undergoing osteosynthesis with spongioplasty (female: , male: , mean age ± . ). phenotype marker expression of osteoblast-specific proteins osteocalcin, alkaline phosphase, type i collagen, and cbfa- (runx- ) was analyzed up to days following incubation using rt-pcr, western blot, and immunocytochemistry. additionaly, the following surface proteins of adscs were analyzed: nucleostemin, cd , cd , cd , cd , cd , and cd . rt-pcr analysis revealed that the non-differentiated adscs contained different types of stromal cells with a large variety of cd marker expression. surface protein expression (cd) did not differ significantly in cells isolated from either fat tissue or bone. author to editor: saved by lookus. background: at our department, classification of the responsiveness to fluid resuscitation and a simple and practical damage control surgery (dcs) scoring system have been used to determine the efficacy of the treatment strategy in trauma patients. cases and methods: we examined out of hepatic injury patients, excluding cardiopulmonary arrest cases. the present study was undertaken to establish a valid strategy for the treatment of hepatic injury, and further improvement of the survival rate was evaluated based on the grater and equal of grade iv [organ injury scale (ois)] hepatic injury necessitating emergency room laparotomy. result: interventional radiology (ivr) treatment cases were all stable or responder patients and all survived with effective hemostasis. transient responder or non responder patients that needed hemostasis were treated by emergency laparotomy, and all the cases that eventually expired needed dcs. the mean injury severity score (iss) was . and the mean probability of survival (ps) was . , and hemostasis treatment was started within a mean of . min, yielding a survival rate of . % in the cases with grater and equal grade iv (ois) liver injury that needed emergency room laparotomy. conclusion: our criteria for deciding the therapeutic strategy based on the response to the initial fluid resuscitation seemed to be useful from the viewpoint of hemostasis for liver injury. the key to securing quality regional trauma care is to designate a trauma care hospital as a trauma center and to transport severely injured patients to the center as rapidly as possible. author to editor: we show that our classification of the responsiveness to fluid resuscitation and a simple and practical damage control surgery (dcs) scoring system is very effective for liver injury strategy. fractures of the proximal femur are, more than ever, an important challenge in the field of traumatology. the gamma-nail, a combination of advantages of the sliding screw with the intramedullary nail, represents an efficient technique in the management of these fractures. a series of fractures of the proximal femur in which this nail was used is reported. the average age of patients was . years (range - years). . % ( patients) of the cases were female. the average duration of the operation recorded was min. in all cases closed reduction was achieved. the mean healing time was . weeks in . % of the cases. there were two cases of delayed consolidation but no pseudarthroses. postoperative complications occurred in cases ( . %). one case of migration of the proximal screw was the most important complication. the most frequent complications ( cases) were seromas and hematomas of the surgical wound, which resolved satisfactorily in all cases. superficial infections ( cases) also evolved favorably, once the appropriate antibiotic treatment had been instituted. no breakages or failures due to implant fatigue were seen. the patient's recovery after suffering the fracture and the operation was evaluated and the % ( patients) recovered their previous walking ability. the overall mortality was . % ( patients) with of the deaths occurring while in hospital. in conclusion, this preliminary study has shown that gamma-nail can be safely used by the average surgeon in the average hospital to treat a common and sometimes difficult fracture. valerio ranieri, loris trenti, aldo rossi, antonio manenti departement of general surgery, university of modena and reggio emilia, modena, italy a years old nigerian woman, at the end of the nd pregnancy, was submitted to a caesarean section for uterine atony. post-operative thrombo-prophylaxis was given. from pod , fever, abdominal pain and increasing tenderness in the right lower quadrant with leucocytosis appeared. ultrasonography showed only small amount of fluid in the douglas pouch, while a contrast-enhanced ct and a rmn revealed a dishomogeneus cylindrical mass of . cm in diameter extending from the right parauterine space towards the duodenum, suggestive of thrombosis of the ovarian vein. laparotomy followed: uterus, ovaries, appendix and bowels were normal. after mobilizing the right colon the ovarian pedicle appeared enlarged and firm; it was dissected, starting from the vena cava, and completely excised preserving the adnexa. post-operative course was uneventful. histology confirmed a suppurative thrombophlebitis; the haematological study ruled out any coagulation abnormality. the patient completed a months low-molecular-weight-heparin treatment. ovarian vein suppurative thrombophlebitis can seriously complicate a caesarean section, till to require a surgical treatment. the imaging is essential for a prompt diagnosis. purpose: to prospectively study the mechanism, distribution of injury, and outcome of patients hospitalized with camel bite injury. methodology: all patients admitted to al-ain hospital with a camel bite were prospectively studied over years (october -october . mechanism of injury including behavior of the camel, distribution and severity of injury, patient's demography, and outcome were studied. results: all patients were males having a median (range) age of ( - ). almost half of them were pakistani. twenty-five were camel caregivers while five were camel riders. seven patients were raised up by the camel's mouth and thrown to the ground while the other patients were only bitten. majority of the injuries were in the upper limb ( ) followed by the head and neck ( ). / upper limb injuries had associated fractures. two patients who were bitten at the neck were admitted to the icu. one of them died due to massive left-brain infarction and the other had complete quadriplegia due to spinal cord injury. the median hospital stay was days. one patient died ( %). conclusıon: the behavior of the camel is occasionally unpredictable and the canine teeth of the camel, which are long, can cause severe penetrating trauma despite the small puncture on the skin. care should be taken when handling the camel. author to editor: dear colleague: this is the only prospective clinical study of camel bites in the literature that took us years to collect. the data is very unique and is of great interest. fikri abu-zidan gastrointestinal cytomegalavirus infections occurs predominantly in immunocompromised patients.involvement of the gastrointestinal tract in acquired immunodeficiency syndrome (aids) patients is frequent. however the prevalence of cytomegalovirus appendicitis is exceedingly rare. case: a year-old male infected with the human immunodeficiency virus, who had chronic abdominal pain with subsequent development of acute right lower quadrant tenderness was admitted to the surgical emergency department. his physical examination revealed no other finding than a mass in the right lower quadrant. his abdominal ultrasonography and abdominal ct revealed a plastron appendicitis. so he was hospitalized for medical treatment and discharged after days of treatment. his control abdominal ultrasonography and ct at the second month showed that plastron appendicitis persisted, therefore the patient was rehospitalized. he was discharged after days of medical treatment. after months the patient experienced severe abdominal pain. appendectomy was performed and histopathogic examination revealed a cytomegalovirus infection. the problems related to diagnose cytomegalovirus appendicitis and therapeutic management of cytomegalovirus infections are discussed. conclusion: aggressive use of ultrasound and abdominal computed tomographic scanning, along with early surgical intervention, is recommended. introduction: spontaneous intramural hematoma of intestine due to anticoagulan therapy is an unusual reason for acute abdomen. the first symptom is usually severe abdominal pain, nausea and vomiting. the most useful radiographic methods is computed tomography. the treatment approach is conservative and surgical. we present four patients treated our clinics due to intramural hematom. two patients are treated surgically and two patients are treated conservatively. material and method: we carried out four patients diagnosed and treated for intramural hematoma of small intestine between and years in haydarpasa numune training and research hospital second surgery department. we examine in this patients age, sex, etiologcy, hematologic parameters, the treatment approach (conservative and surgery), hospitalization times. results: the mean age of the patients was . years (range - ). all patients were male. the etiological factor was warfarin treatment due to aort valve replacement in three patient and ischemic cerebral disease in one patient. laboratuary parameters were elevated leukocyte counts in all patients. two patients was treated by surgical treatment due to intestinal obstriction and ishemia two patient was treated conservatively (nasogastric decompression and total parenteral nutrition). median hospitalization time was . day ( - ). discussion: when patients using anticoagulan therapy applied to emergency unit with abdominal pain, physicians must remember intramural hematoma as reason of acute abdomen. first choice is conservative treatment however cases of acute abdomen with intestinal obstriction and ischemia require surgical intervention. introductıon: motorcycle accidents continue to be a source of severe injury. the joy and exhilaration of riding motorcycles brings with it the risk of morbidity and mortality associated with these accidents. case: it concerns a -year-old man that in / / entered the emergency room after suffering a motorcycle accident. at the admission he had pain, swelling and deformity of the left knee. radiographs showed tibial plateau fracture type vi of schatzker. he was submitted to surgical treatment with open reduction and ostheosynthesis with liss plate and was orientated to rehabilitation. six months after, the fracture was healed in correct alignment, had normal gait, normal knee range of motion and returned to work. eight months after surgery he suffered another motorcycle accident with left leg trauma, radiographs showed a supracondylar femoral fracture type .a ao-asif and diaphyseal tibial fracture below the plate. he underwent surgical treatment with open reduction and osteosynthesis of the supracondilyan femoral fracture with lcp plate, extraction of the liss plate and ostheosynthesis with diaphyseal lcp plate. eleven weeks postoperatively, he was able to walk without crutches. five months after had normal range of motion of the left limb and was working. conclusıon: tibial plateau fractures are serious injuries and stable fixation without compromising the soft-tissue envelope is often difficult but with the liss plate we can achieve fixation of an associated metaphyseal/diaphyseal fracture component with minimal approach. multiple consecutive fractures are an important source of limb deformity and impairment, which we could prevent in this case. introduction: the optimum management of non-united humeral diaphyseal fractures remains unclear. a number of implants are available utilising varying operative philosophies and balancing operative complication risks. we present two cases of humeral shaft non-union treated with an intramedullary compression nail, a technique which is previously unreported. cases: case : a year old male with a closed fracture of the humeral diaphysis ( -a ). initial failed open reduction and internal fixation with an anterior placed . mm dynamic compression plate (dcp) was subsequently revised to a posterior . mm dcp plus bone graft months later. one year post revision, the fracture had failed to unite and was referred to the senior author. he underwent a stage reconstruction with the t humeral intramedullary nail in compression mode. at month review the fracture had united and at years postoperatively he had full range, pain free shoulder and elbow movement. case : a year old female with a closed diaphyseal humerus fracture ( -a ) treated conservatively in a u slab and functional brace developed a mobile, painful non-union. she underwent the same procedure as above and at months the fracture had united. she was pain free and had full range of elbow movement. shoulder movement was restricted due to co-existing glenohumeral osteoarthritis. conclusion: key tenets of fracture and non-union surgery include the ability to obtain stability and compression. this paper describes the first reported use of an intramedullary nail in compression mode for humeral diaphyseal non-union. fingertip amputations are the most common type of amputation injury in the upper extremity and they are important because of an often disproportionately long period of convalescence. different surgical procedures are available for reconstruction, but none is absolutely satisfactory. twenty-two cases ( patients) of fingertip amputation have been treated by primary skin closure using the v-y plasty (tranquilli-leali). there were men and women. the average age was . years. the procedure was carried out under regional anaesthesia using a tourniquet. all devitalized tissue was excised and the bone was smoothed. a triangular flap with a distal base was developed. the width of the base should be the same as the amputated edge of the nail or the nailbed, and the length should be a little longer than the width. the flap was mobilized and sutured to the nail or the nailbed. finally the volar gap was closed. the average follow-up period was months, ranging from to months. all of the flaps survived and achieved normal or adequate two-point discrimination. two patients had some loss of distal interphalangeal joint extension and five patients had cold hypersensitivity. rapid return to work was possible in most cases. the technique is simple and presents an excellent method for fingertip reconstruction in allen type i, ii and iii injuries. bilateral anterior shoulder dislocation is rare, and his aetiology is via various traumatic insults, atraumatic occurrences, and through extreme muscular contractions like epilepsy. in epileptic seizures is more common to occur posterior bilateral dislocation. the aim of this work is to describe a rare case of anterior bilateral shoulder dislocation after a convulsive crisis. it concerns a case of a -year-old male, with alcoholism history, who entered the emergency room in / / with a generalized tonic-clonic seizure. after, he had bilateral shoulder deformity and swelling. radiographs demonstrated a bilateral anterior shoulder luxation and bilateral greater tuberosity fracture. the dislocation was reduced and both shoulders were immobilized. month later, radiographs showed bilateral reduction maintenance and bilateral greater tuberosity fracture deviation. the patient had extremely restriction of active and passive ranges of motion in both shoulders: in the left had º of active external rotation and º of abduction; in the right º of active external rotation and º of abduction. at this moment surgical procedure was done with bilateral open reduction and osteosynthesis with ''phylus'' plate and was orientated to physical rehabilitation. at the month follow up, he had significantly improved both shoulders range of motion, and returned to the normal daily activities and months later returned to work. displaced fractures of the greater tuber-osities after shoulder dislocation may result in motion limitation and functional disability. open reduction and stable fixation allows for early passive motion of the joint and early return to activities of daily living. introduction and objectıves: direct inoculation, hematogenous spread or underlying medical illness which can predispose a patient easily for osteomyelitis are the causes of a vertebral infection. this case report represents a vertebral osteomyelitis of a patient seen after spine trauma. case: an year-old girl was admitted to our out-patient clinic with a history of progressive back pain. her inflammatory markers were high, physical examination revealed only spinous tenderness to palpation and she had a spine trauma history when she was at nine. radiological evaluation demonstrated lumbar and mild anterior compression, an incomplete intervertebral fusion and endplate irregularities with an intact spinal cord. bilateral sequential transpedicular drainage from l vertebra was performed without any complication. she has a pain free course of months with negative inflammatory markers. conclusions: the management of vertebral osteomyelitis is often challenging and in case of continuing pain and progressive kyphosis, surgical treatment is indicated. beside aggressive surgical procedures, minimally invasive techniques can be an option for the treatment of such cases. . instead of standard screws with diameter of mm using screws with diameter of . mm . instead of , diameter cannulated tunnel using , mm cannulated tunnel results: in use of this new modified method the time of surgery is shorter, the percutaneous surgical technique is simplified, the blooded lose is minimalizied, the surgery can be performed by two persons: the surgeon and the scrub nurse and few special instruments required. conclusion: based on our results we recommend this modified minimal invasive percutaneous osteosynthesis in case of garden iii femoral neck fractures, in garden iv one, especially immobile patients and patients with poor general conditions (asa score iv). introduction: pelvic fracture is one of the serious skeletal injuries, resulting in substantial mortality. the large amount of kinetic energy necessary to fracture the bony pelvis often leads to concomitant thoracoabdominal injury. pelvic fracture and combined injuries need effective initial resuscitation. however, it is hard to predict the mortality due to the complexity of multiple injuries. therefore, the introduction and objectıves: in this study, we aimed to investigate the distribution of the diagnosis in patients who underwent urgent surgical intervention in the operating room. methods: distribution of the diagnosis in patients who underwent an orthopaedic urgent intervention in the year are evaluated retrospectively from the medical records. results: patients with orthopaedic complaints [ male, female; mean age . ( - ) years] were operated on urgently in the year . patients ( shoulder, hip and lisfranc dislocations) had traumatic acute joint dislocation in which closed reduction was unsuccessful without general anestesia, one had supracondylar humeral fracture, one had distal femoral epiphyseal type ii fracture, one had isolated radial shaft fracture with neurovascular injury, one had t spinal fracture dislocation with paraplegia, one had type iii acromiaclavicular ligament rupture, one had quadriceps muscle laceration due to knife wound, one had tendo calcaneus rupture and one had patellar tendon rupture with medial meniscal injury due to knife injury. the mean time from admission to operation was found . h (range - ). conclusıon: it was concluded that the closed reduction of joint dislocations under general anestesia were the major group in orthopaedic urgent intervention. why ankle should be reduced urgently? shahzad sadiq, tariq mahmood worcester acute hospital, worcester, uk fracture dislocation of ankle is common orthopaedic emergency. it is paramount that to avoid soft tissue damage, the ankle is reduced as soon as possible. despite all efforts ankle dislocations could lead to significant blister formation. we reviewed a case series in which ankle joint was reduced with external fixator until skin healing methods: the cases who were admitted to our emergency department between august and and were exposed to traumatic extremity amputation were studied. the medical records such as age, sex, education level, occupation, the way trauma occurred, the affected anatomic zones, performed interventions and hospitalization duration parameters were evaluated. results: the data of subjects were evaluated in this study. mean age was , the rate of female/male was / . . there was a reverse correlation between the education level and occurrence prevalence. . % of the cases were laborers, . % various free self employed and . % were farmers. according to their occurrences, industrial accidents . %, pinching finger in the doorway . % and home accidents . % formed the first three rank. hand finger amputation was . %, toe amputation . % and others were . %. while cases were treated at the emergency service and discharged, cases were referred to related clinics. five cases were referred to other centers and two subjects willingly left our clinic. the mean length of stay was . days. conclusıons: traumatic amputation concerns particularly the young and the people in active work life. since the majority of the cases have hand injuries, they are striking because they cause workforce lose in addition to cosmetic and functional defects. introduction: distal radius fractures are one of the most common injuries regardless of age group. due to their localization they pose a serious threat to the fine wrist movements. for most of the patients the perfect functional result is of a vital importance. open reduction and stable osteosynthesis may help to produces desired outcome. methods: we have compared distal radius radius fractures treated with open reduction and stabilization with . mm synthes lcp and treated with synthes , mm lcp. we have compared the functional results, neurological damage and patient comfort with questionare form. measurements from x-rays were also compared. we have included patients of age between and years, with distal radius fracture. of them with intraarticular fracture. results: intraarticular fractures of distal radius treated with synthes . mm lcp show better functional results compared to synthes . mm lcp. there is no relevant difference depending on used material in extraarticular fractures. conclusıons: we recommend the use of synthes . lcp for intraarticula distal radius fractures for its greater diversity and abillity to stabilize even a small fragments. introduction and objectives: surgical treatment of fractures by using resorbable implants is not too expanded alternative to classical steel or titanium implants. indication for using are intraarticular and periarticular fractures at first of all. the most advantage is no necessary of implants extraction. another one is propagation of load callus during the degradation of material. possibility of making profitable ct and nmr is indispensable.in this paper author presents experiences with using of resorbable screws. methods: at our department there are resorbable cortical screws . , . and . mm bionx made from polyamide polymer with minimal stronghold for weeks and total absorption after years. this screws are determinated for cancellous bones in periarticular areas. we are using them in cases of fracture posterior wall of acetabulum, distal humeral intraarticular fractures, radial head. it can be used for treatment children¢s fractures too. the follow up is same like in ''classical'' osteosynthesis. results: there were no infection's complications, no malfunction screws in our group of patients. the postoperative and ambulatory treatment including physiotherapy was same like in group with classical osteosynthesis. the only one failure was during surgery -we have wraped screw four times because of insufficient pre-drilling and using too much power during insertion. we could recommend resorbable screws as suitable alternative in some type of surgical treatment intraarticular fractures at most. the indication have to be well look over and way of using has to be well understand as well as careful manipulation during surgery. the benefits are no metal material, no extraction in future and profitable ct and nmr. heart valve lesions in blunt cardiac trauma -mechanism, diagnosis and treatment robert lipovec, granc gregorcic department of cardiac surgery, university clinical center maribor, maribor, slovenia because of the variation in diagnostic criteria, cardiac involvement in blunt chest trauma is estimated at approximately %. in contrast to cardiac contusion which is often difficult to validate, traumatic valvular lesions are usually associated with some degree of hemodynamic impairment. patients with positive findings on clinical examination, ecg, cxr and troponine should be screened for valvular lesions by transthoracic echocardiography. blunt injury to cardiac valves can lead to progressive ventricular failure often requiring surgical management. patients with structural damage to the left sided heart valves usually require immediate surgical repair, while right sided valvular lesions can be managed in a delayed fashion. the management is based on type of structural injury and hemodynamic compromise. valvular reconstruction is usually attempted, if possible. the paper outlines historical perspective, mechanisms of injury as well as our experience with diagnosis and treatment of traumatic valvular lesions. two case reports are presented. one patient had a traumatic mitral chords rupture and the other had a tricuspid papillary muscle rupture. both cases were diagnosed immediately and surgically corrected. the ruptured mitral valve was urgently replaced. the tricuspid valve was repaired by delayed surgery. patients in al-ain city, united arab emirates . %, respectively. only the difference between group iia and iib was found to be statistically significant. dıscussıon: rib fractures increase the pain and have a negative effect on breathing during postoperative course. ineffective breathing may cause athelectasis, fever and infection which is associated with increased morbidity. the incidence of rib fractures are higher in anatomical resections in whom the thoracic cavity should be opened widely. a longer incision and step to step opening of the thoracic cavity may decrease the incidence of this undesirable complication. objectıve: this case report describes a surgical method to treat multiple rib fractures by using arch bars. case: a year old male patient was admitted to emergency unit with bilateral flail chest, bilateral multiple rib fractures, bilateral hemopneumothorax and pulmonary contusion. the patient was initially tachypneic and had a shallow breathing. because of the respiratory arrest he was intubated. physical examination revealed crepitation from subcutaneous and oseeous tissues especially on the left hemithorax. after left sided tube thoracostomy cc hemorrhagical drainage and massive air leak was observed. ct scan showed bilateral rib fractures extending from the first to the eleventh ribs, bilateral hemopneumothorax and bilateral pulmonary contusion (picture , ). therefore tube thoracostomy was also administered on the right hemithorax and cc hemorrhagical drainage and air leak occured. because of the thoracic deformity, persistant hemorrhagical drainage and air leak from the left hemithorax, the patient underwent exploratris thoracotomy and damaged pulmonary parenchyma was repaired. multiple rib fractures which damaged the thoracic wall stability severely were fixed by using arch bars (picture ). the patient required mechanical ventilation for days postoperatively. the latest ct scans of pulmonary parenchyma and thoracic wall after arch bar application are seen in pictures and . conclusıon: in this case the conventional rib fixation procedures with kirschner wires or plate plaques could not applied because of multiple small fractured segments. despite various materials suggested in literature, the use of arch bars to repair flail segments with multiple small pieces are not mentioned. tariq siddiqui, kimball maull the trauma center at hamad, hamad general hospital, doha, qatar introductıon: intrathoracic fluid following blunt chest trauma is almost always blood, and derangement in the patient's cardiorespiratory status is directly related to the volume of blood accumulated in the pleural space and the associated compression of pulmaonary parenchyma. tension chylothorax in the setting of bilateral chylothoraces is a rare cause for such a condition. a year old man fell from a height of three meters and presented with back pain. examination disclosed abrasion and tenderness over the right paraspinal area. he was discharged home. four days later, he returned in severe respiratory distress -hypertensive, with rapid pulse, tachypneic and with peripheral cyanosis. there were no breath sounds on the right side and decreased air entry on the left, and bedside ultrasound showed fluid in the right chest. chest x-ray confirmed complete opacification of the right hemithorax and loss of the costo-phrenic angle on the left side. a right tube thoracostomy yielded , ccs of pinkish-white fluid with immediate improvement in cardiorespiratory status. computed tomography disclosed bilateral th and th rib fractures, spinous process fracture of the th thoracic vertebra and bilateral effusions. a left chest tube brought back ccs of additional similar fluid. diliatation of the cisterna chyli in the abdomen with collapse of the thoracic duct were confirmed by mri. conclusıons: post-traumatic tension chylothorax causing cardiorepiratory compromise is rare. in this report, the patient responded to chest tube decompression and dietary measures without complication. author to editor: this report is complimented by excellent illustrations, including ct and mri findings, showing the anatomy of the injury… conducive to poster display. introduction: blast lung injury (bli) is a unique injury rarely seen in the civilian population. our objective was to assess its severity, prognosis and associated injuries as compared to victims with chest wall trauma following explosions. material and methods: retrospective study of victims of the march terrorist bombings in madrid who were treated at the closest hospital. we compared the group with pure bli (bilateral infiltrates in a butterfly pattern, and absence of chest wall fractures) (group i) with that of patients with peripheral infiltrates and chest wall fractures (group ii). results: of patients included in the registry, ( %) had thoracic injuries. ( %) were included in group i, and ( %) in group ii. the mean iss in groups i and ii was of . ± and . ± . , respectively. among the critical patient population in both groups (n = ), those belonging to group ii were in need of a longer period of ventilatory support and had more ventilator-associated pneumonias. in group i, the most frequent associated injuries were tympanic perforation ( . %), º- º burns ( . %) and abdominal trauma ( %). in group ii, º- º burns ( %), followed by tympanic perforation ( %) and skeletal trauma ( %). one patient died in each group ( . vs. . %). conclusions: pure bli patients had a greater degree of anatomic severity, had more severe burns and abdominal trauma than patients with lung infiltrates and thoracic wall fractures. overall prognosis was excellent in both groups. aım: aim of the study was to determine the rate of injuries detectable by ultrasonography in patients suffering from blunt thoracic trauma. materıals-methods: this study include the patients suffering from blunt thoracic trauma who have not any pathological findings in routine radiological diagnostic procedures. ultrasonography of the thorax was prospectively performed in patients with blunt chest trauma additionally to the routine radiological diagnostic procedures. ultrasound findings referring to the rate of detection of fractures, pneumothorax, pleural effusions, lung contusions, haematomas of the lung and chest wall was performed. results: we studied consecutive patients suffering from blunt thoracic trauma who has any pathological findings in routine radiological diagnostic procedures. the findings detectable by ultrasonography were the following: pleural effusion %, haemopneumothorax %, haematoma of the chest wall %, contusion of the lung %. conclusıon: rib fractures and pleural effusions are commonly diagnosed by ultrasonography in patients with blunt thoracic trauma. this study showed that ultrasonography may have superiority to chest-x-ray in diagnosis of rib fractures, pneumothorax, haemothorax, haematomas of the chest wall and pulmonary contusions in blunt thoracic trauma patients. Ş adiye emircan , Ö zlem kö ksal , fatma Ö zdemir , halil Ö zgü ç department of emergency medicine, uludag university, bursa, turkey department of general surgery, uludag university, bursa, turkey aım: the purpose of this study is to define the epidemiologic properties of patients that have been subject to thorax injuries and general body traumas, analyze their condition when they are brought to our emergency department, to determine the correlation of physiological and anatomical risk factors with the mortality rate, and to ensure early diagnosis of severe trauma. methods: trauma cases that had been subject to general body trauma have been retrospectively examined in this study. epidemiological properties of the cases have been determined, their initial condition during initial admission to emergency department have been analyzed, and cases have been assessed in terms of mortality developments. survival probabilities and unexpected mortality rates have been computed using trauma revised score-injury severity score (triss) methodology. results: mortality rates was . %. univariance analysis revealed that hypotension, age, pathologic respiration pattern, blunt injury, accompanying injury, abdominal trauma, high injury severity score (iss), low glascow coma scale (gcs), revised trauma score (rts), triss were the factors affecting mortality. in logistic regression analysis, presence of blunt injuries, triss < , iss > and gcs < have been found independent prognostic factors. strongest factor indicating mortality has found to be triss. in presence of factors affecting mortality, patients with thorax trauma should be evaluated as being of high risk group and therefore diagnosis and treatment strategies must be aggressive. case analysis based on triss model shall further reveal the mistakes that may be made in patient care and may improve patient care. introductıon: penetrating thoracal and cardiac wounds are asssociated with high mortality. we aimed to present our experience in such cases. materıals-method: twenty three patients with penetrating thoracal stab injury, between and , were investigated retrospectively. gender, age, injured areas, extent of thoracal damage, accompanying organ damages and outcomes of these patients were evaluated. results: all patients, except one, were male with a mean age of . years (between and years). in patients penetrating abdominal injury accompanied thorax trauma and one of these patients died peripoeratively. patients out of thoracal trauma had an additional cardiac stab wound and half of them were only pericardial injury. one of these cases went into emergency coronary artery bypass surgery due to lad injury. only four patients required intensive care postoperatively and four patients were lost perioperatively all of which had additional cardiac injury. conclusıon: the overall mortality rate was %, but mortality of patients with additional cardiac stab injury was higher, with a rate of %. suspect of cardiac injury should be considered in patients who are injured close around cardiac area and one should intervene quickly both in diagnosis and treatment. introduction: abdomen and thorax blunt and penetrating injuries, common cases of emergency surgery, cause less complication with proper analysis and surgical intervention. material and method: we retrospectively evaluated patients operated due to thoraco-abdominal blunt and penetrating trauma in _ istanbul training and research hospital last year. results: median age was . ( - ) and all were male. patients were operated due to blunt abdomen in , penetrating abdomen injury in , abdomen and thorax penetrating injury in by general surgeons. abdominal exploration in ( . %) were negative laparotomy. background: we described a patient with dysfunctions of all the nerves and ruptured brachial artery and vein due to closed injury caused by spontaneously reduced dislocation of the elbow. case: a -year-old man fallen down onto his left elbow with small skin erosion and a large area with ecchymosis on the elbow presented. left radial and ulnar pulses were nonpalpable but no sign of acute ischemia was noticed. he had drop hand and could minimally make flexion, opposition, abduction and adduction of fingers. strength of fingers, wrist flexion and thumb adduction were weak. radiography was normal. emergent surgical exploration was performed with prediagnosis of severe closed soft tissue injury and vascular damage. brachial artery and vein had complete disruption with rupture of brachial muscle and the anterior joint capsule. elbow joint could be posteriorly dislocated. artery and vein were repaired with saphenous vein graft. median and ulnar nerves had normal appearance. at postoperative th hour nerve injuries showed complete recovery. he could have normal range of motion in the wrist and hand. sensorial examination was normal. he had a well perfused arm. conclusıon: spontaneously reduced dislocations of the elbow can be sometimes missed. large hematoma and neurologic dysfunction in closed injury of the elbow indicate severe trauma of joint also in case of normal bone structure in radiography. immediate diagnosis and operative treatment of brachial artery injury is mandatory. closed elbow dislocation and multiple nerve injuries may have good results with conservative treatment. we present the case of a y male, with his left lower limb severely damaged by a caterpillar vehicle. he was admitted in the er about min after the accident. he presented with exposed fractures of the femur and leg bones, extensive soft tissue and muscle damage, class iii shock, and an umbilical clamp in the exteriorized femoral artery in the thigh, placed by a fireman in site. the mess (mangled extremity severity score) calculated for this patient was . after the initial assessment in the er the patient was transfered to the or. he had a complete transection of the femoral artery and vein with a severe ischemic foot. despite the mess score, a vascular and bone repairs have been considered. two temporary shunts were placed in both femoral vessels (artery and vein) followed by external fixation of the femur and leg fractures. the definitive vascular repair of the artery and vein was made with autologous saphenous vein after the bone fixation. some damaged skin and necrotic soft tissues were removed, and the reminder skin was only proximated. the limb was functionally and anatomically preserved, with no obvious neurologic deficit, despite subsequent debridements and skin grafts. the authors concluded that in similar cases: introductıon: trauma is responsible for . million of death, % of them in young people. vascular injuries of the upper extremity represent % of all peripheral vascular lesions, the majority of them at the braquial artery. objectıve: report a case of chemical injury of braquial artery. methods: -year-old man was admitted in the emergency room with third degree sulphuric acid burn in the middle third of arm ( % of total body surface area). the radial and ulnar artery pulses were palpable. at the th day after injury, haemorrhage was noted and disruption of braquial artery was clear. a braquial-radial reversed long saphenous vein interposition graft was performed. after surgery palpable radial and ulnar pulses were present, without evidence of nerve injury. results: the chemical burns severity depends on the concentration, properties of the agent and the duration of skin contact. sulphuric acid causes coagulation necroses, with thrombus formation in the microvasculature. its corrosive properties are accentuated by exothermic reaction with water. its burns are more serious than those compared with strong acids, and, as observed in this case, it causes frequently third-degree injuries. besides this, it has the ability to cause continuing tissue destruction, from th hour to th day after injury. this fact could explain why there was no artery lesion at the admission but at the th day. conclusıon: sulphuric acid burn is potential devastating and tend to be prolonged in time, obliging to a continuous monitoring and multidisciplinary approach. introduction and objectıves: the medicolegal studies show that the most frequent mechanisms of the lethal major vascular injuries were stab wounds followed by gunshot wounds and blunt trauma. during the blunt traumas, simple lethal major vascular injuries without any fracture are seen rarely. we experienced a case of common femoral artery and vein transection as a cause of death without any femoral fractures which were caused by blunt trauma. case: during the transportation of wood blocks, a wooden log fell from the truck over the forester, -year-old man. he sustained a crush injury and died in the emergency service on the same day of the trauma. it was learnt that no medical intervention was performed on the case. ecchymotic bruises on the left abdominal-pelvic, femoral, right inguinal, genital region, deformation under the right knee were observed during the autopsy. it was determined that there was a traumatic transection on the left common femoral artery and vein, which was accompanied by massive bleeding in surrounding soft tissues and muscles without any fracture of the left femur. all the internal organs were intact and showed paleness. death was due to internal hemorrhage caused by the transection of the femoral artery and vein. conclusıons: during the examination of the cases who were exposed to the blunt trauma, peripheral vascular injury must be investigated without any delay. if vascular injury was determined in the early times after the trauma, surgical and medical treatment could be performed successfully and the case could survive. introductıon: traumatic internal carotid artery dissection is a rare and grave cause of embolic strokes occurred especially in young age group. if it is not diagnosed early and required treatment is not given, thrombosis can be a serious trouble with permanent neurological deficit and high mortality rate up to %. case: we presented a delayed diagnosed traumatic carotid artery dissection in a year-old female case. there were no ischemic infarct findings in the cerebral ct on admission, but there were cerebral infarct findings in the cerebral ct taken twice because of the left hemiplegia noticed days later when the patient regained her consciousness. we made the diagnosis of the case, forwarded to our emergency service with acute cerebral infarct diagnosis, certain through arterial doppler ultrasonography, cerebral mri, diffusion mri and mr angiography. we did not consider invasive treatment since the neurological damage was permanent and dissection grade was iv according to angiography findings. we did not administrate anticoagulant treatment considering that the patient can turn her ischemic infarct into hemorrhagic infarct. the case was discharged within a week and advised physiotherapy. conclusıon: although the advances in diagnostic methods, diagnosis with traumatic carotid artery dissection is still missed out or delayed as in the case we presented. early diagnosis enables permanent neurological damage to be decreased or vanished. however, the vital factors for early diagnosis are the obtained anamnesis to direct to radiological examinations, detailed physical examination and high clinical doubts. introduction: acute arterial occlusion is a serious clinical condition resulting death of patient or related organs. these are usually older patients with a lot of comorbid conditions. method: _ in our clinic, we retrospectively examined the records of patients who underwent surgical treatment for acute arterial occlusion between january and december . mean age of patients was . years. ( %) of these patients were female, and ( %) were male. embolic occlusions were found in an upper extremity in ( %) patients and in a lower extremity in ( %). the most common source of these emboli was cardiac origin. atherosclerosis, trauma and arterial catheters were the other causes of emboli. ( %) of patients were admitted less than h preoperatively, ( %) were admitted - h preoperatively, ( %) were admitted after a delay of longer than h preoperatively. ( %) of patients were in sinus rythm, ( %) were in atrial fibrillation preoperatively. motor dysfunction of extremity was found in ( %) of patients preoperatively. diagnosis was based on the findings of physical examinations and emergent doppler ultrasonography. any other invasive evaluation was not performed to decrease acute occlusive ischemic period. surgical intervention had performed immediately results: the overall mortalıty rate was % ( ). _ in ( . %) of patients, after setting of demarcation line, amputation was performed. conclusıon: early diagnosis, catheter embolectomy and use of anticoagulation are very important therapeutic modalities for limb salvage and reduction of morbidity and mortality. there was a comorbidity in all patients and cardiac disease and hypertension were the most common ones. the most common laboratory abnormalities were leukocytosis, hypoalbuminemia, hyperamylasemia. there was superiory vasculary necrosis in patients, inferior vasculary necrosis in one patient.one patient had nonocclusive mesenteric ischemia. segmentery resection was performed to patients. abdominoperineal resection was performed to the patient with inferior mesenter artery occlusion. we performed duodenotransversostomy on two patients and only laparotomy on two patients. reoperation was required in five patients. causes of death was multiorgan insufficiency in seven cases, cardiac death in two cases.one patient died due to short intestine syndrome. results: the patient was discharged on postoperative th hours without any complications. conclusıon: single incision laparoscopic appendectomy is a safe and effective technique that can be performed in well experienced centers success. jorge pereira, luis filipe pinheiro surgery department, sã o teotó nio hospital, viseu, portugal trauma represents one of the most important causes of death and disability of today. the exponential growth of the major cities, the continuous building of roads and the uprising of terrorism, foresee that trauma will keep is importance as a major cause of disease. recently, the management of the trauma patient as been modified, with the introduction of the atls method. this fact has produced great improvement, proven and reproducible, decreasing mortality and morbidity of trauma. the teaching of this new method, albeit its good results, has not seen many changes over the years. however, in recent days, we have seen the introduction of new computer technologies in teaching. this methods use simulation, e-learning and even interaction as learning techniques. taking advantage of the mentioned techniques, the authors produced an animated video, using computer-animated drawings that allow demonstrations difficult to reproduce in real life. using simple software and computer video editing, the authors invite you to watch a trauma patient in the emergency room, since his arrival to the end of the primary survey, watching demonstrations of life saving techniques and the stabilization of the patient. the authors present a video of a young male, years of age, ± kg victim of a motorcycle crash, with a fall over cut branches of trees, min before his admission in the e.r. he sustained an impalement with a stick in the fourth right anterior para-sternal space. at admission he was conscious, gcs = , bp = / , hr = /m, sato = %, hemodynamically normal. breath sounds slightly diminished in the left. a left anterolateral thoracotomy as been done, as well a left subcostal lararotomy, since the stick also had penetrated the left hemidiaphragm. the patient had no significant thoracic or abdominal injuries despite the violence of the trauma mechanism. the ''foreign body'' was successfully removed by combined abdominal and thoracic route, and a left chest tube was put in place. the patient recovered very well and was discharged in the eighth day. author to editor: ''english'' corrections are welcome, please! berker bü yü kgü ral, mehmet bekerecioglu al-marashda , amgad elsherif , hani o. eid , fikri m univariate analysis was used to compare patients who died and those who survived. significant factors were then entered into a backward stepwise likelihood ratio logistic regression. results: out of , patients of the registry, patients ( . %) had chest trauma with a mean (sd) age of . ( . ) years. ( %) were males . ( . %) got injured in the street or highway, ( . %) at work place, and ( . %) at home. the main mechanism of injury was road traffic collision in ( %) fall from height in ( . %). ( . %) were admitted to icu. the median (range) iss was ( - ). ( . ) of patients got isolated chest injury, ( . %) had head injury, ( %) lower limb injury, ( . %) upper limb injury iatrogenic rib fractures during thoracotomy: comparision of posterolateral and anterolateral thoracotomies operations for thoracic trauma, extended lung resections and re-thoracotomies were excluded. posterolateral thoracotomy incision was performed for group i ( patients; . %), and anterolateral thoracotomy incision for group ii ( patients; . %). groups were also divided into two groups for the type of resection the percentages for rib fractures for group ia, ib, iia, and iib were . , . , . , and . damage control principles can a be used in all surgical fields . general surgeons must have experience in vascular repair skills . the reperfusion of the limb joão filipe coutinho vasconcelos , sandrina braga , pedro brandão , daniel brandão , miguel maia , joana ferreira , paulo barreto , vítor martins , a. guedes vaz , leonor rios vila nova de gaia, portugal department of plastic surgery rectal prolapse describes the protruding of the entire rectum or some parts of the rectum from anus. it is caused by the weakening of the ligaments and muscles that hold the rectum in place.it is associated with advanced age, long term constipation or diarrhea, childbirth, previous surgery, and sphincter paralysis. trauma may cause sphincter paralysis and can be associated with rectal prolapse. it usually begins with prolapse of the rectum during defecation or val salva movement and usually progresses to a chronic stage. long term prolapse can cause ulcerations, bleeding and in some cases perforation if not reducted. a -year-old male presented with rectal prolapse, bleeding, abdominal pain. he stated that he could not replace the prolapsed segment for days and has been suffering for years since after he fell from a tree and he had massive bleeding during the last h. physical examination revealed that a cm segment of the rectum was prolapsed with the whole layers. there were ischemic and necrotic areas and active bleeding from the mucosa. reduction trial was not successfull. emergent laparotomy was performed. bimanual reduction failed.thus transanal intervention, with sigmoid resection was performed. end colostomy was preferred. no complications occurred the following months and colorectal anastomosis was performed with a preventive ileostomy. although rectal prolapse is usually a benign condition it may cause fatal complications such as perforation, necrosis if not reduced for a long time and surgery should be performed promptly in these cases.ing to the age, diagnosis, treatment results, mortality rates between the years of and . results: summarised in the table .in conclusion, the most of our multitrauma cases caused by traffical accidents, were young. the mortality rate % for multitrauma cases, the percentage of multitrauma cases were . % of all intensive care patients. preventing the accidents is as much important as treatment strategies for multitrauma cases. arif tü rkmen, ertan gü nal, mehmet bekerecioglu, berker bü yü kgü ral department of plastic and reconstructive surgery, gaziantep university school of medicine, gaziantep, turkeyintroduction and objectıves: as personal problems dealing with health, jobs, financial status and the family problems increasing, more suicide attempt subjects are consulted in emergency rooms day-byday. although gunshots to the oro-facial region form - % of the total victims, it is important that seconder deformities resulted with aesthetic, functional and psychological problems were usually encountered after primary surgery. this study reviews cases of self-inflinct gunshot injuries of face and our experiences in early and late managements over a -year period.methods: this study is based on subjects who attempted suicide resulting in extensive facial deformities, not in death between and . demographic details, mechanism and direction of injury, early and late management and seconder deformities were recorded. results: after establishing the airway control and completing the primary survey, all patients underwent debridement and bleeding control. reconstruction of maxillofacial fractures were performed in patients on the day of admission and the remaining within days of injury. following procedures as scar revisions, rhinoplasty, mandible reconstruction, ectropion operations or coverage of palatal defects etc. were performed after earliest months from primary operation.conclusıons: after stabilization of life-threatening injuries, the goals of early management are regenerate of anatomic form and function to include dental occlusion and mouth opening to prevent scarring, contractures of mobile structures and ankylosis. seconder operations required for aesthetic and functional problems should be performed earliest after month from primary operation that all the scar formations and wound healing's were completed. background: injuries of maxillofacial region in patients with polytrauma are frequent but are rarely treated primarily. in order to achieve satisfactory treatment results trauma treatment team must include a maxillofacial surgeon.materıal-methods: the study shows treatment results of polytraumatized patients with maxillofacial injuries. dominant trauma was: maxillofacial in %, craniocerebral in %, locomotor in %, thoracic in % and abdominal in % of cases. treatment of maxillofacial trauma was in % of cases surgical and in % conservative. treatment of other traumas was operative in % and conservative in % of patients. results: early mortality rate was %. four exitus were recorded during the first h, exitus on the th day and exitus on the th post-trauma day. dominant trauma was in exitus craniocerebral, in exitus thoracic and in exitus severe locomotor. long-term treatment results in remaining patients were: for maxillofacial regiongood in patients ( %), satisfactory in patients ( %) and poor in patients ( %); for other regions -good in patients ( %), satisfactory in patient ( %) and poor in patients ( %). conclusıon: existing maxillofacial trauma in polytraumatized patients usually directs treatment toward conservative methods.reasons for this are insufficient number of maxillofacial surgeons in trauma teams and delay of surgical treatment of other present traumas due to difficult anesthesia application. unfortunately, conservative treatment approach induces inadequate treatment results from both functional and esthetic point of view. however, as revealed by hospitalization, transportation, and mortality data, women were exposed to more severe trauma. in addition, poisoning and fall caused more death. the rate of mortality of women seems to be less when compared to literature. conclusıon: bicyclists in non-fatal frontal crashes with cars suffered the most serious injuries from the impact to bonnet and windshield, likely due to highest energy transformation. bicycle helmets, collision mitigation system that alerts the driver or automatically brakes the car, and external airbags protecting the bicyclists from hitting bonnet and windshield, may reduce injuries.author to editor: this is a complete analysis of mechanism of injury in crashes carfront versus bicyclist. journals were completed with traffic notes from police at scene, patents own history of the crash from the injury database and furthermore interview. the catch area is welldefined with no other hospitals in the area and total cover of all injuries in the database. this gives a good picture of the dynamics of the the crash and mechanism of injury. or street ( ais +). third impact in patients gave injuries ( head/neck) at windshield ( ais +) or street ( ais +). thirteen persons, who hit the street as the fourth impact point, sustained three injuries (zero ais +) as contusions of the pelvis and lower back. conclusıon: pedestrians in non-fatal frontal crashes with a car suffered the most serious head injuries at second impact in bonnet, windshield or street. safer passageways for pedestrians might preclude the crash. mechanisms preventing the pedestrian of hitting the bonnet and windshield, may reduce the injuries. author to editor: this is a complete analysis of mechanism of injury in crashes carfront versus pedestrian. journals were completed with traffic notes from police at scene, patients own history of the crash from the injury database and furthermore interview. the catch area is welldefined with no other hospitals in the area and total cover of all injuries in the database. this gives a good picture of the dynamics of the the crash and mechanism of injury. one of the primary characteristics which professions possess is to make the members of a profession have autonomy in decision making and practice. nursing practice is evaluated in relation to professional practice standards and guidelines, rules, etc… application of professional standards requires that nurses use critical thinking for the good of individuals or groups. critical thinking also requires the use of scientifically based and practiced-based criteria for making clinical judgments. these criteria may be practice based on standards developed by clinical practice guidelines developed by individual clinical agencies. for example, intensive care units (icus) are designed to meet the special needs of acutely and critically ill patients. a patient is generally admitted to the icu for one of three reasons. the patient may be physiologically unstable, at risk for serious complications and require intensive and complicated nursing support. despite the emphasis on caring for the patient who can survive death is common in icu patients. it is reported that % of patients admitted to icus will die, and another % may leave the icu but will not survive to discharge. this suggests a need for caution and coordination of care when transferring patients from icus to general units. in this article, the practice guideline which titled ''patient appropriateness for adult icu admissions and discharge'' will be discussed. the terminology for pelvic fractures and its recent modifiers are confusion to the trainee to say the least. we surveyed orthopaedic trainees in the latter part of their surgical rotations. the same set of radiographs were shown to all trainees and their classifications recorded. the same set of radiographs were shown to the trainees again after a period of days. we found significant inter-observer variability ( %) and wide intra-observer variability ( %). though trainees were adept at identifying basic fractures patterns and identifying individual column or lip/wall fractures the complex fracture patterns seems to generate different answers from the same observer at different times. the ct scan was the most effective tool identified for accuracy of the fractured fragments but the more complex assignments resulted in the trainees grouping them differently. results: twenty-one fractures ( . %) healed without complication including five fractures where external fixation was converted into internal one. the mean time to union was . ( - ) months. there were two pin-track infections, two deep infections, and only one nonunion. the femur length was equal to the healthy side in cases, and was shorter by - cm in five cases. mean active knee flexion was °. knee flexion was more than °in patients. conclusions: external fixation is a useful technique for the stabilization of severe open and close highly comminuted femoral shaft fractures. it is safe procedure to achieve temporary rigid stabilization of femur fracture in critical polytraumatized patients before delayed internal fixation (damage control orthopedics). purpose of this study was to determine the factors predicting mortality.methods: a retrospective study was performed on cases of pelvic fracture who visited to emergency department from january to june . data were collected regarding demographic characteristics, mechanism of injury, injury severity score (iss), abbreviated injury score (ais), simplified acute physiologic score ii (saps ii), transfusion requirements, fluid requirements, the finding of angiography, hemoglobin, platelet, prothrombin time ( fractures were managed by using an intraarticular, chevron-shaped olecranon osteotomy in all patients. methods: the mean age was . years. a straight posterior surgical incision was performed. a thin oscillating saw was used to begin the olecranon osteotomy. a small osteotome was then inserted and the osteotomy was completed through the subchondral bone. the posterior elbow capsule was incised. the olecranon fragment and the triceps muscle were reflected proximally to expose the distal humeral articular surface. osteotomy fixations were performed with two intramedullary kirschner wires and dorsal tension band in patients. in four patients, an intramedullary screw and a tension band were used for fixation. results: at the final control, the jupiter classification system was used for the evaluation of the patients. eighty one percent of the patients revealed good and excellent results at the long-term followup. none of the patients showed osteotomy nonunion. the most frequent complication was skin problem due to subcutaneous prominence of the implants.conclusions: the goals of treatment of distal humerus fractures are anatomic articular restoration and rigid fixation. olecranon osteotomy provides good visualization for rigid fixation especially in type c distal humeral articular fractures. this is a useful method for excellent anatomic reduction of the articular surface. conclusions: there could be some steps during primary treatment for discussion. but real mistake was vacillation and delay of reosteosynthesis and spongioplasty even it was cause by risk for infection and possible failure of flap. our case demonstrate that sometimes too much care could be hurtful. introductıon: the population who applied to the public emergency services due to the injuries related to butchering the sacrificial animals during the feast of sacrifice were evaluated. materıals-method: eighty-nine patients who admitted to the emergency services in kirikkale during the feast of sacrifice in were evaluated according to age, sex, application day and time, state of experience, type and mechanism of injury and medical treatment. results: the age average was ± and % of them were male. eighty-eight percent of the patients admitted in the first day. seventy percent of the injuries were penetrating injuries and % of them were blunt. the average time passed after the trauma was min. almost half of the cases were wounded with a knife, % were wounded unintentionally by the others and % of the cases were due to hit of animals. fifty-seven percent of the patients had butchering experience before. ninety-one percent of the cases were hand injuries. thirty percent of the cases had fractures. nine percent of all cases had tendon injury, % of the cases were treated primarily skin suturation. conclusıon: the injuries related to butchering of the sacrificial animals sometimes can be serious. in extremity injuries, the number of tendon cuts and bone fractures can not be underestimated. both equipments and medical staff support for the injured people should be provided and preliminary arrangements should be done during the feast of sacrifice. every butchering job in this period should be given to professionals. introduction: osteoporotic fractures of the trochanteric area are often treated with a gamma-nail or similar implants utilizing a screw applied into the femoral head. one of the main problems of these techniques is the cut out in the femoral head. we biomechanically evaluated a novel technique of cement augmentation of the bed of the screw in a standardised osteoporotic bone model and its capability to reduce the cut out rate. material and methods: utilizing a polyurethane-foam osteoporotic model that has been previously described (specific gravity . g/cm ), a biomechanical testing of a neck of femur screw (tgn, stryker, duisburg, germany) was performed. the screw was implanted according to manufacturers instruction, the migration characteristics were then biomechanically tested (zwick testing machine) with a static stepwise load increase ( n). first these tests were performed without, in a second series with the augmentation of a fast hardening biopolymer (corthoss, orthovita, usa). each series was repeated five times. the transfer from a stable to an unstable condition was biomechanically determined. results: on average the applied load at the moment of failure with critical cut out was n for the non-augmented screws. with augmentation, the average load was , n, the difference was statistically significant.discussion: it appears in biomechanical testing that augmentation of the femoral head can improve the load bearing capabilities and thereby possibly reduce the rate of cut-out failure in osteoporotic bone. we proceed now with further biomechanical testing, grant of the local ethics committee for human testing has been applied for. introductions and objectıves: the aim of this study was to examine the relationship between childs' favourite cartoon stars who can fly and falling down from a high place in two cases. methods: in this paper we presented two similar cases who were seen with a history of falling down from a high place. the first case was a -year old girl who fell down from the third floor of their apartment. on her examination it was learned that she wanted to fly like her favourite magical cartoon star girls. the second case was a -year old boy who fell down from the second floor. while falling down he was screaming to his friends that he was flying.results: on the physical examination of the first case, deformity and crepitation in right femur were found. x-rays showed right femur distal epiphysis salter harris type iv fracture. she was hospitalized due to the pneumothrax in pediatric surgery intensive care unit. the procedure of closed reduction and fixation with multiple kirschner wires was performed under general anestesia. closed body fracture in the left femur was found in case ii. introductıon: the purpose of this study was to compare the biomechanical properties of different possibilities of screw placement in multidirectional palmar fixed-angle plate in distal radius osteotomy cadaver model under loading conditions. methods: an extra-articular fracture was created in pairs of fresh frozen human cadaver radii. the specimens were randomized into four groups. all radii were plated with a volar fixed-angle plate. there were different possibilities of screw placement in the distal fragment:group a: screws were used in the distal row of the plate. group b: screws were used alternately in the distal and proximal row. group c: screws were used in the proximal row. group d: screws were used filling all screws holes in the distal and proximal row of the plate.the proximal fragment was fixed with screws each. the specimens were loaded with n under dorsal and volar bending and with n axial loading. results: group d had the highest stiffness of n/mm under axial compression and was statistically significant stiffer than the other groups. group b had a stiffness of n/mm followed by group a with n/mm. group c showed only a stiffness of n/mm. there were no statistically significant differences under dorsal and volar bending.conclusıons: occupying all screw holes in the distal fragment offered the highest stability. using only the proximal row with screws showed an unstable situation. it is therefore recommended to use at least screws in the distal fragment. perilunate dislocations are the most common type of carpal dislocation. they can be produced by high-energy injuries. the population primarily at risk is male young adults. in perilunate dislocations, the proximal articular surface of the lunate retains contact with the distal radius. the dorsal-perilunate/volar-lunate dislocation is more common. we performed a retrospective study of perilunate dislocations from to . a total of were reviewed. mean age of the patients was . (range - ). all the patients were male. the trauma mechanism was fall from height in and motor vehicle accident in . all the dislocations were dorsal-perilunate/volar-lunate dislocations. all the dislocations were together with ipsilateral scaphoid fractures. all were closed injuries and all were reduced by closed reduction maneuvers. percutaneous pinning was applied for the dislocation and scaphoid fractures. mean follow-up time was months (range - months). when compared with the non-injured wrist, there was limited range of movement in only one patient.no limitation of range of motion in the other patients could be obtained. the patients did not have pain and instability. radiologically no arthrosis of the wrist could be obtained but in all patients there was scaphoid pseudoarthrosis. functional range of motion of the wrist after a perilunate dislocation is independent of the concomitant scaphoid fractures. bostjan sluga, tomaz malovrh traumatology department, university clinical centre, ljubljana, sloveniainfective complications of tibia fractures result in nonunion, bone defects and soft tissue envelope impairment. several methods of treatment have been described to deal with bone defect including callus distraction, fibula transfer, muscle flap and bone grafting. there are many possibilities to encourage bone healing; bone morphogenic proteins, platelet rich plasma, electrical, ultrasound or shockwave stimulation and hyperbaric oxygen therapy. a patient with both tibias infected nonunion is presented. high energy trauma primarily and inadequate debridement secondarily were probably the cause of the healing complications. a middle-age man was injured in a gas explosion and suffered comminuted closed fractures of both distal tibias. after an immediate external fixation we operated him on the th day after the injury, anatomical reduction and internal fixation on both sides was done. an infection developed after weeks. ankle joint arthrodesis was necessary on one side and implant removal, repetitive debridement with bone grafting on the other. we could not cure the infection and the fracture did not heal. after years, operations, days of ciprofloxacin, days of gentamicin, days of vancomycin, days of implanted gentamicin antibiotic beds and the use of cultivated autogenous steam cells clinically evident nonunion was still present. surgery was performed again, a resection of cm of bone and callus distraction with an unilateral frame. despite a fast progress in knowledge and improvement of methods, a radical debridement, preservation or reconstruction of soft tissue coverage, systemic and local antibiotic therapy and appropriate stabilization is still a keystone in infected nonunion treatment. some people who live in some regions of our country trust in bonesetter's skills more than these ones of professional orthopaedist in the hospitals. the fact that some bonesetter's particular skills to cure the non-operative back pain seems to make them credible on closed reduction too. in this case report, right humerus proximal body fractures due to falling were discussed. the case was -year-old male. in the treatment of this case, velpau bandage, closed reduction and plaster cast-splint has been applied after that he was called to the clinic control, but he did not come to control. the parents of the case were aware of the fact he cannot raise enough the right upper extremity and he was taken along to the hospital. from his anamnesis, it has been learnt that the bonesetter has removed the castsplint and, tried to perform closed reduction. actual physical examination showed that there was an arm pain, crepitation and deformity. a diagnose has been made: there was an union right humerus proximal body fractures, so he has to be hospitalised. under general anaesthesia, closed reduction and bandage velpeau were applied. on the rd day of the hospitalisation, the case was externed and was advised to come for a polyclinic control. because of the importance of epiphysis lines of bones and of other complications from the upper extremities fractures, the treatments have to be performed by the orthopaedists or in accordance with them. about this medical issue, families should be made conscious by healthy authorities. there were women and men. the mean age was . years (range - years) and mean follow-up period was months (range - months). posterior kocher-langenbeck approach was used at patients and ilioinguinal approach was used at two patients.results: there were both column, posterior column with posterior wall, transverse with posterior wall and posterior wall fractures. anatomic reduction was obtained at patients and adequate reduction at patients according to matta criterias. harris scoring system revealed excellent at , good at , moderate at and bad at patients. over % of these patients had satisfactory function. there were any pulmonary embolism, deep infection or nonunion detected. one of four patients whom had developed osteoarthritis, managed with total arthroplasty. postoperative sciatic nerve injury was developed at one patient. conclusıon: secondary arthrosis, nonanatomic reduction, unstable fixation and nerve injuries were associated with poor results. our clinical experience for acetabulum fractures were similar to that reported previously at the literature with over % of satisfactory results sedat kocak, birsen ertekin, esma erdemir, abdullah sadik girisgin, basar cander introduction and objectives: quadriceps muscle tears are usually seen in middle-aged and older people. particularly people with chronic diseases (such as diabetes mellitus, renal failure and gout) are prone to develop quadriceps muscle ruptures. we present a case of partial rupture of the quadriceps muscle in a -year-old girl after intramuscular injections. we thought that this patient could be the youngest patient reported with a quadriceps muscle rupture. methods: patient presented to our clinic with left knee pain, limitation in knee flexion and a localized palpable swelling at the anterolateral side of thigh. there was no blunt trauma but it happened while she jumping on the sofa. in her detailed history we learnt that she had a serious upper tract respiratory infection a week ago and used some parenteral antibiotics (twice a day, intramuscular clindamycine for days).results: plain radiographies were normal. mri showed a partial tear of the vastus lateralis muscle matching with the injection sites. the patient was placed in a long leg half-cast which was maintained for weeks. she treated with conservative treatment successfully.conclusions: mr imaging is useful to diagnose and differentiate in this pathology. multiple intramuscular injections may contribute to damage muscles and make them prone to tears with muscle contractions. quadriceps muscle ruptures in children can be treated successfully with conservative treatment. twenty year old female attempted suicide by jumping from a four story high building, resulting in multiple fractures of the limbs and a complex fracture of the body of the fourth lumbar vertebra (l ) resulting in paralysis of the inferior limbs. the l fracture was treated by a neurosurgeon with the extraction of the body of the vertebra, insertion of a cage device and arthrodeses of the third and fifth vertebras using a metal plate and screws, thereby stabilizing the affected segment and decompressing the medullar channel. the approach was achieved by a general surgeon using the technique of localio, that consists in a paramedian incision of the abdomen and the dissection of the retroperitoneal space without entering the abdominal cavity, dissecting and isolating the left ureter and the main vascular structures (iliac vessels and the left iliolumbar vein) in order to allow a good exposure of the three vertebra bodies involved. the patient recovered the complete function and control over the limbs, resulting no neurological sequelae from the fracture. it is of major importance that this procedure be performed by a multidisciplinary team of surgeons, involving a neurosurgeon and a general surgeon, in this way achieving a better result and a lower risk of complications. josef märz department of surgery, regional hospital karlovy vary, czech republicabdominal ultrasonography or ct were applied to ( . %) patients with blunt trauma and ( . %) patients with penetrating trauma. one ( . %) negative laparotomy was applied to patients with blunt trauma. to splenic injuries was splenectomy. sigmoid perforation, diaphragm rupture, bladder rupture were observed and were fixed primarily. one patient died during surgery due to liver and vena cava injuries. patients with penetrating injury were operated due to firearm injury in ( %) and stab wound in ( %), mortality was not. negative laparotomy was applied to ( . %) patients. multiorgan injury was observed in patients. tube thoracostomy was inserted to patients. of the intestine injuries and stomach injury was fixed primarily. two resection and anastomose and three diversionary ostomy were done. conclusion: proper examination must be considered according to the formation of trauma. _ imaging methods have been used less in penetrating trauma, and negative laparotomy is reported to be applied more than in cases of blunt traumas introductıon: chest tube insertion is frequently used by thoracoabdominal surgeons in urgent conditions. occasionally, this invasive procedure may be associated with lethal complications in inexperienced hands. in this study, we analyzed patients with visceral and/or diaphragmatic injuries due to chest tube insertions. methods: six patients with diaphragmatic and visceral injuries subsequent to chest tube insertions between and were evaluated. the diagnosis was established with roentgenogram, biochemistry of the fluid drained from the chest tube and confirmed with computerized tomography in all patients. results: pleural effusion accompanying respiratory distress was the main indication for chest tube insertion in all patients. in five patients, coexistent gastric perforations with diaphragmatic ruptures were detected, also the esophagus was additionally perforated in one patient. partial gastrectomies were performed in three patients, whereas total gastrectomy in one and primary repair required in two patients respectively. five of the patients died from septic complications. the only survived patients with early diagnosis and primary repair was discharged from the hospital on the th day. conclusıon: penetration of a drainage tube through viscera is a wellrecognized but seldom reported phenomenon. in the majority of patients with diaphragmatic rupture, abnormalities can be found at initial chest radiography. if transdiaphragmatic herniation is missing, diaphragmatic rupture is difficult to diagnose by chest radiography alone. computed tomography is often necessary to reveal the correct diagnosis. early diagnosis and treatment are extremely important in the management of these patients. bronchobiliary fistula is a rare condition, arising as a complication of hydatid disease of the liver, hepatic tuberculosis, hepatic malignancy, chronic pancreatitis, hepatic trauma or surgery. conservative treatment is directed at non-surgical approaches of relieving biliary obstruction to allow for normal flow of bile into the duodenum via endoscopy or percutaneous routes. however in complicated cases which failed conservative non-surgical therapy, surgical intervention is usually required. we report a -year-old man who presented with bilioptysis from a bronchobiliary fistula resulting from firearm injury after days. for his current admission, the patient reported a -day history of cough productive of yellow-green sputum coupled with fevers and malaise.this was successfully treated surgically with a right medial lobectomy and t-tube drainage. paget-von schroetter syndrome(pss) refers to spontaneous thrombosis of the subclavian vein and constitutes . - % of all venous thromboses. it is prevalent among young and healthy adult males who engage in sports. a -year-old male presented with pain and swelling of the left arm after a sequence of intense, repetitive weight lifting exercises. upon questioning, he disclosed that he had been engaged with weight lifting for a long time and had complaints for a while. bases on these findings, upper-extremity effort thrombosis was suspected. contrast-enhanced mr angiography revealed near-complete occlusion of the proximal left subclavian vein and collateral formations in the distal were observed. color doppler us showed a heterogeneous thrombotic mass that filled almost the entire proximal segment of the left subclavian vein thrombosis extended into the proximal segment of the left internal jugular vein. furthermore, extensive venous collateral formations were present the left proximal cervical localization. both mr angiographic and sonographic findings were consistent with pss. as the patient had already developed extensive venous collaterals, no surgical intervention was performed. instead, treatment with lowmolecular weight heparin and anticoagulants, was initiated and was continued along with the follow-up for bleeding parameters. as of years clinical follow-up the patient is doing well, and treatment is continued with oral anticoagulants and acetylsalicylic. pss should be considered in the differential diagnosis of effort induced upper extremity pain and swelling. conservative non-operative treatment is acceptable and can be successfully used with favorable long-term outcomes. although, blunt trauma of the extremities is a common diagnosis in emergency clinics, compartment syndrome associated with vascular injury following blunt trauma may be difficult to diagnose. urgent diagnosis and treatment of compartment syndrome is of particular importance for limb salvage or even to save the patients' life. years old male patient was referred to emergency clinic due to blunt trauma of the right lower extremity. right thigh was echimotic and swollen. pallor, coldness and severe pain were present at the lower part of the trauma level. distal pulses were not palpable. acute compartment syndrome of the right thigh was diagnosed that led to an emergent operation. intraoperatively, popliteal artery rupture was diagnosed and repaired with end-to-end anastomosis. fasciotomies were performed at the anteromedial and anterolateral portions of the right leg and anteromedial part of the thigh for the treatment of compartment syndrome. in early postoperative period, distal pulses were palpable. preoperatively present pallor and coldness improved in the first few h. fasciotomies were closed with skin grafts at the th postoperative day. patient was discharged at the th postoperative day with palpable distal pulses and failure of dorsal flexion of the right ankle representing mild neurological injury. possible vascular injury should be kept in mind in a patient with compartment syndrome following blunt trauma of extremities. success of surgical repair depends on the early diagnosis and treatment. late repair may result in neurological complications or even the loss of extremities.conclusıon: acute mesenteric ischemia is highly mortal emergency which should always be suspected in elderly patients with cardiac disease suffering from abdominal pain. acute ischemia of the lower member after injury by firearm -case report patient with years, male sex, admitted at the urgency department after injury of the left lower member by firearm. at the admission presented loss of substance and hemorrhage in the medial and lateral faces of left leg and foot with signs of ischemia. an arteriography of the member was carried out showing infrapopliteal arterial lesions of the three axes. during surgery, fracture and losses of peroneum substance was observed with macroscopic tibial and peroneal common nerves integrities. he was submitted to tibial interposition grafts with subsequent reversed contralateral internal saphena vein bypass.in the th postoperative day it was carried out surgical debridement and plastia with partial skin graft. he presented good cicatricial evolution, with hospital discharge days after, oriented to external consultations of vascular surgery, plastic surgery, physical/ rehabilitation medicine and pain consult. five months after surgery, pain was controlled with the medication instituted, with improvement of the left lower member limitations with physiotherapy, good cicatricial evolution and posterior tibial and dorsalis pedis pulses palpables. dıscussıon: the incidence of arterial wounds following penetrating injury of the members is %. the vascular trauma occurs more frequently in the lower extremities, being the most common clinical presentation acute isquemia. the most frequent causes are vehicle accidents, falls and firearm wounds. in the united states, injuries by firearm represents the first cause of death in young individuals of male sex. the arterial bellow-knee injuries by firearm remain like a challenge, with an associated rate of amputation of to %. jorge pereira, luis filipe pinheiro surgery department, sã o teotó nio hospital, viseu, portugaltrauma represents one of the most important causes of death and disability of today. the exponential growth of the major cities, the continuous building of roads and the uprising of terrorism, foresee that trauma will keep is importance as a major cause of disease.recently, the management of the trauma patient as been modified, with the introduction of the atls method. this fact has produced great improvement, proven and reproducible, decreasing mortality and morbidity of trauma. the next stage of treatment implies surgery. the dstc course, and other similar ones, allow the teaching of surgical damage control to surgeons. in this courses, the surgeon not only learns the theoretical basis of the surgical techniques but also acquires the skills to perform them. more importantly, he learns trauma pathophysiology, so he can perform the difficult task of surgical decision-making. using the same computer-animated drawing technique as in a previous video (primary survey), the authors continue to present a trauma patient, after the stabilization of the primary survey, at the operating room. the patient has a severe abdominal trauma and needs damage control of his lesions, for he is already suffering from the deadly triad: hypocoagulation, acidosis and hypothermia. a year-old male patient was admitted to our hospital for severe abdominal pain. thoracoabdominopelvic ct scan demonstrated incarcerated bowel loops in the right hemithorax. strangulated transverse colon segment and omentum through the defect at the dome of right diaphragma was found at diagnostic laparoscopy. diaphragmatic hernia was primarily repaired with endostitches, and supported with a polipropylene mesh fixed with endotuckers subsequent to reduction of strangulated organs to the abdomen. resection of necrotic intrabdominal organs and a side-to-side stapled colocolonic anastomosis was performed through a subcostal minilaparotomy. drainage of right hemithorax was provided with a tube thoracostomy. the patient was discharged on the th post-operative day without any major complications. introduction and objectıves: single incision laparoscopic procedures are accepted as a step towards pure natural orifice transluminal endoscopic surgery. however, loss of requirement of any perforation of visceral organ and an endoscopic equipment make this technique more popular and easily performable. here in we report our first appendectomy case who was performed with single incision laparoscopic surgery (sils) technique. methods: years old male patient with the diagnosis of acute appendisitis underwent single incision laparoscopic appendectomy. a key: cord- - a pviol authors: kamilia, chtara; regaieg, kais; baccouch, najeh; chelly, hedi; bahloul, mabrouk; bouaziz, mounir; jendoubi, ali; abbes, ahmed; belhaouane, houda; nasri, oussama; jenzri, layla; ghedira, salma; houissa, mohamed; belkadi, kamal; harti, youness; nsiri, afak; khaleq, khalid; hamoudi, driss; harrar, rachid; thieffry, camille; wallet, frédéric; parmentier-decrucq, erika; favory, raphaël; mathieu, daniel; poissy, julien; lafon, thomas; vignon, philippe; begot, emmanuelle; appert, alexandra; hadj, mathilde; claverie, paul; matt, morgan; barraud, olivier; françois, bruno; jamoussi, amira; jazia, amira ben; marhbène, takoua; lakhdhar, dhouha; khelil, jalila ben; besbes, mohamed; goutay, julien; blazejewski, caroline; joly-durand, isabelle; pirlet, isabelle; weillaert, marie pierre; beague, sebastien; aziz, soufi; hafiane, reda; hattabi, khalid; bouhouri, mohamed aziz; hammoudi, driss; fadil, abdelaziz; harrar, rachid al; zerouali, khalid; medhioub, fatma kaaniche; allela, rania; algia, najla ben; cherif, samar; slaoui, mohamed taoufik; boubia, souhail; hafiani, y.; khaoudi, a.; cherkab, r.; elallam, w.; elkettani, c.; barrou, l.; ridaii, m.; mehdi, rihi el; schimpf, caroline; mizrahi, assaf; pilmis, benoît; le monnier, alban; tiercelet, kelly; cherin, mélanie; bruel, cédric; philippart, francois; bailly, sébastien; lucet, jc; lepape, alain; l’hériteau, françois; aupée, martine; bervas, caroline; boussat, sandrine; berger-carbonne, anne; machut, anaïs; savey, anne; timsit, jean-françois; razazi, keyvan; rosman, jérémy; de prost, nicolas; carteaux, guillaume; jansen, chloe; decousser, jean winoc; brun-buisson, christian; dessap, armand mekontso; m’rad, aymen; ouali, zouhour; barghouth, manel; kouatchet, achille; mahieu, rafael; weiss, emmanuel; schnell, david; zahar, jean-ralph; artiguenave, margaux; sophie, paktoris-papine; espinasse, florence; sayed, faten el; dinh, aurélien; charron, cyril; geri, guillaume; vieillard-baron, antoine; repessé, xavier; kallel, hatem; mayence, claire; houcke, stéphanie; guegueniat, pascal; hommel, didier; dhifaoui, kaouther; hajjej, zied; fatnassi, amira; sellami, walid; labbene, iheb; ferjani, mustapha; dachraoui, fahmi; nakkaa, sabrine; m’ghirbi, abdelwaheb; adhieb, ali; braiek, dhouha ben; hraiech, kmar; ousji, ali; ouanes, islem; zaineb, hammouda; abdallah, saousen ben; ouanes-besbes, lamia; abroug, fekri; klein, simon; miquet, mattéo; thouret, jean-marc; peigne, vincent; daban, jean-louis; boutonnet, mathieu; lenoir, bernard; merhbene, takoua; derreumaux, celine; seguin, thierry; conil, jean-marie; kelway, charlotte; blasco, valery; nafati, cyril; harti, karim; reydellet, laurent; albanese, jacques; aicha, narjess ben; meddeb, khaoula; khedher, ahmed; ayachi, jihene; fraj, nesrine; sma, nesrine; chouchene, imed; boussarsar, mohamed; yedder, soumaya ben; samoud, walid; radhouene, bousselmi; mariem, bousselmi; ammar, asma; cheikh, asma ben; lakhal, hend ben; khelfa, messaouda; hamdaoui, yamina; bouafia, nabiha; trampont, timothée; daix, thomas; legarçon, vincent; karam, henri hani; pichon, nicolas; essafi, fatma; foudhaili, nasreddine; thabet, hafedh; blel, youssef; brahmi, nozha; ezzouine, hanane; kerrous, mahmoud; haoui, saad el; ahdil, soufiane; benslama, abdellatif; abidi, khalid; dendane, tarek; oussama, ssouni; belayachi, jihane; madani, naoufal; abouqal, redouane; zeggwagh, amine ali; ghadhoune, hatem; chaari, anis; jihene, guissouma; allouche, hend; trabelsi, insaf; brahmi, habib; samet, mohamed; ghord, hatem el; habiba, ben sik ali; hajer, nouira; tilouch, najla; yaakoubi, sondes; jaoued, oussama; gharbi, rim; hassen, mohamed fekih; elatrous, souheil; arcizet, julien; leroy, bertrand; abdulmalack, caroline; renzullo, catherine; hamet, maël; doise, jean-marc; coutet, jérôme; cheikh, chaigar mohammed; quechar, zakaria; joris, magalie; beauport, dimitri titeca; kontar, loay; lebon, delphine; gruson, bérengère; slama, michel; marolleau, jean-pierre; maizel, julien; gorham, julie; ameye, lieveke; berghmans, thierry; paesmans, marianne; sculier, jean-paul; meert, anne-pascale; guillot, max; ledoux, marie-pierre; braun, thierry; maestraggi, quentin; michard, baptiste; castelain, vincent; herbrecht, raoul; schneider, francis; couffin, severine; lobo, david; mongardon, nicolas; dhonneur, gilles; mounier, roman; le borgne, pierrick; couraud, sophie; herbrecht, jean-etienne; boivin, alexandra; lefebvre, françois; bilbault, pascal; zelmat, setti-aouicha; batouche, djamila-djahida; mazour, fatima; chaffi, belkacem; benatta, nadia; sik, ali habiba; talik, i.; perrier, maxime; gouteix, eliane; koubi, claude; escavy, annabelle; guilbaut, victoria; fosse, jean-philippe; jazia, rahma ben; abdelghani, ahmed; cungi, pierre-julien; bordes, julien; nguyen, cédric; pierrou, candice; cruc, maximilien; benois, alain; duprez, frédéric; bonus, thierry; cuvelier, grégory; ollieuz, sandra; machayekhi, sharam; paciorkowski, frédéric; reychler, gregory; coudroy, remi; thille, arnaud w.; drouot, xavier; diaz, véronique; meurice, jean-claude; robert, rené; turki, olfa; ben, hmida chokri; assefi, mona; deransy, romain; brisson, hélène; monsel, antoine; conti, filomena; scatton, olivier; langeron, olivier; ghezala, hassen ben; snouda, salah; ben, chiekh imen; kaddour, moez; armel, anwar; youness, lafrikh; abdelhak, bensaid; youssef, miloudi; najib, al harrar; mustapha, amouzoun; noufel, mtioui; mohamed, zamd; salma, el khayat; ghizlane, medkouri; mohamed, benghanam; benyounes, ramdani; montini, florent; moschietto, sébastien; gregoire, emilien; claisse, guillaume; guiot, julien; morimont, philippe; krzesinski, jean-marie; mariat, christophe; lambermont, bernard; cavalier, etienne; delanaye, pierre; benbernou, soumia; ilies, sofiane; azza, abdelkader; bouyacoub, khalida; louail, meriem; mokhtari-djebli, houria; arrestier, romain; daviaud, fabrice; francois, xavier laborne; brocas, elsa; choukroun, gérald; peñuelas, oscar; lorente, josé-angel; cardinal-fernandez, pablo; rodriguez, josé-maria; aramburu, josé-antonio; esteban, andres; frutos-vivar, fernando; bitker, laurent; costes, nicolas; le bars, didier; lavenne, franck; devouassoux, mojgan; richard, jean-christophe; mechati, malika; gainnier, marc; papazian, laurent; guervilly, christophe; garnero, aude; arnal, jean michel; roze, hadrien; richard, jean christophe; repusseau, benjamin; dewitte, antoine; joannes-boyau, olivier; ouattara, alexandre; harbouze, nadia; amine, a. m.; olandzobo, a. g.; herbland, alexandre; richard, marie; girard, nicolas; lambron, lucile; lesieur, olivier; wainschtein, sarah; hubert, sidonie; hugues, albane; tran, marc; bouillard, philippe; loteanu, vlad; leloup, maxime; laurent, alexandra; lheureux, florent; prestifilippo, alessia; cruz, martin delgado maria; romain, rigal; antonelli, massimo; blanch, torra lluis; bonnetain, franck; grazzia-bocci, maria; mancebo, jordi; samain, emmanuel; paul, hebert; capellier, gilles; zavgorodniaia, taissa; soichot, marion; malissin, isabelle; voicu, sebastian; garçon, pierre; goury, antoine; kerdjana, lamia; deye, nicolas; bourgogne, emmanuel; megarbane, bruno; mejri, olfa; hmida, marwa ben; tannous, salma; chevillard, lucie; labat, laurence; risede, patricia; fredj, hana; léger, maxime; brunet, marion; le roux, gaël; boels, david; lerolle, nicolas; farah, souaad; amiel-niemann, hélène; kubis, nathalie; declèves, xavier; peyraux, nicoals; baud, frederic; serafini, micaela; alvarez, jean-claude; heinzelman, annette; jozwiak, mathieu; millasseau, sandrine; teboul, jean-louis; alphonsine, jean-emmanuel; depret, françois; richard, nathalie; attal, pierre; richard, christian; monnet, xavier; chemla, denis; jerbi, salma; khedhiri, wafa; necib, hatem; scarfo, paolo; chevalier, charles; piagnerelli, michael; lafont, alexandre; galy, antoine; mancia, claire; zerhouni, amel; tabeliouna, kheira; gaja, ali; hamrouni, bassem; malouch, abir; fourati, sami; messaoud, rihab; zarrouki, youssef; ziadi, amra; rhezali, manal; zouizra, zahira; boumzebra, drissi; samkaoui, mohamed abdennasser; brunet, jennifer; canoville, bertrand; verrier, pierre; ivascau, calin; seguin, amélie; valette, xavier; du cheyron, damien; daubin, cedric; bougouin, wulfran; aissaoui, nadia; lamhaut, lionel; jost, daniel; maupain, carole; beganton, frankie; bouglé, adrien; dumas, florence; marijon, eloi; jouven, xavier; cariou, alain; poirson, florent; chaput, ulriikka; beeken, thomas; maxime, leclerc; haikel, oueslati; vodovar, dominique; chelly, jonathan; marteau, philippe; chocron, richard; juvin, philippe; loeb, thomas; adnet, frederic; lecarpentier, eric; riviere, antoine; de cagny, bertand; soupison, thierry; privat, elodie; escutnaire, joséphine; dumont, cyrielle; baert, valentine; vilhelm, christian; hubert, hervé; leteurtre, stéphane; fresco, marion; bubenheim, michael; beduneau, gaetan; carpentier, dorothée; grange, steven; artaud-macari, elise; misset, benoit; tamion, fabienne; girault, christophe; dumas, guillaume; chevret, sylvie; lemiale, virginie; mokart, djamel; mayaux, julien; pène, frédéric; nyunga, martine; perez, pierre; moreau, anne-sophie; bruneel, fabrice; vincent, françois; klouche, kada; reignier, jean; rabbat, antoine; azoulay, elie; frat, jean-pierre; ragot, stéphanie; constantin, jean-michel; prat, gwenael; mercat, alain; boulain, thierry; demoule, alexandre; devaquet, jérôme; nseir, saad; charpentier, julien; argaud, laurent; beuret, pascal; ricard, jean-damien; teiten, christelle; marjanovic, nicolas; palamin, nicola; l’her, erwan; bailly, arthur; boisramé-helms, julie; champigneulle, benoit; kamel, toufik; mercier, emmanuelle; le thuaut, aurélie; lascarrou, jean-baptiste; rolle, amélie; de jong, audrey; chanques, gérald; jaber, samir; hariri, geoffroy; baudel, jean-luc; dubée, vincent; preda, gabriel; bourcier, simon; joffre, jeremie; bigé, naïke; ait-oufella, hafid; maury, eric; mater, houda; merdji, hamid; grimaldi, david; rousseau, christophe; mira, jean-paul; chiche, jean-daniel; sedghiani, ines; benabderrahim, a.; hamdi, dhekra; jendoubi, asma; cherif, mohamed ali; hechmi, youssef zied el; zouheir, jerbi; bagate, françois; bousselmi, radhwen; schortgen, frédérique; asfar, pierre; guérot, emmanuel; fabien, grelon; anguel, nadia; sigismond, lasocki; matthieu, henry-lagarrigue; gonzalez, frédéric; françois, legay; guitton, christophe; schenck, maleka; jean-marc, doise; dreyfuss, didier; radermacher, peter; frère, antoine; martin-lefèvre, laurent; colin, gwenhaël; fiancette, maud; henry-laguarrigue, matthieu; lacherade, jean-claude; lebert, christine; vinatier, isabelle; yehia, aihem; joret, aurélie; menunier-beillard, nicolas; benzekri-lefevre, dalila; desachy, arnaud; bellec, fréderic; plantefève, gaëtan; quenot, jean-pierre; meziani, ferhat; tavernier, elsa; ehrmann, stephan; chudeau, nicolas; raveau, tommy; moal, valérie; houillier, pascal; rouve, emmanuelle; lakhal, karim; gandonnière, charlotte salmon; jouan, youenn; bodet-contentin, laetitia; balmier, adrien; messika, jonathan; de montmollin, etienne; pouyet, victorine; sztrymf, benjamin; thiagarajah, abirami; roux, damien; de chambrun, marc pineton; luyt, charles-edouard; beloncle, françois; zapella, nathalie; ledochowsky, stanislas; terzi, nicolas; mazou, jean-marc; sonneville, romain; paulus, sylvie; fedun, yannick; landais, mickael; raphalen, jean-herlé; combes, alain; amoura, zahir; jacquemin, aemilia; guerrero, felipe; marcheix, bertrand; hernandez, nicolas; fourcade, olivier; georges, bernard; delmas, clément; makoudi, sarah; genton, audrey; bernard, rémy; lebreton, guillaume; amour, julien; mazet, charlotte; bounes, fanny; murat, gurbuz; cronier, laure; robin, guillaume; biendel, caroline; silva, stein; boubeche, samia; abriou, caroline; wurtz, véronique; scherrer, vincent; rey, nathalie; gastaldi, gioia; veber, benoit; doguet, fabien; gay, arnaud; dureuil, bertrand; besnier, emmanuel; rouget, antoine; gantois, guillaume; magalhaes, eric; wanono, ruben; smonig, roland; lermuzeaux, mathilde; lebut, jordane; olivier, andremont; dupuis, claire; radjou, aguila; mourvillier, bruno; neuville, mathilde; d’ortho, marie pia; bouadma, lila; rouvel-tallec, anny; rudler, marika; weiss, nicolas; perlbarg, vincent; galanaud, damien; thabut, dominique; rachdi, emna; mhamdi, ghada; trifi, ahlem; abdelmalek, rim; abdellatif, sami; daly, foued; nasri, rochdi; tiouiri, hanene; lakhal, salah ben; rousseau, geoffroy; asmolov, romain; grammatico-guillon, leslie; auvet, adrien; laribi, said; garot, denis; dequin, pierre françois; guillon, antoine; fergé, jean-louis; abgrall, gwénolé; hinault, ronan; vally, shazima; roze, benoit; chaplain, agathe; chabartier, cyrille; savidan, anne-charlotte; marie, sabia; cabie, andre; resiere, dabor; valentino, ruddy; mehdaoui, hossein; benarous, lucas; soda-diop, marième; bouzana, fouad; perrin, gilles; bourenne, jeremy; eon, béatrice; lambert, dominique; trebuchon, agnes; poncelet, géraldine; le bourgeois, fleur; michael, levy; camille, guillot; naudin, jérôme; deho, anna; dauger, stéphane; sauthier, michaël; bergeron-gallant, krystale; emeriaud, guillaume; jouvet, philippe; tiebergien, nicolas; jacquet-lagrèze, matthias; fellahi, jean-luc; baudin, florent; essouri, sandrine; javouhey, etienne; guérin, claude; lampin, marie; mamouri, ouardia; devos, patrick; karaca-altintas, yasemin; vinchon, matthieu; brossier, david; eltaani, redha; teyssedre, sonia; sabine, meyet; bouchut, jean-christophe; peguet, olivier; petitdemange, lucie; guilbert, anne sophie; aoul, nabil tabet; addou, zakaria; aouffen, nabil; anas, benqqa; kalouch, samira; yaqini, khalid; chlilek, aziz; abdou, rchi; gravellier, perrine; chantreuil, julie; travers, nadine; listrat, antoine; le reun, claire; favrais, geraldine; coppere, zoe; blanot, stéphane; montmayeur, juliette; bronchard, régis; rolando, stephane; orliaguet, gilles; leger, pierre-louis; rambaud, jérôme; thueux, emilie; de larrard, alexandra; berthelot, véronique; denot, julien; reymond, marie; amblard, alain; morin-zorman, sarah; lengliné, etienne; pichereau, claire; mariotte, eric; emmanuel, canet; poujade, julien; trumpff, guillaume; janssen-langenstein, ralf; harlay, marie-line; zaid, noorah; ait-ammar, nawel; bonnal, christine; merle, jean-claude; botterel, francoise; levesque, eric; riad, zakaria; mezidi, mehdi; yonis, hodane; aublanc, mylène; perinel-ragey, sophie; lissonde, floriane; louf-durier, aurore; tapponnier, romain; louis, bruno; forel, jean-marie; bisbal, magali; lehingue, samuel; rambaud, romain; adda, mélanie; hraiech, sami; marchi, elisa; roch, antoine; guerin, vincent; rozencwajg, sacha; schmidt, matthieu; hekimian, guillaume; bréchot, nicolas; trouillet, jean louis; besset, sébastien; franchineau, guillaume; nieszkowska, ania; pascal, leprince; loiselle, maud; sarah, chemam; laurence, dangers; guillemette, thomas; jacquens, alice; kerever, sebastien; guidet, bertrand; aegerter, philippe; das, vincent; fartoukh, muriel; hayon, jan; desmard, mathieu; fulgencio, jean-pierre; zuber, benjamin; soufi, a.; khaleq, k.; hamoudi, d.; garret, charlotte; peron, matthieu; coron, emmanuel; bretonnière, cédric; audureau, etienne; audrey, winters; christophe, duvoux; christian, jacquelinet; daniel, azoulay; cyrille, feray; aissaoui, wissal; rghioui, kawtar; haddad, wafae; barrou, houcine; carteaux-taeib, anna; lupinacci, renato; manceau, gilles; jeune, florence; tresallet, christophe; habacha, sahar; fathallah, ines; zoubli, aymen; aloui, rafaa; kouraichi, nadia; jouet, emilie; badin, julie; fermier, brice; feller, marc; serie, mathieu; pillot, jérôme; marie, william; gisbert-mora, chloé; vinclair, camille; lesbordes, pierre; mathieu, pascal; de brabant, fabienne; muller, emmanuel; robaux, marie-aline; giabicani, mikhael; marchalot, antoine; gelinotte, stéphanie; declercq, pierre louis; eraldi, jean-pierre; bougerol, françois; meunier-beillard, nicolas; devilliers, hervé; rigaud, jean-philippe; verrière, camille; ardisson, fanny; kentish-barnes, nancy; jacq, gwenaëlle; chermak, akli; lautrette, alexandre; legrand, matthieu; soummer, alexis; thiery, guillaume; cottereau, alice; canet, emmanuel; caujolle, marie; allyn, jérôme; valance, dorothée; brulliard, caroline; martinet, olivier; jabot, julien; gallas, thomas; vandroux, david; allou, nicolas; durand, arthur; nevière, rémi; delguste, florian; boulanger, eric; preau, sebastien; martin, ruste; cochet, hélène; ponthus, jean pierre; amilien, virginie; tchir, martial; barsam, elise; ayoub, mohsen; georger, jean francois; guillame, izaute; assaraf, julie; tripon, simona; mallet, maxime; barbara, guilaume; louis, guillaume; gaudry, stéphane; barbarot, nicolas; jamet, angéline; outin, hervé; gibot, sébastien; bollaert, pierre-edouard; holleville, mathilde; legriel, stéphane; chateauneuf, anne laure; cavelot, sébastien; moyer, jean-denis; bedos, jean pierre; merle, philippe; laine, aurelie; natalie, de sa; cornuault, mathieu; libot, jérome; asehnoune, karim; rozec, bertrand; dantal, jacques; videcoq, michel; degroote, thècle; jaillette, emmanuelle; zerimech, farid; malika, balduyck; llitjos, jean-françois; amara, marlène; lacave, guillaume; pangon, béatrice; mavinga, josé; makunza, joseph nsiala; mafuta, m. e.; yanga, yves; eric, amisi; ilunga, jp; kilembe, ma; alby-laurent, fanny; toubiana, julie; mokline, amel; laajili, achraf; amri, helmi; rahmani, imene; mensi, nidhal; gharsallah, lazheri; tlaili, sofiene; gasri, bahija; hammouda, rym; messadi, amen allah; allain, pierre-antoine; gault, nathallie; paugam-burtz, catherine; foucrier, arnaud; chatbri, bassem; bourbiaa, yousra; thabet, lamia; neuschwander, arthur; vincent, looten; beck, jennifer; vibol, chhor; amelie, yavchitz; resche-rigon, matthieu; pirracchio, jean mantzromain; bureau, côme; decavèle, maxens; campion, sébastien; ainsouya, roukia; niérat, marie-cécile; prodanovic, hélène; raux, mathieu; similowski, thomas; dubé, bruno-pierre; demiri, suela; dres, martin; may, faten; quintard, hervé; kounis, ilias; saliba, faouzi; andré, stephane; boudon, marc; ichai, philippe; younes, aline; nakad, lionel; coilly, audrey; antonini, teresa; sobesky, rodolphe; de martin, eleonora; samuel, didier; hubert, noemie; nay, mai-anh; auchabie, johann; giraudeau, bruno; jean, reignier; darmon, michaël; ruckly, stephane; garrouste-orgeas, maïté; gratia, elisabeth; goldgran-toledano, dany; jamali, samir; dumenil, anne sylvie; schwebel, carole; brisard, laurent; bizouarn, philippe; lepoivre, thierry; nicolet, johanna; rigal, jean christophe; roussel, jean christian; cheurfa, cherifa; abily, julien; lescot, thomas; page, isaline; warnier, stéphanie; nys, monique; rousseau, anne-françoise; damas, pierre; uhel, fabrice; lesouhaitier, mathieu; grégoire, murielle; gaudriot, baptiste; gacouin, arnaud; le tulzo, yves; flecher, erwan; tarte, karin; tadié, jean-marc; georges, quentin; soares, m.; jeon, kyeongman; oeyen, sandra; rhee, chin kook; gruber, pascale; ostermann, marlies; hill, quentin; depuydt, peter; ferra, christelle; muller, alice; aurelie, bourmaud; niles, christopher; herbert, fabien; pied, sylviane; loridant, séverine; françois, nadine; bignon, anne; sendid, boualem; lemaitre, caroline; dupre, celine; zayene, aymen; portier, lucie; de freitas caires, nathalie; lassalle, philippe; le neindre, aymeric; selot, pascal; ferreiro, daniel; bonarek, maria; henriot, stépahen; rodriguez, julie; taddei, mara; di bari, mauro; hickmann, cheryl; castanares-zapatero, diego; deldicque, louise; van den bergh, peter; caty, gilles; roeseler, jean; francaux, marc; laterre, pierre-françois; dupuis, bastien; machayeckhi, sharam; sarfati, celine; moore, alex; mendialdua, paula; rodet, emilie; pilorge, catherine; stephan, francois; rezaiguia-delclaux, saida; dugernier, jonathan; hesse, michel; jumetz, thibaud; bialais, emilie; depoortere, virginie; michotte, jean bernard; wittebole, xavier; jamar, françois title: proceedings of réanimation , the french intensive care society international congress date: - - journal: ann intensive care doi: . /s - - - sha: doc_id: cord_uid: a pviol nan introduction the study of the bacterial cartography in thoracic surgery is extremely important for the treatment of post-operative infections due to the severity of the underlying pathology, the fragility of patients after surgery in addition to the choice of the empiric antibiotic therapy. we led a prospective study following all the patients who underwent a pulmonary resection surgery for a period of months from january to july , jointly with the microbiology department, chu ibn rochd, casablanca. the bronchial secretions were collected by a protected distal bronchial sample using a (combicath) after the intubation. results during the period of the study, patients underwent a pulmonary resection, % for a neoplastic pathology. the medium age was years ± and % of our sample were male. % of our patients had smoking habits and of them had pulmonary tuberculosis, had repeated respiratory infections. the antibiotics used in pre-operative: % of beta-lactams; % of fluoroquinolones; % of macrolides. moreover, % of our patients were classified asa . of the obtained samples, were positive ( . %). the most frequently observed germs were the acinetobacter baumannii ( . %), pseudomonas aeruginosa ( . %), klebsiella pneumoniae ( . %), staphylococcus aureus ( . %). the acinetobacter baumannii was the most resistant germ ( % sensibility to carbapenem). these patients were followed until their d after surgery, of them developed a post-operative pneumonitis with cases of multi-resistant acinetobacter baumanii, of which deceased. conclusion pneumonitis after pulmonary resection are common and severe that's why it is necessary to establish a global prevention strategy mainly based on general patricians and pneumologists' awareness concerning the choice of the prescribed antibiotics, in order to avoid the spread of multi-resistant germs. introduction carbapenemase-producing enterobacteriaceae (cpec) are increasingly reported worldwide and constitutes a real challenge antibiotic for clinicians to preserve the bacterial ecology. its incidence has remarkably increased in our intensive care unit during the last years. the esbl spread has a major consequence in term of antibiotic choices. carbapenem antibiotic are regarded as the most effective treatment. however numbers of authors suggest that alternatives antibiotics (i.e. noncarbapenems) could be used in esbl-pe infections. there are some conflicting data regarding the use of alternatives in case of esbl-pe infections. moreover as far as we know, there are no data in icu. objectives the aim of this study was to describe esbl-pe infections in icu and therapeutic options chosen in these specific situations. patients and methods prospective multicentric observational cohort study conducted in volunteers icu. all consecutive patients hospitalized in icu with esbl-pe infection according to cdc definitions were included. severity of illness was defines according to bone criteria, saps ii and sofa. demographic datas, empirical and definitive antibiotic therapy (et and dt), clinical evolution, and outcome were recorded. in vitro antimicrobial susceptibility testing was performed by the disk diffusion method or the vitek system according to the guidelines of the antibiogram committee of the french microbiologic society. results during the study period patients with esbl-pe infection met eligibility criteria with respectively a median age and saps ii score of ( - ) and ( - ). the median sofa score at first day of antibiotic therapy and icu admission were ( - ) and ( ) ( ) ( ) ( ) ( ) ( ) ( ) respectively. the most frequent site of infection were respiratory tract ( %), urinary tract ( %) and abdominal ( %). the most frequent isolated species were: escherichia coli ( %), klebsiella sp ( %) and enterobacter sp ( %). respectively , and % patients had septic shock, severe sepsis and sepsis according to bone criteria. among esbl-pe, . % were carbapenem and . were blbi sensitive. among the whole population, ( %) patients received a carbapenems as et. ( %) received a dt with carbapenems and ( %) patients received an alternative dt. the most frequent reasons for maintaining carbapenems as dt were: antibiotic susceptibility tests ( % of cases), severity level ( % of cases) immunosuppression ( % of cases). the median length of icu stay after infection was respectively ( - ) and ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) days for carbapenems and alternatives dt (p = . ). the d mortality was % for patients with carbapenems dt and % for patients with alternatives dt (p = . ). surprisingly, there were no differences between the groups (carbapenems vs alternatives) in term of severity. conclusion alternatives are frequently used for esbl-pe infections in icu. in our cohort ( %) patients received antibiotics other than carbapenems regardless of the severity. introduction bacterial resistance to antibiotics is a common problem worldwide. in south america, this prevalence is reported to be the highest in the world. however, in french guyana, there is no data on the epidemiology of colonization and infection caused by extended spectrum b-lactamase producing enterobacteriaceae (esbl-pe). we conducted this study to investigate the prevalence of colonization with esbl-pe and subsequent icu acquired infection in french guiana. introduction the implementation of hemofiltration (hf) as a renal replacement therapy in septic shock patients requires the supply of large quantities of replacement solutions. these solutions are either industrially prepared in autoclaved expensive plastic bags (conventional hemofiltration, chf) or continuously provided in unlimited amounts at the dialysis machine directly from the water treatment plant to form the replacing solutions (on-line hemofiltration, olhf).the aim of our study was to evaluate the safety and effectiveness of on-line hemofiltration compared to conventional hemofiltration in septic shock patients. the investigative protocol was approved by the institutional ethics authorities and all patients or their legally authorized representatives provided written informed consent. it was a prospective, randomized, clinical study, including septic shock patients with acute renal failure. patients were randomized to receive either on-line hemofiltration (n = ) or conventional hemofiltration (n = ) for renal replacement therapy during days. hemodynamic monitoring was conducted by conventional devises, including: electrocardiogram and a radial arterial catheter for invasive arterial pressure every h during period study. we collected serum samples also every h (urea, potassium and sodium levels, troponin, hemoglobin, platelets, c-reactive protein and lactates). results the evolution of heart rate (hr), mean arterial pressure (map), biological markers were comparable between the two groups over time except a significant decrease in map in the olhf group compared to chf group only at h (p = . ) and h (p = . ) and a significant decrease in c-reactive protein level in the olhf group at h (p = . ). conclusion on-line hemofiltration seems to be a safe and reliable method of renal replacement therapy in septic shock patients. it may be associated with attenuated pro-inflammatory cytokine profile (c-reactive protein). none. introduction therapeutic plasma exchange (tpe) is crucial for the management of auto-immune diseases like thrombotic thrombocytopenic purpura or myasthenia gravis. tpe is performed either by centrifugation, with specific machines which are not routinely available in icus, or by using specific plasma separation membranes with widely spread in icus hemofiltration machines. regional citrate anticoagulation for tpe is well established with centrifugation but has been seldom described for membrane tpe. we are reporting the experience of our icu in this field. patients and methods retrospective study including all patients who received tpe with citrate regional anticoagulation between and in an -bed icu. tpe is performed solely in the icu in our institution. results patients were included. tpe was required for thrombotic microangiopathy ( patients), vasculitis ( patients), hyperviscosity syndrome ( patients), guillain-barré syndrome ( cases) and others ( patients) . mean saps score was [standard deviation (sd) . ] . tpe were performed, with a mean number of . (sd . ; range - ) tpe per patients. coagulation of the circuit of tpe occurred in ( %) patients. coagulation of the circuit occurred in . % ( / ) of the tpe. minor adverse events have been reported in two patients: one had a rash during the first tpe (no recurrence during the next tpes) and the other had paresthesia during the first two tpes (the calcium infusion was increased and there had been no recurrence during the next tpes). no serious adverse events related to citrate were observed. conclusion regional anticoagulation with citrate allowed us to perform tpe in patients, without significant adverse events. the rate of circuit coagulation was . % per tpe. none. introduction a reduced incidence of membrane thrombosis after injection of anti-thrombin (at) has been reported in septic patients with acquired deficit in at undergoing continuous hemofiltration. as this strategy was routinely performed in our unit until , we investigated its cost-effectiveness. patients and methods data about the use of hemofiltration, the consumption of at and hemofiltration devices during (period with routine use of at) and (period with use of at only if a membrane thrombosis occurred) were extracted from the administrative database of the institution. a decisional tree was built to modelize the impact of at on the consumption of hemofiltration devices and blood products. the decisional tree took into account the probability of membrane thrombosis with and without at and the probability of transfusion after membrane thrombosis. costs were obtained from the pharmacy of the institution (at, hemofiltration devices) and from the literature (blood products). results during , days of hemofiltration were performed, with the use of doses of at ( , €) and hemofiltration devices ( , €) . during , (− %) days of hemofiltration were performed, with the use of (− %) doses of at ( €) and (+ %) hemofiltration devices ( , €) . the mean cost of day of hemofiltration decreased from € to € with the diminution of the use of at. according to the decisional tree, at was almost never cost-effective. the only circumstances associated with a benefit for the use of at was the association of a probability of thrombosis with at inferior to . , of a probability of thrombosis without at equal , of a probability of transfusion after thrombosis equal and a cost of transfusion of €. in these extremely favorable circumstances, at could decrease the daily cost of hemofiltration of . - . €. discussion the model has several limits: the losses of utility related to transfusion and to interruption of hemofiltration due to thrombosis were not taken into account; the cost of at measurement was not estimated; the work load of changing a membrane and of transfusion after membrane thrombosis was not analyzed. conclusion our results suggest that anti-thrombin is not costeffective to reduce the costs of hemofiltration related to membrane thrombosis. none. introduction in intensive care unit (icu), some patients suffering from acute kidney injury need renal replacement therapy (rrt). it requires the circuit anticoagulation, this could be done by a regional citrate method. today, this is a recommended approach for the everyday care, even if the technique isn't widespread yet [ ] . the ionized calcemia dosing through the filter ("post-filter" ionized-calcemia) is used to monitor the technique efficacy, with a target of . - . mmol/l showing a good filter anticoagulation. the objective of our study was the assessment of efficacy and safety of our regional citrate anticoagulation protocol, with a less restrictive post-filter ionized calcemia target ( . - . mmol/l). the main goal was the analysis of the circuit lifespan, considering a lifespan above h, as well as the search of some clinical and biological factors affecting the technique efficacy. moreover, we analyzed the side effects incidence of the protocol (hypernatremia, metabolic alcalosis), and their consequences. the study received the scientific ethical agreement of university hospital of toulouse, and is registered with number - . patients and methods patients, admitted to one of the two university hospital icus of toulouse, needing a continuous rrt method, without any need for systemic heparin anticoagulation, and without severe hepatocellular failure, were included in the study. filters included over a -year period were analyzed. results results show a mean filter lifespan of h, with a lifespan above h for . % of all filters. coagulation was the cessation reason for . % of filters, most of them before h of the filter use. a value of post-filter ionized calcemia at day below . mmol/l was the main factor influencing a filter lifespan above h. an age older than and a saps ii severity score below were other factors conditioning a filter lifespan of more than h. side effects of citrate were rare and didn't have any clinical impact among our patients. discussion these results suggest that citrate used for anticoagulation in rrt could have an additional anti inflammatory effect through the induced hypocalcemia, as well as an energetic gain which could lead to a renal protection against ischemia-reperfusion mechanism [ ] . moreover, these results call into question the need of post-filter ionized calcemia dosing for the monitoring of citrate anticoagulation efficacy, since the method safety is monitored by the total-to-ionized calcium ratio. conclusion during continuous rrt in icu, a regional citrate anticoagulation protocol with a non-restrictive post-filter ionized calcemia target seems to be efficient and could reduce side effects. these results need to be confirmed with a randomised control study. introduction continuous veno-venous haemofiltration (cvvh) is used to treat acute kidney injury in critically ill patients. to optimize its efficiency, cvvh requires effective anticoagulation. systemic anticoagulation with standard heparin, the most used, can lead to major bleeding complications. hemofilters that are able to adsorb heparin molecules on their surface such as an st and oxiris membranes represent an alternative. the objective of this study was to compare these two types of filters in terms of duration, efficiency, dysfunctions and cost. materials and methods from october to may , we conducted a retrospective, observational, and non-interventional study. all patients admitted in the intensive care unit needing cvvh were included. the primary endpoint was the filter lifespan: an st versus oxiris. the secondary endpoint was the filter efficiency (urea reduction ratio: urr). the main analysis did not consider the anticoagulation type. we conducted a subgroup analysis taking into account the use or not of an anticoagulation. results sessions in patients were carried out using filters representing , h of treatment. the mean an st filter lifespan was ± h and ± h for oxiris filters (p > . ). there is no significant difference in terms of duration between the two filters. the subgroup analysis taking into consideration the use or not of anticoagulation did not show any difference either. the mean urr was ± % in the an st group and ± % in the oxiris group (p > . ). concerning the dysfunctions, there were no significant difference between the two filters. one hundred and seventy-six an st filters were used for a total cost of , euros. two hundred and ten oxiris filters were used for a total cost of , euros. conclusion the an st and oxiris lifespans are not significantly different. they were as efficient in terms of blood epuration and had as many dysfunctions. the use of an oxiris filter rather than an an st to extend the circuit's lifespan in the same clinical conditions is not justified considering the extra cost generated. introduction because oliguria is a poor prognostic sign in patients with acute renal failure (arf), diuretics are often used to increase urine output in patients with or at risk of arf. from a pathophysiological point of view there are several reasons to expect that loop diuretics could have a beneficial effect on renal function. however, a review of literature shows that the use of loop diuretics in patients with arf has been associated with inconclusive results despite the theoretical benefits [ ] . to assess the adjunctive effect of diuretics, to alter the progression to kidney injury or failure, in patients at risk for acute renal failure. patients and methods this is a retrospective chart review of consecutive patients who developed arf with oliguria in the intensive care unit. chart abstractors were well trained residents. two chart reviewers (senior intensivists) studied all the charts. an explicit protocol was used to precise all needed definitions. uniform handling of data was ensured especially for conflicting, missing or unknown data. oliguria was defined as urine output lower than . ml/kg/h for at least h. rifle score was assessed before and after urinary output normalisation. therapeutic intervention to optimize pre-renal perfusion was described. mean arterial blood pressure (mbp) before and after therapeutic initiation, oliguria duration, delay from oliguria onset to diuretic administration, delay from diuretic administration to urinary output normalisation were measured. results patients were studied over a years period. ] h. the delay from diuretic administration to urinary output normalization was [ . , ] h. after resumption of diuresis, rifle score was assessed as (patients without risk, %; r, %; i, %; f, % l, zero; e, zero) (fig. ) . increased serum creatinine level, above . fold normal range, was observed only in ( %) patients. conclusion rapid optimization of pre-renal hemodynamic disturbances associated with short delay administration of diuretics could significantly alter the progression to kidney injury or failure in at risk acute renal failure icu patients. the ventilator associated pneumonia (vap) is a common and severe complication of assisted ventilation. it's the leading cause of nosocomial infections in intensive care unit and remain responsible for a high morbidity and mortality because of the emergence of multidrug resistant (mdr) bacterial agent such us acinetobacter baumannii (ab). the aim of this study was to determine the incidence, risk factors and prognosis of ab vap. patients and methods retrospective study extending over a year period (january -january ) that included all patients over patients were divided into two groups: one consisting of patients who developed vap to ab and the second developed vap to another bacterial pathogen. results one hundred and forty patients developed vap. the incidence rate of ab vap was . % with a density of incidence of . per ventilator days. age, male gender, the time between hospitalization and mechanical ventilation and the medical pathology were risk factors for developing ab vap. ab was resistant to ceftazidime in %, to imipenem in %, tobramycin in % and netilmycin in . %, rifampin in % with a sensitivity to colistin in % of cases. the resistance of this germ to imipenem increased from % in to . % in . the evolution of patients with ab vap developed frequently septic shock compared to other patients ( vs . %; p = . ). the ab vap mortality was higher ( vs %; p = . ). conclusion the increasing incidence of multi-drug resistant ab vap is responsible for a high morbidity and mortality. so we need to identify risk factors and to strengthen the means of prevention of hand contamination and cross transmission during invasive procedures. introduction central line associated bloodstream infections (clabsi) are among the serious hospital-acquired infections. the aim of this study is to determine the incidence of clabsi, the pathogens and the risk factors that play a role in the development of bsi among patients followed in a tunisian medical intensive care unit. patients and methods all patients admitted for more than h were included in the study over a -year period in an -bed medical icu. the enrollment was based on clinical and laboratory diagnosis of bsi. blood samples were collected from catheter hub of all patients for culture, followed by identification and antibiotic sensitivity testing of the isolates. was higher compared with the mean rate of clabsi in icu reported by the nnis system surveillance for , which is . / catheter.days [ ] . duration of catheterization, frequent manipulation of catheter, catheter location, catheter type, underlying diseases, suppression of immune system, and types of fluids administered through the catheter are significant risk factors in development of bsis [ ] . in our study both duration of catheterization and number of attempts are independent factors for clabsi. conclusion in a monocenter cohort, clabsi had a moderate density rate but are associated with poor outcome. identifying the risk factors is necessary to find solutions for this major health problem. introduction according to some studies, field-intubated patients have . - times greater risk of ventilator associated pneumonia (vap). endobronchial intubation (ei) can be unrecognized by the physicians and may result in complications such as atelectasis which in turn could increase the risk of vap. the aim of our study was to confirm this hypothesis. patients and methods this monocentric retrospective study included all consecutive patients > years who underwent an out-of-hospital tracheal intubation before their admission to the intensive care unit (icu) between january and december . exclusion criteria were suspected aspiration or pneumonia on admission, patients who died within the first days of icu stay, extubation in less than h and underlying disease making radiological interpretation difficult for vap diagnosis. vap were divided into early onset (< days) and late onset (≥ days) events and were independently diagnosed by two experienced intensivists who had no access to the initial chest x-ray performed to check the position of the tracheal tube, based on the clinical pulmonary infection score. onset of ventilator associated tracheobronchitis (vat) was also noted. inadvertent endobronchial intubation was determined by another independent physician based on the interpretation of admission chest x-ray. results patients were intubated out-of-hospital. of the patients excluded, had an extubation in less than h, were died within the first days, had a suspicion of pneumonia, a suspicion of aspiration and an underlying disease making radiological interpretation difficult. of the patients included, ( . %) had an ei upon admission. no significant difference was observed between the ei and non-ei group for gender, age, saps , comorbidities and diagnostic category (cardiorespiratory arrest, trauma, coma and cardiorespiratory failure). early-onset vap were diagnosed in % in the ei group and in % of non-ei patients (p = . ). adding early onset vat, the respiratory infection rate was % in the ei group and % in the non-ei group (p = . ) (fig. ). late-onset vap were observed in . % in the non-ei group and . % in the ei group, without difference between groups (p = . ). there was no inter-group difference in the duration of ventilation, duration of icu stay and icu mortality. staphyloccocus aureus was the most prevalent pathogen in patients with early-onset vap ( . %, only one strain was methicillin-resistant). conclusion this study found a high rate of inadvertent prehospital endobronchial intubation with a higher incidence of early-onset vap. these results support the implementation of specific procedures to decrease the incidence of ei. introduction ventilator-associated pneumonia (vap) is associated with increased hospital stay and high morbidity and mortality in critically ill patients. the classic dichotomy between early and late onset vap is no longer helpful available. the aims of this study were to determine the incidence of multidrug-resistant pathogens in the first episodes of vap and to assess potential differences in bacterial profiles of subjects with early-onset versus late-onset vap. patients and methods retrospective cohort study over a period of months including all patients who had a first episode of vap confirmed by positive culture. subjects were distributed into groups according to the number of intubation days: early-onset vap (< days) or late-onset vap (≥ days).the primary endpoint was the nature of causative pathogens and their resistance profiles. results sixty patients were included, men and women. the average age was ± years. the igs at admission was . [ ; ] apache [ ; ] . monomicrobial infections were diagnosed in of patients ( %).two different bacteria were isolated in cases ( %). a. baumannii was the most frequently isolated in % (n = ) of patients; followed by p. aeruginosa in % (n = ), enterobacteriaceae in % (n = ) and s. aureus in % (n = ). the isolated bacteria were multidrug-resistant in most cases ( / ). the vap group comprised episodes ( %) of early-onset vap and episodes ( %) of late-onset vap. a. baumannii was isolated in % of early vap (n = ) versus % of late vap (n = ) (p = ns), p. aeruginosa in % of early vap (n = ) versus % of late vap (n = ) (p = ns) and enterobacteriaceae in % of early vap (n = ) versus % of late vap (n = ) (p = ns). for the resistance profile of the different pathogens isolated, there was no difference between early and late onset vap. conclusion according to new data from the literature, there were no microbiological differences in the prevalence of potential multidrugresistant pathogens or in their resistance profiles associated with early-onset versus late-onset vap. the bacterial nosocomial infection is a major cause of morbidity and mortality in burned. the bacterial ecology in an icu has a major impact in terms of morbidity and mortality, particularly in the center of burned or length of stay of patients is increased compared to a general intensive care. we conducted an observational study spread over months in icu for severe burned burnt including any who have spent more than h with nosocomial infection (modified cdc criteria), and in which all biological and bacteriological samples were taken. the different types of infections studied were: skin, urinary, lung and bloodstream infections. they excluded all patients belatedly supported or having stayed in other healthcare facilities. results one hundred twenty ( ) patients showed nosocomial infection during this period. the sex ratio (m/f) was . and the mean age was ± years. bacteremia was present in . % of cases, followed by the urinary tract infection that was present in . % of cases, followed by the cutaneous infection in . % of cases, and last pulmonary infection in % of cases. infection was polymicrobial in . % of cases. the main bacteria identified were: acinetobacter baumanii ( . %) of which % is resistant to imipenem, enterobacteriaceae ( . %), pseudomonas aeruginosa ( %) of which . % is resistant to ceftazidime and . % is resistant to imipenem, enterococcus ( %) and staphylococcus aureus ( . %). conclusion the incidence of nosocomial infection is very high compared to literature. the rate of resistance to common antibiotics is very high. a drastic management of antibiotics in our context, the selection of patients and the frequent use in the operating room for skincare allow a better management of these patients. introduction acinetobacter baumannii (ab) ventilator-associated pneumonia (vap) is common in critically ill patients. the aims of this study were to describing the epidemiological characteristics of ab-vap, to identify risk factors for acquisition and factors predictive of a poor outcome. materials and methods a retrospective-prospective study was conducted at the medical intensive care unit of the university hospital ibn sina, rabat-morocco from january to december . they were included in the study that all patients developed vap with identified germ. for identification of risk factors of acquisition of ab vap, two groups of patients were compared: patients with ab vap versus patients with vap caused by other germs. to identify factors associated with mortality, two other groups were compared: survivors versus died. results patients presented vap among which were caused by acinetobacter baumannii. among isolates of ab, . % were drug susceptible, and . % were multidrug-resistant while % were extensively drug-resistant. they were independent risk factors for acquisition of ab vap in multivariate analysis: the presence of a central venous catheter before the occurrence of vap, duration of prior hospitalization ≥ days and icu duration of stay ≥ days. the mortality rate of ab vap was %. the independent risk factors for poor outcome in multivariate analysis were: duration of antibiotic treatment > days, the reintubation and the presence of a previous hospitalization. discussion our data were similar to those of the literature with a high incidence of vap due to the ab ( %) and a high rate of resistance to this bacterium particularly to carbapenems. however, and compared to the literature, the vap ab were responsible for a death rate much higher ( %). conclusion our data were similar to those of the literature with a high incidence of vap due to the ab ( %) and a high rate of resistance to this bacterium particularly to carbapenems. however, and compared to the literature, the vap ab were responsible for a death rate much higher ( %). introduction ventilator-associated pneumonia (vap) is common in critically-ill patients. in fact, - % of patients requiring invasive mechanical ventilation develop this complication. the onset of vap has been reported to be associated with increased mortality. however, data related to critically-ill elderly patients are scarce. the aim of this study is to assess the prognostic impact of vap in critically-ill elderly patients. patients and methods mono-center, retrospective study conducted from / to / / . all old patients (age ≥ years) requiring mechanical ventilation were included. two groups were compared: patients who developed vap (vap (+) group) and those who did not develop vap (vap (−) group). results during the study period, patients were included. the causes of admission in the intensive care unit (icu) were shock (n = ), acute respiratory failure (n = ) and disturbed level of consciousness (n = ). diabetes mellitus, hypertension and chronic obstructive pulmonary disease were the most common comorbidities ( . , . and . % respectively). mean age was . ± . years. sex-ratio (m/f) was . . mean apache(ii) score was ± . the mean duration of mechanical ventilation was ± days. thirty patients ( . %) developed vap. icu-mortality was significantly higher in the vap (+) group ( vs . %; p = . ). multivariate analysis identified two independent factors predicting icu mortality: shock on admission (or = . , ci % [ . - . ], p < . ) and vap (or = . , ci % [ . - . ], p = . ). conclusion vap is common in critically-ill elderly patients and is associated with worse outcome. therefore, preventing its onset is of paramount importance. increased health-care costs. among pathogens responsible of vap, acinetobacter baumannii which is characterized by its ability to spread in the hospital environment and to acquire resistance leading sometimes to therapeutic impasses is associated with a particularly high mortality reaching - %. objective to describe the epidemiological characteristics of a. baumannii vap, to determine their prognosis and identify factors associated with mortality. patients and methods it is a monocentric observational study conducted over a period of years in a tunisian intensive care unit (icu) including mechanical ventilated patients for more than h with confirmed a. baumannii vap. results one hundred and twenty-three patients were included in the study. a. baumannii was responsible for % of vap in our icu. the vap were late in % of cases. more than % of isolates pathogens were resistant to ticarcillin, piperacillin, piperacillintazobactam, ceftazidime and ciprofloxacin. sixty percent of germs were sensitive to imipenem. resistance to imipenem has increased consistently from % at the beginning of the study to % in . all pathogens were susceptible to colistin. a. baumannii vap was complicated by septic shock in % of cases. the median duration of mechanical ventilation and of icu stay were (iqr: [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and days (iqr: - ) respectively. the use of parenteral nutrition was the only factor associated with the occurrence of a. baumannii vap resistant to imipenem (odds ratio . , % ci [ . - . ], p = . ). icu mortality was %. it was higher in patients with a. baumannii vap resistant to imipenem ( vs %, p > . ). in the multivariate analysis, the age, the use of renal replacement therapy and the occurrence of vap relapse have been identified as factors associated with mortality. conclusion a. baumannii resistance to imipenem became threatening. the use of parenteral nutrition was the only factor associated with the occurrence of a. baumannii vap resistant to imipenem. the choice of empiric antimicrobial for vap caused by this pathogen must take in consideration the epidemiologic data of each country and each icu. a. baumannii vap was associated with high mortality. the age, the use of renal replacement therapy and the occurrence of vap relapse have been identified as predictive of poor outcome. none. admission in intensive care unit for severe adverse drug event: what finding? julien arcizet , bertrand leroy , caroline abdulmalack , catherine renzullo , maël hamet , jean-marc doise , jérôme coutet introduction adverse drug events (ade) remain a serious public health problem. they represent between . and . % of hospital admissions and between . and . % of intensive care unit (icu) admissions. they are defined as any injury related to a drug, and include both adverse drug reactions, expected or not, but also underuse, overuse and misuse, unintended or undesired, preventable or not. indeed, mortality from iatrogenic event would rise between . and . %, whereas these ade that resulted in icu hospitalization could be prevented in . - . % of cases. these unplanned admissions overload icu, limit access to health care for other patients and have serious economic consequences for the health system. it is therefore necessary to study these ade to know their main causes and attempt to find a solution to avoid them. the main objectives of our study were to clinically and pharmaceutically analyze and stratify the different ade leading to hospitalization in our icu. this is a monocentric prospective study, between june to january , in medico-surgery icu. from all admissions, we had included patients admitted in our hospital for involuntary ade (plausible, likely and very likely causal). we had collected clinical aspects (failure mode, igsii score, mortality in icu) and pharmaceutical aspect (number of drug, offending drugs) at daily medical staff meeting. conclusion hospitalizations in icu for ade are still too common despite their preventability for most cases. many patients with known cognitive disorder manage their treatment themselves and this is probably one of the reasons of iatrogenic events. anticoagulants and antiplatelet agents, by side effects, misuse, underuse or overuse are very often involved. the onset of kidney failure from dehydration and the continuation of nephrotoxic and antidiabetic treatment also remain one of the most common causes. consequently, it is necessary to continue and develop primary, secondary and tertiary prevention strategies to prevent their appearance, to limit their consequences and to reduce recidivism. introduction intensive care unit (icu) is usually identified as a place of acute care, concentrated over a short period. for many reasons, a prolonged stay in the icu has a pejorative connotation for the intensivist physician. the aim of our study is to describe the epidemiological, clinical, paraclinical profile of patients hospitalized for a long time in icu (over days) and to identify the main prognostic factors and those that can predict the duration of stay in icu. we conducted a retrospective study, over a period of years and months (january to june ), enrolling patients whose length of stay was greater than or equal to introduction despite an improvement in prognosis of patients with hematologic malignancies for the last decade, mortality of such patients admitted to the intensive care unit (icu) remains high. yet, it seems that a first icu stay does not modify prognosis of the malignancy. until now, there is no data on readmission in the icu of such patients and its effect on short and long term prognosis impact. patients and methods this retrospective, single-center study conducted on a years period in the medical icu from our university hospital included patients with hematological malignancies admitted for a first stay. objectives were to evaluate the icu, day and months mortality, to identify prognostic factors associated with mortality within uni-and multivariate analysis, to evaluate readmission rate within the days after discharge, to indentify the admission risk factors associated with icu readmission and the prognosis factors associated with mortality during the second icu stay. multivariate analysis poor performance status, igs ii, hlh, mv and anti-fungal administration were associated with increased icu mortality, infections with pseudomonas were associated with higher day mortality. catheter related infections were associated with better icu survival and cr was associated with lower day mortality. of ( . %) candidate patients for icu readmission after a first stay were readmitted within the days following discharge. median overall survival was lower in readmitted versus non readmitted patients. months mortality was . % for readmitted versus . % for no readmitted patients (p < . ). the second icu stay mortality was . % and month mortality was . %. by multivariate analysis, only mv was associated with prognosis. the months mortality rate of patients who survived to the second icu stay was significantly higher than the patients who survived to the first admission but were not readmitted ( . vs . %, p = . ). conclusion main features, short and long term mortality and prognostic factors associated with icu admission are in lines with previous studies. early readmission rate was high with a negative impact on survival. despite admission in the icu of patients with hematologic malignancies seems not to affect long term prognosis, early readmission seems to have a pejorative impact on the course of the malignancy. introduction lung cancer is among all types of cancer, the most common solid tumour admitted in intensive care [ ] . recent studies showed that the prognosis of patients with lung cancer during intensive care unit (icu) stay has improved [ ] . the aim of our study was to determine the causes of icu admission of lung cancer patients, their prognosis and to identify factors predicting hospital mortality and survival after hospital discharge. in fact, temporary full-code icu management in patients with relapsed aml seems to be appropriate. none of the life-sustaining interventions at admission and on day were able to predict survival. an icu trial of days might not be enough to appraise precisely the outcome. bone marrow transplant was associated with a high mortality in our study. in case of relapsed aml with bmt, icu management is still challenging. the growing population of chronically critically-ill patients has a poor prognosis despite all the resources mobilised [ ] . our primary objective was to analyse the prognostic value of different definitions used to describe them. our secondary objective was to look for early clinical and biological factors that could be associated with the in-hospital mortality. we conducted an epidemiological prospective study in intensive care units (neurosurgical, cardiosurgical and medical) of a large french teaching hospital (henri mondor, créteil). we included all the patients hospitalized for at least days. we tested definitions: the prolonged mechanical ventilation, the definition taken up by kahn et al. [ ] , the prolonged length of stay, the persistent critical illness and the persistent inflammation-immunosuppression and catabolism syndrome. two biological examinations were performed: upon entering the study and week later. the study endpoint was the in-hospital mortality. results thirty patients were included between april and july . among them, only % matched the definition of prolonged mechanical ventilation, which is still the most used in the literature. further, it was not associated with the mortality, but the prolonged length of stay was, with % of these patients, that did not survive to their hospital stay. other parameters that were significantly different between the patients who died and those who survived were an advanced age, an elevated igs ii score at hospital admission, an elevated sofa score at study entry, a late healthcare-associated infection and several biological variables: a high c reactive protein, low albumin and prealbumin and a poor percent of monocytes expressing hla-dr, all measured at day . conclusion the in-hospital mortality of chronically critically-ill is still high. a prolonged length of stay is the only definition who may be helpful to identify the patients with the poorest outcome. among the early factors associated with mortality, we found a late healthcareassociated infection and a low percent of monocytes expressing hla-dr, pointing to the value of studying the immune system of these patients. introduction as a result of demographic transition, the proportion of «very elderly» (≥ years) patients is increasing worldwide and more of these patients are nowadays admitted to intensive care units (icu). among physicians the discussion about appropriateness of these icu admissions still remains controversial mostly due to questionable outcome, limited resources and costs. the aim of the study was to determine and evaluate the clinical characteristics and outcome in a very old population admitted to a medical icu in an urban teaching hospital. we present here a monocentric, retrospective and observational study. we reviewed the charts of all patients (≥ years) admitted to a medical icu between and ( years). we collected epidemiological, clinical and biological parameters and all therapeutic measures during the icu stay. a longterm survival follow-up was also performed. two hundred eighty-four patients were included for statistical analysis. multivariate cox regression was also performed to identify risk factors for -day outcome. results a total of patients were included, which represented . % of admissions to the icu during the period of the study. the mean age was . ± . years, the sex ratio was . . most of patients ( %) were admitted from the emergency department. % of these admitted patients suffered of previous dementia. the mean charlson comorbidity score was . ± . and the mean mccabe score was . ± . . the admission diagnosis in the icu was mainly respiratory distress ( %), septic shock ( %), cardiac arrest ( %) and coma ( %). the mean saps-ii score within h of icu admission was . ± . . half of these patients required support by mechanical ventilation (mean duration . days) and vasoactive drugs and % of patients received renal replacement. icu and in-hospital mortality rates were and % respectively. overall survival at months after hospital discharge was %. multivariate regression revealed necessity of catecholamines and mechanical ventilation as independent risk factors and urinary sepsis as protective factor for -day outcome. in fine, for % of these patients, a limitation of active treatment was decided (on average after days of stay). for all others there was no justification for limiting care because of a well-established treatment plan (with family, gp, icu team). conclusion the proportion of elderly patients remains low, but they are increasingly being treated in intensive care units. nevertheless, the in-hospital mortality is high compared to the average mortality in our icu over the same period ( %). the prognosis is often not as poor as initially perceived by physicians. the indication for icu treatment in our study was mostly justified; in the setting of consistent patient care and good clinical practice. it remains therefore appropriate to discuss every single icu admission of elderly patients without any restriction related to age. thus, the ongoing cluster-randomized trial of icu admissions for the elderly patients (ice-cub study) is deeply awaited to confirm or not these results [ ] . keywords intensive care; prognosis; outcome; elderly patients; over -years old. introduction regardless of the route of delivery, the postpartum hemorrhage (pph) is defined as blood loss ≥ ml after childbirth, and severe pph as blood loss ≥ ml. pph is the leading cause of maternal mortality in africa. the aim of this prospective study was to assess the quality of the initial management of pph in algeria in oran ehu and to determine the factors of care with the severity of this complication. we conducted a prospective cohort study between april and september at the ehu oran. all women who delivered vaginally and showed hpp including the suspected cause was uterine atony were included. the severe pph was defined as bleeding that required invasive surgical treatment (hysterectomy, arterial ligation), a transfusion, a transfer to an intensive care unit or death of the patient. the quality of care was evaluated using objective criteria defined by a delay of diagnosis and care and mortality. results among the women who delivered vaginally during the study period, had a pph, link with uterine atony alleged at diagnosis, of which presented signs of severity. in % of cases, the delay in diagnosis of pph was less than min; % of women received oxytocin within min after diagnosis. the tranexanique acid was used in case. the examination of the cervix, uterine exploration and uterine massage was performed in , and %, respectively. the failure of first line treatment involved % of patients. among them, the time between the diagnosis of pph and administration of blood derivatives was greater than h in a third of cases. the administration of oxytocin delay exceeds min multiplied by . the risk of severe pph. however we had deaths in our series. discussion in our study the optimal period of care was not adequate, obtaining blood derivatives in our institution remains among the factors aggravating among the main risk factors for pph, uterine atony was the main source of complication. bleeding postpartum aggravated in our two patients has led to the deaths from late diagnosis and care that was not optimal. these hemorrhages pp is the leading cause of mortality: % of obstetric deaths ( % in the confidential survey - ) [ ] . a hysterectomy was indicated after failure to conservative treatment. the death rate is estimated at % following a disorder complicated hemostasis of disseminated intravascular coagulation (dic). in some series, the mortality rate is estimated between and % [ ] . conclusion the management of pph in obstetrics gynecology service the ehu oran was not optimal. the issue of timing of diagnosis and initial treatment is crucial. solutions must be sought locally to ensure the administration of essential medicines in time, especially the injection of oxytocin within min after diagnosis. introduction chronic obstructive pulmonary disease (copd) is a common pathology that would represent the third cause of death worldwide by . its evolution is interspersed with episodes of acute exacerbations (aecopd) that may indicate an admission in intensive care unit in the most. objective to study the evolution of management modalities of patients admitted in our intensive care unit for aecopd, to determine their prognosis and to identify factors associated with mortality. patients and methods it is a retrospective, monocentric study, performed in a tunisian intensive care unit (icu) over a period of years. we including all patients admitted in icu for aecopd. parameters collected were demographic features, comorbidities, regular treatment, dyspnea assessed by the mrc scale, initial clinical severity reflected by saps ii and apache ii scores, modalities and icu admission deadlines, initial arterial blood gas analysis, management of patients in the icu (ventilation modalities, prescription of antibiotics, use of vasoactive drugs) and their outcomes (incidence of nosocomial infections and their sites, length of stay and icu mortality). results a total of patients, which represents . % of all hospitalizations, with mean age of years (iqr: - ) were admitted for aecopd during the study period. the mean saps ii and apache ii were respectively (iqr: - ) and (iqr: - ). of these, % were ventilated with niv whose overall failure rate was % with a significant decrease between the beginning and the end of the study ( vs % p = . ). sixty-four percent of patients received antibiotics at admission. the prescription rate of antibiotics has decreased significantly over the years from to %. the incidence of nosocomial infections was %. it remained steady between and %. their sites were pulmonary in % of cases. icu mortality was %. in multivariate analysis, icu admission deadlines, niv failure and the use of vasoactive drugs were identified as factors associated with mortality. conclusion our study showed the importance of aecopd in the activity of our icu. the management of these patients has evolved over the years, which was reflected by the significant decrease in the prescription of antibiotics and the enhancement of niv success rate. this result could be attributed to the combination of several factors: precocious management of patients, experience of the healthcare team and the use of efficient ventilators. icu admission deadlines, niv failure and the use of vasoactive drugs were identified as factors associated with mortality. introduction aim. investigate the effect of music therapy on the tolerance of non-invasive ventilation (niv) during its introduction. currently, % of the trauma are intubated. thirty-three percent of the patient admitted in intensive care suffers from acute respiratory distress syndrome (ards). the fmhs chose oxygen concentrator as oxygen source in addition to oxygen pressurized bottles. their supply can be uncertain in conflict areas. insufficient data are available concerning the use of oxygen concentrator in intensive care unit. the primary endpoint was to determine over the total duration of oxygen therapy, the number of days on which the use of pressurized oxygen was needed for patients oxygenated by oxygen concentrator. the secondary endpoints were to identify when pressurized oxygen was needed, describe the characteristics of the population with oxygen therapy and estimate the oxygen quantity economised thanks to the use of oxygen concentrator. the study took place in the forward surgical unit of bouffard. it's a french role located in djibouti republic in africa. all patients over admitted in the intensive care and needing oxygen therapy were included. all the patients were oxygenated with an oxygen concentrator. the oxygen concentrators used were sequaltm integra om, that could deliver up to l/min of normobaric oxygen. the ventilator used were pulmonetictm ltv and . results thirty-six patients were included over the months' study period. sixty percent of the patients were men with an average age of two hundred and fifty-one days represents the total number of days of oxygen therapy divided into days of invasive ventilation, days of noninvasive ventilation and days of oxygen mask. the use of pressurized oxygen was necessary times over the days of oxygen therapy which represents . % of the total time. the causes of its use were in ten cases ( . %) criteria of severe ards, in six cases an emergency intubation and in three cases a transfer. one dysfunction of an oxygen concentrator happened during our study. the oxygen concentrator produced m of oxygen over the study period, which represents oxygen pressurized bottles of litres. this enabled an economy of , euros. conclusion it is safe to use oxygen concentrator to take care of critically ill patients in limited resources environment. the use of pressurized oxygen is still compulsory in two situations: in case of electricity failure and in case of high fio (above %). oxygen concentrators are sufficient in . % of the time. they enable to deliver oxygen any time which is essential when supply is uncertain in conflict areas. none. table ). for the same mv and level of ofr, fdo was in our experiment, with an ofr of l/min, when ifr = l/min (mv = l/min and ti/ttot = . ), the fdo is equal to % (± %) (see table ). to this value of ifr, the fdo is in accordance with the formula of ats, but when ifr increase beyond l/min, the fdo decrease and the formula is not in accordance with ats. this can be explain because during inspiratory phase, air room (fractional oxygen = . ) entry in airway mixes with ofr (fo = ), which modifies the fdo . in this case, when ifr increase then fdo decrease and vice versa. medical and paramedical staff must be aware that with patients who receive ofr by nasal cannula, any change of ofr and/or inspiratory flow changes the fdo . in this case, for maintain the same fdo , it is necessary that modify the value of ofr. the actual fio delivered under oxygen mask in patients with acute respiratory failure and the factors that may influence the fio are poorly known. in clinical practice, different methods including formula or conversion tables based on oxygen flow can be used to estimate delivered fio . we aimed to assess first the factors influencing measured values of fio , and second the best method to estimate fio in patients breathing under oxygen mask. we included icu patients admitted for acute hypoxemic respiratory failure from a previous prospective trial [ ] in whom fio was measured under oxygen mask using a portable oxygen analyzer. we collected demographic variables and respiratory parameters that may influence measured fio . low fio was defined according to the median measured fio . for each patient, measured fio was compared to "calc + %" formula (fio = oxygen flow in liters per minute × . + . ) to "calc + %" formula (fio = oxygen flow in liters per minute × . + . ), and to a conversion table [ ] . a ± % limit of agreement for each estimation method was arbitrarily considered acceptable. results among the patients included, median measured fio was % [ - ]. after adjustment on oxygen flow, the three variables independently associated with low measured fio using multivariate analysis were patient's height, a low paco , and a respiratory rate greater than breaths/min. using paired analysis, each estimation methods differed significantly from measured fio (p < . for each). values outside the limits introduction acute hyperglycemia is common in intensive care. it was associated with poor prognosis and increased mortality. the purpose of our study is to investigate the frequency of hyperglycemia in our icu, to determine the main causes of high blood sugar and to analyze the impact of this hyperglycemia. our study is prospective during months. it was conducted in the intensive care unit of the university hospital habib bourguiba sfax-tunisia. were included in our study all patients admitted to the service during the period of the study. for each patient included were collected from the icu admission, clinical and biological data. results during the study period, patients were hospitalized in our icu and the diagnosis of hyperglycemia (> mmol/l) was admitted in patients ( %). the comparison between patients who developed hyperglycemia and those free hyperglycemia group showed that, the patients of the first group were significantly older (p < . ). additionally, hyperglycemic patients had more medical history including history of diabetes (p < . ), a higher saps ii (p < . ), a more significant frequency of active infections (p < . ). moreover, the presence of hyperglycemia was associated with shock (p < . ) and respiratory distress (p < . ). their evolution was marked by the significantly higher frequency of infectious complications (p < . ), thromboembolic complications (p < . ) and acute renal failure (p < . ). the average duration of mechanical ventilation and the length of stay were also significantly prolonged in hyperglycemia group patients (p < . for both). finally, the presence of hyperglycemia was significantly associated with a higher mortality rate. conclusion we concluded that hyperglycemia is correlated with poor prognosis of morbidity and mortality. but strict glycemic control remain controversial. thus, further studies on this subject will be recommended to define the exact place of glycemic control in intensive care. none. the rrt was prophylactic in four cases started when phophatemia was more than mmol/l, and therapeutic for renal failure and established tls in three cases. the median duration stay in icu was [ ] [ ] [ ] [ ] j. thirteen patients left the icu without major metabolic dysfunction. two patients deceased due to infectious complications. discussion monitoring of electrolytes was done on average, three times a day which is hard to do in onco-hematology unit. the early use of rasburicase and the aggressive iv hydration helped to prevent tls for seven patients. the aggressive iv hydration was made according to echocardiography data and close monitoring of vital signs and urine output which has allowed to avoid volume overload and acute pulmonary edema. the early prophylactic rrt prevented renal failure and metabolic complications. conclusion early management of tls in icu can prevent tls and most of its serious complications and should be considered in tls prophylaxis recommendations. none. the both urinary (expressed as the ratio of ngal on urinary creatinine) and plasma ngal were predictive of aki stage . predictive value of plasmatic measurements was higher than the urinary one (auc of . and . , respectively, p = . between auc), but not higher than either baseline serum creatinine (auc = . ) or h diuresis (auc = . ). backward multivariate regression showed that plasma ngal concentration was associated with serum creatinine, crp and albumin, whereas urinary ngal was associated with leucocyturia and baseline creatinine. discussion previous positive studies with ngal did not compare the performance of this costly biomarker with simple usual clinical parameters to predict aki. moreover, several parameters were associated with ngal concentrations with a high risk of collinearity (crp) and/or false positive results (leucocyturia). our data do not support any added value of ngal concentration over baseline serum creatinine or urine output to predict aki. introduction acute renal failure (arf) is a common entity in intensive care, concern that the heavy morbidity and mortality it is associated [ ] . early diagnosis of this entity remains difficult, neither diuresis and creatinine are early parameters in the diagnosis of arf. the kidney is an organ that suffers long to become faulty, the priority is to recognize renal aggression and to achieve a therapeutic allowing reversibility of the infringement. a number of markers have been developed for the diagnosis of the ira but costs remain high not allowing their routine use. the measurement of resistance index with the renal doppler could be a solution for the diagnosis of aggression and also of the etiology. the elevation of creatinine was seen later within h after the ir > . discussion in our series the resistance index has a value of early diagnosis of renal prognosis aggression in the occurrence and development of renal failure. renal doppler associated with a strictly applied standardized protocol achieves the two goals of monitoring who aid in the diagnosis and guide treatment. although the recommendations of experts to this tool provides that it should probably not use the resistance index measured by renal doppler to diagnose or treat an ira (grade ) [ ] . identifying the cause of kidney aggression is a prerequisite before any therapeutic action. hypovolemia and soda hydro overload are the causes principales. excess filling hyper intra thoracic pressure and hypoxia are the main causes of kidney congestion. conclusion doppler is an early renal medium in the diagnosis of renal aggression. a larger series could assert this observation. none. ), had significantly more pre-eclampsia, / ( %) versus / ( %) p = . . pe were started at an average of . days after foetal extraction, and with an average of sessions. patients of the pe group had significantly lower nadir of hemoglobin but also lower hemoglobin level at day and day . nadir of platelets count was also lower and level remain lower at days , , and . acute kidney injury (using kdigo classification) was more frequent with a higher rate of dialysis in icu, in the pe group ( / ( %) vs / ( %) p = . ) with a more frequent need for dialysis at the exit of icu. proteinuria was significantly higher in the pe group ( . mg/mmol vs . mg/mmol, p = . ). adamts dosage was done only in patients with pe. we find a diminution of adamts activity (before pe) with an average of % [ - ] in this group. there was no death, and adverse effects were not significantly different. discussion this study shows that pe was used when diagnosis was uncertain in the most severe form of pp-tma. low hemoglobin, low platelets, acute kidney injury and high level of proteinuria are the main factors associated with the decision to begin pe. this technique was safe and not associated with major adverse events. several studies show that there are physiopathological crossovers between diseases associated with pp-tma, for example low adamts activity in hellp or mutation in alternative complement pathway which induced hellp. moreover, studies and case reports show a benefit of pe in hellp syndrome. our study did not find significant difference in adverse events (maybe due to a lack of power), but this is another argument to discuss pe in the management of pp-tma in severe patients. the main limits of our study are that none of the patients who had a plasmatic exchange had a diagnosis of ptt and that diagnosis tests were not performed in all patients with pp-tma (complements level, adamts …). conclusion pp-tma treated with pe has lower hemoglobin, lower platelets, higher rate of kidney injury and proteinuria than those treated without pe. no difference were found for adverse events. begining of pe should be discussed for management of a pp-tma without amelioration after foetal extraction. none. introduction diffuse alveolar damage (dad) is the typical histological feature of acute respiratory distress syndrome (ards). however, in a previous study including patients with criteria for ards, we found that only % of them had dad at autopsy exanimation [ ] . it has been shown that patients with ards and dad on open lung biopsy had higher mortality than those without dad [ ] . thus, we aimed to identify markers associated with dad in patients with ards. we included the patients who met criteria for ards at time of death in our large database of clinical autopsies [ ] . we assessed the proportion of dad according to the severity of ards including the degree of hypoxemia and the ancillary variables from the berlin definition: use of high levels of positive endexpiratory pressure (peep at least cmh o), radiographic severity ( or quadrants on chest radiograph), altered respiratory system compliance (≤ ml/cmh o), and large dead space defined as a corrected expired volume per minute (≥ l/min). results dad was associated with all the severity markers abovementioned using univariate analysis. after multivariable logistic regression, the three markers independently associated with presence of dad were the gender with an odds ratio ( conclusion dad was significantly more frequent in females. in addition to the severity of hypoxemia, diffuse infiltrates involving the quadrants was a significant marker of dad. introduction ventilation induced lung injury (vili) is responsible for an increased mortality in ards [ ] . mechanical ventilation may trigger an inflammatory response, comprising alveolar macrophage activation and recruitment, which may be specifically, repeatedly and spatially assessed by functional imaging techniques such as positron emission tomography combined with computerized tomography (pet/ct) [ ] . c-pk is a pet radiotracer with potential to quantify macrophage inflammation. we aim to assess its performance to detect lung macrophage recruitment in an experimental highvolume vili model. materials and methods vili was performed in anesthetized pigs under neuromuscular blockade by rapidly increasing the tidal volume (vt) to obtain a transpulmonary pressure (tpp) between and cmh o under zero end-expiratory pressure. pet/ct acquisitions were performed before (t ) and after h of high-volume ventilation (t ), and image-derived measurements were realized on the whole lungs, and regionally on distinct lung regions (divided along the anteroposterior and the cephalocaudal axes). c-pk lung uptake was estimated using the standardized uptake value (suv), normalized to the ct-derived tissue fraction in the region of interest (roi). mechanical lung aggression was estimated by ct-derived dynamic and static strains, and tidal alveolar hyperinflation (expressed as a fraction of the tidal variation in the roi volume). after euthanasia, alveolar damage and macrophage recruitment were assessed in the lung regions, using semi-quantitative scores. results between t and t , vt and tpp significantly increased from . ± . to . ± . ml/kg and . ± . to . ± . cmh o, respectively. suv on the whole lung significantly increased from . ± . to . ± . between t and t and dynamic strain from . ± to . ± . , whereas static strain did not significantly vary. tidal alveolar hyperinflation significantly increased from ± to ± % on the whole lung between t and t . regionally, dynamic strain, and tidal alveolar hyperinflation significantly differed between regions, as well as between t and t . regional suv differed between t and t but not between regions. regional static strain did not differ between regions, nor between t and t . in multivariate analysis, regional suv was independently and significantly associated with dynamic strain and tidal alveolar hyperinflation. histologic analysis showed significant regional differences in alveolar damage but not in macrophage recruitment. suv was positively associated with macrophage recruitment but not with alveolar damage. discussion in this experimental vili model, c-pk suv was significantly increased after h of injurious ventilation, and was significantly and positively associated with high-volume ct-derived mechanical parameters, such as dynamic strain and tidal alveolar hyperinflation. the radiotracer's specificity for macrophages is confirmed by the suv significant association with macrophage recruitment and the lack of association with alveolar inflammatory edema. conclusion c-pk is a macrophage-specific pet radiotracer, with potential to dynamically and specifically assess alveolar macrophage inflammation induced by high-volume ventilation. research founded by the french society of intensive care medicine (srlf) and la fondation pour la recherche médicale (dea ). the reverse triggering (rt) is the term used to name the contractions reflexes of the muscle diaphragmatic provoked ("triggered") by the periodic insufflations, delivered by the ventilator, at sedated patients under mechanical ventilation [ ] . the rt constitutes a new form of patient-ventilator interaction clinically difficult to detect and little known. the rt could have potential implications during the management of acute respiratory distress syndrome (ards). at present, the management of severe ards consists among others, on the use of an early and systematic perfusion of neuromuscular blockade agents (nmba) during a h' period, continuation to the acurasys essay which showed a reduction of the mortality in the group of the severe ards patient receiving nmba. the reason of the beneficial effect of curare is not perfectly known. it is possible that the phenomenon of rt is a mechanism implied in the deleterious role of the mechanical ventilation during ards. the abolition of this phenomenon by nmba could explain the beneficial effect of nmba in ards [ ] . the objective was to look for the phenomenon of rt in two groups of ards patients: a group receiving nmba and a group not receiving nmba. patients and methods physiological observational and comparative study in intensive care units. we record continuous signals of airflow, airway pressure, and esophageal pressure during h of consecutives patients with ards criteria and pao /fio ratio ≤ at a positive end-expiratory pressure (peep) of cmh o evolving for less than h under mechanical ventilation. recording of esophageal pressure of consecutives moderate to severe ards patients were blinded analyzed (group nmba n = ; group unless nmba n = ). any phenomenon of rt was observed in the group of mild ards patients receiving nmba (fig. a) . we confirmed the existence of rt on patients of in the group of mild ards who not receiving nmba (p = . ) (fig b) . discussion one of the main limits was the quality of the collection of the signal of esophageal pressure. the monitoring of esophageal pressure is technically difficult, and can d influence the quality of the signal and the reliability of the results. conclusion this study confirms the existence of the phenomenon of reverse triggering among deeply sedated patients not receiving nmba with a % incidence. more research is needed to determine if the reverse triggering is a risk factor independent from vili, associated with the bad prognosis of severe sdra patients and, if a strategy of early treatment based on nmba, could improve the prognosis of reached patients. after ecmo removal had a significant median reduction of days in the bipap-aprv group, p = . (fig. ). we reported the feasibility of a protocol based on bipap-aprv aiming at resuming sv as soon as possible in ards patients under ecmo. the occurrence of spontaneous inspiratory efforts in ards patients can major variability of transpulmonary pressure and as result jeopardise vt and driving pressure control. this might be an issue if protective ventilation is not guaranteed anymore. vt with bipap-aprv remains within safe range when the ratio fig. circles are pac group, rhombus are aprv group. mv mechanical ventilation, psv pressure support ventilation. data are presented as median (iqr), comparison between the groups at each time mann-whithney test, *p < . of spontaneous minute ventilation to total minute ventilation is between and % [ ] . bipap-aprv is more efficient than psv to increase lung aeration in patients with ards [ ] . recruitment of dependent region is more likely to achieve if sv is not supported by synchronized positive airway pressure as during bipap-aprv [ ] . our strategy targeting a percentage of sv between and % with high peep could be viewed as a compromise in order to promote sv and protective ventilation at the same time. conclusion protective ventilation combined with sv under ecmo by using a specific protocol based on bipap-aprv is feasible and safe. it may facilitate weaning and thus reduce the time under mv after ecmo. to what extend this beneficial effect is directly due to the presence of sv deserve further investigations. introduction since the first transplant from a patient in a state of brain death conducted in at the university teaching hospital ibn rushd of casablanca, the number of transplants has increased. however, it is still inadequate meet the growing needs of organs. the refusal of families remains the main obstacle to the developpement of organ transplantation in morocco. the aim of our study is to monitor and analyse the evolution of family refusal to organ donation in a brain dead patient. patients and methods this is a retrospective and comparative study from august until december .the data were collected from records of brain dead patients candidates for organ donation at the intensive care units on ibn rushed hospital. the coordination registers were also studied. a questionnaire was distributed to families who refused organ donation to investigate the causes of the refusal. results during this period, patients with brain death have been identified and families had been approached. families ( %) refused organ donation. the main causes of refusal were: fear of body mutilation ( %), lack of will ( %) and religious causes in % of cases. the refusal rate for families decreased from % in to % in . only patients experienced cardiac arrest before transplantation. during this period, cornea transplants from braindead patient were conducted with kidney transplants and two liver transplants. discussion the evolution of the refusal of families saw a decline through awareness and communication campaigns for organ donation. conclusion improvements to our health care system must be proposed including strengthening detection of potential donors and relationships with the donor's family and effective communication policy. in the icu, three major actors are involved in the caring relationship: patient, relatives and caregivers. acting as spontaneous testimonials of the lived experience, thank-you letters from relatives may be considered by icu teams as a source of original information which could help in improving care for critically ill patients and families. this study aimed to investigate the qualitative content of thank-you letters from relatives of patients who stayed in the icu. specifically, our research questions were, with regards to the letters' content, ( ) how is the caring relationship tackled and characterized by relatives? ( ) to what extent does this relationship impact their experience of icu? materials and methods the study took place in a -beds icu during a -month period. the research team consisted in a care assistant, a nurse (also clinical research associate), a psychologist (not working in the icu) and an intensivist. the corpus consisted in twenty thankyou letters received in the icu. we conducted a qualitative study according to the thematic inductive approach. the process of coding was intended to create established meaningful patterns. results two main themes emerged as specific determinants of the caring relationship: ( ) the temporality, comprising the time dedicated to the patients and their family, the time spent with the icu team, the striking time corresponding to significant events for relatives needed to be shared with the staff, the extension of the link with caregivers by evocating a new life after icu stay, the writing time as a countergift to the caregivers; ( ) the caregivers behaviour, including human skills detailed in many core values (kindness, availability, devotion, attention, goodwill, sensitivity) psychological support, emotional sharing, capabilities to give informations. relatives feel to be "at the center of all attention" in the same way as their loved ones. through the narration of icu experience, the caring relationship is characterized as follows: ( ) the caregiver becomes a close person with an equal relationship (feelings of friendship, emotional closeness); ( ) the icu team becomes a new family (contrasting with the poor living environment of icus); ( ) the relative becomes a caregiver (with appropriation of medical terms or speaking of his loved one as a patient); ( ) the caregiver is seen as a "super-hero" through an asymmetrical relationship with an overstatement of personal dedication and investment of the staff members (abnegation, vocation, involvement). the caring relationship impacts relatives' experience of intensive care in several ways: ( ) relatives are deeply touched by caregivers' human behavior, emotional support being a source of solace and resilience in particular for bereaved families; ( ) relatives express the idea that taking care of humans is not a valued and rewarded task and the emerging awareness of hospital realities and difficulties of work in the icu; ( ) the most striking transformational change in relatives is the perception of their own vulnerability and humanity, leading them to exhibit an outward-looking attitude (for example filling out their organ-donation card), and encouraging the icu caregivers to continue their missions for the others. conclusion thank-you letters provide both encouraging and informative messages for icu teams about relational care for patients and families notably the indivisibility of the families and their critically ill loved ones. the relatives' experience of the icu appears strongly influenced by the caring relationship in the way they express an authentic revelation of their own humanity and altruistic thoughts. the thematic content of thank-you letters questions determinants and fundamental values at stake in the patient-relatives-caregivers relationship. introduction far from medical paternalism, the doctor-patient relationship has now evolved to respect "the autonomy and patients' rights". changing behavior has been gradual, while the law offered the patient the freedom to consent to care and then of expressing their wishes regarding the therapeutic intensity they would benefit, in critical situations where consent would not be possible, through advance directives (ad) [ ] . their use is of paramount interest for intensivist in many critical situations. unfortunately, the use of ad remains marginal because of the unfamiliarity of patients with their use and an appropriation default by clinicians [ ] . the aim of our study was to investigate the perspective of the coming family physician generation on advances directives. patients and methods population of interest was general practitioner fellow (gpf) from class of to . we built an online questionnaire survey about knowledge and the place they want to give to ad in their forthcoming daily clinical activity. this questionnaire was sent to gpf emails obtained by universities, unions and via the official mailing lists of different regionals classes provided by the first contacted. descriptive analysis of quantitative data was expressed as mean and standard deviation, qualitative data in number and percentage. the comparison of continuous variables was performed by the student t-test and the comparison of categorical variables by a chi test. analyzes were conducted on biostatgv website and microsoft excel ® . results gpf answered the survey, mainly from ile de france (n = ), toulouse (n = ) and lille (n = ). for gpf the majority of patients do not know the ad ( . %) and % think that those who know do not know how to use it. . % of gpf think writing ad by patients requires better information. according to them, the information should concern the support offered in the icu ( . %), the use of mechanical ventilation ( . %), dialysis ( . %) and the evolution of patients after hospitalization in icu ( . %). nevertheless information on the prognosis of chronic diseases or organ failure seems interesting for only and . % of them respectively. . % of gpf wish to propose the drafting of ad to their patients. however, only . % of them are willing to suggest ad to patients with cancer or hematologic malignancies, . % to patients with neurological and/or degenerative disorders, . % to elderly patients. discussion despite the low proportion of the population we think these observations to be of interest because we probably selected the gpf the most interested in ad as the participation was not mandatory. conclusion a large majority of young of future general practitioner is willing to be involved in the implementation of ad with their patients, however the target population remains very limited, considering that half of them do not want to discuss ad with patients suffering from diseases potentially associated with icu admission or therapeutic intensity discussion. this study was conducted in adult intensive care units in public or private hospitals in four countries: canada, france, italy, spain. in each country, health care professionals were solicited for an exploratory interview about the sources of stress in the work environment: senior physicians, residents, experienced nurses (with more than years of experience in the service) and inexperienced nurses (with less than years of experience in the service). all the interview transcripts were analysed using an inductive coding approach. results one hundred and sixty professionals ( physicians and nurses) were included in the study. eight themes emerged from the analysis, and they concerned the stress linked to ( ) patient ( ) care, ( ) team, ( ) family, ( ) institutional context, ( ) environment, ( ) organizational context, ( ) individual dimensions. in each theme, sub-themes have been identified and determine more precisely the difficulties at work. discussion our findings emphasize the complexity of work in icus and show the specifics factors not taken into account in the generic stress scales such as stress in relation with family relationships, the end of life decisions and inequity of health care. conclusion the specific stress scale should allow to better identified stress in icu and to develop measures of prevention and support and training programs. introduction intensive care units (icu) is a place where caregivers face many constraints that can affect their physical and mental health due to the use of specific care and strong emotional charge related to patient death and pain of the families. the aim of the present study is to detect anxiety disorders and/or depression among staff working in icus. on september , a questionnaire was distributed to staff (medical and paramedical) operating in icus in the university hospital fattouma bourguiba monastir, tunisia ( medical icu, surgical icu, cardiologic ccus and nephrologic intermediate care unit). this questionnaire included demographic data of participants (age, sex, marital status, length of service, psychiatric history, consumption of anxiolytic and/or antidepressant) and the hospital anxiety and depression scale (had: scale composed by items to screen the anxiety (a) and/or depression (d) among hospital staff ). results during the study period, participants completed the questionnaire ( %), % of them were women, the median age was years ± . . forty-nine participants were doctors (the majority of them residents: / ). . % of participants (all paramedics) worked on night shift, seniority of more than a year in the icu was found in % of participants. . % of staff interviewed were married and only . % of them reported consumption of anxiolytics and/or antidepressants. . and . % of the participants had respectively symptoms suggesting anxiety and depression. the median had score was (iqr = ); the medical function seems to be significantly associated with the occurrence of symptoms of anxiety and depression compared to paramedics, however the type of icu (medical/surgical icus vs cordiologic/nephrologic icus) does not appear to be related to the occurrence of symptoms of anxiety or depression (table ) . conclusion anxiety and depression are common symptoms among caregivers in icus. improved conditions of work in these units should be a target to avoid burn out syndrome. none. anxiety, n (%) depression, n (%) introduction carbon monoxide (co) poisoning is one of the common causes of poisoning specially in the cold season, which leads to a significant morbidity and mortality. we retrospectively reviewed the medical data of patients who presented to the toxicology emergency department with co poisoning during january to march . we analyzed patients' characteristics, management, and outcomes. results a total of six hundred and sixty-six patients ( female and male), aged of ± years, were included; poisoning occurred between december and february in % of cases, secondary to an indoor heating system exposure in the majority of cases ( %). the estimated duration of exposure was . ± h [ . - h], with a mean carboxyhaemoglobin (cohb) level on arrival at . ± %. neurological changes were the most presenting symptoms including headache (n = , %), dizziness (n = , %), seizure (n = , . %) and loss of consciousness (n = , . %). digestive disorders involving vomiting and nausea were observed in . % (n = ). one woman without cardiovascular risk factors developed non stsegment elevation myocardial infarction complicated by lung edema. the majority of patients (n = , %) received normobaric oxygen during h (n = ) and h (n = ). hyperbaric oxygen therapy was administered at . ata during h to patients for neurological changes (n = ), pregnancy (n = ) and elevated cohb ≥ % (n = ). mechanical ventilation was required for patients, and admission into intensive care unit in patients ( %). death occurred in cases ( . %). conclusion the carbon monoxide poisoning is a common reason for emergency department visits in winter. the physician should be aware of the serious neurological and cardiovascular complications, if symptomatic treatment and oxygen therapy regimens were not respected. none. neuro-respiratory toxicity of baclofen in the rat: study of the concentrations/effects relationships and role of gabaergic introduction baclofen, a gaba-b receptor agonist is used as muscle relaxant agent and recently for the treatment of alcohol dependence. the number of poisonings has significantly increased since this new indication. clinical presentation of poisoning mainly includes sedation, hypotonia, respiratory depression and seizures. to characterize the neurorespiratory toxicity of this molecule at high doses, we aimed at investigating alterations in sprague-dawley rat ventilation and brain electrical activity after baclofen administration and studied their reversal by gaba-receptor antagonists. materials and methods rat ventilation was investigated using plethysmography and arterial blood gas analysis while brain electrical activity was studied using eeg with one implanted frontal electrode. three baclofen doses were used including . mg/kg ( % lethal dose- %), . mg/kg ( %) and mg/kg ( %). baclofen concentrations were obtained using hplc-msms assay. we modeled baclofen pharmacokinetics and analyzed the doses/effects and effects/concentrations relationships. results baclofen induced early-onset and prolonged dosedependent sedation (p = . ), hypothermia (p = . ), eeg and respiratory depression ( . ) characterized by significant increase in the inspiratory (p = . ) and expiratory times (p = . ). significant increase in paco and decrease in arterial ph and pao were observed at mg/kg (p = . ), peaking at min. eeg showed signal slowing, burst-suppression aspects and spikes peaking at - h post-injection without normalization at the end of the experiment at h. we did reverse baclofen-induced decrease in tidal volume with saclofen (a gaba-b receptor antagonist) and interestingly no alteration of baclofen-induced respiratory depression was observed with flumazenil (a gaba-a receptor antagonist). pharmacokinetic parameters of baclofen were obtained at the three doses and were dose-dependent. significant but non-linear relationships were observed between baclofen-induced effects and concentrations. conclusion baclofen causes dose-dependent neurorespiratory toxicity in rats. however, due to increased poisonings, its safety profile at high doses remains to be established in humans. none. poisoning was deliberate in % of cases. mean ingested dose was . ± mg. the majority of patients presented to the emergency room at . ± h after ingestion. digestive decontamination was performed in . % (n = ) of patients. clinical presentation was dominated by neurological symptoms; including coma (n = ), hypotonia (n = ), hyporeflexia (n = ), agitation (n = ), seizures (n = ) and delirium in case. hemodynamic manifestations included bradycardia in patients, three of them required atropine infusion. one patient presented with hypotension responding to vascular resuscitation. sixteen cases required mechanical ventilation. aspiration pneumonia was noted in cases. mean duration of ventilation was . h ± . mean hospital length of stay was h ± . complications included ventilation associated pneumonia in one case and moderate rhabdomyolysis in cases. all patients evolved favorably. there is no correlation between coma and assumed ingested dose. conclusion baclofen overdose causes mainly neurological effects and except for bradycardia cardiovascular effects were uncommon. prognosis is good if full supportive care is administered properly. none. introduction the lack of an effective treatment for the maintenance of abstinence from alcohol has led physicians to take an interest in baclofen. beyond efficacy, safety of baclofen, prescribed in high doses, is a concern, especially in case of drug overdose. indeed, patients with chronic alcohol abuse frequently develop psychiatric disorders, and are at risk of voluntary drug intoxications. thus, we set up a retrospective study to describe morbidity and mortality associated with baclofen overdose. conclusion baclofen, prescribed in high doses, may lead to severe intoxications: self-poisonings frequently require endotracheal intubation and are associated with an increased risk of death. dialysis decreases baclofen elimination half-time but clinical relevance of this difference could not be determined. none. introduction baclofen, a gaba-b receptor-agonist with muscle relaxant properties established since , has been recently used at elevated doses to treat dependence to ethanol. the number of prescriptions has exponentially increased without an exact evaluation of its toxicity. we aimed to describe acute baclofen poisoning requiring intensive care unit (icu) admission and study the relationships between the toxic encephalopathy and the plasma baclofen concentration. we conducted a single-centre retrospective study including all baclofen-poisoned patients admitted to the icu in - . when requested by the clinical situation, repeated electroencephalograms and measurements of the plasma baclofen concentrations were performed. toxic eeg encephalopathy on a scale of zero to five was graded according to the international rating system (markand, ). plasma baclofen concentration was determined using liquid chromatography coupled to mass spectrometry in tandem developed with a quantum ultra apparatus (thermo fisher scientific) and electrospray source ionization in positive mode (limit of quantification: ng/ml). linear regression and chi- or mann-whitney tests were used as requested for subgroup comparisons. baclofen pharmacokinetics and the relationships between the toxic encephalopathy and the plasma baclofen concentration were modeled using winnonlin software v. ) were closed to the observed values reported at therapeutic doses. the relationship between baclofeninduced encephalopathy as a function of the baclofen concentrations was described using a sigmoidal emax model. conclusion baclofen poisoning may be life-threatening. toxic encephalopathy is well-described with eeg and its grade correlated to the baclofen concentration. prescribers should be aware of the dangers of baclofen which benefits to treat dependence to alcohol are still lacking. none. results initial examination suggested that an illness other than bacterial meningitis was the cause of patients' complaints. first hypothesis was meningitis receiving uncomplete dosage regimen of antibiotics. thereafter owing to apparent loss of consciousness with abnormal eyes movements, non-tonico-clonic seizures were considered meanwhile. the ratio of individuals less y-o to those equal to and greater was / %. the male to female ratio was / %. the mean duration of hospitalisation was . ± . days (extremes - days). extrapyramidal syndrome predominant on the upper part of the body was noted by paediatrician neurologists who suggested considering a genetic disease. however, signs and symptoms were present in people from different families in different areas at the same time. the definitive diagnosis made on pictures and videos of children and adults and was facio-troncular dystonia resulting from drug-induced adverse effect. four urine samples were collected in children and sent to a toxicological laboratory in france. all urine samples were positive for haloperidol meanwhile the other causes of facio-troncular dystonia were excluded, including other neuroleptics, metoclopramide, antidepressants, amodiaquine, anti-histaminic drugs, anti-epileptics, and cocaine. from january to august , hospitalisations were recorded in patients. looking for the source of haloperidol showed that tablets sold as 'diazepam' and consumed by symptomatic patients contained haloperidol as the sole active pharmaceutical ingredient, suggesting that this large outbreak was due to haloperidol toxicity from falsified diazepam. initial treatment was diazepam to relieve severe facio-troncular dystonia which was efficient but resulted in long-lasting sedation more especially in children. a dosage regimen using bipéridène administered by intravenous and oral route was refined to prevent adverse effects related to this anticholinergic agent used in children. the complete reversal of the facio-troncular dystonia was the antidotal evidence supporting the toxicological diagnostic. the mortality rate was less than % meanwhile the direct causal relationship with adr is questionable. an epidemiological study, including toxicological analysis in controls in ongoing. indeed, facio-troncular dystonia induced by haloperidol does not result from a drug overdose but is an adr occurring in about % of patients treated with haloperidol. who is involved in the inquiry related to this counterfeature involving different countries. the cause of the error is presently under investigation. discussion this outbreak emphasizes the need to consider toxicity resulting from counterfeatured medicines when facing collective atypical signs and symptoms in countries with unrestricted access to medication with limited control of qualities of the medicinal drugs. conclusion counterfeatured medicinal drug may result not only in poor efficacy but also in onset of unexpected outbreak of unknown diseases that should suggest a toxic origin. in late -early , médecins sans frontières (msf) had to face an outbreak of severe facio-troncular dystonic syndrome (ftds) in north-east congo. this outbreak resulted from counterfeature of pills sold as diazepam. toxicological analysis revealed one pill contained about mg of haloperidol. ftds induced by haloperidol does not result from a drug overdose but is an adverse drug reaction (adr) occurring in about % of patients treated with haloperidol. nine-hundred and twenty-five individuals were admitted in msf structures for ftds. the ratio of individuals less than y-o and equal to or greater of age was / %, including ( . %) of children less than y-o. initial treatment was based on diazepam which relieved ftds but resulted in long-lasting sedation, preventing given any drug by the oral route. owing to the definitive diagnosis, a shift to the use of a more specific antidote was chosen. biperiden was selected as existing in the intravenous and oral form in the swiss pharmacopea. the study was approved by the ethical committee of the ministery of health of the republic democratic du congo. patients and methods as a whole, biperiden was used in cases ( % of the total). treated children presented with severe dystonia as evidenced by inability to cooperate and to swallow. verbal informed consent was obtained from relatives. the dosage regimen to treat drug-induced dystonic syndrome in the swiss pharmacopea is as follows: for parenteral use in children, intravenously or intramuscularly: . mg/kg or . mg/m bsa every , according to response and tolerance; a maximum of four doses per day should be used. the internal msf recommendations for biperiden use in children were . - . mg/kg of body weight that might be repeated four times a day. initially, biperiden administration was administered under medical supervision by the msf referent at the scene. results there was no pediatric preparation of biperiden. accordingly, the adult preparation was used in children. the preparation contained mg of biperiden in one milliter of solvent. the initial planned dose for children of y-o and less and those up to y-o were and mg, respectively. the mg ( ml) of biperiden was diluted in ml of saline resulting in a final dilution of mg/ml. six children were treated according this dosage regimen. however, the one mg dose was either of limited efficacy while being associated in others of signs suggestive of adr, including agitation, heart rate greater than b/ min, the upper limit for children aged of y-o and less. two children greater than y-o presented severe abnormal behavior resulting in an attempt at escape. owing to question about safety, the dosage regimen was changed, as follows: mg ( ml) of biperiden was diluted with ml of saline resulting in a final dilution of . mg/ml. an initial dose of . mg was administered intravenously as a bolus dose. the effects were looked for over min. in the absence of improvement in facial dystonia, a second bolus dose of . mg was administered, a third dose could be considered min later if the ftds did not resume. the cumulative initial dose should not be greater than mg. in addition to the reversal of facial dystonia, the therapeutic effect of biperiden included the return of swallowing to normal allowing to give further doses of biperiden by the oral route for three days. the first oral dose was administered no less than h after the last initial dose at a dose equal to the efficient initial cumulative dose. the following doses were halved every h. no adr related to biperiden were reported using this dosage regimen. the mean duration of hospitalisation was . ± . days. discussion the bioavailability of biperiden by the oral route is equal to %. accordingly, the corresponding intravenous dose should be divided by a factor three. dosage regimen of anticholinergic drugs in children are poorly documented. the dosage regimen recommended by the pharmacopea resulted in frequent and severe adr. titration of biperiden resulted in efficient and safe dosage. conclusion when biperiden administration is required by intravenous route in children of y-o and less, biperiden should be administered intravenously and titred using bolus dose of . mg till the therapeutic effect is obtained. introduction severe poisoning by rodenticides is frequent. it represents nearly % of patients admitted to the new intensive care unit (icu) of the region. that is why we decided to perform this study. the aim of this work was to describe the epidemiology, clinical features and management of all patients admitted to our unit for acute poisoning with rodenticides. patients and methods it was a retrospective study performed in the year from january to december. the study included all patients admitted in the icu for rodenticide poisoning. results patients were enrolled in the study. our patients were young with a mean age of ± years. poisoning was more common in females (n = ; %). the mean delay between rodenticide poisoning and first medical contact was about ± h in the cases where this information. most of our patients ( %) attended the emergency department of zaghouan with a non-medical transportation. it was a suicide attempt in most cases ( %) and an accidental poisoning in % of patients. the most frequent cause of poisoning in our study was organophosphorus pesticide (n = ; %). the second cause was alpha-chloralose poisoning with seven cases ( %). one patient ingested accidentally an anticoagulant rodenticide. most of patients had ingested (oral route) the rat poison (n = ; %). clinical examination found normal vital signs in ten cases ( %). nine patients ( %) had a shock, eight patients ( %) had an acute metabolic disorder and five patients ( %) had acute respiratory failure or were comatose. all patients enrolled in the study were admitted in the icu for a period of clinical observation of h. stomach pumping (gastric lavage) was performed in patients ( %). an antidote which was atropine was needed in twelve patients. three patients ( %) who ingested alpha-chloralose needed intubation and mechanical ventilation. all patients had a good outcome and were discharged from icu and from hospital. the mean icu length of stay was ± days. conclusion this is the first study of acute poisoning with rodenticides admitted in the new icu. the results of our study were similar to those published in recent literature. cases of acute poisoning with rodenticides reported in this work were not severe. none. introduction the systemic arterial load imposed to the left ventricle (lv) is a major determinant of normal/abnormal cardiovascular function. the lv mean ejection pressure (lvmep) is the best estimate of load faced by the lv throughout ejection. the contribution of the steady and pulsatile blood pressure (bp) component of arterial load to lvmep is debated. we studied the hemodynamic correlates of lvmep using carotid tonometry. intensive care unit patients equipped with an indwelling catheter were studied, thus allowing precise calibration of the tonometer. patients and methods carotid tonometry (complior analyse ® alam medical, france) was prospectively performed on hemodynamically stable, spontaneously breathing patients ( f, mean age ± sd = ± years). carotid waveforms were calibrated from diastolic bp and time-averaged mean bp invasively obtained at the radial (n = ) and femoral (n = ) artery. all patients were free of aortic stenosis. lvmep was the area under the systolic part of the carotid pressure waveform divided by ejection time. results lvmep ( ± mmhg) was strongly related to central systolic bp ( ± mmhg; r = . ) and was also related to mean bp (r = . ), peripheral systolic bp (r = . ), peripheral (r = . ) and central (r = . ) pulse pressure (each p < . ). the lvemp was not related to age, heart rate and stroke volume. systolic pulse wave amplification ratio from carotid to periphery was . ± . . conclusion lvmep was most strongly related to central systolic bp, which combines the influences of the steady and pulsatile components of central arterial load (r = . ). lvmep was less strongly related to peripheral systolic bp, which may be less informative given variable systolic pulse wave amplification across patients. introduction myocardial dysfunction is one of the main predictors of poor outcome in septic patients, with mortality rates next to %. many pathological findings were found in the sepsis induced cardiomyopathy including myocardial ischemia, alterations in microcirculation and proinflammatory cytokines. the aim of this study was to assess the prognostic value of a recently developed highly sensitive cardiac troponin i (hstni) assay in patients with septic shock. we performed a prospective observational study in septic shock icu patients within h of admission. exclusion criteria were age > years; pregnancy; post-cardiac arrest and braindead. hstni was measured soon after admission and , , and h after. patients were subjected to transthoracic echocardiography (tte) at study inclusion and regular biochemical and hemodynamic assessments were performed. pearson's chi square and fisher's exact tests were used. p < . was considered significant. conclusion circulating hs-ctni is present in patients with septic shock. a rise of hstni may be an indicator of poor outcome. also, right heart functional abnormalities exist in patients with septic shock. none. evolution of the right distribution width as a pronostic marker during the differents state of shock introduction right distribution width (rdw) has been recently proposed as a pronostic factor in different pathologic situations and especially to the septic patients who stay in icu. some works substantiate the relationship between an alteration of the red blood cell rheology during the septic shock and a severe state of the disease. no one has studied the rdw between the differents shocks yet. we are going to determinate the relationship between rdw and apache ii score, mortality rate in the intensive care unit (icu), at the hospital, at the day and . we investigated those parameters near patients who were admitted at the icu and needed norepinephrine between the first of march and the st of december. they were stratified in différent groups: septic shock n = , cardiogenic shock n = , hemorragic shock n = and obstructive shock n = . results we did not observe any correlation between the rdw and the icu mortality, hospital mortality and at the day and . only a poor significant correlation has been found between the cardiogenic shock and the mortality rate: at the hospital (p = . ), at day (p = . ) and at the day (p = . ) but not in the icu (p = . ). the receiver operating characteristics (roc) curves do not show significant differences between rdw, apache ii score and icu mortality rate or intra hospital. the sample of the hemorrhagic shock and obstructive shock was not usable for this calculation. compared to other studies which were focused on the septic shock where the mortality was approximately %, we determinated a mortality rate near %. conclusion the delta of the rdw d /d did not present any correlation with the mortality rate. in our study, the rdw in the different kind of shocks do not look like to be a good predictive marker of the mortality, except for the patients included in the cardiogenic shock where a poor significant correlation could be highlighted. conclusion cardiogenic shock was the most frequent complication of ami who led to icu admission, whereas mechanical complications are rare at the era of early coronary reperfusion strategies. in addition to severity score, serum creatinine and cardiogenic shock appeared as independent factors of hospital death. none. introduction pulmonary embolism (pe) in high-risk is a partial or total obliteration of the pulmonary arterial network by a fibrin-clot cruoric more than %, the management requires a rapid reduction of pulmonary arterial resistance and right ventricular post load through rapid revascularization by thrombolysis. our aim is to determine the value of thrombolysis in pulmonary embolism and describe the clinical, paraclinical and outcome pulmonary embolism at high risk. patients and methods this is a descriptive study of cases of pulmonary embolism at high risk admitted to the cardiology department to chu oran between and . signs of gravity of (pe) comprising: syncope, circulatory collapse, cardiogenic shock or acute pulmonary sonographic sign of heart. it was confirmed in chest ct. all patients received thrombolysis using the protocol accelerated by two types of molecules: streptokinase or actilyse. the sex ratio was . ; mean age years, ranging from to years; risk factors were dominated by contraception was % and the postoperative % the clinical picture was dominated by cardiogenic shock in % of cases. % cardiovascular collapse and syncope in %; doppler echo all patients had signs of dysfunction of the right ventricle represented by the dilatation of the right cavities and pulmonary hypertension. the cta found a (pe) bilateral in % right in %. thrombolysis using actilyse in patients and streptokinase in cases. the outcome was favorable in patients; with two cases that are complicated by chronic pulmonary heart and the death of patients with cancer. discussion the female predominance is explained by the increase of risk factors hormonal contraception, whose first generation combination hormonal. our patient had a high probability with clinical signs of severity based on the score wells [ ] . this diagnosis was confirmed by chest ct; which shows the vascular bed obstruction degree with a very good sensitivity and specificity. the suspect patients with severe pe and that presented signs of acute pulmonary heart ultrasound have effectively (pe). the indication of thrombolysis was chosen on hemodynamic criteria; success is found in % of patients with improved hemodynamics dice the early hours. this success is explained by the role of thrombolytic in lysis clot to obtain pulmonary arterial revascularization; and reduce pulmonary arterial resistance and the right ventricular afterload which accelerates the healing of right heart failure and improvement of pulmonary capillary volume. the cases who developed a chronic pulmonary heart; it was done immediately a right ventricular dysfunction with pulmonary arterial outset of very high pressures suggestive that the embolism occurred on an already pathological right heart. no cases of massive bleeding were noted in our series. conclusion severe pulmonary embolism is burdened with high mortality; diagnosis is based on the stratification of risk score, was facilitated by the non-invasive strategies that articlent around the doppler echocardiography and ct angiography; thrombolysis can reduce the high mortality related to severe pulmonary embolism. introduction hypertension is a frequent motif for admission to emergencies. the diabetic is increasingly exposed to this risk [ ] . the objective of this study is to evaluate the proportion of diabetic patients presenting to the emergency department with high blood pressure (bp) and to identify their epidemiological and clinical characteristics. introduction sepsis associated liver dysfunction (sld) is usually attributed to systemic and/or microcirculatory disturbance. hypoxic hepatitis, also known as shock liver or ischemic hepatitis, is a life threatening event associated with high morbidity and mortality. doppler ultrasonography is a non invasive method to measure doppler hepatic hemodynamic parameters. the primary objective of this study was to assess the accuracy of the hepatic hemodynamic parameters (portal venous blood flow pvbf and resistance index of the hepatic artery hari) in predicting sld in septic shock patients. the secondary aims were to identify factors associated with sld, investigate the effects of volume expansion (ve) on systemic and intrahepatic hemodynamics and to assess the intra-and interoperator reproducibility. we also analyzed -day mortality. in a prospective design, we included consecutive patients with septic shock ( males; median age: . years) admitted to the icu with septic shock in charles nicolle hospital of tunis from february to july . all patients were resuscitated following the surviving sepsis campaign guidelines. we measured systemic hemodynamic variables (mean arterial pressure (map), and cardiac index (ci)) and performed hepatic doppler before and after volume expansion. we measured pvbf and computed the hari. we recorded the liver function tests (alt, ast and bilirubin) for h. sld was defined as an increase in serum bilirubin ≥ µmol/l (hepatic sofa ≥ ). accuracy of the hepatic hemodynamic parameters to predict sld was measured by the area under the roc curve. p < . was taken to indicate statistical significance. the median sofa score at t was points and the median igs score was points. the sources of infection were as follows: the lungs (n = ), the abdomen (n = ) and the urinary tract (n = ). the incidence of sld in our cohort was . % (n = ). there was no significant difference between "sld group" and "no-sld group" in all hepatic hemodynamic parameters especially the pvbf and the hari. lactate levels were significantly higher in patients with sld (median . vs. . mmol/l). similarly, the platelet count was significantly lower in the "sld group" [mean (± sd) . ± . ( /l) vs. . ± . ( /l); p = . ]. there was no difference in duration of mechanical ventilation, icu length of stay and -day mortality between the groups. the pvbf was significantly lower in patients who died before d (median: vs. l/min in the survivors; p = . ). volume expansion caused a significant increase in ci, mean hepatic artery velocity and the pvbf. the intra-and interoperator reproducibility was good to excellent for the systolic and mean velocities of the hepatic artery, portal vein diameter and the pvbf. conclusion our results don't support the hypothesis that the hepatic sonography is predictive of sld in septic shock. our pilot study showed higher lactate levels and hematologic sofa in sld group. the pvbf was significantly lower in patients who died before d . more experience will be necessary to define the ultimate role of doppler ultrasonography in the evaluation of hepatic perfusion in patients with septic shock. introduction early surgery is the current trend for management of patients with valvular disease. that said many of them, particularly from developing countries, are still operated at a very advanced stage of disease. despite improvements in myocardial protection and surgical techniques, postoperative care after multiple valve surgery (mvs) for advanced rheumatic heart disease (rhd) remains to be a clinical challenge. we conducted a study to determine postoperative complications and morbidity-mortality risk factors in this subgroup of patients. results sixty-two patients were included: with out-of-hospital refractory cardiac arrest and with in-hospital refractory arrest. the initial rhythms was shockable rhythm in ( %) cases. at ecls initiation, the mean no flow was . ± . min and mean low flow (time between the time of refractory cardiac arrest and time at which an ecls flow was provided) was ± min. the mean ecls flow rate was . ± . l/min. initial blood test results were: arterial ph = . ± . and plasma lactate = . ± . mmol/l. eleven ( %) patients survived ( / ( %) acute coronary syndrome, / ( %) severe poisoning due to drug intoxication, / ( %) dilated cardiomyopathy, and / ( %) others). survival was lower for patients with out-of-hospital refractory cardiac arrest, of ( %), than for patients with in-hospital refractory cardiac arrest, of ( %), respectively, p = . . as expected, out-of-hospital refractory cardiac arrest was associated with a more prolonged low flow ( ± min vs ± min, p < . ) and a more profound acidosis (ph . ± . vs . ± . , p = . and arterial lactate . ± . vs ± , p = . ). in univariate analysis, survival was lower for patient with refractory cardiac arrest unrelated to drug intoxication, vs %, respectively, p = . . in addition, mortality was associated with arterial ph ( . ± . vs . ± . , p = . ) and low flow ( ± vs ± min, p = . conclusion in a highly selected group of critically ill patients with refractory cardiac arrest, the potential beneficial effect of ecls could be due only to its clinical impact on reversible causes of circulatory failure (i.e. severe drug intoxication in our cohort). further studies are needed to clarify whether the use of ecls could be considered as a disproportionate tool, specifically in patients with out-of-hospital refractory cardiac arrest due to acute coronary syndrome or associated with prolonged low flow or a profound acidosis. none. post-cardiac arrest shock treated with veno-arterial extracorporeal membrane oxygenation: an observational study and propensity-score analysis wulfran bougouin , nadia aissaoui , alain combes average time between introduction and removed of the ecd was h ( - ). among the esogastroduodenoscopy performed, ( %) were strictly normal. endoscopy showed minor gastric injuries in patients ( %). within these patients, ( %) also presented minor esophageal injuries. esogastric injuries characteristics were mostly similar to usual orogastric probe injuries. one patient ( %) experienced a serious ulcerous esophagitis mimicking a peptic esophagitis, not firmly related to the ecd. no patients necessitated hemostatic local procedure and no significant gastrointestinal bleeding was observed. eight patients ( %) were alive at d , including patients ( %) with a cerebral performance category score of . this compares favorably to outcomes from previous studies. conclusion ecd seems an interesting and safe semi-invasive method of cooling in ohca patients treated with °c-ttm. although it seems slower than more invasive devices to reach °c, ecd was able to strictly maintained the tt within the maintenance phase of ttm. further studies will be necessary to define the exact place of this new device within the cooling strategy in patients necessitating a precise ttm-strategy. none. fig. see text for description introduction since post-cardiac arrest care might influence the outcome, characteristics of receiving hospitals should be integrated in survival evaluation of patients transported in hospital. we aimed at assessing the influence of care level center on survival at discharge in a regional registry of out-of-hospital cardiac arrest (ohca). we prospectively collected utstein and in-hospital data for all non-traumatic ohca patients, in whom a successful return of spontaneous circulation (rosc) had been obtained, from a large metropolitan area (great paris). receiving hospitals were categorized in groups (a, b, c) depending on their respective characteristics (annual volumes, / catheterization availability and temperature management use). we compared patients' characteristics in the groups and performed a multivariable logistic regression using discharge survival at endpoint. results during the study period (may -dec ), patients were admitted in hospitals ( in group a, in group b and in group c). overall survival rate at discharge was / ( %). patients' baseline characteristics significantly differed, as hospitals from group a treated younger patients and more frequent shockable rhythms (p < . ). unadjusted survival rate differed significantly among the groups of hospitals (respectively , and . % for a, b, c, p < . ). however in multivariable analysis, the category of hospital was no longer associated with survival. conclusion in this population-based study, characteristics of receiving hospitals are not associated with survival rate at discharge. this could result from the strategy used for triage, which aims in matching patients' characteristics and resources. introduction acute kidney injury (aki) commonly occurs after cardiac arrest and is associated with an increased mortality and a delayed awaking. early recognition of aki remains challenging, given that serum creatinine increases belatedly after aggression. introduction out-of-hospital cardiac arrests (ohca) are an absolute urgency and have a very poor prognosis. pediatric guidelines differ from adult guidelines for cardiac arrest management. since , adult guidelines apply from the onset of puberty. the main objective was to describe the epidemiological characteristics and outcome of ohca victims while taking puberty into account. the secondary objective was to determine the prognostic factors for survival at d . materials and methods all patients less than years of age, victims of ohca between july , and september , care by a mobile emergency and resuscitation service (smur) participating in french national cardiac arrest registry (réac) were included. patients were split into groups: prepubescent patients (named "children": girls - years, boys - years), pubescent patients (named "adolescents": girls from to years and boys from to years) and "adults" (men and women - years). the "adolescents" group was consecutively compared to the "children" group and to the "adults" group. results children, adolescents and , adults under the age of have been included. ohca in adolescents occurred more often on public roads ( %) or in public places ( %) and were more often traumatic ( %) than those in children and adults. respiratory causes were more frequent in children ( %) than in adolescents ( %) and adults patients ( %). the proportion of shockable rhythm increased with age ( , and % for children, adolescents and adults respectively). survival at d was greater in adolescents ( %) than in children ( %) and adults ( %) (p = . and p = . respectively). in the studied groups, initial shockable rhythm was a survival factor at d (respectively or [ . - . ] for children, adolescents and adults). other risk factors are described in table . conclusion adolescents had better survival at d than the others groups. adolescents and adults had shockable rhythm more often than children. moreover, respiratory failure was less frequent in adolescent and adults patients compared to children. puberty seems to be a good limit to differentiate pediatric patients with ohca. none. introduction non-invasive ventilation (niv) is an effective alternative to endotracheal mechanical ventilation (mv) in the management of acute respiratory failure (arf) patients. nevertheless, it can be still difficult to assess its real feasibility, application and outcome in daily clinical practice. therefore, we report our clinical experience with routine use of niv since the last national recommendations ( ). our aims were to evaluate the clinical efficacy and outcome of niv, and to identify predictive factors for niv failure based on a daily use. patients and methods we conducted an observational retrospective single-center cohort study by reviewing all medical records from january to december in our -bed medical intensive care unit (icu). eligible patients were those having received niv during their icu stay. two groups were defined according to the indication of niv: niv for hypoxemic or hypercapnic arf (arf-niv), and niv used in the post-extubation period for weaning, prevention or treatment of post-extubation arf (post-extubation niv).the main evaluation criteria were the incidence of niv use, success/failure rate of niv and risk factors for niv failure in each group. niv failure was defined as the need for stopping niv whatever the reason (intubation, intolerance, death) within days after its initiation. ( ; ), and was longer in the post-extubation niv group ( days ( ; ) ) than in the arf-niv ( days ( ; ) for hypoxemic arf, ( ; ) for hypercapnic) (p < . ). the overall icu mortality was . % ( . % in hypoxemic group, . % in hypercapnic group, and . % in post-extubation niv group) (p = . ). in multivariate analysis, the main risk factors for arf-niv failure were: saps ii on admission (p < . ), absence of cardiologic history (p = . ) and the cause of arf (p = . ) with a higher failure rate for pulmonary infections than acute cardiogenic pulmonary edema (or . , p = . ). for post-extubation niv, the only independent risk factor for failure was normocapnia before niv initiation (p = . ). conclusion our large longitudinal study demonstrates the feasibility and efficacy of niv applied in daily clinical practice. provided it is performed in a suitable environment by an experienced team, niv should be considered as a first-line ventilatory treatment in various etiologies of arf and a very useful ventilatory support in the postextubation period. nevertheless, risk factors for niv failure should be known by icu clinicians, hypoxemic arf remaining the more difficult indication to manage with niv. réanimation médicale, hôpital saint-louis, paris, france; service de biostatistique et information médicale, hôpital saint-louis, paris, france; réanimation, institut paoli-calmettes, marseille, france; réanimation introduction acute respiratory failure (arf) is the leading cause for icu admission in immunocompromised patients. in these patients, oxygenation strategy is of major interest to avoid the need for mechanical ventilation (mv), which is associated with high mortality rates. in that setting, use of non-invasive ventilation (niv) and oxygen therapy with high flow nasal cannula (hfnc) could be interesting alone or in association, but data about initial ventilation strategy in immunocompromised patients are controversial. to assess how initial oxygenation strategy actually influences the risk of mv on the coming day within the three first days of icu stay. the study end-point was the need for mv on the coming day. we restricted analyses to these first three icu days given, based on our own experience, most of mv was expected to occur by then. we performed a post hoc analysis combining three prospective studies of critically ill immunocompromised patients (two randomized control trials, the ivnictus and the minimax studies and one prospective cohort, the trial-oh study). we only considered patients with arf and a delay between icu admission and study inclusion less than h. we excluded patients who required invasive mv within the first day, those with an icu stay less than day and those with acute pulmonary edema diagnosis at icu admission. in order to estimate and compare the causal effect of daily respiratory management strategy on the probability of intubation in the coming day, we computed inverse probability of treatment weights (iptw) using propensity-score, defined as the probability of actual treatment selection conditionally on observed covariates. to handle confounding in such dynamic regimens, we considered marginal structural models (msm), which have been proposed to estimate the causal effect of a time-dependent exposure when time-dependent covariates that can be affected by the previous treatment are present. two treatment exposure models were considered: niv versus oxygen therapy regardless the device (model ) and hfnc alone, niv alone versus niv + hfnc versus standard oxygen therapy alone (model ). results patients were included in the study. in model , there was no difference between niv and oxygen groups on mv whatever the landmark time. in model , while the unweighted or for intubation at day was significantly higher in the niv group (or . , %ci . - . ) and hfnc group (or . , %ci . - . ) than those in the standard oxygen alone group, these differences disappeared in the weighted samples. using msm, no effect of the oxygenation strategy on mv was found, regardless of the oxygenation devices but the landmark time was associated with a reduced occurrence of mv. conclusion we found no evidence of any significant difference from several oxygenation strategies on mechanical ventilation probability during the first days of icu in a large cohort of immunocompromised patients with arf. none. introduction the role of noninvasive ventilation (niv) is debated in the management of patients with acute hypoxemic respiratory failure. a recent study showed that patients treated with high-flow nasal cannulae oxygen therapy (hfnc) had lower intubation and mortality rates than those treated by the association of hfnc with niv ( ). high tidal volumes (vt) delivewred with niv may be associated with an increased risk of intubation ( ) . we aimed to identify risk factors associated to intubation, in hypoxemic patients with acute respiratory failure and especially the role of vt under niv. patients and methods this is an ancillary study from a multicenter, randomized, controlled trial including patients with acute hypoxemic respiratory failure (florali-study). we focused on only patients with moderate or severe hypoxemia (pao :fio ratio ≤ mmhg) and we excluded those with mild hypoxemia. the criteria for intubation were predetermined including worsened or persisted respiratory failure, impairment of neurologic status and hemodynamic instability. results after adjustment on the oxygenation strategy, the two factors independently associated with intubation were the presence of bilateral pulmonary infiltrates at admission (or . simulation conditions enables to reproduce its occurence, using different types of tools, from physiological parameters to heart rate variability and psychocognitive tests. future research is required to evaluate the impact of these parameters on teaching. none. with stratification by centre and operator experience. an only inclusion criterion was: "patients must be admitted to an icu and require mechanical ventilation through an endotracheal tube". patients were excluded if: contraindication to orotracheal intubation (e.g., unstable spinal lesion); insufficient time to include and randomize the patient (e.g., because of cardiac arrest); age < years; pregnant or breastfeeding woman; correctional facility inmate; patient under guardianship; patient without health insurance; refusal of the patient or next of kin to participate in the study; previous enrolment in a clinical randomized trial with intubation as the primary end point (including previous inclusion in the present trial). post-hoc analysis was performed to assess occurrence of spo < % during intubation procedure between groups of preoxygenation: bvm (at a minimum flow of l/min, niv ( % fio ), hfnc (at a minimum flow of l/min, with % fio ), and nrm (at a minimum flow of l/min). between-groups difference in desaturation occurrence was adjusted for baseline covariates significantly associated with the group membership (p < . ). multivariate analysis of the occurrence of a desaturation (< %) was performed using logistic regression. bag-valve mask was considered reference. results baseline characteristics were showed in table . groups were similar at baseline except for pao /fio ratio. in univariate analysis, age (p = . ), saps (p = . ), pao /fio ratio (p = . ),spo (p = . ) and method of preoxygenation (p = . ) were associated with occurrence of desaturation below %. in multivariate analysis, spo at randomization and method of preoxygenation were only predictors of desaturation below %. bvm and hrm were associated with similar risk of desaturation occurrence whereas niv (or . introduction intubation procedure is a challenging issue in intensive care unit (icu) [ ] . cardiac arrest related to intubation in critically ill adult patients has been poorly studied. the studies were not powered to conclude on this rare outcome [ ] . the main objective of our study was to establish the incidence of cardiac arrest and to assess the risk factors of cardiac arrest in a large prospective database of intubation procedures performed in icu. five prospective studies were included, with similar data collected before, during and after intubation procedures using the same methodology. the primary outcome was the incidence of cardiac arrest related to intubation. the secondary outcomes were the death (cardiac arrest without return of spontaneous circulation (rosc)), the cardiac arrests with rosc, the complications related to intubation, the length of icu stay and the -day mortality. the factors associated with cardiac arrest related to intubation procedures were assessed by univariate and multivariate analysis based on patient, provider and practice characteristics. results among the intubation procedures included, cardiac arrests ( . %) occurred, including with rosc ( . %) and without rosc ( . %). main patient, provider, procedure characteristics and outcomes according to cardiac arrest related to intubation are presented in table . in multivariate analysis, the independent predictors of cardiac arrest related to intubation were low systolic blood pressure prior to intubation, hypoxemia prior to intubation, no preoxygenation, overweight or obesity and age > years. mortality rate at day was significantly lower in patients intubated without cardiac arrest ( . %, of ) than with cardiac arrests overall ( . %, patients of , p < . ) and cardiac arrest with rosc ( %, patients of , p < . ). conclusion cardiac arrest related to intubation in adult icu is not a rare event occurring in . % of cases with high immediate mortality of . % and at day of . %. we identified five independent risk factors to cardiac arrest which of them could be modifiable. optimal preparation to intubation procedure could help to prevent those cardiac arrests. introduction naasotracheal intubation (nti) has been progressively given up in favour of the orotracheal intubation (oti) in intensive care unit (icu). this could be explained by more frequent infectious (sinusitis and ventilator associated pneumonia) and non-infectious (epistaxis, turbinates bones injury) complications the former being thought to be more frequent with nti. however, whereas infectious sinusitis is a risk factor for vap, no study has yet demonstrated that oti decreases the infectious sinusitis rate compared with nti. furthermore, nasal route could improve patient comfort and decrease auto-extubation. finally nti can be performed without laryngoscopy with less risk of lips and dental injury. in this prospective study, we aimed to compare the complication of nti and oti and to assess the comfort of the patient. we performed a prospective observational study in a -bed medical icu including patients requiring endotracheal intubation. the intubation route was let at the discretion of the physician in care of the patient, however oti was compulsory in case of cardiac arrest, severe hypoxemia (p/f < when available) and clotting perturbation. for each patient, age, sex, sapsii, mechanical ventilation duration. intubation route were recorded as well as complications during the placement of endotracheal tube. infectious and non infectious complications during invasive ventilation period were also recorded. in patients who were successfully extubated, pain, burning feeling, dryness and the wish of tube removal were assessed using visual analogic scales (vas conclusion despite its small size, and the absence of randomization, the present study suggests that nasotracheal intubation improves the comfort and the tolerance of tracheal intubation and is not associated to higher rates of vap. none. effect of mode of hydrocortisone administration in patients with septic shock: a prospective randomized trial oussama jaoued , rim gharbi , najla the baseline characteristics of patients were similar between the two groups. sepsis was secondary to community-acquired infection in % of cases. there was no difference in mortality between groups ( % in continuous groups and % in discontinuous group). sofa score was significantly higher at days , and in discontinuous group. length of stay, duration of mechanical ventilation, number of day without vasopressors, and the occurrence of adverse events were similar in the two groups. conclusion the mode of hydrocortisone administration in patients with septic shock has no influence on morbidity or mortality. the occurrence of adverse events was similar. introduction widespread activation of coagulation with platelet consumption is a pathophysiological feature of severe sepsis and septic shock. thrombocytopenia, either defined by platelet count below g/l or by a significant relative - -percent decrease in platelet count is a potent poor prognostic factor in sepsis. besides their role in hemostasis, platelets also carry various immune and inflammatory functions that are likely to impact on host defense against infections. we aimed to assess whether changes in the platelet count induced by sepsis is associated with the development of subsequent nosocomial infections. patients and methods patients were obtained from two prospective studies about immuno monitoring of dendritic cells and innate-like lymphocytes in critically ill septic patients ( , ) . adult patients with severe sepsis and septic shock were included. exclusion criteria were any immunosuppressive condition (hematological malignancy, hiv infection at any stage, bone marrow or solid organ transplantation, daily corticosteroid therapy > . mg/kg prednisone-equivalent, chemotherapy or any other immunosuppressive treatments), pregnancy, do-not-resuscitate orders on admission. in addition patients who died or who received platelet transfusion during the first week after icu admission were also excluded. platelet counts were collected on the day of sepsis diagnosis (d ) and then on d , d and d . the relative variation in platelet count at day n compared to day was calculated as follows: (count at day n − count at day ) × / (count at day between between d and d , between d and d and between d and d were also similar between patients with and without icuacquired infections (fig. ). discussion in this preliminary study from selected cohorts of nonimmunocompromised patients, sepsis resulted in mild alterations in platelet counts, making it unlikely to become associated with the development of nosocomial infections. it would be relevant to address this question in larger cohorts of non-selected patients, as well as the impact of platelet transfusions in this setting. conclusion changes in platelet counts were not associated with an increased susceptibility towards icu-acquired infections in non-immunocompromised patients with severe sepsis and septic shock. introduction sepsis is the leading cause of mortality in the intensive care unit (icu) patients despite the progress regarding their care. the immunodeficiency due to sepsis with the consequent profound lymphocyte alterations is now well proven. the objective of this work was to determine the prognostic impact of lymphocytopenia in septic patients in icu. retrospective study including all patients hospitalized for sepsis or septic shock between / / and / / . the sepsis and septic shock definitions were adjusted with the third international consensus definitions for sepsis and septic shock. were excluded from the study patients of onco-hematology. lymphocytopenia was defined as an absolute lymphocyte count less than level of /mm during the first h of hospitalization. the prognostic factors analyzed for the lymphopenic and non lymphopenic patients were in hospital mortality, the occurrence of nosocomial infections and hospital length of stay. results among the patients, aged ± years, patients were with septic shock and patients with sepsis. igsii score and sofa score were respectively ± and ± . four patients were immunocompromised due to hiv infection in one case and an immunosuppressive therapy in cases. lymphocytopenia was observed in patients ( %). twenty-eight patients ( %) died within an average of ± days. it was noted the occurrence of nosocomial infections. the median length of stay was days with extremes of one and days. the lymphopenic patients were comparable to non lymphopenic patients in terms of medical history and severity scores. mortality was comparable between the groups with a rate of % (n = ) in lymphopenic patients and % (n = ) in non-lymphopenic patients (p = . ). the earliness of death was correlated with the duration of lymphopenia (r = . , p = . ). the occurrence of nosocomial infections was not different between the two groups: % (n = ) for lymphopenic and % (n = ) for non lymphopenic patients. the hospital length of stay was not different between the two groups but was correlated with the duration of lymphocytopenia (r = . , p = . ). conclusion lymphocytopenia is frequently found in sepsis. lymphocytopenia was not associated with excess of mortality nor with the subsequent occurrence of infectious complications during the icu stay. his persistence was associated with an earlier death and a more prolonged hospitalization. none. introduction relative adrenal insufficiency (rai) is common in icu patients, particularly during septic shock ( ). it has been shown that the rai also occurs during cardiogenic shock ( ) . septic cardiomyopathy occurs in a significant proportion of septic shock patients. the aim of this study was to evaluate the role of rai on septic cardiomyopathy. patients and methods prospective observational study conducted in the intensive care in one university hospital in france. patients meeting the criteria for septic shock without prior corticosteroid therapy and without chronic heart disease were included. total blood cortisol levels were assessed immediately before (t ) a short corticotropin stimulation test ( . mg iv of tetracosactrin) and and min afterward. Δmax was defined as the difference between the maximal value after the test and t . rai was defined as an inappropriate adrenal response with Δmax < µg/dl and septic cardiomyopathy as the appearance of cardiac systolic dysfunction (left ventricle ejection fraction < %) within the first days of septic shock. we performed a multivariable analysis using backward stepwise logistic regression to identify independent predictors of septic cardiomyopathy. discussion although the definition of rai is not consensual, a threshold of Δmax at µg/dl has been widely used in septic shock, with or without the use of t ( ). the usefulness of substitutive doses of steroids in septic shock is controversial, but many authors assume this treatment has a potential in reversing overt vasoplegia. our data suggest an implication of rai in septic cardiomyopathy. conclusion we found rai to be an independent predictor of septic cardiomyopathy. these findings may suggest a new role for substitutive doses of steroids in the hemodynamic management of septic shock. introduction regional perfusion parameters, like lactate, pyruvate and glycerol, may predict outcome in septic shock patients. continuous venovenous haemofiltration (cvvh) has been considered beneficial in septic shock patients. the aim of our study was to investigate whether cvvh, in comparison to intermittent haemodialysis (ihd), is able to improve regional perfusion in septic shock patients studied by muscle microdialysis. patients and methods it was a prospective, randomized, clinical study, including septic shock patients with acute renal failure, aged over years. patients were randomized to receive either cvvh (n = ) or ihd (n = ) for renal replacement therapy. intermittent haemodialysis was carried out during the first h of the h study period. systemic haemodynamics and interstitial tissue concentrations of lactate, pyruvate, glucose and glycerol were obtained at baseline, , , and h after initiation of renal replacement by using muscle microdialysis. results regarding systemic haemodynamics parameters, cvvh caused a decrease in heart rate in contrast to ihd after h (− ± vs + ± /mn). there were no changes in vasopressor support throughout the -h study period and so systolic blood pressure remained stable in both groups. during the h of all renal replacement therapies there was no significant change in muscle pyruvate and glucose levels. during cvvh muscle lactate decreased constantly, as did muscle glycerol levels. this decrease reaches a significant levels at h for muscle lactate and at h for muscle glycerol (fig. ) . conclusion our results suggest that among septic shok patients, cvvh may improves regional perfusion in comparison with ihd. none. introduction acquired hypernatremia (h-na) is an independent risk of death among icu patients ( ). in the rct "hyper s" study, we compared normal to % hypertonic saline during the first h in patients with septic shock with normal serum na concentration (sna) at baseline. the study was prematurely stopped for potential harmful effect associated with more frequent h-na. we assessed the role of h-na on mortality. patients and methods data are a post hoc analysis of the "hyper s" study database including patients. sna was measured at h , every h for days and then daily until d . study fluids were stopped if sna > or > mmol/l increase over h. mild, moderate, and severe h-na were defined as sna > mmol/l, > mmol/l and > mmol/l, respectively. sna profiles were compared between d survivors and non-survivors. acute kidney injury (aki) was defined by doubling serum creatinine and/or need for dialysis. results patients with available data were analysed. ( %) developed h-na (mild: %, moderate: %, severe: %). no matter the absence or presence and its severity, h-na did not affect mortality ( , , , and %, respectively without, with mild, moderate, and severe h-na, p = . ). sna profiles were similar between survivors and non-survivors (table ) . a sensitivity analysis performed among survivors at d did not change the results. compared to patients without h-na, aki occurred in % of patients with h-n vs % (p = . ), atelectasis in versus % (p = . ) and icu acquired weakness in versus % (p = . ). conclusion hypernatremia occurrence is not associated with an increased risk of morbidity and mortality during hypertonic fluid resuscitation in septic shock. none. introduction guidelines about the moderate hypokalemia treatment (between . mmol/l and . mmol/l) are based on experts estimations, and non-specific ones for patients in the intensive care units (icu). the aim of this study was to evaluate the correction of the hypokalemia in an icu and the compliance of recommendations. materials and methods an observational epidemiological, retrospective and monocentric trial has been realized during a period of months (from january to february ). the study population included hospitalized patients in the icu who have shown a first moderate hypokalemia episode, all cause considered. patients who have presented an acute renal failure with a kdigo (kidney disease: improving global outcomes) score of three the day of their inclusion were excluded. the main primary study endpoint was percent correction of the serum potassium after h. the secondary study endpoints were the incidence rate of moderate hypokalemia and the efficacy about the hypokalemia correction in accordance with the achieved treatment consistent or not with recommendations. results patients had at least one episode of hypokalemia. the incidence rate of the hypokalemia first episode was . %. the study population included patients. igs score was . (± ). patients required mechanical ventilation at the inclusion. the serum potassium was greater than or equal to . mmol/l after h about patients ( . %) (corrected group). at h one patient had a serum potassium higher than mmol/l. the average total potassium was respectively . infusion of potassium and ( . %) patients have been a management compatible with the most common recommendations (input potassium chloride of mmol, use of the enteral administration and lack of continuous intravenous infusion). the percent correction of the hypokalemia after h was respectively of / ( . %) in the group in which recommendations had been respected and of / ( . %) in the other one (p = . ). discussion in our knowledge there are no previous studies that have specifically focused on the correction of the moderate hypokalemia in critically ill patients. in our study the incidence rate of the moderate hypokalemia was lower than data from the literature because we have only considered the first episode of the hypokalemia [ ] . among patients without contraindication to the enteral administration, this one was used in less than half of the cases. % of these patients received potassium with a continuous intravenous infusion and only patients received medical care conform to the guidelines. the medium potassium quantity provided was very lower to the guidelines. only % of the patients have been corrected after h without any difference in the medium potassium quantity which has been provided in relation to the uncorrected group. conclusion only . % of moderate hypokalemia in icu are corrected after h. the intravenous way is considerably used (in % of cases) with a poor return. a wide-ranging study is necessary to determine the best correction modes. none. results patients were included. mean ± sd age was ± years, % were male, mean ± sd saps ii was ± . icu length of stay was ± days and icu mortality rate was %. during the first days in the icu, % of patients received at least one nephrotoxic drug. % of patients received one, % received two, % received three and % received more than three nephrotoxic medications. diuretics, antibiotics and iodinated contrast media were the nephrotoxic drugs most frequently administered to, respectively, , and % of patients. aki (kdigo stage or higher) occurred in % of patients during the first days in icu. the proportion of patients with aki increased with the number of nephrotoxic drugs received: / ( %) of the patients not exposed to nephrotoxic drugs developed aki whereas, respectively, / ( %), / ( %), / ( %) and / ( %) of the patients receiving one, two, three, and more than three nephrotoxic drugs developed aki. the univariate association between the number of nephrotoxic medication and aki persisted in the multivariate analysis adjusted on baseline saps ii score (p < . ). conclusion the significant proportion of patients exposed to nephrotoxic drugs and the observed association with aki warrants further investigation. statistical adjustments for multiple potential confounders is needed in order to assess a potential causal relationship which would lay foundations for interventional studies. none. ( ) the minimal kidney aggression by current monomeric nonionic low-osmolar contrast media, late serum creatinine increase being explained by the occurrence of later (between the th and the nd hour) kidney injury due to critical illness or its therapy or ( ) insufficient sensitivity of early ( h) measurements of this biomarker to detect contrast-associated aki. competing interests partial financial support, no implication in data analysis and interpretation. introduction diabetic ketoacidosis, generally resulting from an absolute deficiency of insulin, is a frequent cause of hospitalization in intensive care unit. recommendations for diagnosis of diabetic ketoacidosis, care and site of admission have been published by the english society of diabetology. icu admission are recommended if one of the following criteria is present: gcs < , systolic arterial pressure (sap) < mmhg, spo < %, ketosis > mmol/l, hco < mmol/l, ph < . , potassium level < . mmol/l or anion gap > mmol/l. however, it is suspected that adhesion to recommendations remains low. in this study, we aimed at describing patients admitted for diabetic ketoacidosis in icu. we looked at adhesion to published recommendations regarding admission and care. we also described metabolic complications and looked for an association between complications and dose of initial insulin therapy. complications hypoglycemia (< . mmol/l) was observed in % of patients within the first h in which % were < . mmol/l. this was and % of patients between and h of icu stay. hypokalemia below . mmol/l happened in % of patients within the first h and in % between and h. neither hypoglycemia nor hypokalemia were correlated with initial insulin bolus or initial dosage of continuous intravenous insulin. hypophosphatemia < . mmol/l was observed in % of patients. discussion in this study, admission to icu was consistent with british recommendations since most patients presented at least one clinical or biological criterion indicating icu admission. arterial blood gas were sampled in the large majority of patients despite consistent data showing that venous blood gas might be sufficient in non-hypoxemic patients. also, initial insulin bolus and sodium bicarbonate perfusion were performed in a significant subset of patients despite absence of convincing data or recommendations supporting their use. finally, significant hypokalemia and hypoglycemia were frequent in these patients. these complications are in theory favored by insulin therapy but we did not observe a correlation between administration of an insulin bolus or the dose of continuous intravenous insulin perfusion. conclusion in this retrospective multicentre study, patients admitted in icu for diabetic ketoacidosis were correctly oriented regarding the british recommendations. metabolic complications (hypoglycemia and hypokalemia) were frequent but not correlated with initial dose of insulin. the appropriate rate for hypernatremia (h-na) correction is unknown. under-correction could be associated with worse outcome. experts recommend a rapid correction of acute (< days) and sever (> mmol/l) h-na with a rate of − mmol/l/h until na < mmol/l ( ). correction should be, therefore, obtained within h. in patients with septic shock resuscitated with iso-or hypertonic saline and who acquired acute severe h-na, we assessed if the correction rate was associated with mortality. patients and methods data are a post hoc analysis of the rct "hyper s" database comparing normal to % saline for h in septic shock. serum na (sna) was measured at h , every h for days and ) . h-na correction rate was more rapid in non-survivors, p = . (table ). over-correction occurred similarly in survivors ( %) and non-survivors ( %). the time to reach sna normalization was shorter in nonsurvivors (p = . ). after adjustment for sapsii and maccabe scores, more rapid correction rate remained significantly associated with mortality: or . ; % ci ( . - . ), p = . . conclusion in the context of acute severe h-na induced by fluid resuscitation, a rapid correction rate might be associated with even aggravated rather than improved mortality. introduction systemic capillary leak syndrome (slcs) is a rare disease characterized by recurrent life-threatening attacks of capillary hyper permeability in the presence of a monoclonal gammopathy (mg). during acute episodes, the leak of fluid and proteins from the intravascular compartment to the interstitium results in clinical signs of both acute hypovolemia and interstitial edema. biological profile is pathognomonic with marked hemoconcentration and paradoxal hypoproteinemia. hypovolemic shock is the classical feature of severe scls attacks. however, beside this typical hemodynamic profile, several case report described myocardial dysfunction during scls attacks. the objectives of this study were to assess frequency, characteristics and outcome of myocardial involvement during severe scls attacks. ( %) mechanical ventilation, ( %) renal replacement therapy, ( %) veno-arterial extracorporeal membrane oxygenation, ( %) intra-aortic balloon pump and ( %) an impella. compartment syndrome occurred in ( %) patients and ( %) died in icu. we then compared the patients with myocardial involvement to the without clinical and biological manifestations were similar in between groups. however, chest pain ( vs %, p = . ), dyspnea ( vs %, p = . ) and respiratory failure ( vs %, p = . ) were more frequent in patients with myocardial involvement than in others. there was no difference between groups regarding treatment received in icu, complication and outcome except for the use of va-ecmo ( . vs %, p = . ). conclusion myocardial involvement seems frequent in patients with severe scls attack, occurring in % of the cases. such patients exhibited classical features of scls attacks. myocardial involvement was responsible for altered lvef or transient ventricular hypertrophy. myocardial dysfunction could be severe, even requiring mechanical circulatory support. scls attacks should be known as a cause of severe reversible myocardial dysfunction and hypertrophy. none. introduction in refractory cardiorespiratory emergencies, ecmo appears a good alternative to conventional treatment. its extracorporeal circuit justifies curative anticoagulation explaining haemorrhagic and thrombotic complications. activated clotting time (act) is empirically and commonly used to assess anticoagulation but with large inter and intraindividual variabilities. in practice, antixa activity dosage is available to approach anticoagulant effect of heparin and is less expensive, but data during ecmo are missing. we sought to demonstrate the lack of correlation between antixa and act in patients under ecmo support. we prospectively include patients supported by ecmo in chu toulouse, france, between / and / for circulatory/respiratory support. anticoagulation was achieved by unfractionated heparin: initial bolus then continuous intravenous infusion ( - iu/h), for antixa target of . - . . concomitant dosing of antixa (laboratory) and act (hemocron ® ) was conducted two times a day on the same sample throughout the ecmo period. relationship between act and antixa was analyzed by spearman correlation (rho). after transformation into categorical variables (obtained target = ; outside the target = ), analyzes were completed by a concordance study (kappa). as recognized on literature act's targets were between and . results patients were included: men ( %), median age yo ( - ). indications were veno-arterial (n = ) and veno-venous ecmo (n = ). ecmo median duration was days (hours to days). spearman correlation test found low and inconsistent correlation between antixa and act (rho spearman < . ). this correlation lack present from the day one, worsens over time. analyzed kappa showed no discrepancy between the areas "targets" of act and antixa confirming the results (table ) . conclusion use of act for ecmo anticoagulation monitoring doesn't seem appropriate and high price probably justifies preferential use of antixa in clinical practice. analyzes of relationships between antixa and bleeding/thrombotic events are needed to confirm the antixa place and its target in these indications. introduction postcardiotomy cardiogenic shock (cs) has an incidence of % to % after routine adult cardiac surgery. in . - . % of cases, an venoarterial extracorporeal life support (va-ecls) is requested. the -month survival rate is . % ( ). survivors may suffer of physical and psychological impairments as well as an alteration of quality of life. this study was designed to assess the outcomes, long-term health- since icu discharge, % of patients reported physical sequelae., ecls-related limb pain occurs in % of patients while paresthesia occurs in % and chronic-tiredness in %. mean karnofsky score was % (table ) . conclusion after va-ecls for postcardiotomy cardiogenic shock longterm physical and psychological sequelae are frequent in survivor discussion interest for fluid management is growing in critical patients. nevertheless, no study has yet investigated its impact in selected patients with cardiogenic shock treated with va ecmo. our study suggested a possible association between fluid overload and mortality but lack the power to confirm these results with multivariate analysis. conclusion fluid management is a key therapy during va ecmo but fluid overload could be associated with worsen outcomes. further studies with larger population are warranted before considering fluid restriction trials. introduction extracorporeal life support (ecls) has taken an important place in the treatment of cardiogenic shock (cs) or refractory cardiac arrest (ca). however, ecls deplore a high mortality rate in the first days raising important ethic and economic consequences. in this context, continuation of support should be reassessed precociously. the aim of this study was the research of prognostic factors of -days mortality, h after ecls implantation for cs or ca. materials and methods all patients undergoing ecls in our tertiary center during a -year period were prospectively included. the ecls were managed with a multidisciplinary protocol based on consensus. clinico-biological data were collected just before and h after ecls implantation. these data were compared between survivors and deceased at month. , cpc score was respectively for patients, for , for . at months, cpc score changed only for the patients with a cpc score at (one died after another suicide attempt, one changed his cpc score to ). in the group without ca (n = ), had normal neurological status at months and at months (one patient died because of a cancer). among these patients, % returned at home and % returned to work. ( %) patients re-attempted suicide in the year. the major risk factor of mortality is the presence of a cardiac arrest on hanging site. all the other factors found to be related to mortality are well known risk factors in cardiac arrest of other origin. in univariate analysis, risk factors of neurological sequelae at months were a cardiac arrest on hanging site (p = . ) an elevated diastolic blood pressure ( vs mmhg; p = . ), a lower initial glasgow score ( vs ; p = . ), and an elevated blood glucose ( . vs . g/l p < . ) at admission in icu. discussion our cohort of self-hanging patients can be divided in two parts: a) patients with ca in the pre-hospital period with a high mortality and a good neurological recovery in / surviving patient, but with a small group; b) patients without ca with a very low mortality and a very good neurological recovery. these results seem to be better than in the most important cohort [ ] published until now in self-hanging patients without ca and not treated by hbot (mortality at . % and . % of poor neurological recovery). conclusion patients surviving a self-attempted hanging who have not presented ca and treated by hbot have mainly a good neurological outcome. randomized control study should be undertaken to confirm hbot effectiveness in that indication. introduction venoarterial extracorporeal membrane oxygenation (va-ecmo) is increasingly used to treat refractory cardiogenic shock or cardiac arrest. acute brain injury (i.e. ischemic stroke, haemorrhage and/or failure to awaken because of diffuse brain injury) may occur in up to % of patients on va-ecmo and is associated with increased mortality and poor functional outcome in survivors. however, early indicators of neurological outcome are lacking in this population. we aimed to assess the prognostic value of early electroencephalography (eeg) alterations during va-ecmo. we conducted a prospective single-center study in the medical icu of a university hospital on consecutive patients cannulated to va-ecmo. a standardized clinical neurological evaluation including the rass score, the gcs score, the full outline of unresponsiveness (four) score and brainstem reflexes was coupled to an intermittent eeg. eeg was recorded as soon as possible within the first h after va-ecmo cannulation. eeg characteristics were analyzed by a neurophysiologist who was blinded to the patient's condition. a severely altered eeg pattern was defined as a predominant delta frequency, discontinuous, unreactive and/or an isoelectric background. the primary endpoint was poor neurological outcome, defined as the composite of death or acute brain injury on neuroimaging within days. data are presented as median (interquartile range) or number (percentage). false-positive rates (fprs, corresponding to -specificity) of poor neurological outcome were calculated for each significant predictor, using an exact binomial % confidence interval (ci). results sixty-nine (age ( - ) years) patients with a sofa score of ( - ) were included. main indications for ecmo were: post cardiac surgery (n = , %), terminal dilated cardiomyopathy (n = , %), and acute myocardial infarction (n = , %). cardiac arrest before ecmo cannulation was noted in ( %) patients. eeg was recorded ( - ) days after va-ecmo cannulation and ( %) patients were sedated at time of eeg. at day , ( %) had a poor outcome (n = deaths and n = patients alive with acute brain injury). in univariate analysis, a lower rass score (p = . ), a lower four score (p = . ), a lower score on the motor component of the glasgow coma scale (p = . ), and a lack of cough reflex (p = . ) at the time of eeg were significantly associated with a poor outcome. a severely impaired eeg pattern or presence of a discontinuous background activity were also associated with a poor outcome (p = . and p = . , respectively). indicators of poor neurologic outcome are presented in the table . among all parameters, a discontinuous background activity was the only variable that constantly predicted poor outcome (false-positive poor outcome prediction rate of %, % ci - %). conclusion early intermittent eeg has a strong prognostic value for sedated patients on va-ecmo. presence of a discontinuous eeg background activity seems to be more accurate than clinical alterations to predict a bad neurologic outcome at days. none. table ). it was not found a significant association of ctp to mortality ( % in the case group and % in control group, p = . ). other factors that increased mortality were coma, seizures, shock, oedema, cellularity in csf > units/mm . otherwise, the ventilation length was prolonged with ctp group ( . vs . days, p = . ) and neurological sequels namely the epilepsy was more frequent with the group ctp: ( vs %, p = . ). conclusion the occurrence of ctp on bacterial meningitis was significantly associated with ct scan lesions which seems to be an association be in both directions. also, the positive culture predisposed more to the ctp. mortality was higher with the presence of ctp but without real significance. the ctp was a factor that extends the ventilation time and exposed to the post infectious epilepsy. introduction acute bacterial meningitis requires rapid triage and therapeutic decision-making. the aim of this study was to assess the overall ability of a point-of-care glucometer to determine bacterial infection in cerebrospinal fluid (csf). we performed a prospective, observational study. we included patients for whom an analysis of csf was indicated by the physician in charge with blood sampling performed for glucose concentration measurement within h. we simultaneously measured the glucose concentrations in csf and blood using a central laboratory and point-of-care glucometer. the diagnosis of bacterial meningitis was determined by two physicians after reviewing the complete medical chart. we compared csf and blood glucose concentrations and csf/blood glucose ratios obtained at the bed-side with a glucometer versus those obtained by the central laboratory. we determined the performance characteristics of the csf/blood glucose ratio provided by a glucometer to detect bacterial infection in the csf immediately after csf sampling. conclusion we demonstrated that the csf/blood glucose ratio measured by a glucometer can serve as a clinical decision support tool for the early detection of csf with a high probability of bacterial infection. this costless point-of-care method has the potential to expedite medical decision-making for the triage of adult patients with suspected meningitis in the emergency department immediately after lumbar puncture. none. introduction cardiac arrest remains a frequent cause of admission in intensive care unit. a majority of patients will die during their hospital stay mainly from consequences of hypoxic-ischemic brain injury after a decision of withdrawal of life sustaining therapy support by a prediction of poor outcome. the reliability of prognostication is crucial, but is still a difficult and uncertain exercise. eeg is the most widely used prognostic tool to support a clinical examination and is accessible in most hospitals. it is recommended for both prognostication and ruling out subclinical seizures. there is no high-level evidence for predicting poor prognosis using eeg because of the wide variety of classification systems used and the interrater variability. our objective is to assess the prognostic value of simple eeg features based on the recent american clinical neurophysiology society (acns) standardized classification and to study the interrater variability. we conducted a retrospective monocentric observational study in a bed medical intensive care unit of the university hospital la timone, marseille, france. all patients aged of more than year-old admitted for a resuscitated cardiac arrest between november and july who underwent therapeutic hypothermia and a full multimodal prognostic evaluation including a eeg were included in the study. outcome was classified according to the cerebral performance category score measured at day . unfavorable outcome was defined as death (cpc ), persistent vegetative state (cpc ), or severe neurological disability (cpc ). favorable outcome was defined as moderate neurological disability (cpc ), or no disability (cpc ). eeg was performed in all patients still comatose after rewarming between and h after admission and after discontinuation of sedation. eeg interpretation was made by independent senior neurophysiologists, blind to the outcome. eeg features are based on the latest acns classification. for each eeg feature, sensitivity, specificity, positive predictive value (ppv), negative predictive value (npv) for predicting an unfavorable outcome were calculated. results during the study period, cardiac arrest were admitted of which patients went through a full neurologic evaluation and were finally included in the study. according to neurological outcome, % had a favorable evolution, and % had an unfavorable outcome. the presence of burst suppression, and epileptiform activity was constantly associated with an unfavorable prognostic with a % specificity and % false positive. a non-reactive eeg is strongly associated with an unfavorable evolution with a % specificity and % false positive. other features including periodic or rhythmic patterns and low voltage were inconstantly associated with unfavorable outcome. kappa score for all eeg feature was slight or fair and always under . . discussion this study allowed us to identify a homogenous cohort of comatose patient after cardiac arrest who underwent therapeutic hypothermia. we identified simple eeg features based on the new classification of the acns constantly associated with unfavorable outcome. these features must be known by intensivists to better integrate eeg in the multimodal evaluation of neurological prognostic. there is important interrater variability that must lead to caution and to always use multimodal approach to prognostic an unfavorable outcome. conclusion bedside eeg is an excellent tool for predicting outcome of post-anoxic coma through simple eeg features. burst suppression, epileptiform activity and non-reactive eeg are strongly associated to neurological outcome after cardiac arrest. however, the interrater variability emphasize the need of being well trained for the standardized methods of evaluating eeg parameters. introduction emergent reintubation is a well-known risk of laryngotracheal trauma and of ventilatory acquired pneumonia. to precisely define its risk before extubation for each patient is a part of quality of care in intensive care units. none of these consecutive children representative of picu activity has been reintubated. the coming prospective muticentric study which aims to validate alt in childhood must precisely define this criteria of evaluation. conclusion the different methods of alt are feasible in real clinical conditions in picu. because of the increasing use of cuffed etts in a wide variation of patients with different body weight, the best alt to use at the bedside must be definitively validated in this population. introduction prolonged mechanical ventilation (pmv) and chronic mechanical ventilation (cmv) in neonates is associated with a high morbidity and mortality. the objective of the study is to identify, among the patients with pmv, those that evolved to cmv, as well as the adverse respiratory, neurological and feeding sequelae. we conducted a retrospective study of the last years at the chu sainte-justine (montreal, canada). chart review included patients with pmv (≥ days) using the paediatric definition adapted from the namdrc consensus conference ( ) . demographic and clinical data, including follow-up at and months corrected age, was collected for each included patient. the evolution of pmv neonates with cmv (≥ days) and without ( - days) was compared. we identified neonates that met criteria for pmv. patients born between and (n = , % of the cohort) were analyzed. around half of the patients ( - patients a year) are transferred from the neonatal unit to the paediatric intensive care unit. in our center, they represent around % of total admissions, but their length of stay is among the longest. among these newborns, % were preterm (n = ) with % (n = ) born before weeks gestation. of all patients with a malformation ( %, n = ), had a thoracoabdominal anomaly and had congenital heart disease. thirty-six patients had cmv with mean ventilation time of days (range - days). survival at months corrected age was % ( / ) in the pmv group and % ( / ) in the cmv group. at months corrected age, % of patients were dependent on artificial enteral feeding (nasogastric tube or gastrostomy), with % in the pmv group and % in the cmv group. nine percent of patients had oxygen supplementation ( patients in the pmv group and in the cmv group), and % were mechanically ventilated. ten percent of patients had a tracheostomy ( patients in the pmv group and in the cmv group). discussion neonates with cmv have more sequelae. their rapid identification (at days of ventilation) is essential to implement multidisciplinary development care in order to minimize neurodevelopment impairment. conclusion most newborns in our pmv cohort have a congenital malformation. survival at months corrected age appears equivalent in both pmv and cmv group. artificial enteral feeding is more frequent in the cmv group and most patients have no respiratory support at months corrected age. none. the value of pressures and volumes in assessing the fluid responsiveness depend on the systolic cardiac function in adult ( ). we have studied the relative value of static filling volume and pressure to predict the fluid responsiveness, according to systolic cardiac function in children during acute circulatory failure. patients and methods patients under years old with an acute circulatory failure of two intensive care units during a year period of inclusion were analyzed. an exhaustive cardiac echography was performed initially (indexed end-diastolic volume (edvi) and e/e' from transmitral and tissue doppler were recorded), and the stroke volume index (svi) was measured before and after a fluid challenge (a ml/ kg of crystalloid over min results twenty-five children with acute circulatory failure were included. fluid responsiveness occurred in of the fluid loading events with low lvef, and in of the fluid loading events with normal lvef. pressure approach: for low and normal lvef, the auc-roc for fluid responsiveness was respectively . (ci . - )/ . ( . - ) for a e/e' .the best thresholds of e/e' in low lvef was . with a sensitivity of (ci - ) % and a specificity of (ci - ) %. for low and normal lvef auc roc was respectively . (ci . - . )/ . (ci . - . ) for the pvc. volume approach: for low and normal lvef, the auc-roc for fluid responsiveness was respectively . (ci - ) and . ( . - ). the best thresholds in normal lvef was an edvi below ml/m wit a specificity of (ci - ) and a sensitivity of (ci - ) %. discussion our study shows a variation of the diagnostic value of e/e' and edvi according to the left ventricular systolic function. therefore, the systolic function should be taken into account to analysed the e/e' and edvi value. few preload dependency markers are validated in children and none for children in spontaneous ventilation ( ) . our study suffers from a lack of power that calls into question the validity of our results. another limitation is that both approaches with volume and pressure are not very discriminant as it is known for static value in adults. our study illustrates that, on a pressure-volume curve, when the cardiac inotropism is reduced, the filling of the left ventricle is moved to the up and right of the curvilinear diastolic function curve. therefore, pressure variations are larger than volume variations. these values should be monitored on a larger scale to define their exact diagnostic value. conclusion static pvc value is a low preload-dependency surrogate. when lvef is low a pressure evaluation based approach seems more accurate. when lvef is normal a volume evaluation based approach seems informative as predicted by the slope of the end diastolic pressure volume curve. those both static approaches remain of poor diagnosis accuracy. introduction acute viral bronchiolitis is a primary cause of respiratory distress in paediatric intensive care unit (icu). prone position (pp) is commonly used in neonates to improve respiratory mechanics and has been found beneficial to adult patients with acute respiratory distress syndrome. we aimed to evaluate the effect of pp on work of breathing as compared to supine position (sp) in children with severe bronchiolitis requiring non-invasive ventilation. the protocol was approved by our irb ( -a - ). fourteen infants ( boys) with median age days [firstthird quartiles - ] with severe bronchiolitis requiring cpap were included after written informed consent. children were investigated in pp and sp each applied for h in a random order with a washout period of min between them. level of cpap was set at cmh o in both conditions. oesophageal pressure probe was inserted orally (cto- pressure transducer, gaeltec, scotland) to measure oesophageal pressure. flow and airway pressure (pmo in fig. ) were simultanuously recorded using a neurovent data acquisition system (neurovent inc, toronto, canada). one hundred breaths were analyzed in each condition, in which work of breathing was estimated from oesophageal pressure-time product (ptpes) and oesophageal swings (fig. ). data were expressed as median (first-third quartiles) and compared by using the wilcoxon two-sample paired sign test. a p-value below . was considered significant. . the edtb contains data from ventilated patients (invasively and non-invasively) and details concerning ionotropic and sedative treatment during picu courses. discussion as far as we know, this edtb is currently the only one as exhaustive available in picu worldwide. after almost years of multidisciplinary collaboration, we are able to collect many useful physiological, therapeutic and medical data in an ongoing edtb. although many concerns remain concerning data validation, organisation and exploitation, this edtb already contribute to the development of clinical decision support systems and virtual patient validation and we create international collaborations to further develop these tools. three research protocols using the database are ongoing including: validation of a neuromonitoring clinical decision support system, validation of a cardio-respiratory simulator, developement and validation of the automatic diagnosis of pediatric acute respiratory distress syndrome and development of spo forecast using artificial neuronal network. conclusion thanks to informatics and electronic devices improvement, data gathering in intensive care units has empowered. we hope that our work in picu will encourage other teams on the way of data gathering, in order to build an international picu edtb in a close future. none. introduction severe trauma is rare in the pediatric setting ( % of all trauma in france). however, its morbidity and mortality remain high, in relation to brain injury. pediatric traumatic brain injury (tbi) prehospital care is challenging for non-pediatric retrieval teams. though, we disseminated pediatric tbi pre-hospital care regional guidelines and thereafter intended to assess severe pediatric trauma pre-hospital care and secondary cerebral insults control. we conducted a retrospective study in a single pediatric trauma center. children admitted in emergency room with severe trauma and moderate to severe tbi (glasgow coma scale ≤ ) from june to march were included. pre-hospital and hospital data regarding primary care, equipment, medications and secondary cerebral insults control (i.e. blood pressure, oxygenation, co level, temperature, glycemia) were collected from medical files. two pediatric transport team experts assessed the quality of pre-hospital care, based on two major endpoints. results twenty-nine files were analyzed. median iss was . all the children had been referred directly from the trauma scene to the pediatric trauma center. they were all intubated in the prehospital setting, ( . %) presented with spo < % before or at emergency room admission, and ( . %) presented with a pco > mmhg at admission. at least one peripheral catheter was inserted in all the children. mean total fluid bolus was . ml/kg (± ). nor-epinephrine was administered in ( %) children. mean blood pressure was below age threshold in ( %) children during transport or at admission. an intracranial hypertension treatment (apart from sedation) was delivered in ( %) children before admission. body temperature was monitored in patients and were hypothermic at emergency room admission. experts concluded on sub-optimal care in children: major endpoint was "respiratory care", "hemodynamic care" and "neurologic care" in , and patients respectively. discussion on this small series, we showed pre-hospital sub-optimal care regarding secondary cerebral insults control, especially regarding co level, blood pressure and body temperature. our results will help to design new care improvement strategies (e.g. sedation, fluid bolus and ventilation optimization, early use of vasoactive drugs, systematic body temperature monitoring…). conclusion data on pre-hospital secondary cerebral insults care are rare in the pediatric setting. based on our results, we aim to improve quality of care of children presenting with traumatic brain injury, and to reduce its morbidity and mortality. introduction unsuccessful extubation from mechanical ventilation increases mortality and morbidity. to reduce the extubation failures in our intensive care unit we used a mechanical ventilator weaning protocol, based on published data. during the first part of the study, risk factors and incidence of extubation failure were first described. afterwards in the second part, our mechanical ventilator weaning protocol was tested to determined its efficiency regarding the extubation failure. patients and methods a monocentric and observational study, was first conducted. we included children aged from birth to old, during a period of months and collected for each patient their medical history, intubation and extubation parameters, and existing events of extubation failure or extubation complication. the second part of the study was prospective, we include patients extubated by applying our mechanical ventilator weaning protocol. results average duration of mechanical ventilation was . h in the first part of the study. using a univariate analysis, duration of mechanical ventilation was a risk factor of extubation failure with an average duration of . discussion our study confirms published data about extubation failure risk factor like duration of intubation, chronic respiratory affection, history of previous intubation, and the administration of benzodiazepine. it is the first pediatric study that shows a reduction of extubation failure by using a specific mechanical ventilator weaning protocol. the mean bias of our its retrospective and prospective character. conclusion our study shows the interest of a mechanical ventilator weaning protocol to reduce the incidence of extubation failure. we currently continue the apply our protocol to include more patients in order to confirm our results. stroke of the child is formidable though it is ten times rarer than in adults, but this scarcity can have adverse consequences on the speed and quality of the management and the consequences on later psychomotor development. our goal is to describe the clinical and therapeutic aspects of these pediatric stroke while bringing our experience. patients and methods retrospective study of cases of children hospitalized in general intensive care unit to the pediatric hospital canastel oran for stroke during the period from january to january . the clinical, etiological, para clinical, and scalable were studied and transcribed on a standard electronic form.all patients had a brain ct. magnetic resonance imaging(mri) was possible in patients for lack of availability of the technical facilities during the study. results ten cases were selected. the mean age was months ( month to years), % are male, patients had a history of chd like tetralogy of fallot and complicated bronchiolitis myocarditis, one patient had a history of petechial purpura, other was a factor deficiency, headache history was noted in patients, and patients with no particular antecedent was found. all patients arrived comatose / score on the scale of glasgow, isochores reactive pupils with a motor deficit of hémicorps, patients have degraded their neurological score with onset of clinical signs of hypertension intra cranial namely anisocoria and hypertension requiring osmotherapy, sedation and mechanical ventilation with an average duration of - day. o child arrived brain dead, patients had generalized tonic-clonic seizures which yielded after taking a benzodiazepine (diazepam) and phenobarbital (like gardenal). cerebral ct was performed in all cases and could we revealed the nature of the stroke hemorrhagic in cases and ischemic stroke in cases. two patients have benefited from an mri that found a thrombosis of the artery internal carotid right sylvian. besides symptomatic treatment, treatment was initiated based on the type of stroke, patients received low molecular weight heparin (lmwh) at . ml/kg in addition to symptomatic treatment, patients received vitamin k. four patients died in an array of autonomic disorders and evolved favorably and six patients were transferred to a pediatric unit. the average length of stay in icu was . days ( - days). discussion the mortality rate is important since no specialized center for children, and difficulty especially in the diagnostic imaging field while suspected stroke should be confirmed by imaging and the diagnostic delay. which is due to a poor assessment of the initial situation in half of the cases by the parents, the other half by the swiss magazine consulté.une doctor showed that in a study in % of children with stroke, this diagnosis was not primarily discussed and that in % of cases the cause of the stroke was poorly evaluated [ ] . heart disease certainly represent the second most important risk factor. a collaboration of a team must be multidisciplinary, death has affected mostly older children whose age is between and years, who have a hemorrhagic stroke against by infants who have an ischemic stroke have evolved and oriented they exceed the acute phase to pediatric services for further investigation and monitoring. conclusion the child may also be having a stroke, which usually reaches the elderly. this justifies a good knowledge of this disease, and multiply the initial management efforts to reduce mortality and improve prognosis. anwar armel , benqqa anas , samira kalouch , khalid yaqini , aziz chlilek introduction nosocomial infections are a main problem for public health for their cost as well as for the morbidity and mortality they generate. they are particularly common in intensive care units due to patient's lower defenses and of invasive procedures proliferation. work's purpose: • determine the epidemiology of bacterial noso-comiales infections (ibn) in the medico-surgical pediatric intensive care department of children's university hospital of casablanca. • to identify factors associated with these infections. we led a retrospective study of hospitalized patients, spending more than h in medical-surgical pediatric intensive care department, at the university hospital ibn rochd of casablanca, over a period of months from january to december . results during the studied period, patients were admitted at intensive care with a stay of more than h. thirty episodes of inb were recorded. the incidence rate was . % and the incidence density was . % per hospitalization's days. the admission average age was . ± -month starting from month to years with a male predominance ( %). most of admissions ( %) was related to medical background, . % received from other hospital department. furthermore, % of the patients received prior antibiotics, usually prescribed before icu admission. invasive procedures (intubation, central catheterization) were used in . % of patients, vvp only in . %, tracheotomy in . and . % had received surgery. gram-negative bacilli (bgn) were isolated for a lot of patients, dominated by acinetobacter baumannii. these bacteria were isolated throughout the study year. risk factors analysis underlined that the presence of invasive procedures enhances in risk, that is central venous catheter and the need for mechanical ventilation. conclusion nosocomial bacterial infections are dominated by pneumonia and central catheter infections, and are mainly due to bgn. the factors associated with these infections were identified. the guillain-barré syndrome (gbs) is the most common cause of acute flaccid paralysis in children since the acute anterior poliomyelitis eradication. few studies have been held on the topic and knowledge of gbs in children, although it is recognized that the etiologic mechanisms, and clinicobiological background, are the same as in adults, prognosis remains different. our work's aim is to study this disease's mortality factors of children hospitalized in pediatric intensive care. patients and methods it is a retrospective, descriptive, mono centric study to review patients with gbs between january and december and hospitalized at pediatric intensive care department of abderrahimharouchi hospital of casablanca. the used software is spss . to compare the bivariate variables, we used the khi test, and to compare quantitative variables, the anova to factor test was used. the level of significance was fixed at % with % confidence interval. the disease was predominant in male with a sex ratio of . men/women. after a prodromal event, usually infectious ( . %) and a free interval of days on average to start motor disorders. these are of two types: either a hypo or areflectic flaccid paralysis of the lower limbs ( . %) of ascending evolution in . % of the cases. either flaccid tetraplegia or hypo areflectic, ( . %). ventilation was required in . % of the cases, and specific treatments based on immunoglobulins were administered in . % of the cases. death's rate is still high ( . %) and mainly due to hospitalization complications. in our study respiratory disease was noted in . % of the cases, also other signs of serious illness such as swallowing disorders ( . %) and autonomic disorders ( . %) also noted what led to management in intensive care for all our patients. these patients study allowed to identify some mortality prognosis factors of the disease in intensive care units (such as male gender, ig administration duration, the occurrence of autonomic disorders like blood pressure instability), the most discriminating remains the occurrence of nosocomial infections. conclusion it must be underlined, that in view of our strict inclusion criteria, focusing only on patients admitted at intensive care and of the relatively small sample size ( cases), our results must be qualified and must be enhanced by additional and more varied studies to better understand this disease in children. introduction early surgical treatment is recommended for refractory intracranial hypertension (htic) in children to improve vital and functional prognoses, whether traumatic or vascular cause. the main objective of this study was to compare the mortality and morbidity of children with severe intracranial hypertension after severe head trauma (tc) or due to vascular cause after decompressive craniectomy (dc) or medical therapy alone. the secondary objective was to identify the initial severity factors associated with higher mortality. patients and methods a retrospective study was performed with data collected from patients aged under years-old admitted to our pediatric intensive care unit for severe intracranial hypertension of traumatic or vascular cause, between january and january . they were divided into groups: patients who received medical therapy alone and those treated with decompressive craniectomy after optimal medical management. results a total of children were included. among them, were treated with dc ( htic of vascular cause and htic of traumatic cause), and were supported by medical means only ( htic of vascular cause and htic of traumatic cause). in the population "traumatic intracranial hypertension", we note that children in the "dc" subgroup are more often in mydriasis upon arrival (p = . ) than in the subgroup treated medically. in this same population, children in the "dc" subgroup received higher doses of mida-zolam (p = . ), of mannitol (p = . ) and hypertonic saline (p = . ) than in the other subgroup. in the population "vascular intracranial hypertension" the two subgroups were comparable. in the case of traumatic intracranial hypertension, mortality rate in the "dc" subgroup was . % against . % for children treated medically (p = . ); "dc" children had more metabolic complications such as hypernatremia than "not dc" children, p = . . mortality rate in the «vascular intracranial hypertension» group was % for children treated with decompressive craniectomy, and . % for children treated medically alone (p = . ). patients treated surgically in the «vascular intracranial hypertension» group had longer overall stays (p = . ) and longer icu stays (p = . ). popc score (pediatric overall performance category) upon discharge for children with intracranial hypertension of traumatic cause treated with decompressive craniectomy was . ± . against . ± . among children treated medically, p = . . in "dc" children with intracranial hypertension of vascular cause, popc upon hospital discharge was . ± . against . ± . among non-operated children, p = . . the schooling rate was higher among children treated medically for intracranial hypertension of traumatic cause, p = . . the severity factors related with higher mortality identified in the population "traumatic intracranial hypertension" were mydriasis upon admission, a pim score higher and a lower temperature (< . °); the latter being the only factor identified for htic of vascular cause. in the case of traumatic intracranial hypertension, icp monitoring in survivors was . % against . % in children died, with no significant difference. in the population "vascular intracranial hypertension", all the patients who died had not been monitoring pic. discussion the severity factors related with higher mortality identified in the population "traumatic intracranial hypertension" were mydriasis upon admission, a pim score higher and a lower temperature (< . °); the latter being the only factor identified for htic of vascular cause. other studies have related other severity factors as initial glasgow scale, tardive decompressive craniectomy. conclusion decompressive craniectomy doesn't seem to improve the mortality rate or the outcome in patients with hypertension of traumatic cause in our study but the dc traumatic subgroup was more serious than the subgroup treated medically. in children with refractory intracranial hypertension of vascular cause dc significantly improves survival and outcome. further studies are needed to clarify the role of decompressive craniectomy and its timing in the therapeutic management of refractory intracranial hypertension. introduction shortage of heart grafts is a major problem, leading to a significant mortality rate in the national waiting list, essentially for young children with low weight. the potential paediatric brain-dead donors often have myocardial dysfunction (md), which seems to be reversible. the aim of this study is to assess prevalence, causes and consequences of md when the potential paediatric donors are taken over, up to multi-organ retrieval, and the evolution after cardiac transplantation. materials and methods this observational, monocentric, retrospective study included all brain-dead children aged - years old, who had their myocardial function assessed through a cardiac ultrasound performed by a cardiologist and identified from to . all adult patients and those who didn't undergo a cardiac ultrasound were excluded. md was defined as an lvef ≤ % with or without abnormal segmented cinetic parameters. the main evaluation criteria was the prevalence of md in potential identified donors. the secondary evaluation criteria were the causes and consequences of md on heart retrieval and the origin of this md. results out of included patients, had md. prevalence of md was of %. there was no significant difference between groups regarding aetiology of brain death nor administration of catecholamines. having a cardiopulmonary arrest during intensive care unit stay was associated with a significant risk of presenting a md (p = . ). having a md had no consequences on organ retrieval in general (p = . ), but was significantly associated with a decrease in heart retrieval opportunities (p = . ). the cause of heart grafts refusal was a poor ventricular function in % of cases ( cases out of ). the cause for non-retrieval was parental refusal in one-third of cases. evolution of the cardiac grafts was favorable in cases on , one transplanted patient died (from a non-cardiac cause) and patient was lost to follow up. conclusion md in paediatric brain-dead patients has direct consequences on heart retrieval and transplantation, and otherwise, organ shortage is a major ongoing problem. a better transplant management regarding hemodynamics (with the use of a protocol) could increase the number of heart transplants, especially in small children, and reduce mortality rate in national waiting list. the prone positioning (pp) is a strategy widely used in the treatment of severe forms of acute respiratory distress syndrome (ards) in adults. its early use significantly reduces mortality ( ). however, the studies do not strongly demonstrate its prognostic impact in pediatric ards. the aim of this study was to describe the prone positioning practices in the french-speaking pediatric intensive care units (picu). patients and methods this survey was conducted by email questionnaire to pediatric intensivists belonging to the french society of intensive care medicine and the french-speaking group of pediatric intensive care and emergency medicine. it was conducted from february to may . the survey was addressed to doctors, nurses, physiotherapists practicing in picu. it included questions about indications, contraindications, techniques and medical devices used, and complications. results one hundred and three persons answered ( doctors and nurses) which work in french hospitals and canadian hospital. sixty-eight percent of interviewed persons have more than years experience and % of them treat each year more than children ards. only % of the picu have a pp medical protocol. fifty percent of interviewed persons frequently use pp for the medical care of ards and % systematically use it. thirty-six percent begin pp at the early phase of ards during conventional ventilation, while % before the introduction of unconventional ventilatory strategies (ohf); only % use it after the respiratory failure unless unconventional ventilatory strategies. seventy-three percent report that pp is used with prolonged periods (> h/day), % with short periods (< h/day) and % with very long periods (> h/day). regarding the weaning criteria, most of interviewed persons seem to use multiple and combinated criteria: % use hypoxemia severity parameters (pao /fio , pao , sao ), % use the oxygen level (fio ) and % use the mechanical ventilation parameters (peep, p max, p plate). finally, despite a low level of scientific evidence in children, % of the persons gave a strong recommendation for pp as standard care in severe pediatric ards. see fig. . the survey confirmed the widely use of pp in pediatric ards. however, no specific protocol is avalaible in most of the picu. the timing of the pp beginning can be different according to children, early and prior to use of the conventional ventilation strategy in most cases. the duration of pp seems more consensual. most of the centers use extended periods longer than h/day. these results are close to guérin et al. advocating a duration > h/day. finally, the weaning is a great issue and depends on multiple criteria. in guerin et al. ( ) pp was interrupted if one of the following criteria were present: pao / fio ≥ mmhg, with peep of ≤ cm of water and a fio of ≤ . ; decreased pao /fio than %, compared to compared to the supine position, or the occurrence of complications. no study has validated pp weaning criteria during pediatric ards. conclusion the prone positioning is a strategy commonly used in pediatric intensive care units for the severe pediatric ards. the criterias of implementation and timing are variable, as well as the weaning criterias. more pediatric multicenter randomized studies will be necessary to confirm the benefits of pp in pediatric ards and to define clear weaning criteria. introduction allogeneic hematopoietic stem cell transplantation (hsct) recipients have profound defects in every immunity compartments that can lead to severe opportunistic infections (oi). % of hsct patients require admission to the icu because of diverse infectious or non-infectious complications with dismal outcomes. oi specific course in this population has not been described previously and the management of these infections may be a concern. the aim of this study was to investigate risk factors, management and outcomes of io in hsct recipients admitted to the icu. patients and methods this was a retrospective ( - ) single center study of patients admitted to icu after an allogeneic hsct. patients provided written informed consent according to helsinki declaration. data regarding the transplant, infections and life sustaining therapy use were analyzed. oi were considered if present at the time or during icu admission. results hundred and ninety-four patients (pt) were included. median age was [ ; ] years, . % were males. reason for transplantation was acute leukemia in ( %) pt and the hematological condition was still in complete remission at icu admission in % of patients. ( %) and ( %) had received a myeloablative conditioning regimen and anti-thymoglobulin serum respectively. % had acute graft versus host disease over grade at icu admission. oi was documented in patients ( %). an invasive fungal infection (ifi) was found in pt owing to mucormucosis, trichosporon septicemia and invasive aspergillosis ( possible, probable and proven according to eortc criteria). serum galactomannane antigen was positive in ( %). median time from transplantation and icu admission to ifi diagnosis was respectively [ ; ] and − [− ; ] days. lung was involved in % and patients with aspergillosis were admitted to the icu for acute respiratory failure in % (vs. % for others p = . ). they did not required invasive ventilation more frequently ( vs. % p = . ). and % required vasopressors and renal replacement therapy with no difference as compared to others. median icu length was [ ; ] days. demographic, stem cell source, and donor type were not associated with ifi occurrence in this population. however / had received a total body irradiation ( vs. % p = . ). ifi occurrence was not associated with icu or day mortality ( vs. % p = . and vs. % p = . respectively). a viral infection was found in pt owing to cmv, adenovirus, hsv and vrs infections. analyses were focused on cmv reactivation. median time from transplantation and icu admission to cmv reactivation was respectively [ ; ] and − [− ; − ] days. reactivation was mainly positive blood pcr but pt had cmv colitis. a preemptive treatment was started on the same day in median and lasts [ ; ] days. patients with cmv reactivation had more frequently multiple organ failure ( vs. % p = . ) and higher icu admission sofa score ( [ ; ] vs. [ ] [ ] [ ] [ ] [ ] [ ] p = . ). they trend to have higher admission creatinine serum level ( [ ; ] vs. [ ; ] umol/l, p = . ) and more frequently required emergency renal replacement therapy ( vs. % p = . ) mechanical ventilation ( vs. % p = . ) and vasopressors ( vs. % p = . ). median icu length was [ ; ] days and comparable to others. demographic, stem cell source, conditioning regimen and donor type were not associated with cmv occurrence. cmv reactivation was not significantly associated with icu or day mortality ( vs. % p = . and vs. % p = . respectively). conclusion oi was found in % of allogeneic hsct recipients admitted to the icu. ifi were mainly responsible for respiratory distress and cmv associated to multiple organ failure. non-invasive diagnostic tests were positives in a majority of these patients. in this cohort, io treatment was started quickly after the diagnostic and we did not find an association with mortality. intensivists should always consider oi in their diagnostic panel in this specific population. introduction over the last two decades, targeted therapies in patients with solid tumors have both increased their length of survival and significantly altered their immune functions. however, data on opportunistic infections in this setting remain scarce. in this systematic review, we sought to identify published cases of opportunistic infections in patients with solid tumors, with a special interest on clinical findings, trends over time and outcomes. materials and methods we performed a search of medical subject headings (mesh) on pubmed using the words pneumonia pneumocystis (pcp), invasive aspergillosis (ia), histoplasma, mucor, geotrichum, cryptococcus, coccidioidomycosis combined with the mesh term neoplasms (breast, lung, ovarian, urologic gastrointestinal, digestive system, abdominal, brain, carcinoid tumor, sarcoma, testicular, seminoma). we identify published cases of opportunistic infections in non hiv patients with solid tumors between / / and / / included. results regarding pneumocystis jirovecii pneumonia, cases could be identified. there were men and women, aged of . ( - ) years. underlying tumors were chiefly brain neoplasms (n = , %), lung neoplasms (n = , %) and breast neoplasms (n = , %). at the time of pneumocystis pneumonia onset, patients ( %) had a history of chemotherapy, ( %) had received long term or high dose steroids, and ( %) had an history of biotherapy targeting the malignancy. of note, patients ( %) had received only chemotherapy, ( %) had received steroids alone, ( %) everolimus therapy alone and ( %) received none of these treatments. regarding invasive aspergillosis cases could be identified. mean age was . ( - ) and ( %) were men. solid tumors associated with invasive aspergillosis were primarily lung neoplasms (n = , %) and brain neoplasms (n = , %). at aspergillosis onset, ( %) patients had a history of chemotherapy, ( %) were receiving long term or high dose steroids and ( %) had received targeted therapy. fourteen ( %) patients had received only chemotherapy, ( %) only steroids, and ( . %) had received targeted therapy alone. for both infection, there was a trend for a higher number of reported cases throughout the studied period. conclusion this systematic review provides objective data showing that an increased proportion of patients with solid tumors present with opportunistic infections. we are convinced that it is a clinically relevant but still neglected problem. selected oncologic population may be becoming eligible for antimicrobial prophylaxis against pneumocystis or aspergillus. care unit of strasbourg in france. patients were included only if they are non-immunocompromised according to the european organisation for research and treatment of cancer (eortc). invasive aspergillosis was defined as an association of microbiological evidence, a radiological imaging and a clinical context. results eighteen patients ( males) were identified during the study period. the median of igs ii was . (interquartile range (irq), . - . ). ninety-four percent was under mechanical ventilation. fourteen ( %) patients were suffering from liver failure. among liver failure, twelve ( %) were beforehand suffering from cirrhosis. the median meld score was (interquartile range (irq), - ). sixty-four percent of aspergillosis were due to aspergillosis fumigatus. hundred percent were pulmonary aspergillosis. fifty-six percent of aspergillosis were associated with bacterial pneumonia. the mortality rate at the date of the latest news (an average of years) was seventytwo percent. discussion invasive aspergillosis is not exceptional in the non-immunocompromised patient especially in patient developing liver failure. an active research of colonization/infection with aspergillus in these patients remain to be discussed. conclusion invasive aspergillosis in icu has a poor prognosis. the liver failure seems to be the most important risk factor in non-immunocompromised patients according eorct criteria. introduction chest wall elastance (ecw) has been found to increase in prone (pp) as compared to supine position (sp) in ards patients [ ] . this makes respiratory system elastance (ers) not reflecting lung elastance (el). little is known about the changes of ecw, el and lung resistance (rl) when moving the patient from the sp to the pp via the lateral position (lp). the goal of present study was to measure ecw, el and rl in ards patients in sp, lp and pp during the proning procedure. patients and methods it was a prospective, single-center, controlled study. ards patients intubated, sedated and paralyzed with pao /fio ratio < mmhg, peep ≥ cmh and an indication of pp were included. mechanical ventilation was delivered in volume controlled mode with constant flow inflation and end-inspiratory pause . s included into the inspiratory time. ventilator settings were unaltered during the procedure. an esophageal balloon catheter (nutrivent device) was used for esophageal pressure (pes) measurement. pressure at the airway opening (pao) and airflow were measured by fleish pneumotachograph proximal to endotracheal tube and upstream heat and moisture exchanger. pao, pes and airflow were continuously measured during min in sp, then during min in lp and min in pp. the side for the lateralization was that selected by routine practice (in the opposite side from central venous line). ers and resistance of the respiratory system (rrs) were obtained by fitting flow and pao signals breath by breath to the first order equation. ecw and resistance of the chest wall (rcw) were similarly obtained by fitting flow and pes signals breath by breath to the first order equation pertaining to the chest wall. el and lung resistance (rl) were obtained by subtracting ers and rrs from ecw and rcw, respectively. our ethical committee approved the protocol. data are shown as median (first and third quartiles). comparisons between positions were made by using paired-t-test. results twenty-nine patients, males, of ( - ) years, saps ( - ) and sofa score ( - ) were included ( - ) days after ards criteria were met. the ards severity was moderate in cases ( %) and severe in ( %). tidal volume averaged . ( . - ) ml/kg predicted body weight, peep ( - ) cmh o, fio ( - ) %, pao /fio ( - ) mmhg. the cause of ards was pulmonary in cases ( %), extra pulmonary in ( %) and undetermined in ( %). lateral positioning was on the right side in ( . %) and on the left side in patients ( . %). the results are shown in the table . conclusion during prone positioning in ards patients, as compared to sp we observed a higher rl in lp and an increased ecw in pp. introduction neuromuscular blocking agents (nmba) could exert beneficial effects in acute respiratory distress syndrome (ards) through properties on respiratory mechanics and particularly in modifying transpulmonary pressures (pl). patients and methods prospective randomized control study in moderate to severe ards patients within the first h of the onset of ards. all patients were monitored by an esophageal catheter and followed during h. moderate ards patients were randomized in two groups according to the systematic administration of a h continuous infusion of cisatracurium besylate or not (control group). the severe ards patients group received a h continuous infusion of cisatracurium besylate. the evolution during the h of the study of the oxygenation and the respiratory mechanics including inspiratory and expiratory transpulmonary pressures and driving pressure were assessed and compared. delta transpulmonary pressure (∆pl) was defined as inspiratory pl minus expiratory pl. results thirty patients were included, in the moderate ards group and in the severe ards group. nmba infusion was associated with an improvement in oxygenation both the moderate and the severe ards patients group accompanied by a decrease in both the plateau pressure and the total positive end expiratory pressure. the mean inspiratory and expiratory pl were higher in the moderate ards patients group receiving nmba as compared with the control group (fig. ) . in contrast, there was no modification of both the driving pressure and the ∆pl related to nmba administration. conclusion nmba could exert beneficial effects in moderate ards patients through higher observed inspiratory and expiratory transpulmonary pressures. none. introduction prone position (pp) is a major treatment in management of acute respiratory distress syndrome (ards). the use of pp in patients with severe ards associated with brain injury is at high risk of intracranial hypertension. the aim of this study is to analyze the effect of pp on intracranial pressure (icp) and cerebral perfusion pressure (cpp) in patients with ards and acute neurological condition requiring monitoring of icp. patients and methods it is a retrospective descriptive study including sixteen patients with acute brain injury (subarachnoid hemorrhage, severe head trauma, and hemorrhagic stroke) and continuous monitoring of icp who developed a severe ards during icu stay from january to december and for which pp was performed. pp sessions were analyzed. hemodynamic and respiratory parameters, blood oxygenation, pic and ppc were studied in supine, before pp and after pp. the study was approved by fics ethic comity. results a significant increase in pao /fio ratio was observed in pp, from ± to ± (p < . ). in pp, the icp was increased ± . - ± . mmhg (p < . ) while the cpp was stable ± versus ± mmhg (ns). median duration of pp session was h ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . increasing of icp during pp required medical treatment in sessions ( %). pp session was interrupted in sessions ( %). in subgroup of patients who respond to pp in terms of oxygenation, the increase of icp was lower than in non-responders ( vs %) (p < . ). cpp was not modified whatever the nature of the response to pp ( ± - ± in non-responders and from ± to ± in responders (ns)) (fig. ). discussion our study shows an improvement of oxygenation during pp in severe ards patient with acute brain injury. we observe a constant increment of pic during pp sessions. the increment of icp is less in responders to pp. significant increased icp requiring an enhancement in the medical treatment was observed in % of the cases, and lead in most cases to a discontinuation of the session. our data underlined the absolute necessity to monitor icp during pp session in patients with acute brain injury and ards, even if icp is controlled previously in supine. only prospective ( , ) and one retrospective studies evaluate the effects of pp on icp in patients with acute brain injury and acute respiratory failure (arf). they results are similar to ours. in all these studies, the severity of arf was often not well specified. roth and al. ( ) had included only % of ards in a population of patient with icp not controlled. in others studies, monitoring of icp during pp was not systematic. despite the retrospective nature of the study and the small number of patients, it is the only work studying the effects of pp on intracranial pressure in patients with acute brain injury at risk for intracranial hypertension and severe ards according to the berlin's definition. conclusion our work suggest that pp is a quite secure technique for use for the treatment of severe ards even patients at risk of intracranial hypertension with a benefit in terms of oxygenation without major increase of icp particularly in pp responders. introduction influenza-associated acute respiratory distress syndrome (ards) requiring extracorporeal membrane oxygenation (ecmo) support is known to have a good prognosis ( ). however, the incidence and impact of co-infection in this setting remain unknown. we conducted a retrospective, observational analysis of data prospectively collected from all patients admitted to our medical icu who received ecmo support for influenza-associated ards between and . co-infection was defined as isolation of a pathogen in the lower respiratory tract at a significant level or in the blood during the h following hospital admission. when no pathogen was identified in a patient receiving antibiotics prior to bacteriological sampling, an independent adjudication committee reviewed all charts to assess if the patient had a "high probability" or "low probability" for bacterial co-infection, based on clinical, radiological and biological results available. results are presented as median [iqr] . results among the patients hospitalized for an influenzaassociated infection in our icu, had an ards requiring support by either veno-venous-(vv, n = ), venoarterial (va, n = ) or venoarterio-venous-(vav; n = ) ecmo. - . ), pre-ecmo sofa score > (or . ; % ci . - . ) as independent predictors of hospital mortality, but not co-infection (or . , % ci . - . ). in a second analysis, patients with proven co-infection and high probability of co-infection were grouped and compared to patients with no co-infection and low probability of co-infection; and results were similar. as compared to others co-infected patients, those co-infected with a pvl-positive s. aureus had same characteristics and similar mortality rate, but all received a treatment active against pvl production. conclusion co-infection is frequent in patients with influenzaassociated ards supported by ecmo, occurring in roughly % of the cases. mortality of patients with co-infection is higher than those without, but seems mainly due to the severity of the disease. s. aureus was the most frequently identified pathogen, with a high prevalence of pvl-positive s. aureus, infection with a pvl-positive strain was not associated with a poorer outcome as compared to other co-infections. whether a treatment active against pvl production should be given in those patients remains to be determined. none. the pancreaticoduodenectomy (pd) is major surgery in visceral surgery. this technique performed for the first time in by whipple has seen much progress and development over the years that have enabled a significant reduction in mortality, while the morbidity remains high. the aim of this study was to analyze postoperative morbidity pancreaticoduodenectomies. we retrospectively studied cases of cephalic duodenopancreatectomy at the department of surgical emergencies resuscitation (wing ) spanning years, between january and december . the average age of patients was . years with % of females and % of males, the frequence of pancreatic resections was years. the indications of cephalic duodenopancreatectomy were: tumors of pancreatic head ( %), ampulla vater ( %), duodenum tumors ( %). the restoration of continuity after cephalic duodenopancreatectomy was realized with a rate of % for pancreaticogastrostomy and % for pancreaticojejunostomy. the average hospital stay was , days, with extreme lengths of - days. the postoperative course was marked by the occurrence of deaths ( %), the morbidity rate was , % after pj and % after pg; the most frequent complications were the pancreatic fistula ( %), the postoperative peritonitis ( %), the digestive bleeding ( %), the gastroparesis ( %). conclusion advances in the overall care of patients by surgical teams, anesthesiologists and intensivists, the dpc mortality is currently low in experienced centers. the multidisciplinary, involving surgeons, radiologists and especially intensive care, to manage more effectively the complications of this surgery remains burdened with high morbidity. introduction severe acute pancreatitis (sap) is a common but potentially lethal pathology due to the multiplicity and severity of complications that can occur at all stages of evolution. in the last decade, mini-invasive interventional treatments of infected pancreatic necrosis (ipn) have been developed. the aim of the present study was to assess the management and outcomes of sap patients, as well as to identify the role of ipn. this was a retrospective study of prospectively collected data from all consecutive patients admitted in intensive care unit (icu) in a single french center (hospital of nantes) from to . using logistic regression, we evaluated the association between ipn and patients characteristics at baseline and the outcomes. (fig. ) , highlighting the prognostic importance of respiratory failure and acute renal failure at the time of lt, as well as complex interactions between donor and recipient features. conclusion ventilator support and/or acute renal failure at the time of lt are major predictors of mortality but complex recipients/donors relationships may moderate these associations, as demonstrated by our cart analysis. none. subtotal gastrectomy ( / ). enlarged gastrectomy was performed in patients ( %). the mean operative time was . ± min. per-operative transfusion was required in patients ( . %). the average length of stay in icu was . ± days. postoperative mortality was . %. in our series, patients ( . %) had at least one postoperative complication: an anastomotic fistula diagnosed in patients ( . %), patients ( . %) had postoperative peritonitis and patients had ventilator associated pneumonia. reoperation was necessary for patients ( . %), it was performed after . days ( - days). in univariate analysis, risk factors for postoperative morbidity after gastrectomy was hypoalbuminemia (p = . ), anemia (p = . ), bmi (p = . ) and malnutrition (p = . ). age, sex, neoadjuvant chemotherapy, extended lymphadenectomy, splenectomy or pancreatosplenectomy, total gastrectomy and operative time were not significantly associated with higher postoperative morbidity. in multivariate analysis, malnutrition (p = . ) and bmi (p = . ) were significantly associated with the occurrence of postoperative complications. conclusion the results of our study are similar to those reported in medical literature. preoperative evaluation and nutritional rehabilitation are crucial to improve patient's outcome and reduce morbidity and mortality after gastrectomy for cancer. the mesenteric ischemia is a condition relatively rarely. it is marked by high mortality. mortality is primarily related to the land on which ischemia occurs and especially the time taken to diagnose. this delay is due to the low specificity of clinical signs and the absence of diagnostic laboratory test. the mesenteric ischemia remains a diagnostic and therapeutic challenge. patients and methods twenty cases of acute mesenteric ischemia have been collected at the surgical resuscitation (resuscitation ) at the hospital center ibn rochd of casablanca from january to december . results the mean age of our patients is year old. it is about a disease that the incidence increases these last years, particularly because of the waxing number of old patients and/or suffers from advanced cardiovascular diseases. the cardiovascular risk factor has been present in % of our patients. the abdominal pain has been present in all the patients. it is a sudden, intensive pain localized the most often at the level of the epigastria, becomes diffuse in few hours or even few days. other clinical signs have been described as the bilious vomiting that becomes fecaloid after few days. the digestive hemorrhages as the moelena and the hematemeses. a stop of the matter and the gazes was noticed in % of our patients. the absence of specificity of the clinical signs forced the realization of complementary examinations. the scanner becomes the reference imaging. it permits a differential diagnosis, the search of direct signs of vascular obstruction and the emphasis of intestinal pain. four etiologies are noticed: the arterial occlusion by emboli ( %), the arterial thrombosis ( %), the venous thrombosis ( %) and the "non occlusive" form ( %). the strategy of management of the acute mesenteric ischemia is multidisciplinary, based on the equips of radiology, vascular surgery and/ or visceral surgery and resuscitation. the treatment consists in measures of general resuscitation, the techniques of endoluminal vascular disobstruction and techniques of surgical revascularization. in spite of the improvements in the diagnosis and the therapeutic procedure of the ima, the disease still know a rate of mortality between and % according the studies. in our study, we noticed cases of death ( %), cases of good recovery ( %), cases are unknown evolution ( %). conclusion it is a vital emergency that the evolution still knows great mortality. it is very important to remind the acute mesenteric ischemia in the case of any acute abdominal symptom in order to anticipate about the natural evolution and to act in a reversible stage of the ischemia. none. introduction emergency departments staff are frequently exposed to many complex stressful situations and consequently burnout syndrome. our study aimed to describe epidemiological particularities and determine the risk factors of burnout syndrome in different categories of emergency. patients and methods we studied five academics and four regional hospitals. the level of burnout was assessed using the "maslach burn out inventory" score and the degree of depression with major depression inventory (mdi) test. results one hundred and forty-three correctly completed questionnaires were collected. the mean age of study population was ± years. sex-ratio was at . . fifty-one per cent of the care staff were married. physicians represented % and paramedical %. the general frequency of burnout syndrome was % (n = ). low level burnout was present in %, moderate level in % and high level in %. the depression frequency was %. a statistically significant correlation was found between burnout and depression firstly (p = . ) and between burnout and lack of equipment (p = . ). their relative risk was . [ . , ] and . [ . , . ] respectively). main risk factors associated with high level burnout are detailed in table . conclusion burnout syndrome frequency in our emergency departments is alarming. helping to resolve social and psychological problems and improving work conditions may help to decrease it. the healthcare activity is recognized as a major polluting activity. in france, it generates , tons of waste cremated each year, and represents % of the tertiary energy consumptions. in the united states, it generates tons of waste per day and % of total co emissions in were attributed to him. ultimately, such waste production is associated with adverse environmental and health effects. nevertheless, near half of the hospital waste would be recyclable, particularly in our intensive care units (icu) [ ] . furthermore, sustainable development solutions generate profits. the aim of this study is to make an overview of waste produced in a icu and offer solutions to conserve natural resources and reduce the carbon footprint bound to the healthcare activity. materials and methods experimental study, single-center, concerning a period of months in an icu-high surveillance unit compound of beds. we have identified all waste generated. our packaging were given to the recycling company in connection with the hospital. then we have studied the impact of the implementation of sustainable development solutions. results firstly, we have studied the non-recycled waste and the quantity produced over a period of month. approximately kg of waste is produced per patient per day with % of infectious waste and % of general waste. these results were linked with a bad distribution of garbage bags in the rooms ( l of infectious waste versus l of general waste). secondly, we have improved our way to sort and consume and we have created recycling dies without compromising patient safety. all these measures have not increased workload. changing bags in the rooms ( l of infectious waste and bags of l of general waste) allowed to reach the normal goals of sectors with a net benefit estimated at euros per year. the medical broken glass containing drugs was thrown into plastic containers of l for infectious waste to prevent the risk of cuts. by creating a specific die intended to the general waste, we could quantify the production of this glass to kg per week and to spare the use and the incineration of containers of l per year (global economy of euros). plastic packaging represented an important proportion of the cremated waste. we have created sectors of recycling including the polypropylene ( - kg per month), the polyethylene colorless and colored polyethylene. this plastic is sold to be recycled without additional cost for the hospital. the linerboards was cremated. we have created a recycling die ( kg per month). this sector was subsequently extended to the entire hospital structure, particularly the pharmacy that produces containers of l per month. they are now sold without additional cost. many unnecessary plastic waste is generated daily. we have removed using mild soap plastic bottles of ml by using the same mild soap in pump of ml (economy of euros). the use of l plastic bags for the transitional deposit of linen has been deleted (economy of euros). concerning the paper: % of the impressions were made in simplex. printers were parametrized on both sides by default allowing the economy of reams per year ( , sheets), several thousand liters of water and the reduction of co emissions. discussion recycling is only one component of the sustainable development in health. other avenues that could be considered to improve icu sustainability would include examining water use (for linen), electricity use (reducing non-essential use at night…). beyond these actions, we need to encourage our suppliers to turn to sustainable and recyclable packages to reduce the use of polluting and depletable fossil fuels such as oil. but also to develop with them circular economies where waste is returned to them to be reused. conclusion we must ask the question also resuscitate our tons of waste. our icu produce large quantities of waste (over tons per year per bed). however, a significant proportion, especially plastic, is recyclable with a significant environmental and financial benefit. waste management also requires an optimal and rational use of supplies because "the best waste is that which is not produced" and that excess is not a guarantee of quality. as already said st exupéry in : "we do not inherit the earth from our parents, we borrow it from our children. " so do not expect tomorrow to reduce major adverse ecological impact paradoxically generated by a great profession whose ultimate goal is to cure people. moreover, an external consultant is rarely applied and palliative cares are insufficiently developed after «non-readmission» decisions. for providing corrective measures, this study lead to propose a «nonreadmission» process by integrating the discussion for a real «patient's care project» at the end of the icu hospitalization. this process would lead to collect patient's opinion through advance directives, to ensure a collegial discussion including an external consultant and to allow reevaluation of global patient's clinical status and one or more organ failure(s). then, «non-readmission» decisions would be integrated in a therapeutic project which would promote the initiation of a palliative care program if necessary. the purpose of this process is well to respect patient's autonomy and dignity as required by french law and medical ethics. the proportion of elderly patients is steadily increasing. due to the growth of this part of the population who suffer from multiple pathologies, the need for hospitalization in intensive care increases. according to the simulations, the proportion of octogenarian patients in icu will increase reaching the third of icu patients. while chronological age is not a significant factor of poor prognosis in the icu ( ), many factors should be taken into account to evaluate the relevance of icu admission in the senior population and withholding such intensification should be consensually discussed between clinicians and obviously as often as possible with the patient himself ( ) . the aim of the study was to assess the role of stakeholders (ward physicians, intensivists, family doctor and patient himself ) in the decision of withholding icu admission for elderly patients in our internal medicine department. we made a prospective observational monocentric study, including all the elderly patients (defined as older than ) admitted in the internal medicine department from january to june . the only non-inclusion criterion was patient's refusal to participate to the survey. collected data involve physiological (cognitive, autonomy, nutritional status), morbidities (acute and chronic diseases) and social parameters (marital status, relatives). and evaluation of quality of life by the patient himself using an analog visual scale was also obtained. internal medicine physicians were asked to report any icu withholds decision for their patients. in absence of notification, every physician was questioned again the day of the concerned patient's discharge. results one hundred ninety-one patients were included between january and june . factors associated with a significant reduction of in hospital mortality were higher age (p = . ), higher lactate level (p = . ), chronic obstructive pulmonary disease (p = . ), diabetes mellitus (p = . ), immunodepression (p = . ) and respiratory failure (p = . ). conclusion in patients hospitalized for vs high body mass index, low left ventricular systolic function, high white blood cell count, low creatinine clearance, high lactate level and st-segment depression are the variables correlating significantly with high-sensitivity troponin-t concentrations. peak of hstnt was not significantly associated with in-hospital mortality in this setting. introduction mitochondria are evolutionary endosymbionts that are derived from ancestral aerobic bacteria and so might bear and release bacterial molecular motifs supporting the role of mitochondria in danger signal regulations. free circulating mitochondrial dna (mtdna) is elevated in a wild range of critical illness observed in intensive care units, and is associated with bad outcomes and mortality. the mtdna is a molecular pattern that belongs to mitochondrial damage associated molecular patterns (mtdamps), and can interact with pattern recognition receptors (prr) to induce self defense reaction. free mtdna activates inflammatory signaling pathways through toll-like endosomal receptor (tlr ) interactions. nevertheless, new evidence advocates a role of the receptor for advanced glycation end-products (rage) in mtdna signaling. experimental data suggest a role of mtdna-prr interaction in systemic inflammation and organ dysfunctions as septic acute kidney injury or pulmonary inflammation. impact of free circulating mtdna on endothelial cell is not known. the main purpose of this study was to test whether mtdamps and mtdna can induce endothelial dysfunction. we also evaluated the role of mtdna-rage axis in mtdamps induced endothelial dysfunction. mitochondria were isolated from livers of wild type c b mice. isolated mitochondria were sonicated on ice to obtain mtdamp preparations. semi quantitative evaluation of mtdamp content was tested by qpcr, with specific markers of mtdna (cytochrome b (cytb), nadph oxidase (nd )). intraperitoneal injection of mg of mtdamps was used as experimental model in wild type and rage ko mice, as previously described [ ] . the mtdamps were also administrated after ex vivo dnase preparation. endothelial function was assessed with a mulvany-halpern style myograph, h after mtdamp administrations on aorta (conductive vessel) and on d division of mesenteric artery (resistive vessel). endothelial-dependent relaxation was studied by cumulative expositions of the vessels to acetylcholine ( . - - . - m). endothelial-independent relaxation was studied by sodium nitroprussiate exposition. results the mtdamps preparation contains a high quantity of mtdna with a /cycle threshold (ct) ratio of . for cytb expression. intraperitoneal administrations of mtdamps induced a decrease of endothelial-dependent relaxation mainly on conductive vessel (p = . , n = per group) and to a lesser extent on resistive vessel (p = . , n = per group). rage-ko mice were protected from mtdamps-induced aorta dysfunction (p = . , n = per group). the ex vivo exposition of mtdamps to a dnase preparation decreased mtdna content in mtdamps solution with a /ct ratio of . for cytb expression. eventually, the pretreatment of mtdamps with a dnase preparation prevented the mtdamps-induced aorta dysfunction (p = . , n = ). discussion more than prognostic markers, mtdamps particularly mtdna seems implicated in endothelial dysfunction in critically ill patient. new evidence suggest rage interaction in endosomal tlr pro-inflammatory and pro-oxidant response to mtdna [ ] . also in sepsis, physiological clearance of circulating dna might be impaired, this results comfort the possibility of therapeutic regulation of free circulating mtdna to prevent septic organ dysfunction related to mtdamps accumulations. conclusion exogenous mtdamps can induce endothelial dysfunction in mice. the mtdna-rage axis is a key component of the signaling pathway involved in this dysfunction. the use of dynamic parameters to assess fluid responsiveness was supported by cyclic changes in stroke volume induced by mechanical ventilation. however, these parameters have several limits. venous to arterial carbon dioxide difference inversely related to cardiac index. consequently, fluid administration would be beneficial if carbon dioxide gap increases. objective to investigate whether carbon dioxide gap predicts fluid responsiveness in patients with acute circulatory failure. patients and methods we conducted a prospective study in the medical intensive care unit of hospital taher sfar at mahdia, between march and april . patients with circulatory failure and who required mechanical ventilation were included. we measured the variation of cardiac index between baseline and after volume expansion of ml of saline fluid. the picco was used to measure cardiac index. response to fluid challenge was defined as a % increase in cardiac index. before and after fluid administration, we recorded carbon dioxide difference and hemodynamic parameters. results among included patients, ( %) were responders. the causes of acute circulatory failure were septic shock (n = ), cardiogenic shock (n = ), and hypovolemia (n = ). carbone dioxide gap was significantly higher in responders group ( ± vs ± mmhg, p = . ). the area under the roc curve for carbon dioxide gap was . ( % ci . - . ). the best cutoff value was mmhg (sensibility = %, specificity = %, positive predictive value = % and negative predictive value = %). the area under the roc curve for delta carbon dioxide was . ( % ci . - . ). conclusion in this study, baseline carbon dioxide gap was not universal indicator to predict the fluid responsiveness in patient with circulatory failure. introduction supraventricular arrhythmia (sva) is commun in intensive care unit (icu). its incidence seems to be higher in patients with sepstic shock. sepsis-associated myocardial dysfunction promote the occurrence of sva by constituting an arrythmogenic substrate or under the effect of inotropic drugs. the aim of this study is to assess the incidence and prognostic impact of sva in patients with septic shock. patients and methods we retrospectively studied all patients with new onset sva suffering from septic shock in non cardiac surgical icu. myocardial dysfunction was evaluated by transthoracic echography (tte) after an adequate cardiac resuscitation using intravenous fluids expansion and adjunctive vasoactive agents. sva was detected by the electrocardiogram scope. during the study period clinical and biologic characteristics, hemodynamic tolerance (vasopressors doses, arterial pressure changes), current treatment (such as corticoid), duration of mechanical ventilation, duration of vasopressor requirement and hospital mortality were collected. results sixty patients were included in the study. the sva occurred in patients, with an incidence of %. the median time to onset was days. cardioversion was performed for patients with an effectiveness of %. clinical and biological characteristics were similar between the groups with and without sva: saps and sofa score at the beginning of septic shock, the existence of ards and cardiac biomarkers (nt-probnp, troponin). however, renal failure and the use of corticoid in septic shock were more frequent in the group with sva. the maximum doses of vasopressor agent were not significantly different between the groups with or without sva. myocardial dysfunction in sepsis defined by the left ventricle ejection fraction (lvef) less than % (or the need for inotropic drug for lvef > %) was not associated with the occurrence of sva (+sva group: n = ; −sva group: n = ; p: . ). sva was poorly-tolerated, observed by a significant decrease in mean arterial pressure and a significant increase in norepinephrine doses within h of the start of sva. the occurrence of sva was associated with longer duration of use of vasopressor agent and a longer duration stay in icu (+sva group: days, −sva group: days; p = . ). there was no difference in duration of mechanical ventilation and hospital mortality between the two groups. conclusion the occurrence of sva is common in septic shock, poorly tolerated hemodynamically and associated with longer duration stay in the icu and vasopressor need. sepsis myocardial dysfunction isn't necessarily associated to the occurrence of sva. introduction a short term beneficial effect of prone position on cardiac index has been shown in % of ards patients, and was related to an increase in cardiac preload in preload responsive patients ( ) . the aim of this study was to evaluate the long term hemodynamic response to prone position in a larger series of ards patients. patients and methods single center retrospective observational study performed on ards patients hospitalized in a medical icu between july and march . patients included were adults fulfilling the berlin definition for ards, undergoing at least one prone position session, under hemodynamic monitoring by the picco ® device, with availability of hemodynamic measurements performed before (t ), at the end (t ), and after the prone position session (t ). prone position sessions were excluded if they were performed > days after ards onset. the following variables were recorded: demographic, sapsii, ards severity and risk factor, sofa score and cumulative fluid balance at pp onset, delay between ards session and pp session, hemodynamic, arterial blood gas, ventilatory settings, plateau pressure, catecholamine dose and additional treatments. statistical analyses were performed using prone position session as statistical unit and mixed models taking into account both multiple prone position sessions by patient and multiple measurements during a prone position session. p < . was chosen for statistical significance. data are expressed as mean ± standard deviation. results patients fulfilled the inclusion criteria over the study period, totalizing prone position sessions ( ± sessions per patient). patients' age was ± y, % were male, % fulfilled the criteria for severe ards, and sapsii at icu admission was ± . ards risk factors were pneumonia in ( %), aspiration pneumonia in ( %), and sepsis in ( %) patients. duration of prone position sessions was ± h. hemodynamic measurements were performed in pp ± h after pp session onset. at session onset, sofa score was ± , and cumulated fluid balance was . ± . l. vasopressor were used in %, inhaled nitric oxide in %, and neuromuscular blocking agents in % of the sessions. hemodynamic and respiratory parameters before, during and after the prone position sessions are reported in table . cardiac index increased by at least %, decreased by at least % or remained stable in ( %), ( %), and ( %) of the sessions, respectively. as compared to both other groups, pp sessions with significant increase in cardiac index had the following significant differences at t by univariate analysis: lower cardiac index, lower global end-diastolic volume, lower cardiac function index, and lower vasopressor dose. multivariate analysis is under investigation. conclusion prone position is associated with an increase in global end-diastolic volume, reversible after return in supine position that may explain the positive effect of pp on cardiac index observed in ¼ of the pp sessions. introduction make sure that our patient have a good circulatory condition is a daily challenge for the intensivist. one of the therapeutics is fluid and one of his purpose is to increase venous return and then cardiac output. in order to examine that, there are several tools as the transthoracic echocardiogram wich allows the visualisation and the study of the respiratory variability from the inferior vena cava (ivc). unfortunately there are some situations where the ivc visualisation is difficult (obesity, gut surgery, emphysema). the ivc is easily seen by a transhepatic ultrasound in her retrohepatic section. we make the hypothesis that the shape of the ivc could be predictive of fluid responsiveness. we have performed fluid challenge in patients under mechanical ventilation. the need for fluid therapy is the intensivist in charge decision. we performed a echocardiogram and we take two measures of the icv: major axis and minor axis, the icv is measured avec the sus hepatic vena. a elastometry index (ei) is determined which is the ratio of minor axis to minor axis. the fluid challenge is ml of isotonic saline then we perform a new echocardiogram. a tag is written on the patient to take the same ultrasound slice. we retain one increase of % of the cardiac index (ic) as a success of the filling. we exclude the presenting patients a right cardiac insufficiency, an arrhythmia and/or a htap. the statistical analysis is realized with the software r. results between august, and january, we included patients. the average age is of years ( - ), igs of ( - ), ejectionnal fraction of % - ) and the s wave tricuspid is ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the causes of the filling were an oliguria ( %), a low blood pressure ( %), a low cardiac output ( %), a hyperlactatémia ( %) and an other cause in % of the cases. we find a positive correlation between the ei and the increase of the ic, also for the area of the vci and the respiratory variations of the vci (p . ) the other variables are not predictive (bp, e/e' , e/a). the data are summarized in the picture . roc curves has been established ( only % of the journals studied required authors to use stard. a high impact factor and the year of the study were the items associated with a better sqs the presence of a conflict of interest was associated with a lower sqs in univariate analysis. a higher impact factor (> ), was the only independent factors statistically significantly (p = . ) associated with higher sqs in a multivariate regression model. discussion our study showed that the sqs were very low. assessment of a study depends on quality of reporting. blindness and participant sampling are the cornerstone to evaluate such bias as spectrum, verification, review and selection bias of a study, and were unfortunately scarcely reported compared to existing data in diagnosis accuracy reporting. one of the limitation is the years sample of the study. we have planned to continue the analysis for a -year review starting just after the stard publication. conclusion our study showed that several items remain poorly reported. we recommend systematic use of stard criteria in the elaboration and reporting of future studies that evaluates the preload dependence. introduction neurological impairment, i.e. encephalopathy, is commonly observed in patients with decompensated cirrhosis and/or portosystemic shunts admitted in icu. often ascribed to high plasmatic levels of ammonia, encephalopathy could also be induced by drugs or infection, due to altered blood-brain barrier (bbb) permeability. this latter setting is often underdiagnosed and encephalopathy related to hyperammonemia (so called hepatic encephalopathy-he) being pointed out as the culpit of all neurological symptoms in cirrhotic patients. quinolones and betalactamins were recently found in the cerebrospinal fluid of he patients and it has been shown that the expression of efflux pumps, responsible for drugs passing through the bbb, was altered in animal models of he. the purpose of this study was to assess the incidence of neurological impairment, i.e. encephalopathy, in cirrhotic patients hospitalized in discussion overall, we reported a higher rate of lumbar puncture than those reporting in others studies concerning status epilepticus. furthermore the rate of % of pleocytosis directly linked to status epilepticus is slightly higher than in most studies. unfortunately we didn't realize a second lumbar puncture to assess the pleocytosis normalization during the days following the first lumbar puncture. the pathophysiological hypothesis of this phenomenon may be that prolonged/repeated seizures during status epilepticus would induce a blood-brain barrier dysfunction thereby favoring a cerebrospinal pleocytosis. conclusion in our study, % of status epilepticus without infectious or neoplastic origin had a cerebrospinal pleocytosis directly linked to status epilepticus. this pleocytosis was significantly associated with myoclonic seizures and blood leukocytosis. these data may help to interpretation of cerebrospinal fluid pleocytosis during status epilepticus. introduction neurological prognostication from cardiac arrest survivor is a current concern. eeg patterns and nse dosage are two important prognostic factors. nse threshold for prediction of poor outcome appear controversial, in part, because of variability in dosage timing and measurement techniques. synek score is routinely used in our center to classify comatose patients in post cardiac arrest. the aim of this study was to assess the prognostic value of nse and synek classification to predict poor neurological outcome. introduction traumatic brain injury (tbi) is a major public health problem. it is the leading cause of death and disability in young subjects. one of the principles of the tbi management is prevention of secondary cerebral insults including maintaining perfusion and cerebral oxygenation, control of intracranial pressure (icp). an increase in icp above mmhg is associated with poor outcome. cerebral hypoxia can occur with normal level of icp and cerebral perfusion pressure (cpp).monitoring of regional partial pressure of brain tissue oxygen (pbto ) is a safe and reliable method for measuring cerebral oxygenation. a retrospective single-center observational study was conducted between january and december , aimed to study the influence of pbto with severe tbi patients outcome at months through glasgow outcome scale (gos). the hourly values of icp, pbto and cpp were recovered on daily monitoring sheets. we compared two groups according to their gos. during the study period, patients underwent a monitoring icp and pbto . results the mean age was . ± . years. . % were men. the initial glasgow score was . ± . . the mean simplified acute physiology score (saps ii) was . ± . and injury severity score (iss) . ± . . at months, patients had died (gos ). forty patients had a good outcome: gos - (group ). sixteen patients had poor outcome: gos - (group ). in group , there are significantly more pbto hourly values below mmhg at day ( . ± . vs . ± , in group , p = . ); and more pbto hourly values greater than mmhg at day ( . ± . vs . ± . , p = . ). conclusion pbto less than mmhg or greater than mmhg at day is associated with poor outcome at months in the severe tbi. the pbto allows a more individual approach of monitored tbi. none. introduction organ donation in patients after a decision to withdraw life-supportive therapies (wlst) (maastricht condition: m ) have been performed in our hospital since may . we report here main characteristics of donors, data on m procedure and results on renal transplant recipients. patients and methods all potential donors were included in a survey from may to june , according to the french national m protocol defined by the french organ procurement agency (agence de la biomédecine:abm) [ ] .the demographical, clinical and biological characteristics of the donors, the different deadlines and times of the protocol and data of renal transplantation were collected and analyzed. results patients had inclusion criteria. patients were admitted in intensive care unit for cardiac arrest ( %), strokes ( %), traumatic brain injury ( %), ards ( %). of them, procedures ( %) were stopped ( refusals of organ donation, medical contra-indications discovered with additional exams, failure of vessel cannulation, deaths more than h after extubation). kidneys were harvested and transplantations performed ( renal cancer discovered during procurement surgery).the characteristics of the donors, deadlines of the protocol and transplant recipients are reported in the table . conclusion the french programm maastricht offered a new possibility of organ donation in our hospital. thanks to these donors, the number of renal grafts increases and the preliminary results on transplant recipients are encouraging in line with the preliminary report of the abm. nevertheless, it is necessary to follow the transplant recipients and extend the procedure to new centres. in this study, we found some relevant risk factors for microaspiration (age, low score at gcs) consistent with literature on the subject. patients with paralytic agents had less gam which may be due to higher peep, higher cuff pressure and less enteral nutrition because of the severity of the underlying diseases. conclusion this study did not show any increased risk of microaspiration in intubated copd patients, whatever stage of copd. introduction protected specimen brush (psb) is considered to be one of the standard methods for the diagnosis of ventilator-associated pneumonia (vap). to our knowledge, there is no study assessing effect of prior antibiotherapy on direct examination, bacteriological culture and concordance of direct microscopy and culture. patients and methods all consecutive episodes of suspected vap were retrospectively evaluated between january and december in a -bed intensive care unit. patient's characteristics and preexisting conditions were abstracted from the medical charts. after assessment of vap probability using the clinical pulmonary infection score (cpis), psb were performed in patients with a cpis of or more. based on antibiotic treatment in patients when bacteriological specimens were obtained, two groups were defined: no antibiotic group and antibiotic treatment started before psb group. two independent bacteriologists retrospectively reviewed direct examination and culture of psb to assess bacteriological concordance, defined as non-concordant when direct examination and culture were different, concordant when direct examination and culture were similar and partially concordant when either direct examination or culture were comparable but with other microorganisms lacking in one or the other method. results during this -months period, among mechanically ventilated patients, episodes of suspected vap with psb were evaluated. we found % of psb (n = ) performed without antibiotic treatment and % of psb (n = ) performed under antibiotherapy. we found no significant differences in patient's demographics, characteristics, and severity between both groups. patients received antibiotics for the following reasons: aspiration pneumonia (n = ), peritonitis (n = ), vap (n = ), community-acquired pneumonia (n = ), septic shock of unknown origin (n = ), pyelonephritis (n = ), meningitis (n = ), acute pancreatitis (n = ) and others (n = ). the median duration of mechanical ventilation in the antibiotic receiving group and in the group without antibiotics was . days (iqr; - days) and days (iqr: - ), respectively. when psb was performed under antibiotic treatment, direct examination was positive in % (n = ), culture was positive in % (n = ) and those methods were concordant, non concordant and partially concordant in % (n = ), % (n = ) and % (n = ), respectively. on the other hand, when psb was performed without antibiotics, direct examination was positive in % (n = ), culture was positive in % (n = ) and those methods were concordant, non concordant and partially concordant in % (n = ), % (n = ) and % (n = ), respectively. in univariate analysis, we found a significantly higher proportion of negative direct examination and negative culture in the antibiotic group (p > . ). moreover, these methods were significantly more frequently concordant (p = . ), with a higher rate of both negative microscopic exam and culture when compared to the no antibiotic group ( %, n = vs %, n = ). surprisingly, among the patients previously treated with antibiotics with positive culture, % (n = ) of the microorganisms showed antibiotics sensitivity. discussion whether prior antibiotic treatment may induce false negative of false positive treatment is a well-recognized phenomenon, the precise effect of antibiotics on direct examination and quantitative culture is not well assessed in vap. moreover, despite recent development of clinico-radiological score, diagnosis of vap remains difficult, with no gold-standard. therefore, bacteriological guided therapy is of particular importance. we found psb realization under antibiotic treatment is associated with a lower rate of positive direct examination and culture and suggest performing these bacteriological samples without antibiotherapy. some authors have suggested lowering the diagnostic threshold point of this bacteriological technique in order to preserve its accuracy. however, we can postulate that microorganisms responsible of superinfection in mechanically ventilated patients treated with antibiotics may be resistant and therefore the psb could be positive. conclusion in patients with a high pre-test probability of ventilatoracquired pneumonia, recent introduction of antibiotics significantly reduced the diagnostic accuracy of protected brush specimen by reducing rates of positive direct examination and culture. further studies should evaluate if antibiotic discontinuation may revert this effect. ann. intensive care , (suppl ): we have had non conflict of interest in this study. results we included patients in the phase and patients in the phase . baseline characteristics of patients were similar in both groups. compliance with all the measures has been improved between the two period from to . %. the incidence density decreased from . to . vap per ventilator days between observational and interventional period, but the all-cause mortality was almost equal in the groups ( . vs. %). discussion with the implementation of our bundle, observance of the team were improved in the second group, compared to the first and the incidence density decreased from . to . vap per ventilator days between both period. this result is consistent with the littérature. sure enough, many studies show the same effect of vap prevention with a decrease of nearly % of the incidence density of vap, after implementation of a «ventilator -bundle [ ] . conclusion the implementation of a "ventilator bundle, " has significantly reduced the incidence of vap in our service. in the contrary, our study failed to demonstrate a reduction in mortality. introduction with an increasing incidence and high mortality rates, sepsis is a public health issue. there is growing evidence that sepsis induces long lasting alterations of transcriptional programs through epigenetic mechanisms that may lead to protracted inflammation, organ failure, sepsis-induced immune suppression (siis), secondary infections and death. we hypothesized that epigenetic changes contribute to the pathophysiology of siis. to test this hypothesis, we studied the effects of histone deacetylases (hdac) inhibition with trichostatin a (tsa) in a double-hit murine model of siis and secondary pneumonia. materials and methods c bl/ mice were treated with tsa ( mg/ kg ip) or saline serum (ctl) min before induction of sepsis by cecal ligation and puncture (clp). surviving mice underwent intratracheal instillation of . × cfu of pseudomonas aeruginosa days after clp. we evaluated the effect of tsa on survival and cellular responses to the primary and secondary infections. cellular responses in the blood, spleen and bal were assessed by flow cytometry after clp (days , & ) and after pneumonia ( & h). we also studied lymphocyte apoptosis and dendritic cells (dc) expression of cd , cd , and mhcii. bacterial clearance was assessed in the bal and in the blood and h after pneumonia. continuous variables represented as mean ± sd were compared using student t test. kaplan-meier curves were compared by the log rank test. p < . indicated statistically significant differences. results whereas treatment with tsa did not change survival after clp, tsa improved survival after tracheal instillation of p. aeruginosa (p = . , fig. ). tsa-treated mice had significantly higher absolute dc, t and b-lymphocytes counts with reduced lymphocyte apoptosis after clp. four hours after secondary pneumonia, tsa-treated mice had significantly higher dc counts and improved bacterial clearance in the bal, with reduced systemic dissemination of p. aeruginosa. conclusion hdac inhibition with tsa improves survival in our murine model of secondary pneumonia, improves bacterial clearance and attenuate cellular features of siis. these results suggest that sepsisinduced epigenetic changes contribute to the advent of siis. comprehensive characterization of epigenetic changes associated with siis might allow us to identify new therapeutic targets to reprogram immune cells in sepsis and avoid siis. length of icu stay was ± days. patients acquired nis ( . % bsi, . % pneumonia, . % cri and . % uti. there was no bacteriological documentation of ni in . % of cases. nis occured days post burns. the most three isolated pathogens were: acinetobacter spp. ( %), p. aeruginosa ( . %) and extended spectrum betalactamase-producing enterobacteriaceae ( %). the most frequently administered antibiotics were polymyxin/carbapenem/teicoplanin combination ( %), polymyxin/carbapenem combination ( %) and carbapenem/tigecycline combination ( %). in our study, mortality rate was %. conclusion nosocomial infection occured in . % of cases in burn patients, caused by acinetobacter spp, p. aeruginosa and enterobacteriaceae blse. so, eradication of infection in burn patients require effective surveillance and infection control in order to reduce mortality rates, length of hospitalization and associated costs. introduction infection of the lower respiratory tract is the most common cause of infection in intensive care unit (icu) ( ) . although the attributable mortality of ventilator associated pneumonia remains debated, the recurrence of these infections is always associated with a significant morbidity ( ) . staphylococcus aureus methicillin-sensitive (sams) is one of the most frequently germs involved in icu pneumonia especially in trauma patients. the aim of the study was to establish the risk factors associated with microbiological treatment failure of pneumonia, caused by sams. materials and methods we retrospectively identified patients who developed a first episode of ventilator associated pneumonia caused by sams during a years-period ( - ). the primary end point was the microbiological treatment failure defined as a second episode of pneumonia caused by sams corresponding to either a persistent or a recurrence of the pneumonia (fig. ) . the primary aim of the study was to identify factors associated with a treatment failure, the secondary objective was to identify factors associated with the occurrence of second episode (i.e. persistent, recurrence, superinfection and/or relapse of pneumonia caused by any bacteria) during or after treatment of the first episode caused by sams. definition of outcomes was based after analysis of current concepts available in the literature. factors associated with primary and secondary objectives in univariate analysis (p-value < . ), or clinically relevant ones, were entered in a multivariate logistic regression. the final selection was performed using the stepwise selection based on the akaike criterion. results fifty-nine patients ( . %) developed a second episode of pneumonia and among them, ( . %) were considered as a microbiological failure. in a multivariate analysis, the association of oropharyngeal flora (fop) with the sams (or, . ; % ci, . - . ; p = . ) and the need of emergency surgery (or, . ; % ci, . - . ; p = . ) were predictive of a microbiological failure. empirical antibiotic therapy with amoxicillin-clavulanic acid (or, . ; % ci, . - . ; p = . ) and performing emergency surgery (or, . ; % ci, . - . ; p = . ) were predictors of a second episode of pneumonia caused by any bacteria. conclusion in this retrospective, monocentric study, the co presence of orophryngeal flora and the need of emergency surgery were associated with microbiological failure of pneumonia caused by sams in icu. introduction ventilator-associated pneumonia is a major iatrogenic problem since it is a cause of hospital morbidity, mortality and increase of health care costs. it has been studied many times, but data's revision is always necessary. our study aimed to describe epidemiology of ventilator-associated pneumonia and identify local causative pathogens. we carried out a prospective study in an intensive care unit. were included patients intubated for more than h, from april to may , and presenting signs of ventilator-associated pneumonia (fever, abundant and purulent secretion, increase of fio greater than . , signs on chest-x ray) with positive culture of endotracheal aspirate. were excluded patients with germ colonization. results a total of patients were ventilated for more than h. among them thirty-four patients aged of ± . years presented episodes of ventilator-associated pneumonia (that is . ± . episodes per patient). the mean sofa score was . ± . . the main reasons of mechanical ventilation were loss of consciousness secondary to poisoning ( %), respiratory distress ( %) and status epilepticus ( %). the mean duration of stay was . days with extremes at and days. the average time between hospitalization and suspicion of ventilator-associated pneumonia was . ± . days. the average value of the clinical pulmonary infection score at suspicion was ± . . the average time between recurrences was . days with extremes at and days. the culture of endotracheal aspirate identified two pathogens in %. it reveled acinetobacter baumanii in % in which % were imipenem resistant, pseudomonas aeroginosa in %, klebsielle pneumoniae in %, staphylococcus fig. see text for description aureus methicillin resistant in %. extended spectrum β-lactamases bacteria were found in % and carbapenemases producers in %. empirical antibiotherapy was always association of imipenem and colistin. it was necessary to adapt it to antibiograms in / . ventilator-associated pneumonia was complicated by septic shock in % and acute respiratory distress syndrome in %. patients evolved to healing in % of episodes (n = ), to superinfection in % (n = ) and to death in % (n = ). pseudomonas aeruginosa was the most frequent germ in superinfection ( / ) , acinétobacter baumanii was the most pathogen associated to death ( / ). conclusion ventilator-associated pneumonia is an iatrogenic disease that threatens lives. it's in part avoidable. preventive measures have to be implemented to reduce its frequency, consequences and costs. introduction during mechanical ventilation, mismatch between respiratory muscles activity and the assistance delivered by the ventilator results in dyspnea and asynchrony and is commonly observed in intensive care unit (icu) patients. proportional assisted ventilation (pav) is a ventilatory mode that adjusts the level of ventilator assistance to the activity of respiratory muscles estimated by an algorithm. to date, pav has been mostly studied in patients without severe dyspnea or asynchrony. we hypothesized that, compared to pressure support ventilation (psv), pav will prevent severe dyspnea or asynchrony. patients and methods were included icu mechanically ventilated patient exhibiting severe dyspnea or asynchrony with psv. three conditions were successively studied: ) psv on inclusion (baseline), ) psv after optimisation of ventilator settings in order to minimize dyspnoea and asynchrony (optimisation), and ) pav. ten-minutes recording were performed with each condition. the intensity of dyspnea was assessed by the visual analogic state (vas, only in patients able to communicate) and by the intensive care respiratory distress operating scale (ic-rdos) for all the patients. the electrical activity (emg) of extradiaphragmatic inspiratory muscles was measured. the fig. bayesian nma with random effect prevalence of asynchrony was quantified by the visual inspection of the airway flow and pressure traces. results patients were included, % male, aged [ - ] years, saps [ - ], mechanically ventilated for [ ] [ ] [ ] [ ] [ ] [ ] days. the tidal volume (tv) was higher in the optimisation and pav than in the basal condition (table ). the respiratory rate(rr) was lower with pav than in the other conditions. the dyspnea-vas was lower with optimisation and pav than with the basal conditions. the ic-rdos was lower with pav than with the two other conditions. the asynchrony index was lower with pav than with the two other conditions. parasternal emg activity was lower with pav and optimisation (fig. ) . conclusion in icu patients receiving mechanical ventilation with psv and exhibiting severe dyspnea or asynchrony, the optimisation of ventilator settings with psv and the pav mode decrease in the simiar way the severity of dyspnea and the prevalence of patient-ventilator asynchrony. introduction in spite of recent research and progress in weaning protocols, extubation failure still occurs in - % of patients and is associated with poor outcomes, with a mortality rate of - %. many risk factors for planned extubation failure have been suggested, including hypercapnia at end of spontaneous breathing trial (sbt). however, performing arterial blood gases at the end of sbt is not routinely recommended whereas etco may be routinely monitored during a low pressure support sbt. the aim of this prospective observational study was to determine the clinical usefulness of etco to predict extubation failure. patients and methods we recorded clinical data and etco during a successful h low level pressure support sbt (at the beginning, after min and at the end of the trial). patients ventilated through tracheostomy and unplanned extubations were excluded. extubation failure was defined as death or the need for reintubation within h ( ) after extubation; this delay was prolonged to days ( ) in case of noninvasive ventilation after extubation, which was systematic in older patients or those with cardiorespiratory disease, as per our weaning protocol. multivariable logistic regression analysis was performed to identify independent variables associated with extubation failure. results one hundred and fifteen ventilated patients were enrolled in our study from july to june . the median age of these patients was [ - ] years, their median simplified acute physiology score (saps) ii was [ - ] points and . % (n = ) were female. seventeen ( %) patients had chronic obstructive pulmonary disease. reintubation rate was % (n = ). etco at other time points as well as its changes during the sbt were also similar between groups. the three variables predicting extubation failure in the multivariable logistic regression model were a past medical history of cirrhosis, acute respiratory distress syndrome before weaning and lower minute ventilation at the end of sbt. conclusion etco during a successful sbt seems useless to predict outcome of extubation. introduction airway management in intensive care unit (icu) patients is challenging [ ] . "airway failure", defined as the inability to breathe without endotracheal tube, differs from "weaning failure", defined as the inability to breathe without an invasive mechanical ventilation. however, most of the studies assessing predictive factors of extubation failure did not separate airway from weaning failure. we aimed to describe incidence of extubation failure in critically ill patients, separating for the first time airway from weaning failure, in a prospective multicenter observational study. patients and methods a prospective, observational, multicenter study was conducted in french icus. all adult patients consecutively extubated in icu were included. an ethics committee approved the study design (code uf: , register: -a - ). the study was registered on clinicaltrials.gov (identifier no.nct ). clinical parameters were prospectively assessed before, during and after extubation procedure. extubation failure was defined as the need to reintubate less than h after extubation. extubation failure could be due to airway failure, weaning failure or mixed airway and weaning failure. results from december to may , intubation-procedures were studied in patients from centers. patients ( . %) were intubated twice. the median number of intubation-procedures included by center was . the flow chart of the study is shown in fig. . incidence of extubation failure was . % ( of intubation-procedures). incidence of airway failure, weaning failure and mixed failure were respectively . % ( of ), . % ( of ) and . % ( of ). conclusion extubation failure at h occurred in . % of the extubation procedures recorded, % due to airway failure, % to weaning failure and % to mixed airway and weaning failure. specific risk factors will be determined using this multicenter database. introduction acute on chronic liver failure (aclf) have been recently defined by an acute decompensation of a chronic liver disease associated to organ failure and a high mortality rate. few authors reported on the use of total plasma exchange (tpe) in patients with the current definition of aclf. the aim of this pilot study was to evaluate the efficiency and safety of tpe in critically ill cirrhotic patients admitted with aclf in the icu. patients and methods a prospective cohort of cirrhotic patients admitted to the icu between february and february . tpe was performed using a plasma filter (tpe , hospal ® ) on a cvvhdf machine (prismaflex ® , baxter ® ) connected to the patient with a femoral double lumen f catheter. the plasma volume exchanged per session was . - . of the total plasma volume. ratio and type of fluid replacement were % with % albumin solution followed by % with fresh frozen plasma. clinical and biological parameters, and the following scores meld, sofa, clif-sofa, clif-of and child pugh were evaluated prior, after tpe session and days distant of treatment. results seven male patients with a mean age of . ± . years comprised the study and had a total of tpe sessions. the etiology of cirrhosis was alcoholic (n = ) or post-hcv (n = ). the reasons of aclf were acute alcoholic hepatitis (n = ), variceal bleeding (n = ) and sepsis (n = ). prior to tpe, the mean scores of sofa, clif-sofa, clif-of, meld and child-pugh were respectively . , , . , . and c . . mean total bilirubin prior and after tpe sessions was reduced from . ± . µmol/l to . ± . µmol/l (reduction of . %; p = . e− ); at day , mean total bilirubin was still lower at ± µmol/l (p = . ). mean inr prior and after tpe improved from . ± . to . ± . (reduction of inr of . %, p = . e− ) and at day of treatment at ± . (reduction of %, p = . ). mean ggt levels reduced by . % (p = . ). mean platelet counts ( . ± . g/l) reduced by . % (p = ns). the probability of survival at , and days was . , . and . %. one patient was transplanted and still alive. tolerance during sessions was good similar to cvvhdf. two side effects related to the femoral catheter were observed (bacteremia and hemorrhagic shock post catheter ablation). conclusion this preliminary study of tpe in aclf showed a marked reduction of liver enzymes and improvement in coagulation parameters with a relative good safety. a specific caution should be undertaken regarding catheter related complications. tpe worth to be fig. flow chart of the free-rea study introduction extubation is a key moment for the patient on his way to recovery. extubation failure concerns - % of icu patients and is closely linked to nosocomial pneumonia. the practice concerning enteral feeding interruption at time of extubation has not been investigated. fasting before extubation may prevent aspiration and development of nosocomial pneumonia. thus, fasting and gastric content suctioning before extubation may be reasonably considered as a mean to reduce this burden. fasting before extubation may prevent aspiration and development of nosocomial pneumonia. thus, fasting and gastric content suctioning before extubation may be reasonably considered as a mean to reduce this burden. however, fasting, as recommended before elective general anesthesia is likely to be ineffective in the setting of extubation in the icu, due to patients' gastroparesis and prolonged gastric stasis. beyond the potentially unnecessary burden in terms of paramedical workload, fasting may have some side effects such as caloric deficit, hypoglycemia, or delayed extubation. given the current lack of objective data concerning the clinical practice of feeding/fasting and gastric tube suctioning before extubation in the icu, we undertook this descriptive study to assess current practice. materials and methods we conducted a retrospective, multicenter study in eleven intensive care units in the west of france over a month timespan. all patients extubated were included and data about enteral feeding during the peri-extubation period as well as extubation failure and nosocomial that pneumonia occured within days were recorded. data observed in the eleven participating centers were completed with a short email survey concerning declarative practice performed among intensive care units. results during the study period, patients were included. overall, patients ( %) failed extubation and needed reintubation within the days following planned extubation. pneumonia was significantly more frequent reintubated patients than the other ( vs. %, p < . ). hundred patients ( %) received enteral feeding at the time of extubation. compared to patients who did not receive enteral feeding, those patients had a higher disease severity (sapsii score , [ ; ] vs. [ ; ], p < . ; longer duration of mechanical ventilation [ ; ] vs. . [ ; ] days, p < . ). accordingly, those patients had a higher rate of extubation failure ( vs. %, p = . ) and pneumonia ( vs. %, p = . ). among the patients receiving enteral feeding, fasting was implemented before extubation for patients ( %). similarly, the incidence of pneumonia was not different between groups (n = ( %) vs. n = ( %), p = . ). after extubation, the fasting patients experienced a longer delay until feeding resumption as compared to non-fasting patients ( h [ ; ] vs. [ ; ] ), but this difference did not reach statistical significance. overall gastric content suctioning before extubation was not commonly performed; before extubation: % of the fasting patients and % of the non fasting patients. among the participating centers, while some centers imposed a fasting period before extubation to all their patients, some did it infrequently. however, no center never imposed fasting, illustrating between and within center heterogeneity. this heterogeneity was confirmed on the larger scale declarative email survey ( % response rate amont units) which showed that only % of the units had a written standardized operational procedure for extubation. survey respondents reported to practice fasting before extubation "always", "frequently" and "never or rarely" in respectively , and % of cases. conclusion both practices, fasting as well as pursued nutrition until extubation are commonly performed in icus, with little standardization of practice. safety seems equivalent, as no clinically significant difference in terms of reintubation rate and pneumonia were observed. thus, the equipoise condition appears met to undertake a trial evaluating feeding strategies in the peri-extubation period. introduction noninvasive ventilation (niv) has become a cornerstone for the supportive therapy of acute respiratory failure (arf). survival benefits in chronic obstructive pulmonary disease (copd) and cardiac patients have been demonstrated. although arf and copd patients are at risk of malnutrition that adversely affects patient outcomes, few data are available regarding the management of nutritional support in non-invasively ventilated patients. we sought to describe nutritional management in patients receiving niv as the first line therapy for arf. secondary objectives were to assess the impact of early nutrition use on the need for invasive mechanical ventilation, occurrence of icuacquired pneumonia, length of stay, and death. patients and methods we conducted an observational study from the multicenter french database fed by french icus. our institutional review board approved this study. adult medical patients admitted to the icu and receiving niv for more than days were included. exclusion criteria were patients admitted after surgery, readmitted in icu, patients with neuromuscular disease and treatment-limitation decisions on admission. four groups of patients were defined according to nutrition received during the first days of niv: ( ) no nutrition; ( ) enteral nutrition: patients who received enteral nutrition with or without parenteral nutrition; ( ) parenteral nutrition only ( ) oral nutrition only. the impact of nutrition on day- mortality was assessed through the use of a cox model adjusted on clinically relevant covariates. the impact of nutrition on other secondary end-point i.e. icu-acquired pneumonia occurrence, need for invasive mechanical ventilation were assessed using a fine & gray models. patients were censored after days of follow-up. choice among collinear variables was performed considering clinical relevance, rate of missing variables and reproducibility of definitions. results were given as hazard ratio (hr) for cox models and subdistribution hazard ratios (shr) and % confidence intervals (ci). the impact on duration of stay was estimated by a multivariate poisson regression. p values less than . were considered as significant. statistical analysis was performed using sas . (cary, nc). results during the study period, , patients were included in the database and met inclusion criteria. among them, received no nutrition; received enteral nutrition, received parenteral nutrition only, and received oral nutrition only. overall, patients developed icu-acquired pneumonia ( %), required invasive mechanical ventilation ( . %) and died before day- ( %). median length of stay was days [ ; ]. after adjustment for confounders, type of nutrition support was associated with an increase day- mortality (p = . ). compared to oral nutrition, enteral nutrition was associated with an increase day- mortality [shr . , % ci . - . ; p = . ] whereas parenteral nutrition and no nutrition did not influence this outcome. the type of nutrition was not associated with the occurrence of icu-acquired pneumonia (p = . ). however, patients who received enteral nutrition experienced more frequently icu-acquired pneumonia [shr = . , % ci . - . ; p = . ] as compared to oral nutrition patients. ventilator free days within the days were negatively associated with the type of nutrition (p < . ). compared to oral nutrition, parenteral and enteral nutrition were negatively associated with ventilator free days within the days [rr per day = . , % ci . - . ; p < . and rr per day = . , % ci . - . ; p < . ]. delta paco measured between the first days was not associated with any type of nutrition. conclusion more than half the patients receiving niv were fasting within the first two niv days. oral nutrition was prescribed for onethird of them and was well tolerated. lack of feeding or underfeeding had no impact on mortality and ventilator free days within the days. however, enteral nutrition was associated with an increased occurrence of icu-aquired pneumonia and a higher mortality rate. was high, caloric debt during temporary ecls was low in comparison with previous results [ ] . overnutrition was frequent in the nec group and would justify implementation of nutrition protocol. incidence of gi intolerance remains frequent and could justify systematic used of motility agents with introduction of en. conclusion enteral nutrition in patients treated with temporary extracorporeal life support is feasible and may be improve with systematic motility agents and implementation of nutritional protocol. introduction cardiac surgery with cardiopulmonary bypass (cpb) is associated with a generalized inflammatory response with concomitant immune paresis which predisposes to the development of postoperative infections and sepsis ( ) . lymphocytes are essential agents of innate and adaptive immune responses during infections or inflammation processes. lymphopenia has been associated with immune dysfunction during septic shock, and it has been shown that low absolute lymphocyte count was predictive of postoperative sepsis ( ) . furthermore, impaired lymphocyte function probably occurs after cpb. thus, we investigated mechanisms involved in postoperative lymphopenia and impaired lymphocyte function after cpb. the aims of this study were: ) to describe a potential relationship between lymphopenia and occurrence of postoperative infections. ) to demonstrate that cpb induces lymphocytes apoptosis. ) to demonstrate that cpb impaired lymphocyte function (ability to proliferate). ) to demonstrate that il- , pd-l (programmed cell death ligand ) and indoleamine , -dioxygenase (ido) could be interesting targets to restore lymphocyte ability to proliferate after cpb. patients and methods blood cell counts with differentials obtained within the first postoperative week were analyzed in patients undergoing cardiac surgery in . postoperative lymphopenia was defined as a lymphocyte count < . × cells l − . postoperative infections were defined following cdc criteria. study procedures: the following analysis were performed before (t ) and h after (t ) cardiac surgery with cpb: lymphocyte apoptosis; t-cell proliferation ability following polyclonal stimulation; hla-dr and pd-l expression on monocytes; plasma ido activity and il- levels; and the ability of lymphocytes to undergo a clonal proliferation when stimulated using specific inhibitors of il- and ido. the study was approved by our local ethics committee. patients were informed of the observational nature of the study and gave their consent. . early lymphopenia after cpb was associated with the occurrence of postoperative infection: postoperative infections occured with a median delay of days. patients who developed postoperative infections had a significantly lower lymphocyte count at day , day and day than patients without postoperative infections. . cpb induced lymphocyte apoptosis and decreased t-cell proliferation ability. . cpb during cardiac surgery decreased mhla-dr expression. . cpb increased ido activity, pd-l expression and il- plasma levels. . il- or pd-l inhibition of inhibition could restore ability of lymphocytes to proliferate, although ido inhibitors did not show any effect. we provided new evidences that cpb induces immunosuppression. we also demonstrated that il- and pd-l could be interesting targets to restore ability of lymphocytes to proliferate. as maintaining mv during cpb decreased plasmatic levels of il- , our study brings new evidences that ventilator strategies could be of interest to decrease postoperative infections. respectively . % (n = ), . % (n = ) and . % (n = ) of the included patients. mortality was of . % in the overall population (n = ) and was higher in neutropenic patients ( . vs. . % in non-neutropenic patients; p < . ). neutropenia was independently associated with poor outcome when adjusted for underlying malignancy, allogeneic stem cell transplantation and severity as assessed by organ support (or . ; % ci . - . ). mortality decreased progressively over time in both non-neutropenic (from to %; p < . ) and in neutropenic patients (from to %; p < . ). when adjusted for confounders, admission during a more recent period was independently associated with favourable outcome and did not change the final model. conclusion this preliminary analysis suggests a meaningful survival in neutropenic critically ill cancer patients despite an independent association between neutropenia and mortality. additional analyses are on-going in order to adjust for study weight, heterogeneity across studies, assess the influence of neutropenia duration or g-csf use, and confirm the influence of neutropenia in a predefined subgroup of patients. introduction candida bloodstream infections (cbi) are frequent and increasing in hospitalized patients, especially in intensive care units. considering the results of some experimental in vitro and animal studies, it seems that yeasts belonging to candida genus are able, so as to survive, to modulate the immune response of the host by guiding t cells polarization to th profile. th and th cytokines are known to be involved in host defense against cbi. however, these data are mainly experimental or collected after candidemia. the aim of this study is to precise kinetic of cytokines network during human cbi. this was an ancillary study of an institutional project dedicated to pathophysiology of candidiasis. we have included patients with candidemia and controls ( matched hospitalized controls and healthy subjects). the sera of cases were gathered before (almost days before), during and after the isolation of yeasts from blood culture, defined as day (d ). quantitative analysis of cytokines by luminex ® technology and of ( , )-β-d-glucans by fungitell ® test were performed on samples. the amplitude of th profile response was expressed by summing the amount of the most relevant cytokines for th , th and th profiles, in pg/ ml. for each patient, the highest level of response was considered as %. results are expressed for the population by means of the results. we then performed univariate analysis (fischer exact test for qualitative variables, mann-whitney and wilcoxon test for quantitative variables, spearman for correlation; graphpad prism v software) and a multidimensional analysis by principal component analysis (pca; igorpro software). results patients with candidemia exhibited an increase in proinflammatory cytokines (ifnγ, tnfα and il- ), in comparison with the anti-inflammatory cytokines (il- and il- ) before d (p = . ) in univariate analysis. the ratio between mean values reverses at d and d (p = . ) and the increase of th response level from d to d is correlated to the decrease of th response (r = − . ; p = . ) in univariate analysis and pca. a pro-inflammatory response (th ) is associated with a reduced mortality (rr = . [ . ; . ]) and with a lower β-d-glucans levels (p < . ). discussion we describe here a dynamic cytokine profiles in response to candidemia. pro-inflammatory response predominates before d and reverses after. this is contradictory to the postulate that an antiinflammatory background could predispose to invasive candidiasis in icu patients and exhibiting a "post-infectious immune suppression conditions". but the relative deficiency in th response compared to simultaneous anti-inflammatory cytokines secretion observed after cbi is in accordance with experimental data, suggesting the modulation of the immune response by candida. the link between cytokinic profile and mortality can also raise the hypothesis of an influence by genetic factors on the regulation and direction of the immune response and so, the existence of a high-risk population. conclusion these data suggest a relation between candida and the orientation of the immune response towards a pattern deleterious for the infected host. this could allow to determine the most relevant cytokines varying during cbi. they could be used as biomarkers to identify the patients who could benefit from an early treatment in a preemptive targeted therapeutic strategy. these data will be paralleled to genetic background and to circulating candida derived molecules to precise the relative part of the host and the pathogen in this complex interaction. introduction lung ultrasound is widely used in intensive care, ermergency and pneumology medicine, for assessing acute respiratory pathologies. it is noninvasive, radiation free and rapidly available at the patient's bedside and provides an excellent accuracy. so, lung ultrasound may be an interesting tool for the physiotherapist as it allows to assess with more accuracy the patient improving the chest physiotherapy indication and monitoring ( ) . as far as we are aware, no study has evaluated the impact of lung ultrasound on clinical-decision making by physiotherapists in the use of chest physiotherapy. this case report highlights the lung ultrasound interest in chest physiotherapy in patient with lung consolidation. patients and methods this was a case report written following the recommendations of the care guideline ( ). the case was a -years-old female patient, non intubated, hospitalized in a respiratory icu. she was hypoxemic (pao = mmhg and sao = %), with dyspnoea at rest and an increasing radiological opacity at the right lung base. hypoxemia was the indication for physiotherapist referral. at the clinical examination, the physiotherapist's findings were: decreased mobility, dullness and abolished vesicular sound at the base of right hemithorax. this clinical examination and chest x-rays analysis allowed the physiotherapist to propose several clinical hypotheses: pleural effusion, obstructive atelectasis or pneumonia. the chest physiotherapy treatment differs according to the type of lung deficiencies. for example, the physiotherapist must to refer the patient to the medical staff in case of pleural effusion or may implement hyperinflation technique in case of obstructive atelectasis. determining the nature of lung deficiencies is essential to provide the more suitable therapeutic strategy. so, the physiotherapist decided to perform a lung ultrasound examination to retain the more likely hypothesis. results ultrasound examination performed by the physiotherapist highlighted the presence of a lung consolidation at the infero-lateral and posterior parts of the right lung with a pneumonia pattern: presence of tissue-like sign, shred sign, dynamic air bronchogram and fluid bronchogram. the medical staff implemented antibiotic treatment. the ultrasound findings guided the physiotherapist to choose chest physiotherapy technique improving the alveolar recruitment: nearly prone position (left side down) and continuous positive airway pressure during min. the patient response to the treatment was monitored by ultrasound and showed a decrease of the lung consolidation size and apparition of b lines, meaning a gain of lung aeration. these findings were associated with spo improvement but without decrease of dyspnoea. discussion lung ultrasound allowed the physiotherapist to precise the nature of the radiological lung opacity. as it is more accurate than clinical examination or chest x-ray, this suggests a more suitable choice of chest physiotherapy techniques than conventional clinical decision-making process. ultrasound findings suggested a positive response to the chest physiotherapy treatment. the apparition of re-aeration signs (b lines, decreased consolidation size) showed a short-term efficacy of the chest physiotherapy treatment. this allowed the physiotherapist to continue the treatment during week and obtain a substantial clinical improvement. conclusion the use of lung ultrasound in the clinical decision-making process may help the physiotherapist to choose with more accuracy the therapeutic strategy. moreover, it allows to monitor the treatment in real-time and assess the patient's response. the use of this tool may allow the physiotherapist to determine the optimal indications for chest physiotherapy and thus avoid unnecessary or inappropriate treatments. introduction critical illness together with immobilization have deleterious effects on patients outcome, especially in the presence of sepsis. increased muscle catabolism and membrane inexcitability reduce muscular mass and impair function within the first days after sepsis onset ( ). early mobilization could potentially limit muscle wasting and functional impairment in this population. the purpose of this study was to test whether exercise during the early phase of sepsis is safe and beneficial and to which extent it can limit skeletal muscle protein catabolism and preserve function. patients and methods adult patients admitted with the diagnosis of severe sepsis were included and randomly allocated to two groups; ) control group (ctrl-g): manual passive/active manual mobilization twice a day or ) experimental group (exp-g): additional two times min of passive/active cycling exercise. both groups benefited from a reduced sedation, adjusted nutritional intake and bed to chair transfer as soon as possible. skeletal muscle biopsy and electrophysiological testing were realized at day- and day- . muscle histology, biochemical and molecular analyses of anabolic/catabolic and inflammatory signalling pathways were performed. a group of four healthy subjects was used to obtain non pathological values. hemodynamic parameters and patients perception were collected during each session. results twenty-one patients were included, however died before the second muscle biopsy. ten patients in ctrl-g and nine in exp-g were finally analysed. muscle fibre cross sectional area (µm ) was significantly preserved by exercise (relative changes were ctrl-g: − ± % vs exp-g: ± %, p = . ). markers of catabolic systems were highly increased during sepsis compared to healthy subjects and reduced in both groups days after admission. however the reduction in mrna (relative change) tended to be more important in exp-g: murf- (ctrl-g: − ± % vs exp-g: − ± %, p = . ), mafbx (ctrl-g: − ± % vs exp-g: − ± %, p = . ), lc b (ctrl-g: ± % vs exp-g: − ± %, p = . ) and bnip (ctrl-g: ± % vs exp-g: − ± %, p = . ). anabolic and inflammatory markers were not affected by exercise. electrophysiological testing, including direct muscular stimulation, was abnormal on day- in of evaluated patients. since only a limited number of patients could be reassessed a second time, comparison between groups was not possible. in general, all activities were well tolerated by patients with no adverse events. the pulmonary auscultation is used by respiratory therapist (rt) to evaluate the efficiency of a treatment. listen to the noises coming from the primary bronchi (pb) is important because it is the place where secretions can be accumulated. therefore, it is crucial to know exactly where to place the stethoscope's chestpiece on the chest. few studies have analyzed the chest area where the pb were located. our hypothesis is that pb are localized on a line that joins axillary fossa (bi-axillary line: bal). the aim of our study is to evaluate the probability to find the primary bronchi by analysis of chest radiography. patients and methods a retrospective study was performed by analysis of chest x-ray using the software: tm reception ® , which allows precise measures to the tenth of millimeter. all the x-rays were made on confined to bed patients hospitalized within intensive care unit, internal medicine and abdominal surgery rooms. the following measures (in mm) were made between: the exclusion criteria were: bmi < . kg/m and bmi > kg/m , scoliosis, minor patient, lack of visibility of one of the axillary fossa, lack of visibility of pb, clavicular asymmetry, kyphosis, lack of symmetry in the shot, atelectasis and pneumothorax. statistics: normality test: ks. mean values are expressed with their sd and % ci. discussion in this study, we performed analysis of chest x-rays of bedridden patients and we demonstrated that it is possible to localize easily, on either side of the bs, the right and left pb at ± mm distance (lp) above a line joining axillary fossa. this study constitutes a new tool for the rt who, by using stethoscope with a chestpiece of cm surface area, will be able to listen to noise coming from pb. conclusion the data presented herein (fig. ) show that right and left pb are located at a mean distance of (± ) mm and (± ) mm above the bal, on both sides of the bs. the bal represents thus an easy and precise mode to detect right and left pb by bedridden. finally, the distance between the hyoid bone and the sc is about cm. as the pb are located after the bifurcation, this information constitutes another useful way for the localization the right and left pb by bedridden patient. introduction critically ill patients frequently develop muscle weakness, which is associated with prolonged intensive care unit and hospital stay ( ). this randomized controlled trial (clinical trials nct ) was designed to investigate whether a daily training session using a tilt table, started early in stable critically ill patients with an expected prolonged icu stay, could improve strength at icu and hospital discharge compared to a standard physiotherapy program. the study protocol was approved by an ethics committee and informed consent was obtained from all patients. patients admitted in adult icu of marie lannelongue hospital, france, who were mechanically ventilated for at least days were included. exclusion criteria were cerebral or spinal injury, pelvic or lower limb fracture. patients were assessed each day for temporary contraindications for mobilization out of bed (rass score <− or > ; hemodynamic instability; a continuous intravenous dose of epinephrine/ . no significant difference was observed in terms of mrc score or in terms of pts with or without weakness (mrc > ) at icu or hospital discharge. however, the number of pts with weakness was significantly higher in the group before tilt mobilization, suggesting a more rapid improvement in the tilt group. the icu and hospital lengths of stay were not different between groups. discussion the prevalence of muscle weakness in our population is high before mobilization ( . %, % ci . - . ), is still . % at icu discharge but represents only ~ % at hospital discharge. this low hospital discharge prevalence is probably related to the early and intense physiotherapy in both groups, which may explain our inability to demonstrate superiority of the addition of tilt table positioning, although a faster recovery is suggested. conclusion training sessions using a tilt table, in addition to early and intense physiotherapy did not improve muscle strength evaluated using mrc score in surgical icu patients with muscle weakness. proposed modifications to the duke criteria for the diagnosis of infective endocarditis quantifying the relationship between staphylococcus aureus bacteremia and s. aureus bacteriuria: a retrospective analysis in a tertiary care hospital recommandations formalisées d'experts «prise en charge des infections intra-abdominales strategies to reduce curative antibiotic therapy in intensive care units (adult and paediatric) risk factors for developing esbl e. coli: can clinicians predict infection in patients with prior colonization? kdigo clinical practice guideline for acute kidney injury citrate anticoagulation for continuous venovenous hemofiltration benefits and risks of furosemide in acute kidney injury national nosocomial infections surveillance (nnis) system report, data summary from prospective evaluation of the risk factors, etiology and the antimicrobial susceptibilities of the isolates in nosocomial bacteriemic patients unrecognized endobronchial intubation of emergency patients endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial nosocomial infections in a burn intensive care unit outcomes of critically ill cancer patients in a university hospital setting outcome and prognostic factors of lung cancer patients admitted to the medical intensive care unit intensive care of the cancer patient: recent achievements and remaining challenges chronic critical illness the epidemiology of chronic critical illness in the united states designing and conducting a cluster-randomized trial of icu admission for the elderly patients: the ice-cub study estimation de la mortalité maternelle en france: une nouvelle méthode emergency postpartum hys-terectomy for uncontrolled postpartum bleeding music interventions for mechanically ventilated patients effets de la musicothérapie en réanimation hors sédation chez des patients en cours de sevrage ventilatoire versus des patients non ventilés. annales françaises d' anesthésie et de réanimation evaluation of a low-flow oxygen-conserving nasal cannula performance of six types of oxygen delivery devices at varying respiratory rates high-flow oxygen through nasal cannula in acute hypoxemic respiratory failure international study of the prevalence and outcomes of infection in intensive care units medical intensive care urinary and serum biomarkers for the diagnosis of acute kidney injury: an in-depth review of the literature diagnostic strategies for renal impairment in the intensive care unit recommendations formalized expert acute renal failure in the perioperative and intensive care (excluding extrarenal purification techniques) frutos-vivar f. comparison of the berlin definition for acute respiratory distress syndrome with autopsy the presence of diffuse alveolar damage on open lung biopsy is associated with mortality in patients with acute respiratory distress syndrome: a systematic review and meta-analysis ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome alveolar macrophages contribute to alveolar barrier dysfunction in ventilator-induced lung injury references . akoumianaki e. mechanical ventilation-induced reverse-triggered breaths: a frequently unrecognized form of neuromechanical coupling neuromuscular blockers in early acute respiratory distress syndrome driving pressure and survival in the acute respiratory distress syndrome mortality and pulmonary mechanics in relation to respiratory system and transpulmonary driving pressures in ards organ donation, reasons for family refusal: a retrospective study in a french organ harvesting center - du avril relative aux droits des malades et à la fin de vie comité consultatif national d'ethique c. fin de vie, autonomie de la personne, volonté de mourir reliability, validity, and health issues arising from questionnaires used to measure psychosocial and organizational work factors (powfs) among hospital nurses: a critical review aging and death signalling in mature red cells: from basic science to transfusion practice most reliable indices in differentiation between thalassemia trait and iron deficiency anemia stratification du risque dans l'embolie pulmonaire aiguë.realites cardiologiques • n° -cahier • septembre european resuscitation council guidelines for resuscitation : section . executive summary breakthrough in cardiac arrest: reports from the th paris international conference changing use of noninvasive ventilation in critically ill patients: trends over years in francophone countries noninvasive mechanical ventilation in acute respiratory failure: trends in use and outcomes high-flow oxygen through nasal cannula in acute hypoxemic respiratory failure failure of noninvasive ventilation for de novo acute hypoxemic respiratory failure: role of tidal volume réanimation médicale polyvalente, hôpital de la source early identification of patients at risk for difficult intubation in the intensive care unit: development and validation of the macocha score in a multicenter cohort study clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study profound and persistent decrease of circulating dendritic cells is associated with icu-acquired infection in patients with septic shock intensive care med specific mait cell behaviour among innate-like t lymphocytes in critically ill patients with severe infections a -level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin prognostic value of relative adrenal insufficiency during cardiogenic shock: a prospective cohort study with long-term follow-up. shock calcium supplementation during sepsis exacerbates organ failure and mortality via calcium/calmodulin-dependent protein kinase signaling hypocalcemia in critically ill patients diabetic ketoacidosis traps joint british diabetes societies guideline for the management of diabetic ketoacidosis peter radermacher , for the hyper s investigators and reva research network réanimation médicale, hôpital henri mondor réanimation medico-chirurgicale, hopital avicenne institut für anästhesiologische pathophysiologie und verfahrensentwicklung département de réanimation médicale et de médecine hyperbare, c.h.u. d' angers, angers, france; service de réanimation médico-chirurgicale réanimation médico-chirurgicale, assistance publique -hôpitaux de paris, hôpital ambroise paré, boulogne-billancourt, france; service de réanimation adulte quantitative measurement of heparin in comparison with conventional anticoagulation monitoring and the risk of thrombotic events in adults on extracorporeal membrane oxygenation elso guidelines for cardiopulmonary extracorporeal life support, version . . ann arbor: extracorporeal life support organization early and late outcomes of consecutive adult patients treated with extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock the french sf- health survey: translation, cultural adaptation and preliminary psychometric evaluation weaning of extracorporeal membrane oxygenation using continuous hemodynamic transesophageal echocardiography predictors of successful extracorporeal membrane oxygenation weaning after assistance for refractory cardiogenic shock extracorporeal membrane oxygenation in the adult: a review of anticoagulation monitoring and transfusion back from irreversibility: extracorporeal life support for prolonged cardiac arrest microcirculatory perfusion is preserved during off-pump but not on-pump cardiac surgery extracorporeal membrane oxygenation causes loss of intestinal epithelial barrier in the newborn piglet the pulsatile perfusion debate in cardiac surgery: answers from the microcirculation? a meta-analysis of complications and mortality of extracorporeal membrane oxygenation impact of fluid balance on outcome of adult patients treated with extracorporeal membrane oxygenation cumulative fluid balance and mortality in septic patients with or without acute kidney injury and chronic kidney disease comparison of two fluid-management strategies in acute lung injury renal function and survival in patients undergoing ecmo therapy extracorporeal membrane oxygenation and the kidney plasma concentrations of inflammatory cytokines rise rapidly during ecmo-related sirs due to the release of preformed stores in the intestine in-hospital mortality and successful weaning from venoarterial extracorporeal membrane oxygenation: analysis of patients using a national inpatient database in japan is the . % rate of in-hospital mortality in patients receiving venoarterial extracorporeal membrane oxygenation really that high? predicting survival after ecmo for refractory cardiogenic shock: the survival after veno-arterial-ecmo (save)-score outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock usefulness of cardiac biomarkers to predict cardiac recovery in patients on extracorporeal membrane oxygenation support for refractory cardiogenic shock etiology of troponin elevation in critically ill patients esc guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the european society of cardiology (esc) accf/aha guideline for the management of heart failure: a report of the american college of cardiology foundation/american heart association task force on practice guidelines nearhanging injuries: a -year experience unité de réanimation neurologique s rapid diagnosis of bacterial meningitis using a point-of-care glucometer geoffroy rousseau service d'information médicale, epidémiologie et economie de la santé guillain-barré syndrome outbreak associated with zika virus infection in french polynesia: a case-control study early predictors of mechanical ventilation in guillain-barré syndrome paediatric prolonged mechanical ventilation: considerations for definitional criteria cardiac filling volumes versus pressures for predicting fluid responsiveness after cardiovascular surgery: the role of systolic cardiac function respiratory variation in aortic blood flow peak velocity to predict fluid responsiveness in mechanically ventilated children: a systematic review and meta-analysis. pediatr anesth effect of prone and supine positions on functional residual capacity, oxygenation, and respiratory mechanics in ventilated infants and children positioning effects on lung function and breathing pattern in premature newborns l'accident vasculaire ischémique en pédiatrie. quand y penser -quoi faire outcomes of early decompressive craniectomy versus conventional medical management after severe traumatic brain injury: a systematic review and meta-analysis myocardial dysfunction evaluation in pediatric brain death donor service de régulation et d'appui, agence biomedecine prone position for acute respiratory failure in adults prone positioning in severe acute respiratory distress syndrome effects of the prone position on respiratory mechanics and gas exchange during acute lung injury does prone positioning increase intracranial pressure? a retrospective analysis of patients with acute brain injury and acute respiratory failure prone position in mechanically ventilated patients with reduced intracranial compliance maud loiselle -maud.loiselle@outlook.fr annals of intensive care boulogne-billancourt, france; réanimation polyvalente adulte, centre hospitalier intercommunal andré grégoire, montreuil, france; réanimation médicale an audit of intensive care unit recyclable waste s point of care ultrasonography: is there a place for pocket size ultrasonography devices? gabriel preda , vincent dubée , naïke bigé eric maury -ejhmaury@gmail.com annals of intensive care outcome, functional autonomy, and quality of life of elderly patients with a long-term intensive care unit stay berlin: springler; . s icu nurses' perception of end-of-life decision making: a french multicenter survey akli chermak , alexandre lautrette ap-hp) anesthésie réanimation et traitement chirurgical des grands brûlés réanimation médicale hôpital d'instruction des armées percy correspondence: fanny.ardisson@gmail.com (fanny ardisson) annals of intensive care circulating mitochondrial damps cause inflammatory responses to injury rage is a nucleic acid receptor that promotes inflammatory responses to dna beneficial hemodynamic effects of prone positioning in patients with acute respiratory distress syndrome stard : an updated list of essential items for reporting diagnostic accuracy studies towards complete and accurate reporting of studies of diagnostic accuracy: the stard initiative s neurological impairment in cirrhotic patients admitted to icu: hepatic versus drug-induced encephalopathy unité de soins intensifs d'hépatogastroentérologie réanimation polyvalente, hôpital de mercy, ars laquenexy, france; réanimation médicale, centre hospitalier universitaire d' angers, angers, france; réanimation médicale cerebrospinal fluid findings after epileptic seizures effect of epileptic seizures on the cerebrospinal fluid-a systematic retrospective analysis s synek score and nse to predict poor neurological outcome after cerebral anoxia and therapeutic hypothermia réanimation médicale correspondence: dimitri titeca beauport -titeca.dimitri@chu-amiens.fr annals of intensive care guidelines for the management of severe traumatic brain injury. vi. indications for intracranial pressure monitoring reduced mortality rate in patients with severe traumatic brain injury treated with brain tissue oxygen monitoring s organ procurement and kidney transplantation under maastricht condition (m ): update on year of activity coordination prélèvements organes s reference . conditions à respecter pour réaliser des prélèvements d'organes sur les donneurs décédés après arrêt circulatoire de la catégorie iii de maastricht dans un établissement de santé. agence de la biomédecine. version n° mai crcl by cockroft-gault, mean (ml/mn delayed graft function, n (%) ( . %) réanimation médico-chirurgicale infectious diseases society of america. guidelines for the management of adults with hospital acquired, ventilator-associated, and healthcare-associated pneumonia reducing ventilator-associated pneumonia in intensive care: impact of implementing a care bundle chiche@aphp.fr annals of intensive care national nosocomial infections surveillance system. national nosocomial infections surveillance (nnis) system report, data summary from critères d'infection chez les brulés unité d'épidémiologie et recherche clinique international study of the prevalence and outcomes of infection in intensive care units risk and prognostic factors of ventilator-associated pneumonia in trauma patients ventilator-associated pneumonia: never enough, never give up! sahar habacha , bassem chatbri , aymen m'rad , youssef blel , nozha brahmi sahar habacha -sahar.habacha@gmail.com annals of intensive care weaning patients from the ventilator automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children: a cochrane systematic review and meta-analysis unité de réanimation et de surveillance continue, service de pneumologie et réanimation médicale noninvasive ventilation and weaning in patients with chronic hypercapnic respiratory failure: a randomized multicenter trial risk factors for extubation failure in patients following a successful spontaneous breathing trial s a multicenter prospective observational study of extubation procedures in intensive care units: the free-rea study audrey de jong -audreydejong@hotmail.fr annals of intensive care early identification of patients at risk for difficult intubation in the intensive care unit: development and validation of the macocha score in a multicenter cohort study faouzi saliba -faouzi.saliba@pbr.aphp.fr annals of intensive care réanimation médicale polyvalente, hôpital de la source mickael landais -mickaelandais@gmail.com annals of intensive care perioperative fasting in adults and children: guidelines from the european society of anaesthesiology the decision to extubate in the intensive care unit service de réanimation médicale s refeeding hypophosphoremia in a medical critical care unit: -month observational study gioia gastaldi -gioia.gastaldi@chu-rouen.fr annals of intensive care refeeding hypophosphatemia in critically ill patients in an intensive care unit. a prospective study refeeding syndrome: problems with definition and management biosit and inserm u , faculte de medecine, université rennes immune dysfunction after cardiac surgery with cardiopulmonary bypass: beneficial effects of maintaining mechanical ventilation s influence of neutropenia on mortality of critically ill cancer patients: results of a systematic review on individual data quentin georges brazil; department of critical care medicine and division of pulmonary and critical care medicine united kingdom; department of intensive care centre d'infection et d'immunité de lille equipe -basic and clinical immunity of parasitic di delta nlr") were calculated. statistical analysis used appropriate non parametric tests and cox regression for survival analysis. the ability of the variables to discriminate survivors from non-survivors was determined using roc curves results during the study period, cirrhotic patients were admitted in icu. the etiologies of liver cirrhosis were alcoholic in % of cases with severe score: median child-pugh score = %) deaths after icu discharge during the same hospitalization. nlr decreased for survivors between d and d univariate analysis, for predicting survival, higher values of nlrd , delta nlr, meld score at admission, sofa score at admission and at day and delta sofad -d were significant factors. predictors of death in multivariate analysis are shown in fig. . area under delta nlr roc conclusion the blood nlr is a novel inflammation index that has been shown to independently predict poor clinical outcomes. we have demonstrated that delta nlr is an independent predictor of mortality in critically ill cirrhotic patients the association between the neutrophil-to-lymphocyte ratio and mortality in critical illness: an observational cohort study gene-and exon-expression profiling reveals an extensive lps-induced response in immune cells in patients with cirrhosis celine dupre -duprecece@gmail.com annals of intensive care diagnostic accuracy of procalcitonin in critically ill immunocompromised patients the role of pattern-recognition receptors in innate immunity: update on toll-like receptors esm- is a novel human endothelial cell specific molecule expressed in lung and regulated by cytokines thoracic ultrasound: potential new tool for physiotherapists in respiratory management. a narrative review the care guidelines: consensus-based clinical case reporting guideline development department of physical medicine and rehabilitation icu-acquired weakness and recovery from critical illness o where should we place the stethoscope's chestpiece to hear the noise of the primary bronchi? frédéric duprez , bastien dupuis , grégory cuvelier , thierry bonus frédéric duprez -dtamedical@hotmail.com annals of intensive care o aerosol delivery using two nebulizers through high flow nasal cannula: a randomized cross-over spect-ct study correspondence: jonathan dugernier -jonathan.dugernier@uclouvain.be annals of intensive care introduction in , an international consensus conference took stock of the various measures to be implemented for the prevention of ventilator acquired pneumonia (vap) [ ]. these measures are often gathered in groups of or under the term of "ventilator-bundle. " the effectiveness of these "bundles" was poorly evaluated in african environment. objective to establish a vap prevention program and assess its impact on morbidity and mortality of patients under mechanical ventilation in our service. patients and methods prospective, mono centric, quasi-experimental before-after study. it took place in the intensive care unit of the university clinics of kinshasa in the democratic republic of congo (drc). this service is equipped with beds and a respirator for two beds. the observational period (phase ) was carried out from february st to december st, and the intervention period (phase ) from february st, to february st, . all consecutive patients intubated and mechanically ventilated for more than h were included. five preventive measures were held: hand hygiene, the elevation of the head of the bed at °- °, the daily lifting of sedation, oral decontamination with chlorhexidine and control cuff pressure of the endotracheal tube. compliance with this bundle was assessed by direct observation without the knowledge of caregivers. the diagnosis of "vap" was held before a clinically modified sore (m cpis) > . the main outcomes were the incidence of vap and mortality. the protocol for this study was approved by the ethics committee of the school of public health of the university of kinshasa, under the approval number: esp/ec/ / .introduction nosocomial infections (ni) are common in burn patients due to the loss of the first line of defense against microbial invasion, immunocompromising effects of burn injury, and invasive diagnostic and therapeutic procedures. the objective of this study was to identify the incidence of nosocomial infection (ni), the pathogens and their antibacterial patterns, and prognosis of these burn patients. patients and methods a retrospective study was conducted in a bed intensive burn care unit during months. patients were eligible for the study, if they met the following criteria: total burn surface area (tbsa) > %, length of icu stay ≥ h, and infected in accordance with the criteria of the national nosocomial infections surveillance (nnis) and the criteria of the sfetb [ ][ ]. in this study, nis were classified into four main groups: pneumonias, bloodstream infections (bsi), catheter related infections (cri), and urinary tract infections (uti). for included patients, skin levy, blood cultures, urine and sputum cultures were drawn during fever or clinical features of sepsis. results during the -month study period, patients were admitted to the icu, patients were included ( . %). were male and female. the mean age was ± yr. the mean tbsa was ± %. % were admitted from another hospital. burn injuries were due to domestic accidents in % and self immolation in %. the mean none. none. none. none. none. none. none. none. none. none. ann. intensive care , (suppl ): none. none. none. none. none. none. none. none. none. none. none. none. none. none. none. none. none. none. none. consulting activities with fisher & paykel. none. none. none. none. none. none. none. none. none. none. none. none. none. none. none. none. none. none. none. failure extubation in intensive care unit: risk factors, incidence and evaluation of a mechanical ventilator weaning protocol lucie petitdemange , anne sophie guilbert none. none. none. none. none. none. opportunistic infections in patients with solid tumors: a systematic review julien poujade , elie azoulay none. invasive aspergillosis in non-immunocompromised patients hospitalized intensive care unit guillaume trumpff , max guillot , thierry braun , ralf janssen-langenstein , marie-line harlay , jean-etienne herbrecht introduction characteristics and outcomes of adult patients with invasive aspergillosis in intensive care unit have rarely been described. we performed a retrospective study on consecutive adult patients with invasive aspergillosis who were admitted form january through january to the intensive none. noorah zaid , nawel ait-ammar , christine bonnal , jean-claude merle , francoise botterel , eric levesque anesthesia and intensive care medicine, chu henri mondor, créteil, france; unité de parasitologie-mycologie, département de virologie, bactériologie-hygiène, parasitologie, hopital henri mondor, créteil, france correspondence: eric levesque -eric.levesque@aphp.fr annals of intensive care , (suppl ):s introduction liver transplant recipients have high rate of invasive fungal disease (ifd) with high morbidity and mortality, in part due to its delayed diagnosis. the fungal cell wall component ( , )-betad-glucan (bg) is a biomarker for fungal infection but its utility remains uncertain. this prospective study was designed to review our experience in ifd and to evaluate the impact of bg in the diagnosis of ifd. patients and methods from january to may , liver transplantation were performed in our institution. serum samples were tested for bg (fungitell; cape cod inc., usa) least weekly between liver transplantation and their discharge from hospital. ifd was defined as proposed by the european organization for research and treatment of cancer/mycoses study group. results nineteen patients ( %) were diagnosed with ifd including cases of candidiasis infection (ci) in eleven out of patients, invasive pulmonary aspergillosis (including one who had previously ci) and one case of septic arthritis of the hip caused by scedosporium spp. ifd was associated with significantly high mortality (log-rank p = . ). the area under the roc curves, for bg to predict ifd, was . ( % ci . - . ). using a cutoff of pg/ml, the most discriminative cut-off point from the roc curve, the sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) values of bg for overall ifd was % ( % ci, - ), % ( % ci, - ), % ( % ci, - ) and % ( % ci, - ). conclusion based on its high npv, bg value appears to be a good biomarker to rule out the diagnosis of ifd when the value is below pg/ml. a single point bg may guide the investigation and the decision to start antifungal therapy in patients at risk for ifd. none. monitoring of changes in lung and chest wall mechanics in the supine, lateral and prone positions during the prone positioning maneuver in ards patients zakaria riad , mehdi mezidi , hodane yonis , mylène aublanc, , sophie perinel-ragey, , floriane lissonde , aurore louf-durier, , romain tapponnier , jean-christophe richard , bruno louis, , claude guérin , plug working group réanimation médicale, hôpital de la croix-rousse, lyon, france; inserm, u , equipe , équipe biomécanique cellulaire et respiratoire, université paris-est créteil -faculté de médecine, créteil, france correspondence: zakaria riad -zakaria.riad@icloud.com annals of intensive care , (suppl ):s none. introduction systemic rheumatic diseases (srd) are autoimmune diseases that are rare but cause substantial morbidity and mortality. srds chiefly affect the lungs, however, data on critically ill patients with srd admitted for arf are scarce. patients and methods retrospective cohort conducted in french icus ( . the major comorbidities were cardiovascular ( %), tobacco exposure ( %), chronic kidney disease ( %) and neoplasia ( %). two-thirds of patients were on systemic corticosteroids at admission, the median dose of (iqr) mg per day. srd diagnosis was made in the icu in . % of patients. clinically or microbiologically documented bacterial pneumonia was the leading arf etiology ( . %). in % of cases, arf was related to an opportunistic infection (mainly aspergillus (n = ) and pneumocystis (n = )). others arf etiologies included specific lung involvement ( . %) and cardiac pulmonary edema ( . %). sofa on day one was [ ] [ ] [ ] [ ] [ ] [ ] [ ] . associated organ dysfunctions were mainly hemodynamic ( %) and renal ( %). mechanical ventilation was needed in % of patients (non invasive only in . % or invasive in . %), % needed vasopressors, and % renal replacement therapy. systemic corticosteroids were started in % of patients and % of patients received pulse steroids. cyclophosphamide and plasma exchange were required in and % of patients, respectively. length of icu stay was [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] days. icu-acquired infection occurs in % of cases. in total, patients ( . %) died throughout the icu stay. arf etiology was not associated with mortality. by multivariate analysis, shock on admission (or . [ . - . ], p < . ) and the use of invasive mechanical ventilation (or . [ . - . ], p = . ) were independently associated with mortality, whereas non-invasive ventilation was associated with decreased mortality (or . [ . - . ], p = . ). by considering among the connective tissue diseases, the groups of myositis and scleroderma (n = ), these diseases were associated with a trend for a higher mortality (or . [ . - . ], p = . ). conclusion in patients with srd, arf is associated with a high case fatality, primarily when mechanical ventilation is needed. particular attention must be given to specific srd-sub groups for which pulmonary flare may require intensive immunosuppression. none. none. none. severe acute pancreatitis in icu: management and outcomes of infected pancreatic necrosis charlotte garret , matthieu peron , emmanuel coron , cédric bretonnière , jean reignier , christophe guitton réanimation médicale, chu hôtel-dieu nantes, nantes, france; the acute pancreatitis appears as a pathology that we can define with difficulty because of its clinical presentation or prognosis. patients and methods in our study, we analysed cases of acute necrotic and hemorrhagic acute pancreatitis, hospitalized at the department of resuscitation of the surgical emergencies (p ) of the uhc ibn rochd casablanca during the period ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the purpose of this study is to do a descriptive analysis of the epidemiologic, clinic, radiological, therapeutic and evolutive data of the acute necrotic pancreatitits, we included in our study patients with epidemiologic, clinic, radiologic, biologic criteria of acute necrotic pancreatitits diagnosis whatever is the biliary or alcoholic etiology. the valuation gravity of the pancreatitis has been based on:• ranson bioclinical score > /apache ii > ; • visceral failure.• spreading of the necrosis. the analysis of the results shows that: about the epidemiologic aspect: mean age ( year old), the biliary etiology predominates ( %). about the clinical aspect: pain ( %) vomiting ( %), stop of the transit ( %), the visceral distresses are: the shock ( %), respiratory distress ( %), and neurological distress ( %). about the radiological aspect: pleural effusion ( %), abdominal echography: vesicular lithiasis ( %), dilated principal biliary duct ( %), abdominal computerized tomography: stage e ( %). about the biological aspect: hyperglycemia ( %), hyper-amylasemia ( %). the indexes of gravity that have been appreciated in this study are: ranson score > ( %), imrie score > ( %), igs score ≥ ( %), osf score ≥ ( %). the treatment of the anhp has been symptomatic in particular and the evolution has been characterized by mortality about %, the cause was particularly infectious. the prognostic factors predetermined in this study are:• female type (p = . ).• hemodynamic distress (p = . ).• respiratory distress (p = . ).• scores of gravity:• ranson > (p = . ).• imrie > (p = . ).• osf ≥ (p = ).• infection (p = . ).• duration of the hospitalization (p = . ).• rate of c-reagent protein (p = . ). in conclusion, the mortality is still high in the anhp, considerable effort of search is necessary to prevent the infectious complications of mortality. none. predicting -day mortality following liver transplantation in patients with acute-on-chronic liver failure: a decision-tree model from the french national liver transplantation system, the optimatch study, - none. none. none. none. none. none. the french law and recent expert opinions have emphasized the need for a multidisciplinary approach in decisions to forgo life sustaining therapies for the critically ill. we sought to assess how icu nurses actually rank their involvement and perceive this process. materials and methods we conducted a cross sectional survey using a web-based questionnaire between june and september . results of the icus invited to participate, ( %) agreed. a total of icu participants completed the survey of whom % were nurses and % assistant nurses. median age was (inter quartile range - ) years and % were female. median work experience was ( - ) years and time in the icu was ( - ) years. eighty-five percent of the participants have been involved at least once in a multidisciplinary end-of-life discussion. less than half of the participants reported a good ( %) or partial ( %) knowledge of the current end-of-life legal framework. the decision to start a discussion about withdraw life-sustaining therapy (wlst) was initiated by a senior intensivist in % of the cases, by a nurse in % and an assistant nurse in . %. this decision was approved by % of the participants. the decision-making process was considered to be initiated at the right time for % of the participants, too late for %, and too early for %. the discussion occurred mostly in the afternoon ( %) or during the medical staff ( %), in a dedicated place in % of the cases. a median of ( - ) health-care professionals attended the wlst discussion. half the respondents reported being reluctant to talk during the discussions and % never expressed their own opinion. indeed, although the length of the discussion was ( - ) minutes, participants estimated to talk during only ( - ) minutes. the following reasons were mentioned by the participants to explain these facts: having cared for the patient for too short time ( %), lack of medical knowledge ( %), decision of wlst already taken by the medical staff ( %), their opinion not really taken into account ( %), reluctant to talk during meetings in general ( %), consider that the discussion is limited to a medical expertise ( %), limited professional experience ( %), and fear to express a different opinion ( %). nevertheless, % of the participants were partially ( %) or totally ( %) satisfied by the way the decision making process was conducted, % considered that collegiality was applied, and % agreed with the final decisions.conclusion icu nurses rank favorably multidisciplinary wlst discussions. nevertheless their involvement in the discussion remains limited. beyond factors related to work organization and professional experience, efforts should be made to recognize their role and value, and to encourage them to share their own opinions with the other members of the icu team. none. determinants and prognosis of elevation of high-sensitivity cardiac troponin t in patients hospitalized with vasodilatatory shock marie caujolle , jérôme allyn , dorothée valance , caroline brulliard , none. free plasmatic mitochondrial dna-receptor for advanced glycation end-products: a new signaling pathway of critical illness-induced endothelial dysfunction arthur durand , rémi nevière , florian delguste , eric boulanger, none. quality of reporting of fluid responsiveness evaluation studies: a five year systematic review izaute guillame , matthias jacquet-lagrèze , jean-luc fellahi none. none. none. none. none. introduction microaspiration of gastric and oropharyngeal contaminated secretions occurs frequently in intubated critically-ill patients, and plays a major role in the pathogenesis of ventilator-associated pneumonia (vap). at basic state, patients with chronic obstructive pulmonary disease (copd) have an increased risk of microaspiration (due to gastro-esophageal reflux disease, pharyngo-laryngeal dys-function…), this risk may even be more important under mechanical ventilation. the main purpose of this study is to determine if copd is a risk factor for global abundant microaspiration (gam) in intubated critically-ill patients. we gathered data about two prospective multicentric randomized trials focused on microaspiration in intubated patients. data about copd were retrospectively collected in order to complete previous data. microaspiration of gastric and oropharyngeal secretions was respectively determined by quantitative measurements of pepsin and salivary amylase in all tracheal aspirates during the first h after intubation. gam was defined as the presence at significant level of pepsin (> ng/ml) and/or salivary amylase (> ui/l) in at least % of the tracheal aspirates. in order to find gam independent risk factors, we realized an univariate and multivariate analysis of the variables collected. results out of patients included in the studies, were analyzed among which patients with copd. patients ( %) had gam. neither copd diagnosis, nor spirometric severity nor specific therapeutics were associated with gam. risk factors for gam in univariate analysis were the age, diabetes, low score in glasgow coma scale (gcs), and no recourse to paralytic agents or vasopressors. after none. none. implementation and impact assessment of a "ventilator-bundle" at the university clinics of kinshasa: before and after study josé mavinga , joseph nsiala makunza , m e mafuta , yves yanga , amisi eric , jp ilunga , ma kilembe none. none. amel mokline , achraf laajili , helmi amri , imene rahmani , nidhal mensi , lazheri gharsallah , sofiene tlaili , bahija gasri , rym hammouda , amen allah messadi burn care department, trauma and burn center, tunis, tunisia correspondence: amel mokline -dr.amelmokline@gmail.com annals of intensive care , (suppl ):s none. none. none. introduction mechanical ventilation (mv) weaning is a crucial step in critically ill patients. mv duration is associated with an increased risk of ventilator associated events, even though its specific impact on mortality has never been clearly demonstrated ( ). automated closed loop systems might help the weaning process. a recently published meta-analysis has reported a reduction in mv duration when using an automated weaning mode as compared to non-automated mode ( ) . however, the different automated modes have not been compared to each other. the objective of this network meta-analysis was to compare the performance of the three major automated weaning modes, i.e. the automode°, the smartcare° and the adaptative support ventilation (asv°) for mv weaning in critically ill and postoperative adult patients. we included all randomised control trials that compared automated closed loop weaning applications either to another automated application or standard care, including weaning according to a written weaning protocol or nurse driven protocols. the three modes of automated modes included in the study were asv°, smartcare° and automode°. the primary outcome was the duration of mv weaning, defined as the time between randomization and a successful extubation. we also planned subgroup analyses in the icu and the post-operative populations. the quality of the studies was assessed independently by two blinded investigators, using the evaluation recommended by the cochrane collaboration. a network bayesian meta-analysis using random effect models and based on aggregate data from the included studies was performed using the gemtc package (r project, vienna). this trial was declared in pros-pero in august (crd ). results search of databased identified articles; were screened for eligibility after removal of duplicates. abstract analysis led to the exclusion of articles with a final full text analysis of randomised control trials. ultimately, trials were included in the analysis, representing ventilated patients. nine studies included patients in the post-operative period while six were conducted in icu. the automated mode was asv° (a) in studies, smartcare° (c) in studies and auto-mode° (b) in studies. all studies reported the duration of mv weaning as defined in our protocol. in all studies, the control group was standard care with a weaning process driven either by nurses or physicians. in studies ( %) a written weaning protocol was used in the control group. all icu studies used sedation protocols based on sedation scores, none of them including systematic daily sedation interruption. each one of the automated application was associated with a significant reduction in the duration of mv as compared to the control. when comparing all different modes using the network meta-analysis framework, asv° appeared to be the best automated mode when it pertains to reducing the duration of mechanical ventilation weaning (fig. ) . subgroup analysis showed similar results in the post-operative and the icu populations. conclusion compared to standard weaning practice, the major automated weaning modes significantly reduced the duration of mv weaning in critically ill and post-operative adult patients. asv° was associated with the most significant effect when compared to the two other automated modes (smartcare°, automode°). further physiological respiratory studies would help to understand the underlying mechanisms accounting for the superiority of asv. none. none. introduction in intensive care unit (icu) patients, diaphragm dysfunction is associated with adverse clinical outcomes. ultrasound measurements of diaphragm thickness (tdi), excursion (exdi) and thickening fraction (tfdi) have been proposed as estimators of diaphragm function, but have never been compared to phrenic nerve stimulation. our aim was to describe the relationship between tdi, exdi, tfdi and diaphragm function evaluated using the change in endotracheal pressure after phrenic nerve stimulation (ptr,stim), and to compare their prognostic value. patients and methods ptr,stim and ultrasound variables were measured in mechanically ventilated (mv) patients < h after intubation ("initiation of mv", under assist-control ventilation, acv) and at the time of switch to pressure-support ventilation ("switch to psv"). diaphragm dysfunction was defined as ptr,stim < cmh o. results patients were included. at initiation of mv, ptr,stim was not correlated to tdi (rho = − · , p = · ), exdi (rho = · , p = · ) or tfdi (rho = − · , p = · ). at switch to psv, tfdi and exdi were correlated to ptr,stim, (rho = · , p < . and · , p = · , respectively), but tdi was not (rho = − · , p = · ). at switch to psv, a tfdi < % could reliably identify diaphragm dysfunction (sensitivity and specificity of and %, respectively), but tdi and exdi could not. this value was associated with increased duration of icu stay and mv, and mortality. conclusion under acv, neither tdi, exdi nor tfdi were related to ptr,stim. under psv, tfdi was strongly correlated to diaphragm strength and, when decreased, was associated with poorer outcome. alexandre demoule has signed research contracts with covidien, maquet and philips; he has also received personal fees from covidien and msd. none. none. none. management of enteral feeding during extubation in the intensive care unit: a multi-center retrospective study in french intensive care units mickael landais , noemie hubert , mai-anh nay , johann auchabie , bruno giraudeau , reignier jean , arnaud w thille , stephan ehrmann none. none. nutritional support in patients receiving temporary extracorporeal life support: a retrospective cohort study arthur bailly , laurent brisard , philippe bizouarn , thierry lepoivre , johanna nicolet , jean christophe rigal , jean christian roussel , bertrand rozec réanimation ctcv transplantation thoracique, chu de nantes -hôpital nord laennec, saint-herblain, france; chirurgie ctcv transplantation thoracique, chu de nantes -hôpital nord laennec, saint-herblain, france correspondence: laurent brisard -laurent.brisard@chu-nantes.fr annals of intensive care , (suppl ):s introduction the optimal nutritional intake in patients receiving temporary extracorporeal life support (ecls), including extracorporeal membrane oxygenation (ecmo) venovenous (vv) or venoarterial (va), remains controversial. enteral nutrition (en) is suspect to increase risk of gastrointestinal (gi) intolerance and intestinal ischemia. so, total parenteral nutrition (tpn) is often preferred. the purpose of this study is to describe the nutrition practices for critically ill patients receiving ecls and identify opportunities for improving nutrition therapy in this population. patients and methods retrospective analysis of patients requiring ecmo-va or ecmo-vv between and in the cardiac surgery intensive care unit of the university hospital of nantes. nutritional support was daily monitored with parenteral intake (glucose, lipid and propofol, protein and albumin, parenteral nutrition) and enteral nutrition until ecls weaning. two groups were compared during ecls period: no enteral nutrition delivered (none or tpn) (anec, n = ) and at least once enteral nutrition delivered (nec, n = ) including en alone and supplemental parenteral nutrition (spn). primary outcome was incidence of gi intolerance and risk factors. secondary outcomes were nutritional adequacy (calculated as overall of calories and protein delivered divided by the theoretical amount requirements: kcal/kg/d and . g/kg/d) and clinical outcome. data are reported as median ( th and th percentiles) or number (%), and analyzed with student's t test for continuous variables and χ test for categorical variables. p < . was considered as significant. none.introduction refeeding syndrome (rs) is a potentially lethal condition that remains underdiagnosed. it is characterized by severe electrolyte and fluid shifts associated with metabolic abnormalities in malnourished patients undergoing refeeding orally, enterally, or parenterally. clinical criteria have been proposed for determination of its risk and reported in the national institute for clinical excellence (nice) clinical guidelines. hypophosphoremia (hp) is a prominent feature of the rs and seems to be the earliest abnormality. phosphorus is a vital component of nucleic acids, enzyme systems, and various metabolic pathways. objective to determine the incidence of refeeding hypophosphoremia (rh) < . mmol/l, and severe rh < . mmol/l in a medical critical care unit. patients and methods monocentric, retrospective and observational study with patients from french-speaking icu nutritional survey study frans. critically ill adults (more than yo) were enrolled if they were hospitalized for more than days during a -month period and had an artificial nutritional support. refeeding hypophosphoremia is defined by the occurrence of hypophosphoremia after refeeding. we studied the incidence of hr, risk factors, and prognosis. results patients were enrolled between / / and / / . rh appears in . % and severe rh < . mmol/l in . % (fig. ) . there is no correlation between rs risk factors and rh in our study. logistic regression did not permit to identify neither risk factor nor prognostic modification. there is a lack in phosphoremia measuring ( . %), and overfeeding during the first days occurs in . %. discussion we define that an hypophosphoremia appearing after refeeding is a refeeding hypophosphoremia, and we do not consider others etiologies, such as mechanical ventilation, alkalosis, sepsis, alcoholism, malabsorptive states, poor intake, some medication. our cohort is too small to find some possible correlations with risk factors or prognosis. conclusion refeeding hypophosphoremia is common in our population. hypophosphoremia is not an independent predictor of icu or in-hospital mortality in critically ill patients. the knowledge of the sri requires the follow-up of the phosphoremia during nutrition after critical illness in particular in the undernourished patients. none. introduction to determine the possible relationship between days cumulated proteins ( days cpd) and energy deficits ( days ced) observed in ventilated patients and icu length of stay, duration of ventilator support, incidence of infections and days mortality. patients and methods mixed medical or surgical ventilated for at least days adult patients from icus from chu liège belgium were enrolled into the study. they were fed by enteral route with a target of kcal and . g of proteins by corrected kg of bodyweight and by day. if % of the target was not reached on day seven, parenteral nutrition was added with the same target. ced and cpd were calculated for days, taking into account all the sources of nutrition, and was defined as the difference between the amount of energy or protein intake and the target. results from / / till / / , patients were followed. data from patients could be cumulated on the first days. there were males, mean bmi was . ± . ; saps ii score on day was . ± . , sofa score at day was . ± . . they were ventilated for a median of days (iqr - ), median icu length of stay was days (iqr - ). mean sofa max calculated for the first days was . ± . and the day mortality was . %. on day , only % reached the target of kcal/kg and % the target of . g of protein/kg. mean days ced was − . ± . kcal and mean days cpd was − . ± . g. there was a significant negative relationship between both deficits and the sofa max (p = . for ced and p = . for cpd). however, there were no correlations between any of the deficits and icu length of stay, duration of mechanical ventilation, occurrence of infections and days mortality. discussion saps ii level, sofa max level, icu length of stay, all these parameters emphasize the high severity of this cohort of patients. it could indeed been thought that it is in this group of critically ill patients that the impact of nutrition could be easily demonstrated. clear relationships between sofamax on day and the days ced and cpd could be seen. however, both the deficit and the level of organ dysfunctions could be cause or consequence. unlike previous studies, usually performed in less severely ill patients, we did not find any relationship between ced or cpd and patient's outcome. conclusion contrary to some recent studies, we found no relationship between ced and cpe and outcome of patients. future studies are needed. none. cardiopulmonary bypass induces lymphopenia and decreases lymphocyte proliferation ability: il- and pd-l as potential therapeutic targets to reduce postoperative infection fabrice uhel , mathieu lesouhaitier , murielle grégoire , baptiste gaudriot , arnaud gacouin , yves le tulzo , erwan flecher , karin tarte , jean-marc tadié fig. incidence of hypophosphoremia at admission, the first day, and refeeding hypophosphoremia none. the prognostic impact of neutropenia in criticallyill cancer patients remains controversial. hence, several studies in critically ill cancer patients failed to demonstrate the impact of neutropenia on outcome [ ] . this lack of statistical association might however, reflect a lack of statistical power. a previous meta-analysis of aggregated data suggested % ( % ci - %) raw increase in mortality in neutropenic patients. the available data were, however insufficient to allow adjustment with confounders [ ] . the aim of this study was to assess the influence of neutropenia on mortality of critically ill cancer patients using individual data obtained from studies identified by our systematic review. secondary objectives were to assess the influence of neutropenia on mortality of critically ill patients while taking into account underlying malignancy, use of g-csf or changes related to period of admission. patients and methods this systematic review and meta-analysis was performed according to the prisma statements. public-domain databases including pubmed and the cochrane database were searched by using predefined keywords. the research was restricted to articles published in english and studies focusing on critically ill adult patients from may to may . the methods and objectives of this systematic review were reported in the prospero database (crd ). selected manuscripts' authors were then contacted to obtained part of their dataset. mortality was defined as either hospital or day- mortality. this preliminary analysis reports results from the whole dataset before and after adjustment using logistic regression. period of admission and use of g-csf were then assessed and were a pre-planned analysis. results our initial search yielded citations and studies were retained for further analysis. overall, studies were excluded for redundancy with other included studies, as containing only neutropenic patients, and two as containing only palliative patients. finally datasets ( %) containing sufficient data to allow comparison were obtained from authors. overall, patients were included in this study, including patients with neutropenia at icu admission. median age was of years (iqr - ). median sapsii score at icu admission was (iqr - ). respectively and patients had underlying haematological malignancy and solid tumours, and patients underwent allogeneic stem cell transplantation. mechanical ventilation, vasopressors, and renal replacement therapy were required in none. none. ( ) . in icus, cirrhotic patients are widely admitted and revalued after receiving optimal treatments for days. however, little is known about how manage these patients after day according to their prognosis. the blood neutrophil-to-lymphocyte ratio (nlr) as a novel inflammation index biomarker has been reported to be a predictor of clinical outcomes in various malignancies and in unselected critically ill patients ( ) . nlr has also been identified as a predictor of mortality in patients with stable liver cirrhosis. to our knowledge, the ability of nlr to predict outcome in critically ill cirrhotic patients has never been studied. the aim of this study was to evaluate the usefulness of inflammatory marker such as nlr for diagnosis of infection and predicting the outcome in hospitalized critically ill cirrhotic patients. we performed a retrospective monocentric study including consecutively cirrhotic patients hospitalized in a medical icu from to . for each patient, clinical and biological data at admission and day were collected. nlr at admission ("nlrd "), at day ("nlrd ") and the variation of nlr between admission and d none.introduction diagnosis of infection in immunocompromised patients can be difficult. however, diagnosing infection is very important, particularly in critically ill. this study aims to evaluate the benefit of procalcitonin (pct) blood level as a diagnostic marker for bacterial infection in patients with hematological malignancies admitted to the intensive care unit (icu). this retrospective single-center study included all consecutive patients with acute myeloid leukemia or high grade lymphoid malignancy admitted to the icu. patients were sorted into three subgroups, according to clinical and microbiological data: «infectious disease», «no infectious disease» and «unknown». initial serum pct and when available at day and day were recorded. receiver operating characteristic (roc) curve, sensitivity and specificity were calculated. serum pct was considered as decreasing when the decrease was ≥ % at day and/or ≥ % at day . mortality rates in the icu and at day- were also studied. results fifty-four patients were included in the study. at diagnosis, pct levels were significantly different between the "infection disease" group and the "no infection disease" group (p = . ). there was no difference between the "infection disease" group and the "unknown" group (p = . ). for the diagnosis of bacterial infection, best initial serum pct threshold was . ng per milliliter. for that threshold, sensitivity was . % and specificity was . %. pct area under the roc curve was . [ci % = . - ]. youden's j statistic was . . pct levels weren't different between groups according to the presence of neutropenia or in case of inaugural disease. there was a significant difference in pct values between groups according to the sofa score (p = . ), but not the saps score. mortality rate in the icu and at day- were significantly lower for the patients with decreasing pct (p < . and p < . , respectively). when comparing serum pct and crp predictive values, pct was significantly a better marker of bacterial infection (fig. ). discussion we found that serum pct, with a threshold of . ng/ ml, is a reliable marker of bacterial infection disease in patients with aggressive hematological malignancy admitted to the icu. our study confirms the results of a previous study in unselected immunocompromised patients admitted to the icu, showing a % sensitivity, a % specificity and an area under roc curve of . [ . - . ] for a threshold of . ng/ml ( ). the main limitations of our study are its retrospective design and the small number of included patients. conclusion pct is a reliable marker of bacterial infection in patients with hematological malignancies admitted to the icu. pct kinetic seems to be an interesting prognostic marker in this population. none. in this study, we have found that kinetics of secretion and expression of endocan is faster with huvecs stimlated by tlr agonist than tlr agonist. this results could suggest that endocan may be not only a marker of septic shock but could be also a specific marker to recognize the nature of pathogenic microorganisms in septic shock. furthermore, other studies with more tlr agonists could be useful to confirm these results. conclusion studying the effects of diverse tlrs agonists could make the plasmatic dosage of endocan more specific and helpful to recognize the nature of pathogenic microorganisms in septic shock. none. lung ultrasound: help to the diagnostic and the monitoring of response to physiotherapy. a case report of pneumonia aymeric le neindre introduction chronic critical illness (cci) syndrome is a new condition affecting an increasing number of patients, who survived an acute critical illness but have persistent severe organ dysfunction, requiring prolonged specialized care. cci is a iatrogenic process, reflecting the efficacy of modern life support technologies( ), and encompasses multiple organ failure, need for prolonged mechanical ventilation (mv), organ support, and palsy due to polineuromyopathy. the transition from acute to cci is gradual: definitions are based on duration of mv, with cut-offs of , or consecutive days of mv for ≥ h/day. cci patients may come from either medical or surgical icu; their health status fluctuates between improvements and deteriorations implying recurrent transitions between different levels of care ( ) .the risk of death is reported to be as high as %. despite a relatively young age ( years on average), functional status of cci patients discharged is seriously impaired, thus cci patients require long-term rehabilitation. aim: to estimate the frequency of cci syndrome in careggi, a large academic, tertiary care hospital; to describe the clinical course of cci patients through discharge, and their functional status at discharge. patients and methods administrative data on admission, transfer, death and discharge of all cci patients, consecutively admitted in one of the icu beds at careggi hospital from january to december , , were collected. cci was defined with the cut off of ≥ days of icu stay, representing the index event (ie) without contribution of previous or subsequent hospitalization in other hospitals. reasons for admission were grouped into the broad categories of medical causes, surgery, major trauma and cardio-respiratory arrest. patients discharged were evaluated in daily living, cognitive status, and mobility using barthel index. results we identified subjects who developed cci ( males; age . ± . years, mean ± sem); of them came from an external icu, began their cci course within careggi hospital ( from the emergency room, from a regular ward). average duration of the ie was . ± . days. these sample developed accumulative length of icu stay of days, corresponding to a % icu bed occupation over the theoretical total of , . when days of subintensive care and regular ward were separately added, days of highly specialized care and days of total acute hospital stay were reached. surgical patients had longer hospitalizations (p = . ).cci patients confirmed to be highly erratic: a total of transitions across different services were recorded in the patients, with a maximum of in of them. mean age was comparable between the patients who died ( %) and the remaining who were discharged alive ( . ± . vs. . ± . years; p = . ).fourteen subjects continued their icu stay out of hospital. only , whose age was lower ( . ± . years), were discharged home; half of the participants (n = , . %) were admitted to a residential rehabilitation facility. younger subjects scored better in the domains of self care (p = . ) and cognitive status (p = . ) but not in the domain of mobility, including walking ability: patients required maximal assistance in performing activities of daily living and transfers, other required medium/maximal assistance, with no statistical difference between dg group. conclusion cci is a relevant clinical condition that need to be assessed and possibly prevented, as it causes severe morbidity, long-term functional impairment and exceeding healthcare costs. none.conclusion early mobilization during the first week of the sepsis onset was safe and preserved muscle fibre cross sectional area. none. none. study of efficacy on icu acquired weakness of early standing with the assistance of a tilt table in critically ill patients none.introduction patients with high flow nasal cannula may benefit from combined aerosol therapy. clinical efficacy depends on pulmonary deposition which is related to the type of nebulizer. all new nebulizers or delivery methods require rigorous evaluation. the aim of this study was to compare lung deposition between two nebulizers (jet nebulizer vs vibrating-mesh nebulizer) through high flow nasal cannula in healthy subjects. patients and methods aerosol delivery of diethylenetriaminepentaacetic acid labelled with technetium- m ( mtc-dtpa, mci/ ml) to the lungs using a vibrating-mesh nebulizer (aerogen solo ® , aerogen ltd., galway, ireland) and a constant-output jet nebulizer (opti-mist plus nebulizer ® , convatec, bridgewater, nj) through high flow nasal cannula (optiflow ® , fisher & paykel, new zealand) was compared in healthy subjects. flow rate was set at l/min through the heated humidified circuit. pulmonary and extrapulmonary deposition were measured by single photon emission computed tomography combined with a low dose ct-scan (spect-ct) and by planar scintigraphy. results lung deposition was only . ± . and . ± . % of the nominal dose with the vibrating-mesh nebulizer and the jet nebulizer, respectively (p < . ). dose lost in the high flow circuit, humidification chamber and nasal cannula was higher with the vibrating-mesh nebulizer as compared to the jet nebulizer ( . ± . vs . ± . % of the nominal dose, p = . ). expressed as percentage of emitted dose, lung deposition was similar with both nebulizers. conclusion this study demonstrated that aerosol delivery through hfnc is poor in the specific conditions of the study despite the higher efficiency of the vibrating-mesh nebulizer as compared to the jet nebulizer. placing the nebulizer on the hfnc circuit at l/min induces high aerosol loss on the circuit and the oropharynx. key: cord- -oswgjaxz authors: nan title: abstracts: (th) european congress of trauma and emergency surgery may – , brussels, belgium date: journal: eur j trauma emerg surg doi: . /s - - -z sha: doc_id: cord_uid: oswgjaxz nan introduction: frequently fractures of modern sport disciplines are fractures of the clavicle. most of them are uncomplicated and still treated without operation. therefore there is a lack of bigger studies about the treatment of clavicle fractures by elastic stable intramedullary nailing (esin). nevertheless this method becomes more and more popular, especially for young and active people. intention of this investigation was to analyze risks and results of this method to check the indication for operative treatment of simple fractures in this group of patients. material and methods: this study is a retrospective analysis of patients whose fractures of the clavicle were treated by intramedullary nailing. crucial for the decision for operation was the individual request of the patient after information of the relative indication. included were patients with fractures of the middle third, fractures of the lateral third and fractures with concomitant shoulder injuries from to . the duration of operation, intraoperative radioactive loading and complications were analyzed from the medical file. the functional outcome was measured by the constant-score. the anatomical reduction was proved by measuring the difference of the length of both clavicles ( - month after operation). results: the average duration for the middle third was min ( - ), for the lateral third ( - ) minutes and for fractures with concomitant injuries min . the mean radioactive surface dose was , cgy/cm . four complications ( %) cause revision operations: one secondary dislocation which leads to pseudarthrosis and two imminent penetrations of the medial end of the nail. one patient had developed a painful pseudobursa due to lateral penetration of the nail. additional there were two prematurely nail extractions because of medial irritation of the soft tissue. altogether we documented complications in % of the operations. overall an open reduction was necessary in %. after healing there has been no significant shortening of the fractured clavicle in comparison of both sides. the constant-score showed good postoperative results (average: , median: , lowest / ). conclusion: esin with titan nails is an alternative method of treatment with good results. nevertheless we documented complications in %. in the literature complication rates from - % has been described. the complication rate of esin seems to be comparable to the conservative treatment. in our opinion the relevant intraoperative radioactive dose is an often underestimated factor. the operation time is often longer than thought before starting and often an open reduction is necessary. because of these reasons the conservative therapy should still be the standard. esin can be an alternative especially for young athletic ambitious patients after a detailed information about the risks. disclosure: no significant relationships. introduction: the optimal management of clavicle fractures is still controversial, although the nonoperative treatment remains the standard in most fractures. recent studies have reported a higher nonunion rate and unsatisfactory functional results after nonoperative treatment. therefore, there is an increasing interest in the primary operative management of displaced midshaft fractures. however, no treatment-consensus exists at this moment. the goal of the present study was to compare plate fixation with nonoperative treatment of displaced midshaft clavicle fractures in adults with a minimum of weeks follow-up. material and methods: in a multi-center prospective clinical trial patients with a fully displaced midshaft clavicle fracture were included within one week after the injury. after a standard information procedure, patients were asked if they wanted to have a operative or a nonoperative treatment. outcome analysis included standard clinical follow-up, the constant shoulder score, the disability of the arm, shoulder and hand (dash) score and complication rate at and weeks after the injury. results: between january and october a total of patients were included: patients were treated operatively ( . % men, mean age . years) and patients were treated nonoperatively ( . % men, mean age . years). constant and dash scores were significantly higher in the operative group compared with the nonoperative group at weeks ( vs and . vs . ). there was no significant difference at weeks ( vs and . vs . ). in both groups two patients developed pseudartrosis, all four required surgery. in the nonoperative group symptomatic malunion was more frequent: twelve patients at weeks ( . %) versus none in the operative group. other complications in the operative group were mostly hardware related: pain and irritation requiring plate removal after consolidation in four patients ( . %), two broken plates due to the earlier mentioned pseudartrosis ( . %), one early outbreak of the plate ( . %) and one woundinfection ( . %). furthermore, patients with heavy professional work activities returned to their jobs at an average of three weeks after injury in the operative group compared with seven weeks in the conservative group. at weeks after the injury, the patients in the operative group were more satisfied compared to those in the nonoperative group ( % vs %). conclusion: operative fixation of a displaced midshaft clavicle fracture results in improved functional outcome at weeks after injury and in a higher satisfaction rate at weeks. this study shows that patients with heavy jobs restarted their professional activities sooner if they were treated operatively. furthermore, higher satisfaction with the appearance of the shoulder may be a reason for surgery. introduction: the unstable shoulder girdle with a fracture of the clavicle (floating shoulder, ipsilateral serial rib fractures) is a classical indication for a plate osteosynthesis of the clavicle. despite a relatively high complication rate ( - %), such as implant failure, non-union and refracture after implant removal, open reduction and internal plate fixation (orif) has been the gold standard for many years. this open procedure with direct reduction maneuvres might be blamed for at least some of the complications due to iatrogenic damage of the blood supply of the fracture fragments. our hypothesis is that a closed method with indirect reduction might reduce some of the complications. the goal of our study was to test the practicability of the mipotechnique in clavicle fractures in unstable shoulder girdles. material and methods: between and we included, out of internally fixed shaft fractures in total ( x plate, x elastic nail), patients with either a floating shoulder (n = ) or a clavicle fracture in combination with ipsilateral serial rib fractures (n = ), in this study. operative technique: a locking compression plate (lcp) . with - holes was anatomically shaped to the anterior (-caudal) contour of the contralateral clavicle and then inserted percutaneously from lateral to medial using a short incision at the anterior border of the lateral end of the clavicle. using mainly indirect maneuvres, the fracture was reduced and then fixed in a pure bridging technique never using interfragmentary lag screws. free unloaded rom was allowed immediately after the operation with full loading - weeks later. follow-up examination was performed to years later with clinical (dash-score, shoulder function, length measurement) and radiological (fracture healing, length measurement) examination. results: / fractures healed without complications. clinical and radiological length measurement showed no significant differences to the contralateral side (range: + mm to - mm). in all patients a very good functional result was achieved with an average dash score of . ( - ). one implant failure occured two years after the initial trauma in a road workman. at reoperation only a partial consolidation of the original fracture was observed. restabilization and bone grafting led to an uneventful healing. conclusion: the mipo technique is feasible even in clavicle fractures and can lead to good functional and cosmetic results. the advantage might be its low invasiveness which better preserves the vascular supply of the fracture fragments. however it is technically demanding mainly due to the small size of the fractured bone. therefore in our opinion it requires a surgeon experienced in the mipo technique of treating fractures of larger bones as tibia and femur. introduction: there are some reports on the difficulties of removing the locking compression plate in clavicle fractures, due to problems of removing the self tapping locking screws. we retrospectively investigated if this was also the case in our institution in removal of lcp plate of the clavicle and if this was incidential or becoming a trend. material and methods: from october till october , we have removed locking compression plates after claviclefracture stabilization. all of the locking screws were inserted by trauma surgeons with the use of the torque limiting srewdriver according to the manufacturer's recommendations. a total of screws where removed. they consisted of fifty-one . mm self tapping cortical screws and hundred and twenty . mm self tapping locking screws. results: from the locking compression plates that where removed after claviclefracture stabilization, in eleven patients ( %) a problem with removal of the plate arised. this was caused by a total of self tapping locking screws. in all cases jamming of the screwheads in the plate was found to be the reason. there was ''cold welding'' between the threaded head of the locking screw and the locking plate. for removal four different strategies were used. in two screws the head was drilled off and the plate removed and subsequent the rest off the screw removed with forceps. five times the plate was bend around the screw and by rotating the plate (helicopter) both were taken out. in eight screws the recess of the head of the screws were enlarged and a conical extraction screwbit . was used to remove the screws. two times a combination of cutting the plate and helicopter tecnique was used succesfull. in comparison the fifty-one . mm selftapping cortical screws were removed without any problem. conclusion: the locking compression plate is a usefull attribute in fracture treatment of the clavicle. however in one-third of the patients removal of locking compression plates and especially the . mm self tapping locking screws from the clavicle, becomes an increasingly challenging procedure. we find this an unacceptably high percentage. number of mri studies it was possible to describe the intraarticular disc. until now there was no in vivo verifying of one of these mri protocols. the introduction of a high resolution mri protocol using a superficial coil ( d wats and t ffe) that has been developped in an ex-vivo model allows the visualisation of the intra-articular structures. the aim of this study is to ascertain the significance of the mentioned mri protocol and the applicability in the clinical practice in a limited patients cohort with instability of the ac-joint. the mri findings are compared to the arthroscopic findings. material and methods: in a one year period patients with chronic acromioclavicular-joint dislocation rockwood type ii and iii were seen in the outpatient clinic the major symptom was pain followed by loss of power. inclusion criteria where a history of more than three month the exclusion of subacromial pathologies, age over and the indication for arthroscopic revision of the ac-joint. the radiological examiner was blinded to the clinical findings. the mri-scan was performed on both sides. at the time of the operation the surgeon was blinded to the mri reading. the surgical procedure was performed by arthroscopy in beach chair position. the surgical findings have been documented by video and also in a descriptive manner. the examination was performed on a . t mri-system . results: throughout the radiological examination, in / patients a rupture of the intra-articular disc was suspected. in / cases degenerative alterations were described. in one case the reading was negative (e.g. ,,no rupture of the intra-articular disc''). during the surgical examination / patients showed ruptures of the intraarticular disc. in one patient no signs of macroscopical disintegration of the disc could be detected. in the case with negative radiologiocal reading, the disc was verified as intact during surgery. in all other cases the disc was disintegrated, including those with the radiological reading ''alterations without clear signs of rupture''. the significance of the described mri protocol was %. introduction: cancer of the colon is a common disease. the choice of treatment after diagnosis is surgery, in an elective setting, to remove the tumor. however, a large number of patients present with colonic obstruction requiring acute surgery before the diagnosis is known, or before the set date for elective surgery. previous studies have shown a worse outcome for patients who undergo surgery in the acute setting compared to patients in scheduled care. the aim was to establish characteristics and prognosis in patients with acute obstructing colon cancer compared to patients who underwent elective colon cancer surgery. material and methods: all patients diagnosed with colon cancer during - in the linkoping area were identified through the swedish colorectal cancer register (n = ). a retrospective analysis of patients with colonic obstruction (n = ) was done using various criteria from the medical records. exclusion criteria were acute surgery due to reason other than obstruction (n = ), non-surgical treatment (n = ), other diagnosis (n = ), or missing medical records (n = conclusion: acute surgery due to colonic obstruction of colon cancer is common. tumor stage seems to be more advanced in patients with obstructing disease than in patients scheduled for elective surgery and consequently the rate of complications is higher and the outcome is worse. however, when stratified for different tnm-stages, the worse outcome in -year survival for patients with acute obstructing colonic cancer still remains. the explanation for this difference is to be elucidated in further studies. disclosure: no significant relationships. introduction: acute colonic obstruction due to malignancies is often a surgical emergency. hartmann's procedures or one stageresection with primarary anastomosis (with or without ileostomy) have been the treatment of choice. however these procedures are associated with a significant morbidity and mortality rate. self expanding metallic stents (sems) have shown their efficiency as palliative treatment in colonic cancer. colonic stenting has been advocated as a''bridge'' towards surgical procedures in potentially resectable diseases. the aim of this study is to evaluate the efficacy of colonic stenting in the emergency treatment of large bowel occlusion either for palliation or to enable to planned surgical procedure. s. tamulis, e. v. gaidamonis surgical, vilnius unuversity emergency care hospital, vilnius, lithuania introduction: to evaluate the results of the treatment of patients with the small bowel obstruction due to intestinal adhesions. material and methods: medical records for the patients treated with small bowel obstruction due to adhesions from to were reviewed. the patient's age, gender, previous abdominal operations, method of the treatment and outcomes were analyzed. results: there were patients admitted to the vilnius university emergency hospital during years period. appendectomy as a previous operation was recorded in % of cases. surgery was required in of the cases ( . %). strangulated small bowel was found in patients ( , %). in cases ( , %) the surgical procedure was limited to adhesiolysis, whereas in cases ( , %) an intestinal resection was performed. enterodecompresion tube was used in cases ( , %). the operative mortality was , % ( cases). mortality after the treatment due to strangulation was , % ( cases). conclusion: there were % of surgicaly treated patients. main reasons of adhesions formation was previous performed apendectomy and midline lower laparotomy. the criteria of uneffective conservative treatment were absent of the positive results of the physical, laboratory, rentgenological and ultrasound examination. mortality after the strangulated small bowel resection was higher. operative enterodekompresios reduces the risc of the postoperative complications and mortality. disclosure: no significant relationships. introduction: hartmann's procedure (hp) still remains the most frequent performed procedure in diffuse peritonitis due to perforated diverticulitis. [ ] [ ] [ ] nevertheless it is associated with high morbidityand mortality . the aim of this study was to assess feasibility, morbidity and mortality of resection with primary anastomosis (pa) with or without diverting loop ileostomy versus hp in case of diverticular peritonitis. , . material and methods: we retrospectively reviewed our prospectively collected database from / to / of patients who were operated in the emergency department of bellvitge university hospital. only patients operated on generalized diverticular peritonitis (hinchey iii-iv) were included. data on patients' demographics, asa classification, hinchey score, peritonitis severity score (pss), surgical procedure, post-operative morbidity, mortality and post-operative hospital stay were studied. results: a total of patients [median age ( - ) years], female . % were included. sixty ( %) had undergone hp and ( %) pa. only in patients ( . %) a diverting ileostomy was performed. overall post-operative morbidity was . %, most frequent complications were wound infection . %, respiratory complications . % and sepsis . %. overall mortality was . % ( pt). these patients had a mean pss of . while the survival group . . there was an overall reintervention rate of . %, after pa . % and after hp . %. significant differences were found in the hp versus pa group in asa score (asa i-ii: % v %, asa iii-iv: % v %) and the median pss ( versus ) . % ( / pt) with pss £ underwent pa, but none ( / ) with pss ‡ . the post-operative morbidity was significantly higher for hp ( . %) compared to pa ( . %). focusing on hospital stay there was a significant difference between pa (mean . days) versus hp (mean . days). in the stratified analysis considering patients with hinchey iii peritonitis we found a mortality of . % ( / pt) in the hp group versus . % ( / pt) of the pa group. the mortality rate stratified for asa and surgical procedure shows no difference in asa i-ii, but in asa iii-iv a lower postoperative mortality for hp ( . %) versus pa ( . %). including only patients with pss less than ( patients) there is a significantly lower morbidity in pa ( . %) versus hp ( . %). conclusion: our data show that pa can be performed safely with lower morbidity and mortality for diverticular peritonitis in patients with asa i-ii, hinchey iii peritonitis grade or pss less than respectively to hp. these findings are supported by a shorter hospital stay in favor to pa. y. arlettaz orthopaedics and trauma, chcvs hô pital du valais, sion, switzerland introduction: one of the most demanding steps of intramedullary nailing is the distal locking. most of young surgeon are ''affraid'' to treat a long bone fracture by a nail because of the distal locking. the aim of this study is to evaluate a new frendly radiation free targeting device on cadavers. material and methods: the study was conducted on fixed cadavers. femurs were available. the method consists of the following steps: determining the zero position of the device; opening the tip of the great trochanter; introducing the nail (sirus nailÒ x (zimmer inc.)); introducing an emitter inside the nail to be positioned in the distal holes; adaptation of the guide on the standard handle with a receptor; moving the receptor to be aligned to the emitter; changing the receptor for the sleeve and performing the drilling and the locking. for the second or even third screw, the targeting device needs a little adjustment. results: on the distal locking procedures ( screws), we observed only one failure due to the breakage of the prototype. this translates as a % success rate for two screws with a mean time of . min. two surgeons conduct this study. not only the inventor but also a inexperimented surgeon tested the new device with the same succes. conclusion: this new device has the advantage to be fully mechanical, to be solidly linked to the patient and to be totally radiation free. it can be used in any hospital, by any surgeon. the procedure is easy to learn and reproducible. it could be adapted to any nail system and does not need external power supply. introduction: anterior knee pain is one of the most frequent complication of tibial nailing. its aetiology remains unclear, potentially being a multifactorial event. the aim of this prospective study was to evaluate if anterior knee pain has any negative influence on: bone healing(the hypothesis is if the patient has anterior knee pain he or she will not put weight on the affected leg and this will not stimulate the bone healing), ability to return to work and quality of live. material and methods: european level trauma center was involved in this study. methods: between januari and december , patients with a tibia fracture was admitted to the trauma departments we used a standard t tibia nail(stryker) with the possibility of proximal and distal fixation with screws the approach was trans or parapatellar. results: at - weeks, months, months follow-up we had , , patients with anterior knee painthe vas decreased from , to , , bone healing was % and for % of patients it was possible to do their previous full time job after months. the quality of life (walking up and down stairs normally without any help, putting on shoes and socks, sitting/standing from a chair, total weight bearing,) was improving. conclusion: we conclude that anterior knee pain in this study is mild, that the two different method of patellar tendon approach(trans or paratendinous approach) have no relevance and it does not have a negative influence on bone healing, ability to return to work and the quality of live. introduction: the aim of this study was to see if there is any difference between manual traction and fracture was applied in one step. twenty-seven femurs and thirthy-three tibias were treated. the mean distraction rate was . mm (range . - . mm) for the femur and . mm (range . - . mm) for the tibia. the necessary pressure to advance the distraction in the tibia was average of bar (range - bar), to distract the femur, bar (range - bar). results: bone healing index for tibia . and femur . months/cm distraction. implant failure five cases; infections three cases. nonunion of the distraction site or docking site four cases. we did not encounter major stiffness of the adjacent joints. conclusion: although the presented technique is a semi-closed distraction procedure, we find this system appealing because of it simplicity in use, low cost and the ability to immediate weight bearing. introduction: bone transport for treatment of segmental bone defects as a salvage procedure is related to a high complication rate. posttraumatic soft tissue problems and callus insufficiency are to be dealed with especially in posttraumatic conditions. the ilizarov ringfixator allows a stable external bone fixation enabling full weight bearing. in bone defect reconstruction bone transport is commonly used. a major problem is the skin cutting wires for bone fixation. a new method of the cable transport with intramedullary cable passing avoids skin cutting thus reducing skin problems. material and methods: patients with a metaphyseal and diaphyseal bone defect of the tibia after open trauma and posttraumatic infection were treated with debridement, bone resection and soft tissue coverage by local and free flaps. after soft tissue healing the monolateral external fixation was replaced in each patient by a four ring ilizarov fixator with a proximal percutaneous tibia osteotomy. for bone transport a flexible cable was placed around the distal part of the segment and passed intramedullarly through the distal segment out of the tibia and onto the ilizarov fixator and the transport clickers. the bone segment was transported after a delay of days anterograd by the intramedullar placed cable one mm per day. results: in all patients the bone defect was closed by the bone transport. in one patient early consolidation of the regenerate occurred and a rupture of the cable. two patients had an insufficiency of the callus. the distal docking site was augmented in all patients after the segment transport with iliac bone graft for consolidation. the one patient with early consolidation was treated by a second osteotomy; the two patients with insufficiency were augmented during the docking operation with iliac bone graft. conclusion: the intramedullar cable transport is a new modification of the bone transport with the ilizarov ringfixator. the main advantage is the soft tissue spearing and protecting transport mechanism enabling bone transports after free flap soft tissue coverage with micro vascular anastomosis. therapeutical course before and after amputation (number of operations before and after amputation) in relationship to co-morbidities and bacteria which caused the infection. results: hospital data from ( female, male) patients were available for septic amputations in the lower extremities on account of non-manageable infections. the average age was . years ( to years). the first age peak lies with , the second with years. in cases infected endoprostheses were found ( total hip arthroplasties, total knee arthroplasties) in cases osteomyelitis was diagnosed. before amputation the patients underwent an average of . interventions (between and ) in oder to control the infection. the average treatment period before the amputation was . days (from to days). post amputationem an average . interventions were necessary (from to ). the average period of treatment was about . days (from to days). the analysis of the co-morbidities showed that hypertension was the most frequent, cases ( . %), followed by diabetes in cases ( . %), coronary desease in cases ( . %), obesity in cases ( . %) and copd in cases ( . %). conclusion: a statistical relevant risk-assesment based on these data (correlation of microbiological findings co-morbidities and risk of amputation) cannot be carried out due to the relatively small number of patients. however, a trend may be estemated: combination of mrsa, diabetes and cardial disease in combination with a great number of operations leads to an increased amputation-risk independent to the individuals age. introduction: maggot debridement therapy (mdt) as an ancient method is succesfully used for the treatment of acute and chronic wound infections in trauma surgery . the underlying mechanisms of action of mdt are unknown, but could provide information for a novel treatment modality against infection, which is important in these times of increasing antibiotic resistance. therefore, in this research the effect of living maggots on planktonic cells was investigated. furthermore, the influence of maggot excretions on planktonic cells and on bacterial biofilms was tested. material and methods: sterile tubes were filled with living maggots in a bacterial suspension and every two hours samples were cultured and compared with controls. a turbidimetric assay was performed to test the susceptibility of six bacterial species to maggot excretions. bacterial biofilms were formed in vitro on polyethylene, stainless steel and titanium and maggot excretions were added to test their influence. results: the results show that living maggots as well as their excretions stimulate the bacterial growth of s. aureus, e. faecalis, cns, s. pyogenes and k. oxytoca (all p-values £ . ). only p. aeruginosa had a decrease of bacterial growth (p = . ). the strongest biofilms in vitro were formed by s. aureus, s. epidermidis and p. aeruginosa in contrast to the weak and inconsistent formed biofilms by e. faecalis, e. cloacae and k. oxytoca. for p. aeruginosa, stainless steel was the best biomaterial with respect to biofilm formation and for s. aureus and s. epidermidis, the best biomaterial was titanium. maggot excretions were added to the strongest biofilms, named above, and reduced these on all biomaterials. the maximal biofilm inhibition by maggot excretions was seen on polyethylene: % for p. aeruginosa (p < . ), % for s. aureus (p < . ) and % for s. epidermidis (p < . ). conclusion: this study shows that nor living maggots, neither maggot excretions have direct antibacterial properties. however, maggot excretions do reduce biofilms formed by different bacterial species on commonly used biomaterials. future research will focuss on the exact mechanism and the substance(s) that cause biofilm reduction. furthermore, possible indirect antibacterial activity will be investigated and the potential role herein of the immune system. introduction: tetanus is an acute disease caused by a neurotoxin produced by the bacterium clostridium tetani, characterised by generalised rigidity, muscle spasm and fatality. open orthopaedic injuries are at particular risk of developing infection from tetanus spores found in the environment. the uk department of health has established guidelines for the prevention of tetanus infection. we assessed the adherence of these guidelines on the initial pre-operative management of tetanus prone open orthopaedic injuries in trauma patients admitted for surgery. material and methods: a retrospective case note review was conducted on patients admitted to the orthopaedic department for intervention with a tetanus prone wound between february and june . tetanus prone injuries included open fractures, soft tissue injury requiring surgical intervention that is delayed for > h, wounds with significant devitalised tissue, wounds in contact with soil and open injuries containing foreign bodies. we assessed to what extent these patients had their immunisation status ascertained, application of wound irrigation and appropriate dressing, correct tetanus prophylactic cover (tetanus toxoid booster versus human tetanus immunoglobulin) and appropriate administration of antibiotics. results: of the patients included in the study, ( %) of patients were considered to have a 'high risk' tetanus prone injury and ( %) patients were deemed as having a 'low risk' clean wound based on the nature and extent of injury. performance within the high risk category showed that % of patients had their tetanus immunisation status ascertained, % correctly received wound irrigation and betadine dressing, % of patients were appropriately given prophylactic antibiotics. only % of patients with a high risk tetanus prone wound received tetanus immunoglobulin and % of patients were given a tetanus toxoid booster as a method for prophylaxis. conclusion: our study showed that a large proportion of patients correctly received supportive wound care and antibiotics. we also demonstrated that patients with open tetanus prone orthopaedic injuries are not adequately receiving correct tetanus immunoglobulin as the indicated prophylaxis. a large number of patients were given tetanus toxoid instead, which does not protect immunity early enough to cover the acute injury period, thus posing a major risk of developing a devastating and largely preventable infection. the orthopaedic and trauma doctor attending these patients must adhere closely to the correct initiation of simple measures in the management of tetanus prone orthopaedic wounds. all patients were irrigated and debrided, before the application of vac system. required debridements were maintained during vac therapy. time elapse between the injury time and vac application time was days on the average (min , max ). when the granulation tissue became sufficient to cover the bone, these wounds have been closed secondarily with several methods. time elapse between the start of vac and wound closure or formation of sufficient granulation tissue for grafting was days on the average (min , max ). results: distribution mean postinjury time for the osteosynthesis was , hours. three of these wounds were closed spontaneously without any need for other wound closure procedures. split thickness grafting is applied in patients, free flap to patients, full thickness grafting to patients, secondary suturing was applied in wound to close it. there was no infection in any extremities that we had osteosynthesed by internal or external methods. conclusion: wound care is as much important as osteosynthesis in open fractures. even if osteosynthesis is successful, failures in wound care may result in loss of extremity. vac alone does not suffice for wound closure. expectation in this therapy is to obtain ideal granulation tissue and to prevent infection development via appropriate wound care. the greatest disadvantage of vac therapy at the time being is its high economic cost. introduction: surgical haemostasis in trauma patients can be difficult and hazardous. commercial products are promoted to accomplish this task at a reasonable cost. in this study we compared the effectiveness of two topical gelatin-based haemostatic agents, flosealÒ and surgifloÒ in a porcine liver trauma model. material and methods: we compared the activity of flosealÒ (with human or bovine thrombin), surgifloÒ and surgifloÒ with added bovine thrombin in two porcine models. one anesthetised piglet mimicked ''normal'' conditions, while the other was kept in a status of hypotension, hypothermia and haemodilution, necessitating inotropic support (''critically ill''). laparotomy was performed, after which we inflicted five identical stab wounds on each liver lobe. each wound was treated with one of the four agents, while one wound was kept as a control. haemostasis was evaluated clinically. after euthanizing the piglets, the pathologist performed a macroscopic, microscopic and electron microscopic evaluation, blinded for which agent was used in which wound. results: clinically, surgifloÒ was able to produce a clot in some of its applications in the healthy piglet (''normal'' conditions), which was not the case in the critically ill animal, not even with the added thrombin. flosealÒ induced clotting in every wound. both microscopic (hematoxylin and eosin and mallory stain) and electron microscopic examination of the stab wounds confirmed that flosealÒ created a stable and dense agglomerate of gelatin and fibrin, firmly attached to the adjacent liver tissue, whereas with surgifloÒ, the gelatin contained more air bubbles, there was a lot less fibrin included in the clot and the clot was not strongly adherent to liver tissue. conclusion: it would seem that flosealÒ is a superior haemostatic agent, creating a dense and stable blood clot, even in a critically ill animal, hence ensuring haemostasis. disclosure: no significant relationships. introduction: bleedings stemming from splenic traumas are still among important causes of morbidity and mortality. aim of this study is comparison of fibrin glue with hemostasis effectiveness of ankaferd blood stopper lower lob resections on spleen of rats. material and methods: the study was performed at the animal laboratory of istanbul university after obtaining an approval from the ethics committee. twenty-four rats were randomly divided into three groups, namely, fibrin glue group (n = ), abs group (n = ) and control group (n = ). a wedge resection was performed on the lower lobe of the spleen. in fibrin glue group, spleen was hemostasis with fibrin glue (tisseel), while abs was administrated on the lower lobe surface in abs group. chronometric measurements were made to determine bleeding times. blood samples from the tail and vena cava were used for whole blood count and blood chemistry. histopathological scores were measured postoperatively on day th. results: in abs group, chronometric bleeding period is , s. whereas in fibrin glue group it takes , secods (p > , ). it was noted that the hemogramme test results, hemoglobin and hematocrit levels on the th days of abs and fibrin glue groups did not show sensible differences from one another ( . vs . ) p = . ( , vs , ) p = , . conclusion: there are no differences between the hemostasis speed and effectiveness of ankaferd blood stopper and fibrin glue as an applied material in bleeding stemming from experimental partial lower lob resections on spleen of rats. of the hemoperitoneum in right iliac fossa was performed and days after trauma, resulting in drainage of and cc of blood. patients were discharged month later and follow up was successful. conclusion: in selected hemodynamically unstable patients and upon availability of appropriate facilities, nom can be safely challenged over the usual limits. the indicators of tissue perfusion such as ph and be seems to be more reliable and sensitive prognostic parameter than hemodynamic instability evaluated by blood pressure and heart rate, in selecting the patients needing surgical control of hemorrhage. a moderate iah in young patients able to tolerate an increased intra-abdominal pressure, can allow a mechanical compression of the injured parenchyma achieving the arrest of hemorrhage, and extend the indications for nom in selected hemodynamically unstable patients, without signs of severe tissue hypoperfusion. material and methods: our case describes a year old male who fell m and landed on the right side of his torso dislocating a rib through the diaphragm, causing a transecting grade liver injury to liver lobes iv and vii, the right hepatic artery and a lesion of the retrohepatic vena cava (vc). the patient presented alert, hemodynamically stable with normal breath sounds. ct scan showed right sided hemothorax and a grade liver injury. a right sided chest tube drained ml of blood. the patient became unstable and was transferred to the or. profuse haemorrhage from the liver was encountered and massive blood transfusion protocol was initiated. the right hepatic artery showed to be injured and was ligated. pringles manoeuvre and packing of the liver were not enough to control the bleeding. an injury to the retrohepatic vc was suspected and manual compression was not sufficient to gain control. endovascular assistance was called for and using a bilateral femoral vein approach two occlusive balloons were placed and inflated under x-ray and open view in the vc to gain proximal and distal control. the patient stabilized and the injury to the vc could be sutured and covered with a topical haemostatic agent. the balloons were deflated but were left in place as a security measure. the liver was then again packed. the pringle manoeuvre had intermittently been used for approximately h in total. two vessel loops were left tension free around the hepatodoudenal ligament and brought out through the midline incision as a security measure. units of rbcs, units of ffps and units of platelets were given. angioembolization of the right hepatic artery was performed after the first surgery. during the second operation, the haemostats, vessel loops and occlusion balloons could safely be removed. days after the injury the patient showed increasing signs of liver failure. the patient was accepted for liver transplantation days after the injury; this procedure was carried out successfully. the combined open and endovascular approach in this case was crucial. the nature of the injury, the pringle manoeuvre, packing of the liver and arterial embolization caused permanent damage to the liver which had to be managed with liver transplantation which was successful. the use of endovascular occlusive balloons might also have had a role in the permanent damage of the liver, but had great benefit in saving the patients life. introduction: the incidence of pulmonary failure in multiple trauma patients is postulated to be influenced by several factors such as thoracic trauma and liver injury. the incidence of pulmonary failure increases in patients with an abbreviated injury scale thorax ‡ (ais) and they are more likely to face poor outcome. thus, the aim of the present study was to test the hypothesis that patients sustaining significant thoracic trauma (ais thorax ‡ ) in combination with a relevant liver injury (ais liver ‡ ) are more likely to develop pulmonary failure when compared to patients which sustained thoracic trauma without additional liver injury. material and methods: records of multiple trauma patients documented in the trauma registry of the german society for trauma surgery were analyzed using uni-and multivariate analyses. patients were subdivided into four groups according to their liver and thoracic injury: group (ais thorax < ; ais liver < ); group (ais thorax ‡ ; ais liver < ), group (ais thorax < ; ais liver ‡ ) and group (ais thorax ‡ ; ais liver ‡ ). potential relevant variables were subjected to univariate analysis between groups using the chi square test to predict the probability for pulmonary failure rate. subsequently, multivariate logistic regression analysis was performed, employing pulmonary failure as the dependent variable. differences at the level of p < . were considered statistically significant. results: , patients with a mean age of . ± . years and a mean iss of . ± . points fulfilled the inclusion criteria and were enrolled in this study. the overall rate of pulmonary failure was ± %. % of the patients in group , % in group and % in group developed pulmonary failure. the largest proportion of patients ( %) who developed pulmonary failure was found in group . those factors which proved to show a significant correlation with the incidence of pulmonary failure were included in a subsequent multivariate analysis. however, the presence of relevant lung injury, male gender, pre-existing medical conditions (pmcs), transfusion of more than packed red blood cells (prbcs) as well as iss and age played a significant role. in contrast to our hypothesis, liver injury did not proof to be associated with the incidence of pulmonary failure. conclusion: pulmonary contusion and significant liver injury seem to have a synergistic effect on the incidence of pulmonary failure. however, multivariate analysis with adjustment of further relevant factors reveal, that liver injury is not a predictive factor for the incidence of pulmonary failure. rather male gender and reported pmcs together with relevant lung injuries are more likely to develop pulmonary failure following multiple trauma. nethertheless, patients with combined pulmonary and liver injury are at higher risk for pulmonary failure with critical outcome. disclosure: no significant relationships. introduction: thoracic trauma is the leading death cause in % of politraumatised patients and contributes to the death of another % of these fatalities. identifying the determining causes, assessing their severity, early and qualified intervention in a multidisciplinary team may improve outcome of these patients. the goal of this paperwork is to assess the effects of thoracic trauma on clinical management, morbidity, mortality and outcome. material and methods: retrospective study of politraumatised patients admitted in the emergency department of st. pantelimon hospital between jan and jun . the followed parameters were most common injuries, severity, mortality, survival rate correlated with iss and rts, using data from emergency charts, hospital charts and anatomopathologic exams. results: out of patients, associated thoracic trauma, with a survival rate of , %. patients had blunt trauma. injuries that claimed early surgical intervention and had the highest death rate were: massive haemothorax patients ( % mortality rate), aortic and great vessels injuries patients ( % mortality rate), open pneumothorax patient ( % mortality rate), tension pneumothorax patients ( % mortality rate), flail chest patients ( % mortality rate). conclusion: thoracic trauma is often associated to politrauma and may increase significantly the mortality rate of these patients. lifesaving surgical procedures must be immediately performed, on patient arrival. it is important to adopt intervention protocols for multiple trauma, with a leading role of the emergency department medical staff. disclosure: no significant relationships. introduction: to evaluate treatment modalities of penetrating and/or contusive hemothorax, we reviewed our experience with patients admitted for traumatic hemothorax to our center for thoracic surgery. material and methods: from january to we treated consecutive patients (mean age, + sd years; m/f, / ) presenting traumatic hemothorax: patients had contusive hemothorax (cont) following car accident ( %), fall ( %), motorbike accident ( %), crushing trauma ( %), bike accident ( %); patients had penetrating trauma (pen) following stab wound ( . %), gunshot ( %) and impalement ( . %). we recorded demographic data, injury severity score (iss) at admission, endo-and extrathoracic injuries, method of treatment and outcome. results: there were no statistically significative differences between cont group and pen group regarding mean age ( vs years), gender (m/f = / vs / ), mean iss ( vs ) and icu admission rate ( % vs %). the cont group however presented a higher rate of extrathoracic lesions (bone, visceral, cns) than the pen group ( . % vs %: p < . ). in all patients a chest tube was immediately inserted, as the definitive treatment in % of cont pts and in % of pen pts (p < . ). surgical introduction: evaluation of penetrating injuries to the chest presented at a level traumacenter. the main study question was to see whether there was an increase in incidence in time. material and methods: in this retrospective study fifty-nine consecutive patients were included with penetrating injuries of the chest during the period of june until june . the penetrating injury had to be caused by gunshot or stab incident. statistical analyses of the data was performed using spss . . results: the study group consisted of fifty-nine patients. ninety percent were male with a mean age of years (range - ). the mechanism of injury were stab ( , %) and gunshot wounds ( , %). sixteen patients required a thoracotomy. in four other cases a laparotomy was performed. twenty-two ( , %) patients were admitted to the icu. the number of patients treated in the first year of the study period ( of the patients with a shotwound % died of their injuries and mortality rate of the patients with a stabwound was . %. in the last year of the study period the mortality of gunschot wounds was . %. conclusion: there is an increase in incidence of penetrating injury of the thorax for both stabwounds and gunshot wounds. the increase of gunshot wounds was especially large in the period july -june . the risk of suffering a gunshot or stabwound to the chest in our traumaregion is gender related. with the increase in the number of gunshot wounds, and thus experience, the mortality seems to decrease. introduction: rib fractures and more specific the flail chest are currently treated conservative. in our level one trauma centre we have on average patients with rib fractures and flail chests/yr. until recently we mainly treated the patients conservative. according to the literature the morbidity and mortality increases twofold with or more ipsilateral rib fractures and an age > yrs old. , some studies have also shown that operative fixation of rib fractures may reduce the morbididity significantly with this data and the recent development of specific dedicated osteosynthesis material for rib fractures we devised a pilot study in order to analyse the efficacy of this new matrixÒ rib fixation system (synthesÒ) and the effect on the morbidity/mortality of the patient. material and methods: during a month period we included all patients with the before mentioned criteria( rib fractures, > yr) or with a flail chest. we analysed operation details, lenght of icu stay, hospital stay and recorded complications. the results were compaired with a matched control group from . results: patients were included with an average age of yrs and a m:f distribution of : . patients had a flail chest and patients had or more rib fractures. on average all patients were operated within days ( - ). on average ( - ) rib were stabilized with an operating time of min ( - ). no implant failures were seen. patients had an average icu stay of days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . total hospital stay for the whole group was days ( - ), specific for flail chest it was days and for the ipsilateral rib fractures it was days. one patient sustained an extra rib fracture due to the procedure and one patient sustained an iatrogenic pneumothorax. one patient died due to neurologic complications. one patient had a superficial wound infection. no deep infections, pneumonia or chest related mortality occurred. compared to a matched control group of , the overall length of stay was not significant different. vs days. the length of stay for the ipsilateral fractures was not significantly shorter, vs . however the length of stay for the flail chest was significantly shorter in the study group vs (p < . ) the control group had significant more pneumonia, vs (p < , ). conclusion: the new matrixÒ system is easy and safe to work with. the system has good stabilizing capabilities. operative treatment reduces pneumonia and length of stay with flail chest. these results warrant a randomised study, comparing operative treatment vs conservative treatment. introduction: severe thoracic wall injuries can result in long time icu stay with ventilatory support substantial morbidity and even death. if the patient recovers persistent thoracic wall pain, restricted respiratory capacity and/or non union of the rib fractures can be the consequence. in a systematic review of literature we demonstrated that there is some evidence that early internal fixation can shorten the on-ventilator time, the icu stay and lower the short time morbidity. long term pulmonary function is not altered by internam fixation, however the rate of rib nonunion and chest wall pain is decreased. however high quality evidence is lacking. in order to evaluate the feasability of rib osteosynthesis with a new plating system: the synthes matrix system a preliminary study is performed and its results presented. this study preceeds a randomised controled trial comparing plate ad screw osteosynthesis and conservative treatment. material and methods: consecutive patients with flail chest and or serial rib fractures involving at least five ribs necessitating measures other than analgetics to maintain pulmonary function are included and prospectively documented. exlusion criteria: *hemodynamic instability necessitating a damage controle approach *intrathoracic injuries necessitating surgery *normal pulmonary function *patient refusing surgical treatment *patient not available for follow-up all patients are operated upon with use of the matrixrib system. postoperative icu stay, on-respirator time, pain at defined moments of follow-up, healing of the rib fractures and complications are recorded prospectively. patients grade their rate of satisfaction (functional and esthetical) on a scae of to . the results in these patients concerning on-ventilator time, icu stay and morbidity are compared to a historical series of patients with comparable iss. prospective case series with historical control group.(level iii) results: preliminary data indicate: *a shorter time on ventilator than anticipated (based on comparisson to historical data) * a shorter time on icu * less pneumoniae * no intra-operative complications * good healing results of the rib fractures * no implant failures * acceptable pain scores * good overal satisfaction * acceptable cosmetic results conclusion: internal fixation of rib fractures (flair chest or multiple sequential fractures with pulmonary function compromise) results in a earlier recuperation of pulmonary function with shortened icu stay. the overal satisfaction of the patient after operative treatment is good, with acceptable cosmetic results. there were no implant related complications. these results form the basis for a randomised control trial comparing operative fixation with the matrix rib system to conservative treatment. disclosure: no significant relationships. a. e. elsherif , m. fawzy , n. badr , m. marashda surgery, tawam hospital/johns hopkins international, abu dhabi, uae, surgery, tawam hospital, abu dhabi, uae, surgery, tawam hospital/johns hopkins international, abu dhabi, uae introduction: acute airway emergencies result from a wide variety of malignant and benign diseases. for both the patient and the clinician, the presentation can be frightening, and advanced interventional pulmonary/endobronchial techniques are required to achieve prompt relief of symptoms. general anesthesia is sometimes prohibited in these situations with complete loss of airway. we report our initial experience with these patients in a tertiary referral center. material and methods: three patients (two males) with acute proximal airway emergencies were included. two patients presented with acute stridor. the third presented with massive bronchial air leak and purulent drainage after an acute traumatic event. all patients were treated emergently with bronchoscopy and placement of an ultraflex bronchial stent under local anesthesia. all patients were followed up after discharge. results: there was no perioperative mortality or morbidity. the median age was . one patient had anaplastic thyroid cancer obstructing the trachea and was denied treatment elsewhere. the second patient had a malignant tracheoesophageal fistula. the third patient had an acute bronchopleural fistula following pneumonectomy for a gunshot wound. complete symptom relief was obtained after stenting under local anesthesia in all patients. median length of stay was days for the patients with malignancy. on a median follow up of months; two patients were symptom free, one patient died from malignant disease progression. conclusion: stenting under local anesthesia is feasible with acute airway emergency. obstruction of the central airways by malignant tumor is associated with poor prognosis.the alleviation of central airway obstruction by tumor is most often palliative, with improvement of quality of life the primary goal rather than cure. introduction: on april th an earthquake measuring . on the richter scale stuck a large area of the abruzzo region in central italy. the first notice suggested a lot of injured people and destroyed structures, incuded the main hospital of the area, the san salvatore hospital. material and methods: the national civil protection immediately send the field hospital (fh) of the marche regional government, the neighbouring region, together with a large amount of medical staff and personnel by the non governmental organization ares (regional association sanitary emergencies). this association, already involved during other national and international disaster situations and relief efforts, sent professionals volunteers (md and nurses) whit disaster knowledge and specific medical specializations. the international literature demonstrated that a fh is a complex structure and often the time required to be completely functionally is very long, indeed longer than the affected people needs. results: from april th , june th when the mission ended, the fh provided medical treated to almost patients, and the ares personnel ( ) where backed by the sanitary personnel of the san salvatore hospital. conclusion: a well planned medical response is very important to provide health assistance during a disaster, yet it is very hard to substitute a damaged hospital in the hearth of the disaster area. a modular sanitary structure, very light at the beginning, with specific and restricted medical supplies, with a little number of specialists in disaster medicine and disaster logistics, could improve the already good results obtained in the l'aquila abruzzo mission. disclosure: no significant relationships. around , people died, twice as many were injured, and almost million people were made homeless. in any situation of disaster, both natural and complex, may be produced a large number of victims that defeat the ability of local health resources to provide adequate health care. on one hand, the system may be overwhelmed with a high number of casualties. on the other hand, hospitals and other health care facilities generally may be compromised heavily: buildings may be destroyed or damaged and the supply of water, electricity, medical gasses, etc. may be limited. the transportation infrastructures may be severely damaged, creating problems for both people and equipment arriving at the hospital. damage to the health care infrastructure will further compromise the delivery of health services. material and methods: italian government responded immediately to this emergency after the official request for international relief efforts from the president of pakistan. two days after the impact, the first italian evaluation emergency team was already arrived in pakistan and the initial field structure was already fully operative, offering medical care, especially advanced trauma care and life support intervention, provided by specialists. later, when the structure had been completed and became larger provided also hospitalization, and surgical abilities, appropriate treatments and essential drugs. all the medical activities of the responding italian mission team field hospital in manshera were recorded and evaluated. results: a total of , patient contacts occurred at the field hospital during the days it operated, patients were admitted in the field hospital with a total number of nursing days with a average length of stay per admission of , days and with the occupancy rate of , %. a total number of major operations were performed. introduction: mass casualty incident's (mci) management is a present problem which is now more frequent because of iraki, afghan wars and terrorists actions. numerous new plans are evolved in each emergency association or military organization. nato as built a ''masscal'' plan to help teams in role ii in afghanistan to take care mci. through two experiences of mci in french role ii in afghanistan (kaboul) and through the litterature, we discuss the different ways of taking in charge mci. material and methods: the french role ii is located in kaboul near helicopter area. there are surgical teams ( pax, nationalities), emergencies boxes, icu beds and operating theatres. we have a pool of blood units, an echograph, a first generation ct-scan and all materials for traumatologic surgery. for mci, we use nato triage classification. each trauma undergoes ressucitation room, has needing x-ray exams, fast echography and intensive care if necessary. patient who needs urgent surgery runs immediately to operating theatre. iss score is calculated. the first mci concerns patients involved in a suicid bomber's explosion near the role ii. all were taken in charge min later. the second concerns an attack against a french coy occured km in the east of kaboul. there were casualties and soldiers died. they were taken in charge belatedly between to h later. results: fisrt mci : surgical interventions, one %burned, and a blast injury. second mci : surgical interventions, injuries with no surgery, blast injuries. we organize for these second mci a stratevac in france for casualties in less than h. mean iss score is for alive injuries and for the died soldiers. through these mci, we analyse the litterature and discuss about presents concepts in mci management. conclusion: the contemporary history of war, especially in iraqi and afghanistan constrains military surgical teams to improve their way of management of mci. training is necessary. first of all we have to define clearly each place of each actor, the conditions of triage, wich priority for which surgery and the possibility of modern communications and fast and efficient transports. the lower extremity ( %). % suffered multiple severe injuries, % upper extremity injury, % upper extremity and head/neck injury, % back injury, % head/neck injury, % upper and lower extremity injury, % abdominal injury and % miscellaneous. patients ( %) underwent an primary amputation of one or more extremities. ( %) patients underwent secondary amputation. all primary amputated limbs were shortened later. patient ( %)died one day after arrival in the cmh because of multiple severe injuries. conclusion: this single-center, and therefore complete dataset of the repatriated military personnel demonstrates the impact of participating in a nato mission for a small european country. it puts a high and challenging burden on the shoulders of the medical personnel in our hospital. further it shows, in contrast to studies from owens and dougherty, a higher prevalence of lower extremity injuries than upper extremity injuries. data regarding admission time, infection rate, disposition and quality of life will be presented. a lot of medical-ethical decisions had to be made about continuation of medical threatment or to decide whith patient will be treated and with patient will not be treated. as war surgeon you have to do operation for which you were not educated. because there is no other surgeon you have to the operation or the patient will die. it gives the opportunity to learn and gives a lot of surgical experience. this can be useful in civilian circumstances also. conclusion: the period as war surgeon in afghanistan has been of a forse impact. i had to take a lot of medical-ethical decisions and to do operations in which i was not trained. but i have learned a lot about war surgery and on human aspects also. introduction: there are a lot of unique challenges for the medical personnel which are assigned to the combat environment in afghanistan. especially the medical groups are in contact with patients from different nationalities and with different characteristics under special and difficult war circumstances. this article evaluates the effectiveness of the co-operation between a german and a greek surgical team during a -month period in a role ii hospital in north afghanistan. material and methods: from st july through th september , patients were admitted. there were male ( %) and female ( %). we reviewed the type of diseases, mechanism and location of injuries, management, type of surgical procedures performed, blood supply and outcome. results: . % of the patients were international security assistance force (isaf) personnel. most of the patients were men in a percentage of %. four children were included among the local patients. . % of the patients had surgical diseases while the rest . % were of orthopaedic interest patients. ( . %) patients underwent a surgical operation; ( . %) of them were operated immediately. gunshots were the main mechanism of injury for local patients whereas isaf personnel were usually presented with burns after improvised explosive devices (ieds) and rocket attacks. conclusion: the co-operation between medical teams from different countries, when appropriately trained, staffed, and equipped, can be highly effective in order to manage war casualties. introduction: in the emergency caused by natural and social disasters there are evident deficits between the health needs of affected population and the local health system capacity. the causes of disasters are various and not predictable, usually the health structures can not face up to the population needs. knowing that disaster medicine has different protocols and materials from ordinary medicine structures and that improvisation during the disaster's acute phases is not a good practice, it has been created an emergency operating health group, the non-profit ares association. (regional association sanitary emergencies) material and methods: the ares, whose members are about , all over the nation, is configured as an extraordinary health resource, activated by the national civil defence operations centre, in according with the regional centre of marche, in disater situations results: the main objectives of ares are training and organization of medical staff and structures and its growth crosses several missions including: ae earthquake in molise, introduction: cephalomedullary nails rely on a large lag screw that provides fixation into the femoral head. there is an option to statically lock the lag screw (static mode) or to allow the lag screw to move within the nail to compress the intertrochanteric fracture (dynamic mode). the purpose of this study was to compare the biomechanical stiffness of static and dynamic modes for a cephalomedullary nail used to fix an unstable peritrochanteric fracture. material and methods: thirty intact synthetic femur specimens (model # , pacific research laboratories, vashon, wa) were potted into cement blocks distally for testing on an instron (instron, canton, ma). a long cephalomedullary nail (long gamma nail, stryker, mahwah, nj) was then inserted into each of the femurs. an unstable four-part fracture was created, anatomically reduced, and the cephalomedullary nail was reinserted. mechanical tests were conducted for axial, lateral, and torsional stiffness with the lag screws in: ) static and ) dynamic modes. a paired student's t-test was used to compare the two modes. results: the axial stiffness of the cephalomedullary nail was significantly greater (p < . ) in the static mode ( . ± . n/mm) than in the dynamic mode ( . ± . n/mm) (fig a) . similarly, the lateral bending stiffness of the nail was significantly greater (p < . ) in the static mode ( . ± . n/mm) than the dynamic mode ( . ± . n/mm). the torsional stiffness of the nail was significantly greater (p = . ) in the dynamic mode ( . ± . n/mm) than in the static mode ( . ± . n/mm). a post hoc power analysis with a = . and ß = . revealed that the paired t-test on samples was sufficiently powered to determine a difference in mean axial stiffness of . n/mm ( . % of static stiffness), a difference in mean lateral bending stiffness of . n/mm ( . % of static stiffness) and a difference in mean torsional stiffness of . n/mm ( . % of static stiffness). conclusion: our results show that there is a n/mm reduction in axial stiffness of the cephalomedullary nail when the lag screw is changed from static to dynamic mode. this represents a . % reduction in axial stiffness with a change from axial to dynamic modes which may be clinically significant. the differences in lateral ( . n/mm, . %) and torsional ( . n/mm, . %) are small enough that they are likely not clinically significant. we felt that a difference of greater than % in axial stiffness and a difference of greater than % in lateral or torsional stiffness would be clinically significant. our study was adequately powered to detect these differences. given the significant reduction in axial stiffness with dynamization of the cephalomedullary nail construct, we recommend use of the static mode when treating unstable peritrochanteric fractures with a cephalomedullary nail. disclosure: no significant relationships. introduction: minimizing tip-apex distance has been shown to reduce clinical failure of sliding hip screws used to fix peritrochanteric fractures. the purpose of this study was to determine if such a relationship exists for the position of the lag screw in the femoral head using a cephalomedullary device. material and methods: thirty intact synthetic femur specimens (model # , pacific research laboratories, vashon, wa) were potted into cement blocks distally for testing on an instron (instron, canton, ma). a long cephalomedullary nail (long gamma nail, stryker, mahwah, nj) was inserted into each of the femurs. an unstable four-part fracture was created, anatomically reduced, and repaired using one of lag screw placements in the femoral head: ) superior (n = ), ) inferior (n = ), ) anterior (n = ), ) posterior (n = ), ) central (n = ). mechanical tests were repeated for axial, lateral and torsional stiffness. all specimens were radiographed in the anterioposterior and lateral planes and tip-apex (tad) distance was calculated. a calcar referenced tip-apex distance (caltad) was also calculated. anova was used to compare means of the five treatment groups. linear regression analysis was used to compare axial, lateral and torsional stiffness (dependent variables) to both tad and caltad (independent variables). results: anova testing proved that the mean axial (p < . ) and torsional stiffness (p < . ) between the five groups was significantly different, but lateral stiffness was not statistically different (p = . ). post hoc analysis showed that the inferior lag screw position provided significantly higher mean axial stiffness ( . ± . n/mm) than superior ( . ± . n/mm; p < . ), anterior ( . ± . n/mm; p = . ) and posterior ( . ± . n/mm; p = . ) lag screw positions. there as no significant difference in mean axial stiffness between inferior ( . ± . n/mm) and central ( . ± . n/ mm) lag screw positions (p = . ). post hoc analysis revealed significantly less mean torsional stiffness for the superior lag screw position compared to other lag screw positions (p < . all pairings). there were no significant correlations between tad and axial (r = - . , p = . ), lateral (r = - . ,p = . ) or torsional (r = . , p = . ) stiffness. there were significant correlations between caltad and axial (r = - . , p < . ), lateral (r = - . , p = . ) and torsional (r = - . , p = . ) stiffness. conclusion: our results suggest that placement of the lag screw inferiorly in the femoral head when using a cephalomedullary nail to treat an unstable peritrochanteric fracture results in the stiffnest construct in axial and torsional biomechanical testing. a simple radiographic measurement, caltad, provides an intraoperative method of determining optimal cephalomedullary nail lag screw position to achieve greatest construct stiffness. introduction: a potential of polymethylmethacrylate (pmma) augmentation to increase the purchase of cephalic implants in the treatment of intertrochanteric hip fractures has been proven in sev-eral biomechanical studies [ ] [ ] [ ] [ ] . the aim of this study is to compare the cut-out ratio of pmma augmented helical blades to not augmented ones in human cadaveric femoral heads. material and methods: six pairs of osteoporotic cadaveric femoral heads were instrumented with a proximal femoral nail antirotational (pfna) blade in a standardized manner. within each pair, one blade was augmented using ml of pmma cement. cyclic loading was performed at hz. starting at n, the load was monotonically increasing by . n/cycle until failure of the construct. x-rays were taken at cycle increments to monitor the movement of the blade with respect to the head. paired nonparametric test statistics were used to identify differences between groups. results: a significant higher number of cycles to cut-out was found for the augmented group (p = . ). a significant correlation was observed between bone mineral density and cycles to cut-out for the non-augmented specimens (p < . , r = . ), whereas no correlation was found for the augmented group (p = . introduction: when treating distal tibial deformities or fractures with the ilizarov external fixator the ankle joint and foot is often transfixed within the ring construction. for some patients full weight bearing can only be achieved in assembling a walking device on the distal ring. the biomechanical effect of the indirect loading on the fixator stiffness, the osteotomy and the wire tension is still unkown. material and methods: on the basis of a standarized ilizarov external fixator ( rings, mm diameter) with two , mm wires per ring applied in anatomical position on composite tibiae ( rd generation sawbones) direct and indirect loading was analyzed using a universal testing machine (model , uts germany). a middiaphyseal osteotomy of , mm was performed. the following parameters were recorded: micromotion at the osteotomy, relative movement between bone and rings, compressive forces at the osteotomy and strain of the wires. each experimental setup was tested ten times with kg maximal axial loading. results: the osteotomy gap closure occurred at n at direct loading and at an average of n at indirect loading. the compressive forces at the osteotomy were almost double as high at direct loading. regarding the relative motions between rings and bone the amplitude of motion was higher at indirect loading. the stress on the wires was up to four times higher when the walking device was applied on the distal ring for indirect loading. conclusion: the indirect loading using a walking device has a substantial influence on the mechanical characteristics of the ilizarov fixator which determine the biomechanical environment of the osteotomy/fracture. the results showed a higher mechanical load while achieving less compressive forces at the osteotomy. in the need of the walking device we suggest to apply additional half-pins at least in the distal fragment. ) . three randomized groups of pairs were formed. after the osteosynthesis with the implants was done the fracture (a . ) was made with a jigsaw. for further destabilsation the troch. minor was removed. the femura were fixed in the testing machine and tested under dynamic condition with a physiologic load for normal walking ( . x bodyweight) under cycles. we measured the load on the implant, the migration and rotation of the bone around the implant. the data was dokumented with lab view, results: the intramedulare implants showed significant lower migration rates (mean . mm) of the head compared to the extramedular implants (mean . mm). the rotation of the head around the lag screw startet earlier within the dhs an showed higher rates (mean °) followed by the gamma (mean °) until the end of the cycle. the best stabilisation against rotation was documented for the pfn a (mean °). the post x-rays showed a significant migration and sintering process of the femoral head with lateralisation and fracture of the lateral wall. this was even higher in probes with a low bmd. introduction: excising part of an implant through the femoral head is a rare but severe complication of osteosynthesis of proximal femoral fractures. there is little evidence in the literature about incidence and management of this complication. according to opinion leaders in an recent international user meeting most cases end up in total hip arthroplasty (tha). the value of re-osteosynthesis remains unclear. most patients that suffer an excision are geriatric and multimorbid patients, rather suitable to less invasive revision surgery. to assess the incidence and management of cutting out of the pfna blade (proximal femoral nail antirotation by synthes gmbh international) was the aim of this multicenter study. material and methods: the incidence and management of excision of the pfna blade in trochanteric femoral fractures was assessed retrospectively in cases in participating hospitals all over europe in a time period between and . all implantations were screened for this complication. the preoperative, follow up x-rays and patients' medical records including the surgical reports were collected and analysed with a special focus on revision surgery until union or tha. results: the incidence of excision of the implant was . % ( / ). the mean age of patients was years. % of mostly female ( %) patients sustained an unstable a fracture according to the ao classification. final revision surgery was performed with tha in cases ( %). in cases re-osteosynthesis led to union ( %). reosteosynthesis was either exchange of blade with or without cement augmentation alone or re-nailing. in % of tha revisions additional revision was necessary. in % of revisions with exchange of blade additional revision was required (all tha). % ( / )of revision cases with cement augmented blades healed. in % of revision with re-nailing, additional surgery was inevitable. on average . operative procedures were performed after excision of the pfna blade. conclusion: cutting out of the blade of the pfna is a rare complication. nevertheless the management after removal is challenging as indicated by the high number of surgical revisions. revision with total hip arthroplasty showed a lower rate of reoperations compared to re-osteosynthesis. nevertheless % of all revision cases were managed successfully with a minimally invasive osteosynthesis. this gives a rationale for osteosynthesis in managing this complication in geriatric multimorbid patients with a high risk for operation. references: . simmermacher, r. k., j. ljungqvist, et al. ( ) . ''the new proximal femoral nail antirotation (pfna) in daily practice: results of a multicentre clinical study.'' injury ( ) in a prospective series of subtrochanteric fractures with or without involvement of the pertrochanteric region and in revision procedures of this area the pf lcp was applied. in out of patients a fixation failure was observed. this paper reports on these fixation failures. material and methods: all patients with a multifragmented subtrochanteric fracture with or without involving the trochanteric or the femoral neck region which where judged to present a compromised nail entry point from may until may were stabilized using the pf lcp. the plates were applied in a minimally invasive manner through soft tissue windows (mipo). intrinsic stability of the fixation was increased by excentric drilling or applying the tensioning device. all patients were followed up to fracture healing. intraoperative and postoperative complications were noticed. intraoperative and postoperative x-rays were analysed using the ccd angle and the gardens alignment index. results: we report out of patients who sustained a fixation failure with secondary varus collapse requiring revision surgeries until healing. revision consisted in a reosteosynthesis in one, a plate exchange to a o blade plate in the second and a dhs in the third patient. in all our reported cases of implant failure the posteromedial buttress was missing [two ao a and two seinsheimer type v], and all patients were not able to restrict wheight bearing due to different reasons like, noncompliance (alcohol abuse, limited force, advanced age) leading to increased axial bending forces and finally to breakage of the femoral neck screws with varus collapse of the fracture. conclusion: in conclusion the pf lcp proximal femoral plate . / . due to its guide wire technique allows for straightforward plate application and reduction also in very complex fractures of the trochanteric region, including fractures with extension into the greater trochanter or reverse oblique intertrochanteric fractures. however in fracture patterns with missing posteromedial support and limited ability to restricted weight bearing (e.g.: advanced age, additional handicap or mal-compliance) an alternative fixation device should be considered, e.g. the hook plate extension of the lcp proximal femoral plate to apply higher intrinsic stability of the fixation when using the tensioning device. further clinical and biomechanical studies are needed to evaluate the potentiality and limitation of this device for the treatment of these challenging fractures of the trochanteric region. the majority of the the former fixation was replaced by a blade plate. in % we performed a total hip prosthesis. in these cases we saw an overproportional tend to prosthesis-luxations. conclusion: we conclude that mechanical complications like cut out are a little more frequent after dhs-implantation and should be treated by change to a blade-plate-osteosynthesis. this allows a fracture consolidation in that the minor trochanter becomes that stable, that a regular total hip replacement becomes possible. this seems to be the best prevention of mechanical complications after posttraumatic hip replacement like luxations. disclosure: no significant relationships. introduction: hip fractures often concern elderly patients with a high degree of co-morbidity and therefore susceptible for the associated postoperative morbidity and mortality. according to the literature, several factors have an influence on the amount and severity of postoperative complications after hip fractures. low preoperative haemoglobin levels (hb) in elderly patients seem to be associated with increased short-term morbidity and even mortality after surgery. the aim of this study was therefore to establish the impact of anaemia and blood transfusion on postoperative recovery of hip fracture patients. results: there were women and men with medium age of , years ( - years) and with medium follow-up of years ( - years). the lesions occur in sports, % of the fractures occur while practicing soccer. the fractures were bimalleolar (n = ), medial malleolus (n = ), lateral malleolus (n = ), with sindesmotic lesion (n = ) and trimalleolar (n = ). months after surgery % of the patients returned to sports activity ant at months %. at months the younger patients (p = , ) and men (p = , ) returned earlier to sports activity. at one year % of the amateur and % of the professional athletes, had returned to sports practice. fractures of the lateral malleolus returned earlier in , weeks than medial malleolus fracture in , weeks. the smfa and aofas scores were high in all types of fracture. conclusion: correct treatment of instable ankle fractures in athletes, with anatomic reduction and preservation of the integrity of the articular surface, is crucial to the return to sports practice. the fractures that influence an earlier return were younger age, male sex and less severe fracture, and negative predictors were older age and female sex. athletes submitted to open reduction and internal fixation with adequate and precocious programme of physical rehabilitation, can return to the same level of sports practice, despite the seriousness of the fracture without pain and functional limitation( ). results: in all cases anatomic reduction could be achieved. no secondary dislocation was observed and all fractures healed uneventfully. conclusion: indirect reduction of the volkmann triangle from anterior makes an image intensifier mandatory and has potential of not achieving anatomic reduction due intercalated tissue. in larger fragments the fixation with a lag crew from anterior, the buttressing effect might not be sufficient to avoid secondary displacement. with the use a postero-lateral approach and dorsal plate for fixation of the volkmann triangle, it is possible to reliably obtain an anatomical reduction of the dorsal articular surface of the tibia, thus potentially minimizing the risk of posttraumatic osteoarthtitis. introduction: after ankle-and hindfoot fractures, edema often delays surgery and postoperative mobilisation. therefore effective treatment of edema is of great importance. the aim of this study was to evaluate the efficacy of the continuous lymphological multi-layer compression therapy and of the av-intermittent impulse compression (avi) in reducing ankle-and hindfoot edema. material and methods: randomized, controlled, single-blinded, clinical trial. patients ( ± years, m, f) with unilateral fractures of the ankle or hindfoot pre-or postoperatively were randomized into a) the control group (elevation and cold packs), b) the continuous multi-layer compression therapy group (cct) or c) the av-impulse compression group (avi). primary outcome was the pre-respectively postoperative reduction of edema as measured with the figure-of-eight methode . results: pre-and postoperatively the continuous lymphological multi-layer compression therapy (cct) showed a significant better edema reduction when compared to the control group. after three days of intervention the mean preoperative edema reduction in the control group was - . ± . mm ( . %) figure-of-eight methode vs. - . ± . mm ( . %) in the cct group (p < . ) and vs. - . ± . mm ( . %) in the avi group. three days postoperatively the mean edema reduction was - . ± . mm ( . %) in the control group vs. - . ± . mm ( . %) in the cct group (p < . ) and - . mm ± . ( . %) in the avi group. pre-and postoperatively the cct group shows moderate effect sizes after two days of intervention and large effect sizes after three days. avi is more effective when combined with elevation during off-session periods. conclusion: continuous lymphological multi-layer compression therapy leads to a clinical relevant and significant better reduction of ankle-and hindfoot edema as compared to the standard treatment with elevation and cold packs. av-intermittent impulse compression shows a tendency towards a better edema reduction compared to the standard treatment. continuous lymphological multi-layer compression therapy reasonably can be applied when edema delays operation or postoperative mobilisation. considering the avi application we strongly recommend to elevate the leg during off-session periods. introduction: the objective of the study is to define the global hospital costs of a group of patients that suffered from severe trauma. additionally we identify the distribution of the expenses between the different services and the different procedures fulfilled to the patient. ( ), season ( ), moon phases ( ), times on duty ( ) and weather condition ( ) . the observed mortality was adjusted with the risc based prognosis and the smr calculated. results: the selected collective had an average age of . years and % of the patients were males. the mean iss was . and the mean hospital mortality was of . %. for the time of day the highest rate of admission was between : and : p.m., with the highest numbers on saturdays. in the times of on-call duty (weekend, public holiday, weekday between : p.m. and : a.m.) twice as much trauma patients were delivered to trauma centers as within the regularly working hours. in summer, the admission rate was highest ( . %) and lowest in winter ( . %), with more victims of car accidents in autumn and winter as in the warm season and more victims of motor-and bicycle accidents in spring and summer as in the cold season. but none of the mentioned factors showed an effect on survival (smr between . and . ). the moon phases had no influence either on frequency of accidents nor on outcome. the effects of temperature was similar to this of the seasons: with warm temperatures/month less car accidents and more bike accidents occurred (and the opposite for cold temperatures). in the subgroup with temperatures under zero degree the mortality was % higher ( . %) than in the subgroups with temperatures above zero ( , to , , even though a similar iss ( , vs. , to , ) . in a second step a multivariat analysis was done in order to improve the predictive power, but none of the external factors could improve the prognosis. conclusion: there are large variations in the incidence of severe accidents due to time of day, day of week and time of year. but there is no effect of patient's outcome in regard to medical care in german trauma centers. the quality of medical trauma care is consistent around the day, the week and throughout the year. additionally, we observed an increasing difference between mortality rate and risc prediction rate from - , % to - , %, means less deceased polytraumatized patients than predicted. within the late secondary transferring patients with spinal cord injuries were leading ( %), followed by patients with pelvic injuries ( %), infections ( %) and complex extremity injuries ( %). conclusion: with this investigation, we tried to characterize the influence of the new mapping of germany on patient data using the example of the regional trauma network ''saar-(lor)-lux-west-rhineland-palatinate''. although, knowing a lot of interferences, we noticed an abrupt rise of primary admittances of trauma patients in our level- hospital since starting networking. among the load rejection for smaller hospitals this fact leads to a distinct concentration of the treatment of polytraumatized patients in specialized trauma centers. the improved routine by increased quantity could be responsible for the improvement of process and outcome quality in the treatment of severely injured patients. but, the enormous quantity of emergency patients also reflects a future challenge in dealing with emergency operations besides routine operations as well as seldom icu-beds in these trauma hospitals. the role of the nlfc is to work in parallel to doctor led clinics, assessing and treating uncomplicated musculoskeletal injuries with a favourable natural history. since its inception, throughput in this clinic has increased and with greater clinical exposure and training, the spectrum of referred injuries has also broadened. the aim of the present study was to determine patient satisfaction with the nlfc using a validated questionnaire with a specific emphasis on how patients viewed being seen by a nurse rather than a doctor material and methods: consecutive patients were prospectively recruited in the nlfc in january . patients were referred by their resepective consultants after reviewing the presenting history, examination findings and radiographs. after their consultation with the nurse, each patient was asked to fill in a item questionnaire consisting of different domains related to patient satisfaction based on a validated patient satisafction questionnaire adapted for use in the fracture clinic setting. results: there were respondents, men and women, with a mean age of years (range - years). questionnaires were completed by parents, by carers and the remainder by the patients themselves. the most common treated injuries were distal radial, metatarsal and metacarpal fractures. % of patients felt they received the best care from the staff working in the clinic with greater than eighty percent of patients registering satisfaction with the nurse's assessment of their injury, their bedside manner and the treatment and information given. only % of patients felt that they would rather be seen by a doctor for their injury. the highest rates of dissatisfaction related to the building and seating comfort. conclusion: generally, over % of patients were satisfied with their clinic visit with the vast majority of patients not having any objection to seeing a nurse rather than a doctor. patient satisfaction with treatment remains the ultimate outcome measure by which healthcare interventions should be assessed. the results of this study demonstrate the nlfc to be an effective method of managing selected patients in a clinic setting thus reducing the workload of patients which would traditionally be reviewed by the doctor. this has significant implications for improving opportunities for doctors training as well as reducing clinic waiting times. [ ] [ ] [ ] [ ] . the aim of this study is to evaluate the anatomical correlation between the lateral end of the clavicle and the attachment area of the supraspinatus tendon. material and methods: using a mathematical model based upon ct-scan data performed on healthy individuals, the dimensional correlation between the lateral and of the clavicle and the rotator cuff is analyzed. each individual is examined in supine position, using different positions of the arm (maximum external rotation, maximum internal rotation and maximum abduction and external rotation (''aber position''), respectively). for every position the contact area of the lateral end of the clavicle and the spupraspinatus tendon is calculated. results: six healthy individuals ( shoulders) could be included into the study. the average contact area between the lateral end of the clavicle and the supraspinatus tendon (%) is . % for maximum external rotation, . % for maximum internal rotation, respectively. in the aber position only / shoulders showed a contact area > % (av. . %). conclusion: according to these morphological findings the contact area between the lateral clavicle and the supraspinatus tendon is less than %. this contact zone is located in the dorsal aspect of the clavicle. therefore the additional resection of an osteophyte, especially at the anterior part of the lateral clavicle should not have a significant influence on the outcome after subacromial decompression. and good to moderate outcome in the cs (mean ), one patient had a moderate dash score of with a poor cs of . irrespective of treatment strategy the majority of the patients regained normal range of motion and grip strength in the affected shoulder. the most common complication was impingement of the shoulder, which occurred three times in the conservatively and four times in operatively treated patients. all but one conservatively treated patient with a non-union healed without complications. conclusion: minor ( £ mm) and moderate ( - mm) displaced greater tuberosity fractures can successfully be treated conservatively with good to excellent long-term rehabilitation of function with a low risk of complications. whereas there is no doubt that major displaced fractures (> mm) should be treated operatively, special attention must be paid to moderate ( - mm) displaced fractures, as the degree of displacement may be misinterpreted on plain standard radiographs. disclosure: no significant relationships. introduction: a recent study found that after median term follow-up disability correlated with pain rather than the limited residual impairments in motion and strength. we studied impairment and disability an average of twenty-one years after injury in a cohort of dutch patient, with the hypotheses that ) objective measurements of impairment correlate with disability, ) depression and misinterpretation of nociception correlate with disability; and ) patients injured when skeletally mature and immature have comparable impairment and disability. material and methods: seventy-one patients were evaluated an average of years after injury. the majority of the skeletally immature patients were treated conservatively with closed reduction and cast immobilization and the majority of the skeletally mature patients were treated with plate and screw fixation. objective evaluation included radiographs and measurements of range of motion and grip strength. questionnaires were used to measure arm-specific disability (disabilities of the arm, shoulder and hand: dash), misinterpretation or over interpretation of pain (pain catastrophizing scale-pcs-), and depression (ces-d). multivariable analysis of variance and multiple linear regression were used to analyse the ability of the independent variables to account for variation in the dash-score. (spss . , spss inc., chicago). results: there were men and women with a an average age of forty-one at time of follow-up (range, to ). fractures were classified as ao/ota-type a in patients (simple), b in (including wedge fragment) and c fractures in patients (comminuted). the average dash score was points ( to ) and % reported no pain. both rotation and wrist flexion/extension were % of the uninjured side; grip strength was %. there were small, but significant differences in rotation ( versus degrees, p = . ) and wrist flexion/extension ( versus degrees, p = . ), but not disability between skeletally mature and immature patients. the best predictors of dash score were pain catastrophizing, pain, ipsilateral injury and grip strength, explaining % of the variation in dash scores. pain alone accounted for % of variation in dash scores. conclusion: twenty-one years after initial fracture, both skeletally immature and mature patients have limited impairment (averaging over % motion and grip strength) and disability after non operative and operative treatment respectively. patients that were skeletally immature at the time of injury had better motion, but comparable disability. disability correlated with pain and pain catastrophizing rather than motion. results: the mesenteric injuries vizualized on initial ct-scan were mesenteric vascular beading or extravasation in cases, and mesenteric infiltration or hematoma in cases. associated abnormalities of the gastrointestinal tract (thickening, abnormal enhancement, perforation) were present in / cases ( %). nine patients underwent surgery ( %), patients in the early hours, and others after a delay of more than h. indication for surgery was hemodynamic instability in cases and suspicion of bowel perforation in cases. in total, intestinal perforations were found in patients. three patients ( . %) died of associated injuries. no false positive scan has led to unnecessary surgery. however, the negative predictive value of initial ct was % for intestinal associated lesions. conclusion: the mesenteric injuries in blunt polytrauma patients are uncommon but serious. the whole body scanner is a powerful tool for the diagnosis of these mesenteric lesions. conservative treatment is feasible but a clinical and paraclinical reassessment is essential for early detection of intestinal lesions initially undiagnosed, or aggravation of initial lesions. disclosure: no significant relationships. introduction: drug smuggling by gastrointestinal concealment, body-packers, is an increasing problem in developed countries. although conservative treatment is usually successful in most cases, some of these patients suffer complications such as obstruction, gastrointestinal perforation or massive drug intoxication due to a leaking package. despite an urgent surgery and a careful management in the icu, morbidity and mortality remain high. our aim was to assess the outcomes of conservative and surgical management of these patients in our hospital, the referral centre for this entity in madrid. ( ) ( ) pre-hospital fatalities were more frequent (although not statistically significant), which may reflect improvement of trauma organization in recent years ( ) ( ) ( ) ( ) . domestic (may related to delay due to victim's solitude) and urban environment (inexperienced personnel, delay due to referral to another hospital) incidents lead more frequently in pre-hospital death. age and iss as indicators of physiologic reserve and severity of injury were independent predictors of fatality before the victim reaches hospital. introduction: the triad of the elbow is a complex traumatic injury. these injuries have traditionally been considered a poor prognosis for the consequences that arise as a secondary instability, stiffness and loss of functional ability. the objective of this free paper is to review from a clinical and radiological perspective our experience with cases. material and methods: we retrospectively reviewed patients with this type of injury. in patients was not carried out a comprehensive treatment of all existing lesions. the coronoid process was not addressed specifically and fractured radial head was removed or and an osteosynthesis was performed. in the remaining were treated by a treatment protocol trying to repair all the damaged structures (coronoid synthesis, radial head arthroplasty/orif and ligament repair, at least in the external lateral ligament complex). the median followup was months ( - ).the results were evaluated by the scale of may elbow performance score (meps), range of mobility, radiographic parameters and complications during follow up. results: patients treated according to protocol in a systematic manner trying to repair all damaged structures had better outcomes in both the radiological point of view as functional, as well as a lower rate of complications. meps in these patients the average was points (vs. the other group), the arc of º flexoextensió n (vs. º) and the arc pronosupinació n º (vs º). conclusion: despite being an injury traditionally associated with poor results, which have been established treatment protocols that try to treat all manner of injured structures involved in the injury outcomes have improved significantly. we think it must be performed a radial head artroplasty/orif (not resection), anchorage/ osteosynthesis coronoid process and a ligament repair at least of the external lateral ligament complex. if residual instabilty results it may be repaired the medial colateral ligament complex and a temporal external fixator may be used. disclosure: no significant relationships. tion. patients received a secondary implantation including chronic luxations, nonunions, failed osteosynthesis and reimplantation after deep prosthetic infection. the mean follow up was ± months. the functional outcome was measured by using the mayo elbow performance score. results: we had female and male patients with a mean age of ± years. all patients achieved very good results based on the ,,mayo elbow performance score'' with a postoperative mean of points (range between and points) with a maximum performance of points. the mean range of motion concerning extension and flexion was degrees ( to degrees), concerning pronation and supination degrees ( to degrees). the mean flexion deformity was degrees ( to degrees), the mean maximum flexion was degrees ( to degrees). we had two partial ruptures of the triceps tendon, one treated by operative refixation and one conservative, one temporary lesion of the ulnar nerve with complete recovery and one postoperative hematoma which needed surgical treatment. one patient needed revision surgery and resection arthroplasty due to a deep infection, but received a new prosthesis after two months. we recorded no radiographic loosening or other mechanical problems so far. conclusion: according to the used ''mayo elbow performace score'' all patients achieved a very good functional outcome. eventhough they all had severe injuries of the elbow. with modern types of elbow prosthesis the rate of complications and revision surgery is quite low. Ô ur findings indicate that total elbow arthroplasty should be considered as an additional treatment alternative. patients with a lower functional demand and of higher age benefit most from a prosthesis. for younger patients preservation of the joint should be achieved as far as possible. introduction: it is not always possible to reconstruct complex radial head fractures. as non-anatomical reconstruction and healing disturbances result is loss of motion and severe post-traumatic arthritis of the elbow joint, radial head resection as been proposed for these cases. however secondary overload of the lateral facet of the humero-ulnar joint (with consequent arthritis), instability (especially in the presence of medial collateral ligament injury), painfull anteroposterior instability of the radial stump, and radial shortening (in essex-lopresti lesions) with wrist pain can be the result. radial head arthroplasty widely is proposed as prevention of these complication. however as we demonstrated in a systematic review of the litterature, radial head arthroplasty has equally high secondary arthritis rates as radial head resection. the complex anatomy of the radial head, articulating both with the capitellum and the proximal ulna is not reproduced by most contemporary radial head prostheses. material and methods: we describe the complex radial head anatomy based upon an analysis of mriâ e tm s of the elbow performed in healthy volunteers under standardised situations. we describe the next variables: â e¢radial head shape and diameter at the most proximal part of the pruj (proximal radio-ulnar joint) â e¢radial head shape and diameter at the midpoint of the pruj â e¢radial head height medial and lateral â e¢depth of the radial head through â e¢offset of the radial headâ e tm s through relative to the center of the radial head â e¢offset of the radial headâ e tm s through relative to the axis of the radius â e¢offset of the radial head relative to the axis of the radius â e¢angulation of the radial neck to the axis of the radius we compare these parameters to the available radial head prostheses. results: there is a high variability of the different parameters and no relation between all of the parameters could be determined. the existing radial head prostheses do only reproduce the anatomy to a limited extend. conclusion: the high rates of post arthroplasty arthritis can be related to the non-anatomical shape of the existing designs. as the proximal radius articulates both with the capitellum and the proximal ulna, a precise reconstruction of both joints is a necessity to avoid maltracking and/or edge contact in both joints. given the high variability this only can be realised using a theoretic modular prosthesis that allows for reconstruction of the synchronisation between both joints. we found no significant differences (p > . ) in the deficit of the range of motion. flexion: screws ± °, prosthesis ± °, plate ± °e xtension: screws ± °, prosthesis ± °, plates ± °p ronation: screws ± °, prosthesis ± °, plates ± °s uppination: screws ± °, prosthesis ± °, plates ± °a ccording to elbow functional evaluation criteria by broberg and morrey, we found excellent and good results in % of all patients treated with screws, in % of all patients treated with prosthesis and in % of all patients treated with plates (p > . ) the average dash score of patients treated with screws was ± points, of patients treated with prosthesis ± points and of patients treated with plates was ± points (no significant differences, p > . ). the physical and mental component of the sf- score was at the time of follow-up within the normal range at all patients (physical component: screws ± . , prosthesis ± . , plate ± . ; mental component: screws ± . , prosthesis ± . , plate ± . ). in the subcategory of physical functioning, screws performed better than prosthesis (p < . ). no other items of sf- were significantly different (p > . ). conclusion: according to our results osteosynthesis with only screws seem to be the best of the three studied methods. radial head prosthesis replacement yields better functional results than treatment with plates. it must be considered that prosthesis replacement of the radial head has the long-term risk of loosening, especially in young and active patients. plates showed worse clinical results especially in rotation of the forearm even after removing the plate in patients. disclosure: no significant relationships. s is angular stable osteosynthesis of the olecranon more economical than traditional treatment? n. spaepen , k. govaerts , s. nijs , p. broos trauma surgery, uz leuven, leuven, belgium, department of traumatology, university hospitals leuven, leuven, belgium, traumatology, university hospitals leuven, leuven, belgium introduction: although tension band wiring is considered as the gold standard in the treatment of simple olecranon fractures and olecranon osteotomies, the complication rate is high (delayed healing in up to % of cases, hardware migration %). in an historical series using anatomical preshaped lcp plates, we could lower the rate of healing disturbances, but the volume of the implant did make hardware removal necessary in the majority of patients. the lcp , mm hook plate is a low volume angular stable compression plate, designed for the treatment of simple fractures and osteotomies of the olecranon. in this study we want to evaluate the early results of using this new device for the treatment of acute fractures and osteotomies at a level trauma centre. material and methods: we prospectively include all patients treated by lcp , mm hook plate between and. months results considering range of motion (as measued by), meps (mayo elbow performance score), complications and radiographic results are presented. we perform a cost analysis of primary operation using the different implants available, length of stay and time off work. we also perform a cost analysis for reoperation because of delay in union results: we included patients. average age is , years (range - ). there were female and male patients. at months average extension deficit was °, the average flexion °. there was no substantial loss of pro-supination. all factures but one united anatomical (early loss of reduction, but patient refused reoperation). there were complications: early loss of reduction (treated conservatively), crps (complex regional pain syndrome) and arthrofibrosis necessitating implant removal). because of symptomatic hardware two additional hardware removals have been performed. according to the mayo elbow performance score all but patient scored good to based upon the cost analysis the predicted average cost per patient is significantly lower in the hook plate group as compared to the tension band and anatomical preshaped plate group. conclusion: although still a limited series, the early results of this implant are very promising. we document ranges of motion witch are comparable to those described previously in tension band wiring or anatomical plating, but at lower complication and reoperation rates. based upon an analysis of the cost of treatment and of reoperation we advocate the routine use of the olecranon hook plate in the treatment of simple olecranon fractures and osteotomies. disclosure: no significant relationships. material and methods: dutch surgeons (n = ) were asked to draw two incisions for an olac on embalmed human specimen (n = ). they also filled out a questionnaire of their experience. all incisions were photographed and digital measurements were taken. each incision was compared to the gold standard on criteria. incisions should not be closer than two-thirds of the distance between: ) distal tip of the lateral malleolus and the achilles tendon. there was no correlation between number of mistakes and number of procedures per year or years of experience (spearman correlation: . and - . respectively) the median of the mistakes for l-shaped incisions was (iqr = ) and (iqr = ) for j-shaped incisions (p = . , mann-whitney). the spearman correlation between the mistakes for the two incisions drawn by each surgeon was . . conclusion: conclusions: inter-surgeon variation of incision lines was high and since the number of mistakes per incision was not correlated to the surgeon's experience, casam can be useful in two ways: ) pre-operative planning using casam, might assist the surgeon in determining a 'tailor made' safe zone in each patient. ) for educational purposes casam is able to compare a student's incision with the gold standard or the computed location of the sural nerve, thus providing personal feedback. introduction: a precise sustentaculum tali screw placement is crucial for the fixation strength of operatively treated calcaneus fractures, as shown in biomechanical studies. due to the complex anatomic shape of the calcaneus and the limited visualization of the sustentaculum tali fragment via the common lateral approach, the exact screw positioning is demanding and a bright knowledge of the surgeon is mandatory. with the introduction of navigation procedures an increased precision of implant positioning could be achieved for different applications, as reported for pedicle-and iliosacral screw placement. the aim of this study was the evaluation of different navigation procedures compared to the conventional technique for the placement of the sustentaculum tali screw. material and methods: sustentaculum tali screws were placed via a standard lateral approach in artificial calcanei with a prefabricated soft tissue envelope. we used different navigation techniques: group i: d-based fluoroscopic navigation group ii: d-based fluoroscopic navigation group iii: fluoro-free navigation compared to the standard procedure without navigation (group iv). for each screw the time of procedure and time of fluoroscopy was measured. the precision was evaluated in postoperative ct scans. results: no x-ray exposure was necessary for the standard procedure and the fluoro free navigation, whereas ± . and . ± . s of fluoroscopy time were needed for the d-and d-based fluoroscopic navigation. significant differences were observed for the mean procedure time: . ± . (group iv), . ± . (group iii), . ± . (group i) and . ± . min (group ii). no significant differences were seen for the precision with one mal-placed screw in each group. whereas for the image based navigation procedures wide experience in computer assisted surgery was necessary, the fluoro free navigation procedure could easly used without that experience, due to a simplified and self-explanatory workflow. conclusion: all three navigation procedures increase the intraoperative orientation for the placement of the sustentaculum-tali screw, but significant differences of precision compared to the standard technique could not be observed in our experimental set up. potential reasons are a visual and tactile memory effect, despite a randomized order of drillings and a better visualization of the osseous structures in the used artificial model. in clinical situations a lack of surgical routine for this rare injuries and a limited display of anatomic landmarks exist, making all of the evaluated navigation procedures to a helpful tool. if the fracture reduction is controlled intraoperatively by an d fluoroscopic scan, we recommend the d navigation, otherwise we use the fluoro free navigation. disclosure: no significant relationships. overall satisfaction of functional status was measured using a visual analogue scale (vas; range zero to ten). results: four-hundred metatarsal fractures were identified in patients. the distribution of fractured metatarsals was: first metatarsal %, second %, third %, fourth %, and fifth %. multiple metatarsal fractures were seen in . %. most fractures were caused by an inversion injury or fall from height ( %). more than eighty percent of fractures were undisplaced or minimally displaced, and most fracture patterns were transverse or oblique/spiral. a total of patients ( . %) returned the questionnaire with a median follow-up of months. responders were female in % and had a median age of years (p -p - ). in . % of cases the left side was affected. the median aofas-score was points (p -p - ), the median vas was points (p -p - ). in the univariate analysis the aofas and vas score were inversely dependent of the body mass index (r s = - . and - . ; p < . ). patients with known diabetes reported lower vas (p = . ) and aofas scores (p = . ). female patients reported a lower aofas (p = . ). an increase in dislocation (> mm) resulted in a decrease in vas (p = . ). no correlations were identified with outcome and which metatarsal was affected, number of fractured metatarsals, fracture type and location, articular involvement, and smoking habits. in the multivariate analysis the bmi correlated with the aofas (p < . ) and vas (p = . ) and the dislocation with the vas (p = . ). conclusion: this is the first investigation using two validated outcome scoring systems to determine functional outcome in metatarsal fractures. overall outcome in metatarsal fractures is high, as almost all fractures healed without complaints at months. outcome is dependent of bmi, diabetes, gender, and dislocation at the fracturesite. disclosure: no significant relationships. introduction: incidence of fracture non-union is increased after severe trauma. the systemic inflammatory response syndrome (sirs) resulting from major trauma appears to play a role in this healing impairment. especially the cellular reaction associated with sirs influences the inflammatory response, which is of vital importance in fracture healing. we hypothesize that systemic inflammation may impair healing through an altered interaction between neutrophils and stem-or osteoprogenitor cells within the fracture hematoma. we therefore investigated the effect of neutrophils on differentiation of mesenchymal stem cells (mscs). material and methods: osteogenic differentiation of mscs was assessed using an alkaline phosphatase colorimetric assay on the adhered cell lysate after culturing mscs for days in the presence of different quantities of neutrophils. chondrogenic differentiation of mscs was assessed within the same samples using a glycosaminoglycan colorimetric assay in the cell medium. proliferation was measured within the same samples using a picogreen(r) dsdna fluorescent assay. to assess whether any effect was mediated through release of soluble factors or through direct cell-cell contact, supernatants of stimulated neutrophils were used. stimulation of neutrophils was achieved during h with tnf-alfa. tnf-alfa in the supernatant was subsequently blocked with humira prior to interaction with mscs. results: low neutrophil concentrations resulted in increased alkaline phosphatase concentrations compared to control levels. high concentrations of neutrophils resulted in increased glycosaminoglycan concentrations and decreased alkaline phosphatase concentrations. introduction: angiogenesis is a cue element in the early wound healing and is considered most important for tissue regeneration. in addition to aiding research in understanding the regulatory mechanisms of angiogenesis and vasculogenesis, the concept of co-cultures has helped to better understand the mechanisms of interactions between osteoblasts and endothelial cells focusing on new therapeutic approaches for critical size bone defects. here, we describe in detail the cellular and molecular interaction between human osteoblasts (hob) and human endothelial progenitor cells (epc) in a complex d-environment. material and methods: we investigated endothelial differentiation and morphological organization of human epc in cocultures with hob using methylcellulose sphaeroids as well as collagen biomatrices. cocultures of human umbilical vein endothelial cells (huvec)/ hob were used as controls. epc were tracked with cell tracker red, whereas hob were transduced using a lentiviral egfp-vector to allow direct cell visualization using confocal laser microscopy and analysis of cell-specific gene expression. we studied the survival of both cell types and formation of vessel-like sprouts as a criterion of endothelial activity of epc. expression of several relevant angiogenic and osteogenic markers, as well as different extracellular matrix proteins was investigated using quantitative rt-pcr. results: using the hybrid coculture technology we could clearly show that hob regulate the survival, proliferation, and spouting of epcs. concordantly, expression of endothelial cell markers cd and vwf was significantly up-regulated by cocultivation with hob. by contrast, epcs did neither proliferate nor did they form any apparent vessel-like structures when cultured in a monoculture. using the lentiviral egfp-reporter transduction method the expression of osteoblast marker genes was also estimated accurately. we could clearly show that epcs inhibit the terminal differentiation of hob by interfering with expression of specific transcription factors runx and sp . in contrast, cell proliferation and expression of the early osteoblastic differentiation marker alp were induced in cocultures. conclusion: in the present study we demonstrate that human endothelial progenitor cells interact with human osteoblasts on the cellular level. we have identified a complex regulatory mechanism which accounts for endothelial cell survival and cell differentiation of both cell types. this study provides new insight into regulatory mechanisms of bone regeneration and may unveil potential applications in bone tissue engineering and fracture healing. introduction: failure of fixation is more common in osteoporotic than in other fractures. early treatment of osteoporosis as well as early stimulation of the fracture healing may improve the later clinical outcome. bisphosphonates are effective in osteoporosis treatment, and bone morphogenetic proteins (bmps) stimulate fracture healing, although several studies show less effect in estrogen deficient models. in order to determine the effect on early fracture healing of bisphosphonates and bmps in osteoporotic fractures, these treatment modalities were applied in estrogen deficient rats. material and methods: fourty rats underwent an ovariectomy (ovx), followed by low calcium diet during six weeks. ten rats underwent a sham operation, followed by normal diet. after six weeks, a closed femoral fracture was induced in all animals. the ovx animals were then assigned to four different groups: ovx alone, injection of bisphophonate, injection of bmp- in the fracture gap, or the combination of these. all animals received a normal diet after the fracture. after sacrifice at two weeks, fracture healing was evaluated using radiographs and four-point bending stiffness andstrength. results: radiographs showed a higher score in the bmp- treated animals, with or without the bisphosphonates (p = . , kruskal-wallis test). no delay in healing was seen in estrogen deficiency as compared to the sham group. bending stiffness was higher in the bmp- treated groups compared to the others (p = . , kruskal-wallis), as was the strength (p = . , kruskal-wallis). no significant improvement was found by the injection of bisphosphonates conclusion: early fracture healing is significantly stimulated by injection of bmp- in the fracture gap in estrogen deficient rats. early treatment with bisphosphonates showed no effect on fracture healing. introduction: traumatic brain injury (tbi) is associated with an increased rate of heterotopic ossification within skeletal muscle, possibly due to humoral factors. however, the pathophysiological mechanism of heterotopic ossification after tbi is still not fully understood. this study investigated whether cells from skeletal muscle adopt an osteoblastic phenotype in response to serum from patients with tbi. material and methods: blood was collected from patients with severe tbi as well as ten control subjects. primary skeletal muscle cell cultures were isolated from orthopedic surgery patients and characterized using immunohistochemical techniques. proliferation and osteoblastic differentiation were assessed using commercial cell assays, western blotting (for osterix protein) and the villanueva bone stain. results: all serum-treated cell populations expressed osterix after one week. cells treated with serum from both study groups in mineralization medium had increased alp activity and mineralized nodules within the mesenchymal cell subpopulation after three weeks. serum from patients with tbi induced a significant increase in the rate of proliferation of these cells compared to the controls (p < . ). introduction: the current gold standard to establish the diagnosis of osteoporosis and to follow the pharmacological treatment is the measurement of the bone mineral density (bmd). with a growing number of predicted fractures due to osteoporosis the expenses for bmd-measurement will increase. it was therefore the objective of this study to determine parameters that possibly allow a laboratory follow-up of these patients. material and methods: since we operated patients (Ø . y, % female) with an osteoporotic fracture (group ). all of them were more than years old and underwent a laboratory screening including the serum levels of vit-d -oh, vit-d . -oh, calcium (s-ca), phosphate (s-pho), p np, b-cross-laps, intact pth, osteocalcin, tsh and sex hormones as far as the urine concentration of calcium (u-ca) and phosphate (u-pho). in vit d -oh insufficient patients without treatment a therapy with alandronat lg once a week and daily calcium and vitamin d substitution was started. patients (Ø . y, % female) of the orthopedic department underwent the same screening and served as a control (group ). these patients did not sustain a fracture or relevant surgery within at least months. in a second part we checked the evolution of group -patients laboratory screening at a , and -months postoperative interval. results: group and displayed significant differences with regard to s-ca, u-ca, u-pho (p < . ), osteocalcin (p < . ) and vit-d -oh level (p < . ). after separating male and female patients significant serum concentration differences of testosteron (p < . ) in the male patients and of fsh (p < . ) and oestradiol (p < . ) in the female patients could be observed. during the follow up at , and months we could demonstrate a significant elevation of s-ca (p < . ), s-pho (p < . ), osteocalcin (p < . ) and vit-d -oh (p < . ) concentration. further we found a significant elevation of fsh-(p < . ), lh-(p < . ) and testosteron (p < . ) concentration as well as a significant decrease of the oestradiol (p < . ) concentration. as former studies showed we confirmed by comparing group and a deficiency of vit-d -oh, s-ca and an elevation of u-ca in patients with osteoporotic fractures. we could also show a significant difference of the concentration of osteocalcin. by following these blood parameters during treatment we found an improvement or normalization of these differences as a result of the treatment. therefore we believe that vit-d -oh, s-ca, u-ca and osteocalcin could serve as follow-up parameters in the treatment of osteoporosis. further our preliminary results suggest that under the treatment there is a decrease of the testosterone level in male patients and a decrease of the fh-and increase of the oestradiol-concentration in female patients which has not been reported in the literature yet. in consecutive cycli an alternating traction of newton was exerted on the subscapularis and infraspinatus, while a continuous force was applied for the supraspinatus. the motion of the tuberosities and the shaft were recorded by high-speed cameras. the following parameters were investigated: failure of osteosynthesis, intertuberosity motion, motion lesser tuberosity-shaft, motion greater tuberosity-shaft, motion metaphysis-shaft. results: group : cable fixation was significantly more stable for intertuberosity motion and tuberosity-shaft motion. furthermore we found failures for the lesser tuberosity in the suture group. we found no significat difference for the metaphysis-shaft motion. group : the greater tuberosity-shaft motion was significantly lower using two cables. all other parameters showed no significant difference. we found no failures. group : since the tuberosity-shaft motion and the intertuberosity motion were significant higher using fibre-wire, this series was abandoned after / pairs. conclusion: cable fixation is significantly more stable than suture fixation for tuberosities in shoulder arthroplasty. double-cable fixation does not improve intertuberosity stability. we found tendencies for an enlarged tuberosity-shaft stability. introduction: the results following prosthetic treatment of primary humeral head fractures present great variability. dissolving of tuberosities leading to dysfunction of the rotator cuff with limited motion, pain and instability are often reported. the short term results on inverse prosthesis on the one hand are promising, whereas scapular notching turns out to be a major problem leading to a high failure rate in the long run. high complication rates are also reported. material and methods: in an ongoing prospective and consecutive multicentre study until today, cases with an inverse shoulder prosthesis system are documented. in this series we analyse the results of the cases treated for primary fracture as indication. in all cases the affinis Ò fracture inverse prosthesis has been used. this implant was specially designed as a reversed treatment option for selected fracture cases. mechanical and biological notching should be reduced due to the special design features of the prosthesis. patients were asked to describe pain and satisfaction for the injured shoulder one week before the trauma and also to fill in the ases score. the constant score for the healthy shoulder was measured whenever possible. postoperatively constant and the ases score were assessed. the x-rays were evaluated for notching and the healing of the tuberosities. results: from february until today a total of n = cases ( females and males) were treated for primary fracture with the fracture prosthesis. mean age at operation was . years (range . - . ). according to the neer classification we treated patients with a -part fracture, with a -part fracture and cases with a head split fracture. after a mean of months (range - ) the cs reached . points. active forward elevation was . °and passive . °. the active lateral elevation (abduction) was . °for the active movement and . °passive. the ases score was . points at the latest follow-up and the value for pain and satisfaction were . and . respectively. we found no notching in this series and the tuberosities were judged as anatomically healed in % of the cases. we found no difference in the clinical outcome between patients with healed tuberosities compared to the group with non visible tuberosities. postoperatively two complications occurred one fracture of the clavicula and one fracture of the acromion. so far we did not have any luxations or implant disconnections. introduction: the purpose of this study is to evaluate the survival and function of splenic autotransplants using spleen imaging with tc m labeled heat-damaged erythrocytes. material and methods: patients with splenic rupture underwent spleen imaging with tc m labeled heat-damaged erythrocytes at to months after splenic autotransplantation (early scans); also, of them underwent the same imaging technique at to months after operation (follow-up scans). results: on early scans, splenic autotransplants were faintly and the intensity of radioactivity in autotransplants was lower than in liver. the increase of intensity of tracer accumulation in autotransplants was significant higher on follow-up scans. one week after operation the levels of cd , cd and cd /cd ratio were significantly lower than those of controls and returned to normal months later. conclusion: the spleen imaging with tc m labeled heat-damaged erythrocytes is a valuable and effective method for evaluation of the survival and function of splenic autotransplants. , respectively / in the group ''skiers''( %) and / in the group ''snowboarders''( %). the aast grade of injury was: aast case; aast cases; aast cases; aast cases; aast case. of the ''skiers''( %) and of the ''snowboarders''( %) showed a high grade (aast > ) splenic injury. patients has an injury severity score > ( / skiers and / snowboarders): cases of severe brain injury, case of associated liver injuries, cases of associated left renal injuries. patient had associated colonic and pancreatic injury. four patients were not stables at admission and had immediate laparotomy with splenectomies. patients were elected for nonoperative management. results: splenectomies was performed with a splenic salvage rate of. %. there was no mortality and morbidity was %. for thr three patients who had immediate splenectomy the recovery was uneventfull. in te group nonoperative management three patients had angioembolization and four had delayed laparotomy ( for delayed splenic rupture at post injury , and resectively; for sirs). in the patients with availables data, mean hospital stay was days ( - ), . days ( - ) for the group skiers and - days ( - ) for the group snowboarders. patients( %) were recovered less than days. patients were admitted initially in icu ward(from h to days). conclusion: ski accidents are in cause for more the one-third of all splenic injuries admitted to grenoble university hospital. the mean age is lower and male incidence is higher than splenic injuries admitted for others causes (road traffic accident, falls, other mountain accidents). an high number of snowboarder's' accidents was observed and pattern of injury is poor in these patients. the incident of polytrauma cases was the same in two groups and this observation confirm that snowboard practice is at higher risk than skiing for severe splenic injuries. in france, if number of raod traffic accidents is decreasing, the number of sport accidents is imcreasing in the last years. a better comprehension of mechanism, epidemiology and hystological findings of splenic injuries resulting from skiing and snowboarding is necessary to improve trauma preventiin programs. introduction: management of splenic injuries has evolved over the past three decades. prior to that time, a diagnostic peritoneal lavage positive for blood was an indication for exploratory laparotomy because of the concern about ongoing hemorrhage and/or missed intraabdominal injuries. in children the nonoperative management (nom) of splenic injuries rapidly gained interest because of the significant incidence of post-splenectomy sepsis as well as the complications associated with non-therapeutic laparotomies. the last decade has witnessed a proliferation of reports of nom in adults with injuries to the spleen. inclusion criteria for nom in adults, which have been a source of controversy, continue to evolve. moreover we noted that most publications focused on isolated splenic injury and not on patients with multiple injuries. this study was conducted to summarize the indications for the nom of blunt splenic injury with special attention to the multiply injured patient. material and methods: we conducted a medline search. the search was designed to identify english language citations between and : using the keywords: blunt splenic injury, conservative management, multiply injured patients and blunt abdominal trauma. the bibliographies of the selected references were examined to identify relevant articles not identified by computerised search. one hundred articles were identified. a cohort of three trauma surgeons selected articles for review and analysis. we used the methodology developed by the agency for health care policy and research of the united states department of health and human services to group the references into three classes. reviewing all data showed that the nom of blunt splenic injury is a save treatment modality in isolated cases but also the multiply injured patient. conclusion: currently the non-operative management of blunt injury to the spleen is the treatment modality of choice. important is a haemodynamically stable patient, with no signs of peritonitis on physical examination. patients who only maintain their blood pressure by the constant infusion of crystalloid or blood products are not haemodynamically stable and need surgical intervention. ct scan findings and grade of injury are not, in themselves, criteria for laparotomy. these criteria are applied to isolated injuries to the spleen but can also be applied to the multiply injured patient. age itself is not a contraindication. the general condition of an individual patient needs to be decisive. and finally hospitals with a low trauma incidence can safely use these guidelines in their management protocol. introduction: the treatment of trauma patients with solid organ injury has changed over the last years towards a less invasive treatment. still our algorithms especially in dealing with trauma patients with ongoing internal abdominal haemorrhages is still based on fast control en stopping of the bleeding by any means. the use of ct-abdomen and subsequent performing angiography and embolization takes time. we analyzed the time path involved in angiographic control of the bleeding spleen. material and methods: a retrospective study. the study group consisted of ten patients presenting at our institution with a traumatic spleen injury in the period november till november . all patients were managed according to the principles of atls. data were analyzed using spssÒ . . results: the study group consisted of seven men and three women. average age was years (range till ). the iss was on average (range - ). all patients in the study group received an angiography after ct-abdomen which showed an active bleeding focus in the spleen. organ injury score were eight grade and two grade spleen injuries. average time from admission to angiography was min. time to control of bleeding by embolization took average min. time loss between ct and angiography was on average min. conclusion: the time paths involved in managing this group of trauma patients with spleen injuries by embolization are much longer than expected. the time involved after diagnoses to actual control of the bleeding spleen injury is much longer than anticipated. logistic changes to limit the time loss in interpretation of data from the ct-a, transfer of the patient, preparation of the angio-suite and less time consuming technique to actual embolization are needed. articles were eligible if they reported the failure rate of nom with or without angio-embolization (ae) in pediatric patients with splenic and/or liver injuries with a contrast blush on ct and included two or more trauma patients. two reviewers independently assessed the eligibility and the quality of the articles and performed the data extraction. interrater differences were resolved by discussion. results: nine studies were included describing pediatric patients. the median sample size was five (range - ). seven studies (including patients) reported a total of patients with failure after nom without ae. failure rates across these studies ranged from . to %; the pooled percentage was . % ( % ci: . %- . %). the failure percentages after nom with or without ae ranged from to %; the pooled percentage was % ( % ci: . %- . %. two studies (including patients) reported a total of patients with failure after nom with primary ae: a percentage of . %. conclusion: despite the current low level of evidence on failure rate of nom when a contrast blush is present on ct we emphasize that there is a significant amount of patients in whom nom fails. we therefore recommend that the management of splenic and hepatic injury in children should not only be based on the physiological response but also when a contrast blush is present on ct. results: primary blast injury: this form of injury results from the deleterious effects of the blast wave passing through the body. these waves have little or no effect on solid organs but have their major destructive potential in air containing organs, especially lungs. secondary blast injury refers to the impact on a patient's body of projectiles usually inert. the addiction of destructive metal fragment, nails and other such objects to bombs increase the severity of injury and lethality. tertiary blast injury refers to the deceleration and impact with the ground, wall or other inanimate object of the patient whose body is displaced by the blast. quaternary blast injury refers to the miscellaneous forms of injury by-products of explosions, burns, inhalation of dust, contamination in case of ''dirty bombs'' or penetration of allogenic body parts shrapnel. this last one asks the question of contamination by hepatitis or hiv and modalities of surveillance and treatment. conclusion: blast injuries are complex and require the expertise of surgeons for their evaluation, treatment and longterm recovery. the victims of this form of terrorism sustain unusually severe and complex multidimensional forms of trauma not typically encountered in routine surgical practice. surgeons must be leaders and active participants in disaster planning and management; they are uniquely qualified to manage the physical trauma that results from most forms of mass casualty events, including blasts. disclosure: no significant relationships. a. s. dogjani general surgery, military university central hospital, tirana, albania introduction: as the risk of terrorist attacks increases in the world, disaster response personnel must understand the unique pathophysiology of injuries associated with explosions and must be prepared to assess and treat the people injured by them. the explosions at the army depot in gerdec village, some km north of tirana, were heard more than km ( miles) away. introduction: during the last decades there is a debate concerning the fact if the facial fracture can cause further damage or somehow to protect the brain parenchyma from a more severe injury. the aim of our study is to analyze the effects of facial trauma exerted upon brain parenchyma. material and methods: a series of patients with craniofacial fractures was studied. the injuries were separated into five grades of severity based on neurological examination including cranial ct. the injuries was also grouped into three categories based of facial regional involvement ct -facial reconstruction results: the control group included patients with head trauma but without any facial fracture or brain injury. in group a included ( , %) patients with both facial fracture and brain damage.among them diagnosed with temporal-mandibular fractures accounting for , %, patients( , %) had lower mandibular fracture, patients ( , %) diagnosed with nasal fractures and patients ( , %) had orbital fractures. in group b were categorized patients with only brain damage accounting for %. conclusion: the data demonstrated that patients with upper facial fractures were at greatest risk for serious closed head injury (chi).injuries to both the mandibular and the midfacial regions with no upper facial involvement more frequently resulted in mild chi with a modest likelihood of no neurological deficits. trauma to only the mandibular region or to only the midfacial region was least likely to involve chi disclosure: no significant relationships. introduction: post-traumatic stress disorder (ptsd) is a psychiatric disorder that results from exposure to a traumatic event. the individual may develop symptoms of three distinctive types: intrusive and unwanted recollections, avoidance followed by emotional withdrawal, and heightened physiological arousal. people who are exposed to traumatic events may also have somatic symptoms and physical illnesses, particularly hypertension, asthma and chronic pain syndromes. hospitalized victims of suicide terror attacks are unique due to the circumstances and severity of their injuries which could have possibly affected the occurrence of ptsd and delayed the recognition of ptsd development. our objectives were to evaluate the prevalence and severity of ptsd among hospitalized victims of suicide bombing attacks and to assess variables of physical injury as risk factors for the development of ptsd. material and methods: forty-six hospitalized victims of suicide bombing attacks were evaluated for ptsd using the pss-sr questionnaire by phone. demographic and medical data considering the severity of injury, type of injury and medical treatment were collected from the medical files. injury severity scale (iss) was used to assess severity of physical injury. results: the prevalence of ptsd among hospitalized victims of suicide bombing attacks was . %. presence of blast lung injury was significantly higher in the ptsd group compared with the non-ptsd group ( . % vs. . % respectively, p < . ). there was no significant difference in iss values between ptsd and non-ptsd groups. blast lung injury and intracranial injury were found to be predictors of ptsd (odds ratio and , respectively). no correlation was found between length of hospital stay, length of icu stay or severity of physical injuries to the severity of ptsd. conclusion: hospitalized victims of suicide bombing attacks are considerably vulnerable to develop ptsd. they should be evaluated with a high level of suspicion in order to identify ptsd symptoms and treated as soon as possible in conjunction with physical treatment. blast lung injury and intra cranial injury are predictors of ptsd. victims suffering from these conditions should be monitored closely and treated in conjunction with their physical treatment. conclusion: from the use of the smart adopted for the evaluation of the code of entrance in emergency department, we have deduced and confirmed the facility and the speed of use of this new model of triage. the triage smart typically holds not only besides in consideration the traumatic pathologies but also internists that, it is an usable advanced triage both on the territory and in the hospital. we can classify the model smart triage as a valid system in case of a disaster as is reliability and sensibility of assessment of patients result to be more appropriates in comparison to the other models of triage taken in examination. conclusion: we showed that alcohol, massive bleeding needed blood transfusion and age were risk factor of trauma and japanese emergency medical technician attendance was effective for trauma care. we suggested the reason of detachment by the injury form was that japanese penetrating wound include many stub wound not gun shot wound. introduction: rapid aging of japanese population is causing numbers of emerging problems in trauma patients care which consists of trauma in elderly people and increased pre-existing co-morbidities such as cardiovascular diseases, neoplasms and organ failures. nevertheless, little is known about the relationship between co-morbidities and trauma. the aim of the study was to clarify the influences of co-morbidities on the trauma mortality, using data from the japan trauma data bank (jtdb), a multicenter, nationwide and prospectively recruited trauma registry in japan. material and methods: we selected the records from jtdb which fulfilled the requirements to estimate trauma injury severity score (triss) system. logistic regression analysis after adjustment for baseline trauma severity based on triss system assessed the risk of in-hospital trauma death for following co-morbidities: hypertension (ht), diabetes (dm), psychotic disorders (pd), dementia (de), stroke (st), chronic obstructive lung diseases (cold), bronchial asthma (ba), coronary diseases (chd), congestive heart failure (chf), liver cirrhosis (lc), chronic hepatitis (ch), chronic renal failure on dialysis (crf) and active cancer (acn). we conducted a couple of analysis which were adjusted or unadjusted by age in consideration for confounding between co-morbidities and elderly in age. introduction: monitoring the quality of trauma care is frequently done by analyzing the preventability of trauma deaths and errors during trauma care. in the academic medical center traumatic deaths are discussed during a monthly morbidity and mortality meeting. in this study an external multidisciplinary panel assessed the trauma deaths and errors in management of a dutch level- trauma center for (potential) preventability. material and methods: all patients who died during or after presentation in the trauma resuscitation room in a two year period were eligible for review. all information on trauma evaluation and management was summarized by an independent physician. an external multidisciplinary panel individually evaluated the cases for preventability of death. disagreements in classification were resolved during two consensus meetings. potential errors or mismanagements during the admission were classified for type, phase and domain. overall agreement on (potential) preventability was compared between the panel and the amc consensus. results: of the evaluated trauma deaths one was judged preventable and were judged as potentially preventable by the review panel. overall agreement on preventability between the review panel and the amc consensus was moderate (kappa . ). the classification of the panel was more favourable than the amc consensus. the interobserver agreement between the review panel members was also moderate (kappa . ). the panel judged errors to have occurred in the (potential) preventable death group and errors in the non-preventable death group. most frequently mentioned errors were related to choice or order of diagnostics, rewarming of hypothermic patients, and correction of coagulopathies. conclusion: the preventable death rate in the present study was comparable to the available literature. external review does not seem necessary to improve our current internal reviewing system. however, multidisciplinary reviewing of our trauma deaths provided us potential insights to optimize trauma care. disclosure: no significant relationships. arab emirates (uae). the aim of this paper is to report on the long term effects of our early analysis of this registry. material and methods: data in the early stages of this trauma registry were collected for patients during a period of months in . data was collected on a paper form and then entered into the trauma registry using a self-developed access database. descriptive analysis was performed. results: most were males ( %), the mean age (sd) was . ( . ). uae citizens formed . %. road traffic collisions caused an overwhelming . % of injuries with . % of those involving uae citizens while work-related injuries were . %. the early analysis of this registry had two major impacts. firstly, the alarmingly high rate of uae nationals in road traffic collisions standardized to the population led to major concerns and to the development of a specialized road traffic collision registry three years later. second, the equally alarming high rate of work-related injuries led to collaboration with a preventive medicine team who helped with refining data elements of the trauma registry to include data important for research in trauma prevention. conclusion: analysis of a trauma registry as early as six months can lead to useful information which has long term effects on the progress of trauma research and prevention. disclosure: no significant relationships. as a result of injuries related to skating on natural ice. we analysed epidemiological aspects, diagnostically examinations, prevalence of injuries per anatomical location as well as the necessary therapeutic interventions and costs for national health services. results: injuries related to skating on natural ice accounted for % of all attendances. the mean age for man and women did not significantly differ ( , and , years resp.; p < . ), but adults aged - years are more prone to injuries. women were affected in %. radiological examinations were requested in % ( % xrays; % ct-scans). the upper extremity was affected in %, with the wrist accounting for % of those injuries. fractures accounted for % of all ice-skating related attendances. an operative therapy was indicated in %. the mean costs for national health services were e per patient. conclusion: fractures, especially those of the upper extremity, were the predominate type of injury as a consequence of collectively performed skating on natural ice. this incidence is > times higher compared to fractures occured during skating on artificial ice-rinks [ ] . wearing wrist guards is an effective tool in protecting skaters against injuries. we recommend wearing wrist guards during skating on natural ice [ , ] . especially (employed) adults aged - years are very prone to injuries resulting in a high loss of work days [ ] . in contrast to children, adults might be more accessible for wearing protectors [ ] . in future it seems reasonable for national health services to provide steps to increase public awareness on the benefits of prophylactic safety measures. this might result in a substantial reduction of costs for health care and society. introduction: liver cirrhosis has been shown to be associated with impaired outcome in patients who underwent elective surgery. we therefore investigated the impact of alcohol abuse and subsequent liver cirrhosis on outcome in multiple trauma patients. material and methods: using the multi-center population-based trauma registry of the german society for trauma surgery, we retrospectively compared outcome in patients (iss > = , > = ) with pre-existing alcohol abuse and liver cirrhosis with healthy trauma victims in univariate and matched-pair analysis means were compared using student's t-test and analysis of variance (anova) and categorical variables using chi (p < . = significant). results: overall , patients met the inclusion criteria and were, thus, analyzed. ( . %) patients had a documented alcohol abuse and ( . %) suffered from liver cirrhosis. patients abusing alcohol and suffering from cirrhosis differed from controls regarding injury pattern, age and outcome. more specific, liver cirrhotic patients showed significantly higher in-hospital mortality than predicted ( % vs. predicted %) and increased single-and multi organ failure rates. while alcohol abuse increased organ failure rates as well this did not affect in-hospital mortality. of note, alcohol abuse significantly decreased -hour mortality. conclusion: patients suffering from liver cirrhosis are at maximised risk for impaired outcome after multiple injuries. pre-existing condition such as cirrhosis should be implemented in trauma scores to assess the individual mortality risk profile. introduction: early in-hospital treatment of severely injured patients has been internationally standardized by the implementation of algorithms such as the atls Ò -concept. however, due to lack of time, the instability of the patients and the complexity of injuries, there is a risk that some lesions will be missed at this stage. the purpose of our study was to evaluate the incidence and significance of these missed injuries. material and methods: retrospective chart analysis (in-hospital and follow-up as outpatient) of data prospectively collected via an accessÒ-based documentation system was performed. missed injuries were determined as injuries not found during primary and secondary survey. introduction: complication registration is important for monitoring the quality of health care. aim of this article was to describe the incidence, type and impact of complications occurring within months after the initial trauma in multitrauma patients. second, we assessed potential risk factors for the occurrence of complications. material and methods: during a -year period all trauma patients presented to the academic medical center and having an injury severity score of ‡ were included. patients who were directly transferred to other hospitals were excluded. we used the prospective dutch national surgical complication registry of the amc, a level- trauma center, to assess complications within months after the initial trauma. for verification we additionally performed a chart review and searched the decubitus specialists-and icu registration. complications were graded (no real health loss) to (lethal). identification of risk factors associated with an increased risk of complications was performed by univariate analysis. we also analyzed an autopsy findings of these patients and found that of ( . %) had a difference between clinical and autopsy iss. the most frequent missed injury were rib fractures. six of these patients were hospitalized in a period when we did not use msct routinely in multiple injured patients. conclusion: triss is not a clinical prognostic tool but is used retrospectively for clinical and epidemiological research, performance evaluation, and resource allocation. it is required as a basis for quality assessment and improvement. in combination with autopsy findings, triss methodology can be an valuable tool for recognition of unexpected trauma deaths and further analyze of possible treatment errors. patients had to be operated , times and were treated days in the icu and stayed days in hospital. mortality rate was % and rate of multi-organ failure %. % demonstrated severe senso-motoric dysfunction as well as residues of severe head injury. % recovered well or at least moderately. out of survivors answered the polochart. a personal interview was performed with patients. the state of health was at least moderate in % of patients. in % interpersonal problems and in % severe pain was observed. in % problems in working ability concerning duration, as well as quantitative and qualitative performance were observed. symptoms of post-traumatic stress disorder were found in %. the more distal the lesions were located (foot/ankle) the more functional disability affected daily life. in only %, working ability was not impaired. out of interviewed patients demonstrated complete work disability. conclusion: even severely injured patients after polytraumatization have a good prognosis. the iss is an established tool to assess severity and prognosis of trauma, whereas prediction of clinical outcome cannot be deducted from this score. introduction: one of the most common cause of preventable deaths in severe trauma is represented by delay in diagnosis and treatment of injuries, therefore a good teamwork aimed to reduce time consumption and errors is essential. there is in fact good evidence that the outcome of trauma care depends on effective trauma team performance (ttp). critical points during trauma management are represented by lack of leadership, information sharing, difficult communication and decision making. to improve ttp, advanced simulators with full scale realistic patients ( ) and trauma crew resource management (crm) educational programmes are increasingly being used. material and methods: we made a survey among health care professionals (hcp) from different level i and level ii trauma centers in the milan area that confirmed that difficulties in communication and conflictual behavior during trauma action is perceived as a barrier to ideal management. after a focus group interview to establish the need to improve performance we tested in our hospital a tailored trauma teamwork course using an advanced human patient simulator. the peculiarity of this course is the recreation of the same location of the trauma bay using same trauma team components and teamwork laboratory conducted by a professional coach as facilitator for the teamwork. this role is particular important since with this facilitation hcp can reach the awareness of wrong attitudes that lead to errors and bad performance. in particular, the tasks of the facilitator were the following: to help people understand their common goals to assists the trauma team to plan to achieve common goals to assist the group in achieving a consensus of any disagreements that preexist or emerge in the meeting so that it has a strong basis for future action a second survey few months after the course was made among hcp of our institute to evaluate the possible improvement of the ttp. results: the second survey confirmed a perceived benefit among hcp who started to work in a proactive manner. in particular % of hcp reported the feeling of a better ttp and % suggested regular practice with advanced simulation. conclusion: integration of a tailored advanced simulation and a facilitator assisted teamwork could be a powerful method to improve quality of treatment in trauma patients. a score index to evaluate the improvement of the ttp during the course and in reality is although needed and is under evaluation. introduction: our university hospital is one of the only two national university hospitals in tokyo and our emergency medial center is one of the busiest emergency center in japan that receives to ambulances per day. japan has a quite unique emergency medical system in the world. in japan, emergency patients are stratified into tiers, minor-primary, moderate-secondary, severe-tertiary. japanese emergency doctor, that is not same as the emergency physician in the usa, take care only for the most severe emergency cases, tertiary level emergency patients. and if they find out the patient who needed an emergency operation, then they do the surgery by themselves. if the patients need to admit to icu, they take care the patient in icu by themselves. this unique system was installed in mid- s. japanese emergency doctors do not only trauma cases, but also nontrauma severe emergency cases. for talking about trauma, they do not only the initial management of trauma patients but also do emergency surgery and trauma critical care. the mou came into effect with the signatures of the appropriate representatives, acknowledging that four courses had been run in portugal prior to its signature and that all future courses would be conducted in accordance with the essential requirements established by iatsic. in practical terms, the first two courses run after signing the mou must be of the form and nature as laid down by iatsic. thereafter, variations as determined by the nsc may be allowed. the slide material will be provided ''locked''. after the two initial courses, the ''unlock'' code will be provided. details of all modifications must be lodged with the iatsic. nsc will be responsible for ensuring the maintenance of high standards in the conduct of all courses and the selection of participants, ensuring that they meet the minimum standards as laid down by iatsic. nsc is entitled to appoint two representatives at international subcommittee meetings. introduction: clinical skills must be to the fore of medical occupation, especially in surgery, where the mastery of basic skills is of great importance for the young learner. the acquisition of basic clinical skills during surgery clerkships has been shown to be inadequate. this work presents an analysis of different teaching methods in a standardized training program for basic clinical skills in surgery. material and methods: the program is part of a four week surgical rotation for th year medical students, consisting of the one-week training program in basic surgical skills and a three-week clerkship on surgical ward. during the skills training, a maximum of students per group rotate through modules. in a randomized study, the effects of different teaching modalities as skills lab, simulation and role play, as well as different teaching methods as four-step-approach, short-lecture, video were tested on their effect on theoretical and practical skills acquisition. results: a total of students participated on a voluntary basis. the theoretical and practical examinations revealed significant differences in the acquired skills comparing the different teaching modalities and methods. the use of video as part of the -step approach was effective for training the basic skills such us suturing and wound care. least effective for all skills were short-lectures. conclusion: the choice of teaching modality and method has a significant impact on students' skills acquisition and its long term retention. disclosure: no significant relationships. training in trauma center: where to pay attention to? l. handolin traumatology, helsinki university hospital, helsinki, finland introduction: systematic trauma team simulation training was started in helsinki university hospital in . in terms of getting the optimal advantage of training and maintaining the justification of resource allocation, an advantageous balance in various team training principles has to be applied. the aim of the present study was to analyze the standardized written feedback given by trainees after training sessions. material and methods: the study period was three years ( ) ( ) ( ) . the collected data consisted of a subjective self-assessment on the level of knowledge, skills, and team work in traumaresuscitation. also a selfassessment on the effect of training on decision making, communication, skills, team work, and leadership, as well as a general rating of training session were collected. self-assessment was done using five step scoring system from one to five. results are presented as means. conclusion: the actual evaluated interspinous devices led to a significant reduction of rom during flexion-extension, but to a significant increase of rom for the whole specimen (l -l ) during lateral bending and rotation, which increases the risk of adjacent level degeneration. therefore the decision for the optimal individual treatment should be made on the knowledge of the biomechanical effect of each device and the underlying disease of the patient's symptoms. introduction: gait analysis is a powerful tool to monitor the degree of convalescence in fracture care after fracture fixation and during bone healing. because of the availability of a large array of monoclonal antibodies and gene-targeted animals, the mouse has become the preferred species for molecular studies on fracture healing. of interest, gait analysis after fracture fixation and during the bone healing process has not been performed in mice yet. we present a novel technique for dynamic gait analysis in mice and report the change of motion pattern after femur fracture and fixation. materials and methods: all animal procedures were performed according to the national institute of health guidelines for the use of experimental animals and were approved by the german legislation on the protection of animals. ten cd- mice were divided into two groups: fracture group (n = ) and control group (n = ). all mice were anesthetized by an i.p. injection of xylazine ( mg/bw) and ketamine ( mg/bw). a standardized closed midshaft fracture according to ao-classification a -a was stabilized by a common pin. the non-fractured tibia was additionally marked with a pin, allowing a measurement of the tibio-femoral angle by a digital videoradiography system recording images/s. for the control group, one pin was inserted into the femur and one into the tibia without producing a femoral fracture. dynamic gait analysis was performed at day fourteen after surgery in a x-ray compatible running wheel and the following gait parameters were determined: the minimum and maximum tibio-femoral angle, the stride frequency, the stride time, the stride length and the stride velocity. eighteen representative strides per mouse were analyzed. all measurements were done using osirix imaging software and the open source program imagej. all data are given as means ± standard error of the mean (sem introduction: single distal locking screw insertion had been accepted as an option in clinical practice of femoral nailing. however, effect of number and location of the screw on rotational stability of the construct was still doubtful. therefore, this experimental study was conducted to compare rotational stability of the femoral nail construct among three different conditions (two distal screws, single distal screw in different locations). materials and methods: eight right femoral sawbones were selected for this study. each of which was implanted with gk femoral interlocking nail ( · mm) and a static proximal locking screw follow by single distal screw insertion in the most distal screw hole. then, transverse osteotomy was performed at the mid-shaft to simulate simple fracture. after the femur was stabilized on the custom holding jig, rotational force was applied to the femoral condyle by using a torque wrench connecting to the distal part of the jig starting from to nm in nm increment. total rotational angle in each situation was measured by modification of navigation system. thereafter, testing protocol was repeated to the same specimen but two distal locking screws and single distal locking screw in the most proximal screw hole, sequentially. different angle in each testing condition was compared among the different constructs by using paired t-test. results: rotational stability was significantly better in the group of two distal locking screws in every testing condition (p < . ). single distal screw in the most proximal screw hole provided more rotational stability than that in the distal screw hole at nm (p = . ). conclusion: this study demonstrated that two distal locking screws provide more rotational stability than single screw in the case of simple mid-shaft femoral fracture stabilized with interlocking nail. if single distal screw was considered, insertion in the most proximal hole would be a better option in term of rotational stability than that in the most distal hole. introduction: the exothermal reaction of pmma leads to an extensive interaction between the bone cement and the plastics of the application system. this chemical reaction changes the structure of the bone cement and especially makes air pockets. it is necessary to develop application systems with a special composition of the plastics so that there is no interaction between the cement and the application system. in this study a new application system is presented for the first time which does not interact with the bone cement. materials and methods: two different application systems for bone cement were tested in this study. one popular and frequently used system made of polyethylene and a new system made of polypropylene. a special testing unit, in which the application systems were mounted, was used. the testing unit worked with a certain pressure so that a defined amount of bone cement was injected. the resistence data and the time were digitally collected and statistically evaluated. in all procedures were carried out. after the injection all application systems and the injected bone cement were microscopically analyzed. results: two groups, old versus new application systems, were divided. both groups showed significant differences. when using the old application systems made of polyethylene the time frame for injection of the cement was min while the time frame with new system made of polypropylene was min. microscopically there is a significant interaction between the plastics and the cement in the old systems with massive air pockets. in contrast there is no interaction, no air pockets and a homogeneous pattern of the cement when using the new systems. conclusion: the new application system made of polypropylene showed a significant longer time frame for application of the cement as well as no interaction with the plastics. it is possible to treat more than one localization with one application system which makes it financially rewarding. additionally there are no air pockets reducing the danger of infection und increasing the structural stability of the bone cement. introduction: femoral neck fractures are common fractures. despite the frequency of this fracture and the consequences associated with it, little is known about the functional changes that can be expected during and after rehabilitation. the aim of this study was to identify prognostic factors for functional outcome, using a modified harris hip score, after a femoral neck fracture treated with an arthroplasty. materials and methods: we included patients who sustained a displaced femoral neck fracture treated with an arthroplasty. functional outcome after surgery was assessed using a modified harris hip score, and was evaluated after (hhs ) and (hhs ) years. we analyzed the following prognostic factors for functional outcome of patients after treatment of femoral neck fractures with an arthroplasty: age, pre-operative co-morbidity, asa-score, type of arthroplasty (hemi-or total hip replacement), surgeon experience (resident or attending surgeon), interval between trauma and operation, blood loss, direct (associated with the arthroplasty) peri-and post operative in-hospital complications related to the arthroplasty and general post operative in-hospital complications. to challenge the outcome of the analyses we used the cronbach's alpha coefficients for testing the internal consistency. results: after one year the existence of co-morbidities ( ‡ ) was a significant predictor for a poor functional outcome. with and without co-morbidities the mean hhs was . and . , respectively. after years all potential prognostic factors did not have significant influence on the functional outcome. to further analyse this outcome, internal consistency of the hhs was assessed. when pain and function of the hhs were analysed together the internal consistency was poor (hhs : . and hhs : . ). the internal consistency of the harris hip score solely in function (without pain) improved to . (hhs ) and . (hhs ). when the potential prognostic factors were analysed with only the functional aspect, age and the existence of co-morbidities could be defined as a predictors for the functional outcome of femoral neck fractures after and years (r and % resp). conclusion: pain has such a dominant position in the harris hip score that even immobile patients without pain can obtain a reasonable hhs score. the hhs, with the omittance of pain, is therefore a more reliable score to estimate the functional outcome. after using the hhs in this modification, age and the existence of preoperative co-morbidities appeared to be predictors of the functional outcome after and years. many studies have shown that delay to theatre beyond h has an associated increased risk of morbidity and mortality in this cohort. our data revealed that there is certainly room for improvement regarding treated more patients within the h guideline however, there will always be a group of patients whom medical input is required prior to surgical management. lack of theatre time appears to be a significant administrative reason for delay. this is an area of potential improvement however it must be noted that any system of this nature will carry an intrinsic delay in processing. . x-rays and post-op data were analyzed on displacement, postoperative reduction, loss of reduction, and avascular necrosis (avn) and revision rates. high volume surgeons were defined as surgeons who performed > fixation procedures for proximal femoral fractures annually. results: mean age ( vs. years) and percentage of fracture displacement ( vs. %) were equal in both groups. re-operations following loss of reduction or infection was seen in ( %) patients. less frequent complications were avn ( %), coxarthrosis ( %) and pain due to screws bulging out ( %) led to a total conversion rate to arthroplasty in %. displaced fractures show a higher rate in loss of reduction ( %, p < . ) and revision ( %, p = . ) than non-displaced fractures ( . %; . %). patients > years showed % loss of reduction, % avn and taking the reoperations due to coxarthrosis and pain into account, a total revision rate of % was seen compaired to , , and % in younger patients. radiological analyses revealed that the lack of medial support lead to revisions in % of the cases, dorsal angulation in %. low volume surgeons did not perform worse than high volume surgeons. the latter group showed % loss of reduction, % avn and total revision rate %, compared to , and % in the low volume group. we found no differences in the outcome of treating displaced fractures. conclusion: the outcome of fixation of femoral neck fractures is poor. especially displaced fractures, inadequate fracture reduction and high age were associated with poor outcome. therefore, arthroplasty should be considered in patients older than years with displaced fractures that cannot be reduced anatomically. we could not demonstrate that high volume surgeons performed better in this group but we are convinced that further specialization of care is mandatory to improve results of this unsolved fracture. ( ) ( ) ( ) ( ) . internal fixation has shown to provide minor results. the majority of these patients are therefore treated by a hemiarthroplasty of the hip. since the primary goal is to regain the pretraumatic level of mobility as soon as possible( ; ), we sought to investigate, if a minimal invasive anterior approach would be beneficial in regard of perioperative blood loss ( ), postoperative pain( ; ) and thus postoperative mobility ( ) . material and methods: in a randomised controlled trial, patients were treated by a hemiarthroplasty of the hip via an anterior or lateral approach in supine position within hours after trauma( ). apart from parameters like age, asa-score or body-mass-index, the main focus was set on perioperative blood loss, pain and postoperative mobilisation. all data collected were compared between groups to detect statistical significant differences. additionally the same parameters were checked for significant differences comparing patients with or without complications within their group. results: a significant difference between groups was found for postoperative pain within the first hours and for operation time, both to the disadvantage of the minimal invasive approach group. within groups, time of operation and patient's age were significantly higher in patients with complications in the minimal invasive group such as pain at hours was rated higher in patients with complications in the lateral approach group. these results though did not seem to influence postoperative mobility since no significant differences were found between groups at follow-up. conclusion: despite some differences in the postoperative course, postoperative mobility does not seem to be greatly influenced by the choice of the approach for hemiarthroplasty of the hip in femoral neck fractures. still, the operation time was significantly linked to postoperative complications. in this respect, it can be concluded, that the approach an individual surgeon is most familiar with is likely to lead to best results. of the patients, ( . %) received a formal assessment for antiresorptive therapy. the outcomes of this assessment is as follows: . % did not require any antiresorptive therapy, . % awaiting bone clinic assessment on discharge, . % awaiting a dexa scan, . % of patients were started on antiresorptive therapy and % were continued on antiresorptive therapy from pre-admission. conclusion: our study highlighted that in our trust only . % received this assessment formally. we can conclude that when this assessment occurs the guidelines and hence subsequent fragility fracture secondary prevention is addressed. we have then presented this data locally and amended our integrated neck of femur documentation pathway to include a section on antiresorptive therapy assessement. to follow this up we plan to re-audit from st january to st january . in the upper thoracic spine / ( %) could be placed with navigation, / ( %) were controlled intraoperatively. occasionally, scan-setup was problematic, in addition, we experienced technical problems. correct placement was seen for each screw, thus correlating well with theintraoperative findings. conclusion: the application of the combination of intraoperative d-imaging and navigation for posterior instrumentation of the cervical and the upper thoracic spine is technically feasible and reliable in clinical use. user-and software-dependant sources of error could be solved during the first course of the series. image-quality at the cervical spine is depending on individual bone density, and possible metal artifacts. with undisturbed visibility of the vertebral body, the reliability of d-based navigation at the cervical spine is comparable to that of ct-based procedures. additionally, it has the advantage of skipping preoperative acquisition of data as well as thematching-process. furthermore, exposure to radiation is reduced due to the possibility of sparing pre-and postoperative ct. disclosure: no significant relationships. the average lka measurements in order were: . °, . °, . °( p < . ), and for aca: . °, . °, . °(p < . ). while a significant difference between the averages of lka, e/f of group and group (p < . ), no statistical difference was found comparing the average aca angle (p = , ). while there was no significant change in e for all groups (p > . ), the increase in f after surgery was considered significant (p < . ), and no difference was observed between the averages of group and group (p > . ). vas was . ( - ). conclusion: at the end of an average year follow up period of posterior tl fractures no difference was found between the early and late period measurements of aca and anterior height although lka showed a statistical loss in height the correction degree achieved in the late period was found to be significantly higher than preop. ( cases), crushing without skeletal injuries ( cases) in all these cases, pulse was present at the first evaluation, and the onset of acute post-traumatic ischaemia was at - hrs after trauma . tha diagnosis, based on clinical suspicion, became definite after doppler evaluation and arteriography. the anatomical base of ischaemia was late thrombosis ( cases) and compressive hematoma ( cases). thrombosis was due to obstruction of the big arteries ( cases) and microcirculation, due to overrun compartment syndrome- cases.vascular restoration and fasciotomy was performed whenever muscles were viable, but amputation was necessary in cases results: the patients were analysed from the point of view of the corelation between the moment of onset of the ischaemia, the type of injury, the status of the muscular structures, the algorithm of diagnosis, the type of the treatment, and the clinical outcome. the study revealed that the clinical outcome was better when the time between trauma and ischamia onset was less, since the muscular ischaemic had less time to develop. in the same time, there were cases in which clinical symptomes were not corresponding to the imagistic evaluation. conclusion: high energy trauma affect all the structures of the limbs. clinical suspicion has particular importance especially when trauma affects one of the regions which is known as establishing a dangerous environment between the arteries and the bones / joints. in all the cases that authors analyse, complete and early diagnosis and treatment of acute post-traumatic ischaemia, based on the close monitoring of the patient and '' clinical alarm signs '' seemd to be the conditions for the favourable outcome of the patients. introduction: the aim of presentation is to demonstrate the surgical treatment and postoperative period of a patient who was caught on a fence-pole and suffered severe injuries of perineal region and lower extremity. material and methods: after a long time of technical rescue the patient arrived to our department with a one meter long portion of fence in his perineal region. after the urgent extraction of metal fence we performed an intraoperative rectoscopy. during the debridement and exploration of deep perineal injuries we realised a heavy swelling around the punctated wound of the left leg. we made a femoral incision and exploration and recognised the several injury of the femoral vein and artery. we provided the cm long injuries with stitches. results: in the postoperative period we made a second-look and debridement because of lymhphatic retention and small skin necrosis around the incision. no real vascular or circular lesions were recognised during the control period of the patient. injuries were totally improved. conclusion: the edification of this case is that it's never sure that the major wound makes the biger trouble to the patient or to the surgeon. in our presentation we plan to demonstrate the intra -and postoperative pictures and the results of controll period. results: the incidence of various types of trauma were blunt in patients ( %), gunshot wounds in patients ( %), and stab wounds in patients ( %). only ( %) patients were hemodynamicaly stable. isolated abdominal vascular trauma was detected in patients ( %). vessels injured included aorta ( , %), inferior vena cava ( , %), named visceral arteries ( %), named visceral veins ( %), iliac arteries ( , %), and iliac veins ( , %), epigastric, hypogastric, intercostal arteries ( , %), epigastric, hypogastric, intercostal veins ( %), gonadal vessels ( %), renal veins ( %), non-named mesenteric vessels with segmental bowels necrosis ( , %). two or more vascular injuries were found in ( , %) patients. according to organ injury scaling, st grade injuries were found in ( %), nd -in ( %), rd -in ( %), th -in ( %), and th -in ( , %) patients. the most frequent associated injuries were small bowel - , liver - , colon - , stomach , duodenum - , diaphragm - , pancreas - , spleen - , with an incidence of %, %, %, , %, , %, %, % and , % respectively. all injuries were managed according to injury score. infrarenal v. cava ligation was performed in all cases of hemodynamic instability. minor named abdominal vessels were ligated in all cases. segmental intestinal resection was performed in all patents with th grade of intestinal injuries due to devascularisation. overall mortality rate was %. the vessels with the highest mortality rates were inferior vena cava ( % - / ). there were no mortalities in isolated abdominal vascular trauma patients and in cases of st grade of injury. mortality rate in accordance to ois was: nd - patients ( %), rd - patients ( , %), th - patients ( %), th - patient ( %). no differences in mortality rate were found according to type of trauma (blunt or penetrating). the associated injuries with the highest mortality rates were pancreas ( / - %), diaphragm ( / - , %), liver ( ( ), a rupture of the heart ( ) or a aneurysma dissecans with a rupture of the aorta ( ). in addidtion to the detailed forensic examination and autopsy, we took the anthropometrical measurement of all corpses in dimensions, so that we were able to create a biomechanical simulation of the accidents with ''finite element models''. there the shear forces affecting the aorta can be calculated. as three forces (frontal impact, side impact and deceleration) are the most important, we will present three comprehensible example accidents. the reason of death is always the ''aortic rupture'', but every time the biomechanical way of application of the force was completely different. in detail they are a car accident (frontal collision of a small car with a wall); a downfall from the height of meters in suicidal purpose and a compression of the thorax of a eight year old boy with a shovel of an excavator. results: although all three accidents have completely different course of crash, we were able to see the same reason for death: a rupture of the aorta at the onset of the ligamentum arteriosum botalli. by using the numerical simulation, it can be shown that three main directions of force are important in an accident: the frontal impact, the side impact and the deceleration. in all these examples, it was able to simulate the reaction of the aorta in relation to the development of the force. the simulation will be presented as well as all clinical treatement made by the medical stuff. conclusion: although the rupture of the thoracic aorta is a frequent cause of death, the injury mechanism has not been comletely known. a database with several victims of aortic ruture was created and special accident types will be presented and simulated. introduction: overlooked compartment syndrome represents a catastrophic complication for patients and orthopedic surgeons. invasive compartment pressure measurement continues to be the gold standard. however, repeated measurements in uncertain cases can be difficult to achieve. we, therefore, developed a model for a noninvasive technique to assess tissue pressure by ultrasound based elastography. material and methods: a perforated plastic tube filled with saline was surrounded by a silicone sealed plastic cover, mimicking the shape of the tibial compartment. a pressure transducer inside the compartment was installed. a second pressure transducer was installed on the ultrasound probe to allow simultaneous monitoring of the pressure inside the compartment and the tissue deformity. for calibration, ultrasound images were generated at and mmhg. the plastic cover to tube distance was measured before and after compression (delta d). subsequently, increments of mmhg pressure increases were used to generate a standard curve ( - mmhg), thus mimicking rising compartment pressures. the intra-observer reliability was tested by using subsequent measurements. a correlation was determined between the skin to bone distance (delta d) and the pressure measurement (p). the pearson correlation coefficient was calculated, and a regression analysis was performed. ( ), better antibiotics and computed tomography-guided percutaneous drainage ( ). however, when everything else has failed, the burder of decision making the choice of a 'last resort' operation will be shifted again to the surgeon. we here described our recent experience with such cases treated by abbreviated laparotomy using the bogota bag technique ( ). results: for the seven first patients, we performed colon resection with colostomy. after extensive debridement, lavage and drainage, the peritoneal cavity was closed with a sterile gastric bag sutured on the rectus aponeurosis according to the so-called bogota-bag procedure ( ). the mean operative time was minutes. a second look laparotomy was planned after hours: one patient required one reexploration, four patients required two and two required three. the decision of re-exploration was based on the visual aspect of the peritoneal content, the clinical evolution and the bacteriologic results. for the last three cases, we elected perform colon resection without colostomy followed by anastomosis in two patients in the second look laparotomy and colostomy in one because of two relaparotomies. none of the ten patients required further percutaneous drainage. two patients died in multiple organs failure (one with perforated diverticulitis and one with ischemic colon after aneurysm repair). conclusion: abbreviated laparotomy with temporary closure of the abdominal wall associated with planned re-exploration of the peritoneal cavity is a simple and effective way to treat patients with severe abdominal sepsis. introduction: pelvic fractures usually are the result of high energy trauma and such patients often have many associated injuries. long term outcome data of pelvic injury patients is sparse, we present our information with special emphasis on poly-trauma patients, with consideration for the combined involvement of associated injuries on functional outcome. material and methods: general functional outcome and clinical outcome were determined with an examination by a physician and patient assessment at a minimum of years after the injury. pelvic fracture patients that had suffered poly-trauma were categorized by fracture location: acetabular, pelvic ring, or a combination. results: the long term outcome in the patients with pelvic ring fractures (exclusive of acetabular fracture) was the worst clinically, as evidenced by evaluation of pain( . %), increased use of special medical aids( . %), a poor merle d'aubigne score( . %), and worse sf- and haspoc scores. patients with acetabular fracture had poorer general functional outcomes than those with combined pelvic acetabular fractures and were noted to have higher incidence of associated injuries such as type iv pipkin fractures. further subcategorization of pelvic ring fractures into anterior, posterior or combination showed specifically those patients with combined anterior posterior pelvic ring fractures had the worst long term outcome. conclusion: a combined anterior posterior pelvic ring injury accounts for the worst long term outcome of pelvic injury poly-trauma patients. we found that bilateral pelvic injury and particular associated injuries greatly influence long term functional outcome. disclosure: no significant relationships. material and methods: canulated screws were placed in human semi-cadaver models and plastic pelvis models in d navigated, d navigated and conventional matta technique. aim of this study was to evaluate intraoperative time, intraoperative radiation dose (fluoroscopy time, area dose product and images per screw) and accuracy (amount of exactly placed screws, mean deviation of tip placement and misplaced screws per group). results: the accuracy of d navigated procedures is significantly higher (p < , ) than in the conventional technique. there is a significant lower radiation dose in the navigated procedures (p < , ) for the operation team. the intraoperative radiation dose is increasing significantly from conventional method to d navigated to d navigated procedures for the patient (p < , ). there is a significant higher time per screw necessary for navigated procedures (p < , ). conclusion: the usage of flatpannel technology seems promising in d navigation. our data shows a benefit from using navigated procedures in transilliosacral screw placement. the higher precision and lower radiation exposure for the operation team show that d navigation is superior to d navigated procedures. the higher accuracy of the d navigated procedures renders a postoperative routine ct scan obsolete thus lessening the total radiation exposition of the patient. introduction: the purpose of this biomechanical study was to determine whether locking screws or smooth locking pegs optimize fixation of ao a distal radius fractures. material and methods: pairs of fresh-frozen human distal radii were used. ao a extra-articular distal radius fractures were created by removal of a -cm-wide dorsal wedge of corticocancellous bone centered cm from the articular margin of the distal radius and were fixed using palmar locking plates. the radii were divided into matched-paired groups for comparison. the side order, the fixation order and the testing order were randomized. the distal fragment in group i was stabilized with angular stable screws. the distal fragment in group ii was fixed with locking pegs. the proximal fragment in both groups was fixed with screws. the probes were tested with . nm for torsion and with n axial load for cycles each. stiffness was measured from the first cycles regarding torsion and axial load. then the differences of the stiffness were recorded during the remaining cycles. the wilcoxon test was performed, a value of p £ . was considered statistically significant. results: there were no statistically significant differences in the first load cycles within the eight matched pairs. after cycles the constructs with locking screws (group i) showed statistically higher stiffness values (p = . ) compared to the constructs with smooth locking pegs (group ii introduction: plate fixation of the odontoid process without c -c arthrodesis appears to a practicable option for the management of odontoid fractures that are not suitable for conventional screw fixation. although previous biomechanical works have evaluated the effectiveness of different odontoid screw fixation techniques, no study has quantified the mechanical stability of odontoid fixation by a plate device. the purpose of this study was to measure the mechanical stability of odontoid plate fixation using a specially designed plate construct, and to compare the results to those after odontoid single-and double screw fixation. material and methods: the second cervical vertebra was removed from fifteen fresh human spinal columns. the specimens were fixed to the experimental apparatus, with the load cell at the articular surface of the odontoid process. in a first test series, stiffness and failure load of the intact odontoid were measured. type ii odontoid fractures were created by °oblique extension loading at the articular surface of the odontoid process. afterwards, the specimens were randomly assigned to one of the following three groups: in group i (n = ) the fractures were stabilized using a specially designed plate construct, in group ii the fractures were fixed using two . mm cortical screws, and in group iii we used one regular . mm cortical screw. in a second test series, stiffness and failure load of the stabilized odontoid fractures were assessed for comparison and statistical analysis. results: group i (plate device) showed a significantly higher mean failure load than group ii and group iii. the mean failure load of group i after fixation of the odontoid fracture was % of the mean failure load that was necessary to create a type ii odontoid fracture, initially. comparing group ii (double screw technique) and group iii (single screw technique), there was no significant difference regarding the mean failure load. in both groups the mean failure load after odontoid fixation was approximately % of the mean failure load of the intact odontoid. statistical analysis also revealed a significantly higher stiffness of the stabilized odontoid after plate fixation, than after single or double screw fixation. conclusion: plate fixation of the odontoid process as an alternative procedure in certain fracture patterns provided a significantly higher biomechanical stability than the technique of odontoid screw fixation. using a specially designed plate construct fixed with two cancellous screws into the body of c and an additional cortical screw inserted in the odontoid process, % of the original stability of the intact odontoid was restored. single or double screw fixation of the odontoid only restored approximately % of the original strength. results: extension and flexion were not influenced of all implants significantly. all dynamic implants and also the rigid implant led to a significant increase of the mobility during side bending and rotation in the area of the adjacent segments. conurrently the cephaled adjacent segment (l /l ) showed a significantly higher mobility than the caudal adjacent segment (l /l ). conclusion: dynamic implants such as the interspinous spacer enlarge the mobility of the adjacent segments during side bending and rotation in a comparable size as the rigid implant. to this extent is to be assumed that reinforced adjacent degeneration cannot be prevented by the use of the interspinous spacer substantially. introduction: osteoporosis is a systemic skeletal disease characterized by reduced bone mineral density and disrupted microarchitecture of bone tissue. the most severe consequence of osteoporosis are osteoporotic fractures. these are mainly low-energy fractures, which anamnestically, clinically and radiologically differ from fractures in healthy bone. we tried to find the answer to a queston, whether it is possible, that osteoporotic compression fractures are single events, or if they represent a gradual, progressive vertebral collapse in patients with osteoporosis. we evaluated the forces, necessary for vertebral fractures, regarding the bone mineral density. material and methods: cadaver vertebrae were isolated with the approval of ethics committee. we mesured their bone mineral density and then subjected them to the stress-test. we used the computer-controlled hydraulic press and stress vertebrae to the fracture point and beyond, monitoring the deformation and the load. a sigma-epsilon diagram was constructed from the data. results: with the loading of vertebrae the pressure grew exponentially as a function of deformation to the breakage point. then we observe a plateau of saw-like shape, which corresponded to the progressive vertebral collapse. further deformation led to gradual compacting of vertebrae and we observed once again an exponential increase in pressure. this bone compaction is therefore the first mechanisms of fracture repair. the saw-like plateau form suggests progressive collapse of vertical trabeculae and their jaming into the horizontal, which then with the increasing deformation and load also fail. a similar phenomenon can be observed in the collapse of buildings during the demolition. (the - phenomenon). conclusion: unlike a high energy vertebral fractures, the osteoporotic fractures are presented as a gradual vertebral collapse. they take place parallel with the processes of bone reparation and remodelation. from this standpoint, osteoporotic fracture is unique. vertebral collapse increases the bone mineral density in the broken vertebrae, what is observed radiologically and densitometrically. repair of medium to large, but reparable, rotator cuff defects, augmented with a restore patch or not. patients have been randomly assigned to receive standard repair augmented with the restore implant or to receive non-augmented standard repair as the repair procedure is exactly the same in both patient groups, and the implantation of the restore implant does not necessitate any additional incision or measures, neither the patient nor the assessors are aware of the fact an implant has been used. the ethical committee of the university hospitals leuven has approved the study. all patients get full information and are enrolled in the screening program after written consent only. clinical evaluation, both pre-operatively and at months post-operative is performed by the same, independent physiotherapist trained in shoulder evaluation using the constant score structural evaluation is performed by ultrasonography, performed by a radiologist specialised in musculoskeletal radiology and sonography. unpaired two-tailed t tests, performed with prism software for mac osx, were used to compare the results of the scores in the control group with those in the xenograft group. fisher exact tests were used to evaluate the significance of differences in the proportions of retears in the patients for whom a sonography was obtained. results are expressed as the mean and standard error and significance was set at p < . . results: we included patients. there were female and male patients. in the non-augmented group there were females and males. in the restore group there were female and male patients. the average age of patients was years of age. in the non-augmented group the average age is , y (+/- , ) years of age, in the restore group , y (+/- , ). the mean pre-operative constant score of the non-augmented group was , +/- , points whereas it was +/- , points for the restore augmented group. post-operative the functional outcome months after surgery again was scored using the constant score. the mean score in the non-augmented group was +/- , points; in the restore group it was , +/- , points in the non-augmented group we documented a retear in / patients, in the restore group we had a retear in / patients ( small tears, massive tear). introduction: it has been estimated that up to % of adults suffer from rotator cuff tears [ ] , which can impair their ability to work or perform household tasks [ ] . management of rotator cuff tears is difficult as a large proportion of technically correct surgical repairs re-rupture, estimated between - % [ ] . it has been estimated that thousands of extracellular matrix repair grafts are used annually [ ] to augment surgical repair of rotator cuff tears and act as temporary scaffolds to support tendon healing. the only mechanical assessment of the suitability of these grafts for rotator cuff repair has been made using tensile testing only, and compared grafts to canine infraspinatus [ ] . as the shoulder is subject to shearing as well as uniaxial loading, we compared the response of repair grafts and human rotator cuff tendons to shearing mechanical stress. we used dynamic shear analysis (dsa), which is a form of rheology and allows the study of flow and material deformation. material and methods: the shear properties of four different commercially available rotator cuff repair grafts were measured (restore, graftjacket, zimmer collagen repair and sportsmesh). mm punch biopsies were taken from the grafts and subjected to oscillatory deformation under compression. the bulk storage modulus (g') was calculated [ ] and used as an indicator of mechanical integrity. to assess how well the repair grafts were matched to torn and normal rotator cuff tendons, the storage modulus was calculated for human rotator cuff specimens obtained from the edge of rotator cuff tears during surgery, from patients aged between and years. age and sex matched normal controls were also obtained during shoulder hemiarthoplasties and stabilisations. results: we report a significant difference in the shear moduli of all four rotator cuff repair grafts (p < . , way anova). of the repair grafts (restore and graftjacket) had a significantly lower storage modulus when compared to human rotator cuff tendons (p < . , dunn's multiple comparison test). only the zimmer collagen repair and sportmesh had a storage modulus which was comparable to that of normal rotator cuff tendons (p > . ), and thus were most closely matched. conclusion: with increasing numbers of repairs of rotator cuff tears, and augmentation of these repairs, there is a need to understand the mechanical and biological properties of the both repair grafts and the tendons they are designed to augment. there is no clear definition of the ideal mechanobiological properties. current rotator cuff repair grafts display a wide variation in their shear mechanical properties, and how closely they are matched to the mechanical properties of human rotator cuff tendons. it is hoped that this study, in conjunction with others, will help to guide surgeons in deciding on the most appropriate repair graft. three-dimensional computed tomography reconstructions also improved the average intraobserver reliability for all fracture characteristics, from j d = . (substantial agreement) to j d = . (substantial agreement). the addition of three-dimensional images had limited influence on the average interobserver reliability for the recognition of specific fracture characteristics (j d = . versus j d = . , both moderate agreement). three-dimensional computed tomography images improved interobserver reliability for the recognition of coronal plane fractures from fair (j d = . ) to moderate (j d = . ) but this difference was not statistically significant. conclusion: three-dimensional computed tomography is helpful for; ) individual orthopaedic surgeons for preoperative planning (improves intraobserver reliability for the recognition of fracture characteristics), and for ) comparison of clinical outcomes in the orthopaedic literature (improves interobserver reliability of classification systems). disclosure: no significant relationships. introduction: in recent years, d fluoroscope has used increasingly in orthopaedic surgery because it offers some advantages such as generation d data without anatomic registration requirement. previous studies have focused on the clinical use of d fluoroscope in surgical procedures such as calcaneus or acetabular fracture reduction, or placement of screws in spinal surgery. there are no reported data on radiation exposure of d flu to orthopaedic theater staff. we want to correlate radiation exposure and distance concerning the patients and members of surgical team during using three-dimensional fluoroscope and study how far is enough until radiation exposure can not be measured. material and methods: an isocentric c-arm fluoroscope (siremobile isoc d) was used for the study. human cadaveric extremity was used for target. digital dosimeters (mydose mini pdm- , aloka) were used to measure radiation exposure at specific distances. dosimeters were systematically exposed by the following protocol. represented positions were direct contact and every -cm. radius from the center of the beam. the distances were increasing until the dosimeters could not detect the radiation. each radius distances were designed to record different positions; top, bottom, left and right side. dosimeters were exposed and removed ( dosimeter positions at a time from each radius). first we used low resolution scan technique to obtain the images. after all radiation exposure records were collected, we changed to use high resolution scan technique and repeated the protocol. each technique was repeated in times to obtain the mode of data. results: radiation dose at ground zero is lsv in high resolution and lsv in low resolution. radiation in high resolution technique can not be measured beyond meter from the center of the beam at the top, bottom, and right direction and . meters at the left direction. in low resolution, radiation cannot be detected farther than cm. in the top, bottom and right direction and . meters at left direction. conclusion: radiation dose measurements in each direction are decreased during increasing distance and dose in left direction is higher and farther than others. beyond . meters is safe from radiation in knee application. high resolution gives higher radiation and farther than low resolution. introduction: tibial plateau fractures with impression are often associated with poor outcomes and a high rate of complications. the current guidelines advocate anatomic reduction, re-establishment of tibial alignment, stable fixation, and filling of the sub-articular defect. we hypothesized that fixed-angle liss-plates provide adequate stabilization with less need for void filling, minimal complications and good radiological outcome. material and methods: retrospective evaluation study. in the period - , we operated patients with an intra-articular tibial plateau fracture. forty were treated with a liss-plate. mean age was years, were male. all fractures were classified as ao type b or c; were schatzer type ii, type iv, type v, and type vi. five patients were initially treated with external fixation. mean time until definitive surgery was days (range, - days). in fractures, the subchondral void was filled with either hydroxy or bone graft, in the other cases no graft was used. demographic data and fracture classification were equal in both groups. articular impression was measured by independent evaluators pre-operatively, post-operatively and months after surgery on plain x-rays. results: mean pre-operative impression was . mm (with void filling . mm, without . mm, ns). thirty-four fractures were additionally stabilized with k-wires or screws. the post-operative impression was on average . mm. evaluation criteria included the lysholm and tegner activity score. all fractures were stabilized post primarily. the surgical main approach was strictly medial. exposure of the entire medial condyle fracture was first performed anteromedial following the fracture line to the articular border. the posterolateral impaction was addressed directly through the main fracture gap. small fragments were removed, larger reduced and preliminarily fixed with separate kwire(s). the posteromedial part of the condyle was then prepared for main reduction and application of a buttress t-plate in a posteromedial position, preserving the pes anserinus and medial collateral ligament. in addition a parapatellar medial mini-arthrotomy through the same main approach was performed for reduction and pds-suture-fixation of the anterior eminence (acl and anterior horn of lateral meniscus). results: we treated patients with fractures. median age was years ( - ). we could evaluate patients ( %), patients were lost to follow-up due to foreign residency. the fractures were treated post primarily at an average of days, of them in a twostaged procedure with initial knee-spanning external fixator. all fractures healed without secondary displacement or infection. patients showed none to moderate osteoarthritis after a median of years. one patient showed a severe osteoarthritis after years. all patients judge the result as good to excellent. the lysholm score reached ( - ) and the tegner activity score ( - ). all patients have achieved a minimum flexion of °. conclusion: in our view it is crucial to recognize this increasingly observed type of knee injury in winter sport areas. with our strategy we achieved good results in nearly all patients. the described larger medial approach allows addressing most of the injured parts of the tibial head (medial condyle with posteromedial buttressing, tibial spine, posterolateral impaction). material and methods: it is presented one new minimally invasive method for closed fracture reduction and one extramedullary selfdynamisable internal fixator (sif). there is no contact between bone and internal fixator in fracture area. it has been widely investigated biomechanicaly. in clinical use it has been applied to metaphyseal fractures of distal femur and proximal and distal tibia. the age of patients was from to years. this internal fixator is applied by two small incisions. reduction is achieved using standard traction table or using special reduction device. for opened fracture it has been used high mobile external fixation system as temporarily ( fractures) or definitive ( fracture) method. results: received clinical results are promising, as it has been shown early callus formation and radiological union within the . - months. it has been allowed to patients early full weight bearing, if fractures not intraarticular. during the treatment it has been confirmed working of self-dynamisation concept, which probably all together with d configuration resulted in unexpectedly quick fracture healing. follow up was months ( - ). when used external fixation system, axial dynamisation has been regularly activated. conclusion: according to results obtained, it can bee concluded that new biological internal fixator is suitable for minimally invasive technique, without opening of fracture site if no intraarticular dislocation. it can be used as primary method or soon after external fixation if damaging control concept used. introduction: disaster, is the disproportion between the need for medical care and the means available in the community. this discrepancy of needs /means is the major problem in every step of the rescue chain, when a disaster situation is present. this is more obvious at the end of the chain, which is the hospital and especially, the bottleneck of the entire disaster's management system, the emergency department. material and methods: in greece, the most common and frequent disaster situation is the earthquake. and so, the most expected pathology of the victims is trauma. because of the lack of . special organization of emergency medicine and . independent modern emergency departments in greek hospitals, their directors did not give the appropriate attention to organize a disaster plan (internal or external introduction: accurate response to major incidents requires accurate decisions on all levels, from command level to the care of the individual patient. development, evaluation and training of the process of decision-making requires standardized models providing complete and accurate information as a base for the decisions; a decision based on incomplete or incorrect data can not be properly evaluated. the aim of the present project was to design a simulation model that could be used both for evaluation of different methods in the response to major incidents and for training and evaluation of skills in making correct decisions. material and methods: a system was created providing the information required for this process in the whole chain of management and performance: scene, transport, hospital response, co-ordination and command. input data were based on real scenarios and real resources. for evaluation of methodology, all parameters except the one studied, in this study triage, were standardized. the results from (a) physiological and (b) anatomical triage, performed by staff on different levels of competence and experience, serving as their own controls, were compared. for training, the system was used in courses in medical response to major incidents with training of the whole chain of management and performance, from prehospital patient management to over all co-ordination and command. results: the methodological evaluation showed differences in priority and outcome between anatomical and physiological triage related to the level of experience and to the position in the chain of response, providing a base for choice of method related to those factors. the results from training with the use of the system, so far only evaluated by the participants own ranking, showed high percepted improvement of relevant skills. conclusion: a methodology for simulation of major incident response designed for scientific evaluation of methodology also provides a very good educational tool, since correct and complete data as a base for decision making also gives an effective and realistic training. disclosure: one of the authors, sl, has the copyright to the mac-sim system, a non-commercial system intended mainly for scientific use. equipment for training can be produced by users, but also purchased for production costs. introduction: interhospital referral of traumapatients for reasons of special (most neuro-)surgical competencies to a specific level traumacenter, is common practice in the netherlands. these traumapatients are sometimes admitted directly through specialized intensive care units and therefore do not enter the emergency department (ed). therewith the standard assessment according to the atls guidelines is bypassed in these cases. this withholds the risk of an incomplete assessment. we therefore consistently coordinate the assessment of all transferred traumapatients. in this study we analysed the number of newly found injuries in referred polytraumatized patients and the clinical consequences in terms of extra treatment, permanent damage or death to the patient. we also analysed possible risk factors for missing injuries. introduction: synchronous admission of large numbers of patients into the hospital requires a perfect coordination of activities of designated teams in the process of reclassification at the entry to the hospital and subsequent continuous provision of medical care for the patient in the course of examination and treatment, up to his hospitalisation at the target department, in accordance with the characteristics of the injury and seriousness of his medical condition. this process cannot be accomplished through improvisation but only with creating a uniform organisational scheme, defining the recommended structure of medical teams and their activities during a multiple admission of casualties into the hospital. in this article, we present a proposal of such consensual organisational scheme, partially verified in practice. the organisational scheme is defined in the following areas: -space arrangements -places of admission and organisation of work -creation of mini trauma teams (anaesthesiologist, traumatologist and surgeon or another traumatologist take over the most serious patients, the teams are accompanied by consulting specialists of relevant specialities (neurologist, neurosurgeon, radiologist), the whole teams or at least parts of them, accompany the patients for the whole period up to the definite treatment at operating theatre, or his placement at a destination department -the continuity of care is secured in this way, without the need to pass on any findings and information -placement of patients into individual hospital departments (follows certain rules, it is necessary to direct all the admitted patients into as few departments as possible (one or two), and thus keep the best possible view over the priorities during their treatment -entry corridors -,,green corridor'' -patients are immediately transported through this area by transport teams into the ''green'' designated area, the ''red'' and ''yellow'' entry area does not have to be extremely large, however it requires an adequate equipment from the material and technical point of view results: multiple admission of patients must be well-organised and managed, most often by a head-physician of the ua department, or another authorised specialist (in hospitals without the ua department). the idea of the traumanetwork d dgu is to built up regional networks of various trauma centers with the objective to standardise and optimise the treatment of severely injured patients -with the additional involvement of rescue services, physicians and competent facilities and centres for the treatment of specific injuries as severe burn or spinal cord injuries etc. to assure that all participating hospitals meet the criteria needed for the treatment of trauma patients, a certification firm (diocert) was assigned to accomplish the audits and to control the process of certification. thus, every hospital has to pay a sum of nearly eur for audit, certification, benchmarking, yearly quality reports and the use of special it-tools which were designed for the traumanetwork d dgu. material and methods: coordination of traumanetwork implementation coordination of audit and certification process results: since the beginning in the year actually hospitals are participating the traumanetwork d dgu. these hospitals are organized in regional traumanetworks. % of the hospitals are preliminary categorized as local trauma centers, % as regional trauma centers and % as over-regional traumacenters (the highest category). % still aren¢t categorized. hospitals have already signed the contract with the german trauma society and paid the participation fee. hospitals meet the criteria for audit and hospitals are already audited by the firm. in october the first regional trauma network (trauma network east bavaria / tno) was certificated with a total of participating hospitals. conclusion: in the past years the number of participating hospitals increased year by year. the nationwide acceptance and the high level of participation in the traumanetwork d dgu in germany show that the treatment of severely injured patients is one of the main topics and exercises for trauma surgeons in germany. if the expected improvement in treatment quality and the decline in trauma mortality is only wish and fiction or reality and fact has to be proven by studies in the next years. therefore a working group with focus on quality improvement, changes in mortality, improvement in rehablitation results etc. was founded. introduction: one of the challenges in trauma care is diagnosing all injuries. any delay in treatment can lead to increased morbidity, prolonged length of hospital stay, costs, and even mortality. despite the use of standardized guidelines for initial evaluation such as atls, the incidence of missed injuries in the literature is considerable. the aim of this study was to assess the rate of missed injuries in trauma patients evaluated in two dutch level- trauma centers and to determine potential factors that contribute to injuries being missed. we assessed all radiological reports during initial admission and operation records of the patients included in the prospective randomized react trial. this study was part of a randomized trial conducted in two dutch level- trauma centers investigating the role of ct scanning in the trauma room. missed injuries were defined as not diagnosed during initial radiological evaluation in the trauma room. we assessed all missed injuries and the phase in which these injuries were diagnosed. second, we assessed potential contributing factors by univariate analysis. results: there were a total of total calls performed with real patients and test calls. of the actual calls, ( %) were performed while moving and ( %) were done from a stationary position. initial video quality in was rated good in cases ( %) and initial audio quality was rated good in ( %) cases with actual patients. of the actual calls ( %) experienced some sort of temporary video drop during the entirety of the call and calls ( %) experience some sort of temporary audio drop. these drops were a result of the setup of mesh wifi and the need to jump from router to router. users in the hospital found the program to be a very useful trauma and emergency medicine tool, but adjustments need to be made to improve the network. conclusion: the use of telemedicine in a pre-hospital setting may play a significant role in the management and treatment of trauma and critically ill patients as hospital medical staff can intervene in real time during transport. patients can be evaluated in real time which allows the necessary staff and resources to be available on arrival. initial user feedback has been encouraging with users acknowledging its usefulness as a pre-hospital tool. ( ) in the elective setting it is logical that a lower egfr reflects poor renal function and low overall physiological reserve. the same is not obviously true for emergency patients who may have an ''artificially'' low egfr merely as a reflection of acutely altered fluid balance. change in egfr from admission to hospital to itu admission was also significantly different between survivors and nonsurvivors. this would suggest that egfr reflects a response to treatment as well as renal function. this study supports the use of egfr in the decision making process when trying to predict outcome in emergency general surgery patients. introduction: the surgical medium care (smc) in our hospital is a bed ward with monitoring facilities, and is used critical ill patients from the trauma and other surgical wards. over the last years there has been an increase in the number and severity of trauma patients admitted to out hospital, as well as there has been an increase in patients undergoing major elective surgery. the aim of this study was to verify if these trends are reflected in an increase in patient-and workload on our smc. in this study we describe the patient-and workload on the smc between and using the tiss- . the modified therapeutic intervention scoring system (tiss- ) is a validated score of therapeutic activities and an alternative approach to evaluate outcome of critically ill patients ( ) ( ) ( ) . material and methods: a prospective cohort study of all consecutive patients admitted to the smc between / / and / / was performed, using the tiss- database. of all admitted patients a daily tiss-score was performed. besides the tiss data, patients demographics, referring ward, discharge destination, length of stay, and hospital mortality were retrieved from the database. results: there were a total of admissions of patients in the study period. % of patients were male, % were female. the median length of stay was days ( - ). the overall hospital mortality rate was , %, with no significant differences over the years. % of the patients admitted to the smc came from the icu, % came from the emergency department, , % came from home, , % came from the recovery ward, and % came from the trauma and surgical ward. these percentages did not change over time. the average tiss score during the study period was and did not significantly differ during the study period. there was, as expected, no significant difference in tiss score between patients who survived and the non survivors. introduction: the demands placed on systems and organisations that protect the general population are constantly growing. the reasons for this include, among other things, circumstances altered by the threat of inter-national terrorism and the increasing frequency and magnitude of mass public events and natural catastrophes. crisis situations such as these present unique, often completely unprecedented chal-lenges to those affected and to all actors with responsibility for crisis management and the protec-tion and rescue of people.with regard to effective interdisciplinary crisis management, both germany's security and rescue forces and its general population suffer from widely acknowledged and scientifically proven deficits. impact on people and the society. in this context, all natural and man-made threats will be considered (''all hazards approach''). elearning and virtual reality modules based on these scenarios will be offered to target groups via the internet on an individualised basis. results: the aim of this project is to develop a platform to prepare security and rescue forces, doctors, caregiv-ers and the general population for terrorist attacks, crises and disasters. an online platform with a modular structure (employing teaching methods such as e learning, blended learning etc) will offer innovative and specialised instruction and advanced training to all users. conclusion: experts agree that the modern teaching methods and computer-based simulations mentioned here (such as virtual reality methods) are excellent tools to help train people efficiently to respond to events that cannot be planned, such as terrorist attacks and other catastrophes. the use of these innovative methods and com-pletely novel, userfriendly, web-based instruction and information modules is designed to address -to a heretofore unprecedented degree -all security and rescue forces concerned as well as the general population in particular. ultimately this will signifi-cantly improve security and rescue operations in the event of terrorist attacks, crises and disasters. conclusion: in a proper setting, laparoscopic emergency is feasible, effective, safe and beneficial for patients to be a part of a common surgical practice, as long as adequate training is obtained and proper preparation observed when more advanced procedures are attempted in critically patients. the diagnostic and therapeutic versatility afforded by the laparoscopic approach avoids extensive preoperative studies, averts delay in operative intervention and minimize morbidity and shorten the postoperative hospitalization. we do think that laparoscopy should be incorporated into general surgeon's armamentarium for the management of patients with acute abdomen as just as another tool to be used selectively when indicated. laparoscopy, however, must not be used as an alternative to good clinical judgment. about our algorithm in patients with acute abdomen: if there aren't any contraindications to laparoscopy, obtained an informed consensus, in presence of a well trained surgical team in minimally-invasive surgery, excluded any major gynaecological diseases (about which we and our gynaecological colleagues haven't a skilled experience with a laparoscopic approach), we always approach laparoscopically. introduction: stable patients with thoracoabdominal penetrating or blunt injuries resulting in diaphragmatic injuries represent a difficult and challenging management dilemma. although laparoscopy and thoracoscopy have now emerged as the most reliable and efficient diagnostic and treatment modality of these injuries, a conversion to laparotomy for mere evidence of peritoneal penetration and or diaphragmatic injuries is common for most trauma surgeons. we hypothesized that laparoscopically-assisted mini-thoracotomy for repair of diaphragmatic injuries will be as effective as open laparotomy or thoracotomy and will prevent the morbidity associated with open technique and should be used in hemodynamically stable trauma patients. we designed a minimally invasive technique that combines laparoscopic exploration of the intraperitoneal cavity and existing injury site as an entrance to the injured site or organ. open hassan technique, using vertical midline incision is used to create the pneumoperitoneum. additional two to three or mm ports are placed to enable thorough examination of the peritoneum, running the small bowel and examining other abdominal viscera. diaphragmatic lacerations are repaired by extending ( - cm) the existing thoracic stab or gunshot wound. the diaphragm is grasped with two graspers and brought to the operative field. continuous or interrupted suture are used for repair. we applied this technique to hemodynamically stable trauma patients (la group) treated over a year period at the university level i trauma center and compared to trauma patients requiring laparotomy (og) for isolated diaphragmatic injury repair . all laparoscopically assisted procedures were performed by the senior author (rl). length of stay, morbidities and complications were studied in both groups. both groups were matched for iss, age, and gender and mechanism of injuries. results: there were patients (five with stab, two with gunshot wound and one with blunt trauma and chronic diaphragmatic injury) in the la group. introduction: acute small bowel obstruction is mostly due to adhesions ( %), while internal hernia can cause acute small bowel obstruction in % of cases. this clinical condition has been considered for many years a relative contraindication for laparoscopic surgical treatment. with the introduction of ct-scan in the diagnosis of this clinical situation and the experience in laparoscopic techniques, more surgeons are now attempting laparoscopic management for this indication. the advantages of laparoscopy in abdominal surgery are now well defined, such as a shorter intestinal function recovery, a shorter hospital stay and less post-operative pain complained by the patients. in our presentation we want to analyse the importance of laparoscopy in the diagnosis and the treatment of acute small bowel obstruction, in order to underline advantages and limits of this technique. material and methods: in san raffaele hospital milan (italy) a total of patients underwent a surgical intervention for small bowel obstruction from january to december . % of the obstructions was due to adhesions, % to internial hernias. all the patiens underwent preoperative abdominal x-ray and ct-scan. results: of the total of patients, have been operated on with a laparoscopic approach, with a conversion rate of . %. postoperative morbidity was % in the laparoscopic group and . % in the traditional surgical approach, with a shorter hospital staying in the first group. conclusion: the analysis of our data suggests us that the selection of patients that can benefit from a laparoscopic approach to acute small bowel obstruction has to be made accurately, better with the use of ct-scan, in order to limit the percentage or useless laparoscopy and to diminish the conversion rate and to give the patient the better curative option. introduction: intestinal obstruction has remained one of the most common surgical emergencies. the aim of our study is to evaluate the feasibility, safety and palliative role of laparoscopic bowel surgery in the management of large bowel obstruction. material and methods: in a period of years, patients were subjected to loop sigmoidostomy. in patients the diagnosis was bowel obstruction due to rectal cancer. in patients the obstruction was attributed to ovarian cancer. from those patients with rectal cancer, patients had contominant liver and lung metastases and had an unresectable liver lession. in that period lapassisted ileo-transverse anastomosis were performed due to obstruction from cecum carcinoma together with mlitple liver and lung metastases. single surgeon-performed pocus in the evaluation of acute appendicitis led to a correct diagnosis in , % ( / ). surgeons trained in us ordered a ct scan in , % of cases and ratio of negative appendectomy was , %. surgeons not trained in us ordered a ct scan in , % and their ratio of negative appendectomy was , % (including pts that underwentent surgery on clinical investigation basis only). conclusion: surgeon-performed pocus has a high sensitivity in the assessment of acute appendicitis and it is a powerful tool that minimize the use of ct scan and ratio of negative appendectomy with reduction of hospital and social costs; furthermore an advantage for the patients in terms of radiation exposure can be achieved. moreover, to reduce additional costs, laparoscopic approach should be indicated only when the appendix cannot be perfectly visualized and localized. introduction: severe bleeding is, besides head injury, the most important predictive factor in severe trauma. therapy of hemorrhagic shock starts already at the scene of accident. however, the best strategy regarding preclinical volume therapy is controversially discussed. the traumaregister of the german society for trauma surgery (tr-dgu) observes the routine management of severely injured patients since many years. this registry will be used to describe the behaviour of preclinical volume administration as well as the consequences in early hospital care and its changes during the last ten years. material and methods: the tr-sdgu is a voluntary anonymous documentation of severely injured patients for the purpose of quality management. data collection started in . about parameters are collected per patient. for the present investigation only adult patients (age >= ) admitted directly from the scene to one of the participating hospitals during the past ten years ( - ) were considered. a minimum injury severity of iss > = and available data for volume administration and blood transfusion were required. means and prevalence rates were analyzed on a yearly basis. results: a total of , patients injured between and were analyzed. mean age was . years, and % of patients were males. in % of cases there was a blunt trauma mechanism, and % of cases were unconscious at the scene (gcs £ years that required presentation in one of the two level- trauma centers (amc or vumc) were eligible. in the amc the ct scanner was located in the trauma room (intervention group) and in the vumc the scanner was located in the radiology department (control group). randomization was performed prehospitally at the time of dispatch from the scene. primary outcome measure was the number of non-institutionalized days within the first year following trauma. secondary outcomes were mortality, length of initial admission and transfusion requirements. preplanned subgroup analyses consisted of multitrauma patients and severe traumatic brain injury (tbi) patients. results: in total, patients were included for analysis of which were multitrauma patients and had severe traumatic brain injury (tbi). demographic data were comparable between both groups except that there were more multitrauma patients evaluated in the amc. introduction: the effective initial treatment in the emergency room of polytraumatized children requires a sound knowledge of common injury patterns, incidence, mortality, and consequences. the needed inital radiological imaging remains controversial and should be adapted to the expected injury pattern. material and methods: in this retrospective study, the injury patterns of polytraumatized paediatric patients (age £ years) in the period from december to may were evaluated. all children were initially diagnosed with a whole body ct scan. the cause of accident, the localization including the detailed diagnose, the lethality and the severity of the injuries were analyzed. the ais (abbreviated injury scale) and iss (injury severity score) were used to classify the severity of injuries in different body regions. moreover the number and the kind of operation as a consequence of the initial made diagnoses were investigated. results: the mean score of the iss was ± in boys and girls with a mean age of ten years. the lethality was % and only % in the first hours. the most severe and most frequent injury was craniocerebral trauma in % with an ais ‡ in %. surgical intervention of the head was done in %. thorax injuries were found in % with % with an ais ‡ and in % a thoracic drainage was needed. abdomial trauma was found in % (surgery %) with an ais ‡ in %. fractures of the spine occured in % (surgery %) with an ais ‡ in % and pelvic injuries were diagnosed in % (surgery %) with an ais ‡ in %. injuries of the upper extremity were found in % (surgery %) with an ais ‡ in % and of the lower extremity in % (surgery %) with an ais ‡ in %. conclusion: especially because of the detected high percentage of head and thorax injuries in polytraumatized children and the needed head surgery the authors recommend a whole body ct scan in children who are potentially polytraumatized. not only in adults but especially in children the authors suggest the initial use the quickest imaging with a high sensitivity-the whole body ct scan. introduction: patients who suffer physical injuries following a traumatic event are at risk for developing posttraumatic distress. care workers in hospitals treating polytrauma patients are in an optimal position to screen and identify patients developing posttraumatic stress disorder (ptsd). to start early intervention procedures and possibly lower the prevalence, a screening instrument to identify patients at a higher risk is needed. aims of this study were to determine if the severity of injury is related to the prevalence of ptsd and to review the personality traits of patients with ptsd. with these results a screening instrument might be developed. to simulate an unstable extraarticular distal radius fracture, an osteotomy with a mm gap was made. axial loads of - to - n and torque loads of - , to , nm were applied by a testing machine to the intact radii and to the radii after each device was fixed as recommended by the manufacturer. after that, cycles of dynamic torque load alterations of , to , nm (or - , to - , nm convenient to side) at , hz with a preload of - n were performed. in the specimens that were still intact after cycles, loading in torque was continued until failure occurred. axial and torque stiffnesses of the osteosynthesis system were calculated. results: with a median of , n/mm axial stiffness of xscrewÒfixed specimens was higher than of dnpÒ-fixed specimens with a median of , n/mm but did not reach statistical significance. with a median of , nm/°torque stiffness of xscrewÒ-fixed specimens was significant higher than of dnpÒ-fixed specimens with a median of , nm/°. the xscrewÒ-group reached % of the axial stiffness and % of the torque stiffness and the dnpÒ-group reached % of the axial stiffness and % of the torque stiffness of the intact radii. conclusion: fixation of unstable extraarticular distal radius fractures with a xscrewÒ provide biomechanically more stability than a fixation with a dnpÒ. disclosure: no significant relationships. after distal radius fractures occur in % to % of fracture cases. the resulting deformity resembles madelungs deformity and is also called pseudo-madelungs deformity. this deformity leads to ulnocarpal impaction and dorsal dislocation of the distal radioulnar joint (druj). several treatment options such as lengthening of the radius and shortening of the ulna or epiphysiodesis of the distal ulna have been described. the taylor spatial frame (tsf) is a hexapod based external ring fixator, which is widely used to perform six-axis deformity corrections of the lower limb. tsf-planning is web based (www.spatialframe.com) but its use is only available for lower extremities. the purpose of this study was to apply the tsf to the upper extremities to correct pseudo-madelung deformities. material and methods: defining the nomenclature to correct bony deformities with the tsf, one must determine the deformity parameters, the frame parameters, and mounting parameters for the web based planning program. the six deformity parameters and the four mounting parameters use the anatomic nomenclature for the lower extremities. to use the tsf on the forearm, one must transfer the nomenclature of the deformity parameters and the mounting parameters to the nomenclature of the forearm with the transferred nomenclature, one can correct forearm deformities with the correction mode long bone of the planning program for the lower limb. patients two boys (patient , years, patient , years old) and two girls (patient , years, patient , years) were seen in our clinic with progressive pseudo-madelung deformities after an epiphysial fracture of the distal radius at age in the boys and in the girls. skeletal maturity (rus, tw method) was equivalent to the patientâ e tm s age. results: in the four patients, the multiplanar deformitiy of the distal radius could be corrected anatomically with the tsf. there were no frame changes or frame modifications necessary for deformity correction. patient was slightly overcorrected because of some growth in the distal ulnar growth plate. during the distraction, each patient had two low-dose ct scans for better visualization of the radiocarpal and radioulnar joint. the web-based planning program was adjusted twice until total deformity correction was achieved. no further immobilization after frame removal was required. the one-year follow-up showed an anatomic aligned forearm/hand relation with increased pronation and supination compared to the preoperative range of motion in all patients. the wrist and especially the druj were stable and reduced at the one-year follow-up examination. the patients did not complain about any pain or functional deficits in the hand. conclusion: in conclusion, the power of the tsf with the ability to move two fragments precisely can be transferred to the forearm. this allows for the correction of multiplanar radial deformities simultaneously without the need for frame modifications of rotational and translational deformities, as is necessary with the standard ilizarov system. material and methods: thirty-four consecutive patients with a suspected scaphoid fracture (post-injury tenderness of the scaphoid and normal radiographs) underwent ct and mri within ten days after trauma. ct-reconstructions were made in planes defined by the long axis of the scaphoid. the reference standard for a true fracture of the scaphoid was -week follow-up radiographs in four views, based on current available evidence in the literature. a panel including surgeons and radiologists came to a consensus diagnosis for each type of imaging considered in a randomized and blinded fashion, independent of the other types of imaging. we calculated sensitivity, specificity and accuracy as well as positive (ppv) and negative predictive values (npv) for both imaging modalities. results: according to the reference standard there were six true fractures of the scaphoid (prevalence % both mri and ct are better at ruling fractures out than in ruling them in and both were subject to false positive and false negative interpretations. the best reference standard for a true fracture is debatable, but for now it is not clear when bone edema on mri and small unicortical lines on ct represent a true fracture. we advice ct because costs are lower and overall availability is higher. introduction: the scaphoid bone is the carpal bone most commonly fractured in wrist trauma. traditionally, non-displaced scaphoid fractures are considered by most as stable with predictable rates of healing with conservative treatment. conversely, displaced fractures are recognised as unstable, with a significant risk of non-union if not treated surgically. there is a current trend in orthopaedic practice, however, to treat non-or minimal displaced fractures also with early open reduction and internal fixation. this trend is not evidence based. in this systematic review and meta-analysis, we pool data from trials comparing surgical and conservative treatment for acute scaphoid fractures, thus aiming to summarise the best available evidence. material and methods: fourty fresh frozen cadaver scaphoid bones have been sampled at our disposal for testing of screws. the bone density measurement of all specimens has been performed using a qct scan. a transverse osteotomy will be performed at the waist of each scaphoid simulating a b fracture according to the herbert classification. a load cell will be interposed, in an already established method, between the proximal and distal pole of the bone to measure compression force while introducing the screw. the screws will be applied as recommended by the manufacturer using original instruments. the intrascaphoid compression will be recorded at the peak during insertion of the screw, and after and seconds, , , and minutes. results: preliminary results determined that a greater compression can be sustained over a time by headless compression screws with significant differences between those screws. the tests will be finished at the end of january and we will present the final results. conclusion: in more than % of our cases a fracture was missed with the initial radiograph. bone scintigraphy is still a good choice to detect an occult fracture around the wrist. introduction: operations in trauma patients represent a second insult and the extent of the surgical procedures influences the extent of the inflammatory response. the aim of this study was to evaluate the operative burden related to femoral intramedullary nailing. our hypothesis was that a reamer-irrigator-aspirator (ria) system would cause lesser inflammatory response than traditional reaming (tr) due to a lesser intramedullary pressure increase and thereby reduced intravasation of bone marrow content. material and methods: coagulation, fibrinolysis and cytokine responses were studied in norwegian landrace pigs during and after intramedullary reaming and nailing with the two different reaming system; the tr (n = ) and the ria (n = ) reaming system, and compared to a control group (n = ). the animals were followed for hours. simultaneously arterial, mixed venous and femoral vein blood were withdrawn peroperatively and until two hours after the nail was inserted for demonstration of pulmonary, systemic and local activation. results: significantly procedure-related increased levels were found for tat, t-pa and il- in the tr group and tat in the ria group. the local and the pulmonary activation of coagulation, fibrinolysis and cytokine response was more pronounced in the tr than in the ria group, but the difference did only reach significance for il- (femoral vein) and pai- (arterial). the arterial levels of il- and tat exceeded the mixed venous levels indicating an additional pulmonary activation. these differences, however, did not reach significance. two animals in the tr group, who died prior to planned study end point, demonstrated higher inflammatory response compared to rest of the tr group. conclusion: the inflammatory response to the reaming and nailing procedure was modest, and the response was lesser in the ria group than in the tr group. introduction: approximately . million joint arthroplastic operations are performed annually worldwide. implant failure due to massive bone loss and aseptic prosthesis loosening, however, is a major complication of joint replacement. it is generally accepted that small particles (''wear debris'') and activated macrophages play a key role in aseptic loosening. but also the prosthesis loosening fibroblast (plf) plays an important role. material and methods: between and abg- -hip arthroplasties were implantated. after a year analysis % had to be removed because of massive wear of polyethylene (pe) and consecutive acetabular osteolysis. we analysed the influence of patient and surgeon, the implantdesign incl. pe-thickness, anchorage coupler, material roughness i.e. and the material i. medtronic) the application of the cements was done according to the specifications of the manufacturer. after extrapedicular kyphoplasty on cadaveric lower thoracic spine vertebrae (th - ), the intervertebral distribution pattern was investigated by microtomography ( lct). besides creating high resolution d and d reconstructions, the mathematic calculation of the porosity of the vertebra, the bone substitute material and the relative part within the different compartments was performed. of special interest were the characterization of the bone substitute material -spongiosa -interface and the penetration of the calcium phosphate cement into the adjacent spongiosa. the following parameters were investigated: . trabecular structure, porosity and hydroxylapatite concentration of the native vertebrae . structure (homogeneity, distribution of pores) of the bony substitute material . characterization of the bone-bone substitute-interface a. central located, filled kyphoplasty defect b. transition zone with spongiosa and bone substitute material c. solitary spongious bone results: the investigation of the native spongiosa yielded a comparable trabecular structure, porosity and hydroxylapatite concentration in the intra-individual comparison of the vertebrae of the lower thoracic spine. between the cements differences in the solitary structure as well as distribution pattern during kyphoplasty were observed. especially the analysis of the ability to penetrate into the spongiosa adjacent to the centrally located kyphoplasty defect yielded significant differences. the main influencing factor of the ability to penetrate into the spongiosa is the different viscosity of the -according to manufacturer specification -used calcium phosphate cements. the cements differ in their native structure as well as in their distribution pattern during kyphoplasty. the differences in micro-morphology of the calcium phophate cements have a high probability to influence the degradation of the sedimentation products and later osseointegration. disclosure: this research was funded by a grant of ao germany. introduction: it is difficult to predict the long-term clinical outcome in the early period following an acetabular fracture. introduction: the tremendous increase of acetabular fractures in the elderly provides new challenges for the surgical treatment of acetabular fractures. surgical reduction of the acetabular joint represents the most reliable possibility to prevent the development of premature arthrosis even in the elderly. biomechanical studies showed, that plates with periarticular long screws result in an increased stability of the osteosynthesis, it has to be considered that the insertion of these screws always bears the risk of penetrating the joint the aim of this study was to evaluate the biomechanical properties of these standard plates and newly developed minimal invasive osteosynthesis techniques for stabilization of an anterior column combined with posterior hemitransverse fracture type (acphtf), which represents a typical acetabular fracture in the elderly. material and methods: using a single-leg stance model we analyzed different implant systems for the stabilization of acphtfs in synthetic pelvises (standard reconstruction plate, new developed prototype and definitive repofix Ò (adi -ao foundation, switzerland). applying an increasing axial load in a biomechanical testing machine, fracture dislocation was analyzed with a multidirectional ultrasonic measuring system (zebris, germany). differences in change of center of gravity are statistical analysed by man-whitney-u -test. results: analog to a long bow, the repofix Ò supports the quadrilateral surface sufficiently and reconstructs the surface of the pelvic brim from the inner side of the pelvis. in synthetic pelvises, the new repofix Ò is associated with a significantly less pronounced dislocation (center of gravity) of the fractured quadrilateral surface when compared to prototype and the standard reconstruction plate. the biomechanical results could be seen at a measuring point at the quadrilateral surface and in the rotation around the x -axis (angle y results: we collected data on acetabular fractures. a conventional image intensifier was used in cases (group a), d-navigation was used in cases (group b). in group a the kocher-langenbeck-approach was used in most of the cases ( %), followed by the maryland-approach ( %). in group b, the kocher-langenbeck-approach and the ilio-inguional-approach were used in an almost equal number of patients ( % / %), but extended approaches were only used twice. in % of the cases in group b fractures were stabilised by navigated placement of percutaneous lag screws. when we excluded the percutaneous operations in group b (n = ), the difference in or-time between navigated (n = , ± min) and conventional treatment (n = , ± minutes) was significant (p < , ). in group a we detected relevant postoperative complications in % of patients. the complication rate was significantly lower in group b ( %, p < , ). the postoperative radiological analysis revealed a better qualitiy of reduction in group b (n = ) with an average post-op fracture gap of , mm vs , mm in group a (p < , ). conclusion: by using a navigation system and a d image intensifier we found a significant increase in the or-time in the navigated group. however, in the postoperative radiological analysis, we detected a better quality of fracture reduction in the navigated group. navigation in combination with the -dimentional pictures of the iso-c d led to a better visualisation of the acetabulum, therefore the need for extended approaches was reduced. to our opinion, this explains the significant reduction of postoperative complications in group b. we conclude that navigation and a d image intensifier should always be used for orif of acetabular fractures. disclosure: no significant relationships. introduction: the traumatism is the first cause of the mortality in patients under . it means a serious incapacity in of trauma patients. the initial management in trauma patients is essential to improve these results material and methods: this is a prospective and multicentric study with the participation of hospitals in catalunya (spain). the objectives are to improve the evaluation and the initial management of trauma patients, and to improve the knowledge of the frequency, the magnitude and the approach of these trauma patients. we defined points to improve which are: to intubate patients with glasgow < ( ); to not remove the cervical collar without clinical or radiologic cervical exploration ( ); to move trauma patients monitorized ( ); to not move haemodinamically instable trauma patients ( ); to use two thick intravenous cannulations ( ); to take thorax and pelvic simple radiographies in the trauma box ( ); to fix pelvis fracture with a grassland before moving the patient ( ) we took more thorax and pelvic radiographies in the trauma box (from . % and % in the first period to . % and . % in the second period, p < . ). and we also fixed more pelvis fracture with a grassland before moving the patient, from % in the first period to . % in the second period. conclusion: the registration of the information about trauma patients allows the identification of the points to improve. we improved the evaluation and the initial management of the trauma patients, especially in the monitorization of trauma patients and in the management of the thoracic and pelvic traumatism introduction: there is wide evidence about the importance of having good protocols for assisting trauma patients and a teaching system for the personnel involved in this assistance is needed. it is also well known that the formation for assisting trauma patients in spain is not very much spread in general. material and methods: we describe how we have arranged the care for this type of patients in a level ii center and a teaching system for our staff and we prospectively analyze the impact of this specific formation by means of a questionnaire and analyzing how correctly the trauma team is activated. results: from november through october ( months), editions of our course have taken place and people have participated ( , % of the staff for whom the course is aimed to). we found a clear improvement on the results of the test (prior and after the course: % of improvement for physicians and % for nurses, p < . ) and the qualification of the final exam was superior. the incidence of rightly activated trauma team improved as the staff was completing the course. conclusion: we conclude by enhancing the importance of having adequate protocols for treating these patients and the correct means for teaching the personnel because they can improve the care of these patients. (tonk) score. this system is specialty specific and tries to eradicate the weaknesses in a previously published scoring system, which was generic. material and methods: a total score of is assigned to each firm from the beginning and marks are deducted for missed documentation. sets of notes are randomly selected from discharged patients for each firm, one from trauma and one from elective surgery, each having at least entries. each case note is given marks and the total deduction for both case notes are then subtracted from the total score of to give the resultant score. the tonk score has four major parts comprising initial clerking, subsequent entries, discharge letter and legibility. an objective system of scoring the legibility of medical notes is part of the tonk score. this scoring system is easily reproducible and it's been validated using the kappa statistic. introduction: despite the increasing mechanization in medicine, clinical skills must be to the fore of medical occupation and consequently must have a main focus in medical training. especially in surgery, the mastery of basic clinical skills is of great importance for the young learner as it besides the knowledge of elementary principles substantially contributes to the understanding of the subject, the development on the wards, the operation theatre and the ambulance. in order to assure a standardized training using reliable, effective modern teaching methods, a ''train-the-teacher''-course was developed. material and methods: in an -hour training, the important teaching modalities and methods for surgical skills as skills lab, simulation, role play, -step approach are presented and trained in small groups with a maximum of participants per group. furthermore, the training focuses on ,,giving adequate feedback'' and examining practical skills. the training is evaluated using a standardised evaluation form. furthermore, the teachers are evaluated by their students after each of their teaching sessions before and after the training. results: a total of surgeons participated in the training program ( chief physicians, senior physicians). overall, the training was rated to be very good ( %) or good ( %). in students' evaluation, there was a significant increase in positive ratings for teachers' didactical compentencies as well as for their overall training after the participation in the training program. introduction: sports injury risk management and prevention is a very complex challenge that must be addressed . one of the basic tasks is to perform epidemiological studies to estimate the risk in different types of sport. up to now many studies were conducted on injury rates in specific organised sports . just a few taking into account any physical activity (pa) . therefore only for specific sports data about the influence of higher sport skills on injury risk can be found . the goal of our study was to investigate the relevance of motor skills and sport education on injury risk, including the total pa and the occurrence of any injury in any type of sport. material and methods: in two austrian secondary schools (gymnasien) fifty-five of classes were asked to fill out a two sided questionnaire regarding pa and sports injuries within the last year. demographic data and information about the types of sport, the intensity and the occurrence of injuries was collected. pupils, from a ''normal'' school (ng) and from a ''sports-school'' (sg) filled out the questionnaire. in the sg every child has to pass an entrance exam containing basic coordinative and motor tasks as well as complex motion sequences in different types of ballgames. in the educational program of this school a strong emphasis is placed on sports. in the ng just the basic sport lectures are held. results: the total physical activity (pa) containing organised, unorganised sports and leisure time activities was significant higher in the sports-school (sg), . hours per week vs. . h/w (p < . ). the most performed types of sport were similar: in the sg soccer (n = , %), riding bike (n = , %) and running (n = , %); in the normal school (ng) riding bike (n = , %), soccer (n = , %), snowboarding (n = , %) and running (n = , %). proportionally there were more boys than girls in both schools: % boys, % girls vs % boys, % girls. boys ( . h/w, . h/w) were more active than girls ( . h/w, . h/w) in both schools. the rate of injury was statistically significant higher in boys ( . ) than in girls ( . ) (p < . ). the mean age was higher in the normal school . vs . years. the proportion on injured children was at the same highest level ( %) in and , and , and in and year-olds. the ratio of injury per pupil is statistically significant higher in the sg ( . ) than in the ng ( . ) (p < . ). but including the extension of activity the injury risk is a little bit lower in the sg: . injuries in hours of pa vs . . conclusion: it seems that better motor skills and intense sport education have no effect on the population risk . the individual risk has to be investigated more extensively in future studies. references: fuller, spinks, spinks, schwebel disclosure: no significant relationships. introduction: pain is one of the main complaints of trauma patients in emergency medical care ( ). in the netherlands, a third of all prehospital emergency medical systems (ems) rides concern trauma patients and yearly . patients are treated in the accident & emergency department (ed) due to an injury. significant deficiencies in pain management in emergency medicine have been identified ( ) . as a consequence, patients unnecessarily suffer from pain, and also recovery and healing are delayed. furthermore, chronic pain is reported one year after trauma ( ). there is no appropriate systematic approach to acute pain management in the chain of care for trauma patients in prehospital ems and the ed. aim: the aim of the research project is the development of a national evidence-based guideline for the management of acute pain in adult trauma patients in prehospital ems and the ed. during the open reduction we applied a incision allowing to remove soft tissues and to set fragments of fractured bone correctly. in patients we performed close reduction of the fracture without the fixation because of a patient's age. results: xr month after surgical procedure was done and in all cases we achieved consolidation of the ulnar fracture and good of radial head reduction. complication after the treatment was the paresis of the median nerve, neurosurgical procedure needed. the nails were remove , month after procedure ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . after obtaining the union of the fracture and rehabilitation of the limb we removed the nails ( - month after procedure). conclusion: featured way of the operative treatment doesn't claim wide opening region of the fracture and reduces possibility of complications. dislocated radial head after close reduction and immobilization period shows full stability. years. data and x-rays were retrospectively gathered and analyzed. all fractures were scored according to the ao-pediatric classification. patients were treated with solely closed reduction and cast immobilisation and patients were additionally treated with k-wire fixation. spss version . was used for all statistical analysis. results: incidence of recurrent dislocation was significantly higher in patients treated solely with closed reduction ( %) compared to patients treated with additional k-wire fixation ( %) (p . ). the proportion of patients requiring a second surgical intervention was also higher in patients treated with closed reduction: % versus % of patients treated with additional k-wire fixation (p . ). additional k-wire fixation results in a relative risk reduction of % and % for recurrent dislocation and secondary surgical interventions respectively. complications of k-wire fixation comprised local infection (n = ) and k-wire migration (n = ). conclusion: additional k-wire fixation might reduce the incidence of recurrent dislocation and secondary surgical interventions after closed reduction of displaced distal forearm fractures in children. larger and randomized studies will have to be obtained to confirm the results from our data. radiographic controls were planned after one and six month and until the removal of the intramedullary nailing. we documented all peri-and postoperative morbidity, further operative procedures, the radiographic findings as classified by capanna and the time till removal of the nails. results: a cohort of children (four girls, six boys) was recruited. mean patient age was , years ( - y). the bone defects included eight juvenile and two aneurysmatic bone cysts. four patient suffered earlier unsuccessful treatment after pathologic fracture. the other six presented with acute pathologic fractures (five humeral, one femoral). no postoperative complications occurred after the treatment combination of elastic intramedullary nailing, curettage, artificial bone substitute and autologous platelet rich plasma (gps Ò-system). the radiographic findings showed at six month a total resolution of the cysts in eight cases (capanna typ i), in two cases a tiny residual cyst remained (capanna typ ii). the removal of the nails was possible after six to nine month. one fourteen year old boy (typ ii capanna) wished a further gps application to reach a total resolution. all patients showed very good functional results and no refracture occurred. conclusion: the gpsÒ-system enhances the treatment of bone cysts in children. it is a save method without additional perioperative complications. by this, total treatment time can be shortened and secondary procedures as difficult changes of the elastic nails will be lessened. technically the decisive factor is the debridement of the . albumin values were significantly lower in patients with two or three complications than those with zero complications (zero and two complications p = . , zero and three complications p = . ). no significant difference in levels was found between one and zero complication (p = . ). admission albumin was not significantly lower in patients with wound infection than those without ( . ± . g/l versus . ± . g/l, p = . ). patients with a dry and intact wound had a higher mean albumin value than those with wound healing complications (mean albumin ± . g/l versus ± . g/l, p = . ). conclusion: our study findings support the hypothesis that lower preoperative albumin levels are associated with a more adverse inpatient post-operative recovery. these patients can be identified and optimised early in preparation for adverse events likely to occur in the post-operative period. material and methods: the targon fn is a new kind of side plate with six locking screw ports. the two distal holes are used to fix the plate to the lateral cortex of the femur with angle stable . mm cortical screws. the proximal holes allow the implementation of up to four ''telescrews'' which cross the fracture site. these . mm screws are dynamic and allow therewith the collapse of the fracture at the femoral neck. we present a prospective study on patients with a comparative patients case control with a total hip cementless arthroplasty for the same indication at the same period. results: this new device show a lower incidence of complications on the first weeks than with the total hip group. wereas the month control show no difference between the two groups. there are an x rays neck collapse one year folow up in osté oporotic patients with singh an stade with no significant consequences on the functional score. conclusion: targon fn is a good alternative for older and multimorbid patients with less surgical burden and reduced early access morbidity in comparison to the prosthesis group. conclusion: the number of re-interventions and the mortality within one year after hip fracture surgery is sizable. nonetheless, our numbers are not unfavourable in comparison with international literature. the percentage of re-interventions in the cannulated hip screw group is significantly higher than in the other subgroups. on the contrary, the mortality in this group is low. this is undoubtedly an expression of our attempts to preserve the femoral head in vital, active patients. possibly, the combination of the two standardsnamely the re-intervention and mortality-is a new accurate performance indicator. informed. the operative treatment with lcp and tension bandages shows small morbidity regardless the comorbidities and the geriatric cohort. it remains standard procedure for periprosthetic fractures of the femur at our institution. we are expecting the number of periprosthetic fractures to be increasing rapidly. introduction: periprosthetic femoral fractures are rare but severe complications following total hip-or knee-arthroplasty. the incidence for of these fractures are increasing, caused by a raising frequency of total arthroplasty for both younger and elderly patients as well as by a higher life expectation. so far there are very little long-term results regarding this issue. material and methods: patients ( female, male) with a mean age of years ( - ) were clinically and radiologically examined on average months after surgery. we investigated the prosthesis (total hip arthroplasty vs. total knee arthroplasty) and compared the treatment (revision arthroplasty vs. osteosynthesis) in this study. for the clinical examination we used the harris-hip-score (hhs), oxford-hip-score (ohs), the oxford-knee-score (oks), the sf- and the funktionsfragebogen hannover (ffh) which measured the functionality of patients in his daily routine in his environment. results: tha + osteosynthesis (n = ) % of the patients had fair or better results with an average hhs of . % of this group had a good or excellent result with an average ohs of and % had a ffh score of ‡ %. % of the patients had a possible hip flexion of ‡ °and ( % ‡ °). the average sf- score for this group was . tha + revision arthroplasty (n = ) % of the patients had fair or better results an average hhs of . % of this group had a good or excellent result with an average ohs of and % a mean ffh score of ‡ %. % had a possible hip flexion of ‡ °( % ‡ ° the results of the scores are mainly caused by the high age, the common multimorbidity and the low overall functionality of the patients and confirm the severity and importance of these kinds of fractures. most authors suggest a treatment of these fractures according to the classification by using osteosynthesis to treat stable fractures and revision for unstable fractures. however we see a slightly better outcome of the revision arthroplasty compared to the patients that were treated with osteosynthesis. we suggest more studies with a higher number of patients regarding this issue. introduction: fracture dislocation of the proximal humerus is a rare but challenging situation for the orthopaedic surgeon. if a closed attempt to reduce the dislocation fails, a demanding surgical procedure is required and the emergency setting is not always the best situation to face difficult cases. as a matter of fact a proper approach to this fractures involve an experienced surgeon, more than one assistant and a variety of instrumentation that often lack in emergency. fracture dislocation of the humeral head is related with a significant increase of the risk of the humeral head necrosis and it is widely accepted that these lesions are best treated in emergency, but there are no reports on the influence of the dislocation time on the results of the surgical procedure. with this study we wanted to determine if a delayed procedure could affect the outcome of these lesions and if there is a rationale in postponing the procedure to allow a better organisation of the surgical time. material and methods: we retrospectively analysed the clinical and radiological records of patients admitted at out institute for fdhh between jan and jan . ten out of them were operated in emergency while with a minimum delay of hours. all the patients underwent open reduction and fracture fixation with locking plates. results: the results of the two groups were similar and influenced mainly by the bone quality and age of the patient. it seems that a delay in the procedure do not alter the result in terms of rate of necrosis of the humeral head or influence a worse clinical outcome conclusion: on the basis of these results we do not consider these fractures as emergencies anymore: our preference is still an immediate operation provided the presence of an experienced surgeon, assistant and nurse and the availability of the proper instrumentation, conversely we believe that the risks of an immediate procedure overwhelm its benefits. introduction: minimal invasive plate osteosynthesis (mipo) should belong nowadays to the armentarium of each trauma surgeon. applied correctly, mipo not only meets the criteria of a ''biological'' osteosynthesis by minimizing invasivity as well as iatrogenic soft tissue damage caused by the operation, but can also provide adequate reduction and stability for fracture healing and early functional aftertreatment. up to date, only few publications report on mipo of humeral shaft fractures mainly using the antero-lateral deltopectoral approach for plate insertion - . material and methods: in this present study, we evaluated patients (mean age years, range - ) with displaced metadiaphyseal fractures of the proximal humerus treated in mipo technique using an angular stable long philos Ò -plate. a lateral deltoid-split approach was used proximally and a brachialis/ brachioradialis intermuscular approach with exposure of the radial nerve was used distally. there were acute fractures including two periprosthetic as well as one pathological fracture. three patients were operated after failed conservative treatment, one for delayed-union and two cases were revision surgeries. results: there were no infections and no iatrogenic injuries to the axillary and radial nerve, respectively. all the patients were immediately allowed active shoulder and elbow movement. one patient had to be reoperated ten weeks postoperatively for redislocation of the distal fragment with screw breakage, which was most likely due to incorrect screw placement. this patient was successfully operated using the same method and implant. whereas one patient refused follow-up, patients showed entirely healed fractures and satisfactory shoulder and elbow function after a mean follow-up of months (range - months). conclusion: minimal invasive long philos Ò -plate osteosynthesis using a combined lateral deltoid-split and brachialis/brachioradialis intermuscular approach proved to be a safe and viable procedure for the treatment of metadiayphyseal fractures of the proximal humerus with low morbidity and good functional outcome. introduction: plating for reduction and stabilization of proximal humerus fractures is a common orthopaedic procedure. however, angular and rotational malalignment is not an infrequent result, and extensive use of fluoroscopy is commonly involved. we checked the accuracy of a computerized navigation system(vector vision trauma navigation system, brain lab) to enhance multiplanar fracture reduction and to decrease the requirement for fluoroscopy. material and methods: men and women aged to (mean, ) years underwent philos plate fixation for proximal humeral fractures. all fractures were closed with no associated injuries and classified as -a (n = ), -b (n = ), and -b (n = ), according to the ao classification. the cases were assessed operation time, radiation time. and accuracy measurements were taken. results: patients were followed up for to (mean, ) months. all the fractures united and occured no avascular necrosis. the mean operation time and radiation time were minutes (range, - ) and . minutes (range, - ). the mean distance between fluoroscopy and navigation of reduction accuracy at the fracture site were . mm (range, - ). conclusion: the fluoroscopic operation using pilos plate was troublesome, but navigated operation was easy to reduce the fracture because of the direction visualization at the same time. and computerized navigation has the potential for increasing precision in fracture reduction while minimizing fluoroscopic requirements at proximal humerus fractures. introduction: the proximal humerus fracture is a frequent fracture in the elderly people. the lower density of the bone with increasing age is one of the main reasons for implant failure after osteosynthesis with a range of - %. the options of therapy are including the screw-, platelet-or nail-osteosynthesis or the endoprosthesis.belonging to failure rates and the demand for early activity there is a tendency to be seen for early and strong stabilisation. material and methods: since august proximal humerus fractures were operated with the retron-humerus-shortnail. the average of age was , +- , ( - ) years. the demographic data, bone quality and fracture classification were documented including procedure of reposition, details of the implants, complications and postoperative course. results: there were , % a fractures, , % c , , % c and , % c fractures (ao-classification). the reposition was done in a closed mannor with a direct percutaneous assistance respectively. intraoperatively secondary dislocations and corticalis brake was to be seen. there have been insufficient nailing procedures. screws had to be exchanged. the gymnastic began immediately after operation or with a delay of - weeks depending on the fracture classification. the evaluation of the constant score is on the way. the results show a good stability of the nail especially in osteoporosis. comparing with platelets or antegrade nailing it is a minimal invasive procedure. the exraarticular access avoids any damage to the shoulder structures, especially to the rotator muscles. therefore early gymnystic of the shoulder is possible. shoulder impingement, screw dislocation and problems with the shoulder are avoided principally. the learning curve is short. shoulder score was used to evaluate functional outcomes. anova was used for statistical analysis, with significance set at p < . . results: files were available on patients. failure rate was . % at mean follow-up of . years and a mean ases-score of . . there was a reoperation rate of . %. mean age at operation was . years. mean operative delay was days (range - ). delay did not influence outcome. young age at operation was associated with better results. when evaluating fracture characteristics significant better outcomes were evaluated with ao type aand b-fractures, valgus or neutral fracture type, the presence of impaction and less displaced fractures. quality of reduction and fixation of the fracture was evaluated with significant better results with anatomic reduction of the medial cortical border, less residual displacement and a ccd-angle that was corrected or in residual valgus. osteosynthesis failed significantly more in c-type fractures, in fractures with an avascular head fragment, in varus displaced fractures and in fractures where an anatomical reposition was not obtained. introduction: fractures of the proximal humerus are responsible for - % of all fractures.the most extensive used operative treatments are the plate osteosynthesis and the intra-medullarry nail fixation with proximal locking nailsscrews. especially the latter technique can give iatrogenic injury of the axillary nerve. in this study, we define a safe-zone by using radiological parameters material and methods: the following procedure was performed in ten shoulders of embalmed specimen. first, the deltoid muscle was dissected from the clavicle. then the axillary nerve was identified together with its branches and was marked with clips and radioopaque wires. the muscle was then re-attached to its anatomical position.standard ap radiographs were made with the forearm in neutral (anatomical) position and exorotation. on these radiographs, the distance between the cranial side of the humeral head and the axillary nerve and its branches was measured. results: the median distance from the head of the humerus to the axillary nerve is mm (sd = . mm, range - mm) measured on the ap radiograph in degrees exorotation. the mean number of branches to the deltoid muscle is three. the distances vary from to mm. the median distance from the first proximal branch measured from to the humeral head is mm (n = , range - mm), to the second branch mm (n = , range - mm), to the third branch mm (n = , range - mm) and to the fourth branch mm (n = , range - mm). conclusion: there is a great variation in the course of the axillary nerve and its branches. with the insertion of an intra-medullar nail from the proximal side or by placing locking-screws nails the surgeon has to reckon with the course of this clinically important nerve. it is unsafe to place the locking-screws nail in the zone between mm and mm from the humeral head with the arm in exorotation. the greatest risk to damage the main branch of the axillary nerve is in the zone between and mm. this study provides distances to avoid damage to the axillary nerve. in contrast to the existing literature these distances are measured from the humeral head. there are several reasons to use the humeral head instead of the acromion are: first, the distance between the humerus and the acromion can vary due to the preceding trauma, relaxation of the deltoid muscle or by manipulation of the arm. second, from an anatomical perspective, the position of the axillary nerve is determined by the position of the humerus due to the connection to the deltoid muscle. results: emg/eng records were without pathologic variances of the axillary nerve. of them pre-operatively showed pathologic variances. of these continued to show variances months after the operation, which indicates a chronic lesion. just one patient showed a pathologic eng after surgery which was not seen before. the constant score was as expected. introduction: patella recurrent dislocation and patellofemoral pain syndrome is a common cause of instability in young patients and especially athletes. in the present study we present the results of the extension mechanism realigment throughout the fulkerson oblique osteotomy of the tibial tubercle and soft tissue balancing. material and methods: during the last two years patients ( men, women, mean age . / range - ) were treated operatively for recurrent dislocation of the patella using the fulkerson procedure. all our patients had as onset a traumatic dislocation of the patella that developed to recurrent. all patients were underwent knee arthroscopy for the treatment of potential chondral trauma or loose bodies removal and lateral retinaculum release. after that, we performed oblique osteotomy of the tibial tubercle, medialization and internal fixation with two cortical screws. this oblique osteotomy provides additionally to the medialization, anteriorization of the tibial tuberosity as we move it medially. moreover we perform medial plication. all patiens used functional brace locked in  º immediately after the operation and gradual rom increase untill the th p.o. week. results: the patients had no initial or long term complication. during their last follow up examination had a painless knee with full rom and marked improvement of the patella tracking. the mean lysholm score was improved from . to . . no patella dislocation was referred. conclusion: our findings show that fulkerson procedure of the tibial tubercle osteotomy and anteriomedialization, with additional intervention on the lateral and medial patella retinaculum is an excellent option for the treatment of recurrent patella instability and relief of patellofemoral pain. disclosure: no significant relationships. introduction: injuries to the knee involving the anterior cruciate ligament (acl) are very common related to sports especially in soccer and skiing. more than % of those with acl injury will develop radiographic osteoarthritis (roa) within years of injury although it is not known if return to sports is a risk factor for longitudinal roa development. in this retrospective study, we evaluated the long term radiographic and clinical results of acl reconstruction by comparing the injured knee with the contralateral knee in athletes returning to pre-injury sports. material and methods: twenty-eight patients ( men and women, mean age years at the time of acl surgery, bmi . ± . kg/ m ) were studied. patients returning to previous sports and without meniscal injury at baseline were selected. acl reconstruction was performed using patella tendon or hamstrings tendon graft. radiological assessments using x-ray and a -t mri of both legs were obtained at a mean follow up of years after acl reconstruction. roa was determined according to the classification of bohndorf. the ikdc score and tegner activity index were used for clinical evaluation and the knee injury and osteoarthritis outcome score (koos) for evaluating self-reported knee function. results: the -t mri revealed positive signs of roa on the operated knee in % and on the non-operated knee in %. these changes were however limited to small localized areas of the knees. the statistical difference of morphological and clinical outcome of acl reconstructed patients weeks after injury vs. replacement after this period showed no significance (p = , - . ). the total ikdc score was . ± . points and the total koos was . ± . . the median pre-injury tegner score was (range - ) corresponding to (range - ) at follow up. in % of the patients the tegner score was unchanged from pre-injury to follow up. according to the ikdc score % had type a symptoms, % type b, % type c, and none type d. conclusion: eight years after acl reconstruction in athletes returning to pre-injury sports, the risk of developing knee roa in the injured knee was not higher than the risk of developing roa in the contra lateral knee. disclosure: no significant relationships. radiographs and a mri of the knee were available for all patients. all patients were followed prospectively and lysholm, tegner and ikdc score were surveyed before treatment and after at least months. after diagnosis, a brace immobilization with tibial supporter with full extension of the knee was applied for weeks followed by another to weeks of pcl brace with tibial supporter and posterior elastic rubber band to prevent posterior sagging of the proximal tibia. all patients received concomitant physiotherapy. after at least weeks, stress radiographs were taken for evaluation of the pcl. the further treatment depended on the harner classification based on the stress radiographs. in cases of grade a or asymptomatic grade b injuries, conservative treatment was continued. in cases of symptomatic grade b, grade c or d injuries, operative treatment with arthroscopic transtibial pcl reconstruction using single bundle hamstring tendons was performed. results: patients were treated conservatively (group i), patients had an arthroscopic pcl reconstruction (group ii). mean patient age was . years (range - years). the mean tegner score in group i raised from . before treatment to at follow up, in the operative group from . to . . the mean lysholm score ascended in the conservative group from to , in group ii from . introduction: the virtual reality (vr) d arthroscopy surgical simulator provides arthroscopy training on knees in a controlled, stressfree, and virtual-reality environment. it is unknown whether better visomotoric three-dimensional ( d) condition will facilitate arthroscopic training. therefore, our objective was to evaluate the visomotoric condition to novice individuals and assess whether visomotoric abilities ameliorates arthroscopic performance within a d surgical environment. material and methods: medical students without any knee arthroscopic experience were investigated. both groups received a fixed protocol of simulator based arthroscopic skills training and a visomotoric skills test. this consisted of an arthroscopy of a longitudinal meniscus tear on a vr knee arthroscopy simulator. . their learning curve was assessed objectively using motion analysis. time taken, path length and roughness for probe and camera were recorded. results: motion analysis demonstrated objective improvement in performance during simulator training, if visomotoric skills performed better. conclusion: better condition of visomotoric skills lead to subsequent improvement at an arthroscopic vr skills training simulator. this may assume that visomotoric skills training before arthroscopic vr skills training is a useful tool. however further studies are necessary to find preliminary practice exercises to get a better performance at an arthroscopic vr skills training simulator. -ii and c-iii after tscherne § open fractures o-ii and o-iii after gustilo o urgent operative treatment § first stabilisation with miniosteosynthesis and external fixation § soft tissue debridement and their temporary closure o second look after - hours, next looks after the soft tissue condition o delate treatmentdefinitive stabilisation -osteosynthesis conversion in - days after injury. o type of osteosynthesis § orif with lcp distal tibia platesmedial or anterolateral § imterlocked intrtamedullary nail § external fixation -in cases of serious soft tissue defects we prefer fracture stabilisation ae serious soft tissue defects closing with rotation or microsurgery stem lobs. introduction: fractures of the distal tibial metaphysis account for . % of fractures over the distal end of the tibia. many of them are high-energy injuries causing extensive articular damage and compromise the soft tissues. managing these fractures continues to challenge most orthopaedic surgeons, as soft tissue injury could be further compromised by unjudicious surgical technique. aim of the treatment is to restore physiological alignment of the distal tibia and stabilize the fracture with minimal damage to soft tissues. material and methods: we designed an implant for the stabilization of distal tibial metaphyseal fractures, and gave the name ''angle stable''. the features of the implant are: precontoured plate with holes above the distal metaphysis providing positioning of screws with angular stable characteristics. the screws are self tapping and self cutting at the threaded part (far end) and have a cylindrical shape with a rim at the near end, that tightly fits into the holes at a special angle, guided by a targeting device. the distal screws penetrate the opposite cortex, and when they are tightened, compression is achieved. the plate is introduced through a small incision and guided onto the surface of distal tibia. screws can be inserted distally, proximal screws are inserted through stab wounds. biomechanical tests of this system were performed on cadaver bones. since the ''angle stable'' system has been used in patients in cases as a primary stabilization, and in cases as conversion of external fixation. follow-up time was months. outcome was assessed with regard to function, pain and alignment. introduction: the fracture of the distal lower limb with or without participation of the ankle joint remains a challenge to the surgeon. due to the high energy released at the time of fracture, these injuries are usually accompanied by a severe soft-tissue damage. the success of the surgical therapy of tibial pilon fractures depends largely on the extent of the soft tissue damage as well as the quality of reconstruction of the tibial joint surface. a problem of the minute anatomical reconstruction is an increase in soft tissue problems and bone infection. aim of this study was to investigate the results gained by a primary stabilization by external fixator followed by a multidirectional locked plate osteosynthesis after soft tissue consolidation. material and methods: setting is a level trauma centre, the design a consecutive series with a retrospective data evaluation. between and , patients with high-energy fractures of the tibial plafond were treated using a two-staged treatment plan: . the fracture was stabilized with an external fixator immobilizing the ankle joint. . after stabilization of the soft tissue situation (mean . days) internal fixation with a locked-screw plate was performed. the implant used was a multi-directional locking internal plate fixator (tifix, litos, hamburg/germany), made of pure titanium with locking holes for titanium screws which can be fixed in different angles and is available in seven different lengths ( - holes in the diaphyseal area). the mean follow-up time was . months. all follow-up examinations were supervised by a specialized orthopedic trauma surgeon. the examination consisted of a set of standardized questions, clinical evaluation, the aofas score and radiographs. results: superficial wound-necrosis was noted times, conservative treatment led to complete wound healing. dvt of the injured leg occurred in cases. in cases autologous bone graft was necessary after and months. deep wound infection or postoperative osteomyelitis was not observed. the definitive treatment was performed after an average of . days. in cases an autologous bone graft was used. in a further cases a later autologous bone graft was performed for delayed union at and weeks after orif. full weight bearing was reached after an average of . weeks. bony union was achieved in all cases after an average of . months as determined by conventional radiographs. in cases range of motion (rom) of the ankle did not show any restriction compared to the opposite side. in cases the range of motion was reduced by less than / compared to the opposite side, of up to / in patients and restriction of > / was not noted in cases. the mean aofas score was . . conclusion: a twostage treatment plan in fractures of the distal lower limb with external fixation followed by locked-plate osteosynthesis reduces local complications with a good functional result. disclosure: no significant relationships. introduction: the internal fixation for complex distal tibial fractures is sometimes challenging. nowadays, successful outcome were reported about osteosynthesis through medial and anterior approaches including minimally invasive plate osteosynthesis (mipo). however, there are cases in which such methods are not indicated because of their soft tissue problems or their fracture pattern. in this presentation, the new posterior plating procedure using the mipo technique is reported. material and methods: this procedure was indicated only when no other internal fixation methods were present, which includes intramedullary nailing or medial/anterior plating, were found. so the indication for this procedure was extremely rare. from to , cases of ao classification -a and c type fractures were treated operatively in our institution. cases met the criteria. both of them were female and aged and . the follow up period was and months. the procedure was as follows; before the operation, the spanning external fixator was applied and the alignment was reduced as properly as possible. the patient was in the supine position and the knee was flexed at about degrees. the distal window for mipo was positioned between the distal fibula and achilles tendon, which is called a ''posterolateral approach.'' blunt dissection was performed, and exposed the edge of the flexor hallucis longs muscle (fhl). the tunnel over the periosteum at the posterior surface of the distal tibia was made and the plate was inserted. then an incision was made at the posteromedial border of the tibial shaft and exposed the proximal part of the plate (proximal window). the plate was placed properly under the image intensifier and fixed with screws. the wounds were irrigated and sutured in layers. postoperative rehabilitation included a range of motion exercise and non-weight bearing gait and use of crutches immediately begun. full weight bear was permitted around twelve weeks post operatively. time to union, complication and final ambulatory ability were evaluated. results: bony union was uneventfully completed within three months in both cases. there were no complications such as infection, skin problems, or plate irritation/impingement. free gait was achieved within four months in both cases. conclusion: posterior plating using the mipo procedure for complex distal tibial fractures can be a good option, although our experience is very limited. however, this procedure should be indicated only when no other osteosynthetic methods are found because irritation/ impingement of the fhl or the achilles tendon or some other complications may arise, which has already been reported in open reduction and internal fixation through posterolateral approach. references: hayes ag, nadkarni jb. extensile posterior approach to the ankle. j bone joint surg ; b: - . disclosure: no significant relationships. introduction: even the most modern technology has failed to induce satisfactory functional regeneration of traumatically severed peripheral nerves. delayed neural regeneration and in consequence slower neural conduction seriously limit muscle function in the area supplied by the injured nerve. this inferiority study aimed to compare a new nerve coaptation system involving an innovative prosthesis with the classical clinical method of sutured nerve coaptation. besides the time and degree of nerve regeneration, the influence of electrostimulation was also tested. material and methods: the ischiatic nerve was severed in female gö ttinger minipigs with an average weight of approx. - kg. the animals were randomized electronically to four groups: group i: nerve prosthesis without stimulation; group ii: nerve prosthesis with stimulation; group iii: microsurgical coaptation without stimulation; group iv: microsurgical coaptation with stimulation. in groups iii and iv, the nerve was sutured microsurgically, while the animals in groups i and ii received the new nerve prosthesis. postoperative monitoring and the stimulation schedule covered a period of months, during which axonal budding was evaluated monthly. results: preliminary data indicate that results with the nerve prosthesis are comparable to those with conventional coaptation. the results of this pilot study indicate that implantation of the nerve prosthesis allows good and effective neural regeneration. this new and simple treatment option for peripheral nerve injuries can be performed in any hospital with surgical facilities as it does not involve the demanding microsurgical suture technique that can only be performed in specialized centers. disclosure: no significant relationships. in mean there were , previous operations. in cases a change of osteosynthesis was neccessary. in cases bmp was used alone. in cases bmp was expanded by autologeous bone grafting. in cases the bmp was extended by autografts or ceramic scaffolds. results: divided in a healing group and a not healing group we found in the healing group a excellent clinical result by . points (able for sports) for the atrophic non unions and a good result of . points (walking long distances) for the post infected non unions. the radiological score is as high . / . ( cortices healed and bridging callus). in the non healing group the clinical rate was . / . (walking with splint) and the radiological rate was . / . (two cortices healed) the overall healing rate was %. divided in several groups the healing rate increases from % (infected non unions not tibia) to % (atrophic aseptic non union tibia). overal the secondary intervention rate was %. the healing time is . months in the middle. we see only mild side effects in %, like swelling. the most serious complication was the bony reinfection in %. there were amputations. conclusion: compared to the literature the healing rate of non unions could be increased using a strong concept in the treatment. as a part of the treatment the bmp treatened group increases the healing rate from % (friedlä nder) to %. the results are similar to the papers from kanakaris or zimmermann. there were no significant side effects noticed. material and methods: methods: at our level i trauma institute, from july, to september, each patient who presented with a clavicle fracture that was deemed operative received plate fixation alone or supplemented with bioresorbable calcium phosphate cement or autogenous bone grafting. patient records and radiographs were retrospectively reviewed. follow-up included standard radiographs to evaluate union at a minimum of months. all complications were also reviewed. results: results: two different clavicle plating systems, smith and nephew (smith and nephew, memphis, usa) ( clavicles) and implant technology systems (i.t.s., lassnitzhohe, austria) ( clavicles), were used with orif alone ( ), autogenous bone graft ( patients), or bioabsorbable calcium phosphate ( clavicles). of patients treated with open reduction internal fixation, complications have occurred at a minimum of month follow-up. three prominent hardware occurrences necessitated plate removal. one nonunion, one distal screw cut-out and one hardware breakage have been treated successfully with revision plating. using fisherâ e tm s exact test, no statistical significance was seen between the orif alone, autogenous bone grafting ( ) and bioabsorbable calcium phosphate ( ) in regard to overall failure incidence (p = . ). complications necessitating revision orif with bioabsorbable calcium phosphate ( ) and bone graft ( ) were not statistically significant either (p = . ). conclusion: there appears to be no statistically significant difference between union and complication rates between orif alone, or orif augmented with bioresorbable calcium phosphate cement or autogenous bone graft in this retrospective study. introduction: the purpose of the present study was to determine the effect of two anti-osteoporotic treatments on fracture healing in osteoporotic ovx rats, days after fracture occurrence. pth which has been proven to influence fracture healing in ovx rats, was taken as a control treatment. strontium ranelate is acting on both resorption and formation. we combined the rat model of a closed, standardised diaphyseal fracture of the femur with the model of a post-ovariectomy osteopenic rat, mimicking post-menopausal bone loss. material and methods: forty-five animals were ovariectomised at the age of weeks and a further were sham operated. at the age of weeks, osteopenia in the ovx rats was diagnosed. then, in all animals, a standardised mid-diaphyseal fracture was induced. at the time of fracture, the animals were divided into four groups. group was the sham control group, groups , and were the ovx treatment groups. groups and were treated with nacl . % s.c. daily, group was treated with mg/kg/d strontium ranelate p.o. daily and group received lg pth - x/ week s.c. the animals were killed after days and the fractured femur removed. the samples were scanned using microct by scanco medical, zurich, switzerland. the evaluation of the data focused on outer callus contour, cortical contour and marrow contour as well as cortical thickness. torsion testing on the bones was carried out using the axial-torsional system by instron (darmstadt, germany). results: treatment with strontium ranelate significantly improved the mechanical properties of the callus when compared to the ovx control group, while the improvement induced by the treatment with pth - did not reach significance. pth - and strontium ranelate both showed a significant increase in bone volume of the callus when compared to ovx control rats with no significant difference between the two treatments. as for the callus tissue volume, the increase induced by strontium ranelate was significant compared to ovx whereas pth induced no change and the difference between both drugs was significant . in both the pth - -and strontium ranelate-administered animals bv/tv was significantly increased compared to the ovx control rats . the bv/tv of the pth-treated rats was even higher than in the sham rats. conclusion: this is the first report on the enhancement of fracture healing with strontium ranelate. the callus in strontium ranelatetreated animals is even more resistant to torsion in comparison to ovx and sham-untreated animals and even to those treated with pth - . pth did not significantly enhance the resistance of the callus versus ovx, despite a significant increase in bv/tv within the callus. the superior results obtained with strontium ranelate compared to pth could be the consequence of a better quality of the new bone formed within the callus. introduction: recent clinical and animal studies suggest an elevated homocysteine serum concentration to be a risk factor for osteoporosis and fragility fractures ( ) . in vitro studies showed that increasing homocysteine concentrations stimulate the activity of human osteoclasts ( ). however, there is no data demonstrating that circulating homocysteine is related to structural and biomechanical properties of human bones. this study aimed to investigate the relation between morphological as well as biomechanical bone properties and homocysteine serum concentrations in humans. material and methods: fasting blood samples and femoral heads were obtained from males and females who underwent hip arthroplasty. bones were assessed by dual energy x-ray absorptiometry (dxa), biomechanical testing (indentation method), and histomorphometry. blood was sampled to measure homocysteine, folate, vitamin b , and vitamin b . according to their homocysteine serum concentration, subjects were classified as hyperhomocysteinemic (> lmol/l, n = ) and normohomocysteinemic (< lmol/l, n = ). results: folate and vitamin b , but not vitamin b , were significantly lower in hyperhomocysteinemic subjects when compared to controls. however, dxa, biomechanical testing, and histomorphometry did not reveal significant differences in bone quality between hyperhomocysteinemic subjects and controls. the results of the present study do not indicate a significant relation between circulating homocysteine and morphological as wells as biomechanical bone properties. introduction: sometimes fractured bones heal poorly with standard treatment and sometimes a bone defect is a major problem. although the bone grafting technique is considered a standard, there is a need for enhancement of this procedure. healing of the cancellous bone is a complex process in which many inflammatory and signaling molecules take part. to improve the outcome of the healing process, one can influence it by applying platelet rich plasma gel locally, thereby releasing cytokines and growth factors ( ). cancellous bone is rich with mesenchymal stem cells that produce new bone when stimulated. material and methods: we enlisted patients with hard to heal fractures and fractures that demonstrated poor healing in the study. five of the patients had osteomyelitis in the fracture and all fractures resulted in a bony defect as a serious complication after treatment. we designed a protocol for the preparation of allogeneic platelet rich plasma gel with suspended autologous cancellous bone, based on laboratory experiments in vitro ( ) . cancellous bone was harvested from iliac bone crest. we used standard ab and rhd identical, leukocyte depleted and irradiated platelets from a blood bank. activation of the platelet gel was achieved by using a cacl and thrombin mixture. we accepted patients after fulfilling the inclusion criteria and they were operated on in a standardized manner by their elected surgeons under technical supervision. in their follow-up, the ingrowths of bone grafts were measured by using x-ray analysis ( ). results: in patients the transplant was sufficiently incorporated in the fracture to give a limb full function. there were no major complications related to the platelet rich plasma additives. in one patient a nerve paresis was observed, which resolved spontaneously. in patients bone graft was not sufficiently incorporated, once because of poor compliance and the other time because of complex nature of distal tibia fracture. the clinical outcome of the operated patients ( %) is satisfactory and encouraging. conclusion: the preliminary clinical results show that using platelet rich plasma and cancellous bone in the treatment of large bone defects has a promising therapeutic potential. ( ) marx re. platelet-rich plasma: evidence to support its use. time from injury to reduction and to surgical intervention was noted. apoptosis was verified by microscopy with tunel, hematoxilin and eosine stained specimens after decalcification of the samples, a time consuming process. the number of live, apoptotic and necrotic chondrocytes were counted. the patients are followed with harris hip score, merle de aubigne score and radiographs for two years. results: patients were admitted directly to our hospital, the rest transferred from other hospitals. patients had their hip reduced after a mean time of minutes. had femoral traction applied and patients were not reduced. mean time from trauma to operation was ± . days. three patients received total hip arthroplasty. the results of will be presented at the congress. conclusion: the conclusions will be given at the presentation. introduction: distal inter-locking using free-hand technique in intramedullary nailing is always a time consuming procedure. the use of xray amplifier is mandatory and the exposure to radiation is rarely modest. if we use navigation devices we rarely trust the device completely and that is why we check the position with x-ray amplifier more than we need to. that is why we did laboratory testing of the new system using the electromagnetic navigation with the use of micro sensors for free-hand interlocking technique in laboratory without the use of x-ray amplifier to ensure the use of system in the operating theatre. material and methods: three residents with little experience in distal interlocking and no experience with this device were testing the electromagnetic navigation system with the use of micro sensors for free-hand interlocking technique. interlocking holes were drilled by the use of guiding star platform in lidis module, ekliptik, slovenia. the system producer had minutes of introduction time, afterwards drilling was done. distal locking was done on utn synhes nail and instead of bone, cannulated hard wood rods were used. we measured time needed for calibration and time needed for reaming and weather we were successful or not. introduction: percutaneous catheter drainage (pcd) is a useful method to manage pericardial effusion. however, pcd is not always effective in a case of hemopericardium due to clot. to perform subxiphoid pericardiotomy within a minute for emergency cases, we have done this procedure in a blind method following finger dissection by subxiphoid approach, which was preliminary reported in . we present the final data to report the usefulness of blind subxiphoid pericardiotomy (bsp) for emergency cases with acute hemopericardium. material and methods: we designed a study to determine a favorable management for cardiac tamponade due to hemopericardium. emergency patients with acute hemopericardium secondary to trauma (n= ), acute aortic disease (n= ) and cardiac rupture following acute myocardial infarction (n= ), were the subjects. board certified surgeons performed bsp (n= ) and other emergency physicians performed pcd (n= ) for patients with cardiopulmonary arrest (cpa) or near cpa due to cardiac tamponade from to . since , bsp (n= ) or pcd (n= ) has been performed at the physicians' discretion. results: bsp was effective to relieve cardiac tamponade in all cases but pcd was ineffective in cases ( . %, p=. ) because of clot in pericardium (n= ) or right ventricular puncture (n= ). in addition to ineffective drainage, acute occlusion of percutaneous drainage tube (n= ) were observed and resulted in deaths in the pcd group. procedure-related complication rates of bsp and pcd and survival rates of bsp and pcd were % and . % (p=. ), . % and . %, respectively (p=. ). sixteen patients (bsp, ; pcd, ) could discharge following emergency surgery (n= ) or conservative treatment (n= ). conclusion: blind subxiphoid pericardiotomy was safe and could be performed quickly in an emergency situation. percutaneous catheter drainage for hemopericardium could not avoid critical complications because of clot in pericardium in some cases. disclosure: no significant relationships. introduction and objectives: heart trauma, mostly penetrating, is not common in our community, but carries a significant morbidity. its clinical presentation can be variable. our objective was to asses the incidence, clinical presentation, associated injuries and mortality of our patient population with trauma to the heart. material and methods: observational, descriptive, retrospective analysis of patient with heart trauma included in our trauma registry between and . we reviewed demographic characteristics, mechanism of injury, associated injuries, injury severity score (iss) and new injury severity score (niss), mortality, triss probability of survival (ps), and hospital length of stay. results: we found ( . %) patients with cardiac traumatism out of . patients included in our registry, ( %) with associated injuries and ( %) isolated; ( . %) were from penetrating trauma, and only ( . %) were from blunt trauma. mean iss and niss were of (+/- ) and (+/- ), respectively. three patients presented ''in extremis'' (agonal status), nine presented with hemodynamic ''stability'' (sbp> mmhg) ( % of them with a hr> bpm), and five patients presented with hemodynamic instability. only % of the patients presented with cardiac tamponade, without hemothorax. two pericardiocentesis ( %), pericardial windows ( %), and emergency room thoracotomies were done ( . %). the most frequent location was in the left ventricle, followed by right atrium and right ventricle. the most frequent associated injuries were in the lungs ( %), followed by the abdomen and vascular injuries ( . %). fifty-nine percent required icu admission, with a median length of stay of days. ten patients died ( %), and three of them ( . %) were dead on arrival. two patients ( . %) died with a ps > . . conclusion: heart trauma is not frequent in our community, and displays great variability in its clinical presentation, with a high mortality. over half of the patients presented with hemodynamic ''stability''. disclosure: no significant relationships. approach of two cases of secondary aortoesophageal fistula results: the st patient was a -y-old man in which fistula was secondary to a fish-bone ingestion, days before the admission. in the nd cause, a -y-old man, fistula was secondary to rupture in oesophagus of a known thoracic aortic aneurysm. diagnosis was made by a contrast-enhanced ct scan; a gastrografin x-ray in the st and an endoscopy in the nd case completed the examination. in both cases the lesion consisted of a few-mm-diameter defect of the oesophageal wall. in the i case an emergent endovascular repair of thoracic aorta by bolton relay · mm stent graft was per-formed; in the ii case, endovascular repair of thoracic aorta (by bolton relay x mm) was associated to an endoprosthesis placement for primary treatment of a preexisting infrarenal abdominal aortic aneurysm. postoperatively tpn was administered. definitive treatment of fistula was performed in both cases by an explorative right thoracotomy (in v and vii post-operative day respectively): oesopagus was primarily repaired and reinforced by a pedicled intercostal muscle flap and a nutritional jejunostomy was associated. subsequent post-operative course consisted in ne administration, prolonged nasogastric suction, resuscitation with fluids, antibiotics. hemorrhagic complications or infections were excluded by repeated ct scan. oral feeding was in th and th postoperative day, after exclusion of a persistent fistula at a gastrografin x-ray of oesophagus. hospital stay was of days in both cases. no late complications were registered at follow-up. conclusion: when an aortoesophageal fistula occurs (if consists of a small oesophageal lesion), emergent treatment of endovascular aortic repair can be successfully associated to a second-step primary repair using a pedicled intercostal muscle flap via a right thoracotomy. results: case : a -year-old male is taken to our hospital after a car crash. on ct scan there was a periaortic hematoma from isthmus to diaphragm, multiple rib (flail chest) fractures, and a pelvic fracture. the aorta was repaired with an endograft with good immediate results. case : a -year-old male, injured in a frontal car crash. on ct scan a mediastinal periaortic hematoma was seen, with a pseudoaneurysm at the origin of the descendent thoracic aorta, distal to the sublavian artery. the aorta was repaired with an endograft, which was replaced at day th because of a leak. on follow-up he is doing very well. case : a -year-old male, injured in a car crash. ct scan findings were as follows: a left diaphragamatic herniation, bilateral lung contusion, traumatic laceration of the descending aorta, pelvic fracture and spleen laceration. he underwent an emergency laparotomy with splenectomy and diaphragmatic repair. on the nd postop. day an endograft was placed at the descending thoracic aorta, without complications. case : a -year-old male, injured in a frontal car crash. on ct scan there was a thoracic aortic laceration, distal to the isthmus, and an aortic endovascular repair was undertaken at day th , after complete hemodynamic normalization. the patient died at day th from multiple organ failure. conclusion: traumatic thoracic aortic injuries are frequently associated to severe thoracic, abdominal and orthopaedic injuries. traditional early surgical aortic repair through thoracotomy, with single lung ventilation and, occasionally, extracorporeal circulation carries a high morbidity and mortality. that is the reason why aortic repair has classically been delayed, but this carries an additional mortality rate of between % and %. endovascular treatment allows for an early management in severely traumatized patients who otherwise wouldn't stand such a risky surgery. it has also revealed lower rates of paraplegia after years of follow-up. introduction: injuries in zone i of the neck are rare and difficult to manage particularly in environment of war. this area gathers aerodigestive, vascular, lymphatic and nervous elements. all the difficulties lie in diagnosis of the lesions, in the decision of a surgical exploration and in the way of repair if necessary. in that situation, fistula between carotid artery and jugular vein is very uncommon, accounting for % of all arterial injuries. through one case, which has occurred in afghanistan, we discuss the various possible solutions to repair such a lesion. material and methods: we report one case of a french soldier, yo, who was wounded by a rocket splinter on left side of the area i of the neck. he was transported immediately in french role ii in kaboul. respiratory tracks are not injured, there's no neurologic lesions. he had a huge haematoma of the area with a tracheal back pushing (xray exam). during an effort of cough, a haemorrhage through the wound occurred requiring an oro-tracheal intubation and a surgical exploration by a cervicotomy. no obvious vascular lesions were found but just a thrill at the base of the neck. the patient was hemodynamically stable. he was transferred by medevac to france in the night. an angioscanner showed a fistula between carotid and jugular vein ( photos). results: he was re-operated h after. the fistula was just behind the first rib requiring an enlarging by sternotomy to control the origine of left carotid. there was a section of left pneumogastric nerve. after exclusion of the fistula and the vein, we interposed an allograft on carotid artery ( photos). the patient discharged from the hospital one week later without lateral damage except a bitonal voice with no need of re-education. conclusion: arterio-veinous fistula is an uncommon consequence of carotid injury. the taking in charge of this patient and the decision of the kinds of repair are difficult. stenting has also been used to repair distal internal carotid injuries that are not easily approached surgically. the favorable outcome of this case illustrates that surgery is a reasonable alternative when an endovascular approach is not feasible in patients with trauma-acquired arteriovenous fistulae. allograft or vein graft, if possible, is also a good solution for this kind of injuries. introduction: we report cases of subclavian artery injury caused by traffic accidents. in all cases, surgical vascular reconstruction was undertaken. in of the cases, the subclavian artery was obstructed by intimal dissection caused by falling down from a motorcycle. in the remaining case, subclavian artery aneurysm caused by seat belt injury occurred. material and methods: case : -year-old male while driving a large motorcycle, the patient collided with a car and the left side of his body was trapped in the car. this resulted in traumatic pneumothorax and severe ischemia of his left upper limb, and he was transported to our level trauma center for surgical treatment. bypass surgery using a mm diameter ptfe was performed. postoperative arteriography showed good patency of the graft and the patient was discharged. recovery from the motor dysfunction caused by brachial plexus injury took months. case : -year-old male for this case, the patient ran into a wall while driving a cc motorcycle. bypass surgery and clavicular orif were undertaken simultaneously for right clavicular fracture and ischemia of the right upper limb. postoperative arteriography showed good patency of the graft and the ischemia improved. however, rehabilitation was needed for the motor dysfunction caused by brachial plexus injury. case : -yearold female the patient ran into a tree while driving a car resulting in hemorrhagic shock caused by bilateral femoral and humeral fractures. she was transported to our center by helicopter. a scar from seat belt injury was found in the right cervical area. she presented with an expanding mass around the subclavian artery with accompanying pulsating pain. arteriography detected a cm-diameter pseudoaneurysm and aneurysmectomy was undertaken. postoperative computed tomography confirmed the disappearance of aneurysm and she was discharged. results: these cases showed favorable outcomes with surgical vascular reconstruction. conclusion: traumatic subclavian artery stenosis is caused by crushinduced local dissection and is frequently complicated with brachial plexus injury. subclavian artery aneurysm caused by seat belt injury occurred. disclosure: no significant relationships. results: case description: years old male patient who was brought in after receiving a large stab wound below the mid-portion of the left clavicle. severe external bleeding was prevented by manual compression in transit to the hospital. three foley catheters introduced through the wound at the ed failed to temporarily control the bleeding due to its large size, and he was rushed to the or. an emergency left antero-lateral thoracotomy allowed for the blind manual compression of the bleeding vessel from within the thoracic cavity, and was very successful in stopping the external bleeding. a long supra-and infra-clavicular incision was done, and the clavicle was divided. this failed to expose the bleeding vessel, due to the large muscle mass of the patient. a decision was taken to split the sternum in a ''trap-door'' approach, which nicely exposed a large laceration of the subclavian vein. this was suture-ligated, and the incision closed, in a surgical field with profused oozing from coagulopathy. he was taken to the icu, and then back to the or two hours later because of persistent bleeding through the chest drains. the ''trap-door'' incision was reopened and careful haemostasis was performed. the patient had a protracted course in the icu but eventually recovered. as a striking and very uncommon sequel he developed severe blindness from bilateral ischemic optic neuropathy attributed to hypotension and use of vasopressors. he is free of pain at the incision and with good cosmetic results conclusion: ''trap-door'' incisions are very infrequently used nowadays, but should be kept in mind in the armamentarium of trauma surgeons. disclosure: no significant relationships. conclusion: mortality in patients with ivc injuries can be well predicted by hemodynamic parameters on arrival and intra-operative findings .hemodynamic instability and intraoperarive findings of expanding hematomas and active intra-peritoneal bleeding are associated with high mortality. introduction: vascular complications due to intravenous drug abuse pose significant challenges to vascular surgeons and no standardized surgical management of the resultant infected pseudoaneurysm was established. material and methods: we present our successful management of a case of an expanding retroperitoneal haemathoma due to external iliac artery pseudoaneurysm caused by self inflicted trauma (heroin administration). mri showed an external iliac artery pseudoaneurysm surrounding by an infected old haemathoma, venous thrombosis (external illiac and femoural) and multiple muscular abscesses of the left thigh. a self-expandable stent-graft was deployed across the pseudoaneurysm after crossing the lession with an exchange glide wire through the left brachial artery route. post-stenting angiography showed complete exclusion of the pseudoaneurysm with no residual stenosis. we decided local surgical debridement; after haemathoma evacuation we identified external illiac artery presenting a stent graft and reinforced it by double layer of tissue sealing surgical patch. results: postoperative course was favorable under complex general and local therapy. conclusion: endovascular treatment of arterial pseudoaneurysms has become feasible as natural extension of the endovascular techniques. ct, mri, sonography and angiography may all be valuable in the imaging working of pseudoaneurysms. prompt diagnosis and treatment are necessary to avoid the morbidity and mortality secondary to hemorrhage and rupture. although endovascular stent-grafting is not considered a standard therapy for infected aneurysms, our case suggest that stent-graft deployment, secondary surgical debridement and major antimicrobial therapy may be the most favorable treatment option for patients unfit for major surgery. introduction: the incidence of traumatic vascular injuries (tvi) has increased significantly in the last decades, with penetrating trauma as the most frequent mechanism. our aim was to estimate the incidence, management by interventional radiology, and the preventable death rate in our patient population. material and methods: a retrospective observational study based on our trauma registry covering a -year period (july to july ) . we have assessed the demographics, severity, diagnostic and therapeutic approaches, outcome, and triss probability of survival (ps). results: patients ( % males, with a mean age of years) suffered a tvi located at the head ( ), neck ( ), thorax ( ), abdomen ( ), upper extremities ( ) and lower extremities ( ), respectively. ( . %) were caused by a blunt mechanism, and ( . %) by an open one. the average time spent before being taken to hospital was minutes. upon arrival to hospital, were in shock, required orotracheal intubation, and a cardiac massage. the diagnostic methods used were a ct scans in , dpl in , fast in , angiography in , echocardiogram in and duplex-doppler in . ( . %) patients underwent emergency surgery and ( . %) were treated with interventional radiology ( of them associated with surgery). only ( . %) were treated conservatively. overall mortality was of patients ( . %) ( of them died upon their arrival to hospital or in the operating room, all of them with an aortic injury), out of which ( . %) had a triss ps > . . the incidence of tvi increased from cases in the - period to in - , remaining stable in - ( ) . however, the mortality rate has shown a steady decline over the years (from % in - , to % in - ) . conclusion: the incidence of traumatic vascular injuries has increased considerably during the last years in our hospital. these injuries are most commonly located in the lower extremities, followed by the thorax. % of patients could be managed by interventional radiology techniques. introduction: the tip apex distance (tad) is a simple measurement that predicts screw cut out in the femoral head in peritrochanteric fractures treated with a fixed angle sliding hip screw device. we wanted to assess whether the tad measurements in our centre were comparable to previously published results, how reproducible these measurements were between observers and how accurate we were at reducing the fractures. material and methods: a retrospective review was conducted of consecutively treated peritrochanteric fractures over a month period. patients were excluded because they did not sustain a peritrochanteric fracture, had treatment of a pathological fracture or because of incomplete radiographic data. three observers used a standardised method to measure the tad (from orthogonal projections with a correction for magnification). the stability of the fracture patterns and the accuracy of reduction were measured according to criteria from the original baumgaertner paper introduction: distal locking screw insertion of the short gamma nail is normally performed by using a targeting device attached firmly to the proximal part of the nail. generally, the accuracy of targeting device should be promising. however, missing the target in the process of drilling might be a potential risk. we report cases of such condition in term of early radiographic finding, method of solving and the result of treatment. material and methods: the patient records, operative notes and intraoperative c-arm images of the patients underwent short gamma nailing for unstable pertrochanteric fractures during october to october have been reviewed in order to identify an error of distal locking screw insertion via a targeting device. the intraoperative radiographic finding, solving procedure and the outcome has been analyzed. results: there were cases of short gamma nailing over the past one year in our institute. five of which had an error during distal screw insertion even using the targeting device. an error occurred in the drilling process in all cases. intraoperative images showed that the drillbit missed its target posteriorly after perforating the near cortex of the femur. all has been corrected by using a free-hand technique under c-arm guidance. no any serious complication afterword and all fractures healed in an appropriated time. conclusion: distal screw insertion during gamma nailing can be missed even though using the targeting device. therefore, radiographic confirmation on the lateral view after perforation the near cortex is recommend in all cases in order to obtain early detection prior to bicortical perforation. freehand technique can be carried out in order to correct the error. . systemic antibiotics were used in patients ( %). ten different types of antibiotics were used after wound exploration for a period between and weeks. in-hospital mortality was %. sixty-nine percent (n= ) was finally discharged from follow-up. conclusion: we conclude that our infection rate was higher than reported in literature and the infections classified initially as superficial required a prolonged treatment as well. moreover, the treatment of this disastrous complication showed no uniformity whatsoever and should be the topic of further research, resulting in a clear protocol to increase survival and decrease morbidity. introduction: allograft meniscal transplantation is known as a possible procedure to solve pain and loss of function in the knee of patients with a history of subtotal or total meniscectomy. medium-term and long-term results after meniscal allograft transplantation in the knee are scarce. in this study patients who received an arthroscopically assisted meniscal allograft transplantation with a follow-up between and years were evaluated using subjective questionnaires, a clinical and a radiographical evaluation. material and methods: demographic data of all patients were collected and pre-operative results, using the koos (knee injury and osteoarthritis outcome score), the lysholm score, the tegner score, the sf and the vas (visual analogue scale) for pain were compared with actual results of those questionnaires to evaluate the therapeutic effects of allograft meniscal transplantation in the knee during medium-term follow-up. patients were evaluated with a standardized clinical examination of the knee to objectivate knee related symptoms. standard weight bearing radiographs and a full leg standing radiograph were performed to evaluate the evolution of osteoarthritis and malalignment. results: for all questionnaires (vas, koos, lysholm, sf ) there is a significant (p< , ) and clinically relevant increase in postoperative score. this improvement stays consistent during the followup period. the more severe the osteoarthritis, the lower the improvement. despite the meniscal transplantation, there is still a significant (p= , ) increase in osteoarthritis. an increase in osteoarthritis grade was seen in % of the patients, as scored following the kellgren-lawrence classification. when strictly respecting the indications, there is no significant correlation between preoperative cartilage damage, pre-operative osteoarthritis, alignment deviation, gender and body mass index on the one hand and outcome scores or improvement on the other hand. conclusion: meniscal allograft transplantation results in important pain relief and functional improvement in patients with a history of (sub)total meniscectomy and pain localized in the affected compartment. strictly following the indications, meniscal transplantation can give good and predictable results. introduction: intramedullary nailing of the tibia has become the conventional therapy for tibial shaft fractures. one of the most common complaints associated with this procedure is chronic knee pain. incidence rates between % and % have been reported and a significant number of patients have problems in kneeling, affecting professional and recreational activities. surgical damage to the infrapatellar nerve is one possible causative factor for post-nailing knee pain. the infrapatellar nerve is exclusively sensory and runs subcutaneously almost perpendicular to the patellar tendon just below the patella. the purpose of this study was to determine the prevalence of chronic knee pain in our institute and its relation with sensory disturbances in the knee area. material and methods: a chart review was conducted. all patients between and years with healed traumatic tibial shaft fractures treated with an intramedullary nail between and were included. exclusion criteria were: fracture lines extending into the knee or ankle joint, any other fracture in the affected leg, lacerations in the knee area, pre-operatively existing knee pain and loss of follow-up. chronic knee pain was defined as persisting pain in the knee area months after tibial nailing. sensory disturbances were defined as hyperesthesia or anesthesia at the nail entry site. introduction: femoral nailing causes an influx of fat in the circulation. in the multiply injured patient, especially in the patient with concomitant lung or brain contusion, this can lead to ards, fat embolism syndrome and multiple organ failure. the timing and kind of fixation of femoral fractures in patients with multiple injuries is controversially. the advantage of damage control orthopaedics (external fixation) would be less fat embolisation but some authors report more problems of infection and delayed healing. the aim of our study was to investigate the effect of external fixation on healing and infection rates of femoral shaft fractures in the multiply injured patient. material and methods: between january and januari , we treated femoral shaft fractures. in this group there where polytrauma patients with a total of fractures. we compared the rate of infection and delayed union in the group treated by damage control external fixation to the group primarily treated by intramedullary nailing. results: no significant difference in infection or union rates could be demonstrated between the damage control external fixation and the primary nailing group. we also noted that there's a correlation between the complexity of the fracture and the percentage of prolonged healing. and although not statistical significant there seems a tendency of less healing problems with the reamed femoral nail in comparison with the unreamed femoral nail. introduction: the diagnostic information power of a level one emergency room has risen excessively within the last years. the need for quality control, judicial regulations, insurance claims and forensic reasons still lead to a high number of autopsies being performed in patients not surviving the first h after admission to the er. however, the number of autopsy clarification featured in a level one trauma centre after trauma related deaths considerably vary and also the rate of deathly diagnoses missed within er assessment of early stage deceased patients differ in the literature. the aim of this study was to assess the value and necessity of autopsy after modern er assessment with a multi-slice ct-scan as an integrated part of the diagnostic algorithm. material and methods: prospectively reviewing our emergency database, case histories, laboratory values and radiological findings compared to findings in autopsy between jan and sep , we charged for missed deathly diagnoses in early stage deceased trauma patients (< h). patients were classified into two groups: group : patients with limited diagnostic assessment (conventional xray, sonography). group : patients with full er assessment (msct). all patients in group could not be sufficiently stabilised in terms of circulation patterns and therefore did not receive full assessment. non-trauma patients and patients reaching the er under cpr were excluded. results: the autopsy rate of all included patients was %. the overall incidence of missed deathly diagnoses was . %. in terms of missed deathly diagnoses, groups varied significantly (group : . %;group : . %).the iss after autopsy increased significantly in group from to . . in group there was no difference of iss between status emergency room and after autopsy. the most concerned region of missed deathly injuries was thorax with . % of all patients with autopsies followed by pelvic ( %) and spine injuries ( . %). conclusion: in spite of complete and nearly ideal conditions within a modern emergency room assessment nowadays, detecting all diag-noses is still challenging. overall, our findings show that almost every tenth early stage deceased patient showed at least one missed potential deathly diagnose in a level one trauma centre. regarding the insufficient assessment performance in group , the relative high rate of missed diagnoses seem explicable. nevertheless, even having acquired full assessment power (group ), still . % deathly diagnoses were missed. for this reason, autopsy is still the most powerful and indispensable tool in finding the ''whole'' diagnosis. completeness of autopsies after trauma related death therefore is essential referring a continuous gain of quality. introduction: in a physiological environment metallic biomaterials undergo corrosion through a variety of mechanisms. this study investigated whether, beside the well recognized electrochemical aspect of corrosion, human osteoclasts are able to directly corrode titanium alloys, uptake and finally release corresponding metal ions into their environment. the released ions are believed to cause inflammatory reactions and activate osteoclastic differentiation and activity, which most likely play a role in the pathophysiological mechanisms of aseptic loosening [ ] . material and methods: human monocytes and in vitro generated osteoclasts were seeded onto titanium and aluminum (positive control) foils. after days scanning electron microscopy analysis was performed in order to assess whether monocytes were able to grow and differentiate on the metals. in order to visualize uptake and distribution of intracellular metal ions, a novel protocol using confocal microscopy analyses with newport greentm dcf diacetate ester staining was developed [ ] . additionally, the concentrations of metal ions released into the culture supernatant were measured using atomic emission spectrometry. ). nine bre-gfp mice were used. mice were allowed unrestricted activity. a mini-external fixator fixed to the proximal and distal tibia was applied under general anesthesia on day . the animals were permitted full weight baring and unrestricted activity after awakening from anaesthesia. the gfp signal of tibia and fibula in bilateral limbs was measured on days , , , and after application of the external fixator. results: baseline measurements of the gfp-signal ranged from . x e photons to . x e photons between individual mice. after application of the external fixator, the gfp signal of the unloaded tibia and fibula decreased in all mice to on average % of baseline on day (sd ± %, p = . ), % on day (sd ± %, p < . ), % on day (sd ± %, p < . ), % on day (sd ± %, p = . ) and % on day (sd ± %, p < . ). in the contra-lateral non-operated limb, the gpf signal increased to an average % on day (sd ± %, p = . ), % on day (sd ± % p < . ), % on day (sd ± %, p = . ), % on day (sd ± %, p < . ) and % on day (sd ± %, p < . ). introduction: the aim of the present study was to assess the effect of antibiotic loaded fresh-frozen allografts and compare it with antibiotic loaded acrylic bone cement in staphylococcal tibia osteomyelitis and to combine the effects of bone repair and eradication of infection in one stage surgery. material and methods: a unicortical . -mm-diameter defect was created in the proximal tibial metaphysis of thirty-six new zeland albino rabbits. after contamining the wounds with x colony forming units of staphylococcus aureus, we divided the animals into four groups. the negative control group received no treatment, the positive control group received teicoplanin-impregnated polymethylmethacrylate beads, the allograft group received fresh-frozen allografts and the experimental group received teicoplanin-impregnated fresh-frozen allografts. histopathological evaluation with light microscope were made and intraosseous tissue cultures were performed on postoperative day . clinical evaluation in a daily-routine were made. results: the cultures showed no evidence of intramedullary infection in the experimental or the positive control group in eight of the nine rabbits, but they were positive for staphylococcus aureus in one of the nine rabbits in the experimental group, one of the nine rabbits in the positive control group and all of the rabbits in the negative control and allograft groups. the experimental group and the positive control group has similar effects in eradication of the infection. conclusion: teicoplanin-impregnated allografts was effective in preventing intramedullary staphylococcus aureus infection in a staphylococcal tibia osteomyelitis model. this combination therapy could potentially eliminate the need for surgical removal of cement beads. using an antibiotic-graft compound, eradication of pathogens and grafting of bony defects may be carried out in a one stage procedure. introduction: we first report a case of an infection in humans by streptococcus pluranimalium, a new streptococcal species that has been isolated in the genital tract and tonsils of cattle, tonsils of a goat and a cat, and from the crop and the respiratory tract of canaries. according our knowledge there are a few reports in the literature reporting infections by this strain of streptococcus in animals, but never since now in humans. a year old farmer, fit and well, nonimmunocompromised has been treated in our department, for a close tibial plateau fracture (schatzker vi), with a circular external fixator. postoperatively, i.v antibiotics -cefuroxime mg every h was administrated for hours. radiological and clinical healing of the fracture achieved successfully within weeks of the fracture. the frame removed and the patient was followed up as an outpatient. six days after the removal of the frame, the patient turned up to the a&e department, systematically unwell, complaining for a swollen painful knee, and a discharging abscess in one of the proximal pin sites near by the joint line.fluid samples from the abscess and the knee aspiration, obtained and revealed streptococcus pluranimalium in all samples. debridement of the abscess and an arthroscopic wash out was performed twice, followed by i.v antibiotics according to the sensitivity test (levofloxacin ( mgx ) ceftriaxone ( grx )) for six weeks, and p.o antibiotics (clarithromycin mg every h and levofloxacin mg every ) for another two weeks. results: symptoms were settled and the patient is free of infection for the last months. conclusion: we hypothesized that the bacterium was settled on the wires of the circular fixator and was inoculated in the patient during the removal of the frame. according our knowledge, it is the first case of infection in a human individual by this specific strain of streptococcus. disclosure: no significant relationships. introduction: post traumatic knee joint contracture is the most difficult complication of the lower limbs traumas, considerably limits the functional abilities and make the patients invalids. besides, the frequent consequence of knee joint injure is gonarthrosis, and kinesitherapy is one of the element of the complex treatment. the basis of the procedure is the joint relief, leading to adjoining muscles tonus lessening, and paraarticular tissues general tense lessening and infrajoint hydrostatic pressure, joint tissues nourishing improvement. the introduction: ilizarov frames are still removed in the operating theatre in a lot of centers. this is due to a variety of reasons, the main one being that it is a painful procedure. we decided to evaluate patient satisfaction and pain experienced on removal of ilizarov frames in an outpatient setting, using oral analgesia and entonox. material and methods: seventy consecutive patients, who had their frames removed in the out patients department, had their level of pain scored using a visual analogue score (vas) and a simple questionnaire. results: the mean score for frame removal was . on the vas. there was no difference between male and female scores. the age of the patient does make a difference in the pain score, the pain score decreases with the age of the patient. pain increases when there are or more olive wires to be removed conclusion: removal of ilizarov frames in the outpatient department is a moderately painful but well tolerated procedure. introduction: the proximal metaphyseal tibial fractures are difficult to treat due to their frequent association with tibial plateau fracture and due to their aspect, which is often comminuted and has a significant impact on the function of the knee. surgery has to restore local anatomy and to allow early rehabilitation, meaning proper evaluation and stabilization of the fracture. material and methods: cases, operated between . . - . . (mean age - yrs) with proximal metaphyseal tibial fractures, were analysed. pre-operative planning using ct scan was used. the fractures were complicated with compartment syndrome ( cases) which needed additional fasciotomy.the fractures were stabilized with : plates and screws ( cases) or external fixation ( cases) depending on the soft tissue status. bone graft was used in cases. the patients were monitorised at , , , and months postoperative, concerning: bone healing, restoring of the axis of the knee, joint mobility, septic complications. results: the axis of the knee were completely restored in all the cases. bone healing appeared in all the patients (starting from months- cases, at months in the rest of the fracture) depending on the initial aspect of the fracture. flexion of the knee was limited in cases ( % of the pactients) and extension was affected in patients, depending, also, on the initial characteristics of the fracture. the frequency of the complications depended on the initial aspect of the fracture, initial stabilization, time from intial stabilization to final fixation. conclusion: results after surgery for tibial plateau fractures depend on the initial aspect of the fracture, but also on the results of surgery . the method proposed by the authors, which allows the suspension of the articular surphace, is valuable especially when the fracture is cominuted and has small fragments. the double plate fixation (medial and lateral) with single anterior incision is the best, effective and simple procedure in treatment of complex proximal tibial fractures (type v and vi of schautzker classification). introduction: compartment syndrome is one of the most frequent complications after proximal metaphyseal tibial fractures, due to the anatomical characteristics of this area. the importance of the problem is that the compartment syndrome radically changes the local and general and especially the type of fixation of the fracture. the purpose of this study is to evaluate the impact of the compartment syndrome on the outcome of the patients with this type of fracture, when recognized and treated early and complete. material and methods: the authors analyse cases of proximal metaphyseal tibial fractures treated in the emergency hospital, bucharest, between . . - . . . from these, in cases, compartment syndrome was diagnosed. in all these cases, the patients were operated and the fracture stabilized (with plates and screws in cases and external fixation in cases). decompressive fasciotomy was performed in all the cases with installed compartment syndrome and intra-compartimental pressure was monitored post-operative in all the other cases. frome these, in cases secondary compartment syndrome developed and fascitomy was necessary - hours after surgery the patients are analysed concerning: the moment of surgical treatment, and the characteristics of the patient in that moment, post-operative treatment, the postoperative local and general outcome, local and general complications. results: the incidence of the complications was influenced by the time between trauma and complete surgery. there were cases of superficial infection and case of deep infection, without needing implant removal. all the fractures healed, the interval proved to be longer when external fixation was first used. there were no systemic definitive complications after these trauma. conclusion: compartment syndrome is frequent after proximal metaphyseal tibial fractures and the incidence of this complication was significant in the group of patients we studied, and the outcome was good when the treatment was early and complete . the compartment syndrome influenced the local and general prognosis, due to the importance of microcirculation in healing after trauma. results: a ct pulmonary angiogram illustrated a metallic density, which appeared to lie in the lumen of the main pulmonary artery just proximal to the pulmonary valve. conclusion: in this case, the respiratory symptoms and signs were due to a metallic pulmonary embolus rather than fat or thrombus. formal anticoagulation was initiated and the patient's clinical condition consistently improved without the need for cardiothoracic surgery, although this is described in the literature with retained catheter fragments. eight months after the injury, the fracture has consolidated with the patient returning to work. toid is often necessary to obtain adequate exposure. as an alternative to this we promote the minimal invasive transdeltoid approach. material and methods: the operative technique of the minimal invasive transdeltoid approach is explained in a first section. this approach has the advantage of direct access to the fracture site with more opportunities for adequate reduction and good plate placement without extensive distraction of the muscles. an important step in the procedure is the palpation of the axillary nerve. in a second section the results of a prospective cohort of the first patients treated with this technique will be presented. the neer criteria were used as guidelines for operative treatment. fractures were classified according to the ao-classification. the ases shoulder score was used to evaluate functional outcomes. preoperative xrays were used to evaluate displacement, vascularity of the humeral head (according to the hertel criteria) and ao fracture type. postoperative x-rays were analyzed for quality of reduction of the ccd angle, reconstruction of the medial hinge and reposition of the tuberosities. follow-up x-rays were evaluated for healing, avascular necrosis, loss of reduction and implant related failures of osteosynthesis. the -year-old male patient was taken to hospital after a traffic accident. he was a pedestrian hit by a car. he suffered comminuted proximal humeral fracture on the dominant right side. the fracture was closed. the glenoid cavity was damaged and acromion was broken. the fractures of the v-vi th ribs were found without complication. otherwise the patient's condition was good. he had only a controlled hypertension. for preoperative planning ct scan was performed. as pieces of the humeral metaphysis wedged into the glenoid cavity insertion of glenoid component seemed uncertain. an early shoulder replacement was done on the th day. the denudated fragments were removed. the tubercles with the muscle attachments were preserved. as a long bone defect remained in the metaphyseal zone normal stem would have been insufficient. a cm long stem used in tumor cases was implanted. the length of the arm and size of the humeral head were compared to the intact side. the tubercles were attached to the prosthesis by non absorbable sutures. after the operation long bone defect remained which was filled up by heterotopic bone visible on x-ray. the postoperative period was complication free. fever, severe pain, hematoma did not occur. the arm was in rest for weeks, only controlled pendulum exercises were done from the second week. active physiotherapy was started on the th week. after months the patient finished the follow up treatment. he was pain free and self-sufficient. conclusion: for three-or four-part displaced fractures in which replacement is indicated, hemiarthroplasty with tuberosity reattachment remains the reference treatment/ , /. in trauma cases short prosthesis stem is usually sufficient but in comminuted fractures involving the metaphyseal zone long stem has to be used for certain bone-prosthesis contact. introduction: there is a trend to apply plate and screw fixation directly medial and lateral (so-called parallel plating), and many implants designed specifically for the distal humerus extend more laterally to improve fixation. this may risk injury to the origins of the common extensor and flexion musculature and the collateral ligaments either via operative dissection or by damage to the blood supply. internal plate and screw fixation is often accomplished with subperiosteal elevation of muscle attachments and tight apposition of the plate to the bone, but this should not be done over the epicondyles. plates applied to the medial and lateral aspects of the lateral and medial epicondyles should be placed directly over the soft tissues without elevating or disturbing them. damage to the collateral ligaments could cause elbow instability. material and methods: in order to emphasize these important technical aspects, we report three patients in whom detachment of the origins of the lateral collateral ligament and common extensor muscle origins from the lateral epicondyle led to post-operative instability after open reduction and internal fixation of a fracture of the distal humerus. results: while the cases are very complex and the exact cause of elbow instability by necessity somewhat speculative, our concern is that the operative dissection performed to apply implants to the lateral side of the elbow contributed to the ulnohumeral instability. injury to the lcl is the most common cause of recurrent elbow dislocation. attempts to place a direct lateral implant directly on the bone by elevating soft tissues will put the origin of the lcl at risk. it is preferable to place implants directly over the soft tissues, although there is a risk of interfering with blood supply leading to soft tissue insufficiency. it seems safe to assume that the operative treatment contributed in some way to the instability in each patient. patient one in particular had osteoporotic bone noted intraoperatively, so that one would expect failure to occur through bone with any subsequent trauma. the failure through the ligamentous structures seems to implicate the operative technique. conclusion: in any case, these three patients establish that instability of the ulnohumeral joint is an uncommon complication or sequel of the operative treatment of a bicolumnar fracture of the distal humerus. our intention in reporting these cases is to increase awareness of these potential complications and we encourage others to report any similar cases so that we can learn enough to limit the risk of this complication. introduction: orif of comminuted distal humerus fractures carries a high risk of complications such as secondray loss of reduction, pseudarthrosis and heterotopic ossifications. especially elderly patients with osteoporotic bone quality are struck by these complications. therefore total elbow arthroplasty (tea) is gaining more and more in importance as it has proven to achieve good results in elderly patients with poor bone quality. the latitude total elbow system (tornier inc., stafford, usa) is a modular, convertible implant that allows not only linked and unlinked tea with or without radial head replacement but also hemiarthroplasty. the aim of this system is to reproduce the patient's anatomy to reconstitue the elbow's physiologic kinematics. therefore the latitude prosthesis is offered in four different sizes, respecting the flexion-extension axis and three different humeral offsets based on anatomical findings. the purpose of our study was to evaluate the short-term results after elbow arthroplasty with the latitude system. introduction: it is not always possible to reconstruct complex radial head fractures. as non-anatomical reconstruction and healing disturbances result is loss of motion and severe post-traumatic arthritis of the elbow joint, radial head resection as been proposed for these cases. other authors propose radial head arthroplasty as an alternative to radial head resection to avoid the complications of radial head resection. different concepts of radial head prostheses are available: silicon prosthesis, monopolar prosthesis (loose fit and cemented/thight fit) and bipolar prostheses. evidence is lacking on the exact place for arthroplasty as opposed to radial head resection. to answer this question we performed a systematic review of litterature. material and methods: inclusion criteria are clinical studies reporting on radial head resection or radial head arthroplasty, published between and today in english, french, german or dutch language. a search has been performed using the pubmed and embase databank. a secondary search has been performed based upon the reference list of the included publications. exclusion criteria are: â e¢cadaver or animal studies â e¢biomechanic studies â e¢clinical studies with a follow up of less than years â e¢clinical studies with less than patients data extraction â e¢elbow function â e¢complication rate â e¢arthritis rate data are reported according to the moose guidelines. results: only low evidence studies are available. we did not find any randomised controlled trial comparing resection to radial head arthroplasty. there is evidence that radial head resection results in high complication rates (including arthritis) and poor function in case of elbow instability and/or essex-lopresti lesions. the rate of complications in these indications is higher than for radial head arthroplasty. in cases without instability or essex-lopresti lesion there is a trend to better function in radial head resection. complication rate is higher in the prosthesis patients. the rate of post-traumatic arthritis is not significantly differing between the resection and the arthroplasty group, and remains very high (+/_ %). conclusion: complex radial head fractures remain difficult to treat. based upon the findings of this systematic review we suggest: â e¢that adequate level of evidence studies are a necessity â e¢that in case of fracture without evident instability or essex lopresti lesion resection results in better function and less complications than arthroplasty â e¢that in case of fracture with evident instability or essex lopresti lesion resection results in worse function and higher complication rates than arthroplasty â e¢as secondary arthritis rate remains %, further therapeutic optimisation is a must. often, mortality. a new pelvic stabilizer (t-pod Ò ) provides secure and effective simultaneous circumferential compression of the pelvis. material and methods: in this study we have managed fifteen patients with a prehospital untreated unstable pelvic fracture with signs of hypovolaemic shock with the t-pod Ò . before and minutes after applying the t-pod Ò , heart rate and blood pressure were measured. an x-ray before and after applying the t-podÒ was made to measure the effect on reduction in symphyseal diastasis. results: application of the t-pod Ò reduced the symphyseal diastasis with % (n= ; p= . ). the mean arterial pressure (map) increased significant from . to . mmhg (n= ; p= . ) and the heart rate declined from beats per minute to (n= ; p= . ). in ten patients of whom circulatory response before and after the t-pod Ò was recorded, there were seven good responders, one transient and two poor responders. conclusion: in the acute setting, the t-pod Ò device has a clear compressive effect on the pelvic volume in unstable pelvic fractures. the t-pod Ò is therefore an easy to use and effective way of (temporarily) stabilizing the pelvic ring in an acute setting. introduction: thoracolumbar and lumbar fractures treated with surgical methods aim to decompress the spinal cord and correct the deformity. we aimed to compare the effects of anterior, posterior and anterior-posterior surgery on the local kyphosis angle in thoracolumbar and lumbar vertebral fractures. material and methods: thoracolumbar and lumbar, burst or compression fractured and surgically treated patients were evaluated retrospectively. preoperative, postoperative and follow-up local kyphosis angles were measured on the x-rays and changes in these angles were compared according to the applied surgical treatment methods. results: early application of surgical treatment following trauma decreases the correction loss suffered after surgery. the increase in correction loss continues after removal of the hardware. it is observed that laminectomy applied in the course of posterior surgical interventions has no effect on the correction loss. the length of the implantation, fusion and the addition of a hook to the lamina of the vertebra which is located one segment lower than the transpedicular screw applied vertebra do not affect the loss of correction. conclusion: in the surgical treatment of thoracolumbar and lumbar vertebral fractures, different degrees of correction loss are observed after each surgical treatment modality. considering the corrective effect of combined anterior-posterior surgery on the correction of kyphotic derformity due to trauma and the preoperative local kyphosis angle, follow-up correction achievement is higher when compared with anterior and posterior surgical approaches. domain questionnaire (eq- d), the point self-rated back pain (vas) and device and/or procedure related adverse events. the ethic committee of the hospital did not accept a randomized study because of the results in this proof of concept, they accepted the study with a minimum of patients (based on the results of a previous proof of concept). the incidence of missed injuries without the application of the tertiary survey was % and this incidence has been reduced to % with the application of the tertiary survey (it means a reduction of the . % in the incidence of missed injuries). the incidence of clinically significant missed injuries without the application of the tertiary survey was % and it has been reduced to % with the application of the tertiary survey (it means a reduction of the % in the incidence of missed injuries). the tertiary survey is an essential task in the management of the trauma patients to reduce the incidence of missed injuries and clinically significant missed injuries. introduction: knee-arthroscopy is a complex surgical ability. it is a combination of factors like anatomical knowledge, hand-eye coordination, three-dimensional mental activity and operating experience. surgeons as well as students were not able to train knee arthroscopy before. parts of these abilities were trained by playing video games. former studies indicated a correlation between a better performance in virtual reality (vr) laparoscopy simulation and video game experience. the aim of this study is to show that experienced video gamer perform better in a virtual arthroscopy simulation. material and methods: medical students did an arthroscopy of a longitudinal meniscus tear on a vr knee arthroscopy simulator (the insight arthro vr Ò gmv, madrid, spain). the students completed a questionnaire asking for their game experience: none (n = ), monthly (n = ) weekly (n = ) daily (n = ) before they did the arthroscopy. the simulator assessed different parameters: time, distance moved and roughness both for probe and camera and a global score (combination of all metrics). results: students with game experience (n = ) performed significantly (p <= , ) better than not experienced students (n = ). there is a tendency that the performances get better with more game experience. conclusion: gamer performed better in a vr knee arthroscopy than not gamer. these result correlates to the laparoscopic simulator training. there is a tendency of achieving a better performance in vr arthroscopy simulation due to a higher frequency of playing games. extensive training on the simulator improves the abilities of nongamers with respect to their arthroscopy skills. we will evaluate these dates in the future. ) and mostly injuries of tendons (n = ) and/or vessels / nerves (n = ). buzzsaws of different manufacturers and different price ranges were used. the work conditions were well in all cases, the saws were placed firmly on the ground and the lighting was sufficient. most injuries appeared on the week-end (friday n = , saturday n = ). a break or a meal, taken shortly before the accident, had no influence on the injury risk. all patients had a several years lasting experience in dealing with buzzsaws, half of the patients even for at least years. the safety device of the saw was folded back in most cases (n = ), only few patients (n = ) had correctly put on the saw safety device at the accident time, patients provided moreover no information. the accident had entered in cases shortly before working end, mostly with the last cut. in cases a wooden piece had become stuck in the saw and the patient had tried to solve it. conclusion: a many years' routine in dealing with buzzsaws can lead to the fact that necessary safeguarding measures are not followed any more and so cause an increased injury risk. in particular shortly before working end the attention decreases and the injury risk rises. an especially injury-laden situation is becoming stuck of wooden parts in the saw. the attempt to solve these parts without switching off the saw before bears a high injury risk. the patients showed predominantly heavy injuries. this might be the result of our clinic as a university clinic. patients with less severe injuries are concerned to be treated in smaller clinics next to their residence . ethibond was then used to anatomically oppose the ends of the sleeve fracture. the construct was reinforced with a circlage wire with the wire twisted so that it could be retrieved later through a small lateral incision post operatively the legs were immobilised in lightweight casting material for a period of weeks followed by an unlicked hinged knee brace for weeks. the circlage wires were removed at months. the child now has full, pain free range of motion. the knee is stable and he has no functional problems. conclusion: we report a rare case and emphasize the timing of diagnosis as being crucial in outcome. early operative intervention with accurate open reduction will yield good results. this publication serves to educate and refresh those who deal with general and paediatric lower limb trauma. introduction: the purpose of this study was to evaluate the effect of electromagnetic fields in healing progression of delayed union of long bones in the lower extremities. we defined delayed union, as failure of expected healing progression and nonunion when a minimum of nine months has elapsed since injury and failure or halting of healing progression was observed in three successive monthly radiographs (infection ruled out results: an average of . x-rays were performed on each patient from the time of diagnosis to discharge from clinic. none of these fractures displaced on follow up x-rays. conclusion: stable undisplaced ankle fractures treated conservatively with a below knee non weight bearing cast do not displace. hence these patients do not require to be followed up frequently with serial x-rays as they may be exposed to unnecessary harmful radiation and follow up appointments thereby saving time, money and resources. ( ). we aim to describe the rate of postoperative complications after calcaneal plate osteosynthesis in relation to the hospital fracture load as a means to increase insight into the clinical audit data. material and methods: a search was performed using the disease code for intra-articular calcaneal fractures and operative code for orif for the period - . the medical records of all included patients were obtained. as postoperative complications we included superficial and deep wound infection, mobilisation problems with need for orthopaedic shoes or walking aid and secondary arthrodesis. current complication rate of deep infection and arthrodesis rate from the clinical audit were compared with the mean logarithmic correlation coefficient relating complication rates with the institutional fracture load data, reported earlier in the literature ( ) . results: over a period of months a total of intra-articular calcaneal fractures were reconstructed with a calcaneal plate using orif (mean institutional fracture load = . fractures per month). eight patients had a wound infection, six of them were treated with antibiotics and two of them needed surgical debridement. thirteen patients have mobilisation problems, patients suffered from pain when walking, patients used orthopaedic shoes and one patient mobilised using a wheelchair. two patients had an secondary arthrodesis (n = , . %). in seven patients the osteosynthesis was removed due to pain. both deep infection rate and arthrodesis rates related to the institutional fracture load were below the % ci reported in the literature. the outcome of open reduction and internal fixation of intra-articular calcaneal fractures is known to be determined not only by factors related to patient and the fracture, but also to the institutional fracture load ( ) . the complication rate regarding deep wound infection and arthrodesis is below the data reported in the literature, related to the institutional fracture load. clinical audits studying the complication rate should take the institutional fracture load into account. introduction: toe fractures are the most common fracture of the foot. there is little data on demographics and no studies on functional outcome of toe fractures. material and methods: the initial radiographs of all consecutive patients with toe fractures treated between january and september at the reinier de graaf groep in delft, the netherlands were re-evaluated; patient and fracture characteristics were collected. all patients in aged to ( patients) were sent a questionnaire concerning pain, activity and functional limitations, footwear, walking distance, and gait (aofas midfoot score). overall satisfaction was measured using a visual analogue scale (range zero to ten). results: a total of patients with digital and phalangeal fractures of the foot were identified. the distribution of fractured toes was: first %, second %, third %, fourth %, and fifth %. multiple digital fractures were seen in . %. most fractures were caused by stubbing the toe or a crush injury ( . %). more than % of the fractures were undisplaced or minimally displaced and most fracture patterns were transverse or oblique/spiral. a total of patients ( %) returned the questionnaire with a median follow-up of months. responders were female in . % and had a median age of years (p -p - ). in . % of cases the left side was affected. the median aofas-score was points (p -p - ), the median vas was points (p -p - ). no correlations were identified with outcome and which toe or phalangeal bone was affected, number of fractured toes, fracture type and location, articular involvement, gender, age, body mass index, smoking habits, and diabetes. in the univariate analysis a trend was found for dislocation and aofas score (p = . ). in the multivariate analysis the vas was dependent of age (p = . ) and gender (p = . ). the aofas midfoot score was not influenced by any of the parameters. conclusion: this is the first investigation using two validated outcome scoring systems to determine functional outcome. almost all toe fractures were healed without complaints at months. patient satisfaction is slightly less in younger female patients. the appendix has been one of the most common site of carsinoid tumors( ). carsinoid tm is seen incidental in appendectomised cases( , - , ) and frequently in female( , ). mean diagnosis age is between - in literature, whereas in our serise it is ( ). postoperative living prognosis is good in incidental carsinoid tumors of appendix ( ) .in our cases, additional surgical procedure was not applied because tumor is less than cm, mesoappendix is healthy, and vascular invasion was not seen in hystopathologic examination. introduction: for clinical importance, two cases are presented who were operated with diagnosis of acute apppendicitis. intraoperatively,appendixes were normal, for this reason meckel's diverticulas were explored and diverticulitis were seen. material and methods: two cases are explored retrospectively results: case :the case is years old male patient.he admitted to emergency department with abdominal pain for days.there were defans and rebaund on the right inferior quadrant of the abdomen. leucocytosis( , x /mm ), aperistaltic intestinal ans in ultrasonografic examination were seen. in the operation appendix was normal,so meckel's diverticula researched and diverticulitis was seen at th cm from ileocecal valve.wedge resection for diverticulitis and appendectomy for appendix were performed.in microscopic pathologic examination appendix was normal, and meckel's diverticulitis was seen case :the case is years old male. he admitted to emergency departmant with abdominal pain for days because his pain increased last days. he has nausia, vomiting, fever( , °c), leucocytosis( , x /mm ), defans and rebaund on the right inferior abdomen. in the operation appendix was normal,so meckel's diverticula researched and diverticulitis was seen at th cm from ileocecal valve.wedge resection for diverticulitis and appendectomy for appendix were performed.in microscopic pathologic examination appendix was normal, and meckel's diverticulitis was seen. conclusion: meckel's diverticula is the most congenital anomalies of the gastrointestinal anomalies and it was found % in autopsy ser-ies. ( ) .it is asymptomatic generally. risk of complication is - %( ). preoperative diagnosis may not be done frequently, so to delay of operation may be serious complication.( )in our clinic, we explore meckel's diverticula, over(in female) and duodenum, if we do not see pü rü lant material on the appendix. results: patients with abdominal tb were diagnosed by laparoscopy and peritoneal biopsy in cases and by laparotomy in cases. from these patients we observed peritoneal tb in cases, intestinal tb in cases, mesenteric lymph nodes tb in case. at admission patients presented complications: cases with perforations and peritonitis, case with intestinal obstruction and cases presented as ileo-cecal ''tumors'' (solved by right colectomy); other surgical procedure performed was enterectomy with either entero-entero-anastomosis, either ileo-colic anastomosis. in abdominal tuberculosis ascites was present in cases. other common findings were weight loss ( cases), weakness ( cases), abdominal pain ( cases), anorexia ( cases) and night sweat ( cases). only patients had chest radiography suggestive of a new tb lesion. in those patients with peritoneal tuberculosis subjected to operation, the findings were multiple diffuse involvements of the visceral and parietal peritoneum, white ''miliary nodules'' or plaques, enlarged lymph nodes, ascites, ''violin string'' fibrinous strands, and omental thickening. biopsy specimens revealed granulomas, while ascitic fluid showed numerous lymphocytes. postoperative management was applied by the tb medical system. all patients were treated for months by specific drug therapy, with favorable evolution. pcr of ascitic fluid was positive for mycobacterium tuberculosis (m. tuberculosis) in all cases. introduction: abdominal trauma represents an important cause of morbidity and mortality in children. conservative management is preferred in blunt trauma with hemodynamic stability although there is a risk of intestinal damage when free fluid without solid organ injury is found in image studies. early laparotomy may be unnecessary in most cases but a delay in diagnosis of bowel perforation could lead to increased rate of complications. on the other hand the presence of a penetrating abdominal trauma is considered an absolute indication of laparotomy. we present five cases of abdominal trauma treated in our department in which laparoscopy proved to be an optimal diagnostic and therapeutic tool. material and methods: chart review of our cases and literature review results: three cases of blunt abdominal trauma underwent laparoscopy. we found a small bowel perforation in one case that was repaired by externalization of the jejuna loop by one of the ports. in the other two cases we found intestinal and mesenteric contusions that were treated by peritoneal drainage. two cases of penetrating trauma underwent laparoscopy. one of them presented omentum evisceration with no other injuries and the second presented a gastric perforation that needed reconversion to laparotomy. conclusion: in our experience and according to literature, laparoscopy should be taken into account as a diagnostic procedure in blunt abdominal trauma in stable children with abnormal abdominal examination and moderate free fluid and no solid organ injury in image studies, and it could be a first and sometimes definitive approach to minimal penetrating abdominal trauma. %) patients, biliary tract injury in ( . %) patients, multiple stones in the abdomen due to perforation in ( . %) patients, inadequate technical equipment in ( . %) patients, liver injury in ( . %) patient, intraoperatively detected umbilical hernia in ( . %) patient, uncontrollable bleeding in trocar entry site in ( . %) patient, insufficient insufflation in ( . %) patient, and unstoppable bleeding of arteria cystica in ( . %) patient, respectively. conclusion: although laparoscopic cholecystectomy is the golden standard of treatment in cholecystectomy, it involves the risk of conversion to open surgery. the rate of conversion to open surgery has been reported to be between - % in many series and is considered to be % on average. in our study, we found it as . %, a rate which is close to the rate reported in the literature. chief reasons for conversion from laparoscopic to open cholecystectomy include the difficult dissection of callot's triangle due to obscured anatomy and adhesions, gallbladder perforation, bleeding, the failure to produce pneumoperitoneum, gallbladder cancer, and injury in main biliary tracts and neighboring organs. the presence of pericholecystic adhesion and liquid in acute cholecytitis cases and the presence of edema in the tissue affect regional anatomy and complicate dissection, which increases the risk of gallbladder perforation. in our study, changes due to acute cholecytitis and difficulties in the preparation of callot's triangle ranked first among the indications for open cholecystectomy with a rate of . % ( / introduction: the most difficult decision in the management of the patients with severe necrotizing pancreatitis is whether surgery is required and which of the complementary approaches to necrosectomy and drainage is appropriate. recently a great deal of data has emerged suggesting that a pulsating irrigation stream delivered at high pressure and with a high flow effectively decreases bacteria, foreign bodies, and necrotic crushed tissue in wounds and decreases the incidence of resultant wound infection. this study evaluates the effect of inter pulse jet irrigation, used for the first time in open abdominal surgery. material and methods: twelve patients presenting proven infected/ non-infected pancreatic necrosis during course of acute pancreatitis and not responding to radiological or laparoscopic drainage were prospectively offered necrosectomy using itner pulse jet irrigation. open necrosectomy and subsequent jet irrigation were performed using a midline laparotomy. in all patients, to tube drainages were placed during necrosectomy for continuous closed lavage. temporary abdominal closure using modified mesh-foil laparostomy was applied for relief of abdominal compartment syndrome. results: no intraoperative complications were recorded with a median operative time of +/- minutes. in cases two sessions of necrosectomy were sufficient to completely clear the necrotic tissues. another patients with extended retroperitoneal necrosis required irrigation procedures. necrosectomy using inter pulse jet irrigation was successful in all patients, and none required complementary surgical or radiological treatment. introduction: intra-abdominal hypertension (iah) and abdominal compartment syndrome (acs), have been described often in patients with abdominal trauma or after emergency abdominal surgical operations. we present patients with vomiting, meteorism, acute abdomen and acute respiratory insufficiency provoked by phytobezoars. aetiopathogenesis, symptoms and differential diagnosis are analyzed and a brief report of the literature is discussed. material and methods: three patients, were admitted to the emergency department of our hospital during the last year. all patients were presented with acute respiratory failure, abdominal pain, discomfort, meteorism and vomiting. the first patient, a years old man, alcoholic was admitted with meteorism, acute abdominal pain and discomfort. a fr nasogastric tube was introduced and the symptoms were remitted after gastric evacuation. the second patient suffered from bowel obstruction after closure of colostomy as a result of traumatic injury of sigmoid colon. a laparotomy was performed and a phytobezoar was revealed at the level of anastomosis. the last patient was presented with meteorism, vomiting and dyspepsia, as a result of enlarged gastric mass, revealed after endoscopy. results: gastric evacuation in the first patient revealed lt of fluid mixed with a smelly gas under pressure (iap = cmh o after evacuation) followed by washouts. laparotomy was performed in the second patient revealing a large phytobezoar at the level of anastomosis. mini laparotomy and gastrotomy in the third patient (after two unsuccessful gastroscopies) revealed large phytobezoars. introduction: the objective was the substantiation of using dcs tactics in wounded with ctmi. material and methods: in case of cranial injuries dcs tactics implied treating superficial wounds of skin, arrest of exterior bleeding and subsequent evacuation of the wounded within the first hours after getting trauma. in case of extremity injuries, dcs tactics implied first of all the operations on the occasion of gunshot injuries, including the arrest of bleeding, application of the external fixation apparatuses, application of temporary shunts for injured vessels. the burn wounds treating were carried out after helping the patient out of shock. in case of the wounded with chest injury in the presence of hemo-and pneumothorax, drainage of pleural cavity of silicone tubes with active air aspiration was fulfilled. in case of abdomen injuries after laparotomy abdominal cavity was cleaned and inspected including examination of the most probable sources of bleeding: liver, spleen, magistral vessels. on the background of unstable hemodynamics the abdominal cavity tamponage along the right and left side canals, supraliver and underliver space and small pelvis. results: thus, in accordance with dcs principles in case of ctmi, operations regarding gunshot injuries were made in the first turn, and operations connected with burns -in the second turn. the first were urgent operations. then, intensive therapy in the conditions of resuscitation unit. conclusion: the repeated operation of the second stage -final removal of lesions -was carried out after the condition of the wounded had been stabilized. introduction: the aa highlight the importance of the damage control philosophy in difficult emergency surgery situations like the perforation of an oesophagojejunal anastomosis by an oesophagojejunal tube. material and methods: man, age , rd pod after total gastrectomy with precolic reconstruction for gastric cancer (t n mxr ) in another institution. no significant past diseases. mechanically ventilated, in septic shock, with purulent drainage from right hemithorax and blue drainage from right abdominal upper quadrant, after ''methilene blue'' swallow. distended abdomen. relaparotomy with median frenotomy (pinotti) and damage control procedures for oesophagojejunal and cardiophrenic pleural sinus perforation by an esophagojejunal tube, with right pleural empyema, mediastinitis and peritonitis: primary closure of the perforation, washing and drainage of the pleura, mediastinum and peritoneum, delayed abdominal closure (dac, rotondo and schwab) and intensive care unit (icu). on th pod, revision of the mediastinum and peritoneum, no evidence of fistula: internal pleural drain retired, fibrin glue and collagen placed to protect the anastomosis, dac and icu. on th pod, anastomotic leak: a ttube (kehr) has been placed as a minimal drainage procedure; dac and icu. on th pod, descendent feeding jejunostomy and abdominal closure. on th pod, subfrenic abscess on ct scan: surgical drainage through the upper third of the previous closed laparotomy. on nd pod, intestinal suboclusion: drainage jejunostomy above the feeding one. on st pod, right pleural drainage: oesophagoscopy, t-tube removed and expansible silicon covered oesophageal prosthesis inserted, covering the anastomotic fistula. on nd pod, patient left the icu. results: on th pod, patient sent back to the institution where he has been operated first. on th pod, endoscopical removal of the prosthesis with baritated swallow control, with patient sent back home. conclusion: this case highlights the importance of the damage control philosophy in difficult emergency surgery situations like the perforation of an oesophagojejunal anastomosis by an oesophagojejunal tube. disclosure: no significant relationships. y. el-ashaal , a. hefny , y. saadeldinn , f. m. abu-zidan al-ain hospital, department of surgery, al-ain, united arab emirates, al-ain hospital, department of radiology, al-ain, united arab emirates, surgery, department of surgery, uae university, al-ain, united arab emirates introduction: acute gastric dilatation due to superior mesenteric artery syndrome in healthy subjects is extremely rare. herein we report its sonographic findings and highlight the value of point of care bedside ultrasound in such a case. material and methods: a -year old female was admitted to al-ain hospital complaining of epigastric pain of two days duration following excessive eating. she was nauseated but could not vomit. succussion splash was positive. bedside ultrasound has shown a hyperactive duodenum, a distended stomach compressing on the ivc, and a narrowed angle between the superior mesenteric artery and the aorta. these findings were confirmed by abdominal ct scan. the angle between the aorta and superior mesenteric artery was only â -p p . gastrographin follow through has shown complete obstruction of the third part of the duodenum. nasogastric tube immediately drained ml of yellowish fluid. results: five days later gastrographin follow through has shown free passage of the dye to the small intestine with significant reduction in the stomach size. the patient was discharged home in a good condition. conclusion: bedside ultrasound has proven extremely useful for both the diagnosis and management of this rare case. introduction: a rare and potentially lethal complication during right hemicolectomy material and methods: a year-old male, underwent a right hemicolectomy due to malignancy in the cecal region. during the operation the relatively constant venous anastomosis between the middle colic vein and the inferior pancreaticoduodenal vein close to the lower border of the pancreas was injured, resulting in excessive haemorrhage. in the effort to manage the bleeding, the superior mesenteric vein (smv) was torn, and after multiple unsuccessful efforts to repair the vein, we finally had to ligate the smv. the operation was completed by typical right hemicolectomy and the abdomen was closed. five hours later the patient showed acute distention of the abdomen together with respiratory distress. due to increased abdominal pressure (> cm h o), the patient was taken back to the or. the small bowel was edematous, bluish but viable. the abdomen left open and was closed by using the vac. the patient was taken to the icu. six days later the small bowel returned to normal colour and thickness, but the generalized edema made the closure of the abdomen impossible. by day ten the patient was on full enteral feeding, and was taken to the or, where free partial thickness skin grafts were used to close the abdomen. results: the patient was extubated by day sixteen and was taken to the rehabilitation center. conclusion: accidental injury of the venous anastomosis between the middle colic vein and the inferior pancreaticoduodenal vein close to the lower border of the pancreas, may prove a potentially life threatening condition. we present this case in order to point out this rare complication of right hemicolectomy. aimed to explore the influence of different surgical diagnosis groups on long term health status and to make comparisons with general population norms. material and methods: qol was measured in all surviving surgical icu patients admitted to a dutch teaching hospital between and . patient-reported data on qol were collected with the euroqol- d + after a mean follow up of (range - ) years. patient characteristics, surgical diagnosis group, length of icu stay and survival were prospectively registered. eq-utility scores (eq-us), eq visual analoge scales (vas) and prevalences of domain-specific health problems were calculated. the effect of surgical diagnosis group on eq-us/eq-vas was assessed by multivariable generalized linear regression analysis. logistic regression was used to explore the influence of surgical diagnosis group on domain specific health problems. long term quality of life of surgical icu patients was compared to an age-and sex-matched general dutch population using the t-test analysis. results: patients survived the icu and were available for follow up. in ( %) patients the health-related qol was measured. for all surgical groups combined, after - years nearly half of all patients still suffered from problems in the dimensions mobility ( %), usual activity ( %), pain ( %) and cognition ( %). compared to the age-and sex matched general dutch population hrqol was worse with a difference of . on the eq utilities score (range - ). oncological surgery patient had the best (eq-us . ) and vascular patients had the worst (eq-us . ) hrqol. trauma (odds ratio between . - . ) and vascular surgery ( . - . ) showed significantly increased prevalences of problems in mobility, self-care, usual activities and cognition. conclusion: more than years after a surgical icu admission, quality of life of this patient population is largely reduced. many patients still suffer from a variety of health problems, including decreased cognitive functioning. treatment advances should be made to reduce the current health deficit of surgical icu survivors compared to the general population. disclosure: no significant relationships. u. sekmen , g. altaca , s. aktas kalayci , g. moray general surgery, baskent university, ankara, turkey, general surgery, baskent university, ankara, turkey, internal medicine and division of gastroenterology, baskent university, ankara, turkey introduction: predicting the prognosis in severe acute pancreatitis is cruciate in order to constitute effective treatment strategies. material and methods: thirteen consecutive patients admitted with the diagnosis of severe acute pancreatitis according to glasgow or ranson criteria were evaulated. we searched the prognostic values of age, gender, etiology of pancreatitis, comorbidity and labarotory values and their affects on complications and length of hospital stay. results: mean age was , years (range: - yrs). etiology was biliary in patients ( after ercp). acute cholecystitis was also present in patients. patients had diabetes mellitus. two patients had percutaneous cholecystestostomy. five patients had ercp at a mean of , days after admission. cholecystectomy was performed in patients, either at the first admission (n: ) or after - weeks. mean wbc, alt, ast, and ldh values on admission and mean highest hscrp levels and mean lowest serum calcium (ca) levels in the first hours were /mm , u/l, u/l, u/l, and mg/l and mg/dl, respectively. pancreatic necrosis ( , %) was diagnosed by computerised tomography in patients ( / in diabetics, / in nondiabetics); a total of patients ( %) had systemic complications. mean ldh ( u/l vs u/l) and lipase levels ( u/l vs u/l) were higher in patients who developed necrosis, though not statistically significant. other parameters were similar in patients with or without necrosis. two patients who had pancreatitis due to ercp underwent pancreatic necrosectomy. median hospital stay was days (range: - days). all patients survived. mean highest hscrp and lowest ca levels in the first hours correlated significantly with the hospital stay (r: . p: . for hscrp, and r: - . p: . for ca). conclusion: although we have a limited number of patients, we may conclude that high levels of ldh, lipase, hscrp and low levels of ca can be used as predictive factors for severe pancreatitis. pancreatitis seen after ercp and in diabetic patients tend to be more severe. abdomen. abdominal imaging reveals persistent bleeding and multiple bone lesions compatible with bone hemangioma with low blood platelets count -kasabach-meritt syndrome. patient is transferred to a central hospital for arterial embolization of the right hepatic artery that is not effective. the authors describe surgical control of the bleeding without liver resection. second look surgery was undertaken with removal of hepatic packing and pringle's manoeuvre with temporary control of the haemorrhage with haemostasis and ligation of the right hepatic artery. it was needed several surgery's more with additional packing, haemostatic mesh and haemostatic products in order to control the bleeding. the patient was proposed for liver transplant during the process but was not accepted. introduction: management of splenic injury has evolved over the past years. nonoperative management has gained currency, first in children and after in adults. material and methods: we present a case of a years-old man who falled for m, haemodinamically stable, presenting pain on the left part of thorax and upper abdomen. results: the patient fall for m hours before the arrive in our er; he was haemodinamically stable (bp= / mmhg, av= bpm) and presented pain on the left thorax and left hypocondrium. laboratory showed , g/dl haemoglobin. radiologic test: laterally th left rib fracture. ct scan revealed iv grade spleen injury and perisplenic hemoperitoneum. we choosed non-operative managementafter days ct scan showed reduced dimensions of dilacerated spleen injury and no hemoperitoneum. the patient status was stable during the days hospitalisation. imagistic control after month: homogenous spleen structure. conclusion: the haemodinamic status of the patient is the most reliable criteria for non-operative management, not ct aspect of the injury. years old) submitted to upper partial splenectomy for blunt trauma. residual spleen after surgery was / and / respectively. ceus was preceded by standard b-mode us with color flow mapping in all cases; videoclips of each exam were stored for forensic medicine issue too. mean time for ceus exam was - minutes. results: ceus allowed to recognize regular perfusion of the residual spleen in both patients. conspicuity of ceus imaging was high and impressive. homogeneous complete distribution of the contrast medium in the parenchyma was observed on day in both pts. ceus follow-up on day and did not add any supplementary information. pts were discharged on day and day respectively, without indications for vaccinations or antibiotic prophylaxis. conclusion: ceus is an effective method for assessing perfusion of the residual spleen after partial splenectomy. ceus can be performed bedside by the surgeon in the early po period or on an outpatient basis. imaging interpretation is immediate and distribution of the contrast medium assure about viability of the splenic tissue. ceus imaging allowed us to omit prophylactic vaccinations. it is the first description of the use of ceus in this particular setting. introduction: injuries to the abdominal visceral vessels are uncommon but devastating entities that incur extremely high rates of mortality.the rarity of these injuries prevents many trauma centers and trauma surgeons from developing a significant knowledgement learning curve. the authors describe a case with abdominal visceral vascular abdominal blunt trauma, presented with laceration in the confluence of inferior mesenteric vein and splenic vein, laceration of the hepatic artery associated with hepatic hematoma, periduodenal and peripancreatic hematoma. the routine principles of vascular surgery were applied to the management of these visceral blood vessels injuries :adequate exposure, proximal and distal control, dé bridement of the vessel wall,meticulous arteriorraphy and venorraphy with fine monofilament vascular sutures and early instituition of damage control resulting a successfull repair. material and methods: the authors made a review of several large series in the literature wich are also consistent with a low incidence of visceral vessel injuries. vascular trauma is complex and ideally is carried out by experts in a multidisciplinary environment a broad spectrum of surgical specialities are involved in the ressuscitative phase of trauma care including general, trauma, thoracic and vascular surgery . despite a relatively low incidence of vascular trauma in portugal, the results are satisfactory because of active and early management by surgeons on call, weather with vascular training or not, treating all kinds of vascular surgical emergencies. a trauma and emergency surgical speciality is a challenge. results: little information describing the first repair or ligation of any visceral vessel injuries can be found in the literature. visceral vascular injuries carry a significant mortality rate. vascular injury poses a small but significant challenge in portugal trauma care. opportunities such as better practise guidelines and minimum standars will allow surgeons to improve delivery of quality care to the next generation of vascular trauma victims. training in the management of vascular trauma surgery with integration of vascular and general surgeryin trauma care should optimize outcomes. conclusion: from reviews of large series dealing with the management of abdominal vascular injuries, the incidence can be estimated to be between . % to . %of all vascular injuries. few data are available describing the mortality rate for patients with portal veins injuries. te author's vision is that all vascular and general surgery trainees would eventually undertake the definitive surgical trauma care course and improve outcomes and reduce mortality. introduction: high rates of intra-abdominal pressure, has been proved to increased mortality, especially in multi-trauma patients followed laparotomy. multiple organ failure syndrome (mofs), derived by intra-abdominal hypertension, has been called abdominal compartment syndrome (acs), the epidemiology and the characteristics of which, have not been thoroughly determined. introduction: intercostal pulmonary hernias are rare and mostly resulting from complications related to the chest trauma.the authors report a case of traumatic intercostal pulmonary hernia in a -yearold man. he was admitted to the hospital as a traumatic patient after a motor-cycle accident . material and methods: beside multiple polytraumatic injuries the patient had a blunt injury to the left chest.physical examination revealed a bulge on palpation of the left chest wall.computed tomography (ct) scan of the chest revealed the protrusion of lung tissue outside the intercostal space.size of hernia, incarceration and respiratory insufficiency mandate immediate surgical intervention.postoperative course was uneventful, and there has been no sign of recurrence of hernia. results: post -traumatic lung herniation through a defect in chest wall is an uncommon injury .various methods of tratement and repair have been described, including both purely thoracoscopic to full open techniques.the authors repaired a case using a minithoracotomy. conclusion: lung hernia is an uncommon entity defined as the protrusion of pulmonary tissue and pleural membranes through defects of the thoracic wall.chest trauma is the most common cause.timely surgical intervention is critical to favorable patient outcomes.effective management, surgical approaches and repair of thoracic injuries are discussed and the available literature. of the hernia from the outside, dé bridement and closure layer-bylayer with maxon- was performed. the postoperative course was uneventful. conclusion: a tawh after blunt trauma is a rare entity. the reported incidence of acute hernia ranges from ,%- , % . in our case the tawh was already diagnosed in the trauma room. mahajna et al. reported the case of herniation of the right colon with vessel strangulation, which wasn't seen in the primary survey. a right hemicolectomy had to be performed on the nd posttraumatic day. in our case we decided intraoperatively to perform a primary reconstruction of the abdominal wall without mesh repair. the potential advantage of a mesh implantation lies in the augmentation of the abdominal wall, thereby potentially lowering the risk of incisional hernia. however, the benefits of such augmentation should be cautiously weighed against the risk of foreign body contamination when resecting bowel during the same operation. introduction: impalement is an uncommon and spectacular injury, which combines aspects of both blunt and penetrating trauma. impalement injuries from falls are rarely seen, because most of the patients die at the scene of injury. we present an unusual case in which a patient survived a perineal impalement after a fall.with reference to our latest case and discuss the initial management and the operative treatment of this rare injury according to a literature review. material and methods: a young man was working on a construction site when he suddenly lost his footing and fell m off a scaffold. he orientated such that he landed in a sitting position on a vertical aluminium u-tube, which penetrated his perineal region and stucked. upon arrival at the emergency room he was in stable condition, intubated. after the initial treatment and diagnosis according to atls a ct of the abdomen was performed; it showed a penetrating tube perianal left, from caudal into the cavity of the pelvis, the point of the tube stucked in the sacrum -in the hole of neuroforamina s . there was no intraabdominal or laceration. the patient was taken to the operating room in stable condition. the laparotomy was performed. there was no laceration detected, explorating the praesacral cavity brought out a profuse bleeding of the main pelvic vein. after the active bleeding was stopped the tube was removed from the outside. after lavage and positioning of drains, a protective loopileostoma was placed to avoid further contamination. the perineal wound was carefully debrided, drains were inserted and the wound was not completely closed by adapting stitches. a wash-out of the colon was performed, he received antibiotics and the perineal wound was rinsed daily. he was dismissed days post-trauma. results: impalement injuries result when a solid object pierces a body cavity or extremity. the object often remains fixed within the body. this case report showed a positive outcome. impalement injuries are impressive but also rare, so it is important to show an algorithm in management of such injuries. the object should be in situ during transport. in large or immoveable objects, the impaling device should be cut just above the skin. the management of the injuries depend on the particular body region of penetrating. perineal impalement often appear quite complex. these injuries may need the assistance of gynecology and urology surgery praesacral drainage and distal rectal washout is recommended. wound care is essential in the care of impalement injuries. the skin should generally left open. even uncomplicated wounds have to be treated with antibiotics. conclusion: impalement injuries are rare and treating is a challenge for the surgeon. the degree of the injury determines the functional result. strict adherence to the transportation and management principles outlined in this paper are necessary to decrease morbidity and mortility disclosure: no significant relationships. introduction: the insertion of foreign objects into the anus and rectum is a well-known phenomenon. rectal foreign bodies can present a difficult diagnostic and management dilemma. . a foreign body may be inserted by a doctor for diagnosis or treatment like rectal thermometer, enema tubes or anal packs, by the patient for self eroticism or by a third party as a result of assault or sexual activity, but the most common cause for insertion of a foreign body is sexual stimulation. , , . anorectal foreign bodies are more common in men than in women . they can be caused by a wide variety of objects, lead to variable degrees of local trauma to the surrounding tissues, rectal bleeding and can be associated with perforation or delayed injury. material and methods: in this study, in the ten years from to , we used the medical records of patients with foreign bodies in the rectum have been diagnosed and treated,at izmir teaching and research hospital,izmir. results: all patients were men.they ranged in age from to (mean age ).two of these patients had impulse body spray, two patients had bottle, one patient had eggplant,one patient had brush and one patient had wishbone (after oral ingestion) in the rectum. five objects were removal transanally extracted by anal dilatation under general anesthesia.two patients required laparotomy.one patient of these the object was high lying in the rectosigmoid and performed laparotomy.the object was removal transanally extracted by abdominal manuplation.one patient had a intraperitoneal rectosigmoidal perforation.the perforation was treated by primer suture, proximal colostomy and appropriate antibiotic therapy. routine rectosigmoidoscopic examination is performed after removal.one patient had perforation of the rectosigmoid and had lacerations of the mucosa. no patient had a mortality. conclusion: foreign bodies in rectum should be managed in a wellorganized manner. the diagnosis is confirmed by means of plain abdominal radiographs and rectal examination. manual extraction without anaesthesia is usually only possible for very low lying objects. patients with high lying foreign bodies generally require general anaesthesia to achieve complete relaxation of the anal sphincters to facilitate extraction.open surgery should be reserved only for those patients with perforation, peritonitis and impaction of the foreign body. results: definitive pathological examination confirmed the diagnosis of pancreatic pseudocyst. the patient postoperative outcome was unremarkable and was discharged from the hospital at the seventh postoperative day. conclusion: retroperitoneal and ''well protected'' location implies that a high energy traumatism is needed to injury the pancreas. the fact that in this case a non-classical injury mechanism has occurred, makes the diagnosis more difficult to reach. pancreatic pseudocyst is the most frequent complications in this type of traumatisms. effective treatment of fracture-dislocations of the olecranon requires a stable trochlear notch uncomplicated mason type-ii and iii fractures of the radial head and neck in adults. a long-term follow-up study surgical treatment of intra-articular fractures of the distal part of the humerus. functional outcome after twelve to thirty years disclosure: one or more of the authors received funding from the small bone innovations (dr) fractures of the neck of the talus. long-term evaluation of seventy-one cases tuberosity malposition and migration: reasons for poor outcome after hemiarthroplasty for displaced fractures of the proximal humerus tuberosity osteosynthesis and hemiarthroplasty for four part fractures of the proximal humerus abdominal -mdct for suspected appendicitis: the use of oral and iv contrast material versus iv contrast material only socioeconomic factors, medicolegal issues, and trauma patient transfer trends: is there a connection? are patients being transferred to level-i trauma centers for reasons other than medical necessity? the delaware trauma system: impact of level iii trauma centers improving outcomes in a regional trauma system: impact of a level iii trauma center jupiter -metaanalysis: nondisplaced scaphoid fractures. operative vs. nonoperative management(update to nov dodds -minimally invasive management of scaphoid nonunions chess -a biomechanical analysis of intrascaphoid compression using the herbert scaphoid screw system. an vitro cadaveric study is the mortality rate for septic shock really decreasing? systemic inflammation after trauma in vivo effects of a synthetic -kilodalton macrophage-activating lipopeptide of mycoplasma fermentans after pulmonary application alveolar macrophages from septic mice promote polymorphonuclear leukocyte transendothelial migration via an endothelial cell src kinase/nadph oxidase pathway macrophage inflammatory protein- alpha mediates lung leukocyte recruitment, lung capillary leak, and early mortality in murine endotoxemia fracture-dislocation of the hip joint. the nature of the traumatic lesion, treatment, late complications, and end results cervical spine trauma in the pediatric patient spinal injuries in children and adolescents long-term clinical and radiographic outcomes after open reduction for missed monteggia fracture-dislocations in children elastic stable intramedullary nailing as alternative therapy for pediatric monteggia fractures unstable diaphyseal fractures of both bones of the forearm in children: plate fixation versus intramedullary nailing delayed radial paralysis after monteggia fracture-a case report, unfallchirurg a simple modified arthroscopic procedure for fixation of displaced tibial eminence fractures a fracture of the intercondylar eminence of the tibia treated by arthroscopic fixation an analysis of different types of surgical fixation for avulsion fractures of the anterior tibial spine modified arthroscopic suture fixation of a displaced tibial eminence fracture tibial spine fractures in children fractures of the tibial spine in children seventeen-year follow-up of a reattachment of a nonunited anterior tibial spine avulsion fracture arthroscopic fixation of displaced tibial eminence fractures: a new growth plate-sparing method the mechanism of clavicular fracture: a clinical and biomechanical analysis functional outcome following clavicle fractures in polytrauma patients evidence-based orthopaedic trauma working group. treatment of midshaft clavicle farctures: systemic review of fracturese: on behalf of the evidence-based orthopaedic working group harnroongroj t, vanadurongwan v. biomechanical aspects of plating osteosynthesis of transverse clavicular fracture with and without inferior cortical defect autologous bone versus calcium-phosphate ceramics in treatment of experimental bone defects iliac crest autogenous bone grafting: donor site complications clinical results of harvesting autogenous cancellous graft from the ipsilateral proximal tibia for use in foot and ankle surgery healing and graft-site morbidity rates for midshaft clavicle nonunions treated with open reduction and internal fixation augmented with iliac crest aspiration literature review of current techniques for the insertion of distal screws into intramedullary locking nails a new fluoroscopy-free navigation device for distal interlocking screw placement disclosure: we all are surgeons at gregorio marañ ó n hospital, madrid. dr. turegano is the chief of the emergency surgery department. references: -nandapalan and al factors related to mortality in inferior vena cava injuries: a year experience disclosure: we certify that all our affiliations with or financial involvement (employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending) with any organization or entity with a financial interest. references: . blaisdell, f.w. the pathophysiology of skeletal muscle ischemia and the reperfusion syndrome: a review. references: robinson cm evaluation of consecutive patients with the extended data set of the standardised audit for hip fractures in meniscus allograft transplantation: a current concepts review homologous meniscus transplantation: experimental and clinical results cell survival after transplantation of fresch meniscal allografts: dna probe analysis in a goat model freezing causes changes in the meniscus collagen net: a new ultrastructural meniscus disarray scale meniscus replacement with bone anchors: a surgical technique meniscal allograft transplantation: long-term clinical results with radiological and magnetic resonance imaging correlations clinical evaluation of arthroscopic-assisted allograft meniscal transplantation knee joint biomechanics following arthroscopic partial meniscectomy an evaluation of a shockroom located ct scanner: a randomized study of early assessment by ct scanning in trauma patients in the bi-located trauma center north-west netherlands (react trial) overlooked spine injuries associated with lumbar transverse process fractures frequency and importance of transverse process fractures in the lumbar vertebrae at helical abdominal ct in patients with trauma traumatic lumbosacral dislocation: report of two cases references: prevalence of suicide ideation and suicide attempts in nine countries uptake and intracellular distribution of various metal ions in human monocyte-derived dendritic cells detected by newport green dcf diacetate ester biomechanical analysis of bicondylar tibial plateau fixation:how does lateral locking plate fixation compare to dual plate fixation? operative treatment of tibial plateau fractures.:five to years follow-up results treatment of high energy tibial plateau fractures with half ring external fixation combined with minimal internal fixation. nan fang yi ke da xue xue bao disclosure: no significant relationships de smet l, debeer p, degreef i. fixation of a periprosthetic humeral fracture with ccg-cable system results of non-operative and operative treatment of humeral shaft fractures. a series of cases complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. surgical technique the anteromedial facet of the coronoid process of the ulna ring d, doornberg jn. fracture of the anteromedial facet of the coronoid process. surgical technique broberg ma, morrey bf. results of treatment of fracture-dislocations of the elbow disclosure: one or more of the authors received funding from the small bone innovations (dr perilunate and axial carpal dislocations and fracture dislocations evaluation of the spanish versió n of the dash and carpal tú nel síndrome health-related quality-of-life instruments: cross-cultural adaptation process and reliability philadelphia: w. b. saunders company; . p. - . . meyer pr. complications of treatment of fractures and dislocations of the dorsolumbar spine no significant relationships. references: . general medical council. consent: patients and doctors making decisions together is informed consent effective in trauma patients is informed consent in trauma a lost cause? a prospective evaluation of acutely injured patients' ability to give consent factors affecting the quality of informed consent the impact of objective assessment and constructive feedback on improvement of labrascopic performance in the operating room united arab emirates, medical education at the main trauma hospital. results: patients were studied ( . % males) having a mean age of . years. % of patients were from the indian subcontinent and % were uae nationals. % of patients presented immediately following injury. ambulances brought only % of the patients. % of trauma took place in the street or highway, % in work places and % at home. the mechanisms of injury were road traffic collision in % and falls in %. % of injuries were to extremities, % to head, face and neck, and % to chest. the mean iss was . . the mean (range) hospital stay was . ( - ) days; ( %) patients needed icu admission of whom ( . %) died. the mean icu stay was . days (range - ). overall mortality was ( . %). conclusion: road traffic collisions and falls are the main cause of trauma admissions in al ain city. extremities, head, neck, face and chest are the main body regions sustaining injuries. disclosure: no significant relationships hip fractures in the elderly: a world-wide projection disclosure: no significant relationships. references: d. ring et al.: predictors of acute carpal tunnel syndrome associated with fracture of the distal radius pm non-surgical treatment of the distal radial fracture. is there an advantage in immobilization in degrees dorsiflexion compared to immobilization in a neutral position? janzing , l. horta emergency department, viecuir medical centre the netherlands introduction: according to the literature immobilization of collespoints where radiological (dorsal dislocation, radial inclination), functional, the necessity for surgical intervention a comparison of methods of plastic cast fixation in treatment of loco classico radius fracture. a prospective, randomized study, unfallchirurg pm buzzsaw injuries: mechanisms of damages and predisposing factors r. ziegler , w. knopp woodworking injuries: an epidemiologic survey of injuries sustained using woodworking machinery and hand tools references: beasley ls, vidal af. traumatic patellar dislocation in children and adolescents: treatment update and literature review long-term functional outcome after lateral patellar retinacular release in adolescents: an observational cohort study with minimum -year follow-up mri of traumatic patellar dislocation in children reconstruction of the medial patellofemoral ligament for the treatment of habitual or recurrent dislocation of the patella in children injuries to the inferior pole of the patella in children disclosure: no significant relationships pm results of electromagnetic fields in healing progression of delayed union in the lower extremities the effect of low-frequency electrical fields on osteogenesis references: complex trauma of the limbs with vascular injuries-olivera lupescu, mihail nagea carcinoid tumour of the appendix:an analysis of consecutive emergency appendectomies tuberculous peritonitis of the wet ascitic type: clinical features and diagnostic value of image-guided peritoneal biopsy. dig. liver dis at perforated ulcer treatment, suture of the place of prefotation was used at ( , %) people, billroth ii stomach resection at six ( , %), suture of the place of prefotation with psv at three ( , %), and billroth i stomach resection at one ( , %) patient. postoperative complications were noticed at ( , %) people. we had postoperative mortality at four ( , %) patients. recidive ulcer was registred at ( , %) patients who were surgically treated for perfored ulcer before. conclusion: ulcer perforation is an acute complication of the ulcer disease that appears most frequently after bleeding and which usually requires surgical treatment. references: . behçet disease complicated by a perforated ileal ulcer presenting as an acute abdominal emergency gastro-duodenal ulcers with perforation caused by short-term acetylsalicylic acid ingestion: case report culafiÄ à d, matejiÄ à o perforated gastroduodenal stress ulcer melinte c, dragomir c pubmed -indexed for medline] spontaneous rupture of the spleen as immediate complication in autologous transplantation for primary systemic amyloidosis delayed splenic rupture as a cause of haemoperitoneum in a capd patient with amyloidosis boluda garcà a f, calvo català ¡ j, campos fernà ¡ndez c, parra rà denas jv, gonzà ¡lez cruz mi laparoscopic cholecystectomy for acute cholecystitis disclosure: no significant relationships. references: . pokorný j. et al. urgentní medicína, . st edition: praha, galé n . stetina et al. medicína katastrof a hromadný ch neštÄ >stí pt perforation of oesophagojejunal anastomosis by venous anatomy of the right colon: precise structure of the major veins and gastrocolic trunk in cadavers pt validation of fournier's gangrene severity index score (fgsis) general surgery dobrzanska l, newell r. readmissions: a primary care examination of reasons for readmissions of older people and possible readmission risk factors pt spontaneous rupture of giant cavernous hemangioma of the liver in a patient with systemic hemangiomatosys and kasabach-meritt syndrome. an interactive and multidiscipline case b general surgery general surgery portugal introduction: hemangiomas are frequent benign tumors of the liver nonoperative management of blunt splenic and liver injury is ct grading of splenic injury useful in the nonsurgical management of blunt trauma? management of blunt splenic trauma: ct contrast blush predicts failure of nonoperative management references: . ochsner mg. factors of failure for nonoperative management of splenic injuries associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management introduction: aim. to establish the diagnostics and management trauma, ( , %) -head trauma, ( . %) -limbs injuries, and ( %) -severe shock. in cases the splenic injury was initially manifested - ( . %), and in ( , %) cases the clinical signs developed later (p < . ) practice management guidelines for the evaluation of blunt abdominal trauma: the east practice management guidelines work group diagnostic accuracy of surgeonperformed focused abdominal sonography (fast) in blunt paediatric trauma surgeon-performed bedside organ assessment with sonography after trauma (boast): a pilot study from the wta multicenter group disclosure: no significant relationships. pt incidence of abdominal compartment syndrome in patients with multiple injuries. a single institution experience koulas , o. mousafiri hatzikosta general hospital, ioannina, greece, intensive care unit, g. hatzikosta general hospital intensive care unit, g hatzikosta general hospital delayed presentation of traumatic parasternal lung hernia management of retained colorectal foreign bodies:predictors of operative intervention disclosure: no significant relationships. treatment. disclosure: no significant relationships. references: .demetriades d, velmahos g. technology-driven triage of abdominal trauma: the emerging era of nonoperative management management of high grade renal trauma: -year experience at a pediatric level i trauma center pt blunt abdominal trauma. year experience in our department greece ( , %), without spinal fractures. resection/anastomosis was permorbidity. in first group, there were deaths ( , %), cases due to intestinal injuries. the second group (without seatbelt sign) had deaths ( , %), none due to intestinal injuries but related with multiple thoracic and cranial lesions. conclusion: in this study we found a consistent evidence that ''seatbelt sign small-bowel and mesentery injuries in blunt trauma mortality reduction with air bag and seat belt use in head-on passenger car collisions disclosure: no significant relationships. references: management strategies in isolated pancreatic trauma disclosure: no significant relationships. references: enterocutaneous fistula complicating trauma laparotomy: a major resource burden the american surgeon staged management of giant abdominal wall defects injured patients -documentation of black spots j. heinzmann , u. culemann , t. pohlemann universitä tsklinik des saarlandes, klinik fü r unfall-, hand-und wiederherstellungschirurgie, homburg, saar, germany, trauma-, hand and reconstructive surgery, university of saarland, homburg, saar, germany, klinik fü r unfall-, hand-und wiederherstellungschirurgie, universitä tsklinikum des saarlandes, homburg, saar, germanyintroduction: nonunions of the tibia represent a complex problem, particularly if they occur at the distal third of the tibia. the aim of the study was to evaluate a standardized treatment concept to manage different types of nonunions of the tibia with regard to their location within the tibia. material and methods: prospective, non randomised study ( / - / ); nonunions of the diaphyseal and metaphyseal tibia (ao type / ); standardized treatment concept: diaphysis: reamed intramedullary nailing; dia-metaphyseal junction and pilon: lcp with a minimal invasive approach or an open approach plus bone grafting from the iliac crest; infected nonunions: external fixator. analysis parameters: demographic data, fracture type (ao classification), primary surgery, healing process, time to union (radiographic), complications. results: forty-eight patients ( m, f; mean age , y) with hypertrophic (primary surgery: x nail, x external fixator) and atrophic nonunions of the tibia (primary surgery: x nail, x plate, x screws and x external fixator) were included in the study. fifteen tibial nonunions had been primary treated in our department, patients had been admitted from other hospitals. seventy-three% of all nonunions were located at the distal third of the tibia ( % at the diaphyseal-metaphyseal junction, ao-classification type ; % at the pilon, ao-classification type ). seventy-five% of the dia-metaphyseal fractures and % of the pilon fractures were primary treated with an intramedullary nail. the mean time between injury and nonunion-surgery was , ( - ) months. follow up: / patients ( %) for an average time period of , months; union-rate: / (hypertrophic nonunions / ; atrophic nonunions / : re-nonunions each). complications: death by lung embolism, re-nonunion (united after second surgery), implant (plate) loosening with the need of reosteosynthesis, x varus malalignment, x valgus malalignment, x peroneal nerve lesion. conclusion: especially the distal third of the tibia still represents a high risk area for nonunions. impaired perfusion, thin soft tissue coverage, as well as the rising number of nailing even of distal tibial fractures are some of the causes. we think that the herein introduced treatment concept is effective to manage tibial nonunions. thus, the union-rate in this study population was % , . an adequate primary osteosynthesis as well as the prevention of extensive soft tissue damage during surgery are mandatory to improve the outcome of tibial fractures. besides, new therapy options as e.g. the application of growth factors and ultrasound have to be considered also for the treatment of tibial nonunions. g. heinrichs , a. p. schulz , e. wilde , r. oheim , c. jü rgens trauma&orthopedics, university lü beck, lü beck, germany, trauma&orthopaedics, university lü beck, lü beck, germany, trauma + orthopaedics, university lü beck, lü beck, germany, trauma&orthopedics, university lü beck, hamburg, germanyintroduction: high energy tibial head fractures with bicondylar involvement have a much poorer outcome compared to the other forms of tibial head fracture. soft tissues are almost allways compromised. bilateral plating carries the risk of soft tissue and bone infections. due to loss of reduction, steps or gaps might remain in the joint surfaces. aim of this study was to evaluate the clinical and radiological outcome of schatzker , and six type fractures treated with locked osteosynthesis plating. material and methods: between january und january we treated patients suffering from a tibial head fracture. in cases osteosynthesis was performed with the use of an angular stable implant, this group forms the study population. indication for locked screw plates were bicondylar fractures treated unilateral to avoid bilateral approach with double-plate osteosynthesis and tibial head fractures with a shaft involvement (schatzker ). follow-up was performed after an average of . months after surgery. we treated male and female patients with an average of . years of age ( to years). there were no patients with open fractures or primary nerve injury included in this study. operative treatment was performed after an average of . days after trauma. we used an angular stable plate fixator made from pure titanium (tifixÒ, litos, hamburg/ germany). the plate is consisting of the softer titanium grade ; the screws are made from harder titanium grade .results: there was one case of a postoperative peroneal nerve lesion with spontaneous regression after two weeks. no postoperative wound necrosis or infection occured. all patients showed bony consolidation after a mean of . weeks as judged by radiographs. additional autologous bone transplantation was not necessary. we did not observe any secondary loss of reduction or loosening of the internal plate fixator when comparing direct postoperative radiographs to those at follow up. rom of the knee did not show any restriction compared to the opposite side in patients. cases showed mild and cases a remarkable restriction of rom compared to the not injured side.applying the rasmussen score, cases achieved a good and very good result. patients had to be judged as moderate and as poor conclusion: unilateral plate fixation for the treatment of bicondylar tibial head fractures seems to offer advantages in particular concerning infection rate and implant failure in the treatment of tibial head fractures. results: the adjacent level th-l fracture was found in . % ( / patients) in kyphoplasty group and in % ( / patients) in vertebroplasty group. we did not found any serious complication but established postoperative bmd loss. we did not found any intradiscal cement leakage in cases with adjacent level fractures. intraoperative correction of kyphosis was better achieved in kyphoplasty group; pain relief was similar in both groups.conclusion: natural process of further bone loss seems to be the most influent factor for future compression fractures in elderly patients. trauma patients represent a challenge in terms of obtaining informed consent as they are often in significant pain and maybe under the influence of strong medication at the time of the consent process. we designed a prospective, randomised un-blinded control study to test the hypothesis that there would be no difference in the ability of trauma patients to recall details of the consent process whether the patients were given verbal compared with verbal and written information.material and methods: a consecutive cohort of trauma patients presenting to a major teaching hospital were recruited and randomised into two groups. group a received structured verbal information only. group b received structured verbal information and written information about the proposed procedure. all patients were interviewed within the first post operative week (mean . days) and scored on their ability to recall key facts given in the original consent interview. results were analysed using the mann-whitney u test.results: patients have been recruited. information recall was significantly improved in the group receiving written information (mean questionnaire score % vs % for verbal information alone, p= . ). patient satisfaction with the consent process was also significantly improved in the group receiving written and verbal information, with . % of patients reporting they understood the risks of surgery when they signed the consent form, compared to . % who received verbal information alone (p= . ).conclusion: written information improves patient recall of the consent process. it is a simple, cost-effective intervention with high patient acceptability. introduction: survivorship of second hip fracture patients is worse than initial hip fracture patients. however, previous studies included in-hospital mortality. the actual survivorship of initial hip fracture patients with subsequent second hip or major long bone of extremity or vertebral body fracture by exclusion of in-hospital mortality patients have not been studied. we aim to compare the actual survival of initial hip fracture patients with and without second hip or subsequent major fracture. in addition, risk factors, mortality causes, and hazards ratio of each fracture groups were studied. material and methods: in - , after exclusion of in-hospital mortality patients, initial hip fracture patients were reviewed and divided into four groups. group i, ii, iii, and iv were initial hip fracture patients with second hip, subsequent major long bone of extremity, vertebral body fracture, and without any subsequent fractures, respectively. we set group i, ii, and iii as study groups comparing the data with group iv (control group). age, gender, mobility-status, co-morbidity, causes of death, and survival years after hospitalization of last fracture treatment of each group were recorded. actual survival rate and risk factors difference between initial hip fracture with and without subsequent fracture were analyzed by chi-square test. hazards ratio differences among the groups were analyzed by cox regression models.results: there were ( . %), ( . %), ( . %), and ( . %) subjects in group i, ii, iii, and iv respectively. at one-year and one-to-five year mortality of group i were . % and . %, group ii were . % and . %, group iii were . % and . %, and group iv were . % and . % respectively. statistical analysis by using chi square test of one-year mortality and one-to-five year mortality rate showed no significant difference among four groups (p > . ). but from cox regression analysis, second hip fracture produced significant hazards ratio as . (p = . ). the actual survivorship of initial hip fracture patients with second hip or other subsequent fracture were not different from patients who have only one hip fracture. however, special care should be focused in patients with second hip fracture which produced significantly highest hazards ratio for mortality.reduction or redislocation after one week of treatment. due to the lack of sufficient patient data a statistical analysis was not carried out. it was obvious that the dorsal dislocation after reduction was worse in the dorsiflexion group. there was no obvious difference in radial inclination or functional outcome between the two groups. conclusion: mainly the dorsal inclination was worse in the degrees dorsiflexion group. a possible explanation for these results is the technique used when modeling the plaster cast. in our hands immobilization in dorsiflexion yielded poorer results then immobilization in a neutral position. due to the poor results the study was terminated prematurely. the traumatic patellar luxation in adult patients is operatively treated with medial reefing and lateral release. the value for the treatment of adolescents is still discussed controversially in literature. the aim of the present study was to evaluate the efficacy of the minimal-invasive treatment of traumatic patellar luxation in adolescents. , that was treated with acute angular shortening using a monolateral ao fixator followed by gradual correction using the taylor spatial frame (tsf). the conversion in the tsf was achieved in exchanging only two half-pins. results: the deformity was anatomically corrected without any soft tissue complications. the fixator was worn for weeks under full weight bearing while the actual correction took only days. we did not see any typical external fixator complications like pin trac infection. conclusion: acute angular shortening can lead to direct soft tissue closure without any additional plastic surgery. the accuracy the the fixator allows the gradual anatomical reduction of the fracture and simplifies the correction of the mostly multiplanar deformities. when the surgeon is familiar with the tsf even a primary treatment of such fractures could be recommended. the image control (plain x-rays, ct) revealed and definitively determined whether a two-part or three part triplane fracture in the distal tibial physis were present, the amount of the displacement, and the co-existed fracture of the fibula. the principal goal must be the anatomical reduction of the fracture initially closed and in failure opened. an open reduction and fixation with steinmann via anterior approach followed. a long-leg cast worn for initial weeks, followed by a short-leg cast for weeks. results: at a minimum of fourteen months of clinical follow -up all patients lacked complaints and had full range of motion in ankle.conclusion: these injuries occur in the adolescent age group generally slightly younger than the child with a tillaux fracture, needed good image control (ct) and must reduced anatomically and fixed. disclosure: no significant relationships. it is necessary in - % of patients. to provide dynamisation using conventional methods, it is necessary to perform one additional surgery. in this presentation it is shown one new method of selfdynamisation. material and methods: it is presented one new minimally invasive method for closed fracture reduction and one extramedullary selfdynamisable internal fixator. there is no contact between bone and internal fixator in fracture area. it has been widely investigated biomechanicaly. in clinical use it has been applied to , patients in treatment of femoral fractures. the age of patients was from to years. this internal fixator is applied by two small incisions. reduction is achieved using standard traction table or using special reduction device. this reduction device provides possibility of reduction with minimal using of fluoroscopy or even, after more experience without using of any imaging technique as fluoroscopy, ultrasound or computer navigation. results: received clinical results are promising, as it has been shown early callus formation and radiological union within the - months. it has been allowed to patients early full weight bearing. during the treatment it has been confirmed working of self-dynamisation concept (in % of patients), which probably all together with d configuration resulted in unexpectedly quick fracture healing. follow up was months ( - the severity of injury was measured by the injury severity score (iss). the outcomes for categorical variables were tested using v test and a significance level at p < . was maintained. delayed complications were defined as any complication directly attributable to the splenic injury that occurred more than hours after injury. the following data was retained: age, sex, mechanism of injury, iss, number of icu days, overall length of stay, number of blood units transfused, day of operation and discharge status. results: our study found , % incidence of delayed complications after nom. these complications include delayed hemorrhage ( cases), splenic artery pseudoaneurysm ( ) and splenic abscess ( case). the need for operation due to ongoing bleeding was retained in following situations: more than u of blood to maintain a hb higher than g/dl, systolic pressure to less than mm hg despite resuscitation and evidence of peritoneal signs. of the patients failing nom, % failed between days and and % in the first week. in all cases a splenectomy is performed with no mortality rate. the results of this study indicate independent risk factors of failure of nom: a high ct grade of splenic injury (grade iii and above) and a transfusion with more than u of blood. results: results : out of the patients suffering of liver injuries patients had grade , and grade liver injuries and were treated conservatively. patients had grade and liver injuries and were operated. patient who was initially managed conservatively was operated due to inability to control the blood loss. out of the patients suffering injuries of the spleen, were grade and grade and were successfully operated and were grade and and were treated conservatively. all patients suffering of injuries of the retroperitoneal space, unilateral kidney injuries and injuries of the hypogastrium were managed conservatively. conclusion: blunt abdominal injuries can be managed successfully and safely by conservative treatment whenever it is allowed by the circumstances. the ct scan is a very sensitive diagnostic scanning, capable of diagnosing intrabdominal haemorrhages retroperitoneal lesions as well as the extent of the organ injury and is a necessary tool for the physician in order to diagnose accurately any abdominal injury. disclosure: no significant relationships. introduction: more and more hepatic injuries are treated non operatively if the hemodinamic's and lesion's stability is confirmed. the count and the scaling of lesions doesn't directly influence surgical indications. we report about cases of blunt trauma with serious hepatic and renal lesions treated successfully with a non operative management material and methods: we treated liver and renal injury associated in a period from to . patients were admitted to tor vergata -roma and hospital universitario clínico san carlos-madrid. data collected were: age, sex, comorbidities, sequence of events, type and number of associated lesions, management, morbidity and mortality. all liver and renal organ's injuries were evaluated by abdominal ct scan with contrast and classified according to ct-based scale results: middle age was ± sd years. patient were male in ( , %) of cases. ct scale of liver lesion was °for ( , %) patient and °for two ( . %) patients. renal lesions were i°category in cases ( , %) and ii°category in patient. no ureteral or major vessels rupture were founded. all patients have been treated non operatively. a ct based follow up of lesions was planned (at admittance, after hours, after a week and after a month). the mean length of hospitalization was ± sd days. during hospitalization, patients were monitored by clinic and labs daily. all patients were dismissed in good conditions and are in in health on a months follow up. at ct follow up, one patient presented an intra-hepatic biloma, that was successfully treated with ct-guided drainage conclusion: this work support the hypothesis that the association of liver and renal lesions in a blunt abdominal trauma, doesn't necessarily influences indications for an explorative laparotomy. if an ureteral rupture is suspected, a more aggressive treatment is necessary, in order to prevent peritonitisintroduction: the aim of this study is to analyze the most frequent mechanisms of injury, the evaluation in the emergency department and the period of increase of the blunt abdominal trauma incidence. material and methods: during the last years ( - ) patients were admitted to our department for blunt abdominal trauma.the most frequent mechanisms of injury were: traffic accidents (automobile crashes and motor vehicle collisions) ( , %) work accidents ( , %) . others (fall from high altitude, beating) ( , %) we analyzed the most frequent injuries observed, the final treatment for these patients and the period of increase of blunt abdominal trauma.results: the peak incidence occurs in persons aged - years. the male/female ratio was : . the most frequent abdominal injuries regarded: spleen ( , %), liver ( , %), large bowel ( , %), small bowel ( %), pancreas ( , %). patients underwent surgical treatment ( , %). the incidence of missed injuries is quite low, one case with pancreatic injury and one with small bowel injury. during summer period a significant increase in blunt abdominal trauma incidence occurs because of the increase of population due to tourism. the initial physical examination, after appropriate primary survey and initial resuscitation with the help of diagnostic studies such as ultrasonography, abdominal ct scan, is essential for the final treatment for these patients, operative or not operative. abdomino-throcal injuries were found in ( %) patients.abdominal organ injuries were found in decreasing frequencies in small bowel( %),liver ( %),large bowel ( %), spleen ( %), major vasculer, stomach and others. thoracal injuries were found in lung and heart in and cases.one organ injury was found in ( %) patients,mostly small bowel,and these group had a good haemodynamic status.thirty-two( %) patients had two organ injuries which of them associated with lung injury.three, and < organ injuries were found in , and patients. haemodynamic unstability at presentation,and shock was found in five patients( , and organ injury in , and cases). the overall mortality was found in ( %) patients.mortality from gun injury was % from major vascular injury ,lung,pancreas and large bowel ,lung and large bowel one.mortality from penetrating trauma was % from lung and multipl abdominal organ injury ,heart ,lung,spleen and stomach injury and major vasculer injury from blunt trauma in one ( %) patient. five patients who remain haemodynamically unstable after resuscitation died intraopreoperative period.these group was not received some resuscitation, and they referred to our hospital later than hours of injury. introduction: retroperitoneal location of the pancreas makes the diagnostic of any traumatism to be difficult, especially when this is not suspected. we report on a case of blunt pancreatic trauma with months delayed diagnosis, after injury due to maneuvers in a difficult birth. material and methods: we report on a case of a twenty-nine year-old female who consulted at the emergency department for constant right upper quadrant pain that didn't ease with any analgesic prescribed by the general practitioner. these symptoms started after a birth six months before and loss of kg of weight was associated. after reviewing the previous history of the patient, the birth had been difficult and forceps, suction pad and repeated abdominal pressure maneuvers were needed. abdominal examination showed a painful non-pulsatile mass located at epigastrium and both right and left upper quadrants. abdominal ultrasonography and enhanced ctscan were performed and demonstrated the presence of multicystic x x cm mass located between the stomach, spleen and left kidney. the high density content seemed to be blood. the mass was pushing the stomach anteriorly and no communication between both of them was shown. the splenic vein was pushed superiorly and thinned and plenty collateral circulation was evidenced. the tail and the body of the pancreas were not identified in any of the studies. the first choice diagnosis was posttraumatic complicated (with bleeding) pancreatic pseudocyst. the patient underwent emergency operation and a big cystic pancreatic mass was encountered, with plenty of collateral circulation. intraoperative biopsy confirmed that it was a pseudocyst and therefore, the majority of the cyst was removed and roux-en-y pancreatojejunostomy was performed. cholecistectomy was also done. introduction: unnoticed traumatic injuries produce avoidable morbidity, mortality and a higher medical cost. we present a special case of the reconstruction of a catastrophic abdomen with several intestinal fistulae and giant abdominal wall defect. material and methods: we present the case of a year old woman with blunt thoraco-abdominal trauma secondary to a road traffic accident. several lower left rib fractures, a fast echo with free fluid without solid organ injury and fractures of l and l were seen in the initial assessment. on the third day surgery was required due to septic shock with diffuse peritonitis due to a jejunal laceration and section of the body-tail of the pancreas. simple suture of the jejunal laceration, distal pancreatectomy, and abdominal packing without closure of the abdomen was performed. she developed several intestinal and colonic fistulae. over surgical procedures were performed on her and she was discharged months later with night parenteral nutrition, a closed abdomen by secondary intention and intestinal fistulae. she was readmitted a year later for reconstruction. we performed monoblock resection of the abdominal wall and the fistulized loops, subtotal colectomy and bowel transit reconstruction with three enteroenteric and an ileosigmoid anastomosis, leaving , m of small bowel. abdominal plastia with permacol mesh was also performed. results: surgical time was of minutes and oral tolerance was initiated on the th postoperative day. she was discharged on the th day postop. the only complication was a fever secondary to infection a central venous catheter on the rd day. key: cord- -l n is authors: nan title: poster sessions - date: - - journal: intensive care med doi: . /s - - - sha: doc_id: cord_uid: l n is nan total protein concentration in bal increased significantly and led to peak at ± mg/ml hour after intubations . mucin concentration was highest at hour after ventilation ( . ± . mg/ml). bal sp-a concentration ratio increased about times after hour ventilation. compare to mg/ml total protein, the ratio was . ± . in hour later, and . ± . in hours after ventilation.the change of bal wbc level led to peak in after hour ventilation, but blood wbc level led to peak in hours later. for elastase level both peak were hours later in bal and blood.in the caller components of bal, the neutrophyl cells were dominant in hour after intubation, but hours after ventilation, mast cells with phagocyted mucine and dusts were dominant. just introduction. coronary disease is prevalent in diabetic patients resulting in a frequency of invasive cardiac procedures four times that of non-diabetics. after cardiac surgery diabetics have twice the mortality and morbidity in early and late phases after operation. the reasons for this increased risk are poorly understood. diabetics exhibit complex abnormalities of lung structure and of the control of the cardiorespiratory system. these include pulmonary micro-vascular disease, autonomic neuropathy associated with an increased cardiovascular instability, an increased incidence of central and obstructive sleep apnoea and a reduced response to hypercapnia. this study was undertaken to determine whether at risk diabetic patients could be identified pre-operatively. methods. patients awaiting urgent cardiac surgical re-vascularisation were studied with measurement of: spirometry; percentage increase in transfer factor from sitting to lying position (tf) as an indicator of micro-vascular lung disease; overnight oximetry on air; and hour holter monitoring at present arf is one of the most spread and serious complication of postoperation period. practically the experience of carring nimv on patients with arf on early stadies of mosf is absent. until now, the criteria of uneffectiveness of nimv and indications for cessation of mask ventilation and moving of patients to mechanical ventilation are not determined. methods. there were included patients with ali in the examination. the cause of this condition was the mosf, developed in postoperative period. diagnosis of ali/ards was stated on the criteria adopted the american european consensus conference on ards ( ). presence of organs failure was determined on multiple organ dysfunction score (table ) . nimv was carried out by seances from to hours. average duration of nimv consisted . ± . hours. results. improvement of gases change was determined on patients ( %) out of . though patients with mosf were reintubated, out of which patients ( %) died lately as the result of mosf progressing. the condition of gases changing functions before intubation is one of the determining factors of prognosis. the patients reintubated under satisfactory indices of gase blood composition and early symptoms of mosf survived. patients, who were reintubated on decreased indices of arterial oxygenation under mosf progressing died in % cases ( nimv is effective method in complex therapy of arf, developing in postoperative period after cardiac surgery, that leads to significant improvement of lungs biomechanics and gases change function. progressing of mosf and storage disturbance of lung oxygenation is absolute indication for intubation and applications of special regimes of mechanical ventilation. references. . bernard gr, artigas a, brigham kl. am j respir crit care med - : : introduction. several bioimpedance cardiac output systems have been developed in the past in order to measure cardiac output in a wide variety of clinical situations. however, open thorax surgery negatively influences the accuracy of the measurement of thoracic electrical bioimpedance cardiac output (teb-co) ( ). the purpose of the present study was to evaluate the performance of a new bioimpedance cardiograph hl- (vrije universiteit medical centre amsterdam and hemologic amersfoort, the netherlands), using a new algorithm and a new electrode configuration, during open and closed chest in cabg patients, comparing teb-co with transcardiopulmonary thermodilution (tcpco). methods. after hospital ethics committee approval and written informed consent, fourteen patients with preserved lv-function at cineangiography or echocardiography, scheduled for coronary artery bypass grafting were included. for the teb system two current injecting electrodes were placed on the forehead and the left thigh respectively and two voltage sensing electrodes were used: one above the left clavicle at the base of the neck and the other at the level of the xyphoid in the left midaxillary line. for tcpco, the picco-system (pulsion, munich, germany) was used. hemodynamic measurements were recorded at three time points: t before the operation, t after weaning from bypass before sternal closure and t after sternal closure. teb-co and tcpco data were compared with pearson's r correlation coeficient. p< . was considered significant. bland-altman analysis ( ) with bias and precision was carried out at each of the three time points. results. ten males and females with age ± yr, body weight ± kg and height ± cm were included. a total of matched data pairs were available for analysis. table shows the results of correlation, bias and precision of the measurements at the three different time points. teb consistently underestimated tcpco. at all time points, there was a good correlation between both techniques. introduction. isoflurane sedation of icu patients has previously been shown to be useful but has not come into wide clinical use for a number of reasons.a new device(the anesthetic conserving device,"acd") enables easy and safe administration of isoflurane in the icu setting.we conducted a randomised, controlled study to evaluate efficacy of sedation and environmental safety during administration of isoflurane with the acd. the acd is a modified heat and moisture exchanger connected to the breathing circuit at the endotracheal tube.isoflurane is administered via a syringe pump to a vaporiser rod in the acd.due to the physical properties of the acd most of the exhaled isoflurane is returned to the patient. mechanically ventilated patients were randomised to receive isoflurane via the acd. control patients received midazolam intravenously. all patients received morphine analgesia. quality of sedation was assessed hourly in all patients."adequate sedation" was pre-defined as a set interval on the bloomsbury sedation scale. additionally, the patient's nurse determined if sedation over the previous hour in general had been adequate or not. time from discontinuation of the sedative drug until the patient followed verbal command and to extubation was compared between groups. in the isoflurane group a gas evacuation system was used during isoflurane administration. athmospheric concentration of isoflurane was measured at . m from the acd. results. in the isoflurane group patients were adequately sedated by the bloomsbury scale for ± % of the study period, compared to ± % in the control group.nurse satisfaction in the isoflurane group was % of time and % of time in the control group.mean time to extubation after cessation of sedative administration was min in the isoflurane group and min in the control group, mean time to patient cooperation was min in the isoflurane group, and min in the control group. no significant hemodynamic changes were noted at initiation of the sedation in either of the groups. no serious complications related to sedation were noted in either group.opioid requirements in the isoflurane group were lower, with a mean rate of . . mg/hr, compared with a mean rate of . . mg/hr in the control group.mean isoflurane infusion rate was . ml/hr, with mean end-tidal isoflurane concentrations of . % ( . - . %).environmental levels of isoflurane were generally low,with a mean of . ± . ppm, well below the recommended long-term exposure limit of ppm. brief peaks (< min) between and ppm were noted during endotracheal suctioning, etc on an average of . times/hour of exposure. conclusion. isoflurane administered via the acd for sedation of icu patients is environmentally safe, requires small volumes of isoflurane and may provide better quality of sedation than midazolam. it appears to be more titratable with a shorter time from adequate sedation to extubation and ability to cooperate. references. millane ta, bennett ed,grounds rm,anaesthesia ; : - .spencer em,willatts sm,intensive care brudney c. s. , gosling p. , manji m. anaesthesia, biochemistry, anaesthesia, university of birmingham, birmingham, united kingdom increased capillary permeability has been implicated in the pathogenesis of ards and organ failures. surgery and ischaemia-reperfusion injury are both associated with stimulation of the acute inflammatory response, an early feature of which is an increase in systemic capillary permeability. the kidneys amplify small changes in systemic capillary permeability ( ).the aim of this study was to explore any association between acr during and after cardiopulmonary bypass (cpb) and subsequent pulmonary and renal function. methods. forty patients ( female) mean (range) age . ( - ) yrs undergoing coronary artery bypass grafting were enrolled. patients with severely impaired left ventricular function (< % ef) were excluded. ten ml of urine was collected at intervals from the start of surgery until hours post cpb. microalbuminuria was measured by automated immunoturbidimetry and expressed as the albumin creatinine ratio (acr: ref. range < . mg/mmol). acr was compared with po /fio ratio, hours on ippv, renal function and duration of inotropic support, using spearman's rank correlation procedure. results. two patients were excluded (death at hours and acute renal failure post cpb). the median (range) duration of ippv was ( - ) hours. patients required inotropic support for median (range) ( - ) hours. median (range) acr increased during surgery and was maximal minutes post cpb. (table) two hour acr was inversely correlated with the mean po /fio ratio up to hours (rs = - . p = . ). two and hour acrs were both positively associated with duration of ippv (rs = . p = . and . p < . respectively). acr at and hours were associated with serum creatinine hours post cpb, (rs = . p = . , rs = . p = . respectively). acr at , and hours post cpb were associated with serum creatinine hours post cpb (rs = . p = . , rs = . p = . and rs = . p = . respectively). there was no significant association between duration of inotropic support and acr at any time point up to hours. conclusion. cpb leads to a perioperative microvascular insult, causing increased capillary permeability which influences later pulmonary and renal function. these rapid changes in microvascular permeability can be monitored as the acr, and in the patient group studied, the magnitude of the acr as early as hrs post cpb is associated with later organ function. acr may provide a tool allowing early identification of patients at risk of developing organ dysfunction, who may benefit from early intervention aimed at modifying the inflammatory response. acute lung injury (ali) is a major complication of gram-negative bacterial sepsis. to date, bacterial lipopolysaccharide has been held responsible for triggering ali ( ). whether additional bacterial toxins play a role in the development of acute pulmonary inflammation during gram-negative sepsis remains an unresolved issue. flagellin, a principal component of bacterial flagella, has been recently shown to elicit immune responses via activation of the toll-like receptor ( ). we have newly found that flagellin induces an expression of icam- and a massive production of il- by human lung epithelial cells. in mice, flagellin produces a severe acute lung inflammation with local release of pro-inflammatory cytokines, accumulation of inflammatory cells and increased pulmonary permeability that was more pronounced than following endotoxin ( ). the purpose of the present investigation was to evaluate the influence of flagellin on lung fluid filtration in rats. wistar rats ( - g) were exposed either to intravenous injection of flagellin . - mg/kg or corresponding volume of normal saline (controls). after - h, the rats were anesthetized and the lungs were isolated. the isolated lungs were ventilated under a normoxic condition and perfused with homologous blood ( ºc) at a constant flow for h or until development of irreversible edema. airway pressure, pulmonary arterial pressure, pulmonary vascular resistance, and changes in the lung weight were assessed. the increments in outflow pressure of . kpa for min were used to determine the fluid filtration rate and filtration coefficient in the lungs every min ( ). flagellin induced a dose-and time-dependent increment in the lung fluid filtration rate. in parallel, flagellin markedly increased airway pressure, pulmonary arterial pressure, pulmonary vascular resistance, and filtration coefficient. in contrast to the control lungs, all the lung preparations from flagellin-treated animals developed irreversible edema within the first two hours of perfusion. in isolated blood-perfused rat lungs, flagellin enhances fluid filtration, most likely, through elevation both of pulmonary microvascular permeability and hydrostatic pressure. the present study provides further evidence that flagellin may contribute to the development of sepsis-associated ali. . whether protein c conversely affects eosinophil function has not yet been reported. we investigated the effects of protein c and activated protein c on chemotaxis of eosinophils. possible involvement of endothelial protein c receptor (epcr) in the regulation was studied by using specific epcr antibodies. for preparation of eosinophils we used macs cd+ microbeads according to the manufactor's protocol. chemotaxis assays were performed using a -well boyden microchemotaxis chamber in which a -micrometer pore sized cellulose nitrate filter separates the upper and the lower chamber. eosinophils were pretreated by various protein c preparations with or without epcr antibodies, followed by washing and assessment of their migratory responses toward eotaxin. protein c and activated protein c exerted no significant chemotactic effect on eosinophils. however, eosinophils pretreated with protein c or activated protein c showed a sigificantly reduced response to the specific chemoattractant, eotaxin. moreover, this effects of protein c and activated protein c were inhibited using an antibody against epcr. conclusion. protein c as well as activated protein c inhibit the chemotactic effect of eotaxin on eosinophils via mechanisms involving epcr. this result indicates that protein c as well as activated protein c may decrease the number of eosinophils in tissue and thereby inhibiting inflammation and coagulation. deleterious effect of severe sepsis may be related to an oxidative stress, particularly related to peroxynitrite. selenium (se) toxicity is supposed to be related to oxidative stress through reaction with thiols. we perform a study to compare these toxicities. methods. wistar rats were studied. after day quarantine lipopolysaccharide (lps) or se was administered intraperitoneally in ml saline water. lps and se were administered in groups of rats with increasing doses from to mg/kg for lps, and from . to . mg/kg for se. mortality was observed at hours. animals were sacrificed under halothane. blood samples were taken in surviving rats of each group. nitric oxide (no) and nitrotyrosine (nit), a marker of oxidative stress especially related to peroxynitrite, were measured by elisa techniques, and plasma se concentration using atomic flame absorption. results. septic rats were rapidly sick. they rolled up into a ball. their fur was dull, and stood on end. they were asthenic and had diarrhea. at autopsy, intestinal abnormalities, and in some rats echymotics dots and hemolytic plasma were observed. rats were dehydrated. se rats developed an encephalopathy the first day and later recovered. se rats were lively, and seemed to required higher level of halothane for induction. ( )however the mechanisms responsible for this alteration remains under investigation. depressed micochondial respiration has also been found in different tissues during sepsis. ( ) the objective of this work was to study diaphragmatic function in rats after peritoneal sepsis and to correlate these findings with diaphragmatic mitocondrial respiration. cecal ligation and perforation was done under general anesthesia in wistar rats (septic group, n= ) . after hours the animals were monitored for arterial blood gases, systemic hemodynamia and body temperature. then, they were sacrified and the diaphragm force-frequency curves were obtained in vitro before and after fatigue. contraction time and relaxation time were also measured. mitochondrias were isolated from the diaphragm and oxygen consumption and other respiratory indexes were studied in septic animals. the results were compared to sham operated animals (control group, n= ). the septic group showed significantly lower values of aortic blood flow, arterial oxygen partial pressure, body temperature and arterial bicarbonate (p< . ) when compared to the control group. the forces measured at the different frequencies of stimulation were lower in the septic diaphragms both before and after fatigue when compared to controls (p< . ). mitochondrial respiration evaluated by oxygen consumption and rcr indexes was found decreased in the septic animals (p< . ). diaphragmatic contractile failure along with hemodynamic, respiratory and metabolic dysfunctions was found in peritoneal sepsis in rats. diaphragmatic dysfunction could be explained by mitochondrial damage during sepsis. we speculate that mitochondrial injury and dysfunction could be related to oxidative stress in this animal model. introduction. protein c is activated by thrombin bound to thrombomodulin and this effect is enhanced in the presence of the endothelial protein c receptor (epcr). in vivo and in vitro studies have revealed that components of this pathway may also inhibit inflammatory responses. protein c was able to inhibit leukocyte adhesion to vascular endothelial cells and to reduce neutrophil accumulation in rat lungs [ ] . protein c inhibits proinflammatory cytokine release in monocytes [ ] that were shown to express epcr [ ] . soluble epcr binds to proteinase- and cd b/cd of activated neutrophils [ ] , which were previously shown to synthesize thrombomodulin but not to promote thrombin-dependent protein c activation [ ] . if protein c directly affects neutrophil functions has not jet been sufficiently demonstrated. we investigated the in vitro effects of protein c and activated protein c on chemotaxis of isolated human neutrophils and explored wether epcr may be involved. neutrophils were obtained from forearm venous blood by standard methods. leukocyte migration toward gradients of soluble attractants into cellulose nitrate micropore filters was measured using a -well microchemotaxis chamber. cells were either directly exposed to gradients of protein c or were pretreated with protein c followed by washing; then chemotaxis toward typical attractants was tested. neither protein c nor activated protein c induce chemotaxis of neutrophils. both inhibit neutrophil chemotaxis toward interleukin- , fmlp and c a and there is no significant difference in the effects of these two substances. a blocking antibody against the epcr is able to diminish the effects of protein c and activated protein c. conclusion. protein c as well as activated protein c is able to inhibit neutrophil chemotaxis. this indicates that an activation of protein c is not necessary for effects on neutrophils to occur or that neutrophils are able to activate protein c followed by migration. the reduction of the protein c effects by an antibody against the endothelial protein c receptor suggests that neutrophils express epcr capable to signal anti-migratory stimuli. during sepsis increased vascular permeability results in fluid extravasation and edema. lymphatics contribute in draining interstitial fluid from the abdomen to central circulation, but several factors (outflow venous pressure, pattern of mechanical ventilation) can act upon flow in the thoracic duct ( , ). we have tested if lymph flow is affected by endotoxin infusion under different ventilatory conditions. methods. anesthetized pigs ( . ± kg) were studied. septic damage was induced by continuous infusion of endotoxin (lipopolysaccharide e.coli, lps). abdominal lymph flow was continuously recorded by an ultrasound flow probe positioned on the thoracic duct at the diaphragm level; hemodynamics, respiratory system data, bga and intra-abdominal pressure (iap) were registered. during the first . hours of lps infusion animals were ventilated in volume controlled mode tv - ml/kg, rr bpm, peep , fio . ; during the next hours animals were divided in group (control, peep ), (peep ) and (spontaneous breathing, cpap peep ). during lps infusion lymph flow significantly increased from . to . ml/min (p< . ), cardiac output and compliance decreased from . to . l/min * and to ml/cmh o * respectively, while mean pulmonary artery pressure and iap increased from to mmhg * and to cmh o * (* p< . ). in all the pigs a positive correlation was found between iap and lymph flow (mean pearson´s coefficient . ). no correlation was found between lymph flow and central venous pressure and airway pressure (mean pearson´s coefficient . and . ). in group and lymph flow changes averaged - % and + % (versus value before randomization). cpap increased lymph flow by %. lymph flow from the abdomen increases during lps infusion: role of lymphatics in draining abdominal fluid could thus be significant during sepsis (~ ml/h are drained). these preliminary results suggest that spontaneous breathing could improve lymphatic flow from the abdomen. despite the following rise in intra-thoracic pressure, increase of peep is not associated with lymph flow reduction. animals in peep group have however shown different patterns of response, and more data are needed to clarify this aspect. introduction. : ischemia/reperfusion or sepsis is initially responsible of an acute activation of pro-inflammatory cytokines (e.g. tumour necrosis factor (tnf-)). it is followed by a rise of anti-inflammatory cytokines (e.g. interleukin- (il- )). in human umbilical vein endothelial cell (huvec) tnf-induces a mitochondrial release of reactive oxygen species (ros) in a dosedependent manner. the signalisation pathway which links tnf-at mitochondria involves ceramide pathway ( ).the goal of our study is to evaluate the action of il- on the oxidative stress induced by tnf-in huvec and to define the mechanism of this interaction. huvec were grown on plastic cover slides. at confluence they were placed in a perfusion chamber under a microscope equipped with a digital camera connected to acquisition software. cells were perfused with krebs solution containing two fluorescent probes: dichlorodihydrofluorescein diacetate (dcfh) to study the release of reactive oxygen species (ros) and propidium iodide (pi) to study cell mortality. three cell groups were studied: a reference group, a tnf-group where, after one hour stabilisation, tnf-was added ( ng/ml) in perfusion medium during one hour, · a group tnf-+ il- where il- was added to perfusion medium minutes before tnf-. variations in fluorescence were recorded each minutes for dcfh and each one hour for pi. for a non lethal concentration (pi remaining unchanged), il- reduces significantly the ros production induced by tnf-(anova for repeated measures). interleukin- has an inhibitory effect on the release of ros induced by tnfin huvec. this effect could be the result of an interaction with acid sphingomyelinase. ( ) am. j. cell. molecular biol. : - , . the immunosuppresive drug cyclosporine a (csa) is an inhibitor of mitochondrial permeability transition (mpt) which could afford protection against cell death [ ] .to test whether csa protects against endotoxin-induced myocardial apoptosis [ ], we produced i-annexin v [ ], a marker of apoptotic cells, and measured its myocardial uptake during endotoxaemia in csa-treated rats. the specificity of the signal has been previously verified with caspase inhibitors and i-human serum albumin. methods. ) i-annexin v was produced with a radiochemical purity higher than % as confirmed by hplc. ) young male sprague-dawley rats were either given iv : saline ( . ml) : control group, n= , or lipopolysaccharide (lps) from e coli ( mg/kg) ± csa ( mg/kg): lps group, n= and lps+csa group, n= . h later, all animals were given i-annexin v ( mbq, mg protein). after h, hearts were harvested and divided into apex, septum, right and left ventricle (rv, lv) for determination of i-annexin v myocardial uptake with a lkb gamma counter. results were expressed as a mean percentage ± sd of the injected dose per gram of tissue (%id/g). statistical analysis was performed by mann-withney test; a p value < . was considered as significant (*). i-annexin v myocardial uptake is significantly increased in the lps group compared to control group; there is no significant difference between the septic groups . control lps lps+csa mean + -sd . + - . . + - . * . + - . ns mortality % % % i-annexin v myocardial uptake conclusion. our results confirm that endotoxaemia is associated with significant myocardial apoptosis but fail to demonstrate that csa can reduce the cell death signal detected by i-annexin v . in spite of its action on mpt and its myocardial dysfunction reducing effect in septic rats [ ] , csa provides no myocardial protection in this model . a reducing effect of csa on endotoxin-induced mortality is not excluded but remains to be demonstrated. further investigations are needed to clarify the effect of csa on the inflammatory responses due to endotoxaemia. sepsis induced alterations in hemostasis with dysbalances in fibrinolysis may lead to capillary obstruction due to fibrin deposition. the aim was therefore to investigate regional net fluxes of the fibrinolytic enzyme tissue-type plasminogen activator, tpa, and its main inhibitor plasminogen activator inhibitor type- , pai- , in response to endotoxemia. methods. anesthetized pigs (n= ) were instrumented for registration of cardiac output (co, thermodilution) and portal (qpv), hepatic (qha) and renal (qra) blood flows (ultrasound flowmetry, transonic). blood samples were collected from the aorta and pulmonary artery as well as the portal, hepatic and renal veins. after baseline registrations, all animals were subjected to an e. coli endotoxin infusion for min, followed by a volume/norepinephrine resuscitation for min targeting baseline co levels. plasma concentrations of both total and active tpa and pai- were determined as described [ , ] and net organ fluxes (ng/min) were calculated based on in-/outflowing plasma concentrations and local plasma flow [ ]. results. endotoxemia induced a low co state and a decrease in qpv. total liver blood flow was preserved due to a concomitant increase in qha. during resuscitation co and qpv were restored to baseline values. systemic plasma levels of total tpa increased over time during endotoxemia, peaking at min, whereupon a decline occurred. however, plasma levels of total tpa had not returned to baseline values at the end of the registration period ( min). changes in systemic levels of active tpa mirrored changes in total tpa. a marked ( -fold) increase in mesenteric net release of total tpa was observed. this response was paralleled by a pronounced increase in hepatic uptake of tpa. pai- described a different response to endotoxemia. by the end of the experiment plasma levels of both active and total pai- increased. in contrast, no significant net fluxes of pai- were observed across any of the investigated vascular beds except for the hepatic vascular bed, where a net release of both total and active pai- occurred at approximately min. hepatic pai- release rates then increased progressively. conclusion. endotoxemia induced a marked increase in mesenteric release of tpa which however was not entirely responsible for the increase in systemic plasma level of tpa. the results indicate that this profribrinolytic response at later stages are counteracted by increased plasma levels of pai- and this increase is mainly derived from the hepatic vascular bed. thus, patients with altered regional endothelial functions or liver capacity prior to a septic challenge can be expected to demonstrate varying susceptibility to thrombotic events. antithrombin has been shown to reduce mesenteric venular leukocyte interactions and intestine injury in a leukocyte-dependent model of endotoxemia ( ). however, endothelial damage during early endotoxemia has been shown to be leukocyte-independent ( ). the role of antithrombin in this setting is still unknown. therefore, it was the aim of the study to investigate the effects of antithrombin on leukocyte-independent endothelial damage. in male wistar rats, microvascular permeability (mp) and leukocyte-endothelialinteraction (leukocyte rolling, lr) were determined in mesenteric postcapillary venules using intravital microscopy at baseline, and min after start of a continuous infusion of endotoxin (etx; mg/kg/hr, e.coli o :b ) (group a, n= ). therefore animals were laparotomized and the mesentery was exposed beneath an in-vivo videomicroscope. mp was measured using fluorescein isothiocyanate (fitc) labelled albumin. leukocyte-endothelial interaction was blocked in all groups by fucoidin ( mg/kg b.w.), a l-selectin-binding carbohydrate, min before laparotomy. animals in group b (n= ) received antithrombin (kybernin®, aventis-behring, germany; ie/kg b.w.) prior to baseline measurement and additionally to the procedure described above. animals in group c (n= ) received equivalent volumes of nacl . % instead of antithrombin and endotoxin. statistical analysis was performed using two-way repeated measures anova followed by the scheffé test. a p-value < . was considered significant. in groups a-c, fucoidin prevented lr during the entire experiment. however, in all groups mp increased significantly, starting at min. animals in group a were characterized by a stronger increase in mp and showed significantly higher values in mp in comparison to groups b and c at min. there were no significant differences in mp between groups b and c. leukocyte-independent endothelial damage during early endotoxemia is attenuated by antithrombin. endothelial damage during early endotoxemia has been shown to be leukocyte-independent ( ). paf (platelet-activating factor)-and serotonin-receptor antagonism has been shown to reduce leukocyte-independent macromolecular leakage significantly ( , ). nevertheless, the exact mechanisms involved in leukocyte-independent endothelial dysfunction are unknown. therefore, it was the aim of the study to investigate the effects of nitric oxide (no) on leukocyte-independent endothelial damage during endotoxemia methods. in male wistar rats, microvascular permeability (mp) and leukocyte rolling (lr) were determined in mesenteric postcapillary venules using intravital microscopy at baseline, and min after start of the experiment. in all groups, leukocyte-endothelial interaction was blocked by fucoidin. rats were randomized into groups, animals each. the experiments were divided into two parts. part i (no-inhibitor): in group a, the mesentery was superfused with a l-name superfusion ( mmol/l) combined with a continuous infusion of endotoxin (etx; mg/kg/hr) after baseline measurement. group b received a l-name superfusion of the mesentery combined with a continuous infusion of saline . %. groups c and d were treated like groups a and b but without l-name. part ii (no-donator): group x received sin- (initial bolus of mg/kg b.w. followed by . mg/kg b.w. after min-measurement) followed by a continuous infusion of endotoxin (etx; mg/kg/hr). group y was treated similar to group c and group z was treated similar to group d. statistical analysis was performed using two-way repeated measures anova followed by the scheffé test. a p-value < . was considered significant. fucoidin prevented leukocyte-endothelial-interaction in all groups. part i: pe increased in all groups, being significant in group d at min (p< . vs. baseline) and being significant in groups a-c starting at min. animals in group d were characterized by a slighter increase in mp and showed significantly lower values in mp in comparison to groups a and b at min, and to groups a-c at min. there were no significant differences in mp between groups a-c at min. part ii: pe increased in all groups being significant in group z at min (p< . vs. baseline) and being significant in groups x and y starting at min. animals in group y were characterized by a stronger increase in mp and showed significantly higher values in mp in comparison to groups x and z at min. there were no significant differences in mp between groups x and z. leukocyte-independent endothelial damage during early endotoxemia is a nitricoxide mediated event. overproduction of nitric oxide (no) is thought to be a principal cause of the hypotension of septic shock. two nitric oxide synthase (nos) enzymes have been described in blood vessels: endothelial nos (enos) and inducible nos (inos). constitutive activity of enos in the endothelium is a major determinant of blood vessel tone in health; however, in experimental sepsis it appears endothelial enos expression is reduced while smooth muscle inos expression is increased ( ). in contrast, another model of human sepsis found an increase in enos but not inos in the vessel wall ( ). to resolve this discrepancy, we studied enos and inos protein concentrations in arterial smooth muscle (asm) from patients with clinical sepsis. asm was isolated from mesenteric vessels from patients undergoing bowel resection for perforated viscus (who in the perioperative period met the accp/sccm criteria for septic shock), and from controls with bowel cancer. after mechanical removal of endothelium and adventitia, the tissue was homogenised in protease inhibitor and frozen until sufficient samples had been accumulated. western blotting was performed under reducing conditions, with membranes incubated in : (inos) or : (enos) primary antibody followed by : peroxidase labelled secondary antibody. protein bands were quantified by computer analysis of the chemiluminescence detection film, then normalised to the protein concentration of the sample prior to dilution. . enos protein was increased in arterial smooth muscle from patients with septic shock (control . . units/mg, septic . . units/mg; n= controls and septics; p = . , student's t test). in contrast, there was no increase in concentration of inos; indeed inos protein was only detectable in asm from control and septic patients. we suggest that overexpression of enos, rather than inos, in the arterial smooth muscle of patients with septic shock may be responsible for the hypotension observed in these patients. introduction. data published in the literature concerning the effect of sepsis on intestinal motility found a reduction as well as a stimulation of intestinal motility . the settings used are mostly in vivo settings, and therefore not usable to investigate intestinal motility independent from circulatory changes. the aim of our study was to evaluate the direct effect of endotoxinemia on guinea-pig small bowel motility in vitro, independent from circulatory changes, and in a second step to evaluate the effect of vasoactive drugs on motility of these septic animals. two groups of guinea-pigs received mg/kg e. coli lps intraperitoneally or hours before the experiments started. in the following hours the animals developed severe symptoms of sepsis. a control group did not receive lps before the experiments started. the small bowel of sacrificed guinea-pigs was excised, cleaned and kept in tyrode's solution. after a resting period segments of cm length were set up in parallel organ bathes containing oxygenated tyrode's solution. peristaltic contractions were elicited by perfusion of the segments with tyrode's solution at a rate of . ml/min, against an aboral resistance of pascal. the intraluminal pressure increased gradually until it reached a pressure threshold (pt) which triggered peristaltic contractions. these contractions were recorded via a pressure transducer at the aboral end of the segments. increasing concentrations of epinephrine, norepinephrine, dopamine, dobutamine, clonidine and dexmedetomidine were cumulatively added to the organ bath at min intervals. each drug was tested on different segments. statistics was performed using ncss for windows, one-way and two-way anova for repeated measures were used, p values < . were considered statistically significant. in the control group all tested vasoactive drugs had a dose-and substance-dependent inhibitory effect on peristalsis. higher concentrations of all tested substances led to a complete block of peristalsis. hours after lps application a pronounced reduction of the inhibitory effects of clonidine, epinephrine, norepinephrine and dopamine were found. the reduced inhibitory effect of dexmedetomidine was not significant. hours after lps application the inhibitory effect was reduced again, but for most substances this reduction was not statistically significant. dobutamine was the only tested substance with a more pronounced effect after hours than after hours. endotoxinemia per se did not affect small bowel motility in vitro. a possible explanation for the controversy to in vivo data demonstrating an inhibitory effect on peristalsis might be that intestinal ischemia is a common event during sepsis, and ischemia in turn might cause paralysis. a described reduced sensitivity of alpha-adrenoceptors during sepsis, or a central effect of lps additionally inhibiting peristalsis ( ), might also be responsible for our findings. high cytokine levels in patients admitted to the emergency department are associated with an increased incidence of sepsis/septic shock. patients with cardiogenic shock (cs) who often develop sepsis during icu-stay,have not been particularly studied. we studied whether plasma levels of cytokines are better predictors of sepsis/septic shock than routinely determined laboratory parameters. il- ,il- and il- plasma levels were determined in pts with cs(cardiac index < . l/min/m²,pcwp > , mean arterial pressure < mmhg or need for vasopressor therapy and signs of organ hypoperfusion) on admission to the icu (median hrs after shock onset). patients who were not surgically treated during icu stay were eligible for the study and evaluated for development of sepsis or septic shock within week after onset of cs. c-reactive protein (crp) levels and white blood cell (wbc)-counts were routinely evaluated once daily in all patients until discharge. data are given as median and interquartile range. all pts with cs were free of demonstrable infection at time of blood sampling. nevertheless % had a crp-level > mg/dl at time of enrollment. pts ( %) developed septic shock within week after onset of cs. pneumonia ( %, n= ) and catheter related infections ( %, n= ) were the leading causes of sepsis. sepsis after cs was not associated with a higher mortality rate ( % vs. %, p=ns) and sirs that was encountered in % of cs pts at the time of blood sampling did not predispose for development of sepsis ( vs. %, p=ns).crp levels,and wbc-counts as well as il- , il- and il- plasma levels on admission to the icu did not differ significantly between cs-pts who developed sepsis and cs-patients without sepsis ( in pts who survived for more than hrs (n= ) the absolute crp levels hrs after admission (crp hrs) and the increase in crp levels over hrs following icu admission (dcrp) were significantly higher in pts who developed sepsis as compared to pts without sepsis. (crp hrs: . mg/dl [ - . ] vs. . [ . - . ], p= . ; dcrp: . mg/dl [ . - . ] vs. . [ . - . ], p= . ). a dcrp > . mg/dl in hrs was more sensitive than an absolute crp level > mg/dl hrs after icu-admission for predicting sepsis ( vs. %), but both parameters had equal specificity ( %). conclusion. although many pts with cs exhibit elevated crp levels the increase in crp over hrs (dcrp hrs)is a valuable parameter to identify pts at risk for sepsis. single-point determination of cytokines on admission to the icu is not superior to follow-up determinations of crp for predicting sepsis. mitochondrial dysfunction may be implicated in sepsis-induced multi-organ failure. glycolytically-generated atp may thus be an important alternative energy source if aerobic respiration is compromised. little is known about glycolysis during sepsis, though both up-and down-regulation are reported , . we therefore examined changes in glycolytic activity in a longterm sepsis model. an instrumented, fluid-resuscitated, faecal peritonitis rat model was used. this has a -hour mortality rate of approx. %. septic (n= ) and sham (n= ) rats were sacrificed at various time points ( , , , h) and liver samples harvested and assayed for maximal activity of the rate-limiting glycolytic enzymes, hexokinase (hk), phosphofructokinase (pfk) pyruvate kinase (pk). we demonstrate an initial rise (albeit non-significant) then significant downregulation in two rate-limiting glycolytic enzymes during sepsis. the lack of difference at h may reflect prior demise of the severely ill animals. whether the degree of glycolytic down-regulation is related to subsequent death requires further study. we presume the interesting finding of upregulation seen in the sham animals to be a response to surgery and/or fluid loading. recent studies have shown that low-dose vasopressin infusion or terlipressin bolus (tp, its long acting analogue; o'brien, ) restores blood pressure and reduces norepinephrine (ne) requirements in septic shock. however they have no effect upon blood pressure in non-septic patients. exact mechanisms underlying this hyperreactive effect in sepsis patients remain unknown. we chose to investigate this using our established in vivo and in vitro models of endotoxic shock in rats. in vivo -spontaneously breathing anaesthetised male wistar rats was given either saline (sham) or endotoxin (lps) (klebsiella mg kg - ) over mins and then fluid resuscitated with colloid mls kg - hr - for mins. at mins either a bolus of tp ( . mg kg - ) or a bolus and infusion of ne ( . mg kg- and mg kg hr - ) was administered. measurement of flow and pressure (mean arterial pressure -map) were made from appropriately sited probes and transducers. in vitro -rings of rat mesenteric artery (rma) were harvested, cleaned and incubated for h with or without mg ml - lps (s. typhosa). they were then mounted in organ baths for measurement of isometric tension. cumulative concentration-response curves to phenylephrine (pe: - to - m) or vasopressin (vp: - to - m) were then constructed. statistical analysis was by anova. results. in vivo -while ne had a significantly greater effect upon map in shams compared with lps rats (p= . ), tp caused a greater increase in lps animals than shams. a bolus of tp lasted approximately mins. in vitro -lps significantly depressed contractile responses to pe compared to control tissues (max contraction controls - . ± . g, lps - . ± . g, p< . , anova). however there was virtually no contractile response to vp even in control tissues after h incubation. the cytokine cascade activated in response to injury consists of a complex biochemical network with diverse effects on the injured host. leukocyte activation after trauma is essential for inflammation. it is a multistep process in which chemokine -interleukin (il)- has pivotal role. in two-hit hypothesis, sepsis represent a second insult to a previously injured and primed host, converting a low-grade or regulated host response into an accelerated or dysregulated host response, triggering new or progressive organ dysfunction ( ). aim of this study was to assess pro-inflammatory response to trauma with or without sepsis as a second insult. twenty five patients with severe trauma (explosive and sclopetarious) who developed sepsis and patients with same kind of severe trauma without sepsis were enrolled in this study. in the trauma+sepsis group patients developed multiple organ dysfunction syndrome (mods) and died. in trauma group developed mods and died. blood was drown on the first, third and fifth day of trauma. concentrations of il- , il- , tumor necrosis factor (tnf)alpha and interferon (ifn)-gamma were determined in plasma using elisa assays. when compared trauma+sepsis group with trauma group we found statistically highly significant difference (p< . ) in il- and ifn-gamma and statistically significant difference (p< . ) in tnf-alpha concentrations; mean values of il- were -fold higher, ifn-gamma -fold higher and tnf-alpha -fold higher in patients with trauma with sepsis. il- was not statistically different (p> . ) between two groups. when compared mods group with group without mods, we found statistically highly significant difference (p< . ) in il- and tnfalpha concentrations; mean values of il- were -fold higher and tnf-alpha . -fold higher in patients with mods; il- and ifn-gamma were not statistically different (p> . ) between two groups. when compared non-survivors with survivors, we found statistically highly significant difference (p< . ) in il- and tnf-alpha and statistically significant difference (p< . ) in il- concentrations; mean values of il- were . -fold higher in non-survivors, mean values of tnfalpha were . -fold higher in survivors, il- was also higher in survivors. ifn-gamma was not statistically different (p> . ) between two groups. there is augmented pro-inflammatory response after trauma with secondary sepsis. high concentrations of il- and tnf-alpha indicated higher severity (mods). but, fatal outcome was predicted with high concentrations of il- only; survivors had higher concentrations of tnf-alpha and il- . therefore, pro-inflammatory response was partly beneficial and partly detrimental to the host. in patients with shock hypoxia is considered to be the most important cause of organ failure and death. the goal of treatment therefore is to restore tissue oxygen delivery (tdo ). due to impaired oxygen extraction in distributive (septic shock) the relation between tdo and tissue oxygenation is less conclusive. direct measurement of tissue oxygen pressure (pto ) could be of great importance in gaining a better insight in tissue oxygenation in these patients. previously published data concerning pto in patients with sepsis/septic shock are contradictory ( , ). furthermore the techniques used were not easily applicable at the bedside. in a prospective observational study we performed bedside pto measurements in patients with sepsis/septic shock to gain insight in pto values and their dynamic changes related to the course of the illness, as well as investigating the practical applicability of tissue oxygen measurement in the icu setting. pto was measured continuously during the course of the illness using polarographic clark-type o electrodes (licox catheter measurement system, gms), which were placed subcutaneous in the upper arm. disease progression over time was expressed as the daily calculated sequential organ failure assessment (sofa) score. results. five men and women with septic shock n= or sepsis n= were included. the median (range) age was years ( - ), median apache-score on the day of admission was ( - ), median duration of pto measurement per patient was , days ( - ). in none of the patients technical problems were encountered during the pto measurements. the first day of measurement the median pto of the eight patients was ( - ) mmhg. in the six surviving patients the sofa score decreased over time and this was associated with a concomitant decrease in pto to a median of ( - ) mm hg. in the nonsurvivors an increasing sofa score was associated with an increase in the mean pto to mmhg on the day of death. in seven patients linear regression analysis showed a positive correlation between the daily sofa scores and the daily mean pto : r= . , . , . , . , . , . , . . in one patient no correlation was found. conclusion. bedside pto measurements in the icu using the licox measurement system are easily performed. pto in septic patients is variable but changes with the clinical course reflected by the sofa score: clinical improvement was associated with a decrease in pto while deterioration was associated with an increase of pto . these findings suggest that in patients with septic shock decreased oxygen utilisation may play a more important role than tissue hypoxia as such. to precise the diagnostic value of macrophage migration inhibitory factor (mif) as a marker of severity in patients with sepsis and to determine relations between mif and interleukin (il- ), we conduced a prospective, observational, cohort study, in two general intensive care units. we analyzed patients with septic shock, patients with sepsis, and healthy volunteers. the median mif serum level was significantly higher in septic shock patients ( . ng/ml, range . - . ) than in sepsis patients ( . ng/ml, range . - . ) or in healthy volunteers ( . ng/ml, range . - . ). there was a direct correlation between mif and il- concentrations (r= . , p< . ). the area under the curve (auc) of the receiver-operating characteristic (roc) for prediction of septic shock was . (p< . ) for mif and . (p< . ) for il- . the auc under the roc curve for prediction mortality was . (p< . ) for mif and . (p< . ) for il- . in this trial we found significant elevated serum levels of mif in patients with septic shock and sepsis. moreover, mif levels were discriminative for septic shock and mortality, and had a direct correlation with levels of il- with a similar diagnostic accuracy. in conclusion, mif appear to be a promissory marker of severity in sepsis. high density lipoprotein (hdl) modulates the inflammatory response to injury and infection via several pathways. hdl also directly binds and neutralises lps. administration of reconstituted hdl reduces cytokine release and attenuates shock in experimental endotoxaemia ( ). the hdl associated enzymes paraoxonase (pon) and lecithin cholesterol acyl transferase (lcat), destroy oxidised lipids that induce inflammatory changes in vascular endothelium ( ). incorporation of serum amyloid a (saa), an acute phase protein, into the hdl particle during the inflammatory response, may displace these protective enzymes producing a particle with proinflammatory properties ( ). alterations in hdl composition may, therefore, be implicated in dysregulation of the inflammatory response and could influence outcome from septic shock. methods. patients with septic shock, not given tpn or propofol, were recruited. apache ii scores and icu mortality were recorded. plasma and serum samples were taken within hours of the onset of shock. hdl cholesterol was measured by microenzymatic colorimetric assay. apolipoprotein ai (apo ai) was quantified by liquid phase radioimmunoassay. pon activity was determined by measuring the rate of paraoxon hydrolysis and described as percent of a control serum pool. lcat activity was quantified by measuring the esterification rate of c labelled cholesterol. saa was measured by elisa. results were compared with those of a pool of healthy volunteers and between survivors and nonsurvivors. (mann whitney u test). results. patients were recruited. there were survivors (s) and nonsurvivors (ns). pon activity was significantly higher in s than ns: . ( . - . ) vs. . ( . - . ), p< . . saa concentration was significantly higher in s than ns: ( . - ) severe trauma and sepsis are the major sources of morbidity and mortality despite the rapid development of intensive therapy. studies have indicated that there are marked alterations in immune response in patients exposed to major trauma or prolonged surgical procedures, including altered pro-and anti-inflammatory mediator/cytokine release ( ). traumatic injury results in profound immunosuppression which predisposes the patients to sepsis and/or multiple organ dysfunction syndrome (mods). aim of this study was to assess the prognostic value of anti-inflammatory cytokines: interleukin (il)- receptor antagonist (il- ra) , il- , il- and transforming growth factor (tgf)-beta regarding severity and outcome in patients with trauma and sepsis, trauma only and sepsis only. twenty five patients with severe trauma (explosive and sclopetarious) who developed sepsis, patients with same kind of severe trauma without sepsis and patients with severe sepsis were enrolled in this study. twenty nine patients developed mods (of all patients), died. blood was drown on the first, third and fifth day of trauma or sepsis. concentrations of il- ra, il- , il- and tgf-beta were determined in plasma using elisa assays. when compared mods group (regardless of initiating insult -trauma or sepsis) with group without mods, we found statistically highly significant difference (p< . ) in il- ra and il- concentrations; mean values of il- ra were -fold higher and il- -fold higher in patients with mods; il- and tgf-beta were not statistically different (p> . ) between two groups. when compared non-survivors with survivors, we found statistically highly significant difference (p< . ) in il- ra and il- concentrations; mean values of il- ra were . -fold higher and il- . -fold higher in non-survivors; il- and tgf-beta were not statistically different (p> . ) between two groups. when compared trauma+sepsis group with trauma group, we found statistically highly significant difference (p< . ) in il- ra and il- concentrations, they were higher in trauma+sepsis group (il- ra . -fold, il- -fold). il- and tgf-beta were not statistically different (p> . ) between two groups. when compared trauma+sepsis group with sepsis group and trauma group with sepsis group, we found no statistically significant difference in either one of anti-inflammatory cytokines. our study shows that il- ra and il- are excellent predictors of severity and outcome of critical illness; higher concentrations were found in group with more severe clinical status (mods) and in non-survivors. il- and tgf-beta had no significance as predictors of severity and outcome what so ever. fifty-eight patients admitted to two medical intensive care units for reasons other than acute coronary syndrome were consecutively included and analyzed according to their troponin status. thirty-day mortality, left ventricular ejection fraction, the presence or absence of underlying coronary artery disease, and a panel of inflammatory cytokines were compared between troponin-positive and troponin-negative patients. thirty-two of critically ill patients ( %) without evidence for an acute coronary syndrome were troponin-positive. positive troponin levels were associated with higher mortality ( . % vs. . %, p < . ) and lower left ventricular ejection fraction (p = . ). troponinpositive patients had significantly higher median levels of tumor necrosis factor a, its soluble receptor and interleukin- . a subgroup of ten aplastic patients was troponin-negative at study entrance. three became troponin-positive during leukocyte recovery and subsequently died, whereas all the others stayed troponin-negative and survived. conclusion. elevated troponin is a mortality risk factor for medical intensive care patients admitted for reasons other than acute coronary syndromes. it is associated with decreased left ventricular function, and this may be mediated by tumor necrosis factor a and mediators produced by neutrophilic granulocytes. it is very interesting to notice the high correlation among protein c and atiii activity levels and sofa scores (p< . ) and the dramatic decrease of the protein c system is already firmly present hours before negative outcome (not survivors). we also register the significant alterations of c inhibitor specially in the group (ns) patients with severe candidemia and this marker assumes a significant role with an interesting clinical future . tumour necrosis factor-a (tnf) is an important pro-inflammatory mediator and high levels of this cytokine have been associated with a poor outcome from sepsis. recently, genetic polymorphisms of the tnf locus and its promoter region have been associated with the incidence and outcome of severe sepsis ; , although the results have been conflicting . we chose to investigate the association between a known functional single nucleotide polymorphism (snp) in the tnf gene promoter (- g/a, guanine to adenine substitution) and outcome in severe sepsis and septic shock. caucasian adult patients with a diagnosis of severe sepsis or septic shock on icus in the uk and from an icu in sydney, australia were recruited. whole blood was collected in edta, dna extracted and amplified by pcr using specific primers and digested with the restriction endonuclease nco . this enzyme cuts the wild type (allele g) but this cutting site is abolished by the polymorphism (allele a). the restriction fragments were then size separated, visualised and scored on agarose gels. fisher's exact test was used for statistical analysis. shedding of membrane bound tumour necrosis factor receptors to produce soluble molecules (stnfrsf a and b) is an important inflammatory control mechanism . we and others have previously demonstrated that increased levels of stnfrsf a and stnfrsf b are associated with decreased survival from sepsis. furthermore, there appears to be an association between polymorphisms of the tnfrsf b locus and plasma levels of stnfrsf b . we have therefore investigated whether polymorphisms of the tnfrsf b gene and its promoter region might influence outcome from severe sepsis and septic shock. caucasian adult patients with a diagnosis of severe sepsis or septic shock from icus in the uk and from an icu in sydney, australia were recruited. we analysed polymorphisms of the tnfrsf b gene. a single nucleotide polymorphism in exon (snp t/g) was studied by pcr-rflp, a microsatellite in intron (ms ) using an abi a sequencer and a base pair insertion/deletion in the promoter region (indel) by polyacrylamide gel electrophoresis. analyses of associations between genotype and allele frequencies and outcome were by fisher's exact test. . icu mortality was %. overall genotype and allele frequencies for each of the polymorphisms were similar to published population frequencies. there were no statistically significant differences in allele frequencies in any of the three polymorphisms between survivors and non-survivors (snp p= . , ms p= . , indel, p= . ). the mortality was lower in patients homozygous for the base pair repeat in the microsatellite polymorphism in intron (the genotype associated with high levels of stnfrsf b) (mortality % v . %) and was higher in those with the snp (t/g or g/g) (mortality . % v . %). these differences, however, did not reach conventional levels of significance (p= . and . respectively). larger studies will be required to confirm or refute associations between tnfrsf b gene polymorphisms, particularly ms homozygosity, and outcome from sepsis. when associated with end organ dysfunction, sirs is a major cause of morbidity and mortality in the intensive care unit (icu) population ( ). lps concentrations in the gastro-intestinal tracts of these patients are elevated as a consequence of bacterial overgrowth. lps processing in the mesenteric circulation may influence the systemic inflammatory response ( ). tlr is an integral part of the lps receptor complex. a tlr polymorphism (asp gly) is associated with hypo-responsiveness to lps in human bronchial epithelial cells. we examined the association of this polymorphism with clinical outcome in icu patients with severe sirs. methods. adult icu patients with evidence of severe sirs were studied. patient demographics, apache ii data, length of stay and outcome data were collected. genotype was determined using pcr amplification. statistical analysis was performed using spss . . results. patients have been genotyped of whom are still in icu. of the remaining patients, / ( %) died in icu and died in hospital after discharge from icu, giving an overall hospital mortality rate of / ( %). mean (sd) apache ii score was ( ).the tlr genotype frequencies were asp/asp . % ( / ), asp/gly . % ( / ) and gly/gly . % ( / ). the allele frequencies were asp % and gly %, similar to previously reported frequencies in caucasians. preliminary analysis revealed no significant differences between apache ii scores in patients with the asp/asp genotype (mean . , sd . ) and those with asp/gly or gly/gly genotypes (mean . , sd . ) (p= . , student's t-test). / ( %) of patients who died during the hospital episode carried the gly polymorphism, compared to / ( %) of those who survived the hospital episode (p= . , fisher's exact test, or . , % ci . - . ). conclusion. no associations with severity of illness on admission to icu, icu length of stay or hospital outcome were detected with the present sample size. recruitment is ongoing, to attain sufficient power. we aim to study genes coding for components of the lps receptor complex, which are biologically relevant to innate immunity and the development of sirs. detailed, prospective study of the role of polymorphisms in innate immunity has the potential to improve our understanding of the pathogenesis of sirs, and to influence risk stratification and management of this severe complication of life-threatening infection. the present study was designed to evaluate the effect of low dose albumin infusion vs. control on the local inflammatory response following abdominal surgery. albumin loss during surgery is a well described phenomenon. in previous experiments a loss of plasma proteins, resp. albumin was observed during abdominal surgery. intravital microscopy for five hours was used to evaluate the effect of low dose albumin on the mesenteric microcirculation. urethan-anesthetized sprague-dawley rats underwent median laparatomy and placement of a doppler flow probe around the abdominal aorta. an ileal loop was prepared for eventration onto a microscopic stage using a plastic foil technique and the mesentery was immersed with krebs-henseleit buffer( %co in n ). low dose albumin ( . g/(kg bw*h)) was given vs. control (nacl . %) during the experiment. heart rate, map, aortic blood flow were registered on a beat-to-beat basis. abg's were drawn hourly for analysis of metabolic(be), respiratory (po , pco ) and hct values. rolling and adherent leukocytes significantly increased in the control group until the end of the experiment, whereas they constantly remained on a low level in the albumin group. velocity and shear rate in the mesenteric microcirculation were significantly higher in the albumin group which was supported by increased abdominal flow and stroke volume vs. control. low dose albumin infusion significantly reduces the inflammatory response on the mesenteric microcirculation following abdominal surgery. beneficial effects on systemic hemodynamics, mesenteric microcirculation and attenuation of leukocyte rolling and adhesion in mesenteric venules could only be observed in the albumin group, whereas the inflammation progressed in the control group. iasonidou c. , pertsas e. , koletsos k. , kapravelos n. , tsagalof s. , riggos d. icu, g.papanikolaou, thessaloniki, greece optimizing patient's hemodynamics in the icu can be challenging.the pa catheter has been used to determine preload, afterload and myocardial performance. however,insertion of a catheter is not a risk-free procedure and the values obtained can in some circumstances be misleading.the use of tee in icu has been increasing.previous studies have examined the correlation between the pulmonary vein (pv) velocities and mitral valve (mv) velocities and pcwp. the purpose of our study was to evaluate the relationship between these variables during different loading conditions as assessed by tee in icu patients. ( ) patients,with a mean age of ± years, requiring mechanical ventilation were prospectively studied. in all patients a pa catheter was inserted and baseline measurements were obtained.the pv velocities and mv velocities were evaluated during three different loading conditions: ) in a control situation ) in a state of decreased preload by intravenous administration of nitroglycerin )in a state of increased preload by administration of fluids.in all patients we used the following indices from the pv velocity : s (systolic),d (diastolic), decelaration time(dt) of d wave, apv (atrial reversal) and from mv velocity: e,a wave and deceleration time of e wave. the decrease in preload resulted in a trend toward a lower amplidute of d wave peak velocity as compared with the control state and a significant prolongation of the deceleration time (p< , ).there was a decrease in height of the systolic (s) wave (p< , )and the apv (p< , ). the mv curve demonstrated a significant decrease in e velocity (p< , ) and prolongation of deceleration time (p< , ).the increase in preload resulted in a significant increase in systolic and diastolic wave in pv (p< . ) with a shortening of the dt of d wave.the apv became significantly higher (p< , ).the mv curves demonstrated a significant increase in e wave (p< , ) with a decrease in dt.there was a good correlation between d wave and pcwp (r: , ),apv wave and pcwp (r: , ) and e wave and pcwp (r: , ).a direct correlation was present between changes in e and d waves (r: , ) and changes in dt of e and dt of d velocities (r: . ). this study provides evidence that tee gives information additive to the pa catheter in the assessment of preload in an icu population. examination of pv velocities and mv velocities and their changes during different loading conditions provide additional information regarding diastolic function. this may prove useful in minimizing the use of invasive methods for hemodynamic monitoring in icu patients. further investigation is required to correlate these doppler measures with the invasive hemodynamic measurements. methods. patients with spe ( women and men), with a mean age of years (sd of ; range: to years), were studied prospectively. coloured doppler-echocardiography was performed in all cases at admission, confirming that diagnosis by perfusion gammagraphy and / or helycoidal ct scan. emboli were observed in six patients ( %): in right atrial chamber, in pulmonary artery and in output tract of right ventricle. in patients ( %) right ventricular dilatation with a mean value of . mm (sd ), and tricuspid insufficiency in ( %) with mean estimated systolic pulmonary arterial pressure of mmhg (sd ). pulmonary acceleration time was measured in patients and found shortened in all of them: milliseconds (sd ), and septal abnormal movement was detected in patients ( %). out of patients had more than one sign of severe pulmonary embolism (spe), had two sign and the other had three or more signs. echocardiography is a simple technique, which allows the diagnosis of spe by the detection of emboli in the right heart cavity and / or the objectivation of indirect signs of functional alteration of right ventricle. coagulopathy and systemic inflammatory response have been previously reported in patients after cpr ( ). the coagulopathy includes activation of coagulation and inhibition of fibrinolysis, alterations similar to those reported in sepsis where profound depletion of anticoagulation proteins have been evidenced, and had significant therapeutic consequences ( ). however, anticoagulation proteins: protein c and s (pc -ps), as well as antithrombin (at) levels were not reported after cpr. consequently, serial measurements of markers of coagulation (thrombin-at [tat], d-dimers), fibrinolysis (plasminogen-activator inhibitor : pai- ), inflammation (il- ) and endothelial injury (soluble thrombomodulin: stm) were performed in patients (age: ± years; saps: ± ) after successful cpr.analyses on biomarker levels by anova were performed. the aim was to evaluate the effect of thrombolytic therapy in massive and submassive pulmonary embolism methods. patients ( women and men), with a mean age of years (sd ), range: to , studied prospectively. diagnosis at admission was confirmed with spiral ct scan and/or ventilation-perfusion (v/p) gammagraphy. a study protocol was performed in all patients consisting of: complete analysis, electrocardiography, thorax radiography and echocardiography.one hundred milligrams of rt-pa was infused in hours due to severity of the clinical presentation: haemodynamic instability ( cases) and/or severe hypoxemia or echocardiographic abnormalities ( patients). clinical improvement was seen in the entire group. studied variables pre and postthrombolysis are shown in the table. mean arterial pressure (map); right ventricular diameter (rvd), systolic pulmonary arterial pressure (spap), acceleration pulmonary time (apt), oxygen saturation (os), fibrinogen, hematocrit and heart rate (hr). postthrombolytic changes in electrocardiogram were objectivated, showing that some abnormalities had disappeared, such as: right bundle heart block in out of patients ( %), s q t pattern in out of ( %), t wave alterations in out of ( %), and the pulmonary p in out of ( %). minor hemorrhagic complications were observed in cases; only one needed transfusion. one patient had hematuria, one other hemarthrosis, and another one suffered pericardial blood effusion (after coronary by-pass graft). we have previously shown that the measurement of gut intraluminal redox potential (eh) during progressive bleeding and reperfusion is useful to monitor changes in oxygen transport . eh could provide with a different type of information from other parameters of tissue oxygenation, such as lactate and intramucosal ph. our goal was to show the rate of decrease of eh after the occlusion of superior mesenteric artery blood flow (qintestinal). eight anesthetized and mechanically ventilated sheep were studied. eh was measured as a voltage difference using a milivoltmeter with a platinum electrode, against a reference electrode. qintestinal was measured with an electromagnetic flowmeter. after basal measurements, superior mesenteric artery was occluded and eh was continuously registered during minutes. data (mean ± sd) were analyzed with repeated measures of anova followed by dunnett's test. response time was defined as a decline greater than three sd from basal values. assessment of heart rate variability (hrv) has been used in risk stratification after acute myocardial infarction, in congestive heart failure, and in the early diagnosis of diabetic neuropathy. patients with end-stage renal disease (esrd) constitute a population of increased cardiovascular morbidity and mortality. hemodialysis patients often show signs of autonomic neuropathy. data on hrv are usually derived from -hour holter recordings. however, short term rr interval variation as measured on standard -lead ecg holds important prognostic implications in subjects with dilated cardiomyopathy. the purpose of this study was to look at short term rr variation in esrd patients, and its modification after dialysis. methods. ( male, female) patients were included in the study.all of them were in three times a week hospital hemodialysis. twenty control subjects, of similar age and gender distribution, with normal renal function and blood pressure, were recruited among ward stuff. the rr intervals were measured from a continuous -min recording of lead ii. rr variation was calculated as the standard deviation of the rr intervals (rrsd), and the coefficient of variance of the rr (rrcv), i.e. standard deviation divided by the mean rr and expressed as percentage. ecgs were also analysed for left ventricular hypertrophy (lvh). . rrsd and rrcv were significantly decreased in dialysis patients compared to controls. rrsd was . ± . vs . . p= . , and rrcv was . ± . vs . ± . , p= . . rrsd and rrcv were not affected by dialysis, but were significantly decreased in those with ecg evidence of lvh, compared to those without. rrsd was . ± . vs . ± . (p= . ), and rrcv was . ± . vs . ± . , (p= . ). rrcv was associated with mg and k postdialysis. rrsd and rrcv were inversely correlated with cornell voltage, an ecg index of lvh. hemodialysis patients present with low short term rr variation in comparison with control subjects. electrocardiographically detected lvh among esrd patients is also associated with depressed rr variability. increased intracranial pressure,as that was seen in patients with large cerebral tumors, reduces frequency of the pulse.prolapsus of the brain masses in tentorial incissura of foramen magnum and consequently bradycardia,respiratory arrest,coma and death might occur in these patients. the aim of this study is to examine the ecg changes in patients with brain tumors in regard to the kind of tumors and localisation . the study group was consisted of patients ( male and female) of average age , years (range to ). there were patients with temporal lobe tumor ( left and right), patients with frontal lobe tumor ( left and right), with parietal lobe tumor ( left and right) and with occipital lobe tumor ( left and right). ecg changes were evaluated during the first hours from receiving in the icu. large cerebral tumors confirmed with ct, and definitive diagnosis was made pathohystologicaly. the most common ecg abnormalities associated with central lesions that we found were: prolongation of the q-t interval in . % patients with right and % with left cerebral hemisphere tumor; elevated, peaked, or notched t waves in . % patients with right and . % with left cerebral hemisphere tumor; and increased p-wave amplitude in . % with right and . % patients with left cerebral hemisphere tumor. the most frequent ecg changes that we registered among rhythm and conduction disturbances were: narrow-qrs tachycardia with regular rhythm; sinus tachycardia in % with right and % patients with left cerebral hemisphere tumor, sinus bradycardia in . % with right and % with left cerebral hemisphere tumor, and incomplete/complete right bundle branch block (bbb) in % patients with left cerebral hemisphere tumor. we did not find any specific differences according to the pathohystologicaly type of the tumors. conclusion. ecg abnormalities associated with central lesions in the patients with brain tumors are not depend from the kind of tumors and side of the brain where tumor is located. in the patients with brain tumors on left side of the brain prevails incomplete and complete right bundle branch block (bbb). prolonged mechanical ventilation support (mv) is associated with increased morbidity and less cost -effective admissions in the postoperative period (po) of heart surgery (hs). study conducted to identify variables associated with prolonged mv in patients that underwent hs. methods. cohort study; consecutive patients enrolled from / to / of . inclusion criteria: patients submitted to hs and admitted to intensive care unit (icu) in use of mv. exclusion criteria: non-cardiac surgery, admission to icu in spontaneous ventilation or death during the first hours of the po. variables that could be associated with prolonged mv were pre-selected for analysis and grouped according to the period it represented. preoperative period: in-hospital stay duration, age, body mass index, gender, severity of left ventricular dysfunction (lvd), pulmonary hypertension, chronic obstructive pulmonary disease, redo, urgency for the procedure. peroperative period: surgery, extracorporeal circulation (ecc) and aortic clamping duration, fluid and blood input/output differences, type of surgical procedure, combined procedures, need for post-ecc intraaortic balloon counterpulsation (iab). admission to the icu: oxygen alveolar/arterial difference, blood oxygen partial pressure/oxygen inspired fraction ratio (p/f). first hours of po: dobutamine or norepinephrine (nor) use, blood drainage volume, lowest blood lactate measurement and prognostic scores sofa, tiss and mods. for dichotomyc variables, mann-whitney test was applied; for continuous variables we used kendall's tau non-parametric correlation test; cuzick tendency test was used to evaluate association with lvd. results. median mv duration: hours; mean duration time . hours ( to ). increased mv duration was associated with emergency surgery (p= . ), coronary artery bypass graft surgery (p= . ), need of iab counterpulsation after ecc (p= . ), use of nor (p< . ). increases in mv duration were associated with increasing values of some variables (positive correlation): age (p< . ), surgery duration (p= . ), blood input/output difference (p< . ) and sofa, tiss and mods scores (p< . ). negative correlation was presented for fluids input/output difference (p= . ) and p/f (p< . ). increased linear tendency for mv duration correlates with worsening of lvd (p= . ). conclusion. more sophisticated statistical analysis should be applied in order to determine the cause-effect correlation for these variables. interventional studies will be conducted in the following months. cerebral vasospasm is a, potentially, life threatening phenomenon after aneurysmal subarachnoid hemorrhage (sah). as part of "triple h" therapy, fenylephrine and norepinephrine in combination with dobutamine and dopamine, are used most frequently to elevate systemic arterial blood pressure (abp) in order to preserve optimal cerebral blood flow. in obtaining increased arterial blood pressure during episodes of vasospasm we altered medical therapy from fenylephrine to norepinephrine but experienced an increasing incidence of paralytic ileus. in a retrospective cohort study we evaluated clinical outcome and the incidence of paralytic ileus. methods. in - , a consecutive series of patients had surgery (aneurysmal clip ligation) within hours after sah. patients with clinical vasospasm, were subdivided into two groups with respect to medication used. group a (n= ) was treated with a combination of dobutamine, dopamine and fenylephrine (mean increase syst. abp . ± . mm hg). in group b (n= ) norepinephrine was used instead of fenylephrine (mean increase in syst. abp . ± . mm hg). we compared basic variables of the two treatment groups, and investigated the clinical outcome using the glasgow outcome scale (gos), one year after initial sah. complications were registered and compared between these treatment groups. results. the two treatment groups were evenly matched concerning age (p= . ), wfnsscore at admission (p= . ), amount of subarachnoid blood on ct-scan (fisher) (p= . ), and observed prognostic variables as hypertension (p= . ) and smoking (p= . ). the clinical outcome, was not influenced by the kind of medication used (p= . ). the incidence of paralytic ileus differed between the two groups (group a: / vs group b: / , p< , ). paralytic ileus occurred mainly in patients treated with norepinephrine ( / = . %, odds ratio= . ). no relationship was found in height of systolic abp or dosage of norepinephrine administered to these patients. we observed a significant difference in duration of administration of norepinephrine in patients, who did develop a paralytic ileus (see - . / - . p= . table: norepinephrine use in cerebral vasospasm; patients with or without paralyticileus. conclusion. -the use of norepinephrine in patients with cerebral vasospasm after sah did not influence clinical outcome, although higher blood pressure levels were reached. -norepinephrine administered during longer periods than days, increases the risk of paralytic ileus.-fenylephrine is recommended in the treatment of cerebral vasospasm after sah. amigues l. , klouche k. , massanet p. , canaud b. , béraud j. j. intensive care unit, lapeyronie university hospital, montpellier, france introduction. slow discontinuous ultrafiltration (sduf) is nown recognized as an effective complementary treatment for congestive refractory end stage cardiac failure(escf). however, an organic kidney disease is often associated with heart failure and may worsen the prognosis. this study was undertaken to compare the effects of sduf in escf patients with and without previous kidney disease. methods. patients fullfilling escf criteria with fluid overload and oliguria (grade iv nyha) were treated by sduf. sduf was performed with a double head pump monitor (bsm , hospal), blood flow rate: - ml/mn, ultrafltration rate: . to l/h. vascular access was provided by femoral silicone twin catheters. a renal replacement therapy was institued when indicated. age, sex, cardiopathy, and nephropathy were collected in each patient. patient follow up before and after sduf: systolic arterial pressure, heart rate, diuresis, total fluid volume removed, cardiothoracic index, creatinemia, blood urea nitrogen, natremia, natriuresis, mortality and average survival. datas were compared between two groups: group without and group with nephropathy. mean age was ± yo and sex ratio was / , . myocardiopathy origin was: ischemia ( ), hypertension ( ), valvulopathy ( ), primary non-obstructive cardiopathy ( ), multifactorial ( ). oliguric renal failure: fonctional in patients (group ) and associated with mild chronic nephropathy in patients prior to heart attack (group ). no significant differences in clinical and biological datas were observed between the two groups except for blood urea nitrogen: , ± in group vs , ± , mmol/l in group . during scud, hemodynamic stability was observed in both groups; diuresis and natriuresis significantly increased and remained stable at the end of the treatment despite significant decreased diuretic doses. mean sessions of sduf was , ± , in group and , ± , in group (ns). renal replacement therapy was institued in both groups but the number of sessions was significantly higher in group : , ± , vs , ± , . mortality during hospitalisation was % in group and %in group . from the surviving patients, / patients in group and / patients in group underwent a chronic hemodialysis treatment. average survival was higher but not significant in group ( , ± vs , ± months). our study sugests that sduf remains a long term beneficent treatment for patients with both escf and renal failure. paradoxically, prognosis is slightly better than in patients with isolated refractory congestive heart failure. organic renal failure could artificially worsens cardiac function by increasing diuretic resistance which may be improved by sduf. ( ). this study aims to evaluate the influence of factors affecting renal blood flow including map, cvp, pulmonary artery wedge pressure (pawp), cardiac index (ci), systemic vascular resistance (svr) and pulmonary vascular resistance (pvr) on immediate graft function. methods. consecutive patients undergoing live-related kidney transplant were included. prior to anaesthesia, a . f continuous cardiac output pulmonary artery catheter was placed via the right internal jugular vein. a continuous cardiac output monitor (baxter edwards px ) was used for haemodynamic monitoring. baseline values of the map, cvp, pawp, ci, svr and pvr were computed. data was collected at -minute intervals thereafter and immediately before and after release of the vascular clamps. the ischemia time, intravenous fluids, dopamine use and blood transfusion were noted. if warranted by low preoperative haemoglobin or increased surgical blood loss, blood was administered as ml packed cell units using leukocyte filters. the outcomes chosen for graft function were the urine output on table (uo-ot), -hour urine output (uo- ), fall of serum creatinine from the preoperative value on day (creat- ) and day (creat- ). using spss statistical software, multiple linear regression analysis was done to find the variables significantly affecting the outcome. results. the only variable found to have a statistically significant influence on uo-ot was the map. no variable had any effect on the uo- . blood transfusion had a negative influence on the fall of creatinine on day and day ( since clinically adopted during cardiac surgery, cardiopulmonary bypass (cpb) has been implicated in complement activation and postoperative acute phase reaction. corticosteroids are usually employed as an attempt to dampen these phenomena and related postoperative morbidity. methods. after informed consent previously approved by the local ethical committee, we included adult patients submitted to cardiac surgery under cpb at a non-emergency setting. preoperative risk stratification employed euroscore (es) and cleveland clinic score (ccs). methylprednisolone (mp) - mg/kg, was added to cpb priming solution for group (n= ) but not for group (n= ). blood samples were collected from all patients at anaesthesia induction (t ), (t ), (t ) and -hour postoperative (t ) for measurement of total c and c-reactive protein (crp) levels, by nephelometric technique. postoperative multiple organ score (mods) were daily registered. results. the groups were considered comparable concerning to preoperative risk stratification, length of cpb and postoperative organ dysfunction at h postoperative (mod , as well. starting from similar levels of c and crp, we did not observe significant differences between groups and concerning to postoperative levels of c . nevertheless, patients treated with mp (group ) exhibited higher crp levels at h postoperative, as shown bellow: . ± . . ± . . perioperative administration of mp failed to show evidences of beneficial effect over postoperative organ failure and complement activation. the acute phase response, expressed as crp systemic levels, instead of softened, was significantly enhanced among patients to whose cpb priming solutions was added mp. these results support a larger randomised trial to reassess routine use of corticosteroids during cpb. objective: to evaluate the influence of enteral application of an immunoglobulin enriched bovine milk preparation on endotoxin plasma levels, endotoxin neutralizing capacity of plasma (enc) and the acute phase response (il- , crp) during and after cardiac surgery in a pilot study. design, patients and methods. patients who were treated by coronary bypass operation were enrolled in a controlled randomized study. the patients were treated by enteral application of g of a bovine colostrum milk preparation per day for days preoperatively. endotoxin and enc were sequentially determined intra-and postoperatively by a chromogenic modification of the limulus amebocyte lysate test. interleukin- , crp, transferrin, alpha- macroglobulin, albumin, apo-a, apo-b, igg, iga, igm were determined by "elisa" and nephelometrically. the clinical course was followed up by daily evaluation of the apache-ii-score. main results: demographic data were comparable in both groups. no differences of the apache-ii-score ( . . verum group, and . , control group, on admission) were observed. endotoxin plasma levels and enc showed high levels at the end of the procedure and seemed to have a trigger function for the acute phase response but were not significantly reduced throughout the observation period in patients receiving the milk preparation as calculated by comparing the area under the curve. plasma levels of endotoxin binding proteins did not differ significantly. plasma levels of il- increased to maximal median values of pg/ml in the verum and pg/ml in the control group and h after surgery. a tendency to lowered il- levels was observed throughout the whole observation period for the verum group. crp-levels showed their maximum values h after the procedure and were significantly reduced in patients of the verum group (p = . ). conclusion. this study revealed that endotoxemia occurs early during an elective surgical intervention, which is followed by a subsequent increase in mediators of the acute phase reaction. the prophylactic enteral application of a bovine milk preparation for two days in cardiac patients did reduce postoperative crp-plasma levels but contrary to a former prospective double blind study in abdominal surgery did not reduce perioperative endotoxemia. one reason could be the too low application of the bovine colostrum milk preparation. to compare a possible effect of improved therapeutical approaches in head trauma, epidemiological data should be compared at certain time points. due to the legal obligation to document all in-patient treatments in germany and to forward these data in an anonymous form to the office for statistical affairs (statistisches bundesamt) it is possible to provide a nationwide epidemiological analysis of head trauma and to compare the yearly obtained data. the incidence, the mortality, and the duration of hospital stay for the treatment of all hospitalized patients suffering from head trauma were calculated and compared to the data from while considering the data obtained from the office for statistical affairs in bonn and wiesbaden. the data were investigated while separating them according to the international classification of diseases (icd- ; no. - and - ). to further elucidate the causes of altered mortality and duration of hospital stay the number of cts and mris in german hospitals in and were compared. in addition, data indicating the number of patients admitted to neurological rehabilitation centers were analyzed. the incidence of head trauma did not change between and and was calculated to be at / . . the mortality, however, decreased from . / . in to . / . in ( vs. patients). in addition, the duration of hospital stay declined in all icd- encoded subgroups including mild brain trauma. this could be due to the increased number of ct devices and mris in german hospitals (ct: vs / mri: vs ) while comparing and . the number of patients transferred from hospitals to neurological rehabilitation centers increased from in to in (+ %). it could be speculated that both improved knowledge on the field of brain trauma therapy and a higher number of technical devices allowing rapid diagnosis of brain injury or potential intracranial complications following head trauma accounted for the reduction in mortality due to brain trauma in germany from through . the decline of the duration of hospital stay especially in patients with more severe head injury could also be due to a more rapid transfer of patients with head trauma from hospitals to rehabilitation centers. therapeutic hypothermia may improve outcome in patients with severe head injury, but clinical studies have produced conflicting results. we hypothesised that severe side effects of artificial cooling might have masked positive effects in earlier studies, and treated a large group of patients with severe head injury with hypothermia, using a strict protocol to prevent the occurrence of cooling-induced side effects. methods. consecutive patients admitted to our hospital with severe head injury (glasgow coma scale (gcs) < ) in whom icp remained above mmhg in spite of therapy according to a step-up protocol described previously [ ] were included in our study. those who responded to the last step of our protocol (barbiturate coma) constituted the control group (n= ). those who did not respond to barbiturate coma (n= ) were treated with moderate hypothermia ( oc- oc). average apache ii scores were higher, and average gcs at admission slightly lower in the hypothermia group, indicating greater severity of illness and more severe neurologic injury. predicted mortality was % for the hypothermia group vs. % in controls. actual mortality rates were significantly lower: % vs. %, p< . . the difference in overall mortality between hypothermic patients and controls was statistically significant (p< . ). the number of patients with good neurologic outcome was also higher in the hypothermia group: . % vs. . % for hypothermic patients vs. controls, respectively (p< . ). these differences were explained almost entirely by the subgroup of patients with gcs of or at admission (mortality % vs. %, p< . ; good neurologic outcome % vs. %, p< . ). artificial cooling can significantly improve survival and neurologic outcome in patients with severe head injury, when used in a protocol with great attention for the prevention of side effects. these effects are especially clear in patients with gcs of or at admission. because there is likely to have been bias against the hypothermia group in this study, the positive effects of hypothermia might even have been underestimated. introduction. s b, a glial calcium-binding protein, is a serum marker of cerebral damage. posttraumatically, however, s b in increased in all patients suffereing from hemorrhagic-traumatic shock, regardless of whether trauma is cerebral or extra-cerebral. the aim of this experimental study was to determine whether the posttraumatic s b increase is caused by extra-cerebral trauma or by hemorrhagic shock and whether it is influenced by the severity of shock. hemorrhagic shock was achieved by bleeding anesthesized rats to a mean arterial pressure (map) of - mm hg through a femoral catheter and maintaining this map until incipient decompensation. subsequently, map was either increased immediately to - mm hg (moderate shock) or maintained at - mm hg until % of shed blood had been returned (severe shock), and then increased to - mm hg. resuscitation was provided after - mm hg map had been maintained for min. trauma was achieved by midline laparotomy. hemorrhagic-traumatic shock caused an early s b increase at the onset of decompensation. s b in serum was highest at the end of the min. period during which map was maintained at - mm hg and was significantly higher at all time points after severe shock than after moderate shock. in contrast, trauma (laparotomy)without hemorrhagic shock did not cause any increase of s b in serum. the posttraumatic s b increase in serum appears to be caused by hemorrhagic shock rather than by extra-cerebral trauma. regardless of whether the source of s b is cerebral, indicating cerebral damage linked to shock, or extra-cerebral, the main determinant in the clinical setting remains the severity of shock. romera m. a. , chamorro c. , silva j. a. , pardo c. , marquez j. , ortega a. intensive care unit, clínica puerta de hierro, madrid, spain in patients with non-traumatic subarachnoid hemorrhage (sah), the development of myocardial abnormalities has been widely described. however, the true incidence of myocardial injury in this group of patients is unknown yet. we analyze the incidence of myocardial injury, in this population, using cardiac troponin i (tn i) assay and also we assess if the increase in tn i concentration has prognostic value. prospective study, including all patients with non-traumatic sah admitted to our intensive care unit (icu), from december to december . serum tn i concentration was measured, at least once, within the first hours after onset of symptoms. inmunoassay based on the "sandwich" principle was employed. the chi-squared test and fisher exact test were used for statistical analysis. of the patients admitted, were excluded ( admission later than hours, absence of tni determination, previous cardiopathy or renal failure ). eighty-two patients were included in the study ( women ). mean age ± years. the tni concentration was increased in / patients ( % ). sixteen ( . % ) patients died in icu. twelve of the ( % ) with a high tni concentration and / ( % ) with a normal tni concentration died [ relative risk (rr) . ( . to . ; % confidence interval (ci); p< . ]. thirty-seven ( % ) patients had a hunt-hess (hh ) grade greater or equal to iii. poor grades of sah ( hh>or = iii ) were associated with a higher incidence of raised tni concentration ; ci %); p< . ]. among this group of poor grade patients, elevated tn i levels were associated with a higher mortality [ / ( %) with a raised tni compared with / ( % ) with a normal tni concentration; rr ( . - ; ci % ); p< . ]. however, mortality in every case was related to neurological problems. seven patients ( . %) suffered from pulmonary edema and all had elevated tni levels. echocardiography was performed in all patients, being abnormal in of them. conclusion. in our series, the incidence of myocardial injury in sah was %. this cardiac injury was more frequent among patients with severe grades of sah. elevations in tn i levels had prognostic value, being associated with a higher mortality. therefore, we should closely monitor those patients with sah who develop an increase in the tni levels. renaud e. , matéo . j. , benlolo . s. , payen . d. dept of anesthesiology and critical care, lariboisiere hospital, department anesthesiology intensive care, lariboisiere, paris, france respiratory failure is one of the major complication of acute stroke ( ). we have investigated the impact of the location stroke on respiratory failure incidence, cause of intubation and outcome. we reviewed consecutive patients with acute stroke admitted to icu from to . following data were collected, glasgow coma score (gcs), cause of icu admission, presence of acute respiratory failure (arf), reason for intubation, presence of aspiration, length of mechanical ventilation (lomv), severity of hypoxia, length of stay in icu (los) and mortality. continuous data were compared by paired t-test and nominal data by chi-test. explicative variables for arf were assessed by univariate analysis. . patients had a middle cerebral artery (mca) stroke and had brainstem stroke (bs). age (mca ± sd yrs vs bs ± sd for), gsg score (mca ± sd vs bs ± sd for), length of stay in icu ( ± sd days for mca vs ± sd) were not significantly different. % bs and % mca patients were admitted in icu for respiratory failure (p= . ). admission to icu with loss of consciousness was significantly higher in mca ( / , %) than in bs ( / ) (p= . ). indication for intubation was always for aspiration pneumonia that was the leading cause of arf ( . ) associated with swallowing paralysis in bs (p= . ) and to unconsciousness in mca (p= . ). there was no difference for the lomv, the severity of hypoxia between the groups. arf, intubation or reason for intubation were not associated with mortality in the groups (p= . ). the major cause of death was the presence of cerebral herniation in the groups (p= . ). pulmonary complication due to aspiration more predominant in bs than mca stroke, represents the major cause of intubation and arf for bs patients. in the contrary, loss of consciousness in mca stroke group predominates for icu admission. outcome in all patients (mca and bs) was not influenced by presence of respiratory failure or reason for intubation. the major cause of death for stroke's patients is the neurologic state, and especially the presence of herniation. stroke code (sc) is a guidelines of united actuatio between out of hospital enmergency services from barcelone and the most four important hospitals of the city; which aim is to optimize the sequence time for stroke treatment; this allows to increase the number of candidates for reperfusion therapy. the present study aim is to evalute differents times sequences in the acute strokes in which trombolysis has been practised according to the acute stroke code first priority; and secundary to describe findings in the ct scan of these patients pro-inflammatory cytokines, such as tnf and il- are released in the brain within hours after closed head injury (chi). they were shown to have deleterious effects, mainly when active in the early post-injury period. a variety of anti-inflammatory and anti-apoptotic modalities have been shown to ameliorate the outcome of chi. erythropoietin (epo) is a kidneyderived cytokine regulating haematopoiesis both by acting as a growth factor and by inhibiting apoptotic cell death. recently it has been shown to be produced in cultured neurons, brain astrocytes and neurons under hypoxic/ischemic conditions and in response to oxidative stress. other studies have shown that the erythropoietin receptor (epor) is present under normal conditions on neuronal and brain capillary endothelial cells. epo has been found to have newly discovered neuroprotective properties in different models. these models include neuronal cultures against glutamate toxicity, global glutamate toxicity and rodent models of cerebral ischemia. in addition it induces brain endothelial cell proliferation and stimulates neovascularization in vivo. the present study was designed to test the protective effects of epo in rats udergoing controlled chi. methods. chi in rats was induced using a weight-drop device. clinical status was evaluated by the neurological severity score (nss), which tests tasks including reflexes, behavior and motor activity. a point is awarded for failing to perform a task so a higher score corresponds to a more severe trauma. study animals were treated with doses of i.p. units/dose ( ml) of rhu-epo, h and h after chi (treatment group) or with ml of vehicle injected i.p. at the same time points (control group). nss was evaluated by an observer blinded to the different groups at , and days post chi. nss scores were compared using a two tailed student t-test. control and study rats were subjected to chi of similar severity, ( h nss . + . and . + . respectively, p= . ) and followed at d, d and d following chi. clinical recovery was facilitated in the treatment group starting at h after chi and reached statistical significance at days post chi. the treatment group's d nss was . (n= ) vs. . in control animals (n= ) p= . . the present findings point to a neuroprotective role of epo in traumatic brain injury. brain tissue of treated and control animals is currently being analyzed for parenchymal cytokine levels. we have examined the role of post trauma treatment with epo of rats undergoing chi. as has been shown in other models of brain injury (stroke, ischemia, glutamate toxicity) epo seems to have a neuroprotective effect in head trauma. the exact mechanism of this protection has yet to be elucidated. this is the first time, to our knowledge, that epo has been studied in an animal model of traumatic head injury. ( ) ( ) ( ) is . %. it is difficult to know how to apply these figures to individual patients. we have used the anaerobic threshold in a prospective observational study to try and identify patients with an increased risk of mortality. forty-five patients scheduled for elective aaa repair had their anaerobic thresholds measured pre-operatively. the anaerobic threshold is the patient's oxygen consumption in ml/kg/min when anaerobic metabolism occurs(reference ). it is calculated by using a bicycle ergometer and a metabolic cart. clinical presentation and evolution of valvular heart disease (vhd) patients have great significance in determining the best moment for surgical correction but lacks correlation with surgical outcome in most cases. this study tries to determine the preoperative variables associated with mortality in the course of surgical treatment of vhd. cohort study conducted from january to february . inclusion criteria: patients submitted to vhd surgery during the period of study. exclusion criteria: vhd surgery combined with non -vhd procedures. data were analyzed with chi -squared, fisher and mann -whitney tests. one hundred five patients met the inclusion criteria. the preoperative variables associated with surgical mortality were: systemic arterial hypertension (p= . ), peripheral vascular disease (p= . ), redo (p= . ), age (p= . ), blood creatinine level (p= . ), left ventricular dysfunction (p= . ). conclusion. based on these data, efforts will be held in order to develop a prognostic score index for mortality in vhd surgical patients. in our setting, the diffusion of institutional education in basic cardiopulmonary resuscitation (bcpr) is low. the number of patients admitted to our units after resuscitation following cardiac arrest is rising due to the population demand on the out-of-hospital emergency services, . the patients with neurological sequelae secondary to incorrect bcpr in the first minutes are common. through the association of ex-patients of the intensive care medicine department, and with the psycho-social support of voluntary helpers on patient discharge, relatives are offered bcpr as part of the quality care programme. every three months, professionals from the department organise this course for relatives in the form of a hour module. the concepts of the prevention of ischaemic heart disease are presented together with the content of the national plan for bcpr. practical sessions are undertaken in small groups of to persons, using dummies. a total of relatives in courses have received this training over the past years. the mean age of the students was . (sd ) years ( - ), % women, % with middle and higher education, % housewives, and % manual labourers. the evaluation of the scores obtained in the item test before and after the course is shown in the tables below. multiorgan system failure (mosf) is an infrequent but very serious complications after cardiac surgery, with high rates of mortality. this study was undertaken to determine the frequency, prognosis and risk factors for mosf this study was performed in a twelve-bed cardiac surgery intensive care unit over a -month period. all adult consecutive patients undergoing coronary, valvular and combined (valvular and coronary) surgery were prospectively studied (n = ). all patients were assessed by the "modified" parsonnet score results. mosf developed in ( . %) patients, of whom ( . %) died. this was the main cause of overall hospital mortality ( / , . %). in a logistic-regression anlysis, the development of sepsis, postoperative low cardiac output syndrome, mechanical ventilation more than hours, a "modified" parsonnet score more than and and preoperative ventilatory support were independantly associated with the development of mosf. an organ system failure index (osfi) of or more was most significantly associated with icu mortality (p< . ). conclusion. in our series mosf was a leading cause of mortality after open-heart surgery. the development of mosf with an osfi of or more was the main predictor of postoperative mortality. we studied patients who underwent cabg surgery. fifteen patients ( male and female) were younger than years and patients ( male and female) were older than years. perioperative death occured in one patient from the < years group and in patients from the > years group (p=ns). categorical data were compared using the chi-square test and numerical data were analysed using the student t-test. differences were considered significant at p< . . in a n investigation conducted in ours icu, % of patients hospitalised after elective cardiac surgery presented a pain score > ( min score ; max ) . these results were considered inadequate. a quality improvement initiative was undertake. the aim of the present study was to test if pain evaluation and treatement improved following pain guidelines implementation in a surgical icu. the design consisted in observing de pain evaluation both before and month after implementation of guidelines. these guideline are divided in two item : first introduction of a regular pain evaluation using a visual analogue scale (vas) and second in a proportional vasderived analgesic prescription protocol. recommendation were given during repetitive meetings, feedback sessions and regular poster information on the icu walls. pocket guideline and vas tool was distributed. pain intensity evaluation of the nursing team was checked by an independent observer and compared with the nurses-charted vas. improvement of pain control was tested based on the following criteria: utilisation of the algorithm at least twice per working shift; corresponding analgesic drug to observed vas; and follow up check of vas after analgesic administration. the independent observer measure vas at a.m. and at p.m. postoperative day and . proportion of algorithm adherence before and after introduction of the recommendation were tested using fisher's exact test. variance of median vas was tested using mann-whitney test. these preliminary results indicate that the implementation of an algorithm on pain intensity evaluation and treatment increases the number of pain evaluation and re-evaluation after drugs administration. although the administration of analgesic drugs increased, the number of patients with insufficient pain treatment stays still high. the prognosis of liver transplant has improved the last few years due to advance in surgical techniques and immunosuppressive regimes, but early complications show a high prevalence affecting morbi-mortality in these patients a beds icu in a teaching rd level hospital. prospective observational study on all patients with the mentioned condition treated in our centre from october to october . follow up during icu stay. we have collected data from patients ( grafts) with a mean age of . ± . years, . % women, mean apache ii on admission ± . , median child score , ( - ) and mean sofa score . ± . . surgical data were as follows: fluids balance ± , hours of graft ischemia . ± . , reperfusion syndrome in % and fibrinolysis in . %. at admission mean core temperature was . ± ºc. median icu stay . ( - , max. ) days and median hours under mechanical ventilation ( . - , max ). the prescribed immunosuppression was cyclosporine in % and tacrolimus in % of patients results. icu mortality was . % ( patients). complications were present in % ( . % of them more than two episodes). patients had to be reoperated, one because early graft dysfunction treated with mars and retransplantation (death because a new graft dysfunction), and the other because abdominal haemorrhage. one patient developed an early rejection. metabolic complic . % (high insulin requirements . %) -renal failure . % (renal replacement , %)-cardiac complic . % (chf . %, hbp . %) -respiratory complic . % ( . % sdra) -bleeding % -neurological complic . % (myelinolysis patient) -infection . %. patients who died had higher apache ii, child and sofa scores, lower serum albumin levels, longer graft ischemia, higher percentage of fibrinolysis and reperfusion syndrome during surgery and higher percentage of acute renal failure an need for renal replacement (not statistical analysis due to the low mortality rate we report the effects of substitution with a virus-inactivated protein c (pc) concentrate in disseminated intravascular coagulation (dic) in preterm infants and children with sepsis (meningococcal in the children and aldolecent; staphylococcal and enterobacter in the preterms) associated with purpura fulminans. this was a prospective open-label study. a total of patients, paediatric and adolescent patients age . to . years with dic associated with severe acquired pc deficiency (range . to . iu/ml; median, . iu/ml) in meningococcal septic shock and purpura fulminans; and preterm infants with severe acquired pc deficiency (range . to . iu/ml; median, . iu/ml) due to staphylococcal and enterobacter sepsis were studied. replacement therapy was initiated with a virus-inactivated pc concentrate with an initial intravenous bolus of to iu/kg followed by iu/kg up to six times per day as an adjunctive therapeutic regimen to otherwise optimal intensive care treatment. after initial pc administration, plasma pc levels rose to normal ranges and were maintained under pc replacement therapy. improving or even normalising global hemostatic parameters were assessed in all patients. markedly elevated plasminogen activator inhibitor type (pai- ) levels prior to treatment, reflecting a reduced fibrinolytic potential, decreased rapidly under pc substitution. concomitantly improving signs of purpura fulminans reflected by decreasing size of skin lesions, demonstrated a restoring microcirculation. seven of the nine paediatric and all of the neonatal patients survived. one patient (paediatric) required limb amputation; two patients died because of multiorgan failure. both presented with a severely low plasma pc activity of . iu/ml on admission to the hospital. no adverse effects were observed with the pc concentrate administration. ait can be concluded that the administration of pc concentrate had a marked benefit on the deranged coagulation status of patients with purpura fulminans and septicaemia. normalisation or even partial correction of haemostasis as well as improvement of microcirculation accompanied by improving signs of purpura fulminans were demonstrated in all patients the main purpose of this study is to report medical and surgical complications of spine surgery in a third level universitary pediatric hospital with a reference spine surgical program. methods. study design is a retrospective clinical series of pediatric spinal surgeries.all spine surgeries performed on children under years of age between january and january were included. patient were grouped in four diagnostic categories (idiopathic, neuromuscular, congenital scoliosis and miscellaneous) and procedure performed (posterior (p) fusion, anterior/posterior (ap) fusion, anterior (a) fusion, (iw) instrumental withdrawal). next data were recorded from clinical chart:age, gender, needs of transfusion products, volume demands during first postoperative day,days on mechanical ventilation,medical and surgical complications. results. study sample included patients, female and male. age ranged between and years with average of . years. characteristics were: idiopathic , neuromuscular ,congenital scoliosis ,miscellaneous . procedures performed were:p fusion ,ap fusion ,a fusion ,iw . .average lenght of stay in pediatric intensive care unit were . days (range - ).average days on ventilatory support . ( range - . ). no patient required intubation after weaning.major complications were: deep wound infection( ), respiratory distress( ), large intraoperative blood loss ( ),and paraplegia ( ).no deaths were observed.minor complications were: atelectasis( ), pleural effusion( ), pneumonia( ), pneumotorax( ), superficial wound infection( ), urinary tract infection( ) and electrolitical disturbances( ). postoperative transfusion needs were . ml/kg ( % confidence interval (ci) . - . ) for ap fusion, . ml/kg ( % ci . - . )for p fusion; a fusion and iw doesn't need postoperative blood replacement. total blood transfusion was . ml/kg ( % ci . - . )for ap fusion, . ml/kg ( % ci . - . )for p fusion; . ml/kg for a fusion and . ml/kg for iw.volume demands(no blood products)during first postoperative day were . ml/kg ( % ci . - . )for ap fusion, . ml/kg ( % ci - . ) for p fusion; ml/kg for a fusion and . ml/kg for iw. conclusion. spine surgery has few major complications rate in a reference spine surgery pediatric hospital. minor respiratory complications affect % of our patients without repercussion in outcome. total blood loss is greater in ap fusion than in other procedures, but postoperative blood replacement in picu didn't differ between procedures. background elevated intra-abdominal pressure (iap) adversely affects pulmonary, cardiovascular, renal, splanchnic and central nervous system physiology, and it determines the common clinical picture called "the abdominal compartment syndrome". nevertheless the direct monitoring of iap is not always practicable, because it requires an abdominal drainage. a lot of authors demonstrated in the adults that the bladder pressure is a reliable index of iap, but there are not studies on pediatric population. the aim of this study is to evaluate the level of significance of this index in a pediatric population. population: we enlisted a group of pediatric patients, sedated and paralysed ( oltx, abdominal surgery, cardiac surgery), age . ± , (range - ) months. methods. the bladder pressure was measured with the patient in supine position, with a trasduction circuit connected to the bladder catheter and to the abdominal drainage ( jpratt, pig tail, catheter for peritoneal dialysis). to obtain a good transduction of pressure, a volume of saline was pushed into the bladder. the volume of saline was variable according to the weigth and age: we obtained a scheme (table ) from our empirical evaluation of the pediatric bladder compliance and urodinamic data. table , there aren't significative differences between the level of pressure measured in the bladder and in the peritoneal cavity ( p= . ). mean: , ds: , from to , pediatric patients (age range . to years, mean . years) were treated using nppv during distinct episodes of acute respiratory failure (arf) of neuromuscular origin. in all patients immediate intubation for an acute, life-threatening presentation was avoided and respiratory status improvement was achieved. few data are available up to now about nppv application and indications in the acute setting in infants affected by neuromuscular disorders (nmd). a prospective observational study was carried out on non-consecutive neuromuscular patients admitted to picu because of arf and managed with nppv in the acute phase;remarkably, out of were < months aged. all the patients were treated by a flowtriggered intensive care mechanical ventilator (siemens servo ventilator, siemens-elema, sweden) through a tight fitting face mask. nppv was administered for at least hours postadmission. a pressure-control mode was adopted for better compensation of leaks around the mask. flow-sensitive trigger permitted a better synchronization of patient's spontaneous breathing, limiting the need for deeper patient sedation (low-dose midazolam drip). initially, a relatively low ventilator frequency delivery was set ( - b/min). peak inspiratory pressure was tritrated upward to obtain an exhaled tidal volume of - ml/kg maintaining a paco value < mmhg and a ph > . ; peep value was adjusted to maintain an oxygen saturation > - % with a required fio < . . results. all patients were referred to picu on spontaneous breathing: those admitted with et tube already positioned were not considered eligible for this study. an oxygenation improvement was obtained in all patients within hours from the onset of nppv . the pao /fio increased from . ± . to . ± . (p< . ) and . ± . (p< . ) on selected time points ( and hours after nppv introduction, respectively); conformly, alveolar-to-arterial oxygenation difference (a-ado ) decreased from a . ± . to . ± . (p< . ) and . ± . (p< . ) respectively. conclusion. nppv resulted a safe and effective therapeutic approach in both hypoxemic and hypercapneic arf episodes in this children group affected by nmd. even in cases of emergency presentation or when resuscitation is needed, it is of importance to identify nmd children with residual ventilator-free breathing ability thus performing a nppv trial. life-threatening respiratory distress and young age should not preclude nppv application in a picu setting. pulse oximeters are widely used in paediatric intensive care but they have some severe limitations. the technique relies on the presence of adequate peripheral arterial pulsations, which are detected as photoplethysmographic signals (ppg). when peripheral perfusion is poor as in states of hypovolaemia, hypothermia and vasoconstriction oxygenation readings become extremely unreliable. hence, pulse oximetry becomes unreliable in a significant group of children just at the time when accurate readings are most needed. to overcome this limitation, the oesophagus has been investigated as a potential measurement site on the hypothesis that perfusion may well be better preserved at this central site. studies on adult patients have shown that measurable ppg signals at red and infrared wavelengths can be detected within the whole depth of the oesophagus. a new system to investigate the quality of oesophageal ppg signals is being constructed with the aim of developing a neonatal and paediatric oesophageal pulse oximeter. a reflectance optical sensor has been constructed comprising miniature infrared and red emitters and a photodetector. the sensor was design to fit into a conventional disposable transparent stomach tube, french gauge. the oesophageal ppg sensor within the stomach tube was inserted through the nose into the oesophagus of a kg, day old neonate. the stomach tube was advanced into the oesophagus under direct vision until the probe was cm from the nose. ppg traces from the oesophagus were recorded for approximately minutes at this depth on a laptop computer. measurements were repeated at and cm from the nose. measurable ppg traces of good quality were obtained in the oesophagus at all three depths. the ppg signals in the mid to lower region of the oesophagus on average had larger amplitudes at both red and infrared wavelengths than the ppgs recorded in the upper oesophagus. artefacts on both wavelengths due to oscillations as a result of high frequency ventilation. filtering successfully eliminates the artefact. the new oesophageal reflectance optical sensor has allowed ppg measurements to be made within the whole length of the neonatal oesophagus. the red and infrared wavelengths used are suitable for pulse oximetry. these results are the first to demonstrate that pulse oximetry may be feasible in the neonatal or paediatric oesophagus. further studies are required to develop a neonatal/paediatric pulse oximeter. we used protein c (ceprotein; baxter -immuno) in two patients with moderate or severe, therapy-resistant vod. . patient (e.g, swiss, , y) suffered from an acute myelogenous leukemia (m with t( ; ) of early infancy after complete first remission by conventional chemotherapy an allogeneic stem cell transplantation with a matched unrelated donor was performed. conditioning comprised busulfan, vp and cyclophosphamide. patient (m.k, iranian, y) suffered from beta-thalassemia major with secondary moderate hemosiderosis, as well as chronic persisting hepatitis c infection with liver fibrosis. he received a matched related bone marrow transplantation, using i.v. busulfan , reduced cyclophosphamide dose and fludarabine. both patients received low dose heparin ( iu/kg) and antithrombin iii substitution. in addition, pat. got prophylactical defibrotide ( mg/kg) and n-acetylcystein. two weeks after transplant both patients developed vod (severe (pat ); moderate to severe (pat ))with weight gain, hepatomegaly, massive ascites and severe thrombocytopenia. maximal bilirubin was mg/dl (pat ) and mg/dl)(pat ). therapy with defibrotide ( mg/kg) was started immediately. in pat. the pulmonary situation deteriorated rapidly with massive aszites and oxygen need and a reversed portal venous flow. defibrotide was stopped after days. thrombolytic therapy using rtpa and a continuous pc substitution (pc level %; bolus iu/kg, followed by iu/kg every h)) were started. lysis therapy had to be abandoned due to respiratory tract bleeding global coagulation (pt %, aptt sec) and pc level normalized within hours after pc substitution. a normal centripetal portal flow could be achieved by high dose defibrotide ( mg/kg) and continued pc substitution after several weeks. pat. showed only a temporary improvement under defibrotide treatment. due to clinical deterioration (hepatic pain, increased ascites) and low pc level ( %) a continuous pc substitution ( iu/kg every h) was initiated. there was a prompt recovery after adding pc with a dramatic reduction of ascites, weight and abdominal pain within - days after start of pc infusion. elevated bilirubin levels returned to normal in both patients. in our patients neither prophylactic administration of at iii nor of defibrotide were able to prevent moderate to severe vod.our data indicate that pc substitution may be a useful adjunctive treatment in severe vod. until controlled studied will be initiated we recommend a stratified treatment in vod, starting with defibrotide, and adding pc in unresponsive cases. ( ) showed recently that restrictive strategy of red-cell transfusion could be at least as effective as and possibly superior to a liberal transfusion strategy in critically ill patients. the aim of this study was to assess the impact of local transfusion guidelines emphasizing restrictive strategy on patients undergoing heart surgery and the prognostic value of transfusion following those restrictive criteria. methods. two groups of heart surgery patients were compared before and after the introduction of local transfusion guidelines. these guidelines involved general information on blood transfusion risks and obligation for the physician to respect predetermined transfusion criteria (hb < g/dl or > g/dl associated to systolic arterial pressure < mmhg or age over yrs or hr > /min or ci < . l/mim/m² or other associated disease . . . * . . . . * < . mortality (%) * * < . conclusion. introduction of local restrictive transfusion guidelines was associated to a significant reduction in red cell transfusion during the postoperative period of heart surgery. the global morbidity and mortality rates in the whole group of patients were not affected. however patients who required blood transfusion following the restrictive strategy had a worse outcome. transfusion was probably more the consequence than the cause of this worse prognosis. if transfusion was the cause of the worse prognosis, then morbidity and mortality rates would have been higher among patients requiring transfusion during liberal period than in the whole group of patient. ( ) hebert pc and col. a multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. n engl j med ; : - . risk factors and outcome in european cardiac surgery higgins tl. quantifying risk and assessing outcome in cardiac surgery intensive care medicine, hospital del mar, servicio de microbiología to analyze if morbid obesity (mo) is associated with critical pathology in relation to patients undergoing vertical banded gastroplasty (vbg). all critical patients (cp) suffering mo, with a mean body mass index = , , receiving programmed surgical treatment, and admitted in the icu during the next period: st oct. to th feb. , were prospectively included. · surgery procedures. *restrictive: vbg according to masson's technic. *derivative: vbg + gip according to salmon's technic. vbg + gip according to capella's technic. ·type of study: descriptive. -vbg in association to other surgical procedures: cp ( cholecystectomies, right inguinal herniorhaphy, and other procedures). · mortality: cp: -septic shock -multiorganic disfunction · readmission: cp (subphrenic abcess and ards). complications . hypoxemia: cp ( % of the total) . . . . not secondary to hypoventilation: cp ( . %). . . . . associated to hypoventilation: cp ( . %) . need for noninvasive mechanical ventilation: cp ( %) . high blood pressure: cp ( . %). . disturbances of cardiac rythm and conduction: cp ( %). . metabolic acidosis: cp ( %). . other complications: cp ( %). conclusion. -the mo patient undergoing vbg, with or without gip, rather than a patient bound to the reanimation or recovery room, is indeed a patient who requires admission in the icu for, at least, - hours. -hypertension of difficult management and hypoxemia not due to hypoventilation nor shunt are the most frequent complications. -an important percentage of cp requires also mechanical ventilation. -complications related to surgery are exceptional. karlicek a. , haveman j. w. , verhoeven e. , van den dungen j. j. a. m. , tielliu . i. f. n. , hulsebos r. g. , nijsten m. w. n. surgery, groningen university hospital, groningen, netherlands introduction. the mortality in acute abdominal aortic aneurysms remains high. recent series still report a hospital mortality rate of more than % ( , ). despite the large number of published studies on hospital outcome, long-term outcome after icu admission has hardly been studied. here we present hospital survival and long-term outcome in patients with an acute abdominal aortic aneurysm. the records of all patients operated for aneurysm surgery between and were retrospectively reviewed. in patients surgery was performed for an acute abdominal aortic aneurysm. all operation reports were analysed. for complete follow-up the general practitioner was contacted if necessary. after arrival in the emergency department and confirmation of the diagnosis by physical examination and/or ultrasound all patients were immediately brought to the operation room. in our hospital even patients with cardiac arrest on arrival in the operation room are treated without delay, and were thus included in our study. all surviving patients were admitted at the intensive care. in case of postoperative haemodynamic instability, multiple organ failure, sepsis or diarrhea a sigmoidoscopy was performed to assess the presence of ischemia or infarction. three hundred and eight patients were operated for an acute abdominal aortic aneurysm, men and women. operative mortality was % ( / ). calculated from the moment of icu admission, day survival was %. cumulative survival rates calculated with the kaplan meier method at , , and years were %, %, % and % respectively. in patients in whom sigmoid resection was performed, day survival was % compared to % in the other patients. mortality in ruptured abdominal aortic aneurysm remains high, day survival was % in our group. sigmoid resection was associated with lower survival but sigmoidoscopy should be augmented to exclude sigmoid necrosis. outcome in these patients is not invariably poor. long term follow-up shows that also after discharge from the hospital these patients have a high mortality. carvalho a. g. r. , gomes r. v. , santos jr. b. , barbosa o. n. , weksler a. , pontes a. p. , camara a. c. surgical intensive care unit, instituto nacional de cardiologia laranjeiras, rio de janeiro, brazil introduction. prognostic markers developed in europe and north america cannot be applied in latin america where life expectancy is % lower according to world health organization. the objective of this study is to analyze patients profile submitted to heart surgery (hs), type of surgery distribution and the impact of variables, previously reported in medical literature, in the mortality and duration of intensive care unit (icu) stay in a public tertiary hospital. cohort study of patients submitted to hs from january to april . patients profile, type of surgery distribution and many variables were analyzed. variables that were studied: age, gender, body mass index (bmi), body area (ba), preoperative in-hospital stay (preop), extracorporeal circulation (ecc) duration, ventricular function (vf), surgical indication, combined procedures (comb), urgency for the surgery, presence of diabetes mellitus (dm), systemic arterial hypertension (ah) and cigarette smoke (cs). the profile and patients variables were analyzed and compared in two different groups. group a (ga): patients discharged from icu or in-icu stay lower than or equal to days (median in-icu stay in this study). group b (gb): death during icu admission or in-icu stay longer than days. t-student, mann-whitney, chi-squared and fisher tests were used in the statistical analysis. conclusion. there is a rather singular distribution of surgeries in this group. many of the previously described variables showed correlation with mortality or longer admission in the icu. prospective studies will be held in order to adjust these variables and determine new ones more relevant to underdeveloped countries. pierce c. m. , fortune p. , petros a. j. picu, great ormond street hospital, london, united kingdom, picu, royal children's hospital, melbourne, australia there are anecdotal reports of sildenafil, a type phospodiesterase inhibitor, being used to reduce pulmonary artery pressure in children with mainly cardiac induced pulmonary hypertension (pht). we have given oral sildenafil to children on our paediatric intensive care units with pht from various causes. diaphragmatic hernia ( ), avsd ( ) vsd ( ) pda ( ), pphn ( ) pulmonary hypoplasia ( ). the median age of the group was m (iqr - m). were receiving inhaled nitric oxide during sildenafil. median dose was . mg/kg (iqr . - . mg/kg hrly) and duration was days (iqr - ). pulmonary artery pressures were directly measured in of the cardiac children and deduced from doppler echocardiographic measurements of the tr jet in children.results. pap decreased significantly (p< . ) following oral doses of sildenafil (n= ). mean pulmonary/system (p/s) ratios decreased from . to . (n= ) within hours of the oral dose. systemic pressure was unaltered in all children. in one child with pulmonary hypoplasia the p/s ratio was unaffected. oral sildenafil can significantly reduce raised pap in children when there is a reversible etiology. this may be particularly useful in children and neonate with pphn. central venous catheters (cvc) are an important means of securing intravascular access in pediatric intensive care unit patients. one of the major morbidity's in use of cvc is catheter-related infection (cri). the incidence of bacteremia with cvc use is approximately . / catheter days and mortality as high as %. one approach to reduce the incidence of cri has been to decrease catheter bacterial colonization (cbc). reduction in cbc is achieved by coating or impregnating antimicrobial substances into the catheter material. use of minocycline/rifampin treated catheters has been shown to reduce the rate of cri in critically ill patients. the concern in pediatric population is the use of minocycline. tetracycline and its derivatives (minocycline), when used in young children, carry the risk of dental and sceletal abnormalities. the problem of potential eluting of minocycline from minocycline-impregnated catheters may pose a risk for young children. our study examined whether detectable levels of minocycline and rifampin were present in the serum of the pediatric intensive care unit patients with indwelling minocycline/rifampin impregnated cvc. methods. patients admitted to pccu age - years and in need of cvc were eligible for study. six patients were enrolled. each patient had two samples of blood and . ml withdrawn for rifampin and minocycline assays respectively. collection times were at the time of catheter insertion and h thereafter for seven days or until catheter removal, whichever came first. rifampin serum samples were processed prospectively soon after colection by standard hplc. minocycline serum samples were stored frozen in - centigrade and assayed in one batch using reverse phase hplc. results. demographic data are in table. ranges with mean values in ( ). none of the minocycline samples had detectable level of antibiotic. the limit of sensitivity for minocycline was . mg/l. therapeutic levels are . - . mcg/ml. one patient had consecutive samples to with low therapeutic levels of rifampin ( - mcg/ml). therapeutic levels of rifampin are - mcg/ml. rifampin sensitivity was mcg/ml. rifampin has distinct peak time and no interfering substances were identified.sex ( ), the emergence of this consequences required fast and corrective treatment. an inotropic agents commonly used in vlbw infants such as dopamine and norepinephrine in some cases do not produce elevation in blood pressure despite using of very high dose. in this study i would like to exam the influence of hydrocortisone administration in vlbw infants with hypotension unresponsive to stndard catecholamine treatment. i have reviewed the cardiovascular response to hydrocortisone therapy in preterm infants. mean gestation age was . ( - ) weeks, postnatal age . ( - )days, mean birth weight g ( - ). eight of them suffered from respiratory distress syndrome and eight from sepsis. the first line of hypotension therapy was always volume administration (normal saline or albumine) and catecholamine infusion. hydrocortisone at the dose mg/kg was administered when dopamine at the dose mcg/kg/min ( patients or norepinephrine . mcg/kg/min ( patients)failed to normalized arterial blood pressure. pneumococcal meningitis is an important cause of morbility and mortality in children. we describe the epidemiological characteristics and clinical features of pneumococcal meinigitis in children admitted to a children's hospital in barcelona. medical records of children with a diagnosis of pneumococcal meningitis based on identification of s. pneumoniae in the blood or cerebrospinal fluid between january, , to april, , were retrospectively reviewed. results. cases of pneumococcal meningitis were diagnosed in patients. median age was months (range . m- . y). children were younger than years old ( %). male-female ratio was . : . none of the children had a previous immunological deficit. thirteen patients ( %) were pre-treated with antibiotics. the most frequent signs on admission were fever ( %), vomiting ( %), headache and irritability ( %), othalgia ( %) and shock ( %). neurological findings were lowered level of consciousness in patients ( %), signs of meningismus in patients ( %) and arreactive mydriasis in patients ( %). the mean leukocyte counts in blood were /mm and the mean c-reactive protein was mg/l. cerebral spine fluid indices on admission were: white blood cell= ( - ) /mm ; protein= ( - ) mg/dl; and glucose= ( - ) mg/dl. main serogroups were: ( %), ( %), ( %), ( %), ( %), ( %), ( %) and ( %). overall, % of the pneumococcal isolates were penicilin-nonsusceptible, % cefotaxim-nonsusceptible and % were vancomycinnonsusceptible. an initial abnormal cranial computed tomography was found in patients. the median duration of parenteral antibiotic therapy was days. all patients were empirically treated initially with cefotaxime (associated to vancomycin in of them). twenty-six patients ( %) received dexamethasone. the administration of mannitol was necessary in patients ( %) and anticonvulsants were administrated in patients ( %). only patients ( %) needed inotropic support (no longer than hours). mechanical ventilation was required in patients ( %) during a mean of . days (range - ). acute complications were: metabolic acidosis ( / ), disseminated intravascular coagulopathy ( / ), seizures ( / ), siadh ( / ) and diabetes insipidus ( / ). twelve patients ( %) suffered deafness, three patients ( %) hemiparesia and four ( %) were exitus. the mean hospital stay was . days and mean intensive care stay was . days. there is an increased prevalence of pneumococco with decreased susceptibility to penicillin and to cefotaxime. deafness is one of the most common and serious sequelae of pneumococcal meningitis. corticotherapy has reduced the incidence of hearing loss. the new, antipneumococcal conjugated vaccine will confer effective prevention from the age of two months and will reduce the incidence of this meningitis. aims : to analize sedation/anesthesy methods used in our hospital for painfull or unconfortable procedures in children in relation to : )patient confort, )sedation complications, )and efficacy of the procedure a prospective study was conducted from january to march in disconfortable procedures in children. mean age was m ; their asa score was in %, in %, in %, and in %. more frequent procedures were : lumbar punctures (lp), thoracentesis or drainages, central catheters insertion, endoscopys . we identified different groups in relation to methods of sedation/analgesy : -procedures done in the emergency department with local anesthesia; -procedures done with administration of intravenous midazolan+ketamine; -procedures done with anesthesic support. we used the ramsay scale to classify the degree of anesthesia and the serna behavioral scale to classify the reaction to the procedure.results. group (n= ): %patients fighted against the procedure (serna scale ) and in % of the patients, complications of the procedure were found to be related to inadequate sedation. group (n= ): in %, sedation was considered inadequate -serna level (n= ) and (n= )-and in case there were complications of the procedure related to unsufficient sedation; there were ( %)cases of minor complications sedation-related; group (n= ): patient confort and adequacy of the sedation were found in %, with ( %) complications of the anesthesic method.conclusion. sedation/anesthesia were needed for the confort of the patients; only minor complications of sedation/anesthesy were found ; efficacy of the procedure was best achieved with the anesthesic method. introduction. the goals of emergency airway management are to antecipate and recognize respiratory problems and support therapy. the endotracheal intubation ( et) is not a routine procedure and it requests planning and personnel qualified to reduce the complications associated to this technique . the purpose of this study is to evaluate early complications associated with endotracheal intubation methods. data were collected prospectively from february to january in tertiary teaching hospital. the variables were obtained in four age groups: group (> month); group (between month to months); group (between months to months)and group (> months). the data were collected as demographic data, reason for endotracheal (et) intubation, sedation administered, local of et, physician responsible for et, complications associated with airway management. the major complications were defined as technical problems that resulted increased morbidity. minor complications were incidents that should be avoided. the complications were compared between emergency or elective et intubation. statistical analysis by chi-square, fisher exact test . we evaluated ( % female and % male) no consecutive patients. indication for intubation were: respiratory failure ( %), coma or depressed sensorium ( . %), post-operative ( %) and shock ( %). sedation and/or analgesic were used in % of patients and . % did not receive a sedative or analgesic for et intubation. a total et emergency intubation ( we report an outbreak due to rsv in a bedded picu with an annual admission rate of approximately patients, cardiac and medical patients accounting each for % of the population and % surgical.methods. an outbreak is defined as an event in which minimally patients develop bronchiolitis due to rsv following transmission via hands of carers within a limited period of week.nasopharyngeal aspirates were obtained from children with symptoms of lower airway infection, all samples were tested for rsv using the enzyme immuno assay, followed by tissue culture when the assay was negative. rsv positive children were isolated in cubicles and strict standards of hygiene were implemented. introduction.the objective of the study was to investigate the validity of outcome prediction after severe head injury using serum levels of protein s- b and of neuron specific enolase nse. methods.fifteen patients with severe head injury were included in this prospective study ( men and women) mean age yrs ( - ). none of the above patients had spinal cord injury or any other neurological disease. venous blood samples were taken on admission and consecutively the , , , , and day. immunoluminometric assay was used for the specimens. we tried to correlate the s- b and nse serum concentrations with the ct scan intacerebral pathology as well with the age, gender and outcome. results. all patients had elevated s- b and nse serum concentrations, with a gradual reduction towards the th day of icu stay. the mean values of day , for s- b were . ìg/l and for nse were . ìg/l. of day , they were for s- b . ìg/l and for nse . ìg/l. patients who died had the first day mean values of s- b . ìg/l and nse . ìg/l, whereas the survivors had mean values of s- b . ìg/l and of nse . ìg/l (p < . ). there was no strong correlation between the ct scan findings, the initial serum s- b and nse values and the gcs, on admission. conclusion. the protein s- b and nse are biochemical markers that seems to be elevated during the first days of injury, in patients with severe head trauma and could be used as markers of he severity of the injury. if protein s- b and nse could be used as a prognostic factor of the patient outcome, needs more investigation. our study is continued. estimates such as -day survival may be grossly misleading for assessment of intensive care utility. late mortality and morbidity may severely affect overall outcome. we studied -day survival rate in addition to survivors´ general health evaluation and prevalence of signs indicating post-traumatic stress disorder (ptsd). the setting is a university general intensive care unit. during the study period all adult patients who had been intubated and mechanically ventilated for at least hours were included (patients who died before hours are excluded). three to six months after their critical illness, survival data were retrieved from hospital and national registers. all patients surviving at this time were sent a health survey questionnaire (sf- ) and the post-traumatic stress syndrome -questions inventory (ptss- ). results. patients fulfilled the inclusion criteria. the mean age was years, % were women. health questionnaires were returned by ( %) of the survivors at follow-up time. -day survival rate was %, at days survival rate had fallen to %. among the responding survivors the frequency of a response pattern compatible with ptsd was %. survivors without signs of ptsd had sf- mean scores more than standard deviation (sd) below the swedish norm in the domains of physical functioning, role-physical and social functioning. survivors with signs of ptsd scored below non-ptsd survivors in every domain, and were more than sd below the swedish norm in the domains of social functioning, roleemotional and mental health. in total, there were only five persons ( % of respondents) who scored at or above the swedish norm for both the physical and the mental health summary scales. assuming the same outcome in non-respondents this figure would correspond to about % of all the included patients. conclusion. in this cohort of severely ill patients -day mortality was in the expected range but much mortality (another %) occurs in the following weeks, indicating a number of patients who have been subjected to long-lasting care with very meagre benefits. at - months following onset of their disease, survivors show considerably reduced subjective rating of their general health and life quality. as much as % of the survivors show signs compatible with ptsd. it could be estimated that about % of all patients included will both survive and within - months reach a level of general health comparable to that of the general population. the aim of this study is to probe that critically ill patients gender is not associated with differences in severity of illness and related mortality. we had tested the premise in front of a controversial evidence offered by several years of our icu activity. observational study. retrospective analysis using data prospectively collected in a medical-surgical icu of beds, in a teaching reference hospital, from november to july . we analyzed consecutive admissions considering reason for admission, age, icu length of stay, severity of illness (mpm , mpm , saps ii and spanish version of apache iii) and related risk of death. cases were analyzed according to gender and age decades. therapeutic effort was analyzed according nems system. standarized mortality ratio (smr) and its % ci was determined. one thousand and twelve cases out of were women. mean age (sd) was ( ) years. significative differences were founded in mpm prognostic values ( . ± . for men and . ± . for women, p . ). the rest of epidemiological data do not offer significant differences. smr for men was . , and for women . , but % ci overlapped . - . vs. . - . , p ns. the same differences were found when different age intervals were analyzed. only admission diagnostic (ischemic cardiopathy, post cardiopulmonar arrest and multiple trauma with no head trauma) showed greater mortality rates in women, but these differences disappeared when age intervals were considered. in spite of certain confusing data about greater mortality ratios in women admitted to our icu, accurate analysis does not show significant differences in severity of illness, associated prognosis and mortality, and therapeutic effort between male and female. bacterial infection is one of the most frequent and most feared complications in patients with a hematologic malignancy (phm). in a retrospective study, we found that bacteremia precipitating icu admission in phm was associated with a better outcome [ ]. however, it remained unclear whether this finding could be extrapolated to all bacterial infections. the aim of this prospective study was to evaluate whether bacterial pneumonia (bp) and bacterial sepsis or other bacterial infections (bs) had a better outcome compared to non-bacterial or noninfectious complications (nbc) in critically ill phm.methods. consecutive phm admitted to the icu over a year period were categorized into bp (n= ), bs (n= ) or nbc (n= ) according to strict diagnostic criteria by an independent panel of physicians who were blinded for the outcome. the impact of bp and bs on the inhospital mortality was assessed by logistic regression after adjustment for severity of critical and underlying hematologic illness, duration of hospitalization before icu admission and other potentially important prognostic factors. two models were tested, the first using a classical severity of illness score (apache iii) and the second using a score system especially designed for cancer patients (groeger score) [ ] . bacterial infection is one of the more favourable complications precipitating icu admission in phm and is associated with comparable mortality rates as in general icu patients. therefore, reluctance to admit phm to the icu for advance support is unjustified, especially when a bacterial infection is suspected to be the cause of deterioration. ( , ) the cleveland clinic score is the only one, to compile intraoperative data until the timepoint of icu admission.( , ) we wanted to find out, whether the combination of pre and postoperative score, in alliance with additional parameters, improves the predictability of outcome. from from until adult cardiothoracic patients were examined. logistic regression was used for analyzing those variables, dealing with mortality. the selection of significant factors is based on a stepwise forward procedure(p< , ). the accuracy of multivariate analysis is shown as roc(receiver-operator characteristic) curve. . variables, pre as well as intraoperative parameters proved to be statistically significant in the analysis, in the multivariate analysis: both scores, operation and aox time, preop at iii, assessment of intraop course, hb at icu admission, blood loss h< ml and rethoracotomy for bleeding. the pre and the postoperative cleveland clinic risk score were both statistically significant in the uni and multivariate analysis, but their combination improved roc. additional parameters had only little further impact. pre and postoperative cleveland clinic score are reliable in predicting the risk of cardiothoracic patients. adding further intra and postoperative data, risk stratification becomes more precise. the appearance of unexpected intraoperative difficulties was highly significant for adverse outcome. the collection of data should be continued on the icu and therapy should be reevaluated and modified any time. objective: to describe the frequency, etiologies, forms of presentation, and foci of bacteremia identified in patients admitted to the icu. prospective epidemiological surveillance study carried out from april to march . bacteremia was defined as the isolation of a pathogenic microorganism in one or more blood samples. bacteremias were classified into contaminating or true according to clinical manifestations. a descriptive analysis of variables including mean values, ranges, and standard deviations is presented. a total of episodes of bacteremia were identified, of which were true bacteremias ( . episodes per patients). the characteristics of patients with true bacteremia were as follows: mean (sd) age ( . ) years; male sex . %; mean apache ii score on admission . ( . ); and mean length of previous hospitalization ( ) days. in ( . %) cases, bacteremias were acquired in the icu and in ( . %) episodes were polymicrobial. a total of pathogens were cultured. these included gram-positive cocci in ( . %) cases, gram-negative bacteria in ( . %), and fungi in ( . %). initial presentation included severe sepsis in ( . %) cases and septic shock in ( . %). the most frequent origin of intra-icu true bacteremias was unknown in . % of cases (primary bacteremia) followed by catheterrelated bacteremia. crude mortality was . % and bacteremia-related mortality . %. primary bacteremia and catheter-related bacteremia were the most common. a total of . % bacteremias were polymicrobial. gram-positive cocci were the predominant causative pathogens. gyurov e. g. , milanov m. s. , milanov s. g. , neichev p. g. general icu, emergency medicine hospital "pirogov", sofia, bulgaria intensive care units are unique because they house seriously ill patients in confined environments where antibiotic use is extremely common. since our last publication ( ) there is a substantial rise in emergence of nosocomial infection namely gram-positive as well as changes of pattern of emergence. to study the frequency of emergence of nosocomial infection (nci) in intensive care unit (icu) we studied retrospectively data from case records and flow sheets of postoperative patients in our icu during - and compared data with last period. results. of patients in our icu during two years, we include those ( . %) who stayed for more than hours. according to results from cultures we divided them to three groups. group one included ( . %) patients without bacterial growth. group included patients with proved nosocomial infections /nci/. we obtained samples: from urinary catheters ( positive- . %), from tracheal tube ( positive- . %), from blood ( positive- . %), intradermal segments from central venous lines ( positive- . %), and from sputum ( positive- . %). the most common place for emergence of nci in our icu is respiratory tract. on -th icu day the tract became infected in almost % of the patients. the major role among pathogens played acinetobacter spp. ( . %), citrobacter spp. ( . %), p.aeruginosa ( % and serratia spp. ( %). the second place for emergence of nci is "reserved" for blood-stream infections. almost the half of the cultures ( . %) showed bacterial growth. the isolated pathogens were the same: acinetobacter spp ( %), serratia spp. ( %), but there was substantial rise in frequency of emergence of s. epidermidis during the last years (see figure) . its frequency almost equalized that of acinetobacter spp. the other two main sources for nci were urine catheters and cv catheters. they remained on -rd and -th place. group included patients with endogenous surgical wound infections. in this group we obtained samples from surgical wounds and drainages. in . % of cultures showed bacterial growth. during next this figure rose nearly twice ( . %). the leading role played the same acinetobacter spp., citrobacter spp., p. aeruginosa, enterococcus spp. and e. coli. the role of s. epidermidis increased greatly during this period de waele j. j. h. c. , hoste e. , blot s. , colardyn f. icu, ghent university hospital, gent, belgium introduction. intra abdominal infections frequently complicate the postoperative course of patients with acute necrotizing pancreatitis. the objective of this study was to analyze the incidence of pancreatic surinfection after surgery for acute necrotizing pancreatitis, describe its characteristics and identify associated risk factors. we retrospectively ( ) ( ) ( ) ( ) ( ) ( ) ( ) analyzed patients treated surgically for acute pancreatitis. surgical treatment consisted of debridement and postoperative continuous lavage. we recorded demographic characteristics, incidence of organ failure, data on surgical and infectious complications, data on surgical and medical treatment and disease severity by ranson and apache ii score. surinfection of the pancreatic necrosis was present in out of patients ( %). the surinfection was polymicrobial in patients. most of the organisms were gram-negative ( %), the others were gram-positives ( %) or fungi ( %). patients with surinfected necrosis were younger ( y vs. , p< . ), had surgical complications more often ( % vs. . %, p= . ), needed retroperitoneal lavage for a longer time ( days vs. , p< . ), and had a longer hospital stay ( days vs. , p< . ) than patients without surinfection. multivariate analysis demonstrated that age (or . ; % ci: . - . , p< . ) and the occurrence of a surgical complication or ; % ci . - . , p< . ) were independently associated with pancreatic surinfection. the mortality in patients with infected necrosis was higher ( % vs. %, p= . ), although in multivariate analysis no association was found. pancreatic surinfection is high after debridement and retroperitoneal lavage, with mainly gram negative bacteria involved. surgical complications and younger age are significant risk factors for surinfection. the aim of this report is to describe the current status of sap in spanish icu's methods. sap cases are identified in accordance with generally accepted criteria in each icu, such as ranson, imrie, pcr and ct-dynamic criteria. sap was selected from the data base of the national study of spanish nosocomial infection monitoring (envin). this study covered the period from to . envin is an observational, prospective and multicentre study. sap patients hospitalized during more than hours in all the participating icu's have been included in the study. these patients were monitored until their discharge from the icu or up to a maximum of - days. secondary infections have also been monitored. severity is measured by means of apache ii. infections, mortality, epidemiological data and antibiotics used as a means of prevention are described. the statistical analysis used the chi x test for the association of qualitative variables, the student t for the comparison of averages and the % statistical significance level results. patients ( . %) of the , patients monitored by envin were found to have sap. the average apache ii was . and the average stay was . days. the base illness was medical ( . %) and surgical ( %). . % of the patients underwent emergency surgery. ni accumulated incidence was . % and density incidence was / hospitalization days. crude mortality was % and ni-related mortality was %. infections were detected: of abdominal origin ( . %), ventilator-associated pneumonias ( . %), secondary bacteremias related to abdominal infection ( . %), catheter-associated urinary tract infections . %; primary bacteremias ( . %); central venous catheter-associated bacteremia ( . %). a total of pathogens were isolated. bgn . %, cgp . % (mrsa . %), fungii % (principally candidas), enterococci % and anaerobes . %. . % of the sap patients received antibiotic treatment. the antibiotic most frequently used in prophylaxis was imipenem-cilastatine ( %) and piperaciline-tazobactam ( %). the antibiotics most frequently used in absolute indication were imipenem %, piperaciline/tazobactam . %, metronidazol %, vancomicina . %, ciprofloxacino %, amikacina in % and fluconazol . % conclusion. sap cases in spanish icu's account for little more than % of all hospital cases, but they result in high levels of severity, morbidity and mortality. crude mortality and sap septic complication-related mortality in spanish icu's are much higher than the average indicated in the literature ( . % and . %). imipenem is the antibiotic most frequently used in prophlaxis. the irruption of candidas has been detected. fluid /blood warmers help to prevent hypothermia by raising the temperature of intravenously administered fluids & blood. the hl- hotline fluid warmer is the model used in our hospital. it consists of disposable tubing set with a central channel through which the fluid is infused and outer tubing through which heated water circulates. the water is contained in a reservoir, which is heated by an electric element. the manufacturer's instructions recommend changing the water in the reservoir every days. this water is a potential source of infection and we therefore sampled the water in the reservoir for microbiological contamination. this study was conducted at royal london hospital during the month of december .there are fluid warmers, all hotline in our operating theatres. samples of water were taken from each of the reservoirs at the end of the working day. using aseptic techniques ml of water were added to a labeled blood culture bottle. each sample was cultured for hours. after one week we repeated procedure results. after hours of incubation, pseudomonas sp. grown in out of culture bottles. the results from the second sets also grew pseudomonas sp. in the same out of water reservoirs.conclusion. the water in the reservoir is heated to - degree celsius. this temperature does not inhibit the growth of pseudomonas. each time the disposable tube is disconnected from the reservoir approximately ml of water is spilled potentially spreading microorganisms. in addition there are case reports of cracks/splits in the inner tubing of the disposable tubing potentially exposing infused fluid or blood to heated water from the reservoir ( ). methods. ( . %) of consecutive cardiac surgery patients operated at onassis cardiac surgery center, from january st to june th , developed t> . c and leucocytosis, without evidence of specific site of infection. those patients were examined for possible catheter related infection, by removing central and arterial catheters and sending them along with blood specimens for culture. infections within the first postoperative h were defined as early, whereas those developed after the first h were defined as late. we examined the relation between the incidence of catheter related infection and the type of microorganism isolated, the type of operation performed, the icu stay and the hospital mortality. . coronary artery bypass grafting(cabg), valve or ascending aorta replacement(vr), combined(cabg+vr), acute dissecting aneurysm(ada) and other operations were carried out. positive blood or catheter cultures were found in patients ( . %). staphylococcus epidermidis was cultured from all patients with early(n= ) and % of those with late(n= ) infection, while candida was found in % of those with late infection. icu stay and hospital mortality was ten times higher in patients with positive blood or catheter cultures compared to the general icu population ( . vs . days and . % vs . %, respectively). finally, mortality was higher in patients with late compared to those with early infection( % vs %). (pts) who had suffered traumatic brain injury (tbi) as well as the immune response of these pts. pts with moderate to severe tbi (gcs =< ) and age > were enrolled under the presupposition they remained on mechanical ventilation (mv) > days. a total of tbi pts were followed-up; infected pts were identified and associated factors were studied. in addition, serum immunoglobulin (sig) levels and soluble interleukin- receptors (sil- r) were measured in infected pts. c. albicans species. candidemia in icu patients is associated with a high mortality rate. c. albicans was the most common yeast isolated from blood. non-c. albicans species have a frequent occurence among candidemic icu patients. the moderate susceptibility of azoles against non-c. albicans species indicates the usefulness of susceptibility testing for antifungal treatment. prospective, cohort, observational, and multicenter study. urine cultures were performed once a week to all patients admitted to the icu. samples were processed at the different clinical microbiology laboratories of the participating hospital using specific culture medium (sabouraud) and the bactec technique and the a c (biomerieux) system for the identification of species. candiduria was defined as < cfu of candida spp. in the urine. frequencies are expressed as cumulative incidence (%) and incidence density (episodes per days of urinary catheter). . results. a total of patients admitted > days to the participating icus between may to january were included in the study. of these patients, ( %) had a urinary catheter inserted, with , urinary catheter days. one or more candida spp. in the urine were detected in patients. the rate of candiduria was per patients/icu and the incidence density . per days of urinary catheter. in cases, candida spp. in association with different bacteria ( . %) were found, mostly gram-negative pathogens ( cases), in particular p. aeruginosa (n= ) and e. coli (n= ), and gram-positive pathogens ( cases) especially enterococcos (n= ). in respect to candida spp., c. albicans predominated ( . %) followed by c. glabrata ( . %), c. tropicalis ( . %), c. parapsilosis ( . %), and c. krusei ( . %), independently of the week in which isolation of pathogens was made. conclusions: candiduria was diagnosed in % of critically ill patients admitted for more than days in the icu. candida albicans was the pathogen most frequently recovered ( . %), although c. non-albicans was isolated in one out of each three cases. a retrospective study was done over the last year that included neonatal patients admitted at the intensive care unit. all patients had congenital anomalies ( patients with gastroschisis ( . %), patients with esophageal atresia ( . %), and others with intestinal obstruction, duodenal atresia and malrotation). . % of the patients were on total parenteral nutrition and mechanical ventilation. the average stay in the icu was . days. candida albicans was checked for in swabs of wound, in blood-culture, stool-culture, urine-culture, tracheal aspirate, gastric asp results candida albicans was identified in patients ( . %). it usually appeared - days after the introduction of the antibiotic therapy. it was most commonly found in gastric aspirate ( . %), stool-culture ( . %) etc. it would first appear in gastrointestinal tract (stool-culture and gastric aspirate after days). in respiratory and urinary tract candida was identified after days, and in blood-culture after days. . % of the patients received cephtriaxon or ampicillin, and . % amikacin or gentamycin and metronidazol. morbidity in patients with yeast infection is very high. the most common causative agent is candida, and the predilection organ is digestive tract. risk factors are: prematurity, mechanical ventilation, total parenteral nutrition, longer hospital stay and widespectrum antibiotics. due to unspecific clinical picture early diagnosis is usually made according to the results of taken cultures. there are still many dilemmas regarding systemic antimycotic profilaxys. key: cord- -p q f c authors: nan title: posters_monday_ october date: - - journal: intensive care med doi: . /s - - - sha: doc_id: cord_uid: p q f c nan a huge variability in excess risk of death, ranging from to %, from ventilator associated pneumonia (vap) have been reported in the literature [ ] . this large between-study variation can be attributed to difference in definitions but also to incorrect estimation by standard statistical methods, i.e. inappropriate adjustment for informative censoring and time dependent confounders. the aim of this study was to take into account above statistical shortcomings and to assess the excess risk of vap by using an extension of a recently developed techniques from the field of causal inference [ ] . materials and methods. data was retrieved from a large longitudinal, high quality multi-centric icu database from france (outcomerea). a random sample of consecutive patients ventilated [ h from icus over a year period were included. vap was defined as clinical suspicion plus at least one positive proximal or distal sampling with quantitative count using classical thresholds. only the first vap episode was taken into account. we considered discharge from the icu as a competing risk and estimated the attributable -day icu mortality of vap by comparing the counterfactual cumulative incidence of death for the entire population under different hypothetical infection paths. baseline characteristics indicating underlying co-morbidity and longitudinal (daily measured) severity of illness indicators together with all other known confounders until vap developed were taken into account through the use of a marginal structural model [ ] . results. a total of , icu patients were included. mean (sd) age and saps ii score were ( ) and ( ), respectively. seventeen and % were admitted after scheduled and emergency surgery respectively, % were medical patients. forty-two percent had an underlying chronic illness (knaus). nine percent received dialysis in the icu. a total of ( %) patients developed vap within days of admission ( and % within and days, respectively). crude icu-mortality rates in patients with and without vap were and %, respectively. when taking into account all the confounders, we found a . % increase ( % ci . - . , p = . ) in the hazard of -day icu-death per additional day since the development of vap. provided vap could have been prevented in the whole population -day mortality would have decreased by . %. conclusion. the excess risk of death from vap estimated by marginal structural models is lower than commonly reported in the literature. this indicates that underlying comorbidities and the evolution of severity of illness until vap are insufficiently taken into account by current standard statistical methods. reference (s) . . rello et al ( ) introduction. the intensive care society (uk) has recently published national guidelines regarding many aspects of percutaneous tracheostomy management [ ] , however, these guidelines do not make any recommendations regarding antibiotic prophylaxis during the procedure. we recently audited uk practice and have established that only % of the units give prophylactic antibiotics for patients known to be colonised with methicillin-resistant staphylococcus aureus. the low rate of antibiotic use is surprising given that pneumonia and/ or bacteraemia following pt is frequently caused by organisms (non-mrsa) that colonise the patients' skin and/or airway [ , ] . objective. to establish the incidence of mrsa positive sputum and/or blood cultures following pt in patients colonised with mrsa in their nose or throat. methods. we audited all the patients who had pt performed between and who were known to be colonised with mrsa in their nose or throat, (but who had negative sputum cultures) before pt was undertaken. we wanted to find how many of these patients developed mrsa positive sputum and/or blood cultures in the first week following their pt. results. from a total of patients admitted to critical care between and only seven mrsa colonised patients required pt. all of these patients had mrsa colonised throat or nose with negative sputum and blood cultures prior to the pt. no patients were given prophylactic antibiotics during the pt as this was our standard practice. four ( %) developed mrsa positive sputum cultures in the first week following the procedure. one ( %) developed mrsa bacteraemia on day following pt. over the same period there were no case of mrsa bacteraemia in the mrsa colonised patients who did not undergo pt. microbiology bacterial biofilm has been observed in the surface of the endotracheal tube (ett) in mechanically ventilated patients and recent studies relate the presence of biofilm with the incidence of ventilator-associated pneumonia (vap). acinetobacter baumanii is a gramnegative opportunistic nosocomial pathogen involved in the production of vap, and capable of biofilm formation on abiotic surfaces. objective. to analyse the presence of biofilm in the ett by using scanning electron microscopy (sem) and to identify the microorganisms contributing to its formation in patients admitted in an icu endemic for a. baumanii. methods. from march to september , consecutive patients admitted to our unit and mechanically ventilated were included in the study. etts after extubation were (a) sent to microbiological culture, and (b) fixed with % paraformaldehyde- % glutaraldehyde for one hour, dehydrated with increasing ethanol concentrations, and processed for sem. etts were observed under sem to assess the presence and extension of the biofilm, and to recognize bacterial or fungal forms. results. there were males ( %) and females ( %) with a median age of years (range - ).the median apache ii score in the first h was (range - ). the median duration of intubation was days (range . causes of intubation were coma in patients ( %), respiratory failure in ( %), and heart failure in ( %). the microbiological isolations showed: a. baumanii ( %), staphylococcus non aureus ( %), pseudomonas spp. ( %), streptococcus viridans ( %), staphylococcus aureus ( %), enterococcus faecalis ( %), candida albicans ( %), and others ( %). under the sem, biofilm was identified in the % of all cases and was abundant in ( %), regular in ( %), and scarce in ( %). morphological identification of microorganisms observed under sem showed: cocci in ( %), bacilli in ( %), and yeast in ( % introduction. hospital-acquired infection is often linked to the standard of ward cleaning however the impact of increased quality of cleaning and deep cleans are unknown. objectives. this study aimed to determine the effect of enhanced cleaning on local contamination rates of hospital pathogens and whether this results in a reduction in patient colonisation. a cross-over one-year study was performed in the intensive care units (icu) of two teaching hospitals, which screened patients weekly for mrsa. in randomized two-month periods and in addition to conventional cleaning using detergent and mops, high contact areas were cleaned twice daily by a team of trained hygiene technicians using microfibre cloths. using contact plates, samples were taken at nine sites around the bed area and ward over bed-days per week. hand hygiene was encouraged and compliance audited. results. only . % of the planned , local samples were missed and this was equal between study phases. average hand hygiene compliance was similar between enhanced and standard phases [hospital a . % ( / ) vs. % ( / ) and hospital b . % ( / ) vs. . % ( / )]. patient characteristics were similar during standard and enhanced cleaning periods. of the sites tested, samples taken from bed rails were most likely to be contaminated with mrsa (or = . ; % ci: . - . ) followed by nurses' hands (or = . ; % ci: . - . ). analysis of these site-samples also confirmed that enhanced cleaning significantly reduced environmental contamination (or = . ; % ci: . - . ; p \ . ). the effectiveness of enhanced cleaning in removing mrsa contamination did not vary with the sample site. a sub-group analysis of samples only taken from nurses' hands showed a non-significant reduction in mrsa hand contamination associated with enhanced cleaning although associated uncertainty was large (or = . ; % ci: . - . ; p = . conclusions. this is the first prospective controlled study examining the effectiveness of enhanced cleaning in preventing spread of multiresistant pathogens within icu. although both environmental and hand contamination were reduced, enhanced cleaning of high contact surfaces was not associated with a reduction in cross infection. conclusions. isd of secretions reduces the incidence of vap in patients receiving. css alone, or in combination with isd has no significant effect on incidence of vap. hence, isd may be recommended for vap prevention, considerations other than prevention of vap should determine the choice of the suction system in a mechanically ventilated patient. to show a mortality benefit, larger, multi-center trials may be required. decreasing incidence of ventilator-acquired pneumonia (vap) is increasingly regarded as a priority in icu quality programs. subglottic secretion suctioning (sss) has been associated with a decreased risk of vap. a previous metaanalysis concluded that sss reduces the risk of vap, but it included only five randomized controlled trials (rct), and sss is still underused, perhaps considering the available evidence is insufficient. we planned a systematic review and metaanalysis of sss for vap prevention. pubmed, embase and cdsr were searched for rct studying the influence of sss on vap incidence. additional outcomes were mortality (within icu or hospital), icu and hospital stay, mechanical ventilation duration and time from intubation to vap diagnosis. additional references and sources of information were searched, and authors were contacted as necessary. rct were found, but one of them was excluded for not having enough data for analysis. rct were analysed, including , patients. quality of the rct was only moderate. qualitative outcomes were homogeneous between studies, so were analysed by a fixed effects model; quantitative outcomes were very heterogeneous, and were analysed by a random effects model. compared to control, sss decreased vap incidence (rr . ; % ci . - . ), but not mortality (rr . ; % ic . - . ). sss delayed vap onset for . days ( % ci . - . ), shortened mechanical ventilation for . days ( % ci . - . ) and decreased icu length of stay for . days (ic % . - . ). in two rct, no differences were found in the hospital length of stay. conclusion. sss reduces vap incidence and delays vap onset, shortening mechanical ventilation and icu length of stay, but not decreases icu or hospital mortality. data from rct support the use of sss as an adjunctive tool to prevent vap. introduction. in comparison to ventilator-associated pneumonia (vap), less data are available on ventilator-associated tracheobronchitis (vat). however, vat may be associated with considerable morbidity [ ] . aim. to investigate prospectively the incidence and outcomes of vat. we studied prospectively all patients who received mechanical ventilation in the general intensive care unit of a tertiary hospital in greece between september-november . vat diagnosis required temperature ([ °c) or leukocyte count [ . per ml or leukopenia \ . per ml) (at least one of these) plus new onset/change of purulent endotracheal secretions. vap diagnosis required the aforementioned criteria plus appearance of new and persistent pulmonary infiltrates on chest radiography. microbiological documentation was based on the growth of microrganisms in bronchial aspirations ([ . cfu) or bal ([ . cfu) . results. forty-six patients were included, median (iqr) age was ( . years. eleven ( %) patients presented vat, presented vap and patients presented none of these two disorders (np). there were no significant differences between vat and vap cases in terms of baseline characteristics (diagnosis, respiratory compliance, apachee, murray score), occurrence of sepsis or ards and microbiology; pseudomonas aeruginosa, acinetobacter baumannii, staphylococcus aureus and klebsiella pneum. were the most common bacteria in both vat and vap. patients who presented vat or vap had significant longer hospitalization and mechanical ventilation duration (days) compared to , ( - ) vs. ( - ), (p = . )] and [ ( - ) , ( - ), ( - ) , (p = . ), respectively]. icu mortality was , , %, for patients with vap, vat and np, respectively (p = . ). conclusions. incidence and microbiological pattern was similar in vap and vap in these case series. both vat and vap were associated with longer hospitalizations and mechanical ventilation duration. further analysis with a larger cohort of patients is required to give conclusive remarks. reference (s) . . nseir s et al ( ) nosocomial tracheobronchitis in mechanically ventilated patients: incidence, aetiology and outcome. eur respir j : - . g. c. choutas , v. g. nolas , a. kalantzi , a. moutzouri , g. k. anthopoulos intensive care unit, \ \ [ [ general air force hospital, athens, greece introduction. endotracheal suctioning is an essential part of care for patients receiving mechanical ventilation, to keep the airways free from bronchial secretions, assuring ventilation and oxygenation. there are two types of suction systems. in the open system, endotracheal suctioning requires disconnecting the patient from the ventilator and introducing a single-use sterile suctioning catheter into the endotracheal tube. closed systems are changed every and h. to determine whether ventilated patients treated with css in an intensive care unit (icu) differ as to airway bacterial colonization and colonization of the suction system based on cultivation of both bronchial secretion and suction catheter tip and if cultivation of suction catheter tip is adequate in place of bronchial aspirate cultivation. methods. patient, incubated and ventilated in the icu ward were studied in a period of one year ( to ) , on admission to the icu a css (trach care mac) was connected. closed multi-use catheters were changed daily. two-pass endotracheal suctioning was performed as needed. ba cultures were obtained on admission and the next day. radiographs taken before, during, and after ba and css cultures were graded for pneumonia and a modified score for vap. of the patients css samples ( . %) and ba samples ( . %) were sterile. airway colonization with gram-negative bacteria and fungi occurred in the majority of the patient . % and gram-positive bacteria in %. cultivation of css revealed gramnegative bacteria and fungi occurrence . % and gram-positive bacteria in . %. with the current sample no significant difference was found between the positive results of trach care tip cultivation and ba cultivation p = . . objectives. to reduce the use of sedatives and to decrease the amount of time spend on a ventilator by specific ramsay-instructions and checks for sedation-protocol-adherence. methods. in april , after introductional lessons to doctors and nurses, we started and collected data for months. a yellow reminder was attached to the medical-instructions-form and doctors were requested to fill in the ramsay-score on a daily basis. once in a week patients and records were screened to assess protocol-adherence. each nurse and each intensive care-unit received feedback on their compliance to the bundle-elements. the total amount of sedatives per month was divided by the number of ventilator days, resulting in an average dose midazolam/propofol per ventilator day. the median and interquartile range of ventilator days/patient was also calculated and all data were compared with the same period in . we accomplished a reduction in the use of sedatives and costs. introduction. ventilator associated pneumonia (vap) often occurs in patients who are mechanically ventilated. the incidence rate varies between and % for patients in the intensive care unit. it has been the second most common hospital-associated infection after that of the urinary tract. the diagnosis of vap is difficult because of different existing definitions. hypothesis. our hypothesis was, that lowering vap incidence rate, could be done by a bundle of five interventions. the purpose of introducing multiple ventilatory interventions as a bundle, was to lower vap incidence rate by %. methods. during the last months of all patients who were ventilated [ h, were investigated for vap. the diagnosis of vap was done according to the criteria supposed by the dutch working group on infection prevention. a new infiltrate on chest x-ray after h ventilatory support in combination with fever, leucocytosis, increased need for oxygen and culture of blind bronchial secretion c cfu/ml. a ventilator bundle was introduced on all icu wards as inspired by the institute of healthcare improvement. five interventions were introduced: head of bed [ °, reduction of sedatives as low as possible according to prescribed ramsay score, assessment of readiness to extubate, cuff-pressure measurement times a day with application of cuff pressures between and cm h o, and oral care with chlorhexidine . % times a day. icu nurses were trained in the first months of . the last months of were used to evaluate the bundle intervention in comparison with the last months of . results. patients were included in and in . after introduction of the ventilator bundle, the incidence per , ventilator days decreased from . % to . % per , ventilator days. introduction. continuous positive airway pressure (cpap) may improve oxygenation in patients with mild to moderate acute hypoxemic respiratory failure (ahrf) and avert further deterioration and need for intubation. objectives. aim of our study was to assess the physiologic effects produced by the addition of periodic hyperinflations (sigh) to cpap in patients with ahrf. we studied patients with non-cardiogenic ahrf. four trials of one hour each were performed at a constant fio % during ( ) spontaneous breathing (sb) via a venturi mask, ( ) cpap , ( ) cpap ? sigh/min of cm h o for s (cpap sigh ), ( ) cpap . cpap, via helmet, was maintained at cm h o troughout the whole study period. pao /fio ratio (p/f), paco , ph, respiratory rate (rr), arterial blood pressure (abp), heart rate (hr), dyspnea and patient comfort (by means of separate visual analog scales) were measured at the end of each trial. results. overall, p/f was significantly (p \ . ) improved by cpap (cpap ± mmhg, cpap sigh ± mmhg, cpap ± mmhg), as opposed to sb ( ± mmhg). overall, the sigh did not significantly improved p/f. in the six patients with bilateral infiltrates, however, the rate of improvement in p/f significantly (p \ . ) augmented with the introduction of a sigh as compared with those with monolateral infiltration ( vs. % respectively, being % the increase from venturi to cpap ). paco , ph, rr, hr, abp, dyspnea and comfort were not significantly different between trials. conclusions. in patients with ahrf, cpap improves oxygenation without affecting hemodynamics. the addition of a sigh to cpap further improved oxygenation only in patients with bilateral pulmonary infiltrates. background. adaptive support ventilation (asv) is a novel electronic ventilator protocol that incorporates the recent and sophisticated measurement tools and algorithms. the target tidal volume and respiratory rate are continually adapted to patient's respiratory physics and varying medical conditions. in injured lung, the asv should actively adjust ventilatory parameters achieving minimal work of breathing to meet the lung protective strategies. but there were little literatures describing its efficacy when applied to korean population. methods. from may to january , we observed initial mechanical ventilation parameters in patients receiving asv due to various causes ( lung injuries including community acquired pneumonia, hospital acquired pneumonia, interstitial lung diseases, pulmonary tuberculosis and idiopathic cases; without lung injury which comprise trauma cases, strokes, suicidal attempts and other cases). the mean age of studied population was . years (male:female = : ). the data were collected within the first h of mechanical ventilation. conclusion. as expected, adaptive support ventilation delivered smaller tidal volume and higher respiratory rates for injured lungs. asv efficiently operated in korean ali patients without any serious drawbacks and favorably adjusted the tidal volume and respiratory rates combination in relation with rcexp to meet lung protective strategies. introduction. neurally adjusted ventilatory assist (nava) is a mode of mechanical ventilation that uses the electrical activity of the diaphragm to control the ventilator obtaining an improved patient-ventilator synchrony and an efficient unloading of the respiratory muscles. nava is characterised by a variability of the breathing pattern and the absence of a constant flow, which makes impossible the determination of reliable data of respiratory mechanics by using the rapid occlusion method. we have previously demonstrated that the least squares fitting method (lsf) could be used during pressure support ventilation (psv), provided that the level of ps is sufficiently high to unload the inspiratory muscle. hence we made the hypothesis that ( ) reliable data of respiratory mechanics can be obtained by applying the lsf method during nava and ( ) the lsf method should work better during nava because of the characteristics of the flow and pressure traces. methods. ten patients undergoing mechanical ventilation for acute respiratory failure were enrolled. they were ventilated using randomly either psv or nava with the the same peepe and tidal volume (v t ). data of resistance (r rs ), elastance (e rs ) and total positive end expiratory pressure (peep tot ) were obtained by fitting the equation paw = r rs v ? v t / c rs ? peep tot during inspiration, because of the possible presence of expiratory flow limitation. the coefficient of determination (cd) of the applied equation was used to compare data obtained during nava and psv, the higher being the cd, the better the quality of the data. moreover patients were sedated and ventilated in volume controlled ventilation (acv) with the aim of calculating data based on rapid occlusion method and compare them with those obtained with lsf method by using the bland-altman analysis. ( ) data obtained with lsf were statistically more reliable during nava (mean cd: . ± . ) than during psv (mean cd: . ± . ; p \ . ). ( ) the cd obtained at every level of nava was always higher then . . on the contrary, the cd obtained at low level of psv was less than . due to the presence of inspiratory muscle activity. ( ) the bland-altman analysis demonstrated lower bias and higher precision between traditional data and those calculated during nava (bias: . ; limit of agreements: - . / . ) compared to psv (bias: . ; limit of agreements: - / . ). conclusion. the application of the lsf method during nava allows calculation of reliable data of rrs, ers and peeptot, which are independent of the level of nava applied. this is of clinical relevance since psv allows calculation of reliable data only at high level of pressure support. it appears that the influence of inspiratory muscle activity on respiratory mechanics is less relevant during nava ventilation, suggesting a more physiological ventilation during nava both in terms of timing and of delivering adequate level of assist throughout each breath. introduction. nava is a new spontaneous-assisted ventilatory mode based on the detection of diaphragmatic electrical activity (eadi) and its feedback to adjust ventilator settings. nava uses the eadi, an expression of the respiratory center's activity, to initiate pressurization, set the level of pressure support and cycle the ventilator into exhalation. therefore, nava should theoretically allow near-perfect synchronization between the patient and the ventilator. however there are few data documenting these effects in intensive care patients. to determine whether nava can improve patient-ventilator synchrony compared to standard pressure support (ps) in intubated intensive care patients. comparative study of patient-ventilator interaction during ps with clinician determined ventilator settings and nava with nava gain (proportionality factor between eadi and the amount of delivered inspiratory pressure) set as to obtain the same peak airway pressure as the total pressure obtained in ps. a min continuous recording with each ventilatory mode was performed allowing determination of trigger delay (t d ), patient neural inspiratory time (t in ), duration of pressurization by the ventilator (t iv ), excess duration of pressurization (t i excess = t iv -t in /t in ) and number of asynchrony events by minute: non-triggering breaths, auto-triggering, double triggering, premature and delayed cycling. results are given in mean ± sd. p is considered significant if . . . ± . . ± . . ± . n asynchrony/minute . ± . . ± . * . ± . respiratory rate (min - ) . ± . . ± . na * p \ . conclusion. compared to standard ps, nava improves patient ventilator interaction by reducing td and the overall incidence of asynchrony events. there is also a strong trend in reducing delayed cycling. this ongoing trial should provide evidence that nava can indeed improve patient-ventilator synchrony in intubated patients undergoing ps. introduction. high fio and hyperoxia may induce pulmonary injury and may increase oxidative stress. guidelines suggest a target arterial oxygen tension of kpa [ ] . a canadian questionnaire study found considerable variation in the attitudes, beliefs and practices of intensivists in the management of oxygen therapy [ ] . however, the actual response of intensivists to hyperoxia in patients has never been studied. in this retrospective database study we investigated adherence to guidelines concerning oxygen therapy in a dutch academic intensive care. all arterial blood gas (abg) data from mechanically ventilated patients from to were drawn from an electronic storage database (metavision) of a mixed -bed icu in a university hospital in amsterdam. mechanical ventilation settings at the time of the abg as well as the successive abg were retrieved. the statistical analysis was carried out with spss . . results. . abg's from mechanically ventilated patients were retrieved including corresponding ventilator settings. in . ( %) of the abg's po was[ kpa. initial ventilator settings and adjustments based on abg's of this group are shown in table [data represent median ( th/ th percentile)]. in % of the lowest fio group, fio was exactly %. in only % of cases with po [ kpa the fio was decreased. hyperoxia was accepted with no adjustments in ventilator settings if fio was % or lower. introduction. major patient ventilator asynchronies are frequent during non-invasive ventilation (niv) especially due to leaks.niv can be delivered using icu ventilators or specifically designed niv ventilators. although icu ventilators are traditionally used for invasive mechanical ventilation, specific niv modes have been recently implemented. the impact of these niv modes as well as niv ventilators on patient ventilator asynchrony is unknown. our objective was to compare the incidence of patient ventilator asynchrony between invasive or niv mode of icu ventilators and niv ventilators. patients and methods. icu patients with acute respiratory failure requiring niv were studied during three randomized consecutive min-periods of niv: icu ventilator with and without niv mode and niv ventilator. we used two icu ventilators: evita xl (dräger) and engström (general electrics) and niv ventilator: bipap vision (respironics). flow and airway pressure were continuously recorded to determine breathing pattern. to detect major patient ventilator asynchrony we used surface diaphragmatic and/or sternocleidomastoid electromyogram allowing to assess neural patient's inspiratory time and to define asynchronies: ineffective triggering, auto-triggering, double-triggering, prolonged and short cycles. asynchrony was quantified using an asynchrony index as previously described. results. these preliminary results concern ten patients ( males and female) with a mean age of ± and a saps of ± . reason for niv was acute exacerbation of copd (n = ), acute pulmonary edema (n = ) and post-extubation (n = ). at time of study, ph was . ± . , paco ± mmhg and pao ± mmhg. ventilatory settings were set by the clinician and kept constant during the three periods with a ps level of ± cm h o and a pressurization ramp of ± ms, a peep level of ± cm h o and a fio of ± %. using icu ventilators, inspiratory trigger was l/min and cycling off was % when adjustable. median asynchrony index was . % ( . - . ) using icu ventilators versus . % ( . - . ) using niv mode and . % ( . - . ) using bipap vision (p = . between invasive and niv mode, p \ . between niv mode and bipap vision). asynchrony index was greater than % in three patients using invasive mode, two patients using niv mode and no patient using bipap vision. auto-triggering was the main asynchrony. conclusion. niv ventilator (bipap vision) allowed a marked reduction in patient ventilator asynchrony during niv as compared to niv mode currently available on new generation of icu ventilators. grant acknowledgement. this study was supported by a research grant from respironics. a. armaganidis , k. stavrakaki-kallergi , c. sotiropoulou , a. koutsoukou , j. milic-emili , c. roussos athens university, athens, greece prevalence of expiratory flow limitation (efl) was estimated using the negative expiratory pressure method (nep) in anesthetized, paralyzed mechanically ventilated patients in icu. patients were studied in supine position at zero positive end-expiratory pressure (peep). a nep device especially designed and in build in an evita -draeger respirator, allowed the application of a pressure equal to- cm h o, starting at ms after the onset of expiratory flow and sustained throughout the end of the expiratory time set on the ventilator. patients were categorized in two groups: . non efl ( patients without flow limitation), in whom nep elicited an increase of expiratory flow over the entire expiratory flow-volume (v -v) curve. . efl ( patients with efl), in whom part or the expiratory v -v curve during nep was superimposed on the baseline v -v curve. half of our patients ( %) were flow-limited. no patient without pulmonary disease was found flow-limited, except of a percentage of morbidly obese patients ( %). efl was recorded in % of icu patients with pulmonary diseases: % of ards patients, % of patients with respiratory infection, % of asthmatics and % of patients with copd. time constant (s) and inspiratory flow (v insp) were found to predict the severity of flowlimitation expressed as efl % v t . objective. tidal volume (v t ) administered to ards patients can be adjusted depending on body weight. body weight may be estimated, measured or calculated for an ideal or a predicted value based on different formulas [ , ] . besides, those formulas require the measurement of height and may differ depending on gender. we hypothesized that v t value (ml/kg of body weight) may be different and show intrameasure variability depending on the method used. methods. ards patients were included prospectively in the first h after icu admission. the ventilatory parameters were selected by the attending physicians that were foreign to the study. all patients were ventilated by volume controlled-assisted mode. five independent observers estimated the weight (estw) of each patient. they also measured height with a metric tape for calculate the predicted body weight (pbw) [ ] and the ideal body weight (ibw) [ ] . after previous measurements, patients were weighed once with a calibrated scale (scaw). results were compared using analysis of variance. results. patients were studied, % women (age . ± . , saps ii . ± . ; apache ii . ± . ). ventilation parameters at inclusion: v t /scaw (ml/kg) mean ± sd . ± . . ± . . ± . . ± . . ** mean ± sd mean ± standard deviation, min minimum, max, maximum, pbw (men) or . (female) ? . (height in centimetres - . ), ibw (height in meters) , mean diff average of the intraindividual differences of calculated/estimated weight, range intraindividual difference in weight (estimated/calculated) expressed as minimum and maximum * estw versus pbw p \ . , pbw versus ibw p \ . , pbw versus scaw p = . ** v t /estw versus v t /pbw p \ . , v t /pbw versus v t /ibw p \ . , v t /pbw versus v t /scaw p \ . conclusions. our data show that there is no gold standard method for estimate or calculate body weight to adjust tidal volume in ards patients. recommendations based on pwb and ibw not guarantee that tidal volume administered is really those that we want to administrate. reference (s) . . ardsnet. nejm ; : - . . stewart te et al ( hôpital raymond poincaré ap-hp, service de réanimation médicale, garches, france, hôpital saint-louis, paris diderot university, paris, france, centre hospitalier d'etampes, etampes, france, université versailles saint quentin en yvelines, versailles, france rationale-objectives. dyspnea is a major respiratory symptom, which can reveal a severe disease. additionally, it can also result from an inappropriate ventilator setting in mechanically ventilated patients. if these patients are nowadays more and more conscious, prevalence of dyspnea and its clinical, biological and radiological correlates has never been assessed in this population. prospective cohort study conducted in two medical intensive care units (icu) during months. all patients intubated more than h and conscious have been included. the first day when the patient regained consciousness, dyspnea, anxiety and pain were assessed using a visual analogic scale (vas). if dyspnea was found, patient was asked if he experienced ''air hunger'', and/or ''excessive respiratory effort'' and if dyspnea vas was improved after ventilator setting has been changed. demographic, clinical, biological and chest x-ray data and ventilator settings have been collected. results. patients were included (age: ± years; simplified acute physiology score ii (saps ii): (iqr - ). reasons for mechanical ventilation included acute respiratory failure (n = , %), neuromuscular diseases (n = , %), coma (n = , %), and exacerbation of chronic obstructive pulmonary disease (n = , %). dyspnea was present in ( %) patients and was qualified as ''air hunger'' in patients ( %), ''excessive effort'' in ( %) and both in ( %). age, saps ii, reason for mechanical ventilation, respiratory rate, clinical examination, x-ray chest, pao /fio ratio, paco were not statistically different between patients with and without dyspnea. anxiety . ); p \ . ), assist controlled ventilation [ . ( . - . ) ] and diastolic blood pressure ; p = . ) were independently associated with dyspnea in multivariate analysis. ''air hunger'' tended to be associated with controlled ventilation (p = . ) whereas ''inspiratory excessive effort'' was significantly associated with low inspiratory flow, severe hypoxemia (median pao /fio ratio: , p = . ) and marked hypercapnia (median paco : mmhg, p = . ). in % of breathless patients, of ventilator resetting decreased dyspnea. length of icu stay was greater in patients with dyspnea (p = . ) whereas extubation within three days and icu mortality did not differ between the two groups. conclusions. dyspnea is frequent in mechanically ventilated patients and is strongly associated with anxiety, more frequently when controlled ventilation is used and is often reduced after ventilator resetting. assessment of dyspnea in conscious mechanically ventilated patients should be routinely performed in order to improve patients' comfort. methods. an experimental study design was used with a group of first year health care provider students. the students were divided into two groups related to familiarity of the location of exam. a part of students (n = ) were examined in demonstration room (dr) and the other part of students (n = ) in public place (pp) . every student received the same number of training hours ( h) and the same training method in demonstration room. during this exam the students performed a min long, single person cpr related to erc guideline. their performance was measured with calibrated ambu cpr software and the adapted point system of brendan b. spooner's scale. v and t test were used for comparison. p values less than . were considered statistically significant. we did not find difference between dr and pp groups in the correct sequence of bls steps, hand position, adequate frequency and depth of chest compression. between groups of characteristics of ventilation were not significant differences observed. it is first critical point in bls process to assess the quality of patients' spontaneous breathing; therefore it is crucial that the duration of check breathing may be sufficient long. the duration of checking for breathing was significantly (p = . ) shorter in dr groups than pr groups. in the pp groups time interval between chest-compression cycles were significantly (p = . ) longer-more than s-than in dr group. conclusions. the altered location of bls final exam shortens duration of checking for breathing which determines bls providers' decision making on starting chest compressions. the students may be full of confident in the well-known place represented by the shorter time of checking for breathing. the changed place of exam extended time interval between chestcompression cycles, therefore weaken the continuity of chest compressions, and decrease the chance of return of spontaneous circulation. aims. this paper reports an evaluation of the student experience of using a clinical competence assessment tool (ccat) in postgraduate critical care nursing education. the focus is on the perceptions of students in relation to the validity, reliability and usability of the assessment tool. the domains of competence assessed are based on five domains outlined by an bord altranais ( ) . they are: professional/ethical practice, interpersonal relationships, practical and technical skills, utilising a holistic approach to care, clinical decision making and critical thinking skills and organisation and management of care. the assessment process encompasses three clinical assessments and clinical competence is measured using the developmental process of novice, advanced beginner, and competent as described by benner ( ) . students are asked to reflect on their own learning needs prior to each assessment. the assessment includes a discussion on the knowledge that underpins practice thereby showing the integration of theoretical and practical knowledge. questionnaire was administered to all students who recently completed a graduate diploma in nursing studies (critical care) at a specific third level institution. results. the evaluation of the ccat as a mode of competence assessment in postgraduate critical care nursing education was generally positive from the students' perspective. some students considered the holistic nature of the ccat document to be a limitation, suggesting that their level of competency could have been better addressed with a tool that was more oriented toward critical care rather than being so 'broad' in nature. overall respondents considered that the ccat helped them to identify learning needs and found the use of the tool to be a positive experience and easy to use although some respondents considered that the wording of some of the sub-domains and indicators was difficult to interpret. competence assessment is about ensuring the delivery of safe and competent patient care. in order to determine competence a valid and reliable tool is needed. this small scale study presents the views of post registration critical care nursing students on using a competence assessment tool. the findings of this study cannot be generalised, however they do provide insight for educators and students using competence assessment tools in programmes preparing registered nurses for specialist nursing practice. the use of a holistic assessment process needs further explanation. students need to be encouraged to move away from the reductionist approach, which is focussed on tasks and move towards a broader understanding of competent practice. reference (s) . . an bord altranais ( ) requirements and standards for nurses registration education programmes, nd edn. . benner p ( ) from novice to expert excellence and power in clinical nursing practice. addison-wesley, california. to assess the usefulness of a web-based interactive learning package designed to supplement an undergraduate acute care course (very basic) taught to final year medical students. a web-based interactive learning package was developed to supplement a highly rated traditionally taught -day acute/critical care course consisting of pre-course reading, lectures, skill stations and interactive tutorials [ ] . the additional web-based package consisted of narrated lectures, interactive lessons, videos and animations to demonstrate practical procedures and clinical signs, self assessment quizzes and a question and answer forum. topics covered included arterial blood gas sampling and interpretation, acute metabolic disturbances, non-traumatic coma, acute respiratory failure and sepsis. both the package and the course are available to other medical schools free of charge. usefulness of the package was assessed by examining activity logs, a student questionnaire, formal focus group (conducted by an investigator not involved in course preparation or teaching), comparing the results of a post-course mcq based summative assessment with historical controls and comparing results of formative assessment included in the package with the summative assessment. results. over , student-activities were logged by students during the two week course. students completed the questionnaire. with regard to usability, [ % agreed or strongly agreed that interactive lessons and self assessment ran smoothly without faults, with a corresponding score of [ % for narrated lectures and ease of browsing. with regard to usefulness, c % agreed or strongly agreed that the question and answer forum was useful in clarifying areas of doubt and narrated lectures improved understanding of the course material; [ % agreed or strongly agreed that the content as a whole was useful in preparing the respondent to work as a doctor, interactive lessons improved their understanding of how to apply their knowledge, and their understanding of arterial blood gas interpretation and self assessment exercises improved their understanding of the course material. participants in the focus group indicated that the resources provided in the website were useful for learning, specifically the animations, narrated lectures and the question and answer forum. suggestions for improvement included improving the quality of the video and animations, increasing the range of topics covered and ensuring consistency with the printed course manual. there was no correlation between formative and summative assessments but, compared to historical controls, performance in the summative assessment improved ( vs. %, p \ . ). conclusions. the package provided a useful supplement to a traditionally delivered acute care course. introduction. faculty development refers to that broad range of activities that institutions use to renew or assist faculty in their roles. it includes activities that improve an individual's knowledge, skills and attitudes in important areas in teaching, education, research, leadership, administration and career development. in this abstract we will introduce one of the most important methods of faculty development programs. a meeting by the authors ''organizing group'' was conducted to decide on a topic for our workshop and discussed the planning and designing process. we decided on conducting a workshop on clinical teaching methods. a scientific and organizing committee was established, and accordingly work loads and assignments were distributed among them. we gave this workshop a title of ''i am the best clinical educator…are you!? our target audience was acute care management providers, with a capacity of up to participants. we gave a specific time and location of this event. venue was arranged. computers for group work, audiovisual and other logistics were provided. after summarizing the main points for the workshop the organizing committee distributed an invitation letters throughout the higher management and educational leaderships. an address remark was done through invitation from the organizing committee. hot and cold beverages and break lunch meals were provided. posters on the workshop were distributed through out the institution. folders with educational materials were provided for each candidate. pre-course registration was done. once the program for the workshop was finalized a reminder was sent out to the participants on the date and venue for the workshop. participants attended on time, folders, badges with usbs were handed out. a questionnaire was distributed to the audience to estimate their learning experiences and approaches towards teaching styles and methods which were used in their practice. certificates of attendance with cme credit hours were distributed. results. candidates attended this faculty development workshop. % were nurses and % were physicians, during this workshop, three topics were distributed over three groups, one group on how to break bad news. second group about how to conduct microteaching and the third group about how to give feedback. each group was evaluated by three members of the organizing committee, each group was ranked accordingly. all were performed by role play. at the end of the workshop an evaluation form was filled % responders. a five performance scale was used. the strength of the workshop was innovativity and ranked as strongly agree. the only weakness was the place constraint. conclusion. we concluded that a well organized workshop using role play, interactive sessions are effective modality for faculty professional development programs among acute care providers with high satisfaction rate. only of the respondents ( %) indicated they did understand the statistics they encountered in journal articles and % felt it was important to understand these concepts and that they would like to access more easily to biostatistics training. a patient is referred to a higher centre when services are needed to maintain continuity of care.there are guidelines for the safe inter and intrahospital transport of critically ill patients but no guidelines are available for the minimal mandatory content of interhospital referral notes of critically ill patients.this problem is manifold in developing countries. objective. to educate the critical care physicians regarding the deficits in the physicians referral notes with which critically ill patients are referred from one centre to another. it is a prospective observational study on out of hospital referred patients transferred to our intensive care unit (icu) over a period of year. after permission from the institutes ethical committee we reviewed the referral summaries of these patients at the time of icu admission regarding the information available of clinical details, course in the previous hospital and therapeutic interventions. patients with more than h of hospitalization before transfer were included in the study. introduction. in japan, closed icus have been gradually increasing at university hospitals. a closed icu is necessary for a university hospital not only for the hospital activity but also the education of medical students and the training of fellows. they can learn how to manage the circulation and respiration status of severely ill patients in icu. it is indispensable for effective education to ensure sufficient proper icu staffs. but the present condition of our country is that there are not so many intensivists enough to perform both of clinical duties and education of students and fellows. each icu of university hospitals is endeavoring to increase the number of intensivists. one of the popular methods is the announcement on web site to promote interest of young fellows. regrettably, the homepage of the japanese society of intensive care medicine has no such specific pages. each icu of university hospitals has to create attractive its own pages in the homepages of the hospitals. [ ] . most subjects are taught using lectures and group tutorials and the theory is applied in clinical areas to facilitate greater understanding of the newly acquired knowledge. there is no reported best practice mechanism for teaching medical ethics in a practical setting to medical students. objectives. the routine use of an ethical checklist has been proposed as a tool for the medical team to consider ethical issues on critical care [ ] . its use as a tool for teaching medical ethics within critical care has not previously been reported. the aim was to use this checklist to facilitate learning providing clinical case material for discussion in daily tutorials. one medical student (sm) undertook a one week period of study to learn about ethics in critical care practice. the checklist was used to review patient notes, guide further discussion with patients, when observing the professional behaviours and communication of the multidisciplinary team, and as a guide for case based discussions. results. the complexity and severity of patient conditions in critical care makes it the ideal setting for learning about ethics. sm considered more ethical dilemmas in this practical attachment than in the previous years of clinical placements. the checklist allowed identification of possible ethical issues relating to each patient and a deeper understanding of the patient's health care needs. it was used for daily tutorials to discuss the ethical principles and observed professional behaviours in a similar way to a discussion of clinical diagnosis and management of a patient case with a supervising doctor on a normal clinical attachment. complex issues such as capacity to consent, end of life treatments or resource allocation were seen in relation to ongoing care. on ward rounds it was observed that their conduct in an open environment could at times potentially compromise patient confidentiality. there was also a benefit from the consideration of ethics issues in a real time basis which allowed exploration and reflection on personal moral or spiritual beliefs and how they may differ from those of the patients and other medical professionals. conclusions. using an ethical checklist allowed application of theoretical lecture and workshop material to real life situations. by discussing the cases and observed behaviours with a senior critical care doctor it is possible for trainee staff to appreciate how difficult medical management decisions are made, and to improve the acquisition of the skills necessary to start to assess and discuss ethical issues surrounding a patient's care confidently. introduction. accurate data on patient's weight and height are important for management in intensive care units (icus). unfortunately, weight beds or bed scales are not available in a significant number of icus and these variables are often estimated by health care personnel. the accuracy of such estimations is poorly described. objective. to investigate the accuracy of visual estimation of weight and height in critically ill patients. methods. prospective study conducted in a -bed mixed medical and surgical icu. patients were consecutively weighed by an unblinded physician with a stretcher scale (t metric), and measured by a physical therapist using a measuring tape. the ideal weight was calculated using the ardsnet's formulas for predicted body weight. medical staff (ms), internal medicine resident (imr), nursing staff (ns), physiotherapist (pt) and nutritionist (nu) were asked to estimate patient actual weight, ideal weight and height. they were blind to the estimations during all the protocol. estimations in each healthcare group were computed as means, medians and percentage of error from actual and ideal weight and height, respectively. anova test was used to compare mean estimations between the groups. there were no significant differences between the groups in estimation of either weight (p = . ) or height (p = . ). conclusion. weight estimations from healthcare personnel are often inaccurate. there are no significant differences in accuracy between the estimations of weight and height in different healthcare groups. an effort should be made to weigh all critically ill patients. intraabdominal hypertension (iah) is often diagnosed in icu and it can lead to abdominal compartment syndrome, multiple organ failure and death [ ] . in clinical setting biochemical signals based on which iah is considered severe or detrimental on visceral tissues are scarce. currently, the only clinically relevant signal is decreasing hourly diuresis. in an attempt to find an early sign of metabolically relevant signal on clinically marked iah we investigated abdominal wall metabolite concentrations. previously high lactate/pyruvate has been detected in dialysate from rectus abdominis muscle (ram) in animal models of iah [ ] . in the present experiment we hypothesized that laparoscopic surgery which induces iah could lead to clinically significant increase of l/p ratio as a signal of anaerobic metabolism caused by iah and insufficient tissue perfusion. introduction. among the techniques proposed to assess microperfusion and oxygenation, nirs sounds to be convenient [ ] . if baseline measurements do not provide useful information for outcome of micro-vascular impairment, functional evaluation using vascular occlusion test (vot) seems to be promising [ ] . technological development of the nirs device (inspectra models and , hutchinson technology, hutchinson, minn) proposes to use a new probe measuring hemoglobin saturation at less depth than previously ( vs. mm between fiberoptic) with more data output ( value/ s vs. value/ . s) associated with an automated software to compute occlusion and reperfusion slopes. objective. to compare nirs results obtained, using the two different probes, at day of septic shock (ss) in two groups of patients having similar clinical characteristics. methods. patients (g ) and patients (g ) were included within the first h of ss. macrohemodynamic: heart rate (hr), mean arterial pressure (map), central venous pressure (cvp), cardiac output (co) and svo (mixed venous o saturation), ph, base excess, and lactate were collected as saps ii and sofa scores. baseline sto at thenar eminence was continuously monitored and a min upper arm(brachial artery) vot was performed. sto occlusion and reperfusion slopes were calculated manually in g (probe mm) using linear adjustment (r c . to be valid) or calculated by the software in g (probe mm) using the same method, p \ . was considered significant. results. median ± iqr. the two groups did not differ for macrohemodynamic nor for metabolic data (table ) . nirs data surprisingly were largely significantly different between the two groups for both baseline and slopes ( background. hypovolemia and hypovolemic shock are life-threatening conditions that occur in numerous clinical scenarios. near-infrared spectroscopy (nirs) has been widely explored, successfully and unsuccessfully, in attempt to function as an early detector of hypovolemia by measuring tissue oxygen saturation (sto ). in order to investigate the measurement site-and probe-dependence of nirs in response to hemodynamic changes, such as hypovolemia, we applied a simple cardiovascular challenge; a posture change from supine to upright, causing a decrease in stroke volume (as in hypovolemia) and a heart rate increase in combination with peripheral vasoconstriction to maintain adequate blood pressure. methods. multi-depth nirs was used in nine healthy volunteers to assess changes in peripheral vascular tone in the thenar and forearm in response to the hemodynamic changes associated with a posture change from supine to upright. a posture change from supine to upright resulted in a significant increase (***) in heart rate. thenar sto did not respond to the hemodynamic changes following the posture change, whereas forearm sto did. in the forearm, sto was significantly lower (***) in the upright position with respect to the supine position. conclusion. the primary findings in this study were that ( ) forearm sto is a more sensitive parameter to hemodynamic changes than thenar sto and ( ) cerebral hyperperfusion syndrome, caused by inflow at normal blood pressure into maximally dilated fine vessels, is a recognized complication of carotid endarterectomy (cea) strict blood pressure control in the early postoperative period can minimize the risk of cerebral hyperperfusion. until yet, diagnosis of cerebral hyperperfusion mainly relies on intermittent postoperative examinations (spect; ct angiography). non-invasive absolute cerebral oxygen saturation (scto by fore-sight technology) was validated to jugular bulb saturation (sjo ) monitoring with a constant difference of % higher for scto values. previously, sjo monitoring after severe head injury indicated cerebral hyperemia. in this study, we evaluated scto monitoring after carotid surgery as possible continuous on-line monitoring of cerebral hyperperfusion. fourteen pts scheduled for cea were monitored for h postoperatively after cea. bilateral scto monitoring was started before induction of anesthesia and maintained until h postoperatively. intra-operative eeg monitoring guided the decision to intraluminal shunt insertion. strict blood pressure control was applied at maintaining normotensive levels throughout the clamping procedure. early postoperative care focussed on strict maintenance of normotensive blood pressure. in no pt, any change in eeg was observed after carotid clamping. in all pts, ipsilateral scto significantly decreased after carotid clamping, without any scto value below %. we observed no changes in contralateral scto . mean clamping time was min ( - min). in all pts, clamp release restored ipsilateral scto to baseline values. in all pts, emergence from anesthesia was uneventful, without any new neurological deficit. in of pts, significant increases (scto [ %) in ipsilateral scto were observed in the postoperative period (m scto . %), without any changes in contralateral scto . this increase occurred at a mean of . h after carotid declamping with a mean duration . h. in these pts, we could not make any significant correlation to arterial blood pressure, as none of these pts needed more aggressive antihypertensive control. we noted that of these pts suffered from diabetes mellitus, while of pts revealed high ([ %) contralateral stenosis. further data will have to reveal the importance of these comorbide factors. non-invasive cerebral oximetry, enabling absolute cerebral oxygen saturation monitoring, could provide on-line estimation of cerebral perfusion state after cea. this could allow bedside detection (and eventual therapeutic interventions) of cerebral hyperperfusion after cea. introduction. analysis of microcirculatory alterations obtained by side-stream dark field (sdf) is time consuming. automated analysis with modern softwares could accelerate this process and help to quantify blood flow velocity. however, perfusion detection is based on the contrast between pixels and this may be influenced by image settings. objective. we aimed to compare data obtained with a new software to the traditional semi-quantitative analysis of sdf images. methods. we selected from our database six images of poor sublingual microcirculatory perfusion and six images of good microcirculatory perfusion registered by the sdf technique (microscan; microvision medical, amsterdam, the netherlands). the proportion of perfused vessels [ppv = (number of vessels with continuous flow/number of all vessels) ] \ % was used to define microcirculatory perfusion. total vessel density (tvd) was determined automatically by the software ava . (microvision medical) and also by the semi-quantitative technique, considered as the gold-standard (number of capillary crossing three equidistant vertical and horizontal lines divided by the total length of these lines). ava software was also used as default definitions or set to optimize analyses according to manufacturer instructions. vessels falsely detected (false positive = fp) or missed (false negative = fn) by the software, in comparison to the semi-quantitative evaluation, were also counted. results. tvd was significantly higher by the ava software either on default or on optimized mode than by the semi-quantitative method, and these differences were present with good or poor perfusion images (table ) . overall fp rate was %, and it was greater in poor perfusion images ( %). optimization of the ava set parameters attenuated fp rates both in poor and good perfusion images, at the expense of increasing fn rates (table) . due to intrinsic characteristics of the software, the mean total grid length was significantly lower in the ava than in the semi-quantitative analysis ( . vs. . introduction. perfusion index (pi) is the proportion of constant absorbed light compared to pulsatile absorbed light emitted from a pulse oxymeter. it ranges from a value below up to depedant of peripheral perfusion. it is measured primarily to evaluate the signal quality for the pulse oxymeter and is displayed by some pulse oxymeters to be acknowledged by the clinician. the pi changes with vasodilation and vasoconstriction. however, intubation is a stimulus able to increase endogenous catecholamines and thus leading to vasoconstriction possibly declining the perfusion index. therefore we found intubation with a double lume tube in a thoracic surgery setting as a suitable setting to evaluate changes in perfusion index as a reaction to intubation. after informed consent, we enrolled seven patients undergoing lung surgery requiring an double lume tube. they were monitored as it is standard of care in our institution with invasive blood pressure, ecg, and a pulse oxymeter displaying the pi. (radical , masimo, irvine, ca) the patients received the medication to induce anesthesia calculated adequately to their body weight. midazolam, propofol and fentanyl where used to anesthetize the patient, cisatracurium was used for muscle relaxation to facilitate intubation. pi, pulse and arterial saturation were recorded every minute from prior to induction until after successful intubation. a baseline value was recorded prior to induction and compared to the value minutes after induction. then the pi measured next to intubation was compared to the pi after induction and analysed using students t test. introduction. anticoagulation strategies for albumin dialysis suppose a difficult compromise between risk for bleeding and a high tendency to clot in the circuit. even thought the sessions are short, a premature clotting is a serious event because the lost of blood (high priming volume) and a high cost of the systems. we intended to demonstrate that the classical approach based in heparin is not adequate in these patients and should be substituted for a different strategy (mixed low dose of heparin plus epoprostenol). methods. data of a prospective registry of all cases treated in our centre (a third level, teaching hospital) with albumin dialysis (mars system). initially we used non-fractionated heparin at - u/(kg h) in patients without coagulation problems, epoprostenol [ - ng/ (kg min)] in cases with risk or thrombocytopenia and no anticoagulation when high risk for bleeding or contraindication for anticoagulation. after an intermediate analysis of our registry we detected a high number of filters clotted when heparin was used and changed our approach to use as first indication a mixed protocol with non-fractionated heparin [ u/(kg h) ] plus epoprostenol [ ng/(kg min) ]. data are presented as percentages. analysis was performed with chi-square test. to detect variables related to coagulation a stepwise backward logistic regression analysis was performed. we registered patients with a total of sessions. selecting only the first session for each patient to validate the first choice for anticoagulation, we used heparin in cases and detected the loss of filters ( . %) because clotting. after the change to mixed anticoagulation we used this as first indication in patients and in only ( . %) the sessions were prematurely ended because clotting (p ns). the rest of patients received isolated epoprostenol in cases (with - %-cases of premature clotting) and no anticoagulant in five cases (with - %-premature clotting). between the cases with heparin as first choice, three episodes of mild and one episode of severe bleeding were detected while no patients in the mixed group presented bleeding complications (p ns). in a logistic regression analysis over all registered sessions using coagulation of filters as dependent variable and type of patient, anticoagulant, arterial pressure, inr, tpta, platelets, haematocrit or bilirubin as independent variables, none of these was included in the regression model. even though more studies are necessary to validate this conclusion, a mixed protocol based in low dose heparin plus epoprostenol could be adequate as first indication for non-complicated patients submitted to a mars treatment with lower risk for bleeding than the classical approach of isolated non-fractionated heparin. optimizing oxygen delivery in critically ill patients is vital for the promotion of aerobic cellular metabolism. current practice includes the measurement of variables such as partial pressure of arterial oxygenation (pao ), cardiac index (ci) and percentage of oxygenated haemoglobin in arterial blood (sao ). these parameters reflect global oxygen delivery. the real point of interest is the end point of the oxygen cascade; oxygen utilisation in tissue mitochondria. near infrared spectroscopy (nirs) has been developed in an attempt to measure tissue oxygen saturation (sto ) in peripheral muscle microcirculation. manufacturers state normal values as ± %. it uses four wavelengths near the infrared spectrum ( - nm) to measure sto , a ratio of oxygenated haemoglobin to total haemoglobin. it is continuous and non-invasive. sto has proven efficacious in predicting oxygen delivery in trauma patients and claims to have been successfully used to guide early resuscitation [ ] . objectives. we were interested in assessing whether sto had a role in measurement of oxygen delivery in the intensive care population, and how it compared to the parameters currently used to predict oxygen delivery. we had particular interest in the usefulness of nirs in septic patients, where the pathophysiology of tissue oxygen utilization is disrupted. patients from a general, adult intensive care unit were enrolled over an month period. all patients had lidco monitoring. exclusion criteria were gtn, atrial fibrillation and patient refusal. mm sto probes were sited on the thenar eminence. serial recordings of sto , cardiac index, hr, sao , map, and pao were recorded. sto results were compared to more traditional parameters of oxygen delivery. sixteen patients were recruited, all met criteria for sirs and shock. four were excluded with incomplete data. results were analysed for individual patients and as a collective series. we found: • no statistical correlation between nirs and sao or pao . • a weak and clinically insignificant correlation between cardiac index and nirs (p \ . ). • supra normal nirs readings (normal [ %) were not infrequently gained in patients where all other parameters were indicating severe shock and poor oxygen delivery. conclusion. theoretically nirs has potential to be beneficial in measuring oxygen delivery. our results demonstrate that nirs is not accurate for our septic population. we found poor correlation with current methods used to predict oxygen delivery and it may well be more misleading than beneficial. more traditional methods of intensive care monitoring, although sometimes invasive, appear to provide a more accurate representation of a patient's oxygen delivery. background. urine output is a crucial parameter of renal function and fluid balance. conservative urine output monitoring harbors problems such as subjective reading, sampling time errors and nursing workload. an electronic urine collection device was introduced into the icu and connected to a computerized information system. this created a more reliable and accurate means for urine output monitoring and the ability to develop new calculated parameters. . to evaluate the effects of introducing an electronical urine collection device into a fully computerized icu. . to evaluate new parameters that were created by the combination of the device and a computerized data management system. patients included were all admitted to the icu at rambam medical center, haifa, israel, during the years - . urine production and flow were monitored continuously by the urinfo Ò device (med-dynamix, israel), a novel electronic urinometer, connected to a patient data management system (imdsoft, israel). graphical analysis of urine production was done and derived parameters continuously calculated. comparison was done to the conventional mechanical urine collection system. variables studied were: measurement accuracy, sampling time accuracy, nursing workload before and after the implementation process. correlation between derived parameters and conventional renal function measurements such as plasma creatinine and creatinine clearance time. results. the conservative urine output measuring system demonstrated percentage error span in range of - %, compared to a range of - % percentage error in measurement after implementation of the computerized system. before implementation, sampling time error span was found to be - min, while no sampling time error was present after implementation due to the automated recording system. time consumed by the workload of the conservative urine output monitoring system was measured at - min per nursing shift ( h). the computerized system eliminated this workload completely. derived parameters evaluated were continuous urine flow (in cc/min or cc/h), urine production acceleration rate (calculated via the slope of the ''up-rise'' in cc/min ) and the peak urine production rate (cc/min). these parameters were able to demonstrate immediate changes in renal function, hours before conventional measurements and calculations would show them. conclusion. implementation of a computerized urine monitoring system can lead to improved accuracy in renal function monitoring and eliminate a significant amount nursing workload. use of derived calculated parameters may lead to earlier detection of renal malfunction and thus lead to earlier intervention. ( g/ , ml), cica dialysate k tm (na mmol/l, k . mmol/l, mg . mmol/l, cl . mmol/l, hco mmol/l, glucose anhydrous . g/l, ph * , ) and calcium chloride mayrhofer tm cacl , mol/l. the filter was an ultraflux av s tm , the material of the bloodline tubing system was medical grade soft pvc. in three circuits used in two different patients we found an opaque white precipitation starting at the cacl side port growing along the line with the direction of the bloodflow up to a maximal mm wide and mm long stripe. to identify the composition of the white stripes we included histological examination of hematoxylin-eosin stained sections and lyophilisation with wet chemical analysis. blood samples were simultaneously taken from the venous port of the cvvhd circuit and the arterial line of one patient. results. histology showed **an organic material in form of calcific deposit, covered with coagulated blood. chemical analysis identified this deposit as calcium phosphate. the results of the blood samples are shown in table . calcium phosphate precipitates may have reached patient circulation and been deposited in the capillary bed of the lungs or other organs. no histological examinations of tissue were taken and adverse events could not be attributed to the described phenomenon. citrate anticoagulation was stopped and switched to combined heparin-epoprostenol sodium anticoagulation. conclusions. the combination of the fluids and materials used in this specific cvvhd circuit with citrate anticoagulation resulted in some patients in a detectable calcium phosphate formation in the circuit. physicians using the described setting should be aware of the phenomenon and stop citrate anticoagulation as soon as a deposit occurs. in vitro studies, using different compositions and concentrations of dialysate and substitution fluids and simulating different patient conditions (ph, ph, hb, alb,…) should clarify, which solutions could safely be used. in addition the material of the circuit should be investigated, since surface characteristics have been identified to influence the formation of a calcium phosphate layer [ ] . reference (s) objective. the aim of this study was to assess, in a medical population of critically ill patients, whether intraabdominal pressure at admission was an independent predictor for mortality and to evaluate the effects of intraabdominal hypertension on organ functions. all patients admitted to the medical icu of the hgu gregorio marañón over a period of days were studied prospectively. patients who fulfilled two or more risk factors for wsacs (diminished abdominal wall compliance, increased intra-luminal contents, increased abdominal contents and/or capillary leak /fluid resuscitation.) were included. iap was measured via a foley bladder catheter, according to the modified kron technique. data recorded on admission were the patient demographics with, acute physiology and chronic health evaluation ii score (apache ii), and type of admission; during intensive care stay, sepsis-related organ failure assessment score (sofa) and clinical concomitant factors and conditions. intraabdominal pressure were measured at least daily together with fluid balance. patients were followed throughout their hospital stay. forty-four patients were included in the study (age - , apache ii . . half were admitted for cardiopulmonary disease. twelve ( %) had pancreatic or gastrointestinal disease. twenty-two ( %) had severe sepsis or septic shock. the incidence of iah was %. mortality was %. the cause of the iah was capillary leak syndrome/fluid resuscitation in % of cases. there was no relationship between the presence of iah and the number of organ failure during admission. the only variables associated with mortality of the patients were sofa and apache ii. the presence of iah was not a factor associated with increased mortality, although these results may be confounded by sample size. conclusions. there is an unusually high incidence of iah in the population of critically ill medical patients with two or more medical risk factors for wsacs. however, unlike in other populations, our study does not demonstrate that the iap monitoring allow detecting a group at higher risk of developing multi-organ failure or death. background. drainage of ascitic fluid is a common practice in order to relief the respiratory discomfort of patients. the aim of the present study was to determine abdominal compliance after ascitic fluid removal by transcutaneous drainage. methods. twelve patients presenting with ascitic fluid were included. all patients had transcutaneous blind drainage with a wide catheter. the ascitic fluid removed was recorded, while the intraabdominal pressure (iap) was measured as proposed by wsacs. iap was measured before and min after the puncture. abdominal compliance (cabd) was calculated. results. the pre-drainage iap was . mmhg (ranging from . to . mmhg, sd . mmhg), while the post-drainage was . mmhg (ranging from . to . mmhg, sd . mmhg). the mean volume of ascitic fluid removed was ml (ranging from to , ml, sd ml). cabd after drainage was ml/mmhg (ranging from to ml/ mmhg, sd ml/mmhg). a linear correlation was found between ascitic fluid removal and iap variations. conclusion. the drainage of ascitic fluid reduces iap, facilitating in this way respiration. moreover, iap variation seems be in linear relation with the volume of ascitic fluid removed. this linear relation between iap and volume may probably predict the cabd quite accurately and vice versa. however, larger studies are necessaries in order to safely draw predicting diap-dv (cabd) diagrams, and determine the optimal ascitic fluid removal in order to achieve best comforting of the patient and slower fluid reformation. introduction. use of stroke volume variation (svv) to guide fluid therapy in preload responsive state has been studied well in patients undergoing cardiac or neurosurgery during anaesthesia. use of this dynamic monitoring variable has not been studied much in septic shock. we undertook this prospective study to evaluate utility of svv to optimize preload in patients with septic shock and ards. setting. bedded medical surgical icu of a bedded tertiary care centre in pune, india. inclusion criteria: ( ) patients with ards (po /fio b ), svv readings were taken every h with flotrac-vigileo system after confirming abolishment of spontaneous breaths by sedation or paralysis and increasing tidal volume transiently to ml/kg. fluid boluses were given to keep svv \ % for h after enrollment. attempts were made to reduce vasopressor doses keeping map c mmhg. results. patients with average age . ± . years and apache ii score . ± . were studied. each patient received an average . ± . l fluid in h after enrollment to keep svv below %. svv at h after enrollment was . ± . % improvement in microcirculation was evident as plasma lactate reduced from . ± . (at h) to . ± . mmol/l (at h) there was no worsening in pulmonary edema as po / fio increased from . ± . (at h) to ± . (at h) only out of patients needed renal replacement therapy. in patients, vasopressors could be stopped completely in . ± . h. of them survived till discharge from the icu and died of ards. in patients, vasopressors could not be weaned off completely and all of them succumbed. overall survival rate was %. conclusion. svv guided fluid therapy is a promising modality for pre load optimization in mechanically ventilated patients with septic shock and ards. introduction. cardiovascular function is an important determinant of outcome in sepsis, and heart rate (hr) has been associated with cardiovascular risk and mortality in large patient cohorts [ ] . to investigate the association between hr and or day mortality in septic shock. methods. this study is a post hoc analysis of septic shock patients who were included in the control group of a multicenter trial [ ] . demographic and clinical data, average hr and catecholamine requirements during septic shock, occurrence of acute circulatory failure, and day mortality were documented. a binary logistic regression model adjusted for the simplified acute physiology score ii (excluding hr) was used to investigate the association between mean hr and acute circulatory failure or / day mortality. a multiple logistic regression model was applied to identify independent risk factors for developing hr critical for outcome. conclusions. hr is associated with and days mortality in septic shock. hr persistently exceeding bpm during septic shock seems associated with a significant risk of death. introduction. different colloids can be used for treatment of hypovolaemia in septic pts. recently, small-volume resuscitation was introduced for initial therapy of severe hypovolaemia and shock. the concept of small-volume resuscitation encompasses the rapid infusion of a small dose of . % nacl/colloid solution [ ] . however, in septic pts hypovolaemia often associates with acute lung injury (ali). therefore in these pts great importance has influence of colloids on oxygen transport. objectives. the aim of the study was to evaluate and compare the effects of hhes and hes on oxygen transport in pts with sepsis and ss. methods. hypovolaemic pts with sepsis and ss were enrolled in the study. pts received - ml/kg ( ml) hhes ( . % nacl ? % hes) (fresenius kabi) within min and pts received hes / (voluven, fresenius kabi) ml/kg. in all pts before and after infusion the parameters of oxygen transport was measured by pulmonary arterial catheter and transpulmonary thermodilution (pulsion medical system). after infusion of hhes oxygen delivery index (ido ) increased because of increase of cardiac index (ci) despite of decrease of hemoglobin (hb) levels and absence of changes of arterial oxygen content. extravascular lung water (evlw) and shunt increased significantly immediately after hhes infusion, but this increase was not accompanied by deterioration of pao /fio . introduction. severe sepsis is characterised by a wide array of haemodynamic changes including increased capillary leak, vasodilatation, vascular hyporeactivity and myocardial depression. the resultant tissue hypoperfusion is an important catalyst of multi-organ failure [ ] . to further develop our understanding of the underlying mechanisms, we have developed and characterised a fluid-resuscitated mouse model of intraperitoneal polymicrobial sepsis. objectives. to assess alterations in cardiac performance in mice at , , and h following faecal peritonitis. methods. sepsis was induced in week old male mice (n = ) by intraperitoneal (i/p) injection of dilute faecal slurry. sham animals (n = ) received n-saline i/p. animals were fluid resuscitated at time ( ml/kg . % saline), and at and h ( ml/kg . % saline- % dextrose each time). under a minimum concentration of isoflurane to achieve light anaesthesia, peak velocity, stroke distance, heart rate and fractional shortening were measured in the short axis plane by echocardiography at the , and h timepoints. in separate sham and severe septic mice (n = per group) the cardiac response to intravenous colloid boluses was assessed at and h. results. we clinically characterised septic animals into 'mild' and 'severe'. mice with severe sepsis showed a % drop in peak velocity and cardiac output at h (vs. and % falls in the mild septic and sham-operated animals, respectively, p \ . ). while mild septic animals showed recovery by hr, cardiac output in severely ill mice remained significantly depressed (due to both low heart rate and stroke volume) compared to mild septic and sham animals [*p \ . ( fig. ) ]. stepwise . ml boluses of intravenous fluid at h in severe septic animals led to restoration of cardiac output to baseline ( h) values. however, in the h septic animals, fluid challenge produced an initial improvement in cardiac output followed by deterioration [ fig. purpose. myocardial dysfunction has been well-documented in sepsis even in hyperdynamic state, and may develop and contribute to morbidity and mortality. nicaraven, a radical scavenger, has been shown to protect the coronary endothelial and myocardial function from ischemia and reperfusion injury due to hydroxyl radical scavenging activity. the purposes of present study were to determine the effects of nicaraven on cardiac function and cytokine production in lipopolysaccharide (lps) induced sepsis. methods. this protocol was approved by our institutional committee. following arterial and venous cannulation and tracheostomy, rats ( - g) were anesthetized with pentobarbital, and mechanically ventilated with a control mode (v t = ml/kg, rr = rpm). after baseline measurements, rats (n = ) were administrated with lps ( mg/kg, intravenously) and randomly assigned to following two groups: the nicaraven group treated with nicaraven [ mg/(kg min), intravenously] and the control group treated with saline. the left ventricular pressure and volume were measured with the pressure and conductance catheter every one hour. cardiac function, including cardiac output (co), ejection fraction (ef), and maximal elastance of left ventricle (e max ) were analyzed with a computer soft. blood was collected, centrifuged ( , g, min, ) , and stored (- °c) from rats every h after operation to measure plasma concentration of tnf-a, il -b and macrophage migration inhibitory factor (mif) using enzyme-linked immunosorbent assays kits. blood lactate concentration was also measured. data were analyzed by repeated measure anova. results. the co in the nicaraven group was kept significantly higher than the control group (p \ . ). the ef and e max in the nicaraven group were also kept significantly higher than the control group (p \ . ). arterial lactate, tnf-a, il -b and mif were significantly lower in the nicaraven group versus the control group (p \ . ). conclusion. the current study indicates that the treatment with nicaraven improved cardiac dysfunction and reduced plasma concentration of cytokines, and improved lactic acidosis in septic model. methods. this protocol was approved by our institutional committee. following arterial and venous cannulation and tracheostomy, rats ( - g) were anesthetized with pentobarbital, and mechanically ventilated with a control mode (v t = ml/kg, rr = rpm). after baseline measurements, rats (n = ) were administrated with lps ( mg/kg, intravenously) and randomly assigned to following two groups: the oxytocin group treated with oxytocin ( iu/kg iv and followed by the continuous infusion of mg/(kg min), intravenously) and the control group treated with saline. the left ventricular pressure and volume were measured with the pressure and conductance catheter every h. cardiac function, including cardiac output (co), left ventricular peak pressure (lvpp), and cardiac work (cw) were analyzed with a computer soft. blood was collected from rats every h after operation to measure plasma concentration of blood lactate. data were analyzed by repeated measure anova. results. the co in the oxytocin group was kept higher than the control group but there is no significance (p \ . ). the lvpp and cw in the oxytocin group were kept significantly higher than the control group (p \ . ). arterial lactate was significantly lower in the oxytocin group versus the control group (p \ . ). conclusion. the present study indicates that the treatment with oxytocin improved cardiac dysfunction and reduced plasma concentration of lactate in septic model. introduction. conventional hemodynamic monitoring parameters like heart rate, mean arterial pressure (map), and central venous pressure may be misleading in assessment of circulating blood volume in severely septic patients. inadequate blood volume may compromise renal blood flow leading to acute kidney injury (aki). stroke volume variation (svv) is a sensitive indicator of relative preload responsiveness and has high sensitivity and specificity when compared to conventional indicators of volume status and their ability to determine fluid responsiveness. to assess the efficacy of svv guided fluid therapy in preventing aki in patients with severe sepsis on ventilatory support. mechanically ventilated patients with septic shock who had undergone resuscitation based on surviving sepsis campaign guidelines and still requiring vasopressor support were enrolled. patients with pre-existing renal failure were excluded. a total of patients were randomized to receive fluid therapy according to conventional indices or svv, in the first h after mechanical ventilation. svv was measured with flotrac vigelio after abolishing spontaneous ventilation by sedation and paralysis if required. fluid boluses were given to keep svv less than %. vasopressor therapy was optimised to maintain map [ mm hg. patients were followed during their icu course with respect to development of aki, need for renal replacement therapy (rrt), length of icu stay and icu mortality. aki was diagnosed as per the rifle criteria. primary outcome measure was development of aki. results. patients in both groups were similar with respect to age (p = . ), sex (p = . ), and admission apache ii score (p = . ). incidence of aki was / ( . %) and / ( . %) in conventional and svv groups, respectively (p = . ). there was no statistically significant difference in terms of need for rrt, icu length of stay and icu mortality ( [ ] . moreover, pnu- a (pnu), an inhibitor acting through the poreforming subunit of the channel, did not affect bp in our awake peritonitis rat model [ ] . given that vasoconstrictors, including ne, inhibit k atp channel activity [ ] , we speculate that the high sympathetic tone seen in sepsis [ ] objectives. the goal of this study was to determine if hfav improves microcirculatory alterations in ss patients. methods. by using side dark field videomicroscopy (microscan Ò , microvision medical) we evaluated sublingual microcirculation in ss patients who according to our local protocol care [ ] underwent a h-hfav as rescue therapy for refractory septic shock. hemodynamic parameters and microcirculation were assessed at baseline, after h of hfav, and h after stopping hfav. microcirculation assessments were performed at to different sublingual areas ( - s/image). images were analyzed according to recent consensus [ ] by semiquantitative scores of flow (mfi, mean flow index and ppv, proportion of perfused vessels), density (tvd, total vascular density; pvd, perfused vascular density), and heterogeneity (het mfi) of small vessels (\ lm introduction. disturbances within the microcirculation represent an important factor in the pathogenesis of multiple organ dysfunction in sepsis and septic shock [ ] . gender-specific effects may modulate the septic pathophysiology [ ] . therefore, we studied sepsis-induced changes within the intestinal microcirculation in randomly cycling and ovariectomized female rats. objectives. we hypothesized that estradiol (e ) and dehydroepiandrosterone (dhea) may have a beneficial effect on the microcirculation during experimental sepsis and resubstituted these hormones in the ovariectomized animals. methods. fifty female rats were divided in to five groups of ten animals. group received sham laparotomy without further treatment. in group - we induced experimental sepsis (colon ascendens stent peritonitis-casp model). animals of groups - were additionally ovariectomized weeks before sepsis induction. in group we administered mg/kg estradiol immediately after and h following casp surgery. the animals of group received mg/kg dhea immediately after sepsis induction. twenty-four hours after casp surgery intravital microscopy was performed to study leukocyte-endothelial interactions and functional capillary density. blood samples were taken for the measurement of estradiol, dhea and inflammatory cytokines. results. in ovariectomized rats subjected to casp the number of activated leukocytes was significantly increased in comparison to sham and not ovariectomized casp animals (p \ . ). in ovariectomized rats treated with e leukocyte adhesion was significantly reduced in comparison to untreated ovariectomized rats subjected to casp (p \ . ). the same observation was made in ovariectomized rats treated with dhea. in addition, in ovariectomized rats subjected to casp the functional capillary density was significantly decreased in comparison to sham and casp groups (p \ . ). in ovariectomized rats treated with e or dhea functional capillary density was completely restored. the results demonstrate the role of e and dhea in the sepsis-induced changes within the microcirculation. a rapid, non-genomic effect of both e and dhea is suggested [ ] . dhea may play a role through conversion to e or through direct acting on the e receptor. further investigations should be done to elucidate the underlying mechanisms. both e and dhea appear to be a promising adjunct for the prevention and treatment of sepsis-induced multiorgan failure. liver is involved in the production of no. the aim of this experimental study was to evaluate the time course of hepatic no production at the onset of hypotension occurring during septic shock. methods. male wistar rats were anesthetized with isoflurane Ò , and mechanically ventilated. a first group (sepsis group) underwent a cecal ligature and puncture (clp) peritonitis, the second one (control group) a laparotomy only. animals were euthanized at different times: h after surgery, at shock onset, and h after shock. shock was defined by systolic blood pressure lower than mmhg. each rat of sepsis group was matched with rat of control group. liver perfusion was measured using a direct laser doppler flowmetry probe. no generated in the liver was measured using a pulse voltametric method. results. rats were studied ( in each group). in sepsis group, shock occurred at ± min after clp. in sepsis group, a significant decrease of hepatic perfusion was identified h after clp ( fig. ) whereas hepatic no production was increased only at the time of shock onset (fig. ). intra hepatic no production conclusion. this study shows a time shift between hepatic perfusion disturbance, hepatic no production and shock onset in a septic animal model. introduction. microvascular blood flow alteration is a key element of severe sepsis and septic shock [ ] . one study show that microvascular alterations in septic patients could be improved with a nitric oxide donor nitroglycerin [ ] . studies in human have shown that infusion of magnesium sulphate has endothelium dependent and independent vasodilation properties, increase of red blood cells deformability in specific conditions. we hypothesized that combination of nitroglycerin with magnesium sulphate and order of priority influence microvascular improvement in patients with severe sepsis and septic shock. methods. ten septic patients who had already been fluid resuscitated randomly assigned to one of two groups. one group received magnesium sulphate infusion g/h with nitroglycerin . mg/h infusion added after min. another group received nitroglycerin . mg/h infusion with additional magnesium sulphate g/h infusion after min. if required we added crystalloids and use norepinephrine. sublingual microcirculation was evaluated using side dark field videomicroscopy (microscanÒ, microvisionmedical) . each patient's microcirculation was evaluated by examining different sublingual areas ( - s/image). in all patients measurements were obtained at baseline, at and min. images were analyzed by semiquantitative scores of flow (mfi, mean flow index; ppv, proportion of perfused vessels) and density (tvd, total vascular density; pvd, perfused vascular density). capillaries were defined as microvessels with a diameter \ lm. data are presented as median values (percentiles ; ). . the median age of the patients was ( ; ) years. in both groups we see tendency progressively increase of pvd, ppv and mfi after drug alone and combination after min, but pvd has tendency to be higher [ . ( ; . ) n/mm vs. . ( . ; . ) n/mm , p = . ] after min. in group, where magnesium sulphate infusion was given first. combination of magnesium sulphate with nitroglycerin, when magnesium sulphate is given first, has tendency to higher potential for improving of microcirculation in severe sepsis and septic shock patients, but further studies are needed to obtain more detailed results. severe sepsis remains one of the leading causes of death in critical care, with around % of patients dying within one month of diagnosis. rapid diagnosis and therapy of sepsis improves survival [ ] . in november the whittington hospital introduced a hospital severe sepsis guideline, based on the first surviving sepsis campaign guideline [ ] . the sepsis guideline was published on the hospital intranet and specified actions to be completed within the first h of the diagnosis of severe sepsis or septic shock [ ] . objectives. to assess whether publication of a sepsis guideline on the hospital intranet, coupled with departmental educational campaigns, improved the management of severe sepsis. the whittington hospital is a university associated general hospital in london. we audited the early management of severe sepsis and septic shock before and after the introduction of the new hospital sepsis guideline. the 'before' phase comprised patients with severe sepsis or septic shock admitted to critical care between november and november . the 'after' phase comprised patients with severe sepsis or septic shock admitted to critical care between january and november , after introduction of the guideline. data was retrospectively collected from case notes and observation charts. the audit tool compared immediate, , and h actions following diagnosis against the hospital guideline. the main outcome measures were compliance and day mortality. compliance was defined as the average of the percentage compliance with each of the items specified in the guideline. results were compared by chi squared. compliance with the severe sepsis guidelines was only % after publication of the hospital sepsis guideline, compared with % before publication (p. )! there was similarly no significant difference in day mortality (before %, after %, p. ). publication of a sepsis guideline on the hospital intranet, coupled with departmental teaching sessions, failed to improve compliance with surviving sepsis recommendations, perhaps because the guideline competes for attention with over other guidelines on the intranet. next we will implement an interdepartmental educational programme to try and improve guideline compliance. as guidelines proliferate it is difficult to ensure they are followed, but failure to implement a published hospital guideline may represent a significant clinical and medicolegal risk. methods. the icu is an intensivist-led bed intensive care in a bed non-academic teaching hospital. hospital mortality from sepsis in icu-patients was . % in . patients are treated under modern icu conditioning, including continuous venovenous hemofiltration and a lung-protective ventilation strategy including prone position. an intensive insulin therapy protocol for glycemic control is used. in the period between march until june , we prospectively screened all patients admitted to the icu for (severe) sepsis, without the knowledge of the nurses and most of the doctors. all severe septic patients were included in our surviving sepsis database. after h, we examined how many targets of the resuscitation and management bundles were applicable and reached. in the period between march until june , patients were admitted to the icu. twenty-two of them were suffering from severe sepsis ( . %), of which had a septic shock. focus of the sepsis was abdominal in patients ( %), pulmonary in five patients ( %), urogenital tract in five patients ( %), meningitis in one patient ( %) and catheterrelated in one patient ( %). table shows us the applicability and achievement of the bundle elements. only in one of the patients all targets were reached. however, mean individual bundle element performance was . % (sd . ). all patients received fluid resuscitation when indicated, and all patients on mechanical ventilation were ventilated in a lung-protective manner with plateau pressures \ cm h o. only percent of patients had glucose levels within the target range. scvo was never measured, though it was indicated in patients. one patient had an apache iiscore c and had no contraindications for administration of activated protein c. treatment was not considered for this patient by the attending physician. of these patients suffering from severe sepsis, three died within days after the diagnosis ( . %). introduction. the surviving sepsis campaign (ssc) guidelines give a group of interventions (''sepsis bundles'') expected to improve the outcome of patients with severe sepsis [ ] . objetives: the aim of this study was to evaluate the impact of the implementation of the ssc guidelines on the mortality in our intensive care unit (icu). methods. prospective, observational study. during one year period (january -january ) the sepsis bundles were applied to each patient with severe sepsis-septic shock and they were followed up until discharge. we considered as ''time o'' (the time of delay of the implementation of the sepsis bundles) the time of admission of the patients in the icu. for each severe septic patient the following data was registered: time delay, apache ii and sofa scores at icu admission, diagnosis, the rate of compliance with the resucitation and management bundles, microbiological data, evolution of levels of serum lactate, empiric antibiotic therapy, length of stay and mortality in icu. the application of guidelines impact on mortality was compared with historical data years before implementation in our icu ( . %) and spanish icu ( . %) [ ] . a total of severe septic patients were included in the study. ( . %) patients had severe sepsis and ( . %) septic shock. the median age was years. the mean apache ii was . (± ) and sofa was . (± . ). the main sources of infection were abdomen ( %), lungs ( %), urinary tract ( . %) and soft tissues ( . %). the most common clinical diagnosis related to an episode of severe sepsis was peritonitis ( %). a microbiological diagnosis of the infection was reached in . % and the infections were mostly caused by gram-bacilli. once the antibiogram was obtained, the initial treatment was considered appropriate in . % patients. the rate of compliance with sepsis bundles was %. the length of icu stay was . days. mortality was . %. the implementation of the sepsis bundles decreased icu mortality significantly ( . % before implementation vs. . % after implementation). non survivors were older (median age ± . ), had higher apache ii (mean . ± ) and sofa (mean ± . ), % had septic shock, . % had negative cultures and an increased on the levels of serum lactate in h. age, apache ii and sofa scores and the increased on the levels of the serum lactate were useful tools to predict mortality. conclusion. implementation of the surviving sepsis campaign guidelines was associated with a reduction in icu mortality. introduction. the objective of this before-after study is to assess the impact of a protocol of care for severe sepsis in a french emergency setting. methods. two months periods were surveyed before and after the initiation of a protocol of care for severe sepsis and septic shock. after the control period (p : november -february ), a procedure for early recognition, aggressive treatment and standardized antibiotherapy of severe sepsis was initiated. a campaign to raise medical physicians and nurses awareness concerning this new strategy of care was performed. the intervention period (p : november -february ) assessed the impact of these actions. . patients with severe sepsis or septic shock were included during p ( % of patients with a suspected infection and . % of all non trauma admissions) and during p ( . % of patients with a suspected infection and . % of admissions). the age and the proportion of patients with co-morbidities were similar during the p and the p periods ( years in median versus years, and vs. %, respectively). and % of the patients lived in long term care facilities. severe sepsis and septic shock were correctly identified by the emergency team in / ( . %) during p and in / ( . %) in p (p = . ). the delay between the admission in the emergency department and the administration of antibiotics was in median equal to h min in p and h min in p (p = . ). adequate iv fluid resuscitation was administered to % of patients in p and % of patients in p (p = . ). during p , % of patients did not qualify for admission to the intensive care unit compared to . % in p . hospital mortality did not change from . % ( / ) in p to . % ( / ) in p (p = . ). conclusion. the introduction of a standardized treatment protocol in an emergency department allowed a better recognition of severe sepsis with earlier adapted treatment . the study was not powered to demonstrate a reduction of the mortality in this elderly population. multiple studies have shown that early detection and therapy is crucial for the prognosis of a severe septic patient. many hospitals have joined the surviving sepsis campaign and its fight for the decrease of mortality in severe sepsis and have implemented the severe sepsis bundles into their daily practice. other institutions such as ours had so far not taken this step, perhaps because the process is hard and time consuming. we have tried to find an easy way to audit the implementation of severe sepsis bundles and its change in time in an institution without a set system and database for the implementation of severe sepsis bundles to help us prove, that a systemic change in clinical practice is essential. we have decided to use the first step of the resuscitation bundle-the measurement of lactate and audit the lactate requests in blood samples with elevated inflammatory markers in our hospital laboratory information system. we retrospectively audited the number of lactate requests in blood samples with c-reactive protein (crp) c mg/l and its evolvement in time between and before and after the introduction of surviving sepsis guidelines and severe sepsis bundles in our regional hospital with beds. we compared the total number of blood samples with elevated crp c over mg/l with or without procalcitonin request in our institution with the number of blood samples with crp c mg/l and lactate request (both arterial and venous) in the hospital laboratory information system. . the total number of lactate requests in samples with crp c mg/l had increased in time, the incidence widely differed between departments. the main increase was in patiens from intensive care units, the number of lactate requests in samples from general wards, emergency department and intermediate (step down) units had also increased ( lactate requests in samples with crp c mg/l- , % in and lactate requests in samples- . % in ) but still remains insufficient. surprising was that procalcitonin was in non icu patiens with crp c mg/l requested more often than lactate. although many lectures and seminars on severe sepsis bundles and the guidelines for the management of severe sepsis were organised in our intitution between the year and , it was not sufficiently effective. conclusion. retrospective audit in the hospital laboratory information system of the number of lactate requests in samples with elevated inflammatory markers appears to be a fast and a very easy first step for auditing how the surviving sepsis guidelines and severe sepsis bundles are implemented in your institution. the results help to quantify the present state, its change in time and may serve as an impulse to make systemic changes in the system of early detection and therapy of septic patients. introduction. early goal-directed therapy (egdt) is the accepted gold standard for resuscitation in septic shock [ , ] . international guidelines for the treatment of septic shock [ ] set an initial h limit to accomplish this goal. to test the hypothesis that egdt with fluids and vasopressors has better patient outcomes if each intervention is completed within h. thirty septic shock patients from the spring of and from spring were reviewed prospectively (n = ). septic shock was defined as a lactic acid c mmol/l and/or hypotension unresponsive to fluids. apache ii and sofa scores were calculated. patients were subjected to the hospital septic shock protocol according to guidelines [ ] . firstly, egdt compliance was met if the following interventions were achieved within h: lactate levels drawn, map c mmhg and cvp c mmhg; and secondly, if antibiotics were given\ h, blood cultures were taken before antibiotics and if ml/kg fluid bolus was administered prior to vasopressors. in patients / interventions were performed in time (''egdt-compliant''). the other were deemed ''egdt-noncompliant''. outcomes were mortality rate and discharge destination. fisher test was used in statistical analysis. . mr was % amongst the compliant and % amongst the noncompliant and admission to long-term care facilities (ltcf) was and %, respectively. neither one of these differences was statistically significant. a power analysis revealed that patients are required to attain statistical significance for mortality. discharge home was the same in both groups. there was no difference between groups in the number of new tracheostomies or new hemodialysis. conclusions. in a us community teaching hospital, compliance with guidelines in the treatment of septic shock had a trend towards lower mortality and higher discharge rates to ltcf but the difference was not statistically significant. larger numbers are needed for the benefits/effects of egdt-compliant therapy to reach statistical significance in the treatment of septic shock in this hospital setting. improve the survival rate of septic patients by means of education and implementation of a sepsis operative protocol including the activation of a specific consultation by an intensivist and an infectious disease specialist (i.e. sepsis team, st). aim of this study was to describe the first months activity of st, with a focus on the patients not admitted in intensive care unit (noicu). methods. the sepsis operative protocol, introduced in clinical practice in june , provides for specific instructions for the early identification and management of septic patients and for the early activation of the st for patients with severe sepsis or septic shock admitted in non-intensive departments. the st consultation ought to support the departmental health personnel in the management of septic patient and allows an early intensive care admission in case of shock or if mechanical ventilation is needed. to assess st activity, we evaluated in noicu patients the correct st activation rate, the number of st activations for each patient, the rate of central venous catheter insertion (cvc) and the days mortality. results. from june to december , the st was activated for patients ( . patients per month) whose ( %) were admitted to icu and ( %) were considered too sick to benefit. in ( %) of the remaining patients, st was properly activated: patients with severe sepsis and with septic shock. thirteen patients ( %) had no sepsis and ( %) had sepsis without organ dysfunction. % of st activations originated from medical departments (including emergency department) and % from surgical departments. the number of st activations for each single patient was ± . the days mortality was . % in patients with sepsis, % in patients with severe sepsis and % in patients with septic shock. conclusion. the rate of correct activation of st and the number of activations for each patient were acceptable considering that more than % of the activations refers to septic patients and that a mean of activations was sufficient for patient management. mortality rates observed are slightly lower than those reported by others, but further data are needed to evaluate the impact of st on patient outcome. a. estella , l. pérez fontaiña , j. i. sanchez angulo , e. moreno hospital of jerez, emergency and critical care unit, jerez, spain clinical evidence suggests that an early diagnosis and treatment of severe sepsis has been shown to improve outcome. frequently the initial management of septic patients occurs outside of the icu. objective. to describe clinical characteristics and outcome of septic shock patients admitted in icu and to compare mortality according origin prior admission in the icu (emergency department versus medical or surgical wards). consecutive patients with septic shock admitted in icu from july to november were registered. age, icu length of stay, source of infection, isolated bacteria, blood lactate concentration, apache ii score and mortality were collected. patients were classified according the origin prior admission in icu. . consecutive septic patients were admitted in icu during the time of study, global mortality was %. patients were admitted from medical or surgical wards and patients from the emergency department. mean age was years, male and female, icu length of stay was . ± . days, the mean apache ii score at admission in icu was . ± . abdominal infection, . %, was the commonest source of infection followed by pulmonary and urinary infection, . and . % respectively. patients ( %) had a positive bacterial culture, the mean baseline lactate level was . ± . mmol/l p \ . ( . ± mmol/l in the medical and surgical wards group versus . ± mmol/l in the emergency department group).there were not differences in clinical characteristics according origin prior admission in the icu except for lactate level, and mortality, . % in the medical and surgical wards group and . % in the emergency department group (p \ . ). conclusion. there were not differences in clinical characteristics, icu length of stay, source of infection, isolated bacteria and apache ii score between groups. mortality was lower in the group of patients admitted in icu from the emergency department than the group admitted from medical and surgical wards. although very high circulating concentrations are detectable in plasma, it is not known which organs actually produce the cytokines. we hypothesized that key abdominal organs affected by sepsis such as the kidney and liver produce cytokines and tested this hypothesis by measuring cytokine flux. materials and methods. pigs ( - kg) were randomised to control (n = ) and endotoxin (n = ) groups. hemodynamic measurements using picco and pulmonary arterial catheters and arterial blood gases were collected hourly. portal, hepatic and renal arterial blood flows were measured with transit time probes. arterial and venous cytokine concentrations (tnfa, il- b, il- and il- ) were measured from samples taken from each respective organ. cytokine flux was calculated as: organ blood flow (venous-arterial cytokine concentration difference). endotoxemic pigs had significant increases in heart rate (p \ . ) and mean pulmonary arterial pressure (p = . ) and decreases in cardiac output (p = . ). in contrast, these hemodynamic variables remained stable in the control animals. renal, hepatic and portal vein flows decreased significantly in all endotoxemic animals but remained stable in the control group. renal [ml/(kg min)]:control . ± . , . ± . , . ± . , . ± . versus endotoxin . ± . , . ± . , . ± . , . ± . for baseline, t = , , , respectively. portal [ml/(kg min)]: control . ± . , . ± . . . ± . , ± . versus endotoxin . ± . , . ± . , . ± . , . ± . for baseline, t = , , , respectively. hepatic [ml/(kg min)]: control . ± . , . ± . , . ± . , . ± . versus endotoxin . ± . , . ± . , . ± . , . ± . for baseline, t = , , , respectively plasma cytokines tnfa was detectable in very low concentrations (\ pg/ml) in of the endotoxemic animals, and none of the control animals. il- b, il- and il- increased significantly with time peaking at t = , and respectively in the endotoxin group. in the control group only few animals showed a cytokine response, in numbers insufficient for statistical analysis. in the endotoxin group there was a negative cytokine flux in the renal circulation, maximal at t = [- . ± . for il- b and - . ± . for il- (pg/ml), respectively]. there was a positive cytokine flux for il- reaching its peak at t = ( . ± . pg/ml). a similar pattern was seen in the hepatic ? portal circulation with maximal flux for il- b and at t = (- . ± and - . ± . pg/ml, respectively). for il- there was a positive flux peaking at -= ( . ± . pg/ml). although there was a negative il- b and il- cytokine flux in the renal, portal and hepatic circulations indicating net uptake, and vice versa for il- , none of these values reached statistical significance. conclusions. these data do not support that cytokines are produced nor consumed in the kidney and liver during endotoxemia. discussion. non-survivors show more severity at the beginning and during their icu stay, more altered biological markers and a higher mean glycemia, but do not show significant difference either at initial glycemia, history of diabetes, hypoglycemia event or insulin treatment. elevated mean glycemia appears to be a factor independently associated with higher mortality. hyperglycemia prevalence in critically ill patients is very high and the controversy whether it is a mortality marker or a mediator still remains. our results would justify starting an intensive insulin protocol and its subsequent analysis. the interest of continuous scvo was proven in the management of severe septic patients [ ] , but the place of discontinuous scvo remains unclear. objectives. to compare continuous scvo to discontinuous scvo concerning the number of therapeutic interventions in the management of severe sepsis (ss) and septic shock (ssc). methods. prospective randomized comparative study. inclusion criteria: age [ years, ss or ssc [ ] . two groups were defined: continuous scvo (c group) monitored by a central venous oximetry catheter (edwards lifescience x hs, irvine, usa), and discontinuous scvo (d group) measured on blood samples drawn every h and at the request of the treating physician. the hemodynamic management of these patients was based on the algorithm established by rivers [ ] . the primary endpoint was the number of therapeutic interventions (fluids, transfusions, inotropic drugs) triggered by a scvo \ %. non parametric tests (chi-square and mann whitney) and repeated-measures anova were used in statistical analysis (p \ . was considered significant). results. patients were included in a polyvalent intensive care unit (icu). the two groups were comparable concerning age, sex, weight, height, apache ii score, mods on admission and mechanical ventilation (mv). there were no statistical differences between the two groups concerning: mortality, duration of icu stay, duration of mv and the evolution of mods and plasma levels of lactate from day to day . the therapeutic interventions data are shown in table . introduction. the calcium activated potassium channel (bkca) exists in smooth muscle cells in most vascular beds and is believed to be important in sepsis induced hypotension and vascular hyporeactivity [ ] and also in neutrophil killing and macrophage production of proinflamatory cytokines. however the latter two roles have been disputed [ ] and we have found that bkca expression is not upregulated in aorta from septic mice using real time polymerase chain reaction. as its role in sepsis remains uncertain we sought to determine whether null mice for the bkca channel were (a) resistant to hypotension and (b) showed improved survival in a clinically relevant model of fecal peritonitis. methods. bkca null mice (based on balc) were obtained from jax Ò mice. agematched litter mates homozygous for bkca were wild types (wt). mice (age - weeks) had tethered arterial and venous lines inserted under isoflurane anesthesia. the tether enabled mice to roam cages freely whilst continuous blood pressure (bp) traces were obtained. h post surgery, echocardiogram and intraperitoneal injection of rat slurry was administered under anesthesia. fluid resuscitation of . ml/h voluven/ % dextrose ( : ) was given. at and h echo was recorded and mice culled with mesenteric arteries dissected for myography. data expressed as mean(sem) and statistical analysis anova. results. genotypic study and whole cell patch clamp recording in aortic smooth muscle cells confirmed bkca current was absent in null mice. fecal peritonitis induced equivalent hypotension in both wt (n = ) and bkca null mice (n = ) at - h (fig. a ). echocardiography at h post slurry showed no difference in cardiac output between wt- . ( . ) and bkca null mice- . ( . ) ml/min and no difference or improvement cf time (fig. b) . thus this fall in bp is due to reduction in total peripheral resistance not myocardial depression. in addition / of the bkca null mice died prior to h as opposed to / wt. hence myography was only performed on wt mesenteric arteries which were hyporeactive to norepinephrine (p = . , fig. c ). conclusion. there is no evidence from this transgenic mice study of fecal peritonitis that inhibition of the bkca channel would be beneficial for the treatment of hypotension in septic shock or would improve survival. reference(s). introduction. pro-and anti-inflammatory responses play a key role in the pathophysiology of sepsis [ ] . phosphodiesterase (pde) inhibition could play an anti-inflammatory role in this setting [ ] . previously, it was shown that among the three inhibitors of pde five currently available (sildenafil, vardenafil, tadalafil), only tadalafil could exhibit anti-inflammatory properties on endothelial cells (ec) stimulated by modified oxidized ldl or tnf alpha [ ] . to assess the potential anti-inflammatory role of tadalafil in ec stimulated by lps. methods. thp- cells ( . /ml in rpmi) were incubated alone (control group) or in the presence of either tadalafil ( lm; eli lilly, in, usa), lps from e.coli :b ( ng/ml; sigma-aldrich, inc.) or both. tnfa production, as a marker of inflammation, was measured in the supernatant (elisa assay; roche, mannheim, germany) after h of incubation ( independent experiments in quadruplet). comparisons were made by one-way anova, with bonferroni's post hoc test (mean ± sem). results. production of tnfa increased significantly after stimulation by lps alone compared to control ( . ± . -fold over the control, p \ . ) or tadalafil ( . ± . vs. . ± . -fold over control, p \ . ). levels of tnfa were significantly reduced in the lps ? tadalafil group, compared with the lps group ( . ± . vs. . ± . -fold over the control, respectively; p \ . ) (graph ). we hypothesized that daa provides varying protective effects in different organs as indicated by higher amounts of epcr in early murine sepsis. methods. sepsis was induced by cecal ligation and puncture (clp) in male nmri-mice (n = , body weight ± g). animals were randomly assigned to vehicle infusion (control), or clp sepsis with daa infusion [daa; lg/(kg hr)]. a third group received only sham operation and vehicle infusion (sham). h prior to clp all mice were given a permanent central i.v.-line and an arterial transmitter (pa-c , st. paul, mn, usa) to measure heart rate (hr) and mean arterial pressure (map). clp was adjusted to survive h. after h hearts, livers and kidneys were fixed in formalin and embedded in paraffin. immunohistochemical analysis of the paraffin sections was performed using the avidinbiotin-peroxidase complex (abc) method. for analysis an anti-mouse epcr antibody (clone , natutec, frankfurt, germany) was used (dilution : ) after heat pretreatment. anti-epcr positive cells were counted in fields in light microscopy (original magnification: . ) of each tissue and the average was recorded. data are presented as mean ± sd. *p \ . was considered significant. results. there were no significant differences in hr between the groups (sham ± per min; daa ± per min; control ± /min). map was significantly higher in sham group ( ± mmhg; p = . ) and non-significantly higher in daa group ( ± mmhg) when compared to control ( ± mmhg). anti-epcr positive cell count in heart tissue was significantly higher in sham-treated mice ( . ± . cells; p \ . ) and daa mice ( . ± . cells, p = . ) compared to controls ( . ± . cells). in kidney tissue epcr positive cells were significantly more in sham group ( . ± . ; p = . ) compared to control, but not in daa group ( . ± . ). liver samples showed no significant differences (sham . ± . ; daa . ± . ; control . ± . ). conclusion. our data showed higher amounts of epcr in murine sepsis undergoing daa therapy in heart and kidney tissues, but not in the liver when compared with control animals. this suggests that daa provides different effects in early experimental sepsis. background. caspofungin treatment is often initiated in hypovolemic shock patients, what could affect its pharmacokinetics and efficacy. the present study investigated the influence of hypovolemic shock and fluid loading on the plasma pharmacokinetic parameters and the pulmonary penetration of caspofungin in a pig model. after anesthesia and mechanical ventilation, pigs ( ± kg) were bled to induce a -h deep shock and resuscitated for h using normal saline based on hemodynamic goals. a -h perfusion of mg caspofungin was started at the beginning of the resuscitation period. lungs were removed h after the initiation of hemorrhage. sixteen animals were used as controls without hemorrhage. caspofungin concentrations were measured using high performance liquid chromatography method. in the shock group, the volume of removed blood was ± ml/kg and a volume of ± ml/kg of saline was infused through the resuscitation period. conclusion. hypovolemic shock followed by fluid loading in pig results in a significant decrease in plasma caspofungin exposition. it resulted in a decrease in the pulmonary concentration of caspofungin without affecting its diffusion to the lung. future investigations should focus on the interest for monitoring of plasma caspofungin concentrations in icu patients and on optimal dosing in these patients. objectives. the present study was designed to assess the effects of mps from septic origin on systemic hemodynamics as well as on the inflammatory, oxidative and nitrosative stresses. methods. forty healthy rats were randomly allocated to three groups: animals inoculated with mps isolated from control rats (cmps), animals inoculated with mps isolated from sham rats (shmps) and animals inoculated with mps isolated from rats with peritonitis (smps). rats were anesthetized, mechanically ventilated and were infused with the same amount of cmps or shmps or smps. we measured heart rate (hr), mean arterial pressure (map), carotid artery blood flow (cbf) and portal vein blood flow (pbf). hemodynamic parameters were recorded during h, and then animals were sacrificed. aorta and heart were harvested for further in vitro tissue analyzes. . the cellular origin (phenotype) but not the circulating concentration of mps was different in septic rats, characterized particularly by a significant increase in leukocyte derived mps. . smps but not cmps or shmps decreased mean arterial pressure without any effect on carotid artery and portal vein blood flows. all rats survived in the cmps and shmps groups whereas three rats died before the end of the experiment in the smps group. . rats inoculated with smps exhibited an increase in superoxide ion production and nf-kb activity, over-expression of inos with subsequent no overproduction and decrease in enos activation. pulse blood pressure recordings conclusions. rats with sepsis induced by peritonitis exhibited a specific phenotype of mps which could play a detrimental hemodynamic effect as a systemic vasodilatation. inoculation of smps in healthy rats decreased map likely by up-regulating nf-kb activity with subsequent inos, no and superoxide anion overproduction. these data confirm a proinflammatory detrimental role of mps in the vascular pathophysiology of septic shock. introduction. heat shock proteins (hsps) play an active part in modulating intracellular responses to stress. in the classical model for their activation de-repression of heat shock transcription factor (hsf ) occurs as a result of the titration of hsps away from hsf by misfolded proteins [ ] . however, hsps may change in many diseases without any changes in the levels of denatured proteins [ ] . objective. we propose that hsps are activated, in part, by a membrane dependent calcium channel receptor, possibly transient receptor potential vanilloid type- (trpv ). capsaicin, a known inducer of trpv , and capsazepine, a selective antagonist, were used on different mammalian epithelial cell lines. cells were pre-treated with micromolar concentrations of capsaicin or heat shock (hs) followed by treatment with capsazepine. results. capsaicin or hs induced hsf activation and the consequent accumulation of hsp , and chaperones. pre-treatment with capsazepine prior to hs or capsaicin abolished the heat shock response (hsr). capsazepine treatment prevented capsaicininduced stabilization of ikb and cell to cell adhesion and induced apoptosis. capsazepinemediated blockage of the heat shock response was reproduced with egta. moreover, treatment with trpv sirna resulted in a similar response to capsazepine. conclusion. hsr-sensing and signaling in mammalian cells depends, in part, on the transient entry of calcium by way of membrane dependent calcium channel receptor. these hsr modulators may hold promise in treating inflammation in the future. introduction. hydrogen sulphide gas, or its intravenous donor-sodium hydrogen sulphide (nahs), are promising therapeutic agents in ischaemia-reperfusion and haemorrhagic shock [ ] . we studied nahs in a short-term endotoxaemia model as relatively little is known about its effects during sepsis. methods. under isoflurane anaesthesia, male wistar rats (approx g weight) underwent left common carotid and right jugular venous cannulation for blood sampling/continuous bp monitoring and fluid administration, respectively. animals were kept normothermic on a heating mat. tissue oxygen tension (tpo ) was monitored using oxylite probes (oxford optronix, oxford uk) placed in thigh muscle. after a -min stabilization period, fluidresuscitated rats [ ml/(kg h)] were subjected to iv lps ( mg/kg over min). comparisons were made against animals receiving nahs ( . mg/kg bolus given immediately after lps, followed by a mg/(kg h) infusion). echocardiography (vivid , ge healthcare, bedford) and blood gas analysis were sequentially performed. sham-operated, non-septic animals also received nahs (n = ) or placebo (n = ). at the doses given, nahs had no effect on either sham-operated animals (data not shown), nor on the endotoxic rats (table ) . data shown as mean (±se). timepoints chosen reflect the biphasic response to endotoxin: = baseline, = initial hypotensive phase, = maximal recovery, = end of experiment. conclusion. nahs does not improve haemodynamics, tissue oxygenation nor shockrelated biochemical parameters in a severe model of fluid-resuscitated endotoxaemia. we will further investigate the effects of dose and time of therapeutic intervention in this model, in addition to testing it in a long-term septic model. intestinal endothelial and epithelial barrier dysfunction remain severe clinical problems as they may contribute to the development of sepsis and multiorgan failure. we have recently established an isolated rat small intestine model with access to vasculature, lumen and lymphatics for study of inflammatory changes in fluid balance [ ] stable for min, rendering it less suitable for examination of changes in gene and protein expression profile. the aim of this study was to assess the long term functional and metabolic stability of this model. adult female wistar rats were anaesthetized, small intestines cannulated and perfused vascularly ( . ml/min) and luminally ( . ml/min) and placed in a warm humidified chamber for up to h. arterial, venous and luminal pressures as well as venous, luminal and lymphatic effluent flows and intestinal weight were recorded continuously. as measures of metabolic integrity, oxygen consumption, lactate/pyruvate ratio and galactose uptake from luminally administered lactose were analysed every min. structural and barrier integrity were assessed as histostability score (mesenteric and antimesenteric fraction of fully epitheliated villi), wet/dry weight ratio and translocation of vascularly applied fitc albumin to lumen and lymphatics. data were compared using paired t tests. ± . / . ± . ml/(min g) dry weight (**)) as well as galactose uptake ( . ± . / . ± . mg/(min g) dry weight (n.s.)) were very stable with time pointing towards high metabolic stability. during the whole experiment, luminal effluent flow was slightly lower than applied ( . ± . ml/min, min) resulting in net liquid absorption over the whole time period ( . ± . / . ± . ml/min (n.s.)), and lymph production stayed in the physiologic range ( . ± . / . ± . ml/min (n.s.)). the organ weight did not change with time which, together with the balanced luminal fluid flow and end experimental wet/dry weight ratio of . ± . (compared to . ± . at the beginning of the experiment (**)), indicate absence of edema. minimal leakage of vascular fitc albumin to the lumen ( . ± . %) and a histostability score of . ± . show integrity of the vascular-luminal barrier until the end of the experiment. the isolated small intestine model presented earlier [ ] displays excellent long term physiologic, metabolic and histologic stability and opens up a wide field of applications including inflammatory gene transcription and protein expression. introduction. mitochondria play a major role during ischemia-reperfusion as well on cytotoxic pathways as protective such as ischemic preconditioning. the aim of this study is a better understanding of the mitochondrial pathophysiologic response to several oxygen regimens in an isolated mitochondria model. mitochondria were isolated from rat heart. enriched mitochondrial pellets were conditioned in presence of glutamate ( mm) and malate ( mm) inside the oxygraph chamber during min. oxygen partial pressures were: mmhg for control group; to mmhg for hypoxia group and mmhg for anoxia group. then, after a min oxygenation period, several measurements were realized: oxygen consumption (vo ) were measured with or without adp ( mm) (state and of mitochondrial respiration); calcium retention capacity (crc); mitochondrial membrane potentiel (dwm). to explore the involvement of reactive oxygen species (ros), mitochondrial vo were measured in presence of a specific mitochondrial antioxidant drugs (xbj). all results were expressed in percent of variation in comparison to control group [median (minimum-maximum)]. the different groups were analyzed using a kruskal-wallis, a mann-whitney with a bonferroni correction or a sign test when necessary. after hypoxia and reoxygenation the mitochondrial function was altered. this impairment of mitochondrial function was not found after anoxia and reoxygenation. this difference in mitochondrial function between hypoxia and anoxia suggests the involvement of ros. this hypothesis was confirmed by the effect of the antioxidant xbj that reestablished after hypoxia the same level of vo than after anoxia. [ ] . superoxide dismutase (sod) catalyses the dismutation of superoxide oxygen free radicals to oxygen and hydrogen peroxide (h o ). the therapeutic potential of exogenous sod administration in ards is evidenced by demonstrations of efficacy in acute lung injury models [ ] . anti-oxidant defenses, particularly the extracellular sod isoform, extracellular sod (ec-sod), are downregulated by endotoxin [ ] . we proposed that ec-sod delivered via a novel viral vector would ameliorate lung injury caused by lipo-polysaccharide (lps) pulmonary instillation. methods. three groups with nine rats per group were randomised to receive either adenoassociated virus expressing ec-sod (aav-ec-sod), adeno-associated virus coding for no product (aav-null), or vehicle control, days prior to planned lps instillation. a model of lipo-polysaccharide (lps) induced acute lung injury by pulmonary instillation was established in male sprague dawley rats. twenty-four hours following lps delivery, animals were anaesthetized and mechanically ventilated and their baseline compliance and oxygenation recorded. there was a statistically significant improvement in the oxygenation of animals recieving aav-ec sod as compared to aav-null or vehicle control (mean pao = . vs. . and . , respectively). there was a significant increase in amount of ec-sod as determined by real time pcr in the group who were administered aav-ec sod. no significant differences in static compliance or bronchoalveolar lavage cells counted were noted. conclusion. aav delivered ecsod is protective in a animal model of lps induced acute lung injury. the down regulation of the ec sod system seen in the systemic inflammatory response [ ] and its subsequent replacement exogenously may explain our findings. further work will focus on other components of cellular anti-oxidant pathways and confirmation of down regulation of ec sod in our injury model. aims. the endothelial specific angiopoietin (ang)-tie ligand-receptor system has been identified as a non-redundant mediator of endothelial activation in experimental sepsis. binding of circulating ang- to the tie receptor physiologically protects the vasculature from leakage, whereas binding of ang- antagonizes tie signaling and disrupts endothelial barrier function. we tested whether administration of exogenous recombinant ang- improves survival and attenuates multi organ failure in a lethal murine sepsis model. to induce septic acute kidney injury and to evaluate survival time cecal ligation and puncture (clp) was performed in twenty sv mice. half of the mice received an intravenous application of recombinant human ang- ( lg) immediately before clp and every h thereafter. in the other half, saline was administered in the same fashion. for tissue assessment (western blot, immunohistological) clp was induced in versus (ang- vs. saline) additional mice; animals were sacrificed after h. laparotomy served as sham control (n = ). further, a panel of cytokines has been assessed with a cytometric bead array (cba) system after h. . ± . mmol/l, p \ . ) were lower in ang- treated septic mice compared to controls. similar results were obtained at h after clp. renal tissue revealed that saline treated mice exhibit a marked loss of expression of vascular endothelial (ve)-cadherin, a major component of endothelial adherens junctions. in contrast, loss of ve-cadherin expression was prevented by ang- (pre-) treatment (wb densitometry: ang- : . ± . ; saline: . ± . ; p = . ). however, contrary to previous reports, intravenous injection of exogenous ang- enhanced not only the expression of adhesion molecules (icam- , vcam- ) in renal vasculature, but also circulating cytokine levels (tnfa, mcp- , il- , il- ). conclusions. our study demonstrates that administration of exogenous recombinant ang- improves survival time in a lethal experimental sepsis model. enhanced survival was accompanied by an improvement in microcirculatory function, probably via stabilization of adherens junctions. however, ang- injection deteriorated expression of vascular adhesion molecules and raised plasma cytokine levels. although ang- may have utility as an adjunctive agent for the treatment of septic multi-organ failure, additional dose-finding and efficacy studies are required. adaptive immune responses to infection. in contrast to neutrophils, macrophages or lymphocytes, there are virtually no data on the time course of circulating dcs in septic shock (ss). using a novel specific and sensitive assay, we analyzed the evolution of circulating myeloid (mdcs) and plasmacytoid (pdcs) dcs in ss. we enrolled immunocompetent adult patients with ss (n = ), shock from other etiologies (nss, n = ) and with sepsis without organ dysfunction (s, n = ). age-matched healthy controls (hc) served as reference for mdcs and pdcs. blood samples ( ll) were drawn on the day of shock, then after and days. dcs were counted using the dc-labelling kit trucount Ò assay (bd biosciences). cd c? cd -(mdc) and cd c-cd ? (pdc) cells were selected by flow cytometry (facscanto tm , bd biosciences). hla-dr mean fluorescence index (mfi) was measured. age, sex ratio, saps ii, sofa score, nosocomial infection (ni) and mortality rates did not statistically differ between ss and nss pts. at day , mdcs and pdcs counts were significantly lower in ss and nss pts as compared to hc and s ( fig. ). pts with ss had significantly lower mdcs and pdc counts than nss at days and . hla-dr mfi of mdcs and pdcs was lower in ss pts compared to hc (p = . and . , respectively). interestingly, of the ss pts developed ni after a median time of ( . - ) days in the icu. whereas mdcs increased in pts without ni, mdcs counts remained low at day in pts who developed ni: mdcs counts and their relative variation between day and were significantly lower in pts who developed ni than in those who did not (p \ . ). logistic regression analysis indicate that a negative mdcs relative variation is associated with an increased risk of nosocomial infection with an or ( . - ) (p = . ). figure conclusion . ss is associated with quantitative and qualitative abnormalities of circulating mdcs and pdcs as early as day , independently of the haemodynamic injury. the persistence of low counts of mdcs after ss is associated with the advent of nosocomial infection during the icu stay, suggesting that dcs play a role in the development of sepsisinduced immunosupression. introduction. liver dysfunction is common in sepsis but its mechanisms are unclear. the aim of the study was to evaluate the effects of lps on cultured primary human hepatocyte respiration over time. methods. human hepatocytes were isolated and cultivated from human liver resection specimens. cultivated cells were exposed to lps ( lg/ml) for , and h. after incubation, cells were trypsinized and respiration rates were measured using a high-resolution oxygraph (oxygraph- k, oroboros instruments, innsbruck, austria). glutamate ? malate (g ? m), succinate (s) or ascorbate/tmpd (a/t) were used as substrates to test the function of complex i, ii and iv, respectively. human hepatocyte mitochondrial function in the cells treated with lps for h exhibited a significant reduction in the maximal complex ii-dependent mitochondrial respiration [control: ± vs. lps: ± pmol/(s million cells) ( table ) ]. after and h of lps incubation no significant reduction in cellular respiration was observed ( and h: n = and h: n = ). statistics: paired t test, *p = . control vs. lps ( h incubation). introduction. acute kidney injury (aki) in critically ill patients is a frequent clinical problem and a rising incidence has been reported over the past several years. recently two consensus definition for aki have been developed: rifle [ ] in by the acute dialysis quality initiative workgroup (second conference) and akin [ ] in . insofar akin and rifle criteria have been applied in large retrospective studies, limited to the initial days of icu. nefroint is an italian initiative for an observational prospective multicenter study to evaluate epidemiology of aki in italian icus employing rifle and akin classifications. a pilot study has been performed in one of the centers enrolled. objectives. primary endpoints of nefroint are: application and comparison of rifle and akin criteria for aki definition in a prospective observational study; estimate, along such criteria, of aki incidence in critically ill patients; correlation of aki stages with prognosis. method. an observational prospective multicenter study has been designed, in italian adult icus (medical and surgical). all incident icu patients have been enrolled over a month period. exclusion criteria was age \ years, or icu stay \ h. data collection about patients was performed on a web-based electronic case report form. data included icu admission diagnosis, daily urine output ( h interval), daily laboratory data. sepsis events diagnosed on clinical and/or microbiological basis where as well marked for each patient. severity scores have been calculated at admission and daily. aki patients had higher severity of illness scores and higher serum creatinine values on admission. they also were older and more likely to have a respiratory diagnosis as reason for icu admission. conclusions. nefroint is an initiative aimed at comparing rifle and akin scores to promote a uniform use of a single definition of aki that will render subsequent studies comparable. early aki recognition could potentially allow implementation of timely corrective interventions, and hopefully prevent progression to more severe stages. aim. sepsis and septic shock remain the most important causes of acute kidney injury (aki) in critically ill patients and account for more than % of cases of acute renal failure (arf) in intensive care units (icu). its mortality varies with the severity of sepsis from % to %. the aim of this preliminary study was to investigate the differences in the course and prognosis of aki that was induced by community and hospital acquired sepsis. method. patients with sepsis induced aki were included in the study. rifle criteria were used to define aki. clinical and laboratory characteristics of the patients were compared with student t test and chi square tests. results. forty-one patients were included in the study and of them had community acquired septic aki (akic). ninety percent of the patients received mechanical ventilation (mv). etiologies of sepsis were mostly community acquired pneumonia and ventilator associated pneumonia. age, gender, admission apache ii scores and sofa scores at the time of aki diagnosis were similar across the groups (p [ . ). hospital acquired septic aki (akih) developed later when compared to community acquired septic aki ( th and rd days of sepsis respectively, p . ). akih was significantly and more frequently associated with oliguria ( vs. %, p . ), bacteremia ( vs. %, p . ), nephrotoxic antibiotic usage ( vs. %, p . ) and tend to progress more frequently to acute renal failure( vs. %, p . ) compared to akic. akic episodes were more frequently ( vs. %, p . ) and rapidly ( vs. days, p . ) reversible. mean blood pressure and scvo % were significantly lower and more vasopressor and steroid therapies were required during akih episodes compared to akic (p \ . ). while length of mv and mortality rates were similar, duration of hospitalization was significantly longer in the akih group ( vs. days, p . ). conclusion. these results suggest that, akih has worse clinic and prognosis than the akic so further and larger studies are necessary to investigate the preventive and therapeutic approaches. introduction. severity-of-illness or organ dysfunction scores are inaccurate to predict outcomes in patients with acute kidney injury (aki), even when specific aki scores are used. in recent years, the third versions of simplified acute and physiology score (saps ) [ ] and of mortality probability model (mpm -iii) [ ] scores were developed, and information on their use in patients with aki is scarce. objectives. to validate the use of saps and mpm -iii at the start of renal replacement therapy (rrt) in patients with aki. prospective cohort study conducted in the icus of three tertiary-care hospitals. data used to calculate the scores were collected at start of rrt. discrimination was assessed by area under receiver operating characteristic (aroc) curves and calibration by hosmer-lemeshow goodness-of-fit test. a total of consecutive patients were included between january and july . the mean age was . ± . years. the main contributing factors for aki were ischemia/shock ( %), sepsis ( %), contrast/nephrotoxins ( %), rhabdomyolysis ( %) and urinary tract obstruction ( %) (a patient could have more than one contributing factor). eightnine ( %) patients received rrt on the first day of rrt and ( %) thereafter; continuous rrt was used as first indication in ( %) patients. the icu and hospital mortality rates were and %, respectively. the mean saps score at the start of rrt was . ± . points. both the standard equation of saps and mpm -iii scores tended to underestimate mortality. discrimination was better for saps [aroc = . ( % ci, . - . )] than for mpm -iii [aroc = . ( % ci, . - . )], as was the calibration. however, mortality prediction and calibration improved when the customized equation of saps for countries from central and south america was used. in multivariate analyses, both higher prognostic scores and length of icu stay prior to rrt were the main predictive factors for hospital mortality. conclusions. the saps score at the start of rrt was accurate in our cohort of patients and seems a promising instrument for predicting hospital mortality critically ill patients with aki. objectives. the aim of this study was to investigate the effect of hes administration on kidney function compared with other colloids or crystalloids. methods. systematic review and meta-analysis of the effects of hes administration on kidney function. inclusion criteria for the study were prospective randomized trials comparing hes to control with reporting on variables of kidney function. aims. during the initiation phase of experimental acute kidney injury (aki), subtle but devastating changes, such as loss of brush borders, disruption of tubular cell polarity and cytoskeletal changes are detectable only to a certain extent by routine histologic methods. for this reason, subjective and moderate reproducible semi-quantitative scoring of tubular changes (e.g. vacuolization, detachment, cast formation, and necrosis) still remains the method of choice to quantify the extent of experimental aki. lectins are glycoproteins which are able to bind carbohydrate structures specifically. it has previously been shown that immunolabeling of the lectin phaseolus vulgaris erythroagglutinin (pha-e) is highly specific to the brush border of proximal tubular epithelial cells of rats, mice, and humans. the aim of this study was to ( ) develop a simple and fast lectin (pha-e) based staining protocol ( ) to objectively quantify, and ( ) to analyze brush border loss in a murine model of septic aki. methods. septic aki in mice (n = ) was induced by cecal ligation and puncture (clp). animals were sacrificed h after clp.sham operated (n = ) and healthy animals (n = ) served as controls. in order to specifically stain the tubular brush border, binding of biotinylated lectin pha-e was visualized by the biotin-avidin-complex (abc) glucose-oxidase (go) method coupled to tetranitroblue tetrazolium (tnbt) in -lm paraffin sections of renal tissue. the mean brush border area of five randomly chosen, non-overlapping cortical highpower fields was analyzed by planimetric software. lectin pha-e staining was highly selective for brush border of proximal tubules (black colour). virtually no staining was present in glomeroli and medulla. the xx software reliably identified lectin-positive areas, as confirmed by image overlay controls. we found a significant difference between sepsis induced aki, sham operated animals, and healthy mice (clp: . ± . ; sham: . ± . ; healthy controls: . ± . pixel ratio; p \ . ). our findings with the pha-e staining protocol correlated significantly with the conventional semi-quantitative scoring system (r = . , p \ . ). conclusion. the here presented lectin pha-e staining method followed by computerassisted planimetric quantification of brush border area is a highly reproducible and objective tool to analyze early histological changes during septic aki in mice. when an imbalance between oxygen supply and demand exist, anaerobic respiration commences and a metabolic acidosis develops. base excess and lactate have been used to identify a higher risk group of patients who should be admitted in icu prior to development of multiple organ failure. and at a time when appropiated therapy may previne the decline to death. acute kidney injury failure is a common complication in critically ill patients and it always difficult separate the acid base effects of critical illness per se from those of aki. the aim of this study was to examine wheter values of base excess or lactate taken on admission of patients with aki to a intensive care unit indicate prognosis and if wheter this can be used as screening tool for future intensive care admissions. we restropectively examinated data from patients with aki. to define the unique acid base characteristics of aki patients, we used a control group. the matched group consisted of icu patients wihtout aki matched for apache ii score. the base excess and lactate were collected at admission and then at h. a total of patients were enrolled at study over a month-period. there were no difference with respect age, sex and apache score between groups. the icu survival rates were % to the aki group and % to control group. the value of base excess with the best predictive prognosis ability was - mmol/l to the aki group and- . (p \ . ) to the matched group and the corresponding value for lactate was higher than . to both groups. the combination of these two markers on admission to the intensive care unit led to a sensitivity of % and specifity of % for mortality. conclusion. both base excess and lactate, or the combination of the two, can be used to predict day mortality in patients admitted to the intensive care unit. in patients with aki a different cut off of base excess should be used.these variables could be utilized to identify patients who have a higher risk for mortality to whom resources could be better directed. nonthyroidal disease (ntd) is a common finding in patients who are critically ill or on dialysis or with cardiovascular disease. its presence has been associated with inflamatory conditions. the aim of this study was to analyse the posible association of ntd with the development of acute kidney injury (aki). secondary targets where to estimate the incidence of ntd in a polyvalent icu and observe the realationship between the levels of t and some inflamatory markers: c reactive protein (crp), albumin and cortisol. during months in , after approval of the local ethical committee, we prospectively determined the following parameters in every patient admited to the icu: t , t , tsh, serum creatinine (scr), crp, albumin and cortisol. after excluding patients who died or were discharged before h, patients were studied. the degree of aki was calculated using the rifle scale. at admission the values of the analysed parameters were (mean ± sd): t . ± . pg/ml; t . ± . ng/dl; tsh . ± . liu/dl; scr [ ] . its incidence ( - %) is rising due to increasing numbers of ct scans and contrast studies conducted, and the higher prevalence of risk factors such as chronic renal impairment, diabetes mellitus and old age. although usually selflimiting, cin can be associated with a need for ongoing dialysis or increased mortality [ ] . to highlight the problem of contrast induced nephropathy and the difficulties in interpreting the current evidence for possible prevention strategies. we present the case of a year old man admitted to intensive care with acute pancreatitis. he underwent eight contrast-enhanced abdominal ct scans and received nacetylcysteine (nac) for all but one of these, after which he developed acute renal failure which did not recover. we also present a review of evidence for various proposed strategies. results. several studies have examined possible renal protective strategies around contrast administration. saline and bicarbonate have been shown to be beneficial when given pre-contrast [ , ] . theophylline has been shown in meta-analysis to have a significant beneficial effect, but heterogeneity of methodology between studies makes it difficult to clarify the degree of benefit achieved [ ] . nac has shown benefit in of trials. twelve meta-analyses showed inconsistent results, with showing nac to be beneficial. none showed harm. we analysed the heterogeneity of methods, endpoints and patient groups that makes these studies difficult to compare. critically ill patients may be considered at even greater risk of cin. only one study has specifically looked at this group. strategies such as volume loading may be inappropriate in some patients and there may not be time for nac for h pre-contrast. we were unable to find specific guidelines for the prevention of cin in critically ill patients. conclusion. the evidence for strategies to prevent cin specifically in critically ill patients is unclear. we review the current literature and propose renal protective strategies including hydration, nac and theophylline for this patient group based on the evidence available. objectives. the present study addresses the issue of how the different modes of rrt are currently used and performed. we conducted a prospective observational study in three portuguese intensive care units (icu). patient demographics, type of rrt used and outcomes were collected. we studied patients who were treated with rrt for rf, with a median age of years and a saps-ii score of . ± . , a sofa score of . ± . at admission; patients ( . %) were treated with continuous replacement therapy (crrt), patients ( . %) with sustained low-efficiency dialysis (sled)and patients ( . %) were initially treated with crrt and latter with sled. using the rifle criteria for the stratification of acute renal dysfunction at the beginning of the rrt we observed: risk- ( . %), injury- ( . %), failure ( . %), loss- ( . %), esrd- ( . %). we used anticoagulation in almost all patients ( . %). among patients who received anticoagulation, heparin was the most common choice ( . %), followed by low molecular weight heparin ( . %), and by sodium citrate ( introduction. in the intensive care unit (icu), severe sepsis and multiple organ failure are frequently associated with renal failure. continuous veno venous hemofiltration (cvvh), which is used as renal replacement therapy, also removes circulating inflammatory mediators. standard cvvh is currently prescribed with a substitution flow of ml/(kg min). theoretically, when hemofiltration is performed with higher volumes, buffer balance will be restored more rapidly, while also more inflammatory mediators will be removed. this may result in faster stabilisation from septic shock. indeed, animal-and some human studies show promising results, but have several (methodical) limitations. to evaluate hemodynamic and metabolic changes during hv-cvvh in patients with septic shock in comparison to (standard) cvvh. we performed a retrospective, observational, single-center study. all patients admitted with septic shock who were treated with cvvh in the period until were included. cvvh was defined as a substitution-flow b , ml/h, hv-cvvh as[ , ml/h. the decision to start with lv-cvvh or hv-cvvh was made by the attending icu-physician on an intention-to-treat basis. statistical analyses were performed with spss . introduction. haemostatic changes in critically ill patients are complex due to simultaneous pro-and anticoagulant processes. routine ptt and aptt assays monitoring clot formation poorly reflect hypo-or hypercoagulant state, especially during anticoagulation. endogenous thrombin potential (etp) comprises an in-vitro system for measuring thrombin generation beyond clot formation and may be more informative. objective. to assess whether etp has a role in monitoring systemic anticoagulation and predicting circuit clotting in critically ill patients receiving cvvh. methods. in a prospective study in an -bed general icu, we included patients with acute renal failure (arf) requiring cvvh (postdilution, - l/u). patients received a bolus of , iu of nadroparin followed by iu/h. samples of arterial and postfilter blood were taken at baseline and , , and h after start of cvvh to measure aptt, ptt, anti-xa and etp. we compared patients with early circuit clotting (circuit life £ lower quartile) and those with normal circuit life. median baseline arterial etp-area under the curve (auc) was ma (iqr - ma) (normal values - ma). baseline etp-auc was positively related to antithrombin and inversely to ptt, aptt, anti-xa (p \ . ) and sofa score (p = . ). median circuit life was . h (iqr - h). at baseline, the four patients with early filter clotting (£ h) had prolonged ptt and aptt, higher sofa score and a tendency to lower etp (table ) . during cvvh and nadroparin infusion, arterial and postfilter ptt and aptt were prolonged (p \ . ), antixa lower (p = . ) and etp-maximal concentration (cmax) lower (p \ . ) when circuits clotted early. while arterial etp-auc tended to be lower (p = . ), postfilter etp-auc was not different between groups. in critically ill patients with arf requiring cvvh with nadroparin anticoagulation, baseline etp is lower than normal and inversely related to organ failure and (a)ptt, probably reflecting consumption of coagulation factors. within the cvvh circuit, etp-auc and anti-xa show opposing patterns. the concurrence of early filter clotting with prolonged (a)ptt, lower antixa, lower etp and higher sofa score emphasizes the role of severity of disease and associated coagulation activation and heparin resistance in circuit clotting. introduction. nadroparin is a low-molecular-weight heparin (lmwh) used to prevent clotting in the extracorporeal circuit during cvvh. in renal failure lmwh accumulates and is associated with more bleeding (ref) . whether nadroparin is removed by hemofiltration and whether the anticoagulant activity accumulates during continuous infusion is controversial. objective. to study the kinetics and removal of anti-xa activity during continuous infusion of nadroparin in patients requiring cvvh using a cellulose tri-acetate filter. methods. in a randomized crossover trial in an -bed general icu, patients with acute renal failure (arf) were randomized. in group , postdilution cvvh was initiated at filtrate flow of l/h (blood flow (bf) ml/min), which was converted to l/h (bf ml/min) after min; in group , l/h was converted to l/h. patients (\ kg) received a bolus of , iu nadoparin followed by iu/h. samples of arterial blood, postfilter blood and ultrafiltrate were taken at baseline, h after the start and min, , and h after the conversion to measure anti-xa activity. results. fourteen patients with arf were equally randomized. patients in group had higher median sofa scores ( vs. , p = . ), baseline coagulation markers were not significantly different. arterial and postfilter anti-xa values are presented in fig. . during cvvh arterial anti-xa tended to decrease in time (p = . ). the median ratio of postfilter to arterial anti-xa was . (iqr . to . ). there were large differences between patients; differences between groups were not significant, except for postfilter anti-xa at h, which was significantly higher in group ( l/h) (p = . ) . anti-xa activity was not detectable in the ultrafiltrate. conclusions. critically ill patients receiving nadroparin during cvvh showed no signs of accumulation of anticoagulant activity, although extracorporeal removal of anticoagulant activity could not be demonstrated. apparantly, nadroparin is cleared by these patients despite renal failure. the differences in anti-xa between patients may be related to severity of disease. introduction. unfractionated heparin (ufh) is used as the first-line agent for anticoagulation of the extracorporeal circuit during continuous renal replacement therapy (crrt) in % of icus in the uk (uk) [ ] . its use is monitored with serial measurements of activated partial thromboplastin time (aptt) or its ratio (apttr) in % of icus [ ] . there is, however, considerable variation in practice [ ] . anticoagulation is useful for prolonging haemofilter life and facilitates the provision of continuous therapy, but must be balanced against the risk of haemorrhage, which has been correlated with increasing apttr [ ] . most icus in the uk use an apttr target of . - . [ ] , despite recent guidance that a target range of . - . provides adequate filter life with less risk of bleeding [ ] . objectives. to investigate the adherence to our local target range for ufh therapy (apttr . - . ) and the occurrence of over-anticoagulation in our patients. ]. there were apttrs ( %) which were above our target range, and incidences ( %) where the apttr was greater than or equal to . . the apttr was greater than . on occasions ( %). conclusions. this study was conducted in an icu which delivers crrt at a higher than average frequency [ ] , and which consistently has a standardized mortality rate below the national average. despite this, there was wide deviation from our target apttr range and a considerable incidence of significant over-anticoagulation, which may place our patients at risk of haemorrhage. the vast majority of apttrs were in excess of recent guidance [ ] . regional citrate anticoagulation (rca) may provide longer filter life with a lower incidence of bleeding [ ] . its use is increasing worldwide [ ] , though it is not commonly used in the uk [ ] . we are investigating the possibility of introducing rca in our icu. in the meantime, we will set a lower apttr target for our patients. we prospectively studied patients who received cvvh from july to december . age, gender, admission diagnosis, and apache-ii were obtained and the patients were divided into three groups: low dose heparin group, low molecular weight heparin group (lmwh), and no anticoagulation group (normal saline washing) based on assessment of coagulation status. for each circuit, circuit life, bleeding, platelet count, pt, inr, aptt, creatinine and urea were collected before and after crrt. results. seventy-seven critically ill patients with acute renal failure were treated with crrt and circuits were observed. among these circuits, received unfractionated heparin (ufh) anticoagulation, received lmwh anticoagulation and received no anticoagulation. the mean circuit life ( . ± . h) in low dose ufh group, was significantly longer than in lmwh ( . ± . h) and in no anticoagulation group ( . ± . h). there was no significant difference in baseline patient pre-crrt hb, creatinine and urea among three groups. the inr and pt and aptt in baseline were significantly higher in no anticoagulation group compared to the other two groups (p \ . ). the platelet count was significantly lower in the no anticoagulation group compared to ufh group and lmwh group in baseline and during crrt. there was no significant difference in the filter pt, aptt, among the three groups during crrt. the clearance of creatinine and urea during crrt were no significant difference among the three groups. bleeding complication secondary to crrt were no significant difference among the three groups. objectives. the purpose of the study was to assess the duration of time spent off therapy during the first five days of crrt in post-traumatic arf, and to identify the reasons for this. ullevaal between january and december , were retrospectively reviewed. the hospital is the regional trauma referral centre for approximately . million adult ([ years) persons. according to the local treatment protocol, dialysis filters were routinely changed after h due to time-out. individuals were identified and data collected using several institutional registries. patients were grouped according to presence of rhabdomyolysis based on peak serum creatine kinase levels exceeding , u/l or not. categorical data were compared employing two-sided pearson chi-square test, whereas continuous data were analyzed utilizing two-tailed mann-whitney u test. results. patients were included during the study period. during the first five days of therapy there was a total of dialysis days, and the total number of pauses was . the median duration of crrt was . h per day, giving a downtime of . h per day. the number of pauses per day was significantly larger in patients with rhabdomyolysis compared to patients without rhabdomyolysis ( pauses in dialysis days vs. pauses in dialysis days, p \ . ). this resulted in a shorter duration of crrt in rhabdomyolytic compared to non-rhabdomyolytic persons ( . vs. . h per day, p \ . ). overall the reasons for pauses during crrt were filter clotting ( %), therapeutic procedures ( %), catheter problems ( %), filter time-out ( %) and diagnostic examinations ( %). patients with rhabdomyolysis had more pauses due to therapeutic procedures ( vs. %, p = . ), whereas non-rhabdomyolytic persons had more pauses due to catheter problems ( vs. %, p = . ) and filter time-out ( vs. %, p \ . ). the number of pauses per day stayed relatively stable during the first five days of crrt, but the reasons for pauses changed during the study period. conclusions. this study indicates that trauma patients with rhabdomyolysis had more frequent dialysis pauses during the first days of crrt than those without rhabdomyolysis, resulting in shorter duration of dialysis therapy. the reason for this was more frequent use of therapeutic procedures, i.e. surgery and radiological interventions, in rhabdomyolytic compared to non-rhabdomyolytic persons. grant acknowledgement. the author is supported by institutional grants. introduction. treatment of acute pancreatitis is aimed at correcting any underlying predisposing factor and at the pancreatic inflammation itself. hypertriglyceridemia is an uncommon cause of pancreatitis. a serum triglyceride level of more then , to , mg/ dl is an identifiable risk factor. interestingly, serum pancreatic enzyme levels may be normal or only minimally elevated in such cases. severe necrotizing pancreatitis is associated with a high rate of complications and significant mortality. the reduction of triglyceride level to below , mg/dl effectively prevents further episodes of pancreatitis. this study aimed to determine the effectiveness of plasma exchange (pe) in reducing triglyceride levels during an acute attack of hyperlipidemic pancreatitis (hlp). methods. prospective, observational study including six patients hospitalized with hyperlipemic pancreatitis treated with plasmapheresis between and in the medical icu of a teaching hospital in malaga. demographic data, apache ii score, organ support needed and prognosis were prospectively collected. a total of hypertriglyceridemic patients with the complication of acute pancreatitis received one or two consecutive sessions. mean age was ± years and mean apache ii was ± . icu mortality was %. we performed sessions. the development of multiorgan failure in patients with hyperlipemic necrotizing pancreatitis was associated with grave prognosis ( %), needed mechanical ventilation, vasoactive agent and renal replacement therapy. however, we had a good outcome in the majority ( %) with a effective reduction of triglycerides after the session of plasmapheresis (pe). four of six patients ( %) recovered completely in a single session. two patients developed intraabdominal abscess, requiring more than one consecutive session and surgical debridement of infected necrosis and died due to both septic shock and multi-organ failure. the respective mean removal rates during a single pe for triglyceride were %. conclusions. the best treatment of hypertriglyceridemic pa is a drastic reduction of tg-s to normal. experiences with plasmapheresis are limited. we report six patients of hypertriglyceridemic necrotizing pancreatitis with mildly elevated amylase and lipase, treated successfully with plasmapheresis. in summary, pe treatment is an effective method to clear lipids and enzymes from plasma in a single session for most hlp patients. the presence of multisystem organ failure appears to be a more important indicator of outcome than does the presence of infection. results. sixteen ( %) patients were female and ten ( %) were male. the median age was years old. the median apache ii score was . . mechanical ventilation ( %), vasoactive agents ( %) and renal replacement therapy ( %) were the most common forms of organ support needed. sessions of plasmapheresis were performed. ( %) patients had been diagnosed with thrombotic thrombocytopenic purpura (ttp), six ( %) patients had hyperlipemic pancreatitis, five ( %) patients had pulmonary-renal syndrome (prs), three ( %) patients had guillain-barré syndrome (gbs) and two ( %) had myasthenia gravis. we obtained a decreased in the values of apache ii score following the plasmapheresis performed. there were six death ( % mortality) due of the severity of the disease. the number of complications were minimal and commonly described in the literature and there was a low mortality as a result. conclusion. results indicate that the performance of plasmapheresis was on a heterogeneous sample of patients with neuroimmunological diseases, rheumatology diseases and hyperlipemic pancreatitis. we conclude that plasmapheresis is a safe treatment which can be made by the staff trained in intensive care in any moment with a wide spectrum of clinical indications and with a minimum adverse effect. the aim of the study is to evaluate that early treatment of septic shock with cpfa may improve patient outcome. methods. twenty septic patients who were admitted to the icu have been enrolled in this study. cpfa treatment was performed immediately after septic shock was diagnosed (early group h after diagnosis). every patient had - cpfa treatments for h with q blood = ml/h, q ultrafiltration = ml/(kg h) and q plasma = % of q blood. we measured the plasma concentration of procalcytonin (pct), blood lactic acid levels, crp, serum creatynine, wbc and pao /fio ratio. the apache ii score, hemodynamic parameters, norepinephrine dosage were evaluated before cpfa (t ), t (after first cycle), t (after second), t (after third cycle) and t (after h). introduction. the development of electrolyte disturbances in intensive care patients could be prevented by the use of better adapted dialysis fluids. a common problem is hypophosphatemia which has been shown to occur in up to % of the patients. correction by intravenous phosphate supplementation is known to improve respiratory muscles, cardiac index, oxygen delivery to tissues and insulin resistance. lately it has been reported that phosphate can be added directly to the dialysis fluid. this facilitates phosphate handling, but there is a risk of precipitation with calcium. an additional problem is that the amount of phosphate required to correct total body deficit varies and repeated serum measurements are needed to establish phosphate insufficiency. the process is time consuming and leads to treatment delay and excessive cost. objectives. this study evaluated the possibility to achieve and maintain normal phosphate balance over time by using a new phosphate-containing dialysis fluid. objective. the purpose of this study was to evaluate the impact of different dialysate and replacement flows in the acid-base balance of the blood. furthermore we tried to assess the way partial pressure of oxygen (po ) in the blood is affected by high flow crrt. methods. this was a prospective observational study. thirty consecutive critically ill patients that were admitted in our icu and required crrt during their course were enrolled in the study. for each patient, blood flow, dialysate and replacement flow as well as ultrafiltration adjustments were performed by the responsible intensivist. any time that the clinical condition required a modification in any of these parameters, and after a period of time of no less than h, a simultaneous blood sample was drawn from both the arterial and the venous part of the circuit and the samples were analysed by a blood gas analyzer. arterial and venus samples were then compared for differences in ph, po and pco concentration. results. in total we performed measurements in patients. mean patient age was . years, mean apache ii score was , mean icu stay was days and mean crrt days was days. overall, ph in the venous line of the circuit was higher, pco was lower and po was lower as well compared to the respective values in the arterial line of the circuit, with no difference reaching a statistical significance. concerning the blood flow, we observed that when using high hemodiafiltration flows the difference in oxygen partial pressure between the arterial and the venous line of the circuit was greater, but again it did not reach statistical significance. conclusion. the use of crrt may influence the po in the returning blood. although we did not reach statistical significance in our study, there was a definite trend towards lower po in the venous line of the circuit when high flow crrt was applied. introduction. renal failure (rf) is a common complication in critically ill patient and is associated with high mortality and has a separate independent effect on risk of death. the continuous renal replacement therapy (crrt) is physiologically superior; however, there is lack of strong evidence to prove a clinical benefit. hybrid therapies (sled) that combine the benefits of intermittent haemodialysis and continuous therapies have emerged in the past few years. objectives. the aim of this study was to assess what type of renal replacement therapy (rrt) used and relate them to severity of the illness and outcome we conducted a prospective observational study in three portuguese intensive care units (icu). patient demographics, type of rrt used, saps ii and sofa score at admission and when we started the rrt and outcomes were collected. we studied patients who were treated with rrt for rf, with a median age of years and a median saps-ii score of ; patients ( . %) were treated with continuous replacement therapy (crrt), patients ( . %) with sustained low-efficiency dialysis (sled) and patients ( . %) were initially treated with crrt and latter with sled. aim. tetanus is traditionally treated with very high doses of diazepam and morphine. it often required prolonged periods of paralysis and was associated with very high mortality and prolonged periods of ventilation. magnesium sulphate (mgso ), due to its effects on neuromuscular and autonomic system should be effective in controlling muscle rigidity, spasm and autonomic instability in patients affected with tetanus. we introduced an icu protocol using mgso as first line treatment. we wanted to evaluate our patient outcome following the introduction of our protocol. we retrospectively analysed the effects of introduction of mgso in our intensive care for management of tetanus. aim. electrolyte disturbances were often seen in patients in intensive care unit (icu). hypomagnesemia is not enough described but can be contributed in icu mortality. the aim of this study was to define the prevalence of hypomagnesemia in critically ill patients and to evaluate its relationship with duration of mechanical ventilation day, length of icu stay and mortality. a prospective study was done on patients with respiratory failure admitted to the icu between . . and . . . total serum magnesium level, electrolyte levels, albumin, total protein, and lactate levels were evaluated at the admission. patients demographic features, accompanying neurological and cardiac diseases, apache ii score, duration of mechanical ventilation, and the length of icu stay and mortality were recorded. at admission % of patients had hypomagnesemia. a positive correlation was found between serum magnesium and calcium level (p = . ), but there was no relationship between other laboratory tests. also there was no relationship determined between hypomagnesemia and duration of mechanical ventilation, and the length of icu stay and mortality (p [ . ). conclusion. electrolyte levels are important in critically ill patients. however routine monitoring of serum magnesium level is not necessary. so we should increase the case number and also evaluate the serum magnesium level with urine magnesium level to see the effects of hypomagnesemia. method. medical records of copd patients who underwent invasive mechanical ventilation (imv) were reviewed. the patients' age, sex, body mass index (bmi), apache ii scores at admission, previous diagnosis of hypothyroidism or hyperthyroidism, history of thyroid replacement therapy or antithyroid medications, and the serum thyroid stimulating hormone (tsh), free triiodothyronine (ft ), and free thyroxine (ft ) at admission were recorded. the primary outcome measure was prolonged mv (pmv), which was defined as dependence on mv for [ days. the outcome and the relation between the serum thyroid levels were evaluated. results. ninety-five copd patients were included, % were male, with a mean age of . ± . years. bmi's of the patients were . ± . and the mean value of apache ii score was . ± . . only two patients ( %) had a history of hypothyroidism. two more patient were diagnosed hypothyroidism at admission and treated with thyroid medications. the patients treated with thyroid replacement therapy were liberated from mv successfully. patients ( . %) could not be weaned. serum ft level ( . ± . ) of the patients, who could not be weaned, was statistically lower than other group who could be liberated (p = . ).however there was no statistical difference between serum ft and tsh levels and two groups. hypothyroidism is an uncommon cause of ventilator dependent respiratory failure with an incidence of %, but it is treatable, so it should be considered in patients who can not be liberated.more prospective studies are also needed to evaluate the significance of hypothyroidism in patients with respiratory failure and failure to wean. smoke inhalation injury represents an important prognostic factor in patients admitted in the hospital after smoke exposition. objectives. we determined whether initial antithrombin (at) levels help in diagnosis and prognosis of sepsis after smoke inhalation. smoke inhalation was diagnosed according to classical clinical and laboratory findings in patients admitted in the hospital with suspected inhalation after smoke exposition. at levels, coagulation parameters (fibrinogen levels, prothrombin time (pt), activated partial thromboplastin time (aptt) and liver function tests were determined on admission and correlated each other and with outcome of the patients. . initial at and fibrinogen levels were significantly lower in patients with severe smoke inhalation compared to control (p \ . ). initial at levels were lower in the ones who developed septic complications with disseminated intravascular coagulation (dic) compared to those without dic (p \ . ). initial at levels were significantly lower in patients who died as compared to survivors (p \ . introduction. x-ray finding of pleural effusion is fairly common in icus. this may vary from mild to massive effusions and of different etiologies. epidemiological and outcome data for this icu problem are scarce in literature. the objective of this study was to find how common this finding is in our icu, their respective etiologies and any bearing on icu mortality. a single centre, prospective, observational study conducted in two mixed medical and surgical icus in kolkata, india. over six month period (october to march ) all consecutive patient admissions to these two icus were screened for a x-ray evidence of pleural effusion, either on admission or during their icu stay. as per icu protocol apache ii scoring were done in all patients. those with effusions were grouped according to etiology. finally in icu mortality were observed for those with or without an effusion. a total of icu admissions were studied. among these patients were found to have x-ray evidence of pleural effusion. median apache ii score was (iqr - ) among the study population with predominant ( . %) medical admissions. incidence of bilateral effusions were a total of ( %). the common causes of pleural effusion include chronic kidney disease (n - %), heart failure (n - %), pneumonia (n - %), post operative (n - %), chronic liver disease (n - %) and rest others (e.g. trauma, pancreatitis, pte, malignancy). the overall icu mortality was ( . %) and ( . %) in groups with and without effusion respectively with a p value of . , showing number of deaths in pleural effusion group were significantly higher. our study showed x-ray finding of pleural effusion quite common in icu patient population even many a times being bilateral. in this small study the overall icu mortality were also higher in pleural effusion group, but a wider multicentric study is needed. introduction. acute lung injury (ali) is a clinical manifestation of respiratory failure caused by lung inflammation and the disruption of the alveolar-capillary barrier. to prevent alveolar edema, it is of critical importance to preserve the physical integrity of the alveolar epithelial monolayer which is regulated by the balance between centripetal forces arising from cytoskeletal tension and cell-cell and cell-matrix tethering forces [ ] . intercellular junctions, such as tight junctions are closely related to actin cytoskeleton-related barrier regulation. proteins of the coagulation cascade such as thrombin (thr)-that stiffens [ ] and contracts [ ] alveolar epithelial cells (aec)-or activated protein c (apc)-an endothelial barrierprotective agent [ ] -could modulate this balance of forces in the epithelial monolayer. to study the combined effects of thr and apc on the barrier integrity through the tight junction zo- of aec by western blotting and immunofluorescence. methods. aec (a ) were incubated for h with apc ( lg/ml) or vehicle (control). subsequently, thr ( nm) or medium was added to the cell culture. for zo- western blotting, cell lysates were first ultracentrifuged ( , g, min, °c) to obtain membrane and cytosol fractions. then the samples were subjected to western blotting and the amount of zo- fractions was calculated by densitometry. for zo- immunofluorescence, aec were grown on glass coverslips and fixed in . % formaldehyde solution. zo- antibody was used to localize the tight junction and the zo- integrated optical intensity was then measured. . treatment with apc did not induce significant changes in any zo- amount of fraction protein analyzed by western blot. thr induced a *fivefold increase ( ± % of control values) in zo- membrane fraction while no changes were detected in zo- cytoplasm protein content ( ± % of control values). by contrast, apc concentration of lg/ml showed a clear tendency to reduce the effects induced by thr on zo- membrane fraction ( ± % of control values). for zo- inmunofluorescence, apc and thr treatments resulted in different patterns of zo- in the cell-cell contacts. after thr challenge cells showed discontinuous staining of zo- compared to untreated cells indicating a disruption of alveolar monolayer. conclusions. the increase in zo- amount of membrane fraction after thr challenge lends support to a protective mechanism avoiding cell-cell contacts disruption. treatment with apc reduced the increased zo- amount of membrane protein induced by thr suggesting an improvement of the barrier integrity in this model. ( ) interleukin- (il- ) is said to be involved in organ injury. we investigated the il- values of septic acute lung injury (ali) and acute respiratory distress syndrome (ards) patients. the subjects were patients during the -year period from to from whom it was possible to collect a blood specimen within approximately h of the onset of septic ali or ards. their mean age was years, and their mean apache ii score was . their sofa score was , and their mean pao /fio (p/f) ratio was . the p/f ratio was in the ali group and in the ards group. there were cases ( . %) in the -day mortality group, and cases ( . %) in the -day mortality group. the value of il- in died group was significantly higher than in survived group ( , ± , vs. , ± , pg/ml; p \ . ), and in the ards group also significantly higher than in ali group ( , ± , vs. , ± pg/ml; p \ . ). these results suggested that il- may play an major role in progression of ards in respiratory disorder as multiple organ failure (mof). [ ] . it is well-known that the pathophysiological mechanisms and factors involved in the liberation of no and the activation of inflammatory responses differ between aud and non-aud patients. objectives. the main hypothesis of this study is that ards patients with aud and non-aud differ in their response to the application of evidence based algorithms with respect to no response (aud patients are more frequent non-responders). patients with ards (meeting aecc criteria) were included in this ethically approved study. patients with severe chronic lung fibrosis and/or bridging for lung transplant were not included. patients were allocated to aud and non-aud patients. the auddetection was performed by the published algorithm [ ] . statistical analysis: wilcoxon-mann-whitney and chi-quadrat test was used. results. so far, patients with ards were included. prevalence of aud was % in our ards patients. baseline characteristics are given in table . frequencies of no nonresponse, extracorporeal lung support and mortality are given in table . frequency of no non-response was in tendency different: % in aud patients versus % in non-aud. overall mortality was % in aud patients versus % in non-aud patients. introduction. acute lung injury (ali) is a critical illness characterized by increased vascular permeability and impaired gas exchange leading to death in some cases. inflammation plays a pivotal role in the induction and maintenance of ali and is therefore therapeutic target to treat ali. rho, a small gtpase, is involved in the regulation of inflammation through the activation of recruitment of neutrophils to the site of inflammation and through activation of transcription factors such as nf-kb. we hypothesized that a rho kinase (rock) inhibitor, y- may be beneficial to dampen the inflammatory response in ali. male sd rats were intravenously pre-treated with either saline or rock inhibitor (y- , mg/kg). ali was induced by intratracheal instillation of mg/kg e. coli lipopolysaccharide (lps). control rats received saline intratracheally. h after the induction of ali, lungs were harvested and analyzed for myeloperoxidase (mpo) activity and expression of the proteins ijb, inos and enos. bronchoalveolar lavage fluid (balf) was used to assess total protein concentration as a measure of vascular permeability. pre-treatment with the rock-inhibitor resulted in significantly decreased levels of lps-induced mpo expression and prevented the upregulation of both lps-induced inos and enos expression. furthermore, lps-induced degradation of ikb was attenuated by pretreatment with y- . finally, y- improved vascular permeability by decreasing the lps-induced protein concentration in the balf. conclusion. inhibition of rho-kinase decreases lung inflammation and vascular permeability in acute lung injury and may therefore be a good approach to treat patients suffering from ali. we hypothesized that due to the cyclic changes of pulmonary air content there are po oscillations also in the mixed venous blood (pvo ), potentially influencing pao oscillations. in each of three healthy pigs of kg, anesthetized and ventilated with constant minute volume we studied three different tidal volume settings ( , and ml/kg) resulting in different respiratory rates. a calibrated oxygen probe (fiber optic, fluorescence-quenching probe, foxy-al ; ocean optics, dunedin, fl, usa) was inserted into the pulmonary artery through a fr catheter. the catheter position was previously controlled by pressure tracing. pvo was sampled with temperature compensation at hz with a multi frequency phase fluorometer (mfpf , tau theta, fort collins, co, usa) after a generated timestamp to synchronize with the electric impedance tomography (eit) signal (goettingen goemf ii, viasys healthcare, the netherlands) sampled at hz. eit and pvo were simultaneously recorded for min during each tidal volume setting and analysed with and without low pass filtering at the heart rate. we obtained pvo oscillations with amplitudes between to mmhg with the main frequencies matching the respiratory rate. ventilation with tidal volumes of ml/kg provided higher pvo amplitudes than ventilation with ml/kg. these results are preliminary and the source of the measured pvo oscillations is not clear. alternate backflow from the superior and inferior vena cava due to changes in intrathoracic pressures during mechanical ventilation may be responsible for these oxygen partial pressure oscillations in the mixed venous blood. conclusion. mixed venous oxygen partial pressure oscillates in accordance to the respiratory rate. whether arterial po oscillations are due to cyclic recruitment and derecruitment of the lung or to corresponding mixed venous oscillations remains to be evaluated. [ ] and in neonates [ ] . to our knowledge this is the first validation of the model using a large cohort of samples from intensive care patients. aim. to assess the ability of the severinghaus equations [ ] to estimate values for po and so in critically ill adult patients. methods. , sequential blood gas samples were analysed to validate the severinghaus oxygen dissociation curve, of these , measurements had a so b . % and were included in subsequent analyses. bland-altman plots were used to examine the agreement between measured po and that calculated from the severinghaus equations, and between measured and calculated so , both with and without correction for ph. the differences between measured and estimated values were analysed using paired t tests with a p value \ . considered significant. results. the severinghaus oxygen dissociation model accurately reflects the relationship between po and so observed in clinical samples. there is reasonable agreement between the measured and calculated values for po and so , with the majority of values falling between the lines of % agreement. there was a statistically significant difference between observed and calculated values of po even when adjustment for ph was made (p \ . ), however the mean difference between the groups was not clinical significant ( . mmhg when ph adjusted). there was also a statistical difference between measured and calculated values of so (p \ . ), again, however, this difference may not be considered clinically significant ( . %). patient data and severinghaus oxygen dissociation conclusions. the severinghaus equations accurately reflect the oxygen dissociation curve in critically ill adult patients and whilst they provide values for po introduction. zinc (zn) is an essential trace element, which plays a role in many biological functions including immune function. development of respiratory infections and changes in respiratory tract cells may be affected by low zn levels. in critically ill children mortality of septic shock and degree of organ dysfunction were associated to low blood zn levels , . our aim was to study serum zn in the beginning of acute respiratory failure (arf) and its association to development of organ failures and day mortality. during an -week study period (from april to june ) adult patients with arf were treated in intensive care units (= finnali-cohort). after consent blood sample for zn analysis was drawn at baseline). samples were taken in zn-free tubes, freezen and stored in - °c for analysis. all samples were analyzed with an atomic absorption spectrophotometry in the oulu university hospital laboratory. the range of normal values is - lmol/l. organ failures were assessed by daily maximal sequential organ failure assessment (sofamax) score. results. serum zn samples were obtained during h after the baseline with median time of h. only zn values were within and two over the normal range. median (iqr) serum zn levels were . ( . - . ) and . ( . - . ) lmol/l for survivors (n = ) and nonsurvivors (n = ), respectively, with no significant difference (p = . ). in patients with or without infection (pneumonia, respiratory infection or sepsis) during h prior to arf, zn levels were . ( . - . ) and . ( . - . ) lmol/l, respectively (p = . ). zn levels were significantly lower (p \ . ) in patients with cardiovascular sofa - than - , . ( . - . ) and . ( . - . ) lmol/l, respectively. a significant correlation of zn level and daily sofamax (spearman's q - . , p \ . ) was found (fig. ) . conclusions. low serum zn levels were detected in almost all patients with arf. no association to day mortality was detected to support the earlier findings with pediatric critically ill patients. however, we found a significant correlation to organ failure development in adult patients with arf. mountaineering is closely related to a range of adverse influences. the overriding factor that affects a climber may be the hypobaric hypoxia, which is compensated by hyperventilation and other adaptive changes in the pulmonary and systemic circulation. west ( ) theoretically predicted hypoxemia combined with respiratory alkalosis [ ] , and low oxygen saturation ( … %) has been observed on peak broad, karakorum [ ] . lack of adaptation is known as mountain sickness (occurrence … % [ , ] ), which may be alleviated by acetazolamide. the importance of understanding pathophysiology of mountaineering is dictated by the gradual expansion of western consumer-oriented society to higher altitudes. the goal of our study was to obtain precise information on changes in arterial blood gas composition, acid-base status, and degree of hemoglobin desaturation relative to altitude. materials and methods. experienced athletes-four males between and years and female years attempted to ascend mt. makalu ( , m) in april-may . acetazolamide , bid was used from april till may . femoral arterial blood rather than radial arterial blood was analyzed before reaching base camp ( background. ventilator associated lung injury is a complication of mechanically ventilated patients. knowledge about pathological pathways comes from animal studies, which are necessary to generate hypotheses to be tested in humans. various experimental methods of inducing acute lung injury (ali) have been used in animal models. the results of animal studies and human research appear to be conflicting; however, this may be a consequence from the different animal models used as such for comparison. we hypothesized that effects on gas exchange, respiratory mechanics, histo-pathologic lung damage and systemic inflammation are depending on the model of ali used. in five groups of pentothal anesthetized rats acute lung injury was induced by either lung lavage or hydrocloric acid aspiration. rats were then ventilated with lung protective settings in pressure controlled mode with positive endexpiratory pressure (peep) of cm h o or breathing spontaneously with continuous positive airway pressure (cpap) = cm h o for h. blood pressures, cardiac output, pulmonary mechanics and gas exchange were measured. results. the tidal volume was . ± . ml/kg in ventilated and . ± . ml/kg in cpap groups. respiratory rate and minute ventilation were constant in ali animals and controls, but showed variability in spontaneous breathing animals. only half of the cpap animals with ali survived [ h. no significant differences were found for pco , cardiac output or blood pressure between models, but mean arterial pressure decreased in ali. in the lavage and aspiration model, pao was lower after induction of ali ( ± and ± mmhg, respectively) than controls, and increased in lavage ( ± mmhg) but not the aspiration model ( ± mmhg) after h (p \ . ). dynamic compliance of the respiratory system decreased permanently after induction of ali to . ± . ml/cm h o (lavage) and . ± . ml/cm h o (aspiration) as compared to controls, which maintained at . ± . ml/cm h o after h. the lungs from five additional anesthetized, unassisted breathing animals, taken directly after induction, showed significant atelectasis, neutrophil infiltration and interstitial and alveolar edema (diffuse alveolar damage (dad) score . ± . ), as compared to control animals without ali (dad . ± . in ventilated, . ± . in cpap, respectively). the dad was higher in aspiration ( . ± . ) than in lavage ( . ± . ) induced ali, with no significant differences between ventilated and cpap animals. no hyaline membranes were observed. conclusions. anesthesia induces significant alveolar inflammation, which is partially reversible by use of peep. the ali model of acid aspiration induces persistent changes in gas exchange, respiratory mechanics and alveolar damage, which are more severe and consistent than those induced by the lavage model. background. acute lung injury (ali) is characterized by exaggerated inflammation and a high metabolic demand. mechanical ventilation can contribute to ali, resulting in ventilator induced lung injury (vili). a suspended animation-like state induced by hydrogen sulfide (h s) may reduce metabolism and co production, allowing for a lower minute ventilation to maintain gas exchange, thereby decreasing vili. h s may also limit lung injury via reduction of inflammation. the effect of h s-induced suspended animation on myocardial function is unknown. methods. in rats, vili was induced using a peak inspiratory pressure (pip) of mmhg and zero peep. controls were ventilated with a pip of and peep of mmhg. respiratory rate was adjusted to maintain normocapnia. suspended animation was induced by infusion of a h s donor, controls received saline. blood gases were drawn, bronchoalveolar lavage fluid (balf) was collected, lungs were removed. aortic flow was measured. statistics include kruskal-wallis and mann-whitney u. introduction. alveolar oedema is a hallmark of ards and ali. fluid clearance and the influence of anaesthetics on oedema resolution are poorly understood on a molecular level in the injured lung. oedema resolution is mediated by osmotic water reabsorption, following active sodium reabsorption via the apically located epithelial sodium channel (enac), driven by sodium-potassium-adenosin-triphosphatase (na ? /k ? -atpase). objectives. our aim was to investigate the influence of mac (= . vol%) sevoflurane on mrna and protein levels of enac and na ? /k ? -atpase in injured alveolar epithelial cells (aec). methods. primary culture of aec was stimulated with lipopolysaccharide (lps, lg/ ml) and exposed to normal air containing % co with or without sevoflurane. mrna levels were measured at h using the taq-man real-time pcr method. additionally, proteins for western blotting were analyzed at , and h (n = ). in the presence of sevoflurane mrna level of the a -subunit mrna of na ? /k ? -atpase in control cells was downregulated by % (p \ . ). a-subunit na ? /k ? -atpase protein expression, however, was not influenced by lps or sevoflurane at all time points. mrna of c-enac was decreased by % in the presence of sevoflurane and by % upon stimulation with lps. in the lps-sevoflurane group downregulation was even more pronounced with % (p \ . ) after h, but not statistically different from the lps group. on the protein level of c-enac protein expression a first change was observed at h with a downregulation of % upon lps exposure (p \ . ). sevoflurane did not have an effect of this transporter protein. previous studies have shown that halothane decreases na ? /k ? -atpaseand sodium channel activities in alveolar epithelial type ii cells [ ] . despite this finding for halothane, we could not see similar effects for the volatile anaesthetic sevoflurane. our results suggest that neither the driving force of alveolar oedema resolution, the sodium potassium atpase, nor c-enac, which is considered the rate limiting step in sodium coupled water reabsorption are influenced by sevoflurane and lps in an in vitro model of ards. to further characterize the impact of sevoflurane on water transport, functional analysis of these two transporters have to be performed. grant acknowledgement. objectives. we evaluated the effects of two nebulised sfa perfluorohexyloctane (f h ) and perfluorobutylpentane (f h ) at different dosages ( ml/kg vs. . ml/kg) on pulmonary mechanics and gas exchange in healthy lungs. design. after approval by the local animal care committee, prospective, randomized animal study. subjects. thirty-five new zealand white rabbits. interventions: tracheotomised and ventilated juvenile rabbits were nebulised intratracheally with either a high or a low dose of two different sfa (f h low/high and f h low/high ) or saline (nacl). ventilated healthy animals served as controls (sham). arterial blood gases, lung mechanics, heart rate and blood pressure were recorded prior to nebulisation and in min intervals during the -h-study period. results. immediately after starting aerosol therapy p a o /f i o -ratio and dynamic lung compliance decreased in all groups, with the exception of the f h low group which behaved like the sham group. although p a o /f i o -ratio showed a continuous improvement in the other groups over time respiratory mechanics still remained impaired. high dose groups with nebulisation of liquid perfluorohexyloctane (f h high ), perfluorobutylpentane (f h high ) or saline (nacl) showed no significant differences neither in oxygenation, blood pressure nor in pulmonary compliance and resistance. in contrast to f h high , there were no residues of f h high detectable in bronchoalveolar lavage. regarding f h low we were not able to detect any adverse effects on gas exchange or pulmonary mechanics. additionally, wet-dry-ratio of apical lung tissue samples revealed no significant edema. conclusions. high dose aerosolized sfa ( ml/kg), either f h or f h , equals effects of high dose inhalation of saline. when comparing the low-dose sfa-groups, there is a convincing discrepancy in favour of f h . f h low impairs pulmonary function, whereas a low dose application of f h (low) shows no interference. this may be due to the faster evaporation of f h . a new sfa-based pulmonary drug delivery system for lipophilic or water-insoluble substances could be developed on the basis of a low-dose application of f h . objects. hypertonic exposure reduces cell volume and thereby creates a relative excess of plasma membrane (pm). as a result the lipid bilayer of the pm can simply unfold with a minimal increase in lateral tension when an externally imposed shape change demands it. to test this hypothesis, we determined the effects of osmotic pressure on the susceptibility of deformation injury and pm wound repair. we measured deformation injury and repair responses of a . cell culture media were consisted of x hmem and mannitol (v/v / ) with osmolarity of (iso), (hyper) and mosm (hypo). cells conditioned with media were either stretched or deliberately injured with a scalpel. the fraction of wounded and healed cells was measured using a dual label method. . ( ) exposure to a hypertonic environment tends to lower the susceptibility of a to deformation injury ( . ± . % for iso, . ± . % for hyper), while exposure to a hypotonic environment uniformly increases it ( . ± . % for hypo) in stretch injury. introduction. the migration of polymorphonuclear leukocytes (pmns) into the lung plays a critical role in the development of acute lung injury (ali). adenosine receptor a (a ar) is one of four g protein-coupled adenosine receptors that has been demonstrated to modulate pmn trafficking in various models of inflammatory disorders including sepsis and asthma. however, the role of a ar in ali has not been investigated systematically yet. the objective of this study was to determine the role of the a ar in a murine model of lpsinduced lung injury and in an in vitro transmigration system with human cells. methods. the migration of pmns into the different compartments of the lung was determined by flow cytometry in adult male c bl/ mice (wildtype [wt] ) and homozygous a receptor knockout (a ko) mice. we used chimeric mice that were generated by transferring bone marrow between wild-type and a ko mice to differentiate the role of a on hemopoietic and nonhemopoietic cells. furthermore, microvascular permeability was assessed by the extravasation of evans blue and the release of chemotactic cytokines into the alveolar airspace was determined by elisa. paraffin-embedded sections of the lung were stained for pmns after lps inhalation to illustrate their accumulation in the lung. in a human in vitro assay, we quantified neutrophil transmigration across an epithelial monolayer (a cell line). in all murine in vivo experiments and in the in vitro transmigration assay, we assessed the effectivity of the specific a -agonist cl-ib-meca. all statistical analyses were performed by using anova. p \ . was considered statistically significant. results. inhalation of lps significantly increased the number of pmns in wt and a ko mice in all lung compartments. no differences in pmn counts were observed between wt, a ko, and chimeric mice. pretreatment with cl-ib-meca led to a significant decrease of pmns in all lung compartments of wt mice but not in a ko mice. pharmacological activation of a ar diminished the lps-induced microvascular permeability in wt mice but not in a ko mice. upon lps-inhalation, a ko mice exhibited significantly higher levels of the cytokines cxcl und cxcl / in the alveolar airspace than wt mice. in wt mice, pretreatment with cl-ib-meca reduced levels of tnfa and il- significantly. transmigratory activity of human pmns across an epithelial monolayer was reduced when a was activated in pmns. in contrast, pretreatment of the epithelial cells did not inhibit migration of pmns. introduction. lung overdistention during mechanical ventilation causes an increase in pulmonary vascular permeability, which is characterized by interstitial and alveolar edema secondary to a diffuse endothelial and epithelial injury. thrombopoietin (tpo), a humoral growth factor that stimulates the proliferation of megakaryocytes, has also been identified as a pro-inflammatory mediator in various clinical conditions. the receptor of tpo, c-mpl, is constitutively expressed on endothelial cells and may modulate the permeability of the endothelium. we investigated the contribution of tpo in the development of acute alveolar edema formation by mechanical stretch. in an ex-vivo model of mechanical ventilation (mv), lungs of c bl mice were ventilated for h with high stress pressure cycled ventilation (end inspiratory pressure = cm h o, peep = cm h o, i:e ratio = : ) and perfused with % bovine serum albumin rpmi medium at a rate of ml/min, in the presence or absence of tpo ( mg/ml). following ventilation, lung elastance was measured and protein concentration was analyzed in the bronchoalveolar lavage. data are mean ± se. mechanical ventilation (mv) to treat patients with ards or acute lung injury (ali) has the end objective to increase the dynamic functional residual capacity (dfrc), thus increasing overall functional residual capacity (frc). simple methods to estimate dfrc at the end of expiration for a given positive end expiratory pressure (peep) would provide a valuable metric to track and modulate therapy. however, such methods do not exist and current methods are time-consuming and relatively invasive. methods. this study utilizes a constant stress strain ratio for an individual patient's volume responsiveness to peep to estimate dfrc at any peep. the estimation model identifies two population parameters from clinical data to estimate a patient-specific dfrc, b and mb, where b captures physiological parameters of frc, lung and respiratory elastance and varies depending on the peep level used, and mb is the gradient of b versus peep. dfrc was estimated at different peep values ( , , , , ) cm h o, and compared to the measured dfrc for ali/ards patients to validate the model. patients and methods. in a years period patients ( males, females) with haematological malignancies were admitted in icu. malignancy type, reason for admission, haematological profile, requirement for invasive ventilation, bronchial and blood cultures and survival rate were recorded. results. patients suffered from: hodgkin's lymphoma ( ), non-hodgkin's lymphoma ( ), chronical lymphocytic leukaemia ( ), acute myelogenous leukaemia ( ) and multiple myeloma ( ) . admission to icu was precipitated by: emergency surgical procedure ( ), respiratory failure ( ), sepsis ( ), pulmonary oedema ( ) and coma ( ) . pulmonary infiltrates was the main finding in chest x-ray. bronchial secretions cultures were positives in patients while blood cultures were positives in patients. apache ii score ranged from to (average . ) and the icu days ranged from to (average . ). all the patients required invasive ventilation. all the patients with sepsis and serious neutropenia were died, while the total mortality was / ( . %). conclusion. the admission of patients suffering from haematological malignancies in icu is associated with high mortality. immunosupression that renders them susceptible to infections, thrombocytopenia, and invasive ventilation are factors that contribute to this. early recovery of bone marrow and non invasive ventilation could improve the outcome in these patients. in liver transplanted patients, immunosuppressive therapy can increase the risk of infections and post-operative arf. nimv has been proposed as an alternative technique to reduce complications related to endotracheal intubation. the aim of our study was to evaluate nimv in liver transplanted patients, developing arf in the post-operative period. materials and methods. in this study we evaluated liver transplanted patients, developing postoperative arf. measurements of respiratory and haemodynamic parameters were performed at baseline, after h and at the end of the treatment. we evaluated intubation rate, nimv tolerance, length of stay in the icu (los), icu and hospital mortality. results. ( %) out of patients were successfully treated with nimv, while ( %) failed and were intubated. we observed no significant differences among groups in gas exchange, but rr was significantly reduced in the success group during treatment (p \ . ). in both groups we found no significant differences in pao /fio initial improvement, but the success group showed a significantly higher rate of pao /fio sustained improvement (p \ . ). no significant differences between the two groups were found in terms of hours and days of nimv. success and failure groups were significantly different in saps ii (p \ . ) los (p \ . ), icu and hospital mortality ( vs. %, p \ . , vs. %, p \ . ). reasons for nimv failure were not related to respiratory causes, but acute systemic causes such as septic shock and mods. conclusions. nimv can represent a valid alternative to invasive mechanical ventilation for the treatment of postoperative arf in liver transplanted patients; in nimv success patients reduced los and mortality can be expected. the influence of body posture on expiratory flow-limitation (efl) was estimated in flowlimited, mechanically ventilated patients using the negative expiratory pressure (nep) method. a device especially designed and in build in an evita -draeger respirator allowed the application of a pressure equal to- cm h o, starting at ms after the onset of expiratory flow and sustained throughout the end of expiration. patients were considered flowlimited, if despite the application of nep part or the expiratory flow-volume curve was superimposed on the baseline curve. patients were studied in supine and in semi-seated position ( ) at baseline and then min after administration of bronchodilators ( mg of inhaled salbutamol) with a nebulizer connected to the inspiratory port of the ventilator. supine position was significantly related to the occurrence of efl (p = . ). efl was abolished in % of our patients when changing from supine to semi-seated position, while in general a significant improvement of efl was noticed (from to % of v t , p = . ). significant improvement of efl was achieved as well (p = . ) after bronchodilative therapy. peepi was the only variable significantly related to efl improvement when changing body posture from supine to semi-seated, while for bronchodilative therapy, none of the variables studied was significantly related to efl improvement. l. c. woodson , university of texas medical branch, anesthesiology, galveston, usa, shriners hospital for children, anesthesiology, galveston, usa aims. laryngeal injuries are common among burn patients and can result in long term functional deficits. we have included careful laryngeal examination with our initial fiberoptic bronchoscopic evaluation of burn patients. the goal has been to allow early identification of laryngeal injuries and to facilitate laryngology consultations. methods. digital video recordings were made of upper airway endoscopies performed during airway management on admission or at the time of anesthesia for initial wound excision. these recordings were used to identify laryngeal injuries and to facilitate laryngology consultations. a wide variety of laryngeal injuries were identified and the digital recordings (which can be communicated by email) greatly facilitated laryngology consultations. in many cases these recordings guided therapeutic interventions and were often sufficient to avoid a separate exam under anesthesia. diagnosis of thermal necrosis provided an indication for early tracheostomy. identification of the mechanism of mechanical airway obstruction (e.g. supraglottic edema, fibrinous exudates, granulomas, vocal fold dysmotility) resulting in failure of a trial of extubation frequently guided therapy. early identification of posterior glottic damage provided more timely corrective laryngological interventions. educational use of these videos helps increase awareness of risks of laryngeal injury in thermally injured patients. aims. the most used weaning predictor f/v t ratio, is not a consensual predictor. when it was reported on the first time, this ratio was considered highly sensitive and specific. but others papers seems to disagree with it, suggesting other cutoff values to determine weaning failure in specific populations, as the elders. advanced age is thought to be an import associated factor in the intensive care unit (icu), but its effect on the weaning process is unclear. no studies have found strong evidence that conventional weaning parameters are reliable for this population. the widest used weaning criteria, f/v t ratio, does not seems to keep the same performance in this kind of population. the main purposes of this study were to identify the possible differences of the f/v t ratio measured in a spontaneous breathing trial, between an adult and an elderly group. we designed a protocol to study the variation, sensibility and specificity of the frequency-to-tidal volume ratio between an adult group (ag; up to years) and an elderly group (eg; older than years) in a daily weaning screening trial. methods. the study cohort comprised patients ready to undergo weaning trial. the parameters studied were: weaning success ( h of spontaneous ventilation after extubation), respiratory rate (f), tidal volume (v t ), frequency/tidal volume ratio (f/v t ), gasometric and ventilatory parameters. the weaning method was spontaneous breathing trial (sbt). measurements were made in the beginning of sbt (t ) and min after (t ). we analyze possible differences in the sensibility and specificity of the f/v t ratio between elderly and adults and compare with previous values already published. the chi-square test, anova and the t test were used in the statistical analysis. weaning success was . % in eg and . % in ag (p = . ). the baseline characteristics were similar. comparisons of ag and eg at t and t showed statistical differences in weaning criteria: f, v t and f/v t ratio. conclusion. weaning success in our study was low, but similar to the described in other trials. elderly patients showed higher f and lower v t . consequently, f/v t ratio was lower too. the area under the roc curve for f/v t ratio was smaller than already published. results. / ( %) were successfully extubated and patients required re-intubation. the demographic data showed no differences in age, bmi, apache ii, icu admission diagnosis or sex distribution between groups (table ) . patients who failed extubation had small but statistically significant differences in vital capacity (vc), peak negative inspiratory pressures (pnip), pao /fio ratios (pf) and were ventilated longer prior to extubation. paradoxically, patients failing extubation had positive end expiratory pressures that were statistically but not clinically significant higher. the ratio of respiratory rate to tidal volume (f/vt) was not significantly different. patients failing extubation were also more likely to have weaker cough, gag, level of consciousness as measured by glasgow coma scale and more secretions ( table ). having no cuff leak did not predict failure of extubation. the most common reasons for reintubation were secretion retention and/or absence of cough ( %). pressure support ventilation (psv), a widely used assisted mode, has the purpose to avoid diaphragm disuse allowing the patient to generate spontaneous inspiratory efforts optimizing comfort and work of breathing. however, still little is known about the individual response of respiratory muscles under these conditions. we hypothesized that respiratory muscles of patients ventilated with clinic psv might result, at least sometimes, excessively unloaded. we performed an observational study in the intensive care unit on patients ventilated with psv set by the clinician in charge. twenty intubated, mechanically ventilated patients ( ± years old) during the weaning phase entered the study. the patients had no sedation at least for the last h. respiratory timing, tidal volume (v t ), peak airway pressure (paw peak ), electrical activity of diaphragm expressed as percentage of its maximum (edi/ edi max ), inspiratory (ptpes) and diaphragm (ptpdi) muscle effort were measured during min of clinic psv. results. we found that seven out of twenty patients generated a negative pes swing only during the psv inspiratory triggering phase (psv t ) in comparison with the remaining patients in whom pes was negative throughout most of the mechanical breath (psv n ). in the psv t group, pes swing was either flat or positive after inspiratory triggering. therefore, in the psv t group both ptpes /min and ptpdi /min were fivefold lower than normal values. v t / predicted body weight (pbw) was significantly higher in the psv t versus psv n group (see table ). during weaning with psv: ( ) a significant number of patients ( %) showed a pes shape similar to that observed during pressure assist/control modes, and inspiratory muscle effort abundantly lower than normal, both indicating excessive inspiratory muscle unloading; ( ) among the variables used to set psv, only a high v t /pbw (higher than ml/kg) hallmarked excessive unloading; ( ) due to the ample prevalence of the phenomenon, the question whether high levels of inspiratory muscle unloading can cause detraining and prolonged mechanical ventilation merits an answer from further research. introduction. the liberation from mechanical ventilation (mv) should be done as soon as possible in order to avoid complications and the risks associated with prolonged unnecessary mv, such as ventilator-associated pneumonia, ventilator induced lung injury, and increased icu and hospital stay. this procedure should be carried out properly and safely. objective. evaluate the extubation success rate, mv time and weaning time using a daily weaning screen followed by a spontaneous breathing trial (sbt). patients who were ventilated for more than h were subject to this procedure, which was carried out by respiratory therapists. methods. in our icu, between february and august of , all intubated patients who were ventilated for more than h underwent a daily weaning screen, which contained variables such as hemodynamic, gas exchange, consciousness and resolving the need for mv. if these variables were stable, these patients were submitted to a sbt and were extubated if they did not show any signs of respiratory discomfort or hemodynamic changes for at least min. conclusion. the use of a daily weaning screen followed by a sbt was associated with a high extubation success rate and a very short weaning duration with % of unsuccessfully extubations. c. chatt , d. pandit , g. raghuraman birmingham heartlands hospital, critical care, birmingham, uk, birmingham heartlands hospital, birmingham, uk aim. the aim of the study was to assess the impact of pmv on the course of weaning in mechanically ventilated patients. we wanted to assess the optimal pressure support at which pmv can be initiated which would enable prolonged use of pmv without affecting the duration of respiratory support. method. data on all patients who were mechanically ventilated for greater than eight days were obtained from icnarc database, who underwent tracheostomy as part of their weaning process. satisfactory level of pressure support was achieved (between and cm h o) pmv was introduced into the patient's breathing circuit and spontaneous ventilation was attempted. we applied mann whitney u tests for parametric data, fisher exact tests for non-parametric data and anova was used to compare the three groups with different pressure supports at initiation of pmv. a p value \ . be statistically significant. results. patients who were ventilated for greater than eight days identified. of these, patients were excluded because they did not have a tracheostomy during their period of ventilation. of the remaining patients, pmv was used in patients ( %). there were no significant differences between the demographic data (sex, age) or the data on admission to intensive care (apache ii score, ratio of medical to surgical patients) and duration of mechanical ventilation between the two groups. however, there were significant differences in the mortality, total respiratory support days after tracheostomy and length of stay in intensive care and length of hospital stay between the two groups. in the group on pmv, no record of aspirations was found documented on the intensive care charts. in patients in whom pmv was used (n = ), pmv was initiated at cpap (continuous positive airway pressure) in patients ( %). patients ( %) had pmv initiated at a pressure support of b cm h o and in patients ( %) pmv was initiated at a pressure support of [ cm h o. there was a significant difference in the duration of mechanical ventilation post tracheostomy (p = . ) and the length of hospital stay (p = . ) between the two groups, with the cpap group being ventilated for a shorter duration but with a longer stay in hospital the same difference was shown when comparing three groups of pressure support when pmv was commenced (cpap, pressure support b cm h o and pressure support [ cm h o). however, in the pressure support [ cm h o group we observed that the duration of use of pmv was lower than in the other two groups despite longer duration of mechanical ventilation and total respiratory support days. although this was not statistically significant, it could be clinically significant. our study suggests that use of pmv at pressure support b cm h o could increase the duration of its use without affecting the length of mechanical ventilation. we would therefore recommend weaning to a pressure support b cm h o before pmv is commenced in the acute setting. no data are available concerning the oxygenation target to aim during the weaning phase from mechanical ventilation. also, in opposition to ards patients there is no clear recommendation for the upper limit of spo to maintain during weaning. this study is part of a research project on peep and fio settings automation during mechanical ventilation. methods. this observational study was designed to assess the spo target aimed during the weaning phase of invasive mechanical ventilation (fio b . and peep b cm h o). patients were recruited in icus from several countries (canada, france, italy, tunisia, argentina). the following data were prospectively collected by the respiratory therapists at each round during a months period: spo , fio , peep level, ventilatory mode, anatomic site of the pulse oxymetry sensor, quality of the spo signal. results. data from centers ( icus) from quebec city, canada, and center from créteil, france are available. patients were prospectively included. , observations were performed. the mean level of fio was . ± . with fio c . and . in . % and . % of observation times respectively. the mean level of peep was . ± . cm h o and was below, equal or above cm h o in . , . and . % of the cases respectively. the most frequent ventilatory modes were pressure support ( %), simv ( %) and acv ( %). the pulse oxymetry sensor was applied on a finger of the hand in . % of the cases and was deemed of good quality in % of the time. the mean spo was . ± . % for the whole population and was . ± . % for patients with fio c . . spo was higher than % in % the observations. desaturation with spo below % were recorded in . %. the spo signal was deemed available by the bedside nurse in . ± . % of the time. conclusion. this study demonstrates that spo levels may be maintained at high levels unduly. this may have an impact on the weaning phase of mechanical ventilation. this study also shows that the spo signal availability was high enough to be used in a closed-loop oxygenation system. introduction. automated weaning systems are viewed as a challenge to weaning decision-making autonomy by some clinicians. clinician perceptions of the utility of such systems may influence uptake in to practice. to assess the perceived utility of the automated weaning system, smartcare/ ps. a survey was generated based on comprehensive literature review and -year's experience using smartcare/ps. survey pilot testing was conducted with senior clinicians experienced in smartcare/ps weaning in an independent icu. questions addressed perceived system usability and appropriateness of automated weaning, system benefits and disadvantages, as well as patient indications deemed suitable and unsuitable for smartcare/ps weaning. participants were also asked to indicate if they would continue using smartcare/ps on trial completion. the survey was administered to clinicians on completion of a randomized controlled trial conducted to compare smartcare/ps to non-protocolized weaning . of staff surveyed, surveys were returned by nurses and doctors (response rate %). eight respondents had no experience with smartcare/ps despite the year trial duration, leaving surveys with evaluable responses. the majority of respondents perceived smartcare/ps was easy to activate ( / , %) and to use once activated ( / , %). the system was observed to wean appropriately by / ( %) respondents; experienced smartcare/ps to wean inappropriately. comments on inappropriate weaning identified clinically unacceptably increases of pressure support (ps) for patients with profound tachypnea and complicated lung pathology. smartcare/ps' ability to reduce the overall duration of weaning was questioned by all but / ( %) respondents. ps adjustment according to patient requirements was the most frequently perceived benefit ( / , %). most respondents did not perceive any advantage of smartcare/ps for patient comfort / ( %), assessment frequency ( / , %) and automated control of weaning ( / , %). less control over weaning was the most regularly cited disadvantage of smartcare/ps ( / , %). system issues such as program abortion without identifiable reason and mandatory peep reduction prior to a spontaneous breathing trial to assess readiness for separation were less frequently cited disadvantages [ / ( %) and / ( %) respondents respectively]. most respondents ( / , %) felt smartcare/ps was best suited for weaning postoperative patients and should be avoided for patients with neurological dysfunction ( / , %). only / ( %) respondents stated they would not continue to use smartcare/ps. clinicians demonstrated moderate acceptance of smartcare/ps. more work is needed to identify those patients more likely to benefit and confirm the overall utility of smartcare/ps as a weaning tool. introduction. physician approaches to ventilation withdrawn varies among physicians whereas the prompt recognition of respiratory failure reversal and usefulness of weaning protocols in reducing duration of mechanical ventilation (mv) have been largely demostrated as nursing staff attend patients h a day its leadership in this process can be effective and safe. objective. to demonstrate that a nurse-directed protocol to withdraw mv could reduce a % its duration. prospective sequential study performed in two periods. during de first period ( months) data concerning weaning definite criteria appearance, duration of mv, reintubation or need for nonninvasive ventilation (nimv) and demographic data were collected to all mechanically ventilated patients blinded by attending nurses and physician. after a three months phase of staff training there was a second months period where weaning criteria were checked al each nurse working shift during the first days of mv. when criteria were fullfilled a min of spontaneous breathing trial was perfomed and tracheal tube removed if there were no intolerance criteria. same data as the first phase were collected. we used mann-whitney s u test to compare mv duration, time to reach weaning criteria (trwc) and extubation delay (mv duration minus trwc). weaning failure was compared using x square. data are presented as median ( - percentile). results. patients were screened ( in the first period and in the second) but only patient reached weaning criteria in the first days ( in the first period in the second), . % men, aged ( - ) years. aim of this study is present our experience about elective bedside pdt with the blue-rhino kit over an year period, in order evaluate its efficacy in terms of intraoperative and postoperative complications. patients and methods. the study included a total of consecutive icu patients requiring tracheostomy. all pdt were performed by icu staff physicians at patients' bedsides, using a blue rhino kit. the following data were recorded: age, sex, simplified acute physiology score (saps) ii, fraction of inspired oxygen (fio ) before the tracheostomy, days on mechanical ventilation before the tracheostomy, bleeding, tracheal tear, subcutaneous emphysema, pneumothorax, wound infection, hypotension, lowering sao during the procedure, inability to complete the procedure, and procedural mortality. distance follow-up included fiberoptic bronchoscopy to evaluate tracheal stenosis. results. there were a total of ( . %) complications (tracheo oesophagel fistula and bleeding). forty -one patients died in the icu ( %), although none of these deaths were related to technique complications. mean duration of the procedure was . ± . minutes. the pdt performed at bedside in the icu, using the blue rhino kit is a simple and safe procedure that offers many advantages in terms of safety and efficacy. objectives. questioning the need for several specialized physicians or extra assistance to perform a single percutaneous tracheostomy using fibrescopic tracheoscopy, we performed a prospective study into the complication rate of percutaneous tracheostomy without tracheoscopy on our mixed medical and surgical icu. , consecutive patients were included after having received a percutaneous tracheostomy. indication for tracheostomy was always a long anticipated duration of mechanical ventilation. if no contra indications were present, percutaneous tracheostomy was performed. if contra indications against the use of percutaneous tracheostomy without tracheoscopic control were present, tracheoscopy was performed to ensure maximum patient safety. the mean age at the time of receiving a tracheostomy was . ( - ) years. the cohort consists of male patients en female patients. only ttwo percutaneous tracheostomy were performed under fibrescopic control due to contra-indications for an uncontrolled procedure. in procedure, sixteen minor, and no major complications were encountered. this resulted in a . % minor complication rate. conclusions. the number of complications in our group is approximately the same as those which are suggested in international literature where tracheoscopy was performed during percutaneous tracheostomy. none of the complications encountered could have been prevented by the use of tracheoscopy. therefore we postulate that in the hands of an experienced team and in adherence to strict guidelines, percutaneous tracheostomy can safely and successfully be performed without tracheoscopy. objective. to assess the risks and complications associated with the bedside pdt in our years experience of over pdts in icu. pdt is a relatively newer technique and has been introduced as an alternative to open tracheostomy as a safer and convenient procedure. however, the risks and complications of the pdt have not been highlighted in the icu of a developing country. a retrospective analysis of the data gathered from patients undergoing pdt was done in a -bedded tertiary level multidisciplinary icu of a teaching hospital. the data was collected between april and march . all intubated patients with indications for elective tracheostomy, as well as patients who required emergency tracheostomy were included in the study. demographic and other clinical details of the patients who underwent pdt were collected. griggs [ ] technique was most commonly adopted while other adopted techniques were ciaglia [ ] , white tusk/blue rhino tapered dilator and percutwist technique. a total of , pdts were done in , patients, over a period of years. of the , patients ( %) were males and ( %) were females. the mean age of patients was . years. the average duration of intubation before pdt was . days. ( %) pdt were done bedside in icu while ( %) were done in wards, coronary care unit, high-dependancy unit and liver transplant unit. griggs technique was adopted in ( . %), ciaglia in ( . %), white tusk/blue rhino tapered dilator technique in ( . %) and percutwist technique in ( . %) patients. long-term ventilation was the most common indication in ( . %) followed by airway protection in ( . %), facilitation of weaning in ( . %) while airway obstruction/difficult intubation was observed in ( . %) patients. pre-procedure coagulopathy was observed in ( . %) patients, ( . %) were morbidly obese while ( . %) required emergency tracheostomy. no complications were observed in ( . %) patients. procedural complications were seen in ( . %) patients. bleeding from the site was the leading complication affecting ( . %) patients. difficult tube placement was seen in ( . %) patients, premature extubation in ( . %), false passage in ( . %), guidewire dislodgement in ( . %), subcutaneous emphysema in ( . %), arrhythmia in ( . %) and bleeding requiring transfusion was seen in ( . %) patients. no procedure related mortality was observed. conclusion. on the basis of this large single centric study we found that pdt is a safe, reliable and convenient procedure which can be easily performed bedside by experienced intensivists. results. of the recipients who underwent pdt, were liver, kidney and heart transplant recipients. the respective mean values for age, weight and apache ii score were . ± . years, . ± . kg, and ± . all pdts were performed at bedside by experienced staff anesthesiologists with direct bronchoscopic guidance. in all cases, the indication for pdt was prolonged mechanical ventilation due to acute respiratory failure. the mean time from transplant to pdt was ± months and the mean duration of endotracheal intubation before pdt was ± days. twelve patients had coagulopathies. the calculated lung compliance and pao :fio ratio improved after pdt ( . ± . vs. . ± . ml/cm h o, p = . and ± vs. ± , p = . respectively). transient hypoxemia (n = ) and mild extratracheal bleeding (n = ) were the only early complications. there were no procedural failures and no pdt-related late complications and deaths. conclusion. the results suggest that percutaneous dilational tracheotomy is an efficacious and safe technique for prolonged airway management with improved ventilatory mechanics in solid organ transplant recipients. a. vianna , g. cabral , r. azambuja , g. carleti , t. balbi , g. pereira clinica são vicente, rio de janeiro, brazil aims. we studied diferent aspects of tracheostomy procedures performed in intensive care units (icus) located in the municipality of rio de janeiro and compared them with the medical literature. a questionnaire was elaborated and sent through email to the coordinators of every icu in the city of rio de janeiro in the period of july to august . the questionnaire was sent to the coordinators of the icus located in rio, and was answered by ( . %) of them. among the studied icus, ( . %) are public, ( . %) are private, and ( . %) are part of university hospitals. ( . %) are medical/ surgical, ( . %) are medical, and ( . %) is a surgical unit. the average number of beds is ± . . the decision to perform the procedure is taken by the icu team in ( . %), by the patient's primary team in ( . %), and by both in ( . %). tracheostomy is performed by a surgeon in ( . %) units, by an intensivist in ( . %), and by both in ( . %). the procedure is performed at the bedside in ( . %) of the icus. the most frequent indications for tracheostomy are: prospect of prolonged mechanical ventilation, coma, and airway protection. . % of are performed between the first and second week of mechanical ventilation, and % between the second and third week. control chest x-ray is performed in . % of the units. surgical tracheostomy is available in all the studied units. only ( . %) units perform percutaneous tracheostomy. the reasons given for the preference for surgical tracheostomy were the lack of a qualified team for performing the percutaneous tracheostomy or material needed for this procedure. all icus that perform the percutaneous procedure use the ciaglia technique with bronchoscopic guidance. late followup is performed in ( . %) of the studied units. the study showed great differences between the tracheostomy protocols used in the hospitals of rio de janeiro and those found in the medical literature. in particular, the use of percutaneous tracheostomy is still infrequent in the icus of rio. on all the patients, aged at least years or more, admitted to our postoperative icu since january through december , we collected demographic profiles, operative data and short and long-term outcomes. spss . was used for statistical analysis and p \ . was considered the level of significance. a total of patients ( . %), . % males and with a median (iqr) age of ( - ) were admitted to our post-operative icu over the study period. iddm was recorded in the . % of the population, copd in the . %, hypertension in the . %, chronic renal failure in the . % and arteriopathy in the . %. out the total population, . % of patients, with a median (iqr) pre-operative crs of ( - ) underwent a coronary-artery bypass grafting (cabg) surgery, whereas . % of them, with a preoperative median (iqr) nyha of ( . - ) needed a valve replacement (vr) and . % of them combined (cabg ? vr) operations; moreover, . % of patients underwent other type of cardiac and aortic surgery. overall median (iqr) post-operative mechanical ventilation length was ( . - ) hrs. while no statistically significant difference was recorded in terms of mv duration among the four surgical groups. overall recorded mortality rate was %, with the lower . % for cabg and the higher . % for vr (p = . ). kaplan meier curves showed no differences in survival likelihood at th (log rank = . , p = . ) th (log rank = . , p = . ) and th (log rank = . , p = . ) days after surgery among the different surgical groups. conclusions. the outcome after heart surgery in octogenarians is excellent; the operative risk is acceptable and the late survival rate is good. therefore, cardiac surgery should not be withheld on the basis of age alone. introduction. re-do cardiac operations have been reported to be increasing in incidence and are associated with a higher operative risk [ ] . this study aimed to determine the impact on intensive care provision. methods. data from , procedures spanning twelve years (april -march ) was examined. the re-do operations were further analysed by gender, age, pathology (new, progressive, combined) , duration between procedure, theatre time, length of stay, complications and mortality. as the number of cardiac operations performed has increased over the twelve year period, the relative incidence of re-do procedures have remained stable at . %. operative length at re-do was significantly longer (mean min vs. ) however anaesthetic time pre surgical incision was not significantly increased. subsequent length of stay on the intensive care or high dependency unit increased by % (mean . vs. . days), with higher complication rates affecting all systems (except post operative myocardial infarction). renal and pulmonary complications showed the most significant increases. renal related complications occurred in % and pulmonary in . % of cases which represents an and % increase on first operation rates. infection rates were also significantly increased at double that of the initial procedure. the total hospital stay was found to be % longer (by . vs. . days, respectively) while in hospital mortality increased from . % at initial procedure to . % at re-do. mortality rates were further elevated in the presence of renal failure post operatively, as re-do valve mortality increased from . to % and re-do cabg from . to % in this subgroup. conclusion. these results, combined with the stability of percentage re-do surgery over the twelve year period, enable specific planning and management of intensive care provisions. the knowledge of extended theatre times and subsequent stay in intensive care/high dependency units has a further impact on the throughput of routine cases. the data also highlights the increased costs associated with these patients, as they not only require longer hospital stays but also suffer increased complications requiring more investigations and interventions. specific costing therefore applies to this subgroup of intensive care patients. objectives. we aimed to assess hrqol at days after surgery in relation to preoperative hrqol. we compared patients with decreased hrqol to patients with unchanged or increased hrqol to identify disparities between these two groups. a prospective cohort study including patient scheduled for cardiac, vascular, abdominal and orthopedic surgeries in a tertiary hospital was performed. patients filled-out a hrqol questionnaire (sf- ) the day before surgery and days after. preoperative, intraoperative, postoperative data were collected. changes of pre-and postoperative physical component summary ( simultaneus kidney-pancreas transplantation is the best treatment option for type diabetic patients with chronic kidney disease. currently, the medical and surgical complications have decreased significantly, although these represent a high risk of morbidity and mortality in the short term. objectives. this study sought to investigate the incidence of medical and surgical complications, the clinical characteristics and prognostic factors influencing graft and patient's survival in a recent cohort of pancreas-kidney recipients. patients and methods. the present study included patients who received simultaneous pancreas-kidney transplantation in our center from january to february . we studied demographic, clinical and immunological characteristics of patients, and surgical and medical complications during his admission to intensive care unit. results. the average age of recipients was . years and mean age of donors was . years. the median cold ischemia time was . h ( % confidence interval - ). the average stays on the waiting list was . days. % of patients were extubated within the first h. % of patients required transfusion during their icu admission, amine infusion was started at % patients in the early hours. during follow-up, surgical reintervention in the immediate postoperative occurred in % of the patients. major surgery complications reported in the literature are graft thrombosis, although in our serie there have been only kidney graft thrombosis and pancreas graft thrombosis. only % of patients died within the first months posttransplantation surgery. conclusion. surgical complications after pancreatic transplantation remain a significant concern. hence we our results add further evidence to support the notion that the double and simultaneous pancreas-kidney transplant is in fact the treatment of choice in selected patients with end-stage renal failure due to type diabetes mellitus. a. shono , t. mihara , y. murakami , j. ota , f. kono , y. saito shimane universiy hospital, anesthesiology, izumo, japan pulmonary catheter is widely used for cardiac surgery. the complications of indwelling pulmonary catheter, such as perforation of pulmonary artery, pulmonary embolism, are well known. however, the thrombosis associated with introducer sheaths has received much less attention. we evaluated the incidence and risk factors for internal jugular vein thrombosis (ijvt) associated with introducer sheaths for pulmonary catheter after cardiac surgery. methods. the patients who underwent cardiac surgery and insertion of introducer sheaths ( . f) at right internal jugular vein (ijv) were included. ultrasonographic evaluations of ijvt were performed prior to insertion and daily until introducer sheaths removal. we investigated demographic data, underlying disease, length of surgery, use of cpb and iabp, complications during cannulation and duration of catheterization. coagulation status (pt, aptt, platelet count, d-dimer) and cardiac index at before and after surgery were also recorded. the student's t test, v test, and fisher's exact test were used for statistics and p value of . was considered significant. results. patients were included in this study. mean age of patients was ± years (range - ), mean duration of catheterization was ± days. ( . %) patients developed ijvt which occurred only one day after insertion. the incidence of ijvt was related to presence of underlying disease (relative risk, . ; % confidence interval, . to . ) and was unrelated to emergency operation, the use of iabp and cpb, number of insertion attempts. there were significant differences between patients with or without ijvt in duration of catheterization ( . ± . vs. . ± . days, p = . ), cardiac index at day after surgery ( . ± . l/(min m ) vs. . ± . l/(min m ), p = . ), the value of d-dimer at day after surgery ( . ± . vs. . ± . lg/ml, p = . ). no clinical symptoms related to ijvt were found in observation period. our results demonstrated that ijvt associated with introducer sheaths was a frequent complication and cardiac index was significantly lower in patients with ijvt. though the incidence of ijvt was higher in patients with prolonged catheterization, it developed even on day after surgery and was usually asymptomatic. this risk should be carefully considered when the insertion of pulmonary catheter is chosen for cardiac surgery. methodology. it is a prospective study of patients admitted to our icu after undergoing robotic radical prostatectomy (da vinci) in the time interval going from january up to april . we analyzed clinical and demographic data, the length of stay in the icu and hospital, the need for blood transfusion, surgical times and the complications suffered during hospital stay. data are expressed as mean, median or percentage, using the student's t test and chi-square to compare averages and detect possible associations between variables. results. seventy three patients underwent surgery with a median of years. mean surgical time was min. in recent months this time is reduced to min. the mean haemoglobin at admission ( . g/dl) was significantly higher than when dismissed ( . g/ dl), p \ . . an average of two units of concentrated red blood cells was transfused in the surgery room in . % of patients. only one patient required transfusion at the icu. cardiac or renal mild complications appeared in . % of patients. this could not be associated with age. the median of mechanical ventilation length was h. one patient required conversion to open surgery due to profuse bleeding. there was no hospital mortality and no need for reoperation. mean stay at icu was day, significantly less than those patients who suffered complications (p \ . ). the median stay in ward was days. conclusion. robotic radical prostatectomy (da vinci) has a very low associated morbidity, minimal blood transfusion requirement and short is the stay at the icu and hospital, in contrast to published data with open surgery. there was no hospital mortality. objectives. to evaluate short-and long-term outcome in patients undergoing coronary artery bypass grafting (cabg), who received an intra-aortic balloon pump (iabp) prior to surgery. methods. between january and june , all patients (n = ) who received an iabp prior to on-pump cabg in our center were included. patients received the intra-aortic balloonpump for vital indications (i.e. either unstable angina refractory to medical therapy or cardiogenic shock; group ; n = ) or for prophylactic reasons (group ; n = ). a cox proportional hazards model was used to identify predictors of long-term all-cause mortality. compared with the euroscore predictive model, observed -day mortality in group ( . %) was not significantly higher than predicted ( . %). a dramatic decrease in -day mortality occurred in group (median predicted mortality was . % and observed was %, p \ . ; fig. introduction. physiological abnormality is associated with adverse outcome and a high percentage of patients admitted to icu have abnormal physiology in the hours prior to admission [ ] . track and trigger systems are used to enable timely intervention to a deteriorating patient. the mews system is used in our level care general wards with more intensive monitoring in our level care facilities. objectives. we hypothesised that the mews for patients admitted from the general wards were being inadequately documented and that this be may influencing outcome. we therefore also hypothesised that patients admitted from the level care general surgical and medical wards in our hospital had a poorer outcome following icu admission than those admitted from sites of level care, such as the high dependency unit (hdu), emergency department and theatre recovery. we undertook a prospective week audit of all patients admitted to our district general icu. all patients' case notes and monitoring charts were reviewed by an icu consultant with additional data (e.g. apache ii scores) obtained from the ward watcher icu database. day mortality data was obtained from the hospital's sci patient database. we then compared the data with that available for patients admitted over the previous year ( ) background and aim of study. aorto-femoral bypass (afb) is widely used for the patients with peripheral vascular disease (pvd). nevertheless, there is no consensus about the type of anesthesia for this difficult group of patients. we hypothesized that continuous spinal anesthesia (csa) will be more secure and suitable for the patients with pvd combined with pulmonary and cardio-vascular co-morbidities. the aim of our study was to compare alterations of the mean arterial pressure (map) and delivery of oxygen (do ) during afb and in the early postoperative period under the influence of ga and csa. after approval of our hospital helsinki committee prospective randomized study was performed between and : male patients with pvd were included in our work. risk of anesthesia was equal to the third degree according to asa scale. in the first group of patients (n = ) ga with mechanical ventilation was employed. in the second group of patients (n = ) csa was used. both groups of patients were similar with respect to age and co-morbidities (copd % in both groups, ischemic heart disease and arterial hypertension). for ga we used propofol, midazolam, fentanyl, and isoflurane. bupivacaine was used for csa. in combination with mental sedation by intravenous midazolam. map was measured directly through radial artery catheter and do with the help of tetrapolar rheovasography. both parameters were measured during fixed points: before the operation, at the end of induction of anesthesia, after cross clamping of the aorta, after release of aortic clamp, first hour after operation, h after operation and h after operation. mann-whitney test was used for statistical analysis of our results. in the patients with csa during the operation and in the early postoperative period, map was lower but statistically non significant. map was lower statistically significant only during the cross clamping of the aorta and in the first postoperative hour, most probably due to the influence of the sympathetic block. at the same time do had almost no difference in both groups. only in induction stage it was lower in the ga group that most probably was connected with negative influence of propofol on cardiac output. conclusions. both methods of anesthesia ga and csa gave us opportunity to preserve stable map and do during afb that we performed in this difficult pvd patients with copd and cardiovascular co morbidities. over the last few decades, several scoring system have been developed for use in critically ill patients, not only to assist therapeutic decision making but also to guide resource allocation and quality of care. to evaluate the tiss- in surgical intensive care unit (icu) patients and the possible relationship between tiss- and the type of surgery, severity of illness, and outcome in these patients. prospectively collected data from all patients admitted to a postoperative icu between st march and th june were analyzed retrospectively. a-priori subgroups were defined according to gender, age, saps ii score, sofa score, surgical procedures, and the occurrence of major morbidity or death in the icu or in-hospital. a total of , patients were admitted during the study period ( . % male, mean age . years) constituting , observation days. the highest tiss- scores were observed on the day of admission. the highest tiss- was observed in patients who underwent cardiothoracic surgery, the lowest in neurosurgical patients. during the first week in the icu, tiss- was correlated to the severity of sepsis syndrome; however tiss- scores remained elevated only in patients with severe sepsis/septic shock. tiss- score was correlated to saps ii (r = . , p \ . ) and sofa score (r = . , p \ . ) throughout the icu stay and was consistently higher in non-survivors than survivors during the first weeks in the icu. conclusions. the highest tiss- scores are observed on the day of admission to the icu with marked variations according to the type of surgery. tiss- correlates well with the severity of sepsis syndrome and outcome in these patients. our data could be helpful in icu planning, risk stratification, and resource allocation in the surgical icu setting. introduction. pain and opioids for treatment of pain can affect immune function in cancer patients, which may in turn influence metastatic capability of a primary tumour during and after surgical excision. it is also been shown morphine has a direct effect on cancer cells, but results of these studies have been conflicting. we therefore aimed to determine effect of morphine, commonly used in anaestehsia and intensive care, on in vitro breast cancer cell migration using two breast cancer cell lines. we used two cell lines: mcf is er positive breast cancer cell line while mda-mb- is er negative, less differentiated and more invasive. cells were incubated with or without morphine (concentrations - ng/ml) for , and h, corresponding to clinically relevant concentrations and exposure times. cell proliferation was determined using an mts (promega inc.). h cell migration was determined using a -well flourescent kit (chemicon). results were compared using independent sample t test for differences between the groups. morphine had positive effect on cell proliferation, which was greater in mda-mb- cells. proliferation of mda-mb- was increased the most at h incubation and higher concentrations ( and ng/ml caused and % increase in proliferation at h incubation and up to % increase at h incubation). proliferation of mcf cells was increased by % in and h incubation periods. morphine caused an increase in migration of both cell lines, which was again more evident with mda-mb- cells at higher concentrations of morphine ( , % and % increase with , and ng/ml respectively). our experiments have shown morphine has potential to directly stimulate breast cancer cell proliferation and migration in vitro, especially in less differentiated breast cancer cell line. further studies are needed to determine its effect on other metastatic mechanisms such as invasion and gene expression as well as the implication of these results for clinical practice. objectives. aim of this study was to evaluate the predictive value of nt-probnp levels and inflammatory markers (crp, il- , tnf) on late mortality in patients who underwent thoracic surgery for lung cancer. methods. patients median age ( ± years) without history of heart disease or renal failure. the blood tests for nt-probnp, crp, il- and tnf analyses were drawn one day preoperatively, h, h and days postoperatively. patients' demographic data, laboratory results and mortality were collected and assessed. results. nt-probnp at h was significant higher in non-survivors ( , ± , pg/ ml) compared to survivors ( ± pg/ml, p = , ). furthermore, nt-probnp at h was associated with survival in the cox-regression analysis (p = . , hr = , , % ci: , - , , units: pg/ml). crp preoperatively was significant higher in non-survivors ( ± mg/dl) versus survivors ( ± mg/dl, p = , ). il- preoperatively was significant higher in non-survivors ( ± pg/dl) compared to survivors ( ± pg/dl, p = . ). conclusions. high nt-probnp levels at h postoperatively, associated with increased mortality in patients undergoing thoracic surgery but there was no relation ship between crp, il- and mortality. introduction. the occurrence of post-operative delirium in elderly orthopaedic patients is associated with neurological complications and cognitive decline [ ] . although the etiology of the decline is less understood, cerebral ischemic events may be involved [ ] . high plasma concentration of n-methyl-d-aspartate (nmda) receptor antibodies (nr ab) has been proven highly predictable for occurrence of the postoperative neurological events in cardiac surgery [ ] . objectives. the aim of the present study was to investigate the predictive value of blood levels of nr ab for postoperative delirium, cognitive dysfunction or any other neurological complications after hip and knee replacement surgery. methods. the study enrolled consecutive patients, aged over , requiring acute or elective knee or hip replacement surgery. cognitive impairment was evaluated by minimental state evaluation (mmse) test administered before and after surgery. daily postoperative delirium was evaluated by confusion assessment method for intensive care unit (cam-icu). plasma levels of nr ab were recorded before surgery, at the moment of hospital discharge ( - days postoperative) and weeks after discharge. all other possible risk factors for postoperative delirium were also recorded. cognitive decline was present in patients ( %) before surgery and in patients ( %) at the moment of hospital discharge (p \ . ). plasma levels of nr ab were . ± . ng/ml preoperatively, . ± . ng/ml at the moment of hospital discharge and . ± . ng/ml weeks postoperatively, with no significant differences. conclusions. the incidence of cognitive decline in elderly patients after othopaedic surgery was significantly higher when compared with the preoperative status but there was no correlation between the cognitive decline and the plasma levels of nr ab. methods. patients older than years, whose performed endoscopic, colonoscopic or both procedures, under sedation performed by the intensive care deparment of the hospital del tajo. data were collected for months. demographic characteristics, medical history, asa (american society of anesthesiologists classification), drugs bolus and total dosages, respiratory and hemodynamic data, the length of procedure and recovery, and complications were collected. tolerance was assessed by endoscopist, with a (very bad) to (very good) scale. quantitative data are expressed with mean and standar desviation, and qualitative data with percentage. results. procedures were included. table shows main characteristics. tolerance and complications are referred in table . the . % of the procedures were appropriate ( or ) . the main complications were vomiting ( . %) and hallucinations ( . %). there were only incidences of respiratory depression and of hypotension. background. the authors hypothesized that the efficacy and quality of a remifentanil (r)-based regimen versus a piritramide (p)-based analgosedation in major post-surgical patients with renal and hepatic impairments still more potent even if prevention of narcotic induced hyperalgesia (nih) [ ] was done. the nih was made by sulphate magnesium (m), ketamine(k) or clonidine(c). methods. patients were randomly allocated to receive a blinded infusion of either r at a rate of . l/(kg min) (± . ) (g : n = ) or p at . mg/(kg h) (± . ) (g : n = ) coupled to an hypnotic sedation of propofol. r and p were titrated in icu after surgery, to achieve an optimal sedation as defined by a sedation conclusions. the remifentanil-based regimen allowed a more rapid emergence from sedation and facilitated earlier extubation diminishing total icu hospitalisation time and cost. even if we prevent the narcotic induced hyperalgesia by used of magnesium, ketamine or clonidine, needs of tramadol in rescue still lower in the remifentanil group due to its high power coupled with its high fexibility compared to piritramide. its reducing, by the way, risks of tramadol's metabolites accumulation in case of renal or leaver impairment. a ''fast track'' approach to cardiac surgery has significantly shortened the length of icu stay. however, quick awakening from anesthesia and subsequent extubation after discontinuation of sedative drug sometimes cause instability of hemodynamics, such as increase of bp or hr. dexmedetomidine (dex), a agonist, is a sedative drug that can be continuously infused during weaning and extubation. the aim of this double-blind study was to evaluate the effect of dex on time to extubation and hemodynamics during weaning from mechanical ventilation after cardiac surgery. with irb approval and informed consent, the patients undergoing cardiac surgery were randomly divided into two groups, dex group [infusion of . lg/(kg h) of dex] and saline group. drug administration was started at sternal closure and continued h. ramsay sedation score, times to extubation, systolic blood pressure, heart rate, respiratory rate, pulmonary artery pressure, central venous pressure, cardiac index were examined. we analyzed these parameters on icu admission, when the patients opened their eyes on order, at immediately before extubation, min, h, and h after extubation. unpaired t test was used for statistics and p value less than . was considered significant. results. patients were included in this study (n = in the dex group, n = in the saline group). there were no significant differences between two groups in age, length of surgery, length of anesthesia, and total dose of propofol and fentanyl. time to extubation was ± min in the dex group and ± min in the saline group (mean ± sd), which were also no significant differences. ramsay sedation score were maintained and no patients needed additional sedative drug during assisted ventilation in the dex group. althought mean systolic bp and mean pa, mean cvp, rr were similar in both groups during infusion. hr at eye opening, immediately before and after extubation were significantly lower in the dex group than in the saline group. conclusion. our results demonstrated that the infusion of . lg/(kg h) of dex decreased hr during weaning from mechanical ventilation. dex could not only provide adequate sedation but also suppress the stress response after cardiac surgery. dex is a useful sedative drug for preventing instability of hemodynamics on fast track approach. however, most anxiolytics impair intellectual function. dexmedetomidine (dex) is an alpha agonist that may offer sedation without overt cognitive decline. we performed a comparison between dex and propofol (pro), a drug often used for icu sedation. methods. prospective, randomized, double-blinded, cross-over study of awake and intubated brain-injured (bi, n = ) and non-bi ( ) icu patients, each receiving pro and dex using a cross-over design with periods of baseline (analgesic use fentanyl only), drug a, interval washout (fentanyl only), drug b. sedation was titrated to a score of or - (calm, cooperative) on the rass and hopkins nics scale. cognitive testing was performed at each study period using the validated -pt hopkins ace cognitive battery. objectives. we evaluated the effect on final outcome of a treatment regimen with lowdose haloperidol initiated when a positive cam-icu occurred as a quality improvement project. methods. the cam-icu was previously implemented in daily care in all patients who stayed[ h in our bed medical-surgical icu. in the first months of the study (period ), the cam-icu was used as an adjunct to daily care and the treatment of delirium was left to the physician on an intention to treat basis. subsequently, a month study pause was defined. thereafter, in the second months of the study (period ), the cam-icu was judged to indicate the presence of delirium and haloperidol was directly started with a loading dose of mg iv with subsequent daily dosing of . - . - mg iv (age \ ) or - oversedation is still common in many intensive care units (icu) despite the demonstrated benefits associated with sedation sparing strategies, including shorter duration of mechanical ventilation, and shorter length of stay in the icu and hospital. our aim was to observe whether a minimal sedation policy could be feasible in a multidisciplinary department of intensive care. prospective observational study over a two month period (december , to january , ) in a -bed medico-surgical department of intensive care of a university tertiary hospital. all adult patients who stayed in the icu for more than h were included. data were collected on duration, type, dose, and indication for sedative and opiate analgesic agents. self extubation was used as a safety surrogate. disease severity was assessed by the apache ii score within the first h of admission. statistical analysis was performed with spss software (spss incorporation, chicago, il, usa). a total of patients (male %) with a median age of years were included; ( . %) received some sedation, the majority [ ( . %)] during mechanical ventilation. midazolam ( %) and propofol ( %) were the most frequently used sedative agents. the most common indications for sedation were: early postoperative ( %), severe respiratory failure ( . %), short term procedures ( . %), and withdrawal syndrome ( . %). the median percentage of time during which patients received mechanical ventilation without sedation was . %, and was not related to severity as assessed by the apache ii score (rho . -p = . ). in the group of patients who required sedation for longer than just short procedures or uncomplicated postoperative care ([ h), the median percentage of time during which patients received mechanical ventilation without sedation was . %. analgesic opiates were often required ( %), predominantly by continuous infusion ( %). morphine was the most frequently used agent ( %). self-extubation occurred in patients, but only needed re-intubation. conclusion. in a mixed medical-surgical population of critically ill patients, a strategy of minimal or no sedation (''sedationless'') is feasible and without major adverse effects. we propose that comfort, hemodynamic instability, and mechanical ventilation should be abandoned as usual indications for sedation. grant acknowledgement. drs received grants from the doctoral fellowship program of capes/ brazilian ministry of education and from the federal university of rio de janeiro. r. russai the royal free hospital, anesthetics, northwood, uk postoperative cognitive dysfunction (pocd) is reported to occur frequently after cardiac surgery, even in low-risk patients. predictors of neurocognitive deficits can suggest the potential etiology and outcome of patient that has developed pocd. there is a wide range of neurological manifestations from subtle cognitive impairment to deadly stroke. over a period of weeks a population of patients underwent cardiac surgery in our hospital. we have looked for any signs of pocd in correlation with the possible etiology. data have been collected prospectively focusing on past medical history (pmh), possible contributors, manifestation, complications and treatment. pocd has occurred in patients ( male, female) with age range of to years (median age years), of whom % has had pmh of neurological impairment (predementia; cerebrovascular disease). multifactorial etiology was found: respiratory failure %, morphine %, tramadol %, renal failure %, remifentanyl %. in patients no related causes were recognised. all patients showed confusion as leading manifestation, although in patients confusion presented in combination with aggressive behaviour ( ), cognitive dysfunction ( ), paranoia ( ). in occasions pocd resulted in major complications such as difficulties in airway management ( ), removal of cvp line ( ), removal of arterial line ( ). the majority of patients ( ) required pharmacological treatment with single or multiple drugs therapy, the most common used was haloperidol ( % pts). the average length of stay in itu was . days, and the average length of hospital stay was . ( - ) days. conclusion. pocd is a common and potentially devastating complication with a complex and broad etiology, which may affect the rehabilitation process and the final outcome. early diagnose is essential for personalise treatments and therefore preserve in both life quality and life expectancy. introduction. sedation and analgesia is given to the icu patient for adaptation to the intensive care environment. however, side-effects of drugs used are increasingly acknowledged as negative factors increasing the risk of delirium, vasopressor therapy, prolonged ventilation and length of stay. objectives. the purpose of the proposed study was to study the practice of sedation in norwegian icu's and the challenges experienced by nurses and physicians. a national postal survey for clinicians in all norwegian icu's was conducted in september and october . all intensive care units treating mechanically ventilated patients for more than h (n = ) were included. two respondents from each unit ( intensive care nurse and icu physician) were invited to answer the questionnaire. the survey was based on two previous danish surveys. questions on practice and perceived problems were scored on a numeric rating scale and a lickert scale, as well as a few questions with response categories based on theme. results. the response rate was % (n = ). all icus were represented with nurses with formal education in intensive care and physicians specialized in anesthesiology as respondents. written protocols are not routine in norwegian icus, but half of the departments titrated sedation according to a scoring system, most commonly maas. the most commonly used sedatives were propofol and midzolam, while fentanyl and morphine were the most used analgesics. the main indication for sedation was to achieve tolerance to ventilation and to treat other bothersome symptoms. side-effects were reported to be frequent with both sedatives and analgesics. the most frequent side effects (% reported as often present or always present) with sedative agents were circulatory instability ( %), delayed awakening ( %) and sleep disturbances ( %), while the most frequent side effects experienced with analgesics were gastrointestinal problems ( %), circulatory instability ( %) and delayed awakening ( %). the main indication for tracheostomy was reported as longterm ventilation and the wish to reduce sedation. discussion/conclusion. written protocols were not routinely used. side-effects of sedation are perceived as a problem by the majority of clinicians, leading to circulatory instability and delayed awakening. tracheostomy is used first of all to be able to reduce longterm ventilation and sedation. these results indicate a potential for new sedative agents and analgesics with fewer side-effects and more focus on the use of sedation protocols. [ ] and has been associated with gaba agonist use [ ] . delirious patients may not be overtly agitated, so signs of delirium must be actively sought. the confusion assessment method for the intensive care unit (cam-icu) is a validated and easy to use screening tool [ ] . in a recent study on this bed medical and surgical intensive care unit (icu), more patients who had received gaba agonists were delirious compared with those who were sedative free [ ] . however, the percentage of patients having at least one episode of delirium was lower than expected ( %), perhaps because they were screened only once daily and in the daytime. we repeated this study with twice daily assessments (morning and after dark) and a larger number of patients in order to obtain a more accurate prevalence of delirium and confirm an association with gaba agonist use. methods. two doctors attached to the icu received a min tutorial on using the richmond agitation and sedation score (rass) and the cam-icu assessment tools. the cam-icu was performed on all rousable patients (rass score [ - ) twice daily (morning and after dark). the following information was also noted: ( conclusion. this study shows that the prevalence of delirium on this unit is comparable with published research [ , ] and higher ( . vs. %) [ ] when patients were screened after dark as well as in the daytime. the study shows that any sedating drug was associated with significantly increased prevalence of delirium. the unexpected higher prevalence of delirium in the patients receiving non-gaba agonists versus gaba agonists cannot be explained by haloperidol use to treat delirium. results. there were patients in the icus. the mean age was . years old with a predominance of chinese ( . %) and a slight male predominance of . %. forty-six per cent of the patients were mechanically ventilated and . % had tracheostomy done. there were an average number of devices per patient. sedation was administered in . % of the patients with no sedation scales used in a quarter of these patients. only . % of the sedated patients were on sedation protocol. the majority of patients ( . %) were monitored hourly and on propofol ( %) and midazolam ( . %). up to . % of sedated patients did not have daily interruption of sedation. there were no significant difference noted in the use of sedation between medical and surgical icus. slightly more than a third of patients were given analgesia (n = ) with no analgesia scales used in a third of these patients. one third of them were administered with paracetamol and about a third with morphine. patients in surgical icus were more likely to receive analgesia compared to medical icus patients. most of these patients ( . %) were monitored hourly. only patients were on neuromuscular blockade. there was no usage of any formal delirium assessment tools at all with . % of the patients being assessed for delirium based on clinical judgement of the caring team. only % of the patients had some form of sleep promotion in the icu. conclusions. this national multi-center study reveals several deficits in the adult icu with regards to sedation, analgesia and delirium assessment and management. several initiatives should be implemented to improve patients' safety and quality of care in the icu. methods. this study was conducted in patients who visited emergency care center following caustic ingestion during a period ranging from january of and august of , in whom a retrospective analysis of medical records was performed. findings for the esophageal lesion were classified according to the change of the esophageal wall and the infiltration of periesophageal soft tissue. also, clinical, laboratory, and endoscopic data from this patients were reviewed. the correlation between the degree of esophageal damage seen on ct scans and esophageal constriction seen on esophagography were then evaluated. a total of cases of caustic ingestion were identified (age range, - years). the most common caustic agent ingested was acid ( %). the most frequent cause for ingestion was attempt of suicide ( %) as opposed to accidental ( %). the findings of thoracic ct in patients were follows: first-degree esophageal injury in ( . %), seconddegree in ( . %), third-degree in ( . %), fourth-degree in ( . %). fourteen patients ( . %) developed caustic esophageal stricture. the degree of esophageal damage got closer to grade iv, the more prevalent esophageal constriction became. this correlation was statistically significant (p \ . ). of the total patients, underwent endoscopy in the early stage after they visited emergency care center. an analysis of the correlation between the degree of esophageal damage seen on endoscopy and that seen on ct scans was performed. this revealed a significant correlation (p = . , r = . ). conclusions. thoracic ct grading suggesting periesophageal soft tissue infiltration and fluid collection (grade iii to iv) rather than only edema (grade i) may be associated with stricture formation. early ct grading was very safe and useful for predicting the development of stricture induced by caustic ingestion. conclusion. in our area critical care transport teams provided safe transfers for critically ill patients.adequate preparation, strict adherence to checklists and adequate personal are the key of optimal solving of problems. introduction. although endovascular repair of traumatic aortic injury (ertai) has revolutionized the practice of vascular surgery, many questions still remain unanswered. endoleaks, coverage of the left subclavian artery, stent fold/collapse, access complications and durability are the most important complications associated with the procedure. we describe our experience with stent fold/collapse after endovascular repair of blunt aortic injury in otherwise healthy and young patients. from january to december , patients (mean age years, mean apache score , mean length of stay days) who underwent endovascular repair of a blunt aortic injury were admitted in our icu. every day clinical examination and invasive blood pressure monitoring were employed for all our patients. when persistent hypertension was detected, transthoracic (tte) and transoesophageal echocardiography (tee) were initially used, followed by spiral computed tomography (ct) and angiography as confirmatory methods. of the patients, ( %) developed a pressure gradient of [ mmhg at the level of the stent that was initially investigated with continuous wave doppler at the descending thoracic aorta (suprasternal view). the complication presented with refractory hypertension (requiring more than two classes of antihypertensives in high doses) and difficult weaning. the cause of hypertension in of those patients was a stent collapse, while in the other patients the stent appeared folded but not collapsed. endograft revision by open surgery was necessary in of the patients. conclusion. the absence of especially designed grafts for the treatment of blunt aortic injury and the subsequent use of oversized grafts are associated with severe complications. refractory hypertension after ertai can be a manifestation of poor stent alignment and/or stent collapse. echocardiographic monitoring proved to be a useful tool in the early diagnosis of this kind of stent-graft complication. as far as we know, it is the first time that echocardiography is described in the relative literature as an early diagnostic technique for this serious complicationction. facing an aging population, the number of interventions of the french emergency medical service (ems) among very elderly is increasing. a previous retrospective study showed that except from out-of-hospital cardiac arrest survival to discharge was remarkably high after ems intervention for life-threatening pathology [ ] . the aim of the present study was to evaluate prospectively outcomes of very elderly patients managed by ems. methods. after irb approval, we conducted a prospective study over year, including all patients aged years or more managed by our physician staffed ems department. characteristics of patients including previous medical status (mccabe and knaus scoring systems), functional independence (katz adl scale), clinical conditions, the index de gravité simplifié ambulatoire (igsa) severity score were recorded. patients were followed until their hospital discharge. the -month mortality was recorded as well as the adl score. data are expressed as mean ± sd, median [iqr] or percentage of patients and compared using univariate and multivariate analysis. a p \ . was considered the threshold for significance (*). results. of the patients included, died on-scene, were transferred to the hospital and patients were left on scene because of significant improvement in medical status making hospitalization unnecessary, or on the contrary in near-death situations. mean age was ± years ( men). their adl was ( - ) and % of patients were living at home. main conditions were pneumonia (n = ), acute coronary syndrome or chest pain (n = ) and acute pulmonary oedema (n = ). at months, survival rate was % (n = ). the proportion of patients living at home was % and adl among survivors was ( - ) (vs. ( - ) initially for this subpopulation, p = . ]. when compared with deceased patients, survivors were significantly younger ( ± vs. ± years*), had lower adl penetrating anterior chest wounds causing cardiac injury are typically fatal, with only % of patients surviving to reach hospital. while the majority of patients with thoracic trauma can be managed conservatively or with simple intercostals catheter, a small but significant number of blunt ( %) and penetrating ( - %) injuries, require emergency resuscitative mediam sternotomy as a component of initial resuscitation. case report. a years old men, fall from meters high, while working in a truss. he was immobilized with semirigid cervical collar and backboard in the scene and transport to our trauma center, witch was a h car-distance. anesthesiologist team was present since the initial management in emergengy room (er) and act according to advanced trauma life support principles. in primary survey, patient was paraplegic, had a gcs of / , a normal respiratory rate, a slight hypotension and a slight tachycardia. when surgeon places a chest drainage, it drains immediately more than , ml blood, and the patient vital signs started to fade, to extreme bradicardia. the patient was then intubated with a rapid sequence intubation, with a single lumen endobronquial tube, and ventilated with protective lung ventilation. hypotension postinduction was promptly treated with vasoactive drugs (nor-adrenaline and dobutamine) and ongoing volume resuscitation. an emergency resuscitative mediam sternotomy incision was perfomed in the er and reveled a clavicule and sternum fracture and laceration in the braquiocephalic artery which has repaired. maintenance was performed with total intravenous anesthesia with fentanyl and nondepolarizing muscle relaxant. monitoring include standard monitoring plus direct arterial and central venous pressures. during the surgical procedure we treat massive blood loss, with multiple transfusions of units of red blood cells (unmatched type-specific), seven units fresh plasma, and pools of plaquets, fibrinogen and cryoprecipitate. at the end of the surgery, still ongoing blood loses, made us suspect of coagulopathy, and to use octaplex Ò . it was also performed a nasal tamponade, to stop severe epistaxis and suture a major scalp wound with evidence of basal skull fracture. patient was transferred to an intensive care unit (icu) ventilated.we was extubated at the th day post-operative. after days, he still remains in icu, because he is recovering from lumbar spine fixation for a total fracture-dislocation of d -d . discussion. although he remains paraplegic, we think emergency sternotomy have had a significantly impact in this life-threating situation. the use of cell-saver Ò would have been beneficial, but it was unavailable in er. we included only patients attended in this unit by icu personnel. these patients belonged to the area assigned to cruces which has been reference centre of the northern area of spain until december . we collected all the information needed from the clinical history and the treatment sheet, and used the spss . programme to perform the statistic analysis. results. we found patients that meet the severely burned patients criteria and that were attended by the icu personnel in colaboration with the plastic surgey unit. their medium age was . ± . years, % of those patients were men, and the medium burned body surface was ± . %. these patients remained hospitalized in this unit during a medium time of . ± . days. during their stay, the % of them needed mechanical ventilation, % presented acute renal failure, % had a pao /fio less than , and . % suffered some kind of infection. methods. prospective and observational study developed in a burn unit, in which were included all patients with total surface body area burn (tsba) [ % and/or inhalation syndrome who were admitted in our unit from march to december . we used transpulmonar thermodilution by means of monitor picco Ò in a total of measurements per patient (admission and every h). we collected measurements of cardiac index (ci), intrathoracic blood volume (itbv), extravascular lung water (evlw), inhalation syndrome or not (it was diagnosed by broncoschopy), percentage of tsba and abbreviated burn severity injury score (absi) in a total of patients.the average change of measurements of ci, itbv and evlw was studied in the following determinations and their association with few factors with a general and lineal model of mixed effects longitudinal data unbalanced. results. the evolution of thermodilution measurements was the following (graphic ) cardiac index: ci = . , ci = . , ci = . , ci = . , ci = . , ci = . , ci = . , ci = . , ci = . , ci = . . intrathoracic blood volume: itbv = , itbv = , itbv = , itbv = , itbv = , itbv = , itbv = , itbv = , itbv = , itbv = . extravascular lung water: evlw = . , evlw = . , evlw = . , evlw = . , evlw = . , evlw = . , evlw = . , evlw = . , evlw = . , evlw = . . in our serie, % of patients were male and the average age was . ( - ). nine out of all the patients ( . %) suffered inhalation syndrome, the average absi was . ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) and the average of tsba was % ( - %). mortality in our serie was % ( patients).ci and itbv measurements increased significantly while the reanimation advanced (ci p . ) (vsit p . ). in evlw we only find significantly differences in post hoc study between first measurements and fourth one (p . ), th (p . ), th (p . ), th (p . ), th (p . ) and th (p . ).in the evlw/itbv ratio (permeability index = pi) we did not observe significantly changes in the evolution.the inhalation factor did not change ci outcomes neither magnitude nor in the measurements evolution (p . and p . respectively), the same form, itbv (p . and p . respectively), but inhalation modified evlw (p . ) and the permeability index was in the signification stadistic limit (p . ).mortality was higher in patients who ci was lower and evlw was in higher values. conclusions. thermodilution in the reanimation period in critically ill burn patient shows significantly haemodynamic changes in the evolution that can help to adapt the treatment.the inhalation syndrome only modified the measurements of evlw significantly in this period but it influenced neither ci, itbv nor pi. introduction. one major issue in trauma management is to get every patient directly from the scene to the appropriate hospital for the injury he sustained. patterns of interfacility transfers have been thouroughly investigated in trauma system settings, but scarce data are available about transfers in non trauma system settings. objectives. this study aims to assess interfacility transfers that eventuate in the abscence of a formal trauma system and to estimate the potential benefits from the implementation of a more organized process. the 'report of the epidemiology and management of trauma in greece' is a one year project of trauma patient reporting throughout the country. it provided data concerning the patterns of interfacility transfers. in greece there is no formal trauma system employed and to our knowledge, all available data concerning the epidemiology of trauma in the country are either extrapolations of relevant data from other countries or based on police reports and individual hospital reports. in this study, we attempted to evaluate the paterns of interfacility transfers, information reviewed included patient and injury characteristics, need for an operation, intensive care unit (icu) admittance and mortality. trauma patients were devided in two groups, the transfer group was compared to the non-transfer group. analysis employed descriptive statistics and chi-square test. interfacility transfers were furthermore assessed according to each health care facility's availability of five requirements; computed tomography scanner, icu, neurosurgeon, orthopedic and vascular surgeon. results. data on , patients were analyzed; . % were treated at the same facility, whereas . % were transferred. in transferred group there were more male, the mean age was lower than that of the non transferred group and the injury severity score was higher. transferred patients were admitted to icu more often, had a higher mortality rate but were less operated on compared to non-transferred. the transfer rate from facilities with none of the five requirements was . %, whereas the rate of those with at least one requirement was . %. facilities with at least three requirements transferred . % of their transfer volume to units of equal resources. conclusions. the assessment of interfacility transfers can reflect current trends in a nontrauma system setting and could indicate points for substantial improvement. results. , patients included, , injuries analyzed. average age was . , . % men. . % were car accidents, % falls, . % motorcycle, . % run over and . % bicycle. . % had one injury, . % two and . % three. most frequent injury was tbi ( . %), thoracic traumatism ( . %) and ortophaedic ( . %); severe tbi was . %. ctrate according to marshall classification was . % ii, . % v and . % iii. iss averaged , higher in dying patients than in the survivors ( ± . vs. . ± . ; p \ . ). of the non mechanical-ventilated patients, . % were so in the first h following admittance. during this, . % patients were given blood transfusions, platelets . %, plasma . % and prothrombinic complexes . %. in the first h . % underwent surgery, most frequent was neurosurgery ( . %). complications: nosocomial pneumonia ( . %), catheter related bloodstream infection ( . %), acute kidney injury ( . %), ards ( . %), cns infection ( . %). . % renal replacement therapy. invasive ventilation was used in . % with . ± . days, non invasive ventilation in . %. average stay in the icu was days. . % of the patients were transferred to a ward. . % were transferred to another hospital. gos on discharge was higher than on . %. % died in icu, % brain death. tbi as a main injury showed a . % mortality rate. depending on trauma type, mortality was higher in fall ( %) and run over ( . %). if due to car accident ( . %), motorcycle ( . %) or bicycle ( . %), mortality in icu was lower (p \ . ). prehospitalary variables related to mortality were age, gcs \ and a motor component \ , pupil alteration, shock, respiratory failure, prehospitalisation intubation and iss (p \ . ). on arrival to hospital, the variables were: haemodynamic instability in the first h, transfusions need and number, marshall iv-vi, mechanical ventilation (p \ . ) and initial fibrinogen (p \ . ). evolutive variables related to a higher mortality rate were days of stay, invasive ventilation, tracheostomy and the show up of complications (catheter related sepsis -p \ . -, nosocomial pneumonia, acute kidney injury, ards, renal replacement therapy (p \ . ). in a logistic regression model, prehospitalisation variables having an influence on icu mortality rate were age (or . ; p \ . ), mydriasis (or . ; p \ . ), gcs-motor component (or . ; p \ . ), shock (or ; p \ . ) and iss (or . ; p \ . ). conclusions. multiple trauma patients show a high need of resources, with many peaks of treatment involving a high monitorization and handling. many of the variables are related with a higher mortality rate in icu: iss, mydriasis, gcs motor component and shock. introduction. trauma systems are multifactorial modules that incorporate any aspect of traumatic injury from the very moment of the injury to the final outcome. a significant prerequisite for the development of a trauma system is the trauma registry. trauma registries are the actual core of any trauma system since they provide valuable information about the standard of care offered to the patients and are amenable to quality control and statistical evaluations, which in turn allow improvements and amendments in the definite care. contrary to what is common practice in the usa, trauma registries in european countries are in embryonic stage. in our country with no actual trauma system, the epidemiology of trauma and the reports on care outcomes are based on police reports and national emergency service reports. objectives. the purpose of this study was to assess the possibility of a national trauma registry in greece and to provide accurate data on the epidemiology of trauma in the country. methods. the project, entitled ''report of the epidemiology and management of trauma in greece'', was initiated in october and lasted for twelve months. all the national representatives of the hellenic society of trauma were invited to participate. the representatives are certified surgeons employed in hospitals receiving trauma. data presented here are those reported from two tertiary care facilities in athens and twenty eight other primary and secondary hospitals around the country. inclusion criteria were defined as trauma patients with documented need for admission in the hospital, patients that arrived dead or died in the emergency department of the receiving hospital and patients that required transfer to a higher level center. in total . trauma patients were included in the study in twelve months time. of them . % (n = , ) were male, aged . ± . (mean ± sd) and . % were female (n = ), aged . ± . (mean ± sd). as expected and reported in most trauma registries, males are leading in all subcategories of iss. the age group - years incorporates . % of the total injuries, in accordance to the axiom that trauma is the disease of the young. conclusions. trauma registries are the cornerstone of any trauma system. even in a non-trauma system setting, registries are a valuable tool for quality control of the provided health care and for further development of the health care system. objectives. determine the impact of rurality in epidemiology, injury severity, health care facilities, length of stay (los), mortality, functional outcome and quality of life in trauma patients. retrospective study in trauma patients that were admitted in our emergency room(er) between and . data was collected from the prospective trauma registry and follow-up registry months after the accident. we classified patients according to statistical national institute classification: urban areas-areas with more than inhab/km or have a place with more than , inhabitants; semi-urban areas-areas with more than inhab/km and less than inhab/km or have a place with more than , inhabitants and less than , inhabitants; rural areas-areas that were not classified as semi-urban or urban areas.patients were divided in three groups according to residence area: r (rural), su (semi-urban), u (urban). we studied several variables in order to find a relation with rurality: sex, age, type of injury, los in hospital and intensive care (icu), anatomic severity (ais), politrauma severity (iss), physiologic severity (rts), surveillance probability (triss index), pre-hospital care, previous admission in other hospital, icu admission and mortality. we report two outcome measures: euroqol to evaluate quality of life and extended glasgow outcome scale for functional outcome. we used qui-square test, t test, mann-whitney test, kruskal-wallis test for statistic analysis. results. , patients were admitted in the er. patients ( . %) were excluded with missing data related to residence area. we studied patients, where patients were from rural areas ( . %), from semi-urban areas ( %) and from urban areas ( . %). we find a statistical significant relation between rurality and pre-hospital care, previous admission in other hospital and icu admission. urban area patients had a higher incidence of pre-hospital care(r: . %; su: . %; u: . %, p \ . ). semi-urban and rural patients were admitted more frequently in other hospitals before admission in er (r: . %; su: . %; u: . %, p \ . ) and also had higher admissions in icu (r: . %; su: . %; u: . %, p \ . ). there were no statistical differences in the other variables studied. conclusions. rural trauma patients are similar from those that live in urban areas concerning epidemiology, injury severity and outcome. despite lack of pre-hospital care and higher previous admission in other hospital in rural patients, mortality between groups did not differed in our trauma centre. introduction. metformin-associated lactic acidosis (malta) is a rare but severe complication ( . / , patients/year) of metformin treatment in type-ii diabetes. metformin impairs neoglucogenesis and liver lactate clearance in the presence of a disease that enhances its production. although frequently used, there is no recommendations regarding hemodialysis in this poisoning. to study the prognostic factors of malta and the interests of blood metformin measurement. . on admission, patients presented profound lactic acidosis with arterial ph . ( . - . ), serum bicarbonate . mmol/l ( . - . ) and plasma lactate . mmol/l ( . - . ). early symptoms associated coma ( %), asthenia ( %), vomiting ( %), abdominal pain ( %), and diarrhoea ( %). renal function was significantly altered [creatinine clearance: ml/ min ( - ); p \ . ). all patients received massive alkalinization, / ( %) were hemodialyzed while / ( %) were mechanically ventilated and received catecholamines. six patients ( %) died in the icu. duration of icu stay was days [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . there was no significant differences regarding malta severity and treatments between suicidal and accidental poisonings. neither lactic acidosis severity nor acute renal failure were predictive of death. there was no correlation between prognosis and the time-course of plasma metformin concentrations, with or without dialysis. toxicokinetics showed significant tissue distribution when the patient was early admitted or plateaued concentrations if he was later admitted and survived, even though his situation improved and his lactates decreased. metformin dialysance suggested an interest for extra-renal elimination enhancement although its impact on survival could not be analysed based on this limited study. our study showed that malta is severe with elevated mortality in icu whatever the poisoning is accidental or intentional. metformin toxicokinetics are useful case by case to better understand the patient's outcome. the most important guidelines [ ] for trauma care recommend (us)-fast as the first step investigation to rule out major bleedings. however, us is less sensitive and accurate than multislice computed tomography (ct). the spreading concept that ''moderrn cts require little time'' often brings surgeons to ask for total body ct also in haemodynamically unstable patients. to understand how long it really takes to perform a total-body ct in patients suffering from major trauma (mt) we analysed the data of the ritg project, a pilot multicenter study to define the national standards for trauma care and establish a national trauma registry. methods. italian level trauma centers were involved into the first stage of the ritg project. data of all major trauma patients (iss [ ) who were admitted to either one of the three hospitals during a months period of time ( july - june ) were prospectively entered into the ritg database. time between hospital admission and the first scan were recorded for all patients. patients who, for any reason, were submitted to a ct with a delay of °or more were excluded. the time elapsed between the first scan and the patient's exit from the ct room was measured in a subset of pts from a single center equipped with a new generation ct next to the emergency room. during the study period mt patients were admitted to the three trauma center. patients were submitted to an emergency total body ct scan within . patients died before arrival in the ed. more died soon after admission and before the secondary survey. the interval times are shown in table . seven patients died in the ct room. the average interval between hospital admission and the first available scan was °. however, even where a new generation ct next to the er was used, the average time needed to stabilize the patients, get a correct position on the ct and start the scanning process was °as an average. in the most severely injured patients, who are frequently artificially ventilated, the time required to stabilize the patient and perform a total body ct scan is longer than expected and to a certain extent, independent from the ct scanner itself unless the very last technology as the sliding ct scanners are employed [ ] , thus ct should be considered with extreme caution in the unstable patients. in univariate analyses, survival to discharge was significantly lower with two of acute conditions (acute coronary syndrome and acute inflammation), and with five of chronic conditions (chronic heart failure, diabetes mellitus, kidney failure, hepatic cirrhosis and malignancy). recent surgery was strongly associated with higher odds of survival. the most consistent multivariate predictors of survival to discharge were liver cirrhosis (or . ; % confidence interval . - . ) and malignancy (or . ; . - . ). malignancy was not predictive for outcome after cpr attempts, whereas liver cirrhosis was predictive both in all dispatches and in dispatches involving cpr. recent surgery was strongly associated with higher multivariate odds of survival (or . ; . - . ) after cardiac arrest. in dispatches without cpr, absence of chronic conditions was associated with higher likelihood of survival (hr . ; % ci . - . ). increasing numbers of chronic conditions were significantly and continuously associated with lower survival (p for trend \ . ). advanced age only weakly predicted survival, but age c years was, along with malignancy, the strongest predictor of not attempting cpr in patients with cardiac arrest. conclusions. comorbidities are important determinants of survival after in-hospital met dispatches, with and without cardiac arrest. survival odds are lowest with malignancy and liver cirrhosis. recent surgery increases odds of survival by exclusion of those most severely ill. advanced age at best weakly predicts worse survival, but strongly predicts not attempting cpr. design. retrospective, cohort study. setting. emergency department (ed) and intensive care unit in a university hospital. measurements and main results. the study subjects included of consecutive severe trauma patients. a systematic review of the computer-based medical records of the patients was conducted to provide the base line characteristics and dic-related variables. the worst data of these variables were obtained at time points within h after arrival to the ed; time point , immediately after arrival at the ed to h after the arrival; time point , to h after the arrival; time point , to h after the arrival; time point , to h after the arrival. one hundred and forty one patients ( / , . %) diagnosed as jaam dic showed significant differences in the prevalence of multiple organ dysfunction syndrome (mods) and the outcome in comparison to the non-dic patients. a stepwise logistic regression analysis showed that the maximum jaam dic scores during the study period independently predicted the patient death (odds ratio . , % confidence interval . - . ). all of the patients who developed isth overt dic during the study period could be identified by the jaam dic criteria at early time points. the mortality rate and the incidence of mods of the patients with the isth overt dic were higher than those only met the jaam dic criteria. stepwise increases in the isth overt dic scores and the incidence of the isth overt dic were observed in accordance with the increases in the jaam dic scores. while the mortality rates were identical, there were marked differences in the incidence of mods and sequential organ failure assessment scores between the dic patients associated with trauma and sepsis. conclusions. the jaam scoring system has acceptable validity for the diagnosis of dic at an early phase of trauma. the jaam dic further exists in a dependent continuum to the isth overt dic. in addition to mods, other factors may affect the prognosis of the trauma patients associated with dic. introduction. in the uk, more than , units of fresh frozen plasma (ffp) are transfused every year. since there has been a reduction of % in its use, but it has been suggested that as many as % of transfusions in critical care may be inappropriate. there is significant morbidity associated with the transfusion of ffp. guidelines for the use of ffp do exist, but the indications for its use are limited. coagulation studies, such as prothrombin time (pt), abnormalities are often assumed to be a risk factor for bleeding prior to invasive procedures, but evidence suggests that ffp may not have a prophylactic role. in addition to this the pt or international normalised ratio (inr) were not intended to assess haemostasis in patients without a history of bleeding. review of the blood bank database between st january and st december revealed all prescriptions of ffp for patients on intensive care (itu). the case notes were analysed to find the indication and timings of administration and weight of the patient. the pathology database was examined to find the clotting studies immediately before transfusion. in patients received ffp; this was only . % of the total admissions to the itu. there were prescriptions and a total of units transfused. the mean prescription of ffp was . units and overall each patient received a mean of . units. the mean dosage of ffp was . ml/kg. the pt pre-transfusion mean was . ± . s with a median of . s. the aptt pre-transfusion mean was . ± . s with a median of . s. only . % of transfusions had not had a clotting screen done prior to administration of ffp. % of administrations were given prior to procedures being undertaken on the itu and a further % were given in preparation of the patient for the operating theatre. a significant number of patients are receiving ffp outside international guidelines. a third of transfusions were given for prophylactic correction of coagulopathy prior to an invasive procedure where there is least evidence for using ffp. most patients received a sub-therapeutic dose of ffp; there is ongoing debate on the correct dosage required to normalise coagulopathy, but it is likely to be greater than ml/kg. [ ] . little data exists on the demographics of mt and subsequent demand on a hospital's blood bank. we examined the mt requirements of a bedded tertiary referral hospital over a month period. objectives. to establish the mt demographic, speciality distribution, prbc demand and associated mortality; within a tertiary referral hospital over a month period. to assist with future mt logistics, planning, implementation and audit. methods. the hospital blood bank database was reviewed for cases of mt from jan to aug . inclusion criteria were the administration of c units of (prbc) within a h period. cross referencing with the laboratory records and medical notes was undertaken to establish patient demographics, hospital specialty, diagnosis, outcome and number of prbc transfused. results. patients received mt over a -month period; male ( . %) female ( . %). median age years (range - ). median mt of prbc was (range - ) units. units of prbc were transfused in the treatment of mt during the study period, accounting for a hospital expenditure of over € , . the main specialties associated with mt were the: emergency department ( patients, . %), cardiothoracic surgery ( patients, . %), and general surgery ( patients, . %). of the patients receiving massive transfusions ( . %), did not survive to hospital discharge. % of those patients who died, did so in the first h with a further % dying in the next h. % of the further deaths occurred within and % after thirty days. conclusions. mt in our establishment is associated with a high mortality and predominantly early deaths. recipients were generally elderly with significant co-morbidity. provision of prbcs and blood components for massive transfusion recipients, is challenging for blood bank services [ ] . the demand of mt, within our establishment, was predominantly within the acute specialties; emphasizing the need for close communication between them and the laboratory services. in light of this data we propose the implementation of a mt protocol together with continuous audit, to assess its effect on outcome. in the department of health updated the 'better blood transfusion' circular, a drive to decrease the use of blood products which have become increasingly scarce and expensive [ ] . there is evidence that blood product transfusions in icu patients are associated with an increase in morbidity, length of stay and mortality. there has been concern over the increasing use blood products and despite guidelines [ ] for their use, both national and local audits have demonstrated a high degree of inappropriate transfusion [ ] . derriford hospital is a -bedded tertiary referral centre. the blood bank database was examined for the use of blood products on icu from st january to st december . there was a steady rise in icu admissions from , patients in to , patients in . during this time there was a marked decline in both the transfusion of fresh frozen plasma (ffp) and cryoprecipitate. the decreased use of these blood products has occurred with only a very modest introduction of new pro-coagulant therapies, prothrombin complex concentrate (pcc) and recombinant factor viia (rfviia). usage of rfviia and pcc conclusions. our usage of blood products does not reflect the national trends of increasing use of cryoprecipitate and pcc with a small reduction in ffp transfusion, and is more in line with the hsc requirements for better use of blood products. this has been achieved with little use of the newer rfviia and pcc. the evidence for the use of all these blood products is not strong, particularly in critically ill patients. national guidelines exist for their use, but these are poorly adhered to. to test the hypothesis that transfusion of prbcs has a deleterious effect on clinically relevant outcomes in patients with septic shock receiving early goal directed therapy (egdt). retrospective cohort study of patients who presented in an academic center in septic shock and received egdt. data was collected on patients identified via the surviving sepsis campaign chart review database and linked to the project impact database. pearson chi square and fisher's exact test were used to test for clinical significance. primary outcome was mortality and secondary outcomes included mechanical ventilation days, intensive care unit (icu) length of stay, and hospital length of stay. . / patients presented via the emergency department. / patients received at least one prbc transfusion during their hospital stay. the two groups were balanced with respect to age, gender, apache ii, and baseline lactate levels. the prbc group had a mortality of . vs. . % in the no prbc transfusion group (p = ns). the prbc group also had more mechanical ventilation days ( . vs. . days, p = \ . ), longer hospital length of stay ( . vs. . days, p = \ . ), and longer icu length of stay ( . vs. . days, p = \ . ). conclusions. in this study, transfusion of prbc was associated with worsened clinical outcomes in patients with septic shock treated with egdt. this trial is limited by its small sample size and retrospective nature. however, the results are consistent with data from previous trials pointing to a deleterious effect associated with prbc transfusion. further studies are needed to determine the impact of transfusion of prbc within the context of early resuscitation of patients with septic shock, as the beneficial effects gained by an early and goal oriented approach to resuscitation may be lost by the negative effects associated with prbc transfusion. introduction. blood transfusion therapy (btt) is thought as one of transplantation of living cell, that means btt includes several risk such as infection and btt should be thought to derived from precious material by courtesy of donors. patients with traumatic cardiopulmonary arrest on arrival on the hospital (t-cpa) usually suffered from lethal hemorrhage and required rapid supplement of red blood cells for resuscitation of circulation and oxygen transport, that is to say btt. however, the prognosis of t-cpa patients is well known hopeless. the aim of this study is to evaluate the propriety of our strategy concerning btt for t-cpa patients. we retrospectively examined the medical records of t-cpa patients for the past years. we do btt until (the first period) for t-cpa patients regardless of rosc without any restriction. after then (the second period), we do btt case by case but only after rosc in principle. the rate of rosc, admission to icu, survive to discharge were compared between these two period, and were compared within the first period between the patients group who underwent btt (btt group) and the group who did not underwent btt (non-btt group). in blunt t-cpa and penetrating t-cpa patients, and % achieved rosc, and % admitted to icu, and and % were survive to discharge. in penetrating t-cpa in the first period, units of packed red cells (prc) were used before rosc for non-survivors. in the second period, no prc was used for non-survivor before rosc. in blunt t-cpa in the first period, prcs were used for non-survivors before rosc. in the second period no prc was used for non-survivors before rosc. concerning the effect of btt on the prognosis of t-cpa in all cases, the rate of rosc and admission to icu were statistically higher in the first period than in the second period (p = . and . ). however, there was no statistical difference in the rate of survive-to-discharge between these periods. there was a same tendency in witnessed cases. in cases with electrical rhythm on the scene, only the rate of rosc were higher in the first period (p = . ). restricted in the first period, only the rate of rosc was statistically higher in non-btt group than btt group in all cases, in witnessed cases, and in cases with electrical rhythm on the scene (p = . , . , and . ). however, there was no statistical difference in the rate of admission to icu and survive-to-discharge between these groups.. our retrospective serial study showed a possibility that btt before rosc for t-cpa improves the success rate of rosc but add no effect on the improvement of survival rate. btt is thought to be futile for t-cpa before rosc. management of refractory coagulopathy due to adult onset acquired autoimmune haemophilia. d. hendron , g. allen , m. brady , g. benson belfast city hospital, intensive care, belfast, uk, belfast city hospital, department of haematology, belfast, uk we report a case of life-threatening haemorrhage occurring as a result of a rare acquired condition caused by the production of an antibody to clotting factor viii. this necessitated administration of recombinant activated factor viia (novoseven) to bypass this step of the clotting cascade. a -year-old man presented to intensive care following ogd for acute upper gastro-intestinal haemorrhage, with recent haemoptysis and haematuria. ogd had demonstrated a large clot obstructing the oesophagus and extending through stomach into duodenum. this could not be removed and no bleeding points were identified. a coagulopathy was detected which failed to correct with administration of appropriate amounts of fresh frozen plasma, cryoprecipitate and activated prothrombin complex concentrate (apcc), necessitating clotting factor studies. this demonstrated a factor viii level of % with a detectable antibody inhibitor. acquired haemophilia was diagnosed and activated factor viia was administered resulting in rapid correction of coagulation studies and arrest of haemorrhage. it was necessary to continue daily activated factor viia at a dose of mg a day in addition to anti-inhibitor coagulant complex (feiba-vh)-an activated prothrombin complex with factor viii inhibitor bypassing activity. definitive treatment of the coagulopathy was chemotherapy with cyclophosphamide, vincristine and rituximab. this destroyed the factor viii inhibitor and returned his factor viii levels to almost %. laparotomy and gastrotomy were required to relieve the oesophageal obstruction from the accumulated clot. he was eventually discharged from hospital and remains well. acquired haemophilia is a rare haematological condition that presents with refractory haemorrhage and coagulopathy and these patients are likely to be referred to critical care services for ongoing support and management. it has an incidence of approximately . cases per million per year [ ] . underlying medical conditions can be identified in up to % of patients and include autoimmune disease, solid tumours, lymphoproliferative malignancies and pregnancy [ ] . international recommendations on the diagnosis and treatment of patients with this condition have recently been published and advise recombinant activated factor viia to control bleeding followed by a combination of corticosteroid and chemotherapy [ ] . the paucity of cases presents an obstacle for randomised controlled trials and therefore these recommendations are based on anecdotal evidence and expert opinion. reference (s) objective. to analyze the application of blood transfusion in critically ill trauma patients after wenchuan earthquake. a retrospective study was made in icu of huaxi hospital on patients who had received transfusion at least once during month after the earthquake. their primary diagnosis and clinical features and apacheii score were obtained at admission. non-active bleeding patients were classified into s group if operation was done during his icu stay, otherwise n group. the function of liver and kidney, and the state of circulation and oxgenation were compared between groups, as well as the hemoglobin level before each transfusion were investigated. a total of patients ( . %) had received transfusion at least once, among which were non-active bleeding. the average frequency was . ± . and . ± . , amount was . ± . ml and . ± . ml, the incidence of transfusion-related complication was . %( / ) and . %( / ) in active and non-active bleeding patients respectively. the apacheii score, mean arterial pressure, ast, serum creatinine, oxgenation index and hemoglobin level on day , , after admission to icu showed no statistically significant difference between s and n group. the frequency and amount of transfusion were similar also, while the hb level before each transfusion was significantly lower in n group ( . ± . g/l)than in s group ( . ± . g/l) (p \ . ). the incidence of transfusion-related and infectious complications, time with ventilator and the -day mortality were similar. conclusion. transfusion strategy is more strict in icu doctors than surgeons, while the similar result on organ function, incidence of complications and outcome raises the need for a more wide-accepted transfusion trigger. keywords. earthquake trauma transfusion trigger. extracorporeal life support (ecls) represents an ultimate rescue technique in poisonings. the optimal anticoagulation protocol remains unclear. objectives. we aimed to investigate the coagulation status at ecls decision in order to validate the best heparin protocol to administer. [ packs ( - ) ] and fresh plasma [ packs ( - ) ] transfusions were required within the first h. hemorrhages ( / ), thrombosis ( / ) or lower limb ischemia ( / ) seemed equivalent to previous series using more complicated anticoagulation protocols. conclusions. poisoned patients present at ecls time with important alteration in their clotting tests, associated with various degrees of hepatocellular failure, dic, defibrination, as well as dilution. a simple heparin protocol appears optimal to reduce complications in these critical situations. henna is the dried and powdered leaves of the henna plant. the plant is lawsonia alba and the powdered leaves are used to apply decorative designs over the skin. henna application is widely practiced in the arab and asian communities. they create fascinating designs over the skin, especially over the hands and feet. it is widely practiced during wedding ceremonies and at childbirth. g pd deficiency is common in the community of the arab world. lawsone, the chemical compound in the henna leaves, is capable of inducing severe acute hemolysis in g pd deficient cases. the compound is chemically related to naphtha. we report a case of acute sever hemolysis in a young girl who presented with dizziness and jaundice and diagnosed to have acute severe hemolysis. her symptoms had started while preparing for her wedding by henna application. the girl was g pd deficient, and found to have severe hemolysis resulting from henna application on her skin. very few cases have been reported of similar nature. the matter is also of tremendous practical implication in areas of g pd deficiency. the relevant literature is reviewed as well. background. lactate has prognostic use in critically ill medical and trauma patients, and is a core component in identification of early sepsis. elevated lactate levels in these patients prior to icu admission, e.g. in an a&e setting or pre hospital setting identify patients at risk of death and can trigger an earlier optimization of triage decisions and earlier targeted treatment. a range of poc methodologies for lactate measurement are available but there is little standardization between methodologies. stat sensor lactate is a new poc lactate meter based on a patented multiwell and multilayer electrochemical technology that incorporates control wells that measure and correct for common interfering substances. the electrochemistry technology is layered onto a gold platform providing a stable and robust surface for the electrochemical reaction kinetics. the aim of this study was to assess the performance and functionality of stat sensor lactate. whole blood venous samples were collected from adult patients admitted to a&e. samples were tested for lactate using statsensor lactate (nova biomedical) and the omni b bga (roche) routinely used for lactate measurement. precision was assessed using donated whole blood and spiked with a concentrated lactate solution. results. within run precision was acceptable at all levels tested. for the lowest level sample (mean . mmol/l) %cv for the two meters tested was ( . and . %) at the three other levels tested (mean . , . , . mmol/l) % cv precision was \ %. lactate values during the method validation ranged from . to . mmol/l by the reference method (nova . to . mmol/l background and objectives. this research work's intention is to describe the epidemiology in patients suffering from anemia who were interned into emergency room (er). a preliminary work will be conducted in which three days in june will be randomly chosen. during these days, all patients satisfying certain criteria will be registered. the criteria fitted to this work are the following: be using the emergency channel of the hospital, score any diagnostic and be over years old. paediatric, gynaecologic and traumatic cases fall out of this research. anemia was diagnosed according to who criteria. outcome. patients were interned through the aforementioned er channel. . % were subject of blood analysis using classification proceedings. from the latter, . % were diagnosed with anemia. age, intake of clopidogrel and/or aspirin, admission and place of admission resulted statistically significant among anemia patients versus non-anemia. anemia was to be found in . % of patients younger than years old, % of the times in patients between and and . % among patients above years old. according to vcm, . % were microcitic-anemia, % were normocític-anemia and . % resulted macrocític ones. conclusion. anemia is among a large share of patients coming into the hospital through emergency proceedings. its likelihood increases accordingly to the risk group analysed and dominating among the elderly population and among patients suffering from renal disfunction and non aggregated. most common are normocitic and macrocitic anemia-types. early identification and valuation could bear prognostic consequences. a. s. omar tawam hospital, critical care medicine, al ain, united arab emirates introduction. an elevated serum creatinin phosphokinae (cpk) and the presence of myoglobin in the urine characterize rhabdomyolysis. rhabdomyolysis had been described in various traumatic and non-traumatic conditions [ ] , there are few reports of its association with anaphylaxis. in this paper, we report cases of anaphylaxis both complicated with rhabdomyolysis. aim of the work. to discus the association between rhabdomyolysis and anaphylaxis and the value of early screening of cpk in such cases. setting. two patients were included in this review in multidisciplinary intensive care unit of tawam hospital/uae. the two patients survived, both developed rhabdomyolysis shortly after admission, evidenced by fivefold or greater increase in serum cpk [ ] . both patients had transient hypotension through the presentation, but none of them had persistent shock requiring vasopressors or complicated with acute renal failure. conclusion. we observed rapid increase in serum cpk in our two cases suggesting the potential benefits of early assessment of cpk in such patients which may amplify early goal guided management and avoiding logistic organ dysfunction. keywords. rhabdomyolysis, anaphylaxis. the blood oxygen and carbon dioxide levels are a direct measure of the effectiveness of ventilatory support in patients on mechanical ventilation. head injury patients require strict control of the cerebral homeostatic state. these patients also need careful management of sedation, maintaining a fine balance between patient comfort, hemodynamic instability and ability to assess conscious levels. biphasic intermittent positive airway pressure (bipap) ventilation is thought to be better tolerated by the patient allowing for spontaneous breathing at any point, thus reducing the amount of sedatives and muscle relaxants used. but the effectiveness of this ventilatory mode in achieving stable blood oxygen and carbon dioxide levels in this group of patients is not known. we hypothesised that bipap is more labour intensive to adapt to the target blood gas parameters as the volume delivery is not constant and that the blood gases may be more unstable in the initial resuscitation phase of head injury patients without conferring much advantages in terms of usage of sedatives and muscle relaxants. retrospective data collected from case record review of head injury patients with no primary respiratory insult, requiring mechanical ventilation with volume controlled synchronised intermittent mandatory ventilation (simv) was compared to the data from similar patients treated with bipap ventilation. both the data groups specifically looked at two time periods, the first h and - h after intensive care admission. blood gas parameters classified as hypocarbic, hypercarbic and/or hypoxic, use of muscle relaxants, number of episodes of raised intracranial pressure (icp) above mmhg as recorded in the intensive care chart every hour, number of episodes of cerebral perfusion pressure (cpp) below mmhg as recorded in the chart every hour was noted. need for muscle relaxant in the first h of admission was noted. the outcome was recorded as either ''alive'' or ''dead'' at the end of itu stay. the data was checked for normality of distribution and compared using non parametric tests (spss for windows). results. baseline characters were comparable between the groups. increased episodes of hypoxia ( . ± . vs. . ± % p = . ) and hypocarbia ( . ± . % vs. . ± . % p = . ) in bipap mode, compared to simv volume control mode. all measurements being percentages of total blood gases for that patient in the first h. there was no difference in the usage of muscle relaxant ( . vs. . % p = . ), raised icp, reduced cpp or mortality between the groups. conclusion. bipap mode of ventilation requires more intensive monitoring and changes in ventilatory settings before adapting to the target blood gas parameters in the first h of admission. at the same time the quoted advantage of using less sedatives and muscle relaxants is not significant. acute post-traumatic brain swelling is one variety of the pathological forms, which needs emergent treatment following traumatic brain injuries. we investigated the effects of clinical effects of decompressive craniectomy (dc) in patients with acute post-traumatic brain swelling (bs). seventy-four patients of acute post-traumatic bs with midline shifting more than mm were divided randomly into two groups: dc group (n = ) and routine temporoparietal craniectomy group (control group, n = ). the vital sign, the intracranial pressure (icp), the glasgow outcome scale (gos), the mortality rate and the complications were prospectively analysed. the mean icp values of patients in dc group at , , and h after injury were much lower than those of routine temporoparietal craniectomy group ( . ± . , . ± . , . ± . and . ± . mmhg vs. . ± . , . ± . , . ± . and . ± . mmhg, respectively). the mortality rates at month after treatment were % in the dc group and % in the control group (p \ . ). good neurological outcome (gos score of to ) rates year after injury for the groups were . and . %, respectively (p = . ). the incidences of delayed intracranial hematoma and subdural effusion were and %, respectively (p \ . ). in conclusion, dc has superiority in lowering icp, reducing the mortality rate and improving neurological outcomes over routine temporoparietal craniectomy. however, it increases the incidence of delayed intracranial hematomas and subdural effusion, some of which need secondary surgical intervention. therefore, the effects of dc in patients with acute post-traumatic bs should be further evaluated. we analyze among others variables: age, injury severity score (iss), abbreviated injury score (ais); admission and discharge glasgow coma score (gcs), extended glasgow outcome score (gose), complications, icu and hospital mortality. differences between groups were tested with students t test and v testing for statistical analysis. results. fourteen patients with intracranial hypertension were treated with decompressive craniectomy . compared with control group, patients with dc had a better gcs ( ± g ; ± g p = , ) and gose index not only at icu discharge ( ± g ; ± g p = , ) but also at hospital discharge ( ± g ; ± g p = . ). the mortality rate was lower in the craniectomy group (g : %, g ; % p = . ). conclusions. in our center, the use of dc for treat patients with severe tbi and refractory cranial hypertension (gcs b and pic c ) improved outcome and mortality significantly compared with medical conventional approach. method. in this retrospective study we present patients who underwent decompressive craniectomy following traumatic brain injury at king's college hospital between and . results. % of these patients presented at a&e with a glasgow coma scale of or below whereas the remaining % presented with gcs above and deteriorated following admission. the patients underwent decompressive craniectomy to reduce raised icp resistant to medical treatment (barbiturate coma excluded). the procedure resulted in significant decrease in icp. out of patients had the operation within h following their injury. we also found that dc in younger patients (\ years) was correlated with lower icp following the operation compared to older patients ([ ) . our study also showed that early dc (\ h) is correlated with a shorter stay in itu. conclusions. the findings of the present study are limited by its retrospective nature and small sample size which does not permit any definitive conclusions from these results. however, they form the basis for further investigation. we present the study with a review of the recent literature. introduction. the objective is to study the correlation of secondary icp indices with ct findings and outcome in tbi. a cerebrovascular pressure reactivity index (prx) can be determined as the moving correlation coefficient between mean icp and mean arterial blood pressure . it is a surrogate marker of cerebrovascular reactivity. the rap coefficient was calculated as the running correlation coefficient (r) between slow changes in pulse amplitude (a) and mean icp (p). it is a surrogate marker of pressure-volume compensatory reserve. all components of the icp waveform that have a spectral representation within the frequency limits of . to . hz can be classified as slow waves. methods. prospective observational study of patients with tbi at the royal london hospital. all patients were managed according to the local guidelines for the management of tbi . secondary indices derived from the icp waveform were analyzed by icm ? software. an initial ct was performed in all patients before admission to icu. marshall classification has been shown to predict mortality in tbi. we found a strong association between all these secondary indices and the initial ct findings. all these markers of cerebral haemodynamics correlate significantly with outcome in headinjured patients. conclusions. surrogate markers of cerebrovascular reactivity and pressure-volume compensatory reserve correlates with ct findings and outcome in tbi. these secondary icp indices may be used in the management of tbi. introduction. following the introduction of national guidance [ ] on the management of patients with head injury, the use computed tomography (ct) imaging of the head has increased markedly. the impact on anaesthetic and critical care services is unknown. . determine the impact of national guidelines on ct scanning in the head injured patient upon anaesthetic and critical care services in a university teaching hospital. . determine the incidence of acutely abnormal ct appearances in patients referred for ct scanning under the guidelines. . estimate in-hospital mortality in this population and its sub-groups. a case-note analysis was performed in october of consecutive emergency department (ed) patients who were recorded as having a ct head. of the cases, did not actually have ct head. details of the analysed subjects, indications for the scan and day mortality rates are reported in table . in patients with severe traumatic brain injury pro-and anti-inflammatory mediators are released into the systemic circulation. however, the relationship between the inflammatory response and the kind and duration of secondary insults remains unclear. objectives. the aim of this study was to investigate in severe traumatic brain injured patients the relationship between the systemic concentrations of pro-and anti-inflammatory mediators and the total duration of secondary insults occurring during the icu stay. methods. ten consecutive traumatic brain injury patients admitted to the icu were included. physiological variables were continuously recorded and analyzed minute-by-minute to identify the occurrence of secondary insults (intracranial hypertension, systemic hypotension, hypoxemia and hyperthermia) according to the edinburgh university secondary insult grading scale. serum samples were obtained at admission, , and h, in which pro-and anti-inflammatory mediators were analyzed by a bioplex assay. results. ten male patients were enrolled, mean age ± , gcs ± , apache ii ± , iss ± . patients were monitored for . days (median value, range - ; , total minutes recorded); intracranial hypertension occurred for , min ( . % of total period recorded, range . - %), hypotension occurred for , min ( . % of total period recorded, range . - %), hypoxemia occurred for min ( . % of total period recorded), not enough data were validated for fever. interleukin (il)- , il- beta, il- , il- and il- ra were in the detectable range. a significant correlation was found between the total duration of intracranial hypertension and the median value of il- (p \ . , r = . ), il- beta (p \ . , r = . ), il- (p \ . , r = . ), il- (p \ . , r = . ), and il- ra (p \ . , r = . ) measured during the period of observation. no correlation was found between these inflammatory mediators and the occurrence of hypotension or hypoxemia. no significant correlation was present between the baseline values of these inflammatory mediators and the severity indexes (gcs, iss and apache ii). conclusions. these results suggest that the duration of secondary insults such as intracranial hypertension was associated with a systemic inflammatory reaction, while the severity of injury on admission was not related to the initial concentrations of these inflammatory mediators. grant acknowledgement. aim. assessing behavioral responses to pain is difficult in severely brain-injured patients recovering from coma. we here propose a new scale developed for assessing pain in vegetative (vs) and minimally conscious (mcs) coma survivors: the coma pain scale (cps) and explore its concurrent validity, inter-rater agreement and sensitivity. methods. concurrent validity was assessed by analyzing behavioral responses of postcoma patients to a noxious stimulation (pressure applied to the fingernail) ( vs. and mcs; age range to years; non-traumatic and of traumatic origin). patients' were assessed using the cps and four other 'pain scales' employed in non-communicative patients: the 'neonatal infant pain scale' (nips) and the 'faces, legs, activity, cry, consolability' (flacc) used in newborns; and the 'pain assessment in advanced dementia scale' (pa-inad) and the 'checklist of nonverbal pain indicators' (cnpi) used in dementia. for the establishment of inter-rater agreement, fifteen patients were concurrently assessed by two examiners. results. concurrent validity assessed by spearman rank order correlations between the cps and the four other validated pain scales was good. cohen's kappa analyses revealed a good to excellent inter-rater reliability for the cps total and subscore measures, indicating that the scale yields reproducible findings across examiners. finally, a significant difference between cps total scores was observed as a function of diagnosis (i.e., vs or mcs). conclusion. the cps constitutes a sensitive clinical tool for assessing pain in severely brain injured patients with disorders of consciousness. this scale constitutes the first step to a better management and understanding of pain in patients recovering from coma. methods. study group: consecutive patients with cervical spinal cord injury admitted to icu. mean age: , years. patients asia a, asia b, asia c. the more frequent neurological level was c ( %). the requirement of mechanical ventilation was considered the key sign for establishing the diagnosis of severe respiratory failure. the blood gas values (po , pco , and pao /fio ) before and after connection to mechanical ventilation [mv(if needed)], were used to estimate the more probably mechanism of respiratory insufficiency. the increase of pco levels was considerate as a sign of neuromuscular weakness; the low po level before ventilation, and the persistence of pao /fio below normal values was considered a sign of v/q mismatch. for this purpose statistic analysis (mean values comparison using student t test) comparing blood gases before and after mechanical ventilation treatment was performed. results. ( %) patients developed severe respiratory failure. mean delay between admission and mechanical ventilation was h. previously to mechanical ventilation patients developed pulmonary atelectasis, and four pneumonia. the incidence en respiratory failure was significantly higher in patients with neurological level above c (p \ . ). conclusions. the incidence of respiratory failure is related with the severity of neurological deficit (relationship between incidence of respiratory failure and neurological deficit level). in addition, our data support that, besides the neuromuscular weakness (moderate increase of co levels), a significant v/q mismatch with shunting phenomena associated (significant hypoxemia no completely solved after mv) is involved in the respiratory failure of cervical spinal cord injured patients. . moderate and severe traumatic brain injury is more likely in middle aged men; more than one third present other major trauma and intensive first level medical treatment is required in most of them. . the most frequent complications found were infectious diseases like ventriculitis and vap. . independent mortality risk factors in moderate and severe trauma brain injury were age, high apache ii score, neuromuscular blocking drugs and icu los. . outcome was significantly improved after six months, and most of the patients only present mild disability and good recovery. nosocomial infections are leading causes of increased morbidity and mortality of severe brain injured patients [ ] . the mechanism underlying the susceptibility to the infections is a subject of great scientific interest and still to be clarified [ ] . it has been recently recognized that injury of brain induces a disturbance of balance between the central nervous and immune system [ ] . objective. the aim of this study was to investigate changes in frequency of lymphocytes subpopulation in peripheral blood of patients with severe brain injury during the course of intensive care treatment. human peripheral blood samples were taken from the severe brain-injured patients at day , and and peripheral blood mononuclear cells (pbmc) were immediately isolated by gradient density centrifugation. the percentage of lymphocytes subpopulation were analyzed by simultaneous detection of surface antigens using fluorochrome conjugated monoclonal antibodies directed toward cd , cd , cd , cd , cd , cd , cd . t lymphocytes were distinguished from the other lymphocyte subpopulation as cells labeled with anti-cd monoclonal antibody but negative for cd staining (cd ? cd - patients. eighty-seven patients with head injury, glasgow coma scale \ . measurements and main results. clinical and demographic data, and head ct scan were taken at admission. patients underwent advanced neuromonitoring and were treated according to brain trauma foundation guidelines. s b concentration was quantified at admission and , and h post-tbi (days , , and ). outcome was assessed months after discharge using glasgow outcome score. significant negative correlations were found between -year gos and s b concentrations on days - , but not on day (day , p = . ; day , p = . ; day , p \ . ; day , p \ . ). patients who deceased showed higher s b concentration than survivals for all the samples. good versus poor outcome (gos = - ) differed significantly on days and . logistic regression analysis showed that samples , and h post-tbi sample predicted death outcome. roc curve analysis showed -h sample was the strongest predictor for decease. poor outcome was only predicted by the -h sample. conclusions. s b levels h post-tbi was the strongest predictor for poor and fatal -year outcome, whereas levels at admission do not. a temporal profile of s b release from admission to h post-tbi is strongly recommended for use in identifying the subset of patients liable of developing a worse outcome. according to our results, s b protein might be an early, sensitive, accurate and useful biomarker for predicting long-term outcome in patients with acute severe tbi. grant acknowledgement. this research was made possible in part by the generous donation of protein s b electrochemiluminescence assay kits by roche diagnostics, mannheim, germany. introduction. brain intercellular fluid glycerol concentration as measured by microdialysis catheters has been recognized as an index of glial and neuronal cellular destruction. we present a data analysis correlating glycerol levels with intracranial pressure (icp), cerebral perfusion pressure (cpp), brain tissue oxygen partial pressure (pbtio ), lactate to pyruvate concentration ratio (l/p) and outcome. methods. data of head injured patients is presented. all had simultaneous monitoring of icp, pbtio and metabolic biochemistry by three brain intraparenchymal bolt catheters inserted via the same one burrhole (icp codman or camino, pbtio licox and microdialysis-cma). there was not a clear straight correlation of raised glycerol levels with bad outcome. however, glycerol elevation seemed to be a predictor of intracranial hypertension together with l/p raise. in subarachnoid hemorrhage patients glycerol elevation was an early sign of secondary ischemic insult. conclusion. multimodal monitoring with intracranial catheters is a useful clinical tool for management of critical neurosurgical patients. metabolic biochemistry as measured by microdialysis, and specially l/p and glycerol levels, can early predict incoming intracranial hypertension as well as secondary ischemia. the pulsatility index (pi), a parameter derived from the blood velocities along the cardiac cycle, has been used as an indirect way to evaluate intracranial pressure. the aim of this research has been to evaluate the accuracy of transcranial doppler sonography (through pulsatility index) in the inference of intracranial pressure. methods. population of the study group (high-pi-group): severe head injured patients (gcs at admission \ ; mean age . years; patients with diffuse injury (traumatic coma data bank) type ii ( %) and iii ( %)) who presented episodes of increase of pulsatility index (pi [ . ) in the acute phase of head injury. control group (normal-pi-group): severe head injured patients, with tcd recordings of normal pi (pi b . ). in all the patients the intracranial pressure (icp) was continuously monitored using a intraparenchymal device. all the tcd recordings are referred to the middle cerebral artery of the cerebral hemisphere were icp catheter was inserted. in the transcranial doppler recording, the pulsatility index was automatically calculated derived from the formulae: pulsatility index = (systolic velocity -diastolic velocity)/mean velocity. transcranial doppler sonography recordings of with pulsatility index c . (high normal value of pulsatility index) were correlated with the simultaneous icp value. the incidence of intracranial hypertension (icp [ mmhg) was analyzed in the high-pi-group, and compared with the incidence of intracranial hypertension in the normal-pi-group. methods. in a double-blind, randomized, placebo-controlled clinical trial, patients scheduled for elective cabg was randomly assigned into two groups. after matching inclusion and exclusion criteria and induction of general anesthesia, one group received intrathecal sufentanil (s) and the other group received the same dose of sufentanil plus supplemental bupivacaine (sb). except for this, all the cases were similar regarding anesthesia and surgery. mean arterial blood pressures were measured before and after induction of anesthesia, during the bypass time and after weaning from bypass were checked. also, the need of the patients for administration of inotropic agents after weaning was compared. results. there was more stable mean arterial blood pressure and less inotropic need after weaning from cardiopulmonary bypass in the sb group. also, the sb patients had a more stable hemodynamic profile during the bypass period; especially after the initiation of the bypass. less inotropic agents were needed after weaning in the sb patients. there was no difference between the two groups regarding the extubation time. discussion. the administration of intrathecal sufentanil plus bupivacaine seems to keep the hemodynamic status of the patients more stable than intrathecal sufentanil alone. methods. this study was approved by the hospital s ethics committee. prospective observational study including consecutive patients. preoperatory and postoperatory data were collected. interventions included blood samples for nt-pro bnp taken prior to operation, and and h in postoperative. troponin-i was taken and h postoperatively. blood obtained was processed for nt-probnp with cobas h system Ò point of care (poc) by roche diagnostics, with range from to , pg/ml. the serum nt-probnp level was also correlated with the logistic euroscore and ejection fraction (ef). serum ntpro-bnp and troponin i values were compared between patients with and without postoperative length of stay in the intensive cardiac unit (icu) [ h. and hospital [ days. all results are in median ± sd * p \ . , **p \ . tables ??? and ??? conclusions. preoperative euroscore and nt-probnp levels were higher in patients with ef \ %. the troponin i after surgery increased more in patients whose length stay in icu was longer. after surgery nt-probnp levels increased significantly,and they differ significantly between patients with length stay in icu for more than h and days at hospital. our data collection confirmed that measurement of nt-probnp is useful and helpful during postoperative period and it also predicted a higher possibility for a long stay in icu and a later hospital discharge. however, owing to the small size sample, these results must be regarded as preliminary. conclusions. in spite of the limitations of our trial, percutaneous aortic valve implantation appears to be safety. a high rate of maccv events were observed, essentially due to a disruption of the a-v conduction, in most cases transitional. despite the definition of ''inoperability'' is difficult, less-invasive aortic valve procedures will undoubtedly find a place within current cardiac surgical practice. objective. to describe the evolution of cardiac transplant patients, presenting clinical low cardiac output in the immediate postoperative period, and after handling routine, they are treated with levosimendán (lv). descriptive, prospective and observational in a postoperative care unit for cardiac surgery from a terciary hospital. study period: january -december . lv was used when the patient had inotropic dependence over h, to try to remove the amines or added to them in those cases that do not get these drugs with an adequate hemodynamics. bolus was used in occasions and then infusion of . - . mcg/ (kg min). we analyzed demographic variables, hemodynamic response to the input of the drug if you can reduce or discontinue other medications, clinical tolerance and side effects, overall development, the icu and hospital stay. we studied patients ( women and men). presented a mean age of . . before surgery, all of whom were in nyha functional class iii-iv. three patients were transplanted in emergency. in this series, there is a case without pulmonary hypertension (pah) pre-transplant, patients with mild htp and htp moderate to severe, with a transpulmonary gradient(gtp) between and mmhg. the patients with gtp [ mmhg had a positive reversibility test with sildenafil. ischemia time of surgery was . . in the immediate post, all the patients studied had low cardiac output syndrome by graft postoperative ventricular dysfunction, cardiac index measured by pulmonary artery catheter. in all patients echocardiography was performed to rule out a pericardial effusion with hemodynamic deterioration in cardiac cavities and showed ventricular dysfunction, right dominance in patients. in all patients we observed a good tolerance to the drug. in lv cases facilitated the withdrawal of the remaining. patients were used lv only after the withdrawal of treatment with inotropic dependence on it. in the remaining cases to be associated with other drugs. only two cases could not withdraw inotropic treatment after the lv infusion. in five patients with pulmonary arterial hypertension and prevalence of right ventricular failure, to reduce poscarga also added pulmonary arterial vasodilators. patients have a stay in icu between and days. one patient mortality. . the primary graft failure is a severe potential complication of post-cardiac, which is associated with a worse prognosis. . lv shows good tolerance, without serious adverse effects attributable to the drug, and facilitated the removal of amines and clinical recovery. . it is necessary to expand the case to confirm the results, and to establish the most appropriate indications and patterns of use of this drug. post-infarction ventricular septal defect (infarctvsd) is a rare but serious complication of myocardial infarction, usually quickly followed by low cardiac output. repair of infarctvsd is still a challenging procedure with a high risk of mortality. improvement of surgical outcome depends on results of large studies in this setting. the aim of this retrospective study was the evaluation of preoperative and surgical parameters influencing the -day mortality following surgical repair. conclusions. in this large study, pre-operative left ventricular function and troponin level were found to be the best predictors identifying patients at high risk for -day mortality following surgical closure of infarctvsd. both parameters may be helpful in deciding on the time of the operation and preoperative preparation. in contrast to other findings, in our cohort the location of the vsd (anterior vs. posterior) did not affect mortality. this may be due to improvement of surgical technique and perioperative management over time. adequate fluid therapy is the first step of hemodynamic optimization after cardiac surgery [ ] . cardiac surgery exposes patients to ischemia and reperfusion, which are well known risk factors for a systemic inflammatory response and increased capillary permeability in the lungs [ ] . it is still unclear what type of fluid should be given in the presence of increased pulmonary vascular permeability at hypovolemic status. objectives. aim of this study was estimate the optimal type of fluid for intravascular volume deficit treating without evoking pulmonary oedema. a prospective clinical study at the intensive care unit was performed on mechanically ventilated patients within h after elective cardiac surgery involving cardiopulmonary bypass. patients, divided into four groups, were subjected to fluid challenge according to the global end-diastolic volume index (gedvi) measurements with normal saline , ml or the colloids % gelatin, % hes / . or % albumin ml in min. hemodynamic and extravascular lung water index (evlwi), gedvi measurements were performed exactly before fluid challenge, afterwards and min after challenge. results. the change in evlwi did not differ between saline and colloid fluid challenge. gedvi increased by % in saline group, by % in % gelatine, in % hes / . and in % albumin. conclusions. all colloid fluid infusion leads to the greater increase in cardiac preload compare to normal saline (saline in four times larger volume). the change in evlwi did not differ between saline and colloid fluid groups and did not increase pulmonary oedema despite in the presence of increased pulmonary vascular permeability, when fluid overloading is prevented. introduction. the annual incidence of prosthetic valve thrombosis is up to - % (patients-year) despite the anticoagulant therapy. conventionally, the treatment of choice for this event was the surgical valve replacement. however, fibrinolytic therapy has become a valid alternative for the treatment of this serious complication, especially in high-risk surgery patients. to analyze the clinical factors, diagnosis and treatment management of patients with prosthetic valve thrombosis admitted to the acute cardiac care unit. we designed an observational-descriptive study, including patients admitted between and . clinical factors were analyzed: sex, age, prosthetic valve position, time from valve replacement, inr at admission, clinical features, diagnostic technique and treatment used. results. patients were included. . % were women, . % men. mean age was . ± . years. the highest incidence was at the tricuspid prosthetic valve position ( . %), followed by the mitral ( . %) and the aortic position ( . %). when a triple valve replacement was performed, the tricuspid position was the most often affected. mean time from the first valve replacement surgery was . ± . years. clinical features which led to the diagnostic were: acute heart failure ( . %), peripheral embolization ( . %), chest pain ( . %) and syncope ( . %). the diagnostic techniques used were transesophageal echocardiography (tee) and cinefluoroscopy in all the patients. inr at admission time was lower than adecuate anticoagulation recommendations in . % of patients. the most widely used treatment was the systemic fibrinolytic therapy ( . %), followed by surgery ( . %) and conservative treatment with heparin alone ( . %). the most widely used thrombolytic was rtpa in . % of patients, with a mean dosage of . ± . mg. one patient was treated with . mil. ui of streptokinase. unfractionated heparin was added to all patients whom received fibrinolytic therapy, with a mean dose of ± ui/h. a . % incidence of minor bleeding was found in the fibrinolytic group. there were no major complications due to fibrinolytic. total mortality rate was . %. our experience, suggests that systemic fibrinolytic therapy is safe and effective in patients with prosthetic valve thrombosis. objective. to describe the outcomes of patients with acute, refractory, non-ischaemic and not postcardiotomy, cardiogenic shock treated with extracorporeal membrane oxygenation (ecmo) and to evaluate whether survivors and non-survivors differed with respect to clinical characteristics, pre-ecmo treatment and laboratory values. design. in this retrospective cohort study, information is collected from a database with additional review of medical records. patients. consecutive adult patients, males, mean age . ± . year, presenting to hospital with non-ischaemic acute severe, refractory cardiogenic shock, supported by central or peripheral venoarterial (va) ecmo. measurements and main results. characteristics of survivors and non-survivors were compared using chi square test. twelve patients ( %) were transported to our institution on ecmo. eleven patients ( %) were weaned from ecmo, seven ( %) bridged to ventricular assist devices. in two patients ( %) ecmo support was withdrawn. mean duration of ecmo support was . ± . h. overall survival was %, and did not differ between patients with myocarditis (n = ), cardiomyopathy (n = ) and acute on chronic non-ischaemic cardiogenic shock (n = ). a larger proportion of the three patients with or more complications died as compared to the seventeen patients with less than complications ( % versus %, p = . ). pre-ecmo intra-aortic balloon counterpulsation (iabp) was used in patients, % survived, as compared to % of those who did not receive iabp (p = . ). we have not identified any other significant differences between survivors and non-survivors. conclusion. the survival of patients on ecmo in this unique heterogeneous patient cohort is similar to the survival of ecmo support for fulminant myocarditis in the literature. we recommend to institute ecmo early in all medical patients with acute non-ischaemic cardiogenic shock, refractory to conventional therapy, or to refer these patients in time to an ecmo centre. introduction. human parvo b virus is associated with a broad spectrum of clinical manifestations, mostly in children or immune-compromised patients. in adults, severe myocarditis due to this viral agent is a rare disorder, presenting as acute congestive heart failure. we describe a patient with rapidly progressive heart failure, needing circulatory support by extracorporeal membrane oxygenation (ecmo). methods. case report. a -year-old previous healthy female was admitted to our icu with nausea, vomiting, bradycardia and hypotension with a blood pressure of / mmhg. two weeks before admission, patient had signs of erythema infectiosum. on physical examination the patient was pale, with venous congestion, third heart sound and hepatomegaly. the initial electrocardiogram showed a slow, regular, ventricular rhythm. admission chest x-ray showed normal heart size with bilateral pleural effusion. echocardiography revealed dilated ventricles (rv and lv) with depressed systolic function and a thrombus in the rv apex. patient was initially treated with intravenous medical therapy, but unfortunately developed progressive cardiogenic shock. troponin levels, serum transaminases and bun were extremely elevated. it was therefore decided to implant a percutaneous ecmo by femoro-femoral cannulation which permitted to stabilize hemodynamic conditions while peripheral organ functions returned to normal range. progressive cardiac recovery was observed after days with a circulatory assistance with a mean flow rate of . l/min. as myocardial function improved, ecmo was gradually weaned and removed after days of support. however, atrioventricular conduction did not recover, necessitating implantation of temporary vvi-pacemaker, which was later replaced by a permanent ddd pacemaker system. pathology of the endomyocardial biopsy showed extensive lymphocytary infiltration with destruction of myocytes. parvo b dna-pcr was positive in both the biopsy and serum. these findings suggest that this patient developed severe myocarditis induced by parvo b viral infection. to our knowledge, parvo b viral infection is an uncommon cause of severe myocarditis in adult patients. sparse literature is available describing the use of ecmo in these adult patients. conclusion. this case report shows that parvo b virus should be recognised as a potential infective agent in adult patients presenting with severe myocarditis. furthermore, ecmo can be safely used to stabilize hemodynamics and peripheral organ perfusion in expectation of myocardial recovery in these patients. copeptin is easier to measure than vasopressin, and could be used as a marker of vasopressin release [ ] . the aim of the study was to compare plasma concentration of avp and cop during cardiac surgery, and specifically during post cardiac surgery vasodilatory syndrome (pcsvs). methods. two-month consecutive patients scheduled for cardiac surgery with cardiopulmonary bypass (cpb) were included in the study except patients suffering from chronic renal failure and under dialysis. blood samples were obtained from blood withdrawals routinely operated before cpb, during cpb and after surgery, at the postoperative hour (h ). these samples were used for avp and cop measurements. pcsvs, assessed as hypotension unresponsive to volume replacement therapy and without cardiogenic shock features, was treated with norepinephrine (ne). patients treated with ne have been compared to the others. statistical test consisted of variance analysis, non parametric test (mann whitney or wilcoxon) and linear regression. a p value of less than . (p \ . ) was considered statistically significant. results. patients have been included, out of which have been treated with ne. correlation between avp and cop plasma concentrations is significant (r = . , p \ . ). avp and copt concentrations increased significantly at h but the increase is less pronounced in ne-treated patients (fig. ) . ne-treated patients had lower preoperative left ventricle ef ( . ± . vs. . ± . %, p = . ), longer cpb ( . ± . vs. . ± . min, p \ . ) and clamping times ( . ± . vs. . ± . min, p \ . ), higher incidence of low output syndrome ( / vs. / , p \ . ) longer extubation time ( . ± . vs. . ± . h, p \ . ) and higher plasma cop before (t ) and during cpb (fig. ) . avp (ng/ml) et copeptin (cop, pmol/l), in patients. *p \ . ne versus others discussion. correlation between avp and cop is similar to that observed in other studies [ ] . the correlation coefficient is rather weak that is possibly related to avp dosage limitations (binding of avp to blood platelets, lack of antibody-specificity). increased cop plasma concentrations before and during cpb is observed in sicker patients undergoing more complex surgery, which seems to expose them to relative postoperative vasopressin deficiency and pcsvs. background. waiting list for heart transplantation has been growing up. high doses of cathecolamines has been an exclusion criterion for heart donation and norepinephrine use is still controversial. to assess if norepinephrine used on heart donors modify receptors outcome. methods. historical cohorts study from april to march . patients were divided in two groups: group : patients with local donors treated with norepinephrine (n = ). group : patients with local donors managed with other cathecolamines (n = ).cathecolamines were used at least for h and doses were between . and mcg/(kg min) if norepinephrine and between and mcg/(kg min) if dopamine or dobutamine. mortality risk factors published on the last international society for lung and heart transplantation guidelines were recorded. graft dysfunction risk factors were also collected. heart transplant outcome was measured by -day mortality, mortality rate at first, second, fifth and tenth years; and graft dysfunction incidence. chi-squared and t student test was used. multivariate logistic regression was used to evaluate norepinephrine impact on the outcome. mortality in group was . and % in group . no differences in mortality or graft dysfunction incidence were found in multivariate analysis. conclusions. norepinephrine used for donors management compared with dopamine and dobutamine does not increase mortality or graft rejection incidence in heart transplantation. groups were not uniform so further studies may be made to determine this association. introduction. coronary artery bypass surgery on cardiopulmonary bypass is associated with significant morbidity and mortality. with present technology, all arteries on the heart can be bypassed off-pump. the benefit of this technique is higher for patients whom are at increased risk of complications from cardiopulmonary bypass, such as those who have heavy aortic calcification, carotid artery stenosis, prior stroke, and compromised pulmonary or renal function. to evaluate the short-term follow up results of off-pump coronary artery bypass (opcab) and postoperative management of these patients admitted to our coronary care unit. we designed an observational study that included patients who underwent opcab from july to december . data were collected on preoperative age, sex, major cardiovascular risk factors, history of prior ami, number of affected vessels and ventricular function. after the surgery we evaluated: the extubation time, postoperative bleeding, troponin maximum level, need for blood transfusion, use of vasoactive drugs and intra-aortic balloon pump, development of renal failure, atrial fibrillation, neurological complications and reintervention. results. patients were included. . % were men and . % women. mean age was . ± . years. % of patients had one or more cardiovascular risk factor: hypertension was present in . %, smoking . %; diabetes mellitus . % and dyslipidemia in . %. there was prior myocardial infarction in . % of patients. prior coronary angiography showed . % of patients with vessels disease and . % of vessels disease. mean lvef was %. mean number of grafts was . . mean extubation time was . h. mean postoperative bleeding was estimated in cc. . % of patients needed blood transfusion; . % vasoactive drugs; and . % needed an intra-aortic balloon pump. . % of patients developed troponin t elevation with a mean level of . ng/ml. . % of patients developed atrial fibrilation, and . % renal dysfunction (two patients needed hemodialysis). there was no neurological complications. patient needed a reintervention. mean of intensive care unit stay was . ± . days. total mortality rate was . %. our experience shows that the off-pump coronary artery bypass graft surgery is a safe and effective technique for coronary revascularization, with low mortality and morbidity rates and reduced postoperative complications. objectives. to assess if deterioration of left atrial function in patients with severe sepsis and septic shock could predict mortality. we studied patients with severe sepsis or septic shock with mean age of . ± . . underlying echocardiographic parameters were measured on admission, th and th day, which comprised left ventricular ejection fraction (ef), and atrial function which is expressed as atrial ejection force (aef), with aef defined as the force that the atrium exerts to propel blood into the left ventricle (lv). all patients were subjected to bnp assay well. multivariate analyses adjusted for acute physiology and chronic health evaluation score ii (apache ii score) was used for mortality prediction. results. underlying source of sepsis was lung in patient ( %), blood in seven patient ( . %), abdomen in seven patients ( . %), while three patient ( %) had urinary tract infection (uti) as a cause of sepsis. only one patient had cns infection. severe sepsis was admission diagnosis for patients, patients were labeled as septic shock. look for days mortality. in-hospital mortality was . % ( patients) . admission ef showed significant difference between survivors and non-survivors . ± . versus . ± . % (p \ . ), on the other hand admission aef showed insignificant changes between the same groups . ± . versus . ± . k/dynes p = . , while bnp was significantly higher in the non-survivors , ± . versus . ± . pg/ml (p \ . ). multivariate logistic regression, the predictable variables for mortality was apache ii score, bnp then ef. conclusion. in septic patients, left atrial function unlike the ventricular function and bnp levels cannot be used as independent predictor of mortality. objectives. to analyse the relationship between plasma levels of nt-probnp and lcd diagnosed by echocardiograph during ss. methods. prospective observational cohort study. inclusion criteria: consecutive patients with ss [ ] . non inclusion criteria: creatinine clearance \ ml/min, years \ age \ years, cardiac surgery patients, pre existing coronary or cardiac insufficiency, neoplasia and systemic diseases. the evaluation of the left ventricular function was realised by a trans-thoracic or a trans-oesophageal echocardiograph on day . the lcd was defined by a left ventricular fraction of ejection \ % evaluated by teicholtz. the blood tests for nt-probnp analyses were drawn on days , , and . serum nt-probnp measurements were made automatically by elecsys analyser with the truss nt-probnp (roche diagnostics, myelan, france) by the electrochemiluminescence immunoassay method (eclia). data are expressed as mean ± sd and percentages. statistical analysis was performed by repeatedmeasures anova and roc curves (p \ . indicated statistical significance). . patients were included in a period of months (medical patients n = , surgical patients n = and trauma patients n = ), age = ± years, bmi = ± kg/m , apache ii = ± , igs ii = ± , duration of intensive care unit stay = ± days, mortality = %. lcd was observed in patients. the statistical analysis showed a significant elevation of nt-probnp in patients with lcd (table ) . on day , the area under roc curve was . , and the cut off value of nt-probnp predictive of lcd was , pg/ml (sensibility = %, specificity = %). introduction. fluid responsiveness can be predicted by the respiratory variation of arterial pulse pressure (ppv) or of pulse contour-derived stroke volume (svv) as well as by the changes in pulse contour-derived cardiac index during a passive leg raising manoeuvre (plr) or a tele-expiratory occlusion (teo). we evaluated the ability of an infrared photoplethysmography arterial waveform (cnap device) to estimate ppv. we also tested the ability of this non invasive estimate of ppv to predict fluid responsiveness compared to the invasive measure of ppv, to svv and to the plr and teo tests. in patients with septic shock ( ± years of age, receiving norepinephrine, saps = ± , lactate = . ± . mmol/l), we measured the response of cardiac index (pulse contour analysis, picco device) to fluid administration ( ml saline over min). before fluid administration, we recorded the ppv directly calculated from the non invasive arterial pressure signal (ppv ni ), the ppv directly calculated from the invasive arterial pressure signal (ppv i ), the ppv automatically provided by the picco device (ppv picco ), the svv automatically provided by the picco device, the changes in cardiac index induced by a plr test and the changes in cardiac index induced by a -s teo. results. five patients were excluded because the arterial curve could not be obtained by the cnap device due to excessive vasoconstriction. in the remaining patients, fluid administration increased cardiac index by more than % ( ± %) in ''responders''. the fluid-induced changes in invasive (? ± %) and non invasive (? ± %) mean arterial pressure were correlated (r = . , p \ . ). at bland-altman analysis, ppvni accurately reflected ppvi (bias %, limits of agreement ± %). for predicting fluid responsiveness in the patients, the receiver operating characteristics (roc) curves for ppv ni , ppv i , ppv picco , svv, plr and teo were . ± . , . ± . , . ± . , . ± . , . ± . , . ± . (all non significantly different). when considering only the patients ventilated with a tidal volume b ml/kg predicted body weight, were falsely classified as non responders by ppv ni , ppv i and two others by ppv picco and svv, but all four were well classified by plr or teo. in septic shock patients, provided that vasoconstriction is not excessive, the non invasive assessment of arterial pulse pressure seems valuable for predicting fluid responsiveness. introduction. mechanical ventilated patients often require inotropic support. however, the role of mechanical ventilation (mv) in myocardial depression is not well understood. septic patients often have impaired cardiac function and are in need of mechanical ventilation. we hypothesized that mv enhances sepsis-induced myocardial depression. objectives. in this study we investigated the influence of mechanical ventilation on cardiac function in an acute sepsis model. sepsis was induced in male wistar rats using ip injection of lps. healthy and septic rats were randomized to one of three ventilation groups; ( ) non-injurious ventilation with a tidal volume of ml/kg and cm h o peep (low tidal volume, ltv), ( ) injurious ventilation with a tidal volume of ml/kg and cm h o peep (high tidal volume, htv) and ( ) spontaneous breathing. arterial pressure was kept at least at mm hg. cardiac output (co, thermodilution method), central venous pressure (cvp) and mean airway pressure were measured in vivo. after h of ventilation, animals were sacrificed and cardiac function was measured ex vivo in a langendorff setup and expressed as developed pressure and ?dp/dt. cardiac wet to dry weight ratio was calculated. results. cardiac output in vivo was lower during htv ventilation than during ltv ventilation (p \ . ). cvp did not differ between ventilation strategies while mean airway pressure was higher in htv ventilation than in ltv ventilation (p \ . ). ex vivo, cardiac function of septic animals was depressed compared to healthy controls (p \ . ) in septic animals, cardiac function was better in htv ventilated animals than in non ventilated animals (p \ . ). ventilation lowered cardiac wet/dry ratio (p \ . ). developed pressure (p \ . ) and ?dp/dt (p \ . ) correlated inversely with cardiac wet/dry ratio. [ ] . perfusion may be also evaluated by other parameters such as lactate or venous-arterial pco gradient (delta pco ). objectives. to evaluate if early normalization of scvo after emergency intubation in septic patients persists over time and if it is associated with similar trends in lactate and delta pco . methods. ten septic patients subjected to emergency intubation for respiratory or circulatory failure and in whom scvo increased to [ % after the procedure. these patients were included in a large prospective study published elsewhere [ ] . patients used a common intubation protocol and we evaluated several perfusion related parameters before, min and h after emergency intubation. statistical analysis included friedman and wilcoxon tests. results. evolution of perfusion parameters after intubation is presented in table . five patients died during icu stay. as a whole, scvo remained stable in pts and decreased dramatically at h by[ % in non-survivor patients (lowest %). only pts had a high lactate before intubation that did not normalize at h (both non-survivors). delta pco exhibited erratic changes over time with no correlation with scvo changes and with mortality ( fig. ). introduction. venous to arterial carbon dioxide difference (pv-aco ) could reflect the sufficiency of blood flow in shock states. time evolution of pv-aco during early phases of resuscitation in septic shock has not been widely characterized. we proposed to describe the association between time course of pv-aco during the initial resuscitation and outcomes in septic shock. methods. patients with a new septic shock episode admitted to icu were included. general management was guided according surviving sepsis campaign recommendations. time (t ) was set when a central venous catheter was inserted to guide reanimation. simultaneous measurements of lactate and arterial-venous gases were obtained at t and h after (t ). pv-aco was calculated as the difference between venous co (blood samples drawn from a central catheter) and arterial co . a value of pv-aco [ was considered as high. survival at day was described for four groups: persisting high pv-aco (high at t and t ), increasing pv-aco (normal at t , high at t ), decreasing pv-aco (high at t , normal at t ) and persistently low (normal at t and t ). survival probabilities were estimated using kaplan-meier method. log-rank test was use to estimate a two-tailed p value for the differences in survival among groups. results. sixty septic shock patients were analyzed. mortality rate was . %. no demographic differences at baseline between survivor (s) and non-survivors (ns) were found. there were no differences in the amount of fluids administered at t and t . no significant differences in scvo at t for s introduction. septic shock (ss) has been defined as sepsis related hypotension despite adequate fluid resuscitation ? perfusion abnormalities such as lactic acidosis [ ] . despite this, an operationally simplified definition overlooking perfusion parameters, has been utilized in several landmark studies during the last decades [ ] [ ] [ ] [ ] . more recently, a new consensus reemphasized the pivotal role of hypoperfusion in ss definition and added low svo as a surrogate [ ] . several problems emerge from these apparently interchangeable definitions, including pathophysiologic and epidemiologic (incidence, outcome) issues. objectives. our aim was to evaluate if applicating different commonly used ss definitions to vasopressor-requiring septic patients leads to distinct outcomes. methods. we applied the two most utilized ss definitions to hypotensive septic patients managed with a ne-based algorithm [ ] for years, generating two major subgroups for analysis (fig. ) . statistical analysis included chi-square test. (fig. ) . pts of subgroup , exhibited persistent normal lactate levels with a mortality of . % which was similar regardless of svo [ or \ : p = . . (fig. ) . conclusions. commonly used ss definitions are not interchangeable and when applied to the same vasopressor requiring septic patients lead to statistically different mortalities. our data suggest that lactate and svo cannot be used indistinctly to define shock condition. a reappraisal of clinical septic shock definition appears to be necessary. objectives. to assess intra-and inter-observer agreement of ecg interpretation in adults with septic shock (vasst, nejm ; : ) . methods. patients were randomised to receive a blinded infusion of low-dose vasopressin or norepinephrine in addition to open-label vasopressors. eight icus participated in this ecg sub-study; and -lead ecgs were recorded at baseline (prior to study drug infusion), and h, and days after initiation of study drug. an intensivist (reader ) and a cardiologist (reader ), blinded to patient data and randomization group, interpreted all of the ecgs in duplicate, using a checklist. prior to ecg interpretation, a calibration exercise was performed to refine definitions and maximize inter-observer agreement; both readers reviewed ecgs (from the current study) representing the spectrum of normal to abnormal. cohen s kappa statistic was used to assess intra-and inter-rater reliability. methods. the model consists of eight elastic chambers including the heart and circulations. identification of the parameters is made only from measured pressures in the aorta and pulmonary artery, and the volume in the right ventricle. septic shock was induced in (n = ) healthy pigs with endotoxin infusion over min. right ventricular pressure-volume loops were recorded by conductance catheter and end-systolic ventricular elastance was assessed by varying right ventricular preload. consent was obtained from the university of liege medical ethics committee. errors for the identified model are within % when the model is identified from data, re-simulated and then compared to the clinically measured data. even with a limited amount of available experimental data to identify the parameters of the model, all simulated parameters trends match physiologically expected changes during endotoxic shock. in particular, a close match of the trends of the right ventricular end-systolic elastances are obtained, when compared to previously reported experimental results [ ] , including capturing of the peak after min and a decaying oscillation after min. conclusions. pig-specific parameters for the cvs model were accurately identified using a significantly reduced data set. this research shows the ability of the model to adequately and realistically capture the impact of pressure-volume changes during endotoxic shock. in particular, the model is able to aggregate diverse measured data into a clear, clinically and physiologically relevant diagnostic picture as the condition develops. this research thus increases confidence in the clinical applicability and validity of this overall diagnostic monitoring approach. background. conflicting data exist concerning the effects on the microcirculation of increasing mean arterial pressure (map) with norepinephrine (ne) in septic shock. nearinfrared spectroscopy (nirs) has been proposed as a tool to quantify microvascular dysfunction in patients with sepsis. by inducing a vaso-occlusive test (vot), a variety of nirsderived variables can be measured to assess local metabolic demand and microvascular dysfunction. this trial was conducted to test the effects of increasing map by ne on microvascular reactivity in patients with septic shock. after local ethical committee approval and informed consent, we enrolled patients in septic shock with an arterial pressure stabilized by ne. in addition to hemodynamic measurements, svo and blood lactate level, we measured thenar muscle oxygen saturation (sto ) and muscle tissue hemoglobin index (thi) by a tissue spectrometer (inspectra tm model , hutchinson technology inc, mn). serial vot (upper limb ischemia induced by a rapid pneumatic cuff inflation around the upper arm) were performed. we also recorded during the vot: basal sto , thi, the slope of the decrease in sto during the occlusion (desc slope; %/min) and the slope of the increase in sto following the ischemic period (asc slope; %/s). muscle oxygen consumption (nirvo i) was calculated as the product of the inverse of the slope value by the mean of thi over the first minute of arterial occlusion and is expressed in arbitrary units (u) (skarda shock ). all these data were obtained at different times: baseline and with map of mmhg, then at mmhg and mmhg of map by increasing the ne doses and finally to baseline . we report here data corresponding to the mean and sd of baseline and versus map mmhg analyzed by repeated measures analysis of variance (at % level) with bonferroni adjustment to account for multiple comparisons. increasing ne dose induced an increase in cardiac output (from . ± . to . ± . l/min, p \ . ) without any changes in heart rate and an increase of svo (from . ± . to . ± . %, p \ . objectives. to investigate: . the effects of ''successful'' protocolised resuscitation (egdt) on microvessel perfusion (particularly density). . whether there is different effects of egdt on the microcirculation of septic compared to critically ill non-septic patients and . whether there is a difference in the behaviour of ''true'' capillaries (i.e - lm) compared to larger microvessels ( - lm) at baseline or after resuscitation. prospective observational study in the emergency and intensive care departments of an urban teaching hospital. subjects: septic and critically ill control patients requiring shock resuscitation (map less than mmhg, ±cvp less than mmhg, ±central venous saturations less than %). all patients had invasive monitoring and identical cardiovascular targets. patients with known cardiogenic shock or pre-stabilised trauma were excluded. we performed sidestream dark field (sdf) videomicroscopy of sublingual microcirculation at the point of egdt initiation and again on attainment of at least out of cardiovascular goals. three sites were imaged for s and the clips were analysed randomly off-line to provide an average value for capillary density (total length and count per mm) and a semi-quantitative description of microvessel flow (continuous, intermittent or stopped) as previously described. vessels were grouped according to diameter as small ( - lm) and medium ( - lm). non parametric analysis was used for all within or between group comparisons, data is displayed as median values with [range]. *p \ . was considered significant. ( ) ( ) ( ) ( ) duration of occlusion (min), mean ± sd . ± . . ± . . ± . . ± . minimal sto (%), mean ± sd ± ± ± ± as expected, all septic shock patients, except one (for the vot fa % ) and two (for the vot a % ) had a recovery slope lower than normal when sto decreased to % during arterial occlusion. by contrast, when occlusion lasted min, many patients including patients who eventually died, were misclassified since their recovery slopes were in the normal range. these results could be due to the smaller decrease of sto and in turn a less strong hyperemic response when ischemia lasted only min. additionally, a significantly (p \ . ) shorter time to reach % was required when arm (compared to forearm) occlusion was performed. conclusion. when a vot is required for assessing microcirculatory disturbances in septic shock, we recommend performing it using an arm occlusion until sto reach %. aims. to analyze the correlation between sto (and its changes derived from a transient ischemic challenge) and global oxygen delivery (do ) parameters measured invasively using a pulmonary artery catheter (pac). observational study, performed in a -bed medical-surgical icu, at a university hospital. we recruited adult patients with cardiovascular insufficiency that required a pac placement for hemodynamic monitoring and resuscitation. we collected demographic data, and hemodynamic and oxymetric data derived from the pac. simultaneously, we measured sto and its changes derived from a vascular occlusion test (vot). results. twenty-two patients were studied. all the patients had a mean arterial pressure (map) above mmhg. the do index (ido ) range in the studied population was - mlo /(min m ). the mean svo value was ± %, mean cardiac index (ci) . ± l/ (min m ), and blood lactate . ± . mmol/l. the correlations found between sto and invasive oxygen delivery-related variables are shown in table . the sto -deoxygenation slope (deox) during the vot showed a significant correlation with svo (r . , p . ). we did not find any correlation between sto and global flow measurements, such as cardiac index (ci), but we found a correlation between sto and ido . this correlation seems related to the arterial oxygen content, and not to global flow. normal sto values could not rule out low ido and low ic states. therefore, sto seems to be poorly sensitive to exclude hypoperfusion states. in clinical practice there remains issues over the appropriate prescribing of antibiotics in patients with unproven sepsis. the prescribing of antibiotics is not without risk and creates a selective pressure on existing bacterial flora resulting in the emergence of virulent and resistant organisms [ ] . there is also a cost issue from the inappropriate prescription of antimicrobials [ ] . the diagnosis of sirs can be made with confidence [ ] , sepsis cannot and requires confirmation from microbial tests. empirical usage of antibiotic therapy is commonplace but not ideal. rapidly detectable, reliable markers of sepsis would help in directing antimicrobial therapy. objectives. the aims of this study are to determine the significance of % band forms in sirs patients suspected to have sepsis. can they be used as a diagnostic tool in conjunction with procalcitonin in order to direct antimicrobial therapy? methods. this is an observational study aiming to assess the ability of serum procalcitonin and percentage band forms in identifying nosocomial sepsis in patients with sirs. patients were recruited over an month period in a mixed medical-surgical university teaching icu. all patients had suspected sepsis arising 'de novo' and had not received prior antimicrobial therapy. patients had a septic screen performed along with baseline, and hpct and % band form count. introduction. pneumonia is the most frequent infectious complication after successfully resuscitated cardiac arrest (ca). however, diagnosis is difficult because of many clinical, biological and radiological confounding factors as well as the widespread use of therapeutic hypothermia. this could lead to a broad antibiotic prescription. to assess the utility of plasma procalcitonin (pct) measurements for diagnosis of early-onset pneumonia in successfully resuscitated ca. monocentric study (july -march with retrospective review of a prospectively acquired icu database focusing on all consecutive patients admitted for ca and surviving more than h. patients with an infection prior to ca or with an extra-pulmonary infection developing within days following admission were not studied. all files were reviewed to assess the diagnosis of early-onset pneumonia p(?), or not p(-) during the first days of icu stay. p(?) was defined by the presence of a new pulmonary infiltrate on chest radiography, persistent for at least h, associated with either positive quantitative culture of the endotracheal aspirates, either, in case of lack of bacteriological sample, conjunction of purulent sputum and hypoxemia (p/f \ ). pct was measured at admission, days (d) , and (brahms kryptor Ò ). among patients admitted for ca, were studied ( death before h, evolutive infections and incomplete samples). pneumonia was diagnosed in patients ( %), and antibiotics were prescribed in during the first days of icu stay. characteristics of p(?) and p(-) patients were (median, iqr): age ( - ) versus ( - ) (p = . ), ''no flow'' ( - ) versus ( - ) min (p = . ), ''low flow '' ( - ) versus ( - ) min (p = . ), shockable rhythm versus % (p = . ), cardiac etiology versus % (p = . ), therapeutic hypothermia versus % (p = . ), post-resuscitation shock versus % (p = . ) and icu mortality versus % (p = . ). using a threshold value of . ng/ml, negative predictive values were % at admission, % at d , % at d , whereas positive predictive values were , and %, respectively. patients with post-resuscitation shock had higher pct levels than those that did not require vasopressors: . versus . ng/ml at d (p \ . ), . versus . at d (p \ . ) and . versus . at d (p = . ). conclusion. diagnosic value of pct is poor in survivors of ca and pct should not be recommended to assess early-onset pneumonia. post-resuscitation disease could play a major role in the lack of specificity and predictive values. in acute community respiratory infection, low levels of procalcitonin (pct) have been shown to allow a marked reduction of antibiotic use. the aim of the study was to look for the same efficacy in case of suspicion of infection during icu stay. method. from april to december , patients hospitalized in the five intensive care units (icu) of the university hospital of liège in belgium, were prospectively randomized to either a procalcitonin guided approach to antibiotic therapy (pct group, n = ) or to a standard approach (ctrl group, n = ) when they were suspected of developing an infection. for pct group guided therapy only, the use of antibiotics was more or less strongly discouraged (pct level . or. lg/ml, respectively) and more or less recommended (pct level [ or[ . lg/ml, respectively) . number and duration of antibiotic treatments were recorded. diagnosis and treatment decisions were reviewed by infectious disease (id) specialists at the end of icu stay. results. there were no differences between groups in terms of age ( vs. ), saps ii score ( . ± . vs. . ± . ), type of patients (medical: vs. %, scheduled surgery: vs. %, emergency surgery: vs. %, trauma: vs. %), icu length of stay [ (iqr - ) vs. days (iqr - )] for pct and ctrl group respectively. suspicion of infection was either evoked on admission (in and %) or during icu stay (in and %) in pct group and ctrl group respectively. at the time of suspicion, pct levels was. lg/ l in . % of the infectious episodes in pct group and . % in ctrl group. episodes of suspected infection with pct level . lg/ml were recorded. clinicians decided not to treat % of these episodes (n = ). the remaining episodes were treated, of which % were eventually considered as probable or confirmed infections by id specialist (n = ). at the end of icu stay, id specialists classified infectious episodes of both groups as confirmed (n = ; . %), probable (n = ; %), possible (n = ; %) or absent (n = ; . %). for confirmed episodes of infection, pct levels were . lg/ml in as much as . % and above lg/ml in . %; for absence of infection, pct levels were . lg/ml in only . % and above lg/ml in . %. the ability of pct to discriminate between confirmed and probable infections on the one hand and possible or absent infection on the other hand, was tested by the measurement of the surface under the roc curve, which was . , which is too low to recognize pct as a valuable marker of infection. there were no difference in the number of treated patients ( vs. %) nor in the number of antibiotic days ( vs. %) between pct and ctrl group respectively. conclusions. procalcitonin level as an aid for the decision to treat infection in icu patients appeared not to be helpful. antibiotic consumption was not reduced using this tool in our study. introduction. respiratory infections, pneumonias in particular are a common cause of mortality in the intensive care unit (icu) patients worldwide. early identification and prompt management of these patients especially with associated sepsis is crucial in reducing the mortality. many clinical and laboratory markers have been studied extensively to predict the outcomes in them. there have been numerous studies on the clinical utility of serum procalcitonin (pct) in the past decade, in systemic inflammation, infection and sepsis. objective. to evaluate the role of serum procalcitonin, in predicting the outcomes of patients admitted in the icu with respiratory infections associated with sepsis. setting: bedded icu of a tertiary referral hospital. study design: prospective observational study. subjects: adult ([ years) patients admitted in the icu with lower respiratory tract infections with associated sepsis during the period july to january were prospectively followed up. primary outcome measure: day mortality. we measured pct levels using the brahms immunochromatographic technique(semiquantitative estimation) on the first day of admission into the icu . normal pct was taken as . ng/ml. patients were grouped into four groups-group a (pct \ . ng/ml), group b (pct [ . - ng/ml), group c (pct [ - ng/ml),group d (pct [ ng/ml). sepsis, severe sepsis, septic shock are defined according to the accp/sccm criteria. results. the overall mortality was . % with mortality of . , . , , and % in groups a, b, c and d, respectively. there is a statistically significant difference (p \ . ) in the mortality rates of groups c and d as compared with group a and b, but no difference was observed in the mortality rates between groups a and b and groups c and d .also significant statistically are the apache ii scores, septic shock and multiorgan failure incidence in the groups c and d as compared to groups a and b. conclusions. serum procalcitonin level [ ng/ml on the first day of admission in icu appears to be a good predictor of mortality in patients admitted with lower respiratory tract infections and associated sepsis. methods. in a retrospective study we assessed acutely ill patients investigated for pct and treated by a physician blinded for pct value. for each patient we also calculated new simplified acute physiology score (saps ii). we evaluated many clinical and instrumental parameters and diagnosis was done upon our usually clinical practice results. the mean age of patients (pt) was . yeats, shock was found in patients ( . %),median value of saps ii score was (iqr - ), and median estimated mortality from saps ii was % (iqr - ). bacterial infection was found in . % (septic shock . %, pneumonia . %, cholecystitis . %, pleural empyema . %, other infections . %) non infective disease in . % (pulmonary embolism . %, acute coronary syndrome . % heart failure . % other disease . %. a pct value [ . ng/ml was considered positive: so pct was elevated in . % of bacterial infection patients and in . % of non infective disease patients. we also compared pct values with antibiotic therapy and considered appropriate the administration if pct [ . ng/ml: there was discrepancy in . %. the review of these cases found medical decision wrong in cases versus ( . %); pt with pct \ . ng/ml had antibiotic therapy without bi and cases with pct [ . ng/ml did not have antibiotic therapy but had a bacterial infection. subsequent to this review discrepancy felt to . % (ci % . - . ) and was found especially in pt with pct \ . ng/ml. at cut off point of . the sensitivity was . (ci %: . - . ) specificity . (ci %: . - . ) or . and at point . the sensitivity was . (ci %: . - . ) specificity . (ci %: . - . ) or . , with high predictive positive value. all-causes mortality was . %. mortality if pct \ . ng/ml was . %, if pct . - . ng/ml was . %; if pct . - . lg/ml was . % and if pct [ ng/ml was . % without significant difference between bacterial infection and non infective disease group. comparing pct with saps ii score, area under roc-curve was not significantly different (pct . -ci %: . - . ) (saps ii . -ci %: . - . ). conclusions. pct in acutely ill patients is a useful marker to discriminate bacterial infections with high sensibility but low specificity and it may be useful to guide the therapy also with values higher than . ng/ml. our data suggest a real prognostic utility of pct in these patients, regardless of bacterial infections, but our efforts to elaborate a mathematical predictive model aren't still satisfying and further data are required in this setting. h. taniuchi , t. ikeda , k. ikeda , s. suda tokyo medical university, hachioji medical center, division of critical care medicine, tokyo, japan introduction. its apparent that detection of the causative bacteria is useful for the therapeutic strategy. however, conventional tests for the detection of the causative bacteria are not high sensibility. in order to diagnose sepsis or septic shock and start appropriate therapy rapidly, it's also important to know whether the infection is cause of gram negative bacteria, that is to say, whether the infection is cause of endotoxin. in this study, we investigate the severity level of sepsis and initiation criteria of direct hemoperfusion with polymixin b immobilized fiber column (pmx-dhp) treatment from the result of severity level by using endotoxin activity assay (eaa) and using measurement of procalcitonin (pct). subjects and methods. patients who developed severe sepsis or septic shock and admitted to icu were included. on the day of icu admission, a general blood biochemistry, eaa and pct levels, and apache ii and sofa score were measured. patients were evaluated retrospectively the relationship between the severity of sepsis and each measurements and investigated the relationship between the measurements and pmx-dhp. serum eaa level was measured using smart line eaa luminometers. serum pct level was measured using immune luminometric assay. results. the average age of the patients is ± , apacheii score was . ± . , sofa score was . ± . , the median pct was . ng/ml (range - ), eaa was . ± . . the underlying diseases of the enrolled patients were the abdominal infection ( patients), the urinary tract infection ( ), pneumonia ( ), the meningitis ( ), the soft tissue infection ( ) and other infection ( ) . the causative bacteria were gram positive bacteria ( ), gram negative bacteria ( ), virus ( ), and unknown ( ). there was no statistical correlations between eaa or pct level and apacheiiscore. there was no statistical correlations between eaa level and sofa score. although there was no statistical correlation between pct level and sofa score, the pct level tended to rise as pct level rises. we investigated the relationship between eaa and pct levels. there was also no statistical correlations between eaa and pct. we investigated the relationship between the causative bacteria (gram positive bacteria, gram negative bacteria and the others) and eaa or pct level. there was no statistical correlations between the causative bacteria and eaa level nor pct, that was contrary to our expectation that eaa level should be high for gram negative bacterial infection. we further investigated the relationship between whether or not the pmx-dhp was implemented and eaa or pct level. there was no statistical relationships. conclusion. high levels of the eaa and pct would not indicate the severe infection with gram negative bacteria, and the initiation of pmx-dhp. further study is needed, in which more patients will be enrolled and evaluated. introduction. sepsis still the major cause of death in the late post traumatic period in patients with major burns. early diagnosis of sepsis is crucial for management and outcome of critically burn patients. attempted in this study to assess whether plasma procalcitonin (pct) level was related to diagnostic and prognostic of sepsis in burned patients. patients and methods. pct was measured over the entire course of stay in patients with predictive signs of sepsis according to american college of chest physician. the patients were assigned to two groups depending on the clinical course and outcome: a = no septic patients, b = septic patients. optimum sensitivity, predictive values, and area under the receiver operating characteristic (roc) curve were evaluated. results. over a month period starting from july to december , patients were admitted. were investigated. in group a et in group b. procalcitonin was significantly higher in septic group . ± ng/ml compared to no septic group . ± . ng/ml. area under the curve was . on the day of sepsis diagnostic. pct cut-off value of . ng/ ml was associated with the optimal combination of sensitivity ( %), specificity ( %), positive predictive value ( %), and negative predictive value ( %). in survived septic patient the pct value was significantly lower than in deceased septic patients . ± . versus . ± . ng/ml. pct cut-off value for optimum prediction of outcome in septic patients was . ng/ml with sensitivity ( %), specificity ( %), positive predictive value ( %), and negative predictive value ( %). conclusion. procalcitonin appears to be a powerful marker of sepsis in burn patients. it is sensitive, specific, reliable and easy to measure. a high pct concentration ([ . ng/ml) would indicate poor outcome in septic patients. n. v. beloborodova , a. s. khodakova , a. y. olenin , s. t. ovseenko bakulev scientific center for cardiovascular surgery, moscow, russian federation objectives. accurate and timely diagnosis of sepsis remains challenging for clinicians. the diagnosis of sepsis is defined as typical symptoms of systemic inflammation (temperature, tachycardia, respiratory rate, leukocytosis) with clinical evidence of an infection site, but the criteria are met by a large number of intensive care unit (icu) patients. among studied biomarkers, serum procalcitonin (pct) has been described as one of the most promising predictors of bacterial sepsis, but in some clinical situations it is not enough. the search of reliable markers of sepsis is still in progress. in present study the significance of raised levels microbial phenylcarboxylic acids in serum of patients with sepsis are assessed. methods. the present study evaluated serum samples of patients (pts) with documentary sepsis, according to well known consensus criteria. the comparison groups were: no. - clinically healthy volunteers, no. - pts. with acquired heart diseases, no. - pts with ventilator-associated pneumonia. blood concentrations of phenylcarboxylic acids were determined by gas chromatography-mass spectrometry (gc-ms). results are presented as median and range of th and th percentiles. the statistically significant differences between the various groups were calculated using mann-whitney test. results. increased levels of phenyllactic (pla), p-hydroxyphenylacetic (hpaa), p-hydroxyphenyllactic (hpla) acids were observed in group of pts with sepsis. the level of hpaa was increased up to two orders in comparison with groups no. and [ . ( . - . ) vs. . ( . - . ) and . ( . - . ) lm, p \ . ). the levels of hpla and pla were increased up to one order [( . [ . - . ] table for illustration of importance of phenylcarboxylic acids blood level monitoring. introduction. acute kidney injury (aki) is a frequent complication of sepsis, and is associated with high mortality and morbidity rates. routinely used measures of renal function, such as levels of blood urea nitrogen (bun) and serum creatinine, increase only after substantial kidney injury occurs, resulting in delayed diagnosis of aki. therefore biomarkers, which enable early diagnosis, are needed. objectives. this clinical study was designed to investigate whether human interleukin- (il- ) and neutrophil gelatinase-associated lipocalin (ngal) are early predictive markers for sepsis-induced aki. urine and blood samples have been collected prospectively from icu patients, who met defined clinical criteria of severe sepsis. aki was defined by rifle criteria. urinary and serum levels of n-gal and il- have been quantified by elisa in patients with sepsis without aki (n = ) and in patients with sepsis induced aki (n = ). results. both, urinary il- and serum il- considerably increased (respectively, . and . -fold over the baseline) two days before the patients reached rifle risk. urinary ngal raised significantly ( . -fold over the baseline) one day before occurrence of aki, whereas serum ngal did not show any prior elevation. no increase in the levels of any of these markers could be found in patients who did not develop aki. conclusions. both urinary and serum il- seem to be sensitive early biomarkers for sepsis associated aki, while urinary ngal has less accuracy for aki prediction. objectives. to define a biomarker panel able to predict infection in case of severe acute dyspnea in emergency situations. we designed a prospective observational study of patients admitted in the emergency department (ed) and in medical polyvalent intensive care unit (icu) in a university hospital. inclusion criteria were acute dyspnea with spo b % and/or respiratory rate (rr) c b/min. patients with an immediate need of coronarography or with obvious spontaneous pneumothorax were excluded. five biomarkers were measured from blood sample at admission on ed or icu: nt b type natriuretic peptide (nt probnp), cardiac troponin i (ctni), ddimeres (dd), c-reactive protein (crp) and procalcitonin (pct). all clinical and biological data were recorded. an independent blinded data monitoring committee classified the patients according to all the available data including response to treatment and outcomes but blindly to biomarkers. the roles of biomarkers were assessed quantitatively and then using terciles of the distribution. the contribution of the biomarkers in the diagnosis was assessed using multiple logistic regression taking into account other clinical and biological explanatory variables. . patients were enrolled consecutively. the final diagnosis was: severe sepsis (n = ), acute heart failure (n = ), pulmonary embolism (n = ), copd (n = ), other causes (n = ). the days mortality was %. there was no significant association between infection diagnosis and dd, ctni, nt probnp. interestingly, a crp value of less than mg/l was not discriminant in predicting infection. adjusted on clinico-biological covariates selected, both pct with cutpoints of . and . ng/ ml (discrimination auc . ; p = . ) and crp with cutpoints of and mg/l (discrimination auc . ; p . ) were significantly associated with the diagnosis of sepsis. both biomarkers used simultaneously lead to a discrimination of the model (auc . ). conclusion. both crp and pct are able to predict the diagnosis of infection in case of severe acute dyspnea independently of clinico-biological variables. in this particular subpopulation, the best threshold for crp is higher than the standard one. an external validation is needed to prospectively validate the clinical utility of these findings. t. trefzer , i. nachtigall , a. weimann , c. de grahl , c. spies charite universitaetsmedizin berlin, campus virchow, department of anesthesiology and operative intensive care medicine, berlin, germany, charite universitaetsmedizin berlin, campus virchow, zentralinstitut für laboratoriumsmedizin und pathobiochemie, berlin, germany aims. infections are the most relevant icu-admission complication. crp and pct are labvalues used for diagnosis of infections. however, their use is often not evidence based. this study aimed to access whether the adherence rate increased after introducing an evidencebased standard operating procedure (sop). in an evidence-based sop was approved by experts of our department. in july it was made available to icu-physicians via intranet, which is accessible from every work station. altogether, we assessed sop-adherence rates of patients: in june (pre-sop), patients in august (one month post-sop) and in january ( months post sop). every crp and pct measurement was assessed for adherence to the standard operating procedure (sop). at first, the three periods were assessed for significant differences concerning the adherence. according to the percentage of sop-conform measurements the patients were then divided into two groups: the sop-group (c % of measurements sop conform) and the non-sop (nsop) group (\ % conform) in a second step, patients in the sop-and nsop-group were compared concerning icu scores (sofa, tiss, apacheii, saps) and outcome parameters (length of icu-stay, length of hospital stay, duration of mechanical ventilation, hospital mortality). statistics: p b . was considered as statistically significant; hospital mortality was assessed by a v test, icu scores and outcome parameters were compared using the mann-whitney u test. all parameters with p \ . were included into a logistic regression analysis. no change was observed concerning the implementation of the sop pre and postintroduction: . % in june , . % in august and . % in january . the non-conform pct-and crp-measurements resulted in additional costs of approximately . euros/year. the univariate analysis revealed significant differences in the sop-and nsop-group: the nsop-group had higher saps-, sofa-and tiss-scores, as well as increased length of icu-stay, length of hospital stay and duration of mechanical ventilation. logistic regression analysis revealed tiss score and length of hospital stay as an independent predictor for low sop adherence. conclusion. distribution of an evidence based sop without further education did not lead to a significant increase in adherence rates, but tiss score and length of hospital stay have shown to be independent predictors for low adherence to the sop. the significant higher tiss-scores in the nsop group might be a indicator for actionism of clinicians in the face of more severely ill patients. objetives. to asses the evolution of the risk-adjusted mortality rates of sepsis and septic shock in our icu in a ten years period. patients and method. analisys of prospectively recorded data of all pacients admitted with severe sepsis and septic shock in a bed icu during a period of years. patients were followed up until death or discharge from the hospital, excluding those with unknown outcome. mortality prediction was made using apache ii model with % confidence intervals. statistical analisys was made with spss . using anova test or t test to compare means and chi square test to compare categorical variables. results. from january to december a total of patients with sepsis were admitted, with an anual increase to reach % of all icu admissions. age and severity of illness increased anually as did sofa in the first h (sofa ) thus rising up calculated risk of death. from to mortality rate was between % ics of calculated risk of death, falling below inferior ic from and after . (fig. ). hospital mortality versus risk of death per year mortality was . % in the pre- period and . % from and on (p = . ) with non significant differences in apache ii, risk of death nor sofa , but with significantly greater age in the post- period ( . vs. . years p = . ). this non significant difference between the two periods of the study became significant when we analized the outcome in both sex. being significant in women (mortality . % in pre- period vs. . % in post- p = . ) but not in men ( . vs. . % p = . ). overall sepsis moratlity is lower in female without significant differences in age, apache ii score nor risk of death (table ) , being the only signifficant difference found in sofa ( . in male vs. . in female p = . ). introduction. low-grade systemic inflammation has been shown to play a key role in the pathophysiology of several chronic noncommunicable diseases [ , ] and may be attenuated by anti-inflammatory treatments such as administration of statins [ ] . so far, the association between acute systemic inflammation experienced during critical illness and long-term mortality after hospital discharge has not been investigated in intensive care unit (icu) patients. objectives. to assess the association between acute systemic inflammation, assessed by crp levels, and post-hospital mortality in non-surgical icu patients. methods. the study was performed as a prospective, observational follow-up study and included non-surgical critically ill patients with an icu length of stay [ h. patients who died during the icu or hospital stay, were \ years or pregnant, as well as patients discharged from the hospital with the plan to limit life support were excluded. demographics, chronic diseases, admission diagnosis, the simplified acute physiology score ii, length of icu stay, maximum crp levels during the icu stay (crpmax) and crp levels at icu discharge (crpdis) were documented. after a mean ± sd follow-up time of . ± . years, mortality and causes of death were determined. adjusted cox models were calculated to investigate the association of crpmax and crpdis with post-hospital mortality. a receiver operating characteristic analysis was used to identify optimal cut-off levels to predict post-hospital mortality. background. the prevalence of hiv infection is increasing worldwide as a public health problem. survival of hiv/aids patients has improved since highly active antiretroviral therapy, but sepsis has grown as an important cause of icu admission in this population. an international conference has set a system composed of specific risk factors, site and microbiology of severe infections and host response and organ dysfunctions (piro) to help identify patients at risk for sepsis. piro factors have not been classified for hiv/aids population yet. objectives. to identify predisposing factors, microbiology of infections, host clinical response and incidence of early organ dysfunctions of severe sepsis on hiv/aids patients, admitted to a specialized infectious diseases icu; to analyze long-term survival of hiv/aids critically ill patients. a prospective case-control study of septic and non-septic hiv/aids patients admitted between june and may was performed. demographic data, causes of admission, time since aids defining condition, cd cell count, and opportunistic infections were evaluated as predisposing factors to sepsis. microbiology and site of infections were registered. clinical response to severe infections was evaluated by ali/ards and shock incidence on day of icu admission. organ dysfunctions (sofa score) were reported soon after icu admission. icu length of stay, hospital and -month mortality were compared between septic and non-septic groups. a multivariate regression analysis was done to identify risk factors for icu mortality. kaplan-meyer survival curve was built. . icu admissions of hiv-infected patients were studied. half ( ) fulfilled criteria for severe sepsis diagnosis. septic group was younger ( . ± . vs. . ± . years, p \ . ) and had more female patients ( vs. %, p \ . ). time since aids diagnosis, cd cell count and opportunistic infections prevalence were not different. sites of infection were predominantly pulmonary ( %) and catheter-related ( %). ninety percent of infections were nosocomial. forty-three percent of septic patients presented bacteremia. pseudomonas sp, s aureus and enterobacteriacae were commonly identified, but five patients had mycobacterium tuberculosis isolated ( on blood cultures). multiple organ dysfunction syndrome was frequent, and incidence of cardiovascular, respiratory and hematological dysfunctions was significantly higher in septic group. longer length of icu stay ( . ± . vs. . ± . days, p \ . ) and icu mortality ( vs. %, p \ . ) was observed for septic patients. severe sepsis also influenced long-term survival, as mortality continues significantly higher after months (log rank . , p \ . ). conclusions. piro system is applied to septic hiv/aids patients. shock, ali/ards and hematological dysfunctions are prominent for septic hiv/aids population. septic hiv/ aids patients are at severe risk of short and long-term mortality. international guidelines for management of severe sepsis and septic shock suggest the use of recombinant human activated protein c (rhapc) in adult patients with high risk of death (apache ii c or multiple organ failure). the objective of this study is to analyse the characteristics and outcome of patients treated with rhapc in our medical intensive care unit. retrospective study of patients with severe sepsis/septic shock treated with rhapc between january to december . all of them were c years, with apache ii c and two or more organ dysfunction, and were treated on basis of a bundle for severe sepsis management: complete early goal-directed therapy, early administration of broadspectrum antibiotics; corticosteroids in vasopressors unresponsive patients and monitor for lactate clearance. chi-square analysis were used to compare categorical data. continuous data were compared using student's t test. prognostic factors of mortality were studied by means of multivariable logistic regression analysis. results. forty-one patients were studied. % were male. their mean age was ± years. % had comorbidities ( % immune pathology). severity scores. apache ii ± , sofa ± , % of patients had three o more organ dysfunction. % had septic shock. serum lactate level was . ± . mmol/l. the primary location of infections was: respiratory %, abdominal %, urinary %. . % were positive blood culture. % of patients needed mechanical ventilation ( ± days). % of rhapc infusions were not completed, mainly for bleeding risk ( %) and death ( %). . % of patients had bleeding event. at the end of the infusion % of patients remained with two or more organ dysfunction and % were vasopressors dependent. mean hospital stay was days and days in icu . days mortality was %, icu mortality . % and hospital mortality . %. analyzed data included age, comorbidities, primary location of infections, severity scores and serum lactate level. univariable analysis showed that statistically significant factors related to mortality were: apache ii ( ± vs. ± , p = . ), organ dysfunction number: vs. [ ( vs. %, p = . ) and primary location of infections: pneumonia versus others ( vs. %, p \ . ). a multivariable logistic regression analysis showed that age (or . , % ci . - . , p = . ), organ dysfunction number (or . , % ci . - . , p = . ) and serum lactate levels (or . , % ci . - . , p = . ) had statistically significant relationship to mortality. conclusion. in our study the patients with severe sepsis and septic shock remained with high vasopressors dependency and organ dysfunction at the end of the rhapc infusion. despite of rhapc therapy the mortality of patients was very high. the age and the severity at icu admission were independent prognostic factors of mortality. a higher incidence of severe sepsis in blacks compared to whites is well documented, however prior analyses do not discriminate whether this is due to a higher incidence of infections, a higher risk of developing organ dysfunction once infected, or both. objectives. we sought to understand whether higher severe sepsis incidence in blacks is due to higher infection susceptibility, higher risk of organ dysfunction once infected, or a combination of both. we analyzed , , hospitalizations from hospital discharge records of us states ( % of us population). we linked these records to us census data to generate age and sex-standardized incidence rates. we identified infections of bacterial and fungal etiology based on icd- cm criteria, including characterization by site and type of infection (gram negative vs. gram positive). we defined severe sepsis as documented infection plus acute organ dysfunction based on previous work by angus et al we estimated the risk of organ dysfunction among those hospitalized with infections using logistic regression, adjusting for age, sex and comorbidities (charlson score). fig. b ]. the combination of both events led to a % higher severe sepsis hospitalization rate for blacks ( . vs. . per , population, irr: . - . ). these differences persisted when stratified by sex, comorbidities, site and type of infection. infection incidence and severe sepsis risk conclusion. the higher incidence of severe sepsis among blacks is due to a higher hospitalization rate for infections, as well as a greater likelihood of organ dysfunction once infected. future interventions to reduce racial disparities in severe sepsis incidence should target both distinct events. grant acknowledgement. dr. mayr was supported by t hl - . objective. to describe recent epidemiological data and mortality risk factors of patients admitted to icu for severe pneumococcal pneumonia (pp). multicentric retrospective study (january -june ). prospective acquired data from patients admitted in french medical icu for severe pp were considered. patients with concurrent meningitis, severe copd with known sp colonization, hiv or aspiration pneumonia were not included. pp was defined by the combination of a suggestive clinical context, the presence of a new pulmonary infiltrate on chest radiography and a s.pneumoniae positive bacteriological sample (pulmonary quantitative culture, pleural fluid, blood culture or urinary antigen assay). all files were reviewed and approved by two independent investigators (nm, am). . patients were included. median age was ± . hospital survivors were significantly younger ( ± vs. ± , p = . ). sex ratio m/f was / , but male sex was associated with higher risk of death (male: vs. %, p = . ). active tabagism ( %) or alcohol abuse ( %) were more common than asplenia ( %). organ dysfunctions were mainly respiratory ( %), haemodynamic ( %) and renal failures ( %). low doses steroids were prescribed in % of patients with septic shock. icu mortality rate reached % ( % in the first days); hospital mortality rate was %. univariate analysis demonstrated that age, male sex, cirrhosis and organ failure support were strong predictors for icu mortality. multivariate analysis only highlighted age [or . ( . - . )], cirrhosis [ . ( . - . ) ] and renal replacement therapy [ . ( . - . )] as independent mortality predictors. activated protein c treatment was associated with decreased mortality [or . ( . - . )]. bacteremia had no impact on outcome. conclusion. this is the most important cohort of pp requiring icu admission. despite adequate antibiotherapy, mortality is still preoccupant. determination of factors related to the bacteria (virulence) or to the host (genetic susceptibility) could allow a better understanding of this important health problem. introduction. to identify the risk factors of mortality for patients with severe community-acquired bacteremic pneumococcal pneumonia. retrospective study realised in the intensive care units of two hospital medical centers. the studied population was patients with serious community-acquired bacteremic pneumococcal pneumonia. all the patients entered the intensive care units between january of and december of . study variables were: age, sex, concomitant pathology, toxic habits, pre-vaccinal ( - ) and postvaccinal periods ( ) ( ) ( ) ( ) ( ) ( ) ( ) , serotype and sensitivity of streptococcus pneumoniae to penicillin, the initial use of the non-invasive mechanical ventilation, the development of empyema pleural, apache ii and sofa scores during the first h after admission. results. the age average was of years. forty one percent of our patients required mechanical ventilation, and % had acute renal failure that required hemofiltration. average values of apache ii and sofa were . and . respectively. in hospital mortality of the series was of %. in patients with severe community-acquired bacteremic pneumococcal pneumonia: ( ) the presence of empyema pleural is an independent risk factor for mortality. introduction. procalcitonin (pct) is an interesting marker of pulmonary infection [ ] . it is useful as an help for infection diagnosis but also for treatment follow-up [ ] . besides, initiation of effective antimicrobial therapy is the strongest predictor of outcome in patients with septic shock [ ] . the aim of the study was to analyse whether kinetics of pct decline may reflect sensitivity of identified infectious agents to initial antimicrobial therapy (at). patients with diagnosis of severe pneumonia following major cardio-thoracic or vascular surgery were retrospectively included in the study. severe pneumonia was suspected as a combination of several manifestations including fever or hypothermia, hyperleucocytosis or leucopenia, new radiological infiltrate, and/or a clinical pulmonary infection score [ , pct [ ng/ml and pao /fio \ . initial antimicrobial treatment was chosen according to the guidelines in use in our institution for community-acquired or nosocomial infections. microorganism identification from endotracheal aspiration or bronchoalveolar lavage, and antibiotic susceptibility testing, allowed to classify patients according to appropriate (aat) versus inappropriate initial at(iat). pct was measured daily over days and its kinetics compared between both groups. data are expressed as median (extremes) or mean ± sd (decrease rate). results. patients aged ± ( - ), operated on vascular (n = ), thoracic (n = ), or cardiac surgery (n = ) have been studied from october to july . pneumonia occurred within the st to the st postoperative day (median . days), with a septic shock in cases and deaths at day . initial at was appropriate in % ( / ) patients. pct peak was not statistically different between aat versus iat patients ( . ± . ng/ml vs. . ± . , respectively) but pct decrease was significantly steeper and constant in iat patients (fig. ). pct decrease (%) from peak value over days discussion: the results suggest that absence of early decrease in pct within days may reflect failure of the at. conversely, an average decrease in pct plasma concentration of % in days seems to be a good marker of sensitivity of the causative infectious agent to the initial at. in case of unchanged pct within days at change should be considered. icu mortality was % for pts with rb early vap while it was % ( of cases) in those with sb or negative cultures (p = . ). mortality was higher than the predicted according to apache ii score in pts with rb vap ( vs. ± %, p \ . ). however, it was lower than predicted in those with negative or sensible isolates ( vs. ± %, p = . ). conclusions. rb were the most common cause of early vap among our patients. the burden of illness, los in icu before intubation and previous use of antibiotics were associated with early vap due to rb. inappropriate empiric therapy and mortality were higher among patients with early vap due to rb. to evaluate the performance of the saps piro model in patients with severe community acquired pneumonia (cap), over a period of years ( - ) , in a general icu in a central hospital. material and methods. we analysed data prospectively registered in an informatic data base, which contains information referring to all patients admitted in this unit. analysed were patients. discrimination was accessed by the area under the roc curve (aroc). calibration was evaluated by the by the hosmer-lemeshow Ĉ test. conclusion. implementation of a sedation protocol requires constant follow up and regular adaptation to prove efficient over time. constant feed back information to both the medical and nursing staff is mandatory. treatment of hyperactive delirium. hal haloperidol, bzd benzodiazepine, pro propofol, aa atypical antipsychotic, nd no drugs, na not answered discussion. there tends to be a general pessimism regarding obese patients within the intensive care community. our data indicates that this opinion could be misplaced. reduced ventilator days may reflect a reluctance to invasively ventilate obese patients. the apache ii scoring does not take into account the bmi which would eliminate any severity scoring bias. high bmi alone should not be a consideration in the decision regarding suitability for admission to critical care. during the last decades, a growing medical knowledges have changed the clinical approach to elderly patient diseases. they receive major surgery or intensive treatment for acute medical illness but often the recover is condictioned by the previous chonical diseases. this determines a long period to stay in intensive care unit (icu) because the slow improvement and cause an occupation of bed places. in our hospital, after a period of training performed by an intensivist (bc) and an internist (ag), icu patients who need a non invasive ventilation (niv) or tracheostomized elderly patients who have difficult weaning were admitted in a dedicated area in a medical department (md). this study desribes the results of one year of observation. in the last year, forty nine patients (age . ± . ; m f ) were transferred from icu to md. twenty three patients were treated with niv (age . ± . ; m f ), fourteen tracheostomized patients (age . ± . ; m f ) receive positive pressure ventilation because the difficult weaning in icu while twelve don't need any respiratory support. at the admission was performed a multidisciplinary plan and many specialists were involved (dietist,physiotherapist, pneumologist) and in invasively ventilated patients (ivp) was done a program of weaning. we follow all the patients until the discharge at home where someone need oxigenotheraphy, niv or mechanical ventilation. for the invasive ventilated patients we try to identificate significative differences beetween patients discharged at home and patients who died in hospital. data are given as mean ± sd and statistical analisis t test was performed results. patients underwent niv stay in hospital for . ± . days ( . ± . days in icu- . ± . in md) and ventilation was performed for the entire period in icu while for . ± . days in md. all the patients were discharged at home: twelve with niv, fourteen with oxygen. the lengh to stay in hospital for the ivp in wich weaning was failed in icu was . ± . days ( . ± . days in icu- . ± . in md). in md they continue the invasive ventilation for . ± . days. seven were weaned from ventilation after . ± . days, one was discharged at home with the ventilator while six died in hospital. patients who died were older ( . ± . vs. . ± . years-p . ), have more chronical diseases ( . ± . vs. . ± . -p . ), longer hospitalization ( . ± . vs. . ± . days-p . ), glascow coma scale ( . ± . vs. ). elderly patients often require a long period of recovery from acute ilness. in selected patients md could be a useful place where continue the treatment started in icu. in our study ivp who died had more chronical diseases and a more significative cognitive compromission. aim. documenting the qualitative and quantitative properties of administered and lost fluids is a common critical care monitoring practice. these nurse-registered fluid balances (fb) are used to optimize patient care and in clinical decision-making. this ''good clinical practice'' has also found application in research: recent studies reporting superior outcomes expressly refer to (negative) fb. we prospectively assessed the accuracy (review of all fluid balance charts and correction of arithmetic errors) and consistency (gold standard: body weight changes [bwc] registered with standardized measurements of body weight on admission and discharge [precision ± g]) of nurse-registered cumulative fb. total (tfb) and daily fb (dfb = total fb/los) were calculated. we analysed the unadjusted cumulative fb (unafb: without considering additional losses, i.e. perspiration/fever/liquid faeces) and the adjusted cumulative fb (adjfb: considering the above as proposed in the literature) in all patients (all) and in three subgroups (cardiaccerebral:card; septic:septic; others). exclusion criteria: lack of admission/discharge weight, incomplete fb data. we calculated l = kg. among patients admitted during the study period were eligible and analyzed. fb were inaccurate in cases ( %) (error range: - . to ? . l, mean arithmetic error ± sd: ? . ± . l, mean absolute error: . ± . l). the body weights at admission and discharge were . ± . kg and . ± . kg, with a bwc of . ± . kg ( . ± . kg per day). unatfb were . ± . l, unadfb . ± . l. adjtfb was . ± . l, adjdfb . ± . l. correlation (r ) and bland and altman was poor between bwc and unatfb ( . and - . ± . kg) and slightly better between bwc and adjtfb ( . and ? . ± . kg). the sd of the difference between bwc and fb per day of the icu stay was always [ kg. a multiple regression model including unatfb, duration of intubation, maximum temperature, estimation of liquid faeces, age and the calculated caloric deficit during the icu stay, only modestly improved correlation (r . ). compared to the two other groups, septic were significantly more severely ill, had a higher and longer fever, a longer los, larger bwc and cumulative fb, and presented larger differences between bwc and cumulative fb (poor correlation and bland and altman). though, consistency betwenn bwc and cumulative fb in card and other was still scarce. conversely, another multiple regression model (including only unatfb and the maximal temperature) in septic yielded an r of . . conclusion. fb are often inaccurate and they are not consistent with the gold standard of bwc. the correlation and the agreement with bwc of both adjtfb and unatfb are poor, with sd per icu day-stay[ kg or l. multiple regression models including several variables slightly improve correlation, yet remaining disappointing. consequently, clinical decisions should rather be based on other methods than fb. a prolonged hdu los was associated with a high sofa score for respiratory, hepatic and coagulation variables, preoperative ecg alterations, an increased urea and bmi and important bleeding. sofa score should be use in the first h to assess organ failure and a possible icu transfer for patients with an elevated score. evaluation of procalcitonin, neopterin, c-reactive protein, il- and il- as a diagnostic marker of infection in patients with febrile neutropenia financed by the following fellowships: rd / / from retics, fiss pi and fijc p-ef- reference(s). . bohoun c ( ) a brief history of procalcitonin biomarkers of sepsis: is procalcitonin ready for prime time? definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis procalcitonin assay in systemic inflammation, infection, and sepsis. clinical utility and limitations usefulness of procalcitonin for diagnosing complicating sepsis in patients with cardiogenic shock patients at our er, icu and wards of internal medicine and surgery meeting the ssc criteria were included. blood cultures were taken before administration of antibiotics, other cultures when appropriate. laboratory tests included wbc, crp, lactate, and pct. we categorized patients using bacteriological criteria group bacteriological proven infection (negative blood cultures but any other culture(s) positive) using chi square test there was no difference in survival, pct and findings on chest x-ray between the groups. with the mann whitney u test we found no differences in wbc, crp and lactate between survivors en nonsurvivors in a cohort of patients meeting the ssc criteria only % met bacteriological criteria for sepsis. wbc, crp, lactate and pct did not differ between patients with and without bacteriological proof of infection nor between survivors and non-survivors il rn and tnfr in the severity and outcome of community-acquired pneumonia to investigate whether polymorphisms within genes encoding for inflammatory or anti-inflammatory molecules are associated with susceptibility design. prospective observational, cohort study a cohort of , spanish caucasians with cap and subjects were genotyped for the following polymorphisms: tnfa - and - , lta ? sequential kaplan-meier survival analysis of tnfrsf b ? g/t polymorphism showed a protective role of the gt genotype. cox regression analysis adjusted for age, gender, hospital of origin and comorbidities showed that patients with gt genotypes had lower mortality rates compared with those patients with gg or tt genotypes (p = . our study does not support a role for the studied polymorphisms of the tnfa, lta, il and il rn genes in the susceptibility or outcome of cap. a protective role of heterozygousity for the functionally relevant tnfrsf b ? variability in genes involved in the inflammatory response in patients with community-acquired pneumonia to investigate whether polymorphisms within genes encoding for inflammatory or anti-inflammatory molecules are associated with susceptibility design. prospective observational, cohort study a cohort of , spanish caucasians with cap and , controlsinterventions: subjects were genotyped for the following polymorphisms: tnfa - and - , lta ? sequential kaplan-meier survival analysis of tnfrsf b ? tt versus gg/gt genotypes suggested a detrimental role of the tt genotype. longrank c tests at and days yielded p = . and . , respectively; cox regression for -and -day survival, adjusted for age, gender ghent university hospital, intensive care we aimed to describe the incidence and characteristics of healthcare-associated pneumonia (hcap) diagnosed at the emergency department of our university hospital compared to cap, hcap occurs in more debilitated or at-risk patients, is more frequently caused by nosocomial pathogens, and has worse outcome. nursing-home pneumonia is included within the definition of hcap but could have characteristics different from the other categories of hcap ) with a diagnosis of 'pneumonia'. episodes were categorized in cap and hcap according to the definition of the american thoracic society/infectious diseases society of america. within hcap, distinction was made between nursing-home pneumonia (nhp) and non-nhp hcap. severity of the pneumonia was assessed using curb- during the study period, episodes of pneumonia were diagnosed in patients; episodes ( %) were categorized as cap, and ( %) as hcap. within hcap, ( %), respectively ( %) episodes were further classified as respectively nhp and non-nhp hcap. median age of the patients was years ( - ) and % of patients were male median curb- pneumonia severity score in patients with cap and hcap was ( - ) and ( - ) respectively (p = . ); in nhp and non-nhp hcap, median curb in bivariate logistic regression analysis, both increasing curb- (or . , ci . - . ) and categorization as nhp (or . , ci . - half of the episodes of pneumonia diagnosed at our emergency department could be classified as hcap. severity of the pneumonia was higher in patients with hcap as compared to cap. categorization as nhp, but not as non-nhp hcap was independently associated with hospital mortality after adjustment for severity of the pneumonia medical intensive care unit community-acquired pneumonia (cap) is the leading cause of infectious death, severe sepsis and the seventh leading cause of overall death. severe cap (scap) is defined as need of aggresive intensive care unit (icu) management due to shock to describe the episodes of severe community-acquired pneumonia (scap) in a multicentric european study and to assess management practices and outcome of scap patients admitted to icu observational, prospective, multi-centre study conducted in icus of consecutive patients requiring invasive mechanical ventilation for an admission diagnosis of pneumonia or mv for [ h were recruited in each icu. statistic analysis was performed using spss years p \ . ) and presented a higher saps ii score at admission ( . sd . vs. . sd . p \ . ). patients were treated with monotherapy in . % and combination therapy . %. empirical antibiotic treatment was in accordance with idsa guidelines in ( . %) patients. combination was prescribed with macrolides in . % and quinolones in . %. in patients receiving combination therapy in accordance with idsa guidelines, a cox regression analysis adjusted by saps ii and age identified that macrolides use was associated with lower icu mortality when compared to the use of quinolones in patients with severe community acquired pneumonia who had therapy in accordance with the idsa guidelines, only combination therapy with macrolides was associated with better outcomes the eu-vap/cap project was endorsed by eccrn hospital de mataró, critical care, mataró, spain, hospital universitario germans trias i pujol, microbiology, badalona, spain, hospital de mataró, microbiology, mataró, spain, hospital universitario germans trias i pujol this leads to improved survival in a sterile acute lung injury model in wild-type mice, compared to mmp- knockout mice. we recently showed that mmp- deficient mice had better survival in a cecal ligation and puncture (clp) sepsis model than wild-type mice. in humans, functional genetic variations of the mmp- gene exist, but their relation to outcomes of severe infections, such as cap, is unknown. objectives. we hypothesized that functional human single nucleotide polymorphisms (snps) leading to increased mmp- levels are associated with worse survival and higher incidence of severe sepsis in patients with cap. methods. we examined data from genims, a multicenter prospective cohort study of patients with cap and analyzed potentially functional snps (rs , rs , rs ) in the mmp- gene in caucasians by polymerase chain reaction (pcr) the overall incidence of severe sepsis was . % (n = ), and . % of patients (n = ) died within days. the rs genotype distribution was significantly associated with -day mortality by armitage's trend test failure plot for rs conclusions. the non-synonymous rs snp is associated with -day survival in patients with cap. our findings suggests a trend towards a transcriptome analysis of ventilator associated pneumonia in trauma patients the sepsichip project the diagnosis of acute infection in the critically ill remains a challenge. transcriptional profiles (tp) of circulating leukocyte can be used to monitor the host response to infection. ventilator-associated pneumonia (vap) is a frequent complication of major trauma, raising morbidity and mortality data files were analyzed with r and bioconductor. unsupervised analysis was conducted using the dbf-mcl algorithm. supervised analysis was conducted using the significance analysis of microarray algorithm, using siggenes library. all statistical analysis used corrections for multiple comparisons. results. vap occurred in of the trauma patients ( . %). one hundred and fifteen samples were hybridized on husg k microarray ( sirs and sepsis samples for the patients who developed a vap, and sirs samples for those who did not). whereas clinical parameters (iss, chest trauma) discriminated trauma patients with or without vap, admission samples transcriptome analysis did not lead to the identification of prognostic markers. analysis of paired samples of the patients who developed a vap identified a transcriptional signature. these genes were involved in transcriptional regulation, cell survival, hemostasis and endocrine regulation. conclusions. by comparing whole blood admission samples, we were not able to identify transcriptional prognosis markers in trauma patients who did or did not develop vap. however, using vap as a model of sepsis in trauma patients, we identified a set of genes which may serve to diagnose vap in trauma patients to investigate the correlation between transfusion practice and the development of ventilator associated pneumonia (vap) in patients with traumatic brain injury (tbi) we analyzed which tbi individuals developed vap in regard to the transfusion practice and if the number of transfused prbcs increases the risk of pneumonia development. we counted the total amount of prbcs units received by each patient during icu stay, as well as those given before vap development. patient's data included: demographics, apache ii, iss, gcs, vap characteristics, duration of mechanical ventilation (mv), length of stay (los) and outcome. cpis and mods were calculated on the day of vap detection.statistical evaluation was performed using univariate and multivariate logistic regression, students t-test and pearson's chi square test %) tbi patients who developed vap received on average units of prbcs during icu stay, compared with non vap individuals who were transfused on average with two units of prbcs (p \ . ). vap patients received on average four units prbcs before vap development. after correcting for age, apache ii, gcs and iss, transfusion was independently associated with vap. the odds ratio for vap aspiration pneumonia (ap) in comatose patients (pts): clinical and microbiological findings ap is a common complication in comatose pts. we aimed to update data on their incidence standard guidelines were used for diagnosis and treatment of ap. daily chest x-ray were retrospectively reviewed. ap was diagnosed if pts met following criteria: persistent radiographic infiltrate within days following ti, and at least two of the following: purulent sputum, fever/hypothermia duration of mv was days ( - ) and length of stay in icu days ( - ) on the day of ap diagnosis, main pts characteristics were: saps ii %) received empirical antimicrobial therapy. main empirical antibiotics were coamoxiclav ( %) and third generation cephalosporin ( %) ) and mv duration ( vs. days, p \ . ), even considering only non-cardiac arrest pts. gcs h after ti and ap were associated with a [ days duration of mv in multivariate analysis ap was associated with higher overall -day mortality in univariate analysis ( vs. %, p = . ) but no longer in multivariate analysis mortality in the icu was . % with a corresponding hospital mortality of . %. a microbiological documentation was obtained in . % of the patients, with streptococus pneumonia being the most frequent ( % of the isolates). the cap was classified as localized in . %, unilateral mean (±sd) saps piro score was . ± . points, with a corresponding predicted mortality of . ± . % (standardized mortality ratio . ). the aroc was . ( . - . ). the value of the hosmer-lemeshow Ĉ test was saps piro presented a discrimination similar to the originally described. however, it significantly overestimated mortality sepsis mortality prediction based on predisposition, infection and response the piro-cap score was proposed earlier this year to stratify patients with severe community acquired pneumonia (cap) to evaluate piro-cap score in patients with severe cap, over a period of years we analysed data prospectively registered in an informatic data base, which contains information referring to all patients admitted in this unit survival curves were built as proposed by the original authors. outcome was evaluated at icu discharge overall, it was a severe population: . % of the patients presented at least one chronic disease, saps : . ± . points (predicted mortality . % ± . ), length of stay in the icu . ± . , icu mortality was . %. a microbiological documentation was obtained in . % of the patients, with s. pneumoniae being the most frequent ( % of the isolates). the cap was classified as localized in . %, unilateral icu mortality was piro-cap presented an excellent discrimination. however, mortality rates were greater than the ones described by the original authors in all groups (except group ), with the system significantly under-predicting mortality. consequently, we recommend caution in their widespread use. cumulative survival reference(s). clinical and biological assessments in icu patients delirium is a life-threatening, acute organ dysfunction with an incidence of % in uk mechanically haloperidol is recommended as treatment [ ] despite limited evidence base. objective. a national postal survey of consultant members of the uk intensive care society (ics) was performed to determine the current management of delirium in the ) drug treatment of hypoactive and hyperactive delirium as described by two clinical vignettes and ( ) level of agreement with five statements regarding delirium. results. six hundred and eighty one replies were received from , questionnaires senta response rate of %. twenty five percent of respondents routinely screen for delirium. only % use a validated screening tool, most ( %) of whom use the confusion assessment method, icu. hyperactive delirium is treated pharmacologically by %, the majority using haloperidol. hypoactive delirium is treated pharmacologically by %, with haloperidol again the most common treatment ( %) grant acknowledgement. intensive care foundation, intensive care society a practical algorithm to diagnose delirium in critical care-validity and reliability delirium occurs in up to % of critical care patients [ ], but often remains undiagnosed because standardized delirium monitoring is often dismissed as being too time-consuming or too complicated [ ]. the 'harvard flowsheet', derived from the 'confusion assessment method for intensive care unit' (cam-icu) [ ], provides a practical, algorithm-type handling advice to assess the four dsm-iv delirium criteria in a standardized fashion in intubated patients. it mostly allows for truncation of assessments to save time after approval from our institution's ethics committee, patients of a -bed surgical icu-department were screened in five sessions for delirium ( ) by a psychiatrist as the reference rater using the dsm-iv delirium criteria, and ( ) by two 'harvard flowsheet'-investigators, each unaware of other's ratings. motoric delirium subtypes were classified according to the richmond agitation sedation scale (rass) [ ], which was rated for the feature ('altered level of consciousness') of the 'harvard flowsheet'. patients were deemed as having hypoactive delirium if they were dsm positive by the reference rater and had rass - to , or having hyperactive delirium if their rass was between ? and ? . for interrater reliability the median time to complete the 'harvard flowsheet' in delirious patients was s (iqr, - s) vs. s ( - s)] in non-delirious patients. conclusions. the 'harvard flowsheet' has high sensitivity, high specificity and very high interrater reliability. false-negative ratings can occur infrequently and likely reflect the fluctuating course of delirium with intermittent lucid states a decrease of the overall cost of sedation and of sedation/day of mv followed protocol implementation and has been pursued each year: sedation cost which was greater than €/day in / has decreased to less than €/day in acute renal failure in critically ill patients: a multinational, multicenter study to evaluate current transfusion practice and the association between the age of red blood cells (rbcs) and outcome in critically ill patients design. prospective, multicenter observational study patients: critically ill adult patients receiving at least one unit of rbcs %)] revealed an unadjusted absolute reduction rate (arr) in mortality of % ( % ci - %). after adjustment for disease severity, patient age, other product transfusions, number of transfusions, pre-transfusion haemoglobin concentration, pre-icu transfusions, and cardiac surgery the odds ratio (or) for hospital mortality in critically ill patients in australia and new zealand transfusion of rbcs is delivered within current international recommendations. however, within such a practice patients enrolled included men and women, with mean age of ± years. there were ( %) liver transplantation, ( . %) renal transplantation and ( . %) pulmonary transplantation and ( . %) renal-pancreas transplantation. the days mortality for liver, renal, pulmonary and renal-pancreas was: ( . %), ( . %), ( . %) and ( . %). the mean saps score for liver, renal ic apache ii auc . % . - . , ic % . - . . conclusions. in these study, no differences were observed comparing saps and apache ii in the mortality prediction from liver, renal and pulmonary transplantation current opinion in critical care introduction of a rapid response team: why we are glad we met dew ma and members of the medical emergency response improvement team (merit) committee ( ) mature rapid response system and potentially avoidable cardiopulmonary arrest in hospital the effect of a rapid response team implementation in a private hospital adult patients often exhibit physiological deterioration hours before cardiopulmonary arrest to determine the effect of a rapid response team on the rate of in-hospital cardiac arrests, total and unplanned intensive care unit admissions, and icu and hospital mortality before and after implementation of a rapid response team standard criteria were used to activate the rrt and included acute changes in the patient's mental status, respiratory rate, heart rate, oxygenation, or blood pressure and hypoxia, chest pain, or worry from clinical staff. we measured: admitting diagnosis after rrt were a total the activations. the most common reasons for rrt activation were ventilator dysfunction ( %), cardiac changes ( %) and acute neurological changes ( %). % were transferred to icu and the main reasons were cardiac changes ( %), ventilatory dysfunction ( %) and acute neurological changes ( %) the rrt implementation was associated with decreases in rates of inhospital cardiac arrest, but was not associated with reductions in hospital or icu mortality the . lives campaign: setting a goal and a deadline for improving health care quality gender difference in critical care response team activations impact on outcome saudi arabia, king saud bin abdulaziz university for health sciences, riyadh, saudi arabia introduction. gender-related differences in outcome of ccrt intervention has been documented in the literature indicating that more men were admitted to the intensive care unit our center is the only center in the kingdome of saudi arabia which implements an intensivest-lead ccrt services h/ . the team is leaded by in house board certified in critical care medicine. ccrt services started in chest pain unit-viable option when risk of cardiac etiology is modest. multitudinous patient population brought together for structured survey and care at appropriate level what alters physicians' decisions to admit to the coronary care unit? m. camara , g. silva , s. silva , c. dias , j. nóbrega , e. maul hospital central do funchal, funchal, portugal introduction. procalcitonin (pct) and c reactive protein (crp) are markers of sepsis and the levels correlate with the severity of illness.aims. to evaluate the relationship of procalcitonin (pct) and c-reactive protein (crp) kinetics within the first days of sepsis with the appropriateness of antibiotic therapy and the outcome. a prospective cohort study, over months including patients with documented sepsis in our -bed intensive care unit. crp and pct were simultaneously measured four times (m -m ) during the first days of antimicrobial treatment. the pct and crp time course were analysed according to the appropriateness of the empirical antibiotic therapy as well as according to the patient outcome.results. between january and march of , patients were admitted to the icu. patients presented with sepsis on admission or during their stay. the most common infection site was the lung ( . %) followed by primary bacteraemia ( . %). gram-negative and gram-positive bacteria were isolated in the following proportion: . and . %, respectively. enterobacter, acinetobacter and escherichia were the most frequently isolated ( . % each). gram-positive sepsis was mainly caused by haemophylus influenzae ( . %). sepsis was polimicrobial in . % of cases. . % of the patients were given inappropriate antibiotics. the proportion of gram-negative bacteria isolated was significantly higher in patients who did not receive appropriate antibiotics. the magnitude of the pct and crp elevation was not associated with the appropriateness of antibiotic therapy. logistical regression analysis showed that infection without agent was an independent predictor of inappropriateness of antibiotic therapy.age, saps ii, apache ii and sofa were not associated with an unsuccessful treatment. regarding the absolute value of crp and pct there was no significant difference between successful or unsuccessful. multivariate analysis showed that dpct was not associated with antibiotic appropriateness and mortality.conclusions. although the sample is small, our study suggests that crp and pct kinetics are not associated with the appropriateness of antibiotic therapy and outcome. introduction. patients with hematological malignancy who need advanced life support in the icu because of a life-threatening complication may have a poor prognosis. that's why it is necessary to identify clinical, analytical and biological factors that can help doctors with the decision to admit these patients into the icu.objective. the aim of this study was to assess the utility of procalcitonin serum levels (pct) in predicting the outcome of patients with hematological malignancies admitted to the icu. a total of patients with hematological malignancy were admitted to the icu from january until march . epidemiological data were collected before admission, and patients were followed up clinically and analytically during icu stay. serum samples were collected from icu admission until a maximum period of days. pct values were measured by an immunofluorescent assay based on trace (time-resolved amplified cryptate emission) technology (kryptor pct, brahms ag, hennigsdorf, germany). mean age: (sd ); men/ women. among the patients included, hematological diseases were: non-hodgkin lymphoma ( patients), acute myeloblastic leukemia ( ), acute lymphoblastic leukemia ( ) , multiple myeloma ( ), chronic lymphoproliferative disorder ( ) , others ( ). twenty patients ( %) had previously received hematopoietic stem cell transplantation. thirty patients ( %) presented neutropenia at the moment of icu admission. the main causes for icu admission were respiratory failure in patients ( %) and septic shock in ( %). pct levels were not significantly higher in those patients that required mechanical ventilation. pct levels were significantly higher (p = , ) in those patients admitted because of septic shock. pct levels were lower in days , and in the patients who survived with respect to those who died: day : . ng/ml (sd . ) versus . (sd ); day : . (sd . ) versus . (sd . ) ; day : . (sd . ) versus . (sd . ). the differences were significant in days (p = . ) and (p = , ). there was a trend to have higher pct levels in those patients who had microbiologically documented infection respect to the rest; day : . ng/ml (sd . ) versus . (sd: . ); day : . (sd . ) versus . (sd . ) and day : . (sd . ) versus . (sd . ) .conclusions. serum pct levels are higher in patients with septic shock. serum pct measurement might be useful for predicting mortality in patients with hematological malignancy who require advanced life support. introduction. sepsis is a major cause of mortality in the intensive care unit (icu). efforts have been made to reduce the time needed to diagnose sepsis in order to reduce mortality from sepsis-related multiple organ dysfunction. procalcitonin (pct) has been reported elevated levels at the onset of bacterial infections and seemingly correlated to severity of infection. several clinical trials have detected a high pct level in patients with evidence of systemic bacterial infections, whereas relatively low pct levels occur in patients with only localized bacterial infections.objective. the aim of the present study was to assessed the ability of pct through sensitivity, specificity, positive and negative predictive value (ppv, npv) in patients with suspected sepsis, septic shock, inflammatory systemic response syndrome (sirs) and compared it with variables like crp, mortality, band%, renal failure, active cancer and an isolated bacterial cultures. finally we wanted to evaluate if exists a no infectious correlation in patients who received blood transfusions. we conducted an observational study including all patients admitted to the multidisciplinary icu of the abc medical center (tertiary reference hospital) to whom requested pct at admission in the suspect of sepsis and we followed their outcomes. total populations was patients (p). % were females and % were males. median age was years. of the total of pct sample % were positive and % were negative. the sensitivity and specificity in septic patients were and %. ppv and npv were and %, respectively. we did not found any statistical difference between positive value of pct and sepsis, septic shock, sirs, mortality, crp, band%, acute renal failure, acute lung injury, ards (acute respiratory distress syndrome), blood transfusions and active cancer. the mortality in the populations was %.conclusions. the pct has a wide range of diagnostic in the septic patients. in our study the rate of false positive was % and limited the use for sepsis diagnosis. we suggest that the better utility is for outcome biomarkers more than diagnosis biomarkers of sepsis. y. jin , c. guolong , iit study group of zhejiang province in china zhejiang hospital, hangzhou, china introduction. the use of intensive insulin therapy (iit) in severe sepsis and septic shock has been shown to decrease morbidity and mortality rates significantly when given to high risk surgical patients.objectives. the aim of this study was to assess the efficacy of iit in severe sepsis and septic shock patients in intensive care unit.methods. this is a muticentre, prospective, randomized and controlled study. we randomly assigned patients who admission to icu with severe sepsis or septic shock into three groups: a group (target range for blood glucose is - mg/dl); b group (target range for blood glucose is - mg/dl); c group (target range for blood glucose is - mg/dl as a control). primary end point ( -day mortality for any cause) and secondary end points (icu stay days, mv duration, apacheii scores and mods scores) were obtained serially for days and compared between the three groups. of the enrolled patients, were randomly assigned to group a and to group b and to group c; there were no significant differences between the groups with respect to base-line characteristics. -day mortality was percent in the group a and . percent in the group b assigned to iit, as compared with . percent in the group c assigned to conventional therapy (p = . ).during the interval from first hour to -day stay in icu, the patients assigned to group a and group b had a significantly lower apache ii scores( . ± . and . ± . vs. . ± . , p = . ) and mods scores( . ± . and . ± . vs. . ± . , p = . ) than those assigned to conventional therapy, there were no differences in icu stay days( . ± . , . ± . , . ± . , p = . )and mv duration( . ± . , . ± . , . ± . , p = . ) between the three groups. compared with the conventional therapy group, the group a had a higher rate of severe hypoglycemia [blood glucose level b mg/dl ( . mmol/l); . . vs. . %; p \ . ]. intensive insulin therapy provides significant benefits with respect to outcome and scores in patients with severe sepsis and septic shock in icu, on the other hand, intensive insulin therapy brings a higher rate of severe hypoglycemia. to determine the prognosis factors in elderly patients (c years) with severe sepsis admitted to an intensive care unit (icu).method. an observational, prospective and multicenter study was realized. it includes all the patients of the database edusepsis study (adults with severe sepsis admitted to spanish medical-surgical icus). the clinical and demographic characteristics of all patients including age, sex, origin of the infection, location of the patient at the moment of diagnosis of sepsis, apache ii modified score (apache ii score age excluded), number of organic failures, initial therapeutic strategy (measures of resucitación and measures of treatment), icu length of stay and hospital mortality were registered. the patient were classified in young cohort (\ years) and elderly cohort (c years). elderly cohort patients were also classified in young-old patients ( - years) and very-old patients (c years). descriptive comparative study of both cohorts was realized and multivariate logistic regression for the two subgroups of elderly patients was performed to study the risk factors of hospital mortality. a total of , patients wer enrolled ( . ± . years, apache ii modified score of . ± . , . ± . organic failures, hospital mortality . %). the elderly cohort (n = ; . %) presented a lower apache ii modified score ( . ± . vs. . ± . , p . ), higher abdominal infection as origin of the sepsis ( . vs. . %, p \ . ), higher nosocomial infection ( . vs. . %, p . ) and a lower application of measures at initial treatment ( . vs. . %, p . ) than the young cohort. there were not significant differences in the number of organic failures and days of stay in uci between both cohorts. the apache ii modified score (or . ; % ic . - . ; p \ . ), the nosocomial infection (or . ; % ic . - . ; p \ . ), the thrombocytopenia (or . ; % ic . - . ; p . ) and the acute renal failure (or . ; % ic . - . ; p . ) were associated independently to mortality in the subgroup of young-old patients. in the very-old patients only the apache ii modified score (or . ; % ic . - . ; p \ . ) was independently associated with higher mortality and in this population subgroup the application of measures of initial resuscitation was a protective factor (or . ; % ic . - . ; p . ).conclusions. the elderly patients (c years) admitted in the icu whith severe sepsis have higher mortality, more abdominal infections as origin of the sepsis and fewer application of measures of initial treatment than the young patients (\ years). nevertheless, in the subgroup of very-old patients (c years) the aggressive initial treatment decreases the mortality. objectives. the aims of this study were to determine the crude and related to bacteremia mortality rates in icu patients with bacteremia who receive appropriate empirical antibiotic therapy and to describe the factors associated to mortality in this appropriated treated patients material and methods. during a twelve years and a half period, from to , icu-patients with clinically significant bacteremia were prospectively evaluated. for purposes of this investigation, appropriate empirical antimicrobial treatment of a bloodstream infection (aeat) was defined as the microbiological documentation of infection that was effectively treated based on its antibiotic susceptibility at the time the causative microorganism were suspected. clinical and microbiological variables were recorded. logistic regression analysis was performed to determine the risk factors associated to global and associated to infection mortality. results. among icu-bacteremic patients, aeat was applied in patients ( . %). apache ii and sofa score were . ± . and . ± . , respectively and the incidence of septic shock was . % in this aeat patients. global and associated to infection mortality rates were . and . %, respectively in aeat patients. logistic regression analysis confirmed copd (or . ; % ci: . - . ) and age (or . ; % ci: . - ) as factors independently associated to global mortality and diabetes mellitus (or . ; % ci: . - . ) presentation as septic shock (or . ; % ci: . - . ) and serum levels of albumin (or . ; % ci: . - . ) as a protective factors for global mortality whereas factors as nosocomial origin (or . ; % ci: . - . ) and again serum levels of albumin (or . ; % ci: . - . ) were considered protective for related mortality to bacteremia conclusions. mortality rates remains excessively high in aeat bacteremic-icu patients. different factors were identified as predictive factors for global and associated to mortality in aeat patients. only serum levels of albumin seems to be an independent protective factor for both global and associated to infection mortalities. introduction. severe sepsis is hallmarked by organ hypoperfusion or dysfunction. the transition from severe sepsis to septic shock carries with it an increase not only in morbidity but also in mortality [ , ] . objectives. the aim of the study was to demonstrate the effect of shock at admission in sepsis comparing severe sepsis and septic shock admission diagnoses.methods. single center retrospective study in a bed mixed icu of a tertiary university hospital. during a -years period of study patients were unplanned admitted in the unit: the median was age of ( - ), the males were . % and the mean of sapsii was ± . we randomly select two groups: severe sepsis ( patients) or septic shock ( patients) at admission. statistical analysis of variables: v , mann-whitney test, unpaired t student test, cox regression. no statistical significant differences were found about age and sex between groups. about the origin of infection no statistical significant differences were found between groups, meanwhile the diagnosis respiratory infection appears to be more frequent in the severe sepsis group ( . vs. . %, p . ). the proportion of post-operative admissions (in surgical related conditions) was not different between groups. the sapss ii and sofa at h were higher in the septic shock group [ ( - ) vs. ( - ) , p \ . ]; ( - ) vs. ( ) ( ) ( ) ( ) ( ) , p \ , , respectively]. sofa at discharge appears to be higher in the shock septic group (excluding deaths) [ ( - ) vs. ( - ) (p . )]. the mortality and length of stay (excluding deaths) was higher in the shock septic [ . vs. . % (p \ . ); ( - ) vs. ( - ) (. ), respectively]. the ventilator associated pneumonia was not significantly different between groups. the probability of discharge, across an initial period of days, was lower in the septic shock group [hazard ratio . ( % ci: . - . )], mainly between the th and th days, as shown in the kaplan-meier plot (see graph ) .admission diagnosis: probability of discharge conclusions. septic shock at admission patients had a poorer outcome. the difference in the probability of discharge between groups was higher when mechanical ventilation related events are likely to occur [ , ] . we emphasize the importance of the institution of early goal-directed therapy in the wards and emergency departments prior to admission in an intensive care unit [ , ] .introduction. it is not clear whether patients with community acquired severe sepsis (cass) or hospital acquired severe sepsis (hass) have a same presentation. objectives. to evaluate the characteristics of a severe sepsis (ss) population admitted through the er (cass) and those coming from the ward (hass). all patients were treated by the same team of intensivists and er doctors in a shock room, so we could minimise the differences due to management. methods. all adult patients admitted to the medical icu were eligible if they met the criteria for ss. we collected demographic characteristics, apache ii and sofa score, comorbidities and immuno-compromised conditions. scvo or svo (if possible), lactate concentrations. the milestones of the surviving sepsis campaign (ssc) were measured regularly during the first h of treatment. the data collection went on in the icu stay too. treatment for septic shock was conformed to the recommendations of ssc. results. we enrolled pts with ss, including with cass and with hass. there was no difference in demographic features and comorbidities, including immuno-compromised conditions, haematological malignancy and chronic respiratory diseases .there were no significant differences in hemodynamic variables or indices of tissue perfusion like scvo (or svo ) and blood lactate levels, or in amounts of fluids infused or needs of vasopressor agents. the need for mechanical ventilation (mv) after the first has greater for hass than for cass patients, but during the icu stay the need for mv was the same for both groups; similarly, during the icu stay there was no difference in the need for extracorporeal renal support or need for adrenergic agents. at the beginning the scvo was around % for the entire population. after the first h both groups reached the target of %. at the admission % of patients had a scvo less than % ( . % for hass patients and . % for cass, without any difference between groups) and % of patients had a scvo higher than %. the mean svo for both groups was higher than % already at the beginning of the observational period. conclusion. only a half of pts with ss or sho had fever. the presence of fever is often associated with a positive microbiological diagnosis, but better prognosis. while hypothermia was often viewed in severe ill pts and was associated with a worse prognosis. to investigate the possible differences in characteristics and outcome between early and late-onset severe sepsis in surgical intensive care unit (icu) patients. we conducted a retrospective analysis of prospectively collected data from all adult patients ([ years) admitted to our -bed surgical icu between st march and th july .results. of , patients admitted to our icu during the study period, patients ( . %) had severe sepsis; ( . %) had early-onset and ( . %) late-onset severe sepsis. respiratory infections ( . vs. . %, p = . ) and infections of unknown origin ( . vs. . %, p = . ) were more frequently recorded in patients with late-onset than those with early-onset severe sepsis, whereas abdominal infections were more frequent in early-onset than in late-onset severe sepsis ( . vs. . %, p = . ). gram-positive infections were more frequent in late-onset than in early-onset severe sepsis ( . vs. . %, p = . ). the time of onset of severe sepsis was not independently associated with an increased risk of in-hospital death (early vs. late: or . % ci . - . , p = . ).conclusions. respiratory infections and infections of unknown origin were more frequently recorded in patients with late-onset than in those with early-onset severe sepsis, whereas abdominal infections were more frequent in early-onset than in late-onset severe sepsis. the time of onset of severe sepsis has no impact on mortality. objectives. to describe the causes, microbia spectrum, and prognosis of pregnancyassociated sepsis treated in icu in france along the last years. we conducted a retrospective study in a medico-surgical icu of beds in a non-teaching hospital in france where a high risk maternity unit was opened in . patients admitted between and for sepsis occurring during pregnancy or the post-partum period were included. the patients were excluded if the sepsis was due to a nosocomial icuacquired infection. charts were reviewed to collect data on sources of infection, microbia, maternal and fetal prognosis. data are shown as median (extremes) or percentage. data before and after were compared using non parametric tests.results. patients were admitted for pregnancy-associated sepsis ( % of total pregnancy-related icu admissions). included patients had the following characteristics on admission: age: ( - ) years, gravidity: ( - ) pregnancies, parity: ( - ) children, , . vasopressors, mechanical ventilation, and hemodialysis were required in respectively , , and % of cases.characteristics of infections are shown in table . microbiological data about bacterial infections, and specially infections of pelvic origin (chorioamniotitis, endometritis, septic thrombophlebitis), are shown in table .all urinary infections were due to e. coli. lung infections were most often documented clinically but not microbiologically.maternal mortality rate was % ( deaths before and deaths after ). for those infections that occurred in the pre-partum period, fetal mortality was %. after exclusion of fetal deaths that had occurred before icu admission, pregnancy was interrupted during icu stay in % of cases, resulting in fetal mortality of %.conclusions. despite of disappearance of post-abortum sepsis in france, sepsis remains a significant cause of icu admission during or after pregnancy, and a significant cause of maternal and fetal mortality.grant acknowledgement. none. introduction. the glasgow coma scale (gcs), universally used for assessing comatose states, has the advantage of ease of use making it accessible to all levels of clinical competence. there are, however, significant drawbacks. its relative subjectivity in the interpretation of verbal and eye responses and its mesencephalic limit in the rostro-caudal assessment of brain vitality. these two drawbacks limit its use particularly in icu intubated patients. we propose a new score, the sousse coma score (scs) that overcome the eye and verbal responses and explore the brain vitality up to brain death. the score ranges from (normal consciousness) to (brain death). the performance of this score was compared to a modified gcs (gcsm; gcs reduced to its only eye and motor components) and four score. our study interested prospective and consecutive comatose patients who were admitted to a medical icu, intubated and under ventilatory support. the level of consciousness was assessed at admission by physicians of different levels of competence. the inter-observer reliability was assessed by measuring the spearman correlation between the responses of different observers to the scs, gcsm, four score and their respective components. the prognostic predictive value of the three studied scores was assessed by the analysis of possible correlation with mortality and the roc curves. inter-observer reliability was excellent (spearman rho [ . ) for the three studied scores, but with better performance for the scs ( . , p \ . ) compared to the gcs ( . , p \ . ) and four ( . , p \ . ). the level of overall inter-observer reliability for gcs and four was paradoxically higher than that of their respective motor components. this is probably the result of a summation effect of their respective components.regarding the relationship between mortality and the studied coma scores, there was for all three scores a threshold below which mortality was %; / for scs, / for the gcs and / for the four. beyond this threshold, only the scs provides a highly significant correlation with the risk of death (spearman = - . , p = . ). a similar correlation was observed with the motor components of the gcs and four. a better correlation was found between mortality and the scs. the area under the roc curve, however, was poor for all three scores. in evaluating the minimally consciousness states and from eight value of scs, the gcs and four scores provided a wider and more subtle level of consciousness assessment. the scs provides a better inter-observer reliability and a better prediction of death while being easier to achieve. the apparently good inter-observer reliability of gcsm and four was simply the result of summation effect. however, scs was not very sensitive in detecting variations of the minimal consciousness states. the results of our study should be confirmed in larger multicenter studies for the external validation. introduction. the use of a sedation assessment scale and a sedation goal is recommended in critically ill adults [ ] . several studies have found a reduction of icu length of stay (los), of mechanical ventilation (mv) duration, and of cost [ , ] . but, durability and efficiency of such procedures over time have not been evaluated. a -bed medical icu in a university hospital. a sedation and analgesia protocol has been implemented since - . the sedation goal is prescribed each day by the intensivist; the ramsay sedation score is evaluated by the nurses every h and doses of drugs are adapted accordingly. we conducted an annual survey from to to evaluate the quantity of sedative drugs utilized, the impact on icu los and on mv duration, and cost of sedation; both the medical and nurse staff were regularly informed and the protocol was modified if necessary. u. guenther , j. weykam , u. andorfer , t. muders , h. wrigge , c. putensen university of bonn, anaesthesiology and intensive care, bonn, germany background. acute brain dysfunction (delirium and coma) is reported to occur in up to % [ ] , and to be associated with longer mechanical ventilation and stay in the icu, and increased -months mortality rates up to % [ ] . such outcome data, to the best of our knowledge, are predominantly given on medical patients with delirium incidences and mortalities much higher than we expected in surgical patients. this study assessed incidence and impact of acute brain dysfunction on length of stay on the ventilator and in the icu, and mortality in cardiac surgery patients. after approval from our local ethics committee, every patient admitted to our cardiac surgery -beds icu from october through november was daily monitored for delirium with the ''confusion assessment method for the intensive care unit (cam-icu)'' [ ] , level of consciousness was assessed with the richmond-agitation-sedation scale (rass) [ ] . acute brain dysfunction was diagnosed if patients were comatose without sedative medication or delirious. patients were contacted months later to obtain information about their further clinical course.results. patients were eligible for analysis [male , female , age, mean (iqr), ( - ) years]. % had acute brain dysfunction while in icu, these had significantly higher apache-scores on admission, higher tiss-and saps-scores, were longer mechanically ventilated [ ( - ) vs. ( - ) days, p \ . , mann-whitney test) and had longer stay in icu [ ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) vs. ( - ) days, p = . , mann-whitney test). patients were lost to follow-up; -months mortality in patients with acute brain dysfunction in icu was vs. % (p = . , log-rank test).discussion. incidence of acute brain dysfunction and mortality found here in cardiac surgery patients are lower compared to reports on medical patients. even though, duration of mechanical ventilation, length of stay in icu, and -months mortality were increased in patients with acute brain dysfunction in our icu.conclusion. these data emphasize the need for routinely monitoring of consciousness and delirium and to develop strategies to reduce incidence of acute brain dysfunction. introduction. the incidence of obesity is increasing globally, with billion overweight people (body mass index (bmi) [ kg/m ), and million of them obese [ ] (bmi [ kg/m ). the number of obese individuals presenting to critical care is likely to increase, but data on effect of obesity on outcome is conflicting [ ] . there is a general perception that obese patients are likely to have a higher incidence of adverse outcome in critical care. to investigate the effect of bmi on length of stay and mortality in patients admitted to critical care in city hospital, birmingham, uk.methods. an observational study was performed over a month period from february-april . pre-morbid data on bmi was collected from medical records and direct questioning of patients. apache ii score at h, critical care length of stay (los) and survival data to hospital discharge were collected. the figures were compared against their predicted mortality. readmissions, patients with a los \ h, patients \ years old and those without complete apache ii data were excluded. a total of patients were admitted. met the exclusion criteria, bmi data was unavailable for patients and apache data was unavailable for patients. patients were included in the final analysis. . % were female and . % were male. % of patients were above their ideal body weight, and % were obese. the obese cohort had a mean apache ii score of . with a mean los of . days and a mean hospital mortality rate of . %. the corresponding figures for the non-obese group (bmi \ ) was . , . days and . % (table ) . obese patients had reduced hospital mortality in comparison to predicted rates from apache ii scores. statistically, there was no increase in mortality of obese patients. the los and ventilated days were also comparable to the nonobese patients. introduction. managing glucose levels in critically ill hospitalised patients has been shown to play a role in improving clinical outcomes. as a result glycaemic control protocols are widely used in critical care settings and require rapid and frequent testing of patient glucose levels. poc glucose meters have migrated from ambulatory testing into hospital.there is increasing recognition that the clinical accuracy of nearly all commonly used glucose meters are affected by components or substances often present in the blood matrix of critical care patients giving rise to an increase risk of adverse incident. the aim of this study was to challenge the accuracy of a glucose meter designed to correct for these interferences.methods. paired random arterial whole blood samples were collected from icu patients admitted for [ h, samples were tested for glucose using stat strip glucose (nova biomedical) and the omni b bga (roche) routinely used for blood gas analysis.statistical methods: spearman rank correlation/regression, bland-altman analysis. results were compared to iso standard for glucose measurements. omni bga: correlation coefficient r = . , slope = . with intercept - . .bland altman plot for absolute glucose concentration showed that mean bias compared to reference was - . ± . mmol/l with limits of agreement - . - . mmol/l. study aim. to assess predictors of t and its impact on icu-, hospital-length of stay and costs in a cardiac surgical patient cohort admitted to our eight bedded icu, since through june .methods. all the pre-, intra-and post-operative variables were prospectively put into an electronic database. patients were divided into: ( ) ntg group, not needing a tracheostomy;( ) tg group, undergoing a tracheostomy. p values \ . were considered significant. out of a total of , patients with a median (iqr) age of years ( - ) ( ) from post-operative icu to the cardiac surgical ward and ( ) from the cardiac surgical ward to the rehabilitative one, increased significantly higher in the ntg group than in tg group (respectively: log-rank = . , p = . and log-rank = . , p = . ,). tg group showed a lower mortality ( . vs. . %, p = . ) than ntg one.conclusion. this study allowed us ( ) to define a predictive model for identifying patients that are likely to undergo a tracheostomy ( ) introduction. patients admitted to itu increasingly have significant medical comorbidities that require chronic therapy for adequate control . on admission to itu, acute medical problems take precedence and many long term medications, such as thyroxine, may be withheld or ceased. in chronic hypothroidism the patient is physiologically dependent upon ongoing administration of thyroxine. the optimal management of chronic medical conditions such as hypothyroidism within the itu may be essential to patient recovery and should be a quality assurance issue. to assess the prescription of thyroxine and the thyroid function in patients admitted to itu with previously diagnosed chronic hypothyroidism. a six year retrospective review of the electronic records of patients with hypothyroidism who were admitted to a bed tertiary referral hospital itu from to was performed. patients were included if they were admitted to the itu for a period of more than days and were on thyroid replacement therapy prior to itu admission. patient demographics, daily thyroid replacement dose/route, thyroid function tests (tsh and free t ) and rate and type of nutrition were obtained. patients were grouped by their worst recorded tsh according to predefined ranges . conclusions. patients did not receive their thyroid replacement for a significant proportion of their admission. this was predominantly due to either lack of prescription or lack of tolerance of enteral feed. the tsh was appropriate for the free t level. a significant proportion of patients ( %) did not have their tsh measured at all. of those that did, abnormal tests were inconsistently repeated or acted upon. having processes in place to ensure the appropriate prescription and adjustment of relevant chronic medications is essential in the provision of high quality care in itu.background. cell-free dna has been investigated as a diagnostic marker in many diseases, including acute conditions such as stroke, myocardial infarction, burns, sepsis etc. its serum and plasma levels have been shown to correlate with disease severity in all those. free circulating dna is released from dead cells (necrotic or apoptotic) and activated inflammatory cells. our hypothesis was that in acute pancreatitis free serum dna correlates with the extent of pancreatic necrosis and that it may be an early marker of severity. free dna was measured in sera from patients with acute pancreatitis at admission, on the first, fourth and seventh day following admission. severetiy of illness was assessed with atlanta criteria. on the first day following admission patients who would develop severe pancreatitis had significantly higher serum dna levels than those with mild disease (median . vs. . ng/ml respectively; p \ . ). this parameter showed very good characteristics as a potential predictor (area under roc curve . ). free serum dna was in correlation with the extent of pancreatic necrosis.conclusions. free serum dna correlates with the extent of pancreatic necrosis and is a potential early marker of severe acute pancreatitis.keywords. acute pancreatitis, cell-free dna, prognostic marker, pancreatic necrosis. introduction. the performance of general prognostic models in patients with transplantation in need for intensive care unit (icu) admission is poor, showing a tendency towards significant underestimation of the risk of dying. the objective of our study is to evaluate the acute physiology and chronic health score ii (apache ii) and simplified acute physiology score (saps ) and their days mortality prediction after liver, renal and pulmonary transplantation [ ] [ ] [ ] .methods. this is a prospective cohort study in a transplantation icu in porto alegre, brazil, during the period of may -december . clinical data of pos transplantation patients admitted at icu were collected at admission and saps and apache ii calculated with respective estimated mortality rates. the area under receiver operating characteristic curve (auroc) was obtained for both scores. objectives. to validate the saps model, over a period of one year, in a general icu. material and methods. we analysed data prospectively registered in an informatic data base (icdoc), which contain information referring to all patients admitted in this unit.we studied all the patients admitted in the year ( patients). excluded from the analysis were readmissions and one patient still in the hospital. analysed patients.results. discrimination was accessed by the area under the roc curve (aroc) and calibration by the hosmer-lemeshow ĉ test for the general equation and for regional equations (southern europe and mediterranean countries).the mean age of the patients was . ± . years. from the total of the patients, were medical ( . %), were scheduled surgical ( . %) and were emergency surgical ( . %). the mean icu and hospital mortality was . and . %. the mean saps score was . points ( - ). discrimination was good with an aroc of . ( . - . ).there was a statistical significant difference between the mortality predicted by the general equation and the observed mortality (ĉ = . ; p = . ); this discrepancy was not significant by using the regional equation (ĉ = . and p = . ). the saps overestimated hospital mortality with the predicted mortality by the regional equation getting closer to the observed mortality [standardized mortality ratio (smr) = . ] than the predicted by the general equation (smr = . ).conclusion. the saps model, particularly using the regional equation introduction. saps has been previously validated in our icu and it has been routinely used in hospital mortality prediction. as we have shown before, saps had a good accuracy regarding discrimination and calibration, with better predictions done by north american and western europe customized equations than the south american one [ ] . in a larger sample we have been observed deterioration in calibration model, especially among groups of lower probability of death, regardless of the equation in use. therefore we tested saps accuracy considering days mortality in comparison to hospital mortality. we considered consecutive admissions in a medical-surgical icu in a private tertiary hospital in sao paulo -brazil, in the period from january to november of . probability of death was derived from given equations of the original study [ ] . hospital and days mortality were considered as end point. discrimination was performed by the area under the roc curve (auroc) and calibration by the hosmer-lemeshow (hl) statistic. observed to expected (o/e) mortality ratio was also calculated. to assess factors concerning prognosis of patients older than years admitted to the icu: group a, to years old and group b, older than years. both groups were compared for the apache ii, admission group, lenght of stay, mortality and usual intensive care procedures (arterial and venous catheters, mechanical ventilation). statistical anlysis: quantitaive variables were expressed as mean and standard deviation (sd). student t test was employed for these variables. categorical variables were compared by the chi-square. p \ . was considered statistically significant. a total of patients were included in group a (mean age . , sd . ) and in group b (mean age . , sd . ). apache ii score was . for group a and . for group b (p = , ); predicted mortality was . and . % respectively (p = . ). ther were no differences for admission group or procedures among groups. mortality was significantly higher in group b ( . vs. . %, p = . ). when mortality was analyzed for admission groups, it was higher just in cardiological group, wich included ischemic cardiopathy, cardiac failure and arrhythmia ( . vs. . %, p \ . ). the investigation of the association between a differential access to intensive care services and patient or hospital outcomes is increasing markedly [ ] [ ] [ ] [ ] . objectives. the aim of this study was to compare demographic, clinical characteristics, and outcomes of patients admitted to tertiary-level intensive care units from a tertiary hospital ward (intrahospital transfer) to patients transferred from a secondary hospital ward (interhospital transfer). single centre retrospective study in a bed mixed icu of a tertiary university hospital. during the study period ( ) ( ) conclusions. the interhospital transferred patients are younger, but at admission severity of the disease is comparable.these findings, within this case mix of patients, suggest there are not significant differences in mortality, length of stay, icu-nosocomial respiratory infection or physiological disability at discharge between intrahospital and interhospital transferred patients to our unit. in this study we did not find a different impact in outcome considering these differential sources of admission. we prospectively analysed data of all patients (pts) undergoing cardiac surgery between january and june , and discharged from our icu by h from surgery. on all patients the following was collected:(i) demographics, risk factors and gravity scores anamnestic illnesses (ii) intra-operative variables [i.e. type of operation, cardiopulmonary by-pass (cpb) and aortic cross clamp (acc) times] (iii) icu-related variables. one-way anova test was used for continuous variables whereas, differences in proportions were compared using chi-squared test.a binary logistic regression model was used to estimate the effect of each considered risk factor on discharging from cardiac surgical to rehabilitative ward, considered as a dycotomous outcome (yes = early b days/no = late [ days). statistic analyses were performed using spss software. p values less than . were considered significant. on all the patients, aged c years, admitted to our post-operative icu since january through december , we collected demographic profiles, operative data and outcomes. a logistic regression model was set up to assess predictors of hospital outcome. a total of patients ( . %), . % males and with a median (iqr) age of ( - ) were admitted. the below table shows the outcome predictors (see table ). objectives. the purpose of this study was to evaluate prospectively in our medium the capacity of apache iii score to stratify prognostically critically-ill-patients upon their admission to the icu, not only with regard to hospital mortality, but also to hospital length of stay. study aim. to assess if cardiopulmonary by-pass (cpb), aortic cross clamp (acc) time and duration of mechanical ventilation (mv) may impact on icu and hospital length of stay in a cardiac surgical patient cohort admitted to our bedded icu, since through june . all the patient pre-, intra-and post-operative variable were prospectively put into an electronic database. on all patients the following was collected:(i) demographics, risk factors and gravity scores anamnestic illnesses (ii) intra-operative variables [i.e. type of operation, (cpb) and (acc) times] (iii) icu-related variables (i.e. duration of mechanical ventilation, use and type of inotropes. statistic analyses were performed using spss software. p values \ . were considered statistically significant. a total of , patients with a median (iqr) age of years ( - ) were admitted through the study period. . % underwent a cabg operation, whereas . % valve surgery and . % aortic and lung surgery. a bivariate analysis was performed considering as independents variables respectively the natural logarytm (nl) of ( ) cpb time, ( ) acc time, ( ) mv duration, whereas dependent variable was considered the nl of the total hospital stay. we showed that a linear correlation exists between total hospital stay (ln) and ( ) conclusion. this audit allowed us to assess that the longer is the cpb and acc time and mv duration the longer is likely to be the total hospital length of stay of the patients undergoing heart surgery. introduction. high-dependency units (hdu) were designed as a bridge between the operating theatre and the surgical ward for postoperative patients demanding a higher than standard level of care. the aim of our study was to determine the risk factors as well as the predictive value of four severity scores for a prolonged hdu length of stay (los). three hundred fifty-eight consecutive adult patients were included in the study for a period of months. asa, saps ii, possum and sofa scores were calculated for the first h following admission. the demographic and the scores variables were subjected to a univariate and, consecutively, a multivariate logistic regression analysis. a receiver operating curve (roc) model was used to determine the predictive value of the scores for a prolonged los. the presence of a patient for three or more days in the hdu was defined as prolonged stay.results. the median los was ( - ) days, patients were transferred to the intensive care unit and the in-hospital mortality was . % ( patients). the univariate logistic regression revealed the following variables as significant for a prolonged los (p \ . ): asa, possum preoperative, possum postoperative, possum total, possum cardiac, possum ecg, possum type of surgery, possum blood loss, sofa, sofa respiratory, sofa cardiovascular, sofa liver, sofa coagulation, igs ii, igs respiratory, igs urinary output, igs urea, igs potassium, igs bicarbonate, and bmi. seven variables were identified as having a statistically significant association with the los (table ) . according to the roc model, sofa score was the best predictor for a prolonged los, with an area under the roc (auroc) of . .warning systems and rapid response team: - s. saxena , s. jafrey , j. zwaal kingston hospital, anaesthetics, kingston, uk, kingston hospital, kingston, uk background. published data suggests that the patient group with the highest mortality in icus comprises those patients admitted from the hospital wards [ ] . studies have shown that in-hospital cardiac arrests are commonly preceded by physiological abnormalities [ ] . if admission to icu, is preceded by specific physiological derangement, then early identification of these high risk hospital in-patients may be possible. this may improve survival of patients. objectives. to determine . the effectiveness of new track and trigger pathway in identifying patients requiring icu admissions. . the impact of new system on outcome of icu admissions method. . retrospective case notes survey of all icu admissions from the ward over a month period. . the pathway is triggered when abnormalities are present in two or more of the following parameters: response to painful stimuli, respiratory rate, oxygen saturation, systolic blood pressure, and heart rate. . .triggering steps progress through involvement of junior medical staff and outreach teams at step , to more senior staff at step , to consultant involvement at step , depending on the level of deterioration of the patient. . forms were collected over a period of months. icu mortality: patients with abnormality at any time prior to icu admission: / ( %) icu mortality: patients with c abnormalities any time prior to icu admission: / ( . %) mortality of patients who were pathway followers: / ( %) mortality of patients who were pathway non-followers: / ( . %) average length of stay in icu who were survivors from pathway followers: days average length of stay in icu who were survivors from pathway non-followers: . days discussion. . there was low sensitivity of pathway for identifying icu admissions. . poor documentation of triggering events . pathway followed inadequately in majority of patients due to combinations of delay in, or absence, of triggering when indicated . lack of consultant involvement at step . no patients with chronic kidney disease admitted to intensive care have poor outcomes [ , ] . in % of cardiac arrest calls in our hospital were from the renal unit (personal communication.) at this time critical care outreach teams were recommended as means of improving intensive care outcomes through earlier ward assessment of critically ill patients [ ] [ ] [ ] . in modified early warning system (mews) charts to wards and a dedicated seven-day ward-based consultant led service ( - ) were introduced on our renal unit [ , ] . aims and methods. the impact of these change interventions was analysed. primary outcomes were the incidence of cardiac arrests calls to the renal unit, admission apache ii scores and icu mortality. secondary outcomes were age, sex, intensive care and hospital length of stay, in-hospital mortality, cpr prior to icu admission and emergency admissions to the renal unit. cardiac arrests, mortality rates and emergency admissions were compared with the v test; other outcomes via mann-whitney u test. a p value \ . was regarded as significant.results. the results are outlined in the table [ ] ; this group has a high mortality [ ] . deterioration in vital signs often precedes referral to critical care and this is evidenced by a rise in the patient at risk score (pars). higher pars may be associated with worse patient outcomes [ ] . most pars systems have a trigger value at which critical care input should be sought. we hypothesised that the duration of physiological deterioration prior to critical care admission would be associated with mortality and used the delay between pars trigger and admission as an estimate of this.methods. we collected data on over consecutive patients that had deteriorated on the ward and required admission to general critical care (hdu and icu) at both acute hospitals in sheffield. patients admitted to specialist facilities such as cardiac and neurosurgical units were excluded. those already triggering at time of hospital admission were also excluded. to assess if any of the ccrt activation criteria was associated with higher incidence of icu or hospital mortality. our hospital is bed tertiary care center. cohort analysis of prospectively collected data of each ccrt activation including demographic data of the patients and their outcome in terms of icu and hospital mortality and ccrt activation criteria. ccrt activation from st january to th september .the activation criteria for ccrt includes: threatened airway,tachypnea defined as respiratory rate more than or less than breath/min, hypoxemia defined as oxygen saturation less than % on oxygen flow l/min, arrhythmias defined as heart rate less than or more than beat per minute, hemodynamic instability if systolic blood pressure less than mmhg or more than mmhg, decrease level of consciousness defined as drop of gcs = or more points from baseline, seizure and serious concern about the patient.we analyzed each factor separately as independent predictor of icu and hospital mortality. [ ] . with this in mind efforts have been made to develop physiological early warning scoring systems which have been shown to predict subsequent outcome [ ] . we have recently introduced an early warning system (ews) chart for all patients in our hospital and we wanted to assess its impact on our icu admissions. to assess the calculation of the ews, the scores of patients admitted to icu and the compliance with guidelines regarding further intervention for patients who were ultimately admitted to icu.methods. chart review of twenty five consecutive emergency icu admissions, examining the ews in the h prior to admsission.results. ews charts were completed for % of emergency icu admissions; of these % of scores were calculated correctly. only % of ews had all parameters completed for all set of observations. the mean peak ews prior to icu admission was . with a range from to . higher peak ews was strongly associated with increased icu mortality: a ews of - was associated with mortality of . %, whereas a ews of - was associated with a mortality of % (see below). for each ews recorded specific action was required to be triggered according to the protocol. in % of cases appropriate action was taken, however, in % the required action was not taken and a number of patients were thought to have delayed referral to critical care as a result of this.conclusions. following this audit we have introduced a critical care outreach team and have embarked on an educational programme for staff with emphasis both on the complete and accurate recording of early warning scores and the necessity for appropriate action to be taken on the basis of these scores. aim. the quality of care prior to icu admission has been a focus of attention [ ] . mews had been chosen by the trust as a trigger device to identify deteriorating (sick) patients in the general wards. this retrospective study looked at the clinical characteristics of unplanned admissions to our icu and assessed the mews as a predictive tool to trigger early intervention in such cases.methodology. all patients who were non-electively admitted to our icu from the medical wards were included in the study (january-march [ ] score and standardised mortality ratio(smr) had occurred since the introduction of our nurse lead outreach serrvice and high dependency unit. this seemed counterintuitive so we decided to look at in futher detail and whether the phenomena of lead time bias occurred.objectives. primary end point was to assess if the apache ii scores and smr were different if assessed from the point of contact with outreach or hdu for patients admiitted to general intensive care. secondary endpoints looked at which physiological scores were most altered by these systems. a cohort prospective study was setup with ethics committee approval. all patients seen by outreach (group ) or on hdu (group ) prior to admission to general icu were included over a six month period. two sets of apache ii scores and mortality prediction were generated for each group, a 'pre' and 'post' score. the pre score was a h scoring period started from up to h prior to admission to icu on point of contact on hdu or by outreach. the post score was a period for scoring taken h from the point of admission to icu, ie the conventional apache ii score .therefore each patient had two sets of scores for apache ii and predicted mortality. the apache ii and predicted mortality scores were then compared using a two tail paired t test, the individual physiology scores were compared via a wilcoxon rank sum score. in total patients from hdu were included and patients from outreach were included.the primary question was answered as a significant difference in apache ii and smr was found in both groups. introduction. unplanned admissions to intensive care units (icu) are associated with an increased mortality. in order to identify in-hospital patients at risk of deterioration, several scores based on physiological parameters have been published. however, routine application of these parameters is not common in all european hospitals yet. the goal of this prospective study was to evaluate the efficiency of the current practice of handing over ward patients at risk for decompensation by physicians and nurses. furthermore, factors associated with admission to the icu or alarming of the physician on duty should be identified. the study was conducted at the university hospital of regensburg, germany on wards with predominantly gastroenterological and general medical patients ( beds). over a time period of months, the daily routine report of patients at risk to the physician on call after hours was recorded. in addition, the nurse assessment of patients at risk and the documentation of the decompensation defined by calling the physician on duty during the night were registered.results. patients were treated during the surveillance period. in total, patients ( women, men) with a mean age of ± years were either judged by the attending physicians or the nurses at risk for deterioration. patients suffered from decompensation during the night shift. of those, patients were correctly identified by physicians and patients by nurses, respectively. in patients ( %), an icu admission was necessary.discussion. only a small portion of patients reported at risk experienced a severe decompensation at night, defined as icu admission. interestingly, those were only in part correctly identified by the physician and nurse reports. a further evaluation of the correlation of those reports with the previously published ''early warning score'', and physiological parameters associated with decompensation are currently being performed in order to estimate the value of standardized patient assessment, and will be presented at the meeting. introduction. the need to implement a patient follow-up program after icu discharge arises from several facts: ( ) at icu discharge patients are now more fragile (aged, chronic comorbidities, complex). ( ) the demand for intensive care exceeds its availability. as much as % of patients die after discharge from the icu, many of them in spite of a low predicted mortality, perhaps due to premature icu discharge. ( ) compared to nursing care in the icu, the level of that received upon transfer to the floor, as measured by tiss- , may be reduced up to more than %. we believe that, in order to change icu behavior towards focus on long term outcomes, we need to increase global awareness of disability post-icu discharges, and expand the involvement of the icu team in key decision management outside the icu. we propose an alternative model of care for the critically ill patient. this involves an expanded role for clinicians with expertise in critical illness at several points along the continuum of care.objectives. due to lack of adequate clinical resources to care for some recoverable patients when are discharged to hospital wards after a long time in icu, we have planned a follow-up program focused in detecting risk factors associated to bad prognosis and, decreasing adverse events in general hospital wards. qualitative, prospective and interventional study realised during seven months (from march to september ), in the medical uci of a teaching hospital in malaga. we determined demographic data, icu admission reason, comorbidity index (charlson scale), follow-up reason (polineuropathy, tracheostomy, analgesia), family support in ward, difference in nursing activities score between icu and ward (tiss- ), intervention done out of icu with patient; satisfaction of patient, icu readmissions, reason to end follow-up and mortality at day after icu discharge. we enrolled patients in this analysis. comorbidity was charlson scale (very high) in . % of patients, apache-ii mean score points and mean expected mortality rate %. more than % of patients had five or more risk factors (age [ years, icu stay [ days, transfusions, inotropic drugs, mechanical ventilation, tracheostomy, kidney failure, parenteral nutrition, polineuropathy). nursing activities score in icu was . before discharge versus . in ward ( . % decreasement). mean follow-up were . (range - ).in hospital mortality rate was . %, rest of the patients were discharged at home. our study found the implementation of continue follow-up program from icu staff is associated with an important decreased of the mortality. encouraging clinical results and a non excesive workload for icu staff justify to continue this follow-up program in cases in which is going to be an important decrease in nursing care after icu discharge, and have bad prognosis risk factors. objectives. we examined the prevalence of adverse events (ae), suboptimal assessments of vital signs and whether there were advance directives prior to icu admission from the general wards among patients who died within days of icu admission. the patients were those admitted to the general icu from the general wards at the university hospital, lund in and who died within days after icu admission. there were patients with a mean age of years and a mean apache ii score of . we used the global trigger tool model for measuring ae (http://www.ihi.org). the frequency of vital functions assessments, and which parameters were controlled were studied in relation to patient status and the local routine for frequency of modified early warning scoring (mews).the patient records were also controlled for descisions to forgo treatment before admission to the icu. . patients ( %) suffered from at least one ae prior to icu admission. patients had an ae contributing to death, among those patients suffered from an ae that with a probability greater than % was deemed avoidable. seven of those patients suffered from a most likely avoidable ae contributing to death.vital signs were recorded inadequately in % of the patients in the h before admission to the icu. the vital signs most often recorded were blood pressure, heart rate and oxygen saturation, whereas consciousness and breathing frequency were the least recorded parameters.descisions to forgo resuscitation, or some other limitations due to ethical considerations were found only in % of the patients before admission to the icu.conclusions. patients admitted to the icu who died within days suffer from a considerable proportion of avoidable ae contributing to death. vital signs are not recorded in a satisfactory way during the h before admission to the icu in this most severely ill population. there are very rarely documented descisions to forgo treatment in this group of patients before icu admission. thus, poor control of vital signs in the general wards leads to severe and avoidable ae contributing to death. the lack of descisions to forgo treatment before icu admission in this group of patients most probably contributes to prolonged dying and suffering, and unnecessary intensive care. results. a significant correlation (p \ . ) was detected between the type of prehospital care and the early outcome among the patients. the majority of the patients was transported by ambulance services ( . %) from which half of the patients ( . % of the total) were seen by a paramedic and the rest by a physician beforehand. a relevant proportion of the patients visited the cpu without having been seen by medical personnel ( . %) before. a smaller group of patients was referred by an attending hospital physician to the cpu ( . %). . % of all patients were admitted to a cardiologic ward, . % to icu and . % underwent immediate cardiac catheterization. the rest was referred to other departments within the hospital, other hospitals or was discharged and no one died within h after admission to the cpu. almost half of the patients ( . %) who underwent immediate cardiac catheterization was transported by emergency physician car whereas half of the rest ( . %) visited the cpu as out-patient (p = . ). this very similar ratio can be seen within the patient admitted to icu ( . %). conclusion. the detection of the early symptoms of chest pain is an important prevention strategy for lay people because they can immediately turn to a chest pain unit ( . %) where almost half of them might have life threatening situation ( . %) requiring acute intervention (cardiac catherization or icu-treatment). the adequate in-time treatment can reduce the length of hospitalization and secure quicker recovery. key: cord- -ukz hnmy authors: nan title: poster date: - - journal: j frailty aging doi: . /jfa. . sha: doc_id: cord_uid: ukz hnmy nan background: frail older adults are at increased risk of postoperative morbidity compared with robust counterparts. simple methods testing frailty such as grip strength have shown promising results for predicting post-operative outcome, but there is a debate regarding the most appropriate and precise frailty assessment method. objectives: we compared the predictive value of multidimensional frailty score (mfs) with grip strength or conventional risk stratification tool for predicting postoperative complications in older hip fracture patients. methods: from january to december , older hip fracture patients (age >= years) who underwent surgery and comprehensive geriatric assessment (cga) were retrospectively included for analysis. hip-mfs was calculated based on the cga with component of sex, charlson comorbidity index, serum albumin, koval grade, cognitive function, risk of falling, mini-nutritional assessment and mid-arm circumference. grip strength was also measured before surgery. the primary outcome was a composite of postoperative complications (e.g. pneumonia, urinary tract infection, delirium, acute pulmonary thromboembolism, and unplanned intensive care unit admission). results: among patients (mean age . ± . years, . accordingly, grip strength could be used for screening tool to identify high-risk patients who need for further comprehensive geriatric assessment among older hip fracture patients. information and data suspected of post-operative infections. the diagnostic criteria of infection dealt with grade ii or more of clavien-dindo classification. diagnosis of infectious disease was made with reference to vital sign, blood test, imaging and bacterial test results. surgical site infection (ssi) was evaluated based on the infectious control team surveillance. results: elderly patients were registered with necessary data. the average age was . years, males and females were included. in the sarcopenia evaluation, there were cases without sarcopenia and cases with it. cases developed some infectious complications postoperatively. the types of infectious complications (including duplication) were cases of some surgical site infections including suture failures, of pneumonia, of urinary tract infection, of pneumonia and cases of sepsis in patients. infectious complications occurred in cases in the non-sarcopenia group and in the sarcopenia group (p = . ). the average postoperative hospitalization was . days overall, . in the group with postoperative infectious complications, and . in the group without sarcopenia. conclusion: in this study, there was no relation in the incidence of postoperative infections and preoperative sarcopenia. however, the postoperative hospitalization in the group with postoperative infectious complications was almost tripled. background: hypertension is one of the major risk factors for cardiovascular disease. lowering blood pressure is effective for preventing stroke, heart failure (hf), myocardial infarction and possibly dementia. in france, the prevalence of elderly people treated for hypertension rising leading to a possible increase of potentially inappropriate antihypertensive prescribing (piap) that may cause adverse drug events. objectives: to identify associated factors with potentially inappropriate antihypertensive prescribing (piap) in elderly people. methods: we conduct a retrospective observational study based on a cohort from geriatric day hospital for assessment of frailty and prevention of disability in toulouse, between january and april . piap was defined with several explicit criteria: the european list of potentially inappropriate medications, alert and control of iatrogenesis (aci) criteria by the french health authority, the french society of hypertension guidelines, screening tool of older people's potentially inappropriate prescriptions (stopp) version two and summary of product characteristics. the piap has been considered as a binary variable (logistic regression) then as a counting variable by number of nonconformities on antihypertensive drugs (negative binomial regression). results: among the patients, % had piap. frailty, polypharmacy, history of angina and hf are associated with a higher risk of piap. similarly: frailty, polypharmacy and history of angina are associated with an increase in the number of non-conformities antihypertensive drugs. analysis of subgroup of patient hf -piap indicated that % had aci criteria whose % the aci criteria " antihypertensive drugs or more" and % the aci criteria " diuretics or more". analysis of subgroup of patient history of angina -piap indicated that % had stopp criteria, focused on loop diuretics. conclusion: our work suggests that some elderly people characteristics are associated with an increase likelihood of piap. targeting these patients would be beneficial in preventing medicine-related illness. background: social frailty was reported to be associated with age, sex, income, education, marital status, and household status. however, mood status including depression and emotion was relatively less investigated. objectives: the aim of this study is to clarify the association between depression and apathy status and social frailty in community-dwelling japanese elderly. methods: a health promotion project (teng tv project) is designed to distribute health promotion programs including enhancement of nutrition and physical activity via cable tv channel for community-dwelling elders. we ran a cross-sectional analysis using baseline characteristics of all participants (n= ). demographic data, socio-economic status, comorbidities, and nutrition evaluated by mininutritional assessment-short from (mna-sf) were recorded. functional capacity was assessed by the japan science and technology agency index of competence (jst-ic). mood status including depression, and emotion was measured by geriatric depression scale (gds- ) and apathy evaluation scale (aes). social frailty was defined by household status (living alone or not), financial difficulty, social activity, and fulfilment of social needs. we defined total deficit scores of or more as social frailty, as social pre-frailty, and as robustness. we used a linear regression model to analyze the association between mood status and social frailty after adjusting for age, sex, education, marital status, comorbidities, bmi, mna-sf, jst-ic. results: at baseline, mean age of all participants ( . % men) was ± . years. a total of . % and % of all participants were categorized as social prefrailty and social frailty, respectively. the mean scores of gds- and aes were . ± . , . ± . , respectively. in linear regression model after full adjustment, participants with social pre-frailty and social frailty were associated with increased gds- scores (social pre-frailty vs. social robustness: b= . , %ci . - . ; social frailty vs. social robustness: b= . , %ci . - . ) and aes scores (social pre-frailty vs. social robustness: b= . , %ci - . - . ; social frailty vs. social robustness: b= . , %ci . - . ). in addition, jst-ic was also associated with gds- and aes scores. conclusion: social pre-frailty and social frailty were associated with greater level of depression and apathy. future studies are warranted to determine the causal relationship among mood status and social participation. inthira roopsawang , , hilaire thompson , oleg zaslavsky , basia belza (( ) ramathibodi school of nursing, faculty of medicine ramathibodi hospital, mahidol university, bkk, thailand; ( ) biobehavioral nursing and health informatics, school of nursing, university of washington, seatlle, usa) background: frailty is a common geriatric condition with an impact on surgical outcomes. no research has been published on frailty assessment in hospitalized orthopedic patients in thailand. having a valid frailty measure has the potential to improve screening and could enhance quality of care. objectives: to test the ability of the reported edmonton frailty scale-thai version (refs-thai) in predicting hospital outcomes compared with preoperative assessment measures, the american society of anesthesiologists physical status classification (asa) and the elixhauser comorbidity measure (emc) in older thai orthopedic patients. methods: a prospective study was conducted at a university hospital. the hospitalized patients aged years or older scheduled for elective orthopedic surgery were recruited in this study. multiple firth logistic regression modeled the effect of frailty on postoperative complications, postoperative delirium (pod), and discharge disposition, while length of stay (los) was examined by poisson regression. the area under the receiver operating characteristic curve (auc) and mean squared errors (mse) were used to compare predictive ability of the instruments. results: two hundred participants with mean age of (range - years) were mostly female , % were frail, and % underwent knee surgery; of which . % had postoperative complications, . % developed pod, and % were unable to be discharged home. average los was days. adjusting for other variables, frailty was significantly associated with postoperative complications (or = . , p = . ), pod (or = . , p = . ), and prolonged los (relative risk [rr] = . , p = . ). applying the refs-thai alone shows good performance in predicting postoperative complications (auc = . , % ci = . - . ) and pod (auc = . , % ci = . - . ). the combination of refs-thai with asa and emc demonstrates improvement in predicting postoperative complications (auc = . , % ci = . - . and . % ci = . - . , respectively) and pod (auc = . , % ci = . - . and . % ci = . - . , respectively). conclusion: frailty assessment using the refs-thai was useful in predicting adverse outcomes in older adults undergoing orthopedic surgery. integrating the refs-thai for preoperative assessment may be useful for enhancing orthopedic care quality. anthony frioux , matthieu faure , margot de battista , benoit roig (( ) université de nîmes, france; ( ) université de france) background: the attention of the scientific community to frailty has been drawn over the past several years. frailty is defined as a state of increased vulnerability that may lead to functional disability. if this state is managed soon enough it may be reversible. in parallel, the possibilities of monitoring health status through connected objects such as smartphones are increasing. similarly, it is possible to measure the activity of the inhabitants of a house collecting usage data (water and electricity consumption). our project is in the field of smart home and aging monitoring. objectives: therefore, the objective of our work is to develop an integrative model of frailty based on the contributions of existing scientific tools (fried et al., ; mitnitski, mogilner, & rockwood, ) and current sensors to measure a person's activity. eventually, we are aiming for the detection of the frailty trajectory early on. for example, real-time activity monitoring is used to detect a fall and alert rescue. in our case, these sensors will allow us to identify as soon as possible a dimension that would be abnormal in order to intervene and propose an appropriate intervention. methods: our tool will be able to measure the five fried's frailty criteria which are currently used in clinical practice. we compare the data from the sensors with the results of the evaluation of fried's frailty phenotype. results: we expect to obtain a correlation between our data and phenotype results. conclusion: the main contribution of our tool resides in the possibility to observe deviations from an individual's normal aging trajectory. thus, the evaluation we propose would be more ecological as it will enable us to consider the individual's habits and to have a more detailed assessment of his activity evolution. in conclusion, the holistic aspect of our work will allow the practitioners to base their intervention on a wide range of health data. l. van wagenberg, r.m. wösten-van asperen (department of paediatrics, paediatric intensive care unit. wilhelmina children's hospital, utrecht, the netherlands) background: a frail phenotype is recognized in the elderly population. frailty is associated with a higher mortality for adult intensive care (icu) patients. research in oncology suggests biological age is not the key contributor to frailty, since frailty is also found in the younger population. in paediatrics frailty is an unknown concept and as a consequence, the prevalence and meaning of being frail at young age are unknown. objectives: to assess whether a possible frail phenotype can be found in a critically ill paediatric oncological population. methods: a retrospective cohort study in a paediatric oncological icu population between january and september . demographic data and need for icu resources (mechanical ventilation, inotropic support and s continuous renal replacement therapy (crrt)) were collected. since specific paediatric frailty scores are not available, we addressed patients as having a frail phenotype by textmining their electronic health records on the words "fatigue", "cachexia" and "diminished physical activities" before, during, and after paediatric icu admission. risk factors for a possible frail phenotype (cachexia, use of corticosteroids and lowest serum albumin levels) were collected. primary endpoint was mortality during icu treatment or course of illness. results: admissions were included, of which admissions had a possible frail phenotype. these admissions included unique patients. % of patients was male and the median age was years (iqr - ). patients were predominantly treated for a haemato-oncological malignancy ( %). mortality during icu-admission was %, and % died subsequently during the course of disease after picu discharge. patients were severely ill, with a mean icu length of stay of . days (± ), % on ventilator support, % receiving vasopressor or inotropic support, and % on crrt. loss of muscle function or fatigue was present in % before icu admission and in % acquired atrophy or cachexia was documented during icu treatment. % were treated with corticosteroids during picu stay. in % a serum albumin ≤ gram/dl was measured. conclusion: a possible frail phenotype is present in the oncological patient population of a paediatric icu. more research on the contributing factor of frailty on outcome of these patients is needed in the near future. john muscedere , , amanda lorbergs , jayna holroyd-leduc , anik giguere , leah gramlich , heather keller , ada tang , danielle bouchard , donna fitzpatrick-lewis , , diana sherifali , (( ) canadian frailty network, kingston, on, canada; ( ) queen's university, kingston, on, canada; ( ) university of calgary, calgary, ab, canada; ( ) laval university, quebec city, qc, canada; ( ) background: despite research evidence related to nutritional and physical activity interventions, there is a gap in provision of evidence-based care focused on preventing and managing frailty among older adults. objectives: to systematically generate evidence-based nutrition and physical activity (pa) clinical practice guidelines to improve health and functioning in older adults with or at risk of frailty. methods: we are using the agree ii guideline development protocol to generate guidelines to improve health and functioning in older adults. for each guideline, systematic review of meta-analyses was conducted by searching three databases for english language citations published since that included adults aged y and older with frailty and/or pre-frailty. nutrition or pa interventions with a comparison group were considered eligible. acceptable study designs included rcts, quasi-experimental trials, and observational cohorts with a comparison group. in a face-to-face meeting with multidisciplinary content experts, healthcare professionals, and end-users we will further appraise the quality and strength of the evidence using the grade approach. this group will use this evidence to form recommendations related to nutrition and pa in this population. results: the nutrition and pa searches resulted in and citations, with and eligible for full-text review, respectively. the results will inform guideline recommendations. knowledge translation strategies will be developed to support guideline dissemination and implementation. conclusion: the guidelines will inform health professionals by providing evidence-based nutrition and pa interventions for adults with frailty. ( background: physical and psychosocial factors play important roles in the severity and progression of frailty. frailty screening tools include measures of the more common risk factors, including advanced age, comorbidities, poor diet, weight loss, lower socioeconomic status, and physical inactivity. however, there has been limited standardization in the us on specific frailty screening measures to include in national health surveys or frailty tools/protocols for community health settings. this makes it difficult to monitor frailty incidence/prevalence in the older adult population and to best identify and treat individuals at risk. results: we reviewed the most recent versions of us national health surveys that include older adults, to identify whether frailty screening measures were included in. no national surveys had a battery of measures that would allow for frailty risk screening. most commonly, questions on weight, disability, mental health, physical functioning were included. however, physical functioning measurements such as grip strength or gait speed, measured height and weight, unintentional weight loss, dietary intake or appetite changes were not. further, we used the world health organization criteria for effective community screening programs to review published evidence of the validity, reliability, and feasibility of data-driven screening tools for frailty risk among community-dwelling older adults. of the frailty screening tools reviewed, the frail scale was identified as the most promising, based on test characteristics and cost/ease of use. more community-level s research is recommended, particularly on predictive validity of favorable outcomes following physical activity/nutritional interventions. finally, because nutrition plays a significant role in frailty risk, we surveyed registered dietitian nutritionists who work with older adult populations (n= ) to identify their awareness/use of frailty screening protocols/tools and dietitians' potential role in frailty screening. dietitians practicing in the community recognized a potential role, but few dietitians were aware of (< %) or using (< %) specific frailty screening tools. conclusion: future opportunities to better support healthy aging include: addition of frailty screening measures to national health surveys to help prioritize high-risk populations, conduct additional research to validate/recommend a common community-level screening tool, and promote engagement by dietitians and other health professionals who can establish protocols for community-based frailty screening. ming-yueh chou , , ying-hsin hsu , yu-chun wang , chih-kuang liang , , li-ning peng , , liang-kung chen , , yu-te lin (( ) center for geriatrics and gerontology, kaohsiung veterans general hospital, kaohsiung, taiwan; ( ) aging and health research center, national yang ming university, taipei, taiwan; ( ) department of geriatric medicine, national yang ming university school of medicine, taipei, taiwan; ( ) center for geriatrics and gerontology, taipei veterans general hospital, taipei, taiwan) background: older people with frailty are at risk of adverse outcomes, such as falls, functional decline and mortality, and multi-domain intervention program may prevent those. objectives: the purpose of this study is to evaluate the effectiveness of multi-domain intervention program among those community-dwelling frail older people in southern taiwan. methods: a week multi-domain intervention program were provided for all participants, including physical activity, high protein diet education, medical knowledge education and cognitive simulation activity for hours per week. comprehensive geriatric assessments were performed before and after the intervention program, including basic demographic data, risk for malnutrition (by mna-sf), mood condition (by gds- ), cognitive condition (by mmse) and frailty status according to the definition by the cardiovascular health study (chs) . results: during jan and may , totally participants were invited for study ( . % female, mean age . ± . years). among them, ( . %) were clarified as frailty status and ( . %) as prefrailty status. after the multi-domain intervention program, their mood condition ( . ± . to . ± . , p< . ) and cognitive condition ( . ± . to . ± . , p< . ) improved significantly. in addition, the walking speed ( . ± . to . ± . m/s, p< . ) and physical activity ( . ± . to . ± . mets/week, p< . ) improved, but not handgrip strength (p= . ). for the frailty status, those clarified as frailty status decreased from . % to . % and prefrailty status from . % to . % (p< . ). conclusion: our results showed that through the week multi-domain intervention program, those frail older people could improve their mood condition, cognitive condition, usual gait speed and frailty status. sarah b. lieber , stephen a. paget , , jessica r. berman , , medha barbhaiya , , lisa sammaritano , , kyriakos a. kirou , , john a. carrino , dina sheira , mangala rajan , yingtong lyu , lisa a. mandl , (( ) division of rheumatology, hospital for special surgery, new york, ny, usa; ( ) department of medicine, weill cornell medicine, new york, ny, usa; ( ) department of radiology and imaging, hospital for special surgery, new york, ny, usa) background: frailty is a clinical phenotype that increases with age, but can occur in younger patients with chronic disease. based on few studies, frailty has been found in up to . % of patients with systemic lupus erythematosus (sle) and is associated with increased mortality. whether frailty is prevalent in other sle cohorts and associated with objective and subjective factors is unknown. objectives: we aimed to determine the prevalence of frailty in a prospective cohort of women with sle and whether inflammatory biomarkers, body composition, and patient-centered domains differed between frail and non-frail women. methods: adult women < years old who fulfilled american college of rheumatology sle criteria were recruited from one center. exclusions included pregnancy, dialysis, active malignancy, overlap autoimmune syndromes, and severe sle disease activity. frailty was measured according to fried criteria. patient-reported outcomes (pros) were measured using pro measurement information system (promis) computerized adaptive tests; lupusqol; and disability based on valued life activities. physicianreported sle disease activity and damage indices were collected. inflammatory biomarkers and sarcopenia according to dual-energy x-ray absorptiometry were assessed. differences between frail and non-frail women were evaluated using chisquare tests and kruskal-wallis tests; the association between frailty and disability was determined using logistic regression. results: women enrolled from / - / . despite age under years old, % were frail. frail women had greater disease damage (p= . ) and were more often smokers (p= . ). high-sensitivity c-reactive protein (p= . ) and interleukin- (p= . ) were higher and sarcopenia trended toward greater prevalence (p= . ) in frail women. significant differences in promis mobility, physical function, pain interference and behavior, and fatigue and lupusqol physical health and pain (all p< . ) were observed between frail and non-frail women, with frail women reporting consistently worse scores. frail women were . x more likely to be disabled than non-frail women, including after adjustment for age, comorbid conditions, and disease activity/damage. conclusion: the prevalence of frailty was high in this cohort of mid-aged women with sle. frail women had poorer health-related s quality of life than non-frail women, including substantially higher disability. if frailty is associated with worse health outcomes, it could be a potential therapeutic target. chariya sumcharoen, supreeda monkong, nuchanad sutti (ramathibodi school of nursing, faculty of medicine ramathibodi hospital, mahidol university, bangkok, thailand) background: bed bound older adults need caring of physical activities, mental, mood, and social from family caregivers. family caregivers usually gets the role strain from caregiving. there are many factors associate with the caregiver role strain but have been rarely reported in bed bound older adults at home. objectives: the study examined age, adequacy of incomes, mutuality, health status, preparedness, and social support influencing caregiver role strain from caregiving activities for bed bound older adults at home. methods: caregiver role strain concept by archbold and colleagues with literature review were used to guide this study. the sample was recruited by purposive sampling consisted of caregivers aged years or older, who have cared for bed bound older adults at home in thailand. data were collected by structured interview using the questionnaires including demographic data, preparedness, health perception, mutuality, social support, and caregiver role strain from the care activities. data was analyzed using descriptive statistics, pearson's product moment coefficients, and multiple regression analysis. results: the most of participants were women ( . %), age ranging from to years (m= . , sd= . ) . the result showed that age, adequacy of incomes, mutuality, health status, preparedness, and social support jointly significantly explained . % of the variation in caregiver role strain from caregiving activities. the regression effects were strongest for health status (beta=-. , p=. ), followed by preparedness (beta=-. , p=. ), age (beta=. , p=. ), and adequacy of incomes (beta=-. , p=. ) respectively. conclusion: this finding suggests that healthcare providers should find strategies for promoting health status and preparedness of family caregivers for decrease caregiver role strain from caregiving activities. of life, and hospital admissions. objectives: we estimated the prevalence and describe the characteristics of the population with recurrent falls and fear of falling and their association with frailty, physical performance and cognitive fragility. methods: data came from the "salud, bienestar y envejecimiento" (sabe) colombia study, a cross-sectional study conducted in at the urban and rural research sites ( municipalities) in colombia. sociodemographic, health, cognitive and anthropometric measures were collected from community-dwelling adults aged years and older, representative form the total population. frailty was defined using the frailty phenotype proposed by fried. cognitive frailty was defined using the inaa/iagg consensus definition. low performance was evaluated with sppb (short physical performance battery). logistic regression analyses were used to identify factors associated with recurrent falls and fear of falls. results: our study identified elderly who had recurrent falls and fear of falling ( . % and . % respectively). young elders (≤ years) had more falls and greater probability for fear of falling compared to older ages. sex had no significant differences. the factor associated with an increased risk of recurrent falls and fear of falling in the elderly were low physical performance, fragility and polypharmacy. chronic illness such as osteoarticular disease, mental disease, diabetes and chronic pulmonary disease were significantly associated with recurrent falls and fear of falling. finally, when adjusted for age, sex, sociodemographic factors and comorbidities in a logistic regression model, frailty was associated with fear of falling and recurrent falls, while cognitive frailty and low physical performance only were associated with fear of falling. conclusion: recurrent falls have a significantly association with frailty. there are cognitive, physical performance and clinical factors associated with fear of falling that could be preventable and treatable. rubbieri gaia , ceccofiglio alice , mazzeo nicla , pupo simone , cartei alessandro , rostagno carlo , mossello enrico (( ) department of perioperative medicine, careggi hospital and university of florence, italy; ( ) department of geriatric medicine, careggi hospital and university of florence, italy) background: the prevalence of frailty in patients with hip fracture is high, but little is known about the choice of the best frailty tool in terms of prediction of functional recovery. objectives: the aim of this preliminary study was to determine the most predictive validated frailty tool in older people with hip fracture and to determine whether frailty can predict functional recovery during the hospital acute phase. methods: this study was observational prospective cohort study. participants aged + admitted to hip fracture units in florence, were assessed pre surgery (t ), and post surgery. each participants underwent a comprensive geriatric assessment and frailty was defined using: clinical frailty scale (csf), frail scale (fs), reported edmonton frail scale (refs), postal frailty screening (pfs). the outcome was functional recovery, evaluated by a score of postoperative performance on the cumuleted ambulation score (cas). data recorded included pre-recovery barthel index (bi), charlson comorbidity index (caci), handgrip strenght test (hg), asa score, mini nutritional assessment short-form (mna-sf), delirium. results: sample included patients (mean age ± years, female . %). cfs was the most predictive frailty tool, with a % sensitivity and a % specificity (auc = . , cut off > ). dividing the sample according to premorbid bi, while bi itself had the highest predictive value when premorbid level was < %, cfs was the best predictor of functional outcome in the %+ subsample (auc= . ). conclusion: frailty defined by cfs can predict short-term functional recovery during acute phase following hip fracture. this appears particularly relevant for subjects with a higher pre-morbid functional independence. s % were women. individuals had data for all five frailty measures. nine percent of participants were non-frail by all instruments, % were frail by all measures and thus % had discordant frailty measurements. % were frail by at least one measure method. the prevalence of frailty ranged from % to % for the different measures. those classified as frail by cfs and non-frail by bp were more likely to be men, be co-living, have lower cognitive function and a higher dependency in iadl compared to those classified as frail by bp and non-frail by cfs. conclusion: frailty measures cannot be used interchangeably. specifically the cfs might not identify physical frail women, with high cognitive ability who lives alone. factors contributing to the heterogeneity of groups classified as frail by different measures need to be further explored. background: polypharmacy is increasingly common amongst older, multimorbid adults. in these individuals, studies have shown a high prevalence of frailty. identification of frailty can be performed using comprehensive assessments registering accumulation of deficits like in the frailty index, or using single-trait markers of frailty like gait speed and handgrip strength. polypharmacy is recognized as an independent risk factor for the development of frailty, and the subgroup of psychotropic drugs may be particularly important in the development of this syndrome. objectives: our objectives were to study the relationship between the total burden of polypharmacy on frailty status using three different measurements of frailty, and specifically the influence of psychotropic drug use on frailty status. our overall aim was to explore whether either of these could be used as independent predictors of frailty. methods: we used data from a -year follow-up study of older people living in the community and receiving home care nursing, i.e. the cascade-study. data collection was completed in june . all participants were aged > years (mean years). a item frailty index was calculated based on results from a comprehensive geriatric assessment performed in the patients' own home. a fourmeter gait speed test was performed, as well as measurement of handgrip strength. information on regular medications was collected from the patients if they administered own medications, or from the home care nursing service if they were responsible for administering the patients' medications. psychotropic drugs were selected based on beers criteria. results: we found a significant association between the use of psychotropic drugs and frailty index, and frailty index increased by . for each psychotropic drug added (p< . ). one additional psychotropic drug decreased gait speed by , m/s (p< , ). there was no statistically significant association between psychotropic drug use and handgrip strength. conclusion: our study showed that psychotropic drug use was a significant predictor of increased frailty index and reduced gait speed. this was not the case for handgrip strength in our material. laetitia beernaert , frédéric schuind , sandra de breucker (( )department of geriatrics, hôpital erasme -université libre de bruxelles, belgium; ( ) department of orthopedics, hôpital erasme -université libre de bruxelles, belgium) background: anemia is a condition whose prevalence might reach % in the geriatric population. anemia and frailty are two prognostic factors for patients admitted for a hip fracture. objectives: we analyzed retrospectively if preoperative frailty and anemia were independently predictive of postoperative complications and mortality in old patients admitted for hip fracture. methods: ninety-seven patients above years old have been admitted for urgent surgery for a hip fracture during and . we excluded patients with a pathological fracture or fractures due to high energy trauma. preoperative anemia was defined as an hemoglobin level under g/dl for women and g/dl for men. frailty was assessed with the isar (identification of seniors at risk) score. results: seventy-five percents of patients were considered as frail (isar score> ). the prevalence of preoperative anemia was %. we found no statistically significant correlation between anemia and frailty (r = - . -p = . ). in multiple regression logistic analysis, the only independent parameter associated with anemia was the presence of comorbidities (or . ( . - . )-p = . ), and the only parameter associated with frailty was the presence of malnutrition (or . ( . - . )-p = . ). neither anemia nor frailty was associated with postoperative complications and mortality. conclusion: preoperative anemia and frailty are not interrelated in patients admitted for hip fracture. anemia is associated with comorbidities, but not postoperative mortality. frailty is associated with preoperative malnutrition. the isar score may not be ideal to screen for frailty in old patients admitted for hip fracture, an item being attributed to the current loss of autonomy. settings. m martinez , maria montoya , , davide angioni , lizeth canchucaja , natalia ronquillo , maria luz gallego , claudia bejar , emmanuel gonzalez , olga vazquez , anna renom (( ) institute de viellisement toulouse, france; ( ) hospital del mar, barcelona, spain; ( ) hospital de terrasa, barcelona, spain; ( ) parc tauli, barcelona, spain) background: frailty is a common critical geriatric syndrome which has been associated with poor health outcomes.a wide variety of frailty indices (fis) have been developed. frail-vig («vig» is the spanish/catalan abbreviation for comprehensive geriatric assessment).it contains simple questions that assess different deficits. it has been inspired by the rapid geriatric assessment. objectives: the aim is to compare the prediction capacity of clinical rockwood index frailty (rif) and frail-vig index (vif) for poor health outcomes (pho) defined as: emergency department visits and/or hospital admission and/or mortalityamong elderly patients. methods: a retrospectiveobservational study was conducted with a followup up to months or pho occurred. patients were admitted in acute geriatric unit care and geriatric day hospital at hospital del mar; barcelona; spain during august and march . the inclusion criteria were the admission ones. frailty was measured at admission. survival analysis was conducted; cox proportional hazards regression was used to build a pho predictive model based on both indexes. best model according to contrast of hypothesis log-rank ,aic; bic and c harrel was selected.diagnoses of the chosen model was done. results: a total of patients were included, mean age was and . % female. the mean of follow-up was . , % patients presented a pho. . % died, % were admitted at emergency department, . % were hospitalized and % presented more than one event.survival curves for frail and non-frail according to pho showed statistically significance for vif (x = . p= . )but not for rif (x = . p= . ). cox proportional hazards regression showed vif hazard ratio . (p= . ) and rif hazard ratio . (p= . ). predictive capability resulted in a model for vif containing cognition and sex, with harrel c of . . as for rif the most parsimonious model rif would be absent and harrel c . . the diagnoses of the model showed time covariate variable test with p= . , p= . , p= . for each predictive variable; squared linear predictor with p= . of and outliners. conclusion: the vig frailty index performed better; compared to rockwood clinical index; in predicting a composite outcome composed by mortality, hospitalization and visits to emergency departments in patients admitted in acute and outpatient settings. after hospital discharge. methods: this study was conducted in the departments of internal medicine and neurology of the university hospital of araba (basque country, spain). participants were >= years, scoring >= on the mmse test and able to stand and walk independently for at least -meter. participants performed twice-weekly moderate intensity group sessions of multicomponent exercise at the hospital during -week, followed by a home-based intervention ( week) . both were focused on balance, aerobic capacity and strength. taking together both interventions, participants completed -week of physical exercise. at the beginning and the end of the program, frailty was measured though fried´s index and sarcopenia with different criteria : muscle strength ( -chair stand), muscle quality (dxa) and physical performance (sppb). we compared the results before and after the intervention by mcnemar test. results: patients ( females, %) were enrolled, were lost to follow-up at the -week time point and people finished the intervention. the intervention decreased significantly the percentage of frail individuals (p< . ) according to fried´s index, and the percentage of people who met sarcopenia criteria for sitto-stand (p= . ) and sppb (p= . ). however, there were no differences in the percentage of people with low appendicular muscle mass. conclusion: our study showed that a multicomponent exercise program is effective for posthospitalization patients because after -week intervention there were significant reductions in frailty and improving results in muscle strength and physical performance. we did not find changes related to muscle mass. references: . background: alcohol addiction can impact every part of the body, including bones. research shows that chronic heavy alcohol use, especially during adolescence and young adult years, can dramatically affect bone health and increase the risk of osteoporosis and bone fracture later in life. objectives: the purpose of this study is to compare data from international scientific literature with data from the study of patients admitted for alcohol dependence, to assess whether there are significant connections between alcohol dependence and unrecognized fractures. methods: we analyzed meta-analysis's studies from the pubmed search engine to evaluate the association between bone fractures with alcohol use disorders. only humans studies from the last years have been analyzed. subsequently, data related to patients admitted for an alcohol rehabilitation cycle were analyzed. results: scientific literature show that there is a close correlation between alcohol abuse and greater frequency of bone fractures. this is partly due to association between alcohol consumption and both osteoporotic fracture and bone density, and partly to the fact that there is an increased risk of falls in alcohol intoxicated patients compared to the general population. patients were considered: % male and . % female. the average age was years. of these , . %, patients, had unrecognized fractures. conclusion: intoxicated patients admitted in alcoholic rehabilitation with recurrent falls anamnesis often did not perform any diagnostic assessment. this is due to the lack of pain perception in the patients or due to family members or emergency physicians who placed the state of drunkenness before any consequences caused by repeated falls. there is an increased risk of unacknowledged fracture in the patients admitted in alcohol rehabilitation this is partly due to the fact that alcohol intoxicated patients often do not perceive the pain and therefore do not investigate any falls that occurred in a state of drunkenness, in part it is due to the damages that alcohol causes on the bone. our data show that alcohol dependence and unrecognized fractures can often be associated. studies in the literature confirms that there is an increased risk of non-cone fractures in patients with alcohol dependence. zamudio-rodríguez, hélène amieva, luc letenneur, karine pérès (centre de recherche inserm u université de bordeaux -isped, bordeaux, france) background: although conceptually distinct, frailty and disability are very common among older adults. both are multifactorial conditions and share some risk factors and pathophysiological mechanisms, such as inflammation or sympathetic-parasympathetic balance alteration. furthermore, each individual component of the frailty phenotype defined by the cardiovascular health study (chs) has been associated with disability in basic and instrumental activities of daily living. objectives: the present study aimed to determine whether pre-frail and frailty are part of the natural history of the disability process. methods: a sample of people aged of the three cities ( c) study in bordeaux were followed for four years. pre-frailty and frailty were defined according to the original phenotype proposed in the chs. disability was defined using the basic (adl) and instrumental (iadl) activity of daily living scales. seven mutually exclusive hierarchical groups were distinguished at inclusion: ) robustness (no frailty or disability); ) pre-frail (without disability); ) frailty (without disability); ) iadl (without pre or frailty or adl) ) pre-frail with iadl (no adl); ) frailty with iadl (no adl); ) frailty with iadl and adl. results: deaths ( . %) occurred during the four years follow-up. compared to the robust group, all other hierarchical subgroups had an increased risk of death, with an increasing gradient: pre-frailty (hr= . ; ic %= . - . ); frailty (hr= . ; ic %= , ) , iadl disability (hr = . ; ic %= . - , ); pre-frailty with iadl disability (no adl) (hr= , ; ic %= , - . ); frailty with iadl disability (no adl) (hr= , ; ic %= . - . ); frailty with iadl and adl disability (hr= , ; ic %= . - . ) were significant after adjustment by age and sex. conclusion: there is a gradual risk of mortality across the different groups ( i.e., ) robust; ) pre-frail; ) frail; ) iadl disability without pre or frailty; ) pre-frail with iadl disability; ) frail with iadl disability; ) frail with iadl and adl disability) thus suggesting a hierarchical relationship. this study could have important clinical implications since pre-frailty and frailty are assumed more effectively reversible conditions in order to interrupt the continuum at the early phase of the disability processes. background: joint replacement provides significant improvement in pain, physical function, and quality of life in patients with osteoarthritis. with a growing body of evidence indicating that frailty can be treated, it is important to determine whether targeting frailty in joint replacement patients is feasible and improves post-operative outcomes. objectives: to examine the feasibility of a preoperative multi-modal frailty intervention (mmfi) compared to usual care in pre-frail/ frail older adults undergoing elective unilateral hip or knee replacements. methods: in this pilot randomized controlled trial (rct), participants who are )>= years old; ) pre-frail (score of - ; (fried frailty phenotype (ffp)) or frail (score of - ; ffp); ) having elective unilateral hip or knee replacement with surgery wait times between - months were recruited from the regional orthopaedic clinic mcmaster university, ontario canada. the mmfi included tailored exercise, protein ( - gm/day), vitamin d ( iu/day) supplementation, and medication review with recommendations sent to family physicians. frailty and mobility were assessed at baseline and -weeks post-operative using ffp, short performance physical battery (sppb) and oxford hip/knee score (ohs/ oks) respectively. results: we recruited and randomized participants between september and may . of those, . % were referred for total hip replacement and . % for knee replacement. the included participants' mean age (standard deviation (sd)) was . ( . ) years; . % were women; . % lived alone, body mass index was . kg/ m ( . ) and . % were former smokers. at the baseline assessment, on the ffp, % were prefrail, % were frail and the sppb was . ( . ). for participants with hip osteoarthritis, ohs mean (sd) was . ( . ) and for participants with knee osteoarthritis, oks mean (sd) was . ( . ). the study recruitment rate was . %, and the retention rate was %. eighty three percent of participants of the intervention group completed the intervention. self-reported adherence to the intervention components was as follow: ) exercise sessions: . %, ) protein supplement: . %, ) vitamin d supplement: . % and ) medication review completion: %. conclusion: this is the first study to examine the feasibility of a multi-modal frailty intervention in pre-frail/frail older adults undergoing joint replacement. this study showed that frailty screening, assessment and management is feasible for older adults undergoing joint replacement in orthopaedic surgery clinics. results have informed the current multi-centre rct to determine effectiveness. christine tocchi , sathya amarasekara , michael cary (( ) school of nursing, duke university durham, nc usa; ( ) school of nursing, duke university durham, nc usa; ( ) school of nursing, duke university durham, nc usa) background: inpatient rehabilitation facilities (irfs) provide intensive rehabilitation therapy to patients to reduce functional impairment, enhance independence and return patients to the community. determination of eligibility for irf is currently based on preadmission screening. subpopulations of older adults may require special consideration in determination of irf admission due to greater risk for poor functional recovery such as those with pre-existing functional limitations and those who are frail. frailty, a pervasive characteristic in older adults with hip fractures has not been examined as a clinical factor influencing discharge destination outcomes in irfs. objectives: ) determine the prevalence of frailty among older adult with hip fracture receiving inpatient rehabilitation; and ) determine the association between frailty and discharge destination among hip fracture patients receiving inpatient rehabilitation. methods: a retrospective cohort study design using cms inpatient rehabilitation facility-patient assessment instrument file. multivariate regression models were performed to examine the association between frailty and discharge destination. frailty status was measured using a frailty index of items with the following cut-off points: - . robust/non-frail; . - . pre-frail; and . or greater as frail. the final sample included , hip fracture patients. results: frailty, pre-frailty, and nonfrail were present in . % (n= ), . % (n= ), and % (n= ) of hip fracture patients, respectively. the majority ( %) of the frail hip fracture patients were discharged home. there were significantly greater proportion of females than males discharged home and those of white race, to years of age, and with higher functional status. regression analysis showed significantly lower functional status at discharge (p < . ) for patients with these characteristics: males, non-white race, and older age. additional factors that influenced discharge destination included: marital status, living in the community prior hospitalization, and length of stay. conclusion: frailty was the most common frailty status on admission to irf. home is the most common discharge destination for all frailty status groups. frailty status could be used to identify hip fracture patients at high risk for adverse outcomes. future studies should be used to explore the potential of frailty to provide valueadded utility to clinical settings such as irfs. background: front-line care providers are seeking direction on how frailty measures may be integrated into existing or future care pathways to enhance the experience of individuals who live with it. multidimensional frailty measures such as the edmonton frail scale offer the potential for case-finding, estimation of severity, and definition of frailty components. objectives: test the feasibility of the implementation of a multidimensional frailty order set into acute care. methods: in , we conducted a literature search to identify existing frailty guidelines and systematic reviews related to frailty in acute care. an expert panel graded the quality the evidence, then generated recommendations, graded by strength to inform the generation of a clinical knowledge and content management (ckcm) topic for dissemination throughout alberta health services (ahs). ahs is the largest province-wide, fullyintegrated health system in canada. this ckcm would include graded statements and recommendations, clinical decision support, electronic alerts, and a frailty order set. results: four guidelines, systematic reviews, and one scoping review informed the development of the frailty ckcm. from this, we developed eight recommendations, covering topics such as prevention, case-finding, estimation of severity, definition of components, triggers for expert assessment, and linkage to care processes. the recommendations also addressed safeguards to avoid labelling and other unintended consequences. an order set employs the clinical frailty scale, electronic frailty index, and edmonton frail scale to support a clinician to develop a personalized care plan. the order set empowers front-line clinicians to administer these frailty measures, based on cut points that prompt personalized recommendations on diet, activity, fall prevention, bladder management, and infusions. depending on the frailty component of concern, clinicians are also prompted with specific options to address cognitive impairment, functional dependence, falls and immobility, social isolation, nutritional risk, polypharmacy, urinary incontinence, chronic pain, and constipation. in preparation for the conversion to a province-wide electronic medical record (emr) in november , the ckcm was released in may and the frailty order set was built into the emr by september . conclusion: development and implementation of a multidimensional frailty order set in the setting of acute care is feasible. masayo kojima , toshihisa kojima , yuko nagaya , yasumoto matsui (( ) national center for geriatrics and gerontology, obu, aichi, japan; ( ) nagoya university, nagoya, aichi, japan; ( ) nagoya city university, nagoya, aichi, japan) background: prevention programs for frailty at community usually target healthy older people. to further prolong healthy life expectancy, we need to approach those who already have got chronic diseases such as rheumatoid arthritis (ra). objectives: the aim of this study is to assess the prevalence and factors associated with frailty in japanese ra patients. methods: ra patients aged - -yearold who visited two university hospitals between march and july were consecutively invited to join the study. those who agreed to participate the study provided written consent forms. frailty was assessed by the total score of the kihon checklist >= . self-report questionnaires were used to evaluate patients' demographic characteristics, perceived degree of pain, depression (the beck depression inventory-ii) and physical function (the health assessment questionnaire, haq). rheumatologists' global assessment of disease severity, swelling and/or tender joint counts, years of ra duration, frequency of arthritis surgery and crp level were also measured. results: total of ra patients were included in the study ( women, average age: . ± . years, average disease duration: . ± . years), and the prevalence of frailty was . %. the higher the age and the longer the duration of the disease, the higher percentage of ra patients with frailty was observed. . % among ra patients of working age ( - years), were frail, whereas . % and . % were frail among those aged - years and >= years, respectively. stepwise logistic regression analysis revealed that age, haq, depression severity and trust in neighbors were independently associated with frailty in ra. no significant gender difference was observed. conclusion: frailty is common even among working age in ra patients. physical function, depression and social capital were suggested to be independently associated with frailty. on-going followup study will disclose the influence of frailty on fracture, dependency, and mortality among ra patients. background: frailty is an important modulator of ageing and might impact on clinical presentation and progression of parkinson's disease. objectives: to evaluate the prevalence of frailty and correlation with motor and non motor symptoms as well as mri atrophy and white matter hyperintensities in parkinson's disease. methods: consecutive parkinson's disease patients underwent a comprehensive motor and non motor evaluation and geriatric assessment using multidimensional prognostic index (mpi). a subset of patients underwent mri with assessment of atrophy and white matter hyoperintensities by visual rating. results: pd outpatients (mean age . y, mean disease duration . years) entered the study. pre-frailty assessed by mpi was presented by % of patients and correlated with age and disease duration. when adjusting for these ariables, mpi correlated with updrs-iii, non motor symptoms assessed by umsar, prevalence of prevalence of orthostatic hypotension, rbd and depression. the mri assessment showed a correlation between global atrophy and frailty indipendently from mmse and educational levels. no association between frailty and wm hyperintensities was found. conclusion: frailty is a possible important modulator of pathology and brain vulnerability in parkinson's disease and could explain different severity in motor and non motor symptoms. longitudinal studies are warrented to evaluate the impact of frailty in disease progression. background: accidental falls in older adults have been associated with worse health-related outcomes especially in the frailest individuals, such as nursing home (nh) residents. in this special population of older adults, falls have been related to greater morbidity and mortality, but their impact on nutritional status is still unclear. moreover, so far there are no data on the potential role of unmodifiable (e.g. cognitive impairment [ci] ) and modifiable factors (e.g. assistance from informal caregivers) in influencing the impact of falls on nutritional status in older residents. objectives: we aimed to evaluate the changes in body weight during the six months after the occurrence of a fall in nh residents, and the possible influence of severe cognitive impairment, depressive symptoms and of the assistance from informal caregivers on such variations over time. methods: the sample included older residents who experienced at least one fall since nh admission. for each participant, we collected data on sociodemographic information, mean frequency of visits from informal caregivers, medical history, and cognitive and functional status at nh admission. severe ci was defined as the presence of a physician-based diagnosis of ci or a mini-mental state examination < points. the frequency of the visits from informal caregivers was categorized as none or (low) vs > (high) per week. falls' date and characteristics were obtained from structured forms completed by physicians. monthly body weight in the six months before and after the fall were derived from the nh medical records based on nurses' assessments. linear mixed models were used to evaluate the body weight changes after a fall, as a function of the presence of severe ci and low visits' frequency from informal caregivers, alone or in combination. results: the mean age of our sample was . ± . years and % were women. more than half ( . %) of residents involved had severe ci and . % had low visits' frequency from informal caregivers. after adjusting for potential confounders, the presence of severe ci (b=- . , se= . , p< . ) and the report of low visits' frequency from informal caregivers (b=- . , se= . , p= . ) were associated with steeper decline in body weight during the six months after the fall. when combining these variables, we found an additive effect of severe ci and low visits' frequency from informal caregivers in influencing weight loss (b=- . , se= . for residents with severe ci and high visits' frequency, and b=- . , se= . for those with severe ci and low visits' frequency; p< . for all). conclusion: our results suggest that cognitive impairment may worsen the impact of falls on nutritional status in nh residents, and that this effect may be exacerbated by scarce assistance from informal caregivers. ( ) tokyo women medical university, tokyo, japan, japan; ( ) department of geriatic medicine, kyorin university medical hospital, tokyo, japan; ( ) tokyo metropolitan institute of gerontology, tokyo, japan) background: in consideration of the future rapid aging of the society, to achieve healthy and active aging is indispensable. because especially the major issue is to prevent "multi-faceted frailty", it is necessary to reconsider regarding nutrition, physical activity and sociality/sociability in the elderly. sarcopenia is associated with adverse health outcomes, such as frailty, limited physical function, falls, disability and loss of independence. objectives: our aim to notice evidencebased new information, leading to frailty prevention, and let the community-based activity by elderly citizen only promote as a voluntary motion in each community. methods: we have already established many new evidences from our on-going japanese large-scale longitudinal study 'kashiwa study'. these evidences include the impact of overlapping of slight oral dysfunction, namely "oral frailty", as well as unbalanced diet and inadequate physical activity in early-stage sarcopenia. furthermore, we found the negative impact of several social disengagements including eating alone, so-called "social frailty", leading to subsequent sarcopenia. we developed a simple screening tool, ''frailty check-up activity'', which elderly citizen supporters only can operate in each small gathering place (e.g. community salon) via support by its local government. results: based on the concept of all-including three pillars, ) nutrition (i.e. dietary food intake including diversity and adequate protein intake, and treatment/maintenance against oral frailty), ) physical activity (not only exercises but also social daily activity) and ) social participation, the newly citizen activity ''frailty check-up'' has developed. after elderly citizen supporters received training fully, they could implement this activity completely and repeatedly in each local municipality. elderly participants could learn how to improve/conquer by themselves with raising their self-awareness for the importance of early frailty/sarcopenia prevention and could change their behavior modification. in addition, using big data combined with preexisting database of new-onset regarding care needs and/or all-cause mortality, we found the new cut-off point in our frailty check-up activity. conclusion: we could confirm that our interdisciplinary "action-research" can raise the citizen's early awareness and affect their behavior modification via elderly citizen supporter system for frailty prevention, consequently leading to extend healthy life expectancy. saguez, carlos márquez, bárbara angel, mario moya, lydia lera (inta, universidad de chile, santiago, chile) background: physical phenotype of frailty has been associated with quality of life deterioration and some studies have calculated cost-effectiveness of interventions on frailty in quality-adjusted life years (qalys), however studies on the direct burden of frailty expressed in qualys lost in community dwelling older adults are scarce. objectives: to forecast qalys lost caused by frailty in older chileans and describe health profiles as determined by euroqol (eq- d) in community-dwelling older chileans with and without frailty. methods: cross sectional study in ( , % women, mean age y± . ) community dwelling people >= years participants in alexandros cohorts. the frailty phenotype was defined as having >= from the following criteria: weak handgrip dynamometry, unintentional weight loss, fatigue/ exhaustion, five chair-stands/slow walking speed and low physical activity. qol was evaluated trough euroqol (eq- d) five dimensions: mobility, self-care, usual activities, pain/ discomfort and anxiety/depression and self-rated health trough eq -visual analogue scale (eq- d-vas). qualys were calculated by the eq -d time trade-off (tto) method. to estimate life expectancies (le), multistate methods based on the follow-up of alexandros cohorts, were employed. results: frailty was identified in , % of the sample. selfrated health according to eq- d-vas was lower in frail than non-frail people ( . ± . vs . ± . , p< , ). after adjusted multinomial logistic regression, the eq- d dimensions of anxiety/depression (very depressed rrr= . ; %ci: . moderate rrr= . ; %ci: , ) and pain (much pain rrr= . ; moderate pain rrr= . ; had the highest association with frailty. the valorisation of years in qualys was lower in frail than in non-frail people ( . ± . vs. . ± . qalys per year, p< , ) and among those frail, much lower in people >= y than in the group - y ( . ± . vs. . ± . , p< , ). the qualys remaining years were lower in frail people than in non-frail:total le at - y was , y corresponding to , qalys in frail and , qalys in the non-frail; in the group >= y tle was , y corresponding to , qalys in frail people and , in the non-frail. conclusion: the high burden of frailty on qalys, mostly related to pain and anxiety/depression makes compulsory its early detection and treatment. its knowledge allows calculating cost-effectiveness of interventions. background: + agil barcelona is a real-life a multicomponent intervention against frailty implemented in a primary care center, which promotes a comprehensive and coordinated approach between primary care, geriatrics teams and community resources, to detect and reverse frailty in the older adults. objectives: we aimed to assess the -months impact on physical function of +agil barcelona in community-dwelling frail older adults with cognitive impairment. methods: the study population was driven from the +agil barcelona program population. we included participants with cognitive impairment or dementia past history and those who performed a minicog test < points. after frailty screening by the primary care team, a geriatric team performed the comprehensive geriatric assessment. according to cga results, a tailored and specific multidisciplinary intervention for each person was designed. the intervention could include a) multi-modal physical activity (pa) sessions, b) promotion of adherence to a mediterranean diet c) health education and d) medication review. the physical performance was assessed at baseline and at -omths follow-up by the short physical performance battery (sppb) and gait speed. the pre/post intervention analysis was done by a paired sample t-test for repeated samples for continuous variables and chi-square for categorical variables. results: we included participants (mean age= . ± . , . % woman and . % lived alone). despite being independent in daily life, . % had fallen the past year, . % were vulnerable or frail according to the csf. physical performance was impaired: sppb= . ± . and gait sped= . ± . m/sec and . % had balance impairments. after months, . % of participants completed >= . physical activity sessions. the mean improvements were + . ± . points (p< . ) for sppb, + . ± . m/ sec (p< . ) for gait speed, - . ± . sec (p< . ) for chair stand test, and . % (p . ) improved their balance. additionally, psychoactive treatment was withdrawn in . %. conclusion: according to our results, a multidisciplinary and comprehensive geriatric intervention for frail elderly people with cognitive impairment of the community improves physical function and could reverse fragility at months. clarence mwelwa patrick chikusu, amritha narayanan, joel james (ashford and st peter's nhs foundation trust, chertsey, uk) background: frailty and muscle strength are a critical component of walking ability and presence of these can result in high prevalence of falls. it also results in increased morbidity and mortality among the elderly. despite sarcopenia being very common and a reversible condition in its early stage it is a frequently overlooked and undertreated geriatric syndrome a greater understanding of sarcopenia and frailty among healthcare professionals could have a dramatic impact on outcome and quality of life of the elderly. objectives: this study aimed to assess the current knowledge about the concept of sarcopenia and frailty among the healthcare professionals working in an nhs district general hospital in surrey. methods: this longitudinal study included nhs healthcare professionals (n = ) who were asked to complete a questionnaire regarding awareness of concept, risk, diagnostic strategy and management of frailty and sarcopenia. results: . % of healthcare professionals stated to know the concept of sarcopenia, % indicated to know how to diagnose sarcopenia and % had seen patients with suspected sarcopenia in the last one month. only % knew the risk associated with sarcopenia. . % used sarc f questionnaire as diagnostic method for sarcopenia. percent of the cohort experienced bottle necks during the implementation of diagnostic strategy. lack of awareness and time ( . %) was the main reason for this . . percent heard the term frailty and . % knew that sarcopenia and frailty is not the same . . percent was aware of the scoring methods for the frailty and . % used clinical frailty score as the method. . % was aware of the frailty pathway but only . % knew whom to contact regarding managing frailty. . % heard the term comprehensive geriatric assessment. only . % was aware of key recommendations of managing frailty in the acute settings. conclusion: although concept of sarcopenia and frailty is familiar to most nhs healthcare professionals, the practical and clinical application is limited due to a lack of awareness regarding the diagnostic methodology, risks as well as time constrains. as such the benefits and potential treatment options may be overlooked and we aim to improve awareness so that these measures can improve outcomes for patients. mahtab alizadeh-khoei , fatemeh sadat mirzadeh , reyhaneh aminalroaya , fati nourhashemi (( ) gerontology & geriatric department, medical school, tehran university of medical sciences, ziaeian hospital, tehran, iran; ( ) department of internal medicine and clinical gerontology, toulouse, france) background: frailty is a potentially reversible geriatric syndrome associated with geriatric risk factors. detecting risk factors is a useful purpose to predict frailty levels incidence to plan for institutional or home care services. objectives: the aims were finding frail and prefrailty frequency in iranian geriatric outpatients' and determining demographics related factors and geriatric syndrome predictors on frailty levels, based on frailty fried index. methods: in this cross-sectional study elderly >= years old, selected by convenience sampling from geriatric day clinics in the area of tehran university of medical sciences. the effect of risk factors (adl and iadl dependency, obesity, and polypharmacy) and geriatric syndromes (falling, chronic pain, sleep problems, vertigo, vision and hearing impairments, incontinence, dementia, and depression) were evaluated on frailty fried index. predictor factors by logistic regression model were analyzed, according to demographic risk factors and geriatric syndromes. results: the mean age was / ± / years old, majority were male ( %). prefrailty was . % in men and . % in women based on fi. the significant risk factors in elderly prefrail women were depression ( . %), polypharmacy ( . %), visual impairment ( . %), and chronic pain ( . %); although, in prefrail men were vertigo ( . %), falling ( %), sleep disorder ( . %), and incontinence ( . %). in prefrail older adults>= years, only sleep disorder was significant. in logistic regression model, six significant predicted factors were included depression, iadl dependency, falling, chronic pain, vertigo, and age. depression increased the risk of prefrailty by . times, dependency in iadl increased . times; moreover, chronic pain and vertigo increased prefrailty risk about times. dependency on iadl increased the risk of frailty . times, and chronic pain and falling increased the risk of frailty about . times. by logistic regression model, % of prefrail outpatients elderly could be diagnosed. conclusion: geriatric syndromes in outpatients' elderly could predict prefrail more than frail elderly. in the iranian community dwellers prevalence of prefrailty was high, so the on-time screening and outpatients' interventions can help to prevent frailty. background: frailty is a key condition to be screened among elderly oncological patients. nevertheless, the use of the frailty index (fi) in onco-geriatrics is still limited. objectives: aim of our work is to measure the functional and prognostic value for -year mortality of the frailty index (fi) in a cohort of older women with gynecological cancer. methods: the prognostic value of fi was tested in older women with gynecological cancer (mean age = . years). fi was retrospectively calculated following the rockwood model[ ]. spearman's rho test was used for correlations with other oncological scales: eastern cooperative oncology group performance status (ecog); karnofsky performance status (kps); vulnerable elders scale- (ves- ). cox proportional hazard models and roc curve were performed to estimate prognostic role of -year mortality. sensitivity and specificity were also calculated. results: fi is normally distributed and descriptive statistics define our population as frail (mean = . ± . , range . - . ). . is confirmed as an upper limit compatible with life. fi doesn't significantly correlates with age, ecog and kps while it positively correlates with ves- (r= . , p < . ). fi is the strongest predictor for -year mortality confirmed after all adjustments for confounders (or . ; % ci . - . , p < . ) and by roc curve analyses ( . , % ci . - . , p=. ). conclusion: frailty index is a useful tool to detect vulnerability in onco-geriatrics and it predicts -year mortality. it predicts negative health-related outcomes (mortality) better than other traditional scales. its adoption may support a more efficient identification of patients in the need of adapted and personalized care. further studies are needed to confirm and extend these findings. background: frailty has been studied in the old population due to its association with negative outcomes but more information is needed about frailty in very old samples. the fried frailty phenotype (ffp) has been widely used and includes a set of objective indicators: weakness, slowness, unintentional weight loss, exhaustion and low physical activity. objectives: to determine which sociodemographic, functional and health-related variables predict ffp in a sample of community-dwelling individuals aged +yrs. methods: data from individuals living in the metropolitan area of porto were considered: sociodemographic information (age, sex, education level, living status), ffp ( - ), functionality (basic and instrumental activities of daily living), health information (nr. medicines, nr diseases, nr. falls, cognitive impairment, and self-perception of health). descriptive and correlational analysis were conducted and followed by a linear regression analysis (stepwise method) of variables significantly associated with ffp. results: participants' mean age was . years (sd= . ), they were mainly women ( . %), with - years of education ( . %) and living with a relative ( . %). high disability levels were found both for basic and instrumental activities of daily living. the mean of medicines intake was . (sd= . ) and of diseases . (sd= . ); . % of the participants rated their health as poor. the median number of falls in the last year was (iqr= ). participants scored on average . points (sd= . ) in mmse. gender or age were not associated with ffp. basic and instrumental activities of daily living, selfperception of health and cognitive performance significantly predicted ffp. in the adjusted model (r = . ), the stronger predictor was the higher dependency for basic activities of daily living, followed by worst self-perception of health and lower scores of cognitive performance. the dependency for instrumental activities of daily living lost its significance in the adjusted model. conclusion: our results identify three main predictors of ffp (basic activities of daily living, selfperception of health, and cognitive performance) in participants with advanced age. these results provide relevant information for further understanding of frailty and the ffp among the oldest old. background: unplanned hospital readmissions are associated with poorer prognosis and increased risk of functional decline and dependence in older people. identifying major risk factors and assessing clinical risk scores can help to distinguish patients at risk of worse outcomes and rehospitalization, allowing the proposal of preventive measures. the aim of this study was to compare the accuracy of different instruments and risk factors in predicting readmission, functional decline and death in hospitalized older patients in a brazilian geriatric unit. methods: in a cohort study performed at a geriatric unit, patients, years old or over were included. demographic data, functional status, prisma scale, geriatric depression scale, mini mental state examination, timed get up and go test, gait speed, mini nutritional assessment, palmar prehension strength, charlson comorbities index, frailty score of the cardiovascular health study and the senior index risk for rehospitalization were assessed at study admission. all patients received a follow-up telephone call at days after discharge to assess potential readmissions, deaths and functional status. results: mean age was . years (sd +- . ) and the mean barthel adl score was . (sd +- . ). altered barthel ( . ; ci % . - . ; p< . ), chs score ( . ; ci % . - . ; p< . ), isar-hp ( . ; ci % . - . ; p= . ), tgug ( . ; ci % . - . ; p< . ), palmar prehension ( . ; ci % . - . ; p= . ) and gait speed ( . ; ci % . - . ; p= . ) were associated with higher mortality days after discharge. the risk of functional decline at -month follow up evaluation was higher in patients with altered barthel ( . ; ci % . - . ; p< . ), lawton ( . ; ic % . - . ; p= . ), chs score ( . ; ci % . - . ; p< . ), isar-hp ( . ; ci % . - . ; p< . ), prisma ( . ; ci % . - . ; p= . ), tgug ( . ; ci % . - . ; p< . ), palmar prehension ( . ; ci % . - . ; p< . ) and gait speed ( . ; ci % . . ; p= . ). conclusion: altered iadl, frailty chs score, isar, tgug, palmar prehension strength and gait speed are predictive of functional decline and mortality days after hospital discharge. these tools can be useful to pinpoint frailty in older patients, allowing the implementation of preventive interventions to avoid functional decline. more research is needed to evaluate the role of these tools in predicting rehospitalization. to limit the strain on available resources and prevent an unnecessary increase in patient burden. objectives: this study aimed to improve patient selection for multi-disciplinary care by identifying risk factors for disability after cardiac surgery in elderly patients. methods: two-centre prospective cohort study in patients aged >= years undergoing elective cardiac surgery. before surgery frailty characteristics were investigated. outcome was disability at three months defined as world health organisation disability assessment schedule . >= %. multivariable modelling using logistic regression, concordance statistic (c-statistic), and net reclassification index were used to identify factors contributing patient selection. results: disability occurred in ( %) patients. ten out of frailty characteristics were associated with disability. a multivariable model including euroscore ii and preoperative haemoglobin yielded a c-statistic of . ( % ci . - . ). after adding prespecified frailty characteristics (polypharmacy, gait speed, physical disability, preoperative health related quality of life, and living alone) to this model the c-statistic improved to . ( % ci . - . ). net reclassification index was . (p< . ) showing improved discrimination for patients at risk for disability at three months. conclusion: using preoperative frailty characteristics improves discrimination between elderly patients with and without disability at three months after cardiac surgery and can be used to guide patient selection for preoperative multi-disciplinary team care. fabiola valero , , henry tapia , , enrique valencia , , tania tello , , (( ) facultad de medicina, universidad peruana cayetano heredia, lima, peru; ( ) instituto de gerontología, universidad peruana cayetano heredia, lima, peru; ( ) hospital cayetano heredia, lima, peru) background: frailty is increasingly recognized as a risk assessment to detect vulnerability and complexity. currently, there are limited tools to predict adverse perioperative outcomes for the geriatric population with hip fracture. objectives: to determine frailty and functional dependence as predictors of intrahospital adverse events in hospitalized older adults with hip fractures in the orthogeriatric unit of a general hospital in lima, peru. methods: we conducted a prospective cohort involving patients aged years or older who were admitted to the orthogeriatric unit with hip fracture from june to june . data were obtained at the time of admission to our unit: frailty was assessed with the frail scale, function ability with the barthel scale, cognition with the short portable mental state questionnaire (spmsq) scale of pfeiffer, comorbidities, socio-family assessment and geriatric syndromes. patients were followed up to discharge, and adverse events were evaluated during this period. univariate models were performed, and logistic regression was done subsequently. results: patients with hip fractures were evaluated, the mean age was . ( . ) years, . % ( ) were women and . % ( ) came from nursing homes. hypertension was the most frequent comorbidity in . % ( ). % ( ) had a history of functional dependence on basic activities of daily living (abvd), % ( ) had some degree of cognitive impairment, . % ( ) had social problems, polypharmacy in . % ( ) and . % ( ) history of falls in the last year. according to frail scale, . % (n = ) were robust, . % (n = ) were pre-frail and . % were frail (n = ). . % ( ) had an adverse event while hospitalized (pneumonia, uti, delirium, acute renal injury, pet), of whom % ( ) were robust, . % ( ) pre-frail and % ( ) frail (p = . ). . % of patients with functional dependence on abvd presented adverse events. in the multivariate analysis, the factors associated with in-hospital adverse events were functional dependence in abvd, or: . , (ci: . - . ); frailty with an or: . ic ( . - . ) and social problem, or: . ic ( . - . ). conclusion: older adult patients hospitalized for hip fracture who had frailty, functional dependence, and social problems had significant adverse events at a general hospital in lima, peru. aiko inoue , chi hsien huang , , chiharu uno , kosuke fujita , , tomoharu kitada , , joji onishi , hiroyuki umegaki , masafumi kuzuya , (( ) institutes of innovation for future society, nagoya university, japan; ( ) department of community health and geriatrics, nagoya university graduate school of medicine, nagoya, japan; ( ) department of business administration, seijoh university, aichi, japan) background: social frailty was associated with age, sex, income, education, marital status, and household status. however, the risk factors of social frailty relatively less investigated. objectives: the aim of this study is to clarify the risk factors of social frailty in community-dwelling japanese elderly. methods: a health promotion project (nagoya-teng project) is designed to distribute health promotion programs including enhancement of nutrition and physical activity via cable tv channel for community-dwelling elders. of all participants (n= ), participants with complete baseline information (mean age . ± . years, men ( . %)) were included in our cross-sectional analysis. at baseline, demographic data, socio-economic status, geriatric depression scale (gds- ), japanese version of european health literacy survey questionnaire (j-hls-eu-q ) were obtained. social frailty was defined by household status (living alone or not), financial difficulty, social activity, and fulfilment of social needs. total deficit scores of or more were defined as social frailty, as social pre-frailty, and as robustness. results: a total of ( . %), ( . %), and ( . %) of all participants were categorized as social non-frailty, pre-frailty and social frailty, respectively. in multivariable logistic regression model after adjusting for age, sex, bmi, and education level, living without a spouse is a significant risk factor (p< . ) for social pre-frailty (or . , % ci . - . ) and social frailty (or . , ). low gds- scores were associated with high risk of social prefrailty (or . , % ci . - . ) and social frailty (or . , % ci . - . ). in addition, health literacy was inversely associated with social frailty (or . , % ci . - . ). age, sex, and education level were not associated with social frailty. conclusion: regardless of age and sex, living with a spouse and depression which is associated with activity of daily living and quality of life are associated with social frailty. low health literacy is also a risk factor of social frailty. in literature, loneliness and social frailty were associated with functional decline and mortality in the elderly. future approaches incorporating health literacy interventions are warranted to prevent social frailty in the aged society with increasing number of physical frail older adults. background: frailty increases the risk for morbidity and mortality after cardiac surgery. the influence of frailty on postsurgical functional outcomes is largely unknown. objectives: the aim of this research was to study the association of preoperative frailty characteristics on adverse functional outcomes and to investigate the trajectory of functional recovery among frail and non-frail elderly patients up to one year after elective cardiac surgery. methods: a prospective two-centre observational cohort study in elective cardiac surgery patients aged >= years. preanaesthesia assessment was supplemented with frailty tests covering the physical, mental, and social domain. functional outcomes were assessed at one year and included change in health related quality of life (hrql) measured by the short form and disability measured by the world health organisation disability assessment schedule . . adverse functional outcome was considered when worse physical or mental hrql or disability was present after surgery. results: frailty characteristics were present in ( %) patients of whom ( %), ( %) and ( %) showed frailty in the physical, mental or social domain respectively. adverse functional outcome at one year after surgery occurred in ( %) patients. patients with an adverse functional outcome were more often frail ( ( %)) than patients without an adverse functional outcome ( ( %) p< . ). worse physical or mental hrql occurred in ( %) and ( %) patients respectively. the most important frailty characteristic associated with worse physical hrql was high preoperative physical hrql (β - . per point ( % ci - . to - . ). preoperative mental hrql showed the strongest associations for worse mental hrql (β - . per point ( % ci - . to - . )). disability was reported by ( %) patients and associated with preoperative polypharmacy, gait speed, health related quality of life, living alone or dependent living. gait speed had the strongest association (β . per second ( % ci . to . )). conclusion: preoperative frailty characteristics were common and predictive for adverse functional outcome one year after cardiac surgery. frailty screening can be used to improve risk stratification and decision making in older cardiac surgery patients. background: frailty frailty has many elements and these can be characterised as physical, nutritive (including body composition), cognitive and sensory (including hearing and seeing). the relative prevalence and importance of these elements are not known. objectives: to estimate the prevalence of frailty and relative contribution of physical/ balance, nutritive, cognitive and sensory frailty to important adverse health states (falls, physical activity levels, outdoor mobility, problems in self-care or usual activities, and lack of energy or accomplishment) in an english cohort. methods: analysis of community-dwelling older people. the sample was drawn from a random selection of all people aged or more registered with general practices across england. data were collected by postal questionnaire. frailty was measured with the strawbridge questionnaire. we used cross sectional, multivariate logistic regression to estimate the association between frailty domains and adverse health outcomes. some models were stratified by sex and age. results: mean age of participants was years (sd . ), range to and . % ( / ) were men. the prevalence of overall frailty was . % ( / ) and there was no difference in prevalence by sex (odds ratio . ; % confidence interval . to . ). sensory frailty was the most common and this was reported by more men ( / ) than women ( / ; odds ratio for sensory frailty . , % confidence interval . to . ). men were less likely than women to have physical or nutritive frailty. physical frailty had the strongest independent associations with adverse health states. however, sensory frailty was independently associated with falls, less frequent walking, problems in selfcare and usual activities, lack of energy and accomplishment. conclusion: physical frailty was more strongly associated with adverse health states, but sensory frailty was much more common. the health gain from intervention for sensory frailty in england is likely to be substantial, particularly for older men. sensory frailty should be explored further as an important target of intervention to improve health outcomes for older people both at clinical and population level. background: it live independently. our goal is to encourage independent living, wellbeing and to relieve health and care services budget pressure. longevity is one of the biggest achievements of modern societies. by , a quarter of europeans will be over years of age. combined with low birth rates, this will bring about significant changes to the structure of european society, which will impact on our economy, social security and health care systems. the most problematic expression of population ageing is the clinical condition of frailty. frailty develops because of age-related decline in multiple physiological systems. it is estimated that a quarter to a half of people over years are frail , and this is set to reach epidemic proportions over the next few decades. while frailty increases, the average amount of health spending increases as well with the frailty level in a range from , to , €/person year, depending upon the frailty status and the setting of care. frailty usually comes along associated with another risk facto; loneliness. then, ageing, frailty and loneliness constitute overlapping conditions submitted to multiple health and care interventions. ecare project aims to deliver disruptive digital solutions for the prevention and comprehensive management of frailty to encourage independent living, wellbeing and to relieve health and care services budget pressure, throughout the implementation of a pre-commercial procurement scheme. pre-commercial procurement is an ideal framework for the delivery of innovative solutions. the ecare network of procurers and the service providers are often on the frontline as new needs emerge. this pcp will allow the procurers to voice out their unmet needs, create a new demand to access sustainable products of higher quality, and develop new applications with lower life cycle costs. the demand and the supply side will work together to co-create and co-design the solutions and validate their functionalities against the specific challenges outlined in the pcp call for tender. this will clearly maximize the engagement of innovation in health and care services. solutions should improve outcomes for frailty in old adults entailing the physical and the psychosocial factors. the target group are the pre-frail/frail old adults with emphasis on those that feel lonely and/or isolated. the project will procure the development, testing and implementation of digital tools/services and communication concepts to facilitate the transition to integrated care models across health and social services and country-specific cross-institutional set-ups, including decentralised procurement environments and collaboration across institutions. objectives: the project objectives are: • newly development easy-to-use and reliable solutions that facilitate early detection of frailty based on the most efficient standards and methods. • improve the understanding of the factors affecting frailty and the feelings of loneliness and isolation, and how they do correlate (e.g.: gender dimension, social context, etc.). • deliver personalised intervention plans taking into account the end-user societal context. • innovative and meaningful means to tackle the feelings of loneliness and isolation. • new approaches to engage patients as active self-managers of their own health. • new technology developments designed and oriented to the target end-user. • and among all, investigate to deliver cost-efficient solutions, affordable to the payers involved. methods: ecare procurers will proactively organize the requirements of the demand for care solutions in a coherent way. the procurers (buyers' group) will assess the solution adequacy to the targets. the preferred partners will contribute with solid knowledge of innovative procurement paths to the innovation procurement tender. the project partners will do this by: • providing a solid and informed base for dialogue between stakeholders by determining a coherent picture of the market state of the art of the sector based on practical experience of customers and suppliers. • enabling a genuine and credible dialogue between the supply-chain and customers to determine the practical policy and procurement actions required to deliver the ecare solutions. • defining the common unmet needs, communicating these to stakeholders and initiating a mobilization plan for a pcp addressing ecare needs. the pcp may be summarized in a series of actions: • convey the relevance of innovation procurement to public procurers: encouraging suppliers to offer novel solutions to address ecare challenges rather than the lowest price solutions. • analyze the state of the art of the market with all potential suppliers, as well as the main problematic and barriers faced in the sector and that need to be overcome a set of actions involving both the supply and demand sides will be carried out: a coordinated first analysis of the state of the art conducted by all project members followed by a coordinated market sounding through all dissemination channels managed by the consortium will be undertaken to spread project results aiming to receive feedback from all key market players. for this, the role of procurers is vital to replicate and stretch the impact of the project. • providing public procurers with procurement know-how to improve public sector procurement efficiency and increase public sector market power by giving support to apply the methodologies of innovation procurement. market sounding will provide an opportunity for engagement and two-way dialogue with innovative companies that can offer solutions and guidance on how to overcome the procurement barriers. • launching an agreed, realistic and validated joint pcp tender. results: the ecare consortium is immerse in a deep process of unmet needs detection. our goal is to be extraordinarily concrete when defining what the end users and the healthcare professionals are willing for. those unmet needs will be critical for the definition of the requirements and uses cases that the it suppliers will have to follow to design the ict solutions. then… what a better way to know their needs that asking them personally? the vision of providing tailored fit solutions and tools to the end users led to the consensus in creating and facilitating focus group sessions across the procurers regions -campania (italy), barcelona (spain), santander (spain) and wroclaw (poland)-. these sessions will be involving end users, health and social care professionals, and it internal departments of the procurers' organisations. -the focus group script for the end users sessions integrates as main topics the specific condition and related symptoms; experiences of services and care provided; experiences of managing condition when progressing rapidly ; needs for symptom management and how these can be met ; integration of it supportive tools in the management of frailty and loneliness. -the professionals are invited to reflect and discuss the topics of common symptoms and actual care model; experiences of monitoring elderly when condition is progressing rapidly; views about the supportive care needs of elderly and caregivers; early integration of the new care in the management of frailty and loneliness; integration of it supportive tools in the management of frailty and loneliness. -the identified and proposed topics for the it staff would be the state of the art of the relation in between it and social/healthcare; state of the art of interventions on frailty and loneliness. all the four procurers were challenged to organize, at least, focus sessions, one with each specific target group. so far, all the procurers already organized and scheduled the sessions that will occur until the end of january. in terms of impact, participants are expected to be involved ( end users, healthcare professionals and it people). all the representative of the procurers reported so far that the participants have been considering the sessions so interesting and useful. in fact, new topics have been put in the table for discussion in all the different sessions, adding more important information for the definition of the unmet needs. the journey of the project so far has been providing very powerful insights and evidences that people and professionals appreciate to be involved and e(motionally) cared. conclusion: ecare will progress beyond the state of the art by approaching older people not just in terms of their diseases but also in terms of physical, cognitive and psychosocial care and support to prevent functional decline, frailty and disability. the project key components to address frailty are those that define also integrated care, with the addition of targeting high risk frail individuals, an enablement attitude and a focus on outcomes most relevant to frail individuals and their caregivers. for these, a multimodal comprehensive system able to provide the most effective care will need to be provided. background: maintaining autonomy as life progresses has become a challenge for the health systems. this objective can only be achieved by moving the axis of health policies and health care practice from the disease to the preservation of functional capacity. objectives: the aim of this study is to design and pilot a model for the assessment and support of functionality for community dwelling older people. methods: a space in which nurse and social worker jointly assess the functional capacity of older people and identify and provide responses to the detected deficits was proposed. this study was performed in osi donostialdea (gipuzkoa, spain). three main tasks were carried out: . definition of the joint assessment procedure of functionality. . identification of the existing resources and community assets to give answer to the identified needs. . piloting the model in a sample of older people. the identified needs and the availability of resources to respond to them were obtained from the pilot phase. results: in the initial version of this integral assessment were included, functional capacity, physical activity, cognitive capacity, sense organs, nutritional status, social assessment and housing and environmental conditions. a total of individuals ( % women; mean age years, sd= . ; barthel index, mean . , sd= . ; % living alone; % without cognitive impairment) were recruited during the pilot. the following needs were identified: personalized workout routines, fine motor skill exercises, visual and efficient diets adjusted to each patient, make sure resources reach the community, promote the use and design of gadgets to assist the needs of basic and instrumental activities of daily living, improve strategies to prevent cognitive function impairment, ease loneliness and avoid or minimize physical and environmental barriers to access home, to walk the streets and, particularly, to use public transport. there were no resources available for all the identified needs. conclusion: this study will allow the development of a model for the integral assessment of functionality for the aged population, based in a multidisciplinary team, a space and a new way of working in primary care. mónica machón - , maider mateo-abad , , mercedes clerencia-sierra , , , carolina güell , , beatriz poblador-pou , , kalliopi vrotsou - , antonio gimeno-miguel , , alexandra prados-torres , , itziar vergara - ( ( ) background: multimorbidity and frailty are often present in older people and are found to be associated to increased risk of adverse health events. it is necessary to improve the knowledge of the characteristics of such populations to design adequate clinical guidelines seeking to avoid or delay the onset of dependence. objectives: the aim of this study was to identify clusters of chronic diseases in robust and frail individuals and compare sociodemographic and health characteristics between these clusters. methods: this was a cross-sectional study based on data from two longitudinal studies. the sample was composed of functionally independent community-dwelling older people with multimorbidity living in gipuzkoa (basque country, spain). information from electronic health records (diagnose diseases and medication) and a baseline assessment (sociodemographic characteristics, functional status, self-perceived health, cognitive status, sight and hearing impairments, history of falls and nutritional status) was used in the analysis. the timed up and go test of physical performance was included as a measure of frailty. multiple correspondence and cluster analyses were performed to identify groups. results: the study population consisted of individuals ( . % women; mean age . years, sd= . ). frail individuals (n= ) were older, had a lower educational level and a poorer health status than robust individuals (n= ). three clusters were obtained in robust (rc , n= ; rc , n= and rc , n= ) and four among the frail individuals (fc , n= ; fc , n= ; fc , n= and fc , n= ). in rc and fc , none of the chronic diseases had a higher prevalence than in rc -rc and fc -fc -fc , respectively. individuals pertaining to rc and fc presented more frequently diseases related to mobility limitation or limb pain compare to the other clusters. higher rates of cardiovascular diseases and risk factors were seen in rc and fc . in frail individuals a new cluster emerged, fc , containing individuals with higher rates of cognitive and eye problems and a clearly poorer health status. conclusion: the findings obtained in this exploratory study may provide insight for the designing of more specific health interventions for older patients with multimorbidity, even though the chronic diseases cluster identified were similar in robust and frail individuals. background: older african americans (oaa) are at high risk for becoming frail in later life. interventions can reverse or delay frailty, yet oaa have largely been excluded from frailty intervention research. many interventions are also time and resource intensive, making them inaccessible to socially disadvantaged oaa. objectives: we present results of a feasibility trial of a low dose frailty prevention intervention among community-dwelling, pre-frail oaa aged + recruited from a primary care clinic between june st and october st . methods: using a -arm rct, participants were assigned to the intervention, which was delivered by an occupational therapist (ot) and comprised of four sessions over four months (an ot evaluation, and sessions on healthy dietary practices, increasing physical activity, and maintaining a healthy lifestyle), or enhanced usual care (publicly available information about healthy lifestyle, home safety, and local elder services). feasibility criteria were set a priori at % for participant retention (including attrition due to death/ hospitalization), % for session engagement, participants/ week for mean participant accrual, and % for program satisfaction. results: participants were % female with an average age of . years, . % of which lived alone and . % lived off of less than k per year. feasibility metrics were met. the study recruited . participants per week and retained % of participants who attended % of scheduled sessions. mean satisfaction scores were %. the treatment also resulted in positive trends in the expected direction in the treatment group for the following outcomes (d = effect size): global health (d = . ), mental health (d = . ), qol (d = . ), social functioning (d = . ), depression (d = . ), and pain reduction (d = . ). descriptively, treatment group participants were also less likely to experience a progression (deterioration) in three frailty status indicators at -months compared to controls: weight lost, walking speed slowness, and grip strength weakness. conclusion: the intervention was feasible to deliver. qualitative findings from exit interviews suggested changes to the program dose, structure, and content that could improve it for future use. background: it is well known that frail patients are potentially most at risk of functional decline following a hospital admission. objectives: to measure the effects of an augmented prescribed exercise programme versus usual care, on physical performance, quality of life and healthcare utilisation for frail older medical patients in the acute setting. methods: this was a parallel single-blinded randomised controlled trial. within two days of admission, older medical inpatients with an anticipated length of stay >= days, needing assistance/aid to walk, were blindly randomly allocated to the intervention or control group. until discharge, both groups received twice daily, monday-to-friday half-hour assisted exercises, assisted by a staff physiotherapist. the intervention group completed tailored strengthening and balance exercises; the control group performed stretching and relaxation exercises. length of stay was the primary outcome measure. blindly assessed secondary measures included readmissions within three months, and physical performance (short physical performance battery) and quality of life (euroqol- d- l) at discharge and at three months. time-to-event analysis was used to measure differences in length of stay, and regression models were used to measure differences in physical performance, quality of life, adverse events (falls, deaths) and negative events (prolonged hospitalisation, institutionalisation). results: of the patients allocated, patients' (aged ± . years) data were analysed. groups were comparable at baseline. in intention-to-treat analysis, length of stay did not differ between groups (hr . ( % ci, . - . ) p= . ). physical performance was better in the intervention group at discharge (difference . ( % ci, . - . ) p= . ), but lost at follow-up (difference . ( % ci, - . - . ) p= . ). an improvement in quality of life was detected at follow-up in the intervention group (difference . ( % ci, . - . ) p= . ). overall, fewer negative events occurred in the intervention group (or . ( % ci . - . ) p= . ). conclusion: improvements in physical performance, quality of life and fewer negative events suggest that this intervention is of value to frail medical inpatients. its effect on length of stay remains unclear. background: to propose a simple frailty screening tool able to highlight frailty profiles, already since the initial screening phase. methods: a -item questionnaire (lorraine frailty profiling screening scale, lofpross), constructed by an experts' working group, was administered by health professionals to participants > years old (n= ) and living at home, in different clinical settings: a primary care outpatient clinic (rural population, n= ), a geriatric day clinic (day-clinic population, n= ) and healthy volunteers (urban population, n= ). a multiple correspondence analysis (mca) followed by a hierarchical clustering of the results of the mca performed in each population was conducted to identify participant profiles based on their answers to lofpross. a response pattern algorithm was resultantly identified in the rural (main) population and subsequently applied to the urban and day-clinic populations and, in these populations, the two classification methods were compared. finally, clinically-relevant profiles were generated and compared for their ability to similarly classify subjects. results: the response pattern differed between the subpopulations for all items, revealing significant intergroup differences ( . ± . positive responses for urban vs. . ± . for rural vs. . ± . for day-clinic, all p< . ). five clusters were highlighted in the main rural population: "non-frail", "hospitalizations", "physical problems", "social isolation" and "behavioral", with similar clusters highlighted in the remaining two populations. identification of the response pattern algorithm in the rural population yielded a second classification approach, with % of tested participants classified in the same cluster using the different approaches. three clinically-relevant profiles ("non-frail" profile, "physical frailty and diseases" profile and "cognitive-psychological frailty" profile) were subsequently generated from the clusters. a similar double classification approach as above was applied to these profiles revealing a very high percentage ( . %) of similar profile classifications using both methods. conclusion: the present results demonstrate the ability of lofpross to highlight frailty-related profiles, in a consistent manner, among different older populations living at home. such scale could represent an added value as a simple frailty screening tool for accelerated and better-targeted investigations and interventions. ( ) homburg/saar/germany, saarland university medical center, neurology, homburg/germany) background: frailty is the most important short and long term predictor of disability in the elderly. no study to date evaluate the impact of frailty on short and long term independently from neurological outcome measures. objectives: the aim of the study was to evaluate whether diagnosis frailty predicts short and long-term mortality and neurological recovery in old patients who underwent reperfusion acute treatment in stroke unit. methods: consecutive patients were older than years who underwent thrombectomy or thrombolysis in a single stroke unit from to . predictors of stroke outcomes were assessed including demographics, baseline nihss, time to needle, treatment and medical complications. premorbid frailty was assessed with a comprehensive geriatric assessment (cga) including functional, nutritional, cognitive, social and comorbidities status. at and months, all-cause of death and clinical recovery (using mrs) were evaluated. results: patients, of whom underwent mechanical thrombectomy and venous thrombolysis (mean age . , - years) entered the study. frailty was diagnosed in out of patients and associated with older age (p= . ) but no differences in baseline nihss score or treatment strategies. at follow-up, frail patients showed higher incidence of death at ( % vs %, p= . ) and ( % vs %, p= . ) months. frailty was associated with worse neurological recovery at month (mrs . + . vs . + . , p= . ) and one year followup (mrs . + . vs . + . ) for free survival patients. conclusion: frailty is an important predictor of efficacy of acute treatment of stroke beyond classical predictors of stroke outcomes. larger prospective studies are warranted in order to confirm our findings. background: frailty becomes increasingly common as adults age and has known associations with activity limitations and injurious falls among older adults. while it is believed that frailer older adults are less socially connected than their more functional counterparts, less is known about the relationship between frailty and social isolation among community-dwelling older adults. objectives: the purpose of this study was to examine associations of frailty indicators on self-reported social isolation risk among community-dwelling adults age years and older. methods: the upstream social isolation risk screener (u-sirs) was developed to assess social isolation risk among older adults within clinical and community settings. comprised of items (cronbach's alpha= . ), the u-sirs assesses physical, emotional, and social support aspects of social isolation. using an internet-delivered survey, data were collected from a national sample of , adults age years and older. participants completed the u-sirs and additional items on sociodemographics and other health risks. theta scores for the u-sirs serve as the dependent variable, which were generated using item response theory. an ordinary least squares regression model was fitted to identify frailty indicators associated with social isolation risk. results: participants' average age was . (± . ) years. the majority of participants was female ( . %) and lived with a partner/spouse ( . %). twenty eight percent of participants reported difficulty walking or climbing stairs, . % reported difficulty dressing or bathing, and . % reported a fall in the past year. higher u-sirs theta scores were reported among males (b= . , p< . ) and those with more chronic conditions (b= . , p< . ). participants who reported difficulty walking or climbing stairs (b= . , p< . ), difficulty dressing or bathing (b= . , p= . ), or a fall in the past year (b= . , p< . ) also reported higher u-sirs theta scores. further, higher u-sirs theta scores were reported among participants who had not left their home in the past three days (b= . , p< . ). conclusion: findings suggest frailer older adults and those with functional limitations may have greater risk for social isolation. this highlights the critical demand for easy-to-administer and practical assessments for frail older adults that identify their social isolation risk and link them to needed resources and services. background: peak expiratory flow (pef) has been linked to several negative health-related outcomes in older people, but its association with frailty is still unclear. objectives: this study investigates the association between pef and prevalent and incident frailty in older adults. methods: data come from community-dwelling participants of the swedish national study on aging and care in kundgsholmen (snac-k), aged >= years. baseline pef was expressed as standardized residual (sr) percentiles. frailty was assessed at baseline and over six years, according to the fried criteria. associations between pef and frailty were estimated crosssectionally through logistic regressions, and longitudinally by multinomial logistic regression, considering death as alternative outcome. obstructive respiratory diseases and smoking habits were treated as potential effect modifiers. results: our crosssectional results showed that the th- th and < th pef sr-percentile categories were associated with three-and fivefold higher likelihood of being frail, than the th- th one. similar estimates were confirmed longitudinally, i.e. adjusted or= . ( %ci: . - . ) for pef sr-percentiles< th, compared with th- th. associations were enounced in participants without physical deficits, and tended to be stronger among those with baseline obstructive respiratory diseases, and, longitudinally, also among former/current smokers. conclusion: these findings suggest that pef is a marker of general robustness in older adults and its reduction, exceeding that expected by age, is associated with frailty development. background: as consistently reported in the literature, muscle strength (ms) decreases at a higher rate than muscle mass (mm) during aging resulting in a decreased muscle quality (mq). loss of mq has been associated with loss of mobility, falls, frailty and an increased risk of mortality. however, the degree of muscle declines is varying throughout the population leading to states: successful, normal or pathological. it has been proposed that healthy life habits such as be physically active, having a healthy diet etc. could reduce the muscle aging decline. thus, identifying if life habits could counteract or maintain muscle quality during successful aging is important to better characterize aging and to intervene more specifically. objectives: the aim of the present study was to identify whether a physically active lifestyle could attenuate the effects of aging on mq. methods: active young were compared to active older men. to be considered active, young and older men need to practice voluntary physical activity at least min/week since yrs. body composition (dxa; mri) and maximum knee extension strength were measured. mq was calculated as the ratio of ms to mm. aerobic capacity (vo max; moxus©) and muscle contractility (emg) were also measured. muscle biopsies were performed to determine fiber typing, size, intermuscular adipose tissue (imat) and intramyocellular lipid content (imcl). results: absolute mm (p< . ) and ms (p= . ) was greater in young participants compared to their older counterparts while mq was similar between them. even if total (p= . ) and type iia (p= . ) fiber size were greater in ya than in oa, muscle fiber proportion, muscle contractility and lower limb fat mass (imat, imcl) were similar between both groups (p> . ). conclusion: mq was similar between younger and older physically active men suggesting that being physical activity may have mitigated the loss of mq with aging and delayed some physiological age-related changes (muscle composition, contractility). i r a t x e e g a ñ a , itxaso mugica , , nagore arizaga , maider ugartemendia , nagore zinkunegi , janire virgala , maider kortajarena ( ( ) and sppb test (p< , ). similar results have been found in other researches. the parameters that have higher influence in cognition are handgrip test (p< , ) and frailty (p< , ). in other investigations, they got the same results; better cognition is related to better physical capacity and less fragility. in regards with functionality, the values of tug test (p< , ) and gait speed (p< , ) are the ones that show stronger relation. in other investigations, they observed that physical state and functionality were related. conclusion: the quality of life, the functionality and moca test are interconnected and the parameters that have the strongest statistical relationship are fragility and physical state. the greater the physical capacity of the older person is, the greater the functional capacity is too and the fragility decreases. in conclusion, the quality of life is better. kazuki kaji , jun kitagawa , takahiro tachiki , naonobu takahira , masayuki iki , junko tamaki , etsuko kajita , yuho sato , jpos study group (( ) national center for geriatrics and gerontology, obu, aichi, japan; ( ) nagoya university, nagoya, aichi, japan; ( ) nagoya city university, nagoya, aichi, japan) background: the skeletal muscle mass index (smi), which is the appendicular skeletal muscle mass (asm) adjusted for height squared (kg/m ), is used to assess skeletal muscle mass. we reported at this conference last year that smi was overestimated by height loss due to aging in elderly women. furthermore, age-related changes in smi were inconsistent with changes in physical function such as grip strength and walking speed. objectives: the purpose of this cross-sectional study was to investigate the effects of height loss on agerelated changes in smi and physical function in japanese women aged or older. methods: this study was part of the / -year follow up survey of the japanese population-based osteoporosis (jpos) cohort study conducted in / . the jpos study was started in . the subjects of the / year follow-up were women (mean . ± . years). we divided the subjects into quartiles based on years of height loss (q : the lowest, q , q and q : the highest). asm was measured by dual x-ray absorptiometry (qdr a, hologic, usa). grip strength, maximum walking speed, and timed up and go (tug) were also measured. results: the mean change in height during the / -year follow-up was - . ± . cm. mean changes in height in q (n= ), q (n= ), q (n= ) and q (n= ) were - . ± . cm, - . ± . cm, - . ± . cm and - . ± . cm, respectively. the trend test demonstrated significant increases in the mean age and smi from q to q . on the other hand, there was a significant decrease in asm from q to q . the mean grip strength and maximum walking speed significantly decreased from q to q . tug results were similar, suggesting that greater height loss led to longer times. conclusion: in japanese elderly women with height loss, asm and physical function decreased with age, but the smi adjusted for height increased. it may be necessary to establish a muscle mass parameter other than smi to investigate the relationship between muscle mass and physical function. kota tsutsumimoto , takehiko doi , sho nakakubo , satoshi kurita , hideaki ishii , hiroyuki shimada (( ) section for health promotion, department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology, aichi, japan; ( ) center for gerontology and social science, national center for geriatrics and gerontology, aichi, japan) background: sarcopenia was defined as decline in skeletal muscle mass and muscle function, leading to serious health problems including disability. the modifiable risk factors of sarcopenia should be elucidated to contribute to develop intervention from sarcopenia. objectives: to examine the association between anorexia of aging and sarcopenia among community-dwelling elderly japanese individuals. methods: population-based, cross-sectional cohort study in japanese older adults was conducted and participants were identified from the database of the national center for geriatrics and gerontology-study of geriatric syndromes. anorexia of aging was assessed via a simplified nutritional appetite questionnaire. handgrip strength and walking speed were tested, and skeletal muscle mass was assessed using a bio-impedance analysis device. subjects with sarcopenia were defined as those who met the criteria of the asian working group for sarcopenia. the association between anorexia of aging and sarcopenia was then analyzed via multiple regression analysis. results: in total, , elderly japanese individuals were evaluated. the prevalence of sarcopenia and anorexia of aging was . % and . %, respectively. in multivariable logistic regression model adjusted for the covariates except for nutritional status such as albumin, anorexia of aging was independently associated with sarcopenia (or: . , % ci: . to . ; p = . ). this significant association remained even after adjusting for all covariates including nutritional status (or: . , % ci: . to . , p = . ). conclusion: anorexia of aging is associated with sarcopenia among japanese older adults. further studies are needed to determine whether a causal association exists between anorexia and sarcopenia. background: low grip strength is consistently associated with higher rates of mortality, disability and other age-related health outcomes, and is a key characteristic of sarcopenia. grip strength has thus been proposed as a general biomarker of ageing. life expectancy in russia is substantially lower than in norway but whether this is reflected in differences in grip strength across adulthood, as observed in previous comparisons of older adults from russia, denmark and england, needs to be established and explained. objectives: we aimed to compare grip strength in norwegian and russian populations by age and gender, and investigate whether any observed differences were explained by contrasts in height, weight, smoking or education. methods: we used harmonised cross-sectional data on grip strength for , men and women aged - years. this comprised participants from the russian know your heart study (n= , ) conducted in the cities arkhangelsk and novosibirsk in - , and from wave of the norwegian tromsø study (n= , ) conducted in - . grip strength was assessed using the jamar+ digital dynamometer in both studies, and the maximum of six measurements (three in each hand) was used. the association between grip strength and covariates was assessed using linear regression. results: norwegian males had stronger grip than russian males at all ages, for example they were an average of . kg ( % confidence interval (ci) . , . ) stronger at age years and . kg ( % ci . , . ) stronger at age years. among women, corresponding numbers were . kg ( % ci . , . ) at age and . kg ( % ci . , . ) at age . adjustment for weight, education and smoking did not affect the results, but height attenuated the between country differences, especially at older ages. among women aged +, differences in height between countries fully explained the differences observed in grip strength. conclusion: norwegian -year-olds had the grip strength of -year-old russians suggesting that russians are ageing more rapidly in terms of muscular strength than their norwegian counterparts. the important role of height in explaining these differences, especially at older ages, suggest contrasts in early life circumstances may be of key importance. eleanor lunt , , paul greenhaff , , adam l gordon , , , john rf gladman , ( ( ) background: frailty is a state of vulnerability to stressors resulting in adverse clinical outcomes including falls and fragility fractures. identifying biomarkers associated with these outcomes may help target interventions. objectives: to compare parameters of body composition, muscle thickness and muscle strength between patients and healthy older and young volunteers. methods: six young ( - years) and older (>= years) healthy female volunteers were recruited by advert from community groups. female patients (>= years) with an acute fragility fracture were recruited from hospital wards and measured during first week of admission (median th day (iqr - )). frailty was determined by the -item frail scale. height, weight, handgrip (jamar dynamometer) and knee extension (lafayette manual muscle tester) were assessed. body composition was estimated using whole body bioelectrical impedance (bodystat quadscan ®). midpoint vastus lateralis (vl) muscle thickness and mid-thigh subcutaneous fat thickness were assessed using ultrasound (mylab gold, esaote biomedica, italy) with a hz linear-array probe. oneway anova and post hoc tukey's test were used to compare end-point measures between groups. results: frailty was significantly more prevalent in the patient group ( % frail, % pre-frail, % robust) than the healthy older group ( % robust, p< . ). the patient group was older ( ± years vs ± years, p< . ) and had more co-morbidities (p< . ). there were no significant differences between the patient and healthy older group in weight, height, bmi, percentage body fat or subcutaneous fat thickness of lateral thigh. vl muscle thickness was lower in the patient group compared to healthy older and young volunteers ( . ± . cm, . ± . cm and . ± . cm respectively, p< . ). the patient group also had lower handgrip strength ( . ± . kg, . ± . kg, . ± . kg respectively, p< . ) and lower knee extension strength ( . ± . kg, . ± . kg, . ± . kg respectively, p< . ). vl muscle thickness associated with muscle strength (knee extension r= . , p< . and handgrip r= . , p< . ) and was significantly lower in the frail compared to pre-frail or robust participants ( . ± . cm, . ± . cm, . ± . cm respectively p< . ). conclusion: female patients presenting to hospital with a fall and fragility fracture have lower muscle thickness in the thigh compared to non-frail older women, despite no difference in other body composition variables. register, health technology assessment, nhs economic evaluation database) were searched from inception to april , . cross-sectional and cohort studies that reported adjusted risk ratios with % confidence intervals (ci) for frailty with serum level of total testosterone, free testosterone, sex hormone-binding globulin (shbg) were selected. a metaanalysis was carried out by using fixed effects and random effects models to calculate the or of relationship between low level of testosterone and risk of frailty. results: the crosssectional study concluded articles, there was statistically significant association between lower level of total testosterone and risk of frailty (or= . ; %ci, . - . , i = %), as well as free testosterone (or= . ; %ci, . - . ,i = % ), the highest level of shbg was no significant associated with the risk of frailty(or= . ; %ci, . , . ; i = %). the prospective cohort studies obtain articles, no significant were found between frailty and low total testosterone and frailty (pool or= . ; %ci, . - . , i = %). conclusion: the meta-analysis indicates that low level of serum testosterone is significantly associated with the risk of frailty in the crosssection studies. however, we found no significant relationship between low total testosterone and frailty in the cohort studies. more research is needed to address the underlying mechanisms to explain this relationship and to determine whether testosterone supplementation is effective for preventing frailty syndrome. background: although frailty and abdominal obesity are known risk factors for disability in older persons, few studies have investigated the interaction between both factors on the association with disability. objectives: to investigate the association of frailty and abdominal obesity with disability in older persons. methods: we used data from , participants ( % men) in the prospective, population-based singapore chinese health study cohort, who were interviewed and examined for frailty, abdominal obesity and disability at mean age of (range to ) years from - . we defined frailty as having three or more features of weak handgrip strength, slow timed-up-and-go test, low energy level, multiple comorbidities, and difficulty carrying out usual activities. we defined abdominal obesity by waist circumference using sexspecific cut-offs, and assessed disability using the lawton instrumental activities of daily living (iadl) scale. we used multivariable logistic regression models to compute the odds ratio (or) and % confidence interval (ci) for the association between frailty/abdominal obesity and disability. results: about . % of participants were frail and . % had abdominal obesity. frailty was associated with increased or ( % ci) of . ( . - . ) for disability. conversely, the or ( % ci) for the association between abdominal obesity and frailty was only . ( . - . ). compared to participants who were neither frail nor abdominally obese, the or ( % ci) for disability was . ( . - . ) in those who only had frailty, and . ( . - . ) in those who only had abdominal obesity. however, participants who were both frail and abdominally obese had markedly increased or ( % ci) of . ( . - . ) for disability; p-value for interaction between frailty and abdominal obesity was . . furthermore, while men who were both frail and abdominally obese had increased or ( % ci) of . ( . - . ) for disability compared to their counterparts who were neither frail nor obese, the corresponding or ( % ci) was much higher at . ( . - . ) in women; p value for heterogeneity by sex < . . conclusion: frailty and abdominal obesity interacted synergistically to increase the risk of disability in older persons, and the combined effect of both factors on disability was much stronger in women than in men. background: as the world's population ages, the prevalence of cognitive impairment associated with age increases exponentially. objectives: objective of this study was to investigate the longitudinal association of physical activity and cognitive function in two deferentl populations; older adults from mexico representing latin america and south korea representing asia. based on two large population-based longitudinal studies. methods: this is a secondary analysis of two surveys, mhas and klosa, designed to study the aging process of adults living in mexico and south korea. participants> were selected from rural and urban areas. here we investigate the longitudinal association of exercise and cognition using the two waves of each study. cross cultural cognitive examination and mini-mental state examinarion were used to analyze the association between physical activity and cognition in mexican and korean older adults. multivariate logistic regression models were used to evaluate the said association. results: in mexico, the prevalence of physical activity was . %, physical active older adults obtained a higher score in ccce ( . ± . ) p-value < . . they also had more years of education ( . ± . vs. . ± . ) p-value < . , had depression ( . % vs. . %) . and consumed less alcohol ( . vs. . ) p-value < . . in korea, the prevalence of physical activity was . %. the physical active group performed better in mmse (- . ± . vs. . ± . ) p-value < . . the no physical active group had a higher proportion of women, less alcohol consumption ( . vs. . %) p-value < . , fewer years of education p-value < . and a higher prevalence of depression ( . % vs . %) p-value . . in the multivariate analysis an independent association was found in the korean population between physical activity and mmse score even after adjusting for confounders ( . ( . ; . ) p value . ). conclusion: physical activity could have a protective effect on the cognitive decline associated with ageing. background: aging is related to the increase of several chronic diseases, such as, osteoarthritis, osteoporosis, diabetes, hypertension and sarcopenia. sarcopenia (progressive loss of muscle mass and physical performance) is related to difficulties in treating other comorbidities, whether pharmacologically or non-pharmacologically. it's important to understand the relations between muscular strength (w), muscular mass and the phase angle (pa) of bioimpedance, in sarcopenic subjects to prescribe more accurate treatments. objectives: to study the relations of skeletal muscle index (smi) with w, pa and the presents of comorbidities (nc) in elderly subjects. methods: a prospective, observational secondary analysis of data from the "the sarcopenia screening and health related issues in the region of algarve", was performed. community independent living elderly subjects were recruited. body composition was measured by bioimpedance (seca analytics ), knee flexion and extension isokinetic strength ( º/sec) (humac norm). a screening questionnaire was used to determine the presence of comorbidities. smi levels were assessed using european working group on sarcopenia in older people cut-off points. results: a total of female and males, were included, mean age , (± , sd). subject were divided into groups according to smi: normal (n= ), moderated impairment (n= ) and severe impairment (n= ). pearson correlation were calculated within each group for w; pa and comorbidities. normal smi level, were correlated to knee extensors w in both legs (right: r= , , p< , and left r= , , p< , ) . no significant correlations were found with pa. moderate smi level: were correlated to knee extensors w in both legs (right: r= , , p< , and left r= , , p≤ , ), and also with knee flexors w (right: r= , , p< , ; left: r= , , p< , ). a moderate correlation was also found in this group with pa (r= , , p< , ). severe smi level: no correlations were found, in this group, with w. a moderate correlation was found with pa (r= , , p< , ). comorbidities did not have any correlations with smi levels. conclusion: our results seem to indicate that isokinetic strength (work) may have in the future a role in understanding sarcopenia, once it is related to smi. also, pa may indicate moderate and severe smi impairment. background: body characteristics as low muscle mass and high fat mass (fm) affect the physical function of older people. physical function is a fundamental component for the performance of daily activities and for the maintenance of the independence of older adults. however, the relationship between body composition and physical performance varies in different studies and still demands further research. objectives: this study aimed to investigate the association of fat mass index (fmi) determined by dual-energy x-ray absorptiometry (dxa) with physical performance in brazilian communitydwelling older adults. methods: a cross-sectional study with a sample of participants aged years and older, living in ribeirão preto, brazil, including both men and women, was conducted. fm was measured by dxa and fmi was calculated as fat mass/height (kg/m²). the physical performance was assessed by the -minute walk test, and walking distance was recorded as the main parameter, considering the distance predicted by sex. the kolmogorov-smirnov test was used to verify the normality of data distribution. the association of physical performance and fmi was analyzed using the pearson's correlation test and statistical significance was set at p ≤ . (two-sided). results: the participants were aged . ± . years, fmi was . ± . kg/m and distance walked was . ± . m. there was a significant negative association (r = - , p = . ) between fmi and distance walked, showing that higher fat mass index is associated with worse performance in the -minute walk test. conclusion: high fat mass index is associated with worse physical performance in brazilian older adults. background: sarcopenia and physical frailty have been shown to be risk factors for mortality and major morbidity in older adults suffering from various forms of cardiovascular disease. ultrasound measurement of quadriceps muscle thickness (qmt) is an emerging biomarker for sarcopenia, which we hypothesized could be conveniently acquired during the routine echocardiographic exam. objectives: to demonstrate the feasibility of measuring qmt at the time of echocardiography, and determine the association between qmt and clinical indictors of frailty. methods: adult inpatients and outpatients undergoing a clinically-indicated echocardiogram for known or suspected cardiovascular disease were recruited for this cross-sectional study at the jewish general hospital. prior to the echocardiogram, trained research assistants measured height, weight, and three clinical indicators of frailty: rockwood's clinical frailty scale, handgrip strength (jamar dynamometer), and bioimpedance phase angle (inbody ). at the conclusion of the echocardiogram, cardiac sonographers blinded to the preceding assessments acquired a biplane image of the anterior thigh midway between the anterior superior iliac spine and knee, and measured qmt as the combined thickness of the rectus femoris and vastus intermedius muscles. a cardiac ultrasound machine and probe were used (ge vivid e /e , . - . mhz probe). results: the cohort consisted of patients, of which had an available measure of qmt. the acquisition and measurement of qmt added - minutes to the echocardiographic exam. the mean age was +/- years with % females. the mean qmt was +/- mm, similar in men and women, with the lowest quintile being < . mm. higher age and lower body mass index were associated with lower qmt. after adjustment for age, sex, and body mass index, qmt was found to be associated with the multivariate composite of frailty indicators (p< . ), particularly with the clinical frailty scale (beta - . per mm; ci - . , - . ) and bioimpedance phase angle (beta . per mm; ci . , . ). additional adjustment for heart failure and inpatient status did not alter results. conclusion: qmt can be efficiently measured during a routine echocardiographic exam and can add incremental insights about frailty in a diverse group of patients with cardiovascular disease. background: frailty is a clinical syndrome whose signs and symptoms are predictors of health complications, making this a major public health problem. objectives: this study aims to evaluate the prevalence of frailty, in communitydwelling older adults enrolled in a physical exercise program in the north region of portugal, based on fried's phenotype, its association with other variables. methods: in this crosssectional analysis, we used data from individuals who were enrolled in physical exercise programs. gender and age standardized prevalence and the association between frailty and sociodemographic (age, gender, marital status, education, shortage of money) physical (self-perceived health, polypharmacy, physical fitness, vision, hearing), cognitive (memory), social (emptiness, loneliness and abandonment) and psychological (depression and anxiety) variables were evaluated. results: of the participants, the mean age was . ± . years old, and . % were female. prevalence of pre-frailty and frailty were of . % and . %, respectively. from the fried's phenotype criteria, exhaustion is the most common reported by . % of the pre-frail and . % of the frail participants. age, marital status, self-perception of health, physical fitness, memory and depression were found to be independently associated with pre-frailty, while age, education, self-perception of health, physical fitness and anxiety were independently associated with frailty. conclusion: we reported lower prevalence of pre-frailty and frailty compared with other studies, showing that physical exercise may delay the progression of frailty. interventions aimed to prevent frailty must address the diversity of the associated variables. background: frailty is related with ethnicity and impaired physical capacity which is also affected by diabetes. however, little is known about how physical health indicators of frailty are associated with each other in older hispanics with diabetes. objectives: the goal of this study was to investigate the relationship between physical health indicators of frailty in older hispanics with diabetes. methods: thirty-eight older hispanics with diabetes ( women, men, age = ± years) participated in the study. the variables included age, weight, body mass index, body composition (% of muscle mass and body fat -bio-impedance), fear of falls (falls efficacy scale international -fes-i), chair stands in sec, grip strength (jamar® dynamometer), balance with eyes open and closed (force plate), preferred walking speed, gait velocity during regular and reduce time street crossing simulations (gaitrite®). results: characteristics: body mass = ± kg, % of muscle mass = ± %, % of body fat = ± %, fes-i score = ± points, chair stands = ± repetitions, grip strength = ± kg, center of pressure area with eyes open = ± cm and with eyes closed = ± cm , preferred walking speed = ± cm/s, gait velocity during regular = ± cm/s and during reduced time street crossing = ± cm/s. there were significant correlations (*p< . , **p< . ) between age and gait velocity during regular street crossing (r = - . *); grip strength and % of body fat (r = - . **) and % of muscle mass (r = . **); chair stands and preferred walking speed (r = . **), gait speed during regular (r = . **) and during reduced time street crossing (r = . **) and center of pressure area with eyes closed (r = - . *), and between fear of falls and center of pressure area with eyes closed (r = . **). conclusion: gait speed during street crossing simulations decreased with age. greater grip strength was associated with lower % of body fat and higher % of muscle mass. people who completed less chair stands in s also walked slower and had worse balance, and those with poor balance had increased fear of falls. britta c arends, lisa verwijmeren, peter g noordzij, douwe h biesma, leon timmerman, eric pa van dongen, heleen j blussévan oud-alblas (st. antonius hospital -nieuwegein, netherlands) background: chronic pain after cardiac surgery is common and has a negative impact on quality of life. frailty is an important risk factor for adverse surgical outcomes. the influence of frailty on chronic pain after cardiac surgery is unknown. objectives: this study aimed to address whether frailty characteristics were associated with chronic pain after cardiac surgery in an older population. methods: this study was based on the anesthesia geriatric evaluation (age) and quality of life after cardiac surgery study, which included patients >= years undergoing elective cardiac surgery. preoperatively, frailty was tested in physical, mental and social domains. pain was evaluated with the short form questionnaire (sf- ) preoperatively and one year after surgery. multivariate logistic regression was used to investigate the association between frailty and chronic pain. change in health related quality of life (hrql) was analyzed to evaluate the impact of chronic pain. results: ( %) patients were included in the analysis. / patients ( %) reported new or increased pain one year after surgery. in patients ( %) at least one frailty characteristic was present and patients ( %) were frail in two or more domains. after adjustment for possible confounders in multivariate analysis, patients with single status and polypharmacy were at increased risk for new or increased chronic pain (aors . ( % ci . - . ) and . ( % ci . - . ). new or increased chronic pain was associated with a worse hrql (aor . ; % ci of . - . ). conclusion: frail patients are at risk for chronic pain and worse hrql after cardiac surgery. future research should focus on perioperative interventions to reduce chronic pain in elderly patients. background: frailty is a vulnerability state that is associated with negative outcomes such us falls, in-hospital admissions and mortality. many factors can contribute to the pathogenesis of frailty and nutritional status is playing and important role. that´s why undernutrition and frailty must be overview in older adults before surgical procedures in order to treat them earlier. objectives: identify the relationship between physical frailty and undernutrition in older adults undergoing elective abdominopelvic surgery in a general hospital in lima-perú. methods: this is a secondary database study from the original "physical frailty and adverse events in older adults undergoing elective pelvic abdominal surgery in a general hospital, lima-perú", it was realized between august and march , using validated face to face questionnaires. physical frailty was determined with fried criteria, undernutrition by mini nutritional assesment (mna). in adition, they also evaluated functional status and cognition. univariate models were performed, and logistic regression was done subsequently. results: older adult met inclusion´s criteria, the mean age was . (+ . ) years old, , % ( ) were female, , % ( ) had hypertension, , % ( ) were diabetic, the mean number of comorbidities were . (+ . ), , % ( ) had functional impairment, , %( ) had cognitive impairment. the mean bmi was . ± . . , % ( ) were underweight, . %( ) normal , . %( ) overweigth and . % ( ) obese. by mna % ( ) had risk or undernutrition, . % ( ) of them had functional impairment in contrast with , %( ) who weren´t at risk or undernutrition; p= . . also, . %( ) who had risk or undernutrition had cognitive impairment in contrast with . %( ) who weren´t at risk or undernutrition; p= . . by fried criteria, % ( ) were frailty, % ( ) prefrailty and , % ( ) robust. the frailty patients % ( ) had risk or undernutrition vs , %( ) in prefrailty and . %( ) in robusts; p= . . conclusion: there is an increased risk of undernutrition in frail older adults undergoing abdominopelvic surgery at a general hospital in lima, peru. background: cognitive frailty increases the risk of dementia, dependency and mortality in older people. moderatevigorous physical activity (mvpa) improves frailty syndrome and cognitive functions in older people, but being physically inactive is still prevalent. walking is the most common and inexpensive form of physical activity in older people and brisk walking is a form of mvpa. m-health has been successful in changing health behaviours in many populations. however, its effect in treating cognitive frailty through promoting mvpa in older people is not known. objectives: the aims of this study were to examine the effects and feasibility of an m-health intervention. methods: a pilot randomized controlled trial was employed. eligibility criteria include ) age > years, ) living in community, ) having cognitive frailty, and ) mobility at "outdoor walker" level. the study was conducted in community settings. subjects were recruited in the elderly community centres. subjects were randomized into either intervention or control at a : ratio. in the intervention groups, the subject received a smartphone pre-installed with physical activity tracking and social media applications. they received a course of brisk-walking in daily living training, health education, and a -week behavioural change intervention on the smartphone platform. in the control group, participants received a course of brisk-walking in daily living training, health education, and telephone follow-up. the outcomes were frailty (ffi), cognitive function (moca) and mvpa (actigraph). we targeted at recruiting totally subjects. nonparametric tests were used to compare the effects within and between groups. missing values were replaced by last observed values. results: this study recruited subjects (intervention: n= , control: n= ). significant improvements in frailty (p< . ), cognitive function (p< . ), and mvpa (p< . ) were observed in the intervention group after the completion of the intervention. only cognitive function was also observed to be improved in the control group (p< . ). the compliance of wearing devices (i.e., smartphones and actigraphs) and the usage of the smartphone applications were highly satisfactory. three subjects withdrew from the study (intervention: n= , control: n= ). conclusion: m-health intervention is feasible to treat cognitive frailty in older people. it is more effective to ameliorate frailty and increase mvpa in older people with cognitive frailty when compared to conventional training. background: the prevalence of dementia and associated healthcare cost increases with aging population. population health management and proactive screening with increased emphasis on primary risk reduction may reduce the overall prevalence of dementia. motoric cognitive risk syndrome (mcr) has been increasingly studied as a pre-dementia stage to identify older adults at risk of transiting to dementia while few studies explored the association between mcr and functional capabilities. objectives: the aims are to investigate the prevalence of mcr and its associated factors among community-dwelling older adult and also to examine possible impact of mcr on functional capabilities. methods: data for older adults aged above years old staying in northwest region of singapore was used. mcr was defined as slow gait speed over m ( sd below population mean) with subjective memory complaints in the absence of dementia. functional capability was determined by administering the lawton instrumental activities of daily living (iadls). differences in demographics, socioeconomic and lifestyle factors between mcr positive and mcr negative groups were found using independent t-test and chi-square test. risk factors of mcr and impact of mcr on functional capability were examined using logistic regression. results: the prevalence of mcr in the studied population was . %. after adjusting for demographics and socio-economic factors, indians (adjusted or = . , % ci = . - . , p = . ), increasing age (adjusted or = . , % ci = . - . , p < . ), higher bmi (adjusted or = . , % ci = . - . , p < . ) increased likelihood of mcr while increased years of education decreased likelihood (adjusted or = . , % ci = . - . , p = . ). the odds of having at least one impairment in iadl after adjusting for demographics, socio-economic and health factors amongst those with mcr were . (adjusted or = . , % ci = . - . , p = . ). conclusion: our study found in to have mcr, the pre-dementia stage. indian ethnicity, those with increased age and higher bmi are at greater risk of having mcr. as mcr is also associated with functional impairment, it can serve as a useful screening tool to identify those at risk of progressing to dementia. background: sleep disturbance has been found in older persons with dementia, which impact on the quality of life of older persons and on the caregiving burden of the family. little is known about the sleep patterns and sleep problems of older persons with dementia. exploring these data would provide basic information to develop interventions for this population. objectives: to explore sleep patterns and sleep problems in community-dwelling older persons with dementia. methods: the sample recruited by purposive sampling consisted of community-dwelling older persons with any stage of dementia who used healthcare services at outpatient departments of a university hospital, thailand. data were collected using a demographic data questionnaire, a sleep diary recorded by caregivers, and an electronic wrist activity tracker to assess sleep data for consecutive nights. the data had been collected for three months and were analyzed using descriptive statistics. results: the sample had an age range from to years (m= . , sd = . ). the total sleep data of the older persons with dementia consisted of episodes. almost all of the sleep data showed the polyphasic sleep pattern (sleeps for several periods of time a day), but a few had monophasic and biphasic sleep patterns. the total sleep time per night ranged from to hours with a mean of hours. the mean sleep latency was minutes, by which two-thirds of them had sleep latency less than minutes. three-quarters of the data woke up at night. the mean duration of waking up at night was minutes. two-thirds of the data had sleep problems, including insomnia, waking after sleep onset, and excessive daytime sleeping. also, most of them had snoring ( %), followed by sleep talking ( %). conclusion: the polyphasic sleep pattern was found mostly in older persons with dementia. also, they had sleep problems of insomnia at night and excessive sleeping during the daytime. healthcare providers may use the results from this study to understand the sleep patterns and then find strategies to promote the sleep quality of older persons with dementia. yumi umeda-kameyama , masashi kameyama , taro kojima , masaki ishii , shinya ishii , mitsutaka yakabe , kiwami kidana , tomohiko urano , , sumito ogawa , masahiro akishita (( ) department of geriatric medicine, the university of tokyo school of medicine, tokyo, japan; ( ) department of diagnostic radiology, tokyo metropolitan geriatric hospital and institute of gerontology, tokyo, japan; ( ) department of geriatric medicine, international university of health and welfare, narita, chiba, japan) background: «perceived age» of facial appearance in elderlies was shown to be a robust biomarker of aging that predicts survival, telomere length, and dna methylation. it is also reported to correlate with carotid atherosclerosis and bone status. objectives: this study aims to determine whether perceived age is a better biomarker than chronological age for a variety of aspects in dementia assessment, which includes general cognition, vitality, depressive state, and selfsupportability. methods: one hundred twenty-six patients admitted to the department of geriatric medicine, the university of tokyo hospital with suspect of cognitive decline were enrolled. mmse, vitality index, gds , iadl, and barthel index were performed. ten geriatricians and clinical psychologists determined the perceived age of subjects based on their photographs. results: the average values of rates showed excellent reliability (icc( , )= . ). perceived age showed significantly better correlation with mmse (female), vitality index (total, female), and iadl (total) than chronological age by steiger's test, but not with gds and barthel index. conclusion: perceived age was demonstrated to be a better biomarker for cognitive assessment than chronological age. l a u r a t a y , h u d a m u k h l i s , jolene ho , aisyah latib , eeling tay , shimin mah , candy chan , yeesien ng (( ) department of general medicine, sengkang general hospital, singapore; ( ) office of regional health system, singhealth, singapore; ( ) department of physiotherapy, sengkang general hospital, singapore; ( ) dietetics, sengkang general hospital, singapore) background: cognitive frailty is characterized by co-existence of physical frailty and cognitive impairment. earlier studies reported aggravated health outcomes attributable to cognitive frailty over physical frailty alone. objectives: we examine risk factors for cognitive frailty, and its impact on physical performance and health outcomes, compared with isolated occurrence of cognitive impairment or physical frailty. methods: cross-sectional analysis of communitydwelling older adults who completed multi-domain geriatric screen assessing for social vulnerability, mood, cognition, functional performance, nutrition, physical frailty (frail) and sarcopenia (sarc-f). cognitive impairment was defined using locally validated education-adjusted cut-offs on modified-chinese mini-mental state examination. participants underwent physical fitness tests comprising grip strength, gait speed, lower limb strength and power, flexibility, balance, and endurance. health outcomes included hospitalization, emergency department visits, falls and self-rating of health. each participant was categorized as robust-cognitive intact (pf--/ ci-), pre-frail/ frail only (pf+/ ci-), cognitive impaired only (pf-/ ci+), and cognitive frailty (pf+/ ci+). results: mean age of study cohort was . ( . )years. ( . %) were pf-/ci-, ( . %) pf+/ci-, ( . %) pf-/ci+, and ( . %) pf+/ ci+. in multi-nomial logistic regression referenced to pf-/ci-, older age significantly increased risk for pf-/ci+ and pf+/ci+. cognitive frailty contributes to worse physical performance and poorer health outcomes compared to physical frailty and cognitive impairment in isolation. while social vulnerability and depression were differentially associated with isolated frailty status, malnutrition and sarcopenia should be targets for preventing frailty and cognitive impairment. osamu katayama, sangyoon lee, seongryu bae, keitaro makino, ippei chiba, kenji harada, yohei shinkai, hiroyuki shimada (department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology, japan) background: cognitive frailty is a condition recently defined by operationalized criteria describing coexisting physical frailty and mild cognitive impairment (mci). however, there is no consensus on the definition of cognitive frailty for use in clinical and community settings. objectives: this study aimed to use latent class analysis (lca) to discover potential subtypes of cognitive frail older people. in addition, we explored the relationship between the identified cognitive frailty subtypes, and their demographical, neuropsychological, body composition, and lifestyle activity characteristics. methods: a total of community-dwelling older adults aged >= years participated in the study. we characterized physical frailty as >= of the following criteria: slow walking speed, muscle weakness, exhaustion, low physical activity, and weight loss. we used tests of word list memory, attention, and executive function, and processing speed to screen for cognitive impairment. the presence of >= cognitive impairments were defined as mci. we defined the condition where physical frailty and mci coexist as cognitive frailty. lca was applied to characterize classes or subgroups with different cognitive frailty phenotypes. subsequently, we performed multinomial logistic regression analysis with cluster membership as dependent variable and dichotomized demographics and lifestyle activity characteristics as independent variables. results: lca identified eight distinct subgroups included three different cognitive frailty phenotypes: cognitive frailty composed of physical frailty and amnestic mci (acf), cognitive frailty composed of physical frailty and non-amnestic mci (nacf) and, cognitive frailty in which physical frailty and global cognitive impairment (gcf). cognitive frailty subtypes were associated with distinct demographical, neuropsychological, and lifestyle activity characteristics. in particular, the acf cluster was associated with younger age and also related to the inactivity of productive and cognitive activities (p< . ). the nacf cluster was related to the inactivity of social and cognitive activities (p< . ). finally, the gcf cluster was associated with older age (p< . ). conclusion: using lca, we identified eight distinct subgroups included three different cognitive frailty phenotypes in a large sample of community-dwelling older adults. cognitive frailty subtypes were associated with distinct demographical, neuropsychological, and lifestyle activity characteristics. sara g aguilar navarro, alberto j mimenza alvarado, itzel aparicio gonzález, clarita cabrera juárez, alejandra samudio cruz, monsal alexa, ja avila funes, teresa juarez-cedillo (instituto nacional de ciencias médicas y nutrición salvador zubiran, ciudad de méxico, mexico) background: the prevalence of mild cognitive impairment (mci) ranges between - % and is times more frequent than dementia. the dcl has been associated with cardiovascular risk factors, mainly changes at the executive level. the apoe genotype, on the other hand, is a gene that confers susceptibility to alzheimer's disease in addition to participating in lipid metabolism, giving greater risk of atherosclerosis and cardiovascular risk. however, given the genetic heterogeneity of the mexican population, this association is not clear. objectives: to establish the strength of association between the different types of dcl (amnesic and non-amnesic) in mexican mestizo older adults according to their carrier status of the apoe allele and cardiovascular risk factors. methods: patients in a memory clinic were evaluated from to , older than years, without sensory deficit, psychiatric diseases or uncontrolled metabolic pathology, separating them into mutually exclusive groups: healthy controls, group with amnesic mci, group with nonamnesic mci, performing geriatric and neuropsychological evaluation. parametric and nonparametric statistics (x , anova, multivariate linear regression analyzes) were used to find statistical differences between groups. results: multivariate linear regression analyzes were performed to examine the relationship between vascular risk factors, the presence of the apoe ε allele, and cognitive change. apoe genotype significantly modified the associations between both hypertension and cardiovascular disease and a decline in language abilities as well as diabetes and decline in verbal memory, attention, and visuospatial abilities in non-amnestic mci. associations between increased vascular risk burden and greater cognitive decline were observed among apoe ε carriers but not non-carriers with mci. conclusion: the present study revealed an increase in the association between non-amnestic mci (apoe ε carriers with vascular risk factors) and suggests that the treatment of vascular risk factors could contribute to reducing the risk of progression of cognitive impairment, particularly among patients with apoe ε mexicans. background: a number of cross-sectional and longitudinal studies have demonstrated an association between physical frailty and cognitive impairment ( ). many mechanisms have been suggested to explain the presence of cognitive impairment in frail subjects, such as cardiovascular risk, hormonal disturbances, chronic inflammation or nutrition ( , ). another hypothesis is that cognitive impairment in frail patient may be due to alzheimer's disease (ad) ( , , ). however, the link between frailty and amyloid deposition has to date never been studied in vivo. objectives: ( ) to examine the prevalence of cerebral amyloid pathology as measured with amyloid positron emission tomography (pet) or amyloid-β- - level in cerebrospinal fluid, among frail and pre-frail individuals presenting an objective cognitive impairment ( ) to characterize the cognitive and clinical progression of frail cognitively impaired patients according to the amyloid status. methods: cogfrail is a monocentric observational prospective study of cognitive frail and prefrail older participants (according to fried criteria), aged >= years, with an objective cognitive decline (defined by a clinical dementia rating (cdr) scale scoreat . or ). the participants will be followed up every months, during years. in addition to cerebral amyloid pathology (measured by amyloid positron emission tomography (pet) or amyloid-β- - level in cerebrospinal fluid), measurements include cognitive performance, physical function, nutritional status, depressive symptoms biology, nutrition, magnetic resonance imaging (mri), and body composition to better understand the mechanisms and progression of cognitive frailty. results: the study is currently being recruited. to date, patients were included. mri pet scan and lumbar puncture have been performed. subjects completed the study. conclusion: this study will allow us to determine, for the first time, the prevalence of amyloid pathology, a marker of ad, among frail and pre-frail patients presenting objective memory impairment. the results will help characterize the cognitive decline in frail and pre-frail patients, with important implications for the detection, management and ultimately prevention of neurocognitive disorders among frail old individuals references: ) kojima g, taniguchi background: cognitive impairment is a well-known risk factor for falls in older adults. the risk of falls is increased in those with diminished executive function and reduced processing speed. while participants with cognitive deficits are more prone to falling, it is unknown whether risk of falling on cognitively intact individuals placing them at higher risk for future cognitive decline. objectives: to ascertain the incident development of cognitive decline in those at higher risk for falls using the center for disease control's fall risk assessment tool, steadi (stop elderly accidents, deaths, and injuries) in community dwelling individuals > years of age. methods: we identified individuals >= years old using the longitudinal national health and aging trends study (nhats) that consists of eight years of follow-up. these individuals did not have cognitive impairment at baseline. fall risk was defined using the algorithm from the center for disease control's steadi initiative. participants were classified at baseline in three categories of fall risk (low, moderate, severe). impaired global cognition was defined as nhats-defined impairment in either the alzheimer's disease- score, immediate/delayed recall, orientation, clock-drawing test, or date/person recall. the primary outcome was the risk of incident cognitive impairment over time. cox-proportional hazard models and linear mixed-effects modeling ascertained the incidence of cognitive impairment, adjusting for age, sex, smoking status, education, co-morbidities and an ability to walk. our referent variable was individuals at low steadi fall risk. results: of the , participants ( . % female), median age category was - years. prevalence of baseline fall risk using the steadi measure in participants was low ( . %), medium ( . %) and high ( . %). the rate of cognitive impairment in our sample was . %. in our fully adjusted model, the risk of developing cognitive impairment was hr . [ %ci: . - . ] in the intermediate risk group, and hr . [ %ci: . - . ] in the high risk group. using linear mixed-effects modeling yielded similar results. conclusion: steadi fall risk at baseline was predictive of higher rates of cognitive decline in those with normal cognition. elevated fall risk by steadi may suggest need for more thorough cognitive assessment. background: the concept of cognitive reserve (cr) has been developed as a potential factor able to describe individual differences in vulnerability to cognitive, functional, or clinical decline along aging. the progressive reduction of cognitive and functional performances represents an outcome commonly associated with aging. objectives: the aim of this crosssectional study is to investigate the association of cr with cognitive and functional outcomes in a sample of elderly outpatients. methods: subjects aged >= were consecutively recruited. patients who were unable to undergo the execution of required tasks due to severe cognitive, functional or sensory impairment were excluded. mini mental examination (mmse), brief intelligence test (tib) and cognitive reserve index questionnaire (criq) were administered. handgrip strenght, gait speed and daily life autonomy were measured; a frailty index (fi) was eventually calculated. results: data from patients were analyzed. criq was significantly correlated with mmse (r = . , p < . ), handgrip (r = . , p < . ) and gait speed (r = . , p= , ). furthermore, criq was correlated with badl (r = , , p= , ), iadl (r= , , p= , ) and inversely with fi (r= - . , p < . ). significant correlations were found between tib and mmse (r = . , p < . ), between tib and criq (r = . , p < . ), and between tib and iadl (r = , , p= , ). conclusion: this preliminary report highlighted that patients with higher cr showed not only better overall cognitive functioning, but also better functional status and a lower degree of frailty. in the light of a multidimensional geriatric assessment, the integrative evaluation of cr in elderly might offer the opportunity to track possible trajectories of aging, since it appeared related either to cognitive status, either to functional oucomes and to frailty. background: the clinical syndrome of "physical" frailty has been conceived without regard for cognitive decline. nevertheless, it has been suggested that frail elders exhibit frailty-specific cognitive impairments, and that the cognitive correlates of frailty may be dementing in their own right. meanwhile, we have used confirmatory factor analysis (cfa) in a structural equation model (sem) framework to construct a latent dementia phenotype, "δ". our approach is modular and can be redirected to other clinical targets. objectives: in this analysis, we create a δ ortholog representing the "cognitive correlates of frailty" (df). methods: first, we constructed a frailty index (if) from wave- data collected as part of the hispanic established population for epidemiological studies in the elderly (h-epese). a δ ortholog targeting if was then constructed from a cognitive battery that included the mini-mental status exam (mmse) and clox: an executive clockdrawing task (clox). results: the model fit the data well and df exhibited factor determinance. dfrailty was strongly indicated (r = . , p< . ) by if and explained % of the index's variance. it was also significantly indicated by mmse and clox scores. df was strongly correlated (r = . , p< . ) with instrumental activities of daily living (iadl), independently of age, gender and education. the remaining % of if's variance had no significant association with iadl. the orthogonal latent variable "g'", df's residual in spearman's general intelligence factor "g", was strongly indicated by all three cognitive performance measures. nevertheless, it was weakly associated with iadl. measure specific cognitive performance, residual to both df and g', had no independent: association with iadl. conclusion: these results suggest that the frailty syndrome does indeed have specific cognitive correlates. these are strongly associated with iadl and therefore potentially "dementing". like δ, the cognitive correlates of frailty are extractable from spearman's g, which may constrain the biology and psychometric properties of frailty-specific cognitive changes. independently of df, cognition has little association with iadl. this suggests that frailty may be a major determinant of iadl performance in elderly ma, and possibly a major etiology of "all cause" dementia in that population. background: cognitive-frailty has been proposed as a distinctive entity which preludes dementia. objectives: we aimed to examine the relationship between physical frailty, cognitive status, and gait performance as predictors of cognitive decline and incident dementia. methods: cohort study of community older adults free of dementia at baseline with a year follow-up. inclusion criteria: > years, english speaking, able to ambulate one city block. exclusion criteria: hip/knee joint arthroplasty in past months, parkinsonism, major depression, and diagnosis of dementia (dsm-iv criteria). cognition was assessed using the moca, the mmse, and the clinical dementia rating (cdr) scale was performed. physical frailty was defined using the phenotypic criteria described by fried and walston. cognitive-frailty was defined as the simultaneous presence of physical frailty with objective cognitive impairment, and absence of concurrent dementia. the main outcome measure was all-cause dementia (dsm-iv criteria). cox proportional hazards models were used to estimate the risk of cognitive decline and incident dementia. results: over a -year follow-up, participants experienced cognitive decline and participants progressed to dementia (global incidence rate (ir): per -person/y). participants with frailty had a higher prevalence of cognitive impairment ( %) compared to those without ( %, p= . ) but the risk of progression to dementia was not significant. adding cognitive impairment to the frailty phenotype (cognitive-frailty) predicted further cognitive impairment and progression to dementia. dementia ir for frailty was per person/y and for cognitive-frailty, per person/y. however, when slow gait was combined with baseline cognitive impairment, it showed the highest risk of progression to dementia (hr: . , %ci: . - . ; p = . ) with an ir of per person/y. conclusion: frailty and cognitive impairment are common and often coexist in the same individuals. however, slowing gait seems to be the frailty component driving the association with future dementia. background: assisted bathing requires the most hours of home care. for the frail elderly and their caretakers, the bathroom presents the most risk factors for falls and injury. bathroom adaptation is the primary reason for consultation in community occupational therapy and available resources cannot meet the increasing demand. the hygiene . (h . ) website (https://algo.grismoir.com/) addresses this need by offering a structured questioning to identify bathing assistive technology for the frail elderly living at home. objectives: our actionresearch protocol aims to establish a partnership between actors in the home care social economy enterprises (eÉsad), the home care programs offered through the healthcare system and the private sector (e.g., assistive technology providers). this implies: ) adapting h . to the home care service workers' needs; ) designing an implementation model for h . in order to formalize a partnership in the community; ) conducting pilot testing in two eÉsad. methods: ) user-centered design and a multiple case study where a case represents a home care worker (n= ) from a eÉsad (québec, canada) offering bathing assistance for the elderly. during testing, the home care worker will explore the h . prototype with an elderly in his or her home, sharing their thoughts out loud. the unit of analysis is the usability of h . , allowing improving to the prototype after every three participants. ) all collaborators will participate in the iterative modification of a preliminary logic model for the implementation of h . . modifications suggested will be integrated to the model throughout three meetings, or until a consensus is reached. ) the adapted version of h . (obj. ) will be tested according to the implementation model developed (obj. ). a pilot project using mixed methods in collaboration with two eÉsad will be conducted with older adults having difficulty bathing. results: anticipated results: responsive h . website adapted to the users' needs, an implementation model and pilot data allowing scaling-up technology meeting needs of frail elderly and their caretakers issues during bathing. li-ning peng , , , fei-yuan hsiao , , , wei-ju lee , , , shih-tsung huang , liang-kung chen , , ( ( ) background: the theory of cumulative deficits using big data to develop the multimorbidity frailty index (mfi) has become a widely accepted approach in public health and healthcare services. however, constructing the mfi using the most critical determinants and stratifying different risk groups with dose-response relationships remain major challenges in clinical practice. objectives: this study aimed to develop the mfi by using machine-learning methods that select variables based on the optimal fitness of the model and to further establish four entities of risk using a machine-learning approach as well as to ensure the dose-response relationship and the best distinction between groups. methods: in this study, we used taiwan's national health insurance research database to develop a machine-learning multimorbidity frailty index (ml-mfi) using the theory of cumulative diseases/deficits of an individual older person. compared to the conventional mfi, in which the selection of diseases/deficits is based on expert opinion, we adopted the random forest method to select the most influential diseases/deficits that predict adverse outcomes for older people. to ensure that the survival curves showed a dose-response relationship with overlap during the follow-up, we developed the distance index and coverage index at any time point to classify the ml-mfi of all subjects into the categories of fit, mild frailty, moderate frailty and severe frailty. survival analysis was conducted to evaluate the ability of the ml-mfi to predict adverse outcomes, such as unplanned hospitalizations, intensive care unit (icu) admissions and mortality. results: the final ml-mfi model contained diseases/deficits in this study. compared with conventional mfi, both indices had similar distribution patterns by age and sex; however, among people aged - , the mean mfi and ml-mfi were . (standard deviation (sd) . ) and . (sd . ), respectively. the difference may result from discrepancies in the diseases/deficits selected in the mfi and the ml-mfi. a total of , subjects aged to years were included in this study and were categorized into groups according to the level of the ml-mfi. both the kaplan-meier survival curves and cox models showed that the ml-mfi significantly predicted all outcomes of interest, including all-cause mortality, unplanned hospitalizations and all-cause icu admissions, at , and years of follow-up (p< . ). in particular, a doseresponse relationship was revealed between the four ml-mfi groups and adverse outcomes. conclusion: the ml-mfi consists of diseases/deficits that can successfully stratify risk groups associated with all-cause mortality, unplanned hospitalizations and all-cause icu admissions in older people, which indicates that precise, patient-centered medical care can be a reality in an aging society. to return home. understanding the home environment prior to discharge is crucial. occupational therapists (ots) often depend on client's verbal descriptions, pictures and sketches when planning rehabilitation exercises and suggesting adaptations. the information obtained is therefore partial. mapit is a new mobile application which scans a room producing a d representation with virtual measurements of environmental elements. this could provide a more complete representation of the home needed by inpatient rehabilitation ots. objectives: to target mapit's clinical applications for inpatient rehabilitation of the frail elderly. methods: multiple case study where mapit was introduced in three inpatient geriatric rehabilitation units over days. five ots maintained a logbook and participated in four individual semi-structured interviews. a deductive thematic analysis of the logbooks and interview transcripts was corroborated by two additional ots. results: mapit is useful for ots in rehabilitation settings by allowing them to ) see it: see the home environment, ) measure it: take measurements of desired environmental elements, ) document it: have a copy of the environment on hand, ) communicate it : facilitate exchanges with the client and with colleagues. with mapit, ots gain a better understanding of the environment, which informs the rehabilitation intervention. better communication could also improve the client's implementation of the therapeutic strategies. conclusion: mapit is a useful resource to optimise intensive rehabilitation for the frail elderly. sonia jiménez-mola , javier idoate-gil , david idoate , maría plaza carmona (( ) geriatric department, complejo asistencial universitario, león, spain; ( ) university of salamanca, salamanca, spain; ( ) urgency department, complejo asistencial universitario, león, spain) background: as the age of the population increases, the incidence of osteoporosis and its direct consequence, fragility fractures, are also increasing. hip fractures are associated with the greatest number of complications, functional deterioration, and mortality of up to % one year after the fracture. objectives: the aim of this study is to determine the prevalence of previous diagnosis of osteoporosis in elderly patients who suffer hip fracture and its relationship with age distribution ( - , - and > years old), gender, type of fracture and funtionality. methods: we enrolled patients with hip fracture, aged years or older in an orthogeriatric unit between december and november . underwent comprehensive geriatric assessment that evaluates comorbidities, medication use, ability to perform basic activities of daily living, place of residence, anesthesia risk as measured by the asa score, type of fracture, type of surgery and anesthesia and in-hospital mortality. spss®, v. . . results: the mean age was . ± . years ( - years). . % female. % pertrochanteric fractures. ( %) underwent surgery. only . % received general anesthesia. % walked independently, % had barthel > , ( %) had a previous diagnosis of dementia, and % live in nursing home prior to fracture. we found a previous diagnosis of osteoporosis in patients ( . %). in these patients, statistically significant differences were shown for sex p< . ( . % female vs . % male), age distribution p< . ( . %( - ) vs . % ( - ) vs . % (> ) and the presence of anti-osteoporotic treatments p< . . all other measurements (barthel index, cognitive degree, type of fracture, asa score and type of surgery, did not show statistically significant differences (p>. ). conclusion: patients in very advanced age showed neither significantly higher percentage of diagnosed osteoporosis, not significantly higher amount of preexisting osteoporosis-related medication. although the prevalence of osteoporosis increases with age, the diagnosis and treatment prevalence decreased in higher age groups. background: aging is associated with a decrease in bone density, muscle mass and a gain in fat mass which increase physical disabilities and falls. nevertheless, the impact of obesity on bone density and architecture is still controversial. furthermore, protein intake appears to be associated with maintenance of muscle and physical function, but also with bone density and architecture. however, the role of initial protein intake in osteopenic-obese older adults is still unclear. objectives: to examine the influence of initial protein intake on muscle and bone function in osteopenic-obese older adults. methods: cross-sectional a-posteriori matched study design. fourteen obese (total fat (%): men > ; women: > ) osteopenic (bmd t-score <- . ) older adults (age > years old) were divided in groups according to their initial protein intake (prot-(n= ): < g/kgbw/d or prot+ (n= ): > . g/ kgbw/d) and were matched for age (± years) and gender. body composition (fat, fat-free and bone masses, dxa), muscle composition and bone architecture (qpct), muscle function (grip strength, knee extension strength, muscle power), physical performance (walking speed ( m), tug ( m), unipodal balance, stair and chair tests), cardiorespiratory function ( min walking test) and lifestyle habits (physical activity level: -axial accelerometer and nutritional status: food record) were assessed. results: our groups (prot-vs. prot+) were similar (p> . ) in terms of age ( . ± . vs. . ± . years), bmi ( . ± . vs. . ± . kg/m ), body fat (total(%): . ± . vs. . ± . ), muscle quantity (fat-free mass or limb muscle area) and quality (intra & submuscular adipose tissues), bone density (total hip or spine) and architecture (marrow, cortical or total area, and compressive or torsion strength), physical performance (walking speed(m/s): . ± . vs. . ± . ), cardiorespiratory function, lifestyle habits (steps: ± vs. ± ), except (by design) for the initial amount of protein intake ( . ± . vs. . ± . g/kgbw/d) respectively. conclusion: the initial protein intake does not seem to influence bone architecture, muscle function, or physical performance in elderly osteopenicobese. obesity but also the level of protein intake above the official recommendation (> . g/kgbw/d) could explain these conclusions. thus, future studies are needed to confirm our preliminary results. background: the glim definition of malnutrition is the first intended to be used globally. glim uses five criteria (two phenotypic and three etiologic) for the diagnosis of malnutrition, which is made when at least one etiologic and one phenotypic criterion are present. mna-sf is a validated widespread screening tool used in geriatric settings. glim and mna have not been compared in acute geriatric care. objectives: to measure the prevalence of malnutrition in older patients admitted to an acute geriatric unit using glim criteria and to assess the accuracy of the mna-sf in predicting glim defined malnutrition. methods: a prospective study was conducted among all patients older than years old admitted to an acute geriatric unit. end-of-life situations and wearers of pacemakers were excluded. glim criteria and mna-sf were assessed on admission. muscle mass (one of the glim criteria) was estimated by bioimpedance (thresholds for low muscle mass: < . kg in men; < . kg in women). results: patients were included (mean age . ± . years, % women). on admission, . % were malnourished according to the glim criteria ( . % met at least one etiologic criterion, . % met at least one phenotypic criterion). . % were malnourished using mna-sf. however, there was no correlation between glim and mna-sf (correlation coefficient r=- . , p= . ). mna-sf had low sensitivity ( . %) and low specificity ( . %) to detect malnutrition diagnosed with the glim criteria (roc curve auc= . ). conclusion: more than half of the very old patients admitted to an acute geriatric unit were malnourished according to the glim diagnostic criteria. a very similar proportion of patients had a mna-sf suggesting malnutrition. however, mna-sf had a low reliability to detect patients with glim defined malnutrition. corina naughton , rachel simon , tj white , darren daly ( ( ) background: hospitalised older adults are at risk of hospital associated decline (had). optimising nutrition intake is an important modifiable factor in protecting against had and promoting recovery, but food intake and the quality of mealtimes are frequently overlooked nursing activities. objectives: the study aim was to undertake an in-depth analysis of mealtime practices and to identify patient and mealtime factors associated with low food intake (<eating % of meal provided). methods: we carried out structured observation of mealtimes using a validated tool examining patient positioning, mealtime set up and assistance. the primary outcome was food consumption categorised as , %, % % or % based on visual inspection of food trays. data were also collected on patient characteristics. data analysis used descriptive statistics and univariate logistic regression to examine the association between low food intake and mealtime and patient factors. results: we included mealtime observations on patients aged years and older. at % (n= ) of meals, patients ate half or less of the food provided. meal time factors with a weak association with low intake were: allocated red tray (an indicator of nutrition risk), modified diet, and needing assistance. breakfast time was the most important meal for food intake. nearly half of the patients ( / ) ate % or less of the food provided on two or more occasions over a -hour period. patient frailty and a moderate to high nutrition risk score were independently associated with low food intake. conclusion: patient factors are the strongest predictors of low food intake. increasing the quality of the mealtime experience and more tailored nutrition plans could improve nutrition intake in frail older adults. were hospitalized at least once, ( . %) fell at least once, and ( . %) had at least one fracture during the -year follow-up. no association was found between malnutrition and -year risk of institutionalization, hospitalization, falls, or fractures (p> . ). conclusion: malnutrition according to glim criteria was associated with a . -fold higher mortality risk; double that of the espen criteria, during a -year followup. no association was found between malnutrition according to these two criteria and incidence of other adverse health consequences. glim criteria anticipate outcome and might guide interventions, with important implications for clinical practice and research. background: older adults are at high risk of developing cardiovascular disease. pre-clinical studies indicate that resveratrol (rsv), a polyphenol present mostly in grapes and red wine, may prevent development of cardiovascular disease. objectives: our hypothesis was that rsv will reduce biomarkers of cardiovascular disease risk in obese, rather healthy older adults in a dose-dependent manner. methods: older participants ( years and older) were randomized to a day rsv treatment with mg (n= ), mg (n= ) or placebo (n= ). we measured levels of atherosclerosis development risk biomarkers i.e. oxidized low-density lipoprotein (oxldl), soluble e-selectin- (se-selectin), soluble intercellular adhesion molecule- (sicam- ), soluble vascular cell adhesion molecule- (svcam- ), total plasminogen activator inhibitor (tpai- ). statistical significance was set at p< . . results: changes in svcam- mg vs. mg vs. placebo: (- . ± . ng/ml vs. . ± . ng/ ml vs. . ± . ng/ml) and tpai- mg vs. mg vs. placebo (- . ± . ng/ml vs. . ± . ng/ml vs. . ± . ng/ ml) indicate significantly higher levels in a mg group compared to a mg and a placebo groups. other biomarkers ( mg vs. mg vs. placebo: oxldl, seselectin- and sicam- ) followed the same trend toward higher levels in the mg group compared to the mg and placebo groups, without reaching statistical significance. conclusion: this pilot project suggests that a higher dose of rsv may increase the levels of cardiovascular disease risk biomarkers in overweight older adults. given no change in the cardiovascular disease risk biomarkers in response to a lower dose, future studies should test the effects of different doses of rsv on reduction of cardiovascular disease biomarkers in overweight, rather healthy older adults. background: actual nutrition is a factor that continually effects physiological capacity and workability, the functional aging rate of an elderly persons. objectives: the purpose of this study was to determine the relationship between nutrition and physiological abilities, the work performance, functional aging rate, residual working capacity and frailty of the elderly. methods: it has been studied anthropometric and functional parameters of respiration, physical performance, mental capability, sensory skills, as well as the rate of functional aging in different aging groups: - years - persons, - years - persons, - years - persons. we have also analyzed the professional history, social status, and factual nutrition (according to the questionnaire proposed by the who and adapted for ukraine) of the elderly. results: the nutrition or diet factors influence on the problems dealing with working capability, reduction of the hand grip strength and endurance, independence and frailty (for elderly) in overall . % for all mentioned factors. right and left hand grip strength associate with protein consumption (r = . ; r = . ; p < . accordance) with variety of cereals (r =- . ; r =- . p < . accordance) also with variety of vegetables (r = . ; r = . ; p < . accordance)variety of fruits (r = . ; p < . ; r = . ; p < . accordance). it was studied features of an actual food at centenarians of ukraine which not only have lived to this old age, but also have the relatives who have lived to age of centenarians. it was established, that meals of ukrainian centenarians include high percentage of vegetables, fruits and dairy products. meanwhile menu has been deprived practically all basic alimentary pathology risk factors which accelerates biological age, creates certain preconditions to preservation of health and longevity. conclusion: as a result of a comprehensive study and mathematical modeling was developed a quantitative method for assessing the residual working capacity for elderly persons. background: age-related decline in olfactory function has implications for health and nutrition due to reduced appetite and decreased sensory perception of food. several studies have investigated olfactory performance in the elderly, but studied mostly single odour components often less related to food and meals. food odours are composed of multiple odorants and compensation for specific perceptual losses among elderly may occur. therefore, it is relevant to study olfactory perception of complex food odours to improve understanding of odour perception in the context of foods and meals. objectives: to develop a test method to screen young and elderly ( +) subjects on their olfactory capacity for everyday food odours. the method included a series of sniffing sticks with relevant and familiar complex food odours from primarily essential oils. methods: the olfactory sniffing sticks test kit was developed in four steps: ) selection and validation of relevant, familiar and diverse food odours, evaluated on perceived familiarity. ) standardization of an iso intensity reference level for the food odours in relation to n-butanol. ) assessment of shelf-life stability for the sniffing sticks within an weeks period. ) evaluation of test-retest reliability for intensity and identification of the odours within a weeks period. results: food odours were selected due to their diverse sensory characteristics. they were provided from a french manufacturer which may have compromised the familiarity in a danish context as only out obtained satisfactory familiarity score. however out showed reliable results in a test-retest procedure. n-butanol, in two concentrations provided a satisfactory reference frame for the iso intensity scaling. furthermore the food odours were overall shelf-life stable within an weeks period. conclusion: a new odour test kit for everyday food odours was developed and validated for screening olfactory capacity (intensity perception, familiarity and identification) in elderly subjects. based on the evaluations, odours were included in the final test kit. this olfactory test reflects the complex stimulation of the olfactory system, when stimulated by eating a food, compared to odour test kits with single or few components which makes it relevant when customizing of meals for elderly to improve nutrition and wellbeing. background: nordic nutrition recommendations (nnr) ( ) suggest protein intake >= . g/kg body weight (bw) to preserve physical function in nordic older adults. however, no published study has used this cut-off to evaluate the association between protein intake and frailty. objectives: this study examined associations between protein intake, and sources of protein intake, with frailty status at the -year follow-up. methods: participants were women aged - years enrolled in the kuopio osteoporosis risk factor and prevention -fracture prevention study. protein intake g/kg bw and g/d was calculated using a -day food record at baseline . at the -year follow-up ( ), frailty phenotype was defined as the presence of three or more, and prefrailty as the presence of one or two, of the fried criteria: low grip strength adjusted for body mass index, low walking speed, low physical activity, exhaustion was defined using a low life satisfaction score, and weight loss > % of bw. the association between protein intake, animal protein and plant protein, and frailty status was examined by multinomial regression analysis adjusting for demographics, chronic conditions, and total energy intake. results: at the -year follow-up women were frail and women were prefrail. higher protein intake >= . g/kg bw was associated with a lower likelihood of prefrailty (or= . and % confidence interval (ci) = . - . ) and frailty (or= . and ci= . - . ) when compared to protein intake < . g/kg bw at the -year follow-up. women in the higher. conclusion: protein intake >= . g/kg bw and higher intake of animal protein may be beneficial to prevent the onset of frailty in older women. background: sarcopenia is a geriatric syndrome with increasing importance due to the aging of the population. progressive resistance training and protein supplementation are currently recommended for the prevention and treatment of sarcopenia. however, elderly are less responsive to these anabolic stimuli compared to healthy adults. inflammation is considered an important contributor to this age-related anabolic insensitivity. therefore, anti-inflammatory strategies, such as omega- , are a promising strategy to combat sarcopenia. furthermore, omega- were also shown to improve muscle anabolism though activation of the mtor signalling pathway and reduction of insulin resistance. objectives: firstly, we performed a narrative review of literature that gives an overview of the current knowledge about omega- intake and sarcopenia defining parameters (grip strength, gait speed, muscle strength or physical performance). secondly, we provided an overview of data on omega- supplementation and sarcopenia defining parameters. methods: a literature search was conducted in november , using electronic bibliographic databases (pubmed and embase). the reference lists of all full texts retrieved during the search process or as identified in already published (systematic) reviews were scanned. results were published in a narrative review (dupont j. et al. aging clin exp res.) results: seven observational studies described the associations between omega- intake and sarcopenia defining parameters. four interventional studies looked at the effect of omega- supplementation alone and suggested an improved muscle protein synthesis, improved gait speed and increased muscle strength and physical performance. three studies combining exercise with omega- supplementation suggested an enhancing effect of the supplement on the exercise-induced gains in muscle mass and strength. we found one study combining omega- and protein supplementation with exercise, but omega- dosage was too low for conclusive results. conclusion: observational data on omega- intake and sarcopenia remain conflicting. from current interventional data we conclude that there is growing evidence for a beneficial effect of omega- supplementation in sarcopenic elderly, which may add to the effect of exercise and/or protein supplementation. however, the exact dosage, frequency and use (alone or combined with exercise and/or protein supplementation) in the treatment and prevention of sarcopenia still need further exploration. background: with the growing incidence of cancer in older persons, malnutrition rates have increased. tumor-related malnutrition is a risk factor of treatment side effects. it reduces the quality of life and increases morbidity and mortality. therefore, malnutrition screening and diagnosis are mandatory to implement proper nutritional support. objectives: this study aimed to evaluate and compare the short form of mini nutritional assessment (mna-sf) nutritional screening tool with the new global leadership initiative on malnutrition (glim) diagnostic criteria for malnutrition among elderly patients with cancer. methods: patients >= years old, with a g screening tool ≤ , were referred to an oncogeriatrics consultation between february and september . the data recorded comprehended, demographic variables (age, sex), type of tumor, functional (barthel, lawton index, fac) and mental (mmse, yesavage) status, nutritional (mna-sf, glim criteria) and social assessment and number of drugs. if-vig, cirs-g, rockwood-ms, cci-sf, sppb and handgrip strength were used to estimate frailty. the roc curve was used to evaluate the ability to accurately distinguish malnourished patients. to determine diagnostic concordance between the assessment and the new glim diagnostic criteria of malnutrition, retrospectively analyzed, cohen's К statistic was calculated. results: patients were included, mean age . ± . , . % were women. gastrointestinal ( . %) and gynecological ( . %) neoplasms were most prevalent. . % were independent or had mild dependence on badl, . % on iadl. . % had no cognitive impairment and . % had no depressive symptoms. frailty scales showed a pre-frail patient profile, with good social support and a . ± drugs on admission. according to the new glim diagnostic criteria for malnutrition, % of the patients were malnourished. with the use of mna-sf, . % of the patients were found to be at risk of malnutrition. the roc curve of mna-sf had an area under the curve (auc) of . . no concordance was found between the mna-sf and the malnutrition diagnostic results (К= , p< . ). conclusion: in this small sample, most cancer patients were male, > years old, with low frailty index, good functional and mental status and at risk of malnutrition. the mna-sf scale detected more risk cases so preconditioning and nutritional recommendations before specific oncological therapies could be made. concentration is associated with muscle mass and strength in healthy elderly. however, there are several confounders, including body composition, nutrient intake, physical activity level and blood parameters which may also influence muscle mass. previous studies have not thoroughly examined the relationship between serum (oh)d concentration and muscle indices by comprehensively considering the potential confounders in healthy elderly. objectives: the purpose of this study was to investigate the relationship of serum (oh) d concentration with muscle mass and strength in healthy japanese elderly. methods: this cross-sectional study included healthy elderly in shiga prefecture in japan (age: . ± . years, m = , w = ). total fat-free mass (tffm) and appendicular (affm) were measured using dual-energy x-ray absorptiometry. in addition, handgrip strength and leg extension power were measured. a blood sample was collected in an overnight fasted state, and serum (oh)d concentration was assessed. habitual dietary intake and physical activity were assessed. protein intake, carbohydrate, and vitamin d intakes were adjusted for energy by the residual method. association of serum (oh)d concentration with tffm, affm, handgrip strength, and leg extension power was assessed by hierarchical multiple regression analysis with adjustment for age, gender, weight, energy, energy-adjusted protein, carbohydrate, vitamin d intakes, serum albumin concentration, and physical activity. results: the mean serum (oh)d concentration of participants was . ± . nmol/l. low serum (oh)d status (< nmol/l) was observed in . % ( / ) of participants. the mean affm was . ± . kg, and handgrip strength was . ± . kg. serum (oh)d concentration was significantly associated with affm (β = . , p = . ), but not with tffm (β = . , p = . ), handgrip strength (β = . , p = . ) and leg extension power (β = - . , p = . ). conclusion: serum (oh)d concentration is related to affm japanese healthy elderly people, even if confounders are comprehensively considered. background: muscle quality, often defined as force produced per area or mass of muscle, declines as people age. objectives: we hypothesized that dietary protein quality will better predict muscle quality than energy, carbohydrate, protein, fat, or leucine intakes when controlling for age, bmi, composition, and moderate to vigorous physical activity (mvpa). methods: strength was measured using isokinetic dynamometry at degrees per second, leg composition (lc) was examined via dual-x-ray-absorptiometry, and mvpa was measured with accelerometry. dietary intake was estimated using three-day food logs and esha software. muscle quality was defined as right knee extensor peak torque relative to right leg lean mass. protein quality was the ratio of total leucine over total protein intake. multiple linear regression and stepwise linear regression models were used. results: ninety-four women (mean ± sd; age . ± . years; bmi . ± . kg/m ; lc . ± . % fat; mvpa . ± . min/day; energy , ± kcal/day; carbohydrate . ± . g/ day; protein . ± . g/day; fat . ± . g/day; leucine . ± . g/day) completed the assessments. only protein quality (mean ± sem; beta = . ± . ; t = . ; p = . ) was significant to the full regression model containing all covariates (r = . ; adjusted r = . ; f ( , ) = . ; p = . ). to verify the importance of protein quality, a stepwise regression analysis using the same variables was performed and resulted in a model (r = . ; adjusted r = . ; f ( , ) = . ; p < . ) that included protein quality (mean ± sem; beta = . ± . ; t = . ; p = . ) and energy intake (mean ± sem; beta = . ± . ; t = . ; p = . ). conclusion: dietary protein quality is positively associated with muscle quality when controlling for bmi, lc, mvpa, and energy, protein, fat, carbohydrate, and leucine intakes. the most parsimonious model included protein quality and energy intake, suggesting that they are most related to muscle quality. background: it has been suggested that disruption of the apoptotic process may have an effect on the incidence of sarcopenia. on the other hand, one of the dietary recommendations for seniors is to increase their daily protein intake. however, the effect of protein intake on apoptosis is not well understood. objectives: the purpose of this study was to investigate the effect of eight weeks of protein whey supplementation on the expression of genes involved in the internal and external pathways of apoptosis of long extensor muscle of thumb of aged wistar rats. methods: this is an experimental studies. statistical sample of this study consisted of male wistar rats (age: months, weight: ± gr). they were randomly divided into supplement (n= ) and control (n= ) group. supplement group received . gr per body weigh protein whey daily for eight weeks. the left thumb extensor muscle of all subjects was carefully separated and after freezing in liquid nitrogen transferred to - ° c. quantitative real time-pcr was performed to measure bax, bcl- , caspase , and gene expression levels. independent t-test and mann-whitney u test were used to compare the means and rankings. the hypotheses were tested at the significant level p< . . results: results showed that bax, caspase , caspase , and caspase genes expression increased in all samples in training group compared to the control group but this increase was only significant for bax, caspase and gens (p < . ) and also bcl- gene expression significantly deceresed (p < . ) in comparison with control group. conclusion: it seems that protein supplementation lead to activation of the internal pathway of apoptosis by increasing mitochondria permeability. background: the presence of obesity alongside with impaired aging in general, and with impaired muscular performance in particular, may result in a unique and growing phenotype of obese frail/sarcopenic, which may be hardly diagnosed by simple observation. characterizing the nutritional intake of this phenotype is of a substantial relevance. objectives: to characterize the nutritional intake among frail prone (fp) and obese subjects in a sample of community dwelling older adults in israel. methods: in this cross sectional study we evaluate the nutritional intake of frail, frail prone and robust subjects (with and without the presence of obesity), as well as their adherence to the dietary reference intakes (dri). data were retrieved a series of national studies on the status of health and nutrition in different age groups in israel (mabat zahav) for [ ] [ ] . the frailty likelihood presented here is based on a previous study from our group suggesting a non-direct validated model estimating frailty based on components. results: compared to the robust, fp subjects were more likely to have lower intake of several nutrients. among them are: iron (mg) (mean . vs. . , p < . ), vitamin c (mg) (mean . vs. . , p < . ), folate (μg) (mean . vs. . , p < . ), vitamin a (iu) (mean . vs. . , p = . ). the average overall adherence score according to the dri (based on a sum of nutritional components) was . among fp subjects, compared to . among robust subjects (p = . ). obesity either defined by bmi or by wc had a lower «effect» on the nutritional intake differences as compared to frailty status. this observation was seen when obese subject were compared to non-obese subjects and as fp subjects were more likely to show a poor nutritional status regardless of the presence of obesity. conclusion: our results show a clear association between frailty and poor nutritional intake, regardless of the presence of obesity. moreover, the functional status may better reflect nutritional gaps than obesity -challenging the concept of the frail -obese phenotype regarding to nutritional status. background: the loss of bone density during aging induces risks of falls, fractures and mobility decline. moreover, bone structure seems to be a better predictor of fractures than bone density. these phenomena are exacerbated in the presence of sarcopenia. however, dynapenia alone or in combination with obesity is more involved in falls and loss of mobility than sarcopenia. nevertheless, the impact of obesity on bone density and bone structure is still controversial. furthermore, protein intake appears to be associated with maintenance of muscle, bone density and bone structure. to our knowledges, the impact of protein intake on bone density and bone structure among dynapenic-obese older adults is not known even if this condition reached around % of elderly. objectives: to assess the influence of protein intake on bone density and bone structure among dynapenic-obese older adults. methods: twenty-six older adults (>= years), obese (%fat: men > ; women: > ) and dynapenic (relative to body weight grip strength: men < . ; women < . ) were divided into groups according to their initial protein intake : prot-: < g/kg/d (n= ; . % of women; . ± . years) and prot+: > . g/ kg/d (n= ; . % of women; . ± , years). the following measurements were performed: relative to body weight grip strength using lafayette dynamometer, body composition using dxa, femoral bone structure using ct-scan, nutritional intake using the -day food record method. results: excepted, by design, for initial protein intake, both groups were comparable at baseline. the prot-group had a higher (p< . ) marrow area ( ± ) than the prot + group ( ± ). in addition, the compressive loading strength was greater (p< . ) in the prot-group ( ± ) than in the prot + group ( ± ). finally, the total bone area was larger (p< . ) in the prot-group ( ± ) compared to the prot + group ( ± ). conclusion: surprisingly, a lower protein intake but higher than rda seems to protect bone structure but not bone density among dynapenic-obese older people. these results should be confirmed in larger studies designed to address this question. background: unintentional weight loss occurs in % to % of older adults and has been associated with morbidity, functional incapacity, risk of hip fracture, and overall mortality. while the impact of this condition is well established in frailty, studies involving sarcopenia are still insipient. objectives: to investigate the association between unintentional weight loss and sarcopenia in community-dwelling older adults. methods: a cross-sectional study was conducted among older adults (>= years) assisted in primary care. the unintentional weight loss was assessed by questions contained in three frailty assessment tools and one nutrition screening and assessment tool, described below: ( ) "have you recently lost weight such that your clothing has become more loose?" [edmonton frail scale (efs)]; ( ) "have you lost a lot of weight recently without wishing to do so? ('a lot' is: kg or more during the last six months, or kg or more during the last month)" [tilburg frailty indicator (tfi)]; ( ) "in the last year, have you lost weight unintentionally (i.e., not due to dieting or exercise)? (unintentional weight loss is: more than . kg or of at least % of previous year's body weight)" [phenotype for frailty (pf)]; ( ) «weight loss greater than kg during the last months" [mini nutritional assessment (mna®)]. sarcopenia was identified by european working group on sarcopenia in older people (ewgsop ) criteria. the data were analyzed with use of pearson chi-square test (p< . ). results: a total of older adults were evaluated ( . % female). the mean age was . ± . years ( - y). sarcopenia was identified in . % of the sample (n= ). the frequency of unintentional weight loss in sarcopenics was % in tfi (n= ; p= . ), % in efs (n= ; p= . ), . % in pf (n= ; p= . ) and . % in mna® (n= ; p= . ). conclusion: we observed that the unintentional weight loss evaluated by tfi and efs (frailty assessment tools) was associated with sarcopenia. so, different ways to evaluate weight loss (amount and time) seems to influence this association. funding: this study was financed by fapergs (process number - / - ) and capes (finance code ). background: half of older adults admitted to hospital are malnourished. malnutrition often leads to weight-loss and may lead to a loss of muscle mass, muscle strength and physical performance. nutritional interventions should individualise nutritional requirements, particularly energy and protein. objectives: to assess if energy requirements, determined by indirect calorimetry compared to usual care (predictive equations), can lead to a reduction in weight loss (primary outcome) and improvements in muscle mass, muscle strength and physical performance (secondary outcomes) in geriatric rehabilitation patients at risk of malnutrition. methods: geriatric rehabilitation inpatients were derived from the resort cohort (royal melbourne hospital, australia) and allocated by wards to either the indirect calorimetry or usual care group for the need study. energy requirements were measured using indirect calorimetry; the results were utilised by dietitians in the indirect calorimetry group and concealed for the usual care group. weights were obtained weekly. food intake assessment, muscle mass (bioelectrical impedance analyser), handgrip strength (hgs) and physical performance (short physical performance battery (sppb)) were measured at admission and discharge. within-group and betweengroup differences were calculated for the changes in outcome measures during hospitalisation. results: twenty-one patients (indirect calorimetry n= ; usual care n= ) were included (mean age . ± years; males, females). preliminary results showed that in the indirect calorimetry group, five patients gained weight, four patients maintained weight and one patient lost weight during hospitalisation; the usual care group had four patients with weight gain and five patients maintaining weight. there were no significant within-group differences or between-group differences for changes in weight ( background: many older people have difficulties in performing daily living activities such as preparing meals and food shopping, which could be partly due to cognitive and physical decline [ ]. these factors may influence food choice and represent a potential barrier to achieving good nutrition [ ] . nevertheless, the association between mealrelated difficulties and nutritional risk, as well as dietary intake, has been understudied. objectives: ( ) to examine the prevalence of autonomy in food-related activities, as measured with instrumental activities of daily living scale (iadl), among frail and pre-frail older subjects with an objective cognitive impairment ( ) to characterize the association of food autonomy with an insufficient dietary intake and nutritional risk of cognitive frail older people. methods: this is a secondary cross-sectional analysis using baseline data from the cogfrail study, which is a monocentric observational study of cognitive frail and prefrail older participants, aged >= years, with an objective cognitive decline. dietary intake is evaluated with a dietitian, using a diet history method. autonomy in food-related activities is assessed using iadl scale. nutritional status was categorized according to the mini nutritional assessment (mna). results: ongoing analyses. preliminary results show a mean energy intake of less than kcal and g of protein per day, we considered all nutritional needs cannot be covered under this threshold. conclusion: frail older people, with cognitive impairment, are particularly at nutritional risk and insufficient dietary intake. food autonomy has to be evaluated systematically to prevent nutritional risk in this population. elderly aged years or over, and this number will continue to increase. in order to extend the healthy life expectancy, disease prevention and health management of the elderly are important. preventive intervention of sarcopenia is considered to be an important issue in promoting care prevention for the elderly. objectives: the purpose of this study was to clarify the relationship of muscle weakness and physical characteristics with nutritional intakes. methods: subjects were men and women ( to years old) in the nagoya longitudinal study for healthy elderly (nls-he) in , excluding those who had missing values of the examinations. nutritional intakes were assessed by the food frequency questionnaire (ffq). low grip strength (gs) was diagnosed by asian working group for sarcopenia (awgs) criteria. the cut-off value of gs was kg for men and kg for women. results: the number of the subjects diagnosed with low gs was , ( men and women). comparison was made between the low gs group and the normal group. there were no significant differences between the two groups in age, sex, number of teeth, chewing ability and occlusal force, whereas mini nutritional assessment (mna) score, walking speed at the normal and maximum speed, exercise habits, and percent of body fat were significantly lower in the low gs group than the normal group. also, the rate of polypharmacy was significantly higher. in nutritional intakes, vitamin d and b were significantly lower in the low gs group. in the intakes by food groups, fish and meat intakes were significantly lower, but the intakes of snack were significantly higher. furthermore, the protein ratio and the amount of animal protein intakes were significantly lower in the low grip strength group. conclusion: in this study, muscle weakness was related to lower intake of specific nutrients such as vitamin d, b , and animal protein, independent of number of teeth, chewing ability, and occlusal force. background: the status of calcium intake, the main mineral of the bone has no suitable biomarker to assess it. its evaluation is relevant in clinical practice as in research. postmenopausal women should be evaluated for risk factors for osteoporosis, including poor calcium intake. objectives: to develop and validate a food frequency questionnaire (ffq) to assess the calcium intake of mexican postmenopausal women. methods: after obtaining approval from the institutional ethics committee, a pilot study was performed including mexican women whose calcium intake was assessed trough a day food diary ( dfd). the ffq was designed including the foods reported by the participants of the pilot study that provided more than . % of the calcium requirement and that were reported by at least participants. the ffq was tested through a validation study that included postmenopausal whom also completed the dfd. the validity of the ffq was assessed with the interclass correlation coefficient (icc) alongside a bland-altman analysis. results: postmenopausal women were assessed from june , to january , . participant's characteristics are shown in the table . the ffq underestimated mean calcium intake compared to day food diary (- mg ± . , p< . ). the two methods were strongly correlated by the icc (icc= . , ci . - . ). the ffq could identify individuals who consumed >= mg/ day with a high sensitivity, and a reasonable specificity (table ). figure shows the agreement between the dfd and the ffq were plotted against the average of the two measurements (figure ), the mean (solid line) and the % ci (broken lines) of the difference are shown. conclusion: conclusions: the ffq´s good sensitivity in identifying low calcium intake in postmenopausal women makes it useful also as an educational tool in diet counselling and for identifying subjects in need of supplementation. the difference between methods limits its utility as an epidemiological tool. helen yl chan , winnie kw so , regina cheung , kc choi , brenda ho , francis li , ty lee , janet wh sit , martin mh wong , sy chair ( ( ) background: nutritional status has been recognized as a predictor of the level of frailty. however, little is known about how the eating habits and dietary preferences associated with frailty, especially in the chinese elderly population. objectives: this study aims to identify dietary factors in predicting frailty among community-dwelling older adults. methods: a multicentre cross-sectional correlational study was conducted in hong kong in . frailty was defined by using fried's phenotype model. the frail scale was used to classify level of frailty and the mini-nutritional assessment (mna) was used to evaluate the nutritional status, in addition to anthropometric parameters. association between nutritional status (at risk or malnourished vs normal) and frailty status was examined using ordinal regression in a hierarchical fashion for adjusting participant socio-demographics, health status, lifestyle characteristics, eating behaviours and dietary habits. all the statistical analyses were performed using ibm spss . . all statistical tests were two-sided with level of significance set at . . results: a total of chinese older adults participated in the study. the prevalence of robust, pre-frail and frail were . %, . % and . % respectively. one third of the participants were malnourished or at risk of malnutrition. malnutrition and at-risk of malnutrition significantly increased the likelihood of frailty (or . , % ci . - . ). however, the level of frailty was not associated with age, gender, anthropometric measurements, eating behaviours, and use of dietary supplements. other nutritional factors significantly increased the likelihood of frailty were chewing difficulties (or . , % ci . - . ) and inadequate consumption of vegetables (or . , % ci . - . ). however, good appetite significantly reduced the likelihood of frailty (or . , % ci . - . ). conclusion: the findings showed that chewing difficulties and inadequate consumption of vegetables were associated with frailty, whereas good appetite was a protective factor. hence, interventions for addressing chewing problem and promoting appetite and consumption of vegetables are imperative to counter frailty in the older population. lack of energy was associated with nutritional status in nursing-home (nh) residents. methods: we performed a cross-sectional analysis of the incur study cohort. lack of energy was measured at baseline as part of the -items geriatric depression scale. nutritional status was evaluated according to mini nutritional assessment short-form (mna-sf). a -items frailty index (fi) was computed. logistic regression models were performed to test the association of lack of energy with nutritional status. results: a total of nh residents were available for analysis. the median age (iqr) was ( - ) years, with ( . %) females. at baseline, median mna-sf (iqr) was ( - ) with ( . %) patients that were malnourished. among the patients included . % ( patients) reported lack of energy. at univariate logistic regression analysis mna was inversely associated with lack of energy. at multivariate logistic regression analysis, adjusted for age, sex nursing home years and fi, we found that mna was independently inversely associated with lack of energy (or . , % ci . - . ). being malnourished is independently associated with lack of energy (or . , % ci . - . ). among mna components we found that item a (decrease in food intake), item c (reduced motricity) and item d (psychophysical stress) were inversely associated with lack of energy (or . , % ci . - . ; or . , % ci . - . ; or . % ci . - . ; for each point respectively), independently each one and from the other confounders. conclusion: in a cohort of very old nh residents, we found that an impaired nutritional status is associated with lack of energy. in particular, being malnourished bring a -fold risk of reporting lack of energy. more precisely, decrease in food intake, reduced motricity and psychophysical stress, each one were independently associated with lack of energy. a g e . m a r g u e r i t a s a a d e h , , f e d e r i c a p r i n e l l i , , anna-karin welmer , , weili xu , davide l vetrano , , serhiy dekhtyar , laura fratiglioni , , amaia calderón-larrañaga ( ( ) background: while declines in physical function are a common feature of ageing, the rate of the loss varies substantially between individuals, and has been attributed to intrinsic but also extrinsic (modifiable) factors such as diet, physical activity, and psychosocial well-being. objectives: ( ) to assess the role of food and nutrient intake in the speed of functional decline over years of follow-up. ( ) to explore whether such an association differs between levels of physical activity and psychosocial well-being. methods: we analysed data from individuals aged + from the population-based swedish national study on aging and care in kungsholmen (snac-k). the mediterranean diet score, mds (trichopoulou et al.) and the healthy diet indicator, hdi (who recommendations for saturated fatty acids, monodisaccharides, cholesterol, pufas, protein and fibre) were calculated for each participant, based on baseline data from a validated food frequency questionnaire and the corresponding transformation into nutrient intake. physical activity levels were assessed with questions about type, frequency, and intensity, and categorised as inadequate vs health/fitness-enhancing. we created a psychosocial well-being index by integrating variables linked to life satisfaction, positive/negative affect, social network and social participation. a global score of physical function was obtained by combining data on walking speed, balance, and chair stand tests. linear mixed models were used and adjusted for age, sex, education, smoking, baseline number of chronic diseases and impaired activities of daily living, total energy intake and time to death/drop-out. results: one standard deviation (sd) increase in the mds was associated with a lower functional decline both crosssectionally (β= . ; p= . ) and over the -year follow-up (β*time= . ; p= . ). higher scores of the hdi were also significantly associated with a lower functional decline, but only cross-sectionally (β= . ; p= . for one sd increase). when stratifying the analyses by levels of physical activity and psychosocial well-being, the protective effect of high mds was limited to subjects with health/fitness-enhancing physical activity (β*time= . , p= . ) and high levels of psychosocial well-being (β*time= . , p= . ), respectively. conclusion: a high adherence to a mediterranean dietary pattern, especially in combination with higher physical activity and psychosocial well-being, may slow down the age-relate decline in physical function. background: this cross-sectional study describes the application and follow-up of the self-care actions applied in a white male, years old, . m tall, a former athlete, currently sedentary, who in january presented % of glycated hemoglobin in medical consultation -between . and . %: pre-diabetes; fasting glycemia (mg / dl); (mg /dl) and the postprandial dose between and mg / dl. blood pressure between - mmhg; characterizing hypertension in stage. objectives: the objective was applying and follow-up a food re-education program associated with a resistance training program to reduce non-communicable diseases. methods: during , a program of dietary reeducation was carried out, with a few complex carbohydrates, an increase in proteins of high biological value, associated with a program of resistance exercises, which was adapted and individualized, obeying the individual's particularities. a short physical performance battery (sppb) was also applied to assess walking speed, strength and muscle balance. this program was performed three times a week, under the supervision of a physical education professional. capillary blood glucose was collected and analyzed times and blood pressure times, respectively. it was carried out a basic training for weeks aiming to rescue the muscular memory of the elderly, after beginning the adaptive phase of the physical valence training (cardiovascular endurance, localized muscular resistance); for weeks and the specified. the loads corresponded to % of rm for - repetitions with three series and to minutes intervals at each stage of the training. we used the ibm spss statistics program to perform descriptive statistics. results: the mean glycemia was (mg / dl), the glycated hemoglobin analyzes showed . ; low risk of diabetes. systolic blood pressure and diastolic blood pressure presented a mean of . ± . mmhg, and . ± . mmhg, respectively. we observed a gradual gain every months of resistance training. the sppb score changed from to points; performance between intermediate to high. conclusion: dietary re-education associated with a well-designed strength training program can result in the reduction of diabetes and hypertension, as well as strengthening the muscular system of the elderly. background: diet can be an important non-pharmacological aspect in order to prevent and/or attenuate brain and frailty outcomes in older adfults. objectives: to investigate, by a systematic review, studies associating the dietary inflammatory index (dii) with brain and frailty outcomes in older adults. methods: we searched the publications in pubmed and lilacs databases up to june . inclusion and exclusion criteria were formulated based on pi(e)cos strategy (population= older adults, >= years; intervention/ exposition= dietary inflammatory index; comparison= not applied; outcomes= brain and muscle outcomes; study type= randomized clinical trials, cohorts, cross-sectional, casecontrol studies). results: searches resulted in publications, and after exclusion due to duplicity (n= ) and not compliance with exclusion and inclusion criteria (n= ), eight studies were selected. these studies were published from to , all of them were cross-sectional, with participants above years old, and the outcomes investigated were frailty and frailty risk, survival free of disabilities (by fried's frailty criteria, sppb test, lawton and broady scales); memory, cognitive decline and risk of dementia (by meem, cerad, gds, prime-md, dsst and animal fluency test). conclusion: the data extracted from the articles showed significant association between dii and the outcomes investigated, namely, the more inflammatory diet was associated with higher odds to be frail and pre-frail, and to have any type of cognitive impairment. therefore, the dii showed to be associated to brain and frailty outcomes in older adults, however, to understand causality, longitudinal studies are still necessary. background: it is well established that reactive oxygen species (ros) are increased in skeletal muscle with age. we have recently shown that increased ros with age is associated with increased expression of the senescence-associated microrna mir- a- p (mir- a) in skeletal muscle as well as in muscle-derived extracellular vesicles. these vesicles enriched in mir- a are elevated in aged mouse serum, and can induce senescence in bone stem cells. the histone deacetylase sirt is a validated target of mir- a, and sirt plays important roles in cell survival as well as in muscle hypertrophy with functional overload. importantly, we previously found that mir- a expression was much higher in muscle from aged female mice compared to male mice, a phenomenon others have observed in mouse cardiac muscle. objectives: here we tested the hypothesis that pharmacological ablation of senescent cells could modulate mir- a and sirt bioavailability in skeletal muscle of aged mice. we utilized the senescent drug abt- (navitoclax) since previous studies have shown that oral administration of abt- removed senescent satellite (stem) cells in mouse skeletal muscle. methods: ten male and ten female c bl mice, months of age, received either abt- ( mg/kg bw, ul) or vehicle by oral gavage for ten days. tibialis anterior muscles were removed at the end of the study for examination of mir- and sirt levels using rt-pcr and elisa, respectively. results: abt- reduced mir- a expression in both male and female mice, although the effect was more pronounced in male mice compared to females. abt- significantly increased sirt levels in male skeletal muscle but not in females. the changes in sirt and mir- a levels were not associated with significant differences in muscle fiber size over the treatment period. conclusion: these findings suggest that certain senolytic compounds can modulate levels of senescence-associated mirnas and their targets in aging skeletal muscle. these data also underscore the importance of considering sex differences in the molecular mechanisms underlying age-related muscle atrophy. background: the growth of the elderly population is a worldwide phenomenon and is associated with profound changes in body composition. the purpose of this study was to describe the magnitude of the problem, to evaluate the associated factors and the relation with functional capacity in the study population. objectives: to estimate the association between demographic factors, comorbidities and muscle mass index over time until functional disability or death appears in non-obese elderly individuals. methods: longitudinal study of elderly individuals aged years or over, non-obese and absence of functional disability at the beginning of the cohort on the epidoso project database. the variables gender, age, ethnicity, medical history, functional capacity and death were investigated. the low or normal muscle mass index (mmi) was obtained through anthropometric data and a predictive equation. the functional capacity was measured using a structured and validated multidimensional questionnaire. the deaths occurred in the period were investigated with relatives through household surveys, in registries and registries of the state system of data analysis foundation. estimates of eventfree survival (functional disability or death) were calculated using kaplan-meier curves using the log-rank test in the gross comparisons. a multiple cox proportional hazards model was used to identify the independent effect of time predictors until onset of functional disability or death. results: the mean time found for the onset of functional disability or death was . years ( %ci=[ . ; . ]). in the crude analysis, there were statistically significant differences in the time to occurrence of functional disability or death, by age group (p< . ), arterial hypertension (p= . ), diabetes mellitus (p= . ) and marginal statistical difference muscle mass level (p= . background: a consequence of the ageing population is the increasing number of older adults with physical limitations. these limitations are mainly caused by decreased muscle mass and strength (sarcopenia). treatment or rather prevention of sarcopenia is necessary, as it may lead to lowered quality of life, hospitalization, loss of independence and even mortality. since older ethnic minorities are more likely to have an unfavourable health status compared to the majority population, variations in the prevalence of sarcopenia for ethnic minority groups are expected. further investigation seems imperative to be able to target preventive interventions to those at high risk of sarcopenia within the population. objectives: to examine the sarcopenia prevalence and its association with protein intake in an older multi-ethnic population in the netherlands. methods: we used cross-sectional data from the helius (healthy life in an urban setting) study, comprising the largest ethnic populations living in amsterdam, the netherlands. in total individuals from dutch, south-asian surinamese, african surinamese, turkish and moroccan origin aged years and over were included. sarcopenia was defined according to the ewgsop . in a subsample (n= ), protein intake was measured using ethnic-specific food frequency questionnaires. descriptive analyses were performed to study sarcopenia prevalence across ethnic groups in men and women, and logistic regression analysis were used to study associations between protein intake and sarcopenia. results: sarcopenia prevalence was found to be sex-and ethnic specific, varying from . % in turkish to . % in south-asian surinamese men and ranging from . % in turkish up to . % in south-asian surinamese women. higher protein intake was associated with a % lower odds of sarcopenia in the total population (or= . , % ci . - . ) and across ethnic groups. conclusion: ethnic differences in the prevalence of sarcopenia and its association with protein intake suggest the need to target specific ethnic groups for prevention or treatment of sarcopenia. background: few studies have evaluated the relationship between frailty and acute respiratory illness (ari), despite of increasing heavy burden of ari in older people. objectives: we conducted a prospective cohort study in communitydwelling older people in hong kong, to evaluate the impact of frailty on the risk of acute respiratory infections in the community setting and the potential modifying role of outdoor activities. methods: we recruited and followed up participants who were chinese and aged from to years, from december to may . frailty was measured by fried frailty index (ffi) twice during the study period. daily hours of outdoor activities were collected by a monthly activity journal (n= ) during the whole period, and by wearable gps device from some participants for one week in summer (n= ) and winter (n= ), respectively. the ari incidence was collected by monthly phone calls to the participants. we used a logistic regression model to estimate the odds ratio (or) of ari associated with frailty status (robust as reference group). results: the participants were classified into three groups according to the ffi criteria: ( . %) as robust, ( . %) as pre-frail and ( . %) as frail groups. of them, reported ari during the study period. according to the activity journals, daily hours of staying outdoors in the ari participants were slightly less than those in without ari ( . vs . in whole study period, . vs . in summer, . vs . in winter). while, the gps data showed that the participants with ari had longer daily hours of outdoors activities in summer ( . vs . ) but shorter in winter ( . vs . ), although none were statistically significant (p > . ). after adjustment for age, age, living alone or with family and daily hours of outdoor activities, we found that the frailty and pre-frailty groups had a higher risk of ari incidence compared with the robust group, with or . (p = . ) and . (p = . ), respectively. conclusion: frailty might be associated with a higher risk of ari among older people, but the role of outdoor activities remains inconclusive. background: previous studies have investigated the association between impaired muscle health and mortality. however, muscle health is a dynamic entity which change with time. objectives: to assess the effect of a short-term decline of muscle health (i.e., over year) and its association with long-term mortality (i.e., over years). methods: the sarcophage cohort follows up older belgian adults to assess consequences of sarcopenia. an assessment of muscle mass (dxa), muscle strength (handheld dynamometer) and physical performance (by means of sppb, including gait speed) are performed annually. all-causes deaths are collected annually. the association between short term (i.e. after one year) decline in muscle parameters and -year occurrence of deaths was tested using cox model. roc analyses were performed to assess performance of prediction of the different muscle components and to find optimal cut-points. missing data were handled using multiple imputations. results: from the subjects recruited ( . ± . years, . % women), were discarded from our sample because they died during the first year. therefore, the muscle decline was available on a sample of subjects. deaths occurred within the first years of follow-up. a -point decrease in performance at sppb test resulted in % higher risk of dealth (hradjusted = . [ %ci . - . ]). for each decrease of . m/s of gait speed, we observed an % higher risk of death (hradjusted = . [ . - . ]). a -kg decrease of muscle strength resulted in % higher risk of death in men and % higher risk of death in women (hradjusted = . [ . - . ] and hradjusted = . [ . - . ], respectively). we did not found any association between short-term loss of muscle mass and the occurrence of death (p= . ). then, we tried to find cutoffs optimizing the sensitivity-specificity ratio and we found following results : over year, a decline of sppb superior or equal to , of gait speed superior or equal to . m/s and of muscle strength superior or equal to . kg in men and . kg in women. conclusion: a short-term decline in muscle function is predictive of premature deaths. background: sarcopenia, the age-related progressive loss of muscle mass and function, is associated with an increased likelihood of adverse outcomes like falls, fractures, physical disability, and mortality. international consensus groups continue providing new definitions and clinical cut-off points despite over a decade of work in this area. objectives: we examined the prevalence of sarcopenia using two of the most current operational definitions (foundation of nih sarcopenia project (fnih) and the european working group on sarcopenia in older persons (ewgsop )) in a cohort of older adults (n= , >= yrs) hospitalized for an acute disease at utmb hospital in galveston (jan -may ). methods: testing included measures of: demographics (age, gender, race, education), body composition (dexa), physical function tests (sppb, tug, grip), psychological wellbeing and independence questionnaires, and chart review (comorbidity, length of stay). results: we found % had low physical performance, % had low muscle strength, and % low lean mass. we compared multiple tests and cutoffs for each of the three groupings under the fnih and ewgsop and found there to be differences depending on the test usedespecially for low performance which varied from %- %. in our cohort, the prevalence of sarcopenia was . % by ewgsop and . % by fnih. the subgroupings were found to be near identical across almost all measures despite the definitions' discrepancies in cutoff points between fnih and ewgsop . conclusion: in conclusion, recent updates to the new ewgsop make it almost indistinguishable to the older fnih standard, but the new ewgsop algorithm does provide a grading system to identify different levels of severity of sarcopenia. background: the population is experiencing a fast growth in the number of older adults, therefore determine the prevalence of frailty could help to inform future strategies to reduce its social and health burden. objectives: determine the prevalence of frailty in chilean older adults. methods: participants, aged > years, from the chilean national health survey - were included in this study. frailty was assessed by fried criteria modified, therefore people classified as frail should meet at least out of the criteria (low strength, low physical activity, low body mass index, slow walking pace and tiredness). results: the prevalence of frailty was . % ( . % for men and . % for women). the prevalence of prefrailty was . % whereas . % was classified as normal. the prevalence of frailty increased with markedly with age, . % and . % of men and women, respectively, were frail at the age of . this prevalence increased to . % and . % for men and women at the age of . the prevalence of pre-frailty increased from . % to . % for men and from . % and . % for women from the age of to years, respectively. conclusion: the prevalence of frailty increased markedly with age. with the chilean population expected to increase their life expectancy and number of older adults, it is important to implement prevention strategies that allow for early identification of high-risk individuals. a year follow-up. jair licio ferreira santos , yeda aparecida de oliveira duarte , tiago da silva alexandre background: sarcopenia has been increasingly recognized as leading to poor prognosis in health outcomes. likewise, falls -although important at older ages -have not been studied frequently and may lead to an increased risk of death. we evaluated survival of elderly people living in são paulo -brasil in a -year follow-up, considering the presence of sarcopenia at baseline and the occurrence of falls before the interview. objectives: to investigate whether sarcopenia and/or falls increase mortality among brazilian older adults. methods: data came from the second ( ) and fourth ( ) rounds of the health, welfare and aging study (sabe), which begun in , with a sample of the population over years old in the city of são paulo, brazil. after the first round, follow-up was performed every five years. sarcopenia was defined according to the consensus of the european working group on sarcopenia in the elderly (ewgsop), and the occurrence of falls was assessed by direct questions answered by the elder or his caregiver. a multivariate analysis with robust estimation and control for exposure time was done using the poisson regression model. results: mortality rates (per thousand person years) were: . (non sarcopenic, no falls) ; . (non sarcopenic with falls); . (sarcopenic no falls) ); and . (sarcopenic with falls. the poisson regression resulted in incidence rate ratios (when compared to sarcopenic, no falls) of . for non sarcopenic with falls; . for sarcopenic elders with no falls and . for sarcopenic with falls. conclusion: sarcopenia and the occurrence of falls are important risk factors for mortality. this finding highlights the importance of considering sarcopenia in health risk assessment and developing educational programs to prevent falls. ecosse l. lamoureux, , , alfred t.l. gan , ryan e.k. man , , eva k. fenwick , , bao lin pauline soh , angelique chan , david ng , chong foong-fong mary , preeti gupta (( ) singapore eye research institute and singapore national eye centre, singapore; ( ) duke-nus medical school, singapore; ( ) singapore institute of technology, health and social sciences, singapore; ( ) saw swee hock school of public health, national university of singapore, singapore) background: individually, sarcopenia and frailty are known risk factors for cognitive impairment (ci) in older adults, but information on their conjoint presence on the increased risk of ci is unavailable in this same population. objectives: we examined the association of the combined presence of sarcopenia and frailty with ci in elderly singaporeans. health profile in elderly singaporeans study (pioneer), a nationally-representative, population-based study of singaporean chinese, malays, and indians aged >= years. participants underwent body composition (dual energy x-ray absorptiometry -dxa); grip strength (hand dynamometer) and habitual m-walking speed assessments. sarcopenia was defined using the asian consensus as low appendicular lean mass (lalm; men < kg/m , women < . kg/m ) and low muscle strength (lms; men < kg, women < kg) or slow walking speed (sws; < . m/s); and frailty was defined as meeting three or more of the following components: ) unintentional weight-loss >= . kg in the past - months and/or bmi < . kg/m , ) lms, ) self-reported exhaustion in the past one month, ) sws, and ) low physical activity level. ci was determined using the montreal cognitive assessment (moca) basic scale. logistic regressionb models were used to determine the cross-sectional sarcopenia-frailty and ci relationship. results: of the included participants (mean age [sd]: . [ . ] years; . % females), ( %); ( %); and ( %) had neither sarcopenia nor frailty, either sarcopenia or frailty, and both sarcopenia and frailty, respectively. ci was present in ( . %) individuals without sarcopenia and frailty; ( . %) with either sarcopenia or frailty; and ( . %) individuals with both sarcopenia and frailty. in multivariable-adjusted analyses, presence of either sarcopenia or frailty was not significantly associated with higher odds of ci (odds ratio (or) [ % confidence interval]: . [ . - . ]), while having both sarcopenia and frailty significantly increased the odds of ci by nearly . times ( . [ . - . ]). conclusion: the co-presence of sarcopenia and frailty is independently associated with a higher risk of ci, compared to one condition alone, although longitudinal studies are needed to confirm this finding. strategies to prevent the concomitant onset of sarcopenia and frailty may be warranted to potentially reduce the risk of ci in older adults. background: car accidents related to older adults increased with aging, particularly in japan. safety driving required robust of physical function. however, the association between frailty and car accidents was still unclear. objectives: the aim of this study was to examine the association between frail status and car accidents. methods: participants were , older adults ( . % women, mean age: . years) enrolled current drivers in the national center for geriatrics and gerontology -study of geriatric syndromes. the criterion of frailty used in this study was j-chs index modified according to fried's criteria (chs index). the components of frailty in j-chs index were based on the original chs index: shrinking (weight loss), weakness, poor endurance (exhaustion), low activity level, and slowness. based on the presence numbers of these five components, our study defined "frailty" as and over, i.e., including pre frail and frail. the data of car accidents were collected from self-reported history of car accidents during years. results: among , participants, , participants ( . %) had a history of car accident. higher proportion of car accidents group was observed in shrinking ( . % vs . %, p = . ), exhaustion ( . % vs . %, p = . ), physical inactivity ( . % vs . %, p = . ) and slowness ( . % vs . %, p = . ), but not weakness ( . vs . , p = . ). in a logistic regression analysis, frailty was independently associated with car accidents in an adjusted model (or . [ %ci . - . ], p < . ). conclusion: this population study reveals frailty associated with car accidents. the findings have contribution of enhancing utility of risk assessments among older drivers. further studies were required to clarify risk of car accidents.model. background: frailty, a state of vulnerability to stressors resulting from a loss of physiological reserve across multiple systems. frailty is associated with higher morbidity, mortality and healthcare utilization. the national prevalence of frailty among us older veterans was found to be as high a %. however, little is known about the incidence of frailty in older, community-dwelling veterans. objectives: determine the incidence over years of frailty among robust or prefrail community-dwelling older veterans. methods: this is a retrospective cohort study of community-dwelling veterans years and older who had determinations of frailty from july -june and were followed until their last clinician visit before september , . a -item va frailty index (va-fi) was generated at baseline and during each subsequent primary care encounter as a proportion of all potential variables (morbidity, function, sensory loss, cognition and mood and other) with data from electronic health records. the va-fi categorized veterans into robust (fi<. ), prefrail (fi=>. , <. ) and frail (fi>=. ). using baseline and median duration of follow-up data based on event rates, incidence rates of frailty per person/years were calculated for robust, prefrail, combined (robust and prefrail) and gender groups. results: patients were . % white, . % non-hispanic, . % male, mean age . (sd= . ) years. the proportion of robust, pre-frail and frail patients at baseline was . % (n= ), . % (n= ) and . % (n= ) respectively. among robust veterans surviving a median follow-up of . (iqr . ) years, . % ( / ) became frail with an incidence rate of . cases/per person-years. among prefrail veterans . % ( / ) became frail and the incidence rate was . cases/per person-years. among the combined group, % became frail, with an incidence rate of . per person-years. the proportion of veterans becoming frail and the incidence rates were higher in women than men ( . % vs. . % and . vs . cases per person-years respectively). conclusion: this study shows a high incidence of frailty in community-dwelling older us veterans. identification of older veterans at high risk for frailty may assist in the development of interventions aimed at preventing frailty and its associated complications. background: anticholinergic drugs are prescribed to treat a variety of medical conditions through pharmacological actions opposing the actions of acetylcholine. anticholinergics and may contribute to frailty by causing cognitive, functional and physical impairment. frailty represents a state of vulnerability to stressors resulting from a loss of physiological reserve across multiple systems. frailty may potentially make patients more susceptible to the deleterious effects of anticholinergic medications on cognition. objectives: determine the crosssectional association of anticholinergics with cognitive impairment according to frailty status among communitydwelling older veterans. methods: this is a cross-sectional study of , community-dwelling veterans years and older whose frailty status was assessed october -october . the use of medications (active/inactive) with high anticholinergic burden scale (acb ) and cognitive impairment diagnoses (icd codes for mild cognitive impairment/dementia) were obtained from electronic health records. a -item va frailty index (va-fi) was generated as a proportion of all potential variables at the time of the assessment. we compared robust (fi≤. ), prefrail (fi=>. , <. ) and frail (fi>=. ) patients. after adjusting for age, gender, race, marital status, median household income, and bmi, odds ratios (ors) and % confidence intervals (cis) were calculated using binomial logistic regression with cognitive impairment as the outcome variable and anticholinergics (acb ) as independent variables. we repeated the analysis according to frailty status. results: patients were % white, . % male, mean age . (sd= . ) years, . % ( ) had cognitive impairment, . % (n= ) were taking acb medications, . % ( ) took them in the past and . % ( ) never used them. the proportion of robust, pre-frail and frail patients was . % (n= ), . % (n= ) and . % (n= ) respectively. in binomial logistic regression, active and inactive acb medications were associated with higher risk for cognitive impairment, adjusted or= . background: frailty, a state of vulnerability to stressors resulting from a loss of physiological reserve across multiple systems. the national prevalence of frailty among us older veterans was found to be as high a %. multiple studies have shown a higher prevalence of frailty and mortality in african americans. however, little is known about racial-differences in all-cause mortality in older veterans who had just transitioned to frailty. objectives: determine racial differences in allcause mortality over years among community-dwelling older us veterans who transitioned to frailty. methods: this is a retrospective cohort study of , community-dwelling veterans years and older who transitioned to frailty from july -september and were followed until death or september . a -item va frailty index (va-fi) was generated at baseline and during each subsequent primary care encounter as a proportion of all potential variables with data from electronic health records. the va-fi categorized veterans into robust (fi≤. ), prefrail (fi=>. ,<. ) and frail (fi>=. ). at the end of follow-up, we aggregated data on mortality only on those veterans who transitioned to frailty (robust/prefrail at baseline) and compared whites and african americans. after adjusting for age, gender, ethnicity, marital status and median household income, the association of race with mortality was determined using a multivariate cox regression model. results: patients were . % white, . % african-american, . % non-hispanic, . % male, mean age at frailty transition was . (sd= . ) years. over a median follow-up period of days (iqr= ) from the time they transitioned to frailty, deaths occurred (n= , in whites vs. n= in african americans). african american veterans had a lower risk for all-cause mortality than white veterans, unadjusted hazard ratio (hr) =. ( %ci: . -. ), p<. . however, these mortality differences disappeared after adjustment for covariates, adjusted hr =. ( %ci: . - . ), p=. . conclusion: our study suggests that in community dwelling older us veterans who had transitioned to frailty, race is not significantly related to overall survival when adjusting for other covariates. background: previous studies show that sarcopenic obesity (so) is associated with higher risk of mortality. however, a consensus definition of so is lacking, and more information is needed on the validity of simple measures applicable at a regular health care visit, such as anthropometric measurements and hand-grip strength or chair stand test. objectives: to examine the association between so and mortality, defining so based on body mass index, waist circumference, hand-grip strength and chair stand test, in a representative sample of finnish population. methods: this study was based on , participants aged years or over with data on anthropometrics, hand-grip strength and chair stand test from the nationally representative health survey. baseline sarcopenic obesity was defined as having bmi >= kg/m or waist circumference >= cm (men)/ cm (women), and hand-grip strength < kg in men, < kg in women, or chair stand > s for five rises. register-based follow-up data of the statistic finland containing , deaths during the years of follow-up were individually linked with the baseline data. survival analyses were based on cox proportional hazards models using age as the time scale. results: mean age was . years (sd . ) and . % were females. overall prevalence of sarcopenic obesity was . % at baseline. sarcopenic obesity was associated with higher risk of mortality (hr . , %ci . - . ) in an age and sex adjusted model. further adjustments for education, smoking, alcohol use, and physical activity did not notably change the results (hr . , %ci . - . ). conclusion: sarcopenic obesity, as defined based on anthropometric measurements as well as hand-grip strength or chair stand test, predicted higher mortality over years of follow-up. background: malnutrition and sarcopenia have a negative impact on mobility, risk of falls, fractures, physical disability and mortality. currently, limited information is available on nutritional status and nutritional interventions in geriatric rehabilitation (gr) patients. objectives: to characterize nutritional status and evidence of nutritional interventions with and without physical exercise in gr patients. methods: eight electronic databases were screened for nutritional status and interventions in patients >= years, admitted to gr, one search string was used for both topics. pooled estimates were calculated for mean bmi and prevalence of (risk of) malnutrition (mna). meta-analyses were performed to quantify intervention effects on albumin, muscle mass, barthel index (bi), and hand grip strength (hgs). results: observational and intervention studies were included out of references. pooled estimates ( % confidence interval (ci)) for prevalence of malnutrition and risk of malnutrition were ( - )% and ( - )%. pooled estimate ( %ci) for bmi was . ( . - . ) kg/m². low protein and energy intake and vitamin d deficiency were prevalent. intervention studies were heterogeneous in interventions and outcomes. meta-analyses showed no significant effects on albumin (standardized mean difference (smd) . , % ci - . : . ), muscle mass (mean difference (md) . kg, % ci - . : . ), bi (md . points, % ci - . : . ) and hgs (smd - . , % ci - . - . ), based on - studies. eight interventions tested oral nutritional supplements (ons) with protein, with or without exercise, reported protein intake and showed an increase, / studies showed increased albumin levels and / reported improved functional outcomes. conclusion: a high percentage of gr patients was affected by reduced nutritional status. intervention studies were limited and heterogeneous, but studies with ons improved nutritional outcomes, and functional outcomes in the majority of reporting studies. the results emphasize the need for malnutrition and sarcopenia screening and show benefits of protein supplementation in this population. future well-designed, well-powered trials are needed to clarify existing controversial aspects. therefore, feasibility of an intervention with a high-whey protein, leucine and vitamin d enriched ons (fortifit®), combined with resistance-type exercise in gr hip fracture patients will be investigated in a new intervention study (empower-gr). background: sarcopenia is a progressive and generalized skeletal muscle disorder associated with an increased likelihood of adverse outcomes such as falls, fractures, physical disability and mortality. the geographical region of residence (urban and rural area) may affect the prevalence of sarcopenia due to physical and environmental conditions. in , the european working group on sarcopenia in older people (ewgsop) updated the definition of sarcopenia (ewgsop ). objectives: to describe the prevalence of sarcopenia related to ewgsop and ewgsop criteria and to analyze the association between sarcopenia and geographical regions of residence. methods: this is a cross-sectional study involving elderly women ( years old or more) that were undergoing dxa in a radiology facility located in palmeira das missões (southern brazil). sociodemographic data were collected through a questionnaire. for the diagnosis of sarcopenia, we used the criteria recommended by the ewgsop (low muscle mass plus low grip strength and/or low gait speed), and ewgsop (low grip strength plus low muscle mass and/or low gait speed). the study was approved by the university ethics committee. results: out of the participants, . % was married, . % had education between and years of schooling, . % was caucasian, and . % was retired. the mean age was . ± . years old ( - ). the frequency of sarcopenia in the total sample assessed by the ewgsop and ewgsop was . % and . %, respectively. the prevalence of sarcopenia by the ewgsop was % in the urban area and . % in the rural area (p= . ) and by the ewgsop was . % in the urban area and . % in the rural area (p= . ). conclusion: in a sample of elderly women from the southern brazil, the prevalence of sarcopenia was low through both consensus (ewgsop and ewgsop ), and was higher among urban area. funding: this study was financed in part by the coordenação de aperfeiçoamento de pessoal de nível superior -brazil (capes) -finance code . background: patients with disuse syndrome have gradually increased with aging of inpatients in saitama medical university hospital. because these patients have been inactive in the acute phase, sarcopenia is likely to occur. sarcopenia was graded by three criteria in ewgsop ; muscle strength, muscle quantity and physical performance. muscle volume can be measured only in limited medical centers. many of patients with disuse syndrome can not walk even after the acute phase. for these reasons, muscle strength is the only quantitative factor reflecting sarcopenia, especially in old patients with disuse syndrome after the acute phase. objectives: to show ) muscle strength in old patients with disuse syndrome after the acute phase, ) effect of muscle strength on activities of daily living (adl). methods: subjects were old patients with disuse syndrome admitted in the department of rehabilitation medicine (rm) in saitama medical university hospital from january to december . inclusion criterion were as follows; ) patient age was or older ) patients could not walk independently at admission in the department of rm exclusion criterion were as follows; ) patients with motor paresis, contracture of fingers ) patients in inactivity before the onset of the disease causing disuse syndrome. grip strength (gs) was measured by handheld dynamometer. cut-off point of gs set by awgs in was adopted; kg for men and kg for women, adl was evaluated using functional independence measure motor scale (mfim) one week after admission in the department of rehabilitation medicine . percentage of gs below cut-off point was shown in men and women respectively. effect of gs on mfim was investigated using regression analysis. results: ninety nine out of patients were subjects in this study. median age was . years in men (n= ), . years in women (n= ). only two in men and one in women were below gs cut-off point. correlation coefficient between gs and mfim was . (p= . ) in men, . (p= . ) in women respectively. conclusion: gs was below cut-off point in most of the subjects. gp may affect adl after the acute phase in old patients with disuse syndrome. death, whereas measures of functional ability, physical strength and morbidity were stronger associated with time to death than with chronological age. from the age of and forwards participants have a high life-satisfaction in general, however, a decline is seen as persons get older and with proximity to death. measures of functional ability (e.g. going shopping) and morbidity (e.g. self-related health) had a significantly increasing effect on life-satisfaction with increasing age. whereas social function (e.g. living alone, meeting friends) did not significantly modify the decrease in life satisfaction with increasing age. conclusion: physical strength, functional ability and morbidity were measures mostly linked to biological aging, while social functioning was strongly correlated with chronological age. functional ability and self-related health are important factors to prevent age-related decrease in life satisfaction. background: previous studies mostly conducted in western countries support that physical frailty predicts future cognitive decline in general older populations. however, longitudinal evidence on this association is limited, especially among older japanese women. objectives: this study has investigated the prospective associations of frailty status with cognitive decline over two years among community-dwelling older japanese women, including which individual frailty components (i.e., slowness, weakness, exhaustion, low activity, and unintentional weight loss) could predict cognitive decline. methods: this study was a two-year population-based cohort study conducted in a metropolitan area of tokyo, japan. data were collected in october (baseline) and september (follow-up) and analyzed between december and january . participants were community-dwelling older japanese women, aged to years at the baseline, without any neurological diseases or cognitive impairment as measured by a mini-mental state examination (mmse) score of >= points. cognitive decline was defined as a drop of two points or more in the mmse score over two years. the physical frailty phenotype was classified by the japanese version of cardiovascular health study criteria. multiple poisson regression analyses with a robust error variance were applied to assess risk ratios (rrs) of two-year cognitive decline across the baseline frailty statuses (robust [reference category], prefrail, or frail). results: of the women analyzed, ( . %) were prefrail ( or components), and ( . %) were frail (≥ components) at the baseline. at the follow-up, ( . %) robust, ( . %) prefrail, and ( . %) frail women experienced cognitive decline. after being adjusted for various confounding factors including age, educational attainment, and baseline mmse score, the rrs of cognitive decline were . ( % confidence interval [ci]: . , . ) in the prefrail and . ( %ci: . , . ) in the frail women. among the five frailty components, slowness (rr: . , %ci: . , . ), weakness (rr: . , %ci: . , . ), and unintentional weight loss (rr: . , %ci: . , . ) were significantly associated with cognitive decline. conclusion: over the two-year period, approximately % of women experienced cognitive decline. baseline physical frailty status, particularly slowness, weakness, and unintentional weight loss, predicted this decline. intervention strategies targeting physical frailty may help delay cognitive decline in older japanese women. background: menopause leads to estradiol (e ) deficiency that is associated with decreases in muscle mass and strength. yet the mechanistic role of e in the loss of muscle mass has not been established. programmed cell death termed apoptosis has been proposed a key signaling route in skeletal muscle homeostasis, including muscle aging and sarcopenia. to date several micrornas (mirs) have been found to regulate key steps in apoptotic pathways. objectives: here we studied the effect of e deficiency on mir-signaling in skeletal muscle apoptosis. our aim was to reveal whether e -responsive mirs have mechanistic role in inducing skeletal muscle apoptosis. methods: we utilized c bl mice with three study groups; sham (normal estrous cycle, n= ), ovx (e deficiency, n= ) and ovx+e (high e supplemented by pellet, n= ). in our setup, ovx and ovx+e groups represent the extremes of e level. six weeks following the sham or ovx surgery, mice were sacrificed, gastrocnemius muscles were harvested and rna isolated. mir-profile was studied with ngs and candidate mirs verified using qpcr. the target proteins of the mirs were found using in silico analysis (target scan) and target proteins measured at mrna (qpcr) and protein levels (western blot). results: of the apoptosis-linked mirs found, four ( - p, a- p, - p and - p) indicated differential expression patterns between ovx and ovx+e groups. in qpcr verification, ovx had lower expression in all of the studied mirs compared with ovx+e (p= . ). accordingly, ovx had higher expression of cytochrome c and caspases , and compared with ovx+e at the mrna level (p< . ). at protein level, ovx had greater cytochrome c and active caspase compared with ovx+e (p< . ). conclusion: in muscle from e deficient mice (ovx vs. ovx+e group), several apoptosis-linked mirs were down regulated concomitant with higher mrna expression of the target proteins. furthermore, e deficiency was associated with higher cytochrome c and active caspase protein levels. to conclude, e deficiency down regulated several mirs related to apoptotic pathways that may lead to increased apoptosis and reduced skeletal muscle mass. background: although sarcopenia's pathogenesis is multifactorial, with its major phenotypes, muscle mass and muscle strength, being highly heritable, its genetic underpinning is not well studied. objectives: summarize evidence for use of zebrafish as a model system to decode the sarcopenia's gwas findings. methods: several genome-wide association studies (gwas) of muscle-related traits were published recently, providing dozens of candidate genes, many of them with unknown function. therefore, animal models are required not only to identify causal mechanisms, but also to clarify the underlying biology and to translate this knowledge into new interventions. over the past several decades, small teleost fishes had emerged as a powerful system for modeling the genetics of human diseases. due to their amenability to rapid genetic intervention and the large number of conserved genetic and physiological features, small teleosts, such as zebrafish (d. rerio), are indispensable for skeletal muscle genomic studies. results: we summarize the evidence supporting the utility of small fish model for accelerating our understanding of human skeletal muscle in norm and disease. the following stable mutants (mostly knockouts) exist for the «monogenic muscle» diseases (human gene, fish mutant, disease): for duchenne and becker muscular dystrophy (md), sapje/dmd (homology of human dmd gene); for limb-girdle md, popdc s f (bves); for bethlem myopathy and ullrich congenital md, col a ama (col a ); for nemaline myopathy, froto c (myo b), and tmod trg (tmod ); for merosin deficient congenital md, lama cl /cl ; candyfloss/lama (lama ); for limb-girdle md, bvesicl /icl (popdc ), heltg (ttn), and «foie gras» (trappc ); for native american myopathy, stac mi (stac ), as well as fish homologues of the acvr , cacnb , cavin , cms, dag , fhl , flnc, vcp and other human genes. these models provide evidence of muscle-related gene's conservancy and similarity of skeletal muscle morphology and physiological phenotypes. we will outline challenges in interpreting zebrafish mutant phenotypes and translating them to human disease. conclusion: we conclude with recommendations of future directions to leverage. centenarians exhibit extreme longevity and a compression of morbidity. we showed previously that centenarians display a unique genetic signature, in terms of mrna and mirna profile, which is similar to that found in young people and different from that found in octogenarians. centenarian offspring seem to inherit centenarians' compression of morbidity, as measured by lower rates of age-related pathologies such as hypertension, diabetes, strokes, and heart attacks. we therefore hypothesized that they will also display a lower incidence of frailty. in this study, we aimed to ascertain whether centenarian offspring are endowed which such "genetic footprint" and a lower incidence of frailty, when compared to their contemporaries. for this purpose, we collected plasma and peripheral blood mononuclear cells from septuagenarians, , age-matched centenarian offspring (but not sons or daughters of the centenarians included in this study) and centenarians. mirna expression and mrna profiles were performed by the genechip mirna . array (affimetrix) and genechip clariom s human array (affimetrix), respectively. frailty phenotype was determined by meeting three or more of the following criteria: unintentional weight loss, low grip strength, exhaustion, slow gait speed, and low physical activity. we found that mirna and mrna expression patterns in centenarians are similar to centenarian offspring and different to non-centenarian offspring (p< . ). importantly, we found a lower incidence of frailty among centenarians' offspring (p< . ), when compared to their contemporaries. taken together, our results indicate that centenarian offspring resemble centenarian characteristics and that they enjoy significantly less frailty than their less fortunate contemporaries that are not sons or daughters of centenarians. this lower incidence of frailty may be a key feature to achieve extraordinary ageing. background: hypoglycemic episodes increase in older patients and their consequences are more significant. objectives: the aim of this prospective observational study is to explore unknown hypoglycemic episodes diagnosed by continuous glucose monitoring in older type diabetic patients and to describe the link between the occurrence of hypoglycemia and glycosylated hemoglobin (hba c) level. methods: we included patients with type diabetes aged years or over hospitalized during consecutive months in a geriatric acute care unit in tours university hospital in france. demographic characteristics, type of diabetic treatment, mini mental state examination, hba c levels, albumin and creatinin level were recorded. continuous glucose monitoring (cgm) was used to detect hypoglycemia for a maximum of days, and capillary blood glucose measurements (cbgm) were also performed to times a day. patients with at least one blood glucose measure lower than mg/dl were compared with others for demographic, clinical and biological parameters. results: seventeen patients experienced hypoglycemia. these groups did not differ in demographic characteristics and in diabetic drug class. among these patients, had an episode of severe hypoglycemia (< mg/dl) and patients had nocturnal episodes, more often between and am. twelve patients had unrecognized hypoglycemia by cbgm. the average duration of hypoglycemic episodes was . hours. there was no difference in the hba c levels between the two groups (mean . %, p= . ). conclusion: the prevalence of hypoglycemia is underestimated in the oldest diabetic population receiving hypoglycemic drugs. measurements of cbgm and hba c level in the target may overlook nocturnal and prolonged hypoglycemic episodes. our study showed the benefit of cgm in older diabetic patients in order to detect unknown hypoglycemia. more prospective studies are needed to explore factors that predict hypoglycemia. catenacci, sophie le-gonidec, alizée dortignac, ophélie pereira, romain madeleine, jean-philippe pradère, philippe valet, cedric dray (umr inserm,universitéfédéral de toulouse -universitépaul sabatier toulouse iii, france) background: healthy lifespan does not increase proportionally compared to global lifespan leading to an increased number of disabled aged persons. to increase healthy lifespan, locomotion could be considered in the future as the main targetable outcome to fight against the frailty to dependency transition. the so-called sarcopenia, characterized as the loss of muscle mass and function, affects to % of the populations over . mechanistically, sarcopenia is associated with an imbalance between protein synthesis and degradation, an increase of muscle inflammatory processes, a reduction of mitochondria-driven metabolism and an exacerbated fibrosis. several therapeutic strategies have been proposed such as hormonal replacement but, regarding the adverse effects, these strategies have been abandoned. in this context, we hypothesize that, through a modified secretory profile, adipose tissue could play a crucial role in the muscle loss of function. we previously promoted an unbiased proteomic study and identified haptoglobin as an up-regulated cytokine overproduced by the adipose tissue during aging. objectives: in this context, our project proposes to better understand the role of adipocyte haptoglobin in age-related muscle weakness. methods: to do so, we used complementary in vitro and in vivo models of haptoglobin supplementation and strategies of adipocyte haptoglobin over-expression/deletion. impacts of such interventions have been monitored by measuring myogenesic processes as well as muscle aging. moreover, a human cohort in progress will help to constitute a new biobank by collecting blood, adipose and muscle from sarcopenic individuals in order to evaluate the role of hapatoglobin on sarcopenia (inspire cohort). results: the results obtained in vivo and in vitro suggest that haptoglobin treatments induced an age-dependent decrease in muscle mass. moreover, these protocols indicated a muscle-specific role of haptoglobin when we measured the fiber diameter. in addition, a direct effect of haptoglobin on differentiation alteration was also observed in in vitro human muscle cells. conclusion: these results suggest that haptoglobin induces effects according to the age, the muscle type and the dose on muscle physiology. thus, a better knowledge of adipocyte haptoglobin production could help to better apprehend the age-related muscular complications. background: sarcopenia contributes to loss of independence and is increases risk of mortality. mitochondrial dysfunction and loss of proteostasis are two interrelated hallmarks of aging with well-established roles in skeletal muscle function. mitochondrial dysfunction increases cellular oxidative stress and impairs atp-generating capacity. consequentially, oxidatively-damaged proteins accumulate; however, a dysfunctional mitochondrial reticulum cannot sufficiently provide energetic resources to repair the proteome. in skeletal muscle, this impaired proteostasis and mitochondrial dysfunction promote sarcopenia. thus, improving mitochondrial function by increasing endogenous antioxidants could attenuate age-related loss of muscle function. objectives: using a phytochemical nrf activator (nrf a), we sought to determine if upregulation of cytoprotective genes would improve mitochondrial function and gait, an integrative metric of musculoskeletal function. methods: we utilized dunkin-hartley (dh) guinea pigs that develop primary osteoarthritis and experiences age-related skeletal muscle dysfunction by months of age (~ % of their maximal predicted lifespan). we treated young ( mo) and older ( mo) dh guinea pigs for and months, respectively, daily with a nrf a. we assessed metrics of gait monthly to measure the effect of nrf a on agerelated musculoskeletal dysfunction. we evaluated the effect of nrf a on skeletal muscle protein turnover using the stableisotope deuterium oxide. we also assessed soleus mitochondrial function using high resolution respirometry. results: while nrf a did not affect gait in young guinea pigs, months of nrf a treatment maintained stride length (p= . ) in older male and stance width (p< . ) in older female guinea pigs compared to untreated controls. nrf a improved (p= . ) adp vmax in young females and old males compared to their respective controls. nrf a also increased uncoupled electron transport system capacity in both male and female guinea pigs of both ages (p< . ). nrf a augmented contractile protein synthesis in the soleus of old male and female guinea pigs (p= . ), but did not prevent the age-related declines in the gastrocnemius. conclusion: in summary, long-term nrf a treatment improved skeletal muscle mitochondrial function, increased contractile protein synthesis, and maintained aspects of gait. together, our findings provide evidence that targeting the transcription factor nrf mitigates the decline in musculoskeletal function in a model of osteoarthritis and sarcopenia, with concomitant improvements in mitochondrial function and protein turnover. . j a n n e k e v a n w i j n g a a r d e n , francina j dijk , miriam van dijk , lisette cpgm d e g r o o t , y v e s b o i r i e , , y v e t t e c l u i k i n g background: sarcopenia is a muscle disease rooted in adverse muscle changes that accumulate across the lifespan. multiple factors cause or worsen sarcopenia, with aging as the primary factor and malnutrition, inactivity and diseases as secondary factors. objectives: to design a nutritional strategy to manage sarcopenia. methods: our research program investigated ) specific nutrient deficiencies in sarcopenic older adults, ) muscle protein synthesis (mps) response in cells and rodent models, and ) effect of a specific nutrient combination (whey protein, leucine and vitamin d -actisyn(tm), present in the medical nutrition supplement fortifit(r), on mps in older adults. results: cross-sectional studies indicated a significantly lower intake of protein (- %) and vitamin d (- %) in sarcopenic versus healthy older adults (p< . ) [verlaan, clin nutr ], and higher prevalence of sarcopenia among those with lower blood levels of leucine, total essential amino acids ( the specific combination of whey protein, leucine and vitamin d (actisyn(tm)) provides the right environment for muscle building in sarcopenia, where these nutrients are often deficient. this combination acts through a proven anabolic mode of action with optimal nutrient bioavailability for the muscle to stimulate mps. fortifit and actisyn are trademarks of n.v. nutricia. background: age-related sarcopenia is a major responsible for premature death, poor quality of life and several adverse outcomes, which lead to higher health care costs. despite its recent incorporation as a muscle disease (icd- -cm m . ), early identification of this disease remains challenging. mostly, due to classification and diagnostic criteria, which are predominantly based on technically advanced assessment tools, which may not be available in all clinic settings. recently, a non-invasive technique to analyze variations in biological tissues considering the effect of physiological and biological properties on microwave signals is being studied for its potential to determine muscle mass, with possible applications in the early diagnosis of this disease. objectives: therefore, the principal objective of this study is to preliminarily test the potential of this technique as a new tool for early diagnosis of age-related sarcopenia in a clinical setting. methods: muscle surface area are going to be assessed by abdominal computational tomography (ct) on the third lumbar spine vertebra (l ) and bioimpedance measurements among men and women, aged >= years in the maastricht university medical center, the netherlands. participants will also be subjected to measurements done with the device under test (dut) (the proposed technique) in the same location. the data collected from the three different measurements are analyzed looking for correlation. laboratory experiments made from synthetic materials emulating human tissues and from ex-vivo porcine tissues are used for optimization and interpretation of the clinical measurements. results: up-tonow, the campaign has just started and there is no enough data to give a preliminary result. initial laboratory experiments prove that the thickness of the fat and muscle tissues is correlated to the system response. conclusion: this prospective device will estimate the muscle mass locally using microwave electromagnetic principles. the results of this study can contribute to reveal the potential of this approach as a tissueanalysis tool for early diagnosis and management of age-related sarcopenia. the results might also provide useful evidence to consider in a future planned prospective cohort study, which aims to examine the impact of dietary biomarkers and genetic factors on the incidence of age-related sarcopenia in older adults. background: sarcopenia has become a serious problem in this aging society. at present diagnosis of sarcopenia consist of physical performance and muscle quantity. dexa has been widely applied to examine muscle quantity in clinical but it's radioactive, inconvenient and unaffordable in remote area. as a result, there are more studies in ultrasound in replace of dexa. objectives: based on others researches csa might be a suitable parameter to evaluate the muscle quantity. we develop a cheaper ultrasonic imaging system to evaluate the cross-sectional area (csa) of rectus femoris (rf)muscle. methods: we use a cmos image sensor combing with digital signal processor to detect the displacement of single element ultrasonic transducer. therefore, we combine us a-mode signal with displacement into b-mode image. by circling region of interest (roi), we can obtain the csa of rf muscle. then, we use siemens s evaluating the csa in the same region to testify the reliability. results: we recruited young college students undergoing the experiment. the result shows that the correlation coefficient is up to . . conclusion: in conclusion, our device can successfully evaluate the csa of rf muscle. moreover, our system using single element ultrasonic transducer is much cheaper than linear transducer in practice .it can be affordable in remote village or somewhere lacking in medical resource. a case-control study. camille nicolay , sandra higuet , sandra de breucker (( ) geriatric department, hôpital erasme, brussels, belgium; ( ) geriatric department, hôpital isppc-charleroi, charleroi, belgium) background: ten percents of belgian population are considered to be informal caregivers. little is known about their frailty status and their physical health. objectives: we compared the frailty status, the clinical and psychosocial status of old caregivers with controls (> ). we analyzed the association of frailty status according to fried's criteria and rockwood frailty index (fi) with the characteristics of caregivers and controls in multiple regression analysis. methods: eighty six caregivers and gender and agematched controls were included. frailty was assessed by the frailty phenotype (fried) and the -deficit frailty index (fi). social data, sf- health survey, basic and instrumental adl, geriatric depression scale, mini nutritional assessment, mini-cog, cumulative illness rating scale-geriatric, usual gait speed, handgrip strength, and burden scale (zarit) were collected. results: the prevalence of frailty was similar in caregivers and controls with the fi (p= . ) but higher with the fried's criteria (p= . ). compared with the control group, caregiving was associated with a lower mental quality of life (p< . ), a higher risk of depression (p< . ), a higher consumption of antidepressant (p= . ), a lower nutritional status (p= . ), a more frequent help from health care providers (p= . ), and more problems to maintain physical contacts with a social network (p= . ). in multiple regression, the fried's criteria adjusted for age, gender, marital status and incomes were associated with the age, the grip strength, the physical quality of life, the gait speed and the nutritional status (r = . -p< . ), while fi was associated with the risk of depression, the use of antidepressants, the physical quality of life, the cognitive status and basal & instrumental adl (r = . -p < . ) in caregivers. conclusion: the prevalence of frailty is similar in caregivers and controls when using fi, but higher in caregivers with fried's criteria. compared with controls, caregiving is associated with poorer health and psychological issues. while fried's criteria focus on physical frailty, the fi is more related with geriatric syndromes like depression, cognitive disorders, loss of autonomy, and quality of life. this study could help researchers to choose between frailty scales before starting a study about older caregivers. background: nursing home (nh) residents are often undernourished and physically inactive contributing to sarcopenia and frailty. mobility is identified by older nh residents as being key to their quality of life and well-being. the combination of protein supplementation and physical exercise has been shown to be most effective to maintain and increase muscle mass. objectives: the older persons exercise and nutrition (open) study aimed to investigate the effects of sit-to-stand exercises (sts) integrated into daily care combined with a protein-rich oral nutritional supplement (ons), on physical function, nutritional status, body composition, healthrelated quality of life and resource use. methods: residents in eight nh were randomized by nh units into an intervention group (ig) or a control group (cg) (n= /group). the ig was offered a combination of sts (four times/day) and ons ( bottles/day providing kcal and g protein) for weeks. the participants resided in nh units (dementia and somatic care), were >= years and able to rise from a seated position. the seconds chair stand test ( scst) was the primary outcome. secondary outcomes were balance, walking speed, dependence in adl, nutritional status and body composition, health-related quality of life and resource use. data was analyzed using descriptive and inferential statistics including regression models. results: altogether residents ( ± years, % females) completed the study. no improvement in the physical function assessments was observed in the ig, whereas body weight increased significantly ( . ± . kg, p= . ) vs the cg. twenty-one (of ) participants with high adherence to the intervention, i.e. at least % compliance to the combined intervention, increased their fat free mass ( . kg ( . , . iqr), p= . vs cg. logistic regression analyses indicated that the odds ratio for maintained/improved scst was . (ci . , . , p= . ) among the participants with high adherence compared to the cg. waly dioh , cendrine tourette , carole margalef , amy chen , rené lafont , , pierre dilda , stanislas veillet , samuel agus (( ) biophytis, sorbonne université -bc , paris, france; ( background: sarcopenia is a geriatric condition characterized by loss of muscle mass and functions and can contribute to risks of falls, fractures and hospitalization. sara-obs is a multicenter, observational trial designed to better characterize age-related sarcopenia in a community dwelling population at risk of mobility disability. this is part of a clinical program that strives to provide more understanding of the target population in order to further develop a potential sarcopenia medical intervention. sara-obs study rationale, design and main baseline characteristics are presented. objectives: the objective is to characterize sarcopenia and sarcopenic obesity in older adults through evaluation of their physical performance and body composition. changes in baseline characteristics after a -month period will be assessed and used for development of a phase interventional study on the efficacy and safety of an investigational drug, bio . methods: participant recruitment was based on age (>= years), sppb score =< and body mass based on the fnih criteria. physical functions were assessed by two walking tests ( m walk test and the -minute walk test), the sppb, the handgrip strength test and the stair climb power test. patient reported outcomes were also assessed with the sf- and the sarqol questionnaires. results: subjects were included in this study and the main screen failures were sppb scores and body mass criteria. baseline characteristics indicated that the average bmi was high, ~ % of the participants were women and that the alm/bmi in men was lower than the fnih threshold ( . vs . ) but was similar in women ( . vs . ). m gait speed was . m/s, the mean total sppb score was . with the gait speed component of < . m/s and the chair stand sub-score of . . conclusion: this population has a similar m gait speed as the populations in life and sprint-t studies at baseline. however, the sppb total score and the chair stand sub-score correspond more closely with the sprint-t study. addressing the loss of physical function and preventing mobility disability is still an unmet need of older adults. sara-obs included a population representative of a suitable target for subsequent interventional studies aimed to fulfill this need. yen-lung chen, hui-hua chiang (department of biomedical engineering, national yang-ming university, taipei, taiwan) background: in whole world, the elderly formally entered the aging society , and the patients with sarcopenia were highrisk groups in the fall. more than % of the elderly suffered moderate injuries due to falls. the sarcopenia as defined by the eu's sarcopenia working group was refers to progressive reduction in muscle mass and decreased muscle function. objectives: it is expected to provide diagnostic tools and techniques for the rapid determination of sarcopenia and muscle strength. at the same time, it will also be developed toward portable devices to facilitate the diagnosis of the aging of muscle function in the elderly at home to take care of the health and well-being of the elderly. methods: at present, the clinical measurement part is assisted by the radiation department of the veterans general hospital to collect and measure the subjects. clinical testing methods are mainly for older people over years of age. the walking speed test is firstly performed on the method. if it is normal, then the grip strength test is performed. if the grip strength is too small, the femoral rectus femoris muscle volume test should be performed. generally, dual energy is used. dual-energy x-ray absorptiometry (dxa) is used for testing. if the walking speed is too slow, the dxa test should be performed directly. the test value is less than . (kg/m ) in woman and less than . (kg/m )in man. that is, it is determined as a sarcopenia patient. since dxa has a small amount of free radiation, high cost, and a large space occupation, we expect to obtain a wide range of data through ultrasonic scans. back-end development algorithms are calculated to determine if there is sarcopenia and how severe it is. results: at present, the rectus femoris muscle volume obtained by using ultrasound has a highly linear relationship with the appendicular muscle mass measured by dxa (r = . ,p< . ), and has the ability to distinguish whether it is sarcopenia. conclusion: the use of muscle volume of rectus femoris can improve the accuracy of sarcopenia prediction. in the near future, this plan will be used to develop automated ultrasonic scanners. background: although sarcopenia has multifactorial causes, the decline in physical activity has been considered a very important aspect for its development. since the promotion of higher levels of physical activity can attenuate the progression of sarcopenia, it is possible that the participation in a programmed training increases the spontaneous physical activity of the participants. objectives: to investigate if the participation of sarcopenic older women in a resistance training program and supplementation with fish oil leads to changes in the level of spontaneous physical activity (sedentary time and number of steps). methods: randomized, double-blind, placebo-controlled clinical trial. thirty-two older women, aged >= years, participated in the study. all participants were classified as sarcopenic based on the criteria of the european consensus on sarcopenia (ewgsop). the participants were divided into two experimental groups: ( ) exercise group + placebo (ep) and ( ) exercise group + fish oil (efo). both groups underwent a resistance exercise program over weeks, consisting of three weekly supervised sessions. all volunteers were instructed to take two capsules of food supplement at each main meal, lunch and dinner ( g/day). the ep group used capsules composed of sunflower oil as placebo, and the efo group fish oil capsules, (epa mg and dha mg). measurements of the level of spontaneous physical activity were made before and after the intervention by using the actipal® physical activity monitor (glasgow, uk), for a period of seven consecutive days, during which the volunteers were instructed to maintain their normal routine. the volume of the quadriceps muscle in the pre and post intervention periods was calculated from the images obtained by magnetic resonance imaging. for statistical analysis, a linear regression model with mixed effects was used to compare longitudinal data on mean intra-group differences between groups and moments. for all analyzes, a significance level of . was adopted. results: both groups showed an increase in muscle volume after the intervention ( . cm ( . %) and . cm ( . %), respectively). regarding the level of spontaneous physical activity, both groups had a similar sedentary time and number of steps, at both times (average . h and , steps in the pre-intervention period and . h and , steps in the postintervention period for the ep group, and . hrs and , steps in the pre-period and . h and , steps in the postintervention period in the eop group). conclusion: although sarcopenic older women supplemented with fish oil showed a higher increase in muscle volume, the level of spontaneous physical activity remained unchanged both in the pre and post intervention periods and between groups, indicating that the increase in muscle volume was not associated with significant changes in the level of spontaneous physical activity. background: regardless of improvements in surgical and anesthetic practices, older surgical patients often experience postoperative complications. the purpose of this study was to investigate the association between physical frailty and cognitive function using a validated upper-extremity function (uef) test with in-hospital outcomes in aging adults undergoing abdominal surgery. objectives: to recognize frailty and cognitive function as a risk factor for in-hospital adverse outcomes. methods: we administered pre-operative uef tests, within -hours after admission, among patients aged years and older undergoing emergent/urgent abdominal surgery. the uef involved two tests; -and -sec of respectively fast and consistent elbow flexion, while angular velocity was measured via two wearable motion sensors applied to the wrist and upper-arm of the dominant arm. uef physical score was calculated, based on slowness, weakness, flexibility, and exhaustion (range: resilient= -frail= ). uef cognitive score was assessed based on motor function variability within a dual-task performance that involved uef motor task and a cognitive task of counting backwards by threes (range: cognitive normal= -cognitive impairment= ). adverse outcomes included: length of stay, complications, and death during their hospital stay. a logistic regression model was used to assess the association between uef physical and cognitive scores (independent variables) and in-hospital outcomes (dependent variable). results: a total of participants (mean age . ± . years) completed the preoperative uef assessment. thirty-six participants with an average age of . ± . years experienced at least one adverse outcome while in the hospital. while age independently predicted in-hospital outcomes with receiver operating characteristic area under the curve (roc-auc) of %, this prediction improved by adding either the uef physical or the cognitive score. the physical score predicted in-hospital outcomes with a roc-auc of %, and the cognitive scores predicted in-hospital outcomes with a roc-auc of %. conclusion: the proportion of emergency surgical procedures increases with age, and population trends indicate that this demand will increase significantly. results from the current study showed that sensor-based measures of physical and cognitive function can provide an objective tool for predicting adverse outcomes, with potential applications for other surgical procedures. risk stratification can help to establish targeted management strategies to improve the healthcare system and patient-centered outcomes. background: while sensor-based daily physical activity (dpa) gait performance has been demonstrated to be an effective measure of physical frailty, it is not clear how repeatable the dpa gait parameters are between different days of measurement, especially across frailty groups. objectives: to evaluate the test-retest reliability (repeatability) of dpa gait performance parameters (stride time, variability, and irregularity) and quantitative measures (number of steps and walking duration) between two separate days of assessment among older adults. methods: dpa was acquired for -hours from older adults (age>= years) using a tri-axial accelerometer motion-sensor attached to the trunk. purposeful continuous walking bouts (>= s) without long pauses (> . s) were identified from acceleration data and used to extract gait performance parameters, including stride time, power spectral density (psd) slope (representing the variability of walking cycles), dominant frequency of walking, and gait irregularity (sample entropy, representing predictability of walking cycles). to assess repeatability, intraclass correlation coefficient (icc) was calculated using two-way mixed effects f-test models for day- vs. day- as the independent random effect. repeatability tests were performed once for all participants and once within each frailty group (non-frail and pre-frail/frail). results: data from older adults, non-frail (age: . ± . years) and pre-frail/frail (age: . ± . years) were analyzed. within all participants with purposeful walking bouts on both the days, gait performance parameters of stride-time and gait variability parameters (slope and dominant frequency of walking) showed excellent test-retest reliability values (icc>= %) while quantitative parameters, including number of steps and walking duration showed poor test-retest reliability results (icc< %). among gait performance parameters (stride time, dominant walking frequency and sample entropy), we observed higher repeatability among the pre-frail/frail group with icc> % compared to icc< % for non-frail individuals. conclusion: from our study, it is evident that gait performance parameters including average step-and stride-time and frequency-domain gait variability parameters provided higher test-retest reliability compared to quantitative measures. further, gait performance parameters showed higher repeatability among pre-frail/frail volunteers between the two days compared to non-frail volunteers, which may be attributed to a lack of functional capacity among frail individuals for performing more intense and more variable physical tasks. background: while evaluation methods for skeletal muscle characteristics which are necessary to know the pathogenesis of sarcopenia are being considered, ultrasonography is attracting attention as a method simultaneously evaluate quantitative and qualitative evaluation of skeletal muscle. although we have found many, the statements that examined the relation between muscle thickness, echo intensity, physical function, and sarcopenia by quadriceps muscle ultrasonography in the previous report, there are few reports for the lower leg muscles. objectives: we conducted a study to examine whether the lower leg muscle ultrasonography is useful for evaluating sarcopenia index and muscle quality (muscle strength per unit muscle mass) evaluation in comparison with the quadriceps ultrasonography. methods: the participants were patients over years old ( males, females). the muscle thickness of the quadriceps muscle, tibialis anterior muscle, gastrocnemius muscle, soleus, and echo intensity were measured by ultrasonography, and the relationship between lower extremity muscle mass, muscle strength, physical function, and muscle quality was examined. results: the muscle thickness of quadriceps muscle, tibialis anterior muscle, soleus muscle was related to lower extremity muscle mass, grip strength, leg muscle strength, and only quadriceps muscle was related to gait speed. the echo intensity of the quadriceps, tibialis anterior, gastrocnemius was related to, grip strength, leg muscle strength, and only the tibialis anterior muscle was related to gait speed. the muscle thickness and the echo intensity of tibialis anterior muscle and soleus muscle are highly correlated with the quadriceps. the echo intensity of the tibialis anterior muscle, as well as that of the quadriceps muscle, showed a high correlation with the muscle quality of lower extremity. conclusion: concerning the assessment of sarcopenia using ultrasonography, muscle thickness and echo intensity evaluation by tibialis anterior muscle showed the same utility as them by the quadriceps muscle, and echo intensity of the tibialis anterior muscle can be a marker of muscle quality. lucena germano , cristiano dos santos gomes , juliana fernandes de sousa barbosa , , raysa freitas , , alvaro campos c. maciel , ricardo oliveira guerra ( ( background: phase angle (pha) is emerging as a measure of great clinical relevance provided through bioimpedance assessment and its related to health adverse outcomes such as osteoporosis and sarcopenia. on the other hand, poor physical performance as gait speed and grip strength in elderly is associated with poor health conditions. we hypothesized it is plausible that those two measures might be related and can be used as a tool in clinical practice. objectives: to investigate the relationship between pha and physical performance measures in community-dwelling older adults from brazil. methods: this cross-sectional study enrolled older adults of both sexes who had a comprehensive health evaluation including physical performance tests (gait speed and handgrip strength) and electrical bioimpedance screening. linear regression models were used to estimate the associations between pha and physical performance measures. results: the mean age of . ± . and . ± . for men and women respectively. hand grip strength (n: , ; p-value < , ) and gait speed (n: , ; p-value < , ) were independently correlated with pha. conclusion: pha could help to easily identify elderly on the onset of present heath adverse outcome and guide specific interventions by clinicians. shosuke satake , , kaori kinoshita , yasumoto matsui , background: in japan, we have a simple yes/no questionnaire to assess multiple functions in daily living for older adults; the kihon checklist (kcl). in the questionnaire, questions to assess mobile functions are included. objectives: we examined whether the -item questions in the physical domain of the kcl (kcl-phys) could be a surrogate of validated measurements of physical functions. methods: subjects were independent and ambulatory seniors aged years or older who had been consulted in our frailty clinic. all of them received grip strength test, dual energy x-ray absorptiometry, physical performance tests, cognitive examination, and the kcl questionnaire. among them, we excluded subjects with missing data, and with moderate cognitive impairments. we examined the relationships between scores of the kcl-phys and usual gait speed, short physical performance battery (sppb), and timed up and go (tug) with the spearman's rank correlation. the score of the kclphys were counted when the subject meets any criteria with each question as previously reported. also, we evaluated the cutoff point of the kcl-phys equivalent to slow gait speed (< . m/s), low sppb score (sppb < ), and slow tug (tug >= sec) with the receiver operating characteristic (roc) curve analysis. results: the mean values of age, body mass index, and prevalence of sarcopenia were . years old (women . %), . (kg/m ), and . (%), which were no differences between sexes. on the other hand, physical functions of gait speed, sppb, and tug were all worse in women than in men. relationships between the scores of the kcl-phys and usual gait speed, sppb, and tug were moderate with the coefficients of - . , - . , and . , respectively (p< . for all). the area under the roc curve of the kcl-phys score equivalent to slow gait speed, low sppb score, and slow tug were . , . , and . , respectively. the cutoffs were thought to be the best at points of the kcl-phys to identify low physical functions based on the youden index. conclusion: physical domain of the kcl could be a surrogate of assessments of physical functions in older people. yuji hirano , izumi kondo , tetuya nemoto , naoki itoh , hidenori arai (( ) national center for geriatrics and gerontology, japan; ( ) nihon fukushi university, japan) background: we have developed a new type of grip strength measurement that addresses the time axis in evaluating physical function. it can measure the dynamic force, response in gripping performance, and maximum grip strength. the "kihon checklist" (kcl) is used to screening the frail elderly, based on the japanese long-term care insurance system. however, the relationship between the gripping performance and kcl has not been well investigated. objectives: the purpose of this study was to introduce a novel automatic reading method for dynamic force parameters in gripping performance and to evaluate their relationship with the kcl. methods: the subjects comprised patients ( men, women, average age . ± . years) who visited the integrated healthy aging clinic (locomo-frail outpatient clinic in japanese) of our hospital. the four indices of grip force response measured were: reaction start time (rst), time constant (tc), maximum value of force (mvf), and force rising slope (frs). we examined the relationship between these four indices and seven categories of the kcl; activities of daily living (adl), physical functions and fall, nutrition state, oral functions, outdoor activities, cognitive functions and mood, using spearman's correlation coefficient. results: in the female right hand, the mvf was only significantly correlated with adl and overall scores; whereas, in the female left hand, the mvf and the frs were significantly correlated with many items (adl, physical functions and fall, nutrition state, outdoor activities, and cognitive functions). the time-dependent items (rst and tc) were significantly correlated with outdoor activities in the female left hand and significantly correlated with adl and oral functions in the male left hand. however, in the right hand, the time-dependent items were not correlated with any of items in kcl in both sexes. conclusion: our newly developed grip strength measurement system could automatically calculate not only the maximum grip strength but also the time response of the grip force. moreover, their relationship with kcl was clearly indicated. the relationship between detailed grip strength response indicators and kcl items differed between men and women, and the left hand was correlated with more items than the right hand. ranyah almardawi, rao gullapalli, michael terrin (university of maryland school of maryland, baltimore, usa) background: rotator cuff (rc) tear and shoulder pain are both highly prevalent in older populations. routine medical screening for shoulder dysfunction is uncommon for community-dwelling older adults. the disabilities of the arm, shoulder and hand (dash) survey estimates self-reported dysfunction of both upper limbs in a composite score. dash offers a quick method to identify older adults with potential dysfunction in either shoulder, which otherwise may go unrecognized during routine medical visits. objectives: . to determine if dash, american shoulder and elbow surgeons (ases) and simple shoulder test (sst) surveys are related to one another in older adults. . to assess dash, ases and sst score relationships to the sf- physical functioning (pf) subcomponent score, shoulder forward flexion range of motion (ff-rom) and shoulder abduction range of motion (abd-rom) in older adults. methods: cross-sectional study: twenty-three community-dwelling-older-adult volunteers [mean age, . ± . years; range, to years; female, %] with no history of rc surgery and no history of shoulder injury or shoulder physical therapy in the prior months completed shoulder magnetic resonance imaging (mri) and dash, sf- , charlson co-morbidity index (cci), katz activities of daily living (adls) and lawton instrumental adls (iadls) surveys. for the shoulder ipsilateral to mri, participants completed ases, sst, visual analog scale for pain (vas) surveys; and shoulder ff-rom and abd-rom. descriptive statistics and spearman rank order correlation (rho) were performed. results: frequencies: rc tear (supraspinatus tendon) on mri: . %; shoulder pain >= on vas: . %; no limitation (score= ) on katz adls: . %; no limitation (score= ) on lawton iadls: . %. means: cci, . ± . ; dash, . ± . ; ases, . ± . ; sst . ± . ; . ± . ; . ± . ; . ± . . range of correlation among dash-ases-sst surveys: (|rho|= . - . , p< . ). range of correlation for dash-ases-sst with sf- pf(|rho|= . - . , p< . ), p< . ), abd-rom (|rho|= . - . , p< . ). conclusion: dash, ases and sst correlate well, and all three surveys show a consistent relationship with sf- physical functioning, ff-rom and abd-rom. next steps would be to evaluate the feasibility of dash to identify older adults with shoulder dysfunction during routine medical visits. background: physical performance is closely associated with chronic diseases and dysfunction of numerous organ systems. old persons with chronic renal failure have shown the apparent decline in physical performance, especially in the end-stage. however, it is unclear whether the subclinical kidney dysfunction is associated with skeletal muscle function deficit in the elderly population. objectives: the aim of this study is to determine the association between renal function and skeletal muscle function deficit in old persons without nephropathy. methods: eight hundred fifty-four korean elderlies (female, . %) aged to years were included in the cross-sectional analysis. of the participants, elderlies (female . %) were available for the -year follow-up test session. all participants were interviewed face-to-face and received measures of anthropometry, body composition and serum biomarkers of metabolic diseases. estimated glomerular filtration rate (egfr) was calculated using the chronic kidney disease epidemiology collaboration (ckd-epi) equation based on serum creatinine concentration. skeletal muscle function deficit was defined as a combination of weakness and slowness based on the handgrip strength to body mass index ratio (hs/bmi, men < . , women < . ) and converted timed up-and-go to walking speed (tugspeed < . m/s). results: the subjects with <= egfr < ml/min/ . m showed significantly lower physical performance for muscular strength and functional mobility than those with <= egfr < and egfr > ml/min/ . m , respectively (all for p < . ). logistic regression analysis indicated the significant association between egfr and skeletal muscle function status even after adjustment for potential confounders (p for trend < . ). moreover, the prospective observational analysis by ancova showed the significant effects of enhancement in hs/bmi [f( , ) = . , p = . ] and tugspeed [f( , ) = . , p < . ] on the improvement in egfr during -year followup. conclusion: taken together, skeletal muscle function status is associated with even moderately reduced egfr in an older population. these results suggest that maintenance of physical and functional fitness may be a contributory factor for preserving renal function in elderly persons. rn, brazil) background: sarc-f is a brief and useful test to identify older people at risk of sarcopenia-associated adverse outcomes. previous studies with older populations have suggested that it may be useful to screen those with severe sarcopenia. its ability to screen sarcopenia among low-income brazilian older adults is still unknown and its association with sarcopenia diagnostic criteria may be useful to understand its utility among this population. objectives: this study aims to evaluate the validity of sarc-f in screening low muscle strength and low physical performance among a low-income sample of older adults. methods: in a cross-sectional study, community-dwelling older-adults (>= years old; men and women) from santa cruz (northeast brazil) answered the sarc-f questionnaire and were classified as sarcopenic (>= ) and non-sarcopenic (< ) according to sarc-f scores. they were also evaluated in relation to the sarcopenia criteria of muscle strength (handgrip strength) and physical performance (sppb). the cutoff of < kg for women and < kg for men were used to classify those with low muscle strength. a sppb score of <= was used to classify low physical performance. a chi-square test was used to assess the association between the sarc-f and the objective parameters of sarcopenia. sensitivity and specificity of the sarc-f according to the objective functional parameters were also assessed. results: the sample was composed by % of women, with mean age of . (± . ) years old. according to sarc-f, . % of the sample was sarcopenic. low muscle mass and low physical performance were identified in . % and . % of the sample respectively. sarcopenia was significantly associated to low muscle mass (p< . ) and low physical performance (p< . ). the sensitivity of sarc-f in identifying those with low muscle mass was of % and specificity of %. for low physical performance, sensitivity and specificity were of % and % respectively. conclusion: sarc-f has a moderate ability to identify the sarcopenia criteria of low muscle mass and low physical function among older adults from a low-income setting. since it is a simple measure, it can be advantageous for low-income and rural communities. background: menopause marks a critical transition towards older adulthood for women and studies suggest that it is associated to several sarcopenia parameters, such as muscle mass and physical functioning. understanding how the menopausal transition associates to sarcopenia diagnostic criteria may help to direct screening tests for middle-aged populations and to identify earlier those at higher risk of sarcopenia. objectives: to evaluate the association between menopausal status and sarcopenia diagnostic criteria (muscle strength, muscle quantity and physical performance). methods: in a cross-sectional study, communitydwelling women from northeast brazil ( - yearsold) were evaluated in relation to menopausal status using the stages of reproductive aging workshop classification (premenopausal, perimenopausal or postmenopausal) , and in relation to sarcopenia diagnostic criteria according to european working group on sarcopenia in older people (ewgsop ): muscle strength (grip strength -handheld dynamometer), muscle quantity (appendicular muscle mass adjusted for height through bioelectrical impedance) and physical performance (gait speed). association between menopausal status and sarcopenia criteria was evaluated with multiple linear regression models adjusted for covariates (current age, education, family income, walking, bmi, reproductive history). results: among the participants, . % were classified as premenopausal, . % as perimenopausal, and . % as postmenopausal. menopausal status was significantly associated to grip strength, since premenopausal women were significantly stronger than perimenopausal or postmenopausal women, even in the fully adjusted analyses (b= . ; % ci= . : . ). muscle quantity and gait speed were not significant according to menopausal status. conclusion: perimenopausal and postmenopausal status are associated with less muscle strength among middle-aged women. muscle weakness may be the first sarcopenia parameter that is affected by women's aging and should be tracked among middle-aged to women for early identification of sarcopenia risk.. background: we speculate maintaining good postural stability is the key to good adl in elderly patients. this is a preliminary study to evaluate which factor relates to good postural stability. objectives: we evaluated patients ( males and females) over years old. the average age was . years old ranging to . methods: we measured index of postural stability(ips) using gravicoder gw- manufactured by anima. the ips was adovocated by mochizuki in . it was defined following this equation; ips=log[(area of stability limit + area of postural sway)/area of postural sway). larger ips means better postural stability. the average ips in each age was already known. ips was calculated automatically through gravicoda. we devided these patients into two groups by the results of ips. group a with the patients whose ips was larger, group b with the patients whose ips was smaller than the average in their age. we compared the following items between the two groups. nutrition(albumin, calcium, magnesium, ferritin, vitamin b ,b , , -d , zinc in blood test) , bone status(bone density, % of yam), spinopelvic parameters (pelvic incidence(pi), lumbar lordosis(ll), pelvic tilt(pt) using whole spine x-ray photograph. results: ten patients were classified into group a and patients were into group b. the average age was . ± . years old in group a and . ± . in group b. in group a , ll and pt were respectively . , . . in group b, . , . . ll and pt were significantly different between the two groups. pi minus ll is an important indicator to determine the spino-pelvic balance. it is known that pi-ll< means good spino-pelvic balance. in group a, pi minus ll was . ± . . in group b, it was . ± . . according to nutrition and bone status, albumin was significantly higher in group b. conclusion: our results showed spino-pelvic alignment related to the postural stability. this suggests good spino-pelvic alignment is likely the key to good postural stability. background: physical performance is of main relevance for quality of life and independence in the community. identification of deterioration of physical performance helps to start early interventions to stay independently in old age. objectives: to determine physical performance of communitydwelling older adults above years by using a comprehensive geriatric assessment to find most sensitive tests for functional decline. methods: older community-dwelling adults aged +. analysis of baseline and (t ) and months (t ) of followup data of hand grip strength (hgs), stair climb power test (scpt), timed up and go test (tug), short physical performance battery (sppb), m gait speed ( mgs), -time chair rise test ( tcr), minute walking test ( mwt) and frailty categories according to fried. results are shown in mean (± sd) in total numbers and percentage. results: participants ( , y.± , ) were included, ( %) female. overall physical performance was on high level, above geriatric cut-offs for physical disabilities at baseline: (hgs female: , (± , ) (- , (± , )%) followed by scpt (- , (± , )%). all tests showed a decline except tcr (+ , (± , )%). conclusion: physically active, communitydwelling older people show a high level of functional performance, far from geriatric cut-offs indicating physical disabilities. nevertheless, after two years a clinically relevant reduction of strength in upper (handgrip) and lower extremities (stair climb) was detected. these data may be relevant for the identification of older individuals who may benefit from early intervention exercise programs to keep them physically independent as long as possible. tcr showed divergent results and could be of special interest for continuous measurements to identify gradual decreases in functional performance. background: sarcopenia is characterized by loss of skeletal muscle mass and strength and it is a frequent finding in oncology, being associated with reduced quality of life, impairment in the response to antineoplastic therapy and increased toxicity, especially in older patients. objectives: the aim of the present study was to evaluate the association between low muscle mass (lmm) assessed by computed tomography (ct) analysis and sarcopenia considering the revised european consensus published by the european working group on sarcopenia in older people (ewgsop ) with the variables of the comprehensive geriatric assessment (cga) in older oncological patients. methods: for this purpose, patients ( . % female; mean age of . ± . years) followed at the oncogeriatric outpatient clinic of a university hospital were enrolled. clinical data were obtained from electronic medical records and the skeletal muscle mass evaluation was performed using ct (in the height of the third lumbar vertebra). for lmm and sarcopenia classification, specific cutoff points were adopted. cga variables were compared between lmm and normal skeletal muscle mass (nsmm) and between sarcopenic and non-sarcopenic individuals. groups were compared by the independent t test (r core team®, p< . ). results: the most frequent tumors were breast, intestine, stomach and lung, at different stages of the disease. the prevalence of lmm was . % and the prevalence of sarcopenia was %. of all cga variables evaluated, hand grip strength ( , ± , ) and katz scale ( , ± , ) were associated with lmm and sarcopenia. conclusion: the results highlight the importance of early geriatric clinical assessment of older cancer patients, considering the association of cga variables with low muscle mass and most important, to sarcopenia, for the possible reversal of functional and nutritional impairments and for the indication or appropriate planning of cancer therapy. lygia paccini lustosa , patricia parreira batista , jéssica rodrigues de almeida , andré gustavo pereira de andrade , aimée de araújo cabral pelizari , stephanie aguiar , leani de souza máximo pereira (( ) physical therapy department -universidade federal de minas gerais, ufmg, eeffto, belo horizonte, mg, brazil; ( ) sports department -universidade federal de minas gerais, ufmg, eeffto, belo horizonte, mg, brazil) background: functional tests in the older person reflect the integrity of the interrelationship between muscle mass and function, vascular, endocrine and neurological aspects of central and peripheral command. the reduction in functionality, muscle mass and strength associated with advancing age is related to the increase of circulating proinflammatory cytokines in plasma, which in turn predisposes the individual to negative repercussions, such as the development of chronic diseases, falls and disability. they can identify changes in the intrinsic capacity of the older people. objectives: to compare older women who reported being active or sedentary regarding functional capacity and plasma indices of inflammatory mediators. methods: participated community older women ( years or older), recruited for convenience. those unable to walk were excluded; acute musculoskeletal diseases; lower limb fractures in the last year; neurological diseases and sequelae; history of cancer in the last five years and cognitive impairment (mental state mini-exam). all responded to clinical and demographic information, performed the short physical performance battery (sppb), timed up and go (tug) and plasma tests of stnfr and il- (elisa method). correlation analysis by spearman test. % significance level. approval by the research ethics committee/ ufmg (caae: . . . ). results: older women participated, with a mean age of . ± . y; number of comorbidities . ± . and medications in use of . ± . . mean of body mass index were . ± . kg/m . there was a significant negative relationship between the sppb test and stnfr (rho= . ; p= . ) and a significant positive relationship between tug and stnfr (rho= . ; p= . ). other relationships were not significant (p> . ). conclusion: older women with better functional capacity presented lower plasma dosage of stnfr . the results suggest influence between these variables -functional capacity, mobility and inflammatory process -and no causal factor can be attributed. in these case, longitudinal studies are needed to verify functional performance vulnerability factors and their causal relationship with circulating inflammatory mediators in plasma. however, these results point to the importance of evaluating these variables in daily clinical practice. patricia parreira batista , stephanie aguiar , andré gustavo pereira de andrade , jéssica rodrigues de almeida , leani de souza máximo pereira , lygia paccini lustosa (( ) physical therapy department -universidade federal de minas gerais, ufmg, eeffto, belo horizonte, mg, brazil; ( ) sports department -universidade federal de minas gerais, ufmg, eeffto, belo horizonte, mg, brazil) background: perceptions of health and well-being in the older people are identified as subjective aspects by the international classification of functioning (icf), with direct and indirect interference with overall performance, activities of daily living, social relationships and independence. subjective well-being is associated with the form of coping adopted with a health condition, adaptability and resilience. positive and negative physiological repercussions on functionality and interaction with the family and social network may be consequences of inadequate adaptation and perception of subjective well-being. objectives: to explore the relationship between subjective well-being, functionality and plasma indices of inflammatory mediators in community older wowen. methods: participated community older women ( years or older), recruited for convenience. those unable to walk were excluded; acute musculoskeletal diseases; lower limb fractures in the last year; neurological diseases and sequelae; history of cancer in the last five years and cognitive changes (mini-mental state examination). all answered about clinical and demographic data and information about subjective well-being. they performed tests of functional capacity (short physical performance battery -sppb) and mobility (timed up and go -tug). plasma dosages of stnfr and il- were by elisa method. correlation analysis by spearman test. significance level of %. approval by the research ethics committee/ ufmg (caae: . . . ). results: elderly women participated, with a mean age of . ± . years; number of comorbidities . ± . , final sppb score . ± . , tug of . ± . seconds; body mass index of . ± . kg/m . there was a significant positive relationship between subjective well-being and sppb (rho= . ; p= . ) and tug (rho= . ; p= . ). other associations were not significant (p> . ). conclusion: the results showed a significant association of subjective well-being with functional capacity in the older women. however, this condition was not associated with inflammatory markers, suggesting the need for further studies. on the other hand, it can be thought that the identification of personal strategies and perception of health and well-being act as barriers and/ or facilitators in a functional rehabilitation process, indicating the need for a multidisciplinary approach. background: the united states census bureau projects a rise in the population aged and over from . million in to . million by . the projected rise in the elderly population represents an accompanying increase in geriatric syndromes. frailty is a common geriatric syndrome defined as a clinically recognizable state of increased vulnerability to adverse outcomes related to a decline in physiologic reserve. this decline in reserve places the individual at increased risk for poor health outcomes including falls, disability, hospitalization, institutionalization and mortality. various effective interventions for frailty are established in the literature. the body of knowledge on the role of technology in reducing frailty is less abundant. objectives: to summarize available evidence on frailty and technology use for community dwelling older adults. methods: a comprehensive search of computerized databases was conducted in the following databases published between - : cinahl, pubmed, and academic search complete. the prisma search strategy was utilized for this review. articles were included if they met the following criteria: ) focused on community dwelling adults aged and over; ) peer-reviewed; ) published in the english language; ) featured randomized controlled trials (rcts), cohort studies or qualitative research; and ) included an operationalized definition for frailty. results: the database searches yielded a total of articles. duplicates were removed. results were excluded based on title and abstract. relevant articles were retrieved for full text examination. articles were excluded based on inclusion/exclusion criteria. references of included articles were hand searched for relevant works. four additional relevant articles were identified. the final analysis included articles. conclusion: current research focuses on assessment and diagnosis as opposed to intervention studies. methodological weaknesses limit generalizability and validity of findings. few studies utilize frailty as an outcome measure thus, limiting available research directly related to frailty. emerging technologies represent potentially effective, flexible and integrative solutions for frailty assessment, monitoring and intervention in the home environment. more research is needed on the potential for technological tools as interventions for frailty in community dwelling elderly specifically, for the purpose of detection and prevention of pre-frailty. a study protocol. inae c. gadotti , raquel aparicio ugarriza , , fernanda civitella , jorge g. ruiz , , edgar ramos vieira ( ( ) background: there are several studies on the association of balance and gait impairments with frailty and falls in older adults. however, little is known about the associations between postural alterations, frailty and falls in older adults in general and among older veterans. also, inter-relations among postural alterations, balance, strength, gait impairments, falls and frailty in older adults are not well known. objectives: the objective of this study is to evaluate if postural alterations, gait and balance impairments are associated with falls and frailty in older veterans. methods: sixty veterans, years old or older, will participate on a voluntary basis. one-hour long assessments will be completed at baseline, , and months. participants will fill out a questionnaire including information on demographics (age, sex, height, and weight), health conditions, falls (history, characteristics, and fear of falls), mobility impairments, physical activity level, medication history, medication changes and adherence, and health care utilization. frailty status will be assessed based on fried's frailty phenotype. the following physical health variables will be assessed: sagittal head and neck posture using photogrammetry, spinal curvatures using flexicurve, deep neck flexors activation by performing the craniocervical flexion test with a pressure biofeedback, grip strength using a dynamometer, usual and fast gait analysis using a gaitrite, balance using a force plate, and lower limb functional strength based on chair stands in s. differences among the variables by frailty status and falls history will be assessed using manovas. results: the results will be presented at conferences and published in scientific journals. conclusion: the results of this study may inform interventions to reduce frailty and falls in older veterans and possible among non-veterans as well. background: the number of deaths caused by pneumonia is increasing. the guidelines for pneumonia recommend optimal application of antibiotics based on a pathogenoriented strategy. despite wide distribution of these guidelines, pneumonia demonstrates high mortality in aged people. thus, for developing the next strategy for pneumonia management in aged people, new targets are required. with aging, the loss of skeletal muscle mass and strength occurs, which is named sarcopenia. the sarcopenia phenotype is associated with malnutrition. little is known about relationship between muscles and pneumonia, however, we reported that aspiration pneumonia induced respiratory muscle atrophy. impaired swallowing and/or cough functions often induce pneumonia in aged people. the swallowing muscle weakness is associated with impaired swallowing function. the strong respiratory muscles generate effective cough, which clears the airways and prevents pneumonia. objectives: to investigate presently unknown relationships between onset or recurrence of pneumonia in aged people and; respiratory muscle strength; swallowing muscle strength; and malnutrition. methods: a cross-sectional cohort study consisted of patients aged -year-old and older admitted to the hospital by pneumonia, and controls. the respiratory muscle strength was measured by a hand-held multi-functional spirometer with a pressure sensing transducer. the swallowing muscle strength was evaluated by measuring tongue pressure. a bioelectrical impedance analysis evaluated muscle and body fat masses. malnutrition was evaluated by serum albumin level and body fat mass. results: the respiratory (both the inspiratory and the expiratory) and the tongue muscle strengths, body trunk muscle mass, serum albumin level, and body fat mass divided by height were lower in aged pneumonia patients than in controls. body trunk muscles include the respiratory and swallowing muscles. the multivariate logistic regression model showed the low inspiratory and expiratory respiratory muscle strengths, the low body trunk muscle mass divided by height , and the low serum albumin level as risk factors for onset of pneumonia. for recurrence of pneumonia within months after the onset of pneumonia, low body fat mass divided by height was a risk factor. conclusion: above findings suggest that the respiratory muscles and malnutrition as new targets of the new management strategy for pneumonia in aged people. background: more than % of the people with hiv are older than fifty years. data about this population are still scarce and mainly focused on comorbidity instead of on physical function and frailty. hiv-funcfrail cohort is one of the four european cohorts of older hiv adults launched in . objectives: our main objective in this work was to know the factors associated to physical impairment. methods: longitudinal prospective cohort study. patients from the "hiv-funcfrail: multicenter spanish cohort to study frailty and physical function in years or older hiv-infected patients" were included. eleven centers participated. we recorded sociodemographic data, comorbidities and variables related to hiv infection. physical function was measured by gait speed and sppb and frailty according to frailty phenotype. other components of the comprehensive geriatric assessment such as depression and cognitive impairment were evaluated too. results: were included. median age was . ( . - . ). . % were women. at baseline median cd count was . ( . - . ). viral load was undetectable in . %. % of the patients had > comorbidities and . % had polypharmacy. . % of the patients were able to walk independently and % were completely independent for the activities of daily living. more than half were prefrail, . % prefrail and . % were robust according to frailty phenotype. . % of the patients had a sppb score < and . % had a gait speed < . m/sg. in the univariate analysis we found association between physical impairment defined as sppb score < with: diabetes, copd, osteoarthritis, comorbidities number, moca test < , gds-sf > and age. but in the multivariate analyses the factors associated were just: polypharmacy ) p= . ], gds-sf > [ . ( . - . ) p= . ]. conclusion: functional impairment was prevalent among older adults with hiv in their middleage. polypharmacy doubles the risk of functional impairment and depression increases the risk three-fold. therefore, polypharmacy, depression and physical function should be assessed in all the older adults with hiv in order to implement early prevention intervention to avoid physical impairment. sophie bastijns, anne-marie de cock, maurits vandewoude, stany perkisas (university of antwerp, antwerp, belgium) background: acute sarcopenia is defined as a decline in muscle mass and muscle function within days after hospitalization or acute illnesses, sufficiently to meet the sarcopenia criteria. muscle ultrasound is an objective and non-invasive technique that can measure muscle quantity and quality. muscle elastography can furthermore measure muscle stiffness, which is regarded as an important qualitative parameter. objectives: the primary aim of the study is to assess the effect of acute hospitalization on muscle stiffness. the secondary aim is to evaluate other influencing parameters. methods: this study is a prospective, observational study. patients admitted for at least days to one of the geriatrics departments of the zna antwerp hospitals are included. rectus femoris (rf) and vastus lateralis (vl) muscle stiffness are measured through elastography on day of admission, and then every days until discharge. results: preliminary results show significant differences between rf and vl values in men, but not in women. in rf, a non-significant downwards trend is seen for elastography between day and day . in vl, a non-significant downwards trend is seen in women, but also a non-significant upwards trend is seen in men between day and day . in rf, a non-significant trend of decreasing stiffness is seen with increasing age in men, but an increase is seen in women. a significant negative correlation is seen between elastography of rf and vl on day and hand grip strength on day . conclusion: this study seeks to gain insight in parameters affecting muscle stiffness and of the evolution of muscle stiffness after acute illness or hospitalization. a trend of decreasing muscle stiffness is seen after seven days of hospitalization and illness. this study showed no direct relation between age and muscle stiffness. a decrease in muscle stiffness results in higher hand grip strength and therefore better muscle performance. more data and longer follow-up periods are needed and are expected by march . ainhoa indurain , , jennifer linge , mikael petersson , thobias romu , fredrik uhlin , , anders fernström , mårten segelmark , , olof dahlqvist leinhard (( ) departments of nephrology and medical and health sciences, linköping university, linköping, sweden; ( ) departments of acute internal medicine and geriatrics and medical and health sciences, linköping university, linköping, sweden; ( ) background: sarcopenia is a prevalent condition in hemodialysis patients and it´s associated with poor quality of life, hospitalization and mortality. recent research using magnetic resonance imaging (mri) has demonstrated the importance of proper body size-adjustment in the assessment of muscle mass, and that the addition of muscle fat infiltration reflecting muscle quality, improves functional correlations and prediction of hospitalization in sarcopenia. it is not yet demonstrated if this new mri method, combining body sizeadjusted muscle volume and muscle fat infiltration, improves the evaluation of sarcopenia in hemodialysis patients. objectives: to investigate if adverse muscle composition, defined using mri, predicts survival and comorbidity in hemodialysis patients. methods: in , patients on hemodialysis were scanned using rapid whole body fat and water separated mri. following years, survival and comorbidity index (nci) were recorded using electronic health care records. thigh muscle fat infiltration (mfi) and fatfree muscle volume (ffmv) normalized with height was assessed using amra research (amra medical, linköping sweden). a z-score describing the deviation from expected ffmv/height was calculated using sex and bmi-matched virtual controls (ffmvvcg) and mfi adjusted (mfiadj) was calculated using the sex-specific population mean. for these calculations, normative data from subjects in uk biobank was used. to estimate a combined muscle score (musclecomb), mfiadj and ffmvvcg were projected on the linear regression line describing the normal population relationship between mfiadj and ffmvvcg in the uk biobank dataset. spearman rank correlation was estimated comparing mfiadj, ffmvvcg and musclecomb to nci. wilcoxon signed-rank test was used to estimate the association to survival. roc values and confidence interval were also calculated. results: musclecomb (combined muscle score) was significantly correlated to comorbidity (p< . ) and predicted survival (p< . ) while mfiadj (adjusted muscle fat infiltration) and ffmvvcg (deviation from an individual´s expected muscle volume) did not reach significant level on either test. the roc values for predicting survival were . ( . - . ) for ffmvvcg, . ( . - . ) for mfiadj, and . ( . - . ) for musclecomb. background: frailty is a risk factor for cardiovascular disease (cvd). as declines in bone metabolism and impaired inflammatory response are often associated with frailty, bone analytes and inflammation markers involved in these signaling pathways may act as biomarkers of frailty-related disease progression. objectives: this study sought to examine differences in systemic bone analyte and inflammation marker concentrations based on cvd risk profile and frailty status. methods: females with no prior cvd were stratified into low or high cvd risk groups based on their framingham risk scores. frailty was assessed using the fried phenotype of frailty. greedy matching with pre-frailty as the exposure variable was used to identify a set of closely matched pairs in both the low and high cvd risk groups for a total of females in a case-control design. factorial anova was used to compare differences in log transformed concentrations of bone and inflammation analytes based on frailty status, cvd risk, and their potential interaction. results: differences for il- ( . ± . vs. . ± . pg/ml, p= . ), leptin ( . ± . vs . ± . pg/ml, p= . ) and tnfα ( . ± . vs . ± . pg/ml, p= . ) systemic concentrations were found with high cvd risk status compared to low. no differences in bone or inflammation analyte concentration were found based on frailty status, nor were any interaction effects. conclusion: there was a difference in inflammatory marker concentrations based on cvd risk status indicating that higher cvd risk is associated with impaired inflammatory response in females. there was no difference in bone or inflammation analytes in the pre-frail group compared to their robust peers as these females may be too early in the progression of frailty to have these signs of impaired bone health and inflammation. ( ) pancreato-biliary cancer center, gangnam severance hospital, yonsei university college of medicine, seoul, korea) background: biliary tract cancer (btc) is a highly lethal disease, and improved prognostication methods should be sought. sarcopenia (low muscle mass), poor muscle quality (low muscle attenuation) and excess adiposity (subcutaneous and visceral) can be surrogate markers of sarcopenia and related frailty. however this hypothesis has not been demonstrated conclusively in btc patients. objectives: to evaluate associations of all four body composition measures, derived from clinically acquired ct at the time of initial diagnosis, with overall survival in advanced btc patients. methods: we measured skeletal muscle index (smi), mean muscle attenuation (ma), visceral adipose tissue index, and subcutaneous adipose tissue index via computed tomography at the level of the l vertebra. clinical data were extracted from patients' charts. results: a total of patients ( % males, median age [range - ]) were included in this study, % were metastatic and % were recurrent disease. during the follow-up duration (median of . months; range . month to months), patients ( %) died. sarcopenia, defined as low l smi (lower than cm /m for women and lower than cm /m for men) was noted in patients ( %), and patients ( %) had low muscle radiodensity. for adiposity, % and % of patients had low subcutaneous and visceral fat, respectively. when we combined this four factors and grouped the patients, no risk group (n = ) had the best overall survival (median . months, % ci, . - . ), while the patients who suffered all the risk factors (n= ) showed the poorest survival (median . months, % ci, - . ) which was statistically significant (log-rank test < . ). this classification was independent factor for survival in multi-variate analysis along with other clinical factors, carcinoembryonic antigen (cea), neutrophil-to-lymphocyte ratio, white blood count, platelet, and cholesterol (hr . , % ci . - . ). conclusion: sarcopenia, ma, and adiposity independently predict mortality in patients with btc and can be utilized as surrogate markers for prognosis. background: frailty is a clinical syndrome of reduced systemic physiological reserve that phenotypically overlaps with heart failure. nt-probnp is a cardiac-specific marker that increases with ventricular stress, whereas growth differentiation factor (gdf- ) is a non-tissue specific systemic marker that increases with inflammation, tissue injury and possibly inflammageing. objectives: this study aims to determine if combination of nt-probnp and gdf- organised in a x matrix can classify cardiac dysfunction with and without frailty, non-cardiac frailty, and non-frailty. methods: this is a cross-sectional analysis of a prospective cohort study (phase ), undiagnosed heart failure in older adults (ufo), that recruited community-living older adults aged >/= years in a ratio of : : for robust, pre-frail and frail status classified by the frail scale. participants without a history of heart failure and meeting the eligibility criteria were entered into the study. nt-probnp and gdf- levels were measured using the roche cobas elecsys platform. echocardiography and -minute walk distance ( mwd) were documented. informed consent was obtained from all participants. the study was approved by the local institutional review board. ) was ascertained by correlation with abnormal echocardiographic diastology represented most prominently by increased left atrial volume index (r= . , p= . x e- ). conclusion: a x dual biomarker approach utilising nt-probnp and gdf- may assist in subclassification of cardiac (diastolic) dysfunction and frailty. background: frailty was occurred frequently in elderly and known as higher risk of mild cognitive impairment (mci) and dementia than healthy elderly. hippocampus, parahippocampus and entorhinal cortex as memory system is considered one of the key regions of dementia especially alzheimer's disease. in addition, atrophy of these regions presumably related to higher risk of alzheimer's disease. on the other hand, it is poor understood about neural substrates of relationships frailty and higher incident rates of mci and dementia. objectives: the purpose of this study, therefore, to clarify differences of atrophy level of hippocampus, parahippocampus and entorhinal cortex and total gray matter between healthy, pre-frail and frail in elderly. methods: a total , elderly were measured brain structure with t-mri, and , were fulfilled inclusion criteria in this study. structural brain images were preprocessed and total hippocampal volume was estimated using freesurfer v . . and ubuntu . lts. we classified participants into three groups as healthy, pre-frail and frail characterized by , or and or more of the following domains respectively: low activity, slowness, weight loss, exhaustion and weakness. we compared total gray matter or hippocampal volume between healthy, pre-frail and frail in elderly with one way analysis of covariance (ancova) adjusted for sex, age, educational years, drinking and smoking habit, geriatric depression scale points and estimated total intracranial volume (etiv) and multiple comparison using bonferroni correction. results: the prevalence of pre-frail and frail was . % and . % respectively. hippocampus, parahippocampus and entorhinal cortex volume were significantly decreased in elderly with frail compared healthy and pre-frail (hippocampus: p= . and p= . ; parahippocampus: p= . and p< . ; entorhinal cortex: p= . and p= . respectively). in contrast, total gray matter volume was not significantly difference between three groups. conclusion: hippocampus, parahippocampus and entorhinal cortex were atrophied in elderly with frailty compared healthy or pre-frail elderly. it might be neural substrates of higher risk of dementia in elderly with frailty. rasekh kashkosh , irina gringauz , jonathan weissmann , gad segal , , michael swartzon , abraham adunsky , , dan justo , (( ) geriatrics division, sheba medical center, israel; ( ) biomedical engineering department, israel; ( background: low alanine aminotransferase (alt) blood levels prior to rehabilitation are associated with poor rehabilitation outcomes in terms of low mobility and function in older adults following hip fracture. objectives: we have hypothesized that low alt blood levels prior to rehabilitation are also associated with -year mortality in this population. methods: included were older adults (age >= years, median age years, . % women) admitted for rehabilitation following hip fracture. alt blood levels were documented between one and six months prior to rehabilitation. excluded were patients with alt blood levels over iu/l possibly consistent with liver injury. the study group included patients with low ( iu/l or lower) alt blood levels, and the control group included patients with high-normal ( - iu/l) alt blood levels. the main outcome was all-cause mortality one year following rehabilitation admission. results: the study group included ( . %) patients with low alt blood levels, and the control group included ( . %) patients with high-normal alt blood levels. overall, ( . %) patients died within one year following rehabilitation admission. compared with the control group, patients with low alt blood levels had significantly higher -year mortality rates ( . % vs. . %, or . , %ci . - . ). cox regression analysis showed that low alt blood levels prior to rehabilitation were associated with -year mortality (hr . , %ci . - . ) together with peripheral vascular disease (hr . , %ci . - . ) -independent of age, gender, albumin serum levels, length of rehabilitation, and rehabilitation outcomes. conclusion: low alt blood levels prior to rehabilitation are associated with -year mortality in older adults following hip fracture. fawaz azizieh , dia shehab , khaled al jarallah , renu gupta , raj raghupathy (( ) gulf university for science & technology, mubarak al-abdullah area, kuwait; ( ) faculty of medicine, kuwait university, jabriya, kuwait) background: in addition to some well-characterized bone turnover markers, cytokines and adipokines have also been suggested to be linked to osteoporosis seen in menopause. however, there is much controversy on the possible association between these markers and bone mineral density (bmd). objectives: this study was aimed at measuring circulatory levels of selected cytokines and adipokines in postmenopausal women with normal and low bmd. methods: the study population included post-menopausal women, of whom had normal bmd, had osteopenia and had osteoporosis. circulatory levels of selected pro-resorptive (tnf-a, il- b, il- , il- , il- , il- ), anti-resorptive (ifng, il- , il- , il- , tgf-b) and five adipokine markers (adiponectin, adipsin, lipocalin- /ngal, pai- and resistin) were measured using the multiplex system and read on the magpix elisa platform. further, two bone turnover markers (p np, ctx) as well as estradiol levels were assayed from the same samples. results: while circulatory levels of cytokines were comparable between groups, women with low bmd had statistically significantly higher median circulatory levels of adipokines as compared to those with normal bmd. further, while levels of ctx were not different between the two groups; p np, p np/ctx ratio and estradiol levels were significantly lower in women with low bmd. levels of adiponectin, p np, p np/ctx ratio and estradiol correlated significantly with bmd of the hip and spine. conclusion: while the associations between the studied markers and bmd may be complex and multivariate, our data provide insights into the possible use of circulatory levels of cytokines, adipokines and bone turnover markers on the pathogenesis of postmenopausal osteoporosis. background: with the application of diffusion tensor imaging (dti), a few studies have found that some white matter (wm) structures were closely related to impaired gait speed. however, the evidence is still sparse and the wm structural association with overall lower-body physical function, which can be evaluated by short-physical performance battery (sppb), has never been investigated among older adults. objectives: the aim of this study is to explore the associations between wm structures (evaluated by dti parameters) and sppb scores among older adults. methods: data of participants ( ± years old), who were recruited in the multidomain alzheimer's preventive trial (mapt) study and with no dementia at baseline level, were analysed in this study. based on the functional magnetic resonance imaging data, dti parameters of fractional anisotropy (fa), mean (md), axial (ad) and radial diffusivity (rd) were calculated in wm structures that were annotated by the john hopkins university white matter parcellation atlas. linear regression was used to analyse the association between sppb score and each dti parameter while controlling for age, gender, body mass index, physical activity level, total intracranial volume, cardiovascular risk and time interval between the dti and sppb measurement. results: three dti parameters (the md and rd of left corticospinal tract, and the md of right cerebral peduncle) were associated with the sppb score at a p-value < . . conclusion: the findings indicate that wm structures of corticospinal tract and cerebral peduncle might be related to overall lower-body physical function of older adults. further studies on the changes of these wm structures with physical function alterations during ageing will be more informative. background: ct-derived skeletal muscle index and skeletal muscle density (smd) have been independently associated with mortality in older adults. although smd is a commonly used measure of myosteatosis on ct images, more novel muscle texture (i.e., radiomic) features may provide an alternative measure of muscle quality, independent of smd. there have been no prior studies on the association of ct-derived muscle texture features and mortality. objectives: to examine the association of skeletal muscle texture features with all-cause mortality in older adults from the national lung screening trial (nlst). methods: the relationship between ct-derived skeletal muscle texture and all-cause mortality over years was determined in , participants ( % women, age range - years, mean age . ) in the nlst. using ct images at the level of t vertebra, paraspinous muscle was automatically segmented using machine learning algorithm, and muscle texture features determined using pyradiomics. second order (and higher) texture features were grouped into categories: gray level dependence matrix (gldm), gray level co-occurence matrix (glcm), gray level run length matrix (glrlm), gray level size zone matrix (glszm), and neighbouring gray tone difference matrix (ngtdm). muscle texture features often indicate greater or lower heterogeneity/complexity of an image. associations between standardized muscle texture variables and all-cause mortality were determined using cox proportional hazards models, adjusted for age, sex, race, body mass index, pack years of smoking, presence of type diabetes, chronic lung disease, cardiovascular disease, cancer at enrollment, and smd. multiple comparisons were accounted for using false discovery rate testing. results: after a mean . ± . years of follow-up, ( . %) participants died. in fully adjusted models, the following muscle texture features were associated with mortality: gldm-dependenceentropy (hazzard ratio (hr) per standard deviation (sd)= . , p< . ), gldm-dependencenonuniformity (hr per sd= . , p= . ), gldmsmalldependencelowgraylevelemphasis (hr per sd= . , p< . ), glrlm-graylevelnonuniformity (hr per sd= . , p< . ), glszm-small area low gray level emphasis (hr per sd= . , p= . ), ngtdm-coarseness (hr per sd= . , p= . ), ngtdm-strength (hr per sd= . , p= . ). each of these associations were in the direction that suggested greater heterogeneity of the image was associated with increased mortality. conclusion: in a large multicenter cohort of community-dwelling older adults, ct-derived muscle texture features indicating greater heterogeneity were associated with mortality, independent of common covariates including skeletal muscle density. background: growth differentiation factor (gdf ) has been related with disease progression, mitochondrial dysfunction, and mortality. elevated gdf- level was recently reported to be associated with poorer physical performance in very healthy community-dwelling adults. however, until now, the relationship of serum gdf- level with sarcopenia in community-dwelling older adults has not been well characterized. objectives: this study aimed to investigate the association between serum gdf- levels and sarcopenia in community-dwelling older adults. methods: we analyzed participants (mean age, . ± . years; . % men) who underwent measurement of serum gdf- level and sarcopenia parameters, using their baseline data from the korean frailty and aging cohort study. participants with reduced kidney function, specifically an estimated glomerular filtration rate (egfr) from creatinine of < ml/min/ . m , were excluded. serum gdf- level was quantified with an enzyme-linked immunosorbent assay kit. appendicular skeletal muscle mass was measured using dual-energy x-ray absorptiometry. sarcopenia status was determined in accordance with the asian working group for sarcopenia (awgs) guidelines. results: according to the awgs algorithm, ( . %) of the participants in the whole study population were classified as having sarcopenia. gdf- concentration had significant negative correlations with appendicular lean mass (men, r = - . , p < . and women, r = - . , p = . ), grip strength (men, r = - . , p = . and women, r =- . , p = . ), and gait speed (men, r = - . , p = . and women, r = - . , p = . ). in the multivariate analysis adjusted for potential confounders, the highest gdf- quartile (>= pg/ml) was associated with a greater risk of sarcopenia (odds ratio [or] = . ; % confidence interval [ci], . - . ) than the lowest quartile (< pg/ml). these associations remained unchanged (or = . ; % ci, . - . ) after further adjustment for potential biomarkers (e.g., myostatin, dehydroepiandrosterone, and insulin-like growth factor- ). the or per unit increase in log-transformed gdf- level was . ( % ci, . - . ). conclusion: higher circulating gdf- levels were independently associated with a greater risk of sarcopenia in community-dwelling older adults. gdf- may be considerate a promising biomarker of sarcopenia. background: frailty has been recognized as an emerging public health problem in rapidly aging populations worldwide. use of biomarkers to identify frailty has been suggested for early frailty screening. among multiple risk factors of frailty, inadequate nutrition such as inadequate intake of protein and vitamin d has been shown to be associated with increased risk of frailty. therefore, nutritional biomarkers could be useful for early screening of frailty. objectives: to review the evidence of potential biomarkers, especially nutritional biomarkers for early screening of frailty in community-dwelling older adults. methods: a literature search was conducted using pubmed and scopus databases. studies evaluating blood biomarkers and frailty in community-dwelling older adults from to were included. information on the definition of frailty, study design, characteristics of the study populations, and the associations between biomarkers and frailty was summarized. results: in total, studies were identified in which observational studies were published since . majority of studies used physical frailty. other definitions such as multidimensional, social and frailty were also used. biomarkers were identified. cross-sectional and longitudinal studies consistently showed that low level of vitamin d was associated with frailty. emerging scientific evidence suggested that abnormal level of albumin, low levels of high-density lipoprotein (hdl), beta-hydroxy beta-methylbutyrate (hmb), vitamin b (measured by pyridoxal- -phosphate), carotenoids, or a-tocopherol (vitamin e), and high level of dp-ucmgp (marker of vitamin k) could have the potential for frailty screening. besides nutritional biomarkers, the evidence showed that inflammatory markers such as c-reactive protein (crp), interleukin- (il- ), and fibrinogen, and endocrine-related markers such as hemoglobin, dehydroepiandrosterone sulfate (dheas), and hemoglobin a c could be useful for screening frailty. additionally, there is evidence suggesting that some oxidative or immune-related markers were associated with frailty. conclusion: vitamin d could be a useful nutritional biomarker for early frailty screening in the community setting. other nutritional biomarkers, inflammatory markers and endocrine-related markers could be associated with frailty. further research is needed to validate and refine other potential biomarkers. jonathan quinlan , , , amritpal dhaliwal , , felicity williams , , matthew armstrong , , leigh breen , , , ahmed elsharkawy , , carolyn greig , , , janet lord , , ( ( ) background: end stage liver disease (esld) is associated with reduced muscle mass with a reported incidence of sarcopenia of - % (bhanji, ). loss of muscle mass in esld patients has a negative impact on clinical outcomes including mortality and recovery rates from liver transplantation (montano-loza, ) . previous research has investigated loss of muscle mass in esld via appendicular skeletal muscle mass and psoas muscle cross sectional area (csa) using dxa and magnetic resonance imaging (mri) respectively. however, the quadriceps muscle group has high functional significance and thus should be investigated in esld patients in whom function may be limited. ultrasound (us) offers a non-invasive, bedside imaging assessment of quadriceps muscle mass. however, esld may be associated with increased subcutaneous fat which can present an operational challenge for us and thus its application in esld patients requires validation. objectives: the aim of this research is to validate the accuracy of ultrasonographic measures of quadriceps muscle mass by comparison with the gold standard of mri. methods: parallel mri and us were collected from patients with an esld diagnosis and awaiting liver transplant ( patients, age ± yrs, bmi . ± . ). participants underwent us scanning of both left and right quadriceps followed directly by an mri. specifically, measures of vastus lateralis (vl) muscle thickness (mt) and quadriceps csa were obtained at % femur length during longitudinal and extended field of view us respectively. to enable direct comparison with quadriceps csa obtained during mri, an oil capsule was placed upon the leg to mark the exact location of us image collection. all procedures received research ethics committee approval and written informed consent from the participants. results: a significant (p< . , n= ) positive correlation was found between vl mt and quadriceps csa obtained via mri (r = . ). similarly, there was a significant positive correlation (p< . , n= ) between csa obtained via extended field of view us and mri (r = . ). bland-altman plots demonstrated a bias of - . ± . cm , with % limits of agreement of - . cm and . cm . conclusion: our data demonstrate that the assessment of quadriceps csa and vl mt via us may offer a suitable bedside alternative to mri in patients with esld. background: sarcopenia is defined as the gradual ageassociated loss of both muscle quantity and strength in older adults, and severe sarcopenia affects subject performance (such as reduced gait speed). it is a devastating condition, predicting an increase in mortality, falls, fractures and hospitalizations. current clinical criteria diagnose sarcopenia through dual x-ray absorptiometry (dxa) measures of muscle mass, a test that cannot be performed at the bedside and is rarely used to find this condition. point-of care ultrasound (pocus) is rapidly becoming a standard part of the physical exam, and has the potential to become a quick, noninvasive marker for both muscle mass and function. objectives: we examined the relationship between ultrasound measures of muscle mass (vastus medialis thickness, mt) and other measures of muscle quantity (appendicular skeletal mass, asm; mid-arm biceps circumference, mabc). we also examined the association between mt and measures of muscle strength (grip strength) and muscle performance (gait speed) in an older adult population. methods: older adults (age >= ; mean age . ± . years, women, men) were recruited sequentially from geriatric medicine clinics. each subject had appendicular skeletal muscle mass (asm, by bioimpedance assay), grip strength, mid-arm biceps circumference (mabc), gait speed, and an ultrasonic measure of muscle quantity (mt, vastus medialis muscle thickness) measured. our initial models contained age, sex, bmi, and mt as predictor variables, and our outcome variables were asm, grip strength, mabc and gait speed. results: in our final parsimonious models, mt showed a strong significant correlation with all measures of muscle mass, including asm(standardized ß= . ± . , r = . , p< . ) and mabc(standardized ß = . ± . , r = . , p= . ). with respect to measures of muscle quality, there was a strong significant correlation with grip strength (standardized ß = . ± . , r = . , p= . ) but not with subject performance (gait speed). conclusion: mt showed strong correlations with both measures of muscle mass (asm and mabc) and with muscle strength (grip strength). riki kosugi , yung-li hung , toshiharu natsume , shuichi machida (( ) faculty of health and sports science, juntendo university, inzai, chiba, japan; ( ) institute of health and sports & medicine, juntendo university, inzai, chiba, japan; ( ) coi project center, juntendo university, bunkyo-ku, tokyo, japan; ( ) graduate school of health and sports science, juntendo university, inzai, chiba, japan) background: loquat (eriobotrya japonica) leaves are commonly used in teas and folk medicines. recently, loquat leaf extract (lle) has been reported to promote muscle protein synthesis in vitro. additionally, resistance exercise has been shown to promote muscle protein synthesis in vivo. it is considered that lle and resistance exercise might have a synergistic effect on activating muscle protein synthesis. however, this has never been investigated. objectives: the purpose of the present study was to investigate whether lle enhances the muscle contraction-induced activation of muscle protein synthesis signaling in rats. methods: male wistar rats ( weeks old, n= - /group) were categorized into a control (con) group, an lle-administered (lle) group, an electrical muscle stimulation (ems) group , and an ems with lle (ems+lle) group. rats were administered lle ( . g/kg/ day) or distilled water once in a day by oral gavage for days. on the seventh day, h post-lle administration, the gastrocnemius muscle of the right legs of ems group and ems+lle group rats were stimulated by ems ( hz, v) through sets of isometric contractions ( s contraction, s rest) with min inter-set intervals. rats were then sacrificed and their gastrocnemius muscles were rapidly excised h post-ems. expression levels of muscle synthesis-related proteins [protein kinase b (akt), mammalian target of rapamycin (mtor), and ribosomal protein s kinase beta- (p s k)] were determined by western blotting. results: no significant differences were observed in body weight, water intake, and diet intake among the groups. akt phosphorylation at ser was found to be significantly increased in the ems+lle group compared to that in con group; mtor phosphorylation at ser did not show a significant difference. p s k phosphorylation at thr was found to be significantly increased in the ems group compared to that in con group, while the ems+lle group was observed to have significantly higher p s k phosphorylation at thr than the ems group. conclusion: our study suggests that lle enhances the muscle contraction-induced activation of p s k phosphorylation. background: metabolic aging has emerged as a new sedentarity related syndrome combining metabolic diseases and sarcopenia, a degenerative loss of skeletal muscle mass, quality, and strength associated with aging. it has been recently shown that kynurenic acid (ka), a key metabolite of tryptophan/ kynurenine pathway, improved glycemic control and lipid profile in rodents. objectives: to show that ka has a key role in metabolic aging, we have evaluated its effect on muscle function and mass in vitro and in vivo in muscle cell line and in a model of hindlimb immobilization in mouse. methods: in vitro in c c muscle cells we measured the ability of ka to inhibit myostatin gene expression (endogenous inhibitor of muscle growth), stimulate protein synthesis and enlarge muscle cell size. differentiated cells were exposed to ka for h for protein analysis, h for gene study and the days of differentiation for cell enlargement examination. in vivo, muscle mass (tibialis and soleus) was measured after a week-hindlimb immobilization in mice treated or not with ka ( mg/kg.day per os). results: in vitro, ka significantly and dose-dependently inhibited myostatin gene expression, stimulated protein synthesis and enlarged c c muscle cells. in mice, ka treatment significantly reduced tibialis and soleus muscle wasting induced by immobilization. conclusion: we demonstrated for the first time the positive impact of ka on muscle function and mass preservation offering a promising therapy for patients affected by metabolic aging, who do not currently benefit from relevant therapeutic solutions. Â n g e l a m a r i a p e r e i r a , , , a n a f r e i t a s , a n a p a c i f i c o , c a t a r i n a c o s t a , m a r g a r i d a a l m e i d a (( ) physiotherapy departement, escola superior de saúde egas moniz, portugal; ( ) centro de investigação interdisciplinar egas moniz, monte da caparica, portugal; ( )hospital garcia de orta, almada; portugal) background: as people age they are more likely to fall. although most fall-related injuries are minor, they can cause significant pain and discomfort, affect a person's confidence and lead to loss of independence. some falls can cause serious long-term health problems. one strategy to promote greater adherence and motivation to intervention in physical therapy is the use of virtual environment (ve) programs associated with a balance exercise programs as an effective method of preventing falls. objectives: the purpose of this study was to analyze the benefit of a virtual environment exercise program in non-institutionalized elderly at the end of six weeks. methods: in this randomized controlled trial non-institutionalized elderly were included. subjects, age . ± . yrs constituted the experimental group (eg); and , age, . ± . yrs constituted the control group (cg). the eg was submitted to weeks of a ve exercise program performed on a nintendo wii, and to a set of recreational activities. the cg only performed the activities. the instruments used in the present study to evaluate performance were tinetti's index, which evaluates the static balance and the gait to quantify the risk of fall, and the fullerton's functional fitness tests to assess physical parameters such as strength, aerobic endurance, flexibility and agility/ balance. results: at the end of the weeks of intervention in a virtual environment, significant improvements in upper limb strength, agility and static balance were observed. in the intragroup comparison, it was possible to verify improvements in all physical fitness battery tests. the values of functional fitness tests were significantly different (p<. ) between eg and cg groups for the following variables: -second chair stand . ± . vs. . ± . times; arm curl . ± . vs. . ± . times; -foot up-and-go . ± . vs. . ± . sec; two min. step . ± . vs. . ± . steps, respectively; as well as for the tinetti index. conclusion: this study, suggests that exercise in ve context applied to non-institutionalized elderly, promotes improvements in mobility, in lower limbs muscular strength, and may help to reduce the risk of falls by improving the static and dynamic balance. background: the small non-coding micrornas (mirs) are endogenous regulators of gene expression. they bind to complementary sequence on target messenger rna transcripts resulting in translational repression or target degradation. they are involved in the skeletal muscle response to training in animals and humans (kirby, ) . objectives: the aim of our study was to measure the effects of high intensity interval training (hiit) associated or not with l-citrulline on the expression of serum and muscle mirs in a group of men. methods: we selected men (mean age: . ± . years, men in the placebo group and in the l-citrulline group, gr/day) from a cohort of men and women submitted for weeks to hiit (buckinx, ) . we evaluated the expression of serum and muscle mirs before and after training. the quantification of mir expression was performed using the next generation sequencing (ngs) technique (exiqon). for statistical analysis, the measurements were normalized with the tmm method (trimmed mean of m-values). results: we identified mirs from serum and mirs from muscle above the detection limit (>= tpm, tags per million). after benjamini-hochberg correction, serum mirs from the l-citrulline group had a significantly different level of expression before and after training: - p, b - p, , a- p and - a- p (p < . , % fdr). no mir of the placebo group had a significantly altered expression. in muscle, our approach revealed mirs with a significantly different level of expression before and after training in the placebo group and in the l-citrulline group, of which were common to both groups. these mirs were different from those highlighted at the serum level. the most-expressed muscle mirs with the greatest difference in expression before and after training were - p, - p, - p, - p and b- p (p < . , % fdr). conclusion: with the ngs approach, we identified mirs differentially expressed before and after hiit. expression of circulating mirs appears to be influenced by l-citrulline. the next validation step will be to measure these specific mirs in the entire cohort to determine the clinical utility of these markers. background: recent interventional studies on frailty used multicomponent programs (physical exercise, cognitive stimulation, and nutritional supplementation) with some promising results. however, these emerging programs developed to counter the multidimensional concept of frailty still need methodological improvements to be completely effective. objectives: the objective of this innovative project is to develop personalized multicomponent interventions that could be easily used by frail older adults in order to reverse physical, cognitive and psychosocial symptoms associated with frailty. three original and specific action levers will be used to insure a better effectiveness: /to target a key population (hospitalized frail older adults who will be discharged to home), /to use a real multicomponent program (physical exercises simultaneously associated with cognitive and social components that mimic daily gestures), and /to encourage adherence through medical prescription. methods: one hundred and twenty frail older adults (>= ) will be recruited from the geriatrics unit of the university hospital of tours (france), and randomly assigned to one of the two study arms: the intervention group (ig), who will receive a medical prescription of an adapted multicomponent intervention, vs the control group (cg; no intervention). twelve-week programs will be adapted according to observed intrinsic capacities of the frail older adults. including exercises will be based on effective international physical programs, with original cognitive and social components added to the physical exercises. all participants will perform pre-and post-tests to compare their physical health (gait speed, balance, and strength), cognitive health (global cognition and executive functions), and psychosocial health (self-efficacy and quality of life) before and after the three-month program. results: a pilot study to this rct has already started in tours. the international conference on frailty and sarcopenia research would be the perfect opportunity to share preliminary results. the intervention will be considered as feasible if ig participants adhere to > % of the prescribed exercise and as effective if we observe significant improvements in all clinical outcomes for ig participants, compared to the cg. conclusion: final objective will be to disseminate to a large number of individuals the idea that several concrete ways exist to age well. amanika kumar, clarissa polen-de, gladys asiedu carrie langstraat, aminah jatoi (mayo clinic, rochester, minnesota, usa) background: frailty in patients with advanced stage ovarian cancer (oc) is common and associated with increased oncologic and surgical morbidity and mortality. prehabilitation is one option to reverse frailty in this subset of patients. objectives: our aim was to investigate potential barriers and facilitators of prehabilitation during neoadjuvant chemotherapy (nact) in oc patients. methods: we identified patients who underwent nact from - at a large volume single institution. patients underwent a semi-structured one-on-one phone interview. transcripts from interviews were read by independent reviewers to identify emerging themes related to patients' experience, functioning and exercise during chemotherapy. results: five primary themes emerged following analysis of the participants transcripts. participants were overall willing to participate in exercise during chemotherapy, with / patients stating they would walk or did walk at least minutes daily during treatment; this was linked to a strong motivation to improve surgical and survival outcomes. only / patients stated they were not interested in exercise during treatment. most notable, patients' motivations were tied closely to physician recommendation. patients prominently identified a shift in health as a priority following their ovarian cancer diagnosis, which subsequently lead to an increase in daily activities and exercise. surgery and improvement in mental well-being were strong motivators for patients to start or continue an exercise program. participants also identified barriers to exercise during treatment including a variety of treatment related and nontreatment related concerns, including neuropathy, nausea, pain, program availability, time and most significantly fatigue. despite this, most retrospectively thought they would have been willing to exercise with modifications. almost all participants voiced the importance of a supportive treatment community, including their medical care team, family, friends and the local community. conclusion: patients with advanced ovarian cancer demonstrated high motivation and willingness to exercise during chemotherapy when there was a perceived benefit to overall survival. prehabilitation may be a helpful to improve outcomes, but a prehabilitation strategy should be designed specifically for the patients with the most need and designed with barriers and motivators in mind. randomized control trial. kosuke fujita , , hiroki umegaki , aiko inoue , huang chi hsien , , hiroyuki shimada , masahumi kuzuya , (( ) institute of innovation for future society, nagoya university nagoya, japan; ( ) department of community healthcare and geriatrics, nagoya university graduate school of medicine nagoya, japan; ( ) department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology obu, japan) background: gait disorder in older adults could lead fatal consequence following falling or reducing physical activity, especially in individual with pre-clinical / clinical cognitive decline. effectiveness of exercise intervention for the gait characteristics has been examined in previous studies, however, evidence about differences between exercise modality such as aerobic training (at) and resistance training (rt) for the acute and long phase is unclear. objectives: the aim of the present study was to compare the effect of different exercise modality on the gait characteristics of older adults with preclinical cognitive decline. methods: individuals (mean age, . years) with self-reported cognitive decline were enrolled in randomized controlled trial. subjects assigned to at group (n = ), rt group (n = ) and at+rt group (n = ) underwent exercise intervention days a week for weeks. subjects assigned to control group (n = ) were provided information about healthy aging. gait characteristics were examined before, just after the intervention and after the weeks of follow-up period using an electronical walkway system. results: in the analyses about the change between pre and just after the intervention period, all of three exercise groups significantly improved gait velocity (at, p < . ; rt, p < . ; at+rt, p < . ), stride time (at, p < . ; rt, p = . ; at+rt, p < . ), cadence (at, p < . ; rt, p = . ; at+rt, p < . ), stride length (at, p < . ; rt, p = . ; at+rt, p < . ) and double support time (at, p < . ; rt, p < . ; at+rt, p < . ), and at+rt group improved significantly with cv of step width (p < . ). in the analyses about the change between pre and follow-up period, rt group only had improvements with gait velocity (p < . ), stride length (p = . ) and double support time (p = . ). conclusion: all exercise interventions could improve gait characteristics of older adults with pre-clinical cognitive decline. for the purpose of maintain improved gait characteristics for a long phase, rt is likely to be recommended. activity and a broader array of physical and psychological outcomes among nursing home residents. however, some limitation of this game should be acknowledged (e.g. too long, too bulky, exercises too simple). taking into account these weaknesses, we decided to develop and validate a new version of a giant exercising board game: the gamotion. objectives: to evaluate the impact of gamotion on physical capacity, motivation and quality of life among nursing home residents. methods: a one-month randomized controlled trial was performed in two comparable nursing homes. eleven participants ( . ± . years; men) meeting the inclusion criteria took part in the intervention in one nursing home, whereas participants ( ± . years; men) were assigned to the control group in the other institution. the gamotion required participants to perform strength, flexibility, balance and endurance activities. the assistance provided by an exercising specialist decreased gradually during the intervention in an autonomy-oriented approach based on the selfdetermination theory (ryan & deci, ) . physical capacity (i.e. quantitative evaluation of walking using locometrix; grip strength using jamar dynamometer; knee extensor isometric strength using microfet ; fall risk using tinetti test; dynamic balance using timed up and go test (tug) and physical abilities using sppb test), motivation (i.e. using behavioral regulation in exercise questionnaire- ) and quality of life (i.e. using eq- d questionnaire) were assessed at baseline and at the end of the intervention. a two-way repeatedmeasure analysis of covariance (ancova) was used to assess time*group (intervention vs. control group) effects. results: globally, during the intervention period, the experimental group displayed a greater improvement in symmetry of steps (p= . ), tinetti score (p< . ), tug (p= . ), sppb (p< . ), knee extensor isometric strength (p= . ), grip strength (p= . ), domains of the eq- d (i.e. mobility, self-care, usual activities : p< . ) and intrinsic motivation (p= . ) compared to the control group. conclusion: the effects of gamotion on physical capacity, motivation and quality of life of nursing home residents confirm the results obtained with the previous version of the giant exercising board game. in-hospital stay, even in short stays, is associated with functional impairment in older patients. objectives: the agecar plus study aims to evaluate the effectiveness of a program of physical exercise and health education to prevent the functional deterioration during the in-hospital stay. methods: randomized clinical trial. patients older than years admitted to the ace of the general university hospital gregorio marañón were included and randomized at admission in control group (cg) or intervention group (ig). exclusion criteria were baseline barthel ( days before admission) less than points, severe cognitive impairment or unable to walk. both groups received usual care, and patients in intervention group also performed simple supervised exercises (strengthening of lower limbs, walking, and inspiratory muscle training). in the preliminary analysis, we analyzed the effect of the intervention on changes in short physical performance battery (sppb) and alusti test, at admission and discharge, by t-test of repeated measures in the study periods. results: from may to february , patients were included: gc and ig. the cg and ig were homogeneous in sex (women . %), age ( . ± . vs. . ± . ), comorbidities (charlson: . ± . vs. . ± . ), cognitive impairment (pfeiffer: . ± . vs. . ± . ), fragility (fried >= : % p= . ), and functional-physical capacity (sppb: . ± vs . ± . ; alusti, . ± . vs . ± . ). p < . for all variables. a significant effect of the intervention was found, with a higher mean score in the alusti test in the ig (cg: . ± . vs . ± . ; f( , )= . ; p= . ), not finding such differences with the sppb ( . ± . vs . ± . ; f( , ) = . ; p= . ). conclusion: the preliminary analysis shows that the alusti test could be used as an evaluation test for functional capacity in hospitalized elderly patients. a physical exercise program during hospitalization in an acute unit improves the functional capacity assessed by the alusti test at discharge significantly. funding: instituto de la salud carlos iii (pi / ), ciberfes, fondo europeo de desarrollo regional (feder). the authors declare no conflicts of interest. a. sampaio , i. marques-aleixo , , j. carvalho (( ) ciafel -research center in physical activity, health and leisure, faculty of sport, university of porto, portugal; ( ) faculty of psychology, education and sports, lusófona university of porto, portugal) background: cognitive impairment is a highly prevalent, poorly managed, and disabling consequence of dementia. exercise training that improves physical fitness can represent a promising approach for managing cognitive impairment in persons with dementia. objectives: the aim of this crosssectional study investigated the association of physical fitness and balance with cognitive function. methods: sixty-four institutionalized older adults, aged . ± . years, with dementia, predominately female ( %) and with dementia due to alzheimer's disease ( . %). regression analyses were used to examine associations between physical fitness components (senior fitness test), balance (tinetti index) and cognitive function (mini-mental state examination). results: univariate regression indicates a significant association between the strength of the upper body (p= , ) and aerobic endurance (p= , ) with the cognitive function in older people with dementia. conclusion: these results suggest an association between the specific dimensions of physical fitness and cognitive function. consequently, multicomponent exercisebased therapeutic strategies aiming to improve physical fitness could be an important nonpharmacological strategy for dementia management. satoshi kurita, takehiko doi, kota tsutsumimoto, sho nakakubo, hideaki ishii, hiroyuki shimada (section for health promotion, department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology, aichi, japan) background: women had higher risk of cognitive impairment or dementia compared to men. although studies reported physical activity (pa) and/or cognitive activity (ca) had protective association with cognitive impairment among older adults, it is unknown whether the association is depended on sex or not. objectives: the purpose of the present study was to examine the sex differences in the association of pa and/or ca with cognitive impairment in community-dwelling older adults. methods: a community-based cohort survey was conducted in a total of participants (mean age . ± . years; . % female) who met the study criteria. time of moderate-to-vigorous intensity pa was measured using an accelerometer. ca was assessed by the frequency of engaging in activities using a ca scale including reading, doing crossword puzzles, and playing board games or cards. participants were categorized into four groups based on quartile (low) and to (high) values of pa and ca. cognitive impairment was defined by at least out of neuropsychological tests having a result at least . standard deviation below the reference threshold. results: in both sex, the prevalence of cognitive impairments showed significant differences among groups; that of low pa/low ca group, low pa/high ca group, high pa/low ca group, and high pa/high ca group were respectively . %, . %, . %, and . % for male (p < . ) and . %, . %, . %, and . % for female (p < . ). in binomial logistic regression models for male, all groups showed a low odds ratios of cognitive impairment compared to the low pa/low ca group (odds ratio = . to . , all p < . ), while for female, only high pa/high ca group had significant association with cognitive impairment (odds ratio = . , % confidence interval = . to . , p = . ). conclusion: in male, pa and ca are associated with cognitive impairment even in the case of low engagement in either pa or ca. in female, higher engaging in both activities are associated with cognitive impairment. female older adults may need to engage in more activities than male to acquire benefit on preventing cognitive impairment. ( interventions) were included in the systematic review and in the meta-analyses ( interventions). there was considerable heterogeneity in the number for interventions that detected significant increases in muscle mass ( / , %) and muscle strength ( / , %). of those muscle strength interventions / ( %), / ( %), / ( %) and / ( %) interventions reported a significant increase in handgrip strength, lower body muscle strength, upper body muscle strength and whole body muscle strength respectively. ret factors associated with the greatest gains in muscle mass and muscle strength were: use of combination of equipment, seven to eight exercises per session with three lower body exercises, a volume of three to four sets and to repetitions per exercise, a frequency of two-three days per week, intervention length of greater than six weeks, progressive intensity, intervention duration of - minutes, and in a supervised individually training structure. these results align with current guidelines provided by american, australian, japanese, british, canadian and japanese societies. conclusion: not all ret interventions are effective for improving muscle mass and strength, but our meta-analysis suggests that adhering to the current ret guidelines for older adults are likely to be most effective. duarte barros, andreia pizarro, arnaldina sampaio, joana carvalho (research center in physical activity, health and leisure, faculty of sports, university of porto, portugal) background: sedentary time (sed) and low physical activity (i.e. low levels of moderate-to-vigorous physical activity [mvpa] ) are different behaviours associated with negative health outcomes, but how synergetic combinations of these behaviours impact the risk of frailty are still unexplored. objectives: to examine the relationship between different combinations of sedentary time and mvpa in the risk of being frail. methods: a cross-sectional study including community dwelling elders ( . ± . years; . % female) accessed frailty through the phenotype of frailty. daily sed and mvpa were objectively measured using accelerometry. sed and mvpa were ranked by the median and then participants were categorized into one of four groups: lowsed+lowmvpa, l o w s e d + h i g h m v p a , h i g h s e d + l o w m v p a a n d highsed+highmvpa. results: overall, . % of the participants were frail. mvpa was associated with reduced odds of being frail (or . ic: . - . , p < . ). moreover, compared to the highsed+lowmvpa, the groups lowsed+highmvpa (or . ic: . - . , p = . ) and highsed+highmvpa (or . ic: . - , p < . ) were associated with reduced odds of being frail. conclusion: mvpa seems associated with reduced odds of being frail, irrespective of sedentary time. background: sarcopenia is central to frailty and the strongest evidence for reversal lies in the combination of resistance exercise and protein supplementation. unfortunately, uptake amongst older adults remains low, partly due to a lack of suitable exercise programs. delivery by health professionals alone will not achieve widespread participation. objectives: defrail aims to develop a novel exercise program (focused on resistance training), feasible for delivery to frail older adults in a group setting without the input of health professionals, and to examine its effect when combined with commercially-available protein-supplemented milk. methods: a multi-component exercise program was designed by expert consensus using a modified delphi process. participants were recruited from geriatric medicine clinics and primary care, with assessments at baseline, after eight weeks of regular activity and then after the eight-week intervention. the primary outcome measure was the change in the fried frailty criteria (ffc) during the intervention compared with the period of regular activity. secondary outcome measures included the timed up & go (tug) and -second sit-to-stand ( sts) tests. results: the first participants to complete the program ( females, males, mean age , range - ) had a median ffc score of (interquartile range (iqr) , ), i.e. frail, both at baseline and after the period of regular activity period, but had improved to (iqr , ), i.e. pre-frail, following the intervention. similarly, the median tug was . (iqr . , ) at baseline, increasing to . (iqr , . ) after the period of regular activity, improving to . (iqr . , . ) following the intervention. the median sts was (iqr , ) at baseline, (iqr , ) after the period of regular activity, improving to (iqr , ) following the intervention. conclusion: median frailty improved from frail to pre-frail for the first defrail participants. this program could allow increased community-based participation in resistance exercise for frail older adults. further work now includes completion of the intervention and analysis of data on a range of secondary outcome measures (assessments of cognition, mood, pain, body mass composition and biochemical markers of frailty). background: exercise interventions have been shown to improve functional status and quality of life of frail older people, and in some cases to reverse frailty status. it is important that such interventions are targeted to those people who would benefit the most. objectives: the objective of this pilot study was to assess the effectiveness of a physical activity intervention given to mildly frail older people, who were identified using electronic health records (ehr). methods: the electronic frailty index (efi) was used to identify mildly frail older people and offer them a physical activity intervention of their choice. the pilot study was offered in one area of luton (uk), with invitation letters sent by the participants gp. participants were tested before and after a -week programme of strength, balance and mobility, delivered in a weekly session lasting one hour. participants were assessed at baseline for motivation using the patient activation measure (pam), physical function using the short physical performance battery (sppb), and fear of falling using the falls efficacy scale international (fes-i). each test was carried out in a follow-up test after the programme had concluded. bootstrapped paired t-tests were used to assess the effect of the intervention. results: twenty-seven people aged . ± . years took part in the intervention. the pam scores improved from . % to . % ( . , % ci: . , . ), which is twice the minimal clinically important difference (mcid) of . for sppb, there was an improvement from . to . ( . , % ci: . , . ). the average increase was greater than the mcid for a substantial improvement of . . when fes-i was assessed, only three people ( %) had high concern about falling. there was no significant improvement in fes-i after the intervention (- . , % ci: - . , - . ). after the intervention, % of participants choose to pay for the continuation of the programme. conclusion: the findings of this study suggest that a targeted exercise programme including strength and balance training can significantly improve motivation and functional status among mildly frail older people identified using the efi, with the majority choosing to continue exercising. background: despite frailty has traditionally been examined from a physical standpoint, recent studies advocate for the existence of cognitive frailty ( ), and suggest that both physical and cognitive frailty are interrelated. thus, interventions should aim to prevent or attenuate the effects of frailty from a multidimensional perspective. objectives: to evaluate the effects of three different exercise programs on frailty among older adults living in long-term nursing homes (ltnh). methods: participants ( . % female) met the following criteria: aged years, scored on the barthel index, scored on mec test (an adapted version of mmse in spanish) and capacity to stand up and walk m independently. participants were randomly assigned to a progressive multicomponent group (mcg; n= ), a multicomponent dual-task group (dtg; n= ), or to a walking group (wg; n= ). the mcg underwent a -month moderate intensity strength and balance exercise program twice a week. the dtg performed simultaneous cognitive training (attention, inhibitory control, calculations and semantic memory) to the mc program. the wg walked up to minutes per day for days a week. frailty was measured though the following tests: fried frailty index (ffi), the tilburg frailty index (tfi) and the study of osteoporotic fractures (sof). results: the ffi revealed reductions in frailty in all groups, although only the mcg and the wg reached statistical significance (p< . ). as for the tfi and sof tests, no statically significant differences were found in any of the groups. however, there was a positive trend in tfi in the dtg (p= . ). no group-by-time interactions were found in any of the frailty tests used (p> . ). conclusion: our study showed no differences between interventions regarding frailty. however, the mcg and the wg showed significant reductions in phenotypic frailty, whereas the dtg showed a positive trend in the tfi, which takes into account physical, psychological and social domains. therefore, further studies should explore the effects of different exercise modalities on frailty from a broad perspective in older adults living in ltnhs. references: kelaiditi et al . j nutr health aging. ( ) : - . noirez , , iraj hashemi , deborah kopoin , pierrette g a u d r e a u , m a r c b é l a n g e r , g i l l e s g o u s p i l l o u , josé a morais , aubertin-leheudre ( ( ) background: aging leads to a loss of muscle strength and functional capacity. these phenomena can be slow down by daily exercise practice or resistance training intervention. objectives: the aim of this study was to investigate in elderly men muscle fiber size and type after resistance training. methods: among sedentary older men who completed a -week mixed power training program, were biopsied in the vastus lateralis before and after the program. cross sections were performed on these muscles, followed by triple immunohistochemical staining with antibodies directed against laminin, myosin heavy chain (myhc)- and myhc- a coupled with staining with secondary fluorescent antibodies. immunostaining analysis of laminin allowed us to determine fiber size and these of myhcs to determine fiber type. results: the size of the muscle fibers remained the same between before and after the mixed power training (p= . ).there was no significant difference in the percentage of expression of myhc- , a, x (p= . , p = . , p = . ) between before and after intervention. in addition, there was no difference in the size of fiber expressing myhc- between before and after the training (p = . ). however, significant increase in the sizes of fiber expressing myhc- a and myhc- x (respectively p = e- , p <. ) after the mixed power training was observed. conclusion: in elderly men, an increase of the size in fibers both expressing myhc- a and myhc- x in vastus lateralis muscle could explained the improvement on muscle mass observed previously (carvalho et al. acer ) . to confirm the mechanism explanation of this promising exercise modality, mitochondrial parameters should be also analyzed. background: muscle (in)activation related with sedentary behavior (sb) and physical (in)activity (pa) is a risk for sarcopenia in older adults. although age is not yet a risk factor for sarcopenia in adulthood, other factors such as lifestyle may significantly contribute to its progression. objectives: considering the primary and secondary prevention of sarcopenia, the aim of this study was to analyze associations of sb and pa with markers of muscle strength (lower limb muscle power) and muscle mass (fat mass (fm) to fat free mass ratio (ffm) in adult women and men with and without deficits in these markers. methods: participants were apparently healthy adults ( women) with a mean age . ± . yrs, employed in activities requiring office work. fm and ffm were evaluated by bioelectrical impedance analysis (bia, khz bia rjl, akern bioresearch, florence, italy akern). muscle power relative to body mass (pmax/mass) was assessed during a single two-legged jump on a force platform (leonardo mechanograph, novotec medical, pforzheim, germany) . sb and pa were assessed by accelerometry (actigraph, gt x model, fort walton beach, fl, usa) during four consecutive days ( -week+ -weekend days). the variables analyzed were time spent per day in sb, in light-, moderate-, vigorous-, moderate to vigorous-intensity pa, total pa and breaks per day of sb. multiple linear regressions were performed by stepwise to examine associations of sb and pa with muscle power and fm/ffm, separately for men and women with and without muscular deficits. for the identification of deficits (<- . sd), muscle power and fm/ffm were standardized separately for men and women having as reference their respective mean. results: linear regressions by stepwise evidenced an association of sb with muscle power in women with muscular deficit (β = - . , p = . , adjr = , %%) and an association of vigorous pa with fm/ffm in men without muscular deficit (β = . , p < . , adjr = , %). no associations were observed between sb or pa with muscle power or fm/ffm in other groups. conclusion: sb was negatively evidenced in women with muscle power deficit while vigorous pa revealed to be associated with fm/ffm in men without ffm deficit. funded by portuguese science and technology foundation; project c mup-eri/hc i/ / patricia parreira batista , andré gustavo pereira de andrade , jéssica rodrigues de almeida , aimée de araújo cabral pelizari , leani de souza máximo pereira , lygia paccini lustosa (( ) physical therapy department, ufmg -eeffto, belo horizonte, brazil; ( ) sports department ufmg -eeffto, belo horizonte, brazil) background: the practice of regular physical activity in the older people leads to the decreased of the loss of muscle mass and function with advancing age, and enhances the functionality in activities of daily living and social interaction. in addition, exercise promotes gains in the quantity and quality of muscle fibers and improves muscle strength and power, acting as a protective factor for negative health-related outcomes such as falls, frailty, and hospitalizations. regular practice of physical activity is known to modify the chronic proinflammatory condition common in the older people. probably, exercise reduces the drive of catabolic stimuli from this proinflammatory cascade, modifies the metabolism and production of cytones in tissues and organs, promoting protective and anti-inflammatory effect in the body. objectives: to compare older women who reported being active or sedentary regarding functional capacity and plasma indices of inflammatory mediators. methods: participated women ( years or older), recruited for convenience. those unable to walk were excluded; acute musculoskeletal diseases; lower limb fractures in the last year; neurological diseases and sequelae; history of cancer in the last five years and cognitive impairment (mental state mini-exam). all informed clinical and demographic data and performed the tests short physical performance battery (sppb) and timed up and go (tug). plasma dosages of stnfr and il- were by elisa method. comparison was by independent student t test. approval by the research ethics committee / ufmg (caae: . . . ). results: fiftytwo sedentary older women participated ( . ± . ys.); number of comorbidities of . ± . ; body mass index of . ± . kg/m . from the active group were elderly women ( . ± . ys.); comorbidity number of . ± . ; body mass index of . ± . kg/m . there was significant difference between groups in sppb (p = . ), tug (p = . ) and stnfr (p = . ). conclusion: the results showed that the active older women had better functional and mobility performance and worse plasma stnfr levels. in this case, one can think about the possible influence of body mass index in these older women, which should be explored in future studies. background: our research group designed a comprehensive geriatric intervention program (cgip) consisting of resistance exercise, physical activity increments, oral functional care, and a nutritional guide. we conducted a -week intervention and investigated the effects. after the short-term intervention, we followed up the all participants. we hypothesized that the follow-up could mitigate the loss of short-term intervention effects. objectives: the aim of this study was to compare physical functions before and after the -week intervention, and the end of the follow-up. methods: a total of were willing to participate in the -week cgip. we encouraged them to increase their daily steps and to carry out the program by using daily self-monitoring logs. the participants were randomly assigned to two groups [class-styled session (cs) group ; home-based (hb) group ] based on their residential districts. while cs group attended -minute weekly sessions and independently executed the program on other days, hb group did not attend the weekly sessions but received instructions on program execution. after the shortterm intervention, all participants were instructed to carry out the gcip habitually. also, three optional sessions for all participants were held in order to recommend implementation of the program. physical functions, such as knee extension strength (kes), maximum walking speed (mws), and anterior thigh muscle thickness (mt) were measured before and after the short-term intervention, and the end of the follow-up. results: of the participants identified, (cs ; hb ) took part in the measurements after the follow-up. thus, we analyzed their data. a significant interaction were observed in mws (p= . ). the -week cs intervention significantly improved mws (p< . ). but, mws in cs group significantly decreased after the follow-up (p= . ). there was no significant difference between before the intervention and after the follow-up in mws in cs group. on the other hand, no significant change was observed in hb group. significant time effects were observed in kes and mt (p< . ). both -wk interventions significantly improved kes and mt. while kes was maintained even after the follow-up, mt was significantly decreased. conclusion: the results suggested that appropriate follow-up helps to preserve short-term intervention effects. background: with the increasing prevalence of alzheimer disease and the current absence of drugs therapeutic, nonpharmacological strategies are definitively necessary. physical intervention is often proposed to aid in preventing or slowing cognitive decline. recent studies suggest that combining physical exercise with cognitive stimulation may have more global effect. objectives: we aimed at assessing effect of aerobic exercise alone or combined to intellectual exercises on major cognitive functions: attention (stroop), problem solving (hanoi tower) and working memory (digit span). subjects were trained twice a week for eight weeks. cognitive functions were assessed before training (base line), at the fourth and at the eighth weeks. to evaluate persistency of the effect, subjects were assessed one month after the end of training. methods: two groups were randomly constituted mild cognitive impairment subjects (mci) and alzheimer disease moderate patients (adm). each group was subdivided into three sub groups according to the task to be performed. aerobic exercise (pedaling) alone or combined to cognitive games presented on screen. control groups performed a reading task. results: an effect of training on cognitive functions was observed in adm as well as in mci subjects. however, only adm patient's performances were further improved by adding cognitive games. after four weeks, the observed effects were still maintained in both groups. mci results were obviously better than those of adm. there was no significant change in performances for control groups. conclusion: aerobic exercise induce cognitive improvement in adm and mci patients. combined physical exercise and cognitive games potentiated this effect mainly in adm group. this procedure has long lasting beneficial effect. this supports the necessity of regular aerobic exercise to prevent cognitive deficits in aging cognitive deficits. background: increasing physical activity represent a key therapeutic intervention to prevent the loss of mobility disability for enhancing health related quality of life. hence, we have set up a primary and secondary prevention care path through exercise training and nutrition to improve mobility and physical performances. objectives: our primary goal is to integrate a prevention care path into daily life of elders who may present a mobility disability risk. we aim to improve quality of life and mobility. methods: our program includes years or more who present a risk of developing a mobility disability. initially, we identify and screen a risk of mobility disability in wide elders communities. we diagnose mobility disability risk factors, sarcopenia and frailty, in day hospital (dietician, geriatrician and a kinesiologist). we use the ewgsop algorithm to diagnose sarcopenia. the patient then attend a -months training program, including sessions per week. sessions combine resistance exercises and balance training during minutes. we support the patient for his own project of long-term maintenance quality of life between physical activity and nutrition. results: patients have been seen after sessions. physical performance was significantly improved after months of intervention (sppb p< , , gait speed p< , and time-up-and-go p< , ) likewise grip strength (p< , ). the "sarqol" score was also significantly higher (p< . ). sub-group sppb ≤ with severe sarcopenia improve significantly more its score (+ . ± . p< , ) comparing to the overall population (+ . ± . ). moreover, there was a significant difference (p< , ) for sppb at baseline between responders ( . ± . ) and nonresponders ( . ± . ). conclusion: our intervention enhances mobility through physical performance benefits. we can make the assumption that adverse events will be occurring less and physical dependence will be delayed, regarding gait speed improvement. patients with lower physical performance are responding better than the overall population meaning that our intervention is more specially indicated for patients with severe sarcopenia. furthermore, our program sustains motivation for physical activity and exercise after months. we were able to show that it was possible to set up a comprehensive and effective care path for frail and sarcopenic elderly people. background: middle-aged adults who are pre-sarcopenic are at the highest risk of developing sarcopenia due to the progressive nature of the syndrome. objectives: to determine whether high intensity interval training (hiit) results in greater improvements in body composition, compared to a control group, in middle-aged adults with pre-sarcopenia. methods: eighty-two sedentary adults ( - yrs) with a low appendicular skeletal muscle mass index (asmi) were randomized into control (n= ) or intervention group (n= ) using stratified randomization based on age, sex and bmi. low asmi (asm/ht ) was determined by dxa (lunar prodigy, ge healthcare) using age-and sex-specific cut-scores as proposed by prado. the control group received one education session on general physical activity recommendations. the intervention was supervised, group-based, high-intensity aerobic and resistance interval training (hitt), times weekly for -weeks. an intention-to-treat mixed model linear regression, with a random effect, was used to analyse group differences for body composition. results: . % of the sample were female, the mean age was . yrs ( . ) and the mean bmi at baseline was . kg/m ( . ). people ( %) completed the intervention, people in the hitt group and in the control group. no adverse events were reported. significant group differences were observed for total muscle mass ( . kg, %ci: . - . ), leg muscle mass ( . kg, %ci . - . ), asmi ( . kg/m , %ci . - . ) and visceral fat mass our study indicated that group-based hiit is an effective, tolerable and safe exercise modality to increase total body and appendicular muscle mass, and to decrease visceral fat, in middle-aged adults with pre-sarcopenia. background: aging is related to body composition modifications and functional capacities declines. it is recognized than being active can prevent these changes and improve quality of life. however, it is unclear if gender or age influence this relationship and if a sub-type of voluntary physical activity is more efficient to maintain these physical parameters. objectives: to assess the association between current physical activity level or type and functional capacities and body composition among elderly people and to examine if age (< or >= yrs old) or sex modulate the relationship. methods: functional capacities using different validated tests (i.e. grip strength, timed up and go, sit-to-stand, muscle power, alternate step test, leg extension, vo max), body composition (fat & fat-free masses) using dxa were assessed. current global (total) and specific (aerobic, resistance or body and mind) physical activity levels (duration) were obtained through a questionnaire. multiple regressions, adjusted on age, sex and bmi, were performed to assess the relationship between current physical activity level and functional capacities or body composition. sub-group analysis, according to the sex and age (< y vs. >= y) were also performed by means of pearson correlations. results: a total of subjects ( . ± . years; women: . %; bmi= . ± . kg/ m²) were enrolled. after adjustment on confounding factors, total current physical activity level has positive impact on total fat mass (%; β=- . , p= ) and balance (β= . ; p= . ). moreover, current body & mind activities influence total fat-free mass (kg; β=- . , p= . ) and balance (β= . ; p= . ) whereas resistance activities influence fat-free mass (kg; β= . ; p= . ), fat mass (%; β=- . ; p= . ) and sitto-stand test (β=- . ; p= . ). sub-analysis shows that total physical activity level was significantly associated with fat mass, sit-to-stand test, balance and vo max in women but not in men. moreover, among people under y, the time spent on cardio activities does not affect functional capacities and body composition. nonetheless, among people aged y and over, the time spent on resistance activities is associated with functional capacities and body composition. conclusion: being active is associated with body composition and functional capacities, especially among women aged years and over. itxaso mugica-errazquin , nagore arizaga , janire virgala , julen gomez , garbiñe lozano , yune aranburu , udane elordi , maider kortajarena , ana rodriguez-larrad , jon irazusta ( ( ) background: low physical fitness, frailty and dependency are highly prevalent in people living in long term nursing homes (ltnh). multicomponent physical exercise, including strength, balance and endurance, has demonstrated to be effective for improving physical fitness and reducing frailty in ltnh. however, there is no evidence that this type of programs are capable to improve or even maintain the levels of autonomy in activities of daily living (adl) of this population. objectives: the major aim is to ascertain whether a new approach of months, individualized and progressive multicomponent program focused on functioning maintains autonomy in older adults living in ltnhs; the secondary aim is to assess the effects on frailty and physical fitness. methods: people living in ltnh, between and years, participated in this single group interventional study. inclusion criteria were: >= years, >= barthel index, >= mec- and be able to stand up from a chair and walk meters with or without one person/technical assistance. the intervention consisted of months of a progressive multicomponent physical exercise program (ep) aiming to improve the physical condition, followed by months of physical exercises focused on functional adl with the objective of maintaining/improving autonomy of the participants. barthel index was used to assess autonomy level in adl, frailty was measured by fried frailty index and short physical performance battery (sppb) was used to assess physical fitness. the study is registered in u.s clinical trial (nct ) and approved by the committee on ethics in research of the university of the basque country (m / / ). results: during the first months of ep participants lowered the score in the barthel index (p< , ). however, participants showed significant improvements in frailty (fried frailty index p< , ) and in physical fitness (sppb p< , ) . from the rd to th months, while physical fitness of participants did not change, they improved autonomy in adl, and decreased frailty non-significantly. when comparing the effects of the entire intervention, barthel index did not change significantly and physical fitness and frailty improved (sppb p< , ; fried p< , ). conclusion: this new approach of months of individualized and progressive multicomponent program focused on daily functioning maintains autonomy in activities of daily living, improves physical fitness and reduces frailty in older adults living in ltnhs. shuji sawada , hayao ozaki , , toshiharu natsume , daiki nakano , pengyu deng , toshinori yoshihara , takuya osawa , shuichi machida , hisashi naito (( ) juntendo university, chiba, japan; ( ) tokai gakuen university, aichi, japan; ( ) japan women 's college of physical education, tokyo, japan) background: in previous study, we found that low-load resistance training using own body weight and elastic band even only biweekly could induce muscle hypertrophy in older adults after weeks of training. however, it is unclear whether levels of different blood parameters before training associated with the effects of training. objectives: this study aimed to clarify whether levels of different blood parameters before training influenced the effect of low-load resistance training on lower limb muscle thickness (mt). methods: sixty-nine communitydwelling japanese subjects aged . ± . years ( women and men) volunteered for this study and participated in a lowload resistance training program using their own body weight and elastic band. the training was performed biweekly for weeks. each participant's mt at the anterior aspects of the thigh (at) was measured using a b-mode ultrasound device. further, the levels of the following blood parameters were assessed before and after the training program: serum albumin (alb), hemoglobin (hb), total cholesterol (tc), and hemoglobin a c (hba c). we checked the first quartile value of each blood parameter to establish the cutoff criteria for reduced levelsserum alb = . g/dl, hb = . g/dl, tc = mg/dl, and hba c = . %. participants were divided into low or normal groups in each blood parameter, and their data were analyzed using two-way analysis of variance. results: when using the abovementioned criteria, biweekly low-load resistance training increased mt at the at in every group after training. the interaction between time and groups was only detected with low (< . g/dl) versus normal (>= . g/dl) serum alb levels. in this case, there was no difference in mt at the at before training, but participants in the normal serum alb level group had greater mt after training than those in the low serum alb level group. conclusion: the effect of low-load resistance training on lower limb mt appears to be limited in participants with low pre-training serum alb level. objectives: it was to estimate the affect of complex -week treatment with kinesiotherapy methods on body weight loss and muscle function in patients with obesity. methods: men and women aged - years old with alimentary obesity were enrolled in the study (mean age . ± years, weight . ± . kg, bmi . ± . kg/m , waist circumstance wc . ± cm, hip circumstance hc . ± cm). the complex kinesiotherapy administered daily for week and included interactive sensorimotor trainings on double unstable platform, kinesiohydrotherapy in a pool, special complex of physical exercises in a gym and ergocycle trainings. weight, wc, hc, fall number for last weeks were measured at baseline and after the treatment was completed. muscle strength and walking speed functional tests results assessment ( -meters-walk test, up-and-go test, special tests for back and abdomen muscle endurance to static and dynamic loading) were performed at baseline and in weeks. results: there was a significant reduction in body weight ( . ± . kg at baseline vs . ± . kg in weeks; p= , ), in bmi ( . ± . vs . ± . kg/m ; p= . ), in wc ( . ± . vs . ± . cm; p= . ) and in hc ( . ± . vs . ± . cm; p= . ) in treated obese patients. -meters-walk speed increased from . ± . m/sec at baseline to . ± . m/ sec in weeks (p= . ). up-and-go test results improved from . ± . to . ± . sec (p= . ). we registered statistically significant elevation of the endurance to static loading in abdomen muscles from . ± . to . ± . sec (p= . ) and in back muscles from . ± . sec to . ± . sec (p= . ). the endurance to dynamic loading increased in abdomen muscles from . ± . to . ± . times (p= . ) and also in back muscles from . ± . to . ± . times (p= . ). fall namber markably decreased from . ± . at baseline to . ( %ci: . ; . ) after completion of treatment. conclusion: investigated complex treatment with kinesiotherapy methods promotes body weight loss, wc and hc reduction in obesity. -week special training of obese patients is associated with increasing in gate speed and lower extremities muscle strength, and it also causes improvement in static and dynamic loading endurance of back and abdomen muscles. those changes may probably improve balance function and decrease risk of falling in obese patients. thaiana pacheco, candice medeiros, rummenigge dantas, inae c. gadotti, edgar r vieira, fabrícia costa cavalcanti (department of physical therapy, florida international university, miami, usa) background: integrating technological advances into clinical practice can be challenging. physical therapists have been developing serious games/exergames for a variety of rehabilitation purposes, but uptake has been slow. games with virtual scenarios are an engaging and affordable way to encourage and increase physical activity levels. serious games have been developed to adapt virtual gaming environments to patients' needs and evolving capabilities. games can improve adherence and therapy effectiveness. the sensory and motor stimulation while playing serious games can help geriatric rehabilitation to improve mobility and balance. objectives: this study analyzed the effects of a new serious game on the balance of older adults. methods: this was a pilot quasiexperimental design study in which older adults completed six sessions of dynamic balance training using the virtualter serious game that uses the kinect sensor for motion capture. this game was developed by researchers from the federal university of rio grande do norte in brazil. the game consists of static and dynamic tasks for training balance. it involves stationary walk, lateral reaching and climbing steps up and down. it has phases with increasing the level of difficulty. the participants were evaluated before and after the program using the berg balance scale (bbs) and the short physical performance battery (sppb). t-test for dependent samples was used to analyze the pre vs. post data. results: twenty three participants participated in the study (age = ± ; sex = % women). the results indicate improvement in bbs scores (pre: ± ; post: . ± ; p = . ) and sppb scores (pre: ± ; post: ± ; p = . ). conclusion: playing the virtualter serious game improved balance in older adults. helen chan , duncan wong , cindy fan (( ) the nethersole school of nursing, the chinese university of hong kong, hk; ( ) silver yoga lab, hk) background: evidence showed that both frail and prefrail significantly increase the risk of developing or worsening disability in activities of daily living, poor quality of life and institutionalisation. yoga has been consistently reported as effective intervention in improving physical functioning in terms of balance, lower limb strength, mobility and body flexibility. objectives: to assess the feasibility of silver yoga in older adults and to examine the preliminary effects of silver yoga on their physical health. methods: this was a one group pre-test post-test study conducted in a community centre. people who aged and above, were mentally competent, home-living, and classified as prefrail based on physical phenotypes using fried criteria, were eligible to the study. the silver yoga class included eight . -hour weekly sessions delivered by two experienced yoga instructors with specialized training in silver yoga. senior fitness test (sft) was conducted to assess changes in physical health. paired t-test was used to compare the within-subject differences across -month time. results: a total of older adults were recruited. there were significant improvement in six dimensions of the sft, including upper extremity muscle strength, lower extremity muscle strength, upper body flexibility, lower body flexibility, agility and dynamic balance, and aerobic endurance (ps < . ). all participants except one completed the yoga programme, with high level of satisfaction. in addition to the effects of physical conditions, the participants also appreciated it as mind-soothing and relaxing. conclusion: the findings showed that silver yoga is well-received by older adults generally, with significant effects in improving their physical fitness. more rigorous study is needed to examine its effects in a longer term and also in a more holistic manner. ku leuven, leuven, belgium; ( ) physical activity, sports and health research group, department of movement sciences, ku leuven, leuven, belgium) background: with aging skeletal muscle tissue becomes less responsive to anabolic stimuli, eventually contributing to muscle wasting. inflammation is considered an important player in this age-related anabolic insensitivity. recent reports provide a promising role for omega- polyunsaturated fatty acids (ω- ) in (muscle) health, as they possess systemic anti-inflammatory properties and stimulate muscle anabolic signaling. objectives: we investigated whether ω- supplementation improves the systemic inflammation and muscular adaptations (i.e. strength, mass, molecular signaling) to resistance exercise in an elderly population. methods: twenty-three elderly ( - y; ♀) were randomized to receive either ω- (~ g/d) or an isocaloric amount of corn oil (plac) during weeks. after two weeks of supplementation, participants engaged in resistance exercise (re; x/week) for weeks. prior to and after completion of the intervention, muscle and blood tissue, parameters of body composition, muscle strength and functionality were assessed. results: upon re, -rm significantly improved in plac (+ . %) and in ω- (+ . %), irrespective of condition. isometric strength significantly improved in ω- (+ . %), but not in plac (- . %). muscle volume did not change following re. plasma crp levels decreased, though not non-significantly, in ω- (- . %), whereas only a small increase was observed in plac (+ . %). ω- supplementation nor re affected the muscle anabolic sensitivity (akt phosphorylation) in response to a protein bolus. conclusion: this study confirms that ω- pufas improve the gains in isometric but not in dynamic muscle strength upon re in elderly. however, this was not associated with changes in anabolic sensitivity or systemic inflammation. further analyses will investigate whether the ω- induced gains in strength can be related to systemic hormones or muscle molecular signaling (mtor signaling, inflammation). meera suresh, clarence chikusu, caroline goodger (nutrition and dietetics, st. peter's hospital, chertsey, uk) background: deconditioning is a common phenomenon in patients over years old in acute settings. it is well known that poor nutritional status has a major impact on adverse outcomes in frailty and can exacerbate sarcopenia ( ). currently, there is limited research exploring the impact of dietitians on optimising nutritional status in acute settings in older populations for frailty and sarcopenia. objectives: compare the impact of dietetic intervention on the change in frailty scores between a patient group (n= ; mean age . years) who received dietetic intervention (di) and a patient group (n= ; mean age . years) who did not receive dietetic intervention (ndi). methods: a -month retrospective study (august-december ) was undertaken at the older persons short stay unit at a district hospital in england. frailty scores were calculated based on the rockwood model of clinical frailty. dietary intake was recorded and analysed using a standardised nutritional profile of hospital meals. the di group was given standardised dietetic care including oral nutrition support and build up dietary advice. descriptive statistics were used to determine frequencies. results: the di had higher frailty scores (mean of . ; range: - ) and a higher mortality rate ( %).the ndi had a mean score of . (range: - ) and mortality rate of %. the average oral intake for energy and protein for patients in the di group prior to dietetic intervention was % lower than the espen recommendations. despite the higher frailty scores and mortality rates in the di group, progression in their frailty score was slower compared to the ndi group ( % vs %). conclusion: the results highlight the importance of a timely referral for early dietetic intervention which is crucial for optimisation of better clinical outcomes in these patients. a dietitian is a key member of the mdt and can prevent further deterioration in muscle mass and the impact on patients' frailty and independence and also slow down the progression of sarcopenia and frailty. this has long term impact on health and social services by reducing length of stay, hospital re-admissions and the increasing burden on social care. uz leuven, leuven, belgium) background: while the protein recommended dietary allowance (rda) for healthy adults is . g protein/kg bodyweight (bw)/day (d), expert groups recommend a protein intake up to . g protein/kg bw/d for older people with chronic diseases. in addition, at least - g protein (whereof at least . g of leucine) is recommended per meal. objectives: we aim to assess in (pre)sarcopenic older people the daily energy and protein quantity and quality intake, and their change due to supplementation. methods: dietary protein quantity, and quality (plant/animal source, amount of amino acids, amount of leucine and leucine distribution over a day) and dietary energy intake were calculated from four day estimated dietary records of (pre)sarcopenic participants of the enhance study (clinicaltrials.gov nct ) before and after a -week supplementation period. participants received an individualized protein supplement (resource® instant protein, nestlé) , to achieve a total (dietary + supplemental) intake of . g protein/kg bw/d. results: (pre)sarcopenic adults ( . ± . years, % female) had an average dietary protein intake of . ± . g/kg bw/d, which is higher than the rda, but below the . g/kg bw/d recommended by experts. (pre)sarcopenic adults were supplemented with protein powder, which improved the total protein intake to . ± . g/kg bw/d without affecting dietary protein or energy intake. moreover, supplementation increased the protein intake to at least g protein/meal without affecting dietary intake. more than % of dietary protein intake was of animal origin. leucine intake at baseline was insufficient at all meals, but increased to at least . g at lunch and dinner by supplementation without affecting dietary leucine intake. conclusion: community-dwelling (pre)sarcopenic older people do not reach the recommended protein intake proposed by expert groups. individualized protein supplementation results in adequate intake of protein without substantial change in dietary intake. nutrition and dietetics, internal medicine, amsterdam university medical centers, amsterdam, the netherlands) background: weight loss is a main treatment goal in obese older adults with dm . combined lifestyle interventions (cli) may be more effective in preserving muscle mass during weight loss. whether severe obese benefit similar to less obese is unknown. objectives: our probe-study showed an increase in muscle mass during cli in obese older adults ( +) with dm . do severe obese (bmi > kg/m ) benefit similarly to less obese. methods: in a post-hoc analysis, out of enrolled older adults had both body weight and protein intake data before and after a -month cli consisting of dietary advice (- kcal/day) and resistance exercise. a selection of assessments were appendicular skeletal muscle mass (asmm, by dxa), physical performance (wmax; by cycle ergometer steep ramp test), quality of life (rand- physical component summary score (pcs), visceral adipose tissue (vat, by dxa), crp, insulin sensitivity and resistance (matsuda, homa-ir; by ogtt), blood pressure (sbp, dbp). linear regression analysis was used with protein intake (g/kg, except for asmm being included in kg) as independent and assessments after -months as dependent (with assessment before intervention as confounder) for both groups bmi> (severe obese n= ) and bmi<= (n= ). results: mean age was , mean bmi was . , sex m/ f and protein intake during intervention was + gram/day. mean weight loss was - . + . kg and fat loss - . + . kg. per g protein intake increase + g muscle was preserved (p= . ). however, this appeared + (p= . ) vs + g (p= . ) for severe obese vs not severe obese. severe obese showed higher response for wmax (+ . + . (p= . ) vs - . + . ) and pcs (+ . + . (p= . ) vs - . + . ), for vat (- . + . (p= . ) vs + . + . ) and crp (- . + . (p= . ) vs + . + . ), for insulin sensitivity (matsuda + . + . (p= . ) vs + . + . ) and insulin resistance (homa-ir - . + . (p= . ) vs + . + . ), sbp (- . + . (p= . ) vs - . + . ) and dbp (- . + . (p= . ) vs + . + . ). while whole group and not severe obese group showed no significant effect. conclusion: these results suggest that severe obese might benefit even more from combined lifestyle intervention compared to less obese older adults with dm . further investigation is needed to confirm these findings and identify potential mechanisms. background: nutritional interventions have been shown to stimulate muscle protein synthesis. to optimize muscle mass preservation and gains, several factors, including type, dosage, frequency, timing, duration and compliance have to be considered. objectives: this systematic review and meta-analysis aimed to summarize these factors influencing the efficacy of nutritional interventions on muscle mass in older adults. methods: data sources: a systematic search was performed using the electronic databases medline, embase, cinahl, cochrane central register of controlled trials and sportdiscus, from inception date to nd november , in accordance with the prisma guidelines. inclusion criteria included randomized controlled trials, mean/median age >= years and reporting muscle mass at baseline and post-intervention; exclusion criteria included genetically inherited diseases, anabolic drugs/hormone therapies, neuromuscular electrical stimulation, chronic kidney disease, kidney failure, neuromuscular disorders and cancer. data extraction: extracted data included study characteristics (population, sample size, age, sex), muscle mass measurements (method, measure, unit) , effect of the intervention versus the control group, and nutritional intervention factors i.e. type, composition, dose, duration, frequency, timing and compliance. data analysis: standardized mean differences and % confidence intervals were calculated from baseline to post-intervention for the intervention and control group. a meta-analysis was performed using a random-effects model and grouped by the type of intervention. results: twentyeight articles were included encompassing participants (mean age . years, sd . ). amino acids, creatine, betahydroxy-beta-methylbutyrate, and protein with amino acids supplementation significantly improved muscle mass. no effect was found for protein supplementation alone, protein and other components, and poly-unsaturated fatty acids. high inter-study variability was observed regarding the dose, duration and frequency, coupled with inconsistency in reporting timing and compliance. conclusion: overall, nutrition alone is an effective intervention to improve muscle mass in older adults. due to the substantial variability of the intervention factors among studies, the optimum profile is yet to be established. background: physical and functional capacities decline with age. one new potential intervention is oral citrulline supplementation (cit) since cit seems to increase muscle protein synthesis, mass, size and strength, improve mobility but also decrease adipose tissue mass, particularly visceral depot in old rats. furthermore, exercise is known to be another efficient intervention. however, studies assessing cit supplementation combined or not with exercise on muscle function and mobility in older human adults are emerging and literature conclusions are needed to help health professionals. objectives: establish the potential effectiveness of citrulline supplementation combined or not with exercise on muscle function and physical performance via a systematic review of randomized controlled trials (rcts) in human aged years and older. methods: the preferred reporting items for systematic reviews and meta-analysis (prisma) statement has been followed. medline, cochrane central register for rcts and scopus databases have been searched. studies selection and data extraction have been performed by two researchers independently. methodological quality of each included studies was assessed using the quality assessment of diagnostic accuracy studies- (quadas- ) tool. results: based on prisma guideline, references have been identified. among this number, only rcts ( participants) matched the inclusion criteria (e.g rcts, age> yrs, human, cit supplementation, muscle or physical parameters) and were included in the systematic review. among these studies, / reported beneficial effects of cit on muscle mass. effects on muscle strength is reported on / studies but when cit is combined to exercise better improvements in upper muscle strength are observed. finally, / studies reported beneficial effect of cit on physical performance but suggested that cit with exercise displayed greater improvements in walking speed than exercise or cit alone. the overall quality of studies was rather high. conclusion: cit supplementation seems able to improve muscular and physical factors in specific elderly people (malnourished, women, hypertensive, obese, dynapenic-obese) compared to placebo. more importantly, cit with exercise is more efficient than exercise or cit alone. however, due to the small number ( ) and heterogeneity (dose, duration, population) of the studies, further investigations are needed to confirm its promising intervention for health professionals. background: the medical nutrition supplement fortifit (r), containing the specific nutrient combination actisyn™, is designed to support muscle building in sarcopenia (muscle loss). actisyn (whey protein, leucine and vitamin d) provides high bioavailability of leucine and essential amino acids for the muscle; the nutrients in actisyn act together to optimize the muscle protein synthesis response in a state of sarcopenia where these nutrients are often deficient. preclinical and acute human studies confirmed this mode of action. objectives: to demonstrate the longer-term effects of fortifit supplementation on muscle building in healthy and sarcopenic older adults and on muscle preservation in obese (diabetic) older adults during a weight-loss lifestyle intervention. methods: our clinical research program investigated the effects on muscle mass, strength and function in healthy and sarcopenic older adults and in obese and type diabetic patients. muscle mass was measured by dexa; strength and function by handgrip strength, -times chairstand test and short physical performance battery (sppb). all studies were randomized-controlled trials with an intervention duration of to weeks. results: a significant increase in appendicular lean mass and leg lean mass was observed in healthy older adults after weeks supplementation (p< . vs non-caloric control) [chanet, jnutr ]. in sarcopenic older adults, -week intervention increased appendicular lean mass ( . kg, %ci . - . kg; p= . vs iso-caloric control) [bauer, jamda ] . moreover, during a -week lifestyle intervention of energy restriction and resistance exercise training in obese older adults with or without type diabetes, fortifit preserved appendicular lean mass (p< . vs iso-caloric control) [verreijen, ajcn ; memelink, clin nutr ] . a significant improvement was observed in chairstand time after -week intervention in sarcopenic older adults (- . s, %ci - . to - . s; p= . vs isocaloric control), but improvements in handgrip strength and sppb (primary outcomes) were only significant versus baseline (p< . ) and not versus control [bauer, jamda ] . conclusion: the medical nutrition supplement fortifit effectively supports muscle building in healthy, sarcopenic and obese older adults. moreover, the improvement in chair-stand time observed in sarcopenic older adults is clinically relevant. background: chronic kidney disease (ckd) is commonly found in older persons and it affects the quality of life and economic burden. knowledge and health literacy have been reported as fundamental factors for persons with chronic illness to perform health behavior. however, from a literature review, relationships among knowledge, health literacy, and health behavior in older persons with non-dialysis ckd have rarely been reported. objectives: to examine relationships among knowledge, health literacy, and health behavior in older persons with chronic kidney disease. methods: nutbeam's conceptual framework of health literacy was used to guide the study. the sample recruited by purposive sampling consisted of older persons with non-dialysis stage to ckd, who sought healthcare services at a ckd clinic in a university hospital, thailand. data were collected by interviews using the questionnaires about the demographic data, knowledge about care of ckd, health literacy, and health behavior of older persons with ckd and then were analyzed using descriptive statistics and spearman's rho correlation coefficients. results: the sample consisted of men and women with their age ranging from to years (m = . , sd = . ). the analysis revealed that the sample had the mean scores of total knowledge about care of ckd, health literacy, and health behavior at a high level. health literacy was positively associated with health behavior (r = . , p = . ), but knowledge about care of ckd was not significantly associated with health literacy (r = . , p = . ), nor health behavior (r = . , p = . ). conclusion: only health literacy was significantly positively related to health behavior. although knowledge is fundamental of health literacy, it was not significantly related to health literacy nor health behavior in this study. it is explained that health literacy is the ability and skills that might link knowledge of individuals to perform behaviors. thus, healthcare providers should find strategies for enhancing health literacy of older persons with ckd to promote appropriate health behavior, thereby delaying complications. background: handgrip strength (gs) is linked to the vitality domain of the intrinsic capacity (ic) construct and is a marker of sarcopenia and frailty. low gs is a predictor of adverse health outcomes like disability onset and mortality. small increases in gs have been reported after exercise interventions, suggesting that life-course determinants rather than short-term determinants influence gs. objectives: to assess social inequality in the distribution of gs and the association of gs levels with a proxy of social determinants of health (sdh) among adults and older adults. methods: secondary analysis from wave ( - ) of the world health organization (who) study on global ageing and adult health (sage), which is nationally-representative of six countries, including , participants aged >= years and , < y. gs was computed in kg. wealth quintiles were assigned according to ownership of household assets. the last level of education of the participant and his/her mother was self-reported (the latter was used as a marker of early life sdh). social inequality was estimated using pairwise comparisons among the average of gs of the extreme social groups; and gradient inequality by the slope index of inequality (multivariate linear regression to adjust for age, sex, body mass index). estimations were weighted to consider the complex design of the sample. results: average gs was . kg for participants >= y and . kg for < y. participants >= y who reported a postgraduate level of education or higher showed % ( . kg) higher gs than their illiterate counterparts ( %, . kg, for participants < y). gs was on average % higher in participants >= y in the most top wealth quintile compared to those in the lowest quintile ( % in < y). in the multivariate models, gs was . kg higher in urban than rural participants and . kg higher among participants whose mothers had completed >= years of education compared to those whose mothers were illiterate. slope coefficients were significant after controlling for confounders. conclusion: grip strength displayed an unequal distribution among social groups and also among groups of early life exposures, which suggests that vitality as a domain of ic is shaped by the sdh and built through the life course. background: intrinsic capacity (ic) is the composite of the physical and mental abilities of an individual. the distribution and correlates of ic in older adults (oa) have not been reported using an integrative score with routinely-collected clinical data. it is not clear how ic is associated with multi-systemic biochemical age-related processes captured by alterations in standard clinical laboratory tests. objectives: to describe the distribution and correlates of ic in a population of older adults from the frailty day hospital of toulouse and to test its cross-sectional association with low or high haemoglobin or high crp, accounting for frailty status. methods: using routinely collected cross-sectional data of , first visits of oa aged + to the frailty day clinic of toulouse ( - ), we calculated an index of ic (biomarkers and validated scales for five who domains). low/high haemoglobin levels or high crp levels served as indicators of acute and middleterm multisystem disruption. we used descriptive statistics to learn the distribution of ic across sex, age, education and fried frailty categories. multivariate linear models were used to test the hypothesis that higher ic holds a negative association with the multi-system deficits depicted by altered laboratory tests. results: % of the population was female, and % was frail. our ic score has theoretical limits ( - ). overall, the ic was: mean= . ,sd= . ,min= . , max= . . on average ic men scored . (ic % . , . ) and women . (ic % . , . ). the relationship found between ic and age was not linear. frail older adults displayed % less ic than their robust counterparts and % less ic than their pre-frail counterparts. if frail oa would return to robust in this population, the average ic would potentially* rise %. disruption in haemoglobin or crp was inversely and significantly associated with the ic score after adjusting for age , sex, level of education and fried frailty status. conclusion: the population attending the toulouse frailty clinic displayed highly-heterogeneous ic levels, with frail oa showing significantly lower levels than robust oa. the association between ic and age is not linear. sex, age, education, frailty status and disruption in haemoglobin or crp levels were all significantly associated with ic in a multivariate model. background: older persons tend to be hospitalized increasingly because of the complex interaction among acute problems, age-related changed, and chronic diseases. qualified nursing care needs knowledge, understanding, and a positive attitude towards the care of older persons. however, little is known factors predict the caring behavior of nurses to care for hospitalized older persons. objectives: to examine the predictability of selected factors to explain intention to care and caring behavior for older persons of professional nurses. methods: the theory of reasoned action was used to guide the study. the proportionate stratified random sampling was used to recruit a sample of professional nurses from clinical wards providing care for older patients in a university hospital. data were collected using questionnaires and then, analyzed with descriptive statistics, pearson's product-moment correlation, and multiple regression analysis with the enter method. results: almost all of the sample were female, with their age ranged from to years (m = . ). factors related to professional nurses' intention to care were perceived caring climate in organization and attitude toward caring for older persons. also, factors related to caring behavior for older persons were perceived caring climate in an organization, intention to care, and attitude toward caring for older persons. through multiple regression analysis, perceived caring climate in an organization, attitude toward caring older persons, and basic knowledge about older persons jointly predicted . % of the variance in intention to care. together, perceived caring climate in an organization, intention to care, attitude toward caring for older persons, and basic knowledge about older persons accounted for . % of the variance in caring behavior for older persons of professional nurses. the perceived caring climate in an organization was the strongest predictor of caring behavior, whereas basic knowledge about older persons was not a significant predictor. conclusion: the findings support the notion of the theory of reasoned action. it is suggested that strategies to promote perceived caring climate in an organization, attitude toward caring for older persons, and intention to care should be established and maintained to promote caring behavior for older persons of professional nurses. background: environmental and social conditions play a major influence in the development and progression of negative health-related outcomes. they represent crucial elements when taking clinical decisions and planning the care plans of frail patients. nevertheless, they still often remain overlooked because priority is given to the clinical manifestations. objectives: the aim of this study is to explore the importance of social support in the definition of major health-related outcomes among hospitalized patients compared to other critical factors of older persons (i.e., frailty, age). methods: data were retrospectively collected from the medical records of patients aged years and older admitted to the geriatric unit of the fondazione irccs ca' granda ospedale maggiore policlinico (milan, italy). a -items frailty index (fi) was computed from clinical variables recorded during the first days of hospitalization (i.e., medical history, cognitive, functional and social assessment, physical examination, laboratory tests). mortality, length of hospital stay above the median, and risk of institutionalization were the outcomes of interest. results: we included patients (mean age . , sd . years, women . %). six patients died during the hospital stay ( . %). the median duration of hospital stay was (iqr - ) days. twenty-seven patients were discharged to other institutions ( %). the mean fi was . (sd . ). the fi showed a statistically borderline association with mortality (or . , % c.i. . - . , p= . ), and was predictive of longer length of stay (or . , % c.i. . - . , p= . ), even after adjustment for confounders. the presence of a caregiver was the only factor significantly associated with the discharge at home of patients (or . , % c.i. . - . , p= . ) at the multivariate analysis. age had no significant association with the three studied outcomes. conclusion: health systems should be organized according to an integrated model of care in order to adequately address the complex health needs of older people. social and environmental context plays a critical role in determining the person's health trajectory. social factors (as the presence of a caregiver) may play a stronger role in clinical decisions than biological or clinical aspects. background: the acute therapy team was formulated after the integration of an older persons assessment and liaison team (opal) with medical ward therapists. the team was spread across all acute areas. this team worked closely with the acute geriatric and frailty clinical team and it was recognised that length of stay, and improved patient experience and overall outcomes would be improved with earlier assessment and cga planning at the front door allowing closer collaborative working between the clinicians and therapists. objectives: to enhance service improvement and prevent the impact of sarcopenia and frailty syndromes leading to greater hospital stay and disability as a consequence of a delay to assessment by clinicians and therapists in the acute setting. through the screening of frailty syndrome risk and sarcopenia risk patients by the ed geriatrician and junior doctor, there would be a speedier response to therapy led interventions thereby reducing the conversion rate from ed and also therefore improving overall outcomes in length of stay and reduced disability through prolonged hospital stay. methods: consultant geriatrician and junior doctor (opssu team) to go to the emergency department in the mornings and see up to patients in cdu/a&e beds; the use of a the rockwood frailty score template identified those patients at risk of frailty syndrome and likely to benefit from early therapy intervention. these patients would have been highlighted as having the potential to be discharged within hours. a month data collection period from was chosen with data collected monday to friday only. data examined was categorised as follows: new patients, follow-ups; how many patients were seen on day of ed attendance vs after day of attendance?; number of patients seen by therapists same day of ed attendance number of patients not seen by therapists day of attendance; which team was looking after the patient from a clinically; how much time spent with patients; therapy led plan after initial assessment; an integrated assessment too was instrumental in the cga component of the therapy and clinical assessments. results: % of patients seen by therapists in ed are new patients referred. % of patients referred are seen on the actual date of ed attendance. the rest are seen later admission episode. % of therapy time is spent doing non-face to face tasks such as documentation. but up to % of patients have a discharge plan put in place after being seen by therapists in the ed. conclusion: a great deal of time is spent by therapists on documentation during assessment. this has a negative impact on the amount of time dedicated to clinical assessments and physiological and functional assessments required in the cga. there is a large number of patients referred by the clinical team to the therapists for review but a majority of patients are seen elsewhere during an admission episode and not in the ed. streamlined assessments and screening tools are recommended & planned for the future model of care. yi-chun cheng , li-ning peng , (( ) center for geriatrics and gerontology, taipei veterans general hospital, taipei, taiwan; ( ) aging and health research center, national yang ming university, taipei, taiwan) background: older people with frailty are at risk of adverse outcomes, such as falls, disability, hospital admission, long term care placement, poorer quality of life, and mortality, which denotes the importance of sarcopenia in the health care for older people, and integrated intervention program may prevent those. objectives: to evaluate the effectiveness of an integrated intervention program among those communitydwelling frail older people in north taiwan. methods: a total of participants over years old mild to moderate disability and mild cognitive impairment persons were recruited from a community-dwelling frail older people in north taiwan during august and july , frail older people were invited for the study. a weeks integrated intervention program was provided for all participants. they attended the hours program once per two weeks and physical activity, high protein diet education, and cognitive stimulation activity were included in the integrated intervention program. comprehensive geriatric assessments were performed before and after the intervention program, including basic demographic data, risk for malnutrition (by mna-sf), mood condition (by gds- ), cognitive condition (by mmse), weakness (by handgrip strength), exhaustion (by self-report in chs) slowness (by gait speed) and time-up-go test. pretest on the st week before intervention and post-test on the th week to compare the difference between twice evaluate consequence. results: overall, participants were identified as having pre-frailty ( . %) and frailty ( background: low appendicular skeletal muscle mass (asm), an integral component of current sarcopenia definitions, is commonly measured using bioimpedance analysis (bia). bia equations for estimation of asm are not generalizable across population groups and instrument types, potentially giving rise to inaccurate results when applied inappropriately. there is a lack of bia prediction equations for asian populations, none of which have been developed or validated for singaporean older adults. objectives: to develop a bia prediction equation for estimation of asm in communitydwelling older singaporean adults. methods: we studied healthy community-dwelling subjects (mean age . years) from the gerilabs- cohort. bia was performed using a single-frequency instrument. the reference method used for asm measurement was dual-energy x-ray absorptiometry (dxa). we first identified independent asm predictors by assessing the correlation of demographic, anthropometric and bia variables with dxa-measured asm. the best-fitting prediction equation was derived from these variables using stepwise (backward elimination and forward selection) linear regression with bootstrap validation. using asian working group for sarcopenia (awgs) cutoffs, we then compared anthropometric, strength and physical performance parameters between normal and low bia-derived asm groups. results: the derived bia equation incorporated predictorsimpedance index, weight, gender and body mass index (bmi), i.e. asm(kg) = . + ( . x impedance index) + ( . x weight) + (- . x gender) + (- . x bmi), where males = , females = and impedance index = height(cm )/resistance. the r and standard error of the estimate of this regression model were . and . kg respectively, with impedance index accounting for . % of its variability. individuals with low bia-derived asm have significantly smaller mid-arm and calf circumference and weaker grip strength, compared to individuals with normal bia-derived asm (p< . ). physical performance was similar in both groups. conclusion: we have developed a valid single-frequency bia prediction equation which can provide good estimates of asm in communitydwelling older singaporean adults. validation of this prediction equation in an independent sample of population is required to establish its accuracy and precision. ( ) faculty of sport sciences, waseda university, tokorozawa, japan) background: it has been well known that appendicular lean mass (alm) and skeletal muscle mass index (smi), which is the ratio of alm to height (m), is positively proportional to regional bone mineral density (bmd) in elderly men. however, there is limited information about these relationships in middleaged men. objectives: the purposes of this study were to investigate the difference in bmds (arms, lumbar spine, pelvis, legs, and subtotal: total body without head area) in middleaged men with low and normal smi (alm/height ≤ . kg/ m from asian working group for sarcopenia: awgs), and to determine the associations between alm, smi, and bmds. methods: three hundred and two middle-aged japanese men between and years of age participated in this study. alm and bmd measurements were taken using dual-energy x-ray absorptiometry (dxa, delphi a-qdr, hologic). results: based on the definition from awgs, the prevalence of low smi was approximately % in middle-aged men. the subjects with low smi (low smi group, n = , . kg/m ) had significantly lower body weight ( . vs. . kg), bmi ( . vs. . kg/m ), and fat mass ( . vs. . kg) compared to the normal group (n = , . kg/m ), although there were no differences in age ( vs. years), standing height ( . vs. . cm), and body fat percentage ( . vs. . %) between the two groups. bmds were significantly lower in low smi group than normal group for regional body parts (arms . vs. . g/cm ; lumbar spine . vs. . g/cm ; pelvis . vs. . g/cm ; legs . vs. . g/cm ) and subtotal ( . vs. . g/cm ). moreover, body weight, fat mass, alm, and smi were positively correlated with bmds using partial regression analysis controlling for age in all subjects, except for fat mass vs. lumbar spine bmd. in a stepwise multivariable model, alm was more closely related to bmds, except in the case of pelvis. conclusion: these results suggest that in order to maintain the regional bmd in middle-aged men, a key factor is to maintain or increase both alm and smi. background: the societies on sarcopenia have recently accepted the use of bioelectrical impedance analysis (bia) in the assessment of appendicular skeletal muscle mass (asm). several bia equations and devices have been introduced, which analyze the whole body composition, including the trunk and excluding the left arm and left leg at khz. it is necessary to measure the appendicular body segments of impedance parameters with a specific frequency (hz) that optimally analyze the muscle for valid assessment of asm. prior our study, literature-based bia equations and the two devices estimated asm at > % of r (coefficient of determination) with the significant constant-errors rated as «poor». objectives: thus, the aims of this study were ( ) externally cross-validate the equations and devices of bia on the appendicular skeletal muscle mass and ( ) develop valid equations based on appendicular bioimpedance parameters at the specific frequency (khz) that reflects the muscle for estimating asm; methods: community dwelling koreans over -year-old ( + . yrs, females and males) participated. asm was predicted using bia-based equations available in literature and bia devices and compared to dxa outcomes which is the gold standard. we conduct internal cross-validation and stepwise multiple linear regression to develop asmformulas with segmental multi-frequency bias. results: our new prediction formulas were developed by the appendicular impedance(z) index = height / (z of right arm + z of left arm + z of right leg + z of left leg)) at higher than khz and the appendicular reactance(xc) = xc of right arm + xc of left arm + xc of right leg + xc of left leg at khz. r s were over %, see wes under . kg of asm with the subject rating as «excellent» for men and «good» for women. conclusion: we found that our new protocol resulted in higher agreement with dxa and improved bia accuracy for this specific age group. clinicians can use this lower cost protocol and equations to better diagnose sarcopenia in larger cohorts with comparable to measurement of dxa. background: greater protein intake throughout the lifespan may be related to better body composition through the preservation of lean body mass during aging. objectives: we sought to determine whether an association between dietary protein intake (pi) and body fat percentage (bf) exists among women when controlling for dietary and lifestyle factors. methods: body composition and lean body mass were examined via dual-energy x-ray absorptiometry, grip strength (gs) was assessed using a hand grip dynamometer, and moderate-to-vigorous physical activity (mvpa) was measured by accelerometry. dietary intakes were estimated via threeday food logs and esha software. multiple linear regression and stepwise linear regression models were used. results: a total of women (mean ± sd; age . ± . years) finished all assessments. a full regression model (i.e., containing all covariates; r = . ; adjusted r = . ; f( , ) = . ; p < . ) was created using fat, carbohydrate, protein and leucine intake (g/day), protein quality (g/day of leucine over g/day of protein), energy intake (kcal/day), age (years), lean body mass (kg), bmi (kg/m ), gs (kg), and mvpa (min/day). only bmi (mean ± sem; beta = . ± . ; p < . ), gs (mean ± sem; beta = - . ± . ; p < . ), and pi (mean ± sem; beta = - . ± . ; p = . ) were significant to the full regression model. to verify their importance, a stepwise regression using the same variables was performed and resulted in a model (f( , ) = . ; p < . ; r = . ; adjusted r = . ) that included bmi (mean ± sem; beta = . ± . ; p < . ), gs (mean ± sem; beta = - . ± . ; p < . ), and pi (mean ± sem; beta = - . ± . ; p = . ). conclusion: greater protein intakes are associated with lower bf in women when controlling for various covariates. we theorize that greater protein intakes preserve lean body mass which results in improved body composition. more specifically, a one gram per day increase in dietary protein is predicted to decrease bf by . % when controlling for all other variables. background: muscle aging and the increased prevalence of obesity in the geriatric population create a new area of research: sarcopenic obesity. in prospective cohorts of nonhospitalized subjects, it is associated with an increased risk of developing physical limitation. hospitalization is an event with high risk of loss of independence. the impact of sarcopenic obesity during this episode isn't known yet. objectives: analyze the evolution of functional independence during a hospitalization in an acute geriatric ward, looking for a link between the presence of sarcopenic obesity and a decline of independence. early readmission, length of stay and changes in body composition during hospitalization were also examined. methods: prospective descriptive monocentric cohort study carried out in an acute geriatric ward of the pau hospital. sarcopenia was diagnosed using the european working group on sarcopenia in older people algorithm by an impedancemeter. a bmi over was used to report obesity. functional independence was rated on the adl katz scale. results: patients were included. sarcopenic obesity was diagnosed in . % of cases, sarcopenia and obesity in % and % of patients, respectively. the greatest variation in functional independence during hospitalization was observed in sarcopenic obese patients (mean variation of out of points, p= . ). a total of early readmission at month were counted, with the highest rate for sarcopenic obese ( %, but % at the sample level) (p= . ). the average length of stay was . days. conclusion: sarcopenia is common in patients hospitalized in geriatrics, and when associated with obesity, there is greater variation in functional independence and more readmissions. background: known that is sarcopenic obesity, excessive accumulation of adipose tissue is detected, with a decrease in muscle mass and strength, which is already over the age of years. modern diagnostic methods have their drawbacks for the diagnosis of sarcopenic obesity. bodpod quality and timeliness of diagnosis of signs of sarcopenia in obese patients is improved, which ultimately will contribute to an earlier targeted treatment of sarcopenia and an improvement in its prognosis. bodpod methodology can be recommended for use in complexes for the diagnosis of sarcopenic obesity. objectives: to compare the effectiveness of three methods of body composition assessment such as bioimpedans analysis (bia), air-replacement bodyplatismography (bodpod) and dual x-ray absorptiometry total body program (dxa total body) in the verification of reducing of skeletal muscle mass as sign of sarcopenic obesity in obese patients. methods: the study group included patients aged - y.o. (average age , ± , years) with bmi>= . kg/m . the control group included patients aged - y.o (average age , ± , years) of the same age without obesity with bmi . - . kg/m . body composition was tested using bia, bodpod and dxa with calculating fat, lean and skeletal muscles mass (kg) and % in all the patients. (bodpod) is the most sensitive in the verification of skeletal muscle mass reduction in obese patients. this method shows that patients with obesity have a significantly reduced muscle mass compared with normal weight or overweight subjects. background: in overweight and obesity excess energy and changes in body composition may favor the onset of metabolic derangements. combined with excess adiposity, the age-related decline in lean body mass can accelerate the development of insulin resistance and the consequences in terms of cardiovascular risk. objectives: the aim of our study was to investigate the association between the phenotype of sarcopenic obesity and cardio-metabolic risk in postmenopausal women. methods: postmenopausal women were recruited among subjects admitted to the high specialization centre for the care of obesity (casco), at the sapienza university, rome, italy. fat mass (fm) and fat-free mass (ffm) were assessed by dxa. obesity was defined as body fat >= %. appendicular skeletal muscle mass (asmm) was calculated. sarcopenia was defined as asmm/weight < sd than the sex-specific mean of a young population. the cut-point was asmm/weight< . . the lipid accumulation product was calculated: lap = (waist circumference cm - ) × triglycerides mmol/l]. the estimated glucose disposal rate (egdr) was calculated. high-sensitivity c-reactive protein (hs-crp) was measured. results: women were included (age: . ± . years, bmi: . ± . kg/m ). sarcopenia was diagnosed in . % of study participants. sarcopenic obese women were older than nonsarcopenic women ( . ± . vs. . ± . years, p= . ). lap was higher in sarcopenic obese women compared to their nonsarcopenic counterparts ( . ± . vs. . ± . , p= . ) after adjustment for age, body fat, and hs-crp levels. estimated gdr was significantly lower in sarcopenic obese women ( . ± . vs. . ± . , p= . ) after adjustment for age and body fat. an inverse association emerged between the index of sarcopenia, asm/weight, and lap (beta: - . * - , se: . * - , p= . ), independent of age, body fat, and hs-crp levels. a positive association was observed between asm/weight and egdr (beta: . * - , se: . * - , p= . ) adjusting for age, body fat, and hs-crp levels. conclusion: postmenopausal sarcopenic obese women exibithed a high lap and a low egdr, indicating increased cardiometabolic risk and decreased insulin sensitivity, respectively. l e a t h a a . c l a r k , , , todd m. manini , nathan p. wages , , janet e. s i m o n , , d a v i d w . r u s s , , b r i a n c . c l a r k , , , ( ( ) background: muscle weakness strongly contributes to mobility limitations and physical disability. the role of neural mechanisms contributing to age-related weakness have not been fully delineated to sufficiently target interventions that enhance strength and physical function in older adults. objectives: we sought to compare differences in voluntary inactivation and measures of motor corticospinal excitability in older adults with clinically meaningful muscle weakness compared to young adults and stronger adults without muscle weakness. methods: maximal voluntary isokinetic and isometric leg extensor strength, electrical stimulation of the leg extensors, and transcranial magnetic stimulation (tms) of the motor cortex were performed in older adults and young adults. outcome measures of leg extensor strength relative to body weight, voluntary inactivation (via), motor evoked potential (mep) amplitude and silent period (sp) duration during isometric leg extension contractions at %, %, and % of maximum voluntary contraction (mvc) were obtained. older adults were classified into three weakness groups based on previously established isokinetic leg strength/ body weight cut points (severely weak, moderately weak, or not weak). group differences were examined after controlling for sex. results: the older adults had % lower isokinetic strength/body weight when compared to the young adults. the severely weak older adults were % and % weaker than the moderately weak and older adults who were not weak, respectively. severely weak older adults exhibited higher levels of leg extensor via than older adults who were not weak ( . + . % vs. . + . %). severely weak older adults exhibited % longer sp's compared to the older adults who were not weak, but this difference was not statistically significant (p= . ). the severely weak older adults' mep's were approximately half the amplitude of the older adults who were not weak. regression analyses demonstrated that mep amplitude and sp duration -indices of hypoexcitability-were associated with relative strength. conclusion: weak older adults have significant deficits in their nervous systems' ability to fully activate their leg extensor muscles. additionally, motor corticospinal hypoexcitability is associated with age-related weakness, suggesting that interventions targeting the nervous system could be used to enhance muscle strength and prevent future health risks in older adults with muscle weakness. model. results: we evidenced oxidative stress in a mouse model of the pathology at different ages ( , and months) and aimed to identify the consequences of opa inactivation on redox homeostasis. increased ros levels were observed in cortices of the murine model opa +/-as well as in opa down-regulated cortical neurons. this increase is associated to a decline in mitochondrial respiration and an increase of antioxidant enzyme levels. upon exogenous oxidative stress opa -depleted neurons did not further up-regulated antioxidant defenses. finally, low levels of antioxidant enzymes were observed in fibroblasts from patients supporting their role as modifier factors. moreover, the simulations obtained with our mathematical model of complex i are able to reproduce biological experiments of quantification of ros production by complex i. conclusion: our study shows: (i) the prooxidative state induced by opa loss can be considered as a pathological mechanism (ii) differences in antioxidant defenses can contribute to the variability in expressivity and (iii) antioxidant defenses can be used as prognostic tools to gauge the severity and the evolution of the disease. (iv) furthermore, our mathematical model model of ros porduction by complex i will help to understand the dysfunctions of oxidative metabolism in opa gene related disorders. we will present the last results of our algorithm and wet laboratories experiments. amanika kumar, deepa m narasimhulu, michaela e. mcgree, amy l.weaver, aminah jatoi, nathan k lebrasseur (mayo clinic, rochester, mn, usa) background: patients with advanced ovarian cancer (eoc) are often frail and require multi-agent chemotherapy. objective: to evaluate the relationship between frailty and adjuvant chemotherapy tolerance and toxicity among women with advanced epithelial ovarian cancer. methods: women who underwent primary debulking surgery for stage iiic or iv eoc and received adjuvant chemotherapy at the same institution were identified. a frailty deficit index (fi) was derived from items representing comorbidities and activities of daily living. frailty was defined as a fi ≥ . . if data were unavailable for frailty index calculation, patients were excluded. relative dose intensity (rdi) for carboplatin and paclitaxel was calculated as the percentage of the standard dose that was actually administered and compared between frail and non-frail using the wilcoxon rank sum test. results: of the women who met inclusion criteria, . % ( / ) were frail. frail women were older ( . vs . years, p= . ), had a higher bmi ( . vs . kg/m , p= . ), and were more likely to have american society of anesthesiologists (asa) score ≥ ( . vs . %, p= . ) compared to nonfrail women. frail patients were less likely to complete cycles of adjuvant chemotherapy, ( % versus %, p< . ). despite the decrease in total cycles of chemotherapy, we did not observe significant differences in dose delays ( . vs. . %), dose reductions ( . vs . %), and severe neutropenia ( . vs. . %) between frail and non-frail women. we analyzed a subset of patients ( frail and non-frail) women received both intravenous carboplatin and paclitaxel. we observed that frail women were less likely to have a carboplatin rdi of % or higher ( . % vs. . %, p< . ) and less likely to have a paclitaxel rdi of % or higher ( . % vs. . %, p= . ). conclusion: frail women with advanced eoc undergoing adjuvant chemotherapy receive reduced rdi and are less likely to complete cycles of chemotherapy despite no increase in dose reduction, delays, and neutropenia. physician bias and patient choice may influence chemotherapy intensity decisions. further studies are needed to explore the association between frailty, chemotherapy, and survival. background: gait speed is a core component of physical frailty (pf) and, as a single measure, is correlated with important health outcomes, including mortality. immune dysregulation has been previously associated with pf -including increased il- production in peripheral blood mononuclear cell (pbmc) lipopolysaccharide (lps) stimulation assays. it is not known whether gait speed is associated with lps-stimulated cytokine production. objectives: this pilot study evaluated whether gait speed is correlated with dysregulated immune response in two populations of older adults undergoing procedures -knee osteoarthritis (oa) scheduled for knee replacement, and chronic kidney disease (ckd) approaching hemodialysis initiation. methods: older adults with ckd and older adults with knee oa underwent preoperative evaluation including gait speed (usual pace, -meter walk, best of two trials) and immune stimulation testing (in vitro, thawed pbmcs stimulated with lps at doses , . , and ug/ml, with il- quantified by elisa at , , , and hours; reported as area under the curve (auc)). correlation coefficient and p-value were calculated. results: for ckd, the il- auc of lps stimulated pbmcs was negatively associated with gait speed (lps . ug/ml r = - . , p= . ; lps ug/ml r= - . , p= . ). for oa, the correlation between il auc and gait speed was positively correlated for lps dose . ug/ml (lps . ug/ml r = . , p= . ; lps ug/ml r= . , p= . ). none of these associations were statistically significant. similar results were obtained when age was included as a covariate. conclusion: in people with ckd, increased cytokine production was correlated with decreased gait speed. in people with knee oa, results do not support this hypothesis. further studies with larger sample size are warranted. for participants with knee oa, future studies should account for severity of knee pain at time of gait speed assessment. background: skeletal muscle drives fuel utilization, and carbohydrate (cho) is a major fuel source. metabolic flexibility describes the ability to balance cho and fat oxidation efficiently in response to changes in metabolic demands or conditions. despite its role in long-term metabolic health, little is known about cho oxidation or metabolic flexibility in sarcopenic older adults. objectives: to examine resting metabolism and metabolic flexibility from a fasted to fed state after a cho-rich meal in sarcopenic versus nonsarcopenic older adults. methods: twenty-two men and women (age ± sd= ± y) were enrolled into this pilot study with either normal (non-sarcopenic, n= ) or low (sarcopenic, n= ) handgrip strength, gait speed and relative skeletal muscle index. resting metabolism was assessed in a fasted state at baseline, and metabolic flexibility was assessed after ( min, post-prandial) consuming a meal containing g of fat, g of protein, and g of a rapidly-digestible cho. respiratory quotient (rq), cho, and fat oxidation were measured with open-circuit spirometry, indirect calorimetry. fat and fat-free mass were measured with dual x-ray absorptiometry. blood glucose was assessed from venous samples using glucose oxidase methodology. results: rq was - % higher (p= . - . ) in sarcopenic participants throughout the experiment. after adjusting for fat-free mass, fat oxidation was % lower (p= . ), while cho oxidation was % higher (p= . ) at baseline for sarcopenic men and women. sarcopenic participants also exhibited delayed and limited (p< . ) postprandial increases in cho oxidation, despite greater (p< . ) increases in blood glucose. conclusion: sarcopenic individuals are more reliant on cho and less reliant on fat oxidation than non-sarcopenic adults, which is generally consistent with poorer metabolic health. when compared to non-sarcopenic adults, sarcopenia delayed and truncated cho utilization after a meal, indicating impaired metabolic flexibility in this population. impaired metabolic flexibility could be a mechanism underlying the losses of strength and physical function accompanying sarcopenia. anton de spiegeleer , , , hasan kahya , , nele van den noortgate , evelien wynendaele , tine decruy , srinath govindarajan , dirk elewaut (( ) unit for molecular immunology and inflammation, vib-center for inflammation research, ghent, belgium; ( ) department of geriatrics, faculty of medicine and health sciences, ghent university hospital, ghent, belgium; ( ) drug quality and registration (druquar) group, faculty of pharmaceutical sciences, ghent university, ghent, belgium) background: acute and chronic muscle wasting represent an important unmet clinical health problem. most pathophysiological studies suggest an effect of the immune system, primarily through catabolic cytokine productions such as il- . also endoplasmic reticulum (er) stress is considered to be an important pathway favouring muscle wasting. er stress in turn plays an important role in innate-like t cells, particularly invariant natural killer t cells (inkt cells), by controlling their cytokine production [govindarajan et al., nat. commun. ]. as such we reasoned that inkt cells may play a pivotal role in muscle homeostasis through their excessive cytokine production. previous studies have already highlighted the importance of these cells in a wide range of diseases such as cancer and metabolic disorders such as obesity. objectives: the aim of this study was to investigate the in vivo role of inkt cells in muscle homeostasis. methods: we compared wild-type (wt) versus inkt cell depleted mice (jα ko) for clinical, histological and gene expression differences in lower limb skeletal muscle. results: interestingly, we found that inkt cell depleted mice (jα ko) had a lower relative muscle weight, i.e. a muscle wasting phenotype, compared to wt mice. this clinical muscle wasting was associated with a decrease in oxidative enzymatic activity (succinate dehydrogenase histology). moreover jα ko mice showed a decreased transcription of genes involved in skeletal muscle growth and differentiation (follistatin and myogenin), sarcomere assembly (myosin- ) and neuromuscular junction function (neuronal acetylcholine receptor subunit alpha- ). conclusion: taken together, our results suggest a role for inkt cells in muscle wasting diseases and put innate-like t cells at the centre stage of immune cells controlling skeletal muscle biology. a r m a n d a t e i x e i r a -g o m e s , , s o l a n g e costa , , bruna lage , , dietmar fuchs , vanessa valdiglesias , , blanca laffon , joão paulo teixeira , ( ( ) background: frailty is a multidimensional geriatric syndrome characterised by increased vulnerability and functional decline that may be reversed if addressed early. it has been identified to be the most common condition leading to disability, institutionalisation and death in older adults. despite its known biological basis, no particular biological trait has been consistently associated with frailty syndrome so far. objectives: on this basis, the main objective of the present work was to evaluate the possible association between immunological: biomarkers and the frailty status in a group of community dwellers. methods: a group of older adults (>= years old) was engaged in this study. frailty status was assessed via fried's frailty model. the levels of several immune activation molecules -neopterin, tryptophan, kynurenine -were analysed. results: the classification of the study population was . % robust, . % pre-frail and . % frail. no significant differences were found between robust and pre-frail groups regarding serum concentrations of neopterin. although, the kynurenine/tryptophan ratio was significantly higher in pre-frail individuals as compared with robust subjects. conclusion: the preliminary data obtained suggest the activation of immunobiochemical pathways and are in agreement with previous studies that report alterations of the immune response in frail older adults. nevertheless, further investigation is encouraged and required to consistently demonstrate these findings. in future studies physical activity, nutritional, psychological, sociological and clinical features should also be considered when evaluating changes in immune biomarkers and frailty. the work developed by armanda teixeira-gomes and solange costa is supported by fct under the grants sfrh/bd/ / and sfrh/ bpd/ / , respectively. vanessa valdiglesias was supported by beatriz galindo research fellowship beagal / . background: frailty and hemoglobin count, above what would be considered clinical anemia, are two common findings in older patients and lead to an increased risk of negative health outcomes. objectives: evaluate whether hemoglobin concentration is an independent predictor of frailty and investigate possibe causal pathways in particuliar the relationship between inflammation and nutrition with hemoglobin concentration. methods: communitydwelling participants aged years or older who visited the toulouse frailty clinic between and were included in this analysis. patients underwent a comprehensive geriatric assessment and had a blood sample. a series of multivariate logistic regression models were perfomed after minimizing potential influence from age, gender, kidney function, inflammation, cognition, nutritionnal status and certain socioeconomic factors. results: hemoglobin count and frailty are significantly associated after minimizing potential influence from other covariates (p< . ). an increase in one point of hemoglobin concentration is associated with a % risk decrease of being frail (or= . , %ic= . - . ). there were no evidences of significant impact of inflammation and nutritional status in the relationship between hemoglobin concentration and frailty status (p> . ). conclusion: hemoglobin concentration is strongly associated with frailty in older adults. these results can have potentially important implications for prevention policies targeting frailty, by identifying potential patients with high risk of adverse outcomes and functional outcomes. juliette tavenier , line jee hartmann rasmussen , jan nehlin , morten baltzer houlind , aino leegaard andersen , ove andersen , janne petersen , , anne langkilde ( ( ) background: chronic inflammation is thought to be involved in the development of frailty. we hypothesized that increased monocyte inflammatory activity plays a role in chronic inflammation and thereby in frailty. objectives: to study the potential role of chronic monocyte inflammatory activity in frailty. methods: two groups of elderly adults (>= years) were included: patients with a recent admission to the emergency department (ed) and age-and sex-matched controls, without recent ed admission. data was collected at baseline and after year. participants were considered frail if they had or more of the following: hand grip strength ≤ kg for men or ≤ kg for women, gait speed ≤ . m/s, unintentional weight loss of > kg within the last months. frailty was also assessed using the frailty index (fi)-outref. we measured cognitive function (mini mental state examination -mmse) and chronic inflammation (soluble urokinase plasminogen activator receptor -supar). monocyte inflammatory activity was assessed by nf-κb phosphorylation (pnf-κb) using flow cytometry. results: participants had a mean age of . years (range: . - . ) and % were women. preliminary results show that at baseline, the patient group had a greater proportion of frail individuals compared to the control group ( vs. , p< . ). fi-outref was on average . points higher (p< . ) and supar levels % higher (p< . ) in the patient group, however, there was no difference in mmse score between the groups (p= . ). at year, although the proportion of frail individuals decreased in the patient group, it was still greater than in the control group ( vs. , p= . ). fi-outref remained elevated in the patient group (p= . ), but there was no difference in supar levels (p= . ). pnf-κb was positively associated with age in the control group (p= . ), but not in the patient group (p= . ). pnf-κb was % higher in the patient group compared to the control group (p< . ), and this was unchanged when adjusting for frailty, supar, and mmse. conclusion: the patient group was more frail and had elevated monocyte inflammatory activity compared to the control group. however, none of the frailty measures were confounders for the difference in monocyte inflammatory activity between groups. background: aging is most often accompanied by a loss of body weight: a decrease of fat deposits and muscle body weight. body mass index (bmi) in adults is considered normal if it is in the range of . to . kg / m (according to the who classification). bmi is widely used in the diagnosis of obesity. the association of bmi and cardiovascular and cerebrovascular diseases is known. objectives: the purpose of research is to identify the relationship of bmi with physical abilities and cognitive functions in long-livers. methods: long-living subjects aged . ± . years were examined. in long-livers, height, body weight were measured, calculated bmi. the level and direction of cognitive disturbances was determined by the mmse test (mini mental state examination). physical abilities were determined by the questionnaire and physical tests (tests the muscular strength in forearms and of the hands, chair stand test). results: bmi in long-livers had a normal distribution. the median bmi was . kg / m , the minimum value was . kg / m , and the maximum value was . kg / m . . % of long-livers had a bmi ranging from . to . kg / m . . % of long-livers have lost weight during the past year, including . % by kg or more. . % of long-livers could stand up of the chair. however, only . % of long-livers were able to complete the test correctly. amongst them, . % had a normal bmi. indicators of muscular strength in forearms and of the hand in long-livers who completed the chair stand test were significantly higher compared to long-livers who did not completed the chair stand test (r = . , p < . ). bmi had a positive correlation with the ability of a long-lived to wash without anyone's help (r = . , p < . ), go up and down the stairs (r = . , p < . ), do light housework (r = . , p < . ). mmse indicators also positively correlated with bmi (r = . , p < . ). the average mmse . ± . was observed with average bmi . ± . . conclusion: against the background of a decrease in the bmi indicator in long-livers, a decrease in physical abilities and cognitive functions is observed. however, there is a problem in determining the boundaries of the ratio of height and body weight for elderly people. in all likelihood, there are not linear, but more complex dependencies between bmi and functional abilities of long-livers. suparb aree-ue , inthira roopsawang , jansudaphan boontham , surinrat baurangtheinthong , yuwadee phiboonleetrakun (( ) ramathibodi school of nursing, faculty of medicine ramathibodi hospital, mahidol university, bkk, thailand; ( ) faculty of graduate studies, mahidol university, bkk, thailand) background: depressive symptom results in increasing poor outcomes and care dependency in older adults. the prevalence of depressive symptoms is common with its associated multiple factors. however, this conundrum problem is underestimated, particularly in older people living in rural areas. to promote healthy aging, understanding of the conundrum problem is essential in strengthening care quality and enhancing the quality of life in this population. objectives: to determine the relationships of the number of medication use, pain, frailty, and locomotive syndrome and their effects on depressive symptoms among community-dwelling thai older adults. methods: a cross-sectional study was employed. the sample consisted of community-dwelling thai older adults who met the inclusion criteria. data were assessed by using demographics questionnaire, thai version -question geriatric locomotive function scale: glfs- ; numeric rating scale; the reported edmonton frailty scale: refs-thai version; and the -item geriatric depression scale, tgds- . a path analysis was employed to determine the pathways linking the number of medication use, pain, locomotive syndrome, frailty to influence depressive symptoms. results: there were significant positive direct paths from pain (beta = . , p <. ) to locomotive syndrome and from locomotive syndrome to the number of medication use (beta = -. , p <. ). an inversely, the locomotive syndrome was a negative significant direct to depressive symptoms (beta = -. , p <. ). pain had an indirect effect on depressive symptoms (beta = -. , p <. ). additionally, the model explained . % of the variability in depressive symptoms. conclusion: the locomotive syndrome is a major factor influencing depressive symptoms. the complex relationship among pain, number of medication use, locomotive syndrome, and depressive symptoms should be taken into account for designing an appropriate intervention to reduce depressive symptoms among community-dwelling thai older adults. background: total knee arthroplasty (tka) is a clinical curative treatment for severe knee osteoarthritis. however, the outcomes are differences in each patient's perception. preoperative patients' expectations to functional abilities are one of important factors influencing on postoperative outcomes and satisfaction. objectives: to investigate the association among preoperative patients' expectations, postoperative functional abilities, and satisfaction to functional abilities among older adults undergoing tka at -week after surgery. methods: participants were older adults who were diagnosed with knee osteoarthritis and required to receive tka at a university hospital in bangkok, thailand. the sample was purposely selected based on the following criteria: were aged years or over, received tka for the first time, and had no cognitive impairment. the data were collected at preoperative and postoperative tka by using the demographic data questionnaire, the hospital for special surgery knee replacement expectations survey, and the knee and osteoarthritis outcome score in the part of function in daily living (koos adl) thai version. the data analysis was performed by using descriptive statistics, paired t-test, and pearson product moment correlation coefficient. results: before surgery, patients' expectations to postoperative functional abilities had a high level with the total mean score of . (sd = . ), and the item of improving ability to walk in a short distance was rated as the highest expectation. at -week after surgery, the overall functional ability had a significant improvement (t = - . , p = . ). satisfaction to functional ability also had a high level (mean ± sd = . ± . ), and the improving ability to walk in a short distance item had the highest. patients' expectations to functional abilities had a significantly low positive correlation to postoperative functional ability and satisfaction (r = . , p < . ; r = . , p < . , respectively). moreover, there was a significant moderate positive correlation between functional abilities and satisfaction to functional abilities (r = . , p < . ). conclusion: a better understanding of expectations may be beneficial in gaining knowledge, paving expectations on possible outcomes, and developing trust resulting in enhancing quality of care for thai older adults undergoing tka. background: identifying low muscle strength is a key step in many operational definitions of sarcopenia including the one recently proposed by the european working group on sarcopenia in older people- (ewgsop ). grip strength is widely used to identify people with low muscle strength. however, it is unclear what impact variation in the type of hand-held dynamometer used to measure grip strength has on the prevalence of low muscle strength. objectives: we aimed to assess the impact of estimated differences of between and kg in the measurement of grip strength when using different types of hand-held dynamometer on the case-finding of low muscle strength. methods: study participants were men and women aged - from a randomised, repeated measurements cross-over trial. maximum grip strength was assessed using four hand-held dynamometers (jamar hydraulic; jamar plus+ digital; nottingham electronic; smedley) in a randomly allocated order. ewgsop recommended cutpoints (< kg men; < kg women) were applied to estimate prevalence of low muscle strength for each device. agreement between devices was assessed using kappa statistics. results: prevalence of low muscle strength varied by dynamometer type ranging between % and % for men and, % and % for women. of the men identified as having low muscle strength by at least one of the four dynamometers, only % were identified by all four and % by just one. of the women classified as having low muscle strength by at least one of the four dynamometers, only % were identified by all four and % by only one. when comparing pairs of devices, kappa statistics ranged from . to . suggesting poor to moderate agreement. conclusion: case-finding of low muscle strength is influenced by the type of hand-held dynamometer used. it is important to identify the sources of variation in the measurement of grip strength and consider the implications of these for sarcopenia. further research is required to understand how best to standardise the assessment of each of the different components of commonly used operational definitions of sarcopenia and take account of sources of variation in these measures where standardisation cannot be achieved. background: sarcopenia is characterized by a progressive loss of skeletal muscle mass and strength associated with mortality and severe adverse events on health. for a healthy aging, the quality of life (qol) is essential and it is associated to autonomy of persons, social relations, and socioeconomic factors. objectives: to compare the qol of chilean older people with sarcopenia living in santiago de chile, according to an adapted version of the european working group on sarcopenia. methods: community-dwelling older people (mean ± sd: . ± . years; . % females) were interviewed, registering self-reported chronic diseases and the questions of short-form- health survey (sf- ). anthropometry, dynamometry and physical performance were measured. qol was measured using sf- , validated in chilean older adults. norm-based score of subscales and two summaries components -mental and physical (mcs and pcs; respectively)-were calculated using the chilean-specificscoring for older people. low score was defined as having a score ≤ th percentile of mcs and pcs. logistic regressions were estimated. results: sarcopenia was identified in . % of the sample ( . % women; . % men; p= . ). the average score of the subscales were significantly higher in non-sarcopenic adults than sarcopenic. the average of mcs and pcs were also significantly higher in non-sarcopenic adults than sarcopenic (mcs: . vs . ; p= . ; respectively; pcs: . vs . ; p< . ; respectively), and were significantly higher in men than women non-sarcopenic (mcs: . vs . ; p= . ; respectively; pcs: . vs . , p= . ; respectively). there were non-significant differences in sarcopenic adults by sex. logistic regressions demonstrated an association between sarcopenia and low mcs and pcs (or = . ; %ci: . - . ; or = . ; %ci: . - . ; respectively), adjusted by age, sex, multimorbidity, body mass index and lean/fat mass ratio. conclusion: sarcopenia was associated with a worse quality of life, which shows the impact of this pathology and the importance of developing programs for its prevention, delay or reversal. funded by fondef i p -munich sarcopenia registry (idsar): first results. uta ferrari , , marina schraml , ralf schmidmaier , , navina röcker , , sigrid adler-reichel , , christian lottspeich , , martin bidlingmaier , , benedikt schoser , , sabine krause , , martin reincke , , michael drey , (( ) department of medicine iv, university hospital, lmu munich, germany; ( ) friedrich baur institute at the department of neurology, university hospital, lmu munich, germany; ( ) preventive geriatrics study group, germany) background: since sarcopenia can be coded as disease in germany (icd-gm . ). in the same year we established the first sarcopenia registry linked with a biobank to identify modifiable, crucial risk factors for sarcopenia and its adverse outcomes. objectives: objectives of the registry are (i) how to optimize and standardize the diagnosis over in-and outpatient settings for musculoskeletal health, (ii) identification of clinical and molecular modifiable risk factors (iii) improvement of interdisciplinary treatment and prevention of sarcopenia as a new icd-code-based geriatric syndrome here we present the design as a practical approach for diagnosis in out-and inpatient care and a first descriptive analysis of influencing factors and comparison between in-and outpatients data. methods: patients older than years of age from outpatient clinic and acute geriatric ward at munich university hospital were consecutively screened by the sarc-f questionnaire. patients with high risk (sarc-f score >= ) were further assessed for sarcopenia in line with the european consensus definition (ewgsop ). among further factors assessed in the registry, we retrieved presence of further comorbidities, daily medication, nutritional status, sppb, frailty, and quality of life. results: at time of analysis, patients have been screened and within the first patients with high risk ( % women) % had sarcopenia. patients screened positive for sarcopenia have lower quality of life, even in a subclinical condition (mean euroqol (eq d-vas) = . ± . ). lower bmi ( . ± . , p= . ) and sex (p= . ) were statistically significant different for sarcopenia status, but not age (mean . ± . years, p= . ) or number of medication (p= . ) and comorbidities (p= . ). but the latter two were the most significant factors for inpatient status (both p< . ). the results underline the need for an early screening for sarcopenia in all patients older than years of age, suggested by hand grip strength in inpatients and sarc-f for outpatients. sex differences and further laboratory factors are necessary to add in sarcopenia diagnosis for precision medicine approaches. hospitalised older adults. we consider acute sarcopenia to be the last remaining acute organ insufficiency, with potentially devastating impact on function. characterising this condition will enable development of targeted interventions to ameliorate these changes. mobility disability, and incident mobility disability over . + . years. factor was associated with incident and prevalent mobility disability only, and factor was associated with only prevalent mobility disability. conclusion: muscle mass by d cr co-segregated with strength and physical performance measures, and together was associated with mobility and disability outcomes in older men. body composition measures (including dxa alm) did not co-segregate with strength and physical performance measures and together was associated with only mobility disability. background: currently, there are no registered drug treatments for the loss of skeletal muscle mass, strength and function that occurs during sarcopenia and cachexia. moreover, they are only limited relevant pharmacological screening options available. objectives: to improve in vitro pharmacological screening options, we developed a model of muscle wasting using donor primary muscle cells and our myoscreen™ platform that generates standardized myotubes for high-throughput phenotypic screening (young et al., slas discov. ( ) : - ). methods: myoblasts from four donors aged , , and years were compared in terms of proliferation, differentiation, size of formed myotubes and achr cluster formation using imaging and high content analysis. we then established an assay for muscle wasting: in each of the four donors various molecular pathways implicated in the pathogenesis of sarcopenia were activated using tnfa, tgfb or dexamethasone. results: myotubes formed from elderly patient's myoblasts displayed a reduced capacity to proliferate and differentiate, thinner myotubes and fewer acetylcholine receptor clusters. therefore, myotubes cultured using the myoscreen system continue to reflect age-related properties of donor muscle. interestingly, we also found that myotube sensitivity to atrophy stimulation increased with increasing age. myotubes were then co-incubated with growth/ repair factor igf- or hdac inhibitor, trichostatin a (tsa). both agents attenuated tnfa-induced myotube atrophy and differentiation inhibition in a dose-dependent manner. the extent of fusion index and myotube size increase was highest in myotubes from elderly subjects while myotubes from young subjects were more resistant to the protective effects of igf- and tsa. conclusion: myoscreen can be exploited to quantify age-dependent modifications in skeletal muscle fibers in vitro and identify candidate compounds that counteract the muscle wasting phenotype. andreas friedberger , alexandra grimm , wolfgang kemmler , klaus engelke , (( ) institute of medical physics, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany; ( ) department of internal medicine; ( ) friedrich-alexander-universität erlangen-nürnberg and university hospital erlangen, erlangen, germany) background: sarcopenia is characterized by a progressive loss of skeletal muscle mass, which is infiltrated by adipose tissue. dual energy x-ray absorptiometry can only differentiate overall lean and fat mass. a local muscle analysis requires d imaging like magnetic resonance imaging (mri). usually, t weighted images are used for a visual grading of the amount of intermuscular adipose tissue (imat). however, a quantitative analysis requires segmentation of the fascia lata (fl, deep fascia of the thigh). objectives: our aim was to develop a highly reproducible d segmentation method in oder to quantify imat and the fat fraction of the thigh muscles using a combination of t weighted turbo spin echo (t wtse) and corresponding pt turbo spin echo (tse) dixon fat fraction (ff) images. methods: mri scans were acquired on a t scanner (magnetom skyrafit siemens) at the midthigh (length cm, slices, voxel size t w . x . x . mm³, dixon . x . x . mm³). since the fl is difficult to detect in the ff images, the t wtse images were used for segmentation. this process involved several steps, starting with a fuzzy c-mean clustering followed by several filtering steps to enhance d surface like structures representing the fl. finally, a level set algorithm was applied to obtain a closed d surface. if necessary, results were corrected manually. segmented masks were transferred from the t w to the ff images by rigid registration. imat was then segmented using a threshold determined from the histogram of the ff values within the intra-fascia region. sarcopenic ( ± y) and healthy ( ± y) male subjects were analyzed by three operators once (interoperator reproducibility) and three times by one operator (intraoperator reproducibility). results: inter-and intra-operator variability results of imat are shown in the table as mean / root mean square of the standard deviation (rms-sd) in units of the measured variable / coefficient of variation (rms-cv) in %. overall precision was excellent with errors below . %. conclusion: a semi-automatic d segmentation for the fascia of the thigh was developed. the operator impact on imat was almost negligible. background: sarcopenia a muscle disease that causes muscle mass loss and weakness. the calf circumference is a good screening test for sarcopenia in older adults in primary care. the most commonly used cutoff point is cm, but it is derived from north american studies and it may not be adequate for screening different populations that have lower height, weight and bmi. objectives: the objective of this study was to determine the ideal cutoff point for calf circumference for sarcopenia in community-dwelling older people in northeastern brazil. methods: this was a cross-sectional study of community-dwelling older people with a mean age of ± years ( % women). data on sociodemographics, anthropometrics, grip strength, gait speed, and skeletal muscle mass (bioimpedance) were collected. sarcopenia was assessed based on the diagnostic criteria suggested by european working group on sarcopenia in older people (ewgsop ). the area under the roc curve (auc) was calculated for different calf circumferences to identify the best cutoff point to determine sarcopenia among the participants. results: the prevalence of sarcopenia was %. the most appropriate calf circumference cutoff point was cm, with an auc of . , % sensitivity and % specificity. conclusion: it was found that the most appropriate calf circumference cutoff point to diagnose sarcopenia in older northeastern brazilians was cm. this is a more accurate cutoff point and will reduce the number of false positives and optimize health services in brazil. background: osteosarcopenia is a new geriatric syndrome defined as the presence of both sarcopenia and osteopenia or osteoporosis. this musculoskeletal disorder is related to higher prevalence of disabilities, falls and fractures and higher risk of mortality among community-dwelling older adults. therefore, the early diagnosis of this condition must be considered in order to reduce costs and negative impact on function. objectives: to explore the use of the infrared spectroscopy as a potential screening tool for osteosarcopenic older women (>= years old). methods: sarcopenia was identified by observing the presence of both reduction of muscle strength (grip strength) and mass (appendicular skeletal muscle mass) as suggested by the revised algorithm of the european working group on sarcopenia in older people ( ). reduction on bone mineral density was identified through bone densitometry and a t-score of <- , was adopted to classify the older women as osteopenic/osteoporotic. infrared spectroscopy through attenuated total reflection-fourier transform infrared spectroscopy (atr-ftir) was used to collect the sample information and to perform a multivariate analysis model. vibrational spectrum was obtained from serum. six samples of each group (osteosarcopenic and non-osteosarcopenic) were used to test the model and thirteen ostesarcopenic samples and fifteen non-osteosarcopenic samples were used for training. results: the most suitable model was the ga-svm with an accuracy of . %, % of sensibility and . % of specificity to differ osteopenic to non-osteopenic women. the more important selected variables found in the model were at the spectral regions: ~ cm- for carbs, ~ to cm- for nuclei acids and ~ to cm- for proteins. conclusion: infrared spectroscopy may be a promisor future method to early and easily diagnosis osteosarocopenia and prevent the harms this health condition may cause to the elderly population and minimizing costs to treat them. background: the modified european working group on sarcopenia in older people (ewgsop- ) algorithm to identify older people with sarcopenia contains three steps after initial clinical suspicion. the chair stand test, also known as the fivetimes sit-to-stand test ( sts), is one of two tests that can be used to assess muscle strength. the sts is also a component of the short physical performance battery (sppb), which is used as a measure of severity in the ewgsop- algorithm. objectives: the objective of this study was to determine whether the sts could be used to assess both muscle strength and physical performance in the ewgsop- algorithm to detect sarcopenia. methods: one hundred and ten older people aged . ± . years participated in the study. all participants were evaluated using the sppb score, as well as the timed-upand-go (tug). the ewgsop- algorithm specifies cut-off points of ≤ points on the sppb, ≤ . m/s for gait speed, and ≥ s for the tug. each participant was classified for tug and gait speed using the ewgsop- cut-offs, with stepwise discriminant function analysis used to predict the classification of participants. the remaining participants were used for cross-validation. prediction of sppb classification used the sts score in combination with predicted balance and sppb gait scores from stepwise linear regression. the total sppb score obtained using this method was used to predict sppb classification for the ewgsop- cut-off for sppb. results: the sts scores were able to predict tug and gait speed classification with % and % accuracy, respectively for the learning set of participants. the predicted sppb score had a classification accuracy of %, with % sensitivity and % specificity. when the remaining participants were evaluated, the sppb classification was correctly predicted for participants ( %), with % sensitivity and % specificity. conclusion: the sts can be used to accurately predict sppb classification in the ewgsop- algorithm to detect sarcopenia, meaning that the sts test could be used as a standalone test in an initial screening for sarcopenia. barrientos-calvo (nutritional support department and geriatric department, geriatric national hospital , san josé, costa rica) background: obesity is a disease characterized by increased adiposity with negative impact on patient health. aging process is associated with a progressive loss in muscle function, that may lead to functional decline and frailty. there are only few studies that have compared the prevalence of sarcopenia and dynapenia in obesity. objectives: the aims of this study were to determine the prevalence of sarcopenic and dynapenic obesity in elderly using the european working group on sarcopenia in older people criteria. methods: we conducted a cross-sectional study that included elderly patients with obesity from the obesity clinic since january to june . sarcopenia was defined according to the european working group on sarcopenia in older people (ewgsop ) criteria, and obesity with body mass index (bmi) > kg/m . handgrip strength was assess using a hydraulic dynamometer (jamar). bioimpedance analysis (bia) was performed. results: we evaluated persons, but only had bia data ( %). a total of older ( . ± years), % were women. mean body mass index, waist circumference, weight and calf circumference were . ± . kg/m , . ± . cm, . ± . kg and . ± . cm respectively. all patients had elevated body fat (mean %) and % had abdominal obesity. patients showed higher frequency of hypertension ( %), diabetes ( %), dyslipidemia ( %). sedentary was present in % and falls in %. mean handgrip strength and muscle mass for men and women were . ± . kg; . ± . kg and . ± . kg; . ± . kg respectively. there were ( . %) individuals fulfilling criteria for sarcopenic obesity, all women. but, dynapenic obesity was present in . % men and % women. conclusion: although the loss of muscle mass is associated with the decline in strength during aging, the decline in strength is more prevalent than the loss in muscle mass in our obeses. a large difference in prevalence of the two conditions was observed, sarcopenia obesity . % and dynapenic obesity %, respectively. barrientos-calvo (nutritional support department and geriatric department, geriatric national hospital, san josé, costa rica) background: sarcopenia is a geriatric syndrome characterized by progressive and generalized loss of skeletal muscle mass, strength, and function. several operative definitions for sarcopenia have been proposed over the past two decades. objectives: the aim of this study was to determine the prevalence of sarcopenia in costa rican longevity and health aging study (creles) using the ewgsop and ewgsop criteria. methods: to carry out the analysis, all the available cases of the creles study database in which belong to the cohort that follows in the period - were used. we analyzed community-dwelling older adults. low muscle mass was assessed using calf circumference < cm and low strength if < kg in men or < kg in women (ewgsop) vs < kg in men or < kg in women (ewgsop ). results: according to the ewgsop . % of the participants had sarcopenia, while according to the ewgsop sarcopenia was present in , % of participants. there was an increasing trend of sarcopenia by age group, it was more prevalent in women. mean handgrip strength was , kg in men and , kg in women with sarcopenia. mean calf circumference was , cm. sarcopenia was positively associated with age (or= . ; ci: . - . ), incomplete primary education (or , ; ic , ) , perceived as unhealthy (or , ; ic , - , ), antecedent of ischemic vascular event (or , ; ic , - , ), arthritis (or , ; ic , - , ), and falls ( r , ; ic , - , ). conclusion: the overall prevalence sarcopenia were significantly lower in ewgsop . prevalence of sarcopenia varies widely depending on the grip strength cut-off points applied. based on a -hour dietary recall, and poorer nutritional status as determined using must compared to their non-sarcopenia counterparts (all p<= . ). conclusion: the high prevalence of sarcopenia in community-dwelling older people who are at risk of malnutrition highlights the importance to devise targeted exercise and nutrition interventions to improve muscle health, physical performance and nutritional status. these interventions are essential to reduce the risk of progression to frailty and disability in this population group. v i n c e n z o m a l a f a r i n a , l e t i z i a s u e s c u n p u e r t a , a r a n t z a z u b i a i n u g a r t e , i ñ a k i a r t a z a a r t a b e , virtudes niño martín ( ( ) s o p h i e g u y o n n e t , c a t h e r i n e t a k e d a , philipe de souto barreto , yves rolland , sandrine andrieu , bruno vellas and the inspire study group ( ( ) background: the new geroscience field should not only be focusing on preventing age-related diseases, but should investigate the optimal maintenance of intrinsic capacity (ic): mobility, cognition, psychological, vitality and sensorial (hearing and vision) capacities as defined by the w.h.o. a better understanding about how to measure biological aging is an indispensable step that may lead to the definition of the best putative markers of aging capable of predicting healthspan. objectives: the main objective of inspire bioresource research platform for healthy aging is to build a comprehensive research platform gathering biological, clinical (including imaging) and digital resources that will be explored to identify robust (set of) markers of aging, age-related diseases and ic evolution. methods: the inspire platform will gather clinical data and biospecimens from subjects in the occitania region of different ages (from years or over -no upper limit for age) and functional capacity levels (from robust to frail to disabled) over years (inspire human translational research cohort). data are collected annually. between two annual visits, ic domains are monitored (with or without the help of a caregiver) each -month. once ic declines are confirmed, participants have a thorough clinical assessment and blood sampling to investigate the response of markers of aging at the time declines are detected. biospecimens includes blood, urine, saliva, and dental plaque that are collected from all subjects at baseline and then, annually. nasopharyngeal swabs and cutaneous surface samples are collected from all subjects at time-points (baseline visit and follow-up visits at m , m , m , m and m ). feces, hair bulb and skin biopsy are collected optionally at the baseline visit. results: recruitment started in october for a two years period. the identification of markers of aging will take advantage of three complimentary approaches to look for the best markers of aging: without a priori approach (transcriptomics, proteomics, lipidomics); semi a priori approach (metabolism, inflammation, cell cycle, mitochondrial network…); and targeted approach (pre-identified targets). the inspire platform will also aim to develop an integrative approach to promote novel new technologies for the assessment and monitoring of functional capacities. *acknowledgments: the inspire plateform is supported by grants from the occitania region and the european regional development fund (erdf), and co-funding by the apoc, the ctad, and the edenis, korian, pfizer, and pierre fabre groups. the promotion of this study is supported by the university hospital center of toulouse. background: energy balance is usually regulated by silent information regulator related enzyme (sirt ) and adenosine monophosphate-activated protein kinase (ampk). caloric restriction (cr) can postpone the pathological process of aging-related diseases and has a neuroprotective effect on nervous system degenerative diseases, but the mechanism is complex and not yet fully elucidated, although some of the cr effects may be mediated by sirt and ampk. objectives: to evaluate the beneficial effects of a cr diet on learning and memory ability. methods: six-week-old male c /bl mice were fed ad libitum for week before the experiment began. animals were weight-matched and randomly divided into three different groups: normal control group (nc group, n = ), high-energy group (he group, n = ), and cr group (n = ). the energy of nc diet, he diet and cr diet caloric ratio was : . : . . the total experimental duration was months. results: cr improved spatial learning and memory ability and decreased body weight and serum glucose. nissle staining showed the cell density was significantly decreased in the he group and increased in the cr group. cr decreased the expression of insulin signal pathway-related proteins such as igf- , ir, irs- , pi k, akt/pkb, and p-creb. more sirt -immunoreactive cells and fewer mtor-and s k immunoreactive cells were observed in the hippocampal in the cr group than in the nc group. cr decreased hippocampal mtor and s k protein activation and mrna expression. the expression of beclin , lc and cat b was increased and p was decreased in the cr group. the number of gfap-positive and iba- -positive cells in the cr group was significantly reduced compared to the nc group. conclusion: cr may prevent age-related learning and memory impairment via suppression of pi k/akt pathway and activation sirt / ampk/ mtor pathway in brain. background: head-down ( °) bed rest (hdbr) is a wellaccepted model to understand the pathophysiology of disuseinduced sarcopenia. human centrifugation as a measure to counteract muscle wasting during spaceflight is discussed. previous studies have observed decreases in maximal voluntary contraction force of the knee and hip-extensors of up to % following weeks of hdbr. muscle force is regulated by the recruitment of motor units (mus) and the modulation of mu firing rate. objectives: the aim of this study was to assess whether long-duration hdbr alters motor unit properties as one cause for disuse induced sarcopenia and whether human centrifugation can attenuate this decrement. methods: twelve healthy participants ( . ± . yr; ± cm & . ± . kg) were confined to -days ° hdbr in the frame of the first campaign of the agbresa bedrest study. eight received mins of artificial gravity (ag) daily via human centrifugation whereas four belonged to a control group. estimations of mu number (munix) and size (musix) in the abductor digiti minimi (adm) and tibialis anterior (ta) muscles were made using the motor unit number index method from on day preceding bed rest (bdc ) and on days (hdt ) and (hdt ). mean compound muscle action potential (cmap), munix and musix as a percent change from bdc were compared using repeated-measures anova, where muscle and time were ascribed as within-group factors and intervention a between-group factor. significance was denoted by p< . . results: both cmap and munix were unaltered over time in both muscles, irrespective of the intervention. although musix was also indifferent over time for both muscles, a significant muscle*time interaction was observed, indicating that the changes over time differed between the two muscles. conclusion: the preliminary data from the ongoing study indicate that neurodegeneration due to bedrest might affect muscles differently. there does not seem to be an effect of ag on mu number. analyses have to be repeated when the study is completed with a larger number of participants. additional histological and biochemical data will give further insight in the pathophysiology. living. soumaya msaad , geoffroy cormier , guy carrault (( ) univ rennes, inserm, ltsi -umr , f- rennes, france; ( ) neotec vision , rennes , france) background: several models have been proposed for elderly frailty detection. there is a consensus on two of them: the fried model, and the rockwood model. however, daily monitoring of the elderly is impossible with these models, whereas it is very important to detect any change as soon as possible to prevent dependency, since frailty is reversible only if early detected. objectives: the objective of this study is to propose a non-intrusive and low-cost method that anticipates frailty using depth images. crucial hypotheses are that regularity of daily activities is important for the elderly and that any prolonged change is considered as an indicator of frailty. methods: the proposed method consists in three steps: ) extraction of parameters from depth images: lying and sitting time percentage during the day, walking speed, and number of falls, visits, and exits. ) classification of the daily state using logistic regression and the extracted parameters. the daily state is considered as normal if the daily routine is maintained and abnormal if it is broken. ) computation of the weekly percentage of maintaining routine based on the classification of the nature of the day. results: tracking frailty is a difficult task that requires recording data over several months. as real data has not been collected yet, the feasibility of our approach was assessed on simulated data. in the latter, we reproduced variations of the parameters we would have extracted from real images of a patient after investigating his or her daily life. the classification of the days (normal/abnormal) led to an accuracy of % (training dataset: days, test dataset: days). a patient is considered frail when the weekly percentage of maintaining routine decreases steadily. conclusion: the preliminary results prove that in addition to being non-intrusive, a depth-imaging based approach can be a promising tool for frailty detection. anna franke , ellen freiberger , robert kob simon moskowitz , david w. russ , , leatha a clark , , , nathan p. wages , , dustin r. grooms , , brian c. clark , , ( ( ) background: one putative mechanism explaining mobility limitations (mls) in older adults (oas) is a reduction in the central nervous system's (cns) ability to rapidly drive muscle force/torque production. rapid movements can be mathematically expressed as the time derivative of force/ torque, also termed 'yank' (y). muscles are ultimately responsible for generating y, but cns input (ni) to the muscles clearly influences y. the time derivative of the voluntary electromyogram during maximal efforts is associated with gait speed (gs) and chair rise time (crt). however, since the electromyogram is influenced by non-physiological factors (e.g., subcutaneous adipose tissue acting as a low pass filter), it is difficult to fully ascribe this finding to cns deficits. theoretically, normalizing y to the time derivative of electrically evoked force/torque controls for musculoskeletal factors contributing to y (ymsk), which yields a value representing the cns's ability to rapidly produce force/torque (yni=y/ymsk). objectives: to better understand the role of the cns in mls in oas we ) compared leg extensor yni between young and oas, and ) examined the association between leg extensor yni and measures of mobility. methods: twenty-one young and fifty-nine oas ( . +/- . and . +/- . yrs) were instructed to "kick out as fast and hard as possible" against a fixed lever arm attached to a torque motor, and we quantified y between onset and -msec. next, we quantified ymsk from a supramaximal electrically evoked torque-time recording (potentiated -hz doublet) and calculated yni as described. on a separate visit six-minute walk ( mw) gs, stair climb power (scp), and x crt were measured. results: oas had higher yni vs. young adults reflecting a % reduction in central neural activation during rapid torque development ( . +/- . vs. . +/- . ; p< . ). significant associations were observed between yni and mwgs (r= . ), scp (r= . ), and x crt (r=- . ). conclusion: oas have a slower rate of volitional neural activation during rapid leg extensor torque production relative to young adults. in addition, yni explained ~ - % of the variability in measures of mobility, thereby supporting the notion that age-related reductions in the ability of the cns to rapidly activate muscles contribute to mls. background: opa mutations cause dominant optic atrophy (doa), an incurable retinopathy with variable severity and which mechanisms are still unknown. more than % of patients will endure a doa plus syndrome with ataxia, deafness or parkinsonism. the hypothesis of an oxidative stress has been proposed to explain the variability of these symptoms. objectives: that's why our goal is to improve understanding of the physiopathological mechanisms involved in this disease by developing mathematical models of the production of reactive oxygen species (ros) by the mitochondrial respiratory chain. methods: we monitored the levels of mitochondrial respiration, reactive oxygen species (ros), anti-oxidant defenses and cell death by biochemical and in situ approaches using in vitro and in vivo models of opa related disorders and model the complex i functioning with a detailed stochastic background: the sarc-f is a -question screening tool for sarcopenia. we present results for reliability and validity of the german version of the sarc-f. objectives: translation, adaptation and validation of the german version of the sarc-f for community-dwelling older adults in germany. methods: design: cross-sectional. setting and participants: community-dwelling outpatients with a mean age of . ± . years were included in the study, ( . %) of them were female. ( . %) had a positive sarc-f score of >= points. according to the definition for sarcopenia from the european working group on sarcopenia in older people (ewgsop ), eight patients ( . %) were identified as sarcopenic and ( . %) as probable sarcopenic. methods: translation and cultural adaption was composed of seven different steps that were in general based on the guidelines put forward by the world health organization. validation include test-retest and the inter-rater reliability (intra-class correlation coefficient) as well as internal consistency (cronbach's alpha). further, sensitivity, specificity, positive predictive value, and negative predictive value of the sarc-f were calculated. receiver operating characteristics (roc) analysis was performed to calculate the area under the curve. results: the translated and culturally adopted version of the sarc-f for the german language has shown excellent interrater reliability and good test-retest reliability. the internal consistency is acceptable. sensitivity ( %) and specificity ( %) for sarcopenia is low. for detecting patients with probable sarcopenia, the sarc-f in the german version has shown % sensitivity and % specificity. conclusion: due to a low sensitivity for detecting sarcopenia but an acceptable sensitivity for identifying probable sarcopenia, the german version of the sarc-f is a suitable tool for case finding of probable sarcopenia. background: skeletal muscle is a vital component of the locomotor system necessary for physical function. however, there is increasing evidence that skeletal muscle acts as a secretory organ in itself, communicating with other organ systems. acute sarcopenia is an emerging condition affecting adults following hospitalisation, which should be considered akin to organ insufficiency elsewhere. however, acute sarcopenia remains poorly characterised to date. objectives: • to characterise changes in muscle quantity, strength, physical performance, and patient-reported physical function in hospitalised older adults at one week and three months. • to determine what biological and clinical factors are predictive of changes to enable further research towards targeted interventions. methods: planned recruitment will include hospitalised patients aged years and older; elective colorectal surgery patients, emergency surgery patients, and general medical patients with acute bacterial infections. patients will be recruited to the elective cohort in pre-operative assessment clinic with repeat measures within hours of surgery, at one week, and at three months. emergency surgery patients will be recruited pre-or post-operatively with repeat measures at one week, and at three months. medical patients will be recruited within hours of admission, with repeat measures at one week, and at three months. muscle quantity will be measured by bilateral anterior thigh thickness using ultrasound and bioelectrical impedance. muscle function will be measured by handgrip strength and short physical performance battery. serum and plasma samples will be obtained prior to admission in the elective cohort, within hours of surgery in both surgical cohorts, and within hours of admission in the medical cohort. background: sarcopenia is common in old age and is associated with various diseases. as human life expectancy is projected to increase, this will pose a challenge for the global healthcare industry. since sarcopenia is highly heritable, study of its genetic underpinning can help its etiology. in the past decade genome wide association studies (gwas) have allowed the identification of new genetic markers for various conditions. identification of new genetic markers through gwas requires functional validation using cellular models in order to both prioritize and validate the potential loci/genes. objectives: demonstrate that a locus identified in gwas may affect muscle health, which is approximated by lean mass and hand grip strength. methods: gwas results are screened using a two-step scoring system which utilizes publicly available databases such as genecards, ensembl and coxpresdb to assess the relevance of a certain locus. relevant genes are then knocked out using crispr-cas in c c mouse myotube cells which are induced to differentiate. after cell harvest rt-qpcr and western blot are performed to assess mrna and protein expression, respectively. knocked out cells are also examined against wild type cells for morphological phenotype. results: slc a is a promising candidate based on: (a) muscle gwas results, (b) the expression of the gene in smooth and striated muscle tissue, (c) the lack of co-expression with other genes that have an effect on muscle; (d) mouse phenotypes associated with a mutation in the mouse ortholog slc a , (e) cell epigenetic data and (f) the topologically associated domain (tad) at chr. : , , - , , . rt-qpcr of wild type c c cells showed a fast increase in the expression of slc a 's mrna which remains constant during the entire differentiation process. conclusion: preliminary results indicate that slc a might be a promising candidate to investigate for involvement in muscle health. there is a fast and stable increase of the gene's expression during myotube formation. positive results may suggest that slc a is of importance to muscle health. to farther assess slc a role, wild type cells will be compared to knocked-out cells. this might lead to a new genetic marker for muscle health, thus extending personalized medicine in the field of sarcopenia and muscle health. jesse zanker , terri blackwell , sheena patel , kate d u c h o w n y , , s h a r o n b r e n n a n -o l s e n , s t e v e n r . cummings , , william j. evans , , eric s. orwoll , david scott , , sara vogrin , gustavo duque , peggy m. cawthon , ( ( ) background: muscle mass, strength and physical performance are independent risk factors for disability and mobility disability in older adults. it is not known how measures of body composition (muscle, lean and fat mass), strength and physical performance are interrelated or how empirical groupings of these measures relate to disability and mobility disability. objectives: to determine the relationship between measures of body composition, strength and physical performance in older men and to examine how empirical groupings of these measures relate to adverse mobility and disability outcomes. methods: muscle mass was assessed by d -creatine dilution (d cr muscle mass) in men ( . + . years) enrolled in the osteoporotic fractures in men (mros) study. participants completed anthropomorphic measures, walk speed ( m), grip strength (kg), chair stands (s), and dual x-ray absorptiometry (dxa) appendicular lean mass (alm) (adjusted for weight, body mass index or height ) and body fat percentage. factor analysis was conducted to reduce variables into smaller components. men self-reported limitations in mobility (walking - blocks, climbing steps, or carrying pounds); activities of daily living (adls); and instrumental adls at initial and follow-up visits. negative binomial models adjusted for participant characteristics were used to determine the relative risk of factors with mobility and disability outcomes. results: factor analysis reduced variables into four factors: factor , body composition, with strong loading by alm, body fat percentage, weight and muscle mass; factor , body size and lean mass, with strong loading by height, weight and alm; factor , muscle mass, strength and performance, with strong loading by walk speed, chair stands, grip strength, and muscle mass; and factor , lean mass and weight, with strong loading by alm and weight. only factor was associated with prevalent disability and background: urinary incontinence(ui) is a prevalent and costly condition that affects ~ % of older communitydwelling women.one of the contributors of ui is decreased pelvic muscle strength. objectives: to determine the effect of additional oral glutamine supplementation to kegel-exercise on pelvic floor strength and clinical parameters of ui in females. methods: it is a randomized, double-blind study. females with ui were included. digital test and a vaginal manometer were used for measuring the strength of the pelvic floor muscles. hours pad weight test was examined. participants were randomized into groups as oral glutamine gr/day and placebo. it was asked to use the supplementation and kegel-exercises to all participants for months. basic and th month measurements were compared by paired sample t -test and wilcoxon tests in each group. the progression between measurements at basic and th months was compared between the groups by using mann-whitney-u test. (clinical trials protocol id: / background: it is important to identify if middle-aged people are at risk for sarcopenia. a screening-tool identifying predictors of pre-sarcopenia early in the lifespan may inform prevention focused interventions. objectives: develop and validate a practical screening-tool to identify middle-aged adults at risk for pre-sarcopenia using data from the dunedin multidisciplinary health and development study (dmhds). methods: the dmhds is an ongoing longitudinal birth cohort study from the greater dunedin (nz) metropolitan area. the primary outcome of the screening-tool was low appendicular lean muscle index (almi) in middle-aged adults, at age . low almi was classified using prado's age-specific median cut-scores. the models were developed in % (n= ) of the cohort and cross-validated in the remaining % (n= ). possible predictors at age , were examined for associations with low almi, using univariate logistic regression. significant predictors were selected in a multivariate logistic regression to derive sex-specific prediction models. each individual in the cohort was allocated a risk-score and classified as low, medium and high risk, based on the quartile risk score. overall performance of the final models was estimated with nagelkerke r score, discrimination of the models with the area under the roc curve and calibration of the final models with hosmer-lemeshow tests. results: % of the development set and % of the validation set were female. the final models for both sexes included body mass index (b=- . , p= . ; b=- . , p= . ), vo max (b=- . , p= . , b=- . , p= . ) and grip strength (b=- . , p= . , b=- . , p= . ). the final model for females also included creatinine (b=- . , p= . ). nagelkerke's r showed that . % and . %, of the variance in low almi, is explained by the variables in the screening-tool for males and females, respectively. the area under the roc curve demonstrated good discrimination ( . ). sensitivity in the lowest quartile was . %, specificity in the highest quartile was . %. the hosmer-lemeshow p-values were respectively . and . , showing goodness of fit. conclusion: this screening-tool was able to predict the sex-specific risk of pre-sarcopenia in a large birth cohort of early middle-aged adults. clinical utility and application of this screening-tool require further investigation. background: aging-associated changes in body composition include a decrease in skeletal muscle mass, which may predispose women to physical limitations and disabilities. in women, these changes may already be accelerated during menopause, when ovarian estradiol (e ) production ceases. e , the main female sex hormone, is known to have beneficial effects on female skeletal muscle mass. objectives: the aim of this study was to investigate the effects of menopausal transition on lean body mass, lower limb muscle mass, muscle area and muscle fiber cross-sectional area in middle-aged women. methods: middle-aged women (n= ) were followed from perimenopause to postmenopause. menopausal state was defined based on repeated follicle-stimulating hormone (fsh) measurements and menstrual bleeding diaries. serum hormone levels (e and fsh; immulite ), lean body mass (lbm), right leg lean mass (dxa, n= ), and thigh muscle cross-sectional area (computed tomography (ct), n= ) were measured in peri-and postmenopause. muscle biopsies for immunohistochemistry were obtained from participants at peri-and postmenopausal phases, and muscle fiber crosssectional areas were measured. the level of physical activity (pa) from the previous months was assessed with a questionnaire (met-hours/day, n= ). statistical differences were analyzed with paired t-test and wilcoxon signed rank test. gee-modeling was used to analyze the effects of covariates during follow-up. results: the average followup time was . years (range . - . years) and there was a significant difference in e and fsh levels during the transition (p< . for both). lbm decreased . % (p= . ) and leg lean mass . % (p= . ) during the menopausal transition. no changes were found in the cross-sectional area of thigh muscles or muscle fibers. the level of pa declined during the transition (p= . ). when individual menopausal transition time and pa were controlled, only systemic e levels were positively associated with lbm (b= . , p= . ). conclusion: despite the relatively short follow-up time, significant declines were observed in lbm and leg lean mass during the menopausal transition. the decrease in lbm was associated with lower systemic e level. therefore, it seems that although pa might slow the decrease in muscle mass, estradiol loss is one key factor in whole body muscle loss during menopausal transition. hiroyuki shimada , takehiko doi , sangyoon lee , kota tsutsumimoto , seongryu bae , sho nakakubo , keitaro makino , hidenori arai (( ) department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology, aichi, japan;( ) national center for geriatrics and gerontology, aichi, japan)background: in , the european working group on sarcopenia in older people met again (ewgsop ) to update the original definition of sarcopenia. ewgsop uses detection of low muscle quantity and quality to confirm the sarcopenia diagnosis, and identifies poor physical performance as indicative of severe sarcopenia. however, it is not clear that the relationships between the revised definition of the sarcopenia and disability incidence in japanese older adults. objectives: to examine the associations between sarcopenia for ewgsop criteria and disability incidence among community-dwelling older japanese individuals. methods: a total of older adults participated in the study ( women; average age, . ± . years) form a japanese national cohort study called the ncgg-sgs. skeletal muscle mass was assessed using a bioimpedance analysis device and handgrip strength and walking speed were measured as physical performance. we used the cut-points of the asian working group for sarcopenia to determine the low muscle mass and low physical performances. the participants were divided into non-sarcopenia, sarcopenia, and severe sarcopenia groups. the incidence of disability was determined using data collected by the japanese longterm care insurance system over months. results: the prevalence rates of sarcopenia and severe sarcopenia were . % and . %, respectively. the participants with sarcopenia, included sarcopenia and sever sarcopenia, showed higher risk of disability incidence than those with non-sarcopenia (hazard ratio [hr]: . , % confidence interval [ % ci]: . - . ). in analysis between non-sarcopenia and sarcopenia or severe sarcopenia, although the association between disability incidence and severe sarcopenia remained significant (hr: . , % ci: . - . ), there was no significant association in sarcopenia (hr: . , % ci: . - . ). conclusion: severe sarcopenia combined low muscle mass and low physical performance could have a higher risk of disability than healthy older adults or older adults with low muscle mass alone. further studies are needed to determine whether sarcopenia without poor physical performance is associated with disability incidence.background: sarcopenia is one of the biological hallmarks of frailty that has been associated with adverse events in older adults undergoing cardiac surgery. dual x-ray absorptiometry (dxa) is a recommended modality to measure muscle mass, however, dxa may be less accurate in acute cardiac patients due to the confounding effects of peripheral edema and fluid shifts. objectives: the study aims to determine if sarcopenia as measured by a combination of dxa and timed chair rises is associated with mortality in older adults referred for cardiac surgery. methods: a convenience sample of hospitalized older adults being evaluated for cardiac surgery was prospectively enrolled at the jewish general hospital. after a questionnaire and physical performance battery, patients underwent a dxa scan (ge lunar) to measure their appendicular muscle mass (amm). patients were categorized as sarcopenic based on the european working group guidelines if they had low amm defined as < kg/m in men or < kg/m in women and low muscle strength defined as chair rises > seconds. multivariable logistic regression was used to test the ageand sex-adjusted association between sarcopenia and allcause mortality. results: the cohort consisted of patients with a mean age of . ± . years and % females. the interventions were isolated coronary bypass in %, valve surgery in %, and decision not to proceed with surgery in %. the mean amm was . ± . kg in men and . ± . kg in women. the prevalence of sarcopenia was % (n= ), similar in men and women. sarcopenia was not associated with -year mortality (or . , % ci . - . ) and, in a separate model, neither was low amm (or . , % ci . - . ). slow chair rise time was associated with higher -year mortality (or . , % ci . - . ). when patients with heart failure and reduced ejection fraction were excluded, sarcopenia appeared to be more prognostic (or . , % ci . - . ) although it did not reach statistical significance. conclusion: lower-extremity muscle strength, but not dxa-based measures of muscle mass or sarcopenia, is predictive of survival in hospitalized older adults referred for cardiac surgery. background: the "blue zone" are limited areas with a high prevalence of centenarians, with rather homogeneous characteristics, life styles and environment." this blue zone, located in the nicoya peninsula, is in the province of guanacaste. even though costa rica has this blue zone, there are no studies that characterize the prevalence sarcopenia in the centenarians of the region. objectives: the aim of this study was to determine the prevalence of sarcopenia on centenarians from nicoya, costa rica, using the ewgsop criteria. methods: this is a cross-sectional study using a population base of community-dwelling centenarians from guanacaste. antropometric measures, weight, height and strength were assessed. to assess the nutritional state, the mini nutritional assessment (mna) was used and activities of daily living (adl) scores. low muscle mass was assessed by calf circumference < cm and low strength if < kg in men or < kg in women. results: the mean age of the patients were . ± . years. from this group, ( . %) were men and ( . %) were women. patients showed comorbilities: hypertension ( . %), diabetes ( . %), copd ( . %), cancer ( %), osteoarthritis ( %) and depression ( %). mean body mass index, weight, brachial and calf circumference were . ± . kg/m , . ± . kg, . ± . cm and . ± . cm. mean handgrip strength was . ± . kg. the mean score for the mna test was . ± . and adl score . ± . . with respect to sarcopenia prevalence, a total number of ( . %) subjects were detected, ( . %) men and ( . %) women fulfilled the criteria. according to the nutritional status, patients with sarcopenia had malnourishment, were on nutritional risk and had a good nutritional state. from the sarcopenic centenarians, at least % of the subjects had dependency with adl. conclusion: we had high prevalence sarcopenia in centenarians from the "blue zone". there are few studies in centenarians, but using the ewgsop criteria, it is the first in latin america. background: sarcopenia is a geriatric syndrome characterized by low muscle mass and low muscle function and/or reduced physical performance. malnutrition is a major risk factor for sarcopenia. there is limited data on the prevalence of sarcopenia in community-dwelling older people who are at risk of malnutrition in singapore. objectives: the objectives were (i) to determine the prevalence of sarcopenia and its components i.e. low handgrip strength, low appendicular skeletal muscle mass index (asmi) and low gait speed based on the asian working group for sarcopenia consensus (chen et al., ) , (ii) to describe the characteristics and dietary intake of older adults with sarcopenia to those without sarcopenia. methods: a total of community-dwelling older adults (>= years) who were at risk of malnutrition (malnutrition universal screening tool; must score >= ) took part in this study. sarcopenia was diagnosed by low muscle mass (asmi using bioelectrical impedance analysis) plus low muscle strength (handgrip strength) and/or low physical performance ( -meter usual gait speed). anthropometric measurements, dietary intake, and short physical performance battery (sppb) were also collected. results: over % of participants had a charlson comorbidity score of . the overall prevalence of sarcopenia was %; . % had low asmi, . % had low handgrip strength and . % had low gait speed. participants with sarcopenia were significantly older, shorter, and with lower body weight and bmi, mid-upper arm circumference, calf circumference and bone mass compared to those without sarcopenia (all p< . ). they also had lower physical functions as measured using handgrip strength and endurance, leg strength, and sppb score than those without sarcopenia (all p<= . ). additionally, older adults with sarcopenia had lower total energy intake and energy-adjusted protein intake background: the prevalence of sarcopenia varies according to the diagnostic criteria used, however it is an important geriatric syndrome related to a worse functional state in the elderly. very older adults are often excluded from clinical trials. objectives: the aim of this observational prospective study is to describe the prevalence of sarcopenia in community very older adults with high comorbidity. methods: we included patients who enter the geriatric day hospital of the hospital of navarra, spain, aged more than y, underwent bioelectrical impendance analisys (bia), measurement of hand grip strength (hgs), gait speed (gs), short physical performance battery (sppb), mini-nutritional assessment (mna-sf), barthel index and cumulative illness rating scale-geriatric (cirs-g). sarcopenia were defined according to ewgsop ( ). the study begining in and it is actually ongoing. we registered variables at baseline, and at the time , and months. all-cause mortality were registered. results: we present the preliminary results of baseline value. we icluded patients ( . % men, . ± . y). sarcopenia were present in participts, vithout sex differences. sarcopenic vs no-sarcopenic patiets were older ( . ± . vs . ± . y) (p< . ) and they presented worse nutritional status (bmi . ± . vs . ± . kg/m ) (p< . ), mna-sf ( %ci - ) vs ( - ) (p< . ). sarcopenic patients presented lower barthel index ( , %ci - vs , - ) (p= . ), but we have no observed differnces nor in the sppb , %ci - in sacropenic, vs , - in no-sarcopenic participats (p= . ), neither in comorbididy index (cirs-g , - vs , - respectivelly) (p= . ). sarcopenia is significantly associated with higher mortality (hr . , %ci . - . ) (p= . ). at the present time the mean follow-up is . ± . months. at months in patients ( %) the sarcopenia reverted, and we have observed new sarcopenic cases ( %) (incident sarcopenia). conclusion: sarcopenia is highly prevalent in very older adults with high comorbidity. sarcopenia is associated with malnutrition and with higher mortality. background: disability is a multifactorial trait that contributes substantially to decline of health/wellbeing and increases steeply with age after midlife. progress in genomewide sequencing has created the potential for discovering genes influencing various health-related traits. the vast majority of such studies focus on the genetic bases of different traits assuming that they have independent mechanisms. as conceptualized by geroscience age/aging are major risk factors of geriatric traits of distinct etiologies. accordingly, the same mechanisms can predispose not to just one, but to a large fraction of geriatric conditions. objectives: identify the common genetic architecture of various traits by discovering the genetic architecture of complex multifactorial trait such as disability. methods: genome-wide association study of disability in a sample of , subjects from five studies with , disabled individuals from the women's health initiative (whi) genomics and randomized trials network, whi memory study, cardiovascular health study, framingham heart study, and health and retirement study. disability was defined as having at least one of four basic activities of daily living impairments (bathing, dressing, getting out of bed, and walking). results: we identified promising disability-associated single nucleotide polymorphisms (snps) in loci at p< - . four of them attained suggestive level of significance, p< - . in contrast, polygenic risk scores (prs) aggregating effects of minor alleles of independent snps that were adversely or beneficially associated with disability showed highly significant associations in meta-analysis, p= . × - and p= . × - , respectively, and were replicated in each study. the analysis of genetic pathways, related diseases, and biological functions supported the connections of genes for the identified snps with disabling and age-related conditions primarily through oxidative/nitrosative stress, inflammatory response, and ciliary signaling. we identified musculoskeletal system development, maintenance, and regeneration as important components of gene functions. conclusion: the discovery of adverse and beneficial prs for a multifactorial trait of distinct etiologies such as late life disability supports the concept of geroscience. the beneficial and adverse gene sets may be differently implicated in the development of musculoskeletal-related disability with the beneficial set characterized, e.g., by regulation of chondrocyte proliferation and bone formation, and the adverse set by inflammation and bone loss. key: cord- -r usk authors: nan title: research communications of the th ecvim‐ca congress date: - - journal: j vet intern med doi: . /jvim. sha: doc_id: cord_uid: r usk nan saccharomyces boulardii (sb)is a non-pathogenic yeast used in the prevention and treatment of gastrointestinal disorders in human beings and horses. the aim of this study was to evaluate the effect of sb in healthy dogs and dogs with chronic enteropathies (ce). sb was formulated in x cfu capsules. its concentration and viability within the capsules was controlled by yeast culture in subsequent steps until expiration date. four healthy dogs (hd) and dogs with ce ( inflammatory bowel disease -ibd, protein losing enteropathy -ple) were included. in hd sb was administered for days ( x cfu/kg bid); daily clinical evaluation was performed to assess possible adverse effects and quantitative stool cultures for yeasts were performed before, during and after the administration. in dogs with ce a randomized double blind placebo-control study was performed, administering sb ( x cfu/kg bid) or placebo (pl). sb or pl administration was added to standard therapeutic protocols (diet, antibiotics and immunosuppressive drugs), to evaluate its efficacy for the treatment of ibd and ple. complete blood work, abdominal ultrasonography, gastro-duodenal and colon endoscopy and histopathological evaluation of intestinal samples were performed at diagnosis and after days of treatment. validated score system for the clinical signs (ceccai), ultrasonography, endoscopy and histopathology were applied. significance was set for p < . . results in hd showed the absence of sb in the faeces before treatment, its presence after one day, its steady state ( x cfu/g) after days and its complete elimination days after withdrawal of treatment. no adverse effects were reported. in ce dogs the clinical score improved significantly in dogs receiving sb compared to dogs receiving pl (p = . ). in ple dogs the albumin concentration increased significantly (p = . ) in the group receiving sb with respect to pl. the daily frequency of defecation in the sb group was significantly lower with respect to pl after (p = . ) and (p = . ) days of treatment. no statistical differences were found between dogs receiving sb and pl after treatment, based on the endoscopic evaluation of duodenum and colon. no statistical differences were found between the two groups on the duodenal ultrasonographic and histological evaluation after treatment. in conclusion, sb can be safely used in dogs with ce, in addition to standard treatment, to achieve a better control of clinical signs and a significant increase in albumin concentration compared to the standard therapy alone. no conflicts of interest reported. canine inflammatory bowel disease (ibd) is an immune-mediated enteropathy likely triggered by environmental and immunoregulatory factors in genetically susceptible dogs. previous studies suggest a pivotal role for gut bacteria in disease pathogenesis since luminal microbial composition is markedly altered (ie, dysbiosis) at diagnosis. probiotic bacteria appear to be therapeutically effective in some forms of human ibd. controlled studies evaluating the efficacy of probiotic therapy for canine ibd have not been previously reported. the aim of the present study was to characterize the mucosa-associated microbiota and determine the clinical, microbiological, and mucosal homeostatic effects of orally administered vsl# probiotics in dogs with ibd. twenty dogs diagnosed with moderate-to-severe ibd (cibdai score > ) were randomized to receive standard therapy (ie, elimination diet and glucocorticoids) with or without probiotic vsl# . the mucosal microbiota from endoscopic intestinal biopsies of ibd dogs and controls was evaluated by fluorescence in situ hybridization (fish) targeting the s rrna genes of total bacteria, group-specific organisms, and individual bacterial species shown to be relevant in human ibd. epithelial tight junction protein (tjp) expression was studied using immunohistochemistry. clinical signs and changes in mucosal microbiota and tjp expression were assessed before and after probiotic vsl# therapy. ibd dogs showed a reduction in gi signs following weeks of probiotic therapy compared with baseline cibdai scores (p < . ). adherent and sporadic invasive bacteria (eub) were observed in the small intestines and colon of healthy dogs. the diseased canine duodenum was nearly bacteria-free. ibd dogs given probiotic vsl # had altered spatial redistribution of most bacterial groups in the mucus and adherent compartments of the colon. subset analysis showed that lactobacilli were significantly (p < . ) increased in the lumen and mucus post-vsl # , while the number of mucus laden bifidobacteria approached significance (p = . ). expression of tjp showed that occludin was significantly lower in control intestines as compared to duodenal and colonic mucosa obtained from ibd dogs that received probiotic (p = . and p = . , respectively). in contrast, claudin- expression in the colon was significantly higher (p < . ) in control dogs versus vsl # treated ibd dogs. our data demonstrate that probiotic vsl# alters some of the mucosa-associated microbiota in dogs with ibd. these probiotic changes in bacterial composition are associated with up-regulated tjp expression indicative of enhanced epithelial barrier integrity, similar to vsl# -induced disease protection seen in human ibd. the probiotics used in the trial were supplied free of charge by the manufacturer. canine inflammatory bowel disease (ibd) is thought to be partially caused by an aberrant immune response towards the intestinal microbiome. in humans and mice, administration of probiotics can alleviate ibd severity and/or prevent relapse by induction of a more "tolerant"microenvironment. the aim of this study was to investigate the effect of probiotic enterococcus faecium ncimb e (ef) on intestinal microbiome composition. dogs were recruited to receive ef at x e cfu in a double-blinded, placebo-controlled manner in addition to an exclusion diet (hydrolysed protein). seven dogs were included in the probiotics group and dogs in the placebo group. all dogs improved clinically after treatment, however, there was no obvious effect on clinical severity in those that received probiotics. fresh naturally voided faecal samples were collected from all dogs before and after treatment, snap-frozen in liquid nitrogen and stored at - °c until further analysis. genomic dna was extracted from each faecal sample using the mobio power soil dna isolation kit (mobio laboratories), as recommended by the manufacturer. next generation sequencing was performed on the ion-torrent[trademark] (life technologies) platform based upon the v -v region (e. coli position - ) of the s rrna gene with the following primers: forward f: gag-tttgatcntggctcag and reverse r: gtnttacn gcggckgctg. raw sequence data were screened, trimmed, filtered, and chimera depleted with default settings using the qiime pipeline version . and uchime software, in which microbiome composition between treatment groups before and after treatment was compared. microbiota composition was not significantly different between probiotic and placebo treatment groups, and did not change significantly before and after treatment. however, there was large individual variability in the microbiome composition. species richness of faecal samples increased after treatment in both groups, but was only statistically significant in the probiotic treatment group. in conclusion, probiotic treatment in dogs with ibd leads to a significantly increased richness of the faecal bacterial microbiome. a possible additional effect of the change of diet cannot be excluded. further studies should investigate microbiomic changes in healthy dogs fed the same diet to assess if similar changes in the fecal microbiome occur due to dietary changes alone. this study is based on a phd supported by probiotics ltd., somerset, uk (the manufacturer of the probiotic product enterococcus faecium mentioned in this study). the aim of this study was to assess the prevalence and risk factors for faecal carriage of extended-spectrum beta-lactamases (esbl) and plasmidic ampc beta-lactamases (pampc) e. coliproducers in healthy dogs. a -month cross-sectional study was conducted at a private hospital in lisbon, portugal and rectal swabs were obtained from healthy dogs. the dogs included in the study were healthy with no history of antimicrobial consumption in the previous month. esbl and pampc genes were detected by pcr and were sequenced. potential risk factors for esbl-and pampc-producing e. coli faecal carriage were obtained through a questionnaire to the owner regarding reason for veterinary visit, hospitalisation and antimicrobial treatment within the last year, habitat (shelter, dog breeders and private owner), cohabitation with other animals, street access, kennel/hotel access, age and gender. data were analysed by sas software (version . ; sas institute inc., cary, n.c.) and logistic regression models were used. rectal swabs obtained from healthy dogs yielded positive samples for e. coli. about % of the isolates carried esbl genes (bla ctx-m- n = , bla ctx-m- n = , bla ctx-m- n = , bla ctx-m- -like n = ) and % carried pampc genes (bla cmy- n = , bla cmy- -like n = , bla dha- n = ). thirteen dogs carried an e. coli isolate with both an esbl and a pampc gene. dogs previously treated with antimicrobials within the last year were at higher risk of carrying at least one ß-lactamase (p = . ; or = . ; ci %: . - . ) or both ß-lactamases (p = . ; or = . ; ci %: . - . ) than non-treated dogs. dogs in shelters/breeders tended to show a higher incidence of esbl-producing e. coli (p = . ; or = . ; ci %: . - . ) or at least one ß-lactamase producing e. coli (p = . ; or = . ; ci %: . - . ) than dogs from private owners. males tended to be less likely to carry at least one ß-lactamase (esbl or pampc) (p = . ; or = . ; ci %: . - . ) or a pampc enzyme (p = . ; or = . ; ci %: . - . ) than females. this study suggests that dogs may act as reservoirs for resistant bacteria, namely for cephalosporin-resistant e. coli. three potential risk factors associated with the carriage of esbl-and/or pampc-producing e. coli by dogs were identified, which is important for the implementation of effective control measures and judicious antimicrobial therapy. conflicts of interest: dr pomba currently receives research funding from the government and national programmes (fundac ßão para a ciência e a tecnologia). in the past, she has occasionally received research support or honoraria for lectures from pharmaceutical companies including zoetis and atral cipan. she is vice-chair of the antimicrobial working party there are few reports in the literature reporting long-term relapse rate, owner compliance and clinical severity of dogs with chronic enteropathies. the goal of this study was to compare clinical activity index (ccecai), number of relapses and compliance rates - years after diagnosis. food-responsive disease (frd) was defined as dogs that responded to elimination diet alone within weeks after initiating therapy, whereas antibiotic-responsive disease (ard) dogs had an unsuccessful dietary trial before and responded to metronidazole within weeks after initiation of therapy, and steroidresponsive disease (srd)dogs had an unsuccessful dietary and antimicrobial trial before, and required immunosuppressive therapy to control their clinical signs. ccecai was extracted from the medical record database at - years after diagnosis. relapse rate was obtained by requesting the medical records of the referring veterinarians and defined as number of return visits to the referring practice after diagnosis. compliance data was obtained by telephone questionnaire to the owners. the frd group consisted of / dogs ( %), whereas the ard and srd groups consisted of ( %) and dogs ( %), respectively. there was a significant difference in ccecai at follow-up between frd and ard, and frd and srd (median ccecai . (range - ) for frd, (range - ) for ard, and . (range - ) for srd, p = . ). for the frd dogs, % of owners stated that they deviated from the prescription diet on a daily basis, % once a week, and % once a month, with a median ccecai at the time of deviation from the diet of . (range - ). relapse rate was highest for the ard group, when compared to frd and srd ( for ard, . for frd, and . for srd, p = . ). in the frd group, / dogs had been kept on the prescribed diets, and dogs had been changed to supermarket brands. all of the ard dogs had been given immunosuppressive treatment in addition to antibiotics at the time of follow-up, while / srd dogs were still on immunosuppressive treatments, with one dog being in remission with dietary treatment alone. in conclusion, this pilot study indicates that compliance rate for frd dogs is the lowest, with owners willing to tolerate the highest severity of clinical signs related to deviation from the prescription diet. ard dogs had the highest relapse rate in this cohort, indicating poor response to treatment in the long-term. conflicts of interest: dr allenspach has received research funding from bbsrc, american kennel club, comparative gastroenterology society, probiotics ltd uk, laboklin gmbh germany, and bioiberica sp. she has also undertaken paid consultancy work for bioiberica spain and hoffmann-laroche, switzerland. despite the high prevalence of canine pancreatitis in postmortem studies and the introduction of new diagnostic tests, it is believed that the disease, particularly in its chronic form, remains under recognised due to the non-specific nature of presenting signs. histology is considered to be the gold standard for diagnosis of canine pancreatitis, however, most clinicians are reluctant to take pancreatic biopsies due to significant risks to the patient. numerous serum markers have been reported to be elevated in canine pancreatitis, although most lack sensitivity or specificity. consequently, confirmed diagnosis requires results from a range of tests including imaging, serum biochemistry and physical examination. we and others have previously shown in other diseases that performance of individual low specificity markers can be dramatically improved by combining data from multiple markers with clinical information using analytical algorithms. we therefore applied this approach to the detection of pancreatitis in dogs. the activity of two non-specific biomarkers, amylase and lipase, was determined in serum samples from dogs suspected of having pancreatitis by their veterinarian. of these samples were positive by virtue of their pancreatic lipase (cpli) results (cpli > ug/l). the amylase and lipase data was then used to develop a series of algorithms using mathematical data mining and classification techniques. additional algorithms were developed using extra parameters including age, sex, vomiting, diarrhoea and abdominal pain in addition to the two enzyme levels. the performance of the algorithms was assessed using separate blinded serum samples taken from dogs which were scored clinically for acute pancreatitis according to the system described by mccord et al (j vet intern med ; : - ) . these cases presented for evaluation with vomiting, diarrhoea, inappetance and abdominal pain and were included if a clinical history, results of routine haematology, biochemistry, cpli assay and abdominal ultrasound were available. the results of the multifactorial analysis and cpli assay results were compared to the clinical scores. using amylase and lipase data alone, the algorithm gave a sensitivity of . % and specificity of . %, compared to cpli results for the same samples of . % and . % respectively when both methods were referred to clinical scoring. when the presence of additional clinic data was also included into the algorithm, the sensitivity increased to . % with specificity of %. the data suggests that test performance for canine pancreatitis can be dramatically improved when multiple diagnostic parameters are combined using disease specific algorithms. the author receives a salary as editor of the bsava journal companion, and has undertaken unrelated paid consultancies for bayer and merial. the author also receives a salary from avacta animal health, and duties involved working directly on this project. canine chronic enteropathy (cce) can cause significant long-term morbidity. in some cases this is due to intestinal inflammation, resulting from idiopathic inflammatory bowel disease (ibd). currently, the diagnosis of idiopathic ibd and assessment of disease severity relies on results of subjective clinical indices, laboratory data, diagnostic imaging and intestinal histopathology, whilst ruling out known causes of inflammation. in humans with ibd, a number of faecal biomarkers including lactoferrin, aid with diagnosis and determining disease activity. it may therefore be valuable to develop similar non-invasive objective methods to aid diagnosis and clinical assessment of disease severity in dogs with intestinal inflammation due to idiopathic ibd. this pilot study aimed to measure faecal lactoferrin concentration (flc) in dogs with cce and histologically confirmed intestinal inflammation (hcii) and to compare this with control dogs. in addition, the flc in dogs with hcii would be compared with the canine inflammatory bowel disease activity index (cibdai) and wsava standard histopathological criteria for intestinal inflammation to determine whether there was correlation between these methods when assessing disease severity. faecal samples were obtained from dogs with hcii (n = ) having undergone investigation for cce (serum biochemistry, complete blood count, full faecal and urinalysis, serum cobalamin, quantitative cpli, abdominal ultrasound and intestinal biopsies). the control population were dogs presented for reasons unrelated to cce (n = ). analysis was carried out using a faecal lactoferrin elisa previously validated in dogs (techlab, usa). the flc in dogs with hcii (median . lg/g -range . to . ) was significantly higher than control dogs (median . lg/g -range . - . ) (p < . ). a cut-off flc of . lg/g correctly identified / ( %) of dogs with hcii. using this cut-off, there was no overlap between non-cce dogs flc and the hcii group; giving a sensitivity of % and specificity of %. neither the presence of neutrophils nor the extent of inflammation on histopathology showed significant correlation with flc. the cibdai showed moderate correlation with flc in dogs with hcii (r = . , p = . ). the results of this pilot study suggest that flc is able to discriminate between dogs with cce due to hcii and dogs without cce. it is possible that incorporating flc into a panel of faecal biomarkers will enable non-invasive assessment of hcii and could serve as an adjunct to current measures of disease severity in dogs with idiopathic ibd. ryan bettencourt and james boone are employees of techlab, usa. they provided the elisa kits free of charge for this work. there was no other incentive provided and the results have been openly discussed between all parties. there has been no censorship placed on the results by tech-lab and they have been supportive of the work and submission of this abstract. there are no other conflicts to disclose. fecal s a and fecal calprotectin concentrations have been described as biomarkers in dogs with chronic enteropathies [ ]. however, to date there has been no direct comparison of these two markers in dogs with chronic diarrhea. the aim of this study was to evaluate the performance of these two markers in this situation. thirty one dogs presented for a history of chronic diarrhea were prospectively enrolled. the initial diagnostic workup for all patients included a serum biochemistry profile, fecal parasitology, abdominal ultrasound examination, and gastrointestinal endoscopy with collection of endoscopic biopsies. the severity of clinical signs was evaluated using the ccecai scoring index and patients were grouped by having a ccecai of < or ≥ . fecal calprotectin and s a were quantified as previously described [ ] . correlations were evaluated with the spearman rank correlation test. for both markers a receiver operating characteristics (roc) curve was used to select cut-off value that allowed the best discrimination between dogs with a ccecai< and dogs with a ccecai ≥ . sensitivity and specificity were calculated. correlation analyses revealed a significant positive correlation between s a and calprotectin (r = . ; p < . ). the optimal cut-off value for fecal calprotectin concentration was . lg/g, which was associated with a sensitivity of . % and a specificity of . % (auc= . ; p = . ). the optimal cutoff value for fecal s a concentration was . ng/g, which was associated with a sensitivity of . % and a specificity of % (auc= . ; p = . ). the sensitivity for fecal s a was higher than that for fecal calprotectin (p = . ). no significant difference was observed for the specificity of these two markers (p = . ). out of the dogs ( %) had concordant results for s a and calprotectin tests. among these dogs, presented with a ccecai < and of these dogs had both markers below their cut-off values. among the dogs with a ccecai≥ , dogs had both markers above their cutoff values. % of dogs ( / ) presented histologic signs of inflammation. sensitivities for fecal calprotectin and s a concentrations for histopathological intestinal inflammation were % and %, respectively, and specificities were % and %, respectively. at least in this group of patients fecal s a concentration was more sensitive (but less specific) to detect dogs with a cce-cai ≥ or histopathologic intestinal inflammation than fecal calprotectin concentration. weight loss and malabsorption of fat, protein, cobalamin and tocopherol in the face of normal exocrine pancreatic function have been reported in up to - % of cats older than years of age fed a variety of nutritionally balanced dry and wet foods (patil ap and cupp cj. proc. nestle-purina compan anim nutr summit, focus on gastroenterology, [ ] [ ] [ ] [ ] [ ] [ ] [ ] ) . the objectives of this study were to determine if serum cobalamin concentrations increased after oral administration of a cobalamin supplement to affected cats, and the duration of any positive response following cessation of supplementation. the study evaluated cats older than years of age with fat malabsorption demonstrated by either increased fecal fat (> %) or subnormal fat digestibility (< %), but without exocrine pancreatic insufficiency (epi) as assessed by assay of serum trypsin-like immunoreactivity (ftli). a commercially available solution of cobalamin containing mg mixed with ml of a liquid flavor enhancer was added to the food of each cat in a single dose each day for months, after which supplementation ceased. serum cobalamin (assayed by competitive binding assay performed through the gi laboratory at texas a&m university and evaluated using reference ranges derived by that laboratory) was determined immediately prior to initiation of supplementation, then weekly for weeks, then monthly for months. at the start of the study serum cobalamin was subnormal (< ng/l) in of the cats (range < to ng/l) and within the reference range ( to ng/l) in the remaining cats ( to ng/l). serum cobalamin was above the reference range in every cat ( to ng/l) after one week of supplementation and remained above the reference range in every sample collected during the supplementation period, with the exception of two cats with values within the reference range when supplementation was stopped. serum cobalamin , and months after cessation of supplementation ranged from < to , < to , and < to ng/l, respectively. at the end of the study serum cobalamin was subnormal in of the cats. it is concluded oral cobalamin supplementation can effectively increase serum cobalamin concentrations in geriatric cats with idiopathic chronic enteropathy, but that following cessation of supplementation concentrations decrease rapidly and can become subnormal again within as few as weeks. the primary author collaborated with nestle-purinaon the work reported in this abstract, and a co-authoris an employee of nestle-purina. the primary author has previously received funding from iams, mars, hills and nestle-purina. the author also acts as a paid consultant for the gi-lab, texas a&m university. left atrial measurements are crucial in assessing severity of cardiac disease in dogs with myxomatous mitral valve disease (mmvd). however, linear and area dimensions might not provide a comprehensive assessment of patient status, and cannot differentiate between severe subclinical (b ) and clinical disease (chf). estimates of left atrial function could provide additional information to help categorize these patients. we examined dogs with mmvd ( normal, b , b and c) presented for cardiac evaluations by d echocardiography. left atrial linear and area dimensions in right parasternal short and long axis views were obtained at time points -early diastole (la max ), just prior to mitral valve opening, at the onset of atrial systole (la p ) and just prior to mitral valve closure (la min ). we calculated indices of la function: total la emptying fraction (la tef ), active la emptying fraction (la act ), passive la emptying fraction (la pas ) and la reservoir function (la res ) for all sets of measurements. we examined the differences in selected la function indices between different disease stages with a kruskal wallis test with post-hoc multiple comparisons. we also examined the diagnostic accuracy of selected indices of la function in differentiating dogs in stage b and stage c (chf) using roc analysis. three functional indices consistently differed across the various stages of mmvd -la tef , la act and la res . these differences were most apparent in the rpla view for linear measurements and rpsa view for area measurements. dogs with chf had worse function than all other groups, which differed variably depending on the functional index being examined. laarea act showed the best ability to discriminate between b and chf dogs, with a % specificity, % sensitivity and an auc of . , but this was no better than use of la:ao measurements. our data suggest that la function differs between dogs with differing severities of mmvd, but does not provide a clear distinction between dogs with subclinical disease and chf. no conflicts of interest reported. materials and methods: de was used to evaluate consecutive, non-sedated dogs that weighed more than kg. the study population for the morphologic study included normal dogs, and dogs with acvim stages b or b -c mmvd. de image data were digitally recorded and then analyzed offline, using commercially available software. results: de image acquisition was feasible in / ( . %) consecutive dogs. patient anxiety ( ), arrhythmias ( ) and panting ( ) explained failure to obtain a de dataset. fortyone of ( . %) datasets were of analyzable quality. body weight and heart rate were significantly lower in dogs for which it was possible to perform de. dogs with analyzable de datasets were significantly older and weighed less than dogs in which de could not be analyzed. the mitral valve of normal dogs is saddle shaped (annulus height to commissural width ratio (ahcwr): . ae . [mean ae sd]) and has an elliptical annulus (sphericity index (si): . ae . ). the following measurements were significantly related to body surface area (bsa): antero-posterior diameter (apd) (r = . , p < . ), anterolateral-posteromedial diameter (alpmd) (r = . , p < . ), annulus area (aa) (r = . , p < . ), anterior leaflet length (all) (r = . , p < . ), anterior leaflet area (ala) (r = . , p < . ). these variables were indexed (i) to bsa for subsequent statistical analyses. dogs with mmvd had a significantly greater si, non-planar angle, apdi, alpmdi, alai and alli, while having a significantly lower posterior leaflet area (pla), posterior leaflet length (pll), annulus height (ah), tenting height (th), tenting volume (tv), tenting area (ta), and ahcwr compared to normal dogs. ah, tv and ta were significantly greater in normal dogs, compared to dogs with mmvd. si, apdi, al-pmdi, aai, alai and alli were significantly greater in dogs with stages b -c mmvd, compared to normal dogs and those in stage b . pll and pla were significantly lower in b -c dogs, compared to normal dogs. th was significantly different between the three groups; greatest in normal dogs and lowest in dogs in stages b -c, suggesting that flattening of the mv occurs with disease progression. conclusions: de assessment of the canine mv is feasible. morphologic changes associated with mmvd progression are presented. effective regurgitant orifice area (eroa), calculated from a dimensional measurement of the width of vena contracta (vc) as the narrowest portion of the proximal regurgitant jet, might be used to estimate severity of mitral regurgitation (mr). however, this simplified assumption only holds when the eroa is circular, which might not be true in dogs with myxomatous mitral valve disease (mmvd). the aim of the study was to compare measured eroa using color doppler real-time dimensional echocardiography (rt d) with calculated eroa estimated by dimensional echocardiography ( d) in chamber ( ch) and chamber ( ch) views of the left ventricle (lv) in dogs with mmvd. ninety-three privately owned dogs of breeds diagnosed with naturally acquired mmvd were examined using d and rt d. according to the acvim classification of congestive heart failure (chf), dogs were classified with chf ( in class c and in class c ) and dogs without chf ( dogs in class b and dogs in class b ). age ranged from to years (median years), and body weight ranged from . to kg (median kg). fifty-nine males ( %) and females ( %) were included, and heart rate ranged from to beats/minute (median b/min). eroa was calculated from d measurements of vc diameter, in the ch view only (assuming a circular regurgitant orifice), and from measurements of vc diameter in both ch and ch views (assuming an eliptical regurgitant orifice) of lv. bland-altman plots were used to compare eroa measured by rt d with calculated eroa obtained from d ch and ch/ ch lv views. none of the d estimations of eroa showed good agreement with the measured rt d eroa when corrected for bsa, and the difference between methods increased with increasing eroa. the difference between rt d and d methods normalized to the mean eroa value did not increase with increasing eroa, but showed a systematic underestimation of eroa by % ( ch) and % ( ch/ ch), respectively, compared to rt d. the beat-to-beat variation of eroa assessed by rt d (n = ) had a coefficient of variation ranging from . % to % (median %). in conclusion, substituting assessment of eroa with a measurement of vc in or dimensions might underestimate the mr severity in dogs with mmvd. in some dogs, the beat-tobeat variation of the eroa was large, thereby necessitating the need for several consecutive measurements. no conflicts of interest reported. micrornas (mirna) are short ( - nucleotides), singlestranded, non-coding rnas that specifically anneal with complementary sequences in multiple mrna targets, and they silence mrnas and suppress downstream protein translation. a mirna can act as a fine-tuner of gene expression or an on/off switch. these features highlight the potential of mir-nas as therapeutic targets. the role of mirnas in myocardial fibrosis and hypertrophic cardiomyopathy has been widely studied in human patients. however, there is no data available for canine and human myxomatous mitral valve disease (mmvd). the aim of this study was to investigate mirna transcriptomics in canine mmvd by using global transcriptional profiling, mirna target prediction software (diana tool, targetscan . ) and network analysis software (biolayout express d ). four myxomatous mitral valves (ckcs) and controls valves were profiled using the affymetrix canine gene . st array. in total out of mirnas were found to be statistically significantly differentially expressed (down-regulated) based on the false discovery rate, p-value, and fold-change. expression of three mirna (cfa-mir- b, cfa-mir- c, cfa-mir- ) were also validated by quantitative polymerase chain reaction (q-pcr, taqman), and the results were in agreement with the microarray findings. for network analysis and visualization, markov clustering algorithms were conducted in bio-layout express d , and major clusters of mirnas were exported and uploaded to the diana-mirpath (kegg pathway) web-server. the pathways identified in the main cluster were attributed to the biological functions of focal adhesion, cytoskeleton (actin) regulation, tgf-b signalling, glycosaminoglycan biosynthesis, osteoclast differentiation, notch signalling and vegf signalling. the most significantly down-regulated mirna in mmvd was cfa-mir- , which is an endothelial specific mirna shown to regulate endothelial migration and vessel patterning. the top predicted target of cfa-mir- is glucuronic acid epimerase (glce) which is the main enzyme controlling heparan sulphate biosynthesis. other interesting findings were down-regulation of cfa-mir- and members of the cfa-mir- family. cfa-mir- targets multiple extracellular matrix transcripts, such as collagens, elastin, integrin, laminin, mmp (matrix metalloproteinase) and adamts (a disintegrin and metalloproteinase with thrombospondin motifs), whereas cfa-mir- targets hyaluronic acid synthase (has ). since the major pathology of mmvd is aberrant turnover of extracellular matrix proteins, this may be linked to mir-na regulation. dysregulation of valve mirnas might be potential therapeutic targets in the treatment of canine mmvd. no conflicts of interest reported. mitral regurgitation (mr) progresses slowly, but dogs living long enough often develop congestive heart failure (chf). however, tools to predict onset of chf are sparse. echocardiographic examinations in dogs were performed in a longitudinal, multicenter study with a surveillance time of up to . years. client-owned dogswere enrolled at the university hospitals in finland, sweden and denmark (subset to the svep study). left ventricular end diastolic (lvidd) and systolic (lvids) diameters, fractional shortening (fs), left atrial (la) and aortic root (ao) diameters were estimated. values were normalized for body size (nlvidd, nlvids, and nla, respectively) and, for comparison, ratios to aortic root were calculated (lvidd/ao, lvids/ao and la/ao, respectively). a cox's proportional hazard analysis with a counting process approach was used. spline smoothed graphical models were constructed to evaluate linearity of hazards. curves were then used to find cut-off values for interval hazard ratios (hrs). the hr for nlvidd, nlvids and nla (per . unit, % confidence intervals), were . ( . - . , p = . ), . ( . - . , p = . ), and . ( . - . , p = . ), respectively. the hrs for lvidd/ao, lvids/ao and la/ao ( . unit increase) were . ( . - . , p = . ), . ( . - . , p = . ), and . ( . - . , p = . ), respectively. the hr for fs was . ( . - . , p = . ). the relative hazard plot presented a steep increase for fs values above %. hrs for intervals < %, < %, and ≥ % were . ( . - . , p = . ), . ( . - . , p = . ), and . ( . - . , p = . ), respectively. the hr for nlvidd increased linearly. hrs for intervals . < . , . < . , . < . and ≥ . were . ( . - . , p = . ), . ( . - . , p = . ), . ( . - . , p = . ), and . ( . - . , p = . ), respectively. in contrast, the hazard for nlvids remained stable until . , whereafter it increased. the hrs for nlvids ( < . , . < . , . < . and ≥ . ) were . ( . - . , p = . ), . ( . - . , p = . ), ( . - , p = . ), and . ( . - , p = . ), respectively. hrs for values normalized to ao diameter behaved in a parallel way. we conclude that fs, left ventricular and atrial size may be used to predict chf. however, because the value of a hr is dependent on the unit used and, more essentially, does not account for nonlinear change in hazard, interpretation of hazards is challenging. in contrast, interval hazards are only dependent on the reference interval used. therefore they are easier to implement in every day clinical work. no conflicts of interest reported. systemic arterial hypertension is not frequently recognized in dogs with mitral valve degeneration (mvd), although borderline hypertension is difficult to assess, mainly because of different measurement techniques, inter-operator variability and, most importantly, examination-related stress. the object of this study was to evaluate systolic arterial blood pressure (sbp) at initial presentation and at regular intervals in dogs with various clinical stages of mvd. fifty six dogs with mvd that had not received any heart medication prior to admission, were included in the study. based on the isachc staging system, were assigned to class i (group a), to class ii (group b) and to class iii. small-breed dogs and miniature poodles, in particular, were overrepresented. comorbidities that could affect sbp were ruled out prior to enrollment. sbp was measured using a commercially available veterinary oscillometric device, by applying the proper cuff on the cephalic artery. dogs were left to acclimate for - minutes and measurements were always taken by the same investigator, before any other examination was performed, with the dog sitting on the owner's lap. a total of readings were taken, outlier values were discarded and the mean of the remaining measurements was documented. after initial consultation, treatment was customized according to the clinical stage. sbp was then measured every months, up to months after initial admission. at presentation, all class i dogs had sbp > mm hg, with only / having spb ≥ mm hg, whereas all class ii dogs had sbp < mm hg. of class iii dogs, had sbp > mm hg, and had sbp ≥ mm hg. a linear mixed effects model was used to assess the temporal variability of the measured parameters between groups. groups were matched for gender, age and body weight. blood pressure measurements, for the duration of the study, were higher in group a dogs, compared to groups b and c (p < , ). at the same time, group c had significantly higher sbp values than group b dogs (p < , ). asymptomatic mvd dogs seem to have higher sbp measurements, compared to those with clinical evidence of heart failure. whether this difference is stress-related, a maladaptive mechanism of sympathetic and raas activation to mvd or idiopathic remains to be elucidated. no conflicts of interest reported. sarcoplasmic reticulum (sr) ca + -atpase and its regulatory proteins are pivotal determinants of myocardial active relaxation via calcium uptake against the sr-cytoplasmic gradient. the lowered density of the sr ca + -atpase has been well demonstrated in many species during chronic hemodynamic overload. the genes linked to sr calcium uptake were reported not only being expressed in peripheral blood but serving as potential cardiac biomarkers in dogs with chronic mitral regurgitation, such as sr ca + adenosine triphosphatase isoform a (ser-ca a), phospholamban (pln), and hs- associated protein x- (hax- ). the aim of this study is to determine whether the target genes expressed in the blood will be translatable to the myocardial setting as cardiac biomarkers. the mrna expression levels of the target genes (serca a, pln, hax- ) from biopsied left ventricle (lv) and peripheral white blood cells (pwbc) in surgical mitral valve repair cases were estimated with quantitative real-time pcr using comparative ct method with gapdh. the gene expression levels in lv and pwbc were compared and their clinical relationships were evaluated. the diagnostic power of the genetic expressions in pwbc was analyzed by comparing to those of normal dogs. the levels of all target genes expressed in lv and pwbc were highly correlated each other in linear regression analysis (p < . ; serca a, r = . , r = . ; pln, r = . , r = . ; hax- , r = . , r = . ), although lv and pwbc showed different expression levels in a paired comparison (p < . ). according to the severity of the heart failure (isachc), the expression levels of all genes were gradually and significantly reduced in both lv and pwbc (p < . ). especially, the serca a and pln expressed in pwbc could clearly discriminate all isachc groups from the control (p < . ). multivariate regression adjusted by age and body weight revealed that serca a and pln in lv were negatively associated with lv internal systolic dimension (p = . , adjusted r = . and p = . , adjusted r = . , respectively). pln was also negatively related with lv internal diastolic dimension (p = . , adjusted r = . ). additionally, receiver-operating characteristic analysis using pwbc showed high area under the curve (auc) values for all target genes on overall isachc groups (p < . ; serca a, auc= . ; pln, auc= . ; hax- , auc= . ). in conclusion, the transcriptional changes of the calcium uptake related genes in pwbc may be able to reflect myocardial hemodynamic stress as well as to be utilized as promising cardiac biomarkers. no conflicts of interest reported. the aim of this study was to estimate heart-rate normalized pulmonary transit times (nptt) in cardiomyopathic cats with or without congestive heart failure (chf), to assess potential associations of echocardiographic variables and nptt, and to evaluate nptt as a test for presence of chf. privately owned cats were included. nptt was measured using echocardiography and the ultrasound contrast media sonovue â in groups of cats: healthy cats (group ), cats with cardiomyopathy (cm) but without chf (group ), and cats with cm and chf (group ). receiver operating characteristic curves (roc) were created for nptt, left atrial diameter (lad) and the left atrial to aortic root ratio (la:ao) to assess and compare their usefulness as tests for presence of chf. interrelations between pulmonary blood volume (pbv), nptt, stroke volume (sv) and echocardiographic variables were investigated by means of uni-and multivariate analysis. nptt values in group , group and group were . (interquartile range (iqr) . - . ), . (iqr . - . ), and . (iqr . - . ), respectively. values were significantly different between all groups. pulmonary blood volumes in group , group , and group were . ml (iqr . ml- . ml), . ml (iqr . ml- . ml) and . ml (iqr . ml- . ml). sv, pbv and shortening fraction < % were significant predictors of nptt. nptt and la:ao ratio, not sv were the main predictors of pbv. analyzing roc for nptt as a clinical test for chf yielded an auc of . which was similar for la:ao ratio. nptt may be useful test for the presence of chf in cats with cm and as a measure of cardiac performance. nptt and la: ao ratios predict chf with equal accuracy. increased pbv is significantly associated with higher nptt and la:ao ratios. both decreased sv and increased pbv explain the increased nptt in cardiomyopathic cats. the author received a travel scholarship from zoetis to attend this congress. acute arterial thromboembolism (aate) occurs commonly in cats, and less frequently in dogs, mostly resulting in limb paresis or paralysis. diagnosis is based typically on physical examination and advanced imaging. diminished affected-limb peripheral blood flow induces changes in several analytes concentrations in affected limb venous samples, compared to their peripheral venous concentration. we hypothesized that in aate, local, affected-limb venous glucose concentration decreases below reference interval, while systemic glucose concentration remains unaffected. the study included groups for each species: paralytic aate cases, non-ambulatory controls with limb paralysis of orthopedic or neurologic disorders, and ambulatory controls diagnosed with various diseases. systemic and peripheral, affected-limb blood glucose concentrations were measured. group absolute (dglu) and relative (% dglu) differences were compared. no procedure-associated complications or pain were noted. peripheral blood glucose concentrations were decreased (p ≤ . ) only in cats and dogs with aate. dglu and %dglu were higher in the aate groups in both cats and dogs compared to their respective control groups (p < . , p < . , respectively), with no differences between the control groups. receiver operator characteristics analysis of dglu and %dglu as predictors of aate in cats had areas under the curve of . and . , respectively, and . and . , in dogs, respectively. dglu cutoffs of mg/dl and mg/dl, in cats and dogs, respectively, corresponded to sensitivity and specificity of % and % in cats, respectively, and % in dogs. dglu and %dglu are extremely accurate, readily-available, simple diagnostic markers of aate in cats and dogs. no conflicts of interest reported. glycaemia determination is usually included in routine biochemisty panels. no works are devoted to the evaluation of pheripheral glycaemia in animals suffering from arterial thrombosis. the aim of this study was to document the pheripheral glycaemia variations in hypoperfused limbs of patients affected by mriconfirmed arterial thrombosis. eleven dogs referred for monoparesis or paraparesis were recruited. inclusion criteria were a clinical examination supportive of limb hypoperfusion and availability of blood cell count, biochemical profile and urine analyses. before mri examination, peripheral glycaemia was tested. two blood samples were obtained, one from the affected limbs and one from a healty limb.plasmatic glycaemia was measured using an automated glucose analyser. all the patients underwent a total body mri (mri intera . t, philips medical systems) that provided the final diagnosis. the arterial thrombosis location was documented and the entity was scored. all the eleven patients were diagnosed with a peripheral thrombosis involving an arterial vessel and in some cases the relative branches. the thrombus was located: in the abdominal aorta ( / ), in the subclavian artery ( / ), in the axillary artery ( / ), in the iliac arteries ( / ). of the total amount of abdominal aortic thrombosis, / involved also the internal iliac arteries, / the external ones and / both internal and external. the extent of the thrombosis was classified as grade (g ), when the greatest portion of the thrombus did not reach half of the vessel lumen ( / patients); grade (g ), when the greatest portion of the thrombus was between / and / of the vessel lumen ( / ); grade (g ), when the thrombus exceded / of the lumen ( / ). a substantial decrease in pheripheral glycaemia values was found in sampling arising from the thrombosisaffected limbs. comparing thrombosis-affected limbs values with healthy limbs measurements from the same patient, the reduction was found from . % to . %. accounting only the g scored patients, the percentage of reduction was found up to the . % suggesting a proportional decrease related to the grade of occlusion. results from this study suggest that peripheral glycaemia values are affected by limb hypoperfusion disorders. if an arterial thrombosis is suspected, samples from the affected limbs and the healthy ones could be used to compare glycaemia values and to support the early stage therapy in anticipation of diagnostic imaging. further studies are needed to confirm the proportional relation of the decrease with thrombus entity. no conflicts of interest reported. canine idiopathic pulmonary fibrosis (cipf) is a progressive interstitial lung disease mainly affecting west highland white terriers (whwt). pulmonary hypertension (ph) may develop secondary to hypoxic vasoconstriction and/or pulmonary parenchymal infiltration. in the absence of measurable tricuspid regurgitation (tr), this co-morbid condition may be difficult to diagnose non-invasively. the degree of cardio-pulmonary impairment in cipf dogs can be evaluated through blood gas analysis (bga) and minute walking test ( mwt). a new echocardiographic index, the right pulmonary vein to pulmonary artery ratio (pv/pa) has been described for the detection of pulmonary venous hypertension. the aim of this study was to investigate pv/pa in cipf in order to determine its utility in the detection of ph and in the assessment of cardio-pulmonary disease severity. this prospective clinical cohort study included whwt with cipf (group a), healthy whwt (group b) and healthy dogs from other breeds (group c). diameters of right pv and pa were measured, in bi-dimensional (bd) and m-modes (mm), in a parasternal right long axis view, at the end of the t wave. other echocardiographic parameters for evaluation of ph were also measured: speed of tr, acceleration time to ejection time ratio of the pulmonary flow (at:et) and pulmonary artery to aorta ratio (pa/ao). bga was performed in dogs ( , and in groups a, b and c) and mwt in dogs ( , and ). values are given as meanaesd. in bd and mm mode, the pv/pa ratio was lower in group a (mm: . ae . , bd: . ae . ) compared to group b (mm: . ae . , bd: . ae . , p ≤ . ) and group c (mm: . ae . , bd: . ae . , p ≤ . ). the changes in pv/pa were both due to an increase of pa (p ≤ . ) and a decrease of pv (p ≤ . ). tr was found in % of dogs with cipf; mean pressure gradient was . ae . mmhg. at:et was lower in group a ( . ae . ) compared to group c ( . ae . , p = . ) and tended to be lower compared to group b ( . ae . , p = . ). pa/ao was not statistically different between groups. pv/pa was correlated with arterial po values (b mode: r = . , p = . ) and results of the mwt (b mode: r = . , p = . ). pv/pa was also correlated with at:et and the speed of tr, but not with pa/ao. in conclusion, in whwt affected by cipf, pv/pa is a useful indicator of ph and could serve in the assessment of disease severity. no conflicts of interest reported. ventricular septal defect (vsd) is the fourth most common congenital cardiac defect in dogs and the most common in cats. the aim of this study was to evaluate the long-term outcome in vsd patients. case records of animals were reviewed, of these re-evaluated echocardiographically and followed up by phone interview only. out of dogs pug was the most common breed ( %) followed by border terrier ( %). out of cats domestic short hair was most common ( %) followed by main coon ( %). isolated vsds were present in dogs and cats. complex defects (cds) were present in cases, most frequent anomalies being sub-aortic stenosis ( dogs, cat), pulmonic stenosis ( dogs, cats), tetralogy of fallot ( dogs, cats), cushion defects ( cats) and double-chambered right ventricle (dcrv) ( dogs, cats; in / dogs not present initially supporting the cause-and-effect theory). eisenmenger was observed in dog and cats. aortic insufficiency, not considered a cd, was noted in dogs. in dogs and cats ( % of isolated vsds and cat with a dcrv) the defect closed spontaneously. nine dogs and cats ( %) died of non-cardiac causes with an age at death of to (mean . ) months; dogs and cats died due to cardiac causes with an age at death of . to (mean . ) months. cardiac deaths were sudden ( dogs with cds) or euthanasia for left sided congestive heart (chf) failure associated with cds ( dogs, cat); right sided chf associated with cds ( cats); biventricular failure ( cat with cd); weakness (eisenmenger, dog and cat; fallot dog; cd cat). two cats developed chf due to unrelated hcm. only one dog with an isolated vsd was euthanized for chf. these results indicate that spontaneous vsd closure occurs more often than previously thought, most patients with isolated restrictive vsds live a normal life span without surgical intervention, but non-restrictive vsds or complex defects can be associated with significant morbidity and mortality. echocardiography early in life is crucial to identify the anomaly and cds, as well as useful to prognosticate long-term outcome and to identify patients where a surgical intervention should be considered if available. follow-up echocardiography is indicated to corroborate the prognosis, to detect complications due to the vsd and to detect unassociated acquired cardiac diseases. no conflicts of interest reported. centronuclear myopathy (cnm) is the most prevalent congenital inherited disorder affecting skeletal muscles in labrador retrievers. this disabling condition segregates worldwide and a recessive loss-of-function founder mutation was identified in the protein tyrosine phosphatase-like, member a gene (ptpla/ hacd ). the objectives of this study were ) to describe ptpla expression pattern in hearts from homozygous wild type (wt), heterozygous (het) and homozygous mutated (cnm) dogs, ) to assess and compare the left myocardial function in aging wt, het and cnm dogs. for this purpose, seven wt, four het and eleven cnm dogs were included in the study. ptpla mrna levels were assessed by rt-pcr and rt-qpcr. all dogs were examined using conventional echocardiography, d color tissue doppler imaging (tdi) and tdi-derived strain imaging. we found that the expression of the two wild type ptpla splice isoforms increased post-natally in wt dogs. their levels were halved in het dogs and drastically reduced in cnm dogs. in both het and cnm dogs, a slight left ventricular hypertrophy was detected using conventional echocardiography. tdi and strain imaging revealed that the left ventricular myocardial function was significantly altered in both het and cnm dogs compared to wt dogs. moreover, these functional defects were associated with significantly higher values of systemic arterial blood pressure, although maintained within normal ranges. in conclusion, subclinical myocardial alterations were detected in both het and cnm aging dogs from our french pedigree, suggesting a role for ptpla in long-term cardiovascular homeostasis. these findings prompt globalized confirmation in additional ptpla"'deficient dogs, which may thus be considered as a new large-size model for human left ventricular sub-clinical myocardial dysfunction. no conflicts of interest reported. mitral regurgitation (mr) secondary to degenerative mitral valve disease (dmvd) is the most common heart disease in dogs. in dogs with mr, mitral valve prolapse caused by degeneration of the mitral valve leaflet, chordae tendinae extension and/or rupture and mitral annulus dilation are observed. however, limited data are available on morphological changes in dogs with mr. currently, there are no studies confirming the anomaly of the mitral complex via direct observation in living dogs with mitral regurgitation. at our institution over the last ten years, approximately dogs have undergone mitral valve repair. during surgery, the anomaly of mitral complex can be observed macroscopically (directly visualized). to our knowledge, this is the first study evaluating the anomaly of the mitral valve leaflet and chordae tendineae in dogs undergoing mitral valve repair. animals: dogs that underwent mitral valve repair with cpb at nihon university between february and june were included in this study. methods: confirmation of chordae tendineae rupture was visually confirmed during surgery. the sites of chordae tendineae rupture were also recorded at that time. septal chordae and mural chordae were divided three division depend on the site (s , s , s and m , m , m respectively). results: ninety eight dogs were included in this study. the mean age and body weight were . ae . years and . ae . kg, respectively. of the dogs, ruptured chordae was observed in dogs ( . %). septal leaflet chordae was ruptured in dogs ( . %) and mural leaflet chordae was ruptured in dogs ( . %). chordae of both leaflets were ruptured in dogs ( . %). no chordal rupture was observed in dogs ( . %). in the dogs with ruptured septal chordae, the chordae between s and s was most often ruptured (n = , %). in this study, rupture of the septal chordae tendineae was most commonly observed. this is the first pilot study to visually evaluate the anomaly of the mitral valve leaflet and chordae tendineae in dogs undergoing mitral valve repair. future studies comparing pathological changes and molecular biological analysis to gross findings of mitral chordae tendineae in dogs undergoing mitral valve repair may be useful in advancing the understanding of the disease. no conflicts of interest reported. echocardiographic aortic valve (ao) measurements are routinely obtained during cardiac evaluation of patients. cardiologists commonly use diastolic ao measurements to obtain ratiometric weight-independent estimates of dimensions of other cardiac structures, most commonly the left atrium (la). however, no consensus exists about the point in diastole at which ao measurements should be obtained -immediately after closure of the aortic valve, when la size is largest (ao max , but often with least distinct margins), during the p-wave of the ecg (ao p ) and at the onset of ventricular electrical systole, when la size is smallest (ao min ). we examined the linear and area dimensions of the ao (aod and aoa) to determine if clinically significant differences exist at distinct diastolic time-points, or if these measurements could be interchangeable. we examined patients ( dogs and cats) presented for cardiac evaluations by d echocardiography. three replicates of each time-point linear and area measurement (ao max , ao p , ao min ) were obtained in each patient and averaged for analysis. only patients with aortic valve disease and those with atrial fibrillation were excluded from analysis. beat-to-beat variability of the ao measurements was determined. standard and normalized limits of agreement (loa) plots were generated for each pairwise comparison. the frequency of each ao measurement being the largest or smallest within-patient measurement was determined, and compared via repeated measures anova. all pairwise agreement plots of both aod and aoa demonstrated heteroscedasticity; normalized aod plots showed % loa to be % of the mean aod measurement, with a bias of approximately . % for aod max -aod min , % for aod max -aod p , and % for aod p -aod min . normalized aoa plots showed %loa to be % of the mean aoa measurement, with a bias of approximately % for aoa max -aoa min , % for aoa max -aoa p , and % for aoa p -aoa min . aod max was the largest measurement in / ( %) patients and aod min was the smallest measurement in / ( %) patients; aoa max was the largest measurement in / ( %) patients and aoa min was the smallest measurement in / ( %) patients. rmanova confirmed that ao max >ao p >ao min (p < . ). median within-patient within-measurement variability was % for aod and % for aoa measurements. our data suggest that ao measurements differ throughout diastole, with ao max >ao p >ao min . the disparity is greater for area than linear estimates. the degree of disagreement between ao max and ao p is small and similar to the within-measurement variability. thus, using either ao max or ao p measurements should result in similar ratiometric estimates of cardiac dimensions. no conflicts of interest reported. feline hypertrophic cardiomyopathy (fhcm) is the most common heart disease in cats. hcm is considered an inherited disease of the sarcomere and fhcm has been linked to mutations in one sarcomere protein i.e. mybpc . however, the pathophysiologic mechanisms behind disease development and progression are largely unknown. in this study we investigate whether mitochondrial morphological changes in the myocardium accompany mitochondrial dysfunction and enhanced oxidative stress formation that we recently found in fhcm. myocardial tissue from the left ventricle (lv) was obtained immediately after euthanasia from cats diagnosed with primary hcm on echocardiography ( maine coon, british shorthair, exotic shorthair, norwegian forest cat) and age-matched control cats ( maine coon, norwegian forest cats). ultrastructural examination was performed by the use of transmission electron microscopy. in hcm cats, marked ultrastructural changes of the cardiomyocytes were observed. the population of subsarcolemmal mitochondria (ssm) was absent in large cellular areas in cats with moderate and severe lv hypertrophy. flattening of the sarcolemma was a common finding, causing disorganization of the t-tubular system. interfibrillar mitochondria (ifm) were disorganized but not depleted. additional changes in cardiomyocytes from cats diagnosed with fhcm included remodeling of sarcomeres, disorganization of myofibrils, convolution of gap junctions, accumulation of intracellular z-disc material, perinuclear lipofuscin granula and extensive extracellular deposits of collagen. in healthy mammalian cardiomyocytes, the t-tubular system upholds cellular structure, prevents mitochondrial reticulum formation and provides calcium, oxygen and substrates, necessary for normal functioning muscle. disorganization of the sarcolemma and t-tubular system may cause the depletion of ssm. possible mechanisms are atrophy or disruption of the mitochondria or altered fusion-fission dynamics. calcium cycling and substrate supply are likely to be compromised by the observed structural changes. we propose this to be related to mitochondrial dysfunction and oxidative stress formation that occurs in fhcm, however a causative relationship remains unknown. in conclusion, morphological changes of mitochondria and extra-sarcomeric structures are common in fhcm, regardless of breed, genotype and phenotypic disease expression. moreover, mitochondrial subpopulation-specific changes occur in fhcm with depletion of ssm. ultrastructural and functional changes of cardiac muscle mitochondria are considered important molecular mechanisms, responsible for the development and progression of fhcm and may be relevant future treatment targets. no conflicts of interest reported. patent ductus arteriosus (pda) is one of the most common congenital cardiac defect in the dog. ductal patency is associated with pulmonary overcirculation, left ventricular volume overload and can rapidly determine congestive heart failure if untreated. several devices to close the pda have been used, with amplatzer canine duct occluder (acdo©) being considered the safer device with lowest complication rates. echocardiography represents the cornerstone of pda diagnosis, but its role has been recently expanded to wider field of application: device sizing and intraoperative monitoring, as well as a tool to quantify cardiac morphology and function. speckletracking echocardiography (ste) has been used to evaluate cardiac function in a wide variety of diseases in human and veterinary patients, however no study has evaluated its usefulness in dogs affected by pda both before and after percutaneous closure of pda. the aim of our study was therefore to assess standard m/bmode derived parameter of cardiac function and ste derived longitudinal, radial and circumferential strain and strain rate before and after pda closure. twenty-five dogs of different breeds, age and weight were prospectively recruited and a complete echocardiographic evaluation was performed before and hours after pda closure. end diastolic and systolic diameters indexed for body surface area (edvi/esvi) both derived by m-mode and b-mode views, allometric scaling derived allod and allos, sphericity index (si) and pulmonary to systemic flow ratio (qp/qs) were assessed both pre and postoperatively. ste derived parameters assessed were longitudinal, radial and circumferential strain and strain rate. a statistically significant difference was found in all standard parameters of cardiac function before and after pda closure (p < . ), with a general decrease in values hours postoperatively. ste derived parameters of cardiac function showed a trend toward a decrease back to normal values, which was statistically significant (p < . ) for circumferential and radial strain and strain rate, while longitudinal strain and strain rate did not reach statistically significance. based on our results, no cardiac dysfunction was identified by the use of ste derived parameters both before and after pda closure, with an increased contractility as identified by higher than normal ste values before pda closure and a decrease back to normal strain and strain rate values for both circumferential and radial immediately after percutaneous closure. longitudinal strain persists on higher than normal values, refusing the hypothesis of systolic dysfunction after pda closure and suggesting a longer reverse remodeling process after pda closure. dr bussadori receives royalties from esaote (florence, italy) related to an european patent (nr ) he developed for xstrain software. the study was not funded by a research grant. cardiac cachexia which is characterized by progressive weight loss and depletion of lean body mass, is an independent predictor of survival in human patients with congestive heart failure. chronic degenerative mitral valve disease (cdmd) is one of the most common cardiac diseases in dogs. the aims of this study were to evaluate the prevalence and the effects of cardiac cachexia in survival of dogs with cdmd. medical records of client-owned dogs with cdmd were reviewed. the mean age at entry was . ae . years; were females, and were males. data obtained from the records including breed, sex, body weight, age at diagnosis, complete blood counts, biochemical profiles, urinalysis, systemic blood pressure, thoracic radiographs, electrocardiograms, ultrasonography and echocardiographic examinations at initial visit and survival time. diagnosis of cdmd was based on echocardiographic characteristics and categorized by modified new york heart association (nyha) functional classification. cardiac cachexia was defined as presence unintentional weight loss (> % within months after diagnosis) together with anorexia and muscle weakness, anemia (red cell count < . /ll, hemoglobin < g/dl, or both), hypoalbuminemia (plasma albumin < . g/dl), and azotemia (blood urea nitrogen > g/dl, creatinine > . g/dl, or both). dogs with other cardiac disorders and other systemic disorders those would cause anemia and hypoalbuminemia were excluded from this study. prevalence of cardiac cachexia, anemia and azotemia was . %, . % and . %, respectively. these conditions were the most prevalent in nyha class , followed by nyha classes and . the prevalence of hypoalbuminemia was not significantly different among classes. the one-year body weight change was found in the nyha classes (increased . ae . %), (decreased . ae . %) and (decreased . ae . %). the difference between classes and was significant. results of the cox proportional hazard model indicated that survival time was significantly positively associated with nyha functional severity at diagnosis (p < . ), presence of cardiac cachexia, weight loss, anemia, hypoalbuminemia and azotemia (p < . , p = . , p = . , p = . and p = . , respectively). the prevalence of cardiac cachexia was common in advanced cdmd dogs, and the parameters of cardiac cachexia, namely weight loss, anemia, hypoalbuminemia and azotemia were strong prognostic factors associated with survival. no conflicts of interest reported. mitral valve disease (mvd) is the most common cardiovascular disease in dogs. it's characterized by myxomatous degeneration, which causes mitral valve prolapse (mvp), mitral regurgitation (mr) and a left apical systolic murmur (lasm). mvd affects small breed dogs with a very high prevalence in cavalier king charles spaniels (ckcs). the main goal of this study was to determine the prevalence of lasm, mvp and mr in the maltese, the most presented breed among dogs with mvd in taiwan. the correlation between these measurements and the influence of age, gender, reproductive state, and body weight were also investigated. study results were compared to other mvd prevalence studies in europe and north-america. client-owned maltese dogs ( males and females; body weight . - . kg; age - yrs) with no signs of heart failure were recruited. the intensity (grade - ) of lasm was recorded. grade of mvp (mild/severe) and mr severity (mild/moderate/ severe) were evaluated by echocardiography. logistic regression was used to determine the correlation between age and presence of lasm, mvp and mr. a chi-square test was used to evaluate whether sex and reproductive-status were related to prevalences of lasm, mvp and mr. spearman's correlation coefficient was used to assess the relationships between age, body weight, lasm intensity, grade of mvp and severity of mr. the prevalence of lasm, mvp and mr were . %, % and . %, respectively. all have positive correlation with age (p = . ). the age at which % of the dogs had lasm, mvp and mr was . , . , and . years, respectively. the lasm intensity, mvp grade and mr severity were all positively correlated to age (all p = . ) and had no correlation with bw and reproductive status. females had a significantly higher prevalence of lasm than males ( % vs. . %, p = . ). maltese dogs in taiwan have a very high prevalence and an early development of mvd as compared to other small breed dogs, similar to mvd in ckcs in other countries. since we only recruited asymptomatic dogs, this study may underestimate the prevalence of mvd in the whole maltese population. to our knowledge, this is the first report to document the high prevalence of mvd in taiwanese maltese.the maltese may be a new canine model for genetic, pathology, and natural history studies in mvd. boehringer-ingelheim sponsored the author's accommodation costs for this congress. esvc-o- cardiorenal syndrome in dogs with chronic valvular heart disease: a retrospective study. e. martinelli , p. scarpa , c. quintavalla , c. locatelli , p. brambilla . university of parma, parma, italy, university of milan, milan, italy in human medicine, primary disorders of the heart often result in secondary dysfunction or injury to the kidneys. the coexistence of the two problems in the same patient is referred as cardiorenal syndrome (crs). just little information about crs is available in veterinary medicine. the aim of this study was to define the prevalence of chronic kidney disease (ckd) complicating chronic valvular heart disease (cvhd) in dogs and to investigate the relationship between class of cardiac insufficiency (acvim) and class of renal insufficiency (iris). medical records of dogs presented at the cardiology service of the department of veterinary science and public health, university of milan, between january and december were retrospectively evaluated. dogs with a complete physical examination, thoracic radiographs, a cvhd diagnosis based on echocardiographic examination, and a serum biochemical panel, including assessment of serum creatinine (scr) and serum urea (bun), were included in the study. dogs with other heart disease, neoplasm or systemic diseases were not included in the study. one hundred eighteen dogs of both genders ( males and females), to years of age ( . ae . years), to kg of bodyweight ( . ae . kg) fulfilled the inclusion criteria. the % of males and the % of females were neutered. the most represented breeds were mongrel ( %), miniature poodle ( . %), york shire terrier ( . %), shih -tzu ( . %), pinscher ( . %) and dachshund ( . %). dogs were classified as follow: % acvim a, % acvim b , % acvim b , % acvim c and % acvim d. while the % of the dogs were normoazotemic (scr < , mg/dl), % were staged in iris , % in iris and %in iris . statistical analysis was performed using jmp . (sas institute inc.). a p value < , was considered significant. the prevalence of ckd associated with azotemia in dogs affected by cvhd was %. there was a statistically significant direct correlation between acvim and iris class (pearson test p = . ). unexpectedly, the % of dogs receiving drugs for medical management of heart failure (acvim class c and d) were normoazotemic. despite a definite conclusion about the role of cvhd on the induction and/or progression of ckd cannot be drawn from this cross-sectional study, these results suggest that there is a direct correlation between the severity of ckd and cvhd. no conflicts of interest reported. there is growing evidence of breed differences in concentrations of several blood variables in dogs. the aim of the study was to investigate breed differences in plasma concentrations of components of the renin-angiotensin-aldosterone system (raas), endothelin- (et- ) and serum cortisol concentration in healthy dogs. healthy, privately-owned dogs of nine breeds were examined at five centers as part of the european lupa-project. absence of cardiovascular or other clinically relevant organrelated or systemic disease was ensured by thorough clinical investigations. plasma concentrations of et- and aldosterone, renin activity, and serum concentration of cortisol were measured by ria or elisa assays. overall significant breed differences were found (p < . for all variables). bonferroni-corrected pair-wise significant differences between breeds were found in % of comparisons for et- , % for cortisol, % for renin and % for aldosterone. for et- , the highest median concentration was found in newfoundlands with values > times higher than most other breeds, while renin was highest in dachshunds, > times higher than in newfoundlands and boxers, which had the lowest concentrations. aldosterone was especially low in belgian shepherds with median concentration < times than the other breeds. cortisol was highest in finnish lapphunds, almost times higher than boxers with the lowest concentration. in conclusion, considerable inter-breed variation in concentrations of et- , components of raas and cortisol was found in healthy dogs. these differences are likely influenced by genetic factors and should be taken into account when designing clinical trials and tests. breed-specific reference ranges might be necessary. no conflicts of interest reported. most studies that assess weight management in obese dogs only examine the early stages of weight loss, and this may not properly reflect a complete weight management regime. the aim of the current study was to examine the kinetics of a complete weight management cycle in obese client-owned dogs. dogs referred to the royal canin weight management clinic, university of liverpool, for the management of obesity, were eligible for inclusion. all dogs were followed until they had either completed (i.e. reached target weight) or the programme was discontinued. rate of weight loss, percentage weight lost, and energy were assessed at different time points. a total of dogs were included, with a range of breeds, ages and sexes represented. rate of weight loss steadily decreased throughout the weight loss period (d : . ae . %/wk; d : . ae . %/wk; d : . ae . %/wk; d : . ae . %/wk; d . ae . %/wk; d : . ae . %/wk; p < . ). the energy intake required to maintain weight loss also progressively decreased (p < . ). by day , mean aesd weight loss was ae . %, and compliance was good, but most had not com-pleted ( % completed, % ongoing, % discontinued). thereafter, more dogs completed, but the number of discontinuing also increased (d : ae . % weight loss, % completed, % ongoing, % discontinued; d : ae . % weight loss; % completed, % ongoing, % stopped). initial weight loss is good in obese dogs but, thereafter, steadily worsens. thus, studies examining only the first few months of weight loss are not fully representative of the entire weight loss process. conflicts of interest: the following conflicts of interest apply: the diet used in this study is manufactured by royal canin.whilst vb is employed by royal canin. vb and ss are employed by royal canin. ajg's readership is funded by royal canin. obesity and obesity-related metabolic dysfunctions are increasing in humans as well as in dogs. obese dogs become affected by chronic diseases at young age, have a decreased quality of life and a shorter life-span. the aim of the study was to describe the metabolic and hormonal response to a feed-challenge test in lean and overweight dogs. twenty-eight healthy intact male labrador retrievers aged . ae . years with varying body condition score (bcs, scale - ) were included. twelve dogs were classified as lean (bcs - ), ten as slightly overweight (bcs ) and six as overweight (bcs . - ). an overnight fasting period and blood sample collection was followed by a high fat meal. after food intake, blood samples were collected hourly for four hours. a glucagon elisa was validated for use in dogs. the assigned bcs was supported by positive association with serum leptin concentrations. postprandial triglyceride concentration was significantly higher in the overweight group. a tendency to higher cholesterol concentration was seen in the overweight group but cholesterol was not affected by food intake. glucagon concentration rose after food intake and resembled the response seen in humans after a mixed meal. glucose and insulin concentrations followed the same pattern while free fatty acids had declined one hour after the meal. in this study, the metabolic and hormonal response to a high fat meal was similar between lean and slightly overweight dogs, whereas the response of overweight dogs differed. studies on the health significance of postprandial hypertriglyceridemia in dogs are warranted. conflicts of interest: the study was financially supported by the swedish veterinarian federation, the companion animal research foundation, and the foundation of thure f. & karin forsberg. feline weight-loss programs are often hindered by compliance issues and sedentary lifestyle. the purpose of this study was to assess the effectiveness of a new dietetic weight management food (ndwmf)* in achieving weight loss in overweight/obese, client-owned cats. the objectives were ) to evaluate weight loss parameters in cats fed the ndwmf* and ) to describe the owner's perception of the cat's quality of life. overweight/obese, otherwise healthy, client-owned cats (> / body condition score -bcs) were enrolled in the study (n = ). initial veterinary evaluation comprised a physical examination, nutritional assess-ment, determination of ideal body weight (ibw), and development of weight loss feeding plan. daily energy requirement (der) for weight loss was calculated as der = . x ( x ibw kg . ). initial and follow-up evaluations (monthly for months) consisted in determination of body weight (bw), bcs, body fat index (bfi), muscle condition score (mcs), and current feeding practices. quality of life assessment by owners included cat's level of energy, happiness, appetite, begging behavior, flatulence, stool volume, and fecal score. statistical analysis encompassed scatterplots, regression analysis, summary statistics as appropriate for the type of analyses (continuous or categorical variables, distribution), a mixed model anova was used to assess changes over time (statistical significance at p < . ). eighty three percent of the cats (n = ) lost weight with an average weight loss of % (sem, . %) over months and an average weekly weight loss rate of . % (sem, . %). a significant decrease in bcs from week - and in bfi from week - compared to baseline was observed. mcs did not change. average duration of weight loss was days (sem, . days) with days (sem, . days) between visits. fourteen percent of cats achieved ibw ( . , ci: . - . ). seventy nine percent of cats ate more than the recommended der (median fed above der= %), and the majority of these cats still lost weight. owners perceived a significant increase in energy and happiness (>week ) compared to baseline in the cats that lost weight without changes in appetite or begging behavior. no significant changes were seen in scores for flatulence, stool volume, and fecal score. in conclusion, this clinical study showed that feeding the ndwmf* to client-owned, overweight/obese cats resulted in weight loss. owners reported significant improvements in cat's quality of life without negative side effects. * porphyrias are a group of inborn errors of metabolism resulting from accumulation of porphyrins due to deficient activities of specific enzymes in heme biosynthesis. in humans, they are clinically classified as either erythroid with cutaneous involvement or hepatic with acute neurovisceral attacks. here we describe the clinical, biochemical, and molecular genetic studies in porphyric cats from new brunswick, canada. from to , three separately identified adult domestic shorthair cats from the city of saint john in new brunswick were found to have erythrodontia (brown discolored teeth which fluoresced pink) and pigmenturia. a mild compensated hemolytic disorder with numerous small dark blue irregularly shaped erythrocyte inclusions was noted. there was no evidence of acute lifethreatening neurovisceral attacks or cutaneous lesions. necropsy of one cat revealed massive deposition of porphyrins in all bones and teeth. urine and edta blood samples from one cat were metabolically studied, while molecular genetic studies were performed in all cats either from edta blood or a formalinized splenic tissue block. urinary d-aminolevulinic acid, porphobilinogen, uroporphyrin i, and coproporphyrin i concentrations were increased in the cat studied, suggesting an acute intermittent porphyria (aip). the erythrocytic hydroxymethylbilane synthase (hmbs) activity in erythrocytes was approximately half normal suggesting a dominant enzymopathy, while the erythrocyte uroporphyrinogen iiisynthase activity was normal. sequencing the feline hmbs gene revealed a heterozygous intronic base deletion (c. - _- del) which results in an insertion in the mrna and would predict a truncated protein. in conclusion, these three domestic shorthair cats had the same hmbs mutation causing an autosomal dominantly inherited aip. cats with discolored teeth and normal or mild hemolysis may have either acute intermittent porphyria or congenital erythroid porphyria. interestingly, seven disease-causing mutations have now been found by us in the hmbs gene -more than in any other gene in cats. the biochemical and molecular characterization facilitates clinical screening of affected cats to reach a specific diagnosis. supported in part by nih od . urs giger and raj karthik are also part of the laboratory that offers dna testing for this mutation. fibrinogen decreases when coagulation is activated to form fibrin, while fdps and d-dimers represent the products of fibrinolysis. in humans, activation of coagulation and fibrinolysis develops in all type of ascites and it is also associated with signs of systemic fibrinolysis.these results have lead to the suggestion that ascitic fluid is inherently fibrinolytic. preliminary studies showed similar results also in dogs (javma nov. , ecvim proceedings . in addition, in an old experimental study conducted in dogs, inoculation of blood or of a solution containing fibrinogen and thrombin into the pleural cavity resulted in the activation of the coagulation system followed by fibrinolysis. therefore, the objective of the present study was to determine whether the activation of coagulation and fibrinolysis (i.e. low fibrinogen and elevated fdps and ddimer) occurs not only in the ascitic fluid, as alredy been demonstrated, but also in all type of pleural effusions in dogs. thirty-three dogs referred to the san marco veterinary clinic with pleural effusion, but without ascites, were studied. fibrinogen, fdps, and d-dimer concentrations were measured and then compared in both pleural fluid and venous blood via wilcoxon signed ranks test. the dog's pleural effusions were categorized based on pathophysiology of fluid formation into dogs with transudate ( due to increased hydrostatic pressure and due to decreased osmotic pressure), with an exudate (of which due to septic causes), with a haemorrhagic pleural effusion, and with a chylous effusions. the fibrinogen concentration in the pleural effusion (median: mg/dl; range: - ) was significantly lower (p < . ) than the plasma fibrinogen concentration (median: mg/dl; range: - ). in all dogs, the fibrinogen pleural fluid concentration was lower than the plasma concentration. the fdp concentration in the pleural effusion (median: mg/dl; range: . - ) was significantly (p < . ) higher than plasma fdps concentrations (median: . mg/dl; range: . - . ). in case, the fdps pleural fluid concentration was lower than the plasma concentration and in cases the pleural fluid concentration was higher. the d-dimer concentrations were significantly(p < . ) higher in the pleural effusion (median: . lg/ml; range: . - . ) than in the plasma (median: . lg/ml; range: . - . ). in one case, the d-dimer pleural fluid concentration was lower than the plasma concentration and in cases was higher. these findings support the hypothesis that activation of coagulation followed by fibrinolysis occurs in all type of pleural effusions. no conflicts of interest reported. during primary hyperfibrinogenolysis (phf), fdps production is increased but production of d-dimer is not. therefore, elevated fdps and normal d-dimer are considered an indicator of phf. in humans and dogs, activation of coagulation and fibrinolysis develops in all type of ascites and it is associated with systemic phf, suggesting that ascitis is inherently fibrinolytic. preliminary data have shown that activation of coagulation followed by fibrinolysis occurs also in all type of pleural effusions (pe). the objective of this study was to determine if systemic phf occurs also in dogs with pe. thirty-three dogs referred to the san marco veterinary clinic with pe, but without ascites, were studied (group ). from the electronic data-base of the clinic dogs for inclusion in control groups (healthy dogs) and (sick dogs without pe or ascites) were randomly selected and individually matched to group dogs for age, sex, and breed. fibrinogen, fdps, d-dimers, c-reactive protein (crp), fibrinogen/crp ratio, and prevalence of phf (i.e., dogs with elevated plasma fdps and normal d-dimer) were determined. differences between the groups were analyzed using anova (fibrinogen), chi-square (fdps and prevalence of phf) and kruskal-wallis test (crp, fibrinogen/crp ratio, and d-dimer). post-test analysis were performed by tamhane and mann-whitney test. fibrinogen concentration in group was significantly increased compared to group (p < . ), but not compared to group (p = . ). fdps concentration in group was significantly increased compared to groups (p < . ), but not compared to group (p = . ). d-dimers concentration in group was significantly increased compared to group (p < . ), but not compared to group (p = . ). crp was significantly increased in group compared to group and (p < . for both comparison). fibrinogen/crp ratio was significantly decreased in group compared to group and (p < . for both comparison). prevalence of phf was significantly higher in group compared to groups (p = . ), but not compared to group (p = . ). these results support the hypothesis that phf occurs significantly more often in dogs with pe compared to healthy dogs. despite there was a trend of increased phf also in dogs with pe compared to sick dogs, this difference did not reach significance. nevertheless, the decreased in fibrinogen/crp ratio in group compared to group , in the face of a similar d-dimer concentration, would suggest that phf is also more prevalent in dogs with pe compared to sick control dogs. no conflicts of interest reported. the systemic inflammatory response syndrome (sirs) refers to clinical signs of systemic inflammation in response to (non-) infectious insults. current diagnosis of sirs is based on clinical and basic laboratory data and is a sensitive screening to identify patients at risk. c-reactive protein (crp) is a major canine acute phase protein with concentrations related to disease severity and underlying cause. crp rises in response to proinflammatory cytokines, mainly interleukin (il)- and tumor necrosis factor (tnf)-a, which are considered the main triggers of sirs. we therefore evaluated crp, il- and tnf-a kinetics in canine emergency sirs patients hypothesizing that crp is ( ) increased in dogs with a clinical sirs-diagnosis, ( ) correlated with il- and tnf-a concentrations, ( ) influenced by the underlying etiology, and ( ) a prognostic marker. canine emergencies with clinically diagnosed sirs were prospectively included. serum and plasma were immediately stored at - °c after sampling at presentation, after (t ), (t ), (t ) and (t ) hours, and at a control visit (t m) over one month after discharge. serum crp was measured with a caninespecific immunoturbidimetric crp assay. plasma il- and tnfa were measured using a bioassay measuring biologically active cytokine concentrations. disease categories were infection (i), neoplasia (n), trauma (t), gastric-dilation and volvulus (gdv), other gastrointestinal (gi), renal (r) and miscellaneous (m) diseases. statistical analysis was performed with sas. concentrations of inflammatory cytokines were expressed logarithmically, with univariate analysis confirming normal distribution. a correlation procedure, mixed procedure on a linear model and a logistic procedure were performed (p-value < . ). sixty seven dogs (i = , n = , t = , gdv= , gi= , r = , m = ) were included. forty-three patients survived (seven died, seventeen were euthanized). twenty patients had a control visit. crp was elevated in . % of dogs at presentation, and only remained within reference range ( - . mg/l) throughout hospitalization in four dogs ( . %). crp concentrations were significantly higher from t ( . ae . mg/l) to t ( . ae . mg/l) decreasing at t ( . ae . mg/l), and returning within reference range at t m ( . ae . mg/l) in all but one dog ( . mg/l). crp was significantly correlated with logarithmical concentrations of il- and tnf-a, however, these did not change significantly over time. none of the evaluated parameters was associated with disease category, nor outcome. crp appears useful to diagnose sirs in emergency patients, and tends to decrease during hospitalization. however, crp, neither il- nor tnf-a concentrations appear useful to predict the underlying disease and outcome in sirs patients. no conflicts of interest reported. calprotectin (s a /a complex) belongs to the s /calgranulin family, and is primarily released from activated neutrophils and macrophages. serum calprotectin concentrations (cp) were shown to be increased in dogs with inflammatory diseases such as inflammatory bowel disease, pancreatitis, systemic inflammatory response syndrome, and sepsis. canine cp thus appears to be a biomarker of inflammation. considerable day-today variation of fecal canine cp was found in both healthy dogs and dogs with chronic gastrointestinal disease. however, the biological variation of canine cp in serum has not been reported. the aim of this study was to determine the biological variation of serum canine cp and its minimum critical difference (mcd). eleven healthy dogs were used for this study. biological variation of serum canine cp was evaluated over a . -months period. tests for outliers were carried out at levels (within-run analytical variance, intra-, and inter-individual variation). a nested analysis of variance (anova) model was used to calculate analytical (cv a ), intra-individual (cv i ), inter-individual (cv g ), and total variation (cv t ), and to determine the index of individuality (ii), index of heterogeneity (ih), and mcd. a total of serial specimens were collected from dogs, serial samples from dogs, and serial samples from dogs. four within-subject outliers were detected and excluded from further analysis, yielding a total of serum samples and slightly right-skewed data. no outlying observations (cochrane test) or outliers among mean concentrations of subjects (reed's criterion) were detected. cv a was calculated as . %, cv i as . %, and cv g as . %, resulting in a cv t of . %. index of individuality (ii) was determined to be . and ih was . , yielding a one-sided mcd of . mg/l. the analytical goal of cv a ≤ ½ cv i was satisfied. although serum canine cp remained within a relatively narrow concentration range in healthy dogs, moderate individuality was detected. moderate changes in serum canine cp ( . mg/l) between sequential measurements are needed to be considered clinically relevant, and using a population-based reference interval may or may not be appropriate for serum canine cp. using the mcd with the previously determined median canine cp concentration ( . mg/l) for the reference sample group yielded a serum canine cp concentration close to the upper limit of the previously established reference interval ( . mg/l), showing that the reference interval for serum ccp ( . - . mg/l) is within reasonable limits. the assay used in the study was developed at the gi laboratory, texas a&m university. most authors also work at the gi laboratory, texa a&m university. canine leishmaniasis (canl) is a multisystemic disease that is endemic in the mediterranean region. in the past, concentrations of acute phase proteins (apps), and specifically c-reactive protein (crp), haptoglobin (hp), ceruloplasmin (cp), serum amyloid a (saa) and albumin (alb), have been reported to change in dogs with leishmaniasis, and revert to normal after successful treatment, highlighting the intrinsic inflammatory reaction of the host to the parasite. since the spectrum of clinical and laboratory derangements is broad, it is possible that apps are increased specifically because of certain clinicopathological syndromes associated with canl. a total of dogs with canl, diagnosed on the basis of cytological amastigote identification and ifat serology, were retrospectively included in the study. in all of them, crp, saa, hp and alb were measured at interlab-umu, murcia, spain, in aliquots of serum, which were stored in - °c for - years (median: years). results for each of the apps were correlated to laboratory and clinical parameters (n: ), clinical and parasitological scoring (n: ), ehrlichia and leishmania serology (n: ), and clinical staging according to leishvet (n: ), using an array of linear and ordinal regression models, as well as one-way anova, t-test and fisher's lsd test. crp and alb were by far the apps most frequently correlated with clinical and laboratory abnormalities such as nutritional status, lethargy and skin ulcers (p < , ), as well as urinary protein to creatinine ratio (upc), total serum protein, and urine specific gravity (p < , ). there were limited associations between hp, cp, saa and clinicopathological parameters. a minor linear relationship was observed between crp and clinical scoring. crp and alb were also correlated with parasitological scoring in bone marrow, but not lymph node cytology (p < . ). dogs with ehrlichia titers had higher crp, cp and lower alb concentrations. finally, crp concentrations were higher in later compared to earlier stages of the infection, as defined by the leishvet criteria. the inflammatory component to leishmania infection doesn't seem to be exemplified by the reaction of a particular tissue, with the possible exception of glomerulonephritis. the magnitude of increase in crp and decrease in albumin is correlated with clinical staging and bone marrow parasitological scoring. no conflicts of interest reported. the consequences of abnormal platelet function in dogs and cats can be devastating and the use of anti-thrombotic therapy to prevent thrombotic events is increasingly common. the ability to measure platelet function and the efficacy of anti-thrombotic therapy is difficult due to limited availability of equipment and inability to delay platelet function analysis. the aim of this study was to adapt and validate test procedures and protocols previously developed for humans for use in dogs and cats. residual samples of citrate anticoagulated blood were used from dogs and cats presented to a specialist referral centre for various reasons unrelated to clotting abnormalities. initially the blood was stimulated using specific combinations of either arachidonic acid/epinephrine (aa/epi) or adp/u , designed to assess the effects of the anti-thrombotic agents aspirin and clopidogrel respectively. after minutes stimulation, the blood samples were fixed using a patented platelet fixative solution developed for human platelets, which allows the delayed analysis of p-selectin an established marker of platelet activation. all analysis was performed by flow cytometry. in order to do this, specific antibodies were selected for the recognition of both canine and feline platelets. cd was used as a platelet identifier antibody while appropriate cd p (p-selectin) antibodies for each species were chosen. fixed samples were repeatedly analysed at time points between to days following fixation to establish the stability of the fixed samples. thirteen dogs and three cats were analysed. high p-selectin expression was detected following stimulation with aa/epi and adp/u in both dogs and cats following fixation. this was significantly different to unstimulated blood (p < . ). there was no significant difference in detectable pselectin expression following storage of the fixed samples at any time-point up to days. this confirmed the fixative was suitable as a preservative of canine and feline platelets. a limited number of dogs were evaluated whilst receiving antithrombotic medication. there was a significant difference in the activation of platelets in the dogs treated with either aspirin (p < . ) or clopidogrel (p < . ) compared with untreated dogs following stimulation with aa/epi (aspirin group) or adp/ u (clopidogrel group). our results show that fixation and delayed analysis of platelet function in dogs and cats is possible for up to days. this demonstrates an exciting opportunity to analyse platelet function remotely and to determine the efficacy of thromboprophylaxis in animals presenting to clinics that do not have on-site platelet analysers. no conflicts of interest reported. several authors consider thyroid hormone supplementation as a valid initial treatment option for dogs with aggression related problems. indeed, mood and behaviour modulating properties of thyroid hormones may, in part, be mediated through the interaction of thyroid hormones with neurohormones such as serotonin and prolactin. at present, prospective trials evaluating neurohormonal status or behaviour in hypothyroid dogs before and after thyroid supplementation are lacking. therefore, the aims of this study were to assess behaviour and measure serum serotonin and prolactin concentrations in dogs with spontaneous hypothyroidism before and after treatment.twenty three client-owned dogs diagnosed with spontaneous primary hypothyroidism were prospectively included in our study. after diagnosis all dogs were treated with levothyroxine ( micrograms/kg bid). behaviour of dogs was screened at initial presentation, at weeks and months after initiation of therapy. owners had to fill in a hard copy of the standardized canine behavioural assessment and research questionnaire (c-barq) consisting of scored questions evaluating seven behavioural categories. the average score on all questions was calculated for each dog at each of the three time periods and a paired t-test was used for comparison. serum serotonin and prolactin concentrations were evaluated at each time period using a commercially validated elisa kit and heterologous ria, respectively.results of the c-barq after six weeks of thyroid hormone supplementation when compared with the time zero demonstrated a significant increase (p < . ) in excitability, activity and aggression, which most likely became unmasked owing to improved overall activity of dogs. conversely, at six months period when compared with the time zero no significant changes in any of the behavioural symptoms were observed. serum serotonin was measured in / dogs colorimetrically at nm. at time zero, weeks and months serum serotonine was . (range, . - . ), . (range, , - . ) and . (range, . - . ). no significant difference was noted between week and month period comparing to time zero (p = . and p = . ). serum prolactin concentration measured in / dogs at time zero, weeks and months was . ng/ml (range, . - . ), . ng/ml (range, . - . ) and . ng/ml (range, . - . ) and did not differ significantly in either time period when compared with time zero (p = . and p = . ).altogether, results of this study failed to demonstrate a significant role of thyroid supplementation on the majority of evaluated behavioural symptoms as well as neurohormonal status of hypothyroid dogs during months of therapy. no conflicts of interest reported. iatrogenic hypothyroidism is a recognized complication of radioiodine treatment of hyperthyroidism in cats, but no prospective studies of the prevalence, clinical features, routine laboratory findings, or results of thyroid function tests have been reported in a series of hypothyroid cats. in this study, we describe the features of hypothyroidism in cats treated with radioiodine over a -month period (october -march ). during this same period, we treated % hyperthyroid cats with radioiodine, providing a prevalence rate of %. hypothyroidism was diagnosed - days (median, days) after i treatment, with doses ranging from - mbq (median, mbq; median pretreatment t , nmol/l). the hypothyroid cats ranged in age from - years (median, years). all were dsh/dlh; ( %) were female and were males (p = . ). clinical signs in these cats included overweight/obesity in ( %), lethargy/dullness in ( %), poor appetite in ( . %), and polyuria/polydipsia in ( %). abnormalities on physical examination included dermatologic signs (dry coat, seborrhea, matting) in ( %) and bradycardia (< bpm) in . twenty-two cats ( %) had no noticeable clinical features of hypothyroidism. routine laboratory abnormalities included hypercholesterolemia (> mmol/l) in ( %) and new or worsening azotemia (> lmol/l) in ( %) and ( %) cats, respectively. median serum concentrations of total t ( . nmol/l; reference interval [ri], - nmol/l), t ( . nmol/l; ri, . - . nmol/l), and ft ( pmol/l; ri, - pmol/l) were all in the low end of the ri. normal ri values for t and ft were maintained in ( %) and ( %) of the cats, respectively. serum ctsh values were high in all cats (median, . ng/dl; range, . - . ng/dl; ri, . - . ng/ml). thyroid scintigraphy showed less-than-normal amounts of residual tissue, as well as low values for thyroid-to-salivary ratio and %-uptake of pertechnetate, in ( %). of those cats with normal scintiscans, serum ctsh decreased into the ri without treatment when retested - months later. in conclusion, this study confirms that i-induced hypothyroidism is not uncommon, with an apparent female sex predilection. serum t and ft remain normal in most cats, but high serum ctsh values and thyroid scintigraphy aid in diagnosis. unless cats have overt, long-standing hypothyroidism, most cats with subclinical disease are relatively asymptomatic, other than worsening azotemia. subclinical hypothyroidism will be transient in some cats, with normalization of ctsh values within a few months. no conflicts of interest reported. iatrogenic hypothyroidism is a recognized complication of radioiodine treatment for hyperthyroidism in cats. at our clinic where we use a variable -i dosing protocol (based on tumor volume and severity of hyperthyroidism), the prevalence of overt or subclinical hypothyroidism is at least %. during the -month period from october to march , we treated cats with iatrogenic hypothyroidism, which had developed - days (median, days) after treatment with radioiodine (median dose, mbq). these cats ranged in age from - years (median, years); all were dsh/dlh; ( %) were female and were males. new or worsening azotemia (> lmol/l) was documented in ( %) and ( . %) cats, respectively. diagnosis of hypothyroidism was based on the following: ) low to low-normal serum concentrations of t , ft , and t ; ) high serum tsh concentration (> . ng/dl); and ) less-than-normal amounts of residual tissue on thyroid scintigraphy. all cats were given thyroid hormone replacement as a liquid l-t preparation (leventa; merck animal health). cats were monitored at - month intervals by repeating serum t and tsh concentrations - hours after the morning l-t dose. ten of the cats were started on a once-daily l-t regimen ( lg); of these, only ( %) had suppression of high serum tsh values into the reference interval (ri). of the cats that had persistently high tsh values, were switched to twice-daily administration ( - lg, bid), which successfully lowered high tsh concentrations in cats. the remaining cats were started on twice daily l-t ( lg, bid); of these, normalization of tsh occurred in cats. overall, l-t treatment was successful in normalizing tsh concentrations in ( %) cats, with once-daily and with twice-daily dosing. peak serum t concentrations of ≥ nmol/l were needed in most cats to normalize tsh values. higher serum t and lower tsh concentrations were achieved when l-t was administered on an empty stomach rather than given with food. a significant decrease (p < . ) in serum creatinine occurred after treatment with l-t . in conclusion, our results indicate that twice-daily administration of l-t is needed in most cats with iatrogenic hypothyroidism to normalize high serum tsh concentrations. many cats appear to absorb l-t rather poorly, which can be enhanced by giving the drug on an empty stomach. the azotemia that commonly develops in cats with hypothyroidism improved or stabilized with adequate l-t supplementation. no conflicts of interest reported. congenital hypothyroidism (ch) has been reported in many species; the hereditary forms can be divided into thyroid dysmorphogenesis and dyshormonogenesis. while thyroid hypoplasia has been described in dogs and cats, the molecular basis remains unknown. in contrast few breeds of dogs with goiterous ch were found to have deficient thyroid peroxidase (tpo) activity. the purpose of our study was to characterize a family of domestic shorthair cats with goiterous ch and disease-causing tpo gene mutations. clinical features included dwarfism and dullness, known as cretinism and seen with ch in all species, but also constipation and megacolon which are unique to cats with ch. pedigree analysis documented an autosomal recessive mode of inheritance. affected kittens developed a goiter and had low serum thyroxine (t ) and triiodothyronine (t ) when compared to controls, but high thyroid stimulating (tsh) hormone levels indicating thyroid dyshormonogenesis. oral thyroid supplementation corrected the progression of clinical signs and prevented further constipation and reversed the megacolon. the tpo enzyme activity was extremely low in hypothyroid cats when compared to that of normal cats. genomic dna and cdna from affected, carrier, and normal cats were extracted and sequenced based upon primers developed from the feline genome database. a homozygous missense point mutation (c. g>a) in tpo, which results in an amino acid change (p.ala thr), was discovered in affected cats and the mutant allele segregated within the family with goiterous ch. this is the first report of a tpo deficiency in cats. other unrelated domestic shorthair cats with goiterous ch did not have this same tpo mutation. the prevalence of this tpo mutation in the domestic cat population seems low, but ch is likely underreported in cats. supported in part by nih od . some of the authors are members of diagnostic laboratories (penngen). supported in part by the nih od # . glucagon-like peptide- (glp- )is a gastrointestinal hormone released in response to food intake that increases insulin secretion, inhibits glucagon secretion, slows gastric emptying and induces satiation. it is also assumed to stimulate beta-cell proliferation. glp- agonists are successfully used in humans with type diabetes mellitus usually either in combination with insulin or other anti-diabetic drugs. in healthy cats twice daily (exenatide) as well as once weekly (exenatide extended-release (er)) application of glp- agonists induced pronounced insulin secretion. benefits of exenatide er are the regimen of once weekly injection and less side effects. the objective of the study was to assess whether administration of exenatide er in addition to standard treatment leads to improved glycemic control and higher remission rates in cats with newly diagnosed diabetes. the study was designed as a prospective, placebo-controlled clinical trial. cats were randomly assigned to two groups receiving exenatide er (group : bydureon â , mg/kg, q d, sc) or . % saline solution (group : q d, sc). both groups additionally received insulin glargine (lantus â , initial dose: ≤ kg: . iu, q h; > kg . - . iu, q h) and diet (purina dm â ). exenatide er was applied over weeks or, in case of remission, for additional weeks after cessation of insulin application. cats were rechecked , , , and weeks after starting therapy. remission of diabetes was defined as absence of clinical signs of diabetes and normal blood glucose and fructosamine concentrations for at least weeks after discontinuing insulin injections. so far cats have completed the study. mild and transient side effects in group (n = ) were reduced appetite (n = ), nausea (n = ), vomitus (n = ), tiredness (n = ) and hiding in dark spots of the house (n = ). in group remission was achieved in / ( %) cats and good metabolic control in / ( %) nonremission cats. in group remission was achieved in / ( %) cats and good metabolic control in / ( %) non-remission cats. median insulin dose given during the study period was . iu/ kg/day in group and . iu/kg/day in group . the preliminary results suggest that exenatide er can be used safely in diabetic cats. a tendency for higher remission rate, better metabolic control and lower insulin requirement was seen when exenatide er was added to the standard treatment regimen. further cases need to be evaluated to verify the potential beneficial role of exenatide er. no conflicts of interest reported. feline diabetes mellitus shares many similarities with human type diabetes mellitus (t dm), including clinical, physiological and pathological features of the disease. domestic cats spontaneously develop diabetes associated with insulin resistance in their middle age or later, with residual but declining insulin secretion. humans and cats share the same environment and risk factors for diabetes, such as obesity and physical inactivity. moreover, amyloid formation and loss of beta cells are found in the diabetic cat pancreas, as in humans. subsequently, studying the molecular mechanisms in the failing beta cells may contribute to a better understanding of the pathophysiology of t dm in both cats and humans. the aim of the present study was to develop a method to study mrna expression of islet-specific genes in healthy and diabetic cats. previous attempts in isolating feline islets with different collagenase-based protocols have led to damaged islets or islets coated with exocrine acinar cells, which either way compromise the results obtained from gene expression studies. by using the laser microdissection technique, we were able to sample islets that were not contaminated with exocrine tissue, from both healthy and diabetic cats. high rna quality was confirmed with gel electrophoresis. by quantitative real-time pcr (qrt-pcr), mrna levels of the islet-specific genes insulin, pdx- , iapp, chga and ia- were detected in both healthy and diabetic cats. we used actin b, gapdh and rps as internal reference genes for normalizations of our qrt-pcr data. the laser microdissection technique allows studies of islets without contamination of acinar cells, as shown in this study, and is of great advantage since it is difficult to get pure feline islets from collagenase-based isolation. differences in gene expression in healthy and diabetic cats may reveal underlying mechanisms for beta cell dysfunction and decreased beta cell mass in human and feline type diabetes. conflicts of interest: the study was financially supported by the swedish juvenile diabetes foundation, the fredrik and ingrid thuring foundation, the magnus bergvall foundation, the lars hierta memorial foundation, and the foundation for research, agria insurance company. feline acromegaly is an increasingly recognised endocrinopathy among diabetic cats, caused by chronic excessive growth hormone secretion by a functional somatotrophinoma in the pars distalis of the anterior pituitary gland. the majority of human somatotrophinomas are sporadic, however up to % of familial isolated pituitary adenomas are caused by germline mutations of the aryl-hydrocarbon-receptor interacting protein (aip). feline acromegaly has phenotypic and biochemical similarities to human familial acromegaly with aip mutations, such as male predominance, somatotroph macroadenoma and resistance to octreotide therapy. the objective of this study was to identify the feline aip gene, identify single nucleotide polymorphisms (snps) within this gene and compare any snps with reported human aip snps. stored pituitary tissue from an acromegalic cat was used to create feline aip cdna using feline specific aip primers. stored edta blood from acromegalic cats (diagnosis of insulin resistant diabetes mellitus, serum igf- > ng/ml and pituitary mass > mm identified using pituitary computed tomography or necropsy) and control cats (no history of diabetes mellitus and greater than years of age) were selected, dna extracted and genotyped using pcr, agarose gel electrophoresis and sanger sequencing. the feline aip gene was identified, encoding a amino acid protein with % homology to the human aip protein. a blast search revealed this gene contained exons and exon specific primers were created to enable sequencing. a single nonconservative snp was identified in exon (aip:c. g>t), encoding for an amino acid change from aspartic acid to glutamic acid in / acromegalic patients and / control cats. two additional conservative snps were also identified (aip:c. t>c and aip:c. t>c). exon encodes for a region of the aip protein considered essential for aip-aip receptor interaction. although different human aip mutations have been identified to date, a human aip:c g>t mutation has not yet been identified. the aip n-terminal is required for the stability of the aip protein-aip-receptor complex, and essential for the regulation of translocation into the nucleus, where it binds to aryl hydrocarbon receptor nuclear translocator leading to activation of genes thought to act as tumor suppressors. loss of normal aip activity is thought to promote somatotrophinoma development. it is therefore possible that the detected aip:c. g>t mutation predisposed to somatotrophinoma tumorigenesis in the two affected patients, and a study containing a larger number of cases is indicated. no conflicts of interest reported. hypersomatotrophism (hs) is an important cause of feline diabetes mellitus (dm). in humans surgical removal of the somatotrophinoma is generally recommended, though hypophysectomy programs have suffered from significant initial morbidity and mortality given a documented steep learning curve in newly established programs. hypophysectomy as treatment for feline hs has thus far only been described in a handful of cases, all having been treated by one single experienced hypophysectomy team. this study's aim was to evaluate the learning curve of a de novo established hypophysectomy program, through analysis of peri-and post-operative morbidity and mortality, and endocrine outcomes in the first cohort of cats with hs treated. from owners of diabetic cats with confirmed hs (igf- > ng/ml, pituitary mass) presented at the royal veterinary college were offered hypophysectomy. all cats undergoing surgery were operated by one neurosurgeon with previously only cadaveric experience of the procedure, through an adapted transsphenoidal approach referencing bony landmarks to computed tomographic scans reconstructed on neuronavigation software. the somatotrophinoma was extirpated using fine surgical tools. all cats received intense electrolyte and blood pressure monitoring, peri-and post-operative ddavp and intravenous insulin and hydrocortisone infusion, transitioning to subcutaneous glargine, conjunctival ddavp, oral hydrocortisone and levothyroxine. between april -february , cats underwent hypophysectomy (median + range age: . years, . - . ; igf- : ng/ml, -> ; pituitary height . mm, . - . ). all displayed uncontrolled dm due to hs (median fructosamine: umol/l); none displayed overt central neurological deficits. two cats ( %, cats and ; pituitary height (mm): . and . ) required mechanical ventilation post-operatively and both were euthanized. post-mortem magnetic resonance imaging revealed brain herniation and cerebral ischaemia was suspected. one cat suffered cardiac arrest post-operatively at time of jugular catheter placement, though made an uneventful recovery. four other cats developed congestive heart failure within days, which was successfully treated not necessitating ongoing therapy. temporarily diminished tear production was seen in cats. seven of the ten surviving cats went into diabetic remission within a median of . days ( - ); others saw reduction of insulin needs by %. serum igf- normalised rapidly and significantly in all but one cat (median serum igf- ng/ml within days). persistent neurological deficits or palatal wound breakdown were not encountered. starting a hypophysectomy program to treat feline hs was associated with some risk of mortality, though surviving cases benefited from the procedure with a high incidence of diabetic remission. no conflicts of interest reported. pituitary dependent hypercortisolism (pdh) in dogs is frequently associated with high serum phosphate and parathormone concentrations. the pathogenesis of such abnormalities remains unknown and the evaluation of the urinary fractional excretion of phosphate and calcium in pdh dogs might be helpful in enhancing the knowledge regarding this issue. the aim of the present study was to evaluate the serum and urinary concentrations and the urinary fractional excretion of phosphate and calcium in dogs with pdh. medical records from one referral center were retrospectively evaluated between and . the diagnosis of pdh was confirmed using the cortisol to creatinine ratio, the ldds test and/or acth stimulation test, the plasma acth concentration, ultrasonography of the adrenal glands and computer tomography (ct) of the pituitary and the adrenal glands in dogs with consistent clinical signs. only newly diagnosed dogs, before treatment for pdh, were evaluated. two control groups were included: one healthy and one sick control dog (without pdh) for each dog with pdh were included. healthy control dogs (hcd) and sick control dogs (scd) were matched for age (ae months), breed, sex and sexual status. data were analysed using non-parametric tests and expressed as median and ranges. significance was set at p < . . one-hundredsixty-seven dogs with pdh were eligible for inclusion in the study. the median age at diagnosis was years (range: - ) and the median body weight was . kg (range: . - . ). there were female ( spayed) and male ( castrated). serum phosphate concentration ( . mg/dl, . - . ) was significantly (p < . ) higher compared to hcd ( . mg/dl, . - . ) and scd ( . mg/dl, . - . ). serum calcium concentration ( . mg/dl, . - . ) was significantly higher compared to scd ( . mg/dl, . - . ) but not different compared to hcd ( . mg/dl, . - . ). urinary fractional excretion of phosphate ( . %, . - . ) was significantly lower compared to hcd ( . %, . - . ) and scd ( . %, - . ). urinary fractional excretion of calcium ( . %, - . ) was significantly higher compared to hcd ( . %, . - . ) and scd ( . %, - . ). urinary calcium to creatinine ratio ( . , - . ) was significantly higher compared to hcd ( . . - . ) and scd ( . , - . ), while urinary phosphate to creatinine ratio were not significantly different in pdh dogs, hcd and scd. in conclusion pdh dogs have lower phosphaturia and higher calciuria compared to control dogs. this findings suggest that, at least in part, the high serum phosphate concentrations are related to the renal retention of phosphate. no conflicts of interest reported. four cortisol-based methods of monitoring trilostane treatment of canine hyperadrenocorticism were compared to the results of a clinical scoring scheme based on an owner questionnaire. cases of canine hyperadrenocorticism that had received a consistent dose of trilostane for more than one month were recruited from first opinion and referral practice. each dog was used only once. owners were asked to complete a questionnaire that assessed clinical control. the dogs were then categorised as being over-controlled, well-controlled, moderately-controlled and poorly-controlled. cortisol was measured in serum samples taken pre-trilostane (peak), hours post-trilostane (trough) and hour post-acth injection. dogs that had an increase in cortisol after trilostane administration were excluded. a scoring system was developed for each of these measurements. a fourth scoring system was developed using a novel algorithm that combined the peak and trough cortisol (peak-trough). the results of each of the scoring systems categorised the dogs into those that would be expected to be over-controlled, well-controlled, moderately-controlled and poorly-controlled. weighted kappa was calculated to assess the agreement between the categorisation according to each of the methods compared to the categorisation using the owners score. the pearson correlation coefficient was calculated to assess relationships between the various parameters. in total tests were analysed. when compared to the results of the owner's questionnaire , , and dogs were correctly categorised using the peak-trough, peak alone, post-acth and trough alone respectively. amongst the miscategorised results , , and dogs were incorrect by category and , , and dogs by categories using the peak-trough, peak alone, post-acth and trough alone respectively. all methods correctly recognised the over-controlled dog that had been identified by the owner's score. the weighted kappas for post-acth and trough cortisol categories compared to the owner score categories were . and . respectively (defined as slight agreement). in contrast the weighted kappas for the peak and peak-trough categories were . and . respectively (defined as fair agreement). there were no significant correlations between the absolute clinical scores and cortisol concentrations. there were significant correlations between the cortisol measurements. the novel methods of peak-trough and peak cortisol better reflected the level of clinical control of hyperadrenocorticism identified by the owners' questionnaire than either post-acth stimulation or trough cortisol. peak-trough and peak cortisol concentrations should be further investigated as monitoring methods for trilostane. financial support from dechra pharmaceuticals. the prognosis of canine adrenocortical insufficiency is generally regarded to be excellent. however, there is paucity of sur-vival analyses in the literature. the aim of the present study was to evaluate the survival of dogs with the diagnosis adrenocortical insufficiency based on data from a cohort of , swedish client-owned dogs insured in one insurance company (agria pet insurance, stockholm, sweden) during the time period - . dogs were identified by search for insurance claims with the register code for adrenocortical insufficiency. dogs were excluded from analysis if they had a previous history of hypercortisolism, and if they were born before begin of the study period. kaplan-meier survival analysis was performed. dogs were regarded as censored when the registered cause of death was other than adrenocortical insufficiency or hypercortisolism that was registered after the first claim for adrenocortical insufficiency. data from dogs was included. one hundred twenty-four dogs were registered to be dead. in dogs the cause of death was related to the adrenocortical insufficiency. the -year estimated survival-rate was % ( % ci, - %). the -year estimated survival-rate was % ( % ci, - %). the -year estimated survival-rate was % ( % ci, - %). twelve dogs ( . %) were still alive after years. in conclusion, the long-term survival of dogs with adrenocortical insufficiency was reasonably good. however, the diseases-related mortality was higher than expected, and occurred mainly during the first years after diagnosis. conflicts of interest: this study was supported by grants from the swedish research council and the foundation for research, agria insurance company. the concomitant occurrence of two or more endocrine tumors and/or hyperplasias, known as multiple endocrine neoplasia (men) is a well-known entity in humans. multiple gene mutations have been identified. the two major forms are men and men . in men , the main affected organs are parathyroid, pancreas and pituitary gland. men occurs in clinical variants: men a, characterized by medullary thyroid carcinoma (mtc), pheochromocytoma and primary hyperparathyroidism; men b, characterized by mtc, pheochromocytoma and additionally abnormalities; familial medullary thyroid carcinoma. in dogs and cats only a few cases have been reported and it is unknown whether hereditary men-like syndromes exist in these species. the aim of this study was to evaluate the prevalence of multiple endocrine tumors in dogs and cats at our institution, to identify possible breed and sex predispositions and to investigate similarities with the human men syndromes. autopsy reports of dogs and cats from until were reviewed. animals with at least two endocrine tumors/hyperplasias (eth) were included. autopsy reports of dogs and cats were examined. dogs had eth affecting a single organ, had multiple eth; cats had single eth, had multiple eth. in dogs with multiple eth, the most common breeds were west highland white terrier (whwt, / ), poodle, golden retriever, mixed-breed dogs (each / ). / were male ( intact); / were female ( neutered). median age was years (range - ). the most common combination was multiple testicle tumors of various types ( / ). the most common affected organs were the adrenals ( / ). adrenal cortical adenomas/carcinomas/hyperplasias were mainly associated with pheochromocytomas ( / ), testicle tumors ( / ) and insulinomas ( / ). all whwts had adrenal adenomas. both poodles had pheochromocytoma associated with pituitary adenoma or adrenal hyperplasia. dogs showed tumor combinations similar to the human men syndrome: pituitary adenoma and insulinoma; pituitary adenoma and parathyroid hyperplasia. / cats were domestic short/long hair, / were persians. / were male ( castrated); / were female ( neutered). the median age was . years (range - ). the most common affected organs were thyroid glands ( / ), combined mostly with lesions of parathyroid ( / ) and adrenal glands ( / ). none of the cats had combinations similar to the human men syndromes. the prevalence of multiple eth in dogs and cats was . % and . %. men-like syndromes were extremely rare in dogs and non-existing in cats. no sex predisposition was observed. possible breed predispositions need further investigations. no conflicts of interest reported. canine angiostrongylosis is an increasingly reported disease worldwilde, including many european countries, possibly due to climatic factors, presence of foxes (acting as reservoir) or more simply, to the availability of more accurate diagnostic methods. although detection of the first-stage larvae (l ) using the baermann technique on faecal samples (preferably collected over three consecutive days) remains the gold standard, recently developed serological and molecular tests (quantitative polymerase chain reaction, qpcr) are now available. until now, the prevalence of canine angiostrongylosis among healthy and coughing dogs in belgium was unknown. the aims of the present study were ( ) to describe a clinical series of recent autochtonous cases and ( ) to retrospectively assess angiostrongylus vasorum qpcr in bronchoalveolar lavage fluid (balf) samples, collected over the last years from a larger series of dogs, healthy or with other respiratory conditions, in order to investigate the past prevalence of the disease in belgium. seven dogs, living in southern or eastern belgium, were recently diagnosed as having angiostrongylosis (mean age= . y, mean body weight= . kg). they all presented with respiratory signs of variable severity. in dogs, balf was obtained and qpcr was positive in all of them, at moderate or high level (ct from , to , ) while larvae were detected in the faeces of only animals. in the remaining two dogs, no balf was obtained, but coproscopy was positive. all dogs responded to medical treatment, consisting in a -week course of fenbendazole and/or two spot-on application of moxidectin at -month interval. balf samples were collected between and from asymptomatic client-owned dogs and dogs with various respiratory conditions, including dogs with confirmed bordetellosis, dogs with eosinophilic bronchopneumopathy (ebp), dogs with chronic bronchitis and dogs with bacterial bronchopneumonia, and were retrospectively assessed with a a. vasorum qpcr assay. amongst those dogs, only one balf, from a dog with ebp, yielded a positive qpcr result. in this dog, faecal analysis was negative. the present data show that, based on balf qpcr and coproscopy, presence of angiostrongylosis in healthy and coughing dogs was negligible in belgium until the last months. it is now considered as an emerging condition and must be included in the differential diagnosis in coughing dogs. the present results also support that qpcr detection of a. vasorum in balf, when available, is an adequate and reliable detection technique. no conflicts of interest reported. ligneous membranitis is a rare chronic inflammatory disease associated with congenital plasminogen deficiency. it has only been described in six unrelated dogs. the objective of this study is to report the presentation, clinicopathological and post mortem findings in three related scottish terrier puppies with ligneous membranitis. ligneous membranitis is well described in humans, where it is inherited in an autosomal recessive manner. patients commonly present as infants. ocular, oral and genital lesions are most common, but other organs are occasionally involved and congenital obstructive hydrocephalus is reported in some individuals. numerous mutations and polymorphisms in the plasminogen gene have been identified in affected individuals. the affected scottish terriers (two male and one female) presented at months of age with severe proliferative and ulcerative conjunctivitis and gingivitis/stomatitis; biopsy confirmed ligneous membranitis. other clinical signs included increased upper respiratory tract noise, nasal discharge and lymphadenopathy. one male was cryptorchid. clinical pathological findings included neutrophilia, proteinuria and hypoalbuinaemia. serum plasminogen activity was measured in two dogs, and was low in one. the dam and sire of the affected dogs had normal serum plasminogen activity and no history or clinical signs consistent with ligneous membranitis. no significant clinical improvement was evident following treatment with antibiotics, glucocorticoids, topical ciclosporin or heparin. one dog died of cardiopulmonary arrest in the hospital and the two other dogs were euthanized due to progressive clinical signs. post-mortem evaluation of the affected dogs revealed multiple abnormalities including severe proliferative fibrinous lesions affecting the trachea, larynx and epicardium, and multiple fibrous adhesions throughout the thoracic and abdominal cavities. the male dog had internal hydrocephalus and lacked a cerebellar vermis. this is the first report of ligneous membranitis in related dogs and the first report in scottish terriers. sequencing the plasminogen gene in the affected dogs, their parents and unrelated control dogs to identify polymorphisms or mutations that may be associated with ligneous membranitis in dogs is ongoing. the author received a travel scholarship from zoetis to attend this congress. health screening of elderly dogs is often recommended, but scientific information on clinical and laboratory abnormalities in senior and geriatric dogs is scarce. this study was undertaken to describe blood pressure measurement, physical examination (pe) abnormalities and routine laboratory test results in senior and geriatric dogs that were apparently healthy for the owner. because life expectancy in dogs is related to body size, the inclusion of dogs was based on a human/pet analogy chart to determine whether a dog was senior (n = ) or geriatric (n = ). to verify health status, owners were asked to complete an extensive questionnaire. systolic blood pressure (sbp) was measured using the doppler technique according to the acvim guidelines. subsequently a thorough pe was performed, including body and muscle condition scoring, orthopedic examination, neurologic evaluation, indirect fundoscopy and bilateral schirmer tear test. complete blood count, serum biochemistry and urinalysis (including urinary sediment, urinary protein:creatinine ratio (upc) and bacterial culture) were evaluated. in of dogs sbp exceeded mmhg, none of the dogs had fundoscopic lesions secondary to hypertension. body condition score was abnormal in animals, were overweight or obese. physical examination revealed a heart murmur in , submandibular lymphadenopathy in , moderate to severe dental plaque in and one or more (sub)cutaneous masses in dogs. twenty-three dogs were leukopenic, had a decreased phosphorus, an increased serum creatinine and one dog a decreased total thyroxine (with concurrent increased thyroid stimulating hormone). crystalluria was commonly detected ( / ) and mostly due to low numbers (< /high power field) of amorphous crystals ( %). struvite crystals were present in % of the crystalluric dogs. overt and borderline proteinuria were detected in and of dogs, respectively. four dogs had a positive urinary culture. sbp was not significantly different between the senior and geriatric group. there was no significant effect of obesity or gender on sbp. the platelet count (p = . ), total thyroxine concentration (p = . ) and the frequency of orthopedic problems (p = . ) and cutaneous masses (p = . ) were significantly higher in the geriatric compared to the senior dogs. hematocrit (p = . ) and body temperature (p = . ) were significantly lower in the geriatric group. these findings indicate that physical and laboratory abnormalities are common in apparently healthy senior and geriatric dogs. this underlines the necessity for regular health screening in elderly dogs and the urgent need for reliable and maybe age specific reference intervals in veterinary medicine. the cost of examinations reported in this study were covered by hill's pet nutrition belgium. systemic lupus erythematosus, sle, is a chronic autoimmune disorder with varying clinical manifestations and diagnosis is based on both clinical signs and laboratory findings. other systemic rheumatic diseases, referred to as sle-related diseases or immune-mediated rheumatic disease (imrd), are also described. the most common clinical signs in dogs are stiffness and pain from varying joints. one hallmark of sle and sle-related diseases in both dogs and humans is high titres of circulating antinuclear antibodies (ana), which can be demonstrated by the indirect immunofluorescence (iif) ana test. earlier studies have shown that canine iif ana positive samples may be divided into two main subgroups: homogenous (ana h ) and speckled (ana s ) iif ana fluorescence pattern. in humans, further determination of the specificity of ana positive sera is frequently employed to characterize the ana reactivity. some of these ana specificities have been demonstrated in man to strongly associate with different systemic autoimmune diseases and also with different iif ana staining patterns. presence and character of antinuclear antibodies in canine sle-related diseases are not well described. the aim of this work was to further characterize the ana specificity in dogs with sle-related disease/imrd. sera from anapositive dogs, including different breeds, were analyzed with elisa and line blot techniques (elisa and euroline ana profile, euroimmun, germany). the five most prevalent breeds were german shepherd dog, nova scotia duck tolling retriever, cocker spaniel, crossbreed and golden retriever. sera displayed a homogenous and a speckled iif ana fluorescence pattern. several specific ana-reactivities earlier characterized in human patients were identified. the majority of ana h , n = , %, showed reactivity against nucleosomal antigens and ( %) against dsdna when conducted on line blot. these sera also reacted against nucleosomes and dsdna on the elisa. there were some additional positive with the elisa, so in total the elisa identified % with nucleosomal and % with dsdna reactivity. in few cases, other reactivities identified were against histones, pcna, jo- and rnp. in the ana s subgroup, the sm+rnp antigen evoked the most frequent reactivity, n = , % with both line blot and elisa. in few cases, reactivity against dsdna, pcna, jo- , pmscl kd, scl- , ssa and ssb were identified. in several dogs no specific antigen was identified. further studies are in progress in order to in more detail characterize and identify subtypes of already known and unknown antigens with clinical importance in canine autoimmunity. one of the authors, erik lattwein, is employed by euroimmun where the analyses were performed. chronic kidney disease (ckd) has a high prevalence in cats. routine renal markers, serum creatinine (scr) and urea are not sensitive or specific enough to detect early ckd. serum cystatin c (scysc) has advantages over scr for the detection of early kidney dysfunction, both in humans and dogs. a significant higher scysc concentration in ckd cats has been demonstrated. the objective of this study was to determine the effect of age, gender and breed on feline scysc and to establish a reference interval for feline scysc. in total, healthy cats between one and years were included. serum cysc was determined with a validated particleenhanced nephelometric immunoassay (penia). serum cr, urea, urine specific gravity (usg), urinary protein: creatinine ratio (upc) and systolic blood pressure (sbp) were also measured. to test for difference between the groups, the f-test was used. the lower and upper value of the % reference interval were obtained as the . % and . % quantiles of the scysc observations. no significant differences in scysc concentration were observed between young, middle-aged and old cats; between female, female neutered, male and male neutered cats; and between purebred and domestic short-or longhaired cats. the % reference interval for feline scysc was determined as [ . - . mg/l]. there was a significant difference in scr concentration between domestic short-or longhaired cats and purebred cats. the sbp was significantly influenced by gender as well as age, while urea was influenced by both age, gender and breed. this study showed that the biological factors age, gender and breed have little or no impact on feline scysc, in contrast to scr and serum urea, making it an interesting marker. therefore, further studies are warranted to evaluate the diagnostic value of scysc as a renal marker in cats. this study recieved support from the institute for the promotion of innovation by science and technology in flanders (iwt) through a bursary to l. ghys. assessment of renal function is often needed, however existing methods including urine and plasma clearances are invasive, cumbersome and time consuming. in this pilot study the feasibility of a transcutaneous glomerular filtration rate measurement was investigated. the transcutaneous disappearance rate (expressed as half-life) of fluorescein-isothiocyanatelabelled sinistrin (fitc-s) was measured in three healthy research dogs and three healthy research cats. plasma clearance of sinistrin ( data points) was performed in both species as previously described (res vet sci ; : - and j fel med surg ; : - ) and half-life was calculated using a -compartment model with a freely available pharmacokinetic calculator (comput meth prog bio ; : - ) . renal elimination of fitc-s was measured transcutaneously for hours ( - data points) using a miniaturized device as described previously for the same purpose in rats (kidney int : - ). the procedures were performed in awake, freely moving animals using escalating doses of fitc-s ( mg/kg, mg/kg, mg/kg) with a wash-out period of at least h in each animal. to find the best position for the device, multiple devices were placed on each animal. the resulting fitc-s disappearance curves were visually assessed to determine the most suitable location and the appropriate dose to reach an adequate transcutaneous peak signal for kinetic analysis. in both species mg/kg were adequate for kinetic calculation. the most suitable place for the device was the lateral thoracic wall in dogs and the ventral abdominal wall in cats, respectively. transcutaneous fitc-s clearance was then repeated using the optimal dose and location and in parallel with the plasma sinistrin clearance. plasma sinistrin clearances [ml/kg/min] were . , . and . in the three dogs, respectively. corresponding plasma elimination half-lives [min] were , and , and corresponding transcutaneous elimination half-lives [min] were , and , respectively. plasma sinistrin clearances [ml/kg/min] were . , . and . in the three cats, respectively. corresponding plasma elimination half-lives [min] were , and , and corresponding transcutaneous elimination half-lives [min] were , and , respectively. in conclusion, transcutaneous fitc-s clearance is a feasible method for assessment of gfr in awake dogs and cats. it is noninvasive, well tolerated and easy to perform even in a clinical setting with results being readily available. a dose of mg/kg of fitc-s seems adequate for kinetic assessment. further studies are now needed to establish reference values and evaluate transcutaneous renal clearance in various conditions. conflicts of interest: zhp and sg are supported by the ec fp marie-curie programme: nephrotools. the device development was supported by the fp activity: place-it.ng is owner of a patent covering fitc-sinistrin and the technology for its measurement. excretion of urinary biomarkers of renal damage should occur at an early stage of chronic kidney disease (ckd), thus facilitating earlier diagnosis of renal disease. albumin and cystatin c in the renal ultrafiltrate are mostly reabsorbed by the proximal tubular cells, therefore increased urinary excretion of albumin and cystatin c (uac and ucysc) would be expected to correlate with the presence of renal tubular damage and ckd. the aim of this study was to establish biological validity of two particle enhanced turbidimetric assays (petias) for the measurement of albumin and cystatin c (previously validated for use in feline urine) by comparing the uac and ucysc between non-azotaemic cats and cats with azotaemic ckd. blood and urine samples were obtained from cats at three uk first opinion practices as part of a geriatric screening programme. haematology, serum biochemistry (including total thyroxine concentration (tt )) and urinalysis (including urine protein:creati-nine ratio (upc)) were performed. dental disease score (calculus and gingivitis) and body condition score (bcs) were recorded. cats with tt > nmol/l, evidence of pyuria or bacteruria, or significant systemic disease were excluded. uac and ucysc were determined in non-azotaemic cats (n = ) and cats with azotaemic ckd (n = , defined as a serum creatinine concentration > lmol/l and concurrent urine specific gravity < . ). comparisons between the non-azotaemic and azotaemic ckd groups were made using the mann whitney u test. correlations were assessed by spearman's correlation coefficient. data are presented as median [ th , th percentile] and statistical significance was defined as p < . . uac was significantly higher in the azotaemic group than the non-azotaemic group ( . [ . , . ]x - vs. . [ . , . ]x - ; p = . ), whereas upc was not significantly different between the groups (p = . ). unexpectedly, ucysc tended to be lower in azotaemic cats than non-azotaemic cats ( . [ . , . ]x - vs. . [ . , . ]x - ; p = . ). uac was weakly positively correlated with serum urea concentration (r s = . , p = . ), but was not correlated with serum creatinine concentration. ucysc was not significantly correlated with serum concentrations of urea, creatinine or tt . uac was also weakly negatively correlated with dental calculus score (r s = - . ; p = . ) and bcs (r s = - . ; p = . ). uac appears to be a more sensitive test for azotaemic ckd than upc, however the apparent low specificity may limit the utility of uac as a urinary screening test for ckd. increased ucysc (determined by petia) would not appear to be a marker of azotaemic ckd in cats. no conflicts of interest reported. cystinuria is an inherited metabolic disorder that causes defective tubular reabsorption of the aminoacids cystine, ornithine, lysine and arginine (cola). the low solubility of cystine in acidic urine promotes formation of cystine crystals and uroliths in the urinary tract resulting in the clinical signs of stranguria, urinary obstruction and renal failure in affected individuals. cystinuria occurs in > breeds of dog and has been classified into types ia (newfoundland, landseer, labrador), iia (australian cattle dog), ib (miniature pinscher) and iii (androgen-dependent; e.g. mastiff, irish terrier). the kromfohrl€ ander is a medium-sized companion dog, bred initially as a cross between a wire fox terrier and a grand griffon vend een, first recognised internationally in . cystinuria has been suspected in this breed but no cases have been reported in the literature to date. we determined urinary cola concentrations in adult kro-mfohrl€ ander dogs aged - years comprising intact and castrated males, and intact and spayed females. a total of ( %) intact males aged . to . years had cola values > lmol/g creatinine and several developed cystic calculi. furthermore, intact male dogs had increased cola but normal cystine levels. all castrated males had normal cola concentrations. no females had increased cola and cystine concentrations or formed any cystine calculi. we conclude that cystinuria with cystine calculi occurs frequently in adult intact male kromfohrl€ ander dogs but neither is seen in females. this appears to be an androgen dependent type iii cystinuria, as seen in mastiff-type dogs and irish terriers. thus, castration may resolve the increased urinary cola excretion and risk for cystine calculi formation and obstruction. the precise mode of inheritance is still unclear. all adult intact male kromfohrl€ ander dogs should be screened by urinary cola testing. work carried out at the author's previous place of employment (university children's hospital, frankfurt, germany). acs, rk, em, md and ug provide a diagnostic service for cystinuria and other inborn errors of metabolism in companion animals. ureteral urolithiasis is an emerging medical concern in cats. there are few reports on epidemiology, diagnosis or medical management of ureteral calculi in cats, particularly in europe. cats diagnosed with ureteral urolithiasis in the teaching hospital of the veterinary school of alfort from to were included in this study. diagnosis was confirmed with radiographs, ultrasound scan and/or laparotomy. signalment, clinical signs, clinicopathologic and diagnostic imaging findings, medical treatment and outcome were recorded. epidemiological data were compared to a reference population of cats. eighty three cats were included in the study. the occurrence of ureteral urolithiasis was significantly higher in birman to the author knowledge, it is the first time that a higher prevalence of ureteral calculi in birman cats is reported in europe. spontaneous elimination of calculus is associated with a small size (< . mm). if the size of calculi tends to be bigger in cats with no improvement of renal function after medical treatment, prospective studies are still needed to determine the best medical treatment. no conflicts of interest reported. feline immunodeficiency virus (fiv) infection has been associated with kidney disease, mainly characterised by an increased prevalence of proteinuria in fiv-infected cats. however, studies evaluating renal variables in fiv-positive cats are scarce. recently, a higher systolic blood pressure (sbp) was reported in a small number of fiv-infected cats. hypertension is an important cause of proteinuria and a frequent cause of renal disease in human immunodeficiency virus (hiv) positive patients. therefore, our main objective was to describe sbp in clinically ill fivpositive cats. secondly we aimed to evaluate routine renal variables in this population. naturally infected clinically ill fiv-positive cats were prospectively included. the doppler ultrasonic technique was used to measure sbp according to acvim guidelines. serum creatinine (screat) and urea (surea) concentrations, urine specific gravity (usg) and urinary protein:creatinine ratio (upc) were determined. the study included cats, with a mean age of . ae . years and a mean body condition score of . ae . on a nine-point scale. the sbp ranged from to mmhg, with a mean of ae mmhg. only two cats were hypertensive (sbp > mmhg). both had isosthenuric urine, were borderline proteinuric (upc . - . ) and one of them was mildly azotemic. mean screat was . ae . lmol/l (reference interval (ri) . - . lmol/l) and mean surea concentration . ae . mmol/l (ri . - . mmol/l). thirteen cats showed increased screat levels, with decreased usg (< . ) in eight, proteinuria (upc > . ) in seven and increased surea concentrations in ten of them. five out of ten azotemic cats were proteinuric with a decreased usg. mean upc was . ae . , with a wide range from . to . . borderline proteinuria was present in / ( . %) and proteinuria in / ( . %). half of the proteinuric cats had a decreased usg. mean usg was . ae . . one third of all cats had a decreased usg, with isosthenuria in seven of them. these results demonstrate that proteinuria and poorly concentrated urine are common in naturally infected clinically ill fivpositive cats, confirming previous reports in cats and humans. however, longitudinal studies of (borderline) proteinuric patients are needed to elucidate the clinical relevance. the low number of hypertensive patients and low mean sbp in our study indicate that hypertension is uncommon and unlikely to be the cause of renal damage in clinically ill fiv-infected cats. aratana therapeutics nv financially supports a clinical trial on the use of antivirals in fiv cats at our university. screeninng examinations repoorted in this trial were part of the required pre-trial investigations for that study. the presenting author is also funded by a scholarship from aratana therapeutics av. the objective of this study was to identify the prevalence of bacterial species and the susceptibility of isolates to doxycycline, trimethoprim-sulfamethoxazole (tms), ampicillin, amoxicillinclavulanic acid (amc), cephalothin, and enrofloxacin in cats with urinary tract infections (uti) with and without predisposing comorbidities. a retrospective analysis of case records between and was performed and resulted in inclusion cats into the study: cats with a systemic comorbidity, cats with indwelling urinary catheters, cats with other local comorbidities, and cats with no comorbidity. the most commonly isolated bacteria were escherichia coli (e. coli), streptococcus species (spp.), staphylococcus spp., and enterococcus spp.. the proportion of gram-negative isolates was significantly higher in the cats with systemic comorbidities than in cats with indwelling urinary catheters (p < . ) and cats with other local abnormalities (p < . ), whereas gram-positive isolates were significantly more commonly isolated from cats with indwelling urinary catheters and other local comorbidities than in cats with systemic comorbidities (p < . ). the proportions of isolates susceptible to amc, enrofloxacin, and tms and the antimicrobial impact factors (if) were higher than the proportions of isolates susceptible to doxycycline, ampicillin, and cephalothin and the respective if. based on these findings, amc and tms would be the firstchoice antimicrobial agents for empiric treatment of bacterial the increasing rates of resistance exhibited by uropathogens represent a serious problem for the selection of an appropriate antibiotic. the aim of this study was to determine secular trends of companion animal urinary tract infection (uti) that involve extended-spectrum b-lactamase (esbl)-and carbapemenase-producing gram negative bacteria (namely, escherichia coli, klebsiella pneumoniae, proteus mirabilis, acinetobacter baumannii), methicillin-resistant-staphylococci (mrs) and ampicillin and high-level-gentamicin-resistance (hlgr) enterococci. nine hundred and twenty two uropathogenic bacteria were isolated from dogs and cats, between january and march , at the veterinary teaching hospital of the faculty of veterinary medicine and at veterinary private practices in the lisbon area. isolates were identified using standard commercial systems. susceptibility testing was performed using the disk diffusion and broth microdilution methods. clsi breakpoints were applied. extended-spectrum b-lactamases (esbl) production was screened by double-disk synergy test. the esbl, plasmid-mediated ampc, carbapemenases, meca and aac( ')-ieaph( '')-ia genes were detected by pcr and gene enzymes were sequenced. among enterobacteriaceae . % were dhaproducers, . % were esbl-producers and . % were cmyproducers. all isolates were also multidrug-resistant. cefalosporinases-producer enterobacteriaceae were detected in , the first being a cmy- -producer e. coli. all the esbl-producers were e. coli or k. pneumoniae producing ctx-m-group enzymes. ampicillin-resistance in enterococci was present throughout the years ( , %, n = ). hlgr appeared in enterococci in and was confirmed by the detection of the bifunctional enzyme that confers high level resistance to aminoglycosides ( out of isolates). in this study we showed that in the last decade the emergence of resistance to critically important antimicrobials among uropathogens from companion animals is a concerning fact. the multidrug-resistant enterobacteriaceae may compromise effective therapeutic options, namely third and fourth generation cephalosporins, fluoroquinolones, trimethoprim/sulpha combinations. the emergence of mrsa/mrsp and hlgr among uropathogens is also a therapeutic challenge. the detection of uropathogens with antimicrobial resistance is not only an animal health issue but also a matter of public health, since companion animals may act as reservoirs of antimicrobial resistant bacteria or resistance genes for humans. the author currently receives a phd grant funded by the portuguese foundation for science and technology. in the past, the author received once research support and honoraries from portuguese merial for a project on canine vector borne diseases. the aim of the present study was to use insurance data to estimate morbidity and mortality related to kidney disease in the swedish dog population. insurance company data from veterinary care-insured and lifeinsured dogs during the years - were studied retrospectively. incidence-and mortality rates were calculated for the whole group of dogs as well as divided by sex and breed. for the breeds with the highest incidence-and mortality rates, respectively, the reasons for kidney disease were investigated by dividing the diagnoses into ethiology groups. the total number of veterinary care-insured dogs was , . the total incidence rate of kidney disease in this group of dogs was . ( . - . ) cases/ , dog-years at risk. the number of dogs in the life insurance was , and in this group the total kidney-related mortality rate was . ( . - . ) deaths/ , dogyears at risk. the most commonly reported ethiologies of kidney disease were "ethiology not determined"and "infectious/ inflammatory". the breeds with the highest incidence rate of kidney disease were the bernese mountain dog, miniature schnauzer and boxer. the breeds with the highest mortality caused by kidney disease were the bernese mountain dog, shetland sheepdog and flatcoated retriever. in conclusion, the epidemiological information provided in this study concerning kidney disease in dogs can assist clinicians in establishing diagnoses, and can assist breeders in defining priorities for preventative measures. it can also provide valuable information for future research. the senior author has received money from the insurance company we have used data from to write our study, for another project. jens h€ aggstr€ om and ingrid ljungvall have received financial support for research from sante animale, agria insurance ltd, sveland insurance ltd, forsgren research foundation. both of these authors have also undertaken paid consulatcny work for boehringer-ingelheim, ceva sante animale. mast cell tumours represent the most common cutaneous tumour in the dog. diagnosis of a mast cell tumour can be achieved through cytological examination of fine needle aspirate. however the grade of the tumour is an important prognostic marker and requires so far histologic assessment. a -tier histologic grading system based on number of mitoses, multinucleated cells, bizarre nuclei and karyomegaly was recently proposed by kiupel et al. the aim of this study was to assess if the cytomorphological criteria proposed in the -tier histologic grading system are applicable on cytology specimens. ninety-three mast cell tumour specimens of grade i or grade iii according to patnaik with both histological specimens and fine needle aspirates were retrospectively taken from a data set and histologically and cytologically re-evaluated. according to the kiupel grading system thirty-six were diagnosed histologically as high grades and fifty-seven were considered low-grade mast cell tumours. the cytologic examination of the corresponding specimens revealed thirty-one high grade and fifty-five low-grade tumours. an agreement between histologic and cytologic diagnosis based on the kiupel grading system was achieved in eighty-six cases (accuracy . %, specificity . %, sensitivity . %). five high-grade tumours ( . %) were considered as low grade on cytology. cytologic grading of mast cell tumours in the dog has satisfactory accuracy, sensitivity, and specificity. histologic grading of canine mast cell tumours still remains the gold standard, but cytology already gives reliable information. no conflicts of interest reported. in canines mastocytomas are among the most frequently diagnosed neoplasms of the skin. high grade mastocytomas (grade iii, patnaik classification) are characterized by an uncontrolled growth of neoplastic mast cells (mc) and a poor prognosis. recently, the kit-targeting tyrosine kinase inhibitors masitinib and toceranib have been approved for the treatment of canine mc tumors. these drugs are able to induce responses in mastocytoma patients. however, in many patients, relapses are seen. therefore, research is focusing on new drug targets. recently, the transcription factor stat has been reported to play an important role in the proliferation and survival of human neoplastic mc. the aim of the present study was to evaluate the jak -stat pathway in canine mastocytomas. to address this aim, the canine mastocytoma cell lines c and ni- as well as inhibitors directed against jak or stat were employed. as assessed by immunocytochemistry, c cells and ni- cells were found to express pstat in their cytoplasm and nuclei. intracellular expression of pstat was confirmed by flow cytometry. interestingly, c cells were found to express higher levels of pstat compared to ni- cells. next, we treated c cells and ni- cells with various concentrations of the stat inhibitors piceatannol and pimozide and the jak inhibitors azd and tg . as assessed by h-thymidine uptake, all compounds were found to inhibit the proliferation of canine mc in a dose-dependent manner. drug effects were found to vary in different cell lines, with the following rank-order of potency (ic values): tg : . - . lm; pimozide: . - . lm; azd : - lm; piceatannol: - lm. to further explore the mechanism of drug-induced inhibition of proliferation, we examined cell cycle progression and apoptosis in drug-exposed cells. whereas all drugs tested induced only moderate cell cycle arrests in the g phase, these drugs were found to induce substantial apoptosis in c cells and ni- cells as evidenced by microscopy and annexin-v/pi staining. together, our data show that jak -and stat -targeting drugs exert anti-proliferative and apoptosis-inducing effects in canine mastocytoma cells suggesting that this signaling pathway may be a promising new therapeutic target in canine mastocytomas. the clinical relevance of this observation remains to be determined. no conflicts of interest reported. subcutaneous mast cell tumours (sqmct) in dogs are relatively uncommon compared to their cutaneous counterparts. the veterinary literature describes these tumours as a specific pathological entity with, in general, a low probability of aggressive progression. surgery is considered the main treatment modality, while medical treatment has not been described. the purpose of this study was to determine progression free survival (pfs) for a chemo na€ ıve cohort of dogs presented with non-resectable and/ or metastasized sqmct, which all underwent masitinib-based therapy. data were collected for patients with sqmct presented to participating centres in the netherlands and the uk from / / to / / , which received masitinib-based therapy. treatment protocols employed, included masitinib alone (m), masitinib and prednisolone (mp), masitinib plus vinblastine and/ or lomustine and prednisolone (mpc). response to therapy was measured conforming to recist . . adverse events were graded using vcog-ctcae . . patients were grouped according to presence or absence of metastasis, treatment protocol used, previous surgery, and remission status achieved; simple comparisons were made to evaluate possible significance. twenty-five cases were identified. / were female. median age of occurrence was years ( - ). diagnosis was made by histology in / ; proliferation indices were defined in only dogs. fourteen cases exhibited metastasis at initiation of therapy. pfs for all cases ranged from - days. median/mean pfs (days) according to treatment was m: / d (n = ), mp: / d (n = ), mpc: / d (n = ). median/mean pfs according to metastasis status was m : / d (n = ) and m : / d (n = ). dogs who underwent previous surgery (n = ) had a median/mean pfs of / d compared to those who had no surgery / d. looking at remission status, median pfs of patients who achieved a complete remission was not reached, with a mean pfs of d (n = ). median/mean pfs of patients with partial remission was / d (n = ), stable disease / d (n = ), and progressive disease / d (n = ). / cases experienced suspected adverse events. three dogs, two of which ultimately died, had seven grade - adverse events (anaemia (n = ), hepatotoxicity (n = ), gastrointestinal toxicity (n = )). masitinib-based treatment is effective in the management of sqmct perceived to be aggressive. patients do not appear to benefit from prior surgery. metastatic status did not influence outcome. adding chemotherapy negatively influenced pfs. complete remission is a very favourable prognostic development. the authors have received financial support from ab science to help with the costs of statistical analyses in an unrelated project advances in distinction between morphological subtypes of canine non-hodgkin's lymphomas (nhl) have provided a better understanding of this cancer in dogs. diffuse large b-cell lymphomas (dlbcl) are the most frequent form of nhl in dogs including some distinguished morphological subtypes (mainly centroblastic polymorphic and immunoblastic) according to the who classification. few clinical studies reported dlbcl clinical outcomes under treatment while survival times of the centroblastic polymorphic subgroup were reported. the aim of this retrospective study was to evaluate the response of dlbcl to a standardized multi-agent chemotherapy protocol. medical records from dogs with a diagnosis of dlbcl between and were retrospectively reviewed. inclusion criteria were the availability of complete initial and follow-up information and the application of a standardized multi-agent l-cop chemotherapy protocol as previously described. dogs which received corticosteroids before the initiation of treatment and dogs which died for other reasons than their related disease before the end of the induction period ( d) were excluded. response to chemotherapy was evaluated every week during the induction of treatment, then every to weeks. statistical analysis was performed using kaplan-meier analysis. thirty cases of dlbcl meeting all inclusion criteria were included from the initial population. seven dogs were in clinical stage iii according to the who classification, in stage iv and in stage v. nineteen dogs were in substage a, and in substage b. on dogs which have an adequate response evaluation, dogs ( . %) achieved a complete remission. the median and mean duration of first remission were d and d, respectively (range - d). the median and mean durations of survival time were respectively d and d (range - d). one year and -years survival rates were % and % respectively. according to the statistical analysis, neither clinical stage (p = . ) nor substage at presentation (p = . ) or morphological subtype (immunoblastic vs centroblastic polymorphic, p = . ) were considered as a significant prognostic factor regarding the duration of the first remission and the overall survival time. a complete response was significantly associated with longer survival times (p = . ). to conclude, the dlbcl displayed a good clinical response to l-cop protocol, with a median survival time of days. the only significant prognostic criterion identified was a complete clinical response to the treatment. a prospective controlled study on a larger population is warranted to confirm these results. no conflicts of interest reported. canine histiocytic sarcoma (hs) is an aggressive round cell neoplasm with a poor prognosis. both lomustine and doxorubicin have been evaluated as first line chemotherapy agents with response rates of up to % and median survival times around - months. the aim of this study was to evaluate the response to epirubicin in a population of dogs with hs pre-treated with lomustine. medical records of dogs with a diagnosis of hs that were treated with lomustine and subsequently epirubicin were retrospectively evaluated. fifteen dogs received lomustine followed by epirubicin. there was a measureable response to lomustine in seven of dogs with evident disease, % ( cr & pr). an additional dogs achieved stable disease for an overall biological effective response of %. median ttp following lomustine could be assessed in dogs and was days (range - ). all fifteen dogs received epirubicin as a rescue agent: nine following progressive disease and three with stable disease on lomustine. one dog received epirubicin after completing six doses of lomustine in complete remission and two dogs in partial remission changed to epirubicin due to hepatotoxicity associated with lomustine. response rate to epirubicin was % and biologic effective response was % ( cr, pr, sd, pd) in dogs. one dog was euthanized due to epirubicin associated gastro-intestinal toxicity and dog stopped treatment with no assessment of response. median duration of response to epirubicin was days (range: - ) and dog is still alive and in remission ( days). overall median survival time for dogs receiving epirubicin following lomustine was days (range: - ). single agent epirubicin is a valid rescue therapy after lomustine for canine histiocytic sarcoma and results in modestly improved overall survival times in responding patients. the author received a travel scholarship from zoetis to attend this congress. the incidence of melanocytic lesions is increasing among canine population. canine malignant melanoma could have an aggressive behavior, metastasize early in the course of the disease and be resistant to most current therapeutic regimens leading to the need of finding markers with potential as therapeutic targets. the overexpression of cox- seems to play a key role in melanocytic tumours, having being described an association between high cox- immunoexpression and the malignant behavior. in order to contribute to the understanding of the role of cox- in melanocytic tumours, three main pathways were investigated: angiogenesis, tumour cell proliferation and inflammatory microenvironment (t-lymphocytes and macrophages). fifty one ( ) melanocytic tumours [ cutaneous ( malignant melanomas and melanocytomas) and oral malignant melanomas] were included. all the samples were submitted to immunohistochemical staining carried out by the streptavidinbiotin-peroxidase method, with a commercial detection system with or without melanin blanching, for detection of the following markers (cox- , ki- , factor viii, vegf, cd and mac ). in melanocytic tumours (n = ), both cox- labelling extension and intensity revealed a statistically significant association with angiogenesis by factor viii (p < , ), vegf (p < , ); ki- (p < , ), cd + t-lymphocytes (p < , ) and mac (p < , ). considering only malignant melanomas (n = cases), cox- labelling extension revealed a statistically significant association with angiogenesis (p = , ) and cd + t-lymphocytes (p = , ). cox- intensity was also positively associated with angiogenesis (p = , ) and with mac (p = , ). present study demonstrated a link between high cox- immunoexpression and increased angiogenesis and tumoural t-lymphocyte and macrophage infiltration in malignant melanomas. these findings reinforce the usefulness of using selective cox- inhibitors as a valuable therapeutic tool in malignant melanocytic tumours. this study received financial support from a company (merial). neuter status and risk of malignant neoplasia is not well evaluated in the canine population, when excluding neoplasia not normally believed to be sex-hormone dependent. denmark and the scandinavian countries have a high proportion of intact dogs compared to populations from other parts of the world. in the present study it was hypothesized that there would be no difference in gender and neuter status between the population of canine patients with a non-sex-hormone dependent malignant neoplasia reported to the danish veterinary cancer registry and a general population. from august to march , canine neoplasms were reported to the danish veterinary cancer registry. the total number of malignant ( ) and benign ( ) were comparable ( % and %). malignant neoplasms totalled , when tumors from areas of distribution with known sex-hormone dependency (reproductive organs, mammary gland, perineal), and cases with unknown area of distribution were excluded. the overall distribution of malignant neoplasia was ( %) intact male dogs, ( . %) neutered male dogs, ( %) intact female dogs and ( . %) neutered female dogs. the distribution was even between male and female dogs ( . % and . %). compared to a known standard population of dogs, there was an overall statistically significant association of malignant neoplasia with neuter status in both sexes. for both genders this was significant for lymphoma, mast cell tumors and osteosarcomas,. for neutered females, but not males, there was increased risk of hemangiosarcoma, squamous cell carcinoma and malignant melanoma. these findings indicate that there might be an association between neuter status and development of malignant neoplasia but larger prospective studies are needed to evaluate the risk of non-sex hormone dependent cancers in neutered dogs. no conflicts of interest reported. serum acute phase proteins (apps) are considered biomarkers of the acute phase reaction, and are being increasingly used in human and veterinary medicine in diagnosis and monitoring of neoplastic diseases. in the cat, serum amyloid a (saa) is considered a positive major app, haptoglobin (hp) a moderate app, and albumin and insulin-like growth factor- (igf- ) negative apps. the aim of the present study was to characterize the apps response in cats with mammary tumours. for that purpose, saa, hp, igf- and albumin serum concentrations were determined in female cats with malignant mammary tumours. cats with history of previous tumours or with concomitant tumours or other diseases were excluded. information on cats age, gender, breed, tumour type, histological grade, tumour size and location, skin ulceration, vascular neoplastic infiltration, necrosis, metastasis to regional lymph nodes, thoracic or abdominal organs, and survival time from diagnosis was assessed. blood samples were collected before surgery in all cats, and whenever possible, serial samples collected on control visits. owners gave informed consent. studied population included domestic short-haired cats with ages ranging from eight to years ( , + /- , ). all had carcinomas, including solid carcinomas (n = ), tubulopapillary carcinomas (n = ), one cribiform carcinoma and one carcinosarcoma. at the time of diagnosis, % of cats had an increase in serum concentration of hp and % of saa, and % had a decrease in concentration of albumin. mean and standard deviation values were of , + /- , g/dl for albumin (reference range , - , g/ dl), , + /- , lg/dl for igf- , , + /- , lg/ml for saa (reference value ˂ lg/ml), and , + /- , g/l for hp (reference value ˂ g/l). a positive correlation (r = , ) was detected between increases in serum concentrations of saa and hp. the increase in the size of tumour was significantly associated with the concentration of saa (p˂ , ). serum hp concentrations were significantly increased in tubulopapillary carcinomas (p˂ , ), and igf- decreased in solid carcinomas (p˂ , ). in the cats where serial determinations were performed, development of thoracic metastasis was significantly associated with a decrease of serum concentration of albumin (p˂ , ), and with an increase of saa (p˂ , ). this study suggests that feline mammary tumours are associated with an acute phase response. according with the results obtained, saa, hp, albumin and igf- might be important serum biomarkers in diagnosis and monitoring of the evolution of feline malignant mammary neoplasias. no conflicts of interest reported. histiocytic sarcoma (hs) is a neoplastic proliferation of interstitial dendritic cells or tissue macrophages. dogs with hs can present with local disease or with multifocal (disseminated) involvement. disseminated hs is poorly responsive to therapy and almost always fatal. little is established regarding the aetio-pathology of histiocytic sarcoma in dogs. the purpose of this study was to establish and characterise a hs cell line from fresh tumour samples obtained from a dog with disseminated hs in order to further clarify disease pathogenesis and behaviour. with owner consent, treatment-na€ ıve tumour sections were collected from a dog with disseminated hs that was euthanased. tumour tissue was assessed with immunohistochemistry (ihc) using antibodies against canine cd , cd , and pax- to support the diagnosis of histiocytic sarcoma. primary cell cultures (hscs), established from the tumour were cultured and maintained in modified eagle's medium with % fetal bovine serum, l-glutamine, penicillin and streptomycin, in standard conditions. hscs were characterised by alpha naphthyl acetate esterase (anae) and lysozyme staining while pcr was used to detect cell markers cd a, cd c, mhc ii, cd , ccr , e-cadherin, and cd . cell surface markers were compared to an established canine hs cell line (dh ). phagocytic activity of hsc cells was assessed using cellular uptake of carboxylated fluorescent beads and documented using flow cytometry and fluorescent microscopy. tumour tissue was strongly cd positive and negative for cd and pax- . cultured cells exhibited morphological characteristics consist with dendritic cells, such as projections and pleomorphism. hsc cells stained positively for non-specific esterase (anae) and lysozyme, and pcr indicated cells were positive for cd a, cd c, mhc ii and cd and negative for cd and e-cadherin. hsc cells were positive for mhc ii and ccr while dh cells were negative. phagocytic activity was evident. a novel hs cell line (hsc) was established and characterized from primary tumour tissue collected from a dog with disseminated disease. hsc cells were most consistent with interstitial dendritic cell origin based on cd a, cd c, and mhc ii staining as well as demonstrable phagocytic activity. hsc cells also displayed expression of ccr , unlike the established dh line, supporting a notion that hs consists of a variety of subtypes. ccr has been linked to hs growth and metastasis, suggesting it may represent a possible therapeutic target. further studies establishing and characterising canine hs cells may contribute to the elucidation of mechanisms of tumourigenesis. no conflicts of interest reported. virulent-systemic (vs)-fcv that induce cutaneous edema, ulcerations of the head and feet, and occasionally jaundice have been described in the usa and europe. here we characterize for the first time vs-fcv outbreaks in cats in switzerland and liechtenstein. the four outbreaks occurred in three geographically separated locations: schaan (liechtenstein, shelter ), zurich (switzerland) and lausanne (switzerland, shelter ) between november and january . pcr (fcv and feline herpesvirus- , fhv- ), virus isolation and felv/fiv testing were performed on saliva and blood samples collected from clinically affected cats. furthermore, saliva for pcr was collected from additional cats in shelter . phylogenetic analyses were performed based on the capsid (vp ) gene sequence of fcv. vs-fcv isolates were tested for virus neutralization with sera raised against common fcv vaccine strains. outbreak occurred in a cattery in liechtenstein and involved five non-vaccinated, -months old siblings with fever, edema, skin and tongue ulcerations. outbreak occurred in a small animal clinic in zurich. a -year old cat presented with severe paw edema, fever, tongue and skin ulcerations, progressive hypoproteinemia and hyperbilirubinemia. outbreaks and happened in a cattery in lausanne five months apart and involved two litters of non-vaccinated, -to -months old kittens. the cats presented with fever, nasal discharge, edema and skin and oral ulcerations. all affected cats tested fcv-positive but negative for fhv- , felv and fiv, except for one kitten from outbreak (fiv-positive). all cats in outbreaks and recovered, whereas all cats in outbreaks and died or were euthanized because of clinical deterioration. each outbreak was caused by a phylogenetically distinct vs-fcv strain. in shelter , the queen and three in contact cats remained asymptomatic although infected with the same vs-fcv strain. furthermore, / other cats of shelter were infected with closely related, but distinct fcv strains. the vs-fcv isolates from the two outbreaks in shelter were distinct but phylogenetically related. all vs-fcv isolates from cats from the same outbreak showed a similar virus neutralization pattern, but neutralization differed between different outbreaks. in conclusion, all vs-fcv outbreaks involved multi-cat environments. the same vs-fcv strains with similar virus neutralization patterns were isolated from cats from the same outbreak. not all cats infected with a vs-fcv strain developed disease and mortality varied between the outbreaks. the sera for virus neutralization were provided by merial, france. defined herein as presence of sneezing, nasal-and/or ocular discharge, conjunctivitis and/or keratitis), but also oral cavity lesions, chronic stomatitis, limping syndrome and, rarely, virulent systemic disease. the aims of the present study were to compare cats suspected of fcv (fcv-sc) based on clinical symptoms and healthy controls (controls) and to investigate potential risk and protective factors, such as co-infection with feline herpesvirus- (fhv- ), mycoplasma felis, chlamydophila felis, bordetella bronchiseptica and feline retroviruses, vaccination, gender, age, breed, housing and corticosteroid and antibiotic treatment. oropharyngeal, nasal and conjunctival swabs from fcv-sc and controls were collected into transport medium, processed within hours after collection and analyzed for fcv by virus isolation and for all tested pathogens using molecular assays. the samples were collected by randomly selected veterinary practices in different areas of switzerland ( fcv-sc and controls/ area). to record clinical data, retroviral status and vaccination history of the cats, a questionnaire was filled out by the private veterinarian. the seven tested pathogens were found in the investigated population. the prevalence (fcv-sc vs. controls) was: fcv % vs. %; fhv- % vs. %, c. felis % vs. %, b. bronchiseptica % vs. %, m. felis % vs. %, feline leukemia virus % vs. % and feline immunodeficiency virus % vs. %. fcv-sc were positive for fcv significantly more often compared with controls (or . ) and shed more fcv. co-infections with up to four pathogens were detected; fcv-sc were significantly more frequently co-infected ( %) compared with controls ( %). gingivostomatitis and oral ulceration but not urtd were highly associated with fcv infection. in contrast, c. felis was associated with urtd; fhv- was associated with nasal and ocular discharge and m. felis with conjunctivitis and ocular discharge. risk factors for fcv infection were housing in groups (especially ≥ cats), an intact gender, maine coon breed and corticosteroid therapy. fcv-positive cats with gingivostomatitis were older and more commonly vaccinated than fcv-positive cats without gingivostomatitis. moreover they shed more fcv than cats with urtd. vaccination and primary immunization defined as two vaccinations - weeks apart with the same vaccine brand were protective factors against fcv but not fhv- infection. vaccination was associated with a decreased incidence of urtd in fcv-infected cats (or . ). further analyses will investigate cross-neutralization patterns of the prevailing fcv isolates. conflicts of interest: the study was partially funded by merial, france, and biokema, switzerland. antibody preparations are commonly used for the treatment of feline upper respiratory tract disease (furtd), although their efficacy has not been proven. the aim of this study was to evaluate efficacy of a commercial serum containing antibodies against feline herpesvirus- (fhv- ) and feline calicivirus (fcv) in cats with acute viral furtd. this prospective, randomized, placebo-controlled, double-blind study included cats with acute (< days) clinical signs of fhv- and/or fcv infection (confirmed by quantitative pcr). all cats received symptomatic treatment and either hyperimmune serum (n = ) (≤ weeks ml, > weeks ml, subcutaneously q h, topically into eyes, nostrils, and mouth q h) or saline (n = ) for three days. clinical signs, including a 'furtd score' and general health status, were recorded daily (day to and on day ). fcv shedding was determined on day and . statistical analyses included one-way analysis of variance, mann-whitney u, and student's t-test (improvement of clinical signs), fisher's exact test (fcv shedding), and spearman analysis (correlation clinical signs with virus load). clinical signs and general health status improved significantly in both groups. however, while placebo-treated cats had only improved significantly by day , cats receiving antibodies already significantly improved in their 'furtd score' (p = . ) and general health status (p = . ) by day . there was no significant difference in the number of cats shedding fcv and no correlation between viral load and clinical manifestation. administration of antibodies lead to faster improvement of clinical signs in cats with acute viral furtd, but did not influence fcv shedding. no conflicts of interest reported. different viral and bacterial pathogens can be involved in feline upper respiratory tract disease (furtd). although some clinical signs have been associated with certain pathogens, clinical signs can be variable and non-specific. aim of the study was to compare detection rates of feline herpesvirus- (fhv- ), feline calicivirus (fcv),and chlamydophila felis (c. felis) in cats with furtd on different sampling sites, and to correlate test results and clinical signs. swabs of nose, oropharynx, tongue, and conjunctiva were taken from cats with signs of furtd. on all samples, reverse transcription polymerase chain reaction (rt-pcr) was performed for detection of fcv, and polymerase chain reaction (pcr) for detection of fhv- and c. felis. fisher's exact test was used for all comparisons. the level of significance was p < . . pathogens were detected in . % of cats. of these, . % were positive for fhv- , . % for fcv, and . % for c. felis. fcv was isolated significantly more often from oropharynx ( . % of fcv-positive cats) and tongue ( . %) compared to conjunctiva ( . %) (p < . ). there was no significant difference between the sampling sites for detection of fhv- and c. felis. in addition, there was no preferred sampling site in cats with respective clinical signs, including oral ulceration, conjunctivitis, and keratitis. in cats with furtd, the oropharynx can be recommended as the preferred sampling site for detection of fcv, fhv- , and c. felis. based upon clinical signs it cannot be determined which sampling site should be selected for detection of the pathogens. no conflicts of interest reported. pulmonary haemorrhage syndrome (lphs). s. schuller , s. callanan , s. worrall , t. francey , a. schweighauser , j.e. nally . bern university, bern, switzerland, university college dublin, dublin, ireland leptospiral pulmonary haemorrhage syndrome (lphs) is a severe form of leptospirosis, which has been increasingly recognised in humans and many animal species in the past years. patients with lphs may develop rapidly progressive intra-alveolar haemorrhage, leading to high mortality. the pathogenic mechanisms of lphs are poorly understood hampering the application of effective treatment strategies. studies in humans and experimentally infected guinea pigs have demonstrated deposition of immunoglobulin and complement c in lphs lung tissue in the absence of significant numbers of leptospires, suggesting that lphs is, in part, caused by autoimmunity. the aim of this project was to describe the histopathologic features of lphs in dogs and to investigate whether igg and igm deposition is present in affected canine lung tissue. single-step immunohistochemistry (ihc) for dog igg, igm and leptospiral outer membrane vesicles was performed on lung tissues from dogs with lphs, dogs with pulmonary haemorrhage due to other causes and healthy dog lungs. acute intra-alveolar haemorrhage and oedema in the absence of significant inflammatory infiltrates were present in all lphs lung tissues. three ihc staining patterns were observed in lphs lung tissue: alveolar septal wall staining with (igg n = /igm n = ) and without intra-alveolar staining (igg n = /igm n = ) and staining of intra-alveolar fluid only (igg n = /igm n = ). intra-alveolar staining appeared to favour alveolar surfaces in some cases (igg n = /igm n = ). healthy control lungs showed no staining, whereas haemorrhagic lung showed staining of intraalveolar fluid (igg/igm n = )) and occasional, mild and discontinuous staining of alveolar septa (n = ). leptospiral antigens were not detected in any of the tissues. results indicate that histopathologic features of canine lphs are similar to what has been described in other species. ihc demonstrated that alveolar septal deposition of igg/igm is present in most dogs with naturally occurring lphs. while these findings support a role of the humoral immune response in the development of lphs, our findings do not indicate whether autoimmunity is a primary or secondary event in the pathogenesis of lphs. no conflicts of interest reported. leptospirosis, a zoonotic bacterial disease with a worldwide distribution, is a re-emerging disease in humans and dogs. acute renal and hepatic failure are the most frequently reported clinical manifestations of canine leptospirosis. the aim of this study was to describe clinical, laboratory and radiological features, the outcome as well as the distribution of leptospira serogroups in dogs with leptospirosis ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . medical records of dogs diagnosed with leptospirosis were evaluated retrospectively. diagnoses were based on microscopic agglutination testing (mat), blood/urine pcr, and histopathology (levaditi staining). mat-titers ≥ : against non-vaccine and ≥ : against vaccine serovars or a -fold rise of titers within - weeks were considered diagnostic. dogs met the inclusion criteria. in dogs diagnostic mat-titers were present (mainly against serogroups grippotyphosa ( %), australis ( %), and pomona ( %). at initial presentation, the most common clinical signs were lethargy ( %), anorexia ( %), vomitus ( %), a painful abdomen ( %), diarrhea ( %), oliguria ( %), tachypnea ( %), delayed capillary refill time ( %), pale mucous membranes ( %), fever ( %), hypothermia ( %), and icteric mucous membranes ( %). abnormal findings of the cbc included anemia ( %), thrombocytopenia ( %) and leukocytosis ( %). biochemistry abnormalities included increased creatinine concentrations ( %), increased liver enzyme activities ( %), hyperbilirubinemia ( %), hyperphosphatemia ( %), hyponatremia ( %), and hypoalbuminemia ( %). urinalysis often revealed glucosuria ( %) and an elevated urine-protein/creatinine-ratio ( %). radiological pulmonary changes were detected in % of the dogs initially or during the course of disease. dogs died or were euthanized, of them due to "leptospiral pulmonary hemorrhage syndrome". in this study, non-vaccine serogroups were the most common serogroups detected by mat. in the majority of patients renal ( %) and/or hepatic ( %) disease was detected. a pulmonary form of leptospirosis was present in % of the dogs. lung involvement represented a severe complication causing increased mortality depending on the severity of respiratory signs. no conflicts of interest reported. leptospirosis is a zoonotic disease that can affect multiple organs with renal and hepatic involvement being considered to be the most common. the aim of this study was to evaluate a large number of dogs with leptospirosis for cardiac and/or exocrine pancreatic involvement. a total of dogs were diagnosed with leptospirosis based on clinical signs and either microscopic agglutination test, blood/ urine polymerase chain reaction, and/or histopathology. at the time of admission and, in most patients, after an average of two weeks canine pancreatic lipase immunoreactivity (cpli, as measured by spec cpl â ), ultrasensitive cardiac troponin i (ctni), and c-reactive protein (crp) were analyzed. data were analyzed with non-parametric statistics. the level of significance was set at p < . . upon admission, common clinical signs reported included lethargy (n = ), vomiting (n = ), abdominal pain (n = ), dyspnea (n = ), pale mucous membranes (n = ), oliguria (n = ), hypothermia (n = ), and fever (n = ). anemia (n = ), thrombocytopenia (n = ), leukocytosis (n = ), were frequently reported hematology findings. increased concentrations of creatinine (n = / ), phosphorus (n = / ), alt (n = / ), sap (n = / ) and bilirubin (n = / ) were also frequently recorded. crp (median: . mg/l; range: . - . mg/l, reference interval (ri): . - . mg/l), ctni (median: . ng/l; range: . - . ng/l, ri: - . ng/l), and cpli (median: lg/l; range: - lg/l, ri: - lg/l) concentrations were above the upper limit of the reference intervals in / ( %), / ( %), and / ( %) dogs, respectively and serum cpli concentration was above the suggested cut-off value for a diagnosis of pancreatitis in / ( %) dogs. crp and ctni, but not cpli were higher upon admission compared to the re-check measurement (p = . and . , respectively). dogs with increased serum cpli concentrations also showed a higher proportion of dogs with increased serum ctni concentrations (p = . ). there was no statistically significant correlation of cpli concentrations with a history of abdominal pain and/or vomiting. biochemical results were compatible with multiple organ impairment with involvement of kidneys, liver, heart, and exocrine pancreas where at least two organs were affected in / ( %) dogs. forty ( %) of dogs recovered, ( %) died, and ( %) were euthanized. ctni and cpli were higher in non-survivors, but these differences did not reach statistical significance. however, the number of organs affected and outcome were significantly correlated (p = . ). our data suggest that infection with leptospira is characterized by a systemic inflammation with variable multiple organ involvement and damage, often including the heart and also the exocrine pancreas. the study was funded by texas a&m university. the primary author and two co-authors work at the gi laboratory, texa a&m university. canine bartonellosis is increasingly recognized worldwide and may be associated with diverse clinical manifestations. recent evidence suggests that bartonellosis also causes lameness and polyarthritis in dogs. however, pcr amplification of bartonella dna and isolation of bartonella species from canine synovial fluid (sf) samples have rarely been reported. canine leishmaniosis (canl) due to leishmania infantum is a multisystemic disease commonly associated with polyarthritis. based on the hypothesis that concurrent bartonella infection may be a contributing factor for the development of arthritis in dogs with canl, the main objective of this study was to investigate the microbiological and molecular prevalence of bartonella spp. in dogs with naturally-occurring canl, with or without cytologically documented arthritis. from a previous study, dogs with canl were retrospectively studied for bartonella spp. infection. diagnosis of canl was based on compatible clinical and clinicopathological abnormalities, positive serology, and lymph node or bone marrow (bm) cytology. dogs with serological evidence of other vector-borne infections (anaplasmosis, borelliosis, dirofilariosis and ehrlichiosis) and dogs recently vaccinated or medicated were excluded from the study. arthritis defined as a neutrophil percentage in excess of % of nucleated cells in sf cytology was documented in / ( . %) of dogs. a total of archived specimens from dogs, including edta-anticoagulated blood samples, bm and sf aspirates were tested for bartonella spp. dna using a bartonella alpha proteobacteria growth medium (bap-gm) diagnostic platform. eight ( . %) dogs were infected with one or two bartonella species, including candidatus bartonella merieuxii(n = ), b. henselae sa (n = ) and b. rochalimae (n = ). bartonella spp. dna was amplified from bm in dogs and from blood in dogs but was not amplified from any sf sample. overall, ( . %) dogs with and ( . %) dogs without arthritis were infected with a bartonella species. the prevalence of bartonella spp. dna in the dogs with or without arthritis did not differ (v test for independence, p = . the prevalence of giardia in dogs ranges between . % and . %, with a higher prevalence in puppies. however, the risk factors for giardia infection around weaning have been poorly described. the aim of the study was to evaluate risk factors for giardia infection in puppies during the first weeks of life and to determine an impact of this parasite on feces quality. puppies from litters living in a breeding kennel were followed between and weeks of age. each puppy was treated with fenbendazole (panacur â , msd, france, mg/kg, per os, q h) for consecutive days at , , and weeks of age. for each puppy, fecal consistency was evaluated using a -point scale. excretion of enteropathogens was evaluated by qpcr for canine parvovirus type (cpv ), qrt-pcr for canine coronavirus (ccv), coproantigens quantification for giardia (prospect-giardia, remel), and mcmaster flotation technique for any eggs and oocysts. a generalized linear mixed model (proc glimmix) with giardia infection as a binary outcome was used to assess the following effects: breed size, age, and cpv , ccv and isospora ohioensis infections. a linear mixed model (proc mixed) with fecal score as outcome was used to determine the following effects: breed size, age, and giardia, cpv , ccv and i. ohioensis infections. a total of fecal samples were collected; cpv , giardia, i. ohioensis and ccvwere detected in respectively . %, %, . % and . % of the samples. the risk of giardia infection increased with age (odd ratio= . ; %ci= . - . ; p = . ). neither breed, nor cpv , ccv and i. ohioensis infections influenced risk of giardia infection (p = . ; p = . ; p = . ; p = . respectively). giardia infection did not impact feces quality (p = . ), whereas a significant influence of cpv (p < . ), ccv infection (p = . ) and breed size (p < . ) was evidenced. this study underlines that even with an adapted deworming program the eradication of giardia is difficult to obtain in large dog packs. the higher prevalence of giardia in puppies of weeks and older could be linked with the immunity gap during this period. giardia was not associated in our study with an increased risk of diarrhea. the lack of pathogenicity of the parasite per se could be hypothesized, but also an efficacy of the treatment for the prevention of the clinical signs or a local and systemic immunity limiting clinical signs. financial support from royal canin. hepatic encephalopathy (he) can occur in dogs as a complication of primary liver disease or as consequence of congenital portosystemic shunts (pss). the aim of this study was to assess magnetic resonace spectroscopy (mrs) usefulness in he diagnosis. twenty dogs with a presumptive diagnosis of he were enrolled. inclusion criteria were: a clinical examination, a blood cell count and biochemical panel, at least one plasmatic ammonia determination higher than lmol/l, optional hystopatology of the liver, requirement of magnetic resonance imaging (mri) investigation by the clinician. even though mrs represents a non-invasive procedure, informed consent was obtained from dogs'owners. he diagnosis was confirmed in / : / had a pss, / showed hepatic microvascular dysplasia and / had hepatic cirrhosis histologically confirmed. the control-group was made of patients retrieved from our database that underwent mri without showing any abnormalities on brain scans. the mr protocol included t -weighted fast spin-echo, t -weighted sequences, proton density, and radio-frequency pulses gradient-echo. on mri examination cerebral atrophy was evident in all the patients ( / ), ranged from mild to severe. in / patients symmetrical bilateral hyperintensities in the globus pallidus on t -weighted images were evident. mrs was performed using a short te ( ms) and it was defined a volume of interest in the parieto-occipital region by -mm side cube ( cc of volume). glutamine-glutamate (gln), n-acetylaspartate and n-acetyl aspartyl glutamate (naa), choline derivatives (cho), and myo-inositol (ins) were analyzed. comparing spectra from the he affected dogs with those from the control-group decreased values of ins, cho, naa as well as high field mri combined with brain mrs provide accurate and non-invasive diagnosis of canine he. in accordance with human medicine publications, it could be state that mrs has a role in he diagnosis and follow-up with particular mention monitoring. no conflicts of interest reported. diagnosis of hepatobiliary diseases often requires hepatic tissue sampling for histologic evaluation. the laparoscopic technique is a safe method and allows acquisition of tissue by wedge and needle biopsies from different liver lobes in a minimally invasive way.specimens obtained with an -gauge biopsy needle must be interpreted with caution due to considerable variability in tissue involvement with certain disease processes. we hypothesized that needle biopsy specimens would produce findings divergent from those produced by wedge biopsy specimens. the goal of the study was to compare histological findings from two laparoscopic biopsy methods (wedge and needle) and assess which sampling technic can represent the overall disease process. procedure: all dogs included in this prospective study study were suspected diffuse hepatic disease and underwent laparo-scopic hepatic biopsy (wedge and needle - g) between and . all biopsy specimens were examined on the basis of morphologic criteria and a comparison was made between the two types of biopsies procedures according to wsava liver standardization group morphologic criteria. results: twenty-two dogs were included. no complications were reported during the laparoscopic procedure. the median number of portal triads per needle biopsy specimen was (range, to ) compared to (range ; ) with wedge biopsy specimen. the median length of needle biopsy specimens was mm; (range, to mm) and mm for all wedge biopsies. on the basis of biopsy interpretation, the diagnosis was overall similar with the two methods: dogs had vacuolar hepatopathy, acute cholangitis, non-specific acute form in dogs. chronic hepatitis with cirrhosis was found in cases, dogs had diffuse neoplasia and miscellaneous hepatic disorders. the fibrosis was considered to be severe in dogs, moderate in dogs and mild in dogs. no quantitative and qualitative difference was observed between the two types of biopsies specimen. this study demonstrates that the biopsies with a needle length of at least mm brings satisfactory information for the evaluation of most of the inflammatory, vacuolar hepatopathies, fibrosis and diffuse tumoral infiltrations. wedge biopsies allow to examine the largest number of portal triad, more contributory for certain forms of cholangitis affecting larger canals and for a single case, images of peri-hepatitis were counted at the level of the capsule. fibrosis does not seem to be more important in the sub-capsular zone contrary to what is observed in human pathology. no conflicts of interest reported. indocyanine green (icg), a fluorescence dye, is excreted solely by the liver without enterohepatic re-circulation. hence it has been used for decades as an ideal albeit invasive marker of hepatic function and blood flow in cats and dogs. here we evaluated the feasibility of a minimally invasive transcutaneous icg clearance to assess hepatic function instantaneously. transcutaneous icg clearance was performed in healthy research cats and healthy research dogs with normal liver function (bile acid stimulation test, ammonia tolerance test) using a modified device (kidney int : with an excitation wave length of nm and an emission wave length of nm. the devices were placed on different locations (lateral thoracic wall, ventrolateral abdomen, metatarsus and antebrachium) and fixed with a light bandage. to find a suitable dose to reach adequate transcutaneous peak concentrations escalating doses of icg ( . , . and . mg/kg) were injected intravenously with a wash out period of at least h in-between. measurement was continued for hour after injection in awake animals moving freely. the resulting icg disappearance curves were visually inspected to find best location (minimal artifacts, acceptable background noise) and dose. in all animals a dose of . mg/kg was deemed ideal and the thoracic and abdominal wall gave consistent results. half-life of icg clearance was calculated using a one-compartment model. half-lives in cats were . , . and . minutes, respectively; in dogs: . , . and . minutes, respectively. in conclusion, the transcutaneous assessment of icg clearance is feasible in a clinical setting. results are obtained within one hour and can be assessed instantaneously. the procedures are minimally invasive and well tolerated by the animals. given that most patients with a presumed liver problem undergo abdominal ultrasound no further clipping of hair is necessary as the device might be placed in this area. further studies are necessary to obtain reference values in healthy pets and those with various conditions leading to impaired hepatic function. no conflicts of interest reported. gallbladder diseases like gallbladder mucocele and cholecystitis can reduce gallbladder motility and may lead to cholestasis. since impaired gallbladder emptying contributes to sludge and gallstone formation, the evaluation of gallbladder motility requires accurate and appropriate methodology. three-dimensional ( d) ultrasonography has been shown to be accurate and appropriate tool for measurement of gallbladder volume in humans. therefore, we applied this novel technique for the first time to study preprandial and postprandial gallbladder volume in healthy mixed-breed dogs and compared the results to twodimensional ( d) ultrasonography. the dogs were placed in dorsal recumbency to obtain ultrasonographic measurements of the gallbladder. measurements by both d and d ultrasonography were recorded in preprandial state and after ingestion of full-fat milk. the preprandial and postprandial gallbladder volumes determined by d ultrasonography were significantly higher than corresponding volumes by d ultrasonography ( . ae . vs . ae . and . vs . ml/kg, respectively, p < . ). in d ultrasonography, most dogs ( / [ %]) had a preprandial gallbladder volume ≤ . ml/kg. however, in d ultrasonography, / ( %) of dogs had a preprandial gallbladder volume ≥ . ml/kg. gallbladder contraction index was higher in d ultrasonography than d ultrasonography, however, it did not reach statistical significance (p = . ). in conclusion, d ultrasonography showed larger gallbladder volumes than d ultrasonography in healthy dogs. it seems that d ultrasonography is appropriate adjunct device to d ultrasonography to estimate gallbladder volume when d ultrasonography could not detect whole gallbladder volume. more research is needed to determine clinical value of d ultrasonography in canine gallbladder imaging. no conflicts of interest reported. the aim of our study was to compare high-definition oscillometry (hdo) and doppler ultrasonographic measurements with direct blood pressure measurements in conscious dogs. the doppler study was performed by three investigators and by using different sphygmomanometers with different sized cuffs. devices and measurement sites were changed randomly among the investigators. cuffs were wrapped around the antebrachium in the forelimb or around the mid-metatarsus in the hind limb. in addition to the limb sites, cuffs were also placed around the base of the tail in case of the hdo method. cuff sizes were - % of the measured limb circumferences during the doppler measurement. for the hdo method all measurements were performed by the same investigator and the cuffs provided by the manufacturer were used: the smallest cuff was used for the hind limb and tail, and the medium cuff was used for the forelimb measurements. dogs were gently held in lateral recumbent position, measurement were performed on the nondependent limbs. radio-telemetry transducers were implanted to the right femoral artery some months to a year preceding the blood pressure measurements for reasons unrelated to our study. direct blood pressures varied - mmhg and - mmhg during the doppler and hdo measurements, respectively. two-hundred paired simultaneous doppler and direct measurements from dogs and paired simultaneous hdo and direct telemetric measurements from dogs were obtained. at least successful consecutive measurements could be obtained by the same investigator at the same site during the doppler or hdo measurement in and cases, respectively. thus, the mean of these measurements could be calculated similarly to the established everyday clinical practice. bias (mean difference), precision (standard deviation) and limits of agreements were calculated both from the individual paired measurements and from the means of the consecutive measurements using bland-altman spot analysis. systolic measurement performed on the tail with the hdomethod yielded the smallest bias and deviation and the best limits of agreement during this study. both doppler and hdo-measurements performed on the forelimb overestimated, while hind limb measurement underestimated the direct telemetric pressures. results of all three measurement sites by hdo performed better than forelimb or hind limb doppler-measurements, however hdo-measurements were more difficult to obtain and more often resulted with measurement failure compared to the doppler technique. cuff size above % of the measured limb circumference showed better results than smaller cuff sizes during the doppler measurements. no conflicts of interest reported. the doppler technique is considered the most repeatable indirect method to measure systolic arterial pressure (sap) in dogs. however, recent studies emphasized the effect of body position and used limb on sap measurement. the aim of this study was to determine whether a difference existed in sap measured simultaneously in dogs using different limbs, with two doppler units by two different operators. sixty clientowned dogs, admitted to the veterinary hospital for different reason, were enrolled. they were divided in groups based on body size: small breed dogs (< kg); medium breed ( - kg); large breed (> kg). for each dog the anxiety status was recorded. sap was measured via doppler technique when dogs were in right lateral recumbency in a quite environment. right and left forelimb sap and left forelimb and left hindlimb sap were recorded simultaneously, with two identical doppler units equipped with headphones, by two operators. measurement was performed based on the acvim guidelines. five measurements were recorded, the higher and lower values were discarded from the analysis. the relationship of mean sap for each limb with body weight, sex, anxiety status and sap value was evaluated. mean ae sd sap was significantly higher for the right forelimb ( . ae . ) compare to the left forelimb ( . ae . ) on overall population. the difference was significant for large breed dogs, males and dogs with sap ³ mmhg. sap was higher for the left forelimb ( . ae . ) compare to the left hindlimb ( . ae . ) on overall population. the difference was significant for medium and large breed dogs, females, calm animals and dogs with sap ³ mmhg. the mean sap from the left forelimb recorded by two different operators at two different moments, were compared and no difference was evident. in conclusion, sap measurement from different limbs, in dogs in right lateral recumbency, is poorly correlated. measurement of sap from the left forelimb is more repeatable during time and between different operators. sap trend monitoring should be done using the same measurement site for any animal. no conflicts of interest reported. amlodipine has been considered the treatmenf of choice for hypertension in cats for more than a decade. there is, however, an unmet need for a cat-specific formulation. the aim of the study was to assess the efficacy of chewable amlodipine tablets in reducing systolic blood pressure (sbp) in cats diagnosed with hypertension. seventy-seven client-owned cats were included in the study (mean age years). the study was randomised, double-blind, placebo controlled, and consisted of two phases. in the blinded phase, cats received . mg/kg amlodipine once daily for days. if they responded the dose remained the same to day . for non-responders, the dose was increased to . mg/kg. thirty-five cats received placebo following the same protocol. arterial blood pressure was measured using a high definition oscillometry method. at day a responder was defined as a cat showing a decrease of sbp to ≤ mmhg or a decrease from baseline of at least %. after days all cats continued with amlodipine for - months in an open phase with the placebo cats repeating the same dose escalation protocol as in the blinded phase. the responder rate was % in the amlodipine group and % in the placebo group following the dose escalation from day being applied to % and % of cats receiving amlodipine and placebo respectively. cats receiving amlodipine were . ( % ci . to . ) times more likely to be classified as responders when compared to those receiving placebo (logistic regression model, p = . ). from a baseline value of . ae . and . ae . mmhg the mean sbp decreased to . ae . mmhg with amlodipine and to . ae . mmhg with placebo (repeated measures analysis of covariance model, p < . ) by day . the responder rate was not influenced by factors other than amlodipine treatment (e.g. baseline blood pressure, concomitant ace inhibitor therapy, renal disease). there were no differences between the amlodipine and placebo groups in the frequency of adverse events reported during the -day blinded phase. likewise, there were very few changes in the laboratory values over time in either group. the present study is the first large clinical trial to show that amlodipine is clearly superior to placebo in the treatment of cats with hypertension. the chewable amlodipine formulation effectively reduced sbp, had a good palatability and was well tolerated. it can be used concomitantly with ace inhibitors and in cats with renal disease. conflicts of interest: m. huhtinen and j. aspegr en are employees of the sponsor j. elliott has the following information to disclose: amlodipine is the treatment of choice for feline hypertension. limited published data exist on serum concentrations achieved in hypertensive cats. the aim of the study was to assess serum amlodipine concentrations in cats treated with a new formulation of amlodipine and relate these to the blood pressure reduction achieved. seventy-seven client-owned hypertensive cats were enrolled into a randomized, double-blind and placebo controlled study consisting of two phases. in phase one, cats (group a) received . mg/kg amlodipine once daily for days. if they were deemed to have responded (see below) the dose remained the same to day . for non-responders, the dose was increased to . mg/kg. thirty-five cats (group b) received placebo following the same protocol. blood pressure was measured using high definition oscillometry. a responder was defined as a cat showing a decrease of systolic blood pressure (sbp) to ≤ mmhg or a decrease from baseline of ≥ %. following day (phase ), group a continued on amlodipine and group b switched to amlodipine and the dose was adjusted as per phase . both groups were followed for days on amlodipine. blood was collected at days (group a) and (both groups) and serum [amlodipine] measured by liquid chromatography mass spectrometry. the sbp measured on treatment was calculated as percentage of the baseline sbp and plotted against serum [amlodipine] using a sigmoidal emax model (winnonlin software). data are expressed as mean ae se. the serum concentrations of group a cats that remained on . mg/kg were . ae . ng/ml whereas those switched to . mg/kg were . ae . ng/ml. when data from groups a and b were pooled, a sigmoidal relationship between percentage baseline sbp and serum [amlodipine] was found. estimated values of lowest percentage baseline blood pressure on treatment (emax) was . ae . %, with an ec value of . ae . ng/ ml and a slope function of . ae . . the serum concentration required to reduce blood pressure by % was estimated to be ng/ml. the present study related blood pressure reduction to serum [amlodipine] in feline clinical hypertension. the limitations of this study were the limited number of blood samples collected and lack of information relating to the exact timing of blood sampling relative to dosing in some cats. however, these data could be used to define appropriate therapeutic serum [amlodipine] in hypertensive cats. m huhtinen is an employee of the sponsor; j. elliott has the following information to disclose: consultancy: pfizer animal health / zoetis, ceva animal health, boehringer ingelheim, vetoquinol ltd, orion ltd., elanco ltd, idexx ltd, niche generics ltd. triveristas ltd., virbac ltd., advisory board membership: international renal interest society (supported by novartis) european emesis council (sponsored by pfizer animal health -now zoetis) cardiorenal board -vetoquinol ltd. idexx renal advisory board research grants or contracts: vetoquinol ltd, novartis ltd, pfizer animal health ltd (now zoetis), royal canin ltd, boeringher ingelheim ltd, waltham centre for pet nutrition, ceva animal health orion ltd.; l pelligand has the following information to disclose: in receipt of research grant / contract funding from orion ltd., novartis animal health, transpharmation ltd, deltadot ltd; acted as a consultant for: triveritas ltd. and novartis animal health. commercial assays for the measurement of canine and feline pancreatic lipase immunoreactivity (spec cpl â and spec fpl â , respectively; idexx laboratories, westbrook, me, usa) have been available for a few years and have previously been analytically and clinically validated. recently, new commercial assays for the measurement of these parameters have become available, though neither one of these assays have been analytically or clinically validated in the literature. thus, the goal of this study was to compare these newly available assays to the established assays. leftover serum samples from diagnostic submissions to the gi laboratory were collected based on certain parameters (e.g., results throughout the working range of the assay, good quality sample or hemolytic, lipemic, or icteric sample) and were assigned random sample id numbers. the samples were evaluated by spec cpl â or spec fpl â , sent on dry ice to the klinik am hochberg, and one aliquot of each sample was blindly submitted to laboklin for measurement of cpli and fpli by their newly released in-house assay and also to the gi lab at texas a&m university for repeated analysis by spec cpl â and spec fpl â to exclude any effect of shipping. there was no significant difference between serum cpli or fpli concentrations before or after shipping at the gi lab (pvalues for wilcoxon matched-pairs signed rank tests: . and . , respectively). in contrast, there was a significant difference between serum cpli or fpli concentrations between the newly released assays and the previously established assays (pvalues < . and . , respectively). while there was a significant correlation between the newly released and the previously released assays (spearman r: . and . , respectively), this correlation was very poor for assays that supposedly measure the same analyte. also, the interpretation for serum cpli and fpli results between the previously developed assays and the new assays did not agree for many of the samples. finally, both newly developed assays showed some erratic results. in conclusion, the newly released assays for the measurement of cpli and fpli do not agree with previously established and validated assays, provide different interpretations, and show erratic results. thus, further research is needed before these newly released assays could be recommended for clinical use. dr. steiner serves as director and dr. suchodolski serves as associate director of the gastrointestinal laboratory at texas a&m university. dr. steiner also serves as a paid consultant to idexx laboratories, westbrook, me, usa. both the gastrointestinal laboratory and idexx laboratories offer cpli and fpli testing on a fee-for-service basis. digestive health is a main concern for growth, morbidity and mortality in weaning puppies. fecal immunoglobulin a (iga) has been suggested as a useful noninvasive biomarker for mucosal immunity. the purpose of this study was to evaluate the effect of infection with enteropathogens on fecal iga concentrations in puppies and that of physiological factors such as age and breed size. puppies from breeding kennels were included in the study. puppies were between and weeks of age (meanaestandard deviation (sd): . ae . weeks). depending on the mean adult body weight of their respective breed, the puppies were divided into small (if mean adult body weight < kg) or large (> kg) breed puppies. for each puppy, fecal consistency was evaluated using a -point scale and feces were collected for the evaluation of presence of fecal enteropathogens and fecal iga concentrations. the presence of enteropathogens in fecal samples was evaluated by qpcr for canine parvovirus type (cpv ), qrt-pcr for canine coronavirus (ccv), coproantigen quantification for giardia (prospect-giardia, remel), and mcmaster flotation technique for other parasite eggs and oocysts. fecal iga concentrations were measured by an elisa test. statistical analyses were performed using sas software. a linear mixed model (proc mixed) with fecal iga concentration as outcome was used to determine the following effects: enteropathogen infection, breed size, age, and fecal score. the respective influence of litter and breeding kennel as random effects was also determined. data is presented as mean ae sd. small breed dogs represented . % ( / ) of the total number of dogs included. at least one enteropathogen was identified in . % of puppies ( / ). fecal iga concentration was significantly influenced by fecal enteropathogens (p = . ). puppies infected with at least one enteropathogen had significantly lower fecal iga concentrations than puppies without any enteropathogens ( . ae . lg/g vs. . ae . lg/g). breed (p = . ), but not age (p = . ), influenced iga concentration. small breed puppies had significantly higher fecal iga concentrations than large breed puppies ( . ae . lg/g vs. . ae . lg/g). no significant relationship between fecal iga concentration and feces quality was evidenced (p = . ). this study suggests that fecal iga concentration is a promising marker for subclinical infection by at least one enteropathogen and confirms that digestive physiology varies with the breed size. a link between lower digestive immunity and higher susceptibility to enteropathogen infection needs further investigation. conflicts of interest: financial support of royal canin. canine chronic enteropathies (cce) include diet-responsive, antibiotic-responsive, and immunosuppressive-responsive enteropathies (ire). this prospective study was designed to evaluate a commercial hypoallergenic dry diet a containing oligopeptides as the only protein source for the management of dogs with ire and as an alternative to immunosuppressive therapy over a week period. nineteen dogs across france and quebec entered the study. dogs with food or antibiotic-responsive chronic enteropathy, hypoproteinemia, or treated with immunomodulating drugs were excluded from the study. dogs were included in the study after complete clinical, ultrasonographic, endoscopic evaluation and histopathological evaluation of intestinal biopsies showing signs of intestinal inflammation. the owners were instructed to feed exclusively the study diet a . canine inflammatory bowel disease activity index (cibdai) scores, fecal scores as observed by the dog-owners, and body weight were evaluated at baseline, , and weeks after inclusion. dietary treatment was regarded successful if the cibdai score was reduced by at least %. the protocol has been reviewed and accepted by royal canin ethics committee and owners completed an informed consent. results are presented as meanaesd (range). statistical comparisons were performed with a wilcoxon test. thirteen dogs ( intact males, neutered and intact females) completed the trial. seven dogs were excluded ( diagnosed with giardia, s with no histological evidence of inflammation, with hypoadrenocorticism). mean age was . years ae . ( . - . ), mean body weight . kg ae . ( . - . ). cibdai score was . ae . ( - ) at inclusion, was . ae . ( - ) after weeks and was . ae . ( - ) after weeks (p = . and p = . vs inclusion, respectively). fecal scores after [ . ae . ( - )] and weeks [ . ae . ( - ) ] were improved compared to inclusion scores . ae . ( - ) (p = . and p = . , respectively). the low molecular weight poultry feather hydrolyzed proteinbased dry extruded diet a appears to be effective in the management of idiopathic ibd without any concurrent immunosuppressive drug over the week period of this pilot study. these preliminary findings should be confirmed by a prospective, randomized double blind study. feline pancreatitis is the most common exocrine pancreatic disorder with varied mortality. however, there is no available and reliable method to evaluate the severity and prognosis of the disease. ninety-two cats diagnosed as pancreatitis with acute onset of compatible clinical signs and a positive snap â fpl tm test between october and september were enrolled in this study. all cats were divided into survival (n = ) and nonsurvival (n = ) groups. fifty-two parameters including signalments, clinical signs, physical examinations, clinicopathological examinations, diagnostic images, complications and concurrent diseases were analyzed and compared between the two groups. parameters with p ≤ . were considered for further analyses. the mortality in this study was . %. hematocrit, albumin, bun, creatinine, total bilirubin, calcium, phosphorous, body temperature, systolic blood pressure, the body cavity fluids, complications, e.g. systemic inflammatory response syndrome (sirs) and acute renal failure (arf) were found to be significantly associated with disease severity and prognosis, and were selected for constructing the scores. continuous variables outside the reference interval were separated into quartiles to yield quartile-specific odds ratios (ors) for survival. based on the integer value of the or, the scoring system was then developed by incorporating weighting factors assigned to each quartile. a predictive total score was calculated for each cat by summing all weighting factors. the total scores of each cat ranged from to . the severity scores in this study achieved an area under receiver operating characteristic (auroc) of . . the optimal cut-off point for discriminating outcome was . with the sensitivity of . % and specificity of . %, respectively. the mortality was . % with a score ≥ , whereas . % with a score ≤ . there was significant difference (p < . ) between the two groups of the cut-off point. furthermore, the mortality reached to % when the score more than . the severity scoring system of this study provides a reliable and clinical applicable method to predict clinical outcome in cats with pancreatitis. no conflicts of interest reported. convincing evidence for the role of clostridium (c.) perfringens as a primary pathogen in acute haemorrhagic diarrhoea syndrome (ahds) in dogs was recently found. it is suspected that clostridial toxins, especially c. perfringens enterotoxin, play a relevant role in the disease process. however, to date enterotoxigenic c. perfringens strains have only been described in single case reports. thus, the aim of this study was to indentify the specific c. perfringens genotype involved in adhs. small intestinal biopsies were collected with a sterile single-use biopsy forceps from ten dogs with ahds and immediately cultured. in / dogs, clostridial strains were isolated and identified as c. perfringens by mass spectrometry using maldi-tof ms. c. perfringens colonies from each dog were submitted for specific detection of the four major toxin genes (alpha, beta, epsilon, and iota), the enterotoxin gene, and the beta toxin by multiplex pcr. every clostridial isolate was typed as c. perfringens type a based on the detection of the alpha toxin encoding gene. in / isolates, additionally the beta toxin gene was identified, however, none of clostridial strains encoded for the c. perfringens enterotoxin gene. the results of this study suggest that c. perfringens type a is the most important c. perfingens genotype involved in the disease process of dogs with ahds. although c. perfringens enterotoxinhas been associated with intestinal diseases in humans, dogs, horses, pigs, and other animal species, this enterotoxin is most likely not responsible for the intestinal lesions in dogs with ahds. no conflicts of interest reported. p < . ). lack of treatment response was significantly associated with il (il: / , sre: / , fre: / , are: / ; p < . ). anemia, thrombocytopenia, and increased plasma urea were significantly associated with il (anemia: il: / , sre: / , fre: / , are: / , p < . ; thrombocytopenia: il: / , sre: / , fre: / , are: / , p = . ; increased urea: il: / , sre: / , fre: / , are: / , p = . ). hypoalbuminemia (< g/l) and hypocobalaminemia (< pg/ml) occurred significantly more frequently in dogs with sre (hypoalbuminemia: il: / , sre: / , fre: / , are: / , p < . ; hypocobalaminemia: il: / , sre: / , fre: / , are: / , p = . ). results of this study show that elderly and large breed dogs were more frequently affected with il and sre compared to other etiologies and both il and sre were associated with greater disease severity and/or a negative outcome. in comparison, anemia, thrombocytopenia, and increased plasma urea were most frequently detected in il whereas severe hypoalbuminemia and hypocobalaminemia were significantly associated with sre. no conflicts of interest reported. alpha -proteinase inhibitor (a -pi) is a proteinase-resistent protein that can be quantified in fecal, urine, and serum samples from dogs. recently, increased fecal and urinary canine a -pi (ca -pi) concentrations have been described in dogs with gastrointestinal diseases (e.g., inflammatory bowel disease [ibd] , but also in dogs with exocrine pancreatic insufficiency) and in dogs with chronic hepatitis or chronic kidney disease, respectively. decreased serum ca -pi concentrations have been reported in dogs with ibd, protein-losing enteropathy (ple), and hypocobalaminemia. treatment protocols for dogs with ibd and/or ple commonly include corticosteroids, but the effect of corticosteroid therapy on serum ca -pi concentrations have not yet been reported. the aim of this study was to evaluate the effect of hydro-cortisone on serum ca -pi concentrations in healthy dogs. twelve healthy beagle dogs were randomly allocated to a placebo-group (n = ) and to a treatment group (n = ; hydrocortisone-group). the placebo-group received an empty gelatin capsule po q h, whereas the hydrocortisone-group was treated with hydrocortisone at a dose of . mg/kg po q h. serum samples were obtained at baseline and on day , , , , and during treatment as well as day , , , , and post-treatment for all dogs. serum ca -pi concentrations were measured at all time points using an in-house radioimmunoassay. a mann-whitney u test was used to compare the baseline measurements of both groups. the effect of hydrocortisone-treatment on serum ca -pi concentrations was evaluated by comparing ca -pi at baseline and during treatment and between baseline and posttreatment period using a manova. baseline serum ca -pi concentrations did not differ between the hydrocortisone-and the placebo-group (p > . ). serum ca -pi concentrations increased significantly (p = . ) during the treatment period in the hydrocortisone-group (baseline [median in mg/l: , ] ). in contrast, no difference was observed between both groups when comparing serum ca -pi concentrations at baseline and during the post-treatment period (p > . ). this study showed that hydrocortisone-treatment over weeks did affect serum ca -pi concentrations in healthy dogs. whether corticosteroid therapy has any effects on fecal or urine ca -pi concentrations in healthy dogs remains to be determined. the author works at texas a&m university, whose gi lab currently offer a commercial assay for faecal alpha -proteinase inhibitor. canine chronic enteropathy (ce) is a common, but poorly understood syndrome, with variable response to therapy and prognosis. there is a need for novel biomarkers that are specific for intestinal disease and that provide objective measures of disease severity, progression, and prognosis. serum citrulline is a useful biomarker in human intestinal disease as it is specific to the small intestine and indicates globally reduced enterocyte mass and absorptive function in various disease states. it is used to determine, quantitatively, intestinal integrity at the enterocyte level and is not influenced by nutritional or inflammatory status. the aim of this study was to determine whether serum citrulline can be used as a biomarker for ce in dogs. in this retrospective study, computer records from the university of liverpool small animal teaching hospital were used to identify dogs with ce. disease severity was quantified by cibdai. controls were age-and breed-matched dogs without gastrointestinal disease. serum citrulline was measured by ultra-high performance liquid chromatography with tandem mass spectrometry. in dogs with ce, serum citrulline concentration was measured at presentation and at various time points after starting treatment. serum citrulline was measured in dogs with ce and controls. dogs responded to dietary manipulation (food-responsive enteropathy, fre) and responded to antibacterials (antibiotic-responsive diarrhoea, ard), with a further having invasive mucosal bacteria, of which one responded to antibacterials and one was refractory. dogs were diagnosed with idiopathic ibd (on the basis of exclusion of known causes and failure to respond to therapeutic dietary and antibiotic trials), of which responded to immunosuppressive therapy, were refractory, and were lost to follow-up. serum citrulline concentration did not differ between dogs with ce (median . lg/ml, range . - . ) and controls (median . lg/ml, range, . - . , p = . ). there was also no difference in serum citrulline concentration amongst dogs with fre, ard, ibd, and controls (p = . ). serum citrulline did not differ between dogs that responded well, or were refractory to treatment (p = . ), between dogs with and without protein-losing enteropathy (p = . ), or between dogs that survived and that were euthanased because of ce (p = . ). serum citrulline did not correlate with cibdai (r = . ). these findings do not support the use of serum citrulline as a biomarker in determining diagnosis, prognosis, or quantifying severity in dogs with ce. one of the co-authors (marco caldin) has a diagnostic laboratory offering citrulline assays. chronic enteropathy (ce) is a multi-factorial disease, which involves aberrant immune responses to commensal bacteria or dietary antigens. macrophages have an important role in human disease but little information is available in canine intestine. data to date have relied solely on macrophage identification using mac , an antibody directed against calprotectin, which recognizes both macrophages and neutrophils. in this study an alternative antibody for macrophages, am- k, directed against a scavenger receptor (cd ) was used and distribution of both markers was compared. this antigen is of interest as positive cells accumulate in intestine of humans with ce. endoscopic duodenal biopsies were obtained from seven crossbreed dogs. serial histologic sections were stained with mac or am- k. positively-stained cells were counted from random areas from both villous and crypt regions. stained cell localisation was subjectively evaluated and the percentage of positively stained cells from the total nucleated cells per , lm in the villus or crypt was compared between both antibodies using a wilcoxon signed-rank test. mac and am- k did not co-localize on serial sections. there were significantly more am- k positive cells than mac in the crypts ( . % [ - . ] versus . % [ - . ], p = . ). in contrast there was no difference in expression of either markers in the villi ( . % [ - . ] versus . % [ - . ], p = . ). this study reports for the first time the existence of two populations of macrophages in canine intestine. these results in normal dogs will be used to explore further the distribution and function of macrophages in dogs with ce. no conflicts of interest reported. chronic diarrhea and vomiting are common clinical signs in dogs. primary (e.g., inflammatory, infectious, neoplastic, mechanical, or other) and secondary gastrointestinal diseases (e.g., exocrine pancreatic, hepatic, renal, or endocrine disease) are possible underlying causes. the aim of this study was to evaluate the final diagnoses in dogs with chronic diarrhea and/or vomiting and to determine the prevalence of various primary and secondary gastrointestinal diseases in dogs with these gastrointestinal signs. medical records of dogs presented between july and august with chronic diarrhea (d), vomiting (v) or both (diarrhea and vomiting [vd]) were retrospectively reviewed. dogs were included if a minimum work-up (hematology, plasma biochemistry profile, and fecal parasitology) had been performed and if a final diagnosis was recorded ( / ). a primary gastrointestinal disease was recorded in % of the cases ( / ) and included inflammatory diseases ( / , exocrine pancreatic insufficiency, hypoadrenocorticism, polyendocrinopathy, dilated cardiomyopathy, and leukemia in one dog each). in total, % of the dogs were presented with d ( / ) followed by % with vd ( / ), and % with v ( / ). d and vd were significantly more frequent in dogs with primary gastrointestinal disease (d: / , vd: / ), compared to dogs with secondary gastrointestinal disease (d: / ; vd: / ; p = . , chi square test). v was significantly more common in dogs with secondary gastrointestinal disease ( / ) as compared to dogs with primary gastrointestinal disease ( / ; p = . ). in this study, food responsive enteropathy ( %) was the most commonly diagnosed cause of chronic gastrointestinal signs. chronic pancreatitis was the most frequent cause of secondary gastrointestinal disease ( %). diarrhea was significantly associated with primary and vomiting with secondary gastrointestinal disease. no conflicts of interest reported. matrix metalloproteinases (mmps) and are zinc-dependent endopeptidases that contribute to the control of breakdown and reconstitution of extracellular matrix under both normal and pathological conditions. intestinal mucosal levels of mmp- and - have been shown to be increased in animal models and human ibd. to our knowledge, the presense of mmp- and - has not been studied in the intestinal mucosal samples of healthy dogs as well as in canine spontaneous ibd. thus, the main aim of this study was to identify the presence of mmp- and - in the mucosa of the small and large intestines of clinically healthy beagle dogs using gelatin zymography technique. for the study, historical intestinal tissue samples from four different parts of the intestine (duodenum, jejunum, ileum and colon) were used. the samples were taken and snap frozen in liquid nitrogen during necropsy from healthy laboratory beagle dogs after being euthanized when finishing unrelated long-term trials studying canine intestinal microbiota. based on wsava histology standards, recorded findings of all samples were considered insignificant. pro-mmp- and - activities were found in / ( %) and / ( %) of the samples, respectively. among four different parts of the intestine of dogs, the ileum had the highest positivity rates of / ( . %) and / ( . %) for pro-mmp- and - activities, respectively. however, statistical analysis showed no significant difference of pro-mmp- and - activities between the separate parts of the intestine (p > . ). the enzyme activities ranged for pro-mmp- between . and . arbitrary units (au) and for pro-mmp- between . and . au. none of the intestinal samples showed gelatinolytic activity corresponding to the control bands of active mmp- and mmp- . this study showed that pro-mmp- and - could be detected in the intestinal mucosa of healthy dogs using zymography, which seems to be a useful tool to evaluate the role of mmp- and - in the pathogenesis of canine chronic enteropathies, including inflammatory bowel diseases. no conflicts of interest reported. digestive perforation is called spontaneous when it arises in the absence of foreign body ingestion, gastric dilatation and volvulus, external trauma, or previous digestive surgery. in dogs many predisposing factors have been identified, including antiinflammatory administration, severe hepatic or renal disease, stress, shock, gastric hyperacidity, neoplasia and idiopathic inflammatory bowel disease. spontaneous digestive perforation has been uncommonly reported in cats. the objectives of this study were to describe the clinical characteristics of spontaneous digestive perforation in cats, and to compare the frequency of malignant versus non-malignant causes for these perforations. to be included in this study, the perforation had to be spontaneous and confirmed by exploratory surgery. the medical records of cats diagnosed as having spontaneous digestive perforation between and were reviewed. the mean age of cats was . years ( months to years). five cats had concurrent illnesses including viral upper respiratory tract disease, pancreatitis and chronic kidney disease. the most frequently reported signs included anorexia ( %), vomiting ( %), and lethargy ( %). histological examination was performed in cats and diagnosed alimentary lymphoma in % and inflammatory lesions in the other % of them. six cats had received anti-inflammatory within the previous months. half of them were finally diagnosed with lymphoma. five cats with lymphoma received chemotherapy.three cats died early in the postoperative recovery period, cats were euthanized to days after surgery, and cats were still alive at the end of this study. in the absence of pneumoperitoneum, clinical signs and clinicopathological abnormalities are not specific enough to allow differentiation between cats with gastrointestinal ulceration and those with perforation. in most cases, there is no diagnostic test that individually determine whether perforation has occurred or is impending, and clinicians should use of multimodality diagnostic procedures such as radiography, ultrasonography, endoscopy, and abdominal fluid cytopathology to avoid delay in diagnosis of digestive perforation. histological examination of ulceration is essential as lymphoma should be suspected in all cats presented with spontaneous perforation. the link between anti-inflammatory administration and spontaneous perforation in cats is not established. no conflicts of interest reported. campylobacter species are commonly isolated from faeces of dogs and cats with c. upsaliensis (cu) and c. helveticus (ch) being the most frequently isolated. these two species are usually not considered pathogenic in dogs and cats and are closely related to each other and to c. jejuni, the most common cause of bacterial gastroenteritis in humans in the developed world. interestingly, despite their close genetic relationship, in humans cu is considered a pathogen while ch is not. this study aimed to describe whole genomes of cu and ch isolated from dogs and cats and to in silico investigate their pathogenic potential with comparison to several published genomes of c. jejuni and c. coli. genomic dna was extracted from three isolates of each of cu and ch recovered from the faeces of healthy dogs and cats. sequencing was performed using an illumina miseq to generate base paired reads. reads were trimmed for both length and quality. contigs were assembled using the velvet assembler. the concatenated contigs generated for each assembly were quality ranked (by number, size, maximum length and n ) and the three top ranked assemblies were annotated using the prokka annotation tool. ribosomal mlst nucleotide sequences were used as a proxy for the core genome to compare the phylogeny of cu and ch with other species in the campylobacter genus and visualised as a neighbornet using splitstree. annotated draft genomes were clustered using orthomcl and pathogenic traits were investigated in silico using pathogenfinder and viru-lentpred software. the cu and ch draft genomes were~ . mb and . mb in size, and comprised on average and contigs, and on average and predicted genes, respectively. of these cu had on average and ch hypothetical proteins. using orthomcl, a core genome of and genes resulted for cu and ch, respectively. neighbornet trees based on ribosomal mlst nucleotide sequences and the core genome confirmed the close phylogenetic relationship of ch and cu within the campylobacter genus. pathogenfinder predicted all isolates as human pathogens with probabilities of . - . %. both pathogenfinder and virulentpred identified many pathogenic proteins in cu and ch of different functions (e.g. chemotaxis, transporter and motility systems) but considerably fewer than in c. jejuni and c. coli. this study provides many insights into the pathogenic potential of pet-associated emerging campylobacter pathogens and is to our knowledge, the first to report a draft genome of ch. no conflicts of interest reported. there are only few laboratory markers being evaluated for diagnosing and/or monitoring canine chronic enteropathies, including inflammatory bowel disease (ibd). s a belongs to the s /calgranulin-protein family and has been proposed to play a central role in both innate and acquired immune responses. it has been reported to be increased in stool samples, serum and/or intestinal mucosa in human patients with ibd. myeloperoxidase (mpo) is an enzyme found mostly in granulocytes. intestinal mucosal levels of mpo have been shown to be increased in animal models and human ibd. to date, s a and mpo levels in intestinal mucosal samples have been reported neither from healthy dogs nor from dogs suffering from ibd. to start investigating this aspect in dogs, the objective of this study was to evaluate mucosal s a and mpo levels in the small and large intestines by using enzyme-linked immunoassay (elisa) and spectrophotometric methods, respectively. for the study, historical intestinal tissue samples from four different parts of the intestine (duodenum, jejunum, ileum and colon) were used. the samples were taken and snap frozen in liquid nitrogen during necropsy from healthy laboratory beagle dogs after being euthanized when finishing unrelated long-term trials studying canine intestinal microbiota. based on wsava standards the histologic findings of all samples were considered insignificant. s a concentrations were from the highest to the lowest: ileum, . ( . - . ) lg/l; colon, . ( . - . ) lg/l; duodenum, . ( . - . ) lg/l; and jejunum, . ( . - . ) lg/l. the concentration in the ileum was significantly higher than in all other segments (p < . ), and the colonic mucosal concentration was higher than the jejunal (p < . ). the highest mpo activity was found in the ileum ( . [ . - . ] da/min), followed by jejunum ( . [ . - . ] da/min), duodenum ( . [ . - . ] da/min), and colon ( . [ . - . ] da/min). mpo activity was significantly higher in ileal and duodenal than in colonic mucosal samples (p < . ). the jejunal mpo activity was higher than the colonic and duodenal activity (p < . ). this study showed that using elisa and spectrophotometry allow the detection of canine intestinal mucosal s a and mpo, respectively. the levels on s a and mpo seem to differ between certain parts of the intestinal mucosa of healthy dogs. both assays appear to be useful to further evaluate the role of s a and mpo in the pathogenesis of canine chronic enteropathies, including ibd. dr. heilmann, dr. suchodolski, and dr. steiner have a patent pending that includes the canine s a assay used in this study. the authors declare that they have no further conflicts of interest. the aim of the present study was to establish the incidence of innocent cardiac murmurs in a fairly large number of clinically healthy puppies. a second aim was to evaluate a possible correlation between the presence of an innocent cardiac murmur and a lower hematocrit value. puppies of certain breeds are routinely screened for the presence of congenital porto-systemic shunts in the netherlands. breeders bring their nests to our clinic for individual measurement of blood ammonia concentration. in one year time (from february until january ) dogs of different breeds were examined, with of them being cairn terriers. the age of the dogs varied from to days (mean days). while the breeders were waiting for the blood results, the cardiac auscultation was performed by a single board-certified cardiologist (vsz). hematocrit was measured with an automatized hematology analyzer system from the surplus blood sample. cardiac murmur was found in dogs ( %). in all cases this was a soft ( - out of ) systolic murmur, most of the time with a musical character and with the point of maximal intensity on the left hemithorax, compatible with the description of an innocent cardiac murmur. no murmurs were found that could be compatible with a congenital cardiac anomaly. the hematocrit was significantly (p = . ) lower in the group of dogs with a murmur (mean . %, standard deviation . %) compared to the group without a murmur (mean . %, standard deviation . %). multivariate analysis shows that the presence of murmur is correlated with the hematocrit, but not with the age of the dogs. physiologic anemia has been long suspected to be one of the possible causes of innocent cardiac murmurs in young animals and children. however, according to the authors knowledge, no published reports exist that looked for a possible correlation. which other factors contribute to the presence of an innocent murmur is largely unknown. because of a large overlap between the hematocrit values of dogs with and without a cardiac murmur, measuring hematocrit in a particular pup would not help a less experienced first line veterinary practitioner to decide whether a murmur is innocent or the result of a congenital cardiac anomaly. limitation of this study is that no echocardiography was performed to rule out congenital cardiac anomalies as the cause of the murmurs. neither were the dogs re-checked for spontaneously disappearance of the murmur. no conflicts of interest reported. low intensity systolic murmurs, with point of maximal intensity over the outflow tract on the left side of thorax, are not uncommonly heard during cardiac auscultation of apparently healthy siberian husky dogs, often with excellent exercise tolerance. the origin of these murmurs in athletic dogs such as huskies is unlikely to be due to heart disease but more likely due to turbulent blood flow in the outflow tract caused by a large stroke volume and forceful cardiac contractility in early systole. the differentiation of these murmurs from "pathological"significant murmurs can however be problematic in general practice. the aim of the present study was to investigate the prevalence of murmurs in a sample of successfully racing siberian husky dogs and furthermore to study the phonocardiographic characteristics of these murmurs. phonocardiograms and ecgs were recorded in actively racing siberian husky dogs, with normal or excellent exercise tolerance. normal stamina was confirmed by successful racing. phonocardiograms were easy and rapid to record on a pc laptop connected to the meditron stethoscope in ambulant "field"practice. systole was measured as the duration measured from the onset of the first heart sound to the onset of the second heart sound and the murmur duration from the onset the first heart sound to the end of the murmur. the duration of the first heart sound plus the murmur was measured and calculated as a percentage of the duration of systole. cardiac murmurs of grade - were heard in % of dogs examined. phonocardiogram from these dogs revealed early systolic crescendo-decrescendo or decrescendo murmurs with a duration of maximally % into systole. all dogs with murmurs had a silent pause at the end of systole. ecg was normal in all dogs. murmurs in adult athletic dogs should not be regarded as a definite sign of heart disease. physiological flow murmurs of up to % of systole is a common finding in active siberian husky dogs (prevalence % in the examined sample). phonocardiography is a rapid and practical method for differential diagnoses between pathological murmurs and physiological flow murmurs. no conflicts of interest reported. nt-probnp has a degree of overlap with clinically normal animals, particularly those with mild or subclinical heart disease. prior studies have evaluated the sensitivity and specificity of a point-of-care second generation elisa that utilizes snap technology. the snap feline probnp test uses the same biological reagents as the cardiopet probnp test but provides results in minutes. we sought to prospectively validate the assay in a population of clinically normal cats. cats were recruited based upon the absence of a heart murmur, gallop, and/or arrhythmia. all cats received physical examination, non-invasive blood pressure measurement, complete biochemical analysis including a t , urinalysis and echocardiogram. only cats considered free of underlying cardiac or systemic disease were enrolled. sixteen adult cats were enrolled and blood samples were obtained for nt-probnp concentrations at , hr, hr, hr, hr, hr. samples were placed in edta tubes and centrifuged within one hour and split into two tubes for duplicate samples at each time point and stored at - °c. once all samples were collected, they were shipped on dry ice overnight and run in one batch (idexx laboratories) for measurement of nt-probnp concentrations. snap tests were visually evaluated by one blinded reader. comparison of snap assay vs. quantitative elisa revealed a . (auc) degree of correlation between assays, and that a positive snap test result was associated with a nt-probnp concentration of . pmol/l or greater. the average bnp concentration of abnormal cats ( . ae . ) determined by the snap assay was significantly greater than the normal ( . ae . ). this study was funded through idexx and the university of florida college of veterinary medicine resident grant competition. we acquired d echocardiographic cineloops from the left apical -chamber view optimized for the la, and analyzed atrial longitudinal strain (st) and strain rate (sr) in dogs ( healthy dogs and dogs with mmvd - acvim stage b , stage b and stage c). endocardial la ste curves were obtained and peak atrial longitudinal strain (pals), peak atrial contraction strain (pacs), conduit atrial longitudinal strain (cals); pals-pacs) and contraction strain index (csi -pacs/pals* ) were calculated. la sr curves were similarly obtained to determine the peak positive strain rate (srs) during left ventricle systole, the first negative peak strain rate (sre) during early diastole and the second negative peak strain rate (sra) during atrial contraction. for all variables, a mean of measures was used for the statistical analysis. we compared each of these variables between each acvim stage by kruskal-wallis tests and post-hoc pairwise comparisons, with comparison-wise a= . . normal dogs had higher pals and cals than dogs with mmvd (p < . and p = . ); stage c dogs had lower pals, pacs and cals than all other dogs (p < . , p = . and p = . ), but csi did not differ between groups (p = . ). stage c dogs had lower srs (p = . ), higher sre (p = . ) and sra (p = . ) than other dogs. normal dogs had lower sre and sra than dogs with mmvd (p < . ). our data suggest that ste might be useful in assessing la function in dogs with mmvd, and might potentially differentiate dogs with severe subclinical disease from dogs with congestive heart failure. no conflicts of interest reported. sighthounds are athletic dogs and they have been claimed to have larger hearts compared to similar sized breeds. the left ventricle (lv) may enlarge in response to cardiac disease, but also in response to training, so called athlete's heart syndrome, which is a benign condition. to distinguish abnormal echocardiographic measurements from normal, breed-specific reference values are needed. the aim of this study is to establish normal reference ranges for echocardiographic measurements in the saluki breed. the study comprised clinically healthy salukis ( males and females), mean age months (ae sd months), bodyweight (bw) , kg (ae , kg). case history was ascertained and dogs underwent physical examination, complete blood count, serum biochemistry profile, thyroid profile, blood pressure measurement and -min ecg. standard m-mode and d echocardiographic measurements were obtained. dogs with systolic murmur / , and dogs with mitral valve regurgitation (mr) < % (mr color flow jet area/left atrium areax % in apical view) were considered normal. linear regression models were used to establish reference ranges. heart rate (hr) varied from to bpm ( ae bpm). bw was a significant predictor for lv dimensions, i.e. m-mode lv diameter and d volume in diastole (lvidd and lvedv) and systole (lvids and lvesv), and mitral valve end point septal separation (epss). hr was a significant predictor for fs % (fractional shortening). predicted values ( % prediction intervals) were calculated from regression models where mean bw ( , kg) and age ( months), and median hr ( bpm) were used. normal reference ranges were: lvidd , mm ( , - , ), lvids , mm ( , ) , lvedv , ml ( , - , ), lvesv , ml ( , - , ), fs%: , % ( , - , ), ejection fraction ef%: , % ( , - , ), epss , mm ( , - , ), sphericity index , ( , - , ), interventricular septum in diastole , mm ( , - , ) and systole , mm ( , - , ), lv free wall in diastole , mm ( , - , ) and systole , mm ( , - , ), left atrial (la) diameter , mm ( , ) , aortic (ao) diameter , mm ( , - , ) , la/ao , ( , - , ), and aortic and pulmonic flow velocity , m/s ( , ) and , m/s ( , - , ), respectively. this study provides echocardiographic values for normal salukis which can be used as a reference values. no conflicts of interest reported. in mitral valve disease, atrial remodeling is an indicator of evolution and prognosis, the duration of the p wave being considered suggestive of the dilatation of the left atrium. in humans' studies, neurological conditions have a significant impact on cardiac electrophysiology by altering the electrical impulse conductibility. the aim of this study is to examine the duration of the p wave in dogs suffering from mitral valve disease in comparison to dogs diagnosed with different neuropathies without cardiac abnormalities. we analyzed standard electrocardiograms ( min of ecg, on peripheral leads) performed on three polymorphic groups of dogs (different age, weight and breed): group (n = ) healthy dogs, group (n = ) dogs diagnosed with mitral valve disease and group (n = ) dogs suffering from different neuropathies (without any associated or previously diagnosed cardiovascular disease). the duration of the p wave was measured for all dogs (five consecutive p waves without anomalies or artifacts) and reported to the degree of atrial remodeling, assessed by left atrium/ aorta ratio on echocardiography. the interpretation of the ecg and echocardiography was made by the same examiner (md). the results were statistically evaluated in a specialized program (ibm spss vs. ). the p wave recorded average values was . ae . seconds for the mvd group with significant differences between the stages of heart failure (p = . ). no correlations were found between its increase and the dilation of the left atrium (r = . ). there was no statistically significant difference regarding p wave duration when compared dogs of the neuropathy group and those of the mitral valve disease group (the p wave recorded average values = . ae . sec.). both, atrial tissue lesions (as in mitral valve disease) and autonomic nervous system anomalies (secondary to a neurological condition), may change the conductibility of the electrical impulse in the left atrium. the conductibility of the electrical impulse at this level does not seem to be influenced by its actual dilation, but by the impairment of the intra-atrial and inter-atrial conduction pathways. caution must be given when p wave is analyzed in dogs with concurrent cardiologic and neurologic condition. no conflicts of interest reported. newfoundland dogs were prospectively recruited among those undergoing screening for congenital and acquired heart disease. screening includes patient history, physical examination, and systemic arterial pressure measurement by doppler flow meter and transthoracic echocardiography (m-mode, d and echo-doppler). screening is performed on conscious dogs of at least year of age. dogs without historical, clinical, electrocardiographic and echocardiographic signs of cardiovascular disease were included in the study. unpaired, two-tailed student's t-test and linear regression were performed to evaluate the influence of gender, age and body weight (bw) on echocardiographic parameters. echocardiographic measurements were compared to previously reported reference values. the reference limits of echocardiographic parameters in the newfoundland dogs were calculated. forty-six healthy adult newfoundland dogs of both genders ( males and females), to years of age (mean . ae . years), to kg (mean . ae . kg) fulfilled the inclusion criteria. significant but weak correlations were detected between aortic diameter (ao) and age (p = . , r = . ), left atrial to aortic ratio (la/ao) and age (p = . , r = . ), e-point to septum separation (epss) and bw (p = . , r = . ), m-mode left ventricular internal diameter (lvid) in diastole (d) and systole (s) and bw (respectively p = . , r = . and p = . , r = . ), and between ao and bw (p = . , r = . ). none of the echocardiographic measurements was statistically different between males and females. left ventricular internal diameter in diastole, lvids, ao, epss increased with bw, as expected. the aorta appears to become wider with advancing age. a proportion of the studied population had m-mode parameters below the allometric scaling reference range, suggesting that this method can over-estimates m-mode parameters in this breed. these findings stress the importance to report newfoundland breed specific normal ranges for echocardiographic parameters. no conflicts of interest reported. canine idiopathic pulmonary fibrosis (cipf) is a progressive interstitial lung disease usually diagnosed by thoracic ct-scan that mainly affects west highland white terriers (whwt). pulmonary hypertension (ph), a severe co-morbid condition with a challenging diagnosis, may develop in cipf dogs. the ratio between the right pulmonary vein and pulmonary artery (pv/ pa) has been described as an echocardiographic indicator of ph in cipfdogs. this study was intended to investigate whether ct-scan angiography cardiac findings are ) altered in dogs with cipf compared to healthy control dogs and ) correlated with pv/pa measured by echocardiography (pv/pa us ). thoracic cta images from whwt with cipf (group a) and healthy controls from various breeds (group b) were retrospectively reviewed by one observer. all measurements were obtained in transverse post-contrast images displayed in a soft tissue window. pv and pa were measured dorsal to the right atrium, perpendicular to the long axis of these vessels. in addition, pulmonary trunk (pt) was assessed just ventral to the division of pulmonary arteries, perpendicular to its long axis. ascending aorta (ao) was also measured perpendicular to its long axis. transverse reformatted images were obtained to have a view equivalent to the standard chambers-echocardiographic view where right ventricle (rv) and left ventricle (lv) were measured. three ratios were calculated pv/pa ct , pt/ao and rv/lv, compared between groups and correlated with pv/pa us in both bi-dimensional (bd) and m-modes (mm). statistical analyses were performed with xlstat â software. values are given as mean ae sd. statistical significance was set at a p ≤ . . pv/pa ct was lower in group a ( . ae . ) in comparison to group b ( . ae . , p = . ) and correlated with pv/pa us (bd: r = . , p = . ; mm: r = . , p = . ). pt/ao was higher in group a ( . ae . ) compared to group b ( . ae . , p = . ) and correlated only with pv/pa us measured in bd mode (r = - . , p = . ). the rv/lv ratio was increased in group a ( . ae . ) in comparison to group b ( . ae . , p = . ) and a correlation between rv/lv and pv/pa us was found (bd: r = - . , p = . ; mm: r = - . , p = . ). in conclusion, in whwt with cipf, pv/pa ct , pt/ao and rv/lv ratios measured on thoracic cta images are correlated with pv/pa us and may serve in the assessment of ph. no conflicts of interest reported. companion animals presenting to the emergency room in distress need to be assessed rapidly and accurately to implement life-saving therapies. focused cardiac ultrasound (focus) can be a useful adjunct to the physical examination in assessing dyspneic animals in the emergency room. rapid bedside ultrasound evaluations performed by ec are commonly used in human medicine, however feasibility and utility of focus by ec in veterinary medicine has not been fully evaluated. the purpose of this study is to determine the baseline accuracy of focus performed by ec and whether or not a basic training session could improve accuracy compared to evaluation by a cardiology specialist. fifteen ec including boarded emergency-critical care specialists and emergency res-idents performed focus on four animals; a normal cat and dog, and a cat and dog with severe valvular and myocardial heart disease, respectively. ec semi-quantitatively assessed thoracic and echocardiographic parameters including left atrial dimension, left ventricular systolic function and wall thickness, right heart dimension, and presence or absence of pleural or pericardial effusion before and after a structured didactic lecture and hands-on practical session. primary outcome was the level of agreement with examination performed by a cardiologist. level of agreement regarding ec assessment of all parameters improved from . to . after training (p < . ). level of agreement concerning left atrial diameter improved from . to . (p < . ). ec confidence in their overall focus evaluation and findings improved from % to % (p < . ). in summary, ec accuracy and confidence in semi-quantitatively assessing basic cardiac parameters using focus were improved following a simple structured training session. focus might be a valuable tool to rapidly assess simple thoracic and cardiac parameters in the emergency setting. no conflicts of interest reported. obesity is an increasing health problem in dogs. success of weight-loss programs is often limited by compliance issues. the purpose of this study was to determine the effectiveness of a new dietetic weight management food (ndwmf)* in achieving weight loss in overweight/obese, client-owned dogs, under typical household conditions. the objectives were ) to evaluate weight loss parameters in dogs fed a ndwmf* and ) to assess the owner's perception of the dog's quality of life. overweight/obese, otherwise healthy, client-owned dogs (> / body condition score -bcs) were enrolled in the study (n = ). initial veterinary evaluation included physical examination, nutritional assessment, determination of ideal body weight (ibw), and development of weightloss feeding guidelines. daily energy requirement (der) for weight loss was calculated as der = x ibw kg . . initial and follow-up evaluations (monthly for months) encompassed determination of body weight, bcs, body fat index (bfi), muscle condition score (mcs), and feeding practices. quality of life assessment by owners included dog's level of energy, happiness, appetite, begging behavior, flatulence, stool volume, and fecal score. statistical analysis comprised scatterplots, regression analysis, summary statistics as appropriate for the type of analyses performed (continuous or categorical variables, distribution), and a mixed model anova to assess changes over time (with statistical significance at p < . ). ninety four percent of the dogs lost weight (n = ) with an average weight loss of . % (sem, . %) over months and an average weekly weight-loss rate of . % (sem, . %). the mean duration of weight loss was days (sem, . days) with an average of days (sem, . days) between rechecks. thirty nine percent of dogs achieved ibw ( . , ci: . - . ). fifty five percent of dogs ate more calories from ndwmf* than the recommended der for weight loss (median fed above der= %) and % of these dogs ( . , ci: . - . ) still lost weight. thirty six percent of dogs received treats. bcs and bfi decreased significantly over time compared to baseline. owners perceived a significant increase in energy and happiness in the dogs that lost weight without changes in appetite or begging behavior. in conclusion, this clinical study confirmed the effectiveness of the ndwmf* in achieving weight loss in overweight/obese client-owned dogs in spite of higher than recommended caloric intake. owners reported significant improvements in dog's quality of life without negative side effects. * haptoglobin is a moderate acute phase protein in cats. as a part of the innate immune system its concentration rises within - hours after tissue damage. aim of the study was to validate an elisa which was recently developed for the measurement of feline haptoglobin and to compare it with a commonly used spectrophotometric assay. the concentration of haptoglobin was measured in healthy and sick cats using a sandwich-elisa (tecomedical group, rheinbach, germany). the validation included the detection of intra-assay and inter-assay variation, dilution linearity, spike recovery and lower detection limit. a spectrophotometric assay (tridelta development ltd, maynooth, ireland) was used as a reference method. all samples were measured in duplicate. statistical analysis was performed using ibm â spss â statistics (ibm corporation â ) and included descriptive statistics, spearman correlation (rs) and coefficients of variation (cv). the coefficients of variation were . %, . % and . % for intra-assay variability and . %, . % and . % for inter-assay variability. the ratio of observed to expected dilutional parallelism of serum samples diluted times ranged from to %. the ratio of observed to expected spike recovery of serum samples ranged from % to %. the lower detection limit was . mg/ml. the correlation between the assays was significantly strong (rs = . , p < . ). the recently available sandwich-elisa provides a high accuracy and precision and can therefore be used for the measurement of feline haptoglobin. the rd and th author (m. hennies and c. wienen) work for the company tecomedical group that developed the elisa which was evaluated in the study. they provided the kits and they helped with performing the tests, but they did not have any influence on the results and the interpretation of the data. canine idiopathic pulmonary fibrosis (cipf) is a progressive interstitial lung disease that mainly occurs in the west highland white terrier (whwt) breed. the cipf diagnosis commonly relies on thoracic high-resolution computed tomography (hrct) findings and ultimately on histopathology. as those tests are not easily performed in practice, identification of measurable markers of fibrosis, that might help to diagnose and/or monitor the course of cipf, is helpful. vegf is an angiogenic regulator involved in a variety of physiological and pathological processes. in human ipf, serum vegf concentration has been shown to be higher in ipf patients compared to healthy volunteers and may reflect the severity of the lung disease. the aims of the present study were ( ) to investigate the potential role of vegf as a peripheral blood biomarker in cipf; and ( ) to investigate possible breed-related differences in basal vegf concentration, that might explain the high predisposition of the whwt breed for cipf.therefore, vegf was determined by elisa (canine vegf quantikine elisa kit, r&d systems) in the serum of whwt with cipf confirmed by hrct and/or histopathology (median age years, range - ), healthy whwt ( , - ), and healthy dogs of other breeds, including: scottish terrier (st) ( , - ), jack russell terrier (jrt) ( , - ), maltese ( , - ), king charles spaniel (kcs) ( , - ), labrador retriever (lr) ( , - ) and malinois belgian shepherd ( , - ). health status was based on clinical examination, serum biochemistry and haematology in all healthy dogs and a thoracic hrct was performed in / healthy whwt. the khi² test with the threshold % was used for the statistical analysis (xlstat â software). eight cipf whwt ( %) have serum vegf concentrations above the kit detection limit ( . pg/ml) compared to whwt ( . %) in the group of healthy dogs (p = . ). concerning inter-breed differences in healthy dogs, most values obtained were below the kit detection limit with only kcs ( %), jrt ( %), lr ( %) and st ( %) having vegf serum levels above . pg/ml (p = . ). results of the present study show that ( ) vegf might be an interesting blood biomarker for cipf; ( ) canine vegf quantikine elisa kit is not appropriate for measurement of serum vegf levels in healthy canine populations. no conflicts of interest reported. the total protein (tp) concentration and cell count of pleural and abdominal fluid is used to differentiate a transudate from an exudate. tp can be measured by automated wet chemistry analyser or more easily using a refractometer. the aim of this study was to assess if refractometer values of tp are useful for this purpose. retrospectively samples from canine pleural and abdominal effusions in which tp concentration was measured both with a refractometer as well using pentra (abx horiba, montpellier) were included. samples were collected into heparinized tubes and analysed within hours. bland-altman diagrams were created and correlation between both measurements was calculated by spearman s nonparametric correlation. over a -months period, pleural and abdominal effusion samples were analysed with both techniques. median (range) tp concentrations in pleural effusion measured by refractormeter or by pentra was ( - ) g/l and ( - ) g/l, respectively. median (range) tp concentrations in abdominal effusions measured by refractometer or pentra was ( - ) g/l and ( - ) g/l, respectively. tp measurement between refractometer and pentra values were significantly correlated in pleural (r = . , p < . ) and abdominal (r = . , p < . ) effusion. the bland-altman graph showed a bias in the thorax and abdomen of . and . . the refractometer is an acceptable, rapid and efficient method for determination of total protein concentration in pleural and abdominal effusions in dogs to differentiate transudates from exudates. no conflicts of interest reported. coagulation factor vii (fvii) deficiency has been reported in beagles since the 's. deficient dogs show a mild hemorrhagic tendency, but often remain asymptomatic and are incidentally discovered by an isolated prolonged prothrombin time due to < % plasma fvii activity. factor vii deficiency occurs commonly in beagles, alaskan klee kais and scottish deerhounds. in these breeds it is caused by a single missense mutation (c. g>a, p.gly glu) in the second epidermal growth factorlike domain of fvii, which drastically reduces the secretion and activation of fvii. research beagles were also commonly affected which may have pharmaco-toxicologically affected studies but specific dna screening programs have been established. we report here on the discovery of fvii deficiency in welsh springer spaniels (wss) in finland based upon a novel screening panel for~ known mutations underlying inherited disorders in different canine breeds (www.mydogdna.com). among wss initially tested, were heterozygously ( %), and homozygously affected for the same fvii mutation, which was confirmed by sequencing in all dogs. in order to determine whether the mutation causes fvii deficiency also in this breed, we recruited littermates and their mother. none of these wss had shown an increased hemorrhagic tendency, but affecteds bled excessively following blood collection. we found that the homozygous affected dogs of the litter exhibited markedly prolonged prothrombin time but normal partial thromboplastin time. they also had drastically reduced fvii activities but normal to high fviii and fix activities compared to their littermate controls. the heterozygous carriers tested did not show any prolongations in their prothrombin time, but had half normal fvii activity. in conclusion, we document here the presence of fvii deficiency in wss based upon dna and coagulation activity testing. the common gly glu mutation must have arisen prior to the separation of the very different fvii deficient breeds. there is no knowledge of an advantage of the heterozygote state. while there is only a mild hemorrhagic tendency, bleeding dogs could be treated with fresh frozen or cryo-poor plasma or human recombinant fviia. this preliminary study indicates a high carrier frequency in wss. screening by new platform dna methods for this and other ancestral defects is helpful to detect additional hereditary diseases and genetic predispositions in different breeds, while other mutations are new and restricted to one or related breeds. authors are affiliated with genetic disease screening test laboratory. remarkably little has been published on haematological and serum biochemical phenotypes of the domestic dog. information on the signalment and complete blood cell count of all dogs with normal red and white blood cell parameters judged by existing reference intervals was extracted from a veterinary database; similar information was collected from all dogs with normal serum biochemical profiles, considering all parameters other than glucose as inclusion criteria. normal haematological profiles were available for dogs, of which also had machine platelet concentrations within the reference interval; normal serum biochemical profiles were available from dogs, of which also had accompanying normal serum glucose concentrations. for the haematological data, pure breeds plus a mixed breed control group were represented by or more dogs, while for the serum biochemical data, pure breeds plus a mixed breed control group were represented by or more individuals. all measured haematological parameters except mean corpuscular haemoglobin concentration (mchc), and all serum biochemical analytes except sodium, chloride and glucose, varied with age. concentrations of white blood cells (wbcs), neutrophils, monocytes, lymphocytes, eosinophils and platelets, but not red blood cell parameters, all varied with sex, as did total protein, globulin, potassium, chloride, creatinine, cholesterol, total bilirubin, and activities of alanine aminotransferase (alt), creatine kinase (ck), amylase and lipase. neutering status had an impact on haemoglobin concentration, mean corpuscular haemoglobin (mch), mchc, and concentrations of wbcs, neutrophils, monocytes, lymphocytes and platelets, as well as all serum biochemical analytes except albumin, sodium, calcium, urea and glucose. principal component analysis (pca) of haematological data revealed pure breeds with distinctive phenotypes, while pca of serum biochemical data revealed over pure breeds with distinctive phenotypes. furthermore, all haematological parameters except mchc and all serum biochemical analytes except urea and glucose showed significant differences between specific individual breeds and the mixed breed group. twenty-nine breeds had distinctive haematological phenotypes and breeds had distinctive serum biochemical phenotypes when assessed in this way. tentative breed-specific reference intervals were generated for breeds with a distinctive phenotype identified by comparative analysis. this study represents the first large-scale analysis of haematological and serum biochemical phenotypes in the dog and underlines the important potential of this species in the elucidation of genetic determinants of haematological and biochemical traits, triangulating phenotype, breed and genetic predisposition, as well as the urgent need for breed-specific reference intervals in clinical practice. the author has received funding from bbsrc, petplan charitable trust, and cruk), but none of thesegrants were for this study. for each cat aged years or older, irrespective of their suspected thyroid status, presented to eight veterinary practices in portugal, the veterinarian and the pet owner had to complete a questionnaire and the veterinarian had to take a venous blood sample (into a plain tube) from the cat, after obtaining signed owner consent. the veterinary questionnaire included history, attitude, activity, heart rate and thyroid palpation. cats aged < years and those diagnosed previously with hyperthyroidism were excluded. blood samples were centrifuged and the serum harvested and stored frozen until collection by the laboratory within days of sampling. total t was measured using a chemiluminescent method (immulite , siemens). cats were classified as hyperthyroid, equivocal or euthyroid based on a total t concentration of > nmol/l, - nmol/l or < nmol/l, respectively. repeat measurement of total t after - weeks was recommended for all equivocal cases. the individual cat was the statistical unit. descriptive statistics was used to summarise the data and associations between different clinical signs analysed using chi-square, fisher's exact test or the mann-whitney u test. the level of significance was set at . . thirty cats were excluded from the prevalence analysis because they were aged < years (between and years, n = ) or their age was not stated (n = , four of these cats were hyperthyroid). by the end of february , samples had been submitted from cats that met the inclusion criteria. based on the thyroid hormone analysis, there were / ( %) hyperthyroid, ( %) equivocal and ( %) euthyroid cats. very few follow-up blood samples were taken. hyperthyroidism appears to be not uncommon in portuguese cats. getting owners to return for follow-up blood sampling appears to be problematic. under-reporting of hyperthyroidism appears to be a significant problem in portugal, as has been reported for some other countries. thyroid palpation should form part of routine physical examinations, especially of middle aged and older cats. older cats in portugal should be screened for hyperthyroidism even in the absence of a detectable thyroid nodule. both authors are employees of msd animal health. msd animal health funded the study. msd animal health has an approved veterinary medicinal product for the treatment of feline hyperthyroidism. this product is available commercially in some eu markets but not in portugal. diabetes mellitus is one of the most commonly encountered endocrinopathies in cats and its prevalence has increased in the past. similar to human type diabetes, feline diabetes is associated with comparable lesions occurring in the pancreatic islets, namely islet amyloidosis and beta-cell loss. studying the pathophysiology of feline diabetes and the molecular mechanisms through which glucose metabolism is disturbed is largely hampered by the lack of a method for the isolation of pure pancreatic islets. the aim of this project was to improve a previously established method for the isolation of pancreatic islets; in particular enhancing the purity of isolated islets in this species. cats that died or were euthanized due to severe illness other than pancreatitis or other pancreatic disease were enrolled. pancreata were perfused post-mortem with ml collagenase type iv ( . mg/ml) through the pancreatic duct. the perfused organ was then digested for ', ' and ' at °c in a water-bath and purified using a filtration method. islet cell viability and purity were determined by thiazolyl blue tetrazolium bromide (mtt assay) and dithizone staining, respectively. perfusing the pancreas through the pancreatic duct allowed collagenase to access the islets using anatomical structures and to improve islet yield compared to previously established protocols in this species. the digestion time of ' provided the best islet yield. after digestion, feline pancreatic islets remained satisfactorily viable for days in the culture system following regular media changes. the current study has successfully optimized the isolation, purification and culture maintenance of feline islets. the successful yield and viability of islets isolated through the suggested protocol may provide promising potential as a source of islets for diabetes research in cats. no conflicts of interest reported. nesidioblastosis describes a syndrome of acquired hyperinsulinaemia and associated hypoglycaemia secondary to focal or diffuse (non-neoplastic) beta cell hyperplasia within the pancreas. beta cell dysregulation is thought to occur secondary to pancreatic injury. this syndrome has been reported in humans with increasing frequency, but it has not previously been described in domestic pets. a six year old, de-sexed female british shorthair cat presented with acute onset weakness and mental dullness. upon initial presentation the cat was mildly hyperglycaemic ( . mmol/l; . - . mmol/l). over the following hours the cat developed central blindness, tremors, intermittent seizures and opisthotonus. repeat blood sampling revealed a marked hypoglycaemia ( . mmol/l). an insulin level (performed on serum obtained while the cat was hypoglycaemic) was inappropriately elevated ( pmol/l; reference range - pmol/l). an intravenous bolus of % glucose resulted in rapid resolution of all clinical signs and mild transient hyperglycaemia ( . mmol/l). despite frequent feeding, the hypoglycaemia ( . mmol/l) recurred, so an intravenous glucose continuous rate infusion was commenced. an abdominal ultrasound was unremarkable, although three cranial mesenteric lymph nodes were noted to be prominent ( mm in width). an exploratory laparotomy revealed a firm and erythematous left limb of the pancreas. the body and right limb of the pancreas appeared grossly normal. following surgical resection of the left limb of the pancreas, the cat returned to a euglycaemic state after a brief rebound hyperglycaemia. histopathology revealed pancreatic fibrosis with marked multifocal micronodular hyperplasia of exocrine and endocrine cells, mild lymphoplasmacytic inflammation and ductular ectasia. synaptophysin immunohistochemistry confirmed nodular beta cell hyperplasia. mild granulomatous lymphadenitis and hydropic change within hepatocytes was also noted. the cat recovered uneventfully without any further intervention. it gained weight and remained euglycaemic over the following six months. while beta cell hyperplasia has been reported as an incidental histopathological finding in euglycaemic young beagles, this is the first reported case of clinically significant hypoglycaemia secondary to nesidioblastosis in a domestic pet. while this condition is rare, nesidioblastosis is being increasingly recognised in the human field and it is an important differential to consider when investigating hypoglycaemia as it cannot be differentiated from insulinoma without histopathological evaluation. age of onset may provide a clue to this non-neoplastic disease, as this cat was much younger than all previously reported cases of feline insulinoma (all > years of age at diagnosis). while recurrence has been reported in humans, a favourable outcome is anticipated following partial pancreatectomy. no conflicts of interest reported. hyperthyroidism is the most common feline endocrinopathy of geriatric cats worldwide. nonetheless, data concerning the accurate prevalence of feline hyperthyroidism (fh) is scarce; and apparently exhibit geographical variation, which can be an important instrument in investigating risk factors through the analysis of exposure to different factors in areas of high and low prevalence. in europe, fh is considered more frequent in the northern than in the southern countries. the aims of this study were to determine the occurrence of fh in a region of portugal, to characterize clinical presentation and potential risk factors. during an -month period, geriatric cats ≥ eight years from aveiro (central region of portugal) were selected. cats were excluded if presented in shock or moribund, or in treatment with drugs that might affect total t (tt ) serum concentration. the tt concentration was determined through chemiluminescence (immulite â , siemens), and diagnosis of fh established if tt serum concentration ≥ . lg/dl (reference values . - . lg/dl) associated with compatible clinical signs. information on age, gender, breed, weight, housing conditions (indoor vs outdoor), use of external parasiticides, food (dry vs canned food and flavor), use of litter box, environment, clinical signs and laboratory data was collected. all owners gave informed consent. population studied included males ( . %) and females ( . %), mainly domestic short-haired cats ( . %). ages ranged from eight to years old ( . + /- . ). eight ( . %) cats were diagnosed with hyperthyroidism. if only cats ≥ years of age were considered (n = ), prevalence raised to . %. hyperthyroid population comprised four males and four females, ranging from to years old ( . + /- . ). increasing age (p = . ), polyphagia (p˂ . ), weight loss associated with increased (p˂ . ) or normal appetite (p˂ . ), presence of thyroid uni or bilateral nodules (p˂ . ), vomiting (p = . ) and hyperactivity (p = . ) were significantly associated with hyperthyroidism in the geriatric population studied. environment was also significantly associated with development of fh (p˂ . ), with cats from urban or semi-rural areas at higher risk of developing the disease than cats living in a rural environment. no other significant associations were found between hyperthyroidism and other factors analyzed. in our knowledge, no epidemiologic studies on fh have been performed in portugal, a country where the occurrence is believed to be low, but in which the population of pet cats, the feline geriatric population and the clinical cases diagnosed have been increasing. conflicts of interest: the study was partially supported by laborat orio segalab s.a. and dechra veterinary products. canine diabetes mellitus (cdm) has been proposed to be a spontaneous animal model of human autoimmune diabetes, and comparative research can be undertaken to investigate the interaction between genetic and environmental factors. most epidemiological studies of cdm have been performed in northern european and north american populations. our aim was to evaluate the epidemiology and clinical features of the diabetic dog population from the canary islands, with special focus on immune-mediated disease. dogs attending our veterinary teaching hospital were included from january to january . previously diagnosed and new cases were considered. prevalence was calculated as number of cdm/total number of dogs attending the hospital and incidence as newly diagnosed cases divided by the same value per year. anti-insulin antibodies were assessed by elisa. genotyping for dog leukocyte antigen (dla) and measurement of canine anti-gad and anti-ia antibodies by radio-immunoprecipitation assay were performed in dogs with suspected immune-mediated diabetes. twenty-nine dogs with cdm were identified from a mean population of ( - ) dogs per year (mean prevalence . % and mean incidence cases per year per , ). age at diagnosis was . years (range: . - y). most dogs were not neutered ( % females; % males). nine breeds were represented, including poodle ( %) and andalusian wine-cellar rathunting dog ( %). seasonality was observed in the diagnosis with peaks in december and march-april. diabetes was classified as dioestrus diabetes ( %), idiopathic/immune-mediated ( %), iatrogenic ( %) and secondary to pancreatitis ( %) or other endocrine disorders ( %). insulin-treated dogs were negative for anti-insulin antibodies (n = ). from the suspected immune-mediated cases (n = ), autoantibody reactivity was shown in two cases (anti-gad , n = ; anti-ia , n = ). no previously described, diabetes-risk dla-types were identified. although age, prevalence and incidence did not differ from previous studies, the high proportion of entire females likely explained the high frequency of dioestrus diabetes. the andalusian wine-cellar rat-hunting dog was identified as a high-risk breed for cdm. most of the dla-types seen have not been previously described, but at least two have been associated with increased risk of autoimmunity in dogs. further population-based studies are needed in different regions, to assess the heterogeneous nature of this disease. no conflicts of interest reported. the cortisol-dehydroepiandrosterone (dhea)-ratio is widely used in human medicine as a marker for stress however it is not clear whether it could also help in distinguishing hyperadrenocorticism (hac) from other diseases which might have a negative impact on the outcome of a dexamethasone low dose test. therefore the aim of the study was to evaluate the cortisol-dhea-ratio as an additional diagnostic marker for hac in dogs. to achieve this aim, a reference range of this ratio depending on the sex should be evaluated in healthy dogs and compared with dogs having a hac. in healthy dogs (age: - . years) and in dogs with hac (age: . - . years) of different breeds the plasma concentration of cortisol (immulite system, siemens healthcare diagnostics) and dhea (beckman coulter) was measured and the ratio was calculated. all dogs were patients of the small animal clinic except five of the healthy dogs which were recruited from the institute of pharmacology, toxicology and pharmacy of the university. with these data the cortisol-dhea-ratio was calculated for male dogs (healthy dogs n = ; dogs with hac n = ), neutered males (healthy dogs n = ; dogs with hac n = ), female dogs (healthy dogs n = ; dogs with hac n = ) and spayed females (healthy dogs n = ; dogs with hac n = ). the statistical analysis was performed with sigma stat. the plasma cortisol-dhea-ratio of healthy male dogs was the lowest ratio of all sexual categories (mean average . ae ) and it differed significantly to all other sexes (neutered males = ae , p = . ; females = ae , p < . and spayed females ( ae . , p = . ). the cortisol-dhea-ratio showed no significant difference between male and female dogs with hac. spayed females with hac had significantly higher cortisol-dhea-ratios ( ae ) than healthy spayed females (p = . ) but no significant differences were found in other sexual categories. this preliminary data indicates that the cortisol-dhea-ratio might not be a very promising tool for the diagnosis of hac. in addition, the significant gender-dependency of this parameter has to be considered and may generally limit its clinical usefulness. this study is financially supported by the bruns-stiftung. no conflicts of interest reported. hyperthyroidism is common in older cats. the aim of this study was to assess the prevalence of feline hyperthyroidism and potential intrinsic risk factors in a hospital population in southern germany. total thyroxine (t ) was prospectively measured by enzyme immunoassay (eia) in sera of cats older than years that were presented to the clinic of small animal medicine. a standardized physical examination was performed, and body condition score (bcs) and thyroid palpation score (tps) were assessed. association between signalement, bcs and tps was analyzed by student s unpaired t-test, chi-square, and mann-whitney test. level of significance was set at . . fifty nine cats were diagnosed with hyperthyroidism leading to a prevalence of . % (ci . - . ). hyperthyroid cats were older than non-hyperthyroid cats (p < . ) and more often female (p = . , odds ratio . ). domestic short or long hair cats were more often affected than pedigrees (p = . ). hyperthyroid cats had higher tps (p < . ) and lower weight than non-hyperthyroid cats (p < . ) although bcs was not different (p = . ). in ( . %) cats, the elevated t was an incidental finding. in of those, the disease was confirmed later (the others were dead due to unrelated diseases). in patients, hyperthyroidism was considered a differential diagnosis and was confirmed in ( . %) cats although in cats additional diagnostic means were necessary. older female domestic cats are predisposed to hyperthyroidism which is frequently diagnosed after the initial clinical suspect. in a few affected cats an elevated t is not present or can precede clinical signs. conflicts of interest: the study was partially funded by msd intervet. the main endocrinopathy affecting both humans and pet felines is diabetes mellitus. accurate diagnosis is the most important aspect in the future outcome of the disease. a computer based decision support system (dss) is targeted on assisting clinicians with one or more steps of the diagnostic process. the novelty of our dss emerges from the possibility of assisting both clinical and paraclinical diagnosis stages of diabetes mellitus and all common combination of disorders associated with this endocrinopathy. the motivation behind the development of such system is the desire to maximize the reliability of clinical decisions. the design of our feline diabetes mellitus dss emerges from the syndrome of polyuria-polydipsia, with the possibility of spotting the accompanying pathologies. fuzzy logic is used for dealing with knowledge representation and uncertainty. the fuzzy rules proposed to represent this knowledge emerge from anamnesis, clinician's input, clinical and paraclinical description, and confirmation diagnostic tests. clinical signs such as polyuriapolydipsia, persistent hyperglycemia, polyphagia, weight fluctuations, administration of drugs with a diabetogenic potential, were considered decisive in the pattern of diagnosis establishment. registered medical records of cats, males and females, whit ages from to years old, were analyzed in order to validate the dss. using matlab software, the dss was implemented and tested. for any case with polyuria-polydipsia the system provides, via a friendly graphical user interface, the diagnosis with the highest probability. the set of diagnoses which can be generated by the dss consists in: a) diabetes mellitus; b) diabetes mellitus induced by (b. ) hypersomathotropism, (b. ) hyperthyroidism, (b. ) hyperadrenocorticism and (b. ) diabetogenic medication; c) diabetes mellitus in association with (c. ) chronic kidney failure and (c. ) heart failure; d) ketoacidodic diabetes mellitus; e) pancreatitis. the dss was applied with success on all cases, revealing the following diagnoses / no of cases: (a) - , (b. ) - , (b. ) - , (b. ) - , (c. ) - , (c. ) - , (d) - . an adequate treatment protocol requires an accurate and complete diagnosis. advanced computational systems accompany clinicians in their decision making, leaving a reduced space for medical errors and superfluous, expensive and time consuming tests. future work will be targeted on exploring the possibilities of combining the dss with an artificial neural network model for diabetes mellitus. this can be the foundation of a complete case oriented management system for feline diabetes mellitus and associated disorders. no conflicts of interest reported. activins are cytokines belonging to the transforming growth factor (tgf)-b superfamily. it is thought that activins may be the key intermediary in tgf-b mediated fibrotic response. activin a has been suggested to participate in the pathogenesis of human idiopathic pulmonary fibrosis (ipf), but studies regarding the role of activin b are still spares. canine ipf (cipf) is a chronic, incurable interstitial lung disease occurring particularly in west highland white terriers (whwts). during the disease course, acute exacerbations (aes), with poor prognosis, can occur. histopathologically aes of cipf are featured by diffuse alveolar damage, which is also a key feature in acute respiratory distress syndrome (ards). our objective was to study the expression of activin a and b by immunohistochemistry in the lung tissue of cipf whwts (n = ), cipf whwts with concurrent ae (n = ), and dogs of various breeds with ards (n = ), and to compare these findings to healthy whwts (n = ). in addition, western blot analysis of activin b from bronchoalveolar lavage fluid (balf) of cipf whwts (n = ) and healthy whwts (n = ) was conducted. we demonstrated that activin b, but not activin a, is strongly expressed in the altered alveolar epithelium in lungs of diseased whwts as well as in ards lungs. furthermore, activin b was detected in balf of cipf whwts, most notably in samples from dogs with ae, but not in balf of healthy whwts. this novel finding suggests that activin b participates in the pathophysiology of cipf and might act as a potential marker of alveolar epithelial damage. no conflicts of interest reported. dogs of the breed nova scotia duck tolling retriever (nsdtr) are affected by several immune-mediated diseases, in particular steroid-responsive meningitis-arteritis (srma) and an immune-mediated rheumatic disease (imrd). imrd is a systemic lupus erythematosus-related disease characterized by chronic stiffness and pain in several joints. the aim of this study was to investigate the morbidity in nsdtrs and to test the hypothesis that nsdtrs are predisposed to srma and imrd. insurance data from a swedish insurance company (agria insurance company, stockholm, sweden) from - was used for the study. approximately one third of swedish dogs are insured by agria and the insurance database is a validated tool for epidemiological studies. assessment of morbidity was based on veterinary care events. disease diagnoses were grouped in both general and specific disease categories. individual diagnoses that were likely to represent imrd were combined. morbidity was defined as incidence rates and presented as number of cases per dog years at risk (dyar). relative risk (rr) for nsdtrs compared to other breeds combined was calculated. the study included dogs, were nsdtrs. the most common general causes of veterinary care for nsdtrs were injuries followed by gastrointestinal and musculoskeletal disorders with significant increased risk (rrs between . and . ) for nsdtrs compared to other breeds. the highest relative risk for nsdtrs was for systemic lupus erythematosus (rr . ). compared to other breeds, nsdtrs had an increased risk for srma (rr . ) and imrd (rr . ) with an incidence rate of . cases per dyar for srma and . cases per dyar for imrd. the incidence rate for srma and imrd in nsdtrs were also compared to dogs of other retriever breeds. the comparison revealed that nsdtrs also had a significant increased risk for both srma (rr . ) and imrd (rr . ) when compared to other retrievers only. this study is the first to investigate the morbidity for imrd in nsdtrs, which is important for further research and breeding practice. for several reasons the incidence rates might be underestimated and exact numbers should be interpreted with caution. however underestimation of incidence rates should not differ between dogs of different breeds, therefore not affecting the risk calculations. it can be concluded that nsdtrs are predisposed to the diseases srma and imrd with an increased risk compared to other breeds and to other retrievers. brenda n. bonnett consults with agria insurance company on various projects. agria insurance company has also funded work leading to the development of the insurance data base that my study was based on. canine infectious respiratory disease (cird) is a multifactorial contagious disease caused by respiratory viruses and selected bacterial pathogens. cird has been shown to be a predisposing factor in the development of bacterial pneumonia (bp) in dogs housed in dense populations such as kennels and rehoming centers. the aim of this study was to determine the prevalence of viral co-infection and to assess its effects on disease severity in household dogs diagnosed with bp. a prospective cross-sectional observational study was conducted and dogs diagnosed with bp caused by opportunistic bacteria were included. dogs with chronic (> days) tracheobronchitis caused by bordetella bronchiseptica were included as controls for virus analysis. diagnosis was confirmed by thorough clinical examinations as well as with cytological and bacterial analysis of bronchoalveolar lavage (bal) or transtracheal wash (ttw) samples. canine parainfluenssavirus (cpiv), canine adenovirus, canine herpesvirus, canine distempervirus, canine respiratory coronavirus (crcov) and canine pneumovirus were analysed in bal or ttw samples using rt-pcr assay. cpiv was detected in / ( %) and crcov in / ( %) respiratory samples in dogs with bp. respiratory viruses were not detected in dogs with chronic tracheobronchitis. there were no significant differences in the duration of hospitalization (p = . ) or arterial pao at presentation (p = . ) between bp dogs with and without a viral co-infection. these results indicate that co-infections with respiratory viruses are common also in household dogs with bp. additionally, viral co-infections did not cause a more severe course of bp. the author's researcjh is financially supported by the finnish foundation of veterinary r and the finnish veterinary foundation. esvim-p- causes of canine anemia in taiwan: a five-year retrospective survey. e.c.y. lin , p.c. liu , l.l. chueh , b.l. su . graduate institute of veterinary medicine, national taiwan university, taipei, taiwan, institute of veterinary clinical sciences, national taiwan university, taipei, taiwan anemia is a common hematologic disorder in dogs, however, few data are available regarding epidemiology and causes in taiwan. to investigate the causes of anemia, anemic cases (pcv< %) collected between january and december at national taiwan university veterinary hospital (ntuvh) were analyzed. most dogs ( . %, n = ) presented with a mild form ( %≦pcv< %), which was followed by a moderate form ( %≦pcv< %; . %, n = ) and a severe form (pcv< %; . %, n = ). among the dogs with identifiable causes, . % ( dogs) were induced by single cause, whereas . % ( dogs) by multiple causes. neoplasia-related anemia (n = ), infectious pathogens-related anemia (n = ), renal disease-related anemia (n = ) and post-surgery/ traumarelated anemia (n = ) account for . , . , . and . % of single-cause cases, respectively. furthermore, of them ( . %) presented with severe anemia. severe anemia primarily resulted from infectious disease-related anemia ( . %), followed by imha ( . %), and tumor-related anemia ( . %). of the infectious disease-related severe anemic dogs, the most common diagnosed pathogen was babesia gibsoni ( . %, n = ), followed by ehrlichia canis ( . %, n = )and babesia canis ( . %, n = ). taken together, tumors, infectious diseases, and renal failure are the most frequently causes of canine anemia in taiwan, furthermore, b. gibsoni appeared to be the most important infectious pathogen causing severe anemia which may be associated with the climate in this geographical area. no conflicts of interest reported. bordetella bronchiseptica (bb) is one of the primary causative agents of canine infectious respiratory disease (cird). this contagious disease, commonly seen in young dogs, is often self-limiting, although a wide range of respiratory signs can be found, from mild illness to severe pneumonia leading to death. although mycoplasma cynos (m. cynos) was recently identified as an emerging and possibly lethal pathogen in cird , the role of m. canis and m. cynos as primary respiratory pathogens still remains unclear. detection of these bacteria is now improved by quantitative polymerase chain reaction (qpcr). in dogs with cird due to bb, the frequency of co-infection with mycoplasma spp, in par-ticularm. cynos, and their possible role in the severity of the clinical signs are unknown. the aim of the present study was to investigate the presence of m. canis and m. cynos in a population of dog infected with bb, compared with other populations: healthy dogs and dogs with bacterial bronchopneumonia where bb was not involved (bbp). therefore, bb, m. canis and m. cynos were detected by qpcr in the bronchoalveolar lavage fluid (balf) sample in dogs with bb (mean age = . y, mean bw = . kg), dogs with bbp ( . y, . kg), and healthy dogs ( . y, . kg). bordetellosis was diagnosed based on clinical findings together with demonstration of pleiomorphic cocci/coccobacilli adhering to the cilia of the epithelial cells on cytospin balf preparations, and positive qpcr on balf. a clinical severity index (csi to ) was assigned based on clinical signs (cough - , dyspnea - , lethargy - , fever - ), thoracic radiographic pattern ( - ), and balf score ( - ). bbp was diagnosed based on clinical findings, balf cytology and culture. m. canis was indifferently detected in healthy ( / , %), bbp ( / , %) and bb dogs ( / , %) while m. cynos tended to be more frequently detected in bb group ( / , %) than in healthy ( / , %) and bbp dogs ( / , %) (khi² test, p = , ). in bb dogs, no correlation could be detected between csi and presence of m. cynos (khi² test p = , ). in conclusion, the present data suggest that, in cird, coinfection with bb and m. cynos is frequent, but is not correlated with clinical disease severity. further studies are required to investigate whether coinfection of bb and m. cynos deserves specific therapeutic considerations. no conflicts of interest reported. canine idiopathic eosinophilic bronchopneumopathy (ebp) is a disease characterized by eosinophilic infiltration of the lung and bronchial mucosa in young adults. aetiology remains unclear although immunologic hypersensitivity is clearly suspected, while inciting antigens are generally unidentified. in humans as in cats, infections with mycoplasma spp. have been discussed as potential triggers in inflammatory bronchial disease , . bordetella bronchiseptica (bb) is a recognized pathogen agent of canine infectious tracheobronchitis. detection of bb and mycoplasma spp, especially mycoplasma cynos (m. cynos), and their potential role of in canine inflammatory bronchitis, have not been investigated. the aim of the present study was to investigate the frequency of bb, mycoplasma canis (m. canis) and m. cynos in canine ebp. therefore, presence of bb, m. canis and m. cynos were retrospectively assessed by quantitative polymerase chain reaction (qpcr) in bronchoalveolar lavage fluid (balf) samples from dogs with ebp (mean age = . y, mean body weight = . kg) as well as in dogs with aspecific chronic bronchitis ( . y, . kg). based on clinical signs, a clinical severity score (css, - ) was assigned each ebp dog. although all balf culture and cytology were negative for this bacteria, bb was more frequently detected by qpcr in ebp dogs ( / , %) than in cb dogs ( %) (khi² test, p = , ). presence of bb in ebp dogs was independant of age but significantly associated with css (khi² test, p = , ). results of qpcrwere positive for m. canis and m. cynos in ( %) and ( %) ebp dogs and in ( %) and ( %) cb dogs, respectively. there was no difference between the groups for any of the organisms. any relation between age or css and presence of m. spp in ebp dogs was observed. in conclusion, m. canis and m. cynos do not seem to be predominantly involved in the pathogenesis of canine ebp. however, bb is more frequently detected in balf from ebp dogs than from dogs with aspecific cb and its presence is associated with clinical severity. whether bb is able to trigger eosinophilic inflammation or is only more easily collected in an inflamed environment is unclear. but ebp dogs could potentially act as bb carriers and source of infection. therefore, bb should be systematically searched for in canine ebp cases and treated accordingly. no conflicts of interest reported. distal renal distal renal tubular acidosis (drta) was recently reported in three dogs with imha. the purpose of this study was to explore the hypothesis that drta is an underdiagnosed concurrent disorder in dogs with imha. we report the clinical presentation and outcome of three dogs where the combination of imha and drta was strongly suspected. the medical records of dogs diagnosed with imha at the university of edinburgh hospital for small animals between january and may were reviewed to identify cases where venous blood gas analysis and urinalysis had also been carried out. for the purpose of this retrospective study imha was defined by the presence of anaemia with pcv < %, and one or more of the following criteria; a positive slide agglutination test, positive coombs' test or moderate to marked spherocytosis. the criteria for diagnosis of drta included moderate to marked hyperchloremic metabolic acidosis with a normal anion gap; urine ph (> . ) in the face of metabolic acidosis; hypokalaemia (< . mmol/l). fifty-seven records were evaluated, with cases being excluded due to insufficient clinical information, including inability to determine urinary ph due to the severity of pigmenturia in four cases. of the cases where there was sufficient clinical data to assess the likelihood of drta only one case fulfilled all the criteria; two cases fulfilled all but one of the criteria and drta was strongly suspected based on clinical progression and persistence of urine ph > in the face of severe metabolic acidosis. of the three cases where concurrent imha and drta was suspected, two survived to discharge; one was still alive at the time of writing ( months after discharge) and the other was euthanased months after discharge following the development of multiple joint effusions and skin lesions suggestive of sle. venous blood gas analysis and assessment of urine ph should be considered in all cases of imha to exclude the possibility of concurrent drta, particularly where persistent hypokalaemia is detected. prospective evaluation of a larger cohort of imha cases is required to determine the actual incidence of concurrent drta. no conflicts of interest reported. persistent renal proteinuria is considered an early marker of chronic kidney disease (ckd) and it is listed among the initiation factors and progression factors according to kdoqi guidelines. nevertheless, few data are available about the prevalence of proteinuria in cats affected with ckd, in which it is assumed that nephropathy is mainly characterized by tubulointerstitial damage. the aim of this study is to determine the prevalence of proteinuria in cats affected with ckd and to valuate the relations between urine protein to creatinine ratio (upc) or iris substaging by proteinuria, towards purebred, sex, age, haematology, biochemistry and urinalysis. wilcoxon test, linear regression and chi-square test were used for the statistical analysis. data from cats were considered. non-renal proteinuria was an exclusion criterion. proteinuric cats (upc> . ) were . % in ckd cats, while . % could be substaged as bordeline proteinuric ( . ) in cats, proteinuria tends to increase with aging (p < . ) and with worsening of the nephropathy (p = . ). proteinuria was related to the anaemic state in ckd cats: upc significantly increases with rbc count, hb, ht and mch decreasing (p < . and p = . respectively). proteinuria tends to increase with wbc count (p = . ) and neutrophils increasing (p = . ), while tends to decrease with lymphocytes increasing (p = . ). furthermore, upc significantly increases in presence of an inflammatory serum protein electrophoretic pattern. upc tends to increase with phosphorus and alp increasing (p < . and p = . respectively); while the role of phosphorus in ckd is well known, the increase of alp is questionable: it has been hypothesized that higher alp levels in ckd could be related to b-alp increase due to bone remodelling in secondary renal hyperparathyroidism. considering urine parameters, upc increases when urinary specific gravity and ph decrease (probably related to worsening of ckd and development of a metabolic acidosis) and when glicosuria is present, regardless of the cause. furthermore, proteinuria increases in presence of rbc in urinary sediment and in samples where casts were observed, in particularly when rbc casts (considered always pathological and indicative of glomerular damage) were present. upc values assessed in proteinuric cats and data analysis suggest the need of deepen the analytical variability of upc and the opportunity to reconsider the intervals of substaging by proteinuria in cats. no conflicts of interest reported. the aim of this retrospective study was to evaluate: a) the relations between urine culture results and urinalysis parameters; b) the results of the antimicrobial susceptibility tests. urine samples were collected by cystocentesis from dogs and cats, whose diagnostic workup included a differential diagnosis of uti: all samples underwent a complete urinalysis, upc ratio assessment and urine culture. infected vs sterile results were related to urine physical, chemical parameters and observations from urinary sediment analysis. statistical analysis was performed using jmp . (sas institute inc.). a p value < , was considered significant. urine culture resulted positive in dogs ( %) and cats ( %). the presence of uti was significantly related to urine physical properties (color and turbidity), usg and leukocyturia: infections tended to be more frequent in urine samples characterized by a light yellow color, cloudy or sub-limpid aspect and low usg. nevertheless, urine was limpid in % of infected samples, and a normal usg was found in . % of dog's uti but only in . % of cats. although leukocyturia tends to become higher in infected samples both in dogs and cats (p < . ), in . % of infected sediments wbc count was normal. haematuria detected by dipstick was significantly related to uti in dogs but not in cats, nevertheless the rbc count in sediment was not related to infection in both species: rbc count was normal in . % of infected feline samples and in . % of canine samples. no significant relation between presence or absence of uti and albuminuria, bilirubinuria, glycosuria was detected, while upc tends to become significantly higher in dogs. although the chi-square test showed a significant relation between infection and the detection of bacteria in urinary sediment, a pseudobacteriuria was found in . % of samples; furthermore bacteria weren't observed in . % of infected samples (usg< . ). e. coli was isolated in the majority of samples ( , %), compared to other species: staphylococcus( . %), proteus ( . %) and streptococcus. ( . %). the urinalysis pitfalls and the high antibiotic resistance verified towards the most widely used molecules (penicillins, cephalosporins, quinolones) strongly indicates the importance to perform antimicrobials susceptibility tests to avoid the risk of failure associated with the use or abuse of empiric therapies in utis. no conflicts of interest reported. azotemia in dogs with chronic heart failure may reflect impaired renal function not only because of inadequate renal perfusion, but also due to organic renal injury. impaired renal function is observed in % of dogs with heart failure. altered renal hemodynamics due to decreased cardiac output results in renal hypoperfusion, and resultant elevation of blood urea nitrogen and creatinine, defined as azotemia. azotemia is a prognostic factor in dogs with mitral regurgitation, therefore, preservation and/or restoration of renal function is thought to improve prognosis. medical treatment for heart failure, however, includes angiotensin converting enzyme inhibitors and loop diuretics, which has been shown to increase the risk of developing azotemia. we hypothesized that mitral valve repair surgery ameliorates renal function by improvement of systemic hemodynamics. the change in renal function in dogs with mitral regurgitation was assessed by evaluating time-dependent changes in glomelular filtration rate by inulin clearance before and after cardiac surgery. eighteen dogs with severe mitral regurgitation with azotemia (plasma urea nitrogen level > mg/dl, plasma creatinine level > . mg/dl) were included in this study. the glomerular filtration rate in all dogs were evaluated by determining inulin clearance before and months after surgery. serum atrial natriuretic peptide level, plasma nt-pro brain natriuretic peptide level, plasma urea nitrogen concentration, and plasma creatinine concentration were measured at each time point as well as during the initial staging of heart failure based on the international small animal cardiac health council (isachc). left atrial/aorta ratio by echocardiography and vertebral heart size by thoracic radiographs were also measured. glomerular filtration rate significantly increased months after surgery ( . ml/min/m [ . - . ], . ml/min/kg [ . - . ]) compared to before surgery ( . ml/min/m [ . - . ], . ml/min/kg [ . - . ]) (p < . ). the isachc stage of heart failure was improved at months after surgery compared to before surgery. in addition, serum atrial natriuretic peptide level, plasma nt-pro brain natriuretic peptide level, plasma urea nitrogen concentration, la/ao and vhs significantly decreased after surgery (p < . ). the use of diuretics decreased after mitral valve repair surgery and consequently, a decrease in plasma urea nitrogen and creatinine levels were observed. therefore, this suggests that the main cause of azotemia in dogs with mitral regurgitation may be due to inadequate renal blood flow and exacerbation by the use of diuretics. no conflicts of interest reported. glomerular filtration rate (gfr) is generally considered to be the gold standard measurement of kidney function. gfr can be calculated by measuring serum iohexol clearance using concentrations at , and hours following a bolus injection. for validation, serum samples were spiked at low ( . mg/ ml), medium ( . mg/ml) and high ( . mg/ml) iohexol concentrations. they were analysed, along with standard calibration curves ( concentrations ranging from . to . mg/ml), using deltadot's label-free high performance capillary electrophoresis (hpce) system. data were analysed using deltadot's general separation transform (gst). clinical and spiked serum samples were also sent for analysis by mass spectrometry (ms) at a reference laboratory ( samples for comparison). concentrations obtained by hpce and ms were compared in a bland altman plot. gfr for clinical samples was calculated from the measured iohexol concentrations using the method reported by bexfield ( ) . a validated method was produced, with a lower limit of detection of . mg/ml and an lower limit of quantification of . mg/ml. the upper limit of quantification was . mg/ml. the standard curve had excellent linearity (r = . ). maximum inaccuracy was less than . % of the true value, except at lloq, where it was within . %. average within day variability was less than . % at all levels, while between day variability was less than . %, except at lloq, where it was less than . %. agreement between the results obtained by measurement with hpce and ms was good (bias . %, lower and upper limits of agreement of - . and . %, respectively). method specificity was confirmed by the absence of matrix effect in six serum specimen obtained from clinical dogs. clinical samples were analysed and gfr reported with a day turnaround time. in conclusion, hpce provides an accurate and precise method for measuring iohexol in canine serum. conflicts of interest: l pelligand has the following information to disclose: in receipt of research grant / contract funding from orion ltd., novartis animal health, transpharmation ltd, deltadot ltd; acted as a consultant for: triveritas ltd. and novartis animal health; s williams is an employee of the rvc and works in collaboration with deltadot ltd; j. elliott has the following information to disclose: consultancy: pfizer animal health / zoetis, ceva animal health, boehringer ingelheim, vetoquinol ltd, orion ltd., elanco ltd, idexx ltd, niche generics ltd. triveristas ltd., virbac ltd., advisory board membership: international renal interest society (supported by novartis) european emesis council (sponsored by pfizer animal health -now zoetis) cardiorenal board -vetoquinol ltd. idexx renal advisory board research grants or contracts: vetoquinol ltd, novartis ltd, pfizer animal health ltd (now zoetis), royal canin ltd, boeringher ingelheim ltd, waltham centre for pet nutrition, ceva animal health orion ltd. esvonc-p- cystic pancreatic neoplasia in cats. c.m. borschensky , k. steiger , a. staudacher , m. schlitter , i. esposito , h. aupperle . laboklin gmbh&co. kg, bad kissingen, germany, tu m€ unchen, institute of pathology, m€ unchen, germany, veterinary clinic dr. staudacher, aachen, germany pancreatic neoplasms in the cat mostly exhibit a solid growth pattern and are diagnosed as carcinomas. in contrast, only few reports about cystic pancreatic lesions exist. until now, only benign cystic pancreatic lesions are described in the literature. according to the histological pattern, they have been termed as cysts, (acinar) cystadenoma or pseudocysts. in man, cystic pancreatic neoplasms are classified according to the localisation (intra-/extraductal), growth pattern and differentiation (mucinous, (tubulo)papillary, serous, acinar). the aim of this study was to characterise feline pancreatic neoplasms in more detail, based on the human classification system with a special view on cystic lesions. pancreatic masses sent to laboklin from domestic cats ( - years) were investigated routinely macroscopically and by histological methods (h.&e. stain). the neoplasms showed a cystic (n = ) or solid (n = ) pattern. cystic pancreatic tumors were up to cm in diameter and were classified as benign variants in five and malignant variants in three cases. based on the human classification system, they were classified as tubulopapillary (n = ), acinar (n = ) and mixed (n = ) adenomas and mixed carcinomas (n = ), respectively. solid pancreatic nodules were diagnosed as carcinomas with a tubular (n = ) or acinar (n = ) differentiation pattern. in summary, the gross structure (solid versus cystic) seems to be of prognostic relevance. in contrast to solid tumors, cystic pancreatic lesions in the cat behave benign in a higher percentage of cases, resulting in a better prognosis. therefore, surgical excision of these cystic masses can be recommended. with respect to the human classification system, three different subtypes of cystic pancreatic neoplasms were detected in the cat that have not been described before in veterinary medicine: tubulopapillary, acinar and mixed. to best of our knowledge, this is the first report of cystic adenocarcinomas in feline pancreas. further corresponding clinical and histological investigations are needed for a better diagnostic (ultrasound, mri) and prognostic characterisation of cystic lesions in feline pancreas. no conflicts of interest reported. the immunohistochemical detection of cyclooxygenase- (cox- ) expression in canine mast cell tumours was recently described by our team (prada et al., ) . however its prognostic value needs to be established. the aim of the present work was study the prognostic value of cox- expression by investigating the relationship with several clinical and pathological variables including the overall survival (os) time. we included dogs with mast cell tumours ( grade i; grade ii and grade iii). cox- immunohistochemical expression was carried out by a streptavidin-biotin method. for the cox- immunoreactivity evaluation were considered the number of positive cells (cox- extension), the intensity and the score of cox- . the following clinical and pathological features were considered: animal age, sex, tumour anatomical location, tumour size, skin ulceration, histological grade, histological safety margins and number of mitosis. cox- expression was correlated with the clinical and pathological data and with the overall survival. cox- intensity was statistical significantly associated with skin ulceration (p = , ); histological grade (p = , ) and absence of histological safety margins (p = , ), high mitotic number (p = , ) and with overall survival (p = , ). both cox- extension and cox- immunohistochemical score present no statistical relationship with the variables considered neither with the overall survival. our results suggest that cox- have an important role in dog mast cell tumours progression and could constitute a promising therapeutic target in this neoplasia. however, our study also demonstrated that in mcts, is the cox- intensity that has the prognostic value, not the number of cox- positive cells (cox- extension) and not the cox- immunohistochemical score. consequently, cox- intensity should be elected for evaluating the cox- positivity in mcts immunohistochemical studies. merial provided financial support for immunohistochemical analayis. the research centres has also received financial suppoprt from cecav, ceca and citab. dogs which were radiated for a subcutaneous sarcoma between and were included. medical records were reviewed and patient characteristics, treatment protocols, adjuvant therapies and outcome were analysed. follow-up information was obtained from medical records and by phone conversations with veterinarians or pet owners. thirty-two dogs were included into this study. mean age was years and mean body-weight was kg. male dogs were slightly overrepresented ( . %). curative intent radiotherapy was applied in dogs and palliative intent in dogs with a mean total dose of and . gray, respectively. in dogs microscopic disease was radiated. five dogs received liposomal doxorubicin concomitantly with radiotherapy, two received adjuvant doxorubicin and one intralesional cisplatin. overall median survival time was days with curative and days with palliative treatment. overall median survival time in dogs with macroscopic disease was days and in patients with microscopic disease it was not reached. radiotherapy was generally accepted as new treatment modality by pet owners and referring veterinarians. comparable to the literature, best outcome was achieved for dogs radiated with microscopic disease conflicts of interest: no conflicts of interest reported. oncept â , is indicated for the treatment of stage ii or iii oral melanoma after local control with survival times significantly increased following vaccination. a similar improvement in survival times has also been reported with digit melanoma. medical records of dogs diagnosed with melanoma between march and december were retrospectively evaluated. inclusion criteria were a histopathological diagnosis of melanoma, surgical excision of the tumour, and vaccination using the oncept â vaccine. dogs met the inclusion criteria. nificant renal involvement in dogs with cvl. this result indicates staffordshire terrier ( ), bouvier, giant schnauzer, maltese, irish setter, kerry blue terrier, golden retriever, scottish terrier, and great dane ( of each). dogs had stage ii digit melanoma with an equal sex distribution and a median age of . years (range - ). currently still alive and one dead, the latter following surgery for resection of a rib osteosarcoma the median survival time of the dogs still alive is . months (range - ) versus . months (range - ) for the dogs that have died. none of the dogs showed any adverse effect to the vaccine infected macrophages can cause injury in different organs, including the kidney. cvl is known as a common cause of glomerulonephritis. thus, this study aimed to investigate and characterize the renal lesions in dogs seropositive for leishmania sp. in brazil. this project was approved by the animal ethics committee of uece, brazil. twenty adult dogs seropositive for cvl from center for zoonosis control were randomly selected for this experiment. cvl was diagnosed by immunofluorescence and elisa. urine and blood sampling and kidney harvesting were performed immediately after euthanasia that the glomerulonephritis is a common sequelae related to leishmaniasis infection. even dogs in stage of ckd showed significant renal histopathological changes. animals infected with leishmania sp. may have severe renal damage and risk of progressive chronic kidney disease even when no increase of creatinine levels or proteinuria is detected.conflicts of interest:the authors received funding to pay the phd scholarship of one student (conselho nacional de pesquisa e desenvolvimento -cnpq-brazil) and received a research grant from fundac ßão cearense de apoio ao desenvolvimento cient ıfico e tecnol ogico -funcap. anaplasma phagocytophilum, the causative agent of canine granulocytic anaplasmosis, is an obligatory intracellular bacterium transmitted by ixodes ticks. transmission via blood transfusion has rarely been described in human medicine and once in a dog. in the berlin/brandenburg area the seroprevalence rate in dogs was % regardless of health status.the aim of this study was to evaluate pcr screening results for a. phagocytophilum in canine blood donors between - in order to estimate the risk of transfusion-transmitted infection. edta blood samples from dogs were submitted for a. phagocytophilum real-time pcr testing (targeting the msp gene). altogether dogs were tested up to times. clinical and laboratory data were examined before each donation. statistical analysis was performed using spss . .the pcr test was positive for of the samples. none of the dogs tested pcr positive more than once. positive results were most often detected in june ( ), may ( ), and july ( ), but also in five other months. in three dogs a mild increased in rectal temperature (≥ , °c) was documented. mild laboratory abnormalities were noted in dogs: thrombocytopenia ( ), leukocytosis ( ), leukopenia ( ), anemia ( ) and hyperproteinemia ( / ); four dogs had more than one abnormality. there was no significant difference between the pcr negative and positive blood samples in regard to laboratory abnormalities.altogether, . % of blood samples from healthy canine blood donors were pcr positive for a. phagocytophilum. therefore, blood donors should be screened by pcr in endemic areas all year round. no conflicts of interest reported. the study population consisted of cats, including control cats recruited from veterinary practices across the country. among the disease cats, cats presented urtd, cats had conjunctivitis and cats suffered chronic gingivostomatitis, many of them presenting more than one clinical sign. pcr for the above-mentioned pathogens was performed from pooled conjunctival and oropharyngeal swabs for each cat. a questionnaire regarding signalment (age, breed, sex, neuter status), environment (indoor, number of cats in household) and vaccination history was obtained. data was analysed by multivariable logistic regression with alpha equal to < . .the prevalence for the four pathogens has been previously reported in detail. briefly, the prevalence among the four groups (including controls) ranged from to % for fhv- , - % for fcv, - % for chlamydophila felis and - % for mycoplasma felis.in the univariate analysis, age, neutering status, being purebred, indoor keeping, number of cats in the household and body weight were variably associated with the different groups of disease and the presence of the pathogens. in the multivariable analysis, only the following factors remained significant. in the multivariable analysis, only the following factors remained significant: urtd was significantly associated with positive results for fhv- , chlamydophila felis and mycoplasma felis (in addition to being male and not castrated); conjunctivitis was significantly associated to positive results for fhv- and chlamydophila felis (in addition to being young, not castrated and purebred) and cgs was significantly associated to positive results for fcv (in addition to being young, male and purebred). not being properly vaccinated was a significant risk factor only when all three groups were analyzed together. the number of cats in the household was an independent risk factor for detecting each of the pathogens studied. the age was also a significant factor in cats with fcv and chlamydophila felis, being older cats predisposed to fcv and younger cats predisposed to chlamydophila felis.the present study describes important epidemiological data for cats presenting urtd, conjunctivitis and/or cgs, and emphasizes the complex interrelationships occurring among the different pathogens. our results also support the role of fcv in cats with chronic gingivostomatitis.conflicts of interest:the study was funded and designed by merial laboratories. reports of methicillin-resistant staphylococci (mrs) in animals have become more frequent in last years. various studies have demonstrated the transmission of mrsa between animals and humans in daily contact with animals, however there is only limited data so far available on the transmission of methicillinresistant coagulase-negative staphylococci between animals and humans. the objective of this study was to investigate the frequency of methicillin-resistant staphylococci (mrs) carriage in healthy veterinarians, veterinary nurses, veterinary assistants, veterinary students and farm workers from several veterinary hospitals, clinics and farms.nasal swabs were collected from veterinarians ( small animal veterinarians and pig veterinarians), veterinary nurses, veterinary students, veterinary assistants and farm workers. mrs were screened on brilliance tm mrsa agar (oxoid) or chromid tm mrsa (biom erieux). after - h of incubation at °c, suspected colonies on both media were subcultured onto blood agar plates. species identification was obtained by species-specific pcr. methicillin-resistance was confirmed by pcr amplification of the meca gene. mrsa isolates were characterized by mlst.thirty-nine mrs were identified in humans ( veterinarians, veterinary nurses, veterinary students, veterinary assistants and farm workers). the mrs isolates were identified as staphylococcus aureus (mrsa, n = ), s. epidermidis (mrse, n = ), s. pseudintermedius (mrsp, n = ), s. haemolyticus (mrsh, n = ) and mrs coagulase-negative staphylococci. the frequency of colonization by mrs was similar in both small animals and pigs veterinarians (ae %). one veterinary student was colonized simultaneously with an mrse and an mrsh. the predominant st in humans in contact with small animals was st and in humans in contact with pigs was st .in our study the frequency of colonization by mrsa was high, but the frequency of mrse should not be underestimated. mrsa isolates in this work belonged mainly to the st lineage which is the most frequent in small animals and humans in europe. humans in daily contact with animals can become colonized by mrs of animal origin and thus are important keys for infection control programs in veterinary hospitals and farms.conflicts of interest: dr pomba currently receives research funding from the government and national programmes (fundac ßão para a ciência e a tecnologia). in the past, she has occasionally received research support or honoraria for lectures from pharmaceutical companies including zoetis and atral cipan. she is vice-chair of the antimicrobial working party (awp) and member of the antimicrobial advice ad hoc expert group (ameg) of the european medicines agency (ema). , species not determined [ ]) did not. all cats underwent antibiotic treatment (doxycycline or a fluoroquinolone); cats received blood transfusions and/or oxyglobin â . three cats were euthanatized within days due to concurrent disease (fiv, pancreatitis/cholangitis) or financial constraints, one cat due to persistent anemia after weeks. four cats were lost to follow-up. the remaining cats underwent follow-up for a period of - weeks (median ). hemoplasma pcr analysis was conducted - times on blood samples at variable time points from of the follow-up cats. the first negative pcr in cases occurred after (cmhm, during antibiotic treatment), (cmhm, during antibiotic treatment), (cmhm, during antibiotic treatment) and (mhf, after completion of antibiotics) weeks. one cat remained pcr positive (cmhm) at , , and (all during antibiotic treatment) weeks, and another cat (cmhm) was pcr positive at weeks. reactivation of the hemoplasma species (documented by hemolysis and positive pcr) occurred in cats (both cmhm) and times, respectively, up to weeks after initial presentation. reactivation was suspected (no pcr testing available) in additional cases (cmhm [ ], mhf [ ]). four of the follow-up cats were euthanatized after - weeks (median ) due to concurrent disease (cardiomyopathy, immune-mediated thrombocytopenia, postoperative complications, diabetes mellitus). infection with hemoplasmas is often chronic, can reactivate months later and is rarely the reason for euthanasia. no conflicts of interest reported. canine distemper (cd) is a worldwide occurring infectious disease caused by a morbillivirus of the family paramyxoviridae. cdv infection can result in a systemic infection. dogs presented with neurologic signs revealed the terminal stage of the disease and usually failed to therapy. additional passive immunotherapy is hypothesized to be beneficial in the early stage of cdv infection. porcine anti-cdv antibody subunit f (ab') [f(ab') ] was produced by animal technology laboratories, agriculture technology research institute. eighteen cdvnaturally infected dogs showing respiratory signs but no neurological signs were treated with the combination of f(ab') and supportive therapy (group ). group included dogs in a similar clinical signs (without neurological signs) that received only supportive therapy. the survival rate was . % ( / ) in group and . % ( / ) in group , respectively, with a significant difference between the two groups (p < . ). the progressive rates of developing neurological signs during therapy of group and group were . and . %, respectively. there was no significant difference between the two groups. the survival rates of dogs developing neurological signs during therapy were % ( / ) in group and . % ( / ) in group , respectively, with a significant difference between the two groups. in conclusion, additional administration of porcine anti-cdv antibody subunit f(ab') before developing of neurological signs could decrease the mortality and furthermore reduce the rate of developing neurological signs. no conflicts of interest reported. key: cord- -tqd m i authors: zheng, yi; zhang, xuewen; guo, jiaoli title: application in medicine systems date: - - journal: dan shen (salvia miltiorrhiza) in medicine doi: . / - - - - _ sha: doc_id: cord_uid: tqd m i modern pharmacological studies on danshen have shown that the pharmacologic actions of danshen mainly include dilating vessels, promoting blood flow, improving microcirculation, changing blood viscosity, increasing myocardial blood and oxygen supplies, reducing myocardial consumption of oxygen, etc. the drug is used to treat diseases of the cardio-cerebrovascular system. in addition, danshen also has antitumor, antibacterial, and anti-inflammatory functions. therefore, danshen has wide clinical application. in recent years, there has been an increase in the number of reports on the clinical application of danshen extract and danshen compound preparations. danshen is seldom used alone; rather, it is usually combined with other drugs to form compound preparations. various danshen preparations have been developed, such as compound danshen tablets, compound danshen dropping pill ( dantonic™), compound danshen granules, compound danshen capsule, compound danshen oral liquid, compound danshen aerosol, and compound danshen injection (cdi), etc. the successful development of these preparations has improved product quality, enhanced efficacy, and opened up broader prospects for danshen’s clinical application. modern pharmacological studies on danshen have shown that the pharmacologic actions of danshen mainly include dilating vessels, promoting blood flow, improving microcirculation, changing blood viscosity, increasing myocardial blood and oxygen supplies, reducing myocardial consumption of oxygen, etc. the drug is used to treat diseases of the cardio-cerebrovascular system. in addition, danshen also has antitumor, antibacterial, and anti-inflammatory functions. therefore, danshen has wide clinical application. in recent years, there has been an increase in the number of reports on the clinical application of danshen extract and danshen compound preparations. danshen is seldom used alone; rather, it is usually combined with other drugs to form compound preparations. various danshen preparations have been developed, such as compound danshen tablets, compound danshen dropping pill (dantonic™), compound danshen granules, compound danshen capsule, compound danshen oral liquid, compound danshen aerosol, and compound danshen injection (cdi), etc. the successful development of these preparations has improved product quality, enhanced efficacy, and opened up broader prospects for danshen's clinical application. danshen has the function of effectively dilating the coronary artery, increasing coronary blood flow, reducing heart rate, inhibiting platelet aggregation and thrombopoiesis induced by platelet activation factors, promoting the recovery of injured cardiac muscle, increasing cardiac contractility, and protecting cardiac muscle cells; thus it can be widely applied in treating the diseases of the circulation system. the preparations of danshen used in the clinical treatment of coronary heart disease are mainly decoctions and compound injections. compound danshen decoctions are usually combined with other drugs such as the qi-boosting drugs ginseng and astragalus root, qi-moving drugs common aucklandia root, sichuan lovage root, and sandalwood, and the blood-invigorating drug safflower. compound injections are usually combined with drugs for supplementing qi, nourishing yin, and activating blood circulation. the application of danshen preparations can also be adjusted in timing and dosage. liu [ ] observed the effect of modified danshen beverage on the treatment of patients with coronary heart disease and angina pectoris. patients in the treatment group were administered modified danshen beverage; the prescription included g danshen, g ginseng, g american ginseng, g villous amomum fruit, g leech, g sanchi, and g sandalwood, with a course of treatment lasting weeks. patients in the control group were orally administered compound danshen tablet. the results showed that the total effective rates in the treatment group and control group were . and . %, respectively, and there was a significant difference between the two groups (p \ . ). ecg efficacies in the treatment and control groups were . and . %, respectively, and the difference was statistically insignificant (p [ . ). the blood lipids and hemorheology indices in the two groups changed after treatment. the rate of reduced or ceased use of nitroglycerin in the treatment group was . %, and in the control group was . %; the difference was significant (p \ . ). the authors concluded that the modified danshen beverage has the functions of improving coronary artery blood supply, reducing blood lipids, reducing blood viscosity, and inhibiting myocardial ischemia. li et al. [ ] observed the clinical therapeutic effects of combined chinese and western medicines on the treatment of unstable angina pectoris (uap). patients with uap were randomly divided into treatment and control groups, patients in each group. the patients in the control group were administered with -isosorbide dinitrate ( -ismn ) by intravenous drip; the patients in the treatment group were administered with, in addition to -ismn , compound danshen aerosoleach, four sprays per time, three times a day. the results showed that in the treatment group, some therapeutic effects on improving angina pectoris symptoms, physical signs, and ischemic electrocardiogram, etc. were observed; the drug also has the function of reducing total cholesterol, ldl level, and platelet adhesion rate, and stabilizing plaques. they found that combined treatment with danshen for uap was better than that of -ismn used alone. meng and zou [ ] reported the effect of modified pulse-engendering powder combined with danshen beverage on the treatment of patients with coronary heart disease and angina pectoris. the patients in the treatment group were administered with g of heterophylly false satarwort root, g of radix ophiopogonis, g of chinese magnolia vine fruit, g of danshen, g of villous amomum fruit, and g of liquorice root. the above drugs were decocted with water and taken one dose twice a day for weeks as one course of treatment. the patients in the control group were administered with mg of isosorbide dinitrate three times a day. the results showed that angina pectoris in the two groups after treatment was significantly relieved and the average number of days in the treatment group and control group was . ± . days and . ± days, respectively. the average number of days when angina pectoris disappeared in the treatment group and control group was . ± . and . ± days (p \ . ), respectively. hu and yang [ ] reported the effect of modified muxiang danshen beverage (木香丹 参饮) on the treatment of coronary heart disease and angina pectoris. the basic prescription contained g of common aucklandia root (木香), g of clove flower (丁香), g of round cardamon kernel (白蔻仁), g of villous amomum fruit (砂仁), g of agastache (藿香), g of sandalwood (檀香), g of danshen, and g of liquorice root (甘草). the above drugs were decocted and administered with water and divided into two parts, to be taken as one part twice per day. the results showed a therapeutic effect on the symptoms of angina pectoris: of the patients, there were patients with a marked effect, patients with an effect, and patients without effect. the effective rate was . %. regarding therapeutic effects on the electrocardiogram st-t segment, of the patients, patients had a marked effect, patients had an improving effect, and patients had no effect; the effective rate was . %. chen and gao [ ] reported the effect of modified harmonious yang decoction and danshen beverage on the treatment of patients with coronary heart disease and angina pectoris. patients in the control group were treated with western medicines; mg of isosorbide mononitrate was orally administered twice a day, along with mg of enteric-coated aspirin once a day. the patients in the treatment group were administered with the above western medicines plus tcm decoctions, i.e., modified harmonious yang decoction and danshen beverage, which contained g of prepared rhizome of rehmannia (熟地), g of danshen, g of antler glue (鹿角胶), g of mongolian snakegourd fruit (全瓜蒌), g of cassia bark tree twig (桂枝), g of villous amomum fruit (砂仁), g of sandalwood (檀香), g of raw liquorice root (生甘草), g of szechwan lovage rhizome (川芎), and g of white mustard seed (白芥子). the above drugs were decocted and taken with water, one dose twice a day, for days as one course of treatment, and the two groups were treated in two consecutive courses. the therapeutic effects were evaluated at the end of the treatment. the result showed that effective rate in the treatment group was . %, which was significantly higher (p \ . ) than that of the control group, which was . %. in the clinical application of danshen's modern preparations, compound danshen injection (cdi) occupies a very important position. cdi can significantly improve blood viscosity, so that blood flow is accelerated and intravascular pressure is reduced. cdi can antagonize calcium, dilate blood vessels, increase blood flow, and improve microcirculation of the heart. it also has the function of inhibiting platelet adhesion, aggregation and release, and improving prostacyclin metabolism, etc. these functions have been documented in large amounts of clinical literature, and cdi has been proven to have reliable therapeutic effects. on the basis of using cdi alone, various injections with the function of activating blood circulation, such as daidzein, and with the function of supplementing qi and nourishing yin, such as shenmai injection, etc., have been developed. lu and xu ( ) observed patients with average ages of ± years in a control group, and patients with average ages of ± years in the danshen treatment group. the patients in the control group were administered with ml of low molecular dextran combined with ml of % magnesium sulfate, ml of % potassium chloride, and iu human insulin by intravenous drip at - drops/min, once a day, for - weeks as one course of treatment. the patients in the danshen treatment group received the same treatment as those in the control group, but received an additional - ml of danshen injection. the therapeutic effects were evaluated according to clinical symptoms and electrocardiograms. the results showed that the marked effective rate and improvement rate in the danshen treatment group were higher than those in the control group, the total effective rates of the two groups were . and . %, respectively, with a significant difference (p \ . ). judging by ischemic electrocardiograms, the marked effect rate and improvement rate in the danshen treatment group were significantly higher than those in the control group, and the total effective rates were and %, respectively (p \ . ). the effective rates of reducing arrhythmia recurrence in the two groups were . and %, respectively (p \ . ), which demonstrated that the recurrence rate of arrhythmia in the danshen treatment group was significantly reduced compared to that in the control group. during the treatment period, neither abnormal changes nor any adverse reactions were shown in blood and urine routine assays, and the blood sugar and liver and kidney functions were normal. yang [ ] reported the application of shenmai and danshen injections in the treatment of patients with coronary heart disease and angina pectoris. the patients were administered with ml of shenmai injection and ml of danshen injection by intravenous drip, once per day for weeks, and the results showed the treatment had significant anti-angina pectoris effects. fu et al. [ ] reported the application of . / ml of puerarin and glucose injection combined with ml of cdi in the treatment of patients with coronary heart disease and angina pectoris, and the results showed that in the treatment group there were patients with a marked effect, patients with an effect, patients without effect, and the total effective rate was . %. there is a report showing that the effectiveness of danshen drugs might vary with the timing of drug administration. xing [ ] reported the application of cdi in the treatment of patients (treatment group: patients, control group: patients) with coronary heart disease and angina pectoris and blood stasis based on temporal rhythm. the patients were divided into a morning group and afternoon group, with the same drug and dosage ( ml of cdi) administered by intravenous drip. the results showed that the total effective rates of the treatment group in the morning and control group in the afternoon were . and . %, respectively, and the difference between the two groups was significant (p \ . ). the results demonstrated that better therapeutic effects of danshen could be obtained when the heart of the patient was in a vigorous condition. mao et al. [ ] reported the application of cdi and danshen injection in the treatment of patients with coronary heart disease, based on the theory that danshen has the effects of activating blood circulation, dissipating blood stasis, nourishing the heart to promote blood circulation, and benefiting vital energy and strengthening yang. ml of cdi and ml of danshen injection were mixed together, then the acupoints of inner pass (pc ), heart shu (bl ), and jueyinshu (bl ) were selected and the liquid was injected after needle sensation. heart shu and jueyinshu received ml of the injection each time, and inner pass received ml. the acupunctural injection was performed once every other day for days as one course of treatment, and usually two courses of treatment were necessary. the synergistic effects were obtained by the combination of acupuncture and medication. the effects were judged according to clinical symptoms, electrocardiogram and hemorheology. the total effective rate of clinical symptoms was . %, the total effective rate of improvement of electrocardiogram st-t was . %, and both whole blood viscosity and serum viscosity were significantly reduced. zhang [ ] reported the application of compound danshen aerosol on the treatment of patients with coronary heart disease and angina pectoris. the patients were sublingually administered with - sprays of the aerosol three times a day, for days as one course of treatment. patients in the control group were administered with isosorbide dinitrate tablet. the results showed that the total short-term effective rates for angina pectoris in the treatment group and control group were . and %, respectively; judging by electrocardiograms, the total short-term effective rates were and %, respectively, and the differences were significant (p \ . ). the immediate effective rates in the two groups were and %, respectively; the onset times were . ± . and . ± . min, respectively. the therapeutic effects on angina pectoris in short term, immediate effects, and the effects on severe angina pectoris and unstable angina in the treatment group were significantly better than those in the control group (p \ . ). the mechanisms for the treatment of coronary heart disease by danshen injection were clinically investigated. kong et al. ( ) found that after treatment with danshen preparations, the platelet aggregation test (pagt), β-tg (β-thromboglobulin) txb (thromboxane b ), and pgf α (prostaglandin f α) in patients with coronary heart disease were significantly reduced, and there were downward trends in pagt ( μmadp) and pf (platelet iv factor) after treatment, though the differences were not statistically significant. there were no significant changes in the ratios of β-tg/pf and txb /pgf α. the results demonstrated that danshen had wide cardiovascular pharmacologic actions (e.g., inhibiting platelet aggregation, dilating coronary artery blood vessels, cleaning oxygen radicals, anticoagulation, etc.) and reducing oxygen consumption by the myocardium so as to antagonize angina pectoris. zhang et al. [ ] reported the application of danshen in the treatment of patients with coronary heart disease and angina pectoris by injectio ad acumen at heart shu (bl ). the results showed that the blood plasma et- and mda were significantly reduced to a normal level after treatment. the authors concluded that danshen injection at heart shu point could remit the impairment of blood vessel endothelial cells in the patients with coronary heart disease and angina pectoris and alleviate angina pectoris. xing [ ] used danshen injection to treat patients with coronary heart disease, and observed the changes in the contents of lipid peroxides (lpo) and superoxide dismutase (sod) before and after the treatment. healthy individuals were used as the control. the results showed that lpo of patients with coronary heart disease was significantly higher than that of healthy individuals (p \ . ), but blood sod was lower significantly than that of healthy individuals (p \ . ); after treatment with danshen, lpo was significantly reduced (p \ . ), and sod was significantly increased (p \ . ). the results demonstrated that danshen had the function of reducing lpo and enhancing the activity of sod in serum. lin [ ] used danshen powder injection combined with nitroglycerin to treat high myocardial infarction patients with st segment elevation, and obtained satisfactory therapeutic results. danshen (lyophilized) powder has the function of dilating the coronary artery, inhibiting platelet aggregation, inhibiting thrombopoiesis, and improving hemorheology and microcirculation. danshen powder injection can be used to substitute longterm use of aspirin in the treatment of coronary heart disease. drug resistance can be induced by long-term use of nitroglycerin, and thus the therapeutic effect can be reduced to some extent. when danshen powder injection was added to the comprehensive treatment scheme (nitroglycerin, low molecular heparin, etc.), the total effective rate was . %, the blood rheology was significantly improved, and no apparent toxicity or sideeffects on liver and kidney function was observed. qi et al. [ ] observed the therapeutic effects of sodium tanshinone ii a sulfonate (sts) injection on the treatment of acute myocardial infarction (ami). patients with ami were randomly divided into an observation group ( cases) and control group ( cases). conventional therapy methods were performed in the control group, but sts injection in addition to conventional therapy was performed in the observation group. the results showed that the incidence of angina pectoris after infarct in the treatment group was significantly reduced weeks after treatment, and there was a significant difference between the treatment group and control group but no significant difference in arrhythmia and hospital mortality rate between the two groups. the results demonstrated that ventriculus sinister function and myocardial ischemia in patients with ami can be improved by sts injection, and it was safe and effective in clinical application. how to reverse left ventricular remodeling and slow down congestive heart failure after myocardial infarction (ami) is an important issue for physicians. clinically, β receptor blockers, angiotensin converting enzyme inhibitors, angiotonin ii receptor antagonists, and aldosterone receptor antagonists have been used for left ventricular remodeling treatment after ami. chao et al. [ ] observed the therapeutic effect of tanshinone ii a (tsn) on left ventricular remodeling after ami, and they found that tsn had significant inhibitory effects on remodeling compared with the control group. the results showed that tsn could significantly reduce the levels of ledvi and lesvi and increase the levels of lvef and e/a - weeks after treatment, thus inhibiting the post-ami enlargement of left ventricular internal diameter at the end of diastasis and left ventricular remodeling. the results demonstrated that tsn had a marked effect on the disease. it was revealed that the main pharmacologic actions of tsn on the cardiovascular system included anticoagulation and antiplatelet aggregation, improving coronary artery collateral circulation, reducing infarcted cardiac muscle area, reducing left ventricular end-diastolic pressure, reducing myocardial consumption of oxygen, and increasing left ventricular work. cheng et al. [ ] reported the application of san shen decoction (三参汤) in the treatment of patients with old myocardial infarction (omi) and premature ventricular contractions (vpc). - days later after taking antiarrhythmia drugs, the patients began to take san shen decoction which contains g of danshen, g of lightyellow sophora root (苦参), g of pilose asiabell root (党参), pieces of common jujube (大枣), one dose taken twice a day (morning and evening), continuing for - days. the dilatation drugs and cardiac diuretic were not discontinued while taking san shen decoction. the results showed that the total effective rate was %. there were three patients who suffered from accidental nausea and vomiting, but no significant side effects were observed in the other patients. danshen has the function of dilating vessels, enhancing the cardiac muscle's resistance to hypoxia, and improving heart function; combining the three drugs for the treatment of omi accompanied by vpc is an effective method. danshen has the function of dilating the coronary artery, enhancing resistance of the cardiac muscle to hypoxia, dilating peripheral vessels, and improving microcirculation. it especially has the function of improving cardiac contractility in the situation of can't affecting oxygen consumption when the patient is suffering from cardiac insufficiency, reducing the heart rate, significantly improving heart function, accelerating blood flow, and opening more capillary beds. these improvements are very important for patients with chronic congestive heart failure. in the treatment of chronic congestive heart failure, the dosage of cdi is usually ml or more; the therapeutic effect will be lessened if the dosage used is less than ml. the drug has poor efficacy on edema, which might have something to do with the amount of activity, salt intake, age, and other complications. huang and chen [ ] reported the application of true warrior decoction combined with danshen beverage in the treatment of patients with deficiency in heart-yang and kidney-yang types of heart failure; the prescription includes - g of red ginseng, - g of prepared common monkshood daughter root (熟附子), - g large head atractylodes rhizome (白术), - g of indian buead (茯苓), g of danshen, g of villous amomum fruit (砂仁), g of sandalwood (檀香), - g of oriental waterplantain tuber (泽泻), and - g of asiatic plantain seed (车前子) (decocting in wrapped condition), with days for one course of treatment. after the treatment, cases were clinically cured, cases showed a marked effect, cases showed an effect, and cases showed no effect; the effective rate was . %. liu [ ] observed the effect of cdi combined with shenmai injection on the treatment of patients with chronic congestive heart failure, of which there were males and females; cases of pulmonary heart disease, cases of coronary heart disease, cases of hypertensive cardiopathy, case of rheumatic heart disease, case of coronary heart disease, case of lung cancer; cases of class ii cardiac function, cases class iii, cases class iv; cases of left congestive heart failure, cases of right congestive heart failure, and cases of whole congestive heart failure. ml of % glucose was mixed with ml of shenmai injection and administered by intravenous drip; ml of % glucose was mixed with ml of cdi and administered by intravenous drip. the drugs were given once daily for - days as one course of treatment. the patients were usually treated for - courses, with an average period of . courses and an interval of - days between the courses. after various symptoms and physical signs were improved, the patients took compound danshen tablet and shengmai beverage orally to consolidate the therapeutic effect. the results showed that there were patients with marked effect, patients with effect, patients with no effect, and the total effective rate was %. hong et al. [ ] reported that patients with congestive heart failure were randomly divided into two groups; cases were treated with conventional therapy, and cases were treated with conventional therapy plus mongolian milkvetch root (黄芪) and cdi by intravenous drip. the changes of clinical therapeutic effect, heart function, and lpo and sod in the two groups were observed. the results showed the total effective rate in tcm group was . %, which was higher than that in the conventional group ( . %) (p \ . ). the heart functions of the two groups were improved after the treatments (p \ . ). the therapeutic effect in the tcm group was significantly better than that in the conventional group (p \ . ). the lpo levels in the two groups were reduced after the treatments, sod levels were increased (p \ . ), lpo in the tcm group was reduced, and sod was significantly increased compared to the conventional group. the authors concluded that the treatment of congestive heart failure with mongolian milkvetch root and cdi has the effects of strengthening the heart, relieving cardiac load, and improving blood circulation. the combination of the two drugs has the effects of benefiting vital energy and activating blood circulation, and promoting diuresis, which is consistent with tcm principles of treating heart failure. transluminal coronary angioplasty (ptca) with thorough understanding of the etiological factors of coronary heart disease and the increasing maturation, improvement, and advancement of cardiac cathetenization, percutaneous transluminal coronary angioplasty (ptca) is becoming an important method for physicians to treat coronary heart disease with. however, clinical studies have shown that about one-third of patients with a successful ptca operation suffer from coronary artery restenosis within months, which seriously affects the long-term therapeutic effects of ptca. the occurrence of restenosis is a complex biological process involving various factors. so far, there are no marked effective drugs for the prevention and treatment of restenosis, therefore the research and development of such drugs which can effectively prevent coronary artery restenosis is of great significance. danshen injection can inhibit the propagation of rabbit aorta smooth muscle cells cultured in vitro, and also has the function of inhibiting in vivo hyperplasia after the operational removal of endothelium in rabbit artery, which suggests that the development of danshen into an effective drug for restenosis is hopeful. xu [ ] observed the application of cdi in the treatment of patients with dilated cardiomyopathy. ml of % glucose solution or ml of . % physiological saline were added into - ml of cdi and administered by intravenous drip, once daily for days as one course of treatment. the dosage of cdi in the treatment of dilated cardiomyopathy was usually greater than ml/time; a lesser amount will give a poor therapeutic effect. glucose solution should be substituted by . % physiological saline for patients with diabetes. a small amount of patients after using cdi suffered from side effects such as active bowel sounds, loose stool, or increased number of dejection, etc., but the majority of patients suffered no adverse reactions. zhu et al. [ ] observed the therapeutic effects of mongolian milkvetch root injection combined with cdi on the treatment of patients with dilated cardiomyopathy. the patients were divided into two groups; both groups were treated with conventional therapy (low salt diet, using cardiotonic and diuretic drugs and converting enzyme inhibitors, etc.), then the patients in the control group were administered by intravenous drip with mg of atp, units of coenzyme a, g of vitamin c, . g of vitamin b , and ml of trommcardin, in ml of % glucose, once daily for days as one course of treatment, and the patients were treated for - courses. ml of mongolian milkvetch root injection ( ml injections contains g of mongolian milkvetch root) and ml of cdi were mixed with ml of % glucose injection and administered by intravenous drip to the patients in the treatment group, once daily for days as one course of treatment, and the patients were treated for - courses. the results showed that cases in the treatment group showed marked effect, cases effect, cases no effect ( cases died), and the total effective rate was . %; in the control group, cases showed marked effect, cases effect, cases no effect, cases died, and the total effective rate was %. the differences in effective rates and fatality rates between the two groups were statistically significant (p\ . ). it was concluded that cdi has the function of activating blood circulation and dissipating blood stasis, regulating vital energy and inducing resuscitation, inhibiting platelet aggregation, dilating the coronary artery, increasing blood flow, reducing heart rate, and promoting the repair of damaged myocardial cells. in the combination of the two drugs, the ml of mongolian milkvetch root injection is the principal drug which has the major function of nourishing qi and the adjutant function of diuresis; the ml of cdi is the adjutant drug which has the function of activating blood circulation. the combination of the two can complement each other. in this study, the total effective rate of the treatment group was . %, and the difference was significant compared with the control group. no toxicity or side effects were observed and no tolerance was induced. yan wanying and he jianping reported the application of a self-made decoction in the treatment of patients with elderly sick sinus syndrome; the prescription included g of pilose asiabell root (党参), g of mongolian milkvetch root (黄芪), g of chinese angelica (当归), g of red peony root (赤芍), g of danshen, g of szechwan lovage rhizome (川 芎), g of rehmannia dride rhizome (生地), g of spine date seed (酸枣仁), g of cassiabarktree twig (桂枝), g of common motherwort herb (益母草), g of lobed kudzuvine root (葛根), g of fried submature bitter orange (炒枳壳), and g of prepared liquorice root (炙甘草). among the patients treated, cases showed marked effect, which was defined as the disappearance of clinical symptoms and an increase in heart rate by beats/min in month of treatment; cases showed effect, which was defined as improvement of the clinical symptoms and an increase in heart rate by - beats/min in months of treatment. cases were classified as no effect, which means there were some improvements in clinical symptoms, but no changes in heart rate after months of treatment. fu [ ] reported the application of salbutamol and danshen in the treatment of patients with idiopathic sick sinus syndrome. the patients were administered with . mg of salbutamol by intravenous drip, three times a day, and ml of danshen injection, one time a day. a half month after treatment, the patients were administered orally with compound danshen tablet, three times a day, three tablets each time, for months as one course of treatment. the results showed that months after salbutamol and danshen treatment, all patients showed some degree of alleviation of clinical symptoms. the sinoauricular node recovery time (snrt) and sinoatrial conduction time (sact) were significantly shortened in patients; the maximal shortened snrt was , ms, the minimal was ms, and average was , ms; the maximal shortened sact was ms, the minimal was ms, and average was ms. there was no significant change in snrt and sact in three patients. there are many causes of sick sinus syndrome, but after examining the electrocardiograms, echocardiograms, sternum x-rays, blood fat, and blood sugar of the patients, no definite etiological causes were confirmed and thus they were classified as having idiopathic sick sinus syndrome. salbutamol is a β receptor stimulant which has the function of dilating vessels, improving sinoauricular node blood supply and enhancing pacing. danshen preparation has the function of activating blood circulation, promoting qi, dilating vessels and increasing coronary artery blood supply, increasing sinoauricular node blood supply, and reducing blood viscosity, thus preventing fibrosclerosis of the sinoauricular node. the therapeutic effects were enhanced by the combination of the two drugs, and satisfactory clinical therapeutic effects were obtained. shi et al. [ ] reported that patients having intracardiac operations under direct vision were randomly divided into a treatment group and control group, with patients each. the patients in the treatment group were administered with mg/kg cdi by intravenous injection before operation and after heart resuscitation after rewarming, and the patients in the control group were administered with physiological saline. the results showed that cdi has the function of increasing the pgi /txa ratio in the reperfusion phase, effectively inhibiting the production of endothelin and promoting the recovery of cardiac function after ischemia-reperfusion. base upon the above reviewed data, we can see clearly that danshen has significant therapeutic effects on the treatment of heart and circulation system diseases such as coronary heart disease, myocardial infarction, heart failure, cardiomyopathy, myocardial ischemia, sick sinus syndrome, and so on. the therapeutic effects are especially better when danshen is combined with other traditional chinese drugs. besides the functions of antiplatelet aggregation, reducing thromboxane a and promoting prostacyclin production, danshen also has the function of blocking ca + channels, improving the tolerance of brain cells to ischemic and hypoxic conditions, reducing free radical content, stabilizing cell membranes, and improving microcirculation. danshen has the function of increasing brain blood flow, and improving brain circulation. it is widely applied in the treatment of stroke (such as nervous system diseases, cerebral thrombosis, cerebral hemorrhage, subarachnoid hemorrhage (sah), etc.) in tcm, and satisfactory therapeutic effects can be obtained. li et al. [ ] demonstrated that the function of danshen was mild and comprehensive. large doses of mannitol could induce pachyemia, aggravate the high viscosity and hypercoagulability of the blood, and aggravate ischemic damage after cerebral hemorrhage. however, danshen can reduce blood viscosity, inhibit platelet aggregation, and improve microcirculation, and has the function of regulating the fibrinolysis system and promoting fibrin degradation, has anti-free radical activity, and relieves ischemic damage after cerebral hemorrhage and promotes hematoma absorption. when combined with dehydrating agents, danshen can relieve cerebral edema, promote the absorption of hematoma, promote the repair and regeneration of brain tissue, and alleviate sequelae. patients with cerebral hemorrhage were treated with cdi, and the rates of recovery and significant improvement in the treatment group were significantly better than those in the control group, and no side effects were observed. especially for patients with a small amount of hemorrhage, danshen can improve neurologic impairment and enhance the recovery rate. it is believed that senile patients usually suffer from blood system abnormalities, and the majority of research has reported that fibrinolysis activity in the elderly is low, thus they can easily suffer from thromboembolic disease. however, special attention needs to be paid to the possibility of hyperfibrinolysis or rehaemorrhagia or hematoma enlargement, which can be induced by various causes, in patients with cerebral hemorrhage. pang et al. [ ] observed the therapeutic effect of danshen injection on the treatment of cerebral hemorrhage. patients with cerebral hemorrhage were randomly divided into two groups; patients in the treatment group, and patients in the control group. the basic prescription in two groups was the same, namely, ml of % mannitol by intravenous drip, each for - h, continued for - days. days after the onset, the patients in the treatment group received ml of danshen injection by intravenous drip, once a day for weeks. ct examination was performed before and and weeks after treatment to measure hematoma volume. nerve function was also evaluated for the patients in the two groups. there was no significant difference in hematoma volume between two groups before the treatment (p [ . ), and hematomas in the treatment group were smaller than in the control group after treatment (p \ . ). there was no significant difference in neurological deficit between the two groups before treatment (p [ . ), but it was significantly reduced after treatment in the treatment group compared to the control group (p \ . ). the difference was especially obvious months later (p \ . ). these results demonstrate that danshen injection can promote hematoma absorption and nerve function recovery. pang et al. [ ] investigated the preventive nerve protective effect of dantonic™ on hypertensive patients. a large-sample epidemiological survey was conducted, and patients with hypertension who met the diagnostic criteria were selected. the patients were divided into groups. cases in the treatment group were administered with dantonic™ and nifedipine or captopril. cases in the control group were administered with nifedipine or captopril alone. they were followed up for months, and the changes in blood pressure, blood lipids, microcirculation, blood flow, thrombin, and other indices and the incidence of cerebral ischemic stroke were monitored. after treatment, there were significant differences in the clinical marked effective rate; effective rate and average pressure decrease between the two groups (p \ . ). the improvements in blood lipids, microcirculation, blood flow, and thrombin etc. in the treatment group were significantly better than those in the control group (p \ . ). the incidences of cerebral ischemic stroke in the treatment group and control group were . % ( / ) and . % ( / ), respectively, and the difference was significant (p \ . ). the results demonstrated that dantonic™ has a good prophylactic neuroprotective effect on patients with hypertension. zhang ( ) reported the application of a prescription with the function of unblocking the orifices, invigorating blood, and promoting urination in the treatment of patients with apoplexy. the ct examination showed patients with cerebral hemorrhage, patients with cerebral infarction, and patients with brain atrophy. the prescription included danshen, szechwan lovage rhizome (川芎), red peony root (赤芍), peach seed (桃仁), safflower (红花), common motherwort herb (益母草), medicinal cyathula officinalis root (川牛膝), indian buead (茯苓), forest musk (麝香) [or taiwan angelica root (白芷), synthetic borneol (冰片)], mongolian milkvetch root (黄芪), suberect spatholobus stem (鸡血藤), and earthworm (地龙). the above drugs were decocted and taken with water, one dose a day. after treatment, patients almost completely recovered, patients showed marked effect, cases showed no effect, and the total effective rate was . %. the prescription was especially effective on slurred speech. qi [ ] reported the application of sanqi panax notoginseng and cdi in the treatment of patients with cerebral infarction. the patients were - years old and all hospitalized h to days after onset; among them there were mild cases, moderate cases, and severe cases. the patients were divided into two groups, with cases in each group. the patients in the treatment group were administered with sanqi panax notoginseng and cdi by intravenous drip, and the patients in the control group were administered with cdi by intravenous drip. the two groups were comparable in gender, age, number of cases, and clinical classification. the patients in both two groups were treated according to the conventional procedure for cerebral infarction: those without significant anticoagulation contraindication or ulcer or hemorrhagic diseases were administered with anticoagulation drugs, such as mg heparin by intravenous drip for - h; mg antiplatelet aggregation drug aspirin, one time a day. % mannitol and dexamethasone were administered according to individual situations to reduce intracranial pressure, relieve cerebral edema and clean free radicals, and maintain water and electrolyte equilibria. the patients in the treatment group received ml of sandi panax notoginseng in ml of % glucose solution and ml of cdi in ml of % glucose solution, both administered by intravenous drip once a day. the patients in the control group received ml of cdi in ml of % glucose solution, with days as one course of treatment, and the patients were treated for courses. the interval between courses was days. for cured patients, the treatment was stopped immediately, and these patients were treated for - days. the results showed that there were patients with near complete recovery in the treatment group, patients with significant improvement, patients with improvement, patients without improvement, and the total effective rate was . %. in the control group, there were cases of recovery, cases of significant improvement, cases of improvement, cases of no improvement, and the total effective rate was %. the difference in effective rates of the two groups was significant (p \ . ). huang et al. [ ] observed the therapeutic effect of intravascular irradiation by a low energy he-ne laser and danshen treatment on acute cerebral infarction. in addition to traditional neurological treatment, cases of cerebral infarction (research group) were treated with intravascular irradiation by a low energy he-ne laser and danshen, and there was a corresponding control group. the hemorheology and blood fat indexes were determined before and after the treatment. the results showed that the effective rate in the research group was . % compared to . % in the control group, and the difference between the two groups was significant (p \ . ). the results demonstrate that intravascular irradiation by low energy he-ne laser combined with intravenous drip of danshen is a good method for the treatment of acute cerebral infarction. zhai et al. [ ] observed therapeutic effect of high-dosage danshen on the treatment of patients with acute cerebral infarction; ml of danshen injection was added into ml of low molecular dextran and administered by intravenous drip to patients in the treatment group, and mannitol and antibiotics etc. were administered according to pathogenetic conditions. anticoagulation, thrombolysis, and dilating vessel drugs were not used in the treatment. the patients in the control group were administered with the same drugs as in the treatment group, except for cdi. the drugs were administered by intravenous drip once a day, for weeks as one course of treatment. the results showed that there were cases with a clinical cure, cases with marked effect, cases with improvement, cases without effect, and the total effective rate was % in treatment group. in the control group, there were cases with marked effect, cases with improvement, cases without effect, and the total effective rate was . %. there was a significant difference in therapeutic effects between the two groups (p \ . ). it was revealed that compound danshen can significantly improve the majority of cerebral hemodynamic indexes, especially those of brain blood flow speed, vessel wall elastic wave speed, and critical pressure, which demonstrated that it had important functions in promoting cerebral blood flow, improving the elasticity of cerebral vessels, and reducing blood viscosity. therefore, application of danshen in the early stage can enhance the therapeutic effect and reduce disability rate. sun [ ] investigated the cerebral hemodynamic change of patients with sah, and the protective effect of danshen on brain ischemic damage. patients with sah were divided into two groups, with patients in both groups on absolute bed rest. the patients were administered conventional drugs with the function of reducing intracranial pressure and antifibrinolysis. ml of cdi was added into ml of % glucose injection and administered by intravenous drip to the patients in the danshen treatment group once a day, and the maximal length of the treatment was weeks. the cerebral hemodynamic changes and fatality rate in the two groups, ecg abnormal incidence, and cerebral vessel spasm incidence were observed. the results showed that the cerebral hemodynamic parameters of patients with sah were significantly changed, especially the minimum blood flow speed and cerebral vessels peripheral resistance; the cerebral hemodynamic changes between the danshen group and control group were very significant (p \ . ). it was revealed that sah can induce cerebral hemodynamic abnormality, and danshen preparation has a protective effect on brain ischemic change due to sah. with further pharmacology and clinical research on danshen, an increasing number of clinical documents have demonstrated that there are satisfactory therapeutic effects of danshen and its preparations on the treatment of cerebral vessel diseases, including cerebral hemorrhage and cerebral infarction. numerous facts have demonstrated that danshen can be actively used in the prevention and treatment of cerebral vessel diseases. zhang [ ] reported the application of integrated medicine to the treatment of trigeminal neuralgia. tcm preparations were anointed on the surface of the trigeminal neuralgia site. after locating the "trigger points" in the trigeminal neuralgia site, about ml of % lidocaine was injected at each point. min later, μg of vitamin b combined with mg dexamethasone were injected in the same site, once every days. during the blocking period, the patients took compound danshen tablet orally, tablets each time, times a day, plus . g of spiramycin each time, times a day. the results showed that patients were cured by times of blocking treatment, patients were cured by times of blocking treatment. the patients were followed up for - months, and there were no recurrences during the months to years period; the curative rate was %. the results demonstrate that integrated medicine can be used to treat trigeminal neuralgia, which can rapidly control the onset of the pain. the method is simple and practical, and can be further extended. wu [ ] reported the treatment of trigeminal neuralgia cases with cdi and "wu bai decoction" (五白汤). the patients were administered with ml of cdi by intramuscular injection, twice a day. traditional chinese drug "wu bai decoction" contains g of white peony root (白芍), g of giant typhonium tuber (白附子), g of taiwan angelica root (白芷), g of white stiff silkworm (白僵蚕), g of troubles territories (白蒺藜). the above drugs were decocted twice with water and administered one dose a day. the recovery rate was . %, the total effective rate was . %, and therapeutic effects were significantly better than those in the control group. it was revealed that compound danshen by intramuscular injection has the function of dilating microcirculation and improving local blood supply; a high dosage of white peony root has the function of nourishing blood and retaining yin with astringent, nourishing liver, and relieving pain. there was no toxicity or side-effects in clinical application, and the courses of treatment were short. gao et al. [ ] reported the application of dantonic™ in the treatment of patients with middle-aged and elderly facial neuritis. the patients in the control group received treatment with hormones, vitamins, antiviral drugs, physical therapy, and anti-inflammatory drugs, etc., and the patients in the treatment group received the same treatment as the control group plus - pills of dantonic™, times a day for days as one course of treatment, and courses of treatment were performed. the results showed that the total effective rates in the treatment group and control group were . and . %, respectively, and there was a significant difference in the total effective rate between the two groups. the study demonstrated that dantonic™ has the function of relieving vasospasm, improving local blood circulation around the facial nerves, and relieving inflammatory edema, thus it can be used to treat the disease. zhang [ ] reported the treatment for cases of migraine. - ml of cdi was added into % glucose salt water, and administered by intravenous drip for days as one course of treatment. patients without improvement after the first course received another course of treatment after - days. the results showed that five cases significantly improved after one course, and cases improved after the second course of treatment. it was believed that danshen's effects might be related to its function of stabilizing vasoconstriction and improving microcirculation. ge et al. [ ] reported the treatment of serious migraine with danshen, diclofenac sodium, and β-sodium aescinate. cases of serious migraine were treated with ml of danshen, . g of diclofenac sodium, and mg of β-sodium aescinate, and the effects were compared with those in cases of serious migraine treated by diclofenac sodium alone. the results showed that the total effective rates of the combined drug treatment group and single diclofenac sodium group were and %, respectively, and the differences in total effective rate and control rate between the two groups were significant (p \ . ). wang [ ] reported the treatment of migraine with compound danshen and - in cases. mg of - injection and cdi was added into ml liquid and administered by intravenous drip to the patients in the treatment group once per day, and days later they were orally administered with three tablets of compound danshen tablet and mg of - tablets, three times a day for month as a course of treatment. the patients in the control group were administered orally with not more than six tablets of ergotamine and caffeine tablets each day, then mg of nimodipine tablets twice a day after pain remission. the results showed that in the treatment group, cases showed marked effect, cases showed effect, cases showed no effect, and the total effective rate was . %. in the control group, cases showed marked effect, cases showed effect, cases showed no effect, and the total effective rate was . %, with a significant difference (p \ . ). it was believed that the effect of compound danshen and - on migraine treatment was related to their functions of vessel dilation and vasospasm relief; the study demonstrated that there was both blood vessel constriction and vasospasm during the migraine attack phase, compound danshen and - has the function of regulating vasoconstriction to stabilize blood vessels, thus controlling the migraine attack. there was a synergistic effect when the two drugs were used together, and with gentle adverse reactions; a few patients suffered from dry mouth, pharyngalgia, and other symptoms which might be related to the side effects of - . zhou et al. [ ] administered a mixture of ml of danshen injection and ml of cerebrolysin by intravenous drip to elderly patients with functional insomnia. the results showed that the clinical recovery rate and effective rate were . and . %, respectively, which were significantly better than those of the control group (p \ . ). it was believed that danshen has the functions of cleaning oxygen radicals and antilipid peroxidation, so it can delay the degeneration of brain cells and improve sleep. tong [ ] reported on patients with insomnia randomly divided into two groups; the patients were, respectively, treated with danshen zaoren decoction (丹参枣仁汤) and diazepam tablets, and the therapeutic effects in the two groups were observed. the patients in the treatment group were treated with self-made danshen zaoren decoction, which contains g each of danshen, raw dragon's bones (生龙骨), raw common oyster shell (生牡蛎), tuber fleeceflower stem and leaf (夜交藤), silktree albizia bark (合欢皮), and g each of stir-baked semen ziziphi spinosae (炒枣仁), and chinese arborvilae seed (柏子仁). the patients in the control group were administered with . mg of diazepam tablets orally before sleep, once a day. the therapeutic effects were evaluated days after the treatment. the results showed that the effective rate in the treatment group ( . %) was significantly higher than that in the control group ( . %), and the difference was significant (p \ . ). li [ ] reported the treatment of meniere's disease with a combination of cdi and qingkailing injection (清开灵注射液) for cases. - ml of cdi was added to - ml of % glucose injection and administered by intravenous drip, and - ml of qingkailing injection was added to physiological saline or - ml of % glucose injection and administered by intravenous drip in the treatment group. for the control group, mg of anisodamine injection was added to physiological saline or ml of % glucose injection and administered by intravenous drip, ml of low molecular dextran was administered by intravenous drip, and mg of atp, u of coenzyme a, mg of inosine, mg of vitamin b , and g of vitamin c were added to ml of % glucose injection and administered by intravenous drip. the symptoms of acid-base imbalance and electrolyte disturbances were treated at the same time. the therapeutic effects in the two groups were compared days after the drug administrations. the results showed that the recovery rate ( . %) in the treatment group was significantly higher than that in the control group ( . %). it was revealed that cdi has the function of activating blood circulation and dissipating blood stasis, regulating vital energy, and inducing resuscitation. qingkailing injection has the function of clearing heat and resolving toxins, cooling the blood and dissipating blood stasis, calming the liver and extinguishing wind, awakening the brain and opening the orifices, and eliminating sputum and dredging collaterals. the treatment using the combination of the two drugs targets both the causes and symptoms of meniere's disease, so satisfactory therapeutic effects were obtained. liu et al. [ ] reported that ml of danshen injection and mg of - injection were administered by intramuscular injection every h; or ml of % glucose combined with ml of danshen and ml of % glucose combined with mg of - injection were administered by intravenous drip each day. days after administration, the dosage of - was gradually reduced to mg, mg or complete withdrawal, depending on the patients' conditions and whether a toxic effect was induced by - . the dosage of danshen was not changed. patients with polyneuritis were treated and all of them were cured. the course of treatment was - days. xiao [ ] observed the therapeutic effect of cdi combined with banxia baizhu tianma decoction (半夏白术天麻汤) on acute dizziness. patients with acute dizziness were randomly divided into a treatment group and control group. in the treatment group, ml of cdi was added to ml of % gs and administered by intravenous drip for days, once a day; modified banxia baizhu tianma decoction was administered for days, one dose per day. in the control group, . - . g of venoruton injection was added into ml of % gs and administered by intravenous drip for days, once a day. the results showed that among the cases in the treatment group, cases were cured, cases showed an effect, and only cases showed no effect; the total effective rate was . %. in the control group, cases were cured, cases showed effect, cases showed no effect, and the total effective rate was . %, there was a significant difference between the treatment group and control group (p \ . ). liu et al. ( ) reported that cases of pulmonarye encephalopathy were randomly divided into a treatment group ( cases) and control group ( cases). the patients in the two groups were treated with the conventional therapy. ml of cdi was added to ml of % glucose solution and administered by intravenous drip to the patients in the treatment group, and ml of niuhuang xingnao injection (牛黄醒脑注射液) i and ii were administered by intramuscular injection, - times a day. the results showed that in the treatment group, the remission rate was % and mortality was %, and in the control group, the remission rate was . % and mortality was . %. the difference in fatality rate between the two groups was significant ( . \ p\ . ). it is believed that danshen has the functions of reducing blood vessel fragility and permeability, relieving the stagnation and aggregation of erythrocytes, reducing blood hypercoagulability, improving microcirculation in important organs such as the brain, heart, lung, and kidney, regulating tissue repair and regeneration, enhancing the body's compensatory ability, and promoting blood circulation. niuhuang xingnao injection was developed from the prescription of angong niuhuang wan, which has the function of clearing heat and resolving toxins, and calming the nerves and relieving spasms. it promotes consciousness recovery, and has significant anti-inflammatory effects. it can improve the body's tolerance to hypoxia. some therapeutic effects have been obtained by the combination of the two drugs in the treatment of pulmonary encephalopathy. lin [ ] investigated the effect of compound danshen preparations on the treatment of craniocerebral injury. patients with craniocerebral injury confirmed by head ct were selected in the study and randomly divided into two groups. the patients in the treatment group were administered with compound danshen preparations in addition to conventional therapy. the total effective rates in the treatment group and control group were . and . %, respectively. the results showed that better therapeutic effect was obtained in the treatment of craniocerebral injury by application of compound danshen preparations, and no significant side effects were observed. danshen has extensive applications to the treatment of nervous system diseases. besides on the pathological changes of cerebral vessels, it also has satisfactory therapeutic effects on trigeminal neuritis, facial neuritis, migraine, insomnia, dizziness, etc., so it is worthy of physicians' consideration when they face these diseases. respiratory system disease there was no significant difference (p [ . ) in common condition (gender, ages, pathogenesis), levels of infection (body temperature, symptoms, physical signs, x-ray, blood routine assays, bacteriology examination, etc.), and baseline disease and so on between the two groups. the patients in the two groups were treated according to their disease conditions. besides the above treatments, ml of cdi was added into ml of % glucose and administered by intravenous drip for the patients in treatment group, once a day. all patients were treated for days. the results showed that in the treatment group, cases recovered, cases showed marked effect, cases showed effect, cases showed no effect, and the effective rate was . % ( / ); in the control group, there were cases of recovery, cases of marked effect, cases of effect, cases with no effect, and the effective rate was . % ( / ). the effective rate in the treatment group was significantly higher than that in the control group (p \ . ). no toxicity or side-effects were observed. it was believed that cdi has the function of activating blood circulation and dissipating blood stasis, dilating vessel and restoring blood capillary relaxation ability, relieving blood vessel obstructions and blood stasis, relieving lung arteriola spasm, improving and promoting lung microcirculation, recovering pulmonary ventilation function, enhancing pulmonary oxygen function, promoting absorption of rales, and improving dyspnea conditions. in recent years, it has been demonstrated by research that danshen has inhibitory effects on gram-positive bacteria and some gram-negative bacteria, enhancing the body's immunity and thus enhancing the body's ability to fight infection. in addition, cdi also has the function of changing the blood rheology, improving pulmonary hypertension, shortening the course of lower respiratory infection in senile patients, and reducing mortality. shi ( ) reported the treatment of patients with persistent pneumonia who had been treated with various antibiotics, gamma globulins, plasma or fresh blood transfusions, physical therapy, and cortical hormones for more than month, but had obtained no significant therapeutic effects. the patients in the study were administered by intravenous drip with - mg of tanshinol, twice a day. - days after the treatment, patients were cured and patients had improved. it was revealed that in the pathogenesis of pneumonia, viruses and anoxia act upon the lung tissues to produce vasoactive substances and thus induce lung arteriola spasm and microcirculatory disturbance. compound danshen has the function of vascular dilation and improving microcirculation, thus promoting the patients' recovery from pneumonia. xu et al. ( ) used the ultrasonic atomizing inhalation of cdi to treat bronchial asthma. ml of cdi was diluted with ml of distilled water, and ultrasonic atomizing inhalation was performed once a day for days as one course of treatment. among the patients treated, there were cases of acute bronchitis, cases of chronic bronchitis, cases of asthma, and the average number of treatments was - times. the results showed that cases showed marked effect, cases showed effect, and the total effective rate was . %. the effect of the treatment on asthma patients began slowly, but the therapeutic effect was strengthened after the asthma was relieved. cases were followed up, and the disease did not recur one year after treatment. li et al. [ ] reported the application of cdi in the treatment of cases of bronchial asthma during the attack phase. the patients in the control group were treated with regular treatments such as oxygen inhalation, spasmolysis, β agonists, glucocorticoids, antibiotics, and so on. the patients in the treatment group were treated in the same way as those in the control group, but received an additional ml of cdi which was added into ml of % glucose and administered by intravenous drip, once a day for days as a course of treatment. the results showed that the total effective rates in the treatment group and control group were . and %, respectively. statistical analysis showed that there was a significant difference in therapeutic effect between the two groups. the mechanism of cdi in the treatment of bronchial asthma might be: ① inhibiting the release of bioactive compounds, reducing the high reactivity of airway, improving lung ventilation; ② improving microcirculation, enhancing the body's tolerance to anoxia; ③ dilating the coronary artery, increasing coronary blood flow, improving myocardial blood supply, enhancing cardiac contractility, and promoting remission of asthma; and ④ the obvious of antibacterial and anti-inflammatory functions have adjuvant therapeutic effects on lung infections. zhang [ ] reported that patients with acute aggravating stage pulmonary heart disease were randomly divided into a treatment group ( cases) and control group ( cases). comprehensive treatments (relieving cough and eliminating sputum, cardiotonics, anti-inflammation, low flow oxygen inhalation, etc.) were performed on the patients in the two groups, and ml of cdi in ml of % glucose was administered by intravenous drip to the patients in the treatment group, once a day for weeks as one course of treatment. the results showed that in the treatment group there were cases with marked effect, cases with improvement, cases without effect, and the total effective rate was . %. in the control group, there were cases with marked effect, cases with improvement, cases of no effect, case of death, and the total effective rate was %. the effective rate in the treatment group was significantly higher than that in the control group (p \ . ). patients with chronic pulmonary heart disease have some changes in their hemorheology, which include three characteristics: "dense" (increased erythrocytes), "sticky" (increased whole blood viscosity), and "accumulation" (enhanced erythrocyte aggregation). compound danshen has the function of improving the blood rheology, reducing blood viscosity, inhibiting erythrocytes and platelet aggregation, promoting the activity of fibrinolysis system, dilating vessels, promoting blood flow, improving microcirculation, increasing heart renal blood supply and anti-infection, enhancing body immunologic function, and so on, so it has significant clinical therapeutic effects. to calculate the effect of danshen on the pulmonary artery pressure (pap) of patients with chronic lung disease, the cardiac output (co), lung circulation resistance (rvr), and lung blood vessel compliance (pvc) were compared for some patients before and after treatment. the results showed that after injection of danshen, the extents of pap reduction in the high pressure group and normal pressure group were . - . and . - . kpa, respectively, and the differences before and after the treatment were significant. the results demonstrated that danshen has the function of reducing pap, and the reduction period was usually about - min with no cases taking longer than min, suggesting that danshen has circulation dynamic effects similar to those of dihydropyridines. zhang and chen [ ] reported the use of cdi to treat patients with chronic pulmonary heart disease. the patients were administered by intravenous drip with ml of cdi in ml of % glucose, once a day for days as one course of treatment, and four indexes (lpo, erythrocytes sod, whole blood gsh-px, and catalase activity) were observed. the results showed that danshen could significantly reduce enhanced lipid peroxidation and correct the imbalance of antioxidant enzymes in patients with chronic pulmonary heart disease. the studies demonstrated that the drug has the function of cleaning and inhibiting free radicals, thus inhibiting the occurrence and development of pulmonary hypertension in patients with chronic obstructive pulmonary emphysema. it is believed in traditional chinese medicine that the heart controls blood circulation and the lung controls respiration; the normal circulation of blood depends on the pushing power of qi, and the movement of qi depends on the normal circulation of blood. for this reason, danshen and its preparations, which are good drugs for activating blood circulation and dissipating blood stasis, can exert satisfactory therapeutic effects on pulmonary system diseases, which has been shown in the above examples. experimental research has already demonstrated that danshen can improve disturbances in liver microcirculation, has the functions of anti-lipid peroxidation, protecting hepatocytes, promoting the repair of liver damage, increasing fibrin levels in plasma, enhancing the phagocytic function of the reticuloendothelial system, inhibiting hepatic fibrosis, and promoting the resorption of fiber. in addition, danshen also has the function of promoting the secretion of mucus by the stomach mucous membrane, relieving intracellular calcium overload, increasing blood flow in mucous membranes, improving microcirculation, inducing the synthesis and release of endogenous prostaglandin, and inhibiting gastrointestinal motility. therefore, it can be extensively used in the treatment of digestive system diseases such as chronic hepatitis b, hyper-bilirubinemia, cirrhosis, peptic ulcers, chronic gastritis, etc. viral hepatitis is a complex and high incidence disease, and there are no effective drugs available for its treatment. in recent years, it has been found by pharmacological research and validated by clinical practice that danshen has the function of improving liver as well as systemic blood circulation, promoting the regeneration of liver cells, preventing and curing hepatic fibrosis, detoxication, regulating immunity, recovering liver function, etc. lu et al. [ ] reported the treatment of patients with hav igm positive and hyper-bilirubinemia. after one course of treatment, the degrees of bilirubin reduction were compared. the results showed that danshen injection's effective rate of jaundice elimination was %, which was better than those of yinzhihuang (茵 栀黄), ( . %), aspartate potassium magnesium ( %), and potenlin ( %). zhao [ ] reported that significant therapeutic effects were obtained by the application of danshen injection to the treatment of patients with chronic hepatitis b. ml of danshen injection ( ml of injection was equivalent to g of raw danshen) was added to ml of % glucose injection in the treatment group, and the drug was administered by intravenous drip once a day. a traditional chinese drug decoction (no danshen) was used in the control group. the results showed that the total effective rates in the treatment group and control group were . and . % (p \ . ), respectively. there were cases ( . %) in the treatment group with marked effect, cases ( . %) with effect, cases ( . %) without effect, and the total effective rate was . %. danshen injection can improve blood circulation in the liver and has the function of relieving ischemia anoxia and stagnant blood in the liver and relieving toxic injury from oxygen radicals; therefore, it has significant therapeutic effects on chronic hepatitis b. sun [ ] clinically observed the protection effect of danshen on hepatocyte ischemia in patients with hepato-vascular disease and liver cancer. the porta hepatis was blocked by operation and danshen injection by preoperative and intraoperative intravenous drip was administered, and the protecting function of danshen on ischemia in hepatocytes was observed. ml of cdi was added to ml of % glucose and administered by intravenous drip to the patients within days before the operation in the treatment group, and ml of cdi was added to ml of % glucose and administered by intravenous drip before blocking the porta hepatis. during the partial hepatectomy, blood was collected from the hepatic vein before blocking the porta hepatis for min and recovering blood flow for min; at the same time, the residual hepatic tissue was observed under a light microscope and electron microscope. the results showed that the content of oxygen radicals in the hepatic tissue and hepatic vein during the ischemia and reperfusion phase in the treatment group was significantly reduced, and pathological changes were significantly relieved. zhang and sun [ ] observed the therapeutic effects of tiopronin combined with cdi on the treatment of patients with chronic hepatitis b. the patients were divided into two groups; in the treatment group were orally administered with mg of tiopronin times a day, and ml of cdi was added to ml of % glucose injection and administered by intravenous drip once a day. cases in the control group were administered orally with mg of tiopronin, times a day. patients in both groups received g of vitamin c injection and mg of vitamin k injection by intravenous drip once a day. the course of treatment was months. the results showed that in the treatment group, there were cases ( . %) with marked effect, cases ( . %) with effect, and cases ( . %) without effect; the total effective rate was . %. in the control group, there were cases with marked effect ( . %), cases with effect ( . %), and cases with no effect ( %); the total effective rate was . %. the total effective rate in the treatment group was significantly higher than that in the control group (p \ . ). it was believed that the combination of tiopronin and cdi has a synergistic effect on the treatment of chronic hepatitis b and can promote the recovery of liver function. there are some important factors acting on the formation of cirrhosis, such as disturbance of liver microcirculation, overactivation of lipid peroxidation, deposition of collagen fibers, and specific binding of plasma fibronectin (pfn) and the corresponding pfn decrease and phagocytic function weakening in the reticuloendothelial system. danshen has the function of improving liver microcirculation, enhancing pfn levels, and enhancing the phagocytic function of the reticuloendothelial system. in addition, danshen has the function of inhibiting the growth and propagation of fibroblasts, promoting reabsorption of the formed fibrous tissue of the liver, and delaying and blocking the process from chronic hepatitis to cirrhosis. danshen has the function of promoting degradation of the formed collagen fiber and enhancing reabsorption of the fibrous tissue of the liver. experimental research has shown that salvianolic acid is an important component of danshen with the function of inhibiting hepatic fibrosis, and its strength is equivalent to that of raw danshen and colchicine. li et al. [ ] reported changes in the hemodynamics of the portal vein of patients with cirrhosis - weeks after orally taking danshen decoction. the hemodynamics were monitored by doppler ultrasound, and it was revealed that both the internal diameter and blood flow of the portal vein and the internal diameter and blood flow of the splenic vein in the patients were significantly reduced, and there were improvements on acratia, anorexia, and abdominal distension, as well as on liver function. there were no side effects. the study demonstrated that danshen is a safe and effective drug for the treatment of portal hypertension. in addition, danshen has the function of preventing hepatic fibrosis, reducing blood viscosity, inhibiting txa production, etc., and can reduce resistance from the portal vein. zhou [ ] observed the therapeutic effect of danshen injection on cirrhosis in cases. cases with cirrhosis were randomly divided into two groups. . g/kg danshen injection was added to ml of % gs and administered by intravenous drip to patients in the treatment group, and common hepato-protection treatment was performed for the patients in the control group. the course of treatment was month, and the patients were treated for a total of three courses. the changes in five indices of liver function and hepatic fibrosis were observed. the results showed that the liver function of the patients in the treatment group was significantly improved at the end of treatment, five indices of hepatic fibrosis were significantly reduced, and there was a significant difference between two groups (p \ . ). it was revealed that danshen injection has the function of inhibiting liver damage and hepatic fibrosis in patients with cirrhosis. wang [ , ] combined diammonium glycyrrihizinate with danshen injection to treat hepatic fibrosis. cases of patients with chronic viral hepatitis were randomly divided into three groups: cases in the treatment group (diammonium glycyrrihizinate + danshen); cases in control group (diammonium glycyrrihizinate); cases in control group (danshen), and hepatic fibrosis indices were detected at the end of the treatment. the results showed that the symptoms and physical signs of the patients from the three groups improved to different extents after treatment, liver function improved as time elapsed, hepatic fibrosis indices were significantly reduced in the treatment group after treatment (p \ . ), and hepatic fibrosis indices in the control group were also reduced after treatment, but the extent of reduction was less than that in the treatment group. it was revealed that diammonium glycyrrihizinate combined with danshen injection can improve the symptoms and physical signs of chronic viral hepatitis, recover liver function, significantly reduce hepatic fibrosis indices, and has good anti-hepatic fibrosis function. it was demonstrated that there was an additive effect in the combination. ma et al. ( ) observed the therapeutic effect of compound danshen combined with mongolian milkvetch root (黄芪) and aspartate potassium magnesium on the treatment of old cirrhosis ascites. the patients were allowed to rest, on a low-salt diet, and treated for hepatoprotection and diuresis. however, after weeks' treatment, no effects were observed and ascites volume was not significantly changed. ml of cdi, ml of mongolian milkvetch root injection, and ml of aspartate potassium magnesium injection were added to ml of % glucose and administered by intravenous drip to the patients in the treatment group once a day. ml of cdi was added to ml of % glucose and administered by intravenous drip to the patients in the control group once a day. the ascites volume was determined by b-ultrasound each week. the liver function and magnesium and potassium ion levels were determined before and after treatment, with days as one course of treatment, and the patients were treated for two courses. there was a significant difference in liver function, magnesium ion, and potassium ion levels between the two groups, and before and after treatment (p \ . ). the total effective rates of the treatment group and control group were . and . %, respectively, and the difference was statistically significant (χ = . , p \ . ). ye [ ] observed the effect of compound danshen on the -year mortality of decompensated liver cirrhosis. based on comprehensive treatment, cases in the treatment group were treated with a high dosage of cdi (or tablets) for a long term, and the changes in -year mortality and alimentary tract hemorrhage rate were observed. the results showed that the -year mortality in the treatment group was . % ( / cases), and in control group was . % ( / cases), and there was a significant difference between the two groups (p ); the incidence of upper gastrointestinal hemorrhage within years in the treatment group was . % ( / people), and in the control group was . % ( / people), and the difference between the two groups was significant (p \ . ). it was concluded that an early and continued high dosage of compound danshen preparations benefits the stabilization of the disease condition, reduces complication, and thus enhances the long-term survival rate. it has been discovered that danshen has a strong inhibitory function against helicobacter pylori. the tanshinol in danshen can rapidly eliminate necrotic tissue in ulcer sites and has the function of activating macrophages and promoting cell regeneration, thus promoting ulcer healing. liu and yi [ ] reported the application of cdi in the treatment of patients with peptic ulcer disease, and the effects were compared with those in patients in the ranitidine treatment group. ml of cdi was added to ml of % glucose and administered by intravenous drip to the patients in the treatment group once a day; . g of ranitidine was administered orally twice to the patients in the control group. the two groups were treated for weeks, and then the therapeutic effects were recorded. the results showed that in the treatment group, there were recovery cases, effective cases, and case without effect; the recovery rate was . %. in the control group, there were recovery cases, effective cases, and case without effect; the recovery rate was . %. there was no significant difference in recovery rate between the two groups (p [ . ). peptic ulcers usually belong to the category of chronic disease, and according to tcm theory, chronic illness is usually associated with stasis, and prolonged disease and pathogens usually intrude into the collaterals. danshen has the function of activating blood circulation and dissipating blood stasis. it is believed in modern medical research that danshen has an inhibitory function against helicobacter pylori, and that tanshinol in danshen can effectively clean necrotic tissue in ulcer sites, activate macrophage function, and promote cell regeneration, thus promoting healing. there was no significant difference in the therapeutic effects of compound danshen and ranitidine for the treatment of peptic ulcers. however, compound danshen had scanty side effects and was welcomed by the patients. liu et al. [ ] observed the treatment of peptic ulcers with danshen and ranitidine; ① the treatment group: danshen and ranitidine were administered at the same time. g of raw danshen each day was soaked in ml of water for min, then ml of water was added and decocted by slow fire for three times. the physic liquor was concentrated to ml and taken orally in two times. mg of ranitidine was administered in two times a day. ② the control group: mg of ranitidine was administered in two times in a day. the course of treatment for the two groups was weeks. the therapeutic effects were evaluated by endoscopy. the results showed that after weeks of treatment, the peptic ulcer recovery rates of the control group and treatment group were and . %, respectively, and there was a significant difference (p \ . ). the lpo and et plasma contents in the control group were . ± . µg/ml and . ± . pg/ml, respectively, which were lower than . ± . µg/ml and . ± . pg/ml before treatment (p \ . ). in the treatment group, the numbers were . ± . µg/ml and . ± . pg/ml, respectively, which were significantly lower than . ± . µg/ml, . ± . pg/ml before treatment (p \ . ). the results demonstrated that danshen's mechanism of action in the treatment of peptic ulcers might include ① cleaning oxygen radicals and inhibiting lipid peroxidation, which could protect the mucous membrane of the stomach and duodenum from injury, thus promoting ulcer healing. ② reducing blood plasma et levels, improving microcirculation, and increasing blood flow in the mucous membranes of the stomach and duodenum. it has been demonstrated in recent years that et can be produced by the intestinal mucosa epithelial cells of the stomach, and the mechanism through which et causes ulcers is related to its ability to cause vasoconstriction in the stomach and duodenum, which leads to mucous membrane ischemia, anoxia and acidosis. on the other hand, ischemia, anoxia and endothelium cell damage can stimulate the release of et, creating a vicious cycle. danshen can be used as an et antagonist, and it has the function of reducing et content in the blood plasma and improving the blood supply of the gastroduodenal hemorragemucous membrane, thus preventing ulcer formation. in tcm, chronic gastritis belongs to the category of blood stasis. research has shown that there is a close relationship between blood stasis and microcirculatory disturbance. danshen is one of the traditional drugs with the function of activating blood circulation and dissipating blood stasis; it can improve microcirculation, eliminate metabolism disturbances of the stomach mucous membrane, and antagonize inflammation, thus promoting the regeneration of tissue, softening the proliferative pathological changes, and enhancing absorption function. li [ ] reported the application of modified danshen beverage in the treatment of patients with chronic gastritis. the patients in the treatment group were treated with modified danshen beverages according to their symptoms. the basic prescription contains g of danshen, g of sandalwood (檀香), and g of villous amomum fruit (砂仁). the patients in the control group were orally administered mg of omeprazole twice a day, . g of amoxicillin three times a day, and . g of metronidazole three times a day. the above three drugs were administered together for weeks, and then omeprazole was administered for another weeks. during the treatment period, the patients should correct their poor eating habits, have a regular diet, avoid eating various stimulatory foods or drugs, and avoid smoking and drinking alcohol or strong tea. there was a significant difference (p \ . ) between the two groups in therapeutic effects; the effective rate of the treatment group was %, which was significantly higher than the % of the control group. the research in recent years has shown that hemorheology abnormality is one of the important etiological factors of severe pancreatitis. it is the main cause of blood circulation disturbance in the pancreas. compound danshen has the function of inhibiting platelet adhesion, aggregation and release, and it can significantly reduce erythrocyte aggregation, improve the blood rheology, regulate blood viscosity, improve microcirculation, enhance the tolerance of pancreatic tissue to anoxia, reduce the production of oxygen radicals, and relieve pathological changes in pancreatic tissue. in addition, tanshinol in danshen has the function of rapidly cleaning necrotic tissue in the pancreas, promoting the regeneration of pancreatic cells, dilating pancreatic blood vessels, and promoting recovery from pancreatitis. xie [ ] reported the treatment of severe pancreatitis cases with cdi. ml of cdi was diluted with ml of glucose solution and administered by intravenous drip once a day, for - days as one course of treatment. the patients were treated after operation, and cases in the control group were treated with normal western medicine. the results showed that the fatality rate in the treatment group was only . %, while the fatality rate in the control group was higher ( . %), and the difference was significant (p \ . ). the hematocrit levels in the treatment group were reduced from ± . % before operation to . % ± . % after operation, and the difference was significant (p \ . ). it was concluded that hematocrit can be reduced to the normal lower limit by cdi after severe pancreatitis surgery, reducing blood viscosity, improving circulatory disorders of the body organs, promoting pancreatic tissue recovery, and contributing to the correction of serious complications such as adult respiratory distress syndrome (ards), so that mortality in the treatment group was significantly lower than in the control group. zhang and liu [ ] reported the treatment of ulcerative colitis cases. cases in the treatment group were treated with the general treatment plus danshen injection. ml of danshen injection was added into glucose solution and administered by intravenous drip for weeks, once a day. the results showed that no significant differences were found in the levels of platelet α granule membrane protein (gmp- ), thromboxane (txb ), -ketone-prostaglandin f α ( -keto-pgf α ) and von wilebrand factor related antigen (vwf:ag) before and after the general treatment. in the danshen treatment group, however, the levels of gmp- , txb , and vwf:ag were significantly reduced compared with those before the treatment (p \ . ), and there was no significant changes in -ke-to-pgf α. it was believed that the combined treatment of active phase patients with danshen injection and conventional methods could correct hypercoagulability, relieve inflammation responses, and improve disease conditions. blood stagnation is one of the most common types of syndromes in tcm. it exists in many systemic diseases, including diseases of the digestive system. based on clinical practice and observation, different degrees of stagnation could be induced by the prolonged pathogenesis of both lung and stomach intestinal diseases. therefore, the application of danshen and its preparations in the treatment of chronic diseases of the digestive system has its theoretical and practical foundations. urinary system diseases wang and wen [ ] observed the effect of - and cdi by intravenous drip on the treatment of patients with acute nephritis. the patients in the treatment group were treated with conventional therapy (mainly benzylpenicillin, low salt diet, symptom relief, etc.), and at the same time, mg of - and - ml of cdi were, respectively, added into ml of % glucose and administered by intravenous drip, once a day, for - days as one course of treatment. if necessary, the drugs were discontinued for days, then the second course of treatment was performed, and the treatment could be stopped if no effect was obtained. urine-routine was measured before and after treatment. the patients in the control group were administered with the traditional treatment. the results showed that in the treatment group cases were cured, and among them cases had their symptoms of nephritis all disappear after one course of treatment (spirit and appetite were recovered, edema was dissipated, and urine protein turned negative) and cases had their urine protein turn negative after courses of treatment. five cases showed improvement, and two cases showed no effect. the average time for edema to subside was . ± . days, the average time for blood pressure to return to normal was . ± . days, the average time for urine protein to turn negative was . ± . days, and the average time of hospitalization was . days. in the control group, cases were cured, cases improved, and cases showed no effect. the average time for edema to subside was . ± . days, the average time for blood pressure to return to normal was . ± . days, the average time for urine protein to turn negative was . ± . days, and the average time of hospitalization was . days. cdi has the function of reducing platelet aggregation and adhesion, inhibiting platelet generation, inhibiting blood coagulation, promoting fibrinolysis, improving hemorheology, and so on. the combination of - with danshen has the function of dilating the renal arteries, reducing blood viscosity, increasing renal blood flow, improving kidney microcirculation, increasing the flow rate of urine in renal tubules, and preventing and relieving the occlusion of cast and cast-off cells on the distal convoluted tubules, thus realizing the effects of diuresis, subsiding edema, and eliminating proteinuria in a short time. months of follow-up was performed, with affirmative therapeutic effects. patients with chronic glomerulonephritis (cgn) usually suffer from a disequilibrium of thromboxane-prostacyclin (txa-pgi), which can result in kidney vessel and mesangial constriction, reducing the filtration area of the renal glomerulus, promoting the adhesion and aggregation of platelets and leucocytes, and participating in thrombopoiesis, inflammation response, and nephridial tissue and cell damage; thus, it is one of the causes of the sustained development of chronic glomerular lesions and renal dysfunction. experiments have demonstrated that danshen has the function of improving microcirculation, increasing the content of cyclic adenosine monophosphate in blood capillaries, and increasing pgi synthetase. it also has the function of inhibiting txa synthetase, which can improve the balance of txa-pgi. with the improvement of txa-pgi balance, renal blood flow and glomerular filtration rate increased and urine protein was reduced. in addition, danshen can enhance fibrinolysis activity, thus promoting fibrinolysis, relieving fibrin deposition in the renal glomerulus, and relieving renal glomerulus damage. shen [ ] reported the treatment of cgn with danshen. ml of cdi was added to ml of % glucose injection and administered by intravenous drip to patients with cgn, once a day, for days as one course of treatment. the results showed that there were cases of complete remission ( . %), cases of general remission ( . %), cases of partial remission ( . %), and cases of no effect. the total effective rate was %. patients with chronic renal failure (crf) usually suffer from reduced plasma-albumin and increased fibrin. fibrin is related to the increase in cholesterol. high levels of fibrinogen will increase blood viscosity, thus leading to blood hypercoagulability and fibrinolysis disturbance in patients with crf. danshen is a traditional drug with the function of activating blood circulation and removing blood stasis. it has functions of anticoagulation, thrombolysis, reducing blood lipids, etc., and improving crf-induced disorders in renin and blood plasma volume and the chain reactions induced by the increase of renin, such as increased renal tubule resistance, deposition of erythrocytes, blood vessel occlusion, reduced renal blood flow, local disturbance of circulation, reduced oxygen supply and renin release, etc. jiang [ ] reported the use of cdi for the intervention of peritoneal dialysis; cases with acute or crf were treated, and the drug was added together with anisodamine ( - ) into peritoneal dialysis solution for cases in the control group. the results showed that the serum creatinine (scr) of cases in the treatment group was reduced by more than %, cases by more than %, and cases by more than %; cases in control group reduced by more than %, cases by more than %, and cases by more than %. the blood urea nitrogen (bun) of cases in the treatment group was reduced by more than %, cases by more than %, and cases by more than %; cases in control group reduced by more than %, cases by more than %, and cases by more than %. the total effective rate in the treatment group was . %, and in the control group was . %; the total effective rate in the treatment group was significantly better than that in the control group. zhang [ ] reported the treatment of crf with cdi combined with energy mixture. patients with crf were randomly divided into groups; cases in the treatment group were treated according to their symptoms and administered with cdi and energy mixture by intravenous drip. cases in the control group were treated according to their symptoms and administered with glucose and insulin by intravenous drip. the therapeutic effects in the two groups were observed after one course of treatment. the results showed that the total effective rate in the treatment group was . %, while the total effective rate in the control group was . %, and the treatment group was significantly better than the control group (p \ . ). bun and scr were reduced after cdi treatment, and there was a significant difference before and after the treatment (p \ . ). there was no significant difference in bun and scr in the control group before and after the treatment (p [ . ). it showed that cdi combined with energy mixture can protect residual renal function, delay the development of crf, and there was a promising perspective. acute renal failure (arf) belongs to the category of "difficulty in urination-defecation" and "disuria and urine retention" in traditional chinese medicine. its pathological feature is that the root is deficient and the branches are excessive, namely, the cause is kidney deficiency and blood stasis is the symptom, which may also include water-dampness and heat bind. danshen has the function of activating blood circulation and removing blood stasis, cooling the blood and clearing heat. rosewood heart wood (绛香) has the function of activating blood circulation and relieving pain. the combination of the two drugs has the function of breaking the constraint of qi and dispersing the stasis of blood, so as to recover renal function. modern medical research has shown that tanshinone and tanshinol in danshen can dilate small blood vessels, increase microcirculatory flow rate, increase capillary networks, etc., and that rosewood heart wood has anticoagulation function. when the drugs are combined with western medicine, the functions of dilating kidney vessels, correcting hypercoagulability, improving microcirculation, increasing renal blood flow, enhancing glomerular filtration rate, and improving renal function can be obtained. in addition, microcirculation can be directly improved by intraperitoneally administered danshen, thus increasing the peritoneal dialysis rate, and it also has antibacterial and anti-inflammatory effects and prevents the occurrence of peritonitis. huang et al. ( ) reported the effect of danshen on the treatment of afr. patients with arf were treated with ml of cdi in ml of % glucose by intravenous drip, once a day, for - days as one course of treatment. the results showed that all patients were cured, and that bun was reduced by . mmol/l within days and the diuresis stage began within - days (average of days) of treatment. jiang [ ] used cdi in peritoneal dialysis solutions to obtain a concentration of ml. cases were treated with a total effective rate of . %, and the total effective rate in the - injection control group (concentration was mg) was . %. there was no significant difference (p [ . ) between the two groups, but the effects in the treatment group were significantly better than those in the control group, and no patient was complicated by peritonitis in the treatment group during hospitalization. patients with nephrotic syndrome (ns) usually experience hypercoagulability; the blood viscosity is increased, microcirculation is dysfunctional, and even vascular microthrombosis is complicated, which aggravates ns treatment. modern pharmacological studies have shown that danshen has the function of dilating peripheral arteries, improving local blood circulation, reducing inflammation effusion, promoting absorption, etc., thus localizing the nonspecific inflammation in nephridial tissue, which is conducive to renal tissue repair. danshen also activates blood circulation, removes blood stasis, and acts as an anticoagulant. in addition, danshen can cool the blood and eliminate carbuncles, relieve restlessness and calm the nerves. thus, it can be used to alleviate the blood-heat and stasis induced by taking hormones, and to treat hormone-induced sore swelling and sore toxin, as well as sleeplessness. huang and wu [ ] reported that good effects on the treatment of nephrotic syndrome were obtained by using cdi and hormones. ml of cdi was added to ml of % glucose and administered by intravenous drip to cases in the treatment group, once a day, and mg of prednisone was administered orally, three times a day, for days as one course of treatment. the patients in the control group were administered prednisone only. the results showed that the remission rate in the treatment group was %, and in the control group was . %, and the difference between the two groups was significant (p \ . ). when people suffer from nephrotic syndrome, their blood capillary filter membrane in the renal glomerulus experiences immunoinflammatory reactions, their glomerular basement membrane proliferates, their blood is in a state of hypercoagulability, and their kidneys have different degrees of fibrosis. compound danshen has the function of reducing cholesterol, inhibiting fibroplasia, relieving fibrin deposition, improving hypercoagulability induced by renal insufficiency, and recovering renal function, thus it can effectively treat nephrotic syndrome. liu et al. [ ] reported therapeutic effects of compound danshen and mongolian milkvetch root (huangqi, 黄芪) in the treatment of nephrotic syndrome. patients with nephrotic syndrome were randomly divided into two groups, and patients in the control group were administered orally with prednisone and dipyridamole. the patients in the treatment group were administered orally with prednisone and by intravenous drip with dipyridamole plus ml of cdi and ml of huangqi injection, once a day, for weeks as one course of treatment. before and after treatment, plasma-albumin, urine protein, cholesterol, and triglyceride levels in each group were determined. the results showed that plasma-albumin levels in the two groups increased after treatment compared to before treatment, and the levels in the treatment group were significantly higher than in the control group (p \ . ). urine protein, cholesterol, and triglycerides in the two groups were reduced after treatment, and the reductions in the treatment group were significantly larger than those in the control group (p \ . , p \ . ). it was concluded that the therapeutic effects in the treatment of nephrotic syndrome can be increased when the conventional prednisone and dipyridamole treatments are combined with compound danshen and mongolian milkvetch root. purpura nephritis, or henoch-schönlein nephritis (hsn), belongs to the category of bruising and urine hemorrhage in tcm, which is usually caused by the heat injury of blood collaterals. the main clinical manifestations include hemorrhage and stagnant blood symptoms. danshen is bitter in taste and slightly cold in nature, and has the function of activating blood circulation, cooling blood, eliminating congestion, and stopping bleeding. pharmacological studies have demonstrated that compound danshen has the function of promoting microcirculation, regulating the metabolism and immunologic function, and increasing renal blood flow and filterability, thus increasing urinary production, eliminating edema, reducing blood pressure, eliminating haematuria and proteinuria, and promoting hsn recovery. meng et al. ( ) reported that cdi . - ml/(kg·d) was added to % glucose injection and administered by intravenous drip to patients with hsn. the results showed that cases were cured, cases improved, case showed no effect, and the total effective rate was . %. zhang et al. ( ) reported that a high dosage of cdi, - ml, was added to ml of % glucose solution and administered by intravenous drip to patients with hsn, once a day. the results showed that cases were cured, cases improved, cases showed no effect, and the total effective rate was %. research has shown that diabetic nephropathy (dn) is related to factors such as microangiopathy of the renal glomerulus, increased plasma viscosity, abnormal platelet function, abnormal coagulation and anticoagulant mechanisms, etc. in addition, patients with dn also suffer from sod activity reduction, glomerular basement membrane thickening, and glomerulosclerosis, which are typical pathological changes of dn. danshen has the function of activating blood circulation, removing blood stasis, improving microcirculation, inhibiting platelet aggregation, and reducing blood lipids and blood viscosity, etc. it can also increase sod activity, eliminate oxygen radicals, relieve small vasospasms, and improve renal anoxia conditions, thus it could eventually reverse the pathological changes of the glomerular basement membrane, so as to cure dn and delay the process of renal dysfunction. yang [ ] mixed ml of cdi in ml of physiological saline and administered by intravenous drip to patients with dn, once a day, for week as one course of treatment. patients in the control group were administered with western medicine only. the results showed that the total effective rate in the treatment group was . %, while in control group was %, and the difference was significant (p \ . ). li et al. [ ] divided patients with dn randomly into a treatment group ( cases) and control group ( cases). the patients in the treatment group were treated with normal therapy plus ml of danshen injection, administered for weeks by intravenous drip, once a day. the results showed that blood plasma endothelin (et- ), type iv collagen (civ), and -h urinary protein excretion rates in the treatment group were significantly reduced (p \ . ). the results demonstrated that danshen has some preventative and treatment effects on dn at the early stage, and the mechanism the drug's inhibition of the production of et- and synthesis of civ. zhang [ ] showed that danshen had inhibitory effects on renal desmocytes and inducing cell apoptosis by promoting the high level expression of c-myc protein. taking high dosages of danshen for a long period of time could have some therapeutic effects on interstitial fibrosis, thus preventing or reducing the production of lesions and delaying the occurrence of uremia, demonstrating that danshen could promote the absorption of excessive connective tissue. huang and wu [ ] reported the effect of danshen on the treatment of chronic allograft nephropathy. besides the routine anti-rejection therapy, ml of danshen was added to physiological saline and administered by intravenous drip to patients with chronic allograft nephropathy for weeks. the results showed that the improvement in renal function indexes in patients in the treatment group was better than that in the control group (p. ), and danshen has the function of reducing urine nagase activity (p \ . ). it was concluded that danshen has protective effects against acute or chronic renal damage, and the mechanism is danshen's inhibition of the overproduction of nitric oxide and peroxide. danshen has the function of preventing chronic rejection and thrombopoiesis induced by the ciclosporin damage to the renal tubule, thus improving transplanted kidney function. zhang et al. [ ] reported the treatment of hypertension accompanied by renal injury with cdi combined with benazepril hydrochloride in cases, and the changes in urinary albumin were observed. blood pressure was measured twice each day for all patients with hypertension over the days before treatment, and the average of the six blood pressure values was used as the baseline blood pressure before treatment. urinary albumin was measured within h before drug administration. the patients in the control group were administered with mg of benazepril once a day, and the patients in the treatment group were administered orally with mg of benazepril once a day, and ml of cdi in ml of % glucose injection was administered by intravenous drip once a day. blood pressure was measured once each day for the patients in the two groups. two weeks after treatment, if the blood pressure was not reduced to / mmhg or lower, benazepril would be increased to mg, once a day, treated for weeks. the average blood pressure over days at the end of treatment was used as the blood pressure after treatment, and urinary albumin was measured within h after treatment. urinary albumin was examined by radiation immunity. the results showed that there was no statistical difference in blood pressure reduction between the two groups after treatment (p[ . ). there was, however, a statistical difference in the reduction of urine protein between the two groups after treatment (p \ . ). the results demonstrated that the effect of danshen and benazepril treatment on urinary albumin was significantly better than that of benazepril alone, and significant therapeutic effects could be obtained by the combination of the two drugs. the method is convenient and the side effects are few, making it an effective method for the treatment of hypertensive renal injury. he et al. [ ] reported the use of cdi in the treatment of patients with benign prostatic hyperplasia by local injection to the perineal prostate capsule, ml each time, once every days, for injections as one course of treatment. the results showed that the international prostate symptom score (ipss) was reduced compared to the conditions of patients before treatment (p \ . ), the maximal urinary flow rate increased (p \ . ), and the residual urine volume was significantly reduced (p \ . ). danshen activates blood circulation and dissipates blood stasis, promotes blood circulation and nourishes blood, promotes the excretion of prostatic fluid, shrinks the gland, and improves urination function. huang ( ) reported the administration of danshen and metronidazole mixture by prostate injection. one course of treatment later, symptom disappearance occurred in cases, improvement in cases, and the total effective rate was . %. reexamination showed that in cases, the swollen gland was significantly shrunken and tubercles were softened. tian [ ] reported the use of cdi to treat impotency. cdi was administered by injection to acupoint qugu (rn ) in patients with impotency; the patients were - years old, the average age was . , and the course of disease was - years. before treatment, the patients were asked to empty their bladder, then normal skin disinfection was performed. . - ml of cdi was injected at qugu, once every days, times as one course of treatment, and sexual intercourse was prohibited during the treatment period. the results showed that cases were cured, cases showed effect, cases showed marked effect, cases showed no effect, and the total effective rate was . %. although the application of danshen in the urinary system is not as popular as in the cardiocerebrovascular and digestive systems, what is affirmed is that danshen and its components have relatively good therapeutic effects on acute or chronic nephrosis due to the retention of stagnant blood, interior harmful retention of toxin and heat, such as acute nephritis, acute and crf, nephrotic syndrome, dn, chronic prostatic hyperplasia, and so on. jiang [ ] reported the treatment of cases of type diabetes mellitus (the majority were complicated with angioneuropathy) with cdi. the patients were randomly divided into the treatment group and control group, cases each. the patients in both groups had reasonable dietary control, and one or more hypoglycemic agents were used for blood sugar control according to their conditions. some patients were treated with vitamin b , b and other treatments according to their symptoms. - ml of cdi in - ml of physiological saline was administered by intravenous drip to the patients in the treatment group, once a day for - weeks. the results showed that in the treatment group there were cases showing marked effect, cases showing improvement, cases showing no effect, and the total effective rate was %. in the control group, cases showed marked effect, cases showed improvement, cases showed no effect, and the total effective rate was %. the therapeutic effects in the treatment group were significantly higher than those in the control group (p \ . ). the mechanism of the effects might be that the activity of sod, which has the function of cleaning oxygen radicals, was reduced in patients with type diabetes mellitus, and there was lipid peroxidation damage. cdi has the function of enhancing the tolerance of pancreatic tissue to anoxia, reducing the production of oxygen radicals, increasing sod activity, and effectively relieving lipid peroxidation damage. danshen also reduces blood sugar and protects pancreatic islet β cells in experimental diabetes. therefore, cdi will have important clinical significance in the prevention and treatment of diabetic complications. lü [ ] observed the therapeutic effects of huangqi injection combined with danshen powder injection on the treatment of type dn at the early stage. cases in the control group received conventional hypoglycemic antihypertensive therapy. the patients in the treatment group received conventional therapy plus ml of huangqi injection and . g of danshen powder injection in ml of physiological saline, administered by intravenous drip, once a day, for month as one course of treatment. the changes in urinary albumin excretion (uae) within h were observed. the results showed that there was no significant change in uae in the control group before and after the treatment (p [ . ), but in the treatment group, the uae was significantly reduced after treatment compared to before (p \ . ). it was concluded that huangqi injection combined with danshen powder injection has therapeutic effects on dn at the early stage. chen [ ] observed the therapeutic effect of cdi combined with domperidone on diabetic gastropathy. inpatients and outpatients suffered from type diabetes mellitus, male, female; cases were complicated with coronary heart disease; fasting plasma glucose was . - . mmol/l; average fasting plasma glucose was . ± . mmol/l. all patients received the conventional diabetes treatment, and those who had complications of peptic ulcers, stomach and duodenum operation, and ketosis acidosis were excluded. cases in the control group had no dyspepsia symptoms or peptic ulcer history, and liver and kidney functions were normal. cases with dg were divided into groups based on gastric emptying function and medication condition. cases in the domperidone group were administered orally with mg of domperidone, three times a day; cases in the danshen group were administered by intravenous injection with ml of cdi, once a day; cases in the domperidone + danshen group were administered with domperidone and danshen, and the dosage and administration were the same as the above therapies. the course of treatment was weeks, and fasting plasma glucose, liver and kidney functions, and gastric emptying function were reviewed within days after treatment. there were no significant differences in gender, age, or disease condition and fasting plasma glucose among the groups. the results showed that the gastric emptying half-times in the diabetes group and control group were . ± . min and . ± . min, respectively, and the difference between the two groups was significant (p \ . ). the gastric emptying function of patients with diabetic gastropathy was significantly improved, and that of the drug combination group was the most significant. there were different extents of improvement in the pathological changes of the peripheral nerves and cardiovascular system after treatment with danshen, but there was no significant difference in fasting plasma glucose before and after treatment. li et al. [ ] observed the treatment of diabetic peripheral neuropathy (dpn) with danshen combined with mecobalamin (methycobal). cases of dpn were randomly divided into two groups. cases in the treatment group received ml of danshen injection in ml of physiological saline, administered by intravenous drip each day, and μg of methycobal, administered by intramuscular injection, once a day for weeks. cases in the control group received the conventional diabetes treatment. the results showed that the marked effect rate and the total effective rate in the treatment group were . and %, respectively, which were significantly higher than those in the control group, . % (p \ . ) and . % (p \ . ), respectively. therefore, it was concluded that better therapeutic effects were obtained by danshen combined with methycobal in the treatment of dpn. gong [ ] observed the therapeutic effect of yinxing (ginkgo) damo injection combined with danshen injection on the treatment of dpn. patients with type diabetes mellitus complicated with dpn were randomly divided into three groups according to the chronological order of hospitalization. there were patients in group administered with yinxing damo injection combined with danshen injection, patients in group administered with yinxing damo injection, and patients in group administered with danshen injection. the treatment period in the above three groups lasted for weeks. all three treatments showed some degree of therapeutic effects on dpn; they could improve symptoms such as numbness, pain, chill, fever and others, and neural conduction function was significantly enhanced. the clinical therapeutic effects in group were better than those in treatment group (p \ . ), but those in group were better than in group and group (p \ . ). there were significant therapeutic effects of yinxing damo injection combined with danshen injection in dpn treatment. diabetes is a common clinical disease and is one of the three diseases which threaten human health. the patients' quality of life is usually directly reduced due to related complications which appear during the later stages of the disease. from the related documents we have found, danshen and its preparations are mainly used in the treatment of dn, stomach diseases, and peripheral nerve pathological changes etc., and satisfactory therapeutic effects have been obtained, so it is worthy of consideration. lin [ ] reported the application of danshen injection in the treatment of cases of high blood viscosity syndrome, and observed the effect of danshen on the hemorheology hemorheology. ml of danshen injection in or % glucose was administered by intravenous drip, one time a day, times as one course of treatment. after - courses of treatment, the rate of total plasma viscosity reduction was . %; among them, improvement in - indexes was . %, and in - indexes or more was . %. it was revealed that the drug can effectively improve hematocrit, erythrocyte electrophoretic time, fibrinogen and blood plasma viscosity, and thus can be used as one of the adjuvant therapies for polycythemia, pulmonary heart disease, heart failure, burn, frostbite, ischemic stroke induced by fibrinogen and blood plasma viscosity increase, myocardial infarction, diabetes, hyperlipidemia, globulin increase, and other diseases. yan et al. [ ] investigated the effect of salvianolate on platelet function and its clinical therapeutic effect on stable angina pectoris. patients with stable angina pectoris were randomly divided into the salvianolate low dosage group (group a), high dosage group (group b) and danshen injection control group (group c). the patients were treated for days, observing symptom remission, treadmill tests, platelet aggregation rate, and changes in p-selectin level. platelet aggregation reduction rate and p-selectin in group a and group b were better than in group c, but symptom remission and treadmill tests were similar to those in group c. salvianolate significantly inhibits platelet aggregation and activation, and improves angina pectoris and st-t changes in electrocardiograms. secondary increases in erythrocytes and blood viscosity can be induced by anoxia during an attack of pulmonary heart disease. qian [ ] reported the application of normal therapy combined with cdi in the treatment of pulmonary heart disease in cases. the results showed that there were significant changes in whole blood viscosity in hemorheology, viscosity, and plasma viscosity in the treatment group before and after treatment (p \ . ). the treatment period for primary nephrotic syndrome is lengthy and the recurrence rate is high. blood hypercoagulability plays an important role in the occurrence, development and turnover of the disease. to search for a safe anticoagulation drug, cases with primary nephrotic syndrome were treated with compound danshen by li et al. ( ) . the patients were treated with prednisone and compound danshen tablet (danshen, sanchi, synthetic borneol), one tablet a day, two times a day for patients younger than years old and three times a day for patients older than years old, for month as one course of treatment, - courses of treatment were observed. indexes (platelets, blood clotting time, plasma viscosity, packed red cell volume, blood sedimentation) were observed. the results showed that there was a significant difference between the observation group and control group before and after treatment (p \ . ). hui [ ] observed platelet recovery in cases with epidemic hemorrhagic fever treated with danshen injection. the patients in the treatment group were treated with conventional therapy plus danshen injection, ml each time, times a day. administration was discontinued until platelet levels were × /l or more, which was used as the standard for marked effect. the results showed that there were cases ( . %) with marked effect and cases ( . %) without effect. the effective rate in the control group, who were treated with conventional therapy only, was . %, the ineffective rate was . %, and there was a significant difference between the two groups. it was revealed that danshen can directly or indirectly reduce damage to platelets and promote platelet production, so the platelet number was rapidly recovered. in theories of traditional chinese medicine and western medicine, there are common and different aspects of stagnant blood in tcm and hyperviscosity in western medicine. however, danshen's functions in activating blood circulation and dissipating blood stasis are confirmed by both tcm theory and modern pharmacological experiments. from this point of view, the effect of danshen and its preparations on hemorheology is self-evident, and the data presented above are corroborative evidence. china's naturopathy integr tradit chine west med pract crit care med mod recovery key: cord- - hoksa authors: waito, marianne; walsh, scott r.; rasiuk, alexandra; bridle, byram w.; willms, allan r. title: a mathematical model of cytokine dynamics during a cytokine storm date: - - journal: mathematical and computational approaches in advancing modern science and engineering doi: . / - - - - _ sha: doc_id: cord_uid: hoksa cytokine storms are a potentially fatal exaggerated immune response consisting of an uncontrolled positive feedback loop between immune cells and cytokines. the dynamics of cytokines are highly complex and little is known about specific interactions. researchers at the ontario veterinary college have encountered cytokine storms during virotherapy. multiple mouse trials were conducted where a virus was injected into mice whose leukocytes lacked expression of the type i interferon receptor. in each case a rapid, fatal cytokine storm occurred. a nonlinear differential equation model of the recorded cytokine amounts was produced to obtain some information on their mutual interactions. results provide insight into the complex mechanism that drives the storm and possible ways to prevent such immune responses. overly robust cytokine responses are responsible for a broad array of very challenging and often fatal clinical conditions. these include infectious diseases such as influenza [ ] , severe acute respiratory syndrome (sars) [ ] , bacteria-induced toxic shock syndrome [ ] and sepsis [ ] , as well as multiple sclerosis [ ] , graftversus-host disease [ ] and sometime adverse effects of therapies [ ] . cytokines are released by cells to coordinate an immune response to help protect against foreign and/or dangerous matter. they are produced in response to infection and inflammation [ ] . there are five major classifications of cytokines; interferons (ifn), interleukins (il), chemokines, colony-stimulating factors (csf), and tumour necrosis factors (tnf) [ ] . together they function in order to stimulate a response that will control cellular stress as well as minimize the amount of damage to a particular cell or group of cells [ ] . although the goal of each cytokine is to ultimately protect the host against dangerous insults, it is not uncommon for this process to become unbalanced. for reasons unknown, positive feedback loops can become up-regulated during an immune response involving complex interaction between cytokines and immune cells. the fine balance that is typical of healthy individuals is lost and gives rise to a cascade which is termed a cytokine storm. the dynamics of cytokines during normal immune responses and even more so during storms are highly complex and little is known about specific interactions [ , ] . cytokine storms not only have very negative effects on the immune response, they often have life threatening effects including a decrease in blood pressure, increase in heart rate and can often lead to death of the host [ ] . as more biological data is collected, the immense complexities of the immune system is becoming increasingly apparent [ ] . it is clear that mathematical modelling has become an essential tool to complement experimental techniques both in vitro and in vivo. combining these approaches can result in major advancements in both the understanding of cancer and immune system dynamics including cytokine interactions, with the potential to identify strategies to control toxic cytokine storms [ ] . previous mathematical models include at most two cytokines and do not focus the research on the interactions and function of the cytokines. typical cytokines included in models are il- , il- , il- and tnf. unfortunately, even the models that contain cytokines do not investigate the specific interactions that we are interested in. these models exclude many of the cytokines that are of greatest interest to us [ , , , ] . since our focus is to model only the dynamics of cytokines, we turn to ordinary differential equation (ode) models to provide a good framework for exploring interactions between different cytokine populations. to keep the model relatively simple, we ignore the effects of effector cells (activated immune cells) due to the complexities it brings to the model. to date, the only model that is of a similar nature is produced by [ ] called dynamics of a cytokine storm. in this paper, the interactions of nine cytokines were modelled using data from a human clinical trial where six volunteers took part in a study that accidentally led them to undergo the effects of a cytokine storm [ ] . this model was primarily constructed to look at the effects of the antibody responsible for the cytokine storm using a linear ode model where parameter estimation determined coupling parameters between cytokines. the coupling parameters identified which cytokine was responsible for enhancing or inhibiting each other cytokine as well as self-regulation [ ] . in this paper, we determine how cytokines interact with one another based on a set of time series data provided by dr. byram bridle and his lab members dr. scott walsh and alexandra rasiuk at the ontario veterinary college (ovc). following administration of a highly attenuated virus to mice with leukocytes lacking the type i ifn receptor, a deadly cytokine storm developed leading to death in only h. down-regulation of anti-viral ifn signaling is a common mechanism used by viruses during infection, including those associated with cytokine storms (e.g. influenza virus [ ] , sars-coronavirus [ ] and ebola virus [ ] ). thus, a natural question arises: what are the specific dynamics of cytokines with respect to both initiating and exacerbating a cytokine storm when type i interferon signalling is impaired? most biological systems are innately non-linear and thus a non-linear ode model is essential to obtain the proper dynamics [ ] . the model we use is given by: for i; j d ; ; : : : ; : the first and most common assumption throughout the literature is that the concentration of a particular cytokine, x i , continues to decrease linearly when there is no outside stimulus [ , ] . since cytokines are secreted by other cells it makes sense that in the absence of these producers, the number of cytokines will rapidly decline at a rate i (> ) [ , , ] . the second assumption is that the rate of production of cytokines is dependent on interactions with other cytokines and is sigmoidal in shape of the form where m i (> ) is the maximum production rate. the interaction with other cytokines, y i , determines the slope of the function, and thus how much of a cytokine is produced, potentially offsetting some or all of the decay [ , , ] . the interaction factor y i is given by meaning that y i is composed of effects from the presence of other cytokines,˛i ;j ; effects from components for which there is no data,˛ ;i ; and the stimulus, s i , by the virus. the stimulus is of the form where there is an initial dose of the drug, b, which decays exponentially with characteristic time . data was collected and provided by dr. byram bridle, dr. scott walsh and alexandra rasiuk who study the role of type i ifn signalling in the regulation of cytokine responses at the ovc. chimeric mice were made by lethal irradiation of the bone marrow of c bl/ mice (charles river laboratories) followed by reconstitution with bone marrow from either wild-type or type i ifn receptor (ifnar)-knockout donors (the latter provided by laurel lenz, university of colorado school of medicine). these mouse-based experiments were approved by the institutional animal care committee and complied with the standard of the canadian council of animal care. these mice were infected intravenously with recombinant vesicular stomatitis virus with a deletion of methionine at position of the matrix protein (vsv m ) [ ] . the matrix protein of vsv suppresses antiviral type i ifn responses. therefore, this mutant virus renders the already attenuated laboratory strain of vsv even safer and it is being developed as an oncolytic virus for the treatment of cancers via intravenous infusion [ ] . surprisingly, mice lacking the ifnar on their leukocytes experienced a profound cytokine storm, ultimately leading to death in only h. the resulting time series data provided concentrations of different cytokines in plasma, measured using a multiplex array (biorad). concentrations of cytokines were recorded at times , . , , and h for both the wild-type mice and mice lacking the ifnar on % of their leukocytes. raw data was then normalized to account for the vast variability in the concentrations. this was done by dividing the concentration at each time point by the sum of the concentrations across all time points for a particular cytokine. in order to produce an accurate fit to the model it was essential to group cytokines to reduce the number of parameters. grouping was based on the inflammatory classification of each cytokine as well as similarity of cytokine profile. the time at which the peak concentration occurred was recorded along with either the pro-or anti-inflammatory classification. groupings can be seen in table . parameter estimation techniques, specifically fmincon in matlab, were used to fit the model to the data. the cost function is the typical least squares function with a normalization matrix to offset discrepancies between groups. mathematical analysis is an important tool for biological predictions and for producing more questions and further areas of research both in biology and mathematics [ ] . model results from parameter optimization of ifnar-knockout mice data are shown in fig. . the model provides an accurate fit to the cytokine time series data for both ifnar-knockout and wild-type mice (not shown). the model parameters that provide the most interesting information are the˛i ;j values, as they relate how each cytokine group interacts with each of the other groups. the sign and magnitude of these values indicate the type of effect a particular cytokine has; a negative parameter value indicates an inhibitory effect, a positive value an enhancing effect and the largest magnitude produces the most significant coupling. the three largest˛i ;j values for each group of the ifnar-knockout mice are displayed in fig. where the lines indicate either enhancing (solid line with an arrowhead) or inhibiting (dotted line with a 't') and the line thickness displays the magnitude (the thicker the line, the greater the magnitude). preliminary results from fig. show that groups , , and are the most significant. each of them have a large number of interactions, multiple two-way paths, exhibit definite enhancement or inhibition, and fit well with what is known biologically. the most significant group, group , consists of three pro-inflammatory cytokines: mip- ˇ, tnf-˛and il- . of the three, tnf-˛is assumed to be the dominating cytokine. tnf has been thoroughly studied and is one of the most well known cytokines as it plays an important role in the outcome of immune function [ , ] . model results for group show that it is an integral part of six significant interactions and has multiple two-way paths, one with group and another with group . all three interactions that affect group are enhancing, indicating that as the storm progresses, the amount of cytokine will continue to rise. tnf-˛, along with il- ˇ(found in group ), are considered early-response cytokines, occurring soon after an immune response is triggered. it is known biologically that tnf-p romotes the generation of il- ˇ [ ] . although the results are not shown for the wild-type case, the model results indicate that in fact group does enhance group . in the case of ifnar-knockout mice however, group inhibits group (the relatively small interaction is not shown in fig. ). this difference begins to shed light on why a storm occurred in mice lacking ifnar on leukocytes. another central group is group which is made up of two anti-inflammatory cytokines, il- and il- , with the latter being a very prominent inhibitor. il- is often produced once a cytokine storm has begun in an attempt to return the balance that has been lost, termed immunoparalysis. although overproduction can often allow the host to survive the cytokine storm longer, it is not likely it will survive long term [ , , ] . model results for group show that there are six interactions that are significant as well as two primarily enhancing two-way interactions with groups and . the three interactions that affect group are all enhancing, meaning that the amount of group will likely increase as the storm continues. biologically it is known that il- plays a role in the down regulation of both tnf-˛(group ) and il- ˇ(group ) [ ] . referring to fig. , the model verifies that in fact group does inhibit group , however group enhances group . this could be due to the grouping of cytokines, since group contains mip- ˇand il- as well. on the contrary, in the wild-type case, group inhibits group while it enhances group . a well-studied cytokine that is known to be a key component of a cytokine storm is il- , group , which has both pro-and anti-inflammatory properties and is a central cytokine used to assess cytokine responses in the host [ ] . figure displays the importance of this group with the eight interactions and two primarily enhancing two-way paths. it is known biologically that the production of il- is stimulated by tnf-˛and il- ˇ [ ] . results from the model using wild-type data verify that indeed both groups and enhance group , however the interaction between group and is relatively small. ifnar-knockout results shown in fig. imply that groups and inhibit group and that those interactions are significant. again, this can provide some insight into how a storm was able to occur. group , mip- ˛, is required for a typical inflammatory response to viruses [ ] . it is a pro-inflammatory chemokine that inhibits proliferation of hematopoietic stem cells in vitro and in vivo [ ] . model results for mip- ˛show that six interactions are significant as well as a two-way interaction with group . the three interactions that affect mip- ˛are both inhibiting and enhancing whereas in the wild-type case the interactions are purely enhancing, causing an increase in the amount of mip- ą s the storm continues. it has been noted that the fine balance of pro-and anti-inflammatory mechanisms is critical in maintaining stability, and if these mechanisms become unbalanced, the outcome may contribute to a cytokine storm [ ] . groups and are antiinflammatory cytokines, while the remainder act primarily as pro-inflammatory cytokines. for wild-type populations, of the three most significant groups ( , , and ), the anti-inflammatory cytokines are being inhibited, while the pro-inflammatory cytokines are being enhanced. this balance in this system becomes lost in mice lacking the ifnar on their leukocytes, as shown in fig. . instead of the antiinflammatory cytokines (group ) being inhibited, they are instead enhanced. immediately it becomes apparent that the fine balance that is typical of healthy individuals has become unstable. future work including sensitivity analysis of cytokine groupings could provide further information on the significance of the groupings and individual cytokines. in conclusion, cytokines belonging to groups , , and , particularly tnf-˛, il- , il- and mip- ˇ, have the largest effects on the dynamics of this particular cytokine storm. changes introduced into the system by knocking out ifnar cause key interactions to swap from enhancing to inhibiting and vice versa. it is possible that reducing the alterations in the effects of groups , , and could lead to the reduction in severity and possibly even the entire storm. on the foundations of cancer modelling: selected topics, speculations, and perspectives ebola zaire virus blocks type i interferon production by exploiting the host sumo modification machinery sars coronavirus papain-like protease inhibits the type i interferon signaling pathway through interaction with the sting-traf -tbk complex the role of mip- ˛in inflammation and hematopoiesis cytokines in cancer pathogenesis and cancer therapy interactions between the immune system and cancer: a brief review of non-spatial mathematical models cytokine dysregulation as a mechanism of graft versus host disease immunoparalysis and adverse outcomes from critical illness sepsis: calming the cytokine storm mathematical analysis of artificial immune system dynamics and performance the hippo signaling pathway coordinately regulates cell proliferation and apoptosis by inactivating yorkie, the drosophila homolog of yap modeling immunotherapy of the tumor-immune interaction the cytokine storm in multiple sclerosis influenza a virus: new research developments modeling the cytokine network in vitro and in vivo type i ifn triggers rig-i/tlr /nlrp -dependent inflammasome activation in influenza a virus infected cells empirical investigation of an artificial cytokine network cytokine response signatures in disease progression and development of severe clinical outcomes for leptospirosis assessment of cancer immunotherapy outcome in terms of the immune response time features staphylococcal toxic shock syndrome: mechanisms and management vsv strains with defects in their ability to shutdown innate immunity are potent systemic anti-cancer agents cytokine storm in a phase trial of the anti-cd monoclonal antibody tgn into the eye of the cytokine storm. microbiol some attenuate variants of vesicular stomatitis virus show enhanced oncolytic activity against human glioblastoma cells relative to normal brain cells analysis of a three-way race between tumor growth, a replication-competent virus and an immune response an approach to modelling in immunology dynamics of a cytokine storm acknowledgements this research was supported in part by the government of ontario and the university of guelph. key: cord- -cyhcbk j authors: nan title: ps - date: - - journal: intensive care med doi: . /s - - -y sha: doc_id: cord_uid: cyhcbk j nan in our -bed icu-cum-hdu of a -bed tertiary referral cancer centre, medical oncology admissions increased from < % of total admissions to over % in the last years. we audited outcomes in these patients to determine prognostic factors that may aid patient selection and management. methods. consecutive admissions ( males, females, age > years) from february , to february , were prospectively studied. the total sofa score on day (sofa ), the highest sofa score of the first three days (max ) and the change in sofa score between day and day (delta ) and between day and day (delta ) were calculated. predictors of outcome were identified using univariate and multivariate binary logistic regression. results. patients had solid tumours , had leukemia, lymphoma, myeloma, and had other diagnoses. mean age was . ± years and apache ii score was . ± . . icu mortality was % and hospital mortality . %. / patients ( . %) with icu stay < day died. overall length of icu stay was . ± . days. in survivors vs. nonsurvivors, sofa , delta and delta (median, interquartile range) were . ( . to . ) vs. . ( . to . ; p< . ), - . (- . to ) vs. . (- . to . ; p< . ) and (- . to . ) vs. . (- . to . ; p< . ), respectively. several factors were associated with mortality on univariate analysis (table ) . on multivariate analysis, only need for vasopressors (or . , p= . ) and max (or . , ci . - . , p= . ) were independently associated with hospital mortality, while type of cancer and leucopenia were not. for patients staying > days, no factor predicted hospital mortality, but sofa (or . , ci . - . , p= . ), delta (or . , ci . - . , p= . ) and delta (or . , ci . - . , p= . ) predicted icu mortality. usually, the cgr transfused in our icu are old (about % of rbc are stocked more than days). icu outcome is independently associated with the number of rbc transfused, but not with their age. this result in contradiction with previous report could possibly be explained by the systematic leucodepletion performed before storage in france, contrary to precedent studies where rbc were not leukodepleted. we compared them with ≥ years old and an icu stay < days patients, the differences in icu mortality, apache ii, age, gender and the necessity for renal replacement therapy (rrt) were not significant (see table) . the survivors patients (≥ years old and an icu stay ≥ days) were more older and ( ' %) were still alive one year later. when we analyzed the overall patients, according their stay < or ≥ days, did not find statistically significant differences between both groups in the mortality (p= ' conclusion. icu mortality rates in elderly patients with a stay < or ≥ days at icu were comparable. the year-survival of elderly patients with a long-term intensive care unit stay was high. results. seventy patients were admitted to our icu with the diagnosis of acute pancreatitis during study period and of them were later confirmed as having sap. the average icu length of stay in patients with sap was days compared to days in patients with mild form of the disease. pancreatic infection was present in patients. the mortality rate in the group with sap was % compared to , % in the group with mild acute pancreatitis, p< , . the most common etiology of patients with sap was biliary and this was similar both in survivors and non-survivors. the most common cause of death in the group with sap was multiple organ dysfunction/failure syndrom(mods/mof) in % followed by bleeding complications in %. twelve patients with sap ( %) underwent the surgical intervention. mortality in the group of patients who underwent a surgical intervention was % ( patients). , +/- , , +- , apache ii score( mean+/-sd) , +/- , , +- , * necrotising form (%) infected necrosis (%) ct guided fnab (%) * p > . conclusion. the patients with mild form of acute pancreatitis had low mortality rate (similar to general ward population) despite positive icu admission criteria in our case series with fifty per cent development of severe form with organ dysfunction/failure later on. apache ii score was better predictor of mortality in patients with sap than presence, extent or infection of pancreatic necrosis. patients with higher risk for development of severe form of acute pancreatitis should be admitted to multidisciplinary icu prior to definitive diagnostic evaluation of pancreas. further studies are warranted. conclusion. absi is an aprropiate score for estimating the probability of death in critical brun injury patients. preexisting cardiac and liver diseases have a little influence on mortality and its addition to the absi variables don't predict mortality more accurately. poisoned patients constituted up to , % of all icu admissions in our hospital. demographic data and specific poisons have been presented at the table. the total poisoned mortality rate was , %. methyl alcohol poisoning has a higher mortality than others poisoning. conclusion. childhood poisoning is usually accidental and is usually associated with a low morbidity and mortality. in adults, self-poisoning is usually deliberate suicide or parasuicide) and has a higher morbidity and mortality rate. ( ) the most important part of the poisoned patient's care are the general supportive management and specific antidotes therapy. it has abundantly been demonstrated that duration of mechanical ventilation can be reduced by the use of protocols for weaning and sedation [ , ] . utilization of the required sedation scales and adherence to protocols, however, is poor in daily practice, as has been shown in recent studies [ , ] . it has been proposed to use daily checklists to improve the quality of care [ ] . to improve adherence to the established guidelines for weaning and sedation in our icu, we included two questions in a checklist printed on patients' charts which had to be answered daily by the physician on duty: conclusion. the checklist as a daily reminder to observe established weaning and sedation protocols may have significantly accelerated weaning from mechanical ventilation. we carried out a prospective and descriptive study in patients admitted to our icu from to . we defined tolerance as the need to use more than mg/h, at least for four hours, or the need either to use or to change to other sedatives to obtain a to level on the ramsay scale ( ). the appearance of tolerance in the first hours was considered as tachyphylaxis or early therapeutic failure to this sedative. in our sedation protocol we use propofol preferably in patients who need frequent neurological consciousness evaluations, or in patients whose sedation is expected to have short to medium duration, and who have haemodynamic stability. also, we use propofol as a sequential strategy when early weaning from ventilation is expected. all patients received analgesic drugs. during this time, we admitted patients, of them needed mechanical ventilation and in patients we administered continuous analgesic and sedative infusions. continuous propofol infusions were administered in patients at some point of their sedative strategy, and ( % of the sedated patients) received propofol for more than hours. tolerance development was observed in patients, % of the patients sedated with propofol. in thirty-seven of them, this situation was present in the first hours (early therapeutic failure). conclusion. in our sedative protocol for propofol use, the incidence of tolerance in patients sedated with this drug was %, which is substantially less than the usual described midazolam tolerance. most of these cases ( %) happened in the first hours. diabetes mellitus (dm) with its chronic and acute complications puts patients suffering from the disease at increased risk. none of the scoring systems used for risk prediction in intensive care units accounts for diabetes as a risk factor, although, in everyday practice, patients with dm admitted to icus may be recognized as those with higher risk. not much data is available on how much risk can be attributed to diabetes. we have compared course and outcome of patients with dm with non-diabetics to try to answer this question. we have analyzed data from the "croicu.net", national pilot-project which collects data on patients from icus in croatia. data collected during the first months (nov -dec have been analyzed. adult patients from icus in university hospitals were included; three most frequent admission diagnoses were selected for comparison of diabetic and non-diabetic patients. the diagnosis of dm had to be established prior to admission according to the usual criteria. icu mortality and icu length of stay (los) were primary outcome measures. incidence of organ failure was a measure of disease course. in the analysed period there were admissions to the analysed icus, ( . %) with documented dm prior to admission. patients with md did not differ significantly from non-diabetics in age or sex distribution. overall mortality was higher for dm patients ( . % vs. . %), as was los ( . vs. . days). three most frequent diagnoses were: sepsis (n= ; . %), pulmonary oedema ( ; . %) and myocardial infarction (n= ; . %). patients with diabetes had significantly higher mortality and higher los in all three subgroups. in the sepsis subgroup, patients with diabetes had higher incidence of organ failure and higher number of failing organs. in the other two subgroups, the differences were not significant. in multivariate analyses which was performed separately for all three diagnoses and included dm, age, apache ii score and sofa score, diabetes mellitus was shown to be an independent predictor of mortality and los in all three cases. although some chronic effects of diabetes mellitus can be included in multiparameter scoring systems such as apache ii score, the disease itself is not scored. we have shown on three most common diagnoses in icus of university hospitals that diabetes mellitus is an independent predictor of mortality and los and that it has significantly higher incidence of organ failure in sepsis. patients with dm should be given appropriate attention as high risk patients in the icu. introduction. neuromuscular abnormalities are common in critically ill patients with systemic inflammation and organ failures. we assessed the incidence of a clinically diagnosed critical illness polyneuro-myopathy (cipm), and its potential impact on mortality and long-term neurological outcome. methods. consecutive critically ill patients on mechanical ventilation for hours and with the presence of or more sirs criteria were prospectively studied. based on daily clinical neurological examinations, cipm was defined as symmetric limb muscle weakness [ or more muscle groups, m or less (mrc)] without other explanation than cipm in patients with normal neurology at icu admission. a barthel index (score for activities in daily living) was performed at day and months after icu discharge. after months a neurological examination was also performed. . cipm was diagnosed in patients ( %). patients with suspected cipm had a prolonged icu stay and a high mortality. the barthel index was significantly lower in this group at day but improved over the next six months. of patient who survived could be reached months after discharge and of them were clinically examined. at this time the most compromised activity in daily living is climbing stairs. patients with a clinical diagnosis of cipm have a high mortality. if they survive, they are severely limited in simple daily activities one month after icu discharge, but improve later. host infection by pathogens triggers innate immune response leading to a systemic inflammatory response, often followed by a paradoxical compensatory antiinflammatory response. this immune dysfunction can impair the eradication of primary infections and favor the emergence of nosocomial sepsis. dendritic cells (dcs) have a central role in initiation and control of innate and adaptative immune responses to infectious challenges. dcs might contribute to sepsis-induced immunodepression. indeed, depletion of dcs has been reported in secondary lymphoid organs of patients who died from sepsis and in animal models of lethal sepsis. in order to investigate the mechanisms of sepsis-induced immunodepression, we studied quantitative and functional features of dcs in a murine model of sublethal sepsis. we developed a sublethal murine model of polymicrobial sepsis through cecal ligature and puncture followed by short course of antibiotics and volume resuscitation. we isolated splenic dcs by immunomagnetic procedure and generated bone marrow-derived dcs (bmdcs) by -day culture of medullar progenitors in the presence of gm-csf before stimulation with lps to induce maturation. we counted spleen dcs and studied the following functional features of spleen dcs and bmdcs in the early (day ) and late (day ) phases of sepsis : maturation (expression of mhcii, cd and cd through facs analysis), production of cytokines (tnf-alpha, il- , il- ) and priming of cd -positive t-cell lymphocytes ( h-thymidine proliferation assay in allogeneic mixed lymphocyte reaction). upon anesthesia induction with isoflurane sepsis was initiated by cecal ligation and double puncture in groups of c bl/ j-mice per group [ g, g, g] (clp). control mice underwent laparatomy and manipulation of the cecum only (sham). , and hrs post-surgery in and g mice and hrs post surgery in g mice single cell suspensions of thymus and spleen were analyzed by means of cell surface staining and flow cytometry. fluorescence-labeled antibodies included cd , cd , cd , b , igm, igd, cd , cd . data are presented as mean+sem. results. similar to previous results, thymi primarily demonstrated a time-dependent reduction of cd +cd + double-positive cells which was more pronounced during severe sepsis ( + g). at hrs post-clp cd + cells and cd + t-cells recovered to values of sham mice in g animals, which previously recovered fastest with highest survival rates of about %. in contrast cd + cells and cd + cells, respectively, raised to maximum levels at hrs in g animals. concerning spleocytes cd + and cd + cells were similarly reduced to about % and % after hrs and to % and % in g and g mice compared to sham mice. splenocytes of g-treated mice, which could only be investigated at hrs postclp showed no difference to sham mice. as far as b cells are concerned no significant differences between the groups or different time points could be detected. relative numbers of peripheral t cells expressing the early activation marker cd or cd were clearly more pronounced at hrs compared to hrs in and g mice. in g treated mice cd and cd positive t cells were significantly higher at hrs compared to sham mice. a mild clp model is more appropriate to study during murine sepsis. the rapid occurrence of peripheral activated t cells suggest a very early function of the adaptive immune system during sepsis. considering a milder disease course of g mice they seem to more efficiently use their t cells to fight the infection. thymocyte data suggest a block in lymphopoiesis from cd -cd -to cd +cd +. b cells are not likely to play a major role in polymicrobial murine sepsis. further studies have to be performed to elucidate the turnover and the homing of lymphocytes during sepsis. endotoxaemia is associated with intestinal perfusion deficits and gut barrier failure. regional sympathetic blockade by means of thoracic epidural anaesthesia (tea) has been shown to positively affect intestinal microcirculation during endotoxaemia. this study tests the hypothesis that the microvascular changes observed with tea go along with an increase in overall gastrointestinal blood flow. in addition we investigated whether the use of tea influences gut barrier function. after approval of the animal care committee rats were anaesthetised (urethane/ketamine), hemodynamically monitored and mechanically ventilated with room air. lidocaine % or normal saline were administered as a bolus ( µl) and subsequent continuous infusion ( µl x h − ) via an epidural catheter (tip at t / , spread t -t ). organ blood flow (n = rats) was measured by the fluorescent microspheres technique at baseline, min after epidural infusion, and min and min after the infusion of endotoxin (e. coli lipopolysaccharide, . mg x kg- x h − ) or normal saline. for assessment of gut barrier failure rats (n = ) received a bolus infusion of endotoxin ( mg x kg- ) or normal saline and epithelial permeability to low molecular fluorescein isothiocyanate-dextran ( kd) was quantified using a ligated loop of terminal ileum after hours of normotensive endotoxaemia. in hypodynamic shock models pure o breathing was shown to redistribute blood flow in favour of hepato-splanchnic organs and to improve survival. in contrast, this therapeutic approach has not yet been evaluated in hyperdynamic septic shock, since an increased production of o radicals, which is directly related to the increased o partial pressure, is considered as harmful. therefore, we investigated the effects of pure o breathing on hepato-splanchnic macro-and microcirculation, energy balance and tissue cell death during porcine fecal peritonitis. after induction of fecal peritonitis, pigs were randomly ventilated for h with % o (n= ) or an fio adjusted to yield a sao > % (n= ). before as well as at and h of peritonitis we measured cardiac output as well as hepatic artery and portal vein (pv) flows (ultrasound flow probes), microcirculation in the intestinal wall (laser doppler flow), intestinal wall oxygenation, portal and hepatic-venous acid-base status, and lactate/pyruvate (l/p) ratios. apoptosis was analysed post-mortem in liver biopsies with the tunel assay. within group effects were analyzed using a friedman anova on ranks, intergroup differences with an unpaired rank sum test. at the end of experiment the contribution of both pv and total liver blood flow to cardiac output was significantly higher in the hyperoxic animals than in the control group (qliver/co ( ; )% vs. ( ; )%, p= . ; qpv/co ( ; )% vs. ( ; )%, p= . , respectively), which was concomitant with attenuated regional venous metabolic acidosis and lower hepatic-venous l/p-ratios. intestinal wall microcirculation and oxygenation did not significantly differ between the two groups. the hyperoxic animals presented with a markedly reduced number of apoptotic cells in the liver. our results show that early % o ventilation redistribute blood flow in favour of the hepato-splanchnic system even in peritonitis-induced hyperdynamic septic shock. furthermore, the hepatic energy balance is improved and the morphologic integrity of the liver better maintained under these conditions. grant acknowledgement. supported by the eli lilly-esicm sepsis elite award, the alexander-von-humboldt-stiftung, and the deutscher akademischer austauschdienst glucocorticoids are known as strong modulators of immune response that play an important role in patophysiology of sepsis and inflammation. they have strong influence on the development of immune system, its effector functions, and trafficking of immune cells.the biological activity of glucocorticoids depends not only on their plasma concentration, the number of receptors and the responsiveness of the target cells but also on the local metabolism of glucocorticoids that is predominated by b-hydroxysteroid dehydrogenase ( hsd). two isoforms of hsd are known. the isoform hsd operates in vivo predominantly as a nadph-dependent reductase that locally increases glucocorticoid concentration (cortisol, corticosterone) by reduction their -oxo derivatives (cortisone, dehydrocorticosterone) . the isoform hsd is a sole nad+-dependent dehydrogenase that inactivates biologically active glucocorticoids to their inactive -oxo derivatives. the aim of this study was to investigate peripheral metabolism of glucocorticoids in immune cells and tissues in experimental model of sepsis and inflammation. sepsis was induced in balb/c mice and wistar rats by intraperitoneal administration of lipopolysaccharide or pooled fecal inoculum. in these animals and in healthy controls we measured expression and activity of hsd in lymphatic nodes, peripheral blood leukocytes and alveolar macrophages. activity was measured by incubation with corticosterone and -dehydrocorticosterone, following hplc determination. the abundance of hsd mrna was measured by semi-quantitative real-time rt-pcr. for years etomidate has been known to cause adrenal insufficiency in the critically ill and is a confounder when studying corticosteroids in septic shock. subgroup analysis of a prospective, randomized, placebo-controlled study of corticosteroids in septic shock. patients underwent a short high dose acth test before study drug administration. patients received d treatment with hydrocortisone (hc) or placebo (p). the affects of etomidate administration on acth responsiveness and d mortality were studied. results. patients were enrolled. overall . % patients died in the hc group and % in the p group (p= . ). in total % of patients received etomidate. received etomidate before baseline [ % hc group + % p group] and in after baseline [ % hc group + % p group]. overall, more of the patients receiving etomidate were acth nonresponders [ % vs %] . no mortality differences was seen between patients receiving etomidate at any time during study and those who did not receive etomidate [ . % vs. . %](p= . ). there was a possible trend towards a difference in mortality between patients who received etomidate in the hrs before randomisation [ % hc vs. % p] or not receiving etomidate during this time period [ % hc vs. % p](p= . ). etomidate was commonly used in patients in the corticus study. etomidate was associated with an increased likelihood of adrenal hyporesponsiveness in all patients. there was no increase in mortality associated with etomidate administration at any time, there was a trend towards increased mortality in those who received it in the hours before trial baseline. this result comes from an underpowered subgroup and should be considered exploratory. d. pestaña* , e. martinez-casanova , a. buño , r. madero , a. criado anestesia-reanimación, análisis clínicos, bioestadística, hospital universitario la paz, madrid, spain introduction. steroids are indicated in septic shock patients when relative adrenal insufficiency is suspected. our aim was to study if the measurement of total proteins ( ) and eosinophil count ( ) improves the accuracy of cortisolemia to predict the hemodynamic response to steroid treatment in this setting ( ). we analysed data from consecutive surgical patients with criteria of septic shock receiving steroid treatment. four criteria were chosen to define hemodynamic improvement based on the combination of noradrenaline (na) withdrawal (at and h) and an increase of the hemodynamic index (hi = mean arterial pressure/na dose) of % at h and of % at h. the accuracy of the baseline cortisolemia to predict the hemodynamic response to steroid treatment following the four criteria was determined by roc curve analysis. the largest area under curve (auc) was found for the noradrenaline withdrawal or an increase of the hi > % at h after starting the steroid treatment (table ) . this criteria was met by patients ( %) and was associated with a lower mortality ( . % vs . %, p= . , % sensibility and . % specificity). however, no clear cortisolemia cut-off value for the diagnosis of adrenal insufficiency based on the hemodynamic response could be found. neither the basal proteins nor the eosinophils improved the accuracy of cortisolemia to predict a hemodynamic improvement. mortality was also related to age (p= . ), apache ii (p= . ) and sofa score (p= . ). neither basal cortisolemia nor lactate were related with icu mortality. twelve septic shock patients admitted to the icu < hours after family consent were enrolled. we excluded all patients in use of steroids in the preceeding months, etomidate, espironolactone, oestrogens, oral contraceptives, ketoconazole or any other drug known to suppress adrenal function; aids, pregnancy, history of disease of the hypothalamic-pituitaryadrenal axis, shock of other etiologies. after a baseline serum cortisol was obtained, a ld ( ug) corticotropin stimulation testing was performed. subsequently, serum cortisol at and min was measured. four hours later, another bc was obtained. then, a hd ( ug) corticotropin stimulation testing test was performed and serum cortisol was again measured after and min. results. both baseline serum cortisols were similar. delta hd cortisol was higher than delta ld cortisol ( . ± . vs. . ± . ug/dl, p= . ). five patiens had a bc < ug/dl, but only one showed rai in both tests. concordance between ld and hd tests was % ( / ). it was strong for responders ( %, / ) but weak for non-responders to ld test ( %, / ). the preliminary results of our study suggest that a ld test is a more sensitive test than a hd test. a further study comparing treatment of rai defined by a ld or a hd test is still needed. the potassium channels (kc), atp-sensitive k+ (katp) channels and calcium-activated potassium (bk) channels, may be implicated in shock induced vasoplegia. the aim of our study was to demonstrate that the potassium channels are overexpressed in experimental shock independently of the etiology. three rats models of shock were used : peritonitis by caecal ligation and perforation (clp, n= ) observed at h, ischemia-reperfusion model (hemorrhagic shock + resuscitation + laparotomy, n= ) observed at h, and pressure fixed hemorrhagic shock (n= ) observed at h. these three models were compared to a control group. we performed quantitative real-time pcr (lightcycler technology -roche -and sybr green -sigma) and western blot on aorta and mesenteric arteries. we studied the expression of the vascular smooth muscle katp channels -kir . and sur b subunits -and bk channels -bk alpha subunit. we assessed the inflammatory syndrome in studying inos expression. we were able to detect kir . , sur b, bk alpha and inos arnm in both vessels. quantitative real-time pcr results (reference gene : beta-actine) clp clp ir ir hs hs aorta mesenteric aorta mesenteric aorta mesenteric inos . ± . * . ± . * . ± . * . ± . * . ± . * . ± . * expression kir . . ± . . ± . * . ± . * . ± . * . ± . * . ± . * expression sur b . ± . . ± . * . ± . * . ± . * . ± . * . ± . expression bk alpha . ± . * . ± . * . ± . * . ± . * . ± . . ± . expression * : p< . vs control group conclusion. various potassium channels are activated and up-regulated during shock independently of the etiology. thus, potassium channels likely play a major role in sepsis but also in prolonged and severe hemorrhagic shock and in ischemia reperfusion. (cars) . a predominantly anti-inflammatory reaction induces immunosuppression with impaired host defense. application of gm-csf to patients with major surgery or sepsis has been proposed to improve host-defense. in this study we investigated the differential effects of gm-csf production in an ex-vivo model. and lps on the tnf-a. whole blood of healthy donors (age - years, mean years) was used to determine optimal concentrations and incubation time for lps. the immunomodulating properties of gm-csf (leukine ® (sargramostim), berlex)) were investigated in whole blood of healthy donors ( - years, mean years) and icu patients suffering from sepsis. six of the patients had immunoparalysis as defined according to local standards by a monocytic hla-dr expression of < mfi and an ex-vivo stimulation test of < pg/ml after lps incubation (dpc biermann, bad nauheim , germany), whereas the other displayed a hla-dr expression of > mfi and a ex-vivo stimulation test of > pg/ml. samples were primed either with gm-csf, gm-csf simultaneously or lps prior to incubation. tnf-a and il- concentrations were determined with the immulite chemoluminescence immunoassay system (dpc-biermann, bad nauheim, germany). leukocyte phenotyping was performed by dual-colour flow cytometry using whole blood lysis technique and monoclonal antibodies. in healthy donors, ex-vivo stimulation with lps leads to a massive increase of tnf-a production. however, if whole blood is incubated with gm-csf hours prior to the lps challenge, the tnf-a production is significantly increased. the simultaneous incubation with lps and gm-csf leads to a significant decrease in tnf-a levels in the same patient population. gm-csf stimulation of whole blood hours after the production. in patients lps challenge causes no significant change in tnf-a levels of with sepsis and endogenous tnf-a < pg/ml, gm-csf pre-incubation production, whereas patients leads to a significant increase in ex-vivo tnf-a had a blunted ex-vivo reaction to lps with higher endogenous levels of tnf-a stimulation. both the sequence of stimulation with either gm-csf or lps and the presence or absence of systemic tnf-a determine the ex-vivo cytokine response of whole blood. hence, it may be speculated that . the administration of gm-csf prior to the inflammatory stimulus would be most efficient, and that . the lack of stimulation effect in patients with high endogenous tnf-a may mirror endotoxin tolerance. the most common acquired causes of weakness and muscle wasting in the critically ill patient in the intensive care units (icu) are critical illness polyneuropathy and critical illness myopathy. there is significant clinical and neurophysiologic overlap between the two conditions, such that the term critical illness polyneuropathy and myopathy (cipnm) is often used. over a -mo period, critically ill patients who needed prolonged intensive care were studied. clinical manifestations include delayed weaning from the respirator not explained by pulmonary complications, muscle weakness and prolonging of the mobilization phase. included patients were classified as having mof, sirs and sepsis according to established consensus definitions. the occurrence of a positive emg for cipnm, as defined by an electrophysiologist who was blinded for treatment allocation, was analyzed during icu stay. variables recorded at baseline and during follow-up included patient demographics, principal diagnosis, routine blood tests and microbiological culture results. levels of tnf-alpha, il- , il- , il- , procalcitonin (pct) and c-reactive protein concentrations were repeatedly measured by elisa. all patients were divided in: patients without cipnm at any time (group a, n= ), with a positive emg during icu stay (group b, n= ), and with a diagnosis of cipnm since the admission (group c, n= ). emg testing demonstrated severe acute denervation with striking involvement of proximal muscles in patients. patients died of complications of sepsis. critically ill patients without cipnm showed serum il- levels lower (p < , ) than those with a diagnosis of cipnm while no differences were found as concerned serum il- levels. il- and tnf-alpha did not show any difference between the two groups. il- levels resulted higher in groups a and b (p < , ) while il- levels were higher in group a (p < , ). in the group b, we observed a characteristic pattern of il- and il- serum concentrations that may be important for clinical outcome. il- levels were higher than il-l in patients with worse clinical outcome. the opposite pattern was observed in those with a good prognosis. no differences in clinical and laboratory variables were observed between patients with and without cipnm. pct appeared to be most helpful in differentiating patients with sepsis from those with sirs (p < , ), exhibiting a greatest sensitivity ( %) and specificity ( %). conclusion. the analysis of the serum cytokines il- , il- , tnf-alpha and il- to standard indicator did not improved the predictive power of detecting cipnm but may contribuite to explain its pathogenesis. high dose glucocorticoids are known to induce muscle weakness. we investigated in a pilot study the occurrence of cip/cim in septic shock patients treated with low dose hydrocortisone (hc). patients were enrolled in the randomized controlled study of hc in septic shock (corticus) and received hc ( mg q h for days, tapered until day ) or placebo (pl). electrophysiological testing (ep) consisted of the assessment of compound muscle (cmap) and sensory nerve action potentials (snap), spontaneous activity (spa), and muscle membrane excitability investigated by direct muscle stimulation (dms). clinical muscle weakness was defined by a medical research council scale (mrc) below . cmap and snap were categorized based upon normal age related values. ep results were categorized as unspecific (cim or cip or both) when cmaps and spas were pathological in >/= muscles. presence of cip was defined by pathological snaps in >/= nerve, and cim by dms values < mv. data are shown as mean and %ci, chi square test and mann-whitney-u-test were performed for statistical analysis. from jun -feb , patients were enrolled in sites: hc and pl. median time for ep assessment was days ( - ) after study enrolment. pl and hc patients had unspecific electrophysiological signs; pl patients, but only hc patient had reduced snaps indicating cip. in patients dms could be performed, / pl and / hc patients showed reduced muscle membrane excitability indicating cim. in patients (pl , hc ) evaluation of mrc score was possible. muscle strength did not differ between placebo [ . ( / . )] and hc group [ ( . / . )]. none of the parameters reached statistical significance. conclusion. the frequency of cip/cim diagnosed by electrophysiological examination was higher in patients who received placebo. the clinical diagnosis of muscle weakness assessed by mrc scale was not different in both groups. with limitations of the small sample size, this first prospective evaluation showed no impact of hc on the development of cip/cim in this cohort of patients with septic shock. surviving sepsis campaign guidelines recommend treatment with hydrocortisone in septic shock patients requiring vasopressor support. however, the association of fludrocortisone remains controversial. the objective of the study was to determine if the association of fludrocortisone in patients with septic shock and adrenal insufficiency treated with hydrocortisone is related to an improved outcome. from a database including patients with septic shock requiring vasopressor support, we retrospectively studied patients who fulfilled criteria for adrenal insufficiency (baseline cortisol less than µg/dl and/or an increase after injecting µg synacthen less than µg/dl). all patients included received treatment with hydrocortisone (h) or hydrocortisone plus fludrocortisone (h+f) for at least h. data are presented as mean ± standard deviation. groups were compared by using student's t test for continuous variables and chi-square test for categorical variables. long rank test and kaplan-meier curves were used to analyze time to shock reversal and mortality. forty-eight patients received hydrocortisone (h group) and hydrocortisone plus fludrocortisone (h+f group). overall mortality was % ( patients). both groups were comparable in baseline clinical and demographic characteristics. no differences were found in age (mean age ± ), gender, weight ( ± vs ± , p , ) (kg), infection site and severity scores: saps ii ( ± vs ± , p , ), apache ii ( ± vs ± , p , ) and sofa max ( ± vs ± , p , ). both groups presented no differences regarding baseline ( ± vs ± ,p , ), stimulated ( ± vs ± , p , ) and delta cortisol values ( , ± , vs , ± , , p , )(µg/dl). we did not find differences between both groups in norepinephrine(ne)maximal dose received(µg/kg/min), time to shock reversal (days of ne use), time of mechanical ventilation, icu and in-hospital length of stay (days) and mortality ( prospective, randomized, double-blind, placebo-controlled study of -day mortality in patients with septic shock for less than hr who underwent a short high dose acth test in centres in european countries. patients received -day treatment with hc ( mg q h for days, q h for days, q hr for days) or placebo (p). serum electrolytes levels were obtained at baseline, day (d ), day (d ), day (d ) and day (d ) from randomisation. from mar -nov , patients were enrolled. baseline serum sodium were ( ) mmol/l and ( ) mmol/l in the hc and p group respectively. serum sodium peaked at d ( mmol/l) and remained elevated up to d ( mmol/l) in the hc group. in the placebo group, serum sodiumpeaked at d ( mmol/l). the mean change in serum sodium were, in hc treated and p treated patients respectively, at d : . ( . sd) vs . ( . ) mmol/l; d : . ( . ) vs . ( . ) mmol/l; d : . ( . ) vs . ( . ) mmol/l; and at d : . ( . ) vs . ( . ) mmol/l. the difference between groups reached statistical significance at day (p= . ). there were no significant changes in mean potassium levels over time between the two treatment arms. according to the guidelines for the management of severe sepsis and septic shock, low doses of steroids are recommended in septic shock patients requiring vasopressors, despite adequate fluid replacement. the aim of this retrospective case control study was to assess the effectiveness of low doses of hydrocortisone in patients with late septic shock and mods. the study was held in a bed multidisciplinary icu of a tertiary hospital. twenty four norepinephrine dependent (> . γ /kg/min) patients, fulfilling the criteria of septic shock, were enrolled in the study. patients were divided in groups according to the continuous administration of mg hydrocortisone for days (group a: pts) or conventional treatment (group b: pts). end points of the study were, the within days vasopressors weaning, evolution of mods and -day as well as -day survival. mods was described by sofa score. statistics : statistical analysis was computed by using paired t-test and linear regression analysis. groups were similar regarding demographics ( ± vs ± y), initial sofa score ( ± vs , ± ), initial norepinephrine dose ( . ± . vs . ± . γ /kg/min) and mean elapsed time from the onset of shock ( . ± . vs . ± . days). an early and significant decrease in norepinephrine dose (p< . ), was observed in all group a pts, while no difference was detected in group b pts. this decrease was associated with hemodynamic stability. on days and mean abp was significantly higher in group a pts (p< . , p< . ). weaning from vasopressors within days was achieved in pts in group a ( . %) and pts in group b ( . %). seven day mortality was . % in group a vs % in group b while -day mortality was % and % respectively. in the treatment group a positive correlation between the within days shock reversal and survival (cor coeff = . , r = . , p= . ) was found. there was no relation between the time elapsed from the onset of shock to the steroid administration and survival (p= . ). oxygenation parameters (fio /po ), sofa score and creatinine did not differ between groups. wbc in group a pts were significantly higher (p< . ) only on day . no significant adverse effects were detected. in late septic shock patients with mods the administration of low doses of hydrocortisone is associated with decreased vasopressors requirements, hemodynamic improvement and beneficial effect on survival. the within days shock reversal was a good predictor of survival. introduction. early microcirculatory impairment followed by mitochondrial dysfunction may combine to produce multi-organ failure in sepsis. we recently reported that tissue oxygen tension (tpo ), the balance of local o supply/demand, is variably affected in four different organs (kidney cortex, liver, muscle, bladder) at h' post-endotoxin challenge ( ). we seek to measure temporal changes in tpo in these organs in a resuscitated rat model for up to h following the onset of faecal peritonitis. here we present our -hr timepoint results with assessment of the impact of fluid loading. methods. male wistar rats (approx g weight) with tunnelled right jugular venous cannulae in situ received i.p. injection of faecal slurry. fluid ( : mixture of % glucose/ % hetastarch; ml/kg/h) was started h later. at h, rats were anaesthetised with isoflurane, and then instrumented with a left common carotid arterial line and tissue po probes (oxford optronix, uk) sited in thigh muscle, between right and left liver lobes, in the left renal cortex and within the bladder lumen. after -min stabilisation, recordings were made of bp, tpo , and end-diastolic volume (edv) and cardiac output (co) by echocardiography (vivid , ge healthcare, bedford, uk). this was performed before (bi, baseline instrumented) and after fluid challenge (f) of ml/kg bolus of % hetastarch given to optimise lv filling. comparisons were made against sham-operated animals that underwent instrumentation but received no i.p. injection. notwithstanding considerable volume resuscitation beforehand, left ventricular filling and output were significantly reduced at h in this faecal peritonitis model. despite the % reduction in output, baseline tpo values were similar in bladder and renal cortex compared to sham animals but showed a decreased trend in muscle and a significant reduction in liver. fluid loading restored cardiac output to control values, however only muscle and liver tpo increased, albeit not significantly. these data suggest a combination of microcirculatory and mitochondrial dysfunction with each predominating in different organ beds at this timepoint. confirmation is required using complementary techniques. microcirculatory dysfunction leads to inadequate tissue oxygenation and multi organ failure during sepsis or septic shock. aim of this study was to compare non-invasive assessment of tissue oxygen saturation (sto ) with systemic oxygenation using mixed venous oxygen saturation (svo ) as an indicator in an established model of porcine septic shock. in a prospective animal study anaesthetised, ventilated pigs ( . ± . kg) were investigated. animals received g/kg/body weight faeces into abdominal cavity to induce sepsis and were observed over hours. volume therapy was administered to maintain a central venous pressure of mmhg. svo measured by co-oxymetry (radiometer, copenhagen) was obtained hourly after induction of sepsis. at the same time quadriceps muscle sto was measured by near-infrared spectroscopy (nirs) (inspectra tm , hutchinson, usa). correlation was analyzed by linear regression analysis. a total of measurements were performed in animals. sto was significantly correlated with the svo . r = . (r = . ) (p< . ) and y = , x + , . comparing the change in sto and svo of two successive measurements reveals a correlation of r = . (r = . ) (p< . ). changes in sto and svo were parallel in % of two successive measurements (both measurements changed at the same time in the same direction). although there is a significant correlation between sto and svo in our experimental septic shock model, paired sto and svo changed in the same direction only in %. thus, svo may not be estimated on the basis of sto in treatment of experimental septic shock and tissue oxygenation may not be estimated on the basis of svo either. whether a combination of sto and systemic oxygenation measurements is a useful monitoring approach in sepsis needs to be revealed. grant acknowledgement. inspectra device was provided by hutchinson. systemic immune response syndrome (sirs) frequently develops in critically ill patients and may lead to multiple organ dysfunction or failure even in the presence of normal or normalized global hemodynamic parameters, mainly due to tissue dysoxia and microvascular dysfunction. near infrared spectroscopy (nirs) is a validated method for the assessment of tissue oxygenation but its accordance with routine parameters has not yet been sufficiently studied. aim: to compare nirs parameters to routine monitoring parameters of the critically ill. thirty two consecutive critically ill patients (age= ± years, male/female= / , length of icu stay= ± days) were enrolled. all patients were evaluated with nirs and the occlusion technique within hours of icu admission. all patients were mechanically ventilated and were sedated. routine hemodynamic parameters (mean arterial pressure= ± mmhg, central venous pressure= ± mmhg, heart rate= ± ), full blood analysis (hemoglobin= . ± . g/dl, white blood cells= , ± , /dl) and arterial blood gases analysis were recorded. sofa, apache ii and saps iii ( ± ) scores were assigned on icu entry day. tissue oxygen saturation (sto %) was continuously monitored before, during and after -min occlusion of the brachial artery via pneumatic cuff inflated up to mmhg above measured systolic arterial blood pressure. (elwi) has been demonstrated to predict mortality and to correlate to pao /fio -ratio and to the compliance of the lungs in patients with sepsis and ards. however, with an increasing number of obese patients, there is the question which body weight should be used for indexation of elwi. therefore it was the aim of our study, to investigate the correlation of elwi to pao /fio -ratio and oxygenation index (mean airway pressure* / pao ) using different weight parameters for indexation. in patients of a medical icu with a body mass index > kg/m , measurements of extravascular lung water were performed using the picco system (pulsion, munich; . . software). extravascular lung water was indexed using the actual body weight (abw), predicted (pbw), ideal (ibw) and adjusted body weight(adbw) , respectively. these data were correlated to pao /fio -ratio and oxygenation index. spearman correlation, spss-software. the highest correlation to pao /fio -ratio was found using adbw, the highest correlation to oxygenation index for elwi adjusted to pbw. .) although the extent of correlation varied within smaller limits (- , to - . and . to . , respectively), the distribution of the patients within "normal", "modestly elevated" and "significantly elevated" elwi would have changed markedly using different indices. .) with regard to impaired respiratory function in the patients of our study, pbw, ibw and adbw seem to more accurately reflect "functional" extravascular lung water than abw with % of the patients in the normal range. our objective is to analyse the hemodynamic profile and the extravascular lung water in the first stages of severe acute pancreatitis (sap) that are admitted at the intensive care unit (icu), through the collected data by transpulmonary thermodilution. observational and prospective study, in which -sap-diagnosed patients consecutively admitted at the icu were analyzed. all of them were monitorised at their admission with continuous cardiac output system picco ® (pulsion medical systems). demographic variables, general (apache ii and sofa) and specific (balthazar) severity scores as well as the development or not of respiratory failure, were collected. the ordinary hemodynamic parameters [heart rate (hr), mean arterial pressure (map), cardiac index (ci), vascular resistances (svri)] were determined on days , , and as well as preload parameters [intrathoracic blood volume index (itbi), global end-diastolic volume index (gedi)], extravascular lung water index (elwi) and pulmonary vascular permeability index (pvpi) according to picco ® methodology. the results are expressed as means±sd and percentages. the non-parametric mann-whitney test for quantitative variables was performed and statistical significant level was established at p< . . age was ± years with a majority of males ( %). the biliar was the most frequent cause ( %). apache ii= ± and sofa= ± . all patients showed an alteration determined by ct scan (balthazar grading system) degree c or higher. seven patients ( %) needed mechanical ventilation in the first hours. hospitalary mortality was of %. on day , the ci ( . ± . l/min/m ) and the rvsi ( ± din.seg.cm - .m ) were at normal parameters and only patients needed vasopressor support. however, on days and , the preload parameters were low (itbi= ± ml/m and gedi = ± ml/m ) and improved on the th day (itbi= ± ml/m and gedi = ± ml/m ). patients with respiratory failure and mechanical ventilation showed neither higher elwi nor higher pvpi than the rest (day , elwi: . ± . vs . ± . ml/kg; pvpi: . ± . vs . ± . ; p=ns). in our population, certain hypovolemia degree in the first stages of the disease was found, corresponding to the development of the third space. the respiratory failure associated is not mainly due to an extravascular lung water increase or to a permeability increase. . ( . - . ) . ( . - . ) . cpo after dobutamine (w) . ( . - - ) . ( . - . ) . poap: pulmonary occlusion arterial pressure, swi: stroke work index. conclusion. cpodelta after dobutamine challenge is a good predictor for mortality in ss. septic shock is a common disorder with a high mortality. recent guidelines for the haemodynamic management of severe sepsis have emphasized the importance of aggressive volume resuscitation in the initial phase. central venous pressure (cvp) and pulmonary capillary pressure (pcp) are common end-points for volume resuscitation, however these cardiac filling pressures are poor predictors of fluid responsiveness in septic patients. right ventricular end diastolic volume index (rvedvi) is a better predictor of preload, and it allows the identification of patients with right ventricular (rv) dysfunction and dilation (> - ml/m ), as well as predicting mortality. we correlated rvedvi with pcp, cvp and hypoperfusion variables during septic shock initial management. longitudinal, prospective and observational study. demographic, haemodynamic (rvedvi, pcp, cvp) and hypoperfusion (lactate, base deficit) variables were obtained. descriptive statistics with mean ± sd (numerical variables) and frequencies and percentages (categorical ones). comparisons between groups with u mann-whitney test and x and fisher exact test as needed (statistically significant value if p< . ). results. patients (mean age ± )were divided in: survivors n= (rvedvi ± ml/mt ) and non-survivors n= (rvedvi ± ml/mt ). early dilation of rv predicts survival with a sensibility of % sensibility and specificity of %. methods. ten patients with severe sepsis ± yr, patients with septic shock ± yr and polytrauma patients with hemorrhagic shock ± yr, who remained in icu more than hours were included in the study. serial bnp measurements were performed for at least days. consecutive hemodynamic measurements were done using a right ventricular ejection fraction (rvef) thermodilution catheter (edwards). transthoracic echocardiography was performed in the first two days. . bnp values ( st day) was dramatically elevated in septic shock ( ± pgml- ), significantly elevated in severe sepsis ( ± pgml- ), but within normal limits in hemorrhagic shock ( ± pgml- ) (p< . ). inotropes (noradrenaline) were similar in patients with septic or hemorrhagic shock on day . bnp levels did not correlate with pulmonary arterial wedge pressure, right atrial pressure, rvef or left ventricular ef (lvef) measured by echocardiography. eleven patients with septic shock, with sepsis and with hemorrhagic shock died during days. bnp decreased gradually in survivors from septic shock after day . septic shock survivors had lower apache ii, and increased rvef and lvef compared to non-survivors ( ± , ± and ± vs ± , ± and ± respectively, all p< . ), but not bnp ( ± vs ± pgml- ). in conclusion, bnp is significantly elevated in sepsis, mainly in patients with septic schock, probably indicating the level of inflammation severity. inotropes, shock and myocardial stretch, as it is expressed from hemodynamic parameters, do not seem to be implicated to bnp release. sepsis and septic shock are major causes of mortality and morbidity in the icu. if inflammatory mediators responsible of sepsis remain elevated or if there is a poor cardiac function, septic myocardial dysfunction may occur, increasing morbidity and mortality. brain natriuretic peptide (bnp) is an adequate biomarker for cardiac failure so our objective was to determine its utility in predicting myocardial dysfunction in septic patients. the role of hemofiltration, its dose and biological effects in sepsis remain a contentious issue. although some beneficial effects on systemic hemodynamics and reduced vasopressor requirement were reported, the potential of hemofiltration to prevent sepsis-related disturbances of microcirculation and energy balance has not been evaluated. therefore, we investigated the effects of standard hemofiltration (hf, ultrafiltration rate ml/kg/h) and high volume hemofiltration (hvhf, ml/kg/h) during h hyperdynamic porcine septic shock. in mechanically ventilated and instrumented pigs fecal peritonitis was induced by inoculating autologue feces. h after induction of sepsis pigs were randomly assigned to three groups: ) controls (n= ), ) hf (n= ), ) hvhf (n= ). before, , and h after the induction of peritonitis we measured, in addition to systemic and regional hemodynamics, ileal mucosal and renal cortex microvascular perfusion (ops and laser doppler flowmetry). energy balance was determined by measuring arterial lactate pyruvate (l/p) and hepatic venous ketone body (kbr) ratios. in the control group hyperdynamic septic shock resulted in a progressive deterioration of intestinal mucosal and renal cortex microvascular perfusion despite well-maintained regional blood flows. altered microcirculation was paralleled by gradually increased l/p and kbr indicating disturbed energy balance. compared to six animals in the control group, only three and two pigs required noradenaline support in hf and hvhf group, respectively. however, neither hf nor hvhf blunted the sepsis-induced alterations in microvascular perfusion and cellular energetics. in this clinically relevant model of septic shock, the protective systemic hemodynamic effects of early hemofiltration did not translate into the improved microvascular perfusion and energy metabolism. hvhf did not confer any additional benefit. the value of hemodynamic improvement as a surrogate marker for efficacy of hf is therefore ambiguous. patients in prolonged septic shock show enhanced pressor sensitivity to vasopressin(vp) yet decreased response to norepinephrine(ne). as both act via g protein-coupled receptors and activate the inositol phosphate cascade to increase vascular smooth muscle(vsm) ca + levels, the reason for this disparity is uncertain. we postulate that these drugs may have diverse effects on different ca + mobilisation pathways during sepsis. we investigated this using specific modulators of ca + release and influx on contractile responses to vp and ne in mesenteric arteries from septic and sham-operated rats. sepsis was induced in awake, fluid-resuscitated wistar rats by ip injection of fecal slurry. paired sham controls received no injection. rats were sacrificed after h, and mesenteric arteries mounted on a wire myograph to measure isometric tension responses to vp and ne. the contributions of sarcoplasmic reticulum(sr) ca + release and ca + entry through the store-operated channel(socc) were assessed by removing and returning extracellular ca + respectively. the contribution of the voltage-gated ca + channel(vgcc) was assessed by applying vp/ne in the presence of nifedipine. contractions were significantly enhanced to vp but depressed to ne in septic vessels . in all arteries, constriction to both agonists relied predominantly on extracellular ca + influx rather than sr ca + release. ne responses were more sensitive to extracellular ca + removal in septic vessels. the ca + influx in response to ne was almost entirely vgcc-mediated, with a negligible contribution from soccs in both sham and septic arteries. soccs contributed significantly to vp contraction however, and socc-rather than vgcc-mediated influx of ca + predominated in septic arteries. patients in prolonged septic shock show enhanced pressor sensitivity to vasopressin (vp) yet decreased responsiveness to norepinephrine (ne). we have reproduced this pattern in ex-vivo contractile responses of resistance arteries taken from rats subjected to a clinically realistic septic insult ( ). we hypothesise that an underlying mechanism is vp-mediated sensitisation of the vascular smooth muscle contractile apparatus to calcium. to investigate this, we performed simultaneous wire myography and fluorescence microscopy to examine the relationship between contractile response and intracellular calcium concentration ([ca + ]i). sepsis was induced in conscious, tethered, male wistar rats by intra-peritoneal injection of faecal slurry. paired sham controls received no such injection. both groups received ml/kg/hr of intravenous fluid. after hours, animals were sacrificed, and rd order mesenteric arteries dissected and mounted on a wire myograph (danish myo technology). arteries were loaded with a fluorescent calcium indicator (fura- , mum) for hour and imaged by fluorescence microscopy. [ca + ]i and isometric tension kinetics were measured simultaneously in response to vp ( nm) and ne ( mum). ]i was higher in arteries taken from septic rats. tension responses to vp were significantly enhanced in septic arteries, however the associated increases in [ca + ]i were comparable in septic and sham groups. tension responses to ne were significantly decreased in septic arteries, with a similar degree of depression in delta [ca + ]i. data were analysed for statistical significance using un-paired t tests. conclusion. the higher baseline [ca + ]i in the vascular smooth muscle of septic arteries suggests an abnormality of intracellular calcium storage. the ability of vp to produce a greater contractile response in septic compared to sham arteries, despite an equivalent degree of [ca + ]i elevation, implies sensitisation of the contractile apparatus to the effect of vp. there was contractile hyporesponsiveness to ne in the septic vessels and no evidence of calcium sensitisation to this agonist. these findings provide one potential explanation for the hypersensitivity to vp observed in patients with septic shock. mitochondrial dysfunction and compromised cellular energetic status are associated with poor outcome in septic patients [ ] . maintenance of mitochondrial function is mediated in part by activity of transcription factors nrf- and nrf- , the transcriptional co-activator pgc -alpha and mitochondrial transcription factor alpha (tfam). these markers of mitochondrial biogenesis were elevated in a rodent model of endotoxaemia [ ] . in an ongoing study in critically ill patients, we have investigated the relationship between cellular energetics and mitochondrial biogenesis. with ethics approval and appropriate consents, critically ill patients were recruited within h of icu admission. age-matched control patients were undergoing elective hip surgery. muscle biopsies were taken from vastus lateralis. atp and creatine compounds were determined by hplc of perchloric acid extracts and standardised to total creatine [total cr = phosphocreatine (pcr) + creatine (cr)]. mrna levels for pgc -alpha, nrf- and tfam were determined by rt-pcr and standardised to s mrna. data were analysed for significance using one-way anova. the ratio of pcr/cr was significantly decreased in both survivors and non-survivors. mrna levels of the mitochondrial biogenesis markers pgc- alpha and nrf increased in survivors but not in non-survivors. a similar pattern was observed with the mitochondrial transcription factor tfam, although statistical significance was not reached. ( ) the decreased pcr in both survivors and non-survivors indicates increased demand for atp in the acute phase of critical illness. ( ) increased levels of markers of mitochondrial biogenesis in survivors indicate that maintenance of mitochondrial function, specifically atp synthesis, may be crucial to recovery. failure to maintain adequate mitochondrial function through biogenesis may contribute to atp depletion and mortality. local metabolic changes are not well investigated in sepsis and sirs. our aim was to describe subcutaneous metabolic changes using microdialysis (md) concurrently with systemic hemodynamics over days in patients with sepsis/sirs and circulatory failure. methods. patients with severe sepsis/sirs were recruited. at inclusion, all patients had circulatory failure despite resuscitation according to the rivers concept. cardiac index (ci), intrathoracic blood volume index (itbvi), extravascular lung water index (evlwi), blood lactate (p-lac), md lactate (md-lac) and md lactate-pyruvate ratios (md-lac/pyr) were analysed - hourly. data were tested for differences over time using anova. patients were subdivided into sepsis and sirs groups, and intergroup differences were tested using the rank sum test. mean apache scores were & for sepsis & sirs respectively. sofa decreased from . to . with no difference between sepsis & sirs. ci increased over time and itbvi, evlwi, p-lac & md-lac decreased. md-lac & p-lac were maximal at day . lactate concentrations were generally higher in md than in blood, and in the sepsis group. severe sepsis and septic shock have been recognized as a serious clinical problem that shows an increasing incidence and that is responsible for substantial morbidity and mortality in intensive care units. sepsis has been defined as the systemic host response to infection with an overwhelming systemic production of both pro-and anti-inflammatory mediators. continuous hemofiltration has been suggested as possible therapeutic option that may remove the inflammatory mediators. on the other hand, hemodialysis and hemofiltration were reported to influence cardiac electrophysiological parameters and to increase the arrhythmogenic risk. therefore, in this study we have investigated the effects of hemofiltration on electrophysiological properties of the septic pig heart. methods. pigs of both sexes were divided into groups: ) control group without hemofiltration; ) control group with conventional hemofiltration ( ml/kg/hour); ) septic group without hemofiltration; ) septic group with conventional hemofiltration ( ml/kg/hour); ) septic group with high-volume hemofiltration ( ml/kg/hour). in septic groups, the sepsis was induced by fecal peritonitis and maintained for hours. hemofiltration was applied for the second hours of this period. ecg was measured just before and after -hours period of sepsis in septic groups and at the same time points in non-septic groups. action potentials were recorded in isolated ventricular preparations obtained from the hearts at the end of experiments. . rr and qt intervals were significantly shortened by sepsis in all septic groups, in non-septic groups they were not influenced by the experiment. action potential duration (apd) was also significantly shortened by sepsis (septic group without hemofiltration vs. control group without hemofiltration) at all cycle lengths tested ( , , ms). both conventional and high-volume hemofiltration in septic groups shortened apd further at slow pacing rates. hemofiltrate obtained in septic groups by both conventional and high-volume hemofiltration prolonged significantly and reversibly apd at all pacing rates. substitution solution alone had no effect on apd. neither hemofiltration nor hemofiltrate in control, non-septic groups influenced apd. we conclude that the hemofiltration in septic groups and the septic hemofiltrate influence significantly the electrophysiological properties of the heart, probably due to removal/content of various inflammatory mediators in the septic hemofiltrate. introduction. the precise mechanism by which multiorgan failure develops in severe sepsis and septic shock remains unclear. potential mechanisms include alterations of microvascular flow distribution, mitochondrial dysfunction and treatment effects. we investigated the effects of lps and different catecholamines on oxidative respiration of rat skeletal muscle fibers and hepatocytes. muscle fibers (m. gastrocnemius) were isolated from anesthetized male wistar rats ( - g). human hepatocytes (hepg cells) and human monocytes (monomac -mm ) were also used. to avoid systemic effects of endotoxin and catecholamines, experiments were performed in vitro using the skinned-fiber technique. the mechanically dissected muscle fibers were incubated with lps ( µg/ml) for h. after h of lps incubation, norepinephrine, dopamine, and dobutamine ( µm each) were added. monocytes and hepatocytes were treated with different concentrations of lps only. mitochondrial respiration was determined after permeabilization with saponin, using a clark type electrode (oxygraph k, orobros instruments, innsbruck, austria). septic shock is associated with severe cardiac dysfunction, whose mechanisms remain only partly defined. recent data suggested that it might be triggered by the direct action of microorganisms and their products on the heart itself. we previously shown that flagellin (flag), the protein monomer from bacterial flagella, is a potent activator of nf-κb-dependent pro-inflammatory signaling in cultured cardiomyocytes. therefore, the aim of the present study was to evaluate whether flag might induce such an inflammation in the heart in vivo and contribute to cardiac dysfunction. h c cardiomyocytes were stimulated with recombinant salmonella muenchen flag ( - ng/ml, min to h). in vivo, balb/c mice were injected (tail vein) with - µg flag ( min to h). the effects of flag were evaluated by its ability to activate nf-κb, and to induce transcription of tnfα and mip- cytokines. in vivo, cardiac neutrophils recruitment was evaluated by myeloperoxidase (mpo) activity. the expression of the flag receptor tlr was also determined. in vivo physiological measurements: left ventricular pression-volume curves. a microtip pressure-volume (pv) catheter (spr- ; millar instruments) was inserted into the left ventricle (lv) via the right carotid artery. the pressure and volume signals were continuously recorded and heart rate, cardiac output, end-systolic and end-diastolic volumes, stroke volume, ejection fraction and end-systolic and end-diastolic pressures were measured. load-independent indices of lv systolic and diastolic functions were determined by the slope of the end-systolic, respectively end-diastolic pv relationships in conditions of rapidly reduced preload (transient compression of the vena cava). . flag activated nf-κb in cardiomyocytes in vitro and in vivo, and also upregulated the transcription of tnfα and mip- . flag also increased cardiac neutrophils recruitment. flag induced significant increases in end-systolic and end-diastolic lv volumes, indicating cardiac dilation, and a significant reduction of the load-independent indices of lv systolic function (end-systolic pv relationship, espvr, and maximal elastance, emax), indicating significant lv systolic dysfunction. in contrast, no change in the slope of the end-diastolic pv relationship (edpvr) was noted. bacterial flagellin induces a prototypical inflammatory response in cardiomyocytes in vitro and in the myocardium in vivo. these effects are associated with a profound alteration of the lv systolic function in vivo, suggesting that flagellin may represent a critical mediator of cardiac dysfunction in septic shock. current guidelines recommend either dopamine (da) or norepinephrine (ne) as the initial vasopressor in septic shock (ss), but the management of moderate to severe ss is still controversial. to explore this issue is important, because pharmacodynamic differences between vasopressors might be irrelevant in mild cases, but could potentially affect outcome in more severe patients. beside clinical implications, there are also economical considerations since these drugs are not cost-equivalent. this subject may be specially important for developing countries. the aim of our study was to compare ne vs da as the exclusive vasopressor for established moderate to severe septic shock (requirements of > . mcg/k/min of ne or > mcg /k/min of da to maintain map to mmhg) multicentric rct involving nine polivalent icus from argentina, brazil and chile, randomizing moderate to severe ss patients to ne or da titrated to target map or maximal dose of mcg/k/min ne or mcg/k/min da. after inclusion patients were switched blindly to the assigned drug. the study could be stopped if severe hypotension or arrhythmias developed. epinephrine was used as a rescue drug. main outcome criteria were day mortality, organ dysfunctions and adverse effects (ae). the study was stopped early after randomizing patients because of low enrollment rate. only patients were evaluable. main results are shown on the table. adverse effects with da were cases of atrial fibrillation (af) and supraventricular paroxysmal tachycardia (spt), which were considered serious in cases. aes with ne were two af and one spt, which resolved with no drug suspension. aes occurred more frequently with higher doses of da. conclusion. the use of dopamine as exclusive vasopressor for established moderate to severe septic shock appears to be associated with a worst outcome and more adverse effects. this should be explored in a future better powered rct. although arterial blood pressure (abp) is a widely used guide for hemodynamic therapy in sepsis, few data exist on its association with mortality and on critical abp limits that should be maintained. in this retrospective cohort study, clinical, hemodynamic, and laboratory parameters were extracted from a prospectively collected database in sepsis patients. the severity and duration of hypotension was calculated by the area under the curve (auc) of systolic arterial blood pressure (sap), mean arterial blood pressure (map), and mean perfusion pressure (mpp = map -central venous pressure). laboratory parameters included the most aberrant variables during the icu stay. urine output per hour during the first hours and need for renal replacement therapy were recorded. the sepsis-related organ failure assessment (sofa) score was calculated from given clinical and laboratory parameters. binary and linear regression models were corrected for the severity of disease by inclusion of the saps ii (excluding sap count) as a covariate and were used to examine the association between abp and day-mortality or organ function. similarly, a binary logistic regression model including saps ii as a covariate was used to determine the best discriminating cut-off limit of abp in regards of day-mortality. the goodness of fit of each limit was assessed by the r -value according to the nagelkerke method. . sap and map were recorded for . ± . hours, mpp for . ± . hours. there was a significant association between day-mortality and the auc of sap (p< . , r = . ), map (p< . , r = . ), mpp (p< . , r = . ). the area under map mmhg and mpp mmhg was associated best with day-mortality. one or more episodes of map < or mpp < mmhg increased day-mortality by . (ci % . - . , p= . ) and . (ci % . - . , p= . ), respectively. there was a linear association between time under the critical map and mpp limit and day-mortality. while abp was significantly associated with the sofa score, arterial lactate levels, and renal function, no association with liver function or troponin i was observed. the critical map and mpp limits for the need for renal replacement therapy were mmhg (r = . , p< . ) and mmhg (r = . , p< . ), respectively. during early sepsis, abp is associated with day-mortality and organ function. mpp shows the best association with mortality and may be a new resuscitation target. animal models of traumatic brain injury (tbi) are used to elucidate sequelae underlying human head injury in an effort to identify potential neuroprotective therapies. although human tbi is a highly complex multifactorial disorder, animal trauma models tend to replicate only single factors involved in the pathobiology of clinical head injury and may thus partly underlie the discrepancy between preclinical and clinical trials of neuroprotective therapeutics. we here present our experience with a large animal model of tbi which was designed to closely resemble the forces impacting the brain in e.g. traffic accidents. anesthetized, mechanically ventilated instrumented sheep (n= ) were placed in prone position with the head resting on a support to allow free lateral movements of the head. a left-temporal head impact was then delivered by mechanical stunning device (mk , schermer, germany), which is approved for euthanasia of domestic lifestock. a captive bolt with a mushroom-shaped head is propelled from the muzzle of the stunner against the skull by the discharge of blank cartridge inserted in a chamber behind the proximal end of the bolt. depending on the charge and the positioning of the stunner, this device delivers an intracranial atmospheric pressure of approximately bar in sheep at a bolt velocity of approximately ms- . to prevent skull fractures, a steel plate was attached to the left temporal fossa. a fiberoptic intracranial pressure (icp) catheter and a brain tissue oxygen (pbro ) probe were introduced in the parietal white matter. unilateral ultrasound flowprobes were attached to the internal carotid artery to measure cerebral blood flow. after measurements, sheep were killed and the brains removed for neuropathological examination. brain injury was characterized by a marked increase in icp from ± to ± mmhg (mean values ± standard deviations) hours after head impact. intracranial hypertension was accompanied by a significant decrease of cerebral blood flow. pbro significantly decreased from ± to ± mmhg. the decrease in sinus venous oxygen saturation did not reach statistical significance. in instrumented control animals (n= ), parameters remained unchanged. neuropathological examinations revealed the presence of multifocal traumatic subarachnoid hemorrhage in , and diffuse axonal injury in out of animals. while interstitial brain edema was found in all sheep brains, contusion zones were present only in a minority of the animals. the pathobiological characteristics of the head impact model presented here closely resemble the alterations frequently found in human tbi. the relatively high variability of neuropathological changes after head impact may be seen as a disadvantage of this model. non-neurologic organ dysfunction triggered by infection represents a frequent and independent predictor of poor outcome in traumatic brain injury (tbi) patients admitted to intensive care units ( ). because tbi itself significantly increases susceptibility to infection ( ) and infection is a potentially modifiable risk factor, we developed a combined experimental model of tbi and sepsis in the rat. controlled cortical impact (cci) was produced in left parietal cortex by using a mm diameter tip (velocity m/sec; depth mm). sepsis was induced contemporarily by cecal ligation and puncture (clp). the outcome was evaluated in terms of mortality, neurological function (via the morris water maze (mwm) and beam balance (bb) tests)and histologically. rats were subdivided into groups: sham, cci, clp, and cci + clp. -day mortality was % in sham, % in cci and % in clp group respectively. adding clp to cci increased mortality up to % (p< . vs cci and p< . clp alone). at h and week post-injury mwm and bb test performance was significantly worse in cci and cci + clp than in sham and clp groups (p< . ). lesion volume was similar in injured groups. ca cell loss in left hippocampus was unaffected in the sham and clp groups, while it was % in cci and % in cci + clp groups (p< . cci vs cci + clp). our results show that the occurrence of systemic sepsis exacerbates mortality and cerebral damage in rats subjected to traumatic brain injury. t. j. p. lieutaud* , j. rhodes , p. j. d. andrews anesthesiology and intensive care medicine, hospices civils de lyon, lyon, france, anesthesiology and intensive care medicine, university of edinburgh, edinburgh, united kingdom introduction. human recombinant erythropoietin (epo) appears promising in different brain injury models but its cellular mechanisms remain poorly understood. following brain trauma injury (tbi), inflammation (il- b) and chemokine expression (mip- , neuropath appl neurobiol ) are important. the aim of this study was to measure the effects of acutely administered rhepo on il- b and mip- after tbi. methods. with home office approval, under isoflurane anesthesia rats sd were subject to lateral fluid percussion tbi ( . - . atm) (dixon j neurosurg ) of the left parietal cortex. epo ( , or iu/kg) or placebo were injected in a random and double blinded manner by the intra-peritoneal (ip)route. the ipsi-and contra-lateral cerebral cortices were removed h later and homogenized. il- b and mip- were measured in the surnageant using elisa kits. results are expressed as pg/mg of protein (mean ± sem). there was a significant increase in il- b and mip- in the ipsilateral cortex in comparison with the contralateral side for both proteins analyzed. neither nor and iu/kg rhepo did not exhibited any significant effect (figure ). conclusion. this study confirms that inflammation is important and occurs early after lfp-tbi. epo did not display significant effects on two of the main inflammation mediators. the purpose of this study was to evaluate the effects of agmatine on histopathological damage following traumatic injury using a clinically relevant model of diffuse axonal injury (dai) on the rat. a total of male sprague-dawley rats weighing - g were anaesthetized and subjected to head trauma using marmarou's impact-acceleration model. the rats were then separated into two groups; one group was treated with agmatine and the other group was treated with saline for up to four days immediately after the head trauma. rats from both groups were killed one, three or eight days post-injury. the brains were examined histopathologically and scored according to the neuronal, vascular and axonal damage. there were no significant histopathological differences between the control and agmatine-treated group after one or three days (p> . ), but evaluation after eight days revealed a significant improvement in the group treated with agmatine (p< . ). our data indicate that agmatine has a beneficial effect in diffuse axonal injury and should be tried for therapeutic use in the management of this condition. d. morii*, y. miyagatani critical care department, national hospital organization kure medical center, kure, japan the disadvantageous effect of haemorrhagic shock on head trauma related mortality are well known. thus, efficacious shock treatment is a surely significant measure against the development of secondary brain damage. the small volume resuscitation by hypertonic saline has been shown to promote systemic and cerebral haemodynamic benefits. similarly, many clinical studies have demonstrated the effects of long-term mild hypothermia on outcome of traumatic brain injury. in this study, we evaluated the new strategy consisting of therapeutic mild hypothermia and hypertonic saline therapy to the multiple trauma patient with severe traumatic brain injury. severe multiple trauma patients (iss>= , head ais>= ) were studied to evaluated the efficacy of therapeutic hypothermia ( . ˚c for h) and hypertonic saline therapy (na+: meq/l for the first h , meq/l for to h, meq/l for to h) which were applied to them in parallel with massive blood transfusion . we evaluated glasgow coma scale (gcs), injury severity score (iss), the probability of survival (ps), the volume of blood transfusion, infusion and urine volume during the first days, and glasgow outcome scale (gos). we monitored the extent of brain swelling by head ct. four male patients (age: ± y.o., mean±sd) were examined. the characteristics of injury mechanism were explosion , mva , fall . on admission, gcs, head ais, iss and ps were . ± . , . ± , ± and . ± . , respectively. the sum of blood transfusion, infusion, and urine volume during the first h were ± ml, ± ml, ± ml. no patient was died and their gos on posttrauma day was . ± . . the combined therapy of therapeutic hypothermia and hypertonic saline to multiple trauma patients with brain injury may lead to good outcome in spite of the necessity of a large quantity of blood transfusion and infusion. recent data suggest that commonly used anaesthetic agents, e.g. propofol, cause neurodegeneration in the developing brain. the intention of our study was to investigate the effects of propofol on primary neuronal cultures referring to the cell survival rate. primary cortical neuronal cultures were prepared from wistar rat embryos at days gestation. to test the effect of propofol on neuronal survival, cultures were exposed to µl gibco neurobasal-a medium per well with propofol at a concentration of mg/ml for , , , , , and hrs. cell viability was assessed using the methyltetrazolium method (mtt) and was related to untreated cells as controls. all cells were kept in normoxia. after three and six hours of exposition to propofol cell viability values of the propofol treated cells were significantly higher ( . ± . %, p= . and . ± . %, p= . , respectively) compared to untreated control cells ( %). after hours, values were decreasing to levels of the control cells ( . ± . %). after , and hours of exposition to propofol, in contrast, cell viability was significantly reduced ( . ± . %, p= . , . ± . %, p< . and . ± . %, p< . ) compared to controls. at high concentrations, propofol has a time-dependent effect on the viability of primary cortical neurons. during the first hrs propofol has a potential neuroprotective effect, whereas it seems to cause neurodegeneration in the period of to hrs of exposition. e. paramythiotou* , j. papanikolaou , p. ntagiopoulos , a. armaganidis , a. karabinis icu, attikon university hospital, icu, george gennimatas hospital, athens, greece multiple trauma patients constitute a significant majority of admissions in a general icu. brain injury is often present in those patients. the aim of our study was to investigate demographic, clinical and management characteristics in trauma patients suffering a brain injury in a five year period. in a retrospective study all trauma patients hospitalized in the -bed multivalent icu of a bed -tertiary hospital between st jan and th dec suffering a traumatic brain injury were enrolled. recorded data included age, gender, cause of the injury, icu length of stay, initial glasgow coma score (cgs), submission or not to an emergent neurosurgical intervention, all cause mortality and neurological outcome. a total of trauma patients were hospitalized during the study period. tbi was present in patients ( . %). among them, were women ( %) and ( %) were men. their mean age was . years (range - ). icu length of stay (los) ranged between two and days (mean . days). traffic road accidents were the cause in cases ( . %) while tbis ( %) were due to fall from a height on the ground which happened either accidentally or as a result of a suicide attempt. the rest cases ( . %) were due to accidents during work. mean glasgow coma score was seven (range - ). an extradural hematoma was present in p and a subdural one in p. intracerebral hemorrhage was noticed in p, hemorrhagic contusions in p (with or without diffuse axonal injury) and a traumatic subarachnoid hemorrhage in p. twenty nine patients were submitted to craniotomy and p were submitted to unilateral or bilateral decompressive craniectomy. mean los was . d for p submitted to a surgical intervention versus d for the other group. barbiturates were used in p ( %). a total of patients survived ( . %). death was due to neurological cause (herniation of brain stem and subsequent cerebral death) in p. other causes of death included sepsis, multi organ failure, severe injury in other organs, and hemorrhage from upper gastrointestinal tract. a poor neurologic outcome (mean glasgow outcome score < ) was noticed in % of patients. almost two thirds of trauma victims suffer from a cerebral injury. most of them are young males, victims of traffic road accidents. the injury is often severe and one third of patients are submitted to a neurosurgical operation. though overall mortality is rather low, long duration of treatment is often required and severe disability is present in a not negligible number of patients. in the majority of the intensive care units (icu), several of the admissions involves patients with primary nervous system illnesses. a great progress of the technologies used in the icu in the last few decades had reduced neurological illnesses mortality and morbidity. since september of we had beginning an longitudinal e prospective coort study verifying the characteristics of the patients years older that had been admitted in the icu for primary neurological cause (clinical or surgical). the study occurred in a private hospital icu with beds. we recorded patients until the moment. the number of neurological patients corresponds % of the admissions in the unit. the average age of this group of patients is significantly lesser of the remain icu patients ( vs. years), however does not have difference estatistically significant between apache ii ( vs. ) and the mortality ( vs. %) of the neurological patients and others. the stay of length in the unit is bigger ( , vs. , ) . we also recorded mechanical ventilation time length ( % ventilated patients with for average time days). in ventilated patients, % was tracheostomyzed (on average in days). % developed sepsis ( % with septic shock). the patients were divided and analised in several goups (for example: trauma, surgery, central nervous sistem infection, vascular disease,...). neurology was one of the most benefited specialties with the intensive care units progress and evolution. however, high mortality and morbidity caused by the neurological illness, and the social and economic impact that its sequels cause, still deserve the attention of the involved professionals cares of these patients in the acute illness. n. baffoun* , w. gdoura , h. ouragini , k. baccar , m. lamourou , t. chaoua , r. souissi , c. kaddour , n. ben romdhane , s. mahjoub anesthesia and intensive care, national institute of neurology, departement of haematology, chu la rabta, tunis, tunisia trauma victims develop frequently various degrees of haemostatic disorders. the severity of such post traumatic coagulopathie is considered to be major detrimental factor of outcome. the aims of our study were: to identify the origin of such disorders, time course and their correlation with mortality. our aim was identification of coagulopathy disorders and relation to outcome in severely head injured. prospective study,june -march . included:critically ill isolated closed severe head trauma. collected data:demographics,management prior and during icu hospitalization (sedation, catecolamin drug use, blood product transfusion, intra-cranial pressure monitoring, neurosurgical emergency surgery etc.),ct-scan results, daily worst glasgow coma scale, admission simplified acute physiology score ii. we inserted an arterial catheter for invasive pressure monitoring, a central venous catheter and a unilateral jugular bulb in front of the most damaged brain hemisphere(cf. ct-scan). jugular bulb thrombosis was prevented by continuous infusion of ml per hour isotonic serum without heparin. blood samples were obtained simultaneously from the central venous line(k) and jugular bulb(b) at admission, th, th hour, and then in case of neurological aggravationt or daily till th day. we measured platelet count,prothrombin time (pt),activated partial thromboplastin time (act),fibrinogen concentration (fib), prothrombin fraction + (f) and thrombin anti-thrombin complex (tat). during the study only central venous blood samples (pt, act, fib and platelet count) could be available if necessary. otherwise blood samples were centrifuged and preserved refrigerated for post hoc analysis. statistical analysis by student's t test, paired t test for paired results and analysis of variance. significance set as p< , . results. n= ; survivors(s) and deaths (ns). no differences between s and ns in demographics,management modalities, admission gcs( ± ), ct-scan,saps ii ( ± vs ± , p= , ). b vs simultaneous k platelet count was significantly lower in all drawn blood samples,with a trend to decrease overtime. s vs ns at day and day : ± vs ± (p= , ). admission b thrombin fractions was higher in ns( ± vs ± , p= , ). b day tat was higher in ns: ± vs , ± p= , . no difference for other tests between b vs k and s vs ns for different paired tests. pro-coagulant factors (f and tat) are valuable prognostic factors at day in closed isolated severe head trauma. severe traumatic injury is a multisystemic disease where normal homeostatic mechanisms are lost. this situation involves an increase in physiological needs. usually these patients present anormalities in the hypothalamic-hypophyseal axis, which become neuroendocrine dysfunctions with deteriorated physical or neuropsychological secuelae. the aim of this study is to improve our knowledge about this part of the axis in acute phase of politraumatism. methods. an observational prospective study was carried out, with patients who were admitted to our icu with a critical traumatic injury, for six months. demographic and epidemiological data were registered. apache-ii (acute physiology and chronic health evaluation system) and apache-iii scores during the first three days were measured. tiss (therapeutic intervention scoring system) score during the hospital stay was recorded. also gh (grown hormone), igf- (insulinlike-grown-factor- ) levels and nitrogen urinary losses in the first three days after traumatic event were measured. statistical data were analysed with the spss . program. in our study , % ( cases) were men and , % ( cases) were women. the average age was , years old. the hypothalamic-hypophyseal-somatotrophic axis role in the first three days was characterized by a progressive increase in gh levels and a progressive decrease in igf- levels. connections between average hormonal levels in the first three days and apache-ii, apache-iii and tiss scores during this time were studied. a good inverse connection between igf- and prognosis was shown si (spearman index) - , , - , p value , and , respectively with apache-ii and apache-iii. this appropriate connection could not be shown with tiss score sp - , p value , ; but the connection between gh and tiss was better, sp , p value , . conclusion. gh levels increase and igf- levels decrease in the first three days after acute trauma. lower igf- levels can mean a worse prognosis. there are no connections between igf- and sanitary resources used (tiss score) but these connections seem to get better when gh levels are higher. trimodal distribution of deaths and the golden hour concepts are in part responsible for the genesis of all modern trauma systems but these concepts have been challenged recently. our aim was to describe distribution of death in trauma using data from a trauma system and discuss what can be done from the organizational point of view to improve outcome. all traumatic deaths occurring between and in a trauma system were. data on age, gender, time and place of injury, time of first and second hospital arrival, cause of trauma and type of accident, hospital characteristics, dominant injury and time of death were collected for this study. for mortality distribution the variable time was transformed applying a natural logarithm. results. deaths occurred over a period of months. % at the scene, % in the level i trauma centre, % in level iii trauma centre and the remaining in level iv/v trauma centre. death distribution using a logarithmic scale in minutes showed four peaks: deaths at the scene, deaths in the first hours, deaths in the first two days and finally deaths in the second week that we referred as minutes, hours, days and weeks peak (image ). we found statistically significant differences in age and dominant injury concerning timing of death. a tetramodal pattern of death distribution could be described. our data support the need to focus on the treatment of severe head injuries namely in the intensive care environment. anaemia is usually detected in critically ill patients. red bloos cell transfusion is not free of risk. we want to start an alternatives to transfusion protocol but fist we tryed to dercrive our critically ill patients anaemia. our objectives were to: study the red blood cell and iron metabolism in the icu patients at admission. observe changes in these parameters across the first seven days after admission. observe rbc transfusion and his relation whit morbidity and mortality. find transfusion predictors at the admission moment. during tree mounths of , we include all the admissions in a trauma and neurocritical icu of our hospital that stay in unit more than hours. at the moment of admission we determinated haematocrit, (hto), haemoglobin (hb), and reticulocytes (%retic) levels, iron metabolism, folic acid, b , epo and creatinin (kr) we repeated determinations seven days after admission if patient was still in icu. adverse events occurred during icu stay were also registered (mainly infections) together the number of rbc transfusions (with hb levels before and after administration). we included in the study patients. severe traumas ( %), neurocritical patients ( %), tumoral neurosurgery ( , %) and other patients ( %) . average age was . years and apacheii . ± . points. % were males . results of admission blood determinations and seven days after are exposed in table i . there is a tendency to decrease in hto and hb parameters, but not significant. the only parameter we observe difference statistically significative was the reticulocites rate (%retic), significative lower days after admission. (p< . ) in graphic we describe anaemia groups in admission and the evolution of anaemia groups seven days after admission. we appreciated that no anaemia group suffers a severe decrease. % of patients were transfused during their fist week stay. average levels of pre-transfusional hb were . g/dl . we analysed transfusion predictors. hto and hb levels at admission predict transfusion. there is no other analytical parameter at admission that predicts transfusion. we also detected tracheal intubated patients at admission and patients with inotropic drugs perfusions at admission were significative more transfused (p< . and p< . ). conclusion. the high mortality rate in our patients is related to the initial gcs and cranial cat at the moment of admission. it is necessary to continue the study to determine the influence of the rest of the variables in the mortality rate of these patients. introduction. traumatic brain injury, subarachnoid hemorrhage (sah) and spontaneous intracerebral hemorrhage (ich) are associated with systemic inflammatory response syndrome (sirs). early diagnosis of sepsis versus sirs is frequently difficult in neurointensive critical care units. procalcitonin (pct) has been used as a predictor marker of bacterial infection in different groups of patients. there is variable and scarce information about pct in neurocritical patients. the aim of this study was to evaluate the utility of serum pct in the early diagnosis of fever from bacterial infectious origin in patients with acute brain hemorrhage. we made a prospective diagnostic study between july and january . we analyzed serum level of pct and c-reactive protein (crp) on consecutive patients with diagnosis of sah, ich or tbi who have fever during the intensive care unit admission. we excluded patients with antibiotic therapy previous to admission. pct and crp were blindely measured from samples of serum extracted within hs of fever onset and within hs of antibiotic administration. blinded to pct and crp results and according to previously defined criteria patients were classified in two groups: proved bacterial infection (pbi) and non proved bacterial infection (npbi). serum pct was measured by immunochromatographic semiquantitative method brahams pct-q (brahams diagnostica, berlin, germany). its sensitivity is . ng/ml. we analyzed sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) of serum pct and crp for diagnosis pbi. we defined negative serum pct as < . ng/ml and negative crp as < mg/l. we studied patient, with sah ( %) and with ich ( %). ten patients had pbi ( %, %ci - %). pbi were pneumonia ( ), urinary tract infection ( ), meningitis ( ) and central line associated blood infection ( ). two patients had simultaneous infection sources. there were bacteremic infections. pct was positive in patients in pbi group ( pneumonia and bacteremic central line associated blood infection) and in of npbi. sensitivity was % ( %ci - %), specificity % ( %ci - %), ppv % ( %ci - %) and npv % ( %ci - %). crp was positive in pts, pbi and in npbi. sensitivity was % ( %ci - %), specificity % ( %ci - %), ppv % ( %ci - %) and npv ( %ci - %). in this study serum pct had an adequate ppv to diagnose pbi, without false positives results. however, it has a low negative predictive value to diagnose pbi. due to the results obtained, we consider that the quantitative pct assay with a sensitivity limit of . ng/ml should be used for the future study to evaluate the role of pct as a predictor marker of acute bacterial infection in patients with acute brain hemorrhage. in different published series cerebral infarction occurs in - % of patients with symptomatic vasospasm after subarachnoid hemorrhage (sah) despite maximal therapy. standard triple-h treatment is associated with life-threatening side-effects (such as myocardial ischemia and pulmonary edema) and has not been properly validated. milrinone, a phosphodiesterase iv inhibitor, has few side effects and exhibits inotropic, vasodilatory and immunomdulatory properties besides inhibiting platelet aggregation and thromboxane a synthesis. we present our experience using our m&h protocol (milrinone and homeostasis) in patients with vasospasm. it consists of cvp-guided normovolemia (maintain cvp=or> ), aggressive temperature control, maintenance of normal serum sodium and step-wise interventions based on symptoms (milrinone . - . mg/kg bolus plus infusion, levophed and angiogram plus intra-arterial milrinone). we retrospectively reviewed the charts and imaging studies of patients diagnosed with symptomatic vasospasm based on the development of focal symptoms and the results of angiographic and doppler studies. cerebral infarction was defined as a new hypodensity on ct scan appearing at least days after aneurysm clipping or coiling. conclusion. among the different physiological scores, the sah-pds was most strongly associated with the major outcomes and the h&h score was better than the other aneurysmal bleed scores. the strong association of physiological scores with outcomes suggest that interventions targeting physiological derangements may improve outcomes in sah patients. contrast induced nephropathy (cin) is the acute deterioration of renal function due to parenteral administration of radio-contrast media. cin is defined as an increase in serum creatinine concentration of > µmol/l ( . mg/dl) or % above baseline within hours after contrast administration. [ ]epidemiologic data in neurosurgical patients undergoing endovascular coiling are sparse and only one study in stroke patients reported figures of % prevalence. [ ] cin is associated with increased morbidity, length of hospital stay and costs. pre-existing renal failure and the dose of contrast media are known risk factors for the development of cin in cardiac patients where the condition is well-described. [ ]although the pathogenesis of cin is not entirely clear, several mechanisms for contrast-induced renal injury have been proposed, including alterations in renal medullary perfusion, direct cytotoxicity and oxygen-free radical generation. [ ] we conducted a twelve month retrospective electronic patient record based review of data from patients presenting to the hospital for endovascular coiling. renal dysfunction was based on increase in serum creatinine of µmol/l ( . mg/dl) or % above baseline within hours after contrast administration; the incidence of contrast induced nephropathy was investigated. peri-operative care and post-operative management were analysed. a multi-variate analysis of risk factors was conducted and statistical tests done using microsoft excel. . patients visited our hospital neurosciences unit and underwent endovascular coiling over a one year period (sept -sept ). the incidence of contrast induced nephropathy was %. . % had pre-existing renal disease and . % needed haemofiltration on intensive care for renal failure post-operatively. the odds ratio for developing cin in patients with diabetes mellitus was . ( . - . ) p= . . the odds ratio for developing cin with pre-existing kidney disease was . ( . - . ) p= . . the development of cin did not show any correlation with patient age, emergency or electively performed procedure or the number of coils used. no anti-oxidants were given for prophylaxis and no protocol for peri-operative hydration was used though fluids were administered intra-operatively. conclusion. cin is a common cause of acute renal functional impairment and accounts for significant morbidity in patients undergoing endovascular coiling. patients with pre-existing renal failure are at high risk; other predisposing factors should be identified. there is some evidence regarding use of peri-procedural hydration and anti-oxidants and, therefore, management protocols should be developed. open prospective observational study. were studied patients treated by embolization after spontaneous intracranial aneurysm rupture. included: embolization complicated by rupture of aneurysm during the obliteration procedure. rupture was ascertained by extravasation of contrast. current results of period ranging from july till october . thirty two patients embolized for aneurysms. one patient pesented a rupture during the embolization: she was a y.o female; she came to our institution's emergency suffering from acute headache, nausea vomiting and a mild meningism. she got no neurological defect (wfns grade i). ctscan showed a mild sah (fisher class ). an angiography followed, confirming presence of a mm ruptured pericallosum aneurysm. during embolization procedure, a sudden hemodynamic instability (bradycardia, unstable blood pressure) was noticed and rerupture of aneurysm confirmed by extravasation of contrast medium. this complication occurred during placement of the first coil. the procedure continued successfully and aneurysm was completely obliterated by three coils. ctscan performed immediately after end of the procedure showed no massive cerebral haemorrhage (class fisher). the patient was thereafter transferred to our icu where she was extubated. she developed a transient neurological defect (right hemiparesis). she was discharged alive without any disability. aneurysmal perforation during embolization seems to be a rare event. in our case it doesn't cause much damage, but clinical severity is variable and far from being predictable. re-bleeding can result in severe intracranial hypertension and ultimately brain death. aneurysm thrombosis complicated procedures, and was fatal for both (respectively and days after embolization) due to massive ischemia (aneurysm of the internal carotid artery) and refractory intracranial hypertension (aneurysm of anterior communicating artery). those two patients got respectively wfns grade / fisher classification: iii/ and ii/ . the patient with wfns grade iv got a successful uncomplicated procedure days after the initial insult and partial clinical recovery. he continued to improve and was discharged alive from hospital without major neurological disability (gos: good, modified rankin scale = ). conclusion. endovascular coiling could be an efficient therapeutic tool. incidence and outcome of procedures complications is still to be determined. strategy in patients with high wfns grade is certainly try embolization because of too risky surgery. right management timing is still to be determined. the quantitative estimation of blood loss helps in the choice of the best treatment tactics. the purpose of the study is to evaluate the ability of central blood volume index (cbvi, volume in heart and lungs and large vessels divided on body weight) and total end diastolic volume index (tedvi, sum of the end-diastolic volumes of the atria and ventricles divided on body weight) to reflect the magnitude of a hemorrhage. normo-volumic values of cbvi and tedvi were measured in cardiac icu cardiac patients, pigs and rats with weight range of . kg to kg. blood loss in the order of - ml/kg ( - steps) was applied in rats and pigs. ultrasound dilution technology utilizes the decrease in blood ultrasound velocity caused by injecting isotonic saline, and can be used in species of any size. cardiac index (ci), cbvi and tedvi were measured by hcp (transonic systems inc., usa) before and after blood loss. a disposable extracorporeal av loop filled with heparinized saline was connected between an existing artery catheter and central venous catheter. reusable ultrasound sensors were clamped on to the arterial and venous limbs of the loop. a peristaltic pump (nipro, japan) was used to circulate the blood from the artery to the vein at - ml/min for - min. measurements were obtained by injecting . - ml/kg (max ml) of isotonic saline. at the conclusion, the av loop was flushed with heparinized saline. in normo-volemic situations indexes are in the range of cbvi = - ml/kg and tedvi = - ml/kg, despite times differences in weight. a dramatic blood loss of - ml/kg in experimental animals produces the same magnitude - % decrease in cbvi and tedvi. severe dysphagia associated with silent aspiration and the danger of asphyxia requires translaryngeal intubation or tracheostomy. the aim of the study was to apply the clinical screening test (cst) and fibrooptic evaluation of swallowing test (fest) to determine the best method of upper airway protection. it was a prospective cohort study during the period of - . it included patients operated for fpt. all patients were delivered to icu intubated and mechanically ventilated after operation. after full recovery from anesthesia, returning to consciousness and passing spontaneous breathing test (sbt) (if not -mechanical ventilation continued) they underwent cst of points. the patients who passed cst without deficit were considered to have none or low level of dysphagia. the patients who passed cst with some deficit were considered to have dysphagia. all the patients were extubated and underwent fest. in patients with poor cst, icu crew was ready to perform translaringeal intubation immediately if necessary. patients with severe cases of dysphagia underwent tracheostomy and received cuffed tracheostomy tubes to prevent aspiration and ensure free air passage. on the next day after performing tracheostomy, swallowing rehabilitation therapy began. tracheostomiesd patients underwent fest every week. after passing fest with blue dye, decanulation was possible. results. patients of total group who did not recover consciousness or did not pass sbt in hours after operation were determined for prolonged artificial ventilation and were excluded from further study. the patients who passed cst without any deficit were successfully extubated and showed absent or mild dysphagia in fest. patients passed cst with deficit and after fest were divided into three groups by the level of dysphagia -mild, -intermediate and -severe. the regress of swallowing disorders was evaluated by fest every week. in the first group the earliest recovery was in three days, in the two other groups none recovered earlier than after three weeks. the latest recovery was determined after a year of swallowing rehabilitation therapy. two patients were not decanulated at all. postoperative recovery made possible to reduce rs. but insufficient rs exhaust the patient and may result in secondary impairment of the brain. the aim of the study was the analysis of different respiratory strategies in these patients to choose the best. it was a prospective cohort study of patients after removal of pft with complicated postoperative period during and no significant difference in± - . the age of the patients was severity of complications and neurological status. all patients included into study demanded rs after operation because of low rd. all patients had bulbar palsy syndrome (bps). patients with bps were tracheostomiesed. after full recovery from anesthesia and returning to consciousness ventilation modes were simv+ps or cpap+ps (ventilator pb ). rr (respirator and patient), tv, ps, fio , peep, pao and paco and neurological status were evaluated and registered daily. the criteria of readiness to wean were determined as: pao /fio > , peep< , ps< - , spo > %, rr< , fio < %, gcs> . weaning was successful if patient could breathe spontaneously for more than hours without neurological deficit arise. patients were divided into groups: . simv+ps ventilation (respirator rr - % of total rr) - cases; . cpap+ps ventilation - cases; . failed extubation in first hours - cases. all patients of the group were ventilated in simv+ps after reintubation. the patients of the group were extremely unstable and the modes of ventilation were corrected - times per day. duration of ventilation was minimal in the group with maximum replacement of spontaneous breathing with artificial ventilation -simv+ps (table ). in this group was minimal number of breathing disorders (minimal number of ventilator mode corrections) and patients were most stable. in first group was tendency to regress of bps ( %) and there wasn't cases of arising neurologic deficit. but in the group there was increase of bulbar palsy syndrome in % cases and no regression. c. a. eynon* , p. collins neurosciences icu, wessex neurological centre, southampton, wessex regional transplant, queen alexandra hospital, portsmouth, united kingdom the management of severe brain injury in the uk is undergoing significant change. national recommendations are that all severely brain-injured patients are referred to specialist centres. protocolised guidelines for the management of brain injury have resulted in improvements in mortality and morbidity. with this has come a reduction in the numbers of brainstem dead patients suitable for solid organ donation. however, there still exists a group of patients for which continued treatment is felt to be futile and who may be suitable as solid organ donors following death by cardiorespiratory criteria. all deaths during a -month period were audited prospectively. when patients did not fulfill the requirements for brainstem testing, futility in continuing medical treatment was determined by the supervising consultant neurosurgeon, neurointensivist and senior nurse. in such patients, treatment other than comfort care was withdrawn. patients (< yrs) where medical treatment was to be withdrawn were considered for nhb organ donation. . patients died during a -year period. patients had death confirmed by brainstem tests of which became solid organ donors. patients were potential nhb donors. nhb donation was considered in cases and offered to the family in . in one case the next of kin were untraceable, in one case the coroner refused permission. consent for donation was obtained from the family in / cases. nhb organ donation occurred in cases. in the remaining cases, patients died outside the time window for organ retrieval, in one the next of kin withdrew permission and in one the coroner did not grant permission. of the patients who died outside the time window for nhb organ donation, subsequently donated tissue. a total of kidney transplants, liver transplants and one double lung transplant were performed from nhb donors. conclusion. the number of brainstem dead patients is declining in the uk. patients in whom continuation of medical care is felt to be futile can provide a source of solid organs suitable for tranplantation. successful transplantation of solid organs from potential nhb donors occurs in a significant proportion of cases. feedback from family members has been supportive regarding the decision to donate. the studies on treatment of patients with head injury and brain damage, with sudden cardiac arrest due to various reasons revealed, that it is very useful to introduce neuroprotective therapy in those patients. it allows to decrease the consequences of local and global brain ischemia. the aim of the study was to present the efficacy and tolerance of treatment with amantadine sulphate (amantix, merz, germany), as a neuroprotective therapy. in the intensive care unit, between and we monitored a group of patients with consciousness disorders, in the age of . +/- . , with average bmi of . +/- . . the level of coma's deepness and its reasons were different. the examination plan, methods used, choice and classification of patients were carried out based on previously prepared protocols. the minimal period of treatment with intravenous infusion of amantadine sulphate was days, however, if possible, the therapy was continued for days. after this period the patients received amantix in tablets. many additional therapeutic measures from different groups were used in those patients. an endotracheal intubation and ventilation were necessary in all of the patients. amantix was used as treatment's supplementation in the dose of x mg/day. at the admission the patients were classified with the use of gcs (glasgow coma scale). in order to evaluate the effects of use of the preparation, some specific function of the patients were examined before the use of amantix and after finishing of the therapy. the examination was carried out by the intensive care unit doctors, neurologist and nurses taking direct care of the patients. the results were compared with the control group of patients, age , +/- , . those patients were treated with the use of standard methods. all of the collected data were worked up statistically. the authors revealed statistically important difference in gcs grading between the groups. the average gcs score in amantix group at the admission was: . +/- . , and at the discharge: . +/- . . analogically, in the control group the admission score was: . +/- . , and at the discharge: . +/- . . in patients using amantix we have noted the presence of side effects, usually it was hiperactivity. patients were transferred to different wards. patients died. the average hospitalization period in the amantix group was: . +/- . , and in the control group: . +/- . days. . this has been fuelled by increasing evidence demonstrating either sub-optimal care or poor end of life decision making as antecedants to cardiac arrest calls on acute wards. outreach and medical emergency teams have developed as a result, but their effectiveness remains unproven [ ] . at southend, development of a critical care outreach service began in . the aim of this study was to establish the trends in cardiac arrest call rates from the acute wards in the years prior to, during and after the introduction of the outreach team, to assess any potential impact this may have had. hospital switchboard records were analysed retrospectively to provide data relating to the date, time and location of ward cardiac arrest calls occurring between january and december . arrest calls to all acute wards except the critical care unit were included. the data collected was then related to hospital inpatient activity (in terms of completed in-patient consultant episodes, supplied by the hospital's information department) to enable meaningful interpretation of the observed trends. table summarises the results from the medical and surgical wards separately and then together to present data for the hospital's acute wards as a whole. the data shows an upwards trend for the years prior to and during the establishment of the outreach service, and a falling trend subsequently. conclusion. the establishment of a comprehensive outreach service that promotes all aspects of outreach critical care (expediting appropriate and preventing inappropriate critical care admissions, following up patients post critical care discharge and promoting critical care skills throughout the hospital) is likely to lead to a reduced frequency of cardiac arrest calls. however, this effect may take years and not months following introduction to be manifest. we suggest all outreach services should collect and present this simple data locally to demonstrate the potential impact of their activities. intracerebral haemorrhage (ich) represents - % of all strokes. the acute and subsequent blood pressure management presents a therapeutic dilemma. it is necessary decrease high systolic blood pressure, but there is the risk of decrease cereb. objective: can the regional cerebral oximetry helps us to determine individual adequate blood pressure? ral perfusion pressure and risk of ischemia developing. methods. regional oxymetry is the method of measurement the cerebral oxygen content based on near-infrared spectroscopy, which is carried out by means of the invos device (in vivo optical spectroscopy). this method is non-invasive, delivers continuous information and it allows the possibility of emergency therapeutic response. rso is transcutaneous monitoring of regional cerebral saturation with hemoglobin oxygen (rso ) in mixed blood in the frontoparietal regions, which represents interface beetween the basin of the anterior and middle cerebral arteries. the normal value of rso is beetwen - % in a majority of the population, and every change from the baseline in both directions by more than - % signifies the risk of ischemia for the observed tissue. during a twelve-month period all pacients admitting with ich in our neurointensive care unit (nicu) were managed by regional cerebral oximetry (n = ). arterial blood pressure was monitored and was corrected farmacologically. the functional outcome of patients when discharged from the nicu and after six month were evaluated by the glasgow outcome scale, barthel index and modified rankin scale. data was collected retrospectively for comparison with pacient which didn't monitor by rso . we found correlation between discovery of patological rso values and age, initial gsc and volume of ich. there are less septic and hemodynamic complications in the group with monitoring rso . using this method, the probability of successful improving outcome all patients with intracerebral haemorrhage will be estimated. there is the need for guidelines regarding the blood pressure managemet of these patients. elaborated data are available on iccollege.be. of ( , %) icu directors, representing icu beds completed the extended query. main findings were: visits limited < h/day ( h + h ) ; hcp dedicated to family ( %) children admitted from y of age ( %) ; family accompanied by hcp during resuscitation ( %) ; no witnessed resuscitation procedures ( %) ; scare possibilities for family to stay during night ( %) ; insufficient bad news delivery ( , %) ; poor team psychological support ( - %). icu physicians completed the follow-up simplified query. main findings were: psychological support for family ( , %) and team ( , %) ; post-resuscitation debriefing ( , %) ; identification of dedicated hcp ( , %) ; use of ( , %) and written ( , %) dnr-orders ; comprehension of ( , %) and family witness ( , %) of patients' will ; structured bad news delivery ( , %) ; witnessed resuscitation ( , %) and invasive procedures ( , %) ; children accepted < y ( , %). in belgium, although there's obvious concern from the majority of icu's to communicate with relatives, recommendations for psychological team support, teaching bad news delivery, schedule of visits and witnessed procedures are made. sudden death constitutes an important sanitary problem. early diagnosis and advanced cardiorrespiratory live support are considered the most important factors related with short term prognosis. the objective of this study was to analyze the prognosis, clinical characteristics and evolution of patients who initially recovered after an episode of out-of/hospital or in-hospital cardiac arrest and who were admitted to a medical-surgical intensive care unit (icu). sixty three consecutive patients were included and retrostectively studied when they were admitted to a medical-surgical icu. for two years, from april of until april of , sixty three consecutive patients were included. eighteen of the patients were women ( . %) and were men ( %). cpr was given out of hospital to patients, and patients suffered sudden death on a conventional hospital ward and patients in special units (surgery, coronary, emergency room, etc.). the etiology of the arrest was considered to be of probable primary cardiac origin in % of the episodes and the rest of the origin of arrest was considered secondary to other pathologies (respiratory, sepsis. . . ). mortality in icu was . % and , % were discharge alive but of that percentage of patients only % were released without important neurological damage. patients recovering following cardio-pulmonary arrest out of hospital and hospital ward had greater mortality than those who suffered an event in a monitored area ( %).(p< , ) the lengthy resuscitation times (greater than minutes), elevated apache ii scores and advanced age is associated with greater mortality. recovered cardiac arrest is a pathology with high mortality and morbidity in intensive care. in our series only % were released alive without severe neurological damage. the existing condition of the patient and the excessively long resuscitation times were decisive factors in these results. we conducted a retrospective case-note study in a six-month period at an innercity district hospital (distant from any international airport), and report three patients who deteriorated about the time of overseas travel by air. results. case . a retired gentleman of -years with progressive idiopathic pulmonary fibrosis requiring home oxygen therapy travelled by air without a medical escort. he deteriorated shortly after his arrival at the family home in the uk. he presented to the emergency department in respiratory failure requiring non-invasive ventilatory support. he died during prolonged hospitalization. case . a -year old woman with obstructive sleep apnoea reduced her diuretic prescription without her physician's knowledge prior to a long-haul flight. she deteriorated with acute shortness of breath shortly after her arrival at the family home in the uk. she was brought by her family to the emergency department where she was found to be in cardiogenic pulmonary oedema, requiring non-invasive ventilation. she survived hospitalization and was discharged with home oxygen therapy. case . a -year old man collapsed in the street explaining to passers-by that he had swallowed some packages. he had a travel ticket from the airport in his possession but was able to give no other history. he was taken to the emergency department and required intubation due to extreme agitation. he was found radiographically to have ingested multiple wrapped packets. he required laparotomy to remove differently coloured packs some of which had ruptured releasing their contents. urinalysis revealed cocaine metabolites. he subsequently made an uneventful recovery after extubation and transfer to a surgical ward. patients may present to hospitals distant from international airports with clinical deterioration consequent upon risks associated with long-distance air travel. ( ) prospective observational study of a cohort including every septic patient admitted in a medical icu of an university hospital from may to december . demographic, clinical, laboratory and therapeutic variables were registered. a clinical examination assessing motor deficit and tendon reflexes was daily performed in order to check cipnm criteria. univariate and multivariate logistic regression tests were used. . septic patients were included with age ± , apache ii score ± , maximum sofa score . ± , icu mortality %, in-hospital mortality %. patients survived at least days. patients did not require mv and none of them developed cipnm. finally the analysis was performed with the patients who survived at least days and required mv, with a cipnm incidence of %. variables were included in the univariate analysis. after multivariate analysis, it was found that several variables were significantly related with risk for the development of cipnm (odds ratio, or; % confidence interval, ic; signification level of change in log likelihood, p): . mv length (days): or . patients in the icu often develop an acute neuromuscular disorder characterised by difficulty of weaning from mechanical ventilation and associated with variable degrees of muscular weakness including quadriplegia [ ] . often associated with steroid treatment, neuromuscular blocking agents (nmba) and septic patients, the pathogenesis of cim is poorly understood [ ] . originally thought to be neuropathic in nature, however, today myopathy is more often diagnosed [ ] . to further clarify this point we present a series of patients. between and a retrospective study was carried out on patients diagnosed with cim and whose muscle samples were analysed in the dept. of neuropathology of chuvi, spain. in the clinical studies special attention was paid to the neuromuscular status apache ii, and treatments with steroids, nmba,total parenteral nutrition (tpn)and insulin. all patients underwent electromyographic studies and biopsy and in those with sensitive neurography an abnormal nerve biopsy. of the patients, were women and were men, all aged between and , (mean ± ). in three of the patients admission to the icu was not necessary. all save two received prolonged high doses of steroids and two were on chronic treatment of steroids. only one was treated with nmba for more than days. two patients were diabetic with no electromyographic signs of neuropathy. seven needed insulin to control glucemia during the critical period. received tpn, and had sings of sepsis. muscle biopsy showed signs suggestive of cim (atrophy of both types, alteration of the intermiofibrilar pattern) and in some cases miofagia and thick filament loss. in two cases there was discrepancy between neurophysiologic and biopsy findings (muscle and nerve). the seven patients that survived the acute illness showed neuromuscular symptoms on release from hospital. follow up was possible on three patients for , and years respectively. all recovered muscle strength, the electromyography normalized and currently have normal independent daily life activities. the aim of this clinical trial is to study cip in icu patients (pts) after surgical procedures. we enrolled retrospectively icu pts ( men ( . %), women ( . %) who underwent at least one surgical procedure under general anaesthesia and developed cip. all of them were mechanically ventilated and stayed > days. underlying diseases: multiple trauma , complicated surgery , pancreatitis . mean age: . ± . years. operation sites: abdomen , cns , orthopaedics , thorax , other . mean anaesthesia time: ± min. in all pts an electromyogram was performed twice, as well as daily neurological examination. we analyzed several parameters predisposing to cip. conclusion. ) sepsis predisposes to cip, but cip can be appeared without sepsis ( . %). ) age and serum albumin values do not predispose to cip (p< . ); however the early implementation of a nutritional protocol is useful. ) although not well correlated, we try, if possible, to avoid neuromuscular agents. ) high pgl predispose to cip (p< . ); it is important to maintain pgl < mg%. ) cip prolongs lmv (p< . ), los in icu (p< . ) and los in hospital (p< . ), but does not increase mr significantly (p< . ). s. kjaergaard* , s. e. rees intensive care, anaesthesia and intensive care, region north jutland, aalborg, center for model-based medical decision support, aalborg university, denmark ( ) is accepted as the gold standard method of describing pulmonary gas exchange. in the clinical setting, if any, only very simple one-parameter models are used. the parameters of these varying upon changing the fio . in a previous paper we have compared the miget with a simpler model, and shown that this simpler model is a good fit to the inert gas data obtained from the miget experiment ( ) . this study explores whether the simpler model can reproduce oxygenation data in an oleic acid lung damage model upon changing the fio and compared these results with those obtained using the miget. seven pigs were used for the study. lung damage was induced by an intravenous infusion of oleic acid. six inert gases were infused to estimate the distribution of v/q-ratios of the miget model and dead space, shunt and a parameter describing v/q mismatch, i.e. fa , of the simpler model ( , ). measurements were taken at five different ventilator settings. the two models were then used to simulate arterial oxygenation data when the model-parameters along with measurements of mixed venous blood gases at different values of fio were given as input to the models. both models can be used to simulate sao at varying fio . this is shown in the figure where the models have been used to simulate sao at varying values of fio (miget "+", simple "squares") ranging from . - . . it shows that the models simulate identical values of sao with a mean difference = - . +/- . . since the miget and the simpler models provide both equally good fit to the inert gas data ( ) and precise predictions of arterial oxygenation, they might be interchangeable in a clinical setting where only a limited amount of data are accessible. in addition, the parameters of the simpler model can be obtained quickly and non-invasively ( ). the model could therefore have applications a clinical situation. ethanol may be used in the management of toxic alcohol poisonings , or as sedation in alcohol withdrawal. ethanol may be a component within drug formulations, for example nimodipine infusion or chemotherapeutic agents . ethanol flush has also been used to restore the patency of occluded catheter lumens . in clinical practice, ethanol should only be infused via a pcvc and not a peripheral venous cannula, as the high osmolality of ethanol can cause thrombophlebitis. given anecdotal reports of pcvc deterioration during ethanol infusion , , this study applied a bench testing method and statistical modelling to develop clinical practice guidelines at our institution. the test solutions used were: dextrose (d) %; ethanol (e) %, %, %, %, % and %. each test solution was perfused through pcvcs. a total of pcvcs were perfused. (b) hour perfusion. the test solutions used were: d %, e %, e % or e %. each test solution was perfused through pcvcs. after perfusion, the strength of all pcvcs was assessed. the pcvc was attached to a force gauge. a known force was applied to the pcvc and the pcvc length was measured. this was repeated for increasing forces until the pcvc broke. length-force relationships were plotted and were described statistically using linear mixed effects models. . this bench test model produced reproducible data. the pcvcs were not directly traumatised by the testing apparatus. (a) minute perfusion. pcvcs perfused with e % , e % or e % perished with obvious structural deterioration. two distinct length-force relationships were described on linear mixed effects models: e %, e % or e % weakened the pcvcs , whilst d %, e %, e % and e % had no effect upon pcvc structure (p< . ) (b) hour perfusion. the pcvcs did not perish. on linear mixed effects models, e % and e % weakened the pcvcs, whilst d % and e % had no effect (p< . ). conclusion. this model quantifies the effect of ethanol infusion upon pcvcs. this has not been demonstrated previously. the infusion of e % e % or e % via pcvcs should be avoided. infusion of e % and e % for hours weakens pcvcs. nimodipine and other drugs using ethanol as a carrier vehicle should be infused via pcvcs with caution. these potential hazards should be outlined in individual pcvc package inserts and drug product information leaflets. ( ) in septic shock patients tissue microcirculation is altered despite an increased tissue oxygen tension ( ). microcirculatory distress could be one of the earliest stages in the progress of sepsis to multiple organ failure, and microcirculatory shunting could be an important contributing factor to this development ( ) . sofa score has been suggested to clinically assess the level of organ dysfunction( ). we've done a prospective observational study to determine if changes in the rate of thenar muscles tissue deoxygenation during stagnant ischemia in patients with severe sepsis and septic shock are related to changes in organ dysfunction using the sofa score. fourteen septic shock patients were included in a preliminary study during the first days of sepsis evolution. , hutchinson?thenar muscle sto was measured noninvasively by nirs (inspectra technology, usa) before and during upper limb ischemia. sto decrease (downslope) after limb ischemia were analyzed during first and fifth day after icu admission. changes in sto downslope, sofa score, cardiac output, lactate and the use of vasoactive drugs between first and fifth days were recorded. we found good correlation between ∆sto downslope and ∆sofa between the first and the fifth day. (spearman's rho = - , ; p< , ). our results are in accordance with those reported by pareznik( ) wich correlated isolated values of sto with sofa in septic shock patients but moreover we show that changes in both variables during evolution are also correlated. in septic shock patients, thenar muscle ∆sto downslope is well correlated with changes in ∆sofa, a clinically accepted tool to measure organ dysfunction evolution during sepsis. ∆sto downslope monitoring could be not only a good marker of microcirculatory state but also a good indicator of organ dysfunction evolution during sepsis and consequently a potentially therapeutic objective. one of the important tasks that the anesthesiologist should perform is to monitor the functions of body organs; lung airway pressure is among the most important ones. a real-time continuous monitoring device which would be designed in a small volume and is portable could be used by anesthesiologists for this purpose. so, this device could improve the quality of anesthesia care while being efficient and cost containing. the device consists of four consisting parts as follows: sensors (pressure transmitter and gas velocity transmitter), processors (two avr microprocessors), monitor and software. software simulation: the performance of the monitor was controlled through a simulation process with matlab-simulink software (the mathworks inc. ma, usa),( ). the monitoring device demonstrated acceptable results, both clinically and at the lab assessments. the study demonstrated this device as an effective, reliable and cost containing device. a. rodríguez salgado* , a. socias , b. comas , a. llompart , i. losada , p. ibáñez , m. borges intensive care unit, emergency department, internal medicine, h. son llàtzer, palma de mallorca, spain since we have a global computerized system on our hospital we used it to develope an integral and multidisciplinary working protocol for the early recognition of sepsis and its appropiatte therapy. prospective study conducted in a four-hundred bed teaching hospital with medical and surgical areas and the support of a global computerized system and on line internet conexion among areas. a computerized protocol to improve management of sepsis was developed. it automatically produces an annotation on the medical chart and a serie of analytics forms when activated. additionally clinical guidelines on sepsis management can be consulted. it was started on january , and here we present all patients included until january . during the study period patient were included in the protocol, with a mean age of , ( , ) y, , % were male. we have observed an ascending tendence in the number of patients included in the protocol, having arised from patients on january to on january . the protocol was activated at the icu in ( , %) cases, at the emergency department in ( , %) and at hospitalization units in ( , %). two-hundred and two ( , %) patients were admited at the icu. though initially the protocol was exclusivelly directed to patient with severe sepsis or septic shock, lately some patients with sepsis have been included. so, ( %) had sepsis, ( , %) severe sepsis and ( , %) septic shock. only ( . %) had fever and ( . %) had arterial hypotension at the protocol entry. sepsis was community-adquired in ( , %) cases, nosocomial-non icu adquired ( , %) cases and icu adquired in ( , %). the the most frequent site of infection was the lung in ( , %) patients, followed by the abdomen in ( , %) patients. isolation of the causal microorganism was achieved in ( %) patients. blood cultures were positive in ( . %) cases. forty seven ( %) had organ disfuntion (od), ( . %) od, ( . %) od and ( . %) or more od. mean lactate levels were , ( , ) mmol/l, , ( , ) mmol/l and , ( , ) mmol/l at the activation moment, at and a hour respectively. mean c-reactive protein levels were , ( , ) mg/l. eighty-five ( , %) patients deceased, of whom ( %) had sepsis, ( , %) severe sepsis and ( , %) septic shock at the moment of activation. conclusion. it is possible to implement a global multidisciplinary computerized protocol for identification and management of the sepsis, although this is a laborious and continual process. t. kyprianou* , g. panayi , d. zeinalipur-yazti , m. dikaiakos intensive care unit, nicosia general hospital, ngo, intensive care forum, dept of computer science, universiy of cyprus, nicosia, cyprus introduction. the physiological condition of icu patients is marked by rapidly evolving and frequently life-threatening derangements as well as 'silent' yet important alterations in homeostasis. reliable monitoring i.e. the capability to collect, store, process, and share inpatient monitoring data along with physicians' remarks can bring tremendous benefits to all aspects of intensive care medicine (practice, research, education). currently, grid infrastructures assemble an extensive collection of resources and expertise (egee grid: + sites around the world with more than , cpu's - pb of storage, adequate for storing and managing icu-related data. we present the design and implementation of the intensive care window (ic-window), a software tool that enables the retrieval and integration of data from patient-attached medical sensors. ic-window follows a modular design to retrieve data from different patient monitoring devices. the tool includes a full-edged interaction protocol and graphical user-interface to interact with the phillips intellivue mp monitor. ic-window is implemented in the context of icgrid (intensive care grid), a novel data-grid framework that utilizes the egee infrastructure to enable the seamless integration, correlation and retrieval of 'clinically interesting episodes' across intensive care units clusters. we present preliminary data from software's use in icu patients. conclusion. ic window belongs to a new generation of tools that could improve dramatically intensivist's capabilities as offers virtually unlimited storage capacity for every possible type of patient's data. in the future we plan to extend the ic-window application to communicate with other medical devices found within the icu. this will provide an open platform for the aforementioned applications. introduction. strict glycemic control by lowering blood glucose levels to - mg/dl reduces the intensive care unit (icu) mortality, morbidity, duration of the hospital stay, and overall medical care costs. to provide an intelligent system for tight glycemic control, the eu-project "closed loop insulin infusion for critically ill patients (clinicip)" was started in january . three different sensor technologies -two based on an enzymatic reaction with immobilised glucose oxidase using either amperometry or fluorimetry as transducer and another based on reagent-free infrared spectroscopy -have been developed to continuously monitor the glucose levels in the subcutaneous interstitial body fluid. monitoring of the subcutaneous interstitial fluid is realized using a microdialysis catheter cma from cma microdialysis ab as a body interface to all glucose sensors. experiments were carried out at the center for medical research (graz, austria), lasting up to h with the probands starting under fasting condition, but receiving later their normal diet. after microdialysis probe implantation, the perfusate (either % mannitol solution or elo-mel) flow rates were around µl/min. for reference measurements, dialysate samples were collected. in parallel, blood glucose concentrations in venous blood samples, collected under arterialised conditions with the arm resting in a hot box, were determined using a glucose analyzer from beckman instruments. a clarke error grid analysis of the results from all three sensors has shown all values in clinically acceptable zones. the blood reference and sensor measurements were further compared using bland-altman plots. owing to the tubing connecting the catheter outflow and sensor, the lag times for the sensor readouts were between and min. for the electrochemical and infrared sensors a simultaneous micro-dialysis recovery rate determination has already been implemented for improving the correlation of the sensor readout to the whole blood levels. some observational studies suggest that the use of pulmonary-artery catheters to guide therapy is associated with increased mortality. we performed a randomized trial to study outcome benefit of using pulmonary artery catheter (pac) in ards patients when compared to standard care using central venous catheter (cvc). the subjects were ards patients on mechanical ventilator who were assigned either to pac (pac group), or cvc (cvc group). the base-line characteristics of the two treatment groups were similar. the primary outcome was icu and in-hospital mortality from any cause. the pac group had a significantly lower icu mortality than the cvc group ( vs , p value= . ) but there was no difference between the groups in in-hospital mortality (one case mortality in cvc group). there were no significant differences between pac and cvc groups in urine output ( . ± . vs. . ± . ), use of vasopressors ( . ± . vs. . ± . ), and length of hospital stay ( . ± . vs. . ± . ) respectively. our findings suggest that pac can be used in ards patients for better hemodynamic assessment that may result in reduced icu stay and mortality rate. ethanol may be used in the management of toxic alcohol poisonings , or as sedation in alcohol withdrawal. ethanol may be a component within drug formulations, for example nimodipine infusion or chemotherapeutic agents . ethanol flush has also been used to restore the patency of occluded catheter lumens . in clinical practice, ethanol must be infused via a pcvc, as its high osmolality can cause peripheral thrombophlebitis. given anecdotal reports of pcvc deterioration during ethanol infusion , , this study applied a bench test and a statistical model to develop clinical practice guidelines at our institution. each cm triple lumen pcvc was perfused with a single test solution only. (a) minute perfusion. the test solutions used were: dextrose (d) %; ethanol (e) %, %, %, %, % and %. each test solution was perfused through pcvcs. a total of pcvcs were perfused. (b) hour perfusion. additional pcvcs were perfused with d %, e %, e % or e %. after perfusion, the strength of all pcvcs was assessed. the pcvc was attached to a force gauge. a known force was applied to the pcvc and the pcvc length was measured. this was repeated for increasing forces until the pcvc broke. length-force relationships were plotted and were described statistically using linear mixed effects models. . this bench test model produced reproducible data. the pcvcs were not directly traumatised by the testing apparatus. (a) minute perfusion. pcvcs perfused with e % , e % or e % perished with obvious structural deterioration. two distinct length-force relationships were described on linear mixed effects models: e %, e % or e % weakened the pcvcs , whilst d %, e %, e % and e % had no effect upon pcvc structure (p< . ). (b) hour perfusion. the pcvcs did not perish. e % and e % weakened the pcvcs (p< . ). not been demonstrated previously. the infusion of e % e % or e % via pcvcs should be avoided. infusion of e % and e % for hours weakens pcvcs. nimodipine and other drugs using ethanol as a carrier vehicle should be infused via pcvcs with caution. these potential hazards should be outlined in individual pcvc package inserts and drug product information leaflets. ( ) introduction. inadvertent esophageal intubation may lead to serious complications such as hypoxia, cardiac arrythmias and death. auscultation of breath sounds may be an inaccurate method to determine correct endotracheal tube placement of endotracheal tube placement. vibration response imaging (vri) is a novel non-invasive technology that measures vibration energy of lung sounds during respiration. as air moves in and out of the lungs, vibrations propagate through lung tissues and are recorded by sensors spacially distributed on the patient's back over the lungs and a dynamic image is created. a year old female patient presented with lung cancer. plain chest radiograph and ct scan revealed a large left lung mass comparable for a neoplasm. she was admitted for left lung lobectomy. after informed consent was obtained, she underwent vri before and after intubation. the esophagus was inadventently intubated and recognized immediately after the vri recording was obtained. the patient went on to have a successful operation. analysis of the vri data obtained during esophageal and tracheal ventilation are compared along with a normal vri image. during esophageal ventilation most of the vibrations ( %) were detected by the upper sensors and the least by the lower sensors ( %) (fig. ) . following the endotracheal intubation as well as in a normal image, the vibrations were more evenly distributed with the sensors from the middle region receiving more vibrations. quick detection of inadvertent esophageal intubation is crucial to prevent serious complications but commonly used methods of confirmation such as auscultation and plain chest radiograph are inaccurate or do not provide timely results. vri is a novel technology that offers the potential to quickly identify inadvertent esophageal intubation in the or and perhaps other settings. the acapella ® is a small hand-held vibratory device that combines the resistive features of the positive expiratory pressure (pep) and the vibratory features of a flutter valve to mobilize secretions in the airway. vri is a novel dynamic imaging technique that measures vibration energy of lung sounds generated during respiration. in this study, our aim is to determine, using the vri, what regions of the lungs receive the most vibrations when the acapella is being used. a second vri recording was performed on a healthy volunteer during normal breathing (first three breaths) and while using the acapella device (last four breaths). the vri recordings were obtained in second periods of respiration. dynamic digital images and numerical raw values for vibration energy are analyzed and compared any regions of interest. . vri images at maximal expiration while using acapella show increased total vibration intensity. when the distribution of expiratory vibration is examined, it appears that vibration from the acapella goes more to the lower lung regions (figure and ) . asymptomatic catheter-related central vein thrombosis (cvt) which is diagnosed by venographic studies is mentioned to be as high as %. moreover, when thrombosis occurred, the risk of catheter related sepsis was declared to be . % higher. in this prospective study we aimed to diagnose cvt early as possible, its incidence and risk factors. icu patients (pts) that needed a central venous access for at least hours without chemotherapeutic agents administration were included in this prospective study. the catheters were inserted via internal jugular or subclavian vein at bedside under aseptic conditions using the seldinger technique. diagnosis of vein thrombosis was detected by color doppler ultrasound examination performed in less than h after catheter removal (picture). the protocol was approved by the ethic committee. three hundred and thirty eight pts ( f, m), mean . years old ( - years), were included in the study. catheters mean duration time was . days and duration of insertion mean time was . min ( - min). in pts catheter insertion was performed with a single puncture, in pts with double and in pts with three and more punctures. catheter localization was : in pts right subclavian vein, in pts left subclavian vein, in pts right internal jugular vein and in pts left internal jugular vein. catheter related thrombosis was diagnosed in pts ( . %) while catheter infection was seen in patient ( . %) (table). generally the chemotherapeutic agents administered via the central vein catheter have thrombogenic effect. when we study our cvt diagnosed pts we found out that all of them were over years old, the mean catheter duration time was . days (table) . but these results were not statistically significant when compared with the other pts under years old and more than . days of mean catheter duration time. out of pts who were not under anticoagulant therapy had cvt while out of pts under anticoagulant therapy had cvt diagnose which was found statistically insignificant (p> . ). our results show that patients under anticoagulant therapy have a three fold more cvt risk ratio than the others who are not using this anticoagulant therapy. patients under anticoagulant therapy have to be followed more closely regarding to cvt. the provision of good glycaemic control is thought to have some beneficial aspects in critical care patients. we have previously described the introduction of a web-based insulin dose calculator program to support the control of blood glucose in critical care. the aim of this study is to describe a modified version of a calculator program based on van de berghe's studies. this allows nursing staff to enter blood glucose values together with the insulin infusion rate into a calculator. the calculator then provides a recommended insulin infusion rate to control blood glucose with the added ability to recommend small bolus doses of insulin when appropriate, store blood glucose concentrations, insulin rates, bed number and the date and time of calculation. we also modified our feeding protocol to restrict the target enteral feed from kcal to kcal per day and removed the night time rest period. we studied the data stored by the program which was used for all patients admitted to a -bedded intensive care unit (approximately % of whom have neurological injuries) between june and may . overall there were patients admitted (mean apache ii score [sd +/- ], with a mean age of years [sd +/- ]. patients died prior to icu discharge. there was a total of patient days with recorded calculation data points. the mean blood glucose concentration was . mmol ( ci . - . ). there were episodes of treated hypoglycaemia of which were on an insulin infusion. there were two troughs in the time of data entry that corresponded with staff handover. there was no diurnal variation in blood glucose concentration or in insulin infusion rates, although this did peak slightly in the early morning. the mean value of the insulin infusion rate was . units / hr (sd +/- . ). in normal subjects there is a decreased level of endogenous insulin in the early morning, that is only partly lost with constant nutrition. from this study we concluded that the web based insulin calculator facilitates the dosing of insulin in critical care in an economic manner. the lack of diurnal blood glucose concentration variation, suggests that once daily estimation of blood glucose may be an acceptable method of monitoring blood glucose concentrations in critical care. systemic inflammatory response syndrome (sirs) is a common entity in the intensive care units. early institution of an appropriate antimicrobial regimen in infected patients is associated with a better outcome. both c-reactive protein (crp) and procalcitonin (pct) are accepted sepsis markers. however, there is still controversy concerning the correlation between serum concentrations, infection and sepsis severity. objective:to determine the clinical aplication of procalcitonin (pct) and c-reactive protein (crp) plasma concentrations in the detection of sirs related to infection and sepsis and the assesment of severity of sepsis. desing: prospective observational study. setting: medicosurgical intensive care unit. patients: over a period of months (january-february ), forty seven consecutive adult patients admitted in a intensive care unit for an expected stay > hrs.and sris symtoms and signs. informed consent was obtained from all patients. measurements: pct and crp plasma concentrations and white blood cell counts , apache ii y sofa within the first h . each patient was examined at the time of enrollment and was classified in one of the following four categories according to the accp criteria: siris and sepsis group (sepsis, severe sepsis and septic shock). statistical analysis: were performed with spss . . differences in continuous variables between infected and non infected patients were compared with the nonparametric mann-whitney test. and lineal.regressión. pct levels were significantly higher in the severe sepsis(p= , ) and shock septic group (p< , ). pct and cpr levels no weren found differences between sepsis of less gravity group and noninfectious sirs. pct and crp levels are significantly correlated to the severity of organ dysfunction (sofa y apache ii). pct and crp levels were significantly higher withing short space of time in patient with infection than in patients with non-infectious sirs, but for sepsis of less gravity, pct and crp plasma values not differentiate between sepsis and non-infectious sirs. investigators have reported microcirculatory alterations in critically ill patients using various techniques. persistent microvascular alterations might be associated with the development of organ failure and death. in this study, microcirculatory blood transit time was measured in intensive care patients using micro-channel flow analyzers and related to the severity score and mortality. thirty-one patients were included in this study. mean apache-ii score was . . patients were divided into two groups, group l (apache-ii< , n= ) and group h (apache-ii>= , n= ). in both groups, blood transit time was measured using microchannel flow analyzers (mc fans). the micro-machined silicon chip is utilized in these instruments to simulate human capillary blood flow. microcirculatory alteration was presented as a blood transit time (second) of heparinized blood through micro-channel array under the pressure difference of cmh o. hematocrit, white blood cell (wbc) count, platelet count, and labolatory data were obtained at the same time. blood transit time was significantly longer in group h comparing that in group l ( . +/- . sec, . +/- . sec, p< . ). wbc count was larger in group h comparing that in group l ( +/- /ul, +/- /ul, p< . ). triglyceride (tg) and immunogloblin (igg/m/a) levels were significantly higher in group h comparing these in group l. none of the group l patients died, however, hospital mortality rate was . ? in group h. blood transit time through micro-channel array was prolonged in patients with high apache score )wbc, tg, and immunogloblin levels might be associated with patients blood fluidity. ) micro-channel flow analysis may become a valuable tool to monitor microcirculation in critically ill patients. a. roman* , t. el mahi , c. hanicq , d. gnat , f. vertongen , e. stevens intensive care, clinical chemistry, chu saint-pierre, brussels, belgium bedside glucose monitoring is mandatory for icu patients under tight glycemic control. point-of-care (poc) glucometers are based on glucose-dehydrogenase coupled with pyrroloquinoline-quinone/ferricyanide (gd/pqq)or phenanthroline-quinone/nad (gd/pqnad), or glucose-oxydase/ferricyanide (go) enzymatic methods for whole blood measurements. the laboratory reference method is hexokinase for measuring the plasma glucose levels. some drugs and metabolites can interfere with poc methods. the aim of this study was to evaluate the effect of the uric acid levels on the accuracy of these bedside methods. in this prospective observational study, arterial blood glucose was measured simultaneously on the accu-chek inform roche (gd/pqq), on the precision pcx abbott (gd/pqnad), on the rapidlab bayer (go) and each value was compared with the reference laboratory result. measures were done in adult icu patients. uric acid was obtained only once a day. a bland-altman analysis was done. biases were expressed as the poc minus the laboratory result. data were also analysed using linear regression. spearmann's rho squares were calculated to evaluate the uric acid level effect on the difference between poc and laboratory methods. the uric acid level range was . to . mg/dl. the biases, the % limits of agreement between each poc method and the reference method, the r of spearmann for the correlation between uric acid level and the difference of result glucose level for each poc method are shown in table . the accu-chek inform overestimates moderately the glucose level while the precision pcx and the rapidlab underestimate it slightly. the wilcoxon ranked test with bonferroni correction gave a p < . for comparing the bias from the accu-chek to the bias from the precision pcx, p < . when compared to the bias obtained for the rapidlab. no statistical difference between the precision pcx bias and rapilab was found. the r of spearmann correlating the effect of the uric acid level and the difference between the accu-chek and the reference method was . . the weak effect of the uric acid level of the patient on the overestimation of the glucose measured by the accu-chek can be summarized as : glucose difference(accu-chek-laboratory) = . x uric acid (mg/dl) - . . for the other poc glucometers, such correlations were absent. a patient presented with severe acidosis, point-of-care (poc) lactate of mmol/l, suspicion of mesenteric ischemia and potential need for laparotomy. however, plasmalactates was < mmol/l, and ethylene glycol (eg) ingestion was subsequently diagnosed. we, therefore, wished to determine why discrepant lactates occur and if this "lactate-gap" could be clinically useful. we phlebotomized blood, added various concentrations of eg metabolites, and tested with the five most common lactate analyzers. the pressure-volume(p-v)curve of the respiratory system defines the mechanical properties of the lung and the chest wall by relating airway pressure(paw)in no-flow conditions with lung volume at the same pressure level. objective:to evaluate a new technique for p-v curve tracing. two p-v curves were obtained in ali/ards patients using the continuous positive airway pressure (cpap) method and an automated system built into a commercial ventilator (p-v tool , galileo, hamilton). for the cpap method, ventilators were switched to cpap and pressure was raised from to cmh o in cmh o steps and then decreased while respiratory inductive plethysmography measured lung volume. for the automated method, we selected the automatic pv mode(galileo, hamilton)with flow l/m and maximum pressure of cmh o. lung-volume and airway-pressure data were recorded. p-v pairs were fitted to a mathematical model. lower (lip) and upper (uip) inflection points on the inspiratory limb and maximum curvature point on the deflation limb were obtained. correlation between methods was calculated using bias and % agreement limits for lips and uips and the intraclass correlation coefficient (icc) for absolute agreement for each pressure level. no adverse events were observed. p-v curves were equivalent for each method, with icc > . for each pressure level. bias and precision for lip and uip were:lip . ± . cmh o and uip . ± . cmh o. the automated method for tracing p-v curves is equivalent to the cpap method. easily applicable at the bedside, it avoids ventilator disconnection and can obtain both inspiratory and deflation limbs of p-v curves. introduction. hypoxic hepatitis (hh) is a common cause of acute hepatic impairment. however, few is known about the degree and duration of the reversal of the liver impairment. therefore we assessed the liver function by indocyanine green (icg) clearance via limon (pulsion medical systems, munich, germany) in patients with hh. icg clearance was assessed in critically ill patients fulfilling the criteria of hypoxic hepatitis. mean apache iii score was ± . nine patients were male. icu survival was %. icg -plasma disappearance rate (pdr) (normal range: - %/min) and the retention rate of icg extrapolated to minutes (r ) were obtained on the day of development of hh and till day five. nine patients with decompensated liver cirrhosis child c requiring intensive care therapy served as control group. results. icg-pdr and r expressed as mean ± standard deviation were . ± . %/min and . ± . %, respectively ( patients), on the day of development of hh. icg-pdr and r were . ± . %/min and . ± . %, respectively, in the control group and was comparable to the hh group (p=ns). icg-pdr and r improved continuously from time of development of hh to day five ( patients alive and at icu) and were comparable to the course of laboratory data during observation period (table ) . exhaled breath condensate (ebc) is a non-invasive means of collecting samples of airway lining fluid from the lower respiratory tract and monitoring respiratory diseases. we have used ebc acidification to study the effects of mechanical ventilation. ebc was collected ( - minutes at - o c: ecoscreen, jaeger). immediately after collection and as soon as the sample returned to room temperature, we measured conductivity and ph before and after deareation with helium ( minutes). results are expressed as median (interquartil range). we have applied spsswin with spearman correlation and mann-whitney test. our earlier evaluations of a decision support system for tight glucose control (tgc) in the critically ill utilising model predictive control (mpc) documented clinically acceptable performance with hourly bg sampling. the mpc advises on insulin infusion based on blood glucose (bg) measurements and carbohydrate content of parenteral and enteral nutrition. in the present study, we evaluated an improved version of the mpc (v . . to . . ), which extends the advice by suggesting the time of the next bg measurement in the range from half-to four-hourly to reduce nurse workload. patients were admitted at one medical (mug; n= ) and two surgical (kul: n= ; cup: n= ) icus. patients were followed for a minimum of hours and up to hours. we evaluated safety of tgc (hypoglycaemia frequency), efficacy (mean bg; hyperglycaemic index, hgi; and time spent in the target range . - . mm), and efficiency (time between bg measurements). nonparametric statistical tests evaluated differences among icus. one hypoglycaemia (bg < . mm) occurred in one subject at mug and in another at cup. there was no hypoglycaemia at kul. bg was within the target range but differed among icus with values of . ( . - . ), . ( . - . ), and . ( . - . ) mm [median ( strict glycemic control of plasma glucose has become general practice in most icus. frequent glucose control is required to titrate the amount of insulin infused and detect episodes of hypoglycemia. for practical reasons bedside glucometry is often used. aim of our study was to determine the accuracy of several glucose point-of-care (poct) devices in critically ill icu patients. arterial blood samples from unselected icu patients were collected and glucose measurements were performed on a bloodgas analyzer (glucose-oxidase; rapidlab bloodgas analyzer, bayer diagnostics) and three different poct devices (gdh-pqq, accu-chek sensor, roche diagnostics), gdh-nad+ (precision, abbott diagnostics) and modified gdh (hemocue). results of paired measurements were compared in three ways. paired values were plotted on a bland-altman plot. the pearson correlation coefficient (r) between the different methods was determined by linear regression. each pair was also analysed using the international organization for standardization (iso) criteria: -glucose > , mmol/l value within % of reference -glucose ≤ , mmol/l value within . mmol/l of reference. comparison between accu-chek and rapidlab of samples from unselected icu patients (n= ) showed a good correlation (r = . ). bland-altman analysis and analysis by iso criteria revealed clinical significant differences in . % of pairs. in all cases the poct values were higher than the values from the bloodgas analyzer. comparable results were found using the precision and hemocue: although correlation was high, analysis by iso criteria showed differences in / ( . %) and / ( . %) of pairs. a clinically important inaccuracy was found between poct devices and bloodgas glucose measurements in critically ill icu patients. in the most cases values from poct devices were false high, increasing the risk of hypoglycemia. in the context of an insulin infusion protocol for aggressive glucose control in sedated icu patients poct devices are potentially dangerous and should be avoided. acute hyperglycaemia associated with insulin resistance is common in critically ill patients. acute tight control of blood glucose is considered important, although difficult to perform in routine care. we developed a software to implement tight glycaemic control (cgao): after each glucose level measure, the cgao advises a new insulin pump rate and the schedule for the next glucose control, gives indication for correcting any hypoglycaemia episode, and presents numerous parameters describing the quality of glycaemic control. in a retrospective case control study, we compared the software cgao (lk , igny, france) used routinely in our unit since may with our previous method for glycaemic control based on daily medical prescriptions. patients without cgao (group pres) were randomly selected from our prospective intensive care database (admission after january , ) and matched : for sex, age, simplified acute physiologic score (saps ii), medical or surgical category, history of type diabetes, and length of stay (los) with patients for whom we used cgao. type diabetic patients or patients with los < days were excluded. endpoints were average glucose level, hyperglycaemic index calculated above . mmoles/l, fractions of time (ft) resp. with normoglycaemia [ . - . mmoles/l] and hyperglycaemia [> . mmoles/l], cumulative duration of hypoglycaemia [< , mmoles/l], average insuline requirements per day, and mean sampling interval for glucose control. we included patients (mean age: ± years, saps ii: ± , surgical: %, type diabetic: %), permitting to compare cgao patients with pres patients. a. sigalas*, d. w. patch, a. k. burroughs, j. p. o'beirne liver transplantation and hepatobiliary medicine, royal free hospital, london, united kingdom recently a number of studies have reported that relative adrenal insufficiency (rai) is common in critically ill cirrhotics. depending on the definition used the prevalence of rai in critically ill cirrhotics has been reported to be - %, whilst in patients immediately post liver transplantation the incidence of rai has been reported to be %. given the high prevalence of rai in critically ill cirrhotics and patients undergoing liver transplantation, we hypothesised that adrenal function impairment may be a feature of chronic liver disease per se. the aim of this study was to define the prevalence of impaired adrenal function in patients with stable cirrhosis. we also examined whether the use of the µg or µg acth tests was associated with different responses. methods. patients with biopsy proven cirrhosis (or compatible imaging and biochemistry) underwent adrenal function testing with the µg (n= ) or µg(n= ) short synacthen tests (sst). patients were those with stable cirrhosis undergoing evaluation for transplantation or assessment for tips insertion for refractory ascites. patients with a recent history of infection or bleeding were excluded. . patients underwent adrenal function testing. the median age of the group was (iqr - ). the commonest cause of cirrhosis was alcohol in %. disease severity was measured by meld and childs-pugh scores. the median meld was (iqr . - . ) and the median childs-pugh score was (iqr - ). patients ( %) showed a baseline cortisol < nmol/l and an increment < nmol/l following sst. patients ( %) had an increment in cortisol < nmol/l following sst. patients ( %) had a baseline cortisol < nmol/l. overall abnormalities in the sst (low baseline, peak or increment) were seen in patients ( %). there were no significant differences in the frequency of abnormalities in the sst between the µg or µg sst groups. in multivariate analysis only meld score significantly predicted abnormalities in the sst. the above data suggest that adrenal dysfunction is a frequent finding in patients with stable cirrhosis and is correlated with liver disease severity. the underlying mechanism of this finding is unknown but may account for the very high frequency of rai in critically ill cirrhotics. the direct relation between glucose and lactate levels in critically ill patients has hardly been studied. we studied the relation between glucose and lactate in general and during hypoglycemia. intensive insulin therapy was performed with the nurse-centered grip computer system that aimed at a glucose level of . mmol/l or less. glucose and lactate were routinely measured together. all hypoglycemias detected over a -month period at the surgical icu were analyzed. hypoglycemia was divided in mild ( . thru . ), moderate ( . thru . ) and severe (<= . mmol/l) hypoglycemia. . , glucose/lactate measurements were analyzed in patients. glucose and lactate both were not normally distributed. after taking these distributions into account no evident relationship between simultaneous measurements of glucose and lactate was seen. hypoglycemias were identified ( mild; moderate; severe). lactate showed a with a nadir value two hours after the hypoglycemia. the magnitude of hypoglycemia was not related with lactate response. evidence accumulates that improved glucose control in intensive care patients results in better outcome. improved glucose control requires rapid point of care glucose measurement. however, the reliability of point of care glucose measurements has been questioned. this study was done to evaluate the accuracy of accucheck point of care glucose measurement in intensive patients as compared to glucose measurement by the central hospital laboratory. the unit is a bed mixed closed format icu. glucose regulation is performed by nurses for all patients using a computerised protocol( ). for this study, paired glucose measurements were randomly done in patients in the icu, only when glucose measurement was clinically indicated and only if workload permitted the extra task. the accucheck inform device (roche diagnostics) measures whole blood glucose in a single drop of blood. the central laboratory uses glycoseoxidase vitros to measure glucose in serum. from patients paired measurements were obtained (table ) . central laboratory glucose measurement was generally higher than accucheck glucose measurement. the mean difference was , mmol/l. correlation coefficient r was , . the difference was more than , mmol in % of cases. blood samples were mostly ( %) derived from arterial lines. the correlation and bland altman plots are presented in figure . related literature was examined for benchmarking purposes. data collection was carried out over a one month period, two days a week, in the icu. each blood sugar level (bsl) was recorded and ensuing action chosen on adjusting the insulin infusion rate, and resultant information analysed. a survey was carried out on nursing staff regarding their views on the protocol. statistical analysis was carried out using microsoft excel ® . the bsls were in the target range of . - . mmol/l . % of the time (n= ). the proportion of bsls that complied with the surviving sepsis guidelines target of less than . mmol/l was good at . %. the incidence of severe hypoglycaemia, defined as less than . mmol/l, was low at . %. compliance with the action chosen on adjusting the insulin infusion rate was high at . %. total compliance (action and timing) with the protocol was %, and a relationship between compliance and achieving target bsls was shown. in general, a positive view of the protocol was obtained from the nursing staff regarding the protocol. the amnch icu insulin infusion protocol is effective at achieving tight glycaemic control in a safe manner. the low incidence of severe hypoglycaemia and high proportion of bsls complying with the surviving sepsis guidelines illustrates this. compliance with the protocol is achievable, demonstrated by the high level of compliance on action taken on the insulin infusion rate and the survey responses. however the timing of bsl checking needs to be addressed in future drafts of the protocol, as this is an area that needs improvement in terms of feasibility and compliance. further changes and auditing of the protocol are necessary to ensure consistency and improvement of the tight glycaemic control. introduction. intensive insulin therapy might be able to reduce mortality and/or morbidity in critical patients. besides adherence to strict protocols this strategy implies multiple, accurate measurements of glycemia. gold-standard laboratory assessment isn't able to provide immediate readings and capillary or arterial blood samples may differ too much when bedside reflectance meters are used, particularly in shock patients. our aim was to assess the accuracy of two methods of blood glucose analysis (bedside "glucometer" using capillary and arterial blood) in two groups of critical ill patients (shock and non-shock). prospective non-randomized, cohort study, in a university hospital general icu. a group of consecutive icu patients with shock syndrome and vasoactive amines and another contemporary patients without shock, were included (shock-sg and non-shock-nsg groups). for each patient to "triplets" of blood samples were collected in a h period, and included concomitant samples of blood drawn from fingerstick (cap) and non-heparinized arterial line(art). drops of capillary and arterial blood were analyzed with a bedside glucometer (glucotouch ® , lifescan), and a sample of arterial plasma was sent to laboratory for glycemia determination (lab). . total group had a median age of years, mean saps ii of , . sg was older (median age - vs ys) and more ill (mean saps ii , vs , ) than the nsg. total mortality was , % (sg- , %; nsg- , %). in the sg , % had septic and , % cardiogenic shock. in the nsg , % had politrauma and , % pneumonia. a total of "triplets" were studied. non parametric wilcoxon test was applied to test agreement between cap-lab and art-lab paired samples. although we've found a highly significant correlation (spearman r> , ) between cap-lab and art-lab values, agreement were rejected by -tailed wilcoxon signed ranks test, both in total, sg and nsg (p= . ). an error grid-analysis using iso for blood glucose determination showed that , % of cap and , % of art determinations had a deviation more than % the reference lab value in the sg. in the nsg % of cap and % of art samples had more than % deviation. this study show that the glucometer we used had an unacceptable accuracy, both in shock and non-shock patients, far from the iso criteria that imposes only % of values can be more than % apart the reference value. glucose control is a major issue in the icu and standard procedures for its determination are still lacking. introduction. arginine (arg) is a precursor of the vasodilator nitric oxide (no), while asymmetric dimethylarginine (adma), derived from proteolysis of methylated arg residues, is a no synthase inhibitor. accumulation of adma is related to oxidative stress, impairing its degradation, and to renal-and liver failure. accumulation is associated with increased mortality ( ). aim of this study was to evaluate the relation between plasma arg, adma, arg/adma ratio, organ failure and survival in patients with shock. we measured plasma concentrations of arg, adma and lactate, sofa scores and hospital mortality in septic (ss) or cardiogenic shock (cs) patients on d , d and d of icu admission. patients were enterally fed with impact (arg-enriched). values are presented in mean ± sd or median (iqr). for regression analysis, arg, adma and arg/adma were log transformed. of the patients, had ss, cs. mean age was ± yrs, sofa ± , apache ii ± . . hospital mortality was %, predicted mortality was ± %. at d , median (iqr) of arg was ( - ) mumol/l (normal range - mumol/l), adma . ( . - . ) mumol/l, arg/adma ( - ) and lactate . ± . mmol/l. arg and arg/adma at d were inversely related to lactate (r = . , p < . , for arg; r = . , p < . for arg /adma), and to sofa scores. the table presents the relation between arg and arg/adma to sofa score during sampling, and of arg and arg/adma on day to maximum sofa score. apneic oxygenation (ao) is apllied during several operations in thoracic surgery and some procedures in th icu. retention of co often leads to hypoxemia, limiting the tolerable time in ao. this experimental study was designed to evaluate the effects of recruitment maneuver on oxygenation, co retention and survival times ao. following the ethic committee approval, male sprague-dawley rats were anesthetized, tracheostomized, cannulated via the a. carotis and ventilated with pressure controlled ventilation (peak pressure: cmh o, frequency: /min, cm h o peep) for minutes. following the basal (t ) arterial blood gas sample, they were randomized into groups and disconnected from the ventilator: in group (n= ), rats underwent ao with a cannula inserted to carina (o -flow: . l/min), in group (n= ), recruitment maneuver ( cm h o (peep) ventilation pressure during seconds) was performed before ao. in control group (group , n= ), data were recorded after apnea (this group was stopped after the first subjects have died during the study period). further arterial blood gas samples were drawn in st, rd and th minutes, and ph, po , pco , hco and be values were recorded. survival times after the initiation of ao were also investigated. kruskal-wallis test was used to compare the values in different times, and mann-whitney-u the values in different groups. there were no significant difference in t values. compared to t values, there was a significant decrease in po and a significant increase in pco during rd and th minutes in all subjects, with a less change in g . there was a significant difference between g and g in po after and minutes p< . ; table ), the difference in pco was not significant. survival time in g was significantly longer (g : , ± , min; g : , ± , min; p< . ). to investigate potential prognostic factors and to predict extent of risks for postoperative pulmonary complications by logistic regressive analysis, and to evaluate the role of non-invasive ventilation in reducing the incidence of complications in elderly patients. stair-climbing test was carried out with asa score, fev , changes of spo and hr et al were noted at the same time. logistical regressive analysis based on the parameters above were used to assess the relation between potential prognostic factors and postoperative complications. patients with limited pulmonary reserves were selected using the equation, and protective effect of non-invasive ventilation on these patients was assessed. incidence of postoperative pulmonary complications for high-risk patients with non-invasive ventilation was . %, and incidence of pulmonary complications for high-risk patients without non-invasive ventilation was . %. there was not a significant difference between these two groups with low-risk (p> . ). conclusion. the mathematical model of logistic regressive analysis using stair-climbing testing combined with other parameters is a simple, reliable method to predict the cardiopulmonary reserved function in elderly patients. non-invasive ventilation can effectively reduce the incidence of postoperative pulmonary complications for high-risk patients, but it has no effect on patients with low-risk. continuous epidural analgesia (ea) and intravenous analgesia (ia) are widely used for postoperative thoracic pain control. the aim of this study is to compare the advantages and the disadvantages of both analgesic techniques. ropivacaine . % to mg/h using thoracic epidural catheters (ea) vs intravenous analgesia with remifentanyl . µgr/kg/min (ia). one hundred patients, undergoing pulmonary surgery, were recruited and divided, after randomization into groups. patients included in ea group had an epidural thoracic catheter placed at th -th space, received ropivacaine . % by continuous infusion (rate ml/h). patients included in ia group received an ev continuous infusion of remifentanyl (rate . µgr/kg/min for hours). rescue medication consisted of morphine mg ev at patients demand. analgesia at rest and while coughing as evaluated by visual analogue scale (vas). haemodynamics, motor blockade (bromage scale) and side effects such as nausea, vomiting and pruritus were observed. the follow-up took place after weaning and every hour to hours at rest and coughing. data are reported to media ± standard deviation (sd). analgesic effects were compared by using chi square statistics (p< . ). both groups showed good analgesic effects. remifentanyl seems to decrease the incidence of side effects and the need of rescue analgesia. conclusion. )our data show that both analgesic techniques are able to guarantee a good pain relief after thoracotomy. )epidural analgesia was more difficult to perform and it showed less acceptance by patients. non-invasive ventilation (niv) has become an effective treatment to reduce morbidity and mortality in patients with acute respiratory failure. its application has been restricted to critical care o intermediate care areas, and little data is available on its usefulness in the post-anaesthesia care units (pacu). the aim of this study is to document our experience after eight patients treated in the pacu. we undertook a retrospective audit of patients treated with niv between october and december . data of past medical history, age, asa physical status, surgical procedure, anaesthesia modality, type of respiratory failure, ventilatory mode, and time of niv were recorded. we also recorded side effects related to niv application. descriptive statistical analysis was used. eight patients were included. the mean age was . ± . (sd) years. five patients were classified as asa ( . %), two as asa ( . %), and one as asa ( . %). three patients had morbid obesity, two chronic heart failure, and two chronic obstructive pulmonary disease. general and regional anaesthesia were employed in and cases respectively. type of surgery was thoracic ( %), urologic ( %), and plastic ( %). there was one case of abdominal surgery and another one of oral surgery. hypoxemic failure was detected in three patients ( . %), and cpap was applied in these cases. bipap was applied in cases of hypercapnic ( . %) or global ( %) respiratory failure. the mean time of niv was . ± . (sd) minutes. no complications related to niv occurred. no patient required either intubation or transfer to the icu. all of them were transferred to the surgical wards the same day. conclusion. niv can be safely applied to selected patients in the pacu, to treat respiratory failure after either general or regional anaesthesia. it is an effective method to avoid intubation and icu stays, with minimal side effects. further studies should be conducted to analyze the clinical and economic impact of niv in the pacu. the routine use of volatile anesthetics in intensive care medicine has been limited so far due to technical difficulties and the need for an anaesthetic machine. the new anesthetic conserving device (anaconda)can provide a safe application of isoflurane or sevoflurane under intensive care conditions. this system is a modified heat and moisture exchanger which includes activated carbon fibres and works as a miniaturized vapor with recirculation. we studied the effectiveness of sevoflurane sedation in operative intensive care patients undergoing mechanical ventilation. we included ventilated patients (neurosurgery, septic patients) in our retrospective analysis. the anaesthetic conserving device (anaconda-system) replaces the common heat and moisture exchanger in the ventilator circuit. the volatile anaesthetic is continuously applied in liquid status via a syringe pump to the minivapor where the anesthetic is vaporized. the expired anaesthetic gas is stored in the carbon filter and about % are resupplied into the breathing circle. first experiences with sevoflurane at our institution with a mean application time of . ± . hours per patient, showed a mean dose of . ± . ml sevofluran to achieve the individually targeted sedation level. . ± . minutes after the end of sevoflurane application, the patients could be neurologically evaluated or transferred to spontaneous breathing or extubated. no relevant side effects like nausea, vomiting or elevated enzymes were observed. we could demonstrate a safe application route, no development of tolerance as well as short wake-up times after long-term sedation with sevoflurane. the current literature suggest that volatile anaesthetics present an alternative for long-term sedation on intensive care units, providing optimized pathways from a medical as well as from an economical viewpoint. safety and effectiveness of sedation and analgesia in permanent pacemaker implant (ppm) is of special concern, due to age and comorbidity of the implanted patients. remifentanil pharmacological properties appear to be of interest in this setting. to date, there are no reports describing the use of remifentanil in this procedure, without the use of mechanical ventilation. consecutive patients in whom a ppm or other procedures, such as pacemaker battery change, was scheduled were included. a sedation and analgesia protocol for ppm implantation was performed: metoclopramide premedication, remifentanil infusion ( mg/ml), local anaesthesia with mepivacain %, magnesic metimazol administration at the end of procedure, and remifentanil infusion withdrawal minutes later. remifentanil infusion was initiated at a rate of mcg/min, increasing the rate to attain a sedation ramsay scale grade or , to a maximum of mcg/min. remifentanil failure was defined as the need to administer a different sedation after the maximum dosage was attained. adverse effects, lenght of infusion and dosage were recorded. .two hundred and thirty-six consecutive patients were included. the men age was , ± , . procedures: bicameral pacemaker , %, unicameral , %, battery change , %, other , %. infusion description and adverse effects are showed in tables and . serious adverse effects were resolved with remifentanil infusion withdrawal. all the procedures were completed. remifentanil is safe and effective as sedation and analgesia for ppm implantation, even for old patients, with the dosages used in our protocol. nausea is the most frequent adverse effect. serious adverse effects are uncommon and can be resolved with infusion withdrawal. glass psa, gan tj, howell s. a review of the pharmacokinetics and pharmacodynamics of remifentanilo. anesth analg ; : s -s . peripheral arterial occlusive disease (paod) can cause intense neuropathic/ischemic limb pain in patients (pts) with end stage renal disease (esrd). although fentanyl may be an excellent choice in esrd due to the absence of active metabolites, the use of fentanyl as pca in esrd has never been reported. we used iv fentanyl pca for ischemic lower extremity pain in esrd patients ( m, f), of whom were scheduled for amputation. pts received iv fentanyl pca via a gemstar (abbott) pump. initial settings were mcg bolus, min lockout, no basal, and dose was adjusted as needed to achieve visual analogue scale (vas) score < . pca started hours preamputation and continued postoperatively for h in pts ( pts had epidural postoperative analgesia and one terminal cancer pt did not have surgery). pain was assessed twice daily with vas. the mcgill pain questionnaire (mpq) -total ranked rating index (pri(r)), was administered immediately before and h after pca started. sedation was assessed twice daily on a four-point scale: ) agitated, ) awake, ) roused by voice and ) unarousable. pain scores were compared with paired t-test. group data are presented as mean ± sd. mean sedation score was in men and in women. we did not observe respiratory depression in any patient. the aim of this study was to determine risk factors for relapse, and for icu-mortality in patients with ventilator-associated pneumonia (vap) related to nonfermenting gram negative bacilli (nf-gnb). retrospective case-control study based on prospectively collected data. vap diagnosis was based on clinical, radiographic and microbiologic (endotracheal aspirate ≥ cfu/ml) criteria. patients with monobacterial vap related to nf-gnb were eligible. patients with subsequent superinfection or persistent pulmonary infection were excluded. patients with relapse of nf-gnb vap were matched ( : ) with patients without relapse according to duration of mechanical ventilation before vap occurrence. univariate and multivariate analyses were used to determine risk factors for relapse, and for icu-mortality in cases and controls. . patients were eligible. patients were excluded for superinfection. no persistant infection was diagnosed. ( %) patients developed a relapse of nf-gnb vap, and were all successfully matched with controls. pseudomonas aeruginosa was the most frequently isolated bacteria ( %), followed by acinteobacter baumannii ( %) and stenotrophomonas maltophilia ( %). no significant difference was found between cases and controls with regard to age ( ± vs ± ), male gender ( % vs %, p = . ), and surgery ( % vs %). however, saps ii at icu admission ( ± vs ± , p = . ) was significantly lower in cases than in controls. duration of adequate antibiotic treatment for first vap episode was significantly shorter in cases than in controls ( ± vs ± d, p = . ). inadequate initial antibiotic treatment was the only variable independently associated with relapse of vap related to nf-gnb (or [ % ci] = . inadequate initial antibiotic treatment is independently associated with relapse of vap related to nf-gnb and with icu-mortality. ∆ radiologic score and saps ii at day after vap diagnosis are independent risk factors for icu-mortality in these patients. s. blot* , j. solé-violán , j. blanquer , j. almirall , a. rodriguez , j. rello icu, ghent univ hosp, ghent, belgium, icu, dr negrin hosp, gran canaria, respiratory care, clinic hosp, valencia, icu, mataró hosp, barcelona, icu, joan xxiii univ hosp, tarragona, spain practice guidelines suggest processes of care such as timely pulse oximetry monitoring and antibiotic therapy, as quality indicators for the management of communityacquired pneumonia (cap). the objective of this study was to determine whether postponed initial processes of care such as pulse oximetry monitoring delays initiation of antibiotic therapy and adversely affects intensive care unit (icu) survival in patients with severe cap. a prospective observational multicenter study was conducted including patients with cap admitted to the icu in hospitals. a secondary analysis was conducted to evaluate processes of care and icu survival. postponed blood culture sampling, arterial blood gas sampling and pulse oximetry monitoring was predictive for delayed antibiotic administration (p< . ). linear regression analysis demonstrated that a delay of > h in blood culture sampling was associated with a delay of . h ( % confidence interval [ci], . - . ) in antibiotic therapy, a delay of > h in blood gas sampling with a delay of . h ( % ci, . - . ), and a delay in pulse oximetry monitoring of > h with a delay of . h ( % ci, . - . ). a delay in antibiotic administration of > h was associated with increased mortality in univariate analysis (relative risk [rr], . ; % ci, . - . ), but not after adjustment for disease severity. a delay in pulse oximetry monitoring of > h was associated with increased mortality in univariate analysis (rr, . ; % ci, . - . ) and after adjustment for disease severity (hazard ratio, . ; % ci, . - . ). in patients with severe cap timely executed processes of care are associated with a short time to antibiotic administration and reduced risk of death. appropriateness of antibiotic therapy is associated with reduction of bacterial load. c-reactive protein (crp) is a valid biochemical surrogate. our objective was to determine the correlation of bacterial load, measured by quantitative tracheal aspirate (qta), with crp as an indicator of inflammatory response in episodes of lower respiratory tract infection. to evaluate whether appropriateness of antibiotic treatment influences microbiologic (qta), biochemical (crp) and clinical resolution criteria (temperature, wbc, sofa and po /fio fraction). prospective cohort study. sixty-five intubated patients with monomicrobial lower respiratory tract infection were included. crp and bacterial load variation were evaluated through the ratio between d and d measures. a qta was performed on lower respiratory tract onset (d ) and h afterwards (d ). its logarithm value (logqta) was recorded. logqta correlated positively with crp, temperature and wbc. logqta has decreased significantly more from d to d in patients receiving appropriate empirical antibiotic therapy compared to those with inappropriate treatment (logqta ratio . vs . , p< . ). mean crp levels showed a similar pattern, decreasing from d to d in patients receiving appropriate empirical antibiotic treatment, but not in episodes with inappropriate treatment (crp ratio d /d . vs . , p< . ). ancova showed that crp level on d was significant lower in patients with appropriate antibiotic treatment compared to inappropriate empiric treatment ( ± mg/l vs ± mg/l, p< . ). the best cut-off to predict appropriateness of antibiotic therapy is a crp levels reduction of % on d (auc= . ). conclusion. c-reactive protein correlates with bacterial load and is a valid biochemical surrogate of bacterial burden in lower respiratory tract infection. follow-up measurements of crp anticipate the appropriateness of antibiotic therapy. a. günther* , p. schenk , m. maggiorini , a. betbesé , p. f. laterre , n. fedorovskiy , f. j. h. taut , r. g. spragg university of giessen, lung center, giessen, germany, , medical university vienna, vienna, austria, , universitätsspital zürich, zurich, switzerland, , hospital sta cruz y san pablo, barcelona, spain, , hôpital saint luc, brussels, belgium, , city clinical hospital n , moscow, russian federation, altana pharma ag, a member of the nycomed group, konstanz, germany, , uc san diego, san diego, united states the formal diagnosis of ards requires the acute onset of a severe impairment in oxygenatio(pao /fio <= mm hg), exclusion of a hydrostatic cause, and the presence of diffuse bilateral opacities. pneumonia is one of the most common underlying reasons for development of ards, but when only unilateral opacities are present, these patients fail to fulfil ards criteria. it is currently not known whether fulfilment of the formal ards criteria has any impact on -day mortality in patients with pneumonia suffering from severe gas exchange abnormalities. the valid study, a randomised, double-blind study in intubated and mechanically ventilated patients with severe respiratory failure (pao /fio <= mm hg) due to pneumonia or aspiration of gastric contents investigates the effect of rsp-c surfactant (venticute ® ) on mortality. the study does not require a formal diagnosis of ards for patient enrolment. however, the presence or absence of ards is documented. we conducted univariate and multivariate logistic regression analyses using preliminary blinded data from the first patients randomised with a diagnosis of pneumonia. the prognostic value of the formal diagnosis of ards was determined. univariate logistic regression analysis failed to identify a significant correlation (p= . ) between the formal diagnosis of ards and mortality at day . pao /fio was more likely to be associated with mortality (p= . ) as was the number of quadrants on chest radiograph that showed opacities (p= . ). age and apache ii score were highly associated with mortality (p< . ). multivariate logistic regression identified age (p< . ), the number of involved quadrants (p= . ), and apache ii (p= . ) as independent factors affecting -day mortality. conclusion. the prognosis of ventilated patients with pneumonia is not dependent on the formal diagnosis of ards. instead, age, apache ii score, and the number of lung quadrants with radiographic opacities are more predictive of outcome. bernard gr et al. intensive care med. ; : - . to determinate the clinical-epidemiological characteristics and risk factors for postsurgical pneumonia (psp) after lung cancer resection in a university hospital. a retrospective case-control paired study ( : ) was performed in cases of lung cancer collected from to . definition of psp case was a new or changing radiographic infiltrates with two or more of the following criteria: fever > o c, wbc> mm or/and purulent secretions. control group was formed by patients matched by age and lung cancer stage. . patients were evaluated ( psp and controls). overall, data of both groups were: age ± yr, males ( %), smoking habit (active or past smokers) patients ( %), copd patients ( %) and weight loss over kg in patients ( %). incidence of psp was %, crude mortality rate and attributable mortality estimated for psp was % and %, respectively. in the psp group, we found the following isolates ( %): p. aeruginosa ( %), s. viridans ( %), h. influenzae ( %) s. pneumoniae ( %) and undeterminated ( %). psp was associated with low bmi (p= . ), low fev (p= . ), stage iiia (p= . ), anaesthetic time (p= . ), pneumonectomy (p= . ), thoracic pain (p= . ), reintubation (p= . ) and haemorrhage (p= . ). conclusion. the incidence of psp in our series is low but with a high mortality. identification of risk factors (some of them suitable for medical intervention) may improve the management of lung cancer patients treated with surgery. j. karhu* , h. syrjälä , p. ylipalosaari , j. laurila , p. ohtonen , t. i. ala-kokko anesthesiology, division of intensive care, infection control, surgery, oulu university hospital, oulu, finland introduction. scap (severe community acquired pneumonia) and hap (hospital acquired pneumonia) requiring icu treatment have been shown to be associated with significantly higher mortality compared to those not requiring icu treatment ( , ). we compared pneumonias acquired outside the icu to that acquired in the icu, during mechanical ventilation (ventilator-associated pneumonia, vap). patients admitted into a mixed university level icu during a month period whose icu stay was longer than hours were included. the occurrence of scap, hap and vap were prospectively assessed. the following information was collected: age, severity of underlying disease on admission, underlying malignancy and recent use of immunosuppressive therapy. the length of icu and hospital stay as well icu, hospital and day mortalities were recorded. a total of patients fulfilled the inclusion criteria during the study period. there were a total of pneumonias. majority of the pneumonias were scap ( / ), while there were hap and vap cases. patients with hap tended to be older ( . , p= . ) and a larger proportion of them had malignancy ( %, p< . ), compared to vap ( years, %) or scap ( years, %). there were no significant differences between the mean admission apache ii scores (scap . vs. hap . vs. vap . ) . the icu length of stay was longest in vap; while the hospital stay was longest in patients with hap (table ). the survival rates were highest in hap, although this did not reach statistical significance. in apache ii and age adjusted multivariate logistic regression analysis vap (or . , % ci . - . , p= . ) and scap (or . , % ci . - . , p< . ) remained significant risk factors for hospital mortality together with immunosuppression (or . , % ci . - . , p= . ). heart surgery in infants is often associated with pulmonary inflammatory process. at the same time, the blood level of pro-inflammatory factors: interleukin- (il- ) and interleukin- (il- ) is increased. the number of polymorphonuclear leukocytes (pmn-elastase) and neutrophils is raised as well. a qualitative evaluation of the factors, cellular composition analysis of nonbronchoscopic trachebronchial lavage (ntl) combined with clinical findings can help early diagnose pneumonia. the objective of the study was to reveal the peripheral blood level of pro-inflammatory cytokines (il- , il- ), the activity of pmn-elastase and α antiprotease inhibitor (α -pi), as well as examine the ntl cellular composition and cytokine level in infants before and after heart surgery. we studied infants aged from days to months, weighting between . and kg. patients underwent cardiopulmonary bypass surgery, patients were operated on without cardiopulmonary bypass. in cases a clinical diagnosis of pneumonia was made between and days postoperatively. early postoperative survival was %. the peripheral blood cytokine concentration in operated infants pre-and postoperatively is presented in the study (table ) . a significant increase in pro-inflammatory factors after surgery can be observed. we examined the ntl of infants who underwent heart surgery and who did not develop pneumonia. we noticed that the number of neutrophils increased significantly in all patients after cardiopulmonary bypass surgery, sometimes reaching %. we consider it as a sign of pulmonary inflammatory process. the number of nonviable alveolar macrophages before and after surgery exceeded %. it indicates a decrease in cellular pulmonary protection. the pmn-elastase peripheral blood activity was . ± . iu/ml preoperatively and ± . iu/ml postoperatively; the α -pi level was . ± . iu/ml and . ± . iu/ml, respectively. conclusion. thus, an increase in the peripheral blood level of pro-inflammatory cytokines was observed in infants who underwent heart surgery. at the same time, the ntl relative number of neutrophils was increased. an early detection of the mentioned factors appears to be a diagnostic marker of the pulmonary inflammation reaction onset. all colistin resistant gram-negative isolates from patients hospitalized in a -bed icu during one-year period were retrospectively recorded. demographic data, the underlying disease, prior antimicrobial therapy, microbiological data and the clinical and bacteriological response to treatment were recorded. the antimicrobial susceptibility of the isolates was determined using the disk-diffusion (kirby-bauer) method, the vitek ii system and the etest method (ab biodisk, solna-sweden). interpretation of the susceptibility results was in accordance to the clinical and laboratory standards institute (clsi). nine patients with infections caused by colistin resistant gram-negative isolates were recorded. all patients had prolonged icu stay, were under mechanical ventilation and had a significant exposure to antibiotics including colistin for mdr gram-negative bacteria. three k.pneumonia isolates producing metallo-beta-lactamases (mbl), two k. pneumonia isolates producing extended spectrum b-lactamases (esbl) and mbl, two acinetobacter baumannii isolates susceptible to tetracyclines, one pandrug resistant (pdr) acinetobacter baumannii and one pdr pseudomonas aeruginosa were recorded. the bacteria were isolated from bronchial secretions in four cases and from the blood stream in five patients. in five patients antibiotic treatment was based on susceptibility tests, with clinical and bacteriological success. antibiotic combinations including colistin plus meropenem or colistin plus cefepime were provided in patients harbouring pdr isolates. these patients failed to respond to treatment and had a fatal outcome. the overall clinical success and survival rate was . % at days. conclusion. the development of colistin resistant strains with increasing mortality rates urges for the continuous surveillance on these highly resistant organisms and the strict implementation of infection control practices. ventilator-associated pneumonia (vap) is one of the most severe infections in the icu, continuing to complicate a high percentage of the patients receiving mechanical ventilation and leading to increased morbidity and mortality, especially when it is due to highrisk pathogens. our aim was to study the incidence and outcome of vap due to mdr bacteria in our icu. prospective, epidemiological study, in a mixed icu of a tertiary care hospital. all patients admitted from august to march were included. lower respiratory tract samples of all patients with suspicion of vap were cultured. standard diagnostic criteria were followed. statistical analysis was performed with spss v. . during the months period of the study patients were admitted. their mean age was years and % of them were male. their mean apache score was and the average duration of stay in the icu was days. forty-two episodes of vap due to mdr bacteria were recorded in patients. the bacteria isolated from lower respiratory tract samples were acinetobacter baumanii, pseudomonas aeruginosa, klebsiella pneumoniae and enterobacter cloacae, while in cases concomitant bacteremia was recorded. the mean time from admission to the icu to diagnosis of vap was days. positive outcome was noted in % of cases and was found to be reversely related to the apache ii score (p= . ), to days of stay in the icu (p= . ) and to multi-organ failure (p= . ). of the patients with vap, had normal renal function before the lung infection. of these, developed renal failure due to the lung infection and had to be started on renal replacement therapy. the mortality of these patients was significantly higher than for the patients who did not develop renal failure (p= . ). regarding the crude mortality of patients with and without vap, this was found to be . % and . % respectively (p= . ). (pa) is not a frequent pathogen in this setting but could be associated with poor prognosis. in our population of patients undergoing cs, we compared risk factors and prognosis of pa-eop with eop due to others micro-organisms. this retrospective study performed on years ( - ) involved patients (pts) who underwent cs with cardiopulmonary by-pass. diagnostic of pneumonia was based on clinical and laboratory criteria: t˚> . , purulent tracheal secretions, wbc> , /mm , chest x-ray changes and microbiological criteria (broncho-alveolar lavage> cfu/ml). pre, per and postoperative risk factors, empiric antibiotic, and prognosis of pa-eop were compared with those obtained for eop due to others germs. the groups were compared using chi-square. p< . was considered significant. over the studied period, eop occurred in pts (incidence %), including pts ( conclusion. in our experience, pa-eop following cs seems to be more frequent than what was previously reported. criteria for prediction of pa-eop remain to be assessed. in case of pa eop, empiric antibiotic is often inappropriate with a possible increased risk of mortality. these results lead us to modify our empiric broad-spectrum antibiotic treatment and to take into account pa, especially in severe forms of eop and in copd pts. antibiotic exposure and timing of pneumonia onset influence ventilatorassociated pneumonia (vap) isolates. the first goal of this investigation was to evaluate whether trauma also influences prevalence of microorganisms. a retrospective, single-center, observational cohort study. . vap isolates in a multidisciplinary icu documented by quantitative respiratory cultures and recorded in a -month database were compared, based on the presence (t) or absence of trauma (at). causative microorganisms were classified in four groups, based on mechanical ventilation duration (> days), and previous antibiotic exposure. one hundred eighty-three patients developed episodes of vap ( trauma). methicillin-sensitive staphylococcus aureus (mssa) was more frequent ( . % vs . %, p< . ) in trauma, whereas mrsa was more frequent ( % vs . %, p< . ) in nontrauma. no significant differences were found between trauma and nontrauma patients regarding prevalence of other microorganisms. in trauma patients, mssa episodes were equally distributed between early and late-onset vap( % vs %) but no mrsa episode ocurred in the early-onset group. conclusion. trauma influences the microbiology of pneumonia and it should be considered in the initial antibiotic regimen choice. our data demonstrate that patients with trauma had a higher prevalence of mssa, but the overall prevalence was sufficiently high to warrant an s. aureus coverage for both groups. on the other hand, since no mrsa was isolated during the first days of mechanical ventilation on trauma patients, mrsa coverage in these patients is only necessary after ten days of admission. a retrospective study of a hiv patient's cohort that stays in icu with acquired community pneumonia in the period between january and december . data analyzed included age, clinic stage, years of disease evolution, antiretroviral therapy, cd levels and viral charge at the hospitalization, positive hcv and/or hbv, severity scores and microorganism isolated. chi-square analysis was used to compare categorical data. continuous data was compared using student's t-test. prognostic factors of mortality were studied by multivariate logistic regression analysis. . fifty-three patients were studied. % were males. the average age was ± years. the most frequently risk practice was intravenous drug addiction ( % we prospectively collected data regarding demographics and microbiology of bacteremias. blood cultures were obtained on clinical suspicion of bacteremia and followed up on days , , and th. severity of illness scores, apache and sofa were recorded at baseline and days , , and th. improving hand hygiene is a cost-effective way of decreasing hospital-acquired infection rates. in this study we recorded opportunities for and compliance to hand hygiene in our icu. four trained nurses and a doctor monitored opportunities for hand hygiene performance (hand antisepsis and glove use) as well as compliance to the cdc guidelines in our icu for days. the procedure was anonymous, involved all icu personnel and was performed in -min sessions, throughout all shifts. we collected opportunities for hand hygiene, mostly related to nurses ( %). compliance to hand antisepsis was %, higher in nursing and assistant staff ( % and %, respectively) compared to doctors ( %). compliance was lowest before contact of healthcare staff with a patient or his inanimate environment ( % and %, respectively). the activity index (=the need for hand antisepsis performance) for the nursing staff was high ( opportunities per hour per nurse in the morning shift, ie opportunities per shift). however, no significant correlation was found between compliance rate and activity index of the staff (r=- . , p= . ). alcohol-based hand-rub was used in % of the cases. technique of antisepsis performance was uniformly poor and mean duration of the procedure was low ( . seconds). compliance with glove use guidelines was % and was high in all staff categories and all types of opportunities. is an aerobic non-fermenting gram negative bacillus. it is generally considered an opportunistic pathogen. s. maltophilia is increasingly recognised as a cause of nosocomial infection among ventilated and immunocompromised patients, and in those receiving broad spectrum antibiotics. s. maltophilia infections are commonly resistant to multiple antibiotics including beta lactams, quinolones, aminoglycosides and carbapenems. reported mortality rates for patients with bacteraemia due to s. maltophilia vary from - %. the mid western regional hospital, limerick, ireland, is a bed hospital located on three sites. the intensive care unit(icu) is a seven bed medical and surgical unit with approximately admissions per year. the s. maltophilia clusters prompted epidemiological investigation, restriction fragment-length polymorphism typing (rflp) of genomic dna of outbreak strains, and finally, instituting revised infection control measures to limit spread. we conducted a retrospective chart review of affected patients noting admission apache ii scores, medical co-morbidity, immunocompetence, antibiotic history, and patient outcome. we collected cultures of icu cubicle/ room surfaces, sinks, ventilatory equipment, and water sources. patients and environmental isolates were examined by rflp typing. this preliminary analysis suggests that pct can be use to accurately early identify sepsis only at levels above ng/ml and then use them to decide to rapidly beginning the use of antibiotic. in patients with pct below ng/ml we cannot use them to exclude the diagnosis of sepsis. with the cutoff , ng/ml we found the same analysis. other studies with more samples are necessary to confirm this conclusion. during these three years patients were hospitalized in total. one hundred and thirty one ( . %) were hospitalized less than h and were excluded. a total of bacteremias were observed. forty -four bacteremias were catheter related bloodstream infections. fifty five were due to gram negative microorganisms (pseudomonas aeruginosa %, acinetobacter baumanni %, klebsiella pneumonia %). in the following table, resistance to broad spectrum antimicrobials is presented during these three years. infection in patients with severe stroke is an important problem and the sensitivity and specificity of its diagnosis with clinical criteria are deficient. fever is a common event and, as leucocytes or c-reactive protein, its specificity is very low in this kind of patient. our objective was to evaluate the utility of a biological marker such as procalcitonin (pct) in the diagnosis of infection in patients with severe stroke. we followed patients with severe stroke receiving mechanical ventilation because of coma. during the first days of evolution nih and apache ii scales were registered, we measured pct and c-reactive protein on days and and if infection was suspected microbiological samples were collected. infection was diagnosed if the patient fulfilled the cdc criteria. mann-whithney u and x-square tests were used. twenty-six cases corresponded to haemorrhagic stroke. baseline characteristics were: mean age years, % males, glasgow scale ( - ), nih scale ( - ), apache ii ( - ), temperature . o c ( - . ), leucocytes /mm ( - ), pct . ng/ml ( . - . ) and c-reactive protein . mg/dl ( . - ). on the third day of evolution cases of ventilator-associated pneumonia were diagnosed. when compared with the noninfection group there were no differences in baseline characteristics and on the infection day we only found differences in pct, . ng/ml in front of . ng/ml; p < . . seventeen ( %) of the patients without infection presented a temperature o c sometime during the follow-up and in all cases pct did not show any change. these results indicate that pct is a useful tool in the diagnosis of infection in patients with severe stroke. the ongoing challenge of accurately diagnosing infection in the icu motivates a search for novel molecular diagnostics. we reported recently that microarray analysis of circulating leukocytes can be used to derive a "riboleukogram", which captures the dynamics of the host response to and recovery from ventilator-associated pneumonia (vap). in the current study, we tested the hypothesis that the informational content of circulating leukocytes differs, thereby allowing one to rank leukocyte populations on their potential to contribute to rna diagnostics for pneumonia. sixteen patients ( male, female) at risk for vap were entered into our irbapproved study that collects blood and clinical data every hours for up to days. four of the sixteen patients developed vap as diagnosed and treated by the attending icu physician. previously reported blood protocols were used to isolate buffy coat, enriched neutrophil, and enriched monocyte populations by using negative selection. cellular purity was assessed by facs for one of the vap patients. genome-wide expression analysis was performed on rmanormalized signal from affymetrix u . plus genechips. edge software (fdr= . ) was used to determine changes in mrna abundance over time for each cell population. during the -day window in which each of the four patients (all males) developed vap, significant changes in gene expression were observed (table) , but the information content (number of genes altered) varied across leukocyte populations. these differences were not due to signal variance (coefficient of variation, cv) or differences in the number of samples available for analysis. moreover, only . % of the monocyte gene list overlaps with the neutrophil list, arguing that neutrophil contamination of monocyte populations is insufficient to explain the -fold difference in gene number. the aim of the present study was to evaluate the relationship between the cytokine expression in bronchoalveolar lavage fluid and bacterial burden in mechanically ventilated patients with suspected pneumonia. mechanically ventilated patients with suspected pneumonia admitted in icu from november to january were prospectively enrolled. fiberoptic bronchoalveolar lavage (bal) was performed with ml of sterile isotonic saline in aliquots of ml, local anesthetic were not used. bal samples for microbiologic quantitative cultures and bal cytokines: interleukin (il) , il , tumor necrosis factor-alpha (tnf-alpha), granulocyte colony stimulating factor (g-csf) and granulocyte-monocyte colony stimulating factor (gm-csf) were measured. . patients were included, most of the patients ( . %) were with prior antibiotic therapy. patients ( . %) had a positive bacterial culture defined than a diagnostic threshold of > colony-forming unit/ ml. the concentration of tnf-alpha was significantly higher in the group of patients with positive bal (table ) . it has been demonstrated in a swine model that therapeutic hypothermia ( ˚c) facilitated transthoracic defibrillation. however, the mechanisms leading to reduced defibrillation threshold (dft) remain unclear. we hypothesized that therapeutic hypothermia promotes the wavefront organization of ventricular fibrillation (vf), therefore facilitating defibrillation. methods. by using a two-camera optical mapping system, epicardial activation patterns of vf were studied in isolated rabbit hearts at baseline ( ˚c), -min therapeutic hypothermia ( ˚c), and -min rewarming ( ˚c). in additional hearts, dft (voltage required to achieve % probability of successful defibrillation, n= hearts) and apd (action potential duration)/conduction velocity (cv) restitutions (n= hearts) were determined at these stages. results. comparing with at baseline ( ± %) and rewarming ( ± %), there was a higher percentage of vf duration containing organized repetitive activities during hypothermia ( ± %, p< . ). however, there was no significant difference of dft among these stages ( ± , ± , and ± v, p= . ). the electrophysiologic characteristics of ventricles at these stages were summarized in table . in brief, hypothermia prolonged apd, decreased cv, and subsequently shortened wavelength. hypothermia also failed to flatten the slope of apd restitution. furthermore, apd dispersion at the epicardial surfaces of both ventricles and cv heterogeneity among epicardial lines were all enhanced by hypothermia. (pt) with acute coroanry syndrome (acs) at admission is a associated with a high mortality. the mechansims are poorly understood. we sought to determine an interrelation between no coronary reflow after percutaneous coronary intervention (pci), the likelihood of developing cardiogenic shock, death in hospital and plasma glucose level at admission. we performed a prospective analysis of consecutive pt presenting with an acs in our emergency room. we recorded basis data (gender, age, bmi), cardiovascular risk factors, burden of coronary artery disease (cad), coronary blood flow after pci, killip-classification, left vetricular ejection fraction, probabilty of developing cardiogenic shock and the likelihood of dying in-hospital. our findings suggest that elevated bs at admission is a useful risk marker to identify pt with a high risk to develop coronary no reflow-phenomenon after pci. this may be due to increased inflammatory activity and hypercoagulability. if one dies in cardiogenic shock, these pt present always with elevated bs at admission. prull mw, trappe hj. activation of blood coagulation in nstemi: does diabetes mellitus matter? intensivmed . we measured serum cortisol levels before and minutes after a , mg corticotropin stimulation test in pts with cs following acute myocardial infarction (mi) and in a control group of pts with uncomplicated mi at day , , , , , and after onset of shock/mi. rai was defined by an increase in serum cortisol levels in response to corticotropin of less than µg/dl. data were correlated to vasopressor-need and interleukin (il) levels (il ,il ,il ,il ). baseline cortisol levels in pts with cs were significantly higher than in control pts especially on day ( ± vs ± , p= . ). in cs-pts the test-series were stopped at day to because the physician in charge started a therapy-trial with hydrocortisone due to increasing vasopressor need. three other pts died within the seven day period. rai was observed only at day in of the cs-pts but in none of the control pts (p= . ). these cs pts with rai had higher il- and il- levels at baseline ( during tidal mechanical ventilation, an end-expiratory pause abolishes the cyclic increase in intra-thoracic pressure. this may produce a transient increase in cardiac preload and then in cardiac output in volume responsive patients. our objective was to test whether the effects of an end-expiratory pause on cardiac index and pulse pressure may help in detecting fluid responsiveness in patients with acute circulatory failure. in mechanically ventilated patients with an acute circulatory failure and no spontaneous ventilator triggering who were deemed at volume expansion, we performed a -sec end-expiratory pause. we continuously measured the systemic arterial pressure and the pulse contour-derived cardiac index (picco device) at baseline, during the last seconds of the end-expiratory pause and after a ml saline administration. volume expansion induced an increase in cardiac index ≥ % in patients (classified as responders). in these patients, volume expansion increased the cardiac index by ± % from . ± . l/min/m . before volume expansion, the end-expiratory pause had induced an increase in cardiac index by ± % and in pulse pressure by ± % as compared to the baseline values. by contrast in the non-responders, before volume expansion the cardiac index and the pulse pressure did not change during the pause as compared to baseline ( ± % and ± % increases, respectively). importantly, an increase in cardiac index ≥ % during the end-expiratory pause predicted fluid responsiveness with a sensitivity of % and a specificity of %. a pause-induced increase in pulse pressure ≥ % detected fluid responsiveness with similar sensitivity and specificity ( % and %). in responders, a second end-expiratory pause was performed again immediately after volume expansion. in patients, the increases in cardiac index induced by this second pause induced had dropped below %. in the remaining responders, the second pause induced an increase in cardiac index still higher than % ( ± %). in these patients, the pause-induced increase in cardiac index was abolished by a second ml saline administration. conclusion. an increase in cardiac index and in pulse pressure during an end-expiratory pause enables to detect fluid responsiveness in critically ill patients with mechanical ventilation and acute circulatory failure. , and tissue doppler imaging measurements of the mitral annulus velocities like early (ea) peak diastolic velocity. the aim of the study was to examine which echocardiographic index is the best marker of preload by making the hypothesis that a good measure of preload should increase with fluid-induced increase in stroke volume (sv) but not with dobutamine-induced increase in sv. comparison of the capacity of the intra thoracic blood volume index (itbvi) and the central venous pressure (cvp) to predict fluid responsiveness in critically ill patients with acute circulatory failure (systolic blood pressure < mmhg or vasopressor requirement). methods. this prospective interventional study performed in a surgical intensive care unit of a tertiary university hospital included ( males) mechanically ventilated and sedated patients with acute cardiovascular failure requiring cardiac output measurement (transpulmonary thermodilution technique)and a fluid challenge. intervention: fluid responsiveness was defined as an increase in stroke index (si = cardiac output/heart rate/body surface area) ≥ %. receiver operating characteristic (roc) curves were generated for itbvi and cvp. in eligible patients, could not be included because of cardiac arrhythmia (n = ) or moribund status (n = ) or protocol violation (n = ). the cause of acute circulatory failure was septic shock in ( %) patients, haemorrhagic shock in ( %) patients, and systemic inflammatory response syndrome in ( %) patients. fluid challenge induced an si increase ≥ % in ( %) patients (responders(r). no statistical difference was shown between responders and non responders for cvp and itbvi. the areas under the roc curves of itbvi and cvp were . [ % ci: . - . ], and . [ % ci: . - . ], respectively, without any statistical difference (p = . ). the best cut of value for cvp and itbvi were mmhg (sensitivity = %; specificity = %) and ml.m- (sensitivity = %; specificity = %), respectively. the relative changes in si and ci were correlated with relative changes in itbvi (r = . , p = . ; r = . , p = . respectively) but no correlation was found between relative changes in si and ci and relative changes in cvp (r = - . , p = . ; r = . ; p = . ). conclusion. itbvi is similar to cvp to predict fluid responsiveness in critically ill patients with acute circulatory failure. the pulse pressure variation (ppv) is used to predict fluid responsiveness in mechanically ventilated patients. nevertheless false positive of this parameter have been reported especially in patient with right ventricular dysfunction. the peak systolic velocity of tricuspid annular motion (sta) assessed by doppler echocardiography (dec) is a parameter of right ventricular systolic function. the aim of the study was to find out whether sta can discriminate between false and true positive of vpp. methods. mechanically ventilated patients were prospectively included. all patients had a measurement of ppv> %. a dec was realised before and after infusion of ml of colloid solution. patients were separated into groups as they were responders (r) (at least % increase in stroke volume (sv)) or non-responders (nr) to fluid infusion. all data are expressed as mean [standard deviation]. the comparison of demographic, hemodynamic and echocardiographic parameters in r and nr patients was performed using a t-test. a p value < . was considered statistically significant. roc curves were plotted. a threshold value of sta was calculated with roc curve. in the resting patient, pulse pressure (pp = systolic -diastolic pressure) is mainly related to arterial stiffness and stroke volume index (svi). the dynamic effects of fluid loading on pp are poorly documented and were studied in the critically ill using arterial tonometry. we tested the hypotheses that i) arterial stiffness was unchanged after fluid loading, ii) pp changes paralleled svi changes such that pp increased in fluid-responders only, and iii) aortic pp was more indicative of svi changes than radial pp. twenty-two critically ill patients ( f), mean age(sd), ( ) years, were prospectively included. radial pressures were calibrated from brachial cuff pressures. radial applanation tonometry (sphygmocor ® ) allowed us to estimate aortic pp, left ventricular ejection time, and the augmentation index which quantifies wave reflection. the svi was calculated by transpulmonary thermodilution. the arterial stiffness was estimated from the aortic pressure curve using standard formula. fluid challenge ( ml saline . %) was required by the patient's hemodynamic status. data were obtained before and immediately after fluid loading. responders had increases in svi > %. baseline mean values were as follows: svi = ( ) ml.m- , heart rate= ( ) bpm, mean arterial pressure (map) = ( ) mmhg, radial pp = ( ) mmhg, aortic pp = ( ) mmhg. after fluid loading, svi increased from ( ) to ( ) ml.m- and map increased from to ( ) mmhg (each p < . ). arterial stiffness was unchanged ( . ( . ) vs . ( . ) mmhg.ml- . m ) as well as heart rate, left ventricular ejection time, radial and aortic pps and augmentation index. there was a positive linear relationship between the svi changes and the changes in radial pp (r = . ) and aortic pp (r = . ) (each p < . ), not map (r = . ). when responders (n= ) and non responders (n= ) were compared, the increases in map were similar while the changes in pp were higher in responders (radial: mmhg, %; aortic: mmhg; % ) than in non responders. (radial: - mmhg, - . %, aortic: - mmhg; - . %) (each p< . ). given the unchanged arterial stiffness throughout the fluid infusion, the changes in aortic pp (and slightly to a lesser extent radial pp) paralleled the changes in svi. both radial and aortic pps increased in responders but not in non responders, while map similarly increased in the two groups. the capability of arterial pp changes to track svi changes during fluid loading appears promising but deserves a further large scale study. new device may be used in intensive care unit to measure cardiac output (co) by arterial pulse pressure waveform analysis , but comparative studies with co thermodilution in cardiac surgery have shown large bias between the methods . aim of this study is to evaluate in critical ill patients not submitted to cardiac operation -cardiac output (co wave) obtained using flo track tm vigileo . -the correlation with co obtained by thermodilution (co therm). methods. critical care patients admitted to a general intensive care were enrolled in the study . all patients were mechanically ventilated ( tv - ml /kg pl press < cmh ) and connected to an integrated monitoring system ( flow trac tm / vigileo tm , ewdards lifescience ,irvine ,ca, usa ) that attaches to an arterial cannula . a central venous catheter and a pac ( thermodilution catheter ; arrow international , inc ., reading ,pa,usa ) was inserted via the jugular internal vein . after haemodynamic stabilization co wave was calculated from an arterial pressure based algorithm that utilises the relationship between pulse pressure and stroke volume , primarily based on the standard deviation of the pulse pressure waveform. at the same time a co therm. determination was performed by triple injection of ml of iced isotone na cl into the central line of the pac. every patients had two co determination at two time point. for each measurement of co therm corresponding simulataneous co wave was documenteted . a regression analysis and bland altman analysis was used to compare the two methods of co determination. a total of co determination was performed in patients . co vigileo correlated co thermodilution with r = . , p< , . at table are reported the bland altman's results. the left ventricular ejection fraction (lvef) as measured by echocardiography is considered as the reference estimate of the lv global contractility at the icu bedside. the transpulmonary thermodilution technique (picco system) continuously provides a measure of the cardiac function index (cfi), which is the ratio of cardiac output over global end-diastolic volume. thus it could be considered as a marker of cardiac global contractility and could enable a continuous monitoring of this key parameter. we tested whether cfi could actually behave as an indicator of lv systolic function by testing if it fulfilled the following criteria: (i) increase with inotropic stimulation, (ii) no alteration by fluid loading, (iii) correlation with the echographic lvef and (iv) ability to track the changes in lvef during inotropic stimulation. in patients ( cases) with an acute circulatory failure, we simultaneously measured the echographic lvef (transthoracic -chambers apical view) and the cfi at baseline, after a ml saline administration in a group of cases and after -min of dobutamine administration in a group of cases. volume expansion did not alter lvef significantly ( ± % vs. ± % at baseline) nor cfi ( . ± . vs. . ± . min- at baseline). by contrast, dobutamine infusion induced a significant increase in lvef from ± % at baseline to ± %(+ ± %) and in cfi from . ± . at baseline to . ± . min - (+ ± %). considering the whole set of cfi:lvef pairs of measurements (n= ), a significant correlation was observed between cfi and lvef (r= . , p< . ). importantly, a cfi value < . min - predicted a lvef value higher than % with a sensitivity of % and a specificity of %. in patients receiving dobutamine, there was a significant correlation between the changes in cfi and the changes in lvef induced by dobutamine infusion (r= . , p< . ). our study demonstrates that cfi fulfilled the criteria that are required from a bedside indicator of lv contractile function: it was increased by inotropic stimulation while it was not altered by volume expansion, it was fairly correlated with the echographic lvef and it was able to track the changes in echographic lvef with reliability. this suggests that the continuous monitoring of cfi provided by transpulmonary thermodilution could help in assessing the effects of inotropic therapy and could alert the physician in case of abrupt lv contractile deterioration. passive leg raising (plr) is a predictive test of preload responsiveness in patients with acute circulatory failure. it could predict fluid response to fluid loading in mechanically ventilated patients. critically ill patients have an increased risk of lower extremity deep venous thrombosis. elastic compression stocking (ecs) is frequently used in association with unfraction or low molecular weight heparin. the aim of this study was to evaluate the effect of the elastic compression stocking on the plr test variations. methods. patients undergoing cardiac surgery were included. all of them were anaesthetised and mechanically ventilated (tidal volume ≥ ml/kg). pre-operative left ventricular ejection fraction was > % for all patients. they were monitored with central venous pressure (cvp), invasive blood pressure and esophageal doppler. hemodynamics parameters were obtained before and after plr, without and with elastic compression stocking respectively (ssv = systolic stroke volume, co = cardiac output, ppv = pulse pressure variation and sbp = systolic blood pressure). results are presented as median [inter quartile range](iqr) and compared with mann whitney test. . table represents hemodynamics variations after plr without and then with elastic compression stocking. second table represents hemodynamics effects of the elastic compression stocking in supine position (sp). conclusion. this study shows a clear improvement in gut permeability after surgery. the effects of early feeding shall be assessed in a future study. methods. descriptive-prospective study. pre and post-class question -survey (administered one week before and after). the transplant co-ordination team gave informative classes in secondary schools, - / - . . surveys collected; pre/ post-class: % of eso ( years old), % bachiller ( years old) and % ciclo formativo ( years old) / post-class: % eso, % bachiller and cf % . % had some prior awareness and % broad knowledge. massmedia is usually sole information channel ( %), ticked in all cases. other sources were: family, school and peers. regarding attitude to donation: we found no differences in refusals between own donation or relatives'( %); or in doubts % - %. related to transparency and parity of the health system: % believed equality did not exist and % had doubts. % felt this inequality was worse abroad. % are convinced that organ trafficking exists and % assume it is possible. pre-course standpoint by course is showed in figure . % had prior knowledge about spanish transplant law. following classes the students claim higher awareness ( %). in general they maintain their standpoint on donation, % have reconsidered their previous attitude. regarding transparency and equality, % maintain doubts and % are convinced of its absence. on trafficking: % assume it is possible, % occurs exclusively abroad, uniform group distribution. post-course attitudes by course are in figure . despite an in-depth discussion about the law and its consequences (presumed consent), they generally disagree and some consider this too extreme , refusing to accept that donation is an obligation (only % agree) and believing that it should be an optional act of solidarity ( %). conclusion. knowledge about donation and transplant in urban areas is slanted, due to information sources ( usually mass media ) and a warped (tv-dominated) perception of the health system's transparency and equality. a considerable number of students still refuse donation or maintain their scepticism, despite a decrease following classes. however, our desire is not to convince them to become donors, we simply wish to provide decision-making tools. generally college students ,without gender differences, are the most resistant to the process, having the greatest incidence of refusals and doubts about transparency, equality and organ trafficking. ( - ) . c (pao /fio ) / peep day . ( . - . ) . ( . - . ) . c (pao /fio ) / peep day . ( . - . ) . ( . - . ) . c (pao /fio ) / peep day . ( . - . ) . ( . - . ) . c conclusion. the pao /fio ratio on day one is useful to predict mortality, but not in the subsequent days. the (pao /fio )/peep index is a better predictor in later days, specially on the third and seventh day of mv. a. roch* , l. fouché , j. forel , d. blayac , c. aglioni , d. lambert , j. carpentier , l. papazian réanimation médicale, dar, hôpitaux sud, réanimation, hôpital laveran, marseille, france introduction. general anesthesia promotes atelectasis of the dependent parts of the lung. we evaluated the differential effects of neuromuscular blocking agents (nmba) on consolidation formation in healthy or injured lungs. methods. pigs ( ± kg) were anaesthetized with pentobarbital, fentanyl and ketamine in order to prevent spontaneous ventilation and ventilated using volume controlled ventilation (vt ml/kg, fio . ) for hours after randomization into groups: healthy lungs ventilated without (hzeepno) or with nmba (cisatracurium, hzeepnmba), healthy lungs ventilated with nmba and peep (hpeepnmba) and injured lungs ventilated without (tweenpeepno) or with nmba (tweenpeepnmba). lung injury was induced using instillation of . ml/kg of . % tween . injured lungs were ventilated with peep , fio . and vt ml/kg. after lung removal, six sections of equal thickness were obtained from the right lower lobe and from the upper. sections were photographed and analyzed using a software (sigmascan pro , spss inc). the areas of consolidated, edematous and normal parenchyma were measured on each section and then added to obtain the percentage of consolidated lung. . nmba use induced a two-fold increase of the consolidation (from ± to ± %)that was totally prevented by peep . the deleterious effect of nmba on derecruitment did not occur in injured lungs. consolidation was located to the dependent parts in healthy lungs and nmba extended consolidation towards more cephalad parts. in injured lungs, consolidated parenchyma was diffuse and its cephalo-caudal distribution was not affected by nmba. pao to fio ratio was affected neither by nmba nor by peep. * p< . vs hzeepno and hpeepnmba; **p< . vs hzeepno and hzeepnmba. conclusion. nmba increase dependent lung consolidation during volume-controlled ventilation of healthy lungs. this effect is prevented by a moderate peep level. in contrast, nmba do not increase the extent of pathologic lung areas in injured lungs ventilated during a -h period. th esicm annual congress -berlin, germany - - october s m. amigoni* , m. scanziani , g. bellani , g. balconi , e. zanotto , s. masson , n. patroniti , r. latini , a. pesenti dept of experimental medicine, milano-bicocca university, monza, cardiovascular research, istituto di ricerche farmacologiche mario negri, milano, italy introduction. surfactant dysfunction seems to play a pivotal role in the deterioration of gas exchange and lung mechanics that occurs in ali/ards following aspiration pneumonitis. we investigated the effects of exogenous surfactant administration in a murine model of unilateral acid-induced lung injury. we instilled . ml/kg bw of . m hydrochloric acid in the right bronchus of anesthetized and mechanically ventilated mice (vt - ml kg- bw, rr min- , fio and peep of . cmh o). mechanical ventilation was stopped minutes after injury; animals were then placed in an oxygenated chamber (fio . ). after ', hr or hrs from acid instillation, the mice were reintubated and received a single bolus of surfactant in the injured lung at a low or high dose. each animal was again mechanically ventilated for minutes, placed in oxygenated chamber until full awakening. acid-injured mice instilled at the same time and with the same volume ( ml/kg bw) of sterile saline ( . % nacl) were used as controls. lung mechanics, blood gas analysis, and lung myeloperoxidase activity (mpo) were assessed hrs after acid aspiration. no effect of surfactant administration was present upon oxygenation hrs after the injury. at the opposite the high dose group showed a significantly better compliance at hrs, when compared to both the low dose and control groups. this effect was present only in the late ( hrs) administration group. mpo activity did not change after surfactant treatment in the right (injured) lung while in the controlateral, it tended to be lower in both low and high dose when treatment administration occurred at hrs (n= /group: n right lung ± left lung . ± . ; s(low dose) right lung . ± . left lung . ± . ; s(high dose) right lung . ± . left lung . ± . ). pulmonary aspiration is associated with significant morbidity and mortality . several risk factors for aspiration have been highlighted in the literature . the aims of this study were to: (i) identify specifically which patient factors predispose to aspiration and (ii) determine the outcome of patients admitted to our inner city hospital intensive care unit (icu) with a diagnosis of aspiration. we identified patients with a diagnosis of pulmonary aspiration on our icu over a year period (august - ), by using our institution's icnarc (intensive care national audit and research centre) database. of these patients' case notes were able to be retrieved and reviewed in detail. patient demographics, risk factors for aspiration, number of ventilated days, icu & hospital length of stay and mortality were analysed. we also looked at any documented signs that supported the diagnosis of aspiration. median age of the patients was years (range - ). / patients ( %) were male. the main risk factor was a reduced glasgow coma score ( / patients, %): the median score was (range - ). the following risk factors were also identified: obesity ( / patients, %), excessive alcohol intake ( / , %), acute cerebrovascular event ( / , %) and cardiorespiratory arrest ( / , %). the following signs were most frequently observed: perioral vomitus ( / patients, %), acute hypoxaemia ( / , %) and a new radiographic infiltrate ( / , %). one patient exhibited all three markers. all patients required mechanical ventilation. the median duration of ventilation was days (range - ). the median length of icu stay was days ( - ) and the median length of hospital stay was days ( - ). icu mortality was % ( / patients) while hospital mortality was % ( / ). patients who presented to our inner city icu with aspiration had risk factors that included impaired conscious level, obesity, a recent cerebrovascular event or cardiorespiratory arrest. signs that supported the diagnosis of aspiration were the presence of perioral vomitus, acute hypoxaemia and a new radiographic infiltrate. icu and hospital length of stay were both prolonged, but icu and hospital mortality were no higher than our institution's overall rate. a high index of suspicion should be applied to these patients at risk of aspiration, to facilitate the early initiation of appropriate care. reference(s). . hickling k. a retrospective survey of treatment and mortality in aspiration pneumonia. int care med ; : - . . kozlow j. epidemiology and impact of aspiration pneumonia in patients undergoing surgery in maryland, - . crit care med : - . t. tagami* , s. kushimoto , t. atsumi , r. oyama , k. matsuda , m. kawai , h. yokota , y. yamamoto surgery, tokyo metropolitan saiseikai central hospital, critical care medicine, nippon medical school, tokyo, critical care medicine, yamanashi prefectural central hospital, yamanashi, japan introduction. restoration of intravascular volume by massive fluid administration without pulmonary edema formation is one of the biggest challenges in the early treatment of burn shock. although it is not easy to predict the development of the respiratory failure before the treatment, the hallmark of the edema is increased capillary permeability which may be possible to measure by the pulmonary vascular permeability index (pvpi). the aim of the present study was to clarify whether the pvpi is predictable indicator of pulmonary edema formation in patients with burn. we studied mechanically ventilated patients with burn involving more than % of the body surface area that were treated at intensive care burn unit between july and january . all patients had a central venous catheter and a thermistor-tipped arterial thermodilution catheter (picco system) for hemodynamic management. we measured the extravascular lung water index (evlwi) and the pulmonary vascular permeability index(pvpi) as soon as the picco catheter was inserted. infusion volume was calculated according to the parkland formula. only crystalloid fluid (lactated ringer's) was infused during the first hours after the thermal injury. we investigated the medical records and defined the respiratory failure during the period of burn shock as a clinical syndrome of acute respiratory distress associate with pulmonary rales and radiographic evidence. inclusion criteria were: )acute onset and rapid progress, )oxygenation index (pao /fio ratio< and ) bilateral infiltrates on chest x-ray. those are the part of the standard criteria of acute respiratory distressed syndrome. the pvpi was significantly higher in the patient with respiratory failure (n= pvpi: . ± . ) than in patient without respiratory failure(n= pvpi: . ± . ) before the fluid treatment. there was no significant difference between the groups in terms of evlwi at the beginning ( ml/kg vs . ml/kg). although the evlwi increased after hours in the patient with respiratory failure, it did not change in patient without respiratory failure( . ml/kg vs . ml/kg). the pvpi increased before the evlwi increased in patient with respiratory failure. the pvpi is considered to be the predictable value to identify the risk of respiratory failure during the period of burn shock. ultrasonography allows observation of diaphragm. in healthy subjects, a correlation was found between its excursion and the tidal volume. in addition, diaphragm thickness variation measured in the zone of apposition has been used to evaluate paralyzed diaphragm. we assessed the accuracy of these indexes to assess diaphragmatic function and respiratory workload. five patients were studied in spontaneous ventilation (sv) and during noninvasive ventilation at different levels of pressure support (ps). diaphragmatic excursion (e) was carried out subcostally. diaphragm thickness was measured in the zone of apposition and the thickening fraction (tf) was calculated as tf = (thickness at inspiration -thickness at expiration)/thickness at expiration. diaphragmatic pressure time product per breath (ptpdi) was measured by assessment of esophageal and gastric pressure. ptpdi and tf both decreased as the level of pressure support increased (fig and ) . a positive correlation was found between ptpdi and tf(r= . ; p= . ; fig ) . in addition, there was also a significant correlation between tidal volume and e (r= . ; p< . ; fig ) . ultrasonography of the diaphragm could be applied in intensive care to assess diaphragmatic function. tf and ptpdi decrease as the level of pressure support increases. these results suggest that tf could help to assess diaphragmatic contribution to respiratory workload. reference(s). ( ) fantus g. metformin's contraindications: needed for now frequency of inappropriate metformin prescriptions systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing arteficial ventilation catheter infection is a common concern in the intensive care unit (icu). recent works have pointed that the site of catheters is related to this problem. we analysed data obtained from our data base to confirm the results of previous works. methods. catheters were inserted in a surgical-medical icu, along five years. semiquantitative cultures were obtained if the catheter was kept in place more than hours and it was no longer necessary, the catheter was withdrawn because of fever of unknown origin or an infection was suspected at the point of insertion. every catheter site, culture and germ was registered in our patient data base. we studied the following variables: type of catheter, site and results of cultures. statistical analysis: variables were compared by chi-square. a p< , was considered statiscally significant. results. a total of . catheters were registered (venous catheters , arterial ). rate of germs was as follow: gram-positive , %, gram-negative , %, fungi %, contaminated flora , %. site and germs were not statistically associated. table shows type, site and rate of infection of cultured catheters. femoral arteries were more frequently cultured than radial arteries (p< , ); no differences were found for cultured venous catheters. femoral arteries were infected more frequently than radial (p< o, ); yugular and femoral venous catheters were more frequently associated to infection. (sc) in non neutropenic patients is increasing with a high cost and mortality. we define the clinical and epidemiological profile of patients admitted to our icu and the microbiological aspects of the pathogen. mortality analysis was done, including sevilla score system (sss). we include patients admitted in icu from to with candidas ssp (cd) positive blood cultures (bacter system). we analysed demographic factors, reason for admission to the unit, associated risk factors, need of multi-instrumentation or parenteral nutrition, value of apache ii, and length of stay in the icu. the kind of cd diagnosed, its sensitivity profile, and the existence or not of previous wide spectrum antibiotic or antifungic therapy were determined. the sevilla score system was applied and correlated with mortality. chi square, t-test and multivariant analysis were made. there were . % male patients, with years old median age and with a length of stay longer than days. the reason for admission was sepsis ( %), surgery ( . %), acute respiratory failure ( . %) and trauma patiens ( %). apache ii median was . points.risk factors related with fungal infections were diabetes ( . %), neoplasia ( %), steroid therapy ( , %), a length of stay longer than days ( %) and antibioticoterapy. none had neutropenia. % of patiens received antibioticoterapy previous to diagnosis, . % parenteral nutrition and % of them underwent multi-instrumentation. patient isolation was achieved in % of them ( % in period - ). candida albicans was isolated in . % of cases against . % of candida nonalbicans, specially c. parapsilosis , %. first antifungal therapy was fluconazole ( %), caspofungin ( . %) and lipid amphotericins ( . %). we found a significant increase of sc cases along the years, ( % in - vs . % in - , p< . ), being unresponsive to azoles . %. mortality was specially high ( . %), unrelated with cd type; those with high/moderate sss risk had a significative higher mortality (p< . ). candida albicans was more frequently found in septic patients while candida nonalbicans was gaining place in patients under parenteral nutrition (c.parapsilosis).conclusion. ) systemic candidiasis affects men admitted with sepsis or surgery, with a high apache ii index, multiple organ failure, multi-instrumentation and more than two weeks intensive care unit stay. ) we observe a progressive incidence of non albicans candidiasis (c. parapsilosis). ) type of candida ssp did not affect mortality. ) c. albicans was more frequently isolated in septic patients, while candida nonalbicans was predominant in cases with parenteral nutrition. ) mortality was greater in moderate/higher sss risk group. f. alvarez-lerma* , m. palomar , p. objetive: to present changes of multiresistance markers in icu-acquired infections. a prospective, cohort, multicenter study. all patients admittted to the participating spanish icus between the years and were included. patients were followed until discharge from the icu or up to a maximum of days. the following infections were studied: mechanical ventilation-related pneumonia (mv-p), catheter-related urinary tract infection (cr-uti), and primary bacteremia (pb). markers of multiresistance were those defined by the cdc ( ) of a total of , pacientes included in the study, , ( . %) developed , infections ( . %) during their stay inthe icu, in which a total of , pathogens were identified.multiresistance markers are shown in table . pulse pressure variation greater than % predicts fluid responsiveness in patients ventilated with large tidal volumes. the aim of this study is to evaluate the influence of a low tidal volume on the capacity of pulse pressure variation (deltapp) to predict fluid responsiveness.methods. this is a prospective interventional study that took place in a -bed university hospital medico-surgical icu. the study included eighteen mechanically ventilated critically ill patients with a low tidal volume ( - ml/kg) requiring fluid challenge. fluid challenge was performed with , ml crystalloids or ml colloids. complete hemodynamic measurements including deltapp were obtained before and after fluid challenge. overall, the cardiac index increased from . ± . to . ± . l/min/m (p < . ). it increased by more than % in patients (responders). pulmonary artery occluded pressure was similar ( . ± . vs. . ± . mmhg, p= . ) but deltapp higher in responders than in non-responders ( ± % vs. ± %, p= . ). fluid responsiveness was equally predicted by deltapp (roc curve area . ± . ), pulmonary artery occluded pressure ( . ± . ) and right atrial pressure ( . ± . ) (p=ns). the best cutoff value for deltapp was % with a sensitivity of % and a specificity of %. the preliminary results suggest that deltapp is not a better predictor of fluid responsiveness then paop or rap in mechanically ventilated patients when tidal volume is - ml/kg. if used, a lower critical value may help to predict fluid responsiveness. svv and ppv are proven influenced by the different airway pressures due to depth of tidal volume and peep. the effect of respiratory rate or respiration frequency on svv and ppv is however unclear. aim of this study was to evaluate the effect of respiration frequency on svv and ppv in mechanically ventilated patients. after obtaining informed consent, (coronary bypass grafting) patients were studied immediately after surgery. cardiac output (co), svv and ppv were assessed by arterial pulse contour analysis (lidco, lidco ltd). all patients were ventilated in pressure controlled mode (settings: fio . , tidal volume ml/kg, peep cmh o, frequency min- ) and sedated with propofol. in this study svv and ppv were evaluated with fixed ventilator frequencies of , and min- . this protocol was repeated to times (before and after volume loading of ml) in each patient. during the study the mean airway pressure was maintained constant by adjusting inspiration time. collected data points are described in means (sd) and evaluated using anova. in six patients (female/male ratio / ) after coronary bypass grafting, mean age (± . ) years [range - years], data points by fixed respiratory frequencies could be analysed ( / , / and / ). all measurements were performed in hemodynamically stable conditions, hr mean (± . ) min- , map . (± . )mmhg, cvp . (± . )mmhg and co . (± . ) l/min (p for all ns). mean airway pressure . (± . )mbar (levene statistics, p = . ), for resp-f . (± , )mbar, resp-f , (± , )mbar and resp-f . (± . )mbar. on fixed respiratory rates svv and ppv were unchanged: for svv (resp-f ) . (± . )%, (resp-f ) . (± . )%, (resp-f ) . (± . )%, p = . , for ppv (resp-f ) . ( . )%, (resp-f ) . (± . )%, (resp-f ) . (± . )%, p = . . in ventilated cardiothoracic surgical patients, svv and ppv were not influenced by forced changes in respiratory frequencies between and min- . (svv) has been studied as a dynamic preload marker to predict fluid responsiveness in critically ill patients. patients undergoing major abdominal surgical procedures with the aid of pneumoperitoneum may have a difficult preload management, due to either a preoperative hypovolemic status or an excessive intraoperative fluid loading to maintain an adequate volume and tissue perfusion. the aim of this study was to use the svv to optimize the fluid management in patients undergoing major abdominal robot-assisted laparoscopic surgery. methods. patients (asa score - ; mean age . +/- . ) were prospectively enrolled. cardiac index (ci), stroke volume variation (svv), and central venous saturation (scvo ) were calculated with the vigileo system. gastric carbon dioxide pressure (pgco ) was measured with a gastric tonometer. before the induction of anesthesia, ml/kg normal saline solution was administered. later, colloids were infused whenever a svv > % resulted. hemodynamic variables and pgco were measured before, during, and after the end of surgery. the total amount of intraoperatively administered fluids (iaf) was calculated. subsequently, the iaf was compared with theoretical iaf using the formula proposed by miller. analysis of variance and student's t-test were applied. mean surgery time was . +/- . hours. ci ranged from . to . liters/min/m . scvo ranged from % to %. the pgco ranged from . to . mmhg. anova did not show significant variations of ci, scvo and pgco . mean baseline and postoperative svv% were +/- . and . +/- . , respectively. with respect to preoperative values, anova showed a significant reduction for svv%. moreover, at the end of surgery the svv% resulted less than % for each patient. the total amount of fluid was . +/- vs . +/- . ml/kg per hour (calculated vs theoretical, respectively. p< . ). no patient showed signs of hypoperfusion. no complication or death occurred.onclusion. the vigileo system seems to be a reliable tool to provide indications for fluid administration and volume responsiveness. it could be useful especially in major surgical procedures at risk of fluid overfilling. svv continuously monitored may help physicians to avoid fluid overloading in patients undergoing major abdominal robot-assisted laparoscopic surgery. recently, the preload parameters global enddiastolic volume gedv and intrathoracic blood volume itbv measured with transpulmonary thermodilution were convincingly shown to be superior to the historically used central venous pressure . the extravascular lung water evlw was shown to be a prognostic marker in critically ill patients . however, in our clinical experience, we failed to achieve the proposed normal ranges for gedv/itbv indexed to body surface area in a substantial number of patients. as hypothesis, we investigated the dependence of transpulmonary thermodilution parameters on the patient's age. we retrospectively analyzed the transpulmonary thermodilution data in a series of patients treated on our neurosurgical intensive care unit. diagnosis was predominantly severe subarachnoid hemorrhage, but included traumatic brain injury and polytrauma, too. itbvi and gedvi were measured with the picco ® system (pulsion medical systems ag, munich, germany). measurements were performed with cc iced saline injected repeatedly in a central venous line. all data was stored online and pooled for analysis. mean patient age was . (sd . ) years. pooled thermodilution measurement sequences consisting of single injections were analyzed. mean gedvi was (sd ) ml/m , mean itbvi was (sd ) ml/m and mean evlwi was . (sd . ) ml/kg. younger patients had lower mean values calculated by linear regression, with an increase of . ml/m for gedvi and . ml/m for itbvi per patient year. evlwi was independent of age.conclusion. the thermodilution data from our patient collective contrasts the use of fixed age-independent normal values for gedvi and itbvi but not for evlwi. this data set, however, comprises a neurosurgical patient collective and may not be validly extrapolated to other clinical surroundings. . michard f., et al.: chest ; : - . sakka, s., et al.: chest : - thirty mechanically ventilated patients with severe sepsis or septic shock (age ± ; apache-ii score ± ; male) requiring invasive hemodynamic monitoring due to cardiovascular instability were included in a prospective observational trial. the study was performed in a university hospital setting with a -bed medical intensive care unit (icu) and a -bed anaesthesiological icu. volume-based hemodynamic parameters were assessed using the single-pass thermal-dye transpulmonary dilution technique. simultaneously, ivc diameter was measured throughout the respiratory cycle by transabdominal ultrasonography. we found a statistically significant correlation of both inspiratory and expiratory ivc diameter with central venous pressure (p= . and p= . ), extravascular lung water index (p= . , p< . ), intrathoracic blood volume index (p= . , p= . ), the intrathoracic thermal volume (both p< . ), and the pao /fio oxygenation index (p= . and p= . , respectively).conclusion. sonographic determination of ivc diameter is useful in the assessment of volume status in mechanically ventilated septic patients. this approach is rapidly available, non-invasive, inexpensive, easy to learn and applicable in almost any clinical situation without doing harm. ivc sonography may contribute to a faster, more goal directed optimisation of fluid status and may help to identify patients in whom deleterious volume expansion should be avoided. it remains to be elucidated whether this approach influences the outcome of septic patients. a severe burn injury is associated with hypermetabolism and catabolism that has been shown to persist for over months post injury. propranolol has been shown to reduce hypermetabolism during the acute hospital course. the effect of propranolol, a nonselective beta blocker, on respiratory variables in children with severe burns has not been established. beta-blockade is associated with a known risk of bronchoconstriction in children with hyper-reactive airway disease, but it is not known whether the effects are also seen in severely burned children. the purpose of this study was to determine the effect of propranolol, given during acute hospitalization, on respiratory variables. forty-six patients with burns > % total body surface area (tbsa) were enrolled into the study and randomized to receive propranolol at . mg/kg/day (n= ) or placebo (n= ). administration of propranolol was started the day following the first operation and continued for three weeks. respiratory variables were measured by a flow transducer attached to a bicore cp respiratory monitor. all patients were breathing spontaneously and non-intubated. study variables included respiratory rate (rr), minute ventilation (mv), tidal volumes (vt), and peak inspiratory/expiratory flow rates (pifr/pefr). baseline measurements were taken at rest before the drug or placebo was initiated. follow-up measurements were performed at the end of the study period. data were analyzed using paired t-test within groups and un-paired t-test between groups. data are reported as mean ± sd. significance was accepted at p< . . the mean age in both groups was ± years. as expected, heart rate was reduced by approximately % in the propranolol group compared to placebo (p< . ). there was a significant increase in pefr from . ± . to . ± . l/s in the propranolol treated group (p= . ). in contrast, neither placebo nor propranolol significantly affected rr, vt, ve or pifr. results indicate that short term administration of propranolol showed significant effects on pefr suggesting increased pulmonary conductance. further studies on the effects of propranolol on gas exchange and lung compliance are needed. grant acknowledgement. funded by nih grants p -gm and ko -hl a. storesund* , e. wallestad , l. rygh postoperative section, surgical department, surgical department, haukeland university hospital, bergen, norway international studies point out that to work with agitated children, described as restless and disorientated are particularly stressful for the child, parents and caregiver. this project is based on the assumption by nurses in the post anaesthetic unit (pau) that there was a noticeable post anaesthetic agitation difference between the children who received long-term opioids initially and in the end of the operation (refill, a) compared to those who only got long-term opioids in the beginning of the operation (no refill, b). the main purpose of this project was to examine whether there were any difference in postsurgical agitation between the refill and no refill group. further, this project seeks to uncover if there are any factors that can be improved per-and postoperative for these patients. we observed post anaesthetic children, lip-(n= ), cleft-(n= ), and palateclosure (n= ), adeno-(n= ), & adeno-tonsillectomy (n= ). these children were recruited using a convenience sampling strategy at the pau at haukeland university hospital, norway, over a week period in - . a pilot-tested fixed cross sectional designed questionnaire was utilised by the nurse responsible for each patient. several statistical tests by the use of spss made it possible to analyse and answer the research question: are children who only get long-term opioids in the initial anaesthetic phase (b) of the operation more agitated than those who where also given a refill of long-term opioids (a)? we found that / got refills of long-term opioids (a), / did not get refills (b), % were recorded as missing values. t-test result = , is greater than , , hence there is no statistically significant difference between the two groups. levene's test tells us that the two variances are not significantly different (levene's test sig= , ). there were no significant relationships between the parameters recorded. however, there was a tendency that more preoperative anxious children got refills ( / ) compared to non-anxious children ( / ) (fisher's exact test p= , ). the latter results may conceal the agitation-scores in the two groups; refill and non-refill-group. this possible bias may have been eliminated if the patients had been randomized to either refill or non-refill. the present study confirms previous observations by others indicating no singular factors can explain why some children experience agitations and others do not. analysis of the parameters studied did not discover any statistical significant relationships. thus, how to minimise the cohort of children who experience post anaesthetic agitation still remains a recurrent challenge. pulmonary hypoplasia with severe cardiorespiratory dysfunction is often the leading cause of death in neonates with congenital renal disease and oligo-anhydramnios. aim of the study was to determine whether ino is effective to improve respiratory function in these critically ill neonates. we retrospectively reviewed the charts of all newborns who were admitted between february and september with the diagnosis of oligo-anhydramnios of renal origin. during this period all patients were treated according to a standardised algorithm. they were intubated either if post cpr or if fio had to be increased above . . mg/kg of bovine surfactant were applied for improvement of ventilation. pre-and postductal oxygen saturation were measured simultaneously with target values of - %. if fio remained above . a transthoracic echocardiography was performed. the presence of a ductal or atrial right to left shunt or a difference in oxygen saturation between the pre-and postductal measurements of > % led to the diagnosis of pulmonary hypertension and to the initiation of ino therapy. further, ino was applied as a rescue therapy if oxygen saturation remained below % despite a fio of . and optimization of ventilator settings and therapy with catecholamines. all patients had informed parental consent. the patient population (n= ) included children receiving ino of whom suffered from obstructive uropathy and two had polycystic kidneys, whereas patients did not receive ino treatment. in this group there were children with obstructive uropathy and born with polycystic kidneys. all data are presented as median (range). we concentrated on the group receiving ino. in this group mortality was . %. therapy was started at an age of . ( - ) hrs. initial dose of ino was . ( - ) ppm with peak dose of . ( - ) ppm. ino led to a decrease of oxygenation index (oi) from . ( . - . ) to . ( . - . ). five children suffered from obstructive uropathy. three of them had a favourable long-term outcome, one child died immediately, whereas one child was initially stabilized but finally succumbed to its underlying disease. two children demonstrated genetically determined pulmonary hypoplasia due to the presence of polycystic kidneys. both children died within the first three days despite ino treatment. children with obstructive uropathy and severely impaired oxygenation seem to benefit from ino therapy. patients suffering from a hereditary renal and pulmonary hypoplasia did not respond favourably to ino therapy and had a fatal outcome. a. khaldi*, k. menif, a. bouziri, a. hamdi, s. belhadj, n. ben jaballah pediatric intensive crae unit, children's hospital, tunis, tunisia the use of high-frequency oscillatory ventilation (hfov) and ino resulted in a decline in the need for extracorporeal membrane oxygenation (ecmo) in near-term and term neonates with persistent pulmonary hypertension (pphn). association of hfov and ino is actually an accepted treatment modality even in non-ecmo centers. however, because not all neonates respond to hfov + ino, identification of factors related to a poor response is very important for prognosis and for early transfer to ecmo canters if possible. the objective of this study was to identify the risk factors predicting poor shortly outcome in near-term and term neonates with pphn treated with hfov and ino in a tertiary care pediatric intensive care unit in a university hospital. we conducted a prospective clinical study including all neonates with gestational age ≥ weeks with echocardiographic signs of pphn. patients with pulmonary hypoplasia or congenital diaphragmatic hernia were excluded . patients were ventilated with conventional mechanical ventilation (cmv) with ino ( - ppm). hfov were instituted if patient required, on conventional ventilation (cmv)+ino, a fraction of inspired oxygen (fio ) . , and a mean airway pressure > cm h o to maintain adequate oxygenation or a peak inspiratory pressure > cm h o to maintain tidal volume between and ml/kg of body weight. hfov were used in association with ino in seventy infants (gestational age, ± , weeks), after a mean duration of cmv of ± hours. arterial blood gases, oxygenation index (oi), and alveolararterial difference in partial pressure of oxygen (p[a -a]o ) were recorded prospectively before and during hfov. there were a rapid and sustained decreases in mean airway pressure (map), oi, and p[a -a]o during hfov (p ≤ . ). this improvement, along with decreased need for oxygen, was sustained through the subsequent course of hfov. sixty-six infants ( %) were weaned successfully from hfov. five infants ( %) were classified as meeting treatment failure and died from their underlying disease. treatment failure was associated with lack of improvement in p[a -a]o and oi at hour of hfov (p < . ) and the presence of intractable shock requiring epinephrine or norepinephrine (p= , ). in near-term and term neonates with pphn, the association of hfov and ino lead to a rapid and sustained improvement in gas exchange in the most cases. the magnitude of improvement of oi and p[a -a]o at hrs can predict outcome early. early burn sepsis is notable for the complexity of diagnostics, malignant course and high lethality. the problem remains actual for the children who got a severe burn trauma (more than % body surface area). purpose to define procalcitonin test (pct) effectiveness for early sepsis diagnostics for children with thermal trauma. during the period of time from january up to april there were children in our clinic with extensive burns from %up to % body surface area (bsa) at the age from months to years old. patients at the age from months to years old with the burns from % to % bsa were included in our research. all the children got surgery in shortest time after trauma (tangential excision with authodermoplastics), antibacterial, and infusion therapy. from the moment of registration in icu all the patients, who were suspected to have sepsis, simultaneously with traditional examinations (blood analysis, bacteriological investigation) were taken pct analysis with the help of "pct-express test" (brahms, germany). . patients ( , %) were diagnosed sepsis, children died. these patients pct level was from to ng/ml; together with this all the patients had increasing quantity of leucocytes, acceleration the level of c-reactive protein, fever. ( %) patients had no sepsis, so pct figures fluctuated in the bounds of , ng/ml. among these patients traditional markers of inflammation were increased. no trustworthy difference is found as for the level of leucocytes and c-reactive protein figures between the patients without infectious complications and with sepsis. only with the help of pct the beginning of sepsis and sirs manifestation can be differentiated.conclusion. . burn trauma itself is not the reason for pct increase. pct level increases in cases of burn injuries as the sign of infectious complications joining. . with the help of traditional sepsis markers it is difficult to differentiate sirs manifestation and first stages of infectional complications in case of thermal trauma. . in cases of severe burns pct test is a highly sensitive method of sepsis early stages diagnostics. . surgery treatment at early stages after trauma allows to avoid development of severe sepsis. h. knoester* , m. b. bronner , a. p. bos , m. a. grootenhuis pediatric intensive care unit, psychosocial department, emma children's hospital, amc, amsterdam, netherlands introduction. improved survival in children with critical illnesses has led to new disease patterns due to long-term complications and effects of the original illness and its treatment. as a consequence, health related quality of life (hrqol) has become an important outcome measure in pediatric intensive care unit (picu) survivors. little is known about hrqol in picu survivors,. hrqol evaluation could contribute to improvement of support after discharge. the purpose of this study was to assess hrqol in picu survivors. october all parents of children, acutely admitted to our picu were invited to complete hrqol questionnaires, and months after discharge. hrqol in children from - years of age was evaluated with a dutch validated questionnaire, the tno-azl preschool children quality of life questionnaire (tapqol). the tapqol covers domains of hrqol; norm data from the general dutch population are available. data analyses was done by non-parametric testing (patients versus norm group) and by calculating effect sizes (difference in mean scores between the patients and the norm group divided by the standard deviation of the scores in the norm group). effect sizes give an indication of changes in hrqol in comparison with the norm group. . of ( . %) eligible patients were evaluated. statistically significant differences with the norm group were found on domains, and months after discharge (more lung problems and worse liveliness) and on domain months after discharge (better appetite). moderate ( . ) and large ( . ) effect sizes were found on five respectively four domains and months after discharge: indicating worse hrqol on lung problems, sleeping problems, motor functioning, anxiety, positve mood and liveliness; and indicating better hrqol on problem behaviour. no statistically significant changes over time were found for all domains and months after discharge. our results indicate that hrqol in young picu survivors is decreased in some domains of physical and emotional functioning. these problems do not diminish over time. positive evaluation by parents regarding appetite and problem behavior could be influenced by response shift (changing of internal standards and values due to confrontation with a life-threatening disease). more research is necessary because of the small study group and to determine the influence of risk factors such as length of stay, age of the child at admission, severity of illness and physical sequelae of the disease and its treatment on hrqol. hrqol evaluation can be a useful tool as part of screening after picu survival to determine the necessity for follow-up care. coarctation of the aorta is not an uncommon congenital heart defect. one of the possible postoperative complications is the so-called postcoarctectomy syndrome (mesenteric arteritis). the purpose of the present study is to assess the changes in gut flow through the dual sugar permeability test. five patients have been included in the study until now. median age month ( . - ) and median weight . kg ( - ). premedication and anaesthesia was the same for all the patients. the test solution contains -o-methyl-d-glucose, d-xylose, l-rhamnose and lactulose. patients received ml/kg of the test solution after induction of anaesthesia, at and hours after the initial dose. urine production is measured during a three-hour period after each instillation. the sugar content is analysed by capillary gas chromatography (normal values l/r = . , omdg and xylose - %). a. monsel , p. durand , v. haas , c. beaujard , p. rouleau , s. el aouadi , d. benhamou , k. asehnoune* anesthesie reanimation, reanimation pediatrique, anesthesie réanimation, hopital de bicetre, bicetre, anesthesie réanimation, chu hotel-dieu, nantes, france pediatric epidural anesthesia (ea) is considered to be without hemodynamic impairment in children. however, when compared with information relating to adults, little is known about the hemodynamic effects of epidural anesthesia on the cardiac output (co) in infants. using transesophageal doppler (ted) monitoring of co, we prospectively studied infants < kg who were scheduled for abdominal surgery. during sevoflurane general anesthesia, ted monitoring of co was performed before and after lumbar ea with . ml/kg of . % bupivacaine and : , adrenaline. co, arterial blood pressure, and heart rate were measured before and , , and minutes after performance of ea. in patients anesthetized with sevoflurane and sufentanil, ea resulted in an increase in stroke volume by % (p< . ) and a decrease in heart rate by % (p< . ). ea also induced a significant decrease in systolic, diastolic, mean arterial blood pressure and systemic vascular resistances by %, %, %, and % respectively. conversely, co remained unchanged. the increase in sv observed is probably explained by optimization of afterload due to the sympathetic blockade induced by ea. these results confirm that ea provides hemodynamic stability in infants weighing < kg and support the use of ea in this pediatric population. bleeding is the most frequent complication during extracorporeal life support (ecls) after pediatric cardiac surgery. we would like to present our experience with ecls and recirculation blood saving, volume auto-regulation system using the law of connected vessels based on converted cpb set in infants after cardiac surgery with significant bleeding. since to ecls in the postoperative period was performed ( , % of all cardiac operations in this period). the significant bleeding (> ml/kg/h) was noted in pts. in most recent pts the volume recirculation system was implemented, whereas in previous patients blood was sucked out the circuit. the retrospective analysis of data was carried out. there were infants with single ventricle anatomy and with two-ventricle anatomy. there were no significant differences with respect to age, weight and prevalence of single ventricle anatomy between groups. the indication for ecls was cardiac arrest in , low cardiac output in , hypoxemia in and sepsis in patients. the overall mortality rate was %. the mortality did not differ significantly between groups ( , % versus % in non-recirculation group; p= , ). there was significantly lower number of blood products transfusions(p< , ), lower number of surgical explorations(p< , ) lower mean lactate level hours after ecls institution p(< , ) and shorter ecls duration (p< , ) in the recirculation group. the system of blood recirculation in children with bleeding on ecls is simple, highly effective in stabilization of the haemodynamics and no-cost consuming. it can reduce necessity of chest exploration, blood product transfusions and duration of support. t. tunc* , t. topal , m. kul ,Ö.Öngürü , a. korkmaz , s.Öter neonataloji bilim dali, fizyoloji anabilim dali, patoloji anabilim dali, gülhane askeri tip akademisi, ankara, turkey necrotizing enterocolitis (nec) is the most common gastrointestinal emergency in the premature infant. the major risk factors in nec include prematurity, hypoxia, enteral feeding, and bacterial colonization. these factors predispose at-risk infants to an exaggerated intestinal inflammatory response leading to ischemic bowel necrosis. experimentally induced ischemia and reperfusion (i/r) of the intestine is a model which can be appropriately used to imitate nec. n-acetylcysteine (nac), erdosteine (erd) and alpha-lipoic acid (ala) are well-known antioxidants with similar structural properties. in the present study, the effectiveness of these three sulfur-based antioxidants against intestinal i/r-injury was evaluated.methods. one month old male spraque-dawley rats were randomly divided into five groups (n = for each): i/r (control), i/r+nac, i/r+erd, i/r+ala and sham-operated group without i/r. animals were operated at a temperature of o c under ketamine anesthesia. ischemia was provided by occluding the superior mesenteric artery via a microvascular clamp. collateral vessels of the small intestine were ligated to prevent collateral circulation. min of ischemia was followed by min of reperfusion. nac ( mg/kg/day, i.p.) was administered first min before operation and followed once daily for days. erd ( mg/kg/day, oral gavage) administration was begun days before operation and continued daily doses. ala ( mg/kg/day, i.p.) was injected only one time h before operation. at day after operation the ileum was resected and the rats were sacrificed. protein oxidation (carbonyl content, pco), lipid peroxidation (malondialdehyde, mda), superoxide dismutase (sod) and glutathione peroxidase (gsh-px) were measured in the ileal tissue. oxidative and antioxidant parameters of resected ileal segment (mean ± sd) groups as a clinically relevant model to nec, our experimental i/r protocol resulted with marked rise in oxidative stress levels and fall of antioxidant enzymes activities. these changes were ameliorated with the antioxidants used. among all, ala presented the strongest and nac the weakest effect. this outcome promises beneficial usage of these sulfurbased antioxidants against oxidative stress which plays an important role in nec pathogenesis. a. khaldi* , k. menif , a. bouziri , a. hamdi , s. belhadj , n. ben jaballah pediatric intensive crae unit, children's hospital, pediatric intensive crae unit, children's hospital, tunis, tunisia high-frequency oscillatory ventilation (hfov) may significantly improve oxygenation and outcome in newborns with respiratory dysfunction and beyond the neonatal period in patients with a variety of diffuse alveolar diseases. in small airway disease like respiratory syncytial virus (vrs) bronchiolitis, hfov is considered potentially hazardous because of the risk of air trapping. however, a few studies had reported utility of hfov in children with acute hypoxemic or hypercapnic respiratory failure caused by vrs and failing optimal conventional mechanical ventilation (cmv). the objective of the study is to evaluate the effectiveness and safety of hfov in pediatric patients with acute respiratory failure due to rsv and failing cmv. we conducted, over -year period (october to october ), a prospective clinical study in a tertiary care pediatric intensive care unit. fourteen ( ) patients (ages to days) with acute respiratory failure due to rsv bronchiolitis and failing optimal cmv were included. passage to hfov was indicated for severe hypoxemia in patients (median alveolar-arterial oxygen difference [p(a-a)o ]: [ - ] mmhg, median oxygenation index [io]: [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ) and for severe hypercarbia in patients (median ph: , [ , - , ] , median paco : [ - ] mmhg). hfov was instituted after a median length of cmv of ( - ) hours. ventilator settings, arterial blood gases, oi and p(a-a)o was recorded before hfov (h ) and at a predetermined intervals during hfov and compared using the one-friedman rank-sum procedure and a two-tailed wilcoxon matched-pairs test. after starting hfov, a distinct decrease in fio at hrs that continued to hrs (p< , ). in all patients, there were significant decreases in oi and p(a-a)o at hrs, that were sustained up to hrs (p< , ). target ventilation was achieved in all cases and paco significantly decreases after hr of hfov (p= , ) and remained within the target range thereafter ( - mmhg). the median maximum pressure amplitude used on hfov was ( - ) cm h o and the median maximal paw was ( - ) cm h o. no significant complications associated with hfov were observed. twelve patients ( %) survived to hospital discharge without supplementary oxygen. tow patients ( %) died from septic shock. in pediatric patients with either hypoxemic or hypercapnic acute respiratory failure due to rsv bronchiolitis, hfov can be used successfully and safely if conventional ventilation fails to improve gas exchange. however, randomized controlled trials are needed to identify its benefits over conventional modes of mechanical ventilation. and are influenced by numerous factors like patient's disease severity, policies of the treating unit, religious and cultural traits, education and awareness of the patient's family, financial status of the family and legal provisions. majority of published studies on eol reflect either european or american ethos; that is either physician's paternalistic approach about the patient or patient's autonomy and self determination,( , ) about this sensitive process. studies on eol which reflect the influence and pivotal role of closely knit indian family on eol decision making are scant. we retrospectively analysed the eol decisions taken by the family in our icu as majority of the patients which merit eol care were not in a condition of decision making. setting- bedded multidisciplinary icu of a bedded tertiary care teaching hospital in pune in india. case papers of all icu admissions during one year i.e. st january to st december where eol decision was documented, were reviewed. data collected included demographics, underlying disease process, duration of aggressive treatment till eol consent, duration between eol decision and death, consenting person's relation with the patient, organ failure & level of life sustaining supports at decision and mode of payment of the treatment. during the study period patients died in our icu of which eol decision and consent was explicitly documented in cases which constitute study population. average age of the patient was years (range to ), average duration of active treatment till eol consent was . hours(range to ),average duration between consent and death was . hours(range to ). . % consents were signed by close relatives( son/daughter, brother/sister, spouse, father/mother) and . % were by other relatives( cousins, son in law/daughter in law). at the time of eol decision . % patients were having glassgow coma scale and below, . % patients were on mechanical ventilation, . % were on vasopressors and . % were needing renal replacement. metastatic disease ( . %) and traumatic or vascular brain injury( . %) were the commonest causes of death. only . % patients had medical insurance or employer assistance as a mode of payment for the treatment and in . % cases family members were the payers. withholding of non beneficial life sustaining therapies as eol process was practised in . % of the total icu deaths. all ( %) eol decisions as well as directive requests and consents were signed by patients' relatives, reflecting the importance of close family ties in indian eol practices. our objective was to study frequencies of withholding and withdrawing treatment and time until death in a dutch university hospital icu. between october and february we collected data of all patients that died. data were collected from patient files and during interviews with the doctors and nurses who were responsible for the patient at the time of death. we analyzed which treatments were withheld or withdrawn and calculated the time until death following withholding or withdrawal. preliminary results show that of admissions, patients died ( %). nonsurvivor's (median age years [range - ]) median length of stay was days (range minutes - months). in patients ( %) treatment was withdrawn and in patients ( %) treatment was withheld but not withdrawn. of all patients ( %) were mechanically ventilated of which ( %) were weaned and extubated before death. in of these patients it was decided not to intubate again and other patients not to intubate at all (median time until death: hours). in ( %) ventilator-dependent patients mechanical ventilation was withdrawn; ( %) were extubated. the median time until death after ventilator withdrawal was minutes. when patients were also extubated, it was minutes (p= , [mann-whitney test]). in patients mechanical ventilation was not withdrawn, but fio was decreased to . (median time until death minutes). in patients ( %) inotropic medication was withdrawn (median time until death minutes). in cases, the withdrawal of inotropic medication was combined with the withdrawal of mechanical ventilation. in patients ( %) it was decided not to increase inotropic support (median time until death : hours). in patients ( %) the decision was made not to resuscitate in case of cardiac arrest. median time of this decision before death was hours. in the patients that died treatment was withdrawn in the vast majority of patients. withdrawal of mechanical ventilation and/or withdrawal of inotropic support were most often used. a considerable number of patients died within minutes following withdrawal of therapy. r. veiga* , g. silva , g. campello , c. dias , c. granja intensive care department, hospital pedro hispano, matosinhos, biostatistics and medical informatics, faculty of medicine, porto, portugal the high mortality of critically ill patients underscores the need for icu teams to recognize end-of-life care as an integral component of critical care. besides survival, the success of intensive care should also include the quality of lives preserved and the quality of dying. the aim of this study was to evaluate the incidence and type of end-of-life decisions in critical patients that died in an icu. retrospective analysis of all patients that died in the icu in the period of january to december and evaluated the following variables: demographic characteristics (age, gender); co-morbidities: (heart failure, chronic obstructive pulmonary disease (copd), diabetes mellitus, neoplasia, chronic renal disease, hiv/aids, alcoholism); reason for admission; saps ii; length of icu stay (icu los) and type of end-of-life decisions. three concepts were defined in order to classify the end-of-life decisions: comfort care: a change from curative therapy to comfort care therapy; limited therapy: maintenance of curative therapy but without escalating it (e.g. not raising rate of vasopressor agents, no renal substitution); without previous end-of-life decisions: when no attitudes toward end-of-life care were considered. given the diminished number of patients in the without previous end-of-life decisions group we decided to evaluate them apart from the other two groups.results. two-hundred and twenty seven patients were admitted in the icu and of them died ( %). reason for admission in those who died was septic shock/ severe sepsis ( %), post-cardiac arrest ( %); cardiogenic shock ( %); acute respiratory distress syndrome ( %). the most common co-morbidity was alcoholism ( %), followed by diabetes mellitus ( %), neoplasia ( %), heart failure ( %) and copd ( %). forty seven patients ( %) died after comfort care decision, eleven patients ( %) after limited therapy decision and four ( %) patients died without previous end-of-life decisions. comparing the groups comfort care and limited therapy we found significant differences in the following variables: hemorrhagic shock at admission ( % vs. %) (p= . ); saps ii ( vs. ) (p= . ); icu los ( . days vs. . days) (p< . ). patients in the limited therapy group had more admissions with hemorrhagic shock, a higher severity score and stayed less time in the icu. this analysis suggests that end-of-life decisions in this group express their higher severity. patients of the comfort care group presented less severity and stayed longer in the icu. their shift of curative therapy to one designated to provide comfort care reflects an absence of a clinically favorable response. the low percentage of patients without previous end-of-life decisions is consistent with previous reports and should be seen as a positive issue. non invasive positive pressure ventilation (nippv) is widely accepted as an initial approach to providing ventilatory support to many patients with acute respiratory failure (arf). palliative approaches focused on the quality of life and comfort; represent a challenge for family's physicians and the patients. nippv is an attractive option to treat acute respiratory failure in end stage patients when the failure is irreversible and it is a final outcome of the primary disease. the approach to providing ventilatory support to patients with arf, to relieve them from the sensation of dying suffocate without intubating them because they don't wish it either, is very challenging. after institutional approval and patients consent, we conducted a prospective observational study of patients that fulfilled the criteria. cases received nippv ( with end stage cancer and with pulmonary fibrosis). when nippv was ordered we recorded: respiratory rate, heart rate, arterial blood pressure, neurological status and arterial blood gases, before nippv initiation (baseline data) and then st, th and th hour. at the time of initiation of nippv, all patients were alert and cooperative with nippv. analgesia and/or sedation were used when it was necessary. pao , pco and ph measures were analyzed using statistical methods. percentage changes from baseline (pre-nippv) of these measures were used as dependent variables. (mean value of measurements at different time points was used). dependent variables (percentage of pao , pco and ph) were regressed on time, for each patient. in all cases the results were statistically significant, with p-values ranging from a low of . to a high of . . for all patients, the regression coefficient for the percentage change was positive; indicating that the percentage change was increasing with time. we can remark that pao increases over time, pco and ph p values > . . we believe that nippv via helmet cpap is a means of potentially ensuring the highest quality of end-of-life care. nippv can be applied for palliative care, and it might be used to keep patients whom developed acute respiratory failure comfortable before the inevitable. decisions regarding the resuscitation status of patients are among the most difficult facing healthcare professionals, patients and families. these groups often need to discuss decisions regarding resuscitation yet their understanding and expectations can differ greatly. this study sought to determine the knowledge and beliefs of doctors, nurses and the general public regarding resuscitation decisions.methods. an observational study was designed. three study groups (doctors, nurses and general public) were interviewed using a face-to-face interview by a single interviewer and questionnaires completed. questions examined opinion, factual knowledge and knowledge of the ethics surrounding hospital resuscitation attempts. . doctors, nurses and general public were randomly selected. % doctors, % nurses and % of public correctly estimated survival to discharge following in-hospital resuscitation attempt. the remainder overestimated survival. . % of doctors and % of nurses consider resuscitation decisions to be made too infrequently. deficiencies were identified in doctor and nurse knowledge of the ethics governing resuscitation decisions and public opinion was found to conflict with ethical guidelines. public understanding of the nature of cardiopulmonary arrests and resuscitation attempts, and of the implications of a dnar order is poor. . % of public report television medical dramas as their primary source of information on such matters. knowledge regarding resuscitation principles, outcomes and ethics is poor among both healthcare staff and the general public. these knowledge differences may not be appreciated or addressed in discussions regarding resuscitation and this reduces the likelihood of meaningful discussion and acceptable decisions. there is a need for educational initiatives to address these deficiencies. public apprehension surrounding this subject needs to be identified and corrected during discussions and this could be facilitated with a patient information leaflet. [ ] poor communication during this process may lead to unnecessary anger and a delay in the grieving process that could linger for many years to come. giving the family the option to be present during resuscitation offers a more compassionate and family-centred approach to this crisis. this option of family presence however is frequently met with resistance and uncertainty by health care workers who may view the family's presence as increasing their risk of making a mistake or worse, being sued. a study in the uk estimated that out of one-hundred-and-sixtytwo uk emergency departments family witnessed resuscitation was allowed by % for an adult patient and % for a child. [ ] another us study also found that amongst patients in emergency departments, % preferred to have their family present during resuscitation. [ ] a survey was conducted amongst the doctors, nurses and paramedics who work in two uk eds to assess their attitudes and beliefs. experience, life support training, years in practice, consent issues, ethical factors and concerns regarding medico legal implications were sought for. a -point likert scale was used and mean scores analysed using microsoft excel. . staff were surveyed. % of doctors, % of nurses and % of paramedics believed in the concept in trauma fwr. in cardiac arrest patients, % were in favour of it, % opposed to it and % undecided. % of staff believed that litigation was possible with family witnessed resuscitation. % of respondents thought that critical incident de-briefing would be of benefit to assist staff dealing with stress. fewer doctors believed in cardiac fwr compared to nurses (p= . ) and paramedics (p= . ). in trauma, difference was non-significant. as health care professionals caring for families in the emergency departments, we need to recognize the need for compassionate family-centered care. with a well trained and motivated team equipped with effective, well thought out guidelines, there is considerable benefit for family members and staff in this difficult situation. thorough information about the events that are going to take place in the icu after an elective procedure might facilitate the awakening process and weaning from the ventilator, mitigating patient's anxiety and increasing their comfort. the aim of this study was to analyze the impact of preoperative information on the patient's perceptions and reactions to the usual inconveniences, such as orotracheal tube (ott), associated with the first postoperative hours in the icu. prospective, cohort study with a group of cases (a) and a control group (b). duration: two months. inclusion criteria: all patients undergoing elective cardiac surgery. there were no exclusion criteria. setting: cardiac surgical icu of a tertiary hospital. the survey was made in the first hours. the study was blinded for the doctors in charge of the patients. the characteristics of both groups are presented as a/b with the p value into brackets. the quantitative variables are shown with the mean value and the qualitative variables as a percentage. the number of patients included was : cases (a) and controls (b). age: , / , years ( , ); men: / %( , ); time receiving sedative drugs: , / , hours ( , ); total hours with ott: , / , ( , ); hours with ott after stopping sedation: , / , ( , ). the first patient's perceptions were: discomfort related to ott in , / , % ( , ); surgical pain in , / , % ( , ); thirst in , / , % ( , ); welfare or calm in , / , % ( , ), and nothing in , / , % ( , ). additional sedatives were required in , / , % ( , ). information was considered very useful in , %. patients valued very positively the provided information. in addition, this information had a significant impact on the tolerance to the ott, requirement of additional sedatives, and in the sense of welfare. there were not differences in the time under sedative drugs or in the perception of thirst or pain. a multiparameter questionnaire was sent to icu. each questionnaire comprised informational topics groupe into categories (table). one relative per patient was asked to quote (yes/no) within days after admission, each item, i.e. if he would like to find information on that item in an ib. if "no" was quoted, he was asked to say why (closed answers). demographic data on patient and relatives were correlated to the scores (nbre of "yes"), in each item category (factor analysis with varimax rotation followed by stepwise multiple linear regression). . questionnaires were analyzed (patients: age ± year, saps : ± , sofa: ± ). table: % of positive response for each item ("would you like information on this topic in an icu booklet?") grouped into categories. "no" answers were mostly explained by "i trust the team to manage information about this" (median: %, range: - ). mulitvariate analysis showed that demographics data describing patient condition (age, saps , chronic disease) correlated (p< . ) with "yes" score of the items comprized in "icu rules" (table) but not with other items grouped in other information categories. conclusion. interestingly, as a whole, most items were highly wished in a booklet, suggesting that - % of relatives express a plea for transparency in face of "difficult icu issues", without taboo. only the "yes score" to "icu rules" items correlated with patient status whereas items from other topics did not. this sounds, as relatives visiting the most severe patients may consider visiting rules as crucial. other items did not correlate to profiles, and may thereby be considered as societal standard requirements in terms of information. in / , our -bed medical icu signed a convention with the asp iroise association defining hv's role and presence. the association, a member of a national network of hv associations, works with our university hospital. four hvs took alternate turns in the icu one afternoon per week. hv were free to meet any conscious patient or any family member who wished so; icu staff also asked them to meet patients or families who seemed particularly distressed. hv wrote a brief commentary in a special transmission logbook which could be consulted by the staff and gave feedback about their visits whenever needed. patients (pts)and families (fam)who met an hv were sent a questionnaire either in / or in / . pts were admitted during the period of study: the hv met pts ( , %) and families ( , %). people answered the questionnaire ( , %): pts and fam: spouse, parents, sister, children( no answer). ethics consultation has been introduced into the practice of medicine during the last decades as a way to help physicians and nurses come to a decision about a medical treatment where value-laden conflicts are involved. the primary goal is helping to identify, analyze, and resolve ethical problems. the aim of this study was to evaluate ethics consultation in a dutch university hospital intensive care. intensivists, residents, fellows and nurses can consult a clinical ethicist specialized in intensive care for advice in value-laden situations. we evaluate ethics consultation on our icu between january and april . the clinical ethicist was consulted times. in / cases ( %) advice was asked before withdrawal of life-sustaining therapy. in this category / ( %) cases concerned palliative care. in / cases ( %) the independent advice was in confirmation with the physician's view. in / cases ( %) advice was sought in cases were there was doubts to proceed with intensive care therapy. in four cases relatives wanted to withdraw therapy, where the intensivist did not consider this as futile. in / cases ( %) the advice was in accordance with the treatment plan. in cases ( %) questions about information asked by non-relatives. all advises were followed. cases concerned triage, cases withholding therapy, brain death declaration, a deadly iatrogenic complication and in patients a question concerning emergency research. in ( %) cases a lawyer specialized in health care was consulted. in the cases about 'withdrawal of therapy', the advise could be given within minutes in % of the cases. ethical advise by a clinical ethicist specialized in intensive care can be additional, affirmative and reassuring, and improves quality of care. in most cases advice could be given immediately. . deferred consent has been proposed as a surrogate for a priori subject or proxy consent. the aim of this report is to evaluate the practicality and efficacy of a deferred consent procedure in an ongoing dutch multi-centre clinical trial. screening logs were collected from two participating centres of a clinical trial that is currently conducted to evaluate the efficacy of early lactate-directed therapy and that uses deferred consent. screened patients were analyzed for eligibility and reasons for exclusion. ( %) were not reported to the study investigators, patients ( %) were not included for medical-ethical reasons (e.g. treating clinician deemed risk/benefit ratio of the study intervention unacceptable), in patients ( %) study participation was practically impossible (e.g. unavailable study materials) and the reason was unknown in patients ( %). only patients (or their relatives)( %) refused informed consent. in an ongoing dutch multi-centre emergency clinical trial using deferred consent, only % of patients or their relatives refused informed consent. deferred consent in emergency research is practical and facilitates a high inclusion rate. adult respiratory distress syndrome (ards) and peep have been linked to right ventricular dysfunction (rvd). this has been attributed to elevated pulmonary artery pressure (pap) and pulmonary vascular resistance (pvr) due to ards as well as increased intrathoracic pressure due to peep therapy. we wondered if rvd was a late phenomenon in ards or could also be detected during early peep treatment of hypoxia in patients with multiple ards risk factors. pulmonary embolism is a highly prevalent disease associated with severe morbidity and mortality. although the hemodynamic changes induced by pulmonary embolism are known, the alterations in respiratory mechanics after an embolic event are not completely understood. the aim of this study was to evaluate acute changes in hemodynamics, static and dynamic respiratory mechanics and lung histology induced by an experimental model of pulmonary microembolism. ten large white pigs (weight - kg) were instrumented with arterial and pulmonary catheters and pulmonary embolism was induced in pigs by injection of polystyrene microspheres (diameter ∼ µm), in order to obtain a pulmonary mean arterial pressure (pmap) of twice the baseline value. five other animals were injected with saline and served as controls. hemodynamic and respiratory data were collected and pressure x volume (pxv) loops of the respiratory system were performed by a quasi-static low flow method. animals were followed for hours and after death lung fragments were dissected and sent to pathology. the average amount of microspheres necessary to generate microembolism was . ± . mg/kg. pulmonary embolism induced a significant reduction in stroke volume ( ± ml/min/bpm pre vs ± post, p< . ), an increase in pmap ( ± mmhg pre vs ± post, p< . ) and pulmonary vascular resistance ( ± mmhg/l/min pre vs ± post, p< . ). respiratory dysfunction was evidenced by significant reductions in pao /fio ratio ( ± pre vs ± post, p< . ), dynamic lung compliance ( ± ml/cmh o pre vs ± post, p< . ) and increase in dead space ventilation ( ± pre vs ± post, p< . ). pxv curves of the respiratory system were affected by embolism, with shift of the loops to the right and consequent reduction in static compliance and pulmonary hysteresis. pathology depicted inflammatory neutrophil infiltrates, alveolar edema, collapse and hemorrhagic infarctions. pulmonary microembolism induced by polystyrene microspheres is associated with cardiovascular dysfunction, as well as respiratory injury characterized by decrease in oxygenation, dynamic and static lung compliances and pulmonary hysteresis. pathology findings were similar to those verified in inflammatory-induced acute lung injury. the similarities between respiratory and histologic features of this model and those from conditions associated with lung inflammation suggest that pharmacologic and ventilatory interventions already used to treat acute lung injury may also be tested in pulmonary embolism. the presence of patent foramen ovale (pfo) is frequently underdiagnosed in icu patients suffering from refractory hypoxemia. however, it is relatively common in the general population. we examined the prevalence of pfo in mechanically ventilated icu patients with refractory hypoxemia and abnormal chest x-ray findings. over a period of five years, mechanically ventilated patients with refractory hypoxemia and abnormal chest x-ray findings were examined with transesophageal echocardiography (tee) for the presence of pfo as a contributing factor to their hypoxemia (right to left intracardiac shunt). all patients were ventilated with tidal volume - ml.kg - and peep between - cmh o. their mean pao /fio ratio was ± mmhg. the coexisting pathology consisted of: ards ( cases), massive pulmonary embolism ( cases), copd ( cases), cabg surgery with rv infarction ( cases), cerebrovascular accident ( case) and pulmonary oedema due to fluid overload ( case during a two-month period we investigated the possibility of opening of the foramen ovale during a recruitment maneuver in either patients with ards or in patients with atelectasis and a pao /fio ratio< . we enrolled consecutive patients (ards: cases, patients with atelectasis and hypoxemia: cases), likely to benefit from a recruitment maneuver. mean pao /fio ratio was and mean compliance was ml.cmh o - prior to the maneuver. all data regarding the mechanical properties of the lung were recorded from the ventilators monitor screen. after deficits of intravascular volume had been addressed and hemodynamics had been optimized, a baseline transesophageal echocardiographic study using contrast material was performed to rule out the possibility of a foramen ovale already patent prior to the maneuver. the recruitment inflation pressure was chosen as the lesser of cm h o or the peak pressure at ml.kg - tidal volume. the ventilator was then adjusted to deliver this high inflation pressure for secs. five seconds after the onset of inflation, ml of a contrast material were injected through a central venous line with the transesophageal probe already in place to detect the passage of the material to the left atrium. passage of the contrast material to the left side of the circulation was detected using two dimensional echocardiography. we found that the sustained high inflation pressure resulted in foramen ovale opening in patients, whereas it did not produce such a result in patients. in of the studied patients, the baseline transesophageal study revealed a patent foramen ovale before recruitment was attempted. no adverse effects following the recruitment maneuver were noted. mean pao /fio ratio was and mean compliance was ml.cmh o - twenty minutes after the recruitment maneuver, with only one of the recruited patients showing a significant improvement in oxygenation.conclusion. patent foramen ovale may be a contributing factor of refractory hypoxemia in icu patients. opening of the foramen ovale is not an unlikely event during a recruitment maneuver. acute respiratory distress syndrome (ards) remains a major problem in critically ill patients, with mortality rates of - %. to date, no specific treatment has been shown to decrease mortality, but this may largely be due to the heterogeneity of the populations meeting the ards criteria.objectives: to evaluate patients who died with a clinical diagnosis of ards and who had a postmortem examination in order to: -define the pathological alterations associated with the syndrome, with particular reference to the typical pattern of diffuse alveolar damage (dad); -evaluate whether etiologies or precipitating factors were missed; and -speculate whether a lung biopsy could have guided the clinical management. three year ( ) ( ) ( ) review of all patients with ards (using the aecc criteria) who had a postmortem examination. comparisons between ante-and post-mortem diagnoses were classified as major and minor discrepancies using the goldman classification. results: of a total of admissions, patients had a clinical diagnosis of ards. of these, died; had a postmortem examination and of these had complete data for analysis. the main causes of death were multiple organ failure in ( %) and refractory hypoxemia in ( %). postmortem lung examination revealed dad in ( %) patients ( associated with a lung infection), (broncho)pneumonia without dad in ( %), invasive pulmonary aspergillosis without dad in ( %), and other diagnoses in ( %). major unexpected findings were found in ( %) patients, classified as goldman class i errors and class ii errors. the class i errors included cases of invasive pulmonary aspergillosis.conclusion. ards as a syndrome, can be due to various pathological patterns; at autopsy, only half of patients with ards have typical dad. special attention should be paid to the possibility of aspergillosis; in this setting, lung biopsy may have a role. g. s. georgieva*, s. kurata, c. zhu, a. bilali, t. imai critical care medicine, tokyo medical and dental university, tokyo, japan development of efficient lung preservation method has been anticipated and we elucidated that positive pulmonary venous pressure (pvp) ( mmhg) prevented ischemia-reperfusion (i/r) injury in isolated mechanically ventilated rat lungs. the aim of this study is to determine whether cpap accompanied with mmhg of pvp would be effective for prevention of i/r injury. after tracheostomy rats were ventilated at strokes /min with air ( % c ) and with peep of . cmh , cannulated to the left atrium and pulmonary arteries (pas), and perfused with krebs -henseleit solution supplemented with albumin ( %) ( . ml/g/min). the lungs and heart "en block" were isolated and placed in a chamber; right and left bronchus as well as pas were dissected which permit each lung to be ventilated and/or perfused selectively by selective occlusion of each bronchus and/or pa. after min control condition, the left lung (ll) was maintained under cpap (selective occlusion of left broncus); the control right lung (rl) was ventilated with peak airway pressure of cmh above peep;perfusion to the both lungs was stopped (ischemia). pulmonary venous outflow was elevated so as to be applied mmhg to the left atrium during ischemia. after -min ischemia, reperfusion with mmhg pvp and both lung normal ventilation were resumed for min. perfusion pressures of rl and ll was measured at the beginning and at the end of the experiment by occlusion either the left or right pulmonary artery, as appropriate. albumin content in bronchoalveolar lavage fluid (balf) separately for each ll and rl, and lung weight were measured. protein content in balf was calculated as (mg of protein)/(ml of balf)/(g of lung dry weight). all the data were compared by wilcoxon's rank-sum or mann-whitney u-test and expressed as mean +/-sd. in i/r lung maintained at cpap, wet/dry and balf as well as perfusion pressure increased compared to the control rl. conclusion. cpap( . cmh ) and mmhg pvp cannot prevent ischemic lung injury despite constant distention of pulmonary vasculature and alveolar space. this suggests that gas exchange during ischemia would be necessary for escaping from i/r injury. potential peripheral airway obstruction is of importance for the choice of ventilatory strategy in acute lung injury (ali). use of a limited expiratory time counteracts early regional expiratory collapse but might cause hyperinflation in case of significant peripheral obstruction. the aim of this study was to assess regional expiratory time constants and gas trapping in early ali. ten anesthetized pigs were ventilated in volume-controlled mode with i:e ratios of either : or : at a rate of breaths per minute. starting from the end-inspiratory level, sequential computed tomography (ct) exposures were performed during passive, uninterrupted expiration to the atmosphere. the procedure was performed before and after oleic acid-induced lung injury (oai) had been induced in the lower lobe on one side. the gas volume of bilateral dependent and non-dependent regions of interest (rois) was calculated from radiographical attenuation values. the expiratory time constant was calculated from a mono-exponential decay of roi gas volumes during expiration. gas trapping in injured and non-injured regions were compared. during ventilation with i:e ratio : , oai caused overall compliance to decrease from +/- . to +/- . ml/cmh o (p< . ). dependent, injured regions showed a shorter time constant and a lower volume of gas than dependent non-injured regions regardless of whether the preceding end-inspiratory volume had been increased or not by application of a limited expiratory time. in non-dependent, non-injured regions, the gas volume was similar on both sides after both patterns of ventilation. one of the additional approaches in the therapy of the acute respiratory distress syndrome (ards) is the use of a pumpless arteriovenous extracorporeal membrane oxygenator (interventional lung assist (ila)). the aim of our study was to test the effects of an ila system on hemodynamics and gas exchange during resuscitation and to establish whether ila should be kept open or clamped under these circumstances. the study was designed as a prospective experimental study. the experiments were performed on pigs ( to kg body weight). the pigs were anesthetized and mechanically ventilated. one femoral artery and one femoral vein were cannulated and connected with ila. acute lung injury was induced by repeated bronchoalveolar lavage until arterial partial pressure of oxygen (pao ) was lower than torr for at least min during ventilation with % o . ventricular fibrillation was then induced by an indwelling pacemaker. manual compressions of the thorax were started at once and continued for minutes. in animals, ila was kept open, in the other it was clamped immediately. statistical analysis was performed using graphpad prism. two-way analysis of variance was applied and significance was accepted at p values < . . the data is given as mean ± sd. with a mean systolic arterial pressure in the group with ila open of ± mm hg and ± mm hg with ila clamped and mean blood pressures of ± mm hg with ila open and ± mm hg with ila clamped the blood pressure did not differ between the two groups. endtidal carbon dioxide decreased from ± torr with ila open and ± torr before intervention to ± torr and ± torr, respectively. the arterial partial pressure of carbon dioxide (paco ) was significantly lower in the group with the ila system open ( ± mm hg versus ± mm hg at minutes) and the pao was higher (although significant only at minutes, mm hg ± mm hg versus mm hg ± mm hg). the blood pressure generated with thorax compressions did not differ significantly between the two groups and endtidal co was also in the same range. therefore we assume that circulation was not significantly affected by ila and that the shunt caused by the ila system did not deteriorate circulation. paco was significantly lower in the group with the ila system open and pao was higher. our results indicate that the ila system was not harmful during resuscitation, it even might have a beneficial effect.grant acknowledgement. the study was partially supported by novalung, hechingen, germany. respiratory failure -miscellaneous - increased thorax rigidity and high intraabdominal pressure reduce the stretch ability of the thoracic cage and modify the regional lung function. this phenomenon is often seen in intensive care patients, e.g. with abdominal compartment syndrome. objective of this study was to determine the effect of decreased thoracic cage compliance on regional distribution of spontaneous ventilation in different postures by the non-invasive method of electrical impedance tomography (eit). for this survey we examined ten healthy male spontaneously breathing volunteers (mean age ± sd: ± years; body weight: ± kg, height: ± cm). the compliance of the thoracic cage was restricted by external abdominal and thoracic corsets respectively. the eit examinations were performed with the goe-mf ii eit device (viasys healthcare, höchberg, germany). sixteen self-adhesive electrodes ( m red dot , m health care, borken, germany) were applied on the chest circumference in one transverse plane and used for rotating electrical current injection and voltage measurement. the eit data were acquired at a rate of scans/s. impedance data and spirometry were obtained during spontaneous ventilation in three body positions (sitting, left and right side). statistical analysis was performed using repeated anova with bonferroni's multiple comparison test and student's t test. p values < . were considered significant.results. the regional distribution of ventilation in subjects without restrictions revealed a close match with physiologically expected values. thoracic and abdominal restrictions led to reduction of ventilation in the dependent lung areas. the non-dependent lung areas were not affected. the fractional ventilation in the dependent lung areas was reduced in the right side position from . ± . % to . ± . % (thoracic restrictions) and . ± . % (abdominal restrictions), in the left side position from . ± . % to . ± . %, and . ± . %. thoracic and abdominal restrictions of the thoracic cage reduce ventilation only in the dependent lung regions in spontaneously breathing healthy volunteers. eit is a suitable method for non-invasive determination of regional lung ventilation. k. raymondos* , k. vieweger , j. ahrens , m. przemeck , m. homann , s. piepenbrock anaesthesiology, medical school hannover, anaesthesiology, annastift, johanniter-unfall-hilfe e.v., ortsverband wasserturm, hannover, germany germany are still performed with ambulances in that only limited monitoring and usually only volume-cycled emergency ventilators can be used. we established an intensive care ambulance system and evaluated the transfers of critically ill patients performed with this system. we prospectively recorded interhospital-transfers. the ventilatory modes before and during the patients' transfer and further characteristics of the interhospital-transfers were evaluated. transport ventilation was performed with the raphael ® silver ventilator (hamilton medical ag, rhäzüns, switzerland) with that also pressure-support ventilation (psv), airway pressure release ventilation (duopap ® /aprv) and the combination of both could be used. indications for the interhospital-transfers included ischemic ( . %) and other ( . %) cardiac diseases, cerebral diseases ( . %) of which % required neurosurgy, pulmonary disease ( . %) and others ( . %). ( . %)% of the transferred patients received ventilatory support, patients ( . %) breathed spontaneously with and patients ( . %) without oxygen insufflation. the majority of the mechanically ventilated patients received ventilatory modes supporting spontaneous breathing before ( . %) and during the transfer ( . %). the patients were transferred in minutes ( minutes - hours) over a distance of km ( - km) (median (range)). at least motor syringe pumps were needed during the transfer of patients ( . %). monitoring during the transfer was similar or more extended compared to the monitoring in the hospital prior to transfer (ecg % vs. %, pulse oximetry % vs. %, non-invasive blood pressure % vs %, intraarterial pressure % vs % and capnography % vs. %). most ventilated patients received weaning techniques and most of these ventilatory modes were continued during the transfer. these ventilatory modes and a more extended monitoring including intraarterial pressure monitoring and capnography cannot be applied in emergency ambulances. the less invasive ventilatory modes and the extended monitoring enable a less invasive and safer interhospital-transfer as the intensive care treatment and monitoring prior to transfer is maintained or even extended during the transport. a. sánchez*, m. palomar, r. alcaraz, a. socias, d. moreira intensive care unit, hg vall d'hebron, barcelona, spain introduction. some series have shown the bad prognosis of patients with pulmonary fibrosis (pf) who require admittance at icu for respiratory failure. there are doubts of the benefit of the ventilatory support if the precipitating cause is not well defined. lung transplant (lt) could be a therapeutical option. the aim of this study was to analyze the prognosis of the patients with pf who are admitted to an icu of a hospital with lt program.methods. case-series, observational study of patients with pf and acute respiratory failure admitted to the icu of a third level hospital with lt programm between january until june . information about the cause of pf, clinical course, current status, ventilatory support, length of stay, pulmonary functional tests, possibility of trasplantation, complications and mortality was collected. . patients ( men, women) with pf ( idiopathic pf, connectivopaty and due to radiotherapy) were admitted for acute respiratory failure (arf) to our icu. mean age was , ( - ) years. the median duration of illness from diagnosis until admittance was , ( - ) years. apache-ii score was ( - ). the precipitating cause of arf was identified in patients: bacterial pneumonia was documented in patients; had a pulmonary embolism; fungic infection and cases were due to the progression of the disease. in cases the precipitating cause could not be identified. mechanical ventilation (mv) was required by patients ( , %) during an average of , ( - ) days with a mortality rate of , %. pa o /fi o at admittance ( - ) mm hg; and paco at admittance ( - ) mm hg. respiratory functional studies were available in eleven patients with a fev of . ( . ) l and fvc of . ( . ) l. patients ( %) died during their stay at icu. the cause of death was multi-organic failure in ( . %); refractary hypoxemia in ( . %) patients and of them died while the transplantation was being performed. mean length of stay was ( - ) days. patients were included in the urgent lt list and were transplanted. no donor was found in cases and died on the waiting list. there were performed single-lung and double-lt. mean age was ( - ) years. the time from the admittance until transplantation was ( - ) days. of them ( %) required mv with a mortality rate of , %. from this group ( , %) patients died during their stay at the icu. of the patients died while the transplantation was being performed.conclusion. literature shows a bad prognosis of patients with pf who need admittance to an icu for arf. in our experience the survival was % so the existance of a lt programm could offer a chance to these patients. m. e. lugarinho*, p. p. souza intensive care unit, hospital de clinicas mario lioni, rio de janeiro, brazil introduction. acute kidney insufficiency (aki) worsens the outcome in critical ill patients. we investigate whether the presence of aki had any effect on lenght of mechanical ventilation and mortality rate. observational, prospective study in a -bed general intensive care unit (icu) from january to december . the inclusion criterion was invasive mechanical ventilation for more than hours. aki was defined as the presence of dialysis during the icu stay. patients were then separated into aki and non-aki patients (control group). the primary end point was duration of total length of mechanical ventilation and the secondary end point was the icu mortality. a total of patients were studied: with aki and non-aki. the groups were similar in regard to age, sex, and apache ii score. the median (interquartile range) duration of mechanical ventilation [ - ] versus [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] days, (p< , ). the icu mortality rate were significantly greater in the aki patients: % versus , % (p< , ).conclusion. this study shows that renal insufficiency has serious impact on the duration of mechanical ventilation and morbi-mortality in critically ill patient. these data elicits the poor outcomes of mechanical ventilated patients who demands for dialytic methods. it will be useful in end of life discussions and decisions in our icu. introduction. -ht a-r-agonist -oh-dpat has been shown to counteract morphine induced ventilatory depression, while opiate antinociception remained unaffected. repinotan-hcl, another -ht a-r-agonist, is unlike -oh-dpat suitable for the use in humans. it was hypothesized that repinotan-hcl is capable to antagonize ventilatory depression without impairing anti-nociception in rat. with approval from local animal care committee, rats were anesthetized with sevoflurane and tracheotomized to record respiratory rate (rr), tidal volume (vt) minute ventilation (mv). inguinal vessels were catheterized to monitor arterial blood pressure and apply drugs iv. nociception was assessed by tail-flick reflex. morphine was administered at increments of mg/kg until a target % reduction of rr was achieved. subsequently, repinotan-hcl was added cumulatively at increasing doses ( . , . , , , µg/kg, n= ). another group received nacl . % to serve as control (n= ). morphine ( . ± . mg/kg) depressed rr to - ± %, and tfr was abolished with first dose of morphine in any experiment. repinotan-hcl antagonized ventilatory depression dose-dependently, mcg/kg repinotan-hcl re-established ventilation almost at pretreatment level (rr + . ± %, p< . , -anova, compared to control). tfr remained absent throughout repinotan administration. repinotan functionally antagonized morphine-induced ventilatory depression, while suppression of nociceptive reflex sustained. -ht a-r-agonists such as repinotan-hcl appear to be promising candidates to stabilize spontaneous breathing. a. makowski* , b. misztal , c. plowright , k. safranow anaesthetics, medway maritime hospital, gillingham, united kingdom, biochemistry, pomeranian medical university, szczecin, poland vapotherm's (vap) patent pending membrane technology makes higher flows from to lpm possible by saturating breathing gases with water vapor at body temperature. fio is ranging from . - . . heat and humidity allow nasal flow to be well tolerated by the patients. high flow in animal study caused small amount of peep. can we achieve desired therapeutic goal in treatment of respiratory failure (rf) with this very simple, non-invasive method? we investigated effectiveness and hospital outcome of patients with rf treated on vap at surgical hdu between december and march . data were taken during retrospective investigations. we analysed type and reason of rf as well as respiratory rate (rr), fio , flow, arterial blood gases (abg). data were collected before (bef) vap was commenced, hour after, and every day of treatment. we also recorded length and outcome of vap therapy and patient satisfaction. data were analysed with wilcoxone and also spearman's rank correlation tests. the patients ( % female, % male) at age - ( . ± . ) were treated - ( . ± . ) days. we applied vap therapy for . % patients with type i rf and . % with type ii rf. the reasons of rf were pneumonia in . %, sepsis in . % pulmonary oedema in . %, copd in . %, others in . %. for . % patients there was a sufficient and definite treatment whereas . % required mechanical ventilation and icu admission. the . % of patients were satisfied with therapy. the . % survived and were discharged from the hospital. high flow and small amount of peep reduce work of breathing and significantly decrease rr. after effective vapotherm therapy we observed in abg significant increase of oxygen saturation and pao . vast majority of patients were satisfied during the treatment. in critically ill patients who need long-term mechanical ventilation, early tracheostomy may facilitate weaning and shorten the length of stay in intensive care ( ). however, there are no clinical tests that identify patients as being at an increased risk for prolonged ventilatory support; clinicians must predict the duration of arteficial ventilation by their clinical experience. in our surgical intensive care unit we conducted a prospective clinical study to determine if there was an association between different clinical parameters (age, body mass index, gcs, saps score, vasopressor use, pao /fio ratio) and long-term mechanical ventilation. furthermore, we examined the positive predictive value of clinicians' prediction; to do that, clinicians had to indicate whether they considered prolonged mechanical ventilation as the most likely (but not always certain) outcome or not. we enrolled patients and collected date on days - th and th of treatment. prolonged meshanical ventilation was defined as at least more days on respirator. none of the examined parameters could be used alone to predict long-term mechanical ventilation. overall sensitivity of clinicians' prediction was . %, and positive predictive value was . %. . % of patients died, . % was weaned from respirator ( . % extubated) within days despite predicted by clinicians as having prolonged ventilatory need. suprisingly, the best positive predictive value ( . %) was found on the day of admission, the worst ( . %) on day ; the difference was not significant (p= . with chi-square test). this result could be explained by the fact that most patients in the study group were ventilated on day , but only a few on day .conclusion. prediction of prolonged mechanical ventilation was found to be very inaccurate, and did not improve in the course of first week of treatment. however, in our department where many neurosurgical patients are treated, only a minority could be extubated within days when long-term ventilatory support was predicted. as selection of patients who need tracheostomy seems not to be better after one week of treatment than at an early stage, there can be a reason for early tracheostomy if we anticipate prolonged arteficial ventilation. n. abidi , h. thabet* , o. béji , h. elghord , n. brahmi , m. ben othmen , n. kouraichi , m. amamou intensive care medicine, emergency medicine, centre d'assistance médicale urgente, tunis, tunisia introduction. acute exacerbation of copd is a frequent cause of admission in icu and usually have a poor outcome. such a patient consume a large amount of resources particulary if they need endotracheal intubation. the aim of this study is to report epidemiological, clinical features,treatment and outcome of patients admitted in icu for acute exacerbation of copd. a retrospective study was carried out of consecutive admisions in icu over a years (from january to december ). american thoracic society criteria are usued to define copd. exacerbation is defined as a worsening of copd symptoms. a total of patients were included in this study with episodes of acute exacerbation. mean age was ± , years. the sex ratio was , (m/f: / ). eighty percent were current tobacco users. seventy two percent had one or more associated comorbities mainly cardiovascular disease. according to copd severity , % of patients were in stage iii. , % were receiving home oxygen and ( %) were previously mechanical ventilated. on icu admission severity score are apache ii ± ; igsii ± . patients ( %) have a shock and ( , %) have a coma (gcs< ). treatment consist of starting non invasive ventilation (niv) for patients ( %); patients ( %) need immediate intubation and mechanical ventilation. failure of niv was noted for patients. in the course of hospitalisation in icu main complications were: nosocomial infection for patients ( , %), barotrauma patients ( , %) and thromboembolic complications for patients ( , %). the median icu stay was , ± , days and mortality was , % ( patients). the main cause of mortality were septic shock ( cases, , %) and ards ( cases, %). in this retrospective study patients admitted for exacerbation of copd need a mechanical ventilation in , %. failure of niv were %. main complications were nosocomial infection ( , % of cases). mortality is high , % but not different for patients admitted in icu for other disease. it is described, that gelatin leads to red blood cell (rbc)-coating, which is protective against shear stress in extracorporeal circuits. ( ) an increase of mean corpuscular volume (mcv) without an increase in mean corpuscular hemoglobin content as well as a reduction of red blood cell (rbc) counts can be assumed to reduce pulmonary oxygen transfer. increased rbc aggregability (accelerated blood sedimentation rate, bsr), as could occur due to coating, impairs microcirculation. since adequate oxygen delivery is important in ventilated patients to counteract metabolic acidosis, we compared rbc features in acidotic pigs undergoing hemofiltration. healthy pigs (male, dlxde, - kg) were anesthetized, received acid infusion ( . m) and low tidal ventilation with fio > . resulting in normoxic acidosis (ph . - . ; paco - mmhg). tris-hydroxymethylaminomethane (tham) was infused to titrate a ph of . - . . either hes or gel (n= - /colloid-group) was infused additionally to crystalloids (colloid to crystalloid ratio was : ). samples were collected before acid and colloid infusion (bs), after induction of acidosis (baseline acidosis, bsa), and after h of continuous acidosis ( ha). thereafter, acid infusion was stopped and tham was infused with . mol/kg/h for h in order to normalize ph-values. final values (fv) were taken. parameters investigated were: paco , rbc counts, mcv, and bsr. the fio /pao ratio was also determined. compared to hes application, gel infusion was associated with a reduction in rbc count, an increase in mcv and an accelerated bsr from bsa until fv. values did not recover from initial deterioration (bsa) even not after normalization of ph (fv). based on the healthy lungs in this porcine model, these changes did not impair pao /fio ratio. whether increases in mcv were due to gel coating or due to unhampered swelling of rbcs during acidosis could not determined. however, in acidotic pigs gel induced unfavorable effects concerning rbc features with respect to rheology while hes did not. in individuals with impaired pulmonary function and hypodynamic state the described difference between the two types of colloids could become crucial with respect to total oxygen delivery. perctaneous dilational tracheostomy (pdt) has become more common procedure used in intensive care. however, several complications, such as hemorrhage, posterior tracheal wall injury, tracheal stenosis have been recently reported. the aim of this study was to confirm whether the ultrasound can easily and clearly delineate the pretracheal anatomy and identify the potential problems for pdt. we also examined the accuracy in identifying the correct puncture level between and tracheal cartilages blindly (by hand). we studied patients and volunteers. before ultrasound scanning, the circumference of the neck was measured and the puncture level between and tracheal cartilages was marked blindly in each subject. in ultrasound scanning, we examined the relationship of the thyroid to the trachea, aberrant vascular anatomy in the pretracheal region, counted the number of extrathoracic tracheal rings. the distances from the skin to cricothyroid ligament and anterior tracheal wall at the level between and tracheal cartilages were estimated and the relationship between depth of trachea and circumference of the neck was analyzed by simple regression. we also checked the level of trachea pointed by operator blindly was correct or not by comparing the level identified by ultrasound images. the mean age and circumference of the neck were ± years (range: - ) and ± cm. ultrasound examination of the trachea and thyroid was easily carried out in each subject except subjects. approximately extrathoracic tracheal rings could be imaged with ultrasound. anterior jugular veins were seen in subjects ( %) and six were near the midline. the depth of trachea between and tracheal cartilages were varied in each subject ( . - . cm) and there were stastistically relatioship between circumference of the neck and depth of trachea (r = . , p= . ). the accurate decision of trachea level was made in % of the subjects.conclusion. this study showed that: ) ultrasound can delineate the neck structure and detect variations related to the complication of pdt; ) blind identification of the puncture level for tracheostomy without ultrasound was not necessarily correct. our results demonstrated that the routine use of ultrasound could be recommended before pdt. introduction. fluid therapy system of critically ill patients is very variable, and it is based in the interpreting of differents physiologic parameters with a double aim, by one hand keep an adequate perfusion of vital organs, and the other hand avoid overload volumen. our objective was analyze changes in critically ill patients fluid therapy when we including evlw in treatment protocol and evaluate response in short time. observational and prospective study in a neurotraumatological icu. we included consecutives patients that were admited with acute lung injury/adult respiratory distress syndrome and/or septic patients who needed monitoring with central venous and arterial catheterization with picco system. we made a therapeutic reassessment of the fluid therapy and/or vasoactives after we knew evlw when one of the following events in the patient evolution hapenned: hypoxemia, hypotension, olyguria/anuria, or its addition. response in short time was also evaluated. our sample included patients and determinations( patients with determinations, patient with determination and patient with determination). after we knew evlw we changed initial therapeutic plan in . %; this change affected fluids in . % and vasoactives in . %. evlw in patients who therapeutic plan was modified was . ± . and if therapeutic plan was not modified, evlw was . ± . (p< . ). association is observed between evlw value and decision about fluids, so when we decided increase fluids was . ± . ; if the decision was decrease fluid, evlw was . ± . and in the cases that diuretics were added . ± . , in all cases statistics significant was found. no differences was observed in evlw values about vasoactives decision. we found improvement of initial event in short time after intervention in . %.conclusion. evlw determination affects in important way to fluids therapy plan in critically ill patients. we think that inclusion of evlw contributes to a more racional management of these patients. patients who had received ino were identified from icnarc records. hospital notes and icu charts were reviewed. data collected included diagnosis, apache ii and unit and hospital outcome. the pao /fio ratio (in mmhg) was recorded prior to starting ino (day ) and subsequently on days - using the data from the time at which oxygenation was best in each hour period. . patients received ino. patients received it for treatment of hypoxaemic respiratory failure, and for treatment of pulmonary hypertension. mean apache score was . on admission (survivors . ; non-survivors ) . the mean pao /fio ratio was . on day and improved to . on day . in unit survivors, the mean pao /fio increased from . to . on day , compared with unit non-survivors in whom it increased from . to . . ( %) of patients were responders to ino (defined as a > % increase in pao /fio ratio). unit and hospital survival figures for responders and non-responders are presented below. hospital surviviors (n= ) hospital non-survivors (n= ) responder (n= ) ( %) ( %) non-responder (n= ) ( %) ( %) fisher's exact test ( tailed) p= . conclusion. ino was used in patients with more severe hypoxia than those included in randomised trials. ( ) in this review, responders were found to have a significantly reduced unit mortality and a reduced hospital mortality compared with non-responders. we believe ino may be a valuable therapy in ards patients with severe refractory hypoxaemia, and that studies in this subgroup of patients are warranted. outcome predictors of hfov in severe ards are not well studied. we prospectively evaluated the outcome predictors of hfov in adult ards. methods. ards patients receiving mechanical ventilation as per the ardsnet protocol with po /fio ≤ inspite of peep≥ cm and fio ≥ . ,were considered for hfov. continuous distending pressure(cdp),frequency ,amplitude, inspiratory time and bias flow of hfov were optimised with the help of frequent blood gas analysis. weaning from hfov to pressure support ventilation was attempted once po /fio ratio remained ≥ with cdp≤ cm &fio ≤ . . responders(r) were defined as patients who were successfully weaned to a state which required no ventilatory support for > hrs. non responders(nr)were defined as patients who could not be weaned off ventilatory assistance. results. out of total patients were r & were nr. both the groups were similar prior to hfov as shown in table. improvement in po /fio ratio and oxygenation index (oi) at hrs & hrs in r group was statistically significant as compared to that in nr group. we could show that chaotic variation of pressure support improves pressure support ventilation (psv), and named this new mode noisy psv. in this work, we compared noisy psv to conventional biphasic positive airway pressure ventilation (bipap), which has been claimed to be a "gold standard", in experimental acute lung injury. after approval by the local animal care committee, juvenile pigs ( . - . kg) were anesthetized and mechanically ventilated (dräger evita xl lab; volume controlled ventilation, vt = ml/kg; fio = . ; peep = cmh o). after induction of acute lung injury by saline lung lavage ( ml/kg), lungs were recruited and a decremental peep trial was performed to determine the optimal peep according to the elastance of the respiratory system (ers). thereafter, spontaneous breathing was resumed and animals were randomly assigned to noisy psv or bipap groups (n= each group). the ventilator settings were as follows -bipap: fio = . ; plow = according to peep of minimal ers; phigh = titrated to generate vt of ml/kg; thigh = s; tlow = s -noisy psv: fio = . ; peep = according to peep of minimal ers; mean pasb = titrated to generate vt of ml/kg. noisy psv was accomplished by means of remote control of the evita xl lab by a laptop, which generated a sequence of respiratory cycles with different pressure support levels (mean = pasb; sd = % of mean). gas exchange, respiratory parameters and hemodynamics were measured at baseline, injury, after resuming of spontaneous breathing (baseline ) and during an observational period of h. statistical analysis was performed with general linear model statistics adjusted for repeated measures using baseline as covariate. significance was accepted at p< . . bodyweight, peep and number of lavages as well as hemodynamics did not differ significantly between groups. oxygenation and co elimination were significantly improved with noisy psv (p< . both). analysis of respiratory parameters revealed significant lower mean airway pressures with noisy psv as compared to bipap (p< . ), as well as increased mean peak airway pressure, spontaneous respiratory rate, and mean tidal volume (p< . all).conclusion. this study represents the first evaluation of the recently developed noisy psv combined with peep levels titrated according to lowest ers. noisy psv was found superior to conventional bipap with regard to gas exchange and respiratory parameters. further experimental studies are necessary to determine the potential role of noisy psv in intensive care therapy. we investigated if chaotic variation of pressure support (noise) can improve the performance of pressure support ventilation (psv) in experimental acute lung injury (ali). with approval of the local animal care committee, pigs weighing to kg were anesthetized, intubated and mechanically ventilated (volume-controlled mode, fio = . , peep= cmh o, tidal volume= ml/kg). following that, ali was induced by surfactant depletion, and biphasic intermittent positive airway pressure (bipap) was initiated with: lower cpap (cpaplow) = cmh o, higher cpap (cpaphigh) titrated to obtain tidal volumes of - ml/kg, respiratory rate set to obtain paco between - mmhg. then, depth of anesthesia was decreased to allow spontaneous breathing, and animals were ventilated with two different modes ( hour each, random sequence): ) traditional psv, with pressure support level set at cpaphigh -cpaplow; ) noisy psv, with random variation of pressure support and mean value set at cpaphigh -cpaplow, and standard deviation set at % of the mean value (normal distribution). gas exchange, inspiratory drive (p . ) and inspiratory pressure time product of esophageal pressure (ptp) were assessed. helical computed tomography (ct) of chest was performed at end-expiration and the hyperaerated, normally aerated, hypoaerated and non-aerated lung compartments were calculated in animals. patients with respiratory failure treated with vm with fio . were included. after minutes of oxygen therapy, arterial blood gases were collected and patients were asked to quantify (from to ) three items: dyspnea, dry mouth and general confort. then, vm was changed for hfnc (optiflowtm, fisher & paykel, new zeland) . the same variables were collected after minutes using hfnc. results are expressed as median (interquartil range). we have applied spsswin v . with wilcoxon test. patients n= ( m), age ( - ). in the moment of inclusion, one patient ( %) presented mods and sofa score was ( . - . ). during their evolution, five patients ( %) finally need endotracheal intubation. main results are presented in the following tables: a computer-driven system (cds) has been recently used to optimise psv to patient's needs during weaning. in some pts, the cds fail to find a "comfort window" despite stepwise increase in pressure support (ps) levels. for these pts, cds could further increase respiratory muscle workload. we speculate that failure to adapt respiratory rates (rr) and vt following changes in ps levels might identify a subset of pts unlikely to benefit from the cds.to test this hypothesis, we used a bedside test before switching ventilated pts to a closed-loop algorithm of psv. we studied pts at initiation of weaning with psv using the smallest ps level resulting in rr≤ , vt> ml/kg. we collected baseline values and assessed changes in vt (dvt), rr (drr) during min after cmh o-increase and decrease in ps levels. then, a cds session was started at the baseline ps level. we searched for correlations between dvt, drr, and outcome (failure/success) of the cds sessions. a cds session was deemed successful when the system detected criteria for separation of the ventilator or when psv was efficiently adjusted by the cds within h after starting the session. in pressure support ventilation auto-peep is considered a major contributor to the inspiratory work of breathing. measurement of auto-peep requires esophageal pressure tracings, which are not routinely available. the presence of auto-peep is likely, when flow is interrupted at end-expiration, a pattern well-established in controlled ventilation. we studied expiratory flow-volume relationships as substitute for detection of auto-peep in patients on pressure support ventilation. in patients successively admitted to our icu respiratory mechanics were obtained from consecutive breaths on pressure support ventilation. auto-peep was considered present when in flow-versus-time recordings flow was interrupted at end-expiration. from flow-volume relationships expiratory time-constants were calculated and related to actual expiration times. all measurements were obtained with a nico-computer; for analysis a computer program analysis plus was used (both respironics/novametrix, inc.). in of the patients flow at end-expiration was interrupted suggesting the presence of auto-peep (interrupted flow group). in the remaining patients flow was zero at end-expiration (zero flow group). in the flow-volume curves of patients in the interrupted flow group versus the zero flow group end-expiratory flows varied between . - . l/s and . - . l/s respectively. the expiratory time-constants ranged from . - . s in the interrupted flow group and . - . s in the zero flow group. the ratios between expiration times and expiratory time-constants varied between . - . and . - . for the interrupted and zero flow groups respectively . the means and standard deviations for both groups were:means +/-sd in patients on pressure support ventilation with interrupted flows at endexpiration higher expiratory time-constants and lower ratios between expiration times and time-constants were found, suggesting the presence of auto-peep. these variables can be used as substitute for detection of auto-peep. non invasive ventilation (niv) is the delivery of assisted mechanical ventilation to the lungs, without the use of an invasive endotracheal airway. niv has decreased the need for invasive mechanical ventilation and its attendant complications. acute cardiogenic pulmonary edema (acpe) is defined as an episode of acute heart failure accompanied by severe respiratory distress and oxygen saturation < % on room air before all treatment. our study aimed to asses the respiratory effects of a device that delivers a continous positive airway pressure via face mask in patients with severe acpe, the feasibility of using this technique in an emergency department (ed) and estimed the need of endotracheal intubation (ei). we evaluated a series of patients consecutively treated in our ed for acpe, from june to december . a peep level of cm h o delivered by cpap-boussignac device (vygon, ecouen, france) was used in all patients. fio was estimed to range from to %. clinical and blood gas parameters were recorded at entry and also after minute and hour of treatment. all patients were treated with standard medical therapy. the average of age was years ( - ), were male and were female. the inclusion criteria for niv were: ph < , but > , , paco > mmhg or an acute augment of - mmhg, respiratory rate > /min, pao /fio < mmhg on room air and score kelly max . resolution of respiratory distress occurred from to minute ( media minute). all patients showed an improve of clinical and emogasanalytic impairment. only patients needed ei and were transferred in icu. patients were treated in ed and after normalization and stabilization of their vital signs they were discharged in other medical departments ( cardiology department and pneumology department). the rate of ei was %.conclusion. cpap delivered using boussignac device is feasible in an emergency care setting. it can quickly improve respiratory distress in acpe patients and reduce the need of ei. in clinical practice niv is being used as a sole respiratory support modality or in the weaning period in at least % of arf patients admitted to emergency department. the remaining patiens need imv as primary and secondary forms of respiratory support. failure of niv seems to predict higher mortality rates. as a conclusion we need both support modalities and the physician has to use them carefully according to patients condition and their expertise. methods. medline, pubmed, cochrane, & cinahl databases ( to were searched using the terms: aprv, bipap, bilevel & lung protective strategy, individually and in combination. reference lists of identified papers were also examined. two independent reviewers determined eligibility of papers based on predefined criteria. database searching yielded citations, of which were selected on review of title and abstract. data were abstracted onto pre-designed forms from experimental studies and discussion articles on further review. of the experimental studies, used a randomised design, were cohort studies and case series. aprv was the named mode in ( %) studies, bipap in ( %), and inverse mandatory pressure release ventilation in one study. extreme inverse inspiratory:expiratory (i:e) ratio was used in ( %) aprv compared to bipap studies (p = . ); ( %) aprv and ( %) bipap studies used mild inverse ratio (up to : ). a : ratio was used more often with bipap ( , % vs , %, p = . ) as was a normal i:e ratio ( , % vs , %, p = . ). in adult studies, mean inspiratory pressure was cmh o (aprv) and cmh o (bipap) (p= . ). mean expiratory pressure was . cmh o for both modes (p= . ). seven aprv studies described synchronisation, ( %) stated the mode did not synchronise to patient effort. all bipap studies that described synchronisation stated it was available.conclusion. aprv assumes inverse ratio ventilation (irv). some studies advocate extreme irv with short release times to improve gas exchange, haemodynamic stability, renal and splanchnic blood flow( ). extreme irv was used in only % of aprv studies, % described an i:e ratio of : . further, ventilator settings used for studies of aprv may be indistinguishable from bipap studies ( , ) . given the variation in ventilatory settings described, uncertainty of optimal settings may exist. commercial ventilator branding may further add to confusion. generic naming of ventilatory modes, as with drug prescribing, combined with consistent definitions of the parameters that define the modes, may avoid confusion, improve consistency of patient response and assist the implementation of these modes into clinical practice. pav is intended to normalize neuro-ventilatry coupling by assisting each breath in proportion to patient effort, but requires reliable measurements of elastance (e) and resistance (r). pav+ allows to (a) automatically and non invasively measure e and r, and (b) continuously adjust ventilatory support accordingly. aim of our study was to test the physiological effects of pav+ versus cmv (ardsnet lung protective strategy) in a model of ards. in pigs ards was induced through chloridric acid inhalation ( ml/kg). at t (after damage) each pig was randomly assigned to pav+ or cmv. gas exchange and lung ct scan at (t ) hours were compared with those obtained at t (delta = t -t ). data are mean +/-standard deviation; *) p < . pav+ versus cmv cmv pav+ ∆ hyperinflated areas (cm ) +/- +/- ∆ normally aerated areas (cm ) - +/- +/- * ∆ poorly aerated areas (cm ) +/- +/- * ∆ nonaerated areas (cm ) +/- - +/- * ∆ pao /fio - +/- +/- * ∆ paco (mmhg) +/- - +/- * our data suggest the ability of pav+ to improve gas exchange, principally through an increase in normally aerated areas. the impact of pav+ on ventilator induced lung injury deserves further investigation.grant acknowledgement. university of bari. introduction. the major advantage of high-frequency oscillatory ventilation (hfov) to conventional mechanical ventilation (cmv) is delivery of smaller tidal volumes to an optimally recruited lung. assuming there is a save window in the pressure volume curve of the lung between a lower zone with atelectasis and a upper zone with overdistension, surpassing this zone would result in either cyclic recruitment and decrecruitment, overdistension, or both. in diseased lungs this safe window may be too small to harbor the relatively large tidal volumes of cmv. co removal (v'co ) and therefore paco is a function of frequency (f) and alveolar delivered tidal volume (vt): v'co = f x vt . it is an inherent technical feature of all oscillators that vt at maximal power decreases as frequency increases. in addition, pressure swings fall down the endotracheal tube and the airways. this fall in pressure swings is a function of frequency and mechanical properties of the respiratory system. as a result of both phenomena vt delivered to the alveoli decreases substantially at higher frequencies. up till now oscillation is set at a fixed frequency, in adults at hz, in children and neonates at hz. paco is regulated by adjusting the power, and thus the pressure swings (delta p) and the delivered volume. if the maximum power has been reached, decreasing the frequency can lower the paco further. we calculated vt required to keep v'co constant at different oscillation frequencies and measured the delivered vt at maximal power as function of frequency with the sensormedics a. . vt needed to keep v'co constant and maximal delivered vt can be plotted against oscillatory frequency. by increasing frequency, vt needed to keep v'co constant and maximal delivered vt both decrease. however, a point is reached at which the required vt to maintain v'co equals the maximal delivered vt. at this point vt has its lowest possible value to maintain paco . at higher frequencies the delivered volume of the oscillator is lower than required and paco would rise above the pre-arranged level. we advocate a ventilatory strategy with the oscillator set at its maximal power and the frequency to be adjusted according to the paco . with this strategy the lowest vt is delivered to the alveoli with the largest safety margins between atelectasis and overdistension. automatic tube compensation (atc) compensates the resistance caused by the endotracheal tube. tube resistance is defined by the equation hagen-poiseuille: r = ( x x l) / π x r . (r= resistance, = viscosity, l= length of the tube, r= radius of the tube). atc is designed to lower the work of breathing in intubated spontaneous breathing patients by creating a higher initial flow and therefore a higher peak pressure. the aim of this study was evaluate the consequences of atc during controlled mechanical ventilation without spontaneous breathing activity on peak pressure distal of the tracheal tube, in comparison to the set pressure. moreover, the time needed to reach the set inspiratory pressure distal of the tube with and without atc was assessed. in an experimental laboratory setting using an artificial lung the maximum pressure in the ventilator (draeger evita ), proximal and distal of the tube with and without % inspiratory atc in a tube id , and a tube id , were measured. the time needed to reach the set inspiratory pressure distal of the tube with and without % inspiratory atc were compared. baseline ventilator settings were bipap, asb , peep mbar, i:e-ratio : , fio %, rise time seconds. a set of measurements where performed for each of the following settings: pressure constant group (pcg): frequency of respectively: , and a minute at a fixed pinsp of mbar. frequency constant group (fcg): pinsp of respectively: , and mbar at a fixed frequency of a minute. no peak pressure were measured at any time distal of the tube regardless of frequency or set pressure. the pressure distal of the tube never exceeded the set pressure level in the ventilator. the time needed to reach the set inspiratory pressure distal of the tube was significant shorter during atc. (see table) conclusion. there is no danger of creating a higher pressure distal of the tube than the set inspiratory pressure at any time during the use of atc % with the draeger evita . with the use of atc the set inspiratory pressure at the distal end of the tube is reached more quickly. atc creates a faster rise time on the tracheal level, resulting in a higher mean airway pressure. key: cord- - eawrjt authors: ogbondah, chris wolumati; agbese, pita ogaba title: terrorists and social media messages: a critical analysis of boko haram’s messages and messaging techniques date: - - journal: the palgrave handbook of media and communication research in africa doi: . / - - - - _ sha: doc_id: cord_uid: eawrjt post-colonial nigeria has been plagued with violent conflicts. a bloody civil war in which an estimated million people were killed ravaged the country from to . interethnic and intra-communal conflicts have also shaken the foundations of the nation since when colonial rule ended. other violent conflicts that have plagued the country are religious conflicts in kano, bauchi, kaduna, kafanchan, zaria, jos, maiduguri, and many other places. blood-letting in the name of religion in these and other places in nigeria has left thousands dead and wounded. destruction of property in the course of religious violence in nigeria has also wreaked economic calamity on the country. for instance, wanton destruction of property during the maitatsene religious uprising in kano from to resulted in the loss of lives and of millions of dollars. clashes between members of the militant shi’ite religious sect and the nigerian army in led to the demolition of an entire neighborhood in zaria city nigeria’s latest bout of violence emanates from a deadly terrorist group, boko haram. since , it has killed over , people, displaced more than one million people, and contributed to the devastation of nigeria’s northeast region. initially, boko haram could not be contained by nigerian security forces. it captured and held on to local government districts and it constantly churned out online propaganda about its invisibility and its certainty that it would impose a radical islamic government over the entire country. this chapter provides a critical analysis of boko haram’s propaganda. it examines the group’s core messages and the stylistic techniques used in delivering them. the chapter notes that boko haram deliberately used crude, unvanished imagery to reinforce the brutality of its actions in suicide bombings, drive-by shootings, and direct attacks against military barracks, markets, mosques, and churches. we contend that the effectiveness of boko haram’s propaganda began to decline as it suffered military defeats by nigerian forces. post-colonial nigeria has been plagued with various types of violent conflicts. a bloody civil war in which an estimated million people were killed ravaged the country from to . accounts of the war, both real and in fictional forms, have been provided by several writers, including amadi ( ) , achuzia ( ) , shillington ( ) , st jorre ( ) , madiebo ( ) , forsyth ( ) , kirk-greene ( ) , iroh ( ) , ademoyega ( ) , adichie ( ) , and johnson ( ) . interethnic and intra-communal conflicts have also shaken the foundations of the nation since when colonial rule ended. other violent conflicts that have plagued the country are religious conflicts in kano, bauchi, kaduna, kafanchan, zaria, jos, maiduguri, and many other places. blood-letting in the name of religion in these and other places in nigeria has left thousands dead and wounded. destruction of property in the course of religious violence in nigeria has also wreaked economic calamity on the country. for instance, wanton destruction of property during the maitatsene religious uprising in kano from to resulted in the loss of lives and of by the government that the group is a spent force. its success in the attack also shows that the jihadist group has continued to acquire enough resources to attack what it may consider as targets of high value in the country. boko haram rejects the secularism of the nigerian state and wishes to foist its own brand of islamic ideology on the country. it views itself as being at war with the nigerian state. boko haram also denies the legitimacy of the nigerian government and constitution, and opposes secular western-style education. the terrorist group opposes democracy and rejects christianity in nigeria, and it seeks to convert christians and other non-muslims to islam. other things that have incurred the ire of the group have included the consumption of alcohol and participation in civic activities such as voting and running for elective posts. the terrorist group, operating in the name of islam, rejects any ideology and teachings of the faith that differs from its own. it sees itself as part of a global movement for the restoration of the glories of islam. boko haram shot its way into the global limelight in when it abducted students from a girls' boarding high school and threatened to sell them into slavery or forcefully marry them off to its members. that successful operation, and its bombing of the united nations' offices in abuja in august , as well as its pledge of allegiance to the islamic state(is) in march , further beamed an international searchlight on its military capabilities and prowess. the nigerian government, its armed forces and scholars have concentrated their analysis of boko haram based on its military exploits. in contrast, this chapter examines the terrorist organization through the lens of its social media presentations and messaging. it provides a critical analysis of boko haram's media strategy and shows that its social media messaging is part of its overall military and ideological strategies. the authors examine boko haram's attempts to wage a battle for the hearts and minds of nigerians through a deliberate use of social media to disseminate its messages. focusing on statements and video appearances by its leader, abubakar shekau, boko haram's overt and subtle messages to nigerians and the world at large are outlined. using content-analytic methodology, the chapter examines the thrust of the messages to decipher their major themes, intents and target audiences. the authors contend that boko haram's messages reveal what the group thinks of itself, the nigerian government and the nigerian security establishment. we contend that boko haram deliberately uses crude and unsophisticated messaging techniques to convey its brutality, military invisibility and total disdain for the nigerian government and its armed forces. we contend that boko haram uses its social media messaging to assert the righteousness of its interpretation of islam, arguing that boko haram uses islamic religious imageries and rhetoric to justify its atrocities. we have analyzed boko haram's media strategy within the theoretical framework of propaganda and conclude that unlike is, al qaeda and other terrorist organizations that use social media messaging as a recruitment tool, boko haram uses its messaging to instill fear and to convince its viewers of its inevitable victory over the nigerian government. our analysis reveals that not only does boko haram use its messaging to claim that the nigerian government is anti-islamic but also that it utilizes it to define good or proper muslims. as noted earlier, boko haram's reign of violence has been the biggest national security threat that nigeria has faced since when the country returned to civil rule. it has also been the biggest blood-letting since the end of the civil war in . from august until february when combined military operations by nigeria and its neighbors-cameroon, chad, and niger-reversed boko haram's territorial gains, the jihadist group controlled a good portion of nigeria. during that period, it controlled fourteen local governments areas, several major towns and many villages-swathes of nigerian territories that amounted to over , square miles, about the size of belgium, and six times more land than is in iraq and syria controlled at about the same time. all of the territories amounted to about % of nigeria, according to a new york times report. according to a november , report in the new york times, boko haram was responsible for deaths in , overtaking is, which killed in the same year as the world's most number one terrorist organization. like is in iraq and syria, it decapitates some of its enemies by slitting their throats. in fact, it openly pledged allegiance to is in march . like is, it intends to create an islamic caliphate. unlike is, however, what boko haram opposes is more certain than what it intends to do with power. since its violent phase began in , the insurgency has led to the death of over , nigerians, according to adaramola (february , ) . according to the report, kashim shettima, the governor of borno state, noted that . million people had been displaced, and property worth $ billion destroyed by boko haram as at december . in addition, shettima said that , private houses, representing % of the number of houses in borno state, were destroyed across the twenty-seven local government areas of the state. in a single attack on the city of baga in january , for example, boko haram killed over people. churches, banks, schools, markets, car parks, farms, government offices, police stations and military barracks have been the principal targets of boko haram's attacks. suicide bombings, motorcycle ride-by shootings, detonation of improvised explosive devices (ieds) and invasions by a large contingent of its fighters are the main instruments of the terrorists' destructive strategies. in addition to creating millions of internally displaced persons (idps), boko haram has forced over , nigerians to seek refuge in neighboring countries. an editorial in the guardian (nigerian) newspaper of november , stated that "there were in cameroun alone, , nigerians that fled gwoza, a town in borno state…." although boko haram began its terrorist activities in nigeria, it has become a regional menace in west africa as it has spread its attacks to niger, cameroon, and chad. boko haram's terrorist activities, in addition to causing thousands of deaths in nigeria, have virtually brought all economic activities in the northeastern zone of the country to a halt. apart from the humanitarian crisis created by the jihadist organization, the economic costs of the violence have been enormous. by september , boko haram had destroyed infrastructure that would cost more than $ billion to rebuild in borno state alone (ibukun and olukayode, ) . shehu ( ) has argued that violent attacks by boko haram paralyzed businesses, banking, tourism, transportation and investments in the affected region. the group has seriously disrupted agricultural production, the mainstay of the economy in the area. drastic reduction in agricultural production has created a specter of famine for millions of people in the violence-ravaged areas. in , the nigerian government budgeted billion naira to feed people in internally displaced persons' camps. the government earmarked billion naira in the budget for that purpose. according to the presidential committee on north-east initiatives (pcni), this was grossly inadequate as the figure to feed the idps at the displaced camps should have been billion naira. quoting a united nations estimate, the economist magazine in its september , issue reported that " , children in borno are suffering from severe acute malnutrition-the deadliest category of it. more than persons will die each day without assistance. across the wider north-east part of nigeria, a population equivalent to new zealand's, is in need of food aid." searcey and santora (november , ) , noted how boko haram's violence has caused food shortages in cameroon. according to their report in the new york times: "farmers have fled, leaving behind fallow fields. herdsmen have rerouted cattle drives to avoid the violence. throughout the region, entire villages have emptied, leaving a string of ghost towns with few people for boko haram to dominate-and little for the group to plunder." boko haram's attacks on baga and other fishing communities in the lake chad area have drastically reduced the quantity of fish harvested in the area. attacks by boko haram have also curtailed tourism in the north-western part of cameroon as well as various parts of north-eastern nigeria. in addition, the nigerian government has expended billions of dollars in extra defense in response to boko haram. boko haram's bloody attacks have naturally led analysts to focus on its military strategies and capabilities, but the group recognizes the potency of propaganda, and hence it devotes time and resources to the dissemination of its messages through statements and video appearances. we contend that a comprehensive understanding of what boko haram stands for and the implications of its attacks can be understood by adding succinct analyses of its media strategy to what is already known about its military strategy. boko haram uses its media strategy to advance its military goals as it frequently utilizes video appearances by its leader, abubakar shekau, to threaten military attacks. we also seek to demonstrate, using boko haram for illustrative purposes, that social media make it relatively easy for extremist groups such as al shabaab, is, al qaeda, and other jihadist groups to articulate and disseminate their messages to a worldwide audience, a global reach that would not have been possible without the commitment of enormous and resources. a group such as boko haram may be particularly successful in articulating its messages when it is not confronted with counter-narratives by governments and other entities, or when the counter-narratives appear less persuasive than the propaganda that the group is churning out. an examination of boko haram's attempts to win the battle for the hearts and minds of nigerians through a deliberate use of video propaganda as well as a critical analysis of the statements by its leader, shekau, will provide governmental and institutional policymakers in nigeria a deeper understanding of the nature and operations of boko haram. in particular, this chapter will provide government policymakers in north africa, middle east, and europe with a further understanding of major terrorist organizations in these parts of the world. an understanding of the nature and operations of one terrorist organization-whether al qaeda, is, boko haram, or al-shabaab-can help shape the formulation of governmental policies on how to counter the efforts of such organizations to radicalize potential recruits. therefore, this chapter is significant in the sense that its conclusions can be useful in the formulation of policies on global terrorism. terrorists have discovered that social media can be important tools for recruitment of fighters and supporters and for the dissemination of their world views. is has been very deft in using twitter and its english language magazine, dabiq, for its propaganda. according to koerner ( ) , tashfeen malik who, with her husband syed farook, shot and killed fourteen people in san bernardino, california, in december , used facebook to pledge allegiance to is leader abu bakr al-baghdadi a few minutes after the killings began. berger ( ) acknowledged the indispensability of social media to terrorism. as he noted, "jihadists have figured out how to use social media to make an impact, even though their numbers are minuscule in comparison to the overall user base … its highly organized social media campaign uses deceptive tactics and shows a sophisticated understanding of how such networks operate" (p. ). blaker ( ) , examining is' use of social media, asserted that: isis has made great use of the internet and online social media sites to spread its message and encourage others, particularly young people, to support the organization, to travel to the middle east to engage in combat-fighting sideby-side with other jihadists, or to join the group by playing a supporting rolewhich is often the role carved out for young women who are persuaded to join isis. (p. ) this chapter is also significant because by analyzing the speeches made by boko haram's leader in the social media and in particular youtube videos and major acts of terrorism carried out by the group, nigerian and west african leaders and leaders elsewhere in the world might further understand how the minds of the leaders of terrorist organizations work. the more they are understood, the more the world will be able to know what motivates them to commit such heinous, atrocious and acrimonious crimes. understanding the mindset(s) of these groups and how they operate is critical for the governments of nigeria and other west african countries, so that policymakers can predict major acts of terrorism in the region and nip them in the bud. if government policymakers had been able to predict the abduction of secondary school girls in chibok, and heinous massacres in baga and elsewhere, they would have been able to stave off the colossal loss of innocent lives and billions of dollars in property in those acts of terrorism. this is why this chapter, which has highlights the motivations and operations of a terrorist group such as boko haram is unquestionably significant and potentially enormously valuable. as a concomitant outcome, the chapter will enrich the literature on the nature of global terrorism, and the terrorism that is now on the rise in sub-saharan africa. as the number of studies like this increases, scholars and experts on global terrorism will be able to analyze the media coverage of terrorism more holistically. they will be able to compare, for example, acts of terrorism committed by boko haram and those committed by other terrorist organizations. boko haram was formed in maiduguri, borno state, in by a young muslim cleric, mohammed yusuf. after his expulsion from two mosques for preaching a radical brand of islam, he set up his own mosque and was able to attract a large following among the city's young men. the group became better known in when it clashed with the police, attacking police stations and other public institutions in maiduguri. when the police could not contain the group, the federal government deployed the armed forces. the military fought pitched battles with boko haram fighters, and its mosque and headquarters were destroyed. yusuf was apprehended by the military and handed over to the police; he was subsequently shot to death while being held in police custody. according to mu'azu ( ) , the police stated that he died during gunfire exchanges with their officers. yusuf 's father-in-law and about eight hundred members of boko haram were killed during the fighting in . some of the group's survivors fled to the neighboring countries of chad and niger. boko haram was able to recover from its losses, and, as subsequent events clearly demonstrated, it became even more deadly. it is now led by another young cleric, abubakar shekau. however, one abu musab al-barnawi claims that he leads another faction of the group. boko haram views its members as warriors in a holy war between islam and the rest of nigeria. in a statement rejecting calls for it to cease hostilities, the leader of the insurgency spelled out its mission: we want to reiterate that we are warriors who are carrying out jihad in nigeria and our struggle is based on the traditions of the holy prophet. we will never accept any system of government apart from the one stipulated by islam because that is the only way that muslims can be liberated. we do not believe in any system of government, be it traditional or orthodox except the islamic system and that is why we will keep on fighting against democracy, capitalism, socialism and whatever. we will not allow the nigerian constitution to replace the laws that have been enshrined in the holy qur'an, we will not allow adulterated conventional education to replace islamic teachings. we will not respect the nigerian government because it is illegal. we will continue to fight its military and the police because they are not protecting islam. we do not believe in the nigerian judicial system and we will fight anyone who assists the government in perpetrating illegalities. the sophistication of boko haram's bombing operations and its simultaneous and co-ordinated attacks on multiple targets indicate its ability to tap into external resources in the form of weapons, training, logistics and financing. evidence of the group's military capability is the use of rocket-propelled grenades and anti-aircraft guns in its may attacks on bama and its september , downing of a nigeria air force jet plane. while its immediate grievances are directed against the federal government of nigeria, boko haram operates under a global brand of islamic fundamentalism. it is thus a grievous error to view the group solely through the prism of the internal dynamics of nigerian politics. its ability to attract fighters from niger and chad as well as its pledge of allegiance to is in march and the acknowledgement that some of its fighters are trained in somalia and mali are clear pointers to its global dimensions. even though some of its complaints are wrapped around nigeria-specific issues, boko haram is motivated by a global islamic radicalism. as was the case with al-shabab in somalia and al dine in mali, boko haram has struck with a deadly force in nigeria because the country's poor governance made it a target of opportunity. the group merely capitalized on the weakness of the nigerian state, and exploited existing ethnoreligious tensions to launch its insurgency against the country. the external dimensions of boko haram are also signposted by the similarities between its tactics and those adopted by islamic insurgents in iraq, afghanistan and north africa. this is not a mere coincidence. boko haram's suicide-bombing, co-ordinated simultaneous attacks on multiple targets, the use of ieds and the utilization of motorcycle ride-by assassinations are precisely the methods that have recently been used by islamic terrorists in other parts of the world. the ruthlessness and brutality of boko haram, such as slitting the throats of schoolchildren, their teachers and other victims also mirror those in iraq and afghanistan. its opposition to secular education recalls the ideology of the taliban in afghanistan. it is therefore fallacious to argue that boko haram is a political tool of northern nigerian elites who were unhappy with the president goodluck jonathan administration. the clashes between boko haram and security forces that marked the group as a serious threat to nigerian security pre-dated the jonathan administration. it was a northerner, umaru yar'adua, who was president of the country at that time. moreover, given the opportunity, boko haram will go after the elites as ferociously as it has gone after ordinary nigerians. its january attempt to assassinate the former emir of kano, ado bayero, during which the emir's driver and some of his loyal bodyguards were killed, is a testament to its loathing and disdain of the elites. this was also attested to when the group warned the elites in sokoto to avert the replication of the kano attack by releasing its members who had been detained in that state. in a january letter, its leader, shekau, said: this is an open letter to the emir of sokoto (sultan of sokoto) alhaji muhammad sa'ad abubakar , the speaker of the house of representatives, alhaji aminu tambuwal and the acting governor of sokoto state. before we visited kano, we wrote open letter [sic] to senior citizens on the imperative of releasing our members but nobody cares [sic] to talk. indeed, we sent three warnings to kano before strike" [sic] . what happened in kano will be inevitable in sokoto unless you (sultan and others) intervene and ensure the immediate and unconditional release of our members who were specifically arrested in the city of sokoto… former president goodluck jonathan belatedly recognized the dangers that boko haram poses not just to security in nigeria but also to the territorial integrity of the country. he vowed in march that the insurgency would be defeated by june that year, but this did not happen. by august , boko haram was operating with impunity, seizing many towns and villages. it intensified its attacks, and it increased the frequency of such attacks. its ability to strike well beyond the geography of its home base was expanded with its attacks on kano, kaduna, abuja and other cities several hundred miles from its home base. by the end of , its ability to strike terror into the hearts of many nigerians and its ability to seize swathes of territories at will made the north-eastern region and several other parts of northern nigeria virtually ungovernable. as the group's mayhem intensified in , a nigerian national daily newspaper, the nation, in its editorial commentary on january , aptly noted that: the scourge of boko haram has inflicted dislocations on our country on a number of levels. some point to its psychological damage, others to the physical and geographical fissures and a few others to the decimation of families. we experience these instances almost daily, showing that the nigerian government is grasping with futile energy to curb this modern day spasms of savagery. although, boko haram claims that it was motivated to take up arms against nigeria because it was incensed by corruption, moral decadence and immorality, it has waged much of its war against ordinary and innocent nigerians who themselves are victims of the corruption and misgovernance that characterizes the country. moreover, its tactics of kidnapping schoolchildren, bombing churches, public buildings and schools, and cutting the throats of children and their teachers cannot build a better society than the one that boko haram is purportedly seeking to replace. its latest strategy of abducting women and children and holding them hostage as well as forcefully taking women, even under-age girls as wives for its members is as repulsive as its other dastardly acts. there is also much arrogance in boko haram's utterances and ultimate objectives. for instance, it aims to cleanse the north-eastern region of nigeria, if not the entire country, of christians and christianity. it wants southern nigerians living in the north to leave the region. even if boko haram was truly fighting for islam, it should embrace the southerners who are themselves muslims. propaganda, which we define in this chapter as communication used by individuals, groups, institutions or organizations to inform, persuade or scare others to adopt their beliefs, ideas and creed or to mobilize attitudes in order to win minds or to convert them to a cause, is as old as human history. as gambrill and reiman ( ) have noted, propaganda aims to promote ideas and actions that would serve the interests and benefits of those promoting the ideas and actions. the word, propaganda, was derived from sacra congregatio de propaganda fide (congregation for the propagation of the faith), a vatican organization, created in rome on june , by pope gregory xv (bernays, ; jackall, ; pratkanis & aronson, ) . the organization's duty was to spread the faith and to regulate church affairs in heathen lands. therefore, the roman catholic church used the term first (black, ) . combs and nimmo ( ) pointed out that this early form of propaganda was considered as "a moral endeavor by the church" (p. ), but interest in the subject today has expanded owing to its importance in international politics (chapman, ) . according to lasswell ( a lasswell ( , b , propaganda refers solely to the control of opinion by using pictures and other forms of social communication; it is concerned with the "management of opinions and attitudes." qualter ( ) argues that propaganda is the deliberate attempt by an individual or group of persons to form, control or alter attitudes of other individuals or groups. he suggests that propaganda is any form of persuasion aimed to change attitudes. jowett and o'donnell ( ) point out that "propaganda is a form of communication that attempts to achieve a response that furthers the desired intent of the propagandist" (p. ). they argue that the use of the terms propaganda and persuasion interchangeably is inappropriate-hence they propose that, in as much as propaganda makes use of persuasive strategies, it differs from persuasion in its purpose. thus, they categorize propaganda as a specific class of communication that is a "subcategory of persuasion, as well as information" (pp. [ ] [ ] . british historian and scholar, taylor ( ) , identifies three main reasons why propaganda gained prominence in international relations. these are: (i) a general increase in the level of popular interest and involvement in political and foreign affairs as a direct consequence of world war i (ii) technological developments in the field of mass communication which provided the basis for a rapid growth in propaganda as well as contributing towards the increased level of popular involvement in politics, and (iii) the ideological context of the inter-war period, sometimes known as the 'european civil war' in which an increased employment of international propaganda could profitably flourish. (pp. [ ] [ ] taylor strongly suggests that an increase in the use of propaganda to influence opinions is due to advances in mass communication technologies. this is to say that media play a vital role in propaganda. analyzing the use of propaganda to manipulate opinions or attitudes, ellul ( ellul ( , argues that propaganda is the inevitable result of the various components of the technological society, and plays so central a role in the life of that society that no economic or political development can take place without its influence. this suggests that a society, organization or group that seeks development or change of any sort uses propaganda to achieve its goals. baines and o'shaughnessy ( ) argue that political leaders manipulate myth, symbolism and rhetoric in influencing opinions and ideologies. ogden and wilson ( ) describe what they termed "propaganda techniques" as: • name calling: this involves giving an idea a label, either good or bad, to encourage the public to accept and praise or reject and condemn the idea without examining evidence. • glittering generality: this technique associates something with a "virtue word" designed to encourage the public to accept and approve the idea without examining the evidence. • plain folks: transferring the aura of authority and prestige of a celebrity or opinion leader to a product, person or idea in order to persuade the public to accept or reject it. • testimonial: a technique used to endorse a product by a celebrity or opinion leader who uses the product. • plain folks: this is a technique used to convince the public that a speaker's (often politician's) ideas are good because s(he) is "of the people" or "one of us." • card stacking: selective use of facts to tell only one side of the story, often obscuring the other side(s). • bandwagon: this is an appeal to line up with the opinion of the majority on an issue-a method that tries to persuade by encouraging people to join their friends and neighbors because "everybody's doing it." • emotional stereotypes: evoking an emotional image such as the "ugly american." • illicit silence: withholding information that would verify a situation or correct a false impression or assumption. • subversive rhetoric: as a strategy used in political campaigns, this appeal involves attacking the spokesperson rather than an idea. propagandists employ all these techniques to achieve their goals. propaganda goals generally aim to shape public opinion in the particular direction that is desired by the propagandist. adolf hitler was one of the best-known persons to use propaganda, with his shaping of public opinion in germany during the second world war having been documented by many scholars, including welch ( welch ( , , george ( ) , steinert ( ) and kershaw ( ) . published material on boko haram has examined various aspects about the group and its reign of terror. they include the following: ( ) the origins and objectives of the insurgency; ( ) boko haram's tactics and strategies; ( ) nigerian military campaigns against boko haram; ( ) threats that boko haram poses to nigeria's unity and stability; and ( ) the place of boko haram within the context of ethnic and religious violence in nigeria. other published materials on the group further examined the following: ( ) the character of boko haram as a terrorist group; ( ) the nigerian government's response to the insurgency; ( ) links between boko haram and other islamic terrorist groups; ( ) boko haram as a reflection of the weaknesses and failure of the state in nigeria; and ( ) the impact of the insurgency on civil-military relations, including human rights violations committed by nigerian security forces as they countered boko haram attacks. some studies have attempted to situate boko haram within the overall ambit of other security issues, such as kidnapping for ransom, armed robbery and militancy in the oil-producing niger delta region. one of the best-known books about boko haram is boko haram: islamism, politics, security and the state in nigeria, an edited volume by marc-antoine perouse de montclos. kyari mohammed's chapter in the book examines boko haram's message and the methods used by the group for disseminating it. another notable chapter, written by manuel reinert and lou garcon, chronicles the islamic sect. it highlights boko haram's evolution from a relatively peaceful and little-known group to its manifestation as a violent and dreaded organization. in this same volume, rafael serrano and zacharias pieri analyze how the nigerian government has responded to the insurgency. the chapter highlights the inadequacy of the government's responses and notes how the successes recorded by boko haram in its military attacks against nigerian security forces are largely a reflection of the weaknesses and failures of governmental responses. a myth about boko haram that seems to endure is that nigeria's muslim population has not vigorously condemned the group, and that they tacitly support its insurgency. johannes harnischfeger in an analysis of this claim clearly shows that boko haram has many muslim critics. his chapter in montclos' ( ) volume draws on criticisms of boko haram from islamic clerics in yobe state. in the same volume, henry gyang mang examines how christians in nigeria view the insurgency, providing a detailed examination of nigerian christians' attitudes towards and perceptions of boko haram. mang maintains that nigerian christians consider boko haram as islamic radical fanatics who are intent on imposing islam on the entire country. another collection of analyses appears in boko haram ioannes mantzikos' edited volume boko haram: anatomy of a crisis. in his chapter jideofor adibe examines what is actually known of boko haram. he deftly separates facts from fiction and mythologies. the volume also contains a chapter by osumah oarhe that analyzes the challenges that the boko haram insurgency has posed to the nigerian military and security establishments. it details the growing inability of the nigerian military services, including its intelligence services, to suppress the insurgency. while oarhe's chapter specifically looks at the responses of the nigerian defense and intelligence establishment to boko haram, hakeem onapajo's chapter in the same volume provides a general overview on the failure of nigeria to defeat the insurgents. focusing specifically on the handling of the insurgency by nigerian security forces, a. abolurin highlights the challenges that boko haram poses for the nigerian armed forces. boko haram's choice of targets for its attacks has been a major source of debate in the media. focusing specifically on the targeting of telecommunications infrastructure by boko haram, freedom onuoha outlines the motivations behind boko haram's choice of targets. onuoha argues that by targeting telecommunications infrastructure, boko haram seeks to isolate the geographical areas of its attacks from the rest of the country. he also contends that the choice of telecommunications infrastructure as a target is to frustrate the ability of nigerian security forces to monitor the movement of its members. the response of the rest of the world, particularly the united states, to boko haram, has equally been a subject of scholarly analyses. caitlin c. poling, for instance, has examined how the us congress has reacted to boko haram. poling argues that us responses to terrorism in the aftermath of / are framed within the context of those attacks. she posits that the american congress, alarmed by boko haram, views the group as a dangerous islamic terrorist organization in the tradition and mold of al qaeda. other publications have analyzed boko haram within the context of islamic terrorism in other parts of the world. freedom onuoha, for instance, has examined boko haram in light of the ideology of an islamic sect, the salafists. onuoha contends that the salafists' jihadist ideology provides an important window for understanding the threat that boko haram poses to nigerian security. sean m. gourley has shown that the ideology, rhetoric and strategies of boko haram are similar to those of al qaeda. he cautions that this should raise serious concerns by those pursuing the war on terrorism. shannon connell has also explored the linkage between boko haram and other islamic terrorist groups. similarly, ely karmon has explored the international dimensions of boko haram. karmon notes that boko haram's attack on the united nations offices in abuja, nigeria, in marked its transformation from a purely nigerian and localized terrorist outfit to an international one. pinpointing connections between boko haram and other islamic terrorist groups is also the subject of machael tanebam's long piece in the israel journal of foreign affairs. tanebam sees a direct link between boko haram and al qaeda, and argues that islamic terrorism in both mali and nigeria represents the expansion of al qaeda to africa. the role of primordial identities such as religion, ethnicity and regionalism in framing the discourse on boko haram is the subject of hussein solomon's chapter "boko haram, identity and the limits of counter-terrorism." solomon examines how ethnic, religious and regional identities have shaped the nigerian war against boko haram. he notes that those identities have made the struggle more challenging. for abimbola adesoji, islamic revivalism in nigeria provides the best prism for analyzing and understanding boko haram. to some nigerian scholars, the biggest challenge posed by boko haram is its potential to disrupt the country's delicate ethnic and religious balance. some even fear that the insurgency could lead to the break-up of nigeria. daniel egiegba agbiboa has analyzed boko haram from the perspective of religious identities in nigeria. he also uses the relative deprivation theory to examine boko haram's origins. jideofor adibe, in his book nigeria without nigerians? boko haram and the crisis in nigeria's nation-building, warns that an inability to suppress the insurgency could lead to the demise of nigeria as a single political entity. he views boko haram as a frontal challenge to the desire of many nigerians for a strong, viable and united country. boko haram's threat to national unity is also the subject of another volume by two nigerians, adeyemi ademowo and matthew olusola. ademowo and olusola analyze boko haram against the backdrop of nigeria's fragile national unity. similarly, oluwaseun bamidele has examined boko haram against the backdrop of the threats that it poses to nigeria's peace and stability. he cautions that failure to rein in the insurgency could threaten peace, security and economic development in nigeria. boko haram has made several propaganda videos that it has distributed through youtube, twitter, news wire services, etc. the group uses its propaganda videos to scare nigerians as well as to, radicalize and persuade potential recruits, many of them young boys and under-age girls, to adopt its creed and ideas, and to enlist as suicide bombers and fighters and believe in the group's mission to carve out an islamic caliphate in nigeria. in our analysis of the messages embedded in boko haram's propaganda videos we found that they contained the following themes: unlike is, which uses deftly produced videos and magazines as part of its social media messaging to inspire disaffected muslim youths in europe and north america to join its cause, boko haram's videos are crude and poorly produced. however, the crudity of the production is itself part of its messaging technique: the rawness is intended to instill fear and dread of the terrorist organization in the nigerian viewers. boko haram's social media messaging is not directed specifically at potential recruits. in fact, members of the nigerian armed forces are the target audience, the aim being to convince them of the futility of fighting against a superior force. boko haram's leader also frequently speaks in these videos directly to nigerian, cameroonian, and nigerien leaders, warning them or calling them liars. boko haram does not use its social media messaging to galvanize populist support for its ideology but rather to discredit the nigerian state by demonstrating that it could not offer security to its citizens. the jihadist group presents itself as a fearful and marauding force that cannot be stopped by the incompetent, corrupt and visionless nigerian state. its leader, shekau, in his propaganda videos intends to contrast the weak, inept and vacillating persona of then president goodluck jonathan with his bold and vigorous persona. boko haram recognizes the barbarity of its actions but uses social media to justify such actions in the name of islam. it tries to convey the notion of the righteousness of its interpretations of islam, and hence the legitimacy in the eyes of islam of any of its atrocities. in one of his propaganda videos, shekau displays boko haram's formidable stock of sophisticated weapons as a way to persuade his followers to believe that the sect is militarily well equipped-in fact, so richly equipped that it is stronger than the nigerian government. in the video, he states that boko haram began its insurgency with sticks and knives but has grown strong with its acquisition of armored personnel carriers, multi-purpose vans, ak and pump action riffles, heavy machine guns (hmgs), mortars, artillery shells, anti-aircraft guns, heat-seeking missiles, bombs, rocket-propelled grenades, hundreds of motorbikes, pick-up trucks and so on. as an evidence of boko haram's military strength, shekau displays the groups's sophisticated assault weapons in some of his propaganda videos. the aim is to illustrate the sect's strength as well as persuade his followers to believe that boko haram is rich and wealthy-hence it can afford to purchase all these weapons. ironically, boko haram leaders claim that the group does not condone western civilization, but they make use of western technological gadgets such as cellular phones and video recorders to disseminate their propaganda (maiangwa, ). an added dramatic effect when they display these sophisticated weapons is the fact that some of them were seized from fleeing nigerian soldiers. at the height of its power in january , boko haram had taken over swathes of nigerian territories amounting to over , square milesabout the size of belgium, and six times more land than is at the time; about % of nigerian territory (schmitt, december , ) . nigerian territories under boko haram's control by january included michika, konduga, munguno, gambaru, mafa, mallam fatori, abadam, and marte. the group made videos of its control of those territories, an indication to its members that boko haram was militarily stronger than the nigerian state. in one of his propaganda videos, shekau prominently shows boko haram's black and white islamic caliphate flag flying over the above-mentioned nigerian territories. the video, with an islamic caliphate song in the background, shows boko haram fighters confidently roaming around the seized territories without any challenges from nigerian soldiers. the aim is to persuade and convince his audiences that boko haram has grown so strong and powerful that it was able to capture these territories from the "weak" nigerian government. shekau also used the video to inform his followers that boko haram's successes in capturing those swathes of territories was an unquestionable demonstration of the superiority of the sect's military might and strength. the video's purpose was to portray the weakness of the nigerian government as well as the cowardice of its fleeing soldiers. in one thirty-six-minute youtube video that the authors accessed at https://www.youtube.com/watch?v=mgdkblgzggq, shekau boasts that the avalanche of weapons that boko haram captured from fleeing nigerian soldiers including those seized during its attack on baga in borno state would be enough for the jihadists to successfully prosecute the entire war. an account of boko haram's military invasion of baga town was provided in a bbc news report on january , . the report can be accessed at http://www.bbc.com/news/world-africa- . shekau appears in the video, standing in front of three patrol jeeps mounted with an anti-aircraft gun, dressed in his usual expensive-looking military khaki with an ak hanging from his shoulder across his chest. in the video, he warns that boko haram will bring nigeria to its knees following which he will unleash a punitive attack on the neighboring countries of cameroon, chad, and niger. the boko haram leader ends his speech in that video by burning the nigerian flag, part of his propaganda to show the group's contempt for the nigerian nation. the video showing shekau and boko haram officers wearing expensivelooking military khaki and three-color desert camouflage pattern of dark brown, mint green and beige desert fatigue uniforms was used to send a direct message to the group's members. it was used to subliminally persuade his audience to believe that boko haram is a rich and wealthy professional military organization and not a rag-tag army of poor criminals in search of relevance. yet in another video, posted on youtube on april , (https:// www.youtube.com/watch?v=el-o tnim ), shekau shows off boko haram's assorted military weapons, including those that it claimed to have seized during its raids on nigerian military barracks, one of them, the munguno barracks. this is another propaganda video that shekau used to persuade his followers to believe that the organization and its fighters were stronger than the nigerian nation and its soldiers. shekau appeared in several other propaganda videos that were made after a series of the group's successful attacks in various parts of north-eastern nigeria. the subliminal message in those videos was that boko haram had the capability to successfully attack government facilities time and again. one of these attacks was carried out at the united nations headquarters in abuja on august , . according to a bbc news report of the incident, eighteen people were killed in that attack (http://www.bbc.com/news/worldafrica- ). another attack was on the composite group air force base at the maiduguri international airport on december , . in the video of this, shekau shows how boko haram fighters set five nigerian air force aircraft ablaze as well as the sect's destruction of the airport. a bbc report of the attack said that "the large-scale, coordinated attack was a big setback for the nigerian military" (http://www.bbc.com/news/worldafrica- ). the airport remained closed to civilian aviation from december , until june , . the objective of the video was to convince boko haram fighters and its followers that the sect is stronger than the nigerian state, and that the islamic sect was so strong that it would prevail over nigeria in the long run. earlier, on november , , boko haram suicide bombers penetrated the armed forces command and staff college (afcsc) at jaji, a security hub of the nigerian military. it successfully attacked st andrew's military protestant church inside the college. on november , , members of the sect attacked the special anti-robbery squad (sars) police headquarters in abuja, where they killed several nigerian police officers before freeing scores of suspected criminals, including their own members who were detained in the facility. a bbc report of the incident titled "nigeria gunmen attack abuja sars police hq" may be found at: http://www.bbc.co.uk/news/world-africa- . then, on december , , boko haram fighters attacked and burned down the divisional police station, the prison, customs area office and the presidential lodge in maiha, adamawa state. they killed dozens of people in the attack, and freed scores of prison inmates. the vanguard newspaper, one of the nigerian dailies, reported the attack in its edition of december , . on january , , boko haram fighters attacked and sacked the police station in banki, borno state. in january alone, the jihadist group sacked thirty-seven communities in kwaljiri, kaya, ngawo fate, limanti, njaba, yahuri, mude, wala, and alau, among others in damboa, konduga and gwoza council areas in the north-eastern part of nigeria. in those attacks, members of the group killed thousands of people and many more were forced to take refuge in neighboring villages in the republic of cameroon and other nigerian towns. an editorial in the november , issue of the guardian, one of nigeria's leading newspapers, pointed out that "there were in cameroun alone, , nigerians that fled gwoza, a town in borno state…." in january , the jihadist group attacked baga and killed hundreds of its residents. amnesty international has published aerial photographs of baga town before and after the attack to illustrate the mayhem boko haram unleashed on the town. the "before" images taken on january , were part of its report on the atrocities, while the aftermath was documented in pictures taken on january . the aerial photos may be found at http://www.dw.de/ amnesty-publishes-before-and-after-satellite-images-of-boko-haram-nigeriaattacks/a- . boko haram made a propaganda video of these violent attacks. its leader intended to use this on one hand to scare nigerians and on the other to convince its own members that the islamist group is strong, that nigerian soldiers were cowards and that the establishment of a caliphate rule in nigeria was a matter of when rather than whether. in the video, shekau said: "we killed the people of baga. we indeed killed them, as our lord instructed us in his book … we will not stop. this is not much. you'll see" . another video it utilized to scare nigerians was made in november , following its successful attack and destruction of vintim, hometown of the then chief of defence staff, of the nigerian military, air vice marshal alex badeh. the insurgent group burned down badeh's country home as an illustration of its contempt for the chief of defence staff and the nigerian military that he represented. the video also showed the group's successful attack on mubi, the commercial nerve center of adamawa state and in particular its destruction of the army battalion of the nigerian army that had been based in the city. as lasswell ( a lasswell ( , b noted, propaganda refers to the control of opinion by using picture and other forms of social control. this was indeed what shekau intended to achieve with these videos. boko haram produced another propaganda video after its brazen abduction of female students from the government girls' secondary school, chibok, borno state on november , . the group intended to use this video to serve two purposes. first, it aimed to persuade his audiences to believe that the jihadist sect was stronger than the nigerian government. secondly, the video aimed to show that the nigerian government was untruthful and could not be trusted. when boko haram abducted the girls, the nigerian government at first denied that the group had successfully done so. the wife of the president at the time, patience jonathan, as well as some government supporters, denied boko haram's claim that it had abducted the girls. mrs jonathan said that members of the opposition political party had fabricated the abduction story as a smear campaign against her husband, who was getting ready to run in the presidential election. kema chikwe, a prominent leader of the then ruling people's democratic party (pdp), added her voice to president jonathan's wife's denial. as chikwe contended that boko haram did not abduct any girls in the school, on april , she challenged the authorities of the school to release the names and pictures of the girls as a proof of the abduction. chikwe's comments were published in the may , issue of national leadership, one of nigeria's dailies. according to the paper, chikwe said: "there are many questions to be asked and many more to be answered. how did it happen? who saw it happen? who did not see it happen?" another supporter of the then president, also the founder of the militant niger delta peoples volunteer force, asari dokubo, described boko haram's claim of the abduction of the chibok girls as fake news. according to a report of the daily post of may , , in a terse message posted on his facebook page after the abduction of the girls, dokubo urged his friends to help disseminate the message that no girls at the school were abducted (ameh, may , ) . following all these denials by the federal government and its supporters, shekau then posted propaganda videos of the girls on youtube as proof to his audiences that his group had successfully abducted them, and that the nigerian government was not telling the truth about the abduction. to prove the veracity of his group's successful abduction of the chibok girls, he released a video showing the girls squatting on the ground, wearing black veils over their heads and reciting the quran. in the video, shekau spoke in hausa, arabic and english. for the first fourteen minutes of the fifty-seven-minute video, he took a swipe at the concept of democracy, western education and efforts by muslims and christians to live in peace. to persuade his audiences that boko haram was strong and that nigerian government lied about the abduction, he said: "i abducted a girl at a western education school and you are disturbed. i said western education should end. western education should end. girls, you should go and get married." shekau further said: "i will repeat this: western education should fold up. i abducted your girls. i will sell them in the market by allah. i will marry off a woman at the age of twelve. i will marry off a girl at the age of nine." the video can be viewed at http://www. theguardian.com/world/video/ /may/ /boko-haram-sell-girls-marketvideo. another video in which shekau boasted that he had the girls can be seen at http://search.tb.ask.com/search/video.jhtml?searchfor=video+of+bok o+haram+leader+warning+obama+and+western+leaders&cb=ux&p =% eux% exdm % eyya% eus&n= bb a &qid=c d b ba d f bce e c bfd&ptb=ea e - - abe- a -c e c & ct=ss&si= &pg=ggmain&pn= &ss=sub&st=tab&tpr=tabsbsug&vi dord= &vidid=umkj suzck. boko haram further utilized a video of its downing of a nigerian air force jet on september , to instill fear into nigerian air force pilots and persuade its members and the public to believe that the nigerian government was untruthful, whereas boko haram was sincere and truthful in its claims. the nigerian government at first claimed that it never lost any air force jet planes. the former director of defence information of the army at the time, major-general chris olukolade, said: "we are definitely searching for the jet, it is too early to either talk of a crash or attack by the insurgents." (alli, march , ) . following the government's denial, shekau released a video that showed the wreckage of the jet plane and the captured pilot. in the video, he shows the pilot's own confession in the english language. the video also shows burned parts of a nigerian air force plane in the bush, with the pilot in a camouflage vest kneeling on the ground, as well as a member of the islamist sect hovering over him with an axe. boko haram later claimed that it would behead the pilot. in the video, the pilot identifies himself as a wing commander in the nigerian air force, and says he was undertaking a mission in the kauri area of borno state on september , when his plane was shot down by boko haram fighters. he says: "we were shot down and our aircraft crashed. to this day i don't know the whereabouts of my second pilot." shekau used the video of the downed plane to persuade his followers and audiences to believe that the nigerian government was being untruthful. the government of nigeria betrayed its soldiers by not rescuing the pilot, whose name was chimda hedima. notably enough, the nigerian government has remained silent about his whereabouts. it did not take any known action to seek how the pilot could be rescued or brought back alive. this was utterly in contrast to the jordanian government's reaction when is downed and captured a jordanian pilot, lieutenant moaz al-kasasbeh, in december during a mission to support the us-led anti-is military coalition. the jordanian government sought the release of its pilot, perhaps in return for the release of is prisoners. when is burned the jordanian pilot alive, the government decided to fly military missions into syria to punish jihadists. in september , the nigerian government claimed that it had killed shekau during its offensive against boko karam in konduga. the nigerian press published photographs of the severed head of a person whom the government claimed was shekau. for example, the vanguard reported in its september , - to the jubilation of nigerians-that: nigeria and cameroon were, yesterday, locked in an argument over who killed boko haram leader abubakar shekau and where he was killed. in a rare public show by the cameroonian army (armée camerounaise), photos of shekau were made public alongside a statement claiming he was killed during a cross-border raid deep inside nigeria by its military. a cameroon military source, according to cameroon concord, said on sunday night that shekau was killed following an aerial bombardment of his hideout inside nigeria. (daniel et al. september , ) the vanguard further reported: "the nigerian army said its soldiers might have killed shekau in konduga, a town some kilometres away from maiduguri, the borno state capital" (ibid). many nigerians took to the streets in jubilation of the news. the euphoria that greeted the government's claim had hardly died down when shekau appeared in a two-minute video which was released to the french news agency (afp), debunking the government's claim as false. in the video shekau assures his audiences that he is alive and that only the allah (god almighty) could take his life, not the nigerian government. in the video, he says: "i am alive. i will only die the day allah takes my breath." the video can be seen at (http://search.tb.ask.com/search/video.jhtml?searchfor= boko+haram+in+camouflage+outfits&p =% eux% exdm % eyya % eus&n= bb a &ss=sub&st=tab&ptb=ea e - - abe- a -c e c &si= &tpr=sbt). shekau also used this propaganda video to subliminally persuade his followers and audiences that he is invincible and unpredictable. in the video, he lashes out at the then nigerian president goodluck jonathan and other world leaders, including barack obama, françois hollande, benjamin nethanyahu, angela merkel and david cameron. these authors accessed the video at http://search.tb.ask. com/search/video.jhtml?searchfor=boko+haram+in+camouflage+outfits&p =% eux% exdm % eyya% eus&n= bb a &ss=sub&st=tab&p tb=ea e - - abe- a -c e c &si= &tpr=sbt. in a different video, shekau warns western leaders that the jihadist group will "enslave" all supporters of hollande and obama: "whoever supports hollande and obama, as they supported bush and clinton before, and supported the state of jewish israel, he is an enemy and a target to us and we will enslave him and sell him in the markets." he says that boko haram will unleash deadly attacks on those who believe in the democratic system of government. the video can be accessed at http://universalfreepress.com/ boko-haram-leader-threatens-enslave-supporters-obama/. baines and o'shaughnessy ( ) , qualter ( ) , ellul ( ellul ( , , taylor ( ) , jowett and o'donnell ( ) and others have pointed out that propaganda is a form of communication that attempts to achieve a response that furthers the desired intent of the propagandist. this is what shekau intended to achieve with his propaganda videos. he distributed them to the powerful european news wire services as well as via different social media platforms, so they would receive maximum global attention. boko haram utilized social media to disseminate its messages. unlike other terrorist organizations, boko haram did not use social media as a primary tool to recruit followers but primarily to convey a message about its ruthlessness vicuousness and its total disdain for the nigerian government. it utilized its messaging to showcase its military prowess and the invincibility and nine lives of its leader, shekau. boko haram employed social media to excoriate the nigerian government for its ineptness, corruption, deceitfulness and incompetency. so long as boko haram achieved military successes against the nigerian armed forces, its ability to use the social media to its advantage was immense. each spectacular military victory enhanced boko haram's social media messaging of brutality and military efficiency. however, as the tide of the war turned against it, and shekau was on the run, it became less effective in using social media to advance its cause. moreover, while its astute use of brutality achieved its aim of scaring soldiers and civilians, it undercut its larger message that it was fighting on behalf of islam, since the vast majority of the victims of its brutality were muslims. shekau is able to turn his lack of fluency in english to his advantage by seemingly speaking a smattering of english in a disdainful manner in order to signal boko haram's rejection of western-style education. he frequently speaks in hausa and arabic and tries to convey an air of expertise, but he is not able to pull this off as his rambling speaking style betrays his shallow understanding of islam. ironically, the urge to convince his viewers and listeners of his brutality undercuts the air of intellectualism that he seeks to portray. boko haram initially succeeded in utilizing social media to its advantage because of a poor response by the nigerian government. claiming to have killed shekau so many times provided fodder for boko haram's claim that the nigerian government lied to its citizens. moreover, the inability of the armed forces to crush boko haram under deadlines imposed by the government itself ended up reinforcing boko haram's claim that it could not be defeated. boko haram's ability to infiltrate the army, and the enormous corruption involving the purchase of arms to fight the terrorist group, all aided boko haram's success in depicting the nigerian government as an inept and clueless entity. boko haram's social media messaging lived by the sword and is apparently dying by the sword. the jihadist's fundamental message of its sheer brutality and invisibility was credible so long as nigerian soldiers were fleeing in disarray from the terrorist group. however, as new military commanders, including lieutenant-general yusuf buratai, the chief of army staff, took over and began to take the fight to boko haram, the tables were turned against it. for over a year, shekau was not heard from. he has begun to speak again but his threats now sound hollow. although boko haram continues to launch deadly attacks, it has been uprooted from all the towns and villages which it had captured from nigerian forces. in addition, it has been driven out of sambisa forest, which for many years served as its operational base for attacks. shekau is now on the run and even his leadership of the group has been threatened from within. boko haram's serious military setbacks have not totally silenced its social media propaganda but its loud and boastful braggadocio has been reduced to an occasional whimper. as has been the case of is, military defeats blunt the allure of terrorist propaganda. they demystify terrorists and their seeming ruthless efficiency and invisibility. initially, nigeria did not have a credible means to counter boko haram's social media messaging but militarily routing of boko haram has proven to be the most effective response to the group's reign of terror both on the battlefield and on social media. in june , the largest social media platforms, facebook, youtube, microsoft, and twitter, agreed to set up a common database to identify terrorist propaganda in order to check the distribution of extremist ideology. this step was a recognition of the increasing use of social media by terrorist organizations and the dangers inherent in such usage. terrorism cannot be curbed unless terrorists and their organizations are well understood. social media messaging by extremist groups provide an important avenue for understanding terrorist groups' world views, goals and objectives. we have utilized the analysis of boko haram's social media messaging to demonstrate how this vicious and ruthless terrorist group has used social media to illuminate itself and what it stands for. for an understanding of scholarly analyses of the maitatsene riots see, for example the maitatsene riots in kano, : an assessment for accounts of nigerian newspapers report on the conflict see, for example, the vanguard for an understanding of some of the violent attacks of members of the niger delta avengers on nigeria's oil and gas infrastructure see, for example, the report of al jazeera report of with schoolgirls taken by boko haram still missing amnesty publishes before and after satellite images of boko haram nigeria attacks boko haram ahead of isis for deadliest terror group see also agbese, p.o. internal military deployment and civil-military relations: the boko haram insurgency in nigeria for an understanding of media reports of boko haram's downing of an alpha jet (naf ) belonging to the nigerian air force that was involved in a counter-insurgency operation against the extremist islamic sect see, for example, a premium times news report titled boko haram: islamism, politics, security and the state in the message and methods of boko haram boko haram crisis: a chronology by the numbers: the nigeria state's efforts to counter boko haram boko haram and its muslim critics: observations from yobe state christian perceptions of islam and society in relation to boko haram and recent events in jos and northern nigeria boko haram: anatomy of a crisis, bristol, e-international relations what do we really know about boko haram? responses of the nigerian defense and intelligence establishments to the challenge of boko hara why nigeria is not winning the anti-boko haram war an assessment of roles of security agencies in checkmating insurgent movements in nigeria understanding boko haram's attacks on telecommunications infrastructure anatomy of a crisis haram and the evolving salafi jihadist threat in nigeria linkages between boko haram and al qaeda: a potential deadly synergy to be or not to be: is boko haram a foreign terrorist organization? boko haram's international reach al-qa'ida's west africa advance: nigeria's boko haram, mali's touareg, and the spread of salafi jihadism boko haram, identity and the limits of terrorism the boko haram uprising and islamic revivalism in nigeria the nigerian burden: religious identity, conflict and the current terrorism of boko haram, conflict, security and development why boko haram exists: the relative deprivation perspective nigeria without nigerians? boko haram and the crisis in nigeria's nation-building boko haram: peace culture and the quest for a united nations boko haram catastrophic terrorism: an albatross to national peace, security and sustainable development in nigeria an assessment of roles of security agencies in checkmating insurgent movements in nigeria requiem biafra killed, . m displaced by b/haram-shettima. daily trust boko haram: peace culture and the quest for a united nations why we struck: the story of the first nigerian coup nigeria without nigerians? boko haram and the crisis in nigeria's nation-building half of a yellow sun the nigerian burden: religious identity, conflict and the current terrorism of boko haram. conflict, security and development why boko haram exists: the relative deprivation perspective boko haram: military jet missing in adamawa. thisday sunset in biafra no girls are missing, chibok abduction is a scam boko haram claims baga attack in new video political marketing and propaganda: uses, abuses, misuses boko haram catastrophic terrorism: an albatross to national peace, security and sustainable development in nigeria the evolution of terrorist propaganda: the paris attack and social media semantics and ethics of propaganda the islamic state's use of online social media the power of propaganda the new propaganda: the dictatorship of palaver in contemporary politics boko haram: islamism, politics, security and the state in nigeria propaganda: the formation of men's attitudes the ethics of propaganda: propaganda, innocence and morality. communication the biafra story: the making of an african legend a propaganda index for reviewing problem framing in articles and manuscripts: an exploratory study propaganda analysis: a study of inferences made from nazi propaganda in world war linkages between boko haram and al qaeda: a potential deadly synergy boko haram's cost to nigeria's borno: s billion and rising propaganda: main trends of the modern world across the gulf propaganda and persuasion boko haram's international reach how effective was nazi propaganda? crisis and conflict in nigeria: a documentary sourcebook why is isis winning the social media war? wired propaganda technique in the world the nigerian revolution and the biafra war killing in the name of god? explaining the boko haram phenomenon in nigeria boko haram: anatomy of a crisis understanding the emerging trend of terrorism in nigeria: a case study of boko haram responses of the nigerian defense and intelligence establishments to the challenge of boko hara strategic communications planning for public relations and marketing why nigeria is not winning the anti-boko haram war understanding boko haram's attacks on telecommunication infrastructure boko haram and the evolving salafi jihadist threat in nigeria u.s. congress and boko haram ipskamp drukkers age of propaganda: the everyday use and abuse of persuasion propaganda and psychological warfare boko haram crisis: a chronology with schoolgirls taken by boko haram still missing, u.s.-nigeria ties falter by the numbers: the nigeria state's efforts to counter boko haram the impact of boko haram on nigerian national development encyclopedia of african history boko haram, identity and the limits of terrorism the brothers' war: biafra & nigeria hitler's war and the germans al-qa'ida's west africa advance: nigeria's boko haram, mali's touareg, and the spread of salafi jihadism film propaganda: soviet russia and nazi germany nazi propaganda: the power and limitations the third reich: politics and propaganda key: cord- - qfecv h authors: velasquez, t.; mackey, g.; lusk, j.; kyle, u. g.; fontenot, t.; marshall, p.; shekerdemian, l. s.; coss-bu, j. a.; nishigaki, a.; yatabe, t.; tamura, t.; yamashita, k.; yokoyama, m.; ruiz-rodriguez, j. c.; encina, b.; belmonte, r.; troncoso, i.; tormos, p.; riveiro, m.; baena, j.; sanchez, a.; bañeras, j.; cordón, j.; duran, n.; ruiz, a.; caballero, j.; nuvials, x.; riera, j.; serra, j.; rutten, a. m. f.; van ieperen, s. n. m.; der kinderen, e. p. h. m.; van logten, t.; kovacikova, l.; skrak, p.; zahorec, m.; kyle, u. g.; akcan-arikan, a.; silva, j. c.; mackey, g.; lusk, j.; goldsworthy, m.; shekerdemian, l. s.; coss-bu, j. a.; wood, d.; harrison, d.; parslow, r.; davis, p.; pappachan, j.; goodwin, s.; ramnarayan, p.; chernyshuk, s.; yemets, h.; zhovnir, v.; pulitano’, s. m.; de rosa, s.; mancino, a.; villa, g.; tosi, f.; franchi, p.; conti, g.; patel, b.; khine, h.; shah, a.; sung, d.; singer, l.; haghbin, s.; inaloo, s.; serati, z.; idei, m.; nomura, t.; yamamoto, n.; sakai, y.; yoshida, t.; matsuda, y.; yamaguchi, y.; takaki, s.; yamaguchi, o.; goto, t.; longani, n.; medar, s.; abdel-aal, i. r.; el adawy, a. s.; mohammed, h. m. e. h.; mohamed, a. n.; parry, s. m.; knight, l. d.; denehy, l.; de morton, n.; baldwin, c. e.; sani, d.; kayambu, g.; da silva, v. z. m.; phongpagdi, p.; puthucheary, z. a.; granger, c. l.; rydingsward, j. e.; horkan, c. m.; christopher, k. b.; mcwilliams, d.; jones, c.; reeves, e.; atkins, g.; snelson, c.; aitken, l. m.; rattray, j.; kenardy, j.; hull, a. m.; ullman, a.; le brocque, r.; mitchell, m.; davis, c.; macfarlane, b.; azevedo, j. c.; rocha, l. l.; de freitas, f. f. m.; cavalheiro, a. m.; lucinio, n. m.; lobato, m. s.; ebeling, g.; kraegpoeth, a.; laerkner, e.; de brito-ashurst, i.; white, c.; gregory, s.; forni, l. g.; flowers, e.; curtis, a.; wood, c. a.; siu, k.; venkatesan, k.; muhammad, j. b. h.; ng, l.; seet, e.; baptista, n.; escoval, a.; tomas, e.; agrawal, r.; mathew, r.; varma, a.; dima, e.; charitidou, e.; perivolioti, e.; pratikaki, m.; vrettou, c.; giannopoulos, a.; zakynthinos, s.; routsi, c.; atchade, e.; houzé, s.; jean-baptiste, s.; thabut, g.; genève, c.; tanaka, s.; lortat-jacob, b.; augustin, p.; desmard, m.; montravers, p.; de molina, f. j. gonzález; barbadillo, s.; alejandro, r.; Álvarez-lerma, f.; vallés, j.; catalán, r. m.; palencia, e.; jareño, a.; granada, r. m.; ignacio, m. l.; cui, n.; liu, d.; wang, h.; su, l.; qiu, h.; li, r.; jaffal, k.; rouzé, a.; poissy, j.; sendid, b.; nseir, s.; paramythiotou, e.; rizos, m.; frantzeskaki, f.; antoniadou, a.; vourli, s.; zerva, l.; armaganidis, a.; riera, j.; gottlieb, j.; greer, m.; wiesner, o.; martínez, m.; acuña, m.; rello, j.; welte, t.; atchade, e.; mignot, t.; houzé, s.; jean-baptiste, s.; thabut, g.; lortat-jacob, b.; tanaka, s.; augustin, p.; desmard, m.; montravers, p.; soussi, s.; dudoignon, e.; ferry, a.; chaussard, m.; benyamina, m.; alanio, a.; touratier, s.; chaouat, m.; lafaurie, m.; mimoun, m.; mebazaa, a.; legrand, m.; sheils, m. a.; patel, c.; mohankumar, l.; akhtar, n.; noriega, s. k. pacheco; aldana, n. navarrete; león, j. l. Ávila; baquero, j. durand; bernal, f. fernández; ahmadnia, e.; hadley, j. s.; millar, m.; hall, d.; hewitt, h.; yasuda, h.; sanui, m.; komuro, t.; kawano, s.; andoh, k.; yamamoto, h.; noda, e.; hatakeyama, j.; saitou, n.; okamoto, h.; kobayashi, a.; takei, t.; matsukubo, s.; rotzel, h. b.; lázaro, a. serrano; prada, d. aguillón; gimillo, m. rodriguez; barinas, o. diaz; cortes, m. l. blasco; franco, j. ferreres; roca, j. m. segura; carratalá, a.; gonçalves, b.; turon, r.; mendes, a.; miranda, f.; mata, p. j.; cavalcanti, d.; melo, n.; lacerda, p.; kurtz, p.; righy, c.; rosario, l. e. de la cruz; lesmes, s. p. gómez; romero, j. c. garcía; herrera, a. n. garcía; pertuz, e. d. díaz; sánchez, m. j. gómez; sanz, e. regidor; hualde, j. barado; hernández, a. ansotegui; irazabal, j. m. guergué; spatenkova, v.; bradac, o.; suchomel, p.; urli, t.; lazzeri, e. heusch; aspide, r.; zanello, m.; perez-borrero, l.; garcia-alvarez, j. m.; arias-verdu, m. d.; aguilar-alonso, e.; rivera-fernandez, r.; mora-ordoñez, j.; de la fuente-martos, c.; castillo-lorente, e.; guerrero-lopez, f.; lesmes, s. p. gómez; rosario, l. e. de la cruz; pertuz, e. d. díaz; hernández, a. ansotegui; romero, j. c. garcía; sánchez, m. j. gómez; herrera, a. n. garcía; ramírez, j. roldán; sanz, e. regidor; hualde, j. barado; león, j. p. tirapu; navarro-guillamón, l.; cordovilla-guardia, s.; iglesias-santiago, a.; guerrero-lópez, f.; fernández-mondéjar, e.; vidal, a.; perez, m.; juez, a.; arias, n.; colino, l.; perez, j. l.; pérez, h.; calpe, p.; alcala, m. a.; robaglia, d.; perez, c.; lan, s. k.; cunha, m. m.; moreira, t.; santos, f.; lafuente, e.; fernandes, m. j.; silva, j. g.; rosario, l. e. de la cruz; lesmes, s. p. gómez; herrera, a. n. garcía; romero, j. c. garcía; pertuz, e. d. díaz; sánchez, m. j. gómez; sanz, e. regidor; echeverría, j. g. armando; hernández, a. ansotegui; hualde, j. barado; podlepich, v.; sokolova, e.; alexandrova, e.; lapteva, k.; kurtz, p.; shuinotsuka, c.; rabello, l.; vianna, g.; reis, a.; cairus, c.; salluh, j.; bozza, f.; torres, j. c. barrios; araujo, n. j. fernández; garcía-olivares, p.; keough, e.; dalorzo, m.; tang, l. k.; de sousa, i.; díaz, m.; marcos-zambrano, l. j.; guerrero, j. e.; gomez, s. e. zamora; lopez, g. d. hernandez; cuellar, a. i. vazquez; nieto, o. r. perez; gonzalez, j. a. castanon; bhasin, d.; rai, s.; singh, h.; gupta, o.; bhattal, m. k.; sampley, s.; sekhri, k.; nandha, r.; aliaga, f. a.; olivares, f.; appiani, f.; farias, p.; alberto, f.; hernández, a.; pons, s.; sonneville, r.; bouadma, l.; neuville, m.; mariotte, e.; radjou, a.; lebut, j.; chemam, s.; voiriot, g.; dilly, m. p.; mourvillier, b.; dorent, r.; nataf, p.; wolff, m.; timsit, j. f.; ediboglu, o.; ataman, s.; ozkarakas, h.; kirakli, c.; vakalos, a.; avramidis, v.; obukhova, o.; kurmukov, i. a.; kashiya, s.; golovnya, e.; baikova, v. n.; ageeva, t.; haritydi, t.; kulaga, e. v.; rios-toro, j. j.; perez-borrero, l.; aguilar-alonso, e.; arias-verdu, m. d.; garcia-alvarez, j. m.; lopez-caler, c.; de la fuente-martos, c.; rodriguez-fernandez, s.; sanchez-orézzoli, m. gomez; martin-gallardo, f.; nikhilesh, j.; joshi, v.; villarreal, e.; ruiz, j.; gordon, m.; quinza, a.; gimenez, j.; piñol, m.; castellanos, a.; ramirez, p.; jeon, y. d.; jeong, w. y.; kim, m. h.; jeong, i. y.; ahn, m. y.; ahn, j. y.; han, s. h.; choi, j. y.; song, y. g.; kim, j. m.; ku, n. s.; shah, h.; kellner, f.; rezai, f.; mistry, n.; yodice, p.; ovnanian, v.; fless, k.; handler, e.; alejos, r. martínez; romeu, j. d. martí; antón, d. gonzález; quinart, a.; martí, a. torres; llaurado-serra, m.; lobo-civico, a.; ventura-rosado, a.; piñol-tena, a.; pi-guerrero, m.; paños-espinosa, c.; peralvo-bernat, m.; marine-vidal, j.; gonzalez-engroba, r.; montesinos-cerro, n.; treso-geira, m.; valeiras-valero, a.; martinez-reyes, l.; sandiumenge, a.; jimenez-herrera, m. f.; helyar, s.; riozzi, p.; noon, a.; hallows, g.; cotton, h.; keep, j.; hopkins, p. a.; taggu, a.; renuka, s.; sampath, s.; rood, p. j. t.; frenzel, t.; verhage, r.; bonn, m.; pickkers, p.; van der hoeven, j. g.; van den boogaard, m.; corradi, f.; melnyk, l.; moggia, f.; pienovi, r.; adriano, g.; brusasco, c.; mariotti, l.; lattuada, m.; bloomer, m. j.; coombs, m.; ranse, k.; endacott, r.; maertens, b.; blot, k.; blot, s.; amerongen, m. p. van nieuw; van der heiden, e. s.; twisk, j. w. r.; girbes, a. r. j.; spijkstra, j. j.; riozzi, p.; helyar, s.; cotton, h.; hallows, g.; noon, a.; bell, c.; peters, k.; feehan, a.; keep, j.; hopkins, p. a.; churchill, k.; hawkins, k.; brook, r.; paver, n.; endacott, r.; maistry, n.; van wijk, a.; rouw, n.; van galen, t.; evelein-brugman, s.; taggu, a.; krishna, b.; sampath, s.; putzu, a.; fang, m.; berto, m. boscolo; belletti, a.; cassina, t.; cabrini, l.; mistry, m.; alhamdi, y.; welters, i.; abrams, s. t.; toh, c. h.; han, h. s.; gil, e. m.; lee, d. s.; park, c. m.; winder-rhodes, s.; lotay, r.; doyle, j.; ke, m. w.; huang, w. c.; chiang, c. h.; hung, w. t.; cheng, c. c.; lin, k. c.; lin, s. c.; chiou, k. r.; wann, s. r.; shu, c. w.; kang, p. l.; mar, g. y.; liu, c. p.; dubó, s.; aquevedo, a.; jibaja, m.; berrutti, d.; labra, c.; lagos, r.; garcía, m. f.; ramirez, v.; tobar, m.; picoita, f.; peláez, c.; carpio, d.; alegría, l.; hidalgo, c.; godoy, k.; bakker, j.; hernández, g.; sadamoto, y.; katabami, k.; wada, t.; ono, y.; maekawa, k.; hayakawa, m.; sawamura, a.; gando, s.; marin-mateos, h.; perez-vela, j. l.; garcia-gigorro, r.; peiretti, m. a. corres; lopez-gude, m. j.; chacon-alves, s.; renes-carreño, e.; montejo-gonzález, j. c.; parlevliet, k. l.; touw, h. r. w.; beerepoot, m.; boer, c.; elbers, p. w. g.; tuinman, p. r.; abdelmonem, s. a.; helmy, t. a.; el sayed, i.; ghazal, s.; akhlagh, s. h.; masjedi, m.; hozhabri, k.; kamali, e.; zýková, i.; paldusová, b.; sedlák, p.; morman, d.; youn, a. m.; ohta, y.; sakuma, m.; bates, d.; morimoto, t.; su, p. l.; chang, w. y.; lin, w. c.; chen, c. w.; facchin, f.; zarantonello, f.; panciera, g.; de cassai, a.; venrdramin, a.; ballin, a.; tonetti, t.; persona, p.; ori, c.; del sorbo, l.; rossi, s.; vergani, g.; cressoni, m.; chiumello, d.; chiurazzi, c.; brioni, m.; algieri, i.; tonetti, t.; guanziroli, m.; colombo, a.; tomic, i.; colombo, a.; crimella, f.; carlesso, e.; gasparovic, v.; gattinoni, l.; neto, a. serpa; schmidt, m.; pham, t.; combes, a.; de abreu, m. gama; pelosi, p.; schultz, m. j.; katira, b. h.; engelberts, d.; giesinger, r. e.; ackerley, c.; yoshida, t.; zabini, d.; otulakowski, g.; post, m.; kuebler, w. m.; mcnamara, p. j.; kavanagh, b. p.; pirracchio, r.; rigon, m. resche; carone, m.; chevret, s.; annane, d.; eladawy, s.; el-hamamsy, m.; bazan, n.; elgendy, m.; de pascale, g.; vallecoccia, m. s.; cutuli, s. l.; di gravio, v.; pennisi, m. a.; conti, g.; antonelli, m.; andreis, d. t.; khaliq, w.; singer, m.; hartmann, j.; harm, s.; carmona, s. alcantara; almudevar, p. matia; abellán, a. naharro; ramos, j. veganzones; pérez, l. pérez; valbuena, b. lobo; sanz, n. martínez; simón, i. fernández; arrigo, m.; feliot, e.; deye, n.; cariou, a.; guidet, b.; jaber, s.; leone, m.; resche-rigon, m.; baron, a. vieillard; legrand, m.; gayat, e.; mebazaa, a.; balik, m.; kolnikova, i.; maly, m.; waldauf, p.; tavazzi, g.; kristof, j.; herpain, a.; su, f.; post, e.; taccone, f.; vincent, j. l.; creteur, j.; lee, c.; hatib, f.; jian, z.; buddi, s.; cannesson, m.; fileković, s.; turel, m.; knafelj, r.; gorjup, v.; stanić, r.; gradišek, p.; cerović, o.; mirković, t.; noč, m.; tirkkonen, j.; hellevuo, h.; olkkola, k. t.; hoppu, s.; lin, k. c.; hung, w. t.; chiang, c. c.; huang, w. c.; juan, w. c.; lin, s. c.; cheng, c. c.; lin, p. h.; fong, k. y.; hou, d. s.; kang, p. l.; wann, s. r.; chen, y. s.; mar, g. y.; liu, c. p.; paul, m.; bougouin, w.; geri, g.; dumas, f.; champigneulle, b.; legriel, s.; charpentier, j.; mira, j. p.; sandroni, c.; cariou, a.; zimmerman, j.; sullivan, e.; noursadeghi, m.; fox, b.; sampson, d.; mchugh, l.; yager, t.; cermelli, s.; seldon, t.; bhide, s.; brandon, r. a.; brandon, r. b.; zwaag, j.; beunders, r.; pickkers, p.; kox, m.; gul, f.; arslantas, m. k.; genc, d.; zibandah, n.; topcu, l.; akkoc, t.; cinel, i.; greco, e.; lauretta, m. p.; andreis, d. t.; singer, m.; garcia, i. palacios; cordero, m.; martin, a. diaz; pallás, t. aldabó; montero, j. garnacho; rey, j. revuelto; malo, l. roman; montoya, a. a. tanaka; martinez, a. d. c. amador; ayala, l. y. delgado; zepeda, e. monares; granillo, j. franco; sanchez, j. aguirre; alejo, g. camarena; cabrera, a. rugerio; montenegro, a. pedraza; pham, t.; beduneau, g.; schortgen, f.; piquilloud, l.; zogheib, e.; jonas, m.; grelon, f.; runge, i.; terzi, n.; grangé, s.; barberet, g.; guitard, p. g.; frat, j. p.; constan, a.; chrétien, j. m.; mancebo, j.; mercat, a.; richard, j. c. m.; brochard, l.; soilemezi, e.; koco, e.; savvidou, s.; nouris, c.; matamis, d.; di mussi, r.; spadaro, s.; volta, c. a.; mariani, m.; colaprico, a.; antonio, c.; bruno, f.; grasso, s.; rodriguez, a.; martín-loeches, i.; díaz, e.; masclans, j. r.; gordo, f.; solé-violán, j.; bodí, m.; avilés-jurado, f. x.; trefler, s.; magret, m.; reyes, l. f.; marín-corral, j.; yebenes, j. c.; esteban, a.; anzueto, a.; aliberti, s.; restrepo, m. i.; larsson, j. skytte; redfors, b.; ricksten, s. e.; haines, r.; powell-tuck, j.; leonard, h.; ostermann, m.; berthelsen, r. e.; itenov, t. s.; perner, a.; jensen, j. u.; ibsen, m.; jensen, a. e. k.; bestle, m. h.; bucknall, t.; dixon, j.; boa, f.; macphee, i.; philips, b. j.; doyle, j.; saadat, f.; samuels, t.; huddart, s.; mccormick, b.; debrunnar, r.; preece, j.; swart, m.; peden, c.; richardson, s.; forni, l.; kalfon, p.; baumstarck, k.; estagnasie, p.; geantot, m. a.; berric, a.; simon, g.; floccard, b.; signouret, t.; boucekine, m.; fromentin, m.; nyunga, m.; sossou, a.; venot, m.; robert, r.; follin, a.; renault, a.; garrouste, m.; collange, o.; levrat, q.; villard, i.; thévenin, d.; pottecher, j.; patrigeon, r. g.; revel, n.; vigne, c.; mimoz, o.; auquier, p.; pawar, s.; jacques, t.; deshpande, k.; pusapati, r.; wood, b.; pulham, r. a.; wray, j.; brown, k.; pierce, c.; nadel, s.; ramnarayan, p.; azevedo, j. r.; montenegro, w. s.; rodrigues, d. p.; sousa, s. c.; araujo, v. f.; leitao, a. l.; prazeres, p. h.; mendonca, a. v.; paula, m. p.; das neves, a.; loudet, c. i.; busico, m.; vazquez, d.; villalba, d.; lischinsky, a.; veronesi, m.; emmerich, m.; descotte, e.; juliarena, a.; bisso, m. carboni; grando, m.; tapia, a.; camargo, m.; ulla, d. villani; corzo, l.; dos santos, h. placido; ramos, a.; doglia, j. a.; estenssoro, e.; carbonara, m.; magnoni, s.; donald, c. l. mac; shimony, j. s.; conte, v.; triulzi, f.; stretti, f.; macrì, m.; snyder, a. z.; stocchetti, n.; brody, d. l.; podlepich, v.; shimanskiy, v.; savin, i.; lapteva, k.; chumaev, a.; tjepkema-cloostermans, m. c.; hofmeijer, j.; beishuizen, a.; hom, h.; blans, m. j.; van putten, m. j. a. m.; longhi, l.; frigeni, b.; curinga, m.; mingone, d.; beretta, s.; patruno, a.; gandini, l.; vargiolu, a.; ferri, f.; ceriani, r.; rottoli, m. r.; lorini, l.; citerio, g.; pifferi, s.; battistini, m.; cordolcini, v.; agarossi, a.; di rosso, r.; ortolano, f.; stocchetti, n.; lourido, c. mora; cabrera, j. l. santana; santana, j. d. martín; alzola, l. melián; del rosario, c. garcía; pérez, h. rodríguez; torrent, r. lorenzo; eslami, s.; dalhuisen, a.; fiks, t.; schultz, m. j.; hanna, a. abu; spronk, p. e.; wood, m.; maslove, d.; muscedere, j.; scott, s. h.; saha, t.; hamilton, a.; petsikas, d.; payne, d.; boyd, j. g.; puthucheary, z. a.; mcnelly, a. s.; rawal, j.; connolly, b.; mcphail, m. j.; sidhu, p.; rowlerson, a.; moxham, j.; harridge, s. d.; hart, n.; montgomery, h. e.; jovaisa, t.; thomas, b.; gupta, d.; wijayatilake, d. s.; shum, h. p.; king, h. s.; chan, k. c.; tang, k. b.; yan, w. w.; arias, c. castro; latorre, j.; de la rica, a. suárez; garrido, e. maseda; feijoo, a. montero; gancedo, c. hernández; tofiño, a. lópez; rodríguez, f. gilsanz; gemmell, l. k.; campbell, r.; doherty, p.; mackay, a.; singh, n.; vitaller, s.; nagib, h.; prieto, j.; del arco, a.; zayas, b.; gomez, c.; tirumala, s.; pasha, s. a.; kumari, b. k.; martinez-lopez, p.; puerto-morlán, a.; nuevo-ortega, p.; pujol, l. martinez; dolset, r. algarte; gonzález, b. sánchez; riera, s. quintana; Álvarez, j. trenado; quintana, s.; martínez, l.; algarte, r.; sánchez, b.; trenado, j.; tomas, e.; brock, n.; viegas, e.; filipe, e.; cottle, d.; traynor, t.; martínez, m. v. trasmonte; márquez, m. pérez; gómez, l. colino; martínez, n. arias; muñoz, j. m. milicua; bellver, b. quesada; varea, m. muñoz; llorente, m. Á. alcalá; calvo, c. pérez; hillier, s. d.; faulds, m. c.; hendra, h.; lawrence, n.; maekawa, k.; hayakawa, m.; ono, y.; kodate, a.; sadamoto, y.; tominaga, n.; mizugaki, a.; murakami, h.; yoshida, t.; katabami, k.; wada, t.; sawamura, a.; gando, s.; silva, s.; kerhuel, l.; malagurski, b.; citerio, g.; chabanne, r.; laureys, s.; puybasset, l.; nobile, l.; pognuz, e. r.; rossetti, a. o.; verginella, f.; gaspard, n.; creteur, j.; ben-hamouda, n.; oddo, m.; taccone, f. s.; ono, y.; hayakawa, m.; iijima, h.; maekawa, k.; kodate, a.; sadamoto, y.; mizugaki, a.; murakami, h.; katabami, k.; wada, t.; sawamura, a.; gando, s.; kodate, a.; katabami, k.; wada, t.; ono, y.; maekawa, k.; hayakawa, m.; sawamura, a.; gando, s.; andersen, l. w.; raymond, t.; berg, r.; nadkarni, v.; grossestreuer, a.; kurth, t.; donnino, m.; krüger, a.; ostadal, p.; janotka, m.; vondrakova, d.; kongpolprom, n.; cholkraisuwat, j.; pekkarinen, p. t.; ristagno, g.; masson, s.; latini, r.; bendel, s.; ala-kokko, t.; varpula, t.; vaahersalo, j.; hoppu, s.; tiainen, m.; mion, m. m.; plebani, m.; pettilä, v.; skrifvars, m.b.; son, y.; kim, k. s.; suh, g. j.; kwon, w. y.; ko, j. i.; park, m. j.; cavicchi, f. zama; iesu, e.; nobile, l.; vincent, j. l.; creteur, j.; taccone, f. s.; tanaka, h.; otani, n.; ode, s.; ishimatsu, s.; martínez, l.; algarte, r.; sánchez, b.; romero, i.; martínez, f.; quintana, s.; trenado, j.; vondrakova, d.; ostadal, p.; kruger, a.; janotka, m.; malek, f.; neuzil, p.; yeh, y. c.; chen, y. s.; wang, c. h.; huang, c. h.; chao, a.; lee, c. t.; lai, c. h.; chan, w. s.; cheng, y. j.; sun, w. z.; kaese, s.; horstmann, c.; lebiedz, p.; mourad, m.; gaudard, p.; eliet, j.; zeroual, n.; colson, p.; ostadal, p.; mlcek, m.; hrachovina, m.; kruger, a.; vondrakova, d.; janotka, m.; mates, m.; hala, p.; kittnar, o.; neuzil, p.; jacky, a.; rudiger, a.; spahn, d. r.; bettex, d. a.; kara, a.; akin, s.; dos reis miranda, d.; struijs, a.; caliskan, k.; van thiel, r. j.; dubois, e. a.; de wilde, w.; zijlstra, f.; gommers, d.; ince, c.; marca, l.; xini, a.; mongkolpun, w.; cordeiro, c. p. r.; leite, r. t.; lheureux, o.; bader, a.; rincon, l.; santacruz, c.; preiser, j. c.; chao, a.; chao, a. s.; chen, y. s.; kim, w.; ahn, c.; cho, y.; lim, t. h.; oh, j.; choi, k. s.; jang, b. h.; ha, j. k.; mecklenburg, a.; stamm, j.; soeffker, g.; kubik, m.; sydow, k.; reichenspurner, h.; kluge, s.; braune, s.; bergantino, b.; ruberto, f.; magnanimi, e.; privato, e.; zullino, v.; bruno, k.; pugliese, f.; sales, g.; girotto, v.; vittone, f.; brazzi, l.; fritz, c.; kimmoun, a.; vanhuyse, f.; trifan, b.; orlowski, s.; albuisson, e.; tran, n.; levy, b.; chhor, v.; joachim, j.; follin, a.; champigneulle, b.; chatelon, j.; fave, g.; mantz, j.; pirracchio, r.; diaz, d. díaz; villanova, m.; aguirregabyria, m.; andrade, g.; lópez, l.; palencia, e.; john, g.; cowan, r.; hart, r.; lake, k.; litchfield, k.; song, j. w.; lee, y. j.; cho, y. j.; choi, s.; vermeir, p.; vandijck, d.; blot, s.; mariman, a.; verhaeghe, r.; deveugele, m.; vogelaers, d.; chok, l.; bachli, e. b.; bettex, d.; cottini, s. r.; keller, e.; maggiorini, m.; schuepbach, r.; fiks, t.; stiphout, c.; grevelink, m.; vaneker, i.; ruijter, a.; buise, m.; spronk, p. e.; tena, s. altaba; barrachina, l. galarza; portillo, j. h. rodriguez; aznar, g. pagés; campos, l. mateu; sellés, m. d. ferrándiz; tomás, m. arlandis; muncharaz, a. belenguer; skinner, l.; monsalvo, s.; olavarria, e.; stümpfle, r.; na, s. j.; park, j.; chung, c. r.; park, c. m.; suh, g. y.; yang, j. h.; witter, t.; brousseau, c.; butler, m. b.; erdogan, m.; dougall, p. c. mac; green, r. s.; abbott, t. e. f.; torrance, h. d. t.; cron, n.; vaid, n.; emmanuel, j.; siddiqui, s. s.; prabu, n.; chaudhari, h. k.; patil, v. p.; divatia, j. v.; solanki, s.; kulkarni, a. p.; gutierrez, l. a. rincon; bader, a.; brasseur, a.; lheureux, o.; vincent, j. l.; creteur, j.; taccone, f. s.; hempel, d.; stauffert, n.; recker, f.; schröder, t.; reusch, s.; schleifer, j.; breitkreutz, r.; sjövall, f.; perner, a.; møller, m. hylander; moraes, r. b.; borges, f. k.; guillen, j. a. v.; zabaletta, w. j. c.; ruiz-ramos, j.; ramirez, p.; marqués-miñana, m. r.; villarreal, e.; gordon, m.; sosa, m.; concha, p.; castellanos, a.; menendez, r.; ramírez, c. sánchez; santana, m. cabrera; balcázar, l. caipe; escalada, s. hípola; viera, m. a. hernández; vázquez, c. f. lübbe; díaz, j. j. díaz; campelo, f. artiles; monroy, n. sangil; santana, p. saavedra; santana, s. ruiz; gutiérrez-pizarraya, a.; garnacho-montero, j.; martin, c.; baumstarck, k.; leone, m.; martín-loeches, i.; pirracchio, r.; legrand, m.; mainardi, j. l.; mantz, j.; cholley, b.; hubbard, a.; frontera, p. ruiz; vega, l. m. claraco; miguelena, p. ruiz de gopegui; usón, m. c. villuendas; lópez, a. rezusta; clemente, e. aurensanz; ibañes, p. gutiérrez; aguilar, a. l. ruiz; palomar, m.; olaechea, p.; uriona, s.; vallverdu, m.; catalan, m.; nuvials, x.; aragon, c.; lerma, f. alvarez; jeon, y. d.; jeong, w. y.; kim, m. h.; jeong, i. y.; ahn, m. y.; ahn, j. y.; han, s. h.; choi, j. y.; song, y. g.; kim, j. m.; ku, n. s.; bassi, g. li; xiol, e. aguilera; senussi, t.; idone, f. a.; motos, a.; chiurazzi, c.; travierso, c.; fernández-barat, l.; amaro, r.; hua, y.; ranzani, o. t.; bobi, q.; rigol, m.; torres, a.; fernández, i. fuentes; soler, e. andreu; de vera, a. pareja rodríguez; pastor, e. escudero; hernandis, v.; ros martínez, j.; rubio, r. jara; torner, m. miralbés; brugger, s. carvalho; eroles, a. aragones; moles, s. iglesias; cabello, j. trujillano; schoenenberger, j. a.; casals, x. nuvials; vidal, m. vallverdu; garrido, b. balsera; martinez, m. palomar; mirabella, l.; cotoia, a.; tullo, l.; stella, a.; di bello, f.; di gregorio, a.; dambrosio, m.; cinnella, g.; rosario, l. e. de la cruz; lesmes, s. p. gómez; romero, j. c. garcía; herrera, a. n. garcía; pertuz, e. d. díaz; sánchez, m. j. gómez; sanz, e. regidor; hualde, j. barado; hernández, a. ansotegui; ramirez, j. roldán; takahashi, h.; kazutoshi, f.; okada, y.; oobayashi, w.; naito, t.; baidya, d. k.; maitra, s.; anand, r. k.; ray, b. r.; arora, m. k.; ruffini, c.; rota, l.; corona, a.; sesana, g.; ravasi, s.; catena, e.; naumann, d. n.; mellis, c.; husheer, s. l.; bishop, j.; midwinter, m. j.; hutchings, s.; corradi, f.; brusasco, c.; manca, t.; ramelli, a.; lattuada, m.; nicolini, f.; gherli, t.; vezzani, a.; young, a.; carmona, a. fernández; santiago, a. iglesias; guillamon, l. navarro; delgado, m. j. garcía; delgado-amaya, m.; curiel-balsera, e.; rivera-romero, l.; castillo-lorente, e.; carrero-gómez, f.; aguayo-dehoyos, e.; healey, a. j.; cameron, c.; jiao, l.r.; stümpfle, r.; pérez, a.; martin, s.; del moral, o. lopez; toval, s.; rico, j.; aldecoa, c.; oguzhan, k.; demirkiran, o.; kirman, m.; bozbay, s.; kosuk, m. e.; asyralyyeva, g.; dilek, m.; duzgun, m.; telli, s.; aydin, m.; yilmazer, f.; hodgson, l. e.; dimitrov, b. d.; stubbs, c.; forni, l. g.; venn, r.; vedage, d.; shawaf, s.; naran, p.; sirisena, n.; kinnear, j.; dimitrov, b. d.; hodgson, l. e.; stubbs, c.; forni, l. g.; venn, r.; londoño, j. gonzalez; cardenas, c. lorencio; ginés, a. sánchez; gubianas, c. murcia; sánchez, e. clapes; sirvent, j. m.; panafidina, v.; shlyk, i.; ilyina, v.; judickas, s.; kezyte, g.; urbanaviciute, i.; serpytis, m.; gaizauskas, e.; sipylaite, j.; sprung, c. l.; munteanu, g.; morales, r. c.; kasdan, h.; volker, t.; reiter, a.; cohen, y.; himmel, y.; meissonnier, j.; banderas-bravo, m. e.; gómez-jiménez, c.; garcía-martínez, m. v.; martínez-carmona, j. f.; fernández-ortega, j. f.; o‘dwyer, m. j.; starczewska, m.; wilks, m.; vincent, j. l.; torsvik, m.; gustad, l. t.; bangstad, i. l.; vinje, l. j.; damås, j. k.; solligård, e.; mehl, a.; tsunoda, m.; kang, m.; saito, m.; saito, n.; akizuki, n.; namiki, m.; takeda, m.; yuzawa, j.; yaguchi, a.; frantzeskaki, f.; tsirigotis, p.; chondropoulos, s.; paramythiotou, e.; theodorakopoulou, m.; stamouli, m.; gkirkas, k.; dimopoulou, i. k.; makiko, s.; tsunoda, m.; kang, m.; yuzawa, j.; akiduki, n.; namiki, m.; takeda, m.; yaguchi, a.; preau, s.; ambler, m.; sigurta, a.; saeed, s.; singer, m.; jochmans, s.; chelly, j.; vong, l. v. p.; sy, o.; serbource-goguel, j.; rolin, n.; weyer, c. m.; abdallah, r. i.; adrie, c.; vinsonneau, c.; monchi, m.; mayr, u.; huber, w.; karsten, e.; lahmer, t.; thies, p.; henschel, b.; fischer, g.; schmid, r. m.; ediboglu, o.; ataman, s.; naz, i.; yaman, g.; kirakli, c.; su, p. l.; kou, p. s.; lin, w. c.; chen, c. w.; lozano, j. a. benítez; sánchez, p. carmona; francioni, j. e. barrueco; ferrón, f. ruiz; simón, j. m. serrano; riad, z.; mezidi, m.; aublanc, m.; perinel, s.; lissonde, f.; louf-durier, a.; yonis, h.; tapponnier, r.; richard, j. c.; louis, b.; guérin, c.; mezidi, m.; yonis, h.; aublanc, m.; lissonde, f.; louf-durier, a.; perinel, s.; tapponnier, r.; richard, j. c.; guérin, c.; marmanidou, k.; oikonomou, m.; nouris, c.; loizou, c.; soilemezi, e.; matamis, d.; somhorst, p.; gommers, d.; hayashi, k.; hirayama, t.; yumoto, t.; tsukahara, k.; iida, a.; nosaka, n.; sato, k.; ugawa, t.; nakao, a.; ujike, y.; hirohata, s.; mojoli, f.; torriglia, f.; giannantonio, m.; orlando, a.; bianzina, s.; tavazzi, g.; mongodi, s.; pozzi, m.; iotti, g. a.; braschi, a.; jansen, d.; gadgil, s.; doorduin, j.; roesthuis, l.; van der hoeven, j. g.; heunks, l. m. a.; chen, g. q.; sun, x. m.; he, x.; yang, y. l.; shi, z. h.; xu, m.; zhou, j. x.; pereira, s. m.; tucci, m. r.; tonelotto, b. f. f.; simoes, c. m.; morais, c. c. a.; pompeo, m. s.; kay, f. u.; amato, m. b. p.; vieira, j. e.; suzuki, s.; mihara, y.; hikasa, y.; okahara, s.; morimatsu, h.; kwon, h. m.; moon, y. j.; lee, s. h.; jung, k. w.; shin, w. j.; jun, i. g.; song, j. g.; hwang, g. s.; lee, s.; moon, y. j.; kwon, h. m.; jung, k.; shin, w. j.; jun, i. g.; song, j. g.; hwang, g. s.; ramelli, a.; manca, t.; corradi, f.; brusasco, c.; nicolini, f.; gherli, t.; brianti, r.; fanzaghi, p.; vezzani, a.; tudor, b. a.; klaus, d. a.; lebherz-eichinger, d.; lechner, c.; schwarz, c.; bodingbauer, m.; seemann, r.; kaczirek, k.; fleischmann, e.; roth, g. a.; krenn, c. g.; malyshev, a.; sergey, s.; yamaguchi, y.; nomura, t.; yoshitake, e.; idei, m.; yoshida, t.; takaki, s.; yamaguchi, o.; kaneko, m.; goto, t.; tencé, n.; zaien, i.; wolf, m.; trouiller, p.; jacobs, f. m.; kelly, j. m.; veigas, p.; hollands, s.; min, a.; rizoli, s.; robles, c. m. coronado; de oca sandoval, m. a. montes; tarabrin, o.; gavrychenko, d.; mazurenko, g.; tarabrin, p.; garcia, i. palacios; martin, a. diaz; mendez, m. casado; orden, v. arellano; noval, r. leal; mccue, c.; gemmell, l.; mackay, a.; luján, j.; villa, p.; llorente, b.; molina, r.; alcázar, l.; juanas, c. arenillas; rogero, s.; pascual, t.; cambronero, j. a.; almudévar, p. matía; domínguez, j. palamidessi; carmona, s. alcántara; castañeda, d. palacios; abellán, a. naharro; lucendo, a. pérez; pérez, l. pérez; rivas, r. fernández; sanz, n. martínez; ramos, j. veganzones; villamizar, p. rodríguez; javadpour, s.; kalani, n.; amininejad, t.; jamali, s.; sobhanian, s.; laurent, a.; bonnet, m.; rigal, r.; aslanian, p.; hebert, p.; capellier, g.; contreras, m. r. diaz; mejías, c. rodriguez; ruiz, f. c. santiago; lombardo, m. duro; perez, j. castaño; de hoyos, e. aguayo; estella, a.; viciana, r.; fontaiña, l. perez; rico, t.; madueño, v. perez; recuerda, m.; fernández, l.; sandiumenge, a.; bonet, s.; mazo, c.; rubiera, m.; ruiz-rodríguez, j. c.; gracia, r. m.; espinel, e.; pont, t.; kotsopoulos, a.; jansen, n.; abdo, w. f.; gopcevic, a.; gavranovic, z.; vucic, m.; glogoski, m. zlatic; penavic, l. videc; horvat, a.; martin-villen, l.; egea-guerero, j. j.; revuelto-rey, j.; aldabo-pallas, t.; correa-chamorro, e.; gallego-corpa, a. i.; granados, p. ruiz del portal-ruiz; faivre, v.; wildenberg, l.; huot, b.; lukaszewicz, a. c.; simsir, m.; mengelle, c.; payen, d.; sanz, n. martinez; valbuena, b. lobo; de la fuente, m. valdivia; almudena, p. matía; pérez, l. pérez; carmona, s. alcántara; abellán, a. navarro; simón, i. fernández; muñoz, j. j. rubio; ramos, j. veganzones; carmona, s. alcantara; almudevar, p. matia; abellan, a. naharro; lucendo, m. a. perez; perez, l. perez; dominguez, j. palamidessi; rivas, r. fernandez; villamizar, p. rodriguez; wee, s.; ong, c.; lau, y. h.; wong, y.; banderas-bravo, m. e.; olea-jiménez, v.; mora-ordóñez, j. m.; gómez-jiménez, c.; muñoz-muñoz, j. l.; vallejo-báez, j.; daga-ruiz, d.; lebrón-gallardo, m.; rialp, g.; raurich, j. m.; morán, i.; martín, m. c.; heras, g.; mas, a.; vallverdú, i.; hraiech, s.; bourenne, j.; guervilly, c.; forel, j. m.; adda, m.; sylla, p.; mouaci, a.; gainnier, m.; papazian, l.; bauer, p. r.; kumbamu, a.; wilson, m. e.; pannu, j. k.; egginton, j. s.; kashyap, r.; gajic, o.; yoshihiro, s.; sakuraya, m.; hayakawa, m.; hirata, a.; kawamura, n.; tsutui, t.; yoshida, k.; hashimoto, y.; chang, c. h.; hu, h. c.; chiu, l. c.; hung, c. y.; li, s. h.; kao, k. c.; sibley, s.; drover, j.; d’arsigny, c.; parker, c.; howes, d.; moffatt, s.; erb, j.; ilan, r.; messenger, d.; ball, i.; boyd, j. g.; harrison, m.; ridi, s.; muscedere, j.; andrade, a. h.; costa, r. c.; souza, v. a.; gonzalez, v.; amorim, v.; rolla, f.; filho, c. a. c. abreu; miranda, r.; atchasiri, s.; buranavanich, p.; wathanawatthu, t.; suwanpasu, s.; bureau, c.; rolland-debord, c.; poitou, t.; clavel, m.; perbet, s.; terzi, n.; kouatchet, a.; similowski, t.; demoule, a.; diaz, p.; nunes, j.; escórcio, s.; silva, g.; chaves, s.; jardim, m.; câmara, m.; fernandes, n.; duarte, r.; jardim, j. j.; pereira, c. a.; nóbrega, j. j.; chen, c. m.; lai, c. c.; cheng, k. c.; chou, w.; lee, s. j.; cha, y. s.; lee, w. y.; onodera, m.; nakataki, e.; oto, j.; imanaka, h.; nishimura, m.; khadjibaev, a.; sabirov, d.; rosstalnaya, a.; akalaev, r.; parpibaev, f.; antonucci, e.; rossini, p.; gandolfi, s.; montini, e.; orlando, s.; van nes, m.; karachi, f.; hanekom, s.; andrade, a. h.; pereira, u. v.; filho, c. a. c. abreu; costa, r. c.; parkin, m. s. w.; moore, m.; andrade, a. h.; costa, r. c.; carvalho, k. v. silva; filho, c. a. c. abreu; min, h. j.; kim, h. j.; lee, d. s.; choi, y. y.; lee, e. y.; song, i.; kim, d. j.; e, y. y.; kim, j. w.; park, j. s.; cho, y. j.; lee, j. h.; suh, j. w.; jo, y. h.; kim, k. s.; lee, y. j.; ferrero-calleja, j.; merino-vega, d.; gonzález-jiménez, a. i.; sigcha, m. sigcha; hernández-tejedor, a.; martin-vivas, a.; gabán-díez, Á.; luna, r. ruiz-de; de la calle-pedrosa, n.; temprano-gómez, i.; afonso-rivero, d.; pellin-ariño, j. i.; algora-weber, a.; fumis, r. r. l.; ferraz, a. b.; junior, j. m. vieira; kirca, h.; cakin, o.; unal, m.; mutlu, h.; ramazanoglu, a.; cengiz, m.; nicolini, e. a.; pelisson, f. g. f.; nunes, r. s.; da silva, s. l.; carreira, m. m.; bellissimo-rodrigues, f.; ferez, m. a.; basile-filho, a.; chao, h. c.; chen, c. m.; chen, l.; hravnak, m.; clermont, g.; pinsky, m.; dubrawski, a.; varas, j. luján; montero, r. molina; sánchez-elvira, l. alcázar; díaz, p. villa; delgado, c. pintado; ruiz, b. llorente; guerrero, a. pardo; galache, j. a. cambronero; sherif, h.; hassanin, h.; el hossainy, r.; samy, w.; ly, h.; david, h.; burtin, p.; charpentier, c.; barral, m.; courant, p.; fournel, e.; gaide-chevronnay, l.; durand, m.; albaladejo, p.; payen, j. f.; chavanon, o.; ortiz, a. blandino; pozzebon, s.; lheureux, o.; brasseur, a.; vincent, j. l.; creteur, j.; taccone, f. s.; fumagalli, f.; scala, s.; affatato, r.; de maglie, m.; zani, d.; novelli, d.; marra, c.; luciani, a.; de zani, d.; luini, m.; letizia, t.; pravettoni, d.; staszewsky, l.; masson, s.; belloli, a.; di giancamillo, m.; scanziani, e.; latini, r.; ristagno, g.; kye, y. c.; suh, g. j.; kwon, w. y.; kim, k. s.; yu, k. m.; babini, g.; ristagno, g.; grassi, l.; fumagalli, f.; bendel, s.; de maglie, m.; affatato, r.; masson, s.; latini, r.; scanziani, e.; reinikainen, m.; skrifvars, m.; kappler, f.; blobner, m.; schaller, s. j.; roasio, a.; costanzo, e.; cardellino, s.; iesu, e.; cavicchi, f. zama; fontana, v.; nobile, l.; vincent, j. l.; creteur, j.; taccone, f. s.; park, m.; you, k. m.; suh, g. j.; kwon, w. y.; ko, s. b.; kim, k. s.; xini, a.; marca, l.; lheureux, o.; brasseur, a.; vincent, j. l.; creteur, j.; taccone, f. s.; beane, a.; thilakasiri, m. c. k. t.; de silva, a. p.; stephens, t.; sigera, c. s.; athapattu, p.; jayasinghe, s.; padeniya, a.; haniffa, r.; santiago, a. iglesias; sáez, v. chica; ruiz-ruano, r. de la chica; gonzález, a. sánchez; kunze-szikszay, n.; wand, s.; klapsing, p.; wetz, a.; heyne, t.; schwerdtfeger, k.; troeltzsch, m.; bauer, m.; quintel, m.; moerer, o.; cook, d. j.; rutherford, w. b.; scales, d. c.; adhikari, n. k.; cuthbertson, b. h.; suzuki, t.; takei, t.; fushimi, k.; iwamoto, m.; nakagawa, s.; mendsaikhan, n.; begzjav, t.; lundeg, g.; dünser, m. w.; romero, d. gonzález; cabrera, j. l. santana; santana, j. d. martín; padilla, y. santana; pérez, h. rodríguez; torrent, r. lorenzo; kleinpell, r.; chouris, i.; radu, v.; stougianni, m.; lavrentieva, a.; lagonidis, d.; price, r. d. t.; day, a.; arora, n.; henderson, m. a.; hickey, s.; costa, m. i. almeida; carvalho, j. p.; gomes, a. a.; mergulhão, p. j.; chan, k. k. c.; shum, h. p.; yan, w. w.; maghsoudi, b.; tabei, s. h.; masjedi, m.; sabetian, g.; tabatabaei, h. r.; akbarzadeh, a.; saigal, s.; pakhare, a.; joshi, r.; pattnaik, s. k.; ray, b.; rousseau, a. f.; michel, l.; bawin, m.; cavalier, e.; reginster, j. y.; damas, p.; bruyere, o.; zhou, j. c.; cauwenberghs, h.; de backer, a.; neels, h.; deblier, i.; berghmans, j.; himpe, d.; barea-mendoza, j. a.; portillo, i. prieto; fernández, m. valiente; gigorro, r. garcia; vela, j. l. perez; mateos, h. marín; alves, s. chacón; varas, g. morales; rodriguez-biendicho, a.; carreño, e. renes; gonzález, j. c. montejo; yang, j. s.; chiang, c. h.; hung, w. t.; huang, w. c.; cheng, c. c.; lin, k. c.; lin, s. c.; chiou, k. r.; wann, s. r.; lin, k. l.; kang, p. l.; mar, g. y.; liu, c. p.; zhou, j. c.; choi, y. j.; yoon, s. z.; gordillo-brenes, a.; fernandez-zamora, m. d.; perez-borrero, l.; arias-verdu, m. d.; aguilar-alonso, e.; herruzo-aviles, a.; garcia-delgado, m.; hinojosa-perez, r.; curiel-balsera, e.; rivera-fernandez, r.; lesmes, s. p. gómez; rosario, l. e. de la cruz; hernández, a. ansotegui; herrera, a. n. garcía; sanz, e. regidor; sánchez, m. j. gómez; hualde, j. barado; pascual, o. agudo; león, j. p. tirapu; irazabal, j. m. guergue; pérez, a. gonzález; fernández, p. alvarez; amor, l. lopéz; albaiceta, g. muñiz; lesmes, s. p. gómez; rosario, l. e. de la cruz; hernández, a. ansotegui; sanz, e. regidor; sánchez, m. j. gómez; calvo, s. aldunate; herrera, a. n. garcía; hualde, j. barado; pascual, o. agudo; león, j. p. tirapu; corona, a.; ruffini, c.; spazzadeschi, a.; marrazzo, f.; gandola, a.; sciurti, r.; savi, c.; catena, e.; ke, m. w.; cheng, c. c.; huang, w. c.; chiang, c. h.; hung, w. t.; lin, k. c.; lin, s. c.; wann, s. r.; chiou, k. r.; tseng, c. j.; kang, p. l.; mar, g. y.; liu, c. p.; bertini, p.; de sanctis, f.; guarracino, f.; bertini, p.; baldassarri, r.; guarracino, f.; buitinck, s. h.; van der voort, p. h. j.; oto, j.; nakataki, e.; tsunano, y.; izawa, m.; tane, n.; onodera, m.; nishimura, m.; ghosh, s.; gupta, a.; de gasperi, a.; mazza, e.; limuti, r.; prosperi, m.; bissenova, n.; yergaliyeva, a.; talan, l.; yılmaz, g.; güven, g.; yoruk, f.; altıntas, n. d.; mukherjee, d. n.; agarwal, l. k.; mandal, k.; palomar, m.; balsera, b.; vallverdu, m.; martinez, m.; garcia, m.; castellana, d.; lopez, r.; barcenilla, f.; kaminsky, g. e.; carreño, r.; escribá, a.; fuentes, m.; gálvez, v.; del olmo, r.; nieto, b.; vaquerizo, c.; alvarez, j.; de la torre, m. a.; torres, e.; bogossian, e.; nouer, s. aranha; salgado, d. ribeiro; brugger, s. carvalho; jiménez, g. jiménez; torner, m. miralbés; vidal, m. vallverdú; garrido, b. balsera; casals, x. nuvials; gaite, f. barcenilla; cabello, j. trujillano; martínez, m. palomar; doganci, m.; izdes, s.; besevli, s. guzeldag; alkan, a.; kayaaslan, b.; ramírez, c. sánchez; balcázar, l. caipe; santana, m. cabrera; viera, m. a. hernández; escalada, s. hípola; vázquez, c. f. lübbe; penichet, s. m. marrero; campelo, f. artiles; lópez, m. a. de la cal; santana, p. saavedra; santana, s. ruíz; repessé, x.; artiguenave, m.; paktoris-papine, s.; espinasse, f.; dinh, a.; el sayed, f.; charron, c.; géri, g.; vieillard-baron, a.; marmanidou, k.; oikonomou, m.; nouris, c.; dimitroulakis, k.; soilemezi, e.; matamis, d.; ferré, a.; guillot, m.; teboul, j. l.; lichtenstein, d.; mézière, g.; richard, c.; monnet, x.; pham, t.; beduneau, g.; schortgen, f.; piquilloud, l.; zogheib, e.; jonas, m.; grelon, f.; runge, i.; terzi, n.; grangé, s.; barberet, g.; guitard, p. g.; frat, j. p.; constan, a.; chrétien, j. m.; mancebo, j.; mercat, a.; richard, j. c. m.; brochard, l.; prīdāne, s.; sabeļņikovs, o.; mojoli, f.; orlando, a.; bianchi, i.; torriglia, f.; bianzina, s.; pozzi, m.; iotti, g. a.; braschi, a.; beduneau, g.; pham, t.; schortgen, f.; piquilloud, l.; zogheib, e.; jonas, m.; grelon, f.; runge, i.; terzi, n.; grangé, s.; barberet, g.; guitard, p. g.; frat, j. p.; constan, a.; chrétien, j. m.; mancebo, j.; mercat, a.; richard, j. c. m.; brochard, l.; kondili, e.; psarologakis, c.; kokkini, s.; amargianitakis, v.; babalis, d.; chytas, a.; chouvarda, i.; vaporidi, k.; georgopoulos, d.; trapp, o.; kalenka, a.; mojoli, f.; orlando, a.; bianchi, i.; torriglia, f.; bianzina, s.; pozzi, m.; iotti, g. a.; braschi, a.; lozano, j. a. benítez; sánchez, p. carmona; francioni, j. e. barrueco; ferrón, f. ruiz; simón, j. m. serrano; spadaro, s.; karbing, d. s.; gioia, a.; moro, f.; corte, f. dalla; mauri, t.; volta, c. a.; rees, s. e.; petrova, m. v.; mohan, r.; butrov, a. v.; beeharry, s. d.; vatsik, m. v.; sakieva, f. i.; gobert, f.; yonis, h.; tapponnier, r.; fernandez, r.; labaune, m. a.; burle, j. f.; barbier, j.; vincent, b.; cleyet, m.; richard, j. c.; guérin, c.; shinotsuka, c. righy; creteur, j.; taccone, f. s.; törnblom, s.; nisula, s.; vaara, s.; poukkanen, m.; andersson, s.; pettilä, v.; pesonen, e.; xie, z.; liao, x.; kang, y.; zhang, j.; kubota, k.; egi, m.; mizobuchi, s.; hegazy, s.; el-keraie, a.; el sayed, e.; el hamid, m. abd; rodrigues, n. j.; pereira, m.; godinho, i.; gameiro, j.; neves, m.; gouveia, j.; e silva, z. costa; lopes, j. a.; mckinlay, j.; kostalas, m.; kooner, g.; dudas, g.; horton, a.; kerr, c.; karanjia, n.; creagh-brown, b.; forni, l.; yamazaki, a.; ganuza, m. sanz; molina, j. a. martinez; martinez, f. hidalgo; freile, m. t. chiquito; fernandez, n. garcia; travieso, p. medrano; bandert, a.; frithiof, r.; lipcsey, m.; smekal, d.; schlaepfer, p.; durovray, j. d.; plouhinec, v.; chiappa, c.; bellomo, r.; schneider, a. g.; mitchell, s.; durrant, j.; street, h.; dunthorne, e.; shears, j.; caballero, c. hernandez; hutchison, r.; schwarze, s.; ghabina, s.; thompson, e.; prowle, j. r.; kirwan, c. j.; gonzalez, c. a.; pinto, j. l.; orozco, v.; patiño, j. a.; garcia, p. k.; contreras, k. m.; rodriguez, p.; echeverri, j. e. title: esicm lives : part three: milan, italy. – october date: - - journal: intensive care med exp doi: . /s - - - sha: doc_id: cord_uid: qfecv h nan months is better than cole's formula. therefore, we conducted a retrospective analysis to investigate our hypothesis. methods: the ethics committee of our hospital approved this retrospective study. we included consecutive patients aged < years who underwent tracheal intubation under general anesthesia in our hospital from august to october . we collected the following data from the anesthesia records: age in months, height, weight, type of a tracheal tube, and id and od of tracheal tube. patients who were intubated using a cuffed tracheal tube or had incomplete data were excluded. we developed a regression formula for calculating id and od based on age in months and calculated the coefficient of determination r by using a regression analyses. a difference of . mm in the actual and predicted tube size was considered clinically permissible. then, we compared the rate of a clinical permissible estimation of the cole's formula and our new formulas used by multiple comparison analysis and a p value less than . was considered statistically significant. results: a total of pediatric patients received general anesthesia during the study period. of these, patients were excluded because they did not meet the inclusion criteria. finally, we included patients for this analysis. the regression formula for predicting id by based on age in months was id = . × age in months + . , and the coefficient of determination r was . . the regression formula for predicting od based on age in months was od = . × age in months + . , and coefficient of determination r was . . the rate of a clinical permissible estimation of our id and od formulas were significantly higher than that of the cole's formula ( %, % and %, respectively; p < . ). conclusions: our results showed that the prediction of id based on age in months is more useful than that using cole's formula. in addition, estimation of od based on age in months might be more rational because od varies according to the type of the tracheal tube used. these results should be confirmed in a future prospective study. introduction: survival among out-of-hospital cardiac arrest (ca) relies primarily on bystanders and their knowledge of basic life support (bls) manouvers [ ] . many medical societies and organizations recommend teaching bls at schools as part of the educative program [ ] ; being this a reality in north european countries, but not yet an education standard issue in others including spain. moreover, less is written about the perception of ca and cardiopulmonary resuscitation (cpr) among the general population, and even less in school age. objectives: describe the perception and knowledge about ca and cpr among a teenager school population in barcelona, spain. methods: prospective, descriptive study carried out between - and - among teenagers school population, based on surveys before and after bls -cpr classes. during this period , th classes were held, in different schools in barcelona. before attending the class , each pupil was asked to answer a survey with questions related to previous knowledge of sudden death, ca, and cpr, and their attitude towards them. the class consisted on a threehour theorical and practical instruction based on the european resuscitation council guidelines, adapted for laypersons. practices were held with an instructor (ratio instructor:pupil : [ ] [ ] [ ] , with the little anne mannequins (laerdal®). after the class, a new survey (post intervention) was distributed, with questions related to the new concepts and skills learnt, the attitude toward ca and cpr. results: we have instructed pupils ( . (± . ) years, . % female). the . % had heard about sudden death and ca before the class. regarding starting cpr: % said they were not capable of doing it, and . % suggested they would be able to do cpr but in a wrong manner. in a ca scene . % would contact the emergency service and start cpr, . % would call and wait, and . % would only do cpr. after attending the classes . % declared had understood the theorical concepts and practical skilles taught; . % would changed positively their attitude towards cpr; and . % would be prone to start maneuvers. conclusions: cpr and ca remain a well known issue among teenager population in barcelona, as long as being an interesting topic. nevertheless they do not feel capable of starting maneuvers. the concepts taught during the class were easy to learn , and after the intervention the majority were prone to start cpr. this population is adequate to teach cpr. introduction: to meet the need of patients family members and staff we started to guide visiting children at our adult icu in the st elisabeth hospital (ez) in tilburg years ago. to do so we developed a guidance leaflet for parents with practical instructions and information. additionally, practical advice is given, such as what to say to the child and what to expect when visiting. the leaflet is subdivided in developmental stages. furthermore we developed a book "mees op bezoek", in which a child visits his father at the icu. pictures show what children can expect, which helps prepare the child for visiting at home. an instruction box is present at the icu with icu materials such as an iv catheter, a pulse oximetry or a tracheal tube. these materials give children a tactile experience of the icu. the box is divided in two parts; the second part contains guidance materials for when a patient may die. pedagogical staff are available to support parents, children and staff. if there are more profound problems a referral to our children's psychologist is possible. we made some improvements to our waiting area to make it more appealing to children. we instructed and educated our nurses and doctors on how to use these materials and how to guide children. we recently merged with the twee steden hospital in tilburg (tsz), in this hospital there was no program to guide children. with the merger we also wanted to introduce our "child as a visitor program" at the icu on location tsz. we wanted to know if there were differences of opinion between the nursing staff on guidance of children. introduction: critically ill children are underfed early in their pediatric intensive care unit (picu) stay and this may contribute to worse outcomes. acute kidney injury (aki) occurs in % of all picu admissions and the risk of acute and chronic malnutrition is high in these patients with aki, and the presence of malnutrition in the context of aki has been associated with more severe clinical deterioration and organ dysfunction. critically ill children with aki are at high risk of underfeeding. objectives: to evaluate the effects of protein feeding on the resolution of aki. methods: this is a retrospective study of critically ill children admitted from / - / to the picu. patients with a diagnosis of end stage renal disease requiring renal replacement therapy or had received a kidney transplant were excluded. nutritional status assessed by weight and height who z-scores after admission and caloric and protein intakes calculated from i.v. fluids and parenteral and enteral nutrition for the first days of admission. energy and protein needs estimated by schofield and a.s.p.e.n., respectively. aki was defined by prifle (creatinine only) and persistent aki was defined as patients who did not resolve their aki during the first eight days of picu stay. introduction: sedation and analgesia are important components of postoperative management of neonates who underwent cardiac surgery. excessive or inadequate sedation may have a significant adverse effect on patient outcome. objectives. we aimed to determine which drug regimen would be most effective with less side-effect and better outcome. methods: from march till march we conducted a randomized controlled prospective study in neonates with congenital heart disease who underwent arterial switch operation in our clinic. inclusion criteria: ) gestational age more than weeks, ) birth weight over g, ) age -up to days, ) absence of concomitant diseases and surgical complications. patients were randomized into cohorts: patients ( %) were given infusion of dexmedetomidine with morphine boluses (study group) and patients ( %) were randomized to the standard regimen -infusion of morphine with diazepam boluses (control group). results: in both groups there were no differences in pre-and intraoperative indexes, duration of mechanical ventilation, sympathomimetic support, and time of infusion of dexmedetomidine/ morphine. in study group time of icu stay - . h -was significantly shorter than in control group - h (p- . ). onset of peristalsis and start of feeding in study group was earlier than in control group - st vs -d day (p- . ) and -d vs . -day (p- . ), respectively. in the control group there were more patients who had complicated feeding (start after -d day, bloating or vomiting) - ( %) vs ( %) in the study group. we did not observe any decrease of mean blood pressure and heart rate in the study group as it could be expected. conclusion: use of dexmedetomidine with morphine hydrochloride boluses for postoperative sedation and analgesia is effective and facilitates feeding process in neonates, leads to earlier onset of peristalsis and start of feeding, decreasing icu stay. impact of positive end expiratory pressure on cerebral hemodynamic in paediatric patients with post-traumatic brain swelling treated by surgical decompression s.m. pulitano' , s. de rosa , , a. mancino , g. villa , , f. tosi , p. franchi , g. conti introduction: asthma exacerbation is one of the most common diagnoses seen in the pediatric ed. several adult randomized controlled trials have shown that administration of high concentration oxygen leads to rise in carbon dioxide and increases admission rates. however, there are no studies in the pediatric population comparing the effects of high concentration oxygen versus titrated oxygen therapy in asthma exacerbation. objectives: we evaluated the effects of transcutaneous carbon dioxide (tpaco ) in high concentration oxygen therapy versus titrated oxygen therapy to maintain saturation between to % in pediatric patients with acute asthma exacerbation in the ed. methods: children to years with previously diagnosed asthma with moderate to severe asthma exacerbation (asthma score > ) were randomized to high concentration oxygen therapy ( % oxygen via face mask at > l/min.) or titrated oxygen therapy (titrated up from % via a blender continuously) to maintain saturations between to % while receiving their nebulized treatments. exclusion criteria included disorders with hypercapnic respiratory failure, unconscious patient, history of congenital heart disease, pregnancy, history of smoking or using sedatives and depressants. asthma therapy was provided per the ed physician. asthma score, tpaco , pefr (age > years) were measured at the start of the study and every minutes for the first hour then every minutes until disposition decision. the primary outcome was increase in tpaco with high concentration oxygen therapy. secondary outcome included rate of admission to the hospital. results: patients were enrolled with mean age of . years. % were males and % had poorly controlled asthma with mean asthma score of . . there were patients enrolled in the high concentration oxygen group (hcot) and patients in the titrated oxygen group (tot). the minute tpaco were not statistically different( . ± . hcot v. . ± . tot,p = . ); whereas, the minutes tpaco was statistically different( ± . hcot v. . ± . tot, p = . ). the minutes tpaco was . ± . hcot v. . ± . tot, p = . . at minutes, % of the patients had a rise in tpaco in hcot v. % in the tot(p = < . ), and at minutes % had a rise in tpaco in hcot v. % in the tot(p = < . ). the asthma score was similar in the two groups at minute ( . ± . hcot v. . ± . tot, p = . ); whereas, the minutes asthma score was lower in the tot( . ± . hcot v. . ± . tot, p = . ). the rate of admission to the hospital was . % in hcot v. . % in the tot. conclusions: high concentration oxygen therapy in pediatric asthma exacerbation leads to significantly higher carbon dioxide levels. it also causes rise in carbon dioxide from the baseline which increases the asthma scores and rate of admission. introduction: in critically ill patients, temperature measurement is a routine important care task and can lead to important decisions. rectal temperature and bladder temperature are now used as a continuous body temperature measuring method in the pediatric intensive care, but these practices have several disadvantages including the patient´s discomfort, the risk of organ injury and the inaccurate measuring caused by the sensor position. a new temperature monitoring system m tm spot-on tm (spoton) is a non-invasive zero-heat-flux thermometer designed to estimate core body temperature from the skin surface. although the usefulness and accuracy of spoton system in adult patients have been demonstrated, there are no reports on pediatric intensive care patients. objectives: the aim of this study was to evaluate the effectiveness of a new temperature measurement system attached to the forehead, and compare it to rectal temperature sensors in terms of correlation and accuracy. methods: pediatric patients weighing less than kg, who were managed in our icu during the period from february to march , were enrolled in this study. core temperature was measured and recorded at every minute from the both thermistor of a rectal thermal probe and with spoton in these patients. the data when the forehead sensor or rectal probe was taken out for nursing care was excluded from statistical analysis. results: sets of data of children (mean bw g) were examined retrospectively. in all patients, spoton showed higher than the rectal temperatures. the spoton temperature was analyzed to be . degrees ( % limits of agreement of ± . ) higher temperature than the rectal one with a moderate correlation(r = . ). discussion and conclusion: rectal temperature measurement is the gold standard method for pediatric patients in icu despite several complications of rectal injury. our children´s study demonstrated the slightly higher temperature in the spoton than rectal temperature with a substantial correlation. one possible explanation could be that the abundance of brain blood flow of children affected the results. our study concluded that spoton system could be used as a highly reliable noninvasive core body temperature measurement for small pediatric patients. introduction: viral bronchiolitis (vb) remains one of the leading causes of hospitalization in early childhood. despite the heavy burden of vb on the healthcare system, little is known about the incidence of acute respiratory distress syndrome (ards) in this cohort of patients. in , the pediatric acute lung injury consensus conference (palicc) published guidelines for the definition, management and research in pediatric ards (pards) ( ) . objectives: to study the incidence and prevalence of pards in vb and to study the association between pards and specific picu outcomes such as incidence of mechanical ventilation, noninvasive ventilator settings length of picu stay in this group of patients. methods: this is a retrospective single center observational cohort study that examined children - years of age admitted to the picu with vb and respiratory failure (rf) from - . palicc criteria were applied to define pards. clinical and demographic data was collected. patients with a diagnosis of congenital heart disease or pre-existing chronic lung disease were excluded. data was expressed as median with iqr ranges. test of bivariate association were performed using mann whitney u test and chi square test. a two tailed p value of ≤ . was used to denote statistical significance. results: out of patients with rf, with vb met study criteria. eighty of these ( %) patients admitted for vb met the criteria for pards or at risk for pards. out of these patients, ( %) met criteria for pards and ( %) met criteria for "at risk of pards". median age was ( , ) months and the median weight was . ( . , . ) kgs. most common etiology for vb was respiratory syncytial virus (rsv) % followed by rhinovirus ( %). there was no statistically significant difference in age, weight, and etiology of vb in patients with pards and those "at risk of pards." patients with pards had longer hospital and picu length of stay (los) and more likely to receive diuretics compared to those "at risk for pards" ( ( , ) vs ( , . ) , p = . ; ( , ) vs ( , . ), p < . ; and % vs %, p = . respectively). nineteen ( / , %) patients with pards received invasive mechanical ventilation with a median duration of ventilation of ( , ) days. conclusions: almost a quarter of children with vb developed pards or were at risk of pards. the presence of pards in children with vb was significantly associated with longer picu and hospital los compared to those "at risk of pards". children with vb are a high risk group for the development of pards. introduction: mean platelet volume(mpv) seems to be a marker of platelet activation and may be related to severity of illness. changes in mpv and platelet count(plc)could be used for disease prognosis and mortality in icu patients. we hypothesized that mpv changes and plc could be used as prognostic tools in pediatric surgical intensive care units(psicu). objectives: to study the association between mpv changes and mortality and morbidity in psicu. also to study the relation between plc and psicu mortality and morbidity. methods: this descriptive observational study was conducted on consecutive pediatric surgical patients who admitted to psicus at cairo university hospitals starting from / - / / .after approval by research ethics committee,informed consents were obtained from parents and pediatric cases aged from month- years and stayed for > h were enrolled.mpv and plc were obtained and recorded at baseline(preoperative values),on the day of icu admission(day ), st , nd , rd , th and th days.to measure daily mpv changes; (Δmpv) was constructed and computed where Δmpv = ([mpvday(x) − mpvday ( )]/mpvday( ) × %. pediatric index of mortality(pim)score was calculated on day and the pediatric logistic organ dysfunction(pelod)score was recorded daily. results: patients who developed icu complications (fever, sepsis, pneumonia, required mechanical ventilation, needed vasopressors or blood transfusion); showed higher Δmpv compared to non complicated cases (fig. ) . this association was statistically significant on days (p value = . ), (p value < . ), (p value < . ) and (p value = . ) of icu stay but it´s insignificant on day (p value = . ).according to receiver operating characteristics(roc) curve analysis, the sensitivity of Δmpv to detect complications on day was . % but its specificity on day was . %.patients who developed icu complications showed lower plc compared to non complicated cases (fig. ) .this association was statistically significant on days (p value < . ), (p value < . ) and (p value < . ) but it was insignificant on day (p value = . ), (p value = . ) and (p value = . ). on other hand, the sensitivity of plc to detect complications day was . % but the specificity was . %, while the sensitivity of plc to detect complications day was . % but the specificity day was %. conclusions: mpv dynamics and plc have prognostic roles and could be used in determining several complications in critically ill pediatric surgical patients. plc is a more specific and sensitive tool to detect complications than mean mpv dynamics. introduction: limited information exists regarding the association between functional status at icu admission at and outcomes. objectives: we hypothesized that initial functional status assessment as well the amount of physical therapy delivered would be associated with outcomes in icu survivors. methods: we performed a retrospective cohort study in one boston teaching hospital on , adults who received critical care from to and survived hospitalization. all patients had a formal evaluation by a physical therapist in the week prior to icu admission and at hospital discharge. the exposure of interest was functional status determined by a licensed physical therapist based on the functional mobility sub scales of the functional independence measure. all patients received physical therapy to improve functional performance. the primary outcome was -day all-cause mortality. we used logistic regression to describe how -day mortality differed with functional status at icu admission. negative binomial regression was utilized to describe how functional status at hospital discharge differed with functional status at icu admission, the extent of physical therapy received and hospital length of stay. results: the cohort was % male, % non-white and had a mean age of . years. % of the cohort had sepsis, % had acute kidney injury, % had respiratory failure and % were surgical cases. the median [iqr] hospital length of stay was [ , ] days. the -day mortality rate was . %. functional status at icu admission was robustly associated with -day mortality. in a logistic regression model adjusted for age, gender, race, surgical patient type, deyo-charlson index, acute organ failure, sepsis, length of stay and the extent of physical therapy received, the second lowest and lowest quartiles of functional status at icu admission was associated with a . in critically ill patients, decreased functional status at icu admission is associated with increased -day mortality. increased intensity of physical therapy is associated with improved mortality outcomes. both functional status at icu admission and the intensity of physical therapy contribute to functional status determined at hospital discharge. introduction: patients admitted to critical care are shown to lose significant muscle mass, with the degree of muscle loss as high as % in the first week for those in multi organ failure (puthucheary, ) . early rehabilitation has been demonstrated as a safe and effective method of improving functional status at the point of critical care discharge and reducing both icu and hospital length of stay (mcwilliams et al., ) , although the specific impact of this on muscle mass has not been reported. objectives: this study aimed to analyse the impact of enhanced physiotherapy incorporating early mobilisation on the rate of muscle decline for patients admitted to critical care. methods: patients admitted to a large uk teaching hospital during the trial period and ventilated for ≥ days were included in the study. patients were randomised to either enhanced physiotherapy or standard care groups as part of a larger rct. baseline measurements were taken on the day of recruitment and then repeated at critical care discharge. muscle mass was measured using ultrasound to calculate cross sectional area of quadriceps and biceps. to ensure validity , measures were taken and the average of these taken as the final value. all scans were reviewed for agreement by therapists trained in muscle ultrasound. results: patients were included in the analysis. patients in the enhanced physiotherapy group mobilised earlier and achieved a higher level of mobility at the point of critical care discharge (see table .) all subjects demonstrated a reduction in muscle mass of both quadriceps and biceps over the course of their critical care stay. the extent of muscle loss was however lower in those receiving the enhanced physiotherapy, although this did not reach statistical significance (quads % vs %. p = . ; biceps % vs %, p = . ). conclusions: a programme of enhanced physiotherapy appeared to be associated with a lower rate of muscle loss in both biceps and quadriceps in comparison to standard care. an appropriately powered rct is required to assess these findings. introduction: survivors of critical illness experience a range of impairments after intensive care, including physical, cognitive and psychological compromise. the provision of information using a diary to describe the intensive care unit (icu) experience is one strategy that has been proposed to improve psychological health. objectives: the purpose of this study was to explore similarities and differences in patients' and relatives' perceptions of information containing strategies, including icu diaries, to assist recovery after critical illness. methods: an exploratory mixed-methods study was undertaken in an australian tertiary hospital with general icu patients admitted for ≥ days and their relatives. semi-structured interviews were conducted - months after icu discharge. transcripts were analysed using content analysis. results: twenty-two patients and relatives consented to participation and completed interviews prior to reaching data saturation. patients were usually male ( %) and aged ± years. patients raised similar themes to relatives, although with diverse opinions. themes of wanting to have a diary kept and considering they would find a diary helpful were consistent across a majority of participants, although with a minority expressing a desire to 'move on' and would not have liked a diary kept. differences between patients and relatives arose in the areas of the purpose, content, ownership and timing of delivery of a diary. patients viewed the diary as a therapeutic tool while relatives considered it as an information sharing mechanism, including as a mechanism to demonstrate to the patient 'how sick he really was' and 'what he put us through'. possibly as a result of these differences, patients considered that ownership of the diary rested with them while some relatives envisaged shared ownership. patients were more likely to note that the diary should not be provided to them until some weeks after icu while relatives considered an early time point soon after icu discharge to be appropriate. patients were more likely to raise concerns about the potential negative impact of information sharing strategies including diaries and return visits to the icu. conclusions: patients and relatives expressed common themes related to information sharing strategies after icu, but with some important differences. differences in purpose, content, ownership and timing of delivery of a diary suggest there is a need to consider whether the same intervention meets the needs of both groups of stakeholders. introduction: in the intensive care unit (icu) several patients are disturbed in their cerebral function due to their critical illness and medication, leading to discomfort, agitation, restlessness, pain and delirium. rocking chair mobilization therapy (rcmt) is a chair with good seating comfort which gives rhythmic movements. rocking chair studies have shown concrete results to improve patient satisfaction, balance and well-being in patients who suffered from dementia ( ) . however, no studies have evaluated the value and the effect of rcmt for critically ill patients in the icu. objectives: the purpose of the study was to evaluate whether rcmt could be used in the rehabilitation of critically ill patients in the intensive care. the focus was to explore the impact of rcmt on critically ill patients comfort, pain, agitation and delirium. methods: the evaluation took place in a medical/surgical icu in denmark in the period from may to july . patients ≥ years, who were physically stable and had the ability to be mobilized to chair could participate in the evaluation. the rcmt session lasted minutes.each session with rcmt was evaluated by registration of patient consciousness (richmond agitation and sedation scale (rass)), pain (numeric rating scale (nrs) - or by critical-care pain observation tool (cpot)), delirium (cam-icu) before and after the session. patient comfort was assessed by the patients as well as by the nurses during the session. results: sessions with rcmt were evaluated. males and females, age between and years, participated in the evaluation. the results showed a decrease in patient agitation level and an increase in patient consiousness. patients´with rass > decreased from before the session to after the session. patients with rass ≤ − decreased from before the session to after the session. a decrease in delirium where patients were assessed cam-icu positive before the session and patients after the session. a decrease in pain where six patients scored nrs > before the session compared to one patient after the session and patients had cpot scores > before the session compared to patients after the session. assessment and evaluation of comfort by patients themselves and by the nurses, who cared for the particular patient, showed that rcmt was associated with a high degree of patient relaxation and comfort. conclusions: promising results gives reason to recommend rcmt for critically ill patients in the icu, as an alternative holistic nonpharmacological intervention to stimulate patients´bodily awareness and enhance patient comfort and rehabilitation. introduction: critical illness and immobility in the intensive care unit (icu) lead to a loss of muscle mass and reduced exercise capacity for many years following hospital discharge. [ ] nutritional management of the critically ill is challenging and most nutritional studies are focused in this period. nutritional recommendations are for a high protein diet to minimise muscle breakdown and support protein synthesis during rehabilitation. nevertheless, during the rehabilitation period little is known of patients' protein intake and physical functioning. objective: to investigate physical functioning, frailty and dietary protein intake after months of icu discharge. method: our icu is recognised as a therapy rehabilitation centre and the only icu member of the uk rehabilitation outcomes (uk-roc). patients cognitive and physical functioning is assessed as part of their rehabilitation therapy with the functional independence measure (fim) score [ ] . the fim contains items on motor ( ) and cognitive ( ) functions that are scored on a -point ordinal scale based on the amount of assistance a person requires to perform specific activities. the fim scores on icu discharge and also on return to the rehabilitation clinic after months were assessed. in addition, frailty was assessed based on a scale ranging from very fit to very severely frail, terminally ill [ ] and patients were asked to complete a protein food frequency questionnaire. results: twenty patients were assessed. data are reported as mean and (standard deviation). patients were male % and . years ( . ). paired t tests of the changes in fim scores from discharge showed significant increments; . ± . (p = . ) and . ± . (p < . ) for motor and cognitive scales respectively. nevertheless, patients reported that they were "vulnerable to moderately frail" in the frailty scale. dietary intake was also inadequate with a protein intake of . g/kg ( . ). objectives: physiotherapy rehabilitation is a recognised component of icu care. the intensive care society -core standards recommends that rehabilitation is 'at a level that enables the patient to meet their rehabilitation goals for as long as they…are able to tolerate it'. in order to investigate and measure the terms 'tolerate' and 'level', physiological measurements and their relationship with self-perceived exertion and tolerance were analysed. methods: the project was registered with guy's & st.thomas' nhs foundation trust, clinical audit group, (project no. ). a convenience sample, of icu patients undergoing active physiotherapy led rehabilitation, were observed between july and september . a modified exertion scale was used to measure patients' perceived effort. patients also rated tolerance of the session using a tolerability scale, created based on the exertion scale. sessions were timed, heart rate, blood pressure and oxygen saturation were monitored and the cardiovascular impact of the session measured using heart rate reserve (hrr). results: nine rehabilitation sessions were observed; mean length of minutes (range - ). minimum target hrr (> %) was achieved, but not sustained, by patients, while peaked within a normal target hrr ( - %). of the patients, were able to use the tolerability scale and the exertion scale. there did not appear to be a relationship between hrr and either perceived scale measurements. there did appear to be a link between perceived exertion and perceived tolerability with of the patients scoring within points. conclusions: reported perception of exertion and physiological markers could both indicate the 'level' patients are working at. we were able to measure effects of rehabilitation on heart rate. the majority of patients were able to use exertion and tolerance scales. however, the change in heart rate was not great enough to suggest a training effect, despite their exertion scores implying high effort levels. to fulfil the icu society recommendations, a good understanding is needed of how hard patients are working during rehabilitation. further research is needed to determine why there may be disparity between heart rate and patient-reported measures of exertion; and if either is a useful guide for exercise prescription with icu patients. introduction: critically ill patients are at risk of developing deconditioning, muscle atrophy and functional impairments long after hospital discharge. there is evidence demonstrating benefits of mobilization in critically ill patients -improved functional outcome and reduced icu and hospital length of stay. however, there is limited information about how these advances are translated to clinical practice. objectives: to obtain a baseline data on patients who are eligible for mobilisation in icu and how many of these patients are optimally mobilised in icu. this would enable us to undertake a clinical practice improvement project (cpip) using the plan-do-study-act (pdsa) implementation strategy to optimise mobilisation in at least % of all eligible icu patients. methods: setting. -bedded intensivist led closed surgical icu. the mobilisation team composed of physiotherapists, bedside nurses and respiratory therapists who worked along with an intensivist. prospective audit conducted to collect data on the patients who met the eligibility criteria of mobilisation over a -month period. cpip team results: our audit revealed that at baseline, only % of all eligible patients were optimally mobilised. rca revealed a total of barriers and through multi-voting and pareto-charting, we identified the top barriers to change. key barriers identified were: . mobility not being a part of the daily review routine . staff were unsure of the eligibility criteria . lack of knowledge the benefits of optimal mobilisation in the critically ill. the team proposed following strategies to overcome the barriers: . combined icu multi-disciplinary handover rounds with the lead consultant asking the question "can this patient be mobilised?" for every patient reviewed. . providing a bedside decision-making algorithm on eligibility criteria, displayed within visibility of staff's work area. . undertake sharing session with ground staff on the importance and benefits of optimising mobility of the critically ill. conclusions: our audit revealed that less than half of eligible patients received early mobilisation. our cpip -a quality improvement initiative identified barriers in translating knowledge into clinical practice. through various tools of cpip, we identified the key barriers and strategies to overcome these barriers and thereby achieving the goal of optimising mobilisation in icu patients. introduction: bed rest and immobility during critical illness may result in profound physical deconditioning. the multidisciplinary team in intensive care includes physiotherapists, who are responsible for performing diagnoses and procedures for critically ill patients, such as ventilation, respiratory monitoring and assessments of musculoskeletal, neurological, metabolic and cardiovascular diseases, and for the prevention and treatment of the effects of prolonged immobility. objectives: to evaluate the influence of physiotherapy on quality indicators in the intensive care unit of the sagrada esperança clinic in luanda, angola. methods: a retrospective before-after study was designed to assess some quality indicators within the intensive care unit between july and september , where there were no physiotherapists specially trained for respiratory care, and from january to march , where the physiotherapists integrated a multidisciplinary team. the quality indicators analyzed were: the average duration of mechanical ventilation, prevalence of ventilator associated pneumonia and the rate of ventilated patients with non-invasive ventilation. the study population comprised patients for and for . in this study the patientsć ategorization was made by age, sex, pathology and also according with the patient classification systems saps and sofa. the statistical analysis used the systems spss version for a % significance level. results: the results obtained after analyzing the two homogeneous groups according to age, gender, type of admission and severity influencing the physiotherapy care in icu quality indicators, in the sagrada esperança clinic, highlights the decrease of the average number of days with mechanical ventilation but it is not observed a significant relation between physical therapy and this indicator (p = : ). furthermore, it is also observed a decrease ventilator associated pneumonia, and a significant relation between this indicator and the respiratory physiotherapy. last, there is a strong relation between the increase on the number of patients without invasive ventilation and physiotherapy (p = . ). conclusions: in this study it is demonstrated the respiratory therapy influences in some quality indicators, namely regarding the reduction of ventilation associated pneumonia and the promotion of non-invasive ventilation in the icu of the cse. introduction: the incidence of candidemia has increased in icu patients ( ) . in addition, there are differences in epidemiology among different countries. we have previously shown an increased proportion of nonalbicans candida species in our icu ( ) . objectives: to identify the variables associated with candidemia due to non-albicans candida species, as well as with fluconazole-resistant strains in a multidisciplinary icu. methods: all icu patients with candidemia were prospectively studied over two time periods ( - and - ) . demographics, illness severity, clinical and laboratory variables were recorded. sofa score value on icu admission subtracted from the value on the day of candidemia occurrence was defined as delta sofa. patients with c. albicans candidemia were compared to those with non-albicans candidemia. also, patients with fluconazole-resistant candidemia were compared to those without fluconazole resistance. results: among patients with icu-acquired candidemia, in patients candidemia was due to c. albicans and in patients to non-albicans species. c. parapsilosis was the most common ( %) followed by c. albicans ( %). the median time from icu admission to candidemia onset was and days for c. albicans and nonalbicans respectively, p = . . similarly, the median time for candidemia due to fluconazole sensitive isolate was days and days for fluconazole resistant, p < . . resistance to fluconazole was % and % in c. albicans and in non-albicans species respectively, p < . ).presence of shock on candidemia day (or . ; ci: . - , p = . ) and the delta sofa score (or . ; ci: . - . , p = . ) were independently associated with candidemia due to c. albicans. independent risk factors for fluconazole resistant isolates were the length of icu stay before the development of candidemia (or . ; ci: . - . , p = . ) and the presence of shock on candidemia day (or . ; ci: . - . , p = . ). previous fluconazole exposure ( patients) was not associated with fluconazole resistance. conclusions: this study confirms the predominance of non-albicans candida species, in our icu patients with candidemia, with high prevalence of fluconazole resistance. early onset of candidemia and the presence of shock were most likely due to c. albicans whereas late onset was associated with fluconazole-resistant non-albicans species. these findings may be of value for empiric antifungal treatment selection. introduction: invasive aspergillus infections are well-known complications of immunocompromised states, chronic obstructive pulmonary disease and haematopoietic stem cell transplant. bacterial coinfection is well described in influenza literature but there is scarce data on invasive aspergillosis complicated severe influenza infection. objectives: the aim of this study is to describe the clinical and demographic characteristics of patients with aspergillus isolation in severe influenza a(h n ) pneumonia. methods: prospective, observational, multicenter study conducted in spanish icus from to . all individuals with severe primary influenza a(h n ) pneumonia requiring invasive mechanical ventilation were included in the study. influenza a(h n ) patients without coinfection were compared with those with aspergillus isolation in respiratory samples. all serotypes were confirmed using rt-pcr at icu admission. patients´demographic, clinical, radiologic features, laboratory values, icu and hospital length of stay (los) and outcomes were recorded. discrete variables are expressed as counts (percentage) and continuous variables as medians with th to th interquartile range (iqr conclusions: the mortality rate was significantly higher in h n patients with aspergillus isolation in respiratory samples. diagnosis of invasive aspergillosis in critically ill patients in the post-influenza era must be re-evaluated. clinical studies should be conducted in order to know the clinical significance of aspergillus isolation in respiratory samples in intubated patients with primary influenza a(h n ) pneumonia. methods: this prospective, monocentric, study performed over months assessed the value of a twice weekly dosage of fungal biomakers (candida serology iga, igm, igg, ß-d-glucan (bdg) and mannan antigens) in icu patients after lt. proven/probable/possible infection was defined according to the eortc/msg criteria. colonisation was defined by presence of candida sp in respiratory samples without any sign of invasive infection. the study was approved by the ethical committee. results are presented as means. results: we analysed icu patients after lt. % had a candida sp colonisation while an invasive infection was proven in ( %) patients. candida albicans was cultured from % of the pulmonary samples. % of the invasive infections were related to c. glabrata. results of biomarkers dosages are presented in the table. positive candida igg serology was observed in % of the cases. mortality rate at -months after lt was % in the immunised patients versus % in nonimmunised patients. an invasive candidiasis (ic) was present in % of the immunised patients versus % in non-immunised patients. at least one bdg dosage was positive in % of the cases. bdg dosage value decreased after surgery, reaching a non-significant value after the th day. in proven ic, bdg measurements reached concentrations > pg/ml, days before initiation of antifungal treatment. no patient had positive mannan antigen measurement. conclusions: a twice weekly dosage of bdg seems to be useful in the decision making process for early initiation of antifungal therapy in lt patients. the cutoff for a significant value of bdg needs to be defined. pre-transplantation assessment of candida igg serology could help to identify patients at risk of post-operative fungal infection. introduction: the antifungal (af) therapy strategy (pre-emptive vs culture based treatment) in intensive care unit is a matter of debate [ ] . the necessity to not delay the initiation of the af in invasive candidiasis (ic) must be balanced with the cost and risk of selecting resistant pathogens when af are prescribed too widely. burn patients are at risk of ic because of the frequent use of antibiotics and immunodeficiency. objectives: to evaluate our antifungal (af) therapy strategy in suspected or proven ic in terms of prognosis and risk factors of ic. methods: observational, descriptive, retrospective study conducted from june to september in the saint louis hospital burn unit. inclusion criteria: patients treated with pre-emptive (severe sepsis or septic shock with candida sp colonization) or curative (proven, pic) af. the outcome was the pic (candidemia and/or positive peritoneal sample). clinical characteristics, organ supports, af treatments and outcome were collected and compared between pic and suspected ic (sic). the results are presented in median (iqr) or n (%). results: patients were admitted during the study period including with a total body surface area (tbsa) > %. treated with af including pic ( %). in those patients: age ( - ), tbsa ( - ), sapsii ( - ), absi ( - ) and sofa ( - ). renal replacement therapy ( %), mechanical ventilation ( %), parenteral nutrition ( %). inhospital mortality = % ( % sic vs % pic, p = . ). patients with pic ( %) were treated before the ic diagnosis ( because of filamentous infection before the pic). the delay between admission and af treatment initiation was days. patients characteristics, organs supports were not significantly different between pic and sic at the treatment initiation except for the sapsii (pic ( - ) vs sic ( - ), p = . ). patients ( %) received an echinocandin as a first-line treatment. ( . - . ) sites were monitored for candida colonization the week before treatment initiation. patients with pic had higher colonization index than those with sic ( % vs %, p = . ) and a candida score significantly higher ( vs ( . - . ) respectively, p = . ). a semiquantitative estimation of the fungal inoculum had no predictive value. conclusions: in this study, the majority of pic were treated after diagnosis confirmation. only / ( %) patient treated preemptively did declare a pic. the outcome was not different when the treatment was initiated after confirmation. the results of this study highlight the difficulty to identify patients at highest risk of ic, and question the strategy of preemptive treatment in this population. objectives: we wanted to determine whether pct guided antibiotic rationalisation could reduce fungal colonisation and antifungal usage. methods: we undertook a retrospective observational study at a nine bedded icu department in the united kingdom. we collected data on all patients admitted to the unit in the year prior and post the introduction of pct guided rationalisation of antibiotics. we used the pharmacy database to assess the use of antibiotics, correcting for changes in costs over this time. we used the microbiology database to assess the rate of patients colonising fungal species and those requiring treatment. results: since the introduction of pct, the average expenditure on antibiotics per icu admission fell . % (p . ). the rate of icu patients colonised with a fungal species fell from . % to . % (p < . ). the incidence of patient's prescribed systemic antifungal therapy fell from . % to . % (p < . ). conclusions: we demonstrated a significant reduction in patients colonised with fungal species and those requiring anti-fungal therapy since introducing pct guided rationalisation of antibiotics. a prospective randomised controlled trial is required to assess whether this equates to improved patient outcome. ), median days. c. albicans was the most commonly isolated species (sp) ( , %), candidemia was the most common diagnosed infection. the sp isolated in blood cultures (bc) were: , % c. albicans, , % c. haemulonii, . % c. parasilopsis. we had + bc for trichosporon asahii. catheter -related infection by c. albicans, c. parasilopsis, and candida haemulonii was diagnosed in patients. positive urine samples were found mostly for c. albicans . %. the most frequently factors associated with fungal infection were: > than days in the icu . %, urinary catheter . %, broad-spectrum antibiotic exposure . %, indwelling central venous catheter (cvc) . %, feeding tube . %, total parenteral nutrition . %, invasive mechanical ventilation . %. to highlight an association with acinetobacter baumannii in . % of our patients. doctors chose fluconazole in . % as a first line of therapy. an antibiogram was performed and the susceptibility was confirmed. icu mortality rate, . %. conclusions: in our environment, c. albicans continues to be the species that causes the largest number of invasive candidiasis. prolonged stay in the icu is an important risk factor to develop fungal infections. even with the particular features of a burn patient, their complexity, and the negative impact of each infection; fluconazole keeps having an important role in the treatment as a first line. the effect of introduction of daily chlorhexidine bathing on healthcare-associated infections and acquisition of multi-drug resistant organisms e. ahmadnia introduction: it has been suggested that daily bathing with chlorhexidine impregnated cloths may significantly reduce the acquisition of multi-drug resistant organisms (mdros), incidence of central line associated bloodstream infections (clabsis), and the development of intensive care unit (icu) acquired bloodstream infections [ ] . however, more recent data have failed to support daily bathing of critically ill patients with chlorhexidine for these purposes [ ] . objectives: to determine if the implementation of a daily chlorhexidine bathing regimen affects acquisition rates of mdros, the incidence of clabsis, and icu bacteraemias. methods: a quality improvement project was conducted at a bedded adult critical care unit within a uk university hospital (incorporating major trauma, medical, and surgical patients). during the year control period (december to november ), all patients were bathed using soap and water. during the subsequent intervention period (december to november ), all patients were bathed using % chlorhexidine impregnated cloths (clinell, gama healthcare). the acquisition of mdros, incidence of clabsis and icu bacteraemias were recorded during these periods ( months pre-and months post-chlorhexidine for clabsis, one year for the other outcomes). results: the study covered patient bed days ( pre-and post-introduction of chlorhexidine bathing). there were an identical number of mdro acquisitions in each group ( ), giving rise to an mdro acquisition rate per bed days of . in the control group compared to . in the chlorhexidine group (p = . ). clabsi incidence per bed days was higher in the control group compared to the chlorhexidine group ( . vs . ; p = . ). the incidence of significant bacteraemias per bed days was similar in the the two groups ( . before and . during chlorhexidine bathing; p = . ), but the incidence of bacteraemias due to skin commensals per bed days was lower in the chlorhexidine group ( . vs . ; p = . ). conclusions: at our large university hospital icu with a heterogeneous patient population, the introduction of routine daily chlorhexidine-impregnated cloth bathing appears to significantly reduce the incidence of bacteraemias due to skin commensals and demonstrates a non-significant reduction in clabsis. given the uncertainties surrounding diagnosis in the icu, the effect seen may be of benefit in reducing the use of antibiotics to cover for these skin commensals -both in terms of antibiotic stewardship and health economics. introduction: the current cdc guideline published in for the prevention of intravascular catheter-related infections recommends skin preparation with a greater than . % chlorhexidine with alcohol solution before cvcs or acs placement and with dressing changes, which was changed from % chlorhexidine recommended in the guideline. however, few studies investigated the superiority of % chg over either . % chg or % pvi for the prevention of catheter colonization as cdc guideline recommends. objectives: efficacy comparison of three antiseptic solutions [ % aqueous povidone-iodine (pvi), and . % and . % alcoholic chlorhexidine gluconate (chg)] for preventing intravascular catheter colonization. this was a open-label, multicenter, prospective, randomized controlled trial conducted at icus in japan. the intravascular catheters included central venous catheters (cvcs) and arterial catheters (acs). patients aged > years of age undergoing cvc and ac insertion in icu were randomized to receive one of three antiseptic preparations pre-insertion. catheters were removed when no longer necessary or if catheter-related infection was suspected. after catheter removal, distal tips were cultured using semi-quantitative/ quantitative techniques. catheter colonization and catheter-related bloodstream infection (crbsi) incidences were compared. results: while a total of catheters were randomized, several catheters were excluded due to withdraw of their informed consent and lack of cultured catheters after randomization, and ( %) catheters were included in the full analysis ( . % chg n = , . % chg n = , and % pvi n = ). the median catheterization duration was . days ( % ci: . - . days); no significant intergroup differences were observed (p = . ). catheter-tip colonization incidence (per catheter days) was . , . , and . events in % pvi, % chg, and . % chg groups, respectively (p = . ). catheter colonization risk was significantly higher in the % pvi group. no significant intergroup differences crbsi probability were observed introduction: spontaneous intracerebral hemorrhage (ich) is the most fatal stroke subtype worldwide caused by spontaneous vascular rupture due to hypertension or amyloid angiopathy. an accurate prediction of ich outcome would assist both families and physicians to decide therapies and monitorization at an early stage. objectives: to evaluate the relationship between the hematoma volume and location with mortality and functional outcome in patients with spontaneous ich. methods: we performed a prospective observational study, included patients admitted in icu with spontaneous ich. we determined hematoma volume at admission with kothari modified formula (axbxc/ ) and divided them in two groups according the location as infratentorial or supratentorial. we collected gcs, sofa, apache ii and graeb at admission, medical history and complications during the first week in the icu. we established modified rankin scale (mrs: poor outcome > ) and glasgow outcome scale (gos, poor outcome < ) at icu discharge. we used %, mean (sd) and median (minimal/maximum). t-student and χ (p < . ) were used for the univariable analysis. we conducted a multivariable analysis for mortality with binary logistic regression ( % ci, or) p < , . roc curve was determined for the volume of hematoma associated with mortality (ic % p < . ). results: we enrolled patients. % were men, mean age (± . ) years. global mortality was . %. . % were supratentorial and . % infratentorial. mean apache ii (± , ) and gcs . (± , ) and median sofa ( - ) and hematoma volume , cc . there were no significant differences between the two groups (infra and supratentorial) except ich volume (p . ) and length of stay (los)-icu (p . ). in the univariable analysis worse outcome with mrs was related with the volume of the hematoma (p , ) but not with gos (p , ). variables associated with mortality: gcs (p . ), apache ii (p . ), graeb (p . ), sofa (p . ), los-icu (p . ) and ich volume (p . ). after the multivariable analysis we determined hematoma volume was an independent risk factor for mortality (or , ; % ci , - , ; p . ). according the location we obtained a significantly association with mortality in the supratentorial group (p , ). we performed a roc curve of this group and obtained an auc , ( % ci , - , ; p . ) with cutoff point of , cc . conclusions: hematoma volume and los-icu are greater in supratentorial ich. the hematoma volume is associated with a worse outcome at icu discharge and a supratentorial ich volume above . cc is related to higher risk of mortality. introduction: aneurysmal subarachnoid hemorrhage (sah) is an acute cerebrovascular event, which leads to devastating consequences, high mortality and is an important cause of neurologic disability among survivors. incidence is reported between to / and mortality rates vary widely, ranging from to % among different authors. many complications associated with sah, such as delayed cerebral ischemia or hydrocephalus, also play a role in the poor functional outcome in survivors. paulo niemeyer state brain institute is a reference and high-volume center for sah, located in rio de janeiro, brazil, receiving patients from all over the state. objectives: the aim of the study was to describe the characteristics of patients with sah admitted to the icu, as part of a large prospective ongoing study, and to evaluate the factors associated with outcome. methods: from july to march , every patient admitted to the icu with aneurysmal sah, years and older was enrolled in the study. data were collected prospectively during hospital stay. the primary endpoint was mortality and dichotomized functional outcome, (poor outcome defined as modified rankin scale - ) at hospital discharge. results: a total of patients were included. the median age was ( - ), patients ( %) were female. demographic characteristics are presented in tables and . twenty-nine patients ( %) were treated by clipping, and patients ( %) were hydrocephalic and needed an evd. an intracranial pressure monitor was inserted in patients ( %). nine patients ( %) developed sepsis or septic shock during icu stay and pneumonia was present in ( %) patients. rebleeding was diagnosed in patients ( %), vasospasm was present in ( %) patients, post-surgical deterioration was diagnosed in ( %) patients and ( %) patients developed dci. twenty-two ( %) patients were mechanically ventilated. hospital mortality was % ( patients); and patients had unfavorable ( %). in univariate analysis, factors most frequently seen in patients with unfavorable outcome were rebleeding ( % vs %, p = . ), vasospasm ( % vs %, p = . ), post-surgical neurological deterioration ( % vs %, p = . ), dci ( % vs %, p = . ) and pneumonia ( % vs %, p = . ). although not statistically significant, there was a trend towards the association between sepsis/septic shock ( % vs %, p = . ) and unfavorable outcome. conclusions: sah is associated with high morbidity. neurological complications such as rebleeding, vasospasm, post-surgical neurological deterioration and dci, as well as clinical complications (eg. pneumonia) were associated with unfavorable outcomes. therapeutic interventions to prevent neurological and systemic complications may have an impact on clinical outcomes. introduction: the management of patient into the icu after been submitted to a cns resection is an important challenge. surgery is indicated for diagnosis, to reduce tumor bulk and to manage raised intracranial pressure. primary brain tumors are classified based on their cellular origin and histologic appearance. the most common malignant brain tumor is glioblastoma multiforme, this group have a poor prognosis. objectives: the goal was to make a descriptive analysis about the evolution of patient submitted in the icu for postoperative control following a surgical resection of intracranial tumors. methods: a retrospective and observational study was conducted on all elective consecutive surgical procedures for tumor resection admitted into the icu. we analyzed variables related with the tumor, predisposing pathology, surgical data and evolution in the icu. we considered as an unfavorable evolution the death into the first month after the intervention or the decrease in two points or more of the canadian´s scale score (css). is a comparative study analyzed by student´s t-test, anova of one factor and pearson´s chi-square test. comparative study expressed by: mean difference, relative risk and confidence intervals at %. results: we analyzed patients over of years ( - ) . of the total, . % are high-grade gliomas, . % low grade gliomas, , % meningiomas , . % metastasis and . % other type of tumors. average age is . years (sd . ), it is significantly lower in the low-grade gliomas, and in the group of other tumor types compared to other groups. . % are men , the most common in men ( . %) and meningiomas and other tumors in women ( . % and . % respectively) gliomas. . % are supratentorial location. average size is . ml (sd . ) . the average score in the preoperative karnofsky scale is . (sd . ) . the average income apache is . points (sd . ). an unfavorable evolution is observed in . % of patients ( . % per patient died and . % decline in the css) after one month , with no differences between different types of tumors. the percentage of deaths in the first month is higher in those undergoing surgery for metastasis ( . %, rr . , ci . to . ) . mortality at two years of intervention is . %, being higher in sifnificativamente undergoing metastasis ( %; relative risk . , ci . to . ) and high-grade gliomas ( . %; relative risk . , ci . to . ). conclusions: patients undergoing brain tumors have a significant risk of poor outcome , which is significantly higher in metastatic patients from the first month of intervention and in patients undergoing high-grade gliomas at two years. introduction: nosocomial infection (ni) is still an issue in neuroritical care. objectives: we analysed ni in a preventive multimodal protocol in patients with acute brain disease. method: we performed a -year prospective observational cohort study in patients (pts) with acute brain disease admitted to an eight-bed adult neuro-intensive care unit (nicu). we defined our preventive multimodal protocol as: ) keeping a hygienic and epidemiological regime including isolation of pts with multi-drug resistant bacteria ) correct antibiotic policy, and ) regular microbiological screening. there were ( . %; wound . %, respiratory . %, urinary . %, bloodstream . % and other . %) pts with ni. we compared ni group pts with the control group of pts and searching predictors of ni in univariete analysis. we did not find differences in age (p = . ), male (p = . ), weight (p = . ) or body mass index (p = . ), but there were more stroke pts and fewer tumour pts (p < . ). ni pts stayed in nicu longer (mean . vs . , p < . ), on admission had lower glasgow coma scale (mean . vs . , p < . ), higher therapeutic intervention scoring system (tiss, p < . ), acute physiology and chronic health evaluation ii (p < . ), and crp (p < . ); in the nicu they had higher crp (p < . ) and nicu mortality (p < . ); on discharge they had worse glasgow outcome scale (p < . ) and higher tiss sums (p < . ). ni pts had more accesses, which were strong predictors of ni: artery (odds ratio [ conclusions: our study confirmed that nosocomial infection is associated with worse outcome and higher cost, and that accesses are still risk factors in a preventive multimodal protocol. the predictive value of emergency triage codes on the outcome of aneurysmal subarachnoid hemorrhage introduction: outcome of patients with aneurysmal subarachnoid hemorrhage (sah) was associated in different studies with different variables (baseline illness severity, physical status, treatments, complications), but the relationship between outcome and triage assessment in the emergency setting has never been evaluated. emergency triage in italy is carried out with color codes: red (immediate life-saving intervention needed), yellow (urgent intervention needed), green (delayed intervention is sufficient), white (not urgent). objectives: to study the relationship between triage severity codes assigned to patients with sah in an italian emergency setting and the outcome expressed as modified rankin score (mrs) at hospital discharge (good outcome for mrs ≤ , poor outcome for mrs > ). methods: a retrospective clinical study included patients with aneurysmatic sah admitted to emergency departments of bologna catchment area, and then to intensive care unit (icu), from january to january . aneurysm coiling or clipping was performed after neuroradiological diagnosis and clinical stabilization, excluding patients too ill to benefit. intensive care treatment was carried out according to current practical guidelines. demographic, clinical and interventional data, complications, severity scores and outcome scores were recorded. the following parameters were considered in univariate analysis: age, sex, clinical condition on arrival in the emergency department (triage code, gcs, wfsn scale, vomiting and seizures) aneurysm clipping or coiling and other neurosurgical interventions, hydrocephalus, vasospasm, cerebral infarction (ct scan), fever, sepsis, acute respiratory failure with p/f ≤ , cardiovascular complications (hypotension requiring vasopressor therapy, acute cardiomyopathy, arrhythmias requiring treatment); the outcome variable was modified rankin score > at hospital discharge. results: poor outcome (mrs > ) was observed in % of triage green codes, % of yellow codes, % of red codes. the univariate analysis showed the statistically significant (p < . ) association with mrs > for the following variables: triage red code, wfsn scale > , acute respiratory failure, cardiovascular complications, sepsis. on logistic regression analysis, the red code assigned in the emergency department, cardiovascular complications and sepsis were associated with poor outcome. conclusions: the severity of general clinical conditions after subarachnoid hemorrhage needing immediate life-saving intervention, feature labelled "red code" in the emergency triage, was associated with poor outcome (mrs > ), while the other triage codes did not show any significant correlation with outcome. cardiovascular complications and sepsis during hospital stay were other variables associated with mrs > . evaluation of intracerebral hemorrhage (ich) score in patients admitted in intensive care by supratentorial brain hemorrhage l. perez-borrero introduction: intracerebral hemorrhage is a stroke subtype with high mortality and significant disability among survivors. objective: to evaluate in our area the intracerebral hemorrage (ich) score in patients with spontaneous supratentorial brain hemorrhage. methods: multicenter prospective observational study in three hospitals in andalusia (spain). we studied all patients with supratentorial brain hemorrhage admitted to the regional hospital of malaga (between to introduction: within the clinical importance of the sah, there are factors described in the scientific literature that speak of an unfavorable evolution of the disease. our hypothesis is based on trying to demonstrate if only one therapeutic intervention could alter the significance of these factors. objectives: analyze the sociodemographic, laboratory findings, clinical and radiological factors that influence prognosis at months in discharged aneurysmal sah patients treated with endovascular intervention. methods: we performed a retrospective longitudinal observational study of all patients who were diagnosed with an aneurysmal sah in icu services of hospitals between march st and november th . they were treated by endovascular intervention. after being discharged from icu and after months of neurologic follow-up. patients were divided into two groups, one formed by those who presented a favorable outcome (ef) and the other by those who didn´t (ed). the variables studied were age, sex, hbp, dm, smoking and dyslipidemia. at the time of admission po , pco , leukocytosis, hyperglycemia and hypertension was determined as well as sodium, magnesium and chlorine plasma levels. the clinical status of patients on admission was assessed using the hunt-hess and wfns scales. the severity of sah was determined by ct using the fischer scale. the aneurysm was located by four vessel angiography. the time between the sah clinic presentation and the procedure was recorded, as well as if aneurysmal occlusion was complete or not. as for the complications, we took into account the presence of fever, hydrocephalus, vasospasm and infarction. results: for the study, patients who underwent acute endovascular sah treatment using coils, were selected. female sex was the predominant sex % vs . % between ed and ef, respectively. the age group most frequently found was between and years ( % for ed and % for ef). logistic regression analysis determined as associated with a worse outcome factor: hyperglycemia on admission(or . , % ci . - . , p = . ), clinical status on admission determinated by hunt-hess (or . ci . - %, p = . ) and wfns scales (or . , % ci . - . , p = . ). the presence of fever on admission also has proven to be a poor prognostic factor (or . % ci . - , p = . ). conclusions: clinical factors for aneurysmal sah patients treated with endovascular procedure that have shown relation with the clinical outcome at six months are: poor clinical grade on admission, hyperglycemia and fever. these data are similar to those found in the literature and support the idea that the therapeutic decision (surgical or endovascular) is not the determining factor for the evolution of these patients, however, the ones mentioned above could be. background: conflicting results have been obtained by studies attempting to assess the risks of ischemic stroke in patients with venous thromboembolism, while the long-term risk of stroke in survivors of venous thromboembolism remains unexplored. objective: we evaluated whether the risk of ischemic stroke in patients hospitalized with venous thromboembolism is higher when compared to the general population. methods: one million patients from national health insurance beneficiaries in taiwan were sampled. there were , patients who had been hospitalized with diagnosis of venous thromboembolism and , unexposed subjects. all adult patients were followed from january to december to evaluate if ischemic stroke was diagnosed. cox regression models were applied to compare the hazards adjusted for potential confounders. results: after controlling for age, gender, urbanization level, socioeconomic status, diabetes, hypertension, coronary artery disease, hyperlipidemia, history of alcohol intoxication, malignancies, congestive heart failure, atrial fibrillation, smoking, peripheral artery disease and charlson comorbidity index, the adjusted hazard ratio of ischemic stroke was significantly increased in patients with venous thromboembolism ( . ; % ci, . - . ). a subgroup analysis based on patients who survived longer than months in the cohort also revealed higher hazard ratio in the patients with venous thromboembolism. ( . ; % ci, . - . ). conclusion: the possible risk of ischemic stroke is significantly higher in patients hospitalized with venous thromboembolism than in the general population. introduction: status epilepticus (se) is a common neurological emergency with considerable associated health-care costs, morbidity and mortality. , se is defined as a prolonged seizure or multiple seizures with incomplete return to baseline. , the overall mortality of se is around % with convulsive status epilepticus representing about - % of all cases. status epilepticus severity score (stess) is a prognostic score that relies on four outcome measures (age, history of seizures, seizure type and extent of consciousness impairment) determined before treatment institution that ranges between and . objective: evaluation of stess as a prognostic measure of functional impairment, neurologic motor deficits and -day mortality. methods: retrospective observational study of patients with se admitted at a general intensive care unit (icu) from to . age, gender, saps ii/iii, type of se, length of stay, number of anti-epileptic drugs, duration of se, functional impairment, neurologic motor deficits and -day mortality were collected through the icu informatics database -picis®. data is presented as mean ± sd and we used logistic regression to correlate stess with study variables. statistical analysis was performed using xstat ®. results: sample included patients, , % male, age , ± , years, saps ii , ± , , saps iii , ± , , icu length of stay , ± , days and hospital length of stay , ± , days. convulsive se represented , % of cases. stess score`s mean was , ± , . se lasted more than day in , %. electroencephalogram was performed in , % of the patients. , % of the patients needed two or more anti-epileptic drug for se. at hospital discharge , % had functional impairment and , % had neurologic motor deficits. mortality was , % at days. there was a correlation between stess and mortality (or = , ; roc = , ), functional impairment (or = , ; roc = , ) and neurologic motor deficits (or = , ; roc = , ). the number of antiepileptic drugs and se duration had no correlation significance. conclusions: we found an excellent correlation between stess and mortality in our study. besides this, we also found this score to be a good prognostic tool for functional impairment and neurologic motor deficits. we consider our main limitations the sample size and lower mortality. despite we recommend using stess as an outcome predictor. introduction: in order to determine optimal airway protection measures in early postoperative period after fossa posterior surgery (pfs), it is important to carry out a prognosis of neurological dynamics based on the preoperative neurological exam. we have designed neurological evaluation scale (nes). objectives: our study was aimed at determining the potential of nes to predict brain stem deterioration in early postoperative period after pfs based on the assessment of the preoperative neurological status. methods: the prospective study was carried out during the period from december to june and included patients operated for fossa posterior tumors (fpt). to be included in the study, patients had to be over years old and operated for fossa posterior non infiltrative paraxial tumors. we examined all patients before and after the operation, immediately after the extubation in icu. nes provided complex neurological assessment with an emphasis on the brain stem function. postoperative nes points were subtracted from the preoperative points -ab-criterion (abc). positive abc corresponds to intensification of neurological deterioration. negative or zero abc corresponds to neurological improvement. all neurological symptoms were grouped in nes blocks according to their relation to cns. results: we divided all patients in two groups depending on their abc, which revealed that the patients with positive abc had reliability less nes points before operation compared to the patients with negative or zero abc. we found out the frequency of occurrence of each nes block for inclusion in the full neurologic status. we discovered that caudal stem affection occurred more frequently in the patients with more nes points. we evaluated the probability of neurological impairment or regression of neurological symptoms depending on abc with sensitivity , % and specificity %. we created a prognostic model, which could predict the discharge from clinic outcome on the basis of the nes blocks points assigned during the early postoperative period. conclusions: we revealed neurological features of postoperative period in patient after fps. our data could predict neurological outcomes, and be useful in optimization tactic of airway protection. and those who died ( . ± ; . ± and ± . ± vs ; . ± and . ± respectively) but difference was not significant. an inverse correlation between inflammatory biomarkers (pct, crp and il- ) and igm endocab was detected. il showed a higher correlation, but without statistically significant differences. icu mortality rate was %. conclusion: igm endocab were detected in septic shock caused by gpb, it could be explain by a bacterial translocation. patients with major endotoxaemia have higher consumption of antibodies and therefore lower levels of igm endocab that is associated with a worse prognosis. the relationship between the neutrophil/lymphocyte ratio and mortality in the severe sepsis patients y. conclusions: sp compliance is below recommended but the mean hobe reaches the lower limit of the recommendation. the factors affecting sp compliance differ according to the method used for data collection and include other factors than patient's clinical condition. politics targeting to increase its compliance should address various areas of care such as team and professionals, resources and equipment and re-consider clinical indications for sp. the project was funded by the °national award of nursing research from marques de valdecilla hospital (spain). gained to collect staff opinions and anonymised patient data. ed, or and icu professionals were surveyed following a pilot to determine options, ranking and scoring criteria a priori where needed. anonymous patient data from intubated patients who were cared for in the ed, or and icu within their first hours were collected. this included physiological observations and supportive care standards around a, b and c. results: the most striking differences in staff opinion involved the preferential use of artificial colloid-based fluid resuscitation in sepsis ( % ed staff; % or staff; % critical care staff); the value and significance of recording end tidal co ( % ed staff; % or staff; % critical care staff); and the potential preferential use of flowdirected fluid boluses rather than pressure-directed fluid boluses in critically ill patients ( % ed staff; % anaesthetic staff; % critical care staff). when observing supportive care standards the largest differences were in the use of stress ulcer prophylaxis (only prescribed in critical care); patient positioning (head-up: % patients in cc; % in ed); the recording of sedation level ( % ed; % anaesthetic; % critical care) and the recording of ventilator parameterstidal volume, peak pressure and et-co -( % ed; % anaesthetic; % critical care) . finally, in respect to patient pathophysiology, all groups were under ventilated and over oxygenated. mean arterial pressure was most divergent from baseline in the ed. however, changes in pathophysiology were related to interventions (fluid boluses, analgesia, surgical interventions, inotropes, pressors) rather than location. despite the divergent views regarding the relative value of flow monitoring, observed fluid boluses were predominantly triggered by pressure changes in all three locations. conclusions: differences in staff attitudes; application of standards and patient pathophysiology were identified between care locations. the influence of variation in resources and professional composition of teams (nurses:doctors) on these results requires further work. it remains uncertain whether more uniform approaches would improve patient outcomes. lung comet score (lcs) for evaluation of extravascular lung water (evlw) in intensive care unit (icu) patients undergoing renal replacement therapies (rrt) a. taggu methods: a prospective observational study was conducted on patients in icu needing rrt. exclusion criteria were age < years, pregnant, amputees, cardiac pacemakers, pre-existing lung diseases and ascites. lung comet score as per validated technique , bia measurements and baseline data were collected pre and post dialysis. lung comet score and other covariates were fitted into a regression model using bia as the standard test. based on bia delta hydration relative (hs rel), patients were divided into normohydration and hyperhydration using a cut-off of %. results: a linear regression model in predialysis state showed that only lcs could significantly predict lung water (const . , coef. . , p value . ). in the postdialysis state lcs perfectly predicted lung water (const . , coef., . ; p value . ).bland altman plots showed good agreement between lcs and hydration status (bia) pre and post dialysis. the lcs > nearly perfectly predicted hydration status in both pre and post dialysis states. conclusions: lung comet score is a good surrogate of evlw and reliably predicts reflects hydration status pre and post dialysis in icu patients. introduction: treatment withdrawal in intensive care is common ( ) . whilst significant research attention has focused on how treatment is withdrawn and what information is communicated to families ( ) introduction: micro-aspiration of subglottic secretions is considered a major pathogenic mechanism of endotracheal tube-associated pneumonia (etap), either postoperative pneumonia or ventilatorassociated pneumonia. endotracheal tubes (ets) with taper-shaped cuffs have been proposed to provide a better seal of the extraluminal airway, thereby preventing micro-aspiration and possibly etap. objectives: to perform a systematic review and meta-analysis to assess the efficacy of ets with taper-shaped cuffs in the prevention of etap. methods: a systematic search of medline, embase and central/ cctr was conducted in march . eligible trials were randomized controlled clinical trials (rcts) comparing taper-shaped cuffs with standard, cylindrical-shaped cuffs in intubated patients. all studies reporting the incidence of etap were included. inclusion of trials was irrespective of publication status, date of publication or language. random-effects meta-analysis calculated the risk ratio (rr) and % confidence interval (ci) for the incidence of etap between both groups using the mantel-haenszel method. results: three rcts, given a total of patients, met the inclusion criteria. one trial was published as a conference abstract only ( ), while the others were published in full ( , ) . none of the trials was blinded for the intervention. patients were allocated to the intervention arm and to the control arm. etap episodes occurred in the intervention group and in the control group. the pooled rr for the incidence of etap was . ( % ci, . - . ; z = . p = . ). conclusions: the use of endotracheal tubes with taper-shaped cuffs did not show to reduce the incidence of etap. however, the number of available studies is small, and there is an inherent risk of bias due to the unblinded designs. background: understaffing of icu's can have serious adverse consequences both for patients and for nurses, and therefore it is important to have an adequate number of nurses on the ward. nurses however are in short demand and resources are scarce. being able to predict the nursing workload for a certain group of patients may help to allocate nursing capacity as efficiently as possible and thus to reduce costs, without endangering the patients safety and nurses' health. nas is a validated tool for the measurement of nursing workload in an intensive care unit. goal: this study was conducted to investigate whether it is possible to predict the nursing workload for a homogeneous group of patients, admitted after an in or out of hospital cardiac arrest and to assess the effects of baseline characteristics, vital parameters and admittance time on this workload. method: we performed a retrospective analysis of nas scores of all ihca and ohca patients admitted to our icu from october until september during the first hours of stay. the nas was recorded per patient per nursing shift. we furthermore recorded patient characteristics and vital parameters. results: during this period patients, males and females, were admitted to the icu after cardiac arrest. the mean age at admission was . years (sd = . ). the mean nas at admission was . (sd = . ). patients admitted in the evening shift had a significantly higher nas compared to patients admitted in the night shift ( . ; sd = . vs . ; sd = . (p = . )), but no significant difference was found with the day shift (mean nas day shift: . ; sd = . ). after admission the workload decreased in all patients by a mean of . points (sd = . ; p < . ). a higher sofa score, a higher peep and a lower ph at admittance resulted in a higher nas score on average over time (p < . ). conclusions: the nursing workload at admission of patients after cardiac arrest is fairly predictable, with no clinically significant difference between shifts , necessitating a nurse-to-patient ratio of at least : . after the first shift it is almost always possible to decrease the nurseto-patient ratio to : . the nas was influenced by severity of illness. these results can be used to assess the needed nursing staff for the treatment of these patients for the first days after admittance. introduction: major trauma and severe sepsis are both leading causes of admission to the resuscitation rooms in emergency departments across the world. despite obvious differences in precipitating mechanism, there are surprising similarities between subsequent pathophysiology: both disorders lead to disorders of the macrocirculation, microcirculation and host inflammatory response ( , ) . objectives: here we compare the baseline epidemiology, pathophysiology, operational and clinical management of intubated resuscitation room patients with these two critical illness syndromes (major trauma/septic shock). the results will be used to facilitate the design and planning of a study to test the feasibility/effectiveness of advanced monitoring systems (thromboelastography, oesophageal doppler flow monitoring, echocardiography, and microcirculatory monitoring) in the resuscitation room management of critically ill patients with these conditions. methods: institutional approval was gained to collect anonymised patient data over a -month period from a mixture of written and electronic records. where appropriate, significance was tested by mann whitney u (sigmaplot . ). results: patients, intubated pre-hospital or in ed resus, were identified with trauma or sepsis diagnoses. trauma patients were commoner (n = ; %) and more likely to be intubated prehospital ( / ; . % vs / ; %). lactate profiles were similar in the two groups at start and end of resus episode ( figure ). patients with major trauma were more hypertensive but equally tachycardic when compared with patients with severe sepsis/septic shock. patients with septic shock/severe sepsis (median minutes vs minutes) spent longer in resuscitation room, but received less documented consultant-level review ( . % vs . %). imaging of major trauma patients was with ct ( / ; %) and ultrasound ( / ; . %) in contrast to septic patients ( / ct; . %; / , % us). icu and hospital mortality was higher in patients with sepsis ( . % vs . %), but death in resus only occurred in the trauma population. only two patients, both with facial trauma, would have had a relative contraindication to the proposed advanced monitoring. conclusions: this novel preliminary work has highlighted some important differences between the epidemiology, outcomes, pathophysiology and clinical/operational management of intubated patients with severe sepsis versus major trauma. these will influence the conduct and outcome measures of any trial of advanced monitoring in this setting. however, contraindications to any of the advanced monitoring technologies being considered were rare and no obvious barriers to the planned study of advanced monitoring were identified. introduction: in our -bedded gicu, demand for beds has increased while recruitment of icu trained nurses has decreased. there is enduring evidence of links between workload and stress [ , ] , with high levels of burnout reported in icu nurses [ ] . there has been a shift towards measuring what makes people positive and engaged [ ] , rather than why people reach the extreme state of burn out. it is important to understand factors that affect work engagement to develop strategies that enhance nurse retention and improve the quality of icu patient care. objectives: to examine the impact of an education initiative for novice icu nurses on work engagement for the icu nursing staff and organisational resource use. methods: a pre -post design was used to collect data from all icu nurses at the start of the education programme and at months following he intervention. work engagement was measured using the self-report item utrecht work engagement scale (uwes) [ ] with an open question to capture staff experiences. organisational impact was measured using levels of sick leave, % staff turnover, use of agency nurses and staff recruitment. results: fifty three icu nurses completed the pre-intervention survey ( % response) and completed the post-intervention survey ( % response). respondents had reasonable years of icu experience (mean . , sd . ) and time in current post (mean . , sd . ). internal consistency for the uwes was high (alpha . ). levels of work engagement (mean [sd]) increased ( . , [ . ] vs . [ . ]) but did not reach significance and remained in the 'average' band as judged by the scale authors [ ] . when examined by senior and junior nurses, the increase was similar. organisational measures showed decrease in sick leave, turnover, agency use and increase in recruitment of experienced icu nurses. qualitative feedback was positive, with perceptions of improvement in unit morale due to time being invested in the individual and reduced stress and workload for shift leaders. conclusions: providing education for the newest icu recruits can have benefits for the whole icu team. however, it is important to examine how work engagement might be further improved. the incidence of silent aspiration on intensive care n. maistry royal brompton and harefield nhs foundation trust, rehabilitation and therapies, london, united kingdom intensive care medicine experimental , (suppl ):a introduction: the incidence of dysphagia on intensive care is an area of growing research. dysphagia is associated with aspiration pneumonia and increased icu bed days. in general, speech and language therapy (slt), makes recommendations based on the results of a clinical bedside swallowing evaluation, despite the unreliability of this method . this is largely due to the difficulty accessing gold standard assessment methods such as videofluoroscopy (vf) and fibreoptic endoscopic evaluation of swallowing (fees) . referral for these assessment methods are based on a local defined criteria. this study evaluates the incidence of silent aspiration identified by vf and fees in a bedded tertiary cardio-respiratory intensive care unit. objectives: to determine the incidence of silent aspiration, defined as "aspiration before, during, or after swallowing in the absence of cough or visible signs of choking and distress ," in icu patients assessed by vf or fees between july and june . method: data was retrospectively reviewed for month period from all icu referrals made to slt for swallowing evaluation. all patients received a clinical bedside swallowing evaluation. the results are presented as percentages and counts for patients receiving vf and fees that silently aspirated. results: a total of patients were referred for swallowing assessment and % ( / ) had a vf or fees. there were males and ages were . ± . years. in this group, patients had videofluoroscopic assessments and patients had fees. in the vf group % silently aspirated whilst in the fees group the values were %. patients ( %) silently aspirated during objective assessment, impacting on how and when oral feeding was commenced. conclusion: this study suggests that silent aspiration is highly prevalent in this population group. consequently, vf and fees should be part of standard routine assessment in the management of critically ill patients. delerium related incidents at the icu and nursing aspects a. van introduction: at the icu of vu university medical center (vumc) nurses are frequently confronted with delirium , . delirium is known to be present in - % of mechanical ventilated patients and - % in non-ventilated patients. immediate consequences are falling incidents or for patients to remove tubes and iv lines that are necessary for treatment. in literature, this is stated as a result of treatment, but often data is missing. consequences of removal are increased risk of complications , prolonged mechanical ventilation, los and increased morbidity/mortality . objectives: to measure the frequency of removing tubes, lines and falling incidents related to delirium. methods: a multidisciplinary focus group was formed ( ) in order to properly diagnose, prevent and/or treat delirium due to the high prevalence. the first steps were increasing awareness and implementing the cam-icu score. to clarify delirium-related incidents a one year period was set in which the dedicated senior nurse informed and trained the nursing staff regarding delirium and potential risks. to register delirium-related incidents a modified report button was built in the epr (metavision, imd soft) and used beside the regular incident reporting system . results: after one year, individual patient incidents were reported concerning falling or tube or iv line removal. this included gastric tubes, airway tubes, iv/cvc/arterial lines, other lines and fall incidents. in % of the cases the patient was diagnosed with delirium. out of patients received medication or were fixated before the incident despite a % cam-icu registration rate. because the focus group doubted about underreporting nurses were interviewed if the results corresponded with their experience. they were unanimous that there was hardly any underreporting. discussion: despite therapy or fixation delirium-related incidents occur on a weekly basis at our icu, causes harm and increases nursing workload. although the incidence rate is presumed to be low, there is no feeling of satisfaction. further improvement is necessary due to the high risks for the patient. therefore, we need to be able to diagnose incidents faster so we can start treatment sooner. although the cam-icu score was implemented, compliance is insufficient. increasing compliance is the first step to further improvement. the follow-up question is whether delirium-related injury can be reduced when cam-icu compliance improves. second step is to investigate the effectiveness of our fixation protocol. prospective study to determine the predictors of extubation success a. taggu introduction: timely extubation is crucial in critically ill patients. traditional indices like rapid shallow breathing index are considered as accurate during the spontaneous breathing trial. multiple other proposed parameters like diaphragm thickness, fluid balance and cardiac indices have been shown to predict succesful extubation in the recent years. objectives: to assess the reliability of the parameters in predicting successful extubation. methods: a prospective observational study done on adult patients eligible for extubation as decided by the attending intensivists. exclusion criteria: pregnant and tracheostomised patients. along with baseline parameters, following measurements were taken pre and post extubation. . cardiac parameters including simpsons method for ejection fraction, e/a, e/e' (lateral) for diastolic function, tapse and tad for right ventricular function. all recordings were taken just before extubation and within six hours post extubation. . just before extubation,high frequency linear ultrasound probe was used to measure the right sided dt at the zone of apposition (zoa) between th to th intercostal spaces in mid-axillary line.the change in dt fraction(Δdtfrac_pre%) was calculated as dt(end-inspiration)-dt(end-expiration)/dt (end-expiration)x .rsbi was simultaneously recorded. . fluid balance hours were recorded. figure ) . we found no significant difference on mortality when limiting the results just to trial employing cvvh at hemofiltration rate lower or higher then ml kg − h − . conclusions: blood purification with cvvh might be associated with a significant reduction in mortality when performed in patients with sepsis or ards. this is the first meta-analysis suggesting beneficial effects of cvvh on mortality and we could suppose that the beneficial effects of cvvh in these inflammatory conditions could arise from the immunomodulatory properties of hemofiltration. further high-quality randomized controlled trials adequate powered for mortality are needed to clarify the impact of cvvh on these inflammatory conditions. the authors declare no support or funding and no potential conflict of interest. we defined extreme hyperbilirubinemia as a state of total bilirubin above mg/dl and selected all patients whose serum total bilirubin increased above mg/dl at least once during their stay in the intensive care unit. we investigated the overall clinical course of the patients and compared the differences between one group with normalization of total bilirubin (recovery group) and the other group without normalization (non-recovery group). furthermore, we evaluated the association between prognosis and various clinical factors, including the peak total bilirubin levels, increasing rate of total bilirubin (vi), results of laboratory analyses related to hepatic function, and clinical features at the time of extreme hyperbilirubinemia. these data were analyzed using chi-square test and cox and logistic regression analyses. introduction: propofol is widely used in critical care sedation due to its pharmacological properties which allow serial neurological examination ( ) .hypo tension is a common side effect of propofol infusion, which affect patient outcome. introduction: propofol is a common intravenous drug used during anesthetic induction and sedation because of its rapid onset and short duration. its downfall, however, is that patients experience injection pain so severe that they recall induction as the most painful part of the sedation process. among numerous reports in efforts to decrease propofol injection pain, the most effective combination of drug and non-drug intervention evaluated through a quantitative systematic review revealed to be pretreatment with . mg/kg lidocaine in combination with a tourniquet for venous occlusion. the majority of these reports conclude that a single method is insufficient in eliminating propofol injection pain. objectives: we evaluated the effect of heated carrier fluids ( °c) in decreasing propofol injection pain. methods: a randomized controlled clinical trial was conducted in patients (asa or ), ages to . patients were allocated into groups (n = ) each. group w received ml of heated carrier fluids for minutes prior to mg/kg propofol injection; group l received ml of heated carrier fluids for minutes prior to lidocaine pretreatment and mg/kg propofol injection: and group c (control group) received ml of room temperature fluids prior to mg/kg propofol injection. propofol injection pain was evaluated using the verbal pain score (vps). results: group w and l showed significant reduction in the incidence and severity of injection pain compared to group c (p < . ). vps was significantly lower in group w (p = . ) and l (p = . ) compared to group c. there was no statistical difference between group w and group l (p = . ). there was statistically significant difference in mean blood pressures measured after mg/kg propofol injection among groups. conclusions: both heated carrier fluids and combination of lidocaine pretreatment effectively reduced propofol injection pain. objectives: we conducted a prospective cohort study to clarify the epidemiology and the nature of aes in surgical inpatients in japan. methods: the japan adverse event (jet) study was a prospective cohort study which had evaluated aes and medical errors (mes) at tertiary care hospitals. the medical and surgical wards were stratified according to hospital and whether they were medical or surgical wards, and study wards were randomly selected. intensive care units (icus) were all included. we included all adult patients aged > = years old who were admitted to any of the selected study wards ( medical, surgical, and icus) over a -month period. the primary outcome of this study was the epidemiology and the nature of aes and mes in the patients who had operation during the study period. trained nurses placed at each participating hospital reviewed all charts daily on weekends, along with laboratories, incident reports, and prescription queries to collect any potential event. they also collected the characteristics of the patients in the cohort. independent physician reviewers evaluated all potential events and classified to whether they were aes or mes, as well as to their classification, severity and preventability. introduction: whereas the importance of low tidal volume to avoid ventilator-induced lung injury (vili) in patients with ards is well known, several uncertainties still exist regarding how to set positive end-expiratory pressure (peep). many approaches have been considered, but no one showed a clear effectiveness in terms of outcome. recently a ventilator strategy using esophageal pressure to estimate the transpulmonary pressure has been proposed by talmor and colleagues . although they found an improvement in arterial oxygenation, it was not explored whether the increase in oxygenation was due to lung recruitment. objectives: the aim of this study was to assess whether the peep set to maintain a positive end-expiratory transpulmonary pressure (p l ) is associated with an increase in lung recruitment estimated by lung ultrasound score (lus) . methods: patients with moderate and severe ards were enrolled. for the first hours, peep was set according to the acute respiratory distress syndrome network standard-of-care recommendations (phase a). it was then adjusted according to measurements of esophageal pressure for the following hours (phase b) to maintain a positive p l at the end of expiration. the primary end point was the improvement in lung recruitment assessed with lung ultrasound. [ ] no data are available on the relationship between opening pressures and disease severity. objectives: to describe lung recruitment as a function of the transpulmonary pressure in mild, moderate and severe ards. methods: ards patients underwent a low-dose end-expiratory ct scan at peep cmh o and three end-inspiratory ct scans at the plateau pressures reached starting from peep cmh o, cmh o and cmh o. in each of the ct slices, lung profiles were manually delineated, excluding hilar structures. thereafter, quantitative analysis of ct scan images was performed and the gas and tissue fractions were computed. we defined the recruitability as the difference of not inflated tissue between and cmh o, that we arbitrarily assumed to be the "full recruitment". [ ] the grams of recruited tissue were computed across the pressure intervals at which the ct scan were performed, as the differences of not aerated tissue. airway and esophageal pressures were continuously measured and transpulmonary pressure was computed as: driving airway pressure (cmh o) -(esophageal plateau pressure (cmh o) -esophageal end-expiratory pressure at peep (cmh o) [ ] . results: thirty-three patients were studied, with mild, with moderate and with severe ards, according to the berlin definition. [ ] as reported in the table and fig. , the amount of tissue which can be opened between and cmh o was %, % and % respectively in mild, moderate and severe ards). mild ards patients nearly completed recruitment at approximately cmh o transpulmonary pressure while in moderate and severe ards recruitment continues up to cmh o transpulmonary pressure. conclusions: at the clinically recommended plateau pressure of cmh o, in severe ards, up to / of the lung tissue recruitable at cmh o, stays always closed. beyond contributing to the gas exchange impairment (depending on the perfusion), these "always" collapsed regions may also act as stress risers at their interface with aerated regions, though they are theoretically protected from the mechanical ventilation. introduction: extracorporeal membrane oxygenation (ecmo) is a rescue therapy for patients with acute respiratory distress syndrome (ards) by providing additional oxygenation, and removing carbon dioxide thus permitting less injurious mechanical ventilation settings that have been shown to protect the lungs from additional injury. objectives: to evaluate associations between distinct ventilator settings during ecmo, and outcome of ards patients. methods: individual patient data analysis of observational studies in adult ards patients receiving ecmo for refractory hypoxemia. multilevel multivariable logistic regression models and cox-proportional hazards models were used to determine which settings and parameters had an independent association with the primary endpoint all-cause mortality. results: nine studies with patients were selected ( figure ). initiation of ecmo was accompanied by significant decreases in tidal volume, positive end-expiratory pressure (peep), plateau pressure (pplat), and driving pressure (Δp = pplat -peep), respiratory rate and minute volume (figure ), and resulted in higher pao to fio ratios, higher arterial ph and lower paco ( figure ). higher age, lower body mass index, and higher lactate were associated with all-cause mortality after multivariable adjustment. Δp, both before and during the first three days of ecmo, demonstrated an independent association with all-cause mortality ( conclusions: in this series of ards patients receiving ecmo for refractory hypoxia, Δp and fio were the only ventilatory variables that had an independent association with outcome. these findings indicate the potential for improvement in the management of patients with ards undergoing ecmo. lungs were analysed for wet-to-dry ratio, bal protein, static compliance, spo and histology. to detect the timing of injury, rats received evans blue dye (ebd- mg/kg iv) at the initiation and were euthanized immediately before lung deflation or at , , or min afterwards ( /group). terminal bal analysed for ebd absorbance. ultrastructural impact was studied by electron microscopy on lungs sampled from rats euthanized before deflation, and at and min after deflation. hemodynamic data was obtained by echo performed at baseline (peep cmh o), immediately before and after deflation, and at mins after deflation. rv pressure was measured with a millar catheter. results: wet-to-dry ratio ( . ± . vs . ± . ; p = . ) and bal protein ( . ± . vs . ± . ; p = . ) was higher; and static compliance ( . ± . vs . ± . ; p = . ) and spo ( ± . vs ± . ; p = . ) were lower in intervention vs control. histology revealed collapse, hemorrhage and neutrophil accumulation in the intervention group. bal evans blue demonstrated that microvascular leak was absent before deflation and was maximal by min of deflation. ultrastructural analysis showed that sustained inflation caused minimal swelling of epithelium and endothelium before deflation; deflation resulted in major cellular and interstitial edema, and endothelial injury. hemodynamic data showed that rv and lv were under-filled during inflation. upon deflation, rv output, pulmonary vascular resistance, rv systolic transmural and diastolic pressures increased precipitously. rv/lv ratio increased progressively. conclusion: sudden deflation after sustained inflation with peep causes protein leak, inflammation, hypoxemia, reduced compliance, endothelial injury and rv failure. the mechanism appears to be endothelial injury resulting in microvascular leakage, pulmonary hypertension and rv failure. significance: deflation injury may be an important entity to prevent when using sustained inflation manoeuvres and may explain -in partwhy several important rcts in ards have been negative. low dose steroids reduce short term mortality in septic shock patients: results of an individual patient data meta-analysis r. introduction: previous research has suggested that the use of low dose steroids may be beneficial during septic shock. however subsequent inconsistent results explain the lack of consensus amongst doctors around the world about whether treatment with low dose steroids does improve the overall recovery and survival in patients with septic shock. we hypothetize that the lack of consistent evidence on the effect of low-dose steroids on short term mortality may be related to underpower. treated for septic shock. objectives: the primary objective of the present study was to estimate the effect of three different therapeutic regimens (hydrocortisone alone, hydrocortisone plus fludrocortisone, neither hydrocortisone nor fludrocortisone) on -day mortality in patients treated for septic shock using an individual patient data meta-analysis. methods: individual patient data meta-analysis including the major recent randomized controlled trials comparing early lowdose short course hydrocortisone and fludrocortisone to placebo (ger-inf ( )), hydrocortisone alone to placebo (corticus ( )) or hydrocortisone to hydrocortisone and fludrocortisone (coiitss ( )) in septic shock patients. the primary outcome measure was all cause -day mortality. secondary outcomes measures were day mortality, resolution of organ dysfunction (as measured by the time to reach a sequential organ failure assessement score < ), time to vasopressor and mechanical ventilation discontinuation, intensive care unit and hospital lengths of stay as well as the rate of superinfection. treatment effect on the primary outcome was quantified using relative risk and estimated using targeted maximum likelihood estimation. results: a total of , patients were enrolled in the trials. when compared to the placebo, hydrocortisone + fludrocortisone significantly reduced -day mortality (rr = . , %ci = . - . , p < . ). hydrocortisone + fludrocortisone was also superior when compared to the placebo and hydrocortisone pooled together (rr = . , %ci = . - . , p = . ). hydrocortisone + fludrocortisone significantly decreased -day mortality (rr = . , %ci = . - . , p < . ) in the nonresponders, while it was associated with an increase in -day mortality in the responders (rr = . , %ci = . - . , p = . ) ( figure ). hydrocortisone + fludrocortisone was also superior when considering secondary outcomes such as vasopressor discontinuation or lengths of stay. conclusions: in this individual patient data meta-analysis including the major randomized controlled trials on the subject, we found that an early short course of low-dose hydrocortisone and fludrocortisone decreases -day mortality and improves recovery from organ failure in septic shock patients non responding to a corticotropin stimulation test. introduction: statin therapy during intensive care unit (icu) stay has been associated with a reduction in all-cause hospital mortality in some studies. this association was especially noted in septic patients. however, potential benefit needs to be validated in randomized, controlled trials. objectives: the purpose of this study was to compare the effect of simvastatin plus standard therapy on mortality and total icu length of stay (los) to that of standard therapy alone in critically ill septic patients. methods: a prospective randomized, open label, controlled pilot clinical trial was conducted on patients diagnosed with sepsis/severe sepsis as defined by the american college of chest physicians (accp). hundred patients met the study criteria and were randomized into two groups; a standard group who received standard treatment and simvastatin group who received the standard treatment plus mg simvastatin. primary outcomes were days icu mortality and total icu los. plasma c-reactive protein (crp), total creatine kinase (ck) and liver enzymes [alanine aminotransferase (alt) and aspartate aminotransferase (ast)] were measured as secondary outcome measures. results: a total of patients completed the study. simvastatin was well tolerated, with no increase in adverse events between the two groups. total icu los was significantly lower in the simvastatin group. however, the number of patients with days icu mortality in the simvastatin group was lower compared to standard group; but survival failed to reach statistical significance. similarly, plasma creactive protein failed to reach statistical significance between the two groups conclusions: treatment with simvastatin mg in patients with sepsis/severe sepsis is safe and associated with an improvement in number of deaths and icu los but without subsequent improvement in survival. the use of anapnoguard system in intubated critically ill patients a randomized controlled study introduction: the anapnoguard system (ag) (hospitech respiration ltd., petach-tikva, israel) is an innovative respiratory guard system that continuously monitors and controls the cuff pressure by measurements of co levels above the cuff, and allowing simultaneous rinsing and aspiration of subglottic secretions. objectives: to determine the safety and clinical efficacy of ag system compared with usual care in critically ill patients. methods: prospective, single centre, open-label, randomized, controlled feasibility and safety trial. sixty patients, without pneumonia, were randomized to be intubated with the ag tube and connected to the system (n = ) or with a conventional tube (n = ) combined with subglottic secretion drainage and manually control of tracheal cuff pressure (p cuff ). primary outcome was the rate of adverse events. other outcomes included the rate of mechanical complications, the level of icu staff satisfaction, the incidence of ventilator-associated pneumonia (vap), the quality of p cuff control, and the amount of ss drained. results: out of patients enrolled in the study, were included in the analysis ( per each group). both groups were similar at randomization in demographic characteristics, icu admission diagnosis, main comorbidities and severity of illness. no device-related adverse events occurred in any of the two groups. no differences were detected using ag system vs conventional tubes in terms of post- introduction: during sepsis, intrinsic stress responses may become maladaptive and contribute to poor outcomes. targeted intervention with β-blockade to 'de-stress' such patients may be beneficial. we developed a -h rodent model of fluid-resuscitated faecal peritonitis in which mortality (occurring between and h) can be predicted at h by a low stroke volume (auroc . ), and where survivors are clinically improving by study end. [ ] objectives: to investigate the impact of β-blockade on outcomes in predicted survivors and nonsurvivors of faecal peritonitis. methods: instrumented, fluid resuscitated, male wistar rats ( - g) had sepsis induced by intraperitoneal injection of faecal slurry ( . ml/kg). at h, under brief isoflurane sedation, echocardiography was performed to differentiate predicted survivors from nonsurvivors based on a stroke volume cut-off of . ml. rats in each prognostic group were then randomised to receive either esmolol ( μg/kg over min followed by μg/kg/min infusion) or matching placebo ( . % nacl) until h. animals were observed for up to h, and time of death was recorded. the study was powered to detect a mortality reduction in predicted nonsurvivors from % to % with esmolol, with a power of . and type- error of . . results: rats were randomised after prognostication to receive either esmolol or placebo. at h, predicted survivors and nonsurvivors were clinically indistinguishable (both groups appeared only mildly unwell), though predicted nonsurvivors (stroke volume < . ml) had lower cardiac output ( ± vs. ± ml/min), higher heart rate ( ± vs. ± bpm) and blood pressure ( ± vs. ± mmhg) and more haemoconcentration (haemoglobin . ± . vs. . ± . g/dl) (all p < . ). survival was significantly improved by esmolol in predicted nonsurvivors (p = . ), but worsened in predicted survivors (p = . ). conclusions: mortality was approximately halved in predicted nonsurvivors by esmolol, but doubled in predicted survivors. early prognostication appears key in identifying the subset(s) of animals (and, potentially, patients) who might benefit from additional treatment, while avoiding iatrogenic harm in those that would naturally survive. mechanisms by which esmolol impact upon mortality are under investigation. introduction: endotoxins (lipopolysaccharides, lps) have become interesting targets in extracorporeal therapies. lps is a major constituent of the outer cell wall of gram-negative bacteria and strongly triggers inflammatory responses in humans at concentrations as low as ng/kg body weight. although the elimination of lps is promising for the supportive therapy of sepsis and liver failure, endotoxin neutralization using endotoxin adsorbents is controversial. objectives: we could recently show that endotoxin inactivation by low-dose polymyxin b (pmb; ng/ml) could be applied for endotoxin inactivation in blood [ ] . aim of this study was to establish an adsorbent-based system which combines constant pmb release for endotoxin inactivation and effective cytokine adsorption during extracorporeal treatment. methods: we established an adsorbent-based pmb release system which ensures a constant pmb level in plasma during extracorporeal therapies. a polystyrene-divinylbenzene based cytokine adsorbent (cg c) with nanostructured pores was coated with a defined amount of pmb by hydrophobic interactions. the endotoxin inactivation and cytokine adsorption was tested in an in vitro model using fresh donated blood which was stimulated with ng/ml lipopolysaccaride from e. coli. results: in plasma or blood an equilibration between the free and bound form of pmb will lead to a constant pmb level in plasma. the pmb release experiments in plasma clearly show that the adsorption and desorption is a function of the ratio pmb concentration: adsorbent surface. furthermore the pmb release depends on the protein concentration of the plasma. it makes a big difference whether the pmb coated adsorbent is used in plasma or in fractionated plasma where the hydrophobicity is much lower. the experiments suggest that the pmb coating of the cg c adsorbent doesn´t influence the cytokine removal which can take place in parallel. the ability of lps inactivation by the pmb coated cg c adsorbents was similar to pmb which was infused directly into the plasma. conclusions: our in vitro model shows that the combination of cytokine removal and controlled pmb release by the same adsorbent results in a strong suppression of inflammatory effects in blood. objective: management of hemodynamically stable pulmonary embolism (pe) with right ventricular (rv) dysfunction is still controversial. the objective of our study is to evaluate the effectiveness of local intraarterial thrombolysis (lit) in this group of patients and analyze its complications. patients and methods: prospective study (january -december ). patients included had been diagnosed of pe by computed tomography (ct), were hemodynamically stable [systolic arterial pressure (sap) > mmhg] and had a clinical suspicion of rv dysfunction (biventricular quotient in ct > or elevated levels of troponin i), that was confirmed afterwards by the presence of at least one of the following findings in the echocardiogram: subjective alteration of rv contractility, rv basal diameter (four chamber view) > mm, tricuspid annular plane systolic excursion (tapse) < mm or estimated systolic pulmonary artery pressure (spap) > mmhg. lit was done with a urokinase infusion (bolus dose of . ui followed by a perfusion of . ui/h) administered thru a pulmonary artery catheter, placed with radiological guidance, using an antecubital puncture. patients received simultaneous systemic anticoagulation with unfractionated heparin. after - h of treatment, and before ending the urokinase infusion, a radiological control was done using angiography or ct. within the seven days after lit, patients underwent a follow-up echocardiogram. statistical analysis was performed with student´s t test for parametric paired data, wilcoxon´s test for non parametric and stuart-maxwell for qualitative values. results: eighty-seven patients were included and their general data are detailed in fig. . mean treatment time was , ± , h. ninety percent of patients experienced a radiological improvement ( . % a complete/almost complete resolution and, . % a significant improvement). only , % didn´t improve radiologically. the evolutions of the different rv parameters studied are shown in fig. . minimum fibrinogen and platelet values where , ± , mg/dl and x ± . x cells/mm . eighteen patients ( , %) suffered form hemorrhagic complications that, in cases, where puncture site hematomas and, in six occasions ( , %) required an early interruption of the treatment. three patients ( , %) received a blood cell transfusion of ≤ blood units. mean icu and hospital stays where ± , and ± , days. all patients survived. conclusion: in our group of patients, lit rapidly improved the function and decreased the hemodynamic strain of the rv, while being associated with a low incidence of major complications. introduction: atrial fibrillation (afib) is associated with higher shortterm mortality in critical illness, but it is still uncertain whether afib independently contributes to unfavorable outcome. objectives: the aim of this study was to test the hypothesis that afib during critical illness is independently associated with increased in-hospital and long-term risk of death. methods: the frog-icu study was a prospective, observational, multicenter cohort study designed to investigate outcome of critically ill patients. heart rhythm was assessed at inclusion and during icu stay with digital ecg recordings. among patients who had any afib during icu stay, newonset and recurrent afib were diagnosed in patients without and with previous history of afib, respectively. primary endpoints were in-hospital and -year mortality. covariate adjusted logistic regression models and cox proportional hazards models were used to evaluate the association between afib and in-hospital mortality or -year mortality, respectively. in-hospital mortality was adjusted for independent covariates (age, gender, simplified acute physiology score (saps ii), treatment with inotropes or vasopressors, serum lactate level, high-sensitive troponin i, b-type natriuretic peptide), -year mortality was adjusted for covariates (age, gender, saps ii, history of congestive heart failure, treatment with inotropes or vasopressors, serum lactate level, c-reactive protein and serum creatinine). results: the study included critically ill patients. the study population consisted of patients for whom data about heart rhythm during icu stay was available. afib occurred in patients ( %). newonset afib (n = ) had higher in-hospital mortality ( %) compared to no afib ( %, p < . ) or recurrent afib ( %, p = . ). newonset afib showed increased in-hospital risk of death after multivariable adjustment compared to no afib ( introduction: the incidence of the supraventricular arrhythmias is increased in septic shock patient, and it is associated with worse short and long term prognosis. objective: to test that propafenon could be a feasible antiarrhythmic in the absence of contraindications. methods: patients with septic shock who received antiarrhythmic drugs for supraventricular arrhythmias were included over months. the patients were divided into the three groups according to antiarrhythmic agent: amiodarone (group ), propafenon (group ) and metoprolol (group ). in the first h the type of arrhythmia, dosages, cardioversion rates, demographic, haemodynamic, laboratory parameters were recorded. mortality was compared between the groups and between the cardioverted vs those remaining in acute and chronic arrhythmias. clinical studies; presumably due to an impairment of myocardial oxygenation and ventricular filling. a randomised control trial of heart rate (hr) control in septic shock showed an increase of survival for the patients receiving esmolol . an animal study observed a similar improvement of survival and an increase in left ventricular (lv) contractility when esmolol was associated with norepinephrine (ne) . however beta-blockers therapy in sepsis is still debated considering its negative inotropic side effect. ivabradine, a pure bradycardic agent, blocking selectively the if channels in the sinus node, could represent a safer option for hr control. objectives: compare the hemodynamic tolerance of hr control either with intravenous (iv) ivabradine or esmolol perfusion, in a large animal model of septic shock. methods: we used a closed chest swine model of fecal peritonitis. analgesia and sedation were provided by sufentanil and sevoflurane. hemodynamic monitoring included arterial blood pressure (abp); continuous cardiac output (cco); lv maximum rate of pressure (dp/dtmax) and lv elastance (e-lv); mixed venous oxygen saturation (svo ) and arterial lactate (lac). after the development of septic shock, fluid resuscitation was started and animals were randomised in groups of pigs: ivabradine (ivb), esmolol (esm) or control. ivabradine was administered with an iv bolus of , mg/kg that could be repeated at , mg/kg, aiming an hr between and beats per minute (bpm). continuous iv perfusion of esmolol was started at mg/kg/h and adapted to reach the same hr range. after hours of hr control, a fixed dose of , mcg/kg/ min ne was introduced in all groups. results: all animals developed an hyperdynamic distributive shock, including tachycardia above bpm. hr control between and bpm was successful in both ivb and esm groups. ivb administration didn't affect abp, cco, dp/dtmax, e-lv, svo or lac. esm perfusion tended to decrease abp, cco and svo ; e-lv and lac were unaffected but dp/ dtmax decreased markedly. under ne perfusion, e-lv was similar in all groups but dp/dtmax was lower in esm group. conclusions: in septic shock, hr control with an iv administration of ivabradine doesn´t alter global organs perfusion and cardiac function. esmolol perfusion, in order to achieve the same goal, reduces lv dp/dtmax and didn´t enhance lv contractility in association with ne. introduction: patients in critical care settings are often at risk of developing hypotension, which can lead to poor outcomes such as increased morbidity and mortality. current hemodynamic parameters for monitoring such hypotension often exhibit pronounced changes only when the hypotensive event is already occurring or when it is too late. we have developed a hypotension probability indicator (hpi™) to predict hypotensive episodes based on machine learning techniques. the hpi™ model was trained on~ icu and or patients. the objective of this study is two-fold: ) to test the accuracy of hpi™ to predict events on a completely independent test data set of icu patients, not used in the development of the algorithm; and ) to compare timing of interventions in response to an event to the timing of detection of an event by hpi™. methods: data used in this study came from the mimic ii mit research database. arterial pressure waveforms of patients were analyzed for hpi™ and then tested for event detection and prediction accuracy. all features of the hpi™ as well as other hemodynamic parameters for comparison were calculated using flotrac (edwards lifesciences, irvine, ca). a hypotensive event was defined as any time period where map < mmhg for at least minute. an roc analysis was performed to assess auc, sensitivity, and specificity of the hpi™ to identify an event during the event, and , , and minutes prior to the start of event. next, clinical records of the patients were reviewed for any drug or fluid interventions during start of event to minutes after an event and the elapsed time from start of event to intervention time was calculated. a drug or fluid intervention was defined as any bolus or iv infusion start. in addition, the time at which hpi™ probability of event > . prior to the start of an event was also calculated for comparison. data are presented in median [ - th percentiles]. conclusion: in conclusion, hpi™ can accurately detect an event up to minutes prior. hpi™ may serve as a useful addition in the care of critically ill patients by potentially facilitating earlier intervention either in response to an event or serve as a decision support and direct a physician's attention to potential oncoming events when hpi™ is high. this statement is valid for both in-hospital as well as out-of-hospital cardiac arrest. regardless of the location of the cardiac arrest, there are at least four factors that appear to be of major importance for survival. the first is the time from collapse to delivery of treatment; the second is the quality of cardiopulmonary resuscitation (cpr); the third is the patient's co-morbidity and the fourth is the aetiology of the ca and the presenting rhythm. the present study will focus on the first three parts of the chain of survival, time from collapse to call/cpr/defibrillation. objectives: to describe the number of survivors following inhospital cardiac arrest (ihca) in sweden during one year and, based on estimations and assumptions, calculate the potential number of additional lives saved following improvements in the chain of survival. there was a strong inverse relation between delay to call for the rescue team and delay to treatment and survival. if delay from collapse to a/call and, b/start of cpr were reduced to < minute in patients with a longer delay than that and if c/time from collapse to defibrillation was reduced to < minutes among those with a longer delay than that: a/ ; b/ ; and c/ further lives could potentially be saved. we speculate that about additional lives (one per hospital beds each year) could theoretically be saved by improved adherence to guidelines regarding the first three components in the chain of survival in swedish hospitals yearly. conclusions: in , approximately patients (four per hospital beds) were successfully resuscitated following ihca in sweden. there was a strong negative relation between collapse and call for rescue team/cpr/defibrillation and -day survival. with reduced delay times a further lives (one per hospital beds) could theoretically be saved each year in sweden. the study was supported by grants from the laerdal foundation of acute medicine in norway (jh) and the scientific council of halland (fh). prophylactic versus clinically-driven antibiotics in comatose survivors of out-of-hospital cardiac arrest -a pilot study s. results: proportion of patients on antibiotics was significantly greater from day to in prophylactic group while there was no difference on days to . peak c-reactive protein in prophylactic group was significantly smaller ( ± vs. ± mg/l; p = . ). there was no difference in peak white blood cell count ( . ± . vs. . ± . ; p = . ), procalcitonin ( . ± . vs. . ± . microg/l; p = . ) and cd . except for positive mini bal on day ( % vs. %; p < . ), there was no significant impact on other microbiological samples and x-ray signs of pneumonia ( % in each group). use vasopressors/inotropes ( % in each groups), duration of mechanical ventilation ( . ± . vs. . ± . days), tracheal intubation ( . ± . vs. . ± . days), icu stay ( . ± . vs. . ± . days), survival ( % vs. %) and survival with good neurological outcome ( % vs. %) were also comparable. conclusions: tracheobronchial aspiration was documented in more than a quarter of comatose survivors of ohca using bronchoscopy on admission. in the absence of aspiration, prophylactic antibiotics reduced peak crp and the incidence of positive mini-bal on day and had no significant impact on other introduction: survival to discharge after in-hospital cardiac arrest (ihca) is poor ( − %) and has not improved despite developments in modern medicine. data on the aetiology of in-hospital cardiac arrests is very limited, and conducted studies include ihca patients resuscitated in emergency departments, intensive care units and high dependency units. objectives: to determine the underlying causes of ihcas occurring on general wards and investigate, whether the aetiology is independently associated with six months survival. methods: a prospective observational study between - in a finnish university hospital. we included all adult ihca patients on general wards who were attended by icu´s medical emergency team. definite aetiology was determined from the autopsy records and medical records. no autopsies were conducted solely for study purposes. the local ethics committee approved the study protocol (approval no: r ). results: the cohort consisted of patients, of which ( %) were male. median age of the patients was ( , ) years. altogether ( %) ihcas were monitored/witnessed, first rhythm was shockable in ( %) cases and ( %) patients survived six months. autopsy was conducted in ( %) cases. aetiology was determined as cardiac in events, of which were due to acute myocardial infarction and due to acute myocardial ischaemia without infarction. congestive heart failure was the third most prevalent reason in cardiac sub cohort ( ). altogether ihcas were considered non-cardiac; most common causes were pneumonia ( ), exsanguination ( ), pulmonary embolism ( ) and peritonitis ( ). cardiac ihcas were more commonly preceded by subjective symptoms (e.g. chest pain, respiratory distress) than non-cardiac ihcas ( % vs. %, p = . ), while objective vital dysfunctions preceded ihcas as often in both sub cohorts ( % vs. %, p = . ). in a multivariate logistic regression model monitored/witnessed event, shockable primary rhythm and low age-adjusted charlson comorbidity index score were factors independently associated with -day survival, but the aetiology (cardiac vs. non-cardiac) was not. conclusions: aetiology of ihcas on general wards is cardiac in % of the events. ischaemic reasons for ihcas were twice as common as shockable primary rhythms in this study. subjective symptoms and objective vital dysfunctions often precede general ward ihcas. however, neither the aetiology nor the presence of antecedents, but low comorbidity, observed arrest and shockable primary rhythm are factors associated with a favorable outcome. reducing in-hospital cardiac arrest by implementation of innovative early warning information system in a tertiary medical center introduction: in-hospital cardiac arrest (ihca) is a common and high-risk issue with less than % surviving to hospital discharge. most patients show signs of clinical deterioration in the hours before ihca. as a result, the development of vital signbased early warning system was designed to detect early signs of clinical deterioration before ihca attack in order to trigger early intensive care. objectives: in this study, we investigate the impact of the implementation of an innovative early warning information system on the rate of ihca and survival rate in ihca patients. methods: a multidisciplinary team among intensivists, cardiologists, emergency physicians, and nursing staffs in a tertiary medical center was organized since may . the key interventions include automatic national early warning score (news) calculating information system, nurses and physicians computer-based reminding alarm if news ≥ or more than highest scores among previous measurements, real time early warning screen saver and electric board, in service education and early warning monitor team. all patients admitted between january and january were enrolled. total , patients were divided into three groups: pre-interventional group from jan to april (n = , ), interventional group from may to june (n = , ) and post-interventional group from july to jan (n = , ). the definition of in-hospital cardiac arrest is the number of in-hospital cardiac arrest per thousand admitted patients. we compared the rates of ihca, hours survival rate and discharge survival rate in ihca patients among these groups. results: the rate of in-hospital cardiac arrest improved from . ‰ in pre-interventional group, to . ‰ in interventional group and to . ‰ in post-interventional group (p < . ). the hours survival rate in ihca patients increased from . % in pre-interventional group, to . % in interventional group and to . % in postinterventional group (p < . ). the discharge survival rate in ihca patients also increased from . % in pre-interventional group, to . % in interventional group and to . % in post-interventional group (p < . ). conclusions: the study demonstrated that implementation of early warning information system and innovative strategies could attenuate the rate of ihca, hours survival rate and discharge survival rate in ihca patients. introduction: although prolonged unconsciousness after cardiac arrest (ca) is a sign of poor neurological outcome, limited evidence shows that a late recovery may occur in a minority of patients. objectives: we investigated the prevalence and the predictive factors of delayed awakening in comatose ca survivors treated with targeted temperature management (ttm). methods: retrospective analysis of the parisian region out-of-hospital ca registry ( - ). in adult comatose ca survivors treated with ttm, sedated with midazolam and fentanyl, time to awakening was measured starting from discontinuation of sedation at the end of rewarming. awakening was defined as delayed when it occurred after more than h. results: a total of patients ( % male, mean age ± years) were included, among whom awoke. delayed awakening occurred in / ( %) patients, at a median time of h (iqr - ) from discontinuation of sedation. in / ( %) late awakeners, pupillary reflex and motor response were both absent h after sedation discontinuation. in multivariate analysis, age over years (or . , % ci . - . ), postresuscitation shock (or . [ . - . ]), and renal insufficiency at admission (or . [ . - . ]) were associated with significantly higher rates of delayed awakening. conclusions: delayed awakening is common among patients recovering from coma after ca. renal insufficiency, older age, and postresuscitation shock were independent predictors of delayed awakening. presence of unfavorable neurological signs at h after rewarming from ttm and discontinuation of sedation did not rule out recovery of consciousness in late awakeners. grant acknowledgment none note: this abstract has been previously published and is available at [ ] . it is included here as a complete record of the abstracts from the conference. introduction: viral infections play a key role in preventable deaths of children globally, and can be antecedents to bacterial pneumonia and sepsis. diagnosis of viral infection is often problematic due to non-specific clinical presentation. we developed a host immune response gene expression signature to distinguish systemic inflammation due to viral infection vs. bacterial or noninfectious causes. objectives: to define and validate the host immune response gene expression signature against multiple independent datasets. methods: four public geo datasets describing transcriptomic responses to viral infection were used to identify biomarkers, ranked by auc, which could separate affected from unaffected subjects. biomarkers that also responded (auc > . ) to non-viral causes of systemic inflammation were removed. remaining biomarkers were then ranked for performance in other geo transcriptomic datasets for viral infection; those with mean auc > . were retained. next, a greedy search was applied to the merged ( + ) viral geo datasets to identify the best combinations of biomarkers for discrimination of viral infection. the signature was then validated using independent datasets. results: a -gene signature (comprised of isg , il , oasl, adgre ) had auc . across the merged ( + ) viral geo datasets. this signature was validated in additional geo datasets covering a wide variety of viral pathogens including a time-course study of respiratory syncytial virus (rsv) in children (fig ) , and in two independent datasets of our own: adults from the emergency department (fig introduction: using a tourniquet to temporary cut off blood supply to the arm (remote ischemic preconditioning -ripc) has been shown to result in myocardial protection and reduced incidence of aki in patients undergoing cardiac surgery. however, a recently performed large multi-center trial in cabg patients showed no beneficial effects on clinically relevant endpoints [ ] . animal studies have shown an`early window of protection' in the - hours after ripc as well as a`late window of protection` - hours after ripc. several mechanisms have been suggested to mediate the protective effects of ripc, of which attenuation of the immune response is an important candidate, although this has hitherto also only been shown in animal studies [ ] . objectives: to determine the effect of single and repeated ripc, thereby investigating both the early and late windows of protection, on the inflammatory response during endotoxemia, a standardized, controlled model of systemic inflammation in humans in vivo. methods: we performed a randomized controlled study in healthy non-smoking male volunteers. subjects were assigned to either the single-dose ripc group, multiple-dose ripc group, or the control group (n = per group). the single-dose ripc group received dose of ripc, consisting of cycles of -minute ischemia of the arm followed by minutes of reperfusion just before administration of ng/kg lipopolysaccharide (lps). the multiple-dose ripc group received one dose of ripc per day on the days before the endotoxemia experiment day, and dose just before lps administration. results: lps administration resulted in a typical increase in body temperature, flu-like symptoms, and hemodynamic changes, with no differences between groups. administration of lps resulted in a sharp increase in plasma levels of the proinflammatory cytokines tnf-α, il- , and il- as well as the antiinflammatory cytokine il- . no differences in plasma levels of these cytokines were observed between the different groups ( figure ). conclusions: in the present study, we demonstrate that ripc does not affect the in vivo inflammatory response induced by administration of endotoxin in humans. these results implicate that ripc does not exert direct anti-inflammatory effects and that the previously observed protective effects are mediated through other mechanisms. furthermore, the absence of immunomodulatory effects of ripc in the present study tempers expectations of using ripc as an immunomodulatory treatment strategy in patients. introduction: sepsis-induced immune alterations are associated with secondary infections and increased risk of death ( ). mesenchymal stem cells (mscs) have been described as a novel therapeutic strategy for the treatment of diseases related to inflammation and tissue injury with their potent modulatory effects on immune system ( ) . objectives: in this study, we evaluated the immune-modulatory effects of human dental follicle mesenchymal stem cells (hd-mscs) on lymphocytes which are isolated from peripheral blood samples of sepsis and septic shock patients. methods: according to the international sepsis definitions conference ( ), patients divided into two groups as sepsis (group i, n = ) and septic shock (group ii, n = ). peripheral blood mononuclear cells (pbmcs) were isolated from venous blood samples of group i, group ii and healthy subjects named as group iii, n = . anti-cd /cd pbmcs were co-cultured with df-mscs, ifn-g stimulated df-mscs and with no mscs about hour. cd + cd + foxp + t cells levels (treg), lymphocyte proliferation and apoptosis were evaluated with the flow cytometry. results: df-mscs and ifn-g induced df-mscs cultures significantly supressed proliferation in sepsis group when compare to septic shock group(p < , ). conclusions: mscs demonstrate their effects on immune system by increasing the number and activity of regulatory t cells (treg) ( ) .in our study, mscs suppressed lymphocyte proliferation and apoptosis but increased the rate of treg cells in sepsis cocultures. this effect was more obvious with ifn -g stimulation. these responses were not seen in septic shock patients´blood samples and might be explained with anergy. our findings revealed that df-mscs application has immunoregulatory effects in sepsis. this approach opened a new area to work how will mscs be used to reduce organ dysfunctions and mortality in the clinical practice. introduction: inhibition of mitochondrial complex i is described in human and animal sepsis. , this may be responsible, at least in part, for the decrease in mitochondrial functionality seen in sepsis. we have recently demonstrated that the mitochondrial uncoupling agent, dinitrophenol (dnp) failed to increase body temperature and oxygen consumption (vo ) in septic rats, as was seen in healthy controls. this suggests that uncoupling is active in sepsis and can contribute to fever. we further postulated that the blunted effects of dnp in sepsis may be related in part to upstream mitochondrial inhibition. objectives: to determine if complex i inhibition by metformin in healthy rats can prevent the increment in temperature and oxygen consumption (vo ) by dnp, and thus mimic the pattern seen in sepsis. methods: vo was measured in awake, cannulated male wistar rats (approx g body weight) in metabolic cages (oxymax, columbus instruments). sepsis was induced with an intraperitoneal injection of faecal slurry at time . sham control animals received no slurry. fluid resuscitation ( ml/kg/h crystalloid) was started at hours and continued throughout the whole experiment. half the septic and sham animals were treated with an iv infusion of metformin ( mg/kg) between hours - . at and hours, all animals received iv dnp ( mg/kg). arterial blood gases, echocardiography and core temperature were measured at times , and , and and hours (i.e. before and after the two doses of dnp). mean arterial pressure was recorded continuously. wilcoxon rank sum test was used to compare groups and two-way anova to compare changes in continuous variables from baseline between groups. p values < . were considered statistically significant. results: pretreatment with metformin completely prevented the increase in temperature and vo induced by dnp in sham animals at hours and reflected that seen in non-metformin treated septic rats ( figure ). the reduction in myocardial contractility (stroke volume and vmax) seen in the septic animals treated with dnp was prevented by complex i inhibition at h. metformin was metabolically well tolerated, with no increase in blood lactate. conclusions: inhibiting complex i with metformin prevents the uncoupling effect of dnp in sham animals. this mimics the pattern seen in septic animals and confirms that both complex i inhibition and pre-existing mitochondrial uncoupling could be active in septic rats. objectives: the inflammasome is a multiprotein complex that stimulates cytokines release such as interleukin- β (il- β) and il- , involved in the inflammatory response. our aim is to quantify the state of activation of the inflammasome complex in septic patients, as well as to study possible differences in the cytokines levels in sepsis and septic shock, its temporary evolution, and its prognostic value. methods: prospective study including patients admitted to the icu with sepsis or septic shock during months. on days , and , il -β serum levels and real-time expression of nlrp inflammasome (nucleotide-binding oligomerization domain, leucine rich repeat domain containing protein and pyrin) were determined by elisa and real time-pcr respectively. demographic variables, severity scores on icu admission (apache ii and sofa), sepsis focus and mortality were collected. statistical analysis: t-student, kruskal-wallis and u-mann-whitney test as appropriate. results: there were included patients (severe sepsis and septic shock ). overall mortality was % ( patients). the levels of il- β on day ( . ± . vs . ± . pg/ml; p < . ) and nlrp inflammasome ( . ± . vs . ± mrna arbitrary units; p < . ) were significantly higher in septic shock patients than in sepsis, with no differences in the following days set ( and ). the il- β and nlrp inflammasome levels decreased significantly on days and compared to first day (p < . ), without differences between survivors and deceased patients. conclusions: in septic patients, inflammasome activation complex occurs, with higher levels detected in septic shock. decreased levels of il- β and nlrp inflammasome in septic process have been observed during evolution, actually without relation with mortality. introduction: according the consensus conference on weaning from mechanical ventilation, intubated patients should pass a spontaneous breathing trial (sbt) to assess their readiness to be extubated. objectives: to characterize patients who are extubated without any sbt and to compare them to patients who had at least sbt during their weaning period. methods: the prospective multicentre observational wind (weaning according new definition) study was performed from april to august . ventilation and weaning modalities were daily assessed until discharge in all intubated patients admitted to the participating icus. we defined ) weaning attempt (wa) as a spontaneous breathing trial (sbt) or an extubation (with or without sbt), ) successful weaning as an extubation without death or invasive mechanical ventilation within days. variables are presented as mean ± standard deviation, median [interquartile range] or number (percentage). comparisons were made using chi test, exact fisher tests, student t-test or wilcoxon rank sum test as appropriate. all statistical tests were two-sided and p value ≤ . were considered significant. results: among the patients included, patients had at least wa comprising patients whose first wa was a sbt and who had another type of first wa. these patients with no sbt had a total of wa: ( . %) planned extubation without sbt, self-extubations ( . %), wa while tracheostomized ( . %) and sbt after their first wa ( . %). the majority of patients with self-extubation had a successful weaning not requiring reintubation ( . %). almost a quarter (n = ) of the patients who were extubated without any sbt had a decision of withholding or withdrawing invasive mechanical ventilation, representing . % (n = ) of the deceased patients. we then excluded patients with a decision of limitation and patients with a self extubation to compare patients who had a planned extubation with or without sbt as first wa (table ) . patients with no sbt were younger, less severe and were more often admitted for unplanned surgery: they had an easier weaning with a lower (but non significative) rate of reintubation, a shorter duration of invasive mechanical ventilation and a shorter length of stay in the icu. conclusion: patients who are extubated without sbt seem to belong to three different groups: self-extubation, terminal extubation and patients in whom physicians anticipate an uneventful weaning and extubation. among the patients with a planned extubation and without any limitation decision, clinical judgment regarding weanability appears to be effective as this group of patients had a good outcome with a low reintubation rate. this study benefited of a grant of the non-profit association départementale des insuffisants respiratoires (adir) of the haute normandie, france introduction: decrease in diaphragmatic maximal relaxation rate (mrr) occurs early in the process of diaphragmatic fatigue and well before the diaphragm fails as a force generator; its measurement would, therefore, be especially valuable in icu patients during a weaning trial. however, the use of oesophageal pressure catheters for that purpose impedes wide clinical use. on the contrary, m-mode sonography, allows non-invasive, real-time measurement of the speed of the diaphragmatic motion. objective: purpose of our study was to investigate a possible correlation between diaphragmatic mrr traditionally acquired with transdiaphragmatic pressure (pdi) catheters (mrr-pdi) and an echo equivalent mrr (mrr-echo) acquired during different breathing conditions. methods: the slope of mrr was measured from the initial steepest part of the descending pdi curve simultaneously with the slope of the initial steepest descending part of diaphragmatic excursion with m-mode sonography. the protocol entrained four consecutive stages: i) breathing spontaneously during t-piece trial, ii) breathing spontaneously with performance of sniff-like maneuvers, iii) breathing with resistances of cmh o/l, and iv) breathing with resistances of cmh o/l with performance of sniff-like maneuvers. statistical comparisons between slope recordings from the two methods were performed with pearson correlation, while bland and altman plots were obtained in order to demonstrate reliable agreement between methods at each different breathing condition. results: a total of separate breaths during the four previously reported breathing conditions from six icu patients were recorded. table summarizes the slopes measured from mrr-pdi and mrr-echo as means ± standard deviations (sd), and their linear correlations with p values. statistical significant correlations were observed in all four stages; i) pearson correlation coefficient r = . , p < . , r = . , ii) r = . , p < . , r = . , iii) r = . , p < . , r = . , and iv) r = . , p < . , r = . . bland and altman plots demonstrating differences of measurements against means, as well as confidence intervals (means of differences ± sd) were obtained for each breathing condition. graph represents the bland and altman plot for spontaneous breathing with sniff-like maneuvers without resistances. high r indexes, indicating high agreement between the two methods were noted: i) . , ii) . , iii) . , and iv) . . the results of our study suggest a statistical significant correlation and reliability between diaphragmatic mrr measured from pdi tracings and the assumed diaphragmatic relaxation rate calculated from simultaneous m-mode sonographic recordings. clinical studies are required to confirm the potential of this non-invasive index of diaphragmatic mrr to be used as a predictor for weaning success. grant acknolwedgement none declared. introduction: high flow nasal cannula oxygen therapy (hf oxy) has been recently shown to decrease re-intubation rate, as compared with low flow oxygen therapy (lf oxy). [ ] , [ ] objectives: to assess the effects of hf oxy as compared with lf oxy on diaphragmatic electrical activity (eadi), respiratory rate (rr), tidal volume (vt) and gas exchange in the post extubation period. our hypothesis was that hf oxy, as compared with lf oxy, would improve gas exchange and decrease eadi. methods: patients underwent a crossover study immediately after extubation. each patient was submitted to three consecutive steps of hour each, according to an on-off design: ) hf oxy; ) lf oxy; ) hf oxy. oxygen fraction was maintained stable throughout the study. the eadi was continuously monitored through eadi cathether (maquet, solna sweden). the heated and humidified hf oxy was delivered through nasal cannula at flow rates of - l/min, (f&p, auckland new zealand). results: rr remained similar throughout the study, vt was significantly higher during the lf oxy step as compared with the hf oxy steps. oxygenation significantly improved during the hf period, whereas paco remained unchanged throughout the study (table ). eadi was significantly higher during lf oxy ( figure ) conclusions: since the eadi is correlated to work of breathing, our physiological data suggest that hf oxy significantly reduces wob while improving oxygenation in the post extubation period. further studies are required to define if diaphragm unloading may explain the favourable results of hf oxy in clinical trials. introduction: i non-invasive mechanical ventilation (niv) has been seen to play a major role in decreasing intubation rates in patients with severe exacerbation of chronic obstructive pulmonary disease and congestive heart failure. unsuccessful niv has been found to be independently associated with increased mortality in patients with arf. the niv failure and their impact on mortality in patients with inlfuenza infection is unknown. objectives: ) to describe non-invasive ventilation failure (nivf) rate, ) to identify risk factor for nivf using chaid (chi-square automatic interaction detection) and ) to determine if nivf is associated with icu-mortality. methods: secondary analysis in , patients with influenza requiring mechanical ventilation(mv). three groups were considered: ) patients with niv who failed (group a); ) patients with niv who succeeded (group b); and ) patients with invasive mv (group c). cox analysis was used to assess survival. risk factors for nivf were obtained using chaid. conclusions: niv failure is frequent and independently associated with icu-mortality in patients with influenza. chaid analysis might be a promising tool to assist in clinical decision-making. introduction: acute kidney injury (aki) after liver transplantation is a common complication with an incidence of approximately % [ ] , resulting in high morbidity and mortality. to increase the possibilities to prevent or treat aki after liver transplantation, it is essential to increase the knowledge on changes in renal physiology after liver transplantation. objectives: the aim of this study was to gain insights into renal perfusion, filtration and oxygenation in the immediate postoperative period in patients undergoing liver transplantation and to compare these data to those obtained from a group of patients undergoing major surgery with no postoperative renal impairment. methods: informed consent was obtained preoperatively from twelve patients with normal renal function accepted for liver transplantation. glomerular filtration rate (gfr) was measured preoperatively by plasma clearance of cr-edta. the patients were studied after liver transplantation in the icu in the immediate postoperative period, sedated and mechanically ventilated. systemic haemodynamics and renal variables where obtained during two -min periods. renal blood flow (rbf) and gfr were measured by the renal vein retrograde thermodilution technique and by renal extraction of cr-edta (=filtration fraction, ff), respectively. arterial (a) and renal vein (rv) blood samples were taken for measurements of arterial (cao ) and renal vein (crvo ) oxygen contents. renal oxygen consumption [rvo = rbf x (cao -crvo )], renal oxygen delivery (rdo = rbf x cao ) and renal oxygen extraction [ro ex = (cao -crvo )/cao )] were calculated. sixty-three patients undergoing uneventful cardiac surgery with no postoperative renal impairment served as controls. results: cardiac index ( %) and systemic oxygen delivery index ( %) were higher and systemic vascular resistance index was lower (− %) in the liver transplant group compared to controls (p < . ). rbf was % higher and renal vascular resistance was % lower compared to controls (p < . ). in the liver transplanted group, gfr was % lower compared to the preoperative value (p = . ), accompanied by a % increase in serum creatinine (p < . ). after surgery, when compared to controls, gfr and ff was % and % lower, respectively (p < . , p < . ), and rvo and ro ex were % and % higher, respectively, in the liver transplanted patients (p < . , p < . ). conclusions: despite the hyperdynamic systemic circulation, gfr is considerably reduced immediately after liver transplantation, most likely caused by a post-glomerular renal vasodilation decreasing upstream glomerular filtration pressure. renal oxygenation is impaired after liver transplantation due to the high rvo , which was not met by a proportional increase in rdo . introduction: acute kidney injury is common in critically ill patients and associated with increased short and long-term mortality. most published studies have focussed on patients with severe aki. little is known about the long-term outcome of patients with less severe aki. our objective was to determine the outcome of patients with different stages of aki at and years after admission to the intensive care unit (icu). we retrospectively analysed the data of all adult patients admitted to a multi-disciplinary icu in a teaching hospital in the uk between march -may . patients with chronic dialysis dependent renal failure were excluded. patients were categorised according to their maximum stage of aki during stay in icu as defined by the serum creatinine criteria of the kdigo classification. apache ii and sofa scores were used to describe severity of illness on admission to icu. in patients with > admission to icu, we only included the first admission in the analysis. results: data of adult patients were analysed of whom % had aki during their stay in icu. patients with any degree of aki had a higher mortality at and years but they were also sicker on admission to icu. conclusions: any stage of aki during critical illness is associated with an increased risk of mortality at and years. mortality is highest in patients with aki ii and iii. more work is necessary to explore the relationship between aki and long-term outcome and to identify independent risk factors for mortality. introduction and objective: observational studies of intensive care unit (icu) patients with acute kidney injury have shown a negative correlation between accumulation of fluids and survival [ ] . it is unknown whether rapid removal of accumulated fluids is feasible and beneficial. therefore we wish to perform a pilot trial of forced fluid removal vs. standard care in critically ill patients with high-risk acute kidney injury and severe fluid overload. methods: the ffaki-trial is a pilot, multicenter, randomized clinical trial recruiting adult intensive care patients with high-risk acute kidney injury and fluid overload defined as > % of ideal bodyweight. to reduce the signal-to-noise ratio we only wish to include patients with a high baseline risk of persistent renal failure. baseline risk will be calculated using a newly developed model, the renal recovery score (rrs), to predict the chance of recovering renal function within days. in-and exclusion criteria are shown in tables and . patients are randomized to either forced fluid removal or standard care for the entire icu stay. forced fluid removal is done by infusion of furosemide and/or fluid removal with continuous renal replacement therapy. the fluid removal rate is adjusted times daily to achieve a therapeutic goal of net negative fluid balance ≥ ml/kg/h. physiologic tolerance to fluid removal is continually evaluated according to predefined criteria of hypoperfusion: lactate ≥ mmol/l, mean arterial pressure < mmhg or mottling beyond the edge of the kneecaps. in case of hypoperfusion, fluid removal is suspended until all criteria have been resolved for a minimum of hour. the flow chart for the experimental ffaki-treatment is seen in figure , , . the primary outcome is cumulative fluid balance days after randomization. by inclusion of patients we are able to detect a difference of . l between groups (α = . and β = . renal recovery score ≤ %. fluid overload defined as a positive fluid balance ≥ % of ideal body weight. able to undergo randomization within hours of fulfilling the other inclusion criteria introduction: enhanced recovery pathways have been a focus for patient optimisation of morbidiy and mortality in the post-operative patient. significant mortality improvement was seen following the implementation of the emergency laparotomy pathway quality improvement care (elpquic) bundle with an adjusted risk of death from . % to . % ( ). the first national emergency laparotomy audit (nela) has since been published demonstrating a -day mortality of % and recommending access to pathways that identify need to escalate care ( ) . however acute kidney injury (aki) in critically unwell patients remains a major source of mortality, of up to %, and morbidity ( ). it is not yet clear whether enhanced recovery pathways, specifically those that utilise early goal directed therapy, affect the incidence of aki. objectives: to determine if there was a difference in incidence of combined aki pre and post implementation of an enhanced recovery protocol, one that had already demonstrated a significant mortality benefit. methods: a subgroup analysis of the data gathered via the elpquic bundle was performed ( ). we obtained buy-in from the participating centres and requested an extrapolation of values from their raw data. if required further data was obtained via the hospital's electronic path system. all data was reviewed by a second investigator. we defined the baseline creatinine as the best available preoperative creatinine from the past year. the data recorded included creatinine at baseline, post-op, worse recorded creatinine between day and day , make , p-possum and -day mortality data. ckd stage was identified via mdrd equation with age, gender and baseline creatinine. patients with aki were stratified according to kidgo stages of akin. primary outcome was the incidence of aki in each of combined pre and post elquic patient population. secondary outcome included the stage specific incidence of aki. results: there was no significant difference between the cumulative incidence of akin pre and post elquic implementation on day post-op ( . % vs . %, p = . ) or day post-op ( . % vs . %, p = . ). conclusion: this multi-centre cohort subgroup analysis demonstrates that the implementation of a quality improvement care bundle does not affect the incidence of aki. this is in contrast to the clear mortality benefit that such a care bundle has provided and provides stimulus to discover what factors may yet improve aki, and so further improve these patients outcome. introduction: it is now well documented that critically ill patients are exposed to stressful conditions and experience discomforts from multiple sources. improved identification of the discomforts of patients in intensive care units (icus) may have implications for managing their care, including consideration of ethical issues, and may assist clinicians in choosing the most appropriate interventions. objectives: the primary objective of this study was to assess the effectiveness of a multicomponent program (mcp) of discomfort reduction in critically ill patients. the secondary objectives were to assess the sustainability of the impact of the program and the potential seasonality effect. methods: we conducted a multicenter, cluster-randomized, controlled, single (patient)-blind study involving french adult icus. the experimental intervention was the implementation of the mcp including the following steps: identification of discomforts, immediate feedback to the healthcare team, and implementation of targeted interventions under control of local champions who received monthly feedback and organized monthly meetings with their healthcare team. all icus started with a -month period with no intervention, and then they were randomized to one of two groups: icus with mcp implemented during a -month period (experimental group) and icus without any programm during the same period (control group). to assess the sustainabilty of the impact of the mcp, the study was completed with a second -month period during which the mcp was no longer applied in the experimental group. the primary endpoint was the monthly overall score of self-reported discomfort from the french -item questionnaire on discomforts in icu patients (iprea) (range from to , the lowest possible level of discomfort to the highest). the secondary endpoints were the scores of each item of iprea. results: at the end of the -month period, taking into account the clustering design, the monthly overall discomfort score was lower in the experimental group ( parents were asked to consent to being contacted months after discharge, at which point they were asked to complete the pedsql, a generic measure of quality of life. the pedsql enables a total score, physical health summary score and psychosocial health summary score to be calculated, with possible scores ranging from - and higher scores equating to better quality of life. results: parents of children aged - . years (median age: . years; ( %) males), the majority of whom had had an emergency picu admission due to sepsis (n = , %) or respiratory problems (n = ; %), completed the pedsql months after discharge from picu. for the group overall the total score was . (sd . ), physical health summary score was . (sd . ) and psychosocial health summary score . (sd . ). babies aged - months (n = ) had total scores (m = . , sd = . ) comparable to those of healthy norms (m = . , sd = . ). however older children in all age groups had lower total scores than healthy norms. whilst % ( / ) of babies had scores of more than one standard deviation below the score of healthy norms, which is recognised as being of clinical significance, this rose to % ( / ) of children aged - years and % ( / ) of children aged - years. of note is that children ( %) aged - years had been admitted to picu for reasons related to trauma or neurological concerns whereas no child aged - months had been admitted for those reasons. conclusions: children who have had an emergency admission to picu are at risk for impaired quality of life months after discharge. the risk appears to be greater for children of years and older which is likely to be at least partly attributable to the underlying reason for their admission. evaluating quality of life outcomes in the longer term after picu discharge is warranted and identification of potential risk factors will enable interventions to be targeted to optimise outcomes after an emergency admission to picu. introduction: cognitive dysfunction is an important long-term complication of critical illness associated with reduced quality of life, increase in healthcare costs and institutionalization. delirium, an acute form of brain dysfunction that is common during critical illness has been shown to be associated with long-term cognitive dysfunction( ). objectives: the aim of this prospective cohort study was to estimate the prevalence and severity of cognitive dysfunction in survivors of critical illness and to evaluate if delirium duration is an independent determinant of the severity of cognitive dysfunction. methods: included were all adult patients admitted to a -bed medical surgical icu over a -month period(from march to february ).we excluded patients with preexisting cognitive dysfunction; those that in the evaluation by the psychologist on admission to the icu had evidence of impaired cognition through the mini mental state examination and patients who could not be reliably assessed for delirium owing to blindness, deafness or language deficit and patients for whom informed consent could not be obtained. after at least months of hospital discharge patients were assessed for cognition using a validated battery of tests including: )the digit span, forward and backward; ) the rey auditory verbal learning test (ravlt); ) the clock drawing test (cdt); ) the verbal fluency test; and the mini mental state examination. we classified patients as having mild or moderate impairment if they had either two cognitive test scores . standard deviation (sd) below the mean or one cognitive test score sd below the mean; we classified patients as having severe cognitive impairment if they had or more cognitive test scores . sd below the mean or two or more cognitive test scores sd below the mean. results: enrolled in the clinical trial were patients and patients were eligible for the cohort (fig. ) . four hundred and thirteen patients were tested ( - ) months after discharge. table shows demographic and clinical data of these patients. cognitive impairment was identified in ( . %) patients; ( . %) had mild or moderate and ( %) severe cognitive dysfunction (table ) . eleven( . %) patients with delirium for days or more presented severe cognitive dysfunction. in logistic regression analysis the duration of delirium for days or more was not an independent predictor of cognitive dysfunction(p = . ). conclusions: this investigation in an unselected population of critically ill medical and surgical patients demonstrates that cognitive dysfunction is a frequent and severe long-term complication in survivors of critical illness. on the other hand, unlike other studies we couldn't demonstrate that the duration of delirium is an independent determinant of cognitive impairment. table positive determinants of the evolution of the eq-index were time and admission glasgow score (p . and . respectively) while age, duration of mv and weakness were negatively associated (p . , . and . ) ]. eq-eva paralleled eq-index changes. conclusions: after icu discharge, patients suffered frequent longterm consequences that negatively affect their hrqol. alterations in mobility, daily activities and personal care exhibited the greatest deterioration. prevalence of pain, anxiety and depression was high even before icu admission, aggravated after -year post-discharge ( % of patients) duration of vm was the only intra-icu variable that affected hrqol. pre-icu conditions as age and the extent of neurological injury and, after icu, time and weakness, were also independent determinants. the present study was supported by the argentinian society of critical care (sati) introduction: diffuse axonal injury (dai) is a common event following traumatic brain injury (tbi), which is likely related to worst long term outcome. diffusion tensor imaging (dti), a magnetic resonance imaging (mri) technique that investigates white matter integrity, is recognized as a useful tool to quantify dai extent in tbi and possibly predict outcome. few studies explored whole brain longitudinal changes of dti-derived parameters in single subjects following tbi. methods: patients with severe tbi underwent brain mri including dti ( directions, b = , voxel size x x ) - weeks and year after trauma. age-matched healthy controls underwent the same dti protocol. we used region of interest (roi) automated analysis (www.mristudio.org) covering the entire brain to quantify white matter integrity. the roi fractional anisotropy (fa), mean diffusivity (md), axial diffusivity (ad) and radial diffusivity (rd) were extracted. abnormalities were defined as dti values more than standard deviations below or above the mean values of controls for each roi. results: tbi patients with a median age of (iqr - ) and a median gcs score of (iqr - ) were included. had diffuse injury according to marshall classification. regions with increased md and reduced fa were more than expected in both early and late scan (p < . binomial test), while ad and rd abnormalities were less common. more than % of the patients had increased md in the early scan in the frontobasal girae, corona radiata and thalami; in late scans md abnormalities were larger and more diffuse, affecting also all frontal and temporal girae and corpus callosum. fa was frequently reduced in the corpus callosum, internal capsule and fronto-basal girae in early scan, while in late phase reductions were similar but more widespread, also including the central girae, cerebellum and inferior longitudinal fascicles. the number of regions with abnormal md increased over time (p < . mann-whitney), whereas for fa it was not statistically different. an inverse correlation between the number of roi with altered md at early scan and outcome evaluated with gose was found (p < . , spearman r). the present results indicate that early alterations of mean diffusivity and fractional anisotropy persist or worsen (for md) at year after tbi, suggesting an ongoing loss of white matter integrity and gliosis. the more frequently affected regions were the frontal girae, corpus callosum, corona radiata, inferior longitudinal fascicles and cerebellum. the number of roi with early abnormal mean diffusivity is inversely correlated with outcome. all patients underwent ssep, aep and tms the day before operation. after operation, all patients were delivered to icu intubated and mechanically ventilated. patients demonstrated full recovery from anesthesia with regaining consciousness, passed spontaneous breathing test (sbt) and gained points on cst without deficiency. these patients had none or low level of dysphagia and were successfully extubated after operation. these patients formed st group. patients had a neurogenic dysphagia and formed nd group. we performed ssep, aep and tms on all patients immediately after admission to icu. results: we revealed no clinical or electrophysiological points that could have predicted neurogenic dysphagia before operation. in our research, we found the ep values which were different for the first group and for the second group. the aep and tms data were not informative. we found instrumental the ssep values that reflected perioperative cct dynamics, lat p , amp n , auc n -n , auc n -n . these ssep values were used to create a prognostic rule through logistic regression and roc-curves. as a result, we were able to predict neurogenic dysphagia in early introduction: eeg monitoring during the first hours robustly contributes to the prediction of either poor or good outcome in comatose patients after cardiac arrest [ ] . quantitative eeg (qeeg) measures can be useful to visualize evolution of the eeg over hours. we recently proposed the cerebral recovery index (cri), an index based on a combination of five qeeg measures grading the severity of hypoxic brain damage on a scale from zero to one to facilitate prognostication [ ] . objectives: to evaluate the prognostic accuracy of a revised cri, after optimalization by the use of a random forest classifier instead of a manually chosen feature combination and the addition of four qeeg measures, resuscitation parameters and patient characteristics. methods: in this prospective cohort study, consecutive comatose patients after cardiac arrest were included in two intensive care units. continuous eeg was recorded during the first three days. outcome at months was dichotomized as good (cpc - ) or poor (cpc - ). nine qeeg measures were extracted: alpha to delta ratio, signal power, shannon entropy, delta coherence, regularity, the number of burst/min, mean and max burst correlation, and fraction of burst correlation > . . these measures were combined with patient characteristics and resuscitation data, including sex, age, initial heart rhythm, in-versus out-of-hospital-cardiac-arrest, and presumed cause of cardiac arrest. patients were randomly divided over a training and a validation set of respectively and patients. within the training set, a random forest classifier was fitted for each hour after cardiac arrest. based on results in the test set, two thresholds were chosen: one for predicting poor neurological outcome and one for predicting good neurological outcome. subsequently, the revised cri was evaluated in the validation set. results: poor outcome could reliable be predicted with the revised cri (with % specificity) in the validation set with a sensitivity of and % at respectively and hours after cardiac arrest. good neurological outcome could be predicted with a sensitivity of and % at a specificity of and %. conclusions: here we show that a combination of qeeg and clinical measures, extracted and combined by a random forest classifier, provides reliable, objective prognostic information. this revised cri can be used for the prediction of both poor and good neurological outcome, thereby poor outcome can be reliable predicted (without false positives) with relatively high sensitivity. the revised cri is expressed as a single index between and , which can be used in real time at the bedside, even by professionals who are not trained in eeg interpretation. introduction: continuous electroencephalography (ceeg) allows real-time monitoring critically-ill patients neurophysiology and to detect non-clinical seizures in comatose patients, delayed cerebral ischemia after subarachnoid haemorrhage, and guide therapies for status epilepticus. the application of ceeg is still limited because it requires awkward analysis by experienced neurophysiologists of huge amount of eeg tracings. quantitative eeg (qeeg) techniques, i.e.amplitude integrated eeg (aeeg) and density spectra array (dsa), have been developed to simplify the complexity of eeg interpretation, to allow rapid evaluation of cerebral background electrical activity and the power spectrum of the eeg frequencies derived from raw data eeg. these developments offer the potentiality to transform an instrument interpreted by neurophysiologist afterwards in a monitoring tool useful to icu staff. objectives: to test the hypothesis that eeg-nonexpert neurointensivists can obtain real-time reliable information from qeeg after training under the supervision of an in-house neurophysiologist. to describe the implementation of qeeg monitoring in neurointensive care units. methods: the implementation occurred in sequential phases. ceeg was recorded using surface electrodes according to the international - system, on a bipolar longitudinal montage in patients with brain injury. qeeg-naïve neurointensivists, after a short training from a neurophysiologist followed by daily supervision for the study period, were subjected to a baseline test evaluating aeeg and dsa traces. each panel consisted of raw eeg data and qeeg tools: the color density spectral array (dsa), amplitude integrated eeg (aeeg) and the burst suppression rate (bsr). after this evaluation, daily qeeg evaluation was performed by the neurointensivists and reviewed by the neurophysiologist. results: from july to april we monitored patients ( ± years, male) admitted for brain trauma ( %), stroke introduction: it has been noted the importance of job satisfaction in healthcare services and the consequences resulting therefrom, such as increasing the quality of care services provided and satisfaction of their users. objectives: to develop a model of influence of human resource management directed to the quality management and organizational excellence in the organizational results, from the perspective of healthcare staff. methods: we carried out a research study, of a transversal nature, whose study population were a total of ( , % physicians, , % nurses and , % nurse assistants) icu staff. a personal questionnaire was used to measure, through likert scales of points, the application of human resource practices of high commitment (hr), the quality of service provided to the patient (quality), the satisfaction with the capacity of the service (capacity), the personal satisfaction with the work done (satisfaction) and the affective commitment with the organization (commitment). results: the measure models of these five constructs were validated by confirmatory factorial analysis, whose results were satisfactory. the measurement model of hr is a second order construct which is introduction: in the period between - , a successful implementation project was finished aimed at strict blood glucose level (bgl) regulation in the intensive care unit (icu) [ ] . we hypothesized that glucose control would afterwards slack and that implementing other measures to modify behavior would be required to regain adequate glucose control. methods: a prospective study was performed in a -bed mixed medical-surgical icu of a university affiliated teaching hospital. all bgl values were extracted from the icu database in years following the implementation project until december . following the project, bgl targets were set at a range of - mg/dl, nurses' instructions for keeping bgl values in target were not changed. after . years, an automated warning system was implemented in the patient data management system that triggered a centrally placed monitor with feedback about the need for obtaining a bgl value, based on the actual value compared to the previous one. the primary outcome measure was mean bgl. secondary endpoints were sampling frequency, bgl within predefined targets, incidences of severe hypoglycemia, and hyperglycemia. the analysis was restricted to patients with at least two blood glucose measurements. these indicators were analyzed over the course of time using the xmr control chart, a tool belonging to statistical process control. results: data of patient admissions were evaluated, which corresponded to , bgl measurements. the bgl sampling interval (figure ), mean bgl and percentage of severe hypoglycemia all increased after introducing nurses' instruction and decreased significantly after monitoring feedback (p < . ). percentage of severe hypoglycemia events, which is associated tosafety, decreased with some delay after nurses' instruction and remained unchanged ( . % on average) and stable after introducing monitoring feedback. percentage of "in range" measurements of both normoglycemia ( - ) and protocol recommended ( - ) decreased after nurses' instructions and then increased after feedback monitoring. mean of per patient's standard deviation as a measurement of variability remained unchanged and stable after nurses' instruction and even decreased after monitoring feedback. conclusion: even after successful implementation of a bgl control system, behavior changed within months with inherent worsening of bgl control. an automated warning monitor in a central location was able to restore bgl control in the icu. using objective: the overall objective of this research program is to use the kinarm to define the neurocognitive phenotype of icu survivors (i.e. required invasive mechanical ventilation and/or vasoactive agents for hemodynamic support). this group is compared to healthy age-and gender-matched controls, as well as active control groups. these active control groups were patients ) pre-and ) post-cardiac surgery, and ) patients postcardiac arrest. methods: participants performed tasks on the kinarm that ranged from simple sensorimotor tasks to more complex executive tasks. for each task, - performance metrics were recorded. these metrics were compared to a normative database of age-and gendermatched controls and z-scores were generated. a composite score for each task was generated using a score derived from maholanobis distance, with increasing scores representing worse performance. cluster analysis was applied to these performance metrics using euclidian distance. (fig. ) . conclusions: serial mlt measurements significantly underestimate muscle wasting in critical illness and are not related to development of muscle weakness. in comparison, changes in rf csa reflect changes in 'gold standard' methods of assessing muscle mass, and are related to loss of muscle mass and function in critically ill patients. there is significant evidence that electronic prescribing can significantly reduce the errors, however implementation of it is a long term project and is not feasible in attempt to improve medicines safety over short period of time. therefore we aimed to improve safety of a current paper based system. multidisciplinary intervention was chosen as this approach has been previously demonstrated to reduce medication errors on icu . objectives: evaluate effect of multidisciplinary intervention to improve medicines safety. methods: over the course of months following interventions were introduced: development and implementation of new icu specific iv infusion chart, prescription checks during nursing handover, introduction of daily pharmacy handover and on-site feedback, additional medicines training for current staff and new medicines safety induction module for new-starters. outcome data was based on monthly spot audits carried out by pharmacy staff. comparison is made between quarter and quarter after the start of intervention. chi-square test was used to compare the two datasets. results: there were prescriptions analysed in q and in q . we observed a five-fold reduction in prescription validity errors from . % to . % (p < . ). and nearly ten-fold reduction in administration of medicines against non-valid prescriptions from . % to . % (p < . ). pre-printed icu specific iv infusion chart eliminated errors related to variable dilutions, choice of diluent, incorrect or inconsistent infusion rates. month-by-month trends are presented in figure . conclusion: multidisciplinary intervention has resulted in significant improvement in medicines safety. introduction: the concept of frailty has been defined as a multidimensional syndrome characterised by the loss of physical and cognitive reserve that predisposes to adverse events. the prevalence of frailty amongst the critically ill is unknown, however it is probably increasing. this audit aimed to look retrospectively at our admissions to intensive care, to categorise them into frail or non frail, and evaluate how frailty correlated with icu length of stay and mortality methods: a retrospective case note review of all patients admitted to intensive care over a six month period in the victoria infirmary and then queen elizabeth university hospital in glasgow. classification of frail or non-frail was done using a combination of the clinical frailty score (cfs) and edmonton frailty scale. [ , ] . once classified into frail and non-frail we looked at icu outcome, length of stay, apache, weight on admission, lowest albumin and admission haemoglobin and compared the frail population to the non-frail population. results: two hundred and eighty four patients were admitted to intensive care in this time period. of those, were over the age of years. of the patients, patients were deemed to be frail, and were deemed to be non-frail using the cfs. approximately % of the patients admitted to intensive care are over the age of . there was no significant difference found in mortality, icu length of stay or hospital stay, apache or weight between the two groups. [see table ] conclusions: we know that the utilisation of intensive care resources by older people is rising. our data shows that almost % of those admitted to icu are over the age of . interestingly, there is no significant difference between the non frail and frail groups of patients admitted to intensive care. this may be because of small sample size. the length of stay of the frail patient is shorter and this may be because as intensivists we are better at treatment limitation in this group of patients. no difference in overall mortality suggests that the patients we deem suitable for intensive care who are frail do as well as the non-frail cohort as the selection process for admission has been adequate. patients deemed to be frail are more likely to be dependant on care if they survive, with % requiring some sort of support on discharge. most studies show that frailty is associated with increased mortality so it is indeed interesting that this audit has shown no difference between the two groups. figure shows a significant increase in admissions among the elder groups along the five-year periods. the severity scores increased significantly as shown in figure (p < . ). icu lenght stay also decreased significantly (table ) introduction: in our intensive care medicine (icu) department we used a database (gespac) with uniform and quality data for all admissions from to , which allows us to study the evolution of severity scales and the clinical activity by age and type of patient. objectives: to describe the effectiveness of severity scales used in our icu over years by age and type of patient. methods: a retrospective, single-center and descriptive study was conducted from to . all patients admitted consecutively were included. patients with lenght of stay less than hours were excluded.the severity scales we analyzed were mpm , mpm , saps , apacheiii. patients were divided in groups of age by quartiles (< years, - years, - years, > years). the type of patient was classified in medical and urgent or scheduled surgery. we used descriptive statistics. qualitative variables are expressed as percentages and quantitative variables are expressed as means and standard deviations (± sd) and roc curves for the analysis of discrimination. we used spss v . results: we included patients, were men ( %), mean age was . years (sd . ). icu mortality was . %. in figure we show curve roc corresponding to the severity scales for all patients, mpm has a significantly worse discrimination respect to the other scales. mpm , saps and apache iii have a similar behavior. in table we show the severity scales effectiveness by age groups. in table we show the severity scales effectiveness by type of patients. we observed a decrease of effectiveness of severity scales over time, however this effectiveness remains optimal in all the severity scales except for mpm . introduction: we implemented a critical care epr using the quadramed system on the th sept . our objective was to evaluate whether the epr had improved the quality of our documention and the responsiveness of our notes. methods: we evaluated the patient record from hospital days prior to the implentation of the epr and hospital days months after using and refining the system. results: the proportion of completed nursing risk assessments did not change after implementation of the epr. they depend on the user to shedule their completion. safety checks for arterial and cvc lines were well established and changed little. there was an improvement in the percentage of shift checks completed when they were automatically sheduled. the system provides a date, time and audit trail for each entry. the user traceability in the medical notes increased. the presence of the author´s name improved from % to %, the date from % to %, the time from % to %, and signature from % to %. legibility improved from % to %. the proportion of entries with a contact number dropped from % to %. the nursing care plans in the paper notes were better completed than the medical notes, but still improved. the presence of the nurse´s name increased from % to %, the date from % to %, the time from % to % and the signature from to %. legibility was % in both groups. the quadramed system provides automatic calculations of early warning scores and fluid balances.the more complicated the calculation, the greater the improvement. integration of data: · the increase in data points that cross populate is: + · the allergy advice populates all the sheets compared to an average of on paper (excluding the drug chart). · the average number of scheduled events (that instruct staff to perform functions) has gone from to . conclusions: . the largest improvement came in the accessibility of the notes. they can now be accessed within one minute from any pc in the trust. previously a standard time to deliver notes was two days, reducing to one day in an emergency. . correct filing of the epr notes and the search facility reduced the average time to complete the audit by minutes per patient. . the user audit trail and traceability improved in both medical and nursing paperwork, more so in the former. this is explained by a baseline of lower documentation standards in the medical group. . the typed out notes are now legible. . there was a large improvement in the quality of data calculations that are now up to %. . there was a large increase in the number of scheduled events, but this these only lead to an improvement in documentation when they were automatically scheduled by the computer. there was no improvement when user scheduling was required. we noticed very high levels of satisfaction regarding the professional care (frequency of communication, physician skill and competence, understanding information, honesty and facilities of getting information) and overall with care. satisfaction was even higher when we considered the usefulness of the ecp. every respondents supported it as a complement to daily information but it was only supposed to replace verbal information in , %. % did not access the website because of sufficient verbal information or cultural or age-related difficulties. the access was mostly via computer ( , %) followed by smarthphone ( , %). particularly desired were daily updates, an established timetable and more detailed information. there were no statistically significant differences in the need of web access among families living near the hospital and not or prior experience with icu familiar admission. conclusions: ecp appears to decrease the level of anxiety of families, improves perceived quality and can help to combine patient care with their work and personal responsibilities without replacing the daily evolution provided by physicians. introduction: neuroimaging shows promise for determining early prognosis after cardiac arrest (ca). nevertheless, conventional mri sequences, as t -weightened sequences, are currently considered not precise enough to detect brain structural anomalies in this context, and therefore are supposed to be unable to accurately predict outcome . objectives: we hypothesize that the combined use of cortical thickness measurement and subcortical grey matter volumetry could provide an early and accurate in vivo assessment of the structural impact of cardiac arrest (ca), and therefore could be used for longterm neuroprognostication in this setting. methods: prospective study undertaken in five intensive critical care units affiliated to the university in toulouse (france), paris (france), clermont-ferrand (france), liège (belgium) and monza (italy). high-resolution anatomical t -weighted images were acquired in anoxic coma patients ( +/− days after ca) and matched controls. patients were followed up one year after ca. cortical thickness was computed on the whole cortical ribbon and deep grey matter volumetry was performed after automatic segmentation . brain morphometric data was employed to create multivariate predictive models using learning machine techniques ( figure ) . results: patients displayed significantly extensive cortical and subcortical brain volumes atrophy compared to controls. a dissociated vulnerability to anoxic insult was observed: subcortical volumes were related to ca duration and cortical thickness values were linked to the time to mri acquisition ( figure ) the accuracy of a predictive classifier, encompassing cortical and subcortical components has a significant discriminative power (auc = . ). the anatomical regions which volume changes were significantly related to patient's outcome were: frontal cortex, posterior cingulate cortex, thalamus, putamen, pallidum, caudate, hippocampus and brainstem ( figure ) conclusions: these findings are consistent with the hypothesis of pathological disconnection within a striatopallidal-thalamo-cortical mesocircuit induced by ca and pave the way for the use of combined brain quantitative morphometry in this setting. clinical and electrophysiological correlates of absent somatosensory evoked potentials after post-anoxic brain damage: a multicentre cohort study conclusions: our data confirm that bilateral absence of n reflects severe post-anoxic cerebral damage and therefore frequently correlates with concordant clinical and eeg signs of poor outcome. however, our study also identified a subset of patients with discordant signs, in whom clinical examination and/or eeg were reactive despite bilaterally absent n . our findings raise further questions on outcome prognostication after ca and underline the importance of multimodal assessment in this setting. the response time threshold for predicting favorable neurological outcomes in patients with bystander-witnessed out-of-hospital cardiac arrest introduction: it is well established that the period of time between when a call in made to emergency medical service (ems) to the point when ems arrive at the scene (i.e., the response time) affects the survival outcomes in out-of-hospital cardiac arrest (ohca) patients. however, the relationship between response time and favorable neurological outcomes remains unclear. we therefore aimed to determine a response time threshold in bystander-witnessed ohca patients that is associated with positive neurological outcomes and to assess the relationship between the neurological outcomes and response time in ohca patient. methods: this study was a retrospective, observational analysis of data from , episodes of bystander-witnessed ohca between and in japan. we used classification and regression trees (carts) and receiver operating characteristic (roc) curve analysis to determine the threshold of response time associated with favorable neurological outcomes (cerebral performance category or ) one month after cardiac arrest. results: both carts and roc analyses indicated that a threshold of . min was associated with improved neurological outcomes in all bystander-witnessed ohca events from cardiac origin. furthermore, bystander cardiopulmonary resuscitation (cpr) prolonged the threshold of response time by min (to . min). the adjusted odds ratios for favorable neurological outcomes in ohca patients who received care within ≤ . min was . ( % confidential interval: . - . , p < . ). conclusions: a response time ≤ . min was closely associated with favorable neurological outcomes in all bystander-witnessed ohca patients. bystander cpr prolonged the response time threshold by min. methods: patients with established out-of-hospital cardiac arrest (ohca) who underwent cardiopulmonary resuscitation with subsequent return of spontaneous circulation were retrospectively enrolled. two hundred and eight dic patients diagnosed by the japanese association for acute medicine (jaam) dic criteria were divided into two subgroups with hyperfibrinolysis ( ) and without hyperfibrinolysis ( ). the definition of hyperfibrinolysis was made by a fdp level > μg/ml. platelet count, global markers of coagulation and fibrinolysis were measured times after admission to emergency department (t , - ; t , - ; t , - ; t , - hr). the outcome measure was the hospital all-cause mortality. results: patients with hyperfibrinolysis had higher dic, sirs, and sequential organ failure assessment (sofa) scores associated with higher prevalence of mods, leading to a higher mortality rate of . % in comparison to patients without hyperfibrinolysis ( . %). stepwise logistic regression analyses confirmed that dic, sofa scores, and lactate levels are independent predictors of patient death. hyperfibrinolysis also predicted patient death. tissue hypoperfusion (as indicated by lactate level) is a main determinant of hyperfibrinolysis. receiver operating characteristic curves showed a significant discriminative performance of dic scores for patient death. kaplan-meier curves showed that dic, especially dic with hyperfibrinolysis, significantly affected patient death. conclusions: dic with the fibrinolytic phenotype during the early phase of post-cpr more frequently results in sirs and mods, and affects the outcome of ohca patients. hypoxia/ischemia during cardiac arrest and cpr are considered to be the cause of increased fibrin(ogen)olysis. the association between tracheal intubation during pediatric inhospital cardiac arrest and survival l.w. andersen , , t. introduction: tracheal intubation is common during pediatric inhospital cardiac arrest, although the relationship between intubation during cardiac arrest and outcomes is unknown. objective: to determine if intubation during pediatric in-hospital cardiac arrest is associated with improved outcomes. methods: this was an observational study of prospectively collected data from united states hospitals participating in the get with the guidelines -resuscitation registry. we included pediatric patients (age < years) with index in-hospital cardiac arrest. we excluded patients who were receiving invasive mechanical ventilation and/or had an invasive airway in place at the time chest compressions were initiated. the exposure was tracheal intubation during the cardiac arrest. the primary outcome was survival to hospital discharge. secondary outcomes included return of spontaneous circulation and neurological outcome. a favorable neurological outcome was defined as a score of - on the pediatric cerebral performance category score. patients being intubated at any given minute (from to minutes) were matched with patients at risk of being intubated within the same minute (i.e. still receiving resuscitation) based on a timedependent propensity score calculated from multiple patient, event, and hospital characteristics. modified poisson regression with adjustment for matching and clustering were then performed to obtain risk ratios. results: patients were included. of these, ( %) were intubated during the cardiac arrest. in the time-dependent propensity score-matched cohort (n = ), survival was lower in those intubated compared to those not intubated during cardiac . ], p = . ) between those intubated and not intubated during cardiac arrest. the association between intubation and decreased survival remained in the majority of our sensitivity and subgroup analyses conclusions: tracheal intubation during in-hospital pediatric cardiac arrest was associated with decreased survival to hospital discharge. these findings challenge the present resuscitation paradigm for pediatric in-hospital cardiac arrest. introduction: substantial proportion of patients who suffered cardiac arrest do not respond to conventional cardiopulmonary resuscitation. recently, extracorporeal cardiopulmonary resuscitation (ecpr) has been introduced as a potentially life-saving procedure in refractory cardiac arrest. objectives. the aim of our study was to evaluate the relation between ecpr survival, lactate levels and blood ph. methods: eligible patients for this analysis had to undergo ecpr after at least ten minutes of unsuccessful cardiopulmonary resuscitation with a minimum of three defibrillation attempts. for extracorporeal life support (ecls) we used cardiohelp system (maquet, germany) or levitronix centrimag blood pump (levitronix, usa). lucas ii system (physiocontrol, sweden) was used for chest compressions during ecls insertion and cannulas were placed with percutaneous puncture under fluoroscopy or ultrasound control. blood lactate and ph levels measured before ecls insertion and after hours were used for this study. results: we analyzed data from patients treated with ecpr for refractory cardiac arrest. the mean age of our patients was years ( - ). out-of-hospital cardiac arrest occurred in patients, patients suffered from in-hospital arrest. thirty-day mortality in our group was % and % of patients recovered with good neurological outcome. percutaneous coronary intervention was performed in ( %) patients. baseline value of lactate was . ± . mmol/l, initial ph . ± . . in comparison with survivors, patients who died had significantly higher initial lactate levels ( . ± . vs. . ± . ; p < . ) and lower baseline ph ( . ± . vs . ± . ; p < . ). moreover, survivors had significantly lower lactate levels after hours. conclusions: ecpr represents virtually the last chance to survive refractory cardiac arrest. the levels of blood lactate and ph are significantly associated with clinical outcomes of ecpr. introduction: post-cardiac arrest survivors treated with therapeutic hypothermia (th) remain comatose after rewarming. in contrast to survivors without th, neurological prognostication is imprecise due to a persistent sedative effect [ ] . objectives: we aimed to evaluate clinical signs and findings that could predict neurological recovery and determined the optimal time for prognosis. methods: we retrospectively reviewed database of post-arrest patients treated with th in our hospital from to . cerebral performance category (cpc), neurological signs and findings in eeg and brain ct were evaluated. neurological recovery was scored as favorable neurological outcome, namely normal cerebral function(cpc ) and moderate disability(cpc ) or unfavorable neurological outcome, namely severe disability(cpc ), vegetative state(cpc ) and death(cpc ). neurological signs and findings in eeg and brain ct, which possibly predicted neurological recovery, and the optimal time to evaluate neurological status were analyzed. results: th was performed in post-arrest patients. approximately % ( / ) of th-patients survived and % of the survivors had favorable neurological outcome. findings predicting unfavorable outcome at discharge were lack of pupillary response and/or gag reflex after rewarming, and the absence of at least one of the brainstem reflexes, no eye opening or motor response worse than pain withdrawal (m ≤ ) on the seventh day. (table ) myoclonus and seizure could not be used to indicate poor prognosis. one of survivors with myoclonus had full recovery and % of the survivors with seizures regained consciousness upon discharge. findings of eeg and brain ct showed that the patients with burst-suppression eeg pattern or brain swelling became vegetative or died, but the prognostic values of these findings were inconclusive. conclusions: our study showed that the simple neurological signs helped predict short-term neurological prognosis of comatose survivors undergoing th. the most reliable signs which determined unfavorable outcome were the lack of the pupillary light response and gag reflex. the optimal time to assess prognosis was either at to hours or days after return of spontaneous circulation. physicians can use these neurological signs to evaluate the prognosis of postcardic arrest survivors treated with th. objectives: procalcitonin (pct) and presepsin are biomarkers associated with severe infections. we asked, if they could be used to reflect the severity of the post-cardiac arrest syndrome and to predict poor outcome. a significantly greater increase in procalcitonin from admission to h was observed in patients with eventual poor outcome compared to those with a favorable one (p < . ). presepsin levels were on average constantly higher in patients with poor outcome but did not show any statistically significant changes in repeated measures analysis of variance. conclusions: plasma procalcitonin may be a useful tool for the evaluation of long-term outcome of out-of hospital cardiac arrest patients at the icu. on the contrary, presepsin did not provide clinically relevant additional predictive value in the study setting. introduction: prognosis of cardiac arrest survivor is mainly determined by ischemic brain injury. post-cardiac arrest state is characterized by elevated circulating cytokines and hemodynamic instability, called as a sepsis-like syndrome. in many critical ill diseases such as acute pancreatitis and sepsis, a low serum level of high-density lipoprotein (hdl) and apolipoprotein a- (apoa ) were associated with poor outcomes. objectives: in this study, we examined whether a serum level of hdl and apoa at intensive care unit (icu) admission is associated with a neurologic outcomes in cardiac arrest survivors. methods: this study was a retrospective observational study conducted in a single tertiary urban hospital icu. all admitted patients following cardiac arrest were screened during from march to december . patients younger than years and without admission lipid panel were excluded. neurologic outcome was determined by hospital discharge cerebral performance categories (cpc). good neurologic outcome was defined as cpc and . note: this abstract has been previously published and is available at [ ] . it is included here as a complete record of the abstracts from the conference. we analyzed all patients admitted on hospital ward that were assisted by the ihca team. patients admitted less than hours on ward and patients not eligible for resuscitation were excluded. demographic data (age and gender) were collected. we analyzed the type of patient (medical or surgical), the schedule in which the ihca happens (weekdays from hours am to hours pm and the rest, every day from hours pm to hours am, weekend and holidays), ihca witnessed, the ihca team time reaction, ihca established or not at ihca team´s arrival, return of spontaneous circulation (rosc) and hospital mortality. statistics:qualitative variables are expressed as percentages and compared using the x -test; quantitative ones are expressed as means and standard deviations (± s.d), and analyzed using student´s t-test. multivariate logistic regression was performed, with hospital mortality as the dependent variable. the level of significance was placed at p < . . the statistical analysis was performed using specific software ( ibm spss statistics for windows, version . . armonk, ny: ibm corp). results: patients were assisted by the ihca team and patients were included. in figure we described the characteristics of the study population. the beginning of cardiopulmonary resuscitation (cpr) maneuvers were immediate on ward, according to ihca protocol. the arrival of ihca team was less than minutes in all cases. table shows an assosciation between hospital mortality and the capability of anticipation of ihca situations (schedule, witness, pre-cardiac arrest …). table shows the persistence in the multivariate analysis of the relationship of these factors with the hospital mortality. conclusions: the number of activations of ihca team is remarkable, mortality of these patients is very high despite being patients on ward without a bad expected outcome. the improvement in the factors associated with the capability of anticipation of ihca situations (schedule, witness, pre-cardiac arrest …) could lead to an improvement in the prognosis of ihca. , and vessels with diameter smaller than μm were defined as small vessel. serum level of endothelial cell specific molecule- (endocan) was measured at specific time points. the hemodynamic parameters, the inotropic equivalent score, and prognosis of the patients were recorded. results: patients were iinvestigated in this preliminary report. they were equally divided into two groups (survival and nonsurvival) according to -day mortality. the baseline patient characteristics were not significantly between the two groups. the perfused small vessel density and proportion of perfused vessels at h were higher in the survival group than in the non-survival group. the endocan level were higher in the non-survival group than in the survival group, but the difference was not significant. conclusions: our results revealed that the perfused small vessel density were higher in the survival group than in the non-survival group. it encourages further studies to investigate whether aiming to improve microcirculation can improve outcomes in patient with venoarterial ecmo life support system. demographic data, sedation and vasopressor dose were recorded. enteral feeding was started as soon as possible. the cumulative grv was recorded up to a maximum of days, with a cut-off value of ml used to define intolerance to enteral feeding (ief). all data is presented as median(p -p .) statistical analysis was performed by stats . with mann-whitney u test and chi-square test. results: data from patients were recorded. baseline demographic data were similar in the groups. the average grv and the doses of midazolam were the highest in patients with vv ecmo, while the number of days with ief and the doses of na were the highest in the va ecmo group (table ) . overall, grv and number of days with ief tended to be higher in survivors (n = , grv ( - ), days with ief ( - )) than in non-survivors (n = , grv ( - , days with ief ( - )). conclusion: early enteral feeding is feasible during ecmo, in spite of impairments of gastrointestinal function potentially related to sedation and/or vasopressor treatment. extracorporeal membrane oxygenation for refractory cardiogenic shock in patients with peripartum cardiomyopathy a. chao results: six patients with confirmed ppcm were found. two ( %) patients died of neurological consequences (cerebral infarct and hypoxic encephalopathy) and their left ventricular (lv) ejection fraction remained about %. one patient underwent heart transplantation. the other three patients weaned off ecmo and their lv function began to improve on day . they were discharged uneventfully. conclusions: ecmo can provide an effective and simple treatment for critical ppcm with a satisfactory result. patients supported by ecmo whose heart function did not begin to recover on day and had neurological complications had a poor prognosis. introduction: the use of venoarterial extracorporeal membrane oxygenation (va-ecmo) for prolonged cardiopulmonary resuscitation (cpr) and severe cardiogenic shock after cpr has widely increased ( ). bleeding complications, due to necessary therapeutic anticoagulation and cpr/sirs induced coagulopathy are common ( ) . targeted temperature management (ttm) has shown positive effects on neurological outcome after cpr. although optimal target temperature is not exactly known, ttm remains a recommended approach in patients after cpr ( ). objectives: to determine the incidence of bleeding complications in patients after cpr, who are on va-ecmo and treated with ttm (target temperature °c) simultaneously. methods: we conducted a retrospective observational study from jan to dec and extracted relevant clinical data from electronically medical records. outcomes of interest were d-mortality and incidence of bleeding complications within hrs of cpr. demographic data, (anti-)coagulation status and need for transfusion were also analyzed. results: a total of patients received va-ecmo during the study period of which patients ( , %) underwent cpr before ecmo. of these, patients ( %) were treated with ttm. the median age was yrs (range - yrs) and patients were male ( %). sofa score on admission was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . patients received cpr mainly because of either acute myocardial ischemia (mi) ( ; %) or malignant dysrhythmias not attributable to acute mi ( ; %). ecmo implantation was performed within hrs ( . - hrs) of cpr and ecmo duration was . hrs ( - hrs). ttm was implemented within hrs ( - hrs) of cpr and the duration of simultaneous treatment with va-ecmo and ttm was . hrs ( - hrs). introduction: during initial resuscitation of patients with shock, last consensus recommend to target a mean arterial pressure of at least mmhg. however, there is no recommendation for the mean arterial pressure target in in the particular setting of extra corporeal cardio pulmonary resuscitation patients in the first hours following a refractory cardiac arrest. objectives: therefore, we conducted an experimental study to assess the effects of two different levels of mean arterial pressure for macrocirculatory, microcirculatory and metabolic functions. methods: randomized animal study in university research laboratory. in fourteen male pigs, a myocardial infarction was induced by a surgical ligature of the inter-ventricular coronary artery, triggering a refractory ventricular fibrillation. after twenty minutes of standardised cardiopulmonary resuscitation, extra corporeal life support was initiated to restore the circulatory flow. then, animals were randomly allocated to a high mean arterial pressure group (high map, - mmhg) or to a standard mean arterial pressure group (standard-map, - mmhg). evaluations at baseline, just before and six hours after ecls initiation were focused on ) lactate, ) amount of fluid infused and ) microcirculatory parameters (sidestream darkfield imaging, renal and liver functions). results: the two groups were similar at baseline and also at time of ecsl initiation including for the lactate levels ( objectives: the goal of our study was to assess the factors associated with percutaneous cannulation success or failure during ca. methods: this was a prospective observational monocentric study conducted between may and february including all consecutive patients with ca (no return to spontaneous circulation after minutes of cardio-pulmonary resuscitation) and an indication of ecls (low-flow below minutes). femoro-femoral cannulation ( fr for arterial cannula and fr for venous cannula, maquet®) was performed using the seldinger technique under ultrasound (us) guidance. patient characteristics, physician's a priori about cannulation conditions (ranging from (expected very easy) to (expected very difficult)) and us measures of femoral vessels diameter were recorded. the primary endpoint was the time to ecls initiation (icu admission -ecls running) and was analyzed using a stepwise multivariable linear regression. as a secondary analysis, we also explored the differences between the patients with a time to ecls initiation < min and all others (> minutes or cannulation failure conclusions: our data suggests that the level of care patients receive does not affect baby being with its mother. however, level patients are admitted to a general critical care unit and not captured in this review. the results also suggest that maternal well-being is affected by and/or affects whether baby is with her, however the % confidence intervals overlap. the above data does not take into account babies being in special care baby units and therefore not able to join their mothers at their bedside (this data will be recorded in the future). when this data is recorded it is expected that a high proportion of babies who are able to be at their mother's bedside during amc will be there. the introduction: high levels of job satisfaction are associated with decreased turnover intention, burnout incidence and absenteeism among health care professionals. moreover, turnover and burnout negatively impact on quality of care and healthcare costs. as the intensive care unit (icu) represents a highly complex and stressful environment, prevention of conflicts among team members as well as improvement of communication and job satisfaction can as such reduce burnout risk. objectives: this study explores the relationship between communication -and job satisfaction and the impact on burnout and turnover intention among icu nurses. %, / ). an average job satisfaction of . / was found. . % ( / ) had a score ≤ on job satisfaction, indicating significant dissatisfaction. icu nurses were most satisfied with the trust received from their supervisor ( . %) and least with the information about accomplishments and/or failures of the organization ( . %). . %, ( / ) had a low, . % ( / ) an average and only . % ( / ) a high turnover intention. % of the icu nurses had an indication for burnout. . % of the nurses had a low experience of their personal accomplishment. conclusions: in this survey icu nurses had a reasonable job satisfaction. they are most satisfied with the trust received from supervisors. despite a low indication for burnout risk, a quarter of icu nurses report low personal accomplishment. this may represent a particular focus for both preventive and interventional actions, which should preferably be developed through and in conjunction with the supervising staff. introduction: in the swiss diagnosis related groups ((swiss)-drg)) was implemented in intensive care units (icu). its impact on hospitalizations has not yet been thoroughly examined. we compared the number of icu admissions according to clinical severity and referring institution, screened whether implementation of swissdrg affected admission policy, icu length-of-stay (los) or icu mortality. methods: retrospective single center cohort study conducted at the university hospital zurich, switzerland between january and end of . demographic and clinical data were retrieved from a quality assurance data base. conclusions: drg introduction had not affected icu admissions policy, except for an increase of in-house patients with a low clinical severity of disease. drg had neither affect icu mortality nor icu los. interactive gaming as part of mobilisation programs is feasible in the icu, but specific explanation about the usefulness of these games to patients is crucial for improving motivation and engagement t. introduction: in recent years, light sedation has gained attention as part of standard daily care in the intensive care unit (icu). consequently, patients are increasingly engaged in their rehabilitation process. particularly early mobilization is associated with shorter time on the ventilator, shorter icu length of stay and better survival [ ] . interactive gaming may be a challenging way of engaging the patient in his own rehabilitation program. few data are available for the use of these interactive games in the icu envirnoment as part of daily routine physiotherapy, although one study showed that it was safe [ ] . we developed a trolley with a wii (tm) device that can be easily used when the patient is mobilized in a chair. we hypothesized that this would be associated with increased motivation to participate in interactive gaming by our patients. methods: the wii device was used with different games. participating patients were offered to play games of their own choice as part of the mobilisation program to improve their strength and coordination. no extensive explanation about the potential usefulness of these interactive games was given to the patients. after finishing the games, a specific survey was administered addressing motivation and affects on mental health. scores were obtained using a likert scale (range - ). results are shown as median and interquartile range {p -p ] results: at the time of abstract submission, participating patients had finished a cycle of games. some of the patients liked to use the wii device, particularly because a choice in games made it more interesting to use. other patients, however, felt they were required to participate. tennis, bowling and boxing were most frequently used. the use of the wii was programmed in the daily mobilization schedule together with a physiotherapist, or just with the attending icu nurse. in general, patients were not that enthusiastic about the wii-games (median score [ - ]), were not convinced that playing these games improved their well-being (median score [ ] [ ] [ ] [ ] ), and most felt that they did not have a choice but to participate (median score [ ] [ ] [ ] ). conclusion: interactive gaming with the wii-device is feasible in icu patients. however, thorough explanation of the potential usefulness of these games is required to engage and motivate patients to participate. methods: descriptive and retrospective study. we include all patients admitted in icu during (previous to rrt establishment) and (year of rrt establishment), and who were discharged to the ward. we analysed the icu and hospital mortality in both groups. results: in we admitted patients ( , % from the ward and , % from the other places like emergency, other icu or other hospitals), with a icu mortality of , % and hospital mortality of , %, with a hospital mortality after icu discharge of , %. in we admitted patients ( , % from the ward and , % from the other places), with a icu mortality of , % and hospital mortality of , %, and a hospital mortality after icu discharge of , % (p = . ). conclusions: after the first year of rrt establishment in our hospital, we appreciate that the continuation of patients after icu discharge, decrease the hospital mortality ( , % versus , %, p = . ). the number of patients admitted in icu from the ward decrease in ( , % versus , %), maybe because we did a previous assessment of this patients, with a stabilization in the ward and avoiding the icu admission. objectives: to identify outcomes and prognostic factors in hm patients admitted over -years to a general intensive care unit in a specialist haematology centre. (figure ). patients with - organ failures had significantly worse outcomes than those with - organ failures (p < . ) or . [ . - . , ci %]. median apa-che ii, sofa and saps ii scores were , and , respectively. median apache ii (p < . ), sofa (p < . ) and saps ii (p < . ) scores were greater in those ventilated for - days vs. ≥ days. conclusions: apache ii scores and mortality were greater than described in similar hm populations. given the severity of critical illness in our cohort, we suggest that admission to icu earlier in the acute illness may improve outcomes. poorer outcomes were observed in those with > organ failures and in ventilated patients. the survival of / rd of patients on icu for ≥ days to hospital discharge suggests that -day trials of icu in hm patients are unlikely to reliably distinguish between survivors and non-survivors. background: dedicated intensive care unit (icu) physician staffing was associated with a reduction of icu mortality in the general medical and surgical icu. however, limited data were available on the role of a cardiac intensivist in the cardiac intensive care unit (ccu). we compared the clinical outcomes in adult patients admitted to ccu before and after implementing the cardiac intensivist-directed care. methods: we enrolled , consecutive patients admitted to a ccu at samsung medical center, from january to december . in january , ccu was changed from a low-intensity staffing model to highintensity staffing model which managed by a dedicated cardiac intensivist. we divided eligible patients into low-intensity group (n = ) and highintensity group (n = , ). the primary outcome was ccu mortality. results: high-intensity group had significantly lower ccu ( . % vs . %; p < . ) and hospital ( . % vs . %; p < . ) mortality compared to the low-intensity group. the decrease in ccu ( . % vs . %; p = . ) and hospital ( . % vs . %; p = . ) mortality in high-intensity group were consistent in (low-intensity group , high-intensity group ) patient with profound cardiogenic shock treated with extracorporeal membrane oxygenation. kaplan-meier survival curve showed significant higher cumulative survival rates in highintensity group at year follow-up (log rank test, p < . ). ccu ( . % vs . %; p = . ) and hospital re-admission rate ( . % vs . %; p = . ) were decreased as well after conversion to highintensity although these results were not statistically significant. conclusions: dedicated cardiac intensivist was associated with reductions of ccu mortality in patient with cardiovascular disease requiring critical care. introduction: opioids are commonly given to alleviate pain and distress in patients admitted to the intensive care unit (icu) patients or undergoing major surgery. previous studies have shown that patients who are already taking opioids prior to surgery or icu admission are more likely to experience an extended duration of opioid use postoperatively or post-discharge ( ). however, it is unknown whether patterns of opioid usage differ between patients who are admitted to the icu and those undergoing a surgical procedure. objectives: the objective of this study was to describe opioid use in critically ill patients before and after icu admission and to compare it with preoperative and postoperative opioid use in a surgical population. methods: retrospective review and comparison of adult patients admitted to the icu or undergoing surgery at a tertiary care center between january , and december , . we divided the populations based on their degree of opioid use into "non-user", "intermittent", and "chronic" opioid users as previously described ( ). we assessed opioid use at months prior to icu admission or surgery, at discharge, and monthly for months thereafter. patients admitted to icu who had surgery were categorized under the icu population. to assess for risk of monthly chronic opioid use, a cox-proportional hazards model was postulated that allowed for recurrent events to account for patients irregularly requiring opioids over the course of the study period. the model showed that the risk of chronic opioid use was . times greater for those with prior chronic opioid use compared to patients who were non-users. there was no difference in risk of chronic opioid use between the icu and surgery group. conclusions: our findings suggest that icu and surgical patients have similar risk of prolonged chronic opioid use post-discharge. chronic opioid use prior to icu admission or surgery is the strongest predictor of chronic opioid usage at and after discharge. a single-centre cohort study of national early warning score (news) and blood gas derived biomarkers in patients with acute medical illness introduction: empirical combination antibiotic therapy for treatment of severe sepsis is a matter of debate. the proposed rationale for using a combination of two or more different antimicrobials is several fold. first, it allows for a broader empirical coverage with a higher likelihood of targeting the causative organism. second, it may decrease the development of resistance to the antibiotics used. third, a combination of active drugs potentially cause a synergistic effect increasing the efficacy of bacterial eradication. the surviving sepsis campaign recommends combination therapy in some patient populations and certain type of infections but the quality of the evidence supporting empirical combination antibiotic therapy is weak and does not include high quality randomised clinical trials (rcts). objectives: to assess benefits and harms of empirical mono-vs. combination antibiotic therapy in adult patients with severe sepsis in the intensive care unit (icu). methods: we performed a systematic review according to the cochrane collaboration methodology, including meta-analysis, risk of bias assessment and trial sequential analysis (tsa). we included rcts assessing empirical mono-antibiotic therapy versus a combination of two or more antibiotics in adult icu patients with severe sepsis. we exclusively assessed patient-important outcomes, including mortality. two reviewers independently evaluated studies for inclusion, extracted data, and assessed risk of bias. risk ratios (rrs) with % confidence intervals (cis) were estimated and the risk of random errors was assessed by tsa. results: thirteen rcts (n = , ) were included; all were judged as having high risk of bias. there was no difference in mortality (rr . , % ci . - . ; p = . ) or in any other patient-important outcomes between mono-vs. combination therapy. in tsa of mortality, the z-curve reached the futility area, indicating that a % relative risk difference in mortality may be excluded between the two groups. for the other outcomes, tsa indicated lack of data and high risk of random errors. conclusions: this systematic review of rcts with meta-analysis and tsa demonstrated no differences in mortality or other patientimportant outcomes between empirical mono-vs. combination antibiotic therapy in adult icu patients with severe sepsis. the quantity and quality of data was low without firm evidence for benefit or harm of combination therapy. introduction: de-escalation antibiotic in sepsis is associated with reduced costs and bacterial resistance. however, often it is not done. objectives: we designed this study with the primary objective to evaluate the prevalence of de-escalation in patients with severe sepsis or septic shock in an academic public hospital in south brazil. secondarily we evaluated antibiotic adequacy and cultures positivity. methods: we analyzed prevalence of de-escalation, antibiotic adequacy and culture positivity in severe sepsis and septic shock patients in an intensive care unit. results: of the patients included, de-escalation could have been performed in % of cases ( patients), but was implemented in only % of cases ( patients). among patients who received deescalation, half was for antimicrobial spectrum narrowing. the mortality was not different between patients with or without de-escalation ( . % versus . %, p = . ). empirical antimicrobial therapy was adequate in % of cases. pathogens were isolate in % of all cultures and . % of blood cultures. conclusion: the rate of empiric antibiotic adequacy was high, reflecting active institutional policy of monitoring the epidemiological profile and institutional protocols of antimicrobial use. however, the antimicrobial de-escalation could have been higher than reported. de-escalation did not impact mortality. there are few data in the literature regarding the care of severe sepsis patients in developing countries. this data can contribute to adequate treatment in this scenario. introduction: despite recent advances, appropriate initial amikacin dose in critically ill patients is still challenging. relationship between pharmacokinetic/pharmacodynamic (pk/pd) parameter peak concentration (cmax)/minimum inhibitory concentration (mic) in critically ill patients is not clear. objectives: we assessed the impact of amikacin pharmacokinetic and pharmacodynamic parameters on clinical and microbiological outcome in these patients. methods: observational prospective study. adult patients (> years) admitted to an intensive care unit (icu) with a gram negative documented infection and treatment with amikacin were included (study period: september -april ). amikacin blood samples were taken to hours after treatment started. amikacin concentration were determined using indiko® (thermo fisher scientific), and drug adjustment were based on the recommendations given by the pharmacokinetics unit (pharmacy service). clinical response, defined as sign and symptoms presented at the moment of infection diagnosis (fever, chest radiography alteration, infection biomarkers elevation and hemodynamic instability), was evaluated. ji-square and u-mann whitney test were used to compare results between treatment responders and notresponders. . mean initial dose was mg (sd: , )/day, equivalent to . ( . ) mg/kg/day. with that dose, patients ( , %) reached a cmax/mic value higher than . final treatment response was higher for those patients with amikacin cmax/mic value > ( , % vs , %; p = . ). no significant differences were reached in early treatment response (initial h) ( , % vs , %;p = , ) or days mortality ( , % vs , %;p = , ). cmax/mic values was not associated with toxicity-related treatment discontinuation ( , vs , ; p = , ). conclusions: initial cmax/mic value is associated with clinical response in those patients treated with amikacin. high initial amikacin dose may be necessary to optimize pk/pd parameters. method: in a bed mixed icu from october , to september , nosocomial infections (pneumonia, urinary tract infections, catheter-related bacteremia (crb) and secondary nosocomial bacteremia) were prospectively collected. envin-helics diagnostic criteria were applied. etiology, inflammatory response to infection, antibiotic treatment (atb t) and treatment modifications according to culture results, were analyzed. sdd was applied to all admitted patients requiring endotracheal intubation over hours. for each groups categorical variables were summarized as frequencies and percentages and number in means and standard deviations (sd) or median with interquartile ranges (iqr).percentages were compared, as appropriate, with the fisher´s exact test or x test and medians with the wilcoxon test for independent samples. for those variables that were associated with de in the univariate analysis were entered into a logistic multidimensional analysis. the model obtained was expressed by p-values and odd-ratios, which were estimated by confidence intervals at %. a hypothesis test was considered statistically significant when p-value was less than . . results: ninety patients ( , %) had atb de and did not. there were no significant differences in demographics or type of admission in both groups (fig. ) . mortality was lower in patients receiving de antibiotic (atb) ( , %, p: . ). in the multivariate analysis, icu mortality and urinary tract infection were the only variables found significant (fig. ) de was performed in out of ( , %) with crb and in out of ( , %) who had nosocomial pneumonia. the atb t was inadequate in out of infections ( , %). targeted therapy was performed in out of patients ( , %) and in out of infections, at least once occasion ( , %). finally, atb were targeted prescribed. in all studied patients with de, this was performed in patients once, in patients twice and in patients three times. the number of antibiotics used was and atb de was performed in occasions. frequency of atb used and of theirs de is shown in fig. of note, meropenem was de in , %. conclusions: patients who received atb de compared to those that did not had a significant lower icu mortality. the factors independently associated to de were icu mortality and urinary tract infection. inadequate atb t in our icu occurred in . % of nosocomial infections. atb de was performed in patients. targeted therapy was applied to , % of infections. the most commonly used antibiotics were meropenem ( , %), levofloxacin ( . %) and piperacillin-tazobactam ( , %). meropenem, was de in , %. introduction: antimicrobial prescription represents a major challenge for clinicians in the daily practice especially in certain difficult clinical scenarios. thus, in critically ill septic patients, prompt and adequate antimicrobial therapy reduces morbidity and mortality objectives: we set out to assess the impact on in-hospital of antibiotic de-escalation in patients admitted to the icu with severe sepsis or septic shock. methods: collaborative study enrolling patients admitted to the icu with severe sepsis or septic shock from two different cohorts. the first one, a spanish prospective and observational cohort and the second one, a multicenter non-blinded, randomized and non inferiority trial conducted in france. severity was estimated by the use of the predicted mortality rate at icu admissionfor every included patientby implementing the likelihood of death logit formule defined according to the apache ii and saps ii scores criteria and taking this cuantititative variable into account as a confounder factor in the regression model. de-escalation was defined as discontinuation of an antimicrobial agent or change of antibiotic to one with a narrower spectrum once culture results were available. to control for confounding variables we performed a multivariatebinomial logistic regression analysis adjusted by wald test. results: nine hundred and one patients with severe sepsis or septic shock at icu admission were treated empirically with broadspectrum antibiotics. eight hundred and seventeen patients were evaluated ( died before cultures were available). de-escalation was applied in patients ( . %). we found no differences in hospital long of stay between de-escalation group comparedto those who did not received it. we also found a significant lower hospital mortality in de-escalation group in front of the others ( . vs. . %; p < . ). by multivariate analysis (adjusted by severity scores-apache and saps), factors independently associated with in-hospital mortality were age (odds-ratio [or] . ; % confidence interval [ci] . - . ), and sofa score at icu admission (or . ; % ci . - . ), whereas de-escalation therapy was a protective factor (or . ; % ci . - . ) as well as urinary focus (or . ; % ci . - . ). analysis of the patients with etiological diagnosis revealed that the factors associated with mortality were age and sofa and conversely de-escalation therapy was a protective factor (or . ; % ci . - . ) conclusions: de-escalation therapy for septic critically ill patients is a safe strategy associated with a lower mortality. efforts to increase the frequency of this strategy are indeed justified. introduction: at the population level, both vancomycin and aminoglycosides are known to be nephrotoxic. the risk of nephrotoxicity might even be higher when combining the agents together ( ). nonetheless, in septic patients, the benefit in terms of sepsis control may outweight the risk of nephrotoxicity. thus, being able to appraise the risk/benefit ratio at the patient level would be of great interest to better tailor individual treatment. objectives: capitalizing on recent statistical innovations in personnalized medicine, our goal was to develop a patient-centered estimation of the impact of the association vancomycin/aminoglycosides on the kidney function. methods: our data come from a cohort study performed between and in the departments of anesthesia, critical care and cardiovascular surgery at a french teaching hospital. this study included all consecutive patients operated for an acute endocarditis ( ). the primary endpoint was postoperative evolution of the kidney function as evaluated by the akin score (stade : elevation in serum creatinine (srcr) ⩾ . μmol/l or ⩾ , xbaseline; stade : elevation in srcr ⩾ xbaseline; stade : elevation in srcr ⩾ xbaseline or creatinine ⩾ μmol/l with increase > μmol/l or need for rrt). the impact of vancomycin/aminoglycosides on kidney function was estimated using targeted maximum likelihood estimation on a risk difference (rd) scale. the association between patient characteristics and the individual effect of the drugs on the kidney function was estimated using conditional recursive partitioning (ctree). results: patients were included in the study. their baseline characteristics are described in table . at a population level, we confirmed the strong association between vancomycin + aminoglycosides and the risk of kidney dysfunction (rd = . , %ci: . - . , p < . ). however, at the patient level, this effect was very variable and could be predicted based on patients characteristics (r = . ) (figure ). conclusions: the individual impact of vancomycin + aminoglycosides on kidney function may be very different than the overall effect at the population level. innovant statistical approaches may be used to identify patients in whom this drug combination is safe, and others in whom it may seriously threaten kidney function. introduction: catheter-related bloodstream infection (crbsi) is one of the most frequent nosocomial infections in critically ill patients, resulting in a significant increase of morbidity and mortality. that is why it is essential to detect crbsi precociously so that optimal treatment can be initiated as soon as possible. objective: our objective is to evaluate the effectiveness of rapid non-invasive tests that may allow clinicians to detect colonisation of the central venous catheter (cvc) as a source of bloodstream infection in critically ill patients, permitting catheter withdrawal and the initiation of early goal-directed antibiotic therapy. methods: over the course of eight months, we selected for evaluation those critically ill patients admitted to our icu who developed fever (> °c) without source, to whom the clinician in charge decided to withdraw the cvc. before extraction, we obtained a skin smear at the insertion site, in addition to a catheter-hubs smear. we sent both smears, along with the catheter tip and blood cultures, to the microbiology laboratory. these results indicate that our test has a negative predictive value of %. to evaluate the degree of association between our test and the gold standard, we calculated the contingency coefficient, which resulted in , out of a maximum , (p < , ). this shows the strong validity of the combination of skin and catheter-hub cultures as a diagnostic method for cvc colonisation. conclusions: the combination of skin and catheter-hub cultures is a rapid and very effective method for detecting the colonisation of cvc as a possible source of bloodstream infection in critically ill patients. while a negative result, which can be obtained within h, would prevent the need for cvc withdrawal, a positive result would not only enable the removal of the likely source of infection, but it would also allow for, if the intensivist deemed it necessary, the initiation of early goal-directed antibiotic therapy. this would mean, in more than % of cases, starting optimal treatment at least hours prior to the diagnosis of crbsi from blood cultures. results: introduction: piperacillin/tazobactam (ptz) is a β-lactam-β-lactamase inhibitor combination with a broad spectrum of antibacterial activity. βlactams are time-dependent antibiotics and their effectiveness is in association with the duration of free drug concentrations over the minimum inhibitory concentration (t > mic) of organisms. prolonged infusion has a pharmacokinetic (pk) advantage compared to intermittent bolus dosing, a continuous infusion lower dose of g ptz may be as effective as a higher dose of intermittent bolus ptz. objectives: in this study we intend to evaluate the continuous infusion of / grams of ptz along with a loading dose of / , grams in patients admitted in a tertiary icu. methods: between october and december eight patients had piperacillin plasma concentration monitored during treatment with continuous ptz infusion in a monocentric prospective observational study. patients received a loading dose of / , grams of ptz followed by infusion of / grams, reconstituted in ml sodium chloride , % and transferred to braun space infusion system®. the pump had a flow rate of ± ml/h. blood was always extracted from the contralateral arm to the infusion, over hours at predetermined times. serum piperacillin/tazobactam concentrations were determined using an hplc method ( ). after extraction, samples ( μl) were injected into a xbridge c column (waters, spain) and were scanned by an uv detector at nm with gradient elution. mobile phase was composed by acetonitrile and a solution of tetrabutylammonium bisulfate ( g/ l). penicillin g was used as internal standard (sigma aldrich, spain). results: patients have been examined ( men and women). the average age was ± , the weight was ± kg, the creatinine clearance ± ml/min and the apache ii score , ± , . the mean concentrations of ptz in serum are represented in the next figures. conclusions: in this icu patient group, our results suggest that continuous infusion of ptz at / g per day is sufficient to obtain therapeutic plasma-concentrations in critical care patients with infections caused by ptz sensitive bacteria with a mic lower than mg/dl. however, in our group there were three patients with levels of mg/dl, which are not sufficient for bacteria with mic lower than mg/dl; these three patients are neurocritical. in conclusion, further studies in this are needed, especially studies regarding the association between piperacillin therapeutic drug monitoring and clinical outcome. introduction: ultrasound guided internal jugular vein cannulation is recommended technique in current anaesthesia and intensive care practice. however, classic short axis view has inherent problem of needle visualization during venous access. in contrast, medial oblique view may enhance needle visibility during venipuncture and decrease overlap between ijv and carotid artery and thereby increase the safety of us guided ijv cannulation ( ) ( ) . objectives: to compare the safety and efficacy of medial oblique view and in-plane technique as compared to short axis view and out-of-plane technique during us guided ijv cannulation. methods: two hundred patients aged between - yrs of either sex and american society of anesthesiologists' physical status i-ii who were undergoing any surgery under general anaesthesia requiring an internal jugular vein cannulation, enrolled for this prospective randomized controlled trial. three patients were excluded due to us machine malfunction. in patients of group m, ijv cannulation was performed with medial oblique probe position and in plane approach. in patients belonging to group s, ijv cannulation was done in out of plane approach with the us probe in short axis position. primary outcome was needle and guide-wire visibility during procedure. results: needle visibility (entire needle tract and needle tip) was significantly higher during ijv puncture in medial oblique probe position ( of patients in group m versus of patients in group s; p = . ). guide wire visibility during insertion was also higher when medial oblique probe position was used ( of in group m versus out of ; p = . ). first insertion success rate for ijv puncture, incidence of posterior wall of ijv puncture and time to cannulation were similar both the groups. no serious complications such as carotid artery puncture, haematoma formation and pneumothorax were reported. conclusions: medial oblique view may increase safety of us guided ijv cannulation in comparison to short axis view by increasing needle visibility during puncture. resuscitation "philosophy" shifted from being heart oriented towards brain oriented since its delay may increase neurological deficits . recent studies are highlighting the role of the bystander-cpr as a critical variable affecting ocha neurological outcome. , objectives: two step prospective interventional observational study to assess the role of the bystander-cpr in affecting neurological outcome in our ohca population. introduction: there is a clear rationale for monitoring microcirculatory behaviour during shock since it is the anatomical location of oxygen and substrate exchange, and may not correspond to global haemodynamics. and yet despite over a decade of research and technological advances such monitoring has not reached clinical bedside utility. analysis of the data is performed offline and too time consuming for clinical use. there is an urgent need for a system to assess the microcirculation at the bedside. we present a novel -point grading system (the point-of-care microcirculation (poem) scoring system) that can be used at the bedside (using sublingual microcirculatory monitoring). objectives: to assess the inter-user variability of the novel poem scoring system amongst doctors and nurses who may use such technology for clinical practice, and to benchmark poem scores against traditional offline computer analysis. methods: the poem score is an ordinal scale from (worst) to (best), and calculated based on assessment of individual video clips. online calculator found at: www.poemscore.com. thirtytwo naïve study participants from two uk teaching hospitals (birmingham and london) participated in a standardised -hour interactive training session in how to assign poem scores based on microcirculatory video clips from sublingual incident dark field (idf) videomicroscopy imaging. they were then asked to assign scores for different video sequences (each of varying clinical status, played in a random order). they were blinded to clinical status. inter-user consistency and agreement were assessed using intra-class correlation coefficient (icc) analysis. blinded expert poem scores were also validated against offline computer analysis of the same clips using traditional microcirculatory parameters, and the time taken to assign each was recorded. results: raters showed good inter-rater consistency (icc . , % ci . , . ) and agreement (icc . , % ci . , . ) for assigned poem scores. expert poem scores correlated well with offline analysis but took far less time to assign (mean times of minutes versus minutes; p < . ). conclusions: a new -point ordinal scale of microcirculatory function has been tested amongst 'front line' emergency physicians and nurses at two large uk teaching hospitals, and has minimal inter-user variability, even after just hour of training. poem scores take a matter of minutes to assign, and correspond well to computer-analysis variables. we present for the first time a bedside microcirculatory grading system that is quick, reliable, and gives potentially meaningful clinical parameters that might guide resuscitation. prospective randomised trials utilising goal directed therapy using the poem score are required to test its reallife clinical utility. introduction: vocal cord palsy is a known postoperative complication following cardiothoracic surgery. , . although the incidence is relatively low its existence cannot be ignored and thus its identification necessary in order to avoid any further complications and maintain patient wellbeing. this study aims to look at the incidence of vocal cord palsy following cardiothoracic surgery in a tertiary referral centre and highlight the importance of the speech and language therapist's role in working with this cohort. objectives: to measure the incidence of vocal cord palsy post cardiac and thoracic surgery and to identify the consequent effects. methodology. a retrospective analysis, within a tertiary cardiothoracic centre. data for all patients who underwent either a cardiac or thoracic surgical procedure between december and april and were referred to speech and language therapy (slt) was collected. vocal cord palsy was identified by fibreoptic endoscopic evaluation of swallowing (fees) or bronchoscopy. results: a total of patients were seen by the slt. patients with vocal cord palsy were identified by fees and bronchoscopy; % and % respectively. six patients assessed presented with vocal cord palsy; patients were post cardiac surgery ( / ) and post thoracic surgery ( / ). the consequence of vocal cord palsy was dysphonia in all the patients and dysphagia in two thirds of patients. the median duration that patients experienced dysphagia was days (range - days) and dysphonia was days (range - ). conclusion: this review highlights the high prevalence of vocal cord palsy post cardiothoracic surgery. vocal cord palsy led to high levels of dysphagia and dysphonia. early identification of these is imperative to ensure patient safety and optimise recovery and quality of life. ) . . % were over years old at the moment of the surgery. figure shows previous cardiac clinical history figure shows other relevant comorbidities. it was first surgery in . % of the patients. , % of the cases were valvular surgery (with or without cabg); , % were isolated cabg; , % thoracic aortic surgery; , % were other surgeries (congenital disease surgery, post ami complications, pericardiectomy). tables and summarizes the results of the application of sf- questionnaire in the patients interviewed in the follow up in the comparative analysis we found worse qol in women than men (p = , ), and a negative correlation between age and qol (p = , ). women in our study were significantly older than men (p = , ). we found no differences between the type of surgery and the postoperative qol, or between surgery or extracorporeal circulation duration and qol. there was a relationship between nyha degree during the follow up and the sf health score prognostic scores showed an inverse relationship with qol, but with a low correlation; pearson coefficient − , (euroscore), − , (saps ). conclusions: in our study, involving hospitals in andalusia (south spain), , % of cardiac surgery patients didn´t show any activity limitation or only a slight limitation before years of follow up. perceived quality of life decreases as age increases or worsens the functional status of the patients. conclusion: concsultation for the severely ill cases in the wards take very much time of the intensivits. it was seen that consultation request was mostly emergent and due to respiratory problems and sepsis. maybe we need another system like rapid response team for decrease the insivists work and decrease the mortality amd morbidity. the limitation of the beds in icu is one of the most important problem, and there must be more empty beds for inhospital emergencies. an external validation study of the qsofa score to predict inhospital mortality in medical patients with infection and derivation of a new enhanced score using automatically available variables: news-hazard l. introduction: sepsis has recently been redefined as´life-threatening organ dysfunction caused by a dysregulated host response to infec-tion´. it is one of the leading causes of mortality internationally. earlier identification of sepsis means more timely management, reduced length of hospital admission, and prevention of septic shock; ultimately reducing sepsis associated mortality. ( ) there is currently no standard diagnostic test for sepsis. distinguishing sepsis from alternative, uncomplicated infections is pertinent to ensuring an appropriate clinical approach. systemic inflammatory response syndrome (sirs) criteria have been used since to define sepsis (sepsis . ). however they have been found to lack sensitivity or specificity. the quick sequential organ failure assessment score (qsofa) is an emerging initial assessment method that uses three simple bedside criteria to measure organ dysfunction; altered mental status, respiratory rate ≥ and systolic blood pressure ≤ mmhg. the aim is to facilitate earlier recognition of sepsis outside of itu by prompting the clinician to think, and adequately screen for sepsis. in cases, the diagnosis of pneumococcal meningitis by culture or pneumococcal crp in csf was confirmed. in all cases, pneumococcus antigen was positive. therefore, there were no false negatives. in cases pneumococcal meningitis was not diagnosed, being the final diagnosis a non-pneumococcal bacterial meningitis or another pathology. in all cases, pneumococcus antigen was negative. therefore, there were no false positives. in conclusion, in our sample of patients, the sensitivity and specificity of the test for s. pneumoniae antigen in csf was %. the ppv and npv were also %. conclusions: in our series, the sensitivity and specificity of the test for s. pneumoniae antigen in csf by immunochromatography ( binaxnow® test ) was %. the vpp and vpn were also %. these results are similar to those reported previously in the literature. knowing the reliability of this fast, simple and inexpensive test, will allow to remove unnecessary isolation and to establish a more specific treatment and a better prognoses of the disease. evaluation of sensitivity and specificity of different criteria using for diagnosis of burn sepsis and without these (group № , n = ). logistic regression was performed to identify the independent factors for the prediction of early death ( days and less). we examined sensitivity and specificity with area under the receiver operating characteristic curve (roc auc). results: there were no significant differences between two groups for demographics, burn size, inhalation injuries. fatal outcome came early in the group № (mean icu length of stay , days vs days, p < , ). organ dysfunction at day was significantly higher in the group № (mean sofa , vs , ; p < , ). there were no significant differences in aba, fsbi and cdbs between two groups, and the highest auc were for cdbs by the day (auc , % ci , - , vs , % ci , - , and , % ci , - , for cdbs, aba and fsbi, respectively). sirs criteria were significantly higher in the group № , auc was , ( % ci , - , ) but specificity and sensitivity was too low (for sirs criteria is , % and %, respectively). independent factors for early death include: more than % immature neutrophils at the day , sofa more than by the day , thrombocytopenia less than by the day . conclusion: patients without specific pathomorphological signs of sepsis have more severe organ dysfunction, greater number signs of systemic inflammation and earlier fatal outcome. diagnostic model of sepsis by chinese experts has more sensitivity and specificity for diagnosis of burn sepsis confirmed by autopsy. immature neutrophils count, thrombocytopenia and sofa score are stronger risk factors for early death. the value of neutrophil to lymphocyte count ratio in diagnosing blood-stream infection s. involved microorganisms: s. pneumoniae and n. meningitidis in communitary abm, s. epidermidis and gram-negative bacilli in nosocomial abm. when comparing both groups, only we observed difference in the c-reactive protein at admission ( ± , in nosocomial abm vs , ± , in communitary, p , ). there were differences with other variables but were not statiscally significant. so, we observed a higher mortality in nosocomial abm group but the difference was not statistically significant (p , ). global icu mortality was % ( ) and hospital mortality was , % ( ). conclusions: the demographic and bacteriological profiles of patients with acute bacterial meningitis have changed in the last years mainly due to the expansion of neurosurgical procedures. still has a high morbidity and mortality. the detection of microbial dna but not cultured bacteria is associated with increased mortality in patients with suspected severe sepsis -a european multi-centre observational study m. introduction: sepsis is a leading cause of worldwide mortality. blood culture results poorly discriminate the mortality risk in critically ill patients with sepsis. here we aimed to determine whether the detection of microbial dna in the blood stream of patients with suspected sepsis was associated with mortality. we performed an analysis of data collected during the rapid diagnosis of infections in the critically ill (radical) study ( ) . patients were considered eligible for this study if they developed suspected sepsis and were either in or were referred for treatment to one of nine intensive care units (icus) in six european countries. when initial blood cultures were taken for clinical indications an additional blood sample was obtained for a culture-independent polymerase chain reaction/electrospray ionization-mass spectrometry (pcr/esi-ms) assay. the results of the pcr/esi-ms test were not communicated to the treating clinicians. results: of the patients analysed in the original study outcome data, blood culture results and pcr/esi-ms results were available for patients (table ) objectives: to evaluate if a "bundle" consisting of a sirs and organ failure (sof)-triage, flow chart response and alert system, and a sirs/ sepsis training course for all wards nurses improved clinical observations, lead to fewer patients developing severe sepsis, decreased length of stay in the high-level care (los) and increased survival. methods: a before and after intervention study in one emergency and community hospital within the mid-norway sepsis study catchment area. all patients with confirmed blood stream infection (bsi) and evidence of sepsis have been prospectively registered continuously since . the severity of sepsis, observation frequency of vital signs, treatment data, los and mortality were retrospectively registered from the patients' medical journals until end . results: the pre-intervention group was patients with confirmed bsi from jan to dec (n = ) whilst the postinterventions group was recruited between nov to dec (n = ). the nurses' observation frequency of vital signs increased in bsi patients with and without severe organ failure comparing these periods. the post-intervention group had, in average, . days shorter los. patients admitted without severe organ failure in the post-intervention group had a lower probability of developing severe organ failure ( . , % ci . - . ) than the pre-intervention group. adjusted for differences in disease severity the post-intervention group also had higher odds of surviving days (or . , % ci . - . ). conclusion: a sepsis specific triage-, flow chart alert and treatment system was an effective tool to increase ward nurses recognition and early treatment of patients with confirmed bsi. in addition to increased survival, the shorter los is important from a hospital perspective in term of resource utilization. this study was supported by the liaison committee between nord-trøndelag hospital trust and nord university introduction: the endotoxin activity assay (eaa™; spectral diagnostics inc., toronto, canada) is a rapid in vitro diagnostic test of the neutrophil's reaction to endotoxin and reflects the endotoxemia ) . recently, eaa is used to confirm endotoxemia such as in the euphrates (evaluating the use of polymyxin b hemoperfusion in a randomized controlled trial of adults treated for endotoxemia and septic shock) trial study in north america ) . however, eaa has not been routinely used to diagnose sepsis, yet. objectives: our hypothesis is eaa is useful to diagnosis for new definition's sepsis due to gram-negative infection. methods: the present study is a single-center retrospective observational analysis. of all adult patients in whom eaa was measured at our medico-surgical icu from july to july , patients with new definition's sepsis in were included in this study. new definition's sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection which is identified with total sofa score of or greater ) . patients were divided into two groups, ) with gram-negative organisms in some cultures and ) with no gram-negative organisms in any cultures. age, sex, body temperature (bt), wbc, crp, procalcitonin (pct), sofa score, and eaa values were compared between two groups. values are expressed as mean ± sd. data was analysed by chi-square test and unpaired students t-test. p values less than . were considered significant. results: five hundred and twenty seven patients ( men and women; mean age . ± . years) were studied. there were ) patients with gram-negative infection and ) patients with no gram-negative infection. eaa values and sofa score were statistically significant differences between gram-negative infection and no gram-negative infection ( . ± . vs. . ± . , p = . , . ± . vs. . ± . , p < . , respectively). pct was different but did not reach to statistically differences between two groups ( . ± . vs. . ± . , p = . ) and age, sex, bt, wbc were no significant differences between two groups. patients and methods: mechanically ventilated patients with severe sepsis/septic shock, treated in icu, were included in this prospective observational study. exclusion criteria were mechanical ventilation for more than hours prior icu admission and brain death. clinical and laboratory data were recorded, on a daily basis. thrombocytopenia was defined as a plt below x /μl. thrombocytopenia was considered as mild ( x /μl ≤ plt < x /μl), moderate ( x /μl ≤ plt < x /μl), or severe (plt < x /μl) depending on plt counts. serum levels of ifnγ, il- , icam, vcam, and soluble urokinase plasminogen activation receptor (supar) were estimated by using luminex xmap technology. results: fifty-six out of ( %) patients enrolled in the study were thrombocytopenic at the time of admission in icu. the overall incidence of thrombocytopenia during icu hospitalization was %, while mild, moderate, and severe thrombocytopenia developed in ( %), ( %), and in ( %) respectively. patients with severe thrombocytopenia had higher apache score, higher serum icam, il- and supar levels, higher incidence of bacteremia and higher probability to present with septic shock as compared with patients with normal platelet counts. moreover, severe thrombocytopenia was associated with statistically significantly higher hospital mortality. patients with severe thrombocytopenia showed significant higher serum icam (p < . ), il- (p = . ), and supar (p < . ) levels respectively, as compared to patients with normal platelets count, or patients with mild or moderate thrombocytopenia. in multivariate analysis, higher apa-che score, thrombocytopenia, and higher serum supar levels were statistically significantly associated with a higher risk of icu mortality. enrolled patients were stratified in different groups according to their apache ii score (apache ii > ), plt counts (plt ≤ . ) and serum supar levels (supar > . ). in multivariate analysis, this new scoring system remained the only and most significant factor associated with statistically significantly increased icu mortality [or = . , ( % ci, . to . ), p < . ]. conclusion: severity of thrombocytopenia in severe sepsis and septic shock parallels the severity of inflammation and subsequent endothelial dysfunction and is associated with higher mortality. the and il- α, were measured and compared between immediately before the first pmx-dhp therapy, before the second pmx-dhp therapy and after pmx-dhp therapy. human cytokine elisa plate array i (chemiluminescence) are used the plate which of cytokine capture antibodies are coated on wells respectively. each cytokine value is shown as relative light units of luminescence. values were expressed as mean ± sd. data were analyzed by wilcoxon signed-ranks test. a p < . was considered as statistically significant. results: all results were provided in about hours after starting this assay. one measurement of all cytokines costed $ . . tnf-α and mcp- values were significantly decreased between immediately before and after the second pmx-dhp therapy ( . ± . vs. . ± . , . ± . vs. . ± . , p < . , respectively). il- , il- and mcp- were also significantly decreased between before the second and after pmx-dhp therapy ( . ± . vs. . ± . , . ± . vs. . ± . , . ± . vs. . ± . , p < . , respectively). there were no statistically significant differences between before and after pmx-dhp therapies in other cytokines. the present study has some limitations because of a retrospective analysis and numbers of patients. however, human cytokine elisa plate array i is a fast and low-cost assay compared with the previous elisa method. and several cytokines are evaluated with one sample at the same time. this assay could be useful especially for the clinical research because small volumes of sample allow to several cytokines' information at the bedside. introduction: critical illness-acquired myopathy in rats is characterized by homogeneous muscle atrophy ( ). conversely, histological abnormalities are heterogeneous: oxidative muscles show patchy alterations (myofascitis, necrosis), while glycolytic types demonstrate normal patterns. akt and mtor are key proteins of the anabolic pathway, leading to myocyte growth when activated. conversely, ampk and foxo are key proteins of the catabolic pathway, leading to myocyte atrophy when activated. whether anabolic or catabolic pathway activation is dependent on skeletal muscle type (i.e. oxidative and glycolytic) during critical illness is unknown. objectives: to characterize activation of the anabolic and catabolic signalling pathways in a long-term rat peritonitis model by skeletal muscle type. methods: male wistar rats were followed for up to weeks after intraperitoneal injection of the yeast cell wall constituent, zymosan or n-saline. soleus (oxidative, slow twitch muscle), and gastrocnemius (mixed glycolytic-oxidative, fast twitch muscle) were harvested from both zymosan and control groups at , and days after the insult. expression of phospho-(p-) and total proteins were assessed by western blots. expression of akt, p-akt (p-threonine , active form), mtor, p-mtor (p-serine , active form), ampk, p-ampk (pthreonine , active form), foxo , and p-foxo (p-threonine , inactive form) were assessed at all time points. results: weight loss was not statistically different in soleus versus gastrocnemius in the zymosan group (− ± % versus − ± %, p = . ) at day . gastrocnemius displayed a decrease in p-akt at day , and an increase of p-akt and p-foxo at day . soleus displayed an increase of p-akt, p-ampk, and p-foxo at day , and an increase of p-ampk, and p-foxo at day . results are detailed in the table . conclusions: in a rodent model of long-term peritonitis, both oxidative and glycolytic muscles display little change in the anabolic signalling pathway. ampk (an autophagy activator) is activated while foxo , (an autophagy and ubiquitin-proteasome system activator) is inhibited up until day in oxidative but not glycolytic muscle. introduction: esophageal pressure (p es ) guided setting of peep has been described in ards patients either to avoid expiratory alveolar collapse or to promote maximum inspiratory recruitment . the proportion of ards patients that may benefit from maximum recruitment strategy and its effects regarding dead space (v d /v t ), shunt, driving pressure (dp), transpulmonary driving pressure (tpdp) and expiratory transpulmonary pressure (tpp exp ) remain unclear. methods: we included moderate and severe ards patients under mechanical ventilation and paralyzed, in the first hours after reaching ards criteria. patients were monitored with esophageal balloon catheter and ventilated with express study settings for hour after recruitment maneuver. then peep was modified to obtain an inspiratory transpulmonary pressure (tpp insp-p ) based on p es between and cmh higher peep in group b led to higher plateau pressure and tpp insp-p , positivation of tpp exp without increase in v d /v t (p = . ), shunt (p = . ), dp (p = . ), tpdp (p = . ) or oxygen stretch index (p = ). however agreement between tpp insp-p and tpp insp calculated from respiratory motion equation and chest wall elastance (tpp insp-e ) was weak with band-altman bias (tpp insp-e -tpp insp-p ) = . ± . [ %ci − ; ]. conclusions: p es measurement in moderate to severe ards patients distinguishes groups of patients in whom peep appears to be taylorized without side-effects. however physiologic studies should assess reliability of transpulmonary measurement based on either p es or chest wall elastance. introduction: to optimize mechanical ventilation different targets are used including tidal volume (tv), peak and mean airway pressure and peep. however, prevention of alveolar collapse not only depends on intra-pulmonary, but also on the extra-pulmonary pressure (epp). epp can be estimated by measuring esophageal pressure (ep). ventilator strategies aiming at optimized trans-pulmonary pressure tpp (difference between intra-and extrapulmonary pressure: tpp = tip-tep) have been shown to improve outcome. tpp-guided ventilator setting might be useful in patients with liver cirrhosis and ascites. however, the impact of paracentesis on tpp is poorly investigated. objectives: to investigate the impact of high volume paracentesis (hvp; ≥ ml) on tpp and on other parameters of pulmonary and circulatory function. methods: analysis of hvp-procedures in patients ventilated with the avea viasys ventilator (carefusion, usa) capable to measure ep via an esophageal tube. haemodynamic monitoring with the picco- -device (pulsion medical systems se, feldkirchen, germany) was available during measurements. intra-abdominal pressure iap was determined by intra-peritoneal (iap_p) and intra-vesical (iap_v) pressure measurement. high grade esophageal varices had been excluded endoscopically before measurement of ep. statistics: spss . results: male, female patients, aetiology of cirrhosis alcoholic (n = ), viral ( ) and cryptogenic ( ) . age ± years, apache-ii ± , sofa ± , meld ± . paracentesis of ± ml resulted in marked increases in inspiratory ( . ± . vs. . ± . ; p < . ) and expiratory (− . ± . vs. - . ± . cmh o; p < . ) tpp. in parallel inspiratory ( . ± . vs. . ± . cmh o; p < . ) and expiratory ( . ± . vs. . x ± . cmh o; p < . ) ep significantly decreased. paracentesis resulted in decreases in iap_p ( . ± . vs. . ± . mmhg; p < . ), iap_v conclusions: paracentesis markedly increases inspiratory and expiratory tpp in parallel with a decrease in iap. increased iap before paracentesis resulted in markedly decreased inspiratory and endexpiratory tpp despite ventilation according to the ardsnet guidelines. to avoid decreased end-expiratory tpp and alveolar collapse in patients with increased iap, paracenteses and/or higher peep-setting should be used. iap and its changes markedly confound cvp, but neither gedvi nor ci. introduction: if the proportional assist ventilation(pav) level is known, then muscular effort can be estimated from the difference between peak airway pressure and peep (△p) during pav. namely, p mus, peak, aw = (p aw, peak -peep) x ( -gain)/gain. pressure time product estimated from airway (ptp aw ) = p mus, peak, aw x inspiratory time/ x respiratory rate [ ] . objectives: validation of this hypothesis by using the esophageal pressure time product calculation. methods: eleven mechanically ventilated patients who received esophageal pressure monitoring under pav were enrolled. patients were randomly assigned to seven pav assist levels ( - %, pav means % pav gain) for minutes. maximal muscular pressure (p mus, peak, es and p mus, peak, aw ) and pressure time product (ptp es and ptp aw ) estimated from △p and esophageal pressure were determined from the last minute of each pav level. results: pav significantly reduced the breathing efforts of patients with increasing pav gain (ptp es . ± . at pav vs. . ± . cmh o•sec/min at pav , ptp es, peepi . ± . at pav vs. . ± . cmh o•sec/min at pav , p < . ). p mus, peak, aw overestimate p mus, peak, es in pav of low gain (pav ) and underestimate in pav of moderate to high gain (from pav to pav ). linear regression analysis revealed that the slope ptp es, br (ptp es per breath)/p mus, peak,es for ptp es, peepi is . (r = . ), for ptp es is . (r = . ), and ptp aw, br (ptp aw per breath)/p mus, peak, aw for ptp aw is . (r = . ). conclusions: adjustments should be made when extrapolating ptp aw into ptp es . an additional % should be added when extrapolating ptp es from p mus, peak, aw and an additional % should be added when extrapolating ptp es, peepi from p mus, peak, aw , assuming p mus, peak, es and p mus, peak, aw are equal. introduction: airway occlusion pressure is a noninvasive measure of motor neural output. if the airway is occluded, the change in pressure in the pleural space and at the airway open, both are equivalent objectives: we studied the similarity of effort and work of breathing measure with pesophageal (peso) at regular cycles, versus inadvertent airway pressure (paw) occluded during end-expiration (paw_occl). methods: esophageal, airway pressure and airway flow, sampling hz, were registered in patients during weaning time, with levels of sedation ramsay , at pressure support ventilation (psv) with differents levels of assistance (high: - cmh o, medium: - cmh o, low: - cmh o). respiratory effort was quantified using pressure-time product (ptp/min) with esophageal and occluded cycle (figure ), and wob_occlusion, using the occlusion pressure with the flow of preceding, not occluded, cycles ( figure ). the work of breathing esophageal referent (wob_peso, j/l)) is obtained from integral of peso versus differential of volume. also we are calculated Δ peso and Δ paw_occl as additional parameter. for all data, the bland-altman analysis and linear regression was applied. the results are expressed as mean ± sd, the comparison was made by t-test. results: a total of paired measures were obtained. the mean comparison of the respiratory effort and work did not show showed statistical differences for all data, except for low assistance (table ) . a good correlation between both measures methods was observed for ptp and wob (r = , and , ; respectively). the mean bias was for ptp and wob: , (± , ) cmh o*sec/min and , (± , ) j/l, respectively; and the % limits of agreement were − , to , cmh o*sec/min and − , to , j/l, respectively; this indicates wide dispersion. conclusions: airway occlusion pressure is a noninvasive procedure that could be useful to assess the effort and work of breathing patients during mechanical ventilation. introduction: chest wall elastance (ecw) is thought to increase in prone (p) as compared to supine (s) position in ards patients ( ) ( ) ( ) . this makes respiratory system elastance (ers) not reflecting lung elastance (e l) . little is known about the changes of ecw, e l and lung resistance (r l ) when moving the patient from the supine to the prone position via the lateral (l) position ( ) ( ) . objectives: the goal of present study was to measure ecw, e l and r l in ards patients in s, l and p position during the proning procedure. methods: ards patients intubated, sedated and paralyzed with an indication of p positioning were included. mechanical ventilation was delivered in volume controlled mode with constant flow inflation. end-inspiratory pause of . sec was set during the breathing cycles. ventilator settings were unaltered during the procedure. airway and esophageal pressures and airflow were continuously measured during minutes in s, then during minute in l and minutes in p. the side for the lateralization was that selected by routine practice (in the opposite side from central venous line). prone positioning was performed manually by caregivers. ecw, e l and r l were obtained by fitting the first order equation model to flow and pressures signals. values are expressed as mean ± sd. results: fifteen patients ( males) of ± years, saps ± and sofa ± were included ± days after ards criteria ( moderate and severe) were met. tidal volume averaged ± . ml/kg predicted body weight, peep ± cmh o, fio ± %, pao /fio ratio ± mmhg. the cause of ards was pneumonia in cases, undetermined in cases. side positioning was the right in and the left in patients. the results are shown in the table . conclusions: during prone positioning in ards patients, as compared to s we observed an increased r l and e l in l and increased ecw in p. introduction: driving pressure of respiratory system (Δp) is defined as the difference between plateau pressure (pplat) and total positive end-expiratory pressure (peeptot) measured after endinspiratory and end-expiratory occlusion, respectively, on airway pressure signal. Δp has recently been shown as a strong predictor of mortality in patients with acute respiratory distress syndrome (ards) ( ) . most of the studies involved in this demonstration measured pplat . sec after onset of endinspiratory pause according to the arma trial ( ) and used peep set on the ventilator (peepvent) instead of the peeptot. this does not take into account slow decay of airway pressure after endinspiratory occlusion and instrinsic peep, respectively. objectives: the aim of the study was to compare Δp when pplat was measured at different times after end-inspiratory pause and whether peeptot or peepvent were used. our hypothesis was that Δp was *p < . versus supine **p < . versus supine higher with pplat measured at . and peepvent than with any other combinations of pplat and peeptot. methods: a retrospective analysis of patients with ards in whom respiratory mechanics was measured. most of the patients had recordings at two levels of peepvent. data were analyzed with acqknowledge software. pplat was measured at . , and seconds after end-inspiratory pause. peeptot was measured after a -sec end-expiratory pause. the low-peep and high-peep measures pertained to peepvent ≤ cmh and peepvent > cmh , respectively. the primary outcome was the comparison of Δp calculated as pplat . sec -peepvent : Δp reference versus Δp computed as pplat sec -peeptot: Δp physiologic . the values are expressed as mean ± sd and are compared by using signed rank test for paired values, anova for repeated measures and bland-altman. results: twenty-three patients were analyzed. Δp reference was significatively higher than Δp physiologic in low and high peep groups: . (± . ) vs . (± . ) cmh o (p < − ) and . (± . introduction: end expiratory lung volume (eelv) is reduced in ventilated patients especially in patients with acute respiratory failure (arf). recruitment maneuvers and different levels of peep are used to restore eelv and to improve oxygenation. however; no matter how useful is the value of eelv in clinical practice his bedside measurement at baseline, at different levels of peep and after recruitment maneuvers is cumbersome. we measured the eelv with two techniques and we noted the technical problems and pitfalls. methods: we measure the eelv in patients with arf at two levels of peep ( and cm h o) with two techniques. with a dilutional nitrogen wash in and wash out method using the carescape r ventilator (ge) and by measuring the expired lung volume after a sudden release of peep to zero peep (zeep). specifically after min of stabilization at each level of peep we performed an expiratory hold and we decrease the ventilator frequency to zero to obtain sufficient time for a complete expiration. therefore, by releasing the expiratory hold we permit the return of the lung to his passive lung volume at zeep(passive frc).the expired volume was calculated by the integration of the expiratory flow. we call this volume Δeelv. correlation and agreement fig. (abstract a ) . variation of driving presure at low peep between the two methods with the bland and altmann analysis were performed. results: mechanically ventilated patients were studied. at zeep eelv was low ( ml) % of the predicted. good correlation was found between the two methods ( ± and ± ml respectively) when eelv was measured at cmh o of peep(r = o. , p < . ). on the contrary at cmh o of peep a wider variability and less agreement was noticed between the eelv values( ± vs. ± , r = . , p < . ). technical problems with carescape were spontaneous breathing attempts or asynchrony in the patient-ventilator interactions leading to instable vo -vco measurements. on the contrary with the release of peep method high expired volumes from peep to zeep induced high expired flow exceeding the lit/sec, thus affecting the linear sensitivity of the ventilator's pneumotachograph. conclusions: the measurement of the eelv remains a precious parameter for the ventilatory management of the icu patients but his measurement is still far away to be accurate by both techniques at bedside. low end-expiratory trans-pulmonary pressure is associated with lung collapse p. somhorst, d. introduction: the open lung concept aims to reduce lung injury due to cyclic opening and closing of alveoli. finding the 'optimal' peep to maintain an open lung proofs difficult and patient-specific. we hypothesize that targeting positive trans-pulmonary pressure (ptp) at end of expiration (ptpee) may prevent collapse. we used electrical impedance tomography (eit) clinically to optimize peep, visualizing over-distention and collapse. objectives: to show the association between collapse and low ptpee, as visualized by eit. methods: we retrospectively analyzed data of ten patients with acute respiratory distress syndrome (ards) who underwent measurement of the ptp and eit due to clinical considerations. a peep trial was performed to identify optimal ventilator settings. esophageal pressure (pes) was measured using endo-esophageal pressure balloons (cooper surgical, germany, or sidam, italy). the ptp was calculated as the continuous difference between the airway pressure and pes. eit was measured at the th/ th intercostal space (dräger, germany) and analyzed using specialized software (dräger, germany). collapse is defined as a local decrease in ventilation after a reduction in peep; over-distention is a local decrease in ventilation after an increase in peep. results: collapse was associated with a lower ptpee at lower peep levels. for most patients ( / ), collapse occurred when ptpee was ≤ cmh o. collapse was also present at a peep level of cmh o. inversely, we showed that collapse and over-distention can occur simultaneously (fig. ) . the ptpee was strongly correlated to the peep level (r = . , p < . ; corrected for each individual patient). the overall regression is shown as a dashed line. conclusions: for most ards patients, collapse did not occur when ptpee was above + cmh o. in addition, peep increase in order to prevent collapse may induce over-distention due to heterogeneity in the ventilation distribution in each patient. introduction: medical experts recommend keeping plateau pressure below cm h o to avoid ventilator-induced lung injury in patients with acute respiratory distress syndrome (ards). transpulmonary pressure (ptp), the difference between alveolar and pleural pressure, has been measured as a surrogate for plateau pressure for lung protective strategies. however, placement of an esophageal balloon catheter is required to measure esophageal pressure. objectives: we investigated the relationship between ptp and ventilator waveform parameters according to the strength of spontaneous breathing effort. methods: eight patients (four patients with ards and four with non-ards) mechanically ventilated with avea® were included in this study. an esophageal balloon catheter (avea® smartcath® esophageal balloon) was placed to measure esophageal pressure. we evaluated the relationship between Δptp (difference between inspiratory and end expiratory ptp) and peak inspiratory flow, or ti ratio (percentage of time until peak negative esophageal pressure to total inspiratory time). spontaneous breathing effort was categorized as strong or weak and was analyzed with inspiratory waveform using voxr data management software. results: although there was no significant relationship between Δptp and peak inspiratory flow (r = . , p = . ), a significant correlation was found between Δptp and ti ratio (r = . , p = . ). median Δptp and ti ratio were significantly higher in patients with strong spontaneous breathing effort compared with those with weak breathing effort ( . vs. . cmh o, p = . , and . vs. . , p = . , respectively). in patients with strong spontaneous breathing effort, median Δptp was higher in the ards group compared with the non-ards group ( . vs. . cmh o, p = . ). conclusions: measuring ti ratio and ventilator waveform parameters may be helpful to estimate ptp. appropriate sedatives, analgesics, or muscle relaxants may be required to limit ptp in cases of higher ti ratio in patients with ards. in vivo calibration of the esophageal balloon catheter: a simplified procedure f. introduction: a calibration procedure has been recently proposed to obtain reliable esophageal pressure (pes) measurements in mechanically ventilated patients [ ] . this procedure helps optimizing esophageal balloon filling and removing esophageal artifacts, but is timeconsuming. objectives: to test accuracy of a simplified procedure, designed according to average values of esophageal elastance (ees) and minimum appropriate filling volume (vmin) previously observed [ ] . methods: in patients under pressure controlled ventilation, pairs of end-expiratory and end-inspiratory calibrated pes values (pes,cal) were obtained with the standard procedure, consisting in measure of ees and detection of vmin and vbest (filling volume associated with the largest tidal swings of pes): pes,cal = pes -ees * (vbest -vmin). "simplified" calibrated pes values (s-pes,cal) were also obtained with a simplified procedure based on detection of vbest and on the assumptions that ees = cmh o/ml and vmin = ml: s-pes,cal = pes -(vbest - ). we used the nutrivent catheter (sidam, italy), equipped with an esophageal balloon that is cm long and has a ml nominal volume. results: in the conditions tested, vmin was . ± . ml, vbest . ± . ml and ees . ± . cmh o/ml. at optimal filling volume (vbest), difference between pes and pes,cal was . ± . cmh o (range . - . ). s-pes,cal strictly correlated with pes,cal (r = . ; p < . ); difference between s-pes,cal and pes,cal was − . ± . cmh o (figure ) . conclusions: when optimal filling of the esophageal balloon is adopted in mechanically ventilated patients, absolute values of pes are affected by significant esophageal artifact. a simplified calibration procedure seems to be adequately accurate in removing this artifact and suitable for clinical use. introduction: mechanical ventilation unloads the inspiratory muscles in case of high work of breathing to prevent development of muscle injury and patient discomfort. on the other hand, over-assist is associated with disuse atrophy and patient-ventilator asynchrony. two indices for assessing respiratory muscle effort have recently been published. patient-ventilator breath contribution (pvbc) index provides an estimation for the percentage of the total work of breathing performed by the patient related to the total work of breathing (patient + ventilator). neuromuscular efficiency (nme) or pressureelectrical activity index (pei) expresses how much pressure the inspiratory muscles generate (pmus) for each microvolt of diaphragm electrical activity (eadi). objectives: the aim of the current study was to assess the repeatability of both pvbc and nme and investigate how these indices changes in time in ventilated icu patients. methods: we included mechanically ventilated adult icu patients with a dedicated naso-gastric feeding tube for assessing diaphragmatic emg activity (eadi catheter). pvbc and nme were calculated at inclusion, after , and hrs and repeated times each with a -minute interval. pvbc was calculated by (tidal volume no assist/ eadi no assist)/(tidal volume assist/edi assist). nme was calculated by measuring change in airway pressure divided by amplitude of the electrical activity during end expiratory occlusion (delta paw/edi). results: the repeatability coefficient (rc) of pvbc and nme was % and . cm h o/uv respectively. median pvbc at t = was % and decreased until % at t = . in the same period, the mean nava level decreased ( . until . ) and mean eadi peak increased ( . until . uv). five patients had a pvbc index > %; four of them had a calculated pressure support (mean eadi peak x nava level) < cmh o. the median nme was . conclusions: we showed a repeatability of % for pvbc and . cmh o/uv for nme. this means that the absolute difference between two repeated measurements lies between this value with a probability of %. for example, with a calculated pvbc of % it is expected that % of the subsequent measurements will be between - %. nme was much more heterogeneous which indicates that neuromechanical coupling changes during icu stay in an unpredictable manner. pressure developed by the diaphragm in our patients appears within physiological limits. use of sigmoid regression for determining the optimal balloon volume in esophageal pressure monitoring: a bench and clinical feasibility study introduction: esophageal pressure (p es ), which has been used as a substitute for pleural pressure, is commonly measured by catheter with air-filled balloon. the accuracy of measurement depends on the proper balloon volume (v b ). assessment of optimal v b is difficult in clinical settings because the surrounding pressure of the balloon cannot be directly measured. in the present study, we introduced a sigmoid fitting method for determining the optimal v b . objectives: to assess the accuracy of optimal v b measured by sigmoid fitting and to evaluate the feasibility of this method in clinical practice. methods: six randomly selected esophageal balloon catheters (cooper catheter, cooper surgical, usa) were tested in a bench model with the lung and the pleural cavity during simulated mechanical ventilation. the balloon was progressively inflated in . ml increments from to . ml, and pressure in the balloon pressure (p b ) and in the pleural cavity (p c ) were measured. balloon transmural pressure (p tm ) was calculated as p b -p c . balloon pressure-volume was fitted by a sigmoid regression: v b = a/[ + e -(p-b)/c ], where a = the vertical distance of the upper asymptote, b = the pressure at the midpoint between zero and a, and c = the pressure range with the greatest volume change ( figure a shows a sample curve). the optimal v b was predicted by zero p tm and zero (p b -b). bland-altman´s analysis was used to assess the accuracy of the optimal v b predicted by p tm and p b . the balloon catheter was introduced into lower third of esophagus in patients with mechanical ventilation, and the balloon was inflated as the same sequence as that in the bench study. p es and v b were also fitted by the sigmoid regression ( figure b shows a sample curve) and the optimal v b was predicted by zero (p es -b). at each v b , dynamic occlusion test was performed, and ratio of changes in p es and airway pressure (Δp es /Δp aw ) was calculated. results: in the bench study, the best-fit coefficient r of sigmoid regression ranged from . to > . with a median (interquartile range, iqr) of . ( . , . ). the natural logarithmically transformed bias (and lower to upper limit of agreement) in optimal v b predicted by p tm and p b was − . (− . to . ). in the clinical study, v b tests were performed. r of sigmoid regression ranged from . to > . with a median (iqr) of . ( . , . ). the optimal v b was . ( . , . ) ml. the b value (r = . , p < . ) and predicted optimal v b (r = . , p = . ) significantly correlated with respective p es measured at the v b with the best Δp es /Δp aw ratio. conclusions: in the determination of balloon pressure-volume response, the performance of nonlinear sigmoid fitting was excellent in introduction: the use of more physiological tidal volumes ( - ml/ kg of ideal body weight) during general anesthesia can minimize the risk of lung injury but may be associated with increased atelectasis. a recent meta-analysis has suggested that high driving pressure and peep level changes that result in an increase of driving pressure are associated with more postoperative pulmonary complications ( ). there is no consensus, however, on how to tailor the level of peep to best suit each patient. objectives: our primary objective is to evaluate the variability of peep titrated by eit in healthy patients submitted to elective abdominal surgery. our secondary objective is to compare the consequences on lung mechanics and on the formation of atelectasis during abdominal surgery in two groups: titrated peep or peep of cmh o. methods: forty patients will be allocated into two groups: laparoscopic (n = ) or open surgery (n = ). after induction of anesthesia and neuromuscular blockade, and before insufflation of abdominal cavity, all patients will be submitted to a recruitment maneuver (rm) in pressure-controlled ventilation mode for two minutes followed by a decremental peep titration starting at peep of and diminished in steps of cmh o. optimal peep is defined as that with the best compromise of atelectasis and overdistention as measured by eit. patients in each subgroup will be randomized to one of two ventilatory strategies during intraoperative period: ( ) peep chosen by the peep titration procedure (titrated peep); ( ) peep set at cm of h o (peep ). a chest ct will be performed one hour after extubation. a density range of − to + hounsfield units (hu) was used to define atelectasis. results: thirty nine patients have been recruited. the median of titrated peep was (iq - ) (table ) . a weak correlation between bmi and titrated peep (r = . ) is shown in figure . lung compliance was significantly lower and driving pressure was significantly higher at baseline, with peep = and before rm, when compared to same measures using titrated peep during peep titration (table ) . during surgery, compliance (p < , ) and driving pressure (p < , ) were also significantly different between peep and titrated-peep group ( figure ). lung collapse evaluated through lung ct after extubation presented less non-aerated lung tissue in patients submitted to mechanical ventilation under eit-titrated peep. conclusions: in this sample of patients, the individualized value of peep titrated by eit had a great variability. peep titrated by eit was able to reduce both lung collapse and driving pressure. introduction: lung protective ventilation strategies could improve clinical outcomes in patients undergoing surgery. these strategies did not include specific goals for oxygenation. there is increasing recognition of potential harmful effect of hyperoxia in critically ill patients. however, little is known about current oxygen management during surgery. objectives: to describe current oxygen administration during general anesthesia in japanese hospitals. methods: a multicenter cross-sectional study was conducted. we screened all consecutive adult patients (≥ years) who received general anesthesia from to september or from to november at the participating hospitals (each participating hospital could choose whichever was more convenient). ventilator settings and the corresponding vital signs were collected hour after the induction of general anesthesia. we investigated the prevalence and risk factors for excess oxygen exposure ( . ± . . ± . . ± . ± . driving pressure with titrated peep (cmh o) . ± . . ± . ± . . ± . fig. (abstract a ) . driving pressure background:. acute kidney injury (aki) is common and is associated with significant morbidity and mortality after liver transplantation (lt). although the creatinine value is highly specific to estimate renal dysfunction, an inadequate sensitivity of creatinine level is demonstrated, particularly in early stage aki. cystatin c is founded to be a stronger predictor of the risk of cardiovascular events and death than creatinine. we aimed to determine whether pretransplant serum levels of cystatin c predict -day major cardiovascular events (mace) and all-cause mortality in lt recipients with normal serum creatinine values. methods: between may and october , consecutive lt recipients (mean age: years; % male; % living-donor lt) who have pretransplant creatinine level < . mg/dl were retrospectively evaluated. the -day mace was a composite of troponin i > . pg/ml, arrhythmias, congestive heart failure, death, cerebrovascular accidents. results: there was a . % -day mace event and . % of lt recipients were dead during a median of . years follow-up. mean values of cystatin c and creatinine were . ± . mg/dl and . ± . mg/dl, respectively. the risk for a -day mace event increased significantly with increasing quartiles of cystatin c; hazard ratios ranged from . to . for the highest versus the lowest quartile (p < . for trend). the kaplan-meier curves showed that the highest quartile (cystatin c > . mg/dl) had a significantly worse survival rate than the lowest quartile (cystatin c < . mg/dl) (logrank p = . ). however, pretransplant creatinine level showed neither increasing mace event rate nor worse survival rate with increasing quartiles of creatinine values (p = . for trends, log-rank p = . , respectively). conclusions: our results demonstrate that pretransplant cystatin c levels were significantly and progressively associated with -day mace and all-cause mortality in lt recipients with normal serum creatinine values, in contrast, the creatinine levels were not significant and gradual predictor of adverse clinical outcomes. were decreased (p < . ), and prevalence of postoperative aki was increased (q : %, q : %, q : %, q : %, respectively, p < . ). odds ratios for aki ranged from . to . for the highest versus the lowest quartile (p < . for trend). on the multivariate logistic analysis, low map was an independent risk factor of the postoperative aki (p < . ), after adjusting factors of age, sex, body mass index, diabetes, hypertension, creatinine, qtc interval, meld score, b-type natriuretic peptide, beta blocker uses, intraoperative red blood cell uses, postreperfusion syndrome, and cyclosporine uses. conclusions: our results demonstrate that pretransplant low map was significantly and progressively associated with the postoperative aki in lt recipients with normal serum creatinine values, therefore, our findings may assist in determining the optimal perioperative management of patients to prevent postoperative aki. introduction: patients undergoing cardiac surgery often develop, in the post operative period, pulmonary impairment and abnormalities gas exchanges ( ) . lung ultrasound (lus) examination may detect main pulmonary abnormalities at the bedside of the patient ( ). to increase bronchial drainage and help lung reaeration, physiotherapy treatment is daily applied starting from the first day after cardiac surgery. objectives: our study was to evaluate if physiotherapy treatment was able to induce changing in lung ultrasound pattern in the postoperative patients. compared total loss of aeration, before and after treatment, we identified a significant increase of rearation after physiotherapy (p = , ) evaluated with wilcoxon test. conclusions: our results confirm an elevate rate of loss of aereation in patients after cardiac surgery. physiotherapy may induce increase of reareation when evaluated with lus even thought it is not able to reduce consolidation. introduction: the therapy of malignant liver diseases has changed over the last years. during this period the frequency of liver resection has increased with great improvement in morbidity, mortality and long-term survival. [ ] thereby, the duration of liver transection and the amount of perioperative blood loss are of great importance for postoperative recovery time and therefore they are measures for choosing the optimal resection method. [ ] furthermore, the release of cytokines, chemokines, and stress hormones correlates with postoperative infection and organ dysfunction [ ] . to minimize cell damage and limit apoptotic cell death the so called heat shock response is initialized by various body cells as countermeasure to increased stress levels [ ] . moreover, pittet et al. showed a positive correlation between the small heat shock protein (hsp ) serum levels and survival after severe trauma. [ ] objectives: measurement of hsp could give an insight about pathological mechanism and their counter regulations of the liver. furthermore the hsp serum level should be correlated with the transection speed of the two resection methods cusa and stabler. . immediately after collection, samples were aliquoted, snap frozen and stored at − °c until further analyzation. to quantify hsp in serum commercially available elisa kits from r&d (duoset ic) have been used according to the manufacturer's protocol. furthermore the duration of transection and the resection surface expressed as cm /s were recorded. results: during surgery a significant increase in hsp levels was detected in patients undergoing stabler hepatectomy or cusa resection (n = , p < . ). during postoperative icu stay, hsp concentrations decline to levels comparable before surgery. the transection speed was significant faster in patients undergoing stapler resection compared to the cusa method (p < . ). the mean length of icu stay after liver resection was in both groups days. conclusions: our data show increased levels in serum of hsp , which might reflect the body's countermeasure to increased systemic stress levels during hepatectomy. moreover the hsp levels are in both groups equal high during surgery even though the resection conducted with the stabler is significant faster than cusa. introduction: performing laparoscopic surgery using carboxipneumoperitoneum usually accompanied with a moderate increase of the concentration of carbon dioxide at the end of expiration, as well as higher peak airway pressure that easily manages to compensate by the correction of ventilation parameters. in the postoperative period marked a fairly long recovery of baseline respiratory function associated not only with the post-operative pain, but with the restriction of the lung as a result of intraabdominal hypertension. objectives: assess the impact of prolonged pneumoperitoneum during laparoscopic surgery on respiratory function and to follow the dynamic of its rehabilitation. the study included patients ( men and women) in the age of . years (min , max ), operated in moscow municipal hospital № . the volume of surgical procedures: gastric resection (n = ), gastrectomy (n = ), pancreatoduodenal resection (n = ), hemicolectomy (n = ), resection of the sigmoid colon (n = ), anterior resection of rectum (n = ). depending on the surgical access patients were divided into two study groups: st -basic -(n = ) group -laparoscopic procedures, nd -control -(n = ) group of traditional laparotomy. all patients were under equal anesthesia during surgery: combined general anesthesia (sevoflurane + fentanil) and epidural infusion of . % ropivacaine solution, as well as myoplegia; postoperative multimodal analgesia: nonsteroidal anti-inflammatory drugs, antispasmodics, epidural analgesia. a study of respiratory function was carried out in four stages: -before surgery, - nd, - th, - th day after surgery. results: in patients of both groups to the second stage of study determined a significant reduction of volume parameters of respiratory function (vc, fvc, fev, fev , mef, mvv etc.). for example vc decreased in patients of group by % against the initial values, and % of patients in group (dynamics presented in the diagram). similarly changes in vc there is a decrease of all volume parameters: fev for the second phase decreased by . % in group and % in group ; mef decreased by . % and . % in the first and second groups, respectively. however, in addition to a statistically smaller decrease in the absolute values of volumetric parameters of respiratory function in the st group, we found them more intense recovery. conclusions: reducing the volume indicators of respiratory function after extensive laparoscopic surgery is less than after similar in volume laparotomy. recovery of acquired restrictive respiratory disorders is more intense and after laparoscopic surgery. at the same time in either group studies we have not observed a complete rehabilitation the initial levels of respiratory parameters, even after days after surgery. introduction: critically ill patients sometimes need laparoscopic surgery. it has been reported that steeped head-down position could increase intracranial pressure during robotic surgery. but we don´t know whether mild trendelenburg position and carbon dioxide pneumoperitoneum cause intracranial hypertension. we conducted a prospective observational study. objectives: the aim of our study was to investigate the change of optic nerve sheath diameter (onsd) in head-down position during carbon dioxide pneumoperitoneum. methods: we included patients scheduled to undergo laparoscopic gynecological surgery. exclusion criteria were ocular disease and central nervous system diseases. onsd were measured mm sagittal behind the globe we assessed onsd after tracheal intubation (t baseline), after pneumoperitoneum and trendelenburg position (t ) and every minutes (t , t , t , t ). anesthetic management were standardized. results: twenty seven patients were enrolled in this study. four patients were excluded from analysis because it was difficult for us to measure onsd. the degree of head-down angle was . ± . . onsd is significantly higher than baseline after pneumoperitoneum and trendelenburg position ( figure ). conclusions: carbon dioxide pneumoperitoneum and trendelenburg position increased intracranial pressure even if the head-down angle was mild. introduction: monitoring the anticoagulant effect of unfractionated heparin (ufh) is mandatory. this monitoring can be done by the mean of the activated partial thromboplastin time (aptt) or by anti-xa levels measurements. compared with anti-xa levels testing, aptt is more frequently impacted by preanalytic variables and biologic factors (increased levels of acute phase reactants, consumption coagulopathy) often encountered among critically ill patients. we studied the agreement of both tests results in unselected critically ill patients. objectives: to study the agreement of both tests results in unselected critically ill patients. methods: aptt and anti-xa levels were simultaneously monitored in patients treated by continuous intravenous infusion of ufh. blood samples were drawn into sodium citrate tubes (greiner bio-one sas, france). aptt was measured with triniclot automated aptt reagent (tcoag, ireland) and anti-xa levels with bio-phen heparin (lrt) (hyphen biomed, france) . an aptt of - times the control and anti-xa levels between . - . iu/ml were defined as therapeutic. results: forty-four patients (mean age . ± . years; mean sap-sii . ± . ) were included. reasons for admission were medical in , surgical in . the indications for ufh therapy were atrial fibrillation ( ), venous thromboembolism/pulmonary embolism ( ), thrombophilia ( ), acute coronary syndrome ( ), arterial thrombosis ( ). paired measurements of aptt and anti-xa were performed on page of samples. linear regression analysis was used to evaluate the relationship between aptt and anti-xa. the correlation between aptt and anti-xa levels was low (r = . ) concordant aptt and anti-xa values were observed in ( . %) data pairs. aptt was discordantly high in ( . %) data pairs and discordantly low in ( . %) ones. considering anti-xa as gold standard, monitoring anticoagulation treatment by aptt leads to a high risk of misdosing. aptt is frequently impacted by biologic factors. although less commonly, anti-xa levels can also be influenced by biological cofounders. poor correlation between aptt and anti-xa could result from lterations in fii and fviii activity. conclusions: use of aptt and anti-xa levels to guide heparin therapy may lead to different estimates of ufh concentration in the same patient. both aptt and anti-xa have limitations when used for ufh monitoring and may not accurately assess anticoagulant status. further investigation (using thromboelastometry or thrombin generation assays) could be useful to determine the optimal anticoagulation testing protocol in critically ill patients. note: this abstract has been previously published and is available at [ ] . it is included here as a complete record of the abstracts from the conference. introduction: the severe capillary leak-induced respiratory and renal failure limit large-volume resuscitation with crystalloids and blood components. the combined use of low volumes of crystalloids and "damage control resuscitation" (dcr), a blood product resuscitation goal of a : : ratio of packed red blood cells (prbc), fresh frozen plasma (ffp) has recently been applied to obstetric patients in hemorrhagic shock. another important consideration is the association of ffp with the risk of transfusion-related acute lung injury (trali), a major cause of death after transfusion. this risk is not present with the use of prothrombin complex concentrate (pcc) as the antibodies responsible for trali are removed during the manufacturing processes. methods: our research involved patients with massive bleeding after cesarean section. patients were divided into groups: st group contained patients as a treatment of massive bleeding with coagulopathy was scheduled pcc in a dose of ml/kg ( iu/kg), packed red blood cells (prbc). nd group ( patients) received fresh frozen plasma (ffp) in a dose of ml/kg and prbc. basic infusiontransfusion therapy was administered according to the protocols of hemorrhagic shock treatment in obstetrics. evaluation of the functional state of the hemostasis system was carried out using lowfrequency pyezoelectric thromboelastography (lpteg) on admission to hospital and every hours after the patient´s admission until normalization of hemostasis state. results: according to lpteg indicators obstetric patients with massive bleeding has a statistically significant abnormality in all parts of hemostatic system: platelet aggregation -intensity of contact coagulation (icc), the coagulation -intensity of coagulation drive (icd), clot maximum density (ma) and fibrinolytic activity -index of retraction and clot lysis (ircl introduction: both anaemia and transfusion of red cells (as defined by who criteria) ( ) have been associated with adverse outcomes, and the potential for anaemia to be a marker of a greater disease burden is frequently raised in discussion. cohort studies of patients aged > years demonstrate that anaemia is associated with increased mortality ( ) . anaemia is also associated with a variety of morbidities in older people, being linked with an increase in hospitalisation, poorer physiological, physical and cognitive function, development of alzheimer´s and parkinson´s diseases, depression, falls and hip fracture rates. we aimed to investigate whether anaemia was associated with adverse outcomes, increased lengths of stay and increased overall mortality in our icu cohort. we also thought it would be interesting to know if there was a difference in haemoglobin level depending on the specialty in which the patients were admitted -hereby defining the physiology of their anaemic process. methods: we conducted a retrospective review of all patients over the age of years that were admitted to the victoria infirmary, glasgow between / / and / / using the wardwatcher national database. we looked at admitting specialty (medicine or surgical), haemoglobin at admission, length of stay and hospital mortality. results: patients were included in the analysis, however full data set was available for patients. the patients were more predominantly male with similar numbers in the medical and surgical groups. medical patients were slightly younger, but with higher physiology scores and mortality. there was no statistical difference between length of stay in intensive care between the two groups. medical patients had a higher admission haemoglobin but this did not trend with outcome or length of stay. (see table ) conclusions: interestingly, and not as expected, it seems that admission haemoglobin to intensive care is not associated with outcome in the elderly population. it is noteworthy that discussion continues in the literature regarding the definition of anaemia in this age group as the population used to generate the who criteria did not include any over ´s. admission haemoglobin levels did not seem to correlate with apache, length of stay or outcome. however, the medical patients with more likely chronic anaemic state had higher apache-ii scores, were younger with higher mortality than the surgical admission who were older, had better outcomes but were more significantly anaemic on admission to intensive care. introduction: because of the substancial morbidity and mortality provoked by massive bleeding, a protocol to guide treatment of this event in each hospital is required. objectives: the aim of this study was to determine whether implementation of the massive transfusion protocol (mtp) was associated with a change in clinical practice or mortality. conclusions: the number of patients is greater in post-mtp group and apache score is lower in the same group since we are warned of these patients at an early stage. there were no differences in clinical practice regarding the administration of blood and hemostatic products.no change in mortality could be documented using the protocol. we have not found any statistically differences probably in part due to the sample size. introduction: discontinuation of life sustaining treatments (lst) is an accepted approach for certain icu patients. there are different ways of limiting lst, and while terminal extubation (te) is one of them, it may lead to dyspnoea and respiratory distress, which can be regarded as morally troublesome. table shows the characteristics of the patients included. conclusions: denial of admission to an intensive care unit due to lst decisions was associated with a high morbidity and mortality. mortality, apache ii and charlson index were significantly lower in the group of patients refused admission to an icu with a non invasive treatment recommendation. introduction: donation after circulatory death (dcd), refers to the procurement of organs from patients whose death is diagnosed and confirmed after circulatory arrest. in the netherlands the timeframe for dcd to proceed is set at two hours. a considerable number of potential donors after circulatory death are lost because they do not die within the specified timeframe after withdrawal of life-supporting treatment (wlst). identification of those dying within hours after wslt results in efficient utilization of the organ procurement teams, hospital resources and above all fulfillment of family expectations. objectives: the aim of this study is to determine factors predicting time to cardiac circulatory death after wslt within hours. methods: in this single-center study we retrospectively evaluated potential and actual dcd iii donors. patients younger than years of age, and clinically brain dead patients in whom relatives requested a dcd procedure, were excluded. univariate logistic regression analyses were performed to establish the effect of different predictors. results: only ( %) converted into actual donor partly due to the fact that cardiac death did not occur within hours. univariate analysis showed an association between the following predicitors and death within introduction: family refusal of organ donation from dbd (donors after brain death) is a limiting factor of the whole donation process and plays an important role in shortage of organs available for transplantation. although croatia is a state with presumed consent when it comes to dbd (donors after brain death) organ donation, family is always informed about the possibility of organ donation after it is verified that the deceased is not registered in the non-donor registry. if the family objects organ donation, their decision is always respected. objectives conclusions: main reason for refusal of organ donation in our hospital is unknown wish or opposition of the deceased person. no family refused donation due to fear of organ trafficking which is an encouraging fact. although refusal rate in our hospital is %, which is higher than croatian average of %, we could not clearly identify contributing factors. we also could not confirm the hypothesis that additional education of transplant coordinators lowers refusal rate. a more detailed prospective evaluation is needed in order to further reduce refusal rate in our hospital. impact of brain injury (bi) and bi with brain death ( the course was aimed to spanish health professionals (nurses and doctors), with a total duration of . hours. it consisted of a small theoretical introduction followed by several workshops, which included: donor after circulatory death management protocol through high fidelity simulator, family interview, preservation and perfusion procedures with extracorporeal membrane oxygenation in animal models. the students sat a pre-course self-assessment -question test to evaluate their knowledge about cdcd. at the end of the course they filled out a survey, offering their opinion on different sections: content, usefulness, documentation and educational support, organization, duration and overall assessment. the score ranged between one, the most negative value, to . average score was analyzed. a survey was sent to students working in different hospitals to evaluate the impact of the course in the cdcd programs at their hospitals. results: students completed the course, their characteristics are in table . students did the pre-course test, with an average score of . points. filled out the survey, results plotted in table . feedback trough the after-course survey was received from students. % of the students worked at hospitals without a cdcd program, established after completing the course. % of these students considered that the course contributed to the development and implementation of cdcd program. all professionals who worked at centers where there was already a cdcd program felt that the course contributed to its improvement. conclusions: despite the fact that there was a high knowledge on the subject among the students, they showed interest and enjoyed the course. the course had a high impact because it helped improving and developing cdcd programs in several hospitals. we believe that this course, based on high-fidelity simulaton training, has been one of the factors that has promoted controlled donation after circulatory death in spain in the last years introduction: the demand for donor lungs thoroughly exceeds the supply.this situation and the application of a strict group of selection criteria, has made donor lung shortage a major problem. to overcome this scarcity, some studies have examined the possibility of using lungs from older donors with mixed results [ ] [ ] [ ] [ ] objective: using as a starting point the favourable clinical evolution of a recipient of a year old lung, we reviewed all of our donors from the last years that were dismissed strictly because advance age (> years) methods: retrospective (feb -jan ) and descriptive study. all donors of a spanish tertiary hospital were analysed. we selected all patients excluded for donation and reviewed their contraindication to serve as lung donors. demographic data and comorbidities, reason for icu admission, icu length of stay, respiratory parameters, days of mechanical ventilation, respiratory cultures and antimicrobial therapy were collected. results: during the period studied we identified potential donors that translated into real donors and only of them ( , %) served as lung donors. after analysing the ( , %) patients that were not considered as lung donors, we identified ( , %) that had been dismissed strictly because advance age. all patients studied were brain death donors. demographic data and comorbidities, reason for icu admission and icu length of stay are detailed on figure .last mean po /fio recorded was , ± (peep , ± , ) and last mean pco recorded was , ± , mmhg. median days of mechanical ventilation were ( - we recorded the main characteristics of the donors, the most important periods in the process and the evolution of liver receptors admitted to the icu. results: patients were admitted. the mean age was , ± , . most were male ( / ). reason for icu admission more frequent: haemorrhagic stroke ( ) . the icu stay until list decision was , ± , days. the cares at the end of life (list) were performed in the first four patients in the uci, and another patients in the operating room, intervening in all of them intensivists who had participated in the previous treatment. the time from extubation to significant hypoperfusion of organs (sbp < mmhg) was minutes, the time to cardiac arrest was , minutes, and to the beginning of the cold perfusión was , minutes. liver transplants were performed without complications in the icu, and the icu stay was days ( , ). the higher alt level was ± , . of the liver transplants are well and with functioning organ today (one died in hospital ward unexpected cardiac arrest). kidneys were obtained from these donors. the maastricht iii donors provide valid organs for transplantation and the intensivists play an important role both in the detection as in the development of care at the end of life. the first transplants had long functional prolonged warm ischemia, which has been reflected in graft function, but the performing of list in operating room, the ultrafast extractions and the presence of the receptor in the hospital are improving the viability of organs, so the results of the last donors are better. thus, maastricht iii donors must be considered today as an additional source of organs for transplantation. ( ), cisatracurium was administered at a constant and high posology without monitoring the depth of neuromuscular blockade. objectives: to assess if the monitoring of the train-of four (tof) and the management of cisatracurium posology by nurses according to an algorithm can ensure an effective neuromuscular paralysis and allow to decrease cisatracurium consumption during ards methods: we conducted a prospective study in medical icus. all the patients with a pao /fio < for more than hours and requiring a continuous perfusion of cisatracurium were included. neuromuscular blockade was monitored by a tof at the adductor pollicis. nurses followed an algorithm of adaptation of cisatracurium posology depending on the tof with an aim of / . the initial posology was based on the maximal doses recommended in anesthesiology and on the patient ideal body weight. this posology was increased and a bolus done each time that the tof was > . the interruption of nmbas was decided by physicians. the initial and final posology and the daily consumption of cisatracurium, the need of performing boli, the results of tof and the occurrence of adverse events such as patient/ventilator asynchrony were noted. effective cisatracurium consumption was compared to the theoretical posology that would have been administered if the patient had been treated according to the acurasys study protocol (i.e. , mg/h). we also evaluated the economic impact of the reduction of cisatracurium consumption. introduction: sepsis-associated acute respiratory failure is frequent, occurs early and is associated with significant mortality. with the increasing use of noninvasive techniques, timing of intubation can vary and may lead to a difference in outcome. objectives: the objectives of this study were ) to draw on practitioners' current practice and perspectives to understand and identify practice variation in intubation and ) to develop an explanatory theoretical model that demonstrates the relationship of various factors contributing to practice variance. methods: between march and july , using a grounded theory approach, we conducted semi-structured interviews with providers involved in intubation and audio recorded them. the interview guide focused on clinicians' perspectives on and practices of intubation in patients with sepsis and impending respiratory failure. results: eighteen interviews were conducted with intensivists, fellows, nurse-practitioners, respiratory therapists and registered nurses. intubation perspective and practice varied dependent on three domains: patient's characteristics, clinician's characteristics, and organizational structure. patient factors included nature of acute illness, underlying comorbidities, clinical presentation, and patient's values. clinician factors included background, training, experience and practice style. system factors included of standardized policies and protocols, hierarchy and team dynamics. although most clinicians agreed that intubation is needed in case of persistent respiratory distress, altered mental status, or shock, they disagreed on when to initiate it. in different contexts, intubation could be considered as preemptive (prophylactic), therapeutic ('just in time'), and as a rescue. assessment, reassessment, and time-limited trial off noninvasive techniques matter. based on these results, we propose a model regarding intubation in sepsis consisting of the steps in the decisional process, a classification of the categories of timing of intubation, and decisional context factors that impact the timing of intubation. conclusions: in patients with sepsis-associated acute respiratory failure, variability of intubation was a natural phenomenon and appeared case-driven. intubation timing should be adjusted based on explicit consideration of each patient situation, their fitness, the cadence and trajectory of their respiratory failure, the team's proficiency in providing noninvasive and invasive ventilator support, and emphasis on clear, frequent closed-loop communication of the treatment plan and rationale within the entire critical care team. ( ) . objectives: to determine the efficacy of rhtm in septic patients with severe respiratory failure. methods: we performed sub-analysis of a retrospective observational study (japan septic disseminated intravascular coagulation study, j-septic dic study), which was conducted in intensive care units in japan. among septic patients enrolled in this original trial, we selected septic patients with severe respiratory failure and compared patients based on rhtm treatment (rhtm group and control group). propensity score analysis was performed between two groups. outcome was the number of ventilator free days. results: patients (rhtm, n = , control, n = ) were analyzed in this trial. after adjusting for baseline imbalances by propensity score analysis, vfds increased significantly in rhtm group (rhtm group: . ± . days vs. control group: . ± . days, p = . ). conclusions: in this analysis, rhtm improved outcomes in septic patients with severe respiratory failure. we need further evaluation. results: during the study period, totally ards patients with pathologic diagnosis of dad were eligible for analysis. these patients were divided as mild (n = , . %), moderate (n = , . %) and severe ards (n = , . %) by berlin definition and the hospital mortality rate were not significantly different between these three groups ( . %, . % and . %, p = . ). according to the etiology, these dad patients were divided into known etiology group (n = , . %) and unknown etiology group (n = , . %), and the hospital mortality rate had no significant difference ( . % vs . %, p = . ). the known etiology group had higher percentage of male and lower pao /fio ratio than unknown etiology group ( . % vs . %, p = . ; . ± . vs . ± . , p = . ). the multivariable logistic regression revealed sequential organ failure assessment (sofa) score at the time of open lung biopsy was the only predictor of hospital mortality (odds ratio . , % confidence interval . - . ; p = . ). in terms of glucocorticoid treatment, there was no significant difference in glucocorticoid use, timing from ards to glucocorticoid use, dose and duration between survival and nonsurvival patients. conclusions: for the ards patients with dad, sofa score was the predictor of hospital mortality but glucocorticoid treatment did not improve the survival rate. introduction: ventilator associated pneumonia (vap) is a known complication of mechanical ventilation. aspiration of oropharyngeal secretions results in infection that leads to significant morbidity, mortality and cost . use of sub-glottic secretion drainage (ssd) devices have been shown to decrease both the incidence of vap and intensive care unit (icu) days , . there have been safety concerns associated with use of ssd devices and herniation of tracheal tissue into the suction port . a study in sheep showed significant tracheal injury associated with continuous suction . human studies have shown conflicting results regarding the risk of tracheal injury , . objectives: to determine the risk of tracheal injury using an ssd device versus a standard endotracheal tube. methods: patients undergoing tracheostomy in the icu were enrolled in the study. patients were intubated in the icu, operating or emergency room, pre-hospital, or referring hospitals. intubation conditions and duration of intubation were documented. at the time of tracheostomy, a bronchoscopy was performed and the presence and degree of tracheal injury were noted. patients were followed to hospital discharge and decannulation, otolaryngology consults, and discharge or death were recorded. results: patients were intubated with a malinckrodt evac ssd device and were intubated with a standard endotracheal tube. patients were found to have a tracheal injury ranging from mild erythema to severe ulceration; / ( %) in the evac group and / ( %) in the standard group (rr - . ; % ci . to . ). / ( %) patients were reported to have injury at the site of the suction port; were reported to have mild edema and erythema and had mild to moderate ulceration. of the patients with tracheal ulceration at the suction catheter port, were decannulated successfully without further complication and patient died prior to termination of mechanical ventilation. conclusions: there was no significant difference in the risk of tracheal injury with ssd devices compared to standard endotracheal tubes. the degree of injury was similar in both groups. a small introduction: vap rates in brazil are higher than those listed in europe and eua.no municipal hospital moyses deutsch since implemented the protocol, applied the five strategies to reduce vap, however we maintained vap density with little reduction and we never zero target . objectives.objective of the study was to examine the effect of healthcare improvement ventilation bundle institute in addition to focusing on three strategies : oral decontamination with chlorhexidine (odc), the head elevation and awakening daily in the incidence of vap in a unit intensive care. methods: the study was conducted in a -bed, medical-surgical icu. criteria for nosocomial pneumonia are those from the cdc. strategy was to implement the ihi's ventilator bundle , focused and optimized in the first three the goals were the icu team adhesion of % achieved in six month after bundle implementation and % after one year of follow up. these measures included five strategies to prevent ventilator-associated pneumonia: - °elevation of the head of the bed, -adequate sedation level (rass − a − ), -oral decontamination with chlorhexidine . %, -dvt/pe prevention and -peptic ulcer prophylaxis . from january on, the icu nursing staff and ict performed a daily checklist in order to observe the five issues accomplishment. if any item was found to be inadequate it was promptly corrected. results: in january and december , adhesion to the whole bundle was % and % respectively. vap density was proportionally lower to bundle adhesion in the same period, per ventilation/day and respectively. in we achieved zero vap in both semesters. conclusions: initial vap rates were extremely high even for brazilian benchmarks. although we could not implement expensive technologies like continuous aspiration of subglottic secretions, icu team and ict efforts were crucial for satisfactory results, as well the administrative board support, which turned this issue an institutional priority. our goals are to reduce even more, implementing ''ventilator bundle-getting to zero'' program, maintaining a continuum effort to sustain these results. introduction: ventilators-associated pneumonia (vap) and its prevention is a significant concern for ventilated patients in the acute care. objectives: to determine if the knowledge and awareness of "ventilator bundle" helped in the prevention of ventilator associated pneumonia in the patients admitted to hospital. methods: a prospective observational study that evaluated vap rates from august through october were evaluated. all the adult medical patients who were intubated and ventilated in medical wards from august through october in the year were included in the study. during the period of june to july the staff nurses were educated and made aware about the problem of vap and the use of ventilator bundle in helping to prevent this vap. patients who expired within hrs of admission, who were transferred to intensive care unit within hrs, and those who were diagnosed with pulmonary embolism or metastasis were excluded from this study. intervention. the concept of "ventilator bundle' was introduced after educating the nursing staff and the medical personnel through group discussions."chula ventilator bundle" is a package of evidence -based interventions that include: ( ) clean equipment and environment; ( ) hand hygiene and elevation of patient's head of bed to - degrees; ( ) use . % chlorhexidine as a part of oral care every hour; ( ) labor over weaning and extubation each day; ( ) aspiration precaution protocol. measurement. demographic data was collected from the patient data files. vap was diagnosed when it met the (clinical non-invasive) diagnostic criteria. incidence of vap and protocol compliant were calculated. results: a total of were on mechanical ventilator for a vary period of - days. average age was . ± . with . % of male. introducing the concept of "chula ventilator bundle to prevent ventilators-associated pneumonia" significantly reduced the vap rate per ventilator days from % to % in the medical group ( medical wards). it significantly reduced the incidence of oral cavity problem ( . ± . vs. . ± . , p = < . ). ventilator bundle compliance was . %. conclusions: however, ventilator bundle compliance was less than %, introducing the concept of "chula ventilator bundle" helped us to reduce the incidence of vap and the incidence of oral cavity problem. grant acknowledgment quality improvement center, king chulalongkorn memorial hospital introduction: patient-ventilator asynchrony is a mismatch between patient and ventilator inspiratory and expiratory time. it is associated with prolonged duration of mechanical ventilation (mv), increased need for tracheostomy and increased mortality. five main patterns of asynchrony are described, without universal agreement on definition. studies on patient ventilator asynchrony have quantified asynchrony at heterogeneous time points and during periods of various durations. in addition, most of these studies were of single centre type. objectives: the aim of the present study was to evaluate the factors associated with and the prognosis impact of asynchrony, according to two methods of quantification: visual inspection of airway flow and pressure signal and a computerized method integrating electromyographic activity of the diaphragm (eadi) as a maker of patient inspiratory time at the early phase of weaning. methods: ancillary study of a multicentre, randomized controlled trial comparing neurally adjusted ventilator assist to pressure support ventilation at early phase of weaning. airway flow, pressure and eadi were recorded during minutes , , and hours following inclusion. asynchrony were quantified according to two methods: ) "flow-and-pressure" based on the visual inspection of the flow and pressure signals ) "eadi-based" with analysis of the eadi signal in addition to the flow and pressure signals. asynchrony index (ai) was calculated as the number of asynchronous breaths divided by the total number breaths multiplied by . results: patients mechanically ventilated for days ( - ) were included, men ( %), aged ( - ) years, saps ii ( - ), % were mechanically ventilated for de novo hypoxemic respiratory failure. prevalence of ineffective efforts was higher with flow-and-pressure method than with eadi-based method. auto-triggering, doubletriggering, premature and late cycling were more frequently observed with eadi-based method than with flow-and-pressure method. ai and the total prevalence of asynchrony were significantly lower with the flow-and-pressure method than with the eadi-based method (table ) . no significant difference in term of gender, age, saps , charlson score or length of mv prior to inclusion was observed with severe asynchrony (ai > %) severe asynchrony was not associated with difference in term of hospital length of stay, duration of mv and day- mortality. icu length of stay determined by the flow-and-pressure method was shorter in patients with ai ≥ % ( ( - ) vs ( - ), p = . ). conclusions: the prevalence of patient ventilator asynchrony varies according the methods and definitions used to quantify asynchrony, which suggests the need for a consensus statement in asynchrony's definition. patient ventilator asynchrony was not associated with a poorer outcome. introduction: tracheostomy is a frequent procedure in intensive care units, in the us over the past decades utilization rose substantially, driven by surgical patients [ ] . the optimal timing for tracheostomy in critically ill patients remains a topic of debate. objectives: to analyse tracheostomy utilization and trends in an intensive care unit (icu) and to determine the impact of tracheostomy timing (early vs late) in critically ill patients on duration of mechanical ventilation, icu stay, overall hospital stay and mortality. methods: retrospective study including all critically ill patients who underwent tracheostomy in an icu from to . the sample was stratified in two groups, according to time of invasive mechanical ventilation until tracheostomy: early tracheostomy (≤ days) and late (> days). results: over the study period a total of tracheostomies were performed, representing , % of the admissions in the icu. tracheostomy was more common in medical patients ( . %). mean time until tracheostomy was days. there was no tendency in tracheostomy rates and timing over the years. early and late tracheostomy groups did not differ significantly by gender, age, sofa score and type of admission. in the early tracheostomy group there was a statistically significant reduction in the length of invasive mechanical ventilation ( days vs days, p < . ) and icu stay ( days vs days, p < . ), with impact in icu and hospital mortality. conclusions: early tracheostomy was associated with reduction in invasive mechanical ventilation days and icu stay, with possible implications in long term morbidity and health care costs. reinforcing that tracheostomy timing should be considered in the decision process, when evaluating risks and benefits. introduction: development of critical care medicine has been decreasing mortality of critical illness. however, - % of survivors suffer functional impairment or icu-acquired weakness (icu-aw). in order to address interventions in icu-aw, it is essential to know when icu-aw developed in addition to its incidence and risk factors. objectives: to assess the onset of icu-aw and its incidence and risk factors in the icu of tokushima university hospital. methods: prospective observational study. critically ill adults were enrolled when they were mechanically ventilated at least days. patients younger than years old, with neuromuscular diseases, central nervous system disorders, and pregnancy were excluded. after we determined feasibility of communication, medical research council (mrc) sum score was measured as soon as possible. when mrc score was less than , we diagnosed patient as icu-aw. basic profiles, underlying diseases, apache ii score, administration of neuromuscular blocking agents (nmba) and corticosteroids, and laboratory data were recorded. introduction: severe traumatic brain injury (stbi) remains as the most significant medical and social problem due to high prevalence and mortality, primarily among young and employable population. the leading problem of intensive care of stbi is the prevention and elimination of intracranial hypertension (ich). one of the methods of ich elimination is mechanical ventilation as a component of complex therapy. among the various methods and modes of mechanical ventilation high-frequency jet ventilation (hfjv) is particularly distinguished, which is enduring "the second birth". in hfv transpulmonary pressure and the pressure in airways is much lower than one during traditional methods, the negative pressure in pleural cavity is maintained during inspiration phase and spontaneous breathing. objectives: comparative assessment of efficacy of different modes of mechanical ventilation in patients with stbi. methods: we studied the cerebral perfusion during various modes of mechanical ventilation in patients with stbi. mean age was ± . the general status in admission was severe, glasgow coma score was ± . all patients had traditional intensive care with different modes of respiratory support: controlled mechanical ventilation -cmv (n = ); synchronized intermittent mandatory ventilation -simv (n = ); hfjv (n = ). the efficacy of all modes were assessed by arterial blood gases analysis (sao - - %, pco - . - . mmhg). intracranial pressure were measured invasively and was ± mmhg. all patients regularly had clinical and neurological examination, control of laboratory tests (common blood count, arterial blood gases, arteriovenous gradient of o (avdo ) and oxygen saturation in jugular vein (sjo ). cerebral hemodynamics was studied by transcranial dopplerography. the registered parameters were mean linear velocity of cerebral blood flow (vm), pulsatile index (pi) and overshoot coefficient (oc). results: there were significant differences in parameters of cerebral hemodynamics in various modes of respiratory support: cmv: vm - . most patients found mobilisation to be a positive experience and the beginning of their recovery. however, mobilization was described as a difficult component of the care, mainly due to pain, tiredness and dizziness. almost all patients commented on the benefits of participation in physiotherapy, which was verified by physical improvements and progression in their abilities. although most improvements discussed were physical, two patients also described the psychological benefits that occurred in the sessions. they reported that the physiotherapists 'built them up' and encouraged them. one patient described a mind shift that occurred once she had mobilised out of the bed. she described it as being able to see what she was capable of. it was described as a precious and muchneeded service, without which some patients felt they may not have survived or recovered as quickly. methods: this retrospective study was performed in a -bed medical icu in spain from to . all patients admitted to the icu during this period were included in the study. cci patients were defined as those with more than days of icu stay. data were collected in ways: review of a prospectively elaborated database, review of electronic records, and telephone survey evaluating the functional status of survivors, one year after their discharge from the icu. results: during the study period, patients ( females − %) were considered cci. the characteristics of these patients are shown in table . all the studied patients needed prolonged mechanical ventilation (median days), defined as > hours/day of ventilator support for > consecutive days. the follow-up period is drawn in figure . the in-icu mortality was %. in the first year, patients ( %) were alive. most patients improved their quality of life over a year, with approximately % of them displaying some help for dressing or to performing the transfer of themselves. symptoms of anxiety and depression improved during the first year, being present in up to % (of the patients), but in % if we refer to the presence of nightmares or hallucinations. % these patients were transferred (discharge) to a rehabilitation center and % needed hospital readmission within the follow-up period. conclusions: for cci patients in-hospital mortality rate is still high after discharge from the icu. however, more than one third of them are alive one year after their hospital stay and in an almost independent condition. efforts focused on early specific therapeutic strategies after icu admission to prevent the progress of the acute disease towards chronic critical illness and to improve the outcome must be explored. [ ] [ ] [ ] [ ] . at icu, . % had delirium, . % needed blood transfusion and . % renal replacement therapy. patients worsened in all parameters of the five dimensions of the eq- d after -days: the extreme problems level increased in the mobility dimension from . % at icu to . %, self-care from . % to . %; usual activities from . % to . %; pain/discomfort from . to . and anxiety/depression from . % to . %. the dependence observed in the katz index worsened in days when . % of patients were dependents before icu admission increasing to . % after days. about family members, . % were spouses and . offspring, their mean of age was . ± . years and . % had previous experience of icu. we observed that they presented more symptoms of anxiety ( %) and depression ( . %) at icu when compared days after ( . %) and ( . %), symptoms of anxiety and depression respectively. conclusions: the most common eligibility conditions of cci were sepsis followed by mechanical ventilation. we observed a great mortality on days and among survivors a worsen quality of life with more dependence in their activities of daily living. we also observed that family members suffered more while in icu stay. introduction: tracheostomy is a favored alternative option for providing prolonged mechanical ventilation and safety airway used for more than years. despite its numerous advantages, tracheostomy may have severe complications as being an invasive method for presenting respiratory tract patency. besides, the tracheostomized patients usually have prolonged icu stay, high mortality and morbidity arise from concomitant comorbidities. objectives: the aim of the study was to evaluate the frequency, patient characteristics, complications and the prognosis related with our percutaneous tracheostomy practice. methods: hospital electronic records and icu files of the patients with percutaneous tracheostomies performed in our bed anesthesiology icu were evaluated between january and december . ethic consent was obtained from local ethic committee. the patients who were discharged with home type mechanical ventilator or their relatives were contacted by phone for getting information about their health status or related complications. (tables and ) . conclusions: the blood serum sodium levels at admission, especially hypernatremia, may also be used as an independent predictor of outcome in the surgical critically ill patients. introduction: who estimates that the worldwide dengue fever incidence is about tens of thousands of cases every year. as taiwan is situated in the high risk subtropical region, dengue fever has virtually become a seasonal infectious disease. climate warming, demographic movement and the higher probability of increase in intermittent rainfall in recent years have added many factors unfavorable to dengue fever prevention. years of prevalence and the emergence of different types have also caused the risk of mortality for dengue fever to become relatively high.of the total , confirmed dengue fever cases in , there were deaths (with a mortality rate of . per thousand), marking the largest outbreak over nearly one decade in taiwan. objectives: analysis was conducted on the confirmed severe cases of dengue fever or dengue hemorrhagic fever reported to this hospital over the period between july and september , in terms of gender, age, history of chronic diseases, warning signs and diagnostic criteria for severe conditions. methods: retrospective case study was also conducted to identify risk factors in dengue fever and dengue hemorrhagic fever as well as predictors of death among dengue fever cases for statistical analysis. results: according to the results, those susceptible to infection concentrated on older people aged over (with an average age of ); in total cases had chronic diseases (with an average rate of . %), among which hypertension and diabetes constituted the majorities; and based on symptoms, fever accounted for . % while gastrointestinal bleeding was the most common at . %. of the cases, there were deaths, with an average apache ii score of . and an average mortality rate of . %. conclusions: this study shows that patients with chronic diseases aged over will have times higher risk of death if infected with dengue hemorrhagic fever. it is therefore suggested that older people aged over and patients with chronic diseases who are infected with dengue hemorrhagic fever must be closely monitored in clinical practice to pinpoint the best time for treatment and effectively reduce mortality rates. to sum up, effective use of knowledge about risk factors and prognostic factors in dengue hemorrhagic fever can help epidemic prevention organizations to focus their limited resources on high risk groups and increase the effectiveness of prevention. cardiorespiratory instability risk escalation patterns: an association study with risk factors and length of stay l. chen (fig. ) . % of them belong to "late onset" types whose risk escalated ≤ minutes before cri onset, but with different initial rr levels (low, medium and high). % of patients belonged to "early onset" type with gradual escalating risk starting about hours before overt cri, and % falling into a "persistently high" type. the mean rr during the first hours of sdu stay are . , . and . for "late onset" types; . for "early onset" type, and . for "persistently high" type, comparing with baseline rr of . for cri negative patients. the mean rr derived in the first -hours after admission is strongly associated with risk escalation patterns observed (p-value < . ), specifically, patients of "persistently high" type were more likely to have higher mean risk levels at sdu admission . risk escalation patterns were not significantly associated with age, cci or sdu los. however, they are significantly associated with hospital los (p = . ). conclusions: there is potential "risk stratification value" of vs collected during initial hours of sdu stay in predicting the cri risk escalation patterns later on, which may in turn predict hospital los. these insights may guide monitoring resource allocation for cri management. - . ] mmol/l and most of patients were on vasopressors therapy. coronary angiography was performed in / ( %) patients with a cardiac cause; continuous renal replacement therapy was initiated in out of the patients ( %) developing acute kidney injury during the icu stay. patients showed a full neurological recovery during the icu stay ( %) but only were still alive with intact neurological function at months ( %); / after ohca ( %) and / ( %) after ihca. eight patients ( %) with irreversible brain damage had organ function suitable for donation and were eventually explanted. conclusions: ecpr provided acceptable survival rate with good neurologic recovery in refractory cardiac arrest. these patients underwent several additional therapeutic interventions, which, in case of irreversible brain damage, could stabilize extra-cerebral organ function and potentially provide some available organs for donation. post-resuscitation treatment with inhaled argon improves outcome even after a prolonged untreated cardiac arrest in a porcine model introduction: after the initial success of cardiopulmonary resuscitation (cpr), the majority of patients die, mainly due to postresuscitation (pr) cardiac failure and ischemic brain damage. inhaled argon has shown neuroprotective effects in a porcine model of cardiac arrest (ca) of short duration. objectives: to investigate the effect of post-resuscitation treatment with inhaled argon on outcome in a preclinical porcine model of prolonged untreated ca and cpr. we hypothesized that argon would ameliorate post-resuscitation neurologic dysfunction. methods: the left anterior descending coronary artery was occluded in pigs ( ± kg), and ventricular fibrillation (vf) was induced. after min of untreated vf, cpr, including mechanical chest compression, ventilation and adrenaline administration, was performed for min prior to defibrillation. following successful resuscitation, animals were subjected to hr ventilation with (a) % argon - % o (n = ) or (b) % n - % o (n = ). hemodynamics were continuously monitored and systolic myocardial function (i.e. ejection fraction (ef), shortening fraction (sf)) was assessed by echocardiography. serial blood samples were obtained for blood gas, serum neuron specific enolase (nse) and plasma high sensitive cardiac troponin t (hs-ctnt) assays. animals were observed up to hr for assessment of survival and neurological recovery (cerebral performance categories (cpc) scale). results: twenty animals were successfully resuscitated and enrolled in the study (table ) . ventilation with argon did not have any detrimental effects on respiratory gas exchange during the hr ventilation (table ) . animals receiving argon showed a significantly lower heart rate and higher mean arterial pressure and stroke volume compared to controls during the hr of observation (table ) . animals treated with argon presented also a significantly better recovery of systolic myocardial function, as represented by the higher sf at hr compared to controls (table ) . nine of the resuscitated animals in the argon group survived for h in comparison to out of in the control group. animals treated with argon presented a significantly better neurological recovery (cpc . ± . ) in contrast to animals in the control group ( . ± . , figure ). lower circulating levels of hs-ctnt (median: ng/ml vs. ng/ml, p < . ) and nse (median . ng/ml vs. . , p not significant) were observed in the animals ventilated with argon compared to controls. conclusions: in this severe model of ca, post-resuscitation treatment with argon allowed for improved hemodynamics, myocardial function and neurologic recovery, without detrimental effects on respiratory gas exchanges. munich, germany, which is staffed with physicians working at a university hospital in the specialities anaesthesia or surgery. ( ) test if there is a difference between specialists and residents in pain treatment of trauma patients. methods: after ethics committee approval, retrospective analysis of the protocols of our prehospital emergency service location in munich, germany of - . statistical calculation was done using logistic regressions with stata (college station, tx, usa). results: documented trauma cases. trauma cases could be assessed for frequency of oligoanalgesia, which was present in of these cases (see figure , dashed frames), leading to an relative frequency of % of cases. there was no difference in frequency between residents and specialists (table ) . relatively more trauma cases where handed by specialists, while documentation of pain was better in residents (table ) . documentation of pain, however, was insufficient, since pain assessment at hospital admission was documented in % of possible cases of oligoanalgesia only. conclusions: frequency of oligoanalgesia in trauma patients seems to vary in different systems, since it was much lower in munich compared to switzerland ( % vs. %, respectively). there are several possible explanations: data from swizerland was from an air resuce service while our data is from a ground based system. second, in our system possibility of treatment by a specialist was much higher ( % residents in switzerland). third, documentation in our system was inadequate. theoretically, frequency of oligoanalgesia could increase up to % if all cases without adequate pain documentation were counted as oligoanalgetic. to assess appropriate numbers improvement in documentation is essential. of the attempted resuscitations were immediately unsuccessful, resulted in rosc ( sent to icu for post-resuscitation care, whilst remained on the ward). at hours (both in icu) were still alive. defibrillation was attempted in cases. intubation was attempted on occasions. in ( %) of the resuscitation attempts cpr was the only intervention reported while ( %) received more than vial of adrenaline, or defibrillation, and or intubation. interviewees reported that in ( %) of these patients they were 'not at all' or only a 'little bit surprised' by the patient having a cardiac arrest (fig ) . they further described the chances of a successful outcome as 'unlikely or very unlikely % of the time and likely or very likely only . % of the time (fig ) . conclusions: perspectives of junior doctors interviewed suggest many cardiac arrests were not a surprise and that the probability of rosc following attempted resuscitation was unlikely. there is high incidence of patients receiving cpr attempts before death in hospitals across sri lanka with dnar practices remaining uncommon. outcomes remain poor, with rosc after cardiac arrest being . % and survival at hrs . %. of the unsuccessful resuscitation attempts, defibrillation and or repeated adrenaline was reported in . % of cases. introduction: pro-coagulatoric effects after cardiac arrest and consecutively appearing microthromboses have been considered major contributors to morbidity and mortality after cpr [ ] . in contrast, recently published data suggest that - % of patients after out-ofhospital cardiac arrest (ohca) present with hyperfibrinolysis during and after cpr [ ; ] . the interpretation of these inconsistent observations remains unclear and complicated, because of methodological differences and lacking analytical approach in the underlying studies. fibrinolytic activation might be the physiological reaction to restore perfusion after hypoperfusion due to microthromboses. this leads to the question, if the duration of no-flow (time without chest compressions) after cardiac arrest influences the level of coagulation activation and subsequent fibrinolysis during cpr. objective: to investigate the influence of a delayed onset of cpr on the extent of fibrinolysis and the function of the coagulation system measured by rotational thrombelastometry (rotem). methods: after approval of the local authorities (nds. laves, approval g - ) cardiac arrest was induced in anaesthetized female göttingen minipigs via rapid ventricular overpacing resulting in ventricular fibrillation (vf). in order to simulate a bls-cpr in animals (cpr-group), chest compressions (cc) and ventilation were started after min of vf ( : -ratio, fio = . ). in order to simulate consecutive als-cpr, continuous cc ( min − ) and ventilations ( min − , fio = . ) were started minutes later. no cpr was started in the remaining pigs (non-cpr-group). blood samples for a complete rotem analysis (rotem delta® analyzer, tem int. gmbh, munich, germany) and laboratory analyses were taken before induction of vf (baseline) and , and min after vf. all parameters were investigated for normal distribution (shapiro-wilks-test). statistical significance of differences (p < . ) was investigated using the unpaired t-test (normal distributed parameters) and the mann-whitney-u-test (notnormal distributed parameters). results: figure summarizes laboratory and rotem results. in no group maximum lysis increased significantly after cardiac arrest ( figure ). maximum clot firmness (mcf) in fibtem analyses decreased significantly in both groups (figure ), but plasma fibrinogen levels (measured using the clauss method) remained stable. introduction: perception and knowledge of hospital staff involved in an emergency evacuation of hospitalized patients is usually low. this is especially remarked in an icu due to the complexity of moving patients who depend on invasive monitoring and organ support due to acute illness. objectives: to analyze the differences between different members of icu staff about their perception and knowledge of self-protection and evacuation plans. methods: a quantitative, descriptive and cross-sectional study was carried out by a fully structured and self-administered survey in public and private icu staff through a total sample of participants. they were asked to complete a questionnaire about their perception and knowledge of self-protection and evacuation plans in the icu. this study pretended to analyze the differences between participants, taking into account their demographic and occupational characteristics and their level of satisfaction and commitment to their jobs. results: on a rating scale from to , icus workers perceive that their preparation and knowledge were too low to meet a possible emergency that could require an evacuation, although they were aware of the need to make an update. however, they state that the different icus where they work do not have these plans, and, consequently, they do not feel prepared to act in an emergency situation, even though they think this type of situation may occur. the significant differences (p < , ) were observed when levels of satisfaction and commitment to their jobs were high. the results of this study showed that there is a need for more knowledge in the area of emergency training. this should be the basis for the development of educational programs and also promoting awareness of icu staff on self-protection and evacuations plans. integrating nurse practitioners and physician assistants in the icu: results of a national survey r. kleinpell rush university medical center, chicago, united states intensive care medicine experimental , (suppl ):a introduction: an increasing number of intensive care units (icus) are integrating advanced practice providers (app) including nurse practitioners (nps) and physician assistants (pas) to meet workforce demands to care for acute and critically ill patients. although these roles are established ones, limited information is known about the specific care models used in icu settings. this information is crucial in objectively evaluating the effectiveness of app roles. objectives: to address this gap, a national survey was conducted targeting nps and pas, including those working in icu settings. methods: a web-based survey was used to assess domains including role components (i.e. direct care management; care coordination; performing procedures; education; quality assurance; research); role responsibilities (i.e. practice autonomy, prescriptive authority, credentialing and privileging delineations) unit-level organization (i.e. physician staffing models, components of the multidisciplinary care team); and hospital organization (i.e. academic status, bed size, location, payer-mix). results: a total of apps responded to the national survey including nps and pas. the respondents reported working in a variety of settings including hospitals, clinics, urgent care centers and specialty practice sites. a total of reported working in an icu setting. of these, reported / coverage of acnps and pas in the icu. main role components included patient care management as part of the multiprofessional icu team; teaching to patients, families and healthcare staff; involvement in quality improvement and research initiatives and administrative components such as committee work. specific aspects include conducting history & physical exams, ordering and interpreting diagnostic test/labs; providing care coordination, performing specialty procedures such as wound care or other specialty care. major areas of impact that were identified included continuity of care, improving evidence based practice care, reducing hospital length of stay, preventing hospital readmissions and promoting patient, family and staff satisfaction. the results of the study provide information from a large national sample of nps and pas that identifies the comprehensive care components of the role as well as areas of impact, highlighting the value of app care. globally, this information can be useful to other countries who are considering use of nps and pas in the icu. national health care resources. with icu beds, the reserves of the system are often overwhelmed. the responsibility for a rational management and distribution of these costly resources burdens the admitting intensivist. intensivists not using protocols expressed a strong desire ( %) to introduce protocol based criteria for admission. conclusions: the most important factors influencing decisions about admission (or refusal of admission) in the icu are bed availability and prognosis of the underlying disease. socioeconomic and religious criteria are clearly of marginal significance. drug abuse and severe psychiatric disease do not emerge as compelling causes of biased decisions. it appears that the intensivist's decisions are largely individualized, as application of admission protocols is limited among the icus. however, the responses documented in this survey strongly indicate that introduction of such protocols would be welcome by a majority of our colleagues. conclusions: it is essential that non-cardiac surgery should be delivered in the most appropriate clinical setting. in scotland, adults with moderate to complex congenital cardiac disease are managed by the scottish adult congenital cardiac service (saccs), based at the golden jubilee national hospital (gjnh), near glasgow. [ ] existing guidelines have established when patients should have elective non-cardiac surgery performed at gjnh. however, many surgical specialties are not routinely available at gjnh, the bed occupancy rate is high and with an increasing saccs population there is a need for appropriate patients to receive optimal care at their base hospital. additionally, urgent and emergency non-cardiac surgery ought to be performed at the base hospital. while nitric oxide is a core cardiac therapy we have shown that it is scarce in scotland and unfamiliar to many icus. there is a need for a national discourse and consensus to ensure that nitric oxide is more widely available as part of a bundle of optimal cardiac critical care. this should include education, material resources, clinical guidelines and perhaps cardiac critical care outreach services to support general icus. introduction: scarcity of intensive care unit (icu) beds has long been a problem. among other things, it increases the work load of emergency department (ed), contributing to its crowding and probably to worst care, jeopardizing outcomes. despite the plausibility of this premise, studies aren't consensual about the impact on outcome of delayed icu admission from ed. hospital de são joão is a portuguese tertiary care center. ed receives around adult admissions per year, and is spatially organized according to manchester triage priorities. emergency room (er) receives patients from the street and all patients from other areas of the ed that need critical care. it is staffed by trained personnel and is equipped with level iii icu material. intensive care department is composed by level iii and level ii icu beds objectives: assess if there's a link between time spent in ed and outcome of patients admitted to level ii and/or iii icu beds. methods: this is a retrospective study analysing older than years old patients admitted to icu from ed from st january to st december . we excluded patients transferred from other hospitals. demographic and clinical data was collected from records. we selected hospital outcome (dead, alive, transferred), hospital length of stay, icu length of stay, vital status at and days after admission and ed and er duration as outcomes. simplified acute physiologic score (saps) ii and sequential organ failure assessment (sofa) were calculated by considering the worst values in the first hours of hospital admission. we performed a descriptive analysis, with median and interquartile ranges presented for continuous variables and proportions for categorical variables. for analysis of subgroups we did a chisquare or mann-whitney test. statistical analyses were done on ibm-spss (version ). a p-value of < , was considered significant. results: adults were assisted in ed in this period, with a median length of stay of minutes. were admitted to icu beds, which accounts for , % of all adults cared for in ed. around % of patients admitted in icu were treated in the er at some point of their ed care. patients admitted to icu stayed around minutes in ed. the more severe the disease, the least time spent (p = , ). patients treated in er were significantly more likely to be admitted quickly in icu (p < , ). taking in consideration the time spent in the ed, we found an opposite relation with global outcome, meaning that patients staying longer periods in ed had lower icu mortality and lower length of stay in icu. there was no association with hospital mortality. conclusions: time spent in ed had no negative impact on outcome. however, given the fact that the majority of patients admitted to icu beds were cared in a devoted area with trained staff and full level iii equipment, we hypothesize that what might impact the most on outcome is provision of early critical care. determination of icu bed requirement using resampling k.k. introduction: planning for icu-bed provision, with a statistical confidence level, required the average number of critically-ill patients, their average icu length of stay (los), and the fluctuation/variance of these two parameters. the actual icu bed occupancy would under-estimates the variance, as icu could never exceed its full capacity. with an under-estimate, the predicted icu bed requirement would be inaccurate, with a tendency of under estimation. objectives: estimate the bed requirement to cover . % of time, by resampling of admission/discharge entries in , for the two busiest icus in hong kong (~ admissions/year each) methods: we assumed that the chance of an icu admission was identical in a period of four weeks before and after a certain date. based on this assumption, a computer simulation of icu admissions was performed as if the year happened again. in brief, we pooled patients admitted on a particular date in , and those admitted on the same day of week in the previous four and subsequent four weeks. then patients were randomly selected from the pool to simulate icu admission on that particular date. a mechanism (not described here) was in place to handle the public holidays. the hourly icu occupancy was calculated using the actual icu los of the selected patient. re-sampling for the whole year was repeated times to provide the estimates required. results: the actual hourly medians of icu occupancy were % and %. they were close to that obtained using resampling ( % and %). as predicted, the distributions of the actual occupancy were skewed to left, indicating a negative bias on the variance estimates. the observed standard deviations of the two icus' occupancy were . % and . % respectively. after resampling, the distributions became more symmetrical, and had higher standard deviations of . % and . % (both p = . ). the . percentile occupancy in reality were % and %, while that from resampling were significantly higher at % and % (both p = . ). this corresponded to three or four additional icu beds in each icu. conclusions: in conclusion, using a simple and conservative assumption, resampling could provide valuable insight for icu bed planning. introduction: the number of available intensive care unit (icu) beds are limited while the request for the beds are high. thus rationing the admission to icu is necessary especially in developing countries where the resources are limited. also models are needed to estimate and re-estimate regularly, shortage in the number of icu beds in any hospital. in the current study we tried to design a model for estimating shortage in the number of intensive care beds in a developing country tertiary university hospital after an initial delphi consensus study. objectives: designing a model for estimating shortage in the number of icu beds in a hospital. methods: initially the standard indications for icu triage were extracted from the literature. four intensivists were served as steering committee and the initial questionnaire were further prioritized by experts with three rounded delphi method and formed a standardized checklist for icu triage. indications were considered as critical, important, and all indications. then a cross-sectional study being performed during a -month period from august to september for all admissions to nemazee hospital, a tertiary healthcare center affiliated to shiraz university of medical sciences. cardiac, transplantation and pediatrics patients were excluded from the study, as to be studied separately. the checklist were filled every day by an observing physician and any indications for icu admission were marked in the questionnaire. decision making for requesting icu admission were performed by the specialized physicians of each ward regardless of the results of completed checklists.the results were further assessed according to the mentioned criteria and the reliability and viability was calculated. finally assuming that there was no available icu bed-days, the required icu bed-days were compared with the total icu bed-days of the hospitals, to estimate the shortage of icu beds. results: totally patients were admitted and studied.the required bed-day regarding critical indications, important indications, and all indications for icu admission was , , and . by comparing the required bed-days with available bed-days of the hospital, beds were calculated as shortage of icu beds. the results of the current study indicate that our center has deficiency in the number of icu beds. it seems that a checklist is not only useful for prioritizing patients but also it is useful for estimating the required number of the icu beds.the actual number of shortage is greater as three group of patients were not included. transfer delay from intensive care unit: retrospective analytical study in an indian tertiary care hospital s. k introduction: there lies scarcity of intensive care unit (icu) beds in every tertiary care hospitals, and on top of it delayed transfer of patients from icu to wards is further increasing the burdensome. numerous factors affect in making delayed transfer, which in itself is a risk factor for patient related morbidity and mortality, especially the after hour transfers. objectives: the aim of the study was to analyze the hours of transfer delay and their effect on readmission rates in the icu. methods: we conducted a retrospective study of patients transfer from our icu to the wards over last one year (jan-dec' ).data collected from the icu database by the secretarial staff during the study period and divided into following categories of transfer delays: results: there were patients admitted to our icu during the study period of which patients were shifted to the wards. the average delay in shifting was around . hours ( - . hrs).delayed transfer of more than hrs was found in % patients and the percentage of after-hours transfer was % of the total transfers. there were readmissions into the icu within hrs of shift out among patients transferred in after hours as against in patients transferred during routine hours. conclusions: prevalence of delayed discharge from icu was significant, especially the after hour discharges, which has got an impact on readmission rate as well. discharge delay should be considered as an important quality indicator for critically ill patients to decrease the morbidity and mortality in icu patients. further studies are warranted to identify factors associated with delayed discharge. introduction: critical illness (ci) and stay in an intensive care unit (icu) are known to induce physical and functional changes. bone is often forgotten in survivors. limited published data reported an altered bone metabolism in case of prolonged icu stay [ ] and a decreased in bone mineral density (bmd) in the year following icu admission [ ] . clinical impact of these changes is still not well described. objectives: our retrospective study aimed to assess incidence of any new bone fractures (bf) two years after a severe ci. methods: patients admitted in our icu during were screened. adults > years (y) old with an icu length of stay (los) > days (d) were included. lost to follow-up were considered exclusion criteria. patients who died in icu or who died during the follow-up period (fup) with an icu los ≤ d were also excluded. demographic data, medical objectives: pulmonary arterial hypertension (pah) is associated with reductions in health-related quality of life (hrql). the patient care still played an important role in improvement of hrql, even though more drug therapy was identified in recent decade.. in this study, we investigated to provide quality care for patients with pulmonary arterial hypertension via multidisciplinary care model. methods: a multidisciplinary team was organized.in a tertiary medical center, including intensivists, cardiologists, pulmonologists, cardiac surgeons, rheumatologists, chest surgeons, rehabilitation physicians, psychologist, pharmacologists, hospice care physicians, nutritionist, social workers and nursing staffs. the key interventions include home based rehabilitation therapy, hours hot line care, pah care nurse training program, hospice care information and consultation, phychological care and autogenic training, prompt pah referral system, social care connections, on-line self pah risk assessment system, on-line and innovative mobile apps patient instructions, facebook patient care group and ourdoor pah patient education program. the pah patients were divided into three groups: pre-interventional group from may to dec , interventional group from jan to june and post-interventional group from july to feb . hrql was measured using the short form health survey (sf- ) in all enrolled subjects. results: the average physical compartment scale of sf- , including physical functioning; role limitations due to physical health, pain and general health improved from ± in pre-interventional group, to ± in interventional group and to ± in post-interventional group (p < . ). the average mental compartment scale of sf- , including role limitations due to emotional problems, energy/fatigue, emotional well-being and social functioning, improved from ± in pre-interventional group, to ± in interventional group and to ± in post-interventional group (p < . ). conclusions: the study demonstrated multidisciplinary care model could improve hrql of patients with pulmonary arterial hypertension. blood pressure management with urapidil for patients with aortic dissection is associated with less esmolol usage than nicardipine j.-c. zhou sir run run shaw hospital, intensive care medicine, hanghzou, china intensive care medicine experimental , (suppl ):a introduction: acute aortic disease is a common but challenging entity in clinical practice. titration the blood pressure and heart rate to a target level is of paramount importance in the acute phase regardless of whether the patient will undergo a surgery or not eventually. in addition to the initially intravenous β-blockers, parenteral infusion of nicardipine and urapidil are the most common used antihypertensive therapy currently in mainland china. however, few empirical data was available with respect to the different effect on patients' outcome of the two antihypertensive strategies, especially given the deleterious reflex tachycardia of vasodilators which may increase force of ventricular contraction and potentially worsen aortic disease. objectives: to evaluate the difference of the abovementioned two antihypertensive strategies on the outcome of patients with aortic disease. methods: all patients with new diagnosed aortic diseases presented to our hospitals from january , to june , were retrospectively reviewed. the antihypertensive strategies and their association with patients' outcomes were evaluated with logistics regression. results: a total of patients with new diagnosed aortic disease were included in the study. of them, patients received urapidil while patients received nicardipine antihypertensive therapy. patients with nicardipine were more quickly to reach the target blood pressure level than those treated with urapidil (median vs mins, p = . ). after adjustment for patient demographics, comorbidity, involved extend of aorta, interventional strategies, antihypertensive therapy with nicardipine (with urapidil as reference) for patients with aortic disease was significantly associated with high esmolol cost (or: . , %ci: . - . , p = . ) and longer icu length of stay (or: . , %ci: . - . , p = . ). however, there was no significant correlation between nicardipine use and icu mortality (or: . ; %ci, . - . , p = . ). conclusions: although nicardipine achieved the target blood pressure level more quickly than urapidil for patients with aortic disease, it was associated with more esmolol use and longer icu length of stay. introduction: postoperative bleeding is one of the most common complications of cardiac surgery. excessive perioperative bleeding continues to complicate cardiac surgery with cardio-pulmonary bypass (cpb) in spite of improvements in extracorporeal oxygenation and surgical techniques. even bleeding after cardiac surgery has variable causes, we thought the applying isth scoring system may be able to predict the postoperative excessive blood loss in patients after cardiac surgery with cpb. objectives: the aim of present study was to examine the effectiveness of international society on thrombosis and hemostasis (isth) scoring system in patients with cardiac surgery. methods: the medical records of patients undergoing elective cardiac surgery using cpb between mar. and feb. were retrospectively reviewed. these demographic and clinical characteristics, perioperative laboratory findings, and postoperative complications were assessed using computerized databases from our institution. isth score was calculated in icu and patients were divided with overt dic group and non-overt dic group. results: among patients with cardiac surgery, patients with overt dic group (n = ) or non-overt dic group (n = ) were enrolled. mean dic scores at icu admission was . ± . (overt dic group) and . ± . (non-overt dic group) and overt dic was induced in % ( / ). overt dic group had much more ebl for hrs (p = . ) and maintained longer time of intubation time (p = . ) conclusions: in spite of limitation of retrospective design, management using isth score in patients after cardiac surgery seems to be helpful for prediction of the post-cpb excessive blood loss and prolonged tracheal intubation duration. renal failure, . % vs %, p ≤ , ; respiratory failure, . % vs . %, p ≤ , ; mechanical > h . % vs . %, p ≤ . ventilation. the variables that reached statistical significance in the multivariate analysis as predictors of mortality were apache ii or . ( % ci . - . ), p = . , euroscore or . ( % ci , - . ), p < . ; acute respiratory failure or . ( % ci . to . ), p = . ; acute renal failure or . ( % ci . - . ), postoperative bleeding or . ( % ci . to . ), p < . conclusions: mortality in this group is similar to other series, being patients with more comorbidities, with the highest score in the euro-score and apache ii and more often subjected to mixed surgery. the euroscore, apache ii, respiratory failure, renal failure and postoperative bleeding, predict higher mortality. methods: we measured rea as ratio of pulmonary pressure at the dicrotic notch (dypap) and stroke volume (sv) [ ] and rees as ratio of the difference between mean pulmonary artery pressure (mpap) and wedge pressure (pcwp) and end systolic volume (resv) (mpap-pcwp/resv) [ ] after the induction of anaesthesia (t ) via pulmonary artery catheter (swanganz f and vigilance ii monitor by edwards lifesciences), after weaning from cpb (t ) and h after in icu(t ) in patients. results: measure of rvac has been demonstrated feasible in all four patients undergoing cardiac surgery. as expected all the patients were found uncoupled (rvac > ) before surgery, immediately after weaning from cpb rvac worsen and in icu it was restored to the basal. conclusions: in this preliminary analysis we demonstrated the feasibility of measuring rvac in critical patients undergoing cardiac surgery, to our knowledge this is the first report in this field. as expected rvac is very much influenced by cpb although further investigation is needed to confirm the utility of this technique to monitor the right heart in such patients. introduction: detection of tissue hypoperfusion is paramount in the management of va ecmo. arterial to pulmonary artery co difference has been demonstrated to be an early marker of hypoperfusion in the shock patient [ ] and during hypothermic cardiopulmonary bypass [ ] , objectives: in this report we investigated the accuracy and feasibility of mixed venous to arterial co difference as an early marker of perfusion mismatch during va ecmo. methods: in a patient treated with va ecmo for refractory cardiac arrest due to acute myocarditis we performed serial measurements of pulmonary artery to arterial co difference as well as svo , map, urine output and lactate level. results: during reduced perfusion periods, assessed by elevated lactacidemia (> mmol/l) we observed high > co difference which is concordant to literature [ ] . during episodes of reduced systemic perfusion, demonstrated by increase of serum lactic acid we were able to early detect hemodynamic derangement (avg minutes) by identifying elevated (> mmhg) co difference. conclusions: this case report underlines the importance of pulmonary artery to arterial co difference as an early marker of hypoperfusion if compared to lactate level in the intensive care unit. to our knowledge this is the first report on venous to arterial carbon dioxide difference in va ecmo. further investigation is needed to confirm those preliminary results. introduction: many studies have shown clinical benefits from sdd for critically ill patients. however, there is still doubt concerning the emergence of antimicrobial resistance in the long term. previously no evidence to support this view was found but long-term effects of sdd on antimicrobial resistance on the unit level is understudied. , objectives: to determine the incidence of antimicrobial resistance in aerobic gram-negative potentially pathogenic micro-organisms (agnbs) to the components of sdd and frequently used i.v. antibiotics on icu-level over a year period with unchanged antibiotic policy. methods: this is a single-center observational cohort study in a dutch -bed adult intensive care unit in a teaching hospital. all consecutive patients admitted to the icu between january and december were included when at least one culture was taken during icu-admission. data on all cultures taken during icu stay were collected from the hospital database. susceptibility testing was performed following the guidelines of the 'clinical and laboratory standards institute' (csli) until and 'the european committee on antimicrobial susceptibility testing' (eucast) from until . incidence rates of antimicrobial resistance to tobramycin, ciprofloxacin, polymyxin b or cefotaxime were calculated per year. only icuacquired resistant pathogens were selected by excluding resistant pathogens in cultures taken on day -day . patients at risk were defined as all admissions with a length of stay longer than days. differences between the incidence in the first and last year of the study were tested using chi-square test. results: data of . cultures was analyzed containing . agnbs. the number of admissions with a length of stay more than days was . in admissions newly acquired resistance to cefotaxime was found, in to polymxin b, to tobramycin and to ciprofloxacin. figure presents incidence rates per year. in - date of discharge to the ward was unknown and therefore incidence rates could not be calculated for these years but absolute numbers were comparably low. there was no significant difference in incidence of icu acquired resistance in cefotaxime (χ = . , p = . ), polymyxin b (χ = . , p = . ), tobramycin (χ = . , p = . ) and ciprofloxacin (χ = . , p = . ) between and . conclusions: the incidence of newly acquired agnb resistant to cefotaxime, polymyxin b, tobramycin and ciprofloxacin continues to be low during a year unchanged antimicrobial policy of sdd. the increase in resistance in the society may impact these numbers and should be studied. results: overall, icu and h mortality rates were and %. . % of the pts ( / ) became infected in the early postoperative period. (icu and h mortality rate and % respectively). crpk infections were present in pts ( . % of the entire series, . % of the infected pts). sarcopenia ( % vs %, p = . ) and meld ( + vs + , p = . ) were significant preoperative risk factors. icu and h mortality rates were % and % in crpk pts, % and % in non -crkp infected pts respectively : while icu mortality was not different (p = . ), h mortality was significantly higher in crkp pts (p = . icu vs h, ci . - . ). if compared to non -crkp pts , crkp pts were more often in septic shock ( % vs %, p = . ) and more frequently underwent crrt ( % vs % p = . ). intraabdominal infections were largely represented ( %) among crkp pts. blood loss and transfusion needs, early gratt dysfunction and reolt were more represented in infected vs non infected pts. however, no differences were found when crkp and non-crkp transplanted pts were compared. conclusions: crkp infections are on the rise also in italy. post olt mortality is high and strategies able to control crkp are urgently needed to be implemented. introduction: the prevalence of antibiotic-resistant pathogens in icu conditions makes it difficult to treat these infections, and treatment becomes impossible in some cases. acinetobacter baumannii is important infectious agent icu patients, which effective antibiotic therapy is currently limited. objectives: we aimed to determine the range of a.baumannii associated infections among icu patients, to summarize the level of resistance to antimicrobial drugs, and provide an overview of strategies to prevent the spread of resistance. methods: a prospective microbiological study of the prevalence and antibiotic resistance of a.baumannii strains isolated from adult icu patients hospitalized to the tertiary hospital after cardiac surgery from to . results: a total of isolates from icu patients were included to the study. . % of the isolated strains ( ) were gram-negative, among which . % ( ) of a.baumannii isolates. strains of a. baumannii showed a high level of resistance to the iii generation cephalosporins ( . % to ceftazidime, . % to cefotaxime, . % to ceftriaxone). resistance to carbapenems was at %. investigation of antimicrobial activity of ciprofloxacin showed the resistance in . % of strains, to levofloxacin - . %. the lowest level of resistance recorded to doxycycline - . % and polymyxin - . %. conclusions: rapid microbiological diagnostics (including the results of antibiotic resistance), strict adherence to infection control, the appointment of an effective regime of antibiotic therapy, optimization schemes appointment of antibiotics, all of which are the most important priorities for the effective fight against a. baumannii associated infections in icu patients. in order to reduce the emergence and spread of drug-resistant strains in the icu, it is strongly recommended to carry out microbiological monitoring and optimization of the use of antibiotics in each hospital. therefore local resistance surveillance programs have the greatest value in the development of appropriate therapeutic recommendations for specific types of patients and infections. introduction: acinetobacter spp. are opportunistic, nosocomial pathogens that may colonize the surfaces in intensive care units. their tendency to harbor multi-drug resistance and to develop resistance mechanisms to commonly available drugs make their treatment a challenge. carbapenem resistance, and newly reported colistin resistance has led to a search for new treatment options. there are in vitro studies which report synergistic effect with rifampicin in combination therapies. objectives: we aimed to present and discuss the results of our patients who were infected with either panresistant ( patients) or only tigecycline susceptible ( patients) acinetobacter spp. and were treated with rifampicin combination regimens. methods: patients reported to be infected with colistin resistant acinetobacter spp. and treated with rifampicin combination regimens upon decision of the responsible teams were traced from the intensive care unit (icu) records between the years and retrospectively. their demographic data, liver function tests, icu and hospital outcomes were recorded. results: there were a total of patients, were women. mean age was . . in patients pulmonary site was the source. nine patients had positive blood cultures. mean sofa score at the start of therapy was . ; all were intubated, and ( %) were on vasopressor therapy. combination regimens comprised of at least antibiotics and all regimens included rifampicin and tigecycline. at the end of first week, mean sofa score was . . of these ( %) survived to hospital discharge. patients who were lost had higher initial and follow-up sofa scores. initial and follow-up liver enzymes and renal function tests were similar to their basal values in patients who survived; unlike the patients who were lost. when lost patients were re-evaluated: the first patient had irreversible lung fibrosis due to bleomycine; in the second patient; combination treatment was delayed until days after the cultures were performed; the third patient had been admitted to icu with acute renal failure and acute respiratory distress syndrome, after autologous stem cell transplantation for multiple myeloma. conclusions: when the importance of accurate antibiotic choice is taken into account for treatment success; rifampicin combinations may be considered as an appropriate treatment option for infections caused by colistin resistant acinetobacter strains. introduction: carbapenem resistant enterobacteriacae (cre) emerged in recent years as one of the most challenging group of antibiotic resistant pathogens. polymyxins are considered as the last resort for the treatment of infections with carbapenem resistant gram negative bacilli (gnb). inadequateor extensive use of colistin leads to emergence of colistin resistance, increasing mortality and morbidity and necessitating prudent use of alternative antibiotics. fosfomycin, a phosponic acid derivative which acts by disrupting bacterial cell wall synthesis, is a broad spectrum antibiotic. it is available as sodium/disodium formulation for intravenous use and is showing promising result against multi drug resistant(mdr)/pan drug resistant (pdr) pathogens. methods: a total of eight colistin resistant (mic ≥ ) gnb were isolated from icu patients with nosocomial mdr infections during a period of one year. all eight isolates were klebsiella pneumonia. among these isolates five were from blood and three from endotracheal aspirate. all the isolates were sensitive to fosfomycin in vitro. all of these patients had multiple co-morbidities with recent history of colistin exposure. intravenous fosfomycin was given as a combination therapy. results: among the five bacterimic patients, three recovered completely from sepsis. one patient took discharge against medical advice and the only one bacterimic patient who died during the course of therapy was later on diagnosed to have azole resistant fungemia as super infection. the patient with ventilator associated pneumonia also responded well after initiation of fosfomycin therapy. average duration of antibiotic therapy in all these cases was ten days. conclusions: based on the evidence of clinical experience and available studies, intravenous fosfomycin therapy may be considered as the last option for the treatment of mdr gnb infection where there is documented colistin resistance and where there is literally no other choice of antibiotic therapy. the success of the therapy is encouraging in selected group of patients. further research on intravenous fosfomycin use specially against mdr pathogens and on the effectiveness and safety of the drug in the treatment of patients with such infections may be warranted. introduction: patients at the intensive care units have an increased risk of infection due to their underlying diseases or conditions, impaired immunity, and exposure to multiple invasive procedures (surgery, mechanical ventilation, central venous catheters, artherial catheters, urinary tract catheters). multidrug-resistant organisms infection has become a public health problem and has been associated with increased morbidity, mortality, and costs. objectives: to analyze the principal features of postsurgical patients with colonization or infection by multidrug-resistant organisms, acquired before the admission at the intensive care unit. methods: retrospective observational study, descriptive, case series, collected from / / to / / in a -bed hospital, with a -bed polyvalent intensive care unit in fuenlabrada, madrid, spain. the hospital is attached to resistance zero project, with screening at admission and every week in all patients (pharyngeal, rectal, nasal, wounds and bronchial suction). postsurgical patients have been identified with multidrugresistant organisms isolation in screening in the first hours of admission to the intensive care unit. studied variables: age, sex, adjusted charlson comorbidity index, barthel index, apache ii, saps , days of hospitalization prior to icu, days of antibiotic treatment administered before icu, previous days of parenteral nutrition, prealbumin, surgical wound infection, multigrug-resistant organisms identified sample. statistical analysis: spss . categorical in frequencies and percentages, mean and standard deviation or median and interquartile range. analysis kolmogorov smirnov, shapiro wlik and qqplot to normality. confidence intervals (ci) % by t student for normal variables, boot stramp to not normal. results: in months we identified postsurgical patients with multidrug-resistant organisms in screening at the admission or before the admission to the intensive care unit. multidrug-resistant organisms identified: pseudomonas aeruginosa ( . %), esbl enterobacteriaceae ( . %), mrsa ( . %), stenotrophomonas maltophilia ( . %). isolated on: surgical wound ( . %), bronchial suction ( . %), peritoneal fluid ( . %), exudates monitoring ( . %), blood ( . %). antibiotic therapy: carbapenem ( . %), piperacilina-tazobactam ( . %). conclusions: in our study the risk of prior acquisition of multidrugresistant organisms at the admission to the intensive care unit in postsurgical patients was characterized by long hospital stay, high comorbidity and dependence, malnutrition, prolonged use of broadspectrum antibiotic, parenteral nutrition and surgical wound infection. introduction: the emergence and dissemination of klebsiella pneumoniae carbapenemase (kpc) is of great concern. outbreaks have been reported in different types of intensive care units (icu). in brazil, there have been reports of kpc since . we recently experienced a large outbreak at our hospital. risk factors for kpc colonization and outcome of icu patients are still to be determined. objectives: to study the differences between patients who acquired from those who did not acquired kpc during their stay in the icu, focusing on risk factors and outcomes. introduction: patients with a prolonged weaning represent a small part of the total icu population but this prolonged state has many implications on their later recovery and can highly impact health expenditures. objectives: to better characterize patients with prolonged weaning and assess factors associated with their survival. methods: the prospective multicentre observational wind (weaning according new definition) study was performed from april to august . ventilation and weaning modalities were daily assessed until discharge in all intubated patients admitted to the participating icus. we defined ) weaning attempt (wa) as a spontaneous breathing trial (sbt) or an extubation (with or without sbt), ) successful weaning as an extubation without death or invasive mechanical ventilation within days. we considered patients as having a prolonged weaning if weaning was not terminated at days following their first wa. conclusions: in this multicentre international prospective cohort, . % of the patients entering the weaning process had a prolonged weaning with a high mortality rate of . %. the only baseline factor associated with death were previous immunodeficiency and chronic cardiac failure. these patients highly impact the icu workload as they receive mechanical ventilation for a median duration of days and their median length of stay in the icu is days. patients with a prolonged weaning spend a long icu time after the end of weaning without mechanical ventilation raising the issue of the need for specialized units. introduction: ineffective efforts (ie), defined as the inability of patient's inspiratory effort to trigger a ventilator-delivered breath, is a commonly encountered asynchrony, and has been reported to adversely affect patient outcome , , . the incidence of ie depends on several factors, including patient population, ventilator settings, and the observation period, which in most studies so far was limited , . objectives: aim of this study was to investigate the incidence of ineffective efforts, using continuous recordings, in critically ill patients mechanically ventilated only on assisted mode and their potential effects on patient outcome. methods: adult critically ill patients hospitalized in the icu of the university hospital of heraklion on mechanical ventilation for > h were enrolled. patients were studied when they were on assisted ventilation for > hour and expected to remain on assisted ventilation for the next hours. patients were studied again on the rd and th day if they remained on assisted ventilation. continuous h measurements were obtained using a monitor validated to identify ineffective efforts (pvi monitor) . the output of pvi monitor data was processed before analysis to optimize data quality and re-sampled to a time-series with the number of ies calculated in uniform intervals of secs while preserving the total number and duration of ies . the ie index was calculated as previously described. because ie occurred in clusters, the concept of ie event was introduced, to describe variable periods of time containing ie > % of breaths. ie events were characterized by their duration and power (number of ie) . introduction: the neural timing during mechanical ventilation can be obtained from conventional airway flow tracing, or invasive esophageal and gastric signal; however, it is difficult clinical practice and could be imprecise. the first derivative of airway flow signal show line segments with distinctly different slopes and with welldefined the inflections points, therefore this closely indicate the respiratory times, it can be calculated easily. objectives: to evaluate the accuracy of the derivative of the flow signal (df) as method for measurement of the respiratory times compared with esophageal-gastric signals. introduction: providing appropriate levels of pressure support (ps) at the bedside is challenging. physicians should avoid both over-support, which increases the risk of lung trauma, muscle atrophy and prolonged weaning; and under-support, which increases the risk of patient discomfort and respiratory muscle fatigue. the latter can be determined by the using the tension time index of the inspiratory muscles (tti es ) derived from measurement of esophageal pressure. tti es values higher than . indicate fatiguing patient effort. the beacon caresystem (mermaid care, denmark) advises on level of ps using physiological models of lung mechanics, pulmonary gas exchange, respiratory drive, acid-base status and muscle function; along with clinical preference functions quantifying the risk of muscle atrophy, patient stress, and lung trauma. mathematical models are tuned to measurements allowing advice to be patient specific. objectives: this study investigates the variation of tti es and other indices of respiratory muscle function induced by an increase/decrease of the level of ps, and whether the consequent advice proposed by the beacon system results in appropriate patient effort. methods: ten patients with acute respiratory failure residing in an icu in ferrara, italy, have currently been included for this analysis. an esophageal balloon was inserted and its correct position determined by the occlusion test. the advice of the beacon system was followed for an hour from states of over-and under-support defined as % and % of baseline ps. the level of peep was kept constant throughout the study. data were analysed in terms of tti es and esophageal pressure developed in the first ms of an occluded inspiration (p . ) results: the baseline tti es values of . ± . were consistent with absence of fatiguing effort in all patients but one. as expected, reducing/increasing the level of ps resulted in tti es and p . increase or decrease, respectively. in patients the reduction of ps was associated with impending muscle fatigue. the levels of ps proposed by the beacon system resulted in tti es of . ± . , slightly higher than obtained by the treating physician, but always below the values indicating muscle fatigue, a part from the patient in which the tti es indicated fatigue at baseline. of note, this new value of tties was not associated with a significant variation p . , which implies that the proposed level of ps was not associated with an increased respiratory drive or higher transpulmonary pressure conclusion: these initial results indicate that beacon caresystem responds appropriately to over-and under-support avoiding muscle fatigue and excessive p . . the use of vo level changes as a predictor for weaning success in the mechanically ventilated patients introduction: experimentally, hyperchloraemia may induce vasoconstriction of the renal afferent arterioles and tubular dysfunction, potentially resulting in acute kidney injury (aki). the clinical implications of these findings are not well established, especially in septic patients. objectives: to investigate whether chloride serum and urinary concentrations as well as chloride load, output, balance and urinary anion gap are associated with the development of aki in septic patients. methods: retrospective analysis of an institutional database including all patients admitted to the intensive care unit (icu) for severe sepsis and septic shock from january to june . inclusion criteria were length of stay in the icu ≥ hours and complete data available on serum and urinary samples for at least days. patients were excluded if they had anuria on icu admission, continuous bladder irrigation, if they were on hemodialysis (of recent onset and chronic) and if they were kidney-transplanted. demographics and data on outcome were also analysed from the database. we collected chloride levels on daily blood (bcl) and urinary (ucl) analyses; chloride load (cl) was calculated by considering the amount of chloride present in the iv fluids administered daily to the patient, while chloride balance (cb) was calculated as: cl -co, where co is chloride output (ucl * daily urine output). creatinine clearance (crcl) was calculated on -hr urinary collection. aki was defined according to standard criteria. conclusions: most of septic patients developed aki and this complication was associated with a significant reduction in renal chloride elimination. the impact of such findings on the management of fluid therapy in this setting remains to be further evaluated. introduction: plasma interleukin (il- ) is associated with acute kidney injury (aki) in sepsis. il- receptor (il- r) is not expressed in the kidney. circulating il- in a complex with soluble il- r (sil- r) activates ubiquitously expressed transmembrane signal transducing glycoprotein on renal epithelial cells. this il- trans-signaling is associated with mortality in experimental sepsis. objectives: to study il- trans-signaling in patients with sepsis in a clinical intensive care setting. methods: in septic patients showing first organ failure at intensive care unit (icu) admission ± hours, we measured plasma il- and sil- r at admission and hours later. our primary endpoint was aki during the first five icu days by kdigo criteria. mann-whitney's, spearman's correlation and chi square tests were used. results: plasma il- was significantly higher in patients with aki at h (p = . ) and h (p < . ). plasma il- correlated with kdigo stage at h (r = . , p = . ) and h (r = . , p < . ). plasma sil- r did not differ between aki and non-aki groups. using cut-off values of pg/ml of il- and pg/ml of sil- r at h (detected by youden method), the combination of low il- and low sil r was associated with non-aki (p < . ). conclusions: combination of low il- and low sil- r in plasma is associated with decreased incidence of aki, suggesting that il- transsignaling contributes to septic aki. . % for the non-aki group (or = . ; % ci, . - . , p < . ). multivariate analysis indicated that the bpv was well associated with aki (adjusted or = . ; % ci, . - . , p < . ) while the mean blood pressure was not (adjusted or = . ; % ci, . - . , p = . ). conclusions: elevated blood pressure variability is associated with increased risk of aki in septic patients. this understanding may be helpful to develop requirement for stabilising blood pressure in the bp management of septic patients. introduction: acute kidney injury (aki) is a frequent and serious complication of sepsis in intensive care units (icu). according to acute kidney injury criteria (akin), the most current diagnostic criteria for aki is an abrupt (within hrs.) reduction in kidney function currently defined as an absolute increase in serum creatinine of more than or equal to . mg/dl, or . fold from baseline or a reduction in urine output (documented oliguria of < . ml/kg per hr. for > hr.). by time of occurrence of these criteria actual kidney insult has occurred & probably this leads to late intervention for kidney protection &/or renal replacement therapy (rrt). so early prediction of aki by using biomarkers like urinary angiotensinogen could help patients to benefit from a quicker and more appropriate therapy. urinary angiotensinogen appears quite promising due to its reported correlation with the intrarenal angiotensinogen and angiotensin ii levels which play a major role in molecular mechanisms of aki. objectives: the aim of this work was to evaluate the role of urinary angiotensinogen as a possible predictor of aki in patients with severe sepsis. methods: the study was carried on adult patients who were admitted to the department of critical care medicine, at the alexandria main university hospital and who suffered from severe sepsis. patients were categorized into two groups according to aki development; non aki group which consisted of patients (group i), and aki group which consisted of patients (group ii). patients were excluded if they have chronic kidney disease, already started rrt, received angiotensin convertase enzyme inhibitors (acei) or angiotensin receptor blockers (arbs), or septically shocked. urinary angiotensinogen and creatnine were withdrawn once from each patient on the day of admission to calculate urinary angiotensinogen/creatinine ratio (uancr, ng/mg). akin staging was assessted daily for seven days. results: there was a significant difference between the two studied groups regarding uancr ratio on admission (p < . ), whereas this introduction: acute pancreatitis with organ dysfunction is termed severe acute pancreatitis (sap) and complex sap if local complications develop (such as infected pseudocyst). we receive tertiary referrals of complex sap patients to our unit, who often have multiple ct scans. muscle wasting is known to occur in critically ill patients ( ) and can be quantified by measurement of the cross-sectional area (csa) of para-spinal muscles at the third lumbar vertebral level on ct imaging. aki is one of the most common causes of death in sap patients ( ) and is a risk factor for developing ckd ( ). kdigo guidelines suggest using creatinine changes to detect aki ( ) but creatinine changes may be inaccurate in the presence of musclewasting (myopenia) ( ). objectives: to utilise measurements of l para-spinal muscle csa (l mcsa) from complex pancreatitis patients between april -december and compare these to changes in plasma creatinine during their icu stay. methods: patients were identified from our icu patient database (wardwatcher software) and additional clinical details including creatinine/egfr level on ct-scan days, were acquired from electronic databases. images were exported from our pacs system as dicom files and analysed using imagej software (ref) in duplicate by two independent users, average values were used. for patients who had no renal-replacement therapy (rrt), between-scan l mcsa and creatinine change were paired and analysis was with excel (ms) and graphpad (prism). results: patients met inclusion criteria. patients had ≥ ct scans in icu, enabling serial estimation of l mcsa. / ( . %) patients did not have rrt in icu. there was no statistically significant difference in overall (start to end of icu) % change of l mcsa between patients who did/did not have rrt. there was also no correlation between overall (start-to-end of icu) % creatinine change and % change/day l mcsa: r = − . , p = . . for between-scan data (n = ): the median (iqr) % creatinine change/scan was − . % (− . to − ) and the % l mcsa change/ scan was − . % (− . to − . ). however, there was no correlation between % l mcsa change and % creatinine change between scans ( r = − . , p = . ). conclusions: l mcsa (relating to lean muscle mass) was shown to decrease in complex severe acute pancreatitis (sap) patients. however, there was no correlation with change in l mcsa and change in creatinine. this suggests that normal/stable creatinine values may be falsely reassuring in the context of muscle mass loss (myopenia) and ongoing aki could be under-diagnosed. acknowledging myopenia and interpreting creatinine value in context is therefore vital. introduction: continuous renal replacement therapy (crrt) is the most common therapy in critical ill patients with acute renal failure, having circuit coagulation as the most frequent complication. the crrt circuit requires careful anticoagulation to avoid coagulation and bleeding complications. critically ill patients with acquired antithrombin (at) deficiency, may have a shorter filter lifespan. objectives: evaluate the relation between the modification of at levels from baseline and circuit survival during ccrt. we would like to determine the existence of an at critical level, related to the risk of the clotting filter. methods: we started an observational study with prospective data collection in a university hospital. from october to april , patients were included, with filters in total. we measured the level of at activity at the beginning (basal at), daily, and at the moment of circuit coagulation. we divided the patients in two groups depending in their at´s basal level (< % or > %). then, we observed the percentage of change in at from baseline, and we divided the patients in tertiles to obtain three comparable groups. the main outcome measure was filter lifespan of first circuit and the correlation with at´s levels. results: low at´s basal level (< %) has significant association with longer filter life span (p = . ). we obtained three groups according to a percentage changes of ± % in at from baseline. one group declined the at´s basal level ( % decrease), other had little changes (between % decrease and % increase) and the last one had an increase ( % increase). the group which presented the highest percentual increase showed the largest median survival time to circuit coagulation ( hours; % ci: - ). we observed a significant association (p = . ) between the greater percentage change in at from baseline, and a larger time intervals to circuit coagulation. conclusions: the circuit lifespan shows a narrow correlation with evolution of at´s levels since the start of crrt until filter clotting. at measurement should be considered an essential factor during crrt. calcium supplementation was required with filters ( %) in patients ( %). in these patients, the median supplementary calcium dose (in addition to replacement fluid ca) was . mmol/hr ( . - . ). of those were initiated with calcium with only requiring further calcium in the next filter and did not ( patient who started on calcium only used filter). one patient in the citrate group was discontinued for alkalosis. no patients were discontinued for hypocalcaemia. conclusions: post dilution rca, using replacement fluid which contains calcium, in patients with a relative contraindication to heparin, reduces need for post filter calcium supplementation and provides acceptable filter life. mortality risk factors in continuous renal replacement therapy in a university hospital from colombia c. introduction: acute kidney injury (aki) occurs in more than % of critically ill patients, % need renal replacement therapy, preferring continuous therapies. however mortality seems not to change with this technology. the research available focus on the right time to start therapy, but only evaluating renal dysfunction characteristics. objectives: to identify mortality risk factors at the start of continuous renal replacement therapy (crrt) for acute kidney injury and early mortality risk factors in this patients. methods: a cohort study was performed in patients over years old with aki who required crrt in the intensive care unit of a university hospital in bogota colombia between and . the crrt was provided with aquarius® edwards® technology, polyethersulfone membrane of . and . m (aquamax®) and replacement fluids with lactate (premixed®). modality selection were guided by the hospital guideline. sample size calculation was estimated selecting cases (death) for each variable associated with mortality. a description of demographic and clinical variables was performed, bivariate analysis with mortality and early death defined as death within hours of onset of crrt, and finally we proceed to perform a multivariate prediction analysis. we considered statistically significant p value < . . results: a total of patients required crrt during the period, ( . %) patients were excluded, (age under years old, incomplete data and chronic kidney disease on dialysis). the mean age was . years (± . ), . % men. the most frequent cause of aki was sepsis in . % of cases. a total of crrt days were conducted with a median of days per patient (range - ). mean charlson comorbidity index was . (± . ), apache ii score . (± . ), total non-renal sofa had a median of (range - ) at the time of starting therapy. the hospital mortality was . % and early mortality was . %. in multivariate analysis: age (p = . ), sofa (p = . ), days door-support (p = . ) and the presence of hypotension (p = . ) were independent risk factors for hospital mortality with an area under the curve of . . for early death lactic acid levels (p = . ), glucosa (p = . ) and age (p = . ) were independent risk factors with an area under the curve of . . conclusions: patients with aki on crrt have high mortality. age, multiple organ dysfunction, hypotension and time door-support were independent mortality risk factors. low levels of glucose and high lactate at onset of crrt are independent risk factors of early death. pediatric formulas for the anesthesiologist the role of bystanders, first responders, and emergency medical service providers in timely defibrillation and related outcomes after out-of-hospital cardiac arrest: results from a statewide registry kids save lives-training school children in cardiopulmonary resuscitation worldwide is now endorsed by the world health organization (who) acute skeletal muscle wasting in critical illness enhancing rehabilitation of mechanically ventilated patients in the intensive care unit: a quality improvement project pdf . nice quality standard (qs ) stroke in adults the sentinel stroke national audit programme (ssnap) interventions to improve the physical function of icu survivors core standards for intensive care units icu early mobilization: from recommendation to implementation at three medical centres revista brasileira de terapia intensiva invasive pulmonary aspergillosis is a frequent complication of critically ill h n patients: a retrospective study isolation of aspergillus in three h n influenza patients. influenza other respir viruses grant acknowledgement supported by fucap and ciberes effect of daily chlorhexidine bathing on hospitalacquired infection chlorhexidine bathing and health care-associated infections: a randomized clinical trial outcome of elderly patients undergoing intracranial meningioma resection -a systematic review and meta-analysis references . an expanded definition of the adult respiratory distress syndrome acute respiratory distress syndrome: the berlin definition jama h n influenza a virus-associated acute lung injury: response to combination oseltamivir and prolonged corticosteroid treatment epidemiology, co-infections, and outcomes of viral pneumonia in adults: an observational cohort study. medicine (baltimore) survival from severe pandemic h n in urban and rural turkey: a case series prognostic importance of neutrophillymphocyte ratio in critically ill patients: short-and long-term outcomes. the american journal of emergency medicine reversal of neutrophil-to-lymphocyte count ratio in early versus late death from septic shock the association between the neutrophil-to-lymphocyte ratio and mortality in critical illness: an observational cohort study the mortality risk of over hydration in haemodialysis patients ultrasound assessment for extravascular lung water in patients undergoing hemodialysis. time course for resolution sufficient sleep quality easily measured: a multicenter centre study in dutch icus rd international symposium on intensive care and emergency medicine using nursing activities score to assess nursing workload on a medium care unit nurse staffing levels and the incidence of mortality and morbidity in the adult intensive care unit: a literature review nursing activities score in the intensive care unit: analysis of related factors. intensive and critical care nursing organisation and management of intensive care : a prospective study in european countries impact of performance obstacles on intensive care nurses' workload, perceived quality and safety of care and quality of working life burnout syndrome in critical care nursing staff work engagement: an emerging concept in occupational health psychology diagnostic accuracy of clinical swallow assessment for oropharyngeal aspiration: a systematic review the cruelest lies are often told in silence critical review: is the endoscopic swallowing assessment (abstract a ). lactate (sepsis vs trauma) jaundice in the intensive care unit cooling techniques for targeted temperature management post-cardiac arrest thermoregulatory catheter-associated inferior vena cava thrombus ivtm intravascular temperature management catheter specifications prediction of postoperative pulmonary complications in a population-based surgical cohort lung ultrasound: routine practice for the next generation of internists relevance of lung ultrasound in the diagnosis of acute respiratory failure* assessment of hemostasis after plasma exchange using rotational thrombelastometry (rotem) prevention of pain on injection of propofol: systematic review and meta-analysis prevention of pain on injection with propofol: a quantitative systematic review mechanical ventilation guided by esophageal pressure in acute lung injury ultrasound assessment of antibiotic-induced pulmonary reaeration in ventilator-associated pneumonia ards definition task force endotracheal tubes cuff pressure control: does the co matter? minerva anestesiol incidence and outcome of in-hospital cardiac arrest in the united kingdom national cardiac arrest audit delayed awakening after cardiac arrest: prevalence and risk factors in the parisian registry diaphragm ultrasound as a new index of discontinuation from mechanical ventilation critical ultrasound journal ventilator-induced diaphragm dysfunction: time for (contr)action! the course of diaphragm atrophy in ventilated patients assessed with ultrasound: a longitudinal cohort study critical care effect of postextubation high-flow nasal cannula vs conventional oxygen therapyon early non-invasive ventilation treatment for severe influenza pneumonia use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy the first patient report of the national emergency laparotomy audit acute kidney injury enhances outcome prediction ability of sequential organ failure assessment score in critically ill patients médecine intensive et réanimation development and validation of a questionnaire for quantitative assessment of perceived discomforts in critically ill patients the emotional and cognitive impact of unexpected simulated patient death the efficiency of instructional conditions: an approach to combine mental effort and performance measures long-term cognitive impairment after critical illness satisfacción laboral de los profesionales sanitarios de un hospital universitario: análisis general y categorías laborales the nurse satisfaction, service quality and nurse retention chain: implications for management of recruitment and retention grant acknowledgement am: moulton foundation hospital/kcl the very elderly admitted to icu: a quality finish? crit care med a global clinical measure of fitness and frailty in elderly people cognitive, functional, and quality-of-life outcomes of patients aged and older who survived at least year after planned or unplanned surgery or medical intensive care treatment outcome of elderly patients with circulatory failure. int care med understanding and reducing disability in older adults following critical illness mechanical ventilation in a cohort of elderly patients admitted to an intensive care unit preferences of current and potential patients and family members regarding implementation of electronic comunication portalls in intensive care units caring for the family of the critically ill patient the carina as a radiological landmark for central venous catheter tip position duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study duration of cardiopulmonary resuscitation and illness category impact survival and neurologic outcomes for in-hospital pediatric cardiac arrests duration of prehospital resuscitation efforts after out-of-hospital cardiac arrest neurologic prognosis after cardiac arrest magnetic resonance imaging markers of parkinson´s disease nigrostriatal signature disruption of posteromedial large-scale neural communication predicts recovery from coma james mcdonnell foundation, the belgian american education foundation, university milano bicocca. fig. (abstract a ). study flowchart intensive care medicine experimental neurological prognostication after cardiac arrest strategies for improving survival after in-hospital cardiac arrest in the united states: consensus recommendations: a consensus statement from the cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved -day clinical outcomes in patients with st-segment elevation myocardial infarction complicated with profound cardiogenic shock the current use of impella . in acute myocardial infarction complicated by cardiogenic shock: results from the uspella registry mechanical circulatory support in cardiogenic shock cardiac transplantation research database group, long-term outcomes of cardiac transplantation for peripartum cardiomyopathy: a multiinstitutional analysis cardiopulmonary resuscitation with assisted extracorporeal life support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in countries in europe and the united states nurses' widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial feasibility and observed safety of interactive video games for physical rehabilitation in the intensive care unit: a case series is admission to the intensive care unit associated with chronic opioid use? a -year follow-up of intensive care unit survivors survival to icu discharge in ventilated patients intensive care medicine experimental modified early warning score with rapid lactate level in critically ill medical patients: the views-l score impact of matrix-assisted laser desorption ionization time-of-flight mass spectrometry on the clinical management of patients with gram-negative bacteremia: a prospective observational study. clinical infectious diseases : an official publication of the infectious diseases society of america impact of rapid organism identification via matrix-assisted laser desorption/ionization time-of-flight combined with antimicrobial stewardship team intervention in adult patients with bacteremia and candidemia. clinical infectious diseases : an official publication of the infectious diseases society of america impact of rapid identification of acinetobacter baumannii via matrix-assisted laser desorption ionization time-of-flight mass spectrometry combined with antimicrobial stewardship in patients with pneumonia and/or bacteremia. diagnostic microbiology and infectious disease an international cross-sectional survey of antimicrobial stewardship programmes in hospitals continuous infusion of beta-lactam antibiotics in severe sepsis: a multicenter double-blind, randomized controlled trial hplc determination of plasma free and total tazobactam and piperacillin effectiveness of polymyxin bimmobilized fiber column in sepsis: a systematic review crit care predicting functional impairment in brain tumor surgery: the big five and the milan complexity scale *p. ferroli the "medial-oblique" approach to ultrasoundguided central venous cannulation-maximize the view, minimize the risk medial-oblique" probe position for ultrasound-guided internal jugular vein cannulation: a crossover study improving survival from sudden cardiac arrest: the "chain of survival" concept practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the quality standards subcommittee of the american academy of neurology association of bystander interventions with neurologically intact survival among patients with bystander-witnessed out of hospital cardiac arrest in japan performance of the revised atlanta and determinantbased classifications for severity in acute pancreatitis rational fluid therapy for sepsis and septic shock what do recent studies tell us? review article surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock fluid type and the use of renal replacement therapy in sepsis: a systematic review and network meta-analysis. int care med the third international consensus definitions for sepsis and septic shock fernández-ortega regional university hospital in málaga rapid diagnosis of infection in the critically ill, a multicenter study of molecular detection in bloodstream infections, pneumonia, and sterile site infections grant acknowledgement supported, in part cytokines and signaling molecules predict clinical outcomes in sepsis the application of esophageal pressure measurement in patients with respiratory failure mechanical ventilation guided by esophageal pressure in acute lung injury ecmo criteria for influenza a (h n )-associated ards: role of transpulmonary pressure mechanical ventilation guided by esophageal pressure in acute lung injury fig. (abstract a ) grant acknowledgment national cheng-kung university hospital grant a assessment effort and work of breathing by airway occlusion pressure versus esophageal pressure hospital universitario reina sofia, intensive care unit airway occlusion pressure effects of the prone position on respiratory mechanics and gas exchange during acute lung injury effects of prone position on alveolar recruitment and oxygenation in acute lung injury prone position reduces lung stress and strain in severe acute respiratory distress syndrome lateral positioning of ventilated intensive care patients: a study of oxygenation, respiratory mechanics, hemodynamics, and adverse events the effect of lateral position on oxygenation in ards patients : a pilot study the open lung concept of mechanical ventilation: the role of recruitment and stabilization selecting the 'right' positive endexpiratory pressure level esophageal and transpulmonary pressures in acute respiratory failure spontaneous breathing during lung-protective ventilation in an experimental acute lung injury model: high transpulmonary pressure associated with strong spontaneous breathing effort may worsen lung injury relationship between activation of the sympathetic nervous system and renal blood flow autoregulation in cirrhosis hepatorenal acute kidney injury and the importance of raising mean arterial pressure a fig. (abstract a ) rotational thrombolelastometry produces potentially clinical useful results within min in bleeding emergency department patients: the deuce study thrombelastography and rotational thromboelastometry early amplitudes in trauma patients with clinical suspicion of severe injury a prospective study of anaemia status, haemoglobin concentration and mortality in an elderly cohort a experience with a hospital-wide implementation of a massive transfusion protocol: before and after a references . experience with a massive transfusion protocol in the management of massive haemorrhage rodríguez villamizar hospital universitario puerta de hierro majadahonda recommendations for end-of-life care in the intensive care unit: a consensus statement by the american college of critical care medicine end-of-life care practices in patients dead as a result of a devastating brain injury and organ donation in spain prediction of potential for organ donation after cardiac death in patients in neurocritical state: a prospective observational study causes of family refusal for organ donation development of the croatian model of organ donation and transplantation evaluation of organ procurement in an area under the influence of a training program grant acknowledgment none. a non-heart beating donor program: seville's experience l. martin-villen , the variables analyzed were: total number of queries activation, of pd, of eligible donors (ed) and of real donors (rd). rd attendance times were registered and we defined out-of-hospital time (from cardiac arrest to hospital arrival), inof-hospital time (from hospital arrival to cannulation onset), cannulation time (beginning of cannulation to perfusion onset) and perfusion (from perfusion onset to the first organ removal). we registered number and type of valid organs and tissues, number of family members or judicial negative, number of non-real-donors (nrd) and its causes regarding attendance times, the median time was (icr - ) minutes for out-of-hospital, (icr - ) minutes for in-of-hospital, ( - ) minutes for cannulation and ( - )minutes for perfusion controlled donation after circulatory determination of death in spain rodriguez villamizar puerta de hierro hospital, intensive care unit, majadahonda, spain correspondence: j. veganzones ramos -puerta de hierro hospital the use of lung donors older than years: a review of the united network of organ sharing database marginal donor lungs: a reassessment liberalization of donor criteria may expand the donor pool without adverse consequence in lung transplantation the human organ transplant act. legislative acts and guidelines, ministry of health amendment of the human organ transplant act lebrón-gallardo regional university hospital in málaga grant acknowledgment this work was funded by the innovation awards from the department of medicine recombinant human soluble thrombomodulin in sepsis-induced disseminated intravascular coagulation: a multicenter propensity score analysis a successeful strategy to reduce ventilator getting started kit: prevent ventilator associated pneumonia. cambridge ma: institute for healthcare improvement umr_s and hôpital pitié-salpêtrière, respiratory division and medical icu trends in tracheostomy for mechanically ventilated patients in the united states outcome of patients with cirrhosis requiring mechanical ventilation in icu the impact of organ dysfunction in cirrhosis: survival at a cost? does intermediate care improve patient outcomes or reduce costs abbreviations: tbs, tracheobronchial secretions aki, acute kidney injury hd, hemodialysis a patient perceptions of physiotherapy in icu: a qualitative study m dimensionamento da equipe de enfermagem da uti-adulto de um hospital ensino -rev. eletr. enf critérios para admissão de pacientes na unidade de terapia intensiva e mortalidade patient acuity rating: quantifying clinical judgment regarding inpatient stability identification of deteriorating patients on general wards; measurement of vital parameters and potential effectiveness of the modified early warning score the epidemiology of chronic critical illness in the united states impact of chronic critical illness on the psychological outcomes of family members tracheostomy procedures in the intensive care unit: an international survey percutaneous tracheostomy: a yr prospective evaluation of the single tapered dilator technique can outcomes of intensive care unit patients undergoing tracheostomy be predicted? respir care safety and complications of percutaneous tracheostomy in a cohort of mixed icu patients prognostic consequences of borderline dysnatremia: pay attention to minimal serum sodium change. crit care are the dysnatremias a permanent threat to the critically ill patient? a explore the dengue-related risk factors and death factors in dengue hemorrhagic fever epidemic in taiwan diabeted with hypertension as riak factor for adult dengue hemorrhagic fever in a predominantly dengue serotype epidemic: a case study characteristics of dengue epidemics in taiwan modelling risk of cardio-respiratory instability as a heterogeneous process grant acknolwedgment nih ninr r nr during two years, we included all patients with more than days of stay in a medicalsurgical icu. previous informed consent , we collected demographics data, baseline functional status (barthel scale), mortality intrauci, at hospital and one-year of hospital discharge chronic critical illness a comparison between -dimentional speckle tracking & color-tissue doppler imaging for the assessment of left ventricular global longitudinal systolic strain and strain rate in outcome prediction of sepsis grant acknolwedgment italian ministry of health, italy (convenzione n. /gr- - ); and fondazione sestini exclusion criteria: do not resuscitate order. protocol: data were collected anonymously according to the utstein style. follow-up: months long using registry office and telephonic interview. data: age, sex, cerebral performance category (cpc good moderate disability, severe disability, unconscious), site of cardiac arrest, presumed etiology, initial rhythm (shockable or unshockable), witnessed event, monitored, cpr started within minute. primary end points: return of spontaneous circulation (rosc), survival to hospital discharge and cpc - . secondary end points: months survival and cpc - . statistics: numerical data are expressed as mean ± standard deviation or median (interquartile range), as percentage if ordinal data. chi-square test for ordinal data and t student's test for numerical data were performed. p significant if < . . results: cardiac arrests, cpr was carried out in cases ( %) secondary end points: . % alive at months; . % of them with cpc - . conclusions our experience reflects some aspects common with other european countries: less monitored events as well as more frequent cardiac arrests in unmonitored wards . rrt allowed a reduction of cardiac arrests thus reducing their incidence without modifying mortality incidence and outcome of in-hospital cardiac arrest in the united kindom national cardiac arrest audit epidemiology and outcomes of in-hospital cardiopulmonary resuscitation in the united states effectiveness of rapid response teams on rates of inhospital cardiopulmonary arrest and mortality: a systematic review and meta-analysis national intensive care surveillance, quality secretariat building, castle street hospital for women correspondence: a. beane -network for improving critical care systems and training (nicst), colombo, sri lanka intensive care medicine experimental fig. (abstract a ) fig. (abstract a ) authors thank tem international for providing a rotem analyzer for the study. references . the consort extension for cluster trials mcf fibtem & plasma fibrinogen references . extracorporeal membrane oxygenation for ards in adults cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with inhospital cardiac arrest: an observational study and propensity analysis critical care in resource-restricted settings on behalf of the task force for mass critical care. evacuation of the icu. care of the critically ill and injured during pandemics and disasters: chest consensus statement icu fire evacuation preparedness in london: a cross-sectional study fire on an intensive care unit caused by an oxygen cylinder national questionaire survey on what influences doctors; decisions about admission to intensive care the faculty of intensive care medicine/the intensive care society acute care toolkit . high-quality acute care. royal college of physicians united kingdom; golden jubilee national hospital, department of anaesthesia there is a need for general (non-cardiac) intensive care units (icus) to facilitate more elective and emergency surgery for these patients. inhaled nitric oxide, a selective pulmonary vasodilator, may be required for this purpose. objectives: we wished to determine the availability of inhaled nitric oxide in general scottish icus we excluded tertiary paediatric, cardiothoracic and neuro-critical care units. an online survey was distributed followed, if necessary, by a telephone survey. caldicott guardianship approval was not required. results: four ( %) general icus had nitric oxide immediately available adult congenital heart disease (grown-up congenital heart disease) audit of critical care in scotland scottish adult congenital cardiac service a references . triage of patients consulted for icu admission during times of icu-bed shortage a then performed a cross-sectional survey by visiting each facility, and determining characteristics for each facility critical care in low-income countries functional compromise reflected by sarcopenia, frailty, and nutritional depletion predicts adverse postoperative outcome after colorectal cancer surgery sarcopenia is a predictor of outcomes in very elderly patients undergoing emergency surgery oudemans-van straaten hm, beishuizen a. low skeletal muscle area is a risk factor for mortality in mechanically ventilated critically ill patients acetate-versus lactate-based balanced colloids used as priming solutions for cardiopulmonary bypass: an experimental pilot study h. cauwenberghs , a. de backer , h. neels , i. deblier correspondence: h. cauwenberghs -zna middelheim general hospital methods: following irb approval, male non-diabetics gave consent and were randomly assigned to receive either succinylatedgelatin g (geloplasma®) in meq na+, meq k+, meq cl-, meq mg++, meq lactate (sid ) or succinylated gelatin g (isogelo®) meq na+, meq k+, meq ca, meq cl-, meq mg++, meq acetate and bonferroni corrected. results: demographics were comparable. acid-base variables changed similarly throughout without significant differences between groups (sig shown in figure ). by contrast, glucose levels rose very significantly in the lactate group and persisted post cpb (figure ). oncotic pressure, diuresis, osmolarity and oxygen uptake did not differ between groups. discussion. concerning acid-base variables and secondary endpoints the perioperative period stewart's textbook of acidbase pl effects of intravenous solutions on acid-base equilibrium: from crystalloids to colloids and blood components seric pro-adrenomedullin levels in low cardiac output syndrome (lcos) after cardiac surgery we measured am at time-points (t -t ): before surgery; at admission; h and h after surgery. continuous data were showed as average (sd) and categorical ones in percents. comparisons were performed with kruskall-wallis and anova tests. the roc approach was used to assess the predictor capacity of am. all analyses were performed with stata . the ethical committee approved the study. results: patients were included. the average of age was ± . years, and were women . %. the median (iqr) for euroscore was ( - ). comorbidities were hypertension ( %), diabetes mellitus ( %) and atrial fibrillation ( . %). on-pump surgery was performed in the % and the coronary bypass was the most frequent ( %). the incidence of low cardiac output syndrome was %. am levels (mmols/l) were: . ± . (before surgery) postoperative pro-adrenomedullin levels predict mortality in thoracic surgery patients consensus on circulatory shock and hemodynamic monitoring. task force of the european society of intensive care medicine canadian cardiovascular society position statement on the management of thoracic aortic disease guidelines for the diagnosis and management of patients with thoracic aortic disease early and midterm outcomes following surgery for acute type a aortic dissection importance of blood pressure control after repair of acute type a aortic dissection (abstract a ). pro-adm levels t -t bleeding complications associated with cardiopulmonary bypass prospective validation of the international society of thrombosis and haemostasis scoring system for disseminated intravascular coagulation towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation hospital regional, intensive care, malaga, spain; hospital serrania, ronda, spain; hospital regional, intensive care, málaga, spain; hospital infanta margarita, intensive care, cabra, spain; hospital virgen del rocio, intensive care we analyze differences in the postoperative incidence of af in both groups. results: cohort of patients, mean age . ± . years. . % was elective surgery. euroscore . ± . points. icu mortality was . %.prior to surgery, . % and . % taking statins present a history of af. . % postoperative af episode presented. the patients treated before surgery with statins had af . % vs . % (p = . ) the sample was divided among the patients who died and those who do not. demographic variables, prognostic scales,type of surgery,early complications, icu stay and mortality were compared.the variables that reached statistical significance in the univariate analysis were analyzed in multivariate logistic regression. data expressed as mean and standard deviation, percentage, mean difference, odds ratio and corresponding confidence intervals. statistical significance level of p < . . results: a total of patients were analyzed, ≥ years ( . %) of which died( . %) predictors of postoperative complications in octogenarians undergoing cardiac surgery a ventricular assist devices, transfusion and health-related quality of life %,median rbc transfused ventricular assist devices and increased blood product utilization for cardiac transplantation. stone ml et all bleeding complications and blood product utilization with left ventricular assist device implantation. schaffer jm et all after completion of cardiac surgery. the patients were divided into two groups: aged < and age ≥ years. association analysis of demographic, clinical, therapeutic factors and complications during icu stay. univariate analysis using chi square (fisher if applicable) and t student. data expressed as percentages, means, estándar desviation (sd), mean differences (dm), odds ratio (or), and confidence intervals % (ci %) results: a total of significant differences in cardiac arrest cardiac surgery in octogenarians: a case series outcomes and cost of cardiac surgery in octogenarians is related to type of operation: a multiinstitutional analysis aortic valve replacement with and without coronary artery bypass graft surgery in octogenarians: is it safe and feasible? short-and long-term outcomes in octogenarians after coronary artery bypass surgery diagnosing and treating the failing right heart matching dicrotic notch and mean pulmonary artery pressures: implications for effective arterial elastance. the american journal of physiology university hospital of pisa, department of anaesthesia and critical care medicine, cardiothoracic and vascular anaesthesia venous-to-arterial co differences and the quest for bedside point-of-care monitoring to assess the microcirculation during shock model of pco gap during hypothermic cardiopulmonary bypass central venous o( ) saturation and venous-to-arterial co( ) difference as complementary tools for goal-directed therapy during highrisk surgery patients: closed-vs. opensystem the closed-system pivc was composed of catheter with inteof pivcs, the incidence of bacterial colonization and pivcs-related complications (phlebitis, extravasation, catheter occlusion and hematoma) were recorded. the protocol of the study was approved by the irb of tokushima university hospital. results: ninety-one closed-system pivcs and open-system pivcs were evaluated. the median indwell time did not differ between the closed-and open-system pivcs (median were identified from the database of the microbiological laboratory of the hospital and were included in this study as cases. demographic data, severity of illness, risk factors for colistin-resistance (described in previous studies), clinical management and hospital outcome of all cases were recorded. mdr -resistant to at least one agent from different classes. pdr -resistant to all classes. results: of kp ( . %) and of ec ( . %) isolates were colistin resistant. of ( . %) of kp and of ec ( . %) isolates were colistin resistant colistin-resistant isolates of klebsiella pneumoniae emerging in intensive care unit patients: first report of a multiclonal cluster risk factors associated with the isolation of colistin-resistant gram-negative bacteria: a matched case-control study combination antibiotic treatment versus monotherapy for multidrug-resistant, extensively drug-resistant,and pandrug-resistant acinetobacter infections:a systematic review in vitro synergistic activity of tigecycline and colistin against xdr-acinetobacter baumannii woodlands multispeciality hospital references . combatting resistance in intensive care: the multimodal approach of the spanish icu "zero resistance" program. garnacho montero et als during a kpc outbreak in the -bed icu of a tertiary university hospital in rio de janeiro, brazil. all patients admitted to the icu were included in the study and classified as case (kpc yielded from any biological material, either considered as colonization or infection) or control (all other patients who did not have kpc isolation). both groups were compared according to demographic data, comorbidities, sepsis diagnosis, type and time of life support, sofa and saps iii scores at icu admission, length of stay (los) at icu and hospital, and hospital costs, icu and hospital mortality. results: patients were admitted during the studied period. patients had kpc samples isolated from different biological material conclusions: during a kpc outbreak in the icu of an academic tertiary hospital in rio de janeiro, the isolation of kpc associated with colonization or infection was associated with greater icu and hospital los, more requirements of life-organ support, higher icu and hospital mortality rates impact of carbapenem resistance on the outcome of patients' hospital-acquired bacteraemia caused by klebsiella pneumoniae first report of kpc- -producing klebsiella pneumoniae strains in brazil attributable mortality rate for carbapenem-resistant klebsiella pneumoniae bacteremia zero resistance" (rz) program was swabs (nasal, pharyngeal, axillary and rectal) were routinely performed to all patients admitted, besides diagnostic cultures when needed. furthermore, we analysed other pathological variables and comorbidities. the difference between groups of mrb was made by chi-square test for qualitative variables and the kruskal-walls test for the continuous ones. statistical significance was set at p < . . results: admitted. in patients were identified one or more mrb ( in total). patients ( , %) were esbls carriers, ( , %) mrsa, ( , %) p aeruginosa, ( , %) acinetobacter spp and ( %) others mrb carriers. in cases ( , %) the presence of a mrb caused infection. nasal swabs detected % of mrb carriers ( % of all mrsa), pharyngeal swabs % ( , % of mrsa), axillary swabs % ( % of mrsa, % of acinetobacter), and rectal swabs % ( % of esbls, , % of acinetobacter). in cases ( %) just the axillary swab was positive, and in cases ( %) the rectal was the only swab able to detect a mrb. diagnostic cultures (blood, urine, bronchoaspirate, surgical wound and others) detected mrb in less than %. the checklist did not detected neither colonization nor infection by mrb in ( %) patients ( % mrsa, , % acinetobacter, % of esbls). all patients with p aeruginosa had rf, but one. there was no statistical significance between groups of mrb and other comorbidities. conclusions: the surface cultures realized at admission detected % of mrb not detected by diagnostic cultures ):e . a enteral paramomycin to eradicate colistin and carbepemenase resistant microorganisms in rectal colonization to prevent icu multiresistant nosocomial infections university hospital of gran canaria dr. negrín, pharmacy department hospital of getafe, intensive care unit microbiology unit, section biology pathology and health products ) received catecholamines and ( %) were immunocompromised. icu mortality was . % and did not differ between esbl carriers and non-carriers. the rate of esbl colonization at admission and esbl acquisition were . % and . %, respectively. escherichia coli was the most frequently observed bacteria. the results of the univariate analysis for esbl acquisition are presented in table . in multivariate analysis, igs-ii and icu length of stay were strongly associated with esbl acquisition (table ). discussion and conclusion: the observed rate of esbl carriage on admission was comparable to other rates in french icus ( %). despite the unfavourable twin-bed architecture of our icu, the incidence of esbl acquisition was . % which was actually lower than transmission rates previously published in other icus. esbl acquisition was strongly associated with icu length of stay and severity score at admission. this study is fully consistent with previous ones challenging the geographic isolation in a non-epidemic setting and suggests that environmental contamination may not play a substantial role in the transmission of esbl-pe wipo was diagnosed with lus if, on at least one upper or lower part of both sides, the lus profile moved from a (normal) to b (interstitial oedema) or from b to "b+", where b+ consisted in at least a doubling of the b lines number. the reference diagnosis of wipo was established on other criteria by experts blind for lus. results: wipo occurred in ( %) sbt. among cases with wipo, the lus profile did not change during sbt in one case, changed for lus signs of pulmonary oedema in cases (true positives) and changed but without typical lus signs of wipo in one case university hospital of lausanne, intensive care and burn unit saint michael's hospital and keenan research centre, interdepartmental division of critical care a introduction: many different tools are found to predict weaning success us) assessed excursions of the right hemi-diaphragm could be a useful measurement for prediction success in weaning from mechanical ventilation (mv us was performed after patient met weaning criteria (according to local protocol) and it was decided to discontinue mv. patients with neuromuscular disorders and diaphragmatic paralysis were excluded. measurements were performed once on pressure support ventilation (ps ≤ cmh o, peep ≤ cmh o). the right hemi-diaphragms of patients were evaluated by m-mode ultrasonography (esaote mylabgamma ac - mhz convex probe). the average diaphragm excursions value (de avg ) was estimated from sequential measurements. the rapid shallow breathing index (sbi), dynamic compliance (c dyn ), minute ventilation (m v ) and spontaneous tidal volume (v t spont) were obtained from the ventilator (servo i , maquet) table ) with best de avg cut-off value . mm (sensitivity % , specificity %). conclusions: our findings suggest that right hemi-diaphragm excursions assessed with m-mode ultrasonography is more accurate predictor of weaning success than other common weaning criteria weaning from mechanical ventilation diaphragm dysfunction assessed by ultrasonography: influence of weaning from mechanical ventilation a cycling-off guided by real-time waveforms analysis (intellisync+): pilot study on next-generation psv anesthesia and intensive care methods: in patients under psv, intellisync + was compared to to default setting, ets opti decreased cycling delay and unassisted efforts at ps basal, but these favorable effects were not maintained at ps + . further optimization (ets opti ) decreased cycling and trigger delay but did not affect unassisted efforts. when intellisync + was activated, cycling delay was shorter and values of trigger delay and unassisted efforts were at least as low as with optimized settings of ets. table summarizes the results obtained in the conditions tested. conclusions: bedside optimization of ets guided by waveforms on the ventilator screen improved pvi. increase of pressure support level worsened pvi and mandated re-optimization of ets a characteristics and factors associated with prolonged weaning. a sub-analysis of the wind study g upres ea irib saint michael's hospital and keenan research centre, interdepartmental division of critical care objectives: to determine a predictor of weaning success with a faster reaction time than respiratory rate & pulse rate. methods: patients ( male, female) on mv > days were included in our study diagnosed with sepsis (n = ), pneumonia (n = ), pancreonecrosis (n = ), obesity hypoventilation syndrome (n = ), intestinal obstruction (n = ). oxygen consumption (vo ) monitoring in different stages of mv support reduction was recorded using e-covx evaluation of mortality over time in patients receiving mechanical ventilation the use of mechanical ventilation in intensive care unit in russia: national epidemiological survey ruvent- a prospective, blinded evaluation of indexes proposed to predict weaning from mechanical ventilation a randomized, controlled trial of the role of weaning predictors in clinical decision making cpf) using ventilator built-in flow-meter to predict extubation success: a single centre study f. gobert , , h inclusion criteria were: age > years, intubation > h, no withdrawal decision of life supporting care, eligible for scheduled weaning trial and then scheduled extubation, mechanical ventilation from evita xl ventilator (dräger, germany) and patient's agreement to participate. once daily checked criteria for weanibility were present, patients were switched to a standardised pressure support ventilation (inspiratory pressure = cmh o, peep = cmh o, fio = . ) for h (if no chronic respiratory failure-crf), h (if crf) or h (if neuromuscular crf). the procedure of cpf measurement was explained to the patient, who was encouraged to cough as strong as possible just before extubation. cpf measurements were done by freezing ventilator screen and scrolling the cursor to the maximal value of cpf during expiration and tidal volume (tv) in preceding inspiration. three measurements were averaged. early extubation success rate was defined as the proportion of patients who were alive and not reintubated h after scheduled extubation. median values were compared by using non parametric tests. diagnostic performance of cpf and tv was assessed by using area under curve (auc) of the roc method. after having defined cut-off values for cpf and tv, we described the performance of a test combining cpf and tv values to predict the early extubation outcome. results: during the study period, patients were admitted to our icu of who were intubated and patients included (fig ). between the patients who succeeded and the patients who failed extubation, median cpf was − . l/min and − . l/min, respectively (p = . , fig a), median tv . l and . l, respectively (p = , , fig b), and auc averaged . and . , respectively (fig a). bi-dimensional analysis showed a synergistic effect of cpf and tv to predict early extubation success (fig b). the combination of thresholds (cpf < − l/min and tv > . l) grant acknolwedgment the study has been supported by the sigrid juselius foundation, päivikki and sakari sohlberg foundation the third international consensus definitions for sepsis and septic shock acute renal failure in critically ill patients: a multinational, multicenter study relation between mean arterial pressure and renal function in the early phase of shock: a prospective, explorative cohort study grant acknolwedgment this study is supported by the national key technology r&d program of china conclusions: in patients with chronic renal impairment who undergo cardiovascular surgery requiring cpb, a lower level of preoperative shp is independently associated with higher risk of paki. a urinary angiotensinogen as a possible predictor of acute kidney injury in severe sepsis s we aimed to compare the incidence of aki according to rifle (risk, injury, failure, loss of kidney and end-stage kidney disease united kingdom intensive care medicine experimental ):a introduction: cytokine elimination during continuous hemofiltration (chf) depends largely on the character of the filter membrane a references ( ) (kidney disease outcomes quality initiative. kdigo clinical practice guidelines for acute kidney injury antithrombin supplementation for anticoagulation during continuous hemofiltration in critically ill patients with septic shock: a case-control study acquired deficit of antithrombin and role of supplementation in septic patients during continuous veno-venous hemofiltration the influence of venovenous renal replacement therapy on measurements by the transpulmonary thermodilution technique effect of the venous catheter site on transpulmonary thermodilution measurement variables the influence of haemodialysis on haemodynamic measurements using transpulmonary thermodilution in patients with septic shock: an observational study when drugs disappear from the patient: eliminaiton of intravenous medication by hemodiafiltration cardiac arrest in intensive care unit: case report and future recommendations omni® (b. braun, melsungen, germany), a new third generregional citrate anticoagulation. we collected patients' characteristics, filter life time, circuit pressures, interruption of therapy duration and reasons (alarm types), achieved and targeted renal dose, metabolic parameters (serum creatinine and potassium levels and arterial base excess). in addition, we adminof total therapy time) in cvvhd-citrate mode. mean achieved renal dose was . ml/kg/hr corresponding to % of the targeted dose in cvvh-heparin mode and . ml/kg/hr corresponding to % of the targeted dose in cvvhd-citrate mode. in both rrt modes, excellent metabolic control and adequate fluid balance were achieved. overall, the interface, design and ease of use were evaluated by users as excellent. conclusions: crrt in both cvvh and cvvhd modes could be provided using omni® in a safe and efficient way in ten critically ill patients. users provided positive feedback regarding therapy setup, management and user interface. a intermittent haemofiltration outside itu led by the intensive care team. experience at a tertiary cardiothoracic centre s following modification of the aquarius haemofilter (nikkiso), we designed and implemented a protocol for rca with stand alone citrate administration pre filter (acd-a (acid citrate dextrose formula-a) containing mmol/l of citrate) and post dilution cvvhf using calcium containing replacement fluid (accusol containing . mmol/l ca) and, when needed, supplementary calcium depending on systemic ica. the protocol can deliver or mls/kg/hr of crrt. we compare the efficacy of this new protocol, which we have initially implemented in patients with a relative contraindication to heparin, to a historical cohort of patients who received crrt with prostacyclin and or pre-dilution cvvhf but would not have been contraindicated for rca. we also present relevant biochemical data. methods: a prospective audit of the first adult critically ill patients receiving rca with post dilution cvvhf. crude comparison was made with a historical group of consecutive critically ill patients who received crrt without heparin prior to the introduction of the rca protocol. patients were excluded from the rca protocol and the comparison if they had, severe acute liver injury. data is presented as median (range) with non parametric analysis and filter survival as a kaplan meier for the event´filter clotting´and censored for medical cessation or technical failure. results: there were filters used in patients who received rca and in in the comparison group respectively. one patient ( filters) from the rca group was excluded from the filter survival analysis due to a triglyceride level of . mmol/l, causing repeated filter failure epidemiology of acute kidney injury in critically ill patients: the multinational aki-epi study conclusions: there is no relationship between copd patients, bmi, age and extubation failure. this new formula combine parameters, dtf*rsbi, as a good parameter for extubation.methods: we used the administrative claims data of all diagnosis procedure combination (dpc) hospitals in japan from april , to march , , and retrospectively reviewed the number and outcome at discharge of patients who were on ecmo support. results: we identified , patients who received ecmo support during the -year study period. the average age was . , and only . % of the patients were under years old. the most common diagnosis was acute coronary syndrome, followed by cardiac arrest and pulmonary embolism. the overall survival rate at discharge was . % [ %ci . - . ]. among the , acute care dpc hospitals, ecmo support was provided in hospitals ( . %), and therefore the annual ecmo patient volume per hospital was . , which is much lower than international standards for ecmo centers. adjusted odds ratio for discharge alive stratified by annual ecmo volume per hospital were . [ %ci . - . ] and . [ %ci . - . ] for medium ( hospitals treating to patients) and high volume centers ( hospitals treating or more patients), respectively, compared with low volume centers ( hospitals treating or less patients). conclusions: ecmo support was administered to many adult cardiac patients, and provided in a substantial proportion of acute care hospitals in japan. no significant patient volume effect for survival discharge was found. funding from the american nurses association impact grant is gratefully acknowledged. history and icu related data were analyzed. basal fracture risk before ci was calculated using the frax tool (https://www.shef.ac.uk/frax). in january , referent family doctors were contacted by phone to check out new bf occurred during the years after icu discharge. data are expressed as median (min-max) or percentages. unpaired data were compared using mann-whitney test (p < . = significant). results: from the patients admitted in , had an icu los ≤ d, were < y, died in icu or died after an icu los ≤ d and were lost to follow-up. we analyzed patients who were alive in january and patients who died outside icu during the fup after an icu los > d. regarding alive patients ( % males), admission was mainly related to cardiovascular, respiratory and neurological failure, or trauma. age was ( - )y, simplified acute physiologic score (saps ii) was . ( - ), icu los was ( - )d. according to the frax tool, the -y probability of major osteoporotic bf (major frax risk) was . ( - )%. nine patients ( men) developed bf in . ( - ) months after ci, equivalent to a % risk of new bf y after ci. a context of fall at home was noted in every case. age, icu los and saps ii of these patients were not statistically different from non-fractured patients. their major frax risk was ( - )%, significantly higher than non-fractured patients (p = . ). finally, among the dead patients, only one y man experienced hip fracture at the th month after ci. conclusions: present incidence of new bf in the y following severe ci with a prolonged icu stay is similar to previously published data [ ]. patients who experienced new bf after ci had a higher frax risk than the non-fractured patients. influence of ci or icu stay on bf risk is thus questioned. however, to be relevant, our results need to be compared to a control population: this work is ongoing. conclusions: we detected a rise in pro-adrenomedullin levels after cardiac surgery. the results suggest that am could be useful for lcos prediction. more data are necessary to confirm the role in the prediction of relevant outcomes. conclusions: the icu stay and early complications evaluated not differ between the two groups , except for acute renal failure and higher mortality, despite the use of shorter times in cardiac surgical in octogenarians. there is a progressive decrease in coronary artery bypass surgery in recent years in this group probably in favor of percutaneous techniques.high-risk patients who require intensive perioperative management,should be identified to reduce the incidence of postoperative complications.conclusions: previous renal replacement treatment and the colonized patients' long stay at icu increase the transformation of the vre colonization into vre infection. strategies to reduce the duration of icu stay of vre-colonized patients are the main objects to controlling vre infection rate. identification of sirs/sepsis signs by ward nurses reduces -days mortality in patients with sepsis m. torsvik , l.t. gustad , , i.l. bangstad , l.j. vinje , j.k. damås , , , e. solligård , , , a. mehl , , nord university, faculty of health science, levanger, norway; nord-trøndelag hospital trust, levanger hospital, internal medicine, levanger, number of patients had ulceration at the site of the suction port but did not suffer any complication as a result. drainage of pleural effusion with small bore tube in mechanically ventilated patients s.j. lee , y.s. cha , w.-y. lee correlate with decannulation failure but future studies are necessary in this field. objectives: to weight all sharps containers in a cardiac intensive care over a one-week period. to then review the financial implications of the cost of this waste. to review ways to redistribute this waste.methods: all closed sharps containers were weighed. research the cost implications of different waste types from the waste management team within the trust. look into ways of reducing this waste. results: a total of items where weighed, totaling . kg, costing £ . . this can be broken down in six l chest drain boxes, weighing . kg, costing £ . . four l sharps bin, weighing . kg, costing £ . . l sharps bin, weighing . kg, costing £ . , and thirty-nine l sharps bins, weighing . kg, costing £ . . this would take eight weeks to produce a tonne. producing around . tonnes a year costing £ , . . compared to other types of waste: sharps containers: £ per tonne clinical waste: £ per tonne domestic waste: £ per tonne recycling: £ per tonne clinically objects that aren't sharps are placed in sharps bins, for example arterial blood gas syringes, this item could be put into a clinical waste bin. while this suggests education is needed there are other methods to reduce sharps bin wastage. these include: having needle only sharps bins, and solidifying chest drain bottles post removal.conclusions: this cardiac intensive care unit produces a volume of high-cost waste. a large proportion of this waste can be redistributed to other types of waste. this could make the unit more efficient, and reduce it's environmental burden. this audit suggests that it should be looked at other types of waste and other departments in the same manner on other units. in the bloodstream infection density related to hemodialysis catheter in the hospital moyses deutsch was . , which represents patient in its entirety. due to this high rate, it was necessary to review all related process through institutionalized and supervised practice, minimizing the risks of hemodialysis procedure and maintenance of the catheter, in order to directly reduce the length of hospital stay, morbidity and hospital costs. objectives: objective of this study was to evaluate the application of strategies according to ihi to reduce infection of the bloodstream related to cvc hemodialysis. methods: the study was conducted in a -bed, medical-surgical icu. criteria for infection catheter related bloodtream infection are those from the cdc. strategy was to implement the permanent education of employees, highlighting the importance of prevention of infections;training of new employees as the hemodialysis routine and safe and aseptic techniques; optimize other measures that can reduce the risks, such as early removal of invasive devices.raise awareness of nursing staff about the importance of their role in the prevention of infection, such as maintenance of the catheter with use of aseptic techniques; disseminate monthly for teams infection rates; make benchmarking with other services; the goals were the icu team adhesion of % achieved in six month after bundle implementation and % after one year of follow up. from june on, the icu a effect of therapeutic hypothermia on mitogen activated protein kinase pathway in the brain tissue of a swine cardiac arrest model y. c objective: to investigate the change in mitogen-activated protein kinase pathways in the brain tissue after therapeutic hypothermia in swine cardiac arrest model. design. prospective animal study setting. university animal laboratory subjects. male domestic pigs (n = ) interventions: after the return of spontaneous circulation by cardiopulmonary resuscitation following min of no flow time induced by ventricular fibrillation, pigs were randomly assigned to one of four groups (sham, normothermia, hr of therapeutic hypothermia, hr of therapeutic hypothermia). therapeutic hypothermia (core temperature - °c) was maintained and the pigs were then rewarmed for hr. at hr after the return of spontaneous circulation, the pigs were sacrificed and brain tissues were harvested. measurement and main results: we measured the tissue levels of p , jnk, and erk pathway expressions in swine brain hippocampus of the four groups. the phosphorylated p to p ratio and phosphorylated jnk to jnk ratios were significantly increased in all of the intervention groups, relative to the sham group. but the phosphorylated erk to erk ratio was increased only in the therapeutic hypothermia groups (p-value = . in the hr of therapeutic hypothermia group and p-value = . in the hr of therapeutic hypothermia group, both compared to the sham group). conclusions: normothermia activated the p and jnk pathway. and did not activate the erk pathway in ischemia-reperfusion injury after cardiac arrest. therapeutic hypothermia, however, did not attenuate the activation of the p and jnk pathways, but activated the erk pathway, which seemed to be dose dependent with the duration of therapeutic hypothermia. effect of permissive hypercapnia on outcome of cardiac arrest in a porcine model of cardiopulmonary resuscitation g. babini , g. ristagno figure ). pigs in the hypercapnic group showed a trend towards longer survival. etco and pco were significanlty higher in the hypercaninc group compared to the normocpanic one (table ). ph and po trended to be lower in the hypercapnic group during the hrs of observation. hypercapnia was associated with significantly higher mean arterial pressure during the post-resuscitation (pr) period ( lesser neuronal degeneration was seen in the frontal cortex in the hypercapnic group compared to the normocapnic one (figure ) . neurological recovery was equivalent in the two groups ( figure ). conclusions: permissive hypercapnia after resuscitation was associated with better mean arterial pressure and lesser neuronal degeneration in pigs. grant support. laerdal foundation for acute care, norway introduction: pain is the main indication for utilisation of the physician staffed prehospital emergency service in germany. data from switzerland showed that oligoanalgesia (inappropriate treatment of pain with nrs > ) is common in trauma patients. objectives:( ) determination of the frequency of oligoanalgesia in trauma patients at our prehospital emergency service location in objectives: assessment of characteristics and outcomes of patients who suffer cardiopulmonary arrest resuscitated in a tertiary hospital, inside and outside intensive care unit, according to utstein style.methods: a prospective cohort study was performed according to utstein style. every arrest occurred in the hospital "virgen de las nieves" (granada, spain) for a period of years (july/ -june/ ) were included. all arrest occurred in all areas of the hospital were included, except those in operating rooms and anesthesia recovery room (not attended by the resuscitation team) and those commenced in the prehospital setting. we also excluded patients in whom no resuscitation attempt was made or those suspended either by existence of a living will, by orders dnr or considered futile. the variables were grouped according to the location (inside or outside the icu). chi test was performed when the dependent variable was qualitative and a t-student test when it was quantitative.results: during this period a total of patients suffered at least one episode of arrest and they were resuscitated. most frequent sex was male ( . %) with a median age years ( . ± . years; interquartile - years). the cardiac origin was the most common aetiology ( . %). the icu was the area most frequent location ( . %). when comparing the characteristics of icu arrests with the rest of the hospital, significant differences were observed. it was most likely to have a shockable initial rhythm (χ : . ; p = . ), younger age ( , ± , vs , ± , years; t = , ; p = , ), shorter interval to defibrillation ( , ± , vs , ± , min; t = , ; p = , ), shorter period until start of resuscitation ( , ± , vs , ± , min; t = , ; p < , ) and shorter total duration ( ± , vs , ± , min; t = , ; p < , ). however, no differences were found in coronary aetiology, sex, recovery of spontaneous circulation and hospital survival ( . % vs . % in icu).conclusions: despite higher frequency in initial shockable rhythms and lower intervals until defibrillation and resuscitation in the icu, no differences were found in initial recovery or hospital survival. delayed onset of cardio-pulmonary resuscitation (cpr) does not induce hyperfibrinolysis in a piglet model of ventricular fibrillation -a pilot study in göttingen minipigs n. introduction: pulmonary arterial hypertension (pah) is a disease with gradually increased pulmonary vascular resistance and pressure, often leads to right ventricular (rv) failure and death. excessive proliferation of pulmonary arterial smooth muscle cells (pasmcs) is regarded as the major cause of the remodeling of pulmonary artery, whereas the underlying mechanism is largely unclear. caffeic acid phenethyl ester (cape) is the main component of propolis, which is known as a versatile compound of antimitogenic, anticarcinogenic and anti-inflammatory potentials. objectives: to investigate the effects of cape on the improvement of the hemodynamic function in pah animal model and to explore the underlying mechanisms in in vitro pasmcs. methods: animal model of pah symptom was induced in - grams sprague-dawley rats by subcutaneous injection of monocrotaline (mct, mg/kg). weeks later, the mct-induced pah rats received intraperitoneal administration of cape with various dosages of or mg/kg once per day, for further weeks. hemodynamic functions, including rv systolic pressure (rvsp) and fulton index, were measured before sacrifice. the lung tissues were harvested for examining the vascular remodeling of pulmonary artery. to investigate the molecular mechanisms, in vitro cultured human pasmcs challenged with either % oxygen level or recombinant human pdgf ( ng/ml), followed by the treatment of cape in or mm. the change of expression level and phosphorylation of the cellular signaling molecules, including erk, akt, nf-kb, or hif- a, were analyzed by semi-quantitative pcr and western blotting, respectively. results: in mct-induced pah rats, cape significantly improved the hemodynamic values of rvsp, fulton index, and attenuated the severity of pulmonary vascular remodeling. furthermore, the administration of cape critically reduced the expression levels of hif- a, nf-kb and pdgf molecules in the lung of mct-induced pah rats. in vitro assay showed that an increased expression level of hif- α and pdgf genes in hpasmcs was observed under hypoxia or pdgf stimulation, which was significantly suppressed following cape treatment. for chemical inhibition, we indicated that cellular signaling molecules erk, akt and nf-kb were involved in the up-regulation of hif- a and pdgf genes, which were responsible for the proliferation of hpasmcs exposed to hypoxia or pdgf stimulation. in addition, cape also significantly promoted the number of apoptotic cells and the number of cell arrested in g phase of hpasmcs by tunel assay and sa-b-galactosidase staining, respectively. conclusions: we showed evidence that the natural compound cape could provide therapeutic benefits on the reversal of experimental pah rats. importantly, the results further indicated that the hif- a-mediated pdgf expression is a positive feedback mechanism underlying the pathogenesis of pah, which was regulated by the akt/erk/nf-kb signaling. right ventricular arterial coupling after cardiac surgery: a preliminary report p. introduction: right ventriculo-arterial coupling (rvac), defined as the ratio of end-systolic elastance (rees) to pulmonary arterial elastance (rea) is considered a sensitive method to assess right heart performance [ ] . objectives: in this study we aim to identify the feasibility of measuring rvac in hemodynamic deranged patients undergoing complex/ emergency cardiac surgery using cardiopulmonary bypass (cpb) as an experimental model of further hemodynamic impairment. objectives: this study aims to determine the frequency of the vre colonization and the transformation into infection and the risk factors, which lead to infection. methods: the patients who were hospitalized for at least hours in tertiary mixed type icu between and and had vre colonization and vre infection during or following their hospitalization were included in the study and their medical records were examined retrospectively. vre rectal swab sample was taken from each patient at his arrival and once a week afterwards. when negativity was detected in the rectal swab sample, which had been taken total times successively from those with positive vre; that patient was considered vre negative. their demographic data, apa-che ii scores, invasive procedures, treatments (corticosteroid, antibiotics, etc.), nutrition types, laboratory results and icu outcome were recorded. results: vre colonization was detected in of patients ( . %) admitted to icu. vre infection developed in of vre-colonized patients ( . %). among these infected patients; it was (n = ) . % primary bloodstream infection, (n = ) % urinary tract infection, (n = ) % . pneumonia. in vre colonized patients ( . %) and infected patients ( %), the most frequent factor was e. faecium. in % of the vre-colonized patients, vre became negative in their stay at icu. previous renal replacement treatment was significantly higher in statistical terms in the vreinfected group ( . %) when compared to vre-colonized group ( . %) (p < . ). in the vre-infected group, colonization with vre lasted longer than week in patients ( . %) were determined. demographic data, apache ii scores, treatments, nutrition types, previous antibiotic usage and types, invasive procedures, laboratory results and icu outcome were similar between the vre-colonized and infected patients.objective: to assess the value of enteral paramomycin to decontaminate patients with rectal colistin and/or carbepemenase resistant microorganisms colonization to prevent the development of icu nosocomial infections methods: all consecutive patients admitted to the icu from october to september , expected to require tracheal intubation for longer than hours, were given sdd with a -day course of intravenous cefotaxime, plus enteral colistin, tobramycin, nystatin in an oropharyngeal paste and in a digestive solution. oropharyngeal and rectal swabs were obtained on admission and once weekly. rectal swabs colonized by colistin and/or carbepemenase resistant microorganisms were treated with enteral paramomycin gram every hours a day, in order to eradicate them and prevent nosocomial infections. categorical variables were summarized as frequencies and percentages and the continuous ones as medians and interquartile ranges (iqr) or means and standard desviations. statistical significance was set at p ≤ . . results: we applied paromomycin treatment to colonized patients with rectal colistin resistant microorganisms. all of them had colonization by extended spectrum beta-lactamases (esbls). also, all of them but two were klebsiella pneumonia. out of these two, one patient was colonized by enterobacter spp and other one by escherichia coli. demographic data and type of admission are shown in fig. . forty out of ( , %) of the studied patients the rectal swab became negative. five out of the patients were colonized by carbapenemases producing microorganisms and one of these died with persistent multirresistant rectal colonization. only out of the patients that negativized the colonization received concurrent susceptible iv antibiotics. only of the paromonycin treated patients developed a mediastinitis infection due to one of the treated microorganisms. finally, patients died in the icu. conclusion: our data show that enteral paramomycin is effective in treating rectal colistin and/or carbepemenase resistant microorganisms colonization allowing clinicians preventing the development of icu nosocomial infections. introduction: diaphragmatic thickness increases as lung volume increases towards tlc. it has been shown that in healthy subjects, diaphragmatic thickness, increases as lung volume increases, above . of the vital capacity (vc). in mechanically ventilated patients, different levels of peep are used to improve oxygenation. there is no information about the diaphragmatic thickness when in icu patients, lung volume increases with peep towards tlc. methods: in patients with acute respiratory failure (arf) and lower lobe atelectasis detected by lung echo, two levels of peep ( and ± cmh o) are used to increase lung volume and to improve oxygenation. end expiratory lung volume (eelv), and diaphragmatic thickness was measured at baseline (zeep) and at the two levels of peep. eelv was measured with a nitrogen indirect dilution method and diaphragmatic thickness at the zone of apposition with echography using a mhz linear probe. statistical analysis was performed by one way anova and normal distribution by colmogorof-smyrnof test. results: patients ( m and f) with a mean age of ± were studied. diaphragmatic thickness at baseline was , cm and eelv at ml ( %) of the predicted ( ml). at the intermediate and high level of peep diaphragmatic thickness did not change significantly ( . and . cm, respectively, p = . ) and eelv increased at % ( ml) and % ( ml) of the predicted. the increase in lung volume induced by peep was at % and % of the predicted vc ( ml). mean pao /fio ratio did not change significantly conclusions: mechanically ventilated patients for arf have a severe reduction in their eelv or frc. the use of peep reestablishes partially the eelv, but not to his normal levels(predicted frc). despite high levels of peep, diaphragmatic thickness remained constant because the increase in eelv never attained the % the vital capacity.introduction: the majority of patients entering the weaning process from mechanical ventilation (mv) in the intensive care unit (icu) will have a short and simple weaning (sw) successfully terminated within hours, while other may take up to one week (difficult weaning) or longer. studies have shown that using a sedation or a weaning protocol could reduce the length of mechanical ventilation and the weaning duration. objectives: to describe factors associated with sw and particularly assess if sedation and weaning protocol are associated with the proportion of patients having a sw. methods: we used the data from the wind (weaning according new definition) study, a prospective multicenter observational study performed in france ( icus), spain ( icus) and switzerland ( icu) from april to august . ventilation and weaning modalities were daily assessed until discharge in all intubated patients admitted to the participating icus. we defined ) weaning attempt (wa) as a spontaneous breathing trial (sbt) or an extubation attempt (with or without sbt), ) successful weaning as an extubation without death or invasive mechanical ventilation within days. we considered patients as having a sw if weaning was successfully terminated within h following their first wa. having a protocol for sedation or for weaning (or both) was asked to each center. quantitative and qualitative variables are presented as mean (standard deviation), median [interquartile range] or number (percentage) as appropriate. comparisons of proportions were made using chi or exact fisher tests and continuous variables were compared using student t-test or wilcoxon rank sum test as appropriate. we performed a multivariable analysis of factors associated with sw by means of a logistic regression, forcing both sedation and weaning protocols in the final model. all statistical tests were two-sided and p values of . or less were considered significant. results: among the patients included, patients entered the weaning process and we only kept in the present analysis the patients who did not have any decision of withholding or withdrawing mechanical ventilation. among these patients, ( %) had a sw and ( %) had a weaning duration longer than hours. main clinical characteristics are shown in table . conclusions: in this study of patients with a daily assessment of the weaning process, hospitalization in an icu using a sedation protocol or a weaning protocol (as declared by the center) was not associated with a higher proportion of patients having a simple and short weaning. admission for planned surgery, younger age, lower sofa score at admission and shorter duration of ventilation before any weaning attempt were associated with a higher proportion of simple and short weaning. this study benefited of a grant of the non-profit association départementale des insuffisants respiratoires (adir) of the haute normandie, france. introduction: during weaning from prolonged ventilation overload of diaphragm as main breathing muscle should be avoided. clinical criteria are used for determining the end of the spontaneous breathing trial (sbt) in the context of a discontinuously concept for weaning. in addition the patients subjective feeling of breathing exhaustion plays an important role. in incommunicable patients lacks this possibility for feedback.continuous monitoring of diaphragm electrical activity could give information of respiratory muscle effort during sbt. objectives: in tracheotomized patients undergoing prolonged weaning the relationship between the protocol-based definition of the end of a sbt and the course of the electrical activity of the diaphragm (eadi) should be examined. methods: prospective observation study conducted in a beds intensive care unit in an early rehabilitation clinic. patients that were not communicable because of stroke ( ), cerebral hypoxaemia ( ), traumatic brain injury ( ) have been included. using an eadi-catheter usually applied in nava (neurally adjusted ventilatory assist)-ventilation, peak of diaphragm electrical activity (eadi peak) was continuously recorded minutes before disconnection from ventilator up to minutes after reconnection. the weaning protocol contained two possibilities for terminating of the sbt: reaching clinical signs of ventilation exhausting or reaching a previously fixed time limit. results: median duration of mechanical ventilation at study start was days and days at successful weaning ( / patients, died). sbt have been recorded, terminated because of exhaustion, by time limit. median duration over all was minutes (exhaustion: / time limit: ). with multiple regression analysis, the relationship between the duration of the sbt and the eadi peak was examined. looking at all sbt, which were terminated due to exhaustion, shows that the duration of the sbt has a highly significant impact on eadi ( p < . ). the mean increase of eadi peak was . μv (absolute) and . (relatively). in sbt terminated because the time limit has been reached, there was no significant correlation between the time and course of eadi peak. conclusions: continuous recording of the electrical diaphragmatic activity during weaning of prolonged ventilation in incommunicable patients can be used as supplementary parameter in monitoring the respiratory function. introduction: patient-ventilator asynchronies are associated with poor outcome. it was suggested that bedside analysis of ventilator waveforms may help detecting different types of asynchrony and setting properly the ventilator [ ] . objectives: to test accuracy of a "waveform" method, based on specific signs on airway pressure (paw) and flow curves, in detecting spontaneous respiratory activity and asynchronies in patients under pressure support ventilation (psv).methods: recordings ( min each) of esophageal pressure (pes), paw and flow were obtained in obstructive ( %) and restrictive ( %) patients under psv with clinical evidence of poor patient-ventilator interaction. tracings of breaths were visually analyzed for detection of spontaneous respiratory activity both with pes (reference method) and without pes (waveform method) by different operators. breaths were defined as assisted, unassisted or autotriggered, and assisted breaths as delayed triggered, early cycled or delayed cycled. the waveforms method was applied in a selection of tracings ( min, breaths) by different operators for assessment of inter-rater agreement. results: the reference method detected autotriggered ( . %), unassisted ( . %) and assisted ( . %) breaths; among assisted breaths, delayed triggered ( . %), delayed cycled ( . %) and early cycled ( . %). table shows sensitivities and specificities ( % ci) of the waveform method in evaluating patient-ventilator interaction. the waveform method detected the start of patient's inspiration and expiration with a bias of − and − ms and a precision (± . sd) of and ms respectively. absolute agreement among operators was almost perfect for unassisted breaths, strong for delayed triggered, delayed cycled and early cycled breaths, and weak for autotriggered breaths. conclusions: the waveforms method is a reliable, accurate and reproducible method to assess patient-ventilator interaction and could help optimal setting of the ventilator. automation of this method may allow continuous monitoring of ventilated patients and/or improved breath triggering and cycling.methods: we studied a group de mechanically patients during the weaning time, at pressure support ventilation (psv) with different levels of assistance (high - cmh o, medium - cmh o, low - cmh o). esophageal, gastric, airway pressure, and airway flow were registered, samplig hz. we determined the phase difference (Φ) relationships between the neuronal times obtained from derivative flow versus esophageal or gastric signal respect to machine cycle, by calculating the phase delay, dividing by the cycle time of ventilator* °. times (t) definitions: t = onset inspiratory effort, t / = effort maximum. data were analyzed by descriptive statistical methods and are expressed as mean ± sd, medians, interquartile range (irq, - % quartile), and coefficient of variation (cv). the comparisons were performed by mann-whitney test. the relationships between measurement methods was examined using single linear regression and bland-altman analysis. results: patients were studied. for all data angle phase Φ median (irq): t : , (− , to , ), t / : − , (− , to , ). the mean comparison of t and t / between pes and df did not showed statistical differences for any level of support, and correlation r > , . the cv for all data at the t of pes and df: % and %, respectively; and for the t / of pes and df: % and %, respectively; without differences between levels of assistance. table below show results from bland-altman analysis. figure show representative tracing of df with well-defined inflection points (arrows) at t and t / , as the onset inspiratory flow and transition from inspiratory to expiratory flow. conclusions: the derivative of flow signal is useful to measure with accuracy neuronal and cycling times, it´s more homogeneous and precise than obtained for esophaeal or gastric pressure for all levels of assistance. the derivative of flow signal is a non-invasive signal which can be calculated easily and useful by conventional ventilator. introduction: sepsis has been defined as organ dysfunction as a result of the inappropriate host response to infection. [ ] renal function is often injured at the early stage of sepsis. [ ] autoregulation, which plays an important role in maintaining an adequate renal blood flow against changes in blood pressure, could be impaired during sepsis, [ ] thus resulting in aki if blood pressure fluctuates greatly. objectives: to investigate if there is any relationship between blood pressure variability (bpv) and aki in septic patients. methods: clinical data of patients admitted to our bed medical icu between / and / were reviewed. continuous records of blood pressure were analysed. blood pressure variability was calculated as the coefficient of variation (cv) of mean arterial pressure in the first h of admission. aki was defined by the kdigo definition according to creatinine change and urine output criteria. [ ] results: adult patients with sepsis (age: . ± . years old; apache ii score: . ± . ; male: . %) who stayed at icu for more than three days were identified. aki was presented in ( . %) of them (stage : n = ; stage : n = ; stage : n = ). the bpv was . ± . % for the patients with aki versus . ± . % for the others (p < . ). icu mortality was . % for the aki group compared to difference was not statistically significant regarding creatinine level on admission (p = . ). moreover, there was a positive correlation between uancr ratio on admission with akin staging and creatinine level of the all studied patient in the follow up days. the cutoff value of uancr on admission to predict later occurrence of aki during icu stay was . ng/mg: at this level, ( . % sensitivity and . % specificity). conclusions: urinary angiotensinogen is a new promising biomarker in early prediction of aki in patients with severe sepsis. acute kidney injury in patients with severe sepsis or septic shock: a comparison between the "risk, injury, failure, loss of kidney function, end-stage kidney disease" (rifle), acute kidney injury network (akin) and kidney disease improving global outcomes an st and polymethyl methacrylate (pmma) membranes have strong adsorption capacity. cytokines play important roles as the main mediators affecting critically ill patients. however, differences in the cytokine elimination by specific membranes during chf have not yet been fully investigated. objective: the objective of this study was to determine the elimination of cytokines by an st and pmma membrane filters during chf in a pig sepsis model. methods: piglets (n = ) weighing - kg were anesthetized and administered μg/kg endotoxin. the baxter sepxiris (an st membrane) and the toray hemofeel . w (pmma membrane) were used as hemofilters. samples were taken at , , , and hours after endotoxin administration, and the inlet plasma, outlet plasma, and filtrate concentrations of tnf-α, il- β, il- , and il- were measured. clearance values were calculated for each cytokine. results: endotoxin administration induced increases in the inlet plasma concentrations of all cytokines measured. the an st membrane filter showed higher adsorption and clearance of il- than the pmma membrane filter at hours after endotoxin administration (an st: . ± . ml/min; pmma: − . ± . ml/min; p < . ). however, the pmma membrane filter showed higher adsorption and clearance of il- β than the an st membrane filter. il- did not appear in the filtrate of the pmma membrane filter, while il- was not eliminated in the filtrate of the an st membrane filter. in addition, the filtrate concentration of tnf-α increased after its plasma concentration decreased with the pmma membrane filter. conclusions: shiga et al. previously reported the efficacy of cytokine absorption by an st membrane filters during continuous hemodiafiltration, and matsuda et al. reported the efficacy of cytokine absorption by pmma membranes. however, the cytokine absorption efficacy by these two membrane filters had not been directly compared. the results shown here confirm that there are differences in cytokine adsorption by the an st and pmma membrane filters. introduction: continuous renal replacement therapy (crrt) in intensive care is a cornerstone in the supportive treatment arsenal. its influence on thermodilution cardiac output measurements, and the possible influence of central venous dialysis catheter(cvdc) position, has been studied but the results are of uncertain clinical impact ( ) ( ) ( ) . there have been case reports describing the possibility of direct aspiration into a cvdc of drugs given in adherent central venous catheter(cvc) ( , ) . objectives: the aim of this study was to investigate if different positions of central lines influence infused noradrenaline during continuous renal replacement therapy (crrt) in an experimental animal model. methods: ten anesthetized piglets received a cvc in the right jugular vein and two cvdcs (one via the same jugular vein as the cvdc and the other through a femoral vein). after randomization the crrt was started in either one of the cvdcs and a nitroprusside infusion was started in an auricular vein. the dose was titrated until the mean arterial pressure (map) was mmhg and then kept constant during the rest of the experiment. after reaching the intended blood pressure an infusion of noradrenaline was started and titrated with the goal of increasing the blood pressure to a map of mmhg during minutes. after a washout period the crrt circuit was changed to the other cvdc and the experiment was repeated. results: the median dose of noradrenaline with the crrt in the jugular vein was . (iqr . ) and in the femoral vein . (iqr . ) μg/kg/min (p = . ). conclusions: during crrt, the noradrenaline dose needed to reach a target blood pressure in hypotensive piglets was twice as high with the cvc and cvdc close together, compared with cvc and cvdc on opposite sides of the diaphragm. this suggests that there is a possible clearance of noradrenaline and that the clearance is affected by catheter positioning a first evaluation of omni, a new device for renal replacement therapy p. schlaepfer , , j.-d. durovray , , v. plouhinec , c. chiappa , r. bellomo , a.g. schneider introduction: due to the lack of conventional dialysis facilities in our centre, intermittent renal replacement therapies (irrt) are led and performed by the itu team. this team comprises a group of specialist outreach nurses with the support of intensivists. irrt are performed nocturnally by itu nurses in level areas according to our hospital policy. objectives: to describe the use and results of irrt in level areas in patients that have left itu with established aki. these therapies are directed and performed by specialist intensive care nurses with the support of the itu medical team. methods: retrospective observational study that included those patients admitted to level areas at harefield hospital during that were transferred to level areas still requiring irrt. demographic variables were collected, along with the indication and duration of irrt and results. results: patients were admitted to harefield hospital level areas during , of which patients required continuous renal replacement therapies (crrt). this population included patients admitted after cardiac and thoracic surgery, heart or lung transplantation, mechanical circulatory devices, out of hospital cardiac arrests (oohca) and medical admissions from the cardiology or cardio-thoracic surgical wards. demographic variables were collected, along with the indication and duration of crrt. of those patients still required intermittent renal replacement therapies at their discharge to a level area. of them ( . %) were male and the group was a median age of . years. of them ( %) were hypertensive and ( %) were diabetic. as shown in figure , the most frequent reason for admission to intensive care was cardiac surgery ( . %, patients), followed by lung transplantation, heart transplantation and medical admissions from the transplantation ward. the reasons for admission to intensive care in the general crrt group are also shown in figure . the most frequent indication for initiation of crrt was metabolic acidosis ( . %, patients), followed by a combination of uraemia and fluid overload ( . %, patients), uraemia ( . %, patients) and fluid overload ( . %, patients) as shown in figure . the median time of rrt was days days whilst the median time of filtration in the general rrt group was days. the in-hospital mortality (after discharge from itu) was . % and was . % in the general crrt group. no complications were associated with the use of intermittent renal replacement therapies in level areas. conclusions: the group of patients that required intermittent renal replacement therapies beyond their discharge from itu had longer itu and hospital lengths of stay. these therapies were performed safely in level areas by the itu team, allowing these patients to leave level areas to continue their care. key: cord- -w ysjf authors: nan title: th international symposium on intensive care & emergency medicine: brussels, belgium. - march date: - - journal: crit care doi: . /s - - - sha: doc_id: cord_uid: w ysjf nan ventriculostomy-related infection (vri) is a serious complication in patients with hemorrhagic stroke. in such patients, diagnosis of vris is complicated by blood contamination of csf following ventricular hemorrhage. we aimed to evaluate the diagnostic potential of white blood cells count (wbc), c-reactive protein (crp), and procalcitonin (pct) to identify vris in patients with hemorrhagic stroke during the time of external ventricular drain (edv) in situ. this retrospective study was conducted at the neurosurgical-icu, university hospital of zurich. a total of patients with hemorrhagic stroke and an external ventricular drain (evd) were admitted over a years period at the icu. of those, patients with vris ("vri"), defined by positive csf bacterial culture and increased wbc in csf (> /ul), and patients without vris and with serial csf sampling ("no-vri") were analyzed. patients with csfcontamination or suspected vri (negative csf cultures but antibiotic treatments) were excluded. wbc, crp, and pct were measured daily. csf was sampled routinely twice a week or by t> °c. for the analysis, mean peak values of wbc, crp, pct during the time of evd in situ were compared between groups (t test). data are expressed as mean with ci %. results: between groups, wbc and crp were similar (wbc: . g/l and . g/ l, p= . and crp: . mg/l and . mg/l, p= . in the group vri and no-vri, respectively) ( figure , panel a and b ). in the group vri, pct was low and significantly lower than in the group no-vri ( . ug/l and . ug/l, p= . in the group vri and no-vri, respectively) (panel c). wbc in csf were similar between groups ( . /ul and . /ul p= . in the group vri and no-vri, respectively). in this study, serum-inflammatory markers were not able to screen patients with vris. their routine measurement should be carefully evaluated. introduction: central nervous system (cns) infections constitute a potentially lifethreatening neurological emergency. patients admitted to the intensive care unit (icu) usually present with a severe disease and organ failure, leading to high mortality and morbidity. we have performed a retrospective analysis during a -year period of patients admitted to a polyvalent icu. clinical, demographic and outcome data were collected to evaluate its clinical impact on the outcome of patients with cns infections. we identified patients with the diagnosis of meningitis, meningoencephalitis and ventriculitis, where the median age was , years (range - ). upon clinical presentation, their most frequent signs were fever ( %), meningeal signs ( %), seizures ( %), and a glasgow coma scale score < ( %). all needed ventilation support and % needed cardiovascular support. a definitive microbiological diagnosis was achieved on patients and antibiotic therapy was adjusted on of them. most common microorganisms were streptococcus pneumoniae (n= ), listeria (n= ) and pseudomonas aeruginosa (n= ) (figure ). other gram negative microorganisms were detected and lead to more adverse outcomes. meningitis was the cause of admission on patients and on a minority (n= ) meningitis was considered to be a secondary diagnosis on patients admitted for other causes (traumatic brain injury, subarachnoid or intraparenchymal hemorrhage, postoperatively of neurosurgical tumor). patients that eventually died had at least one risk factor (age> , immunocompromised due to diabetes, corticotherapy, hiv or heart transplantation). patients admitted to the icu were not so aged, but had some comorbidities and risk factors leading to more uncommon microorganisms, increasing the risk of adverse outcomes. this lead to an increase of mortality: % in the icu and an overall of %. study of selenium levels in unresponsive wakefullness (uws) patients with systemic inflammatory response syndrome (sirs) e kondratyeva , s kondratyev , n dryagina the objective of this study was to evaluate the pharmacokinetics (pk) of levetiracetam (lev) in critically ill patients with normal and augmented renal clearance (arc), and determine if the recommended dosage regimen provides concentrations in the therapeutic range ( - mg/l) [ ] . a prospective observational study was conducted in a tertiary hospital. six blood samples were taken during a dose interval at steady state and lev was quantified by hplc. a population pk study was carried out. statistical analysis was conducted to evaluate the differences in pk between patients with and without arc. the suitability of drug concentrations was also assessed. results: seventeen patients were included, with normal creatinine clearance (crcl) ( - ml/min) and with crcl≥ ml/min (arc). ten patients received mg q h, one mg q h and two mg q h. the data were best fitted to a two-compartment model. figure shows lev concentrations during the dosing interval. mean clearance (cl) was l/h and mean volume of distribution of central compartment (v) was l. interindividual variability was and % for cl and v, respectively. no differences were identified between both groups (p> . ) in pk parameters. no correlation was found between lev cl and crcl. trough levels were below the minimum concentration (c min ) mg/l of the therapeutic range in all patients except . furthermore, between - h % of samples were below the c min . conclusions: administered doses were not able to maintain lev concentrations in the recommended therapeutic range. other dosage strategies, such the extension of infusion time with higher doses, could be evaluated in order to obtain a more favourable profile. no correlation between lev cl and crcl was found. the mechanical properties of muscles such as tone, elasticity, and stiffness are often affected in chronic critical ill (cci) patients. a hand-held device known as the myotonpro demonstrated acceptable relative and absolute reliability in a ward setting for patients with acute stroke [ ] . the technology works on the principle of applying multiple short impulses over the muscle bulk via the testing probe. the aim of our study is to assess the feasibility of objective measurement of muscle tone in cci patients with neurological dynamics and serum biomarkers. the study included cci patients with neurological disorders (stroke, traumatic brain injury, neurosurgical intervention for brain tumors) with more than a -weeks stay in icu. dynamic measurements of the muscle properties were taken on the deltoideus, brachioradialis, quadriceps femoris, gastrocnemius using the myo-tonpro. to identify the leading factor in impaired muscle tone also were measured neurological (s , nse), inflammatory (il- ), bacterial load (pct) biomarkers using elecsys immunoassay and the serum level of microbial metabolites using gc-ms (thermo scientific). results: all patients were divided into groups depending on positive and negative clinical dynamics. significant differences were obtained in parameters characterizing changes in muscle tone of lower limbs -f gastrocnemius (tone) - . vs . hz, r quadriceps femoris (the mechanical stress relaxation time) - . vs . ms (p < . , respectively). some significant correlations between five parameters of muscle tone biomarkers and microbial metabolites were revealed. the results of a quantitative measurement of muscle tone objectively reflect the dynamics of neurological status, which in the future may be promising technique for the personalized approach cci in patients. introduction: changes in hormonal status in patients with unresponsive wakefulness syndrome (uws) remains poorly understood. methods: patients in uws were examined at the period from to . patients ( men) with tbi and patients ( men) after hypoxia. acth, cortisol, tsh, free t and t , sth, prolactin and natriuretic peptide were studied in the period from to months uws. in men, the level of total testosterone, lh and fsh was additionally studied. the obtained data was compared with the uws outcome in - months (crs-r scale assessment). none of the studied hormones of the hypothalamic-pituitary-adrenal axis were a reliable criterion for predicting the outcome of uws. most often and consistently was revealed a tendency of disrupt the rhythm of cortisol secretion, with higher rates in the evening hours. the average value of sth was higher in men with the consequences of head injury who had recovered consciousness than in those who remained in uws. significant decrease in testosterone levels, regardless of age, was found in patients with a consequence of tbi. mean levels of lh were higher in patients with tbi and hypoxia who remained unconscious than in patients who later restored consciousness. the average level of fsh was higher in patients who had recovered consciousness . the increase of natriuretic peptide level was observed both in patients who remained in chronic uws and in those who restored consciousness. no certain endocrine background, characterising this category of patients was found. violations of some hormones secretion rhythms, in particular, cortisol can be considered usual for uws patients, especially in patients with tbi. therapeutic hypothermia has not been used before our research in chronically critically ill (cci) patients. temperature decrease in neuronal cells is a strong signal that triggers endogenic cytoprotection programs using early response genes expression. our goal is to determine influences of craniocerebral hypothermia (cch) on level of consciousness in cci patients. we examined patients with different types of brain injuries. males and females, mean age . ± . . patients were divided into groups: main group - patients (vegetative state (vs) - , minimally conscious state (mcs) - ), comparison group - patient (vs - , mcs - ), groups were equal on main parameters (severity, functional state, comorbidity). patients from main group received courses of cch, duration - minutes, scalp temperature - °С, cerebral cortex cooling up to - o c, session end was without slow reheating period, and session's amount was set -until signs of consciousness recovery. cortex temperature check done noninvasively by using detection of brain tissue emi in shf-range. consciousness recovery in vs and mcs patients controlled using crs-r scale. results: cch sessions significantly increased level of consciousness in vs and mcs patient groups. in vs patients vegetative state increased until minimally conscious state and mcs +, and in mcs group until lucid consciousness (p < . ) (figure ). craniocerebral hypothermia is used in chronically critically ill patients for the first time. our research results demonstrated effectiveness of cch as an additive treatment tool in such patients. this let us optimistically determine the perspective of inclusion of cch method in chronically critically ill patient's rehabilitation to increase level of consciousness. despite the clinical benefit of endovascular treatment (evt) for large vessel occlusion (lvo) in ischemic stroke, space-occupying brain edema (be) represents a common complication during the course of disease. routinely, ct imaging is used for monitoring of these patients, notably in the critical care setting, yet novel and easy bed-side techniques with the potential to reliably predict be without repetitive imaging would be valuable for a time and cost effective patient care. we assessed the significance of automated pupillometry for the identification of be patients after lvo-evt. we enrolled patients admitted to our neurocritical-care unit who received evt after anterior circulation large vessel occlusion. we monitored parameters of pupillary reactivity [light-reflex latency (lat; s), constriction and re-dilation velocities (cv, dv; mm/s), and percentage change of apertures (per-change; %)] using a portable pupilometer (neuroptics®) up to every minutes during the first hours of icu stay. be was defined as midline-shift ≥ mm on followup imaging within - days after evt. we assessed differences in pupillary reactivity between patients with and without be (u-test) and evaluated prognostic performance of pupillometry for development of be (roc analysis). in patients ( women, . ± . years) without be, , assessments were compared to assessments in patients ( women, . ± . years) with be. on day , day , and day after evt, patients with be had significantly lower cvs and dvs, and smaller perchanges than patients without be, whereas lat did not differ between both groups. roc-analyses revealed a significant negative association of cv, dv, and per-change with development of be. conclusions: automated pupillometry seems to identify patients at risk for be after evt. a prospective study should validate whether automated pupillometry harbors the potential to reduce unnecessary follow-up ct imaging. the aim of this preliminary analysis is to detect differences between the qualitative and quantitative evaluation of the pupillary function carried out by doctors and nurses of an intensive care unit (icu) of a tertiary level hospital. secondary purpose is to investigate new indications for the use of pupillometry in a population admitted in icu methods: the study has been conducted (currently in progress) at the intensive care unit and ecmo referral center at careggi teaching hospital (florence; italy). the enrolled patients are adult subjects (> years) with alteration of consciousness defined by a glasgow coma scale (gcs) < , following a primary brain injury and/or the use of sedative drugs. the studied parameters, obtained with neurolight pupillometer ® (id-med, marseille, france) are analyzed, integrated and visual/qualitative evaluation of the pupil function shows a lower reliability if compared to automated pupillometry. the estimated error in the proper determination of photomotor reflex is . % (p< . ). no significant difference is reported between quantitative and qualitative pupillometry in the detection of anisocoria. our preliminary results are compatible with previously reported data [ ] [ ] [ ] , even if there was no difference in anisocoria determination. interestingly, a longer latency period among patients treated with opioids has been observed. other results are still in progress. introduction: due to the dynamic of critical care disease, a rapid bedside, noninvasive and highly sensitive and specific method is required for diagnosis. in this study we set out our experience with trancranial color-coded duplex ultrasound (dxt) [ ] . the dxt study identifies cerebral arteries as well as hemorrhagic phenomenon, hydrocephalus, mass-occupying lesions and midline shift. this is the main difference between dxt and conventional transcranial doppler (dtc) which is a blind study and do not provide any image. descriptive, cross-sectional and observational study from december to june . patients were included. inclusion criteria: neurocritical patients. exclusion criteria: no acoustic window, presence of ultrasound artifacts. data collection was performed. it was used a lowfrequency transducer from . - . mhz with trancranial duplex preset ( figure) . the patterns were defined as normal, vasospasm, high resistance, hypermedia and cerebral circulatory arrest, depending on the cerebral flow velocity, lindegaard ratio (lr) and pulsatility index (ip). results: men ( . %) and women ( . %). average age . ( - ). patients diseases: subarachnoid hemorrhage , traumatic brain injury , av malformation , stroke , hemorrhagic cerebrovascular accident and mass occupying lesions . normal pattern: patients (rel. freq . ). vasospasm: patients (rel. freq . ). high resistance: patients (rel. freq . ). hyperemia: patient (real. freq . ). cerebral circulatory arrest: patient (rel. freq . ) conclusions: dxt should be part of the routine of neuromonitoring, it allows real time images especially useful in unstable conditions. although it will be needed a large amount of patients to be statistical significant, dxt is useful considering a non invasive study, bedside and it allows early identification of different clinic conditions. introduction: embolization of the draining vein during endovascular treatment of arteriovenous malformation (avm) may result in venous outflow obstruction and hemorrhage. anaesthesiologist can use deliberate hypotension to reduce blood flow through avm which may be somehow helpful to prevent this scenario. adenosine-induced cardiac arrest may facilitate the embolization too. the goal of our study was to improve the results of endovascular treatment of avm using adenosine-induced cardiac arrest. methods: after obtaining informed consent patients ( male, female) were selected for adenosine-induced cardiac arrest during endovascular avm embolization. main age was , ± years old. of them were evaluated as iii class asa, as iv. endovascular treatment in all cases was performed under general anaesthesia. propofol, fentanyl, rocuronium were used to induce anaesthesia, then all the patients were intubated and ventilated with parameters to keep etco - mm hg. sevoflurane , - , vol% ( cases) or desflurane vol% ( case) were used to maintain anaesthesia. hemodynamic monitoring consisted of ecg, pulsoximetry, non-invasive blood pressure measurement. onyx or/and squid were used as embolic agents. ct was performed to every patient just after procedure as well as neurological examination. results: adenosine dosage was . - . mg/kg. time of consequent cardiac arrest was - sec. there were cases we administered adenosine for time, in one case we had to administer it twice, in one fig. (abstract p ) . circle of willis and pulsed-wave doppler mode of middle cerebral artery - times and times in one more case as well. hemodynamic parameters recovered without any particular treatment in all the patients. embolization has been performed in all the cases uneventfully. postoperative ct showed no hemorrhage. nobody from investigated group had neurological deterioration in postoperative period. our study shows that adenosine-indused cardiac arrest is not very difficult to perform method and it can be useful during avm embolization. a major risk factor for stroke is atrial fibrillation (af). to treat af anticoagulation is needed. there are now several anticoagulants available. however, a lack of head to head data as well as the absence of accurate techniques makes it difficult to compare them and measure determine there efficacy. stroke is known to produce an abnormal clot microstructure which is a common factor in many thrombotic diseases. this pilot study aims to use a functional biomarker of clot microstructure (d f ) and clotting time (tgp) to investigate the therapeutic effects of different anticoagulants in stroke and af. we recruited patients ( af and stroke & af). two samples of blood were taken: before anticoagulation (baseline) and post anticoagulation ( - weeks) . patients were either given warfarin ( %) or axipaban ( %). d f and tgp were measured and compared before and after anticoagulation. results: warfarin increased t gp ( ± secs to ± secs (p< . )), and decreased d f ( . ± . to . ± . (p< . )). apixaban increased tgp ( ± sec to ± sec (p< . )) but did not change df ( . ± . & . ± . ). interestingly we found that in the apixaban group tgp significantly correlated (p= . ) with blood drug concentration levels. in this study we show that d f and tgp can quantify and differentiate between the therapeutic effects of two different oral anticoagulants. showing that warfarin prolongs clotting and weakens the ability of the blood to form stable clots. conversely apixaban prolongs clotting time but does not affect the bloods ability to form stable clots. this shows the utility of the d f and tgp biomarkers in comparing two different treatment options, something no other current marker has proven able to do. where d f and tgp may prove useful tools in a personalized approach to anticoagulation treatment and monitoring in an acute setting. hospital mortality compared to the model with the original hairscore. patients with poor-grade aneurysm subarachnoid hemorrhage (asah) world federation of neurological surgeons (wfns) grades iv and v, have commonly been considered to have a poor prognosis ( - % mortality). though early intervention and aggressive treatment in neuroicu has improved outcome in the past years, it is controversial because most of the patients left hospital severely disabled. the objective of this study was to investigate the clinical and social outcomes in intracranial aneurysm patients with poor-grade asah underwent different intervention therapies. a single center observational registry of poor-grade asah consecutive patients, defined as wfns grades iv and v, treated at tertiary chilean referral center from december to march were enrolled in this study. the clinical data including patient characteristics on admission and during treatment course, treatment modality, aneurysm size and location, radiologic features, signs of cerebral herniation (dilated pupils), and functional neurologic outcome were collected. clinical outcomes were assessed via gose and and sociooccupational outcome, both at discharge and at months. figure ). % mortality is less than previously reported, and survivors had a favorable recovery, confirmed with neuro psychological test. poor-grade asah patients in our study shows a more positive outcome than previously considered. prognosis of subarachnoid hemorrhage (sah) is scarce, indeed almost half patients die or become severely disable after sah. outcome is related to the severity of the initial bleeding and delayed cerebral infarction (dci). infection and more precisely pneumonia have been associated with poor outcome in sah. however, the interaction between the two pathologic events remains unclear. therefore, we hypothesized that dci may be associated to pneumonia in sah patients. thus the aim of our study was to analyze the association between delayed cerebral infarction and pneumonia in patients with sah. in this retrospective, observational, monocentric cohort study, patients included in the analysis were admitted in neurosurgical intensive care unit or surgical intensive care unit in the university hospital of brest (france) for non-traumatic sah. primary outcome was diagnosis of dci on ct scan or mri months after sah. multivariate analysis was used to identify factors independently associated with dci. a total of patients were included in the analysis (female male ratio / , median age [ - ] years). multivariate analysis was adjusted on sedation, intracranial surgery, fisher classification of sah severity, pneumonia occurrence and non-pneumonia infectious event occurrence ( figure ). pneumonia occurred in patients ( . %) and other causes of infections in patients ( . %). dci was found in patients ( . %). factors independently associated with dci were pneumonia (or . [ . - . ]; p= . ) and non-pneumonia infectious events (or . [ . - . ]; p= . ). interestingly severity table (abstract p ). correlation of safety and efficacy markers of thrombolysis and thrombolysis time with distance from stroke centre results expressed as odds ratio with % confidence interval of initial bleeding evaluated by fisher scale was not independently associated with dci. dci is independently associated with the occurrence of pneumonia or other cause of sepsis. those results may highlight the need for rigorous approach for prevention protocol, early diagnosis and treatment of hospital acquired infectious diseases in sah patients. introduction: traumatic brain injury (tbi) can have devastating neurological, psychological and social sequelae. increased psychiatric morbidity after tbi has been shown in both adult and the pediatric population. also, critical illness as such is a risk factor for psychiatric problems in youth. our aim was to assess risk factors for later being prescribed psychiatric medication in survivors of intensive care unit (icu)-treated pediatric tbi. we used the finnish intensive care consortium (ficc) database to identify patients - years of age, treated for tbi in four icu in finland during the years - . we examined electronic health records and ct scans and collected data on drug prescription after discharge. we used multivariable logistic regression models to find statistically significant risk factors for psychiatric drug reimbursement. we identified patients of which patients received psychiatric drug prescription ( %) during follow up. the median time to prescription was months after tbi (interquartile range [iqr] - months). patients received antidepressants, received stimulants and received antipsychotics. increasing age showed a positive association with all drug prescriptions except for stimulants, where an inverse relationship was observed (table ) . using multivariable analyses, we could not find any admission or treatment related factors that significantly associated with being prescribed psychiatric medications. teenage survivors with moderate disability (glasgow outcome scale [gos] ) showed high numbers of psychotropic drug utilization ( % received any medication, % received antidepressants, % received antipsychotics). our data suggests, that the risk of psychotropic drug prescription after tbi depends on factors other than those related to injury severity or treatment measures. the incidence of drug prescription is especially high in patients with moderate disability. the effects of -adamantylethyloxy- -morpholino- -propanol hydrochloride on the formation of steroid neurotoxicity in rats with brain injury a. semenenko , s. semenenko , a. solomonchuk , n. semenenko depending on the nature of the brain injury and the severity of the victims, mortality in traumatic brain injury (tbi) ranges from to % [ ] . one of the targets for pathogenetic influence on the course of tbi is the use of pharmacological agents that are able to counteract the negative effects of excess concentrations of glucocorticoids on brain. the therapeutic effect of new pharmacological derivative adamantylethyloxy- -morpholino- -propanol hydrochloride (ademol) in rats with tbi was evaluated for days. the pseudoperated animals and control group received . % nacl solution and the comparison group received amantadine sulfate. cortisol levels were used to determine the efficacy of the test drugs in tbi. in rats treated with ademol, the level of cortisol in the blood ranged from to ng/ml (p -p ) and was . -fold lower (p< . ) compared to control pathology group on the day of therapy. instead, the effect of amantadine sulfate on the level of cortisol in the blood was significantly less than that of ademol. the concentration of cortisol in rats with amantadine sulfate in the blood ranged from - ng/ml (p -p ), was . times lower (p< . ), compared with the control pathology group, and by . % (p< . ) exceeded the corresponding value in animals treated with ademol. therapeutic treatment of rats with severe tbi with a solution of ademol, preferably better than rats in the group with . % nacl and amantadine sulfate protect the brain from the formation of steroid neurotoxicity by cortisol (p< . ). although cerebrovascular pressure reactivity (prx) well correlate to patient's outcome [ ] , it requires continuous monitoring and mobile average calculation for its determination. we therefore hypothesized that a simplified model of variation between mean arterial pressure (map) and intracranial pressure icp over the first three days of admission would have been able to predict patient outcome: we call this new parameter cerebrovascular pressure correlation index (cpc). we performed a retrospective observational study of all adult patients with severe tbi admitted to icu from january to april inclusive. all consecutive patients with a clinical need for icp monitoring were included for analysis. both for icp and map data were mean value over -hours registration, for a total of observations/day, cpc was therefore calculated as the pearson correlation coefficient between icp values (x axis) and map values (y axis), obtaining one single value every hours. variables included in the model (i.e. cpc, cpp, icp, systemic glucose, arterial lactate, paco , icp, and internal body temperature) were collected for the first days since trauma. for the main outcome only the minimum value of cpc fit the regression analysis (p = . ). the correspondent roc curve showed an auc of . . the associated youden criterion was ≤ . (sensitivity = . ; specificity = . ). of all the variables considered for the secondary outcome only cpcmin fit the regression model (p = . ). table reports the median and iqr range for sg and nsg of all the variables considered in the model. this observational study suggests that cpc could be a simplified model of variation between map and intracranial pressure icp over the first three days of admission predicting patient outcome. introduction: impaired cerebrovascular reactivity (car) after traumatic brain injury (tbi) is a marker for disease severity and poor outcome. it is unclear how dynamic changes in body temperature and fever impact car and outcome. we calculated the pressure reactivity index (prx) using the center-tbi high-resolution intensive care unit cohort, as a moving correlation coefficient between intracranial pressure (icp) and mean arterial pressure (map). minute and hourly values of prx and temperature were averaged in patients with simultaneous recording of icp and abp. demographic data was based the core registry (v . ). linear mixed models were calculated based on minute-by-minute data using r with lme v . - and ggeffects v . . . generalized estimating equation models were used to analyze changes during effervescence (increase of temperature of > °c within hours). we assessed high frequency physiological data during days of patients admitted to the icu with predominantly a closed injury type (n= / ). median age was years (iqr - ), baseline gcs was (iqr - ), and % had at least one unreactive pupil. the main measurement site for temperature was the urinary bladder / ( %). half of the patients ( / ) developed fever(> h with mean t ≥ . °c) with a total of h fever and a median of h fever(iqr - ) per patient. of effervescence episodes ( %) reached the febrile threshold of . °c which was associated with an increase in prx from . (±sd . ) at baseline ( h before) to . (±sd . ) during the febrile peak (p= . ) (figure -a) . linear mixed models showed a quadratic relationship between prx and temperature (p< . ) with an increase in predicted prx with febrile and hypothermic temperatures ( figure b ). the association of increasing body temperature with worsening of car supports prevention of fever in severe tbi. prospective studies are needed to further differentiate between mechanisms involved (i.e. inflammation) and central autonomic dysregulation. fig. (abstract p ) . the patients with a good -month outcome (gose> ) after severe traumatic brain injury showed an increase in root mean square of successive differences between normal heartbeats (rmssd) (compared to baseline -minutes before tracheal succtioning) acute kidney injury (aki) is relatively common in patients with severe traumatic brain injury (stbi) and it can contribute to morbidity and mortality [ ] . nephrocheck is a point-of-care urine test that flags two biomarkers that indicate if a critically ill patient is at risk for aki. we investigated the incidence of subclinical aki in patients with stbi. we performed a prospective observational study of all adult patients with severe tbi admitted to icu from january to april inclusive. all consecutive patients with a clinical need for icp monitoring were included for analysis. urine samples of severe tbi patients was collected at icu admission from patients to measure nephrocheck (nc) test [igfbp ] x was performed using the nephrocheck® astute ™ meter. serum creatinine was collected at admission, during the first three days, at icu dismission and -days follow up to assess renal recovery. the diagnosis of aki was based on kdigo criteria. hemodynamics, electrolytes, peep, p/f, kind of fluid administered, fluid balance, % fluid overload, length of stay, the sequential organ failure assessment score, injury severity scores and mortality were collected. a total of patients ( %) presented a median nc higher values at icu admission. one patient with positive nc value experienced aki at hrs. the positive nc group had more plasma transfusion (p-value . ) and a lower median hematocrit at hrs (p-value . ), but similar hospital length of stay (p= . ) and mortality rate (p= . ) conclusions: nc at icu admission identifies subclinical aki in tbi patients and it maight be used to predictclinical aki. hemodilution (but not fluid overload) seems to be associated with development of subclinical aki. higher nc at icu admission is not associated with worst longterm outcome in tbi patients. severe traumatic brain injury (tbi) is considered a serious public health problem in europe. partly because of the heterogeneity of tbi, considerable uncertainty may exist in the expected outcome of patients. the international mission for prognosis and analysis of clinical trials in tbi (impact) and the corticosteroid randomization after significant head injury (crash) prediction models are considered the most widely validated prognostic models [ , ] . however, studies using these prediction models for benchmarking of outcomes have been scarce. we aimed to compare actual outcomes in a tbi cohort of critically ill tbi patients with predicted outcomes in a quality of care initiative in an academic hospital. in this retrospective cohort study, we included consecutively admitted tbi patients to the icu adults of erasmus mc, university medical center, rotterdam, the netherlands between january and february . we included patients with tbi. -day mortality was %, sixmonth mortality was % and six-month unfavourable outcome was %. the impact core+ct+lab model predicted % -month mortality (vs % actual, p= . ) and % unfavourable outcome (vs % actual, p= . ). the -day mortality prediction by crash prognosis calculator was % versus actual -day mortality of only % (p= . ), whereas -month unfavourable outcome prediction by crash was % (vs. % actual, p= . ) ( figure ). the impact model, although developed more than a decade ago, seemed appropriate for benchmarking purposes in this single center cohort in the netherlands, while crash predictions were less applicable to our setting. introduction: out of hospital cardiac arrest (ohca) continues to be associated with significant mortality and morbidity. centralisation of care has considerably improved patient survival but has resulted in increased morbidity in the form of neurological deficit. accurate neurological prognostication remains challenging incorporating repeated clinical examination and ancillary investigations [ , ] . data was collected retrospectively and analysed for patients admitted post ohca from october to october . patient arrest demographics were collected in conjunction with extensive inpatient investigation findings including ct, traditional pupil assessment, pupillometry and eeg. results: % of patients survived to hospital discharge. patients presenting in a shockable rhythm continue to have higher survival rates ( table ) . % of patients who received immediate cpr survived to hospital discharge in comparison to % of patients who did not receive immediate cpr. % of patients underwent non-contrast ct head. % of patients had traditional pupillary examination performed on arrival. pupillometry was introduced in december ; out of a possible patients had pupillometry during their inpatient stay. eeg was undertaken in % of cases. our data shows receiving immediate cpr and presenting with a shockable rhythm remain positive prognostic factors. ct head as a stand-alone prognostic modality is unreliable with % of patients who survived to discharge, with intact neurology, had an admission ct head reported as hypoxic brain injury. a new neuroprognostic strategy is required in our unit that adds further certainty to likely clinical outcome. this includes increased use of tests such as eeg and pupillometry and the introduction of biomarkers such as neuron specific enolase, somatosensory evoked potential testing and magnetic resonance imaging. introduction: post-resuscitation care of patients following an out-of-hospital cardiac arrest (oohca) is set out by the uk resuscitation council [ ] . this is in line with the european resuscitation council guideline [ ] . the aim of this audit was to review compliancy to this guideline at the intensive care unit at the bristol royal infirmary . a retrospective audit was performed over a six-month period in adults who were admitted to the intensive care unit at the bri following an oohca whom later died during that admission ( patients). the focus was on whether the neuroprognostication and end-of-life (eol) care received was as per the standards set by the uk resuscitation council. the main neuroloical examinations documented were pupillary reflex ( %), corneal reflex ( %) and motor response to pain ( %). . % of patients received an ssep analysis > hours post-rosc, . % underwent an eeg and . % had > serum neuron-specific enolase measurements recorded. all patients ( %) underwent a ct head during their admission. . % of patients were referred to palliative care during their admission. % of patients were prescribed all eol medications. most common prescriptions included alfentanil ( . %) and midazolam ( . %). finally, % of appropriate patients were referred to be potential organ donors. the audit reflected our local practice and that some parameters were not being maintained as set by uk resuscitation guideline. multiple introduction: the prognostication of neurological outcome in comatose out-ofhospital cardiac arrest (ohca) patients is an integral part of post cardiac arrest care. biochemical biomarkers released from cerebral cells after hypoxic-ischemic injury represent potential tools to increase accuracy in predicting outcome after ohca. currently, only neuronspecific enolase (nse) is recommended in european prognostication guidelines. in this study, we present the release dynamics of gfap and uch-l after ohca and evaluate their prognostic performance for long-term neurological outcome in ohca patients. serum gfap and uch-l were collected at , and h after ohca. the primary outcome was neurological function at -month follow-up assessed by cerebral performance category scale (cpc), dichotomized into good (cpc - ) and poor (cpc [ ] [ ] [ ] . outcome prognostic performance was investigated with receiver operating characteristics (roc) by calculating the area under the receiver operating curve (auroc) and compared to nse. results: of included patients had at least one serum gfap or uch-l value at , or h after ohca. gfap and uch-l levels were significantly elevated in patients with poor outcome. gfap and uch-l discriminated excellently between good and poor neurological outcome at all time-points (auroc gfap . - . ; uch-l . - . ) and overall predictive performance measured by auroc of gfap and uch-l was superior to nse (auroc . - . ) ( figure ). however, the roc at the highest specificities of uch-l and gfap overlap those of nse and comparing the sensitivities for uch-l and gfap with those of nse for the highest specificities (> %) revealed higher sensitivities for nse than for uch-l and gfap at and h. gfap and uch-l predict poor neurological outcome in patients after ohca excellently and with a higher overall accuracy than nse, but both biomarkers perform inferior to nse at specificities over % at and h limiting their clinical use to guide decisions on prognosis. blood pressure after cardiac arrest and severity of hypoxicischemic encephalopathy c endisch , s preuß , c storm introduction: blood pressure management in post cardiac arrest (ca) patients ensures sufficient cerebral perfusion to avoid secondary brain injury. in local chain-of-survival improvements affect p-ohca survival [ ] [ ] [ ] [ ] [ ] . also initial rhythm in p-ohca is an important predictor of survival [ , ] . little is known about the relationship between initial rhythm in p-ohca and long-term outcome [ ] [ ] [ ] . our aim was to establish the relation between shockable rhythm and favorable long-term outcome in pohca. all children aged day- years who experienced non-traumatic ohca between - and were admitted to the sophia children's hospital in rotterdam were included. long-term outcome was determined using a pediatric cerebral performance category score at the longest available follow-up interval. the primary outcome measure was survival with favorable neurologic outcome, defined as pcpc - or no difference between pre-and postarrest pcpc. the association between shockable rhythm and the primary outcome measure was calculated in a multivariable regression model, adjusted for the pre-defined variables. from the patients included in the year study period ( %) patients survived to hospital discharge of which patients ( %) had favorable neurologic outcome (median follow-up duration of months). the rate of favorable neurologic outcome rose from % in to % in (p < . for trend) (fig. ) the odds of favorable neurologic outcome at the longest follow-up duration were significantly higher after a shockable initial and unknown rhythm. secondly, trend analysis showed an increase in aed defibrillation and shorter cpr duration. this was followed, finally, by a rise in rosc, survival to hospital discharge and favorable neurologic outcome rate. low socioeconomic status is associated with worse outcome after cardiac arrest. this study aims to investigate if patients´socioeconomic status impacts the chance to receive early coronary angiography after cardiac arrest. in this nationwide retrospective cohort study, patients admitted alive after out-of-hospital cardiac arrest (ohca) and registered in the swedish registry for cardiopulmonary resuscitation were included. individual data on income and educational level, prehospital parameters, coronary angiography results and comorbidity were linked from other national registers. in the unadjusted model there was a strong correlation between income level and rate of early coronary angiography where % of patients in the highest income quartile received early angiography compared to % in the lowest income quartile. when adjusting for confounders (educational level, sex, age, comorbidity and hospital type) there were still higher chance of receiving early coronary angiography with increasing income, or . (ci . - . ) and . (ci . - . ) for the two highest income quartiles respectively compared to the lowest income quartile. when adding potential mediators to the model (initial rhythm, location, response time, bystander cardiopulmonary resuscitation and if the arrest was witnessed) no difference in early angiography related to income level where found. the main mediator was initial rhythm (figure ). higher income is strongly related to the rate of early coronary angiography after ohca. this finding is consistent when adjusting for known confounders. however, the association between income and early angiography seems to be mediated by initial rhythm. patients with low income more often presents with non-shockable rhythms which lowers the likelihood to undergo early coronary angiography. a. the total amount of mortality as a stacked bar: in light-red the number of patients who deceased at scene, in green the number of patients deceased during admission, in red patients who died after discharge. the grey line is the total number of inclusions. b. the rate of bystander aed use, rate of initial shockable rhythm, rate of less than minutes of cpr and rate of favorable neurologic outcome over time. p for trend significant for bystander aed use, less than minutes of cpr and favorable neurologic outcome. trend analysis performed using binary logistic regression for dichotomous data (and a kruskal-wallis test for non-normally distributed continuous data) effect of simulation teaching of cardiopulmonary resuscitation for nursing v spatenkova introduction: simulation teaching is a modern type of critical care (cc) education. the aim of this study was to assess the effect of simulation teaching of cc on a comparison of final examination in different model levels of cardiopulmonary resuscitation (cpr) after the first (cc ) and third, final cc . the success rate of cpr was tested in prospective study ( ) ( ) on two groups with a total of students in cc and cc at the faculty of health studies. three semester of undergraduate nursing simulation education (lectures and training) used the laerdal simman g. quality of cpr was evaluated according to parameters: compression depth, compression rate, chest release and time of correct frequency. we tested if cpr quality differed between the two groups. for the compression depth and compression rate parameters, first the conformity of variance was verified and then two-sample t-test. as the chest release and time of correct frequency are recorded as percentages, the wilcoxon rank-sum test was conducted for these parameters. to ensure good resuscitation, all recorded parameters must be properly performed during resuscitation. thus, pivot tables were used to generate statistics and test if the number of correctly performed resuscitation parameters for cc and cc differ. the compression depth parameter was statistically significantly higher for the cc than for the cc (p= . ). there were no differences in compression rate (p= . ), chest release (p= . ) and time of correct frequency (p= . ). it was also tested how many of the parameters were performed correctly by students at cpr. the chi-square test shows the relative frequency of cpr success is higher for the cc group than for the cc group. at least out of parameters were correctly performed by % of cc students compared to % of cc students. the study showed a significant improvement of cpr in the final cc and supported the three semester simulation education. changes in blood gases during intraoperative cardiac arrest jj wang, r borgstedt, s rehberg, g jansen protestant hospital of the bethel foundation, anaesthesiology, intensive care and emergency medicine, transfusion medicine and pain therapy, bielefeld, germany critical care , (suppl ):p introduction: blood gas analysis (bga) is a common approach for monitoring the homeostasis during surgery. while it is well known that cardiac arrest (ca) leads to circulatory collapse and disturbances in homeostasis, little is known about changes of blood gas during peri-operative ca. we retrospectively analysed patients ≥ years who suffered from peri-operative ca during non-cardiac surgery from / to / . peri-operative ca was defined as need for cardiac compression during anaesthesia care. collected data included ph, paco , pao , return of spontaneous circulation (rosc) and -day mortality after ca. within the study period, we observed peri-operative ca (m= , f= ; age ± ) during anaesthesia procedures (rosc occurred in patients ( %). days after ca, the mortality was % (n= ), % (n= ) were discharged, and % (n= ) still in hospital. % (n= ) of ca patients had an invasive blood pressure monitoring, % (n= ) had bga before and % (n= ) during peri-operative ca. prior to ca, the average values were: ph . ± . , paco ± and pao ± . during ca, the average values were ph . ± . , paco ± and pao ± . table shows the distributions of blood gas before and during ca. there were no statistical differences between the groups (ph: p= . ; paco : p= . ; pao : p= . ). hypercapnia and respiratory acidosis is common in peri-operative ca. these data suggests inadequate ventilation during peri-operative resuscitation. further studies should focus on its impact on the outcome. ]. comparing cases with and without rosc, there were significant more diagnostics done in the group without rosc but more therapeutic consequences seen in the rosc-group (table ) . icu-ca is frequent. diagnostics to detect reversible causes of ca were used rarely in icu-ca ( %), even in patients without rosc. notably, diagnostics often had therapeutic consequences particularly in rosc. further studies are required to define standardized diagnostic algorithms during icu-ca. continuous monitoring of cardiac patients on general ward were improved short term survival of in-hospital cardiac arrest uj go introduction: the importance of early detection in the in-hospital cardiac arrest (ihca) is emphasized. previous studies have reported that clinical outcomes are improved if ihca is witnessed, or if a patient admitted to a monitored location [ , ] . this study aimed to evaluate the association between continuous monitoring and survival of ihca on general ward. a retrospective cohort study of ihca in patients admitted to ward at an academic tertiary care hospital between january and december was performed. the primary outcome was return of spontaneous circulation (rosc). the secondary outcomes were hour survival and survival to hospital discharge. (table ) . cardiac patients with continuous monitoring on general ward showed improving rosc and -hour survival but not survival to hospital discharge in ihca. in-hospital cardiac arrest is associated with poor outcomes. although steroids are frequently used in patients with septic shock, it is unclear whether they are beneficial during cardiac arrest and after return of spontaneous circulation (rosc). of cardiac arrest patients evaluated, were enrolled. advanced life support was conducted according to the resuscitation guidelines. forty-six patients were randomly assigned to receive methylprednisolone mg during resuscitation, and to receive saline (placebo). after resuscitation, steroid-treated patients received hydrocortisone mg daily for up to days, followed by tapering . there was no significant difference between the two groups in scvo andall the secondary outcomes (p> . for all comparisons). the present study found no significant physiologic benefit of corticosteroid administration during and after resuscitation in hospitalized patients with cardiac arrest. the experiences of ems providers taking part in a large randomized trial of airway management during out of hospital cardiac arrest, and the impact on their views and practice. results of a survey and telephone interviews m thomas introduction: the aim is to explore ems experiences of participating in a large trial of airway management during out-of-hospital cardiac arrest (air-ways- ), specifically to explore: . any changes in views and practice as a result of trial participation. . experiences of trial training. . experiences of enrolling critically unwell patients without consent. . barriers and facilitators for out-of-hospital trial participation. an online questionnaire was distributed to ems providers who participated in the trial. in-depth telephone interviews explored the responses to the online questionnaire. quantitative data were collated and presented using simple descriptive statistics. qualitative data collected during the online survey were analysed using content analysis. an interpretive phenomenological analysis approach was used for analysis of qualitative interview data results: responses to the online questionnaire were received from % of airways- study paramedics and study paramedics were interviewed. paramedics described barriers and facilitators to trial participation and changes in their views and practice. the results are presented in five distinct themes: research process; changes in views and practice regardingairway management; engagement with research; professional identity; professional competence. conclusions: participation in the airways- trial was enjoyable and ems providers valued the training and study support. there was enhanced confidence in airway management as a result of taking part in the trial. study paramedics expressed preference for the method of airway management to which they had been randomized. there was support for the stepwise approach to airway management, but also concern regarding the potential to lose tracheal intubation from 'standard' paramedic practice. causes of medical care-associated cardiac arrest on the intensive care unit s entz introduction: cardiac arrest on intensive care unit (icuca) following therapeutic interventions is of imminent importance, because the interventions are comparatively predictable and precautions can potentially be taken. this study investigates medical care associated complications that led to icuca. intensive care database was screened for patients ≥ years who experienced icuca in a tertiary hospital with five icu (two medical, two surgical, one interdisciplinary, with a sum of icu beds) in germany from - . icuca was defined as receiving chest compression and/or defibrillation after admission on icu and classified as "medical care associated" if it was preceded by a therapeutic intervention (i.e. induced by medication, bedding procedures, iatrogenic injuries, procedure associated). subgroups included patients with recurrence of spontaneous circulation (rosc) vs. no-rosc and patients with vs. without vasopressor therapy before intervention. there were icuca in patients of totally , icu patients. medical care associated complications leading to icuca were detected in cases ( %) [incidence . / , (ci . - . )]. icuca following therapeutic interventions occurred because of circulatory insufficiency [n= ( %)], respiratory failure [n= ( %)] and airway associated problems [n= ( %)]. nine of the patients ( %) with care-associated icuca died. table demonstrates therapeutic interventions followed by icuca. care-associated complications were common reasons for icuca. most of events were induced by circulatory insufficiency due to induction of anaesthesia and bedding procedures. further investigations should focus on preventive strategies, such as vasopressor infusion before therapeutic interventions. in-hospital cardiac arrest (ihca) is a lethal event. however, ihca has received less attention than out-of-hospital cardiac arrest (ohca). there have been some studies on ihca; however, there is a lack of information on the evidence and clinical features of ihca compared with information for ohca. we therefore conducted this study to clarify important aspects of the epidemiology and prognosis of ihca in patients with code blue activation. we carried out a retrospective observational study of patients with code blue events in our hospital during the period from january to october . we obtained information on the characteristics of patients including age and gender, ihca characteristics including the time of cardiac arrest, event being witnessed, presence of bystander cardiopulmonary resuscitation (cpr), initial shockable rhythm, vital signs h or h before cardiac arrest, survival to hospital discharge (shd), and the cardiac arrest survival postresuscitation in-hospital (caspri) score. the primary endpoint was shd. we performed univariate and multivariate logistic regression analyses. a total of code blue events were activated during the study period. finally, patients were included in this study. overall, the shd rate was . %. the median time of cpr was min (interquartile range, - min). the rate of initial shockable rhythm was . %. there were significant differences in cpr duration, shockable rhythm, and caspri score between the shd group and non-shd group by univariate-logistic regression analysis. caspri score was found to be the most effective predictive factor for shd (or= . , p= . ) by multivariate-logistic regression analysis. our results demonstrated that caspri score is associated with shd in cpa patients with in-hospital code blue events. caspri score in ihca patients would be a simple and useful adjunctive tool for management of post-cardiac arrest syndrome (pcas). peri-operative cardiac arrest in prematurityincidence and causes at a tertiary care hospital between - g jansen, j popp, e lang, r borgstedt, b schmidt, s rehberg protestand hospital of the bethel foundation, anaesthesiology, intensive care and emergency medicine, bielefeld, germany critical care , (suppl ):p the peri-operative care of premature pediatric patients requires special expertise and is therefore reserved for specialized centers. although premature birth is described as a risk factor for peri-operative complications and cardiac arrest (poca) there are no data on its incidence and causality in this particular population [ ] . the present study investigates the incidence and causality of pediatric poca at a tertiary care hospital and level i perinatal center in germany. in the anesthesia database of the study center, all anaesthesiological procedures in patients < years of age were examined for poca in preterm infants (gestational age < th week of gestational age) between and . the peri-operative period was defined between the beginning of anesthesiological care up to minutes after anesthesia and/or sedation. we defined cardiac arrest as the necessity of chest compressions. the perioperative phase and the cause of the poca, gestational age and birth weight were recorded. between and , ( . %) of the , pediatric anesthesiological procedures were performed on premature infants. in total, poca occurred in of these patients (f= , m= ; average gestional age ± days; average birth weight ± g (incidence . %, ci . - . %). the time of occurrence and the causes of poca are shown in table . poca in premature babies is rare and has an incidence of . %, which is significantly higher than the non-premature babies. the main causes are problems or complications associated with the respiratory tract and its management, as well as massive hemorrhage. introduction: peri-operative cardiac arrest (poca) in children's anesthesia care is a dreaded event. depending on the country and population, studies describe incidences between . - . per , children's anesthetics. there are no data on the current incidence of pediatric poca in germany. the present study investigates the incidence of poca at a tertiary hospital and level i perinatal center in germany. in the anesthesia database of the study center, all anaesthesiological procedures in patients < years were examined for poca. the peri-operative period was defined between the beginning of anesthesia care up to minutes after anesthesia or sedation. cardiac arrest was defined as the necessity of chest compressions. age, weight, asa status, cause of death and survival after days were recorded. results: poca (median weight was g [q ;q ( )]) were observed in , anaesthesiological procedures (incidence . ± . per , [ci . - . ]). table shows the distribution of the individual age groups, incidences and mortalities of poca. peri-operative -day mortality was per , [ci [ ] [ ] [ ] [ ] [ ] . three children died intraoperatively as a result of hemorrhagic shock, one on the picu as a result of malignant hyperthermia. days after poca, more children had died on the icu due to their underlying disease. poca is a rare event. risk factors are an age < days and an asa status ≥ iii. the main cause of peri-operative death in patients < years of age is massive hemorrhage, the -day mortality is determined by the underlying disease. in-hospital cardiac arrest -predicting adverse outcomes t partington, j borkowski, j gross northwick park hospital, anaesthesia/critical care, london, united kingdom critical care , (suppl ):p introduction: cardiac arrest occurs in . per hospital admissions in the uk. return of spontaneous circulation (rosc) is achieved in approximately half of resuscitation attempts, but rate of survival to hospital discharge is substantially lower [ ] . in our centre, post-arrest care accounts for . % of icu admissions. premorbid social function is purported to affect outcomes, but comorbidity scores are more often used for risk stratification. using a novel social function score alongside an existing comorbidity scale, we aimed to identify trends to inform management of patients at risk of deterioration. a six-month prospective observational study was conducted in a major uk hospital from october to april . for all adult inpatient cardiac arrests, medical notes were reviewed and data collected on the following domains: patient demographics comorbidities and functional status admission details post-arrest events statistical analysis was performed using student's unpaired t-test. results: cardiac arrests occurred. % were in medical patients, with the majority male ( %) and aged over ( %). % were emergency admissions, with mean duration of hospital stay pre-arrest days. in cases ( %) sustained rosc was achieved. however, seven of these ( %) were not subsequently admitted to the icu. only six patients ( %) survived to hospital discharge. pre-admission function and comorbidity were worse in patients who did not survive to discharge ( fig. ), but these were not statistically significant in view of small survivor group size. in an increasingly frail inpatient population, a substantial proportion of patients in whom circulation is restored after cardiac arrest are subsequently considered unsuitable for icu admission. given our understanding of inferior outcomes in patients with poor physiological reserve, we encourage early discussion regarding the appropriateness of cpr in selected patients, guided by social function and comorbidity. references: . national cardiac arrest audit / introduction: there are studies that determine events related to poor outcome in cardiac arrest [ ] . in our study, following parametres were determined ohca patients; age median years, asian/europe/syrian, bystander cpr, bystander aed, ems defibrillation, initial cardiac rhythm, prehospital rosc, corneal and pupillary light reflex and day survival. we determineted poor prognostic sign with post-cardiac arrest patients. in this study, we identified the causes of poor outcome in patients with ohca. this was a single-centre, retrospective study. we determined incidence and epidemiological factors including: demographics, initial cardiac rhythm. our study population were non-traumatic ohca. our icu, all ohca patient were evaluated wtih echo, and fluid, inotrope and vazopressor were added according to cardiac performance. results: during our study, patients who were admitted to intensive care unit between - were screened. of these patients were out-of-hospital arrest and of them were in-hospital arrest. development of cerebral oedema during treatment in hospital remains a poor prognostic sign. the evaluation of initial cardiac ritm is useful to predict neurological outcome in post-cardiac arrest patients. survival after ohca remains low. the evaluation of initial cardiac ritm is useful to predict mortality and neurological outcome in postcardiac arrest patients. basic life support (bls) education and training for school children is active in japan. however, the bls action by schoolchildren may be limited by school rules. this study aimed to analyse the time factors for basic life support performance and outcome in classmatewitnessed out-of-hospital cardiac arrest (ohca) and to investigate how schoolchildren act when they detect ohca. methods: nation-wide database for , school children cases with ohca and local extended database for , ems-unwitnessed ohca, both of which were prospectively collected during the period of - , were retrospectively analysed. proportion of schoolchildren-detected ohca was low in classmate cases ( . %, / ) in nationwide database and extremely low in all ems-unwitnessed ohcas ( . %, / , ) in local database. nationwide database analyses revealed that both emergency call and bystander cpr were delayed when a classmate witnessed the ohca case: median, vs. min and vs. min, respectively. classmate-witnessed cases were associated with higher incidences of shockable initial rhythm, aed use and traumatic causes. the rate of neurologically favourable outcome was . % and . %, respectively in classmate-witnessed and other cases: adjusted or; % ci, . ; . - . . of cases detected by schoolchildren in our prefecture, ( %) cases had presumed cardiac aertiology and ( . %) cases were caused by suicide attempts (hanging and fall). school children placed emergency calls as the first action only in ( . %) cases. emergency calls were largely delayed when school children dialled other numbers or left the scene to seek adult help. school children were rarely involved in bystander cpr ( %) and aed placement ( %). school children are rarely involved in entire bls. emergency calls and bystander cpr are delayed when schoolchildren act to seek help. because schoolchildren detect suicide-related ohcas, psychological care to schoolchildren involved in bls may be necessary. prognostic value of neutrophil/lymphocyte and platelet/ lymphocyte predicting cardiopulmonary resuscitation with spontaneous circulation recovery c li the affiliated suzhou hospital of nanjing medical university, suzhou, china critical care , (suppl ):p to investigate the predictive value of peripheral blood neutrophil-tolymphocyte ratio (nlr) and platelet-to-lymphocyte ratio (plr) on inhospital mortality in patients with spontaneous circulation recovery after cardiac arrest. a retrospective analysis was made of patients who recovered from cardiac arrest in our hospital from april to november and were admitted to the intensive care unit for more than hours. they were divided into survival group and death group according to the outcome of discharge.the dynamic changes and differences of nlr and plr in hours and - hours after admission to icu between the two groups were analyzed and compared. multivariate analysis and roc curve were used to explore the predictive value of nlr and plr for in-patient mortality. compared with the survival group, plr in the dead group was significantly lower within hours of admission to the intensive care department (p < . ), while nlr in - hours was significantly higher (p < . ). the nlr of surviving group was significantly lower than that of hours (p < . ), while the nlr and plr of death group were not significantly different (p < . ) from that of hours (p < . ). multivariate logistic regression analysis and roc curve showed that nlr of - h in icu was an independent risk factor for predicting in-patient mortality, and had high sensitivity and specificity in predicting death outcomes. neutrophil to lymphocyte ratio, platelet to lymphocyte ratio can help to judge the outcome of patients with cardiac arrest and recovery of autonomic circulation after cardiopulmonary resuscitation. [ , ] patients with sofa score > (vs sofa score ≤ ) had a higher free iron level ( . μmol/l vs μmol/l, p = . ) ( figure ). we found a positive correlation between free iron level at h and changes of sofa score between h and h (r= . ic [ . ; . ]). out-of-hospital cardiac arrest is associated with a significant change of plasma free iron level. free iron level at admission is associated with short term outcome. further research is warranted to better determine the significance of such changes. the optimal level of arterial oxygen in the post-resuscitation period is unknown. recent studies show conflicting results in regard to hyperoxia and its association with survival after out-of-hospital cardiac arrest (ohca) [ ] . the aim of this trial is to study the association between early hyperoxia after ohca with return of spontaneous circulation (rosc) and -day survival. observational study using data from three swedish national registers (i.e. intensive care, cardiac arrest and national patient registries after a successful resuscitation, a systemic inflammatory response occurs, and the c-reactive protein (crp) level represents the degree of inflammation [ ] [ ] [ ] . this study examined the association between increased inflammation and early-onset pneumonia (eop) in patients treated with extracorporeal cardiopulmonary resuscitation (ecpr) after out-of-hospital cardiac arrest (ohca). this retrospective study included data of patients with ohca treated with ecpr admitted to st. luke's international hospital between april and april . the exclusion criteria were as follows: age < years, therapeutic hypothermia withdrawal due to death or circulatory failure, or sepsis as a suspected cause of cardiac arrest. patients were diagnosed with eop according to clinical signs and symptoms acquired after a hospitalization period of > h and within days of admission. the crp levels were measured daily from admission to day . we studied patients with a median age of years (interquartile range: - years). furthermore, ( %) patients were males, and the median time interval from collapse to adequate flow was ( - ) min. all patients received prophylactic antibiotics, and ( %) of them had favorable neurological outcomes (cpc, - ). eop occurred in ( %) patients, with a significantly higher crp level on day than that in those without eop ( . categorizing reasons for death after ecpr is important for comparing outcomes to other studies, assessing benefits of interventions, and better define this heterogeneous patient collective. a categorizing for death after cardiac arrest in both in-hospital (ihca) and outof-hospital (ohca) arrests has been proposed in non-ecpr patients by witten et al. here, we adopt this categorization to ecpr patients. single-center, retrospective, cohort study of patients without rosc after ihca or ohca and ecpr between and . patients with survival below hours were excluded. patients were allocated to one of five predefined reasons for death. results: va-ecmo patients were included (age . ± . , . % female, % ecpr, day survival . %). reasons for death for patients with va-ecmo for shock (survival %) and ecpr ( %) were: neurological withdrawal of care ( % vs %), comorbid withdrawal of care ( % vs %), refractory hemodynamic shock ( % vs %), respiratory failure ( % vs %), and withdrawal due to presumed patient will ( % vs %) ( figure ). the differences in reasons for death among the two groups were significant (p < . ), driven by withdrawal due to neuroprognostication, comorbidity and hemodynamic instability. categorizing death after va-ecmo into five categories is feasible. there are significant difference between patients with va-ecmo for shock and ecpr. interestingly, only a quarter of patients after ecpr died due to brain damage. introduction: scarcity of potential dead brain donors and the persistent mismatch between supply and demand of organs for transplantation has led the transplant community to reconsider donation after circulatory death (dcd) as a strategy to increase the donor pool. normothermic regional perfusion (nrp) by extracorporeal membrane oxygenation (ecmo) may be the most effective method for preserving abdominal organs in dcd, especially in liver transplantation [ , ] . a pitfall of this method is its complexity and the unavailability of this resource in some hospitals, especially in regional hospitals, where potential dcd donors may exist. aim of this study is to report the use of mobile ecmo team in controlled dcd. from june to november our group has worked as a mobile ecmo team for cdcd outside our center. portable equipment included cannulation material and the ecmo device. the transplant team consisted of transplant coordinator (anesthesiologist-intensivist, ecmo operator and organ extraction supervisor), cardiac surgeon (cannulation), interventional radiologist (cannulation) and one cardiovascular perfusionist (ecmo operator). twenty-five cdcd donations were performed. characteristics of donors and organs retrieved are summarized in figure . from cdcd, livers, lungs, kidneys were obtained. the evolution of grafts and receptors was favorable at day post-transplant. mobile ecmo teams may enable cdcd in hospitals without these resources, thereby increasing the pool of donors and optimizing graft outcomes. what is the useful coagulation and fibrinolysis marker for predicting extracorporeal membrane oxygenation circuit exchange due to intra-circuit thrombus? y izutani, k hoshino, s morimoto, k muranishi, j maruyama, y irie, y kawano, h ishikura fukuoka university hospital, emergency and critical care center, fukuoka-shi, japan critical care , (suppl ):p a thrombus formation is one of the most frequent and adverse complications during extracorporeal membrane oxygenation (ecmo) support. previous studies have reported that increased d-dimer is a useful predictor of thrombus formation within the ecmo circuit. the purpose of this study was to identify coagulation/fibrinolysis markers for predicting the replacement of ecmo circuit due to intra-circuit thrombus during ecmo support. fourteen patients who underwent veno-venous ecmo for acute respiratory failure between january and december were enrolled. these patients received a total of days of ecmo support. of these, days (times) on which the ecmo circuits were replaced was regarded as the replacement group, while the remaining days were considered as the non-replacement group. the several coagulation/fibrinolysis markers were routinely measured every day during ecmo support. we compared with the levels of these markers between two group to identify the most relevant marker for ecmo circuit replacement due to thrombus. the mean duration of ecmo support was ± days, and the mean number of ecmo circuit replacement was . ± . times per patient. ddimer, thrombin-antithrombin complex (tat), plasmin-α plasmin inhibitor complex (pic), and soluble fibrin (sf) were significantly higher in the replacement group rather than in the non-replacement group (p < . , respectively). according to a multivariate analysis, sf was the only independent predictor of ecmo circuit replacement due to thrombus. the odds ratio ( % confidence intervals) for sf ( μg/ml) was . ( . - . ). the area under the curve and optimal cut-off value were . and ng/ml for sf, respectively (sensitivity, %; specificity, %). from these results, we concluded that sf may be the useful marker rather than d-dimer for predicting the replacement of ecmo circuit due to intra-circuit thrombosis. inhomogeneity of lung elastance in patients who underwent venovenous extra corporeal membrane oxygenation (v-v ecmo)-a computed tomography scan study rd di mussi , ri iannuzziello , fm murgolo , fd de carlo , e caricola , na barrett , lc camporota , sg grasso università degli studi di bari "aldo moro", department of emergencies and organ transplant, bari, italy; università degli studi di bari "aldo moro", bari, italy; department of adult critical care, guy´s and st thomas´nhs foundation trust, king´s health partners, london, uk critical care , (suppl ):p in patients with acute respiratory distress syndrome (ards), nonaerated, poorly aerated, and normally aerated regions coexist to variable degrees in lung parenchyma. the recruitment maneuvers aim to reopen collapsed lung tissue. in a theoretical point view, this strategy may also prevent the normal aerated lung tissue hyperinflation [ ] . the objective of our study was to evaluate lung characteristics in terms of hounsfield units (hu), volume and elastance before and after a recruitment maneuver. in patients with severe ards who underwent v-v ecmo, computed tomography scans (ct-scans) at cmh o of continuous positive airway pressure (cpap) and cmh o were performed. the same ct image was selected at the two different levels of pressure. the distribution of lung opacities, in terms of hu, was classified using the "ucla" colour coding table (osirix image processing software, geneva, switzerland). correspondent lung regions of about voxels were selected. the quantitative analysis, in terms of volume air (vair) was performed with maluna software (version . ; maluna, goettingen, germany). elastance was calculated as the pressure(cmh o)/ vair (ml) ratio. results: see figure . lung inhomogeneity occurs also after recruiting maneuvers. our data confirm that the elastance of recruited lung regions is higher than the elastance of the normal aerated lung regions at low positive end-expiratory pressure (peep) (baby lung). on the contrary the "baby lung" frequently develops hyperinflation. the unpredictable pattern of distribution of volume after recruitment maneuverers may explain the controversial role of peep during the ards treatment. . formal recommendations on target, timing, and rate of at supplementation are lacking. we conceived this study to evaluate the effect of prolonged at supplementation in adult patients requiring veno-venous ecmo for respiratory failure on heparin dose, adequacy of anticoagulation and safety methods: before ecmo start patients were randomized to either receive at supplementation to maintain a functional at level between and % (at supplementation group) or not (control group) for the entire ecmo course. anticoagulation was provided with unfractionated heparin following a standardized protocol [ ] . the primary outcome was the dose of heparin required to maintain the ratio of activated partial thromboplastin time between . and . secondary outcomes were the adequacy of anticoagulation measured with anti-factor xa and the incidence of hemorrhagic and thrombotic complications and amount of blood products fig. b) . conclusions: this retrospective analysis was not able to show a survival benefit for additive pp to ecmo support in general. early initiation of pp could be an important factor for improving survival in this setting and should be considered in a randomized controlled trial for further evaluation. cause-specific mortality during extracorporeal membrane oxygenation, a single center review of medical records m panigada, d tubiolo, p properzi, g grasselli, a pesenti fondazione irccs ca´granda ospedale maggiore policlinico, intensive care unit, milano, italy critical care , (suppl ):p introduction: mortality during extracorporeal membrane oxygenation (ecmo) settles around % and the occurrence of bleeding during ecmo is associated with a high mortality rate. however, cause-specific mortality is rarely reported, probably due to the difficulty of its classification. the purpose of the study was to evaluate the agreement between two expert icu physician in the classification of the cause of death of patients supported with ecmo for either respiratory or cardiac support. methods: two intensive care unit (icu) expert staff physicians independently reviewed the entire medical records of all ecmo patients who died before icu discharge from january to september at fondazione irccs ca' granda, milan. they were asked to choose the cause of patient's death among six categories. in case of disagreement, a third expert adjudicated the case. the two reviewers were also asked whether, in their opinion, bleeding during the last hours contributed to death. elso definition of major bleeding [ ] during the last hours was also recorded for each patient. results: two-hundred and two patients were supported with ecmo of whom ( . %) died. most of these patients (n= , . %) died during ecmo. interrater agreement for cause-specific mortality between the two expert physicians was substantial (k . , se . , p< . ) of the discordant cases were categorized as refractory respiratory failure and as multiorgan failure and septic shock respectively. the distribution of cause-specific mortality is shown in figure . major bleeding (elso) was present in ( . %) patients, only in ( . %) of them bleeding contributed to death according to the reviewers. patients treated with early pp while ecmo showed a superior survival to patients treated with late pp or without pp while ecmo. optimal cut off value for duration of ecmo initiation to first pp was calculated using roc-analysis (auc = . ) and the youden-index. highest sensitivity and specificity for beneficial survival were achieved for a beginning of pp in < . days. (log rank= . ). pp: prone positioning p non-invasive mechanical ventilation in veno-venous extracorporeal membrane oxygenation j rilinger, v zotzmann, x bemtgen, pm biever, d duerschmied, c bode, dl staudacher, t wengenmayer heart center freiburg university, department of cardiology and angiology i, freiburg, germany critical care , (suppl ):p introduction: veno-venous extracorporeal membrane oxygenation (ecmo) support can be combined with a variety of different non-invasive ways to deliver oxygen to the patient's lung. several positive effects might be linked to this so called "awake ecmo". so far there is little evidence about indications and outcome of this approach. we report retrospective registry data on all ards patients treated with ecmo support at a university hospital between / and / . in a systematic review of medical records, we distinguished between patients with invasive mechanical ventilation (imv) from the initiation of ecmo therapy (imv group) and patients that received any kind of non-invasive oxygen supply (non-imv group). a total of patients could be analysed. ( . %) patients received non-imv ecmo support. patients receiving non-imv ecmo therapy showed severe underlying pulmonary disease and immunosuppression (fig. ) . these patients had higher rates of lung fibrosis, long-term oxygen therapy, pulmonary hypertension, renal insufficiency and immunosuppression (p< . ). of patients ( %) required imv during the hospital stay in average . ± . [ . - . ] days after ecmo initiation. reasons were hypoxia despite of ecmo, insufficient ecmo-flow, insufficient protective reflexes or patient agitation. patients with initially non-imv ecmo support showed a numerical but not significant lower icu and hospital survival ( . % vs. . %, p= . ). non-imv ecmo support was applied in patients with severe underlying pulmonary disease and/or immunosuppression. in a high proportion of patients the ventilation regime had to be switched from non-invasive to invasive. survival in this very selected cohort was low. in this retrospective analysis no evident benefit for a noninvasive ventilation strategy could be found. the high proportion of patients who switched from non-imv to imv therapy underlines the need for rigorous patient selection. intra-hospital transportation on extracorporeal membrane oxygenation (ecmo) -a single centre experience in ireland. z siddique, s o´brien, e carton, i conrick-martin mater misericordiae university hospital, department of critical care medicine, dublin, ireland critical care , (suppl ):p the objective of this study is to evaluate intra-hospital transportation of patients on extracorporeal membrane oxygenation (ecmo). it is a retrospective analysis of prospectively collected database, performed as part of ongoing quality improvement initiatives. the setting of this study is an -bed, combined surgical and medical adult intensive care unit (icu) located in a -bed hospital that serves as the national referral centre for cardiothoracic surgery, heart & lung transplantation and ecmo in ireland. we reviewed months of data (from to ) regarding patients admitted to our critical care unit who required intra-hospital transfer for diagnostic and/or therapeutic interventions. we also compared the data to available local guidelines. results: patients were transported on ecmo on a total of occasions; the most common indication being ct brain (table ) . ecmo cannulation sites were peripheral in patients, patients were centrally cannulated. median time from start of the transfer until the patient was returned to icu was minutes (range: - ). the ecmo console was placed on a dedicated ecmo trolley apart from two occasions where it was placed on the patient's bed. number of staff required for transport was between to ; with an icu consultant as team leader. ecmo specialist nurses were always present on the transport team. transfers were during normal working hours with happening on a weekend. a total of complications occurred during the transports, of underlying pulmonary disease or status of immunosuppression in ecmo patients without invasive mechanical ventilation which was significant and were not. the significant complication encountered was ventricular tachycardia in a v-a ecmo patient which required electrical defibrillation. no adverse events related to transport were seen following return to icu. in this single-centre study, we have demonstrated safe intra-hospital transport of ecmo patients. the use of local guidelines, appropriate personnel and performance during normal working hours is recommended. a novel approach for flow simulation in ecmo rotary blood pumps a supady , c benk , j cornelis , c bode , d duerschmied heart center freiburg university, cardiology and angiogiology i, freiburg, germany; heart center freiburg university, department of cardiovascular surgery, freiburg, germany; fifty technology gmbh, freiburg, germany critical care , (suppl ):p introduction: extracorporeal membrane oxygenation (ecmo) is used increasingly in critically ill patients suffering from acute respiratory failure, cardiogenic shock or cardiac arrest. however, this therapy can have deleterious side effects such as bleeding or clotting complications and hemolysis. these complications are particularly caused by physical stress acting upon the blood components while passing through the ecmo system, especially within the rotary pump. we here present a novel approach to simulate blood flows through rotary blood pumps used in current ecmo systems in order to better understand the genesis of these complications. geometries of the xenios dp (xenios ag, heilbronn, germany) rotary pump were reconstructed by ct-scans and manual measurements using computer-aided design (cad). the computational fluid dynamics (cfd) simulation was performed using the software preon-lab (fifty technology gmbh, freiburg, germany), which implements a mesh-free lagrangian method requiring minimal preprocessing of the cad data. the geometries are introduced to the simulation model as tessellated surfaces. five operating points have been specified by the rotation of the centrifugal fan and the corresponding inflow and outflow of blood. the blood is approximatively modelled as a newtonian fluid with a density of kg/m . preonlab allows detailed assessment of the blood flow while passing through the rotary pump including analysis of local flow rates, pressure gradients and shear stress acting upon the blood. dead zones in the fluid flow can be detected which gives reference points for optimizations of the pump design. for the first time, we demonstrate a novel approach for flow simulation in an ecmo rotary pump ( figure ). this approach may help better understand hemodynamics within the extracorporeal system to define optimal operating points or re-design components aiming to limit hemolysis, coagulation disorders and bleeding in seriously ill patients. one-year experience of bedside percutaneous va-ecmo decannulation in a territory ecmo center in hong kong km fong, sy au, pw leung, kc shek, hj yuen, sk yung, hl wu, so so, wy ng, kh leung queen elizabeth hospital, intensive care unit, hong kong critical care , (suppl ):p when veno-arterial extra-corporeal membrane oxygenation (va-ecmo) support can be terminated, arteriotomy wounds of the patients of are traditionally closed by open repair in the operation theaters. lots of manpower are involved and timeslots in operating theaters are scarce. transport of the critically-ill is risky. successful va-ecmo decannulation using percutaneous device called proglide has been reported and our group had adopted and modified this approach [ ] . methods: this is a retrospective study analyzing the one-year experience of bedside va-ecmo decannulation. our institution is a -bed tertiary ecmo referral center in hong kong. our first bedside decannulation was performed in november , and since then, this practice had replaced the traditional open repair, unless contraindicated. data from november to october were analyzed. in the study period, patients received va-ecmo. survived to decannulation and received bedside percutaneous decannulation. their median age was ( - ). the default arterial catheter size was fr, with fr in cases and fr in one. five ( %) failed percutaneous closure and they were subsequently surgically repaired without extra corporeal life support (ecls) continues to be associated with high mortality rates. our ability to predict outcome prior to initiation ecls remains limited. here we take a single cell rnaseq approach in an effort to identify novel immune cell types that are associated with-and may contribute to-survival on ecls. whole genome transcriptomic profiles were generated from~ , peripheral blood monocytes obtained from patients at the time of cannulation for veno-arterial ecls (va-ecls). within each subpopulation, differential gene expression analysis was performed to identify new markers associated with survival. findings were validated in a additional cohorts by flow cytometry. surviving patients had significantly higher proportions of cd + nkt cells (cd + /cd + /cd -/cd + ) that were cd + (p = . , fdr < . ) ( figure ). to validate this observation, we performed fc analysis of a second cohort of patients. for each patient, we quantified the proportion of cd + nkt cells that were cd + . using the median proportion as the cutoff, we again found that a high proportion of cd + cells among cd + nkt cells was predictive of hour survival (p= . ). we noted that while high levels of cd + cells among the cd + nkt cells was protective in this cohort of va-ecls patients, this relationship did not hold for patients with sepsis. as only a few the va-ecls patients were septic, we analyzed a third cohort of septic ecls patients. we observed that high levels of cd + cells among the cd + nkt populations was not protective in this population. the proportion of cd + nkt cells that are positive for cd is predictive of survival among patients undergoing va-ecls for noninfection related indications. introduction: the use of calcium sensitizers has grown enormously in the last decade, probably due to their interesting pharmacodynamic properties. levosimendan (ls) is frequently administered in patients under mechanical circulatory support. we performed a retrospective evaluation of patients treated with ls prior to weaning from mechanical support. this evaluation was combined with a review of the literature. a query of our icu patient data management system revealed patients receiving ls prior to or during vad/ecls support. outcome data were obtained from the patients medical records. of our patients, % was successfully weaned off ecls. fourteen patients ( %) died before being discharged of whom while on ecls support. of the weaned patients, died afterwards. of the converted patients needed subsequent veno-venous ecls support for right ventricular support after the implantation. survival to discharge ratio for the whole group was %. more detailed demographic results can be found in table . a pubmed search using the terms "(ecmo or ecls) and ls and weaning" resulted in publications which dealt specifically with weaning of ecls support. several weaning approaches are available, however poor outcome has remains a problem. some recent studies show a possible beneficial effect of ls infusion prior to weaning from ecls. however most of these studies are retrospective or observational at best. because ls is primarily reserved for the most severe cases, outcome interpretation is difficult. overall weaning success ranges from %- % and variation is very dependant of inclusion criteria. the calcium sensitizer ls can be used when weaning off patients from ecls, certainly given its low incidence of complications. future, large randomized trials are however needed in order to confirm this strategy. cardiogenic shock is well described in newly diagnosed pheochromocytoma, and crisis may be precipitated by hemorrhage into tumour. v-a ecmo represents a rescue therapy in a subset of these patients refractory to medical management, facilitating cardiac recovery and subsequent definitive surgery. consent to publish: written informed consent for publication was obtained from the patients. during a spontaneous breathing trial respiratory mechanics can worsen, and respiratory muscle effort can increase, leading to respiratory muscle fatigue, pump failure, hypercapnia and an unsuccessful weaning from mechanical ventilation. this case report discusses the possibility of applying extracorporeal co removal (ecco r) to reduce respiratory muscle effort in a liver transplant recipient who already failed three weaning attempts from mechanical ventilation. the ecco r membrane lung was integrated into a conventional renal replacement therapy circuit and blood flow was increased from to ml/min. measurements of respiratory mechanics (including esophageal pressure, as shown in fig. ) were used to assess the reduction of respiratory effort before and during the application of ecco r. was delivered through a fr-double-lumen-cannula; ml/min blood-flow with lt oxygen sweep-gas-flow and aptt . - baseline were maintained (iv-heparin). in all cases respiratory and metabolic parameters improved without complications ( figure ). ecco r-crrt facilitated extubation ( out imv pts). in out of pts at risk of niv failure, it avoided imv. treatment mean duration was ± hours, mean lenght of icu stay was ± days. all patients survived to the treatment, nevertheless patients died due to irreversible multiple mof. in our aecopd series prismalung®-prismaflex® facilitated weaning from imv and avoided intubation in patients at risk of niv failure without complications. these positive results may be related to minimal invasiveness of the low-flow device used and may constitute the rationale for a larger randomized controlled trial. consent: written informed consent for data publication has been obtained. extracorporeal the primary outcome findings from the supernova trial [ ] demonstrated that the use of extracorporeal carbon dioxide reamoval (ecco r) allows a reduction in tidal volume (tv) to ultraprotective levels (≈ ml/kg predicted body weight or pbw) during mechanical ventilation in ards patients without significant increases in the arterial partial pressure of carbon dioxide (paco ). unfortunately, it was not feasible to directly measure ecco r rates during the trial. we used a mathematical model of whole-body oxygen (o ) and carbon dioxide (co ) transport and biochemistry [ ] to calculate ecco r rates that permit a fit to the data reported for hemolung (alung technologies) and ila (novalung)/cardiohelp (getinge) devices in the supernova trial [ ] . the mathematical model was calibrated under baseline conditions where patients were mechanically ventilated at a tv of ml/kg pbw in the absence of an ecco r device; the o consumption rate, co production rate and pulmonary shunt fraction were adjusted to match the measured baseline arterial partial pressure of o and paco . assuming all baseline parameters were fixed, tv was then reduced to . ml/kg pbw and the mathematical model predicted the ecco r rate to the change in the paco level. model predictions for the devices are shown in table . these predictions suggest that ecco r rates for ila/cardiohelp devices were approximately twice those for hemolung devices during the supernova trial. these results may be useful to evaluate the expected performance of novel ecco r devices. efficiency and safety of a system crrt plus ecco r to allow ultraprotective ventilation protocol in patients with acute renal failure f maldarelli despite renal function replacement techniques (crrt), a patient who develops acute renal failure(aki) in intensive care unit (icu) has a mortality rate of - %. this risk is partly due to the adverse effect of aki on other organs than the kidney. respiratory complications are frequently associated with the development of aki. new machines combining crrt with a carbon dioxide removal membrane (ecco r) allows the setting up of an ultra-protective ventilation ( ml/kg of predicted boby weight (pbw)) to reduce any lung damage from mechanical ventilation (mv). the reduction in tidal volume (vt) is associated with a decrease in lung damage partly triggered by aki. we evaluated the efficacy of a combined system crrt+ecco r to reduce the vt to ultraprotective values in patients with acute respiratory failure and aki. ards is a syndrome with high morbidity and mortality. an emerging treatment option is ecco r, but the benefit its remains unclear. we assess different degrees of ecco r and varying dead space (ds) on ventilator settings in order to minimize mechanical power. we calculated mechanical power as ( ) power=rr*{Δ〖vt〗^ *[ / *el+rr*( +i:e)/( *i:e)*r]+ Δvt*peep} (el: system elastance, r: airway resistance, peep: positive end expiratory pressure, i:e: inspiratory to expiratory ratio). we calculated the combination of respiratory rate (rr) and tidal volume (vt) ("optimal rr" and *optimal vt*) leading to minimal applied power for a stable carbon dioxide elimination of ml/min (vco ) for two scenarios: ) variation of physiological ds from to % of vt at a fixed rate of eccor . ) variation of ecco r of either , , or ml/min at a fixed physiological ds of %. the alveolar ventilation (va) necessary to eliminate the vco was calculated as ( ) va= (-vco *σ_co *r*t*( +k_c ))/(vco /q-p_vco *σ_co *r*t*(( +k_c ))/ ) σco : co solubility in blood, r: gas constant, t: temperature. pvco : venous partial pressure, kc: function of ph ( . for a ph of . ), q: blood flow [ l/min]). increasing ds from to % increases the minimal mechanical power from . to . j/min, primarily caused by an increase of optimal vt ( - ml). optimal rr was only slightly increased ( . - . /min, figure panel a). for varying ecco r removal, necessary ventilation ranges from . to . l/min. this predicts a minimal power between . and . j/min with an unchanged optimal vt ( - ml) and an increasing optimal rr ( . to . /min ( figure panel b)). in order to minimize mechanical power, increasing shunt or co production should be met with increases in rr while increases in ds should be met with increases in vt. our results indicate that during ecco r, mechanical power and thus risk for lung injury can be minimized with higher vt compared to conservative ventilation strategies. validity of empirical estimates of physiological dead space in acute respiratory distress syndrome jd dianti, eg goligher, as slutsky university of toronto, interdepartmental division of critical care medicine, toronto, canada critical care , (suppl ):p increased physiological dead space fraction (v d /v t ) is a hallmark of the acute respiratory distress syndrome (ards) and has been shown to predict ards mortality. v d /v t is also important in estimating the reduction in tidal volume (v t ) and driving pressure (Δp) with extracorporeal co removal (ecco r). v d /v t can be measured with volumetric capnography but empirical formulae using the patient's age, weight, height, gender and paco have been proposed to estimate v d /v t based on estimates of co production (v co ). the accuracy of this approach in critically ill patients, however, is not clear. secondary analysis of a previously published trial [ ] in which v d /v t and v co were measured in ards patients. estimated dead space fraction (v d,est /v t ) was calculated using standard formulae. agreement between methods was evaluated by bland-altman analysis. the predicted change in Δp with ecco r was evaluated using both measured and estimated alveolar dead space fraction (v dalv /v t ). results: vd,est/vt was higher than measured vd/vt, with a low correlation between the (r = . ). vco was underestimated by the predicted approach (table ) , accounting for % of the error in estimating vd/vt. the expected reduction in Δp with ecco r using vdalv/ vt was in reasonable agreement with the expected reduction using introduction: acute respiratory distress syndrome (ards) is a common condition in critically ill patient. however neuromuscular blockers (nmb) result controvertial in early treatment of ards [ ] . we ought to search systematically and realize a meta-analysis on the matter. an electronic search of randomized clinical trials in adult patient treated with early neuromuscular blockers compared without neuromuscular blockers in ards. the primary objective of the analysis was the mortality at to days. secondary endpoints included mechanical ventilation free days, icu acquired weakness and barotrauma. the search obtained studies for the analysis [ ] [ ] [ ] [ ] [ ] [ ] (figure ). the early use of neuromuscular blockers in ards showed no increase in mortality, but the results should be taken with caution. there was no differences in mechanical ventilation free days. barotrauma is less with the use of nmb. ultrasound is fairly sensitive in the detection of lung infiltrates in patients with hematologic malignancies. in patients with pneumonia requiring intensive care (icu) admission, we hypothesise that abnormal right ventricular (rv) function is associated with an increased -day mortality. rv dysfunction in critically ill patients has a well-known association with adverse outcomes [ ] . however, its impact on mortality in patients with pneumonia has not been directly studied. patients admitted to the queen elizabeth hospital birmingham icu between april and july with a diagnosis of pneumonia who had a formal cardiologist tte were included. abnormal rv function was defined by either depressed function, dilated size or moderate to severe risk of pulmonary hypertension (phtn). abnormal lv function was defined by an lv ejection fraction £ % or grade ii or more diastolic dysfunction. patients with a clinical suspicion of pulmonary embolism were excluded. the primary outcome was -day mortality. continuous data is presented as median (iqr). categorical data is presented as % and analysed using a chi-squared test. results: patients were admitted to icu with pneumonia, of which ( %) had a tte. patients were % male, had a median age of ( - ) and -day mortality of %. abnormal rv function was present in % (n= ), with % depressed, % dilated and % with moderate to severe risk of phtn. rv dysfunction was associated with an increased -day mortality compared to normal rv patients ( % vs. %, p< . ). lv function was abnormal in % (n= ) and was not associated with a higher -day mortality compared to normal lv patients ( % vs %, p = . ). rv dysfunction was associated with a higher -day mortality than lv dysfunction ( % vs %, p = . ). conclusions: this is one of the first studies to demonstrate that abnormal rv function is associated with an increased mortality in icu patients with pneumonia. interestingly, abnormal lv function was not associated with an increased mortality. rakuno gakuen university, anesthesiology, hokkaido, japan critical care , (suppl ):p we previously reported a simple correction method of estimating pleural pressure (ppl) by using central venous pressure (cvp) and that it can be used to estimate ppl and transpulmonary pressure in pediatric patients with respiratory failure. however, it remains unknown that this method can be applied to patients with various levels of chest wall elastance and/or intravascular volume. the objective of this study is to investigate whether our method is accurate in various conditions of chest wall elastance and intravascular volume. the study was approved by the animal care and use committee of rakuno gakuen university. ten anesthetized and paralyzed pigs ( . ± . kg) were mechanically ventilated and subjected to lung injury by saline lung lavage. each pig was subjected to different intravascular volume and different intraabdominal pressures; in each condition, the accuracy of our method was tested. specifically, airway flow, airway pressure (paw), esophageal pressure (pes), and cvp were recorded in each condition, then changes in pes (Δpes) and Δppl calculated using a corrected Δcvp (cΔcvp-derived Δppl) were compared. cΔcvp-derived Δppl was calculated as κ × Δcvp, where κ was the ratio of the Δpaw to Δcvp during the occlusion test. means and standard deviations of the two variables that reflect Δppl (Δpes and cΔcvp-derived Δppl) in all pigs with all conditions were . ± . and . ± . cmh o. the bland-altman analysis for the agreement between Δpes and Δcvp showed a bias of - . the activity and functionality of the diaphragm are difficult to measure in patients ventilated in intensive care. ultrasound can be a useful tool for monitoring diaphragm muscle activity during different ventilation modes. few data currently exist on diaphragm muscle activity in critically ventilated patients [ ] . our goal is to evaluate the respiratory muscular work of the diaphragm with different settings of the respirator by means of an ultrasound scan. the ultrasound assessments of the diaphragm were performed with a mhz linear probe at the apposition zone. we measured the thickening of the diaphragm with the respiratory acts, through the thickening fraction (thickening fraction, tf), defined as:tf = (tdimax -tdimin / tdi min)% tdimax: diaphragm thickness at the end of inspiration (maximum thickness) tdimin: diaphragm thickness at the end of expiration (minimum thickness). ventilatory support was divided into classes: -spontaneous breathing (sb) or continous positive airway pressure (cpap); -pressure support ventilation (psv) with low pressure support ( - cmh o); -psv with high pressure support (> cmh o); -controlled mechanical ventilation (cmv). a total of assessments were performed in patients. the evaluations were all possible at the right hemidiaphragm, while on the left they were not possible in % of the cases. the median tf (iq range) of the ventilation classes was respectively: % ( - %) in sb / cpap; % ( - %) in low-psv; % ( - %) in high psv; and % ( - %) in cmv. the kruskal-wallis test confirms a significant difference between the groups (p < . ). the ultrasound of the diaphragm can be a valid tool for monitoring respiratory muscle activity during mechanical ventilation. introduction: extubation failure is defined as reintubation after hours of extubation in mechanically ventilated critically ill patients. it is associated with morbidity and mortality. the aim of our study was to assess reintubation rates in a busy district general hospital and evaluate the impact of high flow nasal oxygen therapy (hfno) on reintubation rates. we performed a retrospective observational study looking at patients admitted to our bedded level critical care unit ( patients a year) for a period of years between st november and st october . we included patients over years of age who were mechanically ventilated and length of stay was greater than hours. exclusions were age < years, tracheostomy and patients requiring ventilation for < hours. data was collected from ward watcher, a sicsag database and electronic patient records. our study failed to show any impact of hfno on reducing extubation failure. further work is needed to develop a standardized approach to weaning and to consider routine application of noninvasive ventilation to reduce reintubation rates [ ] . fig. (abstract p ) . the bland-altman analysis for the agreement between Δpes and cΔcvp-derived Δppl in various conditions. low: low intravascular volume, normal: normal intravascular volume, high: high intravascular volume, abd-: without an abdominal compression band, abd+: with an abdominal compression band oral endotracheal intubation is common to critically ill patients in intensive care unit. oral care for an intubated patient is important to maintain the moisture of oral mucosa. also, the securement method of oral endotracheal tube developed from cloth tape to commercial tube holder. training powerpoint and video for microteaching was prepared to train up icu nurses to perform the new practice. demonstration and re-demonstration was arranged to assess skills of every nurse. afterwards, each nurse answered a quiz to evaluate the understanding of oetth and its special techniques in application. questionnaire was designed to collect the feedback from all nurses too. the result showed there was nurses ( %) out of nurses achieved full marks in the post-quiz which demonstrated their full understanding of the use of oral ett holder and its nursing care. about the feedback from nurse, % of nurses claimed that they were confident in using the new oetth in clinical setting after training. % of nurses agreed in time-saving of nursing care routine with the use of an oetth. however, only % of nurses agreed that the oetth is effective in prevention of oral mucosa injuries and another % of nursing staff disagreed on its function in improving the patient's oral care. in conclusion, some of the nurses did not agree the prevention of oral mucosa injuries by the new securement method with oetth while some nurses welcomed the new oetth as more easy and effective in oral care to intubated patients. execution of percutaneous dilatational tracheostomy using the standard laryngeal mask airway for ventilation: a prospective survey study g gagliardi , v gagliardi , c chiani , g laccania , f michielan aulss -veneto, anesthesia and intensive care, adria, italy; aulss -veneto, university of padua, adria, italy; aulss -veneto, anaesthesia and intensive care, adria, italy; aulss -veneto, anaesthesia and intensive care, padua, italy critical care , (suppl ):p we fulfilled a survey study dealing with bronchoscope-guided percutaneous dilatational tracheostomies (pdt), using the classic laryngeal mask airway (lma) for the airway management [ ] . the aim was to verify the safety and the effectiveness of the aforementioned procedure methods: we performed an observational prospective survey study enrolling patients hospitalized in the intensive care unit. before performing the tracheostomy, the endotracheal tube has been replaced by the laryngeal mask airway. arterial blood gases, ventilation pressures and tidal volumes have been monitored, registered and compared. the median peak inspiratory pressure has been detected stable in all patients. furthermore, during the ventilation with the laryngeal mask, the tidal inspiratory and expiratory volume difference observed between before and after the bronchoscope positioning, has shown a statistically significant variation. finally, in all cases etco , spo . , pao , and blood ph values persisted within the normal range. the standard lma provides for a reliable airway management and allows an effective ventilation while performing the pdt. once positioned in the supraglottic zone, the lma does not need to be moved throughout all the pdt performance, avoiding risks of displacement, glottic harm and airway device damage, and permitting an easy handling of the bronchoscope, which gives an appropriated visualization of the trachea and a more efficient aspiration. in consequence to the large internal diameter of the lma tube, ppeak has continued to be stable in all patients, providing for minor resistance and inspiratory work. eventually, no late complications, such as tracheal stenosis and infections, have occurred. tracheostomies are the most common surgical procedure performed on critically ill patients. randomized control trials comparing tracheostomy timing in intensive care patients have been equivocal. in order to perform non-urgent tracheostomy in our icu, consent is required from the patient or a formal guardian appointed ad hoc by the courts. since tracheostomies are practically the only elective surgery performed in the critically ill, icu requested guardianship almost always indicates a clinical decision to perform tracheostomy. as appointing a guardian and arranging a tracheostomy takes about a week, the decision to appoint a guardian offers a unique "intention to treat" opportunity to evaluate outcomes in patients for whom tracheostomy is planned. we performed a retrospective analysis over years on patients for whom guardianship was sought excluding those requiring urgent tracheostomy and those with a do-not-resuscitate order. patients were divided according to outcome (tracheostomy, extubation or death prior to tracheostomy) and compared. guardianship was sought for ventilated patients. a decision to withhold tracheostomy was made for patients, who were excluded, leaving patients for analysis. tracheostomy was performed for / ( %) patients, / ( %) were extubated and / ( %) died while waiting for tracheostomy (from nonairway related reasons). tracheostomy was performed on mean ventilation day ± . comparing extubated patients to those who had tracheostomy (table) shows similar demographics, but significantly lower mortality and hospital length of stay. a significant proportion of patients initially planned for tracheostomy were successfully extubated. despite demographic similarities, mortality in this group was significantly lower than for patients undergoing tracheostomy. for a selected subgroup of possibly difficult to characterize patients, delaying tracheostomy may be beneficial. figure ). ptis were analysed by speciality and by outcome. complications occurred in cases (incidence . %). there were cases of subcutaenous emphysema, pneumothorax (occuring d post procedure) and case each of stoma and suture site infection. there was unplanned cannula change within days of insertion. % of cases had cuff inflated on discharge from icu. handover of care was suboptimal; follow up care plans were documented in % of cases. a supervising consultant was present for all ptis. there was a trend of increased insertion by consultant and increased reliance on theatre, with corresponding decrease in the number inserted by trainees. pti in our training icu appears safe with low incidence of complications and good senior support for tracheostomy insertion. emphasis must continue on training junior intensivists in pti. transition of care beyond icu requires further work where currently there is suboptimal handover of care and safety netting for non-icu colleagues. supplemental oxygen administration is ubiquitous in the critical care environment, yet evidence is mounting for the deleterious effects of hyperoxia [ ] . concerns over the adverse effects from hypoxaemia often exceed those of hyperoxaemia in developing world settings, and inconsistent availability of blood gas monitoring may limit judicious oxygen titration. the aim of this project was to audit oxygen delivery practice and introduce qi measures to avoid excess oxygen delivery in a tertiary icu in lusaka, zambia. a prospective snapshot of ventilatory parameters were recorded for critically ill patients over a -week period, including positive end expiratory pressure (peep), fio , and time-course spo . systematic education was provided through group and one to one tutorials to empower nursing and medical staff to titrate oxygen safely and appropriately. repeat data collection was then performed over weeks. initially / patients ( %) were over-oxygenated, as defined by fio > . and spo consistently > %. / patients with an fio of > . had peep ≤ cm ( %). no patient had a pao recorded in the past hours. education was provided as well as implementation of unit protocols above all patient beds documenting a stepwise approach to titration peep and fio . post intervention fewer patients were over-oxygenated: / ( %) had fio > . and spo consistently > %, and / with an fio > . ( %) had a peep ≤ cm. in addition, / ( . %) had a pao recorded within hours. this qi project has shown that nurse engagement and systematic education to titrate fio and peep can be achieved in a resource poor setting and may decrease the incidence of hyperoxia in critically ill patients. availability of blood gas monitoring and knowledge of interpretation was a major barrier to oxygen titration tracheal intubation (ti) in adult burn patients might be unnecessary in to % of cases [ , ] . in pediatric burn patients, there is little data on both the rate of ti and the rate of early extubation [ ] . it has been common practice for a child with a facial burn and/or a suspected airway injury to be intubated early due to the risk of losing airway patency. however this risk should be mitigated against the potential risks of ti and mechanical ventilation in children. therefore the aim of this study was to describe the airway status of child burn victims taken in charge of in our pediatric burn intensive care unit. focused on patients arriving with ti, we investigated the rate of early extubation. in addition we compared non intubated patients with those with prolonged ti. this retrospective study described a cohort of patients hospitalized between and . data was retrospectively recorded from the patient's paper clinical chart. the mean age of our patients was . ± . years [mean±sd] with an average burn area of ± %. % had scald burns and % had facial burns. % of the children were admitted in the burn icu with ti. for % of them, tracheal tube was removed within the first hours after admission. the probability of prolonged ti increased independently with the burned skin area (bsa) (p < . ), the presence of facial burns (p = . ), and in case of flame burns (p = . ) ( figure ). among patients with more than % bsa, % were intubated more than h. among patients with less than % bsa, . % were intubated more than h. according to our retrospective data, it seems appropriate to intubate children with % and more bsa, while for patient with less than % bsa, it might be relevant to seek guidance from physician of the nearest burn center. under % bsa, ti seems rarely required. an analysis of the predictive applicability of initial blood gas parameters for the need for intubation and the presence of inhalation injury in patients with suspected inhalation injury c pirrone , m chotalia , t mangham , r mullhi , k england , t introduction: we hypothesise that initial blood gas parameters have a good predictive applicability in detecting the need for intubation and the presence of inhalation injury in patients with suspected inhalation injury. to the best of our knowledge, this has not been directly studied in the literature. patients with suspected inhalation injury admitted to the icu at queen elizabeth hospital, birmingham between april and may were included. the initial blood gas parameters analysed were pao (kpa), paco (kpa), ph, carbon monoxide level (cohb; %) and pao /fio (pf) ratio. receiver operator characteristics (roc) for these parameters were plotted against the need for intubation for more than hours and the presence of inhalation injury as detected by bronchoscopy and laryngoscopy. area under the curve (auc) for each parameter was calculated. results: patients were admitted with suspected inhalation injury to the icu. % were intubated for more than hours. of patients who were intubated, % had inhalation injury as indicated by bronchoscopy or laryngoscopy. table outlines the auc for initial blood gas parameters in detecting the need for intubation for more than hours and the presence of inhalation injury. ph was the parameter with the most prominent auc, with reverse correlation indicating fair accuracy. no clear inflection point was identified, although all patients with ph < . required intubation and had inhalation injury. paco had a fair predictive applicability in detecting the need for intubation. pf ratio, pao and cohb had poor accuracy. conclusions: initial blood gas parameters had a broadly poor predictive applicability for the need for intubation and the presence of inhalation injury in patients with suspected inhalation injury. severe acidosis (ph < . ) was the most useful blood gas parameter. clinicians should be cautious in using blood gas parameters alone to inform intubation decisions. lung cancer surgery is associated with a high rate of pulmonary complications including ards and mandates lung protective ventilation strategies [ , ] . such strategies include non-intubated video assisted thoracic surgery (nivats) with spontaneous breathing [ ] . currently neither data on respirator settings nor on gas exchange have been reported for applying the latter. this data constitutes a prerequisite for meaningful evaluating the respiratory consequences of non-intubated spontaneous breathing during lung cancer surgery. the aim of this case series was for the first time providing such data from lung cancer surgery including pneumonectomy. during a month period patients without contraindications [ ] scheduled for video assisted thoracic surgery (vats) for non-anatomical and anatomical lung resection including one pneumonectomy (px) were offered non-intubated spontaneous breathing. all patients gave informed written consent to the procedure as well as for analysis and publication of data. anaesthetic management included target controlled infusion of propofol and remifentanil, laryngeal mask airway, and pressure support ventilation. we present early data that early trials of cuff deflation within hours of tracheostomy insertion can be achieved using a standardized protocol. its impact on length of stay, duration of ventilation and patient-centered outcomes needs to be investigated in larger multi-centre trials. preventing underinflation of the endotracheal tube cuff with a portable elastomeric device. a randomized controlled study je dauvergne , al geffray , k asehnoune , b rozec , k lakhal hopital laënnec -chu de nantes, service d´anesthésie-réanimation, nantes, france; hotel-dieu -chu de nantes, service d´anesthésieréanimation, nantes, france critical care , (suppl ):p the management of the endotracheal tube cuff pressure (p cuff ) is routine practice for critical care nursing staff. underinflation could lead to ventilator-associated pneumonia [ ] whereas overinflation exposes to tracheal damage [ ] . multi-daily check and adjustment is recommended to ensure that p cuff lies between and cmh o [ ] . to automate this task some devices exist but may be inconvenient, bulky and/or ineffective. their use is not supported by guidelines. a portable elastomeric device could be appealing for p cuff automated regulation. this prospective randomized controlled study tested whether the tracoe smart cuff manager tm reduced the rate of patients undergoing ≥ episode of underinflation (p cuff < cmh o), as compared with routine manual p cuff adjustment. monocentric, randomized controlled study. patients with acute brain injury and receiving mechanical ventilation were prospectively allocated to one of the two arms: manual reading and adjustment of p cuff at least every h (routine care) or adjunction of the smart cuff manager tm (intervention). this study was approuved by an institutional review board. among randomized patients (routine care in , smart cuff manager tm in ), measurements were performed in h. with routine care, a higher rate of patients experienced at least one episode of underinflation ( . vs. . %;p< . ). episodes of underinflation episodes ( % vs. %;p< . ) and manual adjustments ( % vs. %;p< . ) were more frequent with routine care. for overinflation, there was no between-arms difference (p> . ). the adjunction of continuous p cuff control with the tracoe smart cuff manager tm reduced the incidence of p cuff underinflation as compared with manual intermittent adjustments. overinflation was not promoted by this device. direct laryngoscopy as a technique for tracheal intubation is a potentially lifesaving procedure that healthcare professionals in a variety of fields are taught. however, this skill is challenging to acquire and difficult to maintain. poorly performed intubation technique can lead to potentially serious complications [ ] . the intersurgical iview video laryngoscope is a new intubation tool which may have advantages over direct laryngoscopes, such as the macintosh, in the hands of novice personnel. a prospective randomized counterbalanced trial of medical students, who did not have previous airway management experience, was conducted. each student received brief didactic teaching,following this, participants were directly supervised performing laryngoscopy and intubation using the macintosh and iview devices in an alternating pattern. students were permitted up to three attempts to successfully intubate under four conditions, three laryngoscopy conditions using alaerdal intubation trainer and one using a laerdal simman manikin. there was no significant difference in the success rate of intubation or time to intubation between the two devices. the iview outperformed the macintosh in time to intubation in the normal airway in the final scenario, once students gained experience with both devices. no significant difference was found in the number of optimisation manoeuvres, or intubation attempts between groups. areas where the iview outperformed the macintosh included severity of dental trauma and participants' perception regarding ease of use ofthe device. the iview may prove to be a useful teaching tool for novice personnel who are acquiring the skills of tracheal intubation. patients with a primary pulmonary pathology were more likely to respond to aprv. this association has not been described before and warrants further multi-centre exploration in a larger patient group. introduction: airway suctioning is common during mechanical ventilation, using either an open endotraqueal suctioning or closed endotracheal suctioning (ces). closed circuits were developed to prevent arterial desaturation and atelectasis associated to ventilator disconnection. however, ces may cause substantial loss of lung volume. the purpose of this study was to investigate the effects of a compensation method to prevent the loss in aeration during ces. the suctioning technique was performed for seconds, negative pressures limited at mmhg. closed suction catheters with fr (halyard health, georgia, eua) were used. electrical impedance tomography (eit) monitoring and arterial blood gas were collected. a nihonkoden mechanical ventilator (nkv , california, eua) was applied, having a newly developed algorithm for suctioning which overcomes any pressure loss during suctioning (inlinesuction-app). when activated, the app delivers pcv ventilation, adding cmh o of end-expiratory pressure above peep, and delivering driving pressures of cmh o. results: pigs ( ± . kg) with injured lungs and mechanically ventilated. we tested the aspiration procedures using low peep= cmh o, or high peep=± . cmh o with v t o), whereas maintenance of compliance was observed when the app was on (from . ± . ml/cmh o to . ± . ml/cmh o. blood gas in a representative animal showed a drop in pao when app was off (from , to mmhg after min, and to mmhg after min) ( figure ). with app on the pao changed from (pre-suction), to ( min), to mmhg ( min). the new nksoftware, delivering pcv ventilation during suctioning, could prevent atelectasis and functional loss associated to the procedure. tyrosine kinase inhibitor: an effective tool against lung cancer involvement responsible for acute respiratory failure in icu y tandjaoui-lambiotte patients with advanced-stage non-small-cell lung cancer have high mortality rates in the intensive care unit (icu). in the last two decades, targeted therapies have changed the prognostic of patients with lung cancer outside the icu. the fast efficacy of targeted therapies led some intensivists to use them as rescue therapy for icu patients. we performed a national multicentric retrospective study with the participation of the grrroh (groupe de recherche en réanimation respiratoire en onco-hématologie). all patients with non-small-cell lung cancer admitted to the icu for acute respiratory failure between and were included in the study if a tyrosine kinase inhibitor was initiated during icu stay. cases were identified using hospital-pharmacies records. the primary outcome was overall survival days after icu admission. results: thirty patients (age: +/- years old) admitted to a total of icus throughout france were included. seventeen patients ( %) were nonsmoker. adenocarcinoma was the most frequent histological type (n= , %). most patients had metastatic cancer (n= , %). epithelial growth factor receptor mutation was the most common oncologic driver identified (n= , %). during the icu stay, ( %) patients required invasive mechanical ventilation, ( %) catecholamine infusion, ( %) renal replacement therapy and one ( %) extracorporeal membrane oxygenation. eighteen patients ( %) were discharged alive from icu and ( %) were still alive after days (see figure) . moreover, patients ( %) were alive one year after icu discharge. despite a small sample size this study showed that, in the context of lung cancer involvement responsible for acute respiratory failure, the use of tyrosine kinase inhibitor should not be refrained in patients with severe condition in icu. the burned patient is one of the most complex patients whith a very high mortality. those patients with inhalation injury have a worst prognosis, typically associated with respiratory complications. the aim of our study is to evaluate the mortality of burn patientes with inalation injury in a critical burn unit. a prospective, observational and descriptive study was conducted over a period of years. inhalation injury was defined with these criteria (≥ ): history of injury in an enclosed space, facial burns with singed nasal hair, carbonaceus sputum and stridor. if they were intubated it was diagnosed by bronchoscopy. demographic data, tbsa, absi, baux score, apache ii, sofa, mechanical ventilation (mv), complications, length of stay, hospital course and mortality data were collected. results: burns patients were admitted. % ( patients) had inhalation injury. mortality among patients with inhalation injury was , % ( patients). most patients were men and those who died were older and with higher severity scores (fig. ) . we found no significant differences between groups in the need for mv ( % vs. %) or in the percentage of tracheostomy performed ( . vs. . ). however, patients who died had more respiratory complications like ards, and also shock, renal failure and need of renal replancement therapies although infectious complications were similar in both groups. there was no statistically significant difference in volume used during initial resuscitation in the different groups. patients with inhalation injury who died had higher severity scores at the begining. although there were no differences in the need for mv patients who died had more respiratory complications as well as shock, renal failure and need of rrt, but no infectious complications.the volume used during inicial resuscitation, that was always related to the prognosis, was similar in both groups. further studies are needed to see if this greater initial severity corresponds to the degree of inhalation. aerogen, medical affairs, galway, ireland; aerogen, science, galway, ireland critical care , (suppl ):p patients with acute exacerbations such as asthma are prescribed aerosol therapy from presentation in the emergency department to progression through to the intensive care unit. however, the variability in dose delivery to the lung across the possible patient interventions is not well characterized. here, we assess the predicted lung dose of a bronchodilator in a simulated spontaneously breathing adult patient via both facemask and nasal cannula, and via tracheostomy during mechanical ventilation. a standard dose of . mg in . ml salbutamol was aerosolized using the aerogen solo nebulizer (aerogen, ireland). for facemask testing, the nebulizer was used in combination with the aerogen ultra with lpm supplemental oxygen flow. for nasal cannula testing, the nebulizer was used in combination with the airvo system (fisher and paykel, nz) system at both and lpm gas flow rate. tracheostomy-mediated ventilation was assessed in combination with a hme, with the nebulizer placed between the hme and the tracheostomy tube. international standard iso adult breath settings (vt ml, bpm , i:e : ) were used across all tests, and generated using a breathing simulator (asl , ingmar medical, usa) or mechanical ventilator (servo-u, maquet, sweden). the dose delivered to the lung was assessed using a capture filter at the level of the trachea, with drug mass determined using uv spectrophotometry at nm and interpolation on a standard curve. the results of testing are illustrated in figure . the bronchodilator dose delivered to the simulated patient was seen to be relatively consistent between progressive interventions, except during high flow therapy, with the more clinically relevant lpm gas flow rate having a profound effect on the dose. these results may go some way towards explaining how different patient interventions can affect aerosol dose. the the mechanical ventilation (mv) have been identified as an independent factor indicating a worse prognosis for lung cancer patients [ ] . this study was conducted in order to assess the results of noninvasive mechanical ventilation (niv) and/or invasive mechanical ventilation (imv) modalities in lung cancer patients admitted to the icu with acute respiratory failure (arf). in this study, lung cancer patients with respiratory failure who were admitted to the icu between january and december were evaluated retrospectively. results: patients were included in the study. the mortality rate was . %. patients had niv. imv was applied to patients. in the first hours, of the patients who were initially treated with niv were administered imv. the duration of hospital stay, diagnosis of pneumonia and mortality rate were found to be significantly lower in patients treated with niv alone (p≤ . , p= . , p= . ), but glaskow coma score (gcs) was significantly higher in this group (p≤ . ). the mortality rate was similar between the patients who were initially treated with imv and those who were treated with imv in the first hours. charlson comorbidity index (cci) and mv duration were significantly higher in patients who died (p= . , p= . ), but gcs was significantly lower in this group (p= . ). in the linear regression model for the likelihood of mortality, ccl≥ and unsuccessful niv increased the mortality rate by . ( . - . ) and . times ( - . ) respectively (p= . , p= . ). niv has been an effective modality for respiratory support in most lung cancer patients presenting with arf. however, failed niv seems to be a factor for increased mortality. therefore, the choice of respiratory support modality to be applied in this patient group should be decided by considering the gcs, cci and etiology of arf. the interaction between ventilator settings and the occurrence of acute kidney injury is not fully elucidated. this study aimed at investigating the effect of stepwise increase in peep level on the risk of acute kidney injury as evaluated with the renal resistivity index (rri).the primary outcome is to investigate whether increased levels of peep could lead to increase rri and whether rri could predict the occurrence of aki. methods: patients mechanically ventilated for at least hours and without aki at admission were included in the study. rri was calculated at icu admission. posterolateral approach was used for kidney ultrasound. the peak systolic velocity (v max ) and the minimal diastolic velocity (v min ) were determined by pulse wave doppler, and the rri was calculated as (v max -v min )/v max . the exam was performed modifying the peep levels: , and cm h o in random order for minutes. occurrence of aki was defined within days according to kdigo criteria. sixty-four patients were enrolled in the study and incidence of aki was / ( %). demographical and clinical characteristics are reported in table . increase in peep showed a significant increase in rri from peep to peep (p< . ) and from peep to peep (p= . ) ( figure ). the area under the roc curve of rri to predict aki was . at peep , . at peep and . at peep (all p< . ). the youden index analysis showed an rri> . as the best cut off for aki with a sensibility of % and a specificity of %. patients with rri> . were / ( %), / ( %) and / ( %) at peep ,peep and peep respectively. patients ventilated with a peep value associated with rri> . had higher incidence of aki ( / vs / , p< . ). the application of peep can increase intrarenal vascular resistance,which is associated occurrence of aki; peep level should therefore be balanced taking into account the rri. the rri seems able to predict occurrence of aki in mechanically ventilated patients. alveolar and respiratory mechanics modifications produced by different concentrations of oxygen in healthy rats subjected to mechanical ventilation with protective ventilatory strategy d dominguez garcia , r hernandez bisshopp , jl martin barrasa , d viera camacho , a rodriguez gil , j arias marzan , s garcia hernandez high oxygen can damage tissues [ ] . in this study, we analyze the histological and pulmonary mechanics modifications that can occur when identifying different inspiratory oxygen fractions (fio ) in lungs of healthy rats during protective mechanical ventilation. we use sprague-dawley rat. groups were designed, each with animals, the tidal volume ( ml/kg), peep ( cmh o) and respiratory rate ( rpm) were kept constant, changing the fio between the groups. four groups were established: fio . , . , . and . after hours, the lungs were removed for histological study and obtaining the wet/dry index. the histological modifications studied were: alveolar septa (as), alveolar hemorrhages (ah), intraalvelolar fibrin (if) and inflammatory infiltrates (ii). each parameter was rated from to [ ] . peak pressure (pp) and pulmonary compliance were monitored every minutes. different statistical tests will be used to analyze the data. results: references to the damage produced in the as, ah, if, ii and the global histological pattern were identified in the groups with the highest fio and there was more damage (p < . ) ( figure ). the wet/dry index rose significantly as the oxygen concentration increased (p = . ). in the groups to which a fio of . and was administered, the pp selected specific values with respect to the baseline intake from the first minutes, an aspect that was not appreciated in the other groups (p < . ). regarding pulmonary compliance, it will be seen that, in the fio . and groups, it decreased from the first minutes, finding differences with respect to the other groups (p < . ). conclusions: mechanical ventilation applied for hours in healthy animals produces disorders that are more pronounced as oxygen concentration increase. fio greater than or equal to . should be avoided without clinical justification. introduction: patients requiring prolonged acute mechanical ventilation (pamv, defined as + days on mv) are sicker and incur disproportionate morbidity and costs relative to patients on short-term mv (stmv, < days of mv). we quantified specific clinical outcomes among patients requiring pamv vs. stmv in a contemporary database. we conducted a multicenter retrospective cohort study within~ hospitals in the premier database, - . using icd- -cm and icd- codes we identified pamv and stmv patients, and compared their baseline characteristics and hospital events. because of the large sample size, we omitted hypothesis testing. a total of , patients met the enrollment criteria, of whom , ( . %) received pamv. at baseline, patients on pamv were similar to stmv with regard to age (years: . ± . pamv vs. . ± . stmv), gender (males: . % pamv vs. . % stmv), and race (white: . % pamv vs. . % stmv). pamv group had a higher comorbidity burden than stmv (mean charlson score . + . vs. . + . ). the prevalence of each of the indicators of acute illness severityvasopressors ( . % vs. . %), dialysis ( . % vs. . %), severe sepsis ( . % vs. . %), and septic shock ( . % vs. . %)was higher in pamv than stmv, as were hospital mortality and combined mortality or discharge to hospice (figure ), extubation failure ( . % vs. . %), tracheostomy ( . % vs. . %), development of c. difficile ( . % vs. . %), and incidence density of ventilator-associated pneumonia ( . / , patient-days vs. . / , patient-days). conclusions: over / of all hospitalized patients on mv require it for days or longer. pamv patients exhibit a higher burden of both chronic and acute illness than those on stmv. commensurately, all clinical outcomes examined are substantially worse in association with pamv than stmv. identifying the readiness of patients recovering from critical illness for liberation from invasive mechanical ventilation (imv) is not always straightforward [ ] . the scottish intensive care society (sics) trainee audit conducted a scotland-wide study to understand current practices relating to liberation from imv. data were prospectively collected on patient demographics, indication for intubation, spontaneous breathing trial (sbt) practices, physiological markers, icu outcome and icu los. all patients > years ventilated with imv for > hrs from the st nov. - th nov. were eligible for inclusion. exclusion criteria included extubation for end-of-life, death whilst intubated and presence of tracheostomy. logistic regression was performed to detect factors associated with extubation failure (ef). results were analysed via excel and stata v. . . patient benefit and privacy panel approval was granted. total population of patients were included: ( %) male and median apache score (iqr - ). ef at first attempt occurred on occasions ( . %), median icu los of days (iqr - ), mortality rate . %. the cohort successfully extubated first time had a median icu length of stay of days (iqr - ) and mortality rate of . %. methods of sbt and extubation outcomes detailed in table . no sbt prior to extubation had higher odds of ef (or . , ci . - . , p= . ); patient ventilation for < days had a three times higher odds of ef (or . , ci . - . , p= . ). these were independently associated with ef on multivariate analysis conclusions: we found a reintubation rate of . % in scottish icus. type of sbt most commonly used is divergent from the methods advocated in the literature. the lack of sbt and early extubation attempt was associated with failure, which in turn was associated with longer icu los and higher mortality. in patients undergoing prolonged invasive ventilation we hypothesise that abnormal right ventricular (rv) and left ventricular (lv) function are associated with increased -day mortality. whether changes in lv or rv function could aid in the prognostication of these patients has not been directly studied. patients admitted to the queen elizabeth hospital birmingham icu between april and july who were intubated and ventilated for more than days and had a formal transthoracic echocardiogram (tte) whilst in icu were included. abnormal rv function was defined by the presence of depressed function, dilated size or moderate to severe risk of pulmonary hypertension. abnormal lv function was defined by the presence of lv depression (lv ejection fraction £ % or grade ii or more diastolic dysfunction) or a hyperdynamic lv (formally mentioned in tte report). patients who had a neurological cause for prolonged ventilation were excluded. the primary outcome was -day mortality. categorical data is presented as % and analysed using a chi-squared test. continuous data is presented as median (iqr). results: patients required prolonged ventilation, of which ( %) had a tte. patients were aged ( - ), were % male and had a % -day mortality. the median ventilator days were ( - ) and % required a tracheostomy. abnormal rv function was present in % (n= ) and was associated with an increased -day mortality compared to normal rv function ( % vs. %, rr . [ . - . ], p< . ). lv function was abnormal in % (n= ) and was associated with an increased -day mortality compared to normal lv function ( % vs %, rr . [ . - . ], p < . ). abnormal rv function had a trend towards an increased mortality compared to abnormal lv function ( % vs %, rr . [ . - . ], p = . ). in this study, abnormal rv and lv function were present in a quarter of patients undergoing prolonged ventilation and were associated with an increased mortality. introduction: tidal volume delivered by mechanical ventilation (mv) in sedated patients is distributed preferentially to ventral alveoli, causing overdistention and associated collapse in dorsal alveoli, driving volutrauma, atelectrauma and ventilator-induced lung injury [ ] . temporary transvenous diaphragm neurostimulation (ttdn) stimulates diaphragm contraction [ ] . when used in synchrony with mv, ttdn encourages increased dorsal ventilation due to the change in pressure gradients with diaphragm contraction, mimicking a more normal physiological pattern. this may improve gas exchange and reduce injury. a pilot study was conducted using kg pigs undergoing mv in a mock icu. deeply sedated subjects were provided lung-protective volume-control ventilation at ml/kg. ttdn diaphragm contractions were delivered in synchrony with inspiration on every second breath, reducing the ventilator pressure-time-product by - % during mv+ttdn breaths. tidal volume distribution was recorded in each condition using electrical impedance tomography, and compared to never-ventilated, spontaneously breathing subjects (nv). results: dorsal ventilation changed from % during mv breaths to % during mv+ttdn breaths, compared to % in the nv group (p= . ). ventral ventilation changed from % during mv breaths to % during mv+ttdn breaths, compared to % in the nv group (p= . , figure ). conclusions: ttdn diaphragm contraction used as an adjunct to mv yields a more physiological pattern of volume distribution. this translates into less overdistension in the ventral areas and less atelectrauma in the dorsal areas and reduces ventilator-induced lung injury. this technology introduction: by measuring the pes and its derivatives, we can measure the relationship that exist between the diaphragmatic excursion and the oscillation of the esophageal pressure curve: pswing (ps) so we infer that, just as with the pes, the variations of it might be related to a weaning failure [ , ] . however, no nominal value exists in the bibliography to predict the test result. patients who meet with the inclusion criteria start the weaning process through a test of minutes of spontaneous ventilation, t-tube (tt). and also the respiratory rate (rr) and the tidal volume (tv). from this analysis, an average ps (aps) is determined for each moment of the test (aps , initial and aps , final.).a quotient was obtained in relation to these variables using the value previously obtained (quotient dtv/dps x . a total of patients were included (n= ).regarding the evolution during tt, (n= ) ( %) were successful, while (n= ) ( . %) failed when analyzing a rate that relates the variables tv and ps, a quotient was obtained in relation to these variables using the value previously obtained (quotient dtv/dps) for patients who were successful and who failed, (dtv/dps)/ successful patients presented a value of . while those of the failure group presented a value of . , (or , - p= . ) ( table ) . when presenting the relationship between tv and ps through the quotient (dvt/dps)/ , it is observed a tendency to have a higher quotient among patients who failed versus those who did not fail. the process of weaning from mechanical ventilation imposes an additional workload on the cardiovascular system, which may result in impaired myocardial function, increase in left ventricular filling pressure and respiratory distress. among surgical patients, those undergoing heart surgery are particularly susceptible to cardiac dysfunction induced by weaning because of inadequate cardiovascular reserve. the aim of our study was to depict the pathophysiological changes assessed by echocardiography during the steps of weaning and to identify possible predictors of weaning failure (wf). we enrolled consecutive patients undergoing isolated coronary artery bypass grafting in our institution. data were obtained by intraoperative transesophageal echocardiography before sternotomy (t ) and by transthoracic echocardiography at the beginning of weaning (t ) and at the time of extubation (t ). wf was defined as deferral of planned extubation or respiratory failure needing reintubation or non-invasive mechanical ventilation within hours. results: wf occurred in patients ( . %) and involved manifestations of respiratory distress in ( . %). we found a significant association between left ventricle outflow tract-velocity time integral (lvot-vti) and ventricular-arterial coupling measured at t and wf, with lvot-vti emerging as the best predictor of wf with an area under roc curve of . ( figure ); an optimal cutoff value of cm provided % sensitivity and % specificity. significant increase in e/e' measured at t ( . vs . , p . ) suggested a cardiac etiology of respiratory distress in patients who failed the weaning trial. our study showed that serial assessment of hemodynamic parameters by means of echocardiography is feasible in cardiac surgical patients and can provide insight into pathophysiological changes during weaning. although these preliminary data need to be confirmed in a larger population sample, lvot-vti emerged as a promising predictor of subsequent wf. compliance with guidelines for respiratory therapy in preclinical emergency medicine g jansen, n kappelhoff, s rehberg protestand hospital of the bethel foundation, anaesthesiology, intensive care and emergency medicine, bielefeld, germany critical care , (suppl ):p introduction: current guidelines on pre-hospital emergency ventilation are based on the guidelines for lung protective ventilation in the intensive care unit. the present survey was designed to determine the accordance of actual pre-hospital emergency ventilation by german emergency physicians (gep) with these recommendations. recommendations include a respiratory rate (rr) between - /min, a tidal volume (vt) between - ml/kg, a maximum pressure (pmax) < mbar and a positive end-expiratory pressure (peep) of mbar. an anonymous web-based questionnaire encompassing questions was sent to gep from september to december of . gep were asked to specify their level of education, their preferred ventilation settings and the usually chosen parameters employed to guide mechanical ventilation. statistical analysis was performed using the ch²-test with a significance level ≤ . . % of the questionnaires were completed ( / ). % of the participants were trainees (tr), % consultants (co). as target parameters for guidance of ventilation, % of the tr and % of the co use capnometry. the vt controlled % of the tr and % of the co on the basis of body weight. % of the tr and % of the co reported to control oxygenation using spo . table shows our analysis of the given answers. there were no statistically significant differences between the groups. deviations from the guidelines of pre-hospital emergency ventilation settings are common and mainly concern the use of a guidelinecompliant peep. in addition, recommended target parameters for guidance of ventilation were not applied in a significant proportion of gep. prospective observational study including ltx recipients admitted to our icu from february to january , who underwent a spontaneous breathing trial (sbt) using a t-piece for minutes. clinical variables and arterial blood gas samples were recorded before starting sbt and after minutes on the t-piece. diaphragmatic excursion (de) and thickening fraction (dtf) were also assessed using ultrasound(us) after minutes on the tpiece. us-dd was defined as de< mm or dtf< . of at least one hemidiaphragm. patients who successfully completed a sbt, defined according to clinical criteria,were extubated. extubation failure was defined as the need for reintubation within h. results are expressed as medians (iqr) or frequencies (%). ltx recipients were admitted to the icu, of whom underwent an sbt. were male, and the median age was y. main indications for ltx were interstitial lung disease ( . %), copd and cystic fibrosis. were bilateral ltx, and and were left and right unilateral ltx respectively. patients were extubated after sbt and required reintubation within h. presented us-dd, though there were no differences between patients who succeeded and those needing reintubation. in contrast, patients who succeeded showed higher pao /fio after minutes on the t-piece (table ) . similarly, higher reductions in deltapao /fio after minutes on the t-piece were observed in patients who failed. oxygenation after sbt performed using a t-piece may predict extubation failure in ltx recipients with successful sbt. us-dd was not associated with the need of reintubation. descriptive study about the relationship between self-extubation episodes and patient-ventilator interaction s nogales , introduction: to evaluate the relationship between self-extubation and patientventilator interaction, among other physiological variables, in order to predict and to prevent these events. self-extubation (se) are quality indicators in patients under invasive mechanical ventilations (imv) and are related with mortality [ ] . planned secondary analysis of a prospective data base of clinical and physiologic signals of patients receiving imv. we included se episodes ( - ) with continuous record of ventilator and monitor signals (bclink bettercare®). we analysed demographic data, physiological parameters (peripheral oxygen saturation spo , heart rate hr, respiratory rate rr and media arterial pressure map) and patientventilator interaction (asynchrony index ai, ineffective efforts during expiration iee and double cycling dc). we studied a period of hours prior to the se episode. we used the wilcoxon non-parametric test and for a proper analysis a linear mixed effects model. we included episodes of se, mean age ± years, %men, apache ii at admission ± , , ± , days under imv until the episode, reintubation rate . %, icu stay , ± , days, icu mortality %. at the time of the se, % were under sedation, % with physical restraint. the % were in weaning. we observed a trend to increase in spo , rr, hr, map and asynchronies in the -hour period prior to se episode. we compared these variables from this period with a -hour period before and we observed a statistically the data presented in this study show that our results are in accordance with the literature with favorable mortality and early postoperative complication rates and support that this procedure is an excellent alternative for surgery in the elderly patients. it is reported that patients with pulmonary hypertension (ph; systolic pulmonary arterial pressure (spap)≥ mmhg)) have frequent cardiac complications after transcatheter aortic valve implantation (tavi). ph often gets worse in some patients despite the normal cardiac function after tavi. no studies have ever examined prognosis after tavi in patients with or without worsening of ph. therefore, we retrospectively examined the frequency of mid-to long-term heart failure and cardiac death in patients with and without deterioration of ph after tavi. among patients who underwent tavi at our hospital between february and march , we analysed patients with ph (spap≥ mmhg) before surgery. spap was measured in transthoracic echocardiography before and within week after tavi. patients were divided into two groups according to whether spap worsened/ did not change or improved after tavi. we examined the frequency of admission due to heart failure or cardiac death (death caused by heart failure, angina, or myocardial infarction) during the period of years after tavi. ph worsened or did not change after tavi in patients, while it improved in patients. the left ventricular ejection fraction measured within week after tavi showed no difference between the two groups ( . ± . % vs . ± . %, p= . ). the worsened/ no change group was higher in frequency of admission due to heart failure (logrank; p< . ) and cardiac death (logrank; p< . ). despite successful treatment for as by tavi, the frequency of heart failure and cardiac death was higher in patients who did not show improvement of ph after tavi, even in the absence of cardiac function decrease. vigorous intervention for ph worsening after tavi may be helpful to improve prognosis. the there are several different anti platelet drugs that can be used to treat acute cardiac events. currently there are no effective markers that can assess how these drugs modify coagulation profile and quality. a new functional biomarker that measures fractal dimension (df ) and clot formation time (tgp) has been developed [ ] . df quantifies clot microstructure whereas tgp is a real-time measure of clotting time. we aimed to validate df and tgp in st elevation myocardial infarction (stemi) and assess the effect of two p y inhibitors which have different pharmacological mechanisms: clopidogrel and ticagrelor. we prospectively recruited stemi patients in the emergency setting. venous blood samples were collected hours after admission, following treatment with either ticagrelor or clopidogrel, in accordance with the local guidelines at the time. the blood samples were tested using the df and tgp biomarker, platelet aggregometry, clot contraction and standard markers of coagulation. results: patients received clopidogrel and received ticagrelor. the df for clopidogrel was higher than ticagrelor ( . ± . vs . ± . , p= . which corresponds to a decrease in clot mass of % figure ) and the tgp was reduced ( ± sec vs ± sec, p= . a % reduction in time). the results of the study suggest that clopidogrel is less powerful in its effects on clotting characteristics compared to ticagrelor. blood from patients receiving clopidogrel formed quicker and denser clots. this would suggest the risk of secondary events or stent occlusion is lower in those patients on ticagrelor, highlighting that df and tgp may be important in identifying patients at risk of future thrombotic events, the study is ongoing and will investigate the long term outcome in these patients. introduction: new onset atrial fibrillation (noaf) during critical illness frequently resolves prior to discharge. however long-term risks of noaf (i.e. heart failure, ischemic stroke and death)remains high [ ] . previous studies noted that nearly half of noaf cases did not have diagnosis recorded [ ] . addressing this may reduce post critical illness mortality by increasing af surveillance post intensive care (icu) discharge. retrospective data was collected from an electronic health record for icu admissions over a month period from a biomarker is defined as a measurable indicator of some biological state or condition. combined with a good clinical evaluation, they can enable an early and safe diagnostic, thus a faster management for the patient. cardiac biomarker testing is not indicated in routine in the emergency department (ed) because of low utility and high possibility of false-positive results. however, current rates of testing are unknown. the aim of our study was to evaluate the importance of measuring cardiac biomarkers especially troponins, d-dimer, and btype natriuretic peptide in our daily practice, and to identify the latest recommendations for a better use of these biomarkers in the diagnostic and therapeutic approaches. we conducted a prospective observational study, over a months periods performed in the ed of the university hospital center ibn rochd, casablanca, morocco, including all patients admitted during our study period and having a blood test for at least one biological marker. the dataset was analyzed by spss statistics . . a total of patients was enrolled. troponins were tested in . % patients (high sensitive in . % and troponin i tni in . %), ddimer in . %, bnp % and nt pro bnp in . % of cases. the diagnostic impact was significant in . % of cases for troponins, . % of cases for d-dimer and . % for bnp. the therapeutic impact was considered important in . % cases for troponins, . % for ddimer and . % for bnp. cardiac biomarkers have an important role in the ed, not only do they confirm the diagnosis (including the role of troponins in acs) but also eliminate others (with a strong negative predictive value of d-dimer for thromboembolic disease) and prove the cardiopulmonary origin of acute dyspnea (the significant place of bnp in confirming the diagnosis of acute heart failure). a multicenter study on the comparison of inter-rater reliability of a new and the original heart score among emergency physicians from three italian emergency departments the heart (based on history,ecg,age,risk factors,troponin) score is a valid tool to stratify the acs in chest pain. but some reports suggest that its reliability could be low for heterogeneity in the assignment due to the subjective interpretation of the history. we used the chest pain score for the "history". in this study we compare the reliability of the new heartcps and original heart. this is a multicenter retrospective study conducted in italian ed between july and october using clinical scenarios. ten physicians were included after a course on heart and heartcps score. we used scenarios which included clinical and demographic data. each participant independently assigned scores to the scenarios using the heart and heartcps. we tested the interrater agreement using the kappa-statistic (k), the confidence intervals are bias corrected ; we used stata/se . statistical software . a p-value of < . defines statistical significance. the overall inter-rater reliability was good for heart and heartcps: kappa = . (ci %; . - . )and , (ci %; . - . ); with good agreement among all the class of risk for heartcps but moderate in the medium class for heart . we found significant differences of inter-rater reliability among the senior and junior physicians who used the heartcps:k= . (ci %; . - . )and . (ci %; . - . ). heartcps score increased its history inter-rater reliability specially among the junior physicians from k= . (ci %; . - . ) to k= . (ci %; . - . ).the junior physicians seem to be more reliable than senior with the heartcps:k= . ( . - . ) vs k= . (ci %; . - . ). the heartcps showed inter-rater reliability better than original heart among the medium class of risk and the junior group. it could be proposed to young doctors to stratify the acs risk of chest pain. limit: we used scenarios rather than real patients. a hybrid approach as treatment for coronary artery disease: endo-cabg or pci first, does it matter? introduction: the aim of this study is to discuss the short-term results of a hybrid approach combining minimally invasive endoscopic cabg (endo-cabg) with a percutaneous coronary intervention (pci). to bypass the disadvantages and potential complications of conventional cabg via median sternotomy, we developed the endocabg technique to treat patients with single-and multi-vessel coronary artery disease (cad). this procedure is performed with three -mm thoracic ports and a mini-thoracotomy utility port ( cm) through the intercostal space. this technique can be combined with pci: the hybrid approach. the sequence of the procedures (endocabg followed by pci or vice versa) may result in different outcomes. from / to / data from consecutive patients scheduled for a hybrid technique at jessa, belgium, were prospectively entered into a customized database. this database was retrospectively reviewed. subgroup analysis was performed to compare outcomes of patients who first received endocabg with patients who first received pci. a p-value < . is considered significant, a p-value < . is considered as a trend toward significance. four patients underwent revision surgery and patients died within the first days. in patients the left anterior descendens artery (lad) was grafted with the left internal mammary artery (lima), the right coronary artery (rca) was the most stented vessel using pci. patients first treated with pci received more units of fresh frozen plasma after endocabg compared to those who were first treated with endocabg (p= . ). there was also a trend toward significant more transfusion of packed cells in this small subgroup (p= . ). the hybrid approach is a feasible technique as a treatment option for patients with multi-vessel cad. if cabg follows the pci, patients are more likely to receive transfusion. a possible explanation could be the need for dual antiplatelet therapy prior to surgery in this group, but this needs further investigation. prognostic difference between troponin elevation meeting the mi criteria and troponin elevation due to myocardial injury in septic troponin t (ctnt) elevation in critically ill patients is common and is associated with poor outcome. using common assays, - % of patients in the icu will have elevated troponin level. our aim was to determine whether there is any prognostic difference between troponin elevation meeting the mi criteria (rise and fall more than % together with echo and ecg new abnormalities) and troponin elevation due to myocardial injury in septic patients. we enrolled patients with sepsis and mean sofa score , respectively in which ctnt level was measured more than once and analyzed there ecg and echo findings. patients were classified into three groups:definite mi (rise and fall ctnt ≥ % and contemporaneous changes on ecg and/or echo),possible mi (rise and fall ctnt ≥ % and no other findings),myocardial injury (ctnt rise less than %) results: data from patients were analyzed ( % female; mean age . (sd . )). a total of patients had at least one elevated ctnt more than . mkg/l. in ( %) of patients ctnt level rised more than % from the first elevated measurement. ( %) of patients met mi criteria considering new ecg and echo findings. the overall mortality rate in all patients was . %.the mortality rate didn't differ significantly in three groups: in the definite mi group . %, in the suspected mi group %, in the non mi ctnt elevation group , %, p= , . coronary angiography was performed in ( %) of patients from the definite mi group,pci was performed in ( %) of patients. the mortality rate in the invasive group was not significantly lower comparing to the nonivasive group % vs , %, p= , . bleeding complications were significantly more frequent in the definite mi group % vs % and % respectively conclusions: ctnt level elevation is associated with poor outcome regardless coronary or non coronary injury. myocardial revascularization may be beneficial in patients with sepsis and definite mi, but it is also associated with increased bleeding risk. diagnostic interest of "marburg heart score" in patient consulting the emergencies department for acute chest pain chest pain is a common reason for emergency department visits, although this primarily refers to acute coronary syndrome (acs), this symptom may be frequently related to other non-ischemic etiologies. the aim was to validate the marburg heart score as a tool to exclude coronary artery disease in emergency department patients with nontraumatic acute chest pain. methods: a prospective, observational, descriptive and analytic cohort study conducted in the emergency department, from february st to march st, , collecting patients consulting for nontraumatic acute chest pain, the "marburg heart" score was calculated for all these patients. telephone contact was made after weeks to look for an ischemic cardiovascular event. we included patients. the mean age was +/- years, the sex ratio was . . the majority of the patients ( . %) consulted directly to the emergency department, . % were referred by a primary care physician. the median time to consultation after the onset of chest pain was hours. high blood pressure was the most common risk factor ( . %), followed by smoking ( %), diabetes ( . %) and dyslipidemia ( . %). thirty-five patients ( . %) had already coronary heart disease, ecg was pathological in . % of patients, patients had an acs with st segment elevation. at six weeks, . % of the patients had an acute coronary event. according to the patients' answers on the questions of the marburg heart score. the area under the roc curve of this score was . with a negative predictive value of . %; the "marburg heart score" is a simple, valid and reproducible clinical score with a discriminatory power to rule out the diagnosis of coronary artery disease from the first contact with the patient presenting for chest pain in emergencies. the abdominal aortic aneurysm (aaa) surgery is a complex procedure in elderly patients with high cardiovascular risk. anesthesiological techniques should play special attention to the volume status during cross-clamping as well as to the blood loss. goal directed fluid therapies (gdt) in aaa surgery in elderly patients decrease the perioperative morbidity and mortality [ ] . aim of this study is to investigate administration of fluid-based on either a gdt approach or a control method (fluid administered based on static preload parameters and traditional hemodynamic) in all phases of aaa surgery and especially in the phase of clamping and de-clamping. a total of patients asa iii, randomly scheduled for elective, open aaa surgery were included in this clinical trial. they were randomly assigned to two groups i -gdt with targeting stroke volume variation (svv) and ii -control group where fluids were administered at the discretion of the attending anaesthesiologist. in both these groups hemodynamic parameters, central venous pressure (cvp), temperature, blood loss and diuresis were registered during the operation and hours postoperatively. each group was assessed for postoperative complications. gdt group received less fluids and had a higher cardiac index (ci) ( . ± . vs. . ± . l/minute per m , p < . ) and stroke volume index ( . ± . vs. . ± . ml/m , p < . ) than the control group. there were significantly fewer complications in the intervention than control group ( vs. , p = . ). gdt fluid administration enables less use of fluids, improved hemodynamic and fewer postoperative complications in elderly patients undergoing aaa surgery. ultrasonography is a valid diagnostic tool, used to measure changes of muscle mass. the aim of this study was to investigate the clinical value of ultrasound-assessed muscle mass, in patients undergoing cardiothoracic surgery that present muscle weakness postoperatively. for this study, consecutive patients were enrolled, following their admission in the cardiac surgery intensive care unit (icu) within hours of cardiac surgery. ultrasound scans, for the assessment of quadriceps muscle thickness, were performed every hours for days. muscle strength was also evaluated in parallel, using the medical research council (mrc) scale. of the patients enrolled, ultrasound scans and muscle strength assessment were performed in patients. the muscle thickness of rectus femoris (rf), was slightly decreased by . % ([ %ci: - . ; . ], n= ; p= . ) and the combined muscle thickness of the vastus intermedius (vi) and rf decreased by . % ([ % ci: - . ; . ], n= ; p= . ). patients whose combined vi and rf muscle thickness was below the recorded median values ( . cm) on day (n= ), stayed longer in the icu ( ± vs ± hours, p = . ). patients with mrc score ≤ on day (n= ), required prolonged mechanical ventilation support compared to patients with mrc score ≥ (n= ), ( ± vs ± hours, p = . ). the use of muscle ultrasound seems to be a valuable tool in assessing skeletal muscle mass in critically ill patients after cardiothoracic surgery. moreover, the results of this pilot study showed that muscle wasting of patients after cardiothoracic surgery is of clinical importance, affecting their stay in icu. prediction of cardiac risk after major abdominal surgery s musaeva, i tarovatov, a vorona, i zabolotskikh, n doinov kuban state medical university, anesthesiology and intensive care, krasnodar, russia critical care , (suppl ):p the aim is to assess the incidence of cardiovascular incidents in major abdominal surgery [ ] using the revised lee index. a study was conducted of elderly patients who underwent major abdominal surgery in the krasnodar regional clinical hospital no. under combined anesthesia. in the preoperative period, the risk of cardiovascular incidents was assessed using the revised lee index and the functional status was assessed by met. depending on the lee index, groups were identified: group (n = ) -low risk (index value - ), group (n = ) -intermediate risk (index value - ); group (n = ) -high risk (index value> ). we estimated the incidence of critical incidents in groups: hypo-, hypertension, arrhythmias, and bradycardia. in the general population, cardiac risk was . ± . points; functional status - . ± met. the greatest number of critical incidents was recorded in patients with high risk ( . %), the smallest -in patients with low risk ( . %), in patients with intermediate risk - . % (n < , between groups according to chi-square criterion). in the structure of critical incidents, hypotension was most often encounteredin ( %) patients, while some patients revealed several incidents from the circulatory system (n = ). overall, the lee scale showed good prognostic ability (auroc = . ) in predicting hemodynamic incidents. the revised lee index is a useful tool to help assess the risk of cardiovascular incidents and determine patient management tactics in the perioperative period. postoperative cognitive dysfunction (pocd) remains an unresolved problem due to lack of consensus on its etiology and pathogenesis. some believe that pocd is the result of the direct toxic effect of general anesthetics on the nervous system. others claim that surgical trauma activates proinflammatory factors that induce neuroinflammation. wistar rats were allocated into groups: -minor surgery (n= ), major surgery group (n= ). after days of handling and habituation rats undergone surgery under isoflurane general anesthesia ( vol.%). group rats underwent laparotomy with gentle gut massage followed by wound closure. rats in group undergone left side nephrectomy. starting from the th postoperative day spatial memory in rats was studied in morris water maze which is a cylinder metal pool with a diameter of . and a height of . m filled with water (temp. ± o c) up to half. it has a platform with a diameter of cm and a height of cm below the water level. testing was preceded by a training stage, which included sessions daily for days. thus, rats developed spatial memory to the location of the platform. on the th day of the study test stage was conducted to assess spatial memory: rats were launched from points into maze without platform and data were recorded for seconds at each session. time spent on the target quadrant (ttq) and the number of target area crossings (tac) were registered. a second test was conducted days after the first test to evaluate long-term spatial memory. the duration of surgery and anesthesia did not differ significantly between groups. there was a significant difference between groups in average ttq and tac in test (table ). in test minor surgery group showed better results but they were less significant. major surgery is associated with a more pronounced deterioration of spatial memory in rats in early postoperative period compared to minor surgery. cardiac inflammatory markers in icu patients with myocardiac ischemia after non cardiac surgery (a pilot study) p manthou , g lioliousis , p vasileiou , g fildissis national kapodistrian university of athens, athens, greece; national kapodistrian university of athens, general thoracic hospital´´sotiria´´, athens, greece; national kapodistrian university of athens, university of athens, athens, greece critical care , (suppl ):p patients with known coronary artery disease have higher perioperative risk for myocardial ischemia [ , ] . mortality is frequent following cardiac ischemia in the intensive care unit (icu) after non-cardiac surgery. the first group includes patients admitted to the intensive care unit for post-operative follow-up without myocardiac ischemia in the first hours. the second group includes patients with myocardiac ischemia postoperatively and needs intensive care monitoring. cardiac risk assessment was made with the lee index,hemorrhagic risk assessment with the has-bled bleeding score and thrombotic risk assessment with cha ds -vasc score. postoperatively, pathological test values such as bnp, troponin, crp, calcitonin were estimated. the sequential organ failure assessment (sofa) systeme was used to assess sepsis. the nursing activity score (nas) scale was used to measure the workload of various nursing activities in the icu. according to the pilot study, the sample consists of patients. . % had myocardial ischemia. the lee index was significantly higher in patients with myocardial ischemia. the duration of hospitalization, the high dose of vasoconstrictive drugs, the length of stay in the icu, the duration of mechanical stay and the nursing workload were higher in patients with myocardial ischemia. ck-mb and troponin levels differed significantly between the two groups. creatinine, bilirubin and bnp during the hours were significantly higher. patients with myocardial ischemia had significantly higher mortality. cardiac risk assessment, has-bled score and cha ds -vasc score in combination with cardiac enzymes such as troponin could predict myocardiac ischemia in severely ill icu patients. introduction: according to the literature an airway complication followed thyroid gland surgery are: difficult trachea intubation, tracheomalacia, postextubation stridor and bleeding [ , ] . most common cause of death was problem with respiration and airway obstruction [ ] . subsequent hypoxia could require emergency airway and even tracheostomy [ ] . aim of our study was to determine the most common of airway complications and their association with type of surgery in our region. the retrospective cohort study included pts., ( women, men) was performed in odessa regional hospital, oncology centre odessa. there were three types of patients: with euthyroid goiter - ( %), polynodos goiter - ( %) and thyroid cancer - ( %) ( table ) . airway complications were diagnosed after trachea extubation based on indirect laryngoscope, presence of stridor, desaturation. the pearson's criteria was calculated. the ratio of airway complications after thyroid surgery was . % ( pts). the main reasons of airway complications in thyroid surgery included: laryngeal edema - pts ( . %); recurrent laryngeal nerve injury - pts ( . %) and postoperative bleeding pts ( . %). thyroid gland cancer and polynodosal goiter associated with laryngeal edema and recurrent laryngeal nerve injury (pearsen criteria were . -moderate and . consequentially). it's may require more attention from the anesthetists after extubation and readiness for an urgent airway. serum iron level and development of multiple organ dysfunction syndrome in patients in the perioperative period s tachyla mogilev regional hospital, department of anesthesiology and intensive care, mogilev, belarus critical care , (suppl ):p recently there has been attention of researchers to the problem of perioperative anemia. it was found that it increases the risk of death and postoperative complications. threatening complication is multiple organ dysfunction syndrome (mods). the objective was to determine the level of serum iron in the perioperative period in patients with endoprosthetics of large joints, and with the presence of mods in abdominal surgery. a prospective cohort study was conducted in patients, including men and women, age . ± . years. two groups were identified: st (control) -patients after endoprosthetics of large joints (n = ), nd (main) -patients in abdominal surgery with the presence of mods (n = ). the presence of mods was established based on the criteria for the sccm / accp conference. serum iron was monitored using an au analyzer (usa). the study identified several stages: st -before surgery, nd - st day after surgery, rd - rd day, th - th day, th - th day. when studying the indicators of serum iron, its significant decrease (p < . ) in the postoperative period was established. in the st group: st stage - . ( - . ) mmol / l, nd stage - . ( . - . ) mmol / l, rd stage - . ( - . ) μmol / l, stage - . ( . - . ) μmol / l, stage - . ( . - ) μmol / l. in the nd group: st stage - . ( - ) mmol / l, nd stage - . ( . - . ) mmol / l, rd stage - , ( . - . ) μmol / l, stage - . ( . - . ) μmol / l, stage - . ( . - ) μmol / l. moreover, in both groups, iron increased at the th stage against the nd stage (p < . ). when comparing the level of iron between the groups, significant differences were found (p < . ) at the nd, rd and th stages. in patients in the postoperative period, a decrease in serum iron is observed, the level of which rises by the th day, but does not reach the initial values. this decrease is more pronounced in patients with the presence of mods after abdominal surgery. kidney and pancreatic graft thrombosis happened in . % and . %, respectively, and bleeding in . %. forty-one ( . %) developed at least one infection during hospital stay. infection during icu was found in . % and main pathogens were gram negative bacilli sensible to beta-lactam. after icu, the incidence of multi-drug resistant pathogen was . %, predominantly gram negative bacilli. fungal infection was lower %. all-cause hospital mortality rate was . %. infectious complications are the main cause of morbidity and mortality following spk transplantation. the administration of broadspectrum prophylactic antibiotics are leading to the appearance of multi-drug resistant pathogens. knowing local microbiological flora may be helpful, allowing more adequate antibiotic prophylaxis. introduction: cardiopulmonary bypass (cpb) is associated with thrombotic complications. occurrence of thrombosis after cpb is % which takes the third place between cpb-associated complications. our study determined preoperative predictors of thrombosis in children with congenital heart defects. patients with congenital heart diseases in age up to months days (median age - , months, youngest age - days after birth, oldest - months days), underwent cardiac surgery with cpb, were enrolled in this study. all patients were divided into two groups: st -without thrombosis, nd -with thrombosis. protein c, ddimer, von willebrand factor and plasminogen plasma levels were assessed directly before surgery. thrombotic cases were proven by performing doppler ultrasound or mri. thrombotic complications were diagnosed in children ( %). between all thrombotic complications ischemic strokes were diagnosed in % ( cases), arterial thrombosis in % ( cases), intracardiac thrombus in % ( cases) and mechanical mitral prosthetic valve thrombosis %( ). receiver operating characteristic (roc) curves are created for the listed indicators. area under the curve (auc) for protein c , (sensitivity(sn)- %, specificity(sp) - %), d-dimer is , (sn - %, sp %), for plasminogen activity - , (sn %, sp %) and for von willebrand factor level - , (sn %, sp %). an roc curve was created for all three indicators, the auc was . (sn - %, sp - %). these parameters can be recommended as predictors of thrombosis in children after cardiac surgery. cpb is related with a large number of life-threatening complications. in our work, preoperative predictors of thrombosis were identified. based on this data, it is possible to create thrombosis risk scale change the tactics of the anaesthetic approach, the prevention of thrombosis in the postoperative period. further studies are needed to identify other possible predictors of thrombosis. introduction: abdominal ischemia occurs in % of patients submitted to aortic aneurysm repair. its early diagnosis requires an elevated index of suspiction, particularly in more severe patients. we hypothesized that earlier increase and higher levels of c-reactive protein (crp) may help to predict intra-abdominal ischemia. we performed a retrospective study of patients admitted to the intensive care department (icd) after abdominal aorta aneurism surgery. we included all patients admitted during a two-year period, that survived for more than hours. primary outcome was splanchnic ischemia assessed by abdominal ct-scan. we also evaluated the presence of bacteremia, abdominal compartment syndrome and icd mortality. association between inflammatory parameters and ischemia was evaluated by multivariate logistic regression. introduction: crp (c-reactive protein) has been shown to be a useful biomarker in identifying complications after major abdominal surgery. gastrectomy is a high-risk surgical procedure that requires post-operative critical care support to monitor for complications which are predominantly infective in nature. the aims of this study were to determine whether there is a relationship between post-operative crp levels and patients who developed post-operative infective complications. a retrospective analysis was performed on patients undergoing elective gastrectomy for gastric cancer at a single centre between september and july . post-operative crp levels for each day following resection were analysed for all patients. roc curve analysis was used to determine which post-operative day (pod) gave the optimal cut-off. of patients included, the majority were male ( . %), mean age was . years and . % had node-negative disease. a total of patients ( . %) had an infective complication, which includes those who experienced an anastomotic leak. crp levels on post-operative day gave the greatest auc for the gastrectomy group ( . ). crp cut-off of mg/l was significantly associated with infective complications (or . , % ci . - . , p= < . ) and gave a sensitivity of % and specificity % (ppv %, npv %). more patients with a crp > on post-operative day experienced an infective complication ( % vs %, p = < . ) or a leak in particular ( % vs %, p = . ). a crp level of less than mg/l on pod may be useful to predict the development or exclude the likelihood of such infective complications in this group of patients prior to clinical signs (ppv %, npv %). this may prompt and facilitate decision-making regarding early investigation and intervention or prevent inappropriate early discharge from critical care, whilst providing more assurance in identifying those who could be stepped down to ward level care. vasoplegia is commonly observed after cardiopulmonary bypass surgery (cpb) and associated with high mortality. chronic use of reninangiotensin aldosterone system inhibitors (raasi) is associated with its incidence and ensuing need for vasopressor support after cpb. renin serves as marker of tissue perfusion [ ] . we examined the role of renin in the setting of raasi exposure and vasopressor needs in the peri-cpb period. prospective observational study of adult patients undergoing cpb, aged . ± . years ( men, women). blood was collected ) post induction, pre-cpb; ) min post cardioplegia, and ) immediately post bypass. vital signs and perioperative medications were recorded. as control, blood was collected from men and women aged . ± . , not diagnosed with lung disease and not prescribed any raasi. baseline plasma renin in cpb patients tended to be higher than in control subjects (mean= . pg/ml± . vs. . pg/ml ± . , respectively, p= . ). minutes into cpb, mean renin was increased from baseline ( . pg/ml± . , p= . ), and remained elevated immediately post cpb ( . pg/ml± . ). patients using raasi prior to cpb tended to have a larger increase in renin post cpb (delta= . pg/ ml± . ) vs. those not previously on raasi ( . pg/ml± . , p= . ). renin was elevated in patients requiring vasopressor support in the hours post cpb vs. those not requiring pressors ( . pg/ ml± . vs. . pg/ml± . p= . ). in those prescribed raasi and requiring pressors post cpb, there was a tendency toward greater renin increase than those not requiring pressors postoperatively ( . pg/ml± . vs. . pg/ml± . , p= . ). this study suggests a trend toward higher renin levels, particularly during cpb, in patients prescribed raasi, and a positive association between renin and postoperative vasopressor needs. we speculate that increased renin levels may predict postoperative vasoplegia. cardiac surgery is associated with perioperative blood loss and a high risk of allogenic blood transfusion. it has been recognized that high blood product transfusion requirement is associated with adverse clinical outcomes. guidelines on patient blood management therefor aim at reducing blood loss and blood transfusion requirements in cardiac surgery. as there remains controversy about the advantage of minimal invasive techniques on blood loss an transfusion requirements, we wanted to investigate if the average blood loss and transfusion requirement in minimal invasive endoscopic coronary artery bypass graft surgery (endo-cabg) differ from conventional technique. we assessed the influence of pre-operative anticoagulant medication for blood loss. estimated average blood loss after conventional cabg is ml (+/- ) and transfusion requirement , units packed red blood cells . we performed a retrospective cohort study of our cardiac surgical database. from / / to / / , we collected data from patients undergoing endo-cabg. we analyzed blood loss, transfusion as well as pre-operative use of anti-coagulants as a risk factor for blood loss. we found that mean total blood loss in endo-cabg does not differ from conventional cabg, nonetheless mean transfusion requirement was lower in our cohort. use of direct oral anticoagulant is aossciated with increased blood loss and transfusion requirements (table ) . total blood loss is not influenced by minimal invasive technique for cabg (endo-cabg). an explanation for the lower transfusion requirements is the use of a minimal extracorporeal circulation, which is known to reduce the risk of transfusion. another important factor is the implementation of a standardized transfusion-protocol based on available evidence. reducing transfusion requirements is an important component in improving patient outcome after cardiac surgery and is related to multiple factors in perioperative care of our patients. retinal microvascular damage associated with mean arterial pressure during cardiopulmonary bypass surgery v shipulin retinal perfusion corresponds to cerebral perfusion and it is very sensitive to hemodynamic disturbances [ , ] . we investigated the association between retinal microvascular damage and hemodynamic characteristics in patients undergoing coronary artery bypass grafting surgery (cabg) with cardiopulmonary bypass (cpb). methods: patients with coronary artery disease and systemic hypertension were examined. ophthalmoscopy and optical coherence tomography were performed before and - days after cabg. the hemodynamic parameters during cpb were analyzed. results: ( %) patients had changes in the retinal vessels and in the ganglionic fiber structure on - day after surgery: in % of patients the foci of ischemic retinal oedema appeared, in % the decrease of the thickness of ganglionic fiber were observed. these changes may be associated with intraoperative ischemia of the central retinal artery. in ( %) patients the mean arterial pressure (map) during cpb was increased up to mmhg. in ( %) of them the association between map and foci of ischemic retinal oedema were revealed. the ischemic retinal changes were observed significantly more often if the delta of map during cpb was over then mm hg compared with the patients where the delta of map was less than mm hg (p= . ). this is probably due to an intraoperative disorders of the myogenic mechanism of blood flow autoregulation in the retinal microvasculature in patients with coronary artery disease [ ] . the level of map up to mm hg during cpb is associated with retinal blood flow impairment and the foci of ischemic retinal oedema. delta of map more than mmhg was associated with the foci of ischemic retinal oedema and decreased ganglionic fiber thickness in % of cases. atrial fibrillation after cardiac surgery: implementation of a prevention care bundle on intensive care unit improves adherence to current perioperative guidelines and reduces incidence introduction: atrial fibrillation after cardiac surgery (afacs) is a very frequent complication affecting - % of all patients. it is associated with an increase in morbidity, mortality and hospital and intensive care unit (icu) length of stay. we aimed to implement an afacs prevention care bundle based on a recently published practice advisory [ ] , focusing on early postoperative (re)introduction of β-blockers. baseline afacs incidence and β-blocker administration practices in our centre were audited for all patients undergoing valve surgery or coronary artery bypass graft (cabg) during a weeks period. the afacs prevention care bundlean easy to follow graphical toolwas subsequently introduced to the cardiac icu by a multidisciplinary team and audited following a model of improvement approach. after exclusion of patients with preoperative af, differences between pre-and post-implementation groups were compared with chisquare and fisher's exact tests for categorical, and one-way anova for continuous variables, using spss. a total of patients were analysed. patient and surgery characteristics did not differ between groups. significantly more patients received postoperative β-blockers after bundle implementation ( . % pre-vs . % post-bundle, p= . ) with a higher proportion on day ( . % pre-vs % post-bundle, p< . , figure ). the incidence of afacs was significantly reduced from . % to . % (p= . ), with a particularly marked reduction in the age group - years and for isolated aortic valve and cabg surgery. there was no significant reduction in hospital length of stay for this cohort. introduction of an afacs prevention care bundle using a graphical tool improved adherence to current guidelines with regards to early β-blocker administration and significantly reduced afacs incidence. future care bundles should include preoperative interventions and might reduce hospital length of stay. in neonates with univentricular physiology, there is a delicate balance between pulmonary and systemic circulations, with a tendency towards generous pulmonary blood flow, and a risk of systemic underperfusion. preoperatively, the use of hypoxic gas mixture (hm) has been advocated as a therapy to increase pvr, with the aim of improving systemic oxygen delivery. it is a therapy which has been routinely initiated in our institution in the setting of signs of pulmonary overcirculation. we performed a retrospective analysis of all patients in our institution who underwent a norwood procedure and who received hm preoperatively. we compared peripheral saturations, arterial blood gas analysis, serum lactate, regional cerebral and renal saturations and invasive blood pressure, prior to, and then , and hours after hm was commenced. between and (inclusive), patients underwent the norwood procedure. patients received preoperative hm. average fio was % during administration of hm. average peripheral saturations were . % prior to hm, and dropped to . % at hours, and % at and hours after initiation (p < . ). there was no change in any of the measured markers of systemic oxygen delivery, including regional cerebral and renal saturations, lactate, urine output or blood pressure. there was an association between an extended period of hm (> hours) and the need for pulmonary vasodilator therapy post norwood procedure. hypoxic gas mixture in patients with parallel systemic and pulmonary cicrculations causes desaturation and hypoxia. it does not lead to an increase in systemic perfusion and thus an improvement in systemic oxygen delivery. its ongoing use in this fragile population should be considered. introduction: analgesia in the critical patient, and especially in the neurocritical patient, is a basic goal in all therapeutic practices. patients in the icu are frequently administered prolonged and/or high doses of opioids. multiple serious complications due to the use of infusion of opioids at large doses has been described. to reduce high doses of intravenous opioids, multimodal forms of analgesia can be used. prospective observational study of the use of tapentadol enteral and buprenorphine in transdermal patches, at low doses, for the control of pain and its effect on reducing the use of fentanyl infusion in high doses on patients admitted to neuro icu of indisa clinic during consecutive years ( - ). enteral tapentadol (through ng tube) mg/ hours, was considered in patients who required intravenous fentanyl in continuous administration. buprenorphine was also added at low doses ( ug/hr) in a weekly transdermal patch, in cases of neurosurgical spine patients, fractures and long-term neuropathic pain. pain was controlled on behavioral pain scale (bps) and visual analogical scale (vas) scores, according to the conditions of each patient. their hemodynamic, gastrointestinal complications and the appearance of delirium episodes according to cam-icu scale were recorded. results: patients received tapentadol. of them also received transdermal buprenorphine. all managed to maintain adequate level of analgesia, not requiring fentanyl at doses greater than . ug / kg / hr. distribution by diagnoses: neurotrauma patients, guillain barre , spine surgery , hsa , hice , malignant ischemic acv . complications: gastric retention patients ( %), hypotension ( %), acute hypoactive delirium ( . %), acute hyperactive delirium ( %). no drug interactions were found. the introduction of enteral tapentadol and buprenorphine patches in neurocritical patients was safe and resulted in a decrease in the use of endovenous opioids and its adverse effects. we hypothesized that changing the pain management for our post cardiac surgical patients to an assessment-driven, protocol-based approach using fast acting and easily titratable agents will significantly improve patient satisfaction by reducing pain intensity in the first h after surgery as suggested by society of critical care [ ] guideline. we prospectively assessed and ( . vs . ) consecutive patients before and after introducing our pain management protocol. the nursing and medical team received rigorous training on the guideline as well as the correct assessment using appropriate pain scores measured at least hourly (numeric pain score, ≥ is timing of beta-blocker (re)initiation versus incidence of afacs before and after prevention care bundle implementation, per post-operative day and for postoperative days - (insets) moderate to severe or critical care observation tool, > is moderate to severe). we introduced a multimodal approach with a combination of fast acting iv, long acting oral opiates, regular paracetamol and rescue iv boluses for difficult to control situations and we created a prescription bundle on our electronic prescribing record. among other variables we assessed hours spent in moderate to severe pain in the first h after surgery and compared to the data collected before the guideline was introduced. we analysed patients from and from . baseline characteristics were similar between the two groups. in only . % of the patients spent less than hours and . % spend more than hours in moderate to severe pain. the data showed significant improvement in that . % of patients spent less than hours and only % patients who spent more than hours in moderate or severe pain. (p < . , chi square) ( figure ). only % of the patient needed rescue medications. % of time was the protocol inadequate necessitating other approach. introducing an assessment driven, stepwise, protocolized pain management significantly improved patient satisfaction by reducing pain intensity in the first h on our cardiothoracic intensive care unit. introduction: proximal femur fractures are most common fractures in the elderly and associated with significant mortality and morbidity, with high economic and social impact. perioperative pain management influence outcomes and mortality after surgery with early mobilization being possible [ , ] . the goal of the study was to compare the efficacy and safety of the compartment psoas block for perioperative analgesia in elderly patients with proximal femur fractures. the randomized controlled study was held in medical center "into-sana" (odesa, ukraine) from january till july . patients with proximal femur fractures and older than years were included in the study. they were randomly allocated to groupscompartment psoas block group (bupivacaine analgesia was started as soon as possible before surgery and prolonged during and after surgery with additional ischiadicus block before surgery) and general (inhalational) anesthesia with systemic analgesia perioperatively. results: patients were included in this study. perioperative compartment psoas block was associated better pain control, decreased opioid consumption, better sleep quality, earlier mobilization after surgery, decreased incidence of opioid-associated vomiting/nausea and myocardial injury. there were no difference in the incidence of hospital acquired pneumonia and delirium. perioperative compartment psoas block is effective and safe for perioperative analgesia in elderly patients with proximal femur fractures, and is associated with better pain control and decreased complications incidence. parenteral olanzapine is frequently used in combination with parenteral benzodiazepines for hospitalized patients with severe agitation. the fda issued a warning for increased risk of excessive sedation and cardiorespiratory depression with this combination based on post-marketing case reports with overall limited quality of evidence [ ] . the purpose of this study is to evaluate the safety and efficacy of concomitant parenteral olanzapine and benzodiazepine for agitation. this retrospective chart review evaluated agitated patients who received concomitant parenteral olanzapine and benzodiazepine within minutes from / / to / / . the primary end points were rate of respiratory depression requiring mechanical ventilation and hypotension requiring vasopressors. the secondary end points were percentage of patients requiring additional sedatives for agitation during the same time frame, cumulative dose of olanzapine and benzodiazepine (midazolam equivalent) received, and rate of cardiac arrest and death. a total of patients were included with notable baseline characteristics: median age of years old, % with a history of substance abuse, and % with a history of psychiatric illness. for the primary outcomes, . % of patients required mechanical ventilation and % required vasopressors. additionally, . % patients received additional sedating agents to control agitation. refer to table for more details. no cardiac arrests or deaths were observed. concomitant use of parenteral olanzapine and benzodiazepine within minutes for the treatment of agitation appears to have a small risk of respiratory depression without significant hypotension. hip fracture is very common in the elderly,it causes moderate to severe pain often undertreated. ficb is a simple safe method, easy to learn and use. the aim of our study is to assess the efficacy and safety of preoperative ficb compared with intravenous analgesia for elderly patients with femoral fracture and hip surgery in terms of opioid consumption and perioperative morbidity methods: after informed consent obtained, patients - yo asa i-iii with hip fracture were randomized to receive either an us guided ficb( ml of ropivacaine , %) or a sham injection with normal saline ' before surgery. both groups were operated under general anesthesia. postoperative analgesia was done according to vas: vas - mm, paracetamol g iv at h, vas - mm, ketoprofen mg iv at h, vas> , morphine , mg/ kgbw iv. the primary outcome was the comparison of vas score at rest over the first 'following the procedure, at the end of the surgery and at h intervals for h. the secondary outcome were the incidence of the cardiovascular events, of the ponv and of the confusion episodes, the amount of morphine consumption for h results: at baseline, ficb group (a) had a lower mean pain score than the sham injection group (b). the same difference was observed over h of follow-up (p< . ). there was a significant difference between the two groups in total cumulative iv morphine consumption at h and in the incidence of ponv and confusion episodes ( figure ). ficb provides effective analgesia for elderly patients suffering from hip fractures, with lower morbidity and lower opioid consumption compared with intravenous analgesia. pain assessment in chronic disorders of consciousness patients with ani monitoring e kondratyeva, m aybazova, n dryagina almazov national medical reseach centre, minimally conscious research group, st petersburg, russia critical care , (suppl ):p pain and suffering controversies in doc to be debated by the scientific, legal and medical ethics communities. methods: ani (anti nociception index) monitor was used to assess pain in patients with chronic disordersof consciousness (doc) age range to years - in vegetative state/ unresponsive wakefulness syndrome (vs/uws) and minimal consciousness state (mcs). average age: in mcs group , ± , and , ± , in vs/uws group. neurological status was assessed using crs-r scale. the average score on the crs-r scale was ± . in vs/uws and . ± . in mcs. pressure on the nail phalanx was used as a pain impulse. ani and nociception coma scale was evaluated before the application of pain stimulus, immediately after and past minutes. prolactin level was measured before the pain stimulus application and minutes after. ani less than indicates pain, - hypoalgesia, severe pain. the mean value of the ani in mcs patients: before the pain stimulus . ± . , after the pain stimulus application ± . and minutes later . ± . . prolactin level in mcs patients before pain . ± . ng/ml; after pain . ± . ng/ml (p> . ). prolactin in vs/uws patients before pain . ± . ng /ml, after pain . ± . ng / ml (p> . ). conclusions: ani monitor revealed that vs/uws and mcs patients react equally to the pain impulse. prolactin dynamics showed poor statistical mean and can not be consider as a marker of nociception in this group of patients. it is possible that the level of pain impulse was insufficient neuroendocrine response activation or the increase of prolactin level occurs in the long term (more than minutes). in all patients the total hip arthroplasty tha is one of the most common major surgical procedures associated with significant postoperative pain that can adversely affect patient recovery and could increase morbidity. effective perioperative pain management allows an accelerated rehabilitation and improve the functional status of these patients. multimodal analgesia mma combines analgesics with different mechanism of action which by synergistic and additive effects enhance postoperative pain management and reduce complications. the aim of our study is to assess if perioperative association of very low dose of ketamine, a potent nmda antagonist and dexamethasone, by antiemetic and antiinflammatory properties could decrease opioid consumption and postoperative morbidity of patients with tha. after informed consent, patients scheduled for primary hip joint replacement surgery aged - yo asa i-iii were prospective randomized in two groups. both groups were operated under general anesthesia fentanyl/sevoflurane. supplementary, patients in group a received mg iv dexamethasone and mg at h and ketamine mg iv bolus at induction and mg/h iv during surgery. postoperative analgesia was done according to vas, - mm paracetamol g iv at h, - mm ketoprofen mg iv at h, vas> mm morhine , mg/kgbw iv. we recorded perioperative opioid consumption, the number of intraoperative cardiac events, vas score at the end of surgery and at h, the incidence of ponv and persistance of chronic pain at months. we obtain a significant less pain score at the end of surgery p< . in group a, no significant difference at h, a significant less chronic pain at months, a fewer npvo and cardiovascular events in group a, p< . ( figure ). a multimodal approach with very low doses of ketamine and dexamethasone could be efficent in the treatment of pain for elderly patients with hip arthroplasty, decreasing postoperative side-effects and reducing chronic pain persistance. introduction: treatment in an intensive care unit (icu) often necessitates uncomfortable and painful procedures for patients. chronic pain is becoming increasingly recognized as a long term problem for patients following an icu admission [ ] . throughout their admission patients are often exposed to high levels of opioids, however there is limited information available regarding analgesic prescribing in the post-icu period. this study sought to examine the analgesic usage of icu survivors pre and post icu admission. methods: patients enrolled in a post-intensive care programme between september and june . intensive care syndrome: promoting independence and return to employment (ins:pire), is a -week multicentre, multidisciplinary rehabilitation programme for icu survivors and their caregivers. patients' level of analgesia was recorded pre-admission and upon attending ins:pire, their level of prescribed analgesia was categorized using the word health organisation (who) analgesic ladder [ ] . results: . % of patients (n= ) were prescribed regular analgesia preadmission; this increased to . % (n= ) post-admission, representing a significant absolute increase of . % ( % ci: . % - . %, p< . ) in the proportion of patients who were prescribed regular analgesia pre and post icu. in addition, pre-admission, . % (n= ) of patients were prescribed a regular opioid (step and of the who ladder) compared to . % (n= ) post-admission, representing an absolute increase of . % ( % ci: . % - . %, p< . ). this study found a significant increase in analgesic usage including opioids in icu survivors. follow-up of this patient group is essential to review analgesic prescribing and to ensure a long term plan for pain management is in place. introduction: pain, agitation, and delirium (pad) are commonly encountered b patients in the intensive care unit (icu). delirium is associated with adverse outcomes, including increased mortality and morbidity. clinical guidelines suggest that routine assessment, treatment and prevention of pad is essential to improving patient outcomes. despite the well-established improvements on patient outcomes, adherence to clinical guidelines is poor in community hospitals. the aim of this quality improvement project is to evaluate the impact of a multifaceted and multidisciplinary intervention on pad management in a canadian community icu. a pad advisory committee was formed and involved in the development and implementation of the intervention. the -week intervention targeted nurses (educational modules, visual reminders), family members (interviews, educational pamphlet, educational video), physicians (multidisciplinary round script), and the multidisciplinary team (poster). an uncontrolled, before-and-after study methodology was used. adherence to pad guidelines in the assessment of pad by nurses was measured weeks pre-intervention and weeks post-intervention. data on patient-days (pd) and pd were available for analysis during the pre-and post-intervention, respectively. the intervention significantly improved the proportion of pd with assessment of pain and agitation at least times per -hour shift from . % to . % and from . % to . %, respectively ( figure ). proportion of pd with delirium assessment at least once per -hour shift did not significantly improve. a multifaceted and multidisciplinary pad intervention is feasible and can improve adherence to pad assessment guidelines in community icus. quality improvement methods that involve front-line staff can be an effective way to engage staff with pad. oversedation introduction: sedation is a significant part of medical treatment in icu patients. a too deep sedation is associated with a longer time of mechanical ventilation, lung injury, infections, neuromuscular disease and delirium, which can lead to a longer duration of icu hospitalization, as well as an increase of morbility and mortality. many patients spend a considerable amount of time in a non-optimal sedation level. a continuous monitoring system of the sedation level is therefore necessary to improve clinical evaluation. our goal was to evaluate the incidence of non-optimal sedation (under and over sedation) comparing the parameters expressed from ngsedline with clinical evaluations and to correlate oversedation and the incidence of delirium. we have studied a cohort of patients admitted to the icu of spedali civili of brescia university hospital requiring continuous sedation for more than hours. in addition to standard monitoring, the patients have been studied using next generation sedline (masimo). sedation depth was evaluated through rass scale and the presence of delirium was evaluated with cam-icu scale. we collected data from adult patients. our data showed high incidence of oversedation. of our patients had a sr> and had a psi level< . a logistic regression analysis was performed and it showed statistically significant association between incidence of delirium and the age of the patients (p . ). the association between delirium incidence and suppression rate time was at the limits of statistics significance (p . ) and was statistically significant for non neurocritical patients (p . ). our study didn't show an association between delirium and the total time of sedation. non-optimal sedation is an unsolved problem in icu, affecting lot of patients, with a major incidence of over-sedation compared to under-sedation. our study shows an association between sr levels and the incidence of delirium. predictors of delirium after myocardial infarction, insights from a retrospective registry m jäckel, v zotzmann, t wengenmayer, d dürschmied, c von zur mühlen, p stachon, c bode, dl staudacher heart center freiburg university, department of cardiology and angiology i, freiburg, germany critical care , (suppl ):p delirium is a common complication on intensive care units. data on incidence and especially on predictors of delirium in patients after acute myocardial infarction (mi) are rare. by analyzing all patients after acute mi, we aim to identify incidence and potential risk factors for delirium. in this retrospective study, all patients hospitalized for acute mi treated with coronary angiography in an university hospital in were included and analyzed. incidence of delirium within the first days of care attributed to the mi and was defined by a nudesc score ≥ , which is taken as part of daily care three times a day by especially trained nurses. this research is authorized by ethics committee file number / . results: patients with acute mi (age . ± . years, stemi, mortality . %) were analyzed. delirium occurred in ( . %) patients and was associated with a longer hospital stay ( ± . d vs . ± . d, p< . ). patients with delirium were significantly older than patients without ( . ± . vs. . ± . years, p< . ) and had more often preexisting neurological diseases ( . % vs. . %, p< . ) and dementia ( . % vs. . %, p< , ). multivariate logistic regression analysis suggested that odds ratio for delirium was higher in patients after resuscitation or . ( % ci . - . ), preexisting dementia or . (ci . - ) and in patients with alcohol abuse or (ci . - ). while maximum lactate was also connected to delirium or . (ci . - . ), infarct size or type had no effect on the incidence of delirium. in patients with mi, delirium is frequent. incidence is associated with clinical instability and preexisting neurological diseases rather than infarct size. incidence and risk factors of delirium in surgical intensive care unit ma ali, b saleem aga khan university, anaesthesia, karachi, pakistan critical care , (suppl ):p introduction: delirium in the critically ill patients is common and distressing. the incidence of delirium in the icu ranges from % to %. although delirium is highly common among intensive care patients, it is mostly underreported. to date, there have been limited data available related to prevalence of delirium in surgical patients. in a study published in , the risk was observed % in surgical and trauma patients [ ] . the purpose of this study was to find out the incidence and associated risk factors of delirium in surgical icu (sicu) of a tertiary care hospital. we conducted prospective observational study in patients with age more than years and who were admitted to the surgical icu for more than hours in aga khan university hospital from january to december . patients who had preexisting cognitive dysfunction or admitted to icu for less than hours were excluded. delirium was assessed by intensive care delirium screening checklist icdsc. incidence of delirium was computed and univariate and multivariable analyses were performed to observe the relationship between outcome and associated factors. delirium was observed in of patients with an incidence rate of . %. multivariable analysis showed that copd, pain > and . ] were also the strongest independent predictors of delirium while analgesics exposures was not statistically significant to predict delirium in multivariable analysis. delirium is significant risk factor of poor outcome in surgical intensive care unit. . there was an independent association between pain, sedation, copd, hypernatremia and fever in developing delirium delirium is an acute mental syndrome which may cause negative consequences if it is misdiagnosed [ , ] . the aim of this study was to determine the incidence of delirium in different intensive care units and reveal the risk factors. the study was performed with patients hospitalized in intensive care units of anesthesia, neurology and general surgery departments. written informed consent was obstained from patients or relatives. delirium screening test was performed twice daily with camicu (confusion assessment method for the icu). patients who met the study criterias, were evaluated for the possible risk factors of delirium and the data was recorded daily. patients were reevaluated after the treatment. the incidence of delirium was . %. delirium was found to increase with the length of stay (p < . ). the mean age of the patients with delirium was . . this was higher than the patients without delirium ( . ) (p< . ). visual impairment (p< . ), hearing impairment (p= . ), educational status (p= . ), hypertension (p= . ), mechanical ventilation (p = . ), oxygen demand (p= . ), midazolam infusion (p= . ), propofol infusion (p= . ), infection (p < . ), sofa (p = . ), apache ii (p < . ), nasogastric catheter (p= . ), aspiration (p < . ), number of aspirations (p< . ), enteral nutrition (p< . ), albumin (p= . ), steroid (p= . ), hypercarbia (p= . ) hypoxia (p= . ), sleep disturbance (p< . ) were found risk factors for delirium. oral nutrition (p< . ) and mobilization (p= . ) were found to prevent delirium development. various factors are important in the development of delirium. these risk factors should be considered in reducing the incidence of delirium in intensive care units. ). an unplanned and brutal stop of alcohol consumption, as it can occur during icu admission, may lead to an alcohol withdrawal syndrome (aws). the most severe clinical manifestation of aws is described as delirium tremens (dt). there are no current guidelines available for aws treatment in icu. the study's aim was to describe the clinician's practices for dt treatment and the outcome of dt in icu patients. observational retrospective cohort study in two icus of a universityaffiliated, community hospital in france. patient diagnosed for dt during their icu stay, as defined by dsm-v classification, were enrolled in the study. results: patients with dt were included between and . benzodiazepines was administered to % of the patients in order to prevent an aws. as associated measures, vitamin therapy was administered to % of the patients and % had an increased fluid intake (mean . l+/- . ). concerning the curative approach of aws, the treatment's heterogeneity was notable. there was a high frequency of treatment's association ( % of the patients), every patient had benzodiazepines and the use of second line treatments such as neuroleptic, alpha- agonist, propofol was variable ( figure ). complications of dt were the following: need for mechanical ventilation due to unmanageable agitation or acute respiratory distress ( % of the patients) self inflicted injuries such as pulling out of central lines, tubes, surgical drain ( %) falls ( %). seizures ( %). delirium tremens is a severe complication of an untreated aws, which can lead to serious adverse events in icu. the current lack of evidence concerning the management of aws in icu probably explains the heterogeneity of treatments. given the potential severity of aws in icu, further evidences are required to optimize care of aws in icu patients. the incidence and related risk factor of delirium in surgical stepdown unit s yoon , s yang , g cho , h park , k park , j ok , y jung asan medical center, nursing department, seoul, south korea; asan medical center, seoul, south korea critical care , (suppl ):p step down units (sdus) provide an intermediate level of care between the icu and the general medical-surgical wards. the critically ill patients who are in recovery after long-term intensive care or who require monitoring after acute abdominal surgery are admitted to sdus. delirium in critically ill patient is common and leads to poor clinical outcomes. it is, however, preventable if its risk factors are identified and modified accordingly. to determine risk factors associated with delirium in critically ill patients to admitted surgical sdu at asan medical center. this is retrospective study conducted on critically ill patients who were admitted to the sdu from september to april and able to express themselves verbally. delirium status was determined using the short-cam tool. data were analyzed by spss . software, using t-test, fisher's exact test and logistic regression. the incidence of delirium was . %( of patients) and hypoactive delirium( case, . %) was the most commonly assessed, followed by hyperactive delirium( case, . %), mixed type( case, . %). risk factors associated with developing delirium identified from univariate analysis were age(p= . ), admission via icu (p= . ), tracheostomy (p= . ), chronic heart failure (chf) (p= . ), invasive hemodynamic monitoring (p= . ), heart rate (p= . ). after adjusted in multivariate analysis; factors those remained statistically significant were old age (rr we identified risk factors consistently associated with incidence of delirium following admitted to surgical sdu. these factors help to focus on patients at risk of developing delirium, and to develop preventive interventions that are suitable for those patients. patients with sepsis frequently develop delirium during their intensive care unit (icu) stay, which is associated with increased morbidity and mortality. the prediction model for delirium in icu patients (pre-deliric model) was developed to facilitate the effective preventive strategy of delirium [ ] . however, the pre-deliric model has not yet been validated enough outside europe and australia. the aim of this study is to examine the external validity of the pre-deliric model to predict delirium using japanese cohort. this study is a post hoc subanalysis using the dataset from previous study in nine japanese icus, which have evaluated the sedative strategy with and without dexmedetomidine in adult mechanically ventilated patients with sepsis [ ] . these patients were assessed daily throughout icu stay using confusion assessment method-icu. we excluded patients who were delirious at the first day of icu, were under sustained coma throughout icu stay and stayed icu less than h. we evaluated the predictive ability of the pre-deliric model to measure the area under the operating characteristic curve. calibration was assessed graphically. of the patients enrolled in the original study, we analyzed patients in this study. the mean age was . ± . years and patients ( %) were male. delirium occurred at least once during their icu stay in patients ( %). to predict delirium, the area under the receiver operating characteristics curve of the pre-deliric model was . ( . to . ). graphically, the prediction model was not well-calibrated ( figure ). to predict delirium in japanese icus, we could not show the well discrimination and calibration of the pre-deliric model in mechanically ventilated patients with sepsis. introduction: delirium is a serious and common complication and in some cases it treatment is difficult. aim of the study was an evaluation of the prevalence, structure of delirium and efficacy of dexmedetomidine and haloperidol sedation in geriatric patients after femur fracture. after local ethic committee approval case-records of geriatric patients with femur fracture in the period from to in the institute of traumatology and orthopedics in astana were analyzed. patients was divided for groups: in dpatients with delirium treated by i/v dexmedetomidine ( . - . mkg/kg per hour), in g group patients with delirium treated by i/v galoperidol ( . - . mkg/kg). delirium was assessed by rass at day of permission and every day at a.m. the prevalence, structure of delirium and efficacy of sedation were analysed. results: by anthropometric and gender characteristics of the group did not differ. the average age in the d-group with delirium was . ± . years old, which was comparable to the g-group - . ± . years old (p = . ). all study participants had similar comorbidities. delirium in all patients debuted at . ± . days, with an average duration of . ± . days. the effect of dexmedetomidine was better and expressed in % decrease in the duration of delirium in compare to haloperidol (p < . ). dexmedetomidine provided a more controlled and safe sedation compared with haloperidol. the average consumption of narcotic analgesics in the subgroup with dexmedetomidine was two times less than in the subgroup with haloperidol. thus, the average consumption of trimeperidine hydrochloride in patients of group d was . mg versus . mg in group g (p = . ). in gerontological patients with femur fracture treatment delirium by dexmedetomidine was more effective in compare with haloperidol. when using dexmedetomidine, the consumption of narcotic analgesics in postoperative period was % less than with haloperidol. live music therapy in intensive care unit mc soccorsi , c tiberi , g melegari , j maccieri , f pellegrini , e guerra intensive care units (icu) are not comfortable for patients, relatives or next of kin. in the last years many news approaches were described to implement the humanization of medical treatments. the positive effect of music therapy in icu is well described, especially reducing delirium risk [ ] . the aim of this paper is describing the effect in patients and their family of a music live performance in icu. after ethical committee approval (procedure aou / , italy) for three months (november -january ) patients in icu were treated twice a week with live music therapy performed by coral vecchi-tonelli of modena, italy (fig. ). data were collected all awake and conscious patients. vitals parameters, gcs, raas and cam icu were collected before, during and after the treatment, at every performance. after the treatment a feedback questionnaire were given to patients and to next of kin. results: subjects were enrolled in the research with mean age of . years old, delirium rate before the treatment was . % later . %, raas does not show any difference. over % of patients were satisfied, and relatives felt less anxiety. we recorded also a satisfaction also in relatives not enrolled. the study does not demonstrate a delirium risk reduction for the small sample and the length treatment, anyway it was recorded a low delirium rate. the safety and the potential effect of music therapy are well known, surely the research underlines the feeling of patients and their next of kin: icu is the most stressful setting for admitted patients and its humanization is a current topic for medical literature. live performances could be an entertainment moment and probably create a moment of an interaction among patients, their family and medical and nurse: icu become more human. the high level of satisfaction push us to continue this experience. introduction: patients undergoing medical procedures benefit from distraction techniques to reduce the need for drugs alleviating pain and anxiety. this study investigates if medical hypnosis or virtual reality glasses (vrglasses) as adjuvant method reduces the need for additional drugs. in a prospective, randomized, interventional trial, patients undergoing procedures were stratified in four age groups, and randomly assigned into three arms by means of a closed envelope system. all patients received standard care for pain before the procedure; the control group received further drugs for pain and stress as indicated by the visual analog scale (vas; threshold / ) and comfortscore (threshold / ), two index groups received either medical hypnosis or vr glasses as a plus before and during the procedure. vas and comfort were scored continuously and analysed with the kruskal-wallis test. patients, parents and healthcare providers scored their satisfaction at the end. of included patients to years old, % were female. regardless of age, pain and comfort scores were similar before and at the start of the procedure (vas . - . ; comfort - . ), but as of one minute after starting the procedure, both vas and comfort reduced significantly more in both index groups compared to the control (p< . ), remaining far below the threshold for both pain and stress ( figure ). there was no advantage of one index group over the other (p= . ). there were no adverse effects. patients in the vr group were more satisfied than in the standard group (p= . ) or in the hypnosis group (p= . ). there was no significant difference in satisfaction of parents or healthcare providers. from the very start of the intervention, the application of either medical hypnosis or vr glasses significantly reduces pain and anxiety in patients undergoing medical procedures. more studies are needed but both are promising safe adjuvant tools to standard pharmacological treatment. music to reduce pain and distress due to emergency care: a randomized clinical trial ne nouira, i boussaid, d chtourou, s sfaxi, w bahria, d hamdi, m boussen, m ben cheikh mongi slim academic hospital, emergency department, tunis, tunisia critical care , (suppl ):p recent clinical studies have confirmed the benefits of music therapy in managing pain and improving quality of care in the emergency department. the aim wasto evaluate the impact of receptive music therapy on pain and anxiety induced by emergency care methods: a randomized controlled study in patients consulting the emergency department. two groups: the music therapy group; patients needed venous sampling, peripheral venous catheter or arterial catheter. will bless ten minutes music therapy by headphones and a second control group of patients with the same care without music therapy. consent was requested from all participants. the level of pain caused by the act of care was assessed by visual analogic scale. heart rate, blood pressure and the mood of the patient were assessed before and after emergency care. we assessed patient satisfaction, adverse events. patients admitted to the emergency room, patients with communication difficulties and non-consenting patients were not included results: two hundred and forty patients were included randomized in both groups, with music therapy and without music therapy, the results showed comparable characteristics between the two groups: demographic data, pathological history, and initial clinical presentation. after the session of music therapy a difference was noted in the evaluation of the mean vas who was in the group with music of . ± . versus . ± . in the control group p< . ci % [- . ; - . ], and the mean of diastolic blood pressure which was , mmhg in the first group against . mmhg for the control group p = . ci % [- . ; - . ]. as for the mood, the patients were more smiling after the act of care in the group music therapy. all patients were satisfied with their experience and % recommend this therapy to their relatives . music therapy may reduce pain and anxiety in patients during emergency care. the music therapy is the intervention of music and/or its elements to achieve individual goals within a therapeutic.the music has proved to have positive physiological and psychological effects on patients [ ] . patients admitted to the intensive care unit (icu) experience anxiety and stress even when sedated, negatively influencing recovery [ ] . methods: two groups are established, a music therapy group (mg) and a control group (cg). the first one undergoes music therapy interventions, it consists of -minutes sessions of live music. patients of the gc will receive the usual treatment established by the service protocol for weaning management and the data are collected during the same time interval. data collection includes mean arterial pressure (map), heart rate (hr), respiratory rate (rr), oxygen saturation (sao ) and temperature (t). a total of patients were recruited, of which patients had to be excluded for meeting any of the exclusion criteria (n= ). of which (n= ) were randomized in the gm and the rest to the gc (n= ) ic %. regarding delirium in gm ( . %) presented a positive cam-icu, while in the cg were ( . %) (p= . ). when analyzing the variables in the cg and gm, it was observed that there were no differences with respect to hr, rr and map variable ( figure ). according to the results, we can say that music therapy as a nonpharmacological strategy for management of anxiety and delirium in patients of critical care units, might be an useful tool for the management of patients in weaning of mechanical ventilation introduction: coagulopathy and basopenia are common features of anaphylaxis, but the role of coagulopathy in anaphylaxis remains uncertain. the aim of this study is to evaluate the association between coagulopathy and clinical severity or basopenia in patients with anaphylaxis. we conducted a single-center, retrospective study of patients with anaphylaxis about their coagulopathy. levels of fibrin degradation products (fdp) and d-dimer were analyzed with the cause of anaphylaxis, clinical symptoms, medications and outcomes. we also studied the levels of intracellular histamine as a biomarker of basophil degranulation in the peripheral blood in relation to fdp and ddimer. in total, sixty-nine patients were enrolled to the study, and the levels of intracellular histamine were analyzed in patients. the symptoms included respiratory failure (n= ), shock (n= ), abdominal impairment (n= ), and consciousness disturbance (n= ). thirty-two patients needed continuous intravenous vasopressors for refractory shock. the increase of fdp was significantly associated with consciousness disturbance (p= . ) and refractory shock (p< . ). the increase of d-dimer was also significantly associated with refractory shock (p= . ). there was no correlation between the levels of intracellular histamine and either of fdp or d-dimer (p= . and p= . , respectively). the increase of fdp and d-dimer were associated with severe symptoms of anaphylaxis, while they were not correlated with intracellular histamine. these results suggest that anaphylaxis is closely associated with coagulopathy in a mechanism which is different from basophile degranulation in anaphylaxis. cardiac manifestations of h n infection in a greek icu population e nanou , p vasiliou , e tsigou , v psallida , e boutzouka , v zidianakis , g fildissis agioi anargiroi hospital, attiki, greece; agioi anargiroi hospital, icu, attiki, greece critical care , (suppl ):p introduction: cardiovascular involvement in influenza infection occurs through direct effects on the myocardium or through exacerbation of pre-existing cardiovascular disease [ ] . the aim was to study cardiac manifestations in all pts admitted to the icu with severe influenza's attack. clinical, laboratory, electrocardiographic, echocardiographic and hemodynamic data were retrospectively recorded in all pts admitted to the icu due to influenza infection (winter -spring ). diagnosis was established by pcr on bronchial aspirates the next days after admission. myocardial injury was defined by troponin levels > pg/ml ( fold uln). left ventricular systolic dysfunction was defined as ef < % and was characterized as either global or regional. hemodynamic monitoring by fig. (abstract p ) . comparison between mg and cg transpulmonary thermodilution method (picco) was recorded in pts with shock (norepinephrine > . μg/kg/min). values are expressed as mean±sd or as median (ir). results: nine pts ( males) with a mean age . ± . years, apache ii ± . and sofa score . ± . were assessed. icu admission was due to ards ( ) and copd exacerbation ( ) . icu los was . ± . days and mortality rate was %. no history of vaccination or coronary heart disease was referred. results are shown in table . levosimendan was administered in pts with severe cardiogenic shock. in all survivors, shock and indices of myocardial dysfunction subsided till discharge. coronary angiography was performed in pt showing no abnormalities. mortality was attributed to septic shock and multi-organ failure. myocardial involvement, though common in influenza pts admitted to the icu, didn't contribute to a dismal prognosis. the cardioprotective effects of levosimendan could be related to the modulation of oxidative balance. we aimed to examine the effects of levosimendan in patients with cardiogenic shock or with ejection fraction (ef) lower than % on cardiac systo-diastolic function and plasma oxidants/antioxidants (glutathione, gsh; thiobarbituric acid reactive substances, tbars). in patients undergone coronary artery bypass grafting or angioplasty, cardiovascular parameters were measured at t (before the beginning of levosimendan, . mcg/kg/min), t ( h after the achievement of the therapeutic dosage of levosimendan), t (at the end of levosimendan infusion), t (at h after the end of levosimendan infusion), t (at the end of cardiogenic shock). the same time-course was followed for plasma gsh and tbars measurements. we found an improvement in cardiac output, cardiac index and systolic arterial blood pressure. ef increased from mean % to %. a reduction of central venous pressure and wedge pressure was also observed. moreover, indices of diastolic function were improved by levosimendan administration (e/e' from to ; e/a from > to < ) at early t . it is to note that an improvement of gsh and tbars was observed early after levosimendan administration (t ), as well ( figure ). the results obtained have shown that levosimendan administration can regulate oxidant/antioxidant balance as an early effect in low cardiac output patients. the modulation of oxidative condition could be speculated to play a role in exerting the cardio-protection exerted by levosimendan in those patients. table . early administration of vasopressors and their use in the emergency department was associated with survival in septic shock. this seemed to be independent of median map recorded in the ed. we excluded all the traumatic or post-myocardial infarction forms. out of patients, the tuberculous etiology was identified in cases ( , %), mean age was years, , % were men. patients reported a tb contact in their environment, had a medical history of pulmonary tb. after pericardiocentesis, the liquid was citrine yellow in cases and hematic in patients, no patient underwent surgical drainage in our serie. mycobacterium tuberculosis was found in the expectorations in cases and ada was positive in patients. hiv serology was negative in all our patients. a months anti bacillary therapy with isoniazid, rifampin, pyrazinamide, and ethambutol was initiated in all our patients with a good evolution in cases, deaths, chronic constrictive pericarditis, small pericardial effusion and lost to follow-up. althought cardiac tamponade is rarely caused by tuberculosis, this condition remains common in endemic countries such as morocco and affect younger population, hence the importance of a better knowledge of its prevalence and and multidisciplinary management and more importantly the treatment of the underlying cause using combined antibacillary medication that has shown satisfying results. . the main perceived limiting factor is the absence of a standardized didactic program, followed by mentor's availability in residents' perception and by mentor's experience in consultants' one. pocus teaching is present although not optimal and not homogenous in italian acc residency schools. standardisation of residents' ultrasound curriculum is suggested to improve ultrasound teaching. the study included a convenience sample of critically ill patients with supradiaphragmatic cvcs and a cxr for confirmation. us is used for direct confirmation of the guidewire in the internal jugular (ijv) or subclavian (scv) vein and visualizing the guidewire in the right atrium. to evaluate for pneumothorax, "sliding sign" of the pleura was noted on us of the anterior chest. results: patients have been included, % of the catheters have been placed in the scv and % in the ijv. it was possible to confirm the position of the cvc tip for . % ( correct, incorrect cxr) of (figure ). overall, it was not possible to identify the guide in the right atrium cases ( false negatives, of them due to the presence of defibrillator leads). regarding the case where an incorrect position was seen on cxr it was also detected on ultrasound: us of the inserted vein and a negative tte confirmation. in all cases it was possible to exclude a pneumothorax by us. these results show that bedside ultrasound might be a feasible technique to confirm the cvc positioning. it is important to note that the level of the operator's expertise is significant when assessing the feasibility of this method. we only had a limited sample size and the occurrence of only one misplaced catheter. these preliminary results need to be confirmed on a larger scale. central venous catheter (cvc) misplacement occurs more frequently after cannulation of the right subclavian vein compared to the other sites for central venous access. misplacement can be avoided with ultrasound guidance by using the right supraclavicular fossa view to confirm correct guidewire j-tip position in the lower part of the superior vena cava. however, retraction of the guidewire prior to the cvc insertion may dislocate the j-tip from its desired position, thereby increasing the risk of cvc misplacement. the aim of this study was to determine the minimal guidewire length needed to maintain correct guidewire j-tip position throughout an us-guided infraclavicular cvc placement in the right subclavian vein. methods: adult intensive care patients with a computed tomography scan of the chest were retrospectively and consecutively included in the study. the distance from the most plausible distal puncture site of the right subclavian/axillary vein to the junction of the right and left brachiocephalic veins (= vessel length) was measured using multiplanar reconstructions. in addition, measurements of the equipment provided in commonly used - cm cvc kits were performed. the minimal guidewire length was calculated for each cvc kit. the guidewires were up to mm too short to maintain correct j-tip position throughout the cvc insertion procedure in seven of nine commercial cvc kits. four of these are shown in table . when us guidance is used to confirm a correct guidewire j-tip position, retraction of the guidewire prior to the cvc insertion must be avoided to ensure correct cvc-tip positioning. this study shows that most of the commonly used - cm cvc kits contain guidewires that are too short for cvc placement in the right subclavian vein. the reliability of lung b-lines to assess fluid status in patients with long period of supine introduction: ultrasound-guided cannulation is usually done using either longitudinal or transverse approach. the oblique approach utilizes advantages of both these approaches allowing visualization of the entire course of needle including tip and lateral discrimination of artery from vein [ ] . the reported incidence of the complete overlap of femoral vein by the femoral artery is - percent [ , ] . we describe the use of the oblique approach for successful cannulation of such a femoral vein which is not possible by usual approaches (figure ). endothelial cells play a pivotal role in the atherogenic process. endothelial cell dysfunction (ed) is the main risk factor for cardiovascular diseases such as hypertension, coronary heart disease (chd) and peripheral occlusive disease (pod). these diseases significantly increase the risk for perioperative complications. therefore, identifying patients with ed is important and should influence our prospective perioperative strategy. however, sensitive tools to diagnose ed are still missing and do not belong to our standard of care. aim of this study was the validation of a new non-invasive method to detect ed and a correlation with a set of established an new endothelial biomarkers. the cohort includes preoperative patients without anamnestic relevant cardiovascular disease and patients with known peripheral occlusive disease (pod). we used non-invasive endopat® technology from itamar-medical to measure ed by changes in vascular tone before and after occlusion of the brachial artery and calculate a reactive hyperemia index (rhi). in addition, we measured established markers and alternative biomarkers potentially indicate vascular diseases such as substrates and products from the no-metabolism l-arginin, asymmetric/symmetric dimethylarginine (adma/sdma), von-willebrand factor (vwf) and sphingosine- -phosphate (s p). rhi was able to identify patients with pod. rhi was significant lower in patients with clinical signs and symptoms of pod (p< . ). among other markers adma was significant higher in pod patients compared to controls and correlates with rhi. the pad technology is a helpful non-invasive functional test to measure ed and seems able in identify patients with vascular disease. in future, a combination of anamnesis, new diagnostic tools and biomarkers may further increase our sensitivity in identifying risk-patients. single-lumen fr and triple-lumen fr peripherally inserted central catheters (piccs) for cardiac output assessment by transpulmonary thermodilution s d´arrigo achieving effective critical care in low-and middle-income countries is a global health goal [ ] , which includes the provision of effective point of care ultrasound [ ] . we sought to establish zambia's first focused critical care echocardiography training programme in a bedded icu at university teaching hospital, lusaka. the programme was accredited by the uk intensive care society fice programme, with teaching adapted for local disease patterns such as tuberculous pericardial effusions. parasternal, apical and subcostal windows were used to assess ventricular dysfunction, hypovolaemia, pleural effusion, alveolar interstitial syndrome and pneumothorax. zambian doctors working with critically ill patients received an intensive one-day course, followed by mentored scanning at the bedside. teaching was delivered by visiting fellows from the uk who are accredited in echocardiography and experienced ultrasound educators. patients with abnormal mean ci or hr suffer from increased hospital mortality. abnormality of mean svi was not associated with mortality. these data support accurate measurement of ci as a hemodynamic target and the normal range defined for ci. since ci also carries the hr information, ci seems to be the more important target than svi. our data cannot necessarily be interpolated to less invasive and less precise measurements of ci. an evaluative study of the novelty device with the function of auto-aspirating and pressure indicator for safety central venous catheterization ly lin, wf luo, cy tsao national taiwan university hospital, taipei, taiwan critical care , (suppl ):p previous studies have shown that . % of cvc attempts resulted in arterial punctures that were not recognized by blood color. to overcome the problem, our team has developed a concept of pressure detecting syringe that can indicate the artery puncture [ ] . based on previous research, different springs, the actuator of the design, have been evaluated to optimize the proposed device and reduce the risk of cvc procedure. tested devices -the inner-spring is set between the pressure indicator and plunger (fig. a ). three springs are tested. test condition -blood samples were simulated by glucose solution with absolute viscosities of and mpa-s. different blood pressures were applied to simulate the artery and vein (fig. b) . the response time (rt) is defined as the time required to show the indicating signal (is) which is the movement of the piston from the position in fig. b : a - to a - . the rt is strongly influenced by spring (fig. b) but every design can show the is when pressure is higher than mmhg, the assumed minimum artery pressure. the rt of s , the strongest spring design, is about s in the mmhg-pressure and high viscosity condition. during our tests we found the user can realize the is before the position be fully changed from fig. ib : a - to a - . thus, we believe the s rt, the worst case, is still acceptable. we also found the weak spring force may lead to difficulty to empty the syringe because the spring must to overcome the blood pressure and the friction between the piston and barrel. as a result, it was difficult for s to absolutely empty the syringe even if the blood pressure is only mmhg. the spring will be compressed as fig. b : a - and fail to push the piston when pushing the plunger forwardly, which is not acceptable in clinical use. the results indicate the feasibility of using the device to facilitate cvc and we believe the s or s are more suitable for the future application. introduction: models using standard statistical features of hemodynamic vital sign waveforms (vs) enable rapid detection of covert hemorrhage at a predetermined bleed rate [ ] . by featurizing interactions between vs we can train powerful hemorrhage detectors robust to unknown bleed rates. waveforms (arterial, central venous, pulmonary arterial pressures; peripheral and mixed venous oxygen saturation; photoplethysmograph; ecg) of healthy pigs were monitored min prior and during a controlled hemorrhage at ml/min (n= ) and ml/min (n= ). two sets of vs features were extracted: statistical features [ ] and maximal pairwise cross correlations between pairs of vs within a s lag over various time window sizes ( s, s, s, s); and normalized with pre-bleed data of each given animal. for each feature set, a tree-based (ert) model [ ] was trained and tested in a one-animal-out setting to mitigate overfitting on the ml/min cohort, and another trained on the ml/min and tested on the ml/min cohort. we evaluated models with activity monitoring operating characteristics curves [ ] that measure false alert rate as a function of time to detect bleeding. models using cross-correlations show no significant deterioration of performance when applied to detect bleeding at different rates than trained for, while standard models require s longer on average to detect hemorrhage at % false alert rate in the previously unknown setting ( figure ). correlations between vs data encode physiologic responses to hemorrhage in a way independent of the actual bleed rates. this enables training effective hemorrhage detectors using only limited experimental data, and using them in practice to detect bleeding that occurs at rates other than used in training. we validated a dataset of data lines containing hemodynamic variables and treatment options. we selected nine hemodynamic variables as inputs. furthermore, data were collected regarding underlying conditions: heart failure, septic shock, renal failure or respiratory failure or a combination. we applied datastories regression on the dataset (turnhout, belgium, www.datastories.com). six different interventions were analyzed as kpi: administration or removal of fluids, increasing or decreasing inotropes and increasing or decreasing vasopressors. finally, we elaborated and challenged predictive models to generate a decision algorithm to predict each kpi. we first looked at how each hemodynamic parameter impacts the prediction of each kpi individually and performed a standard correlation analysis as well as a more involved analysis of the mutual information content between each kpi and all other hemodynamic parameters individually. confusion matrix and variable importance was obtained for each kpi. the baseline hemodynamic parameters were: gedvi ± ml/m , evwli . ± . ml/kg pbw, svv . ± %, mbp . ± . mmhg, hr . ± . bpm, ci . ± . l/min.m . the results of the regression analysis identified the different variables of importance for each of the different interventions ( fig a) . based on these results the hemodynamic variables (hr, mbp, gedvi, elwi, ci, svv) were used to develop the final hemoguide prediction model ( fig b) . the hemoguide app can be used to advise physicians with respect to basic therapeutic decisions at the bedside or as an educational tool for students. with the collection of new data, the accuracy of the system may grow over time. the next step of the project is to develop a more-sophisticated suite: the icu cockpit. feedback function contributes to accurate measurement of capillary refill time r kawaguchi , ta nakada , m shinozaki , t nakaguchi , h haneishi , s oda chiba university, department of emergency and critical care medicine, chiba, japan; chiba university, chiba, japan critical care , (suppl ):p capillary refill time (crt) is well known as an indicator of peripheral perfusion. however, it has been reported to have an intra-observer variance, partly because of manual compression and naked-eye measurement of the nailbed color change. we hypothesized that a we developed a novel portable crt measurement device with an oled display that feedbacks weather the strength of the nailbed compression is enough and counts the time. we settled the target strength and time as n and seconds according to the study we reported before [ ] . examiners measured crt with and without the feedback function. the pressing strength and time during the measurement were evaluated. there was a significant difference among the pressing strength and time between the crt measurement using the device with and without the feedback function (strength: p< . ; time: p< . ). furthermore, intra-examiner variance was significantly reduced with the feedback function (strength: p< . ; time: p< . ). in all measurements without the feedback function, % was outside the optimal strength while the measurements with the feedback function % achieved the targeted range. without the feedback function, % could not reach the optimal time, while % with the feedback function did. in total, % of the measurements could not achieve the optimal pressing strength and time. the feedback function for crt measurements, guiding examiners to an optimal pressing strength and time, fulfilled the required measurement conditions and reduced intra-examiner variance. our novel portable device would assist an accurate crt measurement regardless of personal work experience. introduction: the aim of the study was to detect the difference of conjunctival microcirculation between septic patients and healthy subjects and evaluate the course of conjunctival microcirculatory changes in survivors and non-survivors over a hours period of time. this single-centre prospective observational study was performed in mixed icu in a tertiary teaching hospital. we included patients with sepsis or septic shock within the first hours after icu admission. conjunctival imaging using idf videomicroscope as well as systemic hemodynamic measurements were performed at three time points: at baseline, hours and hours later. baseline conjunctival microcirculatory parameters were compared with healthy control. a total of patients were included in the final assessment and analysis. median apache ii and sofa scores were ( - ) and ( - ) respectively. ( %) were in septic shock, ( %) required mechanical ventilation. patients were discharged alive from the intensive care unit. we found significant reductions in all microcirculatory parameters in the conjunctiva when comparing septic and healthy subjects. we found a significant lower proportion of perfused vessels and microvascular flow index (mfi) of small vessels during all three time points in non-survivors compared with survivors. in nonsurvivors we observed no significant changes in conjunctival microcirculatory parameters over time. however, survivors had significantly improved mfi of small vessels at second and third time points compared to first time point. microcirculatory perfusion in conjunctiva was altered in septic patients. over hours evaluation survivors in comparison with nonsurvivors had better microcirculatory flow with incremental improvement of microvascular flow index. healthy pigs were centrally cannulated for veno-arterial ecmo and precision flow probes were placed on the pulmonary artery main trunk for reference. ml boluses of iced . % saline chloride solution were injected into the ecmo circuit and right atrium at different ecmo flow settings ( , , , l/min). rapid response thermistors of standard pa-catheters in the ecmo circuit and pulmonary artery recorded the temperature change. after calibration of the catheter constants for different injection volumes in the ecmo circuit, the distribution of injection volumes passing each circuit was assessed and enabled calculation of pulmonary blood flow. analysis of the exponential decay of the signals allowed assessment of right ventricular function. calculated blood flow correlated well with true blood flow (r = . , p < . , figure panel a, individual measurements organ congestion is susceptible to be a mediator of adverse outcomes in critically ill patients. point-of-care ultrasound (pocus) is widely available and could enable clinicians to detect signs of venous congestion at the bedside. the aim of this study was to develop prototypes of congestion scores and to determine their respective ability to predict acute kidney injury (aki) after cardiac surgery. this is a post-hoc analysis of a prospective study in patients for which repeated daily measurements of hepatic, portal, intra-renal vein doppler and inferior vena cava (ivc) ultrasound were performed before surgery and during the first hours after cardiac surgery [ ] . five prototypes of venous excess ultrasound (vexus) scores combining multiple ultrasound markers were developed (figure ). the association between each score and aki was assessed using timedependant cox models as well as conventional performance measures of diagnostic testing. a total of ultrasound assessments were analyzed. we found that defining severe congestion as the presence of severe flow abnormalities in multiple doppler patterns with a dilated ivc (> cm), corresponding to grade of the vexus c score, showed the strongest association with the development of subsequent aki compared with other combinations of ultrasonographic features (hr: . there is an increasing awareness on the consequences of fluid administration in patients leading to the development of methods that evaluate the effects of fluids loading on the cardiocirculatory system. however, most of methods used in the clinical practice investigate the effects of fluids on the cardiac function, instead of investigating those on the determinants of venous return. besides volume of fluids, the determinants of fluid loading are the blood volume distribution and the availability of vascular bed. in this study we aimed to test non-invasively the effects of fluids administration on the venular compartment in the skeletal muscle. in addition to the mean systemic filling pressure (msfp), we calculated changes in the stressed and unstressed volumes (vs, vu) and the venular bed availability. we enrolled critically ill patients in our intensive care unit. we assessed volumes and pressures by the near infra-red spectroscopy on the forearm using graded venous occlusions in steps of mmhg from to mmhg. the msfp, vu and vs were measured as previously reported (microcirculation ; : - ). the vascular bed availability was measured by changes in the volume recruited from the occlusion maneuvers. all the measures were done at baseline and after a fluid load ranging from to ml. values were expressed as median and interquartile range. wilcoxon test was used to compare data and a p< . was considered as significant. introduction: hypotension is a common side effect of general anesthesia (ga) and is associated with organ hypoperfusion and poor perioperative outcome [ ] . post-induction hypotension (pih) is caused by the depressant cardiovascular effect of anesthetic drugs and could be amplified by hypovolemia. the aim of this study was to assess the ability of two echocardiographic fluid responsiveness markers to predict pih: the inferior vena cava collapsibility index (ivc-ci) and the velocity time integral change (Δvti) after passive leg raising. sixty patients > years of age and scheduled for elective surgery were included. ivc-ci and Δvti were measured before ga induction. anesthesia protocol, fluid infusion and vasopressor administration were standardized in all patients. pih was defined as a mean arterial pressure (map) < mmhg or a relative decline from pre-induction value of at least % within minutes of ga induction. receiver operating characteristic (roc) curve analysis was used. the optimal cutoff was selected to maximize the youden index (sensitivity + specificity − ). the measurement of ivc-ci and/or Δvti were unsuccessful in seven patients ( . %). pih occurred in patients (incidence %). the areas under the roc curves ( figure ) preload responsiveness might be detected by the changes of cardiac index (Δcimini) induced by a "mini-fluid challenge" (mini-fc) of ml or even by the changes (Δcimicro) in response to a "micro-fluid challenge" (micro-fc) of ml. however, the smaller the fluid challenge, the larger the "grey zone" of diagnostic uncertainty. we tested whether ( ) micro-and mini-fc monitored by calibrated pulse contour analysis detect preload responsiveness and ( ) adding ml when the result of a micro-fc is within the grey zone improves diagnostic accuracy. in patients with circulatory failure, we infused ml saline over s followed by ml over s. we measured Δcimicro and Δcimini by the pulse contour analysis (picco ). preload responsiveness was defined by an increase in ci (Δciplr) during a passive leg raising test ≥ %. diagnostic uncertainty was described by calculating the grey zone after bootstrapping. Δcimicro were larger in responders than in non-responders ( . for the micro-fc, the area under the receiver operating characteristic curve was . ± . (threshold %), while it was . ± . for the mini-fc (threshold %). for the micro-fc, the grey zone ranged from . % to . % and included ( %) patients. for the mini-fc, it ranged from . % to . % and included ( )% patients, among which were already in the grey zone of the micro-fc. when evaluated by pulse contour analysis, micro-and mini-fc reliably detect preload responsiveness but with a large diagnostic uncertainty. it seems that adding ml more fluid to a micro-fc when its result is within the grey zone does not improve the diagnostic accuracy. the study is ongoing. the starling-sv bioreactance device (cheetah medical) reliably detects passive leg raising (plr)-induced changes in cardiac index (Δci). we tested whether it can also track the small and short-time Δci induced by the end-expiratory occlusion (eexpo) test, and whether shortening the time over which it averages cardiac output ( s in the commercial version) improves the detection. in mechanically ventilated patients, during a -sec eexpo, we measured Δci (in absolute value and in percentage) through calibrated pulse contour analysis (ci pulse , picco device) and starling-sv. for the latter, we considered both ci starling- provided by the commercial version and ci starling- obtained by averaging the raw data over s. we calculated the correlation between Δci pulse and both Δci starling- and Δci starling- , and the area under the receiver operating characteristic curve (auroc) to detect preload responsiveness, defined by a plr test. when considering absolute values, the correlation coefficient r between Δci pulse and Δci starling- was . (p= . ), which was lower than the one between Δci pulse and Δci starling- (rr comparison). when considering percentage changes, no correlation was observed between Δci pulse and Δci starling- . conversely, the correlation coefficient between Δci pulse and Δci starling- was . (p= . ), but it was lower than the one obtained for absolute values (p= . for r comparison). eexpo-induced Δci starling- , both in absolute values and in percentage, detected preload responsiveness with aurocs of . (sensitivity %, specificity %) and . (sensitivity %, specificity %), respectively. shortening the averaging time of the bioreactance signal increases the reliability of the starling-sv device to detect eexpo-induced Δci. moreover, the accuracy of the method is increased when absolute rather than percentage changes of ci are considered. fluids are among the most prescribed drug in intensive care, particularly among patient with circulatory failure. yet, very little is known about their pharmacodynamic properties and this topic has been left largely unexplored. there is a lack of strong scientific evidence in current guidelines for fluid administration in shock. several factors may impact the hemodynamic efficacy of fluids among which the infusion rate. the aim of this study was to study the influence of fluids administration rate on their pharmacodynamics in particular by studying mean systemic pressure (p ms ). we conducted a prospective observational study in patients with circulatory failure to compare two volume expansion strategies. when a patient required a fluid bolus, ml of normal saline were administered and several hemodynamic parameters were recorded continuously: cardiac output (co), arterial pressure (ap), mean systemic pressure (p ms ). infusion rate was let to the discretion of the attending physician and a "slow" and a "fast" group were determined based on the median of the infusion time. fluids effect was measured by the area under the curve (auc), maximal effect (e max ) and time to maximal effect (t max ) for each hemodynamic variable. results: p ms auc was higher in the "fast" group compared to the "slow" group (p= . ). we observed a shorter t max and a higher e max for p ms in the "fast" group compared to the "slow" group (p= . and . respectively). regarding co, t max was also shorter in the "fast" group (p= . ). auc and e max were similar between the two groups. fluid effect dissipated within minutes following the end of fluid infusion for every patient in both groups. the decreasing slope from maximal effect was comparable in the groups, for p ms and co alike. the effect of a ml fluid bolus in septic shock patients vanished within one hour. a faster infusion rate increased maximal effect and shortened the delay to reach it. study is ongoing. fluid management in the control arm of sepsis trials aa anparasan, ac gordon, mk komorowski imperial college london, department of surgery and cancer, london, united kingdom critical care , (suppl ):p in the past, high-volume intravenous fluid resuscitation in severe sepsis and septic shock was common. more recently, concerns over the harmful effects of this practice have led some clinicians to adopt less liberal fluid strategies. we sought to analyse temporal trends in fluid administration in the control arms of recent adult sepsis trials and assess any correlation with patient severity and mortality. a literature search was conducted to identify relevant randomized controlled trials that reported fluid administration published post . we recorded outcomes: total amount of iv fluid administered in the control arms of these trials between hospital admission and hour and hour following trial enrolment, mortality rates at the latest reported time point and apache-ii score at admission. we computed the pearson correlation coefficient and linear regression between study dates and the outcomes. we identified relevant trials [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , which recruited a total of , patients in their control arms, from to . the temporal analysis revealed no obvious trend in the in the total volume of iv fluid given by hour following trial enrolment (correlation p= . ) ( figure ). however, the total volume of fluid given by hour decreased significantly over the period of interest (r=- . , p= . ). in parallel, we observed a decrease in mortality (r=- . , p= . ) but there was no evidence of decrease in illness severity over time (p= . ). we found that in published rcts over the last two decades, the amount of intravenous fluid given to patients with sepsis in the initial hours did not appear to change, however less intravenous fluid was given over the first three days. upcoming large rcts will test the safety and efficacy of restrictive fluid administration approaches in sepsis. clinical practice guidelines recommend prompt intravenous (iv) fluid resuscitation for pediatric sepsis, including an initial fluid bolus of ml/kg [ ] . however, recent evidence is conflicting as to the effectiveness, volume, and consequences of aggressive fluid resuscitation in septic children. therefore, we sought to determine the epidemiology of early iv fluid resuscitation in an integrated health system, specifically at community hospital emergency departments (ed). we studied a retrospective cohort of pediatric patients (ages > month to < years) with sepsis identified in electronic health record data at community eds in southwestern pennsylvania from to . sepsis was defined as ) suspected infection (combination of fluid culture collection and administration of antibiotics and ) organ dysfunction (pediatric sofa score ≥ ) within hours of suspected infection. fluid bolus therapy was defined as electronic documentation of administration of . % normal saline iv bolus within hour of the time of sepsis onset. results: among , patients with pediatric sepsis, ( %) received iv fluid bolus therapy within hour of time of sepsis onset. the volume of fluid administered ranged from ml/kg to ml/kg (figure , panel a), corresponding to a median volume of ml/kg (iqr - ml/kg). patients who received ≥ ml/kg of fluids (n = , %) were younger (mean age years, sd vs. years, sd ; p< . ), more often had blood cultures collected during evaluation ( % vs. %, p= . ), and were more often transferred to another facility ( % vs. %, p< . ) when compared to patients who received < ml/kg of fluids (n = , %). mean fluid bolus volume within hour of time of sepsis onset by hospital ranged from ml/kg to ml/kg (figure , panel b) . in a cohort of community emergency departments, % of septic children received intravenous fluid boluses within one hour, and of those, only one half received volumes concordant with guidelines. (figure ). a wide range of fluid balance exists in septic shock patients cared for in icu. trends of serum albumin in septic and non-septic critically ill introduction: the link between hypoalbuminaemia and poor outcomes in critical care is well established [ ] . limited data are available on serum albumin trends during critical illness [ ] . in this study we assessed trends in serum albumin for up to days in both septic and non-septic critically ill patients. we retrospectively examined the records of adult patients admitted to critical care at the royal liverpool university hospital between and . we then excluded patients who did not have albumin data available for the first days, leaving us with patients. patients ( . %) had sepsis, and of these patients had died by day . of the non-septic patients ( . %), patients had died by day . albumin levels were collected for days from admission to critical care, in addition to other demographic and biochemical data. statistical analysis was performed using repeated measures analysis. septic patients had lower serum albumin than non-septic patients throughout the day period (p< . ). we observed a decrease in albumin by day in all groups, with levels increasing over the subsequent days. there was no difference in daily serum albumin between non-septic patients who survived or died. this is the first study, to our knowledge, to compare albumin trends in septic and non-septic critically ill patients over days. further research is needed to elucidate the optimal recipients and timing of albumin therapy. introduction: burn injury is characterized by marked inflammation, capillary leakage, and profound hemodynamic alterations. early albumin resuscitation is avoided fearing a paradoxical fluid escape into the interstitium. on the other hand, administration of crystalloids in massive amounts causes tissue edema and fluid extravasation, which deteriorates tissue perfusion by increasing oxygen diffusion distance. albumin administration could reduce the amount required to maintain hemodynamic stability in this population. we investigated whether albumin improves tissue perfusion and microcirculation by reducing tissue edema. this is an observational study conducted in the burn unit of maasstad hospital, rotterdam. patients with burns higher than % of total body surface area (tbsa) were included in the study. sublingual microcirculation was measured at admission (t ), (t ), and (t ) hours after burn injury. total vessel density (tvd) and functional capillary density (fcd) were analyzed. fluid management was calculated according to the modified parkland formula. albumin ( %) infusion was started hours after the burn insult. a total of nine patients were recruited between january and december . patients were included in the study after . ± . hours of the insult with a mean tbsa of ± %. the amount of crystalloid infusion was ± ml and ± ml at t and t ,respectively. within the first h (t ) ± ml albumin was given. tvd decreased from . ± . at t to ± . at t (p< . ) (figure ) introduction: spontaneous bacterial peritonitis (sbp) accounts for ≥ % of the bacterial infections that occur in patients with cirrhosis, and sbp has a high mortality rate ( % to %). albumin infusion has been shown to improve the outcome of sbp. the aim of this study is to examine the impact of albumin infusion on hospital length of stay (los) for cirrhotic patients with sbp. we utilized a nationwide electronic health record data set (cerner health facts®) to extract real-world data on adult patients (≥ years old) with cirrhosis and sbp who received antibiotics and admitted between january , , and april , . international classification of diseases (icd- / ) codes were used to identify cirrhosis and sbp. we used laboratory data for calculation of the model for endstage liver disease sodium (meld-na) score and vital signs data for calculation of the quick sepsis related organ failure assessment (qsofa) score at baseline for each encounter. a generalized linear model was used to assess the relationship between albumin infusion and hospital los. results: there were , encounters that identified patients with sbp and cirrhosis, of which , survived hospitalization. albumin was infused within hours of admission ('early albumin') in % (n= ), after hours in % ('late albumin', n= ), and not administered in % ('no albumin', n= ). meld-na was higher at presentation in early albumin cases versus late-or no-albumin cases (mean . and . ). unadjusted los was lower in patients receiving early albumin ( . days versus . days). risk-adjusted analysis demonstrated that early albumin led to a . % reduction in los ( % ci . %- . %, p = < . ). in these real-world data, albumin infusion within hours of admission in patients with cirrhosis and sbp was associated with a shorter hospital stay despite more severe illness. early albumin may not only improve clinical outcomes but may also reduce the costs of hospitalization in cirrhotic patients with sbp. early albumin use in patients with septic shock is associated with a shorter hospital stay: real-world evidence in the united states introduction: septic shock is among the most common critical care illnesses and incidence is rising, with mortality in excess of %. septic shock predisposes patients to multiple organ failure. while albumin is effective in management of circulatory dysfunction in septic shock, its utilization in this population is understudied in the us. we evaluated the impact of albumin utilization on hospital length of stay (los) among septic shock patients. we used a nationwide electronic health record data set (cerner health facts®) to extract real-world data on adult patients (≥ years old) with severe sepsis or septic shock, admitted between january , , and april , , identified by international classification of disease (icd- / ) codes, and receipt of antibiotics and vasopressors. we calculated the charlson comorbidity index (cci) and the acute physiology score (aps) at baseline. a generalized linear model was used to examine the association between albumin and hospital los, especially accounting for the timing of albumin infusion. we identified , unique visits for septic shock patients that survived to discharge. albumin was infused within hours of admission ('early albumin') in %, after hours ('late albumin') in %, and not administered in %. both cci and aps were higher, at presentation, in early albumin cases than late-or no-albumin cases (mean: . and . , and . and . , respectively). unadjusted los was slightly lower in patients receiving early albumin ( . days versus . days). a risk-adjusted analysis demonstrated that early albumin was associated with . % shorter los ( % ci . %- . %, p = . ). albumin infusion within hours of admission was associated with a shorter length of hospital stay. early albumin infusion may lead to better outcomes and reduced costs in patients with septic shock. further research is being conducted to assess other potential benefits of early albumin administration in this patient population. every new septic event follows by hemodynamic instability may lead sequentially to decreased organ perfusion, multiple organ failure. acute renal failure is recognized clinical feature during sepsis (up to - % in all cases). furthermore, urine output close monitoring is a cornerstone diagnostic clinical tool in each septic critically ill patient. in present study, we analyzed the dynamic minute-to-minute changes in the urine flow rate (ufr) and also the changes in its minute-to-minute variability (ufrv) during new septic event in critically ill patients. demographic and clinical data were extracted from the of critically ill patients who were admitted to the icu and developed new septic event (followed by fever and leukocytosis) and analyzed. a foley catheter was inserted into the urinary bladder of each study patient. the catheter was then connected to electronic urinometer, a collecting and measurement system which employs an optical drop detector to measure urine flow. the urine flow rate variability (ufrv) is defined and calculated as the change in ufr from minute to minute. results: ufr and ufrv both decreased significantly immediate after new septic episode until beginning fluid resuscitation (ppvalues < . ) (figure ) . statistical analysis by the pearson method demonstrated a strong direct correlation between the decrease in ufr, ufrv and the decrease in the map (r= . , p= . ; r= . , p= . ) ( figure ), and heart rate (r= . ,p=< . ) since systemic pressure starts to drop. ufrv and ufr demonstrated good clinical response to fluid administration despite the fact that systemic blood pressure did not improve (figure ) . we consider that dynamic changes in ufrv and ufr could potentially serve as a more sensitive signals ofclinicaldeterioration during the new septic event in critically ill patients.we also suggest that those parameters mightbeable to identify the optimal end-point of fluid resuscitative measures in septic critically ill patients. diminished urinary output (uo) is largely used as marker of acute kidney injury (aki) in critically ill patients. we aimed to explore the role of urinary output on incidence and mortality of aki developed during icu admission. the study population consists of all patients admitted between and to one of the dutch icus included in the nice database with an icu length of stay of at least hours, having daily measurement of creatinine and uo. only patients without renal replacement therapy that have a serum creatinine lower than . mg/dl ( . μmol/l) or a uo above . ml/kg/h on the day of the index icu admission were considered at risk for aki. patients were followed during their icu stay and classified according to the highest kdigo criteria reached based on creatinine alone (model ) and creatinine plus uo (model ) using icu admission serum creatinine as baseline. in both models, patients were classified as: no aki, renal impairment at the first day of icu admission, aki stage , aki stage , and aki stage . we identified , patients ( % male, mean age years, median icu-los days). of those, . % of patients had renal impairment at the first day of icu admission. among the remaining patients, . % in model and . % in model were classified as having no aki, . % and . % as aki stage , . % and . % as aki stage , and . % and . % as aki stage , respectively. survival at -day markedly differed according to the aki classification model used (figure) . similarly, adjusted hrs for -day mortality differed among patients with and without aki compared to patients with renal impairment at the first day of icu admission ( figure ) . among patients admitted to the icu % had renal impairment at the first day of icu admission. our findings suggested that uo plays an important role both on aki incidence and mortality and should be carefully interpret in the clinical setting especially in aki stage classification. introduction: acute kidney injury (aki) mostly attributed to renal tubular damage, has a high morbidity and mortality outcome [ ] , so a sensitive tool to assess the degree of tubular affection is needed for early detection and management of this condition. we investigated the ability of furosemide stress test (fst) (one-time bolus dose of mg/kg or . mg/kg if on prior furosemide-intake) to predict progression to akin stage-iii in critically ill subjects with early aki. we studied subjects; consecutive patients in group i receiving fst and consecutive patients in group ii receiving standard medical management for aki; patients ( . %) and patients ( %) met the primary endpoint of progression to akin-iii in groups i and ii respectively. patients with progressive aki had significantly lower urine output following fst in the first hours (p< . ). the area under the roc curves for the total urine output over the first hours following fst to predict progression to akin-iii was . (p = . ). the ideal-cutoff for predicting aki progression during the first fig. (abstract p ) . thirty-day survival according to aki classification model and model . hazard ratios (hrs) for -day mortality adjusted by sex, age, type of admission, apache iv score, sofa score at day of admission (excluded renal sofa score) for patients with aki classified with model and model fig. (abstract p ) . clinical correlation between urine flow rate variability (ufrv) and ufr and mean arterial blood pressure over new septic event (black arrows) and and after initial fluid resuscitation (red arrows). note: the ufrv and ufr decreased progressively in parallel with the falling mean arterial blood pressure and, than, rose again after the administration of fluids hours was a urine volume of less than milliliters with a sensitivity of . % and specificity . % group receiving fst. on the other hand, statistically significant hypotension, hypo-(kalemia, phosphatemia and magnesemia) occurred in group i. the fst in patients with early aki could predict liability for progression of aki, however it should be performed under adequate monitoring. introduction: ischemia-reperfusion (ir) causes renal dysfunction and damage. ir induces renal tubular injury triggered by hypoxia and hyperoxia, mediated by oxidative stress and inflammation. furosemide inhibits na + -k + - clcotransporter in the thick ascending limb of the renal medulla to decrease na + reabsorption, reducing oxygen consumption. we investigated if furosemide could improve renal oxygenation, function and damage by reducing o consumption and oxidative stress after ir. methods: wistar albino rats were divided into groups, with in each group; sham-operated control (c), control + furosemide (c+f), ir and ir+f. after anaesthesia (bl), min supra-aortic occlusion was applied to ir and ir+f groups followed by min (t ) and hours of reperfusion (t ). furosemide μg/kg/h infusion was simultaneously administered to c+f and ir+f after ischemia. systemic hemodynamic, renal blood flow (rbf), renal vascular resistance (rvr), renal oxygen delivery (do ren ), renal oxygen consumption (vo ren ), creatinine clearance (ccr), sodium handling, urine output (uo), cortical (cμo ) and medullar (mμo ) microvascular oxygenation were measured. results: rbf was reduced in ir ( . ± ) and ir+f ( . ± ) at t (p< . ) but it was further reduced in ir+f ( . ± ) (p< . ) at t compared to c and c+f. rvr was increased in ir ( ± ) and ir+f ( ± ) at t compared to c. rvr was normalized in ir ( ± ) but not in ir+f ( ± ) at t compared to c (p< . ). cμo and mμo did not differ between groups after ir insults (figure ). tissue o was reduced at the medulla, but not at the cortex in ir+f group compared to ir. do ren and vo ren were reduced in ir ( ± and ± ml/ min) and ir+f ( ± and ± ) at t (p< . ). pc was higher in ir+f ( . ± . ) compared to ir . ± . (p< . ). vo / tna + was increased in ir+f compared to ir. no change in ccr and uo was observed. furosemide after ir causes further impairment of renal perfusion, energy utilization and renal oxygenation resulting in renal damage. acute renal failure induced by hypoxemia: incidence and correlation study a trifi , h fazzeni , a mehdi , c abdennebi , f daly , y touil , s abdellatif , s ben lakhal la rabta hopital, medical intensive care unit., tunis, tunisia; la rabta hopital, tunis, tunisia critical care , (suppl ):p introduction: acute renal failure (arr) is a common complication in icus and usually caused by hypoperfusion. arf induced by hypoxemia is a concept rarely reported in icu. its incidence and pathogenesis are not well understood. we aimed to study the relationship between hypoxemia and the occurrence of arf. retrospective cohort study including patients with hypoxemia whatever its etiology between january and august . patients with chronic renal failure were excluded. arf was defined and ranked according to the kdigo criteria . arterial blood gas, urea, creatinine and clearance were reordered on the first, third and seventh days of evolution. results: patients were included and groups were obtained: group of hypoxemic patients with arf (arf+, n= ): versus group of hypoxemic patients without arf (arf-, n= ). the incidence of hypoxemie-induced arf was therefore %. clinical characteristics were comparable in both groups with a mean age of ± and a sex ratio of . . the comparative study showed in arf+ group: a lower ph ( . . ], p = . ). the most significant correlation was showed with mdrd clearance at day and p/f ratio at day (rho = . , p = . ). multivariate analysis found that septic shock and non invasive ventilation in hypoxemic patients were the factors related to arf with respectively or= . , % ci= . - . , p= . and or= . , % ci= . - . , p= . . overall mortality was % (n= ) and arf was an independent factor of mortality: or= , and % ci= . - . , p = . . hypoxemia-induced arf is a common complication associated with excess mortality. our study suggests that renal function is correlated with the degree of hypoxemia and that this correlation is rather distinct hours from hypoxemia. in preclinical models of sepsis, we have previously demonstrated that activation of amp activated protein kinase (ampk) using metformin, improves survival and organ function. thus, ampk activation is a potential therapeutic target in sepsis, and we hypothesize that exposure to metformin during sepsis is associated with decreased aki and mortality methods: retrospective analysis of a -hospital cohort of adult icu patients with type diabetes mellitus (t dm) who presented sepsis. we investigated if exposure to metformin during the hospitalization was associated with reduced -day mortality and aki. we used : propensity score matching (psm), propensity score stratification (pss) and propensity score weighting (psw) based on the probability to be exposed to metformin using covariates. for psm an exact match for insulin, amputation, cardiovascular diseases, retinopathy, charlson index, egfr, hba c, and apache iii, were used. sepsis was defined using sepsis criteria, and aki as kdigo stage or . from , patients, we found diabetic adults exposed to metformin during hospitalization and , who were not. metformin exposure during hospitalization is associated with decreased -day mortality and aki in septic adult patients with t dm. these findings suggest that metformin may constitute a potential therapeutic strategy in sepsis, and the potential role of ampk activation as a protective mechanism. however, studies are needed to confirm this association and the specific mechanisms of action. introduction: acute kidney injury (aki) may occur up to % in the intensive care unit (icu). predicting aki recovery may allow for risk stratification of patients, patient and family counseling, and early post-discharge renal care planning. however, predicting aki recovery at an early stage remains a challenge. methods: this is a retrospective study of the epanic multicenter randomized controlled trial database [ ] , which was split into development (n= ) and validation (n= ) cohorts, and patients experiencing aki stage and/or renal replacement therapy (rrt) in the icu were included [ ] . aki recovery was defined as being alive, without any stage of aki, and without need of rrt at hospital discharge. a logistic regression model with backward feature elimination was developed. the model performance was assessed by discrimination, calibration, and net benefit analysis, and internally validated with ten-fold cross validation. only the results in the development cohort are reported. of the patients who developed aki , patients ( . %) recovered from aki. the multivariable model selected age, bilirubin, heart rate, mean arterial blood pressure, surgical diagnostic group on icu admission, mechanical hemodynamic support on icu admission, suspected sepsis on icu admission as aki recovery predictors. the model had a mean area under the receiver operating characteristic curve (auroc) of . (standard deviation (sd) . ), mean calibration slope of . (sd . ), and mean calibration-inthe-large of < . (sd . ) (figure ). at the classification threshold that maximized sensitivity and specificity, mean net benefit with respect to treat-none was . (sd . ) and mean net benefit with respect to treat-all was . (sd . ). by using the routinely collected clinical data, the developed prediction model can fairly identify patients with a higher chance of aki recovery at hospital discharge. introduction: acute kidney injury (aki) is a frequent complication in critically ill patients and is associated with increased morbidity and mortality. sepsis is one of the most common cause of aki. a prospective study was conducted over months (january -june , ).we included patients with septic shock at admission or at any time during hospitalization.the aki staging was based on kdigo criteria.patients were divided into two groups, a group with aki (aki+) and a group without aki (aki-).then we compared the baseline characteristics, laboratory and physiologic data. patients with aki (aki+) were subdivided according to their prognosis. were enrolled patients. the mean (sd) age was . (± ) years.sex ratio was . . fifty-two ( %) patients developed aki.sapsii and sofa score in admission were higher in patients with kidney injury [ vs points (p= . ), . vs points ;(p= . )] respectively.the serum lactate level was significantly higher in (aki +) group patients during the first day of septic shock [ . ± . mmol/l (aki+)vs . ± . mmol/l(aki-);(p= . ) ] and its clearance was lower [( ± . % (aki +)vs ± %(aki-);(p= . )]. a significant difference was observed in c reactive protein level [ ± mg/l (aki +) vs ± mg/l (aki-) ; (p= . )].among (aki+) patients, kadigo iii was observed in . % of cases.nineteen ( . %) patients received hemodialysis.a normal kidney function was recovered in . % of cases.aki+ patients had a higher occurrence in disseminated intravascular coagulation ( vs patients, p= . ),acute respiratory distress syndrome ( vs patients; p= . ) and cardiac dysfunction ( vs patient, p= . ).mortality was higher in aki group ( % vs %; p= . ). the development of septic aki was associated with poor outcomes and prognosis.a better understanding of sepsis induced aki pathway will enable us to develop targeted therapeutic protocols.newer tools,permitting aki early detection, may make these therapies more fruitful. this study aims to show that contrast procedures do not significantly increase the risk of renal injury and should not be deferred. traditionally ciaki is the most important cause of in-hospital renal failure after nephrotoxic drugs and shock. problem is also the non-uniform definition of ciaki proposed by three different initiatives (akin, esur and kdigo). akin, being the most rigorous, defines ciaki as an increase in serum creatinine > . mg/dl or > % of baseline within hours. a retrospective observational single-centre cohort study analyzed patients who underwent a contrast procedure with iomeron . the first group underwent a ct pulmonary angiography (ctpa), and the fig. (abstract p ). internally validated model performance: (top row) roc curve; (middle row) calibration curve; (bottom row) decision curve second a coronary angiography with pci. no patient was previously prepared (raas blockade removal, crystalloid administration etc). we studied demographics, history of ckd and comorbidities and their impact on the ciaki by the akin criteria. a total of patients were divided into two groups (ctpa and pci). ctpa group ( m, f) all had acute pe and the pci group ( m, f) were treated for acs. the mean age was and years respectively. ckd was more prevalent in the pci group ( pt vs. pt) possibly explained by the more advanced atherosclerotic disease. advanced chd (nyha iii/iv) was found in pt (pci) vs. pt (ctpa) while diabetes and shock were equally distributed ( pt and pt) in both groups. the mean amount of contrast was significantly higher in the pci group ( . ml vs. ml). the mean creatinine/egfr measured before and after contrast in the ctpa group was . the goal of this study was to determine whether changing the body mass (bm) with fat-free mass (ffm) in cockcroft-gault (cg) formula could provide a more accurate prediction of aki in obese patients undergoing cardiac surgery. in this retrospective study, we reviewed institutional data of patients who underwent elective cardiac surgery in a tertiary referral university hospital. baseline patient creatinine value was collected and gfr was estimated using the mdrd, ckd-epi and cg formulas. cg formula was further modified by replacing the bm with ffm derived from the bioelectrical impedance analysis. postoperative aki was defined by kdigo creatinine change definitions. accuracy of the egfr values to predict the aki was calculated with roc-auc analysis. all the calculations were performed in different categories of bmi. figure ). the egfr is a poor predictor of aki in obese patients undergoing cardiac surgery. the ffm modified cauckraft-gault formula yield more accuracy in this specific group. retroaki: a ten-year retrospective study of acute kidney injury in intensive and progressive care units introduction: acute kidney injury (aki) is a frequent condition in intensive care units (icu) and progressive care units (pcu), affecting % to % of the patients, depending on the studied population and aki definition. aki has been identified as an independent risk factor of icu mortality and development of chronic kidney desease. the objective of this study was to describe the incidence of each aki stages as defined by kdigo definition (with evaluation of urine output, serum creatinine and initiation of renal replacement therapy (rrt)), in a mixed medical and surgical population of patients hospitalized in icu and pcu over a -year period ( - ). we included all patients who stayed more than hours in icu or pcu of edouard herriot hospital from may to january . data used to classify the patients were the urine output over a sixhour period, serum creatinine and the need for rrt, according to kdigo classification results: , hospital stays were analyzed. median icu/pcu length of stay was days [iqr: . - . ]. among icu patients, % had at least one aki episode graded , or and % had at least one severe episode (stage or ). among pcu patients, % had at least one episode of aki and % a severe episode of aki. patients had an average of . episodes of aki per stay. table represents the incidence of maximal aki stage during one stay. we found that urine output was the more frequent criteria to make diagnosis of aki stage or whereas rrt was more frequent for aki stage . this retrospective study reports a more important aki incidence in our icu/pcu than in previous studies. the difference could be fig. (abstract p ) . when comparing auc in different categories of bmi, the mcg appeared to be the only statistically accurate formula in patients with bmi - . explained by the difficulty to collect urine output from conventional database. serum creatinine and the use of rrt are often the only two criteria used to define and classify aki. these results confirm the high incidence of aki in icu and pcu and the importance to make an early aki screening of patients for whom preventive nephroprotective actions are needed. introduction: icu-patients with acute kidney injury (aki) requiring renal replacement therapy (rrt) are at risk for infections [ , ] . in this study we evaluated the incidence of infection in icu patients with and without less severe aki. finally, impact on outcomes was explored. this is a retrospective study on the pdms (protection data management system) of the adult icus of a university hospital. aki was assessed on kdigo criteria (creatinine (scr) and urine output), during the first -d of icu stay. infection was validated in the pdms by a team of icu specialists. results: during a -year period, a total of subjects were enrolled. aki was diagnosed in . % of patients during icu stay. aki patients were older ( vs. y, p= . ), had higher saps ( vs. , p< . ), and had more urgent icu admission ( % vs. %, p< . ). more aki patients had mechanical ventilation ( % vs. %, p< . ) and vasopressors on d- ( % vs. %, p< . ). aki stage , , and was present in . %, . % and . % of patients. more aki patients had infection ( % vs. %, p< . ) and increasing aki stages were associated with higher infection rates (aki- : %; aki- : %, aki- : %, aki- : %, p< . ) (figure ). we observed - times higher mortality in aki patients with infection, and a stepwise increase of mortality with increasing aki stages. after correction for infection and other confounders we found that all aki stages were associated with in-hospital mortality (ors aki- : . , aki- : . , aki- : . , all p< . ). over half of aki patients experienced an episode of infection and increasing aki severity was associated with higher infection rate. aki patients with infection had marked higher mortality, suggesting that infection was an important driver of outcome. however, after adjustment, aki stages had strong association with hospital mortality. several new biomarkers have been introduced to improve early diagnosis of acute kidney injury (aki). "nephrocheck" (nc; astute medical, usa) is a bedside test calculating "akirisk" (product of urinary concentration of the cell cycle arrest-markers timp- and igfbp ). several studies suggest the usefulness of nc in selected populations. however, the value of early routine measurement of nc is unclear. methods: therefore, we compared the prediction of a combined endpoint (cep: death < days and/or requirement of renal replacement therapy rrt) by nc within h of icu admission (nc ) and h later (nc ) with admission values of serum-creatinine, bun, cystatin c, urinary ngal, apache ii and sofa (roc-analysis). as a secondary endpoint we investigated the additional value of pathological measurements of nc ≥ . critically ill patients showed increased relative uce in the first days of icu admission, which may be attributed to higher protein catabolism. increased relative uce was associated with arc and both had no effect on -day mortality. introduction: this study compared epidemiology, short-and long-term outcomes for patients with community-acquired (ca) and hospital-acquired (ha) acute kidney injury (aki). we retrospectively analyzed all episodes of aki over a period of . years ( - ) on the basis of routinely obtained serum creatinine measurements in , patients whose creatinine had been measured at least twice and who had been in the hospital for at least two days. we used the "kidney disease: improving global outcomes" (kdigo) criteria for aki and analyzed the first hospital admission. a total of were admitted in hospital and fulfilled the inclusion criteria. average observation period per patient was days. the incidence of ca-aki among included hospital admissions was . % compared with an incidence of . % of ha-aki, giving an overall aki incidence of . %. patients with ca-aki were younger than patients with ha-aki ( vs . y) and had significantly less comorbidities, including preexisting cardiac failure, ischemic heart disease, hypertension, diabetes. patients with ca-aki were more likely to have stage aki ( , vs , %, p< . ) and had significantly shorter lengths of hospital stay than patients with ha-aki ( vs d, p< . ). those with ca-aki had better survival than patients with ha-aki (figure ; p< the evidence base for management of fluid removal during renal replacement therapy (rrt) is limited. a recent international survey revealed the extent of practice variation worldwide [ ] . our aim was to summarise the responses from europe-based healthcare professionals who participated in the survey. the international self-administered, cross-sectional, internet-assisted, open survey was disseminated between january and january via website links and emails to members of different critical care societies. results: participants from european countries completed the survey of whom ( %) were intensivists and ( %) worked in university-based hospitals. persistent oliguria / anuria was the most common indication for fluid removal ( % responders). the parameters which guided fluid removal included hemodynamic status ( % responders), cumulative fluid balance since admission ( % responders), and -hour fluid balance ( % responders). % of participants reported using crrt with a median net ultrafiltration rate ml/hr (iqr - ml/hr) for hemodynamically unstable and a rate of ml/hr (iqr, - ml/hr) for hemodynamically stable patients. only % of practitioners checked net fluid balance hourly ( % nurses, % physicians). new hemodynamic instability, defined as new onset or worsening tachycardia, hypotension, or need to start or increase the dose of vasopressors was reported to occur in % fig. (abstract p ). long-term survival patients (iqr . - . ). different strategies to re-gain hemodynamic stability were used. (figure ) main barriers to fluid removal were patient intolerance ( % physicians, % nurses) and interruptions in fluid removal ( % physicians, % nurses). the majority of participants agreed that guidelines and protocols would be beneficial. the practice of fluid removal during rrt is very variable across european countries. nurses and doctors identified a need for evidencebased protocols and clear guidelines. introduction: kidney disease improving global outcomes (kdigo) guidelines suggest the use of anticoagulation in continuous renal replacement therapy (crrt) [ ] . the effectiveness of the anticoagulation is important because replacing the hemofilter and tube interrupts crrt and increases total therapy time. regional citrate anticoagulation (rca) and unfractionated heparin (ufh) are most commonly using methods for crrt anticoagulation [ ] . the aim of this study was to investigate the efficacy, safety and metabolic differences of the patients in icu who underwent crrt and anticoagulation method changed from ufh to rca for different reasons. after ethics committee approval ( - / ) patients who underwent crrt between - at bursa uludag university hospital icu have been investigated and patients who underwent crrt by both rca and ufh included in the study. we divided patients in two groups (rca, ufh), demographic data (sex, age), sofa score, creatinine, urea, mean filter life time (flt) and ultrafiltration flow (uf), platelets, electrolytes (na, k, ca, mg), lactate, nahco and ph of groups at beginning and ending of first rca and ufh hemodialysis collected. we used t-test and bootstraps statistic tests. in agreement with other studies [ , ] , flt and uf was statistically significant lower in ufh group (table ) . there was no statistically significant difference in efficiency (urea and creatinine decrease), ph, lactate, nahco level, platelets count and electrolytes between two groups. to our knowledge, there are no studies comparing these two anticoagulation methods in the same patients. small number of patients and retrospective evaluation are limitations of the study. our results suggest that the implementation of rca method is safe and effective as ufh method with longer flt and uf. regional citrate anticoagulation during crrt in liver failure mj jain, pk kumar g, dg govil, jk kn, sp patel, ms shafi, rh harne, dp pal, sm monanga medanta the medicity, critical care, gurugram, india critical care , (suppl ):p continuous renal replacement therapy (crrt) with regional citrate anti-coagulation (rca) is increasingly being used as a treatment modality in critically ill patients. there is limited experience of use of citrate anticoagulation patients with acute liver failure and acute on chronic liver failure who pose a tough challenge of being at a higher risk for bleeding. an institutional protocol was formulated for use of commercially available citrate solutions and the same was studied to assess filter life and safety of citrate in liver disease. the primary objective was to assess safety of citrate anticoagulation in liver disease. this study was a single centre, prospective, non-randomized, single arm, observational study. all adult patients, with acute liver failure and acute on chronic liver failure requiring crrt were included. blood ionized calcium levels of . to . mmol/l was targeted throughout the therapy and total to ionized calcium ratio of less than . was maintained. rca was stopped if the ratio was more than . for consecutive assessments. incidence of citrate accumulation and toxicity were assessed. average filter life was also assessed. metabolic parameters, electrolytes and strong ion gap were followed till hours after completion on crrt. a total of patients were included in the study. nineteen patients of acute on chronic liver failure and patients of acute liver failure underwent crrt with rca. baseline average serum bilirubin, lactate and inr were . mg/dl, . mmol/l and . respectively. the average filter life was hours minutes. citrate accumulation took place in (n= ) patients and rca had to be stopped for ( n= ) patients due to the same. none of the patients had evidence of citrate toxicity. citrate anticoagulation was well tolerated in patients with acute liver failure in patients with or without pre-existing chronic liver disease on crrt. introduction: the intention of this study is to highlight the levels of citrate load for the general population that increases the risk of citrate complications (insufficient trisodium citrate delivery; net citrate overload and citrate accumulation) [ ] . this was a prospective data collection between february and march in a fourteen bedded critical care unit. eleven consecutive episodes of crrt were collected (a new episode characterized if crrt was discontinued for hours and above). one episode was excluded due to short duration (less than hours). patients undergoing rca-crrt received either a fixed or ml/kg/h effluent dose protocol. median patient age was , male %. average time on crrt was . days ( - ). % of the patients had complications, although % were minor ( figure ). all of the patients with net citrate overload had citrate loads of . mmol/h or above. the main risk factors were found to be shock and liver impairment which occurred in % of cases of which % developed complications. a fixed dose effluent protocol to standardise practice can potentially lead to a higher risk of minor complications. in our experience this is likely due to a lack of appropriate monitoring for rca-crrt complications. despite this, our complication rate of citrate accumulation is in line with that reported in literature. citrate loads in our ml/kg/ hr protocol were . % higher than our ml/kg/hr protocol and strongly related to higher complication rate that worsened in patients with risk factors for poor citrate metabolism. introduction: there is no optimal timing of continuous renal replacement therapy (crrt) in acute kidney injury (aki); however, it is based on volume overload, azotemia, hyperkalemia and severe metabolic acidosis [ ] . an important reason for metabolic acidosis in aki is increased unmeasured anions (ua) [ ] . delta-ph-ua (Δph ua ) detects the degree of metabolic acidosis caused by ua and is calculated by using 'the partitioned ph model' [ ] . in this study, we investigated whether Δph ua was a predictor to start crrt in patients with aki. the study was designed as a multicentric, prospective, observational study in . patients who were ≥ years old and diagnosed with aki [ ] were included. the moment aki was diagnosed, arterial blood gas, albumin, magnesium, inorganic phosphorus, urea, creatinine and Δph ua values were recorded. all patients were divided into two groups as crrt(-) and crrt(+) which consists of patients performed crrt due to traditional criteria. fig. (abstract p ) . incidence of complications introduction: continuous renal replacement therapy (crrt) is labor intensive and requires advanced nursing knowledge and skills. however, % of registered nurses (rn) are less than -year post-registration experiences in our unit. also there is an increasing demand of crrt from crrt days in to crrt days in . the obstacles for crrt in our department, includes variation of regimen, complicated workflow and insufficient training of nurses. a continuous quality improvement project is carried out to standardize the regimen, enhance workflow and provide structured training to nurses in the intensive care unit, to enhance nursing competence. methods: introduction: sepsis and septic shock is a leading cause of mortality in the intensive care unit. we tried to evaluate a novel hemoperfusion cartridge through a retrospective evaluation of patient's data in our centre. we used it as an adjuvant therapy in our patients with sepsis and septic shock due to varied causes. the aim of this study was to evaluate the efficacy of therapeutic hemoperfusion cartridge (hc-foshan biosun medical ® ) in the management of patients with sepsis. we retrospectively analysed data of group (n= sepsis) and group (n= sepsis+hemoperfusison; sepsis treated with hemoperfusion cartridge) admitted between to . group had received hemoperfusion cartridge as adjuvant therapy along with standard of care. demographic data, procalcitonin [ ] and leukocyte levels before and after therapeutic cytokine removal and duration of hc were recorded. while the mean duration of cvvhdf was . hours, the duration of hemoperfusion cartridge (application was . ± . hours). among patients who survived patients were administered hemoperfusion cartridge within hours of icu admission. there was a significant reduction in scores like apache and sofa score post hemoperfusion cartridge therapy procalcitonin and leucocyte levels after therapeutic hemoperfusion cartridge were found significantly lower than the pretreatment values (respectively p= . , p= . ). retrospective analysis showed significant reduction of vasopressors, and improvement in map in group . therapeutic hemoperfusion cartridge with cytokine removal applied with cvvhdf in septic patients have positive contributions to provide survival advantage. removal of activated leukocytes and endotoxin from the blood is a complex therapeutic effect of the device for removing endotoxin. in the main group ( patients with abdominal septic shock) after surgery, the traditional treatment was supplemented with two sessions of endotoxin removal ( hours each with an interval of hours) using "alteco lps adsorber" (sweden). the control group consisted of patients with a similar diagnosis and only traditional treatment. results: % of white blood cells were adsorbed in lps adsorber. among them, granulocytes ( %) were maximally extracted, then cd + monocytes (cd + mo) ( %), hla-dr + mononuclear cells ( %), monocytes ( %). il- , il- , procalcitonin (pct) were not adsorbed. the -day mortality rate in the main group was % and was lower compared to the control group - %. during monitoring, in the main group hours after the first removal of endotoxin, a decrease in the initially increased amount of activated cd + mo by . times, as well as functionally mature defensin + granulocytes (def + gran) by . times was observed. il- , il- , and pct decreased by . ; . ; and . times, respectively. during this period, the control group showed an increase in cd + mo and def + gran, while il- , il- did not change, and pct increased . times. a day after the second removal of endotoxin and then days later, the main group of il- , il- , and pct continued to decline. in the control group, only il- decreased after days, the rest continued to grow. the cellular adsorption of endotoxin-bound cd + mo and mature def + gran is an important part of the mechanism of action of the endotoxin removal device. does the endotoxin adsorption of pmx column saturate in hours? preliminary study c yamashita in the euphrates trial, the polymyxin b-immobilized fiber column (pmx) hemoperfusion (hp) had no significant effect on -day mortality. endotoxin (lps) burden by endotoxin activity assay > . may exceed μg [ ] , so the dose and duration of pmx-hp could be insufficient to lower the lps burden. to confirm this issue, we experimented in a closed-circuit with h continuous lps addition, and pmx can adsorb > μg [ ] . further, lps concentration became constant within h in the single lps spike test for determining pmx-hp duration [ ] . to prove our hypothesis that the single lps spike test reflects the adsorption equilibrium, and not saturation, we added lps intermittently to reaction. methods: lps ( ng/ml) was mixed with ml deactivated fetal calf serum as a reflux solution, as previously described [ ] ; this concentration is much higher than that observed in septic patients. we created a closed circuit that incorporates pmx- r at / th the amount of an adult pmx and performed pmx-hp at ml/min for h. lps was added in two shots (post h: ng, ng/ml; post h: ng, ng/ml). lps was measured using the limulus amebocyte lysate test at , . , , , , and hr. after an initial decrease between and h, lps concentration did not decrease between and h after pmx-hp initiation. post lps pulse addition at h, it increased and then decreased till h. futher, it did not decrease between and h, but it increased and then decreased again after lps pulse addition post h (figure ). lps adsorption rates were . , . , and . % at , , and h, respectively. conclusions: lps adsorption capacity of pmx- r was maintained even after two additional shots of lps, suggesting that the constant lps concentration in the previously reported lps spike test might be indicative of adsorption equilibrium rather than saturation. a coohort study included patients admitted to three intensive care with sepsis / septic shock ( sepsis criteria ) and aki ( akin score). all patients were submitted to cvvhdf with the oxiris filter (baxter, usa) . the main clinical data, il , procalcitonin, endotoxin ( eaa ) and sofa score were evaluated at basal time ( t ) and at the end of the treatment ( t ). all data are expressed as mean ± sd or median and iqr . anova test was used to compare the changes in the time. results: patients were submitted to rrt with the oxiris filter for ± hours . patients had aki stage , patients aki stage and patients had aki stage. at t all groups had an high vasopressor fig. (abstract ) . lps concentration in lps pulse addition test support to maintain map ≥ mmhg. il , procalcitonin eaa and sofa total were also elevated with no difference between the groups. at t creatinine improved better in aki ( p< . vs. t ) and in aki ( p< . vs t ) then in aki group. map increased in aki ( p< . vs t ) and aki ( p < . vs t ) , but not in aki group. il , procalcitonin decreased more in aki ( p < . vs t ) then aki . at t sofa total was higher in aki then aki ( p< . ) and aki ( p< . ). conclusions: aki and aki stage patients submitted to bp with the filter oxiris respond better then aki stage patients . -this transalte in a better clinical course. -crrt with oxiris filter is useful in septic patients with aki, but aki stage septic patients represent an high risk group. a non-interventional, multicenter, non-randomized patient registry for multiple organ dialysis with the advos system multiple organ failure is a challenging problem in the icu. as an advanced dialysis system, the advos procedure can eliminate watersoluble and protein-bound substances, regulate the acid-base balance as well as fluid and temperature. in , a national registry was established to collect data under "real-life" conditions of patients treated with advos without any trial-specific interventions (drks id: drks ). methods: data from / to / from german hospitals (university hospitals in hamburg-eppendorf, mainz, essen, and klinikum weiden) were analyzed. clinical parameters, treatment settings and adverse events were documented. the -and -day mortality rates were compared with extrapolated rates based on the sofa score. results: patients with a median age of years (iqr - ), of whom ( %) were male, were evaluated. patients had a median sofa score of (iqr: - ) before the st advos treatment, which is associated with an expected mortality of %. the number of failing organs was (iqr - ): cardiovascular ( %), lungs ( %), liver ( %), kidneys ( %), coagulation ( %) and cns ( %). treatments with a median duration of (iqr: - ) hours were evaluated. were discontinued, of which ( %) were due to a device error. adverse events were documented, were related to the device (all due to clotting and recovered without sequelae). significant removal of protein-bound (bilirubin: . vs . mg/dl) and water-soluble toxins (bun vs and creatinine . vs . mg/dl). in addition, improvement in acid-base balance was observed: ph ( . vs. . ), bicarbonate ( . vs. . mmol/l) and base excess (- . vs. . mmol/l) ( table ) . -and -day mortality rates were % and %, respectively. in a cohort of patients with multiple organ failure, we observed an improvement in the expected mortality rate, especially if the advos procedure was applied early. adverse events are comparable to other dialysis therapies in intensive care patients. introduction: acute kidney injury (aki) due to ischemia-reperfusion affects onethird of the patients in cardiac surgery. we investigated the potential role of cyclosporine (csa) to prevent postoperative aki and mitigate inflammatory response to extracorporeal circulation (ecc). methods: double-blind, randomized, placebo-controlled single-center study. patients (n= ) scheduled for elective cardiac surgery were randomized to , mg/kg csa or placebo before the surgery. the primary objective was to assess the role of csa to reduce the incidence of postoperative aki. the secondary objective was to study csa induced changes in the inflammatory response to ecc. results: all enrolled patients were analyzed. postoperative aki was more pronounced in the cyclosporine group compared to placebo. or= . ( . - . ), % ci. the cytokine production in response to ecc was not affected by cyclosporine (figure ) . in patients undergoing cardiac surgery, a single preoperative dose of csa does not prevent the postoperative decrease in renal function. csa does not alter cytokine release in response to extracorporeal circulation. elevated post-ecc levels of pro-inflammatory cytokine il- are associated with kidney dysfunction and may be predictive. new generation adsorbent such as oxiris r was introduced as novel technique in renal support for critically ill patients [ ] . septic shock patients require decatecholaminization strategies emphasizing blood purification to remove catecholamine-producing mediators and evacuate overload fluid in interstitials. our -year-old female patient, admitted to icu after surgery with history of ovarium cancer. her septic shock was worsened with ards, hypercoagulable state and aki. vasopressors were set. patient was controlled with mode simv ,ps ,tv ml,peep ,fio %. renal support was implemented by diuretic and cvvh started on the second day. at first,regular adsorbent was used, post-filter mode was set, and periodic fluid removal target was ml/h. but after hours, no significant changes observed. oxiris r added and after hours passed, requirements of vasopressors reduced, tidal volume increased, hemodynamic parameters stabilized, urine production increased. it was continued for days and patient was recovered. our patient had fallen into inadequate cars stage in which not able to counter septic effects on vital organs (figure ). renal would be primary target for filtration and monitoring tool. adsorbent consisted of an and polyethyleneimine was useful to purify blood from endotoxins conjoined with slower filtration. continuous yet cautious process in cvvh evacuate fluid and mediators while maintain steady hemodynamics. biomarkers could not be evaluated due to limited resources, but improving parameters could be signs that showed recovery process had already took place. advanced hemofiltration is a privilege. implementing and enhancing it with new generation adsorbent would increase survivors by extracting unnecessary fluids and eliminating catastrophic endotoxins and mediators. consent to publish: written informed consent for publication was obtained from the patient. analysis of retrospective cohort study data of patients (pt) treated for dka at icu of kaunas clinics during - has been carried out. serum kalemia, glycemia; hypokalemia, hypoglycemia episodes; rate of insulin interruption for hypo-and normoglycemia during ketoacidosis; use of nah co for ketoacidosis, and los in icu were analysed. spss . was used for statistic calculations. traits evaluated as significant at p < . . at the beginning of dka treatment in totally hypokalemia ( . ± . mmol/l) was recorded in / pt ( . %). due to ignoring of blood ph ( . - . ( . ± . ) kalemia was falsely misinterpreted as "normo-" or "hyper-" . - . ( . ± . mmol/l) in / pt ( . %), thus disregarded so complicated by obvious hypokalemia additionally in / pt ( . %). in hypokalemia los in icu was . ± . vs . ± . h, p < . . insulin use has caused hypoglycemia ( . - . ( . ± . mmol/l)) in / pt ( . %), los in icu . ± . vs . ± . h, p < . .insulin use was interrupted in case of normoand hypoglycemia with still persisting ketoacidosis in / pt ( . %), los in icu was found to be . ± . vs . ± . hr, p < . . nah co was given for symptomatic treatment of ketoacidosis during first h of dka in / pt ( . %) with stable hemodynamic: hco - buffer has increased ( . ± . - . ± . mmol/l), p < . , but it didn't control ketoacidosis, and los in icu was . ± . . vs . ± . h, p < . . hypokalemia, hypoglycemia, precocious interruption of insulin use were recorded as complications of dka treatment. all of them have prolonged los in icu. symptomatic treatment of ketoacidosis with nah co had no effect on it, and prolonged los in icu as well. a growing interest exists about co derived parameters in shock management. central venous-arterial pco difference (p cv-a co ) is strictly related to cardiac output; central venous-arterial pco difference to arterial-central venous o content difference ratio, p cv-a co / c a-cv o , has been proposed as anaerobic metabolism when it's > . mmhg/ml [ ] . to evaluate p cv-a co /c a-cv o reliability in detecting anaerobic metabolism, we analyzed it in consecutive patients affected by mala admitted to our icu, considering these patients as a prevalent anaerobic metabolism model. we calculated, by douglas formula, central venous-arterial co content difference to arterial-central venous o content difference ratio, c cv-ca co /c a-ccv o , as a respiratory quotient surrogate. we performed arterial and central venous blood gas analysis simultaneously at admission, we calculated p cv-a co , p cv-a co /c a-cv o and c cv-a co /c a-cv o and we recorded scvo . we verified relationship between p cv-a co /c a-cv o and scvo and arterial ph, arterial lactates, sofa score at admission and c cv-a co /c a-cv o by linear regression analysis. pcv-aco /ca-cvo greatly increases in mala ( . ± . ). pcv-aco / ca-cvo (fig. ) shows significant co-variation with ph (r = . ; p= . ) and sofa score at admission (r = . ; p= . ). pcv-aco / ca-cvo has poor agreement with ccv-aco /ca-cvo (r = . ) and disagrees with it in identifying anaerobic metabolism, in our series, in fact, ccv-aco /ca-cvo is, in patients, < like an aerobic rq value. pcv-aco /ca-cvo shows better agreement with ph, sofa score and lactate level than scvo . in our series, p cv-a co /c a-cv o is good illness and acidosis severity marker, but it seems to be affected by ph value in accord with haldane effect [ ] . p cv-a co /c a-cv o , in our study, doesn't seem to be a reliable anaerobic metabolism marker nor a rq surrogate. it is thought that early administration of basal insulin to patients with diabetic ketoacidosis (dka) may improve outcomes. small studies have shown trends towards decreases in time to closure of anion gap (tcag), rates of rebound hyperglycemia following discontinuation of intravenous (iv) insulin, rates of hypoglycemia, intensive care unit (icu) length of stay (los), and hospital los [ ] [ ] [ ] [ ] . this was a single-center, retrospective chart review of our institution's dka protocol between january and august . patients that received early basal insulin within hours of initiation of iv insulin and before closure of the anion gap (ag) were compared to those that did not receive early basal insulin. the primary outcome was median tcag. secondary efficacy outcomes include: time on iv insulin infusion, time to de-escalation of level of care, hospital los, and re-elevation of ag. secondary safety outcomes included incidences of hyperglycemia, hypoglycemia, and hypokalemia. a total of patients were identified meeting inclusion and exclusion criteria. median tcag was longer in the experimental group ( vs. hours, p < . ). incidence of re-elevation of ag and incidence of hyperglycemia were lower in the experimental group. other outcomes were similar (figure ). early administration of basal insulin to patients with dka resulted in a longer tcag with a lower incidence of re-elevation of ag and hyperglycemia. early administration of basal insulin appears to be safe with respect to hypoglycemia and hypokalemia. glycaemic control continues to be a challenge in critically ill patients. stress induced hyperglycaemia has been associated with increased morbidity and mortality [ ] . conversely, patients receiving intensive glucose control have a higher risk of death [ ] . a quality improvement project was designed to develop a comprehensive insulin protocol that recognized pre-existing diabetes and reduced hypoglycaemia. data was collected prospectively in all adult patients admitted to the rah intensive care unit (icu) between october and august from the national icu audit database and electronic patient records. daily figures were collected for numbers of hypoglycaemic episodes (< mmol/l), "in range" ( - mmol/l) blood sugar measurements and patients with a pre-existing diagnosis of diabetes. data was collected and analysed using microsoft excel. results: patients were identified; patients ( . %) had pre-existing diabetes. a total of blood sugar measurements were reviewed; ( . %) were "in range" and hypoglycaemic episodes ( . %) occurred. there was no significant correlation between number of diabetic patients and measurements within range. of note, there was an increase in number of measurements per patient in the second half of the time period ( vs ). the development of this protocol has improved glycaemic control in our icu. there are considerably fewer episodes of hypoglycaemia and a large proportion of blood sugar measurements are in range. we hope to continue data collection and interrogate the prevalence of pre-existing diabetes further to reduce glycaemic variability. the optimal management of blood glucose levels for critically ill patients remains unclear. hypoglycemia, hyperglycemia and glycemic variability are associated with mortality. the time in targeted blood glucose range (tir) has been suggested to correlate with mortality depending on the status of antecedent glycemic control, but it has not been verified optimal tir and whether there is an optimal disease-specific tir. a retrospective observational study was performed at a single center. in the present study, we enrolled all critically ill patients admitted in intensive care unit from january to october. patients with diabetic ketoacidosis or hyperosmolar hyperglycemic syndrome and patients who had < blood glucose readings were excluded. gathered information included, in part, demographics, comorbidities, severity of illness scores, diagnosis at admission, length of icu stay and hospital discharge status. the primary outcome was -day mortality. we analyzed to find the optimal tir for critically ill patients. several tirs were each tested for correlation with mortality. a total of , patients, . % of whom had diabetes, were studied. tir to mg/dl (or, . ; %ci, . - . ), tir to mg/ dl (or, . ; %ci, . - . ) and tir to mg/dl (or, . ; %ci, . - . ) > % was independently associated with mortality in critically ill patients respectively. the optimal tir did not differ depending on diagnosis at admission. in this retrospective evaluation, tir to mg/dl > % was independently associated with mortality in critically ill patients, especially those with good antecedent glucose control. these findings have implications for the design of future trials of intensive insulin therapy. the prevalence of chronic dysglycemia (diabetes and prediabetes) in patients admitted to swedish intensive care units (icus) is unknown. we aimed to determine the prevalence of such chronic dysglycemia and asses its impact on blood glucose control and patient-centred outcomes in critically ill patients. in this retrospective, observational study, we obtained routine glycated hemoglobin a c (hba c) measured in patients admitted to four tertiary icus in sweden between march and august . based on previous diabetes history and hba c we determined the prevalence of chronic dysglycemia (prediabetes, undiagnosed diabetes and known diabetes). we compared indices of acute glycemic control in the icu and explored the association between chronic dysglycemia and icu-associated infections, mechanical ventilation, renal replacement therapy, vasopressor therapy, and mortality within days. of patients, ( %) had chronic dysglycemia. of these patients, ( %) had prediabetes or undiagnosed diabetes and fig. (abstract p ) . results ( %) had a known diabetes diagnosis. during icu stay, patients with chronic dysglycemia had higher average blood glucose, spent less time in target glucose range, had greater glucose variability, and were more likely to develop hypoglycemia than patients without chronic dysglycemia. chronic dysglycemia was associated with greater need for renal replacement therapy (odds ratio . , % ci . - . ) and increased -day mortality (hazard ratio . , % ci . - . ) after adjustment for simplified acute physiology score . in contrast, chronic dysglycemia was not associated with mechanical ventilation, vasopressor therapy, or icu-associated infections. in four tertiary swedish icus, measurement of hba c showed that / of patients had chronic dysglycemia (prediabetes or diabetes). chronic dysglycemia was associated with marked derangements in glycemic control during icu stay, greater need for renal replacement therapy and with increased mortality at days. case report: modern antidiabetic therapie causes ketoacidosis am heiden, m emmerich krankenhaus bad oeynhausen, institut für anästhesie, bad oeynhausen, germany critical care , (suppl ):p the modern antidiabetic class of sglt -inhibitors, that are known to reduce the risk for cardiac events [ ] , are increasingly used in the last few years. a -year old male patient with diabetes mellitus suffered days after colectomy surgery from abdominal pain and nausea. the patient had an antidiabetic therapy with empaglifozin that was paused until day after surgery (nutrition start on day , weaning on day ). methods: this is a case report of one male patient seen in the icu setting. daily blood values including arterial blood gases, vital parameters and clinical status of the patient were observed and evaluated. the blood gases showed this metabolic acidosis: ph . ; pco . mmhg, bicarbonate mmol/l, be - . mmol/l, lactate . mmol/l, glucose mmol/l. a ketonuria despite normal blood glucose values was noticed, so that the diagnosis of ketoacidosis was clear. after analyzing the possible causes we found out, that empaglifozin in times of catabolism and fasting can cause this severe symptomatic. we terminated the therapie with empaglifozin and under the treatment with insulin the symptoms disappeared within days and the patient could be discharged from the icu on day after surgery. after one episode of ketoacidosis the therapy with sglt -inhibitors should lifelong never be started again. we recommend that intensivists should be aware of the modern sglt -inhibitors because of the shown severe complications and the increased use of this medication. consent to publish: written informed consent for publication was obtained from the patient. while obesity confers an increased risk of death in the general population, numerous studies have reported an association between obesity and improved survival among critically ill patients. this contrary finding has been referred to as the obesity paradox. this retrospective study uses two causal inference approaches to address whether the survival of non-obese critically ill patients would have been improved if they had been obese. the study cohort comprises , adult critically ill patients hospitalized at the intensive care unit of the ghent university hospital between and . obesity is defined as a body mass index of ≥ kg/m . two causal inference approaches are used to estimate the average treatment effect in the untreated (atu): a naive approach that uses traditional regression adjustment for confounding and that assumes missingness completely at random, and a robust approach that uses super learning within the targeted maximum likelihood estimation framework and that uses multivariate imputation of missing values under the assumption of missingness at random. obesity is present in . % of patients. the in-hospital mortality is . % in non-obese patients and . % in obese patients. the marginal associational risk difference for in-hospital mortality between obese and non-obese patients is - . % ( % confidence interval (ci) - . % to . %, p= . ). the naive approach results in an atu of - . % ( % ci - . % to - . %, p= . ), whereas the robust approach yields an atu of - . % ( % ci - . % to . %, p= . ). a robust causal inference approach that may handle confounding bias due to model misspecification and selection bias due to missing data mitigates the obesity paradox, whereas a naive approach results in even more paradoxical findings. the robust approach does not provide evidence that the survival of non-obese critically ill patients would have been improved if they had been obese. bowel management within an icu environment is often difficult. recent data collection from an intensive care unit at the rvi identified either loose stool or constipation on > % of patient days. it was postulated this could be improved with a more tightly controlled bowel management regimen. to test this hypothesis a step-wise bowel protocol was created and introduced. data was collected in the month period following its implementation with the following aims: ) assess effectiveness of the protocol ) further observe the reasons for loose or constipated stool on an diarrhea is an important problem in each critically ill pateints [ ] . we aimed to investigate the frequency and management of diarrhea in our icu. in this study patient retrospectively reviewed, in our icu between . . - . . . patients were divided into two group as diarrhea "positive" and "negative". patients with diarrhea had fluid or loose stools or more times a day. each diarrhea period of the patients with diarrhea was examined separately and compared with the group without diarrhea. nutritional status, enteral product formulation, leukocyte, neutrophil, albumin values, gastric sparing, antibacterial and antimycotic use, los in hospital and in icu were compared. in diarrhea positive group, on the day of hospitalization, laxative and/or enema administration, toxin a in stool, nitrogen balance before and after diarrhea, enteral product change in diarrhea, probiotic, metronidazole or oral vancomycin use were examined. the incidence of diarrhea was . %. the most common diagnosis of icu admision was respiratory failure ( - %) in both groups. diarrhea occurred in two days after laxative and/or enema treatment. enteral nutrition was higher in both groups (≥ %). nasogastric tube feeding was significantly higher in the diarrhea group (p= . ). there was no difference between nutritional product formulation and diarrhea development (p> , ). antibacterial use was high in both groups ( %); however, teicoplanin use was significantly higher in the group diarrhea negative group (p= . ). the los in icu, and hospital was higher in diarrhea group (p< . ). no difference in mortality rates (p> . ). many factors may cause diarrhea in icu, and diarrhea may adversely affect patient treatment and increase morbidity. we think that preventive methods are as important as the treatment of diarrhea. the use of parenteral glutamine is studied in number of rcts and systemic reviews (heyland d , wischmeyer p ), while there is a lack of data about the use of enteral glutamine. the aim of our study was to determine the effect of enteral glutamine supplementation on the incidence of hospital infections and death. design: retrospective cohort study. inclusion criteria: males and females > years of age, tbsa burned %- %, nasogastric intubation.patients were divided in two groups: glutamine group (n= ) and control group (n= ). in the study group enteral glutamine was administered to the patients for days after admission to the icu. baseline characteristics were well balanced between groups. no significant difference was found between groups on patients' age, sex, tbsa, need for mechanical ventilation and rate of inhalation injury. primary outcome was all-cause mortality. secondary outcome was rate of nosocomial infections (skin and skin structure infections (sssi), lower respiratory tract infections, urinary tract infections, bacteremia, sepsis). mortality rate was ( %) and ( %) in the glutamine group and the control group, respectively, p= . . rate of nosocomial infections was ( %) in the glutamine group and ( %) in the control group, respectively, р= . . rates of sssi, lower respiratory tract infections, urinary tract infections and sepsis did not differ significantly between the groups: ( %) and ( %), p= . ; ( %) and ( %), р= . ; ( %) and ( %), р= . ; ( %) and ( %), р= . , respectively. rate of bacteremia was significantly different between the groups: ( %) in the glutamine group and ( %) in the control group, p= . . retrospective design is a significant limitation of our study. enteral glutamine supplementation may reduce the incidence of bacteremia in burn patients, but has no influence on the incidence of other nosocomial infections and mortality. further large clinical trials are needed. with outcomes were assessed with multivariable logistic regression and cox proportional hazard analyses, adjusted for baseline risk factors and randomization. in sensitivity analyses, models were further adjusted for key regulators of ketogenesis to assess whether any effect was direct or indirect. late pn increased plasma hb as compared with early pn, with maximal effect on day (p< . for day to and for the "maximal effect" day in the patients). adjusted for baseline risk and randomization, plasma hb associated with a higher likelihood of earlier live weaning from mechanical ventilation (p= . ) and of earlier live picu discharge (p= . ). as plasma hb replaced the effect of the randomization, the hb effect statistically explained these benefits of the randomization. further adjustment for key regulators of ketogenesis did not alter these findings. plasma hb did not independently associate with the risk of infections and mortality. withholding early pn increased ketogenesis in critically ill children, an effect that statistically mediated part of its clinical benefits. critical care patients are prone to frequent feeding interruptions for various reasons including feeding intolerance. these interruptions can lead to adverse outcomes. the aim of the study was to determine the reasons for and the duration of interruptions of enteral nutrition (en). single-center observational, cross-sectional study in a -bed mixed icu of a tertiary hospital. duration: months. patients, aged . years old (± . ), that stayed in the icu > hrs and were fed with en were included. anthropometric data, bmi, time of initiation of prescribed en, type of en formula, daily calories delivered were recorded. energy intake was calculated according to espen guidelines ( kcal/ kg bw/day). the causes for and duration of interruption were reviewed from the patient's chart. apache ii and mnutric score was calculated for all patients. mnutric score ≤ was used to diagnose malnutrition. all patients included in the study were endotracheally intubated. apache ii was . ± . . % of patients had increased risk of malnutrition. icu stay was . ( . ± . ) days, and the in-hospital mortality was %. there were episodes of en interruptions over a median icu stay of . days. median . interruptions/patient. the most common reason for en interruption was gastric residual volume monitoring followed by diagnostic and therapeutic procedures (figure ). other reasons include surgery, intolerance and/or delayed feeding and extubation. the median lost feeding time was . hours/ day ( . - . ) for all causes, while the mean loss of total energy intake was kcal/day (± )/day. average body weight of the patients was kg (± ). caloric deficit was calculated at kcal/day or % of the prescribed caloric goal. the results of this study showed that interruptions can lead to substantial caloric deficit, malnutrition and adverse events. an interruptionminimizing protocol could be useful in order to reduce the missing hours and to improve the clinical outcomes. relationship of goal-directed nutritional adequacy with clinical outcomes in critically ill patients pc tah there are controversies surrounding the effects of optimal nutritional intake on clinical outcomes in critically ill patients. this study aimed at investigating the relationship of goal-directed energy and protein adequacy on clinical outcomes which includes mortality, intensive care unit(icu) and hospital length of stay (los), and length of mechanical ventilation (lomv). this was a single centre prospective observational study. nutritional requirements were guided by indirect calorimetry and -h urinary urea.nutritional intake was recorded daily until death, discharge, or until day of icu stay. clinical outcomes were collected from patient's hospital record. the relationship between the two groups (< % and ≥ % of overall nutritional requirement) with mortality outcomes was examined by using logistic regression with adjustment for potential confounders. terlipressin, despite being one of the main treatments for acute variceal bleeding, may lead to severe hyponatremia due to its antidiuretic activity.we aimed to identify risk factors for development of hyponatremia during terlipressin treatment. retrospective study of patients admitted to acute intermediate care unit for hypertensive upper gastrointestinal bleeding due to chronic liver disease who received terlipressin(december -decem-ber ).hyponatremia was defined as a decrease in na serum levels ≥ meq and severe hyponatremia as > meq within days of treatment. we studied patients, . % male, mean age of . years (sd . ). alcohol-related liver disease was the most frequent etiology. hyponatremia occurred in patients ( . %). serum na Δbetween - and - meq and serum na Δ>- meq occurred in . and . %, respectively (table ) . severe hyponatremia occurred in patients ( . %) and symptoms were reported in two cases (status epilepticus and altered mental status). patients with higher baseline levels of na were more susceptible to terlipressin-induced hyponatremia and a longer length of stay was observed in patients with serum naΔ>- meq ( . vs . days, p< . ). the prevalence of hyponatremia in our study was lower than previously reported.higher serum na at admission and aih as etiology of cirrhosis were predictors of terlipressin-induced hyponatremia. neither the cumulative dose of terlipressin nor the duration of treatment appear to be related to the development of hyponatremia a Δ h-[na] > mmol/l was associated with larger hazards of mortality ( figure ). an increase in serum sodium in the first hours of icu admission is independently associated with a higher mortality in patients admitted with mild hyponatremia, normonatremia, and hypernatremia. based on our findings, it is possible that mild hyponatremia may be a protective mechanism in critical illness, which questions common practice of routinely correcting serum sodium when it is too low. introduction: acute liver failure (alf) represents a life-threatening organ dysfunction associated with increased mortality and liver transplantation represents the only definitive treatment. the aim of this study was to assess the effects of renal replacement therapy in combination with hemoadsorption in alf patients. twenty-nine patients with alf admitted to the intensive care unit (icu) of fundeni clinical institute were included in the study. after icu admission, consecutive session of hemoadsorption in combination with continuous veno-venous hemodiafiltration were applied. number of organ dysfunctions and sirs criteria were recorded at icu admission. the following data were recorded before and after the hemoadsorption therapies: glasgow coma scale, pao /fio , creatinine, -hours urine output, bilirubin, leucocyte and platelet count, heart rate, mean arterial pressure and vasopressor support, c-reactive protein and procalcitonine. clif-sofa score was calculated before and after the therapy. icu length of stay and -days outcome were noted. the mean age in the study group was ± years. the median number of sirs criteria was [ , ] and the median number of organ dysfunctions was [ , ] . the use of hemoadsorption was associated with a decrease in creatinine (from . ± . to . ± . mg/dl, p= . ), bilirubin (from . ± . to . ± . mg/dl, p= . ) and platelet count ( ± / ul to ± /ul, p= . ). we also observed a decrease in clif-sofa score from . ± . to . ± . (p= . ). overall mortality was . % (n= ). six patients ( . %) underwent liver transplantation with % -days survival. the use of hemoadsorption in patients with alf is associated with improvement in liver and kidney functional tests and may represent a new therapy in bridging these patients to liver transplantation. introduction: impairment of intestinal mucosal barrier function is the initiating factor of sepsis. in order to explore the effect of lactic acid bacteria on intestinal barrier function impaired by sepsis, it is necessary to establish sepsis and lactic acid bacteria ecological models. however, how to construct these models is still unclear. co-cultures with a gradient of lactic acid bacteria and caco- cells were constructed. the symbiotic state was observed under an inverted microscope and lactate dehydrogenase (ldh) toxicity tests, transepithelial electrical resistance(teer) tests and western blots were used to determine effective concentrations of lactic acid bacteria in monolayer cell models. lipopolysaccharide (lps) was used to treat cells, and cell counting kit- , quantitative reverse transcription pcr(rt-qpcr) and enzyme linked immunosorbent assays (elisa) were used to determine the appropriate concentration for sepsis models. the number of living cells decreased significantly when the moi(number of lactic acid bacteria/cell number) reached ( figure , panels a, b). the release of ldh indicated that damage to cells began to increase when the moi exceeded (panels a, b). at an moi of . , resistance values began to increase over time, whereas resistance values began to decrease when the moi reached (panel ). as the number of lactobacilli increased, the expression of tight junction protein increased and then decreased (panel a, b, c). in sepsis model experiments, the cell survival rate began to decrease once the concentration of lps exceeded ^ ng/ml (panel ). rt-qpcr results showed that ng/ml lps significantly increased inflammatory cytokines (panel ), and elisa results consistently showed that tnf-α and il- increased significantly when lps concentrations reached ng/ml (panel a, b). it is feasible to construct a cell monolayer model of lactic acid bacteria and lps. the appropriate moi of lactic acid bacteria is . and the optimal concentration of lps is ng/ml. introduction: sepsis is associated with high mortality and morbidity. as the severity increases, physiological parameters such as ph changes are one of the most notable features in metabolic acidosis secondary to high lactate. currently there is no point of care test other than blood gas measurement that could detect these ph changes. this is challenging especially in prehospital environment. the aim of this study is to develop a novel rapid point of care testing using a sensor to detect ph change in blood. sensors were produced by screen printing graphene and silver electrodes and functionalizing the graphene working electrode with an active layer of melanin. a preclinical sensor model was produced by adding lactic acid to a citrated plasma sample thus altering its ph over a clinically relevant range. the ph sensors were exposed to modified plasma, recording any changes in the voltage. the relationship between the voltage potential and plasma ph was established using weighted least squares regression. a ph dependent change in the measured voltage, with respect to the ph of the solution, was observed with a sensitivity of - . mv/ph +/- . over a physiologically relevant ph range between ph . and ph . . in this first phase proof of concept study a low cost, ph sensor was fabricated and demonstrated to be effective in measuring the ph of the plasma. this is the first time that such a sensor has been demonstrated and validated to work in this preclinical model of acidosis. the technology demonstrated here is a promising candidate for a point of care test whereby abnormal blood ph levels can be detected and monitored outside of a laboratory environment in a rapid manner. further studies are now underway to detect this change in whole blood. (figure ) . over one year only a small proportion of patients (n= , %) were classified as 'intermediate high' risk and potential candidates for reperfusion therapies. the revised national early warning score (news) with modified glasgow prognostic score (mgps) is superior to the news for predicting in-hospital mortality in elderly emergency patients t mitsunaga jikei university school of medicine, emergency medicine, tokyo, japan critical care , (suppl ):p the national early warning score (news) was developed in the ukto identify the risk of death. the previous study showed that the modified glasgow prognostic score (mgps) correlate with frailty in elderly patients [ ] . the aim of this study is to evaluate the predict value of the revised news with mgps for in-hospital mortality (in days) in elderly emergency patients. this study is secondary analysis and was carried out in jikei university kashiwa hospital, in japan, from april to march . the acute medical patients aged and older were included. the news was derived from seven physiological vital signs. the mgps was derived from c-reactive protein (crp) and albumin. discrimination was assessed by plotting the receiver operating characteristics (roc) curve and calculating the area under the roc curve (auc). the aucs for predicting in days in-hospital mortality were . for revised news with mgps and . for the original news. the auc of the revised news with mgps was significantly higher than that of the original news for predicting in-hospital mortality (p < . ) (figure ) . our single-centred study has demonstrated the utility of the revised news with mgps as a high predictor of acute phase in-hospital mortality in elderly emergency patients. the diagnostic performance of the five main emergency department (ed) triage systems has been shown to be poor in distinguishing acute coronary syndromes (acs) from mild severity diseases in chest pain patients. these ed triage systems are either clinically-based, being more sensitive or ecg-based, more specific [ ] . the goal of the study was to evaluate if incorporation of cardiovascular risk factors (cvrf) into ecgbased triage could increase his diagnostic performance. cecidoc is a prospective, observational, single-center study in an academic hospital. all consecutive adult patients admitted for acute chest pain were included. we compared the ecg-based french triage system [ ] to a modified system upgrading patients with a normal ecg but significant cardiovascular risk from a low acuity triage score (waiting period before medical assessment of max. min.) to a high acuity triage score (waiting period before medical assessment of max. min.). the final diagnosis was determined after a -day follow-up. we predefined as being adequate a high-acuity triage score (level or ) for acs and a low-acuity score (level , or ) for mild severity diseases. a total of patients was enrolled over a -month period (age . ± . ; m/f ratio . ). triage scores of patients ( . %) with acs were compared to patients ( . %) with mild severity diseases. taking into account cvrf, the sensitivity of the triage system increased from to % whereas the specificity decreased from to %. area under the roc curve (auc) went from . to . (fig. ) . for chest pain triage at ed, addition of cardiovascular risk factors into ecg-based triage increases his diagnostic performance. approximately % of patients presenting to hospital with an intentional overdose require admission to an intensive care unit (icu) [ ] . there are currently no uk guidelines regarding the optimal use of ct head scans (cth) in this patient cohort [ , ] . this study aims to determine whether we should be performing ct head scans in obtunded patients with suspected overdose requiring admission to intensive care. we performed a retrospective search of the icnarc database for plymouth university hospital trust, looking for patients admitted to the icu with overdose or self-poisoning as a primary diagnosis. patients were identified and of these patients required intubation due to obtundation(gcs< ). there were males and females with an average age of years old. the median length of stay on the unit was day. of the patients has a past medical history of mental illness, and overdosed on prescribed medications. the average gcs recorded on admission was . of the ( %) patients had a cth on admission, of which were part of a trauma scan. were known overdoses and were suspected overdose as per the cth request form. the main rationale behind those requests were to exclude additional intracranial injury. none of those cth showed any signs of acute pathology (figure ) . in this retrospective study, obtunded patients with suspected or known overdose with no history of apparent trauma or injury do not benefit from cth. in the absence of a history of trauma or focal neurological signs our conclusions are that cth provides limited value in the management of these patients. the audit was carried out to objectively investigate the problems associated with technique of folley catheterization in emergency department and indoor units of internal medicine wards [ ] . introduction: cellular and molecular mechanisms, epigenetic aspects of acute clozapine poisoning are studied insufficiently. the aim of this study was to identify morphological and epigenetic alteratons in brain neurons during acute exposure to clozapine combined wit ethanol. the experiments were carried out on male wistar rats weighting - g (n= ). group i (control) received . % nacl solution enterally; group iiclozapine mg/kg in . % nacl solution; group iiiclozapine mg/kg in % ethyl alcohol. after hours euthanasia was performed. autopsy included withdrawal of brain samples for histological examination (n = ) and for determination of global dna methylation level (n = ). the global dna methylation level ( -mc%) was determinated by fluorimetric method. inter-group comparisons were made by kruskal-wallis test. histological examination of paraffin sections of brains stained with hematoxylin and eosin was performed by light microscopy. in acute сlozapine poisoning and its combination with ethanol morphological changes in neurons of the cerebral cortex were detected. in acute сlozapine with alcohol poisoning an increase of global dna methylation level was observed. probably the identified changes have a common pathogenesis which will be clarified in our further studies. there is limited information available regarding the prevalence of adder bites and the complications of envenomation. nhs data suggests there are adder bites annually in the uk with the last fatality in [ ] . we performed an audit into adder bites in south west wales to identify the number attending our emergency departments, their management and clinical course as well as any environmental factors that predict increased likelihood of being bitten or the severity of the bite. a retrospective study of adder bites attending emergency departments in south west wales was undertaken (jan to aug ). measurements included were patient demographics, clinical presentation, type of treatment (conservative vs anti-venom) and outcome. results: patients were included, age range - years ( figure ). the majority of bites occurred in sand dunes ( . %) and all bites were on extremities. anti-venom was administered to . % ( / ) of patients. there was a significant positive association between the use of anti-venom and the length of hospital stay (r = . ; p= . ) and a significant negative correlation between the anti-venom use and both diastolic and systolic blood pressure (p= . and . respectively p= . ). all patients fully recovered. in this study, we demonstrated that with a full clinical assessment on presentation it is safe to decide whether anti-venom is required. the current guidelines are safe and effective in the treatment of adder bites. μmol/l, for pao < . kpa and > . kpa, platelets < * ^ /l and > * ^ /l, and bilirubin > μmol/l. in our population of adult ed patients, the thresholds of vital values associated with increased -day mortality were very close to routinely used values, and most of the thresholds were included in the lowest urgency level in triage and risk-stratification scoring systems. the workload in the emergency room: direct assessment by the therapeutic intervention scoring system- and indirect assessment by the nasa task introduction: the number of emergency room admissions continues to increase each year, which increases the care workload of the emergency department staff, who should to use its theoretical and practical knowledge in order to provide quality care in difficult working conditions. the aim of our study was to assess the emergency room staff workload its impact on health workers and patients and to suggest an improvement strategy to decrease this workload. a prospective, monocentric cohort study with descriptive and analytic approach over one month (december ) conducted at the emergency department of an academic hospital. the workload endured by the emergency room staff was evaluated by the nasa task load index and on patients by the therapeutic intervention scoring system- . there were cumulative days of hospitalization in consecutive patients admitted to the emergency room. the average age was ± years. the average length of stay at the emergency room was about ± h. the average tiss- score was . ± . . factors associated with important care workload were: age ≥ years, diabetes, more than comorbidities, the use of intravenous antibiotics; the use of vasoactive drugs and the use of mechanical ventilation; a high tiss score was predictive of emergency room mortality. in the indirect assessment of the care workload, medical and paramedical staff were interviewed, % of them were under years old with a sex ratio of . . a high level of mental and physical workload was expressed by ed staff with considerable level of frustration; the ed staff suggested mainly to improve the working conditions, communication and to redefine tasks "who does what". our study had shown a significant workload in the emergency room, a process to reduce this workload is being implemented medical simulation is a modern teaching tool increasingly used in specialties such as anesthesia, emergency medicine and obstetrics. however, it's not widely used in specialties like cardiology, althought cardiovascular emergencies are very frequent. the purpose of our study was to assess the effectiveness of simulation-based medical education in the management of cardiovascular emergencies among moroccan graduate students. we conducted a prospective, observational, multi-centrer study including the students of three moroccan universities from the th to the th year of medicine who underwent phases: first a pre-test, then a theoretical and practical training on cardiovascular emergencies after which the students were separated in two groups, one undergoing the medical simulation training (group ) and one who didn't (group ), followed by a theoretical then a practical post-test on resusci anne and simman®. at last, the students were asked to answer a satisfaction survey. the reform procedure in the tunisian army consists in repairing the physical damage and deciding on the applicant's ability to continue working. terrorism increases the impact of the co-morbidity generated and the socio-economic consequences that result from it. the purpose of this work was to study the epidemiological, clinical and evolutionary profile of terrorist injuries, to specify the rates of consequent partial permanent disability (ppi) and the possibilities of returning to work. descriptive retrospective cross-sectional study of reform files on military personnel injured during anti-terrorist operations from fig. (abstract ) . changes in total bcpr rate in family-and friends-witnessed ohca cases with dispatcher-assisted instruction during -week period after the day of disaster during three years january to september . the data collection was carried out on the basis of a collection form. our wounded were male, % of whom belonged to the army. the average age was years and months ± . . half of our wounded were troopers. infantry and special forces were the most exposed military units. half of the accidents were recorded in the kasserine region ( cases). chronic post-traumatic stress disorder (cptss) was found in injured, followed by amputations in injured. the after-effects were psychological in %, physical in % and mixed in % of our injured. the ppi rate ranged from % to % in . % of injuries.. more than half of the injured had returned to their professional activity, % were put on reform for health reasons. our results showed that the esptc was the most recorded sequel, and that the ppi rate was significant in a quarter of our injuries. in our series, a third of our wounded were put on reform for health reasons. to state the importance of initial care and adequate and rigorous follow-up to recover a greater number of war wounded. introduction: the rapid response system (rrs) has been shown to decrease hospital mortality [ ] . the japanese coalition for patient safety has set a major goal for hospitals to more widely implement the rrs. however, prevalence and actual circumstances of use in acute care hospitals (including small scale hospitals) in japan are as yet not well-known. web-based questionnaires were sent to acute care hospitals (of scale beds-or-larger) of prefectures in western japan. each participant hospital selected a certain department which answered the questionnaire. the rrs included the medical emergency team (met), the rapid response team (rrt), and the critical care outreach team (ccot). we investigated the presence and circumstances of in-hospital emergency calls, rrs and other systems, and then illuminated issues to be solved. our study suggests that delays in patient transfer to the icu after rrt activation in the wards were associated with slower physiological improvement.these findings support further and larger studies. blood and blood products use in intensive care unit m akcivan, s bozbay, o demirkiran istanbul university cerrahpasa, anesthesiology and intensive care, istanbul, turkey critical care , (suppl ):p blood and blood product (bp) transfusions are frequently used in intensive care units (icu) [ ] . it is important to know transfusion epidemiology and the effect of adverse transfusion reactions and their effect on mortality and morbidity.we aimed to investigate the blood and bp transfusions in the icu. blood and bp transfusions in icu, between - were reviewed retrospectively. we evaluated each transfusion as a data and examined the pre-and post-transfusion laboratory values, demographic data, cause of icu admission and comorbidities. results: patients who underwent transfusion in the icu, and transfusion data from these patients were included. the most frequent cause of hospitalizations were respiratory failure and sepsis. the rate of patients transfused in the five-year period decreased from . % to . %. the hemoglobin threshold before transfusion decreased from . g / dl to . g / dl. a total of transfusion reactions were observed and the most common transfusion reaction was febrile non-hemolytic reaction. the most commonly transfused product was red blood cell suspension. transfusion reactions were found to be slightly higher in men than women in young age group(< y) (p = . and p= . , respectively). transfusion reactions were found to be more frequent in emergency transfusions (p < . ). the number of transfusions was significantly lower in patients with apache ii score < (p < . ). the need for transfusion was found to be higher in patients with hematological malignancy (p < . ). it was observed that as the mean number of transfusions increased the mortality is also increased (p < . ). transfusion therapies are the treatments that are vital but have a serious mortality and morbidity risk. in particular, intensive care patients should be considered in detail because of their specific features. restrictive transfusion practices have positive results. association between anemia or red blood cell transfusion and outcome in oncologic surgical patients. figure a) . the association between rbc transfusion and adverse events also remained after adjustment (or . [ . - . ] ; p < . ) ( figure b) . in oncologic surgical critically ill patients, there was an independent association between anemia (even moderate anemia) or rbc transfusion and patient outcomes. our findings highlight the need for further research to determine the optimal transfusion strategy in surgical oncologic patients. transfusion impaired skin blood flow when initially high e cavalcante dos santos, w mongkolpun, p bakos, al alves da cunha, c woitexen campos, jl vincent, j creteur, fs taccone erasme hospital, intensive care department, brussels, belgium critical care , (suppl ):p red blood cell transfusion (rbct) increases global oxygen delivery (do ) and may improve microcirculation. however, the effects on blood flow have been found to be conflicting. we studied icu patients with stable hemodynamic status (mean arterial pressure (map) ≥ mmhg for at least hours) and without active bleeding, who received a rbct. skin blood flow (sbf) was determined (periflux system , perimed, index finger; perfusion unit, pu) together with map, heart rate (hr), hemoglobin (hb), lactate levels and scvo before and after rbct. sbf was measured before rbct (t ) and after (t ) for each min. according to previous data indicating the lowest sbf value found in noninfected icu patients was pu, all patients were analyzed according to the baseline sbf (i.e. < pu -low sbf vs. ≥ puhigh sbf). the relative change of sbf (Δsbf) was calculated after rbct and the responders were defined by the function of > %. results: icu patients were studied. rbct was associated with increases in map and scvo but no change in sbf. at baseline, scvo was lower in the responders than in the non-responders (p= . ) and lower in patients with low sbf than in the high sbf (p= . ). there was no difference in hb, map, and lactate, between the patients with low and high sbf. after rbct, map rose in the responders (p< . ) and in the non-responders (p= . ), sbf (p< . ) rose in patients with low sbf, and sbf (p= . ) decreased in patients with high sbf. there was a negative correlation between baseline scvo (r= - . , p< . ) or baseline sbf (r= - . , p< . ) and the relative increase in sbf after rbct. rbct increases skin blood flow only when it is impaired at baseline. severe immune dysregulation is associated with adverse outcomes and is common in intensive care unit (icu) patients [ ] . erythropoietin-stimulating agents (esas) have both anti-apoptotic and immune-modulating properties [ ] . despite potential benefit, both the safety and efficacy of these agents remains unclear [ ] . here we evaluate the impact of esas on morality at hospital discharge in critically unwell adult patients admitted to the icu. we conducted our search strategy in accordance with a predetermined protocol. the use of ffp is associated with an increased incidence of complications such as acute respiratory distress and infections, and the rate of complications increased with the quantities of ffp transfused [ ] . pcc contain several important coagulation factors and it has been suggested that they could replace ffp. this has been shown mainly in case reports or series in which coagulation factor deficit was detected by using poc viscoelastic tests in trauma [ ] or traditional hemostatic tests in obstetric patients [ ] . multicenter observational study of the safety and efficacy of the prothrombin complex concentrate. a survey of anesthetists was conducted in maternity hospitals at various levels of care in the russian federation. data has been collected and processed. as a result, patients were analyzed. pph was determined as a volume of blood loss more than ml during vaginal delivery or cs. the most significant risk factors for pph were: preeclampsia or arterial hypertension and a history of postpartum hemorrhage. . % had no risk factors for pph. it was determined that the use of prothromplex iu decreased the number of patients with transfusion ffp - ml/kg by . % and increased the number of patients without transfusion by . %, compared with patients without use of prothromplex iu (figure ). no complications were detected. the use of pcc safety and efficacy reduce use of ffp during pph. the full analysis included patients on either hfc (n= ) or cryoprecipitate (n= ). the intraoperative and postoperative changes in etp and fibrinogen concentration are shown in table . for fibtem a (intraoperatively) and fibrinogen concentration (intraoperatively and postoperatively), the mean numerical values appeared higher with hfc than cryoprecipitate. fxiii (hfc: . %, . %; cryoprecipitate: . %, . %, at baseline and hr after surgery start), fviii and vwf were maintained throughout surgery in both treatment groups. this was also the case for laboratory tests activated partial thromboplastin time, prothrombin time and platelet count. the forma- coagulation parameters analyses showed broad overlaps between hfc and cryoprecipitate, with satisfactory maintenance of the clot quality parameters, fxiii concentrations and thrombin generation parameters. the study group includes men and women with a mean age of , vs. . years (p= . ) admitted with the diagnosis of multiple trauma. we found a directly proportional and highly significant statistical correlation between base excess and fibrinogen level diagnosed using the mcf/fibtem parameter(r= . , p< . )and an inverse proportional correlation between lactate level and fibrinogen level (r= - . , p= . ). in the roc analysis that uses as a variable the level of base excess and as a criterion of classification the fibrinogen deficit (mcf/fibtem< mm) it can be observed that at a value of be<- mmol/l, we can diagnose a fibrinogen deficit with a sensitivity of . % and a specificity of . % (auc= . ,p< . ). lactate appears to be inferior to the excess base (figure ) , but still has a good diagnostic power, a value of . mmol/l has a sensitivity of . % and a specificity of % (auc= . ,p< . ). the difference between the two roc curves ( . ) is statistically significant (p = . ). both base excess and serum lactate can be used to diagnose fibrinogen deficiency with the mention that base excess appears to have a higher sensibility and specificity ability. based goal-directed algorithm. this approach requires further clinical validation. we conducted a retrospective study comparing transfusion strategies in patients with major trauma between and . we retrieved demographic data and blood products administered from patients with at least one red-blood cell (rbc) transfusion. primary outcome was a reduction of rbc administration. secondary outcomes were mortality, icu length of stay and acute kidney injury. we included patients admitted in the icu due to severe trauma (sapsii: . ± . ), and mainly after emergent surgery ( . %). they featured a mean age of . ± . y, were predominantly male ( . %) and % were in shock. in the first hours of hospital admission a mean of . ± . rbc units were administered. most patients received a fibrinogen-based protocol (fbp) ( %), with an average of ± g of fibrinogen and ± fresh-frozen plasma (ffp) units, versus ± g of fibrinogen and ± ffp units in the ffp group. the fbp was associated with a decrease administration of rbcs in the first hours (r = - . ; p < . ), even after adjustment for severity (p= . ) and for tranexamic acid use (p = . ). it was associated also with a decrease of platelet transfusion (p= . ). fibrinogen-based protocol was not associated with a decrease in mortality, acute kidney injury or noradrenaline dose. treatment of tic in past years has progressively changed to a goaldirected fibrinogen-based approach. in our population, the use of fbp lead to a reduction of rbc administration in severe trauma patients. prospective, multicenter, randomized study comparing administration of clotting factor concentrates with a standard massive hemorrhage protocol in severely bleeding trauma patients the objective of this study was to assess the ability of the quantra® qstat® system (hemosonics) to detect coagulopathies in trauma patients. many level trauma centers have adopted whole blood viscoelastic testing, such as rotational thromboelastometry (rotem®, fig. (abstract ) . study treatment plan instrumentation lab) for directing transfusion therapy in bleeding patients. the quantra qstat system is a cartridge-based point-of-care (poc) device that uses ultrasound to measure viscoelastic properties of whole blood. and provides measures of clot time, clot stiffness and a test of fibrinolytic function. methods: adult subjects were enrolled at two level trauma centers which use a rotem based protocol to guide transfusion decisions. study protocols were approved by the site's ethics committee. for each subject, whole blood samples were drawn upon arrival to the emergency department and again, in some cases, after administration of blood products or antifibrinolytics. samples were analyzed on the quantra (at poc) in parallel to rotem delta (in lab). a total of patients were analyzed. approximately % of samples had a low clot stiffness (cs) values suggestive of an hypocoagulable state. the low stiffness values could be attributed to either low platelet contribution (pcs), low fibrinogen contribution (fcs), or a combination ( figure ) . additionally, % of samples showed evidence of hyperfibrinolysis based on the quantra clot stability to lysis parameter. samples analyzed on standard rotem assays showed a lower prevalence of low clot stiffness and fibrinolysis based on extem, fib-tem results. the correlation of cs and fcs vs equivalent rotem parameters was strong with r-values of . and . , respectively. this first clinical experience with the quantra in trauma patients showed that the qstat cartridge detected coagulopathies associated with critical bleeding and may be useful for directing blood product transfusions in these patients. ability to perform testing at poc may provide additional clinical advantage. the objective of the study was to describe the conditions of use of fibryga® g, a new, highly purified, human fibrinogen (hf) recently granted a temporary import authorization for use in congenital and acquired fibrinogen deficiencies in france. observational, non-interventional, non-comparative, retrospective study conducted in french hospital centres using fibryga®. data from patients with fibrinogen deficiency having received fibryga® from december to july were retrieved from their medical files. indications, modalities, efficacy and safety outcomes were recorded. indications encompassed non-surgical bleeding (nsb) either spontaneous or traumatic, including post-partum hemorrhage (pph), bleeding during surgery (sb) or administration to prevent bleeding during planned surgery. treatment success was defined as control of the bleeding or hemoglobin loss < % for bleeding treatment and as absence of major perioperative hemorrhage for pre-surgical prevention. this analysis included patients aged , ± . years and % were male. all presented an acquired fibrinogen deficiency requiring administration of hf. indications were nsb (n= , . %) including ( . %) pph, sb (n= , . %), and prevention of sb (n= ; , %). cardiac surgeries were the main procedures associated with treatment and prevention of sb. mean total doses of fc were . ± . g, . ± . g and . ± . g for nsb, sb and prevention of sb. success rates were . % ( %ci . - . %), . % ( %ci . - %) and . % ( %ci . - %) respectively. for pph, mean dose of hf was . ± . g with a success rate of . % ( %ci . - %). overall, tolerance was good. fibrinogen concentrate fibryga® is mostly used for bleeding control. in one third of patients, hf was administered preventively to avoid bleeding during surgery. use of fibryga® was associated with favourable efficacy outcomes. functional testing for tranexamic acid effect duration using modified viscoelastometry t kammerer , p groene , s sappel , p scheiermann , st schaefer ruhr-university bochum, institute of anaesthesiology, heart and diabetes center nrw, bad oeynhausen, germany; ludwig-maximilans university, department of anaesthesiology, munich, germany critical care , (suppl ):p tranexamic acid (txa) is the gold standard to prevent or treat hyperfibrinolysis [ ] . effective plasma concentrations are still under discussion [ ] . in this prospective, observational trial using modified viscoelastometry we evaluated the time-course of the antifibrinolytic activity of txa in patients undergoing cardiac surgery. methods: patients were included. modified viscoelastometry (tpa-test) was performed and txa-plasma-concentration, plasminogen-activatorinhibitor- (pai- ) and pai-antigen-plasma-concentrations were measured over h. additionally, in vitro dose-effect-curves from blood of healthy volunteers were performed. data presented as median with interquartile range (q /q ). results: txa plasma-concentration was increased compared to baseline (t : μg ml - ) at every time-point with a peak concentration min (t ) after application (p< . ; see fig. a ). lysis was inhibited from min (lysistime tpa-test : p< . ; lysisonsettime tpa-test :p< . ). maximumlysis tpa-test was decreased at t (t : % ( / ) vs. t : % ( / ); p< . ). of note, after h some patients (n= ) had normalized lysis whereas others (n= ) had strong lysis inhibition (ml< %;p< . ) up to h. high and low lysis groups differed regarding kidney function (cystatin c: . mg l - ( . / . ) vs. . mg l - ( . / . );p= . ) and active pai- ( . ng ml - ( . / . ) vs. . ng ml - ( . / . );p= . ). in-vitro, txa concentrations > μg ml - were effective to inhibit fibrinolysis. in our trial, after h there was still completely blocked lysis in patients with moderate renal impairment. this could be critical with respect to postoperative thromboembolic events [ ] . here modified viscoelastometry could be helpful to detect the individual fibrinolytic capacity. introduction: peri-operative coagulopathy correction based on viscoelastic hemostatic assays (vhas) and single-factor coagulation products has changed the paradigm of bleeding management in cardiac surgery [ ] . in a retrospective study, we analysed patients with emergency surgery for thoracic acute aortic dissection (taad), before and after the introduction of fibrinogen concentrate in clinical practice. data were collected from paper and electronic records. the study was approved by the institutional ethical committee. patients were included in the analysis, operated in , before fibrinogen concentrate was approved for human use, and in - . therapy was guided by a rotational thrombo-elastometry (rotem) algorithm. exclusion criteria were non-compliance with the institutional protocol and intra-operative death. we investigated allogeneic blood transfusion (abt), fibrinogen use, peri-operative bleeding (pob), surgical reexploration and post-operative complications (poc). the groups were similar in gender, age, body weight, additive euro-score and aortic cross-clamp time. fresh frozen plasma, cryoprecipitate and red blood cell transfusion were lower in the fibrinogen group, but not platelet transfusion (table). , % of patients in the study group received fibrinogen concentrate and median dose was g (iqr - ). day postoperative chest tube drainage and surgical reexploration were significantly lower. there were no differences in stroke, renal replacement therapy, mechanical ventilation time and icu stay. in patients with taad surgery, rotem-guided algorithms which include fibrinogen concentrate are associated with less (pob), surgical re-exploration and abt. further research is needed to document the role of vhas and concentrated factors in reducing (poc). andexanet alfa (aa, portola pharmaceuticals, san francisco, ca) represents a modified factor xa agent which is approved antidote for apixaban and rivaroxaban. andexanet alfa may also neutralize the anti-xa effects of betrixaban and edoxaban. this study aims to compare the relative neutralization of these four anti-xa agents by andexanet alfa in different matrices. andexanet alfa was diluted at mg/ml. apixaban (a), betrixaban (b), edoxaban (e) and rivaroxaban (r) were diluted in ph . , . m tris buffer (tb), blood bank plasma (bbp) and in % albuminated buffer (ab) at . - . ug/ml. anti-xa activities of all four agents were measured in three systems and the reversibility indices of aa were profiled. the reversibility index (ri ) of anti-xa effects by aa was determined at - ug/ml. each of the four agents produced varying degrees of inhibition of anti-xa at . - . ug/ml, the ic ranged . - . ug/ml in bbp, . - . ug/ml in ab and . - . ug/ml in tb. andexanet alfa produced a concentration dependent reversal of all four anti-xa agents. in the bbp, the ri values for a ( ug/ml), b ( ug/ml), e ( ug/ml) and r ( ug/ml). in the ab, the ri values for a ( ug/ml), b ( ug/ml), e ( ug/ml) and r ( ug/ml). in the tb, the ri values for a ( ug/ml), b ( ug/ml), e (> ug/ml) and r ( ug/ml). each of the four anti-xa agents exhibit varying degrees of matrix independent anti-xa potencies in different systems, the collective order follows edoxaban > apixaban > betrixaban > rivaroxaban. andexanet alfa produced matrix dependent differential neutralization of the anti-xa effects of these agents. individualized dosing of andexanet alfa may be required to obtain desirable clinical results. the diagnostic and prognostic value of thromboelastogram (teg) in sepsis has not been determined. this study aimed to assess whether teg is an early predictor of coagulopathy [ , ] and is associated with mortality in patients with sepsis. in total, patients with sepsis on intensive care unit admission were prospectively evaluated. we measured teg and conventional coagulation tests(ccts)on preadmission and observed for development of , days and , , days respectively. multivariable logistic regression was utilized to determine odds of icu/hospital mortality. the parameter of teg (maximum amplitude, reaction time; ma/r ratio) was calculated to evaluate sepsis-induced coagulopathy. the admission patients were divided into three groupsma/r group(ma/r= - mm/min); ma/r group(ma/r> mm/min)and ma/r group(ma/r< mm/min). in our cohort of patients with severe sepsis, coagulopathy defined by ma/r ratio was associated with increased risk of icu/hospital mortality. introduction: blood sampling for coagulation assessment is often carried out in either arterial or venous samples in the intensive care unit (icu). there is controversy as to the accuracy of this method due to the inherent differences in physicochemical properties as well as the underlying effects of individual diseases in arterial and venous blood. clot microstructure has shown to be a new biomarker (fractal dimension-d f ) which encompasses the effects of diseases in all aspects of the coagulation system [ , ] . in this study, we compared the effect of all these factors in venous and arterial blood to see if there is a difference in the clot microstructure and quality. patients admitted to a tertiary intensive care unit and busy teaching hospital were recruited. arterial and venous blood was sampled from an arterial line and central venous catheter in situ from the same patient. standard markers of coagulation (pt, aptt, fibrinogen, full blood count), rotational thromboelastometry (rotem), whole blood impedance aggregometry and measured clot microstructure (d f ) were measured on both arterial and venous samples. no significant difference was observed in standard laboratory markers, rotem and platelet aggregation between arterial and venous blood. there were no differences in the fractal dimension (d f ) between the arterial and venous blood samples (d f . ± . vs . ± . respectively, p= . ). samples from patients with critical illness give comparable results from either arterial or venous blood despite their underlying pathophysiological process or treatment. this confirms blood for coagulation testing can be taken from arterial or venous blood. clinicians in the emergency setting use a wide range of hemostatic markers to diagnose and monitor disease and treatment. current methods rely on the anticoagulant effect of citrate on whole blood prior to laboratory analysis. despite the well-recognized modulatory effects of citrate on hemostasis, the use of anticoagulated blood has clear analytical advantages, including repeat sampling and storage. however by altering the physiological state of the blood reproducibility and accuracy of the test is affected. recent studies have shown the potential of a novel functional biomarker of clot formation: fractal dimension (d f ), that may give an improved diagnostic accuracy. in this study we assessed the potential of this new biomarker in scientifically measuring the effects of recalcification of citrated samples. methods: healthy volunteers were included. unadulterated and sodium citrate samples of blood were taken from each volunteer. citrated samples were recalcified using ( m cacl ). in the study we compared unadulterated whole blood d f results to citrated d f results and repeated the citrated d f experiments times for each sample over a hour period to ascertain reproducibility. the d f of citrated blood was significantly lower than that of unadulterated blood ( . ± . vs . ± . , p< . ). the results of the citrate samples when tested times over hrs gave a coefficient of variation of . %. for the first time we show that a functional biomarker of clot microstructure, d f , can precisely quantify and measure accurately the direct effect that the addition of the anticoagulant sodium citrate has on whole blood clot microstructure. the study also shows that the test is reproducible and has potential utility as a biomarker of acute disease in the emergency setting in citrated blood. this procedure now needs to be evaluated in a group of acute disease states. in this study, we analyzed the hematological abnormalities of dengue patients by thromboelastography (teg) at initial and -hour of fluid resuscitation. methods: this is a cross-sectional study evaluating teg readings of dengue patients with different severities presenting to the emergency department. laboratory confirmed dengue patient (positive ns antigen or igg/igm) was consecutively sampled. teg readings were taken at presentation and after -hour of fluid resuscitation. twenty dengue patients with varying severity had a median reaction time (r), α -angle, k time, maximum amplitude (ma) and lysis % (ly ) of . min, . ο , . min, . mm and . % respectively. mean fibrinogen was normal before and after fluid infusion. there is a non-significant reduction in ma with prolongation of other teg parameters between different dengue severities. there is a statistically significant reduction of α-angle and ma between pre and post -hour fluid resuscitation (p= . and p= . ). normal fibrinogen with low ma, which signifies a weak clot strength, may indicate either a platelet reduction, platelet dysfunction or both. reduction in ma and α-angle post fluid resuscitation is an alarming finding. this is in contrast with previous teg studies although none of it used normal saline exclusively, studied initial fluid resuscitation in emergency department settings or studied a subject with dengue. a bigger study, especially in severe dengue is needed to validate our findings. agreement between the thromboelastography reaction time parameter using fresh and citrated whole blood during extracorporeal membrane oxygenation with teg® and teg® s m panigada, s de falco, n bottino, p properzi, g grasselli, a pesenti fondazione irccs ca´granda ospedale maggiore policlinico, intensive care unit, milano, italy critical care , (suppl ):p the r (reaction time) parameter of kaolin-activated thromboelastography (teg) may be used to assess the degree of heparinization of blood during ecmo. a teg analysis is usually performed on two types of samples: fresh (f) or citrated-recalcified (c) whole blood. teg® can perform the analysis on c and f whole blood, the new teg® s (haemonetics corp., ma, usa) only on c whole blood. aim of the study was to compare the response of r to heparin using the two types of samples and two teg devices methods: during a three months period at fondazione irccs ca' granda -policlinico of milan, teg was performed (using teg ® and teg s® with and without heparinase, an enzyme that degrades heparin) on consecutive ecmo patients (as part of the gatra study, nct ) and in consecutive non-ecmo patients in whom a teg was requested for clinical purposes. bland altman analysis and lin's concordance correlation coefficient were used to assess agreement results: a total of paired samples were taken ( in-ecmo and off-ecmo). ecmo patients received . ( . - . ) iu/kg/h of heparin. among non-ecmo patients, of them did not receive any dose of heparin, two of them a very low prophylactic dose ( . and . iu/ kg/h, respectively), and one of them . iu/kg/h of heparin. using teg® , r was - . (- . ; . ) min shorter on c compared to f blood in patients receiving heparin (this difference disappeared using heparinase) and only - . (- . ; . ) min shorter in patients notreceiving heparin. r was - . (- . ; . ) min shorter using teg® s (which performs the analysis only on c blood) than teg® on f blood (figure ) . when evaluating the effect of heparin using teg, clinicians should be aware that results obtained using citrated-recalcified or fresh whole blood are not interchangeable. using citrated-recalcified blood to perform teg might lead to underestimation of the effect of heparin trauma patients are at high risk for venous thromboembolism (vte). the east guidelines recommend low molecular weight heparin (lmwh) for vte prevention and antixa monitoring after initiation of the medication or after adjusting doses in certain populations [ ] . studies have shown standard enoxaparin dosing of mg every hours may result in low antixa levels [ ] . this study aims to evaluate the efficacy of a pharmacist-lead protocol for adjusting enoxaparin dosing based on antixa levels in trauma patients. this single center retrospective chart review included adult trauma patients admitted from / / to / / . per protocol, patients with body mass index (bmi) ≤ kg/m were initiated on enoxaparin mg twice daily, and patients with bmi > kg/m were initiated on enoxaparin mg twice daily. peak antixa levels were drawn to hours after at least the third dose of enoxaparin with a goal therapeutic range of . - . iu/ml. the primary objective was time in days to goal peak antixa level. secondary objectives include vte occurrence, bleeding attributed to lmwh, and dosing regimens utilized. subgroups were analyzed based on body mass index (bmi). of patients identified, patients met inclusion criteria. median time to therapeutic antixa level was days (iqr - ). of patients fig. (abstract ) . agreement between teg® s and r teg® on citrated recalcified and fresh whole blood with bmi ≤ kg/m , patients ( . %) were dosed initially per protocol and / patients ( . %) met goal antixa level at first check (table ) . of patients with bmi > kg/m , patients ( . %) were dosed initially per protocol and / patients ( . %) met goal antixa level at first check. our results indicate the protocol is safe due to lack of bleeding attributed to enoxaparin, but less than % of patients achieved goal antixa level at first check. however, despite low rates of achieving goal antixa level, vte rates also remained low. introduction: most patients in the icu are given prophylactic anticoagulation with a fixed dose of mg once daily of enoxaparin (clexane) if cct is normal and mg if cct is low. studies on non icu patients have shown that afxa is below desired range for venous thromboembolism (vte) prevention. in the icu, many factors might influence afxa levels including weight, creatinine clearance (cct), shock and other medication. atxa activity was not yet reported in a big mixed icu population with variable morbidity. our study hypothesis is that enoxaparin is underdosed in most cases and routine afxa activity should be monitored in all icu patients. preventive enoxaparin ( mg qd) was given to all patients unless therapeutic dose was needed or contraindication existed. levels of afxa activity were taken hours after the rd dose. therapeutic vte preventive effect was defined as afxa activity of . - . . patient data was collected from medical files. the study is still ongoing, preliminary results were analyzed for patients. of patients ( %) had afxa activity below normal (subtherapeutic). weight and cct were negatively correlated with afxa activity (figure ). mean weight in the subtherapeutic afxa was significantly higher than the therapeutic group ( . vs. . respectively, p= . ). cct in the subtherapeutic afxa was significantly higher than the therapeutic group ( . vs. . respectively, p= . ). the normal cct group (> ) had significantly more patients with subtherapeutic afxa ( vs , p= . ). in our icu, % of the patients receive insufficient vte prophylaxis. overweight patients and patients with normal cct should probably receive higher enoxaprin dose. afxa activity should be routinely monitored in icu patients. in this study we use a new bedside biomarker to test its ability to measure anticoagulation effects on patients who present with acute first time deep vein thrombosis (dvt). dvt requires oral anticoagulants to prevent progression to potentially fatal pulmonary embolism and recurrence. therapeutic efficacy monitoring of direct oral anticoagulants (doac) including rivaroxaban is problematic as no reliable test is currently available. advances in hemorheological techniques have created a functional coagulation biomarker at the gel point (gp) which allows quantitative assessment of: time to the gel point (t gp ), fractal dimension (d f ) and elasticity (g') [ , ] . the prospective observational cohort study measured t gp , d f , g', standard coagulation and cellular markers in first time dvt patients at three sample points: pre-treatment and approximately and days following mg bd and mg od rivaroxaban respectively. strict inclusion and exclusion criteria applied. results: dvt patients (mean age years [sd± . ]; male, female) and non-dvt patients were well matched for age, gender and co-morbidities. mean t gp on admission was s (sd± . s) and . s (sd± . s) for dvt and non-dvt respectively. doac therapy significantly increased t gp to . s (sd± . s) after days, and subsequently increased to . s (sd± . s) at days as shown in table . d f , g' and standard hemostatic markers all remain within the normal range. conclusions: t gp demonstrates its utility in determining the anticoagulant effect of rivaroxaban. the significant difference in t gp between males and females needs further exploration. localized stasis as a result of transient provoking factors appears not to generate a systemic strength fig. (abstract p ) . correlation of anti factor xa activity with patient cct and weight. anti fxa activity value below . (red line), was considered "non-effective prevention" introduction: trauma remains the leading cause of death all over the world. to better exploit the trauma care system, precise diagnosis of the injury site and prompt control of bleeding are essential. here, we created a nursing protocol for initial medical care for trauma. the aim of this study was to evaluate the impact of protocoled nursing care for trauma on measures of quality performance. this was a retrospective historical control study, consisted of consecutive severe trauma patients (injury severity score > ). people were divided into two groups: protocoled group (from april to march ) and control group (from april to march ). we set the primary endpoint as mortality for bleeding. the secondary endpoints included time allotted from arrival to start of ct scan and surgery, administration rate of several drugs (sedations, painkillers, preoperative antibiotics, and tranexamic acid). for the statistical analysis, continuous variables were expressed as median (interquartile range) and were compared by wilcoxon rank sum tests given a nonnormal distribution of the data. we included patients in the study: in the control group before the introduction of the protocol, in the protocoled group. as a primary endpoint, the mortality for bleeding was similar between two groups ( % in the control group and % in the protocoled group). as a secondary endpoint, the time to ct initiation [group a ( - ) min vs group b ( - ) min; p < . ], and emergency procedure [group a ( - ) min vs group b ( - ); p < . ] were shortened by the protocol introduction. furthermore, the administration rates of sedations, painkillers, preoperative antibiotics, and tranexamic acid were increased in the protocoled group compared with the control group. although the mortality as a patient-oriented outcome was not affected, improved quality of medical care by nursing protocol introduction may be suggested in this analysis. this single-institutional prospective study included patients with uprf who were admitted to the trauma surgical intensive care unit (tsicu) and survived until discharge to home between and . we evaluated the activities of daily living after the discharge using physical and mental component scores of sf- ® and defined physical dysfunction (pd) as physical function (pf-n) score of or less. we divided the patients in the pd (n= ) and control (without pd, n= ) groups and compared the groups. the patients had experienced blunt injuries, including falls ( %) and pedestrian injuries ( %). the mean age was . years (men: . %); the median injury severity score was (interquartile range: - ); and the mean length of tsicu stay was . days. the average period from the injury until the survey was . months. there was no difference between the pd group and the control group in the patient characteristics, fracture type, pelvic fixation, and complications. at the time of the survey, the pd group had significantly more painful complaints than the control group (pd: . %, c: . %, p < . ), and had more physical and mental problems. the sf- ®subscale score showed a significant positive correlation between physical function and body pain, mental health respectively. the percentage of those who were able to return to work was not different in both groups (pd: . %, c: . %). in the multivariate analysis of pd, only age (odds ratio: . , % ci: . - . , p = . ) was relevant. long-term pd was observed in % of patients with uprf. the elderly were particularly prominent, and there was an association between pain and mental health. cells (rbc) this can lead to inhibition of oxygen transport function and development of hypoxia. currently used methods for analyzing the state of rbc either do not have sufficient accuracy or require lengthy analysis and expensive equipment. the use of a simpler and more informative electrochemical approach to assessing the state of rbc is very promising. electrochemical measurements in rbc suspensions (~ • cells / l) were carried out in a special electrochemical cell [ ] in the potentiodynamic mode in the potential range from - . to + . v using the ipc pro mf potentiostat (kronas, russia); optical measurements were performed using an eclipse ts inverted microscope (nikon, japan), a cfi s plan fluor elwd x / . lens (nikon, japan); rbc morphology was recorded in real time using a ds-fi digital camera (nikon, japan). when examining rbc of patients with severe multiple trauma a decrease in the ability of rbc to change their shape during electrochemical exposure was observed, indicating a decrease in deformability, which can lead to a disruption in the oxygen supply to tissues. at the same time, with the stabilization of the patient's condition a restoration of the ability of rbc to change morphology was detected which in turn could have a positive effect on the rheological characteristics of the blood (fig. ) . the results of the analysis of red blood cells using electrochemical changes in their morphology can be used as an additional method for the diagnosis of critical conditions. severe trauma should be treated immediately. whole-body ct (wbct) is widely accepted to improve the accuracy of detecting injuries. however, it remains the problem of time-consuming. therefore, we focused on the scout image taken in advance of wbct. detecting major traumatic injuries from a single scout image would reduce the time to start treatment. a previous study suggested that even specialists could not easily find chest and pelvic injuries using wbct scout image alone. in this study, we aimed to develop and validate deep neural network (dnn) models detecting pneumo/hemothorax and pelvic fracture from wbct scouts. we retrospectively collected anonymous wbct scouts together with their clinical reports at the osaka general medical center between january , , and december , . we excluded incomplete, younger than years old, postoperative, and poorly depicted images. the part of this dataset from january , , until december , , was used for validation and the rest for training dnn models. pneumo/hemothorax detection model and pelvic fracture detection model were trained respectively. accuracy, and areas under the receiver operating characteristic curves (aucs) were used to assess the models. the training dataset for pneumo/hemothorax contained images (mean age years; % female patients), and for pelvic fracture consisted of images ( years; %). the validation dataset for the former contained images ( years; %), and for the latter consisted of images ( years; %). the models achieved % accuracy and an auc of . for detecting pneumo/hemothorax, % and . for pelvic fracture. our results show that dnn models can potentially identify pneumo/ hemothorax and pelvic fracture from wbct scouts. increasing the number of samples, dnn model could accurately detect severe trauma injuries using wbct scout image. clinical information system (cis) is a computer system used in collecting, processing, and presenting data for patient care. it can reduce staff workload and errors; help in monitoring quality of care; track staff's compliance to care bundles; and provide data for research purpose. however, the transition from paper record format to electronic record involves changes in all kind of workflow in icu. therefore, an effective, efficient and evaluative rollout plan was required to minimize the risk that might arise from the new practice. methods: . small groups training were provided. a working station with different case scenarios were set up for practices. . individual tutorials were conducted to clarify questions. emphasis on patient care was always top priority. . contingency plans were available in case of server breakdown and power failure. downtime drills were conducted to prepare the staff in emergency situations. . step-by-step transition from paper record to electronic format was gradually carried out. a plan was discussed among cis team with clear dates and goals. . new items in cis were first reviewed and amended in team meeting until consensus was made; then were promulgated to all staffs during handover before implementation. fig. (abstract p ) . the effect of therapy on the electrochemically induced change in the morphology of red blood cells in patients with combined trauma . staff compliance and outcomes were then monitored; further review and amendment would be possible if necessary. cis roll-out plan was smooth. all staffs were able to integrate cis into the daily routine. the contingency plans were well acknowledged. new items were followed as planned. ongoing enhancement in cis was put forward on nursing orders, handover summary, and integration with inpatient medication order entry (ipmoe) system. with emerging benefits cis brings along, our staff has more time to devote to direct patient care. human input in data interpretation and clinical judgment on top of cis play an irreplaceable role in patient care. the daily request for laboratory tests in intensive care units is a common practice. although common, this strategy is not supported, since more than % of the exams requested with this rationale may be within the normal range [ ] . misconduct based on misleading results, anemia, delirium and unnecessary increase in costs may happen [ ] . we have developed a strategy to reduce laboratory tests without clinical rationale. observational retrospective study, from july to june . the number and type of laboratory orders requested, the epidemiological profile of hospitalized patients, the use of advanced supports, the average length of icu stay and the impact in outcomes such as mortality and hospital discharge at a private tertiary general hospital in the city of rio de janeiro / rj -brazil were analyzed. a strategy was implemented to reduce the request for exams considered unnecessary. approximately , patients underwent icu during this period. the epidemiological profile and severity of patients admitted to the unit were similar to those observed historically. there was a significant reduction (> %) in the request for laboratory tests and there was no negative impact on outcomes such as mortality, mean length of stay and no greater use of invasive resources. over the period evaluated, the estimated savings from reducing the need for unnecessary exams were approximately $ , per year. the rational use of resources in the icu should be increasingly prioritized and the request for routine laboratory tests reviewed. a strategy that avoids such waste, when properly implemented, enables proper care, reducing costs and ensuring quality without compromising safety. evaluating the medication reconciliation errors in icus after implementing a hospital-wide integrated electronic health record system a rosillette, r shulman, y jani university college hospital, centre for medicines optimisation research and education, london, united kingdom critical care , (suppl ):p introduction: medication errors in intensive care unit (icu) are frequent [ ] and can arise from a number of causes including transition of care. our aim was to investigate the impact of an integrated electronic health record system (ehrs) on medication reconciliation (mr) errors occurring at critical steps: during the transition from an icu to the hospital ward and from the ward to hospital discharge. the objective was to examine the influence of icu admission on long-term medication. we performed a monocentric study in icus of a university-affiliated hospital using drug chart and medical notes review to identify mr errors before, during and after icu admission. data were collected retrospectively from ehrs for consecutive patients discharged from the icu between june- july , and who were newly initiated on specific drugs of interest. results: drugs of interest were initiated in icu. many of these were continued after hospital discharge as shown in table . there was appropriate discontinuation of all the antipsychotics newly initiated in icu. other than anticoagulants, there was no reason documented for continuation of the initiated drugs. the planned durations were documented more often after hospital discharge than icu discharge for the following drug classes (% of patients with a plan after icu discharge to the ward; % after home discharge): antibiotics ( . %; . %), and steroids ( . %; . %), but less so for analgesics ( . %; . %), insomnia ( . %; . %), and gastroprotective drugs ( . %; . %). our study has shown that medications initiated in the icu can be inadvertently continued at icu and hospital discharge due to failure in documenting indication or duration. systems are required to deprescribe icu only drugs at discharge or communicate a plan for ongoing treatment. introduction: the surviving sepsis campaign advocates the use of care bundles to guide the management of sepsis and septic shock [ ] . our study aim was to assess compliance with a locally introduced sepsis pathway and to review intensive care unit admission outcomes. we carried out a prospective audit of patients admitted to the icu at royal surrey county hospital with a diagnosis of sepsis between / / and / / , assessing compliance with local sepsis bundle delivery, outcome of icu admission and degree of associated organ dysfunction. results: patients were identified, male ( . %), with a mean age of . ( - ). mean st hour sofa score on icu was . ( - ). % of patients required vasopressors, with % requiring noradrenaline > . mcg/kg/min, and % requiring an additional vasopressor/ inotrope. % required niv, % invasive ventilation and % rrt. icu mortality was %, in-hospital mortality %, mean icu stay days ( - ), and mean length of hospital stay days . in the presence of septic shock mortality was % with post-resuscitation lactate > , versus % in patients with no vasopressor requirement or lactate < (p< . ). the sepsis bundle was delivered in one hour to patients ( %). where the bundle wasn't completed, antibiotics were delayed in % of cases and blood cultures weren't taken in %. where the bundle was fully delivered, unit mortality was % vs. % where it was not (p< . ), but there was no significant difference in hospital mortality ( % vs. %, p> . ) or rates of vasopressor requirement, niv, ippv or rrt. there is room for improvement in timely delivery of the sepsis bundle in our hospital and various measures are being instituted. though there was no significant difference in hospital mortality, icu mortality was significantly lower in patients when the bundle was fully delivered. surviving sepsis campaign recommends h and h sepsis resuscitation bundle for sepsis. the study was done to assess the feasibility of the guideline and the compliance to sepsis- recommendations at an emergency department. prospective interventional study was conducted during one year. were involved in the study all sepsis cases with a qsofa ≥ . were assessed a composite of six components (measurement of serum lactate, obtaining blood culture before antibiotic administration and provision of broad-spectrum antibiotic before the end of h and provision of fluid bolus in hypotension, attainment of target central venous pressure assessed by cardiac ultrasonography, target lactate to normal level before the end of h ). time base line was the first medical contact at triage zone. secondary outcomes of study were the mortality rate and length of stay at intensive care unit (icu). were involved in the study, patients (mean age ± years, sex ration , ). pulmonary infections were the main cause of sepsis ( %) and urinary tracts infections ( %). at h components were achieved in % of cases [lactates ( %), blood culture ( %) and provision of antibiotics ( %)]. at h components were executed in % of cases (fluid provision achievement in %, ultrasonography assessment in % and normal lactate target achieved in %) (figure ). the reliability-adjusted rate for completion of the hours and hours bundle was at %. patients compliant to composite bundle got the mortality benefit (odds ratios = . , % [confidence interval, . - . ]). the study, however, did not show any benefits of mean intensive care unit (icu) length of stay. faisability of - h bundle ratio was at %. it has shown a significant improvement in adaptation and mortality benefit without reducing mean hospital/icu length of stay. more adapted procedures are needed to improve results targeting full compliance of patients to the - h bundle sepsis management. patterns and outcome of critical care admissions with sepsis in a resource limited setting m edirisooriya maddumage , y gunasekara , d priyankara national hospital of sri lanka, medical intensive care unit, colombo , sri lanka; sri jayawardenepura general hospital, department of critical care, nugegoda, sri lanka critical care , (suppl ):p introduction: paucity of epidemiological data is a major barrier in expansion of critical care services, especially in resource limited settings. we evaluated the patterns and the outcome of critically ill patients with sepsis admitted to a level medical intensive care unit in sri lanka. a retrospective cohort study was performed to describe the characteristics and outcome of patients with sepsis, admitted to a medical intensive care unit. sepsis is defined according to sepsis definition. we examined critically ill patients admitted over a period of months. sepsis was the commonest presentation, accounted for . % of all admissions. mean age was . ± . years. septic shock was present in . % on admission. pneumonia ( . %) was the commonest cause, while leptospirosis ( . %) and meningoencephalitis ( . %) accounted for fig. (abstract p ) . sepsis - h bundle components (% of goals achievment) second and third commonest causes of sepsis respectively. the sofa score on admission ( . ± . vs . ± . , p< . ), occurrence of aki ( % vs . %, p< . ) and the length of icu stay ( . days vs . days, p < . ), were significantly higher in sepsis than in patients without sepsis. icu mortality in sepsis (n= ) did not show a significant difference to nortality (n= ) in those without sepsis ( % vs %, p= . ). patients with leptospirosis had a mean sofa score of . , however the mortality ( . % vs %, p = . ) was similar to others with sepsis. in contrast, mortality related to sepsis was significantly high ( %, p< . ) in the packground of immunosuppression (n= ). respiratory failure secondary to pneumonia was the commonest cause of critical care admission with sepsis. sepsis related icu mortality was high in the background of immunosuppression. introduction: training in placement, and the subsequent safe confirmation of position, of a nasogastric (ng) tube, relies on clinicians completing an e-learning module at our trust. feeding through an incorrectly placed ng tube is a 'never event,' associated with significant morbidity and mortality [ ] . analysis of these incidents reveal that the misinterpretation of chest radiographs, by medical staff, who had not received competency-based training, is the most frequent cause [ ] . e-learning has revolutionized the delivery of medical education [ ] , however, there are barriers to its use [ ] . we hypothesized that, by taking e-learning content, and delivering it face-to-face, we would improve training rates, and thus patient safety. a questionnaire was completed by critical care doctors, concerning their knowledge of the existence of the e-learning module, whether they had completed formal training in ng tube placement, and how confident they were, on confirming correct positioning, using a point likert scale. all clinicians underwent training in the interpretation of ng placement, using chest radiographs. after the session they were asked to re-appraise how confident they felt. results were compared using paired t tests. confidence improved in all, rising from a pre-test average score of . (sd= . ), to post-session . (sd= . ), p=< . . prior to the intervention, % of the doctors were aware of the trust guidelines, but only % had completed the training. after the session, % were aware of the guidelines, and % had completed the training (figure ) . conclusions: e-learning is a useful tool, but has its limitations. by using course content, delivered with more traditional learning methods, we im-proved the number of appropriately trained clinicians, and thus the safe use of ng tubes in our unit. a systematic review of anticoagulation strategies for patients with atrial fibrillation in critical care a nelson, b johnston, a waite, i welters, g lemma university of liverpool, liverpool, united kingdom critical care , (suppl ):p there is a paucity of data assessing the impact on clinical outcomes of anticoagulation strategies for atrial fibrillation (af) in the critical care population. this review aims to assess the existing literature to evaluate the effectiveness of anticoagulation strategies used in critical care for atrial fibrillation. only studies contained analysable data. anticoagulated patients had a lower mortality at days and days post admission to critical care, however there was an increased incidence of major bleeding events compared to the non-anticoagulated population. thromboembolic events were comparable in both cohorts. data from current literature is scarce and inferences regarding the effectiveness of anticoagulation in patients in critical care with af requires further investigation and research. every new admission to the icu prompts a handover from the referring department to the icu staff. this step in the patient pathway provides an opportunity for information to be lost and for patient care to be compromised. mortality rates in intensive care have fallen over the last twenty years, however, % of patients admitted to an icu will die during their admission [ ] . communication errors contribute to approximately two-thirds of notable clinical incidents; over half of these are related to a handover [ ] . nice have concluded that structured handovers can result in reduced mortality, reduced length of hospital stay and improvements in senior clinical staff and nurse satisfaction [ ] . a checklist was created to review the information shared and to score the handover. this checklist was created with doctors and nurses and is relevant for handovers between all staff members. information was gathered prospectively by directly observing handovers on the icu. there is a notable discrepancy in the quality of handovers of new patients ( figure ). this is true of handovers between doctors, nurses and a combination of the two. it is also true of all staff grades. whilst a doctor may have reviewed the patient prior to their arrival, % (n= ) of patients weren't handed over to a doctor. the most commonly missed pieces of information were details of the patient's weight ( %, n= ), their height ( %, n= ), whether the patient has previously been admitted to an icu ( %, n= ) and whether the patient has any allergies ( %, n= ). the handover of new patients to the icu is often unstructured and important information is missed. this can be said for all staff members and grades, and for handovers from all hospital departments. post intensive care syndrome-family (pics-f) describes new or worsening psychological distress in family and caregivers after critical illness but remains poorly studied within specialist groups [ ] . we aim to define the degree of pics-f within our tertiary referral cardiothoracic centre and map change over the course of months. caregivers attended a -week multi-professional clinic alongside patients. peer support was facilitated through a café area and a caregiver group psychology session was offered with individual appointments if required. caregiver surveys were completed including: caregiver strain index; hospital anxiety and depression scale (hads); and insomnia severity index. patients also completed hads questionnaires. repeat surveys were completed at and months. results: over cohorts, caregivers attended, of which were spouses ( %), children ( %), and others ( %), with caregivers completing surveys at months. patients' median apache score was (iqr - . ) and median icu length of stay was days (iqr - . ). most admissions were from scheduled operations ( %). severe caregiver strain was present in / ( %) with changes to personal plans ( %) the most common sub category. hads demonstrated caregivers ( %) with anxiety and ( %) with depression. caregiver anxiety exceded that of patients', only reaching fig. (abstract p ) . each handover was scored according to the information accurately given to icu staff similar levels at months, while depression remained static ( figure ). median number of nights with 'bothered' sleep was (iqr - . ) and % of caregivers expressed problems with sleep. conclusions: significant psychological morbidity in caregivers from our tertiary cardiothoracic centre is in keeping with the general icu population [ ] . caregiver strain was reduced suggesting higher levels of resilience. future work should address mental wellbeing, particularly anxiety, to minimise the effects of pics-f. burnout syndrome is an illness that has increasingly affected health professionals. it is characterized by great emotional stress, physical and mental exhaustion and depersonalization of the individual. more serious cases can lead to job loss or even suicide. the described work identifies the burnout level of the multidisciplinary team through a specific questionnaireburnout syndrome is an illness that has increasingly affected health professionals. it is characterized by great emotional stress, physical and mental exhaustion and depersonalization of the individual. more serious cases can lead to job loss or even suicide. the described work identifies the burnout level of the multidisciplinary team through a specific questionnaire methods: application of a questionnaire suitable for the multidisciplinary group in november . the same was answered by professionals among physicians and nursing team. there was no identification of employees. after analysis of the results it is observed that % of the group presents initial burnout, % with the syndrome installed and about % with characteristics of greater severity. main factors found were: mental and physical exhaustion during the work day, the level of responsibility existing in the activity and the perception of disproportionate remuneration by work performed. all interviewees presented some degree of burnout or high risk to develop it. the most severe cases should be traced through occupational medicine and anti-stress measures with reorganization of work performance should be discussed in order to reduce the prevalence of this syndrome. introduction: burnout affecting the psychological and physical state of healthcare workers is recognized in the last years. burnout has been shown to affect the quality of care. whilst some risk factors have been identified, there are gaps within the literature related to mental health and burnout. the aim of this study is to measure levels of burnout across icu units in the metropolitan setting. to determine the level of burnout we used surveys, the maslach burnout inventory human services survey (mbi-hss) and the centre for epidemiologic studies depression scale (ces-d). with the mbi-hss we analysed different variables of burnout; exhaustion, cynicism and emotional exhaustion. basic demographic data and information regarding workout schedules were collected. we studied prevalence and contributing risk factors using and analysing the outcomes of the self-scoring questionnaires. analysis was performed using descriptive statistical analysis. there were respondents, % scored the threshold for depressive symptoms on the ces-d depression scale. interestingly, % (ci . - . %) of those meeting the score for depressive symptoms identified as having frequent restless sleep compared with % ( . - . %) from those not meeting. gender did not affect depressive symptoms % of females and % of males met the threshold. with the mbi-hss for exhaustion the mean was . (sd . ) which is a high level of exhaustion, the second variable cynicism the mean score was . (sd . ), which was considered high. the final variable was emotional exhaustion the mean was . (sd . ), this is considered moderate levels of emotional exhaustion. fig. (abstract p ) . hospital anxiety and depression scale (hads) scores for patients and caregivers at baseline, months, and months there was high prevalence of burnout in icu in all different categories as well as depressive symptoms. age and gender had no affect on burnout. interestingly, we identified that sleep and shift variables were linked to increased burnout. following the implementation of a fully integrated ehrs on march at our university-affiliated hospital we conducted a prospective study in icus by analysing pharmacists' contributions during data collection periods of days at , , and weeks post implementation. a pharmacists' contribution was defined as contacting the physician to make a recommendation in a change of therapy/ monitoring [ ] . the types of contribution were: a medication errorrectification of an error in the medication process; an optimizationproactive contribution that sought to enhance patient care, and a consult -reactive intervention in response to a request. a panel of experts composed of a senior pharmacist, a consultant, a nurse, and a pharmacy student assessed the impact of each contribution, scoring low impact, moderate impact or high impact. there were pharmacist contributions recorded in the periods. of these, ( . %) were medication errors, ( . %) were optimizations, and ( . %) was a consult ( table ) . % of the contributions were assessed as having medium impact, % as high impact and % as low impact. in general, the consultant assessed fewer contributions as having high impact compared to other members of the panel, with contributions assessed as high impact by the consultant versus by the senior pharmacist. implementing an ehrs in combination with contributions of clinical pharmacists can prevent medication related issues. interestingly the types of incident did not change over time. introduction: most icu's are noisy and may adversely affect patients outcomes and staff performance [ ] . who reports that the noise level in hospitals should not exceed db at daylight and db at night. the aim of this study is to evaluate the noise levels in intensive care unit, to apply awareness training to intensive care staff in terms of noise and to compare the noise levels before and after education. noise measurement areas are separated into points including patient bedsides, nurse desk, staff desk, wareroom, corridor and entrance of intensive care unite. measurements were performed times per day. after day, awareness training were given to staff in terms of harmful effects of noise. after the training, noise measurements were repeated during days. after total days the measurements were terminated. noise was measured with incubator analyzer (fluke model: bio-tek serial no: ). the mean noise values before and after the training were not statistically different from the mean average noise values (p> . ). when the time of measurement were compared, the noise levels were higher between - hours to other measurements before and after the training statistically (p= . ). seventeen different noise measurement areas were compared in terms of noise level, there was no statistically significant difference (p> . ). the differences were examined at the same hours between before and after training. contrary to expectations, noise levels were found to be higher after training statistically (p< . ). all of noise measurements were higher than the threshold values that who recommended. increased noise levels in critical care units may lead to harmful health effects for both patients and staff. our results suggest that much noise in the icu is largely attributable to environmental factors and behavior modifications due to education have not a meaningful effect. critical care medicine has focused on continuous, multidisciplinary care for patients with organ insufficiency in the face of lifethreatening illness. despite significant resource limitation low income countries carry a huge burden of critical illness. available data is insufficient to clearly show the burden and outcomes of intensive care units in these developing countries [ ] . the objective of our study is to evaluate the morbidity and outcomes of patients admitted to the intensive care unit of a tertiary university hospital in hawassa, ethiopia. this was a prospective observational study. data was registered and analysed starting from patient admission to discharge during a month period beginning september . data regarding demographics, sources of admission, diagnosis, length-of-stay and outcomes were analysed. the total number of patients admitted to the icu was , with patients dying over a one year period. the highest admission was from emergency medical unit, % and the lowest source was from pediatrics department, %. out of these, . % were males. the mean age was years ( - ). the most frequent aetiologies of morbidity in the admitted patients were traumatic brain injury ( . %), acute respiratory distress syndrome ( . %) and seizure disorder ( %). average median length of stay was . days (interquartile range: . - . ). the overall mortality rate was . %. the top four causes of death in the icu were respiratory illness at % followed by sepsis with multiorgan failure at %, trauma ( %) and central nervous system infection ( %). infection morbidity and mortality remains very high and needs institution of aggressive preventive strategies. the increase in frequency of trauma patients need to receive due attention. sepsis causes a high number of deaths, though overtaken by respiratory illnesses. improving the overall system of icu may achieve better outcomes in resource limited countries. introduction: icu mortality has been widely studied in the literature in relation to outcome index that primarily value organic failure [ ] . however, early mortality, in the first hours of admission has been little documented in the literature. the aim of this study is to analyze factors related to early mortality in icu. retrospective study at a second-level hospital. time of study was months. patients who died in icu were included, patients were classified according timing of dead, including those who died within the first hours of icu admission. the variables analyzed were age, sex, comorbidity, charlson index, apache ii, need for supportive treatments, more frequent admission diagnosis, origin and support treatment limitation decisions. the statistical study was carried out using the spss statistical program. patients were included during the study period, ( . %) died within the first hours of admission. no differences in the needs of support treatments were observed, more than % of patients received mechanical ventilation and vasoactive therapies. table shows characteristics of patients. half of icu deaths occur within the first hours of admission. severity at icu admisison was the main factor related with early mortality. severe stroke and coronary disease were the most frequent causes of early deaths in icu. in august the royal college of anaesthetists published guidelines on care of the critically ill woman in childbirth and enhanced maternal care [ ] . approximately babies are born across the area covered by leicester university hospitals that includes two large maternity units and is part of the uk ecmo network. this audit sets out to assess current practice and form a basis for future planning, which will likely be representative to most major obstetric centres. a retrospective audit of all patients admitted to 'intensive care units' in leicester over a month period following publication of the guidelines. the focus was on patients admitted to general adult intensive care and excludes all patients cared for in 'enhanced obstetric care' units. simple standards were proposed relating to accessibility, resuscitation, follow up and multi-disciplinary learning. in total women were identified with a broad range of diagnosis. the intensive care services are split across hospitals and we found this led to a number of problems. the presence of trained staff to resuscitate a newborn were easily accessible, no steps to provide necessary equipment pre-emptively were present in any centre. none of our critical care units had a plan for perimortem section. on-going reviews by the obstetric and midwifery teams were very variable. contact with the infant and breastfeeding support was also poor. despite the large number of deliveries significant work needs to be done in order to come in line with the new national guidelines for critically ill woman in childbirth. clearly defined pathways around escalation of care, resuscitation of both the mother and baby, integrating care of the mother and the infant in the first few days of life, and multidisciplinary learning events are being produced de novo in response to these guidelines, some of which will be illustrated in the associated poster. interprofessional collaboration scale [ ] . data were analyzed with ibm spss . results: it was found that cooperative attitudes with an average score of to are considered to be of average significance. interprofessional cooperation at an average score of , states that the level of cooperation is high and the quality of working life averages to , suggesting that it is very good. as far as professional satisfaction is concerned, nurses are happy, content and satisfied with their work, despite workload and burnout conclusions: interprofessional cooperation at the icu of the general hospital of larissa is high, but satisfaction from wages, resources, working environment and conditions is low. in addition, the results showed that improvements in hospital communication between staff, has a positive impact on the quality of professional life (table ) . contrasting with previous reports, decreased admissions per unit population in older and oldest age groups, and those with high comorbidity, suggest resource constraints may have influenced admission discussion and decision-making over the -year study period in wales. further investigation is warranted. icu discharge into weekends and public holidays: an observational study of mortality n mawhood, t campbell, s hollis-smith, k rooney bristol royal infirmary, general intensive care unit, bristol, united kingdom critical care , (suppl ):p introduction: up to a third of in-hospital deaths in icu patients occurs following ward stepdown [ ] . discharge time seems to be associated with in-hospital prognosis, but meta-analyses have not shown a difference in weekday compared to weekend discharge [ , ] . however, papers that examined discharge 'into' out-of-hours days, particularly on fridays, have found differences [ ] . our aim was to assess whether discharge from icu 'into' out-of-hours (ooh -weekends and public holidays) is associated with in-hospital mortality or re-admission to icu, and whether these patients were seen on the wards ooh by medical staff. all adults discharged from the general icu to a ward at the bristol royal infirmary in december - were included. in-hospital mortality rates were assessed for each day, with 'into weekdays' defined as sunday to thursday and 'into ooh' friday, saturday and the day before a public holiday. a subset of patients with data on readmission rate to icu was also examined. all available notes from patients discharged into ooh in were reviewed. the study included patients with a subset of with readmission data. sets of notes were reviewed from patients discharged into ooh (figure ). the in-hospital mortality was significantly higher in patients discharged into ooh ( . % vs . %, p= . ). within the subset, ooh was associated with in-hospital mortality or readmission to icu ( . % vs . %, p= . ), though readmission rate alone was not ( . % vs %, p= . ). of patients discharged into ooh, once on a ward % were reviewed by a specialty doctor but . % were not seen. this is the first study to examine icu discharge 'into' ooh days including public holidays. we found increased hospital mortality in ooh, similar to other studies [ ] . up to a fifth of high-risk icu stepdown patients were not reviewed by a doctor on ooh days. exploring the experiences of potential donors' family members (fm) in a follow up clinic is crucial to analyze the effects of organ procurement (op) on the bereavement process, to gain insight on the reasons of family refusals (fr), and to improve family care during op. a mixed-method study involving fm at and months after patients' death was developed and approved by local ethics committee. fm of potential donors after brain (dbd) and cardiac death (dcd) treated in careggi teaching hospital, florence (italy) were eligible if adult and consenting. invitation letters were sent to the entitled months after death and those who actively responded were involved in an encounter with a multidisciplinary group including a clinical psychologist, two nurses and two cultural anthropologists with expertise in op. organ replacement procedures such as ecmo (extracorporeal membrane oxygenation), lvad (left ventricular assist device) and dialysis are routinely used to treat multi-organ failure (mov). globally transplantation programs struggle with increasing organ shortage. patients (pts) with mov are a potential source for procurement. however, outcome data after kidney transplantation (ktx) from such donors are sparse. we retrospectively studied the cadaveric ktx at the charité berlin in and identified donors with ongoing organ replacement procedures. donor and recipient risk factors were assessed. overall patient and graft outcomes were analyzed at months post-transplant. a total of kidneys were transplanted. we identified ktx from donors with mov ( following cardio-pulmonary resuscitation, with acute renal failure - on dialysis) (figure ). in donors, a venoarterial ecmo was implanted during ecls-resuscitation. one donor needed a veno-venous ecmo due to ards, and donor had a lvad implanted due to cardiac failure. the donor age was ± . years (yrs). in addition, donors had at least one cardiac risk factor. the kidney donor risk index averaged . (sd ± . ) and s-creatinine prior to ktx was . (sd ± . one way to expand the potential donor pool is donation after circulatory death (dcd), and a strategy to reduce the complications related to the ischemic time is the use of normothermic regional perfusion (nrp) with extracorporeal membranous oxygenation (ecmo) [ , ] . we compare the use of standard nrp with an effective adsorption system inflammatory mediators (cytosorb®) in the regional normothermic reperfusion phase via regional ecmo, that involves a reduction in cellular oxidative damage, assessed as a reduction in levels of proinflammatory substances. we report a case series of dcd-maastricht iiia category donors, treated in ecmo with nrp, to maintain circulation before organ retrieval, in association with cytosorb® in patients. during perfusion, from starting nrp (t ), blood samples are collected times, every minutes (t , t , t ). during treatment with cytosorb®, lactate levels progressively decrease, ast and alt increase less than without cytosorb®, as sign of improvement in organs perfusion ( figure ). nrp with cytosorb® might help to successfully limit irreversible organ damages and improve transplantation outcome [ ] . development and implementation of uniform guidelines will be necessary to guarantee the clinical use of these donor pools. introduction: shock is a common complication of critical illness in patients in intensive care units (icus), who are undergoing major surgery. this condition is the most common cause of death in postsurgical icus. nowadays, there are different icu scoring systems for predicting the likelihood of mortality, such as apache or sofa. nevertheless, they are used rarely because they also depend on the reliability and predictions of physicians. in these sense, gene expression signatures can be used to evaluate the survival of patients with postsurgical shock. methods: mrna levels in the discovery cohort were evaluated by microarray to select the most differentially expressed genes (degs) between groups of those that survived and did not survive days after their operation. selected degs were evaluated by quantitative real time polymerase chain reactions (qpcr) for the validation cohort to determine the reliability of the expression data and compare their predictive capacity to that of established risk scales. introduction: this study evaluates the prognostic ability of frailty and comorbidity scores in patients with septic shock. the -day mortality rate of individual medical conditions are also compared. the burden of comorbid illness and frailty is increasing in the critical care patient population [ ] . outcomes from septic shock in patients with chronic ill-health is poorly understood. interstitial lung disease is a group of diseases associated with poor prognosis in the intensive care unit despite major improvement in respiratory care in the last decade. the aim of our study is to assess factors associated with hospital mortality in interstitial lung disease patients admitted in the intensive care unit and to investigate the long-term outcome of these patients. we performed a retrospective study in an intensive care unit of teaching hospital highly specialized in interstitial lung disease management between and . a total of interstitial lung disease patients were admitted in the intensive care unit during the study period. overall hospital mortality was %. two years after intensive care unit admission, / patients were still alive ( %). one hundred eight patients ( %) required invasive mechanical ventilation of whom % died in the hospital (figure ). acute exacerbation of interstitial lung disease was associated with hospital mortality (or= . [ . - . ] ), especially in case of acute exacerbation of idiopathic pulmonary fibrosis. multiorgan failure (invasive mechanical ventilation with vasopressor infusion and/or renal replacement therapy) was associated with very high hospital mortality ( / ; %). survival after intensive care unit stay of patients with interstitial lung disease is good enough for not denying them from invasive mechanical ventilation, except in case of acute exacerbation for idiopathic pulmonary fibrosis patients. if urgent lung transplantation or extracorporeal membrane oxygenation are ruled out, multiorgan failure should lead to consider withholding or withdrawal life support therapies. Αgi is a malfunctioning of the gi tract in icu patients associated with prolonged mechanical ventilation, enteral feeding failure and high mortality risk. the wgap of esicm proposed a grading system for agi. four grades of severity were identified: agi grade i, a selflimiting condition; agi grade ii (gi dysfunction), interventions are required to restore gi function; agi grade iii (gi failure); agi grade iv, gi failure that is immediately life threatening. the aim was to evaluate the feasibility of using agi grades i and ii as predictors of malnutrition and -year mortality in critically ill patients methods: single-center retrospective cohort study in a tertiary university hospital ( - ). agi grade iii and iv patients were excluded. Αnthropometric data, gi symptoms (vomiting,diarrhea), feeding intolerance, gastric residual volumes and abdominal hypertension were recorded. daily prescribed caloric intake was calculated using a standard protocol and daily achievement of caloric intake was recorded. mnutric score was calculated for all patients. a score ≤ was used to diagnose malnutrition. patients ( % men, mean age years) that stayed in the icu for > hours were included in the study. % were at high nutritional risk. -year mortality was %. the prevalence of agi ii was %. age, gender, bmi, mortality and energy intake did not differ significantly between patients with agi ii and those with agi i (table ) . logistic the study aimed to assess the effects of icu admission on frailty and activities of daily living in the ≥ 's population at -months. a prospective observational study with data used as a subset of the vip- trial [ ] . research ethics committee approval from the mater misercordiae university hospital (mmuh). inclusion criteria -≥ years of age and acute admission to icu from may to july . data collected on consecutive patients. frailty and activities of daily living (adl) were assessed using the clinical frailty score (cfs) and the katz index of independence in activities of daily living (katz). results: csf pre-admission frailty was present in % of patients, increasing to % at months ( figure ). % of survivors at -months had a cfs score increase by ≥ point. pre-frail and frail cfs patients suffered an average -point deterioration in their instrumental activities of daily living (iadl). % of katz patients were fully functional preadmission, deteriorating to % at months. % of patients declined by adl at months. % of the deceased were deemed fully functional initially. we demonstrate an association between an icu admission event and enduring functional decline at months. icu admission resulted in patients acquiring on average . new iadl limitations despite their initial cfs. this is echoed in a study by iwasyna et al. who also showed similar deteriorations in iadl and cognitive impairment [ ] . katz benefits may be best used in describing functional decline. % of patients developed at least one new limitation. however, the cfs takes into account iadl's and thus may be more sensitive in predicting the functional outcomes of an icu event at months. frailty: an independent factor in predicting length of stay for critically ill t chandler, r sarkar, a bowman, p hayden medway maritime hospital, critical care, gillingham, united kingdom critical care , (suppl ):p frailty has attracted attention in the healthcare community in recent years, as it is associated with worse outcomes and increased healthcare costs [ ] . our objective was to study the impact of frailty as recorded by clinical frailty scale(cfs) to prospectively evaluate the effect of frailty on hospital length of stay (los). a retrospective analysis of consecutively admitted critical care (cc) patients' data (jan' -oct' ) was performed. electronic health records were used to collect demographics, cfs and clinical outcomes. statistical analysis was performed using stata. students t-test, simple and multiple (adjusted for age, disease severity/icnarc score) linear regression were used for comparison between groups and to see group effect. we excluded extreme outliers (los> days; n= ). frailty was defined as cfs> . out of the patients (male %), ( %) were emergency admissions, the rest elective (table ) . ( %) were non-frail. the mean los were days (d) ± and d± (p< . ) in the frail and non-frail patients respectively. for emergency patients, los were d(± ) and d(± ) for the groups, (p< . ). for elective patients; los were d(± ) and los d(± ), (p= . ) for frail and nonfrail respectively. after adjusting, los was significantly higher in frail patients by days ( %ci , ; p< . ), by days ( %ci , ; p= . ) and by days ( %ci , ; p< . ) for total cohort, elective and emergency admissions respectively. the los was days higher in frail than non-frail (p< . ) for cc survivors. frailty was associated with significantly increased los in this cohort, independent of age and illness severity. hospital capacity planning should take this into consideration when modelling bed allocation fig. (abstract p ) . clinical frailty score -month trend robust clinical governance requires analysis of patient outcomes during an icu admission [ ] . on one adult icu weekly mortality meetings are used for this purpose and aid multidisciplinary reflections on individual patient deaths. however, such reviews run the risk of being subjective and fail to acknowledge themes which may relate to preceding or subsequent deaths. this paper describes a new mortality review process in which: a) reviews are structured using the structured judgement review (sjr) framework [ ] ; and b) themes are generated over an extended period of time to create longitudinal learning from death. the sjr framework has been developed by nhs improvement for the new medical examiner role, looking at inpatient deaths. we adapted this to better suit the icu creating a novel review structure. this involves explicit judgement comments being recorded, and the use of a scoring system to analyse the quality of care during the patient's stay with a focus on elements of care delivered on the icu. tabulation of this information allows analysis over time, identifying trends across all patients, and in specific subgroups. this framework has been rolled out at the st george's cardiothoracic icu weekly mortality meetings. themes that have emerged include parent team ownership, delayed palliative care referrals and inadequate documentation of mental capacity. this will continue as part of a three-month trial and following review of this trial may be extended to other critical care units in the trust. this system allows greater insight into patient deaths in a longitudinal fashion and facilitates local identification of problems at an early stage in a way that is not possible within the traditional mortality review format. the nature of the process means that key areas for change can be identified as a routine part of the clinical week. [ ] . in this study, we evaluated three distinct machine-learning methods for predicting possible patient deterioration after surgery. the data was collected retrospectively from the catharina hospital in eindhoven. this dataset contained all the surgeries conducted in the hospital from up to . the variables in this dataset were tested on their ability to differentiate between patients with a normal recovery versus patients with an unplanned icu admission after being admitted to the ward. the dataset contained variables related to either the preoperative screening, surgery or recovery room. all variables were tested for statistical significance using a univariate logistic regression (lr), from which a subset of statistically significant (p< . ) variables was created. these variables were used to train three different types of models, namely, the lr, support vector machine (svm) and bayesian network (bn). the network structure of the bn was designed using expert knowledge and the probabilities were inferred using the data. the three models were validated using five-fold cross-validation, resulting in the following areas under the receiver operating characteristic curve: . ( . - . ) for lr, . ( . - . ) for svm and . ( . - . ) for bn (fig. ) . the results indicate that machine learning is a promising tool for early prediction of patient deterioration. the bn was included because it permits incorporating clinical domain knowledge into the learning process. however, its performance resulted inferior to the lr and svm. in future work, we will investigate alternative domainaware methods, and compare the performance with that of the clinical experts. intensive care unit (icu) admission decisions of patients with a malignancy can be difficult as clinicians have concerns about unfavourable outcomes, such as mortality [ ] . a diagnosis of a malignancy is associated with an almost -fold increased likelihood of refusal of icu admission [ ] . recent large long-term mortality studies of patients with a malignancy admitted to the icu are scarce. therefore, our aim was to compare mortality of patients with either a hematological or a solid malignancy to the general icu population, all with an unplanned icu admission. all adult patients registered in a national intensive care evaluation registry with an unplanned icu admission from to were included. subsequently, we divided these patients into cohorts: cohort (all patients with a hematological malignancy), cohort (all patients with a solid malignancy), and cohort (a general icu population without malignancy). as primary outcome, we used -year mortality, and as secondary outcome, icu and hospital mortality. we included , ( . %) patients in cohort , , ( . %) patients in cohort and , ( . %) in cohort ( table ). the year mortality of patients of cohort , , and was . %, . % and . %, respectively (p< . ). age, comorbidities, organ failure, and type of admission (i.e. surgical or medical) were positively associated with -year mortality in all cohorts (p < . ). one-year mortality is higher in both patients with a hematological malignancy and patients with a solid malignancy compared to the general icu population. in addition, several factors were positively associated with -year mortality, i.e., age, comorbidities, medical icu admission, and organ failure. future research should focus on predictive modelling in order to identify patients with a malignancy that may benefit from icu admission. introduction: drug abuse is associated with immunosuppression in multiple mechanisms. despite that, the only study retrospectively reviewing drug abusers in the icu demonstrated less infections and better outcomes. we compared matched patient populations in order to fully understand whether drug abuse is a risk factor for infection and a predictor of poorer prognosis as is perceived by most physicians. we hypothesized that the drug abusers admitted to the icu will fare as good as or better than non-abuser icu patient populations. methods: this is a prospective study done between the years - on the entire patient population of the detroit medical center. after the drug abuse population was identified, controls were matched according to age and admission icu units. patients charts were reviewed and data regarding baseline demographics, infectious complication and outcome was extracted. data was retrospectively collected for drug abusers and matched controls. comorbidities and hospital admission diagnosis were significantly different between the two groups. disease severity scores were significantly higher in the drug abuser's patient group (dapg) on admission and during the icu stay. dapg had significantly more organ failure: more need for ventilation ( . % vs . % in the dapg (p< . )), more ards ( % vs . %, p= . ), more renal failure ( % vs . %, p= . ) and more need for renal replacement therapy ( . % vs . %, p< . ) .they had longer hospital length of stay (los). there was no difference in icu or hospital mortality. multivariable modeling did not find drug abuse to be an independent risk factor for hospital mortality, icu mortality (hosp: or = . , p = . ; icu: or= . , pp = . ), but was a risk factor for a longer hospital los (me= . , p < . ). drug abuse is not an independent risk factor for mortality or icu los. drug abusers should be evaluated like other patients based on baseline comorbidities and disease severity. this is a small audit which although it did not include general icu still reflects the need for encouraging clinicians and patients to speak freely regarding escalation plans. medical decsions is clinician led however this audit was carried by nursing staff as we have a duty to be advocate for our patients involvement in medical care [ ] . a retrospective analysis of independent risk factors of late death in septic shock survivors c sivakorn , c permpikul , s tongyoo (fig. ) . the pap and katz scales seem to be adequate for predicting mortality of critically ill patients admitted to a medical icu. this finding may help in the elaboration of future icu mortality scoring systems, as well as in more rational use of resources. however, further multicenter studies are needed to better elucidate these results. adherence this last group was chosen because of its experience and specific training in the field of bioethics as a control group or reference. a total of respondents participated in the study. . % were emergency physicians, . % intensivists, . % emergency nursing, . % icu nursing, . % resident doctors, . % medical students and . % other professions. we observed variability in the responses observed not only between different groups of professionals but even within the same group reflecting the difficulty in decision making. variability was observed regarding decisions in end of life ethics conflicts. a high degree of similarity with the group of master in bioethics was observed in the responses issued by medicine students. the barriers and facilitators to framing goals of patient care (gopc) and factors motivating decision making is relatively unexplored [ , , ] . a three part survey of physicians at an australian hospital in a culturally and linguistically diverse suburb ( table ) . identification of levels of confidence and barriers and facilitators to gopc discussion and decision making was the main outcome measure. factors influencing decision-making was analysed through scenarios. results: out of eligible participants responded; female, male, clinical experience - years. level of confidence was ranked between "somewhat confident and very confident." all but one respondent had six months of icu experience. no differences in the level of confidence among physician groups. barriers and facilitators were identified; poor prognosis and patient or family request were most common facilitators; conflict between treating teams and the patient/surrogate and language barriers were most common barriers. factors driving gopc decision-making included clinical, value judgement, communication, prognostication, justice and avoidance. numerous barriers and facilitators were identified. factors driving decision making did not just consider clinical factors; conflict and we aimed to investigate physician-related factors contributing to individual variability in end-of-life (eol) decision-making in the intensive care unit (icu). qualitative study with semi-structured interviews with specialists in critical care, (experience - years) from swedish icus. data was analyzed in accordance to principles of thematic analyses. most of the respondents felt that the intensivist's personality played a major role in eol decisions (table ) . individual variability was considered inevitable. views on acceptable outcome: respondents experienced that the possible outcome for patients was interpreted very differently and subjectively among colleagues, and what seemed an acceptable patient-outcome for one doctor, was not acceptable for another. values: most of the respondents were well aware that they might be affected by their own values and attitudes in the decision-making process. interestingly, several respondents mentioned that they thought that patients that were marginalized by society, especially drug-abusers could be at risk for receiving decisions to limit life sustaining treatments (lst) more often than others. none of the respondents thought that their own religious beliefs played any part in decision making. fear of criticism: among the less experienced respondents there was a clear sense of fear of making a questionable assessment of the patient's medical prognosis. there was a fear for criticism from colleagues that were not directly involved in the decision-making, and may have made another decision. this created a wish among younger respondents to defer or avoid participating in decision-making. physician-related, individual variability in eol decisions primarily consisted of differing views on acceptable outcome, values and fear of criticism. can (figure ). within each quartile of sofa score, mortality was highest in patients with pneumonia and peritonitis and lowest in patients with cellulitis (see figure ). the sepsis- consensus definition identified organ dysfunction as the hallmark feature of sepsis [ ] . in developing sepsis- , the sequential organ failure assessment (sofa) score was chosen for its prognostic value and relative ease of implementation clinically [ ] . we propose an update based on epidemiologic data from two intensive care databases that more effectively captures organ dysfunction in the context of sepsis- . using the mimic-iii (exploration) and e-icu (validation) databases, we extracted patients with suspicion of infection to form the study cohort. the predictive power of each sofa component was assessed using the area under the curve (auc) for in-hospital mortality. a logistic model with the lasso penalty was used to find an alternative statistically optimal score. results: by utilising alternate markers of organ dysfunction (e.g. lactate, ph, urea nitrogen) we demonstrated a significant improvement in auc for several versions of the new score, sofa . ( figure ). the sofa score can be updated to reflect current advances in clinical practice. using epidemiologic data, we have shown that substitution of existing components with more powerful measures of organ dysfunction may provide an improved score with greater predictive power. moreover, sofa . exhibits equivalent ease of implementation, but better reflects organ dysfunction in the context of sepsis- . introduction: risk of acute organ failure (aof) in cancer patients(pts) on systemic cancer treatment isunknown. however, % of non-hematologic and % of hematologic cancer pts will need admission to intensive care unit (icu). ipop-sci- / is a prospective cohort study designed to ascertain the cumulative incidence of aof in adult cancer pts. single centre prospective cohort study with consecutive sampling of adult cancer pts admitted for unscheduled inpatient care while on, or up to weeks after, systemic cancer treatment. primary endpoint was aof as defined by quick sofa. six months accrual expected an accrual of pts to infera population risk aof with a standard error of %. between / and / pts were on systemic anticancer treatment, had unscheduled inpatient care and were eligible for inclusion and were included. median age was years, % were male, % had adjusted charlson comorbidity index (cci) &gt; and hematologic cancers accounted for % of pts. the cumulative risk of aof on hospital admission was % ( %ci: - ); and of aof during hospital stay was % ( %ci: - ). aof was associated with older age, cci &gt; ,hematologic malignancy, shorter median time from diagnosis and &gt; prior line of therapy. on admission, % of pts were considered not eligible for artificial organ replacement therapy (noaort) and % of pts who developed aof while inhospital were judged noaort. overall, ( %) of aof pts wereadmitted to icu, . % for aort. median follow up . months (min ; max ). inpatient mortalitywas %, with icu mortality rate of %, with median cohort survival . months ( %ci: . - . ). on multivariate analysis, aof was an independent poor prognostic factor (hr . ; %ci . - . ). risk of aof in cancer pts admitted for unscheduled inpatient care while on systemictreatment is %, and risk of icu is %. aof in cancer pts was an independent poor prognostic factor. a severity-of-illness score in patients with tuberculosis requiring intensive care u lalla, e irusen, b allwood, j taljaard, c koegelenberg tygerberg academic hospital, internal medicine, division of pulmonology and icu, cape town, south africa critical care , (suppl ):p we previously retrospectively validated a -point severity-of-illness score aimed at identifying patients at risk of dying of tuberculosis (tb) in the intensive care unit (icu). parameters included septic shock, human immunodeficiency virus with cd < /mm , renal dysfunction, ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (pao :fio ) < mmhg, diffuse parenchymal infiltrates and no tb treatment on admission. the aim of this study was to validate and refine the severity-of-illness score in patients with tuberculosis requiring intensive care. we performed a prospective observational study with a planned post-hoc retrospective analysis, enrolling all adult patients with confirmed tb admitted to the medical intensive care unit from february to july . descriptive statistics and chi-square or fisher's exact tests were performed on dichotomous categorical variables, and t-tests on continuous data. patients were categorized as hospital survivors or non-survivors. the -point score and the refined -point score were calculated from data obtained on icu admission. results: forty-one of patients ( . %) died. the -point scores of nonsurvivors were higher ( . +/- . vs . +/- . ; p= . ). a score ≥ vs. < was associated with increased mortality ( . % vs. . %; or . ; %ci, . - . ; p= . )( table ) . post-hoc, a pao :fio < mmhg and no tb treatment on admission failed to predict mortality whereas any immunosuppression did. a revised -point score (septic shock, any immunosuppression, acute kidney injury and lack of lobar consolidation) demonstrated higher scores in non-survivors ( . +/- . vs. . +/- . ; p< . ). a score ≥ vs. ≤ was associated with a higher mortality ( . % vs. . %; or . ; %ci, . - . ; p< . ) ( table ) . the -point severity-of-illness score identified patients at higher risk of death. we were able to derive and retrospectively validate a simplified -point score with a superior predictive power. chronic critical illness remains a scientific challenge, from its conceptualization to its impact on patient prognosis [ ] . we evaluated the long-term evolution of icu survivors by identifying the real burden of prolonged critical illness on survival, quality of life and hospital readmissions. we conducted a prospective cohort in brazilian hospitals including icu survivors with an icu stay > h. we compared the patients diagnosed with chronic critical illness with the other patients. telephone follow-up at and months. quality of life was measured by the sf- questionnaire. it was observed that % of patients had some definition of chronic critical illness. chronic critically ill patients had higher mortality at months (p= . ). this difference is mainly due to higher intrahospital mortality (p= . ). mortality after hospital discharge was similar between groups. there was no difference in hospital readmission rate at months. various scores are developed to predict pulmonary complications such as ariscat for patients at-risk of postoperative pulmonary complication [ ] and lips for patients at-risk of lung injury [ ] . the aim of this study was to compare these scores with ours for predicting pulmonary complications in mechanically ventilated patients in sicu. this prospective observational study was conducted in sicu at a university hospital. adult patients admitted to sicu and required mechanical ventilation > hours were included. primary endpoint was the composite of pulmonary complications including pneumonia, ards, atelectasis, reintubation, and tracheostomy. multivariate analysis was performed to identify risk factors of pulmonary complications and the predictive score was developed. the roc analysis was performed to compare power of ariscat, lips and our newly developed score for predicting pulmonary complications. outcomes in intensive care units have been reported to be better in higher-volume units [ , ] . we compared outcomes for high-risk patients between low and higher volume units. audit data from irish icus is analysed and reported by the intensive care national audit & research centre (icnarc) in london. icnarc report risk-adjusted mortality rates in all patients and in low-risk patients(predicted mortality rate < %) for each unit, using the icnarch- model to predict the risk of death. we used this data to calculate the proportion of high-risk patients(predicted mortality > %) in each unit, the mortality rate for high-risk patients, the riskadjusted mortality rate and we compared the overall risk-adjusted mortality between low and high volume units. the median number of annual new-patient admissions among participating units was ; units below this were defined as lowvolume and those above as high-volume units. the proportion of all admissions to each unit who were high-risk ranged from % to %(mean %). unit mortality rates for high-risk patients ranged from % to %. the ratio of observed to expected mortality(standardized mortality ratio -smr) for high risk admissions in each unit ranged from . to . (mean . ). in fig. introduction: adl weakening is often seen after intensive care and called postintensive-care syndrome (pics). this is also seen in even outside icu and proposed to be called post-acute-care syndrome (pacs), especially in elderly patients. in patients with infection, sofa score is famous for predicting in-hospital mortality, but there are no tools for predicting adl weakening during admission. to search for risk factors for adl weakening during admission other than the age, we conducted a retrospective observational study. the subjects were surviving patients with infection, aged from to who were admitted to our department from april , to may , . information of basic characteristics, laboratory data on admission and adjunctive therapies were extracted from our database. we use barthel index (bi) as adl evaluation, and the bi at discharge were evaluated by nurses. we stratified patients by bi at discharge of over or not, and investigated factors that predicted it. we compared each factor between groups, and perform a logistic regression analysis with those that had a significant effect clinically or statistically. despite improved outcomes of intensive care unit (icu) patients, sleep deprivation remains a major concern after icu discharge. multifaceted causes make it difficult to treat and understand [ ] . not many studies have explored sleep deprivation beyond icu. this is evidenced by findings from a recent systematic review [ ] which included studies with only one study [ ] reporting sleep deprivation beyond icu. the aim of this paper is to present findings of sleep deprivation beyond icu from a larger study that examined the experience of critical illness in icu and beyond in the context of daily sedation interruption. hermeneutic phenomenology was used to conduct the study. participants aged years and above who fulfilled the enrolment criteria were enrolled into the study. the cohort comprised male and female participants. in-depth face to face interviews at two weeks after discharge were conducted and repeated at six to eleven months. interviews were audio taped, transcribed and thematically analysed. significant statements were highlighted and categorized for emergent themes. six participants continued to experience sleep deprivation up to eleven months after icu. two cited dreams about icu, three could not explain why they continued to fail to sleep and one stated that he continued hearing icu alarms in the silence of the night. sleep deprivation continues beyond icu due to nightmares, delusional memories and unexplained reasons. further research is needed to establish causes of sleep deprivation and explore ways to promote sleep in critical illness survivors after icu discharge. frailty is being increasingly seen as an independent syndrome. frail patients now account for an increasing proportion of hospital and critical care admissions [ ] . we aimed to compare frailty and mortality in our intensive care unit. clinical frailty score (cfs) was incorporated within the electronic health record (ehr) . we performed this retrospective analysis on the data collected between jan' and oct' . the predictor and outcome for this study were frailty and hospital mortality respectively. all demographic data, acute physiology score, critical care and hospital outcome data were automatically collected in the ehr and recorded. we used a cut off of cfs> and above to define non-frail and frail respectively. chi-squared test, simple and multiple logistic regression were used. adjustment was done for icnarc score and age. total number of patients was , of which ( . %) died in hospital. within the patients< years (n= ), ( %) were recorded as frail or vulnerable. the number of elective and emergency admission were ( %) and ( %) respectively. in the frail and nonfrail, mortality rates were % and . % (p< . ) respectively, with odds ratio of . ( % ci . , ; p< . ) ( age is a well-known risk factor for critical care (cc) outcome and is incorporated into many prognostic tools; however, this has been criticized for assumption of normal physiology for young at baseline. in recent years, frailty in cc prognostication has been of interest, with meta-analysis correlating worsening outcomes with increasing frailty [ ] . in this study, we compared the effect of frailty versus age for determining hospital survival for critically ill patients. we conducted a prospective cohort in brazilian hospitals including survivors of an icu stay > h. we compared chronic critically ill patients (icu stay> days) and the other patients. we performed psychological and functional presential assessment in patients within hours of icu discharge and by telephone at and months. the prevalence of chronic critically ill patients was %. regarding outcomes, chronic critically ill patients had a higher incidence of depressive symptoms than other patients in the immediate post-icu discharge (p = . ), as well as a higher incidence of muscle weakness (p < . ). however, in subsequent evaluations, we found no difference between groups regarding psychological symptoms -depression, anxiety and post-traumatic stress. higher functional dependence was observed in critically ill patients, but without difference in the quality of life score, both in the physical (p = . ) and mental (p = . ) domains. chronic critically ill patients, when compared to patients with stay> h, have a higher incidence of depressive symptoms at icu discharge. this difference disappears in the follow up. chronic critically ill patients present higher levels of functional dependence but without repercussions on quality of life scores. introduction: activation of the inflammatory response after cardiac arrest (ca) is a welldocumented phenomenon that may lead to multi-organ failure and death. we hypothesized that white blood cell count (wbc), one marker of inflammation, is associated with one-year mortality in icu treated ca patients. we used a nationwide registry with data from five academic icus to identify adult ca patients treated between january st and december st . we evaluated the association between the most abnormal wbc within hours of hospital admission and one-year mortality. we accounted for baseline risk of death using multivariable logistic regression (adjusted for age, gender and h sequential organ failure assessment [sofa] score). a total of , patients were included in the analysis. of those patients , ( %) were alive one year after ca. we plotted wbc against baseline risk of death and through graphic examination of a locally weighted scatterplot smoothing (lowess) curve found the lowest risk of death to be associated with a wbc of (e /l) ( figure mrps were identified by a specialist icu pharmacist during this programme and classified by their significance on a scale of one to four. logistic regression was used to determine if demographic factors were associated with the occurrence of a clinically significant mrp -a significance score of two or above (figure ) . the adjusted model included age, icu los, hospital los, apache ii, number of days of renal replacement therapy, number of days of ventilation, the number of medications prescribed at icu discharge, and the who analgesia classification at ins:pire. there were increased odds of having a clinically significant mrp for hospital los (or results: · % (n= ) of patients required at least one pharmacy intervention. the median number of interventions required per patient was one (iqr - ); the maximum number was six. mrps were recorded in this cohort. the most common intervention was clarifying duration of treatment (n= ), followed by education (n= ), and correcting drug omissions (n= ). the bnf drug class most frequently associated with mrps was neurological (n= ), which comprises analgesics (n= ) and psychiatric medications (n= ) ( figure ). this was followed by cardiovascular medications (n= ), gastrointestinal medications (n= ), nutritional medications (n= ), and others (n= ). many icu survivors experience mrps. the most common class of mrp was neurological, reflecting the high incidence of chronic pain and psychiatric illness in this population following discussion with icu staff, ward staff and fy doctors, a formal standardized handover system was introduced. this involved a verbal handover to the appropriate fy by an icu doctor and the patient drug chart to be rewritten in icu at the time of handover. the next change was to display posters on the wards to alert staff that the medical team are to be contacted when a patient comes to the ward from icu and to ensure the drug chart is completed. the baseline data showed a median time delay of hours, with one patient waiting hours for a drug chart. following the interventions the median time delay has decreased to hours within months as demonstrated in figure . the changes have received positive feedback from icu staff, ward staff and fy doctors. the aim of reducing the time delay by % has been achieved with the median time delay now hours. this has improved patient safety by significantly reduced delays in medications and through the introduction of a standardized handover. this has also provided an opportunity for junior doctors on the wards to seek clarification regarding medications and the clinical management plan for the patient. this has established a communication channel between icu and the wards making patient care safer and more effective. telemonitoring outside the icu is scarce. but with innovative wearables measuring respiratory and heart rate wirelessly, culture on intrahospital telemonitoring should definitely change. however, culture has been known to be one of the most crucial success factors in innovation, especially in health care. human design thinking is a promising tool in health care innovation but rarely used in a multidisciplinary team to initiate an innovation culture and stimulate sustainable collaboration. the aim of this study was to initiate a pilot project with a multidisciplinary team to start using wearables for early warning score (ews) on a clinical ward. human design thinking was used to write a value proposition on wearables in clinically admitted neutropenic hematologic patients in an academic center. a multidisciplinary team was performed to cover all disciplines involved in the technical, clinical and administrative parts of the project. a vendor was chosen based on its product specifications in relation to the present hospital monitoring infrastructure. in design thinking sessions, critical appraisal of multiple telemonitoring factors was performed by sub teams and a canvas projectplan was constructed. the project team was formed of registered nurses, physicians, itspecialists, electronic health record consultants; a critical care physician was appointed as project leader. the main critical factors were: unseamlessly transmitting of both heart and respiratory rates including appropriate movements filtering to the nurse's smartphones direct uploading into electronic health record with automated ews calculation nurse driven protocol on ews follow up. philips healthcare with their intellivue guardian wearable biosensor was the chosen vendor ( figure ). design thinking in a multidisciplinary health care team could positively influence the innovation culture. scientific evaluation of this wearable will focus on both nurse's acceptance and data storage and is expected in the summer of . severity, readmission and lengh of stay were lower in patients receiving discharges directly to home. it seems like a safe way to discharge low-risk short stay patients. it seems to save resources and reduce costs, as well as the need for hospital beds. however, futher estudies are needed to actualy evaluate this safety. forty-four cultures were analyzed with eplex ( figure ). complete agreement with conventional diagnostics was observed in / cases. no false-positive results were observed, yielding a sensitivity and specificity of % and % respectively for target pathogens. time to result was, on average, . h faster with eplex compared to conventional diagnostics. antimicrobial therapy could have been optimized in patients based on the eplex result, but treatment was only changed in one case (e.coli ctx-m+) receiving meropenem . h before the antibiogram was available. the eplex blood culture panels provide high accuracy and significantly faster results. the current implementation offers substantial potential value at a minimal cost, and is a feasible approach to -h/ days blood culture diagnostics in many hospital settings. however, efforts to increase adherence are needed. the rapid increase of extended spectrum β-lactamases (esbl)-producing pathogens worldwide makes it difficult to choose appropriate antibiotics in patients with gram-negative bacterial infection. cica-beta reagent (kanto chemical, tokyo, japan) is a chromogenic test to detect beta-lactamases such as esbl from bacterial colonies. the purpose of the study was to reveal whether cica-beta reagent could detect esbl-producing pathogens directly from urine rather than bacterial colonies to make a rapid bedside diagnosis of the antibiotic susceptibility of gramnegative pathogens. we conducted a prospective observational study from july to october . patients were eligible if they were performed urinary culture tests and gram negative pathogens were detected at least + from their urine samples. the urine sample was centrifugated at x g for min. the supernatant of sample was re-centrifugated at x g for min and the pellet was mixed with cica-beta reagent. the test was considered positive when the enzymatic reaction turned from yellow to red or orange. (fig. ) . the bundle approach could be an effective strategy to prevent hospital-acquisition of drug-resistant pathogens in icus. fig. in the aspect-np trial, c/t was noninferior to mem for the treatment of habp/vabp. we evaluated outcomes from that study in the subgroup of pts failing current antibacterial therapy for habp/vabp at enrollment. methods: aspect-np was a randomized, controlled, double-blind, phase trial in which mechanically ventilated pts with habp/vabp received g c/t or g mem every h for - days. pts with > h of active gram-negative antibacterial therapy within h prior to first dose of study therapy were excluded, except those pts failing current treatment (i.e. signs/symptoms of the current habp/vabp were persisting/worsening despite ≥ h of antibiotic treatment). primary and key secondary endpoints, respectively, were -day all-cause mortality (acm) and clinical response at test of cure (toc; - days after end of therapy) in the intent to treat (itt) population. pts failing current antibacterial therapy for habp/vabp were prospectively categorized as a clinically relevant subgroup. at baseline, failing current therapy for habp/vabp was reported in / ( %) c/t and / ( %) mem itt pts, mostly piperacillin/ tazobactam ( %), rd/ th-generation cephalosporins ( %), fluoroquinolones ( %), and aminoglycosides ( %). baseline demographic and clinical characteristics in this subgroup, including prior therapy regimen, were generally similar between treatment arms. there were greater proportions of patients with esbl+ enterobacterales ( %) and pseudomonas aeruginosa ( %) in the c/t arm than the mem arm ( % and %, respectively). lower -day acm was seen with c/t than mem, as evidenced by % confidence intervals for treatment differences that excluded zero ( figure ); statistical significance cannot be assumed because subgroup analyses in this study were not corrected for multiplicity. conclusions: c/t was an effective treatment for habp/vabp pts who had failed initial therapy. catheter-related blood stream infection (crbsi) is common serious infections and associated with increased mortality in intensive care units (icu). one of the most important strategy to prevent crbsi is to minimize the duration of central venous catheterization. we built a medical team consisting of doctors, nurses and pharmacists in icu to discuss whether patients needed central venous catheter (cvc) in terms of monitoring hemodynamics and administering drugs, and recommend catheter removal to attending physicians every day in april . the purpose of this study is to evaluate whether our team-based approach could shorten the total duration of catheterization and reduce crbsi. this was a retrospective historical control study conducted from april to october in the icu of a tertiary care hospital in japan. every patient admitted to the icu during the study period was eligible if they were inserted cvc. patients were divided into groups: conventional (from april to march ) or intervention (from april to october ). we set the primary endpoint as onset of crbsi. the secondary endpoints included the duration of central venous catheterization, the length of icu stay and hospital mortality. crbsi was defined as bloodstream infection in patients with cvc, not related to another site. we included patients: in the conventional group and in the intervention group. the reduced, though nonsignificant, tendency of crbsi was observed in the intervention group [hazard ratio, . ( % confidence interval, . - . ; p = . )]. the intervention group was significantly associated with reduced duration of central venous catheterization ( days vs days; p < . ). no difference was observed in the length of icu stay and in-hospital mortality between groups. the team-based approach to assess cvc necessity could shorten the duration of central venous catheterization and might reduce crbsi. introduction: empiric antibiotic therapy decisions are based upon a combined prediction of infecting pathogen and local antibiotic susceptibility, adapted to patients' characteristics. the objective of this study was to describe the pathogen predominance and to evaluate the probability of covering the most common gram-negative pathogens in icu patients with respiratory infections. methods: data were collected from multiple us and european hospitals as part of the smart surveillance program ( ). mic (mg/l) testing was performed by broth microdilution, with susceptibility defined as follows for p. aeruginosa & enterobacterales: ceftolozane/tazobactam results: hospitals from countries provided gram-negative respiratory isolates from patients located in an icu in the us ( %), eastern europe ( %) and western europe ( %) in . the most common pathogens isolated were p. aeruginosa ( %), k. pneumoniae ( %), e. coli ( %), and a. baumannii ( %). among enterobacterales, % ( / ) were esbl positive. figure provides the probability of covering the most common respiratory gram-negative pathogens from icu patients. co-resistance between commonly prescribed first line β-lactam antibiotics is common: when nonsusceptibility (ns) of one agent was present, susceptibility to other βlactams was generally < %. ceftolozane/tazobactam provided the most reliable in vitro activity in both empiric and adjustment prescribing scenarios compared to other β-lactam antibiotics. ceftolozane/tazobactam ensured a wide coverage of the most common gram-negative respiratory pathogens demonstrating high susceptibility levels and provided the most reliable in vitro activity in both empiric and adjustment antibiotic prescribing scenarios. further studies are needed to define the clinical benefits that may translate from these findings. evaluation of compliance of icu staff for vap prevention strategies on the outcome of patients a kaur fortis hospital, critical care, mohali, india critical care , (suppl ):p ventilator-associated pneumonia is the most common nosocomial infection diagnosed in adult critical care units. it is associated with prolonged duration of mechanical ventilation, increased icu stay and increased mortality. it continues to be a major challenge to the critical care physicians despite advances in diagnostic and treatment modalities. the primary objective of the study was to determine the compliance of icu staff towards vap prevention bundle and secondary objective was to determine the incidence, risk factors and outcome of vap patients. single center, prospective, observational study carried out from february to july . patients mechanically ventilated for more than hours and satisfying the inclusion and exclusion criteria were enrolled in the study. vap was diagnosed using the cdc criteria and clinical pulmonary infection score. vap preventive strategies were employed and compliance of icu staff was assessed. a total of patients were admitted to icu over the set time period and out of them patients were ventilated for more than hours. among them only patients fulfilled the inclusion and exclusion criteria and were enrolled in the present study. excellent compliance was observed in head end elevation, sedation vacation, stress ulcer prophylaxis, and heat moist exchanger filter use, good compliance in oral care and hand hygiene and moderate to poor compliance in subglottic suctioning. the incidence of vap was . % with a vap rate of . / ventilator days. there was a significant correlation between primary diagnosis, hemodialysis, massive blood transfusion and development of vap (p< . )). mean duration of ventilation (p< . ) and mortality (p< . ) were highly significant in vap patients. conclusions: improvement in compliance towards vap bundle and reduction of risk factors can help decrease incidence of vap and related morbidity and mortality. preventive strategies are effective in reducing ventilation-associated pneumonia (vap) in adults [ , ] . in paediatric population there are no data about vap prevention, so we introduced a new bundle (vap-p) based on the available evidence for adults. this was designed as a before-after study. we enrolled all patients admitted to -bed medical-surgical paediatric icu at gemelli hospital in rome, requiring mechanical ventilation for at least hours. patients with pre-existing tracheostomy were excluded. vap-p has been introduced since in order to improve quality of assistance. our bundle consisted in twice a day oral hygiene with chlorhexidine swab, daily check of oral bacterial colonization and aspiration prevention. comparison was made with an historical group including patients admitted before vap-p introduction (since to ). all data about demographics, antimicrobial therapy, icu stay and treatments, were collected. results: patients were included ( after and before vap-p introduction). ( %) events of vap were recorded in vap-p group compared to ( %, p= . ) vap-p group had less vap per days of mechanical ventilation ( / compared to . / p= . ). multivariate analysis yielded an or of . ( %ci . - . ) for vap incidence after bundle introduction. mortality rate was slightly reduced in vap-p group ( . %vs . % p=ns). patients who developed vap required more days on mechanical ventilation and had higher mortality rate ( vs days p< . and %vs % p= . , respectively). our vap-p seems effective in reducing vap incidence in critically ill paediatric population. introduction: ceftolozane/tazobactam (c/t) is a new antibiotic against mdr gramnegative bacteria infections, whose target population are the critically ill patients. even though / g dose safety administered as a hour-infusion has been already assessed, these patients can be under renal replacement therapy (rrt) and suffer changes in their volume of distribution (vd) that may affect antibiotic concentrations. the objective was to determine concentration reached by g c/t ( hour infusion) in septic patients on rrt (cvvhdf) and interdose behavior. we have used rrt machine prismaflex with oxyris filter and m . hplc-uv method was used for simultaneous quantification of c/t. study population consisted of three obese critically ill patients with sepsis, on cvvhdf while receiving g c/t every hours. samples were taken of prefilter, post filter blood and effluent, min before infusion and , and hours after the end of it. we found great interpatient variability with the lowest cconcentration values in the patient with more hemodynamic instability using oxyris filter. even though cmax was less than reported in healthy subjects, we found similar values of auc and t ½ in comparison with healthy population studies. cmax of t was also compromised in comparison with values reported in healthy subjects, but with higher auc and t ½. cvvhdf contributes to c/t clearance. m filter showed the least clearance and higher values of auc and t ½. extraction rate was similar in all patients and filters (figure ) . cmax achieved may be impaired because of the varying vd caused by obesity and rrt, but not affecting the antibiotic characteristics and behaviour. we conclude that because of the variety of clinical conditions, c-concentration is compromised particularly in hemodynamically unstable patients. however, the small sample doesn´t let us extrapolate these results. the extended infusion seems to be adequate to achieve the interdose antibiotic concentration. the use of biomarkers in sepsis is useful for early diagnosis and prognosis. the desired marker should be sensitive, specific, fast and accurate. procalcitonin (pct) measurement is approved by the fda even its efficacy is still under question. the determination of alfatorquetenovirus (ttv) could be a useful marker [ ] . we analyzed samples from patients admitted to icu with clinical suspicion of sepsis. analytical data of c-reactive protein (crp), neutrophils and procalcitonin were collected. the sofa and apache ii scales were calculated and patients stratified according to these values in good and poor prognosis. ttv quantitative determination was carried by using a quantitative crp . we calculated area under the curve (auc) of ttv plasma levels as a function of time. the statistical analysis involved u-mann-whitney and spearman test, using chi for qualitative variables. results showed a not significant (ns) inverse relationship between the ttv auc and the patient proinflammatory level. a tendency (ns) was found between poor prognosis and the pct median values and crp being higher in the poor prognosis.group. a trend showed lower ttv dna count related to worse prognosis. an inverse relationship was found between pct and crp values and the ttv copies /ml plasma, ns correlation in the case of pct. there was a clear trend between the neutrophils´expansion and the regression line slope, obtained between ttv loads in the first two study steps. fig. (abstract p ) . patient pk/pd measurements value> . ), suggesting that the adsorptive mechanism wasn't primarily mediated by plasma protein. ha was saturated after adsorption of a total of . ± . mg of van. the adsorptive kinetics showed an exponential reduction of van mass that reached a plateau after minutes of circulation. in our study, simulating in vivo conditions of hp using ha during sepsis, a rapid and clinically relevant removal of van has been shown. after hours of hp, we suggest to assess van plasma concentration and a loading dose of van should be considered. however, not knowing the potential interactions with other drugs, further in vivo studies are warranted to confirm these findings. assessing the volume of blood taken for blood culture and culture positivitydo we need to take less blood? it is commonly accepted that larger blood culture (bc) volumes (bcv) increase the yield of true positive cultures, and optimally cc of blood should be obtained per set ( bottles). only scarce data exists on the matter of optimal bcv. it is unknown what is the minimal volume that is acceptable for bc. the objective of this study was to determine the association between bcv and the rate of positive bc. blood taken for cultures in bd bactec plus aerobic/f negative bottles was collected from icus and acute care floors at hospitals at the dmc over months. blood volume was estimated automatically from blood background signal data in the bd bactec fx instrument. cultures were analyzed for each bottle. data was summarized for every month as the average volume and number of cultures taken and rate of positive bc for every unit. units were classified according to unit type (icu, medicine, surgery, mixed, emergency department (ed), organ/bmt or "other" which did not fit the previous categories) and analyzed as a group. a total of cultures were taken in units. there is a positive association between bv and positive bc rate for ed and "other" units (irr= . , p= . for the ed, irr= . , p< . for "other" unit). all other units had no association between bv and positive bc rate (figure ). secondary analysis, excluding pediatric units, gave very similar results. when comparing bv between unit types, the ed and "other" unit had significantly lower bv ( . ml in the ed and . ml in "other" unit compared to . ml in the icu, . ml in surgery, . ml in mixed and . ml in bmt). the correlation between bv and positive bc rate is probably limited to units taking very low bv for cultures. units taking volumes above ml show no improvement in positive bc rate when higher volumes are taken. better prospective studies should be done to further establish the minimal bcv needed and spare unnecessary blood loss to hospitalized patients without compromising bc yield. de-escalating antibiotics in sepsis with the use of t mr in a bed greek university icu c vrettou, e douka, i papachatzakis, k sarri, e gavrielatou, e mizi, s zakynthinos st icu department, university of athens, evangelismos general hospital, icu, athens, greece critical care , (suppl ):p in septic patients, the early use of appropriate empiric antibiotic therapy reduces morbidity and mortality. de-escalation refers to narrowing the broad-spectrum antibiotics once the pathogen and sensitivities are known. t magnetic resonance (t mr) is a novel method of detecting eskape pathogens. we aim at investigating if using t mr technology can expedite de-escalation of broad spectrum antibiotics. this is a prospective observational study conducted in our -bed university icu. inclusion criteria were critically ill patients age> y.o., with newly diagnosed sepsis and clinical suspicion of eskape bloodstream infection. a sample for t mr and a blood culture (bc) sample were collected simultaneously from the patients enrolled. the t mr bacteria panel test was run according to the manufacturer's guidelines and the bcs were processed according to the hospital standard procedures. we recorded clinical data and administered antibiotics. results: patients were included in the study. mean time to culture positivity was hours while mean time to t mr result was . hours. in patients the results of t mr were in concordance with the bcs. in the remaining cases, the bcs were negative while the t mr detected one or more eskape pathogens. there were no false negative results. de-escalation in at least one drug was applied to patients ( . %). no escalation was applied to patients ( . %) and antibiotic escalation in ( . %). conclusions: t mr provides a quicker detection time that could shorten the time to targeted therapy. in our population this corresponded to early (within - h) antibiotic de-escalation in approximately / of the included patients. antibiotic stewardship in icu. a single experience l forcelledo , e garcía-prieto , l lópez-amor , e salgado , j fernández dominguez , m alaguero , e garcía-carús the increasing antibiotic resistance in microorganisms urged interventions such as the antibiotic stewardship programs in icu focused on reducing the inappropriate use of antibiotics by improving the antibiotic selection, the dosage, administration route and length as well as improving clinical outcomes and reducing antibiotic resistance. retrospective study where antibiotic consumption was analysed and measured in days of therapy (dots) between and in a medical-surgical icu of a university hospital where a multimodal educational program was established. specific training in infectious diseases in critically ill patients, periodic clinical and formative sessions fig. (abstract p ) . correlation of blood culture positivity rate with blood culture volume by unit type were performed for icu staff and specific leaders within the icu staff designated. results: patients were admitted to icu. there was a reduction of , % in dots (figure ), reduction in antimicrobial resistance rates ( , in , , in [days of resistant microorganism/ patientdays]) without an impact in icu global mortality ( , % in , , % in ). the resistant bacteria registered were acinetobacter baumannii, s. aureus mr, blee and carbapenemase-producing enterobacteriaceae, pseudomonas aeruginosa mr and clostridium difficile. the safe in antimicrobial consumption was € ( % reduction). the icu stay decreased from , days ( ) to , ( ) , with no variation in mean apache ii ( , ) . the bigger decrease in antibiotic consumption was in colistin related to the reduction in resistance bacteria, in special acinetobacter baumannii, in linezolid and in piperacilin/tazobactam, even more remarkable in due to shortage of supplies which meant an increase in meropenem. the application of an antibiotic stewardship program in icu succeeded in reducing antibiotic consumption, antibiotic resistance and costs without an impact in clinical outcomes like mortality or icu stay. clinical outcomes of isavuconazole versus voriconazole for the primary treatment of invasive aspergillosis: subset analysis of indian data from secure trial p kundu, s kamat, a mane pfizer limited, medical affairs, mumbai, india critical care , (suppl ):p the secure trial was designed to compare the safety and efficacy of isavuconazole (a) versus voriconazole (v) for primary treatment of invasive mould disease caused by aspergillus and other filamentous fungi. the present analysis is aimed at comparing the indian subset of patients with that of the overall trial population and to ascertain any similarity or difference in the primary efficacy endpoint and safety/tolerability in these two groups. in secure trial, patients in one group received (i) & another patients received (v). the indian subset had patients. we have done a qualitative analysis as the sample size of the indian subset was small. non-inferiority of (i) to (v) in terms of all cause mortality from first dose to day was assessed in overall patients. the treatment difference between (i) and (v) group in the indian subset of patients was analyzed. proportion of patients who had to discontinue treatment due to teaes was analyzed. the all-cause mortality in the overall trial population met noninferiority margin (table ). in the indian subset, it was higher for (i) than (v). there was a lower incidence of ocular, hepatobiliary, skin & subcutaneous tissue disorders in the (i) treated patients (see table ). in indian subset, the above adverse events were less in the (i) group, but statistical inference could not be done due to small sample size. however, similar trend of less number of patients discontinuing therapy due to teaes in the (i) treated patients was seen in the overall patients & the indian subset. the all-cause mortality in the indian subset was higher in the (i) patients. a trend similar to the overall population regarding safety parameters favoring (i) was seen in the indian patients. considering the significantly higher prevalence of ia in india, suitably powered study design is necessary to draw definitive conclusions on the non-inferior efficacy & better safety & tolerability of (i) over (v) in patients of ia. introduction: ventilator-associated pneumonia (vap) is one of the most frequent healthcare-associated infections, correlated with increased mortality,extended hospital stay and prolonged mechanical ventilation. considering the latest outbreak of multiresistant a. baumannii infections in the critically ill patients with vap, there is a growing concern regarding challenges of the antibiotherapy in these patients. although ceftazidim-avibactam is considered to have limited effects on a. baumannii, it is reported to have a synergic activity in combination with other antibiotics. we performed a retrospective, observational study which included icu patients diagnosed with vap(cpis > ). oxa a. baumannii was isolated from the tracheal secretions using a rapid molecular diagnostic platform(unyvero a system). patients were divided in two groups according to the antibiotherapy:group a meropenem + colistin and group b meropenem + colistin + ceftazidim-avibactam.statistical analysis was performed using graphpad applying t-test and kaplan-meier curves, having the in-hospital mortality as primary outcome and days of mechanical ventilation and hospital stay as secondary outcomes. mean age(y.o) in group a was and in group b and in both groups mean charlson comorbidity index was points. survival percent was higher in the group treated with ceftazidim-avibactam ( % vs %, p = . )- (fig. ) . length of stay was significantly decreased in group b ( . days vs days in group a, p = . ). number of days under mechanical ventilation was also decreased in the ceftazidim-avibactam group ( vs ) but the data was not statistically significant. in light of the important thread of multiresistant a. baumannii and the lack of therapeutic measures, the synergistic activity of ceftazidim-avibactam use in combination with other antibiotics may be a promising approach to lower the mortality and hospitalization in critically ill patients diagnosed with vap. impact of patient colonization on admission to intensive care on and days mortality g dabar , c harmouch , e nasser ayoub , y habli , g sleilaty , j infections caused by multi resistant bacteria are a major health problem, especially in icus, and it may be associated with high mortality rates. colonization precedes infection in most instances; therefore it may be a marker of a poor outcome. we tried to determine the impact of colonization on mortality at and days in a population of patients admitted to one medical and one surgical icu in the same institution. medical records review over three years - of all patients admitted to one surgical et one medical icu at hotel dieu de france hospital staying more than h. colonization to resistant bacteria was defined as mrsa, esbl, mdr, and vre. all patient received a nasal and rectal screen on icu admission, in intubated patients tracheal aspirate was considered as colonization in the absence of clinical respiratory tract infection. demographics, apache, sofa, immunosupression, charleston comorbidity index, length of stay, mechanical ventilation, hospitalization and antibiotic use in the previous month were collected. mortality at and days was assessed through medical records or phone call. pearson chi-square was calculated for the association of colonization and mortality at and days, and subsequently odd ratio was estimated. introduction: critically unwell patients have been observed to respond unpredictably to traditional intermittent dosing (id) schedules of vancomycin, likely due to the complex physiological derangements caused by critical illness. continuous infusion (ci) of vancomycin has been suggested to overcome such problems by allowing more regular therapeutic drug monitoring and subsequent effective dose titration [ ] . this study conducted at a tertiary intensive care unit, reports our experience following implementation of a continuous vancomycin infusion protocol. prospective data was collected over two consecuative periods of three months, initially capturing plasma levels for id (target level of - mg/l) followed by reviewing plasma concentration levels in a ci protocol (target level of - mg/l). patients recieving renal replacement therapy were excluded. a total of intermittent vancomycin prescriptions were administered and dosing levels observed. in the three month ci period, patients received ci vancomycin and levels subsequently checked. the ci protocol resulted in increased blood sampling ( samples in ci group vs. samples in id cohort). two non serious incidents were reported in the ci cohort relating to preparation of vancomycin. both groups had a comparable median time to therapeutic range ( hours). however, ci vancomycin group had a greater proportion of first samples outside the desired therapeutic range ( %vs %) (figure ). as the therapy continued, ci vancomycin demonstrated a greater propensity towards consistent therapeutic levels than that observed with id. % of patients on a ci regime achieve the desired target levels compared to % in the id cohort (fig. ) . it was positive for single or multiple microbes in ( . %) and ( . %) samples respectively. single or multiple resistance genes were detected in ( %) and ( %) samples respectively. bfpcr was positive only for bacteria in ( . %), virus in ( . %) and for both in ( . %) cases. influenza a was found in ( . %) cases. the most common organisms in community and hospital acquired pneumonia were streptococcus pneumoniae ( / ) and a. baumannii ( / ) respectively. bacterial cultures were concordant with bfpcr in / ( %) of positive cases. decisions to change antibiotics could be taken earlier based on bfpcr (p< . ) than if were based solely on culturesboth in culture positive ( . ± . vs . ± . hrs) and negative cases ( . ± . vs . + . hrs) where antibiotics would have remained unchanged. based on bfpcr antibiotics were escalated in ( %) patients and teicoplanin ( / ) was most often stopped. bal bfpcr were obtained significantly earlier, identified more organisms and bacterial resistance than culture reports and lead to more frequent and earlier antibiotic changes. severe community-acquired pneumonia (scap) is a frequent cause of hospitalization and mortality. ceftaroline is efficacious for treatment of cap (port risk class iii or iv). most severe patients were excluded from the clinical trials, so the efficacy of ceftaroline in these kind of patients is unknown methods: this is a health record-based retrospective before-after study in a tertiary care hospital. all scap patients admitted in icu between november and february receiving ceftaroline were included. control group included patients with same inclusion criteria but receiving ceftriaxone. propensity scores to adjust for potential baseline differences between groups were performed. levofloxacin or azythromicin were administered in both groups. primary outcome was the change in sofa score over the first h and secondary were days of mechanical ventilation, respiratory failure at h, need of rescue antibiotics, length of stay and mortality results: there were patients in ceftaroline group and in ceftriaxone group. baseline characteristics were similar except from more intubated patients in ceftaroline group (figure ). there were less respiratory failure at h in patients with ceftaroline treatment (- . % vs. - . %; p , ), but no differences in other organ failures, mortality, days of mechanical ventilation or los. there were more need of rescue antibiotics in ceftriaxone group ( . % vs . . %; p , ). we found more streptococcus pneumoniae isolation in ceftaroline group ( ( . %) vs ( . %); p = . ); more empiric use of oseltamir ( ( . %) vs ( . %); p = . ), but no more influenzae infections ( ( . %) vs ( . %); p = . ). s. aureus was detected in patient in ceftaroline group and in in ceftriaxone group. introduction: acute respiratory failure (arf) due to pulmonary infections is a usual cause of intensive care unit (icu) admission. immigration patterns and iatrogenic immune-suppression have made tuberculosis (tb) a common disease in western europe. severe tb requiring icu care is rare. nevertheless, mortality associated with active tb and arf is poor [ ] . adult patients with tb admitted to icu from - were identified retrospectively. diagnosis was based on: positive cultures of sputum, bronchial aspirates or bronchioalveolar lavage fluid. demographic characteristics, reasons for admission, hiv status, anti-tb treatment and mortality were recorded. total of patients with tb were admitted to icu. mean apache ii score was , ± , . sixteen were male. mean age , ± , years. eight ( %) were hiv-positive, ( %) diabetes mellitus type , ( %) chronic liver disease. six ( %) had other causes of immunesuppression. main causes for icu admission were arf due to non- mycobacterium tuberculosis pathogens in %, acute liver failure in %, septic shock due to non-respiratory cause in %. overall, % were on anti-tb treatment at time of admission. tb involved the lung parenchyma in all patients. pleural involvement was present in % and lymph node in %. extrapulmonary sites were present in %: urogenital, gastrointestinal, bone marrow. pathogens identified in over-infections: % gram positive coccus, % gram negative bacilli, % fungal, % mdr-pathogen. one patient hiv-positive suffered arf due to pneumocystis jiroveci. overall, % died during icu stay. besides its latent evolution, mortality of tb patients admitted to icu is extremely high. arf due to over-infection seems to be the main cause for icu admission and mortality. better preventive approach of these patients may improve their outcome. introduction: human african trypanosomiasis (hat) is rarely encountered by critical care clinicians, but is an important differential for fever in the returning tropical traveler. late disease is characterized by seizures, fever and multi-organ failure [ , ] . we present an anonymized case presenting from an endemic area in zambia referred for tertiary critical care management. the patient was too obtunded to give informed consent and his relatives could not be contacted despite extensive efforts. a middle-aged man with no past medical history from rural zambia presented to a local clinical officer post with fever and arthralgia. he was treated twice with anti-malarial medication without resolution of symptoms. two months later he was admitted febrile and obtunded to a local hospital with worsening confusion. he was transferred hours by ambulance to our facility in lusaka, which is the only public tertiary critical care unit in zambia results: gcs on arrival was e m v without localizing neurology. microbiology investigations were negative, including for toxoplasma, cryptococcus, hiv or malaria. the patient suffered a generalized seizure followed by a sustained gcs of and was admitted to the icu for invasive ventilation and seizure control. peripheral blood smears demonstrated trypanosomes consistent with hat secondary to trypanosoma brucei rhodesiense. he was commenced on melarsoprol but rapidly deteriorated, with signs of melarsoprol-induced arsenic encephalopathy and subsequent tonsillar herniation. his death was confirmed by neurological criteria. conclusions: icu management of fulminant hat involves supportive neurocritical care plus melarsoprol, a toxic arsenic compound with common side effects of hepatotoxicity and dysrhythmia. arsenic encephalopathy occurs in % of late hat, with a fatality rate of % [ ] . early diagnosis is associated with a % survival rate in developed world travelers repatriated from endemic areas [ ] . lithium chloride to prevent endothelial damage by serum from septic shock patients (in vitro study) a kuzovlev the aim of the study was to investigate into effectiveness of lithium chloride (licl) as agent that prevents damage to the monolayer of endothelial cells under the action of serum from multiple trauma patients with septic shock. methods: serum from pts with septic shock (sepsis- ) and healthy donors was withdrawn. monolayer of ea.hy endothelial cells were incubated for hrs at °c with healthy person's serum and with septic patient's serum without licl and with it at concentrations of . mmol, . mmol, mmol, mmol. licl was added hour before the change of serum. after incubation cells were washed and fixed with % paraform solution and permeabilized with % triton x- solution. fixed cells were stained with primary antibodies to vecadherin and then incubated with secondary antibodies conjugated with oregon green fluorescent dye as well as with phalloid red and hoechst dye . images were processed by fluorescence microscope and imagej . p and metavue . programs. western blotting was used to detect antibodies to ve-cadherin, claudin and gsk- beta. statistics included mann-whitney test and chi-square test. incubation of a monolayer of endothelial cells with % serum of septic shock patients led to loss of ve-cadherin contacts and decrease of claudine. preincubation with licl . mmol did not prevent dismantling of claudine, actin, ve-cadherins; . mmol licl prevented it (p> . ), but at higher concentrations ( mmol, mmol) almost completely protected endothelial monolayer from destruction of intercellular contacts (p< . ). serum had almost no effect on the phospho-gsk- β level after min, min, min and hr, but caused a significant ( %) decrease in its level after and hrs. licl ( mmol) caused a significant increase in phospho-gsk- β already mins and up to hrs after exposure. licl prevents septic damage to the monolayer of endothelial cells in vitro in a gsk- beta mediated way. introduction: the autonomic nervous system (ans) controls both heart rate and vascular tone, which are known to be impaired during septic shock (ss) . acute inflammation is presumed to increase arterial stiffness of large arteries in experimental studies [ ] . the objectives of this work are to verify if standard ss resuscitation modulate mechanical vascular properties and to verify if alterations in these vascular properties and ans activity are correlated. a protocol of fecal peritonitis septic shock and standard resuscitation (fluids and noradrenaline) was applied on pigs. the arterial blood pressure waveform was recorded in the central aorta and in the femoral and radial arteries. the characteristic arterial time constant tau was computed at the three arterial sites, based on the twoelement windkessel model [ ] . the total arterial compliance (ac) and the total peripheral resistance (tpr) were also estimated. baroreflex sensitivity (brs), low frequency (lf, . - . hz) spectral power of diastolic blood pressure, and indices of heart rate variability (hrv) were computed to assess ans functionality. results: septic shock induced a severe vascular disarray, decoupling the usual pressure wave propagation from central to peripheral sites, as shown by the inversion of pulse pressure (pp) amplification, with a higher pp in the central aorta than in the peripheral arteries during shock. the time constant tau together with ac and tpr were independently decreased. a decrease in brs, lf power, and hrv describe an ans dysfunction. after the administration of fluids and noradrenaline, both vascular and autonomic dysfunction persisted and these were found to be significantly correlated. measures of mechanical vascular function and ans activity could represent an useful end-point to guide further clinical investigations and refine our understanding of ss mechanisms, especially under medical treatment. introduction: lipopolysaccharide (lps), is a component of gram-negative bacteria known for its activation of the host immune system. the phospholipid transfer protein (pltp) has previously been shown to promote the binding of lps to lipoproteins, to limit inflammation and to lower mortality following injections of lps or bacterial infection. the aim of the present study was to investigate the role of pltp and lipoproteins in the detoxification of lps from the peritoneal cavity. injection of lps intra-peritoneally (ip) ( mg/kg) to wild type (wt) and pltp knocked-out mice (pltp-ko) (n = per group). mass concentration and activity of lps were quantitated by lcmsms analysis of -hydroxymyristate and lal bioassay, respectively. lipoprotein fractions in plasma were separated by ultracentrifugation (n= vs n = ). following intra-peritoneal injection, clearance of intra-abdominal lps was faster and plasma neutralization was more efficient in wt than in pltp-ko mice ( figure ) . indeed, lps found in plasma of wt mice was proportionally less active, sustaining a higher capacity for wt mice to neutralize lps (figure b) . quantitative dosage of lps in portal blood, minutes after ip injection, revealed that plasma lps associates rapidly with the lipoprotein fraction (hdl plus ldl), and in higher proportions as compared to pltp-ko mice ( [ - ] % vs [ - ] %, respectively; p < . ). in line with previous studies, these observations now indicate that, lps readily associates with lipoproteins in a neutralizing process pltp mediated. finally, even with a heavy lps load ( mg/kg), the bulk of lps was still found in the lipoprotein fraction ( [ - ] %), suggesting that lipoproteins plus pltp in wt mice have a high capacity to detoxify intraperitoneal lps. in a model of peritonitis, lipoproteins and pltp were found to constitute key playors for peritoneal clearance and neutralization of lps. it emerges as a key pathway for the resolution of the inflammatory response in peritonitis. introduction: autotaxin (atx, enpp ) is a secreted enzyme present in biological fluids that catalyses the production of lysophosphatidic acid (lpa). lpa is a bioactive phospholipid evoking various cellular responses in most cell types. upregulated atx levels have been reported in various chronic inflammatory diseases. given the established role of lpa in the inflammatory response, we investigated a possible role for the atx/lpa axis in lps-induced endotoxemia. methods: lps was injected intraperitoneally ( mg/kg) in mice producing % atx levels (atx df/+ , heterozygous null mutant mice), in mice producing - % reduced atx levels upon inducible inactivation (r creer t /enpp n/n mice) and in mice expressing - % increased atx levels (enpp -tg mice). kaplan-meier survival analysis was performed. atx activity was measured using the toos activity assay. results: atx df/+ mice that produce almost % reduced serum atx levels show increased survival compared to their littermate controls. for the inducible inactivation of atx, enpp n/n targeted mice were crossed with the r cre-er t mice and tamoxifen induction enabled temporal control of floxed gene expression. r creer t /enpp n/n mice were more protected against lps-induced endotoxemia compared to control mice. enpp -tg mice overexpressing autotaxin and showing a -fold increase in plasma levels do not display improved survival rates compared to control group. conclusions: atx participates in systemic inflammation, as reduced atx levels in circulation decrease lethality of mice from caused by lps. the excess amount of circulating atx does not exacerbate the systemic inflammatory response to lps. introduction: pneumonia (pn) is a prevalent and severe infectious lung disease. host genetics plays an essential role in the pathogenesis of infectious diseases including pn [ ] . the aim of the study was to analyze the variability of genes associated with neutrophil activation in pneumonia. to identify differential expressed genes (degs) in communityacquired (cap) and hospital-acquired pneumonia (hap) dataset «genome-wide blood transcriptional profiling in critically ill patients -mars consortium» (gse ) from gene expression omnibus was analyzed (logfc≥ . , fdr-corrected p-value< . ). degs associated with neutrophil activation were selected according to gene ontology go: («neutrophil activation»). with the use of gtex portal and blood eqtl browser, we searched for esnps (expression single nucleotide polymorphisms) in whole blood for neutrophil activation genes differentially expressed in cap/hap. these esnps were further analyzed for their association with pn via the global biobank engine (gbe). a total of degs from gse correspond to go: genes ( up-and down-regulated) of which genes were common to cap and hap. functional enrichment of degs based on disgenet detected top- diseases associated with these genes (fdr-corrected p-value< . ): myeloid leukemia, chronic; sepsis; asthma; lung diseases; allergic asthma. for these genes esnps common to gtex portal and blood eqtl browser were identified. more than half of all variants were located on the second chromosome and influenced the expression of tnfaip and il rap genes. among all esnps we identified variants associated with pn in the gbe (table ) . we identified genes related to neutrophil activation, genetic variability of which was associated with pneumonia. sepsis was induced in wild-type c bl mice (n= ) and cse knockout mice (n= ) by i.p. injection of cfu/mice mdr p. aeruginosa. similar experiments were repeated after cyclophosphamide induced neutropenia. survival was recorded for days. mice were sacrificed for determination of bacterial load and myeloperoxidase (mpo) activity as a surrogate marker of myeloid cell recruitment. cytokines were measured in serum by legendplex inflammatory panel. total leukocytes from mice spleens, with or without pretreatment with the h s donor gyy , were incubated with x cfu/ml mdr p. aeruginosa. bacterial clearance was recorded. we observed a significant decrease in survival of cse -/mice as compared to cse +/+ mice ( % vs. %; p: . ). this survival advantage was eliminated in neutropenic mice ( % for both groups, p: . ). cse -/mice had increased pathogen load in the liver ( . ± . vs . ± . , p: . ) and lung ( . ± . vs . ± . , p: . ). mpo activity was lower in cse -/mice in the liver ( ± vs ± , p: . ) and lung ( ± vs ± , p: . ). cse +/+ mice had increased serum levels of il- ( . ± . vs . ± . of cse -/-, p: . ); mcp- ( . ± . vs . ± . , p: . ) and gm-csf ( . ± . vs . ± . , p: . ). phagocytic activity of leukocytes from cse -/mice was reduced compared to cse +/+ mice. this deficit was eliminated after gyy pretreatment (fig. ) . deficiency of host-derived h s leads to increased susceptibility to mdr p. aeruginosa infection due to an inefficient neutrophil chemotaxis and neutrophil mediated phagocytosis. acknowledgement funded by the itn horizon marie-curie european sepsis academy introduction: neuroinflammation often develops in sepsis along with increasing permeability of the blood-brain barrier (bbb), which leads to septic encephalopathy [ ] . the barrier is formed by tight junction structures between the cerebral endothelial cells [ ] . we investigated the expression of tight junction proteins related to endothelial permeability in brain autopsy specimens in critically ill patients deceased with sepsis, and analyzed the relationship of bbb damage and measures systemic inflammation and systemic organ dysfunction. case series included all adult patients deceased with sepsis in the years - with brain specimens taken at autopsy available. specimens were categorized according to anatomical location (cerebrum, hippocampus, cerebellum). the immunohistochemical stainings were performed for occludin, zo- and claudin. patients were categorized as having bbb damage if there was no expression of occludin in the endothelium of cerebral microvessels. results: % ( / ) developed multiple organ failure before death. . % ( / ) had septic shock. the deceased with bbb damage had higher sofa maximum scores ( vs. , p= . ), and had more often procalcitonin levels above ( % vs. %, p= . ). bbb damage in cerebellum was more common in cases with c reactive protein above mg/l as compared with crp less than ( % vs. %, p= . ). absence of zo- expression in cerebral meningeal samples associated with bbb damage ( % vs. %, p= . ). positive blood cultures (n = ) were associated to absence of zo- expression in cerebellar glial cells ( % vs. %, p= . ). in fatal sepsis, damaged bbb defined as loss of cerebral endothelial expression of occludin ( figure ) is related with severe organ dysfunction and systemic inflammation. loss of zo- in endothelial cells associates with bbb damage, and sepsis contributes to zo- loss in cerebellar glial cells. oxylipins are oxidative breakdown products of cell membrane fatty acids. animal models have demonstrated that various vasoactive oxylipin pathways may be implicated in septic shock pathophysiology but these have been poorly studied in humans. oxylipin profiling was performed on serum samples collected on enrolment to the vanish (vasopressin vs. norepinephrine as initial therapy in septic shock) trial. samples were analysed with liquid chromatography-mass spectrometry. patients were followed up until days. results: samples were collected from of ( . %) patients on inclusion to the trial and ( . %) had died by days. non-survivors were found to have higher levels of a number of oxylipins including: , -dihydroxyeicosatrienoic acid (dhet) (p< . ), , -dhet (p= . ), (s)-hydroxyeicosatetraenoic acid (p= . ), -hydroxyoctadeca-pentaenoic acid (p= . ) but lower levels of the precursor eicosapentaenoic acid (p= . ). when corrected for multiple comparisons with the benjamini-hochberg test, only , -dhet remained significant (p= . ). although there was a difference in median , -dhet levels between survivors and non-survivors, many values were below the level of detection (n= / ( . %)). as such, we also analysed - -dhet as a binary variable (figure ). patients with detectable , -dhet were more likely to die (hr . [ % ci . - . ], p< . ) and have a higher median lactate (p = . ) and total sofa score (p< . ) than those patients where baseline , -dhet was undetectable. our study suggests the oxylipin , -dhet may be associated with septic shock severity and -day mortality. these results are consistent with the known vasodilatory actions of this class of oxylipin. more work is needed to confirm its exact role in septic shock and whether this pathway is amenable to therapeutic intervention. introduction: activation of neutrophils is a mandatory stage and a sensitive marker of systemic inflammatory conditions that can lead to the development of multiorgan failure. the aim of the study was to investigate into the antiinflammatory effects of lithium chloride on human neutrophils in vitro. study was carried out on neutrophils isolated from the blood of healthy donors. % of neutrophils were activated by mkm fmlp, % -by ng/ml lipopolysaccharide (lps); then their activity was evaluated by fluorescent antibodies to cd b and cd b degranulation markers. intact and activated neutrophils were treated with a solution of lithium chloride ( mmol). immunoblotting was used to assess gsk b activity in neutrophils. mann-whitney criterion and p< . were used for statistics. results: lithium chloride mmol decreased the level of expression of cd b on intact neutrophils by % (p= . ), cd b by % (p= . ). fmlp increased cd b expression on neutrophils by . times (p= . ), cd b by . times (p= , ). addition of lithium chloride solution to fmlp activated neutrophils reduced the expression of cd b (p= . ) and cd b (p= . ). lps increased cd b and cd b expression by . times (p= . , p= . , respectively); addition of lithium chloride reduced the expression of cd b (p= , ) and cd b (p= . ) on neutrophils. fmlp led to a dephosphorylation of gsk- b by % (p< . ), lithium chloride increased its phosphorylation by % (p < . ). adding lithium chloride to activated fmlp neutrophils restored the level of gsk- b phosphorylation by % compared to controls (p< . ). lithium chloride modulates the inflammatory activation of neutrophils by bacterial components through the phosphorylation of gsk b in neutrophils. human host immune responses to lipopolysaccharide: a comparison study between in vivo endotoxemia model and ex vivo lipopolysaccharide stimulations using an immune profiling panel dm tawfik introduction: sepsis, a leading cause of mortality among critically-ill patients in the icu, recently recognized by the who as a global health burden. patients that suffer from sepsis exhibit an early hyper-inflammatory immune response which can lead to organ failure and death. in our study, we assessed the immune modulations in the human in vivo endotoxemia model and compared it to ex vivo lipopolysaccharides (lps) stimulation using transcriptomic markers. methods: eight healthy volunteers were challenged with intravenous lps in vivo. in parallel, blood from another volunteers was challenged with lps ex vivo. blood was collected before and after hours of lps challenge and tested with the immune profiling panel (ipp) prototype using the filmarray® system. the use of ipp showed that markers from the innate immunity dominated the response to lps in vivo, mainly markers related to monocytes and neutrophils. comparing the two models, in vivo and ex vivo, revealed that most of the markers were modulated in a similar pattern ( %). some cytokine markers such as tnf, ifn-γ and il- β were under-expressed ex vivo compared to in vivo. t-cell markers were either unchanged or up-modulated ex vivo, compared to a down-modulation in vivo. interestingly, markers related to neutrophils were expressed in opposite directions, which might be due to the presence of cell recruitment and feedback loops in vivo. the majority of ipp markers showed similar patterns of expression post-lps challenge in both models, except for several markers related to neutrophils and t-cells. the ipp tool was able to capture the early immune response in the human in vivo endotoxemia model, which is a translational model mimicking immune host response in septic patients. introduction: serum levels of tyrosine kinase receptor mer and its ligand gas predict mortality in septic patients in the intensive care unit. however, whether their early measurement at emergency department (ed) presentation also predicts mortality and organ failure still needs to be clarified. in this multicentre observational study, septic patients admitted to italian eds were included [ ] . at ed presentation blood samples were taken for routine biochemical analyses and serum mer and gas measurement. urinalyses, blood gas analyses and chest x-ray were routinely performed. mortality at and days, as well as the presence of organ damage such as acute kidney injury (aki), thrombocytopenia, pt-inr derangement and sepsis-induced coagulopathy (sic) were evaluated according to baseline levels of mer and gas . in conclusion, neither mer nor gas are early predictors of mortality in septic patients at ed presentation. however, mer independently predicted the development of sic, thrombocytopenia and pt-inr derangement in this population. glycocalyx shedding correlates with positive fluid balance and respiratory failure in patients with septic shock n takeyama, y kajita, t terajima, h mori, t irahara, m tsuda, h kano aichi medical university, department of emergency and critical care medicine, aichi, japan critical care , (suppl ):p endothelial hyperpermeability would play a major role in septic shock related organ failure. the aim of this study is to clarify the relationship between glycocalyx shedding and respiratory failure, sofa score, plasma angiopoietin (ang)- level and patient survival. methods: plasma samples were collected from septic shock patients from admission to icu discharge and healthy volunteers. plasma syndecan (syn)- and ang- were measured and clinical data was also collected. septic shock patients were classified into groups according to the time-course change of syn- levels. excess syn- (> ng/ml) during to days and remaining high following to days were assigned to group i. excess ang- during to days and decreased following to days were assigned to group ii. moderate increase (< ng/ml) during to days were assigned to group iii. results: plasma syn- levels are positively associated with increased ang- levels (r = . , p= . ), suggesting that ang- is involved in endothelial hyperpermeability. fluid balance and ventilator-free days (vfd) are significantly increased in group i as compared with group iii. sofa score, apache ii and patient outcome does not show any differences between groups i, ii, and iii. the positive correlation between glycocalyx shedding and fluid balance indicates plasma syn- may be a valuable marker for endothelial hyperpermeability. the negative correlation between glycocalyx shedding and vfd indicates plasma syn- may be a valuable marker for respiratory failure. the plasma level of syn- for prognosis and organ failure excluding ards in patients with septic shock requires further investigation. serial procalcitonin measurements in the intensive care unit at hiroshima university hospital k hosokawa, s yamaga, m fujino, k ota, n shime hiroshima university hospital, department of emergency and critical care medicine, hiroshima, japan critical care , (suppl ):p introduction: serum procalcitonin (pct) is a promising biomarker for differentiating bacterial infections from other inflammatory states. moreover, including serial pct measurements in the management of acute respiratory infection reduces the duration of antibiotic therapy without increasing the mortality. however, limited real-world information is available regarding the use of pct in intensive care units (icus). we extracted and analysed data from january to december , from all the orders and results of pct measurements in the icu ( beds) at hiroshima university hospital. a total of , pct measurements from icu patients were included. in patients, pct was tested ≥ times during a single icu stay. serial pct measurements showed a fade-out pattern ( [ %] patients), a second day-peaked decrease pattern ( [ %] patients), and a series of negative patterns ( [ %] patients). compared to patients who demonstrated the fade-out pattern, those who demonstrated the second day-peaked decrease pattern had higher mortality rates ( % vs. %, p < . ). approximately one-third patients in the icu who had decreasing serial pct values demonstrated the second day-peaked decrease pattern. since this group of patients had poorer survival, further studies are needed to clarify the association between a late rise in pct levels and delayed therapeutic intervention. the research was performed on full-term newborns; no clinical signs of bacterial infection were diagnosed. on the , , days the plasmà concentration of il- ß, il- , il- , tnf-α, g-csf, sfas, fgf, no was determined by capture elisa; cd cd , cd cd , cd cd , cd , cd , cd , hla-dr, cd , cd , cd cd , lymphocytes in apoptosis -immunophenotype analysis. by applying the statistical cluster population analysis of the immunological criteria under study we have evaluated the feasibility of sepsis diagnostics at the admission to the intensive therapy unit. the diagnostic rule for sepsis has been formulated by applying the "decision tree" approach to the "r" statistic medium. the cluster analysis confirms the presence of two clusters (presence of absence of sepsis: these two components explain the . % of the point variability). the diagnostic rule for the early diagnostics of sepsis is as follows: disease develops providing during the first hours cd ≥ . %, no≤ . mkmol/l or cd ≤ . %, cd ≤ . %, cd ≥ . % or cd ≤ . %, cd ≤ . %, cd ≤ . % and lymphocytes annexinv-fitc+pi-≥ . %. newborns featured the confirmed sepsis development. the accuracy of this diagnostics amounts to . %; sensitivity to . %; specificity to . %; diagnostic false positive share to . %; diagnostic false positive share to . %; positive result accuracy to . %; negative result accuracy to . %. the aggregate determination of cd , cd , annexinv-fitc+ pi-, cd and the plasma concentration of no enables the pre-clinical diagnostics of sepsis development. efficacy of pancreatic stone protein in diagnosis of infection in adults: a systemic review and metaanalysis of raw patient data j prazak , p egimann , i irincheva , mj llewelyn , d stolz , lg de guadiana-romualdo , r graf , t reding , hj klein , ya que fig. (abstract p ) . impact of h lactate and bio-adm values in patients with elevated lactate level at admission. the green curve in the left km-plot illustrates data from patients with events; the red curve patients with events. the green curve in the right km-plot illustrates data from patients with events; the red curve patients with events. of note, differences in numbers between admission (n= ) and h (n= ) is related to initial mortality introduction: adrenomedullin (am) is a peptide synthesized in vascular endothelial cells and cleared by the lungs. the use of am as an inflammatory biomarker and his predictive value has been studied in critically ill patients, but not yet in veno-venous extracorporeal membrane oxygenation (ecmo). the purpose of this study was to describe the plasmatic levels of am in patients supported with ecmo for acute respiratory failure methods: am (normal values < . nmol/l) was measured at time points: immediately before (t ), -h (t ) and -h after (t ) ecmo initiation and immediately before (t ) and -h (t ) after ecmo removal, in consecutive patients with severe respiratory failure supported with ecmo enrolled in the gatra study (nct ) at fondazione irccs ca' granda -policlinico of milan. data are reported as median ( th - th percentile). statistical analysis was performed using logistic and random effects regression models (to account for repeated measurements within individuals) results: a total of measurements were taken in consecutive patients. am (nmol/l) decreased along the course of ecmo: t = . ( . - . ), t = . ( . - . ), t = . ( . - . ), t = . ( . - . ), t = . ( . - . ) (mean diff.= - . , %: ci - . , - . ). am was lower in patients with viral compared to bacterial ards (mean diff.= - . , %ci - . , - . ) (figure ). am was higher in more severe patients (sofa>= , n= ) compared to less severe patients (sofa< , n= ): . ± . vs . ± . nmol/l, respectively p< . . basal values of am could not predict mortality at days (or= . , %ci: . - . ) after conditioning for sofa score and respiratory failure etiology conclusions: am plasmatic values seem to be higher in more severe patients and in patients with bacterial ards. am decreased along the ecmo course but could not predict mortality in our group of patients fig. (abstract p ) . plasmatic adrenomedullin during ecmo heparin binding protein (hbp) is released from activated neutrophils upon stimulation of b integrins. this pro-inflammatory effect generates the hypothesis that it can be a sepsis biomarker for patients admitted at the emergency department (ed) methods: the prompt study (clinicaltrials.gov nct ) took place at the ed of six greek hospitals. participants were admitted with suspected acute infection and at least one vital sign change. hbp was measured by an enzyme immunosorbent assay in plasma. sepsis was diagnosed by the sepsis- criteria. the primary study endpoint was the sensitivity for the diagnosis of sepsis. outcome prediction was the secondary endpoint. a total of patients were enrolled; had sepsis. the most common infections among patients without and with sepsis were upper respiratory tract infections in . % and . %; community-acquired pneumonia in . % and . %; and acute pyelonephritis in . % and . %. median hbp was . and . ng/ml respectively (p: . ). following analysis of the area under the curve (auc) it was found that the best discriminatory cut-off for sepsis was . ng/ml. the comparative diagnostic performance of hbp versus qsofa score is shown in figure . the odds ratio for sepsis with hbp above . ng/ml was . (p: . ). at the same cut-off point the sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) for the prediction of early death after hours was %, . %, . % and % respectively. hbp is more sensitive but less specific than qsofa for the diagnosis of sepsis in the ed. the rule-out prediction of early death seems the great merit. chronobiological and recurrence quantification analysis of temperature rhythmicity in critically ill patients introduction: rhythmicity and complexity of several circadian biomarkers, such as melatonin, cortisol and temperature have been found to be modified by critical illness. we examined the potential alterations of core body temperature (cbt) fluctuations and complexity in three groups (n= ): patients with septic shock upon icu admission (group a, n= ), patients who developed septic shock at icu hospitalization (group b, n= ) and controls (group c, n= ). the hourly, average cbt was computed for h upon icu admission and discharge in groups a and c, as well as during septic shock onset in group b. cosinor analysis of cbt curves was performed leading to the estimation of mesor (mean value), amplitude (the difference between peak and mean values) and acrophase (phase shift of maximum values in hours). complexity of cbt signals was evaluated with recurrence quantification analysis (rqa). no significant alterations in any circadian feature within groups were found, except for amplitude. controls exhibited increased entry cbt amplitude ( . ± . ) compared to groups a ( . ± . , p < . ) and b ( . ± . , p < . ). higher entry cbt amplitude in groups b and c was related with lower saps ii (r = - . and - . , p < . ) and apache ii scores (r = - . and - . , p < . ) respectively, reduced icu and hospital stay in group b (r = - . and - . , p < . ) and entry sofa score in group c (r = - . , p < . ). recovery cbt time series appeared more periodic in relation with icu entry, for all groups. a more random cbt signals pattern upon results: among . . individuals, . received inpatient treatment for sepsis. % had severe sepsis. % of sepsis and % of severe sepsis patients had an explicitly coded hai. the proportion of hai was higher in patients that received icu-treatment than in patients without icu-treatment ( % in icu/ % in non-icu sepsis, % in icu/ % in non-icu severe sepsis patients). tab. shows the foci of explicitly coded hai. nosocomial pneumonia was the most common hai in all patient groups. clabsi occurred more frequently in icutreated patients; % were affected. cauti and c. diff infections were more common among non-icu-treated sepsis patients. more than one quarter of non-icu-treated sepsis patients had a c. diff infection. hai are common causes of sepsis and pose a significant healthcare burden. the proportion of patients affected and the distribution of foci differ between non-icu-and icu-treated sepsis patients with important implications for sepsis management within hospitals. impact of sepsis protocol triggered by ramathibodi early warning score (rews) in ipd sepsis on clinical outcomes s matupumanon , y sutherasan , d junhasawasdikul , p theerawit sepsis is now early identified and managed during triage in the emergency department. however, there is less focus on the effect of patients' management at the ward level. we aim to evaluate the impact of the implementation of the sepsis protocol on clinical outcomes in in-patients with new-onset sepsis. we conducted a prospective observational cohort study among adult medical patients admitted to the general wards in a university hospital. a -month pre-protocol period (august to august ) was assigned to a control group, and a -month protocol period (september to october ) was allocated to a protocol group. an in-patient sepsis protocol comprised nurse-initiated sepsis protocol by ramathibodi early warning score (rews)≥ plus suspected infection, prompt antibiotic, lactate measurement, and fluid resuscitation was implemented. (table ) . the implementation of in-hospital sepsis protocol was associated with significant improvement in patients' outcomes, namely lactate measurement, starting antibiotic within hr, fluid management, and the shorter length of icu stay. icu routine nursing procedures interfere with cerebral hemodynamics in a prolonged porcine fecal peritonitis model sl liu , dc casoni , w z'graggen , d bervini , d berger , sj jakob routine nursing procedures (np) can interfere with blood pressure and cardiac output and may therefore alter cerebral hemodynamics in critical illness. this may be risk factor of sepsis-associated encephalopathy. methods: sedated and mechanically ventilated pigs were randomized to fecal peritonitis or controls (n= , each). after hours of untreated peritonitis, the animals were resuscitated for hours (resuscitation period). np [assessment of sedation (as), tracheal suctioning (ts), change in body position (cp), lung recruitment maneuver (rm)] were performed at baseline and h, h, h and h after start of rp. systemic and cerebral hemodynamics and o saturations were recorded continuously. shock is the most common cause of death in the postsurgical icu, including septic shock and hypovolemic shock, reaching the - % mortality in septic shock. the inadequate response of the immune system to the infection triggers a potent inflammatory cascade, where the c-reactive protein (crp) is an essential key in the amplification and maintenance of this cascade. the gene encoding to crp is located on the proximal long arm of human chromosome ( q ). the gt polymorphism in the promoter sequence of crp gene (rs ) has been associated with invasive pneumococcal disease. thus, we analyze the relationship between rs polymorphism and the risk of developing septic shock in postsurgical patients. an observational, retrospective and single-center study was conducted on a sample of caucasian patients undergoing major abdominal surgery, of which one part developed septic shock and another part developed systemic inflammatory response syndrome, who were used as control. the rs polymorphism was analyzed by vasoactive medications are commonly used in sepsis treatment but may correlate with peripheral ischemia and the well-publicized complication of limb and digit loss. yet, the association between limb and digit threat and the intensity, duration, and pattern of vasopressor exposure are unknown. we studied adults ( - ) at hospitals in an integrated health system who met criteria for sepsis- . we identified the time to clinically apparent limb or digit threat using clinical adjudication among those with vasopressor-dependent sepsis (i.e. > hour of vasopressors at sepsis onset) who had a surgical evaluation within -days of sepsis onset. we defined daily vasopressor intensity as to vasopressors administered. then, we created a time-dependent model for threat with mortality as a competing risk with a weight function to estimates the varying contribution of vasopressors over time. we determined the subdistribution hazard (sh) ratio of threat for various patterns of vasopressor exposure and intensity, adjusted for age, baseline risk factors, and sequential organ failure assessment (sofa) score at sepsis onset. of , adults with sepsis, , ( %) were vasopressordependent (age, [iqr, - ]; , [ %] males; max sofa score, [sd ] ). of these, , ( %) died and ( . %) had evaluations for limb or digit threat [iqr, - ] days after sepsis onset. the model-based weight function showed the contribution of vasopressors to threat was stable over time ( fig a) . overall, a unit increase in cumulative vasopressor exposure was associated with risk of threat (sh ratio, . [ %ci, . - . ], p<. ). for various patterns of vasopressor exposure, greater intensity associated with increased risk of threat ( fig b) . compared to constant exposure, an increasing and peak pattern associated with the greatest sh (fig c) . cumulative vasopressor exposure was associated with an increased risk-adjusted hazard of limb or digit threat following sepsis. fig. (abstract p ) . relationship between vasopressor exposure and limb or digit threat following vasopressor-dependent sepsis. panel a demonstrates the estimated contribution of daily vasopressor intensity prior to surgical evaluation for limb or digit threat, with mortality as a competing risk. panel b and c explore the relationship between threat and both cumulative vasopressor exposure and the pattern of exposure following sepsis onset. (b) the maximum cumulative vasopressor exposure was associated with the highest risk of limb or digit threat (shr . ) when compared to reference exposure pattern (shr . , reference). (c) increasing (shr . ) and peak (shr . ) patterns of cumulative exposure were associate with an increased sh of limb threat, while a decreasing pattern was associated with a lower risk (shr . ) when compared to constant intensity (shr . , reference). abbreviations: shr: subdistribution hazard ratio proportion of encounters transitioning from phenotype at presentation within hrs, by arrival phenotype assignment and probability of membership. (c) tsne plots for α-type, ß-type, y-type, and ∂-type, with core (dark), marginal (light), and non-members (grey) in plots on the left and core, marginal, non members, and transitioning members (black) on the right fig. (abstract p ). isolated microorganisms critical care references: . wertz et al. critical care explorations : e the process investigators choosing wisely guidelines for the provision of intensive care services, version . ics structured patient handovers references: . care of the critically ill woman in childbirth the proqol manual: the professional quality of life scale:compassion satisfaction, burnout & compassion fatigue/secondary trauma scales references: . shimabukuro-vornhagen a et al. ca the code: professional standards of practice and behaviour for nurses, midwives and nursing associates p introduction: the aim of this study was to compare factors associated with the icu mortality for vap due to multidrug-resistant (mdr) klebsiella spp. in case of monobacterial (mo) vs polibacterial (po) origin. methods: retrospective data analysis of patients treated in icu with mdr klebsiella spp. strains as pathogens of vap during three year period was carried out. results: data of patients were evaluated. mo vs po of mdr klebsiella spp. vap cases was found to be ( . %) vs ( . %), p = . . the icu mortality was / ( . %) in mo, and / ( . %) in po one, p = . . statistical significant differences of survivors vs non-survivors in mo and po vap due to mdr klebsiella spp. were found in medians of neutrophilosis p introduction: we study the population structure and resistome of mdr enterobacterales and pseudomonas aeruginosa isolates, c/t-susceptible or -resistant, recovered from low respiratory, intraabdominal and urinary tract infections of icu patients of portuguese hospitals (step study results: in e. coli, two vim- producers were found (st -b -h -o :h -ctx-m- and st -c-h -o :h ) (c/t-mic= . / - / mg/l). a kpc- -st -cladev-h -o :h ( / mg/l) was also detected. the most frequent esbl-e. coli clone was st cpr klebsiella pneumoniae ( patients), candida spp. ( patients). the comparison subgroup consisted of patients with bacteremia caused by non-escape pathogens. we evaluated the days of mechanical ventilation, duration of antibiotic therapy (amt), icu length of stay (los), hospital los and mortality (table ). results: mortality in patients with bacteremia caused by non-eskape pathogens was . %, candida spp vancomycin mass removal over minutes of hemoperfusion using ha . bars refer to vancomycin mass (mg): blue (experiment ) and red (experiment ) bars using blood while green (experiment ) bar using balanced solution. yellow dashes are mean mass values of the three experiments (with standard deviations) and yellow line represents the reduction curve over time table (abstract p ). results. * p-value versus non-eskape subgroup mechanical ventilation p translational value of the microbial profile in experimental sepsis studies sp tallósy , a rutai , l juhász , mz poles , k burián , d Érces , a szabó , m boros invasive hemodynamic monitoring and blood gas analyses were performed on anesthetized animals between - h of sepsis. the respiratory, cardiovascular, renal, hepatic and metabolic dysfunctions were evaluated with the species-specific sequential organ failure assessment (sssofa) score, the microbial profile was determined with selective media and maldi-tof ms in the initial inoculum and in the abdominal fluid taken h after sepsis induction. results: strong correlation was found between the initial dose of the inoculum (cfu) and the sssofa scores for organ dysfunction (rats: r = . , p= . ; pigs: r= . , p = . ) p introduction: pancreatic stone protein (psp) has shown promise as a biomarker of infection however, its diagnostic potential has not been systematically evaluated. we performed a systematic review and meta-analysis of available data on psp to evaluate its value for detecting infection in adults and determining a plasma or serum threshold value. methods: the pubmed and cochrane library database were searched for studies on psp in adult patients and their raw data were analyzed to estimate the best psp cut-off value that could detect infected patients using the youden's index. the cut-off sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) were computed and compared to those for procalcitonin (pct) and c-reactive protein (crp). finally, we explored the potential value of a model combining all three biomarkers to detect infection. results: from a total of potentially eligible published studies, containing patients were included in quantitative analysis. among them, patients suffered from a clinically confirmed infection. the median appropriate statistical tests were used using spss . cd was expressed as % age of neutrophils expressing positivity. results: sixty patients were analyzed. all parameters were compared between survivors and non survivors. demographics were comparable. most common source of sepsis was lungs and majority were admitted due to medical reason. non-survivors had significantly increased number of days with septic shock. at day median values of all the biomarkers and the sofa score were significantly higher in the nonsurvivor group (p< . ). there was a decreasing trend of all biomarkers and sofa score amongst survivors. on multivariate logistic regression analysis, increased cd and crp levels between baseline and day , increased days with septic shock and increased sofa references: introduction: we characterized the association of c-reactive protein (crp) with extracellular vesicles (evs) in plasma from sepsis patients and assessed a commercial crp adsorbent (pentrasorb, pentracor, hennigsdorf, germany) to deplete free and ev-associated crp. in addition, we characterized the potential pro-inflammatory effects of ev-bound crp on monocytes and endothelial cells monocytes and human umbilical vein endothelial cells (huvecs) were stimulated with isolated evs ( , g, min) monocyte il- secretion was quantified by elisa; the activation of huvecs was assessed by their expression of icam- and e-selectin using confocal microscopy. results: septic plasma (n= ) contained . ± . mg/l crp vs. . ± . mg/ l for healthy controls (n= ). both, total evs and crp + evs were significantly elevated in septic plasma as incubation of septic plasma with pentrasorb resulted in depletion of free crp ( . ± . mg/l before vs. . ± . mg/l after adsorption) as well as in a significant reduction in crp evs from crp-depleted septic plasma induced significantly lower il- levels. huvec icam- or e-selectin expression, however, did not increase upon stimulation with septic evs. conclusions: treatment of septic plasma with pentrasorb efficiently removes free crp and detaches crp from the ev surface, resulting in reduced proinflammatory effects flow cytometry confirmed the association of monocytes with platelets and platelet-derived evs as well as the uptake of evs by monocytes. conclusions: storage of isolated monocytes induces a shift towards cd expressing proinflammatory monocytes, which seems to be mediated by residual platelets and platelet-derived evs. it remains to be clarified whether evs released from activated platelets can also trigger a shift towards proinflammatory, intermediate monocytes in vivo ethical approval was provided by ucl research ethics committee ( / ). paired parametric analyses were performed and data displayed as mean +/- % ci. results: plasma calprotectin concentration began to increase . hours after endotoxin administration, was significantly higher than baseline by hours ( . ng/ml vs. ng/ml, p < . ), peaked at hours (mean ng/ml, figure ) and normalized by hrs. calprotectin peaked earlier than comparator soluble mediators (procalcitonin hrs, crp, hrs) and exhibited % sensitivity; all participants demonstrating a minimum -fold increase from baseline (mean . x). calprotectin displayed greater baseline variability (sd . ng/ml) than either crp or procalcitonin. conclusions: our results indicate the potential of plasma calprotectin as a biomarker for bacterial infection. it increases earlier and peaks more rapidly than standard biomarkers. whilst higher baseline variability was observed p a multicenter randomized controlled study on landiolol for the treatment of sepsis-related tachyarrhythmia: subanalysis of the j-land s study o nishida kagoshima university graduate school of medical and dental sciences, department of emergency and intensive care medicine methods: we analyzed a retrospective cohort of electronic health records from adult sepsis patients at upmc hospitals from to . we defined sepsis- by i.) suspected infection (e.g., administration of antibiotics or body fluid culture) & ii.) organ dysfunction (e.g., or more sofa points) in the first hours of care. data were organized by hour and included vital signs, lab values, and treatments (e.g., total hourly iv fluids (ml) and norepinephrine equivalent dose). for each hour we describe, i.) available data elements, ii.) presence of sepsis- , and iii by hour , most patients had vital signs ( %; n= , ), basic labs ( %; n= , ), fluid cultures ( %, n= , ), while serum lactate was completed in % (n= , ) conclusions: early sepsis care patterns are variable. iv fluids were given during early hours, when uncertainty about sepsis was greatest, while vasopressors were administered after sepsis- elements were present. p effects of abdominal negative pressure treatment on splanchnic hemodynamics and liver and kidney function in a porcine fecal peritonitis model sl liu department of intensive care medicine splanchnic hemodynamics and laboratory parameters were measured at baseline (bl, start of rp), and h, h and h after start of rp. two/three-way rm-anova or mixed-effects analysis, and student t tests were performed. results: npt in controls had no effect. after sepsis induction, mean arterial pressure (map) decreased by ( - ) mmhg, cardiac output (co) by . ( . - . ) l/min, and arterial lactate increased by . ( . - . ) mmol/l. sepsis and resuscitation was associated with increasing hepatic and renal arterial flows (p≤ . , both), and increasing prothrombin time npt in sepsis resulted in numerically less noradrenaline administration ( . ± . ug/ min/kg in sepsis with npt vs. . ± . ug/min/kg without npt, p= . ) and positive fluid balance ( . ± . ml/h/kg with npt vs. . ± . ml/h/kg without, p= . ). conclusions: in our experimental fecal peritonitis model, npt did neither impair splanchnic hemodynamics nor abdominal organ function. whether npt helps to reduce noradrenaline and volume administration in abdominal sepsis should be evaluated in further studies. p association between a c-reactive protein gene polymorphism (rs ) with the risk of develop septic shock in postsurgical patients of major abdominal surgery p martínez-paz valladolid, spain; hospital of medina del campo notably, the three groups received a comparable pro kg dose of acetaminophen. no difference was found between groups in term of toxic effects. patients carrying the cyp a p showed a more pronounced effect on body temperature in respect of wt and ugt a p °c respectively, but it does not reach statistical significance (fig. b). only % of the patients reach a temperature < °c at t and only % < . °c. conclusions: polymorphisms in enzymes involved in the metabolism of acetaminophen are relatively common. cyp a p seems to lead to higher peak plasmatic concentration and a slightly increased efficacy in fever control panel a: variations of acetaminophen plasmatic levels after minutes (t ) and hours (t ) after administration of an iv dose of g of paracetamol in wt patients and patients carrying mutation; panel b: body temperature variations in wt patients and patients carrying mutations clinical research, investigation, and systems modeling of acute illness (crisma) center, department of biostatistics we determined phenotype cohesiveness using probability of assignment at presentation, defining core members as ≥ % and marginal as < % probability. we determined how members transitioned to other phenotypes over hrs using t-distributed stochastic neighbor embedding (tsne) plots and determined the odds ( %ci) of transition. results: we studied , adult sepsis encounters (median age c) the odds of ever transitioning from presenting phenotype increased significantly for marginal members vs publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we thank the department of education of the basque government (piba - ) and the university of the basque country upv/ehu (ppg / , giu / ) for their financial support. a great disaster affects the family-and friend-performance of bcpr by diminishing the willingness of family and friend bystanders to follow the instruction provided by dispatchers. the experimental method ifitem could be an alternative of fibtem in cases when internal coagulation pathways assessment is prioritized (i.e. heparinized patients on extracorporeal supports). patients undergoing limitation of life-sustaining therapy had lower karnofsky scale scores. therefore, this scale may be useful to guide end-of-life decisions in the future, but further studies with larger number of patients are needed. readmission after discharge home from critical care: a qualitative study c robinson , f nicolson , p mactavish , t quasim , jm mcpeake nhs greater glasgow and clyde, nhs greater glasgow and clyde, glasgow, united kingdom; university of glasgow, nhs greater glasgow and clyde, glasgow, united kingdom critical care , (suppl ):p readmissions to acute care occur in a high number of critically ill patients within days of hospital discharge [ ] . biomedical drivers such as frailty and pre-existing co-morbidities have been identified as drivers for readmission. however at present there is limited data on the influence of social problems on readmission. this study, using a grounded theory approach, sought to understand from a patient/caregiver perspective what the drivers for readmission to acute care were. ethical approval was granted from the west of scotland research ethics service ( /ws/ ). a grounded theory approach was used to explore from a patient and caregiver perspective what the drivers for readmission are [ ] . using a clinical database, we identified those patients who had an icu admission ≥ days who were readmitted to acute care within days of hospital discharge. the researcher attended the ward and after discussion with the direct care team conducted a semi-structured interview with patient and/or caregiver. the interview was recorded and transcribed verbatim. the transcripts were analysed to generate initial codes, followed by the development categories and sub-categories. theoretical sampling was undertaken. results: participants were interviewed. ( . %) were patients and ( . %) were caregivers. the themes that have emerged from the data were: pain and polypharmacy; lack of social support and/or isolation; strained relationships with primary care providers and information provision across the patient journey. subsequent theory development is underway to understand how this learning could help reduce readmissions in future. in conclusion, both social and biomedical drivers are likely to contribute to acute care readmission in this group. future interventional work is required in order to identify modifiable factors to reduce this burden for patients and the healthcare service. frailty has shown to have prognostic relevance for patients with critical illness. since a wide range of tools has been described to screen for frailty, we aimed to describe the association of two frailty screening tools, the clinical frailty scale (cfs) score and the modified frailty index (mfi) in critically ill patients. we performed a post-hoc analysis of a multicenter cohort of patients admitted to six canadian intensive care units (icu) between february and july . frailty was identified using the clinical frailty scale (cfs) and the modified frailty index (mfi). concordance of the frailty screening tools was evaluated with partial spearman rank correlation and intraclass correlation (icc). discrimination and predictive ability of the tools for hospital mortality, -year mortality, hospital readmission and adverse events were compared using concordance statistic (c-statistic) and calibration plot adjusting for age, sex, sequential organ failure assessment (sofa) score and icu admission source, respectively. the cohort included patients. prevalence of frailty was . % ( % confidence interval [ci] . %- . %) with the cfs and . % ( % ci . %- . %) with the mfi. concordance between the two tools was low [(icc of . ; % ci . - . ) and partial correlation coefficient of . ( % ci . - . )], even after adjustment. hospital and -year mortality were greater for frail compared to non-frail patients using of both tools. similarly, both tools found frail patients were less likely to be living independently after hospital discharge, and more likely to be rehospitalized when compared to non-frail patients. while the cfs and mfi show low concordance, both showed good discrimination and predictive validity for hospital mortality. both tools identify a subgroup of patients more likely to have worse clinical outcomes. the post-intensive care syndrome (pics) is a myriad of physical, psychiatric and cognitive disorders secondary to critical illness, leading to a decreased quality of life and an important socioeconomic burden. this study aimed to identify if the conformity to a pics prevention bundle was able to reduce the incidence of the syndrome at icu discharge. all patients admitted to the icu from january st to december st were included. the conformity to each of the ten components of the pics prevention bundle was assessed daily, and the patients were evaluated for anxiety, depression, cognitive dysfunction, muscular weakness, mobility impairment and nutritional risk at icu discharge and at a -to- -months follow-up consultation. the patient cohort was divided in terciles according to bundle conformity for the analysis. results: from the enrolled patients, ( %) were evaluated at icu discharge, and ( %) attended to the follow-up consultation. there was no difference in baseline characteristics between the cohorts. there was no correlation between the prevalence of pics at discharge and bundle conformity during icu stay ( % vs. % vs %, p . ), though there was a decrease in nutritional risk and days in mechanical ventilation (table ) . after to months there was a reduction on the prevalence of any kind of pics, mobility impairment, muscular weakness and nutritional risk. the patients that developed pics were older and had a higher simplified acute physiology score iii at icu admission. a higher adhesion to a pics prevention bundle was not able to prevent the occurrence of the syndrome. post intensive care syndrome (pics) is well recognized following general icu care [ ] . intensive care syndrome:promoting independence and return to employment (ins:pire) is a multidisciplinary complex intervention designed to address pics [ ] . with a paucity of evidence on pics after cardiothoracic intensive care, we aim to evaluate pics and the feasibility of the ins:pire intervention in this population. those attending the clinic received weeks of intervention including individual appointments with icm nurse, physician, pharmacist, and physiotherapist. a café area facilitated peer support alongside psychology group sessions. primary outcome was quality of life measured by eq- d- l. further surveys included: pain, mental health, and selfefficacy. questionnaires were taken at baseline, and months. results: over cohorts, patients attended, % male, median age years (iqr - ), median apache score of (iqr - . ), and median icu length of stay was days (iqr - ). a total of ( %) patients completed surveys at one year. scheduled admissions represented % of those attending. mean euroqol eq-vas score was / (sd +/- ) at baseline increasing to / (sd +/- ) by year (table ) . those with problems in at least one domain of eq- d- l fell from % at baseline to % at -year with the breakdown shown in table . severe problems were seen in % falling to % at year. hads demonstrated an anxiety or depression rate of %. brief pain inventory identified patients ( %) with ongoing chronic pain. mean self-efficacy was / (sd +/- ) at baseline and / (sd +/- ) at year. cardiothoracic intensive care patients have ongoing and persistent features of pics with significant effects on health-related quality of life. further, the ins:pire multi-professional complex intervention is feasible within this specialist group. screening approach might be implemented whenever screening of the total icu population is not deemed feasible. influenza is an acute viral illness with a significant financial burden. point of care testing for influenza is available and has demonstrated accuracy [ , ] , the current gap in knowledge is the question around the opportunity cost of influenza testing. if poct is financially a less costly test this could free up scarce resource. the study adopts a cost minimisation approach. the point of care test is the roche cobas® liat® machine which can detect flu a/b and is compared with the west of scotland specialist virology centre's established in house multiplex real time pcr assay.the model was developed using microsoft excel and has arms comparing analysis of the above mentioned tests. the model estimates that the total cost of poct per patient tested is £ . compared with £ . for lab testing ( figure ). this is a saving of £ . per patient when poct is used. the result swings in favour of the lab test when poct specificity falls to . %. if the lab could provide the result of influenza testing within hours the result would swing in favour of lab testing. zanamivir which will potentially be used increasingly in the intensive care setting can more than double the difference between the tests in favour of poct. this research suggests that poct offers potential cost savings in the icu setting. this is the case as long as poct specificity is higher than a threshold of . % and the lab take longer that hours to return the result. the sensitivity analysis should allow for external validity given the usual variations in icu practice. the aim of the present study is to describe the demographic, clinical, microbiological aspects and the outcome of patients with intensive care unit-related (icu-related) bacteremia. moreover, we aimed to study the patient outcome in association with colistin susceptibility. retrospective, single-center study in a -bed icu for months, from / / to / / . icu-related bacteremia was defined as bacteremia in patients with icu stay > hours or icu readmission (first admission ≥ month before). only the first episode of bacteremia was considered. the primary outcome was -day mortality. data regarding clinical, demographic and outcome characteristics were retrieved from the patient files. the hospital's ethics committee approved the present protocol. moreover, the patients with bacteremia due to colistin-resistant pathogens were compared with the patients affected by colistin sensitive microbes. forty episodes of gram-negative icu bacteremia were collected during the aforementioned period in patients ( . % male) with a mean age and apache ii of . ± . years and ± . , respectively. the event had taken place at an average of . days. the responsible isolates were resistant to carbapenems in . % of the episodes. the majority of the events were due to a single isolate ( %). acinetobacter baumannii and klebsiella pneumoniae presented the majority of the implicated microbes ( % and . %, respectively). the crude -day mortality was %. finally, we could not detect any difference in mortality between the colistin sensitive and the colistin-resistant pathogens ( figure ). the present study denotes that, in a setting of extremely drugresistant pathogens with limited treatment options, gram-negative bacteremia in the icu is associated with increased mortality. image : characterization of resistance mechanisms affecting ceftolozane/ tazobactam in enterobacterales and pseudomonas aeruginosa icu isolates using whole genome sequencing (step study) m hernández-garcia , cc chaves , jm melo-cristino , ds silva , ar vieira , mp f. pinto , jd diogo , eg gonçalves , jr romano , rc cantón hospital ramón y cajal-irycis, microbiology department, madrid, spain; introduction: clostridium difficile infection (cdi) is the main cause of hospital acquired diarrhoea [ ] . the aim of this study was to compare characteristics of cdi during yr and . a retrospective observational study was carried out in lithuanian university of health sciences hospital -the largest teaching facility of tertiary care in country. according to department of infection control records, patients (pt) with (w.) diarrhoea and the first positive stool test for c.difficile toxin a/b were included. age, charlson comorbidity index (cci) score, profile of hospital department (medical (md), surgical or icu) where cdi was diagnosed, type of cdi (healthcare-associated (ha), hospital or community-acquired) and rate of risk factors (rf) have been estimated in both and . ibm spss . ; pearson's chi-square, fisher's exact tests were used for statistics. p < . was statistically significant. results: in total pt from , from were enrolled. in n= ( %) pt were ≥ yr old, in -n= ( %), (p= . ). in cci> was estimated in n= ( %) pt in comparison of n= ( %) in , (p= . ). in n= ( %) of cdi cases were ha, in -n= ( %), (p= . ). in n= ( %) of cdi were diagnosed in md in comparison of n= ( %) in , (p= . ). in weeks prior to cdi n= ( %) pt have been admitted to hospitals, n= ( %) have been treated w. antibiotics, n= ( %) -w. ppis, n= ( %) -w. h antagonists, n= ( %) -w. immunosupressants in comparison of n= ( %), n= ( %), n= ( %), n= ( %) and n= ( %) in , respectively, (p> . ). overall rate of cdi cases among in-hospital patients increased tenfold by yr and . in , more elderly patients had cdi and severe comorbidities were less frequent in comparison with . in , more cases of cdi were hospital-acquired and have occured in medical departments. rate of risk factors of cdi remained unchanged.these results indicate a possible relationship between ttv dna count and immunological alteration. the ttv quantitative determination could be useful as a proinflammatory marker in sepsis, with some benefits: low cost, easy determination and good correlation with immune system functionalit. it will be necessary to perform a larger study to check our hypothesis and to establish a ttv level threshold that may allow to anticípate the disease prognosis. introduction: acute kidney injury (aki) is a serious complication in sepsis and associated with high morbidity and mortality. the combination antimicrobial regimens with vancomycin (vcm) and broad-spectrum betalactams (bsbl), such as piperacillin tazobactam and cefepime, have been identified as potentially nephrotoxic combinations, but existing studies have not provided sufficient evidence. the aim of this study was to evaluate detailed association between the combination antimicrobial therapy and the risk of aki in septic patients. this investigation was a post hoc analysis of prospective nationwide cohorts enrolling consecutive adult patients with sepsis in intensive care units in japan. in this study, progression of aki was defined as one or more elevation of renal sub-score in sequential organ failure assessment score from day to day . we regarded anti-pseudomonal penicillins, fourth generation cephalosporines, and carbapenems as bsbl. multivariable logistic regression analysis including a two-way interaction term (vcm x bsbl) was performed to assess the add-on effects of each antimicrobial agent on the progression of aki. the final study cohort comprised patients with sepsis. among them, received vcm without bsbl, received bsbl without vcm, received both vcm and bsbl, and received other type of antimicrobials. the administration of vcm was associated with an increased risk of aki in patients with bsbl [odds ratio (or), . ( . - . ); p= . ]. however, the tendency was not evident in patients without bsbl [or, . ( . - . ); p= . ]. the interaction effect on the progression of aki between vcm and bsbl were statistically significant (p for interaction= . ). the regression model including two-way interaction term suggested that the combination of vcm and bsbl might synergistically increase the risk of aki in patients with sepsis. increasing resistance to carbapenems due to carbapenemase productionone of main actual problems of antibacterial resistance in burn icu. production of several types of carbapenemases (kpc, ndm and oxa- ) is common in k. pneumoniae strains. carbapemenase production is a marker of extreme antibacterial resistance. the aim of our study was to investigate the epidemiology of nosocomial infections caused by producing kpc, ndm and oxa- k. pneumonia strains in burn icu. total of patients with nosocomial infections caused by carbapenem resistance strains of k. pneumoniae were included in the study, from whom had lower respiratory tract infection, had skin and skin structure infection. initial identification of isolates was performed in laboratory by automatic microbiological analyzer. for all of k. pneumoniae isolates presence of bla ndm , bla oxa- and bla kpcgenes were examined by pcr method. baseline characteristics of patients: me (iqr) of age - ( ; ) years, me (iqr) of tbsa - ( ; ) percent, me (iqr) of icu los - ( ; ) days. inhalation injury was diagnosed in ( . %) patients. total of patients died, mortality rate was . %. all patients were diagnosed with nosocomial infection caused by k. pneumoniae. from k. pneumonia strains ( . %) were found to be producing kpc, ( . %)producing ndm and ( . %) -producing oxa . only ( . %) carbapenem resistance k. pneumoniae isolates were not producing carbapenemases. from patients infected by oxa producing k. pneumoniae patients died, mortality rate was %. from patients infected by oxa or ndm producing k. pneumoniae patients died, mortality rate was . %. from patients infected by non-carbapenemase producing k. pneumonia no one died. carbapenemase producing strains are widely spread among carbapenem resistance strains of k. pneumoniae in burn icu. mortality of patients infected by producing oxa or ndm k. pneumoniae strains reaches . %. the rationale for blood purification as adjunctive therapy during sepsis involved the capacity in removing endogenous and exogenous toxins, but currently no recommendations exists [ ] . a critical point may be the potential interaction with antimicrobial therapy, which remains the mainstay of sepsis treatment. the aim of our study was to investigate the vancomycin (van) removal during blood purification using an in vitro model of hemoperfusion (hp) with ha cartridge (jafron, zhuhai city, china), most widely used in china and actually available in europe. this is an experimental study. three independent experiments were performed: we injected mg of van in ml of whole blood from healthy donors (experiment and ) or in ml of balanced solution (experiment ) in order to assess membrane saturation. a closed-circuit (blood flow of ml/min) simulating hp ran using ha . samples were collected from arterial line at , , , , , , , , minutes; van plasma concentrations were measured and removal was evaluated using mass balance analysis. differences in mass removal was assessed using kruskal-wallis test. results: figure shows van mass at each timepoints. we observed no difference between in blood and in balanced solution experiments (p- the aim of this study is to determine if routine bbv testing in the icu contributes to the discovery of undiagnosed bbv infections. icu patients may require renal replacement therapy (rrt). sharing rrt equipment carries a risk of bbv transmission, which mainly relates to hepatitis b (hbv), hepatitis c (hcv) and hiv. since , all glasgow royal infirmary icu patients undergo routine bbv screening, with rrt machines allocated for patients with specific bbv statuses. routine bbv testing is beneficial to both the individual and society. hcv is a pertinent health issue in scotland. the scottish government aims to eliminate hcv by and is researching innovative and costeffective methods to identify undiagnosed infections. this single-centre retrospective observational study examined prospectively collected clinical data from icu admissions. proportions were compared using a two-proportion z-test and a logistic regression model was carried out to determine if deprivation quintile was independently associated with the seroprevalence of bbvs. the bbv seroprevalence in the cohort studied: . % (hbv), . % (hcv), . % (hiv). the seroprevalence of hbv in the cohort studied was similar to that of scotland (p= . ), but the seroprevalence of hcv (p< . ) and hiv (p= . ) were statistically significantly higher than that of scotland. due to the small number of reactive test results for hbv and hiv, the relationship between deprivation and bbv seroprevalence was explored for hcv only. the only independent variable associated with a reactive anti-hcv test result was "current or previous illicit drug use" (adjusted odds ratio of . ; % confidence interval of . - . ; p< . ). this study shows that routine bbv testing in the icu is useful in discovering new bbv infections. this is the first observational study focusing on the value of routine bbv testing in an icu setting to our knowledge. continuous infusion vancomycin protocol is a safe, acceptable and effective alternative to intermittent dosing of vancomycin in critical care. ceftaroline is an efficacious treatment in patients with severe cap, admitted in icu. it relates to earlier resolution of respiratory failure and less rescue antibiotics. we need an adequately pragmatic trial to confirm our findings organ dysfunction in scrub typhus, incidence and risk factor a sarkar , a guha , r dey [ , , , , ] . its preads by bite of larval stageof thromboculid mites or chigger [ ] . clinical features may include fever, headache, myalgia, lymphadenopathy, eschar, skinrash. it may also cause pneumonia, renal failure, shock, meningoencephalitis, multiple organ failure [ , ] . our study aims to discuss the incidence of organ dysfunction in a comprehensive way taking the overall population of patients with identified scrub typhus infection. there is lack of data in eastern india regarding the incidence and risk factors of developing multiorgan dysfunction syndrome (mods) in scrub typhus. in this retrospective study we studied the incidence of various organ involvement and the risk factors associated with the development of mods in scrub typhus. we collected data from december to november in tertiary care hospital at kolkata. we have included all patients who are having fever, scrub typhus igm antibody positive, age more than years. sofa score was used in evaluating patients with mods. exclusion criteria involves patient who are having coinfectional ong with scrub typhus. in a cohort (n= ), patients with multiorgan dysfunction syndrome was seen in patients ( . %), the mean age in group of patients with mods was . +/- . years (mean+/-sd). in group of patients with mods, fever duration in days was of +/- . days (mean+/-sd), interval from treatment to defervescenc in days was . +/- . days (mean +/-sd). among patients with mods, hematologic involvement was seen in patients ( . %), hepatic involvement was seen in patients ( . %), renal involvement was seen in patients ( . %), neurologic involvement was seen in patients ( %), respiratory involvement was seen in patients ( . %), cardiovascular was seen in patients ( . %), icu shifting was necessary in patients ( . %), mechanical intubation was needed in patients ( . %) in multiorgan dysfunction syndrome patients. hospital mortality in patients with mods was patients ( . %). no mortality was seen in patients without mods. other parameters were evaluated among patients with mods. they include eschar in patient ( . %), seizure in patients ( . %), hepatoslenomegaly in patients ( . %), leucopenia in patients ( . %), leucocytosis in patients ( . %), thromnbocytopenia in patients ( . %),decreased hemoglobin in patients ( . %), transaminitis in patients ( . %). the risk factors associated with the development of mods are platelet counts, bilirubin, transaminitis, glasgow coma scale, time interval from treatment to defervescence, hemoglobin, total leucocyte count and fever duration. scrub typhus is an important cause of acute febrile illness in this part of the country and is frequently associated with organ dysfunction. however, the overall mortality is low which is similar to other studies done before [ ] . score at baseline were significant (p< . ) predictors of mortality.highest area under the roc curve was obtained for number of days with septic shock ( . ) followed by increased cd between baseline and day ( . ). though serial pct levels significantly increased amongst non-survivors, it did not predict mortality. serial level of biomarkers in icu patients may predict mortality. larger trials are needed to confirm the results. plasma strem- levels were retrospectively measured at day - , - and - in septic shock patients from the immunosepsis cohort (nct ), included between / and / , using a validated elisa method. the associations between strem- , mhla-dr, -day survival status, and occurrence of icu-acquired nosocomial infection (ni) were assessed. neither strem- nor mhla-dr levels at d / were associated with the occurrence of icu-acquired ni. however, -day mortality was significantly higher in patients with d - strem- value superior to the median ( . % vs . %, p= . ; median= pg/ml). a significant inverse correlation was found between mhla-dr at d - and strem- at d - (sp - . , p< . ) and at d - (sp - . , p< . ). at d - , when stratifying patients based on strem- ( pg/ml) and mhla-dr ( ab/c), patients combining elevated strem- and low mhla-dr presented with significantly higher day mortality ( . % vs . %, p = . , chi-squared test) and ni incidence ( . vs %, p= . ) compared with patients with low strem- / high mhla-dr. this study shows for the first time that trem- pathway activation is associated with septic shock-induced immunosuppression, as shown by an inverse correlation between strem- at baseline and mhla-dr expression at d - . persisting high strem- values and low mhla-dr expression in septic shock patients are significantly associated with higher rate of icu-acquired infection and mortality. introduction: sepsis mortality remains high [ ] . the surviving sepsis campaign (ssc) recommends to guide resuscitation on normalization of lactate levels [ ] , however this is debated [ ] . we have shown that plasma levels of bio-adrenomedullin (bio-adm) were associated with patient outcome during sepsis [ ] . we therefore aimed to evaluate the added value of bio-adm to lactate measurement in the adrenoss cohort. this is a post-hoc analysis of the adrenomedullin and outcome in severe sepsis and septic shock (adrenoss) cohort study. the adre-noss study is a prospective observational study conducted in twenty-four centers and included septic patients [ ] . we studied the relationship between the association of initial evolution of lactate plasma levels and bio-adm level at h and outcome in patients for whom both markers were available at admission and one day later (" h"). bio-adm levels below pg/ml were considered as low, and high if greater than pg/ml [ ] . in patients with high lactate levels (> mmol/l) at admission (n= ), lactate normalization (< mmol/l) at h was associated with better outcome than in patients with persistently high lactate at h ( day mortality . % vs . % respectively, hr . [ . - . ], p< . ) ( figure ). among patients with decreasing lactate, high and low bio-adm levels at h identified patients with different outcomes ( day mortality % vs % for low vs high bio-adm respectively, hr . [ . - . ], p< . ). high and low bio-adm levels at h also differentiated outcome of patients with persistently elevated lactate (hr . [ . - . ], p< . ). in patients with low initial lactate, neither lactate or bio-adm had no added prognostic. our data suggest that measurement of bio-adm in addition to lactate may help physicians to refine risk stratification and therefore to guide resuscitation during sepsis. the effect of fluid replacement in sepsis, severe sepsis and septic shock in first hrs in clot quality and microstructure s pillai , g davies the inflammatory response in sepsis can lead to a spectrum of coagulation system defects [ ] . sepsis and severe sepsis is associated with a hypercoagulable state where the clot microstructure is known to be a tight and highly elastic clot, which is potentially resistant to fibrinolysis ( figure ). conversely, septic shock is associated with a hypocoagulable state where the clot microstructure is loose and structurally weak. the study aim to investigate the effect of fluid resuscitation and replacement in clot microstructure over hours. methods: patients ( sepsis, severe sepsis and septic shock) were included in the study. all these patients received standard fluid replacement therapy with crystalloids. blood samples were collected at hours, hours and hours. clot microstructure, standard markers of coagulation and inflammatory markers were measured. in sepsis group following fluid administration, the d f reduced initially and then remained stable ( . - hours, . - hours, . - hours, normal d f range . ± . ). in severe sepsis group, the d f reduced initially, then increased ( . - hours, . - hours, . - hours) and in septic shock, the df was very low to start with and there were only slight increase with fluid administration ( . - hours, . - hours, . - hours). the hypercoagulable state and clot quality in both sepsis and severe sepsis group improved with fluid resuscitation, however despite an early improvement in clot quality, ongoing fluid resuscitation resulted in markedly reduced functional clot with very low clot strength and functionality. this study demonstrates that d f as a marker of clot quality and function may have potential in fluid and component replacement in critical illness and injury. this study analyses the prognostic ability of white blood cell count (wbc), neutrophil:lymphocyte ratio (nlr) and c-reactive protein (crp). hypo-and hyperimmune responses have been associated with increased mortality from septic shock [ ] . patients with septic shock (sepsis . ) admitted to queen elizabeth hospital birmingham, between december and july were included. the primary outcome was -day mortality. data was tested for normality and presented as median (iqr) and analysed using a mann whitney u test. categorical data was presented as % and analysed using a chi-squared test. a p value of < . was used to determine significance. a multivariate binary logistic regression analysis was conducted using age, apache ii, charlson comorbidity index, performance status, and initial lactate as covariates. a hosmer lemeshow test of > . indicated good fit. results: patients were admitted with septic shock. the majority ( %) were male, with a median age of ( - ) and a -day mortality of %. on day , wbc was lower in patients who died compared to patients who survived ( [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] patients who died of septic shock had a lower wbc, nlr and crp response early on compared to survivors. this may represent early immunoparesis that allows infection to propagate unchecked. however, this was not independently associated with mortality when confounding factors were accounted for. a specific metabolite of mitochondriaitaconic acid is formed upon proinflammatory activation. the attempts of various researches to find the itaconic acid in peripherical blood of patients with sepsis were unsuccessful [ ] . some phenylcarboxylic acids (phcas) are known to be microbial metabolites and sepsis biomarkers; they also affect the mitochondrial functions [ ] . concentrations of phcas (phenyllactic, p-hydroxyphenylacetic, phydroxyphenyllactic acids) and mitochondrial metabolites (succinic, itaconic acids) in serum samples from patients on the st day of diagnosis of sepsis and serum samples from patients with late stages of sepsis (sepsis- ) were measured by gas chromatographymass spectrometry; control group - donors. results: itaconic acid was found in low concentrations ( . - . μm) only at early stage of sepsis. the multiple increase in levels of phcas and mitochondrial metabolites were detected in patients with late stage of sepsis in comparison with early stage and donors, p< . . increased succinic acid (up to - μm) concentration is the result of succinate dehydrogenase inhibition by microbial metabolism intermediates (phcas), which was confirmed by in vitro experiments in isolated mitochondria (fig. ) . itaconic acid may be a promising marker in early stage of sepsis, which needs to be proved. prediction of severe events in clinical sepsis is challenging. for such prediction we aimed to compare the novel biomarker calprotectin in plasma, with routine biomarkers. in a prospective study, blood samples were collected from consecutive patients who triggered the sepsis alert in the emergency department in our hospital. c-reactive protein (crp), procalcitonin, neutrophils, and lymphocytes were analysed according to routine practice. p-calprotectin was analysed using a specific particle enhanced turbidimetric assay (gentian diagnostics as). the composite endpoint, which was termed severe event, was defined as death or admission to the intensive care unit (icu)/high dependency unit (hdu) within hours from arrival. the study included patients with written informed consent, of whom were considered to have infection (defined as obtained blood culture and subsequent antibiotic therapy for at least days or until discharge or death), and had no infection. seventy-four patients ( %) with infection developed a severe event. mean pcalprotectin was . mg/l (standard deviation (sd) . ) among patients with infection and . mg/l (sd . ) among patients without infection (p= . ). in patients with infection mean p-calprotectin was . mg/l (sd . ) among those with and . mg/l (sd . ) among those without a severe event (p= . ). analysis of area under the receiver-operating characteristic (roc) curve for prediction of severe events showed superiority for p-calprotectin compared with procalcitonin and neutrophil-lymphocyte-ratio, both regarding all sepsis alert cases and regarding the patients with infection (p< . for all comparisons), fig . in addition, there was a trend toward superior performance compared to crp (p= . and . ). in sepsis alert patients, p-calprotectin was elevated in those who subsequently developed severe events. p-calprotectin was superior to traditional biomarkers for prediction of severe events. introduction: rapid diagnosis of acute infections and sepsis is critical in emergency departments (eds). current tests have slow turnaround times, low sensitivities, and/or signals from contaminant or commensal organisms. empirical antimicrobial treatment may result in severe adverse events and contributes to antimicrobial resistance. diagnostics to distinguish bacterial from viral infections and noninfectious etiologies support clinicians in efforts toward antimicrobial stewardship. in a prospective, non-interventional study in the eds of sites in greece (prompt study nct ), we evaluated hostdx sepsis, a host response test for suspected acute infections and suspected sepsis. hostdx sepsis measures human mrna targets and employs advanced machine learning to differentiate patients with bacterial and viral infections, and noninfectious etiologies. adult patients presenting with suspected acute infection and at least one vital sign change were enrolled. whole blood rna was quantified using nano-string ncounter. predicted probabilities of bacterial and viral infection were calculated (bvn- algorithm). patients were adjudicated in a retrospective chart review by independent infectious disease specialists blinded to hostdx sepsis results. among patients adjudicated as bacterial ( ), viral ( ), noninfected ( ), or indeterminate ( ) the area under the receiver operating characteristics (auroc) of hostdx sepsis for predicting bacterial vs. viral/non-infected patients was . , and auroc for viral vs. bacterial/non-infected patients was . (fig. ) . our results indicate that hostdx sepsis distinguishes bacterial from viral infections and other etiologies with high accuracy. hostdx sepsis is currently developed as a rapid point-of-care device with a turnaround-time of less than minutes. hostdx sepsis may therefore assist ed doctors in making appropriate treatment decisions earlier, towards the ultimate goal of antimicrobial stewardship. we studied the diagnostic value of a leukocyte deformability assay that rapidly quantifies the immune activation signatures of sepsis in an undifferentiated population of adults presenting to the ed. ed clinicians must balance the benefits of early intervention against the risks of indiscriminate use of resource-intensive interventions. there are no currently available rapid diagnostics with acceptable performance to achieve this balance. we prospectively enrolled adult patients within hours of presentation with signs of suspicion of infection in two eds in the usa. edta-anticoagulated blood was drawn and analyzed using deformability cytometry [ ] . procalcitonin (pct) levels were also measured. patients were retrospectively adjudicated for sepsis- by physician committee using the entire medical record. diagnostic performance characteristics and receiver operating curves were used to examine the diagnostic performance of the assay as well as pct. of the patients enrolled, . % were adjudicated as septic. the leukocyte deformability assay demonstrated % sensitivity, % specificity, and % negative predictive value for a single cutoff. the auc was . ( figure ). pct with a cutoff of . ng/ml had % sensitivity, % specificity, and % negative predictive value. the auc for pct (as continuous variable) was . . the leukocyte deformability assay of immune activation signatures demonstrated superior diagnostic performance for sepsis when compared to pct. the assay's diagnostic performance and rapid turnaround time of minutes may positively impact patient outcomes while minimizing indiscriminate use of valuable resources in the ed. it is already known in literature that high levels of midregional proadrenomedullin (mrproadm) are related with organ disfunction in infections despite of source and pathogens [ ] . similarly, microcirculatory impairment has been reported in sepsis. we examine the correlation between microcirculatory disfunction and mrproadm as a sign of early organ failure. we included consecutive adult patients with suspected infection, sepsis or septic shock admitted to our intensive care unit (icu) as first hospital admission with an expected icu stay of > hours. mrproadm was measured daily during the first five consecutive days and sublingual microcirculation was assessed with incident dark field (idf) technology at t , t , and t . we collected information on saps ii, apache scores, and sofa score for each timepoint. results: ten patients had septic shock, sepsis and infection. three patients died during icu stay. a mrproadm clearance of % or more between t and t was found associated with the improvement of mfi (mann-whitney u test, median increase . % versus . %, p= . ) (figure ) . a mrproadm > . nmol/l at the icu admission was associated with a worse sofa score at all the timepoint. moreover, mrproadm levels at admission was found significantly related with icu mortality (auc . [ . - ]; p= . ). mrproadm shown no relation with absolute value of mfi. the study shows a good correlation between the clearance of the biomarker and the improvement in mfi. moreover, our results support previous findings on the prognostic value of mrproadm in terms of sofa and icu-mortality. clinical performance of a rapid sepsis test on a near-patient molecular testing platform r brandon , j kirk , t yager , s cermelli , r davis , d sampson , p sillekens , i keuleers , t vanhoey immunexpress, seattle, united states; immunexpress, immunexpress, seattle, united states; biocartis nv, biocartis, mechelen, belgium critical care , (suppl ):p the purpose of this study was to clinically validate a new, rapid version of the septicyte™ assay on a near-patient testing platform (biocartis idylla™). septicyte™ lab is the first-in-class sepsis diagnostic to gain fda-clearance but has a complex workflow and a turnaround time (tat) of~ hours. the assay in idylla™ cartridge format is called septicyte™ rapid. septicyte™ lab was translated to the biocartis idylla™ near-patient testing platform and analytically validated. for this study, . ml of peripheral blood paxgene tm solution from previously collected patient samples was pipetted directly into the cartridge and inserted into the idylla™ reader. patients were part of an independent cohort (n= ) from intensive care units located in the usa and europe. septicyte™ rapid results were reported as a septiscore™ between and with higher scores representing higher probability of sepsis. assay performance determined included technician hands-on-time (hot), assay tat, failure rates, and area under roc curve based on comparison to retrospective physician diagnosis. average hot was minutes, and average tat was minutes. clinical samples could be processed immediately with septicyte™ rapid and did not require hour pre-incubation of paxgene blood, greatly improving tat. correlation of septiscore™ values between lab and rapid, based upon a subset of samples run on both platforms, was very high (r > . ). estimated roc auc performance for discriminating sepsis from non-infectious systemic inflammation (nisi/sirs) was similar to that previously reported for septicyte™ lab. this is the first demonstration of a validated, fully-integrated, rapid, reproducible, near-patient, immune-response sepsis diagnostic, providing actionable results~ hr, to differentiate sepsis from non-infectious systemic inflammation / sirs. accuracy of septicyte™ for diagnosis of sepsis across a broad range of patients r brandon , k navalkar , d sampson , r davis , t yager immunexpress, seattle, united states; immunexpress, immunexpress, seattle, united states critical care , (suppl ):p the purpose of the study was to demonstrate sepsis diagnostic performance of the biomarkers of septicyte™ in subjects other than critically ill adults, and in hospital locations other than icu. septicyte™ lab was the first immune-response sepsis diagnostic assay to gain fda-clearance (k ) and, as part of gaining this clearance, clinical validation was performed on adult patients admitted to intensive care (icu) only [ ] . we therefore performed an in silico analysis across a broad range of patients using the septicyte™ host immune response biomarkers and algorithm. peripheral blood gene expression data, including public and private datasets, were chosen based on quality, annotation, and clinical context for the intended use of septicyte™. multiple comparisons were performed within datasets to better understand the diagnostic performance in certain cohorts including healthy subjects. diagnostic performance was determined using area under curve (auc). results: table shows some characteristics of the selected datasets and patients, including number of datasets (n= ) and comparisons (n= ), number of cases (n= ) and controls (n= ) used in comparisons, patient category and hospital location. septicyte™ aucs for the three groups of adults, adult / pediatric and pediatric / neonates were . , . , and . respectively, which is similar to that previously reported ( . - . ) [ ] . these results suggest that the septicyte™ signature has diagnostic utility beyond adults suspected of sepsis and admitted to icu. this signature has now been translated to the near-patient testing platform biocartis idylla™ (as septicyte™ rapid) which promises rapid (~ hour) diagnosis of sepsis in a broad patient population following further validation. introduction: especially extracorporeal cardio pulmonary bypass (cpb) is known to induce severe inflammation. postoperative inflammation is associated with a sepsis like syndrome including endothelial barrier disruption, volume depletion and hypotension. sphingosine- -phosphate (s p) is a signaling lipid regulating permeability and vascular tone. in septic humans decreased serum-s p levels could be identified as marker for sepsis severity. we addressed three main issues: ( ) are serum-s p levels affected by cardiac surgery? ( ) are potential alterations of serum-s p levels related to changes of acute-phase proteins, s p sources or carrier? ( ) is the invasiveness of the surgery a factor that may influence serum-s p levels? methods: elective major cardiac surgery patients were prospectively enrolled in this study. serum samples were drawn pre-, post-procedure and on day and day after surgery. we analyzed s pand its potential sources: red blood cells (rbc) and platelets. we further quantified levels of other inflammatory markers and documented other clinical parameters. median serum-s p levels in all patients before the procedure were . (iqr . - . ) nmol/ml. serum-s p levels decrease after surgery, whereas all other inflammatory markers increase. serum-s p levels dropped by % in the on-pump and % in the off-pump group. changes of serum-s p levels are associated with s p sources and carriers: albumin, hdl and vwf:ag activity. patients with a full recovery of their serum-s p levels after surgery compared to their individual baseline presented with a lower sofa score (p> . ) and shorter icu stay (p< . ). serum-s p levels are disrupted by open heart surgery and levels might be negatively affected by endothelial injury or loss of s p sources. low serum-s p levels may contribute to prolonged icu stay and worse clinical status. future studies may investigate the beneficial effects of s p administration during cardiac surgery. the aim of study is to measure and correlate the expression of ncd , mhla-dr, pct (procalcitonin) and qcrp (quantitative creactive protein) to predict development of sepsis and its outcome. in this tertiary centre based longitudinal cohort study, a total patients were enrolled in whom sepsis was suspected on the basis of clinical diagnosis and supported by lab investigations. they were divided into two groups sepsis/case and non-sepsis/control. disease severity in icu was assessed by sequential organ failure score (sofa). blood samples for routine lab investigations and biomarkers were taken at the time of admission in icu before administration of first dose of antibiotics at time d /d . assessment of biomarkers was done simultaneously with tlc at d /d , d and during follow up of patients till their final outcome. there was no significant (p> . ) mean change in pct, qcrp, sofa, ncd , mhla-dr from day to day , however, mean change was higher among cases than controls.on comparison of mhla-dr between the groups across time periods, mhla-dr was significantly (p= . ) lower among septic patients than controls at both day and day . all biomarker correctly predicted cases among different percentage of patients with different sensitivity and specificity. there was no significant (p> . ) association of mortality with the study biomarkers except for pct. in our study, diagnostic value of pct in differentiating sepsis from non-sepsis was similar to ncd among all biomarkers studied. no advantage of ncd or mhla-dr was found over pct in diagnosis and correlation with disease progression and mortality. introduction: aqp is a water channel protein contributing to astrocyte and immune cells migration, blood-brain barrier maintenance and cell survival [ ] [ ] . aqp genetic variants represent biomarkers associating with outcome after traumatic brain injury and intracerebral hemorrhage [ ] [ ] . linking aqp genetic polymorphism to the course of sepsis has not been studied. methods: study cohort included icu patients diagnosed according to sepsis- consensus. aqp rs polymorphism was studied by analyzing pcr products in a % agarose gel using an aqp specific polynucleotide tetraprimer set. data were analyzed by log rank test (medcalc . . ), and odds ratios/hazard ratios were computed. statistical significance was determined by fisher test (ft) or mann-whitney test. results: of sepsis patients had the minor mutation a for snp rs located within the regulatory ' region of the aqp gene. septic shock occurred more frequently in homozygotic carriers of aqp c allele vs. patients with aa or ca genotype: or= . ( %ci: . - . ), p= . (ft). lethality in septic shock patients, n= , significantly increased compared to sepsis patients with no shock, n= ( % vs. %, p= . , ft). maximum sofa values were significantly lower in patients with minor allele a compared to cc carriers of ( . vs. . , respectively, p= . ). in post-surgery group of patients, carriers of ac or aa genotypes had significantly increased survival compared to patients with cc genotypes: chi-square= . ; hr= . ( %ci: . - . ) for lethality; p= . (figure ) . association of minor allele a of aqp snp rs with survival in sepsis patients seems secondary to linking the snp to decreased development of multiorgan failure and septic shock that contribute to mortality. validation of presepsin as a biomarker of sepsis in comparison to procalcitonin, il- and il- v chantziara , f kaminari , c sklavou , s fortis , p kogionou , s perez , a efthymiou saint savvas hospital, icu, athens, greece; saint savvas hospital, cancer immunology and immunotherapy center, athens, greece critical care , (suppl ):p sepsis is an everyday challenge for the intensivist and biomarkers are useful tools for identification and treatment of this syndrome. we sought to validate presepsin as a biomarker of sepsis in comparison to pct(procalcitonin) and interleukins (il- ,il- ). we enrolled patients, men and women average age ( . - ) years old, apache ii ( . - . ), saps ii ( . - . ), sofa ( . - ). patients were septic on admission (according to surviving sepsis campaign: international guidelines for management of sepsis and septic shock: ), had a septic episode during their hospitalization in the icu while patients never endured sepsis. we measured presepsin, procalcitonin, il- , il- during sepsis and on remission. results: all septic patients had increased values of presepsin, pct, il- and il- during sepsis with a cutoff value for presepsin pg/ml, while the values of these biomarkers were significantly decreased during remission or in comparison to non-septic patients(presepsin p = . , pct p≤ . , il- p≤ . , il- p= . . all patients who were not septic survived while among septic patients died ( % mortality). presepsin correlated significantly with pct, il- and il- (p< . ). presepsin is a valid biomarker of sepsis and correlates significantly with all the other values of pct, il- and il- . clinical sepsis phenotypes are proposed at hospital presentation. these phenotypes, biomarker profiles, and outcomes are not yet reproduced in prospective data. even less is known about the biologic mechanism the drives these distinct groups. thus, we sought to validate clinical phenotypes and to determine markers of innate immunity, coagulation, tolerance and tissue damage in a prospective cohort. we prospectively studied patients with sepsis- criteria within hours of presentation at hospitals in pennsylvania ( - ) using automated electronic alerts. using clinical variables, we predicted phenotypes (α, β, γ, δ) for each patient using euclidean distance anchored to published seneca phenotype centroids. discarded blood was analyzed in a subset (n= ) for markers of innate immunity (e.g. il- , il- ), coagulation (e.g antithrombin iii, eselectin), tolerance (e.g. ho- , igfbp ), and tissue damage (e.g. serum lactate, bicarbonate) results: among patients, α-type was present in ( %), β-type in ( %), γ-type in ( %) and δ-type in ( %, figure a ). on average, β-type was older and more comorbid (mean , sd yrs; mean elixhauser . , sd . ) with renal dysfunction (median creatinine . [iqr . - . ] mg/dl, p< . all). the δ-type had more acidosis (mean hco - . , sd . meq/l), higher serum lactate (median . [iqr . - . ] mmol/l, p < . both) and inpatient mortality ( %, figure b) . the γand δ-type had greater markers of innate immunity and abnormal coagulation (e.g il- , icam p< . both), while markers of increased tissue damage (lactate) and poor tolerance (ho- ) were present in δ-type, compared to α-type (figure c) . the distribution and characteristics of clinical sepsis phenotypes were reproduced in a prospective validation cohort. similar to the seneca study, distinct biomarker profiles of tissue damage, innate immunity and poor tolerance were present for the δ-type. the effect that neoadjuvant chemotherapy and hyperthermic intraperitoneal chemotherapy (hipec) may have in the postoperative kinetics of biomarkers remains unknow. some studies demonstrate that neoadjuvant chemotherapy and hipec do not invalidate the use of inflammatory markers in postoperative patient monitoring, but none have compared biomarkers kinetics between patients who underwent hipec or only cytoreduction surgery. our main purpose was to identify a difference pattern in c-reactive protein (crp). we conducted a single-center observational study from january to november , including all patients who underwent cytoreductive surgery with or without hipec. crp was measured daily until seven post-operative day. we compared patients with and without hipec. a total of patients were included, were female. mean age was yrs ( - ). no clinical and demographical differences were observed between groups. no documented infection was found. after surgery crp increased markedly in both groups. crp time-course from the day of surgery onwards was significantly different in hipec patients ( . ± . mg/dl vs . ± . mg/dl; p= . ). multiple comparisons between hipec and non hipec patients were performed and crp concentration was significantly different on the th and th pod (figure ). no differences were found in other biomarkers (leucocytes and platelets) neither in body temperature. after a major elective surgical insult crp levels markedly increase independently of hipec. serum crp time-course showed a higher pattern in hipec patients despite no infection detected. decreased thrombin generation potential is associated with increased thrombin generation markers in sepsis associated coagulopathy d hoppensteadt , f siddiqui , e bontekoe , r laddu , r matthew , e brailovsky , j fareed. introduction: sepsis associated coagulopathy (sac) is commonly seen in patients which leads to dysfunctional hemostasis in which uncontrolled protease generation results in the consumption of clotting factors. the purpose of this study is to determine the thrombin generation potential of baseline blood samples obtained from sac patients and demonstrate their relevance to thrombin generation markers. baseline citrated blood samples were prospectively collected from patients with sac at the university of utah clinic. citrated normal controls (n= ) were obtained from george king biomedical (overland park, ks). thrombin generation studies were carried out using a flourogenic substrate method. tat and f . were measured using elisa methods (seimens, indianapolis, in) . functional antithrombin levels were measured using a chromogenic substrate method. the peak thrombin levels and auc levels were lower in the sac patients in comparison to higher levels observed in the normal plasma ( table ). the sac group showed much longer lag time in comparison to the normal group. wide variations in the results were observed in these parameters in the sac group. the f . and tat levels in the sac group were much higher in comparison to the normal. the functional antithrombin levels were decreased in the sac group. these results validate that thrombin generation markers such as f . and tat are elevated in patients with sac. however, thrombin generation parameters are significantly decreased in this group in comparison to normal. this may be due to the consumption of prothrombin due to the activation of the coagulation system. thus, persistent thrombin generation with simultaneous consumption of clotting factors such as prothrombin contributes to the consumption coagulopathy observed in sepsis patients. introduction: procalcitonin (pct) is used in the icu as an inflammatory marker to monitor bacterial infections and guide antibiotic therapy. whether pct can predict bacteremia and therefore could prevent expenses attached to bloodcultures is unknown . we investigated whether pct can predict the outcome of blood cultures in the icu and reduce expences. a single centre observational cohort study was performed in a dutch community teaching hospital . adult patients who were staying in the icu and were suspected of bacteremia were included. simultaneously with drawing of blood cultures, samples for pct measurement were obtained. expenses for pct measurement and bloodcultures were calculated. in the study period of one year, a total of patients were included. three patients were excluded because of incomplete data. out of the included patients, ten patients had positive blood cultures. there was a significant difference in pct levels between patients who had positive bloodcultures versus patients with negative bloodcultures ( . ng/ml vs . ng/ml) ( figure ). the negative predictive value for negative blood cultures is % when pct is below ng/ml, there was no difference in crp levels between the two groups ( mg/l vs mg/l, p= . ).a set of negative blood cultures in our centre costs euros. positive blood cultures however costs significantly more depending on the micro-organisms found. pct only costs . euros per measurement. so when blood cultures are omitted when the pct level is below ng/ml, a cost reduction of % can be achieved. a pct value below ng/ml is a good predictor of a negative blood cultures in icu patients suspected of bacteremia. pct guided bloodculture management in these patients could lead to a significant cost reduction introduction: level of cfdna in plasma is a promising prognostic candidate biomarker in critical illness [ ] . oxidized cfdna (ocfdna) have not been studied as a biomarker although its functional role in cellular stress have attracted attention of researches [ ] . the goal of our study was to assess the early prognostic value of plasma cfdna/ocfdna for sepsis in a nicu setting. the cohort included nicu patients diagnosed with stroke, intracerebral hemorrhage (ich), anoxia, encephalopathy. cfdna was isolated from day plasma and stained with picogreen. oxidized dna was determined using dna immunoblotting with anti- -oxo-desoxiguanosine antibodies. genotyping of allelic variants of the tlr rs gene was performed using a pcr and designed allele-specific tetraprimers followed by electrophoretic separation of the products statistics was performed by the fisher test and mann-whitney test. results: sepsis was diagnosed by sepsis- criteria in patients ( . %). average nisu staying was , ± , days. circulating dna plasma levels on day predicted the future sepsis development (figure ): or for cfdna was . ( %ci: . - . ), p< . ; or for ocfdna was . ( %ci: . - . ), p= . . power of both performed tests with alpha= . : . . log rank test demonstrated better predictive value of cfdna vs. ocfdna (figure) . concentrations of cfdna, but not ocfdna, on day significantly positively correlated with maximum sofa values during hospitalization, day and pre-outcome leukocyte count and neutrophil-to-lymphocyte ratios in a limited cohort of nisu patients with tlr rs cc genotype and not in other patients with genotype tlr ct+tt. increased level of plasma cfdna better then ocfdna predicts sepsis development in nisu. further studies are warranted to clarify the fig. (abstract p ) . pct values in patients with positive blood cultures and patients with negative blood cultures possible utility of tlr rs polymorphism determining for sepsis risk stratification early on nisu admittance. admission was related with higher severity of illness and extension of icu stay for all groups. reduced cbt fluctuations upon icu admission was found to more severely ill patients with worse clinical outcomes, while the more periodic cbt patterns were correlated with high cbt rhythmicity and better outcome. the impact of sex on sepsis incidence and mortality have been elucidated in previous studies, and sex is increasingly recognized as one key factor in sepsis [ ] . some studies indicate that women have better immunologic responses to infections [ ] . later investigations assume this advantage is linked to immune modulating genes located on the x-chromosome [ ] . the purpose of this study is to reveal sex differences in incidence of and mortality of sepsis in a large population-based cohort. methods: adult participants in the hunt study ( - ) were followed from inclusion through end of . incident bloodstream infections (bsi) from all local and regional hospitals in nord-trøndelag county were identified through linkage with the mid-norway sepsis register, which includes prospectively registered information on bsi used as a specific indicator of sepsis. we estimated age-adjusted cumulative incidence of first-time bsi and compared the risk of a first-time bsi and bsi mortality in men and women using age-adjusted cox proportional hazard regression. during a median follow-up of . years individuals experienced at least one episode of bsi, and died within days after a bsi. cumulative incidence and cumulative mortality curves are shown in fig. a introduction:the proportion of hospital-acquired infections (hai) among sepsis patients is unknown in germany. systematic differences in hai foci between sepsis patients with and without icu treatment are insufficiently described. retrospective cohort study based on nationwide health claims data of the german statutory health insurance aok. incident inpatient sepsis cases were identified in / among insured persons > y without preceding sepsis in months prior to index hospitalization. sepsis was defined according to explicit sepsis icd- -codes (incl. severe sepsis/septic shock). hai were defined based on specific icd- -codes for surgical site infection, catheter- introduction: elevated renin is associated with an increased risk of death in patients with vasodilatory shock (vs). recent data show that patients with vs and elevated renin levels have improved survival when treated with angiotensin ii (ang ii) + standard care (sc) vs placebo + sc. patients with acute respiratory distress syndrome (ards) can develop angiotensin-converting enzyme (ace) defects that can lead to elevated renin levels and insufficient endogenous ang ii production. we hypothesized that patients with severe ards and elevated renin shock would have improved survival when treated with ang ii + sc vs placebo + sc. in the randomized, placebo-controlled, double-blind athos- study, patients with severe vs receiving > . μg/kg/min of norepinephrine or the equivalent were randomized to intravenous ang ii (n= ) or placebo (n= ). in a post hoc analysis, we assessed the subset of patients with elevated renin (defined as a renin level greater than the median value of the overall athos- population) and ards (defined by a pao /fio ratio < ) at the time of randomization. survival to days was compared between the ang ii group (n= ) and the placebo group (n= ). in patients with elevated renin and ards, baseline age, acute physiology and chronic health evaluation ii score, and blood pressure were similar in the ang ii and placebo groups. the median serum renin level was . pg/ml (iqr: . - . ) compared to the normal range for serum renin: - pg/ml. a significantly higher proportion of patients receiving ang ii survived to day compared to those in the placebo group ( % vs %; p= . ). elevated renin identified patients with vs and ards who were most likely to gain a survival benefit from ang ii. elevated renin is likely caused by an ace defect and may describe an important subset of patients with a biotype that responds well to ang ii therapy. introduction: elevated renin levels have been shown to be associated with an increased risk of death and more severe acute kidney injury (aki) in patients with vasodilatory shock (vs). recent data show that patients with vs and elevated renin levels have improved survival when treated with angiotensin ii (ang ii) + standard care (sc) vs placebo (pbo) + sc. we hypothesized that vs patients with severe aki and elevated renin levels would have improved survival and enhanced renal recovery with ang ii treatment. in the randomized, pbo-controlled, double-blind athos- study, patients with severe vs received > . μg/kg/min of norepinephrine or the equivalent and were randomized to intravenous ang ii + sc (n= ) or pbo + sc (n= ). in a post hoc analysis, we assessed the subset of patients with elevated renin (defined as a renin level greater than the median value of the overall athos- population) and severe aki (defined as those with aki requiring renal replacement therapy [rrt] at baseline). survival and renal recovery were assessed in patients treated with ang ii + sc (n= ) and pbo + sc (n= ). in patients with elevated renin and severe aki, baseline age, acute physiology and chronic health evaluation ii score, and blood pressure were similar between ang ii + sc vs pbo + sc. the median baseline serum renin level in the whole group was . pg/ml (iqr: . - . ; normal range for serum renin: - pg/ml). a significantly higher proportion of patients receiving ang ii + sc vs pbo + sc survived to day ( % vs %, respectively; p= . ). ang ii recipients also had a higher rate of discontinuation from rrt by day ( % vs %; p= . ). in this study, elevated-renin shock patients with aki treated with ang ii + sc gained a survival benefit and earlier discontinuation from rrt compared to those receiving pbo + sc. elevated renin is likely caused by an angiotensin-converting enzyme defect and may identify those patients with a biotype that responds well to ang ii therapy. most clinical trials conclude the ineffective use of anticoagulation for sepsis-induced coagulopathy [ ] . however, post hoc analyses of randomized control trials report positive results [ ] , suggesting anticoagulation is effective in specific populations exhibiting coagulopathy. further, anticoagulants should be administered in the early phase [ ] ; however, methods for precisely predicting the progression of sepsis-induced coagulopathy are not established. this study aimed to create and evaluate a prediction model of coagulopathy progression using machine-learning techniques. we performed a subgroup analysis of data from a retrospective cohort study involving adult septic patients in japanese institutions from january to december and used the japanese association for acute medicine disseminated intravascular coagulation (dic) score as a dic severity index test. the predictive ability of Δdic ([dic score on day ] -[dic score on day ]) was evaluated using various statistical methods. using variables available at the outset, we compared the predictive ability of random forest (rf) and support vector machine (svm) with that of multiple linear regression analysis. a total of adults with sepsis were included in the analysis. the root mean square error in Δdic score for the multiple linear regression analysis model was . compared with values of . and . for rf and svm, respectively. thus, the rf method predicted the progression of sepsis-induced coagulopathy more accurately than multiple linear regression analysis. conclusions: rf, a machine-learning technique, was superior to multiple linear regression analysis in predicting the progression of sepsis-induced coagulopathy. this prediction model might enable us to use anticoagulation in an early phase. this study examined the efficacy and safety of landiolol, an ultrashort-acting β -blocker, for treating sepsis-related tachyarrhythmia, according to patient background characteristics. the j-land s study (japiccti- ) was conducted in patients with sepsis, diagnosed according to the sepsis- criteria, and tachyarrhythmia (atrial fibrillation, atrial flutter, or sinus tachyarrhythmia). the patients had a mean heart rate of ≥ beats/min and required catecholamine administration to maintain a mean blood pressure of ≥ mmhg. the efficacy endpoint was the percentage of patients whose heart rate could be controlled within - beats/min at h of registration. the safety endpoint was the incidence of adverse events within h of registration. subgroup analyses of efficacy and safety were performed after stratifying the patients according to various patient background characteristics. a total of patients were randomized, to landiolol and to the control group. the efficacy endpoint, percentage of patients with a heart rate of - beats/min at h of registration, was significantly higher in the landiolol group ( . % vs . %; mantel-haenszel test: p = . ). the incidence of adverse events was . % and . % in the landiolol and control groups, respectively, and there was no difference between the two groups. most adverse events were related to sepsis or septic shock. the subgroup analyses showed that no patient background characteristic clearly affected the efficacy and safety of landiolol. landiolol is a well tolerated and effective therapeutic agent for controlling heart rate in patients with sepsis-related tachyarrhythmias; its safety and efficacy were not affected by the patient background characteristics investigated. tissue oxygenation monitoring in sepsis r marinova, at temelkov umhat alexandrovska, anesthesiology and intensive care, sofia, bulgaria critical care , (suppl ):p near-infrared spectroscopy (nirs) was proposed as a concept in the end of th century. this method offers noninvasive monitoring of oxy-and deoxyhemoglobin in tissues.nirs could be measured on the thenar or forehead within few santimeters of the skin. it was first applied as a monitoring in cardiovascular surgery. patients with sepsis have changes in the microcirculation which are important target for therapy. invasive monitoring of oxygen delivery and consumption has been used in patients with sepsis but as every invasive technique such a monitoring hides risks. nirs offers a noninvasive method for tissue oxygenation monitoring (sto ) and could be useful in patients with sepsis and septic shock. the aim of the study is to compare noninvasive tissue oxygenation monitoring with hemodinamic monitoring and lactate values in patients with sepsis methods:the study includes critically ill patients in icu of umhat alexandrovska, sofia. of the patients fullfil the criteria for septic state. the other patients do not have sepsis. in both group of patients are measured tissue oxygenation with invios monitor, mean arterial pressure, oxygen saturation in mixed venous blood and lactate values during h after icu admission. patients with sepsis are reported with significantly lower values of tissue oxygenation, compared to patients without sepsis. the values of tissue oxygenation correlate well with the mixed venous blood oxygenation, mean arterial pressure and lactate values but not significantly with apache scores. conclusions: nirs when used for tissue oxygenation monitoring correlates well with the hemodinamic monitoring and lacate values in patients with sepsis and could be used as an noninvasive monitoring for guiding teurapeutic strategies. tissue oxygenation monitoring has no linear correlation with the severity of illness in patients with sepsis and could not be reccomended as a guidance in the early ressuscitating stage of sepsis. further investiganions in these field are needed.the sequenom´s massarray platform and a recessive inheritance model was selected (cc vs tt/ct). the possible association between the cc recessive form of the rs polymorphism and the septic shock risk was analyzed, demonstrating a statistically significant relationship (p= . ) between both conditions. among patients who developed septic shock, . % presented a recessive inheritance pattern while . % showed the ct/tt genotype. on the other hand, those patients with the recessive form of the rs polymorphism were selected and a statistical analysis was performed comparing those patients who developed septic shock from those who did not develop it, obtaining a statistically significant relationship (p= . ) between the presence of the recessive form of polymorphism and the likelihood of developing septic shock. the recessive form of rs polymorphism is a risk factor for septic shock in post-operative patients of major abdominal surgery. introduction: sepsis remains one of the major causes of morbidity with mortality rates as high as % worldwide, representing significant clinical challenge to confront highly intangible therapeutic needs. rnabased structures are emerging as versatile tools encompassing a variety of functions capable to bypass the current protein-and cellbased therapies. rna aptamers act as disease-associated protein antagonists. here, the effects of an aptamer, apta- , were evaluated in animal models that mimic systemic inflammation in humans. high dose of lps endotoxin was used to induce systemic inflammation in mice and in non-human primate animal models. apta- was administered intravenously in two doses post lps infection. animals were monitored and blood samples collected up to hours after apta- administration. healthy-and lps-only treated animals served as control groups. complex analyses of clinical parameters, hematology, serum biochemistry, inflammation and tissue damage markers were performed. results: apta- increased survival of endotoxin challenged animals up to % in a dose-dependent manner and exerted profound effects on wellbeing and recovery of healthy eating habits. administration of apta- led to delayed coagulation and enhanced fibrinolysis; maintained the complement cascade activated while preventing it from further amplification. expression of pro-inflammatory cytokines was reduced while anti-inflammatory increased. endogenous pro-inflammatory molecules (damps), secreted from injured cells, were preserved at healthy level in animals treated with apta- . systemic inflammation and sepsis lead to severe dysregulation of several arms/axis of innate immune response. our studies showed that apta- affects various components of this system and restores the organism's control over its dysregulated immune response. thus, apta- might be a promising potential therapeutic candidate to treat life-threatening conditions such sepsis. several preclinical studies demonstrated beneficial effects for methane (ch ) administration in various inflammatory conditions. our aim was to investigate the consequences of post-treatment with inhaled ch in a clinically relevant intra-abdominal sepsis model. anesthetized minipigs were subjected to fecal peritonitis ( . g/kg, - x cfu i.p.; n= ) or sham-operation (sterile saline i.p; n= ). invasive hemodynamic monitoring with blood gas analyses was started between - hours, organ dysfunction parameters (pao /fio ratio; mean arterial pressure; lactate, bilirubin, creatinine; urine output and platelet counts) were determined according to a modified porcinespecific sequential organ failure assessment (ps-sofa) score system, the perfusion rate (pr) of sublingual microcirculation was measured by incident dark field illumination imaging. the animals were divided into non-treated septic or septic shock groups (n= - ) and ch treated septic or septic shock (n= - ) subgroups, ch inhalation started from the th hr ( . % ch in normoxic air; ml/min). despite the standardized induction, heterogeneous severity of organ damage was evolved. in septic and septic shock groups the median values of ps-sofa score reached ( . - . ) and ( . - ), respectively. septic shock was characterized by significant elevations of creatinine and bilirubin levels, while the platelet count decreased (from to * /l). inhalation of ch increased the sublingual pr by % in the septic group, the creatinine and bilirubin levels were decreased by % and %, respectively. ch post-treatment significantly decreased the ps-sofa score (to ; . - . ) and resulted in lower values in septic shock group (to ; . - . ). methane post-treatment effectively influences sepsis-related end organ dysfunction. up to a severity threshold it may be a promising additional organ protective tool. evaluation of sepsis awareness among various groups in turkey: a survey study s erel, o ermis, Ö nadastepe, l karabıyık gazi university school of medicine, anesthesiology and intensive care, ankara, turkey critical care , (suppl ):p introduction: sepsis is a common life-threatening condition in critically ill patients [ ] . public awareness is important for early recognition of sepsis and improvement of outcomes [ ] . we aimed to evaluate sepsis awareness among different groups of people. methods: prospective paper-based surveys were issued between st july and st august to patients, the relatives of the patiens, hospital staff and general public who gave consent to participate in the study. the questionnaire included ten questions about demographic informations, occupational informations of hospital stuff and sepsis awareness. a total of participated in the survey. of these participants, ( . %) were patients, ( . %) were relatives of patients, ( . %) were physicians, ( . %) were medical students, ( . %) were nurses, ( . %) were other hospital stuff and (% . ) were other people. of these participants, ( . %) had heard of the word "sepsis". ( . %) responded correctly regarding the definition of sepsis. ( . %) of the participants heard the word "sepsis" during their education, but only ( %) heard it through the media. in the groups of high school graduates, university graduates and postgraduates, the rate of hearing the word sepsis and correctly identifying sepsis is significantly higher than the primary school graduates or illiterate groups. (p< . ). physicians, nurses and medical students were heard of the word "sepsis" significantly more than other groups (p< . ). physicians and medical students responded more accurately to the definition of sepsis than other groups (p< . ). public awareness of sepsis is limited compared to healthcare workers. increasing public knowledge of sepsis through education and through media may contribute to raising public awareness and improving outcomes. the association between clinical phenotype cohesiveness and sepsis transitions after presentation jn kennedy , eb brant , km demerle , ch chang , s wang , dc angus , cw seymour key: cord- -twsy oq authors: nan title: siu abstracts date: - - journal: world j urol doi: . /s - - - sha: doc_id: cord_uid: twsy oq nan introduction and objective: th e bladder is generally considered an organ for voiding and storage of urine, with the urothelium serving as an impermeable barrier. recent discovery of aquaporins in the bladder urothelium in rodents and later on also in human challenges this notion of impermeability. upregulation of aquaporins in response to dehydration or bladder outlet obstruction and downregulation following transitional cell carcinoma has been shown. th is emphasize the need to better understand the function and distribution of aquaporins, as well as their role in bladder diseases. th e present study aims at establishing basic knowledge about the expression of aquaporin (aqp ) in the porcine bladder, related to gender and gestational age. th ree pregnant sows at , or days of gestation were sacrifi ced. fetuses were removed and necropsied. th e bladder was rapidly removed and whole wall tissue samples from the bladder dome was snap frozen in liquid nitrogen and stored at - c. genetic gender determination was performed and fetuses with uncertain gender determination were excluded. aquaporin mrna expression was analyzed using qpcr and β-actin was used as the reference housekeeping gene. results were compared using two-way anova. results: a total of samples were analyzed. gestational age was either (n= ), (n= ) or days (n= ). aquaporin was expressed in all samples. aqp mrna expression was increased in the fetal porcine bladder with increasing gestational age (p< . ). however, there was no signifi cant diff erence in aqp mrna expression between genders (p= . ). conclusion: expression of aqp in fetal porcine bladder is demonstrated with increasing expression during gestation. to our knowledge aquaporins in the porcine bladder tissue have not previously been studied. th is exciting new discovery contributes to the ongoing discussion on reviewing the dogma that the lower urinary tract has an impermeable barrier function. improved contractility of the long term bladder outlet obstruction induced bladder underactivity using growth factor expressing mesenchymal stem cells introduction and objective: as the underactive bladder is diffi cult to manage, a new method of increasing bladder contractility in patients with underactive bladder is desired. mesenchymal stem cells (mscs) can serve as vehicles for the gene, proliferate and differentiate into bladder smooth muscle cells to repopulate damaged bladder. th e other is that the exogenous hepatocyte growth factor (hgf) gene can provide complementary functions as angiogenesis and inhibition of fi brosis. th is study was performed to examine the recovery of the decreased bladder contractility in the long term bladder outlet obstruction (boo) models of rats using transplantation of hgf expressing human mscs (hgf-hmscs) into the bladder wall. introduction and objective: suddenly dropping to low environmental temperature, cold stress exacerbates lower urinary tract symptoms (luts) such as urinary frequency and urgency. th is study determined if transient receptor potential ankyrin (trpa ) channels could mediate the cold-stress induced detrusor overactivity in rats. materials and methods: twenty-four female -weeks sprague dawley (sd) rats were used. th is th congress of the sociÉtÉ internationale d'urologie -siu abstract book study used hc (tocris bioscience) as trpa channel antagonist. th ree days prior to cystometric investigations, polyethylene catheters were inserted into the bladder and abdominal cavity. cystometric investigations of the unanesthetized rats were performed at room temperature (rt, ± °c) for min. following, the rats were intraperitoneally injected with vehicle, . -(low dose), or . -(high dose) mg/kg hc (n= , in each). aft er min, the treated rats were exposed to low temperature (lt, ± °c) for min. during the cystometric investigations, the micturition parameters were recorded. introduction and objective: hypoxia-inducible factors (hif , hif and hif ) play a critical role in cellular and systemic responses to hypoxia by inducing a range of diverse genes involved in cell survival, they have also been implicated in development of renal cell carcinoma. we aimed to assess the eff ect of zinc and cobalt on hypoxia-inducible factor expression in immortalized human kidney cells. to cells in mcl). esr at the observed patient aft er the seventh transfusion decreased from initial mm/ hour to mm/hour. aft er the fourth transfusion of mononuclear fraction of peripheral blood at the patient the increase in the content of the total testosterone that allowed to reduce a dose of % of dermal gel of testosterone from . ml per day to . ml per day was observed. aft er the seventh transfusion of mononuclear fraction of peripheral blood because of normalization of production of testosterone the restored number of own leydig's cells an androgen -replacement therapy was cancelled. introduction and objective: ketamine use as a recreational drug is on a rapid increase in young people. many reports have shown that long-term ketamine abuse is liable to lead to lower urinary tract symptoms that resemble interstitial cystitis (ic). ic is a disease characterised by severe and chronic pelvic pain with frequency, urinary urgency, and nocturia in the absence of bacterial infection or other diseases. th is study evaluated the therapeutic eff ect of human umbilical cord blood derived mesenchymal stem cells (ucb-mscs) in a ketamine induced cystitis (kc) rat model. for kc rat models -weekold, female sprague-dawley rats were used. sham treatment (n= ) rats were assigned to the control group. th e rats in the kc group (n= ) and kc+m-scs group (n= ) were intravenously injected with ketamine at a dose of mg/kg for days a week over a duration of weeks. aft er one week, x ucb-mscs were directly injected into the submucosal layer of the anterior wall and dome of the bladder in kc+mscs group. th e cystometric parameters and immunohistochemical results (toluidine-blue, masson trichrome, tunel staining) were measured at one week following the intervention. results: most rats in the kc group exhibited irregular voiding frequency and decreased inter-contraction interval in comparison with the control group ( . ± . vs. . ± . seconds, respectively; p< . ). th e kc+mscs group demonstrated improvement in most voiding parameters to normal levels within week. a single injection of ucb-mscs signifi cantly increased the inter-contraction interval ( . ± . , p< . ) ( figure ). in immunohistochemical analysis, the bladders in kc group were characterized by mast cell infi ltration in toluidine-blue staining, fibrosis in masson trichrome staining and apoptosis in tunel staining which were signifi cantly ameliorated in the bladders in the kc+mscs group ( figure ). conclusion: th e injection of ucb-mscs restored the damaged bladder and associated pathologies including mast cell infi ltration, fi brosis and apoptosis in the kc rat model. stem cell therapy could be valuable treatment option for painful bladder conditions such as ketamine induced interstitial cystitis. mp- . , figure . introduction and objective: currently no markers are available to predict intravesical bacillus calmette-guerin (bcg) response. among the various markers under study survivin has good sensitivity in detecting bladder cancer cases and there has been very limited number of studies regarding survivin as a prognostic marker and predictive marker. prospective evaluation of urinary survivin levels as a potential prognostic and predictive biomarker in non-muscle invasive bladder cancer cases on intravesical bcg therapy was planned in this study. from august to august a total intermediate and high risk group patients of nmibc age ranging from to yrs (mean ) planned for intravesical bcg instillation were enrolled. recurrence and progression score were calculated by using eortc genitourinary scoring system and risk table. patient's urinary samples were taken, pre and post [ (t ), (t ) and weeks (t )], intravesical bcg instillation. urinary survivin expression was studied by elisa technique. results: out of patients, ( . %) had complete remission at months th e mean survivin levels in remission group (group i) was . +/- . which was signifi cantly less than those in recurrence group (group ii) mean . +/- . . pre and post bcg, there was a signifi cant decrease in the urinary survivin levels in group i when compared to group ii where there was a signifi cant rise in pre and post bcg urinary survivin levels (p value< . ). conclusion: low pre bcg urinary survivin level can be used as a useful predictive marker for achieving complete remission in nmibc patients with on intravesical bcg immunotherapy. also pre and post bcg urinary survivin levels act as a useful prognostic marker and can be used as an adjunct to cystoscopy. introduction and objective: th e natural resistance-associated macrophage protein (nramp ) gene modulates macrophage activation in a myriad of infectious and autoimmune diseases. its single nucleotide polymorphisms (snps) have been identifi ed to infl uence susceptibility to tuberculosis and response to bcg therapy in murine models. in this study, we evaluate the predictive role of nramp snps in the oncological outcomes of asian patients receiving intravesical regimes of bcg for nmibc. a total of nmibc patients who underwent post-transurethral resection intravesical regimes of bcg ( mg or mg) or bcg ( mg) with interferon alfa from to and deemed intermediate to high risk by the european organisation for research and treatment of cancer risk tables, were prospectively recruited. from these patients and a group of healthy controls, peripheral blood samples were stored and genomic dna purifi ed. a total of nramp snps were evaluated using high resolution melt analysis. th e corresponding results were verifi ed by dna sequence analysis. kaplan-meier and cox regression methods were used to analyze the data. introduction and objective: microscopic hematuria can indicate presence of underlying urological conditions. aua guidelines recommend evaluation algorithms for microscopic hematuria. population-based studies have focused on risk pools such as heavy smokers and elderly men. we evaluated whether men interested in self-managing their lower urinary tract symptoms (luts) with an over-the-counter (otc) product should be screened for microscopic hematuria to detect undiagnosed signifi cant conditions (including urothelial malignancy) causing hematuria. materials and methods: urine dipstick testing was conducted in men who preferred to self-manage luts using an otc product. urologic assessment was conducted by a urologist to determine conditions causing/contributing to the urinary symptoms for: men < years; and men ≥ years who had traces of glucose, leukocyte, and/or blood in urine; or had an aua symptom index score ≥ . men experiencing complete urinary retention, dysuria, extreme thirst, gross hematuria, or urethral discharge ("do not use" symptoms in this study) were also assessed. men ≥ years of age who did not meet any of these criteria did not undergo urologic assessment. introduction and objective: th is fi rst experience, pilot study, was aimed to evaluate the outcome of en-bloc bladder tumor resection using the plasma-button electrode in cases of papillary non-muscle invasive bladder tumors (nmibt) from the perspectives of surgical safety and effi cacy, perioperative morbidity, histological assessment and short-term oncologic outcome. a total of patients previously diagnosed by abdominal ultrasound, contrast ct and fl exible cystoscopy with papillary bladder tumors over cm in diameter were included in the trial. th e exclusion criteria consisted in solid sessile tumors, lesions located in bladder neck area and tumors involving the ureteral orifi ce. en-bloc tumor resection using the plasma-button approach was applied in all enrolled cases. th e tumor base was subsequently biopsied by standard single-wire loop resection and followed by plasma-button coagulation. th e fi rst follow-up cystoscopy was completed at months. results: all procedures were successfully performed leading to visually complete tumor ablation. th e mean tumor diameter was . cm (range between and cm). no obturator nerve refl ex adverse events or cases of bladder wall perforation were encountered. no signifi cant postoperative hematuria and re-intervention requirements were encountered in this series. th e mean catheterization period was . days (range to . days) and the mean hospital stay was . days (range to days). th e pathological analysis confi rmed the presence of detrusor muscle in the resected biopsy specimens for all enrolled patients, thus enabling for a reliable tumor staging to be established (all nmibt histology diagnosed patients). a single case of other site residual lesion was found during the fi rst evaluation cystoscopy, while no orthotopic recurrences were described. to reduce the overdiagnosis and overtreatment of insignifi cant tumors there is an urgent need for a specifi c test to detect clinically signifi cant prostate cancer (pca). using gene expression profi ling specifi c pca-biomarkers were identifi ed. eight promising biomarkers were selected and the diagnostic accuracy was tested in urine of an intent-to-treat cohort. th e aim of this study was to clinically validate the four-gene biomarker panel (hoxc , dlx , tdrd and hoxc ) using an independent prospective multicenter study cohort. in two independent prospective, multicenter studies (cohort : n= en cohort : n= ) urine was collected aft er digital rectal examination (dre) from men undergoing prostate biopsies based on an elevated serum psa level (≥ . ng/ ml) and/or suspicious dre. klk , hoxc , hoxc , tdrd and dlx mrna levels were measured using rt-qpcr. th e assay was validated according to miqe criteria, hence the test is a standardized laboratory developed test (ldt). results from cohort were used to develop models with (combinations of) the four genes based on the comparative ct method. th e chosen model was validated in cohort , i.e. a fully independent validation cohort. results: pca was identifi ed in % ( / ) and % ( / ) of men from the studies respectively. th e model with the combination of hoxc /dlx resulted in the highest average auc ( . ) and specifi city ( %) at ≈ % sensitivity, based on cohort . furthermore, hoxc and dlx were signifi cant in the logistic regression, in % and % respectively. th is model was independently validated for the diagnosis of pca with gleason score ≥ in prostate biopsies. using roc curve analysis hoxc /dlx outperformed pca in both cohorts (cohort auc= . vs. . ; cohort auc= . vs. . ). adding serum psa to the hoxc /dlx model resulted in an auc of . and . , respectively. th is study showed the promising results of a new urine test for the early diagnosis of clini-cally signifi cant pca using a model which combines hoxc with dlx . th ese results demonstrate that this model could be used to assess the risk of pca with gleason score ≥ and therefore could reduce the amount of unnecessary prostate biopsies. introduction and objective: curcumin contains mul-introduction and objective: a family history of prostate cancer is a well-recognized high risk factor for this disease. various models for an inherited risk for prostate cancer have been described, but to date traditional linkage and association studies have only identifi ed a small number of rare tumor suppressor genes and snps involved in prostate cancer risk and development. we performed whole exome sequencing on multiple participants (n= ) with prostate cancer from families with a signifi cant history of prostate cancer to potentially identify new prostate cancer susceptibility variants. exome variants were fi ltered against a range of parameters with a subset of variants chosen for validation by sanger sequencing and segregation analysis within their respective families. each prostate cancer participant met the following criteria for inclusion if: (i) they had a verifi ed diagnosis of prostate cancer, (ii) there were multiple cases of prostate cancers in the family, iii) pathology, diagnostic and treatment notes were available, and (iv) they were classifi ed as brcax mutation status. results: essential splice site, missense and stop lost variants were fi ltered against a recently published candidate gene list, leaving shared truncating variants and shared missense variants to be genotyped through all prostate aff ected (n= ) and unaff ected male participants (n= ). th ree missense variants demonstrated complete segregation and one missense variant demonstrated partial segregation with the prostate cancers. th ree truncating variants demonstrated complete segregation and three truncation mutations demonstrated partial segregation with prostate cancer. no segregating variants between the three families were shared. conclusion: ten truncating or missense variants showed either complete or partial segregation in our three familial prostate cancer families. of interest, we detected a cyp a and parp variant in our multicase prostate cancer families. th ese two variants have previously been reported to occur in other familial associated prostate cancer families, thereby, potentially adding to the evidence that these two variants may have a role in the risk and development of prostate cancer. another eight novel variants were detected that segregated with disease and warrants further investigation. th congress of the sociÉtÉ internationale d'urologie -siu abstract book were recorded. patients with diabetes, hypertension or known cardiovascular disease were excluded. introduction and objective: traditional methods of prostate cancer diagnosis in males with an elevated or rising psa have relied on outpatient trus biopsy using local anaesthetic and taking between - biopsies. trus biopsy is painful, associated with rectal bleeding in %, uti in % and urosepsis in up to % of patients. it is also has a poor sensitivity (< %) low accuracy rates of < % and a poor specifi city of < %. from we changed to template guided prostatic biopsy (tgpb) carried out transperineally under a general anaesthetic. to date we have carried out tgpb in patients with a positive biopsy rate of % (accuracy of %; and specifi city of %). th e procedure is painless, utis occurred in %, no sepsis and no rectal bleeding. because of the large numbers of biopsies taken % of patients had transient retention. in patients who had a previous -ve trus biopsy % had a subsequent +ve tgbp and patients having tgbp on the fi rst occasion for an elevated psa ( . - ) % had a positive biopsy. results: with the advent of tesla mri and mri fusion technology we have now progressed to mri fusion biopsy using real time ultrasound imaging and fusing the abnormal mri image to perform the biopsy (biojet fusion, global prostate solutions) . th is allows for even greater accuracy of the biopsy without taking large numbers of samples. to date we have achieved a +ve biopsy rate of % with an accuracy of > % (in patients). to date there have been no cases of uti, sepsis or retention. to determine the suitability of circulating tumour cells (ctcs) as prognosticating indicator and biomarker for delivery of precision medicine. patients were recruited and screened (n= ) as a part of admet (androgen deprivation th erapy and adjuvant metformin) trial. five millilitres of whole blood was collected from patients for ctc enrichment, enumeration and propagation. enrichment was performed using cd negative selection kit (rosettesep™). ctcs were identifi ed using immunofl uorescence imaging with antibodies against prostate specifi c antigen, cytokeratin, cd and nucleus. cells were propagated in customized stem cell solution with hypoxic conditions. results: at screening, of patients demonstrated circulating tumour cells with the mean number of (range - , ± ) . in all of the enriched samples, cells could be propagated temporarily with the peak population being reached at . weeks. cells were cultured in both d and d conditions and temporary organoids could be developed from of patients. polymerase chain reaction and immunofl uorescence imaging at weeks aft er culturing demonstrated characteristics consistent with prostate cancer cells. conclusions: circulating tumour cell technology remains a viable option as a means of providing biomarker information and tumour activity indicator in delivering precision medicine. firstly, enumeration can be used to help determine the response to a treatment. secondly, temporary culture and progression into development of organoids may be used to allow for downstream analysis and therapeutic decision. transcriptionally-targeted retroviral replicating vectors: a novel strategy for gene therapy of prostate cancer introduction and objective: while hematospermia is mainly associated with genitourinary infl ammatory disorders, there are very few studies for prostatitis associated hematospermia (pah) via robust prostatitis evaluation methods. for this reason, we evaluated the incidence of pah with systematic evaluation methods for prostatitis. we evaluated hematospermia patients from a single hospital over fi ve years. we classifi ed the patients into pah versus he-matospermia without evidences of prostatitis (hwp) by using a nih-cpsi (chronic prostatitis symptom index) questionnaire and expressed prostatic secretion studies. th congress of the sociÉtÉ internationale d'urologie -siu abstract book cant diff erence in patient's the quality of life impact (table ) . introduction and objective: chronic prostatitis/ chronic pelvic pain syndrome is a chronic pain disease with high prevalence rates and substantial health care costs. chronic prostatitis syndrome is a common urological condition that many clinicians fi nd diffi cult to diagnose and treat eff ectively. th e signifi cance and diagnostic value of semen analysis in bacterial prostatitis has been extensively debated and remains controversial. our objective was to investigate the diagnostic accuracy of semen and urine culture in the diagnosis and treatment outcome of bacterial prostatitis. th e present study is based on a retrospective analysis of a database of over patients (age range - years) who met the consensus criteria for bacterial prostatitis, % of whom had dysuria, % perineal discomfort, % had obstructive luts, % infertility of unknown etiology, % erectile dysfunction and % recurrent infection of the partner. segmented urine cultures and semen culture, were performed in all patients. treatment were started as per the culture report and culture negative patients were treated empirically with quinolones group of antibiotics. patients were followed-up for year to rule out disease recurrence. results: of the patients, had positive semen culture and had positive urine culture; had negative culture for both semen and urine. of the positive cultures % of the bacteria was gram-negative microorganisms (escherichia coli was the commonest specimen isolated) and % had signifi cant positive cultures for gram-positive microorganisms. patients with positive semen culture had % response to antibiotics and full recovery was noted from the symptoms prospective aft er the full course of the antibiotic and recurrence of the disease were noted in % of the patient aft er year follow-up. patients with urine positive cultures, % had response to antibiotic, but % recurrence were noted in year. patients with negative cultures, % had symptomatic relieve but all of them had recurrence in year follow-up. conclusions: th e diagnosis of chronic prostatitis is diffi cult due to the absence of typical clinical symptoms and specifi c ultrasonographic signs. our data support the usefulness of semen analysis in the diagnostic work-up of prostatitis patients. semen culture positive patient responded well to medications and recurrence rate was very minimal compared to urine positive and culture negative patients. in our clinical work-up, semenculture are considered the only tests necessary to diagnose bacterial prostatitis and also guide us through the treatment. (rc) has been shown to be a predictor of poor outcomes in patients with bladder cancer. change in muscle volume during neoadjuvant chemotherapy (nac) administration has not been well studied. our objective was to assess for psoas muscle volume (pmv) change during the period of nac therapy and to assess if such a change was a predictor of pathologic response or survival. mp- . , figure . introduction and objective: alternative approach to the radical cystectomy for muscle-invasive bladder cancer is radical transurethral resection (tur), followed by chemotherapy/ radiotherapy. objectives: primary end points of the study were os (overall survival) and dss (disease-specifi c survival). secondary endpoint -oos survival aft er salvage cystectomy. materials and methods: sixty eight patients with t bladder cancer were treated by 'complete' tur fol-lowed by chemotherapy / radiotherapy. th e follow-up ended in june . all patients were subjected to "safety" resection. patients who had no tumor (t ), or had non-muscle-invasive (t ) tumor were given the option of follow-up with cystoscopy and adjuvant therapy or immediate cystectomy. mostly elder patients are candidates for bladder sparing. th ose with invasive tumor on the safety resection were subjected to cystectomy- patients (control group). we used spss : xi-square and kaplan-meier for statistical processing. results: five years overall survival (os) in the bladder spared group was % (n- ), and % of the cystectomy group (n- ) -p= . . th e disease specifi c survival (dss) was % and % for the bladder spared and cystectomy group respectively (p= . ). th irty four percent ( patients) with preserved bladder developed recurrent tumors. a repeated tur was conducted. fift een percent ( ) of them were with invasive tumor and the action taken was cystectomy. fift y percent ( ) of the salvage cystectomy group and % of the immediate cystectomy group survived years. of the preserved bladder patients, ( %) necessitated dj stenting and ( %) pns. pns in the cystectomy group were ( %). haematuria occurred in patients with preserved bladder and in of the cystectomy group. th e statistical diff erence between both groups according to complications is p = . . infl ammatory conditions were more common in the bladder sparing technique- orchiepididymitis, urosepsis, pyelonephritis, compared to urosepsis and pyelonephritis in the cystectomy group. conclusion: bladder conservation and radical cystectomy for muscle-invasive bladder cancer appear comparable regarding the dss until the th year. cystectomy continues to be standard of care. radical tur is successful bladder-sparing strategy in selected patients with no residual tumor on retur and lower life expectancy. introduction and objective: bladder cancer occurs commonly in the elderly patients. in some circumstance, uremic patients developed bladder cancer. we considered patients who are aged more than years old, end stage renal disease (esrd) or poor performance status (eastern cooperative oncology group, ecog >= ) as fragile patients for operation. we conducted this study to assess radical cystectomy (rc) outcomes and chemotherapy use including neoadjuvant and/or adjuvant chemotherapy in the fragile patients in routine practice. all patients undergoing rc for bladder urothelial cancer in china medical university hospital from to were enrolled. patients' basic characters, surgical and pathology reports and treatment records were retrospectively collected. patients were stratifi ed into fragile and non-fragile group. pearson's chi-square test and student t-test were used to assess parameters of these two groups. results: we identifi ed patients. th ere were patients aged more than years old, patient are uremic status and patients were performance ecog: . total patients were stratifi ed into fragile group. th e sex and pathological staging were no diff erence in these two groups. major perioperative complications defi ned as clavien-dino grade or more were . % in fragile group and only . % in non-fragile group (p= . ). chemotherapy use rate was . % and . % in fragile and non-fragile groups (p= . ). th e -day morbidity rate of non-fragile and fragile group was . % and . %, respectively. th e day morbidity was no signifi cant between these two groups ( . % of non-fragile and . % of fragile groups). in fragile group, -day mortality rate was . % and -day mortality rate was . %. th ere was no -day mortality in non-fragile group. half the patients died within months in fragile patients and fi ft y percent of patients lived aft er years in non-fragile patients. conclusions: fragile patients received radical cystectomy had higher perioperative major complications rate and higher -day mortality rate. we off ered complications and morbidity rate in these patients who received radical cystectomy. in elderly, esrd or ecog>= patients, we need more cautious care to decrease complication and morbidity rate. introduction and objective: primary management of muscle invasive bladder cancer (mibc) is cystectomy (cx). all traumas, including major surgery like cx, induce a stress response (sr), which plays an important role controlling the human immune system. a widely used parameter for systemic surgical sr is measurement of serum levels of c-reactive protein (crp). th is prospective study aims to compare the introduction and objective: several prognostic models predicting survival of patients with metastatic urothelial carcinoma (uc) have been developed, however, of them, the fi rst model by bajorin in is still the most representative and widely-used. th e aim of this study was to validate three major prognostic models constructed based on phase and trials, by using a cohort of real-world patients. we reviewed patients with metastatic uc who received fi rst-line chemotherapy at our fi ve affi liate institutions between and . using this multi-institutional cohort, we validated the following models: the "bajorin model", a model consisting of visceral metastasis and performance status (j clin oncol ; : ) ; the "apolo model", a nomogram including visceral metastasis, performance status, albumin and hemoglobin (j natl cancer inst ; : ) ; and the "galsky model", a nomogram including leukocyte count, number of sites of visceral metastases, site of primary tumor, performance status and lymph node metastasis (cancer ; : ) . cox proportional hazards regression model was used for multivariate analysis. harrell's c-index was calculated for each model. conclusion: all models were demonstrated to have high external validities in real-world patients, and of them, the "apolo model" achieved the highest c-index in the present population. further studies with larger populations are needed for establishment of the next standard model. the impact of female gender on bladder cancer specifi c death risk after radical cystectomy: a meta-analysis of patients liu s, yang t, na r, jiang h, ding q introduction and objective: bladder cancer was one of the most commonly diagnosed cancers in the world. up till now, there has been no study summarizing current studies on gender disparity and bladder cancer outcomes aft er radical cystectomy. to perform a fi rst meta-analysis on the association between female gender and cancer-specifi c death risk aft er radical cystectomy. a comprehensive literature search of the medline and embase databases was conducted for relevant studies published till november, th . th e primary goal of our study was to investigate the impact of gender disparity on cancer-specifi c death risk aft er radical cystectomy in urothelial bladder carcinoma population. th e meta-analysis was performed by estimating the odds ratios (or) and confi dence intervals (ci) through a random eff ect approach. results: a total of studies were included in the meta-analysis with a total population of patients. th e baseline characteristics of the studies were described in table . female gender was associated with a worse survival (pooled or: . , % confi dence interval . - . ) compared with male gender aft er radical cystectomy. signifi cant (q= . , p= . ) statistical between-study heterogeneity was present, with . % of variance secondary to between-study diff erences (i : . %). sub-group analysis found the correlation was signifi cant in north american, european studies (or: . , % ci . - . and or: . , % ci . - . , respectively) and studies from larger size of samples (or: . , % ci . - . ). we also found studies adjusted for the key elements (t stage, n stage and grade) obtained positive correlation (or: . , % ci . - . ). introduction and objective: pathologic response after neoadjuvant chemotherapy for muscle invasive bladder cancer is used widely as a surrogate endpoint for overall survival. controversy persists, however, whether the absence of residual cancer (pt ) or the presence of only non-muscle invasive residual cancer (pt , ptis, pta) is the optimal surrogate endpoint. we aimed to assess survival dependent on these pathologic responses in a large multicenter patient cohort. we retrospectively reviewed records of patients with urothelial cancer who received neoadjuvant chemotherapy and underwent cystectomy at contributing institutions from - . patients with ct - an m and eventual pn disease were selected for this analysis. estimated os was compared between pt and pt /pta/ptis patients. a multivariable cox proportional hazards regression model for overall mortality was generated to evaluate hazard ratios (hrs) for variables of interest (age, gender, number of cycles and type of chemotherapy regimen, surgical margin, and pt vs. pt /pta/ptis). conclusions: pt /pta/ptisn and pt n stage on the fi nal cystectomy specimen are strong predictors of survival in patients receiving nac and rc. we did not discern a statistically signifi cant diff erence in os when comparing these two endpoints. signifi cance of computer materials and methods: fift y patients were included in our study, of them presented with haematuria and a recent diagnosis of bladder carcinoma, and patients with a history of previous transurethral resection of superfi cial bladder cancer in their follow up period. th ey ranged in age years to years with a mean of . ; while male to female ratio was . : . th e main steps to perform virtual cyctoscopy incorporate proper bladder distention with air aft er draining the residual urine through foley's catheter and scanning the patient in both supine and prone positions. an excellent overview of the bladder masses was obtained in all cases and the results of virtual cyctoscopy and conventional one were comparable with excellent sensitivity rates of virtual cyctoscopy in detection, localization and morphology description of the bladder lesions at variable sizes. results: for detection of all lesions (n= ), virtual cyctoscopy alone showed sensitivity: . %, specifi ty: . % with two false positive and one false negative in comparison to conventional cyctoscopy which detected lesion while in axial ct alone the sensitivity: . %, specifi ty: % with false negative fi ndings. conclusion: ct virtual cystoscopy is a promising technique for use in bladder tumor detection of lesions larger than mm. optimal evaluation requires adequate bladder distention with the patient in both supine and prone positions and interpretation of both transverse and virtual images. is an evolving technique aiming to improve upon the diagnostic sensitivity of prostate biopsy for the diagnosis and local staging of prostate cancer (pca). diff erences in interpretation, expertise and application of mpmri may be responsible for the range of reported results. th is retrospective study aims to evaluate the diagnostic accuracy of mpmri in a cohort of patients from melbourne, australia, as compared to the gold standard of radical prostatectomy (rp). th is retrospective study was conducted in through the electronic patient records of a tertiary hospital and several private urology practices in melbourne, australia. patients having undergone rp had their records assessed for the presence of a pre-operative mri performed aft er st january which was then evaluated against the reference standard of a radical prostatectomy wholemount specimen. mri sequences typically included t weighted imaging, diff usion weighted imaging and dynamic contrast enhancement at t. mri reports were evaluated using the prostate imaging-reporting and data system (pi-rads) system. in our cohort the sensitivity and specifi city of mpmri for prostate cancer (pca) detection was found to be approximately - % and - % respectively. th e area under the curve for determining local stage was approximately . . conclusion: mpmri may have a useful role as an adjunct for prostate cancer diagnosis and directing management toward improving patient outcomes. staging information may be less reliable. a randomized prospective trial to assess the outcomes of mri/trus-guided prostate biopsy and traditional -core trus-guided prostate biopsy baco e , rud e , eri l , moen g , vlatkovic l , svindland a , eggesbø h , ukimura o introduction and objective: th e outcomes of magnetic resonance imaging (mri) and -dimensional transrectal ultrasound ( d-trus)-image-fusion-guided prostate targeted biopsy (mri-group) has not yet been compared with traditional -core trus-guided prostate biopsy (control-group) in a randomized control trial (rct) . th e aim of this study was to compare the prostate cancer (pca) detection rates (cdrs) and histopathological outcomes in the two groups. th is prospective rct included prostate biopsy (pb) naïve patients with suspicion for pca, where were randomized to mri-group and to control-group from / to / . in the mri-group, two tb of mri suspicious regions was followed by -core systematic random biopsy (rb). in the control-group, two tb towards palpable and/or trus-visible suspicious regions and -core systematic rb were performed. clinically signifi cant pca (cspca) on biopsy was defi ned as maximum cancer core length (mccl) ≥ mm of gleason score (gs) or any mccl of gs ≥ according to start criteria. cdr of all pca and cspca, and histopathological fi ndings were compared between the two groups. results: in the mri-and control-group cdrs were / ( %) and / ( %), (p= . ). cspca were detected in / ( %) in and / ( %) in control-group, (p= . ). tb (median cores/ patient) detected cspca in / ( %) in mri-and / ( %) in control-group (p= . ), respectively. concordance of gs on biopsy and radical prostatectomy specimen was / ( %, k = . ) in mri-and / ( %, k = . ) in the control-group (p< . ). upgrading of gs biopsy vs. gs-rp specimen was % in mri-group and % in control-group (p< . ). since the present study had a restricted cohort size, this may limit the generalizability of the results. no signifi cant diff erence in cdrs was found between the two groups. pca diagnosis can be achieved with few mri/trus-fusion guided prostate biopsy. gleason score on targeted biopsy was more accurate in the mri-group. introduction and objective: infection is a complication of trus prostate biopsy, despite the use of antibiotic prophylaxis. worryingly the rate of infectious complications following trus biopsy has been shown to be increasing. we aimed to determine the rate, severity, risk factors and microbiology resistance patterns associated with trus biopsy sepsis. as well the standard patterns of care surrounding trus prostate biopsy. a retrospective case-control study was conducted. using electronic coding all patients who presented to cabrini hospital with sepsis following a trus biopsy from to were identifi ed. validated cases were matched to controls in a ratio of : . eligible controls were required to have undergone a trus biopsy at the same surgical institution as the case and in the closest period of time. demographic, procedural and patient related data-points were recorded for all patients using hospital and urologist records. univariate logistic regression models were constructed and used to determine risk factors associated with infection. results: seventy-one cases developed sepsis following trus biopsy and were matched to controls. th e average rate of sepsis over the -year study period was . %. a sofa score ≥ was identifi ed in % of cases. we found a high prevalence of antibiotic resistant e. coli, with % of blood culture isolates classifi ed as multidrug resistant organisms. eight diff erent prophylactic antibiotic regimens were identifi ed. statistically signifi cant risk factors included previous antibiotic use and prior international travel within the six months prior to biopsy. th e addition of a penicillin antibiotic to standard fl uoroquinolone antibiotic prophylaxis was protective. conclusions: trus biopsy is an elective procedure and as such needs to be associated with minimal morbidity. th e patterns of care surrounding periprocedural variables for trus biopsies were non-uniform and diverse. a wide variety of diff erent prophylaxis regimens and bowel preparation routines were recorded. patients with risk factors for sepsis may represent a better target population for intervention with alternative preventative strategies. alternative preventative options include augmented prophylaxis, tailored prophylaxis or the tp biopsy approach either as a fi rst line biopsy modality or based on epidemiological risk factors. psa level) and pathological data was collected for all patients undergoing fi rst-time prostate biopsy with at least months follow-up, at music practices. from this overall cohort we identifi ed all patients whose pathology revealed multi-focal hgpin and/or asap (pre-malignant pathology) . for this subgroup, we examined the frequency of repeat biopsy across music practices and cancer detection outcomes. introduction and objective: nowadays overtreatment is recognisable challenge in pca management. overdiagnosis is possible reason for further overtreat-ment. we hypothesised that repeated prostate biopsies could not only help to cure but also harm patients with pca. consecutive patients who underwent biopsy for suspicious pca following at least one rebiopsy at single tertiary medical centre in - were included. age, initial and subsequent psa, drv, histology and biopsy features were recorded along with characteristics of subsequently diagnosed pca and chosen treatment approach. descriptive statistical methods were used for further analysis. results: basic characteristics were (mean±sd or frequency): age at initial biopsy ( . ± . years), time between initial/fi nal biopsy ( . ± . months), initial/ fi nal psa ( . ± . and . ± . ng/ml), drv (normal/suspicious . %/ . %), and number of initial/fi nal biopsy cores ( . ± . and . ± . ). initial/ fi nal histology was bph in ( . %)/ ( . %), infl ammation in ( . %)/ ( . %) and premalignant lesions in ( . %)/ ( . %) cases. finally, ( . %) pca were diagnosed ( by biopsy, by turp) performing biopsies aft er all. mean number of biopsies per patient was . in total and . to reach cancer positive histology; turp was performed in ( . %) patients. in ( . %) patients ≤ biopsy cores were cancer positive and in ( . %) patients gleason score was ≤ . gleason score ≥ was found in ( . %) cases. treatment with curative intention was held in cases (rrp , external radiotherapy ), no treatment (as/ww) in and hormonal therapy in patients. fourteen patients with minimal low grade cancer (≤ positive cores, gleason score ≤ ) underwent rrp ( % of all surgery cases). conclusion: repeated biopsy is important approach in pca diagnosis. however, based on our results we cannot exclude the risk of overdiagnosis and subsequent overtreatment with signifi cant impact on patients' quality of life, including radical surgery for low risk disease and early hormonal therapy in non-metastatic low-intermediate risk disease. th e study is retrospective, but potential bias became the advantage, since we could exclude prospective "self-control" within treatment decision making process. (siemens, munich, germany) and images were interpreted visually to evaluate uptake in biopsy districts of prostate gland. th e lesions suspicious for pca were submitted to additional targeted biopsies. introduction and objective: multiparametric mri (mpmri) and mri/trus-fusion-guided biopsy (tb) are advocated to detect index lesions and signifi cant prostate cancer (pc) within the prostate more exactly than systematic biopsies (sb) . th e aim of this study was to evaluate the detection accuracy of tumor foci by mp-mri and tb on radical prostatectomy (rp) specimen. we selected consecutive patients who were treated with rp for localized pc diagnosed by tb and/or transperineal saturation sb. on mpmri, all lesions were scored according to pirads. all lesions with pirads≥ underwent tb. on rp specimen, index lesion was defi ned as highest gleason score (gs) or highest tumor volume (tv). gs= + and tv≥ . ml or gs≥ + and tv≥ . ml were considered signifi cant. we performed spearmans correlation coeffi cient between mpmri and rp specimen and fisher's test between mpmri, tb and sb. introduction and objective: prostate biopsy is evolving to pre-biopsy multi-parametric mri (mp-mri), followed by systematic biopsy (sb) ± targeted biopsy (tb). mp-mri combined with trus-guided tb may increase detection rates of prostate cancer (pca), especially clinically signifi cant pca (cspca). however, few studies compare the detection rate of sb versus tb in the same cohort of men, as recommended by the standards of reporting for mri-targeted biopsy studies (start) consensus panel. th is study compares the diagnostic yield of sb and tb in a single cohort. th irty-three patients had a pre-biopsy mp-mri that identifi ed a target lesion. each patient then had a trus-guided sb and tb. th e cognitive fusion technique was used to perform the tb. results: among the patients, mean age was years; mean psa was . ng/ml. th e positivity rate for pca was % (n= ) for both sb and tb. th e positivity rate for cspca was % (n= ) for sb and % (n= ) for tb (p= . ). sb underdiagnosed cases ( %) of cspca that were detected through tb; tb underdiagnosed cases ( %) of cspca (p= . ) . th e positivity rate for sb and tb combined was % (n= ) for cspca (p= . ). conclusion: detection rates for pca using sb and tb were equal, but sb had a higher detection rate for cspca. combining tb with sb increased the rate of detection for cspca by %. tb alone was % more introduction and objective: active surveillance (as) has gained popularity with the intention of avoiding or postponing interventions in subjects with pca of low biological potential. unfortunately, several inclusion criteria have been proposed but many doubts still persist about their performance in predicting favorable disease. we aimed to assess the added value of biopsy factors, like maximum cancer length in a core (mcl), cumulative cancer length (ccl), cumulative length of positive cores (clpc), and percentage of cancer involvement in positive cores (cipc), to the prias criteria in patients who underwent radical prostatectomy (rp) but eligible for active surveillance (as). from january to december , consecutive subjects underwent rp. we identifi ed ( . %) patients who were eligible for as based on prias criteria: clinical stage t c or t , psa level of ≤ ng/ml, gleason score ≤ , psa-d of < . ng/ml and one or two positive biopsy cores. we calculated the diagnostic accuracy of biopsy factors in determining pathological confi rmed unfavorable disease. decision curve analysis (dca) were performed. explored, we examine the feasibility of monitoring low volume gleason sum (gs) + disease compared to gs + disease. introduction and objective: th e selection of prostate cancer patients for active surveillance (as) is based on the criteria for low risk according to protocols such as the national comprehensive cancer network (nccn) or european association of urology (eau) guidelines. we aim to compare pathological upgrading and upstaging rates between prostate cancer patients who met the above guidelines but underwent radical prostatectomy. we also aim to refi ne the selection criteria for our local population. a total of men were treated with rp at our tertiary center from to . seventy-three patients met the nccn criteria for active surveillance: ct -t a, prostate-specifi c antigen (psa) less than ng/ml, and biopsy gleason sum to . th irty-fi ve met the eau guidelines, which had additional criteria of: or less biopsy cores positive and % or less ca detected per core. results: of the patients who met the nccn criteria, ( . %) showed pathological upgrading (gleason > ) while ( . %) were upstaged (pt ). upgrading and upstaging fi gures for the patients meeting the eau guidelines were ( . %) and ( . %) respectively. analyzing the patients who met the nccn criteria, those who had % or more of the number of biopsy cores positive for prostate cancer had a far greater upgrading rate of . %, which was more than the . % (p = . ) seen in the other patients. psa density or percentage of individual core did not show any statistical diff erence in upgrading or upstaging. conclusion: a lower percentage of upgrading was seen in patients meeting the eau. upstaging fi gures were relatively the same. when counseling patients for active surveillance using the nccn criteria for low risk, we should exercise strong caution in patients with % or more of the number of biopsy cores positive for prostate cancer. biochemical recurrence rates in active surveillance candidates and the role of improving gleason grading introduction and objective: to evaluate prospectively the role of prostate-specifi c antigen (psa) density to predict gleason score upgrade in prostate cancer patients eligible for active surveillance (t /t , biopsy gleason score ≤ and psa ≤ ng/ml and ≤ positive biopsy cores). between january and november , among the patients who underwent more than core trans-rectal ultrasound guided biopsy, patients eligible for active surveillance under-went radical prostatectomy. using the modifi ed gleason criteria, tumor grade of the surgical specimens was examined and compared to the biopsy results. results: a tumor upgrade was noticed in ( . %) patients. extra-capsular disease and positive surgical margin was found in ( . %) and ( . %) patients, respectively. a statistical signifi cant correlation between the psa density and postoperative upgrade was found (p= . ); this is in contrast to the other studied parameters which failed to reach signifi cance, including psa, prostate volume, number of biopsy cores and number of positive cores. tumor upgrade was also highly associated with extra-capsular cancer extension (p= . ). th e estimated optimal cutoff value of psa density was . ng/ml , obtained by roc analysis (area under the curve . , p= . , % ci . - . ). conclusions: psa density represents a strong predictor for gleason score upgrade aft er radical prostatectomy in patients eligible for active surveillance. since tumor upgrade increases the potential for postoperative pathological adverse fi ndings and prognosis, psa density should be considered when treating and consulting patients eligible for active surveillance. surgical outcomes of south australian patients who have discontinued active surveillance plagakis s , o'callaghan m , , , moretti k , , foreman d , introduction and objective: active surveillance (as) is a recognized management pathway for patients with low risk prostate cancer (pca). diff ering protocols exist to identify suitable patients and manage their follow up. our study compares surgical pathology outcomes between patients who were initiated on, but discontinued, as and underwent radical prostatectomy (rp) with patients who received surgery immediately at the time of diagnosis. we also explore predictors of as discontinuation. our cohort comprised men diagnosed with pca from the south australian prostate cancer clinical outcomes collaborative database between - , aged - years, gleason score ≤ and psa ≤ . patients were stratifi ed into an immediate treatment group and an as group. to assess if as derivation rules aff ected outcomes, patients were sub-categorised according to enrolment criteria of university of toronto, prias and royal marsden protocols (with psa and gleason adjustment accordingly). all patients had a minimum of two years follow up. chi squared, logistic regression and cox proportional hazards modelling were used to compare outcomes between groups. results: forty-three ( %) patients in the as group underwent rp, compared with in the immediate treatment group. extra capsular extension and upgrading of histology at rp were more common in those managed by as compared to those receiving im-mediate surgery. th ese associations were supported by sensitivity analysis using prias and toronto criteria but not royal marsden selection criteria. as trended to being associated with unfavourable surgical pathology in multi-variable analysis, but this was only statistically signifi cant for prias ), p= . ). in all patients managed by as, sensitivity analysis suggested that the percentage of core positive at diagnosis is a signifi cant predictor of as discontinuation in those meeting the university of toronto selection criteria (hr . ( . - . ), p= . ). to determine if prias has increased rates of active surveillance (as) for patients with low-risk prostate cancer (pca). secondly, to determine whether urologists are operating on greater proportions of high-grade pca as a result of increasing as and what eff ect this has on surgical practice. prospective data was collected on patients from - (cohorts - , - ) who underwent trus biopsy by a urologist in geelong (n= ). positive trus biopsies (n= ) in both the pre and post prias cohorts were assessed to see if they met prias eligibility and whether they received as or active treatment (at). at patients were risk stratifi ed by gleason score and d' amico risk. data on post-prostatectomy staging, margin status and nerve-sparing techniques were collected. chi-squared test were used to calculate statistical signifi cance between cohorts. results: as increased between cohorts ( %, %, p= . ). before prias % ( / ) of patients eligible for as by prias criteria opted to undergo as compared with % ( / ) aft er the introduction of prias (p=< . ). th e relative proportion of high-grade pca (gleason score ≥ and d' amico high-risk) undergoing at increased from to % (p= . ) and to % (p= . introduction and objective: renal trauma is predominantly managed conservatively. trauma nephrectomy is reserved for patients who fail conservative or alternative management options. nephron sparing surgery is the cornerstone of renal preservation. our objective was to review the management of renal trauma at three tertiary facilities in queensland over a year period and compare these outcomes with current literature. a retrospective analysis was performed to fi nd the total number of renal traumas presenting to the princess alexandra hospital, royal brisbane and women's hospital and gold coast hospital, in queensland, australia. renal trauma patients were identifi ed using icd- codes (s . - ) and operative databases. patients requiring angioembolisation were obtained from radiological databases. we accessed the number of conservatively managed patients, trauma nephrectomies and angioembolisations for renal trauma. results: a total of renal traumas were identifi ed from june to june . six hundred and sixteen injuries were managed conservatively. th irty-three patients warranted acute exploration due to haemodynamic instability and resulted in nephrectomy in all cases. a trauma or general surgeon was the primary operator. fift een patients underwent angioembolisation for blunt renal trauma and patients for penetrating injuries. two patients proceeded to delayed nephrectomy for ongoing bleeding and for a ureteric stricture requiring nephrectomy aft er failed auto transplantation. th ese were performed by an urologist. th ere were further devascularised atrophic kidneys. seventeen of renal units were spared and of patients remained with functioning kidneys. all treated patients with angioembolisation were followed up with either mag renogram or ct triple phase and had functional kidneys at . years. conclusion: renal trauma is managed conservatively in most cases, consistent with the current literature. angioembolisation is an eff ective management option in selected patients with renal trauma. th is may prevent the need for trauma nephrectomy. in our cohort, patients requiring a trauma nephrectomy had predominantly grade iv and v injuries. general or trauma surgeons performed trauma nephrectomies in the acute setting of haemodynamic instability with rapid transfer to theatre. delayed nephrectomies were performed primarily by urologists in this cohort. introduction and objective: to review the contemporary management of traumatic extra-peritoneal bladder ruptures at an australian level one trauma centre. patients presenting with bladder injuries from july through to june were identifi ed using the traumanet database. th is was cross-linked with medical records and only patients with extra-peritoneal bladder rupture were included in the study. clinico-pathological data were collected from the database, medical records and health information services coding data. results: over the twelve-year study period, multi-trauma patients sustained an extra-peritoneal bladder rupture. of these patients, . % had a concurrent pelvic fracture and . % had co-existing intra-abdominal injury. a total of patients underwent operative repair for the bladder rupture and patients were managed conservatively with catheter drainage. of the patients managed operatively, % of cases were done at the time of another general surgical or orthopaedic operation and only two cases were done as a stand-alone repair. conclusion: extra-peritoneal bladder ruptures can be managed both conservatively and with operative repair. if operative repair is performed, it is usually done at the time of another operation for concomitant injury. management outcomes of major renal injuries following blunt trauma: changing concepts over years results: a total of / ( . %) of group i, and / ( . %) of group ii were treated non-operatively. diagnosis and grading in group i depended mainly on u/s, ivp and in some cases ct scan, while u/s and enhanced ct scan were mainly used for most of the group ii cases. in the total cohort, grade iii, iv and v renal injury were seen in ( . %), ( . %) and ( . %) patients respectively. open exploration was followed in ( . %) and ( . %) patients of group i and ii, with an overall exploration rate in / ( . %) of grade iv and v injury. th e incidence of nephrectomy have decreased from cases ( . %) in group i to cases ( %) only in group ii ( / kidneys were pathologic). double-j stenting and percutaneous drainage of urinoma was done in and cases, and chest-tube drainage to one patient with traumatic urinothorax in the conservatively managed group. outcomes were excellent, however in the non-operatively managed (grade iv-v) cases, / ( . %) normotensive patients had a non-functioning kidney within one year of follow up. conclusion: non-surgical management of high grade blunt renal injury can be safely undertaken and also recommended unless the patient is haemodynamically unstable. accurate grading is sometimes imprecise in multi-trauma patients, where instability is not always due to renal injury. drainage of extravasation is necessary to reduce morbidity. abdominal exploration does not mandate concomitant renal exploration, which is indicated in selected instances, otherwise it is an aggressive decision with a triple incidence nephrectomy rate. management of grade iv renal trauma: a revision of the aast renal injury grading scale is mandatory chiron p , hornez e , , boddaert g , dusaud m , bayoud y , molimard b , desfemmes f , durand x introduction and objective: th e aast (american association for the surgery of trauma) injury grading scale for renal trauma is currently the most important variable predicting the need for kidney repair or removal, for morbidity and mortality aft er blunt or penetrating injuries of the kidney. th e revision included the renal pelvis, the uretero pelvic junction and the segmental vascular injuries as grade iv, limiting grade v to severe hilar injuries. however, this revision does not permit the identifi cation of the group of patients who will require surgery because of hemodynamic instability due to grade iv renal injuries. th is study aims to propose an add-on for the grade iv of aast renal injury scale, in order to improve the management of these patients. we searched the following electronic databases: medline and scopus database. searches were not restricted by date, language or publication status. searches were last conducted in september . paediatric studies were excluded. results: seventy-one articles were found, were pertinent, including directly related to the topic. th ree risk factors were identifi ed to be associated with surgery for hemodynamic instability: peri-renal hematoma > . cm, intravascular contrast extravasation, medial renal laceration. presence of two or more of these criteria has been validated by others studies to predict the need for intervention. patients with > % devascularized fragments also present a poor prognosis and should be treated more aggressively. conclusion: th ese data should be incorporated into a future reassessment of the classifi cation, in order to better determine the need and time for surgery in grade iv renal traumas, generally leading to a nephrectomy. single panurethral reconstruction can be a surgical challenge. techniques include staged urethroplasty, augmented anastomosis with buccal mucosa graft (bmg) onlay via penile and/or transperineal, skin fl aps, or combinations of these. we report our experience of single stage modifi ed transperineal urethroplasty using a dorsal bmg in treatment of panurethral stricture. aft er obtaining irb approval, we performed a retrospective review of our urethral stricture database and identifi ed patients having undergone single stage transperineal urethroplasty using dorsal bmg as treatment of pan-anterior urethral stricture. patient characteristics, operative, and post-operative outcomes were studied. failure was defi ned as a need to any intervention during the follow-up period. results: th irteen patients underwent complete anterior urethra dorsal urethrotomy with dorsal bmg onlay between september and january . mean age was . years (sd: +/- . ). urethral stricture etiology was lichen sclerosis in patients ( . %), idiopathic in ( . %), hypospadias in ( . %) and infection in ( . %). previous treatments of dilatation and dviu were noted in patients ( . %) and previous urethroplasty in ( . %). mean operative time was . minutes (sd: +/- . ). mean estimated blood loss was . cc (sd: +/- . ). th ere were no intraoperative complications. early postoperative complications were buccal donor site bleed in patients ( . %) one treated with digital compression and other with hemostatic stitch, one patient ( . %) presented a perineal abscess and secondary urethroperineal fi stula. late complications was observed in patients who had postoperatory dribbling ( %). at mean follow up of . +/- . months, had recurrence ( . %) requiring dviu without new recurrence aft er a mean follow-up of . months (range - ) and one had meatal stenosis treated with dilatation ( . %) without recurrence aft er . month of follow-up. conclusion: in this small cohort, reconstruction of panurethral strictures may be safely and eff ective-introduction and objective: we present a novel technique for reconstruction of bulbo-membranous urethral strictures aft er surgery for bph with external sphincter sparing to preserve continence. anatomical studies have shown that the rhabdosphincter is separated from the membranous urethra by a sheath of connective tissue. by meticulous dissection of this sheath we separated the muscle from the urethral wall preserving the sphincteric function. patients with bulbo-membranous strictures aft er turp or open prostatectomy (op) who failed dilation and/or internal urethrotomy were reconstructed with a bulbo-prostatic anastomosis with preservation of the fi bers of the external sphincter. th e bulbo-membranous junction is approached dorsally, the inter-crural space is opened on the midline and the bulb is mobilized only from one side, without detachment from the perineal body. th e bulbo-membranous junction and membranous urethra are exposed and secured with vessel loops. th e membranous urethra sheath is opened circumferentially, carefully refl ecting the circular muscle fibers until exposure of the urethral wall. gentle blunt proximal dissection allows separating the muscle away from the urethra up to the prostatic apex, where healthy urethra is found to perform the anastomosis. results: from january to march we operated patients ( aft er turp and aft er op). all had membranous or bulbo-membranous strictures; bladder neck contractions were excluded. mean age was years ( - ). fourteen patients have been treated with either dilation and/or dviu; seven were with a suprapubic tube. mean length of stricture was cm ( - . ) , mean time from surgery to reconstruction was months ( - ) and mean follow-up was months ( - ) . two patients were not evaluable due to insuffi cient follow up. of the remaining , twelve were completely dry or using one security pad ( . % success). th ere were two clavien complications (both scrotal hematomas) and no stricture recurrence. conclusion: excision and bulbo-prostatic anastomosis with sphincter sparing for strictures aft er surgery for bph is feasible and safe. our technique allows preserving continence in most patients. to our knowledge this technique has not been described before. a larger series and reproduction in other centers will help to validate its therapeutic role. introduction and objective: panurethral strictures are complex and extensive strictures that involve the penile and bulbar urethra. management of these patients is challenging. in the last two decades, oral mucosal graft s have gained widespread popularity as the most versatile substitute tissue for urethral reconstruction. th e aim of this paper to present the shortterm outcome of our experience in the use of oral mucosal graft s in one-stage urethroplasty in patients with panurethral strictures. materials and methods: between april and october , men were evaluated and had one-stage oral mucosa urethroplasty for panurethral strictures. results: th ere were patients age range of - years with a mean of . years. aetiological factors identifi ed were poorly treated urethritis ( . %), post-urethral catheterization ( %) and lichen sclerosis ( . %). th e commonest cause of catheter-associated panurethral strictures was part of intra-operative patient monitoring in ( %), following spinal cord injury ( %). preliminary suprapubic cystostomy was done in patients ( . %). graft length ranged from - cm with a mean of . cm. oral mucosa donor sites were buccal in ( . %), labial ( . %), combined buccal and labial ( . %) and ( . %) for combined buccal/lingual and buccal/labial/penile skin fl ap respectively. twenty eight patients ( . %) had satisfactory voiding on removal of the urethral catheter and subsequent follow-up whereas patients ( . %) experienced diffi culty. of these , one patient had bladder outlet obstruction due to benign prostatic hyperplasia which was the reason for previous repeated urethral catheterization that had resulted in the stricture. oral mucosa donor site complications were present in patients ( . %) and consisted mainly pain and numbness in the mouth. duration of follow-up ranged from - months and there was no mortality among the patients. conclusion: panurethral strictures are common in our practice mainly resulting as complication of prolonged urethral catheterization. urethral reconstruction by one-stage oral mucosa graft urethroplasty is feasible, has good outcome though it may be associated with minor donor site complications. larger number of patients and longer-term follow-up are needed to assess durability of the procedure. missed and delayed ureteral injuries in hasan sadikin hospital, bandung, indonesia introduction and objective: to review our experience with delayed and missed traumatic ureteral injuries. materials and methods: genitourinary trauma database was retrospectively reviewed from - . variables such as time to diagnosis, imaging modalitites, location of missed or delay injuries, management, duration of operation, length of stay and complications were noted. introduction and objective: traumatic urethral stricture as the result of straddle injury or pelvic fracture urethral injury (pfui) is associated with long term morbidity and reduce the quality of life. most patients will end with long life urethral dilatation even aft er endoscopic treatment. anastomotic urethroplasty at present is the answer of defi nitive treatment. general principles of urethroplasty are to defi ne healthy urethra above and below the site of surrounding fi brosis and to perform a spatulated end-to-end anastomosis. prior to the year of , most urethral stricture cases including traumatic anterior and posterior urethral stricture was managed mostly with direct vision internal urethrotomy (dviu) in our institution. we present our experience with transperineal anastomotic urethroplasty. to our knowledge this is the fi rst indonesian local centre report of the changing defi nitive treatment of traumatic urethral stricture in a series of patients. we retrospectively reviewed traumatic urethral stricture due to straddle injury and pfui that had been treated with urethral reconstructive surgery by transperineal anastomotic urethroplasty approach. th e data cases from january -december were analyzed; which were the age of patients, location, length of gap, previous operations, and treatments. th e clinical outcome was evaluated with urofl owmetry aft er , , , and months aft er the surgery. results: a total of patients came with traumatic urethral stricture to hasan sadikin hospital during , which consist of patients with pfui and patients with traumatic anterior urethral stricture due to straddle injury. th e median age was . and . for pfui and straddle injury, respectively. twenty four percent of pfui patients had distraction length > cm and % had distraction length < cm. meanwhile, % of straddle injuries had stricture length < cm and % had distraction length > cm. in order to achieve tension free of anastomotic urethroplasty, % of pfui patients underwent crural separation, % patients underwent inferior pubectomy and only one patient for supracrural re-routing. sixteen percent of patient of pfui are redo case urethroplasty. success rate aft er transperineal anastomotic urethroplasty of pfui cases was %, % for redo case pfui and % for straddle injury cases. mean q max rates at , , , and months aft er catheter removal of pfui patients was , , , and ml/s whereas for straddle injury patients was , , , and . conclusions: in short term follow up, transperineal anastomotic urethroplasty achieved a signifi cant good result for traumatic urethral stricture treatment at our institution. recurrence after urethroplasty in a tertiary care centre in sub-saharan africa: an analysis of preoperative factors introduction and objective: urethral strictures disease remains very common in sub-saharan africa but despite this, there are no available reconstructive urology trainings / fellowships outside the formal urology residency programmes of the region. we reviewed the outcomes of urethroplasties at a tertiary urology centre in nigeria, sub-saharan africa which typically off ers general urology service. preoperative independent predictors of recurrence post-urethroplasty were determined. th e records of a total of men who had urethroplasty for proven anterior urethral stricture disease between february and january were retrospectively analyzed. age, social status, aetiology of strictures, stricture location, length of strictures and type of urethroplasty were assessed. appropriate inferential statistics were performed to determine independent predictors of stricture recurrence. results: mean patient age was years (range to ) and majority of the patients were of low income status ( . %). iatrogenic strictures due to urethral instrumentations and catheterization ( . %) and post infl ammatory strictures ( . %) were more common. isolated penile and long segment peno-bulbar strictures accounted for over two-thirds of all patients ( . %). mean stricture length was . cm (range to cm). most patients had quartey's urethroplasty ( . %), others had buccal mucosal graft ( . %), orandi ( . %) and anastomotic bulbar urethroplasty ( . %). for a mean follow up of . ± months, the overall recurrence rate was . % with mean time to recurrence of . months. of the evaluated preoperative factors (age, p= . ; social status, p= . ; aetiology, p= . ; stricture location, p= . ; type of urethroplasty, p= . ; stric-ture length, p= . ), only stricture length (p= . ) was a signifi cant predictor of recurrence. roc analysis was done and stricture length > cm signifi cantly predicted recurrence (auc of . , p= . ). conclusion: stricture length > cm are a signifi cant cause of recurrence following urethroplasty in the setting of prevalent general urology practice in sub-saharan africa. th e introduction of formal reconstructive urology fellowship or training may help improve skills and outcomes. introduction and objective: males with hypospadias are likely at increased risk for future urologic complications as adults. however, it is unclear how childhood surgery modifi es this risk. th e purpose of this study is to describe the spectrum of adult presentations with hypospadias-related complications and examine the eff ect of childhood surgery on these complications. a retrospective chart review over a year period, from august -december , demonstrated adult patients who presented to an adult reconstructive urologist with urologic complications related to hypospadias. patients were divided into two groups: those with no prior hypospadias surgery (group , n= ) and those who underwent surgical correction as a child (group , n= ). charts were reviewed for age at presentation, initial complaints, history of repair, and surgical intervention required. results: overall, the mean age at presentation was . years old. meatal location was not statistically diff erent between groups and , respectively: glans ( . % vs. . %), subcoronal ( . % vs. . %), coronal ( . % vs. . %), distal penile ( . % vs. . %), midshaft ( . % vs. . %), and penoscrotal ( . % vs. . %). overall, luts ( . %) was the most common presenting complaint, followed by spraying ( . %), urethrocutaneous fi stula ( . %), recurrent uti's ( . %), and chordee ( %). comparison demonstrated group patients were more likely to present with luts ( . % vs. . %, p= . ) and recurrent uti's ( . % vs. %, p= . ). contrastingly, group patients presented more commonly with cosmetic dissatisfaction ( . % vs. . %, p= . ). urethral stricture disease was demonstrated in more patients who had previous hypospadias repair, than those who had not ( . % vs. . % p= . ). of these, strictures were signifi cantly longer in the previous surgery group ( . cm vs. . cm, p= . ). surgical intervention was required in . % of group and . % of group (p= . ). conclusion: correction of hypospadias as a child likely increases the future risk of urethral stricture, recurrent uti's, and subsequent luts, but improves patient satisfaction with cosmesis. follow-up of hypospadias repair patients should extend into adulthood, as a signifi cant portion of adult presentations ultimately require surgical intervention. introduction and objective: during male to female gender confi rming surgery with vaginoplasty, a space is created for the neovagina within the potential space between the prostate anteriorly, and denonvillier's fascia and rectum posteriorly. entry to this plane is challenging, and to date, the only surgical approaches to this space describe blunt and sharp dissection along the ventral surface of the urethra. th e likely trauma to perirectal vasculature muscle-laden connective associated with this approach may account for the observed recto-vaginal fi stula rate associated with vaginoplasty. we describe an alternative, never before published approach using a male urethral sound upon the apex of the prostate to enter this plane with sharp dissection in a reliable and effi cient fashion. we describe our surgical technique, wherein we use a male urethral sound during the dissection to help expose denonvillier's fascia over the apex of the prostate. we dissected a block of tissue containing prostate, denonvillier's fascia and rectum from human cadavers, to describe (using ihc) the location and relative abundance of blood vessels (factor viii ab.), nerves (nf & s- ab.), and connective tissue (h&e and masson's trichrome), to support the sharp surgical approach we describe over the traditional approach to this plane. we describe clinical outcomes and the recto-neovaginal fi stula rate utilizing this approach in our institutions. results: immunohistochemistry results showed that the sharp dissection we describe is associated with incision through signifi cantly fewer blood vessels and sensory-motor nerves as compared to the traditional surgical approach. use of the sharp dissection we describe resulted in, at our institutions, a signifi cant decrease in recto-neovaginal fi stula in the peri-operative period. conclusion: th e surgical technique we describe for dissection of the plane between prostate and denonvillier's fascia during vaginoplasty is well supported by the anatomic studies we performed, and, is associated with lower morbidity. th is surgical approach and technique is also likely useful for gaining access to this same plane for repair of recto-vesical and recto-urethral fi stulas. introduction and objective: mitrofi noff procedure is commonly employed as bladder draining tool in patients who are unable to do clean intermittent self-catheterization through native urethera. it preserves renal function in small capacity and high pressure bladders and to improve quality of life. here we want to share our single centre experience of patients undergoing mitroffi noff procedure. a retrospective study of patients who underwent mitrofi noff procedure from january till december with a median age of (range = to ). twenty eight patients were males while female. indications for catheterizable stoma formation included neurogenic bladder in patients, small bladder in , bladder tumor in , uretheral stricture in one and interstitial cystitis in one patient. median follow-up was month to years. stoma was made from appendix in cases, from tapered ileum in cases and from ureter in cases. stoma location was lower right quadrant in cases, left lower quadrant in cases and at umbilicus in cases. augmentation accompanied by mitrofanoff was done in patients while mitrofanoff alone was done in patients. augmentation was done by using ileum in patients and cecum in one and illeocecum in one patient. data was entered from chart review and analyzed on spss. sixteen patients were analyzed in terms of complications and stoma revision. results: post-operative complications included uti in ( . %) patients, stones formed in ( . %), fistula was seen in ( . %) patient (augmentation cystoplasty + mitrofanoff ), stoma stenosis seen in ( . %), stoma revision done in ( . %). one female ( . %) patient had dribbling urine through urethera (incontinence), she underwent bladder neck closure. metabolic complications were not seen based on serum electrolytes follow-up records. we concluded that aft er mitrofanoff procedure renal function was preserved in most of the patients while no metabolic complications were seen in patients aft er undergoing mitrofanoff +bladder augmentation. stone risk was . % which was not very high. quality of patients was improved aft er mitrofanoff procedure. results: sesfm has higher porosity and larger pore size compared with bam (p< . ). at weeks, the presence of vesical calculus was evident in / rabbits. histological analysis showed that sesfm and bam promoted similar degree of urothelium regeneration (p> . ), and sesfm promoted a higher degree of smooth muscle and vessel regeneration compared to bam at each time point (p< . ). in addition, muscle strips supported by sesfm displayed higher contractile responses to carbachol, kcl, and phenylephrine compared with bam. at weeks, both matrices elicited similar mild acute and chronic infl ammatory reactions. conclusion: our results demonstrated that sesfm has greater ability to promote bladder tissue regeneration with structural and functional properties compared to bam, and with similar biocompatibility. introduction and objective: ureteral access sheaths (uas) can aid ureteroscopy by facilitating multiple passes of the ureteroscope, maximizing irrigation drainage, and reducing intra-renal pressures. however insertion of the access sheath may induce ureteral ischemia, cause iatrogenic ureteric injury, and could ultimately lead to ureteric stricture. in this study, we aim to evaluate the stricture rate following ureteroscopy both with and without the use of uas. we performed a retrospective chart review of consecutive ureteroscopies performed at our center (a tertiary referral center for endourology) between april and april to treat ureteric and renal calculi. th e primary outcome was the development of new hydronephrosis three months following successful ureteroscopy, not due to an obstructing stone. patients without follow-up renal ultrasound (us) or ct scan months post-ureteroscopy were excluded. data on age, sex, size of the stone, location of the stone, stone density, stone-free rate (sfr), time of the procedure, pre-op stenting, postop stenting, use of the uas, size of the uas, length of the uas, stone analysis, and imaging details were recorded. baseline and outcome variables were compared with anova and chi-square analysis where appropriate using spss statistical soft ware. results: a total of patients were eligible. a uas was used in ( . %) patients; ( . %) for renal stones and for proximal ureteric stones. th ere was no signifi cant diff erence in baseline or demographic data. none of the patients developed new hydronephrosis or developed a ureteric stricture, and none required endoureterotomy. conclusions: uas use during ureteroscopy for renal and ureteric stones is both safe and eff ective. even with routine use of . f and f uas, ureteric stricture rates are very low (zero in this series), suggesting that signifi cant ureteric injury is rare with proper technique and case selection. to evaluate the value of fl exible ureteroscopy for the treatment of the upper urinary tract calculi in children. a total of children, males and females, were identifi ed in this study. th e median age was . years, range months to years. among them, patients had the upper ureteral calculi ( with calculi in situ, with middle/fi stal ureteral calculi shift ing to upper ureteral aft er rigid ureteroscopic lithotripsy) and had renal calculi. ipsilateral mild to moderate hydronephrosis was found in all of the cases. four children had melamine-induced stones ( with upper ureteral calculi and with renal calculi). th e calculi were found on left side in cases, on right side in , and on both sides in (upper ureteral calculi). th e median stone size was . (range . to . ) cm. retrograde fl exible ureteroscopy and anterograde fl exible ureteroscopy in mini-percutaneous nephrolithotomy was performed. results: twenty eight cases were performed retrograde fl exible ureteroscopic procedure. one case was conversed to mini-percutaneous nephrolithotomy because the fl exible ureteroscope could not be inserted into the upper ureter. th e fl exible ureteral access sheath was failed to insert into the upper ureter in cases, and the fl exible ureteroscope was inserted into ureter directly. th e successful rate of stone search was % in cases. th irty cases were successfully performed in one stage. th e stones were successfully fragmented aft er two stages in two cases. th e success rate of stone fragmentation was . % with the holmium laser lithotripsy in one stage. th ree anterograde fl exible ureteroscopy with mini-percutaneous nephrolithotomy were successfully performed, and the stones were successfully found and fragmented aft er a single holmium laser lithotripsy. th e median operative time was (range to ) mins. th ere was no major perioperative complication. th e patients were discharged from hospital aft er a median of . days (range to ). double-j stent was removed aft er to weeks when no residual stones more than . mm in size were found. no recurred stones, no urethra stricture, no ureter stricture, no urinary incontinence and no vesicoureteral refl ux were found during the to -months follow-up. conclusion: flexible ureteroscopy is a safe and feasible method for the treatment of the upper urinary tract calculi in children. it is suitable for the stones in the pelvis and calyceal where the rigid ureteroscopy could not reach. introduction and objective: laparoscopic ureterolithotomy is an alternative to open ureterolithotomy for the primary treatment of large, impacted, proximal or mid ureteral stone. transperitoneal and retroperitoneal approaches are the basic techniques and each has its own advantages and disadvantages. th e aim of this study is to compare retroperitoneal versus transperitoneal laparoscopic ureterolithotomy in eff ectivity, pain scale and early complications. in this prospective comparison study from january to december , patients with proximal and mid ureteral stones underwent retroperitoneal laparoscopic ureterolithotomy or transperitoneal laparoscopic ureterolithotomy. th e randomization occurred on consecutive sampling on a : basis. groups and consisted of patients who underwent retroperitoneal laparoscopic ureterolithotomy and transperitoneal laparoscopic ureterolithotomy, respectively. demographic and clinical variable, operative time, length of stay, ureteral suturing, pain scale according to visual analog scale (vas) and early complications data were collected and analyzed. statistical analysis was performed with spss® version . using student t-test and mann-whitney u tests with p value< . considered statistically signifi cant. results: vas on day between the groups was statistically signifi cant, and was higher in group (p< . ). according to the clavien-dindo classification of surgical complication all the patients were in grade classifi cation. th e diff erences in operative time, length of stay, ureteral suturing, visual pain analog score on day , and early complications between the groups were not statistically signifi cant. ionising radiation is commonly used in urological practice in the form of fl ouroscopy. to date there is a relative dearth of information regarding patient exposure during the urological procedures and the subsequent risk of development of a lethal malignancy due to the radiation exposure. objectives: to determine the radiation exposure for a patient for the most commonly performed urological procedures and determine the lifetime additional risk of fatal cancer per procedure. data was collected prospectively in two institutions on endoscopic urological operations. procedures were classifi ed as retro-graphic, semi-rigid ureteroscopic (urs) and fl exible ureterorenscopic (furs). data collected included procure type and diffi culty, dose are product [dap (gy*cm )]). th e eff ective dose (ed) as measured in millisievert was determined from the dap by using the monte carlo calculation. results: a total of consecutive operations from two institutions were assessed. th e mean ed for all procedures in this study was . msev, irq ( . - . ). th e maximum ed was . msev. th e radiation exposure for all procedures was relatively small, for diagnostic retrographic procedures the median ed was . msev. for retrograde procedures that involved a stent insertion the median ed was . msev. th e median ed for all ureteroscopic surgeries was . msev, and the median ed for all furs procedures is . . th e fi ndings of this study are reassuring. endoscopic urological procedures appear to expose patients to relatively small radiation compared to other procedures requiring fl uoroscopy and a very low lifetime additional risk of fatal cancer per procedure. five during the follow no local recurrence was noted and two patients presented with distant metastasis. th e actual -year overall and cancer specifi c survival was . % and . %, respectively. on multivariable cox regression analysis, acci was the only factor associated with increased risk of overall mortality (hr . ; % ci ( . - . )). conclusion: rpn achieves excellent long-term oncological outcomes. age and comorbidities are associated with increased risk of overall mortality. to our knowledge, this is the fi rst series of long-term follow up aft er rpn reported to date. introduction and objective: partial nephrectomy provides equivalent oncologic and superior functional outcome compared with radical nephrectomy over the short and long term. with the development of laparoscopic techniques and increasing laparoscopic surgical experiences, laparoscopic partial nephrectomy (lpn) has become an acceptable alternative to radical nephrectomy for expert laparoscopic urologists to treat small renal mass. it was reported that using barbed suture can reduce warm ischemia time during lpn. we designed a single blind randomized controlled trial to fi nd whether the barbed suture can materials and methods: from july to march , forty-six patients with renal score less than were enrolled for this study. patients were randomized into two groups: control and v-loc group. all patients were evaluated before surgery including performance status, asa score, liver and renal function, abdominal ct, lung function, and cardiac function etc. during the surgeries, standard ports were placed. aft er the renal artery was clamped by bulldog, tumor resection was performed using a cold scissor. th en the inner layer deep vessels and collecting system, and outer layer were sutured with v-loctm respectively in v-loc group. in control group, inner layer was sutured with - absorbable sutures, and the outer layer renal parenchyma was sutured with absorbable sutures. operative characteristics and complications were compared between groups. results: laparoscopic partial nephrectomy was successfully completed in all forty-six patients without open conversion. control and v-loc groups were equivalent in demographic and tumor characteristics. no signifi cant diff erence was seen between control and v-loc groups in operative time ( vs. min, p = . ), estimated blood loss ( vs. , p = . ), warm ischemia time ( vs. min, p = . ), and complication rate ( % vs. . %, p = . ). conclusion: lpn with v-loc sutures for renorrhaphy is safe and feasible. however, using v-loc suture for renorrhaphy doesn't show any superiority in patients with low and moderate complexity renal tumors in our randomized control trial. small th e local recurrence free survival was signifi cantly better in the combined us/ct-guided group than in the us-guided group (p= . ). recurrences were found in % with us/ct-group and in % in usgroup. th e overall complication rate was similar (us/ ct % versus us %) in both groups. th e mean percentage decrease in the estimated glomerular fi ltration rate (egfr) aft er the treatment was . ± . % with us/ct, compared to . ± . % mean decrease in egfr aft er treatment in the us-guided group (p= . ). conclusion: th e use of combined us/ct-guidance when performing renal rfa resulted in superior primary and short term outcome compared to the use of us-guidance alone in patients treated at the same institution. increased experience with rfa treatment probably also contributed to the results. introduction and objective: to present our initial experience in female patients undergoing transvaginal notes-assisted laparoscopic partial nephrectomy (pn). between august and january , a prospective analysis of the initial ten patients who underwent transvaginal notes-assisted pn was entered into an institutional review board (irb)-approved database. th e procedure was performed using two umbilical trocars and one trocar through the vaginal wall. th e main renal artery clamping, segmental renal artery clamping and unclamped pn were performed depending on the circumstances of the tumour. some perioperative parameters including operative time, warm ischemic time, blood loss, and perioperative complications were recorded. sexual function was assessed with the female sexual function index (fsfi) questionnaire before and aft er surgery. th e cosmetic results were investigated by administering patient scar assessment questionnaire and scoring system (psaq). results: nine transvaginal notes-assisted pns were completed successfully. one patient with a right anterior upper-pole tumor was converted to radical nephrectomy because of persistent bleeding from the parenchymal defect. th e median (range) operating time was ( - ) mins and the median (range) estimated blood loss was ( - ) ml. th e median (range) warm ischaemia time (wit) was ( - ) mins. th e median (range) postoperative hospital stay was ( - ) days. all surgical margins were negative. eight patients completed the fsfi questionnaire, and analysis did not show diff erences in fsfi scores before and aft er surgery. th e better cosmesis results were confi rmed by the psaq score. transvaginal notes-assisted pn is a safe and feasible surgical procedure in the treatment of small renal mass with excellent cosmesis results. more prospective studies with long follow-up are needed to investigate the oncologic safety. introduction and objective: to analyze the complications of urologic transvaginal natural orifi ce transluminal endoscopic surgery (tv-notes), and to explore eff ective measures for its prevention and management. materials and methods: from may to february , a total of cases underwent tv-notes in our institute. intraoperative and postoperative complications were graded according to satava and clavien-dindo grade classifi cations system. th e major complications and their treatments were most importantly analyzed. results: among the tv-notes procedures, case conversion to open surgery and one case conversion to suprapubic-assisted laparoendoscopic single-site surgery (sa-less). th irty-one ( . %) patients had intraoperative complications, the minor and major was ( . %) and ( . %), respectively. th e intraoperative complications include cases of pneumoderm, cases of skin ecchymosis, cases of pleural damage, cases of liver injury, case of adrenal central vein injury, cases of spleen injury, cases of inferior vena cava injury, cases of renal veins injury, case of right iliac vein injury, case of bladder injury, case of renal collecting system injury, cases of colon injury, case of rectum injury. th e proportion of patients incurring minor and major postoperative complications undergoing tv-notes was . % (n = ) and . % (n = ), respectively. th e postoperative complications include case of adrenal crisis, cases of incision infection, cases of postoperative fever, cases of postoperative bleeding, case of the right external iliac artery thrombosis and case of urinary leakage. no intraoperative and postoperative deaths occurred. conclusion: tv-notes operation is safe and feasible surgical technique in urology, and does not increase the incidence of complications. but there is a potential risk of major complications occurring, which should be paid more attention to prevent. introduction and objective: knotless barbed suture, a relatively innovative type of suture, can eliminate knot tying, speed the placement of the sutures, and create the possibility of improved scar cosmoses. th e minimally invasive radical prostatectomy (mirp), as one of the earliest surgeries that adopted this advanced technique, was reported about diverse eff ects on the patients and the surgeons. our objective is to present the available evidence about the effi cacy and safety of barbed sutures in minimally invasive radical prostatectomy. we searched pubmed, em-base, and cochrane library for published studies and clinicaltrials.gov for additional information to identify randomized controlled trials (rcts) and cohort studies addressing the application of barbed and conventional sutures in mirp (until feb. ) . quality assessment was performed according to cochrane recommendations. th e data were analyzed using review manager (version . ), and sensitivity analysis was performed by sequentially omitting each study. hemi-pelvises, . % had the periprostatic plexus (ppp) as the largest vein of the dvc. th is was followed by the obturator vein (ov) ( . %), which originates from the lateral part of the plexus and runs laterally. next was the internal pudendal vein (ipv) ( . %), which originates lateral to the posterior part and runs postero-laterally. in the rp group, the dvc bunching stump was an average of . mm from the origin of the cavernous vein. no complications occurred while performing examinations. conclusion: d-ct pelvic venography depicted the dvc and its related veins in all cases. venous systems making up the dvc diff ered among patients. in . %, the main venous system was the ppp, which can be controlled by conventional dvc ligation technique. however, in the remaining % of hemi-pelvises, the ipv and the ov were the main venous systems. th ese will need wider ligation because of existing outside and to the back of pathways. we believe that a better understanding of dvc will lead to refi ned rp. introduction and objective: bladder pheochromocytoma and carcinoid tumors are rare neuroendocrine tumors of the bladder. presenting a series of cases of these rare bladder tumors which were managed laparoscopically. materials and methods: case was a years lady who presented with symptom of giddiness following micturition. ultrasound revealed a . cm bladder mass at the bladder base. twenty four hour urinary biochemical evaluation and mibg scan did not reveal any abnormalities. cystoscopy revealed a submucosal sessile mass above the trigone. on cystoscopic bladder distension a spike in blood pressure ( / ) was noticed which fell rapidly on emptying. patient underwent laparoscopic partial cystectomy aft er weeks of alpha blockade with phenoxybenzamine. case was a years old gentleman who presented with episodes of severe headache following micturition. despite antihypertensives his blood pressures were not under control. ultrasound revealed a cm bladder mass in the left lateral wall encroaching close to the left ureteric orifi ce. twenty four hour urinary biochemistry and mibg scan was suggestive of bladder pheochromocytoma. aft er weeks of alpha blockade he underwent cystoscopy followed by laparoscopic partial cystectomy with left ureteric reimplantation. case was a years old gentleman a hypertensive who underwent an attempted turbt and subsequent hypertensive crisis and bleeding for a bladder mass in a peripheral hospital. he was stabilized and referred to our center for further management. ultrasound revealed a cm anterior wall mass. twenty four hour urinary biochemistry and mibg scan was suggestive of bladder pheochromocytoma. aft er weeks of alpha blockade he underwent laparoscopic partial cystectomy. mri has shown to be accurate in diagnosing index tumours in prostate cancer. a variety of focal therapies has been explored in treating these lesions. th is study aims to compare the detection rate, grade and location of non-index lesions found in radical prostatectomy specimens with their initial mpmri. a prospective database of all men undergoing mpmri for suspicion of prostate cancer in our group practice was kept. ethics approval was obtained from epworth healthcare. of these men, all who had a -d summary diagram including pirads score for each mpmri and who then underwent radical prostatectomy were assessed. volumetric studies were performed for all prostatectomy specimens and compared to each corresponding mpmri -d summary diagram. analysis of non-index lesions was performed. conclusion: a signifi cant amount of patients who underwent radical prostatectomy in treatment for prostate cancer were identifi ed to have non-index tumours in their volumetric analysis. in our cohort of patients, the majority of low grade disease was undiagnosed on mpmri. however, a signifi cant amount of moderate grade non-index tumours were also missed on initial mpmri. th is questions the safety and appropriateness of focal therapy. ongoing research is warranted and we will continue to report our prospective mp-mri database as our experience with this modality grows. eligibility for active surveillance of prostate cancer and functional outcomes after prostatectomy shepherd a , , o'callaghan m , , introduction and objective: we aimed to compare the outcomes following radical prostatectomy (rp) of active surveillance (as) and non-as candidates. we hypothesised that as eligibility at diagnosis would be associated with favourable pathological, surgical and also functional outcomes. using a prospectively maintained database, all patients with a primary treatment of rp conducted prior to were identifi ed, including those who were initially eligible for as. men defi ned as eligible for as were those: diagnosed between and years of age; with gleason score ≤ ; psa ≤ ; clinical stage ≤ a; and with percentage of positive cores ≤ %. we compared the histopathological and functional outcomes of the two groups. results: of patients with a primary treatment of rp, met the criteria for as. pre-operative tumour characteristics of the patients meeting criteria for as were favourable compared with those ineligible (lower psas and less cancer in the biopsies; p< . ). functionally, the groups had similar pre-operative continence ( % vs. %) and potency rates ( % vs. %). histologic characteristics of the prostate specimen in patients qualifying for as were more favourable, with lower rates of positive surgical margins and extracapsular extension observed in this group (p< . ). following rp, at -, -and -month follow-up, there were no signifi cant diff erences in the proportion of men who were continent between as and non-as candidate groups ( months: % vs. %; months: % vs. %; months: % vs. %; p> . ). similarly, no signifi cant diff erences between groups were observed in the proportion of men who were potent at -and -month follow-up ( months: % vs. %; months: % vs. %; p> . ). aft er -month follow-up, however, potency appeared to be higher for the as candidates ( % vs. %; p= . ). were assessed pre-implant as well as at , , and months aft er seed implantation, and every months thereaft er. we evaluated clinical factors, including prostate volume (pv), neoadjuvant combined androgen blockade (cad), radiation dose to % of the prostate volume (d ), and to % of the urethral volume (ud ) to predict urinary disorders aft er brachytherapy using multivariate analysis. results: th e mean pre-implant ipss was . , with the greatest mean score of . at month aft er seed implantation. at , , , , and months, the mean ipss had decreased to . , . , . , . , . and, . respectively. th e mean pre-implant prostate volume (pv) was . g, followed by . g at months and . g at months aft er brachytherapy. in cases with pv more than g, d more than gy, and ud more than gy, ipss levels were signifi cantly high-er even years aft er treatment. on multivariate analysis, d more than gy (p< . ) and ud more than gy (p= . ) were independent predictors for ipss increases of more than points at years aft er brachytherapy. only d was an independent predictor at (p< . ) and years (p= . ) aft er brachytherapy. introduction and objective: metformin has been shown to be protective in prostate cancer (pc). we aimed to assess the eff ects of metformin on pc outcomes in men treated with external beam radiotherapy (ebrt) and/or androgen deprivation th erapy (adt). we also aimed to investigate the eff ects of metformin on the above outcome measures in type diabetic men with pc. th e outcome measures of time to biochemical failure (bf), metastasis, pc specifi c mortality and overall mortality were analysed in men on metformin using a competing risk model and a cox proportional regression model. a total of eligible cases, of whom were on metformin, were identifi ed with a median follow-up of . months. th ere were no diff erences in age, initial psa, gleason scores, t stage, d' amico risk or duration of adt between men who were on metformin and those not on metformin. treatment with metformin did not result in any apparent improvement in time to bf, time to metastases or overall survival but there was an increase of . fold in pc-specifi c deaths (p< . ) in men on metformin and adt when adjusted for cancer risk and co-morbidities. on a subgroup analysis of the men with type diabetes, similar fi ndings were seen with metformin being associated with a . fold increase in pc-specifi c deaths (p < . ). th ese adverse eff ects were lost in men on metformin and statins. conclusions: th e use of metformin did not improve time to metastases, time to bf or overall survival in men undergoing ebrt +/-adt for pc with curative intent. however, in type diabetic men on high doses of metformin there was an increased risk of pc-specifi c mortality. further studies are needed to investigate these fi ndings. th e objective of this study is to assess ire eff ects in prostate tissue and to correlate ire treatment planning with the d-histopathology of radical prostatectomy (rp) specimens that essential structures will be spared. sixteen patients, scheduled for rp, ire procedures were performed weeks before rp. ablation was performed according to two protocols: focal or extended ablation. th e electrode probes were inserted transperineally under ultrasound guidance. th e locations of the electrodes were used as input for the plannings soft ware. following rp, the specimens were processed into whole-mount sections, were histopathologically (pa) assessed and ablation zones were delineated. th e volumes of tissue alteration were determined by adding the delineated areas. th e planned and pa ablation volumes were compared using the pearson correlation coeffi cient. results: th e d volumes of the ablation zones follow the planned lesions volumes with a pearson correlation index r= . with a slope of . ( figure ). th e focally planned ablations results in a volumetric smaller histopathological ablation zone than predicted whereas the extended ablations result in volumetric larger ablation. pa showed sharply demarcated fi brotic and necrotic areas with mild infl ammation. th e urethra was aff ected by the ire treatment in nine mp- . , figure . correlation of ablation volumes t -weighted mri and ceus with h&e pathology (pa) mp- . , figure . scatterplot of planned ablation zone volumes compared with volumes in histopathology patients were observed throughout the neurovascular bundle in thirteen prostates and extended beyond the prostatic capsule in twelve cases. conclusion: ) ire in prostates results in sharply demarcated lesions with fi brotic and necrotic features, but may damage essential structures as urethra, capsule and nerves. ) th e actual ablation zones on d-histopathology follow reasonably the planned ablation zones. ) focal ablation protocols lead to a smaller ablation zone than extended ablation protocols. therapeutic all patients treated at our institution with primary pca t - , n , m were included provided they did not present with a long history of adt. patients were stratifi ed into groups according to their psa nadir occurring between - weeks following hifu. group a (n= : nadir < . ng/ml), group b (n= : nadir > . - ng/ml ng/ml), group c (n= : nadir > ng/ml). th e primary endpoint of our analysis was the onset of any salvage therapy other than hifu. repeat hifu can be performed without undue additional morbidity and is standardly not considered as salvage therapy but rather an adjuvant to the index hifu. multivariate analysis was performed to determine what predicts onset of salvage therapy. results: at inclusion: . % of patients were t and . % were t . outcomes are summarized in table . conclusion: group a (nadir < . ) showed % salvage treatment free survival without adt; preoperative high gleason, high initial psa and "no turp" were negative predictive factors for outcome; % of the patients had nd hifu treatments in follow-up; in case of salvage therapy most patients opted for adt. metastasis-free survival of % at and % at years excludes turp in pca as potential metastasis-inducing factor. combined "turp and hifu" showed its oncological effi cacy, postponing / avoiding classical salvage therapies (rad/adt) and their potential side eff ects. laparoscopic radical prostatectomy (lrp): changing trends in practice introduction and objective: we audited our lrp outcomes in order to evaluate outcomes and how our practice has evolved over the years. we evaluate pathological and margin status outcomes and determine whether there has been a shift towards treatment of higher risk disease and the impact of this practice on margin status. a total of patients underwent lrp performed by one surgeon at our institution from june to september . we divided the cohort into early period from - (group , n= ) and - (group , n= ). results: mean age was yrs. mean preoperative psa ( . ) and gleason score (gs, ) did not diff er between groups. however, preoperative stage ≥t c increased from ( %) to ( %) for groups and respectively. postoperatively, diagnosis of gs ≥ increased from ( %) in group to ( %) in group . similarly, % of group was staged as pt compared to % of group . th ere were more extracapsular extension in group ( %) compared to group ( %). overall positive surgical margin (psm) rate was % (group , % vs. group , %). when stratifi ed according to pathological stage, psm was identifi ed in more men with pt ( %) compared to pt ( %). th e commonest site of psm was at the apex. seminal vesicle invasion rate was similar ( %). results: mean operation time and length of hospital stay for rarp and lrp were . ± . min and . ± . min, and . ± . days and . ± . days, respectively (p = . and p = . ). aft er cases, the mean operation time for rarp was similar to lrp (less than h). positive surgical margins in localized cancer were seen in . % and . % of cases in rarp an lrp, respectively (p = . ). at postoperative months, sexual intercourse was reported in % and %, and pad-free continence in % and % in patients with rarp and lrp, respectively (p = . and p = . ). conclusion: previous large-volume experience of lrps may shorten the learning curve for rarp in terms of oncological outcome. additionally, previous experience with laparoscopy may improve the functional outcomes of rarp. introduction and objective: signifi cant prostate cancer is increasingly diagnosed in younger men. th is patient group has high expectations regarding oncological and functional outcomes at robotic radical prostatectomy (rarp). we reviewed a prospective database ( rarps) at a single tertiary referral centre and obtained erectile dysfunction rates/treatment and continence pre-and post-operatively, positive margins, metastases and death. median follow-up was years. male sprague-dawley rat aged weeks were used. a total of rats were divided into two groups. one group was used as a control and other group received intramuscular injections of testosterone propionate ( mg/kg) plus β-estradiol ( . mg/kg) for weeks to induce bph. th e prostate and genitourinary organ weights, histopathologic change and serum hormones were evaluated. we compared the eff ects of ldd ( mg/kg) with tamsulosin ( μg/kg) in intraurethral pressure responses induced by es of the hypogastric nerves. we performed western blotting for alpha a and d receptor of adrenergic nerve. results: bph-induced rats showed signifi cantly increased absolute prostate weight and prostatic index (prostate weight/body weight x ), increased testosterone, free testosterone and estradiol levels in the serum. histomorphology also showed that epithelial cell layers in the prostates of bph-induced rats were larger than control groups. ldd and tamsulosin signifi cantly inhibited the intraurethral pressure elevation induced by es of the hypogastric nerves. alpha d and alpha a adrenergic receptors in bph rat model were expressed more than control. ldd decreased expression of alpha d adrenergic receptor than control. conclusions: th is study suggested that ldd could be an alternative medicine to treat bph inducing lower urinary tract symptoms. does according to recent studies, atherosclerosis has a key role in the pathogenesis of bph. th erefore, we evaluate the correlation between prostate volume and intima-media thickness (imt) of carotid artery in diabetic bph. from january to august , patients with dm were analyzed, retrospectively. baseline characteristics and diabetic profi le were collected. mean intima-media thicknesses (imt) were collected using carotid doppler ultrasound. and prostate volume (pv) was measured by transrectal ultrasound. two groups were analyzed using lineal regression analysis. results: th e patients were classifi ed into group (n= , . %) and into group (n= , . %) based on the presence of bph. th ere were statistically signifi cant diff erences on bmi, waist circumference and hba c between the two groups (table ) . th ere is a signifi cant correlations between imt and pv and imt and transition zone (tz) (p= . , p= . , figure ). porting symptoms listed on the otc label as reasons for not using the product; traces of glucose, leukocyte, and/or blood in their urine; or an aua-si score ≥ . conclusion: pvp has demonstrated acceptable complication rates compared to traditional turp in treating bph in a cohort of men having a greater frequency of comorbidities and in those having to remain on oral anticoagulation. th is makes pvp an attractive alternative to turp in such men particularly if symptomatic relief and re-treatment rate in the longer term is demonstrated to be equivalent. prospective study of high-risk patients undergoing photovaporisation of prostate (pvp) without cessation of oral anticoagulants ow d , papa n , sengupta s , , lawrentschuk n , , , bolton d introduction and objective: greenlight laser photovaporisation of the prostate (pvp) is suggested to be safe to perform on high risk patients requiring surgical intervention in the management of benign prostatic hyperplasia (bph), where cessation of oral anticoagulation is not possible due to medical comorbidities. we prospectively evaluated the outcomes of patients who underwent pvp with ongoing oral anticoagulant therapy. materials and methods: between january and december , patients with ongoing oral anticoagulant therapy were treated with pvp. types of oral anticoagulants were recorded and perioperative outcomes were collected. th ese metrics included transfusion rate, duration of hospital stay and laser treatment variables. ninety-day readmissions also were recorded as were complications of treatment. results: sixty-two patients were treated by greenlight laser pvp while taking oral anticoagulants. out of this total, patients ( . %) were on warfarin while ( . %) had ongoing clopidogrel. th e remaining were either taking one or a combination of other (non-asprin) oral anticoagulants. nine out of ( . %) patients required readmission post pvp, and all of these readmissions were for management of complications related to haematuria. five of this group of patients ( . % of total cohort) had undergone pvp without cessation of warfarin, while of patients ( . % of total cohort) had undergone treatment without cessation of clopidogrel. th ree patients ( . %) required blood transfusion. conclusions: despite continuation of oral anticoagulants in these high risk patients, the readmission rate is low and transfusion rate is similar to what has previously been reported for conventional turp in patients without anticoagulation. greenlight laser pvp is a viable option for surgical management of bph in patients for whom cessation of oral anticoagulant therapy is contraindicated. introduction and objective: cystinuria is a rare, chronic condition characterised by recurrent urolithiasis. th e condition is due to a variety of genetic mutations in an amino acid transporter and accounts for between . - percent of urinary tract stones. cystine urolithiasis may be treated by preventative medical therapy or therapeutic urological intervention. it is the authors' experience that patients tend to shy away from long-term medical treatment, possibly due to a perceived lack of effi cacy or poorly tolerated side-eff ects. as with all chronic conditions, quality of life for cystinuric patients is expected to be diminished. sub-optimal medical therapy and the need for repeated urological intervention is expected to have a further impact on quality of life. th e authors seek to describe the natural history and quality of life in patients with cystine urolithiasis. th is in turn allows further improvements to the standard-of-care off ered to such patients. a cohort study was carried out involving participants recruited from a single surgeon's case mix. participants suff ering from cystinuria and related urolithiasis were invited to complete a questionnaire involving demographic information, use of medical treatment, surgical interventions and the sf- quality of life survey. attitudes towards the use of current and potential future medical treatments were also explored. results: fourteen participants completed the survey. th e sf- survey showed lower quality of life than the general public in of domains. th e mean interventional rate in patients with cystinuria was . procedures per patient. most patients reported previ-ous use of d-penicillamine and urinary alkalinisation medications, with most ceasing due to side-eff ects or lack of perceived effi cacy. conclusion: cystinuria is associated with a high rate of surgical intervention and lower quality of life than the general public. individuals with this condition report that medical management is either ineff ective or poorly tolerated. th ere is a need for further improvements in medical management of cystinuria, to reduce the rate of operative intervention. recommendations to guide clinical practice, based on patients' experience of cystinuria management can be made. dipstick results: a total patients were retrospectively reviewed for the ph results. th e mean diff erence in ph between spot urine value and the -hr collection values was . ± . ph. higher ph was associated with lower accuracy (p < . ). th e accuracy of spot urine samples to predict -hour ph values of < . was . %, . % for . to . and % for > . . samples taken more than days apart had only % the accuracy of more recent samples (p < . ). th e overall accuracy is lower than % (p < . ). infl uence of diurnal variation was not signifi cant (p = . ). conclusions: spot urine ph by dipstick is not an accurate method for evaluation of the patients with urolithiasis. patients with alkaline urine are more prone to error with reliance on spot urine ph. relationship is the fi rst lithotripter on the market with a unique design that allows for a dual focus system with the option of either a narrow or wide focal zone. ex vivo data on the slk-f lithotripter shows that the disintegration capacity and the renal vascular injury are independent of the focal diameter of the sw generator at the same peak positive pressure and disintegration power. th e objective of this study is to compare the single-treatment success rates of narrow and wide focal zones for the shock wave lithotripsy of renal stones. a total of patients with previously untreated radio-opaque solitary stone located within the renal collecting system, measuring at least mm, were randomized to receive narrow or wide focus lithotripsy while maintaining a constant overall energy level. patients were followed with kub x-rays and renal ultrasound at and weeks post lithotripsy to assess stone area and stone free status. urinary markers indicating the degree of renal cellular damage (microalbulin and beta microglobulin) were measured pre and post swl, hours post swl and days post-treatment. primary outcome was success rate, defi ned as stone-free or adequate fragmentation (sand and asymptomatic fragments <= mm) at months post-treatment. mp- . , figure . introduction and objective: despite being uncommon, infantile kidney stone remains a major health problem due to its higher recurrence rate and morbidity. th e parents usually notice that their infants have recurrent fever and failure to thrive of unknown origin. th ose patients comprise a big challenge for the urologist in management. th erefore, this study aimed to evaluate the outcome of shockwave lithotripsy (swl) in management of renal stones in infants. a retrospective analysis of prospectively collected data performed between january and december for infants underwent swl for single radio-opaque renal stones ≤ mm at a single stone center. swl was performed with dorneir s lithotripter with a maximum of shocks per session. a single session was indicated for each infant, but a second session was performed when satisfactory disintegration was not achieved. follow-up based on urinalysis, urine culture and sensitivity, plain x-ray kidney ureter bladder (kub) and abdominal ultrasonography (us) was carried out weeks post swl and monthly for successive months. multislice computed tomography (msct) was performed -months post-swl to confi rm the stone-free status. results: a total of infants, less than months of age were enrolled in this research. swl success was defi ned as absence of any residual fragments on msct months aft er the last session. stone free rate was . % aft er the fi rst swl session and reached % aft er the second session. rate of retreatment with second session of swl was . %. urinary tract infection (uti) was detected in . %, transient renal obstruction with low grade fever in . % of infants and no major complication had been recorded. conclusion: th e new generation of swl technology with a precise focal area seems to be safe and eff ective in management of kidney calculi in infants. stone introduction and objective: th e incidence of abdominal discomfort is frequent during pregnancy, but renal colic is infrequent. one of the main causes of renal colic during pregnancy is urolithiasis. managements of urolithiasis during pregnancy are hydration, antibiotics, ureteral stent insertion, percutaneous nephrostomy, and ureteroscopic stone removal. in this study, we assessed the reliability and stability of ureteral stent insertion to pregnant patients with renal colic. results: th e overall mean patient age ( years), male to female ratio ( . : ) and mean asa score ( . ) did not vary signifi cantly between years. admissions for elective renal stone procedures, adjusted for population, increased % over the study period. th is growth was entirely in the last years, corresponding with a -fold increase in the use of pyeloscopy (from to cases per year). from the fi rst to last year, there was a % reduction in eswl (from to cases per year) and a % increase in pcnl (from to cases per year). nephrolithotomy ranged from to cases per year. th ere has been an increase in the proportion of associated ureteric stent insertions from % to %. th e proportion of day-only admissions has decreased from % to %. th e average government assigned cost per admission has increased %. conclusion: victorian public hospitals have seen a rapid expansion in the use of pyeloscopy and laser for treatment of renal stones. th is corresponds with a signifi cant increase in admissions for elective renal stone treatment, relatively fewer day-case admissions, higher treatment costs and more associated stent isertions. introduction and objective: th is retrospective study assessed the semirigid ureteroscopy approach coupled with ballistic or ho:yag laser lithotripsy for the treatment of proximal ureteral stones. patients with a single lower calyceal stone with an evidence of a ct diameter between and cm were enrolled in this multicentric study. exclusion criteria were the presence of coagulation impairments, age less than or more than , presence of acute infection, presence of cardiovascular or pulmonary comorbidities. patients were randomized into three groups: group a: patients treated with swl; group b: patients treated with rirs; group c: patients treated with pcnl. patients were controlled with abdomen x-ray and ct scan aft er months. a negative x-ray or an asymptomatic patient with stone fragments less than mm big and a negative urinary colture were the criteria to assess the stone-free status. a statistical analysis was carried out to assess patients' data, success and complications rates, re-treatment rate and need for auxiliary treatment. radiotherapy is an eff ective and common treatment for the prostate cancer. however, there is still an historic deep rooted fear of its use due to the existence of late genitourinary toxicities such as the radiation cystitis. nowadays these toxicities may pose less of a threat due to the use of newer radiotherapy techniques and the reduction of radiation doses applied to the tissues adjacent to the tumor. th e objective of our study is to fi nd predictive factors and determine the cumulative incidence of overall and severe radiation cystitis. conclusion: radiation cystitis is a feared complication of the use of radiation therapy in prostate cancer which occurs infrequently, and the severe cases requiring hospitalization are very rare. th e characteristics of the tumor, purpose of radiotherapy used or radiation dose applied do not seem to infl uence the incidence of radiation cystitis. introduction and objective: th e aim of the study was to assess prognostic factors of biochemical and radiological disease progression (dp) in subgroup of lymph node (ln) positive prostate cancer (pc) pts. evaluation of detection rate of ga-psma pet/ct for biochemical recurrence after radical prostatectomy introduction and objective: prostate specifi c membrane antigen (psma) is overexpressed in more than % of all prostate cancers (pca). since the introduction of pet-imaging with gallium-labelled psma, this method is regarded as a signifi cant step forward in the diagnosis for recurrent pca. from the patients that were scanned for detection of recurrent pca aft er radical prostatectomy between august and december , were evaluable for retrospective analysis. patients underwent pet/ct aft er injection with the ga-hbed-psma. th e potential infl uence of psa-level, primary gleason score (gsc) and psa-doubling time (psa-dt) on the detection rate were evaluated. results: a total of ( %) patients had pathological fi ndings on the ga-psma pet/ct, with an average psa-level of . ng/ml (range . - ng/ ml). detection rates were %, %, % and % for psa-levels < . , . - , > - . and > . respectively. if recurrent pca was detected, oligometastatic disease ( metastasis or less) was most commonly seen ( %). th e detection effi cacy was signifi cantly infl uenced (p< . ) by higher gsc ( % and %, for gsc ≤ and ≥ respectively). for the patients that were evaluated for the infl uence of psa-dt on detection rate, no signifi cant diff erence was found (p= . ) for psa-dt < months and ≥ months (detection rate % and % respectively). conclusion: ga-psma pet/ct has a high detection rate compared to prior studies of conventional imaging modalities, especially in lower range psa-levels. further research is needed to determine to assess whether localization of small volume disease on ga-psma pet/ct can improve diagnostic algorithms and outcomes in patients with recurrent pca. introduction and objective: to assess long-term results of salvage pelvic lymph node dissection (plnd) in prostate cancer (pc) patients (pts) with biochemical recurrence aft er primary local treatment and confi rmed solitary lymph node (ln) metastases. results: a total of , abstracts were screened, full-text papers were considered, and articles were included ( rct, comparative studies, and case series). th is abstract focuses on the comparative studies. primary therapy was prostatectomy in , radiation therapy in , and studies included both therapies. diff erent defi nitions of recurrence were applied among mostly retrospective studies and the adt strategy oft en not specifi ed. factors associated with unfavorable outcomes (overall, pc-specifi c, or metastasis-free survival) included higher age, higher psa nadir, higher gleason score, higher psa-dt, and early start of adt at recurrence. contradictory results were reported on the role of the length of adt aft er ebrt, partly explained by a selection of high risk cases. most patients with disease relapse aft er primary therapy seem not to benefi t from adt while side eff ects are known to be harmful. selected highrisk patients (short psa doubling time, high gleason score) however may have benefi t, and early start of adt may be preferable in this group. an intermittent adt strategy in this setting may be feasible. a rct is indicated, although diffi cult to perform. a personalized approach is warranted, taking disease characteristics, side eff ects, and quality of life into account. adt may only be given in patients with pc recurrence who have high risk characteristics. introduction and objective: locally radio-recurrent prostate cancer (rr-pca) can off er a chance of cure albeit with potential morbidities. current salvage treatment options include radical surgery and minimally-invasive ablative modalities such as hifu and cryosurgery (s-cryo). current data suggests that s-cryo can achieve disease-free survival (dfs) rates up to % at years. however, the majority of data is based on retrospective analysis with mid-term follow-up and there is still paucity of data on longterm outcomes. th e aim of this study was to analyze morbidity and oncological outcomes, with median follow-up years, of s-cryo on rr-pca patients at an academic center. figure ). adverse events were similar between the treatment arms. figure . th ese analyses demonstrates that, during the fi rst year of treatment, men treated with degarelix had a reduced risk of disease-related adverse events. th ere was also a lower risk of death, likely due to the higher incidence of cv events in lhrh agonist patients. introduction and objective: androgen-deprivation therapy (adt) appears to increase cardiovascular (cv) morbidity and mortality in men with prostate cancer, particularly in those with a history of cv disease (cvd). however, the risk is lower with the gonadotropin-releasing hormone (gnrh) antagonist, degarelix, compared with lhrh agonists. here we evaluate regional diff erences in baseline cv status in men with prostate cancer treated with degarelix or lhrh agonists and their subsequent risk of cv events. th is was a pooled analysis of data from three phase studies with a duration > months. individual patient level data on baseline cv status and subsequent cv events over year were summarized by geographic region (usa/canada vs. europe). cv event data were compared using cumulative incidence functions (with all-cause mortality as the competing risk) and cox regression analyses. canada had more severe disease and a higher cv risk (p< . ) ( table ). in men with baseline cvd, cumulative incidence ( % ci) of a cv event was . ( . - . ) in usa/canada vs. . ( . - . ) in europe (p= . ). at baseline, cv status was similar in the degarelix and lhrh agonist groups (table ) . however, in those with baseline cvd, degarelix was associated with a lower risk of subsequent cv events vs. lhrh agonists in both regions (hazard ratio [ % ci]: . [ . - . ]; p= . ). conclusions: men in the usa/canada with prostate cancer and cvd and who were treated with adt were more likely to experience a cv event than their counterparts in europe. th is likely refl ects the greater severity of baseline cvd and higher cv risk in these patients. degarelix reduced the risk of cv events compared with lhrh agonists in both regions. introduction and objective: androgendeprivation therapy (adt) decreases bone mineral density and may increase skeletal complications in metastatic prostate cancer. however, lhrh agonists and gnrh antagonists have diff erential eff ects on follicle-stimulating hormone (fsh), which regulates bone resorption. th e current analysis compared the eff ect of lhrh agonists and the gnrh antagonist, degarelix, on serum alkaline phosphatase (salp), a marker of bone turnover, and the incidence of skeletal adverse events (aes). conclusions: degarelix suppressed s-alp more quickly and for longer than lhrh agonists. it also reduced bone pain and was associated with a lower incidence of fractures. collectively, these data indicate that degarelix provides better control of skeletal disease in men with metastatic prostate cancer, an eff ect that may be mediated by its diff erential eff ect on fsh. prognostic introduction and objective: testosterone (t) regulates nitric oxide synthase and is necessary to achieve an optimum response to pde inhibitors for erectile dysfunction. recently, tadalafi l was found to be eff ective for treating lower urinary tract symptoms (luts) secondary to benign prostatic hyperplasia (bph). we studied the relative importance of the t level in patients with luts and determined whether the t level predicts the response to tadalafi l mg once daily for luts/bph. aft er a -week washout period, men older than years without (n= , t level ≥ ng/dl) and with (n= , t level < ng/dl) hypogonadism were given tadalafi l mg once daily for weeks. we assessed its impact and the severity of luts/bph using the international prostate symptom score (ipss) and bph impact index (bii) and ipss quality-of-life (ipss-qol) subscores. safety was assessed using treatment-emergent adverse events. introduction and objective: diabetes has been reported as a major cause in patients who complain of erectile dysfunction and is frequent in the comorbidity of severe erectile dysfunction. also, patients with diabetes are oft en poor response to treatment for erectile dysfunction. in such patients, according to the mirodenafi l (mvix ) use of the odf (oral decomposition fi lm) mg and mg was to compare the therapeutic eff ects of the treatment period. of the patients with erectile dysfunction were enrolled in a patient with diabetes. and the patients were classifi ed into two groups by randomized double blind controlled trial. th e fi rst group was to take the mirodenafi l odf mg once a daily and the second group was to take a mg at least twice one week, depending on the need to have sexual intercourse. international index of erectile function- (iief- ), international prostate symptom score(ipss) were examined for each time of initial visit, weeks, weeks, weeks. th e questionnaire items of two groups were analyzed at each time point. total of patients were included in the study. th e patients who were taking once a daily were and the patients taking when needed were . th ere was no signifi cant diff erence between age, iief- score, and ipss of each groups on initial visit. ipss score and quality of life score was lowered gradually all aspects in the two groups. iief- score was a tendency to increase in all categories. in comparing the two groups at weeks, once a day group showed a signifi cantly higher score than the group taking when needed for the questionnaire of erection confi dence, erection times, iief- total score(p< . ). th ere was no diff erence between two groups at weeks, weeks. in addition, this study showed the similar therapeutic eff ect between the two groups at end point of continued treatment during the weeks. conclusion: aft er daily dose method weeks, at least twice weekly dosing method and daily dose method is determined to exhibit the same eff ect. th erefore, we think that it is possible to change the intermittent dosing from daily regimen aft er two months. introduction introduction and objective: phosphodiesterase inhibitors (pde i) are the established fi rst line therapy for most cases of erectile dysfunction(ed). it is estimated that - % of ed patients may drop out and discontinue the usage of these drugs. th is study aims to evaluate the patient perspective of discontinuation of on-demand tadalafi l mgm and switching to daily tadalafi l mgm for ed. th e study comprises men with median age years suff ering from ed of average . years duration. co-morbidities included: hypertension ( %), diabetes ( %), dyslipidemia ( %) and smoking ( %). th e primary indication for usage of on-demand tadalafi l mgm was ed. all the patients had used mgm tadalafi l on demand on more than occasions over the last months. results: th irty-eight out of men opted to discontinue on-demand mgm tadalafi l and switch to daily dose mgm tadalafi l. a detailed interview was conducted to identify the reasons for this switch over. th e salient factors were: ) unsatisfactory clinical response to on-demand dose ( %), ) adverse eff ects with on-demand dose ( %), ) concomitant improvement in luts ( %), ) economic factors-daily dose therapy is cheaper than on-demand ( %), ) freedom of spontaneous sexual activity with daily dose ( %), ) patient perception of daily dose as a long-term cure for ed ( %), ) combination of above factors ( %). overall % of patients planned to continue daily dose tadalafi l mgm. conclusion: daily dose tadalafi l mgm appears to be preferred by patients over on-demand mgm tadalafi l for ed treatment. and plateaued aft er two years. in % of men, iief-ef improved by category, in % by and in % by categories. five men remained within the same category despite slight improvements in score, man's score dropped from to changing from "no ed" to "mild ed". fift y six percent men achieved normal erectile function. conclusions: improvements in erectile function were clinically meaningful and signifi cant during the fi rst to years of t therapy and sustained during the full treatment duration. th ey were independent of obesity class. it may be necessary to continue t therapy for to years before an optimal response is achieved. hypogonadal conclusion: all changes were clinically meaningful and sustained for the full observation period, despite the fact that patients' age increased by years. t therapy seems to be highly eff ective in hypogonadal men with t dm, improving both erectile function and glycemic control. needle-free delivery of intracavernosal injections: proof of concept introduction and objective: intracavernosal injection is a well-established second line therapy for the treatment of erectile dysfunction (ed) and has shown very high success rates. despite this, intracavernosal injection is not a therapy suited to all patients for a number of reasons including needle phobia (trypanophobia), pain, and anxiety with self-needling. th e development of needle-free injectable devices has been heralded as a promising advance in the administration of certain vaccines and parenteral medications. initial research into the use of these devices in the delivery of intracavernosal injections however showed inferiority to needle-tipped injectors in terms of efficacy and pain scores. th e use of needle-free injection devices is not currently recognised for the administration of intracavernosal injections. it was the aim of our study to investigate the ability of contemporary needle-free injection devices to successfully deliver intracavernosal injections. two diff erent needle-free injection devices were used to inject . mls of methylene-blue solution into the corporal bodies of a number of australian brangus bullock penises; the bioject®ze-tajet™(spring-loaded fi ring system) and biojector® (pressurized co fi ring system) were used. both products are produced by bioject medical technologies inc., california, usa. all the available syringe depths were used for each device, and compared with the injection of the same volume of methylene-blue with an insulin syringe as a control. following injection, a cross-section of the penis was taken, and the depth of penetration observed macroscopically. results: despite the comparatively thicker and denser tunica albuginia of the bullock penis, the pressurized co device successfully delivered the solution into the corporal body, through the tunica. none of the syringes from the spring-loaded device penetrated the tunica. we have shown that contemporary needle-free injectable devices can in theory be used to administer intracavernosal injections successfully. th e bullock penis model may not be the ideal model for the human penis but we are currently in the process of performing human cadaveric experiments with these devices. needle-free injection devices may be very useful in the administration of intracavernosal injections in the future and extend the use of these therapies to a wider population of patients. penile linear shock wave therapy for poor responders to prior erectile dysfunction therapy ( ), ici with alprostadil ( ), vcd ( ) and muse ( ) . all these patients opted to discontinue these regimen due to unsatisfactory erectile improvement or side eff ects. th ese patients were treated with lswt by renova device with four weekly outpatient sessions without any analgesia or preparation. lswt was applied to four anatomical sites (right, left crura, and right, left corpus cavernosum) at shocks per minute, total shocks per session. patients were followed up at and months aft er the last session. results: at one month follow up statistically significant improvement in iief was recorded in patients ( %) from mean score of . at baseline to . .th e improvement was maintained at months .no side eff ect was noted. overall % patients expressed satisfaction with lswt irrespective of the clinical outcome. conclusion: lswt appears to be a safe and eff ective noninvasive, offi ce based therapy in the management of diffi cult to treat poor responders to prior treatment of ed. introduction and objective: hypogonadism and sexual dysfunction are common clinical presentation in male liver transplant candidate. th e aim of the study was to evaluate the eff ects of living donor liver transplantation (ldlt) on testosterone, sex hormone-binding globulin (shbg), free androgen index (fai) and erectile function in ldlt recipient. introduction and objective: penile size has been a source of major concern and anxiety to the male population since several years. diff erent methods for increasing penile size have been described in the literature, such as, pubopelvic liposuction, lipectomy, suspensory ligament dissection, z-plasty, v-yplasty and injections. combining some of these techniques may be more eff ective to improve the length of the penis. in this study, patients were underwent the combination of z-plasty and suprapubic lipectomy for increasing penile size. between and , patients who complained decreased penile size were underwent surgery. z plasty and suprapubic lipectomy were performed to each patient. informed consent was provided by all participants. th e outcomes were assessed based on the preoperative and postoperative penile length in the fl accid state at maximal stretch and patient-partner satisfaction. th e paired student t test was used for statistical analysis. results: median age of the patients was . ( - ) years. th e etiologies were congenital micropenis in ( %), concealed penis in ( %), previous penile surgery in ( %) and epispadias in ( %) patient. mean preoperative and postoperative penile lengths were . cm ( - cm) and . cm ( . - cm) respectively. th e mean increase in stretched penile length was . ± . cm (minimum . cm, maximum cm) (p< . ). th e patient and partner satisfaction rates were . % ( / ) and . % ( / ) respectively. only one postoperative complication was detected. th is was a wound infection at suprapubic incision site. conclusions: based on our results, the combining of the penoscrotal z-plasty and suprapubic lipectomy is a safety, eff ective and satisfactory procedure for lengthening of the penis in selected cases. corporal lengthening with infl atable penile implants : - ( ) ). recently, we have developed a new technique that combines key aspects of these approaches to create a minimally invasive, no-touch ("mint") technique for penile prosthesis insertion. we theorized that the mint technique would take advantage of the benefi ts that each of these established approaches off ered and therefore our aims were to assess feasibility, safety, post-operative hematoma and infection rate and percentage of patients cycling the prosthesis by weeks. th e principles of the mint technique involve a small infrapubic incision approach combined with a no-touch technique facilitated by using standard surgical drapes ( x clear non-adhesive drape and x ioban® drape) and an alexis® wound retractor. we present results for our fi rst consecutive patients undergoing primary prosthesis implantation from may -july with at least months follow-up. patients having revision surgery, or with complex surgery necessitating > incision were excluded. data was collected using a prospective database. results: average age (±sd) was . (± . ) years. median follow-up was . months. patients had one or more of the following etiologies for erectile dysfunction: vascular disease (n= ), post-radical prostatectomy (n= ), diabetes (n= ), peyronies disease (n= ), venous leak (n= ) and priapism fi brosis (n= ). seventy percent had used intracavernosal injections. implant used: coloplast titan (n= ), american medical systems (lgx; n = ), (cx; n = ). th e average (±sd) cylinder and rear tip extender length was . (± . ) and . (± . ) cms respectively. all operations were completed successfully and there were no peri-operative complications necessitating intervention or re-operation. th ere were post-operative hematomas (treated conservatively). sixty-fi ve percent could cycle prosthesis by weeks. th ere were no post-operative infections. conclusion: th e mint technique for penile implant surgery is a safe and feasible procedure with a zero infection rate in our fi rst patients. effi cacy and safety of botulinum th e initial number of patients to be recruited were twenty-six, but actual patient enrolment was eleven (six control and fi ve botulinum toxin a). all of the patients had a history of vulvar pain for more than six months despite proper medical treatments. patients were randomly assigned to two groups: control -saline injection, toxin -botulinum toxin a (meditoxin® injection, meditox, inc., korea). in both groups, areas of pain were mapped on the vestibule and injections were performed at fi ve sites to cover the entire painful area. th e dosage of each injection was - ml with a maximum cumulative total of ml. at baseline, two, four, and eight weeks aft er the injection, visual analogue scale (vas) and sf- questionnaires were scored. data was analyzed and p value was considered to be signifi cant at < . according to the mann-whitney test. results: th e mean age of patients was . ( - ) years old in the control group and . ( - ) years old in the toxin group. aft er breaking of the blinding, two of the toxin group had iu of botulinum injection, and the others had iu injections. two patients from the control group dropped out because of aggravated pain. th eir vas were and respectively at their drop-out point (baseline and , respectively). at week eight, vas was signifi cantly decreased in toxin group when compared with baseline (table ) . th ere were no drug related adverse reactions. introduction and objective: congenital anomalies of uro-genital system have increased globally as a consequence of higher maternal age at pregnancy and developments in assisted reproductive techniques in the last few decades. aim of the study was to determine the incidence of apparent congenital uro-genital anomalies in north indian newborns and factors associated with them. a prospective study was conducted to collect data of all newborns delivered at our institute between september and august . th e predetermined format included newborn's birth weight and gestational age, maternal age, parity and infertility treatment if any. newborns weighing less than gm or born before weeks of gestation were excluded from the study. results: th ere were , deliveries with , males and females. a total of apparent uro-genital congenital anomalies were recorded with an incidence of . per newborns. th e most common anomaly was cryptorchidism found in newborns, amongst others hypospadias was noted in , ambiguous genitalia in , congenital hernia/hydrocele in , exstrophy-epispadias complex in and prune belly syndrome in newborn. newborns weighing less than , grams had a higher proportion of anomalies ( . %) in comparison to those weighing over , grams having . % (p = . ). maternal age (> yrs), parity (> ) and infertility treatment were recorded in . %, . % and . % respectively and all were independently associated with increased risk of uro-genital anomalies (p= . ). conclusions: incidence of apparent congenital uro-genital anomalies was . %. infertility treatment, parity (> ) and maternal age (> years) were independently associated with increased risk of congenital uro-genital anomalies. comparison conclusions: double-breasting spongioplasty is very good method to decrease complications in hypospadias repair, so it is recommended an as interposing tissue in tipu. advantages of the double breasting spongioplasty are that avoiding of suture line and adding two layers of spongiosum over neourethra decreases the chances of urethral fi stula and gives cylindrical shape to neo-urethra. use stretched penile length (spl) is the standard measurement used in reconstructive penile surgery (rps), but is associated with high inter-rater variability, and is seldom reported. furthermore, ruler-based measurements require that all measurements be made intraoperatively; post-hoc measurements are diffi cult to impossible. we used a novel smartphone application to assess the correlation of post-op digital-photo based length measurements to intra-operative ruler measurements. th congress of the sociÉtÉ internationale d'urologie -siu abstract book materials and methods: intra-operative spl was measured in a consecutive series of pediatric patients undergoing rps who agreed to participate in this study. spl was measured intra-operatively (spl-io), and a picture was taken, with the ruler and from a true lateral view, as proof. a second digital picture was taken at the same time, with a reference object (obj) (object whose dimensions are known and constant). post-op, spl was later measured using the medmeasure! app for iphone and ios android, using the picture with obj, by two diff erent surgeons blinded to intra-op measurements. th e three diff erent measurements (intra-op spl (spl-io), and post-op using the app (spl-s -spl-s ) were then compared to assess overall correlation and correlation to ruler measurements using spss . statistical soft ware package. results: twenty consecutive patients underwent surgery for hypospadias (n= ), buried penis (n= ), epispadias (n= ) and circumcision accident (n= ). median age at surgery was months [ - ]. median penile spl-io was . cm [ . - . ]. when ruler-based measurements (spl-io) and app-photo based measurements were treated as independent measurements (students t test), there was no statistical diff erence between any of the three groups (p . - . ). even with spl-io measurements were treated as the gold standard, by bland-altman limits of agreement analysis, the correlation factor of spl-ip to spl-s & spl-s was > %. conclusions: when compared with intraoperative measurements, digital measurements using medmeasure! are reliable and precise, provided that the picture is taken from a true anterior-posterior or lateral view. because measurements are made based on captured images, a limitless number of length measurements (within the same plane as the reference object) can be made post-hoc. use of digital photography and this smartphone app has the potential to aid in surgical planning, improve documentation, and, facilitate clinical research. aseel's technique for distal penile and coronal hypospadius repair (simple, easy with less complications) introduction and objective: th is technique is modification of the old operation of arab that makes it very simple, easy to learn and even in cases of failure there will be no problem of redoing it or other operation because of the minimal tissue dissection. th is technique was applied in patients. first a transverse ventral incision is done parallel to the circumcision incision and cm proximal to the urethral meatus, figure ( ) . th en proximal and distal skin dissection is done, figure ( ). a longitudinal incision across the urethra plate extending through the meatus is done, figure ( ) and closed transversely that leads to urethral advancement, figure ( ). th en aided by skin hooks the distal skin edge is pulled downwards to create a roof for the advanced urethra, figure ( ) followed by closure of the skin incision, no catheter or stent is left , figure ( ). th is is a -minute operation and the patient is discharged as a day case. results: th irty-eight patients passed without complications and had loss of the skin stitches either partial in cases or complete in cases that were repaired by reapplication of the stitches, no meatal stenosis or fi stula were reported. th is is a very easy technique that can be applied as an outpatient or day case, and done in minutes, with no catheter or stent per urethra left or complications such as urethral meatus stenosis or fi stula formation. th e remained boys ( ) underwent transinguinal laparoscopy during ipsilateral herniorrhaphy. all data were collected prospectively. results: th e incidence of cppv confi rmed by transinguinal laparoscopy was . % ( / ). th e width of hernia sac and mother's age at birth were signifi cant risk factors in the univariate analysis. however, in the multivariate analysis the width of hernia (> cm) sac was only an independent risk factor for cppv (odds ratio . ; p= . ). th e laterality, type of hernia, age, preterm, low birth weight, twin, blood type, father's and mother's age at birth, and the type of delivery were insignifi cant. in this study the width of hernia sac was the independent risk factor for cppv. th is result suggests that the transinguinal laparoscopic examination is benefi cial for the detection of cppv in boys with this risk factor. however, it should be considered in the clinical practice that the one-third of boys with cppv has a narrowed width of hernia sac (< cm). low introduction and objective: traditionally bladder exstrophy complex is managed by staged repair, however now there is trend towards single stage repair. to achieve a satisfactory level of continence, secure abdominal wall closure and preservation of renal functions in patients with bladder exstrophy remains an elusive goal. objective of the study was to assess continence and functional outcome of single stage repair pediatric and adults. materials and methods: th irteen patients, boys and girls with classic bladder exstrophy were treated from to . aft er proper evaluation patients under went complete primary repair of exstrophy repair (ureteric re-implantation, bladder closure with or without cystoplasty, iliac osteotomy, neck reconstruction and epispadias repair). bladder and urethral plate was mobilized as single unit and bladder closure was done to create an adequate capacity bladder. epispadias repair was done by separating the two corpora; tubularization of urethral plate and ventral transposition of neo-urethra to create an orthotopic neomeatus. th en bilateral anterior iliac osteotomies were performed and external fi xators were applied to approximate the pubic symphysis which helps in sphincteroplasty. bladder neck was reconstructed using young dees technique and placed deep within the pelvis; sphincteroplasty was done followed by abdominal wall closure. voiding cysto-urethrography was obtained at months and at one year. continence was defi ned as dry intervals of hours or more. patients were followed-up at , , , months and annually. results: age of patients varied from days to years (mean . years). pre-operative symphyseal gap varied between - cm and post operatively the average diastasis was . cm with the range of cm to cm. in a follow-up period was months to years, patients had good results ( girl and boys) minor supra-pubic leak was present in patients which was managed conservatively, all being able to hold urine for - hours with no leaking at night. colo-cystoplasty was needed in cases with small bladder plate. overall continence rate was . % in single stage. two male incontinent patients were continent aft er second surgery. conclusions: single stage complete bladder exstrophy repair is safe and viable option for both pediatric and adult cases. augmentation enterocystoplasty is required in small bladder capacity cases. anterior iliac osteotomy with approximation of pubic symphysis improves continence and allows tension free closure of abdominal wall and sphincter. long wilms tumor (wt) represents approximately six to seven percent of all pediatric cancers and accounts for more than percent of all tumors of the kidney in the pediatric age group. recently some centers have explored the role of nephron sparing procedures in children with unilateral wilms tumors because of the concern about late occurrence of renal dysfunction aft er unilateral nephrectomy. we assessed the long-term renal functional outcome aft er parenchymal-sparing procedure for non-syndromic unilateral wilms tumor at our center. we retrospectively reviewed the records of all children with unilateral wilms tumor who had undergone nephron sparing surgery at our center. patient's long-term renal function, tumor recurrence, and survival, were determined from a review of each patient's medical record. results: a total of eight patients underwent partial nephrectomy (pn) and the remaining three with polar tumors underwent hemi-nephrectomy (hn) following chemotherapy. smaller tumor volumes were associated with not only preservation of renal function but also increase in egfr during the follow-up period. th e median preoperative egfr was ± . and median egfr at the last follow-up was . ± . . in properly selected children with non-syndromic unilateral wilms tumor, nephron sparing surgery provides excellent renal function preservation. introduction introduction and objective: hyperbaric oxygen (hbo) therapy, which increases the amount of oxygen dissolved in the blood and that carried to tissues, is used in the treatment of several disorders. hbo therapy may be a useful adjunctive treatment in the management of some of challenging conditions encountered in pediatric urology practice. in this paper, we report our experience on the use of hbo therapy in children with urologic problems. we reviewed our department's records to identify pediatric patients who received hbo therapy between and . all patients were evaluated at the department of underwater and hyperbaric medicine and informed consent was obtained from the patient or his parents. total number of hbo sessions was determined based on patient's clinical response to hbo therapy. results: eleven patients received hbo therapy during the study period. all of them were male. th e mean age was . ± . ( - years) . indications of hbo therapy were necrosis aft er hypospadias and epispadias repair, penile glans necrosis, circumcision caused penile skin necrosis, sickle cell crisis induced priapism, and testicular torsion. th e average number of hbo sessions was . ± . ( - ). nine patients ( %) healed aft er hbo therapy, but ( %) patients did not (table ) . . th e essential parameters of kegel exercise are duration of contraction and active relaxation, and, frequency of exercises. to date, exercise duration times could only be captured during in-clinic biofeedback. we hypothesized that a smartphone-based app that provides users biofeedback -and reports mean duration of contraction and relaxation, could help return to continence aft er rp. we designed/made a working prototype of such an app, and validated it. our novel app (ios) was programmed to allow users to record the duration of kegel active pfm contraction and relaxation. it also allows users to record urinary frequency, urgency, voiding, and leakage events, and number of pads used-on a daily basis. it contains a -q visual analog scale questionnaire that queries satisfaction (urinary, sexual, erectile), pain control, depression, sleep quality, and quality of life. data from the app can be "pushed" automatically by the user to a queryable custom database on a hipaa-secure server (ucsf). we provided the app to non-medical colleagues ( women/ men age - ) for evaluation. all completed mock kegel exercises using the app to measure contraction/relaxation duration, which were timed using a stopwatch. measured times were compared to duration times recorded in our database for each user. a -point likert scale was used to query the following items: ) user reported ease of use; ) privacy related anxiety related to use of such an app to submit study data wirelessly; and ) perceived usefulness of the app to improve kegel performance. results: th e pfm contraction and relaxation times recorded by the app within the wireless database disagreed with stop-watch measured duration times by mean +/-< second for all subjects. mean likert scores: . "overall ease of use" score = . (sd . ), "privacy related anxiety" score = . (sd . ), and "usefulness"= . (sd . ). conclusions: our novel smartphone app appears to allow users to accurately record key kegel exercise parameters: duration and progress. th e platform also allows collection of key patient data during daily life. a randomized controlled clinical study is warranted to further assess clinical utility, and, possible means to further enhance utility and research. safety and effi cacy of reduced dose of botulinum toxin-a for patients with detrusor overactivity place j, vyas l, watcyn-jones t, lupton b, miah s, darrad j, kumar v introduction and objective: th is prospective study was carried out to look at the response of a lower dose of botulinum toxin-a for treatment of symptoms of oab, its tolerability and side-eff ects. materials and methods: following due counselling and consenting, all newly diagnosed patients with confi rmed detrusor overactivity on uds (n= , with a mean age of . years (range= - )) were given iu of trigone-sparing, intra-detrusor botulinum toxin-a. of the total of patients, ( . %) were males and ( . %) were females. of this cohort, . % stopped anticholinergic medications because of lack of benefi t. th e rest ( . %) could not tolerate the side eff ects. th e procedure was performed in outpatient department using a fl exible cystoscope under local anaesthetic. th ese patients fi lled up a pre-treatment iciq-sf for oab as well as ui and follow-up scores at week , and . th e per-procedural pain score and follow-up urinary residual volumes were recorded. results: two ( . %) patients did not respond to the treatment at all. in the responders, average scores from the iciq-sf questionnaire fell from the pre-treatment level of . ( - ) to . ( - ) at week , . ( - ) at week and . ( - ) at week (p< . ). th e urgency incontinence scores fell from an average pre-treatment level of . ( - ) to . ( - ) at week follow-up. th e average daytime urinary frequency scores fell from . to . and nocturia scores fell from . to . . five patients went into urinary retention following intra-detrusor botulinum toxin-a injections. in the rest of the cohort, post void residuals remained largely unchanged with pre-procedure fi gure of . mls ( - ) to . mls ( - ) (p=ns). average pain score was . ( - ) on a scale of to . no symptomatic uti was found in post procedural patients. conclusions: th ese results albeit with a small number of cases, have suggested a signifi cant clinical response in over % patients with proven detrusor overactivity with a reduced dose of intra-detrusor botulinum toxin-a injections, thereby maintaining the clinical eff ectiveness of the drug and at the same time reducing the cost of delivery with possibly reduced incidence of urinary retention. prior to the initiation of intravesical onabotulinumtoxina treatment, all patients had an assessment of mid-stream urine for culture and sensitivity, renal tract ultrasound scan, subjective and objective assessments of symptoms (including iciq-ui and iciq-oab questionnaires) and conventional urodynamic study. all patients had proven overactive bladder. onabotulinumtoxina effi cacy and durability was assessed by subjective and objective assessments of symptoms. results: duration of effi cacy of onabotulinumtoxi-na injections is well maintained in the idoa group in comparison with noab group. th ese trends are shown in figure . four injections out of administered in total to the idoa group were unsuccessful ( . %) and brought no relief of symptoms to the patient. th ere were no unsuccessful treatments in the ndoa group ( / total injections administered). results: from the general practitioner's records, none of the non-traceable patients were on botulinum toxin-a treatment elsewhere. of the total number of traceable patients (n= ), ( %) stayed on mirabegron alone. of these % were satisfi ed ( / ). as a whole . % ( / ) were satisfi ed and continued with mirabegron only. one patient moved to combined mirabegron with an anticholinergic. of the patients on mirabegron iciq-sf scores fell from . ( - ) to . ( - ) at months. eighteen of ( %) patients progressed requiring botulinum toxin a treatment. side-eff ects included-palpitations ( ), vomiting ( ), rashes ( ), lethargy ( ) and yellow urine ( ) . th is study showed that % of patient with refractory oab symptoms awaiting fi rst or subsequent treatment with intra-detrusor botulinum toxin a injections will respond to mirabegron and % of these responders ( . % of total) are able to come off botulinum toxin a at months, reducing the burden of the waiting list; with a cost reduction mirabegron= £ vs cost of botulinum toxin a= £ /year/patient. th is is a small study but provides a medium-term option for patients on long waiting list for botulinum toxin a thereby helping to limit use of botulinum toxin-a for patients with detrusor overactivity. introduction and objective: patients that fail to achieve symptom improvements with sacral neuromodulation (snm) may benefi t from increased aff erent stimulation via tined lead placement at the pudendal nerve. we evaluated −year outcomes of chronic pudendal neuromodulation (cpn) in patients that had failed sacral neuromodulation (snm). adults enrolled in our prospective observational neuromodulation study that had a pudendal lead placed were evaluated. medical records were reviewed. outcomes were measured at , , and months with interstitial cystitis symptom/problem indices (icsi−pi), overactive bladder questionnaire (oabq) symptom severity (ss) and quality of life (qol), voiding diaries, and global response assessments (gra analysis of voiding dysfunction after transobturator tape procedure for stress urinary incontinence introduction and objective: voiding dysfunction is common complication of midurethral sling surgery (mus) for stress urinary incontinence. however, the defi nition of post-mus voiding dysfunction is inconsistent in the literature. subjective feeling of slow stream, signifi cant postvoid residual (pvr), additional procedure for bladder emptying, or objective fl ow rates can be a yardstick of voiding dysfunction. in this study we retrospectively investigated the risk factors for post transobturator tape procedure (tot) voiding dysfunction applying various defi nitions in one cohort. four hundred fi ft een patients were evaluated who underwent tot. preoperative urodynamic study were performed and urofl owmetry and international prostate symptom score questionnaire were investigated pre and post-operatively. several postoperatively parameters representing voiding dysfunction were adopted for analysis. acute urinary retention requiring catheterization (aur), subjective feeling of voiding diffi culty during follow-up (vd), and signifi cant postoperative pvr greater than ml or more than % of voided volume (pvr) were adopted for categorization of the defi nition of voiding dysfunction. results: sixteen patients ( . %) required catheterization, ( . %) experienced post-operative voiding diffi culty, ( . %) and ( . %) showed low fl ow rate and signifi cant pvr. in the aur and vd category, concomitant co-operation and general anesthesia were signifi cant parameters, especially anteroposterior repair of vagina. older and menopaused patients complained subjective voiding diffi culty. th e patients in vd category showed lower fl ow rates and larger pvrs. patients in pvr category had old age and low preoperative fl ow rates. th e patients with vd tend to be prescribed alpha blocker during postoperative follow-up period. th ere were no signifi cant urodynamic parameters attributing for various voiding dysfunction categories. with logistic regression analysis aur, vd and pvr category had concomitant co-operation and preoperative retention history as risk factors. conclusion: several factors including preoperative voiding symptoms and intraoperative parameters such as co-operation may aff ect postoperative voiding dysfunction. th e diversity in clinical presentation underscores the importance of a high clinical suspicion with an appropriate diagnostic evaluation. subjective and objective voiding dysfunction should be evaluated aft er midurethral sling operation. introduction and objective: some have hypothesized that patients with lower functional bladder capacity (fbc) experience less improvement in symptoms after staged neuromodulation procedures. th erefore, we evaluated the impact of baseline fbc on generator implant rate and symptom changes. adults enrolled in our prospective observational neuromodulation study were evaluated. functional bladder capacity (fbc) was defi ned as average volume per void on day voiding diary. data were collected from medical records, and validated interstitial cystitis symptom/problem indices (icsi−pi) and overactive bladder questionnaire (oabq) symptom severity and health related quality of life (hrqol) domains, and examined with descriptive statistics, wilcoxon rank sum tests, logistic regression, and spearman correlation coeffi cients. results: of patients (mean age . ± . years; % female), most had urinary urgency/frequency with or without urge incontinence ( %) and a sacral lead placed ( %); % had the lead placed at the pudendal nerve. mean fbc at baseline was . ± . ml. among the , ( %) had ≥ % improvement in overall symptoms aft er lead placement with subsequent generator implant. baseline fbc was similar between implanted/not implanted patients (p= . ), however implanted patients had a median . % increase in fbc aft er lead placement compared to explanted patients whose fbc decreased by median . % (p= . ). logistic regression identifi ed a strong relationship between percent change in fbc aft er lead placement and generator implant (p= . ) but there was no relationship between baseline fbc (ml) and subsequent generator implant. at months, a lower pre-implant fbc weakly predicted a greater improvement in oab-q hrqol from baseline (p= . ; r = - . ). fbc (ml) at baseline, or percent change in fbc aft er lead placement, had no relationship with achieving at least % improvement in icsi−pi or oab−q symptom severity scores at months. conclusions: lower baseline fbc should not be a contraindication to neuromodulation since there was no impact on outcomes. improved fbc aft er lead placement may have contributed to overall improvements in symptoms leading to generator implant. improvement in fbc was equal to or greater than that seen in medical treatment trials for oab. introduction and objective: to present our preliminary experience with the sars (sacral anterior root stimulator) in spinal cord-injury patients with hyperactive bladder at our center. th e sars is an implantable electronic device that allows patients with spinal cord injury to assume voluntary control of micturition, defecation and erectile function. it involves a s -s dorsal (sensitive) rhizotomy and placement of electrodes around those roots, which are connected to a subcutaneous receiver antenna. by transcutaneous radiofrequency stimulation of that antenna the patient can selectively use stimulation programs to activate the diff erent functions: program for micturition, program for defecation and program for erection. results: between january and november nine sars implants (eight men and one woman) were performed in patients with spinal cord injury-related overactive bladder refractory to standard conservative treatment. average age was years and mean follow-up was months (range - ). bladder function: eight of the nine patients exhibit an increase of the bladder capacity and use the device - times daily, voiding - cc with ≤ cc residual urine. one of these patients showed de-novo postoperative stress incontinence due to sphincter incompetence that was solved with placement of a suburethral sling. th e ninth case had a poor compliance and low capacity bladder; despite sars, he failed to increase capacity and persisted incontinent so aft er months he underwent a continent urinary reservoir. voiding objectives were therefore achieved in / patients ( % success). defecation: all patients use the device once a day. erectile function: of the eight male patients, seven achieved erection with sars. however, this erection was not always reliable for intercourse; patients associate sildenafi l and eventually requested a penile prosthesis implantation. complications: th ere were no postoperative complications or failure of the internal components. one patient showed a transient s neurapraxia, which resolved spontaneously aft er months. conclusion: in selected spinal cord injury patients, sars is an excellent option for urinary and defecatory control, being also useful for erectile function in some of them. how to determine the complication rate of urolastic (vinyl dimethyl polydimethylsiloxane, pdms), a bulking agent for female stress urinary incontinence. twenty-eight females with stress urinary incontinence were treated with pdms. th e group mainly consisted of secondary patients (n= ), with extensive comorbidity. six patients had one previous surgical procedure for sui; nine underwent two procedures and ten received three or more interventions. an amount of . - . ml of pdms was injected at - positions paraurethrally at the midurethra. procedures were performed on the outpatient department, with local anaesthesia. th e clavien dindo score was determined aft er months, to assess the severity of the complications encountered. results: aft er six months, % ( / ) of the patients reported a % improvement, % ( / ) a - % improvement and % ( / ) a - % improvement, % ( / ) reported % improvement and % ( / ) was % improved. six patients ( %) had no improvement aft er six months, four of which had also not shown initial improvement. in one patient the implants were removed during surgery, so no follow-up was available. of twenty-eight patients treated, % ( / ) had no complications. in % ( / ) complications were seen, which were classifi ed following the clavien dindo-classifi cation. a score of i was appointed to % ( / ) of the patients. reasons were: implant-exposure, minor pain, anti-emetics use or de novo retention. th ree patients had a score of ii, because of more severe complaints of pain or urge. th ey were treated pharmacologically. in % ( / ) one or more implants were removed, mostly due to exposure, erosion or pain. removal under local anaesthesia was performed in % ( / ) of the patients and this resulted in a iiia-score. th ree patients ( %) had a iiib-score, which meant the implant(s) were removed under general anaesthesia. in the fi rst twenty-eight diffi cult to treat patients receiving pdms, in ten cases a clavien dindo grade ii-iiib is scored, mainly because of surgical removal of implants. in spite of the seemingly high complication rate, this remains a useful therapeutical option for female stress urinary incontinence. magnetic stimulation for stress urinary incontinence: a randomized, double-blind, sham-controlled trial introduction and objective: we conducted a multicenter, randomized, double-blind, sham-controlled trial to evaluate the effi cacy of magnetic stimulation (ms) for stress urinary incontinence (sui). a total of sui subjects were randomized : to active or sham ms for eight weeks (twice weekly). th e primary criterion for response was a reduction of points or more in the international consultation on incontinence questionnaire for urinary incontinence-short form (iciq-ui sf). th e secondary outcomes included objective (leakage of less than gram on -hour pad test) and subjective cure (a 'never' response to 'how oft en do you leak urine?), incontinence diary, pelvic fl oor muscle strength, urofl owmetry, patient global impression of improvement (pgi-i) and international consultation on incontinence questionnaire-lower urinary tract symptoms quality of life (iciq-lutsqol). results: using the primary criterion, ( . %) of subjects were treatment responders in the active group compared to ( . %) of subjects in the sham group (relative risk (rr) . , % ci . - . , p< . ). based on objective cure, ( . %) subjects in the active group were dry versus ( . %) subjects in the sham group (rr . , % ci . - . , p< . ). nineteen ( . %) in the active group and ( %) subjects in the sham group perceived themselves as dry (rr . , % ci . - . , p< . ). th e active group had greater reductions (p< . ) in incontinence frequency than the sham group. changes in pelvic fl oor muscle strength and urofl owmetry parameters were not statistically signifi cant between groups (p> . ). th irty-nine ( %) subjects in the active group reported signifi cant benefi ts (much/very much better) for pgi-i rating compared to ( . %) subjects in the sham group (p< . ). all item scores in iciq-lutsqol were not statistically diff erent (p> . ) except 'eff ect on friends' , 'smell' , feeling of embarrassment' and 'overall impact' in the active group. of all evaluable subjects, ( . %) of subjects in the active group and ( . %) of subjects in the sham group experienced adverse events (p= . ). conclusions: modifi ed tvt abbrevo is a simple, safe and eff ective procedure with comparable short-midterm cure rates to standard tvt abbrevo. th e modifi cations of avoiding the tunnelling device and groin exit helped to minimize the groin pain and analgesic requirements. evaluation of standard practice for artifi cial urinary sphincter implantation auckland dhb, auckland, new zealand; ucd medical center, sacramento, usa introduction and objective: th e artifi cial urinary sphincter (aus) has been available since and over this time it has established itself as the gold standard in management of post prostatectomy incontinence. th e successes, failures and diffi culties are well documented, however little is published regarding the standard implantation practice of the aus. our objective was to review the standard practice for implantation of the aus within a group of high volume implanters. aft er obtaining institutional review board ethical approval a web-based questionnaire was designed using survey monkey soft ware. an email was sent to the current members of the society of genitourinary reconstructive surgeons (gurs) explaining the aims of the confi dential questionnaire with a web link to the aforementioned questionnaire. all results were collected via survey monkey and were then analyzed. results: one hundred and twenty gurs members were contacted by email, members replied. th is group averaged aus placements a year (range to ). pre-operative assessment utilized routinely included pad weights in . %, pad numbers in . % and urodynamic studies in % of participants. additionally % of participants surveyed would routinely perform a cystoscopy in the pre-operative assessment ninety four percent of those surveyed used greater than one pre-operative antibiotic; most commonly gentamicin with either vancomycin or cefazolin. th e antibiotic most commonly utilized alone was levofl oxacin. post-operatively % continue antibiotics anywhere between hours and month, with % continuing intravenous antibiotics for a minimum of days. intra-operatively % have aus componentry prepared on a separate set up stand. th e single cuff aus, size . and . cm cuff were the most commonly placed cuff s, with the - cm reservoirs. radio-opaque contrast is used by % of participants in the aus reservoir. only % of participants would recommend a medical alert bracelet in the post-operative period, and % encourage pump traction. conclusion: despite a uniform technique recommended for the implantation of the aus by american medical systems in order to improve success and decrease complications, there is great heterogeneity in pre-operative assessment, surgical placement and post-operative management of the aus in a cohort of high volume implanters. patients presenting to a multi-disciplinary stone clinic were administered a survey. th ey were asked to elect a treatment modality from shock wave lithotripsy (swl), ureteroscopy (urs) or percutaneous nephrolithotomy (pcnl) for a hypothetical mm kidney stone. th e success rates ( % swl, % urs and % pcnl), morbidity and the risks associated with each treatment options were explained. patients were also to elect whether personal or doctors' decision of treatment is most preferred and the most important variable in deciding a choice of treatment modality. results: of the respondents with mean age . ± . , female/male ratio was : ( figure ). majority of the subjects ( %) elected urs as their treatment choice (table ) . previous experience with urs (p= . ) and pcnl (p= . ) impacted the choice of urs. th e respondents were equally distributed in their primary concern being success rate ( %) versus risks ( %) associated with the procedure of choice (p= . ). age and gender has no infl uence on treatment choice (p= . and p= . ) and on whether the primary concern is success or risk (p= . and p= . respectively). majority ( %) of the surveyed population would prefer the physician recommend the appropriate treatment. conclusion: th ough patients prefer the physician to recommend the appropriate treatment for a medium-sized renal stone, it is important for the physician to consider the patient's priorities of minimizing risk versus maximizing success. as such, majority of patients selected ureteroscopy as a procedure with a balance of moderate risk and moderate success. solo introduction and objective: sonography has been brought in percutaneous nephrolithotripsy (pcnl) as an adjunct to x-ray to restrict radiation exposure. th is study was designed to respond this question that "is sonography proper enough to supersede x-ray in pcnl under spinal anesthesia?" moreover, we investigated possible predictors of success. tract infection were excluded from study. th e intraand post-operative surgical outcomes were evaluated. results: th e mean age of the patients was . ± . years. mean stone size was . ± . cm. mean access and operative time were . ± . and ± . minutes respectively. superior calyx was selected for access in % of patients. th e patients were categorized in following groups; history of more than one section previously open stone surgery ( %), horseshoe kidney ( %), major lumbosacral deformity ( %), failed standard pcnl ( %), children under years old ( %), pregnancy ( %). th e primary complete stone free rate was %, and aft er ancillary procedures (urs, swl), raised to %. th e mean hemoglobin drop was . ± . gr/dl. transfusion needs in patients. signifi cant prolonged or delay hemorrhage was not shown in any cases. pneumothorax was detected in one patient that managed with chest tube insertion. visceral or solid abdominal organ injury was not occurred. conclusion: with some attention, the outcomes of ultrasonography-guided pcnl for challenging renal stones are comparable with standard fl uoroscopic approach, and in some situation, fl ank position contain benefi ts rather than standard prone position. study of ten cases of p.c.n.l in "previously operated kidney stone with incisional hernia" conclusions: p.c.n.l in incision hernia patient is a safe procedure with excellent results. c.t. urogram is necessary tool for puncture. st puncture in virgin fi eld (out of incisional hernia site) and avoiding colonic gas shadow on fl uoroscopy is key point. bowel injury is the concern -which should be taken care during puncture. daycare pcnl: now a reality! introduction and objective: pcnl as a therapy for renal stones is an established modality. th e use of holmium laser has led to miniaturisation of instruments and sheaths and has thus made the procedure less morbid. a stage has come for the patient to now leave hospital on the same day of the procedure. materials and methods: all cases were done under spinal anaesthesia and prone position. aft er placing a retrograde ureteric catheter, pcs was accessed through the appropriate calyx, and a french sheath with suction capability was used. holmium laser was the energy used. aft er fragmentation, clearance was achieved by a combination of suction and retrograde wash and confi rmed radiologically and visually. clots were fl ushed out through the sheath which was then removed having retained the guide wire. finger pressure on the puncture site achieved haemostasis. th e guide wire and the retrograde catheter were fi nally removed. no urethral catheter was kept. a total tubeless procedure in the real sense. all patients were counselled about haematuria and pain. results: from january to march , a total of cases are included comprising renal and upper ureteric stones. stone size ranged from . to . cms. age ranged from to yrs. th e m/f ratio was : . operative time ranged from to mins. th ere was no signifi cant blood loss. all patients received dose of a parenteral analgesic hrs post procedure, were ambulant hours postopt and were allowed oral liquids. patient had leak at puncture site lasting for hours .all had haematuria which cleared completely within to hours. all were off ered discharge on the same day without any major event. one patient had clot retention on the th po day requiring clot evacuation. conclusion: pcnl as a day care procedure has been achieved by the above described method. patient acceptance is fair though most showed apprehension of going home the same day aft er a major procedure. whether it can be accepted universally remains to be seen. initial experience in ultraminiperc we have reviewed our initial experience of ultra-miniperc-ump in patients. between june and march , total patients underwent ultra-miniperc. puncture and dilatation were done under fl uoroscopy in prone position. we used and fr ump amplatz. stones were fragmented by holmium laser and removed by whirlpool eff ect. post-operative stone-free status was confi rmed by ultrasonography and x-ray aft er week. results: mean patient age was years ( to years) and male to female ratio was . : . in % the procedure was bilateral simultaneous and in % in solitary kidney. stone locations were lower calyx ( %); upper calyx ( %), middle calyx ( %), renal pelvis ( %), upper ureter ( %) and rest were at multiple sites. calyx punctures were lower ( %), upper ( %), middle ( %) and multiple in rest. eight punctures were supracostal. mean operative time from puncture to amplatz removal was minutes (range to minutes). signifi cant bleeding (hb drop more than . gm/dl) was in %. all were managed conservatively without transfusion. dj stents were kept in patients. nephrostomy-tube was not kept in any patient. eleven percent of patients had minor complications like pleural eff usion ( %), uti-fever ( %), and mild hematuria ( %). all were managed conservatively. one patient required conversion to miniperc- fr track due to intraoperative poor vision. mean hospital stay was days ( - days). th ree patients required readmission for fever or clot colic. stone-free rate was %. eight percent had small fragments that were treated by oral hydrotherapy. two patients were treated by eswl. introduction and objective: a prospective randomized controlled study was executed to compare minipercutaneous nephrolithotomy (miniperc) and retrograde intrarenal surgery (rirs) in the management of renal stones larger than mm in a single session. between june and february , patients presenting with renal stones > mm were randomized to a miniperc or a rirs group in a ratio of : . randomization was performed by a biostatistician and opened to the surgeon at the time of the patient's admission on the day before surgery. patient and stone characteristics, perioperative outcomes, and complications were compared between the two groups. th e primary end point was "stonefree", which was defi ned as no residual stone or stones < mm on computed tomography within months postoperatively. results: th irty-fi ve patients (miniperc) and (rirs) were included in the fi nal analysis. th ere were no statistically signifi cant diff erences in stone size ( . ± . versus . ± . mm, p= . ) and stone number ( . ± . versus . ± . , p= . ) between the miniperc and rirs groups. laterality, mean hounsfi eld units, stone location, presence of staghorn stone, and stone composition were similar between the both groups (p> . ). miniperc and rirs had stone free rates of . % and . %, respectively (p= . ). operation time ( . ± . versus . ± . minutes, p= . ), hemoglobin drop ( . ± . versus . ± . g/dl, p= . ), and hospital stay ( . ± . versus . ± . days, p= . ) were similar between the two groups. pain visual analogue score at hour postoperatively ( . ± . versus . ± . , p= . ) and analgesic requirement ( . % versus . %, p= . ) were lower in the miniperc group. two patients in the miniperc group and in the rirs group had minor pelvic or ureter perforation. one patient in each of both groups had hypertension and urinary tract infection. miniperc and rirs are safe and feasible surgical options for managing renal stones larger than mm. rirs had a little higher stone free rates, but more immediate postoperative pain and higher analgesic requirement compared with miniperc. colonic perforation during percutaneous nephrolithotomy darabi mahboub m, aslzare m, shakiba b introduction and objective: percutaneous nephrolithotomy (pcnl) is the treatment of choice for large, extracorporeal lithotripsy failure stones and those in the inferior calyx. despite the development of new techniques and the increasing experience in recent decades, complications may still occur. colonic perforation is one of the most dangerous and rare complications of pcnl, which may lead to peritonitis and sepsis. we present our -year experience on the diagnosis and management of colonic perforation during pcnl. we retrospectively reviewed the data of pcnl procedures performed between may and august . preoperative and operative factors, such as age, sex, history of previous ipsilateral stone intervention, stone side, stone location, site of skin puncture and punctured calyx, were reviewed in patients with colonic injury. results: colonic perforation was found in patients ( males and females) and the mean age was . ± . years (range: to ). all injuries were retroperitoneal. th e left side was aff ected in patients and the right side was injured in cases. conservative management was the treatment planned for all patients. it included withdrawal of the nephrostomy tube outside the kidney to the colon as a percutaneous colostomy, insertion of a double-j ureteral stent, intravenous broad-spectrum antibiotics, bowel rest and total parenteral nutrition. under this conservative management, complete healing of the colon was achieved in all patients. early diagnosis and conservative management of colonic perforation can minimize patient morbidity and mortality and result in excellent healing of the fi stulous tract without any serious complications. colon materials and methods: during ten years, pnl procedures performed in our center. extraperitoneal colonic perforation complicated procedures. all cases were managed without any tube in the colon. we took a retroperitoneal drain through pnl tract and a double-j stent inserted in all cases. we reported the results of our cases that managed without colostomy tube. results: male to female ratio was / . th e diagnosis was established aft er nephrostomy tract dilation and nephroscope insertion before lithotripsy in two cases and in other cases, at the end of nephrolithotomy during amplatz sheath removal. conservative treatment was successful in all cases. mean hospital stay was / days. th ere wasn't any fever or other major complication. conclusions: it seems that management of retroperitoneal colonic perforation when diagnosed intraoperatively during tubeless pnl without colostomy tube is safe and eff ective. does intercostals nerve block and peritubal nerve block with bupivacaine reduce post-operative pain after percutaneous nephrolithomy? introduction and objective: to fi nd the most eff ective post-operative analgesia method aft er percutaneous nephrolithotomy (pcnl). in a prospective, -months duration study all patients undergoing pcnl (tubeless or with -f nephrostomy) were divided into groups. group (pcnl in fi rst- -months) had no intervention; group (pcnl between and months) received intercostal block (icb) with . % bupivacaine; group (pcnl in last -months of study) had peritubal track infi ltration (pti) with . % bupivacaine at end of procedure. visual analog pain scores and rescue analgesia requirements at , , and hours in the arms were compared. results: see table . conclusions: peritubular tract infi ltration with bupivacaine established its superiority over both intercostal block and standard pcnl for post-operative analgesia and rescue analgesic requirements. the post-operative fever was defi ned as body temperature above . within hospital stay. relationship between clinical factors and sirs or post-operation fever was assessed using logistic regression analysis. results: a total of male ( . %) and female ( . %) were enrolled in our study (table ) . forty-fi ve cases ( . %) developed sirs and fever was observed in cases ( . %). shock was observed in ( . %) cases. in univariate analysis, stone size (p = . ) and urine wbc (p = . ) were found to be the predictors of sirs. in multivariate logistic analysis, stone size (or= . , p= . ) and urine wbc (or= . , p= . ) were signifi cantly related to the development of sirs (table ). in univariate analysis, post-operative fever was found to be associated with the location of stones (p= . ), stone size (p= . ), urine wbc (p< . ) and albumin (p= . ). by multivariate logistic regression analysis, only stone size (or= . , p= . ), urine wbc (or= . , p= . ) and serum albumin (or= . , p= . ) were associated with post-operative fever (table ) . conclusion: patients with larger stone size and urinary tract infection before surgery might have higher risk of developing sirs and fever, while a normal serum albumin was found to be the protective factors of fever development. introduction and objective: perioperative hemorrhage owing to high vascularity in bph is the fearsome complication of turp that leads to clot retention, reoperation and oft en requiring blood transfusion. finasteride, a type α-reductase inhibitor, by interacting with vascular endothelial growth factor (vegf), reduces prostatic angiogenesis. microvessel density (mvd) is a histological measurement of angiogenesis and thus a marker of bleeding. we aim to determine the eff ect of two weeks preoperative fi nasteride therapy in reducing prostate vascularity in terms of mean microvessel density (mvd) and expression of vegf in prostate urothelium among patients of bph by comparing with controls. trial has been conducted in department of urology at shifa international hospital islamabad from jan to jan . total patients of benign prostatic hyperplasia (bph) planned for transurethral resection of prostate (turp) having prostate sized of more than grams on trans-abdominal ultrasonography were randomized into two groups each group having patients. th e finasteride group (group a) was prescribed oral mg of fi nasteride daily for weeks before surgery. th e control group (group b) didn't receive any drug. aft er weeks, turp was performed and prostate chips were sent for histopathological determination of mvd and expression of vegf. results: mean age . ± . years, ranging from minimum of years to years. th e mean prostate gland size was comparable in both groups ( ± . grams vs. . ± . grams). mean mvd in fi nasteride group was . ± . whereas in control group mean mvd was . ± . . when compared the mean mvd in both group, the mean mvd was signifi cantly low in fi nasteride group as compared to control group with a p= < . . similarly mean expression of vegf was % in fi nasteride group compared to % in control group. th is expression of vegf was also signifi cantly lower in fi nasteride group as compared to control group (p= . ). also mean mvd was clearly correlated with size of prostate gland and the correlation was found statistically signifi cant on pearson correlation test ( -tailed) with p= . . conclusion: finasteride reduces microvessel density and hence prostate vascularity with only week therapy and the mean mvd is clearly correlated with size of prostate. characteristics -alpha reductase inhibitor induced prostate volume reductions yun j , yang h , kim d , jeon y , lee c introduction and objective: benign prostatic hyperplasia develops in the transition zone of the prostate and α-reductase inhibitors ( -aris) reduce prostate volume. we investigated whether oral treatment with the -aris dutasteride and fi nasteride more significantly aff ected volume reduction in the transition zone or in the entire prostate. total prostate and transition zone volumes (tpv and tzv) were measured at baseline using a transrectal ultrasound (trus) and then at yr aft er the commencement of dutasteride ( . mg) or fi nasteride ( . mg). th e ratio of tpv to tzv was used to determine the transition zone index (tzi). volume reduction (%) was calculated as the ratio of volume reduction to baseline prostate volume. additionally, serum prostate specifi c antigen (psa) concentrations were measured at baseline and then at yr aft er the -ari were commenced. results: all of the patients (mean age, . yr ± . ; range, - yr) with clinical lower urinary tract symptoms suggestive of benign prostatic hyperplasia and who were -ari naïve were prescribed dutasteride ( . mg, . %, / ) or fi nasteride ( . mg, . %, / ) for more than yr ( . ± . mos). at baseline, the mean tpv, tzv, and tzi values were . ± . cm , . ± . cm , and . ± . , respectively. at yr aft er the commencement of the -ari, the mean tpv, tzv, and tzi were . ± . cm , . ± . cm , and . ± . , respectively. th e tzi value is not signifi cantly diff erent at yr compared with baseline (p > . ), while the tpv and tzv reductions are . ± . % and . ± . %, respectively; there is no signifi cant diff erence between the tpv and tzv volume reductions (p> . ). conclusion: th ese results show that prostate volume reduction induced by -aris occurs in the entire prostate universally, rather than in the transition zone specifi cally. russo g, favilla v, privitera s, castelli t, fragalà e, cimino s, morgia g introduction and objective: combination therapy with of -alpha reductase inhibitors ( -ari) and alpha-blockers (ab) is the gold standard for the treatment of moderate-severe secondary to benign prostatic hyperplasia (bph). several clinical trials have already analyzed the overall impact of the medical treatment of luts/bph on sexual sphere, but any one investigated the overall impact on erectile dysfunction (ed) and libido alterations (la). th e aim of this this systematic review and meta-analysis was to evaluate the impact of combination therapy on ed and la from randomized clinical trial (rct). we performed a search of the cochrane central register of controlled trials, pubmed, embase, cochrane database of systematic review, and web of science, until december . we conducted a meta-analysis to determine the impact of combination therapy ( ari + ab) in determining the onset of ed or la. a p value < . was used to denote the presence of heterogeneity. of the studies reviewed, only fi ve rct were included, involving participants. th e overall prevalence of erectile dysfunction was of . %, . % and . % in patients treated with combination therapy, ari and ab respectively. th e overall prevalence of altered libido was of . %, . % and . % in patients treated with combination therapy, ari and ab respectively. combination therapy ari + ab was found to be associated with increased risk of ed (or = . ; p < . ) and la (or = : ; p = . ) compared to monotherapy with ab. th e combination therapy was found to increase the risk of ed (or = . ; p = . ) compared to monotherapy with ari, but not the risk of la (or = : ; p = . ). analyzing the individual monotherapies, therapy with alpha-blockers signifi cantly reduces the risk of ed (or = . ; p < . ) and la (or = . ; p = . ) compared to treatment with ari. conclusions: combination therapy ari + ab is associated with a higher risk of ed. in addition, ari monotherapy has the same risk of the combination of having la. th ese results could be taken into account during the counseling therapy in patients with luts/ bph. mladenov b, mariyanovski v introduction and objective: bph bleeding is one of the common causes of gross hematuria in older men. -alpha reductase inhibitor ( ari) treatment has been showed to reduce prostate tissue microvascularity and to prevent bph-associated hematuria. alpha-blockers are oft en prescribed, where their eff ect on hematuria is not well evaluated. th e aim of this study was to investigate the impact and effi cacy of the current used drugs for bph for treatment and prevention of bph-caused hematuria. a total of men with median age of were enrolled for a period of years. all were presented with bph-caused macrospopic hematuria, diagnosed according to an adopted investigation protocol. detailed history was obtained, including usage of alpha-blockers and/or -ari prior to the hematuria episode. patients were released or immediately hospitalized and catheterized according to their status. all patients were followed up for year for recurrent bleeding and were divided into groups -with an alpha-blocker, -ari, or without therapy. in this study patients were sent home and treated conservatively, other with severe bleeding and/or clot retention necessitated catheterization and hospitalization. from patients ( %) were taking alpha-blockers, ( %) -ari, and ( %) had no medications for the bph prior to the hematuria. patients were followed up for recurrent bleeding for year in medication groups. were given alpha-blockers, - -ari and were released without medication for the bph. within year bph-bleeding occur respectively in , , and cases. th ere was a statistically signifi cant diff erence between the group with -ari therapy and the group without therapy (p= . ). no statistically signifi cant diff erence (p= . ) was found between the groups with an alpha-blocker and without therapy. in all cases with medication the hematuria episodes were lighter according to blood loss and/or hospital stay (in days) than the initial one. conclusions: according to our study, bph-associated hematuria can be eff ectively controlled and reduced with ari. although as per our data alpha-blockers have a positive eff ect on the intensity of the recurrent hematuria, much more signifi cant results in treating and controlling bph-bleeding are shown with -ari. effi overactive bladder syndrome (oab) is a common condition with a negative impact on quality of life. botulinum toxin is commonly used. despite the favorable outcomes seen using botulinum toxin a, the method of injection and side eff ects still need to be solved. our aim is to use botulinium toxin with simple method and check its safety and effi cacy. a total of patients with refractory oab were included in this study. inclusion criteria was refractory non neurogenic oab not responding to conservative management for at least months. aft er written consent, patients were randomly divided into two groups. group a ( patients) received botulinium toxin a unit intravesical instillation diluted in cc normal saline, group b ( patients) received placebo in the form of cc normal saline by the same method. patients were evaluated initially by history, physical examination, overactive bladder symptom score (oabss), quality of life symptom score (qolss), urine analysis, routine laboratory investigations, kub, pelviabdominal ultrasound and urodynamics. patients were followed up at one, and two month post instillation for effi cacy and safety by oabss, qol score, side eff ects and postvoid residual urine. introduction and objective: th e authors evaluate the safety and effi cacy of the prostatic urethral lift when performed in conjunction with a second procedure. in this retrospective study, patients underwent the prostatic urethral lift between january and november . sixteen patients received the prostatic urethral lift as a single procedure and the mean patient age for this group was years (range to ). in the remaining patients, a second procedure was performed in conjunction with the prostatic urethral lift . th ese procedures were: th ulium laser enucleation of the middle lobe, optical urethrotomy and bladder neck incision. results: in patients who were treated with the prostatic urethral lift as a single procedure the mean international prostate symptom score was . (range to ) and mean maximum urine fl ow rate was . mls- (range to ). th e average prostate volume was cc (range to ) and mean quality of life rating was . points (range to ). at months aft er the procedure, the mean international prostate symptom score improved by . points ( %), mean maximum urine fl ow rate by . mls- ( %) and mean quality of life rating by . ( %). th e improvements achieved in the combined procedures were greater than the patients who underwent the prostatic urethral lift as a single procedure. th ere was one case ( %) of postoperative moderate pelvic pain which was managed conservatively with a nonsteroidal anti-infl ammatory drug. a urinary tract infection occurred in one case ( %) and resolved aft er treatment with an antibiotic. th ere were no complications in the combined procedure cases. no patients reported any decline in erectile function, retrograde ejaculation or dysejaculation. conclusion: th e prostatic urethral lift is a safe and eff ective treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia while preserving sexual function. in carefully selected patients, the performing the prostatic urethral lift in conjunction with a second procedure may achieve superior results with no major complications. evaluation . we sought to evaluate the effi cien-cy, safety and outcome parameters between green-light pvp and vit. data of xps cases were retrospectively collected from experienced surgeons at high volume greenlight xps centers. preoperative, operative and post-operative parameters were collected and compared between groups. pvp was defi ned as pure vaporization only while vit included techniques to incise into adenoma and allow tissue resection and removal. results: as summarized in table , men undergoing vit (n= ) had larger prostate size, higher ipss∕qol and retention preoperatively than those undergoing pvp (n= ). while vit allowed greater delivery of energy ( . vs. . kj∕g), operative time was longer and had greater need for > fi bres. th ere were no diff erences in intra and post-operative adverse events. while no diff erences were observed in ipss∕qol at months post-operatively, more favorable qmax and pvr were observed at months, along with greater psa reduction, in the vit group. preoperative patient characteristics introduction and objective: to prospectively evaluate at two years, the quality of life (qol) and satisfaction of subjects randomized to either gl-xps or turp for luts/bpo. a total of patients at sites in european countries who were candidates for surgical relief of bpo were randomised : to undergo gl-xps or turp. subjects had ipss scores > and prostate volumes < mls. multiple self-administered patient questionnaires were assessed from baseline to years via: ) a general health status eq- d- l questionnaire (index score and visual scale); ) physical and mental health (sf- physical health and sf- mental health scores); ) erectile function and ejaculatory status (iief- questionnaire); ) urinary continence via oabq-sf symptoms, oabq-sf health and iciq-ui sf; ) overall satisfaction: willingness to undergo the procedure gain or ) recommend to a friend. table and subject satisfaction at years is shown in figure . conclusions: th ere is a statistically similar improvement in qol with gl-xps and turp at years. erectile function is not aff ected by gl-xps or turp and both result in a % risk of retrograde ejaculation at years. functional introduction and objective: technology for photoselective vaporisation of the prostate (pvp) has evolved in recent years. we report our early experience of pvp with the greenlight™ -w xps and assess our institutional learning curve for this technique. we performed a retrospectively analysis of our fi rst patients undergoing pvp using the greenlight™ -w xps over a twoyear period. data was collected on demographics, prostate volume, length of stay, time to trial of void, and complications. complications were graded according to the clavien classifi cation system. th e operative learning curve was analysed via various intra-operative lasering variables including the total delivered energy, total vapourisation time (vt), and vapourisation time/operation time (vt/ot). th e study population was divided into three consecutive equal groups and the three groups were compared. results: mean age was . mean length of stay was . days. mean prostate volume was cc. twenty-fi ve percent were on some form of anticoagulation. twenty-one percent were in-dwelling catheter-dependent preoperatively. th e median duration to removal of in-dwelling catheter was day. seventy-six percent had a successful trial of void on day . th e overall complication rate was %, the vast majority of which were clavien grade i or ii. th ere were no statistically signifi cant diff erences between the groups in terms of age or prostate size. over time, there was a statistically signifi cant decrease in ot and increase in vt/ot but no diff erences in complication rates, time to trial of void or length of stay as experience increased. conclusion: greenlight laser pvp using the -w xps is a safe and effi cient treatment option for benign prostatic hyperplasia, with minimal bleeding and low complication rates. our data suggests that a learning curve exists for this procedure in terms of intra-operative lasering variables with no statistically signifi cant increase in post-operative complications or length of hospital stay during this period. tillou x, le gal s, chahwan c, oitchayomi a, doerfl er a introduction and objective: to compare results of pvp (photoselective vaporisation of the prostate) in elderly patients to those observed in younger male patients taking into account the presence of an indwelling bladder catheter. we performed a review of our prospectively maintained database between december and march . a total of patients were operated for luts related to hbp. th ree groups were fi rst established to compare results of pvp in elderly male patients. we then analyzed the impact of an indwelling bladder catheter by comparing two groups of patients under and above year-old. results: th ere were no diff erences between groups for bmi, neurological disorder or hypertension history, aspirin treatment, ipss, qol and preoperative pvr (post void residual). patients above years old had statistically more heart diseases (p= . ) and had more anticoagulant treatments (p= . ). prostate volume increased with aging (p= . ), which resulted in an increased procedure time (p= . ) and an increased amount of energy delivered (p= . ). for postoperative outcomes, there were no diff erences between groups for bladder catheter removal time, ipss, qol, pvr, and surgical complications. postoperative qmax was statistically lower for patients above years old (p= . ) but with a decreased diff erence compared to preoperative measurements (p= . ). in the group without an indwelling catheter, postoperative catheter time was signifi cantly longer in patients over years (p= . ) with a greater pvr (p= . ). urofl owmetry and ipss voiding were signifi cantly improved in both groups without diff erences. th ere was no diff erence for early or late postoperative complications. for patients with an indwelling catheter, for all parameters studied, no statistically signifi cant diff erences were found except higher post-operative pvr in patients older than year-old. conclusions: pvp is an effi cient and safe procedure in elderly male patients despite more heart diseases and anticoagulant treatments. with or without a previous indwelling bladder catheter, functional outcomes were identical whatever age. introduction and objective: th e procedure of holep has steep learning curve and more than cases are needed for overcoming the curve. th e objective of our study is for identifying the detailed steps in improving skills during learning curve. total patients who underwent holep in single center were included in the study. th e operation was performed by surgeons who were experienced tur-p more than cases. patients were divided into groups. groups were initial cases (group ), mid cases (group ), and later cases (group ) in each surgeons. th e enucleation time, morcellation time, the amount of energy use, diff erential count of hemoglobin between pre-and post-operation, post-operative urofl owmetry parameter were compared between each group. especially, enucleation time was divided into diff erent steps, which was action time that was actual use of laser energy or dissecting prostate tissue using cystoscopy and identifi cation time was time for identifying anatomical structure without any procedure. results: mean ages was . years old and mean bmi was . kg/m . mean psa was . ng/ml and mean prostate volume was . cc. th ere were no signifi cant diff erences in baseline characteristics in preoperative data. aft er cases (group ), there was less use of laser energy, less time consuming for morcellation and identifi cation compared to group . identifi cation time was signifi cantly improved than group and more shortening feature as cases added but had no signifi cant diff erence. aft er cases (in groups ), there was more signifi cant diff erence in all operative parameter. especially morcellation time was signifi cantly improved aft er cases. th ere was no signifi cant diff erence in post-operative urofl owmetric parameters. conclusion: in initial experience, it seemed to be overcoming one step about identifying surgical anatomy in learning curve aft er cases. especially, cases were optimal cases for overcoming learning curve for morcellation. aft er cases, we did not overcome the learning curve but all operative parameter was improved. transrectal ultrasound as an intraoperative tool in the identifi cation of the plane of dissection during holep procedure introduction and objective: holmium laser enuclation of the prostate (holep) has been named since as the potential gold standard of treatment for bladder outlet obstruction as a consequence of benign prostatic hiperplasia. one of the most important steps during procedure is to identify the plane of dissection between the adenoma and periferic zone. in this study we demonstrated the utility of transrectal ultrasound in the identifi cation of this surgical plane during ho-lep for novel surgeons. materials and methods: previews informed concerned, we preform transrectal ultrasound during holep of patients, using the proved of the flex focus ultrasound system of bk medical, obtaining images of the prostate as a method to simplify the identifi cation of the surgical plane. we preformed holep as a standard method with storz endoscopic instruments using fr resectoscope with a kunts element and with the watts holium laser power suite from lumenis, we obtained images of the fi ve patients in real time with axial and sagital planes simultaneously, clearly helping the surgeon to identify the surgical dissection plane between the adenoma and the peripherical zone. conclusions: transrectal ultrasound could be a useful tool during the training of novel surgeons in holep technique. introduction and objective: th e aristolochia family of herbaceous plants has been used worldwide for traditional medicinal purposes for more than two centuries. th ese plants contain aristolochic acid (aa), a powerful nephrotoxin and human carcinogen, which, in susceptible individuals, causes chronic kidney disease and/or upper urinary tract urothelial carcinoma (utuc). bioactivation of aa yields a reactive intermediate that binds covalently with dna to form aristolactam (al)-dna adducts. in the urothelium, these adducts give rise to a unique mutational signature. as there are several reports of renal dysfunction in japan associated with the use of aa-containing chinese herbs, we hypothesize that a fraction of utuc cases in this country may result from past use of aristolochia herbs. patients with histologically confi rmed utuc who underwent nephroureterectomy in kyushu university aft er august were eligible for this study. informed consent was provided by each participant prior to surgery. surgical specimens of tumor and renal cortex were snap-frozen following nephroureterectomy. dna was isolated from renal cortex and analyzed for the presence of al-dna adducts using either mass spectrometry or a p-postlabelling method. dna isolated from matched tumor samples was subjected to mutational analysis of the tumor suppressor gene tp . results: th irty three utuc patients were enrolled in this study between august and march , males and females, with a mean age of years. al-dna adducts were detected in of renal cortex samples ( . %) analyzed; adduct levels were . and . per deoxynucelotides. sequencing analysis of tp in tumor dna revealed the absence of the unique mutational signature associated with aa. conclusion: aa exposure was confi rmed in two utuc patients; however, in these two cases, the mutational profi le of tp in tumor dna was not consistent with aa-induced carcinogenesis. further accrual and analysis of utuc cases are needed to estimate the prevalence of aa exposure in japan, to evaluate the role of aa exposure to utuc in this country, and to confi rm the public health implications of these fi ndings. preoperative introduction and objective: our aims are to assess the association between upper urinary tract urothelial carcinoma (uutuc) development and the polymorphisms in the aurora kinase a (aurka) phe ile (rs ) and survivin rs c>t genes. a total of patients with uutuc and hospital controls with bladder stones were recruited in this study. clinical records, demographic data, and possible confounding factors were collected using a standardized questionnaire. genotyping was determined using a real-time polymerase chain reaction using taqman probe. results: signifi cantly more controls than patients with uutuc drank alcohol and tea, but there were no diff erences in the frequencies of cigarette smokers and coff ee drinkers. aurka phe ile gene polymorphisms, but not survivin rs c>t gene polymorphisms, were associated with uutuc development (χ test and multivariate logistic regression) (χ = . , p= . ; crude or= . , % ci= . - . ; adjusted or= . , % ci = . - . ). stratifi cation analysis and multivariate logistic regression analysis showed that only the association between aurka phe ile gene polymorphisms and uutuc development were diff erentiated between those with and without the habits of smoking, tea drinking, or coff ee drinking. conclusion: our major fi ndings supported that aur-ka phe ile gene polymorphisms, but not survivin rs c>t gene polymorphisms, increase genetic susceptibility to uutuc. metastatic and has thereaft er stabilized around %. th ere was a regional variation in the proportion of patients who underwent cn between % and %. th e relative survival at fi ve years was % aft er cn compared to % in patients who did not undergo cn (p< . ). th e median age of the m patients who underwent cn was years compared to years in patients who did not undergo cn. tumor recurrence, aft er initial treatment with curative intention in primary m patients, was % aft er fi ve years. th e location of the metastases were: lung %, bone %, lymph nodes %, liver %, adrenal % and brain metastases in % of the patients. th irteen percent of the patients suff ered local recurrence in the renal fossa aft er nephrectomy. th e most common treatment for patients with a recurrence was oncological medical treatment ( %). metastasectomy was performed in % of the patients with recurrence and in % of the patients the surgery had a curative intention. conclusions: th e incidence of metastases in renal cell carcinoma in sweden is decreasing and is lower than in historical materials. th e patients with synchronous metastases who undergo cn have a signifi cantly better survival than patients who do not undergo cn, but constitute a highly selected group. recurrence after initial treatment with curative intention is treated surgically in % and oncologically in %. immediate introduction and objective: pretreatment characterization of renal masses (rm) remain suboptimal with overtreatment being a signifi cant concern. we examined the ability of preoperative clinical characteristics to predict histological features of rms. in the global renal mass study conducted by the clinical research offi ce of endourology society (croes), data were collected for consecutive patients with renal masses who underwent surgery for clinical stage i renal mass between - . based on surgical histology, tumors were categorized as benign, low aggressiveness cancer, and high aggressiveness cancer. we assessed the ability of clinical (patient gender, age, smoking history, bmi), laboratory (preoperative hemoglobin and c-reactive protein) and radiographic (tumor diameter, location, exophytic rate and enhancement) characteristics to discriminate between benign and cancer (low + high aggressiveness) and between highly aggressive tumors and others (benign + low aggressiveness cancer). multivariate logistic regression was used to estimate the probability of the histological group by clinical and radiographic features in the entire cohort and a sub group of ct a tumor. th e performance of the models was consequently studied by calibration, nagelkerke's r , and discrimination (roc area under the curve). results: th e study cohort included patients with clinical stage i renal mass of which ( %) had ct a mass. benign lesions were found in ( . %), low aggressiveness tumors in ( %) and high aggressiveness tumors in ( . %). male gender, smoking history, increased tumor size, and lower exophytic rate were associated with malignancy and high aggressiveness features (all p-values < . ). models developed based on these characteristics had the ability to discriminate benign from malignant (bootstrap corrected c-index of . ) and high aggressiveness tumors from benign and low aggressiveness tumors (bootstrap corrected c-index of . ). similar results were achieved in the ct a subgroup. th e c-index of tumor diameter as a single predictor of malignancy and high aggressiveness tumors in the entire cohort was . and . , respectively. conclusions: although older age, male gender, smoking history, increased tumor diameter and reduced exophytic rate are associated with malignancy and high aggressiveness of renal mass, models incorporating these characteristics have modest discriminating power, slightly better than the predictive ability of tumor size alone in clinical stage i tumors. could surgery be prevented in the management of small renal masses? introduction and objective: th e diagnosis, characterization and management of small renal masses (srms) remains an important clinical issue. a proportion of srms may be benign or have low malignant potential. th ese lesions could arguably be managed non-operatively. strategies such as renal mass biopsy may be valuable in reducing the rate of unnecessary surgery. we evaluated a large contemporary surgical series of resected srms in a tertiary center with a very low biopsy rate to determine the number of procedures that could have been prevented for benign and low malignant potential lesions. conclusion: sbrt is a safe and effi cacious modality and appears to be well-tolerated at the dose fractionation we have used, and its use correlates with improved survival in this cohort of patients with rcc. cyberknife can deliver complex treatment plans to multiple lesions while minimizing irradiation to the surrounding healthy tissue, thereby decreasing the risk of complications. cyberknife has the potential to be an excellent treatment modality for renal cancer patients with renal cell carcinomas or patients with bilateral renal cell carcinoma who refuse surgery or are medically inoperable. introduction and objective: th e introduction of the robotic surgical systems has changed the way both surgeons and patients view urological surgical procedures. we tested the same theoretical and tangible benefi ts for partial nephrectomy with tele-lap alf-x system. we review our technique of robot-assisted laparoscopic partial nephrectomy performed using a new robotic telesurgical device (alf-x) on swine large white/landrace model. we set up an operating theatre to test alf-x on partial nephrectomy procedure to be performed on swine large white/landrace in total anesthesia. th e console incorporates the following main components: an ergonomic seat, the laparoscopic teleoperation master (ltm) with haptic handles, a d-hd monitor, an eye-tracking system (ets), a keyboard and a touchpad, and one foot pedal. th e ets is an infrared-based eye tracking system that detects which point the surgeon is looking at. th ere was one surgeon placed at computer-console and one surgeon placed at the surgical table. a random decision on the kidney to be tested is performed before the operation. once the trocars are placed and the kidney isolated a period of warm ischemia is due to perform the partial nephrectomy on the lower or upper pole (random choice). th e haptic sensation can be used for palpation, pushing or pulling to estimate elasticity and consistency of tissues and controlling the tensility of the sutures when tying. low-cost disposable or reusable instruments were used. results: to date, we performed partial nephrectomy with alf-x robot on swine large white/landrace (pigs) models. th ree robot's arms were used. five partial nephrectomies were on the right kidney, while were on the left one. th e mean surgical time was . minutes (range - min). th e mean warm ischemia time was . min (range . - min). th e mean blood loss was . ml (range - ml). conclusions: according to these experimental experiences on pig models, we may assume that robot-assisted laparoscopic partial nephrectomy, using tele-lap alf-x system, is safe, feasible and reproducible procedure. moreover it off ers a good perception when instruments touch each other avoiding collision between robotic arms. we believe that robot-assisted tele surgery approach could be reasonable an innovative contribution in the near future also in humans. it also off ers a reduction of costs per intervention. preoperative chronic kidney disease to reduce the eff ects of selection bias and potential confounding factors, patients in non-ckd group were selected by propensity score matching. results: th e median age of all patients was . years (range, - years) and the median follow-up was . months (range, - months). comparisons of the propensity score-matched cohorts showed that t and n stages were more advanced and the tumor size was larger in the ckd than in the non-ckd group (p < . each). kaplan-meier analyses showed that recurrence-free survival (rfs), cancer-specifi c survival (css), and overall survival (os) were signifi cantly lower in the ckd group (p < . each). multivariate regression analysis showed that preoperative ckd status was an independent predictor of css and os in patients with rcc (p < . each). conclusion: preoperative ckd may be associated with more aggressive features and poorer prognosis in patients with rcc. rcc patients with preoperative ckd should be followed up frequently and carefully aft er nephrectomy. . ) were independent prognostic factors. bone-modifying agents (zoledronic acid and denosumab) were not associated with os. th e median os of patients receiving molecular-targeted therapy aft er diagnosis of bone metastasis was signifi cantly better than that of those who did not receive targeted therapy ( . vs. . months, p= . ). our study suggests that molecular-targeted therapy prolongs survival of rcc patients with bone metastasis. th us, molecular-targeted therapy, nephrectomy and surgery for bone metastasis should be considered for these patients. introduction and objective: ureteric stenting for urinary tract obstruction secondary to malignancy may off er a survival benefi t and buy time for oncological management. since the introduction of the ureteral stent symptom questionnaire (ussq), studies have revealed that up to % of patients with ureteric stents for benign conditions experience stent related symptoms that interfere with daily activities and reduce quality of life. our aim was to evaluate stent symptoms in patients with malignant obstruction and their impact on health related quality of life. patients with indwelling ureteric stents for malignant obstruction were identifi ed from the departmental stent register during a march to june . telephone interviews and face to face interviews at the time of stent change were conducted using the validated ussq. results were analysed according to the questionnaire scoring system. results: twenty patients with a mean age of years completed the ussq. of these patients - % reported bothersome urinary symptoms that included storage symptoms, incontinence and haematuria. fifty percent of patients experienced stent related pain in the fl ank ( / ), suprapubic ( / ) and groin area ( / ). fift y percent of these patients required regular analgesia and - % experienced pain interfered with activities and daily life. seventy percent of patients experienced diffi culty in performing physical activities, with a negative impact on social life. one out of patients reported sexual dysfunction. eighty fi ve percent experienced urinary tract infection (uti) with % having a uti most or all of the time and % requiring admission to hospital. mortality within one year of stent insertion was %. conclusion: ureteric stents are associated with signifi cant debilitating symptoms and reduced quality of life in patients with malignant obstruction. th is has signifi cant implications for management of cancer patients and patient counselling. ureteric stenting can prevent death from malignant obstruction, but may result in prolonged suff ering due to stent symptoms without benefi t in overall survival. introduction and objective: management pheochromocytoma laparoscopic was initially controversial because of the possibility of adrenergic discharge with the generation of the pneumoperitoneum. th e work of a proper medical preparation and anesthetic precise control obvious that circumstance and allows more precise surgery and a better image as it gives the laparoscopy to get with much less aggressive surgical removal. our goal is to present the preparation and the key points in its approach. we present -year-old male with recent diagnosis prostate cancer and high pressure treated with drugs. discovery of left adrenal mass of cm. in ct and mri and scintography with mibg suggestive focus of pheochromocytoma in the adrenal gland. twenty-four-hours urine: total catecholamines: . ug/ ( - ) adrenaline: . ug/ hours ( d- ); normetanephrines ug/ ( - ), metanephrines: ug/ ( - ). vanilvandelico . ug/ ( - ). preparing medical / anaesthetic consisted: entry days before surgery and control alpha-blockers with doxazosin every hours. treatment with beta-blockers with propranolol. expansion of intravascular volume with intravenous fl uid therapy hours before surgery. and control of blood glucose levels. intraoperatively crisis were treated with nitroprusiate. results: aft er adrenalectomy laparoscopic left with a length of minutes and adequate control pressure intraoperative the pathology diagnosis was of pheochromocytoma. postoperative attended without incident (clavien i) and went out hospital to the hours. th e presence a pheochromocytoma should not be a contraindication to laparoscopic approach of the adrenal gland in services experienced laparoscopic, and must be an exhaustive control of anesthetic, as well as a careful dissection of the gland trying to avoid excessive manipulation of the same. robotic assisted "davinci" adrenalectomy al-ansari a, younes n, al-rumaihi k, al-jalham k, gul t, badawi a, kamkoum h introduction and objective: adrenal mass could be challenging, especially when it is large in size or cystic, adrenal had short and variable vasculature, in addition to functional adenoma, adrenal surgery require minimal handling. robotic assisted adrenalectomy (ra) had been proven to be safe and eff ective. objectives: to describe robotic adrenalectomy (ra), to ensure a safe and eff ective removal of complex adrenal mass. we reviewed the record of consecutive patients who underwent ra performed by a single surgeon, between january and january , fi ve were right and fi ve were left , were solid and were cystic, none were functional adenoma patients position and port placement were similar to renal surgery, aft er control of the renal vein the gland was dissected, small arteries were clipped and the gland were removed. results: patients were females and males, age range between to years mean tumor size was . cm range ( . - cm), mean hospital stay was days, no perioperative complications, all masses were intact, one postoperative addisonian crisis pathology was benign cyst, adenoma, ganglionuroma, neuroendocine, adrenal hyperplasia, adrenocortical neoplasm of low malignant potential. conclusion: robotic adrenalectomy is safe and feasible in the management of complex adrenal mass. robotic materials and methods: th e girl was in a good general health and came walking to our out-patients department. she was admitted and her investigations reviewed. she had a right renal mass with cavo-atrial extension with an isolated embolus in the pulmonary artery. she was planned for a complete excision under cardio-pulmonary bypass with deep hypothermic circulatory arrest. under general anaesthesia, aft er establishing complete monitoring, she was opened by long midline laparotomy and mid-sternotomy. mid-sternotomy extension was done up-front in-view of the pulmonary embolus. an incision was made in the posterior peritoneum medial to the inferior mesenteric vein. th e right renal artery was dissected posterior to the left renal vein, ligated and divided. suddenly her end tidal carbon-di-oxide fell. th e video demonstrates the trans-esophageal echo-cardiography confi rming fragmentation of the cavo-atrial thrombus and its migration into the right ventricle and main pulmonary artery. th e patient was immediately put on cardio-pulmonary bypass. initially the venous return was low. she was rapidly cooled to degrees centigrade and aorta cross clamped just above the diaphragm. arterial infl ow was reduced to litre per minute to main blood fl ow to the brain. th e video demonstrates opening, clearing and repairing of the right atrium, right ventricle and main pulmonary artery in a step by step approach. th e branches of the pulmonary artery were cleared with fogarty's catheter. right radical nephrectomy was completed and ivc cleared and repaired. th e total circulatory arrest time was minutes. she was slowly re-warmed and taken off cardio-pulmonary bypass. results: her post-op recovery was uneventful. th e fi nal histo-pathology report showed a primitive neuro-ectodermal tumor. she received adjuvant chemotherapy for cycles and is well at months of follow-up. in an appropriate case pulmonary artery embolectomy along with excision of cavo-atrial tumor thrombus is acceptable in experienced centers. an up-front mid-sternotomy should be contemplated in patients where the risk of embolisation of tumor thrombus is high. a total of consecutive patients who underwent a turbts were identifi ed from january to february by a single surgeon at our institution. we excluded patients as they had a known history of bladder cancer that previously underwent treatment. via rigid cystoscopy, tumors were resected en bloc using a polypectomy snare with electro-cautery and retrieved transurethrally. following turbts, the base of the tumor was either biopsied and fulgurize or a formal turbt was performed. results: nineteen consecutive patients (median age , range - ) underwent an initial turbts for the initial staging and management of bladder tumor. median number of tumors found was (range - ). median tumor size was cm (range cm- cm). median follow-up was months (range - months). tumors sites were: posterior wall, trigone, lateral wall, anterior wall. immediate aft er snaring of the tumor, patients underwent biopsy and fulguration while underwent a turbt in the same operative setting. patient from the turbt group experienced an obturator refl ex. muscle was visualized on of pathology specimens. patients required subsequent redo procedure to obtain muscle for tissue diagnosis and staging. recurrence occurred in patients (median . months, range . - months). conclusion: turbts is a feasible technique for pedunculated bladder tumors. it provides a bloodless fi eld with maximal visibility for the surgeon and may be an adjunct in turbt. dilep-diode laser ( nm technical aspects for overcoming the holep learning curve omori y, matsumoto s, matsumoto s introduction and objective: holep is an excellent surgical procedure and alternative to turp and open prostatectomy for bladder outlet obstruction due to benign prostatic hyperplasia. it has been widely accepted and performed, for its safety and eff ectiveness. however, it may not be considered an option for the majority of worldwide urologists, because of its steep learning curve. our objective is to help beginners and operators who are interested in learning holep to get familiarized with it, and feel confi dent about opting for this procedure. in this video we demonstrate a case of holep using watt holmium laser in a -year-old male with ml prostate. th e operative fl ow is described as follow: ) downward dissection of the left lobe and longitudinal incision; ) downward dissection of the right lobe and longitudinal incision; ) enucleation of the medium lobe; ) lateral side dissection of the both lobes; ) o' clock incision and bladder neck ablation at between and o' clock ) diagonal longitudinal incision of apical lobes; ) enucleation of the both lobes; ) hemostasis; ) morcellation. results: in this video operative time was min (enucleation time: min) and resected tissue weight was g. our procedure has some modifi cations compared to the surgical technique from original procedure of gilling, separating lobes and dissecting in a retrograde fashion. conclusion: holep is a safe and eff ective surgical procedure. we hope our procedure will become the reference for beginners and urologists who are wishing to master it, but are worried about methods and complications. and also we hope holep will become the new gold standard for the treatment of benign prostatic hyperplasia. to obliterate the circular fi bers of bladder neck to the level of proximal urethra, carefully avoiding the external striated sphincter. laser power is reduced to w to prior to vaporization of any pseudomembranous trigonitis, which is commonly found in pbno or recurrent cystitis cases. results: laser vaporization is successful in relieving voiding diffi culties. th is procedure opens the bladder neck and allows for optimal post-operative urine fl ow. th e patient had improvement in both objective and subjective voiding functions immediately aft er treatment. during -months follow-up urofl owmetry, the maximum fl ow rate increased from to ml/s. th e postvoid residual urine decreased from ml to less than ml. conclusion: primary bladder neck obstruction in female can be eff ectively and safely treated with laser photoselective vaporization of the bladder neck. bilateral retroperitoneal laparoscopic nephrectomy using mm instruments introduction and objective: laparoscopy has become the standard nephrectomy approach. it has been shown that th e retroperitoneal approach is comparable to the transperitoneal approach when it comes to safety and results, even more, it can present advantages in selected patients, as in patients with prior abdominal surgery. th e use of mm instruments is gaining acceptance as a safe way to improve aesthetic results and minimize abdominal wall trauma while maintaining the principles of standard laparoscopy. we present the case of a -year-old woman with a history of radical hysterectomy and radiotherapy, aft er which she presents: ) bilateral ureteral obstruction that produces terminal renal insuffi ciency, and, ) vesico-vaginal fi stula, refractory to conservative treatment. th e decision is made to perform a bilateral retroperitoneal laparoscopic radical nephrectomy as a defi nitive treatment of the vaginal fi stula and as preparation for the kidney transplant. results: th e right nephrectomy is performed fi rst. classic retroperitoneal technique is used, using mm trocars (with an mm trocar to create the retroperitoneal space). on the left side, a previously produced nephrostomy catheter tract is used to insert a mm trocar. no relevant intraoperatory complications were observed. preoperative haemoglobin was g/l and the postoperative was g/l aft er transfusion of one bag of packed red blood cells. th e only postoperative complication was the infection of the mm left side trocar tract (where the previous nephrostomy catheter was placed). th e total hospital stay was days. th e pathological anatomy for both kidneys was: chronic pyelonephritis with extended interstitial fi brosis and tubular atrophy. conclusions: retroperitoneal laparoscopic nephrectomy is an effi cient and safe approach, comparable to transperitoneal laparoscopic nephrectomy, and even superior to this one in patients with previous abdominal surgery. th e use of mm instruments (in this case in a combined fashion), allows performing the surgery in a safe way, with superior aesthetic results. pure aft er complete mobilization of the renal artery three hem-o-lok clips were applied and the artery was transected. th e ivc was isolated upwards as far as possible, and intraoperative laparoscopic ultrasound was employed to identify the extent of the thrombus. aft er the inferior vena cava ivc was blocked using tourniquet loops above and below the thrombus and the contralateral renal vein was blocked, the ivc was opened and the tumor thrombus was extracted entirely. th e ivc was stitched with a running - polypropylene suture. th e specimen was extracted in an endoscopic extraction bag through a gibson incision. results: from february to june , fi ve patients underwent pure conventional retroperitoneal laparoscopic nephrectomy and tumor thrombectomy. th e mean patient age was yr ( - yr). th e mean operative time was min ( - min), and the mean estimated blood loss was ml ( - ml). th e mean length of tumor thrombus was . cm ( - cm). with a mean follow-up of . mo ( - mo), one patient was identifi ed lung metastasis four months postoperatively. introduction and objective: partial nephrectomy provides equivalent oncologic and superior functional outcome compared with radical nephrectomy over the short-and long-term. with the development of laparoscopic techniques and increasing laparoscopic surgical experiences, laparoscopic partial nephrectomy has become an acceptable alternative to radical nephrectomy for expert laparoscopic urologists to treat small renal mass. however, higher complexity tumors are associated with more resection of normal tissue, a longer warm ischemia time, and postoperative morbidity, especially entirely endophytic hilar tumor. in order to reduce normal tissue resected during laparoscopic partial nephrectomy for entirely endophytic hilar tumor, we develop a novel technique to deal with the higher complexity tumors. subject is a -year-old female with t a clear cell carcinoma with a diameter of . cm. th e tumor is entirely endophytic hilar tumor. renal nephrometry score is . she underwent laparoscopic partial nephrectomy in retroperitoneal approach. standard ports were placed. th e surgeon opened gerota's fascia and dissects along the renal capsule mobilizing the kidney from within gerota's fascia. th e resection line was marked using the laparoscopic ultrasound probe. aft er the renal artery was clamped by bulldog, tumor enucleation was performed using a cold scissor. one incision above the tumor was made, and careful dissection was performed to approach the tumor. th e tumor was completely mobilized outside its margin. th en the inner layer renal parenchyma and collecting system was sutured with - absorbable sutures and the outer layer renal parenchyma was sutured with absorbable suture. results: th e procedure was successfully accomplished without open conversion and transfusion. th e operative time was min, and the estimated blood loss was ml. th e warm ischemia time was min. histology revealed that the tumor was chromophobe renal cell carcinoma, and the surgical margin was negative. conclusion: laparoscopic partial nephrectomy for entirely endophytic tumor is challenging. tumor enucleation with one resection line can reserve more normal renal tissue during the procedure. more cases are needed to evaluate the effi ciency of the technique. introduction and objective: laparoscopic adrenalectomy by posterior approach carries high recovery and shorter operative time. children with metastatic high risk neuroblastoma arising from the suprarenal gland should undergo local surgical excision of the primary tumor before further intensifi cation of chemotherapy and possible bone marrow transplantation. herein, we report a video of left laparoscopic adrenalectomy showing the diff erent steps of the procedure. th congress of the sociÉtÉ internationale d'urologie -siu abstract book materials and methods: a . -year-old boy with left metastatic suprarenal neuroblastoma, received chemotherapy according to high risk european protocol. child positioned in prone position, fi rst trocar at the tip of the last rib by open introduction, two mm trocars one in costovertebral angle and the other is lateral. balloon development of the space, gerota fascia opened, the upper pole of kidney identifi ed, mass dissected, suprarenal vein is clipped during dissection, extraction in bag. results: oral feeding is begun aft er hours, discharge from hospital in the second day postoperatively, rapid convalescence, rapid resumption of chemotherapy. conclusion: laparoscopic adrenalectomy using posterior approach gives direct access to the adrenal gland, no peritoneal violation, rapid intestinal movement recovery, short hospital stay and rapid recovery. all advantages that might facilitate the early start of adjuvant chemotherapy in children with neuroblastoma, however, oncological outcome should be proven by long-term follow-up, larger number of patients, and good selection of small tumor facilitates surgical extirpation. introduction and objective: robotic multiplex partial nephrectomy (rmxpnx) is minimally invasive partial nephrectomy for three or more tumors in a single kidney. rmxpnx has been previously shown feasible with excellent preservation of renal function. we present our technique of off -clamp robotic transperitoneal multiplex partial nephrectomy in the treatment of multifocal and hereditary renal tumors. a prospectively maintained database was retrospectively queried to identify all patients who underwent rmxpnx from to . rmxpnx is defi ned a resection of or more masses from a single kidney. patients underwent rmxpnx when the largest tumor reached cm in size. tumors were excised using enucleation techniques. from the data of eligible patients, a representative patient was identifi ed and surgical video was edited to demonstrate the important aspects of the surgical technique. results: th e patient is a -year-old white male with von hippel lindau diagnosed with bilateral multifocal renal tumors with several tumors > cm in size. he underwent bilateral robotic multiplex partial nephrectomy separated by weeks with no operative complications. th irty fi ve tumors were excised from the right kidney. fift y two lesions were then resected from the left kidney. his preoperative creatinine was . and at year postop from bilateral multiplex partial nephrectomies his creatinine is . . in the hands of an experienced surgeon, off -clamp robotic transperitoneal multiplex partial nephrectomy is feasible, safe and eff ective in the treatment of multifocal and hereditary renal tumors. th is technique provides exceptional renal functional preservation and decreases technical diffi culty of reoperation. louie-johnsun m introduction and objective: th e advantages of minimally invasive laparoscopic surgery are well documented. as there are few urological emergencies suitable for a laparoscopic approach, the increased use of robotic surgery for elective procedures that can be performed equally as well laparoscopically threatens the acquisition of skills that can be transferred from these elective procedures (e.g. laparoscopic radical prostatectomy, pyeloplasty and partial nephrectomy) to emergency cases. in emergency situations, a robotic approach may not be feasible or practical. we highlight this with three recent cases. materials and methods/results: a video presentation of three of our recent urological emergency cases managed successfully laparoscopically which includes: ( ) a -year-old girl with neurogenic bladder presenting with urinary peritonitis aft er spontaneous rupture of an augmentation cystoplasty: laparoscopic adhesolysis and repair of perforated augmented bladder. ( ) an -year-old woman with intraoperative mid ureteric injury during laparoscopic right hemicolectomy: laparoscopic ureteroureterostomy and insertion of ureteric stent. ( ) a -year-old woman with ureterovaginal fi stula post laparoscopic hysterectomy: laparoscopic ureteric reimplantation with psoas hitch and insertion of stent. conclusion: despite the increasing use of robotic surgery in urology we encourage the continued training and dissemination of advanced laparoscopic skills in the elective setting to allow for the advantages of laparoscopy to be transferred to the less common urological emergency setting. robotic ureteric catheter placement; ) port placement with patient in lateral position; ) bowel mobilization; ) localization of lower calyx by intra-operative ultra sound probe; ) lower segmental nephrectomy; ) anastomosis (ureterocalicostomy) with - v-lock sutures over a pre placed f ureteric catheter and drain placement; ) changing of ureteric catheter to dj-stent on rd day post-operatively. results: th e procedure was completed successfully without any intra operative complications in all the cases. mean operative time was ± minutes and analgesic requirement of ± milligram of tramadol. none of the patients required blood transfusion. urethral catheter was removed on th and drain on th post-operative day and stent aft er weeks. one patient had clavien grade (pyrexia) complication. conclusions: robot-assisted laparoscopic ureterocalicostomy for secondary upjo is safe and feasible in expert hands. apart from the short recovery times, early mobilization, decreased analgesic requirements; robotic approach provides the added advantage of technical ease and precision of suturing. laparoscopic dismembered pyeloplasty for upjo in pelvic ectopic kidney apollo bgs hospital, mysore, india introduction and objective: renal ectopia is a rare anomaly and may be associated with pelvic ureteric junction obstruction (pujo). we report such a case with an ectopic pelvic kidney (l-type) with pujo and its successful laparoscopic management. th rough this report we emphasize the importance of adequate preoperative imaging and intraoperative details to avoid mishaps. a -year-old male was admitted with complaints of right-side lower abdominal pain of a dull aching type lasting months. ultrasonography revealed left pelvic kidney. th ese fi ndings were confi rmed with an intravenous pyelogram, which showed the left kidney low lying in the pelvic region with features of hydronephrosis and upjo. ct angiography revealed no crossing vessel as the cause of pujo. results: th e patient was taken up for transperitoneal laparoscopic pyeloplasty under general anesthesia. aft er creation of the pneumoperitoneum and with the ports in place, dissection was started and the dilated pelvis could be visualized through the peritoneal window. th e peritoneum was incised and the dilated pelvis on the left side was reached. aft er further dissection, the classic anderson-hynes dismembered laparoscopic pyeloplasty was done by using - vicryl. minimal excision of the redundant pelvis was required and because the kidney was not mobilized, nephropexy was not required. care was taken to avoid injury to the right ureter, which was coursing in close proximity to the left renal pelvis. preoperatively placed stent was retained and repositioned during the pyeloplasty. estimated blood loss during the procedure was around ml, and the procedure was completed in minutes without any intraoperative complications. th e patient could tolerate oral feeding on the evening of the same day. conclusion: th e upjo in ectopic pelvic kidneys presents a large spectrum of presentation. th e laparoscopic approach provides good surgical exposure, and operative times are compared to those of laparoscopic procedure in anatomically normal kidneys. laparoscopic we present laparoscopic radical cystectomy (lrc) and intracorporeal orthotopic ileal neobladder with two isoperistaltic aff erent limbs. a -year-old male patient with recurrent urothelial bladder carcinoma. ct demonstrates bulky bladder tumor in right lateral wall. lrc and intracorporeal urinary diversion were performed. six trocars were used in the procedure. aft er lrc and extended pelvic lymph node dissection were accomplished, a cm ileal segment cm proximal to the ileocecum was harvested, of which a cm proximal ileal segment was moved to anastomose with the end of the harvested segment which was right isoperistaltic aff erent limb. th en cm ileal segment was detubularisated leaving cm intact proximal ileum for left isoperistaltic aff erent limb. th e harvested ileal segment was symmetrically folded with identical limb lengths. th e posterior wall of the neobladder was sutured, and ileoureteral stents were delivered into the two isoperistaltic limbs and passed up the ureter and coiled into the renal pelvis, and one foley catheter was delivered into the neobladder at the same time. bilateral ureteroileal anastomoses were performed in a continuous manner respectively. th e anterior wall of the neobladder was closed and the posterior urethra was anastomosed with the neobladder. we have performed cases with this technique. all procedures were completed without open conversion. th e mean operative time was min with a blood loss of ml. th e construction time of the neobladder was min. th e time to orally allow was postoperative day in all. th e mean hospital stay was d. foley catheter and dj stents were removed on postoperative day . no major complication was occurred. conclusion: laparoscopic radical cystectomy and intracorporeal orthotopic ileal neobladder with two isoperistaltic limbs were a safe and feasible for experienced laparoscopic surgeons. however, more cases and long follow-up were required to evaluate the function of the novel neobladder. all in this video, we wanted to share our robotics augmentation ileosistoplasty experience in -year-old male patient with a diagnosis of neurogenic bladder. an -year-old male patient treated with clean intermittent catheterization and anti-cholinergic therapy for neurogenic bladder. bladder capacity was detected cc, the irregularities in the bladder contour and left grade vur was detected in control video urodynamics. so we decided to implement robotic augmentation ileocystoplasty to the patients. results: th e transperitoneal approach is performed by using veress needle to access the peritoneal cavity. th e abdomen was insuffl ated using co and trocars placed under direct vision ( of camera port ( mm), of da vinci ports ( mm) was placed and of mm and of mm assistant ports were placed). a cm segment of ileum with mesentery was incised with about cm proximal from the ileocecal valve and this segment was suspended. intestinal anastomosis was performed with - vicril and - monocril sutures and created a u-shaped ileal pouch. th e bladder was released from the surrounding tissue. about cm, longitudinal incision was made to the bladder. a single-j catheters were placed to the left ureter and bladder for the left ureteral catheter and cystostomy. th e bowel prepared for bladder augmentation and it was sutured with . pds with wate tight anastomosis. operation was terminated by placing the drainage catheter. introduction and objective: although their numerous indications make double-j stents frequently preferred in the armamentarium of the urological practice, serious complications can arise, if they are not used correctly. in endourological surgeries, due to type and stuff of material the breakage or fracture risk of the equipment is more. th ere are various types of surgical procedures for the removal of the foreign bodies. shock wave lithotomy (swl) and ureteroscopy (urs) are the fi rst step in the removal encrusted ureteral stent. th is report presents a case of successful forgotten ureteral stent removal by means of fl exible ureterorenoscope (furs) and fl uoroscopic imaging. a -year-old male patient was admitted to our clinic with the complaint of recurrent urinary tract infection. in his medical history he said that he had an open kidney stone surgery in and aft er months d-j catheter removal had been performed. aft er radiologic imaging it is determined that there are two d-j catheter pieces in the right kidney collecting system. furs and removal of foreign body was performed successfully. postoperative fi rst day patient discharged with no complication. results: various materials and coatings have been developed to avoid ureteral stent complications such as encrustation and infections. th e incidence of encrustation increases with the duration that the stent remains in place. th ere are numerous types of removal techniques for foreign body removal, however furs seems to be the better one with the minimal postoperative rates. our technique was performed easily and in a short surgery time. conclusion: flexible urs modifi ed with fl uoroscopy has particular advantages for treating encrusted ureteral stents. th is procedure is least invasive and is thus considered to be most suitable surgery for encrusted ureteral stents or foreign body materials in the kidney. results: we outline strategies to prevent diffi culties with urethro-ileal anastomosis during rarc iucd neobladder formation. furthermore we off er some key technical points that can be benefi cial in overcoming challenging urethro-ileal anastomosis. conclusions: due to the technically complex nature of rarc icud neobladder formation, the awareness of potential pitfalls during each step of the process is essential. issues and solutions discussed in this video provide a valuable resource for clinicians performing this procedure. robotic in this video we present a patient presenting with concomitant renal neoplasm and a large calculus in the renal pelvis that what was managed with robotic pyelolithotomy at the time of partial nephrectomy. results: aft er exposure of kidney the ureter was identifi ed. th e renal pelvis was exposed and pyelolithotomy was performed. aft er this hilum was clamped and partial nephrectomy and renorrhaphy followed. th e warm ischemia time was minutes. th e procedure was completed without any complications. patient was discharged on the second postoperative day. conclusions: although uncommon, the presence of concomitant stone and renal neoplasm can make the decision of optimal patient care more challenging. using robotic platform simultaneous management of both conditions can be accomplished in appropriately selected cases. single introduction and objective: female epispadias is a rare congenital anomaly and is classifi ed, into vestibular, subsymphyseal, and retro-symphyseal. historically treatment consists of staged repairs with urethral and vulvar reconstruction in fi rst stage followed by bladder neck reconstruction at a later age. in addition, staged procedures require multiple sessions of surgery and anesthesia, and are associated with relatively higher morbidity. recently single stage perineal urethroplasty has been used for epispadias repair. objective of the study is to evaluate the results of single-stage perineal urethroplasty with double breasting of the urethra and bladder neck and sphincteroplasty in female epispadias. we treated patients with severe female epispadias since to . age varied from to years (mean years). perineal urethroplasty with double breasting, sphincteroplasty, and genitoplasty was done in cases. th e urethral plate and bladder neck was mobilized from the surrounding tissue till bladder neck. a urethral mucosal strip of about to mm was denuded from the bladder neck to the end of urethral plate on one lateral edge, and tubularized over a f catheter. urethroplasty was done with double breasting of the urethral muscle margins starting from inside the bladder neck downward to the neo-meatus with corporoplasty, sphincteroplasty, and genital reconstruction. results: all patients were satisfi ed and happy about cosmesis. of the patients, were fully continent with a dry interval of to hours, one of them had occasional night wetting was put on anticholinergic. one was partially continent with dry interval of hours required anticholinergic. conclusions: perineal urethroplasty with double breasting of urethra, from inside the bladder neck to the neomeatus, resulted in continence in most cases because it increased the urethral and bladder neck resistance, as well as bladder capacity, all were important factors in continence. we advocate this procedure as a fi rst choice in all patients with female epispadias, because it is simple, safe, and eff ective for continence. single we had partial penile disassembly to have the advantage of both technique. so objective of the study was to evaluate the functional and cosmetic outcome of single stage partial penile disassembly repair in isolated male epispadias. a retrospective analysis of cases of primary epispadias repair, performed during july to july at our institution. patients were classifi ed on the basis of type of epispadias, urinary incontinence, presence/degree of chordee and penile rotation. exstrophy epispadias complex and secondary repair were excluded. surgical technique: penile de-gloving with mobilization of urethral plate from ventral to dorsal aspect with preservation of blood supply at both ends, distally up to the level of midglans and proximally up to pubic symphysis with division of penopubic ligament to lengthen the penis and position the urethra ventrally. tubularization of urethral plate followed by spongioplasty, corporoplasty with medial rotation of corporeal bodies (without any corporotomy) and glanuloplasty with meatoplasty to bring the meatus ventrally. skin cover with rotation of ventral fl aps and z-plasty when required. results: age of the patients varied from months to years with a mean of years. forty patients ( %) had excellent cosmetic outcome while three patients ( %) had minimal residual chordee/torque but didn't require any surgery in a follow-up to - years. all seven partially incontinent patients in the study group achieved continence aft er surgery. none of the patients developed complications like fi stula or stricture. all the patients in the post pubertal group reported normal erections and successful ejaculations aft er the surgery. post-operative follow-up ranged from - years with a mean of years. conclusions: th e technique incorporates all the benefi ts of cantwell ransley repair, needs less extensive dissection than total penile disassembly. both functional and cosmetic results are good with low complication rate. spongioplasty reconstructs near normal urethra and corporoplasty with spongioplasty also helps in prevention of urethral fi stula. introduction and objective: to introduce a unique technique, single port laparoscopic assisted extraperitoneal closure of patent processus vaginalis using j shaped bended spinal needle. materials and methods: a . -mm -degree laparoscope was inserted through an umbilical incision. th e scope could view both inguinal ring. j shaped bended g spinal needle was inserted just mm lateral to the internal inguinal ring. th e needle was introduced to the extraperitoneal space over the vas deferens and spermatic vessels, injecting of saline for the preperitoneal hydrodilation. a - polyester suture was threaded through an g spinal needle. same - polyester suture was threaded through a g spinal needle from the tip. along the guidance of the suture and g needle, j shaped bended g spinal needle was reintroduced to extraperitoneal space. g spinal needle traveled through the upper margin of internal ring, g needle tip was pulled out of the initial g needle punctured opening. - polyester suture was pulled outside from the g needle tip and then g needle is also withdrawn. aft er all these procedure, internal inguinal ring was completely encircled and tied extracorporeally. th e knot was buried in the subcutaneous area within the punctured needle hole. results: sixteen children underwent laparoscopic transcutaneous extraperitoneal (lte) repair of hydrocele by using j shaped bended spinal needle. all patients were discharged on the same day aft er surgery without any complication. during a mean follow-up period of months (range - mo), no recurrence has been observed except fi rst cases. th is lte technique is simple, fast, safe and cosmetic procedure for pediatric hydrocele. robot assisted laparoscopic ureteral reimplantation for girl and boy patients: differences and similarities introduction and objective: nowadays robot assisted laparoscopic extravesical ureteral reimplantation is getting famous and in the literature is being an alternative for gold standard open surgery. in our clinic we have performed ralur procedures in our clinic for vesicoureteral refl ux and ureterovesical stricture and with this video-abstract we would like to share our experience on ralur in girl and boy patients; diff erences and similarities of procedure. we have performed ral-ur cases in our clinic between july -april for pediatric and adult patients. technique: all procedures have been performed under general anesthesia. nasogastric tube and urethral catheter placed to all patients. for all procedures -port confi guration is used: two robotic mm trocar, one mm camera trocar and one mm (including mm cover) assistant trocar. following docking robotic working arms of robot is placed. in all procedures one monopolar curved scissors, one needle holder and one maryland bipolar forceps is used as the working arms. all procedures performed transperitoneally and extravesically. in the working area of the procedure girls have more structures compared to boys. uterus, fallopian tubes and ovaries are the risky structures for girls while the vas deferens in boys. as seen in the video fallopian tubes, uterus and vas deferens are extraperitoneal organs, but ovary is intraperitoneal organ. we create a peritoneal window to reach the retroperioneal space and to dissect the ureter. dissecting the ureter we have been very careful not to harm vas deferens in boys and fallopian tubes in girls. protecting this structures we open one peritoneal window in boys and two windows in girls to fi nd and to work with the distal part of the ureter. vessel tape is used to hang the ureters. th e bladder is elevated with a - straight needle vicryl suture through the abdominal wall. aft er that the ureter was clipped with a hemoloc clip and sutured with a - vicryl suture in watertight fashion (if necessary). aft er suturing the distal ureter tailoring for the dilated distal rest ureter is performed (if necessary). following detrusorotomy, mucosa is cut for the anastomosis (if necessary). before the ureterovesical anastomosis f nelaton or a dj catheter was placed inside the ureter (if necessary). ureterovesical anastomosis is made with a - monocryl suture (if necessary). in the cases that ureter and mucosa are not cut, realignment suture is used. detrusorraphy is performed by a - barbed suture. following detrusorraphy we repaired the parietal peritoneum to close the peritoneal window one line and two lines in boys and girls, respectively. results: ralur procedure has been used successfully in girls and boys by considering the anatomical differences. bleeding was minimal in all patients. all patients discharged at the nd or rd postoperative days. conclusion: while using ralur procedures in pediatric patients, surgeon must be aware of the anatomy. mistakes during the procedure may damage the reproductive system components. performing this procedure in children, compared in adult patients, there are diffi culties due to the small size of the abdominal cavity. with the appropriate trocar placement this problem can be solved. robot assisted laparoscopic left ureteral reimplantation for ureterovesical stricture introduction and objective: extravesical robot-assisted laparoscopic ureteral reimplantation (ralur) for vesicoureteral refl ux (vur), ureterovesical strictures (uvs) and ureteral pathologies are alternative to the gold standard open repair in the literature. with this video presentation we want to share our initial experience with robot-assisted laparoscopic extravesical ureteral reimplantation using the ureteral advancement technique for a -year-old boy patient who is the youngest patient received this intervention in turkey. we have performed ral-ur procedure for adult and pediatric patients in our clinic. th is patient explained in the video was a -yearold boy who has had recurrent infections due to this condition. when the patient applied to our clinic he had already grade left ureterohydronephrosis. we performed left sided ralur procedure for this patient. technique: th e davinci si system was used via a transperitoneal approach. we used a port confi guration for the procedure; one -mm trochar for optic, two -mm trochars for robotic working arms and one -mm trochar for assistance. th e patient was placed in a modifi ed trendelenburg (approximately °) position. aft er docking the robotic arms, the ureter is identifi ed closed to the vas deferens. th e ureter is dissected distal to the vas and tented up with a tape. th e bladder is elevated with a - straight needle vicryl suture through the abdominal wall. a cm detrusorotomy is performed". aft er that left ureter was clipped with a hemoloc clip and sutured with a - vicryl suture in watertight fashion. aft er suturing the distal ureter tailoring for the dilated distal rest ureter is performed. before the ureterovesical anastomosis f nelaton catheter is placed thorough urethra and bladder inside the left tailored ureter. following this application nelaton catheter is binded to the urethral catheter. ureterovesical anastomosis is made with a - monocryl suture. detrusorraphy is performed by a - barbed suture. following detrusorraphy we repaired the parietal peritoneum and fi nished the procedure. foley catheter, nelaton catheter and drain are left at the end of the procedure. rectourethral fi stula is a morbid complication that can occur post trauma, radical prostatectomy, radiation, or pelvic surgery. th e management of these cases can be challenging and might require multiple procedures to achieve cure. th e use of omentum fl ap between the rectum and the urethra is recommended for its potential benefi ts in prevention of fi stula recurrence. we aim to illustrate the feasibility and safety of a new laparoscopic surgical technique for interposition of omentum in patients with complex pelvic fractures urethral injury (pfui) and rectourethral fi stula (ruf). we performed prospective case series of patients with pfui and ruf from september till october . th e initial approach is perineal with continued dissection until urethral transaction. laparoscopic team mobilises omentum and enters retroperitoneum lateral to bladder. a tvt needle is passed from perineum hugging the posterior wall of pubic symphysis and enters peritoneal cavity. th is tract is dilated and omentum transposed in to perineum. th is omentum is used as interposition between urethral anastomosis and rectum. th e clinical outcome was considered a failure when any instrumentation was needed or the recurrence of ruf. th congress of the sociÉtÉ internationale d'urologie -siu abstract book results: median age is years (range - ). all patients had complex pfui with ruf. th ey all had an attempt of perineal anastomotic urethroplasty with ruf repair that failed outside our center and were referred to us subsequently. all the patients had supra pubic catheters and of the three patients were passing urine through the rectum and the urethral meatus. one of the patients had a loop colostomy that was closed during the fi rst failed surgery. no intra-operative or post-operative complications occurred. patients were discharged home on post-operative day . all patients had the urethral catheter removed aft er weeks. th ree-month follow-up shows no fi stula recurrence with good urine fl ow. conclusion: using our new technique of laparoscopic omentoplasty for interposition of omentum in patients with ruf post pfui is a viable and safe option. th is allows us to perform a perineal surgery with the benefi t of omental interposition using a minimally invasive technique. further studies with larger number of patients as well as longer follow-up would be needed. introduction and objective: to test the hypothesis that a new surgical technique using elaborated perineal anastomotic urethroplasty combined with laparoscopic omentoplasty for patients with complex and prior failed pelvic fracture urethral defect repair was feasible, safe, and eff ective. we performed a prospective, observational, stage a study to observe treatment outcomes of combined perineal and laparoscopic approach for urethroplasty in patients with pelvic fracture urethral defect at a single center in pune, india, between january and february . complex and redo patients with pelvic fracture urethral defect occurring aft er pelvic fracture urethral injury were included in the study. anterior urethral strictures were excluded. th e primary study outcome was the success rate of the surgical technique, and the secondary outcome was to evaluate feasibility and safety of the procedure. th e clinical outcome was considered a failure when any postoperative instrumentation was needed. results: fift een male patients with a median age of years were included in the study. seven patients were adolescents ( - years) and patients ( . %) were adults ( - years). th e mean number of prior urethroplasties was . (range, - ). all patients underwent elaborated bulbomembranous anastomosis using a perineal approach with inferior pubectomy combined with laparoscopic mobilization of the omentum into the perineum to envelope the anastomosis and to fi ll the perineal dead space. of patients, ( . %) were successful and ( . %) failed. one adolescent boy years old developed a recurrent stricture months aft er the procedure and was managed using internal urethrotomy. median follow-up was months (range, - months). conclusion: combining a laparoscopic omentoplasty to a membranobulbar anastomosis for complex and redo pelvic fracture urethral injury is successful, feasible, safe, and with minimal additional morbidity to the patient. th e technique has the advantage of a perineal incision and the ability to use the omentum to support the anastomosis. dorsal results: buccal mucosal graft urethroplasty was done in all the patients with the graft being harvested from the buccal mucosa of the oral cavity. postoperative evaluation was done with voiding cystourethrogram at the time of catheter removal during the th postoperative week. mean peak urinary fl ow rate increased from . ml/sec to . ml/sec with normal fl ow curve stabilised at months to a mean of . ml/sec. patients were followed at , , and months in the fi rst year and then monthly thereaft er with urofl owmetry and ultrasonogram. mean follow-up period is around months. two patients required urethral dilatation for recurrence of symptoms. none of the patients developed stress urinary incontinence during follow-up. conclusions: female urethral stricture disease is under diagnosed and bmg urethroplasty is underutilised. our study adds to the limited evidence base, that bmg urethroplasty can be done safely with good results in females. a introduction and objective: ureteral fi stula's treatment oft en includes long and complex surgical and endoscopic therapies and represent a challenge for the urologist oft en with disappointing results. uventa® stent placement could represent a new option of conservative treatment for ureteral fi stulas. materials and methods: uventa® self-expanding ureteral stent are able to restore urinary fl ow in ureteral stenosis and to facilitate the closure of ureteral fi stulas thanks to its triple layer structure made of two layers of metal mesh with interposed a ptfe membrane. uventa® stents are available in diff erent lengths and diameters, and allow the coaxial overlap of the ends of multiple stents, providing a lumen of large caliber able to ensure the proper urinary fl ow and the possibility of further endoscopic procedures. we show the case of -year-old man that in september , undergone to pelvic surgery for an adenocarcinoma of the sigma in advanced stage. th e postoperative period revealed a urinary leakage, dealt initially in conservative way by the general surgeon. due to unsatisfactory results, the patient was then evaluated by the urologist and subjected to bilateral ascending pyelography highlighting the presence of a high fl ow left ureteral fi stula in pelvic tract; he case was managed immediately with bilateral ureteral stenting prior to placement of a uventa® stent. th e subsequent step was a retrograde pyelography through the left stent, used to identify the site of the ureteral fi stula. aft er hydrophilic guidewire positioning and mono-j stent removal, the delivery system of the uventa® stent is advanced coaxially to the guidewire under radiologia control. once reached the desired position the stent is released from its delivery system whit pull-back technique playing a uventa® stent fr x cm allowing its simultaneous self-expansion. th e next ureteroscopic control has shown the need to placement of an additional uventa® stent to complete fi stula's coverage. following the insertion of a hydrophilic nitinol guidewire a new uventa® stent fr x cm has been positioned further in order that the ends of the two stent's overlap for a length of at least cm. results: intraoperative retrograde pyelography showed that the stent have eff ectively excluded the fi stula. th e absence of contrast medium leakage was also documented by retrograde cystography performed after days from stents positioning. conclusions: in our experience, the application of uventa® stent has proven to be an eff ective option in the conservative treatment of minimally invasive ureteral fi stulas. robotic we performed fi ve robotic ureteroplasties using a buccal mucosal onlay between september and march . th e graft was procured by our otolaryngology colleague (jcl). th e graft onlay was performed using - pds suture and stent was placed robotically. stent was left in place for - weeks, and imaging repeated aft er removal. results: table describes each case and the outcomes observed. th e three patients who have undergone stent removal and reimaging had complete success and resolution of obstruction. th ere were post-operative complications, and none were higher than grade iii (table ) . table shows the demographic and perioperative variables of the patients undergoing this procedure. conclusion: our technique of robotic buccal mucosal ureteroplasty is safe and eff ective. we believe this is a relatively simple technique which is easily replicated. long-term data will be important to prove the validity of this procedure. primary endoscopic realignment of rupture urethra introduction and objective: pelvic fracture urethral injury (pfui) is more common in india and subcontinent. th ere is no consensus on the initial management of this injury. th ere are two schools of thoughts in all cases of suspected or confi rmed urethral rupture: a) initial supra-pubic catheterization (spc) followed by urethral reconstruction of inevitable stricture; and b) realignment of urethra. we demonstrate method of primary endoscopic realignment of rupture urethra and review the literature comparing these two procedures. a /m-presented with retention of urine and bleeding per urethra. he had sustained pelvic trauma when he was crushed between a tank and a wall. aft er initial resuscitation he had x ray pelvis, ct abdomen, rgu. he then underwent spc under ultrasound guidance. on th day aft er spc he underwent primary endoscopic realignment of the rupture urethra. we have shown a technique and reviewed the relevant literature emphasizing advantages of realignment. results: we used a two endoscopes technique one each from the spc route and per-urethral route. intra-operative contrast study was done to see extent of injury and also to see possible patency and continuity of the urethra. additionally methylene blue study was also done. a ptfe guide wire (gw) was passed from below. at the fi rst site of the gw from above it was apparent that further manoeuvers such as "going for light" would not be required. th e gw was carefully pulled in suprapubically. a silicon foley catheter ( f) was gently passed perurethrally over it. th e position of catheter was confi rmed suprapubically. patient had no major or minor complication. catheter was placed in for weeks and removed. post catheter removal patient voided well. th ese results correlated well with other studies in the literature. conclusion: ) technically not a challenging procedure. ) low risk and low complication rate. ) one failure of procedure does not preclude further attempts. ) adequate experience and instrumentation are essential. ) level evidence in favor of this approach over spc alone and further urethroplasty. neourethra with penile skin flap after total amputation of the penis kulkarni s, joshi p, batra v, sharour w, hunter c, surana s, kulkarni j introduction and objective: urethral carcinoma is a rare oncological entity. th e standard treatment for invasive urethral squamous cell carcinoma is radical penectomy, prostatectomy, cystectomy and ileal conduit. in our technique, we describe a palliative surgery that avoids the ileal diversion and perineal urethrostomy through the use of dorsal penile skin tubularization. th is video represents a detailed, step-by-step technique for retro auricular graft harvesting that we have found facilitates resident and general urologist teaching. ears were prepped and draped. th e grafted was areas were marked bilaterally. diluted lidocaine with epinephrine was injected subcutaneously. th e graft was harvested using sharp scissors. donor site was closed in two layers with minimal aesthetic changes. conclusions: our technique to harvest retroauricular graft is a simple and reproducible. it is useful in patients with lack of bmg. th is step-by-step video could be a useful resource for residents and general urologist who wish to learn an alternative graft . hand combined antegrade and retrograde intraureteric surgery in re-implanted ureter introduction and objective: we review a case of re-implanted ureter complicated with stricture and stone impaction. a -year-old gentleman was following the urology department at hmc. between the year until he was managed by the same urology team for his multiple urological complaints. diff erent open and endourological approaches were conducted. at the year of , this gentleman was complaining of colicky pain due to a cm impacted stone in the left lower ureter, sessions of eswl failed to break it. ivu showed left ureteric stricture, cystoscopy with trial of ureteroscopy was unsuccessful because the left ureteric orifi ce couldn't be identifi ed, so left percutaneous nephrostomy access inserted and followed by antegrade fl exible ureteroscopy, small opening found at the lower part of mid ureter and opened widely by laser, then followed by antegrade double j stenting. retrograde rigid ureteroscopy french identifi ed the stone at mid ureter in a later session and fragmented by laser. a double j stent was reinserted and removed later with smooth recovery. results: management of stones, in the male urethra, is a challenge, more so in a reconstructed urethra. th e dilemma always is whether it is worth incising an otherwise normal or reconstructed urethra, to extract a calculus, especially in this minimally invasive era. th e point to note is the 'painting' technique used to powder the stone, rather than fragmenting the stone into large fragments, which are then diffi cult to remove. high frequency and low energy laser setting is the order of the day. conclusion: laser lithotripsy using a high frequency low energy setting, is a good option for urethral calculi in a reconstructed urethra. retrograd introduction and objective: uretery duplication is a most common congenital anomaly of upper urinary system. th e incidence of it, in autopsy and intravenous pyelography (ivp) series, is . % and - % respectively. it is two-fold more frequent in women than men. retrograde intrarenal surgery (rirs) is a new technology in stone surgery with the fl exibility and most eff ective visualing. in patients who suff er from kidney or uretery with ureter duplication, rirs become the best surgery choice with its advantages. in this case, we present a patient who have the symptoms of kidney stone and ureter duplication. a -year-old male patient applied our clinic with the left fl ank pain. in his intravenous pyelography (ivp) and computerized tomography, it was clearly seen left ureter duplication of which both ureteropelvic junction and duplicated ureters obstructed by two kidney stones. other laboratory tests were normal. rirs surgery was performed the patient successfully. postoperative fi rst day patient was discharged without any complication. results: ureter duplication is a rare congenital anomaly of upper urinary system but the rarest thing is that the obstruction of both duplicated ureters with upj by kidney stones. in our case this kind of case successfully treated by rirs. in this surgery a new technique of access sheet entering for rirs was applied. to our knowledge it is the fi rst case in literature. surgical procedures in patients with urinary tract abnormalities are more diffi cult than the normal anatomy. th e development of new technologies is changing approach to such cases. rirs fi eld of use is gradually increasing in urologic practice. rirs in is a preferable method in duplicated ureter with stone formation. a introduction and objective: nephron-sparing surgery is now the standard of management of small renal mass and is increasingly performed for larger and more challenging lesions. th e aim of this study is to report our experience with robotic partial nephrectomy (rpn) and lapascopic partial nephrectomy (lpn) in patient's surgical outcome (blood loss, wit los renal function, complication). ( )) aml (rpn ( ) lpn ( )), oncocytoma (rpn ( ) lpn ( )) and simple cyst (lpn ( )). th e positive surgical margin rate were both % in rpn and lpn group. th e decline in glomerular fi ltration rate at the last available follow-up was similar in both groups. laparoscopy training at home guijarro a, ascencios j, morales s, huertas j, fernández b, navarro f, paniagua p introduction and objective: th e increasing use of laparoscopic surgery makes training fundamental to acquisition of the basics techniques of endourology. unfortunately, laparoscopic fi eld requires high ability and a long learning curve so it's needed simulators to practice. traditional pelvitrainers improve the laparoscopic skills of a trainee but don't simulate the real conditions of the human body. we present a homemade training surgical model that may help to achieve the skills needed and simulates the abdominal space. it is called simulated environment for laparoscopic training (selt). we have developed a laparoscopic training system based in a simulated environment. we modifi ed a dummy who represents a human trunk, this model it easy to fi nd in hardware stores. th en, we performed several orifi ces in order to place traditional laparoscopic ports in pelvic surgery disposition and two additional for our camera. inside the dummy we placed three screws and developed another hole for attaching a cork panel. also, we used a wardrobe fl ashlight as lighting system. as optical system we have used a inch tablet or a photographic camera linked to the tv. finally, for reproducing a vesicourethral model we use two balloons in order to create an anastomosis between them. final price for the selt model, excluding optical system and disposables (we used discarded ports) was euros, what is signifi cantly lower than the commercial pelvitrainers. time needed for installing all the devices is about minutes. results: th e level of simulation is high, it is more realistic, being harder and diffi cult than "traditional" pelvitrainers. th e degree of movements is limited by the real placement of the ports, distance until exercise is similar and we have to be able to work without results: nine patients underwent tmc left pyeloplasty. th ere were female and male patients with age ranging from - years .operating time ranged from - minutes with mean of minutes. per-operative blood loss was minimal ranging from - ml. return of bowel movement was within - days. all patients were discharged within days and drain removed with - days. two patients were discharged on nd day but drain was removed on rd day in outdoor. follow-up of patients showed improvement in their pain status and ivu showed no re-stricture or stenosis. our last patient is yet to come for the fi rst follow-up. conclusion: tranmesocolic approach for left puj obstruction is feasible and seems to have low morbidity with shorter hospital stay. comparison with colon-refl ecting pyeloplasty and larger number of cases are needed for better statistical evaluation. transperitoneal conclusion: th e overall cdr ( %) for our cohort was comparable to results from mri in-gantry biopsy. in volumes > cm , the cdr was % which was signifi cantly higher than that achieved by historical trus controls. th is study reinforces the benefi t of fusion biopsy in prostates in all volumes, but this utility is further enhanced in large volume glands without the potential toxicity associated with increased number of biopsies. fusion mim-transperineal fusion biopsy has the greatest impact in the biopsy naive population results: during the above mentioned period patients underwent radical prostatectomy. in ( . %) cases erp was preceded by mpmri and psm was detected in of them ( . %). in the majority of patients ( / ; . %) with positive margins pca was locally advanced or gleason score was greater than . th e margin was focal in ( . %) cases. th e most frequent location of psm was the prostate apex. it occurred in patients ( . %) and in of them the right side was involved. in ( . %) patients psm was detected in a location in which mpmri did not reveal the presence of pca. in of them, cancer invaded periprostatic tissues. macroscopic evaluation of the specimen performed directly aft er the erp indicated the possibility of psm presence only in patients but in both cases histological evaluation of the prostate specimen revealed extensive psm. the peri-prostate fat seen on mri. prostate volume was calculated using (height x width x length x π)/ . peri-prostatic fat density was then calculated using peri-prostatic fat volume/ (peri-prostatic fat volume + prostate volume). peri-prostatic fat ratio was calculated using (peri-prostatic fat volume / prostate volume). intervention includes cryoablation, brachytherapy, prostatectomy, external beam radiation with or without androgen deprivation therapy. results: a higher periprostatic fat density is signifi cantly associated with a higher gleason score, p= . , odds ratio . . a higher periprostatic fat ratio is also associated with a higher gleason score, p= . odds ratio . .patients with a higher prostate fat density (p= . , odds ratio . ) and higher peri-prostatic fat ratio (p= . , odds ratio . ) was also more likely to undergo intervention for prostate cancer (table ). psa has no correlation between periprostatic fat and periprostatic fat ratio. a higher prostate fat density and fat ratio is signifi cantly associated with a higher gleason score and a higher likelihood of patient undergoing an intervention for prostate cancer. peri-prostatic fat density and fat ratio may be an important risk factor in diagnosing patients higher grade prostate cancer. laparoscopic . th e mean urinary ph among the diabetics was . ± . and among the non-diabetics was . ± . , which was signifi cantly lower (p< . ). conclusions: th ere is a strong association between type diabetes and uric acid stone formation. th ere is also a strong association between diabetes mellitus, bmi, and also with lower urinary ph. the most patients ( %) were discharged on good condition while one patient died post-operatively. majority of patients ( %) stayed in the ward more than days post operation, the long-term post-operative outcome is yet to be assessed. conclusion: usd in our local setting seem to aff ect people of low social economic status whose daily activities in the fi elds, livestock keeping etc. mean survival; therefore longer stay in the hospital has a detrimental economic impact. outdated diagnostic, treatment equipment and technology lead to prolonged hospital stay. th ere is a need therefore for administrators and urologists in tanzania to improve quality of management of usd by acquiring aff ordable equipment and technologies. percutaneous nephrolithotomy in an ambulatory setting introduction and objective: percutaneous nephrolithotomy (pcnl) is the gold standard for the surgical management of large renal stones. various modifi cations have been done over a period of time to bring down the morbidity of this procedure. ambulatory pcnl (a-pcnl) aims at short hospital stay which is less than hours with faster recovery aft er pcnl. th is study aimed at exploring the feasibility and safety of short stay ambulatory pcnl. : th e number of pcnl procedure done at our institute annually ranges between - . hence, carefully selected patients with single renal calculus, size< cm, bmi < kg/m , favorable anatomy, no medical co-morbidities and moreover patients staying within a radius of km to the hospital with a supportive well informed family were given the option of a-pcnl. a total of patients underwent a-pcnl from april to june . all patients underwent totally tubeless pcnl with single puncture, amplatz size < f, minimal saline irrigation and puncture site infi ltration with . % bupivacaine. postoperatively narcotic analgesics were given; catheter was removed in the post-operative ward and patient was discharged within hrs. patients were explained regarding the complications of the procedure and need for homecare management. results: ten out of patients had insignifi cant post-operative period. one patient returned aft er hrs with loin pain which was evaluated and managed with injectable nsaid. another patient had hematuria which resolved aft er hours with conservative management. introduction and objective: chronic kidney disease (ckd) is associated with increased cardiovascular (cv) disease, independent of other risk factors. it is unclear whether anaemia develops in the setting of nephrectomy induced ckd, and whether it leads to an increased risk of cv morbidity. we assessed the impact nephrectomy has on renal function and evaluated our cohort for the presence of anaemia in relation to ckd stage and cardiac specifi c morbidity. pre-operative, post-operative, and yearly creatinine, hb and hct (up to years) was collected from nephrectomy patients between and . th e cohort was stratifi ed by cardiac risk factors and the prevalence of anaemia was stratifi ed by each ckd stage. we collected all-cause mortality and cv morbidity and mortality data. statistical tests were two-sided. where data was non-normally distributed median values and non-parametric tests were used. results: th e eff ect of nephrectomy on renal function is immediate (pre-operative vs. post-operative cr: p= . ) but not progressive (post-operative vs. -year cr: p= . ). elderly patients, patients with ≥ risk factors, bmi≥ or hypertension had signifi cantly higher post-operative cr (p= . ; p= . ; p= . ; p= . ). advanced age and mild ckd were important risk factors for ckd stage progression. th e prevalence of anaemia increased as ckd stage increased. at one year, the prevalence of anaemia was highest in ckd- patients ( . %), compared to ckd- ( . %) and ckd- ( . %) patients. fift een percent of patients experienced a new cv event; % of these patients were anaemic. conclusion: nephrectomy leads to immediate renal function deterioration but with no progression over time. th e clinical impact of nephrectomy is especially important in elderly patients and in patients with mild pre-operative renal impairment. th e prevalence of anaemia is more common in patients who have a higher ckd stage aft er nephrectomy, and may be a key risk factor for cv morbidity in nephrectomy patients. we believe that it is important to be able to predict who will progress to clinically signifi cant ckd, in order to optimise comorbidities and aggressively treat complications of ckd, such as anaemia. renal results: urological complication were observed in . % of all transplants. in an early phase we found that . % of patients showed problems related to the ureterovesical suture (loosening of the suture or attaching the double-j stent in the suture). suspicion of leakage with the formation of a urinoma was noted in . % of cases. more frequent were the late urological complications: hydronephrosis was seen in . % of cases. when further analyzing this group we discovered a distal ureteral stenosis in . % of all transplants. persistent hydronephrosis was resolved by reimplantation ( . %), permanent nephrostomy ( . %) or placement of a double-j stent ( . %). a large group of late complications consisted of infectious pathology. th us . % suff ered from complicated urinary tract infections which slightly more than a quarter of this population presenting with hydronephrosis. recurrent urinary tract infections without complications were found in . % of transplanted patients. conclusion: currently, the urological team mainly plays a role in the pre-and post-operative phase of renal transplantation. given the signifi cant compli-cations associated with the ureterimplantation performed during kidney transplantation, we advocate a place for the urologist in the perioperative phase as well. since the majority of the complications could be related to refl ux pathology, we propose a ureterimplantation with anti-refl ux mechanism. and october , patients were prospectively randomised into two groups. all patients presented with a simple renal cyst underwent ultrasonographic aspiration and injection of a sclerosing agent. in group , patients had the cyst injected with eo, and in group , were treated with ae. one injection was used in cysts of < ml and two injections were used in larger cysts. complete and partial success were defi ned as complete cyst ablation or a > % reduction in cyst volume with symptomatic relief, respectively. patients were followed up using semi-annual ultrasonography and computed tomography for years. results: sclerotherapy was technically successful in all patients. th ere was no signifi cant diff erence in cyst volume between the groups. aft er years of follow-up there was complete symptomatic relief in both groups, and the overall radiological success rate was % of both groups, at % complete and % partial in group , and % complete and % partial in group . th e frequency of transient complications in the form of microscopic haematuria was % and %, and of low-grade fever was % and % in groups and , respectively. a composite outcome parameter, known as "trifecta", has been recently proposed as measure of the surgical quality for partial nephrectomy (pn) procedures. we aim to validate the value of "trifecta" as a predictor of operated kidney functional preservation in a multi-institutional cohort of patients undergoing minimally invasive pn. we retrospectively reviewed records of consecutive cases of minimally invasive (laparoscopic and robotic) pn performed for ct renal masses in centres from usa and europe from to . inclusion criteria consisted of availability of a renal scan obtained within two weeks prior to surgery and follow-up renal scan - months aft er the surgery. trifecta was defi ned as a combination of negative surgical margin, zero perioperative complications and warm ischemia of less than minutes. th e primary endpoint of the study was to compare the degree of ipsilateral renal function preservation in relation to achievement of trifecta. renal function preservation was defi ned as a proportion of post-operative to pre-operative split renal function assessed by mag renal scan. a multivariable linear regression model was used to determine the independent value of several factors (surgical modality, charlson comorbidity score, achievement of trifecta, r.e.n.a.l score) to predict ipsilateral split function preservation. th e logic was that pnet is chemo-responsive and remaining are not. results: a total of patients were identifi ed. th e various histo-pathologies are shown in table . group had and group had patients. mean age in group was . yrs ( - yrs) with ( %) males and ( %) females. tumor was right-sided in ( %) and left -sided in ( %) cases. th e mean tumor size was . ( - ) cm. necrosis was noted in ( %). level of thrombus was level i in , level ii in , level iii in and level iv in . mean age in group was . yrs ( - yrs) with ( %) males and ( %) females. tumor was right-sided in ( . %) and left -sided in ( . %) cases. th e mean tumor size was . ( - ) cm. necrosis was noted in ( %). level of thrombus was level i in , level ii in , level iii in and level iv in . one of these was diagnosed pre-operatively by a biopsy and had received chemotherapy with partial tumor shrinkage. remaining received adjuvant chemotherapy. of relevance is that the youngest patient in group was years whereas the oldest patient in group was years. in patients with renal tumors and venous thrombus who are younger than years, pre-operative biopsy should be contemplated. in patients with a diagnosis of pnet, neo-adjuvant chemotherapy can be studied. introduction and objective: th e use of nephrectomy in emergency is increasingly rare due to the improved critical care urinary sepsis and development of radio-embolization. few series have been reported on this subject. th e aim of our study was to evaluate current indications, morbidity and mortality and results of nephrectomies performed in our hospital in emergency. a single-center retrospective study was conducted from january to december . twenty patients were operated in emergency from total nephrectomy. results: nine women and men with a mean age . ( . to . ) were treated for sepsis on emphysematous pyelonephritis or renal abscess, trauma with haemorrhagic shock, acute bleeding on renal tumours with haemorrhagic shock. one patient required critical care for multiple organ failure. th e time between the initial care and surgery was . days ( . - ). ten patients were referred to the emergency room by their physician and by a peripheral hospital. all these nephrectomies concerned native kidneys ( left kidneys). surgical approach was a lumbotomy for patients and a median laparotomy for patients. one patient died of multiple organ failure following urinary sepsis. one patient required dialysis following nephrectomy. th e mean follow-up aft er surgery was . months ( . to . ). conclusion: th e nephrectomy in emergency remains anecdotal. uncontrolled urinary sepsis were the main indications. th e identifi cation of populations at risk of progression to septic shock is essential for faster and reduced mortality in sepsis care. experiences of adrenalectomy for the incidentally discovered adrenal masses introduction and objective: a diagnosis of urinary tract obstruction (upjo) results in a functionally signifi cant impairment of the urinary transport from the renal pelvis to the ureter. options for the surgical management of upjo include ureteral stent placement, balloon dilation (antegrade, retrograde or cutting balloon), endopyelotomy, and open or laparoscopic pyeloplasty. however, in some cases, surgery is not eff ective, or too invasive for a particular patient. we herein report ten cases of treatment using bethanecol chloride. we retrospectively reviewed the record of patients, men and women, aged - years (mean . ) whose diagnosis was upjo ( cases of hydronephrosis on the left , on the right). th e chief complaints were back pain ( cases) and urinary tract infection ( cases). one patient had no complaint. all patients took mg of bethanecol chloride times a day for two weeks. aft er two weeks, kidney condition was evaluated using ultrasonography. results: five cases of hydronephrosis decreased or disappeared. five cases showed no improvement. among the latter, one had pyelonephritis, two had received laparoscopic pyeloplasty (one of whom had a non-functioning kidney and a pyelonephritis), and another had a non-functioning kidney. guzman martinez-valls p, sanchez rodriguez c, doñate iñiguez g, maluff torres a, honrubia vilchez b introduction and objective: we present man -yearold, hypertensive, diagnosed incidentally of intrathoracic renal ectopia during a constitutional syndrome study. intrathoracic renal ectopia is a very rare fi nd, with an incidence of less than of every , , which mainly aff ects left kidney since the liver protects the right diaphragm from pressure changes. a literature review of incidence, source, clinic, diagnostic and treatment of this type of renal ectopia occurs and we present the case diagnosed in our service. : chest x-ray shows a mass back in mediastinum so it was decided to ask for tomography computer (ct) that shows a hernia left postero-lateral difragmatic with promotion to the thoracic cavity of upper pole and half of the left kidney. since the patient is asymptomatic and the hernia is extrapleural does not need repairing surgical treatment. annual checks will be. intrathoracic renal ectopia is a very uncommon, usually asymptomatic, fi nding oft en diagnosed incidentally and which does not usually require treatment. surgical ( ), non-clamp zero ischemia ( ). th e average blood loss was ml (range ml - ml) and patients ( %) required blood transfusion. postoperatively patients ( %) had surgical complications: severe haemorrhage requiring emergency completion nephrectomy ( ), post-operative urinoma formation requiring ureteric stenting ( ), pneumothorax requiring tube thoracostomy ( ) . early day mortality occurred in one patient with pre-existing stage chronic kidney disease who died of acute on chronic renal failure. th e r.e.n.a.l. score of those with and without surgical complications was . and . respectively. th e complication rate of low (score - ), intermediate (score - ), and high (score - ) r.e.n.a.l. category was . %, . % and % respectively. statistically, blood loss, transfusion rate and surgical complication rate were not signifi cantly associated with medical co-morbidity, r.e.n.a.l. score or mode of ischemia, although more complex mass apparently resulted in more surgical complications. our study suggested that partial nephrectomy is a safe operation with acceptable bleeding risk and low complication rate. further larger scale study is needed to analyze the correlation of complications with renal mass complexity. introduction and objective: th e sound of running water has been eff ectively used for toilet training during the toddler period. however the eff ect of the sound of running water (srw) on voiding function for adult male with lower urinary tract symptoms (luts) has not been evaluated yet. to determine the eff ect of the srw on urination of male patients with luts, multiple voiding parameters of urofl owmetry with postvoid residual urine (pvr) were assessed according to the presence of the srw played by mobile application. a statistically pre-calculated numbers of consecutive male patients with luts were prospectively enrolled between march and april , excluding patients with hearing impairment, disability for movement, neurologic disease, urology deformity, and recent history of urinary tract infection or urethral stricture. urofl owmetry with pvr measured by bladder scan were randomly performed once a week for two consecutive weeks with and without srw in a completely sealed room away from exterior noise aft er pre-checking bladder volume scanned to be more than cc. th e srw was played with river water sound among relax melodies recorded in the smart-mobile application. results: th e mean age of enrolled patients and their mean ipss were . ± . years (range: - ) and . ± . . all patients have not been prescribed any medications including alpha-blocker or anti-muscarinic agents in the last three months. a signifi cant increase in mean peak fl ow rate (pfr) with srw was detected in comparison with pfr without srw ( . ml/s vs. . ml/s, p = . ). however, there were no diff erences in other urofl owmetric parameters including pvr. materials and methods: over a two-year period, men underwent lumbar spinal fusion by a single neurosurgeon. we excluded men with previous prostate or urethral surgery, a history of urinary retention, men taking alpha-blockers or fi ve alpha-reductase inhibitors, and men with prolonged hospital stay, leaving men evaluable. all men left the operating room with a foley catheter in place and were given a void trial on the day of anticipated discharge. twenty-three men were unable to void aft er eight hours and had their foley catheters replaced; they were discharged next day with an appointment for urologic follow-up. th ese men were compared to successful voiders with respect to comorbid medical conditions, age, surgical placement of hardware, operative time, lumbar level, multiple level fusion, and surgical approach. results: using multivariable analysis, successful postoperative voiders were compared with men who failed the initial voiding trial. only insulin-dependent diabetes mellitus (p-value less than . ) and multiple lumbar level surgery (p-value less than . ) were predictive of initial postoperative failure of voiding trial. conclusion: men scheduled to undergo lumbar fusion who have insulin-dependent diabetes or who will require multiple level intervention may benefi t from preoperative initiation of alpha blockade at the time of scheduling, as well as an inpatient postoperative urologic consultation. introduction and objective: heart rate variability (hrv) is a tool to measure autonomic nervous function, however there is no evidence that it is able to defi ne sympathetic hyperactivity in men with luts. we suppose that luts is diff erent between sympathetic hyperactive and hypoactive patients. th erefore we measured their hrv, divided luts patients into two groups, sympathetic hyperactive group and sympathetic hypoactive group according to the lf/hf ratio, and then compared their clinical situations. a total of symptomatic luts patients (ipss> ) and healthy volunteers were enrolled. all subjects had no disease which can aff ect autonomic nervous system, such as diabetes, hypertension and so on. electrocardiographic signals were obtained from subjects in resting state and calculated the hrv indices with spectral analyses. we divided luts patients into two groups by lf/hf ratio . which was mean value in healthy volunteer and compared the diff erence of clinical characteristics, ipss, psa and trus results. th e parameters were compared by independent sample t-test using spss version . results: th ere was no diff erence in age, serum psa and volume of prostate. th e comparative results of pa-rameters of hrv between groups (mean ± standard error) are in the table . conclusions: as most investigators believe that lf and hf represent sympathetic and parasympathetic nervous system activity, respectively, our results may suggest that luts patients with relatively sympathetic hypoactivity suff er from nocturia more than those with sympathetic hyperactivity. we suggest that the imbalance of the autonomic nervous system activity may be a factor that evokes varieties of symptoms in men with luts. introduction and objective: women presenting with urogenital pain oft en have lower urinary tract symptoms (luts). pelvic fl oor dysfunction and hypertonicity is thought to contribute to these symptoms. physical therapy and myofascial release are eff ective for both conditions, suggesting a common underlying pathophysiology. we aim to investigate the association among pelvic fl oor tone, luts, and pelvic organ distress. th ere was a tendency of lower hemoblobin decrease in ari group, however, this results was not statistically signifi cant. th ere were also no significant diff erences in improvement of ipss, qol and urodynamic fi ndings between the two groups. conclusion: preoperative use of ari does not compromise, but rather increase the effi ciency of surgery. th e use of ari is not a contraindication to th ulium laser vapoenucleation. age-specifi c relationships between lower urinary tract symptoms and late-onset hypogonadism symptoms in the japanese general population introduction and objective: aging is known to aff ect sexual, psychological and physiological functions including lower urinary tract symptoms (luts). recent data suggested that severity of luts was associated with that of late-onset hypogonadism (loh) in elderly men. however, information on the association in young adults is limited. in this study, we evaluated the relationship between luts and loh symptoms in young and middle-aged adults. results: th e mean ages of the patient and control groups were . ± . years and . ± . years, respectively (p= . ). th e mean ifsf-total and all of the ifsf sub scales (except pain) in the patient group were signifi cantly lower than those of the control group. th e mean udi- score of the patients was signifi cantly higher than the controls (p= . ). th e mean iiq- scores of the patients was higher than controls, however this increase was not statistically signifi cant (p= . ). introduction and objective: sav is one of the core components of hippo pathway, and this pathway plays a role for cell proliferation, apoptosis and migration through regulation of yes-associated protein (yap ). yap is known as an oncogenic protein in many human cancers, but only a few studies demonstrated that yap acts as an oncogene in renal cell carcinoma (rcc). in our previous study, we identifi ed sav was downregulated in high grade clear cell renal cell carcinoma (ccrcc) cases compared with low grade ccrcc cases and re-expression of sav inhibited rcc cell proliferation in vitro. to evaluate a role of sav in vivo, we created a murine xenograft model of human rcc. a total of -o cells with stable sav re-expression (sav - ) and control cells (control) were subcutaneously injected into the fl anks of mice, respectively. th ese two cell lines were also injected into subrenal capsule. tumor size, histological appearance and proliferation rate were evaluated. furthermore, transcriptome analysis was performed using a whole-genome microarray, in order to identify functional pathway by ingenuity pathway analysis (ipa) soft ware. to explore whether the identifi ed pathway was involved in hippo signaling pathway, western blotting was performed using antibodies against downstream proteins. in addition, the luciferase reporter assay was performed to explore whether the promoter activity is regulated by hippo signaling. results: tumors injected with sav - showed a decrease of tumor size and growth rate, compared with those of control. by immunohistochemical analysis, it was shown that re-expression of sav caused yap to localize in the cytoplasm. pathway analysis revealed that tgfβ signaling was found to be inhibited in tumors with sav - . in sav re-expression cells, protein levels of tgfβ were lower than those in control cells. when yap and tead were introduced, reporter activity of tgfβ promoter was increased. attached to a linear motion stage with a stepper motor. shaft buckling was determined by measuring the peak force to compress a cm section of the shaft a distance of cm. lubricity was measured by extracting each wire through simulated tissue at a constant speed, measuring average force over a second period. tip fl exibility was determined by isolating the distal cm portion of each guidewire and measuring the peak force required to compress a distance . cm while securing the tip in a small hole in a wooden block. perforation force was evaluated by stabilizing each wire in the dilator of a ureteral access sheath and measuring peak force required to perforate aluminum foil. up. , table . th e results showed that kh- protected tm cells against h o -induced oxdidative stress in a dose-dependent manner. it improved signifi cantly both the decline of semen parameters and decrease of testicular weight of androgen-defi cient rats at a dose of mg/kg. also it inhibited the activities of aromatase with and then increase the serum testosterone levels. conclusion: th ese results suggested that the aromatase inhibitory activity of kh- may contribute to the improvement of serum testosterone levels in androgen-defi cient male rats. introduction and objective: although several theories have been suggested, the pathophysiology of interstitial cystitis/bladder pain syndrome (ic/bps) is unclear. disruption of the bladder epithelial barrier is an important pathophysiologic theory of ic/bps, and uroplakin is known to have an important role in the bladder epithelial barrier. th e change in expression of uroplakin subtypes in the bladder could be related to ic/bps. we investigated the change in expression of uroplakin ib and iii in the bladders of patients with ulcerative ic/bps. bladder tissue samples were obtained from patients with ulcerative ic/bps who were treated with augmentation ileocystoplasty. samples for the control were obtained from normal bladder tissue apart from the malignant lesions of patients with bladder cancer who needed radical cystectomy. a voiding diary, the pain visual analogue scale (vas), and the o'leary-sant interstitial cystitis symptom index (icsi), and problem index (icpi) were used to assess patients with ic/bps before operation. expressions of uroplakin ib and iii were compared between the ulcerative ic/bps and control groups by immunofl uorescence staining and western blotting. results: in total, patients with ic/bps (mean age . ± . years, women and men) were evaluated. th e mean symptom duration was . ± . years. preoperative voiding frequency, nocturia, and functional bladder capacity documented in the voiding diary were . ± . , . ± . , and . ± . ml (mean ± sd), respectively. pain vas score, icsi, and icpi were . ± . , . ± . , and . ± . (mean ± sd), respectively. th e mean anesthetic bladder capacity was . ± . ml. immunofl uorescence staining showed that uroplakin ib and iii were localized in the urothelium. in western blot analysis, immunoreactive bands indicating expression of uroplakin iii were signifi cantly increased in the ic/bps group compared with the control group. however, uroplakin ib expression was not diff erent between the ic/bps and control groups. green fl uorescence protein cassette, and the infectivity of kshv was assessed using fl ow cytometry. to investigate viral replication, the levels of expression of representative kshv latent and lytic proteins were analyzed by immunofl uorescence assay. in addition, cell cycle and proliferation following kshv infection was analyzed. finally, cdna microarray was performed to identify gene changes by infection of kshv in bc. results: four bc cell lines, except rt , showed levels of infection similar to or higher than those of hu-vecs. infectivity of kshv in tccsup and huvec cells was similar, but t , , and ht- cells showed signifi cantly higher infectivity than huvec. our tested kshv-infected bc cells were latently infected by kshv. interestingly, a subset of kshv-infected bc cells showed higher brdu incorporation and proliferation rate than non-infected cells. furthermore, in soft agar colony formation assay, the numbers and sizes of colonies of kshv-infected cells were signifi cantly greater and larger, respectively, than non-infected cells. cdna microarray analysis showed that many proliferation and cancer development-related genes were simultaneously up-regulated in kshv-infected cells. introduction and objective: bladder cancer (bca) is the second common genitourinary tumor, and especially muscle-invasive bca (mibc) is poor prognosis. th erefore, it is important to clarify the mechanism of invasion in mibc is useful for the strategy of appropriate treatment. previously, we have showed hgf-met signaling is correlated with invasion in bca cells. here, we investigate the eff ects of met inhibitor, cabozantinib (xl ), in bca cells to investigate the significance of met upregulation in rt , , j , t , um-uc- cells, we conducted western blot analysis. next, we examined eff ect of cabozantinib on proliferation and invasion abilities using mtt and matrigel invasion assays. invasion assays were performed by the xcelligence system. moreover, to investigate biological function of hgf-met signaling, we analyzed gene expression profi le and real time pcr of cells which cultivated with or without hgf stimulation. . th e mechanical properties of scaff olds were measured to compare tensile strength between two types. for in vitro cell study, scaff olds were seeded with human fi broblast cell at x cells and were cultured for up to weeks. th e ability of these scaffolds to support fi broblast cell growth was also investigated in vitro. results: d strand-deposited scaff olds were characterized by sem images and porosity measurement. sem images showed the surface morphology of pcl scaff olds. th e young's modulus of °pcl was . ± . mpa, and °pcl was . ± . mpa, respectively. human fi broblast cells covered well the surface of the scaff olds. immunofl uorescent staining of α-er-tr on fi broblast cells/scaff olds confi rmed that the cells remained viable and proliferated throughout the time course of the culture. th is is a preliminary study to investigate the possibility of using d bioprinting technique for tissue engineered tunica albuginea. introduction and objective: aft er - years at people the decrease in a pool of pluripotent stem cells resulting in insuffi ciency of replenishment of cellular structure of cambial zones and, as a result, to incomplete replacement of the perishing old cells is observed. in reply surrounding epithelial and endothelial cells, and also the macrophages, attracted with death of old cells, stimulate cells division of growth zones by the cellular growth factors (pechersky a.v. et al., ) . to patients aged from till years with a cancer of a kidney, bladder, prostate gland of a stage of t -t the chemotherapy or target therapy was carried out. to patients of - years for restoration of regeneration it was carried out from to transfusions of mononuclear fraction of peripheral blood, same-gender and blood types with recipients. results: in month aft er carrying out chemotherapy or target therapy aft er development of a leukopenia in patients the level of the basic fi broblast growth factor (bfgf) increased on average by . times, at patients from them the increase in level of the human vascular-endothelial growth factor (human vegf-a) on average by . times was observed, the rd of them had an increase in the human epidermal growth factor (human egf) on average by . times. in - months aft er the last transfusion of mononuclear fraction of peripheral blood the maintenance of hemopoietic cells predecessors of cd + in peripheral blood increased on average by . times (at patients with to - cells in mcl). at patients the level of the basic fi broblast growth factor (bfgf) decreased on average by . times, at patients from them reduction of level of the human vascular-endothelial growth factor (human vegf-a) on average by . times was observed, the rd of them had a reduction an human epidermal growth factor (human egf) on average by . times. decrease in levels of cellular growth factors naturally brought at all patients in a buccal epithelium to decrease in an expression of p on average by . times, at the rd of them to decrease in an expression of bcl- on average by . times. excess stimulation of mitotic activity at people years are more senior it is possible to lower to normal level by means of restoration of number of a pool of pluripotent stem cells by transfusion of mononuclear fraction of the peripheral blood from young donors of - years of one with the recipient blood types and a sex. mashhadi r to compare the expression rate of sex steroid hormone receptors of estrogen (er), progesterone (pr) and androgen (ar) in normal urothelium and urothelial bladder cancer (ubc) and to evaluate the possible associations of these receptors expression with cancer progression and patient's survival. we evaluated the clinical data and tumor specimens of patients with patho-logically confi rmed primary ubc with normal healthy controls. both patients and controls selected from list of subjects who have been referred to sina urology clinic, and had a minimum of one year follow-up duration. data collected from medical cords. for evaluation of expression, immunohistochemistry was performed on paraffi n-embedded tissue sections using a monoclonal antibody for androgen, estrogen and progesterone receptors. presence of at least % positive cells defi ned as positive expression. results: none of the control subjects showed ar expression, while % of the patients were ar-positive. er/pr expressions were observed in . %/ and . % of the cases and in . % and . % of the controls, respectively. a statistically signifi cant correlation was found between ar expression and tumor stage and grade (p < . ). ar-positive patients showed a signifi cantly poorer prognosis than ar-negative cases (log-rank test, p = . , hazard ratio = . ; % confidence interval: . - . ). conclusion: ar expression was signifi cantly associated with higher grade and poorly diff erentiated tumors with unfavorable outcome. ar expression test might be useful as a diagnostic tool for determining the malignancy and outcome of ubc patients. park s, park w, yoon s introduction and objective: previous researchers consider interaction roles of ampk and ros as a regulator of cancer cell apoptosis and cancer invasiveness in hypoxia and oxidative stress. th e aim of this study was to fi nd out the other aspect of invasion and cell death mechanisms as a new treatment option in urothelial cancer. we performed western blot analysis to determine association between ampk regulator (compound c, aicar) and ros scavenger (nac and tempol) as cytotoxic eff ectors. using gelatin zymography to measure mmp- , activity, we evaluated the cancer invasion. pathway activation analysis was also determined by western blot. cell survival was investigated by mtt analysis. results: ros scavenger like nac and tempol treated cells showed no change of expressions of phospho-ampk. aicar, compound c and tempol treated cells showed no change of mmp- and mmp- expressions. however, nac treated cells showed decreased expressions of mmp- and mmp- . ai-car and compound c treated cells with or without added nac and tempol showed no change of mtor and phospho-mtor expressions. aicar treated cells only showed decreased expression of phospho-p s k. compound c and tempol treated cells did not showed statistically any change in cell counts. however, aicar and nac treated with or without added compound c and tempol showed increased cell death signifi cantly. conclusions: activator of ampk and ros scavenger like nac decrease t invasion activity and increase t cell death. so, we demonstrate that the cytotoxic mechanism of bladder cancer remains to be further investigated. epigenetic bladder cancer is still one of common human malignancies which some environmental agents play important role in the process of carcinogenesis, such as aromatic amines or chronic arsenism, and easy to be recurrent and progressive despite of therapy. it is continuing to search some novel genetic or epigenetic biomarkers and to investigate their signifi cance in bladder urothelial carcinoma. doc- /dab (diff erentially expressed in ovarian carcinoma- /disabled- ) interacting protein (dab ip), a novel family of ras gtpase-activating protein family, is a potent tumor suppressor gene. th e objectives of this study are to explore the prognostic values of dab ip expression and the possible regulatory mechanism in superfi cial bladder cancer. with irb consent and patient permit, eight human urothelial cancer cell lines and superfi cial bladder cancer tissues were available for exploring dab ip expression using western blotting and immunohistochemical staining, respectively. th e prognostic signifi cance of dab ip expression in term of recurrence and progression were analyzed with log-rank test. aft er treated with demethylizing agents trichostatin a (tsa) and -aza ' deoxycytidine (aza) separately and together, urothelial carcinoma cell lines were then tested with dab ip mrna expression using quantitative rtpcr. data mining was also done using published mrna diff erential array (dataset gse ). th irty patients with non-muscle invasive bladder cancer and agematched healthy controls were included in the study. peripheral blood samples were obtained from the patients before transurethral resection of bladder tumor (turbt), twenty days aft er the operation (fi rst control) and at the end of intravesical immunotherapy (second control). vegf- , mmp- , es and tsp- were measured by enzyme-linked immunosorbent assay (elisa). th e mean marker levels of the patients and controls were statistically compared. th e mean marker levels of the patients before turbt, in the fi rst and second control were also compared. results: th e mean age of the patients ( females and males) and controls ( females and males) were found to be . ± . and . ± . , respectively (p= . ). although the mean vegf and mmp levels in the patients before turbt were signifi cantly higher than the controls (p< . and p< . , respectively), there were no diff erences between the mean es and tps- levels (p= . and p= . , respectively). th e wegf- and mmp- levels signifi cantly decreased aft er turbt (p< . and p< . , respectively). th ese reductions continued aft er intravesical immunotherapy, but these diff erences between fi rst and second control were statistically insignifi cant. th is study showed that elevated angionenic factors in the patients with bladder cancer decreased aft er the treatment. we think that vegf and mmp may be used for the follow-up and therapy of non-muscle invasive bladder cancer. prognostic results: nitrose oxide level and bfgf expression were signifi cally elevated in patients with urothelial carcinoma associated with chronic bladder infection, normal urothelium showed low levels of no and low expression of bfgf. conclusion: th e association of elevated levels of nitrose oxide and over-expression of bfgf indicated that the angiogenic peptide bfgf had been modulated by nitrose oxide. th ese results would indicate an anti-angiogenisis target therapy in urothelial carcinoma associated with chronic bladder infection. the relationships between increase of serum creatinine and recurrence of nonmuscle invasive bladder cancer after transurethral resection of bladder tumor introduction and objective: while impaired renal function had a negative impact on the prognosis of invasive bladder cancer by infl uencing stage of tumor and selection of treatment modality, the relationships between the change of renal function and prognosis of non-muscle invasive bladder cancer (nmibc) have not yet been studied. preliminarily, we investigated the impact of increased serum creatinine and recurrence of nmibc. a total of patients who underwent transurethral resection of bladder tumor (turbt) with minimum follow-up of months were divided into two groups based on with (n= ) or without recurrence (n= ). th e changes of serum creatinine from the preoperative baseline to the time of recurrence were evaluated (Δ creatinine). for subjects without recurrence, serum creatinine was measured at months aft er turbt. th e impact of variables including characteristics of host (age, sex, past medical history, bmi, and smoking history), tumor (location, size, and grade), and laboratory data on recurrence of nmibc were then analyzed. tsai y , jou y , tsai y , liu b , lin h , wei c , chen s , tsai h , tzai t introduction and objective: bladder cancer is a common human malignancy and exhibits a life-long risk of disease recurrence and progression. it is continuing to search some simple, innovative biomarker to monitor the disease status in order to diminish the suff ering during cystoscopic follow-up. th e metabolite of tryptophan aft er indoleamine , -dioxygenase (ido) digestion, -hydroxyanthranilic acid ( -haa) is conventionally thought to be a potential biomarker for bladder cancer occurrence. th e aim to study is to investigate the diagnostic potential of an integrated a -haa-based biosensor for urothelial carcinoma of the upper tract and urinary bladder. human urothelial cancer cell lines and human urothelial carcinoma tissues as well as adjacent benign tissues were available for exploring ido expression, including western blotting and immunohistochemical staining. patients who received urological surgery were enrolled for urine -haa testing using an integrating biosensor for -haa. some of urine specimens were investigated with high performance liquid chromatography (hplc) assay. results: from western blotting assays, eight human urothelial carcinoma cell lines exhibited more ido expression than the immortalized cell sv-huc. both of urothelial carcinoma of urinary bladder and upper urinary tract exhibited more ido immunoreactivity than those of the adjacent benign bladder, ureteral or cortical tissues (chi-square test, p= . ). th ere is a moderate correlation for urine -haa measurement based on between hplc and the biosensor assays (r = . , p= . ). besides, the -haa content within the cultured media of tccsup and bftc measured with biosensors signifi cantly increased with incubation time (p < . ). finally, patients with urothelial carcinoma of bladder and upper tract have higher urine -haa levels than those without recurrence or benign urological disease, such as bph, or hernia (unpaired t-test, p= . ), except for urolithiasis. conclusion: th e integrated biosensor exhibited a modest accuracy in urine -haa detection. both of urothelial carcinoma of urinary bladder and upper tract exhibited higher ido expression and its metabolite -haa in urine. how a cancer spreads: public awareness of genitourinary cancer introduction and objective: patients' perceptions of disease can aff ect the diagnosis and treatment of the disease. it is diffi cult to give a defi nite answer to the questions; "can genitourinary cancers be spread around during coitus or in public bathtub?". doctors know that there is no evidence that cancers can be spread in this way, however many people don't know that. th e objective of this study was to investigate the public awareness of genitourinary cancer. one hundred and forty nine patients who have visited outpatient department of urology completed a self-administered questionnaire from june to july . th e questionnaires included epidemiologic information about age, gender, residential area, level of education and yearly income and the questions whether prostate cancer and bladder tumor could spread out during coitus or bathing. returned responses to questions were analyzed. results: a total of of ( %) patients completed the questionnaires. mean age was years, and ( %) men and ( %) women were included. th e residential area were metropolitan in ( %), urban in ( %), and suburban in ( %), respectively. th e level of education were middle school graduates in ( %), high school graduates in ( %), and college graduates in ( %), respectively. th e yearly incomes were under , dollars in ( %), , ~ , in ( %), and over , in ( %), respectively. seventeen ( %) and ( %) patients answered that they thought that bladder tumor could spread during coitus and bathing, respectively. likewise ( %) and ( %) patients answered that they believed that prostate cancer could spread during coitus and bathing, respectively. moreover, young patients (< years) reported that they have the opinions that coitus spreads prostate cancer ( %) and bladder tumor ( %). of college graduates, % and % reported that they thought coitus spreads prostate cancer and bladder tumor, respectively. conclusion: a signifi cant proportion of patients believed that prostate cancer and bladder tumor could spread during coitus. furthermore, even young and highly educated people also tended to have this misbelief. protoporphyrin we evaluated the feasibility of photodynamic diagnosis of bladder cancer by spectrophotometric analysis of voided urine samples aft er extracorporeal treatment with -aminolevulinic acid (ala). further, we investigate the protein that plays a key role in increased accumulation of protoporphyrin ix in bladder cancer cells. sixty-one patients with bladder cancer, confi rmed histologically aft er the transurethral resection of a bladder tumor, were recruited as the bladder cancer group, and outpatients without history of urothelial carcinoma were recruited as the control group. half of the voided urine sample was incubated with ala, and the rest was incubated without treatment. intensity of the samples at the excitation wavelength of nm was measured using a spectrophotometer. th e diff erence between the intensity of the ala-treated and ala-untreated samples at nm was calculated for photodynamic diagnosis of bladder cancer. immunohistochemistry was used to estimate the expression of peptide transporter , hydroxymethylbilane synthase, ferrochelatase, atp-binding cassette , and heme oxygenase- in samples from patients who underwent transurethral resection of bladder tumors. th e correlation between the expression of each protein in cells from resected bladder specimens and accumulated protoporphyrin ix in bladder cancer cells in voided urine was evaluated using pearson's correlation analysis. results: th e area under the curve was . . sensitivity and specifi city of the method were % and % respectively. th e expression of peptide transporter (p < . , r = . ), heme oxygenase- (p < . , r = . ), and ferrochelatase (p < . , r = . ) was correlated with the accumulation of protoporphyrin ix in bladder cancer cells in voided urine. we demonstrated that protoporphyrin ix levels in urinary cells treated with ala could be quantitatively detected by spectrophotometer in patients with bladder cancer. th e expression of ferrochelatase plays a key role in the accumulation of protoporphyrin ix in photodynamic diagnosis of bladder cancer. assessment of visual inspection as a tool to determine pelvic drain fluid type following radical cystectomy crozier j, papa n, lawrentschuk n introduction and objective: following radical cystectomy, patients generally spend a period of days under observation on a urology ward. during that time, staff closely monitor pelvic drain output to assess for the possibility of a urine leak. we aim to investigate the ability of medical and nursing staff to correctly identify pelvic drain fl uid type using visual inspection alone. investigators collected a series of de-identifi ed images showing pelvic drain fl uid in patients post radical cystectomy. th e fl uid type in each image was confi rmed by measuring creatinine level. investigators then attended a victorian public hospital urology meeting and a victorian gp conference. attendees were invited to participate in a study. present staff included consultant urologists, urology registrars, urology residents, urology nurses, medical oncologists, radiation oncologists, general practitioners and medical students. participants were then provided with a survey. th ey were asked to indicate their level of experience working on a urology ward, the number of years since graduation from their primary medical or nursing degree. participants were then shown the series of pelvic drain fl uid images on a project. th ey were asked to correctly identifying the fl uid type in each image. using the survey, participants had the option of choosing either urine or peritoneal fl uid. results: all groups poorly identifi ed fl uid type. no individual staff group was signifi cantly better at identifying fl uid type. level of experience on a urology ward and years since graduation do not infl uence ability to determine fl uid type. conclusion: visual inspection of pelvic drain fl uid is a poor determinant of fl uid type. chang y, hsiao p, chen g, lee s, huang c, wu h, yang c, chang c introduction and objective: muscle invasive bladder urothelial cell carcinoma occasionally mixed with squamous diff erentiation. we conducted this study to investigate the incidence and treatment outcome of bladder urothelial cell carcinoma with squamous component. we enrolled patients muscle invasion bladder cancer who received radical cystectomy with bilateral pelvic lymph node dissection during to . patients' characteristics, chemotherapy record, and pathological report were retrospectively reviewed. th e following endpoints were assessed: overall survival (os) and recurrence-free survival (rfs). response of neoadjuvant chemotherapy subgroup was also analyzed. all survival data were analyzed by the kaplan-meier method using a log-rank test and multivariate analysis was carried out using a cox proportional hazards regression model. results: it was very clear that more than one third of these cases coming from the south of saudi arabia ( . %). th e bilharzia infestation found in ( . %) of the cases most of them are the southern patients. th e t staging turn to be high in most of our cases ( . % are t b). squamous cells carcinomas was also a striking feature of our result and found in ( . %). lymph node involvement found in one fourth of these cases ( . %). a total of ( . %) had local or lymph node recurrence and ( . %) got distant metastasis. around % ( cases) of our result showing that these cases having high grade and around % ( cases) had a hydronephrosis upon presentation. bladder cancer as a cause of death because of its advancement or recurrence account for ( . %) of deaths happened in these cases. th e survival of these cases severely aff ected by the fact that cases ( . %) could not know there survival status because they stop to show up in our institute for follow-up in spite the fact that there are some of them followed for more than years. arabia showing that the bilharzia infestation is quit high especially in the south and the squamous cell cancer is not as low as we expected. finding of hydronephrosis, lymph node involvement, high t and high recurrence in high percentage of our cases indicating that the bladder cancer aggressiveness behavior is not changing over years. introduction and objective: th is is an observational retrospective study utilising long-term patient follow-up for years (ys). to determine the survival and quality of life in women with age range - years, who had been treated for carcinoma of the bladder with radical cystectomy with preservation of genital organs. materials and methods: study included women patients with invasive urothelial carcinoma of the bladder treated with genital sparring radical cystectomy during the period from to . th ey had orthotopic ileal neobladder. follow-up included recurrence-free survival, metastases-free survival, overall survival, continence, and sexual function. results: overall survival up to - ys was in / women ( . %). survivors up to ys were in / ( . %). survival from to ys was in / patients ( . %). tumours stage of t were / patients, t were / patients, and t a were / patients. tumour grade was g in / , g in / , and g in / . age range of - ys were patients, range of - ys was patients, range of - ys was patients. continence was good in / patients; three patients / needed cic. sexual function tested by fsfi over< - was ( . %). conclusion: th e study provide evidence of safety and effi cacy of radical cystectomy with sparing of genital organs in women aged to with low grade, low stage invasive urothelial carcinoma of the bladder. oncological outcome for - years was good; continence and sexual function were very good. th is procedure should be considered when surgical approach appears to be feasible. tan w, sherer b, nehra a, deane l introduction and objective: radical cystectomy for bladder cancer has been the surgical gold standard for decades. increasingly, experience with robotic assisted techniques has become more common in select centers. in the majority of instances, the urinary diversion has been performed extracorporeally and with the use of stents. herein, we report our center's initial experience with robotic radical cystectomy and stentless totally intracorporeal urinary diversion. a retrospective review of the medical records of all patients undergoing robotic cystectomy and intracorporeal diversion was conducted at rumc from - . specifi cally, attention was focused on perioperative parameters. results: a total of patients were identifi ed (male= , female= ) in the sample. four patients underwent intracorporeal ileal conduit reconstruction and one patient underwent totally intracorporeal ileal neobladder reconstruction. no patients received a pre op bowel preparation, post op pca or epidural and all were allowed oral intake early. no patient received a transfusion for operative blood loss. one patient was readmitted for dehydration. see table for details. conclusion: robotic assisted radical cystectomy with stentless intracorporeal diversion is safe and feasible. eliminating bowel preparation, pca and epidural, and incorporating early refeeding and ambulation may result in a shortened length of stay. a rigorous post-operative plan to optimize return of bowel function, permit rapid reintroduction of diet without restrictions and facilitate early ambulation is critical in improving outcomes for this patient population. computed up. , table . and hypermethylation of these two gene promoters. in order to investigate clinical usefulness for noninvasive bladder cancer detection, we further analyzed the methylation status in urine samples of bladder cancer patients. methylation of the tested genes in urine sediment dna was detected in the majority of cases that were hypermethylated in tumor samples ( . %) and the frequencies were . % . % and . % for apc, rarβ and survivin, respectively. our results indicate that methylation of apc, rarβ and survivin gene promoters is a common fi nding in patients with bladder carcinoma. th e ability to detect methylation not only in bladder tissue, but also in urine sediments, suggests that methylation markers are promising tools for noninvasive detection of bladder cancer. usefulness of the all cases were followed for over year. th e procedure is ) point marking; ) circular incision; ) level incision; and ) specimen retrieval using a needle electrode in accordance with the ukai's method. we investigated pathological fi ndings (margin situation), operation time, complications and recurrence. results: it is possible to diagnose the precise pathological fi ndings by turbo. we judged the width and depth ew in sequential section. th ere were few complications during and aft er the operation. operation time of turbo ( - min) was longer than conventional turbt. urethral catheter holding period and hospitalization period aft er turbo was the same as turbt. turbo is a relatively safe procedure even for beginners. twenty cases had a recurrence in cases. eleven cases had a recurrence in under year, but the same place recurrence was cases. th ere were few cases of same place recurrence in under year among margin-negative cases. th erefore we judged that ew-negative cases had no residual cancers. conclusion: turbo is a safe and useful procedure that provides precise pathological fi ndings with minimal complications. second tur is not necessary for turbo. turbo has a possibility to be gold standard of the treatment for non-muscle invasive bladder cancer (nmibc). the risks of bladder-preserving bacillus calmette-guérin therapy in high-grade non-muscle-invasive bladder cancer continuous physical activity has many eff ects on human body. it doesn't only strengthen the skeleton or muscles; it also affects cardiovascular system, nervous system and etc. in this research we wanted to fi gure out if continuous physical activity (cpa) eff ects the lower urinary tract symptoms in retired military offi cers or not. th is is a retrospective study. retired offi cers attending to urology clinic for annual prostate control and not using any drugs for prostate were enrolled in this study. aft er the patients' permission were taken for the study they were asked for cpa or not and their international prostate symptom scale (ipss) answers were compared. results: th ere were patients in cpa group and patients in non-cpa group. th e mean age is ( - ) in cpa group and . ( - ) in non-cpa group. answers of questions in ipss: incomplete emptying (p= . ), frequency (p= . ), urgency (p= . ), and straining (p= . ) were detected statistically rare in cpa group (table ) . although they were not statistically signifi cant, intermittency (p= . ), weak stream (p= . ) and nocturia (p= . ) were rare in cpa group too (table ) . in order to maintain a better lower urinary tract function, elderly men should continue their physical activity aft er retirement. conclusions: th e number of nocturia episodes was signifi cantly and linearly correlated with ipss total score, voiding, storage, qol and nih-cpsi voiding scores. however, other risk factors, including bmi, body fat percentage, blood pressure, bun, creatinine, lipid panel, ck, t , free t , prostate-specifi c antigen, serum testosterone levels, urine fl ow (assessed using urofl owmetry) and prostate size (assessed using transrectal ultrasound and digital rectal examinations) were not associated with the number of nocturia episodes, despite an a priori assumption that they all infl uence nocturia risk. risk results: symptom prevalence increased to . %, and the mean international prostate symptom score increased by . points during years. aft er adjusting for confounders, smoking history of ≥ pack-years was an independent risk factor for symptom deterioration and storage sub-symptoms, compared with non-smokers ( . and . odds, respectively). physical activity had a protective eff ect for voiding sub-symptoms. high daily protein intake exacerbated the storage symptoms. however, alcohol intake was not associated with symptom deterioration. conclusions: th e symptom prevalence among elderly men living in a suburban area increased to . %, and the international prostate symptom score increased by . points during years. smoking history, physical activity, and protein intake were associated with symptom deterioration. however, there was no signifi cant association with alcohol intake and symptom deterioration. russo g, castelli t, urzì d, privitera s, fragalà e, favilla v, cimino s, morgia g introduction and objective: a signifi cant amount of epidemiological evidences have underlined an emerging link between mets, benign prostatic enlargement (bpe) secondary to benign prostatic hyperplasia (bph) and related lower urinary tract symptoms (luts). we aimed to assess the connections between lower urinary tract symptoms (luts) related to benign prostatic enlargement (bpe) and metabolic syndrome (mets) with its components. is increased prostatic urethral angle related to lower urinary symptoms in male without prostatic obstruction? introduction and objective: th e prostatic urethra is a bent tube, and the clinical signifi cance of the prostatic urethral angle (pua) was recently reported. we investigated the statistical signifi cance of an increased pua on the international prostate symptom score (ipss), with luts/bph. a prospective analysis was made of patients ( . ± . years) with luts and/or bph. patient underwent an evaluation including the ipss, psa, transrectal ultrasonography, urofl owmetry, and measurement of post-void residual. pua were measured by cystourethroscopy ( figure ). in order to minimize the eff ect of prostate, patients with prostatic obstruction under cystourethroscopy were excluded. th e minimum pua degree of symptoms change was constructed as a predictor of the eff ect of medication. all patients received tamsulosin . mg during the fi rst weeks and . mg during the next weeks. results: th e psa, prostate volume and pua were . ± . ng/ml, . ± . ml and . ± . °, respectively. th e area under the roc curve was . at the degrees with a sensitivity of . % and a specifi city of . %. comparing a higher pua (over degree, group a) with a lower pua (under degree, group b), patient with a higher pua had a longer luts period (p= . ), an improvement of symptoms aft er medication (p= . ) and an increase of average fl ow rate (p= . ). however, there was no signifi cant diff erence in age, psa, post-voided volume between the two groups. conclusion: pua showed signifi cantly correlated with the improvement of ipss, the eff ect of medication, and urofl owmetry. our fi ndings suggest that pua under cystourethroscopy may be one method to assess the presence of luts in men and help in the treatment of individuals by better predicting their likely classifi cation from ipss, urofl owmetry, and prostate volume. however, further studies are needed to explore the mechanisms and the eff ects of pua under cystourethroscopy. introduction and objective: th e prevalence of lower urinary tract symptoms increased with age. it is known that irritable bladder symptoms such as urinary frequency, urgency, nocturia increased with age in many studies. recently it was reported that vascular calcifi cation was one of the cause of lower urinary tract symptoms. we studied to evaluate the association between lower urinary tract symptoms of vascular calcifi cation in the abdominal ct using by agar score. th e records were obtained from a retrospective database who underwent abdominal ct due abdominal pain, hematuria. sex, age, height, weight, prostatic size, calcifi cation of aorta and internal iliac artery, amount of subcutaneous fat and visceral fat in the umbilicus level, international prostate symptom score, overactive symptoms score and urofl owmetry were assessed. calcifi cation of aorta was estimated from renal artery bifurcation to iliac artery bifurcation level. and internal iliac artery calcifi cation was calculated from bifurcation of iliac artery to bladder. we scanned each subject of . cm interval on the ct scan. th e calcifi cation of blood vessels was measured as agar score using abdominal ct aft er our explaining about each contents of nih-cp-si and iief- , the paper was checked by volunteers in person, and then we collected it. th e subjects were limited to - s korean male. we analyzed the collected questionnaires, and considered men who have perineal and/or ejaculatory pain or discomfort and a total nih-cpsi pain score of ≥ as having prostatitis-like symptoms, and categorized to four groups by iief- score, mild ( - ), mild-moderate ( - ), moderate ( - ), severe ( - ). results: an average age of volunteers was years old ( - ). th e iief- category was divided to fi ve groups. among total volunteers, persons were chronic prostatitis like symptom patients ( . %), and whose nih-cpsi average of pain score, voiding score, quality of life score and total score were . ± . , . ± . , . ± . , and . ± . , respective-up. , figure . ly. th ere were a little correlations among pain score, voiding score, quality life score, but not signifi cant. an average of total iief- scores in chronic prostatitis like symptom patients was . ± . , it was signifi cantly lower than absent group. th ere were all negative correlations of between iief- and pain score (t=- . , r = . , p= . ), voiding score (t=- . , r = . , p= . ), qol score (t=- . , r = . , p= . ), and total score (t=- . , r = . , p= . ). conclusion: th e higher total nih-cpsi score, especially pain score plays a larger role, adversely aff ects erectile function of chronic prostatitis like symptom patients in - s korean male. a antimuscarinic agent is the mainstay of treatment, but it have side eff ects such as dry mouth, constipation. th ese eff ects resulted in cessation of medication in many cases. th e authors therefore assessed the impact of side eff ects on health-related quality of life (hr-qol) through an analysis of questionnaires. th is study was designed to investigate the patients' satisfaction by quality weight (utility weight) of health status as aff ected by the side eff ects of oab medications in tertiary hospitals in korea. patients who had oab symptoms lasting longer than months and side eff ects aft er any antimuscarinic treatment fi lled in the eq- d. th e questionnaire and vas score for two diff erent health statuses, presence or absence of side eff ects, were analyzed. quality weight was calculated using the score of ed- d health status. results: one hundred patients were enrolled. th e most prevalent side eff ect was dry mouth ( %), followed by constipation ( %). twenty-eight percent of the patients had dry mouth and constipation concurrently. most of the patients with side eff ects tried to overcome these side eff ects ( %), but % desired a change in medication, and % stopped medication altogether. fift y-fi ve patients replied that they consider side eff ects to be an important factor in deciding on the continuation of medication. th e quality weight of eq- d without side eff ects was . , while the quality weight with side eff ects was . (p= . ). th e vas score was in patient without side eff ects and in those with side eff ects, supporting the results of quality weight assessment. th e same trend was observed when stratifi ed according to age and sex. as for the overall distribution of ed- d, the patients with side eff ects were less healthy in terms of daily life, pain/discomfort, and anxiety/depression. introduction and objective: treatment of men with large prostates is challenging with greater risk of complication and retreatment. while photo-vaporization (pvp) has been well described for greenlight w-xps, vapor resection techniques have been described to help improve tissue resection, including vapour-incision techniques (vit). we sought to evaluate the effi ciency, safety and outcome parameters between greenlight pvp and vit specifi cally for men with prostate volumes > . among xps cases retrospectively collected from experienced surgeons at high-volume greenlight xps centers, had large prostates. preoperative, operative and post-operative parameters were collected and compared between groups. results: as summarized in table , men undergoing vit (n= ) had comparable preoperative parameters to those undergoing pvp (n= ). while vit allowed greater delivery of energy ( . vs . kj/g), operative time was longer and there was greater need for > fi bres. th ere were no diff erences in intra-and day post-operative adverse events. both vit and pvp demonstrated comparable marked improvements in ipss/qol at months post-operatively. however, despite greater urinary retention and pvr preoperatively, men with vit demonstrated signifi cantly lower post-operative pvr and greater qmax at moths. no signifi cant diff erence in retreatment rates was noted between vit and pvp follow-up. conclusions: both greenlight pvp and vit techniques can be safely used to treat men with large prostates. both techniques off er signifi cant and durable relief of symptom relief with comparable complication rates at years. longer follow-up is necessary to assess durability. open within two years, one-hundred patients were prospectively randomized into two equal groups. all patients underwent tvp whereas rb was used in group- . rb is a balloon fi xed to -way foley catheter tip by blaster strip making it air tight. we placed it in the rectum opposing prostate and infl ate (pressure controlled) for min. hemoglobin (hg) levels have been assessed pre-and postoperation. blood transfusion, amount of saline for irrigation, catheter duration, hospital stay, and rectal complain were recorded. follow-up was and -mo, postoperatively. results: enucleated adenoma weight was gm in g- and gm in g- . th ere is signifi cant diff erence between both group for hg-loss within fi rst h post-operative and total hg-loss . gm in g- and . gm in g- (p, . ) and . gm vs. gm (p, . ) respectively. also there is signifi cant diff erence between both group in relation to the saline/l for irrigation ( . vs. . l), catheter duration ( . vs. . day), and hospital stay ( . vs. . day), with favorable results to the rb group. blood transfusion was in g- and one in g- . th ere is no rectal complain. conclusion: rb infl ation post-tvp is simple and safe procedure without operative technique, reduces post-operative blood loss, blood transfusion incidence, saline for irrigation, and shortens the catheterization period and hospital stay, without rectal complication. conclusion: th ough this was not a head-to-head study and there were a number of dissimilarities in the study design, we demonstrated a non-inferiority of our study and a signifi cantly shorter median length of catheterization, time until stable health, and hospitalization relative to the goliath study. introduction and objective: th ulium laser enucleation of the prostate (th ulep) has been introduced as a minimally invasive treatment for benign prostatic obstruction (bpo). th e aim of the study is to assess what are the intraoperative key points and possible complications of the morcellation procedure aft er th ulep. to assess whether this events have any eff ect on hospitalization length. a cooperation between the university of milan and moscow was settled. prospective study that analyzes events that prolonged the morcellation process aft er completing thullium laser enucleation procedure in a group of consecutive patients was performed. events related to the morcellation procedure were recorded. patients' hospitalization length were evaluated aft er discharge only considering patients that were not re-admitted because of a surgical related issue. statistical analysis was performed by the student t and chi-square test and logistic regression analysis. for all statistical comparisons signifi cance was considered at p< . . results: mean age was . years. five groups of reasons for prolonged morcellation were recorded. bladder suction with wall damage, bleeding due to "ex vacuo" fast empting, suction problem, morcellation impairment and prolonged morcellation time due to enlarged prostate. each group of issues was related to a signifi cant prolonged operative time (p< . ). th e table shows the key points rate and their correlation with a prolonged hospital stay. a statistical significance between the event and the prolonged hospital stay found only for bladder suction. conclusions: issues related to the morcellation procedure aft er laser enucleation of the prostate (th ulep) causes prolonged hospitalization length only in the case of bladder suction. other events, even if related to a slower operative time, do not mean a prolonged hospitalization. suprapubic cystostomy makes turp more effective and safer introduction and objective: a recent survey found turp the commonest performed procedure in bph, despite the rising popularity of laser prostatectomy. th e reasons for popularity in laser are ease of performance, lesser complications, and good results. it is the complications factor that makes it look attractive. th e onus is therefore to make turp safer. th is is more applicable in india, where the cost of laser excludes - % of patients. numerous innovative procedures have been tried to make turp safer. continuous outfl ow has been described as innovation, the means to achieve it not described. introduction and objective: prophylactic peri-vesical drain placement during suprapubic prostatectomy remains a widespread surgical practice. however the surgical technique of suprapubic prostatectomy has signifi cantly improved and as such the contemporary role of prophylactic surgical drains needs reevaluation. it has been traditionally assumed that prophylactic drains helps prevent fl uid collection (blood, serum, urine) which if not drained can lead to surgical wound complications. th is paper investigates the incidence of surgical wound complications aft er a series of suprapubic prostatectomy done without placement of surgical drains but in the context of modifi cations to the surgical technique. prostatic hyperplasia (bph) were operated upon between and -all using a modifi ed suprapubic prostatectomy technique that includes meticulous dissection, hemostatic suturing that covers the main areas of anatomic distribution of the urethral arterial branches of the inferior vesical artery, non-placement of drains and suprapubic catheter, and also routine irrigation of the surgical wound with normal saline among other modifi cations. pre-and post-operative blood hemoglobin levels, prostate specimen weights and presence of surgical wound complications if any were recorded. th e main outcome measure was to determine the presence of early surgical wound complication defi ned as clinical evidence of hematoma/ seroma, infection, drainage or wound dehiscence. results: th e mean age of the patients was . (range of to years). th e mean prostate weight was . gm-(range of to gm). th e mean hemoglobin diff erence was . mg/dl (range of . mg/dl to . mg/dl). on a minimum days observation of the surgical wounds, there was only one case of superficial wound infection ( . %) that healed with wound dressing. th ere was no mortality and none of the patients received blood transfusion. in the context of an improved surgical technique, suprapubic prostatectomy for bph can be safely performed without the placement of prophylactic peri-vesical drain. non-placement of prophylactic surgical drains in this series was not associated with increased wound complication rate. effects of detrusor underactivity conclusions: according to detrusor activity, there were not diff erent in diff erences between preoperative or postoperative ipss. abnormal detrusor contractility (esp. dua) cannot be a contraindication for tur-p, and turp should be a defi nite therapeutic option in abnormal detrusor activity. geavlete p, dragutescu m, multescu r, georgescu d, geavlete p introduction and objective: th is long-term retrospective study aimed to analyze the re-intervention necessities aft er bipolar plasma vaporization of the prostate (bpvp) in patients with medium sized benign prostatic hyperplasia (bph). materials and methods: th ere were followed patients who underwent bpvp for prostates sized between and ml. th e re-intervention rates were analyzed during a follow-up period of at least months. results: additional interventions consisted of immediate reoperation for secondary hematuria, endoscopic re-intervention for urethral stricture or blad-der neck sclerosis and transurethral resection of the prostate (turp) for residual bph bulk. endoscopic hemostasis during hospitalization was required in cases ( . %) and in discharged patients in other cases ( . %). during the follow-up period, patients ( . %) with bladder neck sclerosis underwent the plasma vaporization approach. urethral stricture was diagnosed in patients ( . %), of them receiving internal optical urethrotomy while urethroplasty was performed in cases. residual adenoma was present in patients ( . %), thus requiring and secondary turp. conclusion: bpvp is a valuable endoscopic treatment alternative for medium size bph cases with higher effi ciency and a satisfactory rate of reoperation. diode laser nm for the treatment of bph: long-term comparison of the enucleation vs. vaporization introduction and objective: to report -years follow-up results of clinical trial comparing diode laser enucleation of the prostate (dilep) with diode laser vaporisation of the prostate (dlvap). a total of consecutive patients were included in the prospective study who had received laser treatment for bph. patients were assigned to two groups based on the type of procedure: to dilep group and to dlvap group. patients with a history of neurogenic bladder dysfunction, chronic prostatitis or bladder cancer were excluded from evaluation. standard follow-up examinations were performed in both study groups in predefi ned time points (in the perioperative period, at month and month , and month , and then every year). primary endpoints included: lower urinary tract symptoms (luts) as measured by the international prostate symptom score (ipss), urinary fl ow rates and post-void residual urinary volume. complications were assessed. an additional endpoint was to review video records to precisely determine the timeframes for individual surgical procedures and to plot the learning curve. results: all the remaining patients had undergone the -year follow-up assessment. measurements were performed at , , , , , , and months. th ere were no statistically signifi cant differences in baseline characteristics between the two groups. no signifi cant intraoperative and early postoperative bleeding was observed. hospital stay aft er surgical intervention covered day that was equal to average time of urethral catheter indwelling. th e improvement rates, calculated based on the ipss scores at years aft er surgery, were . % and . % in the dilep and dlvap group, respectively. th e results indicate signifi cant decrease in severity of luts. th e sustained treatment eff ect was in favor of dilep intervention group. also treatment effi cacy was better in the dilep group compared to the dvlap group, as regards the maximum urinary fl ow rate (qmax). th e diff erence was statistically signifi cant. conclusions: diode laser enucleation and vaporisation of the prostate are low-risk minimally-invasive treatment option of treatment of patients with bph. both methods may be safely performed even in high risk and patients on ongoing oral anticoagulation. treatment eff ects are better and more sustained with laser enucleation than with laser vaporization of the prostate. dilep is a true endourological alternative to turp. changes in urination according to the sound of running water using a mobile phone application introduction and objective: th e sound of running water (srw) has been eff ectively used for toilet training during toddlerhood. however, the eff ect of srw on voiding functions in adult males with lower urinary tract symptoms (luts) has not been evaluated. to determine the eff ect of srw on urination in male patients with luts, multiple voiding parameters of urofl owmetry with postvoid residual urine (pvr) were assessed according to the presence of srw played by a mobile application. eighteen consecutive male patients with luts were prospectively enrolled between march and april . urofl owmetry with pvr measured by a bladder scan was randomly performed once weekly for two consecutive weeks with and without srw in a completely sealed room aft er pre-checked bladder volume was scanned to be more than cc. srw was played with river water sounds amongst relaxed melodies from a smartphone mobile application. results: th e mean age of enrolled patients and their mean international prostate symptom score (ipss) were . ± . years (range: - ) and . ± . , respectively. all patients had not been prescribed any medications, including alpha-blockers or anti-muscarinic agents, in the last months. th ere was a signifi cant increase in mean peak fl ow rate (pfr) with srw in comparison to without srw ( . ml/s vs. . ml/s, respectively, p = . ). however, there were no diff erences in other urofl owmetric parameters, including pvr. th e study showed that srw from a mobile phone application may be helpful in facilitating voiding functions by increasing pfr in male luts patients. th is study aims to analyse how bladder outlet obstruction index (booi) and bladder contractility index (bci) aff ect surgical outcome for bph patients who were treated homium laser enucleation of the prostate (holep). we classifi ed the patients, who were treated holep and observed more than months, into group i (booi≥ and bci≥ , n= ), group ii (booi≥ and bci< , n= ), group iii ( <booi< and bci≥ , n= ) and group iv ( <booi< and bci< , n= ) based on urodynamic study result. patient's characteristics including volume of prostate, psa, ipss, maximum urinary fl ow rate and residual urine volume compared in each group. and we also compared ipss, maximum urinary fl ow rate, residual urine volume before and months aft er surgery. results: th ere was no signifi cant diff erence comparing age, psa, ipss, maximum urinary fl ow rate and residual urine volume among each group. th e prostate volume, ranked in ascending order of group, are as follows: . ± . ml, . ± . ml, . ± . ml and . ± . ml, it had signifi cantly disparity between group i and iii (p= . ), group i and iv (p= . ), and group ii and iv p= . ). using repeated measure anova, we found that ipss, maximum urinary fl ow rate and residual urine volume were signifi cantly improved within group in each group aft er surgery except ipss storage subscore between group ii and group iii and residual urine volume. and the degree of improvement among each group was not diff erent (table ) . th e incidence of aur ( . %) and bph-related surgery ( . %) were low in ct group. in comparison of baseline age, psa, and pv according to switch of medical therapy, baseline pv was signifi cant diff erence in both groups, respectively (p= . , p= . ). conclusion: th ere was more mt than ct in initial treatment. however, there was more switch of medical treatment type in initial mt in real-world clinical practice over -year follow-up. th e incidence of bph progression events was high in initial mt group. th e initial use of ct is recommended in patients with luts and bph. relationship between bladder wall thickness and lower urinary board the antarctic research vessel "shirase" on their way home and approximately two months aft er returning to japan. we analyzed the data of members of the winter party who had responded to the questionnaires more than times before departure and during their stays in antarctica. results: compared to before departure, the mean scores for all of the questionnaires decreased during their stays in antarctica, from . to . points for ipss, from . to . points for oabss, and from . to . points for psqi, but the mean volume voided per micturition increased from to ml. in regard to the amount of change in ipss scores over the same period, a signifi cant diff erence was noted between members with a pre-departure score ≥ points and members with a pre-departure score < points (- . vs. . , p = . ). th is study is the fi rst to report the urinary status of people in a polar environment investigated with questionnaires and voiding logs. we initiated this study under the assumption that one's urinary status would deteriorate in a polar environment, but our fi ndings indicated that urination and sleep tend to improve in antarctica. management of male luts: a southeast asia regional survey on practice patterns and perspectives results: responses were obtained from urologists from centres with size ranging from to patients per week. referral patterns diff er across the region -in hong kong, singapore and malaysia, patients prefer or are required to consult a general practitioner before seeking urologist care. common investigations that respondents proposed included urofl owmetry ± post-void residual volume measurement ( %), psa ( %), urinalysis ( %), voiding diary ( %), physical examination ( %) and trus-biopsy ( %). however, only urinalysis and symptom scores are essential investigations recommended consistently in major international guidelines. whether urofl owmetry should become an essential investigation in sea remains debatable. luts secondary to bph/bpo ( %) and oab ( %) were the two most common diagnoses for the case scenario, and correspondingly, alpha-blocker ( %) and antimuscarinics ( %) were the two predominant treatments suggested by respondents. nocturnal polyuria is a common cause of nocturia especially amongst elderly, yet relatively few urologists ( %) considered this condition as a main diagnosis. respondents felt that there was a paucity of large-scale epidemiology studies on luts in sea, and on the natural history of the disease. more education on the proper evaluation and diagnosis of luts is needed for both gps and urologists in the region. results from this sea survey revealed variations in urologists' practice patterns and guideline recommendations, and pointed to the needs for further research and education in luts. female urethral prolapse: bhalla v , attri a , bhalla s introduction and objective: urethral prolapse means the protrusion of the distal urethra through the external urethral meatus. female urethral prolapse is a rare condition that has bimodal distribution aff ecting postmenopausal women and prepubertal girls. female urethra has two layers of smooth muscles inner longitudinal layer and outer circular which remain adherent to each other by strong connective tissue. separation of these two layers with episodic increase in intra-abdominal pressure leads to complete urethral prolapse. birth trauma during prolonged vaginal delivery, perineal tears, debility, malnutrition and periurethral bulking agent injections have been implicated in postmenopausal group. we present two postmenopausal female patients of urethral prolapse having similar clinical presentation aged years and years respectively. th ey presented with symptoms of blood spotting of undergarments and voiding diffi culty with dysuria of acute onset. on physical examination a doughnut-shaped erythematous infl amed mass was seen protruding from external urethral opening. th e evaluated parameters included pop-q grade, international prostatic symptom score (ipss), overactive bladder questionnaire (oab-q), international consultation on incontinence questionnaires short form (iciq-sf), maximum fl ow rate (q-max), and residual urine volume (ru). we evaluated them before and , , year aft er surgery. results: pop-q grade before surgery tended to be high in elderly group without signifi cance. anatomical cure at year aft er surgery (%) of non-elderly and elderly was and %, respectively. a tendency to having poor scores was observed in elderly group concerning preoperative ipss, iciq-sf and oabss; however they did not attain signifi cance. th ese three parameters improved in both groups aft er surgery; however, the percent improvement was signifi cantly poor in elderly group. th e maximum fl ow rate before surgery was signifi cantly low in elderly group and was still low aft er surgery. th e residual urine volume did not show signifi cant diff erence in each group before and aft er surgery. in the observation period of year, de novo oab and mesh extrusion were observed in elderly group with a signifi cant frequency. conclusions: th ough the anatomical cure was not age specifi c, age apparently aff ected on the outcome of tvm especially in the percent improvement of luts. autologous materials and methods: ten women with sever and complicated stress urinary incontinence secondary to the bladder neck and urethral trauma or congenital epispadias (with or without extrophy) underwent transurethral injection of autologous muscle derived cells. a second injection was performed according to the assessment of patients, months aft er the fi rst treatment session. all patients were followed at one week, , and months aft er injection by physical examination (cough stress tests), one hour pad test and iiq- score. multi-channel urodynamic study and maximal urethral closure profi lometry (mucp) was performed before and months aft er the last treatment session. cough stress test, one hour pad test and urofl owmetry were repeated at months aft er the last injection. in each visit the severity and incidence of complications was recorded. results: all patients completed the study and were followed for months. th ree patients were cured; four and three of patients were improved and failed to the treatment respectively. th ere were no major adverse events related to the treatment. conclusions: according to our clinical results, in a limited number of female patients, muscle derived cell therapy is a minimally invasive and safe procedure in the treatment of patients with severe and complicated sui. th e cure rate is not high, though it may be considered as an option beside other treatment modality. are we evaluated the eff ect of patient position and bladder fi lling status on the q-tip angle for urethral hypermobility. we measured the q-tip angle in the supine position and at a ° angle in a reclining position in patients during bladder emptying and then repeated the measurements while fi lling the bladder, usually - ml. we defi ned urethral hypermobility as the urethral angle straining or coughing minus that at rest > °. results: all female patients (mean age, ± years; range, - ) who complained of urinary incontinence were assessed using the q-tip angle. th e pelvic organ prolapse quantifi cation stages of all patients were ≤ stage . mean q-tip angle with an empty bladder was . ± . ° in the supine position and . ± . ° in the ° reclining position (p = . ). mean q-tip angle during the fi lling bladder state was . ± . ° in the supine position and . ± . ° in the ° reclining position (p = . ). th e urethral hypermobility rate during the bladder emptying state was . % ( / ) in the supine position and . % ( / ) in the ° reclining position. th e relative positive ratio of the reclining to the supine position is . . th e urethral hypermobility rate during the bladder fi lling state was . % ( / ) in the supine position and . % ( / ) in the ° reclining position. th e positive rate was higher in the ° reclining position during bladder emptying than that in the other position during bladder fi lling. conclusion: th e outcome of the q-tip angle measurement and the rate of urethral hypermobility changed in relation to patient position. th e reclining position during bladder emptying increased the q-tip angle, resulting in positive urethral hypermobility. rotational th ere was no mortality from the surgical procedure, whereas pain and catheter blockage was main complication. all patients were followed at , , and weeks respectively. our success rate was %. vesicovaginal fi stula is the most common urogenital fi stula. obstructed labor and its complications are still the leading cause of its development, whereas iatrogenic fi stula is also up-coming warning for all health care professional. the effi cacy of combination therapy of alpha blocker with anticholinergic in adult women with overactive bladder introduction and objective: overactive bladder (oab) is associated with symptoms including urgency, with or without urge incontinence, usually with frequency and nocturia. anticholinergics are mainly used for the treatment of patients with oab, especially women. other than anticholinergics, alpha blockers have been shown in several clinical reports to be useful in treating detrusor overactivity caused by neurological diseases. th e aim of the study is to evaluate the effi cacy of alpha blocker in combination with anticholinergics to treat women suff ering from oab. th is prospective study enrolled female patients with oab. patients have been randomised into two groups. th e interventions for the -week treatment period included solifenacin daily for the group and combination of both solifenacin and tamsulosin daily for the group . at baseline and weeks aft er treatment, patients completed a -day bladder diary, international prostate symptom score (ipss), quality of life (qol) index, overactive bladder symptom score (oabss), maximum fl ow rate (qmax) and postvoid residual urine volume (pvr). results: a total of women were randomised and completed this study (group ; , group ; ). statistically signifi cant improvements in terms of urgency and frequency were observed in both groups at weeks aft er treatment as compared with baseline (p< . and < . ), while no inter-group diff erence was observed between the two groups. although group showed improvement of ipss voiding subscore, qol and qmax than group but not statistically signifi cant (p= . , p= . , p= . ) . no signifi cant diff erence was observed in terms of toxic events between the two groups. conclusion: th e combination of alpha blocker and anticholinergic for weeks was noninferior to anticholinergic alone in effi cacy, and there was no evidence of benefi t of alpha blocker in treating female oab. further studies are needed to assess the role of combined therapy of alpha blocker and anticholinergic in the treatment of female oab. conclusion: advancement of cystoscopy will continue undoubtedly. th is report emphasizes the key people whom contributions will always be a corner stone in the fi eld of urology. "gleason" in a nutshell unusual urogenital disorders introduction and objective: to present some aspects of unusual urogenital disorders, congenital malformations, and syndromes, sometimes occurring in eminent personalities or having been described by famous scientists. th e review of historical sources and biographies of famous suff erers and the study of modern medical literature about all these rare urogenital diseases. results: penile deformities such as hypospadias (the most known representative was henry ii of france - , suff ering also from chordee) and the rare epispadias (respectively the most known was the byzantine emperor heraclius, - ) were recorded by historians because of the infertility consequences or the bizarre urination habits (heraclius needed protective measures to avoid getting wet). historians also were attracted by spectacular and dramatic urological emergencies, such as fournier gangrene, known by the case of the prominent suff erer herod. referring to famous researchers, françois gigot de la peyronie ( - ), founder of the royal academy of surgery of france, described the homonymous disorder ( ), consisting of penile deformity due to induration of the corpora cavernosa of the penis. th e above disease, called also induratio penis plastica (ipp) is one of the extraordinary urogenital problems together with the strongly psychologically and non-physically induced syndromes koro (genital retraction syndrome) and castration anxiety (the latter described by freud). belief that genitals have disappear and fear of damage or loss of the penis characterize them both. much of the research has been done on the two above topics, although still relevant today. conclusions: unusual urological disorders are broadly known when happening on famous personalities or when described by famous physicians or when attract the common opinion as extraordinary events (called mirabilia by historians). koutsiaris e , drettas p , oikonomou a , poulakou-rebelakou e , rempelakos a introduction and objective: th e loss of a testis represents a psychologically traumatic experience in males of any age. testicular loss is commonly the result of torsion, trauma, infection or malignancy. th e patients who experience orchiectomy request the implantation of an artifi cial testis for psychological or cosmetic reasons. testicular prostheses are one of the most commonly implanted devices and we present the evolution of these devices. review of the medical literature regarding the history of testicular prostheses and the various materials that have been used during the decades. results: th e fi rst testicular prosthesis was an alloy of molybdenium, cobalt and chromium and was used in . during the s, other materials were used such as plexiglass and polyethylene without much success. it was then suggested by the scientifi c community that the ideal testicular prosthesis should not produce any infl ammatory reaction and that should be also made by a proven non carcinogen material. it was also suggested that the material of the prosthesis should also resist mechanical press and take and hold the desired form. as a result, solid silicone rubber prostheses were introduced and used in the s. th e demand for more natural feeling implants lead to gel fi lled silicone devices appearing in . in , fi rmer silicone coated prosthesis became the "gold" standard. in the us in , the food and drug administration (fda) halted the use of gel fi lled breast implants due to the risks of autoimmune disorders and the possibility of tumor development. as a consequence, in there was a voluntary withdrawal of silicone gel fi lled testicular prostheses and replacement with saline fi lled prostheses. nowadays both silicone and saline fi lled testicular implants are used worldwide which are safe and eff ective. conclusions: testicular prostheses reduce the psychological impact that results from loss or absence of a testicle and should be off ered to male patients of any age. introduction and objective: we investigated population-based management trends of urinary stone disease in the use of extracorporeal shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy during the recent years in a korean population. we conducted this retrospective study by reviewing the medical records of patients diagnosed with acute ureteric colic in the emergency room and in the urology outpatient from january to december . nine hundred patients were diagnosed with ureteric stone and all of them underwent ultrasound as the primary imaging modality. sensitivity, specifi city, positive and negative predictive value in determining the size, position of the stone in the ureter by ultrasound has been documented. results: out of patients, there were males ( %) and females ( %). age range was - years. our study found that color doppler ultrasound with twinkling sign, diagnosis was made with confi dence in cases ( . %). sixty-fi ve patients who failed the ultrasound, the stones were confi rmed by helical ct, failure to detect the stone was mainly due to poor visualization (due to bowel gases and obesity) and smaller size of stone. right side stones were seen in ( . %) patients while left side stones were seen in ( . %). stones were detected bilaterally in cases ( . %). th e range of stones size was - . mm. th ere were ( . %), ( . %) and ( . %) upper, middle and lower ureteral stones. conclusion: th ere is no doubt that spiral ct is superior in the demonstrating of ureteral calculi. th e present study emphasized that utilization of color doppler ultrasound with twinkling in trained hands can provide an excellent alternative modality with high sensitivity and specifi city in diagnosis of acute ureteric colic and with confi dence can be used as fi rst imaging modality, hence we could avoid high cost, higher radiation dose and high workload. contemporary imaging practice patterns following ureteroscopy for stone disease cleveland clinic, cleveland, usa introduction and objective: routine imaging following ureteroscopy for treatment of renal/ureteral calculi continues to be a topic of debate. however, with the increasing focus on healthcare costs and quality, judicious use of diagnostic imaging to optimize outcomes while minimizing resource utilization is a priority. we sought to identify post-ureteroscopy imaging practices amongst experienced urologists. a redcap questionnaire was sent to urologists in north america. th e questionnaire surveyed demographic data, clinical volume, and imaging preferences post-ureteroscopy. additionally, we surveyed the extent to which stone, anatomic, and procedure-related factors infl uenced these preferences. th e likelihood of altering clinical practice and the desire for specifi c imaging guidelines were also assessed. th e interquartile range (iqr) was utilized as a measure of median consensus, with a lower iqr denoting increased agreement. results: th ree hundred twenty two urologists completed the questionnaire. th e mean number of years in practice was ± ; % of respondents performed more than ureteroscopic stone procedures monthly. routine postoperative imaging was obtained by % of participants as follows: us ( %), kub ( %), ct ( %), ivp ( %), and kub + us ( %). urologists who did not routinely image patients were more concerned about cost ( % vs. %, p= < . ), radiation exposure ( % vs. %, p= < . ), and diagnostic inaccuracy of us ( % vs. %, p= < . ). th ese urologists were also less likely to have completed an endourology fellowship ( % vs. %, p= < . ). th e most compelling predictors of obtaining postoperative imaging were post-op pain and fever (median , iqr ), residual stones (median , iqr ), ureteral perforation (median , iqr ), and presence of a solitary kidney (median . , iqr ). conclusions: currently, about % of urologists who regularly perform ureteroscopic stone procedures obtain post-op imaging. imaging preferences were guided by the presence of residual fragments, ureteral perforation, solitary kidney, and postoperative pain or fever. introduction and objective: ct scans expose patients to ionizing radiation which is associated with risks of secondary malignancy. we sought to evaluate the performance of reduced dose ct scans in patients evaluated for renal colic in the emergency room. up. , figure . introduction and objective: intraoperative exposure to ionizing radiation is a growing concern for the safety of both patient and or staff . eff orts to reduce the amount of radiation during ureteroscopic procedures oft en result in decreased image quality. lessray™ is a device used to digitally enhance images obtained from a c-arm using a low-dose pulse setting allowing for reduction in radiation dose while maintaining image quality. a randomized prospective trial of patients was performed comparing ureteroscopic cases for unilateral obstructing ureteral stones using standard fl uoroscopy compared to lessray™. patient demographics, stone parameters, and operative characteristics were recorded in addition to total radiation dose, total fl uoroscopy time and images obtained ( (table ) . a statistically signifi cant reduction in radiation exposure to the surgeon was also noted (p = . ). image quality was not compromised and no conversion from less-ray™ to standard fl uoroscopy was needed in any case. a nearly threefold reduction in patient radiation exposure was achieved using the lessray™ digital enhancement device compared to standard fl uoroscopy. th is novel technology has not previously been used in urologic surgery and off ers a promising alternative to standard fl uoroscopy while ameliorating risks to both the patient and surgeon. bilateral results: in the cases of cn patients, accepted retroperitoneal laparoscopic cyst unroofi ng, accepted retroperitoneal laparoscopic partial nephrectomy, patient with a preoperative diagnosis of cystic renal cell carcinoma, the maximum diameter of cm and located in the center of the kidney got retroperitoneal laparoscopic radical nephrectomy. one patient recurred yrs later aft er retroperitoneal laparoscopic cyst unroofi ng, and underwent open partial nephrectomy at last. six mestk patients underwent retroperitoneal laparoscopic radical nephrectomy and accepted retroperitoneal laparoscopic partial nephrectomy. twelve cases were followed up for months to years, no recurrence. conclusion: cn and mestk are rare benign tumors of the kidney. preoperative misdiagnosis is high. multi-cystic lesions with no mural nodules should take cn/mestk into consideration, especially when the lesions convex to the pelvis, should be highly suspected for cn diagnosis, and to assess the possibility of partial nephrectomy. cyst unroofi ng for cn has recurrence risk. the value of -t multiparametric mri for detecting prostate cancer of t stage introduction and objective: th e objective of this study was to prospectively determine the value of -t multiparametric (mp) mri with pelvic -phased array coil for prostate cancer of t stage. december , patients underwent -t mpm-ri with pelvic -phased array coil, transrectal ultrasound-guided biopsy and radical prostatectomy for adenocarcinoma. mr images were evaluated by three experienced radiologists with regard to extracapsular extension and seminal vesicle involvement and compared with whole-mount histopathological sections as a gold standard. we estimated the sensitivity, specifi city, positive, and negative predictive value and overall accuracy of mpmri for t disease. introduction and objective: prostate cancer (pca) imaging has undergone a revolution in the past fi ve years with the rise of multiparametric magnetic resonance imaging (mri) for cancer detection and the evolution of positron emission tomography-computed tomography (pet-ct) for staging. initially, choline pet-ct was considered the new standard for detecting metastatic disease where biochemical recurrence (bcr) occurs aft er primary treatment, but a newer agent based on prostate-specifi c membrane antigen (psma) has emerged. despite the reported promising results with this novel imaging modality few reports correlating psma pet-ct with pca histology have been documented. we present the case of a fi t year old gentleman, where psma pet-ct was used to accurately detect pca pelvic lymph node (ln) metastasis in the setting of bcr following primary radiation treatment. results: th e positive psma pet result was confi rmed with histological examination of the involved pelvic lns following robotic-assisted laparoscopic pelvic ln dissection (plnd). larger studies are required to document accurately the role of psma pet-ct but it is likely it will usher in a new era of surgical and even radiation treatment of oligometastatic disease, aiming for cure or prolonged deferring of systemic treatment. introduction and objective: imaged guided radiotherapy has been shown to improve the outcome of pelvic radiotherapy, notably with prostate gold seed fi ducials. lipiodol has been utilized for radiotherapy bladder fi ducials, but can be technically diffi cult to inject as discrete fi ducial markers, particularly in the post-prostatectomy setting. th e objective is to investigate contrast agent/tissue glue mixtures as radiotherapy bladder fi ducials with respect to deliverability and visualisation for radiotherapy verifi cation. two radiopaque contrast agents, lipiodol and urograffi n were investigated. th ese were mixed with a three tissue glues: histoac-ryl™, tisseel™ and glubran™. to simulate the clinical procedure, the mixtures were injected ex-vivo into the submucosa of fl uid fi lled pigs' bladders using a cystoscope and williams needle. th e aim was to produce a small, medium and large fi ducial. th e bladders were transferred to a pigs' pelvis to provide realistic tissue densities for radiotherapy imaging. visualisation of the pelvis was performed in accordance with radiotherapy procedures. th e initial imaging was done on a radiotherapy ct simulator. radiotherapy verifi cation was performed by radiation therapists using widely accepted protocols including cone beam ct (cbct) and kilovoltage (kv) & megavoltage (mv) d planar images. results: delivery: urograffi n glue mixtures were diffi cult to deliver as it polymerized rapidly in the catheter. consequently it was only possible to produce a single fi ducial. th e lipiodol glue combinations were all deliverable. visibility: th e urograffi n glue combinations were only able to produce a single fi ducial that was visible on ct and cbct but were not visible with kv or mv verifi cation. all of the lipiodol glue combinations produced multiple fi ducials that could be satisfactorily visualised on ct and cbct. lipiodol with either hystoacryl or glubran produced visible fi ducials on kv imaging, however the lipiodol tisseel combinations could not be seen. no combination produced suffi cient contrast with mv planar imaging. introduction and objective: th e fl exible urethrocystoscopy is a procedure that is performed routinely in urology for monitoring bladder tumors and diagnosis in patients with lower urinary tract symptoms and hematuria. th e aim of this study is to analyze whether the use or not of antibiotic prophylaxis is indicated in this outpatient procedure. prospective nonrandomized observational study in which patients were divided into two groups: -group : patients with prophylaxis with ciprofl oxacin mg h before urethrocystoscopy; -group : patients without antibiotic prophylaxis. prior to inclusion in the study absence of urinary tract infection is checked by urine culture obtained three days before the procedure. indication of cystoscopy, cystoscopy results, presence of comorbidities, urine culture aft er days, urinary symptoms over the next seven days were analyzed. statistical analysis with spss . with signifi cance diff erences p≤ . . results: th e mean age of patients in group was . ± . years versus . ± . years in group (p= . ). no diff erences in the percentage of men / women included among the groups. fourteen percent of patients in group had bacteriuria compared with % in group , no signifi cant diff erence. in the multivariate analysis, it appears that neither age, diabetes, smoking, lower urinary tract symptoms or immunosuppression were associated with the onset of bacteriuria between groups. conclusion: th e use of ciprofl oxacin prophylaxis in fl exible cystoscopy is not indicated in our health area, because does not diminish the presence of urinary tract infection or bacteriuria. minimal inhibitory concentrations for a novel anti-bacterial peptide eluting urethral catheter introduction and objective: catheter associated urinary tract infection is a serious prevalent medical problem. several strategies have been developed to suppress the seemingly inevitable ascent of foreign pathogens through the urethra. th e primary strategy has been to coat the surface of the catheter with repellant agents, such as silver alloy hydrogels or anti-biotics. anti-bacterial peptides, such as human beta defensing (hbd- ) or cathelicidine are naturally produced peptides from the urothelium, acting to inhibit bacterial attachment and infi ltration as part of the innate immunity of the host. we have recently been able to engineer anti-bacterial peptide elution through gelatin coated catheters. th is study investigates the effi cacy of this strategy in deterring common uti pathogens. materials and methods: e. coli and p. aeruginosa, bacteria commonly associated with uti, were inoculated in tryptic soy broth, and then were aliquoted into each well of plates. anti-bacterial peptides, either recombinant hbd- or cathelicidine, were diluted and added to each well at increasing concentrations, where microorganisms were exposed for hours or for the indicated times following antimicrobial challenge and determination of the planktonic mics. bacteria were then enumerated by serial dilution plating. time-kill studies were performed. bactericidal activities of the antimicrobial agents were defi ned as a log decrease in the cfu/ml over hours relative to cell counts in the starting inoculum. results: th e standard inoculant of e. coli and p. aeruginosa commonly required an mic of μg/ml hbd- , and μg/ml for cathelicidine. time kill studies estimated bactericidal eff ect for hbd- on e. coli and p. aeruginosa both at hours, while for cathelicidine it was and hours, respectively. conclusion: th e current study demonstrates the efficacy and feasibility of a controlled release elution of anti-bacterial peptides, hbd- and cathelicidine, in inhibiting growth of common uti pathogens. the conclusion: co-infections of ng with ct appear less frequently. and mpcr method is rapid and accurate for identifi cation of stp. th e mpcr should be conducted in advance prior to antibiotic treatment as well as it will be better to give suitable antibiotics rather than empirical combination antibiotics for ng with ct in patient with urethritis. introduction and objective: th e prevalence of multi-drug resistant extended-spectrum beta-lactamase-producing (esbl) bacteria in normal gut fl ora in the australian community is increasing. current prophylactic antibiotic regimes for trans-rectal ultrasound (trus) prostate biopsies do not have activity against esbl organisms leaving some men at risk of esbl sepsis. our objective is to determine the prevalence of esbl in gut fl ora in northern tasmanian men and to identify risk factors for colonisation. patients were recruited into two groups. group were volunteers from the urology pre-operative clinic or the general community. group were men undergoing trus prostate biopsies. all patients were assessed via an enrolment questionnaire for the presence of known esbl risk factors. further procedural data were collected for those who had trus biopsies. all patients were assessed for esbl via a faecal culture, prior to any antibiotic prophylaxis. fisher's two-tailed test was used for comparative analysis. patients with ic/pbs were assessed with the o'leary-sant interstitial cystitis index score and global response assessment questionnaire prior to commencing treatment. assessment with these questionnaires was performed aft er treatments ( weeks) and again aft er treatments ( weeks). assessment end points were pain, urgency, symptom score and problem score. results: data was collected on patients, female and male. six patients had failed rimso- dimethyl sulphoxide (dmso) % w/w treatment prior. at baseline the mean pain score was . , urgency score . , symptom score . and problem score . . aft er weeks the mean pain score fell to . , urgency score to . , symptom score to . and problem score to . . at weeks the global response to treatment was %. nocturia was the fi rst symptom to improve with urgency and pain following. no side eff ects were noted no was reported during instillation and all patients tolerated the treatments. conclusion: ic is a diffi cult disease to treat. it requires a multimodal approach. we found that intravesical chondroitin sulphate reduced pain, urgency and o'leary-sant symptom and problem scores in patients with ic/pbs. all patients tolerated the treatment and no side eff ects were reported. introduction and objective: extended spectrum beta-lactamase (esbl) producing enterobacteriaceae are an increasing concern in an era of antibiotic resistance as they cause infections ranging from community acquired urinary tract infection (uti) to life threatening sepsis. we retrospectively reviewed the incidence and antibiotic susceptibility profi le of all esbl producing enterobacteriaceae at a university hospital in the united kingdom. patient gender, age and catheter specimen were assessed as risk factors. patient age, gender and specimen type were recorded in the database. urine samples received from outside our institution (including community isolates) were excluded from the analysis. urine was processed by calibrated loop sampling on to chromogenic clear media (oxoid ltd, basingstoke, uk). a positive culture was defi ned as ≥ cfu/ml except for samples from children and pregnant women where a cut-off value of > cfu/ml was used. susceptibility testing was performed by bsac (british society of antimicrobial chemotherapy) disc diff usion testing and reported for ampicillin, co-amoxiclav, piperacillin-tazobactam, carbapenems (ertapenem, meropenem), nitrofurantoin, pivmecillinam, trimethoprim, cephalexin, fosfomycin, third generation cephalosporins (ceft riaxone, ceft azidime) quinolones (norfl oxacin or ciprofl oxacin), aminoglycosides (gentamicin, amikacin) and others. cultures of more than two organisms (heavy mixed growth) were considered contamination and excluded. other exclusion criteria included missing data such as gender, age or susceptibility results, age < years old or an unusual specimen type such as an ileal conduit, nephrostomy, prostatic secretion, bag specimen or a suprapubic aspirate. results: our initial database included , samples which was reduced to , samples from , unique patients aft er exclusion criteria were applied. causative organisms were found to predominantly be e. coli, enterococcus, klebsiella, pseudomonas and proteus species. th e proportion of causative organisms was largely stable across the ten year period. antibiotic resistance was demonstrated to have increased, particularly across fi rst line agents. male gender and catheter use were associated with multi-resistance. in the modern era of antibiotic resistance we demonstrate that antibiotic resistance in hospital urinary tract infections is increasing. our results may be used to guide empirical treatment of hospital urinary tract infection. chronic pyelonephritis is a risk factor for renal dysfunction after urinary diversion in bladder cancer uehara s , , murao w , otsuki h , shimizu t , yoshioka t , , fujio k okayama university, okayama, japan; abiko toho hospital, abiko, japan introduction and objective: several reports showed that acute pyelonephritis is a risk factor for renal dysfunction in bladder cancer aft er urinary diversion, but the impact of chronic pyelonephritis fer renal dysfunction was unclear. materials and methods: from to , patients underwent radical cystectomy in our institute. among those patients, who showed hydronephrosis (more than grade ) or did not have enough data were excluded in this retrospective study. finally patients were enrolled. th e urinary diversions were divided into types: ileal neobladder (ib), ileal conduit (ic), ureterocutaneostomy without stent (uc) and ureterocutaneostomy with stent (ucws). ureteral stents were indwelled because of the ureteral stenosis aft er ureterocutaneostomy. because the cases of ucws generally showed pyuria and bacteriuria, ucws was determined as the chronic pyelonephritis model, and the estimated serum creatinine-based glomerular fi ltration rate (egfr) was calculated and compared with other urinary diversion. results: median follow-up period was . months (range - months) and median egfr was . ml/ min/ . m before surgery and . ml/min/ . m at the last follow-up. th e median decrease of egfr during the period between pre-surgery and the last follow-up in ib, ic, uc and ucws was . , . , . and . ml/min/ . m respectively. renal function was signifi cantly impaired in ucws cases than other urinay diversion. conclusion: chronic pyelonephritis may be a risk factor for renal dysfunction aft er urinary diversion. to avoid the renal dysfunction, ureteral stents should not be indwelled permanently. comparison of antibiotic susceptibility of escherichia coli between community-acquired and post-biopsy acute prostatitis introduction and objective: th e etiology of acute prostatitis aft er transrectal-ultrasound-guided-prostate-biopsy (pbx-ap) seems to be diff erent from that of community-acquired acute prostatitis (ca-ap). recent studies suggested that pbx-ap should be considered a separate category of prostatitis, distinct from spontaneous acute prostatitis. th us, we aimed to compare antibiotic susceptibility of escherichia coli between ca-ap and pbx-ap. of , patients who underwent transrectal-ultrasound-guided-prostate-biopsy, a total of patients had pbx-ap. in among these, escherichia coli was isolated on urine or blood culture. in of the patients with ca-ap, escherichia coli was identifi ed on urine or blood culture test. th us, a total of patients with ca-ap (n = ) or pbx-ap (n = ) caused by escherichia coli were included in this retrospective study. we compared demographic variables, data on clinical laboratory tests or transrectal ultrasound and antibiotic sensitivity data between the two types of prostatitis. results: in comparison to the ca-ap group, the pbx-ap group showed signifi cantly higher incidence of bacteremia and lower count of white blood cell. th ere was no signifi cant diff erence between the two, regarding to other clinical or laboratory parameters including age, body mass index, serum psa, prostate volume and percentage of patients with ebsl-positive escherichia coli. th e percentages of patients with quinolone-resistant escherichia coli in the ca-ap and pbx-ap groups were . % and . %, respectively, while those with nd or rd cephalosporin-resistant escherichia coli were . % - . % and . % - . %, respectively (table ). in both groups, the percentage of patients with amikacin-resistant escherichia coli were . %. our data suggest that a combination therapy of cephalosporin and amikacin can be recommended for treatment of pbx-ap while quinolone alone may be a feasible treatment option for ca-ap. the effectiveness of prostatic massage in treating chronic prostatitis (cp) tanabalan c, panah a, kabir m, masood j, pati j, nargund v introduction and objective: we review the eff ectiveness of prostatic massage under general anaesthesia (ga) for persistent symptoms aft er failure of antibiotic therapy. th e mainstay of treating cp is empirical antibacterial therapy with varying results. prostatic massage has been used to treat cp with mixed results. retrospective study of patients that were seen in urology outpatient clinics from june to july with symptoms of chronic prostatitis. all patients had a full clinical evaluation and urinary samples were sent for culture/microscopy on their visit. patients were treated initially with a course of -aminoquinolone and doxycycline in combination with lifestyle advice. if initial antibiotic therapy failed and no abnormal results detected in the work-up, a prostatic massage was off ered. th is involved a rigid cystoscopy followed by a -minute prostatic massage under anaesthesia. post-operatively patients received a further course of antibiotics. patients were followed up aft er the procedure and were assessed for improvement in symptoms. a total of patients ( %) commented on an improvement in some or all of their cp symptoms for a mean length of time of . (range . to . weeks). mean psa was . (range . to . ). one bladder tumour and one urethral stricture were detected on cystoscopy with one prostate cancer following prostate biopsies. if voiding urinary symptoms present men were given an alpha-blocker, there was no signifi cant improvement in pain symptoms post-operatively between the two groups (p= . ). th ere were no adverse eff ects from having the procedure with no complications noted. prostatic massage under ga is a safe and eff ective therapy in the treatment of refractory cp in select patients. th e issues of long-term surveillance and assessment of response to treatment remains a challenge. th ere seems little role for alpha-blockers, psa testing and mri prostate in the management of cp. oral antibiotic therapy and lifestyle modifi cations should remain as a fi rst-line treatment option. th e eff ect of stress, lifestyle and ethnicity has not been demonstrated in this study and further research will need to be undertaken. intravesical hyaluronic acid and chondroitin sulfate therapy for interstitial cystitis and painful bladder syndrome shin b, hwang e, chung h, kim s, jung s, kang t, park k, kwon d introduction and objective: damage to the urothelial glycosaminoglycan (gag) barrier layer may underlie the pathogenesis of several chronic bladder pathologies, including interstitial cystitis/painful bladder syndrome (ic/pbs). th is study evaluated the eff ect of intravesical hyaluronic acid (ha) in ic/pbs. twenty patients received intravesical ha mg and chondroitin sulfate (cs) g (ialuril®) in ml saline solutions once weekly for weeks, once every weeks for the next month, then once every month for the next months. results: a signifi cant improvement in urinary symptoms was evident on voiding diaries (number of voids and mean void volume; p= . and . , respectively). th e interstitial cystitis symptom index and interstitial cystitis problem index resulted in a significant improvement in both scores (p= . and . , respectively). th e storage symptom score (ipps) decreased from . to . (p= . ). th e quality of life to urinary symptom reduced from . to . (p= . ). th ere was no statistical signifi cant change in the voiding symptom score of ipps aft er ialuril instillation (p= . ). conclusions: th is promising experience seems to offer an additional therapeutic option in patients with refractory ic/pbs. prevention of surgical site infection: new approach alexander e , , hulda t , edna d introduction and objective: until the middle of the th century, when ignaz semmelweis and joseph lister became the pioneers of infection control by introducing antiseptic surgery, most wounds became infected. in cases of deep or extensive infection this resulted in a mortality rate of - %. most surgical site infections (ssi) are superfi cial, but even so they contribute greatly to the morbidity and mortality associated with surgery. th e aim of this study is to fi nd out rate of surgical site infection by single change of wound dressing. th e study is prospective in two hospitals (ba regional hospital, tophill hospital in kumasi). surgically clean cases are selected for operation. wounds are not opened till the seventh day or when soaked. window is left for wound inspection. results: results are shown in table . table , patients with diff erent surgical conditions were operated. average post-surgery change of dressing was days. ssi= / ( . %). single post-surgery change of dressing is eff ective ssi prevention method. effects of semen cuscutae on the fertilization ability in varicocele-induced rat introduction and objective: th ere is no specifi c medication to improve the sperm motility and count yet. th is study aimed to evaluate the favorable eff ects of purifi ed fl avonoid, semen cuscutae extract (sce) against oxidative stress injuries and other homeostatic imbalances in reproductive organs in adolescent rat with varicocele and to develop the new herbal medication to treat the male fertility. materials and methods: seventy-two rats were divided into groups: control (ctr) + hydroxypropyl-methyl cellulose (hpmc) (ctr + hpmc), ctr + mg/kg sce and ctr + mg/kg sce, varicocele (vc) + hpmc, vc + mg/kg sce and vc + mg/kg sce. in ctr group, they were started with medication for days from weeks aft er environmental stabilization. for the vc groups, they were given medications for days aft er weeks of operation. blood was collected before sacrifi ce for the testosterone test. sperm motility, daily sperm production (dsp), sperm count, and sperm transit time were calculated. th e seminiferous tubules were graded according to johnsen scoring. th e mrna expression of glutathione peroxidase (gpx ) and . nmol/mg protein, respectively) than vc group ( . ± . u/mg protein and . ± . nmol/mg protein, respectively). also, the testosterone, johnsen score were signifi cantly increased in the dose of mg/kg sce group than other groups. th ese results suggest that purifi ed fl avonoid semen cuscutae extract could be an alternative medicine for the infertility patients by inhibition of oxidative stress by favorable mechanisms. the relationship between pregnancy rate and semen quality improvement after varicocelectomy varicocele is the most common cause of male infertility and is generally correctable via surgery. in some reports, pregnancy rates were improved aft er varicocelectomy in male patients with poor semen quality. th e aim of this study was to determine the relationship between semen improvement and pregnancy rate. patients who underwent microsurgical varicocelectomy from jan. to jun. were enrolled. all patients had history of infertility (> year) and confi rmed varicocele on physical examination. th e abnormality of semen analysis results was based on who guidelines. varicocelectomy was performed in patients with poor semen quality in a series of two semen analysis where the female partner was normal in spontaneous pregnancy, as evaluated gynecologically. microsurgical varicocelectomy was performed by single surgeon. follow-up semen analysis was performed months aft er operation. improvement in semen quality was defi ned as > % improvement in total motile sperm compared with pre-operation semen analysis. pregnancy rate, method of pregnancy, and time to pregnancy were investigated. results: a total of male patients were included in this study, ( . %) in the improvement group (ig) and ( . %) in the non-improvement (nig). th e pregnancy rate was % ( / ) in the ig group and % ( / ) in the nig group; there was no significant diff erence between groups. pregnancy methods between the two groups were similar (table ) . introduction and objective: to review the learning curve, complications and outcomes of the fi rst cases of microsurgical vasectomy reversal performed in a developing country. th e fi rst dedicated service in male infertility microsurgery in south africa was established in . between january and december , a total of patients underwent microsurgical vasectomy reversal by a single surgeon (amir d zarrabi). mean patient age was years (range to ), mean age at vasectomy years (range to ), mean number of children for the male partner . and mean age of the female partner years (range to ). th e mean time interval between vasectomy and reversal was . years (range . to . ). five patients had previous failed vasectomy reversals and in patients the indication for reversal was post-vasectomy pain syndrome. a total of % of patients travelled from other countries for their surgery. results: mean surgical time per testicular unit was . minutes (range to ) and total operative time minutes (range to ). sperm motility (intra-operative light microscopy) was good in . %, average in . % and poor in . %. vasovasostomy was required in . % of testicular units and vaso-epididymostomy in . %. in patients sperm was harvested at the time of reversal for cryopreservation. complications occurred in % of patients and were managed conservatively in all but , who required an additional surgical procedure. for patients with adequate follow-up the overall surgical success rate was %. mean post-operative sperm count was . million. nine pregnancies and live births have been recorded during the limited follow-up. comparing the fi rst cases with the last cases revealed no signifi cant diff erences in surgical time, complications or patency rates. th e mean post-operative sperm count was % higher for the last cases. although microsurgical vasectomy reversal is technically demanding and requires specialized equipment and instruments, it can be successfully implemented in a developing country. infl uence of unilateral iatrogenic torsin on contralateral testis in rat, prepubertal and postpubertal introduction and objective: th e present study was conducted to investigate the infl uence of hemicastration and age at hemicastration on the subsequent contralateral testis. sixty-four wistar-derived male rats divided randomly in groups. group named immature intervention, group immature control, group mature intervention and group mature control. in group , rats hemicastrated at days of age (prepubertal). in group , sham surgery (midscrotal incision) was done at same age. in group , rats hemicastrated at days of age (postpubertal) and in group sham surgery was done at same age. twenty days aft er fi rst surgery, in intervention groups contralateral orchiectomy was done and in control groups random orchiectomy (left or right) was done. blood sampling for evaluation of serum testosterone was performed just before second surgery. results: testis weight and the mean testicular weight per g of body weight was greater in hemicastrated rats. th ese parameters was greater in prepubertal group than postpubertal hemicastrated rats. th ere was no appreciable diff erence in serum testosterone levels in groups. our research demonstrated that hemicastration resulted in compensatory hypertrophy of the remaining testis and it decreased as the animals aged. hemicastration does not lead to reduction in serum testosterone levels and remaining testis can retrieve a normal serum testosterone level. role of antibiotic in the treatment of semen hyperviscosity: a single institution study introduction and objective: th e prevalence of semen hyperviscosity is estimated to be between - % and can lead to male factor infertility both in vivo and in vitro. semen is composed of fl uids secreted by the male accessory glands, which contain proteins essential to the coagulation and liquefaction of semen. hypofunction of the prostate or seminal vesicles causes' abnormal viscosity of seminal fl uid. hyperviscosity can impair normal sperm movement in the female reproductive tract, and can lead to decreased sperm count. multiple factors have been predicated which result in the development of semen hyperviscosity, of this infection is considered to be one of the main contributor. aim of the study was to predict the eff ect of antibiotic in the treatment of hyperviscosity. th is is a single institution study, patients (age range - years) were recruited who were diagnosed with semen hyperviscosity (failure to liquefy aft er min). medical, sexual, and family history were documented. all the patients semen were kept for culture and they all got levofl oxacin for days and patient who had positive culture were changed to appropriate antibiotics. all the patients underwent repeat semen analysis aft er weeks. results: seventy seven percent patient had previous history of prostatitis, % patient had past history of sexual transmitted diseases. seventy fi ve percent patient are suff ering from infertility, of this % patient had a family history. th irty seven percent patients had positive culture and of this only % patient had liquefaction post treatment. culture negative patients, % patient had liquefaction post treatment. conclusions: semen hyperviscosity is associated with infertility and exact cause is considered to be multifactorial, of this infection is considered to be the main factor. in our study we did found that most of the patients has infection but antibiotic treatment even for culture positive patients showed minimal eff ect. treatment with antibiotic along to treat hyperviscosity cannot be considered curative since in our study the eff ect was only %. further research is needed to better understand the contributors to semen hyperviscosity and the treatments that can be used for infertile males with hyperviscous semen. modifi ed microsurgical subinguinal varicocelectomy: bundle ligation technique hong y, lee s, choi k, park d, hong j introduction and objective: microsurgical varicocelectomy has become the gold standard because of low recurrence and postoperative complication rate. during the procedure, isvs should be carefully dissected, cut and suture-ligated one by one. however, it is not easy to divide all isvs in a horizontal line, which can result in some uncertainty whether every single isv was divided or the same vein was unnecessarily divided multiple times. th erefore, we have developed a modifi ed technique, so called bundle ligation technique (blt), to make the procedure more reliable and simpler. a total of cases of microsurgical subinguinal varicocelectomy performed from to were grouped as conventional varicocelectomy (cv, n= , age: ± . ) and blt (n= , age: ± . ). mean follow-up time was . ± . months. blt is a simpler procedure because isvs are ligated as a whole, however, it is possible only aft er dissecting and securing the testicular artery fi rst. we compared operation time, resolution of palpable varicocele or pain, recurrence rate and complications. results: mean operation time was . ± . in cv group and . ± . in blt group (p= . ). resolution rates months aft er surgery were . % (cv) and . % (blt) in each group. recurrence aft er surgery during the mean follow-up time was . % (cv) and . % (blt). th e aim of the study is to evaluate the eff ect of hbo on the level of sperm dnaf and on the content of reactive oxygen species (ros) in semen. th e study included men with idiopathic infertility, the level of sperm dnaf was above % and the content of ros in the sperm was above . mv/sec. in the main group (n= ) sessions of hbo were performed and in vitro fertilization (ivf) was carried out months later. in the control group (n= ) ivf was performed without preceding hbo. th e age of patients ranged from to years (median - . years). sperm dnaf was determined by tunel, the level of ros in semen was studied by chemiluminescence. th e assessment was made at the time of entry into the study and aft er months (in the main group - months aft er hbo). in the main group, average sperm dnaf aft er hbo decreased from . ± . % to . ± . % (p< . ), the median level of ros in semen decreased from . mv/sec to . mv/sec (p< . ), whereas in the control group of patients these fi gures have remained almost at the same level - . ± . % and . ± . % (p> . ), . mv/sec and . mv/sec (p> . ). pregnancy resulting from ivf occurred in . % ( / ) of the cases in the study group and in . % ( / ) -in the control group (p< . ). conclusion: hbo is an eff ective method to reduce the number of sperm with dnaf, which can potentially lead to an increased fertility in patients with idiopathic male infertility. to evaluate the natural history and growth kinetics between sporadic clear cell renal cell carcinoma (ccrcc) and ccrcc in von hippel-lindau disease (vhl). we reviewed patients with sporadic ccrccs and patients with vhl ccrccs all confi rmed by delayed surgery aft er at least months active surveillance. th e growth rate was calculated. th e growth kinetics between sporadic and vhl ccrcc were compared. th e initial tumor diameter and pathological grade were reviewed, and their correlation with the growth rate were analyzed. results: th e mean growth rate of sporadic ccrcc was . cm/yr (range, - . cm/yr). th e mean growth rate of vhl ccrcc was . cm/yr (range, . - . cm/yr). th e growth rate of vhl ccrcc was lower than that of sporadic ccrcc (p= . ). for vhl ccrcc, the initial tumor diameter aff ect the growth rate (r= . , p< . ), while the pathological grade not (p= . ). for sporadic ccrcc, the pathological grade aff ect the growth rate (p< . ), while the initial tumor diameter not (r=- . , p= . ). conclusion: th e growth kinetics of vhl ccrcc is more indolent than that of sporadic ccrcc. for ccrcc with aggressive growth kinetics, its growth rate might correlates with the pathological grade, for those with slow growth kinetics, the growth rate might correlates with the initial tumor diameter. effects of trpm silencing on the proliferation, migration, and invasiveness of renal cell carcinoma (rcc) cells proliferation, migration, and invasiveness of human rcc following trpm knockdown. we constructed sirna sequences targeting the trpm gene and then transfected them into rcc cells mediated by liposome. th e potency of nm trpm sirnas was detected trpm mrna measurement by rt-pcr. th e eff ect of trpm sirna on cell viability was determined by wst- assay. cell motility and invasiveness were evaluated by wound healing assays and a matrigel migration and invasion assay. transfected rcc cells were cultured in eagle's minimum essential media supplemented with % fetal bovine serum. all measurements were done hours aft er trpm blocking. results: trpm sirna weakly inhibited the gene transcription of trpm . it was for nothing in the proliferation of human rcc cells. compared with vehicle control, the migration and invasion of human rcc cells were suppressed signifi cantly by trpm sirna until aft er hours. in addition, although protein levels of mmp- were not changed signifi cantly, we found that the protein levels of matrix metalloproteinase (mmp)- were diminished markedly by trpm sirna. th ese results suggest that trpm may have a role in the rcc progression including migration and invasion through upregulation of mmp . role of tnf-and cd in resistance to sunitinib treatment in clear cell renal cell carcinomas introduction and objective: tumor necrosis factor-α (tnf-α) was originally reported as a cytokine to induce apoptotic cell death and cachexia. recent studies have indicated that tnf-α also enhances tumor progression by inducing epithelial-mesenchymal transition (emt). tnf-α is also known as a modulator of cd expression, which belongs to cancer stem cell marker in several cancers. in this study we clarifi ed the signifi cance of tnf-α as well as cd in clear cell renal cell carcinomas (ccrccs). protein expression of tnf-α and cd was examined by immunohistochemistry in primary ccrccs, untreated metastatic ccrccs, and metastatic ccrccs treated with sunitinib, and its association with the clinicopathological parameters and prognosis was analyzed. involvement of tnf-α in emt and induction of cd was analyzed by comparing expression of emt-related genes and cd , and migration and invasion in cultured ccrcc cell lines. results: tnf-α and cd were predominantly expressed in carcinoma cells of high-grade ccrccs with positive correlations with primary tumor stage and distant metastasis. th ere was a positive correlation between tnf-α and cd expression, and elevated expression of tnf-α and cd was a poor predictor of prognosis. tnf-α enhanced migration and invasion of ccrcc cells together with down-regulation of e-cadherin expression and up-regulation of matrix metalloproteinase and cd expression. tnf-α also up-regulated the expression of tnf-α itself in ccrcc cells. twenty-fi ve patients were treated with sunitinib for metastasis, and the patients with cd -high tumors showed a shorter time to treatment failure compared to those with cd -low tumors. furthermore, residual carcinoma cells in the sunitinib-treated metastatic ccrccs were strongly positive for cd , and the cd expression was signifi cantly higher in tumors from the sunitinib-treated patients than in those from untreated ones. conclusions: tnf-α seemed to play an important role in progression of ccrccs by inducing emt, and suggested that tnf-α-induced cd might be involved in the resistance to sunitinib treatment. although further experimental studies on the relations between cd expression and cancer stem cells in ccrccs are needed, our data suggest that therapy targeting tnf-α and/or cd may provide a clue for improving the prognosis of patients with sunitinib-resistant ccrcc. introduction and objective: th e aim of this study was to investigate the relationship between the immunohistochemical expression of hypoxia-inducible factor- α (hif- α) with histological parameters such as tumor size; presence of tumor necrosis and hemorrhage; nuclear grade and pathological stage in patients with clear cell renal cell carcinoma (ccrcc). specimens from cases of rcc patients treated with radical prostatectomy were formalin-fi xed, paraffi n embedded, and stained with h&e. additional sections from each case were stained for hif- α. hif- α immunohistochemical expression was estimated as negative ( ), weak positive (+ ), moderate positive (+ ), and intense positive (+ ). th e statistical package "in stat " was used for data processing. results: immunohistochemical expression of hif- α in crcc was signifi cantly higher than in normal kidney tissue at statistically signifi cant level (hif- α: x -test = . , p= . ). a positive non-signifi cant correlation was found between hif- α and the tumor nuclear grade (r= . , p= . ); between hif- α and presence of hemorrhage (r= . , p= . ); whereas, a negative non-signifi cant correlation of a very weak scale was observed comparing hif- α and tumor size (r = - . , p= . ); hif- α and pathological stage (r=- . , p= . ), as well as hif- α and tumor necrosis (r=- . , p= . ). conclusion: our data showed heterogeneity in angiogenic activity, which might have an impact on biological behavior and anti-angiogenic, anti-vegf therapy of ccrcc patients. th is study suggests that there should be taken more than one tissue biomarkers into the consideration in predicting the biological behavior of ccrcc. introduction and objective: clear cell renal carcinoma (ccrcc) is the most frequent rcc subtype and is characterized by high mortality of %, due to late diagnosis and distant metastases found in % of rcc patients. although the involvement of vhl (von hippel-lindau), hif a (hypoxia-inducible factor -alpha) and vegf-a (vascular endothelial growth factor a) genes in development and progression of ccrcc is widely analyzed, our objective was to perform the common study of those factors in clinical samples of matched tumor-normal kidney biopsies of ccrcc cases. materials and methods: vhl, hif a and vegf-a mrna levels in samples were assessed by quantitative polymerase chain reaction (qpcr); rna was extracted from matched tumor-normal (t, c) kidney samples of ccrcc patients (mean age . ± . , median age ); ccrcc cases were characterized by local or distant metastasis; sunitinib was administrated to patients. vhl, hif α and vegf-a proteins were localized in matched tumor-kidney tissue of patients with the use of immunohistochemistry (ihc). molecular data was statistically calculated with clinical and follow-up data. introduction and objective: to identify tissue biomarker that are predictive of the therapeutic eff ect of sunitinib in treatment of metastatic clear cell renal cell carcinoma (mcrcc). our study included patients with mcrcc; these were selected from patients who received sunitinib in our hospital between the years - according to inclusion criteria of the study. patients were stratifi ed into two groups based on their response to sunitinib treatment; non-responders (progression), and responders (stable disease, regression). th e eff ect of treatment was measured by comparing imaging studies performed before the initiation of treatment with those done between rd and th months of treatment. histological samples of tumour tissue and healthy renal parenchyma, acquired during surgery of the primary tumour, were examined with immunohistochemistry to detect tissue biomarkers (mtor, p , vegf, hif , hif , caix). th e comparison between the two groups of patients was based on comparing the average levels of biomarker expression in both tumour tissue, as well as in healthy renal parenchyma. results were evaluated using student's t-test. results: when considering the results of the group of responders, statistically signifi cant diff erences in marker expression in tumour tissue versus healthy parenchyma were found for mtor ( %/ . %;p= . ), p ( %/ . %;p= . ), vegf ( . %/ %;p= . ) and caix ( %/ . %;p= . ). as for the group without response (non-responders), a statistically signifi cant diff erence was also evident in p a vegf expression in tumour versus healthy tissue ( %/ . %;p= . resp. . %/ %;p= . ). in the responders, a further signifi cant diff erence was found in the frequency of high expression (more than %) between tumour tissue and healthy parenchyma in vegf ( %/ %;p= . ) and caix ( %/ %;p= . ). caix shows high levels of expression in the tumour tissue, in both of the evaluated groups. when comparing the expression levels in the same type of tissue, between the group of responders and non-responders, no signifi cant diff erence in any biomarker was found. conclusion: a signifi cantly higher expression of vegf in crcc in comparison to healthy parenchyma, can predict a better response to sunitinib. on the other hand, the high expression of vegf in healthy renal parenchyma can predict worse response to treatment. the impact of preoperative retrograde pyelography before radical nephroureterectomy for upper urinary tract urothelial carcinoma on intravesical tumor recurrence song p , ko y , choi j , moon k , jung h , kim t introduction and objective: despite its diagnostic role in identifi cation of upper urinary tract urothelial carcinoma (uut-uc), approach to ipsilateral ureteral potentially aggravates spread of tumor, as reported in preoperative ureteroscopy before nephroureterectomy. we thus assessed the impact of preoperative retrograde pyelography (rgp) on intravesical recurrence aft er radical nephroureterectomy for uut-uc. of a total of patients who underwent nephroureterectomy for uut-uc from january to june in our institution, patients who did not undergo preoperative ureteroscopy were selectively enrolled. computed tomography and urine cytology as a basic diagnostic modality were performed in all subjects. th e impact of preoperative rgp and the other variables (age, sex, operating time, clinicopathological factors, and hematological factors) on intravesical recurrence were analyzed by multivariate cox regression model. during a mean follow-up period of . months, ( . %) patients had intravesical recurrence aft er rnu, and subjects ( . %) underwent preoperative rgp. th e mean duration from preoperative rgp to rnu was . ± . days and mean interval of intravesical recurrence was . ± . months. multivariable analysis showed that rgp and pathologic stage over t were independent factors for intravesical tumor recurrence (p= . and p= . , respectively, table ). regarding the duration from preoperative rgp to rnu, no signifi cant diff erence was observed between the recurrence group and the non-recurrence group (p> . ). as with preoperative ureteroscopy, our data demonstrated that preoperative rgp is an independent factor associated with intravesical recurrence of uut-uc aft er rnu. introduction and objective: axitinib which is tyrosine kinase inhibitor is standard nd-line treatment for metastatic renal cell carcinoma (mrcc). th e neutrophil-to-lymphocyte ratio (nlr), an index of systemic infl ammation, is associated with outcome in several cancer types. to assess the relation of pretreatment nlr with progression-free survival (pfs) and overall survival (os) of patients treated with axitinib. twenty-two patients with mrcc were treated with axitinib between october and january . patients were stratifi ed in two groups with nlr > (group a: n= ) vs. < (group b: n= ). pfs and os were estimated using kaplan-meier method. results: median os and pfs were . and . months, respectively. median os was . and . months in group a and group b, respectively (p= . ). median pfs was . and . months in group a and group b, respectively (p< . ). multivariate analysis showed that nlr > was an independent predictor of os (hr . . ; p= . ). in patients with mrcc treated with axitinib, pretreatment nlr might be an independent predictor for the outcome. th e aim of this study was to evaluate whether preoperative neutrophil-to-lymphocyte ratio (nlr) predict the prognosis in patients with upper urinary tract urothelial carcinoma (uu-tuc). a cohort of patients diagnosed with uutuc from to at tokyo metropolitan tama medical center was enrolled in this retrospective study. log-rank test and cox proportional hazards regression models were used for univariate and multivariate analyses. results: on univariate analysis, pathologic t stage, grade, lymphovascular invasion, c-reactive protein (crp) level, and nlr were signifi cantly associated with recurrence-free survival (rfs) and cancer-specifi c survival (css). th e rfs rates for an nlr < . and for one ≥ . at years were . % and . %, respectively. th e css rates for an nlr < . and for one ≥ . at years were . % and . %, respectively. th e multivariate cox proportional hazards regression models showed that the nlr could be an independent predictor for rfs and css. based on the results of multivariate analysis, the scoring model was developed. rfs and css rates at years were as follows: risk factor, . % and . %, respectively; risk factor, . % and . %, respectively; risk factors, . % and . %, respectively; risk factors, . % and . %, respectively; and risk factors, . % and . %, respectively. conclusion: th e preoperative nlr is an independent prognostic predictor. th e model based on the nlr and pathologic factors can be useful in clinical practice. clinicopathological outcome of small cell carcinoma of upper urinary tract: one starting point, diverging paths lu k, wang h, lin v, yu t introduction and objective: primary small cell carcinoma of upper urinary tract (uut-scc) is an extremely rare disease entity with distinct histological and biological behavior, representing less than . % of urinary tract tumor. th e rarity of these neoplasms poses a diagnostic and therapeutic challenge. little is known about uut-scc and the current knowledge of this disease is based on case reports or small series. our aim of study was to characterize the patients with uut-scc and to evaluate patient outcomes with the available treatment modalities. th is was a single-institute retrospective observational cohort study of patients with small cell carcinoma of upper urinary tract followed at e-da hospital, kaohsiung city, taiwan be-tween january , and october , . patient and tumor data were analyzed using descriptive statistical methods. results: six patients with primary uut-scc were identifi ed, consisting of arising from renal pelvis and from upper ureter. th e median age at diagnosis was years with male-to-female ration of : . th e most common presenting symptoms were painless gross hematuria, followed by fl ank pain. th e morphological appearance of the tumor cells and their immunohistochemical reactivity for neuroendocrine markers and cytokeratin helped establish the diagnosis. in of cases, scc coexisted with urothelial carcinoma. surgery was standard treatment given to all patients. of all cases, of patients received chemotherapy, including one receiving neoadjuvant chemotherapy and administering adjuvant chemotherapy. overall median survival was months. conclusion: primary small cell carcinoma of the upper urinary tract is characterized by an aggressive clinical course with early metastatic spread and relatively short overall survival. although high response rate to cytotoxic chemotherapy, its duration of response is limited and the prognosis remains dismal. as there is no standard of care for patients with uut-scc, further eff orts should be directed at its early detection and made to develop more eff ective therapeutic approach for this high-risk lethal disease. prognostic introduction and objective: th e aim of this study was to evaluate the impact of body mass index (bmi) on survival in patients with non-metastatic renal cell carcinoma (rcc) treated with radical or partial nephrectomy. between june and july , patients with rcc underwent radical or partial nephrectomy at two hospitals. among these patients, patients with lymph node or distant metastasis were excluded. th us, the medical records of the remaining patients ( men and women, mean age of . years) were retrospectively reviewed. th e median follow-up duration was months (range to months). th e patients were classifi ed into groups according to their bmi based on the asia-pacifi c criteria for obesity: normal ( . to < kg/m ), overweight ( to < kg/m ), and obese (≥ kg/ m ). th e prognostic signifi cance of various clinicopathological variables including bmi was analyzed using univariate and multivariate analysis. results: of the total patients, patients ( . %) were categorized as normal, ( . %) as overweight, and ( . %) as obese. forty-six patients ( . %) developed local recurrence or distant metastasis and patients ( . %) died of disease during the follow-up period. in the univariate analysis, bmi, tumor size, t stage, fuhrman's nuclear grade, coag-ulative tumor necrosis, and lymphovascular invasion were signifi cant predictors of recurrence-free survival. also, bmi, tumor size, t stage, fuhrman's nuclear grade, and lymphovascular invasion were signifi cant predictors of cancer-specifi c survival. in the multivariate analysis, bmi (p= . ), tumor size (p= . ), t stage (p< . ), fuhrman's nuclear grade (p= . ), and lymphovascular invasion (p= . ) were independent predictors of recurrence-free survival. also, bmi (p= . ), tumor size (p= . ), t stage (p= . ), and lymphovascular invasion (p= . ) were independent predictors of cancer-specifi c survival. our results suggest that bmi is an independent prognostic factor for recurrence-free and cancer-specifi c survival in patients with non-metastatic rcc treated with radical or partial nephrectomy. th ese fi ndings indicate that bmi could be an eff ective tool for predicting recurrence or survival in patients undergoing nephrectomy for non-metastatic rcc. phase i/ii study of multipeptide-based cancer vaccine ima after single-dose cyclophosphamide in japanese patients with advanced renal cell cancer hongo f , ueda t , nakamura t , naya y , okihara k , tamada s , schoor o , singh-jasuja h , nakatani t , miki t introduction and objective: ima is the fi rst therapeutic vaccine for renal cell cancer (rcc) consisting of multiple tumor-associated peptides (tumaps) confi rmed to be naturally presented in human cancer tissue. objective was to assess the safety and tolerability of ima vaccination. in this phase i/ii study in japan, we treated a total of japanese patients with advanced rcc with human leukocyte antigen a (hla-a)* + subjects in - . each of the vaccinations consisted of an i.d. injection of gm-csf ( μg) followed within - minutes by an i.d. injection of ima ( μg of each peptide). th e vaccine therapy was a monotherapy, i.e. no other anti-tumor therapies were concomitantly administered during the study course. no treatment with either anti-cancer agents or immunosuppressants was allowed within weeks before entering the trial. patients were to receive vaccinations in the fi rst weeks of treatment (induction period) followed by further vaccinations at weeks intervals for up to weeks (maintenance period). th e primary endpoint was safety and tolerability. th e secondary endpoints were pfs, os, immunogenicity. results: no treatment-related serious adverse events (saes) or deaths were observed during the study period. at follow-up at months, all cases were assessed for treatment response. ten percent of patients had partial response (pr), % with stable disease (sd), % of patients had progressive disease (pd). median pfs was . months and median os was . months. among all patients analyzed for t-cell response, fi ve showed vaccine-induced (vi) t-cell responses against at least one hla class i-restricted tumap and two patients with responses to multiple tumaps. interestingly, two of the immune responders were of hla-a* phenotype, a hla suballele rarely occurring in europe and us but common in japan. we evaluate the patients who underwent robot-assisted laparoscopic partial nephrectomy (ralpn), laparoscopic partial nephrectomy (lapn), or open partial nephrectomy (opn) in terms of perioperative outcomes. all patients with ct a renal masses who underwent ralpn (n= ), lapn (n= ), or opn (n= ) between november and may at our institute were compared in terms of perioperative outcomes, including the mean operative time, ischemia time, estimated blood loss, change in the estimated glomerular fi ltration rate (egfr), surgical margins, and complications. intraoperative and early postoperative data were collected retrospectively. conclusion: ralpn was signifi cantly associated with shorter ischemia time. any methods of partial nephrectomy preserved renal function at three months postoperatively and showed good oncological outcomes. laparoscopic nephrectomy: does patient obesity affect outcome? introduction and objective: th e prevalence of obesity worldwide is increasing, up to % of men and % of women are now obese. th ere are various means to assess obesity, waist circumference (wc) has emerged as a superior determinant of obesity and then body mass index (bmi). th is study evaluates wc on the outcome of laparoscopic nephrectomy. data was obtained on consecutive patients. a wc of > cm for women and > cm for men is considered obese. data collected includes age, gender, asa score, wc, anaesthetic duration, operative approach, surgery duration, blood loss, renal function, complication rate and duration of hospital stay. overall, patients underwent laparoscopic nephrectomy, were male and female. seventy three ( . %) patients had wc above normal for their gender. mean anaesthetic duration was longer in obese patients . minutes vs. . minutes, (p= . ). operative duration in obese patients was also longer, . minutes vs. . minutes, (p= . ). th ere was no diff erence between groups for conversion, number of ports, intra-operative complications, blood loss, or post-operative complications. however, obese patients had a longer in-patient stay; . days versus . days. conclusion: laparoscopic nephrectomy is safe in obese patients. however, obese patients should be warned that their obesity may be associated with increased anaesthetic and surgical ties and prolonged recovery. the long-term oncologic results of radiofrequency ablation for small renal tumors sung g , bae y , kim s introduction and objective: th e aim of this study was to retrospectively evaluate the long-term oncologic results of radiofrequency ablation (rfa) of small renal masses (srms). : th e patients who had been followed over years aft er percutaneous or laparoscopic rfa for small renal mass were included in this study. a total of patients and renal tumors were included. th e follow-up study included physical examination, chest radiography, creatinine, and contrast-enhanced ct or mri. recurrence was defi ned as contrast enhancement aft er months or lesion growth at subsequent imaging or viable cancer cells on follow-up biopsy. results: th e mean tumor size was . cm and the mean follow-up period was . months. technical success was achieved in / renal tumors ( . %). repeated rfa was necessary in tumors due to incomplete ablation. th e overall complication (oc) occurred in . % of which the low-grade complications accounted for . % of oc. a relevant deterioration of renal function aft er rfa was very rare. th e -year local recurrence-free survival rates, cancer-specific survival rates, and overall survival rates are %, . %, and . % respectively. conclusion: rfa is considered useful treatment for selected patients with srms and also for nephron-sparing. our long-term follow-up results suggest excellent therapeutic outcome with rfa, while achieving eff ective local tumor control. introduction and objective: endoscopic approach of the terminal ureter was proposed as a complementary fi rst step in nephroureterectomy with perimetal cystectomy in order to obviate the low abdominal incision. we aimed to establish the value of a novel method of endoscopic distal ureteral management: pluck technique using bipolar plasma vaporization. during the last years, we performed nephroureterectomy involving plasma-button uretreal desinsertion by bipolar vaporization in upper urinary tract transitional cell carcinoma (uuttcc) cases (pta - cases; pt - cases; pt - cases; pt - cases). th e tumor was pyelocaliceal in cases, ureteral in cases and both ureteral and pyelocaliceal in cases. th e follow-up protocol included cystoscopy with urinary cytology, abdominal ultrasound and ct. th e mean follow-up period was months (range to months). results: all procedures were successfully completed. th e mean duration of the endoscopic procedure was minutes. in cases, aft er the completion of the nephroureterectomy, endoscopic haemostasis of the desinsetion area and margins was necessary. th e postoperative complications' rate was . %: cases of hematuria, one imposing endoscopic approach and another treated conservatively. during the follow-up period, patients presented bladder recurrences, had renal fossa tumor and had secondary lymphnode invasion. th e disease-specifi c mortality rate was %. conclusion: th e endoscopic detachment of the terminal ureter using bipolar plasma vaporization as part of one-step nephroureterectomy is a safe and eff ective method. mid-term evaluation demonstrated good oncologic outcomes. th congress of the sociÉtÉ internationale d'urologie -siu abstract book introduction and objective: we thought that combining open and laparoscopic surgery for partial nephrectomy would be less invasive than open method, easier and expend shorter time to clamp renal artery than pure laparoscopic approach. and combining approach would lead to introduce pure laparoscopic approach safely from open method. we reviewed the records of patients with renal mass treated with partial nephrectomy from to at our hospital. a total of patients underwent partial nephrectomy. of these, patients underwent pure laparoscopic procedures. seventy-seven patients underwent combining method, and two patients of these with solitary kidney and one patient with chronic nephritis were excluded. we compared these two groups in terms of perioperative outcomes, including the mean operative time, ischemic time, change in the glomerulofi ltration rate (egfr), and adverse events. conclusion: th is nonrandomized, comparative study suggests that pure laparoscopic approach had longer cold ischemic time but lower postoperative egfr change. complication rates were almost equivalent for both approaches. th erefore, we might shift safely to pure laparoscopic approach through the combined approach in the way of partial nephrectomy. nephron th irty-four ( . %) had bilateral suspected malignant tumors and were used as material for this study. twenty-fi ve were men and were women. results: eighteen patients ( %) had the same type of tumor in both kidneys. ten of them had clear cell carcinoma and had papillary renal cell cancer. four patients had bilateral oncocytomas. in patients ( %) the lesions diff ered between the kidneys (table ). in all patients only one kidney was operated on one occasion. in two patients treated with radical nephrectomy (rn) over years ago for renal cancer the subtype of the fi rst tumor was unknown. ten patients were treated with nss -nss, with rn -nss, with nss -rn, with nss -observation and with nss -radiofrequency ablation. two of the patients had von hippel-lindaus disease and one had birt-hogg-dubé syndrome. conclusion: bilateral renal masses were found in % of the patients in a material of patients treated with nss. over % of them had the same type of tumor on both sides but % of these were benign. th e combination of diff erent malignant and benign lesions occurred in %. th ese fi ndings are strong arguments for tumor biopsy before surgery is decided. preoperative oita red cross hospital, oita, japan introduction and objective: approximately % to % of patients who underwent total nephroureterectomy for upper urinary tract (uut) urothelial carcinoma (uc) developed recurrence in the bladder during the follow-up period. last year, we presented a risk factor for intravesical recurrence aft er laparoscopic radical nephroureterectomy (lrnu) in patients with uut-uc in siu congress. th is time, we will report the result of analysis of a multi-center study. a total of patients with uut-uc received lrnu between january and december in oita university hospital and affi liated institutions that were enrolled in this study. patients with concomitant bladder cancer or a history of bladder cancer were excluded from this study. postoperative cystoscopy and urine cytology were performed every months for to years, and postoperative intravesical recurrence was evaluated pathologically. th e signifi cance of each variable was analyzed univariately by log-rank test. multivariate analyses by cox proportion hazards regression model was used to estimate simultaneous eff ects of multiple risk factors. statistical signifi cance was defi ned as a p value of < . . results: median follow-up aft er lrnu was months (range - ). of the patients, postoperative intravesical recurrences were shown in / ( %). average time to fi rst intravesical recurrence was . months. in univariate analysis, there were two signifi cant risk factors of intravesical recurrences. one was for patients who did not receive postoperative adjuvant chemotherapy (p= . ). th e other was for patients with preoperative positive urine cytology indicating class iv and v (p= . ). multivarite analysis revealed that preoperative positive urine cytology indicating class iv and class v was a signifi cant risk factor for intravesical recurrence (hr . % ci . - . p= . ). in this multi-center retrospective study, preoperative positive urine cytology was a significant risk factor for intravesical recurrence. th erefore, adjuvant chemotherapy such as intravesical instillation therapy can be eff ective to prevent intravesical recurrence in patients with preoperative positive urine cytology. retroperitoneal laparoscopic nephron-sparing surgery for complicated renal cysts introduction and objective: to evaluate the feasibility, effi cacy and safety of laparoscopic partial nephrectomy for complex renal cystic lesions. a retrospective cohort study on clinical data of patients with complex renal cystic lesions treated by laparoscopic partial nephrectomy from may to april in peking university th ird hospital. according to the bosniak classifi cation, cases were lesions of grade iif, were grade iii, and were grade iv. th e mean diameter of cystic lesions was ( . ± . ) cm, and lesions were larger than . cm. results: all procedures were performed through retroperitoneal approach and successful. th e mean operative time was ( . ± . ) min, ranged from min to min, and the mean renal warm ischemia time was ( . ± . ) min, ranged from min to min. blood loss in operations was from ml to ml, and the mean was ( . ± . ) ml. th e postoperative hospital stay was ~ days, and the mean was ( . ± . ) day. postoperative pathological results included simple renal cysts ( . %), cases of adult cystic nephroma ( . %), mixed epithelial and stromal tumor ( . %), cases of renal cell carcinoma with cystic change ( . %), and multilocular cystic renal cell carcinoma ( . %). th e results showed . % of cystic lesions of grade iif, . % of grade iii and . % of grade iv were malignant. in the follow-up ranged from to months (median months), there was no case of recurrence. conclusion: th e diff erentiation between benign and malignant renal cystic lesions before surgery remains diffi cult. according to the bosniak classifi cation, radiological diagnostic fi ndings are standard but still limit to the accuracy to determine the dignity of pathological entity. laparoscopic partial nephrectomy is feasible to treat complex renal cystic lesions, and is a safe and eff ective minimally invasive option. introduction and objective: th e aim of the study was to evaluate the value of metastasectomy in patients with metastatic renal cell carcinoma (mrcc) in the targeted therapy era. we reviewed the medical records of patients who presented with mrcc and received no systemic therapy before enrollment. of them, underwent complete metastasectomy followed by targeted therapy (complete metastasectomy group), underwent partial metastasectomy followed by targeted therapy (partial metastasectomy group), and treated with targeted therapy alone (non-metastasectomy group). we estimated progression-free and overall survival using kaplan-meier curves. a cox proportional hazards regression model was used to estimate the prognostic signifi cance of metastasectomy. results: clinicopathological variables did not diff er among the groups except for history of nephrectomy, bone metastasis, number of metastatic sites, and time from diagnosis to treatment. th e median progression-free survival was . , . , and . months in the complete, partial, and non-metastasectomy groups (p = . ). karnofsky performance status (hr . , p < . ), cell type (hr . , p = . ), sarcomatoid or rhabdoid features (hr . , p < . ), retroperitoneal lymphadenopathy (hr . , p < . ), number of metastatic sites (hr . , p = . ), lactate dehydrogenase (hr . , p = . ), and time from diagnosis to treatment (hr . , p = . ) were independent predictors of progression-free survival. th e median overall survival was . , . , and . months in the complete, partial, and non-metastasectomy groups (p < . ). complete metastasectomy (hr . , p = . ) was an independent predictor of overall survival, along with age (hr . , p = . ), karnofsky performance status (hr . , p < . ), sarcomatoid or rhabdoid features (hr . , p = . ), bone metastasis (hr . , p = . ), retroperitoneal lymphadenopathy (hr . , p < . ), number of metastatic sites (hr . , p = . ), hemoglobin (hr . , p = . ), neutrophil (hr . , p = . ), corrected calcium (hr . , p = . ), and time from diagnosis to treatment (hr . , p = . ). conclusion: complete metastasectomy performed before targeted therapy signifi cantly increased overall survival in patients with mrcc. if surgically resectable, aggressive metastasectomy should be considered. guideline results: prominent international guidelines and strategies varied signifi cantly in relation to follow-up practice. th e mode and frequency of radiological imaging was signifi cantly diff erent across the guidelines for low and intermediate risk disease. although there is currently no consensus within the literature regarding surveillance protocols, various guidelines and strategies have been developed using both patient and tumour characteristics. th is information raises questions regarding the follow-up practice in australia due to both the lack of guidelines and the fi nancial. introduction and objective: nephrectomy is the cornerstone therapy for renal cell carcinoma (rcc) and its continued refi nement through research may enhance patient outcomes. medical registries are used domestically and internationally to aid research, assess trends and help guide future practice of many medical disciplines. th ere is currently no national australian nephrectomy registry. th is review aimed to explore possible defi ciencies within the australian rcc nephrectomy fi eld and through assessment of literature from established registries, determine if a national nephrectomy registry is appropriate and justifi ed to address these issues. a pubmed search identifi ed records pertaining to rcc nephrectomy in australia. a similar search identifi ed records relating to established nephrectomy registries internationally as well as other surgical registries of clinical importance. th ese records were reviewed to address the stated aims of this article. results: australian rcc nephrectomy fi eld lacks population-based data: resulting key issues identifi ed ) diffi culty benchmarking individual and institutional outcomes; ) small sample sizes and reduced power of studies; ) assessment of regional and nationwide outcome trends: diffi cult to achieve and oft en done years in retrospect with no ongoing monitoring; ) care centralisation debate: can small volume centres provide comparable outcomes to high volume centres? ) best practice guidelines: patterns of adherence to existing protocols is uncertain; and ) limited platform for large scale prospective studies -restricting potential research. review of established international registries demonstrated the registry model can eff ectively address issues comparable to those identifi ed in the australian literature. a centrally held, de-identifi ed national nephrectomy registry could provide a means of ad-dressing defi ciencies identifi ed in the australian rcc nephrectomy fi eld. th e model is supported by evidence from comparable international examples and will provide population-based data needed for studies at the institutional, regional and national level. th e development of a confi dential and non-threatening escalation policy to be implemented should trends in the data emerge is a future possibility. scope exists for possible integration with current or future registries/ databases to develop a more encompassing urological, cancer or surgical registry. need remains for continued exploration of the feasibility and practicalities of initiating such a registry. new technologies of identifi cation of renal artery in retroperitoneal laparoscopic renal surgery hao y, xiao c, liu y, ma l introduction and objective: th e objective of this study was to evaluate the feasibility of a new method to identify renal vessels during retroperitoneal laparoscopic nephrectomy. a total of patients underwent transperitoneal radical laparoscopic nephrectomies from january to august . in the fi rst consecutive patients (group ) we located renal artery with the standard technique; in the last consecutive patients (group ) the medial arcuate ligament (mal)-psoas muscle fat complex was used as an anatomic landmark to identify renal vessels. comparative analysis was carried out between the two groups, including mean hilar exposure time, mean blood loss, duration of hospital stay, conversion rate and complication rate. no diff erences were noted in gender, age, mean body mass index, tumor side and size of the lesions in the two groups (p> . ). mean hilar exposure times were . ± . minutes in group versus . ± . minutes in group (p< . ). mean blood loss was . ± . ml in group versus . ± . ml in group (p< . ). no signifi cant diff erences were detected regarding duration of hospital stay, complication rate and conversion rate between the two groups (p > . ). no complications and no recurrence of disease at ct evaluation were recorded neither in group nor in group . conclusion: radical laparoscopic nephrectomy in use of the mal-psoas muscle fat complex as an anatomic landmark is technically feasible and safe. in conclusion, the mal-psoas muscle fat complex can serve as an objective and belt-and-braces anatomic landmark for the identifi cation of the renal vessels in retroperitoneal laparoscopies. kalpinskiy a, alekseev b, kaprin a, nyushko k, vorobyev n, vokach d introduction and objective: th e aim of our study is to evaluate the results of percutaneous radiofrequency ablation (rfa) of renal tumors in elderly patients with severe comorbidities and a high risk of surgical intervention. th e aim of this study was to evaluate the expression of cd and microvessel density (mvd) in clear cell renal cell carcinoma (ccrcc) as well as the relationship between mvd and possible prognostic markers like tumor size, degree of tumor necrosis and degree of tumor hemorrhage. expression of cd was detected in patients with ccrcc and cases with benign kidney tissue using immunohistochemical staining. th e mvd was studied by weidner's method. results: th e expression of cd in the clear cell renal cell carcinoma (ccrcc) ( . (ds± . ), varied from to .) were signifi cantly higher than the expression of cd in the benign kidney tissue, as the control group, was . (ds± . ) (u= , p< . ). th e mvd values marked by cd were negatively correlated with degree of tumor necrosis (r=- . , p= . ), tumor size (r=- . , p= . ), but no association was found between mvd values and degree of tumor hemorrhage (r=- . , p= . ) in crcc. our results show that mvd in crcc were signifi cantly higher than mvd in the benign kidney tissue. th ere was a negative non signifi cant correlation between the mvd and presence of tumor necrosis as well as between mvd and tumor size. on the other hand, there was no correlation between mvd and degree of tumor hemorrhage in ccrcc. conclusion: expression of hif- α and vegf in crcc was signifi cantly higher than in normal kidney tissue. th e expression of hif- α and vegf may be responsible for angiogenesis in ccrcc, however these angiogenic factors play an important role in the prognosis of ccrcc patients. transvaginal hybrid notes nephrectomy in a low resource setting firaza p, lorenzo e, bardelosa j, reyes e, patron n introduction and objective: hybrid notes decreases the invasiveness of conventional laparoscopic surgery and overcomes the limitation of pure notes especially in the absence of angulated instruments. th e patients are , and -year-old females with complaints of recurrent fl ank pain and urinary tract infection due to an obstructed non-functioning kidney. materials and methods: materials used include standard laparoscopic instrumentations and a endoscope. under general anesthesia the patient was placed in a lithotomy position with the aff ected side up at degrees. veress needle was initially inserted thru the umbilicus and was later replaced with a mm laparoscopic port with additional mm port also inserted at the aff ected lower quadrant site. pa-tient was then positioned in a steep trendelenberg and mm port was inserted thru the posterior vaginal wall under direct vision from the abdominal cavity that was later used for the endoscope. nephrectomy proceeded despite noted severe adhesions and the kidney was placed in the specimen retrieval bag. th e vaginal port site was enlarged to cm for extraction of the specimen. th e vaginal wound was repaired using running - absorbable sutures. results: th ree cases of transvaginal hybrid notes nephrectomy were successfully completed. th e median operative time was minutes (range: - ). th e mean estimated blood loss was ml for the three cases. median renal dimensions (cm) were as follows: craniocaudal . (range: . - ), laterolateral . (range: - . ), and anteroposterior . (range: . - . ). th e patient resumed regular diet as early as day post operatively. drain was removed prior to discharge. th e mean date of discharge was rd day post-operatively. th ere were no noted surgical complications according to clavien-dindo grading system. conclusion: hybrid notes transvaginal nephrectomy is a feasible and reproducible procedure in selected patients regardless of laterality for better cosmesis, reduced post-operative pain and early recovery. however, the view was challenging because it was from the pelvis. th e left side procedure proved to be more diffi cult due to the gonadal vein obstructing the view, which is usually larger in young females. introduction and objective: to summarize our clinical experiences of laparoendoscopic single-site surgery (less) in urology. results: all procedure underwent successfully using single trocar x cone (storz) without any major complications. early recovery with minimal scar is the hallmark of less surgery. duration of time ( - mns), blood loss ( - ml), mobilization ( - hrs), hospital stay ( - days). no intraoperative complication without any conversion to other surgery (multi port laparoscopic surgery) and uneventful post-operative period was the fi nal outcome. introduction and objective: th e use of fl exible cystoscopy to study bladder is usually perform in urology departments using diff erent types of lubricant to reduce pain. th e objective is to compare the use of lubricant gel with lidocaine versus lubricant gel without anesthetic in fl exible cystoscopy in terms of pain and tolerability. materials and methods: seventy two patients are divided in two groups in this observational not randomized study. group : patients with lidocaine gel % and group : patients with lubricant gel without anesthetic. th e main variables analyzed are score in visual analogue scale (vas) and score in spanish pain questionnaire (spq). t-student test and chi-square test are used to compare diff erences using spss program and signifi cant statistical diff erences is considered p≤ . . results: mean age of patients in group is . ± . years and . ± . years in group (p= . ). th e distribution according to sex was men: women in group and men: women in group (p= . ). th e main pain score in vas was . ± . in group versus . ± . in group (p= . ). in the spq, the current intensity value was . ± . in group versus . ± . in group (p= . ), and the total intensity value was . ± . in group versus . ± . in group (p= . ). th e cost of gel with lidocaine is . euro and gel without anaesthetic . euro. conclusion: th e use of lidocaine gel do not produce benefi t in the fl exible cystoscopy and expensive the procedure. new laparoscopic surgery using water filled laparo-endoscopic surgery systems introduction and objective: urologist usual operated under water fi lled condition, such as transurethral surgery, percutaneous renal surgery. however, laparoscopic surgery was done under co . water fi lled condition has several merits. water pressure is suppressing venous bleeding and prevent from co embolism in venous injury condition. to keep water temperature as same as body temperature was useful to avoid low body temperature. simultaneous observation of ultrasound image from the surface of the body and laparoscopic view is possible during surgery. th us we conduct to develop the water fi lled laparo-endoscopic surgery systems (wafles). first problem is dispersion of blood aft er bleeding. it interrupts the laparoscopic view. we solved this problem to control the fl ow of irrigation, aff ording the continuous observation of bleeding point and it is easy to control the bleeding by vessel sealing system or coagulation. second problem is managing fl oating organs such as intestine or nets. th ese are disturbed the operating view and space. to keep the operating space, we use sheath and single port devices. however, obtaining wide view was still hard in the water because fl oating organs disturb the fi eld. to solve this problem, we use -d tracking navigation system. results: using young male pig, we performed partial nephrectomy and radical cystectomy using this new system. wafles is now developing. we will be present the update of this research soon. comparison of safety, effi cacy and cosmetic outcomes between standard laparoscopic live donor nephrectomy and mini-laparoscopic donor nephrectomy: a randomized clinical trial introduction and objective: th is study was conducted to compare safety, effi cacy and cosmetic outcome between standard laparoscopic live donor nephrectomy (sldn) and mini-laparoscopic donor nephrectomy (mldn) in a randomized clinical trial. from march to june , consecutive kidney donors were randomly assigned to two equal groups for laparoscopic donor nephrectomy. from march to june , consecutive kidney donors were randomly assigned to two equal groups for laparoscopic donor nephrectomy. mldn: six to eight centimeters pfannenstiel incision was made slightly above pubis symphysis and millimeters trocar was fi xed through exposed fascia using open technique. five mm port was placed under direct vision at the umbilicus for camera insertion and two . mm ports were placed in subxiphoid and paraumbilical area. sldn: ten mm port was placed at umbilicus using open access technique for camera insertion. five mm trocar for grasping and mm trocar for vascular clipping were placed at subxiphoid and paraumbilical areas under direct vision, respectively. th e second mm trocar was placed in suprapubic area. cosmetic appearance was assessed three months aft er surgery by using the modifi ed patient scar assessment questionnaire (psaq). conclusion: our experience in this study revealed that peri and postoperative fi ndings were comparable between sldn and mldn but mldn has signifi cant better cosmetic appearance than standard laparoscopic approach. qiu m, ma l, lu j introduction and objective: to report our experience and outcomes with retroperitoneal laparoscopic anderson-hynes dismembered pyeloplasty for the repair of ureteropelvic junction obstruction (upjo). we performed retroperitoneal laparoscopic anderson-hynes dismembered pyeloplasty between june and december . ureter was found in the lower pole of the kidney psoas front, then ureteropelvic junction stenosis was dissociated. ureter was cut at about cm distal ureter beyond the part of stenosis, then stenosis was resected. posterior wall was continuous sutured, and double j tube was antegrade placed. at last, anterior wall was continuous sutured. patient characteristics and perioperative outcomes were analyzed. perioperative parameters including operative time, estimated blood loss, postoperative length of hospital stay, and complication. results: th e procedure was successfully accomplished in all patients, and no patient required conversion to open surgery. th e mean operation time was . min ( - min), mean estimated blood loss was ml ( - ml), mean postoperative length of hospital stay was . d ( - d), and mean time of keep drainage tube was . d ( - d) . patients were followed up for ~ months (average . months). eighteen cases were followed up in years, and an- renal cyst ( ) other patients were followed up for - years. th e total remission rate was . %. conclusion: retroperitoneal laparoscopic dismembered pyeloplasty is a safe and effi cacious procedure for upjo in a long time follow-up. positioning-related complications of robot-assisted radical prostatectomy (rarp) in a steep trendelenberg position with physique fixation appliance by the negative pressure takeda h, nakano y, narita h introduction and objective: because of recent advances in minimally invasive surgical techniques, robot-assisted radical prostatectomy (rarp) has become the primary treatment option in prostate cancer. rarp, however, necessitates patients to be placed in a steep trendelenberg position, which presents multiple opportunities for complications relating to the positioning of the patient. our study aims to study the prevalence and demographic predictors of these positioning complications. we included patients who underwent rp from to using data extracted from our hospital database. all patients (n= ) had trendelenberg position with physique fi xation appliance by the negative pressure, hug-u-vac and film dressings. positioning complications (skin, eye, nerve, compartment syndrome/rhabdomyolysis) were identifi ed using patient-level diagnosis and procedural international classifi cation of disease, th edition, clinical modifi cation codes. we analyzed body pressure by portable interface pressure sensor. results: positioning complications occurred in . % of cases with shoulder complications contributing the most to this frequency. rubefaction occurred in cases, without bedsore. having positioning complications not increased a patient's odds of having increased age, bmi, operation time, body pressure, insignifi cantly. conclusion: th e steep trendelenberg position used in rarp was not shown to be associated with patient positioning-related complications in this sample. physique fi xation appliance by the negative pressure is safety and useful. evaluation of nasogastric tube (ngt) suction for evacuation of large bladder blood clot introduction and objective: blood clot formation in the urinary bladder can be caused by many etiologies such as postoperative bleeding, tumor bleeding, radiation cystitis and etc. acute urinary retention may disclose and a large three way catheter with irrigation is placed conventionally to prevent further formation of blood clot and manually remove the blood clot. when this failed an endoscopic procedure takes place to con-trol the bleeding and to relief the bladder. urologists may fi nd it diffi cult to remove a large, thick and bulky clot using ellik evacuator. here we introduce using nasogastric tube as an alternative to procure a safe and effi cient way to remove these bothersome clots. aim: to introduce a novel method to successfully remove large, troublesome blood clots during cystoscopy. we prospectively perform blood clot evacuation on patients within month (september -february ) in hasan sadikin hospital. th e patient, preoperatively have at least ½ of bladder volume with blood clot using ultrasonography. a fr ngt inserted into the bladder through the resectoscope sheath fr and connected to suction unit with a mmhg negative pressure. a calibration of the ngt tip does not exceed more than cm from the cystoscopy beak was made. backward and forward movement was set in motion during the procedure to facilitate blood clot removal. cystoscopy evaluation was performed in the end of the procedure to evaluate any complication. a total cystoscopy time, ngt suction time, and the volume of blood clot were documented. results: a total patients was all successfully managed with this method without any complications such as bladder laceration/perforation. th e mean age was years old with male predominance. most common etiologies of blood clots retention were postoperative bleeding ( %). th e average time for clot removal time was ( - ) minutes. th e average volume of blood clots removed was grams. conclusion: evacuation using ngt suction is eff ective, safe and an effi cient way to remove of large bothersome clot. learning curve assessment of robot-assisted radical prostatectomy in the oncological and functional outcomes takeda h, nakano y, narita h introduction and objective: th is study aims to compare the oncological, safety and functional outcomes between fi rst-step rarp and second-step rarp. th e study was conducted on a total of patients having undergone robot-assisted radical prostatectomy from to . th e fi rst patients (group ) were compared with the second (group ) to evaluate the learning curve eff ects. results: both groups were similar with respect to age, prostate-specifi c antigen level, body mass index, gleason score, and distribution of the clinical stage. th e operative time was minutes for group , and minutes for group (p= . ). individual times of various stages of the procedure (dissection of the seminal vesicles, entering the extraperitoneal space and dissection of the endopelvic fascia, incision of the bladder neck, division of the prostatic pedicles and preservation of the neurovascular bundle, and urethrovesical anastomosis) decreased signifi cantly over time. estimated blood loss was ml for group , ml for group . th e length of stay was . days for group , . days for group . positive surgical margin rates were % for group , % for group . while one patient in group had biochemical recur-rence, no patient in group had biochemical recurrence. continence rates at months were . %, and . % in groups and . conclusion: surgical, oncologic, and functional outcomes of rarp improve with increasing experience. outcomes similar to the published series by high-volume centers could be achieved aft er to rarp cases. possibility of d modeling and intraoperative navigation during procedures in the retroperitoneal space introduction and objective: application of d modeling allows you to get more information about the spatial imaging of the disease. intraoperative navigation in the retroperitoneal space is an innovative minimally invasive procedure, the surgeon improves orientation in retroperitoneal space. we present the method of intraoperative navigation based on virtual simulation during videoendoscopic partial nephrectomy for kidney's tumors. special computer program has been developed, that created three-dimensional image of operative space on the basis of preoperational tomographic data of a concrete patient. we used hardware-soft ware complex (hsc) for virtual modeling of the surgery zone. th e complex consists of a pc, original soft ware and mechanical d digitizer. th e hsc allowing to form virtual d model of a patient according to the results of tomography examination. th e original method of matching the system of coordinates of a virtual model with the patient was off ered. th e procedure was conducted under the conditions warm ischemia, aft er mobilization of the kidney, partial nephrectomy was performed by observing the image of d organ model agreed with the video image of the kidney tumor. th e method was originally performed for the patients with small renal tumors, who needed in surgical treatment, their average age was . (in the range from to ) years, men - ( . %), women - ( . %). size of the tumors were . ( . - . ) cm, they were located in the lower poles of the kidneys. average time of an operation performed with the use of the computerized choice of the surgical approach was . ( - ) minutes. warm ischemia time was . ( - min). th ere were no complications during the operation and in the post-operative period. th ere were no cases of positive surgical margins. conclusions: usage of the introduced computer program allows the surgeon to determine compliance with the contours of the d models of the body shown in the video monitor. th e technique provides additional possibilities for the surgeon in selecting borders in partial nephrectomy. th is method is particularly perspective for teaching beginner surgeons, it can help them acquire skills in minimally invasive surgery. possible impact of continuous drainage after minimally invasive partial nephrectomy introduction and objective: postoperative management of partial nephrectomy without drain placement is common, but the specifi c eff ects on patients are unclear. we investigated the impact of no drain placement aft er minimally invasive partial nephrectomy (mipn). we retrospectively studied consecutive patients who underwent laparoscopic and robotic partial nephrectomy at a single academic center. th e study group included evaluable patients without drain placement. th e quantity of postoperative fl uid collection in the perirenal space was calculated using computed tomography. th e pre-and postoperative serum concentrations of total protein and albumin, in addition to neutrophils, lymphocytes, monocytes numbers and c-reactive protein (crp) levels in the blood were compared. results: drain was placed in ( . %) patients who underwent mipn. th e remaining ( . %) patients were not provided with drain placement. although the average total quantity of fl uid discharged from the drain was ml, the average fl uid remaining in the perirenal space was not signifi cantly diff erent with or without drain placement ( . ml vs. . ml, p= . ). decrease in serum total protein and albumin with drain placement was signifi cantly greater than without drain placement (total protein; . % vs. . % p< . and albumin; . % vs. % p= . ). no drain placement also caused markedly greater decreases in lymphocytes and monocytes than drain placement, while neutrophils and crp were not different. a mipn population was necessary by design, which may limit the ability to generalize these results. conclusion: analysis of the quantity of fl uid collection showed little need for routine drain placement. no drain aft er mipn prevents serum protein loss and might aff ect wound-healing immune responses. initial experiences of laparoscopic radical cystectomy introduction and objective: simultaneous treatment of bilateral lesions is an interesting application of laparoscopy. our goal was to present our experience with simultaneous bilateral laparoscopic pyeloplasty using three midline ports in two adult patients. two adult patients (one male and one female) underwent bilateral laparoscopic dismembered pyeloplasty in one session. one of the patients had horseshoe kidneys. a -mm trocar was placed through the umbilicus, and two -mm trocars were placed midline - cm superior and inferior to the umbilicus. results: intra-and postoperative periods were uneventful. operation time was and minutes in the fi rst and second patient, respectively. obstruction was relieved in both patients bilaterally on a -month follow-up. conclusions: simultaneous bilateral laparoscopic pyeloplasty using three midline ports is safe and feasible in adult patients with bilateral ureteropelvic junction obstruction. introduction and objective: radical cystectomy is considered to be the most eff ective treatment for patients with muscle-invasive bladder cancer. most urinary diversions are performed extracorporeally because of complex procedure time consuming. however, with the development of minimally invasive radical cystectomy techniques, increasing attention has been focused on intracorporeal urinary diversions, including both ileal conduit and orthotopic neobladder. we reviewed cases of laparoscopic radical cystectomy with intracorporeal ileal conduit in our medical center. ten patients with bladder cancer who underwent laparoscopic radical cystectomy and intracorporeal ileal conduit were retrospectively reviewed. with the cystoprostatectomy and lymphadenectomy completed, a - cm segment of ileum was identifi ed cm from the ileocecal junction. division of the isolated segment of bowel and the mesentery was performed using the endo-gia stapler. ileo-ileal continuity was reestablished by creating a generous side-to-side anastomosis with endo-gia stapler. th e left ureter was passed to the right side of the abdomen. aft er placement of single-j stent, the ureters were spatulated and the ureteroileal anastomis was performed with a running suture. results: laparoscopic radical cystectomy and intracorporeal ileal conduit were performed successfully in all ten patients from jan to dec . th e mean operating time was min ( - min), and the mean ileal conduit construction time was min ( - min). th e mean blood loss was ml ( - ml), and no patient received transfusion. th e time to orally allow was postoperative day ( - ). th e mean hospital stay was d. no major complication occurred. results: all the procedures were successfully completed without additional trocars except for one patient who was immediately converted to suprapubic-assisted laparoendoscopic single-site surgery (sa-less) nephrectomy for rectal injury during the placement of the zou-port. in our initial cases, tri-port was used. in the subsequent procedures, zou-port was used. th ere were no other intraoperative complications occurred. postoperative complications included a right external iliac artery thrombosis in one patient who underwent pure transvaginal notes simple nephrectomy. th e mean operative time was (range to ) mins and the mean estimated blood loss was (range to ) ml for pure transvaginal notes renal cyst decortication. th e mean operative time was (range to ) mins and the mean estimated blood loss was (range to ) ml for pure transvaginal notes nephrectomy. th e mean visual analog scale (vas) pain score was . (range - ) on postoperative day . th e mean time for ambulation was . (range - ) d. th e mean time for oral feeding was . (range ~ ) d. th e mean postoperative hospitalization stay was . (range ~ ) d. during the to -month follow-up period, all the patients were in good condition. th e posterior colpotomy incision healed well. th ere was no scar on the abdominal wall. th ere was no retrograde infection of pelvic and abdominal cavity, umbilical hernia, or uterine prolapse. conclusion: th e application of zou-port in pure notes transvaginal eff ectively reduces the diffi culty of operation and avoids the abdominal and pelvic organ injury, which is worthy of clinical application. lower ureter stricture. all the cases presented only one abdominal scar before surgery, including cases with the history of caesarean section, cases with the history of birth control surgery, cases with the history of appendectomy, cases with the history of inguinal hernia repair, cases with the history of ureterolithotomy, one case with the history of bladder lithotomy, and cases with the history of laparotomy surgery. th e mean length of scar is . ( . to . ) cm. under general anesthesia, the patients were positioned in lithotomy with aff ected side elevated at °. two trocars ( mm or mm) were introduced into abdominal cavity from the incisions at the right and left medial margin of umbilicus. a -or -mm trocar was inserted into the abdominal cavity through the abdominal scar under the direct vision. our technique for the transabdominal scar-assisted u-less is similar to that of standard laparoscopy, using conventional operating apparatus placed in the umbilical trocars, under direct vision achieved by a fl exible-tip ° laparoscope placed through the trocar at the abdominal scar. th e specimen was placed inside a homemade bag and removed under direct vision through an extended incision at the abdominal scar. to explore the application of three-dimensional ( d) laparoscopic technique in hybrid transvaginal notes nephrectomy. a total of female patients underwent hybrid transvaginal notes nephrectomy using d laparoscopy system. th ose included cases of hydronephrosis, cases of renal empyema, and cases of renal atrophy. th e median age was (range to ) years, and body mass index was . ( . ~ . ) kg/m . all patients were with unilateral disease and normal contralateral kidney. th e perioperative data including operative time, estimated blood loss, and surgical outcome were analyzed. results: th e procedures were successfully completed. th e median operative time was ( to ) mins. th e median estimated blood loss was ( to ) ml. th e patients were recover ambulation on postoperative day to , and tolerated diet on postoperative day to . th e patients were discharged on postoperative day to . th ere were no intraoperative or postoperative complications. during the -to -month follow-up period, all the patients were in good condition. th e posterior colpotomy incision healed up well. th ere were two hidden umbilicus scars. and p= . , respectively). mean incision length was shorter ( . vs. . cm, p< . ) and the scar satisfaction score was higher ( . vs. . , p= . ) in ldn with fl ank incision group. th e postoperative pain scores were higher (p= . ) in ldn with fl ank incision group but analgesic requirements were similar in both groups (p= . ). conclusion: ldn with fl ank incision had cosmetic satisfaction and comparable graft function, although challenging to the surgeon with longer warm ischemia time and higher postoperative pain. the effect of caudal block on postoperative analgesia in robotic assisted laparoscopic prostatectomy: a prospective study in a national referral centre introduction and objective: caudal block is widely used in paediatric surgery. it provides satisfactory postoperative pain relief in lower abdominal operations with minimal complications. th is pilot study explores its eff ect on postoperative pain control and its safety in patients who underwent robotic assisted laparoscopic prostatectomy (ralp). from to , consecutive patients were randomised into groups of patients. th e intervention group received caudal block using ropivacaine immediately aft er operation, while the control group only received analgesia consisting of paracetamol, nsaids, and opioids. both groups were assessed using verbalised pain scores in recovery room, and , , , , hours aft er the operation. additional analgesic requirements were recorded in the intervention group. opioid-related adverse events and the time to passage of fl atus were also recorded. introduction and objective: th e dorsal venous complex (dvc) ligation and vesicourethral anastomosis (vua) are the most challenging parts during laparoscopic radical prostatectomy (lrp). th is study will introduce a unique technique without any knots for the dvc ligation and vua using the unidirectional single running self-retaining suture. th is study is to examine the eff ectiveness of our knotless laparoscopic radical prostatectomy compared with the conventional technique. materials and methods: from december to december , lrp were separated into groups: group of knotless lrp and group of conventional single-knot lrp. during knotless lrp, the dvc is sutured using a - / circle self-retaining suture with bites at the same place, and the vua is performed with a -cm - / circle barbed self-retaining suture with one needle driver. retroperitonoscopic pyeloplasty is a feasible approach in the management of pelviureteric junction obstruction with a crossing vessel. anterior transposition using the posterior approach demands a good experience. herein, we present a case with complex vascular anatomy representing a real surgical challenge for a retroperitonoscopic approach. in the period from - , cases with a crossing vessel were operated by a single surgeon using both transperitoneal and retroperitoneal approaches. we report here a y old girl with left sided pelviureteric junction obstruction presenting with recurrent loin pain. lateral retroperitoneal laparoscopic approach was used with trocars; mm optic trocar and two mm working trocars. th e pelviureteric junction was tightly pushed anteriorly and close proximity to complex crossing vessels. dissection from the crossing vessels was performed followed by anterior transposition of the pelviureteric junction and a diffi cult anastomosis was performed with antegrade dj insertion. smooth postoperative recovery, no leakage, dj is removed aft er . month; follow-up ultrasound revealed decompression of the pelvis with no recurrence of the symptoms during the follow-up period. conclusion: retroperitonoscopic lateral approach is feasible for the management of pelviureteric junction obstruction with crossing vessel even in the most diffi cult cases in well trained hands. robotic assisted laparoscopic reimplantation for iatrogenic ureteral injury franklin a, jones c, pokala n, cummings j introduction and objective: ureteral injuries are a source of morbidity in pelvic surgery. robotic approaches to these injuries have been proposed. we reviewed our experience with this approach to examine the outcomes in patients undergoing robotic assisted laparoscopic reimplantation (ralr) for iatrogenic ureteral injury. oncological outcomes of robotic prostatectomy in the victorian public sector basto m , , sathianathen n , te marvelde l , landau a , , graves r , , everaerts w , , birch e , lawrentchuk n , goad j , moon d , murphy d , , , , introduction and objective: following the installation of the davinci s at peter maccallum cancer centre in , we aim to report medium-term oncological outcomes of patients undergoing robot-assisted radical prostatectomy (rarp) and to identify factors that act as predictors for biochemical recurrence (bcr) and oncological failure (of). a prospective cohort of consecutive men who underwent rarp in a single victorian public hospital were followed up for a median time of . and . months for bcr and of respectively. of was defi ned as bcr (psa≥ . ng/ml) or the start of adjuvant therapy. however, longer-term data is still required to better evaluate oncological success. functional outcomes of robotic prostatectomy: the victorian public sector experience basto m , , sathianathen n , te marvelde l , landau a , , graves r , , everaerts w , , birch e , lawrentchuk n , goad j , moon d , declan murphy d , , , , introduction and objective: to report medium-term functional outcomes of men aft er undergoing robotic assisted radical prostatectomy (rarp). furthermore, the impact of the procedure on quality of life will also be analysed. a cohort of consecutive men who underwent rarp in a single victorian public institution was assessed post-operatively for continence and potency status. a 'prostate cancer research survey' that was distributed pre-operatively and at , , , and months post-rarp, in combination with hospital medical records were utilized to collect data. th e following validated questionnaires were included in the survey: expanded prostate cancer index composite for clinical practice (epic-cp), sexual health inventory for men (shim) and prostate cancer related quality of life scale (pcar-qols). th e latter primarily evaluated the impact of surgery on quality of life. results: utilising hospital medical records, of the ( %) men that had follow-up post-operatively, % ( / ) were fully continent at months using a zero pad defi nition and % ( / ) were continent using a zero or security pad defi nition. of those who completed the epic-cp questionnaire, preoperatively (n= responders), . % and . % were continent using a zero and security pad defi nition respectively. at -months (n= responders), . % of patients were fully continent using zero pads per day and . % of patients were continent using none or security pad per day. regarding erectile function, shim scores were available for men pre-rarp, of which % were considered to be potent. of this subset of men, only %, % and % are considered post-operatively potent at , and -months. none of the patients that were pre-operatively impotent regained their erectile function at months. sexual confi dence was the facet of life that was most impacted by rarp. other quality of life subdomains showed no signifi cant diff erences aft er robotic prostatectomy. conclusion: th ere has been satisfactory recovery of continence post-rarp, however, erectile dysfunction still remains an important adverse sequela of surgery. overall, robotic prostatectomy has been successfully implemented in the victorian public sector with satis-introduction and objective: to compare patterns of care and perioperative outcomes of robotic prostatectomy to other surgical approaches, and create an economic model to assess the viability of robotic prostatectomy in the case-mix public health funding system. we retrospectively reviewed all radical prostatectomies (rp) performed for localised prostate cancer in victoria, australia, between july and april from the victorian admitted episode dataset (vaed), a large administrative database that records all hospital inpatient episodes in victoria, australia's second most populous state. patterns of care, length of hospital stay (los) and blood transfusion rates (btr) were compared by surgical approach. we then created an economic model to evaluate the incremental cost of robotic assisted radical prostatectomy (rarp) over open radical prostatectomy (orp) and laparoscopic radical prostatectomy (lrp) incorporating the cost off set from diff erences in length of hospital stay and blood transfusion rates. th e economic model constructs estimates of the diagnosis related group (drg) costs of orp and lrp, adds the gross cost of the surgical robot (capital, consumables, maintenance and repairs), and manipulates these drg costs to obtain a drg cost per day which can be used to estimate the cost off set associated with rarp in comparison with orp and lrp. economic modelling was performed around a base-case scenario, assuming a -year robot lifespan and robotic cases performed per fi nancial year, and one and twoway sensitivity analyses performed for the -arm da vinci shd, si and si dual surgical systems (intuitive surgical ltd, sunnyvale, ca, usa). both situations present a challenge to the surgeon contemplating a radical prostatectomy for prostate cancer, due to surgical access and anomalous vascular and ureteric anatomy. open radical prostatectomy has been reported in transplant recipients, but very little has been described using a robot-assisted laparoscopic approach. a case series will be described, illustrating the challenges and techniques required to successfully perform transperitoneal robot-assisted radical prostatectomy in patients with a congenital pelvic kidney or renal transplant within the pelvis. operations were performed using the da-vinci surgical system. we will describe a series of patients between and who underwent transperitoneal ro-bot-assisted radical prostatectomy, including patients with a congenital pelvic kidney and a redo renal transplant within the pelvis. prostatectomy was performed using a partial nerve spare in all cases, and pelvic lymph node dissection was not performed. th ere was a mean console time of minutes with a mean estimated blood loss of ml. histopathology confi rmed gleason sum - disease confi ned to the prostate with no extraprostatic extension or seminal vesicle invasion (pt c), and surgical margins were free of tumour in all cases. th e tumour volume ranged from . to . cubic centimetres. th e psa became undetectable postoperatively and remained undetectable without further therapy. careful perioperative review of imaging and placement of ports under direct vision was essential in avoiding complications. stay suture is applied at glans. circumcision incision is applied leaving at least mm tissue of inner mucosal collar. penile skin is denuded down to the penoscrotal junction. minor degree of chordee is corrected by this procedure. a fr feeding tube in the urethra adds to identify the distal urethra which is just underneath the skin in these case, which removed at the end of procedure. mucosa is defi cient ventrally and is replaced by a triangular patch of skin. th is skin patch is excised and mucosal edges are approximated in the midline. th is simple maneuver gives glans penis an upward tilt and meatus appears almost on the tip of glans. redundant preputial skin is excised and mucocutaneous approximation is done with / pds. no dressing is required. we operated cases of glanular hypospadias between december and january . mean age of children was . ± . years. all cases were day cases. th ere was no need for catheterization and dressing. we used temporary dressing for mild bleeding immediate post op in cases only which were removed in recovery room. th ere was no immediate post-operative complication like urinary retention, severe pain, fever or urinary tract infection. th ere was no complication of meatal stenosis in follow-up ( - month follow-up). urine stream was good and cosmesis was satisfactory to parents. we had low complications in our set up and success of glanular hypospadias by our technique was good in terms of good urine stream and cosmesis. conclusions: th e goal of modern hypospadias surgery is a functional neourethra that appears to be normally circumcised penis. tubularized incised plate urethroplasty is a widely applicable technique for distal hypospadias repair. but our current series shows that modifi ed tubularized incised plate technique has low complication rate and excellent cosmetic results superior to tubularized incised plate urethroplasty for primary distal hypospadias repair. however, these results must be further evaluated by comparison study of large series. the impact (catalona, ) was performed in patients. occult metastatic disease was found in two patients ( groins) at the time of diagnosis and subsequently developed in patients during follow-up. th erefore, a total of ( %) of the patients developed metastatic disease. conclusions: current management protocols place moderately diff erentiated t penile scc without vascular invasion in a low risk group for lymph node metastases. for this reason a primary option for these patients expectant approach is currently recommended. our experience has shown that patients in this group are really at higher risk for metastatic disease, and we suggest early modifi ed groin dissection instead of expectant observation. introduction and objective: penile cancers are rare. in ghana, they account for less than % of all genitourinary cancers. data on penile cancers in ghana is scanty. we report on cases of penile cancers seen over the last years at the komfo anokye teaching hospital (kath). th e aim of the study was to describe the clinicopathological presentation and the mode of treatment of penile cancers in our setting. th is was a retrospective study of histologically confi rmed cases of penile cancers seen at kath from january to december . information gathered included age, the clinicopathological features and mode of treatment using a structured proforma. results: th ere were cases of histologically confi rmed penile cancers over the period. th e age range was from - years with a median age of years. eight were uncircumcised and were married. in only one did the lesion not originate from the glans penis rather aff ecting the base and upper part of the left of hemi-scrotum. in patients, the lesion was restricted to the glans penis, it had involved the distal penis in , midshaft in , proximal penile in and base of penis in one of whom had auto amputation. all were squamous cell carcinoma with majority being moderately well diff erentiated ( %). seven had ulcerative lesions and were caulifl ower-like. majority were advanced (t ) involving the corpora ( %). only one patient reported with a t lesion. eleven patients ( . %) had lymph node involvement and two had distant metastasis at presentation. only one patient had a penile sparing surgery with of them having partial penectomy at various levels with ure-throstomy at the stump ends. one had total penectomy with suprapubic urinary diversion whiles the one with auto amputation had radiotherapy as the primary treatment. eleven of the patients had lymph node dissection. four had adjuvant radiotherapy. conclusion: most patients present with advanced disease making any hope of achieving a functional and cosmetically acceptable penis aft er treatment impossible. further education is needed to ensure early detection and treatment. how does partial penectomy due to penile cancer affect the sexual life? even though the high incidence of penile cancer in brazil, the sexual life of its patients, as well as their partners, has never been evaluated before. th e aim of this study is to evaluate erectile function in patients who underwent partial penectomy due to penile cancer, describe the socio-demographic and clinical data as well as to assess the patient's partners' sexual function. we performed a prospective analysis in patients between and at pernambuco state cancer hospital in brazil. th e sample consisted of patients who were submitted to partial penectomy for the treatment of penile cancer. control group included volunteer couples from the general population with similar socio-demographic features. th e assessment of erectile function and female sexual dysfunction were evaluated with iief- and fsfi respectively. results: th e prevalence of erectile dysfunction (ed) in the group of individuals subjected to partial penectomy was . %, including severe ed in %, moderate ed in %, mild-to-moderate in %, mild ed in . %, and no ed in . % of the participants. th e prevalence of ed in men of the control group was . % and was typically characterized as mild ed (p < . ). between partners of partial penectomy and control groups, % and % reported sexual dysfunction, respectively (p = . ). a comparative analysis of the risk factors for the ed showed that there were not diff erences between both groups (body mass index (bmi); tabagism; diabetes; hypertension; dyslipidemia and hypogonadism). conclusion: th e actual incidence of erectile dysfunction in patients submitted to partial penectomy for penile cancer is . %. comparative analysis between patients who underwent partial penectomy and general population showed a higher dysfunction rate in addition to more severe ed. in despite of that, their partner's sexual function was similar between the analysed groups. the introduction and objective: androgens are essential for the development and growth of the genitalia. th ey regulate the erectile physiology by multiple mechanisms. several studies have examined associations among sex hormones' serum levels, erectile function and sex drive. we sought to identify a protocol for using testosterone in men with erectile dysfunction and late-onset hypogonadism (loh). during a -month period, men with erectile dysfunction who presented to the andrology clinic were selected. th ey underwent a complete physical examination and fi lled out the international index of erectile function- questionnaire. serum luteinizing hormone (lh) and testosterone levels were evaluated. patients received a single intramuscular injection of mg testosterone. th ereaft er, serum levels of lh and testosterone were measured weeks later. results: th e mean age was years old. aft er treating patients with testosterone, ( %) showed improvement in loh symptoms including libido, loss of energy, irritability and quality of life. th e mean international index of erectile function was and . , prior to and aft er treatment respectively. mean serum testosterone levels before and aft er treatment were . and . ng ml_ respectively (p = . ). mean serum lh revealed a signifi cant decrease aft er the study (p = . ) ( . and . ng ml_ , before and aft er the study respectively). our fi ndings suggested that testosterone replacement therapy improves libido and loh symptoms in individuals with almost normal or lower limit normal value of serum testosterone levels. does l-carnitine therapy add any extra benefi t to standard inguinal varicocelectomy in terms of deoxyribonucleic acid damage or sperm quality factor indices: a randomized study to evaluate if addition of l-carnitine therapy to standard varicocelectomy adds any extra benefi t in terms of improvement in semen parameters or deoxyribonucleic acid (dna) damage. one hundred patients enrolled in this study and were randomly divided into groups ( patients in each group). in group , standard inguinal varicocelectomy and, in group , standard inguinal varicocelectomy plus oral antioxidant therapy (oral l-carnitine, mg times a day) were performed for months. for all patients, routine semen analysis and dna damage test of spermatozoa (by methods of terminal deoxynucleotidyl transferase dutp nick end labeling and protamine damage assay) were performed at baseline and at and months postoperatively. results: in both groups, the improvement in semen analysis parameters and dna damage was observed, but there was not any statistically signifi cant diff erence between the groups in these parameters, although the slope of improvement in dna damage was slightly better in group (that was not statistically signifi cant). we observed that addition of mg of l-carnitine orally daily to standard inguinal varicocelectomy does not add any extra benefi t in terms of improvement in semen analysis parameters or dna damage. serum uric acid as a risk predictor for erectile dysfunction introduction and objective: testicular torsion is one of the few urological emergencies that require prompt diagnosis and treatment, since its delay leads to testicular ischemia inevitably leads to testicular necrosis and atrophy. we aimed to determine the pattern of presentation and early outcome of patients with testicular torsion managed at kcmc. th is was a hospital based descriptive retrospective and prospective study involving patients who were managed for testicular torsion between january and january . eighty three ( %) were at the age of years with a mean . and a standard deviation of . . results: left side was more aff ected by . %. th irty two ( . %) patients arrived at kcmc within six hours from the onset of symptoms. scrotal pain was the main complaint. seventy two ( %) patients were misdiagnosed at the peripheral health facilities and treated empirically with antibiotics. ninety six point nine percent of those with more than degrees of rotation and duration of arrival to kcmc beyond six hours were found with missed torsion compared to . % of those with a degree of rotation less than and less than six hours on arrival to kcmc (p-value . ). orchiectomy of the aff ected testis and fi xation of the viable was the mostly adopted treatment option by . %. eighty four percent of our clients had fi rm and smooth testis at follow-up of three months with % having atrophic testis at three months in both groups (retrospective and prospective arms). conclusion: testicular torsion aff ects more young adolescent males. all patients with testicular torsion presented with scrotal pain. most patients arrived to kcmc hospital beyond six hours majority of them being treated empirically with antibiotics at the peripheral health facilities. missed torsion is a common sequel to our patients outcome at three months is promising by having viable testis. ho:yag laser ablation for ulcerative interstitial cystitis tokyo women's medical university aoyama hospital, tokyo, japan introduction and objective: in cases of ulcerative interstitial cystitis are usually treated by tur or by electrocautery, resulting in improvement of pain. efficacy of electrocautery using laser remains unclear because of a very few number of case reports. we treated this time ulcers of interstitial cystitis by cautery using ho:yag laser to evaluate its effi cacy as well as safety. materials and methods: eight cases with hunner's ulcers whose pains were hardly controlled aft er drug therapy and/or hydrodistention were treated with ho:yag laser. patients were evaluated with interstitial cystitis symptom index (icsi), interstitial cystitis problem index (icpi), international prostate symptom score (ipss), quality of life (qol) index and a visual analog pain scale (vas) at base line, one, three and six months post operatively. statistical analysis was performed using the paired t test, in which p< . was considered statistically signifi cant. results: patients were all females aged to years. half of them were treated more than two times. scores obtained by the questionnaire survey were improved aft er the laser therapy. scores of icsi, icpi, ipss, qol index and vas were statistically signifi cantly decreased at one and three months. only vas was statistically signifi cantly decreased at six months. th ere was no severe complication associated by the therapy. conclusion: ho:yag laser therapy for ulcerative interstitial cystitis is effi cacious at least for three months. also this treatment is safe for aged patients. introduction and objective: th e use of methylene blue (mb) to highlight anatomic structures in urology is a well-established practice. a narrow urethral plate can be diffi cult to properly locate intraoperatively, particularly in panurethral strictures. our objective is to assess the value of intraurethral injection of mb during urethroplasty. th ere is cc of mb ( mg/ ml) diluted in cc of normal saline. th e mb is gently injected retrograde into the urethra. a penile clamp is applied for minutes to increase the contact time of the mb with the urethra. th e urethroplasty commenced and the urethra was opened. th e impact of the mb on the anatomy of the urethra was by subjective assessment of a single surgeon (s.b.k.). results: a total of consecutive cases were prospectively evaluated from - . precise staining of the narrow lumen was successfully observed in ( %). in these cases, the diseased urethral strictured portion of the urethra was subjectively stained blue with mb. th e grossly normal appearing urothelium remained pink and did not take up signifi cant mb stain. in ( %) cases minimal or no staining was observed. extravasation in to the spongiosa was seen in ( %) cases. in ( %) cases there was dense staining distal to the narrow lumen. th ere were no known allergic complications. conclusion: normal urothelium does not appear to be stained by mb. mb readily stains diseased and strictured urotheilum. intraurethral injection of mb is a useful tool in urethroplasty. it helps in delineation of stricture and identifying lumen. it guides us to the exact area of urethra to be augmented. it is a simple, non-costly and non-invasive tool. in our high volume tertiary referral unit, it is now standard to inject methylene blue in urethra immediately prior to urethroplasty. demography, preoperative imaging and surgical outcome in penile fracture results: condition was occurred in . % of patients during an abnormal sex such as masturbation, aggressive sex and also taghaandan. all patients except one that refused intervention were treated surgically. only four cases involved bilateral corporal injury. two involved unilateral corporal injury with an associated urethral injury, and one involved bilateral corporal injury with an associated urethral injury that all were repaired primary. urine analysis was performed for . % of patients. gross hematuria was seen in one and microscopic in two patients of urethral injury and did not see in others. retrograde urethrogram were not taken of patients with urethral injuries. diagnostic cavernosography or magnetic resonance imaging was not used in any of the patients. cystoscopy was performed in case of gross hematuria with complete urethral transection. no complications occurred in the patients in early follow-up. we are interested in that report entire result of this study such as longterm surgical outcome at congress. conclusion: based on islam promotion for early and inexpensive marriage, avoiding from abnormal sex can signifi cantly decrease penile fracture. in addition, we recommended immediate surgical exploration and repair of tunica albuginea without any preoperative diagnostic imaging. introduction and objective: cowper's glands are two exocrine glands, which are located in the perineal pouch between the fascia layers of the urogenital diaphragm. th ey excrete pre-ejaculate into the urethra to lubricate it and neutralize acid to enable sperm to pass through the urethra. th e glands form two ducts that are . to cm long. although anatomic variations exist, the majority of ducts combine to make one confl uent passage that opens at the posterior part of the bulbar urethra. cowper's gland collecting ducts dilatation is called syringocele, an uncommon and under-diagnosed anomaly in adults. in pediatric patients there are . % and . % found on autopsy studies. we are presenting case of an adult -year-old male, whose symptoms were unrecognized by many physicians, even experienced urologists. th e patient had diff erent treatments with antibiotics and other diff erent medications without success. results: th e patient's chief complaint was dribbling aft er voiding few drops of urine when smiling, coughing, sneezing, crouching and any kind of eff ort. he received treatment as an outpatient by family physician and dermatologist. a bulging on the perineum was found by palpation, hard to elastic consistency, walnut size formation in the corpus spongiosum, easily movable from the perineal skin. urethroscopy was performed and the fi nding in the bulbar urethra was a cystic formation, gray to white color with very thin blood vessels. it fi lled the lumen of the bulbar urethra, but with pressure very easily passed the urethra and verumontanum to the bladder. voiding and retrograde urethrography showed fi lling defects in the bulbar urethra. th is cystic formation was fi xed to the fl oor of the urethra. an incision and deroofi ng of the cystic wall by resection was done. th e patient aft er this procedure was without dribbling aft er voiding. introduction and objective: th e use of methylene blue (mb) to highlight anatomic structures in urology is a well-established practice. th ere are diff ering opinions regarding the management of short atraumatic bulbar strictures. some favor augmentation with buccal mucosal graft (bmg) while others favor excision and primary anastamosis (epa). th e divergence of opinion is unifi ed toward epa in the face of signifi cant spongiofi brosis. our objective is to determine if mb can be used to assess the degree of spongiofi brosis in short atraumatic bulbar strictures. we term the procedure methylene blue spongiography. five cc of methylene blue ( mg/ml) is diluted in cc of normal saline. th e dissection for the urethroplasty continues until the bulbar urethra is exposed. th e location of the stricture is identifi ed. insulin needles are inserted in three locations. one needle is placed in the sponge proximal to the stricture. another needle is placed in the sponge at level of stricture. th e third needle is placed in the sponge distal to the stricture. large atraumatic clamp is place at the most proximal extent of the bulb to limit the confounding blood fl ow from the bulbar artery. methylene blue is gently injected via distal needle. th e two remaining needles are then observed for mb effl ux. presence of mb effl ux in needle proximal to stricture implies a defi ciency of signifi cant spongiofi brosis and urethral transection with epa is not performed. absence of effl ux of methylene blue in proximal needle implies signifi cant spongiofibrosis and epa is performed. we performed mb spongiosography in short bulbar idiopathic strictures. mean length of the stricture was . (range to . ). in ( %) cases methylene blue was seen across the stricture and transecting urethra was avoided. in ( %) cases where no mb went across primary excision and anastomosis was performed. no patients had adverse reaction or complication of methylene blue. conclusions: methylene blue spongiography can be performed to guide the method of urethroplasty performed. it is a simple, cost eff ective, and time effi cient method to further evaluate the degree of spongiofibrosis. effi . th e allium bulbar urethral stent is a fully covered, self-expandable, large caliber metal stent, specially designed for the treatment of bulbar urethral strictures. th e indwelling time for the stents was planned to be months. all men underwent an internal uretrotomy procedure followed by an endoscopic stent placement. progressive decreasing of the urinary peak fl ow rate, recurrent urinary infection and stent migration were the early removal criteria. th e success criteria aft er the stent removal were: no evidence of stricture on urethrogram or endoscopy, urinary peak fl ow greater than ml/sec and no recurrent urinary tract infection. results: five stents were replaced since very early migration not more than one month period. none of the patients reported discomfort at the stent site. five patients complained of mild urinary incontinence which was resolved aft er stent explantation. all stents were removed very easily without any complication to months (mean . months) aft er implantation. follow-up period was meanly months ( to ) after stent explantation. clinical success was achieved in patients ( %). conclusion: based on our results, temporary placement of allium bulbar urethral stent, for management of the recurrent urethral strictures, is noninvasive, safe and eff ective procedure. the impact of testicular loss on the psychopathology we also compared the results of long-term treatment group and short-term treatment group. th is study showed that cases of long-term continuous administration of doc consisting of or more cycles among patients of castration-resistant prostate cancer (crpc) treated with doc from october to september at our institution, retrospectively. nineteen patients who had treated with doc or less cycles were defi ned as short-term dose group, and both groups were compared. doc was administered every to weeks at to mg/m , and was treated with prednisolone at mg/day as a general. results: th e median number of treatment cycles was (range to ), and the median age of patients was (range to ) years old. th e median psa levels at start of doc based chemotherapy was . (range . to . ) ng/ml. th irteen cases ( %) showed a decrease in psa levels and cases ( %) showed a decrease in psa levels of % or more, the -year survival rate of long-term dose and short-term dose group were % and %. adverse eff ects of grade or lower consisted of leukocytopenia in % and thrombocytopenia in %, stomatitis and general fatigue in some cases, however, grade or higher were not observed in long-term dose group. in multivariable analysis of parameters, long-term treatment was related to psa levels at start of treatment and alp levels. pattern of use of androgen deprivation therapy in prostate cancer: an italian multicenter cross-sectional analysis introduction and objective: androgen deprivation therapy (adt) for prostate cancer (pca) is widely used with diff erent indications, however, some discrepancies exist between clinical practice and the recommendations of the international guidelines. th e aim of this cross-sectional study was to evaluate patterns of use of adt in patients with pca in italy. we also aimed to measure the adherence of adt prescriptions to the recommendations of the eau guidelines. materials and methods: th e choice study was an italian multicenter cross-sectional studying conducted from december to january on patients treated with adt for pca (fi rst prescription or renewal of therapy). th e project involved radiotherapy departments and urology centers. inclusion criteria were: age ≥ years, previous diagnosis of pca and current adt. at baseline all the following information were included: charlson comorbidity index (cci), clinical stage, psa level at the time of the diagnosis, total prostate volume and gleason score; gleason score and pathological stage from radical prostatectomy (rp) when available. we subdivided the cohort into three risk categories for each treatment group, based on d' amico classifi cation. patients were categorized according to primary treatment into rp, radiotherapy (rt), rp + rt and adt only. radiotherapy comprised external beam therapy and brachytherapy. adt included bilateral orchiectomy, gnrh agonists or anti-androgens. th ree geographical areas were considered: northern, central and southern italy. adt change (adt-c) was defi ned as any modifi cation of therapy between previous adt and treatment prescribed aft er enrolment. the prevalence and outcomes of pt disease after neoadjuvant hormonal therapy plus radical prostatectomy in high-risk prostate cancer introduction and objective: to identify the prevalence and clinical outcomes of pt disease following neoadjuvant hormonal therapy (nht) and radical prostatectomy (rp) in high-risk prostate cancer. we retrospectively included patients who had received nht and rp for the treatment of high-risk prostate cancer. we classifi ed the patients into two groups, the pt group and the non-pt group depending on whether a residual tumor was observed or not. we identifi ed cases ( . %) with pt disease aft er reviewing all slides of the patients. th ere was no recurrence of disease in the pt group during a median follow-up of months. among the patients in the non-pt group, biochemical recurrence (bcr) developed in patients ( . %), with the median time to bcr being months. conclusions: among the patients with high-risk prostate cancer, we found cases that showed a pathologic complete response aft er nht and no recurrence of disease during the follow-up, which means that the androgen-deprivation therapy could potentially eradicate high-risk prostate cancer. th is is one of the largest studies demonstrating the prevalence of pt disease and its outcomes aft er nht among patients with high-risk prostate cancer. introduction and objective: in metastatic castration-resistant prostate cancer (mcrpc), data are limited regarding optimal combinatorial or sequential use of available treatments. p - (stride; nct ) is an ongoing, randomized, open-label, phase study evaluating concurrent vs. sequential administration of the androgen receptor inhibitor enzalutamide (enz) with the autologous cellular immunotherapy sipuleucel (sip-t). fift y-two patients (pts) with asymptomatic or minimally symptomatic mcrpc were randomized : to receive sip-t infusions with enz starting weeks before (n= , concurrent arm a) or weeks aft er (n= , sequential arm b) sip-t initiation. th e primary endpoint is peripheral t cell proliferation response to pa , the sip-t immunizing antigen. secondary endpoints include interferon (ifn)-γ elispot and humoral immune responses to pa and prostatic acid phosphatase (pap), product release parameters (total nucleated cell count, cd + cell counts, and antigen presenting cell activation [as measured by cd upregulation]), cytokine production, and adverse events (aes). results through week are described. results: pa -specifi c t cell proliferative response was signifi cantly elevated at all post-baseline time points (p< . ) and was sustained through week , including a > -fold increase at week in both arms. th is pa -specifi c response was observed in nearly all pts, . % in arm a vs. . % in arm b. both arms showed a signifi cant and sustained increase in humoral responses to pa and pap as well as ifn-γ elispot response to pa . sip-t product parameters were similar between arms. cytokines indicative of immune activation (such as ifn-γ, interleukin- , and tumor necrosis factor-α) were also elevated in both arms. aes were observed in % (arm a) and % (arm b) of pts. th e incidence of grade ≥ aes was similar between arms. materials and methods: tur specimens without hormonal use ( cases), specimens aft er three weeks of chlormadinone acetate (cma) ( cases), specimens aft er average six months of dutasteride ( cases), and specimens two weeks aft er initial use of degarelix ( cases) were studied using he and immunohistochemical staining with prostate specifi c antigen (psa), prostatic stem cell markers such as cd , cd , and vimentin. results: specimens treated with cma showed acinar dilatation and atrophy of glandular cells. specimens treated with dutasteride showed marked decrease of gland and increase of fi bromuscular tissue. specimens treated with degarelix showed prominent decrease of gland and glandular cells. psa was stained all of the prostatic glandular cells in all specimens. cd was stained at basal cells in normal prostatic tissue without hormones, however in hormone treated specimens, basal cells elongate and some glandular cells were also stained by cd , especially in cma treated specimens. cd was stained in many glandular cells without special patterns. vimentin was stained in all mesenchymal interstitial cells and a part of basal cells, and not stained in glandular cells. conclusion: elongation of basal cells and increased sensitivity to cd in glandular cells, especially treated with cma, were thought to the result of emt of prostatic glandular cells. th ree weeks use of cma might be a good model to observe emt of prostatic cells among these three hormone models, presumably because six months use of dutasteride is long enough to alter the structure of prostatic tissue, and degarelix has strong apoptotic activity to prostate cells in a short period. aryl plays an important role in normal physiologic responses such as development, cell cycle regulation, and immune function in various tissues. th e strong nuclear ahr expression was observed in the invasive phenotype and an elevated nuclear ahr expression was associated with a poor prognosis of human prostate. on the other hand, the ahr defi ciency results in a smaller volume and in increased susceptibility to prostate tumors in mouse model. in the present study, we investigated ahr expression and its role in the growth and invasiveness of human prostate cancer cells. we checked ahr proteins expression in prostate cancer cell lines and in human prostate cancer specimens by immunoblotting and immunohistochemistry respectively. we used a small interfering rna targeting ahr, constitutive active ahr expression vector, and ahr agonist and antagonist were used to moderate its expression and signaling to examine growth and invasion in prostate cancer cells. introduction and objective: androgen deprivation therapy (adt) has been increasingly used in patient with prostate cancer (pca). it has been considered that adt is associated with greater risk of incident cardiovascular disease (cvd). th e one of the reason is that hyperlipidemia was caused by adt may contribute to greater cvd risk. but the evidence remains inconclusive and sometimes contradictory. in our present study, we investigated an eff ect of adt on arterial atherosclerotic changes assessed by cardio-ankle vascular index (cavi) in pca patients. th e present study was participated in patients with prostate cancer before initiate adt. we recorded and statistically analyzed the data of the patients before adt and at months, months, and months aft er adt. and the patients' arterial atherosclerotic changes was evaluated by cavi at baseline. correlation between the degree of infl ammation and gleason score in prostate cancer patients alexandrescu e, geavlete p, georgescu d, geavlete b introduction and objective: hypothesis regarding the involvement of infl ammatory processes in prostate cancer has been the subject of several recent studies. chronic infl ammation generates the appearance of morphological changes of atrophic type, lesions located predominantly in the periphery of the gland, as well as prostate cancer (pca). th e aim of the study was to assess the possible infl uence of associated infl ammation on the gleason score in pca patients. results: th e gleason score - was detected in patients ( . %), score - in patients ( . %) and score - in patients ( . %). cases of aggressive disease (gleason score - ) were detected by prostate biopsy, while high-grade infl ammation has been mostly associated with pca cases incidentally detected by turp. no signifi cant correlations were found between the presence and degree of histologically proved infl ammation and the gleason score or the presence of pca. identifi cation of n -methyladenosine methylated mrnas in prostate cancer pang k , , cumberbatch m , , catto j , introduction and objective: rna methylation is a common epigenetic event in oncogenesis, and the most common form is the methylation of n -adenosine (m a). th e recent identifi cation of > , m a-methylated human mrnas from > human genes point towards novel epigenetic mechanisms. however, the distribution of m a in the prostate transcriptome is unknown. we aimed to predict the mrnas susceptible to m a-methyation in primary prostate cancer (pca) and castrate-resistant pca (crpc), and identify the functions of these mrnas. th e aim of this study was to assess the contribution of multiparametric mri and pca in pre-decision of initial biopsy in patients with serum psa level - ng/ml and normal digital rectal examination. th e study is planned as prospective and single-centered. patients whose serum psa level - ng/ml with normal digital rectal examination scheduled for initial prostate biopsy were included in the study between february and march . each patient underwent multiparametric mri (diff usion, spectroscopy, dynamic-contrast, t ) one week prior to biopsy. th e lesion seen at least in two mri was accepted as multiparametric mri lesion. twenty to thirty ml initial urine samples were taken aft er minutes prostate massage for pca examination before biopsy. pca score over was considered as signifi cant. guided biopsies were taken according to lesions seen in multiparametric mri. patients with high psa levels were separated into two groups as high pca scores and normal pca scores. each group, then, was separated into two groups due to mri results as lesion positive and negative. tumor incidence and positive predictive values were calculated in patients with high psa and pca scores with positive multiparametric mri lesion. tumor incidence and negative predictive value were also calculated in patients with high psa level but low pca score with negative multiparametric mri lesion. up. , figure . a biopsy-induced hemorrhage was defi ned as a case in which a subject complained of bleeding from the rectum and excretion of blood clots was confi rmed. we categorized signifi cant rectal bleeding into two grades for hemostasis management, including mild and severe. when the bleeding was classifi ed as mild, we inserted the gelatin sponge into the participants in either group b or reinserted it into those participants in group a. if the bleeding could not be stopped by this approach, we additionally used index fi nger pressure for ten minutes or more to promote hemostasis. in the severe cases, an endoscopic clipping was performed to control the bleeding because arterial bleeding was suspected. a blood test and a questionnaire survey, and pain related to biopsy was performed before and aft er biopsy. th e diff erence in background factors between groups a and b was assessed. to identify the independent predictive factors for rectal bleeding for all participants, background factors, including insertion of a gelatin sponge into the rectum were analyzed by logistic regression analysis. results: signifi cantly fewer patients in group a required hemostasis aft er biopsy compared to group b ( ( . %) vs. ( . %), p= . ). th e results of blood tests performed before and aft er biopsy and the results from the questionnaire did not diff er signifi cantly between the two groups. in multivariate analysis, only "insertion of a gelatin sponge into the rectum" emerged as a signifi cant predictor of hemostasis. our results suggest that the tissue elastic modulus of prostate cancer may increase with an increase in the gleason score and that the diff erence in the stiff ness between low-grade lesions and prostate hyperplasia may be slight. th ese basic fi ndings will contribute to the development of quantitative elastography technique. the results: th e median ipss was , the mean psa was . ng/ml; the mean size of prostate was . cc. of the total subjects, prostate cancer was detected in ( . %) patients. among subscores refl ecting specific luts, the nocturia was only symptom score predict the cancer detection. th e detection rate of patient with nocturia more than time a day was . %, but the cancer detection rate of patient without nocturia was only . %. at multivariate analysis adjusting infl uence of covariate of age, psa, prostate size and transitional zone size, frequency and nocturia scores were the two only factor predicting cancer detection. at the roc curve analysis measuring the benefi t of the additional consideration of the severity of nocturia and frequency, the additional consideration induced . % prediction accuracy elevation (from . to . ). conclusions: men with frequency or nocturia have lesser chance of prostate cancer detection rate than the men without luts. however, the infl uence of these storage symptoms seems not strong enough to change current consensus of indication to biopsy the prostate. routine in the discontinuing group were %, %, - . %, - . % and - . %, respectively (p= . ). th e median Δegfr at baseline, , , and months in the continuing group were %, %, - . %, - . % and - . %, respectively (p= . ). th e continuing group decreased months later. however, the renal function in the discontinuing group had a tendency to improve at months aft er treatment insignifi cantly. th ere was not statistical signifi cant diff erence in various factors between discontinuing group and continuing group. conclusions: it was possible that the recovery of testosterone was associated with the improvement of the renal function. it has been reported that the discontinuation of adt recovered the level of testosterone. namely, the discontinuation of adt for prostate cancer might revive the renal function. th erefore, it was suggested that intermittent adt might recover the renal function. introduction and objective: as more and more patients are getting diagnosed as carcinoma of prostate (cap), we would like to look into how prostate cancers are presented at the early age of forties and how they were treated. as cap is more popularised in the media, more and more people are asking gps for psa measurements. introduction and objective: irreversible electroporation (ire) is a novel ablative therapy for prostate cancer, with reported advantages of sparing surrounding essential structures. th ese properties could potentially help to reduce or avoid side eff ects. th e objective is to determine quality of life outcomes (qol) and side-eff ects of ire treatment. sixteen patients planned for radical prostatectomy (rp), were asked to participate in the study. all patients underwent an ire treatment one month before rp, using a focal or extended ablation protocol. th e safety was measured by the number of adverse events graded by the common terminology criteria for adverse events (ctcae). to determine qol validated questionnaires (expanded prostate cancer index composite (epic), the fi ve-item version of the international index of erectile function (iief- ) and international prostate symptom score (ipss)) were used. results: five developed a urinary retention (ctcae grade ) solved by an indwelling catheter or self-catheterisation. two patients developed a urinary tract infection (ctcae grade ), one progressed to urosepsis (ctcae grade ), both resolved without sequelae. mild haematuria (ctcae grade ) was noted in ten patients, spontaneously resolved within days. five patients experienced temporary incontinence with duration of - days, three suff ered from total incontinence and needed pads and pelvic fl oor training (ctcae grade ). two patients reported mild hematospermia, lasting one and thirty days. ipss showed no signifi cant diff erence between baseline (average of (avg) ± ) and four weeks postoperatively (avg ± ). iief showed no signifi cant diff erence between baseline (avg ± ) and four weeks postoperatively (avg ± ). epic outcomes, shown in figure , were not signifi cantly diff erent at baseline, one and four weeks aft er ire, regardless of the used ablation protocol. conclusion: ire treatment for prostate cancer is safe and shows only adverse events that lie within the range of what was expected and shows promising rates of genito-urinary functional preservation. introduction and objective: mri-guided transurethral ultrasound ablation (tulsa) is a novel minimally-invasive technology for treatment of prostate cancer aiming to provide local disease control with low morbidity. th e ultrasound device generates conformal volume of thermal ablation, shaped precisely to the prostate using real-time mri thermometry feedback control. aim of this prospective, multi-national phase i study is to determine safety and feasibility of mri-guided tulsa. biochemical recurrence (bcr) was defi ned using phoenix criteria (psa nadir + ng/dl) and positive biopsy in the treated area was considered recurrence. we compared the perioperative and oncologic outcomes following fc in patients with gs vs. gs ( + ) at initial trus biopsy. th e complications were reported using the clavien-dindo classifi cation. we found patients with gs and with gs ( + ). clinical and operative characteristics were similar (table ) . th e mean follow-up was . (± . ) months. th ere was no signifi cant diff erence noted between gs vs. gs in the biopsy recurrence ( % vs. %, p= . ) and bcr rates. th ere were complications in ( . %) patients. all were low grade, except two patients who had iii b complications (table ) . conclusion: th e perioperative and oncologic outcomes of fc -hemiablation for unilateral, organ confi ned pca appears to similar between gs and gs ( + ) disease. pentafecta in the evaluation of surgical results after open radical prostatectomy de la rosa h, rios s, martinez n introduction and objective: "pentafecta" has been used to evaluate the oncological and functional results in patients with prostate cancer treated with minimal invasive radical surgical techniques. in this study we evaluate, with this quality tool, the outcomes in a group of patients undergoing open radical prostatectomy. we analyzed retrospectively the database of surgeries performed at the urology department of the military hospital of guadalajara and the clinical fi les of patients with localized prostate cancer treated with radical prostatectomy. we describe the patients' characteristics including the charlson comorbidity index (cci) and identify the parameters that conform pentafecta as well as the variables that can infl uence the oncological and functional results using the fisher´s exact test. results: fift y four patients were treated with radical prostatectomy between and , fi nding in their fi les a minimum of months of follow-up. seven patients were discarded of the study because they undergo laparoscopic radical prostatectomy, and more because missing information at their fi les. th e average age was ( - ) and the cci average was . ( . - . ). mean operative time was min ( - ) and intraoperative bleeding cc ( - ). th e presence of potency, continence, biochemical recurrence-free survival, negative surgical margins and no perioperative complications were %, %, %, % and % respectively. seven ( %) patients achieved pentafecta, and patients ( %) failed to achieve. statistical analysis confi rmed the surgeon's experience as the only factor associated with achieving pentafecta. conclusions: th e fi rst cause of failure to achieve pentafecta in our study group was impotence, second were positive surgical margins and third surgical complications mainly intraoperative bleeding. pentafecta is a useful tool for objective assessment of oncological and functional outcomes of patients treated with open radical prostatectomy. plasma introduction and objective: hepatocyte growth factor (hgf) is a well-known multifunctional growth factor, the amount of evidence has accumulated suggesting that the hgf/met (hgf receptor) signaling axis is involved in cancer progression. macrophage stimulating protein (msp) is also known as a growth factor which activates not only macrophages but also cancer cells and osteoclasts through the activation of the specifi c receptor d' origine nantais (ron). hgf and msp are secreted as an inactive single-chain precursor (pro-hgf, pro-msp), which lacks biological activity and, therefore, requires proteolytic activation for conversion to an active two-chain form by hgf activator (hgfa). although, there have been reported a lot of study for hgf/met signaling with castration-resistant (cr) pc and bone metastasis, the report for examination of plasma protein is rare. in addition, msp/ron signaling axis is not well evaluated in pc. here, we analyzed the associations between pc progression and plasma levels of hgf and a closely related molecule, msp. conclusion: dehydroepiandrosterone (dhea) concentrations in blood were examined by newly developed ultra-sensitive quantifying method, lc-ms/ms. we confi rmed that low serum dhea levels in men with prostate were related to high gleason score and advanced clinical stage. th ese results suggest that serum dhea level may be useful as a prognostic factor in men with prostate cancer. introduction and objective: androgen/androgen receptor (ar) signal is known as a powerful driver of prostate cancer (pca) progression. previously we reported the limitation of prostate-specifi c antigen (psa), which is an ar-regulated protein, at diagnosis as a prognostic biomarker of pca. paradoxically pca patients with low psa < . ng/ml had a more advanced stage of cancer compared with those with psa between . and ng/ml. although serum total testosterone (tt) has also been reported as a pca prognostic biomarker, its usability is still controversial. we examine the potential and the character of tt as a biomarker, comparing to psa. serum tt level of patients who underwent prostate biopsy at kanazawa university hospital between and were measured and pca-specifi c survival (pcass), overall survival (os), and the correlation between tnm stage and tt level were analyzed. results: of total biopsied patients, were diagnosed with pca. median tt was . ng/ml (range: . - . ). when patients were divided into groups according to their tt at diagnosis, patients with tt < and ≥ ng/ml had worse pcass than those with ≤ tt < , ≤ tt < , and ≤ tt < ng/ml. os in patients with tt < and ≥ ng/ml also was worse than that in other groups. moreover, tt < and ≥ ng/ml showed worse pcass even in patients with advanced stage (t or n or m ). higher tnm stage was observed in patients with tt < and ≥ ng/ml than those with ≤ tt < ng/ml. low tt level has been reported as a predictive biomarker indicating worse outcomes in pca patients. th is study showed not only low but also high tt level may indicate poor prognosis. th ese data are consistent with our previous studies showing low psa (< . ng/ml) also might indicate poor prognosis as well as high psa. although poor prognosis of high tt and high psa strongly depends on androgen/ar signal, poor prognosis of low tt and low psa patients may be due to other signals than androgen/ar. usefulness of psa as a marker of prostate cancer in men treated with dutasteride takeda h, nakano y, narita h introduction and objective: to analyse whether the use of treatment-specifi c criteria for repeat biopsy maintains the usefulness of prostate-specifi c antigen (psa) level for detecting prostate cancers. th is study was a retrospective investigation to assess the eff ects of dutasteride on psa in asymptomatic men aft er negative st biopsy and on repeat prostate biopsy decision. th e usefulness of psa was evaluated using biopsy thresholds defi ned by three times consecutive rises and . ng/ml up in psa from nadir (the lowest psa level achieved while in the study) in the dutasteride group. prostate cancer pathological characteristics were compared. results: of men, (dutasteride) underwent at least one prostate biopsy during the study and were included in the analysis. mean follow-up (month) was . , ipsa was . ng/ml, mean prostate volume(cc) was . , psad was . ng/ml/cc. nine of ( %) were detected prostate cancer, % ( / ) of gleason and % ( / ) of gleason - cancers were detected in the dutasteride group. in the study, the incidence of gleason and gleason - cancers generally increased with greater rises in psa. sensitivity of psa kinetics with dutasteride was high as usual. conclusion: using treatment-specifi c biopsy thresholds, the present study shows that the ability of psa kinetics to detect prostate cancer is maintained with dutasteride in men with a previous negative biopsy. biopsy decisions based on three times consecutive increased and . ng/ml psa measurement from nadir in the dutasteride group are useful, indicating the importance of confi rmation of psa measurements. our goal was to develop a fi t-for-purpose assay that could be performed on rna from diagnostic needle biopsies, and provide improved risk stratifi cation in early-stage pca. to date, development and validation studies have included > , patients from four academic centers. in these studies, archival tissues were assayed following prospectively designed protocols with pre-specifi ed methods and statistical analysis plans. results: feasibility and development studies confi rmed gene expression and identifi ed genes whose expression was predictive of clinical recurrence, biochemical recurrence (bcr), prostate cancer death, and adverse pathology (ap) at surgery in the face of tumor heterogeneity and multifocality. analytic validation studies showed that the assay provided robust, reproducible results over a wide range of rna inputs, diff erent operators, instruments, and reagent lots. th e fi rst clinical validation study established gps as an independent predictor of ap in men with nccn verylow to intermediate-risk pca. exploratory analyses showed that gps is a robust predictor of ap despite inter-observer diff erences in pathologic grade and stage assessment. a second clinical validation study in a racially diverse population confi rmed the assay as a predictor of ap and validated the assay as a strong predictor of bcr (hr/ gps units= . ; p< . ). gps was also signifi cantly associated with metastatic disease (hr/ units= . ; p= . ). other exploratory analyses showed that the assay can predict ) likelihood of clinical recurrence aft er bcr, regardless of salvage therapy, and ) tumor aggressiveness when assessed in adjacent normal-appearing tissue. all four gene groups contribute to the predictive value of the assay. conclusions: th e development program for the assay addressed challenges of small sample size, tumor heterogeneity, multifocality, and biopsy under-sampling. validation in two large contemporary cohorts of men with pca in two prospectively designed studies provides level ib clinical evidence for gps as a predictor of ap. clinical and therapeutic implications of neuroendocrine prostate cancer: a long winding road to cure lu k, wang h, lin v, yu t introduction and objective: primary neuroendocrine cancer of prostate is an extremely rare variant of prostate cancer, comprising . % to % of prostate malignancies. th is entity encompasses various clinical contexts, ranging from the de novo small cell carcinoma (scc) to a treatment-emergent transformed phenotype that arising from typical adenocarcinoma (ad) of the prostate. th e rarity of these neoplasms poses a diagnostic and therapeutic challenge. little is known about neuroendocrine prostate cancer and the current knowledge of this disease is based on case reports or small series. our purpose was to characterize the cases treated at a tertiary academic center and to evaluate patient outcomes with the available treatment modalities. th is was a single-institute retrospective observational cohort study of patients with neuroendocrine prostate cancer followed at e-da hospital, kaohsiung city, taiwan between january , and october , . patient and tumor data were analyzed using descriptive statistical methods. results: among prostate cancers, six patients were identifi ed with primary neuroendocrine prostate cancer, comprising from de novo mixed variety (scc and ad) and from transformed phenotype (pure scc). th e median age at diagnosis was . years. th e most common presenting symptoms were obstructive symptoms (weak stream, incomplete empty and urine retention). th e morphological appearance of the tumor cells and their immunohistochemical reactivity for neuroendocrine markers, and prostate specifi c antigen (psa) helped establish the diagnosis. overall median survival was months from diagnosis of neuroendocrine prostate cancer/ prostate small cell carcinoma. conclusion: primary neuroendocrine prostate cancer is characterized by an aggressive clinical course with relatively short lifespan. although high response rate to cytotoxic chemotherapy, overall prognosis is poor. as there is no standard of care for patients with neuroendocrine prostate cancer, further eff orts should be directed at its early detection and made to develop more eff ective therapeutic strategy. association th e mean duration for the side eff ect to occur was months (range - months), the mean duration between the onset of side eff ect and beginning of hbo therapy was months (range - months). th e patient with both hemorrhagic proctitis and cystitis completely recovered, and the remaining patients had improvement of side-eff ects. conclusion: hbo therapy can be a choice of treatment for radiation induced side-eff ects. a treatment trend of the prostate cancer in japanese provincial hospital introduction and objective: th e prostate cancer patients can choose various treatment options for cancer. however, the choice is limited by a diff erence in the scale and/or the location of each medical institution. we examined a treatment trend of the prostate cancer in our japanese provincial hospital. we evaluated patients who had a diagnosis of prostate cancer between and . th ey were classifi ed four groups, cases of the middle-aged generation (range - years old), cases of the early advanced-aged generation (range - ), cases of the middle advanced-aged generation (range - ) and cases of the latter advanced-aged generation (range -). we sorted each groups using the d' amico risk classifi cation system. in the middle-aged generation, patients, except for metastatic cases, underwent radical prostatectomy or radiotherapy. in the early advanced-aged generation, of low-very high risk group patients ( %) chose radical prostatectomy or radiotherapy. on the other hand, in the same generation, of intermediate risk group cases ( %) were treated with hormonal therapy. in the middle advanced-aged generation, only of low-very high risk group patients ( %) underwent radical prostatectomy or radiotherapy, which was fewer compared with the early advanced-aged generation. th at means, they oft en chose hormonal therapy. in the latter advanced-aged generation, all patients, except for cases, were treated with hormonal therapy. th e cases belong to the low-intermediate risk group, chose watchful waiting (psa monitoring). introduction and objective: robot-assisted radical prostatectomy (rarp) has emerged as an excellent treatment option for men with localised prostate cancer. as with other surgical treatment options, urinary incontinence remains a signifi cant side eff ect of the procedure and has been associated with weak pelvic fl oor muscle (pfm) strength. we aimed to assess pfm strength preand post-rarp, its relevance to incontinence and relevant predictors of poor outcomes post-op. we conducted a retrospective analysis of a prospectively collected database of men undergoing rarp by urologists over a -month period. each man had a pelvic fl oor strength assessment pre-operatively and at week and weeks post-operatively. pfm strength was recorded as strong (grade ), moderate (grade ) or weak (grade ). continence rates were recorded at weeks post-op, with continence defi ned as no requirement for pads or continence aids. basic demographic data and histological data were also collected. introduction and objective: urethral trauma is reported to occur in . % of patients undergoing catheterisation but, in practice, seems to be more common than this. we have investigated its incidence retrospectively and prospectively and have evaluated a new approach to catheterisation to reduce the incidence of catheter-related trauma and its consequences, which has led to the development of a novel urethral catheterisation device (ucd) produced by urethrotech™. a total of patients being catheterised for cardiac surgery were reviewed retrospectively and studied prospectively to determine the incidence of urethral trauma due to urethral catheterisation. one hundred similar patients were then studied prospectively to trial a ucd to see if it reduced the incidence of trauma. ( ) lavh ( ) myomectomy ( ) lap. ovarian cyst excision ( ) ( ) nephrectomy ( ) ileal ureter substitution ( ) ureterolithotomy ( ) angioembolization ( ) urs c d-j stent ( ) ureteroneocystostomy ( ) ureteroureterostomy ( ) . hospitalization ( notes. none had documented consent and none had been counselled about potential complications. one hundred and forty-six were successfully catheterised. four ( . %) required a suprapubic catheter for traumatic and unsuccessful urethral catheterisation. no other adverse events were recorded. seventy-four consecutive patients were studied prospectively aft er counselling and consenting. th e incidence of urethral trauma was out of ( . %). five had urethral or perineal pain and urethral bleeding ( . %) and ( . %) additionally required a suprapubic catheter. having developed a practice of passing a urethral catheter over a guide wire in patients undergoing reconstructive urethral surgery in our unit we subsequently trialled the urethrotech™ ucd for routine urethral catheterisation. th is ucd was used for catheterisation in consecutive patients without complications. we conclude that urethral catheterisation has a signifi cant risk of trauma -ten times the reported incidence -and to reduce that risk the catheter should be passed over a guide wire, as with the ure-throtech™ ucd, as is the practice for passing catheters and similar tubes into other anatomical structures. th is should particularly apply in high risk patients, such as those being catheterised for cardiac surgery who are about to be heparinised, and in higher risk circumstances such as when catheterisation is being performed by junior medical or nursing staff . results: mean age at the time of transplantation was . ± . years with male to female ratio of . : . etiology of esrd included renal parenchymal diseases ( %), o vesicoureteric refl ux ( %) and o vesicoureteric refl ux due to posterior urethral valve ( %), urolithiasis ( %) and neurogenic bladder ( %). pre-transplant bilateral nephroureterectomies were performed in patients, augmentation ileocystoplasty with mitrofanoff conduit in patients while posterior urethral valve fulguration in patients. mean serum creatinine post-transplantation was . mg/dl and . mg/dl at week and months respectively. surgical complications occurred only in two patients; one developed lymphocele while other presented with febrile uti due to ureteric refl ux in the early postoperative period and was managed by doing a new ureteral reimplantation. th e mean graft and patient survival rates at one year were % and % respectively. one patient lost her graft at months which was turned out case of hyperoxaluria. acute rejection was seen in ( %) patients. all of these were successfully reversed with pulse therapy. none of the patients developed cytomegalovirus (cmv) infections or lympho-proliferative disease. symptomatic urinary tract infections aft er transplantation occurred in ( %) patients including pyelonephritis in ( . %) patients. two of these patients with pyelonephritis had prior bladder augmentation. ureteric stenosis is a well recognised major urological complication of renal transplantation. following initial antegrade decompression, defi nitive treatment options include long-term ureteric stenting, endoscopic stricture dilatation/division or ureteric re-implantation. th ere is minimal current data in the literature to help guide patient choice. we aimed to characterise the outcomes following management of ureteric stenosis at a large european regional transplant centre. a retrospective cohort study was performed for all patients following renal transplantation who required treatment for ureteric stenosis between august and august . case identifi cation was via a prospectively maintained database on all renal transplant patients and international classifi cation of disease procedure codes. results: of renal transplants performed during the study time period, patients developed ureteric stenosis requiring intervention ( . %). eleven patients underwent initial open ureteric re-implantation, had endoscopic management and had longterm ureteric stents. mean length of time between elective stent changes was . months (range - months). one patient opted for open re-implantation aft er a period of stenting with a good outcome. one experienced graft failure due to non-compliance with immunosuppression, otherwise renal function was preserved. of the patients having open re-implantation only one experienced re-stenosis -managed with long-term ureteric stenting and . % had satisfactory renal function at follow-up. two patients received successful balloon dilatation and patient had upper tract stenosis managed with pyeloureteroplasty. all patients have experienced no decline in graft function since. endoscopic, open reconstruction and long-term stenting can all provide satisfactory outcomes for the majority of renal transplant patients aff ected by this problem. medium-term graft function was well preserved. in recent years approximately half of patients have proceeded to open re-implantation. surgical and clinical factors impact the choice of treatment. however, patient choice also plays a significant role. th is study has provided up to date information to aid counselling patients. further prospective study is warranted to assess what variables infl uence patient choice and cost effi ciency of open re-implantation versus long-term ureteric stenting. the angiogenic mechanisms of endothelial progenitor cells in kidney transplantation patients introduction and objective: th e blood fl ow blocking during kidney transplantation oft en results in renal ischemic injury. in this process, endothelial cells and endothelial progenitor cells (epcs) are activated to participate in angiogenesis. epcs and endothelial cells participate in angiogenesis and tissue repair through diff erent signaling pathway. prostaglandin e (pge ) is a kind of metabolites of arachidonic acid, and is a mediator of infl ammation and ischemia. pge took part in angiogenesis and epcs diff erentiation according to our previous study. in this study we will demonstrate the angiogenic function of epcs of kidney transplantation patients and reveal the molecular mechanisms of angiogenesis. materials and methods: epcs from peripheral blood aft er kidney transplantation were isolated by density-gradient centrifugation. facs was used to identify the epcs. th e aa metabolites pge in epcs cultured medium was measured by liquid chromatography-tandem mass spectrometry (lc-ms/ms). q-pcr and wb were used to detect the expression of endothelial markers in human umbilical vein endothelial cells (huvecs) cultured with epcs conditional medium. tube formation assay was performed to elucidate the angiogenic ability of huvecs. results: epcs from kidney transplantation expressed c-kit and cd by facs analysis. multiple types of aa metabolites was detected in the conditional medium by lc-ms/ms and pge was increased to more than -fold aft er kidney transplantation. huvecs cultured with conditional medium highly expressed cd and ve-cadherin and also formed more tubes compared with control. huvecs given pge had the same biological characteristics like the conditional culture. conclusion: pge paracrine of epcs from kidney transplantation enhanced the capacity of angiogenesis in huvecs. graft survival, proteinuria and kidney growth: challenges between pediatric and adult deceased kidney donation basiri a , , , zare s introduction and objective: th e presence of widening discrepancy between supply and demand of donor and recipient in the fi eld of renal transplantation, has led us to compare the graft and patient survivals, post transplantation complications, rate and severity of proteinuria secondary to hyperfi ltration injury and the kidney growth of recipients who underwent transplantation from pediatric (group ) and adult deceased donors (group ). each groups contains patients. outcome measures included, patient and graft survivals, quality of graft function as assessed by serum creatinine (scr) and estimated gfr (egfr), surgical complications, proteinuria that was detected by routine urinalysis and then confi rmed by a -h urine protein > mg, and kidney length that measured by early and following ultrasonography. results: th e mean donor age in groups and were . (range . to y/o) and ( to y/o) respectively. th e nine kidneys ( %) from pediatric donors (group ) were off ered en-block. mean follow-up was month (range to ). th ere were no statistical differences in the incidence of dgf between two groups ( % versus %) (p= . ). group had a slightly higher incidence of acute rejection than group ( versus %), but the diff erence was not statistically signifi cant (p= . ). one year's graft survival were similar between two groups ( % and %). serum cre-atinine (scr) and estimated gfr (egfr) th ere were no statistically diff erences between two groups ( . versus . mg/dl and versus cc/min respectively) (p= . ). th e incidences of surgical complications that required surgical intervention (urinary leakage, ureteral stenosis, lymphocele, vascular thrombosis) were similar in both groups ( versus %) (p= . ). development of proteinuria was not diff erent between two groups ( % versus %) (p= . ). early kidney length within one week was signifi cantly lower in group than in group ( ± mm versus ± mm) (p< . ), but the rate of increase of kidney length in group was signifi cantly greater than group ( ± mm versus ± mm) (p< . ) under follow-up period. conclusion: although in this study, median-term outcomes and complications of single and en-block kidney transplantation from pediatric donors are acceptable and same as those from older donors. but assessment of functional and hemodynamic adaptation of small pediatric kidneys in adult recipients and subsequent hyperfi ltration eff ects requires the study with more cases and greater follow-up periods. george a, singh c, devasia a introduction and objective: th e need for vascular access for hemodialysis (hd) increases with the increasing number of patients with end stage renal disease (esrd) requiring hd, with increasing life span, and with more available facilities especially in developing countries. when the usual accesses (radiocephalic and brachiocephalic) have been utilised or failed, a ptfe graft is usually considered. we present here a 'bridging' option of a basilic vein transposition, as a doable, cost eff ective procedure before av graft ing. patients with end stage renal disease were included. th ey all either had poor cephalic veins at the wrist and cubital fossa, or had previously used and failed fi stulae. anasthesia: regional block (local anaesthetic). technique: th e basilic vein was exposed using three small incisions: cm above cubital fossa, mid arm (medial aspect), and upper arm (medial aspect up to axilla). th e vein was completely freed off surrounding structures, tributaries tied, distal end ligated, patency ensured and vein delivered out of the uppermost incision. using a tunneller, the vein was rerouted subcutaneously, anteriorly to reach the cubital fossa incision. th e brachial artery was identifi ed and looped. arteriovenous anastomosis was done using 'o' prolene, continuous sutures. (images in the poster). results: out of a total of venous access surgeries done during the study period, seven basilic vein transpositions were done. all had pre-operative doppler evaluation to assess size and patency of veins. all fi stulae created were functional at the time of discharge. th e fi stula is used for hemodialysis at - weeks, when the fi stula matures (arterialization of the vein implying good/suffi cient fl ow for dialysis). one patient needed exploration for a venous thrombus, hours later, which was removed with a venotomy and th congress of the sociÉtÉ internationale d'urologie -siu abstract book using a fogarty catheter. subsequently with anticoagulation for hours, the fi stula continued to function and is being used for access. th e second patient had exploration on the th post-operative day for evacuating a subcutaneous hematoma. th e fi stula is patent and will be used once it has matured. five of the seven done were uneventful and are being used for hemodialysis access. conclusion: basilic vein transposition, is the preferred option of vascular access over a ptfe graft , as it is cost eff ective, autologous and doable under regional anaesthesia. retrospective results: a total of renal transplants have been performed since . th e transplants were performed via an extraperitoneal approach with a modifi ed lich-gregoir ureteric anastamosis in most cases. jj-stents were not routinely used. th irty two urological complications were noted in transplants ( %). th ere were boys and girls with ages ranging from . to . yrs (mean . ). th e most common complication was vesico-ureteric refl ux (vur) occurring in patients ( %). all those with vur presented with recurrent urinary tract infections and bladder dysfunction was present in % (none were augmented). vur was managed successfully with reimplant in six and submucosal injection of defl ux in three; eight patients were managed conservatively. post-operative urine leaks occurred in patients ( %) and were managed with reimplant in two, uretero-ureterostomy in one, jj-stent in one and conservatively in two. ureteric stenoses presented in patients ( %) with hydronephrosis and worsening renal function and were managed initially with either percutaneous nephrostomy or jj-stent placement. surgical management was performed in four patients (three reimplants and one uretero-ureterostomy); two patients were managed conservatively with transient jj-stent placement. th ree patients ( %) developed unexplained hydronephrosis -one with worsening renal function due to chronic rejection and two with stable renal function. loss of graft occurred in patients ( %) as a direct result of their urological complication. th ere were deaths -two due to chronic rejection and one due to overwhelming sepsis immediately post uretero-ureterostomy for ureteric stenosis. conclusion: urological complications following paediatric renal transplantation are common and can cause signifi cant morbidity and even mortality. vur was the most frequently observed and, if presenting with recurrent utis, can be managed successfully with surgery. other urological complications observed included urine leaks, ureteric stenoses and unexplained hydronephrosis. kidney transplantation in abnormal bladder: analysis of outcome kumar a, gulia a, chauhan u, sharma a, yadav r, dassi v introduction and objective: kidney transplantation in abnormal bladder is a challenging situation and associated with poor outcome. we have analyzed outcome of our data of last years. materials and methods: from to , patients who had abnormal bladder had undergone kidney tx. average age at the time of transplant was years. average age at bladder reconstruction was years. four patients had neurogenic bladder who were practicing cic, using native urethra and one had appendix as a mirofenof procedure. two patients had bilateral nephrectomy for grade vur and their lower ureters were used for augmentation and other two had ileocystoplasty. four patients of grade vur refl ux had subsequent transplant in the bladder. four patients with puv had bladder augmentation and mitrofenof procedure due to poor compliance. one child with puv had augmentation by stomach patch when he was year old. one patient had cystectomy in the past and ileal conduit reconstruction where transplant ureter was implanted. all patients had very trabeculated and thick bladder during ureteric reimplantations. all patients had extravesical ureteroneocystostomy with stents. urethral catheter was kept on average of days. no patients had any ureteric leak or stricture in postoperative period. all four patients with cic through native urethra had recurrent uti in the postoperative period and required long-term chemoprophylaxis. one patient who had ileocystoplasty before transplant, died due to sepsis just before his transplant. incidence of uti was % in this group. six patients also had pyelonephritis, which was controlled by injectable antibiotic. rejection rate was % in this group in fi rst month which was higher than our normal bladder group. average serum creatinine was . mg% at months and . mg% at year which was high than normal bladder population. average follow-up is . years where serum creatine was . mg%. mean hospital admission was . times. conclusion: kidney transplant in abnormal bladder is a good option but long-term results are inferior. recurrent uti and pyelonephritis are still a troublesome problem. various techniques and procedures are required to overcome these diffi cult situations. analysis of results: th e mean operative time, warm ischemia time and blood loos were minutes, . minutes. ml respectively. th ere were major complications including hemorrhage and injury to organs like bowel, spleen and pancreas. fourteen of these patients required exploration to control bleeding or repair. two patients were explored for adhesive obstruction. th ere were minor complications which were managed conservatively. one patient died in immediate postoperative period due to slippage of a single hemolock clip. all patients have adequate vascular and ureteric length. th ere were cases of multiple vessels. th ere were two urinary fi stulae and one ureteric obstruction. mild atn was noticed in patients. no graft was lost. hospital stay was . days. operative time has also come down to from minutes. th e average cost of the laparoscopic donor nephrectomy is us$ . conclusion: lap donor nephrectomy is a safe and minimally invasive procedure. it is a cost eff ective procedures even for the developing country. prostate carcinoma in solid organ transplant recipients tillou x , guleryuz k , bouvier n , belin a , chiche l , bensadoun h , doerfl er a introduction and objective: improvements in immunosuppression and anti-infection drugs in solid organ transplantation have led to a signifi cant survival increase for patients and graft s. prostate cancer (pc), being the most common tumor in men and given the increasing number of old male recipients, should show an increasing incidence in solid organ transplant recipients (sotr). th e aim of this study was to analyze retrospectively our liver (ltr), kidney (ktr) and cardiac transplant recipients (ctr) treated for a pc. between january and december , we found pc in male sotr ( %): pc in ltr, in ktr and in ctr. a ge at diagnosis was . ± . ( . - . ) years old and the interval from transplantation to diagnosis was . ± . ( . - . ) months. mean psa level was . ± . ( . - ) ng/ml. clinical stages were t , t and t in respectively , and patients. diagnosis was suspected during screening, because of prostatitis or bone pain in respectively , and patients. th ree pc were discovered aft er prostate transurethral resection. results: th irty-one patients ( ktr and ltr) with a localized disease underwent radical prostatectomy (rp). histological fi ndings were pt c and pt tumors, with positive surgical margins. gleason score (gs) was in case, in cases, in cases and in case. one patient with positive pelvic lymph nodes was given hormonotherapy. another had a biochemical recurrence at months and was treated with salvage radiotherapy. with a mean follow-up of . ± . ( . - . ) months, two ktr died from kp, and years aft er hormonotherapy and rp respectively. conclusions: prevalence of pc in sotr remains controversial, even though a signifi cant increase can be expected in the coming decades. it is therefore recommended to systematically screen male transplant recipients aft er years of age because outcome is much better if pc is diagnosed and treated early. radical prostatectomy is feasible in ktr as well as in ltr. conservative introduction and objective: conservative surgery results in the transplanted population remain unknown because they are only presented in small series or case reports. our objective was to study renal conservative surgery for kidney graft renal cell carcinomas (rcc) in a multicenter cohort. nephron sparing surgery (nss), radiofrequency ablation (rf) and cryoablation (ca) were studied. iiib) . none of the patients treated by radiofrequency ablation or cryoablation had complications. th e mean time of follow-up was . months ( . - ). fift y-nine ( . %) patients had a functional kidney graft , without dialysis and no long-term complications. specifi c survival was % at the last time of follow-up. conclusion: nss has proven its effi ciency for treatment of small tumors of transplanted kidneys with good long-term functional and oncological outcomes, which prevent patients from returning to dialysis. cryoablation and radiofrequency ablation seem to be alternative therapies that can be chosen with good results, in selected patients. ureteric implantation into introduction and objective: conventional technique recommends ureteric anastomosis to the bladder during kidney transplantation in patients with bladder augmentation. we report our experience of kidney transplantation in augmented bladders with the transplant ureter implanted into the bowel portion of the cystoplasty. a total of patients (mean age, . years (range - years), female, deceased donors) with augmented cystoplasty and subsequent kidney transplantation by a single surgeon between and was reviewed. following standard arterial and venous anastomosis and reperfusion of the transplanted kidney, ureteric implantation involved continuous pds / anastomosis between the spatulated ureter and full thickness bowel portion of the cystoplasty over a size fr dj stent. a second layer of bowel plication was performed around the anastomosis to prevent refl ux using interrupted / vicryl sutures. chart review was performed to evaluate the short-term urological and kidney function outcomes. results: th e cause of renal failure was bilateral vesicoureteric refl ux in patients, posterior urethral valve with refl ux nephropathy in patients, tuberculosis of the urinary tract with infl ammatory ureteric stricture in patient, and lumbosacral agenesis with neurogenic bladder in patient. bladder reconstruction was performed at a median duration of months ( - months) before transplantation. gastrocystoplasty was performed in patients, while the colon and/or ileum were used in the remaining patients. all reconstructed bladders except had a mitrofanoff created for clean intermittent self-catheter drainage aft er transplantation between to x / day. aft er surgery, th e dose fi nding study, toxicokinetics of human bone marrow-derived mesenchymal stem cells, and study deciding timing and number of cell injection were conducted in order. results: from the dose fi nding study, × was selected as dose per an injection of human bone marrow-derived mesenchymal stem cells. from the toxicokinetics of human bone marrow-derived mesenchymal stem cells, days was selected as interval between repeat treatments. in the third study, the ratio of maximal intracavernous pressure to mean arterial pressure was signifi cantly lower in the control group than in the sham group ( . % vs. . %, p< . ). immediate single injection of human bone marrow-derived mesenchymal stem cells ( . %, p= . ) signifi cantly improved erectile function compared to that in the control group, whereas delayed single injection ( . %, p= . ) showed marginally signifi cant improvement. all histomorphometric changes were signifi cantly improved in the up. , figure . immediate or delayed single injection groups than in the control group. repeat treatments did not provide any incremental eff ect on recovery of erectile function and histomorphometric changes. conclusion: intracavernous injection of × human bone marrow-derived mesenchymal stem cells results in recovery of penile erection along with histomorphometric changes in a rat model of cavernous nerve injury, even when treatment was delayed by weeks following cavernous nerve injury. any incremental eff ect aff orded by repeat treatments remains to be undefi ned. relationship between metabolic syndrome, erectile dysfunction and hypogonadism abou farha m, el-abd s, el-gharbawy m, abou farha o introduction and objective: a strong association between erectile dysfunction (ed) and metabolic syndrome (ms) and hypogonadism was determined. aim of the work: to investigate the relationship between (ms), (ed) and the incidence of hypogonadism. th e correlation between hypogonadism and the metabolic risk factors was also determined. a total of patients with ed were included in the study, patients meet the criteria of ms were estimated. ed was classifi ed based on iief- domain score and the relation between severity of symptoms and the number of metabolic risk factors was determined. th e incidence of hypogonadism in ms patients was determined and the correlation between hypogonadism and metabolic risk factors was identifi ed. introduction and objective: peyronie's disease (pd) is a fi brotic disorder aff ecting the tunica albuginea of the corpora cavernosa. erectile dysfunction (ed) due to pd may be secondary to the penile deformity and the resultant changes in the hemodynamic parameters. th e aim of this study is to defi ne color doppler duplex ultrasound (cddu) characteristics in pd, with specifi c attention to describing the presence and etiology of ed in these patients. introduction and objective: th e cause of peyronie's disease (pd) is unknown. th e most accepted causative theory is trauma to tunica albuginea. because prevalence varies ( . - %), the potential for contributory cofactors have been proposed. we hypothesized that metabolic syndrome and other comorbidities may be found at higher rates in pd. retrospective chart review of patients presenting to a men's health clinic with a variety of complaints: erectile dysfunction (ed), premature ejaculation (pe), premarital checkup, small penis, decreased libido, lower urinary tract symptoms (luts) were screened for pd. variables collected: presence/absence of diabetes mellitus (dm), hypertension(htn), dyslipidemia (dl), body mass index (bmi), total testosterone (t), penile peak systolic velocity (psv) and end diastolic volume (edv), smoking, and glycosolated hemoglobin level (a c) in patients with dm. results: a total of patients, with a mean age of years (range - ) were analyzed. pd incidence ranged widely within individual clinics ( - %, average %). hypertension, bmi, t level, total number of comorbidities, low psv, abnormal edv, and mean a c were not associated with the presence of pd. th congress of the sociÉtÉ internationale d'urologie -siu abstract book diabetes was associated with pd (p= . ) and dm patients had a % higher incidence. patients with the highest a c levels (> . ) had an increased incidence of pd [or . (p= . , ci . - . )]. increased age was correlated with pd (p= . ); for each year of life, the likelihood increases by an or of . (~ % per year) (p= . , ci . - . ). dyslipidemia (p= . ) and smoking (p= . ) were associated with - % lower incidences of pd. conclusion: peyronies disease is found in about % of patients seen for other complaints. diabetes, particularly poorly controlled diabetes, is associated with an increased incidence. several other clinical factors appeared noncontributory. a decreased incidence of pd in smokers and patients with dyslipidemia is seen, but does not necessarily refl ect a protective role, but likely increased levels of erectile dysfunction in these groups--patients with inability to achieve erection are unlikely to complain of peyronies' disease. further research into the interaction of pd and dm are warranted. kim j, park j, chae j, oh m, park h, kim j, moon d introduction and objective: limited data are available concerning sexual behavior of korean men. th is study aimed to perform the national sex survey and to collect the basic data for establishment of the prevention strategies of sexually transmitted infections (stis) and hiv/aids. th is is a national survey performed on a sample of , individuals ( , men and , women) aged - years old. th e online surveys were carried out on a national scale in south korea. subjects were randomly selected from resident registration. a structured questionnaire was developed which elicited information concerning: demographic information, information on their sexual behavior, sexual identity, prostitution, experience of stis, and experience of sex education. results: th e majority of the subjects were either married or living with a partner. mean number of sexual intercourse is . ± . times a month. mean sexual satisfaction score using visual analog scale is . ± . . eighty-four percent had a fi xed sex partner; . % ( . % of men; . % of women) had experience through a speed dating or prostitution; . % of men and . % of women were sexually attracted to the same gender only, . % of men and . % of women were sexually attracted to both gender; . % of participants had the experience of the stis. only . % of the respondents had received sex education in the past year. we performed the national sex survey according to the nationwide distribution of population. it would be useful for establishment of the prevention strategies of stis and hiv/aids. to control stis and hiv/aids, powerful policies containing sex education and medical services will be needed. the introduction and objective: erectile function evaluated by international index of erectile function- (iief- ) tends to decrease in aging, obesity and hypogonadism, but the importance of body composition is unclear. in the present study, we evaluated associations between iief- , body composition and testosterone level (tt) in middle-aged men. design was a population-based cross-sectional study in middle-aged men. between march and september , police officers aged - years who had participated in a health examination were included. total , men underwent a detailed clinical evaluation using the validated international index of erectile function- (iief- ) questionnaires and body composition (measured by bioelectrical impedance analysis). weight, body mass index (bmi), waist-hip ratio (whr), and serum testosterone level were also established. results: data from men were analyzed. th e median age was . years, and median value of iief- score was . th e iief- score was inversely associated with age, whr, and body fat percentage (bfp) (r=- . ; p< . , r=- . ; p< . , r=- . ; p= . , respectively), and positively associated with body muscle percentage (bmp) and body skeletal muscle percentage (bsp) (r=- . ; p= . , r=- . ; p= . , respectively). testosterone level had no correlation with iief- score (p= . ). using logistic regression analyses, age, whr, bfp, and bsp predict moderate to severe erectile dysfunction (ed) in univariate analysis. age, whr, and bfp were independent predictive factors for moderate to severe ed in multivariate analysis (p< . , or . , % ci . - . ; p= . , or . , % ci . - . ; p= . , or . , % ci . - . , respectively). our data showed that erectile function in middle-aged men was closely associated with whr and bfp than with testosterone level and body muscle percentage. however, whr was identifi ed as a negative predictive factor for ed. further studies for the unique form of obesity pattern in korean men will be needed. in order to estimate the magnitude and outline the main components of adult male genital organs "dysmorphophobia" in greece, we surveyed the beliefs of men about parameters potentially aff ecting their sexual performance and activity as they relate with self-perceptions regarding adequacy of their external genitalia image. herein, we present preliminary results of this questionnaire based cross-sectional study. a specially designed self-administered questionnaire, consisting of demographic characteristics and main outcome measure questions aiming at defi ning whether and how beliefs regarding men's sexual image adequacy aff ect their sexual confi dence and function (answers scored - ), was fi lled in by males (aged - ) who consulted a single urology clinical setting, for symptoms unrelated to genital area pathology. statistical analysis was performed using spss- , p< . . results: th e majority of subjects ( . %) were highly satisfi ed of their sex organs image, while only one in seven ( . %) reported moderate to low levels of satisfaction. small penile size in the fl accid state was the most frequent ( . %) complaint followed by small erect penis dimensions ( %). in one out of two men ( . %), sex image inadequacy impression was based on self-assessment, in . % on sexual partner comments and in only . % on expert medical examination. nine out of ten men ( . %) considered external genitalia appearance the most signifi cant determinant of a man's sexual confi dence with . % believing they strongly fulfi l this requirement, while most of them ( . %) were highly satisfi ed with their whole body image. in only one in ten men ( . %) the impression of the sexual partner regarding sex image aff ects signifi cantly his sexual performance. most men ( . %) argued against resorting to surgical techniques to improve their sex image, % considered this option imperative for their well-being, while one in four ( . %) would consider surgery if a spectacular cosmetic result was guaranteed. various statistically signifi cant correlations between demographic and main outcome measures variables were recorded. conclusions: symptoms of genital organs dysmorphophobia, are expressed by one in seven men of the general population, in most cases complaints focus mainly at small penile size, while most frequently impression of inadequate sex image originates from self-assessment and negative sexual partner's comments. th e majority of men consider genital image a strong determining factor for sexual performance, while very few experience sexual relationships difficulties due to feelings of genital inadequacy. only a small minority of men would be strongly willing to undergo external genitalia surgery, which they consider imperative treatment for sexual image inadequacy. abou farha m, el-abd s, el-gharbawy m, abou farha o introduction and objective: metabolic syndrome is a public health problem associated with increased incidence of erectile dysfunction (ed). erectile dysfunction in patients with metabolic syndrome is diffi cult introduction and objective: erectile dysfunction (ed) and lower urinary tract symptom/ benign prostatic hyperplasia (luts/bph) has common pathophysiology. and phosphodiesterase type inhibitor (pde -i) partially reverses the prostatic tissue contraction, and increases cyclic guanosine monophos- phate to show antiproliferative eff ects in the prostatic smooth muscle cells and consequently, voiding symptoms were suggested to be improved. however, there was no defi nite mechanism of the eff ectiveness of pde -i on luts/bph. some previous study has reported the hypothesis which is pde -i improve the blood fl ow rate of prostate and it may improve the luts. in present study, by transrectal ultrasonography (trus), evaluated the change of blood fl ow rate of prostate aft er pde -i administration. materials and methods: total patients were included in this study. among enrolled patients, patients had once daily administrated mirodenafi l (mvix®, sk chemical, korea) mg for week, other patients had administrated placebo daily. peak systolic velocity (psv) and end diastolic velocity (edv) were estimated by trus at before medication and a day aft er last administration. results: baseline characteristics were no signifi cant diff erence between two groups. in mirodenafi l group showed . cm/sec increase of psv and placebo group showed . cm/sec increase of psv (p= . ). moreover, mirodenafi l group showed . cm/sec increase of edv and placebo group showed . cm/sec decrease of edv (p= . ). once daily administration of mirodenafi l mg showed improvement of blood fl ow rate of prostate. factors predicting outcomes of penile rehabilitation with udenafi l mg following radical prostatectomy introduction and objective: udenafi l is a selective phosphodiesterase type inhibitor (pde i) made available in recent years for the treatment of erectile dysfunction (ed). penile rehabilitation using pde is following radical prostatectomy (rp) has been advocated; however, there are no previous reports on the role of udenafi l for potency recovery aft er rp. herein, we evaluated independent predictors of potency recovery in rp patients who underwent penile rehabilitation with udenafi l mg. between january and december , a total of patients underwent rp at a single institute. among them, men were enrolled in a penile rehabilitation program using udenafi l mg every other day. uni-and multivariable cox regression analyses were used to determine independent predictive factors for potency recovery. results: th e overall potency rate was . % during the mean follow-up of . months. on the multivariate cox analyses, preoperative international index of erectile function (iief)- scores (hazard ratio [hr], . ; p = . ), alcohol consumption (hr, . ; p = . ), and gleason biopsy score (hr, . ; p = . ) were independent preoperative predictors for potency recovery. among post-rp variables, the use of robotic procedures (hr, . ; p = . ) and pathologic stage (hr, . ; p = . ) were significantly associated with potency recovery. conclusion: th is study identifi ed predictive factors for the recovery of potency in patients undergoing penile rehabilitation with udenafi l following rp. our results provide physicians with useful information for counseling rp patients and selecting optimal candidates for penile rehabilitation. introduction and objective: androgen replacement therapy (art) effi cacy on late-onset hypogonadism (loh) has been widely investigated in western countries; however, it remains controversial whether art can improve health and prolong active lifestyles. we prospectively assessed long-term art eff ects on the physical and mental statuses of aging men with loh in japan. of volunteers eligible patients > years with loh were randomly assigned to either the art (n= ) or the control groups (n= ). art was conducted with intramuscular injection of testosterone enanthate mg each time every four weeks up to times. th e primary endpoint was health-related quality of life assessed by questionnaires. secondary endpoints included glycemic control, lipid parameters, blood pressure, waist circumference, body mass index (bmi), body composition, muscular strength, bone mineral density (bmd), international prostate symptom scores (ipss), international index of erectile function (iief)- scores, and serum prostate-specifi c antigen levels. th e safety and tolerability of long-term art were also examined in these populations. results: fift y-two weeks aft er the initial treatment, art signifi cantly aff ected the role physical subdomain of the short form- health survey (sf- ) scale (p = . ). art was also associated with signifi cant decreases in waist circumstance (p = . ) and serum triglyceride (tg) (p = . ) and with signifi cant increases in whole-body and leg muscle mass volumes (p = . and . , respectively), serum hemoglobin (p < . ), ipss voiding subscore (p = . ), and the second question on iief- (p = . ). th ere was no signifi cant deference between the groups in terms of bmi, bmd, isometric handgrip strength, serum fasting blood sugar and hemoglobin a c, serum psa, and the incidence of sever adverse events. conclusion: long-term art for patients with loh have the benefi cial eff ects on role physical subdomain of the sf- scale, serum tg, waist circumstance, muscle mass volume, voiding subscore of ipss, and the second question of iief- . we hope our study will contribute to the future development of this area. introduction and objective: hyperoxaluria is characterised by a high urinary oxalate level. super-saturation of urine with oxalate will lead to nucleation, aggregation and the formation of calcium oxalate crystals leading to renal calculi. patients with hyperoxaluria are at increased risk of recurrent urolithiasis. objectives: to analysis the interventions and outcomes of new patients with enteric and dietary hyperoxaluria referred to a metabolic stone clinic. an analysis of patients with hyperoxaluria was performed. data examined included; age, sex, metabolic abnormalities, malabsorptive syndromes, previous treatments, stone composition, medical and life style interventions. all patients had or more hr collections of urine performed at median of months apart. twenty-four-month follow-up was performed to assess need of further stone treatment. results: a total of patients were identifi ed for study. twenty-fi ve were male, were female. th e median age is years, iqr ( - ). first median urinary oxalate level is . mm, iqr ( . - . ). patients that reduced their oxalate intake and increased their fl uid intake were signifi cantly less likely to need further long-term stone treatment. th e arr of increased urinary output and decreased urinary oxalate on the need for further stone surgery is th congress of the sociÉtÉ internationale d'urologie -siu abstract book . %, ci (- . - . ) . th e rrr for the need of stone surgery is . %, ci (- . - . ) . th e nnt to prevent one patient needed further stone treatment is . , ci ( . -- . ) . conclusion: hyperoxaluria is important cause of recurrent stone formation that requires management in a dedicated metabolic stone clinic. compliance with fl uid, dietary and medical management is limited. in compliant patients, urine parameters and stone recurrence rates can be altered. clinical using specifi c diagnosis codes from billing data, patients were identifi ed that met criteria for urosepsis secondary to an obstructive ureteral calculi. data was analyzed in the following areas: demographics, admitting hospital of origin, duration of admission before transfer, need for higher level of care, need for invasive procedures, and length of hospital stay. results: using the screening criteria patients were identifi ed. th e average age was ; % were female versus % male. patients transferred from an outside hospital made up % of the patients and overall hospital admission lasted . days. of the patients transferred % went to the icu for an average duration of . days. of the transferred patients % needed vasopressor/ionotropic therapy, and % required intubation. overall, over % needed urologic intervention; % had ureteral stent placement and % underwent nephrostomy tube placement. patients admitted from the ed made up % of the patients and had an average admission of . days. of these patients % went to the icu for an average of . days. only % and % needed vasopressor/ionotropic therapy and intubation respectively. also, % had ureteral stent placement and only % had a nephrostomy tube placed. conclusion: urospesis in the setting of an obstructive ureteral stone is a medical emergency that merits urgent relief of the obstruction. once this condition is identifi ed, any facility without the resources for prompt intervention should transfer these patients immediately to a center with these capabilities. th is is supported by our data, as transferred patients on average had a longer icu and hospital stay, and needed more aggressive interventions. clinical signifi cance of ureteral wall thickness adjacent to the stone in abdomen-pelvis ct in the patients treated with extracorporeal shock wave lithotripsy park m, yeo j, cho d introduction and objective: although, ivp was standard diagnostic tool for years, the use of abdomen-pelvis ct (apct) without contrast, particularly in an acute setting, is becoming increasingly common. th is study was planned to know the clinical signifi cance of ureteral wall thickness adjacent to the stone in apct in the patients treated with extracorporeal shock wave lithotripsy (eswl). : th e data of patients who took ap-ct to diagnose ureter stone and were treated with eswl was reviewed. aft er maximum zoom of the ap-ct image showing the longest diameter of stone, the ureteral wall thickness adjacent to the stone was measured by same physician. th e baseline characteristics of patients, the parameters related to ureter stone and effi cacy of eswl were investigated. th e correlation between ureteral wall thickness and those parameters was statistically analyzed. th en, the patients were divided into two groups by the median value of ureteral wall thickness and the diff erence of those parameters between two groups was also investigated. additionally, cut-off value of ureteral wall thickness contributing to the diff erence in the effi cacy of eswl was determined. in simple correlation analysis, bmi, stone length at kub, stone diameter in ct, number of eswl, and time to stone removal showed signifi cant positive correlation with ureteral wall thickness. th e median value of ureteral wall thickness was . mm and the patients were divided into two groups. in comparison of baseline characteristics between two groups, group ii showed more incidence of pyuria than group i and stone burden at kub and ct also showed statistical diff erence between two groups. in comparison of effi cacy of eswl, group ii showed more number of eswl and longer time to stone removal than group i. th e cut off value of ureteral wall thickness contributing to the diff erence in the effi cacy of eswl was . mm. conclusions: in addition to actual size of stone, ureteral wall thickness of ct also aff ects the treatment effi cacy of eswl. especially, the ureteral wall thickness greater than . mm has an impact on the results of the eswl. the introduction and objective: th e treatment of large volume bladder stones by current equipment continues to be a management problem in both developing and developed countries. ah- stone removal system (srs) invented by us is primarily used to crush and retrieve bladder stones. th is study evaluated the safety and effi ciency of transurethral cystolitholapaxy with srs to treat the large volume bladder stone. materials and methods: srs, which was invented by aihua li in , composed by endoscope, continuous-fl ow component, a jaw for stone handling and retrieving, lithotripsy tube, handle, inner sheath and outer sheath. a total of patients with bladder stones were performed by transurethral cystolitholapaxy with srs since . th ese patients were divided into four groups by the stone size. fift y nine patients with stone size < cm were in group a, patients with stone size from to . cm were in group b, patients with stone size from to . cm were in group c, and patients with stone size ≥ cm were in group d and the largest stone was . cm. results: characteristics of patients and stone removal time in variable size were evaluated. to patients with single stone, stone size was . ± . cm and the operating time was . ± . min in group a. stone introduction and objective: eswl has emerged as a primary modality of treatment for solitary renal calculi in modern era. th e size of calculus is a major factor for consideration before subjecting a patient to eswl procedure. stone size less than two centimetre is considered ideal for eswl. other factors like obesity, position of calculus, renal infundibular anatomy and stone composition etc. also determine clearance rates. given a choice patients in india still prefer one time clearance by pcnl than multiple eswl sittings for similar sized calculus. our study reiterates the benefi ts of eswl in developing world with multivariate data supporting it. th e objective of this study was to evaluate the feasibility and safety of minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy for upper urethral calculus aft er radical cystectomy urinary diversion. a total of patients underwent minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy from january to august . th ere were cases that were diagnosed urinary stones aft er bricker urinary diversion of radical cystectomy, case of studer orthotopic ileal neobladder, and case of cutaneous ureterostomy. th ere were cases with left side calculi and cases with right side ones, including renal calculus, ureteral calculus and ureterointestinal anastomotic calculus. th e upper urethral calculi were identifi ed by urinary tract ultrasound and the multiplanar ct. all of cases underwent minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy. th e ureteral stent was indwelled for weeks routinely. th e kidney ureter and bladder x-ray or a ct scan was examined weeks aft er the procedure to evaluate the clinical outcomes. any residual calculus larger than mm was taken as signifi cant. results: th e combined lithotripsy was carried out successfully in all the cases. th e mean operative time was ( ± . ) min. th e nephrostomic catheter was removed days aft er the surgery. th e average blood loss was less than ml. no residual calculus was found during the weeks' follow-up. th e average follow-up was months. one case had recurrent calculus months aft er the fi rst procedure, which was successfully managed by the fl exible ureteroscopy again. minimally invasive percutaneous nephrolithotomy combined with fl exible ureteroscopy for upper urethral calculus secondary to urinary diversion aft er radical cystectomy is technically feasible introduction and objective: th e main goal of any intervention for urolithiasis is complete stone removal in order to achieve a stone free status. complete stone removal assures resolution of the immediate adverse outcomes of the stone disease, and prevents possible long-term complications such as pain, obstruction and stone growth. percutaneous nephrolithotomy is an eff ective procedure which is being considered as the gold standard in the treatment of large/complex renal calculi. reported stone free rates are up to %, probably refl ecting the level of experience, stone properties and equipment employed in the procedure. it is well established that higher incidence of residual fragments increases the complication rates and needs further interventions. th e main reason for failure of complete radiolucent stone clearance is inability to visualize the residual stones either by nephroscope or by fl uoroscopy. th e use of intraoperative ultrasound for assessment of residual radiolucent stones during percutaneous nephrolithotomy, will help to increase stone free rate. materials and methods: between sept. and sept. intraoperative ultrasound was used in cases of large complex radiolucent renal stones. results: it showed stone free rate % in patients, false negative in patients ( %) and there was diffi cult scanning in patients ( %). conclusions: th e use of intraoperative ultrasound for assessment of residual radiolucent stones during percutaneous nephrolithotomy, it will help to increase stone free rate. intravenous acetaminophen decreases sedation requirements during extracorporeal shockwave lithotripsy conclusion: th ere is benefi t in pre-operative administration of intravenous acetaminophen in reducing the dose requirements of sedative analgesic for satisfactory pain control during the procedure of swl under conscious sedation. introduction and objective: while most of the bleeding associated with pcnl can be managed conservatively, few need angioembolisation. th ere are diff erent technical methods of embolisation with risk of varying degree of parenchymal damage. we present case of ultrasonography guided embolisation. materials and methods: right lower calyx pcnl was performed successfully in year female with mm renal stone in solitary kidney. she came back on th postoperative day with gross hematuria, with cm by cm clot in renal pelvis and mm arterio-venous fi stula at pcnl puncture site. patient was managed with iv higher antibiotics, strict bed rest, blood transfusion and iv tranexamic acid. but her renal function deteriorated (creatinine- . mg/dl). one haemodialysis was done and patient was explored by sub costal approach, with idea of removal of blood clots and suture ligation of av fi stula. renal pelvis was opened and clots were removed. during operation av fi stula was located with doppler usg and deep suture by - vicryl was attempted to close av fi stula, but due to oedematous kidney suture closure was not possible. so under usg guidance gauze lumber puncture needle was inserted into av fi stula, its position was confi rmed by saline jet on real time usg and cc histoacryl tissue adhesive (monomeric n-butyl- -cyanoacrylate) was injected into av fi stula. intraoperative embolisation of av fi stula was confi rmed by colour doppler. results: renal functions became normal in hours and patient was discharged on th postoperative day. aft er days ivp was done which demonstrated normally excreting whole kidney, showing successful superselective embolisation in solitary kidney. conclusions: usg guided procedure avoids the side eff ects of contrast media in case of acute renal failure. it avoids hazards of radiation and complications of angiographic catheterisation. th e main importance of this procedure is preserving maximum renal tissue, especially in case of renal insuffi ciency and in solitary kidney. th is procedure gives a new vision to do percutaneous usg guided embolisation by thin gauze needle without need of angiography, iv contrast, radiation and minimum morbidity. ultrasound th ree pregnant women in the th, th and th week of pregnancy presented with a symptomatic large renal stone in the fi rst and multiple renal stones in the second and third which were unresponsive to conventional medical therapy. th ey required defi nitive stone treatment. th e operations were done in nov , jun and feb . data was gathered prospectively. all steps of gaining access to the pyelocalyceal system including needle insertion, tract dilation, and amplatz sheath placement were performed under ultrasonography guidance. tract was dilated with single shot technique. th e fi rst two procedures were performed in supine position and the third procedure was performed in lateral fl ank position. results: two patients were stone-free postoperatively and one patient had only an asymptomatic mm residual stone. th ey were discharged on the nd postoperative day and had an uneventful postoperative course. no fever, bleeding or renal colic was noticed during postoperative hospitalization. th e fi rst two patients delivered their fetuses at term without any abnormality reported by the examining pediatric specialist aft er their birth. th e third patient was followed until week of pregnancy without any obstetric complication. conclusion: ultrasonography can be used as an imaging modality guiding all steps of obtaining percutaneous access in pregnant women. supine or fl ank ultrasound guided percutaneous nephrolithotomy can be off ered to pregnant women in whom conservative measures fail to the patient's well-being. introduction and objective: acute ureteral obstruction in pregnancy may result in severe pain, hematuria and serious complications like upper urinary track infection with consecutive sepsis. th e ureteral stenting has been usual in recent years. we evaluated the usefulness of ureteral stenting for ureteral obstruction with symptoms in pregnancy. fift y-three pregnant women participated in this study. abdominal ultrasonography, serum creatinine levels, white blood cell (wbc) counts, urinalysis and urine culture were done in all patients. of these pregnant women, women were treated by ureteral stenting because of not improving with conservative management (positioning, analgesia, antibiotics, etc.). th ey were completely followed-up to removal of ureteral stent. results: of these pregnant women, women who were treated by ureteral stenting, experienced signifi cant relief of pain at least for days. in abdominal ultrasound, patients ( %) had resolution of hydronephrosis. twelve of patients ( %) continued to have problems post-therapeutically irritative voiding symptoms with dysuria, urgency, frequency, and hematuria, but patients experienced relief of symptoms for days. a patient was taken remove of stent due to continuous complaint irritative voiding symptoms. aft er delivery, patients were taken ivp. of patients, were normal fi nding with ivp. four patients were diagnosed ureter stone (upper , mid , lower ). th ree patients were treated by extracoporeal shock-wave lithotripsy for the stone in upper and lower urinary tract. a patient was treated ureteroscopic lithotripsy. conclusions: since the ureteral stents were usually placed without any major problems and well tolerated with only minor and short post-therapeutic discomfort. we concluded that the ureteral stenting was a simple, safe and eff ective method of internal upper tract drainage in case of symptomatic ureteral obstruction during pregnancy. safety introduction and objective: to evaluate objective and subjective outcomes of retrograde intrarenal surgery (rirs) for the treatment of radiopaque - mm renal calculi. a retrospective analysis was performed for patients who underwent rirs to treat renal calculi sized with - mm between april and december . operative and postoperative data were collected for each patient such as stone burden, stone location, number of sessions, and auxiliary procedures. th e term of follow-up was one year at least. surgery was usually performed under general anaesthesia. flexible ureteroscopy with ureteral access sheath and holmium-yag laser were employed. patients were evaluated with simple radiography, abdominal ultrasonography, or ct without contrast. surgery success was determined as stone free rate (sfr) at three months aft er last session. re-treatment rates were also calculated. results: mean age was . ± . years old. th e highest-frequency location was pelvis ( %). single stones were described in % of patients although multiple urolithiasis were detected in the %, mainly located in the lower calyceal. average surgery time was . ± . min. th e auxiliary procedure rate and the re-treatment rate were . % and . %, respectively. th e overall sfr and sfr aft er a single session were . % and . %, respectively. although no serious complications were noted in all of patients (above clavien-dindo classifi cation level iii), clavien level i to ii complications were identifi ed in two-patients ( . %). all these patients were successfully treated conservatively. conclusion: our fi nding suggest that rirs represents a valuable treatment option of - mm radiopaque renal calculi for selected patients. rirs would be also a good therapeutic alternative to extracorporeal shock wave lithotripsy (eswl) and percutaneous nephrolithotomy (pnl). rirs should be considered as fi rst line treatment. prospective analysis is required to be corroborated these fi ndings. ureteroscopic lithotripsy for extremely old patients yoshioka t , uehara s , otsuki h , shimizu t , murao w , fujio k , kikuchi h , fujio k , wada k , araki m , ebara s , watanabe t , nasu y introduction and objective: one of the biggest problems in st century is an aging society. in , the number of old people (≥ years old) in japan was , , . th at is about % of all japanese population. japanese society is becoming not an "aging" society, but an "aged" society, and we have to prepare for this society. on the other hand, upper urinary stone is a common disease, and oft en occurs not only young people but also aged people. however, there are no standard treatments for aged patients of upper urinary stones, especially extremely old patients who are more than years old. in this study, we investigate the safety and effi cacy of ureteroscopic lithotripsy of upper urinary calculi for these patients. between january and october , ureteroscopic lithotripsy (urs) underwent in abiko toho hospital. of these cases, cases are for the extremely old patients (≥ years old). we retrospectively reviewed gender, age, body mass index (bmi), american society of anesthesiology (asa) physical score, stone size, reasons for operation (whether symptomatic or not), operative duration, and stone free rate (sfr) of all cases. all data were reviewed by one urologist, and asa physical scores were evaluated by one anesthesiologist. results: all cases were bedridden female. mean age was . (range to ), bmi was . kg/ m^ (range . to . ), asa physical score was . (range to ). cases had preoperative complicated pyelonephritis, and out of these cases were indwelled preoperative unilateral ureteral catheters. mean stone size was . mm (range . to . ), and operative duration was . minutes (range to ). postoperative complication was pyelonephritis (clavien grade ), and sfr was % ( / cases). in all cases, postoperative unilateral ureteral catheters were indwelled, and were withdrawn weeks later. th ere have been no recurrent stones and/or pyelonephritis (median observation time: . months). conclusion: although sfr was low, urs for extremely old patients can prevent recurrent complicated pyelonephritis even on infected stones. th ere were . % of patients who had a single urinary stone and . % (n = ) had or more. one hundred and nine stones were treated. sixty-three percent of stones were intrarenal. th ere were ( . %) postoperative complications: two stage clavien classifi cation infections (prostatitis at day and two pyelonephritis hours aft er the procedure); three stage b complications (two renal colics requiring ureteral stenting hours aft er discharge and symptomatic perirenal urinoma hours aft er discharge). th ere was one intraoperative complication ( . %): a ureteral wound with contrast leakage. th e rate of transfer to conventional hospitalization was . %. stone size infl uenced the stone-free status and the need for more than one sessions (p < . ). th ere was a signifi cant correlation between operative time and stone size above mm (p= . ). conclusions: flexible and rigid ureteroscopy are safe and effi cient procedures for upper urinary tract stones, and can easily be carried out in an outpatient introduction and objective: renal stone disease is one of commonest urological disorders. pakistan is located in stone belt region with high incidence of urolithiasis. th ere have been innovations and improvement in stone treatment modalities. eswl is one of them. here we share experience of single centre in terms of stone free rate and effi cacy in adults. a retrospective study in which we included adults (age above years old) who underwent eswl from january to december . eswl was done by standard technique. we used modulith sl x lithotripter th generation storz medical. number of shocks per session for kidney and for ureter. energy level for kidney is set at and for ureter at . rate of shock wave delivery is shocks/minute. we followed patients for to months aft er last eswl session done. stone free status was defi ned as residual stone not more than mm in size. we reviewed data charts of patients for diff erent variables mentioned in results. introduction and objective: yolk-sac tumor (yst) is formed almost % germ cell tumors of infant and children. yst is the most common type of testis tumors in prepubertal period, but adult pure yst is extremely rare. in this case we aim to share our surgical experience with an adult pure yst in the right testis. a year-old man was referred to our clinic from cardiovascular surgery department for right testicular mass which is detected during the evaluation of his deep vein thrombosis. th e patient stated having a slowly progressive increase in size of his right gonad. th ere is no history about testicular trauma or epididymoorchitis. physical examination revealed a painful right testis which was uniformly increased in size and presented a smooth surface. usg showed a volumetric increase in the right testis. mass size was detected as . x . x cm, which was characterized by cystic components in heterogeneous echogenicity. serum chemistry revealed a marked increase in afp while β-hcg and ldh levels were within the normal limits. results: a right radical inguinal orchiectomy was performed. during the orchiectomy, because of the invasion to scrotum skin, scrotum skin was removed. th e surgical specimen was rigid, its surface was smooth and necrotic areas were observed ( figure ). pathologic examination revealed a pure yst with positive spermatic cord, tunica albugea, tunica vaginalis and scrotum skin invasion and in light microscopy tumor cells with large hyperchromatic nuclei arranging concentrically around a small vessel were seen (schiller-duval or glomeruloid body). metastasis of lung adenocarcinoma to the testis is an extremely rare occurrence and very few cases have been reported to date. th e authors aim to review the current literature in regard to incidence, clinical manifestation, sources of primary tumour and mechanism of metastasis, in addition to retrospective ten year review of testicular pathology at a single institution. we report an unusual case of a -year-old non-smoking australian gentleman who presented with a six month history of cough and dyspnoea. a physical examination, complete laboratory and radiological work up was performed. a palpable left testicular mass was identifi ed, ct scan revealed multiple bilateral lung nodules and mediastinal lymphadenopathy, however testicular tumour markers were negative. th e patient underwent a radical left inguinal orchidectomy and endobronchial hilar lymph node biopsy with bronchial washings. medical records and pathology results for patients undergoing radical orchidectomy over the past ten years at our institution were obtained and analysed. results: histopathological examination of the left testis and lung biopsy revealed features of a moderately to poorly diff erentiated adenocarcinoma, with morphological and immunohistochemical appearances consistent with lung origin. th e prognosis is extremely poor. a total of patients underwent radical orchidectomy at our institution between january and february . th e mean patient age was ( - ). histopathology is summarised in table . cur-up. , figure . th congress of the sociÉtÉ internationale d'urologie -siu abstract book rent literature review confi rms testicular metastases are rare and may be discovered incidentally at autopsy or following diagnostic orchidectomy. autopsy series revealed testicular metastases in . to . % of specimens. th e most common primaries, excluding lymphoma and leukaemia, include prostate, melanoma, sarcoma, gastrointestinal tract, kidney and lung, with most testicular metastases being a fi nal manifestation of widespread tumours. conclusions: testicular metastases from lung adenocarcinoma origin are scarcely encountered in clinical practice and may create a diagnostic dilemma by mimicking primary testicular neoplasms. extensive pathologic evaluation and specifi c immunohistochemical staining is essential. in patients presenting with a testicular mass, the diff erential diagnosis must include metastatic carcinoma. by . on average compared to only . by non-users (p= . ). many of these fi ndings were only present with recent vge; heavy users from high school and middle school did not show similar trends (table ; figure ). conclusion: th is study shows that subjects with heavy vge perform better on the da vinci skills simulator than subjects who report no vge. th e improvements seen with recent vge are not apparent if stratifying for frequency of use during high school and middle school. th ese fi ndings may have important implications for the future of surgical training. 'virtual urology clinic': a feasibility study in a busy uk teaching hospital introduction and objective: urology is an advancing surgical specialty with a parallel increase in demands from health service commissioners to meet national targets and patients' needs. th is has been refl ected on the outpatient urology service with a rising burden and delays in patients' outpatients' assessments. in our busy tertiary unit, we estimated a total of overdue outpatient appointment (by months or more). th us we designed this virtual clinic feasibility study aiming to: prioritise patients according to their clini- cal needs, enhance their care and decrease the burden by assigning patients to our novel computer based follow-up models. we used the hospital information system to identify one urologist overdue appointments (by months or more). all included cases had thorough review of their medical notes, investigations and treatment before being stratifi ed according to their diagnosis then assigned one of outcomes: urology, cancer nurse specialist (cns) and gp follow-up. results: a total of cases were reviewed in this virtual clinic over a period equivalent to full working days. even though they were all waiting to see one urology cancer surgeon, only % had a primary diagnosis of cancer with the rest being diagnosed with a benign urological condition. th e clinical investigator recommended for only % of all patients to have a urology follow-up with % and % discharged to the gp and computer based follow-up respectively. all patients received a letter explaining the procedure of this clinic along with a tailored management plan. th ere was an evident gap between the dynamic changes in service provision with new available tools and our current practice. th is virtual clinic allowed bridging this gap by categorising the urological priorities and utilising existing resources such as our novel computer based follow-up models. over the last year more than patients' visits have been registered on our computer based clinic which is potentially a cost eff ective model. patients' perspectives of accessibility introduction and objective: patients undergoing major lower abdo/pelvic operations are oft en catheterised (idc) at the start of the procedure to monitor urine output and decompress the bladder to avoid bladder injury. early removal of urinary catheters aft er surgery has been associated with a decrease in urinary tract infections though increasing failure of trial of void (tov), thus being discharged with idc or prolonged admissions. th e aim of this study is to determine the optimal time for tov. th is is a retrospective study looking at patients undergoing abdominal or pelvic procedures due to colorectal/pelvic pathology in the townsville base hospital surgical unit from jan -dec . pre-procedure idc and the deceased were excluded. data was collected from the operating theatre database (ormis). results: out of the total, were female while male, abdominal and pelvic procedures. sixteen male patients had documented prostatic history which include bph, prostate cancer and prostatitis post radiation. four were discharged with an idc failing tov. fift y-seven percent of the patients had their catheters removed on day post-op; . % on day , % on day , . % on day and % > days. th ree patients developed a urinary tract infec-tion (uti) ( . %). patients with good pre morbid function and female tend to pass their trial of void on day post op for pelvic procedures. th e majority of patients had comorbidities and failed tov on day . th ere was no signifi cant diff erence between day and day in uti rates (increasing day onwards). conclusions: idc's should be removed in a timely manner to reduce complications, balanced with monitoring fl uid balance. we proposed that patients should have tov on day , due to increased rates of failed tov day in patients with comorbidities and no diff erence in uti rates between days and . th e limitation of this study is the lack of documentation of preoperative urinary function. to further this study, we can analyse the data to state diff erences between bladder dysfunction as well as tov in groups with various comorbidities. international urology journal club on twitter: a growing educational forum introduction and objective: urologists use urinary and thoracostomy drainage collection systems regularly. pleural and urine fl uid pools at the bottom of dependent loops of both thoracostomy and urinary drainage tubing systems, respectively. we hypothesized that fl uid pooled in a dependent loop ) diminishes the expected negative pressure-head delivered to the pleural space by a chest-tube, and ) obstructs antegrade catheterized urine drainage. we created an ex-vivo thocacostomy tube model, and, performed two separate clinical trials to test our hypothesis. a pleur-evac chest drainage system was connected to - cmh o wall-suction. a digital pressure transducer was connected to the drainage tubing close to the insertion of connection to a chest-tube. model: to simulate dependent loops observed in hospital patients, we created , , and cm-high dependent loops (distance between the bottom of loop and the highest-point en-route to the drainage box). th e pressure close to the (blind-ending) chest-tube was measured as the drainage tube was fi lled in ml. increments. fitted linear regression of pressure and loop-height was performed. clinical trials # . pressure within the drainage tube was measured in six icu patients with thoracostomy tubes in place following cabg surgery. clinical trial # : we performed early-morning hospital icu bedside bladder-scan us on patients with an indwelling urinary catheter and clear urine, to assess for un-drained residual urine. results: with an empty dependent loop, thoracostomy tube pressure equaled the suction pressure (- cm h o). pooled of fl uid within the dependent loop diminished proximal negative pressure (p< . ) in a volume (i.e. loop-height) dependent fashion. th e net range of proximal drainage tube pressure ranged from - to + cmh o. in icu patients, an identical relationship between loops and chest-tube pressure was observed. bladder scan of catheterized ward patients revealed high urine residuals (mean ml) with a dependent loop present, and ~zero residual when no loop present. conclusions: th oracostomy-tube negative-pressure is steadily diminished as a dependent loop fi lls with fl uid. th e resulting air-lock opposes antegrade drainage. th e weight of the fl uid column accounts for positive thoracic pressures, and could account for why many patients fail water seal trials. similarly, urinary tubing dependent-loops result in air-locks that prevent gravity dependent drainage. th oracostomy and urinary drainage tubing should always be positioned without dependent loops. single incision mid-urethral sling (miniarctm) and tension-free vaginal tape (tvt) procedure in women with stress urinary incontinence (sui) at months. a total women with sui were randomized to receive miniarc and tvt. th e primary outcomes were objective and subjective cure rates at a -month follow-up visit. objective and subjective cure of sui were defi ned as a negative cough stress test and absence of self-reported sui symptoms. cure rates of the two groups were compared at -month follow-up. results: a total of ( %) of women originally included in the study (miniarc: , tvt: ) were evaluated at -month follow-up. th ere were no signifi cant diff erences found in demographic and clinical preoperative parameters. objective cure rates for miniarc and tvt groups were % and % while subjective cure rates were % and %. th ere was no statistically signifi cant diff erence between groups (p> . ). conclusions: our -month randomized clinical trial showed that miniarc single incision sling is not inferior to tvt procedure with respect to objective and subjective cures at -month follow-up. introduction and objective: male sui is a debilitating and challenging problem to manage. insertion of transobturator sling off ers less invasive treatment than aus insertion. published data demonstrate cure rates of % but are limited by short follow-up. th e aim of our study was to report long-term outcomes for male transobturator slings for sui with a mean year (minimum year) follow-up. a single-centre retrospective audit of outcomes in male patients who underwent transobturator sling insertion for sui. follow-up was conducted via telephone or in outpatient clinic. incontinence was classifi ed as mild (≤ pads/day), moderate ( - pads/day) or severe (≥ pads/day). classifications post-surgery were: cured -dry; improved -≤ pads/day and ≥ % less pad use; failure -no change or worsened. results: in patients with mild/moderate incontinence, / patients (= . %) were cured/improved with tot. success rates were poor in severely incontinent patients, regardless of radiotherapy history ( %; n= ). of 'cured'/'improved' patients, ( . %) maintained that degree of continence for the duration of follow-up. one patient was lost to follow-up. th ree patients reported a later decline in continence; patients had had previous pelvic radiotherapy. one patient had progression of underlying prostate cancer. conclusion: durable success rates of . % are achievable in men with mild/moderate sui who have not had pelvic radiotherapy. pelvic radiotherapy may play a role in delayed failure of tots with % of patients with mild/moderate sui who were initially cured/improved declining in the second or third year aft er surgery. the mesh wallstent (urolume) in the treatment of detrusor external sphincter dyssynergia in men with spinal cord injury dept. of surgery, div. of urology, king saud university faculty of medicine, riyadh, saudi arabia introduction and objective: to evaluate the longterm effi cacy and safety of the urolume stent for the treatment of detrusor sphincter dyssynergia (dsd) in spinal cord injured (sci) patients. twenty-four spinal cord injured patients with neurogenic bladder and dsd associated with high detrusor pressures and incomplete emptying on pre-operative video-cystometrograms (vcmg) were retrospectively reviewed. twenty-one patients had cervical level injury whilst had a thoracic injury. eleven patients were on clean intermittent catheterization (cic) and with indwelling foley's catheter. all patients underwent urolume stent insertion according to standardized protocol. follow-up assessment included blood chemistry, ultrasound scan (upper tracts and residual urine) at one and three months aft er insertion, and a follow-up vcmg at six months. residual urine volume, autonomic dysrefl exia, catheter need, and presence of bladder stones and hydronephrosis were compared before and aft er treatment. post-operative patient and physician satisfaction, complications and re-obstruction rates were also analyzed. paired t-test is used and p value < . was taken as signifi cant. results: th e twenty-four patients had a mean (range) follow-up of . ( . - ) years. th e mean age was introduction and objective: at present, sacral neuromodulation (snm) with interstim® therapy is indicated for non obstructive urinary retention and overactive bladder, including urinary urge incontinence and signifi cant symptoms of urgency-frequency alone or in combination, in subjects who have failed or could not tolerate more conservative treatments and do not have any neurological disorder. th ere are also reports of the use of interstim® in the treatment of chronic pelvic pain and other conditions. we report our experience with the use of this device in patients with post-traumatic brain injury damage without anatomical anomalies and with severe urinary voiding dysfunction who had failed intensive medical and behavioral therapies. materials and methods: from november to november , patients underwent interstim® placement ( male and female). all had severe voiding dysfunction secondary to post-traumatic brain injury damage; ten of them had also defecatory disturbances ( a chronic constipation and fecal incontinence). th e main goal was to evaluate the improvement of the urinary symptoms and the second goal the improvement of the intestinal symptoms. success was defi ned as a ≥ % improvement in any of the two variables evaluated. results: with a mean follow-up of months, / patients reported ≥ % improvement in their urinary voiding symptoms ( %), in these patients urinary frequency decreased from to episodes per day, mean voided volume increased from cc to cc, incontinence disappeared in of patients and urgency disappeared in all patients. of patients with intestinal disturbances, showed a signifi cant improvement ( %). one patient showed a clavien iii complication (seroma and partial dehiscence of the surgical wound managed with conservative surgical treatment). conclusion: snm in post-traumatic brain injury patients is an eff ective and safe option for urinary and defecatory dysfunction when other conservative therapies have failed. to our knowledge the use of inters-tim® in this scenario has not been reported previously. a larger series and a longer follow-up are needed to validate this indication. introduction and objective: th ere were some reports that in the patients who have stress incontinence (sui) with detrusor underactivity, voiding symptoms aggravated aft er mid-urethral sling operation (mus). we report our experiences of mus cases on the patients who have sui with detrusor underactivity. conclusion: urethral sphincter and bladder function worsen immediately aft er rarp and recover over time. th e bladder storage function aft er rarp returns to almost the same level before rarp, the voiding function improves compared with the condition inserted into the rabbit bladder through the urethra and saline solution is infused using a disposable syringe into the bladder through the end cap. conventional cystometry was performed and the intravesical pressure was measured by prototype intravesical pressure sensor at the same time. we also evaluated the biocompatibility of ecofl ex® by checking changes in the levels of macrophages, macrophage migratory inhibitory factor, and infl ammatory cytokines in the bladder tissue and urine. cape town, south africa th congress of the sociÉtÉ internationale d'urologie -siu abstract book and urgency incontinence are signifi cantly detected luts in children with vur the -gene genomic prostate score assay: initial commercial experience of , patients th congress of the sociÉtÉ internationale d'urologie -siu abstract book th congress of the sociÉtÉ internationale d'urologie -siu abstract book pelvic strength physiotherapy percutaneous treatment of bladder stones in children: -year experience; is blind access safe? extirpative treatment of upper urinary tract urothelial carcinoma: an -year comprehensive review paik l th e overall complication rate was %. no hydronephrosis were seen thought the follow-up period. stricture rate was low, only one patient ( %) at one year, and none at years had urethral stricture. patients ( %) required re-stenting due to stent migration ( patients, %), or stricture ( patient, %), all of which happened during the fi rst year of surgery. patients ( %) required alpha-blockers to control bladder neck dyssynergia post operatively. stents ( %) were removed due to exacerbation of autonomic dysrefl exia symptoms (n = ); encrustation and stone formation (n = ). overall, % of patients and % of physicians felt there was improvement in urination at year. conclusions: th e treatment of detrusor sphincter dyssynergia in spinal cord injured patients with urolome stent is safe and eff ective sacral neuromodulation with interstim® therapy for urinary voiding dysfunctions in post-traumatic brain injury patients: a new therapeutic indication? hospital pablo tobon uribe, medellin, colombia th congress of the sociÉtÉ internationale d'urologie -siu abstract book between pre-and post-operative qmax abstract book before rarp; however, the urethral sphincter func male ( . %) ( %) . ** introduction and objective: we evaluated the clinical eff ect of alternative fl utamide therapy for metastatic prostate cancer that relapsed aft er initial maximum androgen blockade (mab), and investigated the relationship between the eff ectiveness of alternative fl utamide therapy and the eff ectiveness of initial mab. and december , patients with metastatic prostate cancer that relapsed aft er initial surgical or medical castration along with bicalutamide for mab were treated with fl utamide therapy ( mg daily). importantly, patients who had discontinued bicalutamide because of adverse events were excluded.results: of the patients treated with alternative fl utamide therapy, prostate-specifi c antigen (psa) levels decreased by > % (group a) in patients ( %), by - % (group b) in patients ( %), and by - % (group c) in patients ( %), but increased by > % in patients ( %). th e median duration of response was . , . , and . months for groups a, b and c, respectively. th e duration of response for patients ( %) was more than months. aft er alternative fl utamide therapy, decreased psa levels of > % were achieved in of patients ( %) with mab nadir psa levels of < . ng/ ml, in of patients ( %) with mab nadir psa levels of . to ng/ml, and in of patients ( %) with mab nadir psa levels of > ng/ml. during the observation period there were no severe side eff ects.conclusion: approximately % of patients with metastatic prostate cancer who relapsed aft er mab with bicalutamide achieved a decrease in their psa level with no severe side eff ects. th e nadir psa level during mab, however, was not a predictor for the eff ectiveness of alternative fl utamide therapy. th us, alternative fl utamide therapy is a reasonable treatment option for metastatic castration resistant prostate cancer. nevertheless, changing to another therapy should be considered in patients who achieve decreases in psa levels of < % with alternative fl utamide therapy, as the duration of response was relatively short in these patients. association of renal function and androgen deprivation therapy with prostate cancermasuda h, kanesaka m, sugiura m, hou k, araki k, kojima s, naya y introduction and objective: we evaluated the change of renal function by androgen deprivation therapy (adt) and examined the association of the occurrence of renal dysfunction and concomitant diseases. between january and april , patients who could measure estimated glomerular fi ltration rate (egfr) at pretreatment, , and months were evaluated retrospectively. all of them were diagnosed prostate cancer by prostate biopsy pathologically and had taken adt for at least months. we assessed the renal function of prostate cancer patients by using the egfr and investigated the time-independent change rate of the egfr (Δegfr) aft er adt. th e Δegfr was calculated by (post treatment egfr-pretreatment egfr)/pretreatment egfr × ). univariate and multivariate logistic analyses were carried out to identify clinical covariates signifi cantly associated with the risk factors for renal dysfunction at months later.results: th e incidence of the renal dysfunction at months was % ( / ). th e mean Δegfr at , , months were - . %, - . % and - . %, respectively (p= . ). th e incidence of the renal dysfunction at months was signifi cantly associated with the renal dysfunction at month (p< . ), at months (p< . ), hypertension (p= . ) and dyslipidemia (p= . ). th e renal dysfunction at pretreatment with adt did not aff ect the renal function months later (p= . ). th e renal dysfunction at months (odds ratio [or] . , p= . ), renal dysfunction at months ([or] . , p= . ), hypertension ([or] . , p= . ) and hyperlipidemia ([or] . , p= . ) were independent predictors of the renal dysfunction at months in the multivariate analysis.conclusions: it was suggested that the renal dysfunction with adt occurred relatively early. th e earlier renal dysfunction may cause the renal dysfunction at months later. so, when the treatment of adt began, it was thought that an examination of periodical renal function was necessary. th e present results suggested that it was necessary to control the blood pressure and lipid for receiving adt with prostate cancer. immune (pc) and isolated lymph node metastases aft er curative therapy are usually treated with an anti-androgen therapy. th e choline pet-ct is the method of choice in diagnostic of the recurrent psa. controver-sial in the latest debate is the oncological eff ectiveness of the local salvage therapy of isolated lymph node metastases. th e aim of this study is to compare the oncologic outcome of the salvage lymphadenectomy (la) alone versus the la in combination with adjuvant radiotherapy (ar) and androgen deprivation therapy (adt).materials and methods: th erefore we randomized patients with biochemical recurrence of a pc (psa: ≥ , ng/ml) aft er curative local therapy and detection of at least one lymph node metastasis. we applied two treatment arms. a (n= ): single la; b (n= ): la plus ar/adt (bicalutamide) over years. we determined the biochemical recurrence-free survival (bfs) and the time-to-treat (ttt) until complete androgen blockade. conclusion: compared for both treatment arms, the combination of la plus adt/ar is superior to la alone. however, both methods are to be seen as individual decisions in highly selected patients. th e oncological long-term eff ectiveness is questionable. stem cell transformation of prostatic cells after hormonal therapy we reviewed consecutive patients who underwent transperineal mri-trus fusion target biopsy followed by conventional transrectal systematic core biopsy between july and mar in our institution. in all patients, t low region was detected by prostate mri image and target biopsy was conducted for region of interest (roi) of the mri image utilizing biojet system. baseline characteristics and pathological outcome were analyzed.results: in analyzed cohort, mean age was . ± . years, median initial psa was . ng/ml (range, . - . ), median prostate volume (pv) was . ml (range, . - . ) , and median volume of roi was . ml (range . - . ). of patients, prostate cancer was detected in ( %) patients by target biopsy and ( %) patients by systematic biopsy. patients with positive biopsy was likely to be higher psa than men with negative biopsy (p= . ). median roi/pv was not signifi cant between them ( . vs. . : positive vs. negative, p= . ). cancer detection rates per core between target and systematic biopsy were . and . %, respectively (p= . ).regarding pathological results, mean gleason score of target biopsy was . compared with . of systematic biopsy, although which is not statistically signifi cant (p= . ).conclusion: mri-trus fusion target biopsy is gradually spreading in japan, since its higher cancer detection rate compared with conventional systematic biopsy. in our institution, substantial detection ability of prostate cancer by mri-trus fusion target biopsy was confi rmed, which encouraged future clinical trial for prostate focal therapy. multiparametric introduction and objective: sepsis has always been a concern in the traditional transrectal ultrasound (trus) guided biopsy of the prostate. however, rates of sepsis following trus biopsy have shown to be increasing around the world in addition to the emergence of multiresistant organisms found in rec-tal fl ora. as a result, our practice of seven urologists has switched to transperineal (tp) biopsy. we aim to determine the rate of hospital re-admission in our patients undergoing tp biopsy. an ethics approved prospective database of all men undergoing tp biopsy at our practice has been kept including antibiotics used as well as re-admission for infection. introduction and objective: robot-assisted radical prostatectomy (rarp) has become one of standard treatments for localized prostate cancer. however, a feasibility of rarp in elderly patients has not been clear yet. we performed a comparative analysis of peri-surgical / oncological outcomes for younger and elder patients underwent rarp. we reviewed and compared our initial consecutive patients who underwent rarp from / to / for peri-surgical outcomes, including surgical times, blood loss, complications, pathological fi ndings, continence recovery, and oncological outcomes stratifi ed by age less than and over years.results: in our cohort, men were age less than and men were ≥ . preoperative parameters (age, psa, gleason score) were similar in both younger and elder groups. operative time (mean: vs. minutes) and estimated blood loss were similar in both groups. one of elder patients ( . %) needed transfusion. peri/post-operative complications in both groups appeared to be minimal with no cases of intra-operative open conversion. one of younger patients needed a surgical settlement for port site herniation. surgical positive margin rates in organ-confi ned (pt ) disease were also similar ( . %, younger vs. . %, elder). continence at months was % in elder patients as opposed to % in younger patients. biochemical recurrences in short follow-up period (median vs. months) were observed . % in elder patients as opposed . % in younger patients.conclusions: in our study, although urinary continence recovery in elderly patients might show a short delay, rarp in elderly patients was relatively safe and yielded good oncologic results. rarp is feasible eve in elderly patients. quality in the fi rst study, community-based urologists ordering at least assays from / to / participated. clinicopathologic data, the gps and treatment were abstracted from medical records of gps patients and a clinically similar baseline group. th e proportion of men recommended and pursuing active surveillance (as) before and aft er the availability of the gps were computed. in the second prospective study, urologists at centers (academic and community) recorded tr on pre-and post-gps questionnaires, including changes in treatment intensity.results: fift een urologists completed the chart review study on men ( gps; baseline). th e relative increase in tr for as was %, ( % baseline, % gps; absolute diff erence of %). gps pts chose as more than baseline pts ( % gps; % baseline, absolute increase of %, relative increase of %). of men recommended as, % of gps and % of baseline pts chose it. in men in the prospective study, the relative increase in recommendation for as was % and absolute tr increase for as was also % ( % to %). % of tr changed post-gps and tr modality and/or intensity occurred in % of men ( decreased; increased; equivocal).conclusions: both studies, conducted with diff erent methodologies, demonstrate that use of gps provides meaningful change in tr and decisions in men with newly diagnosed pca and results in a net increase in recommendation and/or adoption of as. in the chart review study, tr changes appear to underestimate changes in actual treatment received and more gps patients than baseline patients were assigned to as supporting the clinical utility of gps in the initial assessment and management of men with low risk pca. comparison we prospectively evaluated in patients with clinically localized prostate cancer, the possible association between hce (≥ . mmol/l) and aggressive prostate cancer. pre-operative serum cholesterol levels (ch), triglycerides (tr), were prospectively assessed in men treated consecutively with radical prostatectomy from feb. to oct. . th e results were related to patient specifi c and clinico-pathologic data.results: patients with hce (n= ) had a more aggressive grade gleason score (gs) ≥ b, p< . )), a locally more advanced stage (≥pt a, p< . ), and lymph node metastasis (n+, p< . ). hce was also associated more frequent with a positive surgical resection margin (r , p< . ). in multivariate regression analysis hce is associated with a high-risk pc (hr . , % ci . to . , p < . ) -adjusted for psa, dre, age and poor biopsy score (gs ≥ ).conclusion: th e results indicate that hca is associated with high-grade and metastatic disease in men diagnosed with clinically localized pc. our fi ndings suggest that ch can be used as an additional predictive marker in therapy. conclusion: th e incidence of bs-positive tumours is low in men being staged for radical treatment except in high-risk disease. pelvic/prostate mpmri alone cannot be relied upon to exclude bone metastases in this group. hyperbaric oxygen therapy for radiation induced side-effects introduction and objective: to evaluate the effi cacy of hyperbaric oxygen (hbo) th erapy for prostate conclusions: in our japanese provincial hospital, the comparatively young patients chose a treatment according to treatment algorithm. however, according to aging, the patients tended to choose hormonal therapy regardless of algorithm. as for one of the reasons, it is thought as follows: even if the patients chose operation or radiotherapy, it may be diffi cult to visit the institutions that have such a treatment because public transport does not develop in our prefecture. nurse-led telephone follow-up for prostate cancer surveillanceturner b, tanabalan c, nargund v, pati j, wells p introduction and objective: we review the patients' experience of a nurse-led, telephone follow-up service for men with 'stable' prostate cancer, to measure satisfaction and quality. th e telephone follow-up service is based on the premise that psa measurement can be used as a surrogate for outpatient attendance. telephone follow-up service serves to reduce the number of patients attending hospital appointments. th is has led to increased clinic capacity and reduced waiting times, ensuring urgent care is available for patients who need it. a nurse-led, protocol based telephone follow-up service was set up for patients deemed to have 'stable' disease. questionnaires were sent to all patients. survey was voluntary and anonymous. we addressed a variety of aspects of the service, including time, duration and content of the telephone appointments, patients' preference for type of follow-up (telephone vs. hospital follow-up) and overall satisfaction with the service.results: response rate of %. reported high satisfaction with telephone follow-up ( % were either satisfi ed or very satisfi ed). majority of patients found the length of the conversations to be 'just right' ( %) with a lesser majority expressing that the calls were always at times convenient to them ( %) and that they were always called when they were told they would be called ( %). patients felt that the information given to them over the phone was always easy enough to understand ( %) and the majority felt that they always had the opportunity to ask questions during the conversations ( %). when asked whether they would prefer telephone follow-up or hospital follow-up, % of respondents reported that they would prefer telephone follow-up, citing convenience, time and privacy as the reasons for their preference. twenty-one percent of patients would prefer hospital follow-up, reporting ease of understanding, not liking the telephone and preference for face to face contact.conclusions: telephone follow-up relieves pressure on the outpatient department, increases capacity, reduces waiting times and brings care closer to home. patients perceive the service as a valuable addition to their care and report high levels of satisfaction with the service. prostate ' th e target sample sizes of australasian trials 'currently recruiting' ranged from to men (median= ), the majority of trials investigating medical and radiation oncological interventions. five of the trials 'currently recruiting' were recorded as single-centre studies in new south wales, victoria and queensland. of the remaining trials, % (n= ) were recorded as international, industry sponsored, multi-centre studies with australian and/ or new zealand recruitment sites.conclusion: australasian prostate cancer clinical trial activity (though likely under-recognised in this study, due to trial registration limitations) represents a relatively small fraction of international eff ort. continued investment will ensure that the talented and world-leading scientists and medical professionals across both nations can tackle the big challenges in prostate cancer through working collaboratively. assessment modifi ed laparoscopic intravesical nonrefl uxing ureteral reimplantation with psoas hitch using a submucosal tunneling introduction and objective: we aimed to study the safety and effi cacy of the cystoscopy-assisted nonrefl uxing ureteral reimplantation technique using sub-mucosal tunneling during laparoscopic ureteroneocystostomy (unc) with a psoas hitch in patients with distal ureter stricture aft er gynecologic surgery. we reviewed six female patients who underwent gynecological surgeries. all patients showed persistent postoperative distal ureter stricture or obstruction. th ese patients underwent laparoscopic nonrefl uxing unc with a psoas hitch using a submucosal tunneling technique combined with cystoscopy at our institute.results: th ey had corrective surgery at an average of . weeks aft er ureteral injury. th e short-term success was confi rmed either by voiding cystourethrography (vcu) or by diuretic isotope renal scan (mag- ) conducted months aft er the operation. none of the patients showed evidence of postoperative stricture at the reimplanted site and refl ux on either mag- renal scan or vcu. none of the patients showed major or minor complications during follow-up. it is safe and feasible to perform the laparoscopic nonrefl uxing unc with a psoas hitch using a submucosal tunneling technique combined with cystoscopy for ureteral stricture. upper ureteral injuries were more frequent in the urological surgery group than in the non-urological surgery group ( % vs. . %). complications or serious injuries were more frequent in the urological surgery group. th ere were no signifi cant diff erences in the mean durations of hospitalization and indwelling times between the groups. conclusion: th e occurrence of a ureteral injury during urological surgery is an infrequent but serious complication may occur. urologists should pay attention to the potential for ureteral injury, especially during a ureteroscopic ureterolithotomy for the treatment of an upper ureter stone. reducing the risks of trauma due to urethral catheterisation mundy a, yim i, tamini a, roberts n conclusion: isolated ureteric trauma can be managed successfully using minimally invasive endoscopic and radiological approach. a pcn initially helps in minimizing extravasation and ureteral wall edema subsequently facilitating stent placement. medium-and long- university of sydney, sydney, australia introduction and objective: urethral stricture is a common urological presentation for obstructive lower urinary tract symptoms. th e treatment of choice for a durable outcome is usually substitution urethroplasty using buccal mucosal graft . graft failure is not uncommonly encountered. we present the mediumand long-term outcomes of ventral buccal mucosal graft urethroplasty using spongio fl ap technique. a retrospective review of a single surgeons experience was reviewed for a period of years. data was collected from medical records, surgeon's notes and operation reports. inclusion criteria included reconstruction of anterior urethral stricture using bm graft positioned ventrally and graft support using spongio fl ap technique. patients who were lost to follow-up were excluded from analysis. graft patency was defi ned as having a lumen greater than fr. th is was assessed via cystoscopic examinations at , and months intervals post procedure.results: a total of male patients identifi ed with age ranging from to years and mean age of years. average length of bm graft used was . cm. total of ( %) achieved long-term successful outcome. of these ( . %) patients had successful outcomes with no further interventions, and ( . %) required gentle urethral dilatation at fi rst cystoscopy and subsequently achieved long-term patency. sixteen ( . %) of this cohort formed recurrent stricture at initial cystoscopy, and ( . %) of patients formed urethral stricture formed delayed stricture, despite the initial cystoscopic examination and urethral dilatation.conclusion: ventral buccal mucosal graft urethroplasty using spongio fl ap technique has very good short-term and long-term graft patency outcomes. outcome of paediatric kidney transplantation: single center experience nawaz g, jamil i, athar khawaja m, muhammad s, shohab d, ur rehman a, ali khan i, khan a, hussain i, akhter s introduction and objective: renal transplantation is the treatment of choice for children with end-stage renal disease (esrd) because in addition to making them off dialysis it also improves growth and development of the child. about - % of children have a lower urinary tract dysfunction due to congenital or acquired genitourinary anomaly as the etiology of esrd and they need a diversion or augmentation procedure prior to transplantation. we aim to deter-mine the outcome of paediatric renal transplant at year in term of graft survival and complications. we retrospectively reviewed the record of consecutive children underwent living related renal transplant between jan to jan . all were primary renal transplants and had living related renal donors. patient characteristics, causes of esrd and pre transplant surgical procedure were recorded. patients with lower tract abnormalities as cause of renal failure underwent reconstructive procedure prior to transplant. induction immunosuppression consisted of triple therapy with antithymocytic globulin (atg), prednisone and mycophenolate mofetil (mmf). cyclosporine was introduced when creatinine came down to > % of normal. all patients were treated as cmv positive with either acyclovir or ganciclovir and received daily dose of trimethoprim-sulfamethoxazole as prophylaxis for pneumocystis carnii pneumonia aft er transplantation. post transplant surgical and medical complication, graft and patient survival were recorded.conclusion: ureteric implantation into the bowel portion of augmented bladders appears safe in this population of patients with previously reported increased risk of ureteric complications and urinary tract infections aft er transplantation. transition of cavernous function after radical prostatectomy materials and methods: study subjects were ed patients with a history of rp (median age: ). intervals between rp and examination diff ered among patients (range: to months). we also performed doppler penile ultrasound examination using intracavernous injection of micrograms of prostaglandin e . we adopted an infusion rate of less than ml/min at mmhg of intracavernous pressure as the normal cavernous function limit for dicc.results: arterial velocity in ultrasonic examinations showed a tendency to decrease. cavernous function aft er rp clearly diff erentiated according to phospho-diesterase inhibitors (pde is) response ( figure ). in the pde is responder patient group ( cases), the rate of normal cavernous function was % at month, months, and months, but the rate increased to % at months, and % at months. a diff erent transition was seen in the pde is non-responder patient group ( cases). in this group, the rate of normal cavernous function was also % at month. however, from here, the rate increased to % at months, and then aft er this point, it decreased to % at months. sixteen -week-old sprague-dawley rats were induced diabetes by a onetime intraperitoneal injection of streptozocin ( mg/ kg). one week later, the diabetic rats were randomly divided into groups including a normal control, dm control and two uu treated group ( , and mg/kg/d). th e latter rats were fed uu by intragastric administration for weeks. aft er weeks, penile hemodynamic function was evaluated by measuring the intracavernosal pressure aft er electrostimulating cavernous nerve. we measured nitric oxide (no) and cyclic guanosine monophosphate (cgmp) activity. endothelial nitric oxide synthase (enos) and neuronal nos (nnos) protein expression was determined by western blot. masson's trichrome staining was also assessed.results: serum glucose level in dm +uu group was signifi cant lower than in that of the dm control groups. maximum intracavernosal pressure in dm control rats decreased signifi cantly compared to normal control rats and increased signifi cantly compared to untreated dm rats aft er uu supplementation. dm + uu group had signifi cantly increased no and cgmp level compared with the dm control group. decreased activity and expression enos and nnos were found in the dm groups compare with normal control group. decreased enos and nnos in diabetic rats were improved by uu administration. decreased the cavernous smooth muscle to collagen ratio was improved in dm + uu groups in the masson's trichrome staining.conclusions: uu eff ectively ameliorated erectile function in a streptozocin induced diabetic rat model of erectile dysfunction. you d , jung s , jang m , kim b , lee c , song g , choi k , shin h , suh n , kim y , ahn t , kim c the etiology and management of erectile dysfunction (ed) in patients with metabolic syndrome (ms). eighty-six patients suff ering from erectile dysfunction and metabolic syndrome were included in the study, patients were classifi ed based on iief- domain into three groups: mild ed (n= ), moderate ed (n= ) and severe ed (n= ). th ese patients were treated using upgraded regimen protocol (changing of the life style for months, on demand use of pde- inhibitors for months, chronic dosing with long acting pde- inhibitors for months and combination therapy of pde- inhibitors and intracavernosal injection for months) re-evaluation of the patients was done at the end of each stage by (iief-ef, waist circumference and laboratory investigations).results: aft er months of lifestyle modifi cation there was increase in the iief-ef but this change was not signifi cant the overall improvement was ( %), aft er on demand pde- inhibitors for months( . %) of patients with mild ed were improved, ( %) with moderate ed and ( . %) with severe ed were improved. non-improved patients in each group aft er on demand pde- inhibitors received pde- inhibitors chronic dosing for another months then re-evaluated ( . %) of patients with mild ed were improved, ( . %) with moderate ed and ( . %) with severe ed were improved, combination therapy in the form of tadalafi l mg daily and pge μg on demand were off ered to patient whom reported failure of pde- inhibitors chronic dosing patients with mild symptoms reported the maximum improvement ( %), patients with moderate symptoms reported fair improvement ( . %); however patient with severe symptoms reported no improvement at all.conclusion: pde inhibitors should be considered as the fi rst line phamaco-therapy in treatment of ed in metabolic syndrome patients. non-responders to pde inhibitors may have a benefi t from daily dosing of long acting pde- inhibitors. combination therapy of pde- inhibitors chronic dosing associated with intracavernosal injection of pge may play a role as a salvage therapy aft er failure of monotherapy. following this upgraded regimen case with ms and ed can have overall successful results in . %. comorbidity of premature ejaculation and erectile dysfunction: are they inseparable in chinese adult men?tang y, yang j, jiang x introduction and objective: premature ejaculation (pe) and erectile dysfunction (ed) are usually regarded as a symbol of incompetence. but in china for the inconsistent defi nitions of pe, some of them cannot correctly distinguish pe from ed. th erefore, to fi nd out the real relationship between pe and ed, a detailed investigation was implemented. were enrolled. all the subjects were evaluated by the face-to-face questionnaires of premature ejaculation diagnostic tool (pedt) and the international index of erectile function (iief- ). a professional urologist was invited to measure their lengths of penis and volumes of testes. all the data were analyzed by spss version . soft ware.results: a total of men aged from to years ( . ± . ) were categorized into lifelong pe (lpe) ( men), acquired premature ejaculation (ape) ( men), variable pe (vpe) ( men) and subjective pe (spe) ( men), respectively. th ere was no signifi cant diff erence among the four pe subtypes except for the ielts and the iief- . th e self-estimated ielt of spe was signifi cant longer than that of other subtypes, and the similar case could be seen in iief- . th e highest percentage was found in ape ( . %) for chronic prostatitis (cp) and in lpe ( . %) for ed.conclusion: vpe was the most common subtype, next ape, thirdly spe and the least one is lpe. consistent with the previous reports, we found that the incidence of cp in ape was the highest among all the four subtypes of pe, and cp was a signifi cant risk factor of ape but not for other subtypes. th ere has always been controversial about the relationship between pe and ed. th e results from our multinomial logistic regression analysis showed that ed was not only associated with pe, but also could be regarded as a risk factor of pe. introduction and objective: depression oft en overlapped with late-onset hypogonadism (loh) syndrome. clinically, many loh patients who have depressive symptom were treated with testosterone replacement therapy (trt). however, treatment efficacy of trt for these patients is unclear. in this study, we aimed to identify characteristics of loh patients on trt who had medical history of ongoing mental health treatment for depression syndrome. we reviewed consecutive patients who visited men's health clinic and underwent trt in our institution during june and december . prior to trt, patients received a physical examination and full hormonal evaluation including free testosterone (ft), lutenzing hormone (lh), and follicle-stimulating hormone (fsh). th e aging males' symptoms (ams) score was also evaluated. trt was conducted by mg monthly testosterone injection. effi cacy of trt was noted when diff erential of ams score between pre-and post-treatment was more than points. in the entire cohort of patients, the mean age was . ± . years and pre-trt ams score was . ± . . pre-trt ft, lh, and fsh were . ± . ng/ml, . ± . miu/ml, and . ± . miu/ml, respectively. of total patients, cases ( . %) had diagnosis of depression by psychiatrist and ongoing mental health treatment. patients with positive medical history of mental health treatment were found to be younger ( . vs. . years, p = . ), higher pre-trt ams score ( . vs. . , p < . ), lower lh ( . vs. . %, p = . ), and lower fsh ( . vs. . %, p = . ) compared to patients with negative medical history of mental health treatment. effi cacy of trt was greater in men who have mental treatment history ( . vs. . %, p = . ) based on ams improvements. while, there were no signifi cant diff erence in ft ( . vs. . ng/ml, p = . ), trt duration ( vs. days, p = . ), and trt discontinuation rate ( . vs. . %, p = . ) between two groups.conclusion: even though, loh patients who had diagnosis of depression and underwent medical treatment such as antidepressant, trt can be feasible approach for those patients. majority of those loh patients underwent mental health treatment at the same moment with trt, which may not harm treatment effi cacy of trt. the effect on blood flow rate of prostate in daily administration of mirodenafi l mg for benign prostatic hyperplasia patients: randomized paroxetine is the most eff ective ssris. in few studies, tramadol has been used to treat pe. considering the high incidence of pe in men and lack of consensus on its treatment, we decided to compare the therapeutic eff ects of tramadol, paroxetine and placebo in the treatment of primary pe. in this randomized, double-blind, placebo-controlled clinical trial, patients were randomly divided into groups. one group was treated with tramadol mg, the other group took paroxetine mg and the third group was treated with placebo. before starting treatment and aft er weeks, patients were asked to measure their average intravaginal ejaculation latency time (ielt) and fi ll the pep (premature ejaculation profi le) questionnaire. aft er collecting the data, they were recorded in spss version and were analyzed.results: patients in the groups in baseline characteristics, including mean age, ielt and pep were similar at the beginning of the study and there was no clinically signifi cant diff erence in the groups (p> . ). a total of patients completed the study period. at the end of the th week, the mean ielt and average of pep scores increased in all groups. th ese changes in tramadol group were signifi cantly higher than the paroxetine and placebo groups (p< . ). th ere were no signifi cant diff erences in terms of side eff ects between the groups. th e results showed that despite an increase in mean ielt and pep scores in all groups, the rate of improvement in tramadol group was considerably more than the other groups. th us, tramadol may be considered as an appropriate alternative therapeutic for long-life pe. the effi cacy and safety of tadalafi l mg once daily for the treatment of erectile dysfunction related to the vascular causes after robot-assisted radical prostatectomy: -year follow-updong-a university hospital, busan, south korea; jeil hospital, ulsan, south korea introduction and objective: to evaluate the effi cacy and safety of tadalafi l mg once daily use in the treatment of erectile dysfunction (ed) based on the vascular cause aft er robot-assisted radical prostatectomy (rarp). th e study retrospectively evaluated patients who underwent rarp and had a penile rehabilitation by tadalafi l mg once daily use at our medical center. th e patients were surveyed based on the abridged fi ve-item version of the international index of erectile function (iief- ) questionnaire, which was self-administered before the surgery, and at months, year and years aft er the surgery. th e patients were classifi ed into the tadalafi l group (n= ) and the non-tadalafi l group (n= ). each group was then classifi ed depending on the nerve-sparing (ns) procedure: bilateral ns and unilateral ns. additionally, patients who underwent a penile color-duplex u/s study to evaluate the cause of erectile dysfunction were also analysed.results: at months, year, and years, the total iief score of the tadalafi l group and that of the non-tadalafi l group were . ± . vs. . ± . , . ± . vs. . ± . , and . ± . vs. . ± . , respectively. statistically signifi cant improvements (p< . ) were observed in the tadalafi l group for all domains of iief- score, while in the non-tadalafi l group there was no signifi cant improvement in any of the domains at and years. fift y three patients had a penile color-duplex u/s study. arteriogenic and venogenic ed was seen in patients ( . %) and patients ( . %). fift een patients ( . %) showed unremarkable fi ndings. venogenic ed patients had little response compared to arteriogeinc ed patients by tadalafi l mg once daily use ( % vs. . %). th e overall side eff ects were hot fl ushing in . %, headache in . %, and dizziness in . %. in ed patients aft er ns ralp, a once daily dosage of tadalafi l mg was well tolerated and signifi cantly improved ef compared with the non-tadalafi l group until two years. but in the venogenic ed patients, response to a once daily dosage of tadalafi l mg was relatively limited compared to the arteriogenic ed patients. effects of long-term androgen replacement therapy on the physical and mental statuses of aging males with late-onset hypogonadism (earth): a randomized phase trial in japan introduction and objective: to determine the role of stone density and skin-to-stone distance (ssd) by non-contrast computed tomography of the kidneys, ureters and bladder (ct-kub) in predicting the success of extracorporeal shock wave lithotripsy (eswl). we evaluated patients who received eswl for renal and upper ureteric calculi measuring - mm, over a month period. mean stone density in hounsfi eld units (hu) and mean ssd in millimeters (mm) was determined on pre-treatment ct-kub at the ct workstation. eswl was successful if post-treatment residual stone fragments were ≤ mm.results: e wl success was observed in . % of the patients. mean stone densities were ± and ± hu in e wl successful and failure groups, respectively; this was statistically signifi cant (p < . , student's t-test). mean ssd were . ± . and . ± . cm in eswl successful and failure groups, respectively, this was not statistically signifi cant.conclusions: th is study shows that stone density can help in predicting the out-come of eswl. we propose that stone densities < hu are highly likely to result in successful eswl. conversely, stone densities > hu are less likely to do . th is should be accounted for when considering eswl. assessment th is prospective study was conducted upon children with mean age . ± . years. patients underwent retrograde intrarenal surgery (rirs) under general anesthesia as monotherapy. th e procedure was initially started by the semi-rigid ureteroscope (storz . f) and holmium laser and was completed by the fl exible ureterorenoscope (fl ex x ) for other parts of the stone which were not accessible by the semi-rigid ureteroscope. ureteral access sheath was not used and only hydrodilation was performed. patients were evaluated preoperatively by ultrasound and plain x-ray of the abdomen and pelvis. pre-intervention sterilization of urine was performed in all patients using culture guided antibiotics. follow-up lasted for months.results: stone-free rate aft er a single session treatment was % and % aft er second session. mean operative time was . ± . minutes. th e mean fl uoroscopy exposure time was . ± . seconds. mean hospital stay was . ± . days. all patients had jj stent inserted. no major complications (clavien iii-v) occurred. none of the children received blood transfusion. th ree patients needed a second session of rirs, patient required a pnl session.conclusions: retrograde intra renal surgery using combined semi-rigid and fl exible ureteroscope off ers eff ective and safe option for treatment of medium sized renal stones children with comparable results to shock wave lithotripsy (swl) and percutaneous nephrolithotomy (pnl). introduction and objective: calcium stones are associated with osteoporosis and manifested mainly by elevated fasting urinary calcium/creatinine ratio. th e objective of this study is to demonstrate the presence of abnormal metabolism of calcium and calciuria in women with osteoporotic fracture with no previous-ly known renal lithiasis compared to women without osteoporosis and without renal lithiasis. eighty-seven women were included in the study and divided into two groups: group : postmenopausal women with osteoporotic fracture and without renal lithiasis; group : postmenopausal women without osteoporosis and without history of renal lithiasis. th e following parameters of phospho-calcium metabolism were analyzed: calciuria h, oxaluria h, uricosuria h and citraturia h. th e presence of hypercalciuria, hyperoxaluria, hyperuricosuria and hypocitraturia was compared between the two groups. statistical signifi cance was determined as p≤ . . results: th e mean age was . ± . years in group and . ± . years in group (p = . ). women in group had higher levels of serum alkaline phosphatise (p< . ) and fasting urinary calcium/ creatinine ratio (p< . ) than women in group . th e percentage of women with hypercalciuria in group ( %) was higher compared to women in group ( . %) and statistically signifi cant (p = . ). th ere were no statistically signifi cant diff erences in the percentage of hyperoxaluria, hyperuricosuria and hypocitraturia between the two groups. th is paper has the limitations of cross sectional study in a unique center and with a low number of patients. dept. of urology, ulster hospital, dundonald, uk introduction and objective: bladder stones are more common found in children from developing countries. open cystolithotomy or transurethral cystolithalopaxy are the traditional treatment but a percutaneous approach has been advocated. we present our experience with percutaneous cystolithotomy in children with bladder stones without any ultrasonic or fl uoroscopic guidance. from april to october , a total of children ( boys and girls) with a mean (range) age of . ( - . ) years underwent percutaneous cystolithotripsy (pccl). th e mean (range) stone diameter was . ( . - ) cm. one hundred thirty-eight children ( %) had a solitary stone while nine ( %) had more than one stone. th e main component of the stones were calcium oxalate in patients ( . %).results: all children were stone-free aft er one pccl; no recurrent stones developed. th e mean (range) pccl procedure time was . ( to ) min and intraoperative blood loss was scant. perioperative complications were few. th e mean (range) hospital stay was . ( - ) days.conclusions: blind access pccl (without any ultrasonic or fl uoroscopic guidance) is a facile and safe approach for removing stones in the pediatric bladder stones. advantages include the lack of ionizing radiation, no need for opacifi cation by iodine contrast media and low relative cost. we recommend this minimally invasive technique for management of large bladder stones (larger than cm) in children. to our knowledge, this is the largest single center series re-ported on percutaneous cystolithotripsy of endemic bladder stones in children. retrograde intrarenal surgery (rirs) in an unusual kidney ( ), polycystic kidney ( )]; who underwent rirs for stone management was evaluated. stone size was less than mm in all the cases. bleeding being the commonest complication, hemoglobin drop was measured to fi nd out the blood loss. all patients were assessed by x-ray and usg on the fi rst postoperative day and month follow-up. th e other parameter of focus was operative time, hospital stay, stone free rate and the auxiliary procedure. th e auxiliary procedure was divided as (staged, follow-up ( month) or other-pcnl/swl) so that stone free was the main target for the patients. conclusion: urolithiasis occurs in an abnormal kidney, indeed challenging, but rirs can also be performed successfully. proper handling of instrument can increase the longevity of the instrument for cost eff ectiveness. although complete stone clearance cannot be achieved, but meritorious achievement is less morbidity, early recovery, minimal bleeding with less complication. th us, rirs can be performed effi ciently, effi caciously and successfully in an unusual kidney with prior exposure of rirs. value of intraoperative ultrasound in decreasing of the risk of residual radiolucent stone post-pcnl al shareef j, aboelmagd m introduction and objective: hemorrhage is the most concerning complication aft er tubeless percutaneous nephrolithotomy (pcnl). we compressed the access tract of the kidney with oxidized regenerated cellulose (surgicele) aft er pcnl to facilitate homeostasis for tubeless pcnl. since april to september , pcnl was performed at our hospital. all patients received one stage procedure with metal dilator. aft er the end of stone extraction, the access tract was cauterized and an f foley catheter was inserted to the renal pelvis through the working sheath then infl ated and gently retracted. th e working sheath was withdrawn to the renal capsule and the access tract of the renal parenchyma was packed with surgicele and compressed with small sized dilators through the working sheath for minutes. a bloodless tract usually could be obtained in nearly every patient and all patients underwent tubeless modifi cation. th e results of these patients were analyzed with retrospective chart review.results: th e age of these patients ranged from to (mean . ) years old. th e average stone size was . ( . - . ) cm and the average operation time was . ( - ) minutes. th e target stones had been removed in all patients and the overall stone free rate was . %. th e postoperative blood transfusion rate was . % with no patient underwent angiographic intervention or other management for severe hemorrhage. postoperative fever was noted in . % patients and sepsis was noted in . % patients. th is study was designed to evaluate the adverse eff ects of swl on the metal devices for spine fi xation and the hemoclips for hemostasis. a total of cases who underwent swl for treatment of upper ureteral and renal stones were investigated. th eir ages were from ~ years (mean . ± . ). male patient was one and female patients were . th e piezolith (wolf, germany) was used as the lithotripter. th e metal devices were hemoclips for cholecystectomy in one, and pedicle screw in fi ve patients and bone cement (polymethylmethacrylate) in one patient for spinal fi xation through l to s . th e locations of the stones were the kidneys in and the upper ureter in patients and their sizes were from . cm to . cm (mean, . ± . ) . th e numbers of the swl were . ~ . times (median, ) . th e distances between the stones and metal devices were . ~ . cm (mean, . ± . ). th ey were followed-up for . ~ . months ( . ± . ). th e complications were investigated in terms of pain, fever, damage of the devices (change of morphology and location in simple x-ray fi lm and their function). no patient showed fever and pain in sites of the devices requiring medication, injection or other management during or aft er swl. one patient was admitted for acute colick fl ank pain with tenderness in costovertebral angle caused by acute ureteral obstruction by a crumbled small piece of the stone. th ere was no complication concerning with the eff ect of the swl on metal devices. even though swl is one of the safe treatment modality in various clinical fi elds, it can't be said that swl is always safe without complication. however, it can be said that it would be safe when it being done following the instruction. a prospective study to identify risk factors of pleural injury during percutaneous nephrolithotomy a total of patients with renal/upper ureteric stones, undergoing pcnl between january and june were evaluated for pleural injury. an erect chest x-ray antero-posterior view on inspiration was done within -hours of pcnl. th e patients were divided into groups a and b depending on whether they developed or did not develop pleural injury. patient-, stone-, renal-and procedure-related factors were compared between the two groups. patients with any known disease of lungs or pleura, patients undergoing simultaneous bilateral pcnl, relook nephroscopy, concomitant other procedures such as endo-pyelotomy or retrograde ureterorenoscopy were excluded from study. tract dilatation up to -f was done using alken metal dilators and an amplatz sheath was placed into system. nephroscopy was done with rigid nephroscope and stones were fragmented with pneumatic lithoclast.results: pleural complications occurred in patients ( %). out of patients, had supra-costal puncture and ( . %) developed pleural injury; patients had infra-costal puncture and pleural injury occurred in ( % on multivariate analysis, only low bmi and mean age < -years was associated with higher risk of pleural injury. th e limitation is the small number of patients (as pleural injury is not common a very large number is needed to show signifi cance).conclusions: higher incidence of pleural injury was noted in patients with low bmi and younger age. large multicenter study can provide a true picture. flexible and rigid ureteroscopy in th e success rate was defi ned as radiopacities less than mm on plain fi lm at one month follow-up aft er the fl exible ureteronoscopic procedure. our tips included: tip , moving technique, refers to move the lower pole stones to the upper pole or middle pole depending on the convenient site for fragmenting the stones with the escape basket. if the stones were large or the lower pole orifi ce is narrow, we fragmented the stones into two or more pieces, trapped and moved the stones into the convenient pole. tip , holding technique, refers to hold the stones in the renal pelvis and insert a laser fi ber through the escape to fragment the stones. tip , sheath technique, refers to extract the large stones and pull the stones to the sheath distal side, the stone was too large to pull out, a laser fi ber was inserted though the escape, fragmented the stones. all the videos were recorded.results: overall success rate was . %. th e success rate in the renal pelvis stone, upper pole, middle pole and lower pole was %, . %, . %, . % respectively. th e operating time was . minutes on the average. th ree patients had fever over °c aft er the procedures. no urosepsis occurred.conclusion: our tips are feasible in the treatment of kidney stones with fl exible ureteronoscopy. satisfactory success rate, shortening operating time, less fl exible ureteronoscopy consuming and less complication were obtained in the procedures of fl exible ureteronoscopy with escape. ureteroscopic introduction and objective: patients with underlying diseases, especially in old-aged, the urinary tract obstruction with the ureter stone would progress to the severe condition like renal failure or sepsis. prompt urinary diversion like percutaneous nephrostomy or removal of the stone via ureteroscope is necessary for these patients. however, most of them have poor general conditions to endure regional or general an-esthesia. so, we tried to implement the ureteroscopic removal of stone (urs) without anesthesia for the patients with ureter stone who were in septic conditions or severe urinary tract infections (uti). fift een patients ( males and females) included this study and all of them had serious problems like sepsis, heart problems or lung problems which were diffi cult to endure anesthesia. most of them were inserted pre-operative percutaneous nephrostomy catheter (pcn) due to impending septic shock. all of the stones were impacted in the ureter and urs were successfully performed with painkiller like pethidine mg iv. success rate of stone removal, pain perception during operation using a visual analog pain scale were done. results: th e mean age of the patients was . (± . ). th e position of the stones was as follows; upper ureter, mid-ureter and lower ureter stones. and there was no patient that had to stop the operation because of intolerable pain. th e mean of vas (visual analogue pain scale) was . (± . ). overall success rate was %. however, % of cases were unable to fi nd the impacted calculi but stone debris and blood clots. th e general condition of the patients except one was improved quickly aft er operation and discharged aft er . (± . ) days.conclusion: most obstructive uropathy due to calculi was in serious conditions to need immediate procedures and urs were safely and successfully performed under intravenous analgesics. in some of female patients, urs is well-tolerated even without analgesics. prompt urs procedure with intravenous analgesics can recover these conditions with minimal morbidity. geavlete p, georgescu d, multescu r, geavlete b introduction and objective: percutaneous nephrolithotomy (pcnl) is nowadays a widely practiced procedure. despite the good stone-free rates, it still has a specifi c morbidity. our goal was to describe the complications of this method on a signifi cant series of patients. between january and january , patients (age between and years) underwent pcnl ( procedures). we used f rigid nephroscopes and f fl exible ones ( procedures). th e mean follow-up period was months (range to months).results: intraoperative incidents were encountered during procedures ( . %): losing the percutaneous traject ( cases), poor visibility due to bleeding and imposing the termination of the procedure ( cases) and descendant stone fragments' migration imposing antegrade ureteroscopic removal ( cases). th e overall complications' rate was % ( cases): signifi cant bleeding requiring blood transfusions ( cases), emobolisation ( cases) nephrectomy ( cases) or open surgical hemostasis ( cases), sepsis ( cases), fever ( cases), pyelocaliceal perforations ( cases), hemoperitoneum ( case), persistent lumbar uri-nary fi stulae requiring retrograde jj ureteral stenting ( cases) and extra-renal stone fragments migration ( cases). however, the majority of these complications were minor. th e mortality rate related to pcnl procedures was %.conclusion: according to our experience, pcnl is a safe and eff ective technique. most of the intraoperative incidents or complications are minor and easy to solve. however, an adequate training is imperative in order to reduce the associated morbidity. is spinal anesthesia adequate for percutaneous nephrolithotomy? introduction and objective: to evaluate the adequacy of spinal anesthesia in terms of patient and surgeon satisfaction and convenience during percutaneous nephrolithotomy. patients who were candidates for percutaneous nephrolithotomy and operated by two endourology fellows during july -september were enrolled. spinal anesthesia was performed using an injection of . mg/kg bupivacaine . % in the intrathecal space; no opium (fentanyl) agent was used. all procedures were performed with the patient in the prone position. access was achieved by fl uoroscopic guidance, and the tract was dilated using a single-stage technique. anestheisa duration was defi ned from injection of anesthetic medication to fi xation of nephrostomy tube. operation duration was defi ned from start of cystoscopy to fi xation of nephrostomy tube. patient pain and satisfaction during operation and surgeon satisfaction was measured by an ordinal likert-type scale and collected by an examiner blinded to the study objectives.results: a total of patients (mean±sd age, . ± . years; male) were enrolled during the study period. th e mean±sd of anesthesia and operation duration were . ± . and . ± . minutes respectively. severe pain causing signifi cant discomfort to the patient and surgeon was observed in patients ( %). in three patients the operation was prematurely terminated because of excessive pain and/ or agitation of the patient. mild-moderate pain was observed in eight patients ( %). vomiting and headache was observed in another two patients. the african : our experience of stenting ureters in outpatients without screening or ga introduction and objective: to review ureteric catheters/dj stents placed under local anaesthetic, with antibiotic coverage, without the use of screening, at groote schuur hospital (gsh) over the last years. a prospectively collected database exists from july until present. all patients signed informed consent and received pre-procedural oral antibiotics. a post-procedural abdominal kub radiograph was obtained to ensure correct placement. demographic data and variables (stent/catheter, indication, side, success/failure -including reasons for failure) were collected. patients were asked to subjectively rate the level of pain at the end of the procedure.th e data has been collected and tabulated into an ex-cel® worksheet.results: a total of procedures (average . per year) were performed with age range from to years (average: . years). th e average time taken was minutes (median: minutes). th e shortest procedure recorded was minutes, and longest was minutes (with a failure). th e failure rate totals . % and further inspection shows that . % of failures were with bilateral stents, . % right sided and . % left sided. stated diff erently, % ( / ) of bilateral stents failed, . % ( / ) of right sided stents failed, and . % ( / ) left sided stents failed. th ere was a success rate of . % with stenting under local anaesthetic. th e average subjective pain score was . , which is tolerable. sivalingam et al ( , urology : - ) showed the average cost for stenting under general anaesthetic was almost times more expensive than under local. th eir local group had a failure rate of . %, which was lower than our . %, but we had a larger group ( in years vs. in years).conclusion: flexible cystoscopy and stenting under local anaesthetic without screening is useful and feasible, with minimal morbidity, discomfort and failures. it can be practiced as a cost eff ective, offi ce-based procedure and is suitable for the third world environment. introduction and objective: urolithiasis is an ancient disease with global distribution and is an important health problem all over the world. th ere are diff erent results for stone clearance rate in diff erent renal and ureteric locations aft er eswl. here we share our experience of the comparison of stone free rates and complications in diff erent renal locations. a retrospective study in which we included adults (age above years old) who underwent eswl from january to december . eswl was done by standard technique. we used modulith sl x lithotripter th generation storz medical. we followed patients for to months aft er last eswl session done. stone free status was defi ned as residual stone not more than mm in size. we reviewed data charts of patients for diff erent variables mentioned in results. introduction and objective: tubeless percutaneous nephrolithotomy (pcnl) for staghorn calculi has been reported to be safe and eff ective in select patients. although outpatient pcnl has been recently been shown to be safe and eff ective in a series of patients, it requires further study before urologists embrace same day discharge following pcnl. th e objective of this study is to report our early experience in treating staghorn calculi with pcnl on a completely outpatient basis, assessing its safety and effi cacy. a review of all outpatient tubeless pcnl cases between march and may at two canadian centres was performed, including collection of preoperative, intraoperative and postoperative data. strict preoperative, intraoperative and postoperative criteria were used in the selection of candidates for outpatient pcnl: no intraoperative complications including signifi cant bleeding or collecting system perforation; postoperative hemodynamic stability; adequate pain control; reliable patient with supportive family.results: fift y patients underwent ambulatory pcnl during the study period. staghorn calculi were treated in patients including cases of bilateral staghorn calculi, resulting in a total of staghorn renal units treated by ambulatory pcnl. all patients were discharged home uneventfully - hours postoperatively. th ere were no major postoperative complications, emergency room visits, hospital readmissions or deaths. th e stone-free rate was %, with of the renal units being stone-free at follow-up.conclusion: th is small series represents the largest series of ambulatory pcnl for staghorn calculi to date. in very carefully selected patients, pcnl for staghorn calculi on a completely outpatient basis appears safe and may be feasible. further research on ambulatory pcnl for staghorn calculi is required prior to widespread adoption by urologists. introduction and objective: th e most diffi cult aspect of percutaneous nephrolithotomy (pcnl) is frequently the renal puncture. most are performed under fl uoroscopic control. parallax, the assessment of the displacement of an object when viewed along two lines of sight, is the concept which allows the surgeon to gauge the d relationship of the needle to the kidney from a d fl uoroscopic image. whilst most urologists appreciate successful access correlates with both kidney and stone images moving in unison on rotation of the c arm (or "reverse parallax"), confusion oft en arises with unsuccessful attempts in relating how to amend the puncture with the radiological fi ndings. we create a model to describe visual observation of parallax. by way of a short video we outline how it can be implemented seamlessly into routine pcnl.results: visualization of the theory followed by its application in theatre clearly demonstrates a failsafe technique to allow operators to reliably detect when their puncture needle is deep or superfi cial to the stone.conclusions: parallax, as an adjunct to routine fl uoroscopy during pcnl, allows the operating urologist to rapidly gauge depth of needle in relation to the collecting system in diffi cult access scenarios. familiarity with this technique is important to minimize radiation exposure, ensure satisfactory access to the collecting system and improve operating times. the signifi cance of non-enhanced compute tomography for renal colic has been overestimated in absence of pyuria kim t , ahn s , kang j , kim j , myung s , moon y , kim k , chang i introduction and objective: th e study was undertaken to compare clinical utility in patients undergoing non-enhanced computed tomography (nect) and intravenous urography (ivu) in patient with classic symptoms of renal colic without evidence of urine infection and to determine the clinical importance. th is was a retrospective observational analysis of all adult patients between and . all nect and ivu were reviewed and categorized as the cause of symptoms. non-urolithiasis cause were further categorized as "acutely important", "follow-up recommended", and "other unimportant cause". full record review blinding to imaging fi nding was underwent including demographics, diagnosis, and management. we compared stone characteristics on imaging study, and demographic, exact diagnosis, and management methods between nect and ivu groups.results: a total of , patients were available inclusion criteria and ( . %) patients were underwent ivu and patients were nect. th e incidence of nect was . % at , but . % at . nect group was older ( . ± . vs. . ± . years old, p< . ), less hematuria in urine analysis ( . vs. . %, p< . ) and more admit ( . vs. . %, p< . ) than ivu group. urinary stones were detected ( . %) patients. nect group showed higher proportion of renal stone, mid ureteral stone and multiple stones ( . vs. . %, p< . , . vs. . %, p< . , . vs. . %, p< . , respectively), and smaller stone ( . ± . vs. . ± . mm, p< . ), and more radiolucent stone ( . vs. . %, p< . ) comparing to ivu group. th e incidence of urolithiasis more than mm were no diff erence between nect and ivu groups ( . vs. . %, p= . on radiologic fi nding, and . vs. . %, p= . on full chart record). moreover, the incidence of "acutely important" among non-urolithiasis cause was similar between nect and ivu groups on full record review ( . vs. . %, p= . ) . th e incidence of the active management including surgery and extracorporal shock wave therapy (eswl) were not diff erence between nect and ivu group ( . vs. . %, p= . ).conclusions: nect is a rapid and accurate diagnosis test for suspected renal colic, and nowadays almost renal colic patients in our hospital underwent nect in ed. however, it did not show better advantage for the detection of clinically signifi cant urolithiasis and acutely signifi cant cause of renal colic in patient with renal colic and absence of pyuria. from january to july we reviewed the scrotal ultrasound images of all patients diagnosed with leydig cell tumor and treated with conservative surgery (group a). we considered only patients that were fi rst diagnosed at one of the participating centers. we create a random homogenous control group of patients (group b), in term of age and presentation, diff erent from the group a just for the defi nitive malignant histology. all the images were collected and we analyzed ultrasound features of the lesions classifi ed in terms of length, us lesion homogeneity, shape, presence of hypervascularization. th e collected data were analysed by an online regression (student's t-test, chi-square test, and logistic regression analysis).results: th irty fi ve patients with leydig cell tumor underwent conservative surgery at our centers. a random group b of patients was also considered. pa-tient mean age was . years (range to ) for the fi rst group and . years for the second one (range to ). patients presented either with a palpable testicular nodule ( patients group a, . % - patients . % group b) or a nodule diagnosed by ultrasound ( patients group a, . % - patients . % group b). mean ultrasound size was . cm and . cm for the two groups respectively (range . to . cm and . to cm). both groups had hypervascularization of the lesions with no signifi cant diff erences. patients presenting with lct (group a) had an homogenous ultrasound intralesional aspect and the shape is defi ned with an elliptic or spheroid mold while patients from group b had dis-homogenous intralesional aspect and non-defi ned margins (p> . ).conclusion: although most focal lesions will be malignant and require an orchiectomy, recognition of the benign entity may be challenging. in a small lesion mainly not palpable the presence of a well-defi ned shape with an homogenous intralesional ultrasound aspect do correlate with a lct. adult testicular pure yolk-sac tumor the association of torsion with testicular cancer: a retrospective study introduction and objective: testicular torsion is a medical emergency that usually requires surgical exploration of scrotum to allow reperfusion of the aff ected testis. nonetheless, such surgeries can be frequently resulted in orchiectomy due to tissue ischemia and necrosis. however, testicular malignancy has been anecdotally reported with the association of torsion in the surgical specimens and the literature remains scant on the association of torsion with testicular tumors. th is retrospective study was set to explore the association of torsion with testicular cancer in cases of testicular torsion undergoing orchiectomy during scrotal exploration. a chart review was performed for patients who admitted to our clinic and had a diagnosis of testicular torsion between january and february . data of patients' characteristics, the laterality of the torsion, time and type of intervention and pathological examination were recorded. results: overall, patients with a diagnosis of testicular torsion were identifi ed. th e mean age was . years (ranges from to years). all the patients had unilateral intravaginal testicular torsion aff ecting the left side in cases ( . %) and on the right side in cases ( . %). manual detorsion was successful in patients ( . %) all of whom underwent bilateral testicular fi xation surgery within hours via scrotal incision. twenty-six ( . %) patients underwent emergency surgery with a testicular detorsion and fi xation surgery in ( . %) cases (bilaterally in and right-sided in ) and orchiectomy in ( . %) cases ( in right side and in left side). th e type of incision was scrotal in cases, inguinal in cases and unspecifi ed in surgeries. pathological examination of specimens revealed ischemia and necrosis in cases, while patients underwent testicular removal via inguinal incision had malignancy including seminoma and malign mixed germ cell tumor.conclusion: our retrospective study, as the largest case series in the current literature, showed the association of intravaginal torsion with testicular cancer to be . %. further high-level evidences are needed to establish the optimal incision type in testicular torsion cases with surgical exploration to avoid scrotal violation resulted from suboptimal approaches. wong l , , dickson b , catton c , yap s , , alkasab t , van der kwast t , hamilton r , jewett m st vincent 's hospital, melbourne, australia; princess margaret hospital, toronto, canada; university of california davis, davis, usa introduction and objective: paratesticular sarcoma (pts) is an uncommon disease and the literature is mostly confi ned to small case series with short follow-up. herein we present an update on our institution's experience in the management of patients with pts. fift y-one men with pts at princess margaret cancer center, between and were identifi ed from retrospective chart review. important relevant clinical pathological variables were collected with study endpoints being local recurrence, metastasis and overall survival. univariate analysis of variables associated with survival end points was performed with cox proportional hazards regression.results: median follow-up of our cohort was . years (iqr . - . ) with a median overall survival of . years. at presentation . % (n= ) of men had localized disease. interval completion hemiscrotectomy (performed aft er initial unplanned diagnostic surgery) was done in men, in which % (n= ) had residual disease present. local recurrence (lr) occurred in patients ( . %). median time from diagnosis to lr was months. univariate analysis showed presence of positive margins at diagnostic surgery (hr . , p= . ) and upfront/ completion hemiscrotectomy (hr . , p= . ) to be signifi cant variables. at last follow-up, / men ( . %) with lr were alive and disease free, developed metastatic disease with pts-related mortalities, and deceased of other cancer type. metastasis was present in men ( . %), with median time to metastasis mo, and median to from metastasis to death . mo. at last follow-up, . % (n= ) of the patients were deceased with cases attributable to pts. on univariate analysis, there were no significant variables for metastatic disease, and age (hr . , ci . - . , p= . ) and non-localized disease at presentation (hr . , p= . ) were signifi cant for overall survival.conclusion: in our cohort of pts patients with median years follow-up, aggressive treatment of local recurrence ( . %) resulted in good disease free survival for of men. completion hemiscrotectomy, particularly for positive margin disease, may decrease local recurrence. a rare case of testicular metastasis from primary lung adenocarcinoma: case report and ten-year review of testicular pathology at a single institution demkiw s , jackett l , goad j , wong l introduction and objective: health care websites provide a valuable resource of health information to online consumers, especially patients. offi cial surgical and medical society websites should be a reliable fi rst point of contact. th e primary aim of this study was to quantitatively assess medical and surgical society websites for content and highlight the essential features required for a high-quality, user-friendly society website. twenty specialty association websites from each of the regions, australia, uk, canada, europe, and the usa were selected for a total of websites. medical and surgical specialities were consistent across each region. each website was systematically and critically analysed for content and usability.results: th e average points scored per website was . out of . of the total (n= ) websites, scored at least out of points and scored out of . as well, % ( . / ) of the websites had an infor-mation tab for patients on their respective homepages while % ( . / ) had download access to patient information. a minority of the websites included different forms of multimedia such as pictures and diagrams ( . / , %) and videos ( . / , %). we found that most society websites did not meet an adequate standard for delivery of information. half of the websites were not patient accessible, with the primary focus being for health professionals. as well, most required logins for information access. specialty health care societies should create patient-friendly websites that would be benefi cial to all online consumers. application materials and methods: students were selected by sampling in pbl group (n = ) and pbl-ebm group (n = ), and the two groups received clinical teaching of urology by pbl and pbl-ebm model respectively. at the end of the study, each student received objective and subjective evaluation.results: th ere was no signifi cant diff erence in results of the baseline on evidence-based medicine between two groups (p> . ), but the percentage of high-recommended-level research evidence obtained by the students in the pbl-ebm group was signifi cantly higher than that in pbl group (p< . ). and questionnaire showed more students in pbl-ebm group believed that this teaching model improved their ability of comprehensive analysis and application of medical evidence, and developed their skills in solving problem and obtaining information on various subjects (p< . ).conclusions: th e model of problem-based learning combined with evidence-based medicine is feasible and eff ective in clinical teaching of urology and optimize the outcomes from pbl education. by the pbl-ebm model teaching, students improve the ability to advantage in managing evidence from medical studies, analyzing and solving problem, obtaining and applying medical information. incidence (dvt) or pulmonary embolism (pe), is recognized as one of the most serious complications of surgery. in urologic surgery, this has not been well reported thus the objective of this study is to access the risk factors for the development of vte among patients undergoing major pelvic surgery for prostate and bladder cancer in an australian tertiary referral center. consecutive patients undergoing major pelvic uro-oncologic surgery, namely radical cystectomy and radical prostatectomy over a fi ve-year period ( - ) were identifi ed. patient variables, types of surgery, types of thromboprophylaxis (pharmacological and/or mechanical) used in this patient cohort were collected for analyses as predictive factors.results: an overall incidence of vte was . %. patients undergoing radical cystectomy were more likely to suff er a vte event compared to patients having radical prostatectomy. in this cohort, the risk factors for vte include, prolonged operative time of greater than hours, lymph node dissection (lnd) and patients requiring blood transfusions.conclusion: patient undergoing major pelvic uro-oncologic surgery have a % risk of developing vte. risk factors identifi ed in this study should be used to guide the use of early and prolonged thromboprophylaxis. optimal trial of void after idc insertion for pelvic surgery th am c , ho p introduction and objective: in , we pioneered the fi rst international twitter-based journal club (#urojc) to discuss urology articles on a monthly basis with diverse global participation. since that time, this model of an international twitter-based journal club has been adopted by several other medical specialties including general surgery, respiratory medicine and nephrology. th e objective of this study is to examine the development of the urology journal club into an innovative and thriving forum for exchange of ideas, information and opinions since its conception two years ago. monthly twitter analyses such as number of users, tweets and impressions for the journal club were obtained via a third-party service called symplur using the hashtag #urojc. qualitative analysis was also performed of each individual tweet to assess for relevance to the discussion. comparisons were made between data from the fi rst and second year of operation of the journal club, including the number and geographic location of participants, as well as the quantity and quality of tweets.results: see table for summary statistics. th e total number of unique users of #urojc almost doubled from year one to year two. th e mean number of total participants increased by seven per month, and mean number of total countries represented increased by three per month. while the number of tweets per month also increased from year one to year two, the proportion of content-relevant tweets remained stably high at approximately %. meanwhile, there was a greater degree of participation from authors of the study being discussed over time. journal club continues to draw robust participation from a global audience, and serves as a benchmark for twitter-based journal clubs in other specialties. th e majority of tweets are relevant to the content of the article, providing a novel forum to discuss new research fi ndings with a global audience. prognostic impact of perinephric fat stranding on computed tomography in ureteral urothelial carcinoma introduction and objective: ureteral urothelial carcinoma causes gradual ureteral obstruction. perinephric fat stranding is defi ned as linear areas of soft tissue attenuation in the perinephric space, which can result from any acute process or injury to the kidney. we analyzed the prognostic impact of perinephric fat standing as well as secondary signs of upper urinary obstruction on the oncologic outcomes of patients with ureteral urothleial carcinoma. a total of patients who were evaluated by abdominal-pelvic computed tomography (ct) preoperatively and were diagnosed with ureteral urothelial carcinoma aft er nephroureterectomy conducted between january and december were enrolled in this retrospective study. we analyzed the association between oncologic outcomes and clinical-pathologic fi ndings, including secondary signs of upper urinary obstruction on preoperative ct such as hydronephrosis grade, perinephric fat stranding, renal enlargement, kidney density diff erence, renal cortical thinning, periureteral fat stranding.results: preoperatively patients ( . %) had perinephric fat stranding on preoperative ct. multivariate analysis showed that perinephric fat stranding, higher pt stage (≥ t ), lymph node involvement of cancer, and positive surgical margin were independent prognostic factors of cancer-specifi c survival (p = . , p = . , p < . and p = . , respec-tively). and perinephric fat stranding, higher pt stage (≥ t ), lymphovascular invasion, and lymph node involvement of cancer were identifi ed as independent prognostic factors of recurrence-free survival in ureteral urothelial carcinoma (p = . , p = . , p = . and p = . , respectively).conclusion: perinephric fat stranding on preoperative ct in ureteral urothelial carcinoma was found to be an independent prognostic factor of disease recurrence and cancer-specifi c mortality. our fi ndings indicate that immediate radical surgery and adjuvant therapy should be considered in patients with perinephric fat stranding preoperatively. lower increased urinary tract malignancy in end-stage renal disease (esrd) has been reported. however, little is known in chronic kidney disease (ckd). th is study is designed to explore the association between ckd and upper urinary tract urothelial carcinoma (uut-uc). health insurance database, we included ckd patients between january and december . th e non-ckd controls were selected with the ratio : and frequency matched with gender, age group and index date. chi-square test and t-test were used to inspect sociodemographic information and comorbidities. logistic regression analysis was used to calculate hazard ratio (hr) and % confi dence interval (ci). a year-old man with a strong family history of various cancers presented with haematuria and was subsequently found to have a mass in the right pelviureteric junction suggestive of urothelial carcinoma. work-up confi rmed the diagnosis without evidence of metastatic disease and the patient went on to have an open transperitoneal nephroureterectomy. laparoscopic approach was initially attempted but abandoned due to dense adhesions thought secondary to previous open bowel resection for colorectal cancer. a fl ank incision was used; there were no specifi c operative complications and the specimen was easily retrieved without manipulation or rupture. post-operative recovery was unremarkable and histological analysis of the tumour revealed a non-invasive high-grade papillary urothelial carcinoma at the right pelviureteric junction with clear resection margins. approximately months post-operatively the patient re-presented with a rapidly enlarging mass at the fl ank incision. imaging demonstrated a circumscribed hypodense mass within the muscle layers at the site of the scar and biopsy revealed poorly diff erentiated carcinoma. surgery to excise the mass was subsequently performed and immunohistochemical analysis revealed a lack of staining for msh .results: abdominal wall metastasis following open nephroureterectomy for upper tract urothelial carcinoma is rare, with only one case reported previously. given patient's previous history of colorectal cancer, strong family history and immunohistochemical fi ndings are highly suggestive of lynch syndrome. incisional site tumour recurrence following surgery for urological malignancy is a very rare complication, with only a handful of case reports existing, mostly relating to port-site metastasis following laparoscopic surgery. wound recurrence following open surgery is an extremely uncommon but recognised event, more frequent in certain gynaecological and general surgical malignancies. ls involves inherited defects in the dna mismatch repair system, resulting in predisposition to a number of malignancies. urologists should consider the possibility of lynch syndrome in any patient with de-novo upper tract urothelial carcinoma, and strongly recommend genetic testing where patients meet the amsterdam ii criteria or are diagnosed under the age of . prognostic ) developed recurrent bladder cancer within years aft er nephroureterectomy, and the median interval between surgery and intravesical recurrence was . months (range to months). multifocal tumors, native aristolochic acid nephropathy and distal ureter invasion were determined as risk factors for intravesical recurrence by univariate analysis. however, by multivariate analyses, multifocality (hazard ratio = . , % ci = . - . , p = . ) and native aristolochic acid nephropathy (hazard ratio = . , % ci = . - . , p = . ) were identifi ed as independent predictors for the development of recurrent bladder cancer aft er surgery for uut-uc in renal transplant recipients.conclusions: th e incidence of intravesical recurrence aft er laparoscopic nephroureterectomy for uut-uc in renal transplant recipients is high, and most subsequent bladder cancers recur within years aft er surgery. tumor multifocality and native aristolochic acid nephropathy are signifi cant independent risk factors in developing initial intravesical recurrence aft er laparoscopic surgery for primary upper urinary tract urothelial carcinoma aft er renal transplantation.introduction and objective: transient urinary incontinence may occur in up to % of patients aft er holmium laser enucleation of the prostate (holep). however, there are few published data concerning the factors associated with de novo urinary incontinence (ui). th e aim of this study was to investigate the associated factors of de novo ui aft er holep. our study included patients who underwent holep. enrolled patients were divided into two groups according to the presence of ui. independent t test was used to compare between two groups. logistic regression was performed to analyze a correlation between de novo ui and other factors such as age, prostate volume, retrieved tissue weight, operative time, and the fi rst post-void residual (pvr) urine volume immediately aft er removing postoperative urethral catheter. urethral catheter was removed aft er bladder instillation with a ml normal saline via urethral catheter, and pvr urine volume was estimated immediately aft er the fi rst postoperative self-voiding. all defi nitions of ui corresponded to recommendations of the international continence society.results: aft er holep, patients ( . %) had de novo ui, most of which resolved within - months; had stress ui, had urgency ui, and had mixed ui. age and pvr urine volume were signifi cantly higher in ui group than non-ui group ( . ± . vs. . ± . years; p = . , . ± . vs. . ± . ml, p < . ). in a logistic linear regression analysis, only pvr urine volume was an independent predictor of de novo ui aft er holep. th e most optimal cut-off value of pvr urine volume for predicting de novo ui was defi ned as . ml in the receiver operating characteristics curve analysis (sensitivity, . %; specifi city, . %; auc, . ; p < . ).conclusion: about one-third of patients might undergo de novo ui following holep, and most of them might have been resolved within - months. high pvr urine volume aft er removal of postoperative urethral catheter is associated with de novo ui aft er holep, and could be used a practical tool to predict postoperative de novo ui. concomitant transurethral and introduction and objective: stress urinary incontinence is a common medical problem among women. th e urethral closure complex and/or the support mechanisms are responsible for incontinence in the majority of patients. several surgical procedures with diff erent degrees of invasiveness and outcomes have been reported to treat the problem. although many are reasonably eff ective, a general trend towards study of natural and biocompatible tissues is emerging over popular synthetic materials. here we report our experience with injection of autologous adipose-derived stem cells to the periurethral region as a new method of stress urinary incontinence treatment. ten women with symptoms of stress urinary incontinence were treated by injections of autologous adipose-derived stem cells into the periurethral region via transurethral and transvaginal approach under urethroscopic observation. th is report presents the short-term outcome of the patients. th e outcome measured by pad test results, iciq-sf scores and qmax.results: th e mean age of the participants was . ± . years. urinary incontinence signifi cantly decreased through the fi rst two, and weeks aft er the injection therapy. th e diff erence was signifi cant in pad test results (p< . ) and iciq-sf scores (p< . ), especially comparing results between and weeks and among and weeks, but not for and weeks compared to each other. surprisingly, qmax showed improvement aft er the study period (means . vs. . ; p= . ). th is study showed that injection of the autologous adipose-derived stem cells to periurethral region is a safe, yet shot-term eff ective treatment option for stress urinary incontinence. further studies with longer follow-up are needed to confi rm its longterm effi cacy. sparc sling system for treatment of female stress and mixed urinary incontinence in the elderly sung l, noh c, chung j, yoo j introduction and objective: th e aim of this study was to investigate the safety and effi cacy of the suprapubic arch (sparc) sling procedure for the management of urinary incontinence in elderly versus younger women. a total of women underwent the sparc procedure for female urinary incontinence. of these patients, were classifi ed younger women (sui, . mui, ) and (sui, . mui, ) were elderly (more than year). th e preoperative evaluations included a complete medical history, a female bladder questionnaires, urogynecological examination and urodynamic test with valsalva leak point pressure (vlpp). th e main outcome measures were perioperative morbidity, postoperative sui, persistent or de novo urge incontinence, postoperative complication and voiding dysfunction. th e objective and subjective success rate were evaluated by visual analogue score and global patient impression questionnaire at , , months. th e mean follow-up period was ± mo (range, - mo).results: th e incidence of sparc related morbidity was similar in both groups. for the operation outcome results, in younger group ( patients) there were cases of cure ( . %), cases of improvement ( . %), and cases of fail ( . %) and in elderly group ( patients) there were cases of cure ( . %), cases of improvement ( . %), a case of fail ( . %) (p> . ). th e operation satisfaction rate of patients was . % in the younger group and . % in the elderly group (p> . ). a total of patients ( . %) would like to recommend the sparc procedure to others. th e objective success rate and operation satisfaction rate of the younger group did not diff er from elderly group. no severe intraoperative or postoperative complications occurred in both groups.conclusions: th e sparc procedure is eff ective and off ers a satisfactory cure rate without signifi cant morbidity in elderly women. validity introduction and objective: urinary incontinence secondary to surgery or trauma is a debilitating condition for the patient, and for the urologist a diffi cult situation to manage. because of the complexity of reconstructive surgical techniques and the cost of the prosthetic devices used, there is a need for a simple procedure. aims: we here in report our experience in managing urinary incontinence secondary to sphincteric incompetence in patients using a modifi ed bulbar urethral sling procedure over a period of years. results: all patients were continent postoperatively, with only mild stress leakage in the erect posture in two patients, during a mean follow-up of . months (range - months) and required one or some time two pads per day to remain continent during the daytime. one patient required clean intermittent catheterization for a short period postoperatively. conclusions: th e male bulbourethral sling procedure using a polypropilene mesh is economical and safe but further experience is needed to establish this procedure as an alternative for the treatment of male urinary incontinence. investigation of a teikyo university, tokyo, japan; juntendou university, tokyo, japan introduction and objective: th is study compares the safety and benefi ts of administering anticholinergic agent propiverine hydrochloride in combination with adrenergic alpha- receptor antagonist silodosin (sp group) as therapy for patients diagnosed with benign prostatic hyperplasia with overactive bladder, as opposed to administering silodosin alone (s group). th is study included male patients aged or above who had an international prostate symptom score (i-pss) of or more, an overactive bladder, a qol index of or greater, an overactive bladder syndrome score (oabss) of or more along with an oabss urgency score of or greater, and a maximum urinary fl ow rate of < ml/s. at random, patients were assigned to the sp group, and to the s group. th e sp group was administered mg/day of silodosin along with mg/day of propiverine hydrochloride and the s group mg/day of silodosin only, for weeks respectively. i-pss, qol index, oabss urofl owmetry results, and residual urine were evaluated prior to therapy and , , and weeks post-therapy.results: th ere were no statistically signifi cant diff erences in patient background between the two groups. statistically signifi cant improvements were seen in i-pss total score, qol index, and oabss weeks post-therapy, but there were no statistically signifi cant diff erences between the two groups. both groups refl ected statistically signifi cant improvements in i-pss storage symptom scores and voiding symptom scores, but there were no diff erences between the two groups. analyzing by prostate volume, among those with lower prostate volume (average . ± . mm ), the sp group showed a statistically signifi cant improvement in i-pss total score and oabss as compared to the s "monotherapy" group. no serious side eff ects were shown in either group.conclusion: among benign prostatic hyperplasia patients with overactive bladder, those treated with silodosin alone showed statistically signifi cant improvements in both storage and voiding symptoms, as did those additionally treated with propiverine hydrochloride. results were even more benefi cial when both silodosin and propiverine hydrochloride treatment were used for patients with lower prostate volumes. the effi cacy and safety of fesoterodine in vulnerable elderly patients with overactive bladder takeda h, nakano y, narita h introduction and objective: we evaluated the efficacy and safety of fesoterodine in medically complex vulnerable elderly patients with overactive bladder. in this -week, patients were community dwelling men and women years old or older. patients with oab had scores of less or more on the ves- by nccn (vulnerable elders survey). we evaluated the changes of each parameter before and to weeks aft er the administration of fesoterodine mg per day. th e overactive bladder symptoms score (oabss), ipss were used as a subjective questionnaire for overactive bladder symptoms. we compare between vulnerable elderly group and no-vulnerable elderly groups. statistical comparisons before and aft er the administration were made using the wilcoxon signed-rank test. to examine the relation between oabss and ipss, spearman's testing was used for correlations between independent variables and p< . was considered statistically significant. safety evaluations included self-reported symptoms and post-void residual volume.results: a total of patients were enrolled (mean age . years, . % age years or greater). th e vulnerable elderly patients had high rates of comorbidities, polypharmacy and functional impairment. at week both group had insignifi cantly greater improvements in oabss (p= . ) and ipss (p= . ). adverse eff ects were generally similar.conclusions: fesoterodine improved overactive bladder symptoms not only in no-vulnerable elderly patients, but also in vulnerable elderly patients. the effectiveness and tolerability of fesoterodine mg in "real world" outpatient clinical settings the benefi cial effect of a combination of solifenacin and mirabegron on oab patients persu c, paraianu b, nita g, geavlete p introduction and objective: th e development of a new drug class intended for the treatment of oab patients opened a new and promising era for our patients. th e current study aims to evaluate the eff ects of a combination therapy using an antimuscarinic and mirabegron. we designed a prospective study including oab patients with or without wet episodes. treatment was started with two months of solifenacin mg, then mirabegron mg was added for the next two months. th e patients were evaluated using a bladder diary for three consecutive days at the end of each treatment period. we compared the total number of voidings, the number of urgency episodes and the number of urge incontinence episodes. th e statistical analysis included only the patients who fi nished the whole four month period. a total of fourteen female sprague-dawley® rats weighing - g were used, which were randomly divided into two groups. both the experimental group and the control group, fourteen rats were inserted intrathecal catheter in the spinal l -s segment. seven days later, all rats were catheterized through the bladder dome for saline-fi lling cystometry. in experimental group, seven rats were given intrathecal diff erent concentration ketanserin ( . - . mg/kg) dose-response curves for ketanserin were followed by doi ( . mg/kg) test.in control group, seven rats were given intrathecal normal saline. all rats were intravascularly perfused with % paraformaldehyde aft er the completion of the urodynamic recordings. th e l -s spinal cord were removed and pathological sections and immunohistochemical staining were made. meanwhile, we observed and recorded the distribution of -ht a receptors in the spinal motor neuron. results: th irty-four patients were included in the study. twenty-four of them completed the follow-up. twenty-one were female and were male with an average age of . years ( - years). detrusor sphincter dyssynegia was the most common abnormal urodynamic fi ndings in these patients. th ere was an improvement in bladder capacity, detrusor and sphincter action following de-tethering surgery.conclusion: urodynamics should be considered as a part of preoperative evaluation in all patients with primary tethered cord syndrome to decide the urological aspect of management. urinary bladder reinnervation with creation of a "somato-autonomic" refl ex pathway in rabbits -s ) and detrusor muscle (recipient, s -s ) were located. aft er their resection, intradural anastomosis of donor root to the recipient distal root stub was performed. th ose roots whose stimulation elicited the largest response were always selected. aft er - months (mean months), the artifi cial refl ex arc's function was examined (to date in rabbits). under general anaesthesia, skin segments l -s were peripherally stimulated and then the spinal root above the anastomosis was stimulated. detrusor response was measured using an emg strip electrode and intravesical pressure (pves) monitoring and sphincter response using an emg needle electrode. a root sample from under the anastomosis was resected for histology.results: electromyography confi rmed detrusor response to peripheral skin stimulation in ( %) animals and sphincter response in ( %). five ( %) animals displayed elevated intravesical pressure (pves) up to cm h o. root stimulation induced detrusor and sphincter emg response in ( %) and ( %) rabbits, respectively, and ( %) animals displayed increased pves up to cm h o. micturition was not induced in any animals. with confi rmed detrusor contraction (emg, elevated pves), external sphincter activity was never inhibited. somatic-to-autonomic anastomosis creation was histologically confi rmed in all samples. hind limb paresis occurred in ( %) animals and spinal lesion in ( %).conclusion: lumbar-to-sacral-nerve rerouting is a technically manageable method with donor root fibres verifi ably joining recipient roots. only in a limited percentage of cases, however, can the method achieve positive functional results, i.e. demonstrable detrusor contractions and elevated intravesical pressure. physiological micturition without detrusorsphincter dyssynergia as described in the literature did not occur in our experiment. development in this study, we evaluate the effi cacy of the prototype intravesical pressure sensor integrated into a catheter-like tube and in the rabbit and biocompatibility of ecofl ex® as a packing materials in the rats. th e catheter type wireless pressure sensor is manufactured by direct inserting the prototype sensor into the port split from the feeding tube between the sensor and the port so the tube could hold the bladder pressure. th e tip of the tube is results: th e measured resonance frequencies and the pressure data converted from those signals were compared to the reference pressure data obtained from a conventional cystometry. th e scale factor of the sensor to correlate the prototype sensor resonance frequencies to the reference pressure data is - . kpa/ mhz (=- . mhz/kpa), comparable to the result of its in-vitro measurement, a pressure responsivity of - . mhz/kpa. increased macrophage activity and mif in the bladder were revealed in the early phase aft er implantation of ecofl ex®. however, decreased macrophage activity and mif in the bladder were observed in the later aft er implantation. furthermore, decreased infl ammatory cytokines were also observed at that time. in this study, we demonstrated the feasibility of the catheter type which is non-invasive method and easy to apply to patients in actual examination. further investigation to overcome the limitation of the prototype intravesical pressure sensor is necessary for the application to the real life practice. in addition, ecofl ex is biocompatible materials for the implanted medical devices in the bladder. introduction and objective: urethral pressure profi le (upp) is a primary method for evaluating urethral continence function in human beings. however, upp recording in female rat, a widely used animal model, has been challenging because of the animal's small body size. th is study reports a novel method for recording upp in female rats. seventeen anesthetized female rats were studied. leak-point pressure (lpp) data of rats were included; the other rats were excluded due to animal die or abnormal urogenital organ. upp curves were recorded using a modifi ed method of water-perfusion catheter system, with the lateral hole facing -, -, -, -o' clock positions respectively in a randomized sequence. lpp, functional urethral length (ful), and maximum urethral close pressure (mucp) were the analysis parameters. in the era of aging society, an easy-to-use screening tool for voiding dysfunction refl ecting to activity of daily life is much-needed. bladder diary (frequency volume chart) is gold standard to check urine storage status, but diffi cult for elderly to measure and record all the time. urofl owmetry is useful to check voiding status, but limited to clinics or hospitals. we developed a portable device, p-urofl owdiary®, which records every urine fl ow with bladder diary at home. we elucidate the feasibility and the usefulness of this device. materials and methods: p-urofl owdiary® records voiding time and date, length of voiding, voided volume, fl ow rate and self-evaluation of every urination for a couple of days with gravimetric determination method. th e device consists of a disposable urine cup, a load cell and the circuit board on which microcomputer, clock, acceleration sensor, audio guidance, bluetooth and sd card mounted. self-evaluation of every urination is recorded by pushing one of the four buttons on the body-side, which represent "very good", "good", "bad" and "very bad". th e data in sd card are analyzed using the dedicated soft ware. accuracy of the measurement has been approved in a comparative study of the device and an existing urofl owmeter. th e infl uences of hand shaking are canceled by acceleration sensor and are smoothed by the soft ware.results: th e feasibility study were done under the approval of irb of nara medical university. first semester study in healthy volunteers focused on user-friendliness. th e results were almost acceptable except for female volunteers, especially in elderly. th e urine volume and peak fl ow rate as well as self-evaluation were linearly related in volunteers who measured multiple sessions. a clinical trial in patients with voiding dysfunction is in operation in seven institutions, and summarized data will be reported.conclusion: p-urofl owdiary® is light and small and easy-to-use at home even in elderly. although its practical usefulness as voiding diary have been proved, the usefulness as urofl owmetry and self-evaluation of every urination is not clarifi ed yet. however, p-urofl owdiary® seems to be a useful tool for screening of voiding dysfunction as well as assessment of therapeutic performance. to determine the continence position and the contributory factors in the female canine urethra. materials and methods: by using adult female dogs, we determined the continence function of each mm intervals of the urethra when we excluded these segments by progressively inserting a fr catheter and recording the abdominal leak-point pressure (alpp). th e urethral pressure profi le (upp) and alpp were determined before and min aft er occlusion of the abdominal aorta. each urethra specimen was split into segments averagely and the histological components were determined. th e relationship between the histological components and the urodynamic parameters were analyzed.results: th e striated muscle confi ned to the distal / urethra. th e anatomic structure of the proximal / urethra was found to be quite homogenous, which surrounded by circular smooth muscle. th e connective tissue constituted with abundant collagen fi bers and vascular plexus was most voluminous in the distal / urethra, and relatively richer near the bladder neck. upp had pressure zones: high pressure zone corresponding to the distal / urethra and low pressure zone corresponding to the proximal / urethra. alpp decreased sharply when exclusion progressed over the distal / urethra. alpp and mucp decreased about % and % aft er occlusion of aorta, respectively. th e distribution of the urethral pressure or pressure change is in accordance with the location of the striated muscle sphincter; there is no linear correlation with any other particular tissue component in the diff erent urethral segments.conclusion: th e strongest continence function locates at the distal / urethra with striated muscle layer; the remaining / proximal urethra lacking striated muscle has only weak continence function. striated muscle is the predominant contributory factor to continence and the other components like vascular sinusoids, smooth muscle, collagen fi bers are minor contributory factors. urodynamics in children: a -year experience persu c, mirciulescu v, geavlete p introduction and objective: urodynamics, in the modern defi nition of the term, developed rapidly from a state of the art gadget into an extremely useful tool in the armamentarium of the modern practitioner, who is no longer accepting the clinical exam as the mainstay of the diagnosis, but requires more and more in-depth data from paraclinical investigations.our study aims to review the particular aspects of the urodynamic examination in children. we retrospectively reviewed the data from our archive in patients aged less than years old, examined in our department in the last years. for analysis purposes, patients were divided into two groups, less than years old and more than years old, considering that compliance during the examination improves greatly with age. a total of children were evaluated, in the fi rst group and in the second. we noticed changes in the procedure over time, due to the lack of standardization.results: th e main conditions behind the urinary symptoms were spina bifi da, myelomeningocele, cerebral palsy, spinal cord injury, frontal dementia. children with chronic conditions showed a signifi cantly better compliance during the examination, providing "cleaner" traces and shorter examination times. in cases ( %), the results of the exam were considered unreliable. in the fi rst group, sensations are recorded in only cases ( %), the other traces are marked as pain or crying. in the second group, the sensations are reported by children ( %). in six cases ( %), more than one examination was available, and the intra-individual variability was higher than in adult patients. urodynamics in children is a challenging, yet useful investigation, which requires both a state-of-the-art equipment and dedicated and highly professional staff . th e main question when thinking about urodynamic testing in children is not whether it can be done, but if it is really needed for the management of the patient, keeping in mind not only the benefi ts but also the potential harm that it can do. the underactive bladder syndrome: a single center experience persu c, geavlete p introduction and objective: detrusor underactivity (uab syndrome) is defi ned as a contraction of reduced strength or duration, leading to obstructive symptoms of the lower urinary tract. our study aims to review our clinical experience with such cases. we reviewed the electronic fi les of the patients diagnosed with uab aft er urodynamics in the past years. our review focused on the referral diagnosis and other associated conditions, as well as on the symptoms reported by the patient during history taking or the examination itself. we tried to correlate symptoms with the parameters obtained during urodynamics. th e initial treatment offered was also recorded.results: a total of patients ( males, females) were analyzed. th e most common referral diagnosis was bladder outlet obstruction ( pts - %), followed by oab syndrome ( pts - %) and other conditions ( pts - %). most patients reported signifi cant dysuria ( pts - %), sensation of incomplete voiding ( pts - %) and the need for straining in order to void ( pts - %). other reported symptoms include recurrent utis ( pts - %), urgency ( pts - %), frequency ( pts - %) and urinary incontinence ( pts - %). th e initial treatment consisted of self-catheterization ( pts - %), α blockers ( pts - %), suprapubic cystostomy ( pts - %), double voiding ( pts - %) and neurostimulation ( pts - %).conclusion: th e most common causes for uab include neurogenic conditions and obstructive symptoms associated with aging. th ere are no specifi c symptoms to support this diagnosis but some might suggest it stronger than others. urodynamic evaluation is mandatory to assess the parameters of this condition. underactive bladder: clinical features, urodynamic parameters, and treatmenthoag n, gani j introduction and objective: underactive bladder is a complex clinical condition that remains poorly defi ned in the available literature. we aim to determine its prevalence among those with voiding dysfunction, presenting symptoms, risk factors, urodynamic fi ndings, and treatment undertaken. a retrospective chart review was conducted on consecutive urodynamic studies performed for voiding dysfunction between and , to identify patients with detrusor underactivity. underactive bladder was defi ned as bladder contractility index less than . charts and urodynamic tracing were examined for patient demographics, suspected risk factors, presenting symptoms, urodynamic parameters, and treatment undertaken.results: th e prevalence of underactive bladder in this series was % ( / ). average age was . (range - ). women represented . % ( / ) of patients. th e most common reported symptoms were: urinary urgency ( . %), weak stream ( . %), straining ( . %), nocturia ( . %), and urinary frequency ( . %). prior pelvic surgery and prior back surgery was noted in . % and . %, respectively. most common management was intermittent self-catheterization at . %, followed by observation/conservative treatment at . %, and sacral neuromodulation at . %.conclusion: underactive bladder is common, yet precise diagnosis and treatment remains nebulous. th ere exists signifi cant overlap in symptoms compared to other bladder disorders, and urodynamic evaluation is useful in determining those patients with impaired detrusor contractility. th is will help prevent mismanagement of these patients with surgery or medical therapy that may worsen their condition. th ere remains much work to be done to better understand this condition, and establish optimal management for patients. what is the relationship between the size of a patient's medical notes and their fitness?birring a, jelski j, burns-cox n introduction and objective: assessment of patients' co-morbidities is necessary when considering treatment options. comorbidity tools exist but aren't always used outside of studies. clinicians may infer a patient's fi tness from the size of their notes. th is is particularly apparent in multidisciplinary meetings when the patient, and sometimes the referring clinician, is absent. we aim to establish if any correlation exists between the thickness and weight of medical notes and patient comorbidity. th ickness and weight of medical notes was measured for consecutive patients admitted to a urology/surgical ward. comorbidity was assessed using the charlston comorbidity index (cci).results: mean (and range): age ( - ) years; thickness . ( . - . ) cm; weight ( - ) g; cci . ( - ). male to female ratio : . pearson's correlation (r) between thickness and cci was . (p= . ). th e correlation between weight and cci was . (p= . ). regression analysis showed, an . cm increase in thickness gives in a -point increase in cci (p= . ); and a g increase in weight gives a -point increase in cci (p= . ).conclusion: th ere is a statistically signifi cant relationship between the thickness and weight of a patient's notes and their cci (p= . ), but the strength of this relationship is extremely weak (r= . and . ). on average, an . cm or kg diff erence in size has only a -point diff erence in cci. th is change may reduce the -year survival of a patient by as little as %. size of notes is a highly misleading indicator of fi tness. patients should have a formal comorbidity assessment before deciding treatment options.did you know? siu academy... the endorsed event programme allows approved webcasts from high-quality meetings around the world to be presented and shared on the portal.off ers a wide range of content eligible for selflearning cme credits non-accredited content is eligible for self-learning credits. contact your national accreditation body to fi nd out how. navigate the portal to its full potential by using the top and bottom panels. this allows you to narrow down your search by selecting the type of content, topic, sub-topics and labels to fi nd exactly what you are looking for. what's trendingthe what's trending page gives you an overview of featured content and the most recent material at a glance. the "rate & comment" feature allows you to share your feedback on every piece of material available on the portal. share exciting new content with colleagues through facebook and twitter at the click of a button.www.siu-urology.orgregister today! siu academy reaches over , users.are you one of them?siu members span over countries and represent the full spectrum of clinicians and investigators from all the urological subspecialties, including established academic and non-academic urologists, as well as physicians undergoing full-time training in urology.siu membership gives you an equal voice in this influential organization. we believe that each member can contribute the knowledge and experience needed to forge valuable links between urologists, and between developed and developing nations. by working together, our members carry on the tradition of creating positive change in a changing world. as a new member, you will be a partner in the one urological association dedicated to creating sustainable educational projects and providing and improving urological resources worldwide.members are able to vote for siu leadership, organize siu-endorsed educational activities, become involved in the congress scientific programme, as well as contribute to various siu academy programmes. we strive to make each member feel valued, respected, and supported.the siu network, both virtual and live, is an unparalleled pool of global contacts. siu brings urologists together. key: cord- -li pwigg authors: nan title: esicm monday sessions october date: - - journal: intensive care med doi: . /s - - -x sha: doc_id: cord_uid: li pwigg nan methods. for the present investigation, healthy male volunteers with a mean age of ± . years were recruited for a cardiovascular screening exercise stress test prior to inclusion for the study. during the lbnp protocol, the subjects were exposed to sequential increasing negative pressures of - , - , and - mmhg while resting in a supine position with their legs sealed in the lbnp chamber at the level of the iliac crest. in addition to continuous registration of cardiac output (co) and mean arterial pressure (map), sublingual perfused vessel density (pvd) ( ) and microvascular flow indices (mfi) ( ) were measured using sidestream dark-field (sdf) imaging before (t ), during (t ; - mmhg), and after (t ) lbnp. results. there were no significant differences in mean co and map in our subjects. introduction. fever management remains controversial in sepsis. control of thermal balance might improve vascular tone but fever could play a role in host defence. objectives. the aim of this multicentre randomised controlled trial was to determine primarily whether external cooling might accelerate the weaning of vasopressors in patients with septic shock. patients with septic shock treated with epi/norepinephrine infusion and fever over . °c were enrolled in centres when also requiring mechanical ventilation and sedation. patients received external cooling to reach normothermia ( . - °c) during h (n = ) or had fever respected (n = ). a goal of mmhg for mean arterial pressure was used in the two groups. a similar algorithm was used for weaning of vasopressors. the main end point was the number of patients achieving a % decrease in the initial dose of vasopressor in the two groups. shock reversal was defined by vasopressor withdrawal for at least h. at inclusion the two groups (cooling/respect of fever) were similar for age ± versus ± years, saps iii ( ± vs. ± ), sofa score ( ± vs. ± ), and body core temperature ( . ± . vs. . ± . °c). a similar number of patients received steroids and a pc before enrolment. body temperature became significantly lower in the cooling group within the h of treatment: . ± . vs. . ± . at h and . ± . vs. . ± . °c at h (p \ . ). the decrease in vasopressor was more rapid in the cooling group (fig. ). shock reversal was vs. %, p = . and in-hospital mortality was vs. % in the cooling and the respect of fever groups respectively. conclusions. these preliminary results show that treating fever using external cooling in septic shock patients allows a more rapid decrease in the dose of vasopressor without apparent adverse effect. grant acknowledgment. aphp-scr . we set up to describe the antibiotic treatment regimens prescribed for patients with severe sepsis in spanish icus and to analyze the potential therapeutic benefit of combination therapy. methods. edusepsis subanalysis, including all patients with severe sepsis admitted to the participating icus during months, in three periods between november and june . there was analyzed the time between the presentation of sepsis and the initiation of antibiotic treatment and empirical antibiotic used in terms of focus and origin of sepsis (community/nosocomial). we also studied the combination therapy compared to monotherapy, assessing the impact on outcomes of combination therapy in particular. the results are presented as frequencies (percentage) or mean ± standard deviation. results. there were included , patients with severe sepsis (age . conclusions. combination therapy is not associated with a better outcome in this large cohort of patients with severe sepsis. nevertheless, there is room for improvement since % of patients did not receive antibiotic therapy within the first h from admission, as recommended by the ssc. introduction. tracheostomies are increasingly common in hospital wards and can lead to significant patient harm. this is partly due to bed pressures in uk critical care units and the increasing use of percutaneous and surgical tracheostomies for critical care patients. commonly, hospital wards lack the infrastructure to care for tracheostomies safely. objectives. analyse tracheostomy-related critical incidents reported in the uk over a year period. we wished to identify themes and make recommendations to improve patient safety. methods. the search was conducted from st october to th september and was conducted in february to allow time for incidents to be submitted. the selected incidents were then incorporated into an access database (microsoft office ) and the description of each incident was read and reviewed. we analysed tracheostomy-related critical incidents reported to the uk national patient safety agency over a year period, identified by key letter searches. we categorized the records to identify recurring themes and then performed root cause analysis where possible. results. we identified , incidents from the npsa incident database originating from hospital wards during the study period having the defined letter sequences. of these incidents, were associated with tracheostomies; directly affecting patients with the remaining not directly affecting individual patients. in the incidents where patients were directly affected ( %) were associated with some identifiable patient harm of which ( %) were associated with more than temporary harm. in incidents ( %) some intervention was required to maintain life and in cases the incident may have contributed to the patient's death. there were cardiac arrests and respiratory arrests described in these incidents. of the incidents, involved equipment and there were blocked or displaced tracheostomy tubes described. note: an individual incident could be classified in multiple fields conclusions. we were able to identify themes in incident reports associated with tracheostomies and identify areas where care could be improved to reduce risks to patients. there were a number of recurrent problems that contributed to incident evolution or severity that would be potentially avoidable. these include: introduction. the study of computerized thoracic tomography patterns can be of great help in the diagnosis of the causes of acute respiratory failure in the icu patients. we hypothesized that the consecutive analysis of a series of thoracic cts will contribute to the management of these critically ill patients. objectives. to study, over a three-month period, the thoracic cts performed in the adult icu in the albert einstein hospital in são paulo, brazil. methods. from may st to august st, , all the thoracic cts were analyzed by two radiologists from the albert einstein hospital staff according to a pre-established protocol: ( ) presence of parenchymal consolidations; ( ) ground-glass opacities; ( ) septal thickening; ( ) atelectasis ( ) pleural effusions; ( ) pneumothorax ( ) pneumomediastinum; ( ) subcutaneous emphysema; ( ) presence of nodules; ( ) presence of masses; ( ) presence of cysts; ( ) emphysema; ( ) bronchial thickening. results. hundred and sixteen thoracic cts were performed and analyzed over the study period, from ( . %) males and ( . %) females. the mean age of the patients was . ± . years. thoracic ct analysis revealed: ( ) parenchyma consolidations: ( . %); ( ) ground-glass opacities: ( %); ( ) septal thickening: ( . %); ( ) atelectasis: ( . %); ( ) pleural effusions: ( %) ( ) presence of pneumothorax: ( . %); ( ) pneumomediastinum: ( . %); ( ) subcutaneous emphysema: ( . %); ( ) nodules: ( . %); ( ) presence of masses: ( . %); ( ) presence of cysts: ( . %); ( ) emphysema: ( . %); ( ) bronchial thickening: ( . %). conclusions. thoracic ct is a useful tool for a detailed analysis of the lung parenchyma, specially in the detection of ground-glass opacities, consolidations and atelectasis, improving the diagnostic possibilities and management of acute respiratory failure. s. wolf , , a. rieß , j.f. landscheidt , c.b. lumenta , l. schürer , p. friederich charite campus virchow, department of neurosurgery, berlin, germany, klinikum bogenhausen, neurosurgery, muenchen, germany, klinikum bogenhausen, anesthesiology, muenchen, germany introduction. extravascular lung water index (evlwi) may present a valuable marker for the severity and treatment of acute lung injury and acute respiratory distress syndrome. measured by single indicator transpulmonary thermodilution and indexed to predicted body weight, a threshold of ml/kg is currently regarded as the upper limit of normality. however, so far only critically ill patients were studied and data from subjects with normal cardiovascular function is lacking. objectives. to prospectively investigate evlwi in patients without cardiopulmonary compromise. methods. patients requiring elective brain tumor surgery were equipped with a transpulmonary thermodilution device (picco . , pulsion medical systems ag, munich, germany). triplicate evlwi measurements were performed after induction of anesthesia (time point ), before (time point ), during (time points and ) and after surgery (time point ) as well as after extubation (time point ) and before discharge from the neurosurgical icu (time point ) . data were recorded electronically and investigated with a random effect model to cope for multiple measurements per individual. results. valid measurements were performed in patients ( female/ male, fig. ). no patient showed clinical signs of over-hydration or cardiopulmonary failure and all were discharged regularly from the icu on postoperative day one. indexed to predicted body weight, females had a mean evlwi of . (sd . , range - ) ml/kg and males had a mean evlwi of . (sd . , range - ) ml/kg (p \ . ). % of the measurements in females and % in males exceeded the threshold of ml/kg. no significant differences were between the different time points of measurement (p = . ) or during anesthesia and after extubation (p = . ). conclusions. measured with single indicator transpulmonary thermodilution and indexed to predicted body weight, evlwi frequently shows values above the previously established normality threshold of ml/kg in patients without cardiopulmonary compromise. females present significantly higher values than male patients. as we are not aware of any abnormal hemodynamic profile for brain tumor patients, we propose our findings as a close approximation to normal values for evlwi. introduction. cardiovascular dysfunction is though to be common during weaning from mechanical ventilation. however, its precise incidence is unknown in this setting. in addition, the respective impact of systolic and diastolic dysfunctions on the weaning process have not been studied. objectives and methods. this is an ancillary study of the ''bnp for the management of weaning'' clinical trial. patients were ventilated with an automated weaning system as soon as they tolerated pressure support ventilation with an fio b %, a peep level b cmh o, and a total inspiratory pressure b cmh o. a total of patients underwent transthoracic echocardiography (tte) at day (initiation of weaning). in addition, serial tte were performed in a subgroup of patients to explore left ventricle filling pressures variations during daily weaning trials (low-pressure support with zero end-expiratory pressure). filling pressures were assessed using the ratio of early transmitral peak velocity (e) over early diastolic mitral annular velocity (e ). results. day tte revealed a systolic (ejection fraction \ %) or diastolic dysfunction (defined as e \ . cm/s) in half of patients. treatment during weaning included diuretics ( % of patients), vasodilators ( %) , dobutamine ( %), amiodarone ( %) and betablockers ( %). diastolic dysfunction was more prevalent in patients with difficult or prolonged weaning as compared to those with simple weaning (weaning duration \ days). serial tte revealed a greater increase in e/e ratio during failed weaning trials as compared to successful trials. conclusions. when treated, systolic dysfunction does not seem to jeopardize weaning. in contrast, diastolic dysfunction is associated with difficult/prolonged weaning. during failed weaning trials, there is a more pronounced increase in filling pressures as compared to successful trials. introduction. monitoring and determination of fluid responsiveness in a critically ill patient who presents with circulatory compromise and septic shock is essential but often, challenging and difficult. continuous haemodynamic monitoring using arterial pulse contour analysis is less invasive compared to the thermodilution method using the pulmonary artery catheter. objectives. we aim to assess the utility of stroke volume variation as measured by the flotrac Ò device (edwards lifesciences, irwine, usa) as a predictor of fluid responsiveness in patients with septic shock. we studied mechanically ventilated adult patients with septic shock in the medical intensive care unit (icu) of a university hospital. haemodynamic parameters including stroke volume variation (svv) and stroke volume (sv) were recorded using radial arterial pulse contour analysis (flotrac Ò pressure sensor versions . and . ) before and after a crystalloid fluid challenge. fluid responsiveness was defined as an increase of c % in sv after the fluid challenge. results. the sensitivity, specificity, positive predictive value and negative predictive value of a svv of c % to predict fluid responsiveness were respectively . , . , . and . %. the area under the receiver operator characteristic curve for the prediction of fluid responsiveness using svv (pre) was only . . similarly, there was no correlation between svv (pre) and the absolute change in stroke volume (spearman's rho - . , p = . ). conclusions. our study's findings call for caution with the use of svv measured via versions . and . of the flotrac Ò device to predict fluid responsiveness in patients with septic shock. further studies are now required to assess if recent software upgrades may provide more accurate svv measurements in severely septic patients. objective. our objective was to assess the recent literature with respect to cco monitor validation. in particular we wished to determine if study protocols reflected the dimension of time. we looked at four different cco monitors: vigileo tm , picco tm , pulseco tm , and oesophageal doppler (odm). human validation studies of cco monitors were sought through the ovid interface, generating over , hits. manufacturers' websites were also searched. case reports were excluded, as were abstract-only publications, letters, and studies over years old. ultimately, studies were included. a full reference list and search strategy is available from the authors. a recent article provided suggested criteria for assessment of cco monitors [ ] : this was used to generate a proforma. to check for interobserver bias, a subselection of five studies was assessed by the three authors independently; no differences were found. the authors summarised the remaining studies individually. results. results are summarised in table . w rows do not add up because some studies evaluated more than one monitor researchers have yet to address the necessity of validating cco monitors with respect to their realtime functionality. while most studies give an assessment of bias based on essentially static measurements, fewer than half document sampling time or directional change reliability. response time and response amplitude to a step change in cardiac output are important variables which may influence patient treatment; in the vast majority of studies, these have not been assessed. in this respect, all four monitors have yet to be validated. this study offers two perspectives: one, for clinicians to realise that the cco monitor in their intensive care unit may not have been as extensively validated as they think; another, for researchers, to realise that work is still to be done. initial distribution volume of glucose rather than right ventricular end-diastolic volume is correlated with cardiac output following cardiac surgery j. saito , h. ishihara , e. hashiba , h. okawa , t. tsubo , k. hirota hirosaki university graduate school of medicine, anesthesiology, hirosaki, japan, hirosaki university graduate school of medicine, division of intensive care, hirosaki, japan introduction and objectives. rational decision making for cardiovascular and fluid management in critically ill patients requires reliable assessment of cardiac preload. we have reported that initial distribution volume of glucose (idvg) measures the central extracellular fluid volume and has potential as an alternative preload variable ) . idvg can be approximated rapidly and simply in any icu using a conventional blood glucose analyzer ) . right ventricular end-diastolic volume (rvedv) has been shown to be a better indicator of cardiac preload than cardiac filling pressure ) . this study was intended to determine whether idvg, rvedv, pulmonary artery wedge pressure (pawp) or central venous pressure (cvp) are correlated with cardiac output (co) during the early postoperative days following cardiac surgery in the absence of apparent congestive heart failure. methods. twenty-nine consecutive patients who underwent cardiac surgery such as coronary artery bypass grafting (either off-pump or on-pump: n = ), valve surgery (n = ) and aortic arch replacement (either hemi or total: n = ) were studied. patients associated with excess hyperglycemia ([ mmol/l), arrhythmias or mechanical cardiovascular support were excluded from the study. a volumetric thermodilution pulmonary artery catheter for continuous monitoring of co and rvedv was placed in the operating room. immediately after cardiovascular variables were recorded, idvg was determined using the incremental plasma concentration at min after administration of glucose ( g) as described previously ) . three sets of measurements were performed; on admission to the icu and daily at a.m. on the first postoperative days. the relationship between either volumetric or static variables and cardiac index (ci) was evaluated throughout the study period. a p value. was considered statistically significant. results. all but one patients required vasoactive drugs during study period. indexed idvg (idvgi) had a moderate correlation with ci (r = . , n = , p \ . ), even though indexed rvedv (rvedvi) had a slight correlation with ci (r = . , n = , p = . ). a linear correlation was also obtained between changes in idvgi and those in ci (r = . , n = , p \ . ). however, changes in rvedvi had not a correlation with those in ci (r = . , n = , p = . ). neither pawp nor cvp had a correlation with ci (r = - . , n = and r = - . , n = , respectively). although cardiac dysfunction has a significant impact on determining co early after cardiac surgery, our results demonstrate that idvg rather than rvedv is correlated with co. idvg has potential as being an alternative indicator of cardiac preload following cardiac surgery. (spv) are reliable predictors of fluid responsiveness in controlled mechanically ventilated patients [ ] . ppv and spv are calculated using an intra-arterial catheter. it is unknown whether an arterial pressure signal obtained with the nexfin tm system [ ] using only a finger cuff can be used to calculate ppv and spv. objectives. to validate ppv and spv measured with a finger cuff. methods. after their arrival on the icu, sedated and mechanically ventilated patients after coronary artery bypass graft surgery (cabg) were included. intra arterial pressure (iap) was measured using an arterial catheter inserted in the radial artery, and non-invasively, using the finger cuff of the nexfin tm monitor (bmeye, the netherlands). we took the mean value of ppv and svv in a -min time interval before and after the administration of a fluid challenge. agreement of the ppv and spv measured by the finger cuff and from the iap signal were assessed using the method described by bland and altman. results. nineteen patients were included and twenty-eight volume challenges were analyzed, resulting in simultaneous measurements. ppv and spv measured by the finger cuff correlated with ppv and spv from iap (r = . , p \ . and r = . , p \ . , respectively), see figure . the mean bias was - . and - . % for ppv and spv respectively, and limits of agreement were - . and . % for ppv and - . and . % for spv (see figure ). there was no correlation between the bias and the mean value of the two measurement methods. the correlation between changes in ppv and spv measured by the two different methods was r = . (p \ . ) for ppv and r = . (p \ . ) for spv. conclusions. in ventilated icu patients, ppv and spv can be reliably calculated using the nexfin tm monitor. reference(s). ( ) kramer, a., et al., chest, . ( ) . ( ) eeftinck schattenkerk, d.w., et al., am j hypertens, . ( ) . introduction. the transpulmonary thermodilution (tptd) technique with integrated pulse contour analysis (picco Ò -system) enables continuous monitoring of cardiac index (ci) after calibration by tptd [ ] . this monitoring technique is applied in patients with lung failure who undergo prone positioning (pp) which has been shown to potentially improve pulmonary gas exchange [ ] . objective. we sought to determine the influence of a modified pp ( °) on the accuracy of pulse contour derived ci (pcci) without recalibration by tptd. patients: after approval by our institutional review board and written informed consent by a legal surrogate we studied critically ill patients ( #, $, age - years) who were mechanically ventilated due to acute lung injury following lung contusions or acute respiratory distress syndrome. methods. all patients were prone positioned and had received an extended haemodynamic monitoring (picco Ò , pulsion medical systems ag, munich, germany). before turning from supine position (sp) to pp, ci was measured by tptd (tptdci) and pcci was calibrated. ten minutes after positioning, pcci was read from the monitor and then recalibrated by tptd. after - h, pp was ended and measurements were performed analogously to prone positioning. volume management between the respective time points remained unchanged. linear regression analysis and bland-altman plots were used for statistical analysis. all data are given as mean ± standard deviation, range in brackets. results. the tptdci in sp was . ± . ( . - . ) l/min/m . after proning, a pcci of . ± . ( . - . ) l/min/m and a tptdci of . ± . ( . - . ) l/min/m were measured. linear regression analysis revealed a correlation coefficient of r = . (p \ . ). mean bias (tptdci-pcci) was . ± . l/min/m . immediately prior to turning back to sp, tptdci was . ± . ( . - . ) l/min/m . after re-positioning, the pcci was . ± . ( . - . ) l/min/m and tptdci was . ± . ( . - . ) l/min/m , with a mean bias of . ± . l/min/m . the correlation coefficient was r = . (p \ . ). conclusion. pcci is only marginally influenced by prone positioning and is reliable without recalibration by tptd. however, in case of greater differences a recalibration by tptd is nevertheless recommended. objectives. the aim of this study was to analyze the clinical agreement between the intermittent bolus thermodilution technique (tdco) and apco in patients with non-traumatic intracranial hemorrhage requiring intensive care. methods. this was a prospective observational clinical study in a university level icu. we studied adult patients with non-traumatic intracranial hemorrhage, who for clinical indication underwent co monitoring by the tdco (pac, . fr, criticath tm sp h td catheter, becton-dickinson, singapore). in parallel, arterial pressure waveform was applied using the radial arterial pressure curve (flotrac/vigileo tm , version . and . , edwards lifesciences, ca, usa). tdco measurements were done approximately every h and when needed. the length of data recording was depending on the need for tdco monitoring and icu stays but was no longer than days. every tdco measurements and the simultaneous apco values were recorded and included into the analysis. results. data pairs were obtained. overall, mean co was . (sd . ) l/min for tdco and . (sd . ) l/min for apco. mean bias between tdco and apco was . l/min ( fig. ), % limits of agreement . to . l/min and the percentage error %. there was a large interindividual variation in mean bias and percentage error (minimum to maximum, - . to . l/min and - %, respectively). the bias was significantly greater if patient received norepinephrine ( . vs. . l/min, p = . ) but not if patient received dobutamine ( . vs. . l/min, p = . ) . only a small correlation between the bias and the rate of norepinephrine infusion was detected (q = . ). when cardiac index of . (l/min/m ) was used as a cut off value for need for intervention, the sensitivity and specificity for apco were . ( % ci . to . ) and . ( % ci . - . ), respectively. conclusions. according to our results the second generation of flotrac Ò /vigileo Ò monitoring system underestimates the tpco and the sensitivity is poor. there is also a large interindividual variation in bias. the use of norepinephrine may provoke the error. objectives. to compare cardiac output techniques to the reference tte method, which allows accurate measurement of the aortic flow section and of velocity time integral of aortic pulsed wave doppler signal to measure co. methods. monocentric prospective study included patients requiring invasive blood pressure and hemodynamic therapeutic intervention. tte co measurement was performed with aortic diameter measured in parasternal long axis view at the the aortic leflets, and velocity time integral measured using five apical view averaged on cardiac cycles. tod co was measured only when the pac insertion was decided. tte, uscom Ò , mostcare Ò and vigileo Ò were performed in all patients. each value was the average of successive cardiac cycles with consecutive measurements. each patient could have several measures. results. mechanically ventilated patients ( ± years; sofa ± . ) were investigated allowing to obtain measurements ( under norephinephrine). diagnostics: brain injury (n = ), sepsis(n = ) and others (n = ). patient had the methods ( measurements), patients had techniques ( measurements), patients had techniques ( measurements), conclusions. all methods correlated more or less with tte co, with a slope close to identity, and a low intercept. the best correlation was obtained between mostcare Ò and tod. agreement for almost all methods was large, within an acceptable range. for the pulse contour method, mostcare is correlated better than vigileo with tte co. the arterial signal has to be accurate as possible and requires a high quality chain for measurement avoiding overdamping or underdamping to allow effective signal digitalization. introduction. the lithium indicator dilution technique is attractive in paediatric intensive care because it is non-invasive. however, it requires calibration. the reliability of cardiac output measurement data rests on the reproducibility of the calibration factor (cf). objectives. to establish the number of calibrations (= x) that are required in a paediatric patient material, if the coefficient of variation for the calibration factor does not increase by % or more by (x + ) calibrations. to establish x it is also required that % of the patients do not show an increase in cv by % or more and that % of the patients show an increase in cv by % or more at (x + ). hemodynamically stable sedated and ventilator treated children under intensive care with a body weight of - kg were included. to perform calibration, . mmol/kg of lithium chloride was injected intravenously and the concentration of lithium ions in arterial blood was analyzed by a lithium selective electrode. the calibration process was repeated times and the cf as well as lithium indicator cardiac output (lidco) were calculated. results. results from children with a mean body weight of . kg are presented below. cv was below % throughout the investigation. introduction. stroke volume variation has been shown to be a better indicator of fluid responsiveness than static indices such as cvp or paop. a limitation of dynamic parameters is arrhythmias which produces abnormal svv. beat-to-beat variations reflect altered cardiac filling times not the effects of mechanical ventilation in fluid responsive conditions. a recently developed enhanced algorithm (newsvv) helps eliminate this limitation. newsvv rejects ectopic beats using multi-parameter signal recognition and restores the respiratory variation of the signal using spline-based interpolation. objectives. to evaluate the performance of the new arrhythmia rejection svv algorithm to predict fluid responsive from patient data with frequent arrhythmias. methods. newsvv was developed from data collected in a porcine model to limit the impact arrhythmias had on svv. comparing the current standard svv (svvstd) algorithm (flotrac-vigileo system edwards lifesciences, usa) with the newsvv showed a significantly improved sensitivity and specificity. ( ) in this preliminary study sets of patient data with frequent pvcs and atrial fibrillation (afib) were ran through the new algorithm and compared to the data from svvstd. in one patient fluid boluses ( - cc platelets and packed red blood) during a period of afib caused newsvv to decrease from to % and co to increase from . to . l/min, while svvstd algorithm did not show a significant change (varying randomly between and %). a second patient had non-paroxysmal afib. svvstd showed abnormally high values ranging between and %. patient was a non-responder to fluid and had a co ranging between and l/min. newsvv showed more realistic value of % depicting a non-responder range. the third patient had periods of afib followed by normal sinus rhythm (nsr). svvstd algorithm had abnormally high svv values ([ %) during the afib. during nsr, both algorithms correlated well with svv of %. (fig. .) conclusions. the newsvv algorithm improved svv with ectopics and afib and shows promise in eliminating a limitation of svv in those conditions. further studies are needed to fully evaluate the performance in patients with arrhythmia receiving fluid challenges. rd esicm annual congress -barcelona, spain - - october s methods. mechanically ventilated pigs (median weight kg) under general anesthesia were investigated. after instrumentation, baseline values were obtained after at least h of stabilization. ''shock'' phase (simulation of aaa rupture): ( - ) ml/kg of blood was gradually withdrawn and hemorrhagic shock maintained for h. abdominal cavity was filled with warmed saline to abdominal pressure of mmhg. ''clamp'' phase: infrarenal aorta was cross clamped for min and hemodynamics was resuscitated with shed blood and fluids. ''post-surgery'' phase lasted h and pigs were subsequently sacrificed. hemodynamics was obtained at baseline, every min for first h of hemorrhage, every h until postoperative phase and every h till the end of the study. data are presented as median (iqr), appropriate non-parametric tests were used for statistical analysis. results. baseline co measured by pac was ( - ) ml/kg/min. both vigileo ( - ) ml/kg/min (p = . ) and lidco ( - ) ml/kg/min (p = . ) differed significantly. the course of co is shown in fig. , all values are presented as a difference to baseline. the median difference between pac and vigileo was ( - )% and for lidco ( - )%. study limitations: both devices were designed for co estimation in humans but we do not expect huge differences in arterial system properties in pigs. young pigs reacted to hemorrhage by severe sinus tachycardia which caused failure in some co measurements but at least pigs are presented at every timepoint. conclusions. absolute co values obtained by both vigileo and lidco differ significantly from pac. unlike lidco rapid, flotrac/vigileo was able to track changes in co during severe hemorrhage. grant acknowledgment. iga mzcr ns - and vz msm . introduction. most important role of postoperative sedation is suppressing stress of the patients in icu. urinary -hydroxy- -deoxyguanosine ( -ohdg) can be a good biomarker for oxidative stress in clinical research. the aim of this study is to assess the free radical production under sedation in icu and compare the production between with midazolam and dexmedetomidine. subjects and methods. subjects were twenty-five patients with sedation after neck malignant tumor operation and ventilated for h in icu. patients with renal failure were excluded from this study. all patients received fentanyl ( lg/kg/day), fifteen patients were with midazolam ( . mg/kg/h: m-group) and ten patients were with dexmedetomidine ( . - . lg/kg/h: d-group) we examined the concentration of urinary -ohdg by high performance liquid chromatography (hplc) method with coolaray system every morning in icu. results. the average value of urinary -ohdg of healthy human volunteer is ng/ml. the values of urinary -ohdg were less than ng/ml in the both groups and no significant differences were observed between the groups in this study. conclusions. postoperative sedation with both midazolam and dexmedetomidine were effective in suppressing oxidative stress in icu patients. poorly controlled pain in the postoperative period can lead to slow recovery and life threatening complications, especially in elderly patients. it has also been suggested that the quality of postoperative analgesia could decrease delirium incidence and reduce duration of hospital stay in the elderly patients. however, the ideal postoperative analgesia management of elderly surgical patients in intensive care units remains to be determined. since, continuous epidural analgesia provides the required level of analgesia to support early mobilization and significant reduction in pulmonary and cardiovascular morbidity in the early postoperative period, we postulated that the use of low dose of continuous epidural morphine might improve postoperative analgesia and reduce undesirable side effects in elderly patientstherefore, the present study was designed to evaluate the effects of morphine administered via epidural patients controlled analgesia and intravenous tramadol + metamizol on postoperative pain control and side effects in elderly patients after major abdominal surgery. objectives. the purpose of this study was to compare the analgesic efficacy of morphine administered via epidural patients controlled analgesia (epca) with our standard analgesic for postoperative pain treatment, intravenous tramadol + metamizol in eldery patients undergoing major abdominal surgery. methods. forty patients older than years undergoing major abdominal surgery were randomly assigned to two groups. group i received epidural morphine mg at the end of surgery and used a patients controlled analgesia device programmed to deliver morphine . mg/h, . mg per bolus. group ii received intravenous infusion of mg tramadol plus mg metamizol in ml electrolyte infusion. the patients in group ii received ml of the infusion solution as a loading dose over min (corresponding to mg tramadol plus . mg metamizol) postoperative analgesia was tested at rest on a visual analogue pain scale ( = no pain, = worst possible pain) at , , , and h after surgery. patients' satisfaction, arterial oxygen saturation, respiratory rate, episodes of nausea, vomiting, pruritus and dizziness were also noted. results. both groups obtained adequate pain relief, and there were no between-group differences in pain scores. there were no significant respiratory differences but the patients in the epidural group were more sedated. in the tramadol metamizol group patients were treated for ponv while of the patients in the morphine group showed ponv. we conclude that combination of tramadol and metamizole provided postoperative analgesia equivalent to that provided by epidural morphine in early postoperative period. the both analgesic regimens were safe and suitable for the management of postoperative pain in elderly patients. h. poon , j. hulme sandwell and west birmingham hospitals nhs trust, birmingham, uk, sandwell and west birmingham hospitals nhs trust, intensive care medicine and anaesthesia, birmingham, uk a substantial amount of patients in intensive care units (itu) receive an inappropriate level of sedation with a tendency for over-sedation. although the ideal itu sedation practice is not known, many units use a protocol-based approach incorporating best practice consensus. the use of daily interruption of sedation infusions can reduce oversedation and is included in our current guidelines. objectives. the audit assesses compliance to our current protocols for sedation scoring and adjustment of sedation infusions. provision of sedation breaks in patients sedated more than -day is evaluated. methods. retrospective review of itu inpatients' daily record charts during june and july at sandwell and west birmingham hospitals nhs trust in two -bedded itu. charts were reviewed. results. our guidelines recommend hourly sedation scoring from h to midnight and hourly scoring from midnight till h; at , and h. % of the reviewed charts did not have a recorded hourly score. % did not have hourly scores overnight. % of the charts contain ramsay score - or - ; % of the charts contain ramsay score or . per protocol, sedation infusion is stopped at ramsay score - or - but in % of cases this did not occur. a sedation bolus should be given at a score of or . % did not receive a recorded bolus. our guidelines advocate restarting a sedation infusion at a lower rate after it has stopped and the patient is less sedated and increasing the rate after a bolus is given. however, correct infusion rate adjustments were only performed in % of cases. often, rates were changed but without first stopping, or administering a drug bolus. out of sedation days, there were only true daily breaks. conclusions. there is a tendency to over-sedation in our itu; less so under-sedation. common practice deviates from protocol and there is poor documentation. scores are recorded less often than protocol: there may continuous assessment by nursing staff that is not recorded. boluses are given more often than documented on patient charts. review of the current guidance is required to address appropriate frequency of formal scoring, nurse-led compulsory sedation breaks and pharmacokinetic education about the necessity to stop or bolus before infusion rate alterations. introduction. daily interruption of sedation has been shown to decrease length of stay in icu . recent national guidance in scotland promotes dis as part of a care bundle to decrease ventilator associated pneumonia. a week retrospective first round audit was completed prior to the introduction of dis and demonstrated % of patient hours where sedation could be improved. a second round audit of current practice was therefore undertaken to assess the impact of dis on sedation levels. our aim was to identify the frequency of periods where sedation levels were undesirable and investigate any clinical reason behind these. objectives. to assess whether dis would improve sedations levels of our patients already managed with a simple sedation algorithm (sa) aiming at a ramsay sedation score level - . methods. six months following the introduction of dis, a second period of weeks was studied retrospectively where the icu daily charts were examined to look at: demographic data, sedation score, and whether dis had been successfully carried out. results. cases were identified: males and females with an average age years and similar illness severity scores to the first group. dis was carried out on patient days, omitted on days and contraindicated on a further . , patient hours were examined. ( %) were excluded due to contraindications such as refractory hypoxia, drug overdose, and end of life care. the remaining patient hours were compared to the first round group [ , patient hours with contraindications ( %)] using the mann-whitney test as shown in fig. . conclusions. we could not demonstrate any difference in sedation levels following introduction of dis on our unit. we found a large proportion of patients where dis was unsuitable. introduction. delirium, an acute and fluctuating disturbance of consciousness and cognition, is a common manifestation of acute brain dysfunction in critically ill patients, occurring in up to % of ventilated patients in the united kingdom . delirium is independently associated with more deaths, longer hospital stay, and higher overall cost . hypoactive delirium is much more common, is easily missed and is associated with a worse prognosis than hyperactive delirium . objectives. the aim of our project was to quantify the presence of delirium on our critical care unit and to survey the practice of delirium assessment within our region. we conducted a prospective audit at the critical care unit, birmingham city hospital, uk. we used the confusion assessment method for the intensive care unit (cam-icu) to assess for delirium daily on all our patients for a period of weeks. simultaneously, we conducted a telephone survey to elicit the delirium assessment practice of the other units within the west midlands region of the unite kingdom. results. we carried out our assessment on patients over a -week period, which resulted in assessments ( were on non ventilated patients and on ventilated patients). assessments could not be completed because of deep sedation or language barrier. in total we had assessments positive for delirium giving an incidence of % for those patients we could fully assess. all of the patients with a positive assessment had hypoactive delirium. the telephone survey revealed only three of the twenty units in our region routinely assessed for delirium. none of the units had a formal management protocol/guideline for delirium. conclusions. delirium is a significant problem on our critical care unit. the incidence was lower than that reported in the literature this might be because firstly we were unable to assess a number of patients due to the patients being deeply sedated, and secondly we noted many of the patients during the assessment period were high dependency patients with minimal organ dysfunction. despite a large number of recent publications on delirium and increasing awareness amongst critical care professionals most of the units in our region do not routinely assess for delirium. without regular assessment most delirium will go unrecognised and thus opportunities to instigate preventative measures and early management will be missed. methods. six patients aged - years old ( females) who all sustained brain injury with cerebral oedema alongside other traumatic damage (i.e., fractures, abdominal trauma) are hereby presented. upon admission to the icu all patients received large propofol doses ( - ml/h of propofol infusion %), in an attempt to lower cerebral metabolic demand along with vasopressors to maintain a normal mean arterial pressure. three to days following admission all patients developed metabolic acidosis (base deficit ranged from - to - mmol/l), hyperkalemia (potassium concentration ranged from . to . mmol/l), evidence of muscle cell degradation (creatine kinase and myoglobin concentrations ranged from , to , u/l and from , to , lg/l, respectively) and lipaemia (triglyceride concentrations ranged from to . mmol/l). at that time all patients were clinically stable and usual laboratory tests as well as cultures were inconclusive, hence a diagnosis of pris was suggested. results. three out of six patients developed global left ventricular dysfunction, which was documented by echocardiographic evaluation, with normal cardiac enzymes, while all patients developed acute renal failure. cardiac and renal failure were observed within - h following the manifestation of the above abnormal laboratory findings. continuous hemofiltration was initiated promptly on a daily basis in all cases, while the administration of propofol was discontinued. abnormal laboratory findings normalized within - days, while cardiac and renal function gradually ameliorated within a week, following therapy in all cases. no deaths were recorded. conclusions. the initiation of continuous hemofiltration therapy is a crucial therapeutic tool for the elimination of propofol and its potentially toxic metabolites in cases of pris and may have a beneficial effect upon survival in these cases. l. zurong , w. yichun intensive care unit of hunan province tumor hospital, changsha, china objectives. our purpose was to compare the analgesic properties, effect, and side effects of intravenous butorphanol and fentanyl during chest tube removal in cardiac surgery patients. seventy-four patients with cardiac surgery were enrolled before chest tube removal. each patient received standard doses of either fentanyl ( lg) or butorphanol ( mg) before chest tube removal in a double-blind manner. pain intensity and pain distress were measured before analgesic administration, immediately after chest tube removal, and min later pain quality was measured immediately after chest tube removal. level of sedation was measured before and min after chest tube removal. results. the fentanyl (n = ) and butorphanol (n = ) groups were identical with respect to age, race, sex, and weight. pain intensity, pain distress, and sedation levels did not differ significantly between groups. however, procedural pain intensity (mean . , sd . ) and pain distress (mean . , sd . ) scores for all were low. patients remained alert, regardless of which analgesic was administered. conclusions. if used correctly, either fentanyl or butorphanol can substantially reduce pain during chest tube removal without causing adverse sedative effects. thus, clinicians may choose either safe and effective analgesic interventions during chest tube removal. introduction. delirium is defined as an acute alteration of mental status, with either a disturbance of consciousness or a change in cognition which develops over a short period of time and fluctuates during the course of the day. reported prevalence of delirium in critical care varies widely from to %. despite this, delirium remains grossly under-recognised and is often thought to be temporary and of little consequence in critical care. it is however one of the most frequent complications and, after adjusting for age, gender and severity of illness is an independent risk factor for prolonged length of stay and mortality ( ) . current recommendations are for the assessment and diagnosis of delirium using simple validated tools ( ) . pharmacological intervention should be considered when reversible precipitating factors have been corrected. haloperidol is considered the drug of choice. objectives. the purpose of this study was to detect knowledge and awareness of delirium, attitudes and behaviours towards its assessment and pharmacological management in critical care units of two large uk teaching hospitals a -point survey was distributed to all senior medical and nursing staff employed in critical care at the leeds general infirmary and the james cook university hospital, middlesbrough. a total of questionnaires were collected after four follow up rounds via web-based survey tool ''survey monkey''. results. the survey detected a significant awareness of the problem delirium poses in icu. the vast majority ( %) of practitioners did not screen for delirium routinely. of the % who screened only in used screening tools that were appropriate, the majority lacked the knowledge of suitable methods to do so. % of respondents felt that they required tools to aid diagnosis of delirium in their unit. the pharmacological management of delirium varied significantly, with a wide range of drugs used, suggesting the need for guidance. the majority of respondents ( %) felt that they needed guidelines for treatment of delirium, % felt that guidelines would change their practice. despite an awareness of the problem delirium poses in icu, data from this survey shows a lack of knowledge of assessment and treatment. given that most respondents needed guidelines, we have developed a delirium treatment protocol and implemented the confusion assessment method for icu (cam-icu) training package for all staff in the james cook icu. following its implementation we plan to re-evaluate in the hope that the awareness of delirium can be met with the appropriate knowledge to implement a sustained change in practice. results. patients were included, male ( %), mean apache ii score ± . midazolam was suspended in % after h. maximum dose of sufentanyl was mcg/kg/h. bilirrubin and creatinin did not change from initial values and there was no effect in enteral nutrition tolerance. bis values improved % from ± to ± (p = ns) and there were less hemodynamic effects as well as less necessity of amines and sedatives. results are shown in table . conclusions. sufentanyl is an efficient and safe sedative that reduces necessity of more sedatives, amines and generates adequate sedation without renal or hepatic effects. a.s. puxty , j. kinsella , k. anderson glasgow royal infirmary, department of anaesthetics, glasgow, uk etomidate is a sedative agent often used for the induction of critically ill patients. it is, however, a controversial drug with effects on the steroid axis that have been suggested may lead to a poor outcome. so far this has only been proven in infusions of the drug. despite this some have called for its withdrawal altogether objectives. to determine the attitude of anaesthetists and icu consultants in five hospitals in a major uk city towards the use of etomidate. methods. an online questionnaire was constructed using surveymonkey (portland, oregon, usa). this was then sent out to all anaesthetists in glasgow via an e-mail link. a reminder was sent after weeks. trainees from one of the hospitals were unable to be contacted via e-mail and so hard copies of the questionnaire were sent to them. of a total of anaesthetists in glasgow (trainees and consultants), ( %) completed the questionnaire successfully. of those answering the questionnaire, . % were sho level, . % spr, . % consultants and . % sas grade. these respondents sub-specialities/specialist interest were: general ( %), pain ( %), icu ( . %), obstetrics ( . %) and cardiac ( . %). overall ( % ci - )% of respondents were concerned about etomidate's effect on steroid synthesis, although when asked about induction of an emergency laparotomy ( - )% would still use it [with ( - )% avoiding it and ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) % responding that they were never involved in emergency laparotomies]. of those using etomidate, ( - )% would avoid it in a septic patient, and a further ( - )% would give steroid cover. the most common reason for using etomidate was cardiovascular stability [ ( - )%]. other reasons given were simple dosing ( [ - ] )% and habit ( [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] )%. more than one reason was allowed. looking for differences between groups the following was found: while icu consultants reported more concern over etomidate ( vs. %, p = . ), there was no difference in etomidate usage in emergency laparotomy ( % of general vs. % of icu consultants, p = . ). trainees were more likely to have their habit changed by the recent literature on etomidate ( vs. %, p = . ). conclusions. there is concern among anaesthetists and icu consultants regarding the use of etomidate but usage has not changed markedly by most. further evidence of harm would likely need to be demonstrated before abandonment of the drug. introduction. nociception and requirement of additional analgesia before painful procedures in icu are difficult to anticipate. under anaesthesia, the direct pupil light reflex reflects the sympatho-vagal balance and remains altered by pain and sedative drugs. the pupillometry is a reproductive, non invasive method based on automated flash light device assessing pupillary variations [ ] . to study pupillometric parameters to anticipate the tolerance to painful stimuli (surgical debridement). methods. eligibility criteria: sedated patients (morphinomimetics + benzodiazepines, bps = ) in days after invasive surgery for cervical necrotizing fasciitis (cnf), complicated or not with mediastinitis, requiring a surgical debridement three times a day. clinical evaluation performed before and during debridement: heart rate (hr), mean arterial pressure (map) and behavioral pain score (bps) [ ] . pupillometric test before debridement (calibrated bright flash of one-second at lux, (neurolight, id med) with recording of pupillary parameters: minimum and maximum diameter, variation rate, latency, velocity. noxious procedure was defined as an increase of at least one point of the bps (change in facial expression, upper limb movement or ventilator synchrony). the additional analgesia was decided blindly from pupillometric values. analysis compared two groups defined on bps variation induced by the procedure: group with dbps c and group with dbps = . comparison of pupillometric parameters before procedure between the groups. results expressed as median (interquartile range, iqr), mann-whitney test, significance at p \ . . . patients with cervical cellulitis of which complicated by mediastinitis, h/ fratio = / , age years ( ), igs ( ). in this population, during the procedure, hr and map were unchanged, the bps increased significantly [from ( ) to ( ) , p = . ] but remained unchanged in patients ( %) (group = high tolerance). pupillometric parameters before procedure before procedure group (n = ) group (n = ) p conclusions. all pupillometric parameters, except latency, were discriminant for subsequent debridement tolerance with significantly lower values in the group without pain experience. the pupillometric test seemed adapted to this clinical practice for evaluation of nociception status and may help for rationalizing analgesia for short noxious procedures. introduction. delirium is an acute and fluctuating change in mental status, with inattention and altered levels of consciousness. the incidence of delirium in orthopedic patients was ranges from . to %. delirium may present before or after the patient undergoing surgical procedure and has demonstrate increasing risk, including mortality. objectives. the purpose of this study was to compare the effectiveness and tolerability of intravenous propofol versus midazolam infusions in postoperative agitation/delirium therapy with using an epidural infusion for postoperative analgesia after major orthopedic surgeries in high-risk patients with chronic renal failure. with the institutional ethic committee approval; eighty-two high-risk chronic renal failure patients (asa iii, bun [ mg/dl and serum creatinin value [ ) after a major hip or knee operations with a diagnosis of agitation/delirium were eligible for the study in the postoperative period. richmond agitation sedation scale (rass) or confusion assessment method for the icu (cam-icu) were used for sedation/orientation levels. all agitated patients had an lumbar epidural catheter was inserted preoperatively in combination with spinal anesthesia intraoperatively. after the surgery the catheter was loaded with . % mg bupivacaine at the t to l sensory levels and a continuous infusion of . % bupivacaine was commenced at - ml/h in combination with patient controlled analgesia of meperidine ( mg/bolus). for agitation/delirium therapy in group p (n = ) propofol was used with intravenous loading dose of - mg/kg in a bolus and followed by continuous infusion at - mg/kg/h and group m (n = ) midazolam was used with intravenous loading dose of . - . mg/kg in a bolus and followed by continuous infusion at . - . mg/kg/h to ensure a target of rass in + and - values. hemodynamic parameters (heart rates, systolic and diastolic blood pressures), oxygen saturation with sedation-agitation scales were monitored periodically for h. adverse events were recorded. p \ . showed statistically significant. results. the groups were demographical comparable (p [ . ). group p patients reached the target rass scores earlier in group p (p \ . ). hemodynamic values were significantly higher in group m (p \ . ). the epidural bupivacaine consumption was significantly lower in group p with a limited analgesic requirement (p \ . ) and n treatment required adverse events was seen in group p (p [ . ). conclusions. intravenous propofol infusion may be an effective and safe approach adjunct to epidural analgesia for possible postoperative agitation/delirium treatment after major orthopedic surgeries in high-risk patients with chronic renal failure. introduction. ventilator-associated pneumonia (vap) is the most common nosocomial infection among the critically ill patients admitted in the intensive care units (icus). implementation of the available international evidence-based guidelines and recommendations to prevent and manage vap into the clinical setting may not be adequate leading to suboptimal patient care and increased vap rates. objectives. to assess the implementation of selected vap prevention strategies, and to learn how vap is managed by the intensivists practicing in the indian subcontinent. methods. three hundred -point questionnaires were distributed during an international critical care conference. ( . %) were returned and ( %) questionnaires of delegates from india, nepal and sri lanka were analyzed. most of the intensivists ( . %), reported using vap bundles in their icus with a high proportion including head elevation ( . %), chlorhexidine mouthcare ( . %), stress ulcer prophylaxis ( . %), heat and moisture exchangers (hme, . %), early weaning ( . %), and hand washing ( . %) as part of their vap bundle. use of subglottic secretion drainage (ssd, . %) and closed suction systems (css, . %) was also reported by many intensivists, whereas, use of selective gut decontamination was reported by only . % of respondents. most common method for sampling used for diagnosis of vap was endotracheal suction by ( . %) intensivists, and only . % intensivists reported using protectedsample brush. gram negative organisms (pseudomonas, acinetobacter) were reported to be the most commonly isolated organisms. majority of respondents ( . %) reported using proton pump inhibitors for stress ulcer prophylaxis. majority ( . %) believed that vap contributed to increased mortality in their icus with . % treating vap with an antibiotic course lasting for - days. de-escalating therapy was considered, in patients responding to treatment, by . and . % considered adding empirical mrsa coverage and . % considered adding nebulised antibiotics in certain high risk patients. overall there was good concordance regarding vap prophylaxis among the intensivists with a majority adhering to evidence based recommendations and guidelines. even though the gap between recommended guidelines and the actual clinical practice is closing, we could identify certain issues like the choice of agent for stress ulcer prophylaxis, use of hme, ssd and css, where there still exists some practice variability and opportunities for improvement to provide better patient care. objectives. to reassess the value of individual levels and dynamic alteration of procalcitonin (pct) in predicting the outcome of ventilator-associated pneumonia(vap) patient. methods. forty adult patients with vap were studied and divided into two groups according to their outcome at day after diagnosis of vap: death and survival. serum pct levels were measured on days , and (d , d , and d , respectively) and their alteration between different days (kinetics, pct) were calculated. to control the study, acute physiology and chronic health evaluation ii (apache ii), sequential organ failure assessment (sofa), and clinical pulmonary infection score (cpis) and c-reactive protein (crp) were also recorded and analyzed. all parameters have been investigated as independent variables in relation to -day death as dependent variable. results. the increase of pct levels on day , and were significantly predictive of death in univariate analysis with area under curve (auc) and % ci of . ( . , . ), . ( . , . ) and . ( . , . ), respectively. however, kinetics of pct levels among day , and did not show a significant difference between favorable and unfavorable outcomes (p [ . ). multivariate analysis revealed that only sofa ( ) conclusions. neither pct individual levels nor their kinetics during vap course can predict patient outcome. comprehensive evaluation of patients with multiple methods, in combination with pct levels, may increase predictive accuracy in the future. grant acknowledgment. we have no competing interests. introduction. the presence of new or progressive radiological infiltrates, pyrexia, leukopenia or leukocytosis, and the presence of purulent tracheal aspirates are key features defining the presence or absence of vap. the incidence of vap is dependent upon the number of diagnostic criteria applied, and the demographics of the critical care population to which it refers. a uk government directed ''patient safety first'' campaign in the uk, has highlighted vap as a complication related to mechanical ventilation that can be reduced through the introduction of a ''care bundle''. however, benchmarking between different units has practical limitations. objectives. selective data presentation can distort the perceived occurrence of critical events in order to deliver performance targets. we compared the incidence of vap between a neurosurgical and general intensive care unit in the same hospital. a variety of denominators were applied to explore the potential for data manipulation to realise performance targets a local database of neurosurgical and general intensive care admissions, covering a month period, was analysed retrospectively results. and subjects were admitted to gitu and nitu respectively in the month period. ( %) and ( %) subjects were ventilated for more than days. table summarises the demographics and measures of performance between the two units. a p value . was considered significant. parametric and non-parametric tests were applied as appropriate. . vap is associated with not only mortality but also considerable morbidity, prolonged duration of ventilation and increased cost of hospitalisation. to determine the incidence of vap in patients ventilated at the qensiu, to calculate mv resource utilisation, and to ascertain whether vap relates to outcome in acute sci. we undertook a retrospective case note review of all patients ventilated at the qensiu during a year period. patients were identified using a local computerised database. the qensiu receives referral of patients with sci from the whole country (pop * . m). vap was defined pragmatically as deteriorating gas exchange more than h following mv, coupled with a raised crp or wcc, together with either a positive sputum sample or new infiltrates on cxr. statistics: descriptive, median (range); analytical, mann-whitney u and fisher's exact test as appropriate. death occurred in % of patients, and was significantly greater in the group who were retrospectively assigned to the vap cohort: vap vs survival of the deaths, occurred following discharge from the unit ( of whom developed a subsequent vap). conclusions. vap incidence was apparently high in this patient population ( %), particularly in comparison to the reported general icu population incidence ( - %) . this may partially reflect our pragmatic diagnostic criteria, applied retrospectively. vap was also associated with an increase in mortality following discharge in patients with sci. a modified vap bundle adapted to sci patients is being developed locally, based on recent recommendations . introduction. the implementation of a prevention programme with feedback to nurses and healthcare workers (hcw) was associated with better outcomes and increased compliance [ ] . to assess the effects of feed-back in a study based on implementing a variables care bundle to prevent vap. a multicenter and prospective study was carried out in icus. the element care bundle consisted in hands hygiene, oral hygiene, monitoring cuff pressure, sedation vacation/adjustment and avoid ventilator circuits changing. beweekly feed-back displaying posters with information was carried out to update hcw in the compliance of the prevention measures and vap incidence. a questions with open answer questionnaire was performed months after the implementation of the feed-back in all icus to assess the knowledge of the compliance measures, vap incidence, opinion of the study and improvement suggestions. results. questionnaires were obtained. the median experience in intensive care was . years (sd . - . ). % of the staff was aware of the study: . % agree that was useful, . % disagree and . % didn't know. regarding if they thought that in their units they had a high vap incidence, . % answered that they did, . % answered negatively and . % didn't know. asking about the knowledge of the prevention measures' compliance . % answered right, . % said they knew but didn't specify the percentage, . % didn't know and . % didn't answer the question. finally, about the vap incidence, . % answered right, . % said they knew but didn't specify it, . % didn't know and . % didn't answer the question. . % added comments, the most relevant was: . % of the respondents wanted more verbal information. conclusions. poster feed-back failed to improve compliance on vap care bundle due to lack of information. our survey suggests to implement other communication strategies based on direct verbal interaction to improve implementation. objectives. to compare the effectiveness of two different methods of oral dental hygiene on ventilator-associated pneumonia (vap) prevention using the cpis (clinical pulmonary infection score). methods. twenty-seven critically ill patients, aged - years were studied. patients were randomly separated in groups: group (n = ) received oral care with tooth brushing using the bass technique followed by lavage with chlorhexidine . % (chx) solution in nacl . % (chx:nacl . % = : ). hexetidine . % (hex) was used for oral lavage alone in group (n = ). demographics, sofa, apache ii, gcs and cpis scores were recorded upon patient admission. on days , , and , bal and tongue surface cultures were obtained. the endpoints taken into account were the cpis on days , , , and as well as the number and species of bacteria cultivated. a cpis c was considered positive for vap. two-way anova, t test for independent samples, mann-whitney u, pearson correlation and kruskal-wallis tests were used for statistical analysis. p \ . was considered statistically significant. patient data analysis showed that both groups were homogeneous. on days , and there were more negative tongue surface cultures in the chx group than in the hex group (p = . ). even though the cpis did not differ significantly between the groups, a strong tendency of faster and greater reduction in the chx group was observed. moreover, a continuous gradual improvement of the cpis score was recorded in both groups on days , and . the overall incidence of vap was similar in both groups: group , . % (n = ) and group , . % (n = ). the same bacteria (p \ . ) developed in both bal and tongue cultures on days (p \ . ) and (p \ . ). nevertheless, the cpis was positive for vap only in the above patients on day , while day was totally free of vap. conclusions. even though the cpis improvement was more remarkable in group , both group scores showed parallel improvement overtime, the chx group being in a slightly more propitious position. diligence in patient oral care seems to be an additional effective practice for vap prevention, independently of the method used. introduction. specific patterns of cytokine gene expression are reported to be associated with the occurrence of infection in humans [ , ] . it is unclear whether these characteristic profiles are a consequence of an established disease process or precede the infective process. objectives. our primary endpoint was to determine whether hospital acquired pneumonia was associated with differential gene expression of ifn-c, tnf a and il- family of cytokines. secondary endpoint was to identify whether alteration in gene expression preceded the clinical onset of infection. methods. consecutive patients undergoing elective thoracic surgery were recruited. hospital acquired pneumonia was diagnosed as per nnis guidelines, independent of study investigators. mrna and protein levels were analysed pre operatively, h and days post operatively. . patients had an uncomplicated recovery. patients developed hospital acquired pneumonia. il- , il- , il -p , il- -p , il- -p , tnf-a, and ifn-c mrna and protein levels of il- , il- , and ifn-c in peripheral blood were analysed before surgery, h and day post surgery. il- p mrna levels were reduced in the pneumonia group ( , ; , - , ) compared to non pneumonia group ( , ; , - , ) day post surgery (p = . ). ifn-c mrna levels were reduced in the pneumonia group ( ; - , ) compared to non pneumonia group ( ; - , ) (p = . ) day post surgery. absolute copy numbers of mrna per million copy numbers of b-actin are quoted. all values are quotes as median and th to th centile range. patients with postoperative hospital acquired pneumonia exhibit distinct patterns of cytokine gene expression. these distinctive patterns manifest before the clinical onset of pneumonia. objectives. the aim of this study was to evaluate the impact of the implementation of a ventilator bundle on the incidence of vap in our intensive care unit (icu). methods. prospective, observational study. during a year period (january - ) a ventilator care bundle based on the cdc and canadian guidelines , was applied to each patient requiring more than h of mechanical ventilation (mv). the ventilator care bundle consisted in:hand hygiene. use of barrier precautions. preference of noninvasive ventilation (niv). orotracheal intubation. semirecumbent position. continuous aspiration of subglottic secretions. manteinance of the endotracheal cuff pressure. oral care with chlorhexidine. daily sedation vacation and assessment of readiness for weaning. no scheduled ventilator circuit changes. ventilation circuit maintenance. stress bleeding profilaxis. we followed general measures for infection control:single patient room. microbiologic surveillance. monitoring and early removal of invasive devices. program to reduce antimicrobial prescriptions. for each ventilated patient the following data was registered:age, apache ii, the reason of admission, risk factors, use niv, mv duration, timing of tracheostomy, time of diagnosis of vap, microbiological data, length of stay and mortality in icu. the compliance with the bundle was registered in a check list. the application of the ventilator care bundle impact was compared with historical data. . ventilated patients were included. the median age was years. the mean apache ii was . ± . . the reason of admission was in a % medical and % surgical. the most frequent risk factors were: age [ years, emergency surgery, pulmonary disease and immunosuppression. niv was used in %. the median duration of mv was days. tracheostomy was done in . % patients with a delay of ± days. there were late-onset vap episodes and the rate of vap per , ventilator days was . . the vap were caused by candida albicans, enterobacter aerogenes and pseudomona aeruginosa. the length of icu stay was . days. mortality was % (only one patient with vap). the rate of compliance with ventilator care bundle was %. the rate of vap per , ventilator days after implementation of the bundle decreased significantly (table ) . there is currently no consensus on the diagnostic criteria for ventilator associated pneumonia (vap) which has led to significant variation in the reported incidence ( - %) . icus need a reliable and accurate diagnostic system so that the efficacy of measures to reduce the incidence of vap can be assessed, and if vap is to be considered as a quality indicator of performance. objective. to establish a process to diagnose vap that can be used for continuous surveillance and to assess the effect of new therapeutic interventions. method. potential diagnoses of vap were identified prospectively by a senior intensive care doctor and clinical data was collected to calculate a modified clinical pulmonary infection score (cpis) . each case was subsequently reviewed at a multidisciplinary team (mdt) review forum with intensive care and microbiology clinicians. the case details, modified cpis and semiquantitative microbiological culture results were used to reach a consensus view on the diagnosis. a pilot audit performed over a week period in , gave a vap incidence of % ( vaps; ventilated patients; ventilator days) . a change to our ventilator care bundle was subsequently instigated, with the addition of chlorhexidine paste to daily mouth care before repeat surveillance. result: patients were admitted to the critical care unit over days. patients were ventilated during a total ventilator days. patient episodes were identified as potential vap and discussed at the mdt forum. cases were diagnosed as vap (incidence . %) and patient diagnosed as tube associated pneumonia. the other cases were excluded either due to clinical circumstances (n = ) or absence of positive microbiology (n = ). conclusion. we have developed a process for identifying and diagnosing vap within our critical care unit that continues to be used for ongoing surveillance. collaboration between the intensive care team and the microbiology department, along with a mdt forum, has been fundamental to this process. our data highlights the difficulty in diagnosing vap and the need for multidisciplinary expertise. of the patient episodes prospectively identified as potential vap, were deemed not to be vap when clinical data and results were available for review at the mdt forum. the reduction of vap incidence between the pilot study and subsequent screening suggests benefit from the introduction of oral chlorhexidine, however we recognise other contributing factors. controversially, icus in the uk are increasingly being asked to provide data on vap incidence as a quality indicator. we believe that we have a process that is robust and allows us to accurately monitor the incidence of vap. introduction. bacterial biofilm within the internal surface of the endotracheal tube (ett) may contribute to ventilator-associated pneumonia. the gene expression pattern of those bacteria, embedded within biofilm matrix, greatly differs from their planktonic counterpart and allows survival benefits and increased virulence. to compare biofilm production capability of planktonic versus sessile methicillin-resistant staphylococcus aureus (mrsa) retrieved from within etts, and to assess whether antimicrobials can hinder those processes. ultimately, to study any change in planktonic versus sessile bacterial dna. we previously developed a model of pneumonia in pigs mechanically ventilated up to h and challenged into both lungs with mrsa. from those studies, etts of pigs, treated with placebo (n = ), linezolid (n = ) or vancomycin (n = ) were retrieved. distal and medial parts of each ett were processed ( samples). the planktonic mrsa strain, inoculated to the pigs, was compared with sessile mrsa strains, retrieved from the internal surface of the etts, in capability to form biofilm, assessed through the adhesion-to-aplaque method for gram-positive bacteria. the optical density of biofilm was measured using a microplate reader at wave length k = nm and results are proportional to the planktonic control strain (value = ). pulsed-field gel electrophoresis (pfge) was used to determine potential bacterial dna recombination. introduction. ventilator-associated pneumonia (vap) is a common complication in mechanically ventilated patients and is associated with increased morbidity, mortality and costs. treatment-related risk factors associated with vap, include prolonged duration of mechanical ventilation, lack of antiseptic techniques, improper patient's position, inappropriate cuff pressure, peptic ulcer prophylaxis, and deep sedation. objectives. the aim of this study is to evaluate the presence of these risk factors and their association with vap development in a multidisciplinary icu. one hundred and fifty-seven critically ill patients consecutively admitted to a multidisciplinary icu, were prospectively studied. forty-one of them, developed vap ( m/ f age: ± years, apache ii score on admission ± , sofa score on admission ± ). inclusion criteria were intubation \ h prior to icu admission or after h of admission. exclusion criteria included: prior hospitalization in another icu, icu stay\ h, brain death, age \ years old and pregnancy. bronchial secretions, samples from the pharynx and gastric secretions were collected from each patient times weekly (on days , and ). we also documented the known risk factors for vap; sedation depth (using the ramsay scale), cuff pressure, head-bed elevation, reintubation, ventilator circuit changes, tracheostomy, the presence of levin, deep venous thrombosis and stress ulcer prophylaxis, three times weekly per patient results. in this selected sample of patients, the incidence of vap was per , ventilation days. out of this sample, % underwent at least one endotracheal tube change, % had at least once their ventilator circuit changed, % underwent a tracheostomy, % had levin, % did not have head-bed elevation above °, % had ramsay scale or , % had cuff pressure b cmh o, % did not received deep venous thrombosis prophylaxis and all of them received h -receptors antagonists, as gastric ulcer prophylaxis. these results indicate that several risk factors for vap, do indeed apply for the cases under study and that the incidence of vap is relatively high. therefore, the implementation of preventive strategies and the reinforcement of vap bundles can result in beneficial effects on the appearance of vap, in the monitored icu. introduction. pulmonary inflammatory response and progressive ards may complicate posttraumatic ali. clrt by a motor-driven bed is used in trauma patients to improve gas exchange and to prevent from ventilation-associated complications. we investigated the effect of clrt on the inflammatory response in the posttraumatic course. to assess systemic and pulmonary cytokines (interleukin (il- , il- ), intercellular adhesion molecule- (icam- ) before and days after begin of clrt. conventionally positioned patients served as a control group. after approval by our institutional review board trauma patients presenting with ali (pao /fio \ ) were prospectively randomized in clrt (n = ) and control group (n = ). cytokines were assessed from serum (s) and broncho-alveolar lavage (bal) after admission at the icu and on day , respectively. results. the mean age was ± years and mean injury severity score was ± . pulmonary gas exchange improved significantly in clrt in comparison with conventional positioning on day . changes in cytokine levels are presented in table (median and / percentile values, * = p \ . within groups and $ = p \ . between groups, wilcoxon and mann-whitney-u test). serum il- and il- levels were reduced statistically significant on day in both groups, but this effect was significantly more pronounced in clrt-group. in bal cytokines tended to be increased in clrt and control group on day . icam- levels were increased in s and bal after days treatment. conclusions. the early use of clrt reduces the systemic inflammatory response (il- , il- ), but has no influence on regional pulmonary cytokine expression. clrt might be a helpful tool for stabilization in trauma patients with ali. objectives. the aim of this study was to compare the performance of adaptive support ventilation (asv) with and without closed loop control by end tidal co (etco ) (asvco ) to that of pressure control ventilation (pcv) and volume control ventilation (vcv) during simulated ards and to compare the ability of all modes to manage etco , tidal volume (v t ), and plateau pressure (pp) as respiratory mechanics, peep and minute volume changed. methods. asv and asvco were compared to a v t of ml/kg in vcv and pcv using the michigan instruments test lung set up with co titrated into one of the test lung chambers. the compliance of the system was set at and ml/cmh o and resistance at . cmh o/l/min. at baseline ventilation co was titrated to establish a co production of ml/kg pbw/min ( kg) or ml/min. after stabilization and data collection co production was increased to ml/ min and then to ml/min then decreased to ml/min. after each co adjustment and stabilization period data was collected. statistical analyses were performed by anova or kruskal-wallis tests where appropriate, a p value. was considered significant. overall etco level in asvco ( . ± . mmhg) was higher than in other modes (asv . ± . , vcv . ± . , pcv . ± . mmhg) (p \ . ). at the lowest compliance etco in asvco ( . ± . mmhg) was higher than in vcv ( . ± . mmhg) and pcv ( . ± . mmhg). overall v t was similar in all modes except that v t in asvco ( . ± . ml/kg) was lower than in vcv ( . ± . ml/kg) (p = . ). at the lowest compliance v t in asv ( . ± . ml/kg) and asvco ( . ± . ml/kg) were lower than in vcv ( . ± . ml/ kg) and pcv ( . ± . ml/kg) (p \ . ). overall, pp in asv ( ± . cmh o) and asvco ( . ± cmh o) were lower than in vcv ( conclusions. our high mortality in this group of patients despite improved oxygenation concurs with published data. however, potential improvements with adherence to ph and oxygenation targets could be made to ensure optimal use of hfov as a lung protective strategy. objectives. this randomized cross-over controlled study was designed to assess safety, gas exchanges, and ventilator outputs obtained with intellivent Ò as compared to adaptive support ventilation (asv) ( ) in icu ventilated patients with acute respiratory failure. methods. the study was approved by ethic committee and inform consents were obtained by next-of-kin. intubated, sedated and ventilated patients were included (age = ± years, saps ii = ± , and ali/ards and normal lungs patients, respectively). patients were ventilated using a g (hamilton medical, switzerland) with a dedicated software. asv and intellivent Ò were delivered in random order for two periods of h with half an hour of washout in between. tidal volume (v t ), peak pressure (ppeak), spo , and etco were continuously recorded. blood gas analysis and plateau pressure (pplat) were measured at the end of each period. a paired t test was used to compare ventilation and oxygenation parameters between asv and intellivent Ò period. no patient was removed from intellivent Ò for major safety issue. intellivent Ò delivered a lower mv ( . ± . vs. . ± . l/min, p = . ), peep ( ± vs. ± cmh o, p = . ), fio ( ± vs. ± %, p \ . ), vt/pbw ( . ± . vs. . ± . ml/kg pbw, p = . ), and pplat ( ± vs. ± cmh o, p = . ) than asv. static compliance, pao /fio ratio and paco were not different between asv and intellivent Ò . with both asv and intellivent Ò , v t was between and ml/kg pbw in all the patients. figure is showing the distribution of mean of individual breath by breath peak pressure during the two recording periods. conclusions. intellivent Ò delivered lower volumes and pressures than asv for equivalent results on gas exchange suggesting more efficient ventilation. introduction. during neurally adjusted ventilatory assist (nava) pressure applied to the airways by the ventilator is moment-by-moment proportional (according to a proportionality factor called ''nava gain'', unit: cmh o/lv) to the electrical activity of the diaphragm (eadi, unit: lv), as measured through a modified nasogastric tube with a multiple array of esophageal electrodes. independently from its physiological correlation with real diaphragm activity, eadi and its variations are the only variables through which different nava gains may affect patient respiratory pattern. objectives. we explored how eadi influence the effect of varying the nava gain on tidal volume and peak airway pressure. we included twelve patients recovering from acute respiratory failure. all patients, connected to a servo-i ventilator (maquet critical care, solna, sweden) able of delivering both psv and nava, underwent to a random application of increasing gains ( . - - . - - . - - cmh o/lv) during nava and increasing pressure support ( - - - cmh o) during psv. each level was maintained at least min. all changes in eadi, tidal volume (vt), and peak airway pressure (paw peak ) were referenced respect to their respective values at nava gain . . introduction. lung protective ventilation strategies is considered 'gold standard' for patients with acute respiratory distress syndrome (ards). high-frequency oscillation (hfo) has been used as a rescue measure and claimed to protect the lungs from ventilator induced lung injury ( ) . theoretically hfo should be considered early in the course of ards. objectives. we were interested to determine the time course to achieve optimal gas exchange with early hfo and its impact on the use of other adjunctive therapies; inhaled nitric oxide, prone positioning and extracorporeal oxygenation or carbon dioxide removal. after ethical approval, a total of adult patients with ards were enrolled in this prospective observational study. the oscillation (metran co. ltd, - , -chome, kawaguchi, saitama, japan) was started when fio [ . or level of peep [ cmh o were required on a conventional ventilator. hfo frequencies, cycle volume and bias flow were altered until optimal gas exchange achieved. the pattern of gas exchange was observed for the first h and other adjunctive therapies were used when required. the following parameters were recorded: duration of hfo, arterial blood gases during the first h, frequency of need for other therapies, incidence of barotraumas, and re-requirement of hfo once weaned from. a total of patients (age between - years, male:female ratio = : ) were ventilated - days with conventional ventilator before start of hfo. duration of hfo varied from to days ( median). there was a significant improvement in pao at - h (p = . ) following the onset of hfo (fig. ) . the number of patients requiring other therapies are very low; inhaled nitric oxide n = , prone positioning n = , both prone positioning and nitric oxide n = , ecmo/novalung n = . seven patients required re-hfo once weaned and another two developed pneumothoraces requiring chest drainage. conclusions. the data of this study demonstrates that significant improvement in gas exchange occurs in patients with ards following - h of hfo. early oscillation also appears to reduce the need for other adjunctive therapies. further studies of early hfo strategy are warranted. introduction. neurally adjusted ventilatory assist (nava) is a novel method for patient triggering of pressure support. instead of relying on conventional pressure or flow triggering, the peak diaphragmatic emg signal (edi) is used to precisely synchronise patient demand with ventilatory assist. although, the physiology and science underpinning nava has been described, less is known about its clinical application and efficacy ( ) . in particular, clinical superiority over conventional pressure support has not been established. objectives. here, we describe the clinical, nursing and operational lessons learnt from the introduction of nava platforms (servo-i, maquet) into a -bedded central london intensive care unit over years. in parallel we present some novel data from an observational cohort study examining the effect of nava on sedation use and ventilator days. a protocol for the safe measurement of edi in critically ill ventilated patients was developed through multidisciplinary review and discussion. a year registry of clinical lessons and adverse events from the introduction of nava was kept. in a parallel observational cohort study we examined three populations of ventilated patients (n = ) matched for apache ii, oxygenation index and compliance. group had no nava catheter; group had edi signal measured during conventional pressure support; and group utilised the edi signal to act as a neural trigger to drive ventilatory support. results. the measurement of edi was not associated with a difference in hospital mortality. there was a significant reduction in sedation use, muscle relaxation, ventilator days and icu days in patients with a nava catheter (fig. ) . however, there was no significant difference in any of these parameters with edi measurement guiding conventional pressure support versus nava. ventilator days in nava versus pressure support conclusions. in this study we show that neurally adjusted ventilatory assist can be safely and effectively be introduced into a 'non-expert' intensive care unit. we further show that reductions in sedation use and ventilator days appear to be related to the earlier introduction of sedation holds and reductions in ventilatory assist (with consequent earlier spontaneous breathing trials) in order to acquire an edi signal rather than due to an intrinsic advantage gained by improved patient-ventilator synchronisation with nava. the causes of the respiratory failure were: infections n = ; . % (immunodeficiency n = , tuberculosis n = , aplastic anemia n = , congenital cardiomyopathy n = , sepsis n = ), rsv infection-bronchiolitis n = ; . %, bronchopulmonary dysplasias n = ; . %, leukemias n = ; . %, burn-ards n = ; . %. the mean duration of hfov was . days ( h to days). the parameters of ventillation ranged: fio : - %, mean pressure: - cmh o, dp: - cmh o. the i time and hertzs ranged within the acceptable for age limits. closed suction circuit was used. we didn't notice any side effects from cardiovascular system or distension of the thorax. eadi and respiratory effort indices decrease when assistance increases in nava. nava should also theoretically allow perfect synchronization between the patient and the ventilator, and no asynchrony has been described with this mode. nava level adjustment at bedside, however, is still a matter of research. we assessed breathing pattern, respiratory effort indices, and patient-ventilator synchronization throughout a titration of nava and of pressure support ventilation (psv). we assessed breathing pattern, respiratory effort indices, and patient-ventilator synchronization throughout a titration of nava and of pressure support ventilation (psv). methods. physiological study conducted in seven patients (preliminary results) during the weaning. airway pressure (paw) and flow, esophageal and gastric pressures and the eadi were continuously recorded. for each patient, the following levels of assistance were consecutively applied: in psv: - - - - cmh o; in nava: . - - . - - . - - - - cmh o/mvolt. results are given as median and [ th- th percentiles], and tidal volume (vt) in ml/kg of predicted body weight. results. the increase from the lower to the higher level of assistance was associated with an increase in vt from . [ . - . ] to . [ . - . ] ml/kg in psv and from . [ . - . ] to . [ . - . ] objectives. we describe technical possibilities, tolerance and gas exchange with combination of oscillation device with nimv. a specific oscillator device (sensor medics, vyasis) was selected to change conventional airflow to oscillatory airflow. connected by ''t'' piece with oscillatory devicerespiratory circuit-face mask. we selected bipap ventilator (vision resp inc), facial mask. bipap mode (iap/epap cmh o) to achieve stable mechanical ventilation (t ). a progressive increment in rate of oscillation (hz) and power oscillation to achieve airflow change (t ). to evaluate the differences of peepi during the release phase, referred to mechanical pressure release from p high to p low , and the inspiratory work of breathing (wob) during p high among currently available aprv ventilators, using a lung model (ttl , mi). methods. the six aprv ventilators were evaluated in this study: ) nellcor puritan-bennett (puritan-bennett), ) evita xl (drager), ) servo i (maquet), ) avea (viasys), ) g (hamilton) and ) engstrom (ge healthcare). ventilator settings in aprv ventilators were set as follows: p high /p low cmh o/ cmh o, t high /t low . s/ . s. when evaluated peepi during the release phase, t low was diminished by steps of . s from . to . s. the inspiratory pressure-time product (ptp), as an index of wob, was directly measured under with tidal volume/respiratory rate of ml and /min. measurement for each setting was performed in a random order. three breaths were analyzed and averaged for each measurement. the results are shown in fig. objectives. to perform bench study to test the hypothesis that ett or trach can reduce the insufflated (vti) and/or exsufflated (vte) volume as provided by coflator Ò . methods. coflator Ò is connected to a pneumatic model (ttl, michigan instruments) via ett mallinckrodt . , . , . , . , . ) or trach (mallinckrodt . , . , . ) . the set up is tested in conditions of compliance (c ml/cmh o) and resistance (r cmh o/l/s): c r , c r , c r , c r . the device is set in manual mode, at the highest inspiratory flow, inspiratory/expiratory time / , s pause after expiration. three pressures are used, , and cmh o in both inflation and deflation. a baseline condition without any tracheal prothesis nor r served as reference. airflow and pressure upstream ett or trach are measured (biopac mp ). five insufflations followed each by an exsufflation are performed in each condition. the data are analyzed by using a linear mixed effects model where ett or trach, and pressure have fixed effects and c or r a random effect. the dependent variable is vti and vte. the main end-point is the slope of the relationships between vti or vte and pressure. results. the vti-pressure slope was significantly lower with any ett than baseline at both c ( fig. a and b). the same was true for trach. even though these differences were statistically significant the reduction in vti from the baseline averaged ml with etts as a whole. the vte-pressure relationships were similar for ett and trach and showed no difference from baseline at c ( figure d ). however, at c , the relationships are scattered ( figure c ). moreover, expiratory pressure of - and - cmh o were not reached for ett . , . and . and trach . and . . conclusions. ett and trach slightly but significantly change the performance of the device. however, small sized ett or trach in c condition substantially modify the efficacy of the exsufflation. these findings desserves assessment in patients for relevance. rd esicm annual congress -barcelona, spain - - october s though humidified high flow nasal canula oxygen (hfnc) has been widely studied in pediatric population, few data in adult is available and its and its precise indications and actual benefits in these patients remains unknown. two studies have shown that hfnc generates a low level of positive airway pressure contributing to decrease the work of breathing. one study has reported a favourable effect on comfort and oxygenation of hfnc as compared to venturi mask and in another preliminary one, fewer patients using hfnc went on requiring non invasive ventilation. objectives. to evaluate the efficiency of hfnc (optiflow, fisher and paykel, auckland) in critical care patients with acute respiratory failure. methods. prospective single centre study in a university hospital intensive care unit. all patients exhibiting acute respiratory failure (arf) as defined by clinical signs and/or failure of haematosis, regardless of the aetiology, were eligible. hfnc was used at a mean output of ± l/min and a mean fio of ± % throughout the study period. results. thirty-five patients were included. the mean age was . ± . years old and mean saps ii is ± . pulmonary infection was the most common aetiology of arf. hfnc was used ± days. all but one patient were discharged alive from icu. optiflow significantly reduced respiratory rate (p \ . ), heart rate (p \ . ), dyspnea score (p = . ), sus clavicular recession and thoraco abdominal asynchrony, and improved pulse oxymetry (p = . ). there was no significant difference in ph, pao , paco on arterial blood gazes performed before and , and h after hfnc use. the pao /fio ratio at and h after hfnc initiation was higher than before use of hfnc (p = . ). patients ultimately intubated exhibited a higher respiratory rate min ( . ± . vs. . ± bpm, p = . ) and min ( with an incidence of up to % in routine sonography [ ] , pleural effusion is one of the most common complications in intensive care patients. the use of bedside d ultra-sound to detect pleural effusion is fast, practicable and minimises radiation exposure [ ] . however, sonographical volumetry tends to be imprecise, and ct imagingbased volumetry is the more accurate method to quantify pleural fluid in intensive care patients [ ] . objectives. the aim of this study was to compare the accuracy of d and d ultra-sound volumetry of pleural effusion in intensive care patients. methods. icu patients designated for thoracentesis because of radiological support for pleural effusion were examined both with d and d ultra-sound \ h before and after the intervention. effusion volume was calculated with the formula ''volume [ml] = sep [mm] '' [ ] for d measurements and compared to the d volumetry by the ge d view software. the difference of volumetry before and after intervention was compared to punctured volume (gold standard). the device used for u-sound measurements was the ge voluson i. . within the group under survey (n = ), eight patients were on the respirator. mean punctured volume was ml ( ml; ml). mean absolute value of deviation from punctured volume (gold standard) was ml ( . %) for the d measurements and ml ( %) for d measurements. biggest difference between methods was found between ml and ml punctured volume. none of the methods generally measures higher volumes than the other. conclusions. the size of deviations from gold standard in both directions in d measurements suggests that the method is not reliable in predicting pleural effusion volume. d measurements are more likely to predict the right effusion volume, making the method a better diagnostic tool than d u-sound measurements. although thoracocentesis was found to be safe for mechanically ventilated patients [ ] and d volumetry may not change the therapeutic decision, which depends on high-risk patients' overall clinical condition, it could nevertheless help to avoid unnecessary interventions and thus improve patient safety. ongoing work analyses results for a group of patients with ct imaging-based volumetry of pleural effusion as gold standard. we study the utility of deltacvp changes during pressure support ventilation (psv) as an indication of respiratory effort. patients after several t-trials failures were on psv. the level of ventilatory assistance was changed in order to set the psv. no aditional interventión was used in the management of these patients. we registered data from the ventilator and beside monitor (vt, rr, p , deltacvp) in two levels of ps. optimal-ps, as the lowest support without respiratory distress and with the middle of this level -psv. the inspiratory trigger was used with the highest sensibility without autotrigger, the inspiratory ramp was changed in every patient and expiratory was flow-cycled at % of the peak inspiratory flow. results. patients n, acute on chronic respiratory failure, n, heart failure, n, recovery of acute respiratory failure. age ± years, admission apache ii ± and they needed weaning with ps after ± days with control mechanical ventilation. the respiratory mechanics in this time were cst.rs ± ml/cmh o and raw.rs ± cmh o/l/s. the ramsay score was ± ( ) ( ) ( ) ( ) ( ) . when the optimal level of ps was decreased from ± to ± cmh o, all patients showed respiratory distress, and the variables studied changed significantly: p : . ± . to . ± . cmh o, deltacvp . ± . to . ± . cmh o, vt decreased from . ± . to . ± . l and rr increased from ± to ± bpm (p \ . ). the correlation between p and del-tacvp was . (p = . ). central venous pressure swing provided information about the respiratory effort and may be useful during pressure support ventilation. introduction. the use of a tidal volume of ml/kg of predicted body weight is part of the management of patients presenting with ards ( ) and prevents ventilator induced lung injury in icu patients undergoing mechanical ventilation ( ) . the setting of tidal volume is based on patient height. height seems to be more often estimated by the icu staff than actually measured ( ). objectives. our study aimed to assess the accuracy of the visual estimation of patient height and its impact on ventilator settings. thirty-two patients admitted to a surgical icu were prospectively included in this observational study. patients had their height visually estimated by icu staff members ( doctors, nurses and nurse-assistants) and then measured. we also measured the knee height from which height can be extrapolated. we then compared the mean estimated height for each patient to the actual measured height with the use of bland and altman plots and the consequences of the measurement error on the tidal volume setting. in most patients visual estimation overestimates the actual height. the measurement errors result in an increase in the tidal volume up to + ml/kg. this remains true whatever the subgroup studied: all patients (bias: . ± . , % ci: - . ; . ), male patients (bias: . ± . , % ci - . ; . ), female patients (bias: . ± . , % ci . - . ) and whatever the type of assessor. extrapolated height from knee height results invariably in an underestimation of actual height (bias - ± . , % ci - . ; . ). our results prove that neither visual estimation nor knee height measurement are reliable surrogates for measured height. therefore, measuring patient height should be mandatory in critically ill patients in order to minimise ventilator-induced lung injury. methods. , respiratory acts were recorded in icu patients selected because of severe asynchrony with the ventilator (g , hamilton medical) during psv. by visual analysis (va) of airway pressure and flow trajectory, ineffective efforts and inspiratory/expiratory delays were detected. the results of va were compared with those provided by a new algorithm based on the automatic analysis (aa) of flow trajectory. results. va identified ineffective efforts ( % of patients acts). among , assisted acts, average inspiratory and expiratory delay was ± ms and ± ms, respectively. significant inspiratory and expiratory delay ([ ms) occurred in , ( %) and in acts ( %), respectively. automatic analysis was able to identify , of , patients acts ( %). in , cases ( %), both inspiratory muscles contraction and relaxation were detected. in acts ( %) only relaxation was identified. compared with va, inspiratory and expiratory delay of aa was ± and ± ms, respectively. aa recognized the start and the end of patient's effort before the ventilator in , ( %) and , ( %) of assisted acts. sensitivity and specificity of aa in detecting ineffective efforts, inspiratory delays [ ms, expiratory delays [ ms were and %, and %, and % respectively. the new algorithm proved to be efficient as a real-time, continuous monitoring system of patient-ventilator interaction. the advantage over traditional flow and pressure based triggers has to be tested. introduction. mechanical ventilation remains as one of the most difficult safety issues in the icu, but parameters commonly monitored by ventilators only depict the most extreme risks for patients. new computerized approaches may manage exhaustive data and may include ''intelligent'' software that mirrors expert decision making. to test the clinical usefulness of a new computerized system as a herald for clinically significant alarms and its possible impact in outcome. methods. twenty-five mechanically ventilated patients were continuously monitored in a single mixed icu in a university-affiliated hospital. we recorded age, diagnosis, pao /fio , apache ii and sofa on admission. the computerized system grabs and process data from different devices, usually a monitor and a respirator, and evaluates the most relevant events in a ventilated patient. all the algorithms were designed and validated with the clinical staff. data of ventilated patients were recorded at the icu during months and a total of , , breaths from different patients, each of them with a register of at least % of total ventilation time, were collected. data include biomedical signals (waves and trends) as well as all the clinical events detected by the system, including trapped gas at end-expiration, presence of secretions, double-cycling, asynchronies during expiration, pulse pressure variation in patients not triggering the ventilator and stress index ([ . or . ) in those ventilated with square airflow. outcome variables were icu length of stay, hospital stay and mortality. statistical analysis included multiple regression models for length of stay and mortality. [ ] [ ] [ ] [ ] [ ] [ ] [ ] , icu length of stay . days [ . - ] , hospital length of stay days . the frequency of alarms were: trapped gas at end-expiration: . %, presence of secretions . %, double-cycling . %, asynchronies during expiration . %, stress index [ . . %, stress index . . %, and pulse pressure variation . %. multiple regression analysis found pao /fio associated with length of mv and close to significance with hospital stay and mortality, but any of the computerized alarms reached yet the level of significance. conclusions. the computerized system is able to detect and review more clinically significant problems than clinical routine. however, its impact to define patient outcomes warrants further investigation. objectives. we have assessed the ability of the ventilator t-bird vs and ltv- to deliver to a lung model with ards a set tidal volume (vt) at different simulated altitudes. we used a decompression chamber to mimic the hypobaric environment at a range of simulated cabin altitudes of , , , and , m ( , , , , , feet). ventilators were tested with realistic parameters. vt was set at and ml in an ards lung model. the positive end expiratory pressures (peep) were set at and cmh o. pressure drop across the pneumotachograph was measured by a differential pressure transducer (enertec tm ). the spirometer was checked at each altitude using a calibration syringe. the inspired oxygen content (fio ) was %. respiratory rate was breaths/min. the ratio inspiratory time/expiratory time was / . the protocol included three measurements for each simulated altitude. comparisons of preset to actual measured values were accomplished using a t test for each altitude. a significant difference was defined by p \ . . the standard deviation for the three measurements obtained at each altitude was consistently less than ml. respiratory rate delivered was breaths/min in all cases. variation of peep did not change the volume delivered. the t-bird vs showed a decrease in volume delivered. comparisons of actual delivered vt and set vt demonstrated a significant difference starting at , m for a vt set of ml, at , m for vt set of ml. at these altitudes, the variations between vt set and delivered were more than %. with decreasing barometric pressure, the ltv- showed mostly an increase in volume delivered. comparisons of actual delivered vt and set vt demonstrated a significant difference at , m for a vt set of ml, at , m for vt set of ml. the delivered tidal volume remained within % of the set vt. assuming that the patient is ventilated at sea level and gas exchange is normal, the movement to altitude would result in an increase in tidal volume which might in fact represent a clinical event. conclusions. the ltv- met the trial targets in all settings, whereas the t-bird-vso did not compensate well for altitude and progressively delivered lower volumes as barometric pressure decreased. such variations between delivered and set vt suggest lack of efficacy of altimetric correction in hypobaric conditions in some devices. the ltv showed a moderate increase in volume delivered for ards lung model with increasing altitude, but maintained the delivered volume within % of the set vt up to , m. the accuracy of the vt delivery was superior with the ltv- than with the t-birdvso . oxygen therapy is commonly used to correct residual oxygenation impairment in the post-extubation period. this is usually done through a venturi mask which allows to deliver predetermined fractions of oxygen humidified with bubble humidifiers. the low humidity delivered by such devices and the use of an oro-nasal mask may, however, reduce patient's comfort, possibly resulting in mask displacement or removal and consequent oxygen desaturations. nasal high-flow (nhf) oxygen therapy allows to deliver high-flow oxygen, humidified with heated humidifiers and delivered through nasal cannulae, with the potential to improve comfort and efficacy. objectives. in patients requiring oxygen therapy after extubation, we compared nhf vs. venturi mask in terms of oxygenation and comfort. patients who were mechanically ventilated for more than h, passed a spontaneous breathing trial, and had pao /fio \ at the end of the trial were randomized to receive oxygen with nhf or venturi mask after extubation. exclusion criteria were: tracheostomy, age \ , pregnancy, or anticipated need for noninvasive ventilation after extubation. in both groups, fio was set to obtain spo between and % ( - % in copd patients). with nhf, flow rate was set at l/min. arterial blood gases, respiratory rate, and discomfort were assessed at , , , , , , and h. discomfort was assessed by asking patients to rate their discomfort with the used device by using a numerical scale from (no discomfort) to (maximum imaginable discomfort). discomfort symptoms were also assessed for the dryness of the delivered oxygen (dryness of the mouth, throat, nose, difficulty to swallow and throat pain). incidence of desaturations and interface displacement was also assessed. objectives. to evaluate the optimal humidifier water temperature when using a helmet for noninvasive positive pressure ventilation. oxygen. each was sequentially tested in the following order: using the helmet without humidification at ambient temperature, with humidification with unheated chamber water, and with humidification with the chamber water at , , and °c. at each setting, after a min stabilization period, measurements were taken. comfort level at each setting was evaluated using a visual analog scale (vas) rated zero (most comfortable) to ten (least comfortable). temperature and relative and absolute humidity inside the helmet, and vas scores statistically significantly increased as the humidification chamber water temperature increased. the lowest vas, . ± . , was obtained when water in the humidifier chamber was at ambient temperature. conclusions. for patient comfort during cpap using a helmet, the most desirable conditions are likely to obtained by humidifying without heating, that is by leaving the water in the humidifier chamber at room temperature. introduction. the physiological and clinical effects of non-invasive ventilation (niv) on acute post-operative respiratory failure are relatively unknown. the aim of this study was to determine the prediction factors for failure in the use of niv with a helmet in this context. the use of niv was assessed for a period of years, in a post-operative intensive care unit (icu). demographic data was collected, as well as arf and arterial gas readings. haemodynamic changes were assessed using picco tm technology and the clinical development of patients was recorded. all patients who developed acute respiratory failure (arf) were treated using niv as their primary care, and the two groups for the study were determined in this way, depending on whether the technique was successful, or the patients required intubation. the risk factors that determined failure in the application of niv were subsequently determined. of the patients presenting with post-operative arf treated with niv using a helmet, did not require intubation ( . %). following a multivariate analysis using logistic regression, we determined that there are four independent risk factors for the failure of niv. the primary causes of respiratory failure are as follows: acute respiratory distress syndrome (ards) and pneumonia, and in second place, the high initial evlwi (extravascular lung water index) value, as a protective factor, is the increase in the po /fio ratio after the first hour of niv application. conclusions. niv using a helmet could provide an effective alternative to conventional ventilation in selected patients with post-operative arf. -jaber s, delay objectives. analyze niv practice in emergency departments. we have development an international epidemiology survey (march ) by electronic questionnaire to know niv organization, equipment and training in emergency departments (phase i). design. international multicenter prospective. we have enrolled information from hospitals: spain ( ); italy ( ); india ( ); usa ( ); slovakia ( ); turkey ( ); germany ( ); australia( ); chile ( ); singapore ( ); finland ( ) during to analyze noninvasive practice in prehospital and emergency medicine, equipment, interfase, ventilatory modes and common clinical applications. major results during month period analysis were: noninvasive mechanical ventilation were applied in prehospital: ( ) ( . %). nimv commonly was applied follow a objective pprotocol of nimv: ( ) ( ) ( . %). global rate indication of niv were copd exacerbation ( %) and cardiac pulmonary edema ( - %). all niv applications were successful applications in emergency departments (avoid eti %) with minor complications ( . %) (skin nose lesion). equipment more relavant were (cpap devices ( %) and facial mask ( %) was more frequent, follow total face( %); nasal mask ( %); helmet ( %); type ventilary mode: cpap ventilatory mode was frequent used as first line ( % ( ) suggest niv should be started within h of not responding to the maximal medical therapy for acute type respiratory failure patients. following an earlier audit presented as an abstract at esicm ( ) , which looked at possible delays in starting niv, protocols were implemented to start niv earlier at russells hall hospital acute admissions unit. objective. the aim was to assess the delays in starting the appropriate patients on niv at admission looking at impact on adverse outcomes. method. data was collected retrospectively using bts niv audit tool. cases admitted with type respiratory failure in our hospital between january and march who needed niv were included in the audit. delay was subdivided into a) door to first arterial blood gas (abg) sampling b) abg to decision for niv and c) from decision to actual starting of niv. results. the mean time to get an abg from admission was min. cases with delay more than h skewed the data. the median time, which was more representative of the usual delay between admission and first abg, was min. our audit showed that out of ( %) patients had abg within an hour compared to out of ( %) in the last audit. although noninvasive ventilation (niv) has been widely used in patients with acute on chronic respiratory failure (acrf) due to chronic obstructive pulmonary disease (copd), series studying patients with pulmonary restriction due to morbid obesity (mo) are rare ( ) , despite the disease is highly prevalent in our environment. objectives. the aim of our study is to analyze and compare the effectiveness of niv in patients with copd and om. we analyzed all patients admitted to icu for a period of years with diagnosis of acrf due to copd or mo and treated with noninvasive ventilation. niv success was defined as the avoidance of endotracheal intubation, survival in icu and at least h on a medical ward with no signs or symptoms of respiratory failure. variables are expressed as means ± standard deviation and percentages. comparison between variables by pearson's v test and student t. we analyzed survival and hospital readmission per year (log rank test). during the study period, patients were admitted with exacerbation of copd and with mo. all patients were treated with two levels of pressure. age differs between copd and om, ± and ± years, respectively (p = . ), as well as the percentage of men, . adaptive support ventilation (asv) Ò (hamilton galileo) has been shown to result in better patient synchrony, reduced weaning times and reduced work load for the icu staff ( , ) . but, data is lacking on its efficacy, especially as non invasive ventilation (niv) due to the concern of being closed loop ventilation. also, little is known about the risk factors of late niv failure in patients who improve initially ( objectives. to assess end tidal co monitoring in patients with hypercapnic exacerbations of copd requiring niv methods. simultaneous measurement of paco and petco was performed in groups of patients. paco was measured using arterial blood gas analysis and petco was measured using non-invasive capnography. the groups were; phase a: mechanically ventilated patients post coronary artery bypass graft, used to establish the reliability of the end tidal carbon dioxide monitor in a homogenous group of previously well patients. phase b: patients with copd who did not have symptoms associated with an exacerbation, used to assess the use of a non invasive sampling device and assess the sampling method in stable copd patients. phase : patients with a hypercapnic exacerbation of copd requiring niv. capnography was monitored continuously in this group and petco values were calculated based on a mean value min before and after the arterial blood gas sample. this was to avoid any sampling error as it was impossible to isolate the exact moment of arterial puncture. agreement between the sampling methods was assessed using the bland-altman method. phase a objectives. we aimed to evaluate the possible harm of niv failure in routine practice among spanish icus. methods. we extracted patients with acute respiratory failure requiring either invasive or noninvasive mechanical ventilation in spanish icus during the -month period of the validation of the sabadell score ( ). we recorded demographic parameters and treatments received during the icu stay. patients were followed until hospital discharge or death. results. we analyzed , patients, of whom , ( %) received only invasive mechanical ventilation (imv) and ( %) received niv. niv succeeded in % of patients, but the other % required intubation. niv failure was more common in neurologic ( %) and post operatory ( %) and less frequent in coronary patients ( %). mortality was lower than predicted in niv patients ( vs. %) and similar to predicted in imv patients ( vs. %). mortality was lower than predicted in patients in whom niv was successful ( vs. %) and (similar or slightly lower than to predicted) in those in whom niv failed ( vs. %). conclusions. routine use of niv seems to confer a benefit, even when it fails and intubation is needed. reference(s tables and shows the parameters on respiratory muscles. introduction. the effectiveness of non-invasive ventilation (niv) in the setting of hypoxemia de novo remains controversial. it has been detected that patients in whom niv fails and intubation is required have a high mortality. otherwise, in patients in whom niv avoids intubation, survival rate is also high. to identify the factors involved in success or failure of niv in critically ill patients with hypoxemia de novo. we retrospectively studied all the patients admitted in our -bed intensive care unit (icu) from january to december with the diagnosis of hypoxemia de novo. do-notintubate patients were excluded. the indication of niv was at medical discretion, as well as intubation criteria. we defined the hypoxemia de novo as acute non hypercapnic respiratory failure due to a different cause from cardiogenic pulmonary edema. we defined two groups of patients: ) niv failure, patients who required intubation, and ) niv success, patients who did not require intubation. we collected demographical variables (age and gender), etiology of the hypoxemia, severity scores on admission (saps ii and sofa), glasgow coma scale (gcs), respiratory rate (rr), pulsioximetry (spo ), ph and fio , before and h after starting niv, episodes of nosocomial respiratory infection, length of stay (los) in icu and icu mortality. we compared both groups using the mann-whitney non-parametric test. p \ . was statistically significant. we studied patients ( women and men) with a mean age of ± years. the etiology of respiratory failure was: ards (n = ), pneumonia (n = ) and others (n = ). there were patients in the niv failure group ( %), and in the niv success group ( %). niv failure rate was higher when hypoxemia was due to ards (p = \ . ). objectives. this retrospective analysis aimed to assess outcomes following instigations of niv in a variety of clinical conditions. outcome data for copd/apo and non-copd/apo groups were compared. we assessed whether outcomes differed between these groups. in addition we wished to assess how outcomes varied across non-copd, non-apo conditions. objectives. the aim of this study was to compare patient's respiratory effort with three different noninvasive ventilators currently used on critical care patients and selected from a bench study. six patients treated by niv to prevent respiratory failure after extubation were included. each subject was successively submitted to a randomly assigned min-period of ps-niv with three different ventilators: bipap vision (respironics), elisée (resmed) and oxylog (dräger medical). these ventilators have different performances in a bench comparison. ventilatory settings were adjusted for the first ventilator and maintained for the followings. ps level was increased in order to obtain a tidal volume of - ml/kg of body weight (ps ± cmh o). flow, airway and oesophageal pressures were recorded. the oesophageal pressure time product (ptpoes) and tidal oesophageal swing (dpoes) were measured to evaluate patient's respiratory effort. results. no significant differences in tidal volume, respiratory rate and autopeep were found between ventilators. the dpoes and ptpoes, however, were significantly higher with oxylog as compared to bipap vision and elisée , as expected from the bench comparison. there are limited data on niv s efficacy in hypoxic respiratory failure. objective. to investigate the epidemiology and outcomes of patients administered niv as first line respiratory support in a mixed medical-surgical icu over a year period (jan -dec ), in an academic medical center. methodology. data abstraction from icu database, clinical care manager and chart review. results. surgical patients (sp) and medical patients (mp) were administered niv. the sp were % male, and had a median age of years. the mp were % male, and had a median age of years. % of sp were admitted with type respiratory failure (t rf pao \ kpa), % were admitted with type respiratory failure (t rf paco [ kpa) and the remainder were admitted with respiratory distress (rd). % of mp were admitted with t rf (pao \ kpa), % were admitted with t rf (paco [ kpa) and the remainder were admitted with rd. the median length of stay (mlos) was days for sp (range - ); the mlos for mp was days (range - ). sp were commenced on niv on average . h after admission (range - h), and remained on niv for a median of . (range - ) h. % of surgical patients required intubation, and the mortality rate was . %. mp were commenced on niv on average h after admission (range - h), and remained on niv for a median of (range - ) h. % of medical patients required intubation, and the mortality rate was %. logistic regression was applied to all datasets. among medical and surgical patients there was no correlation between the type of respiratory failure, initial blood gas or ph and the need for subsequent intubation, or risk of death. hematology patients had a mortality rate of % and accounted for % of overall deaths. oncology patients also had a % mortality rate, and accounted for % of overall deaths. amongst the mp that presented with hypoxemia, the intubation rate was % and the mortality rate was % (although not all patients that died were intubated). amongst the mp that presented with hypercarbia, the intubation rate was % and the mortality rate %. summary. niv successfully prevented intubation in more than % of patients. patients presenting with hypoxic respiratory failure were no more likely to be intubated than those presenting with hypercarbia. two-thirds of hematology and oncology patients treated initially with niv subsequently died. a microdialysis system was composed and the time delay of the system, recovery time, was introduced and tested with a fluids switching method. twelve sd rats were divided into ir or control group. myocardial ir was induced by ligating ( min) or releasing ( min) the suture underlying lad. mycrodialyisis probe was implanted into the left ventricular myocardium perfusion area to be occluded. dialysate samples were collected every min. blood samples were drawn at the beginning and at the end of the procedures. dialysate calcium concentration ([ca++]i) was detected with an atomic absorption spectrophotometer. serum calcium and ctnt were detected. recovery time for the microdialysis system was min, recovery rate was %. [ca++]i showed no changes during ischemia and descended immediately after reperfusion,reached the lowest level at min after reperfusion, then escalated slowly while keeping lower than control with significant difference. there was no difference in serum calcium at the beginning ( objectives. to evaluate the causes, incidence and impact on outcome of admission hyperlactatemia in patients admitted to a general micu. methods. data were retrospectively collected from the patient records for all adult patients admitted in the micu during the -months period. data regarding patient demographics, probable cause of hyperlactatemia, presence of shock on admission, need for organ support and icu outcome were recorded. patients were divided into two groups based on admission lactate levels: high lactate, with levels of mmol/l or more and normal lactate, with levels less than mmol/l. patients in these two groups were compared in terms of need for organ support and icu mortality. the efficacy to discriminate between survivors and non-survivors was assessed by area under the receiver operating characteristic curve (auroc). introduction. during critical illness alterations in blood flow are thought to predispose to organ dysfunction and hemodynamic therapy is often targeted at maintaining organ perfusion. however, abnormal blood flow distribution during critical illness may cause regional blood flows to correlate poorly with systemic haemodynamics ( ) . currently, our understanding of blood flow distribution during critical illness in humans has been limited by the invasiveness of established techniques for its measurement. objectives. phase-contrast mri (pc mri) represents an entirely non-invasive, contrastfree, method of measuring blood flow in major blood vessels ( , ) . we sought to apply this technique to technique to the measurement of organ blood flow in the critically ill. in a pilot proof of concept study, we measured renal and portal blood flow by pc mri critically ill humans with sepsis, multi-organ dysfunction and acute kidney injury (aki). in individuals cardiac output was measured by thermo-dilution in the icu, in the remaining patients we measured cardiac output (ascending aortic flow) and also descending thoracic aortic blood flow using pc mri techniques. we studied critically ill individuals with severe sepsis and aki. when studied, were mechanically ventilated, were on continuous haemofiltration and required vasopressors. transport and mri examinations were carried out without complication. in these patients, median cardiac index was . l/min/m (range . - . ), median renal blood flow ml/min ( - , ) and median renal fraction of cardiac output . % ( . - . ). median portal blood flow was ml/min ( - , ). descending aortic blood flow (measured in patients) ranged between and % of cardiac output (median %). conclusions. phase-contrast mri can efficiently and safely assess organ perfusion during critical illness in man. near simultaneous measurement of cardiac output enables organ blood flow to be assessed in the context of the global circulation. preliminary observations suggest renal blood flow is consistently reduced as a fraction of cardiac output in established aki. pc mri may be valuable to future investigation of organ dysfunction and vasoactive therapies in sepsis and critical illness. objectives. we were interested in the effects of the higher pco -levels on the microcirculation of infants with birh weights \ , g. data were collected from infants, who were randomized either to treatment with permissive hypercapnia or normocapnia. inclusion criteria were a birth weight between and , g, a gestational age from rd to th+ weeks, intubation during the first h of life and no malformations. the pco target range was increased stepwise and was mmhg higher in the intervention group. skin microvascular parameters were assessed noninvasively with sdf on the right arm every h during the first week of life and on the th day. results. pco (auc: ± vs. ± ) differed significantly between the two groups (p = . ). functional vessel density (fvd) was significantly lower in the intervention group on the th day of life ( ± vs. ± cm/cm ; p = . ). the proportion of small vessels increased in the control group whereas they decreased slightly in the intervention group, but did not reach stat. sig. increasing target pco lead to a temporary hyperdynamic flow in both groups. conclusions. pco -levels influence significantly the microcirculation in preterm infants. elevation of pco -levels leads to a decrease in fvd, presumably due to shunting and vasoconstriction and might cause temporarily hyperdynamic flow. methods. blood from healthy volunteers were diluted with hes, albumin %, rl or autologous plasma to obtain a final hematocrit of %. in vitro wbv measurements were made by the rheolog tm device (rheologics, exton, pa), a new viscometer with a u-formed capillary. the flow rate (determined by the rate of change in height of the columns of blood) is directly related to the pressure drop across the capillary tube. the shear rate (from , to s - ) and viscosity of the sample can be mathematically derived. results were expressed as median values (with - % intervals) and compared by anova with bonferroni correction. a p value . was considered as statistically significant. hemodilution with rl and albumin decreased significantly the wbv for all shear rate compared with autologous plasma and hes ( fig. ). conclusions. in contrast to albumin and ringer's lactate, hes and autologous plasma increased the whole blood viscosity, suggesting that these solutions may be preferred in severe hemorrhagic shock to better preserve plasma viscosity and microcirculation. we divided into two groups the randomly selected sample from the scope of patients come through open-heart operation assisted with extracorporeal support at the university of pécs: therapeutic (continuous blood gas monitoring/cdi- ) and control (intermittent sampling) group. after the retrospective data collection we carry out the analysis with (prevalence) frequency and confidence interval calculation and khi square test. results. the following accompanying diseases occurred significantly higher rate in the therapeutic group: ami (p = . ), kidney disease (p = . ), chronic pulmonary disease (p = . ), and the aggregation of the accompanying diseases showed also significantly high degree (p = . ). the long interval operations occurred significantly higher rate (p = . ) in the therapeutic group, and the times of the aorta clinch (p = . ) and the perfusion (p = . ) was also significantly longer. despite of that during the perfusion in a significantly more cases remained the rates in the normal range concerning to the therapeutic group (ph: p \ . ; be: p \ . ; pco : p \ . ), and the prevalence of the restart of the heart showed also significantly higher rate (p = . ). the continuous blood gas analyses assure reliable and the postoperative recovery assisted ecc circulation support. this assists considerably for keeping the parameters in the physiological limits even in the higher rate of the incidences of complex operations and accompanying diseases. this could contribute to lower incidence of side effects, preventing the causeless elevation of the postoperative hospital charges. objectives. describe the changes in capillary perfusion after erythrocytapheresis during severe falciparum malaria. we report two cases of severe falciparum malaria and describe the evolution of the sublingual capillary perfusion after erytrocytapheresis. the sublingual microcirculation has been studied with sidestream dark-field imaging (microscan; microvisonmedical tm , amsterdam). the device was applied on the lateral side of the tongue and the video images ( - captures of - s.) of capillary perfusion were recorded. the microcirculatory scores were analysed offline: small vessels (\ lm) density (number of vessels/mm), percent of continuously perfused small vessels (ppv%) and mean flow index (mfi). mmol/l. the capillary perfusion has improved: capillary density increased ( . /mm), the proportion of perfused vessel increased ( %) and flow was continuous in most vessels (mfi: ). clinical evolution was rapidly favourable and the patient was discharged from the intensive care unit. case . severe falciparum malaria with high parasitemia ( %) and acute renal failure. before erythracytapheresis: macrohemodynamic parameters were normal but microcirculation was reduced: vessels density ( . /mm) with % of small vessels perfused and the flow was slow in most vessels (mfi: . ). after erythracytapheresis: parasitemia decreased ( . %). sublingual microcirculation has improved with an increase in small vessels density ( . /mm) among which . % were perfused with a continuous flow (mfi: ). the patient had a good outcome. conclusions. microcirculation monitoring should be assessed specifically in some critically ill patients, even if macrocirculatory parameters are in the normal range. during severe plasmodium falciparum malaria, this monitoring could be specifically important to assess the effect of erytrocytapheresis therapy on tissue perfusion. rd esicm annual congress -barcelona, spain - - october s objective. perioperative myocardial infarction (pomi) is associated with significant mortality and morbidity in cardiac surgery. the primary objective of this prospective multicenter study is to investigate whether monitoring of coronary sinus metabolic markers can reliably predict ischemia and pomi faster than conventional monitoring. method. patients undergoing cardiac surgery were monitored perioperatively using a transjugular implanted microdialysis catheter (cma microdialysis) to study the metabolic changes of the heart. coronary sinus (sc) samples of lactate, pyruvate and glycerol were obtained continuously through -h post-operatively. pomi was defined by ckmb c u/ l and troponin t c . lg/l. a total of patients met the criteria for pomi. patients showed at least one adverse event during the postoperative course. lactate, lactate-pyruvate-ratio and glycerol levels in the sc sharply increased up to h before rise of cardiac enzymes. analyses of regression and discriminate analyses showed statistically significant (p \ . ) relationships between elevated metabolite values and the occurence of pomi. roc analysis revealed that lactate, lp-ratio and glycerol from the sc are sensitive markers to predict pomi and postoperative clinical events. conclusions. coronary sinus metabolic markers are sensitive and early predictors for the detection of perioperative myocardial infarction and severe complications in patients undergoing cardiac surgery. beginning disorder can be detected far earlier than with any existing monitoring device. perioperative red blood cell transfusions (btx) are commonly used in patients undergoing cardiac surgery to correct for anemic conditions caused by blood loss and hemodilution associated with cardiopulmonary bypass circulation and anesthesiological procedures. however, several studies have shown btx might have adverse effects on patient outcome. the goal of btx is to correct anemia and to ensure an improvement in the oxygen delivery to the parenchymal cells by the increased presence of red blood cells in the microcirculation. the aim of this investigation was to test the hypothesis that btx during onpump cardiac surgery have a beneficial effect on sublingual microcirculatory perfused vessel density, and oxygenation. methods. adult patients undergoing on-pump cardiac surgery were selected for this study. sublingual microvascular flow index (mfi), detected vessel length (dvl), and functional capillary density (fcd) were assessed using sidestream dark-field (sdf) imaging in patients. sublingual reflectance spectrophotometry was applied in patients to monitor sublingual tissue oxygen saturation. in group a, btx resulted in increased fcd and dvl as depicted in fig. . mfi for small and medium microvessels was not affected by btx (fig. ). in group b, reflectance spectrophotometry demonstrated increases in microcirculatory hemoglobin and oxygen saturation ( fig. ). the main findings suggest that leukoreduced btx improves the systemic circulation and oxygen carrying capacity of the microcirculation by increasing fcd and thereby reducing diffusion distances without increasing significantly the convection of red blood cells. this reduction in diffusion distances causes an increase in microcirculatory oxygen saturation. d.m.j. milstein , k. yürük , r. bezemer , c. ince academic medical center at the university of amsterdam, translational physiology, amsterdam, netherlands aims. anemia is a common adverse effect of oncologic diseases as is the therapeutic options required for their treatment. however, as blood transfusions are directed at correcting for anemia and intrinsic hypoxic conditions, little evidence exists claiming that blood transfusions have successfully resolved anemic challenges as storage can significantly deteriorate rbc function. the aim of this study was to investigate the influence of rbc transfusions on sublingual microcirculatory perfusion and tissue oxygenation in anemic oncology patients. methods. eight consecutive ambulatory patients scheduled to receive packed rbc transfusion bags were selected for this study. baseline sublingual microcirculation functional capillary density (fcd) was measured using sidestream dark-field (sdf) imaging prior to and after min of the completion of the last infused blood bag. sublingual mucosal oxygen saturation (sto ) was measured at the same anatomical location and time points using near-infrared spectroscopy (nirs). results. figures and capillary refill time (crt) is a generally accepted method of assessing the circulatory status of a patient. we have previously showed that using . s as the upper limit of normality in critically ill patients could discriminate patients with a more unfavourable outcome . however, this upper limit of normality was defined based on variation of crt in an adult healthy population . the best crt in critically ill patients, therefore, should still be redefined. objectives. we aimed to define the best crt as predictor of organic and metabolic dysfunction in an intensive care unit (icu) population. methods. capillary refill time was measured by applying firm pressure to the distal phalanx of the index finger for s, and a chronometer recorded the time of returning to normal colour. we performed receiver operating characteristic curve (auc) to detect the best crt consistent with severe organ and metabolic dysfunction, as evaluated by sequential organ failure assessment (sofa) [ and acidosis (lactate [ mmol/l and be\ - meq/ l), respectively. in addition, we performed logistic regression analysis using the cutoff crt as binary to investigate its estimated odds ratio (exp(b)). of patients included in the study (age ± ; male), had circulatory shock, of whom had septic shock. mean crt in all patients was . ± . . figures and show the roc curve for sofa score[ and metabolic acidosis, respectively. using the best crt value, logistic analysis revelled the following estimated odds ratio: for sofa score[ : exp(b) = . ; p = . ); for metabolic acidosis (exp(b) = . ; p = . ). roc curve for crt relative to sofa score [ roc curve for crt relative to acidosis conclusions. we found that . s is the best time to define prolonged crt in critically ill patients, and that using this crt cutoff value could discriminate patients with a more severe organ and metabolic dysfunction. introduction. impairment of microcirculation in acute situations is associated with organ failure and depends on macrocirculation but also on specific factors ( ) . micro-perfusion, assessed by tissue hemoglobin saturation (sto measurement) or micro-blood flow (laser doppler, ld) are easy to use and non invasive methods. the obtained data could be an end point in critical care resuscitation or optimization. objectives. to assess the impact on microcirculation of cardiovascular (cv) support on the basis of mean arterial pressure (map) and cardiac output (co), to evaluate when microcirculatory parameters improved or not the modifications observed in map and co. methods. observational study: measure of co, map, svco , and lactate, thenar nirs (inspectra ; hutchinson technology) baseline sto , with performance of an arterial occlusion test ( mn, mmhg) so calculate occlusion-os and reperfusion slopes-rs ( ). similarly, forearm skin blood flow velocity (ld, blf d, transonic systems) basal ld, and post-ischemic peak velocity ldmax) ( ) were measured. data were collected before and after cv optimization (fluid loading, vasoactive or inotropic drugs). patients were defined: macrocirculatory responders (r) when co increased more than % versus nonresponders (nr); microcirculatory responders (rs+) when rs increased more than % versus nonresponders (rs-). statistical analysis: nonparametric tests (wilcoxon and mann-whitney test). results. patients ( % in shock) were studied. had sepsis ( %), hemorrhage ( %), pulmonary oedema ( %), or other ( %). therapeutic optimization challenges were performed: fluid challenges ( ml, . % nacl), dobutamine c/kg/min, nitrates, diuretic, electric shock and an increase in dosage of norepinephrine. in r group (n= , %), co was increased associated with map (p \ . ), svco (p = . ) and decreased lactate (p = . ). the micro-oxygenation improved with an increase of rs ( . [ . - . ] vs. . [ . - . ]%/s, p = . ) as microperfusion did: increase in ldmax ( . [ . - . ] vs. . [ . - . ] tpu, p = . ). in the nr group, both the macro or the microcirculation did not change. since no microcirculatory differences between r and nr were observed, patients with good or poor microcirculation could not be detected. the study based on microcirculatory responses showed % of responders (rs+). in this group, baseline sto (p = . ), basal ld (p = . ) and ldmax (p = . ) increased in a large amount in association with an improved co and map (p = . and p = . ). in the rs-group, co and map were also improved (p = . and p = . ). conclusions. improvement of macrocirculatory parameters can improve microcirculation but not in all patients. improvement in microcirculation may also be a target, regardless the effects on macrocirculatory parameters. this concept has to be tested prospectively. introduction. hypothermia is regularly used for brain protection after resuscitation from cardiac arrest but its impact on cardiovascular function, however, is not well defined. objectives. the aim of this study was to evaluate the cardiovascular response to mild therapeutic hypothermia and rewarming in a large animal model. seven anesthetized, mechanically ventilated and invasively monitored sheep were cooled with a cold intravenous saline infusion, ice packs and nasal cooling (rhinochill system, benechill, ca) to achieve a core temperature of - °c (the basal temperature in sheep is around °c). after maintenance of this temperature for h, sheep were progressively rewarmed to baseline temperature. a positive fluid balance was maintained during the entire study period to avoid any hypovolemia. the sublingual microcirculation was observed using sidestream dark-field (sdf) videomicroscopy and the proportion of perfused vessels (ppv) and perfused vessel density (pvd) evaluated using a semi-quantitative method. results. during cooling, systemic and pulmonary artery pressures did not change, but cardiac output decreased significantly along with the increase in vascular resistance. left and right ventricular stroke work index decreased reflecting altered ventricular function. nevertheless, there was an increase in mixed venous oxygen saturation (svo ), reflecting a decrease in oxygen extraction. sublingual microcirculation analysis showed a significant decrease in ppv and pvd. all the variables returned gradually to baseline during the rewarming phase. conclusions. in this intact healthy large animal model, the alteration in cardiac function during hypothermia was well tolerated because of the simultaneous decrease in oxygen requirements. arterial pressure was maintained by an increase in systemic vascular resistance associated with a reduction in peripheral microcirculatory density. grant acknowledgment. *rhinochill system was supplied by benechill, inc. objectives. to evaluate consequences of hypoxemia occurence on intestinal microcirculatory perfusion in mice submitted to controlled hemorrhage. tracheotomized and ventilated balb/c mice were submitted to systemic hypoxemia (pao = mmhg) during h. controlled hemorrhage to mean arterial pressure of mmhg was associated (from th to th min). groups were constituted: hh = hypoxia and hemorrhage, hr = hemorrhage, hx = hypoxia, cl = control (neither hypoxia nor hemorrhage). a segment of ileon was exteriorized through an abdominal midline incision. it was opened along the antimesenteric border and placed on a specially designed piedestal to facilitate observation of the villi with transilluminating and epifluorescent microscopy. the bowel segment was superfused with krebs solution maintained at °c. villous perfused density (dvp), red blood cell velocity in villous tip arteriole (vart) and villous capillaries (vcap) were observed after fitc-labeled erythrocytes were intravenously administered. mice were included in each group. leucocytes adhesion to intestinal wall venules ( - lm) was observed in a separated set of experiments including also mice per group. number of adherent leucocytes (l adh ) and leucocytes flux (l fl ) were observed in each group. measurements and arterial blood gases were collected at , , min (t ). data were expressed as mean ± sem and were compared by analysis of variance (anova). introduction. despite remarkable progress in hemodynamic monitoring, clinical examination, assessment of peripheral perfusion and comparison of surface and body core temperature still are diagnostic cornerstones of critical care. infrared non contact thermometers provide accurate measurement of body surface temperatures. the picco device using an arterial line with a thermistor tip in the distal aorta-in addition to transpulmonary thermodilution (tptd)-provides continuous body core temperature. objectives. therefore, it was the aim of our study to evaluate the predictive capabilities of surface temperatures and their differences to body core temperature regarding ci, svri and parameters of microcirculation. in icu-patients body core temperature was measured four times per day using a picco-catheter (tp), a thermistor-tipped urinary catheter (tu) and an ear thermometer (te) (thermoscan; braun). additionally, surface temperatures were determined on the great toe, finger pad, forearm and forehead using an infrared non contact thermometer (thermofocus; tecnimed). furthermore capillary refill time (crt), lactate and scvo were measured and peripheral perfusion was clinically assessed (normal, pale, mottled). immediately afterwards tptd was performed to obtain ci and svri. statistics: spss . . spearman correlation. compared to tp, t forehead (- . ± . °), t forearm (- . ± . °), t finger pad (- . ± . °) and t toe (- . ± . °) were significantly lower (p \ . for all comparisons). in multivariate analysis tptd-derived ci ( . ± . l/min sqm) was significantly correlated (r = . ) to the difference ''tp-t forearm '' (p \ . ), ''tp-t finger pad '' (p = . ), crt (p = . ), scvo (p = . ) and map (p = . ). tptd-derived svri was multivariately associated (r = . ) with ''tp-t forearm '' (p \ . ) and map (p \ . ). scvo was independently correlated to the difference ''tp-t finger pad '' (r = . ; p \ . ). lactate was independently correlated (r = . ) to crt (p \ . ). the roc areas were . and . for (tp-t forearm ) and (tp-t finger pad ) to predict ''ci \ . '' and ''scvo \ '', respectively. the sensitivity, specificity and negative predictive value of ''tp-t forearm [ . °'' were , and % regarding a ci \ . l/min/sqm. .) measurement of surface temperatures using non contact infrared thermometers and comparison to body core temperature provides useful data on macro-and microcirculation. .) the differences (tp-t forearm ) and (tp-t finger pad ) were independently associated to tptd-derived ci and svri, and ci and scvo , respectively. .) crt was independently associated to lactate level. v. shilov , a. astakhov ural state postgraduate medical academy, chelyabinsk, russian federation introduction. actuality of this problem consists of different disturbances of heart rhythm and heart conductivity (from sinual bradycardia and ventricular extrasystolia till sinuatrial arrest and fibrillation of ventricles) provoked by traction of oculomotorial muscles and pressure on eyeball. this reaction is called oculocardial reflex (ocr). it is necessary to note there is no definite strategy of ocr prevention. objectives. this study was conducted to estimate the possibility of the control of haemodynamic effects of ocr. the haemodynamics and hydrobalance were investigated with electric current probe ( and khz) using monitoring complex of cardiorespiratory system and hydratation of tissues -km-ar- «diamant». data documentation was carried out at stages of evisceroenucleation: . before anesthesia and surgery; . at induction; . during the intubation; . at eyeball mobilization and oculomotorial muscles traction; . while deepening of endotracheal anesthesia by inhalative anesthetics during - min after preceding stage; . at the end of surgery, after the extubation. results. the study confirmed ocr reflex, to appear at eyeball extraction and to manifest as bradycardia, cardiac output decreasing heart productivity, but peripheric vessel resistansce does not change. monitoring-controlled gradual deepening of inhalative anesthesia during - min has restored the haemodynamic data to normal eliminated ocr vessel reactions. hydrostatic changes took place only at the end of the operation, after the extubation. it manifested ad increasing of extracellular liquid confirmed by decreasing of low-frequent impedance. intracellular liquid remained intact. it seems the most possible, hydrostatic changes of extracellular liquid to depend on crystalloid infusion in blood vessels up to , ml during anesthesia and they eliminate with hypovolemia. conclusions. thus we can conclude that vascular manifestations of hemodynamics in ocr at eyeball extraction or active oculomotorial tractions may be eliminated with gradual deepening of inhalative anesthesia and monitoring of registed date of haemodynamic and hydrobalance. probably it's necessary to optimige the anesthesia using of pterygopalatal and pterygoorbital blockade to prevent ocr before the induction as retrobulbal anesthesia may be an ocr trigger. f. corradi , c. brusasco , a. vezzani , f. altomonte , p. moscatelli university of genoa, anesthesia and intensive care, genoa, italy, ospedale maggiore di parma, anesthesia and intensive care, parma, italy, azienda ospedaliera universitaria san martino, emergency medicine, genoa, italy introduction. despite improvements in trauma care, uncontrolled bleeding is the leading cause of potentially preventable early in-hospital deaths contributing to to % of trauma-related deaths ( ) ( ) . about % more deaths occur within the second/third hour after injury due to occult major internal haemorrhage. failure to recognize this situation may in part be due to lack of sensitivity of hb/hct levels, arterial blood pressure, heart rate, respiratory rate, injury severity score and markers of hypoperfusion (lactate and base excess) in initial assessment of blood loss. to study if early changes in spleno-vascular resistance index predict the development of hypovolemic shock after trauma. a prospective observational study conducted in adult haemodinamically stable patients admitted to the emergency department because of suspected or definite severe trauma and retrospectively divided into groups depending on whether or not they developed haemorragic shock requiring blood transfusion. doppler ultrasound measurements of splenic arterial branches at ilum were obtained and splenic doppler resistance index (sdri) was recorded at admittance (within h from trauma) and related to arterial blood gas analysis (haemoglobin, base deficit, lactate, co , ph), heart rate, and outcome in the first h (intensive care unit admittance, blood transfusion, sepsis, mortality). results. statistically significant differences between patients who developed shock within h and those who did not were the following: higher sdri ( . ± . vs. . ± . , p \ . ), lower base deficit (- . ± vs. . ± meq/l, p = . ) and higher lactate ( . ± . mmol/l vs. ± mmol/l p = . ). auc's of roc analysis were significant for sdri (auc = . , ci . - . , p \ . ) and lactate (auc = . , ci = . - . , p = . ), and borderline for bd, hr, hb, and ph. by multivariate analysis, sdri at admittance resulted to be the only good independent predictor of hypovolemic shock and bleeding (p \ . ), whereas haemoglobin, base deficit, heart rate, lactate and ph were not significant. in trauma patients with stable haemodynamic conditions at admittance spleen constriction occurs very early under heavy adrenergic stimulation in response to occult bleeding and can be non-invasively detected by sdri. the present study proposes sdri as a non-invasive measurement of changes in splanchnic circulation to detect blood loss and occult hypovolemia, which may help activate early surgical or radiological intervention for patients with major trauma and guide therapy to optimize splanchnic perfusion. introduction. approximately % of patients require temporary circulatory support due to cardiogenic shock following cardiac surgery. these patients are at risk of a mismatch between oxygen delivery and demand and carry a substantial mortality and morbidity risk. mixed venous oxygen saturation (svo ) is the still the ''gold standard'' for the determination of the ratio between systemic oxygen delivery and consumption (do /vo ratio) in cardiac surgery patients. a nonivasive technique is thought to be cerebral near-infrared spectroscopy determining cerebral oxygen saturation (rso ). purpose. the present analysis aims to compare rso and svo levels in adult patients undergoing ecmo therapy for postoperative cardiogenic shock. methods. data were collected hourly for the first h post operatively. each patient was equipped with a pulmonary artery catheter (pac) for continuous determination of svo connected to a vigilance ii-monitor (edwards lifesciences, irvine, usa) and an invos monitoring system (somanetics, troy, usa) to determine rso . data were analyzed by parametric testing and bland-altman analysis. a total of patients were enclosed. all svo values were in a range between and %. in this range, the linear correlation coefficient between svo and rso was r = . (p \ . ). the correlation coefficient for svo values below % was r = . (p \ . ) and r = . (p \ . ) for svo levels equal or higher than %. bland-altmann analyses of all collected oxygenation data (n = ) revealed a bias of . % (mean % ci: . to . ) and limits of agreement ( . standard derivation) of . to - . % (upper % ci: . to . ; lower % ci - . to - . ) for the raw data of the whole group ( figure ). bland-altmann analyses of svo values below % (n = ) showed a bias of . % (mean % ci: . to . ) and limits of agreement ( . standard derivation) of . to - . % (upper % ci: . to . ; lower % ci - . to - . ). bland-altmann analyses of svo values equal or higher than % (n = ) revealed a bias of - . % (mean % ci: . to . ) and limits of agreement ( . standard derivation) of . to - . % (upper % ci: . to . ; lower % ci - . to - . ). interestingly, despite svo values [ %, we noticed events in patients with rso values less than % for more than min. all events had been associated with arterial co levels below mmhg, whereas no other changes in hemodynamic or oxygenation parameters could be determined. conclusions. this pilot study suggest for the first time that rso highly correlates with svo in patients undergoing ecmo therapy due to refractory cardiac and/or pulmonary dysfunction. therefore determining rso may be a noninvasive alternative to monitor global tissue oxygenation under this condition. additionally, it was noted that cerebral hypoxia may be present despite a svo c mmhg. rd esicm annual congress -barcelona, spain - - october results : during severe hypothermia ( °c) cardiac index (ci), stroke index, mean arterial pressure and indexes of lv contractility (prsw and dp/dtmax) were reduced. after rewarming all variables remained reduced, except for ci that returned to prehypothermic values due to increased heart rate. systemic vascular resistance (svr), lv isovolumetric relaxation time (tau) and oxygen content in arterial and mixed venous blood increased during °c, while lv end diastolic pressure (lvedp) was constant. after rewarming svr and lvedp were reduced, while tau and the blood oxygen contents normalized. troponin-t and tnf-a were constant during °c but increased after rewarming. albumine plasma concentration was reduced during °c and remained so after rewarming. conclusions. surface cooling to °c followed by rewarming caused reduction of systolic, but not diastolic lv function. there were no signs of inadequate global oxygenation throughout experiments. the posthypothermic increase in troponin-t may reflect degradation of myocyte troponins secondary to a hypothermia-induced calcium overload. the increase in tumour necrosis factor alpha together with a posthypothermic reduction of plasma albumin concentration may indicate that the cooling and rewarming initiated an inflammatory response. we studied patients, mean age . ± . years, % male. the etiology of cardiogenic shock was: % (n = ) dilated cardiomyopathy, % (n = ) acute myocardial infarction, % (n = ) acute cardiac allograft rejection and % (n = ) acute myocarditis. the duration of ecmo support was . ± . h. weaning was possible in % (n = ) and the ecmo was used as a bridge to transplantation in % (n = ). -day survival was and . % of our serie were discharged from the hospital. in cases the ecmo was withdrown as a result of a limiting treatment decision. objectives. to describe the characteristics of patients with ca and its management with moderate hypothermia using arctic sun Ò device with hydrogel patches. descriptive, observational and retrospective study of patients who suffered ca and received moderate therapeutic hypothermia ( °c) according to the protocol implemented in a coronary intensive care unit of a tertiary hospital. we collected patients from june to april , first months of this therapy in our hospital. moderate therapeutic hypothermia is applied using the arctic sun Ò device consisting of hydrogel patches applied to the skin covering % of the body surface. the device is connected to a temperature control console, measuring core temperature with an urinary catheter. we analyzed demographic characteristics, cardiovascular risk factors and other relevant comorbidities. we collected data about the ca, its initial treatment and its icu management with moderate hypothermia, analyzing length of events and systemic and neurological outcome at discharge from icu. we also collected data about the infectious complications during the icu stay. results. during this period, moderate therapeutic hypothermia was applied to patients with a mean age of ± years. . % were male. the most frequent cardiovascular risk factor was cigarette smoking, present in % of individuals. the ca cause was an ami by % of cases; however, myocardial infarction or angina was documented before the event only in . % of patients. the ca event was outside the hospital in . % of cases and the initial heart rate recorded was ventricular fibrillation in . % of cases. the average ca length was . ± min. obtaining a temperature of °c took between and h from the ca in most cases; and this temperature was maintained for an average of ± h. the average time of induction of hypothermia was . h. the re-heating was performed between . to . °c per hour, averaging h to reach temperatures of . °c. midazolam sedation was performed in all patients and severe chills required muscle relaxation with cisatracurium in . % of patients. infectious complications occurred in . % of patients, the most common site of infection was respiratory. the average stay was days. at the time of icu discharge, average gcs was and the average gos was . mortality was . % ( patients). -implementation of a therapeutic hypothermia protocol is feasible. -infectious complications are common, being respiratory ones the most observed. -the arctic sun Ò device is quick and safe for induction of moderate therapeutic hypothermia. rd esicm annual congress -barcelona, spain - - october s objectives. up to now, it is not clear, however, whether mild hypothermia influences also markers of oxidative stress and nitric oxide production. methods. eleven patients after out-of-hospital cardiac arrest were included into this study, all were treated with mild hypothermia using endovascular system thermodard xp. target core temperature °c was maintained for h, re-warming rate was set at . °c per hour, followed by normothermia of . °c. blood samples for measurement of nitrotyrosine and nitrates/nitrites were taken at admission and then every h for days. during hypothermia the levels of nitrotyrosine and nitrates/nitrites were comparable with baseline values. in re-warming period serum levels of both parameters gradually increased and in normothermia the levels were significantly higher as compared with hypothermia: nitrotyrosine . ± . vs. . ± . lm/l, p = . ; nitrates/nitrites . ± . vs. . ± . lm/l, p = . . our results revealed that during mild hypothermia in cardiac arrest survivors the levels of nitrotyrosine and nitrates/nitrites are significantly lower. these data indicate that the reduction of oxidative stress and suppressed nitric oxide production may be involved in the protective effect of hypothermia. grant acknowledgment. this study was supported by the grant of the czech ministry of health, nr. . new volumetric variables of preload, such as total end-diastolic volume index (tedvi) and active circulation volume index (acvi) and central blood volume index (cbvi), have been shown to be good predictors of fluid responsiveness. during acute changes of intravascular volume, such as hemorrhagic shock, these variables allow a more accurate intervention. objectives. the aim of our study was to investigate the changes in tedvi, acvi, cbvi in a juvenile model of hemorrhagic shock. seven anesthetized ponies ( - months of age) were studied at normovolemia (base), after blood withdrawal to mean arterial pressure (map) of mmhg (hemo), after infusion of norepinephrine to a map of mmhg (ne), and after retransfusion (resu). tedvi, acvi, cbvi were measured by ultrasound dilution (ud) technology with costatus device. data were analyzed using kruskal-wallis analysis and dunn's t test. comparison of fluid load agreement by blant altman. results. tedvi and acvi had significant change during hemo and resu status. percentage of tedvi and acvi changes agreed with percentage of blood volume removed/ infused with bias and limits of agreement (loa) % (- . , . ) and - . (- . . %) respectively. ne administration induced map and cvp significant changes, whereas tedvi and acvi remained unchanged. cbvi showed high variability and seemed to be inconsistent on the identification of the volume status. conclusions. in this animal model, tedvi and acvi were superior to cbvi in accurately reflecting hemorrhage and were also suitable to predict fluid responsiveness. ne administration did not affect the volumetric variables tedvi and acvi. ( ). objectives. we sought to identify independent predictors of post-arrest neurological recovery, and of survival to hospital discharge with neurological recovery. in the course of a pre-planned interim analysis, we analyzed the data from participants of nct . this three-center, double blind, placebo-controlled, clinical trial is ongoing (estimated enrollment = patients) and aims to asses the efficacy of combined vasopressin and epinephrine during cardiopulmonary resuscitation (cpr) and of steroid administration during and after cpr. post-arrest neurological recovery was defined as glasgow coma scale score[ documented at least once by study-independent physicians in patients not receiving sedation for at least h. we identified a total of patients who were subjected to at least one post-arrest assessment of their neurological status. subsequently, we used backward stepwise logistic regression, and assessed the following potential predictors: cause of cardiac arrest (cardiac vs. non-cardiac); area of cardiac arrest occurrence (monitored vs. non-monitored); use of therapeutic hypothermia; number of cpr cycles; mean arterial pressure and serum lactate at min following resuscitation; and patient group allocation. results. the sole independent predictor of post-arrest neurological recovery was the occurrence of the cardiac arrest in an area of monitored patient care (i.e., intensive or coronary care unit, and operating or emergency room): odds ratio: . , % confidence interval = . - . ; p = . . the sole independent predictor of survival to hospital discharge with neurological recovery was the serum lactate concentration at min after resuscitation: odds ratio: . ; % confidence interval = . - . . conclusions. the results of this preliminary analysis suggest that post-arrest neurological recovery seems to depend more on the use of pre-arrest patient monitoring rather than the employed cpr protocol. also, patients with lower, early post-arrest serum lactate concentration seem to have a better chance of surviving to hospital discharge without concurrent, severe neurological deficits. reference(s). to quantify the attribution of intra-operative defibrillation on markers of myocardial injury (ck, ck-mb, tnt and hfabp). methods. single centre prospective study in which elective cabg patients were included in a month period in . patients with valve, emergency, off-pump surgery or rethoracotomies were excluded. patients were grouped as having had defibrillation or no defibrillation during surgery. serum levels of ck, ck-mb, tnt and hfabp were analyzed in blood samples taken at arrival on the icu and at , and h after admission to the icu. levels of these biochemical markers were compared using a paired t test. results. all data presented as mean ± standrad deviation conclusions. atrial fibrillation is a common problem associated with morbidity and mortality in critically ill patients; however, evidence-based recommendations are lacking leading to variability in treatment. our audit confirmed variability and low compliance to nice in treating new af. inconsistency in using appropriate first line drugs for rate control and inadequate thromboprophylaxis reflects lack of familiarity with nice guidelines. educating itu medical staff and promoting the use of well validated, easy to remember chads scoring system might improve compliance with nice guidance. also,promoting hemorr hages scoring system for assessing risk of bleeding and carat tool to guide prescribing antithrombotics may allow itu physicians to anticoagulate more patients with af with less fear of bleeding complications. in patients with acute coronary syndromes (acs) combined antiplatelet and anticoagulant therapy is recommended in addition to percutaneous coronary revascularization. heparins and glycoprotein iib/iiia receptor inhibition can be associated with immune-mediated thrombocytopenia of clinical significance in less than %, resulting in major bleedings and increased mortality rate. to evaluate the incidence of thrombocytopenia and its impact on in-hospital complications-bleedings, reinfarctions, in-hospital heart failure and mortality in patients with acs. retrospective evaluation of patients admitted during months, fulfilling the criteria for acs: rest chest pain up to h, changes in standard ecg with or without st-elevation with or without elevated serum troponin i. serum troponin i was estimated by immunochemical method (boehringer, mannheim, germany, normal levels . lg/l). patients were treated by combined antiplatelet therapy, heparins and percutaneous coronary revascularization. platelets were estimated by automatic analyzer sysmex xe , kobe, japan (normal levels - /l). thrombocytopenia was defined as platelet count less than /l or a drop in platelet count of more than % during inhospital stay. we registered demographic, laboratory, clinical data and in-hospital mortality. we included acs patients, . % ( / ) with and . ( / ) without stelevation ( . % men, mean age . ± . years). mean admission troponin i was . ± . lg/l, platelet count . ± . /l. in-hospital thrombocytopenia was observed in . % of patients. in thrombocytopenic patients in comparison to non-thrombocytopenic ones we observed significantly increased mean age ( . ± . vs. . ± . years, p = . ) and admission serum creatinine ( . ± . vs. . ± . lmol/l, p = . ), significantly decreased admission systolic blood pressure ( . ± . vs. . ± . mmhg, p = . ) and hdl-cholesterol ( . ± . mmol/l vs. . ± . mmol/l, p = . ), significantly increased bleedings ( . vs. . %, p = . ), in-hospital heart failure ( . vs. %, p = . ), but nonsignificantly increased reinfarctions ( . vs. . %), arrhythmias ( . vs. . %) and in in-hospital mortality ( vs. . %). thrombocytopenic patients were less likely treated by percutaneous coronary revascularization ( . vs. . %, p = . ). admission thrombocytopenia in comparison to normal admission platelet count was associated with significant increase in inhospital mortality ( vs. %, p = . ) and icu-mortality ( . vs. . %, p = . ). conclusions. thrombocytopenia, observed in more than % of acs patients, was associated with in-hospital complications and mortality, especially thrombocytopenia on admission. introduction. stress cardiomyopathy, also known apical ballooning or takotsubo cardiomyopathy (tts), has been recognized for several years. this syndrome is characterized by transient systolic dysfunction of the apex or mid segments of the left ventricle (lv) in the absence of coronary artery disease. several forms of mostly physical stress may evoke this syndrome. in this case we describe a very uncommon cause for tts in an unusual situation. a -year-old woman without cardiovascular history found her husband non-responsive in bed. after resuscitation he was admitted to icu. visiting her husband, she complained of chest pains, shortness of breath and hyperventilation. physical examination revealed no abnormalities but her ecg showed deep negative t-waves in leads i, ii, iii, avf, v -v . her troponin t level was . lg/l (ref \ . ), nt-pro-bnp was , ng/l (ref \ ). ck was ng/l with ckmb of ng/l. echocardiography showed very poor lv function with the typical apical ballooning of the lv along with hyperkinesis of the basal ring ( fig. ). there was no coronary artery disease. she was admitted and treated with beta-blockers. within days, the enzymatic changes normalized and echocardiography showed improved lv function with and normalization of the apical segments. she made full recovery within weeks. discussion. icu admittance has significant impact on family members. in the acute phase of the illness, most medical attention goes to the admitted patient. especially when prognosis is poor, stress to the family may be considerable. mostly spouses and relatives with female gender are at the highest risk for depression and anxiety disorders . in contrast, little is known about the occurrence in relatives of broader physical symptoms like pain and nausea or even acute onset severe medical conditions requiring treatment. in our case the wife experienced pain, anxiety and nausea along with hyperventilation. however, the underlying disease was a severe cardiomyopathy requiring admittance and treatment. the tts cardiomyopathy is known to icu physicians in relation to subarachnoid hemorrhage, but most likely not in the context of severe emotional stress. in summary, we stress the importance for intensive care physicians to be alert to the fact that despite many diverse symptoms related to stress and anxiety, relatives can develop acute medical conditions as well. a retrospective observation study. demographic profiles, operative data and short term outcomes in the icu were reviewed in the patients who underwent beating-heart (b-h) operation. we also compared b-h operation group ( - ) and conventional cardiac arrest (c-a) operation group (before ). both groups of patients were similar with respect to preoperative demographics (age, co-morbidities, lv function). in the b-h operation group, mean age was years ( - ). preoperative mean nyha functional class was . . and the mean lvef was . %. patients underwent single valve operation, and the rests needed combined valve operation or cabg. patients were included in the c-a operation group, with mean age of years ( - ), nyha functional class of . and mean lvef of . %. in the b-h operation group, no dc shock was needed, whereas % of the patient with c-a operation needed dc shock after aortic unclamp. in the single aortic valve replacement, b-h operation group had a tendency of shorter assist perfusion time after intracardiac procedure ( . vs. . min). in the icu, inotropic support (maximum dose of dopamine) was much less ( . vs. . r) than conventional c-a operation (p = . ) and additional iabp support was not required ( vs. % in c-a operation). low cardiac output syndrome was not encountered in the b-h operation group ( vs. % in c-a operation). no major postoperative complication was encountered except ventricular tachycardia in one patient. there was no day mortality ( vs. % in c-a operation). conclusions. in our series, valve surgery on the beating-heart had a superior postoperative hemodynamics and lower associated morbidity compared to conventional cardiac-arrest operation. this procedure is recommended especially in the patients with impaired lv function. ( ) objectives. does hrt measured during daytime or nighttime predict: one-year all-cause mortality in acs?; hospital readmission within one-year? methods. secondary analysis of the immediate aim study, prospective clinical trial of patients presenting to the emergency department (ed) with symptoms of acs (n = , ): holter recordings of patients, positive for acs and admitted to the hospital, started min (median time) after arrival in the ed; -year follow up after hospital discharge in % of the sample; recordings scanned to exclude artifact and non-sinus rhythm. hrt analysis performed using research software at the washington university heart rate variability lab; hrt parameters measured: ) turbulence onset (to), which characterizes the initial rate acceleration after a ventricular premature contraction (vpcs); and ) turbulence slope (ts), which characterizes the subsequent oscillation in heart rate. results. holter recordings eligible for hrt analysis; eliminated due to unanalyzable rhythm, \ vpcs needed to calculate hrt, or recording time \ -h. patients were diagnosed with ua, with nstemi, and with stemi. patients died and were re-hospitalized during follow up. hrt measures were dichotomized into low and high-risk groups based on previously reported cutpoints: to \ % normal, to c % abnormal; ts [ . ms/beat = normal, ts b . abnormal. chi square statistics calculated. findings include: abnormal -h ts significantly associated with -year mortality [odds ratio (or) . (p = . )]; re-hospitalization significantly associated with both abnormal -h to (or . , p = . ), and -h ts (or . , p = . ); abnormal night ( - ) to and day ( - ) ts also significantly associated with -year mortality (or . , p \ . for both); abnormal daytime to (or . , p = . ) and ts (or . , p = . ) each significantly associated with re-hospitalization. conclusions. patients with acs who have a ts \ . measured over h or during the daytime are at higher risk of dying within year after hospitalization. those who either have to c % or ts b . have a greater risk of re-hospitalization. assessment during the daytime only might provide sufficient information for risk stratification. hrt measured close to acs symptom onset may aid in risk stratification. objectives. we tried to find a correlation between trs and the severity of coronary artery disease (cad) found in coronary angiography. we analyzed all consecutive patients with nsteacs admitted to intensive care unit from june to december . all patients were stratified at admission with trs. pci were performed when it were indicated. for the study we grouped patients according to trs and the severity and extend of cad. considering the trs the patients were classified into three categories: trs - , trs - and trs - and considering the results of the coronary angiography were grouped into three categories: normal angiogram, one or two vessel disease and three vessel or left main disease. we excluded patients without pci. qualitative variables are expressed as absolute value and percentage and quantitative variables are expressed as means ± standard deviation or median ± interquartile range when correspond. comparisons between groups were made with the v or fisher's exact test for categorical variables and mann-whitney test for quantitative variables. a total of patients were admitted with nsteacs during the period of the study and underwent to pci. age median were higher in patients with trs - than other groups ( . years ± . p \ . ). men percentage and in-hospital mortality were similar in all groups (pns). between groups there weren't significant differences in prevalence of diabetes, hypertension, dyslipidemia, smoking, mean first troponin i and mean highest troponin i (pns). the v for all comparisons were . (p \ . ). normal angiogram were most likely found in patients with trs - than in those with trs [ (p \ . or , % ci . - ). one or two vessel disease were found more often in those with trs - than in those with trs\ o [ (p \ . or . , . three vessel or left main disease were found more often in those with trs - (p \ . or . , % ci . - . ). conclusions. the relationship between trs and clinical outcomes (recurrent angina, acute myocardial infarction and death) is well known but its relation with the extent and the severity of cad is not well determined. in our study we found a correlation of trs with the number of vessels affected in coronary angiography, making the trs as a good predictor of the extent and the severity of cad. a.b. ratnaparkhi , j. walton freeman hospital, anaesthetics, newcastle upon tyne, uk introduction. acute onset atrial fibrillation (af) is common phenomenon in the intensive care unit. atrial fibrillation poses risk for thromboembolism. practice of commencing anticoagulation after acute onset af varies in different intensive care units. anticoagulation comes with its own side effects in the already compromised patients in the intensive care unit. this regional audit was carried out in intensive care units of the north east region of the uk. to assess the practice of use of anticoagulation after acute onset of atrial fibrillation in the intensive care units. postal questionnaire were sent to the intensive care units of the north east region of the uk including two cardiac surgical intensive care units. the questions asked were; is there a protocol in your unit? are you aware of any guidelines? if yes, which guidelines? do you commence anticoagulation for acute onset af? what do you use for anticoagulation and in what dose? after what duration of onset of af you consider starting anticoagulation? how long do you continue anticoagulation? do you commence anti platelet therapy? we also put six clinical scenarios with acute onset atrial fibrillation. the aim was to assess if the units consider stroke risk stratification for commencing the anticoagulation. one example is; how would you manage anticoagulation for a year old patient with hypertension and diabetes, presented with sepsis following pneumonia. results. we received responses from out of intensive care units. the management of anticoagulation strategy was different in different unit. two units were aware of the nice guidelines, one unit was aware of the accp guidelines and two units were aware of the other guidelines. ten units responded that they commence anticoagulation for acute onset af. commonly used anticoagulation was low molecular weight heparin. four units use anticoagulation within less than h of the onset of af. there was no fixed duration for the continuation of the anticoagulation. different units consider various factors before commencing anticoagulation. conclusions. use of anticoagulation in acute onset af varies in the different units. each unit takes into account different factors for the commencement of anticoagulation. this audit highlights the possible need for the evidence based protocol for the use of anticoagulation in acute onset af in intensive care units. objectives. to study of the clinical features and analytical features of those patients with dilated cardiomyopathy treated with ecmo as a bridge to cardiac transplantation in order to determine which parameters are useful to predict the outcome methods. a retrospective study from december to december . all patients were divided into two groups: the a group: patients who died before transplantation; the b group patients who got transplantation. several clinical and analytical characteristics are compared before starting ecmo, at and h after the onset and immediately before withdrawing (''end time'') ecmo treatment (either for transplantation or for death). qualitative variables are expressed as % and quantitative ones a mean and standard deviation (sd). chi square and t student test are used as appropriated. a p \ . denotes statics significance. there are statistically significant differences between patients who died and patients who survived to be transplantated. the presence of multiorgan failure and severe tissue oxygen hypoperfusion, and its persistence after initiated treatment, denotes a worse prognose. the study of this differences could be useful to decide which patients benefit of ecmo treatment. objectives. to measure the diagnostic contributions of routinely used (nt b type natriuretic peptide (nt probnp), cardiac troponin i (t), ddimeres (dd), c-reactive protein (crp) and procalcitonin (pct)) and new biomarkers(mid-regional pro-atrial natriuretic peptide-(mr-proanp), pro adrenomedullin (pro adm), pro endothelin (pro et) and copeptin [pro vasopressin (cp)] for diagnosing infection in patients with severe acute dyspnea. we designed a prospective study of patients admitted in the emergency department and in medical intensive care unit in a university hospital. inclusion criteria were acute dyspnea with spo b % and/or respiratory rate (rr) c b/min. patients with obvious myocardial infarction or pneumothorax were excluded. clinical-biological data were recorded and biomarkers sampled. an independent blinded expert panel classified the patients according to all the data including response to treatment and outcomes blindly to biomarkers' results. the roles of biomarkers were assessed quantitatively and then using terciles of the distribution. the contribution of the biomarkers in the diagnosis was assessed using auc-roc curves and by multiple logistic regression taking into account other clinical and biological explanatory variables. objectives. to compare differences between a group of patients with lmca treated with percutaneous coronary intervention (pci) and others with cabg. to evaluate direct results and make a long term prognosis analyzing mayor cardiovascular complications (mcc) rate. observational retrospective study that includes a total of patients with lmca submitted to ca between january and december : patients ( %) were treated with pci and compared to patients ( %) treated with cabg. in the total of the pci cases drug-eluting stents were used. we exclude patients in cardiogenic shock and those with protected left main coronary artery. results. average age of the patients was . ± . . in the pci group most of the patients were older than years. in the cabg group there was a majority of male patients ( . vs. . %, p = . ) without significant differences in the rest of demographic information. in the pci group (p = . ) there were more previous record of acute myocardial infarction (ami) and pci found, and also a greater percentage of patients with lvef\ % (p = . ). average euroscore of patients from the pci group were greater than those from the cabg group. complete revascularization was obtained more frequently in the cabg group. in the cabg group (p = . ) the number of days between diagnosis and therapeutic strategy as well as the days hospitalized were greater. in the multivariate analysis, the type of therapeutic strategy wasn t associated to mortality when hospitalize. the median follow-up period was months. according to the classification ccs (p = . ), there was no significant difference in the grade of angina. tendency to a greater restenosis of stent, greater mortality during follow-up and greater mcc without statistically significant. in the multivariate analysis surgical strategy was associated to a lower mortality during follow-up (or . objectives. our objectives were to analyze the characteristics of the patients who were done a cardiac catheterization, the differences of the procedure and the incidence of complications. methods. we randomized consecutive patients referred to the hospital for cardiac catheterization since august until october . results. among patients, the age (mean ± sd) was ± . years and more frequently male ( . %). . % were angioplasty. the radial approach was used in patients ( . %; . % with f arterial sheaths and . % with f), and the femoral approach in patients ( . %). there was no difference in the baseline characteristics of the patients. the time required for the procedure and the fluoroscopy time were longer in the radial group (p = . ). a cross over was more often necessary in the radial group ( patients, . %) due to radial artery spasm, deviousness, loop, unstable catheter or artery dissection. only one patient required cross over from femoral to radial approach ( . %) due to serious deviousness in iliac artery. the intravascular ultrasound (ivus) and rotablator always were done by femoral approach. the incidence of complications was higher in the femoral approach group ( . vs. . %, p = . ). in the radial approach group, the most important complication was wrist haematoma ( % radial artery occlusion checked with allen test), however the femoral approach complications were: inguinal haematomas ( . %), big haematomas required blood transfusions ( . %), femoral artery pseudoaneurysms ( . %), arteriovenous fistulas ( . %), retroperitoneal haemorrhages ( . %), strokes ( . %). these complications increased the hospital stay ( . ± vs. . ± . days, p = . ). conclusions. the radial approach reduces peripheral arterial complication rates and allowed earlier ambulation, so also reduces the hospital stay. however, needs higher learned time, and the size of the artery can limit several procedures (ivus/rotablator on the other hand, the development of bundle branch block after that procedure has been associated with higher rates of complete av block, syncope, and sudden cardiac arrest at long term. objectives: our aim is to describe the incidence of cardiac conduction problems after pavi and to identify possible risk factors associated with these conduction problems. patients and methods. a total of consecutive patients who underwent a pavi were included in our analysis. the indication for pavi was a severe symptomatic aortic valve stenosis in patients who were rejected or had a high risk for conventional savr. permanent pacemaker implantation was performed in case of the presence of complete heart block or symptomatic bradycardia, persisting after at least the second postprocedural day. data are expressed as mean value ± sd for continuous variables and as numbers with percentage for categorical variables. between the variables selected for predicting av block after pavi (basal valvular area, annulus diameter, valsalva sinus diameter, left and right bundle branch block), the only independent predictor was the last one (or . , % ci . ( ). implementation of care bundles have been advocated to reduce the infection rate ( ). objectives. the aim of the study was to identify the effect of the introduction of the central venous catheter (cvc) bundle on crbsi rate on our critical care unit over a threeyear period. retrospective audit on the rate of crbsi for a months period before the implementation of the cvc bundle provided baseline data. prospective audits for the corresponding months were carried out after the cvc bundle was firmly embedded in clinical practice. the data was collected based on the information recorded in our clinical information system (cis). the cvc bundle consisted hand hygiene, barrier precautions on insertion, % chlorhexidine skin preparation, using femoral site as last resort, daily review of necessity of central access, daily inspection of insertion site, use of tpn on a dedicated port and maintaining asepsis when accessing the line. robust educational program was rolled out during the implementation phase for medical and nursing staff. compulsory elements of the care bundle were recorded in our cis. we collected data on overall compliance with the bundle, mean dwell time, number of crbsis, site of infection and whether the patient left the unit with a cvc line in situ. for statistical analysis chi-square test and wilcoxon test were used. our main results are summarised in table . lines removed prior to transfer (n) we have seen a significant increase in the compliance with the bundle and it resulted a significant and sustained reduction in mean dwell time, cvc related infection rate and number of patients transferred to the ward with cvc lines (all p \ . ). the bundle resulted in bigger scrutiny for cvcs, hence the reduction in the number of lines inserted. conclusions. our data shows that implementation of care bundles can significantly and sustainably reduce the rate of crbsi on the icu in a real life setting. our previously unacceptable infection rates were reduced and now are comparable with the recently published data ( ) . evidence-based catheter-care procedures, guided by healthcare workers perceptions and including bedside teaching, reduce significantly the crbsi rate and demonstrate that improving catheter care has a major impact on its prevention. to evaluate the incidence of catheter-related bloodstream infection (cr-bsi) and of the use of central venous catheters (cvc) after an intensive improvement program aimed at reducing cr-bsi. before-and-after study in patients admitted to a -bed medical-surgical icu from january through december . in we implemented an improvement program (analysis of barriers, creation of a working group, review of protocols, and implementation of an educational program and checklist) and a set of measures to reduce cr-bsi during cvc insertion and maintenance based on provonost et al.'s model ( ) . in the postintervention period, we suspended the use of the checklist and evaluated the degree of completion of the online training module ''bacteremia zero program'' and analyzed the staff turnover rate. we have monitored cr-bsi using the ''estudio nacional de vigilancia de infección nosocomial en uci'' (envin-uci) criteria since . we calculated the incidence rate ratio of cr-bsi and cvc utilization ratio for , , and . we compared the incidence rate ratios using the epitab module from the stata program and utilization ratios using chi-square tests. results. nine cr-bsi were diagnosed in , one in , and five in . the incidence rate ratio of cr-bsi in these periods was . , . , and . %, respectively. the incidence rate ratio in the postintervention period ( . %) was significantly lower than in the preintervention period ( . %) ( . : % ci . - . , p = . .) the increase in incidence rate ratio between and was not statistically significant ( . vs. . %, p = . ). the pre-and post-intervention cvc utilization ratios were . and . , respectively (no significant differences). during the year , and for existing staff in , rotating residents, nurses (turnover rate %), and nurse's aides (turnover rate %) joined the icu. the training module was completed by % of the new nurses and none of the physicians or nurse's aides. conclusions. the program was effective; its effectiveness may be related to the intensity of the measures. a low preintervention incidence rate ratio does not preclude the usefulness of an improvement program. introduction. in the intensive care unit (icu) the bloodstream infections (bsi) related to the central venous catheters (cvcs) represent a serious clinical complication and are a substantial economic burden. although the data are still somewhat controversial, the use of antibiotic impregnated cvcs is one of the generally accepted approaches in reducing the risk of bsi [ , ] . objectives. in order to determine the efficacy of antibiotic impregnated cvcs in our clinic we evaluated retrospectively the data of the cultures of cvcs and blood obtained from patients during their stay at icu within the last years (january till august ). conclusions. surprisingly, there was no difference in the incidence of the cvc and bloodstream infections in both groups. we can conclude that the strategy of using mrimpregnated cvcs did not reduce the incidence of catheter related bsi. although earlier studies have indicated that mr-impregnated cvcs are cost saving [ ] , our data add further proof to the suggestion that the cost effectiveness of these catheters is at least uncertain. results. from all patients, ( . %) developed infection from any reason during the icu stay. patients developed crbsi, . % of the total patient number and . % of the patients who developed any infection. we recorded episodes of bacteremia due to cvc during days of cvc placement stay, . % while the standard limit is four episodes of crbsi per , days cvc placement. during the year , we chanced our practice in order to avoid as risk factors as we can, using only antimicrobial/antiseptic impregnated catheters, improving our hand hygiene and aseptic technique, using only chlorhexidine and semipermeable polyurethane dressings and making catheter replacement at scheduled time intervals as a method to reduce crbsi. the previous year the recorded crbsi incidence was . % respectively. conclusions. the incidence of intravascular catheter related infection is recorded above the standard limits for second consecutive year assuming that we have to improve further our surveillance policy. on the other hand, the incidence is recorded smaller than the incidence of the previous year according to the change to our practice, assuming that our reforming policy, although not fully effective, still is better for the prevention of intravascular catheter related infections. introduction. intravenous catheter related blood stream infection is a major factor contributing to in hospital morbidity and mortality and extending hospital stay by days and expenditure by , to , lb . the incidence of central line associated blood stream infections (cr-bsi) in our unit was audited in and a comprehensive infection prevention program that included staff education, hand hygiene, maximal sterile barrier precautions and daily assessment of the need for a central line was introduced. we are also taking part in the national audit project matching michigan. objectives. assess the effectiveness of the infection prevention programme and re-audit the incidence of cr-bsi methods. data was collected daily for a period of months. this included the number of patients with central venous catheters in the unit, the number of lines removed or re-sited, the indications for line change, the site of line insertion and incidence of line infection. the lines were reviewed daily and removed if indicated clinically (pyrexia or raised white cell count) or if not required. results. over a period of months central lines were used amounting to line days. the lines inserted were subclavian (sc)- ( . %), femoral (f)- ( . %) and internal jugular (ij)- ( . %). the percentage of lines removed for clinically suspected cr-bsi reduced in this period from to . %. the average duration of stay for the lines were sc . days, ij . days and f days which was shorter than our previous audit showed. the percentage of microbiologically proven cr-bsi also dropped from . to . % ( from internal jugular lines and one from a femoral line). conclusions. introduction of simple and cost effective practices decreased the prevalence of cr-bsi in our unit by a factor of five. daily review of lines led to earlier removal of central lines once they were no longer required. the unit being a neurointensive care unit has a greater proportion of patients in whom femoral lines are often the only option. our survey proves that with strict adherence to guidelines and following infection control protocols diligently the risk of cr-bsi from all line types can be reduced. conclusion. this study implies that the scale of crbsi may be higher than is currently recognised and that the blood culture positivity rate for crbsi is %( / ). as concurrent antibiotic therapy may reduce blood culture and cvc tip positivity, the blood culture rate of % suggests that crbsi has an inherently high blood culture positivity rate despite concurrent antimicrobial therapy. ( ). in this context, we tested the introduction of chlorhexidine(chx)-impregnated sponges ( ) ( ), acinetobacter baumannii . % ( ), serratia marcescens . % ( ), stenotrophomonas maltophilia . % ( ), escherichia coli . % ( ) jai salmonella enteritidis . % ( ) . production of extended-spectrum beta-lactamases (esbls) was detected in % of klebsiella spp. and e. coli strains, overproduction of ampc beta-lactamases was recognized in . % of enterobacter spp., while only one k. pneumoniae strain was found to produce metalloenzyme. all eight strains of p. aeruginosa were susceptible to aminoglycosides, ciprofloxacin and carbapenemaces, both strains of s. maltophilia were susceptible to ticarcillin/clavulanate and trimethoprim/sulfamethoxazole. among a. baumannii isolates, . % were susceptible only to colistin. in total, . % of isolates were susceptible to imipenem and ciprofloxacin. conclusions. gram-negative bacteremia, in particular in the critically ill, is associated with significant morbidity and mortality. significant susceptibility to ciprofloxacin and imipenem was demonstrated. empiric treatment regimens should be based on unit-specific data. ben objective. to assess whether implementation of a national safety program to prevent cvc-related bacteremia had an impact on rates of devices-associated infections acquired in icu. methods. prospective, multicenter, incidence, surveillance study of vap, crb and uti carried out from - - to - - . simultaneously, a bundle for prevention of cvcrelated bacteremia and a comprehensive safety program were introduced at the national level. infections were diagnosed according helics definitions. the follow-up was carried out until discharge from the icu or to a maximum of days. the severity was assessed by the apache ii score. the rates are expressed as incidence density (id) per , days of risk factor. rates are compared with those of previous years ( ) ( ) . introduction. acute kidney injury (aki) is one of the most dreaded complications of severe malaria. occurs as a complication of plasmodium falciparum malaria in less than % of cases, but the mortality rate in these cases may be up to % [ ] . to evaluate the incidence of aki and compare akin and rifle classification systems with regard to hospital mortality. a retrospective analysis based on medical records of adult patients with severe plasmodium falciparum malaria admitted in the general icu of clínica sagrada esperança, in luanda, angola, from january to december . criteria for diagnosis included the standard who definition for severe malaria. only changes in serum creatinine were used to define the presence of aki by both criteria. logistic regression was used to access the association of each rifle and akin with hospital mortality. data are presented as odds ratios with % confidence intervals (ci). we enrolled patients. thirty-nine ( . %) were males. the mean age recorded was . ± . . the mean apache ii score was . ± . , with a mean predicted dead rate of . %. the mean sofa score on admission was . ± . . the mean length of stay in the icu was . ± . days. rifle allowed the identification of more patents than akin as having aki ( . vs. . % there was no statistic association between corticosteroids therapy and length of icu stay less than days (p = . ), duration of mechanical ventilation less than days (p = . ), severe infection (p = . ), re-intubation (p = . ), tracheotomy (p = . ), nosocomial infections (p = . ), myopathy (p = . ) or mortality (p = . ). although there is a tendency for a higher prescription of corticosteroids in dni patients with severe infection, the difference did not reach statistical significance. the use of steroids is neither associated with a better outcome nor with a higher frequency of adverse events or side effects, namely critically illness myopathy or nosocomial infections. ozbek introduction. q fever, a zoonosis due to coxiella burnetii, is more frequent and severe in men than women, despite a similar exposure. here we explore whether the severity of c. burnetii infection in mice is related to sex differences in gene expression profiles. methods. experimental study analyzing the transcriptome of c bl/ j mice. ten females and males were sterilized at weeks of age. after weeks, males and females ( intact and castrated animals of each gender) were killed. the other series of mice were injected intraperitoneally with c. burnetii organisms and sacrificed at day one after infection. organs were aseptically excised and stabilized in rnalater. total liver rna was retrotranscribed and labelled with cy . labelled cdna were hybridized onto whole mouse genome oligo microarray k (agilent). raw signal data were normalized with the quantile method. the significance analysis of microarrays test was used to study the gene expression in uninfected and infected mice. supervised analyses were carried out with r with the library bioconductor. pca was used to visually explore global effects for genome wide trends, unexpected effects and outliers in the expression data (library made ). in another set of experiments, mice ( intact males, castrated males, intact females and castrated females) were killed at , , and days after c. burnetii infection (same protocol). liver rna was analyzed by rt-pcr to confirm microarray results. results. multiclass analysis (sex and infection) identified , modulated genes (fdr = %, |fold change| [ . ) . we found that % of the genes are specifically modulated in males or females. only % of the genes are sexindependent. castration showed that sexual hormones are responsible for more than % of this sex-specific differential expression. the reduction of gene expression modulation upon castration is seen almost exclusively in males. functional annotation of male specific signature identified groups of keywords linked to cellular adhesion, signal transduction, defensins and cytokines and jak/stat pathway. functional annotation of female specific signature identified two group of keywords linked to intracellular metabolism and circadian rhythm. these results were confirmed by rt-pcr. the increased susceptibility to infection in males may be related to the overexpression of il and stat . the modulation of the circadian rhythm in female is linked to a more efficient bacterial clearance. conclusions. this study showed for the first time that the sexual dimorphism observed in q fever is reflected by sex related gene modulation, and is under the control of sexual hormones. this study also showed that the circadian rhythm seems to play an important role in infection in mice. this work open the way for deciphering the role of sex and circadian rhythm in human infections. the author's report a p.aeruginosa sepsis with skin and heart involvement in a previous healthy woman. a years old woman without a pertinent medical history came to the hospital after days with high fever ([ . °c), vomiting and diarrhea. at admission she was in septic shock with multiple organ disfunction (hemodynamic, cardio respiratory and renal) and presented genital skin lesions (round, ulcerated, painless lesions with necrotic black eschar and erythematous margin-ecthyma gangrenosum). the laboratory tests showed bicytopenia (leucocytes and platelets), hepatic necrolysis and elevated troponin t, associated with t wave inversion in anterior leads in the ecg. the ecocardiogram showed apical dyskinesis with normal systolic function suggesting tako-tsubo cardiomyopathy. hemocultures ( ) were positive to pseudomonas aeruginosa and skin lesions biopsy showed vascular ulcers with local p. aeruginosa inflamation. results. besides the fluid challenge and supportive therapy she began empirically piperaciline-tazobactam with rapid improvement of the clinical picture. she needed vasopressors (norephynefrine and dopamine) for h. the skin lesions have resolved in days and cardiac treatment was conservative and symptomatic. the patient was discharged from the intensive care after days. conclusions. ecthyma gangrenosum although relatively uncommon, was first considered a pathognomonic sign of p. aeruginosa sepsis, but now we known that other bacterias can have the same presentation. tako-tsubo cardiomiopathy or broken heart syndrome is a stress-induced cardiomiopathy characterized by transient systolic dysfunction that mimics myocardial infarction but without coronary disease. although the unusual p. aeruginosa clinical presentation sepsis should be treated with prompt supportive measures and the most adequate antibiotic. objective. we undertook this study to determine the relative frequency of meningitis and sepsis in a paediatric intensive care and to define the clinical and laboratory features at the time of admission and the outcome of these children. we reviewed the medical records of patients with sepsis and meningitis, in our paediatric intensive care, from to . results. among these patients % had meningitis, % had sepsis, % patients had bacteraemia, and % had meningitis and sepsisage ranged from month to years old ( % were - years old. boys %, girls %. temperature at the moment of admission was in % patients greater than °c. leucocytosis was noted in % (from , to , / mm ) and leucopenia % ( , - , /mm ) % of the patients had petechiaes, % had a positive lumbar puncture and % who did not have lumbar punctures had diffuse intravascular coagulationthe species of microorganism were in % meningococcus group b, in % no organism was found, in % were pneumococcus, and meninococcus group d in %. on admission, % of our patients had seizures. the duration of hospitalization in our picu was % (average length of stay from to days) % had hemodynamic instability, and % had a normal arterial pressure. from the patients who had hemodynamic instability, needed only fluids %, and % needed fluids and inotropes % of the patients received intravenous ceftriaxonewe had no mortality. conclusion. meningitis and sepsis remain a serious problem in picu. with the existing guidelines of therapy and prognostic signs at the moment of admission in picu we have a better outcome. howitz introduction. community acute bacterial meningitis is a relatively common disease. three bacteria are responsible in most cases: streptococcus pneumoniae (adults), neisseria meningitidis (older children and young adults) and listeria monocytogenes (in the elderly, alcoholics and immunosuppressed). the mortality rate ranges between and % and is higher in case of pneumococcal meningitis ( %) due mainly to increased intracranial pressure and the intense inflammatory reaction that produces pneumococcus in the cerebrospinal fluid. objectives. to study epidemiology, aetiology, clinical and evolution in acute meningitis in the adult community in our icu. methods. retrospective and descriptive study of patients admitted to a tertiary icu with beds from january to december . a total of patients of whom were males ( . %) and women ( . %). the mean age was . years (range: - ). the apache ii at admission was determined in of the patients with an average of points, which is associated initially with a good prognosis. the glasgow coma scale was found in % of the cases the majority ranging between and with a range: - . the average stay in icu was . days. patients died ( . %). risk factors include: infections in otolaryngology: cases ( . %) alcohol: case ( . %) and states of immunosuppression: ( . %) of which: there were two diabetic patients ( . %); hiv: ( . %) were chronic treatment with corticosteroids in one case ( . %); advp: case ( . %) liver transplantation: one case ( . %) and other case cerebrospinal fluid leak ( . %). in patients (% . ) found no risk factor. the most common complication was the need for endotracheal intubation and mechanical ventilation in a . % of patients, hydrocephalus followed by . %. hearing sequelae were found in patients ( . %) and persistent vegetative state in case ( . %). the outcome was favorable and without sequelae in cases ( . %). the etiology was bacterial germs and virus in cases in . bacteria, not unknown in cases ( %). filiated of the causative agent in the majority ( . %) were streptococcus pneumoniae, followed by neisseria meningitidis in cases ( . %), listeria, staphylococcus aureus, e. coli and mycobacterium tuberculosis were isolated in one case each ( . %) . in relation to the vhs virus was found in one case ( . %) and unable to filial the rest. conclusions. community acute meningitis is a disease with low prevalence and mortality in our environment. the agent most commonly streptococcus pneumoniae, clearly associated with increased morbidity. the most frequent complication was the need for endotracheal intubation and secondly hydrocephalus. mortality was associated with longer hospital stays and lower glasgow at the beginning, but not with age. rd esicm annual congress -barcelona, spain - - october s evaluated factors: patient characteristics, signs, symptoms, abscess location, time between symptoms and hospital admission and surgery, lab results, microbiology, antibiotic therapy, apache , saps , sofa, length of icu stay, surgical re-intervention, duration of mechanical ventilation, infectious complications, critical illness myopathy (cim), renal replacement therapy (rrt), re-intubation, tracheotomy, mortality. descriptive statistics were used to analyze data. objectives. to assess ventriculitis (vg) and to study outcome and disability indices in patients admitted in icu due to cerebral hemorrhage (spontaneous or traumatic). we prospectively studied patients hospitalized due to cerebral hemorrhage in the icu of university hospital of thessaly, between and . patients were followed for median follow up of ( - ) days. on admission, the neurological status of patients was described by the glasgow coma scale; disability was evaluated at months by the rapid disability rating scale (rdrs). results. one hundred twenty-one patients ( male) were studied; median (iqr) age was ( - ) years, gcs before intubation ( ) ( ) ( ) ( ) ( ) ( ) objectives. to analyze characteristics of patients diagnosed with infective endocarditis in a third-level hospital from january until december , evaluating the echocardiography findings, the therapeutic strategy used, and both morbidity and mortality rates in hospital and during long term follow-up. observational retrospective study of consecutive patients with following duke criteria with a mean follow-up of ± months. conclusions. this study showed a low mortality of sepsis and its sequential stages in children with meningococcal disease admitted to the picu, which was probably associated with the early use of antibiotics (up to the sixth hour) and aggressive fluid esuscitation. diagnosis and treatment of infections in critically ill patients: - background. about one-third of hospital mortality in critically ill patients occurs after intensive care unit (icu) discharge. post icu deaths may arise from incomplete resolution of the primary condition or from the development of new complications. some authors have recently hypothesized that unresolved or latent inflammation and sepsis may be an important factor that contributes to death following successful discharge from the icu. aim. the aim of our study was to determine the ability of the clinical and inflammatory markers at icu discharge to predict post-icu mortality. a prospective observational cohort study was conducted during a -month period in an bed polyvalent icu. acute physiology and chronic health evaluation (apache) ii score, simplified acute physiology score (saps) ii, sequential organ failure assessment (sofa) score, c-reactive protein (crp), body temperature and white cell count (wcc) of the day of icu discharge were collected from patients who survived their first icu admission. results. during this period patients were discharged alive from the icu. a total of patients ( . %) died in hospital after icu discharge. there were no differences in clinical and demographic characteristics between survivors and nonsurvivors. c-reactive protein levels at icu discharge were not associated with hospital mortality (mean crp concentration of survivors = . introduction. early diagnosis of bacterial infection can be challenging in critically ill patients, however prompt recognition and initiation of antibiotics improves outcome. serum procalcitonin (pct) has been proposed as a more reliable marker of bacterial sepsis than white cell count (wcc) or c-reactive protein (crp), however there is no consensus in how it should be used and pct measurement has not disseminated widely into critical care practice in the uk. to identify if clinical recommendations based on procalcitonin levels are being followed. we retrospectively studied pct use between october and december . assay results were interpreted as: . ng/ml, possible local bacterial infection . - . ng/ml, possible bacterial systemic infection, moderate risk of severe sepsis . - ng/ml, likely systemic bacterial infection, high risk of severe sepsis \ ng/ml, almost exclusively severe bacterial sepsis or septic shock. , this was compared to changes in antibiotic prescribing which were identified from our local audit database and used as a surrogate marker for clinical suspicion of sepsis. to provide context we also compared this to crp and wcc trends in a larger sample from june to december . results. forty-four episodes had matched antibiotic prescribing data and pct results. a further episodes provided synchronous wcc and crp data. pct assays were typically requested on day (median, interquartile range - ). distribution of pct results pct value (ng/ml) . . - . - [ number (%) ( ) ( ) ( ) ( ) there was poor concordance between pct and both wcc and crp trends and also when wcc and crp trends were compared. pct assays did not have significant correlation with antibiotic prescribing. pct conclusions. our study suggests pct results did not influence clinical practice. pct testing may be of greater benefit if used with a protocol with guidance for clinicians based on assay levels. routine and serial quantitative pct testing protocols may also be useful to guide antibiotic initiation and duration, particularly in cases of greater diagnostic uncertainty, for example traumatic brain injury. , references. introduction. procalcitonin (pct) is a reliable marker for diagnosis of infection after cardiac surgery, except in patients who previously received antibiotics, but its diagnostic role in patients with post-sternotomy pre-sternal wound infection and mediastinitis has not been studied in detail. ( ) . objectives. this retrospective study focused on the role of pct in the differentiation between poststernotomy pre-sternal wound infection and mediastinitis. methods. all patients (n = ; age: median , - years) who underwent surgical treatment due to poststernotomy superficial pre-sternal wound infection and mediastinitis between january and september were included in the study. procalcitonin (pct), c-reactive protein (crp) and leukocyte counts were routinely measured within the last h before surgical wound revision. body temperature and hemodynamic parameters were evaluated immediately before operation. bacteriologic samples were also routinely taken intraoperatively. results. the primary cardiac operation was cabg (n = ), cabg and valve procedure (n = ) and others (n = ). time between primary operation and wound revision was in median days (range sensitivity, specificity, positive and negative predictive value for diagnosing sepsis are presented in table . roc curves and auc are presented in figure . roc curves and auc conclusions. patients with sepsis have significantly higher levels of crp, pct, il- and lbp on admission to the icu as compared to patients with sirs. pct is more usefull in differentiating between sepsis and sirs than crp, il- and lbp. b. ergan arsava , s. bilekli , n. alayvaz aslan , e. er , a. topeli hacettepe university, ankara, turkey introduction and objective. the incidence and mortality of bacterial infections significantly increase with age. aging is associated with an impaired immune response, which causes not only an increased susceptibility for infections, but also a poor inflammatory response against them. procalcitonin (pct) is an inflammatory biomarker used as a diagnostic and prognostic tool in bacterial infections. there is no data regarding the diagnostic yield of pct in elderly patient populations. in this study we sought to identify the relationship between age and the magnitude of pct response in patients admitted to the intensive care unit (icu). methods. patients, who were admitted to icu between january and december , with the diagnoses of severe sepsis, pneumonia and chronic obstructive pulmonary disease exacerbation (copde) were included into the study. patients' demographics, apache- scores, admission pct values, intensive care and hospital outcomes were extracted from a database of prospectively collected clinical data. results. we studied a total of admissions ( female/ male, mean age ± standart deviation . ± . years). median (interquartile range-iqr) apache score was ( - ); the icu and hospital mortalities were . and . %, respectively. median (iqr) admission pct levels were . ( . - . ) ng/ml in patients with severe sepsis (n = ), . ( . - . ) ng/ml in patients with pneumonia (n = ) and . ( . - . ) ng/ml in patients with copde (n = ). there was a negative correlation between age and pct levels (spearman correlation coefficient: r = - . , p = . ); the median (iqr) pct levels were . ( . - . ) ng/ml in patients\ years-old and . ( . - . ) ng/ ml in patients c years-old (p = . ). in subgroup analyses it was found that the inverse correlation between age and pct levels mainly arised from patients with severe sepsis (r = - . , objectives. we intend to define the role of pct in the initial evaluation of the patient with a suspected sepsis admitted to the icu. preliminary data from a prospective observational single centre study (polyvalent icu in a third level university hospital). the ethics committee of the centre has approved this study. we included all patients admitted to our unit with diagnosis of sepsis since june- . we measured pct (lgr/ml) at admission and at the second and third day of stay beside the routine screening for the source of infection. then we analyzed the relation of pct with culture results. chi-square and anova have been used for the analysis. (fig. ). pct at admission showed an auc of . ( . - . ) for discriminating bacterial infection. we detected higher mortality in those patients with bacterial infections and sustained high levels of pct the third day ( fig. ) (p \ . ). figure , conclusions. in the initial approach to the septic patient, pct does not seem in our experience useful as an aid in decision-making but an early decrement of serum levels can be a marker for response and for a better outcome of patients with bacterial infections. ( - ) b-d-glucan (bg) assay in early detecting ici in critically ill pts and assess its reliability on arterial blood specimens compared to venous blood specimens. methods. all pts admitted to the -bed icu of our university hospital, between th of february and th of march , harboring an arterial line for more than days and suspected to have an ici, were prospectively enrolled. from all the pts, two blood samples drawn from the arterial line and direct femoral site were simultaneously obtained and subjected to both conventional cultures and bg assay determinations. candida colonization index (cci) and candida score (cs) were also calculated. results. during the study period, from admissions, pts were enrolled. bg assays, cutaneous and mucosal swabs and urine cultures were collected. in pts bg assays resulted negative from either arterial line and femoral site. all but one did not develop ici. in pts bg assays resulted positive. four of these pts did not develop ici, whereas the other six developed ici ( fungemias and mediastinitis). the positive and negative predictive values (ppv, npv), sensitivity (se) and specificity (sp) of bg assay, cci, and cs are shown in table . among pts with ici, (median sofa score value ± . ; median saps ii value . ± . ) had at the diagnosis bg levels c pg/ml and developed septic shock; two of them died within few days. in contrast, the clinical course of pts with bg assay below pg/ml was not complicated by septic shock (median sofa score . ± ; median saps ii value ± . ) and a rapid clearance of bg levels was observed. in addition, we observed a % agreement between arterial line and femoral site bg assays (positive and negative). in particular, we detected bg levels from arterial site specimens that did not significantly differ by those obtained from femoral site specimens (p = . ). conclusions. although conventional mycological culture remains the gold standard for ici diagnosis, we showed that bg assay seems to be a diagnostic tool that may help physicians in early detecting ici. sampling blood from the arterial line was shown to give a simple and adequate specimen to be used for bg assay. further studies are in progress in order to define the role of bg as a surrogate marker for an early diagnosis of ici. objectives. to assess which marker, if any, and at which cut-off value could add diagnostic information to enhance clinical assessment in the difficult context of long-term icu-patients. methods. long-term ([ days) critically ill patients prospectively enrolled in the general icu of a university-hospital. all patients were daily assessed by the attending physician for the accp-sccm classification. c-reactive protein (crp, mg/dl), procalcitonin (pct, ng/ ml), and interleukin- (il- , pg/ml) were measured after patient's discharge on daily stored sera. an independent overall clinical evaluation after patient's discharge, aware of the clinical course but blinded against biomarker's measurement, an ''a posteriori'' accp-sccm classification, was chosen as reference standard for all comparisons. results. we studied clinical variables and biomarkers in patient-days ( patients). the day by day accp-sccm classification of the attending physician overestimated the severity of the inflammatory response to infection. discriminative ability of each biomarker for diagnosis of sepsis is shown in table . methods. icu patients ( males and females) with new onset of fever and leukocytosis within the first days of icu admission were prospectively included in the study. exclusion criteria: age \ or [ years old, heart or renal failure, hypertension, copd, pregnancy and head trauma. serial plasma samples were taken on days , and after the onset of fever for procalcitonin and bnp levels measurement. procalcitonin and bnp values were correlated with severity scores (apache ii and sofa), progression to septic shock and final outcome. statistical analysis was performed. results. patients included in the study were divided in three groups according to clinical and laboratory findings: sirs, sepsis and septic shock. procalcitonin value on days and and bnp value on days , and was significantly associated with sofa max value and with sofa value at the first day of fever, but not with apache ii. there was found no correlation between procalcitonin value on days , and and final outcome. bnp value on days and was significantly associated with final outcome (p = . and . respectively). the optimal cut-off bnp value on day was estimated to be pg/ml (sensitivity = %, specificity = %). the optimal cut-off bnp value on day was estimated to be pg/ml (sensitivity = %, specificity = %). procalcitonin value on days , and was not able to differentiate between patients with sirs and those with sepsis. also procalcitonin value on days , and was not significantly associated with progression to septic shock. bnp value on day was useful in differentiating between patients with sirs and those with sepsis (p = . ). the optimal cut-off bnp value was estimated to be pg/ml (sensitivity = %, specificity = %). bnp value on days and was significantly associated with progression to septic shock (p = . ). the optimal cut-off bnp value on day was estimated to be pg/ml (sensitivity = %, specificity = %). the optimal cut-off bnp value on day was estimated to be pg/ml (sensitivity = %, specificity = %). conclusions. in icu patients with new onset of fever during the first days of icu hospitalization, bnp value on days and seems to be a good predictor of icu mortality and progression to septic shock. also bnp value on day may be useful in differentiating between patients with sirs and those with sepsis. in our study procalcitonin value on days , and was not found useful in predicting progression to septic shock nor the final outcome. due to the small number of patients included in our research, further studies are needed to confirm these findings. objectives. as c-reactive protein (crp) is regarded a marker for both inflammation and infection we decided to analyse the pct and eo status next to every crp request of critically ill patients, during month. a two-side immunoassay (sandwich principle) for procalcitonin, using both anti-katacalcin and anti-calcitonin (see fig. a ) was used for quantitative analysis of procalcitonin with the roche modular e . pct concentrations [ . lg/l were regarded as positive. crp was measured by immunoturbidimetric analysis using the roche modular p. a positive blood culture was regarded as infection, with exclusion of the coagulase negative staphylococcus aureus since this organism doesn't induce pct expression. every crp request of the icu during month was accompanied by a pct, wbc, and eosinophil count. conclusions. pct at randomly measured at the icu doesn't seem to contribute to an earlier diagnosis of sepsis. pct measurement seems to be useful only when sepsis is suspected and a blood culture request has been summoned. however, its non-specificity for infection, as demonstrated by the high number of pct-positive, no blood-culture requested patients (concerning mostly post-cardiac arrest and post-heart surgery patients), makes it difficult to apply routinely. the recently displayed effort of various companies to market pct in combination with cd and neopterin (other potential markers of infection) supports the conclusion that not one marker by itself can substitute the golden standard of blood culture today. objectives. in this prospective observational study we sought to investigate the role of serum c-reactive protein (crp) and procalcitonin (pct) in the diagnosis and prognosis of patients admitted to the icu with suspected h n infection. all patients older than year-old, presenting with severe acute respiratory disease (cough, fever and respiratory distress) admitted to the icus of an university hospital in southeast brazil were included in this study. serum levels of crp and pct were measured at inclusion and at day , and . were also were also significantly higher (p \ . and p = . , respectively) independently from the presence or not of a co-infection. conclusions. as a conclusion, in our experience, some severe forms of influenza a/ h n with respiratory failure had elevated levels of pct and/or crp in the absence of proven bacterial co-infection. low values were unusual in the presence of co-infection but high values are not synonymous of co-infection and may be related to the severity of the disease. a large prospective randomized study is needed to assess the clinical interest of these biomarkers during the next pandemic of influenza. methods. descriptive study of pregnant with influenza a admitted in the obstetric section icu. the study period runs from september to january . during this period patients were admitted. entry criteria (%): gestosis %, complicated postoperative gynecology and obstetrics , postpartum hemorrhage , acute respiratory failure in influenza pneumonia: . , sepsis and others respiratory failure respectively, others (pregnant myocardial infarction, trauma, renal failure, arrhythmias and heart failure) . acute respiratory failure due to influenza pneumonia was assessed using severity criteria the ats/idsa (major criteria ( ) were admitted in icu cases of severe influenza pneumonia, nasopharyngeal specimens confirmed with rt-pcr positive for influenza a (h n ): pregnant in icu og, and women and men general icu. the average age of pregnant was ± years, average stay days. % were in the rd trimester and one in the nd trimester (week ). two-third pregnancy and two primiparous. the apache ii on admission ranged between and . only one patient with pre-existing disease (diabetes type ). admission due: acute respiratory failure complicating pneumonia multilobar in %, with more than days of typical symptoms (fever [ °c, malaise, myalgia, headache and respiratory symptoms), no starting oseltamivir within h symptoms. caesarean was performed at %; % in the first h of admission and one after days (week ) intrauci, posterior cerebral hemorrhage fetal death. all newborns free of viral disease. invasive mechanical ventilation (mv) in the first h in patients and did not require. required aggressive parameters %: bipap, alveolar recruitment and prone. a percutaneous tracheostomy for weaning. the average duration of mechanical ventilation: ± days complications: barotrauma (pneumothorax and a pneumomediastinum ). % required vasoactive drugs. one patient with acute renal failure that required extracorporeal clearance techniques (hdfvvc), recovering renal function, deep vein thrombosis complicated with shaldon catheter. one brain death by massive subarachnoid hemorrhage. nosocomial infections in patients, most common germ staphylococcus epidermidis catheter and candida sp in urine. initial empiric coverage with ceftriaxone and clarithromycin, as well as oseltamivir. conclusions. during pregnancy, especially in the second and third quarters, there is an increased risk of complications associated with infection by influenza a virus h n , highlighting pneumonia, with more rapid progression to severe respiratory complications. objectives. the aim of this study was to describe baseline characteristics, management and outcomes of critically ill patients with influenza a (h n ) infection who were treated at icu. we performed a retrospective observational study which included critically ill patients with influenza a (h n ) infection admitted to icu between rd november and th march . the primary outcome measure was mortality. secondary outcomes included the rate of influenza a (h n )-related critical illness and introduction of mechanical ventilation as well as intensive care unit (icu) length of stay and hospital length of stay. in the early th century, burns patients were dying of multi-organ failure due to dehydration and hypovolaemia [ , ] . the parklands formula was devised to guide fluid resuscitation and prevent multi-organ failure from occurring. however, over enthusiastic fluid resuscitation will lead to other complications [ ] . objectives. we aimed to assess the adequacy and complications of fluid resuscitation in the st h of a burns patient admitted to our icu, a tertiary centre for burns intensive care. • a retrospective medical case notes audit on all patients admitted to our icu in with [ % tbsa (total burns surface area). • st h of burns resuscitation initiated by the referring hospital and our icu compared to the parkland's formula. • statistical analysis by spss . results. patients audited. • mean duration of transfer from burn injury to our unit = . h • mean age = years, burn area %, length of stay . days • day mortality = % • % had an inhalational injury • no statistical difference between the emergency department (ed) estimation of tbsa and whiston icu. • mean iv fluids given . l but the actual predicted requirement is . l, therefore an excess of . l (p \ . ) • average urine output during this period was . ml/kg/h suggesting that this amount was adequate. iv fluids in the st h conclusions. excessive amount of iv fluids in the st h is associated with prolonged ventilation and length of stay but is not associated with increased day mortality. the mean amount of fluid required in the st h is approximately ml/kg/h which is consistent with other studies [ ] . urine output is still an accurate marker of resuscitation. there was no statistical difference between the determination of tbsa by the ed and burns surgeons, contrary to other studies [ ] . introduction. icu-acquired hypernatremia appears to be associated with mortality in the icu . to reduce iatrogenic rise of serum sodium the use of balanced colloids has been advocated. objectives. aim of this study was to establish the incidence of clinically relevant hypernatremia on our icu and to evaluate the change in incidence of hypernatremia due to the introduction of a natriumacetate based colloid solution. we performed a single centre retrospective study in a -bed mixed icu with all available medical specialities except neurosurgery. sodium measurements of all patients were analyzed during a -month period prior to and after a switch from sodium-based (s) to natriumacetate -based (na) colloids. s contains a % kda polystarch with a mmol/l na and mmol/l cl concentrations (voluven Ò ). na contains a % kda hydroxyeethylstarch with a mmol/l na and mmol/l cl concentrations (volulyt Ò ). serum sodium measurements were routinely performed -hourly. by protocol colloids were provided to a maximum of l/day, independent of bodyweight. patients with hypernatremia at icu admission were excluded. data are expressed as mean ± sd. comparison of na concentrations between groups was performed with a t test for independent samples and comparison of incidence of hypernatremia with a pearson chi-square test. results. patient characteristics and number of samples are summarized in table . after the introduction of na mean serum sodium concentration in the total icu population decreased significantly from . ± . to . ± . , p = . . the incidence of serum na[ mmol/ l decreased from . to . %, p = . . the percentage of patients with at least one na measurement[ mmol/l did not change significantly: . % (s) versus . % (na), p = . . introduction of a natriumacetate based colloid solution in stead of a sodium-based colloid solution reduces the overall incidence of clinically relevant hypernatremia; however, the number of patients with such hypernatremia did not change significantly. patients admitted to intensive care frequently have a metabolic acidosis with previous studies demonstrating an association between the degree of acidosis and outcome. hyperchloraemia is a significant cause of metabolic acidosis and there is increasing interest in the adverse consequences associated with it, which include hypotension, renal dysfunction, impaired gut perfusion and increases in inflammatory cytokines. previous studies, however, have failed to show that hyperchloraemic metabolic acidosis (hcla) has a significant effect on survival. to assess whether patients with hcla had a worse prognosis than our general intensive care unit (icu) population, and the factors associated with the development of hcla. consecutive admissions to the intensive care unit over a month period were studied. patients with a base deficit[ mmol/l and a serum chloride[ mmol/l on the same arterial blood sample during their icu admission were classified as having an episode of hcla. apache ii scores on admission, length of stay on the unit, mortality rates and reason for admission were collected. hospital survival was investigated by logistic regression analysis, controlling for illness severity (apache ii) and admission category, and displayed as a kaplan-meier curve. of patients entering the unit during the retrospective study period, had an episode of hcla, with an odds ratio of death of . ( % ci . , . ) compared with those without hcla. after controlling for apache ii score on admission, and admission category the odds ratio reduced to . but was still statistically significant (p = . , % ci . , . ). the development of hcla was significantly more associated with medical than surgical admissions with an odds ratio of . ( % ci . , . ). within the surgical admissions, the occurrence of hcla differed significantly with the urgency of surgery, with an odds ratio of . ( % ci . , . ) for emergency surgery versus elective surgery. those with hcla had a longer median duration of stay and were overrepresented in the group of patients whose length of stay was c days. kaplan-meier graph showing survival to days conclusions. the results demonstrate that hcla occurs frequently in a general icu population and is associated with a significantly worse outcome. this is in contrast to previous studies which have demonstrated acidosis secondary to lactate and an elevated strong ion gap are associated with poorer outcomes, but not hyperchloraemia. a. dumoulin , a. janssen , j.j. de waele , j. decruyenaere , e.a. hoste universitair ziekenhuis gent, gent, belgium increased creatinine clearance or hyperfiltration has been reported in icu patients. enhanced renal clearance of antibiotics in patients with hyperfiltration may result in suboptimal antibiotic serum concentrations, and so affect patient outcomes. there are only limited data on the incidence of hyperfiltration in icu patients. objectives. assess the epidemiology of hyperfiltration in a cohort of icu patients. single center retrospective cohort study, including adult patients hospitalized during the period / - / in the bed icu of the ghent university hospital, a tertiary care center. data were retrieved by a specially designed electronic alert from the electronic icu database. urinary creatinine clearance (ccr) was calculated as ( h urine volume) (urinary creatinine)/([creatinine day - + day ]/ )/time. we retrieved the initial ccr, and the minimum and the maximum ccr. hyperfiltration was defined as a ccr c ml/min. patient days with anuria were excluded from the analysis. data are reported as median (interquatile range). patients with neurological disease. several factors may interfere with water and sodium homeostasis in these patients, including factors that are also present in other icu patients. in addition, these patients may develop a syndrome of antidiuresis (siad), or salt wasting syndrome (sw). the latter by secretion of brain natriuretic peptide (cerebral salt wasting syndrome (csw)), release of atrial natriuretic peptide in volume overload, or renal salt wasting. objectives. assess the epidemiology of hypona in icu patients with neurological disease. methods. retrospective single center study. data were retrieved from electronic icu databases. inclusion criteria were age c years, hypona (\ mmol/l), and neurological disease. only the first episode of hypona was considered. siad and sw was assessed with tonicity balance on data of the preceding h in patients with urinary sodium[ mmol/l, in whom other etiologies were excluded. sw was defined as negative salt balance and negative fluid balance, and siad as positive fluid balance. to evaluate the prevalence of anaemia among patients attended at the emergency room (er) and to estimate the need of an early diagnose and efficient treatment. observational transversal trial in which days in june were randomly chosen. all patient attending to the er is included. paediatric, gynaecologic and traumatic cases fall out of this research. anaemia was diagnosed according to who criteria. comparison means statistics methods for quantitative variables and chi square for categorical variables were used. prevalence data for the entire cohort, for men and women separately and for different age bands, medical history, anaemia related medication and red blood cells data were extracted. results. patients were interned through the er channel. % men, mean age . ± . years old (median ), and , % were subject of blood analysis using classification proceedings. from the analysed . % were anaemic. . % of them were under years old, % aged from to and . % elderly patients (over years old). most frequent co-morbidity was chronic obstructive pulmonary disease (copd) (n = , . %) and most related drug aspirin (n = , . %). % of the sample had a bleed but only . % needed red blood cell transfusion. we found statistic difference in mean age, antiplatelets therapy use, bleeding episode, need for transfusion, creatinin value and hospitalisation. anaemia classification according to vcm: microcytic . %, normocytic %, macrocytic . %. conclusion. unknown anaemia detection in the er and its following treatment could be a strategy to further reduce allogeneic blood transfusion. the presence of disorders of sodium balance on icu admission could be independently associated with mortality. we decided to study if the existence of dysnatremias at the time of icu admission could be related to mortality in critically ill patients. we conducted a retrospective study in a mixed icu with a database of , adults admitted consecutively over a period of years ( - ) . most patients ( . %) had normal sodium levels ( b na b mmol/l) on icu admission. the frequencies of borderline ( b na b mmol/l), mild ( b na \ mmol/l), and severe hyponatremia (na \ mmol/l) were . , . %, and . %, respectively. the frequencies of borderline ( \ na b mmol/l), mild ( \ na b mmol/l), and severe hypernatremia (na [ mmol/l) were . , . , and . %, respectively. all types and grades of dysnatremia were associated with increased raw and risk-adjusted hospital mortality ratios. multiple logistic regression analysis showed an independent mortality risk rising with increasing severity of both hyponatremia and hypernatremia. odds ratios and % confidence interval (ci) for borderline, mild, and severe hyponatremia were . , . and . , respectively. odds ratios and % ci for borderline, mild, and severe hypernatremia were . , . , and . respectively. conclusions. this observation suggests the possible correlation of natremia on icu admission with hospital mortality and confirms that both hypo-and hypernatremia present on admission to the icu could be independent risk factors for poor prognosis in icu populations. ( ) . a relationship between mortality and delay from time of pars trigger to critical care admission for patients not requiring surgery has recently been described ( ) . objectives. this study was to test the hypothesis that in cases of emergency laparotomy, prolonged physiological deterioration pre-operatively is associated with higher hospital mortality. we reviewed notes of patients that underwent emergency laparotomy between july and february at the northern general hospital, sheffield, uk. time at which patients triggered (pars c ), time of arrival in theatre and hospital mortality were recorded. two-tailed fisher's exact test was used to test null hypotheses that a delay of more than h after pars trigger does not affect hospital mortality. . patients had an emergency laparotomy during this period. of notes retrieved by our patient record service, were incomplete. of remaining patients patients did not trigger, of whom died ( . % mortality). patients triggered, died ( . %). amongst patients that triggered, arrived in theatre within h, of whom died ( . % mortality); of the patients that arrived in theatre after h died ( . % mortality). the odds ratio of death for those with a prolonged pre-operative deterioration (n = ) compared to those without (n = ) was . ( % ci . - . , p = . ). the number needed to treat early to save one life was . conclusions. our data suggest that in cases of emergency laparotomy, those who trigger pars pre-operatively have higher hospital mortality than those who do not. specifically, our data indicate that patients triggering pars c should arrive in theatre within h of first triggering. nothing is known about the effect of the duration of icu-related therapies on acute outcome. to identify the importance of the duration of invasive ventilation and of renal replacement therapy for acute prognosis of surgical patients treated in an intensive care unit (icu). we performed a retrospective analysis of prospectively collected data of an icu patient cohort linked to a local database. adult patients (n = , ) admitted to a -bed icu at a university hospital in munich, germany, between and who had an icu length of stay of more than days and who were followed-up until the end of the acute phase after icu admission. cox-type additive hazard regression models were used to analyse linear, nonlinear or time-varying associations of therapeutic variables with survival time. duration of different invasive therapies was evaluated by constructing specific vectors, which tested potential effects of time-dependant variables on outcome after a lag time of days. . patients ( . %) were still alive at the end of the acute phase after icu admission. during the acute phase, . % of the patients required invasive ventilation, and . % a continuous renal replacement therapy. besides the underlying disease and disease severity at icu admission, the need for invasive ventilation or renal replacement therapy was associated with poorer outcome. duration of invasive ventilation shortened survival (with a lag of week), if treatment lasted for more than days (non-linear association). in contrast, duration of renal replacement therapy was unimportant for acute prognosis. conclusion. prolonged duration of invasive ventilation, but not of renal replacement therapy is inversely related to acute survival. objectives. to identify the prognostic importance of preceding invasive ventilation, renal replacement therapy and catecholamine therapy for long-term survivors after surgical critical illness. we performed a retrospective analysis of prospectively collected data of an icu patient cohort linked to a local database. adult patients (n = , ) admitted to a -bed icu between and , who had an icu length of stay of more than days, were followedup until the end of the second year after icu admission. hazard function was explored by weibull modelling and likelihood ratio tests. cox-type structured hazard regression models were used to analyse linear, non-linear or time-varying associations of therapeutic variables with -year survival time of a patient subgroup, which had survived the period of high hazard. hazard rate declined exponentially up to day after icu admission, and became constant thereafter. patients reached this stable stage of their disease forming the study population. of these patients ( . %) were still alive at the end of the second year after icu admission. underlying diseases were major determinants for long-term outcome. long-term mortality was significantly associated with the acute extent of physiological derangement during icu stay (maximum apache ii score), but was independent from the duration of preceding invasive organ support. in surgical patients with a prolonged icu length of stay, an exorbitant mortality exists for about half a year after icu admission. later on, life expectancy of surviving patients is largely determined by the underlying disease and, to a minor degree, by the acute extent of homeostatic disturbance during icu stay. the duration of preceding invasive therapies does not limit long-term survival. b. rozec , a. desdoits , k. asehnoune , c. lejus , y. blanloeil chu nantes, hôpital laënnec, anesthesia and intensive care, nantes, france, chu nantes, hotel-dieu, anesthesia and intensive care, nantes, france postoperative stroke could be an endpoint in non-cardiac surgery morbidity studies [ ] . therefore, its frequency established in old studies and considered higher than in the non surgical population remains to be estimated more precisely. objectives. the aim of this evaluation was to calculate the frequency of stroke, firstly in a prospective study, and secondly in a review of the literature. strokes diagnosed in the prospective follow-up ( days) of surgery for hip fracture was confirmed by a neurologist and a ct-scan. retro and prospective studies (except abstract) published in journals (pubmed, ovid) from to were included in the analysis. statistics:% ic , multivariate analysis (effects of population size, date of publication, type of surgery, patient age, prospective vs. retrospective studies were evaluated). results. mean pre-operative possum scores between the two groups showed no significant differences. continuous measurements taken by the odm showed a mean stroke volume increase of mls at the end of surgery (paired t test, p-value = . ). ( . %) patients following implementation compared to ( . %) prior to implementation required post-operative critical care admission. following odm implementation, critical care los was reduced from . to . days and post-operative length of stay within hospital was also significantly reduced by . days. introduction. local (skeletal muscle necrosis) and remote (lung neutrophil infiltration) ischemia-reperfusion injury (ir) have been described in animals [ ] and humans after aortic surgery. postconditioning with cyclosporina (csa) was recently shown to prevent skeletal muscle infarction in pig latissimus dorsi muscle flaps [ ] . objectives. the aim of this study was to investigate local (gastrocnemius muscle, gc) and remote (lung and liver) ir in rats exposed to aortic cross-clamping with special focus on mitochondrial respiratory chain complexes activities and reactive oxygen species (ros) production. we also investigated whether pharmacological post-conditioning with csa would be protective in this setting. methods. anaesthetized (isoflurane) and mechanically ventilated wistar rats underwent laparotomy and were randomly assigned to one of the following groups: sham (n = ), ir (n = , clamping of the infrarenal aorta for h followed by h of reperfusion), ir+csa (n = , mg/kg csa administered intraperitoneally and min prior to reperfusion). maximal oxidative capacities (vmax) and complexes i, ii and iv of the mitochondrial respiratory chain were determined using glutamate-malate (vmax) and succinate (vsucc) as substrates in the gc permeabilized fibers and freshly harvested liver and lungs isolated mitochondria. tissue superoxide anion production was assessed with dihydroethidium (dhe) in thin sections of frozen gc. data are expressed as mean±sem and analyzed with anova followed by newman-keuls post-hoc test; a p value. was considered significant. esophagectomy with gastric tube reconstruction is associated with frequent postoperative complications due to a (surgery induced) systemic stress response, provoked by the overproduction of proinflammatory cytokines. in elective postoperative esophagectomy patients, we previously showed that levels of serum crp are associated with the occurrence of postoperative complications and reduced survival. plasma ngal (pngal) and urine ngal (ungal) are early predictors of acute kidney injury, however sepsis/sirs seems to accelerate their production even in the absence of aki. objectives. we examined the role of pngal and ungal as early indicators of postoperative complications at the icu in patients undergoing elective esophagectomy surgery methods. in a prospective follow-up cohort study, data of a total of patients admitted to the icu following elective esophagectomy with gastric tube reconstruction were collected in the period from september to april . patients who developed aki at the icu were not included in this study. postoperative pngal and ungal levels were determined at consecutive time points and the relation between the course of postoperative serum pngal and ungal, development of complications and outcome of the patients was investigated. in our experience, assisted by dv robot radical prostatectomy, despite requiring longer surgery time, was shown to be safer than conventional radical prostatectomy, with a significant less blood loss during surgery, less need for blood transfusion, fewer postoperative complications, included need to reoperate, and also a shorter length of hospital stay than conventional radical prostatectomy. objectives. the aim of the study was to evaluate safety and effectiveness of m infusion, impact on fluid balance and urine output (uo) and also whether we can avoid cvc line insertion. we conducted a prospective analysis of patients (pts) treated with m who were admitted to the shdu between oct and aug . demographic data and vital parameters were collected through the individual questionnaires before ( ) introduction. an ever increasing number of patients over the age of year are being admitted to critical care units [ ] . with no marked expansion in the number of critical care beds in our hospital and in the health region as a whole, this may lead to a huge strain on the service provision, with less availability of beds to treat elective and other emergency admissions. to determine the factors that affect outcome following admission to critical care of patients aged years and above(medical and surgical). methods. ethical approval was sought but deemed unnecessary as our study was observational (non-interventional). we prospectively looked at the number of patients (age year and above) who were admitted to icu/warrington general hospital over the period of year. our unit is a modern, -bedded general icu with an annual admission rate of approximately ( level and level care). we examined data that was related to the source of admission, gender, apache scores, the use of vasopressors (including inotropes) and the need for ippv in the first h of admission. we analysed the effect that each factor had on patient mortality (applying chi-square and z tests). we followed the patients up for months post-discharge from icu. the final report produced results that showed icu, hospital and -month mortality. results. there were admissions during the period st may - th april . last set of mortality data was obtained in september . female: male ratio was : . the overall -month mortality was %. in our study, patients admitted through a&e, theatre and ward had mortality rates of , and % respectively. patients who received vasopressors (including inotropes) in the first h had a significantly lower mortality than patients who did not receive any vasopressor support ( vs. %). invasive ventilation in the first h of admission was associated with significantly higher mortality rates ( vs. %). in this patient cohort, the overall -month mortality is higher than the general icu population. factors that determine mortality include the source of admission to icu, the need for vasopressor support and invasive ventilation in the first h of admission. introduction. the optimization of oxygen delivery (do ) is an intervention with fluids and inotropics to achieve supranormal goals of do during surgery, before disturbances of perfusion occur and oxygen debt accumulates. oxygen debt is directly linked to multiple organ failure and death. we aimed to evaluate the temporal pattern of oxygen debt in the intraoperative period in patients included in two studies of goal directed therapy to supranormal values of do . oxygen debt was calculated from data obtained from high risk surgical patients included in two randomized controlled trials were analysed. , the oxygen deficit was calculated by subtraction of the basal vo value from subsequential values of vo obtained during surgery and after the icu admission. the oxygen debt was calculated by the product of oxygen deficit and time (minutes) between measurements. patients treated with supranormal goals of do ([ ml/min/m ) using fluids and dobutamine showed lower levels of oxygen debt during icu stay. the peak of oxygen debt was , ml/m at min of surgery in the control group in comparison to , ml/ m in the protocol group. in the second study, the peak of oxygen debt occurred at min in the volume group ( , ml/m ) which was significantly higher than in the dobutamine group ( , ml/m ). higher oxygen debt during peroperative period correlated with poor outcome as shown on the original studies. conclusion. the use of supranormal goals of do with dobutamine and fluids in the peroperative period results in lower oxygen debt. post-operative nausea and vomiting (ponv) is a common problem in the patients undergoing laparoscopic surgery. the release of serotonin during surgical procedure may induce ponv. we investigated if postoperative increase in plasma serotonin metabolite was associated with ponv after gynecologic laparoscopic surgery. objectives. the patients who experienced nausea after gynecologic laparoscopic surgery (ponv group, n = ) and patients who had no or mild nausea (control group, n = ) were enrolled into this study. postoperative nausea was assessed during h in post-anesthetic care unit and ondansetron was administered if needed. blood samples were obtained before anesthesia and h after surgery. plasma serotonin metabolite ( -hydroxy indole acetic acid, -hiaa) was analyzed using high performance liquid chromatography (hplc) assay. perioperative change of plasma -hiaa and the degree of nausea were compared between groups. results. the degree of post-operative nausea varied from to ( mm visual analogue scale, vas) and median value was ( - ) in control group and ( - ) in ponv group (p \ . ). average -hiaa concentration of all patients increased after surgery ( . ± . to . ± . ng/ml, p \ . ). baseline plasma -hiaa concentrations were similar between groups, however, -hiaa of ponv group increased higher after laparoscopic surgery compared with control group ( . ± . to . ± . ng/ml vs. . ± . to . ± . ng/ml, p = . ). conclusions. the patients who experienced post-operative nausea showed more increase in -hiaa concentration. ponv after gynecologic laparoscopic surgery may be associated with a peripheral release of serotonin. introduction. the intracavitary ecg method is an easy, accurate and inexpensive methodology for real time positioning of the tip of central venous catheters. in particular, when the ecg method is performed using not the guidewire but the saline-filled catheter as electrode, the methodology is completely safe and can be applied to any central venous access device (vad). we have tested a new specific device (sapiens tls, romedex) which simplifies and standardizes the ecg method; it consists of a hardware (a small box with cables connecting it to a pc and to ecg electrodes) plus a software (which can be used on any pc). we tested the sapiens tls in patients who underwent positioning of central vads ( totally implantable ports, piccs and tunnelled catheters, all inserted by ultrasound guided venipuncture). our goal was to position the tip of the catheter at the cavoatrial junction: the length of the catheter was estimated by anthropometric measurements and the correct positioning was achieved by the intracavitary ecg method during the procedure. the final position was checked by a post-procedural chest x-ray. there was no insertion-related complication. the intracavitary ecg method was easily performed in all cases. at the final x-ray control, % of all tips were correctly positioned at the cavo-atrial junction (± cm), confirming the accuracy of the intracavitary ecg method. the anthropometric measurement tended to overestimate the length of the catheter both in port insertions ([ cm in % of cases) and in picc insertions ([ cm in % and [ cm in % of cases). conclusions. the intracavitary ecg method as performed with the sapiens tls was more accurate than the anthropometric measurement in terms of correct positioning the tip of the catheter during the procedure. the sapiens tls simplified the method, by standardizing the ecg tracking, and making it easy (no need of ecg monitor, no need of ecg commuter since the sapiens tls displays simultaneously the surface ecg and the intracavitary ecg). also, the sapiens tls allows the print-out of the intracavitary ecg reading for documentation, as well as the storing of the ecg reading in a computer-based database. previous studies have shown that hypernatremia impact graft function after orthotopic liver transplant (olt). the purpose of this retrospective investigation was to determine whether differences in serum sodium values after olt influenced postoperative short-term patient outcomes. objectives. the study was aimed at exploring the incidence of hypernatremia after orthotopic liver transplantation (olt) in order to provide critical monitoring and intensive care services. clinical and sicu laboratory data were collected; serum sodium was assessed an average of three times per day. hypernatremia was defined as two daily values of serum sodium above mmol/l. from to , we analyzed patients with hypernatremia after olt. the major outcome was death in the icu after days. conclusions. in sicu, olt patients are easy to suffer from hypernatremia ( . %) and have high mortality ( . %). hypernatremia is associated with an increased risk of death in patients with olt. early active fluid infusion is crucial, besides optional continue venovenous hemofiltration (cvvh). cywinski objectives. the aim of this study was to determine the value of blood lactate sequential dosages during the first postoperative hours for the diagnosis of gd. we conducted a retrospective study on consecutive patients admitted in icu after lt, between july and june . lt with auxiliary or splited grafts were excluded so were patients with septic or cardiogenic shock occurring during the first h after lt. criteria for gd diagnosis were: sgot [ , u/l with pt \ % between d and d , or re transplantation or death between d and d . demographics and biological data (transaminases, pt, serum bilirubin) were recorded between d and d . hopital bicêtre, kremlin-bicêtre, france, hôpital saint-louis, paris diderot university, biostatistics, paris, france, hôpital hôtel-dieu, medical intensive care unit, nantes, france, hôpital gabriel montpied, nephrology and transplantation, clermont-ferrand, france, hôpital edouard herriot, medical intensive care unit, lyon, france, conclusions. in kidney transplant recipients, arf is associated with high mortality and graft loss rates. increased pneumocystis and bacterial prophylaxis might improve these outcomes. early icu admission might prevent graft loss. a. umgelter , k. lange , p. büchler , h. friess , r.m. schmid technical university of munich, transplantationszentrum münchen rechts der isar, ii. medizinische klinik, münchen, germany, technical university of munich, transplantationszentrum münchen rechts der isar, chirurgische klinik, münchen, germany introduction. the shortage of donor organs in the eurotransplant region results in late allocation at a time when liver disease is already very advanced. the severe condition of patients at that stage negatively affects outcomes of orthotopic liver transplantation (olt). to support decision-making in these situations, clinical data are urgently needed. objectives. to evaluate outcomes of liver transplantation (olt) in icu-patients with multi-organ failure due to advanced acute on chronic liver failure (aclf). methods. in our centre, patients on the waiting list for olt are not automatically excluded from the procedure, if their condition deteriorates to multi-organ failure. a consensus of the team in each individual case is based on criteria such as the previously manifested will of the patient, exclusion of current infection, absence of neurologic damage or other organ damage expected to impair the possibility of rehabilitation. we retrospectively analyzed a database comprising data from evaluation for the waiting list of all patients transplanted in our center since implementation of the meld-score for allocation. only cirrhotic patients treated on our intensive care unit before transplantation were included. patients treated on the icu before retransplant for primary graft failure were excluded from analysis. data are presented as median ( th - th percentile). wilcoxon or mann-whitney u tests were used for comparisons of paired and unpaired data, respectively. results. from january until september patients ( m, f; age ( - ) years) fulfilled inclusion criteria. cirrhosis was due to alcohol (n = ), hcv (n = ), alcohol+hcv (n = ), alpha- -antitrypsin deficiency (n = ), budd-chiari-syndrome (n = ) or cryptogenic (n = ). upon icu admission icu, apache ii scores were ( - ), sofa scores ( - ); meld ( - ). after ( - ) days on the icu, directly before transplantation, sofa scores had deteriorated in all patients to ( - ) and meld scores to ( - ). patients had renal replacement therapy and patients were on single-pass albumin dialysis. the -day-mortality was %, hospital mortality % and -year mortality %. in hospital survivors, surprisingly, sofa scores ( ( - ) vs. ( - ); p = . ) and inr ( . ( . - . ) vs. . ( . - . ); p = . ) upon admission to the icu were significantly higher than in non-survivors. there were no significant differences in age, gender, meld scores or use of extracorporeal treatment in survivors vs. non-survivors. conclusions. liver transplantation in selected cirrhotic icu-patients with multi-organ failure is not medically futile. outcome, however, is much worse than usually considered acceptable. objectives. this work tries to study the clinical profile and the results with the immediate postoperative outcome of patients suffered from pancreas-kidney transplantation (pkt) and only pancreas transplantation (pt) admitted in our intensive care unit (icu) setting. methods. prospective study during years (from to ). we recorded epidemiological, demographical and clinical data, surgical and postsurgical complications, therapy, morbidity and mortality rate, length of stay in icu, organs survival, etc. the data were expressed in mean±typical deviation, median and percentages. results. we recorded patients. table expresses some of the data. the mean age was . ± . years old male . %. pkt from unic deceased donor: %. pt: %. the mean ischemia time was . ± . h for the kidney and . ± . for the pancreas. the most frequent surgical complications were bleeding ( . %), technical difficulties ( . %) and anesthetic complications ( . %). postoperative immunosuppression consists in methyl-prednisolone, tacrolimus, mycophenolate mofetil and thymoglobulin (as our protocol recommends) and was administered to the % of the patients. prophylactic antibiotic and antiviral therapy (ampicillin, ceftriaxone, fluconazole and gancyclovir) was given to almost the % of the patients. table expresses the blood test results. the mean insulin requirements per day during the stay in icu was ( - . ) iu. table represents the complications in the icu. the first leading cause of reoperation was vascular thrombosis ( %) followed by intraabdominal bleeding ( %). conclusion. the clinical profile of this patient in our setting is a years old man, with high blood pressure, retinopathy, dialysis, pancreas-kidney transplant recipient, with unic decesed-donor. he needs no insulin or minimal requirements. the principal complication is pancreatic vascular thrombosis that frecuently leads to removal of the graft. ( ) . in a clinical practice, a specific marker to evaluate and predict ischemic-reperfusion injury in liver transplantation (olt) is not available. poor organ perfusion and high pct levels appeared to predict early graft failure only in the cardiac donor ( ) . objectives. we evaluated pct as a predictor of ischemic-reperfusion injury in liver transplantation and pdr, as a predictor of complication and graft outcome. methods. prospective study. patients (age, child-pugh score, aetiology of liver cirrhosis) undergo liver transplant. bilirubin levels and pdr ( . mg/kg of ig in a central catheter with limon system Ò , pulsion medical system, munchen, germany) was measured once a day for postoperative days (pod). on the same day, aspartate aminotransferase (ast/gpt) and alanine aminotransferase (alt/got) were measured. sofa score was as a patient severity score. serum level of pct, c-reactive protein (crp) was collected at the liver reperfusion time and from the st to the rd pod. warm and cold ischemia time was collected. statistical analysis was performed with wilcoxon, spearman tests (p \ . ). linear correlation was performed too. a small rise on pct levels were observed early after olt, with a peak in the st day after olt. it was associated neither with hepatic post-olt dysfunction nor with other non infective complications. pct increased significantly after liver reperfusion (p \ . ) and correlate with pdr on the nd pod, but not correlation were found with crp, white blood cells, or liver enzymes after olt. crp levels increased rapidly after olt. pct increasing after liver reperfusion correlated with child-pugh olt (r = . at nd pod) in the recipients. the cold ischemia time did not correlate with pct serum levels after liver reperfusion as well as the warm ischemia time. a negative correlation was found between pdr and liver function in the recipient. pdr did not correlate with child-pugh score. the cold ischemia time well correlated with ast and alt on the first day after transplant (r = . ). it negatively correlate with pdr (r = - . ) at the same time. the warm ischemia time did not correlate with pdr, ast and alt. the same results were found between pdr and liver enzymes and lactates. no correlation was found between pdr and sofa score. conclusions. pct peak in the recipient at reperfusion and early post operative was not predictive of graft dysfunction or other non infective complication. it may represent a marker of ischemia-reperfusion injury. crp levels increased rapidly after olt and it could be an expression of surgical procedure, and it doesn't correlate with pct. objectives. the aim of this prospective observational study was to describe the kinetics of ngal following renal transplantation and to assess its ability to predict delayed graft function. introduction. lung transplantation is the recognized therapy for end-stage respiratory failure. many serious medical complications have been described occurring from months to years after lung transplantation, often necessitating admission to an intensive care unit (icu), which has been associated with a high mortality. we examined the factors associated with mortality. methods. all patients admitted to the general intensive care unit between and following lung transplantation were included in this retrospective study. data was collected regarding demographic parameters, intensive care unit stay and outcome. over the study period, forty patients were admitted to the icu. the main pretransplant diagnosis was idiopathic pulmonary fibrosis followed by chronic obstructive pulmonary disease. the majority ( %) of patients required mechanical ventilation during their icu stay. the main reason for icu admission was septic shock in patients ( %) of cases. an organism was isolated from of these patients; in cases, the organism was shown to be multi-drug resistant. the icu mortality was . %. non-survivors were characterized by a higher admission sofa score (p = . ), an admission diagnosis of sepsis ( . vs. . % for all other diagnoses, p \ . ), and a requirement for mechanical ventilation (p = . ). in addition, the incidence of chronic rejection was significantly higher in the non-survivors (p = . ). conclusions. severe sepsis remains the most important factor associated with a poor outcome. new strategies are required to alter the course of this common complication of lung transplantation. (the % of the infections were respiratory) and ( %) patients presented pulmonary allograft rejection. according to our immunosuppressive protocol, we started with methylprednisolone and tacrolimus and we added mycophenolate later. the ccd length of stay was ( - ) days and the median days of mechanical ventilation were ( - ). thirteen ( %) patients died, basically due to refractory respiratory failure, multiple organ dysfunction syndrome and haemorragic shock. conclusions. in our large series of lung transplantation a remarkable incidence of complications has been observed. despite this complications, lung transplanted patients presented an excellent short term outcomes. introduction. acute kidney injury (aki) poses a massive challenge after kidney transplantation, especially when kidneys from brain dead adult donors are transplanted into small paediatric recipients. inflammation mediated by cytokines is a key event in experimental models of ischaemic aki. objectives. the aim of this study was to investigate whether remote ischaemic preconditioning (ripc) reduced the inflammatory cytokine load and apoptosis in the kidney after transplantation. methods. kidneys were harvested from eight -kg brain dead donor pigs and transplanted into two groups of -kg recipient pigs after h of cold ischaemia. in one group (+ripc, n = ) ripc was performed before the -h reperfusion period, while no ripc was performed in the other group (-ripc, n = ). non transplanted kidneys from brain dead pigs served as controls. concentrations of tnf-a, il- , il- , and il- in renal tissue were determined by an immuofluorometric assay. renal apoptosis was quantified by immunohistochemistry for activated caspase- . high concentrations of tnf-a, il- , il- , and il- were detected in renal cortex in all three groups. no statistical differences between the two transplanted groups were found for any of the cytokines. compared to controls higher cortical levels of il- (control vs. -ripc, p = . , control vs. +ripc, p = . ) and lower levels of il- (control vs. -ripc, p = . , control vs. +ripc, p = . ) were found in transplanted kidneys. no differences were detected for tnf-a or il- . transplantation significantly increased the number of apoptotic cells in both glomeruli and tubuli (control vs. -ripc, p = . , control vs. +ripc, p = . ). no difference was found between recipients, (p = . ). conclusions. in transplanted kidneys from brain dead donors exposed to h of cold ischemia and ±ripc, we found increased tubular and glomerular apoptosis, but no increase in pro-inflammatory cytokines. the levels of il- were higher in transplanted kidneys compared to controls. remote ischaemic preconditioning did not modify cytokine load or apoptosis in the kidney graft. objectives. we present the case of a patient with confirmed hit and the management of its status during the perioperative period of the cardiac transplantation. a years old patient with a cardiac myxoma was operated under heparin anticoagulation. thrombocytopenia is noted at day after surgery. an enzymelinked immunosorbent assay (elisa) was performed and since the result was positive, the treatment was changed to lepirudin. the hit was confirmed by a heparin-induced platelet activation (hipa) test. the internal jugular vein thrombosis was observed. the post operative evolution was marked by the necessity of the implantation of a ventricular assisted device. the patient was submitted to two sessions of plasmapheresis which turned the antibodies negative. the patient underwent heparin anticoagulation during the surgery time and bivalirudin as the post operative treatment. the antibodies remained negative. two months later, the cardiac transplantation was performed; heparin was used for anticoagulation during surgery. due to a restored renal function, danaparoid was used postoperatively. conclusions. hit is a serious complication of heparin therapy. the diagnosis is difficult. when hit is strongly suspected, a non-heparin anticoagulant is recommended. the choice of the anticoagulant depends on the hepatic and renal function. plasmapheresis is a solution for the antibody purging prior to cardiac surgery. objectives and methods. a nationwide qualitative study investigating their perception of the meaning of professionalism, and how they learn to behave professionally was performed. all eight dutch icm training centres participated. the moderator asked participants to clarify the terms professionalism and professional behaviour. next, participants were asked to explore the questions 'how do you learn the mentioned items?' and 'what ways of learning do you find useful or superfluous?' qualitative data analysis software (maxqda ) facilitated analysis: an inductive approach applying open, axial and selective coding principles was used. results. fellows across eight groups participated. results relating to the subtopics 'elements of professionalism' and 'teaching and learning of professionalism' are described consecutively. elements of professionalism relevant to intensivists: the elements most frequently addressed were communication, keeping distance and boundaries, medical knowledge and expertise, respect, teamwork, leadership and organization and management. medical knowledge, expertise and technical skills seem to become more tacit when training progresses, and relate to ethical, cultural and legal dilemmas originating in the specific icu context, and working as a multidisciplinary icu team member. teaching and learning professionalism: topics can be categorised into the themes workplacebased learning, by gathering practical experience, by following examples and receiving feedback on their actions, including learning from own and others' mistakes. formal teaching courses (e.g. communication) and scheduled sessions addressing professionalism aspects were also valued. conclusions. the emerging elements considered most relevant for intensivists were adequate communication skills, and keeping boundaries with patients and relatives. the specific icm context, and working as multidisciplinary icu team member substantially influenced the icm fellows' perception of professionalism. whereas medical knowledge, expertise and technical skills seem to become more tacit when training progresses, professionalism issues continue to be learned during icm training. professionalism is herein mainly learned 'on the job' from role models. formal teaching courses and sessions addressing professionalism aspects were nevertheless valued, and learning from own and others' mistakes was considered especially useful. selfreflection as a starting point for learning professionalism was stressed. the latter can e.g. be stimulated by means of assessment, structured feedback and use of portfolios, for which guidelines are now being developed within the cobatrice project. introduction: during the past decades there has been an increase in mass casualty events with changing geopolitical and climate situations. in a mass casualty event comprehensive care for the individual is expected [ ] . to meet these obligations further education in disaster medicine seems obligate [ ] . therefore the german home department responsible for mass casualties passed a concept for student education in disaster medicine [ ] . objectives. the introduction of a summer academy ''disaster medicine'' (sadm) is a first approach at charité university of berlin to establish a curriculum for disaster medicine. the sadm is sponsored by the german academic exchange service (daad) for years. the enhancement of student education in disaster medicine is supposed to raise the level of skills and knowledge of future physicians in the face of mass casualties [ ] . international participants and an interdisciplinary approach are keystones of the sadm concepts. in a globalized world international networking should enable students to exchange knowledge about the handling of mass casualties in different parts of the world. disaster medicine needs an interdisciplinary approach [ , ] . psychological aspects are always a key factor in the successful handling of mass casualties. the teaching concept of sadm consists of four parts: e-learning ahead of a week training session, emergency medicine training, disaster medicine training and excursions to evaluate already existing disaster concepts. the concept will be evaluated [ ] using a knowledge test, a skills test and a structured written interview concerning motivation and satisfaction of the students. conclusion. the support of the daad for three consecutive years allows a further evolution of this concept by integrating the evaluation results. the sadm should enable future physicians to meet the challenges of mass casualties with greater confidence and skills. educational programs are being set up to provide training and skills in these core subjects for dental care professionals. objectives. to evaluate dental practitioner (dp) skills and knowledge prior to a day continuous medical education (cme) training session, and assess training efficacy at the end of the session. methods. nine ( ) multiple choice questions concerning medical emergencies and pain treatment were handed out to dps at the beginning of cme training sessions over a year period in metropolitan france. after the day training session, the same multiple choice was taken again and collected for statistical analysis (kruskall-wallis test). examination before and after cme, p \ . we evaluated dps and obtained a % answering rate. before the cme session, the correct answer rate was below % for several items, like the european emergency telephone number or performing back blows before the heimlich manoeuver for severe choking, and below % for identifying vasovagal malaise by bradycardia, giving insulin for diabetic malaise or treating anaphylactic shock by epinephrine. more worrisome still is the fact that nearly out of dps would prescribe non steroidal anti inflammatory drugs (nsaids) during late pregnancy. the overall impact of cme was highly significant (p \ . ), showing real efficacy but correct answering rates after cme still remained between and %, which leaves room for improvement. further studies are under way to evaluate long term memorization of cme sessions in order to determine their optimal frequency. conclusions. medical skill and proficiency evaluation before cme training sessions for dps allows to target the training sessions and to evaluate their efficacy in the short run. introduction. the positive impact of immediate bedside echocardiography for rapid diagnosis and management of acute hemodynamic disturbances in the critically ill patient is well established. it is advocated that peri-resuscitation echocardiography should be an integral part of training for all intensivists. however, a major challenge for the intensive care clinician is access to appropriate echocardiography training outside of specific fellowship programmes. objectives. one suggestion to meet this training need is to combine supervised practical instruction with self-learning through the use of on-line educational tools. the internet is ideally suited to studying echocardiography as e-tutorials serve to convey theoretical principles whilst stills/video clips aid image recognition and interpretation. here we review currently available web based learning resources. methods. an online search was performed using google Ò and yahoo Ò search engines with the following key words: echocardiography, tte, toe, education, training, programme, courses, on-line, web-based, critical care. the resulting hits were screened to identify relevant sites and these were then evaluated independently by each author before an overall consensus was reached. one author had no previous echocardiography training whilst the other had passed the american national board of echocardiography perioperative transesophageal echocardiography examination. a total of sites were identified for evaluation (see table ); these are listed below with a brief description. conclusions. our search demonstrated a number of sites dedicated to facilitating echocardiography training. these varied from those which were essentially atlases, to those with a modular learning programme supported by interactive discussions and self assessment. some were targeted at the beginner seeking a basic understanding of echo whilst others were aimed at the enthusiast preparing for examinations. with growing interest in critical care ultrasound it is likely that we will see the use of such resources increasing. however echocardiography is a practical skill and it is essential that on-line learning is conducted in parallel with supervised bedside training in a process of 'blended learning'. . to determine level of supervision for trainees in the elective mri setting as compared with critical care transfers to mri. . to gain insight into the learning resources used by medical staff on mri to allow existing training to be improved. methods. two online surveys were conducted in february , with invitations to participate via e-mail. the survey population included all anaesthesia and intensive care medicine consultants in the local tertiary neurosciences centre and all trainees for these specialties in the northern ireland deanery. first year trainees were excluded. results. the response rate was % for consultants and % for trainees. in total, consultants responded with over % having no experience of mri at consultant level, even though % worked in areas where mri skills could be required. trainees completed the survey, with % having experience of mri in the elective setting, all of whom had been directly supervised by a consultant. % of trainees had experience of critical care transfers for mri, but this was in an unsupervised capacity more than % of the time. despite this, % of trainees did not feel competent to work in mri unsupervised. web based learning was found to be a poorly utilised mri training tool, particularly among consultants. conclusion. we have demonstrated a need to formalize training for mri in our institution and for trainees in the local deanery. we propose to meet this need by a combination of e-learning and experiential sessions with defined competencies. this should increase the cohort of physicians who can provide optimal care , in this unique environment and subsequently improve both service delivery and patient safety. was not a priority in health systems. following the report: ''to err is human. building a safer health system'', by the institute of medicine, which had a great impact on the media, ''patient safety'' is included as an strategic line in most health systems. training in patient safety is essential to implement safety culture and as a result improve it. for that reason we developed a training program ( courses) in for physicians and nurses from our icu. objetive. patient safety training program assessment. methods. we designed a h course ( % practical), using simulated scenarios common in icu clinical practice. we pointed out the relevance of human factors such as teamwork and communication, and its leading role in the genesis of error. we discussed a ''sentinel case'', using the root-cause analysis method, and analysed an icu process through failure mode and effects technique. adverse events reported to the department website were reviewed. participants and instructors discussed specific aspects about insertion of central venous catheter, prevention of nosocomial infection and improvement of security in the different groups of icu patients, highlighting the need for fidelity to the established protocols for this purpose. finally, participants completed a survey that assessed various aspects in a score from to . results indicated the most and least interesting aspects and suggestions for improvement were included. results. assessment surveys were analysed. participation rate was %. overall results: appropriate and clear targets, accomplished goals and utility ( . ) , appropriate content objectives and organization ( . ) , time invested in development activity and oral presentations ( . ), faculty competence ( . ) , interest and faculty adaptability to the group needs ( . ), degree of satisfaction and practices ( . ) . most interesting comments: practice of root-cause analysis ( . %), continued participation and motivation ( . %), practices with hps and group discussions ( . %), importance of human factors ( %), theory and practice good balance ( . %). least interesting comments: too condensed contents ( . %), few scenarios ( . %)suggestions: do it again( . %), enhance preventive medicine sessions ( . %), increase course duration ( . %). conclusions. overall assessment was positive. adaptability and competence of teaching staff have been the most valued aspects; too condensed contents and oral presentations were the least valued. practice of root-cause analysis ease of participation, ongoing motivation, hps scenarios and group discussions are the most appreciated activities. final comment: good acceptance has encouraged us to continue in to complete participation of all interested professionals. introduction. our intensive care unit (icu) was one of the first to initiate a humanization program in daily routine in . since then, the program suffered changes, the icu grew up in number of beds and complexity and had great renewal of the members of our interdisciplinary group. objectives. to improve our knowledge we continually re-evaluated the stress factors for the patients from our staff members' perspective, putting them in the patients place. methods. between january and march of , a research form was used with the interdisciplinary icu team. the following items were analyzed: profile of the interviewed, evaluation of the environment of the icu and the stress factors for the patients. the results were compared with the questionnaire form filled by the patients after icu discharge, as a part of our quality improvement program. results. about . % of our icu team answered the research (n = ). the mean age is . years (sd . ), . % of female, . % married, . % protestants and . % catholics and icu professional experience of . years (sd . ). our icu is noisy for . %, very illuminated for . %, easy-going for . %, organized for . %. in a preview research we found closed results. according to the team, factors that bother the patients are: noise ( . %), bed bath ( . %), loneliness ( . %), lack of privacy ( . %), anxiety ( . %), distortion of time perceptions ( . %) and fear ( . %). the patients (n = ) described as main complaints after icu discharged: distortion of perceptions of time ( . %), anxiety ( . %), sleeplessness ( . %), noise ( . %), loneliness ( . %), fear ( . %), pain ( . %)bed bath ( . %) and lack of privacy ( . %). the study showed differences of icu team opinions and the patients' complaints. when the team is placed in the patient's perspective they may experience a better view of how harmful is an icu and how much we can do to improve it. this is our daily challenge: take care with quality, respect, affection and always search for improvement. introduction. endotracheal intubation is a routine procedure to protect the airway in critical care, that is performed by a wide variety of clinicians from different specialities with different levels of experience in airway management. serious complications can result from misplacement of an endotracheal tube (ett) in a main stem bronchus. a widely recommended method for the prevention of this complication is bilateral auscultation of the lungs; but this method frequently provides only inconclusive results ( ) . other routinely used tests to verify correct endotracheal tube placement include observation of symmetric chest movements, and inserting the ett to a specific depth, but it remains unclear which of these tests detects endobronchial intubation best. objectives. we therefore designed this study to determine which bedside method has the highest sensitivity and specificity for detecting endobronchial intubation in adults and whether sensitivity and specificity increases as a function of the anesthesiologist's experience. methods. surgical patients were randomized to two study groups. in the first, the ett was fiberoptically positioned . - -cm above the carina, whereas in the second group the tube was positioned in the right main stem bronchus. first year residents and experienced anesthesiologists randomly performed only one of the following tests to verify the position of the tube: ) bilateral auscultation of the chest (auscultation); ) observation and palpation of symmetric chest movements (observation); ) estimating the position of the ett by the insertion depth (tube depth); and, ) a combination of all three mentioned tests (all three). results. patients ( female/ male) with observations by experienced and inexperienced anesthesiologists were included in the study. tube depth and all three had a higher sensitivity ( . and ) in detecting endobronchial intubation than auscultation ( . ) and observation ( . ) (p \ . ). experience increased the sensitivity only for auscultation, with % of first year residents versus % of experienced anesthesiologists detecting endobronchial intubation by auscultation correctly. the optimal ett insertion depth was found to be cm in women and cm in men. we conclude that auscultation alone is inadequate for assessment of correct ett insertion depth, and that checking for symmetric chest movements is of little use. our results suggest that the hierarchy of the methods used to assess the correct ett insertion depth should be changed and that clinicians should rely more on depth of ett insertion than on auscultation. this is especially true for physicians with less experience in airway management and in situations where auscultation is difficult or impossible. min usa) , uses a new probe measuring hemoglobin saturation at a lesser depth ( vs. mm before), with more data output ( value/ s vs. value/ . s). the new device contains automated software to compute parameters such as occlusion and reperfusion slopes of sto obtained during and after a vascular occlusion test (vot). objectives. to compare nirs parameters obtained with the devices used simultaneously in healthy volunteers and critical care patients to test if the new device gave similar results than the older one. methods. micro-oxygenation parameters were collected simultaneously with the different nirs models, one on each thenar eminence, before (baseline) and during a min upper arm (brachial artery) vot in patients ( septic shock (g ), trauma (g )), compared to healthy volunteers (hv)(g ). nirs probes were then shifted to the contra lateral thenar eminence and a second vot was performed. sto occlusion and reperfusion slopes from both devices were calculated in all groups by the same software, using linear adjustment (r c . to be valid); p \ . was considered significant. following parameters were collected in patients: saps ii and sofa scores, macrohemodynamic (heart rate (hr), mean arterial pressure (map), central venous pressure (cvp), cardiac output (co) and svo (mixed venous o saturation) or scvo ), and metabolic parameters (ph, base excess, and lactate). results. median ± iqr. patients (g and g ) did not differ for macrohemodynamic or metabolic data, except map ( ( - )mmhg vs. ( - )mmhg; p = . ). baseline nirs sto values were similar for both groups and for both devices, but were lower than in hv. during vot, reperfusion slopes were also lower in patients than in hv regardless the device used. the minimum sto during vot, occlusion and reperfusion slopes were significantly different between the devices: intraclass correlation coefficient (icc) . , . and . , respectively, and bland and altman poor agreement and large bias. conclusions. data obtained with model largely differ from those obtained with model , regardless of the studied population for both sto baseline and slopes. these differences appeared more pronounced in hv than in patients. such differences may result from muscle depth, number of data output allowing to more precise linear adjustment, or the minimum value reached during occlusion. it becomes hazardous to compare data obtained with these devices either in hv or in critically ill patients. crrt is used increasingly for the management of acute renal failure in critically ill patients. one major problem with crrt is coagulation of the filters, leading to decreased efficacy and increased costs. regional anticoagulation with citrate is an effective and established form of anticoagulation during crrt in critically ill patients ( , ) . objectives. the aim of this study was to investigate the filter life span during regional anticoagulation with citrate and regarding cost effectiveness. methods. this observational, retrospective study was performed in a mixed surgical and trauma icu in a university hospital. clinical characteristics are shown in table . citrate crrt was performed using commercially available equipment and fluid solutions (multifiltrate Ò with integrated cica Ò -system; fresenius medical care; germany). to maintain stable metabolic and hemodynamic conditions we used an internal standard protocol for citrate crrt. reimbursement for crrt is calculated on procedure related rates (according to german drg). data are shown as mean or median and standard deviation. results. f patients treated with citrate crrt from april through december were evaluated ( table ). the mean circuit lifetime of crrt for all patients was ± h (fig. ) . mean daily costs per patient were calculated as eur and mean benefit for crrt as eur (table ) . commercially available interstitial glucose sensors have already been evaluated for this purpose with promising results. however, because of the range of medications administered in the icu, potential interference with sensor performance must be characterized. to minimize the undesired offset caused by these medications, an interference rejection membrane (irm) was uniquely developed for a new subcutaneous glucose sensor for in-hospital monitoring. the novel irm was studied within the icu setting to gain a realistic picture of its performance in clinical use. objectives. acetaminophen is known to be an interfering agent for electrochemical sensors. to study the functionality of the new irm, the effect of acetaminophen on sensors worn by critically ill patients was assessed. sensor signals were characterized to identify any undesired response from the medication. methods. icu patients simultaneously wore - -day sensors that were connected to ipro tm (medtronic diabetes, northridge, ca) recorders to gather blinded sensor glucose values. patients were given acetaminophen or a mix of hydrocodone and acetaminophen during their icu stays; staff charted the exact time of each medication administration. to assess whether a signal offset would be introduced by the acetaminophen, min of sensor signals before and after medication administration were compared. the period of min was chosen based on acetaminophen's pharmacokinetic profile and the time to reach maximal plasma concentration. the normalized medians for the signal segments before and after each acetaminophen delivery were calculated. the medians formed vectors, each with elements representing signal characteristics before and after the medication deliveries. a paired t test was used to compare the vectors and assess for any effect (p \ . ) on sensor performance. across the patients evaluated for this study, acetaminophen and a mix of hydrocodone and acetaminophen were administered a total of times. one sensor was not available during a medication delivery; thus, occurrences of acetaminophen administration were analyzed. no effect on sensor signals could be identified in the instances of acetaminophen delivery. no statistically significant difference was observed between the signal segments before and after administration (p [ . ). conclusions. this study demonstrates that a novel irm effectively reduces the undesired interference of acetaminophen on a continuous glucose sensor signal during clinical use. although this analysis was focused on acetaminophen, the outcome suggests that the irm may also effectively suppress interferences from other medications administered in the icu. [ ] . however, assessing elastance requires a highly invasive vena-cava occlusion maneuver and left and right ventricle pressure/volume waveforms, which are not typically available in an intensive care unit (icu) and may raise ethical issues in regular use. a validated, lumped-parameter chamber cardiovascular system (cvs) model is used to evaluate a time-varying elastance estimate at the bedside using standard clinical measurements. objectives. to assess time-varying elastance at the bedside for the left and right ventricles using available icu data, and prove the concept on a porcine model of pulmonary embolism. five pigs had pulmonary embolism (pe) induced via injection of blood clots over h, developing full pe in stages from a healthy state. at each state several data sets were taken ( in total over pigs), measuring aortic and pulmonary artery pressure waveforms (p ao (t), p pa (t)), left and right ventricular volume and pressure waveforms (vlv(t), vrv(t), plv(t), prv(t)). at each cardiac state in inducing pe, the time-varying elastances are estimated as elv = plv/ vlv and erv = prv/vrv. these values are correlated to readily measured quantities (pao and gedv). these correlations are used to approximate time-varying elastances erv* and elv* for use in a clinically validated -chamber cvs model. note these approximations are load dependent and thus change with cardiac state. a fivefold cross validation was used to validate the model. a time-varying elastance is generated from data from pigs and used to simulate the fifth pig. simulated pv loops are compared to the originally measured pv loops to validate the approach. results. p ao (t) and elv were highly correlated over the data sets (r = . to r = . ). p ao (t) and elv, gedv and erv are also well correlated (r = . to r = . in this case we report the worldwide first use of the novel deltastream-dp -system (medos corp.) in a patient suffering from acute right heart failure due to pulmonary embolism following cardiac surgery. in a year-old male patient days after mitral valve reconstruction cardiac arrest occurred during physiotherapy treatment. after failure of restoring circulation, a short-term ecls system (lifebridge Ò ) was implanted under cardiopulmonary resuscitation by inserting cannulas in venous and arterial femoral vessels and then switched immediately to the dp -deltastream system. ct-scan revealed the diagnosis of a massive central pulmonary embolism. transesophageal echocardiography showed a dilated failing right ventricle. a thrombolytic therapy was carried out by administering mg alteplase. following ct-scan showed reduced thrombus burden. the deltastream system was carried out for h. ptt was maintained to . -fold under i.v. heparine therapy. pump blood flow was held at a maximum of . l/min ( , - , r/min) for days. despite transesophageal echocardiography showing improved left ventricular function the ecls flow was maintained for further days focussed on the improvement of right heart. further on the pump flow was reduced every h and the system could be explanted after days in now stable cardiolpulmonary situation. the patient was discharged on day at home in good state without any neurological dysfunction. overall duration of the ecls deltastream therapy was h. no system related major complication occurred during the time. even in maximum blood flow of . l/min no relevant hemolysis was measured. ldh level was only slightly elevated to - u/l. introduction. airway management has progressed dramatically in the last years but the most significant advance has been video laryngoscopy. several devices have been introduced since, the most important currently available are the glidescope Ò , c-mac Ò , mcgrath Ò , pentax airway scope Ò , airtraq Ò , among others. a common practice has been to abandon direct laryngoscope intubation (dli) after attempts and move onto advance airway devices such as video laryngoscopy which is becoming the first choice when available. although dli is successful in the majority of patients, poor glottic exposure is more likely to require prolonged or multiple intubations attempts and therefore be associated with complications such as oxygen desaturation or airway and dental injuries. in the intensive care environment an airway should always be considered a difficult airway due to scarce time to perform assessment, to make decisions and to act. should the use of video laryngoscopy be implemented as a routine for airway management in a critical care setting ? objectives. the purpose in this study was to describe for the first time the use of video laryngoscopy, specifically the vel , as a routine choice for airway management in the intensive care environment. single center, prospective observational study, from november to february , was conducted in our intensive care facility, which involved utilization of the vel for all tracheal intubations, no exclusion criteria, rapid sequence intubation (rsi) was the standard procedure. information was recorded by the operator assistant on the same day identifying timings of intubation, number of attempts, success or failure and the difficulties encountered. vel was developed in our institution in and later adopted as a standard airway management by the department of anesthesia. the device has an original mccoy blade with an attached port that holds a channel for the displacement of an optical shaft mm long, . mm in diameter with a °angle view (tekno-medical Ò germany) which is assemble to a video camera (telecandx ii, karl storz, germany), an external light source and to a -in monitor. results. there were tracheal intubations performed by operators, crash intubations and rapid sequence intubations. all intubation attempts were successful, mean number of attempts . the median time to successful intubation was s with no complications. subjective assessment post intubation showed that in all cases vocal cords were view in full, all operators manifested to feel comfortable with the handling of the apparatus but felt dependent on a assistant specially to maintain view while maneuvering the endotracheal tube. conclusions. routine airway management with vel in critical care setting is effective with a high rate of success and most important, with a positive impact for patient safety. introduction. hypovolemia is a common complication in many clinical scenarios and its detection is considered of prime importance. in previous clinical studies, tissue oxygen saturation (sto ) measured by near-infrared spectroscopy (nirs) has been explored for this purpose; however, results are disappointing. it has been suggested that the sensitivity of nirs for detection of hypovolemia might be improved when nirs is applied in combination with a vascular occlusion test (vot). nirs in combination with a vot, consisting of a -min period of arterial occlusion followed by reperfusion, allows quantification of muscle deoxygenation during ischemia (sto downslope; a measure of muscle oxygen consumption rate) and muscle reoxygenation after ischemia (sto upslope; a measure of microvascular reperfusion rate). objectives. in the present study we applied multi-site and multi-depth nirs in combination with a vot in a model of simulated central hypovolemia; lower body negative pressure (lbnp). eight healthy male subjects, with a mean ± sd age of ± years, participated in this study. the lbnp protocol consisted of a stepwise increase of lbnp from to - mmhg. stroke volume (sv), heart rate (hr), cardiac output (co), and mean arterial pressure (map) were continuously measured using near-infrared finger plethysmography (nexfin). multi-depth nirs, with probing depths * and * mm, was performed on forearm and thenar for the measurement of sto . three-min vots were performed by rapidly inflating a pneumatic cuff around the left upper arm before application of lbnp and at lbnp = - mmhg. vot-derived sto traces were analyzed for baseline, downslope, and upslope. . from baseline to lbnp = - mmhg, sv decreased from ± to ± ml (p \ . ), hr increased from ± to ± bpm (p \ . ) and co and map were maintained around baseline level. forearm sto baseline decreased significantly from ± to ± (p \ . ) and ± to ± % (p \ . ) for the and mm probing depth, respectively. forearms sto downslope, measured with the and mm probe, decreased from - . ± . to - . ± . %/min (p \ . ) and - . ± . to - . ± . (p \ . ), respectively. forearm sto upslopes remained unchanged during lbnp. vot-derived sto parameters measured on the thenar did not shown any changes as a result of lbnp. conclusions. vot-derived sto parameters measured on the forearm seem to be more sensitive to the hemodynamic changes associated with lbnp compared to sto parameters measured at the thenar. grant acknowledgment. this project was supported in part by hutchinson technologies inc. introduction. hypovolemia is a common complication in many clinical scenarios and its detection is considered of prime importance. in previous clinical studies, near-infrared spectroscopy (nirs) has been explored for this purpose; however results are conflicting due to inconsistencies in methodology with respect to nirs probing depth and site. objectives. in the present study we applied multi-site and multi-depth nirs in a model of simulated central hypovolemia; lower body negative pressure (lbnp). fifteen healthy male subjects, with a mean ± sd age of ± years, participated in this study. the lbnp protocol consisted of a stepwise increase of lbnp from to - mmhg. stroke volume (sv), heart rate (hr), cardiac output (co), and mean arterial pressure (map) were continuously measured using near-infrared finger plethysmography (nexfin). multi-depth nirs, with probing depths * and * mm, was performed on forearm and thenar for the measurement of tissue oxygen saturation (sto ). . from baseline to lbnp = - mmhg, sv decreased from ± to ± ml (p\ . ), hr increased from ± to ± bpm (p \ . ), and co and map were maintained around baseline level. forearm sto decreased significantly from ± . to ± . % (p \ . ) and ± . to ± . % (p \ . ) for the and mm probing depth, respectively. thenar sto measured with the mm probe remained unchanged, but measured with the mm probe, a decrease from ± . to ± . % (p \ . ) could be observed. conclusions. forearm sto seems to be more sensitive to (simulated) hypovolemia compared to thenar sto and the sensitivity of nirs seems to increase for increasing probing depth. grant acknowledgment. this project was supported in part by hutchinson technologies inc. introduction. sidestream dark field (sdf) is a microcirculatory imaging modality implemented in a hand-held microscope for the non-invasive bed-side visualization of the human microcirculation. despite the many studies showing the importance of microcirculatory imaging in intensive care patients the introduction of sdf imaging into routine clinical practice remains cumbersome. one of the challenges is the need for automatic analysis of the images which currently is subjective and time consuming. objectives. in the present study, we introduce a rapid automated software method for automatic quantification of microvascular density, a key microcirculatory parameter, based on sdf image contrast analysis. methods. twenty-five sequential sdf images (duration = s, resolution = pixels) were isolated from an sdf movie clip, stabilized, and averaged. subsequently, the mean ± sd gray scale intensity in a sliding pixel window was calculated and the sdvalue was assigned to the window center pixel, creating an sdf contrast image. this is a simple and rapid algorithm for vessel wall detection as a pixel window at a tissue-vessel junction will have a high sd-value due to the presence of both light tissue cells and dark red blood cells. conclusions. here, we introduce and validate a rapid automated method for quantification of microvascular density in sdf images. as this algorithm detects vessel walls rather than vessel lumen, smaller and larger vessels have similar contribution to the microvascular density assessment. a limitation, however, is that vessel diameters cannot be detected with this algorithm. the preliminary results confirm the proof of concept of the sdf image contrast analysis software, however, further research is required for its optimization. the criteria believed to be necessary for the implementation of hcs in practice were that his name would be written{ ( )}, the document dated{ ( )} and signed{ ( )}. physicians in private practice wanted date(p = . ) and signature(p = . ) more often than in institution. ( ) physicians thought that the patient must be competent at the designation' time of hcs, especially those who possess advances directives(p = . ) and a hcs(p = . ) themselves. ( ) thought the hcs should know about the patient's wishes regarding treatment and care objectives. conclusions: more than / of physicians did not know who the hcs is. more than / thought hcs useful and at least / would encourage a patient to designate one before heart surgery. about % thought that being a hcs is a too high responsibility and that the hcs could not be the best representative when needed. the potential fear this topic might induce is a barrier for this minority. introduction. the use of a daily goals chart has been shown to improve communication between the multi-disciplinary team leading to an increase in understanding of daily patient goals and a decrease in length of patient stay on the intensive care unit (icu) [ ] . we have used a daily goals chart on our icu since . we wanted to assess the value of this initiative in a general adult icu. methods. the royal cornwall hospital is a large uk district general hospital. we conducted the survey over a week period in the icu. each day, after the morning multidisciplinary ward round, the consultant in charge was asked to give the main goals for each patient. these were compared with those written on the daily goal chart, or stated by the house medical and nursing staff. they were graded as complete match ( % of consultant goals matched), partial match ( - % matched) or non match (\ % matched). results. surveys were conducted. the daily goals sheet matched the consultant completely on ( %) occasions and partially on ( %) occasions. in comparison, the combination of house medical and nursing staff had complete match on ( %) occasions and partial match on ( %) occasions. house medical staff had a % complete or partial match, house nursing staff had a % complete or partial match. overall house staff understanding of the goals set on the ward round is far better than that recorded on the goals chart. the goals related by medical and nursing staff showed differences that reflected their differing clinical priorities. combining results of all staff led to higher levels of complete match than either group independently. low levels of non-matches indicate that there is good overall understanding and communication within the team. use of daily goals charts is an effective aid to augment communication on the icu multidisciplinary ward round. objectives. to assess the effectiveness of an icu diary on post-icu psychological symptoms of patients (pts) and their families. single centre prospective study. three periods: = control ( to / ), = diary ( / to / ), = control ( / to / ). all the pts admitted c days for the first time to our medical-surgical icu were included. during the intervention period, the diary was filled both by the caregivers and the pts' relatives, without directives except for the first (medical summary) and the last (recovery wishes) ones. at icu discharge, their families were asked to fill a satisfaction questionnaire (ccfni) and the hospital anxiety and depression scale (hads), and to be contacted by phone to assess peri traumatic stress disorders [dissociation and impact of event scale-revised (ies-r)], hads at months and year after icu discharge. we excluded pts if they or their family refused to participate, were not fluent in french, or if their family was not present around the day of icu discharge. the optimal theoretical content of the diary was determined by a delphi technique involving a panel of icu and non-icu caregivers and a voluntary visitor. the content of the diaries was analysed and linked to the outcome measurements. of the admitted patients, were included. after exclusion of pts, formed the basis of the study. the content of diaries and the results of ies-r are under analysis. the year data is not yet available the saps ii at admission, icu and months post icu mortality were not significantly different between the three periods. the family satisfaction score was high and was not significantly different between the three periods. included: patients with failure of two or more organs in the first h, admitted to icu during . excluded: neurocritical and politrauma patients. contact year following discharge from; questions were asked about the patients' different perceptions during their stay in icu. if it was not possible to contact the patient, the next of kin was asked. results. patients included. general characteristics during admittance to icu: % male; age . ± . ; sofa * ± . ; apache ** ii . ± . ; apache ** iv ± . ; length of stay in icu: . ± . days; . % on invasive mechanical ventilation and . % on non-invasive mechanical ventilation. data collection was carried out over a period of ± . months, on average months (range: - months). . % ( patients) had died at the time of contact. the person interviewed was the patient in . % of the cases, the spouse in . % and immediate family (patient s parent/child/sibling) in . % of the cases. overall, . % do not have any memory of their stay in icu. for . %, the experience was unpleasant and for . % of patients the memory is very unpleasant. . % experienced fear, . % disorientation, . % a feeling of lack of hygiene, . % a feeling of suffocation/drowning (with the endotraqueal tubes, etc.), . % a lack of privacy (nudity, etc.) and . % pain during procedures. . % were very grateful for our phone interview. . % were satisfied with the staff. conclusions. in patients with high severity scores during their time in icu, less than half have memory of their stay after year. in those who do, the feeling of fear and disorientation predominates. to determine the occurrence of communication failures in clinical icus, identifying their main detection tools and disclosing their effects on patient condition. a prospective cohort was conducted in four icus of a -bed academic, tertiary-care urban hospital in sao paulo, brazil, enrolling critical ill patients older than years from july to august . communication failures were identified by daily direct observation of medical and nursing rounds and also by chart reviews. the association between communication failures and adverse event occurence was determined using multivariate logistic regression. results. among the enrolled admissions, as much as admissions ( %) were affected by communication failures, with occurrences. the vast majority of the communication problems was not registered in patient charts, and could only be identified during the medical and nursing direct monitoring. none of the identified communication failures caused patient harm. nine out of ten communication issues involved exclusively members of the multidisciplinary icu health team, patients and their relatives being seldom included in this scenario. despite communication failures are considered important adverse event risk factors, no association was identified between these two variables. conclusions. the incorporation of direct observation as a research tool for identifying untoward events was essential to the detection of communication failures in our study. almost half of the studied admissions was affected by communication flaws, most of them involving exclusively the healthcare team. nevertheless, these figures are underestimated, since the research team remained in the studied icus for no more than h a day. although patients were not harmed fortunately, the presence of these communication issues suggests the existence of important gaps in the provision of critical care. the issue regarding communication deficiencies in icus setting affecting patient safety deserves attention. relatives of patients in the intensive care unit (icu) are exposed to considerable stress . effective communication with relatives has been shown to provide support and minimise stress whilst improving their wellbeing and decision making for critically ill patients . furthermore, satisfaction is dependent on communication by a senior caregiver . no published guideline or recommendation exists for when relatives should be first spoken to, how often they should be updated, or how these conversations should be documented. to determine how well relatives of patients in the icu are kept informed and to assess the quality of documentation. we retrospectively analysed data from the metavision Ò clinical information system of patients staying over days during / / - / / on the -bed icu at the nnuh. data obtained from the 'relatives communication' page included: when relatives were first spoken to, how often they were spoken to (according to the number of entries made) and the members of staff involved in the conversations. these variables were analysed in relation to patient outcome and length of stay on the icu. . patients were analysed. communication with relatives was not documented in % of patients. % of communication was carried out by a consultant. discussions were more likely to occur with relatives of patients who died; % compared to % of patients discharged to the ward. similarly, relatives of patients who died were spoken to more frequently; % were talked to on more than one occasion compared to % of patients surviving to discharge. relatives were more likely to be spoken to with an increased duration of admission on the icu; communication occurred with only half the relatives of patients staying - days, compared to % of those staying more than days. two-thirds of relatives of patients staying more than days were not communicated with until after the fourth day of admission, although the majority of these were spoken to on numerous occasions and all were seen by a consultant. relatives of patients dying on the icu are more likely to be communicated with, and are updated more often than those of patients surviving to discharge. a delay in communication with relatives of patients staying more than days on the icu was noted, but conversations occurred more regularly and involved a consultant. we suspect that our results demonstrate a lack of documentation rather than actual communication; auditing relatives' satisfaction with communication on the icu may help clarify areas for improvement. assessment of satisfaction with the quality of care provided to patients hospitalized in intensive care units, in most cases, is transferred to the relatives of the same, given the context of the patient himself unable to speak. the diagnosis of the needs of families of critically ill patients has been the subject of several studies. aiming to assess the needs of relatives of patients admitted to the picu (polivalent intensive care unit), we conducted studies in particular through an adapted version of the questionnaire ccfni (critical care family needs inventory) developed from the adaptation made by johnson and col. ( ) and focus group. one of the needs identified in these studies was to improve information about what happens in the picu. with this in mind we designed a manual to support relatives in order to improve communication and understanding in the context of the intensive care unit. objectives. this study aims to assess the impact on the level of family satisfaction of a manual we've created. the manual is available from january to all visitors at the entrance of that unit. the questionnaire was mailed to all families who had a family member hospitalized in the picu during the year following the introduction of the manual. together followed a letter to present the study and a stamped and addressed envelope for their return. beyond the satisfaction and access to the manual or not, were collected socio-demographic data from relatives and socio-demographic and clinical data of patients. we obtained responses, representing % of all potential families. questionnaires were returned because of address failure ( . %). statistical analysis was performed using spss Ò v. . results. the satisfaction of family members who had access to the manual was better in all dimensions tested (support, comfort, information, access, trust), and with a statistically significant difference (p \ . ). this difference was clearer in the fields support (med , / . ) and information ( . / . ). conclusions. the impact of the manual on the improvement of family satisfaction was positive in the various dimensions assessed. the questionnaire of family satisfaction monitoring and understanding of information given through a manual created by us can contribute to a better understanding of the needs of families and hence for the continued improvement of service quality. johnson introduction. the burnout can be defined in its multidimensionality: emotional exhaustion, understood as a feeling of exhaustion and failure of the person to give more of herself; depersonalization, in which the person's relationship with patients and with colleagues becomes cold, distant and guided by some cynicism, lack of personal and professional completion, which may manifest itself, on one hand, by the sense of incompetence and inability to respond to requests or, on the other hand, by the sense of omnipotence. the provision of intensive care can lead to health care provider's physical, psychological and emotional exhaustion, which may develop to burnout. we notice the absence of specific studies on this syndrome, in portuguese intensive care units. objectives. the study here presented intend to identify the levels of burnout of physicians and nurses working in portuguese intensive care (adult polyvalent units in the north of the country), and to identify factors that can lead to the development of burnout in the portuguese physicians and nurses working in that setting. the methodology presented consist of application of a questionnaire for self fulfilment with items: , socio-demographic data of the study population; , experiences in the workplace; , maslach burnout inventory-general survey. for the application of methodological tools, we requested the authorization by the competent institutional bodies: the board, ethics committee and directors of services. the professionals who participated in the study were asked informed consent, whether in formal or informal. in addition, each instrument was accompanied by a cover sheet of the same. we have also done observation of the work contexts, and interviews. in this study we will focus on the results of the questionnaire. . sample: hospitals with a total of intensive care units. professionals participants in the study , physicians nurses. the mean ages of respondents , of professional experience years and of experience in intensive care were years. mbi preliminary results:distribution of levels of burnout by occupational category: at the moment, portuguese physicians and nurses who work in intensive care units seam to have medium levels of burnout, obtained through the mbi. results show higher levels at emotional exhaustion in nurses never less in general they showed higher personal and professional completion than physicians. depersonalization were higher in physicians. the results presented here underline the importance of promoting the prevention of burnout at intensive care. the development of the burnout syndrome in physicians and nurses in intensive care has serious consequences, both for themselves, or the consequences that entails for patients and their families. introduction. the hospitalization of a member of the family in the intensive care unit (icu) usually occurs in an acutely and inadvertent way, leaving little time for a family adjustment. facing the stressful situation, the family may feel disorganized, helpless and with difficulties to mobilize themselves, enabling the rise of different types of needs. the scope of those needs leads to the alleviation of tension and uncertainties that could provide to the family the stability needed to cope with the situation disease . to identify the needs of care of family members with persons admitted to the icu. methods. this is a transversal study, held in two icus (a public one and a private one) in the city of feira de santana, bahia, brazil, after approval by ethics and research committees. the relative person is understood by the person who had consanguinity ties or who was closest to the patient, who lived with him and had close relationships. relatives were interviewed when his relative was over h of hospitalization. the the brazilian adaptation of the critical care family need inventory (inefti) was used for measuring the degree of importance, once it has items distributed in five dimensions. descriptive statistics were used for analysis. the inefti reliability was satisfactory (cronbach a = . ). results. the needs of care considered most important by family members were those related to the security dimension, expressed by the items ''to know what are the chances of improvement of the patient'' ( . ± . ), ''to be informed about everything that relates to the evolution of the patient'' ( . ± . ) and ''to feel that hospital people care about the patient'' ( . ± . ). in the category information, the item ''be able to talk to the doctor everyday'' ( . ± . ) obtained more average. in the category proximity was consider more important to ''see the patient frequently'' ( . ± . ). the needs of the categories support and comfort categories showed lower scores. these results are similar to those presented by literature , , what confirms the appreciation of the family to the aspects related to the recovery of the hospitalized relative, in detriment of their own needs. conclusions. having security, information and being around its ill relative is what the families need. the security is provided by the conviction that the person receives the best care in the pharmacological, technological and human aspects, and can be perceived by the information transmitted by the team and by the proximity established in the interaction with the sick relative. a collaborative project was developed between the itu clinical staff of a large, inner city teaching hospital, palliative care clinicians and an academic department of palliative care. qualitative data collection included: (i) semi-structured interviews with staff and relatives of patients thought to be at the end of life; (ii) focus groups with staff (iii) observation of care and (iv) clinical note review. data was analysed using the framework approach to identify key themes. results. semi-structured interviews were carried out with staff and focus groups took place. a total of relatives, representing patients thought to be at the end of life, were interviewed. half the patients represented were female, with diagnoses including infection, hypoxic brain injury, malignancy and liver failure. the participants were aged - and included a range of ethnic groups and religious affiliations. non-participant observations of care took place for and clinical note review for of these patients. data from the interviews with staff describe that an existing withdrawal of treatment document was working well but could be developed further along with suggestions for amendments. the interviews with relatives, observations and review of clinical notes show key themes: communication, decision-making, patient and family needs, and symptoms and their management. through discussion at itu end of life group meetings, a consensus was reached to pilot a complex intervention comprising an amended withdrawal document; a psychosocial assessment; education and awareness-raising; palliative care team input and increased psychosocial support. the psychosocial assessment document was deemed valuable to all patients and was rolled out for all patients admitted to itu. initial evaluation shows greater staff awareness. documentation of end of life issues and the collaborative research process has improved communication between itu and palliative care staff. introduction. consumer-centric healthcare is a key component of nhs policy. when patients are critically ill, family members act as surrogates. family members alone may inform patients of events that occurred, and provide physical, emotional and socioeconomic support during rehabilitation. thus, high family satisfaction (fs) is important. the fs-icu instrument was developed in canada to quantify family satisfaction and benchmark intensive care units (icus). we have piloted and validated previously an adaptation of the fs-icu such that its language was appropriate for the uk . to date, no intervention has demonstrated improvement in the fs-icu for a critical care unit. we hypothesise that provider-driven interventions fail to recognise central issues. co-production is a framework that enables creation of parity between providers and consumers by validating both individual worth and specialised knowledge . there are no published data on the use of co-production in intensive care. we undertook to co-produce interventions targeted to improve family satisfaction. the fs-icu instrument will be used as an objective measure of their efficacy. objectives. to co-produce some interventions targeted to improve family satisfaction and to use the fs-icu instrument as an objective measure of their efficacy. methods. fs-icu questionnaire responses were used to highlight potential areas for service development. focused interviews with families provided detailed descriptions of the ''the way the icu works''. these data were used to build exercises for a workshop of service users and providers which aimed to co-produce service developments. results. fs-icu questionnaires were received over the months to april ( % response). quality and consistency of communication between icu doctors and relatives; the level of relatives' inclusion in decision-making processes; and the icu waiting room atmosphere were identified as needing improvement. four families were interviewed in detail. workshop participants included trust directors, managers, clinicians, nurses, patients and their families. proposed interventions from the workshop included: development of a non-clinical family liaison officer role with a dedicated contact number; increasing focus on managing patients' and relatives' expectations of care delivery; specific improvements to the waiting room area. intensive care patients' relatives provided a unique insight into the icu functioning that should be utilised as a resource. co-production was used to design service improvements that may not have been obvious from a provider perspective. workshop transactions were empowering for both staff members and patients' families, generating social capital that creates and improves social provider-consumer networks, now and in the future. to evaluate the degree of satisfaction of icu patients regarding their icu stay. as the result of a fund sponsored by former patients and their relatives, our dept of intensive care is able to provide a small team of assistants to welcome and accompany the relatives of icu patients. one role of this team is to collect and evaluate impressions and criticisms from patients and relatives shortly after the icu stay. we studied a convenience sample of icu patients who stayed in our multidisciplinary dept of intensive care between september and april . the evaluation included simple questions about the welcome (friendliness of the personnel, explanations), quality of care (including pain control, attention to patient needs, availability of nurses and speed of response) and comfort (temperature, light, noise). data were analyzed using non-parametric (mann-whitney) and chi tests. we collected answers from of patients ( were incapacitated, had died and declined), including unplanned admissions and patients after major surgery. more than % of the patients were very satisfied with all items, except for information provided by the attending physician ( % of patients) and the room temperature ( % of patients) (figure ). post-icu enquiries can provide valuable feed-back information that could improve the quality of care in the icu. introduction. previous research suggests that family members of critically ill patients hospitalized in the icu frequently suffer from severe anxiety. a survey conducted in our unit-a -bed, university-affiliated tertiary-care, closed, general icu with restricted visiting hours-revealed a willingness of family members to participate in a support group. such a group was recently introduced and we report on our initial experience over the last year. methods. the purpose of the support group was to provide a forum where family members could freely raise any topic related to the care of their loved one as well as to family-related issues. the meetings were held weekly in the icu and chaired by a senior nurse and the unit social worker. family members were informed of the meetings when the patient was admitted to the icu and notifications were placed in the family waiting room. all family members were encouraged to take part and to raise any topic they felt was relevant. results. since its introduction in , there has been an increase in the percentage of a family representative attending the meetings from to %. the most frequently raised issues included staff-family interaction (especially lack of empathy), lack of information regarding the patient's status and prognosis, and the lack of adequate visiting hours. in addition, other issues included technical aspect related directly to the family, in particular, overcrowding and lack of privacy in the waiting room. finally, participants wanted to learn skills in order to cope with their new and uncertain circumstance. we have noted an ongoing readiness of family members to take part in the support group. the issues raised have and will allow us to make appropriate changes and to improve the current situation. in particular, the meetings help us to identify family members at risk who require more immediate and personal attention. introduction. the soap study suggested outcomes of cancer patients admitted to icu are similar to those without cancer in contrast to other reports . we wanted to compare this with our own experience. ( ) to determine critical care and hospital outcome of patients with malignancy referred to critical care in the previous years. ( ) to identify any factors influencing treatment decisions and survival after admission. retrospective chart review of patients undergoing treatment for malignancy admitted to icu for medical or surgical reasons from may to feb . leukaemia patients were not included as they are treated at a different hospital by a different group of clinicians. demographic information, tumour/treatment related factors e.g neutropenia, preadmission status and critical care diagnoses e.g. sepsis, were collected in addition to patient outcomes. results. patients were identified ( . % of all critical care admissions). itu mortality was . % (n = ), however only . % (n = ) survived to hospital discharge (comparable overall unit mortality: - %, hospital mortality: %). hospital survivors were younger (median . vs. years), and more non-survivors had pre-existing comorbidities, sepsis, ali and required more organ support (all ns). there was no difference between the groups regarding cancer treatment. non-survivors had a longer stay in critical care and treatment withdrawal/limitation decisions were more common suggesting these were often based on lack of medical progress whilst on icu rather than diagnostic nihilism. hospital mortality in patients with malignancy is higher in our specialist centre than reported for a europe wide cohort ( . vs. % overall and % in the medical subgroup). the majority of our patients were medical and not post-surgical unlike in the soap study. this may account for the greater mortality as a larger proportion of our patients had ali, sepsis, neutropenia and required inotropes. numbers admitted to critical care are much smaller than the . % reported in the soap study, suggesting some referral and admission triaging by the oncologists and the icu team. our results are similar to single centre french (hospital survival rate . vs. . %) and brazilian studies ( . vs. %), although a majority of our patients did not receive mechanical ventilation. , a diagnosis of cancer or active treatment for it should not be the major determinant of critical care support, but the patient's general premorbid status and the extent of organ failures appear to be important factors in decision making as for any other critical care patient. figures from the soap study for non specialist centres do not appear to reflect the experience of specialist oncology centres. historically there has been a negative perception of the prognosis for patients with haematological malignancies requiring admission to the intensive care unit (icu). however, advances in chemotherapeutic regimes and haematopoietic stem cell transplantation (hsct), along with improved monitoring and supportive measures have suggested that outcomes for these patients have improved [ ] . establishing key prognostic indicators predictive of outcome may be useful in identifying patients most likely to benefit from icu therapy. the aim of this study was to describe clinical outcomes and identify prognostic factors in patients with haematological malignancy requiring admission to icu. following research approval, a retrospective cohort study was undertaken in a -bedded specialist cancer icu over a -year period (october -september . recorded patient variables included demographics, haematological diagnosis, reason for icu admission, hsct, apache ii, admission laboratory data, number of organ failure, use of invasive mechanical ventilation, renal replacement therapy (rrt) and vasopressors. the primary outcome was in-hospital mortality. key prognostic variables in determining inhospital mortality were identified using univariate and multivariate analysis. results. patients with haematological malignancies were admitted to the icu during the study period: mean age . (sd . ); . % female; haematological diagnosis ( . % leukaemia, . % lymphoma, and . % myeloma); . % emergency admissions and . % were post-hsct. mean apache ii was . (sd . ), mean number of organ failures . (sd . ), % required invasive mechanical ventilation, . % rrt and . % vasopressor therapy in the first h of icu admission. icu, in-hospital and -month mortality were . , . and % respectively. significantly higher mortalities were seen in patients who were mechanically ventilated ( vs. % non-ventilated patients p \ . ), on vasopressor support ( vs. % no vasopressor support p \ . ), neutropenic ( vs. % non-neutropenic p \ . ) and in multi-organ failure defined as c organ failures ( deaths vs. deaths in patients with b organ failure, p \ . ). univariate analysis revealed mechanical ventilation, vasopressor support, albumin \ g/l, neutropenia, platelet count \ /l and multi-organ failure were all significant with p values . , . , . , . , . and. respectively. multivariate analysis revealed that multi-organ failure was the only independent prognostic predictor of in-hospital mortality. conclusion. mechanical ventilation, apache ii, vasopressor support, albumin\ g/l, neutropenia, platelets \ /l and multi-organ failure all had a significant association with mortality; however multi-organ failure was the only independent factor that predicted poor outcome. c.y.c. michael , a. vasu , s. eillyne tan tock seng hospital, emergency department, singapore, singapore introduction. coronary heart disease is the leading cause of mortality and morbidity for both women and men. although men are affected in greater numbers, women have been shown to have worse outcomes and higher mortality. objectives. this study aims to examine gender differences in risk factors, angiographic severity, treatment and in-hospital mortality after stemi. methods. in this retrospective study, the medical records of patients with an admitting diagnosis of stemi from tan tock seng hospital, emergency department (ttsh ed) between st january and st december were reviewed. we extracted the data from the electronic records of the emergency case notes and inpatient discharge summaries. results. of the patients studied, ( . %) were women and ( . %) men. four hundred and forty-nine ( . %) patients underwent coronary angiography. one hundred and seventy ( . %) patients did not undergo coronary angiography, majority ( . %) were elderly aged c years (men . % and women . %). between women and men, there was no significant difference between the number and distribution of diseased coronary vessels (including triple vessel and left main stem diseases). regardless of age, men were frequently treated with a coronary artery stent ( . %). elderly women (aged c years) were more often treated conservatively ( %) while those younger women (aged b years) were frequently treated with a coronary artery stent ( . %). in-hospital mortality rate was significantly higher for women than men ( . vs. . %, p = . ). amongst the patients treated conservatively, elderly women had the highest in-hospital mortality when compared to the other patients (women c years . vs. women b years . %; men c years vs. men b years . %). compared to men, women were significantly older (p \ . ; % ci . - . ) , more likely to have a history of hypertension ( . vs. . %; p \ . ), diabetes ( . vs. . %; p \ . ), hyperlipidemia ( . vs. . %; p = . ), peripheral vascular ( . vs. . %; p = . ) or ischemic heart diseases ( . vs. . %; p = . ) and less likely to be smokers ( . vs. . %; p \ . ) or consume alcohol ( vs. . %; p \ . ). conclusions. elderly women who were treated conservatively had the highest in-hospital mortality during the early management of stemi. hôpital saint-louis, ap-hp, paris diderot university, hematology department, paris, france introduction. aml is considered as an oncology emergency as a proportion of patients experience life threatening complications within the first hours or days after diagnosis. early death had been shown to be statistically related to high white blood cell (wbc) and monoblastic leukemia - , with leukostasis and lysis syndrome as the most deadful events. objectives. to evaluate the relationship between timing of icu admission and outcomes in high risk aml patients at the earliest phase of the malignancy (before any chemotherapy) methods. retrospective study in a tertiary care teaching hospital. adult patients with newly diagnoses aml from to were included. patients admitted for an immediate life sustaining therapy (ventilation, vasopressors or renal replacement therapy) were excluded. patients admitted directly to the icu (early admission) were matched for age, wbc and fab subtype with patients primarily admitted in hematology ward. datasets were extracted from medical charts. results. patients were included ( early admitted to the icu and admitted first to the wards). median follow up was . months. median age was . years ( - ). fab m or m was retrieved in % of the patients. karyotype was favorable for % and poor for %. median wbc was l - . no statistical difference was seen for demographic and hematological parameters between early admitted patients and matched controls. among the patients admitted first to the wards (controls), were subsequently admitted to the icu (lately admitted) and remained in ward during the entire treatment course (never admitted). the median time between diagnostic and icu admission of this last group was ( - ) days. strikingly, patients lately admitted had more frequently dyspnea,oxygen requirement, high respiratory rate, low diastolic arterial pressure and lower first h urine output. lately admitted patients were less likely to receive the complete dose of induction chemotherapy ( vs. %) furthermore, late admission resulted in increased use of invasive mechanical ventilation ( vs. %) and vaso-active drugs ( vs. %). these differences resulted in longer stay in icu and decreased survival. conclusion. patients at the earliest phase of high risk aml who are lately admitted to the icu experience worse outcomes, with increased use of life-sustaining therapies and higher mortality, compared to patients early admitted to the icu. physiologic parameters at the time of aml diagnosis such as respiratory rate, diastolic blood pressure, spo , or oxygen need are likely to help clinicians distinguish those patients at risk of late icu admission and subsequent adverse outcomes. studies are needed to assess the right place for newly diagnosed aml with physiological abnormalities but no organ dysfunction. atrial fibrillation (af) is the most common sustained tachyarrhythmia in the community. it has a prevalence of * % in those over years of age ( ) . the chronic health consequences of chronic af are significant. it can cause impaired cardiac function, a fivefold increased risk of stroke and decreased life expectancy ( ) . af is also the commonest arrhythmia in the critically ill, though a recent systematic review ( ) was unable to recommend evidence based standards due to the heterogeneity of the studies. objectives. a retrospective cohort study to assess the impact that chronic af has on the outcome from critical illness. methods. all patients admitted with chronic af between / / and / / were identified. we recorded age, apache ii and predicted hospital mortality, actual icu and hospital mortality, past medical history, admitting diagnosis, medication, echo findings, anticoagulants given, therapy instituted, and any further events between icu and hospital discharge. the only data collected for the patients who did not develop af was their age, apache ii and predicted hospital mortality and actual icu and hospital mortality. data analysis using chi square test and mann-whitney u test were used where appropriate. results. patients were admitted to the icu over the study period, of which had a history of chronic af ( . %), the remaining results are shown in table . chronic af had a prevalence of . %, in keeping with previous studies, and the mean age in the chronic af group was significantly higher. interestingly, there was no difference in icu and hospital mortality between the groups. despite the chronic af group being older with significantly worse apache ii scores. indeed the hospital mortality ( . %) of those patients admitted with chronic af was over % less than predicted hospital mortality ( . %). why patients with chronic af are outperforming expectation is not clear. it could be that apache ii is over estimating the severity of illness in these individuals, or is there something about the way chronic af is treated that affects the response to critical illness, for example, anticoagulation therapy? one of the major outcome measurements in burns centers is still mortality after severe burns. there are many predictive factors in admission as well as factors that are related with all the course of the disease responsible for survival after severe burn. many centers have a minimum standard of burn survival or la (the body surface area that kills % of people) and also have generated computer models of death probabilities based on age and tbsa (total body surface area) burned. objectives. to evaluate the outcome of the severely burned patients treated in the burn center and to develop a predictive model for survival from major burns in albania. the medical records of all acute burn patients admitted to the burn center of the university hospital center ''mother teresa'' in tirana, albania are reviewed retrospectively. statistical analyses are conducted using spss version . logistic regression is used for the prediction of death probability for two risk variables, tbsa burned and age. based on the index of evidence the variables are grouped in significant strata, from to for each variable. logistic regression equation is: where z = , - , age - , age - , age - , age + , tbsa - , tbsa - , tbsa - , tbsa after calculating the probability of death for each record, we have done respective grouping according the mortality from - %. results. during - are admitted altogether , patients in the burn center. overall mortality in icu is . % with a significant reduction during the years, up to . in . row burn mortality is . for , persons per year. la for children is % tbsa; for adults % tbsa and for aged % tbsa. based on probability of death, we notice that older age and larger burn size are associated with a higher like hood of mortality. figure gives an overview of death probability in our burn center. conclusions. the mortality reduction speaks up for a better work of our staff toward the patients. the predictive model may assist all the burn team to identify the crucial determinants of clinical outcome to establish a real basis for treatment standards and to allow future comparisons of new treatment strategies. ( ) in mechanically ventilated (mv) critically ill patients. methods. prospective observational multicenter study during weeks in november . consecutive patients admitted to the participating icus and requiring mv for at least h were included. maximal, minimal and mean intra-abdominal pressure (iap), were recorded on day , , and . iah was defined as mean iap c mmhg/ h at least day. following risk factors were recorded if evident during the first icu day or immediately before: respiratory failure, abdominal surgery with fascial closure, damage control laparatomy, major trauma/burns, prone positioning, gastroparesis, ileus, colonic pseudo-obstruction, ascites, hemo/pneumoperitoneum, intra-abdominal fluid collection, acidosis (ph \ . ), hypothermia (core t°\ °c), massive transfusion ([ u of packed red cells/ h), massive fluid resuscitation ([ l/ h), coagulopathy, oliguria and sepsis. results. patients from icus were included; mean apache ii score on admission was . ( . ) and -day mortality %. mean number of iap measurements was . per day. iah occurred in patients ( . %). only pt ( . %) had none of the studied risk factors, nevertheless % of them still developed iah. of the patients with or more risk factors, only . % developed iah (table ) . objectives. to describe the icu admission of our hospital for serious complications of hematology patients in the last years. compare the characteristics of these patients throughout the study period. analyze mortality and their evolution from their admission to the icu. the evolution of hematologic patients has improved in recent years due to better supportive treatment, sometimes involving the use of specific treatments in the icu. a retrospective study of medical records of all patients with hematologic diseases were admitted to our icu from april until may . we excluded patients admitted for channeling central catheter, diagnostic tests and bone marrow transplants. we selected a total of patients ( % male) with a mean age of years (range - ). the main hematological diagnoses were the most common aml ( %), acute lymphatic leukemia ( %), lymphoma (non-hodgkin's lymphoma) ( %), coagulopathy ( %), myelodysplastic syndrome ( %) and myeloma multiple ( %). the principal reason for admission in the unit were: acute respiratory failure ( %), followed by sepsis ( %) and less cns and cardiac problems ( and %) respectively. as important risk factors of neutropenia and peripheral blood stem cells after transplantation. the icu mortality reached . %. the average stay was . days. conclusions. the transfer to the icu allows a high percentage of hematological patients survive severe complications and the benefit continues after discharge. the mortality of icu patients in our series has not changed over the past years, keeping both the characteristics of patients transferred. the consensus among the services of hematology and intensive care is essential to select and treat the best candidates to benefit from support in the icu and to improve current survival results. a retrospective (from to ) and prospective (from to ) analysis of obstetric patients (pregnant or postpartum admissions) admitted in our ccd was performed. results are expressed as mean (standard deviation) or frequency (percentage). chi and t student tests were used for statistical analysis according to the different variables (spss . , inc. chicago, il), accepting a p-value . as significant. results. obstetric patients were included. mean maternal age was . ( . ) years and mean gestational age was . ( ) weeks. apache ii score was . ( ) . ( . %) patients were admitted to ccd due to an obstetric cause. the main diagnosis of this group were thrombotic microangiopathies ( . %) and hemorrhagic shock ( . %). thrombotic microangiopathy included ( %) eclampsia-preeclampsia, ( %) acute fatty liver, ( %) hellp syndrome and ( %) ptt-shu. in the remaining . % ( patients) the main reason for ccd admission not related to the pregnancy was respiratory failure ( . %). from the whole population included, patients ( . %) required mechanical ventilation (mv) with a mean duration of . ( . ) days. furthermore, ( . %) patients required surgical intervention ( . % hysterectomy). the ending of pregnancy was made in patients ( . %), most cases by caesarean . % ( patients). mean length of stay in ccd was . ( . ) days. maternal mortality was . % ( patients), basically in the non-obstetric group ( vs. ) . conclusions. this is a large series of young obstetric critically ill patients with a low mortality. however, a non-depreciable part of the population included presented important morbidity. objectives. to identify the association of co-morbidities with mortality. methods. retrospective analysis of clinical process of diagnosing patients with severe sepsis/septic shock admitted to the intensive care unit (icu) in the period of november to october . we collected demographic data, co-morbidities, and mortality in the icu hospitalization. statistical tests used were student's t and chi-square. we analyzed patients admitted with this diagnosis, median age of years and females . %. in . % ( patients) appear co-morbidities, distributed as follows: hypertension . %, . % diabetes mellitus, cerebrovascular disease . %, . % chronic kidney disease; . % neoplasic disease and chronic obstructive pulmonary disease . %. the mean age ( . , p \ . ) was higher in this group. the overall mortality in the icu was . % that has not increased significantly to . % in the group with comorbidities, and the overall in-hospital mortality was . % and rise significantly to . % (p \ . ). conclusions. in our study, around - patients had co-morbidities and these facts and the age were those who contributed to higher mortality. the factors of greatest weight are those related to metabolic disease. the characterization of chronic illness in the icu is important in future larger epidemiological studies to better characterize this group of patients and the factors predictive of mortality to decrease the suffering of the patient and plan for admission to intensive care units. one year mortality of patients treated with an emergency department based early goal directed therapy protocol for severe sepsis and septic shock: a before and after study. introduction. despite the advances in respect to the development of objective criteria for admission of patients with hematologic malignancies to intensive care unit (icu), no evidence exists that they contributed to a reduction in the mortality, which depends from the aggressiveness of the cancer itself, its complications and even as a consequence of therapy. since the decision to admit one of these patients in icus involves a complex decision-making process, it becomes imperative to identify predictors that may help the clinician to discriminate the patients who may benefit from intensive care than those in which intensive care will be associated with just a prolongation of an agony. objectives.: to identify early prognostic factors in the admission of patients with hematological malignancy, admitted in the icu of a central university hospital. analysis of data prospectively collected and registered in a database of patients with hematological malignancy, admitted to the icu between january and december . we collected for each patient demographic and clinical data (age, sex, length of stay, origin, previous treatment, stage of disease at admission, type of malignancy and aggressiveness, organ dysfunction at admission, co-morbidities, reason of admission), general severity scores (saps ii and apache ii) and organ dysfunction scores (sofa at admission to the icu, maximum sofa score and delta sofa). specific variables were correlated with mortality at the icu and hospital discharge. results. patients ( males and females) fulfilled the inclusion criteria. the average age was ± . years ( - years). the type of hematological malignancy was acute leukemia ( . %), multiple myeloma ( . %), myelodysplastic syndrome ( . %), chronic leukemia ( . %), low grade non-hodgkin lymphoma ( . %), high grade non-hodgkin lymphoma ( . %). the average length of stay in the hospital was . ± . days. most patients were admitted from the department of hemato-oncology ward of the hospital ( . %), . % of the emergency department and . % of another hospital. the icu mortality was . %, with a corresponding hospital mortality of . %. the discriminative capacity of the severity scores, as assessed by the area under the roc curve (aroc) was . for saps ii and . for apache ii. for the delta sofa calculated for each organ dysfunction, progression of respiratory dysfunction/failure and cardiovascular failure demonstrated the best discriminative power (aroc of . ). conclusions. none of the variables showed a statistically acceptable relationship with icu or hospital mortality. the general severity indices saps ii and apache ii demonstrated a better discriminative power than the multiple organ failure scores. however, in this group of patients,it is still difficult to know objectively what factor or combination of factors may be useful in deciding the admission of the patient in an icu. recently due to new developments in interventional gastroenterology and new therapeutic options for treatment, gastroenterological and hepatological (geh) admissions to acute care settings has been decreased. for general intensive care units (icu) gastroenterological and hepatological (geh) diseases consititutes the minority of icu admissions. so we planned to find the incidence and clinical course of admissions due to geh complaints in a medical icu. objectives. main objective is to analyze clinical and epidemiological features of patients admitted to icu with geh disorders. other objectives are to analyze the mortality rate and the factors contributing mortality in these patients. and who stayed for more than h were included. the prospectively developed data including demographics, prognostic scores and clinical features of patients were analyzed retrospectively. patients with geh disorders consituted % of patients admitted to icu. one hundred thirthythree patients with an age of [ - ] years and gender of % male were included. more than half of these patients ( %) did not have any chronic geh disease. the patients were admitted most often from the emergency department ( %). the most frequent admission diagnosis was gastrointestinal bleeding ( %) followed by hepatic diseases including hepatic failure and acute hepatic encepahalopathy, biliary tract infection ( %), pancreatitis ( %) and enteric diseases including massive diarrhea and bowel obstruction ( %). on admission median apache ii and glasgow coma scores were [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , respectively. acute kidney injury (defined by rifle criteria risc, injury or failure) was found in (% ) patients. the most common rifle class was class failure ( %). during icu stay patients ( %) needed renal replacement therapy and patients ( %) received mechanical ventilation. nosocomial infection developed in ( %) patients and icu aqıired severe sepsis occured in ( %) patients. icu and hospital mortality were % and % respectively. length of icu and hospital stays were [ ] [ ] [ ] [ ] [ ] [ ] and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] days respectively. respiratory failure requiring mechanical ventilation, acute renal failure on admission and severe sepsis in the icu were found to be the independent factors determining mortality in these patients (p = . , p = . and p = . respectively). patients with geh constitued % of patients admitted to icu. they usually do not have any chronic geh disease. gastrointestinal bleeding is the most frequent admission diagnosis. respiratuar and renal failure on admission and severe sepsis occured in the icu are the major determinats of mortality in these patients. introduction. in recent years described series with hematological patients in icu, but these studies are often limited because they are retrospective, single center in a few patients divided over many years. to determine the characteristics of mortality in this group is very important to assess their management in the icu. objective. to analyze prognostic factors associated with icu mortality of patients (pts) with hematologic malignancies admitted to the intensive care unit (ptu). method. an observational, transversal, prospective, multicenter oct conducted between june and october . we conducted a descriptive analysis, chi-square, bivariate and logistic regression including variables with a value of p \ . with the sas statistical pauet to assess the factors influencing mortality in icu. we included patients from icus. the mean age was years. the apache ii at admission was . ± . ) and the first day sofa ± . . ( . - . ). the crude mortality icu was . % ( pts). we divide related mortality by infectious etiology ( %) versus other causes ( %). in univariate analysis the variables significantly associated with mortality were: males p \ . , hematology plant from . , . multiple myeloma, respiratory failure at admission . , tachycardia, . , . hypothermia, tachypnea , apache ii c , more than two organ failures . , presence of ards \ . , invasive mechanical ventilation (imv) \ . , niv . , . transfusion (of all products: red cells, platelets and plasma), acquisition intrauci infection . , days longer stay in icu . . the presence of neutropenia was not associated (p = . ) at a significantly higher mortality, or personal history, septic shock, bone marrow transplant or other reasons for admission to the icu. table describe the independent factors associated with mortality in logistic regression analysis. variables classics such as septic shock or neutropenia not associated with mortality. and the independent variables associated with increased icu mortality were: vm, ards, severity and need for transfusion of blood products. results. patients were identified. major haematology diagnoses were acute leukaemia %, nhl % and lymphoma %. mean time to icu admission was . days with % admitted within h. the commonest reasons for icu admission were respiratory failure %, sepsis % and acute renal failure %. the mean number of organs supported was . . % of patients had c organ failure. mean apache ii score was . . increasing organ failure correlated with increasing mortality. patients with or organ failure had % mortality. mean icu stay was days with % having an icu stay of less than h. icu mortality rate was . %. . % received invasive ventilation, . % failed non-invasive ventilation (niv) and required invasive ventilation, . % had niv only and % received no respiratory support. vasoactive support was given to . % and rrt to . %. invasive ventilation and niv were associated with a higher mortality; and % versus % in spontaneously ventilating patients. vasoactive support was associated with more organ failure, longer icu stay and higher mortality. rrt was associated with a higher mortality versus %. patients with a documented poor haematological prognosis had a higher mortality but also more organs supported. conclusions. from this study invasive ventilation, cardiovascular support and multiorgan failure are strongly associated with increased mortality. the need for rrt was not an independent predictor of mortality. close collaboration is needed between the specialities to allow early resuscitation and critical care support to avoid delayed admissions with multi organ failure. introduction. the prescription of stress ulcer prophylaxis (sup) in critically ill patients is relatively commonplace due to the association between physiological stress and gastrointestinal (g.i.) bleeding. however, recent guidelines recommend that only patients who are mechanically ventilated, and/or have a coagulopathy warrant prophylaxis. they also state that histamine receptor blockers (h rb's) can be used primarily for sup ( ). objectives. the aim of this audit was to compare prescription practice of sup at the itu/hdu at mayday hospital with those set out in the guidelines and to calculate the potential cost savings resulting from following these guidelines. methods. data prospectively collected from consecutive admissions to mayday hospital itu/hdu between october and november . . data was collected on patients, had a g.i. bleed on admission, and were already on sup so were excluded. of ( %) patients with major risk factors were prescribed sup, compared with of ( %) patients with no major risk factors. proton pump inhibitors (ppi's) were prescribed preferentially to h rb's; versus . the cost of sup during the audit period was £ , . if we had only prescribed it to those at high risk the cost would have been £ , . , and if we had only used h rb's the cost would have been £ . . prescribing of sup in our unit does not reflect quenot's guidelines. this not only represents an increased cost but there are increased rates of nosocomial pneumonia and c. difficile diarrhoea associated with sup ( , ) . there is little evidence showing the superiority of ppi's over h rbs in the prophylaxis of bleeds; and there is evidence of an increased rate of the aforementioned infections with ppi's as compared to h rb's ( ). we prescribed ppi's to a significant majority of our patients; however, it is our opinion that our current unit practice is not dissimilar to that of the rest of the uk. we would encourage all critical care units to review their sup prescribing as our results show that significant savings can be made with judicious prescription of these drugs. . surprisingly little is published on the cost of drug treatment for critically ill patients. critical care is expensive, mainly due to the high staff ratio, expensive equipment but also due to a significant reliance on pharmacological management, which is usually funded with a limited drug budget. objectives. to explore the relationship between drug expenditure, patient acuity and outcome. methods. data was generated by retrospective analysis of consecutive patients admitted to our bedded general adult icu/hdu in a london teaching hospital, during february . patients were excluded from analysis if they were present in icu for less than h. the first and final ccu days stay were not included so that only full days were analysed. daily drug-use per patient was manually extracted from the computerized icu management system (cis, qs, ge medical). costs of prescribed drugs, fluids and parenteral nutrition (pn) were calculated from the pharmacy computer system and analyzed using regression analysis (spss ver ). results. the patient characteristics and outcomes of the patients are described in table table patient characteristics and outcomes age ( - )* gender (male n and %) ( %) apache ii score . ( . )** tiss score/patient . ( . )** length of ccu stay (days) ( - )* ccu survival (n and %) ( . %) daily drug cost for each patient's stay £ . (£ . - . )* daily drug cost for ccu and hospital survivors n = £ . ( . - . )* daily drug cost for ccu survivors who died in hospital n = £ . ( . - . )* daily drug cost for ccu non-survivors n = £ . ( . - . )* *median (interquartile range), **mean (standard deviation) the median daily drug cost was £ . . of note, the drug cost was highest for ccu nonsurvivors compared with survivors and also compared with patients who died in hospital after ccu discharge (p = . ). multivariate regression analysis demonstrated that median daily drug cost/patient = - . + . (mean tiss score) + . (apache ii score), r = . %; i.e median daily drug cost/patient was positively associated with tiss and apache ii score explaining % of the variation in cost seen. conclusions. this is the first study to show that daily drug expenditure in all general ccu adult patients correlates with patient acuity. median daily drug costs/patient were found to be £ . . this parameter would make an interesting comparison with other units both nationally and internationally. daily drug costs can be predicted on the basis of apache ii and tiss scores. furthermore, this may be further refined to develop a quality marker of daily drug cost in relation to survivors and non-survivors. material, methods and results. all patients admitted to the icu of neurotrauma, which underwent a tracheostomy after admission. data were collected: affiliation, cause of admission, average stay, indication of tracheostomy, tracheostomy time delay from its indication, place of performance of the procedure (icu or operating room), perioperative complications (event during transfer to operating room, event during surgery: hypoxia, hypotension, arrhythmia, bleeding, premature extubation, false cannulation, cardiac arrest, pneumothorax or death), and postoperative complications in the first week (bleeding, difficulty in changing cannula, stomal infection, pneumothorax, death conclusions. tracheostomie is a simple surgical technique and . % of tracheostomíes could be safely performed in the icu, saving hours of scheduled interventions in the operating room. there were no serious event during the transfer to the operating room or during the performance of tracheostomy. tracheostomized patients in icu, had a higher incidence of hypotension during surgery, although this complication in any case was serious or required treatment with vasoactive amines. when the tracheostomy is performed in the operating room, the delay shows a tendency to be higher, although this difference is not ss introduction. the concept of tight glyceamic control in critically ill has led to the rise of number of insulin infusion protocols designed to keep the blood sugar (bs) in predefined range. at the same time monitoring practices and patients populations vary greatly between intensive care units and thus so do the results. the matter is complicated by the absence of a widely agreed common glyceamic control indicators against which protocols can be evaluated and compared ( ). to establish the quality of glyceamic control in two different intensive care units. to compare the quality of glyceamic control between two intensive care units, with different glyceamic protocols and blood sugar measurement practices. we conducted retrospective non-randomized population study comparing quality of glyceamic control in two independent and non-related intensive care units. time spend in pre-defined glyceamic range was chosen as a quality indicator for both units ( , ) . data was collected from the electronic database and point of care bs measuring devices. the frequency distribution was analyzed to establish the patient-to-patient variability and a degree of bs deviation from the target value. results. units were different in method of sampling, frequency of sampling, target for optimal glyceamic range and instigated insulin protocol. data was collected on patients ( , bs measurement) in itu and patients ( , bs measurements) in itu . mean bs was . (sd = . ) mmol/l in itu and . (sd = . ) mmol/l in itu . conclusions. the performance of both protocols were satisfactory- . and . % of the time patients spend with bs less than mmol/l in itu and itu respectively. the quality of glyceamic control on both itus is similar in terms of proportion of time spend in different glyceamic bands, with the exception of the longer time spend in a hyperglyceamic state in itu . this study confirms the notion for a need of unified approach for evaluating quality of glyceamic control for in-patient populations. with an icu mortality of . % and in-hospital mortality of . %. the median transfusion threshold was a platelet count of /l with yearly medians ranging from . /l to /l. the % of platelet transfusions complying with bcsh guidelines increased from . to . % during the year study period. the specialties with the highest platelet requirement were general surgery ( . %), haematology ( . %) and general medicine ( . %) as a % of total units transfused. the yearly median threshold for haematology patients fell from . /l in to x /l in , increasing guideline compliance from . introduction. numerous protocols (e.g. glycaemic control, hhh, renal rescue) have been introduced into icu. these protocols involve blood sampling to assess gases, haemoglobin, glucose and electrolytes. this may result in anaemia and subsequent transfusion and adverse clinical outcome ( , ) . reducing blood loss due to sampling is an important blood conservation strategy ( ) . currently, our icu processes over , blood samples per month. objectives. to study the indications for blood gas sampling in our icu and identify strategies to reduce sampling. methods. we performed a prospective, observational study over week in . the nurses completed a questionnaire per shift per patient to assess the primary and any secondary reasons for each sample. subsequent management changes, haemoglobin levels, active bleeding, and transfusion were also recorded. results. blood samples from patients and questionnaires were analysed ( % of the nursing shifts). the range was - samples per patient per h shift with a mean of . the secondary reasons showed that many samples were also being used for potassium ( %) and glucose ( %) monitoring. only % of samples changed management (potassium %, ventilatory settings %, glucose %). haemoglobin levels dropped by an average of g/dl per week per patient with no active bleeding. units of blood were transfused during the study period. conclusions. our study shows that reasons for sampling are often relatively weak and sampling is promoted by icu protocols. frequent sampling does not change management for a large proportion of samples and may cause anaemia. there are financial implications to frequent sampling-at the time of the study each sample cost £ . (€ . ) to process. each unit of blood transfused cost £ (€ ). we have considered ways to reduce sampling including changing the glucose protocol to capillary sampling, using ml syringes, increased use of end tidal co monitoring, protocol redesign and education of staff. reference(s it has been reported that tight glyceamic control is associated with net savings in terms of length of stay on the itu and critical care bed occupancy ( ) . whilst it might be true for the overall length of stay, there is as yet, an un-quantified effect of frequent blood sugar measurement on the overall available nurse-patient time ( ) . there is finite amount of nurse-patient time within any given shift and so prioritizing nursing care will be an important factor in critically ill and high dependency patients. this is specifically important for any saving to be realized from the introduction of automated blood sugar measurement devices ( ). objectives. to quantify the amount of nursing time devoted to glyceamic control on itu or post-operative critical care environment based on data from four cohort studies on quality of glyceamic control in three intensive care units. a mathematical model, which takes into account frequency of blood sugar measurements and time to take each measurement was developed. stochastic analysis was used to calculate interdependency between quality of glyceamic control and the frequency of blood sugar measurements. introduction. introduction of trans-catheter aortic valve implantation (tavi) has been the latest technological advance in minimizing surgical stress and improving the chances of high-risk patient undergoing a successful aortic valve intervention ( ) . the latest technology comes at considerable cost, which relates to both-the cost of the tavi valve and to it's delivery system. currently, there are no randomized controlled trails addressing the issue of cost-effectiveness of tavi versus surgical avr ( ) . to build a cost-effectiveness model for patients undergoing either a tavi procedure or a surgical avr based on the level of care: level (ward based care), level (high dependency unit) and level (intensive care unit) during in-hospital stay, taking into account the rate of post-operative complications in both groups. methods. tavi patients were matched against patients who had previously undergone surgical avr. the groups were matched for demographic and physiological risk factors, as well as euroscore. a decision analytical tree was constructed based on the length of stay in hospital and post-operative complications. a markov model was built and the effectiveness was measured in terms of improvement in nyha class, which was translated into the quality adjusted life years (qaly) ( ) . results. the average in-hospital cost for tavi was £ , versus £ , for the surgical avr. the cost did not include the theatre time cost. in the surgical avr group the in-patient mean cost was greater than respective cost of the tavi group due to longer overall length of stay as in-patients. patients in the avr group spent more days in level and level care as compared to the tavi group. conclusions. the shorter length of stay and reduced rate of post-operative complications in the tavi group has got the potential to substantially reduce the overall in-patient cost and offset high cost of the valve. the effectiveness arm of the models did not differ for both groups, due to the lack of published literature, and raises a need for a qaly assessment for the effectiveness of tavi. the rate of post-operative complications in surgical avr group (higher rate of stroke and need for cardiac pacemaker) substantially affected the projected long-term cost. objectives. to determine if interventions for permanent pacing (ppm) and change of generator are more efficient in small hospitals. retrospective, transversal, observational study, measured through five diagnosis related groups (drg) that make up the casemix of pacemakers from the spanish minimum basic data set in , descriptively analyzing demographic variables (age, gender), clinical (number of secondary diagnoses (nsd) and procedures (np), mortality) and management (total, preoperative length of stay, access, discharge, hospital size), defining inefficient stays exceeding days the average. a bivariate study contrasting quantitative variables and comparisons between nominal and categorical, evaluating the independent association between short stay and different covariates studied building a binary logistic regression model, introducing as independent variables those that were significant in the bivariate as well as those considered that might be associated with the dependent variable. introduction. blood products are in short supply and with an ageing population the demand is likely to increase. blood use has been shown to be declining within the surgical specialties and intensive care, however overall use has remained unchanged. this audit looks at the use of packed red cells amonsgst medical inpatients to determine appropriateness. to determine if red cell use is appropraite among medical inpatients methods. medical blood transfusions were examined between august and august . patients were selected and pre and post transfusion haemoglobins were determined along with chronicity of anaemia. transfusions with haemoglobins of c . g/dl triggered a case note review. over months , patients were transfused , units. , units ( %) were given to medical patients ( %), of which patients were reviewed receiving transfusions. average age was . in patients pre transfusion haemoglobin was b g/dl ( %) and in patients c . g/dl ( %). in the group b g/dl patients had acute anaemia and had chronic anaemia. in the group c . g/dl patients had acute anaemia and had chronic anaemia. patients were not transfused and had absent data. out of case notes only were available. patients were transfused for acute anaemia, for chronic anaemia of which patients had cardiac disease, had haematological disorders, patients had iron deficiency anaemia and patient was folate deficient. conclusions. chronic anaemia in the over s accounted for the majority of transfusions. documentation was substandard. transfusions in chronic anaemia may be reduced by up-to-date guidance on transfusion triggers and alternative strategies to the use of blood products. ( ) results. the commonest indication for pct was long-term mechanical ventilation ( %) followed by airway protection ( . %). . % patients had platelets count\ lac while . % had severe thrombocytopenia (\ , ). . % patients had an additional coagulopathy (hepatic failure and multiple organ failure), with inr [ . was present in . % and deranged aptt in . % patients. pct was safely performed in all these patients. the patients received platelets or fresh frozen plasma(ffp) before the procedure to optimize coagulation. only . % had minor bleed through stoma, which was stopped in - min requiring gauze compression. conclusions. pct under videobronchoscopic guidance has low haemorrhagic complication rate in patients with deranged coagulation profile. platelets/ffp should be transfused before the procedure in these patients. introduction. blood components transfusion is common in the critically ill patient, as in the acute bleeding or the acute illness with multiorganic failure context. as any medical intervention, it has clinical indications and associated risks. clinical guidelines have evolved in a restrictive direction, suggesting that decision should be based on particular clinical situation and not only on analytical results. objectives. understand our transfusional practice and how close it is to clinical recommendations, as a quality indicator of our intensive care unit (icu). retrospective study using the icu patients data base. the population consists of patients with more than h icu stay in . the variables analysed are sex, age, diagnostic class (medical, surgical, trauma), saps ii score, mortality, number of transfusional events (erithrocyte concentrate, platelets, fresh frozen plasma and albumin) and the concordance to our hospital clinical guidelines. results. the population is of patients, % of male gender, with an average age of years-old. the admission diagnostic is medical in % of patients, with an average saps ii score of , median icu stay of days and a mortality rate of %. % (n = ) of patients received any kind of blood component transfusion, mostly erithrocyte concentrate ( % of patients), followed by albumin ( %). the populations of transfused patients is older ( vs. years-old), has a longer icu stay ( vs. days), higher saps ii score ( vs. ) and mortality rate ( . vs. . %) . pretransfusional values are hemoglobin of . g/dl, , platelets/ul, and albumin of . g/dl. the level of concordance with recommendations is high for erithrocyte concentrate ( %), platelets ( %) and fresh frozen plasma ( %) but not for albumin ( %). conclusions. the level of transfusion is high in icu patients. the population who received transfusion has a more severe clinical condition and higher mortality rate. the level of concordance with recommendations is high with the exception of albumin, which use is still less standardized. with increasing acuity due to escalating icu bed demand, but the impact on patient safety is unclear. sdu continuous non-invasive physiologic monitoring of hr, rr, bp and spo identifies cardio-respiratory instability often unnoticed by caregivers. causes may be alarm fatigue and/or high sdu nurse-to-patient ratios which make bedside monitoring insensitive. instability may become more resistant to intervention the longer it occurs. the impact of instability duration upon sdu patient outcomes is understudied. objectives. the study purpose was to determine the impact of cardiorespiratory instability duration experienced by in-patients being cared for on a monitored sdu upon hospital length of stay (los) and hospital charges. prospective study of monitored patients on a -bed trauma sdu over weeks. noninvasive continuous monitoring data were downloaded from bedside monitors and analyzed for vital signs (vs) beyond local instability criteria: hr\ or [ , rr\ or [ , systolic bp \ or [ , diastolic bp [ , spo \ % . vs time plots of unstable patients were further assessed to judge instability as mild or serious. instability duration categorized as: none, [ ] [ ] [ ] [ ] [ ] [$ k) . relationships between instability duration and outcomes analyzed with chi-square for mild and serious instability. conclusions. there has been a marked improvement in the overall recording of sews since the previous study. it is of concern that respiratory rate was again the least well recorded parameter as this has been shown to be the best physiological predictor of impending cardiopulmonary arrest , . this may be because respiratory rate is not provided by the automated monitoring devices available on the general wards in our hospital, and must be calculated manually. it demonstrated an increase in mortality even when tiss scores were taken into account as an independent risk factor. since these publications critical care outreach and the use of early warning scores have become common place; however it was felt that time of discharge was still impacting on patient outcome. to review our post-unit mortality and readmission rate, with particular focus on the time of discharge. conclusions. our mortality and readmission data compare favourably with a recent publication. there is a clear difference in mortality related to time of discharge; however this is for evening discharges as compared to night discharges in previous papers. [ ] [ ] [ ] [ ] the time of discharge may represent logistical issues of planned discharges or early discharge decisions due to pressure for beds. overnight discharge is an uncommon occurrence in our unit; this evidence suggests that previous concern about night discharges should be extended to evening discharges. transferring critically ill patients is a challenging task in the day to day activities of the critical care team. safe accomplishment of these transfers relies on skills of the persons accompanying and the resources available. guidelines have been produced by various professional bodies [ , ] to safely accomplish these transfers. the competency document released by the royal college of anaesthetists, uk requires that junior trainees have appropriate knowledge, skills, attitude and behaviour in the principles of safe transfer of critically ill patients [ , ] . to obtain information about trainee's perspective, experience and knowledge in transfer of critically ill. a web based online survey was sent to all the anaesthetic/itu trainees in the west midlands region of the uk. results. total number of respondents were . of these, . % had less than months of anaesthetic training before undertaking a transfer. only % had formal training on transfer of critically ill patients. % of the trainee's didn't have any competency based formal assessment of their skills, attitudes and behaviour in transfer of critically ill patients. majority of them ( %) felt that every one should undergo formal training before undertaking transfers. while % of the respondents have undertaken transfers during their training, only % have experienced some form of critical incident during these transfers. more than % of these adverse events were related to equipment failures while % were due to patient deterioration. nearly % of the trainees were not aware of terms and conditions of the insurance cover for these transfers. conclusions. this survey highlights the deficiencies involved in training the trainee's for transfer and the transfer itself. the results demonstrates that majority of the trainees would prefer to attend specific transfer courses before venturing out on an actual transfer. we hence recommended the following for implementation: improvement of training process for those undertaking transfers; regular monitoring of this process; regular analysis of critical incidents and acting upon it; making the insurance compulsory for those undertaking the transfers. greek hospitals, including initial management of critically ill patients and primary care for a growing proportion of the population. the impact of ed length of stay (los) on patient outcome has not been covered adequately by existing surveys so far. objectives. the aim of this study was to determine the association between ed overcrowding and outcomes for critically ill patients. in the present study, we included medical and surgical pts that all of them were intubated promptly to ed of general hospitals of athens gr, for months. pts survived [ h were divided into groups: ed boarding \ h (group a) and ed boarding c h (group b). demographics, apache ii, diagnosis, los, and icu and hospital mortality were recorded. ed boarding time was measured in min. groups were compared using chi-square, mann-whitney, unpaired student's t tests and stepwise regression analysis. the collection of data lasted months. results. in the ed, critically ill patients with a mean age . ± . years and apache ii score . ± . were intubated. pts were males and were females with a mean age . ± . and . ± . years, and apache ii score . ± . and . ± . respectively. main diagnosis was multi trauma ( ) objectives. we sought to assess the baseline characteristics and outcomes of the patients presenting af as a cause of met call activation. using the met database of one tertiary teaching hospital, we retrospectively reviewed all patients for which the met diagnosis was atrial fibrillation. we reviewed their clinical history, immediate treatment and outcome. these data were compared to those of a control group of randomly selected met calls with patients being matched for age, gender and ward of origin (surgical or medical). objectives. to ascertain the proportion of preventable in-hospital cardiac arrests occurring at university hospital lewisham. furthermore, to identify any common predictors of poor outcome that were apparent prior to those arrests and whether these are potentially modifiable. a case note review was performed on the cohort of patients who suffered inpatient cardiac arrests and who were admitted for icu (level- ) care post-resuscitation. these patients were identified using our quarterly feedback from the intensive care national audit and research centre (icnarc) case mix program dataset between april and september . we found that half ( out of ) of our in hospital cardiac arrests resulted in death despite level- care post arrest within the audit period. of these in-hospital arrests were deemed preventable from case note review and trust cardiac arrest call audit forms when available. in addition, in the preventable sub-group an arterial blood gas sample was not obtained in out of , %. in all of these cases, the icu outreach team was not aware of the patient prior to the arrest. conclusions. in keeping with widely published data regarding survival to discharge after in-hospital cardiac arrest, the high mortality rate of % for this cohort of patients emphasises the importance of early recognition of abnormal physiology and timely intervention. with the sensitivity, specificity and validity of ews yet to be validated and no clear benefit proved from the introduction of met/outreach teams, an alternative strategy for earlier recognition of critically ill patients is needed. our data suggests that arterial blood gas sampling, an essential investigation central to the recognition of critically ill patients is being consistently overlooked and is an important factor influencing outcome. results. attended patients were , , with mean age of , years, and women represent , % of them. most demanding services were internal medicine ( %) followed by general surgery, haematology and nephrology. global data may be seen in table . with regards to admissions to the icu of these patients, table depicts the proportion between requested admissions, and refusals. introduction. tradicionally, critical care interventions are highly intensive, expensive and brief. critical illnesses and interventions that we use, can both contribute to posticu disability: catheter-related bacteraemia, polineuropathy, resistant organism, nutricional problems, complications of tracheostomy, prolonged analgesic. all these factors and a premature discharge from an ever full icu, can even have an impact on occult mortality after discharge from icu (between and %). in our unit a follow up program have been implanted. when patients are about to be discharged from icu, icu clinicians selected those considered to be recoverable but fragile enough to have poor prognosis. objectives. to quantify the workload that a after icu follow-up entails, and to determine if this program impacts on mortality posticu. prospective and interventional study carried out during a months period. at a beds medical uci of a teaching hospital in malaga icu, patients were enrolled in the follow up program. we assessed prognosis with sabadell score and severity of illness with apache ii score; and registered our interventions after discharge from icu. the final endpoint was status at hospital discharge: survivant or dead. we did interventions in patients: we changed a venous catheter ocasions ( % of patients), changed analgesic schedule times ( . %), stopped antibiotics times ( %), modified parenteral nutrition times ( %) . we searched and treated sources of sleep deprivation (delirium, anxiety or insomnio) in patients ( %); treated tracheostomy complications in patients. mortality of patients enrolled in this program was . % ( patients) even if the mean expected mortality by apache ii score was [ %. conclusions. in our study, implementation of a continued follow-up program after icu discharge in selected patients, carried out by icu staff, was associated with an important decrease of mortality. encouraging clinical results and a non-excesive workload for icu staff justify continuing this follow-up. objectives. various therapeutic protocols were used for the management of sepsis including hyperbaric oxygene (hbo) therapy. it has been shown that ozone therapy (ot) reduced inflammation in several entities and exhibits some similarity with hbo in regard to mechanisms of action. thus, we designed a study to evaluate the efficacy of ot in an experimental rat model of sepsis and to compare these effects with hbo. methods. forty male wistar albino rats were divided into sham, sepsis+cefepime (control), sepsis+cefepime+hbo (hbo), and sepsis+cefepime+ot (ot) groups. sepsis was induced by an intraperitoneal injection of . cfu escherichia coli; hbo was administered twice daily at . -atm pressure for min; ot was set as intraperitoneal injections of . -mg/kg ozone/oxygen gas mixture once a day. the treatments were continued for days after the induction of sepsis. at the end of experiment the lung tissues and blood samples of the study animals were harvested for biochemical and histopathologic analyses. results. lung tissue myeleperoxidase activities and oxidative stress parameters, and serum proinflammatory cytokine levels, il- b and tnf-a, were found to be ameliorated by the adjuvant use of hbo and ot when compared with the antibiotherapy alone group. histopathologic evaluation of the lung tissue samples confirmed the biochemical outcome. some measures indicated significantly more efficacy of ot than hbo. conclusions. our data presented that both hbo and ot reduced inflammation and injury in the septic rats' lungs; a greater benefit was obtained for ot. these findings suggest that it may be possible to improve the outcome of sepsis by using ot as an adjuvant therapy. objectives. to investigate the regularity for change of paf, tm and vwf in septic rat, and the protective effects of statins on vascular endothelium. methods. fifty-four male sd rats were randomized into simvastatin with lps group (group a, n = ) and lps group (group b, n = ) and control group(n = ). they were respectively accepted ml/kg normal saline (ns) abdominal injection for both control group and group b, ml/kg simvastatin abdominal injection for group a, then h later, total male sd rats from group a and group b were respectively accepted lps ( mg/kg weight) abdominal injection to establish sepsis model and ml/kg ns abdominal injection for control group. thereafter, detected the serum concentration of von willebrand factor (vwf), thrombomodulin(tm) and antithrombin (at-iii) at different point of time ( , , and h after lps abdominal injection) in both group a and group b by elisa, the endothelial cells from thoracic aorta was observed with electron microscope. under electron microscope scanning, endothelial cells in septic rats from group b were found disarranged. under transmission electron microscope, endothelial cells were found to be in prophase of apoptosis characterized by unclear cell membrane, thickened cellcell conjunction, disappeared desmosome and microfilament, dissolved or vacuolized organelles and agglutinated and evaporated chromatin gathering under the karyolemma, but the karyorrhexis were not found. no similar changes were found in group a. ( ) introduction. sepsis induced lymphocyte apoptosis is believed to play an important role in the pathogenesis of sepsis and in the development of the immunesuppresion observed in septic patients. lymphocyte apoptosis not only decreases the number of functional lymphocytes but may also modify the immune response towards an anti-inflammatory state. erythropoietin (epo) has recently been recognized as a multifunctional cytokine with antiinflammatory, antioxidative, and antiapoptotic properties. objectives. this study aimed to test whether epo could mitigate peripheral blood mononuclear cell (pbmc) apoptosis and whether epo could modify the dynamic changes in lymphocyte-subsets in a porcine model of acute endotoxemia. methods. twenty-eight anesthetized and mechanical ventilated pigs were randomized to one of three groups: ) epo group, epo administered h prior to endotoxemia (n = ); ) placebo group, vehicle administered h prior to endotoxemia (n = ); ) sham group, animals only anesthetized and mechanical ventilated. endotoxemia was induced by an infusion of lipopolysaccharide (lps). after h the lps infusion was reduced to a maintenance dose and the animals were fluid resuscitated. pbmc were isolated at time , , , and min of endotoxemia. apoptosis in pbmc and relevant lymphocyte subsets were assessed by staining with -amino-actinomycin d ( aad) and annexin v using multicolor flow cytometry. apoptotic lymphocytes in spleen were quantified by immunohistochemical staining for activated caspase- . endotoxemia increased the number of apoptotic mononuclear cells in both blood (p = . ) and in spleen (p = . ), but with no significant modifying effects of epo. the numbers of both cd + (t-helper) and cd + (cytotoxic) t-cells declined during endotoxemia. cd + cells, defining b-lymphocytes, demonstrated a biphasic response with an immediate decline followed by an increase in number of b-cells. the dynamic changes in the lymphocyte subsets were not modified by epo. , and reduced the number of circulating leucocytes. epo had no modifying effects on these dynamic changes. furthermore, epo did not mitigate apoptosis in pbmcs analyzed by flow cytometry or in spleen lymphocytes analyzed by immunohistochemistry. this study does not support that epo confer protection against lymphocyte apoptosis. objectives. aim of this study was to investigate the effects of combined, recombinant human activated protein c (rhapc) and ceftazidime (cef) in our established model of acute respiratory distress syndrome (ards) and septic shock methods. thirty sheep ( - kg) were operatively prepared for chronic study, and were randomly allocated either to sham, control, rhapc, cef, or rhapc/cef groups (n = each). after tracheostomy, acute lung injury and sepsis was produced in all groups, following an established protocol ( , ) , except the sham group that received the vehicle. the sheep were studied for h in an awake state and were ventilated with % oxygen. pao /fio ratio was determined intermittently. cef ( g) was administered intravenously and h post injury. rhapc was given as a continuous infusion ( mcg/kg/h), starting h post injury. the animals were resuscitated with ringer's lactate solution to maintain filling pressures and hematocrit. lung tissue was obtained during necropsy and analyzed for myeloperoxidase (mpo) using a commercially available kit. statistical analysis: two-way anova and student-newman-keuls post hoc comparison. data are expressed as mean ± sem. significance p \ . . . mpo levels (mu/mg protein) were ± in sham and significantly increased in the control group ( ± *). the rhapc ( ± *) and cef group ( ± *) increased significantly vs. sham and tended to be lower than controls, but not statistically significant. mpo levels of combined rhapc/cef ( ± *) showed no difference to sham, but were significantly lower than controls or rhapc or cef alone. conclusions. combined administration of rhapc and ceftazidime in ards associated with septic shock improved oxygenation more than cef or rhapc alone, and prevented the onset of ards. seleno-compounds, such as sodium selenite (na seo ) show conflicting clinical results in the treatment of sepsis. efficacy, as well as mechanism of action of na seo , are unclear, with prevailing opinion that it acts as an anti-oxidant. however, na seo has also oxidant properties that could have a paradoxical therapeutic role in septic shock by reducing over-activated phagocytic cells. indeed, in septic sheep, high dose na seo injection as bolus rather than continuous administration resulted in a beneficial effect on survival time, macro and microcirculation ( ). objectives. to investigate at the endothelial level the mechanism of action of a bolus injection of a high oxidative dose of na seo . in male wistar rats, lipopolysaccharide (lps, mg/kg) or normal saline were injected intraperitoneally, followed h later by either an intravenous bolus injection of na seo (corresponding to . mg/kg se) or normal saline. after h of lps, extravasation of fluoroisothiocyanate-dextran and leukocyte-endothelium interaction in venules of the cremaster muscle were quantified by intravital microscopy. results. na seo did not alter systemic haemodynamic variables as compared to lps rats. there were no intergroup differences in fluoroisothiocyanate-dextran extravasation. lps significantly decreased leukocyte rolling when compared to control animals (p \ . ). bolus injection of na seo did not alter leukocyte rolling but decreased leukocyte adhesion and extravasation levels to control values. our results in endotoxemic rats suggest that a toxic dose of na seo may have a beneficial effect of on leukocyte-endothelium interaction without a significant effect on plasma extravasation. objectives. to design a model of sepsis in pigs characterized by an unchanged q t over time. methods. after a h fasting, pigs (weight - kg) were sedated with ketamine ( mg/ kg) and midazolam ( . mg/kg) i.m. animals were tracheostomized and anesthetized (propofol mg/kg iv bolus, followed by mg/kg/h), atracurium ( . mg/kg/h) and fentanil ( lg/kg/ h). the internal jugular vein, carotid artery and pulmonary artery were catheterized for iv fluid administration and monitoring. a lumbotomy was performed and an ultrasonic blood flow and a laser-doppler microvascular flow probes were placed in the left renal artery and on the kidney surface to measure renal artery blood flow (rabf) and renal cortical blood flow (rcbf), respectively. a cystostomy was performed to collect and measure urine output (uo). sepsis was induced by the iv administration of live e. coli ( . our previous study showed that citrulline (cit) supplementation during endotoxemia improved microcirculatory flow and endothelial function, and prevented glycocalyx degradation as a consequence of increased arginine (arg)-dependent vascular nitric oxide (no) production. during sepsis the availability of arg, the substrate for endothelial no production, is tempered as a consequence of increased inflammatory no synthase (inos) activity. the reduced endothelial nos (enos) activity and vascular no production is believed to result in endothelial and vascular dysfunction. a shortage of arg availability for enos is considered the main cause of the dysfunction. previous studies have indicated cit as an important, if not exclusive, mediator for enos-derived no production. cit is a substrate for argininosuccinate synthetase, an arg-producing enzyme that co-localizes with enos in the caveolae, thus directly and exclusively supplying arg to enos. objectives. we investigated whether cit supplementation during an ongoing endotoxemia rescues the enos-derived no production in endothelial cells, thereby providing a mechanistic explanation for its positive in vivo effects. mice received a continuous intravenous endotoxin (lps, lg total) infusion for h alone or an h lps infusion with cit ( . mg total) during the last h of endotoxin infusion. after the h infusion, the mice were sacrificed, arterial blood was sampled and the carotid arteries were removed. no production in the carotid arteries was measured ex vivo with -photon fluorescence microscopy, using a fluorescent copper-based no probe. amino-acid concentrations in plasma were measured by hplc. results. both cit and arg plasma concentrations were significantly increased in the lps-cit group compared with mice treated with lps alone (p \ . ). in vivo cit supplementation led to detectable levels of no production ex vivo in carotid smooth muscle cells (smc) and endothelial cells (ec) by using the no-probe with -photon fluorescence microscopy. while ec-derived no production was absent in the carotid arteries of mice treated with only lps, the smc-related no signal was undisturbed. no production in the ec of the lps-cit group was not blocked by the inos inhibitor , w, suggesting enos to be responsible for the observed effect. furthermore, ex vivo incubation of the carotid arteries of the lps-cit mice for min with extra cit ( mg/ml) resulted in prominently increased no production in the carotid ec, whilst this effect was not observed in the carotid arteries of lps without cit treated mice. conclusions. cit supplementation during murine sepsis rescues the enos-derived no production in carotid artery endothelial cells, providing a mechanistic base for the positive effect of cit supplementation on endothelial no synthase during endotoxemia. grant acknowledgment. objectives. investigated the mechanism involved in the clearance of bacteria observed after rpaf-ah treatment in sepsis model. mice were subjected to clp model, after min, the mice were treated with rpaf-ah. the cfu counts and measured of mediators were determined. results. the numbers of bacteria (cfu) recovered in the peritoneal fluid was inhibited in rpaf-ah treated group ( . / . ), suggesting a more efficient clearance of bacteria after rpaf-ah treatment. direct incubation of s. typhimurium, e. coli and s. aureus failed to affect bacterial growth indicating lack of a direct effect of paf-ah on bacteria. administration of rpaf-ah in ccr (receptor for mcp- /ccl ) deficient mice failed to increase bacterial clearance after clp, suggesting that mcp- signaling is involved in this phenomenon. rpaf-ah treatment also failed to increase bacterial clearance in inos deficient mice and no levels were found to be elevated ( . ± . / . ± . ) in peritoneal fluid of the mice treated with rpaf-ah after clp surgery. synergism for no production was also seen when macrophages stimulated with e. coli were treated with rpaf-ah+mcp- and correlated with better bacterial killing by macrophages. peritoneal macrophages from knockout mice for mcp- , stimulated from lps+ifn inhibited no levels when compared to wt mice ( . ± . / . ± . ). this results indicating that, excessive mcp- favors macrophage production of no and hence the ability of macrophages to deal with invading bacteria. conclusions. we conclude that the increase in bacterial clearance is important for the protective effect of rpaf-ah in sepsis and that exist a signaling involving mcp- /ccl and no in this system. introduction. disturbances within the microcirculation represent an important factor in the pathogenesis of multiple organ dysfunction during systemic inflammation and sepsis [ ] . dehydroepiandosterone (dhea) has immunomodulatory effects and improves survival in several animal models of trauma, hemorrhage and sepsis but also causes potent vasodilatation [ ] . to maintain efficient microcirculation we combined dhea with sodium orthovanadate (sov), which augments vascular contraction. furthermore, sov has been identified to attenuate tissue injury and improve survival related to inflammatory response [ ] . objectives. we investigated whether the combined administration of dhea and sov has beneficial effects to microcirculation in experimental sepsis. we divided sixty male lewis rats into six groups: control group; ethanol (solvent) treated control group; dhea ( mg/kg) + ( . mg/kg) treated control group; endotoxemic group (lps mg/kg); dhea + sov treated endotoxemic group; dhea ( mg/ kg) + sov treated endotoxemic group. two hours after lps challenge we performed intravital fluorescence microscopy of the intestinal wall in order to study leukocyte adhesion and functional capillary density (fcd). tnf-a, il- a, il- and infc, gm-csf and mcp were measured at baseline and following h of endotoxemia in all experimental groups. in comparison to untreated rats subjected to endotoxemia the treatment with dhea (both dosages) and sov resulted in a significant reduced number of adhering leukocytes in intestinal submucosal venules. furthermore, the mucosal functional capillary density was significantly improved. we did not identify any changes in cytokine plasma levels. conclusions. the study demonstrated beneficial effects of combined treatment with dhea and sov within the intestinal microcirculation in experimental endotoxemia. concomitant administration of sov permitted to reduce dhea dosage and prevent potential vasodilation without affecting anti-inflammatory dhea action. . spronk pe, zandstra df, ince c: bench-to-bedside review: sepsis is a disease of the microcirculation. crit introduction. sepsis is a disease of the microcirculation and impairment of the intestinal microcirculation during sepsis may cause a breakdown of gut barrier function thus releasing bacteria and their toxins into the systemic circulation [ ] . consequently, the protection of the intestinal microcirculation represents a pivotal therapeutic target in severe systemic inflammation. cannabinoids that interact with cannabinoid receptors (cb r and cb r) have been shown to have immunomodulatory properties in in vivo and in vitro studies and the endocannabinoid system has been shown to be involved during systemic inflammation [ ] . objectives. the aim of the present study was to examine the effects of cb receptor modulation on the intestinal microcirculation in experimental sepsis (endotoxemia) using intravital microscopy (ivm). we studied four groups of animals (lewis rats, n = per group): healthy controls (con), endotoxemic animals ( mg/kg lipopolysaccharide; lps), endotoxemic animals treated with cb agonist, hu ( mg/kg iv), and endotoxemic animals treated with cb antagonist, am ( . mg/kg iv). intravital microscopy of the intestinal microcirculation was performed following h lps/placebo administration. leukocyte adhesion and functional capillary density (fcd) were measured offline in a blinded fashion. results. following h of endotoxemia, a significant increase of leukocyte adhesion in the intestinal submucosal venules (e.g., v venules: con . ± . n/mm , lps . ± . n/mm , p\ . ) was observed. capillary perfusion of the muscular and mucosal layers of the intestinal wall was significantly reduced (e.g., circular muscular layer: con . ± . cm/cm , lps . ± . cm/cm ). treatment of endotoxemic animals with the cb receptor agonist, hu , further increased leukocyte adhesion (v venules: . ± . n/mm ), whereas cb receptor inhibition by am significantly reduced leukocyte activation (v venules: . ± . n/mm ) and restored capillary perfusion (circular muscular layer: . ± . cm/cm ). conclusions. the data support the hypothesis, that cb receptor signalling is involved in the impairment of the intestinal microcirculation during sepsis. blocking cb receptor signalling reduces leukocyte activation and improves capillary perfusion in acute endotoxemia in rats. the long-term effect of modulating cb receptors in more clinical sepsis models needs further investigation. [ ] . this study compares dobutamine and levosimendan for the treatment of circulatory failure in septic shock and assesses survival benefits. objectives. in this controlled randomized doubleblinded study anaesthetized and ventilated pigs ( . ± . kg) were enrolled after approval by the local governmental commission. methods. by continuous infusion of endotoxin (escherichia coli serotype :b , sigma-aldrich; . ± . lg/kg/h) over a time period of . ± . h, septic shock was induced. hemodynamic stabilization was performed by either use of the vasopressor norepinephrine alone (control group; n = ) or in combination with levosimendan ( . lg/kg/min; n = ) or dobutamine ( . lg/ kg/min; n = ). in a setting of h of measurements and treatment heart rate (hr), map, central venous pressure (cvp), pulmonary artery pressure (mpap) and cardiac output (co) were recorded continuously and evaluated hourly. beside norepinephrine requirement and mixed venous oxygen saturation (svo ) mean survival time and survival rate within the measurement period were analysed. results. after endotoxinemia septic shock was marked by reduction of co and svo [p \ . ]. mean survival time and survival rate were superior in levosimendan treated animals ( table ). norepinephrine consumption was lowest in the levosimendan group. after h, co of surviving animals was highest in the levosimendan group and statistically different compared with the control group. comparison of parameters hr, map, cvp and mpap showed no differences between treatments. conclusions. the complementary use of the calcium sensitizer levosimendan provides potential survival advantage in endotoxemic septic shock. beside an increase in co, improvement of regional organ perfusion or protection could be an explanation and has to be shown by further analysis. reference(s methods. the study group consisted of patients with shock on vasopressor support and control group had normotensive patients. arterial and capillary samples were taken simultaneously and were tested immediately at the bedside. the results of the paired measurements were analysed as a scatter plot by bland and altman method and were expressed as a correlation coefficient. values were considered to disagree significantly when the difference exceeded %. results. mean arterial and capillary sugars (mg/dl) in study and control groups were . ± and . ± . , and . ± . and . ± , respectively. on bland-altman analysis, % in study group and % in control group were out of range (acceptable limit \ %) [ figures , ] . correlation between capillary and arterial values was less in the study group (r = . , p . vs. r = . , p \ . ). in addition, the disagreement between capillary and arterial values was more than % in % of the patients in the study group vs. % in control group (p = . ) (iso standard \ %). conclusions. capillary blood glucose monitoring can be applied reliably to patients in icu. however, caution must be exercised in patients with shock in whom arterial blood may be preferred. rd esicm annual congress -barcelona, spain - - october objectives. our primary objective was to evaluate the safety and efficacy of a single oral high dose vitamin d supplementation in an intensive care setting over a one-week observation period. methods. , iu (corresponding to . mg) of cholecalciferol (d) dissolved in ml herbal oil or matched placebo (pbo) were given enterally (via nasogastric feeding tube or swallowed) to patients with vitamin d deficiency [ (oh)d b ng/ml] in the medical icu. results. baseline characteristics including age, sex and saps ii were balanced between the two groups (mean age ± years, % male, saps ii ± ). mean serum (oh)d levels at baseline were ± ng/ml in both groups. the mean serum (oh)d increase in the intervention group was ng/ml (range - ng/ml). two patients showed a small ( ng/ml) or no response ( ng/ml) attributable to gastrointestinal dysfunction after prolonged hypoxia and gastrointestinal gvhd after allogeneic stem cell transplantation. the time course of the (oh)d response is given in figure . introduction. considerable controversy has emerged as to whether tight glucose control (tgc) is warranted in all critically ill adult patients. recently, a new blood glucose upper limit ( mmol/l) has been assessed as more appropriate. rather than blood glucose target ranges, algorithms used to achieve tgc should be numerically evaluated before initiating clinical trials (preclinical validation test). our purpose was to assess performances of tgc algorithms in realistic virtual icu patients. we compared numerically the nice-sugar algorithm (n-s) and the cgao system (cgao) used in the ongoing cgao-rea study [clinicaltrials.gov, id:nct ] . a set of virtual patients constituting the test bench was built with ) real data coming from patients controlled with cgao before starting cgao-rea and ) a non-linear pharmaco-dynamic glucoseinsulin system model where patient endogenous glucose clearance and insulin-sensitivity were time varying parameters. in order to anticipate how algorithms would manage glycaemic control in clinical settings, delayed controls and inaccuracy of glucometers were implemented. the overall performance of each algorithm over the whole stay was assessed according to standard scores. results. the percentage of time in the target range [ . - . mmol/l] with n-s was less than % for almost all patients. in insulin-sensitive patients, glycemic fluctuations and sometimes severe hypoglycemia are induced by n-s (fig. ). the mean time in the target range with cgao was about % and variability scores were significantly lower than with n-s. mean glucose and standard deviations were always lower with cgao than with n-s. a numerical test bench constituted of realistic virtual icu patients, whose features were defined from real data obtained in patients under glycemic control, enabled to determine the best algorithms candidate for further evaluation in clinical settings. according to this approach, the algorithm used to achieve tgc in nice-sugar would not have been selected for such a large clinical trial while cgao reached the first validation step in simulation. we recommend that further glucose control studies focus not only on the target range but also on the algorithmic properties. introduction. there has been much debate in recent years about the appropriate level of blood glucose for intensive care patients with proposals of different levels of glucose control using insulin infusions. one risk of intensive glucose control is hypoglycaemia and this has been proposed as a measure of quality of care given by delivering the protocol safely. the nice-sugar trial found that intensive glucose control increased mortality among adults in intensive care. objectives. the aim of our study was to record hypoglycaemia and study it's relation to insulin therapy. insulin therapy on our unit follows the recommendations of the nice-sugar trial. methods. hypoglycaemia was recorded as a blood glucose level\ mmol/l. levels were detected using the blood gas analyser (radiometer m). data was recorded at the time of hypoglycaemia to provide an explanation using the innovian system which is the paperless patient record system on our unit. data was obtained over a period of months between october and december . data recorded included adverse events which were defined as worsening shock and/or increasing inotropic support. feeding status at the time of hypoglycaemia was recorded. results. there were a total of admissions over this period and there were a total of , blood glucose measurements. incidents of hypoglycaemia were recorded, of which patients were on insulin and were not. of the patients who were on insulin, had adverse events at the time of hypoglycaemia. all these patients died within h of the adverse event. all except one was on full feed. the others had minimal feed due to poor absorption. of the patients who did not have adverse events, were discharged and one died days after the hypoglycaemic event due to worsening sepsis. of the patients on insulin, there were iatrogenic errors where feeding was stopped and the insulin was left on. none resulted in any adverse outcome for the patients. of the patients who were not on insulin therapy, had adverse events at the time. died within h of the adverse event and died days later. the remaining patients were discharged. none of the patients were on full feeding protocol. conclusions. our findings suggest that hypoglycaemia in our unit is not primarily related to insulin therapy. it is related to adverse events and possibly inappropriate feeding at the time of hypoglycaemia. hypoglycaemia, in the absence of insulin therapy, is associated with a poor outcome. use of hypoglycaemia as a quality indicator should be interpreted with caution. introduction. vitamin d deficiency seems increasingly prevalent. pleiotropic effects of vitamin d like immunomodulation and effects on muscle strength may be of special importance to critically ill patients [ ] . however, vitamin d deficiency has only been studied in small and selected groups of icu patients [ ] . objectives. to prospectively determine the prevalence of vitamin d deficiency in winter and summer and relate vitamin d status to outcome in cohorts of critically ill patients. results. vit d was measured in patients admitted in winter and patients admitted in summer (table ). mean vit d was significantly lower in winter than in summer. in winter, % was deficient, % severely deficient. in summer, % was deficient, % severely deficient. predicted mortality was higher in winter and higher in vit d deficient patients. observed mortality was lower than predicted in all groups, but not different between groups. including both vit d and season in a multiple regression analysis, winter (p = . ) and not vit d (p = . ) was related to predicted mortality. introduction. glucagon-like peptide- (glp- ) lowers blood glucose via stimulation of insulin and suppression of glucagon secretion, as well as slowing gastric emptying. we have previously shown that exogenous glp- attenuates hyperglycaemia in non-diabetic critically ill patients [ , ] . however, islet cell function in critically ill diabetic patients may be so disturbed that pharmacological doses of glp- have no effect in this group. objectives. the aim of this study was to evaluate the effect of exogenous glp- on glycaemic excursions during intraduodenal nutrient infusion in critically ill patients with preexisting type- diabetes mellitus. methods. nine critically ill, mechanically ventilated, patients with pre-existing type- diabetes ( m: f, age ± years, hba c . % ± . %, bmi ± kg/m , apache ii on day of study ± , days in icu on day of study ± ) received iv infusions of glp- ( . pmol/kg/min), and placebo, from t = - min on separate days in a randomised, double-blind, fashion. between t = - min a liquid nutrient (ensure) was infused intraduodenally at a rate of kcal/min via a naso-enteric feeding catheter. blood glucose concentrations were measured by glucometer at min intervals. data are mean±sem and comparisons are using student's t test. results. prior to the commencement of iv infusions there was no difference in blood glucose between the groups (at t- min: glp- : . ± . mmol/l vs. placebo: . ± . mmol/ l; p = . ). during fasting, glp- had no effect on glycaemia (at t = min: glp- : . ± . mmol/l vs. placebo: . ± . mmol/l; p = . ). however, glp- attenuated the overall glycaemic response to the nutrient (auc - min : glp- : , ± mmol/l.min vs. placebo: , ± mmol/l.min; p \ . ), as well as the peak blood glucose (glp- : . ± . mmol/l vs. placebo: . ± . mmol/l; p \ . ) conclusions. exogenous glp- is effective in reducing the glycaemic excursions that occur with enteral nutrient critically ill patients with pre-existing type diabetes mellitus. these data indicating that further studies using glp- , or its analogues, are warranted in this group. , , , , whilst raising concerns regarding an increased risk of hypoglycaemia. , , . locally most units adopt a protocol that reflects the practice of the original study. objectives. this study was conceived due to concerns around the safety of tight glycaemic control (tgc). our objectives were to measure adherence to our local policies and ascertain our true rates of hypoglycaemia. methods. this study was designed as a retrospective audit on four critical care units in the cheshire and mersey critical care network. each site used the same audit tool but adapted it to allow for differences in local practice and protocols. data pertaining to the prescribing and administration of insulin was collected daily over a week period (the time of data collection varied from day to day). the doctors and nursing staff were unaware of the audit and the data was collected by the ward pharmacist who suggested modifications to therapy if it was deemed inappropriate or unsafe. results. patient days worth of data was collected with blood glucoses checked in this period. % of patients receiving insulin had insulin prescribed. only % of blood glucoses were within the target range set by the local protocol. however, of all the results only . % were ''low'' as defined by the local protocol, and only . % ( / ) were hypoglycaemic episodes as defined in the greet van den berghe paper of (\ . mmol/l). conversely, . % were above the target range. in the trusts that recorded how many of these levels were[ mmol/l (a proposed alternative upper limit), the rates were and %. in response to a blood glucose the policies suggest dosage adjustments/maintenance. on only % of occasions were the adjustments made correct. insulin infusions appeared to be managed safely by nursing staff. insulin, if given, was always prescribed and hypoglycaemia (blood glucose \ . mmol/l) occurred on only one occasion. although safe, adustments often didn't follow the protocols and the patients' blood glucose were within the target range only % of the time, potentially negating many of the perceived benefits of tgc. reasons for non-compliance with the protocols was difficult to objectively establish reference(s). introduction. diabetes mellitus has been associated with an increased risk of adverse outcomes after coronary artery bypass grafting. hemoglobin a c is a reliable measure of long-term glucose control. it is unknown whether adequacy of diabetic control, measured by hemoglobin a c, is a predictor of adverse outcomes after coronary artery bypass grafting. material and method. we evaluated consecutive diabetic patients who underwent primary, elective coronary artery bypass grafting at the anadolu medical center. hba c levels of all patients with diabetes mellitus were measured and value of % or greater was used as a threshold for uncontrolled hyperglycemia. all the peroperative variables were recorded and then, statistically evaluated. the statistical analysis was realised by t test for parametric variables and chi-square test for nonparametric variables. results. there were consecutive patients that underwent elective coronary artery bypass graft surgery between january and april . among them, patients had diabetes mellitus and others not. there were no significant differences between groups regarding each adverse outcomes (table ) . although, ( . %) of total surgical site infection in patients had been seen in diabetic patients, there were also no significant differences between groups regarding the rate of infections (table ). there was no early postoperative mortality in diabetic patients. insuline treatment (iit) , by implementing a completely nurse driven protocol as in the leuven i study, to achieve tight glucose control in our -bed medical(cardio-)surgical icu and non-ventilator beds. in the last year, the benefit of iit and the possible detrimental effects of hypoglycemia on survival have been heavily debated. objectives. the goal is to analyze our daily practice in all icu patients and compare this with the intensive treated groups from the leuven , visep en nice-sugar trial. methods. we compared mean morning blood glucose levels and the percentage of patients who had a hypoglycaemia, defined as glucose below . mmol/l, from to . the frequency of control and the insulin dosage was comparable to the leuven study. enteral or parenteral feeding was started at admission. no standard intravenous glucose was used. glucose was measured with arterial blood samples on the abl flex radiometer as poct. results. in our patients, the mean morning blood glucose was higher than in the leuven study and comparable to the visep and nice-sugar. the percentage of hypoglycemia on our icu was lower in comparison with the visep and nice-sugar. this may be explained by the availability of a poct on our icu which allows quick adjustments of the insulin dosage. conclusions. effective tgc with sprint resolved organ failure faster, and for a greater percentage of patients who had similar admission and maximum sofa scores, compared to a matched retrospective conventional control cohort. these morbidity reductions mirror the reduced mortality seen with sprint. these results suggest that reduced organ failure, assessed by sofa, is a fundamental element in reduced mortality when tgc is implemented effectively. introduction. tight glycaemic control was reported to reduce mortality in selected surgical critically ill patients and lowering of blood glucose (bg) levels was recommended as a means of improving patient outcomes ( ) . however, this approach has been linked with significant risk of hypoglycaemia. recently, several studies have confirmed significant associations between variability of bg levels and patient outcomes ( ). objectives. to evaluate the association between bg variability and hypoglycaemia in a mixed adult icu. methods. retrospective analysis of the prospectively collected and stored bg measurements over a year period, during which tight glycaemic control was targeted in all patients. every day we have calculated the bg coefficient variation as expressed by sd/mean bg level. we have divided the patients into low, medium and high variability groups ( - , - and [ , respectively) . hypoglycaemia was determined if bg was below . mmol/l. for statistical analysis chi-square test and pearsons correlation test was used. results. patients were admitted over the -year period, providing daily data points. bg variability was high in daily measurements ( . %), medium in ( . %) and low in ( . %). hypoglycaemia occurred in measurement points ( . %). hypoglycaemia was observed at all points ( %) when bg variability was high vs. . % when bg variability was medium and . % when bg variability was low and this difference was statistically significant (p = . ). we observed a significant correlation between increased bg variability and hypoglycaemia (r = . , p = . ). conclusions. increased bg variability as expressed by coefficient variation is associated with hypoglycaemia, when measured daily in a mixed icu population employing tight glucose control. decreasing the variability of the bg concentration may be an important dimension of glucose management. if reducing swings in the bg concentration is a major mechanism behind the beneficial effects of glucose control, it may not be necessary to pursue lower glucose levels with the associated risk of hypoglycemia. ). there were two major outliers which may skew the results in favour of the hypothesis. if these two results are removed (fig. ) the statistical significance remains strong (n v * p \ . ; **p = . ; ***p = . )). standard multiple regression analysis found the most useful predictors of t [mid] were 'time with aki' and 'serum urea' (beta coefficient . and . (p \ . ) respectively). crcl, serum creatinine and urine output did not add further predictive statistical power. conclusions. this study demonstrates a reduction in the hepatic metabolism of midazolam associated with aki. this effect is related most strongly to the length of time the patient has suffered with aki. our results are similar to the ncepod report. even with multiple recommendations by ncepod and the national institute for clinical excellence (nice) recognition of the critically ill remains poor. detection of organ failure risk is vital to implement preventative strategies. we found a delay in aki recognition and a lack of risk assessment. observations, included in admission protocols, were recorded, but investigations outside of these, were often absent. nice suggest management should be physiologically and not diagnosis based but few patients had a documented physiological plan. we suggest improving under and postgraduate education to increase awareness of aki. this could occur as an extension to the national, acute life-threatening events recognition and treatment course. an aki admission protocol may allow identification of at risk patients and instigate appropriate monitoring, investigation and management. improved ward based fluid monitoring and management would reduce deterioration. incorporation of a physiological monitoring plan on the icu observation chart may reduce preventable aki. there was no effect in patients with extensive stroke and high severity of a glasgow score ( - points in an observational prospective study, a total of patients who admitted during months in a medical and surgical intensive care unit and didn t have any recent history of renal replacement therapy were included in the study. ( %) of all patients was in aki (acute kidney injury) group according to the akin (acute kidney injury network) definition. the mean of age in aki group was more than non-aki ( . ± . , . ± . respectively; p \ . ); and had worse condition according to apache ii (acute physiology and chronic health evaluation ii) score ( . ± . vs. . ± . ; p \ . ). the aki patients stayed longer in icu rather than non-aki patients ( . ± . vs. . ± . days respectively; p \ . ); with more mortality rate ( . vs. %; p \ . ). also the mechanical ventilation days, time of vasoacive drugs and the use of dobutamin were more in aki group (p \ . ; p = . and p = . respectively). the aki was a significant predictor for mortality using the multivariate logistic regression (or adj = . ; %ci: . - . ); and had the same sensitivity as the apache ii score in prediction of mortality (sen. = . ). objectives. the purpose of this study was to evaluate renal function in children with congenital heart disease (chd) undergoing cardiac surgery with cpb. we conducted prospective, non randomized observational study at the tertiary care university children's hospital -bed surgical icu. study protocol was approved by hospital ethics commission. the study included patients with chd with body weight from . to kg (mean . ± . kg) and age from days to years (mean age months). there were patients with ventricular septal defect (vsd), patients had atrioventricular septal defect (avsd), two had total anomalous pulmonary venous drainage (tapvd), one had tetrology of fallot (tof), one had transposition of great arteries (tga), and one had aortic stenosis, requiring ross operation. urine was collected in the postoperative period during the first h after surgery for determination of clcr. the serum creatinine (scr) level was determined by jaffé s method (cobas analyzer, roche). harrison am et al. [ ] shows that estimated creatinine clearence (clcr) using schwartz formula does not accurately predict clcr. therefore we used standard formula for clcr calculations. urine output, inotrope score, duration of aortic cross clamping and cardiopulmonary bypass was recorded. we applied rifle criteria to assess renal functions, using clcr as a variable reflecting glomerular filtration rate (gfr). objectives. evaluate whether a real-time alert of worsening of rifle class, through the physicians' dect telephone system, would affect therapeutic interventions for aki and progression of rifle class. single centre, prospective intervention study during a -month period in our bed surgical and medical icu. three study phases were compared: a . -month control phase (con ) where physicians were blinded for the electronic alerts, a -month intervention phase where electronic alerts of worsening rifle class were made available to the physicians through the dect telephone system (int), followed by a second . month control period (con ). pasw statistics was used for statistical analysis and a double sided p value of . was considered as significant. at study entry, before and after to receive antioxidant or placebo concentration the blood was drawn, to posterior determination of thiobarbituric acid reactive species (tbars), protein carbonyls, total nitrite concentration and il- . results. the use of nac+dfx decreases oxidative damage parameters. patients at antioxidant arm have, despite not reaching statistical significance, a decrease on plasma il- levels h after the start of treatment. as observed to oxidative damage parameters, il- returned to the placebo levels after the end of antioxidant administration. the nitrite levels increased h after nac+dfx, returning to placebo levels and h. the incidence of arf using the rifle criteria was not significantly different in the two arms, and this was also true to a number of secondary end points, none of which showed significant differences between the treatment arms. analyzing the subgroups of the sofa score we observed at day a worse cardiovascular sofa in the nac+dfx arm ( . ± . vs. . ± . , p = . ) and a better renal sofa in antioxidant treated patients ( . ± . vs. . ± . , p = . ). conclusions. we demonstrated that nac + dfx administration was able to decrease plasma markers of oxidative damage and to a minor extend il- plasma levels. we believe that the use of antioxidants could be an alternative adjuvant therapy to prevent arf in critical ill patients with hypothension. table were found to be independent risk factors for postoperative aki: objectives. we aimed to access prospectively whether the use of antioxindants has beneficial effects in renal function of critical-ill patients undergoing imaging studies with intravenous radio-opaque agents (ivca). patients were recruited from those hospitalized in a tertiary intensive care unit between and . inclusion criteria were: a) requirement for imaging studies with ivca b) no use of renal replacement therapy. patients were randomized to receive before and after imaging, either antioxidants (n-acetyl-cysteine , mg and ascorbic acid g and ml ns . %) (sg) or cc ns . % (cg). renal function was assessed by serum levels of creatinine and cystatin c assessed before and at , h following administration of ivca. patients were followed until discharge. systatin c was measured by elisa. conclusions. the results of this study suggest that the use of preventive antioxidant therapy may protect critical-ill patients from contrast-induced nephropathy. our preliminary results have to be confirmed in larger cohorts. acute coronary occlusion is the leading cause of cardiac arrest. because of limited data, the indications and timing of coronary angiography and angioplasty in survivors of out of hospital cardiac arrest are controversial. objectives. using data from the parisian region out of hospital cardiac arrest (procat) prospective registry, we performed an analysis to assess the impact of an invasive strategy on hospital survival. between january and december , survivors of out of hospital cardiac arrest were referred to a tertiary center in paris, france. in survivors with no obvious extra-cardiac cause of arrest, an immediate coronary angiogram followed if indicated by coronary angioplasty was performed at admission. the prognostic value of pre-hospital and in-hospital characteristics on in-hospital mortality was evaluated using logistic regression analysis. results. at least one significant coronary artery lesion was found in ( %) therapeutic hypothermia has been shown to improve survival and neurological outcome in patients who have suffered out-of-hospital cardiac arrest and in whom the initial rhythm was ventricular fibrillation (vf) [ , ] . international guidelines now recommend the use of therapeutic hypothermia as part of post-resuscitation care in patients fulfilling the above criteria [ ] . objectives. we surveyed current practice regarding the use of therapeutic hypothermia for post resuscitation care in northern ireland (ni) intensive care units. a questionnaire was devised, reviewed and agreed by each author prior to posting to the lead clinician in each of northern ireland's adult intensive care units. a % response rate was obtained. we asked about the existence of a protocol for cooling, which patients were cooled, duration of cooling, by what particular method(s) cooling was achieved and how temperature was monitored during cooling. results. out of ( %) adult icus in ni institute therapeutic hypothermia routinely as part of their post-resuscitation care. only out of the units ( %) have a protocol for institution and maintenance of hypothermia. all units that utilise hypothermia do so regardless of the initial cardiac rhythm. out of ( . %) icus target a temperature of - °c with out of ( . %) targeting a temperature of - °c. all units utilise surface cooling methods with out of ( %) also using cold intravenous fluids occasionally. out of ( %) units cool for - h, ( . %) unit - h and unit - h. all units use more than one method of temperature monitoring during cooling. all units sedate patients during cooling and out of ( . %) also routinely curarise patients during cooling. the units that do not currently use therapeutic hypothermia cited lack of resources/funding as the main obstacle to adopting this evidence based practice. conclusions. the practice of therapeutic hypothermia post cardiac arrest has been embraced by the majority of icus in ni. there appears however to be variation in the target temperature and duration of hypothermia once instituted. icus that cool patients appear to do so regardless of initial cardiac rhythm. regional protocolisation of this therapeutic modality may help standardise practice across ni icus. reference(s we compared our data with those from retrospective audit [ ] . the method of th was via surface cooling technique together with cold intravenous saline infusion but not ivcd. total patients presented with cardiac arrest: underwent th ( ooh vf/vt and ooh non-vf/vt). in , there was an overall improvement in adherence to the audit standards, as shown in table : table : table hospital survival rate of th % gcs of the survivors at icu discharge / ( %) / ( %) / ( %) / ( %) conclusions. introduction of ivcd has led to an improved compliance with local and ilcor th guidelines. although the total numbers are small, there has been an increase in the patients discharged with gcs from our icu using ivcd. there are areas that require further improvement, notably the time to reach target temperature and prevention of rebound hyperthermia. work continues on protocolised evaluation of neurologically damaged survivors. rd esicm annual congress -barcelona, spain - - october s target temperature management after out-of-hospital car-diac arrest, an international, multi-centre, randomised, parallel groups, assessor blinded clinical trial-rationale and design of the ttm-trial n. nielsen , , and the ttm-trial study group helsingborg hospital, department of anesthesia and intensive care medicine, helsingborg, sweden, lund university, department of clinical sciences, section of anesthesia and intensive care medicine, lund, sweden introduction. experimental studies and previous clinical trials suggest an improvement in mortality and neurological function with induced hypothermia after out-of-hospital cardiac arrest (ohca). previous trials have included highly selected populations and the optimal target temperature is not known. objectives. to evaluate differences in efficacy and safety with target temperature management at and °c for h after ohca of presumed cardiac cause. methods. intervention: patients will be managed with h of temperature control at versus °c according to randomisation. temperature control will be delivered with temperature management equipment at the discretion of the trial sites. to facilitate cooling, when applicable, and to stabilise the circulation all patients will be treated with ml/kg of crystalloid infusion ( °c or room temperature according to treatment arm). design. randomised trial with : concealed allocation of ohca patients to temperature control for h at versus °c with blinded outcome assessment. sample size is based on a relative risk reduction of % with a risk of type- error of % and a power of % with a % loss to follow-up. conclusion. this study demonstrated that health care professionals, despite guidelines, are hyperventilating simulated cardiac arrests patients. suboptimal ventilation was a problem across all the backgrounds investigated; although doctors performed best here, they were still found to be hyperventilating to an unacceptable level. hyperventilation has a number of deleterious physiological effects and is associated with poor outcomes. increased training, awareness and recertification may be the answer, and certainly improves short term compliance with guidelines. however, these effects may be short lived and other changes may be needed. a reasonable course of action may be the use of paediatric ( l) self inflating reservoir bags as a first line device. this simple measure may ensure delivery of more guideline consistent ventilation, independent of the level of experience. extracorporeal life support (ecls) has been proposed as the ultimate heroic rescue measure in prolonged cardiac arrest unresponsive to conventional cardiopulmonary resuscitation. ecls effectiveness in out-of-hospital cardiac arrest remains to be addressed. decision to discontinue cpr due to medical futility is based upon presumed prolonged anoxia, with existing guidelines for termination. however, even when ecls is implemented, failure to maintain stable hemodynamic conditions due to marked capillary leak frequently results in patient's death. to evaluate the usefulness of routine laboratory parameters in the decision to treat refractory cardiac arrest patients with ecls . methods. sixty-six adults with witnessed cardiac arrest of cardiac origin unrelated to poisoning or hypothermia undergoing cardiopulmonary resuscitation without return of spontaneous circulation (duration: min [ - ], median, [ - %-percentiles]) were included in a prospective cohort-study. ecls was implanted under cardiac massage, using a centrifugal pump connected to a hollow-fiber membrane-oxygenator, aiming to maintain ecls flow c . l/min and mean arterial pressure c mmhg. introduction. due to the human lifespan increasing, people are living longer. cardiac arrest (ca) in old people could be seen as a natural end of life process and cardio-pulmonary resuscitation (cpr) in this setting as a disturbance. therefore, the question of prognosis in patients has been raised when performing cpr in the elderly. data from the s found month mortality in % of patients over suggesting that cpr in elderly people could be futile ( ) . the recent progresses in the management of resuscitated patients, such as mild hypothermia, were not evaluated in patients older than years ( , ) . in a recent study, we found that age [ years was an independent pejorative prognostic factor ( ) . hence there is virtually no data of prognosis factor of elderly patients after ca. our aim was to determine the prognosis factors in patients older than years successfully resuscitated. methods. all patients admitted to icu for ca with successful rosc were consecutively included between and . ca data were prospectively entered in a registry according to utstein recommendations. patients were managed following standardized procedures. good prognosis was defined as cpc or at icu discharge. factor associated with a good outcome were identified using multivariate analysis. results. among , patients admitted for ca, were older than years. median age was . years ( - ), ca was from cardiac origin in % of patients and . % had a vt/vf initial rhythm. mean no flow (nf) and low flow (lf) were . (± . ) and . min (± . ). mean blood lactate and creatinine level at admission were . mmol/l (± . ) and lmol/l (± ). . % of patients presented post-resuscitation shock (prs) and . % were treated with hypothermia. conclusions. ca in elderly patients is associated with an in-icu % good outcome rate. this should promote the cpr in non-severely disable elderly patients with ca regardless of their age. we plan to collect the -month mortality and the functional status of survivors. introduction. post-resuscitation phase is often characterized by a ''sepsis-like'' syndrome, which may be associated with the development of organ dysfunction. microcirculatory abnormalities play a key role in sepsis-related organ failure; however no data are available on microvascular function after cardiac arrest (ca). objectives. the aim of this study was to investigate peripheral microcirculation during and after therapeutic hypothermia (th) in ca patients. methods. this prospective, observational study included patients treated by th after ca. sublingual microcirculation was evaluated using sidestream dark-field (sdf, microscan, the netherlands) videomicroscopy at hypothermia and normothermia in all patients. at least images of s each from separate areas were recorded at each time point and stored under a random number to be analyzed, using a semi-quantitative method, by an investigator blinded to time and condition. thenar oxygen saturation (sto ) was measured using a tissue spectrometer (inspectra ; hutchinson, usa). a vaso-occlusive test was performed at hypothermia and normothermia by rapid inflation of a pneumatic cuff around the arm to evaluate sto reperfusion rate, reflecting microvascular reactivity. results. compared to hypothermia, measurements at normothermia showed a significant increase in functional capillary density (fcd) from . ± . to . ± . n/mm (p = . ), the proportion of small perfused vessels (ppv) from ± to ± % (p = . ) and mean flow index (mfi) from . ± . to . ± . (p = . ). fcd and ppv values were significantly correlated with body temperature. sto reperfusion rate was largely decreased when compared to healthy volunteers, but it did not change over the study period (from . ± . to . ± . %/sec) and showed large inter-individual variability. the same was found for sto (from ± to ± %). conclusions. mild hypothermia is associated with decreased fcd and ppv in the sublingual area when compared to normothermia. microvascular reactivity is decreased but changes are unpredictable. introduction. acute posthypoxic myoclonus (phm) occurs in deeply comatose patients, soon after a hypoxic episode. it is characterized by generalized, severe body jerks with violent flexor movements, but more focal myoclonus is reported too ( ) . acute phm and status myoclonus are considered to have a poor prognostic outcome ( , ) . although the cerebral cortex is known to be the most common origin of myoclonus in ambulant patients ( ) , the origin of acute phm is uncertain ( ) . to determine whether acute phm originates from damage in cortical or subcortical structures. for this study patients with myoclonus in the first h after admission were selected from the propac ii study, a prospective cohort study including patients admitted after cpr and treated with hypothermia. exclusion criteria: pre-existing disease with life expectancy\ months and severely disability before cpr. baseline characteristics were used from the main database. additional data of eeg and ssep recordings made after rewarming were collected. eegs were evaluated for presence of epileptic activity, status epilepticus, generalized periodic discharges, burst suppression pattern, iso-electric or low voltage amplitudes and reactivity of the background pattern. data collected from sseps: n potential, giant potential (defined as a potential five times the size of a normal potential) and p /n amplitudes (done by jhk). the glasgow outcome scale (gos) was used to assess outcome after months, poor outcome was defined as a gos of - (death, vegetative state, severe disability), good outcome as a gos of - (moderate disability, good recovery). . from a total of patients included in the propacii study, ( %) patients developed myoclonus. baseline characteristics of this group: age , % male, time to rosc min, primary cardiac arrest in patients, hypoxic arrest in . ssep recordings were available from patients. n potentials were present bilaterally in % ( ) and giant potentials were seen in % ( ) of the patients with a present n potential. eegs were made, epileptic activity was seen in % ( ) and a status epilepticus in % ( ), thus % of the eegs did not show any type of epileptic activity. good outcome was seen in % of the patients, poor outcome in %. mortality was %. conclusions. the results of this study show that acute phm is found in % of patients admitted after cpr and treated with hypothermia. it did not necessarily lead to a poor outcome, but we did not have information about the type of myoclonus. the available data seem to support the idea that the myoclonus originates mainly from subcortical structures, given the low number of patients with eegs showing epileptiform activity and sseps with giant potentials, which can be seen in cortical myoclonus ( ). introduction. the international liaison committee on resuscitation, the american heart association and the european resuscitation council recommend that mild therapeutic hypothermia improve neurological outcome in unconscious adult patients with return of spontaneous circulation (rosc) after out-of-hospital cardiac arrest (ohca) due to ventricular fibrillation (vf) or ventricular tachycardia (vt). in our intensive care unit (icu) we use mild hypothermia in all patients following cpr with successful rosc regardless of initial rhythm. in this study we compared the effect of mild therapeutic hypothermia at neurological outcome and mortality between the patients who had ohca due to vf or vt and them who had ohca due to a different initial cardiac rhythm as asystole or pulseless electrical activity. the study protocol was approved by the local ethics committee on human research. a total of patients were admitted to our icu with rosc after ohca between may and december . therapeutic hypothermia was initiated after admission in icu by intravenous infusion of cold saline ( °c , ml bolus) followed by intravenous cooling device (coolline catheter, coolgard alsius corporation irvine, ca, usa). the target temperature was °c maintained for h followed by slow active re-warming over a minimum period of h ( . °c per hour). intravenous anesthesia was induced in all patients by a combination of propofol and remifentanyl with dose adjustment as needed. to prevent shivering, patients received muscle relaxation by iv administration of sisatracurium every h. the primary end point was the neurological outcome at months according to the pittsburgh cerebral performance category (cpc). secondary end point was mortality at months. prehostital cooling procedures were not applied. nine of the patients ( %) of the group of the patients who had ohca due to vf or vt had favourable neurological outcome cpc or as compared with of ( %) of the group of the patients who had ohca due to a different initial cardiac rhythm. mortality at months was % ( of patients died) in the group of the patients who had ohca due to vf or vt as compared with % ( of patients died) in the group of the patients who had ohca due to a different initial cardiac rhythm. in patients who had ohca due to vf or vt mild therapeutic hypothermia inproves the neurological outcome and reduces mortality as compared with the patients who had ohca due to a different initial cardiac rhythm. objectives. we aimed to compare therapeutic hypothermia using either surface or endovascular techniques in terms of efficacy, complications and outcome at our institution, a bedded tertiary referral icu. a local research ethics committee reviewed the proposed study and waived the need for a full ethics submission, as the study met the national criteria for service evaluation. data were collected from patients undergoing therapeutic hypothermia following cardiac arrest over a . year period by retrospective casenote review and interrrogation of the carevue (phillips uk) database. therapeutic hypothermia was initiated in the icu using iced hartmann's solution, followed by either surface (n = ) or endovascular (n = ) cooling; choice of technique was based upon endovascular device availability. the target temperature was - °c for to h, followed by rewarming at a rate of . deg h - . the mean age was ± years; % of arrests occurred out of hospital, and % were ventricular fibrillation/tachycardia. endovascular cooling provided a longer time within the target temperature range (p = . ), less temperature fluctuation (p = . ), better control during rewarming ( . ), and a lower -h temperature load (p = . ). endovascular cooling also produced less cooling-associated complications in terms of both overcooling (p = . ) and failure to reach the target temperature (p = . ). after adjustment for known confounders, there were no differences in outcome between the groups in terms of icu or hospital mortality, ventilator free days and neurological outcome. conclusions. endovascular cooling provides better temperature management than surface cooling, as well as a more favorable complication profile. the equivalence in outcome suggested by this small study requires confirmation in a randomized trial. introduction. ventricular assist devices (vads) are successfully used in patients with end stage heart failure, usually as a bridge to transplantation or recovery, but increasingly as destination therapy as well. a major threat for patients with a vad is the frequent occurrence of, mainly thromboembolic, stroke, with a reported incidence of up to %. manufacture guidelines for anticoagulation therapy are based on relatively small observational studies and common sense rather than evidence, and as a consequence anticoagulation protocols vary widely between centers. objectives. the aim of this systematic review was to provide more evidence in order to determine the optimal anticoagulation protocol to prevent stroke in patients supported with a vad. a systematic search in pubmed and embase was performed in which we included all types of vads. all types of anticoagulation drugs applied to prevent thromboembolism were included and divided in three categories; heparin, coumarins and antiplatelets. we included references with a full text available, written in english, dutch, german or french, and which described patients with a stroke or tia. our primary outcome measure was defined as the onset of any type of stroke. two authors evaluated independently the results of this search; doubtful references were evaluated by two other authors. after critical appraisal articles were selected as relevant, which include cohort studies, case-control studies and trials, totaling patients with vad support between and . the mean age was years (range - ) and the mean duration of support was days ( - ). stroke occurred in - % patients supported by vad, with an incidence of - /patient-year. the majority of strokes occurred within the first year. six types of anticoagulation protocols were used that combines drugs from one or all three categories. most protocols used a combination of all categories ( , patients with a total follow up of , days) and had an average stroke incidence of . events/patient-years. the lowest average stroke incidence was reported in studies that used only antiplatelets ( . events/patient-years) and the highest in which only heparin was used ( events/patientyears). we could not detect a decreased risk for stroke in patients with vad support when coumarines or heparin were used instead of or in addition to antiplatelets. antiplatelets should be part of an anticoagulation protocol to prevent stroke in patients supported by vad. a.m. de la torre , c. marco , d.j. palacios , a. pedrosa , i. lopez de toro , v.a. hortigüela hospital virgen de la salud, toledo, spain objectives. to analyze the difference between two groups of patients with ich considering severity, treatment, evolution and mortality. methods. description retrospective study of admitted patients between st of january of to st of december and st of january of to st of december in the icu of virgen de la salud hospital (toledo) with the diagnosis of ich. there are patients in the group of - and patients in the groups of - without any difference of age. regarding comorbidity between the two groups no differences can be found regarding the previous presence of hta, but regarding diabetes and dislipemy, we do find a higher prevalence on the second group ( . vs. . %, p \ . and . vs. . %, p \ . respectively). reviewing the presence of anticoagulated patients, no differences of significance can be found, but a trend ( . vs. . %, p \ . ). regarding the location of the hemorrhage, the most frequent is the basal ganglia ( . vs. %), existing no differences amongst the two groups. we don't find differences either in the presence of a intraventricular component, whether it is neither supratentorial nor infratentorial. there are differences between the ich score of both groups with p \ . : with a score of ( . vs. conclusions. an increase in the comorbidity can be observed in the included patients, which can be due to a better screening of these pathologies. we also find that the ich score is higher than in the - sample, which is attributed to the admittance in the icu of patients with the ultimate goal of organ donations. in the evolution, it can only be observed a longer stay in patients from the second sample, likely because they are more serious patients with a higher ich score. the analysis of the two groups has not been conclusive when it comes to assessing the improvements that might have come out in these last years, although it is necessary a deeper analysis of the data. introduction. sodium dysbalances are frequent medical complications in patients with subarachnoid hemorrhage (sah). hyponatremia is more frequent but it is associated with better outcome than hypernatremia. the aim of this study was to observe differences in outcome between hyponatremic and hypernatremic patients with sah. we performed the prospective years study in incidence of hyponatremia (serum sodium \ mmol/l) and hypernatremia (serum sodium [ mmol/l) in patients (pts) with sah. we compared the incidence of cerebral complications, glasgow outcome scale (gos) upon discharge from the neurointensive care unit (nicu) and in mortality nicu. results. there were ( %) pts with dysnatremia, more patients had hyponatremia ( , %), less hypernatremia ( , %). between these groups there were no diferences in stay in nicu (p = . ), duration of dysnatremia (p = . ), fluid intake (p = . , ml/day), daily sodium intake (p = . , mmol/day) and fluid output (p = . , ml/day). hyponatremia was more frequent on admission (p \ . ) and connected with higher diuresis (p \ . ). hypernatremic pts received more antiedematic therapy (p \ . ). hypernatremia was arised in pts with significantly lower glasgow coma scale (p = . ). these pts had more cerebral complications (p = . ), worse glasgow outcome scale upon discharge from nicu (p \ . ) and higher mortality in the nicu (p = . ). conclusion. dysnatremia is frequent in patients with sah ( %). hyponatremia occurs more often, but hypernatremia is connected with worse outcome. objectives. to analyze clinical, epidemiologic and outcome differences and to identify predictor factors of mortality at discharge from icu of patients admitted after craneoencephalic trauma (cet) according to glasgow coma scale (gcs) score. observational prospective study of patients admitted in the intensive care unit (icu) after cet. we classified the traumatic brain injury, according to gcs score of b or c points groups. we analyzed clinical and demographic data during icu stay, as well as physiological, functional and emotional data measured with paecc scale (project for the epidemiological analysis of critical patients) at discharge from icu. qualitative variables are expressed as a percentage and quantitative variables as mean and standard deviation. we used chi test, t-student and multivariate analysis as required with a maximum alpha error of %. we analyzed patients, . % male. at admission . % had gcs b . traffic accidents ( . % in gcs c and . % in gcs b ) were the most frequent cause of cet. there was a higher rate of out hospital hypotension in the gcs b group (p = . , or . , % ci . - . ). cranial computed tomography (ct) scan findings in the gcs c group were diffuse injury i and ii ( . %) after marshall classification versus . % in the gcs b group (p = . ). fewer complications were detected in patients in the gcs c vs. gcs b group ( . vs. . %, p = . , or . , % ci . - . ). icu mortality rate was significantly lower in the gcs c group than in the gcs b group ( . vs. . , p \ . ). predictors of mortality were gcs at admission (p = . ), ct findings type iii, iv and v (p = . , . and . respectively), complications (p = . ), tracheotomy (p = . ), days on ventilator (p = . ), apache ii (p = . ) and the length of icu stay (p = . ). best overall score in paecc questionnaire at discharge from icu was better in the gcs c vs. gcs b group. ( . ± . vs. . ± . , p = . ). conclusions. patients with lower gcs at admission presented higher rate of prehospital hypotension, more severe ct findings, more complications at icu, worse physiologic, functional and emotional outcome, and higher rate of mortality, than patients with gcs c . factors associated with increased mortality were coma level, type of findings in ct, complications, prolonged mechanical ventilation, length of icu stay, apache ii, and the need for a tracheotomy. objectives. the aim of our study was to estimate the influence of hyperhaes infusion on haemodynamic regulation. we examined patients with severe brain trauma (gcs score \ , sedation, artificial ventilation). the bp, stroke volume (sv) and their variability (bpv, svv) were determined by the bioimpedance method. additionally we determined the peripheral pulse (pp) and its variability (ppv) using plethysmography curve registration. special attention were paid to the p ( . - . hz) and p ( . - . hz) bands of bpv, svv and ppv, connected with volume state, breathing, and autonomic regulation, especially baroregulation. all the comparisons were made before and after min. of the infusion of hyperhaes ( ml). all patients had the autonomic dysfunction: the waves of baroregulation (p ) had low power compared with healthy. hypovolemia was moderate: sv ( ± . ) and pp ( ± . ) were slightly decreased, but bp were ± . mmhg. the bp increasing was registered as the first reaction on the infusion of hyperhaes ( ± . mmhg). the same time pp increased more then twice and became ± . , and p of ppv decreased from ± . to ± . , that reflected the improving of the volume state. although sv did not rise significantly, the increasing of p were estimated in svv, as a marker of the baroregulation restoration. conclusions. the infusion of hyperhaes in severe brain trauma not only decrease the range of hypovolemia, but restore the baroregulation as a significant part of autonomic regulation, needed for cerebral perfusion support. introduction. continuous measurement of intracranial pressure (icp) using intraparenchymal sensors has become part of the standard management of patients at risk of developing intracranial hypertension. whilst reliability has been explored previously little is published on the accuracy of depth to which the sensor is placed. a difference in sensor location has been shown to affect the reliability of icp readings and could impact negatively on patient management ( ). to determine whether icp sensors (codman, j&j) placed by neurosurgical staff were within the optimum depth of cm from the cortex. methods. consecutive patients were identified from a prospectively collected neuro icu database who had had a ct of the head (cth) performed whilst an icp sensor was in situ during . the depth of the sensor tip on cth was measured and patients were stratified according to whether they had surgery or no surgery to determine any differences between open and percutaneous placement. of the icp sensors ( %) were placed deeper than cm. the greatest incidence of deep placement was in surgical patients / ( %) and in craniotomy patients % of these were deeper than cm conclusions. this investigation has shown that the majority of patients admitted to our neuroicu have less than optimally placed icp sensors. inappropriately deep sensors appear more common in surgical patients, particularly following craniotomy. the impact of this on patient outcome is unknown and would require further study. this study has highlighted we need to implement new methods to improve the accuracy of our icp sensor placement. graduated marks on the sensor sheath during manufacture may assist accurate placement. conclusions. if icp is largely used, it remains below %. % of the cases have been monitored with at least techniques suggesting an acceptance tendency for a multimodal monitoring. among these techniques, the control of pco seemed considered important as the use of tcd to assess perfusion and vessel tone. on-going analysis of these data will provide information on the therapeutic strategy performed and the impact on outcome. introduction. raised intracranial pressure (ricp) can be evaluated sonographically by measuring the optic nerve sheath diameter (onsd). a wide variation in the threshold measurement of onsd for ricp has been reported in literature. it is likely that exaggeration of the hypoechoic edge artifact around the dura by high frequency ([ mhz) linear transducers and uncertainty over whether to measure -mm behind the papilla or behind the globe (posterior margin of sclera) could have resulted in such differences. to determine the optimal site of measurement of onsd by correlating it with ricp determined clinico-radiologically. we also evaluated if different sonographic appearances of the onsd could be used qualitatively to determine the presence or absence of ricp. methods. initially, in order to precisely delineate the anatomical dura sonographically and assess optimal cursor placement, cadaver orbital preparations were studied before and after subarachnoid fluid insufflation. scans were then done by a single sonographer using a - mhz linear transducer on healthy volunteers and patients admitted to the medical/ neurosurgical intensive care units. onsd was measured at locations; -mm behind the papillae and -mm behind the globe. in each location measurement was made within the anatomical dura and another between the echogenic margins of retrobulbar fat as described in literature. four patterns (fig. ) of the nerve sheath were identified based on the appearance of the csf space and edge artifact. ricp was diagnosed by clinically correlated computed tomography of the brain. an independent sample t test was done to correlate measurements with ricp. classification of optic nerve sheath appearances results. / ( %) scans were done on patients with ricp. all measurements independently correlated with ricp (p \ . ); albeit cut-offs differed substantially ( table ) . the presence of a type pattern (fig.) in both eyes strongly suggested ricp ( % positive predictive value) whilst its absence in both eyes ruled out ricp ( % negative predictive value). methods. three years after the introduction of the concept of bs in our icu, a questionnaire was sent to people directly involved in the nursing of critically ill patients to study the current practice during the previous month. responses were received from persons, a % response rate. ( %) persons had practiced bs. only ( %) employees used calming bath and ( %) an invigorating bath. guided oral care and guided suction was performed respectively by ( %) and ( %) nursing persons. orientative positioning was used by ( %) nurses. everybody is very satisfied with the instruction manual which can be found in each room. ( %) persons estimated to be well informed about bs. others wanted more practice course and training at the bedside. conclusion. pattern suggested an increasing interest in bs since its introduction. initial touch is well implemented. more effort is needed for continuous education and training. introduction. admittance to hospital for surgical treatment, is often linked with insecurity and anxiety for many patients. to most patients, the postoperative care unit constitutes an unknown environment, and can represent a frightening experience. research has shown that preoperative information leads to subjective outcome as anxiety reduction, and objective outcome as shorter hospital stay and less intake of pain medication. few studies, however, have addressed patients' experiences with preoperative information about the early postoperative phase. objectives. the purpose of this study was to describe patients' experiences with preoperative information about events they may experience during their stay in the postoperative unit. patients' experiences may contribute to increased knowledge about this topic. the study design was exploratory-descriptive, and a semi-structured interview based on thematic guide was used. nine patients met the inclusion criteria, and they had an average age of years. they were admitted to elective surgery for cancer and their stay in the postoperative unit varied from to . days. the interviews were conducted - days after surgery and transcribed verbatim. the data material was subjected to qualitative content analysis. results. experience with information before surgery and in the early postoperative phase, was categorized into four themes: being prepared before surgery, reactions to differing experience, discomfort and pain, management of some self-care activities and experiences with the environment of the postoperative unit. conclusions. the patients received a fair amount of information before surgery, but only limited information concerning what to expect while in the postoperative unit. the patients' information needs differed and patients with former experience with surgery were more prepared for what to expect. the patients got mainly verbal information and most of this was given the day before surgery. o.m. peters-polman , m. van roosmalen , j.e. tulleken , j.g. zijlstra umc groningen, intensive care, groningen, netherlands, arup nederland, amsterdam, netherlands, umc groningen, groningen, netherlands background. who guidelines concerning sound levels in hospitals requires a maximum of db in daytime, a nighttime sound level below db to allow good sleep quality and peak levels that do not exceed db at all times. in an icu environment, apart from being critically ill, patients are exposed to typical icu environmental noise. sleeping cycles disturbed by illness are further disrupted by care providers performing procedures and taking vital signs and alarms with delirium as a common result. we describe the acoustic environment in our mixed icu. we conducted an observational study in which we continuously measured the sound level (db), frequency and repetition of sound in our icu. we used a splnet microphone and noise monitoring system which was placed, after informed consent, at the ear level of the patient. results. noise sources are numerous and consist of human voices, doors slamming, pagers, telephones, shoes and equipment alarms. there is a round the clock continuous background noise of - db, staff conversation with levels of - db and peak levels up to - db, mainly due to alarms. these levels of sound are comparable to loud conversation at meter distance ( - db), walking along a motorway ( - db) or standing next to a roaring engine ( db). conclusion. who guidelines clearly state maximum sound levels of db in daytime, db at night and peak levels of db. the sound level in our unit is exceptionally and unacceptably high throughout day and night and requires a behavioral intervention. further research on the influence of these noise levels on our patients is necessary. objectives. this study has been achieved in order to realize the comparison of efficiency of manual and mechanical compression techniques used for the maintenance of haemostasis after femoral sheath removal. methods. this study was planned and applied as a randomized controlled trial. the study was executed at a military education and research hospital in turkey between january and march . data collecting form was prepared by the investigators after the literature examination. the form consists of questions which are evaluating the demographic data of patients, the compression time, the pain level (before sheath removal, during the manual/ mechanical compression and after the sheath removal), the complications occurring in femoral zone, the mobilization/discharge period and the problems (bruise, oedema, hemorrhage and etc.) occurring the th day after the discharge. the patients have been called up in order to evaluate the problems occurring on the th day. the persons that were applied mechanical compression have constituted the experimental group and the patients that were applied manual compression have formed the control group. the patients volunteer to participate to the study have been informed in regard with the implementing procedures before the application. descriptive statistics were shown in numbers and percentages for the variables obtained by counting and in mean ± standard deviation for variables obtained by measurement. results. the average of age is . ± . in the experimental group and is . ± . in the control group. the average of compression time is . ± . min in the experimental group and is . ± . min in the control group (p \ . ). the average of mobilization time after sheath removal is . ± . min in the experimental group and is . ± . min in the control group (p \ . ). it has been observed a lower pain level during compression and after sheath removal in patient that were applied mechanical compression in comparison to the patients that were applied manual compression(p \ . ). when the groups were compared in terms of femoral zone complications while no haematoma was observed in the experimental group, haematoma has been occurred in the . % (n = ) of the control group. conclusions. the mechanical compression provides an earlier mobilization and earlier discharge of the patient. this study shows that mechanical compression is a method as safety as the manual method in order to obtain a haemostasis a correlational survey was conducted in public hospitals located in athens. critical care nurses completed anonymous questionnaires , , yielding a response rate of %. greek critical care nurses believe that open visiting increases family's satisfaction ( . %), exhausts family members ( . %) and provides emotional support to the patient ( . %); nevertheless the effects of visiting depend both on patient and family ( . %). furthermore open visiting hampers the planning of adequate nursing care ( . %) and is not a helpful support for the caregivers ( . %) while increases their physical and psychological burden ( . %). critical care nurses' attitudes toward visiting hours were rather negative and they didn't want to liberalize the visiting policy of their unit ( . %). there was a positive correlation between nurses' beliefs and attitudes regarding visiting (r = . , p \ . , r = . , p \ . ). the factors ''working experience'', ''adequacy in staff'' and ''the number of shifts'' were found to be independently correlated and they predicted the score of the scales of the questionnaire. greek icu nurses have rather negative beliefs and attitudes toward visiting and open visiting policy. this will be a challenging barrier to overcome when imposing new flexible policies in icus . objectives. our aim was to elucidate potential mechanisms for the beneficial effects of rhapc on ali, as assessed by microarray analysis of lung tissue after sepsis induced by clp in rats. methods. sepsis (n = ) was induced in rats by clp. a sham-operated group (n = ) underwent laparotomy and closure without clp. a clp group (n = ) received subcutaneous saline ( ml/kg) and a clp + apc group (n = ) additionally received mg/kg rhapc. twelve hours postoperatively, lung tissue was preserved in mrna later until mrna isolation by promega total rna kit and analyzed using illumina beadarray. data were log variance stabilized and quantile normalized using the lumi package in r and the limma package was used for group comparisons and false discovery rate correction. data were further analyzed using panther and david. the clinical outcomes of this study showed a marked attenuation of the sepsisinduced increase in lung permeability in rats treated with rhapc . although no formal statistical significance was reached for the gene expression changes between the clp and the clp + apc groups, there was a clear attenuating effect of rhapc on the changes in gene expression caused by sepsis reflected in generally lower fold change values and fewer significantly differentially regulated genes in the clp + apc versus sham group compared to the non-treated clp vs. sham group ( vs. genes). nevertheless, there were only genes of which the fold change difference between clp versus sham and clp + apc versus sham was more than one, indicating that although there was a large difference in the number of differentially expressed genes, the difference in fold change between these genes was small. conclusions. these data suggest that the rhapc treatment of septicemic rats does not only cause a down regulation of specific pathways as argued by previous investigators, but leads to a global reduction in the inflammatory response at a mrna level. introduction. septic shock guidelines recommends the use of recombinant human activated c protein (acp) in high risk mortality patients. the aim of our study is to describe the clinical characteristics, and the outcome of patients treated with acp in our hospital. methods. retrospective and descriptive study which includes patients with severe sepsis/ septic shock treated with pca in a tertiary hospital intensive care unit (icu) over years ( - ) . we analyze epidemiological data, reason for admission, infectious focus and agent, severity scores, organ failure, complications, stay and mortality. we used chi-square analysis to compare categorical data and student's t test to compare continuous variables. conclusions. in our study most patients were admitted from emergency department, with organic failure caused by pneumonia. we haven't detected deaths related with acp complications, even in patients undergoing surgery. we found as prognostic factors for mortality: organ dysfunction, acp indication, renal failure, pao /fio relation, amount of vasopressors, bicarbonate and base deficit levels, apacheii and icu stay. objectives. to analyze changes on hemodynamics in patients with severe sepsis treated with high volume hemofiltration ( ml/kg/h) vs. patients treated with very high volume hemofiltration ([ ml/kg/h). we conducted a prospective randomized trial from january to november in patients admitted into icu with a diagnosis of septic shock in which hf was indicated. patients were randomized to one of each group of therapy. the control group received high volume hemofiltration therapy and the experimental group received very high volume hemofiltration. the hemodynamic parameters were measured at the admittance in icu and every h onwards. results. data of patients were collected ( men and women) mean age ± years old. the hemodynamic parameters registered at the admittance and during the therapy had no significant difference between the groups. the control group received hf therapy during . ± . days and the intervention group . ± . days. there wasn't any difference either in the administration of vasoactive drugs between both groups. the most significant difference between the groups was the -day survival rate, . % of the experimental group against . % of the control group (p = . ). from these results we can conclude that very high volume hemofiltration therapy should be the therapy of election because it improves the survival of patients with severe sepsis without impairing the hemodynamic parameters. we have to point out the importance of the nursing staff in the assembly and management of the equipment as well as in the patient care and thus avoiding potential complications. introduction. the use of herbal products is increasing, and may result in increased drug-herb interactions or form a potential for adverse reactions in cardiovascular surgery patients. objectives. the aim of this study was to describe the utilization patterns for herbal products in patients with cardiovascular disease. methods. this was a descriptive study which was carried out among adult patients presenting to cardiovascular surgery department for elective cardiac surgery between september and april in a research and training hospital. after giving informed consent, patients were interviewed by researchers using a structured survey instrument in the preoperative period. results. interviews were conducted with patients (mean age . ± . , range: - years), % of them were married, % were men, and % of the patients had high school or university education. the majority ( %) had coronary artery disease and most of the patients ( %) had concomitant diabetes mellitus and hypertension. the most common used drugs were anti-hypertensives, nsai's, and anti-aggregants. most patients ( %) reported the regular use of drugs. eighty-nine ( %) among the surveyed patients reported the use of herbal products. the most common used herbal products were garlic ( %), apple vinegar ( %), lavandula stoechas ( %), cratageus ( %) and ginger-honey mixture ( %). the average educational degree of herbal product users was found to be higher when compared with the others. many patients report being informed about those products from television, internet, newspapers, herbal-stores personal communications, and report the use of those products after the diagnosis is made. none of those patients have informed physicians or nursing staff about the use of those herbs. the demographic variables of patients and the herbal-product usage has failed to show a statistically significant difference (p [ . ). conclusions. the use of herbal products is common among the patients with cardiovascular diseases. health professionals should be aware of the usage of those products in order to prevent possible adverse reactions and drug-herb interactions. introduction. nurses employed in the icu operate in a complex environment, under time pressure, and with limited information available. thus, errors are inevitable and, besides their adverse consequences, they offer the potential for learning . in this concept, properly copying with errors is a prerequisite for avoiding their recurrence and improving nursing practice. objectives. our aim was to investigate how error-copying strategies are associated with constructive and defensive changes in icu nursing practice. methods. questionnaires were completed (a % response rate) from nurses employed in the icus of adults, children, and the coronary care unit of two greek hospitals, between january-june . ''ways of copying'' scale as revised by wu et al. was used for evaluating copying strategies. this includes copying subscales, each ranging between and . constructive changes in response to error included items (paying more attention to detail, keeping better patient records, reading patient notes more carefully, seeking advice, discussing with colleagues about similar situations, devoting more observation on patients, reading for covering knowledge deficiencies), while defensive changes included items (getting more worried, feeling less confident at work, being more likely not to discuss errors, being less trusting of others, thinking to leave profession.). a four-point likert scale ( - ) was used for evaluating each item, and points were summed to estimate total scores of constructive and defensive changes. . . % of participants were female and . % were registered nurses. mean (±se) age was . ± . years and mean icu experience was . ± . years. multiple linear regressions with constructive and defensive changes in practice as dependent variables and copying strategies as independent variables are summarized in table . participants were more likely to make constructive changes if they coped by seeking social support (p = . ) and accepting responsibility (p = . ). at the same time, they were more likely to make defensive changes if they coped by escape-avoidance (p = . ). reasons for high risks are e.g. sedation and analgesia, immobility, malnutrition and hemodynamic or oxygenation problems as well as poor identification or unsystematic assessment of the risks. in our unit, we performed a months retrospective review of pressure ulcer risks for all patients (n = ) using jackson-cubbin calculator. the risk point level in this instrument is and below. patients of ( %) exceeded the risk limit already in the icu admission phase. objectives. to change care practices of pressure ulcer prevention and care with action research. with the measurement tool nurses are able to identify patients at risk of developing pressure ulcers during the whole icu in-patient time, and to prevent risks of pressure ulcer in an early stage. with the assessment tool, the measurement is systematic which enables the benchmarking and have effects on material recourse planning and cost caused by pressure ulcers. the study unit is a -bed icu for adults taking care annually circa , patients with multiple disorders. firstly, the jackson-cubbin pressure area risk calculator was translated into finnish. a few changes which have an effect on pressure ulcer risk were added; weight limits were also defined with bmi values, hyperbaric oxygen therapy was added in deducted points as well as h limit for blood transfusions and limits for hypothermia from celsius or under. secondly, standardized guidelines for different risk levels were developed; if patients have a high risk specialized mattresses should be used and changes of positions and beds should be stressed. thirdly, an electronic evolution form for patient information system was planned and implemented. finally, a systematic education program for icu personnel including special lectures, material demonstrations and familiarization by the nurse responsible for wound care was started. results. after the development project and systematic education the knowledge of personnel about pressure ulcer risks and care has increased. risk points are counted once a day for every patient using the electronic form. all the mattresses at the icu have been changed to medium and high risk mattresses and are chosen for a patient related to the risk assessment points. conclusions. a reliable assessment scale, systematic measurement and continuous evaluation and education are crucial for identification of high risk pressure ulcer patient at the icus. with a systematic measurement and recognizing high risk patients we can also improve patients' quality of life and reduce the cost caused by pressure ulcers. reference(s ) is considered to be one of the main agents in gram negative sepsis. in recent years several adsorption dispositives have been designed in order to achieve low blood endotoxin levels with a theorical clinical improvement. toramyxin (polymixine b fixed to polyesthirene fibers) and alteco lps adsorber (polyethylene discs) are two of these dispositives. both are used with h sessions for several days until patient clinical improvement. • design a nursery prothocol with the most important procedures in gram negative septic shock patients with acute renal failure that undergo adsorption cartridge therapy. • evaluate initial experience in the use of endotoxin adsorption cartridges. methods. nursery prothocol with special attention to the settlement and management of the cartridge therapy, based on library references and practice guidelines. once prothocol was stablised, prospective observational study was started from january till january . inclusion criteria were: patients admitted to our intensive care department with gram negative confirmed septic shock and acute renal dysfunction requiring continuous renal replacement therapies (crrt). adsorptive cartridge were added and several parameters were studied: heart rate, mean blood pressure, vasopressor support (norepinephrine), pao / fio , and lactate. the information was analyzed in excel. results. nursery protocol was correctly applied in all patients and showed to be basic in the maintenance and early complication detection. hemodynamic improvement that allowed norepinephrine lowering dose and normalized lactate levels with no changes in pao /fio . patient (toraymyxin): years man, acute pancreatitis with septic shock. patient (toraymyxin): years man, pneumococic pneumonia and klebsiella septic shock. patient (alteco): years man, acute pancreatitis with enterobacter cloacae septic shock. patient (alteco): years woman, acute peritonitis with e. coli septic shock. results of a program to reduce catheter-related blood-stream infection in the icu: two years' follow-up a systematic review comparing the relative effectiveness of antimicrobial-coated catheters in intensive care units benefits of minocycline and rifampicin-impregnated central venous catheters which antimicrobial impregnated central venous catheter should we use? modeling the costs and outcomes of antimicrobial catheter use when is hit really hit? anticoagulative management of patients requiring left ventricular assist device implantation and suffering from heparin-induced thrombocytopenia type ii -hit happens: diagnosis and evaluating the patient with heparininduced thrombocytopenia informe del registro mami - grupo de trabajo de la sociedad europea de cardiología (esc) sobre marcapasos y terapia de resincronización cardíaca moreno millán e. variación de la estancia preoperatoria en españa según grupos de edad, sexo y modo de acceso hospitalario reference(s). . association of anaesthetists of great britain & ireland. safety guideline on interhospital transfer intensive care society: guidelines for the transport of the critically ill adult competency-based st st training and assessment. a manual for trainees and trainers. royal college of anaesthetists training and assessment of competency of trainees in the transfer of critically ill patients adverse events experienced while transferring the critically ill patient from ed to the icu a modified mccabe score for stratification of patients after intensive care unit discharge: the sabadell score surviving intensive care. edicion taurine and niacin block lung injury and fibrosis by down-regulating bleomycin-induced activation of transcription nuclear factor-kappab in mice antioxidants and sepsis: can we find the ideal approach? post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. a scientific statement from the international liaison committee on resuscitation therapeutic hypothermia after cardiac arrest: unintentional overcooling is common using ice packs and conventional cooling blankets it's well known that normobaric hyperoxia (nh) increases arterial and brain oxygen tension. however the influence of nh on intracranial pressure (icp) and cerebral metabolism in patients to investigate the dynamics of icp, jugular bulb saturation (svjo ), brain oxygen tension (pbro ) and cerebral metabolism during nh in patients with ich icp monitoring and tissue microdialysis were used in all patients, svjo monitoring -in , pbro -in . microdialysis and pbro catheters were placed in lesioned (les) and intact (int) brain tissue. icp, svjo , pbro , glucose and glycerol levels, lactate/pyruvate ratio dynamics during fio ) to ± mmhg (ð \ . ) (fio . ) and ± mmhg (ð \ . ) (fio . ) cerebral metabolism didn t change significantly, except glycerol level increase in lesioned brain tissue from ( ; ) mlmol/l (fio . ) to ( ; ) mlmol/l (fio . ) and ( ; ) mlmol/l (fio . ). fio . : glucose (int) - . ( . ; . ) mmol/l, glucose (les) - . ( . ; . ) mmol/l, lactat/piruvat (int) - . ( . icp was stable during investigation ( . ± . mmhg nh is accompanied by pao and pbro increase and doesn't influence icp and cerebral metabolism in ich patients with normal vo /do relationships effects of anesthetics oc cerebral blood flow and cerebral metabolic rate isoflurane preconditioning improves long-term neurologic outcome after hypoxic-ischemic brain injury in neonatal rats this no-profit trial has been supported by depuy/ hemedex, providing the probes. no other economical support has been received effect of equiosmolar solutions of mannitol versus hypertonic saline on intraoperative brain relaxation and electrolyte balance a comparison of % hypertonic saline and mannitol for brain relaxation during elective supratentorial brain tumor surgery hypertonic resuscitation and blood coagulation: in vitro comparison of several hypertonic solutions for their action on platelets and plasma coagulation effect of the combination of mannitol and ringer acetate or hydroxyethyl starch on whole blood coagulation in vitro no well defined threshold for transfusion or target hemoglobin (hb) level for these patients exists. objectives. to examine associations of anemia and transfusion with adverse outcomes in patients with sah, and better define hb level thresholds associated with these. methods. retrospective, observational study of consecutive patients with sah admitted to icus at mayo clinic in jacksonville and rochester, usa, over -year period. data included demographics, nadir hb, blood transfusion, ali/ards, vasospasm, radiographically confirmed cerebral infarction, apache and wfns. primary outcome was association of anemia and transfusion with death and secondary outcomes were vasospasm, cerebral infarction and ali/ards. results. we identified patients, mean age was (± ), ( %) were females. mortality was %. seventy-two ( %) of patients were transfused. ( %) patients had vasospasm and ( %) cerebral infarction. there was a strong association between transfusion and increased mortality (p = . ), vasospasm (p = . ), cerebral infarction (p \ . ) and ali/ards (p \ . ) outcome prediction in mild traumatic brain injury: age and clinical variables are stronger predictors than ct abnormalities comparison of simultaneous continuous intracranial pressure (icp) signals from a codman and a camino icp sensor therapeutic actions may correct abnormal values and perform potentially cerebral blood flow/oxygen extraction coupling. objectives. aim of this study was to describe the incidence and the type of bedside icu monitoring devices used in the management of patients with severe tbi in french icu's. methods. multicentric observational study including patients having severe tbi (glasgow coma scale (gcs) \ ) picked on scene by a mobile medical unit for pre-hospital care (samu). inclusion period: months general hospital of athens, department of intensive care unit o poder na relação enfermeiro-utente relacionamento enfermeiro, paciente e família: factores comportamentais associados à qualidade da assistência investigação qualitativa em enfermagem: avançando o imperativo humanista the experiences of families of critically ill patients in greece: a social constructionist grounded theory study. intensive and critical care nursing visiting hours policies in new england intensive care units: strategies for improvement this study was supported by a post graduate programme in nursing surviving the nursing shortage: developing a nursing orientation program to prepare and retain intensive care unit nurses clinical utility of apc-pci (activated protein c-protein c inhibitor) complex as predictors for severity and prognosis in sepsis: preliminary study republic of korea introduction. recently human recombinant activated protein c (drotrecogin alfa [activated]) has been shown to reduce mortality in severe sepsis. in severe sepsis, conversion of protein c to apc (activated protein c) is impaired due to endothelial dysfunction. apc level is related to coagulation cascade known to be important in sepsis pathophysiology. objectives. in this preliminary study, we checked apc-pci (activated protein c-protein c inhibitor) complex level to evaluate protein c activation using apc-pci elisa kit they were admitted asan medical center (seoul, korea) medical intensive care unit (icu) between sep and . , respectively. apc-pci level had no statistically difference among sepsis, severe sepsis, septic shock ( . , . , . ng/ml, p = . ). between hospital survivor group and non-survivor group there was also no difference in apc-pci level ( . , . ng/ml but apc-pci level was tended to decrease in severe sepsis, septic shock group as compared to sepsis group activated protein c versus protein c in severe sepsis endogenous protein c activation in patients with severe sepsis efficacy and safety of recombinant human activated protein c for severe sepsis septic critical patients to evaluate the experience with drotrecogine alfa (da) in septic critical patients (scp) in a analysis of scp admitted in an icu unit between december and which received treatment with da. patients were included or excluded on the approved specifications fda and emea. inclusion criteria were septic patients and apache ii score c and/or two or more organ dysfunction (od) thirty-eight patients were eligible od: respiratory %, renal %, cardiovascular %, metabolic %, hematologic %; sdra . , vmc . , vni, . , all patients received empirical antibiotic treatment in the first h according to epidemiologic characteristics. microbiology: some germens were isolated in patients ( %) mortality (%) by presumed site of infection day /day : respiratory / , abdominal / , urologic / ; skin / . average hours drug administration was h. da was administrated at % of the patients between hour and hour , the other % between hour y critical septic patient treated early with empirical antibiotics, the best standard care and da have a low mortality rate. more early da administration was associated to lower mortality the treatment of severe sepsis in france: overview of a -year survey period bichat hospital, surgical intensive care unit lariboisière university hospital, medical intensive care unit cochrane database leptin is an adipocyte-derived cytokine regulating energy homeostasis, metabolism as well as immune-inflammatory processes. leptin also has thermogenic actions and regulates enzymes of fatty acid oxidation. leptin is significantly increased in response to acute infection and sepsis and exerts direct effects on cd + t-lymphocyte proliferation, macrophage phagocytosis, and secretion of inflammatory cytokines such as il- and tumor necrosis factor (tnf) a. we measured leptin in blood of septic patients we measured leptin serum levels in septic patients leptin levels in septic patients (mw = , . ng/ml ± sem = , . ng/ ml) are significantly higher compared to healthy controls (mw = , . ng/ ml ± sem = , . ng/ml, p \ . ). serum levels of leptin were significantly higher on day (mw = , . ng/ml ±sem = , . ng/ml) and day (mw = , . ng/ ml ± sem = the aim of this multi-centre retrospective observational study was to resuscitation bundle the above preliminary data indicated that an experienced use of rhapc, when compared to other survey ( ), was associated with a reduction of serious bleeding events, a more frequent off-label use and a similar mortality rate. the concomitant adherence to evidence-based guidelines improved significantly the patient survival ) macias et al. sources of variability on the estimate of treatment effect in the prowess trial: implications for the design and conduct of future studies in severe sepsis use of drotrecogin alfa (activated) in italian intensive care units: the results of a nationwide survey acute lung injury (ali) is one of the most frequent complications of sepsis. although coecum ligation and puncture (clp)-induced sepsis is a frequently used model, we found only three microarray studies of clp-induced sepsis - , of which one looked at lung tissue . none of them had examined the effects of recombinant human myocardial transcriptional profiles in a murine model of sepsis: evidence for the importance of age molecular signatures of sepsis: multiorgan gene expression profiles of systemic inflammation sepsis gene expression profiling: murine splenic compared with hepatic responses determined by using complementary dna microarrays endothelin- in endotoxin-and sepsis-induced lung injury activated) in real-life clinical practice for management of severe sepsis in surgical patients in patients with severe sepsis and multiple organ dysfunction, major surgery is not a contraindication for early ( - h after surgery) daa administration retrospective, observational, descriptive cohort study in patients with severe sepsis and multiple organ dysfunction treated with daa the principal focus of sepsis differed between the two groups (p \ . ): in the surgical group it was the abdomen ( . %) followed by the skin and soft tissues %) followed by the urinary tract ( . %) in the perfusion period, the distribution of severe/ moderate hemorrhages in the surgical group was %/ . vs. . %/ . % in the medical group. we found no differences between groups in death from any cause at days ( . vs. . %; rr ; % ci . - . ; p = . ). nevertheless, at days overall mortality had increased in both groups, although this difference was not statistically significant: the percentage of increase with respect to the -day mortality was % in the surgical group and % in the medical group in patients with severe sepsis and multiple organ dysfunction, major surgery is not a contraindication for early ( - h after surgery) daa administration. given our findings at days, studies including a wider period from the initiation of daa administration are necessary to evaluate the cost-efficacy efficacy and safety of recombinant human activated protein c for severe sepsis recombinant human activated protein c, package labeling and hemorrhage risk reference(s). iom. to err is human incidence of adverse events and negligence in hospitalized patients matrix metalloproteinase- promotes repair after ventila-tor-induced lung injury supported by the parker b. francis foundation, physician services incorporate, ontario thoracic society and canadian lung association sepsis-induced immuno-endocrine dysfunction impact of arginine-vasopressin (avp) and apelin (apl) exogenous administrations in a rodent model because the corticotrophic pathway is disturbed during circi, with acth-cortisol dissociation, alternative physiologically nondominant pathways such as the vasopressinergic/apelinergic axis, become essential to the hpa adaptation to stress. objectives. seeking the impact of arginine-vasopressin (avp) and apelin (apl) exogenous administrations on: acth & corticosterone blood contents, and respective pituitary and adrenal gland receptor expression (v b, apj) in a rodent model of endotoxin challenge. methods. a rodent model of endotoxin (lps e. coli :b , mg/kg i/p)-induced hpa axis has been selected to study the committment of avp/apl and related receptors (v b/ apj). rats (n = ) were equipped with subcutaneous osmotic minipumps (alzet, ) containing: saline, apl- ( , , , lg), or avp ( . , lg) for h. results. without lps challenge, exogenous apl administration did not alter acth & corticosterone blood contents whereas high dosage of exogenous avp significantly increased corticosterone blood content (p \ . vs. control). lps i/p challenge induced a huge increased of blood acth & corticosterone, both culminating at . h ( -and -fold increases respectively, p \ . vs. baseline), which was normalizing at h for acth whereas corticosterone remained high. this dissociation validates the model, matchs with human observations, and suggests non acth-dependent corticosterone release after lps challenge apl administration completely reversed the above down-regulation while avp also partially restored apj pituitary expression by almost % in a dose-dependent manner, and to a lesser degree in the adrenal gland (p \ . vs. lps). selective non-peptide v b (ssr ) and peptide apl antagonists (f a) substitutions confirmed the above effects were directely mediated. conclusions. apl and avp pituitary neuronal and bloodstream contents behave differently, and blood acth & corticosterone contents were dissociated, after acute lps challenge. apl as well as avp exogenous administrations were able to reverse (partially for the later) the lps-induced apj down-regulation in both pituitary and adrenal glands. reference(s) supported by the esicm young investigator award from infection diagnosis to therapy an antimicrobial stewardship program (asp) is a method of optimizing antimicrobial prescribing, altering antimicrobial resistance, reducing costs, and improving patient care. the intensive care unit (icu) is an ideal environment for the application of an asp given the complexity of the patient population, the ecology of resistant organisms, and the fact that selection of inappropriate antimicrobials or delays to determine the impact of the introduction of an icu asp on prescribing, patient outcomes, resistance, and costs we implemented an asp in a -bed medical surgical icu of a university-affiliated hospital. the asp team used prospective audit with interaction and feedback providing suggested changes in therapy (e.g. antibiotic choice, dose, duration) on a daily basis. asp provided consultation on all icu patients not followed by the infectious diseases consult service. parameters collected included demographic data, details of antimicrobial regimens, culture results, defined daily doses (ddd)/ patient days and antimicrobial costs mean monthly antibacterial ddd/ patient-days post-asp was reduced by . % ( . vs. . , p \ . ). the implementation of the asp was associated with a . % decrease in mean monthly antibiotic costs/ patient-days ($ vs. $ ) for a total cost reduction of $ , . in terms of prescribing and resistance, the introduction of asp was associated with a reduction in the prescribing of anti-pseudomonal agents (compared with antibiotics not covering pseudomonas) (mean monthly ratio . vs. . ), mrsa vs. mssa covering antibiotics (mean monthly ratio . vs. . ) and improved susceptibility pattern for pseudomonas aeruginosa as demonstrated by increases of , and % to tobramycin, meropenem, and piperacillin-tazobactam susceptibilities, respectively. there was no difference in icu mortality rate the asp team worked collaboratively with the icu team to improve antimicrobial therapy and as a result improved overall antibiotic usage and resistance patterns of important icu microorganisms, and decreased antimicrobial costs. appropriate and judicious antimicrobial use guided by an asp is beneficial to the icu can pct and/or crp help identify associated bacterial infection in patients with influenza pneumonia? procalcitonin (pct) is a recognized marker of bacterial infection and might be a prognostic marker in lower respiratory tract infections. objectives. to determine if pct and/or c-reactive protein (crp) levels at admission in intensive care unit can help identify associated bacterial infection in patients with influenzae pneumonia. methods. a nationwide registry (reva) was set up in france during the h n influenza pandemic. levels of pct and crp at icu admission were compared between patients presenting with influenzae pneumonia associated or not with a bacterial coinfection. results. patients were included, of whom received antibiotics prior to hospitalization. of the remaining patients, ( %) had documented bacterial co-infection. the bacteria involved in the co-infections were streptococcus pneumoniae (n = , . %), staphylococcus aureus (n = , . %), streptococcus a group (n = , . %). figure shows the initial values of procalcitonin and crp. median values for both pct ( . vs. . ng/ml, p \ . ) and crp ( vs. mg/l, p = . ) were significantly higher in patients with bacterial coinfection. the area under the roc curve was . and . , respectively for pct and crp. a cutoff of[ . ng/ml for pct (sensitivity % and specificity %) best identified patients with bacterial co-infection. for crp, a cutoff of[ mg/l (sensitivity %, specificity %) best identified patients with bacterial co-infections. comparison of the h n pneumonia and bacterial pneumonia group revealed no differences except for a higher saps in the latter pro endothelin (pro et) and copeptin (pro vasopressin cp)) for diagnosing infection in patients with severe acute dyspnea. methods. we designed a prospective study of patients admitted in emergency department (ed) and medical intensive care unit (icu) in a university hospital. inclusion criteria were acute dyspnea with spo b % and/or respiratory rate c b/min. patients with obvious myocardial infarction or pneumothorax were excluded. all clinical and biological data were recorded and biomarkers sampled. an independent blinded expert panel classified the patients according to all the available data including response to treatment and outcomes blindly to biomarkers' results. the roles of biomarkers were assessed quantitatively and then using terciles of the distribution. the contribution of the biomarkers in the diagnosis was assessed using auc-roc curves and by multiple logistic regression taking into account other clinical and biological explanatory variables. results. consecutive patients ( % male, med age years, day mortality %) were enrolled. the final diagnosis was severe sepsis for ( . %) (pulmonary: n = , non-pulmonary n = ). the parameters independently associated with infection lead to a clinico-biological model with an auc = . and a good calibration (p (hlchi ) = . ) and included temperature, arterial pressure, cyanosis, stupor and coma, orthopnea, localized chest sound abnormalities, pao /fio ratio and localized infiltrate on chest x ray although new biomarkers were different between septic and non septic patients with severe acute dyspnea, only mid pro-anp may add a significant contribution. further analysis about the prognostic value of these biomarkers is ongoing grenoble university hospital and brahms diagnostic czech republic, st faculty of medicine charles university and thomayers' hospital, anesthesiology and intensive care medicine fluid management with cvp is still common despite lack of efficacy. objectives. implement stroke volume maximisation during major surgery using odm guided fluid challenges. assess impact of odm use on central venous line insertion rates. identify and overcome barriers to adoption of odm technology. methods. nhs technology adoption centre project (ntac) supported an implementation project at hospitals. the audit into central catheter use during major surgery was undertaken at manchester royal infirmary. fourteen anaesthetic consultants volunteered to champion odm use to guide targeted fluid challenges with hes / . (voluven, fresenius kabi) within a range of major surgical procedures (colo-rectal, hepatic, pancreaticobiliary, urological, reno-pancreas transplant and emergency surgery). prospective data was collected for patients who underwent major surgery between with no significant differences in preoperative risk, intervention patients had enhanced post-operative outcomes. cvc insertion reduced after anaesthetists had the opportunity to use odm to guide fluid therapy. reference(s) clinically used fluids modify in vitro phenotype and function of circulating immune cells peri-operative fluid loading, i.e. ''hemodynamic optimization'', reduces post-operative complications and hospital length of stay. mechanisms involving perfusion have been studied, but fluid could also alter phenotype and function of circulating immune cells, and consequently the systemic inflammatory response induced by surgery blood from control donors has been diluted in crystalloid fluid (isotonic saline, wsio), colloids (hydroxyethyl starch (hes kd, . %) and % albumin solution (alb)), or autologous plasma, which corresponds to clinical situations in programmed anesthesia and surgery. two dilution levels have been studied, to achieve - g/dl hemoglobin (dilution ) and - g/dl (dilution ) )* cd mono (sites/cell) , ( , ) , ( , )* , ( , ) , ( , )* , ( , )* cd b pmn (sites/cell) alb only increased ord, but not activation and adhesion markers. conclusions. wsio had clear anti-inflammatory properties, whereas colloids were more inflammatory, with a dissociation of the effects between different types of fluids. mechanisms have to be precised, especially regarding physico-chemical, immuno-inflammatory and metabolic regulations. reference(s). none. grant acknowledgment. plan quadriennal outcome-related factors federacion panamericana e iberica de sociedades de medicina critica y terapia intensiva (fpimcti) our aim was to conduct a multicenter study to evaluate the epidemiology of delirium in intensive care units (icu) a -day point-prevalence study was performed with the aim of describing in icus from countries in south and north america and spain % were admitted to the icu due to medical causes and sepsis was the main diagnosis (n = , . %). patients were sedated and only ( . %) patients could be evaluated with the cam-icu. the prevalence of delirium was . % (n = ). as compared to patients without delirium, those with the diagnosis of delirium had a higher severity of illness at admission as demonstrated by higher sofa increased use of invasive devices such as central venous catheter (p \ . ), arterial catheter (p = . ) and urinary catheter (p = . ) were more frequent in patients with delirium. on multivariate analysis, delirium was independently associated with increased icu mortality in this one-day international study, delirium was frequent in icu patients and associated with increased mortality and icu los. the main modifiable risk factors associated with the diagnosis of delirium were the use of invasive devices and sedatives the study was funded by the federacion panamericana e iberica de sociedades de medicina critica y terapia intensiva (fpimcti). the fpimcti has used in part an educational grant from hospira recent studies suggest that increased blood glucose variability (bgv) is associated with icu mortality . hypothermia is known to induce insulin resistance, thus potentially increasing bgv. no studies however have examined the effect of therapeutic hypothermia (th) on insulin requirements and bgv. objectives. to examine the effect of th on bgv and its relationship to all patients were treated with intravenous insulin (blood glucose target - mm), according to a written algorithm, with nurse-driven adjustment of insulin dose. for each patient, standard deviation of repeated blood glucose samples was used to calculate bgv. two time-points, comparable in duration, were studied: th (stable maintenance phase, i.e. - h, core temp ± °c) vs. normothermia (nt, i.e. after rewarming, stable normothermic phase, core temp ± °c). mortality and neurological recovery (glasgow-pittsburgh cerebral performance categories, cpc, dichotomized as good = cpc - vs. poor = cpc - ) were assessed at hospital discharge. statistical analysis was performed with anova for repeated measures therapeutic hypothermia is associated with increased insulin requirements and higher blood glucose variability, which in turn correlates with worse prognosis in patients with post-ca coma. strategies aimed to maintain stable glycemic profile and avoid blood glucose variability might contribute to optimize the management of th and may translate into better outcome glucose variability is associated with intensive care unit mortality therapeutic hypothermia post cardiac arrest has been shown to improve survival and neurological outcome . there are approximately , treated cardiac arrests in the uk each year with one-eighth we aimed to establish if implementation of an agreed care bundle including therapeutic hypothermia reduced mortality and improved neurological outcome patients were categorized according to initial cardiac rhythm, ventricular fibrillation/tachycardia (vf/vt) or non-vf/vt. we recorded the degree of implementation of the post cardiac arrest care bundle, comprising; coronary reperfusion, haemodynamic optimisation, control of ventilation, blood glucose, temperature and seizures. data was compared with survival to discharge and neurological function there were ihas, male (mean age . years) and female ( . years) and oohas, male ( . years) and female ( . years). the predominant presenting rhythm in oohas was vf/vt ( . %) compared to ihas which was non vf/vt ( . %). underlying co-morbidities included - °c) was achieved in % of vf/vt oohas compared to . % of vf/vt ihas. the complete care bundle was delivered to . % of oohas and . % of ihas survival rates were higher in all patients with complete bundle of care versus those with an incomplete bundle independent of location or rhythm ( . vs. . % p = . ). this improval in survival was also demonstrated in vf/vt arrests receiving the complete bundle of those patients who had a vf/vt arrest, survival with full neurological recovery (gcs on discharge) was higher in those receiving therapeutic hypothermia . versus % where therapeutic hypothermia was not achieved adherence to the post cardiac arrest care bundle led to significantly improved outcome following both vf/vt and non vf/vt arrests. there was a trend towards therapeutic hypothermia improving neurological outcome on discharge reference(s). . the hypothermia after cardiac arrest study group. mild therapeutic hypothermia to improve the neurological outcome after cardiac arrest royal sussex county hospital intensive care unit, brighton, uk for patient data h. altemimi , s. altaf , j. brown , s. al-juboori , v. jadhav queen elizabeth hospital, kings lynn, medical assessment unit, kings lynn, uk introduction. the medical assessment unit (mau) in our district general hospital (with beds) provides assessment and treatment of acute medical patients from general practice (gp) referals and the emergency department (ed). patients arriving in mau are first triaged by the nurses before assessment by junior doctors. the early warning score (ews) is an indepenently verified scoring systems used to prioritise patient assessment. appropriate referal to critical care outreach teams and intensive care units can be triggered by nurses or doctors according to the ews score. clear and seemless referal pathways and communication between those involved with acutely unwell patients is essential. objectives. to measure key performance indicators in the mau and identify specific areas for improvement. methods. retrospective audit of all admissions to medical assessment unit during week in . the following parameters were recorded for patients admitted. patient ages ranged from to : [ . of these, only were reviewed within h. . % of patients reviewed within min. conclusions. in the uk, early warning scores have been developed to trigger early review. the most sophisticated intensive care becomes unnecessarily expensive terminal care when the pre-icu system fails to refer in a timely manner. our results showed that when a patient was recognised as being unwell, they were seen rapidly by the outreach team. however, not all new admissions had their ews documented, overlooking an important opportunity to risk stratify patients before formal medical clerking. our critical care outreach team have prominent role in education to identify abnormal physiology early, and take action as appropriate. immunological host reactions are primarily believed to determine the clinical course of this disease. an overwhelming inflammatory response to microbial invasion may be involved in the pathogenesis of sirs, sepsis and multiple organ failure. it is important to block the inflammatory response and stop or alleviate sepsis injuries. immunotherapy is regarded as effective approach to improve the immunological function. objectives. immunomodulation in the critically ill is an appealing notion because of the abnormal immune responses. the aim of this study is to evaluate the immunomodulation and its mechanism to improve immune function and prognosis in sepsis. methods. experimental part:clp model were divided into three groups including sham group, control group and experimental group. control group only used antibiotic and experimental group used antibiotic plus immunomodulation. blood collection were made after clp model in , , and h. lymphocyte counting, cd +, cd + t lymphocyte and cd /cd ratio were checked. the apoptosis of lymphocyte in thymus and spleen and survival rate were checked. clinical part: prospective analysis seventy patients conformed to the enrolled standard. it was divided into two groups at random. one was control group with regular therapy, the therapy group with ulinastatin plus thymosin-a in a week. the immune index before and after therapy in the , st, rd, thday was observed. results. experimental part: lymphocyte, cd + t lymphocyte and cd /cd ratio in experimental group increased more significant than in control group (p \ . ). lymphocyte apoptosis index of thymus and spleen in control group increased more significant than in experimental group (p \ . ). h-survival rate in experimental group was higher than in control group. clinical part: cd + t lymphocyte, lymphocytes and hla-dr cd + had more significant increase in therapy group than in control group (p \ . ). twenty patients died in the control group and thirteen patients died in the therapy group (p \ . ). conclusions. immunomodulation in sepsis can improve immune function and alleviate the lymphocyte apoptosis and extend the survival time. in recent years, the antiinflammatory effects of niacin by reducing nuclear factor jb (nf-jb) activation have attracted attention. however, the protective effects of niacin on the development of acute lung injury and systemic inflammatory response during sepsis have not been studied.objectives. we performed this study to determine whether niacin attenuates acute lung injury (ali) and improves survival during sepsis and the beneficial effects of niacin are associated with the down-regulation of nf-jb pathway.methods. lipopolysaccharide (lps) at a dosage of mg/kg was injected into the tail vein to induce endotoxemia in rats. then, vehicle, low dose niacin ( mg/kg), or high dose niacin ( mg/kg) diluted in distilled water with same volume ( ml/kg) was administered once to the rats through orogastric tube, respectively. we observed the survival of the subjects. at h post-lps injection, we measured serum tumor necrosis factor-a (tnf-a), interleukin- (il- ) levels, lung cytoplasmic phosphorylated inhibitor jb-a (p-ijb-a), ijb-a, nuclear nf-jb p expressions, nf-jb p dna-binding activity, and ali occurrence.results. high dose niacin improved survival during sepsis. niacin induced dose-dependent reduction of serum tnf-a, il- levels, lung cytoplasmic p-ijb-a, nuclear nf-jb p expressions, nf-jb p dna-binding activity, and ali occurrence in endotoxemic rats. in contrast, niacin preserved lung cytoplasmic ijb-a expression dose-dependently in endotoxemic rats.conclusions. niacin attenuated acute lung injury and improved survival during sepsis in rats. the protective effects of niacin were associated with the down-regulation of nf-jb pathway. niacin can be considered as a therapeutic agent for sepsis. f. barbani , m. boddi , r. cammelli , a. cecchi , e. spinelli , m. bonizzoli , a. peris university of florence, postgraduate school of anesthesia and intensive care, florence, italy, university of florence, department of critical care medicine and surgery, florence, italy, careggi teaching hospital, anesthesia and intensive care unit of emergency department, florence, italy introduction. acute kidney injury (aki) is a frequent complication in critically ill patients. there is emerging evidence that aki can lead to chronic kidney disease and that even only partial renal recovery after aki is associated with a higher long-term mortality.objectives. we investigated whether measurement of renal resistive index (rri) by ultrasound could predict renal function recovery after aki.methods. rri has been determined in patients who had been admitted (jan -feb to our mixed intensive care unit (icu) and referral trauma center (careggi teaching hospital, florence, it) and developed aki. rri measurements were performed within h from aki diagnosis, according to rifle criteria. renal recovery was defined as the return to the normal renal function parameters.results. patients studied were ( male vs. female) with a mean age of . ± . years. aki was due to sepsis (n = ), shock (n = ), rhabdomyolysis (n = ), abdominal compartment syndrome (n = ) and major surgery (n = ). mean length of icu stay was ± days. at discharge patients showed a complete recovery of renal function, while patients had persistent altered renal function parameters or needed renal replacement therapy (rrt); mortality rate was . % ( / ) . rri measured at aki onset was significantly higher in patients with persistence of renal failure than in patients with complete renal recovery ( . ± . vs. . ± . , p \ . ). rri [ . had a sensitivity of % ( % ci - %), a specificity of % ( % ci - %) and a positive likelihood ratio of . ( % ) for persistent renal dysfunction at the discharge.conclusions. our findings suggest that doppler-based determination of rri at the onset of aki can identify those patients who are at greater risk for no complete recovery of renal function. further studies on larger populations are required to confirm these preliminary results so to promote therapies dedicated to this high risk population.conclusions. apache score on admission, hypothermia and mean arterial pressure are not statistically significant, but age approached significance at % level in ccu survival. blood sugar control is not statistically significant at % level but approached significance as p value was less than . for ccu survival. for hospital survival,age is significant at % level; apache score on admission and mean arterial pressure are significant at % level while cardiac index, hypothermia and glycaemic control are not statistically significant . in the intensive care society (ics) published a care bundle for the management of patients following cardiac arrest . the american heart association now recommends regionalisation of post-resuscitation care following out of hospital cardiac arrest (ohca), in a centre capable of providing rapid therapeutic hypothermia, h emergency angiography and percutaneous coronary intervention (pci) as necessary . objectives. the audit's purpose was to evaluate work load, treatment and outcomes of ohca on the icu following publication of the ics care bundle and inception of a h pci service in our hospital. methods. retrospective audit of ohca patients admitted to icu from / to / to examine number admitted, cause of arrest, treatment and mortality. predicted mortality from the icnarc model was used to calculated standardised mortality ratio (smr). comparison was made with an audit of ohca patients between / and / . the sample was subdivided into subgroups with cardiac and non-cardiac cause for ohca. the chi-square test was used in analysis. results. comparison conclusions. we demonstrated: . a significant increase both in the absolute number of ohca and the proportion due to cardiac causes, due in part to in-region transfers for emergency angiography/pci. . a significant increase in the use of angiography and pci, increasing use of therapeutic hypothermia and iabp. . improved survival from previous audit. . better than predicted survival, particularly in the 'cardiac' group. this audit lends support for the protocolised icu care of post-ohca patients in a regional centre able to offer h emergency pci. there is scope for increased use of cooling for arrests of all causes, and extending provision of angiography/pci to vf arrests and those of unknown cause . reference(s). . despite all the research, education and training that has gone into the field of cpr during the last years, survival rates remain bleak for the majority of patients . so, what is lost in translation? much of the problem is that what the medical community is being trained to do is not being replicated in clinical practice . given this discrepancy, along with the deleterious outcomes, we conducted a manikin-based study to assess the quality of ventilation delivered during simulated cpr, in a large uk centre. objectives. to demonstrate whether uk-based medical personal were adhering to ventilation guidelines and to see how this result varied across specialities. methods. a simulated cardiac arrest scenario was undertaken by (a- . , power- %) participants from a range of medical specialties. participants were asked to asynchronously ventilate our manikin for a period of min during which time tidal volumes (tv), minute volume (mv) and ventilation rates (vr) were recorded. to help limit outside influence, at no point during the trial was any feedback about ventilation technique or als principals discussed with the participant. results. the mean and sd across the sample population for the mv, vr and tv were . l min - (sd . ), . min - (sd . ) and ml (sd ) respectively. comparison of groups can be seen in table introduction. mild hypothermia reduces cerebral blood flow (cbf) without concurrent increase of cerebral oxygen extraction rate in the first h after cardiac arrest, indicating a lower cerebral metabolic activity with a preserved metabolic coupling.objectives. the aim of this study was to assess the cerebral blood flow and cerebral oxygen extraction in patients treated with prolonged hypothermia, as previously was performed in newborn infants with perinatal asphyxial encephalopathy . patients were included after restoration of spontaneous circulation (rosc) after asystole, pulseless electrical activity based circulatory arrest or after rosc after ventricular fibrillation based prolonged resuscitation. in this prospective observational study comatose patients after cardiac arrest were treated with prolonged hypothermia for h. after h patients were passively rewarmed. mean flow velocity in the middle cerebral artery (mfv mca ), reflecting cbf, was measured after , , , , , , , , and h after admission to the icu by transcranial doppler (tcd). jugular bulb oxygenation (sjbo ) and arterial oxygenation were measured at intervals of h. introduction. isoflurane is a volatile anesthetic known for its direct vasodilating effect on cerebral vessels, producing a cbf increase. moreover, it has been shown in animal studies that isoflurane has neuroprotective properties, inducing tolerance to ischemia when used as a preconditioning agent. at the present time, isoflurane is not used as a sedative agent in neuroicu because of the fear of an increase in intracranial pressure (icp) caused by the increase in cbf. however, sah patient at risk for vasospasm may benefit from an increase in cbf. the ischemic risk will peak at day - , leaving a window of opportunity for neuroprotection. objectives. we decided to measure rcbf during traditional intravenous sedation with propofol and during volatile sedation with isoflurane in sah patients not having intracranial hypertension. the clinical trial was approved by the hospital irb and registered on trial.gov (nct ). we enrolled sah (fisher - , wfns b ) patients, monitored with an intraparenchimal icp device and a thermal diffusion probe (tdp, hemedex) for the assessment of rcbf. an icp [ mmhg was an exclusion criteria. cerebral and haemodynamic parameters were assessed at steps:step during sedation with propofol - mg/kg/ h; step : after h of sedation with isoflurane . - % mac administered through an anesthetic conserving device; step after h of propofol re-started at the same infusion rate. in all patients sedation with isoflurane produced an increase of rcbf although not yet significant in the population (step : ± ml/ g/min; step : ± step : ± ). jugular vein oxygen saturation, sjo , was significantly higher at the end of the isoflurane step (step : ± %; step : ± ; step : ± ). icp did not change significantly and remained below the pathological threshold (step : . ± ; step : . ± ; step : ± mmhg).conclusions. the small population of this pilot study phase causes a lack in statistical significance, however our data already suggest that isoflurane induces a marked cerebral vasodilatation and an increase in rcbf compared to propofol. patients with a normal icp did not develop an intracranial hypertension. at short and long term and its correlation with severity scales, scales of quality of life and endovascular treatment m there is not a consensus about which scales should be used to define the outcome after aneurysmal subarachnoid hemorrhage. objectives. the purpose of this study was to determine the risk factors and impact on functional outcome and quality of life months after spontaneous sah due to ruptured intracranial aneurysms. methods. we performed a prospective study of patients with aneurysmal spontaneous sah admitted to our centre from july to august . diagnosis of sah was done by ct and ethiological diagnosis by brain angiography. we paid attention to previous pathological history, clinical characteristics at admission and radiological characteristics. the severity was measured by the hunt-hess (hh), wfns, graeb and fisher scales. the months outcome was assessed by the glasgow outcome scale (gos) and modified rankin scale. the basic activities of daily living were evaluated with the barthel index. moreover, patients were asked about their subsequent incorporation to their previous occupation. we divided our population into two groups depending on the clinical grade at admission (hunt-hess scale): group i, hh , or ; and group , hh or . long-term followed up continues. results. during the year of study a total of patients have been included. the mean age of patients was years with a prevalence of % in women, being arterial hypertension and smoking history the main factors of related risk. the angiography was performed in . % of the patients. an aneurysm was confirmed as the origin of the bleeding in . %. poor clinical grade at admission (hh or ) was associated with apache ii, sofa, glucose, more sah computed tomography on admission, and infection and icu stay. there is % mortality in the series. after a months period, group patients (hh or grade) had a severe disability and functional dependence to perform instrumental and basic activities of daily living (p = . ). only % of patients were able to return to their previous occupation months after the initial bleeding. scales and outcome by clinical grade at admission introduction. aneurysmal subarachnoid hemorrhage (asah) remains a therapeutic challenge due to unacceptably high levels of mortality and morbidity. for survivors of the initial insult, cerebral vasospasm and related delayed ischemic deficits are the major determinants of final outcomes. traumatic sah (tsah) occurs in as high as % of patients with tbi, and is associated with a twofold increase in risk of death. statins may be an alternative for conventional treatments of vasospasm due to their beneficial pleiotropic effects on cerebral vasomotor reactivity as well as absence of negative haemodynamic influence.objectives. the goal of our study was to examine the effects atorvastatin therapy on cerebral vasospasm after asah and tsah as well as on short term outcomes of icu patients (length of stay and severity of condition upon discharge from icu). hypertonic saline infusion is an alternative to mannitol to decrease intracranial pressure before craniotomy [ , ] . previous studies have demonstrated that both hypertonic saline and mannitol interfere negatively with various components of blood coagulation [ , ] . normal blood coagulation capacity is essential during craniotomy and, therefore, we created an in vitro model to examine the effects of hypertonic sodium chloride and mannitol solution on whole blood coagulation. fresh citrated whole blood, withdrawn from volunteers, was diluted with . , . or . % sodium chloride solution or % mannitol to make vol.% and vol.% hemodilution in vitro. the diluted blood and undiluted control samples were analyzed with thromboelastometry (rotem Ò ) using two activators, tissue thromboplastin without (extem Ò ) or with cytochalasin (fibtem Ò ). all the study solutions with the same vol.% hemodilution induced comparable decrease in hematocrit. in extem Ò analysis, alpha-angle was smaller in the mannitol group than in the . % or . % sodium chloride group after vol.% dilution (p. ). in vol.% hemodilution, alpha-angle was also more decreased, and clot formation time more delayed in the mannitol group than in the . , . or . % sodium chloride groups in extem Ò analyses (p \ . ). maximum clot firmness (mcf) in extem Ò analysis was similar with all the study solutions after vol.% dilution, but after vol.% dilution mcf was weaker in the mannitol group than in the other groups. mcf was also weaker in . % than in . % sodium chloride group after vol.% dilution. in fibtem Ò analysis, mcf was stronger in the . % sodium chloride group than in the mannitol group after both dilutions (p \ . ). a or vol.% dilution of % mannitol disturbs whole blood coagulation more than equiosmolar . % sodium chloride. this disturbance seems to be attributed to overall clot formation and strength but also to pure fibrin clot firmness. . % sodium chloride might be more favorable than mannitol before craniotomy in patients with high bleeding risk. introduction. delayed cerebral ischemia (dci) is a major complication after aneurysmal subarachnoid haemorrhage (sah), occurring in around % of patients and increasing case fatality . - -fold. induced hypertension, alone or in combination with haemodilution and hypervolemia (triple-h), is used around the world as a therapy in the treatment of dci, but its efficacy in improving outcome is not based on a randomised clinical trial. objectives. to investigate the outcome of induced hypertension versus no induced hypertension in patients with dci after aneurysmal sah. study design a multi-centre, single blinded, randomized controlled trial. study population patients admitted after recent sah with a treated aneurysm and dci based on the onset of a new focal deficit and/or a decrease of the level of consciousness of at least point on the glasgow coma scale with exclusion of other causes of deterioration, will be randomized to either hypertension (n = ) or no hypertension (n = ). interventions in the intervention group, blood pressure will be raised with norepinephrine or additional dobutamin in case of low cardiac output. when clinical improvement occurs, hypertension will be continued for h, after which the dose norepinephrine will be tapered daily, but resumed in case of clinical deterioration. when no clinical improvement occurs within h, induced hypertension will not be continued. patients in the reference group will be treated according to the standardised sah treatment protocol of the participating centre including oral nimodipine and normovolaemia without haemodilution. main outcome measurement the modified rankin scale at months after the sah, will be compared between patients who were randomized to induced hypertension and patients who were randomized to no induced hypertension. objectives. to investigate brain metabolism at different serum glucose levels.methods. six patients with aneurismal sah and vasospasm were enrolled in the study (age . ± . ; male/female / ; . cerebral microdialysis was used in all patients. microdialysis catheters were placed into ''lesioned'' (brain tissue perfused by involved artery) and ''intact'' brain tissue. glucose levels in arterial blood (glu art ) and in brain interstitial fluid were compared. we analyzed brain glucose levels, intracranial pressure (icp), lactate/pyruvate (l/p) ratio, pao , paco and cerebral perfusion pressure (cpp) at blood glucose levels b mmol/l (group i, n = ), . - mmol/l (group ii, n = ), . - mmol/l (group iii, n = ), c mmol/l (group iv, n = ). we found out tight correlation between glucose levels in arterial blood and in ''lesioned'' brain tissue (n = ; r = . ; p \ . ) and weak correlation between gluart and glucose levels in ''intact'' brain tissue (n = ; r = . ; p \ . ). pao , paco , icp and cpp were comparable between groups. glu art was . ± . mmol/l in group i, . ± . mmol/l in group ii, . ± . mmol/l in group iii and . ± . mmol/l in group iv. normal glucose levels in arterial blood (group i) were accompanied by low glucose levels in ''intact'' ( . ± . mmol/l) and ''lesioned'' ( . ± . mmol/l) brain tissue. arterial blood glucose elevation has led to significant increase in brain glucose levels. but brain glucose levels were in normal ranges during hyperglycemia. glucose levels in ''intact'' brain tissue: . ± . mmol/l (group ii), . ± mmol/l (group iii), . ± . mmol/l (group iv). glucose levels in ''lesioned'' brain tissue: . ± . mmol/l (group ii), . ± . (group iii), . ± . (group iv). we didn't find out any significant differences in l/p ratio at different blood glucose levels. however, low glucose levels in ''intact'' brain tissue (b . mmol/l; . ± . mmol/l; n = ) were accompanied by significant increase of l/p ratio ( . ± . vs. . ± . at normal brain glucose levels (c . mmol/l; . ± . mmol/l; n = )). we didn't notice any significant differences in l/p ratio in ''lesioned'' brain tissue at different brain glucose levels, opposite to intact brain tissue. l/p ratio was . ( . ; . ) at glucose levels in ''lesioned'' brain tissue b . mmol/l ( . ± . mmol/l; n = ) vs. ( . ; ) at glucose levels in ''lesioned'' brain tissue c . mmol/l ( . ± . ; n = ).conclusions. hyperglycemia is not accompanied by high glucose levels and brain metabolism impairment in ''intact'' and ''lesioned'' brain tissue in severe patients with aneurismal sah. low glucose levels in ''intact'' brain tissue are related with significant increase of l/p ratio. introduction. the national confidential enquiry into patient outcome and death report found that less than % of patients with a severe head injury received a standard of care that was judged to be good [ ] . our intensive care unit (icu) at the royal cornwall hospital, a large district general hospital, is one of the few non-neurosurgical centres in the uk to use intracranial pressure (icp) monitoring. we aimed to assess if the practice of icp monitoring in our non-neurosurgical centre was valuable and safe. retrospective audit of case notes and charts of all patients admitted with traumatic brain injury receiving icp monitoring over a year period from st january until st january . a total of patients who had icp monitoring for traumatic brain injury were identified. the codman tm strain-gauge catheter was used in all cases, ( %) were male, ( %) were female. mean age was years (range - ). median reported gcs at the scene of injury was (range - ), median gcs prior to intubation was (range - ). median apache score was (range - ). all patients were discussed with the neurosurgical referral centre. patients were monitored for a median of days (range [ ] [ ] [ ] [ ] . icp was raised in patients ( %). elevation of icp triggered the following interventions: patients ( %) received hyperosmolar agents, patients ( %) were treated with therapeutic hypothermia, patients ( %) with barbiturate coma and none of the patients received steroids. patients were transferred to a neurosurgical centre ( % of patients with elevated icp, % of total). complications comprised one minor intracranial haematoma and one monitor failure. review of documented care bundles for head-injury patients revealed: head-up tilt in %, gastric protection in %, normoglycaemia in %, early enteral nutrition in %, appropriate thromboprophylaxis in %, appropriate sedation in % and appropriate analgesia in %. % survived to hospital discharge.conclusions. in our audit the majority of patients received specific treatment for raised icp, which might have gone undetected without invasive icp monitoring. at the same time most patients were managed without neurosurgical intervention. in light of the paucity of neurocritical care beds [ ] this approach appears to help to select a suitable subgroup of patients needing transfer to a specialist centre. our data adds weight to the evidence that icp monitoring is a valuable and safe monitoring modality in a non-neurosurgical icu if used appropriately within established guidelines and in collaboration with a neurosurgical referral centre. introduction. assessment of injury severity and prediction of outcome represent major challenges following severe traumatic brain injury (tbi). objectives. this study was aimed to evaluate relationships between cerebrospinal fluid (csf) levels of purported biomarkers of tbi including glial fibrillary acidic protein (gfap), ubiquitin c-terminal hydrolase (uch-l ) and alpha-ii spectrin breakdown product (sbdp ), and partial pressure of brain tissue oxygen (ptio ) as well as brain temperature during the first h and up to days post-injury.methods. twenty-seven severe tbi patients with csf drainage and invasive monitoring (licox probe) have been studied with quantitative csf-elisa for sbdp , uch-l and gfap on admission and every h up to days. in the first h, biomarker levels decreased while those of ptio increased. all three biomarkers correlated with ptio (p \ . , p = . and p = . , respectively). after the first h, there were statistically significant changes in levels of the three markers as well as in levels of ptio (p = . , p \ . , p = . , p \ . , respectively). however, the correlation between biomarkers and brain tissue oxygenation was sustained and, for uch-l improved (p \ . ). no significant correlations between biomarker levels and brain temperature were found. the results indicate that cfs levels of sbdp , uch-l and gfap are related to ptio following severe tbi. future studies are on their way to unravel whether these biochemical markers and ptio measurement could serve the better care of the head injured. introduction. this was a pilot study to compare the cerebral neurochemical changes in patients with traumatic brain injury (tbi) who underwent conventional blood glucose level (bgl) control and intensive bgl control with continuous titrated insulin.objectives. to demostrate that intensive glycaemic control using insulin induced a decrease of cerebral glucose.methods. this prospective, randomized study was conducted in traumatic brain injury patients in a surgical and trauma intensive care unit. patients admitted over an -month period with tbi were prospectively divided into two groups according to the method used for bgl control: the intensive group consisted of patients who underwent continuous titrated insulin infusion to maintain a lower normoglycemic level of - mmol/l, and the conventional group consisted of patients whose bgl was maintained at between . and . mmol/ l using conventional sliding scale bolus subcutaneous insulin administration. data on cerebral haemodynamics, interstitial brain oxygenation (ptio ( )) and neurochemical monitoring were collected via microcatheters inserted in the penumbral region. we analyzed , cerebral microdialysis samples. in patients treated with intensive insulin therapy, there was a reduction in microdialysis glucose by % of baseline concentration compared with a % reduction in patients treated with a conventional blood glucose level control. intensive insulin therapy was associated with increased incidence of microdialysis markers of cellular distress, elevated glutamate ( ± vs. ± %, p \ . ), elevated lactate/pyruvate ratio ( ± vs. ± %, p \ . ) and low glucose ( ± vs. ± %, p \ . ), and increased global oxygen extraction fraction. cerebral microdialysis glucose was lower in nonsurvivors than in survivors ( . ± . vs. . ± . mmol/l, p \ . ).conclusions. intensive glycaemic control using insulin induced a decrease of cerebral glucose and an increase in microdialysis markers of cellular distress. in patients with severe brain injury, tight systemic glucose control is associated with increased mortality. introduction. we have previously used c-flumazenil positron emission tomography to show that selective neuronal loss in the thalamus is pervasive after traumatic brain injury (tbi) and correlates with functional outcome, findings that are concordant with previous post-mortem data. the mechanisms responsible are unclear, but may involved global hypoxia/ischaemia as well as retrograde degeneration.objectives. we hypothesised that early brain tissue oxygenation would correlate with late diffusion tensor imaging (dti) abnormalities in the thalamus, and therefore, help to provide an explanation for late neuronal loss. nine patients underwent brain tissue oximetry (pbo ) following acute tbi, using a licox pbo probe, sited in structurally normal frontal white matter. mean pbo was calculated for the duration of their intensive care admission. at a median of . months (range - days) they underwent magnetic resonance imaging, including dti. apparent diffusion coefficient adc (maps) were created, adc calculated in regions of interest in the frontal lobes, splenium of the corpus callosum and thalami, and correlated with mean pbo using spearman's rho. ethical approval was obtained from the local research ethics committee, and assent from next-of-kin was obtained in all cases.results. mean pbo was inversely related to adc in both frontal lobes (r = - . and - . ; p = . and . ), and with the adc in the thalamus bilaterally (r = - . and - . ; p = . and p = . ). in contrast, no correlation was seen between mean pbo and adc in the splenium of the corpus callosum, a common site of traumatic axonal injury (tai; p = . ).conclusions. the inverse correlation of mean pbo associated with adcs in the monitored brain region is unsurprising, but the correlations observed with contralateral regions and deep grey matter suggest that the burden of tissue hypoxia has a significant impact on secondary neuronal loss across the brain. in contrast, the lack of correlation with adc changes in an area at risk of tai suggests a less significant impact of hypoxia on the progression or maturation of tai. the correlations with measures of thalamic microstructural injury are particularly significant, since they establish a clear link between acute physiology, tissue fate in key brain regions, and clinical outcome. introduction. earlier studies have suggested that autonomic dysfunction is associated with poor outcome in traumatic brain injury (tbi).objectives. this study was performed to assess changes in baroreceptor sensitivity and heart rate variability as indices of autonomic dysfunction in relation to icu management variables during early tbi.methods. ten patients ( females/ males) with a median age of (interquartile range, iqr, - ) admitted to icu following tbi were prospectively studied for the first consecutive days. all patients were sedated and mechanically ventilated with icp monitoring in place. high fidelity signals at hz were sampled for ecg and invasive arterial pressure (radial) to monitor baroreceptor sensitivity (brs) based on three or more consecutive beats in which successive systolic pressure and rr intervals increased or decreased with the threshold set at mmhg and ms, respectively. heart rate variability (hrv) was analysed by fourier transformation in the low (lf, . - . hz) and high frequency (hf, . - . hz) domains. the lf/hf ratio and total power ( . - . hz) were also calculated for hrv. management variables included use of inotropes, vasopressors, icp, use of decompressive craniectomy, icu length of stay (los) and mortality. statistical significance was set at p \ . using mann-whitney one-way anova and spearman correlation tests. median days (and iqr) were . ( - . ) for inotropes, . ( - ) for vasopressors and . ( - . ) for icu los. brs and lf, hf, lf/hf ratio and total power were all depressed throughout early icu management with no significant changes in the first week. no significant correlations were found between brs/hrv and days on inotropes/vasopressors or icu los. four patients underwent decompressive craniectomy and one patient died while in icu. no correlation was found between these events and brs or hrv changes brs, hrv and icp data conclusions. both brs and hrv were depressed early following tbi but did not correlate to icu management variables. while autonomic dysfunction is evident early in the icu treatment of tbi, no evidence to support an association between severity of impairment and icu outcome was found in this pilot study. introduction. in neurocritical care, raised intracranial pressure (icp) is associated to a poor outcome and its detection still leads the therapeutic management of the patients suffering from head pathologies.objectives. although invasive devices are recommended to detect intracranial pressure (icp), we investigated the correlation and the reliability with non-invasive ultrasound techniques as the optic nerve sheath diameter (onsd) assessed by ultrasonography and the pulsatility index (ip) measured by transcranial doppler sonography (tcd). we included patients suffering from intracranial hypertension, sedated and mechanically ventilated and control individuals, chosen among healthy people. all the patients had icp measured invasively either by external ventricular drains (evd) or intraparenchymal catheter. everyone underwent non-invasive measurements of onsd bilaterally and simultaneous medial cerebral artery ip assessment at the side of the best window.results. onsd had a significant difference between volunteers ( . ± . mm) and patients ( . ± . mm). ip's were . ± . for the control individuals and . ± . for the patients (media icp = ± mmhg) and also revealed a significant difference. onsd strongly correlated with icp (y = . x + . , p \ . , r = . ) whereas ip had some correlation but without statistical significance (y = . x + . , p = . , r = . ). onsd was found wider (p = . ) within patients with both icp and ip abnormal. a strong correlation was found between onsd and ip (y = . x + . , p = . , r = . ). however, we could not find the best cut-off values of onsd and ip for predicting an icp [ mmhg.conclusions. ip and onsd correlated with icp with a stronger reliability results of the latter, suggesting the possibility to integrate their use in the case of icp invasive monitoring would be contraindicated or not available. we studied the effects of normothermic therapy during the acute phase of traumatic brain injury.methods. twenty patients ( males, ± years old) who were admitted in the intensive care unit due to traumatic brain injury (glasgow coma scale upon admission - , marshall scale ii to iv) were studied. if patients' core temperature was above . °c, a cool line Ò , alsius corporation, irvine, ca. usa intravascular heat exchange central venous catheter (coolgard Ò device) was inserted via the femoral or the subclavian route, in order to achieve and maintain a target temperature of °c. intracranial pressure (icp) was measured (a) invasively by means of a intraparenchymal catheter (camino, camino laboratories, san diego, ca, usa) and (b) noninvasively by means of transcranial doppler sonography (tcd), using a philips hd xe (philips medical systems; bothell, wa, usa) equipped with a mhz transducer and a mhz linear transducer. estimated icp was calculated by tcd using the equation proposed by czosnyka and colleagues and the pulsatility index (pi = vs -vd/vm) was assessed in the middle cerebral artery bilaterally. all measurements were conducted at baseline and repeatedly on a daily basis for the next days and the average values were used in the statistical analysis.results. target temperature (t: . ± . °c) was achieved within the next h of the catheter insertion. at baseline (t: . °c) pulsatility index (pimean) was . ± . , icpmean/invasive was ± . mmhg and icpmean/noninvasive was . ± . mmhg. invasive and noninvasive icp values correlated significantly (r = . , p \ . ). following ± h from the insertion of the catheter the above parameters were significantly decreased as compared to baseline values (pimean = . ± . , icpmean/invasive = ± . mmhg, icpmean/noninvasive = . ± . mmhg, respectively; all p \ . ). out of patients, progressed towards brain tamponade, remained in a persistent vegetative state and were discharged with normal consciousness and motor deficits. however, due to the small number of patients no analysis could be performed to estimate the possible impact of normothermic therapy on the survival of these patients. these preliminary results suggest that normothermia during the acute phase of traumatic brain injury may decrease icp and ameliorate cerebral blood flow. introduction. extracranial organ dysfunctions are extremely common in patients with severe traumatic brain injury (tbi). although it has been shown that development of tbiinduced multiple organ failure (mof) is associated with a poor outcome, the underlying mechanisms leading to mof after tbi have not been investigated.objectives. to investigate in vitro the effect of plasma from tbi patients developing different degrees of organ failure on human endothelial cells.methods. ten consecutive severe tbi patients were included. gcs, iss and sofa score were recorded at admission; sofa was also recorded after days. plasma samples were obtained at the same time points. adhesion of freshly isolated human neutrophils on spontaneously transformed human umbelical vein endothelial cells (ecv ) was evaluated after h in vitro stimulation with % of plasma collected from tbi patients days after admission. expression of intercellular adhesion molecule- (icam- ) was assessed by immunofluorescence. to determine the impairment of the endothelial cell barrier function, trans-endothelial electrical resistance (teer) and permeability to fitc-dextran were measured. plasma from healthy volunteers were used as control. data are expressed as mean ± sd. results from different experiments were compared by unpaired t test.results. ten male patients were enrolled, mean age ± , gcs ± , iss ± , sofa was . ± . on admission and ± . on day . plasma derived from tbi patients increased the adhesion of neutrophils on ecv cells ( ± vs. ± cells/field, p \ . ), induced a significant reduction of teer ( . ± . ohm/cm vs. . ± . ohm/cm , p \ . ) and caused a concomitant increase of endothelial permeability to dextran ( . ± . vs. . ± . %, p \ . ) compared to control (healthy plasma). a visual up-regulation of icam- expression was also observed. there was a significant correlation between delta sofa score (day -day ), calculated excluding gcs, and neutrophil adhesion on endothelial cells exposed to plasma from tbi patients (p = . , r = . ).conclusions. plasma from patients with tbi causes the increase of endothelial permeability and neutrophil adhesion, which correlates with the development of extracranial organ dysfunction expressed by sofa. these results suggest a mechanism potentially responsible for the development of mof after traumatic brain injury.grant acknowledgment. fondi universitari ex- %, regione piemonte-ricerca sanitaria finalizzata. objectives. the aim of this study is to describe indications of dc and outcomes in our unit.methods. it is a retrospective revue collecting patients who had a dc for severe icht between january and july . inclusion criteria were: icht refractory to medical management due to cerebral oedema. we define intractable icht as intracranial pression (icp) over cmh o, pupil modification, neurologic deterioration persisting more than min despite medical management or ct scan findings. exclusion criteria were imminent cerebral death, icht due to an acute hematoma, tumour, hydrocephalus and prediction of short life expectancy. objectives. historically, research has targeted problems experienced several months post discharge from critical care, namely using data from follow up clinics \ months after the critical illness. in contrast, this study aimed to review data from patients recently transferred from critical care to the wards. this data can then be compared with patients' progress after earlier rehabilitation. methods. this was a prospective, longitudinal study, involving long stay critical care patients ([ days), between april - . this cohort included all patients nursed within our itu/hdu, regardless of speciality, age or gender. all reviews took place whilst the patients were still hospitalised. the study used qualitative data, using specifically designed questionnaires which highlighted the type of long term problems our patients suffered. these were developed using data from previous informal patient interviews and the had (hospital anxiety and depression) questionnaire. the latter was considered too intrusive for the ward environment. a data base was used to list the frequency of these problems to provide quantitative data. a total of patients were reviewed over years. the qualitative data highlighted different, common morbidities, in addition to disease specific morbidities. between, april - , % of patients demonstrated at least physical or psychological problems and % displayed or more. the quantitative data showed the most prevalent morbidities were: poor mobility at %, nightmares %, loss of appetite % and insomnia %. year showed similar findings, plus global weakness at %.conclusions. this research showed significant post critical illness morbidities in this cohort which appeared to impact on the patients' recovery on the wards. the challenge for our follow up is to target support and rehabilitation whilst the patients are in critical care and then re-evaluate the results. if this expedites a return to a near normal quality of life, it will have improved the efficacy of our service and may impact on follow up care in general. . it may affect the balance of family and change their roles and responsibilities, mainly due to the separation from their relative imposed by hospitalization. this admission may also generate other discomforts to the family, as relationship problems, emergence of diseases, lack of financial resources for expenditures now installed, anxiety, depression, fear and irritability . objective. to get to know the discomfort that characterizes the changes experienced in the daily life of families who have a relative in icu. method. this is a qualitative study, conducted in a general icu of a large hospital in the city of salvador, bahia, brazil, from august to october of . nine relatives of people hospitalized for at least h in icu were interviewed. the data were analyzed by the use of procedures of analysis of grounded theory. results. the hospitalization of a family member in icu produced discomfort for her, as the uncertainty of recovery, the fear of loss and the sudden physical separation of the relative. the interaction between the huge discomfort of life threat and the separation from the relative, in turn, spawned other discomforts in the daily lives of families, expressed by two categories. the first one, having difficulties to answer psychobiological needs, meant for the family member the experience of sleep deprivation, loss of appetite and constant concern with the relative. the second one, suffering a discontinuity in the daily life, meant to the family the disruption of daily activities with the relative, irritability front other family members, removal of the routine of home, loss on work performance and studies and difficulties to enjoy the leisure and recreation.conclusion. the coping of illness and hospitalization of a relative in intensive care produced discomfort for family members, characterized by changing of the routine of the daily life and care for oneself. the family's attention is primarily directed toward the ill relative. it starts to experience the routine of a hospital and disrupts the organization of familiar and personal life, it finds itself suffering a break from daily life. the discomfort experienced by the family can be minimized by practices of the healthcare team, which provide care, information, support, safety and convenience. (fig. ). this is a unique opportunity to study the effects of nursing environment on sleep quality and quantity in icu patients. to study the effects of nursing environment on sleep quality and quantity in icu patients. a total of patients will be included in this ongoing study: ten subjects who were admitted to the old, ward-like icu (fig. ) , and ten patients who will be admitted to the new, single-room icu (fig. ) . objectives. in order to understand the family's perception of nursing care, the authors undertook this study, assessing the family satisfaction and use the results to increase the quality of care.methods. this is a qualitative study of inductive nature. data was collected along the time of the study by in-depth interviews, to six relatives of each patient, after discharge the intensive care unit. for data analysis we followed the steps of the phenomenological method, according to max van manen ( ) . results. from data analysis, the results were divided in categories: ) relative needs; ) icu environment; ) relative's feeling; ) nurses role and ) suggestions. all this categories were grouped in a central theme called ''being a relative in a general intensive care unit''. the results show that relatives of patients admitted to the intensive care unit often require complete knowledge of the medical condition of the patient, a specific area for that purpose and a comfortable waiting room. they express the need to be near the patient and participate in care. they feel fear and anger with the situation that inevitably are forced to live and think, mostly, that nurses are effective and efficient in meeting the needs of the patient and family. conclusions. it is essential to promote attitudes and behaviors that provide comfort, safety and privacy for relatives, and acknowledge that they have a role in the process of care, reinforcing their importance in decision making process.introduction. heart failure (hf) is a complex syndrome that commonly affects elderly patients in whom it has a major impact upon longevity and quality of life. it is usually associated with symptoms such as dyspnoea, fatigue, and fluid retention, and results in frequent episodes of hospitalisation.objectives. this study was planned to examine the relationship between self-care behaviors and quality of life in patients with hf.methods. this study was planned and applied as a descriptive and a cross-sectional study. introduction. the hospitalization of a relative in icu, especially when it's unexpected, is considered a too stressful experience for the family, usually compounded by the disruption of daily life. from the relative's hospitalization at the icu, the family will necessarily interact with health practices, the rationality that underlie it and institutional objects that may be a source of comfort or discomfort , .objectives. to understand the situations defined as comfort to relatives of people in critical state of health and the sense of comfort in this situation.methods. this is a qualitative study conducted in the general icu of a large hospital in the city of salvador, bahia, brazil, from june to october of . fourteen family members of persons hospitalized for at least h in icu were interviewed by a specific questionnaire. all recorded interviews were transcribed and the data were analyzed by the use of procedures to encode the data of grounded theory. seven categories expressed the experience and sense of comfort for the relatives who had a person hospitalized in the icu: ) security: confidence of relatives in technical-scientific and humanistic team and in the possibility of recovery of the person who is hospitalized, ) reception: comfort experienced by the family by being treated as a person by the professional of icu when they interact with a supportive attitude, ) information: comfort experienced by the family when it feels conscious of the reality of the health condition of their relative and to receive guidance about the unit s routine, ) social and spiritual support: comfort experienced by the receiving of help and support of the family, friends and religion, ) proximity: the comfort of being close of the relative and being able to enjoy the interaction established between them, ) convenience: comfort experienced in interacting with pleasant elements and support of basic needs of the family, offered by the environment and physical structure of the hospital; ) integration with itself and the daily: the possibility of the family member to take care of himself, to help the relative and to give continuity to the family routine as it did before the hospitalization.conclusions. the comfort is a positive, subjective and dynamic experience, which changes in time and space, which is the result of the interactions that the individual sets with himself, with those around him and with the situations he faces, without losing view that every family is unique and can experience this process in a proper way. to ascertain the perceptions of icu nurses' about the needs of families of critically ill patients methods. this is a transversal study. the data were collected in four icus in the city of feira de santana, bahia, brazil, after approval by ethics and research committees. all clinical nurses of icus were interviewed. the brazilian adaptation of the critical care family need inventory (inefti) was used for measuring the degree of importance of needs of family members, valued at increasing levels from to . descriptive statistics were used for analysis, needs with a mean score [ were defined as having the greatest importance.results. the nurses identified % of needs as important for family members. the items related to security ''to be sure that the best possible treatment is being offered to the patient'' ( . ± . ), and the information ''to talk to the doctor every day'' ( . ± . ), were pointed out as the most important, with consistent results with the literature. some needs of support ''to have general guidelines on the icu at the first visit'' ( . ± . ) and comfort ''to have a bathroom near the waiting room'' ( . ± . ) were also identified as important. however, the needs of proximity, like being close to their relative was not identified as important to the family for all nurses.conclusions. the nurses identified the need for security and information as important, however the wish that the family has to be near their relative was not considered important, as described in the literature , , . a movement of nursing towards the family can be perceived, so nurses should plan their interventions based on knowledge of the demands of the family in order to promote care for the relief of immediate distress and anguish, which will consequently encourage the recovery of the ill relative reference(s). nurse educator, realized that with an ongoing critical care nursing shortage world wide, even when retention is high, some turnover is inevitable necessitating an orientation tool to guide charge nurses in assigning new hires to critically ill patients. impetus for this clinical orientation tool arose from observations that new hires were often overwhelmed or disengaged at the bedside, and patient assignments did not consistently foster the development of critical care skills. the orientation tool reflected a staged approach to patient assignments; gradually exposing the new hire to progressive levels of complexity. embedded within the tool were guidelines specifying performance competency expected of new hires at month intervals in their first year of critical care practice. evaluation at this stage involved on the spot interviews. use of the tool began in january . since its introduction, this tool has guided patient assignments for newly hired nurses. in six cases, nurses moved through the stages more quickly than anticipated. reports from staff nurses, clinical educator, patient care coordinator and nurse manager suggest that anxiety and stress of novice critical care nurses related to the complexity of patient assignments have decreased, and that the tool's structure provides clear goals and has enhanced satisfaction with the consolidation experience. our goal was to ensure the tool facilitated an optimal learning experience, structured around orientation standards and leading to the development of confident, competent practitioners. future plans for on-going evaluation include: formal surveys with present msicu staff, and exit interviews with nurses new to critical care who have left their msicu positions prior to the introduction of the orientation tool. ( ) has previously been claimed to show an association between improvement of score (or lack of) over time and survival status ( ) . severe sepsis in patients is associated with considerable mortality. activated protein c (apc) is a mediator of the inflammatory and coagulation systems, which has shown decreased mortality in severe sepsis ( ) beyond h sofa scores showed further distinct improvement over the apc infusion period in the survivor group, whereas minimal improvement was seen in the non survivors.change in daily sofa scores conclusions. our analysis appears to agree with levy's previous findings of increasing sofa (albeit modified) scores and mortality. we, however, looked at a different treatment period, (apc infusion rather than first day of sepsis) but, nonetheless, found the same association of increasing score and mortality and decreasing score and survival. the mean age in survivor group was considerably less than that in non survivors and this age discrepancy largely accounts for the difference in mean apache score ( points) between groups. the depicted trend in sofa scores is more apparent beyond the initial h of treatment, and suggests that improving sofa scores and outcome prediction is possible beyond the previously reported h. our numbers are small, but lend support to the predictive potential of repetitive sofa scores and outcome.objectives. this real-life registry was implemented to describe clinical characteristics of patients treated with drotrecogin alfa (activated) (daa) in france and the use of this drug.methods. this national multicenter observational study, proposed to intensive care units (icus) which used daa, was conducted by data abstraction from hospital files of patients admitted in icus and treated by daa. two sets of data were obtained: a) retrospective data collected between january st, and beginning of the prospective phase in each site; b) prospective data for patients treated until november . this current analysis aimed to describe the patients retrospectively enrolled and treated between january and april . statistical analysis was mainly descriptive. conclusions. this study showed a good concordance between the target population and population treated by daa in terms of treating patients with higher disease severity. patients treated in real-life had a particularly severe sepsis as shown by the saps ii score of and high number of organ dysfunctions at time of infusion initiation. the -month observed mortality was lower than the predicted hospital mortality of % with this level of saps ii. introduction. mortality in severe sepsis is variously described, but is often up to % ( ) . activated protein c (apc), a mediator of the inflammatory and coagulation system has shown a decrease of hospital mortality from . to . % ( ) at year post apc we found that patients ( %) out of were still alive ( patients are still less than year post apc and therefore not eligible for consideration). conclusions. this study is limited in size, but demonstrates further favourable evidence to support the administration of apc for patients with severe sepsis, and appears to contradict the cochrane findings ( ) . we have shown that our hospital survival has improved since initial report ( ) . we attribute this improvement in smr to better targeting of apc to the more severely ill septic patients (as evidenced by the increased apache score).longer term survival data was also encouraging, % of our patients were alive at year, post apc. this should be considered against an initial predicted survival to hospital discharge (never mind year) of . %. we find this result very promising, it would appear that initial survival advantage with apc is in fact sustained beyond hospital discharge. objectives. medication errors reported in a self reporting medical incident system were systematically analyzed to identify root causes and obtain preventive measures methods. all medication incidents received within year in a -bed mixed icu, were analyzed by trained persons in analyzing medical adverse events. the systematic approach consisted of five steps. . description of the incident in a causal tree. . all causes were classified into the main categories according to the prisma incident analysis tool (technical failure, organization failure, human failure, patient related and non classified). . all medication errors were categories into the broad stages of medication process (prescription, transcription, preparation, dispensation and administration). . the recovery phase of all near miss were analyzed. . development of an action matrix based on the most suitable solution (equipment, procedures, information/communication, training and motivation) for each root cause. . incidents/near miss were recorded. % were medication or fluid therapy related incidents/near miss. human intervention ( %), verification ( %) and organizational/ protocol ( %) were the most common causes of medication incidents/near miss. % of all errors occurred in the administration phase and % in the prescription phase. the most suitable solution for the recorded medication errors are shown in fig. . conclusions. this systematic approach reveals that introduction of new equipment, such as a patient data management system (pdms), and improvement of the procedures are the most important actions to reduce medication errors in our icu. objectives. this study is a descriptive study which is carried out in order to determine the perspectives of newly graduate and experienced nurses on medication errors working in a military education and research hospital. methods. this study was planned and applied as a descriptive and a cross-sectional study. study was executed at a military education and research hospital in turkey between july and august . totally nurses were involved, of those were newly graduate and were experienced nurses. data collection form which has been prepared by the researches in order to determine the perspectives of nurses on medication errors consists of two parts. the first part consists of questions prepared in order to determine the ages, departments, educational levels, experiences and some informative characteristics of the nurses. in the second part there is questionnaire form on perspectives of the nurses on medication errors which was prepared by gladstone in . the study was applied after written ethical approval of the ethical committee of the military education and research hospital and application permission of the nursing department. the application was realized by surveying on volunteer nurses after making necessary explanations about the aim of the study and the application procedures to the participants. the data were analyzed using percentages, mean ± standard deviation, chisquared test and independent-samples t test. conclusions. in this study among the causes of drug errors; tiredness and exhaustion of nurses is stated in the first place. it is thought that rearrangement of working hours of the nurses, reduction of long working hours by the nursing administration will be effective on preventing drug errors. ( ). to test the basic knowledge and practical implementation of picco measurements by icu personnel. descriptive trial in which (para)medical icu personnel were asked to participate in a written or online survey ( questions based on the information found in the manual of the picco system).results. so far, persons have participated: nurses and medical doctors ( were residents in training), all of them actively working in an icu. in total, % of the respondents knew that a picco co measurement is performed intermittently by transpulmonal thermodilution and on a continuous basis by arterial pulse contour analysis. about % is convinced that a picco measurement is an invasive procedure, while in fact it is considered minimally invasive. opinions are divided upon the indications for picco measurement. some participants do not know that the measurement of extravascular lung water provides valuable additional information in pts with acute hypoxic respiratory failure and some even believe that picco can also measure pulmonary capillary wedge pressures. the basic knowledge on co calibration is insufficient: % do not know that the temperature of the injection fluid should best be below °c and only % know that the volume of the calibration fluid depends on the patients' weight. % faulty believe that the patient has to be in the supine position to perform a measurement and % is not informed on the fact that the co obtained should not differ more than % from the mean co value. only % of the respondents carry out a rapid flush test before each picco measurement and only % know that the calibration fluid has to be injected in less than s to obtain a correct measurement. finally, % believe that it is necessary to input the cvp value to calculate a correct co, although % of the respondents correctly knew what to do in case the delta t°is too small and % could correctly interpret the thermodilution curves displayed in the survey.conclusions. from these data we can conclude that a big variation exists in the knowledge on the basic principles and the practical implementation of picco measurements. some confusion exists with regard to the terminology used. we conclude that (as with any new technique) high quality education on picco measurements is necessary for icu personnel. this education can be facilitated by a good protocol, that can be implemented by nurses and doctors at the bedside to avoid human errors. a.c. beers vu university medical center, intensive care, amsterdam, netherlands health insurance companies in the netherlands sign exclusive contracts with hospitals. patients are more critical and independent. they consciously choose a particular hospital or treatment. this is why our management gave high priority to the subject of customer service in their long term policy plan.objectives. in january a project group was launched, which aimed for a number of specific improvements but also by increasing awareness and enthusiasm for customer experience amongst employees. the project is focused on the experience or perception of patients and visitors.methods. the first step was a baseline measurement by hcg (hospitality consulting group). this measurement included interviews with employees from different icu locations and an online survey that was completed by employees, next of kin and other visitors. this resulted in a high score for commitment of staff towards patients and visitors. remarkably, employees thought that aspects for example reliability, professional care and privacy would be valued higher by customers. they attach more importance to how they are received, to empathy and sympathy. respondents also mentioned other things for improvement for example better signage, improved telephone access, better information about rules and procedures, unambiguity in approach, a better visibility of staff and a pleasant and hygienic department. . several improvements such as product, behavior and environment were achieved: we employed family counsellors, developed an information folder and started a pilot for an improved name badge. we can still make improvements in awareness, behavior and addressing each other on this subject. this year we plan to come to an agreement on standards, competencies and control by means of several management training sessions and workshops for employees. we can measure changes in patient satisfaction by family evaluation surveys or an instrument called netto promotor score. the netto promotor score (nps) indicates how many respondents will recommend our ward or hospital to their family and friends. to quote fred lee: ''if a service is provided as expected, patients or visitors will not remember it, they are merely satisfied. satisfied patients will forget a service quickly, have no story to tell to their family and friends and are not really loyal to your organisation. therefore you must create an unforgettable experience, because an experience that remains in memory, is told to others.'' reference(s). critically ill medical, post-surgical, and trauma patients are at greater risk for hyperglycemia with associated increase in mortality and morbidity. tight glycemic control (tgc) has been well documented as a method to control hyperglycemia by managing blood glucose fluctuations through carefully controlled continuous insulin infusion. in order to determine the amount of time it takes within practice for nurses to implement effectively a tgc protocol within the critical care unit, we conducted a pilot time-in-motion study to elucidate the effect on workload. a time-and-motion study was carried out at a hospital located in london, uk in order to document the time associated with tgc activities. a timing workflow, used to capture the key steps involved with effective tgc implementation when utilizing blood gas analyzers for the determination of whole blood glucose (bg) and the time required to complete each step, was designed and then validated by ccu staff. ccu staff was trained on the timing workflow and mechanism. independent observers shadowed ccu nurses, observing when a blood glucose measurement was taken, which steps were completed, and the length of time required to complete each step. other data such as time of the previous bg measurement and status of the last bg test was collected for analysis purposes. during the past few years, the increased incident rate of medical errors occurring in hospitals under governing of hong kong hospital authority has contributed significant attention from the public and health care policy makers. in such a situation, promote patient safety culture becomes paramount for all health care professionals and hospital settings. interdisciplinary teamwork is important in the intensive care units. the benefits of good teamwork have been well documented in the literatures. they included fewer delays, increase in working moral, increased in job satisfactory and decreased in medical errors. in relation to patient safety, fewer errors occur when there is strong teamwork because patient care activities are planned, well organized and standardized. therefore, substantial attention should be given to decrease of medical errors and nurture patient safety culture within high-risk areas such as icus. objectives.• to examine the perception of teamwork and patient safety culture of doctors and nurses between icus and within icu • to investigate the relationship between teamwork and patient safety culture of icu doctors and nurses methods. a cross-sectional surveyed of doctors and nurses in three intensive care units with various size, level of care and staff to patient ratio of hong kong hospitals. totally icu doctors and nurses have been included in this study. a modification of safety attitudes questionnaire developed by sexton and colleagues in was adopted. results. the overall response rate was . %. there were no significant difference of perception of teamwork and patient safety attitude among studied icu's doctors and nurses. however, icu (a) and icu (c)'s doctors demonstrated more positively and showed significant different in perceptions of teamwork (p = . ; . ) than nurses. regarding patient safety attitude, icu (a)'s doctor also showed significant difference (p = . ) and rated more positively than nurses working in the same clinical area. a highly statistically significant association between patient safety attitude and teamwork was shown in the spearman rho statistics with r s ( ) = . , p = . . conclusions. the rate of agreement on teamwork and patient safety attitude were higher in icu doctors. they were more likely to perceive effective teamwork and patient safety in the working area. nurses tended to rate both items lower. as teamwork has been shown to have strongest relationship with patient safety issues, more attention should be given to improve teamwork for icu nurses. tnf is upregulated within the alveolar space early in the course of ventilator-induced lung injury (vili), and plays a major role in the pathogenesis. we previously found in knockout mice that two tnf receptors play opposing roles during vili, with p promoting but p preventing pulmonary oedema. this suggests that specific blockade of the p receptor within the alveoli is a potential therapeutic strategy for vili. domain antibodies (dabs) are the smallest antigen-binding fragments of the igg molecule, which may have advantages over complete antibodies due to their small size (short half life, enabling regional delivery) and monovalent binding (no receptor cross-linking). objectives. we tested the effects of an intratracheally (i.t.) delivered dab that binds to and inhibits the mouse p receptor (biopharmaceutical r&d, glaxosmithkline), on pulmonary oedema and inflammation during vili. methods. c bl mice were ventilated with a high-stretch protocol (plateau pressure . - . cmh o, tidal volume - ml/kg, peep cmh o, o with - % co ). immediately after the start of high-stretch, mice were given an i.t. bolus of non-specific 'dummy' dab or p -specific dab ( lg in ll) and ventilated for up to h ( -hit model). as a -hit model, ng lps was included in the dab bolus. respiratory elastance (ers) and blood gases were monitored, and bal performed at termination. in the -hit model, lung cell suspension was analysed for intravascular margination of neutrophils (pmn), and bal fluid (balf) assessed for pmn infiltration and alveolar macrophage (am) activation using flow cytometry. results. high-stretch ventilation produced deteriorations in ers and po , and high balf protein in both models. treatment with the p -specific dab substantially attenuated all of these changes in the -hit model (table ). in the -hit model, p blockade prevented deteriorations in ers and po , and significantly decreased pmn margination, intraalveolar pmn infiltration and icam- expression on ams (table ) . introduction. ventilator-induced lung injury (vili) triggers a variety of molecular responses within the lungs. however, the contribution of these pathways to lung repair has not been identified.objective. to identify the molecular mechanisms involved in lung repair after vili.methods. vili was induced in mice by ventilation using high pressures ( cmh o) without peep for min. after this, pressure was decreased to cmh o and peep increased to cmh o for h more to promote lung repair. we quantified histological damage, protein content in alveolar lavage (balf) and different molecules in lung tissue (collagen, matrix metalloproteinases- and - , tnfa, ifnc, il- , il- , mip- and lix) in the different conditions (baseline, after injury and after repair). additionally, survivors and non-survivors to the repair phase were compared. the effects of the differentially released mediators were studied in a wound model using murine alveolar cells cultured in presence of balf obtained from ventilated animals, and human alveolar cells and balf from ventilated patients. results were compared using an anova, with a significance level of p = . . . mice were studied ( at baseline, after injury and after repair). high pressure ventilation caused lung tissue injury, with significant increases in balf protein content, mmp- , mmp- , tnfa and mip- , and a significant decrease in il- . during the repair phase, tissue injury was partially reverted, balf proteins and levels of tnfa decreased, but mmps and mip- persisted elevated. mortality during the repair phase was %. survivors showed lower levels of collagen and higher levels of mmp- ( ± vs. ± units, p \ . ) and mip- ( ± vs. ± pg/mg protein, p \ . ).blockade of mmp- , but not mip- , delayed wound closure in both murine and human alveolar cells cultured in presence of balf from ventilated mice or patients respectively.conclusions. vili is partially reversible by decreasing airway pressures and increasing peep. mmp- promotes epithelial repair.grant acknowledgment. universidad de oviedo (unov- -becdoc), ficyt (cof- - ). introduction. critically ill survivors present significant long-term brain-related morbidity. excessive end-inspiratory stretch during mechanical ventilation (mv), even in healthy lungs, may promote alterations in the local and the systemic inflammatory cascade. the effects of ventilator-induced systemic inflammation on brain structures are unknown. to characterize the role of the ventilatory pattern (high vs. low tidal volume (vt)) in the development of local or systemic inflammatory response and regional neuronal brain activation in rats. brains were processed for c-fos immunohistochemistry, as a cellular marker for activated neurons, in the following regions: thalamus, cerebral cortex, amygdala, hippocampus, hypothalamus, and caudal striatum. data were analyzed using one-way anova (p \ . ). results. map and lung compliance remained stable and in the normal range in both groups. pao decreased and paco increased at h in lvt. mv animals presented high levels of systemic and lung inflammatory mediators compared with baseline levels. hvt significanly increased tnfa and il- in plasma when compared with lvt group. in the lungs mv increased il- , il- , il- b and mip- proteins, irrespective of the vt level (lvt or hvt). mcp- only increased in hvt lungs, while tnfa lung levels are similar in ventilated and non-ventilated animals. a significant increase in the number of c-fos immunopositive neurons was only found in retrosplenial cortex and thalamus in hvt animals as a sign of neuronal activation of those areas. none of these two areas were activated in lvt or in control animals. mechanical ventilation produced a moderated systemic and lung inflammation in the context of a preserved lung function. high tidal volume ventilation promoted differential neuronal activation in the brain compared with lvt animals. these findings suggest a novel cross-talking mechanism between lung and brain in the context of experimental acute lung injury.grant acknowledgment. mec bfu - /bfi, fundació parc taulí. jl-a is senior researcher program i isciii, and ciberes. ( ).in an ex vivo perfused human lung preparation injured by e. coli endotoxin, allogeneic human mscs or the conditioned medium restored normal fluid balance ( ).objectives. we wished to evaluate the potential for mscs to modulate inflammation and enhance repair after ventilator induced lung injury (vili). adult male sprague-dawley rats were anaesthetised, orotracheally intubated and subjected to injurious mechanical ventilation. following the development of vili, animals were recovered and extubated. thereafter the animals received two intravenous injections of mscs ( . million cells) or vehicle immediately post injury and at h. the extent of the inflammatory response and recovery from vili, as measured by systemic oxygenation, respiratory static compliance, lung wet:dry ratio and lung lavage inflammatory cell infiltration, was assessed at h. mscs reduced inflammation and enhanced repair following vili. msc treatment improved respiratory static compliance, reduced total lung water as assessed by wet:dry ratio, and decreased bronchoalveolar lavage total inflammatory cell and neutrophil counts, from , cells/ml to , cells/ml (ci . - . ) (fig. ). there was a trend towards better oxygenation in the msc group.conclusions. these findings demonstrate the potential of mscs to modulate inflammation and enhance repair following vili. further analysis of our work, including bal cytokine assay and histological assessment of injury, will provide insight into the utility of mscs to enhance repair in the lung. to determine the role of vagus nerve signaling in vili and establish whether stimulation of the vagus reflex can mitigate lung injury from high volume ventilation.methods. first we demonstrate that disruption of the cap reflex by bilateral vagotomy results in worsening lung injury in a mouse model of high-volume-induced lung injury. in a clinically relevant rat model of injurious ventilation following hemorrhagic shock/resuscitation (hs; model of lung ischemia/reperfusion injury), we then tested the hypothesis that electrical and pharmacological stimulation of the vagus nerve can attenuate injurious effects of vili. finally, to determine the molecular mechanisms by which stimulation of the cholinergic response mitigates vili, we exposed human bronchial epithelial cells (beas b) to cyclic stretch ( cycles/min, pka) in the presence of specific agonist or antagonist of the subunit of the acetylcholine nicotine receptor. vagotomy exacerbates lung injury from high volume ventilation in mice as demonstrated by increased wet-to-dry ratio, infiltration of neutrophils in bronchoalveolar lavage fluid and lung tissues, and increased tissue levels of interleukin- . vagotomy exacerbated while vagus stimulation attenuates lung injury in rats after ischemia reperfusion injury ventilated with either high or low volume strategies. treatment of both mice and rats with the vagus mimetic drug, semapimod, resulted in decreased lung injury. vagotomy also increased pulmonary apoptosis whilst vagus stimulation (electrical and pharmacological) attenuated vili-induced apoptosis. in vitro studies suggest that vagus-dependent effects on inflammation and apoptosis are mediated via the a nachrc-dependent effects on cyclic stretch-dependent singling pathways c-jun n-terminal kinase (jnk) and fas (tnf receptor superfamily, member ).conclusions. stimulation of the cholinergic anti-inflammatory reflex may represent a promising alternative for the treatment of vili.introduction. so far, histological data on critical illness myopathy (cim) primarily refers to muscle biopsies taken during protracted critical illness (after weeks), repeatedly describing pronounced type-ii muscle fibre atrophy.objectives. we speculate that type-ii fibre atrophy develops during early critical illness in patients with non-excitable muscle membrane which predicts cim. ( ) methods. due to their elevated risk for cim, critically ill patients with sofa scores c on of consecutive days within the first days after icu admission were eligible for inclusion into this prospective, observational study. preexisting iddm or neuromuscular disorder, pregnancy, bmi c kg/m , age \ years, or pretreatment[ days on other icu constituted exclusion criteria. surgical muscle biopsies were taken from vastus lateralis muscles between day and after first sofa c and postprocessed according to standard procedures (isopentane, liquid nitrogen, atpase/toluidineblue staining). we assessed muscle membrane excitability after direct muscle stimulation, abnormal muscle membrane excitabilty indicating cim ( ). after quantifying fibre-type specific median cross sectional areas (csa) with imagej-software, we compared fibre-type specific csa in patients with and without non-excitable muscle membrane. nonparametric tests (mann-whitney u) were used for statistical analyses, results expressed as median and ( th/ th) percentiles for continuous variables. . patients were enrolled and subsequently biopsied. patients were evaluated for muscle membrane excitability, of whom % (n = ) showed non-excitable muscle membrane. reliable csa quantification was obtainable for patients.type-ii but not type-i muscle fibre csa during early critical illness was significantly decreased in patients with non-excitable muscle membrane ( , lm compared to , lm for type-ii, p = . ; , lm compared to , lm for type-i, p = . ; n = ). furthermore, non-excitable muscle membrane was associated with significantly lower mrc scores after end of sedation ( . ( . / . ) vs. . ( . / . ) , p = . , n = ). in patients showing non-excitable muscle membrane after direct muscle stimulation we could observe selective type-ii fibre atrophy as early as within the first days after icu admission (day - after st sofa c ). our findings demonstrate that nonexcitable muscle membrane indeed is associated with a histomorphological correlate previously linked to cim. these results highlight the need to focus on early critically illness in order to investigate pathophysiological aspects of cim. bacterial sepsis is a major threat in neonates born prematurely, and is associated with elevated morbidity and mortality. little is known on the innate immune response to bacteria among extremely premature infants. objectives. identify innate immune defect in premature infants as risk factor for the development of neonatal sepsis. methods. we compared innate immune functions to bacteria commonly causing sepsis in infants of less than wks of gestational age, infants born between and wks of gestational age, term newborns and healthy adults. levels of surface expression of innate immune receptors (cd , tlr , tlr , and md- ) for gram-positive and gramnegative bacteria were measured in cord blood leukocytes at the time of birth. the cytokine response to bacteria of those leukocytes as well as plasma-dependent opsonophagocytosis of bacteria by target leukocytes were also measured in the presence or absence of interferon-c. results. leukocytes from extremely premature infants expressed very low levels of receptors important for bacterial recognition. leukocyte inflammatory responses to bacteria and opsonophagocytic activity of plasma from premature infants were also severely impaired compared to term newborns or adults. these innate immune defects could be corrected when blood from premature infants was incubated ex vivo h with interferon-c. conclusions. premature infants display markedly impaired innate immune functions, which likely account for their propensity to develop bacterial sepsis during the neonatal period. maturation of the innate immune response to bacteria can be induced by interferon-c ex vivo and represents a promising strategy to prevent neonatal sepsis. the anaphylotoxin c a impairs neutrophil phagocytosis in animals and humans with sepsis. although dependency on the phosphoinositol -kinase delta (pi kd) pathway has been identified , , greater understanding of the mechanism will allow novel therapeutic options. objectives. to test the hypotheses that c a mediates its effect on phagocytosis by impairing rhoa activation, and that similar defects will be found in neutrophils from critically ill patients. methods. the mechanism was dissected using an in vitro model of c a-mediated neutrophil dysfunction, treating healthy human donor neutrophils with c a at concentrations found in sepsis ( nm). phagocytosis was assessed by zymosan particle uptake. neutrophils exposed to zymosan were assayed for rhoa activity, a key mediator of actin polymerisation in phagocytosis . phagocytosis by neutrophils from critically ill patients was investigated, looking for correlations with a marker of c a exposure (cd , the main c a receptor) , an examination of the rhoa and actin polymerisation response to zymosan, and the ability of gm-csf to restore phagocytosis ex-vivo. results. c a inhibited phagocytosis of zymosan by healthy donor neutrophils (reducing from to %, p \ . ) and also impaired rhoa activation (figure) . blocking pi kd, using inhibitor ic , prevented the inhibition of rhoa by c a, and prevented the reduction in phagocytosis. treatment with gm-csf restored phagocytosis and rhoa activation (fig. ). neutrophils from patients with critical illness showed a strong correlation between phagocytosis and surface cd expression (r = . , p \ . ), consistent with our previous findings . patient neutrophils failed to up regulate rhoa or polymerise actin in response to zymosan, in marked contrast to cells from healthy donors (p = . and p = . respectively). ex-vivo gm-csf was able to improve phagocytosis by patient neutrophils from to %, p \ . . conclusions. these data demonstrate that c a inhibits rhoa activity through pi kd, inhibiting phagocytosis. gm-csf is able to reverse this inhibition. similar effects are seen in neutrophils from critically ill patients, providing new avenues for therapeutic intervention in critical illness. host infection triggers an innate immune response leading to a systemic inflammatory response, often followed by an immune dysfunction which impairs the lung defence mechanisms in mice and increases susceptibility to secondary p. aeruginosa pneumonia. activation of the toll-like receptor (tlr)-dependent signalling pathways influences the magnitude of the initial pro-inflammatory phase of sepsis. contribution of tlr signaling to the subsequent development of post-infective immunosuppression has been poorly studied.objectives. to investigate the relative contribution of tlr and tlr in lung defence towards p. aeruginosa in the setting of sepsis-induced immune dysfunction. we used wild-type (wt) c bl /j mice and littermates deficient for tlr (tlr ko), tlr (tlr ko) or both tlr and tlr (tlr ko). these animals were subjected to a sublethal polymicrobial sepsis (cecal ligature and puncture, clp) followed by a secondary p. aeruginosa pneumonia at day post-clp . we evaluated -day survival and the lung response and h after instillation through lung histology, quantification of protein level, cell recruitment and myeloperoxydase (mpo) activity. lung expression of tlr , tlr and tlr was assessed through quantitative rt-pcr. bacterial lung clearance was evaluated through quantitative culture of bronchoalveolar lavage fluid (balf). bacteremic dissemination was assessed through quantitative blood cultures. finally, we measured cytokines in the balf and in the whole lung. post-septic wt and tlr ko mice displayed high susceptibility (mortality rate %) towards secondary pneumonia. in contrast, post-septic tlr -deficient mice (either tlr ko or tlr ko), survived the secondary pulmonary infection (mortality rate \ %). in wt mice, clp increased lung expression of tlr , but neither of tlr nor tlr . tlr ko mice displayed improvement in lung bacterial clearance and reduction in bacteremic dissemination as compared to wt mice. with regard to pulmonary inflammation, tlr ko mice displayed decreased alveolar damage. furthermore wt and tlr ko mice displayed differences in the pulmonary release of cytokines. thus tlr ko mice exhibited increased production of tnf-a and ifn-c and a decreased production of il- .conclusions. in a model of polymicrobial sepsis followed by p. aeruginosa pneumonia, tlr deficiency improves survival by promoting efficient bacterial clearance and decreasing pulmonary inflammation. tlr -dependent mechanisms that specifically contribute to lung defence in the setting of sepsis-induced immune dysfunction are currently investigated. infection is a serious complication in critically ill patients, who can be in a state of secondary immunodeficiency due to a severe illness. apart from common nosocomial pathogens, highly unusual microorganisms may be found in these patients, i.e. pathogens whose cultivation requires specific conditions, and/or agents which are difficult to cultivate. molecular biology-based methods (pathogen-specific probes with real-time pcr detection, or universal system pcr detection with subsequent sequenation) make diagnosis faster and more accurate.objectives. i) to assess an agreement of investigation results using classical microbiology techniques and molecular biology-based methods; ii)to evaluate the clinical effect of the diagnoses based on the frequency of changes in antibiotic therapy as a direct result of molecular detection of ''pathogens'' (mpd) and to assess the effect of this change by evaluating a -day trend of inflammatory parameter concentrations i.e. of procalcitonin (pct) and c-reactive protein (crp). a total of samples (blood, bal, tracheal aspirate, urine, cerebrospinal fluid and secretions from abdomen drains and thoracic punctures) were taken from icu patients (aged - ). these were investigated simultaneously, both by classical microbiology and microbial methods, using the system of pathogen-specific probes with real time pcr for agents. each sample was tested simultaneously with the universal pcr detection system for bacteria and fungi with the subsequent sequenation.results. an agreement between the two compared examination methods was found in % of samples and disagreement in % of the samples. % of the results were classified as ''not possible to interpret''. in % of the samples, mbm detected the presence of other agents, which were not confirmed by cultivation. in % of cases, the mdp results did not contribute to the decision to change the atb. in % of cases, a modification of atb treatment followed; a change, reduction or stopping the administration of the drug. in % of cases, atb was changed without any direct connection to the results. in % of patients who underwent the change in atb treatment, a decrease in inflammatory parameters occurred (pct and crp), however, in % there was an increase. the remaining % are divided equally between those ''without any change'' and ''data not available''.conclusions. the advantage of septic-state diagnostics using molecular biology techniques, as opposed to classical microbiology methods, is the fast availability of the examination results ( - h) , and its high sensitivity and specificity. proving the presence of agents in biological material does not necessarily signify its pathogenicity. however, in combination with a thorough assessment of the clinical progression, including laboratory indicators of inflammation, it is of considerable benefit in decisions about the efficacy of antibiotic therapy. common antibiotics and the number of patients on high or low intensity crrt recruited were: ciprofloxacin ( , ) , meropenem ( , ), piperacillin-tazobactam ( , ) , vancomycin ( , ). the clearance of individual antibiotics varied approximately -and fold within a single crrt regimen for high and low flow rates, clearance, estimated using ccrt extraction ratios for the two flow rates, differed significantly: meropenem ( vs. ml/min; p = . ) and vancomycin ( vs. ml/min; p = . ). using dialysate clearances, significant differences for vancomycin ( vs. ( ) objectives. to perform a meta-analysis on incidence and outcome of intra-abdominal hypertension (iah) in different icu populations, the evolution of iap over time and the correlation with organ failure and fluid balance (fb)methods. pts admitted to icu with iap measurements (gastric or bladder) were included. data from existing databases were collected on , pts from centers ( countries [ ] . recently, it was demonstrated that % hes / . induces increased inflammation and leads to more tubular damage compared to % hes / . in an ex-vivo kidney perfusion model [ ] . we investigated whether different hes solutions lead to disturbed cell proliferation or to increased apoptosis in murine kidney cells. we performed a large cohort study on prospectively collected data over a year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . data were extracted from the cub-réa network , a french regional database in which icus from paris and its suburb prospectively record data using standardized coding methods. cancer patients with septic shock were selected through keywords including the malignancy status on one hand (''hematological malignancy'', ''cancer'', ''cancer with metastasis''), and ''septic shock'' or the combination of ''septicemia'' and ''shock'' on the other hand. extracted variables included demographic characteristics, type of malignancy, requirements for organ failure supports (vasopressor therapy, mechanical ventilation, renal replacement therapy) and severity-of-illness score (saps , , , , however, some studies have suggested little effect on morbidity or mortality. , clarification of any differences would improve pre-operative risk assessment, providing more information for the clinician and patient. it would also aid resource planning in the critical care unit. we hypothesized a proportional increase in the extremes of bmi occurring over the -year study period. we analysed data collected prospectively between april and april on patients undergoing cardiac surgery in our unit using the patient analysis and tracking system (pats Ò ) database. the patients were grouped according to bmi. for each group we calculated organ specific complication rates, re-operation and readmission rates, itu and postoperative length of stay and overall mortality. we studied the change in mean bmi of patients over the year period. in comparison with normal bmi range ( . - . ), patients with bmi range \ . had significantly increased rates of peri-operative myocardial infarction (mi) ( conclusions. both the high and low extremes of bmi range show significant increases in complication rates compared to normal bmi patients undergoing cardiac surgery. the bmi group - . shows significant increase in re-operation, readmission and mortality rates.there is a year on rear increase in the bmi group [ . this suggests a greater demand for resources particularly in the intensive care unit as the population with a higher morbidity and mortality increases. we would welcome an opportunity to present a detailed analysis of our findings. with advances in critical care medicine, more patients are surviving intensive care units stays. patients admitted to critical care may experience morbidity that affects their life after discharge . in addition to any physical morbidity, treatment in critical care may also be stressful and psychologically traumatic for patients .objectives. to describe the psychological outcome of patients surviving icu admission at months. a second end-point was to find possible relationships between patients' background and intensive care variables, post-traumatic stress and depression disorders.methods. retrospective analysis of data from icu follow-up clinic. data were collected in questionnaires (ptss- and beck inventory) during an interview at months after discharge of icu in the last years. statistics analysis: pearson's chi-square or fisher's exact test, significance for p \ . . . patients were interviewed, mean age was ± , % were male and . % were trauma victims. mean icu length of stay was ± days and sapsii score ± . . % of patients had less than years of education. concerning previous health status . % were healthy and . % were dependent for daily living activities. . % were retired. more than % had new complaints after discharge. only . % of the previously professionally active patients resumed their work and only % of the retired were able to maintain their normal activity. almost % of patients had new psychiatrics symptoms and only . % were being followed by psychiatry: % were on benzodiazepines and . % on anti-depressants. . % of the patients had symptoms suggestive of diagnosis of post-traumatic stress disorder (ptsd) having a ptss- superior to . regarding beck inventory, % were considered to have a depression, with . % having moderate to severe depression. after the interview % were oriented to a psychiatric consultation. % of depressive patients had new symptoms (p \ . ). of the previously active patients who did not resume normal activities, a significant (p \ . ) part was depressed ( . %). the same is true for the retired patients ( . %), p = . . longer hospital and icu lengths of stay were related with development of depression (p = . and p = . , respectively). patients with higher sapsii were more prone to develop ptsd. women had more ptsd than men (p = . ). patients in risk of ptsd and depression were younger (p = . ; p = . , respectively). as with depression these patients also had more new complains and did not return to work. introduction. mild hypothermia improves outcome after cardiopulmonary resuscitation (cpr). modes of action for it are manifold, though one way might be reduction of basal metabolic rate (bmr). therapeutic hypothermia was able to reduce bmr in patients with traumatic brain injury and critically ill patients with fever.objectives. in the present study we investigated the metabolic effect of therapeutic hypothermia in patients after successful cpr.methods. patients after cpr were treated with therapeutic hypothermia ( °c) for h and subsequently rewarmed with a rate of . °c per hour until °c was reached. all patients received standardized sedoanalgetic medication and neuromuscular blockers. indirect calorimetry was performed at , . and °c, as well as between . and . °c and - h after cpr. for statistical analysis repeated measures anova, linear and logistic regression were used. a linear relation between bmr and temperature was detected ( kj/m / . °c; p \ . ). therapeutic hypothermia ( °c) was associated with a reduction of bmr by ± % compared to °c. in this regard no difference was found between patients with good and bad neurological outcome (good outcome vs. bad outcome: ± vs. ± %; p = . ). concerning substrate oxidation rates only fat oxidation rate showed a temperature dependency ( g/day/ . °c; p \ . ). in contrast to protein oxidation rate (good outcome vs. bad outcome: ± vs. ± g/day; p = . ) patients with good neurological outcome had a significantly higher fat oxidation rate (good outcome vs. bad outcome: ± vs. ± g/day; p = . ) and a significantly lower glucose oxidation rate (good outcome vs. bad outcome: ± vs. ± g/day; p = . ) as compared to patients with bad neurological outcome.conclusions. in patients after cpr mild therapeutic hypothermia ( °c) was associated with a reduction of bmr by %. a linear relation between temperature and bmr was detected. fat oxidation rate was temperature dependent in contrast to protein and glucose oxidation rate. a significant difference in glucose and fat oxidation rates was found between patients with good and bad neurological outcome. objectives. our goal was to determine whether its institution after resumption of spontaneous circulation (rosc) improves survival and neurological recovery in an experimental model of cardiac arrest in rabbits.methods. ventricular fibrillation was induced in anesthetized rabbits. after -min of untreated fibrillation, cardiopulmonary resuscitation was attempted using external massage, electric shocks and intravenous epinephrine. after rosc, rabbits randomly underwent either normothermic life support (control group with conventional ventilation until weaning) or hypothermic support with rapid cooling (tlv group). in this last group, a °c hypothermia was induced by -min of tlv using a perfluorocarbon. subsequently, the perfluorocarbon was removed from the lungs and rabbits were conventionally ventilated with maintenance of hypothermia during h. rabbits were further warmed and weaned from ventilation. in both groups, hemodynamic and biochemical parameters were monitored, as well as survival and neurological recovery. after days, survivors were finally euthanized for post-mortem analyses. neurological dysfunction was assessed by a - % scoring system evaluating reflexes, postural reactions and behaviour ( %: no dysfunction; %: brain death).results. ten rabbits were randomized to the control group and to the tlv one. defibrillation was obtained using . ± . and . ± . electric shocks, respectively. subsequent rosc was observed after . ± . and . ± . min, respectively. oesophageal and tympanic temperatures were rapidly reduced in the tlv group, achieving . ± . and . ± . °c within -min versus . ± . and . ± . °c in control, respectively. in the tlv group, rabbits returned to normothermia within - h after the hypothermic episode. throughout follow-up, no significant difference in blood pressure was observed between both groups (e.g., ± and ± mmhg in control vs. tlv at h after cardiac arrest, respectively) whereas heart rate was decreased throughout hypothermia in tlv vs. control (e.g., ± vs. ± beats/min at h following cardiac arrest, respectively). lactates's concentration and epinephrine dosages were not significantly different between groups. importantly, neurological dysfunction was significantly attenuated in tlv vs. control (e.g., ± vs. ± % after h). in control, / ( %) rabbits survived throughout the follow-up and the others died or should be euthanized earlier following severe disability. in the tlv group, survival was significantly increased as / rabbits survived to the entire follow-up ( %).conclusion. ultra-fast cooling induced by tlv after rosc improves survival and neurological recovery following -min of experimental cardiac arrest in rabbits.grant acknowledgment. (ca) . th involves at least h of induced hypothermia ( - °c), mechanical ventilation and sedation. th may affect sedation through changes in pharmacology. still, no clinical studies have investigated the use of sedation during th. objective. to compare the efficacy of two sedation protocols for patients treated with th. methods. open, randomised, controlled, population based study of patients treated with th ( - c for h) after ca in two norwegian university hospitals. patients were randomised to sedation with remifentanil + propofol (rp) or fentanyl + midazolam (fm). baseline characteristics (age, sex, bmi, saps-ii) and cardiovascular variables during study drug infusion (blood pressure, heart rate, use of fluids, vasopressors and inotropic drugs) were recorded. the primary end point was defined as time from stop of sedation to extubation. results. sixty patients were randomised. one patient was withdrawn by next of kin. baseline characteristics were similar in the two groups. for two patients in the rp group, and one in the fm group, study drugs were stopped shortly after allocation due to cardiovascular instability. the rp group had lower heart rates and more patients needed noradrenaline infusions than the fm group ( . ( . ) (mean(sd)) vs. . ( ) beats/min, p = . , and vs. patients, p = . , respectively). other circulatory variables were similar. reasons to not stop sedation or not extubate after stop of sedation were; cessation of icu treatment (n = ), need for mechanical ventilation (n = ), inadequate awakening (n = ), seizures after stop (n = ), and other (n = ). sedation was stopped according to protocol in of patients. median (range) time from stop of sedation to extubation for the patients who could be extubated according to protocol was . ( - . ) vs. . ( . - . ) h in the rp and fm group, respectively, p = . . ''cerebral performance category'' on day - was similar in the two groups. conclusions. time to extubation after cessation of sedation was significantly shorter in patients sedated with rp compared to fm. however, the benefit from a short time to extubation is limited by that only one-third of the patents can be extubated according to protocol. the rp group had lower heart rates and needed more noradrenaline. no major differences were observed for outcome.grant acknowledgment. ntnu. increased blood glucose variability during therapeutic hypo-thermia and neurological recovery after cardiac arrest key: cord- - xzc uc authors: nan title: esicm wednesday sessions october date: - - journal: intensive care med doi: . /s - - - sha: doc_id: cord_uid: xzc uc nan power spectrums for vt and eadi are shown in fig. (ps and nava) for a typical patient. the enlarged section highlights how changes in eadi are highly synchronized with nava ventilation, but less so for ps. table ) and complications of mechanical ventilation ( table ) did not differ significantly between the two studied groups. introduction. high tidal volumes in mechanically ventilated patients with ards lead to baro/bio-trauma and increase mortality. also, it was recently shown that ventilation with high tidal volumes is a risk factor for ''acquired ards'' in a medical population. objective. we evaluated the impact of high tidal volumes after cardiac surgery. method. we analysed the prospectively recorded data of , consecutive patients who underwent cardiac surgery from to . we predefined groups of patients based on the tidal volume delivered immediately after surgery: ( ) low: - . , ( ) ''traditional'': - . , ( ) high: above ml/kg of predicted body weight (pbw). we assessed the risk factors for organ dysfunction (prolonged mechanical ventilation, hypoxemia, hemodynamic failure and renal failure) by univariate and multivariate analysis, including the initial tidal volume in the models. mean tidal volume/actual weight and tidal volume/pbw was . ± . and . ± . in men (p \ . ), . ± . and . ± . in women (p \ . ). patients ( %) were ventilated with low tidal volumes, , ( . %) with ''traditional'' tv and ( . %) with high tv. the mean body mass index in the groups was . ± . , . ± . and . ± . respectively (p \ . ). with increasing bmi, the tidal volume/ actual weight decreased while the tidal volume/pbw increased (figure) . the percentage of women was . , . and . % respectively for low, ''traditional'' and high tv (p \ . ). high tidal volumes were associated with prolonged intubation ([ h) ( . vs. conclusion. traditional and very high tidal volumes are associated with prolonged mechanical ventilation and organ dysfunction after cardiac surgery and use of high tidal volumes is an independent risk factor. ''prophylactic'' protective ventilatory strategy should be provided in this population with inflammatory state at risk to develop ventilator induced pulmonary edema. women and patients with high bmi are more at risk to be ventilated with injurious tidal volumes. introduction. evidence shows that clinicians' non-technical skills (behavioural and cognitive skills) have a significant impact on teamworking, patient safety, efficiency of care provided and potentially patient outcomes ( ) . such skills are key for cardiac arrest teams (cats), which are multi-professional (anaesthetists, physicians and nurses) and normally function under high pressure. to date, most tools to assess nontechnical skills in healthcare have focused on surgery ( ) and anaesthesia ( ) . no validated, robust tools are currently available for assessing non-technical skills in cats. objectives. to develop and validate an observational skill-based clinical assessment tool for resuscitation (oscar). this should be psychometrically robust for use in both training and assessment contexts. methods. oscar was based on a well-validated tool for surgery (otas) ( ) and was developed in phases. six behaviours were included in the assessment: communication, cooperation, coordination, monitoring, leadership and decision-making. observable behavioural exemplars were derived for each one of these behaviours across the three cat subteams-anaesthetists, physicians and nurses (phase ). quantitative expert consensus methodology was employed to assess content and face validity and observability of the exemplars (phase ). two clinician observers used oscar to blindly rate eight cats performance in a series of simulated cardiac arrests. psychometric analyses of these ratings were used to determine observable behaviour applicability, internal consistency, and inter-rater reliability (phase ). . of oscar behaviours demonstrated high internal consistency (cronbach a = . - . ). psychometric analyses dictated removal of three behavioural exemplars (two in anaesthetic group; one in physician group) to significantly improve internal consistency. inter-rater reliability was also high (inter-observer pearson r = . - . , all p \ . ). inter-observer reliability analyses revealed a learning curve between the two observers, with significant reduction in scoring discrepancies from the first to the eighth observed resuscitations. conclusions. oscar is a psychometrically robust (reliable, content-and face-valid) tool for the assessment of teamworking skills in cardiac arrest events. the tool is feasible to use and can be employed for both training and assessment purposes. introduction. different educational methodologies are used to teach basic skills in emergency medicine. high-fidelity patient simulation offers an ideal venue for presentation of critical events that can be managed by medical students without risk to a patient. therefore full scale simulation training could be superior to paper case based seminary rounds to achieve these specific educational objectives. objectives. the aim was to compare simulation to a standard education measured by multiple choice questionnaire. after written informed consent and approval of the institutional research ethics board fifth year medical students were included in the survey. they took part in the compulsory emergency medicine curriculum of charité universitätsmedizin berlin. the students completed a basic multiple question tests on day including questions concerning the topic of ''acute coronary syndrome'' (acs). on day for the topic ''acs'' half the group was assigned a min session simulation training while half the group was assigned a min session paper case training. on day groups were reversed and the topic ''aic'' was taught in either simulation training or paper case seminary round. the test of day was repeated after each training sessions. results of the tests were evaluated using spss(tm) . the mann whitney u test was used to show any significant differences in reaching educational objectives in the test (a \ . was considered significant). there was an even distribution of men and women among the two groups. the test results showed no significant difference between the two groups on day . on day two for the topic ''acs'' the group with simulation training achieved significantly better test results. for the topic ''acs'' on day there was no difference while students received further training in acs not using a high fidelity simulator. the results were not linked to specific teachers. introduction. rapid sequence induction (rsi) involves loss of spontaneous breathing and mandates airway control. steps to reduce adverse incidents include adherence to minimum monitoring standards, appropriate drug selection, access to difficult airway equipment and presence of skilled anaesthetists. there is substantial evidence that appropriate monitoring reduces risk by detecting the consequences of errors, and by giving early warning of patient deterioration. objectives. to assess conduct of emergency anaesthesia (monitoring and drugs) for critically ill patients not in an operating theatre (or) administered by intensive care doctors. methods. prospective analysis of rsi for critically ill patients in a uk nhs acute hospital over month. or based practice was excluded. reason for anaesthesia, location, drugs administered, monitoring modalities, adverse events and access to airway equipment were recorded. results. data from patient episodes were collected: predominantly in the emergency department ( %) and intensive care unit ( %) for respiratory failure ( %), reduced consciousness ( %) and to facilitate investigations ( %) . the most common induction agent was propofol ( %); thiopentone ( %) and etomidate ( %) were less frequently used. suxamethonium ( %) was preferred for initial neuromuscular blockade. during induction most doctors used pulse oximetry, electrocardiography and blood pressure monitoring. only % used capnography. no doctor used minimum monitoring to association of anaesthetists of great britain and ireland (aagbi) standards. rescue airway equipment immediately available is shown in fig. . complications occurred in cases (fig. ) . patients that had a hypotensive episode during induction all had thiopentone or propofol used as induction agents. % of patients had a period of desaturation, and % required more than one attempt for successful intubation. in cases with complications, rescue airway equipment was unavailable in[ and % did not achieve uk minimum monitoring standards. conclusions. shortcomings during emergency anaesthesia were recorded including monitoring, access to rescue airways and physiological disturbance. procedural guidelines and training are to be developed for emergency anaesthesia; access to capnography and alternative airway equipment will be assured. these issues are unlikely to be unique to our trust and assessment of practice is recommended. introduction. critical care echocardiography (cce) is performed and interpreted by the intensivist at the bedside to establish diagnoses and guide the management of patients with circulatory or respiratory failure in the icu. competence in basic and advanced cce has been recently defined [ ] , but no curriculum to reach the required cognitive and technical skills has yet been elaborated. objectives. to assess the efficacy of a limited, tailored training program for noncardiologist residents without experience in ultrasound to reach competence in basic cce. methods. six noncardiologist residents (anaesthesiology: n = , pneumology: n = ) without previous experience in ultrasound participated to the study during two -month periods. the curriculum consisted in h of didactics, h of interactive clinical cases and h of tutored hands-on. color doppler mapping was excluded from the training. after completion of the training program, all eligible patients underwent subsequently a transthoracic echocardiography (tte) performed in random order by a recently trained resident and an experienced intensivist with expertise in cce who was used as a reference. in each patient, the resident and the experienced intensivist answered binary ''rule in, rule out'' clinical questions covered by basic cce [ ] : global left ventricular (lv) size and systolic function (eye-ball evaluation of ejection fraction), homogeneous or heterogeneous lv contraction pattern, global right ventricular (rv) size and systolic function, identification of pericardial fluid and tamponade, and assessment of both the size and respiratory variations of the ivc. in case of undetermined interpretation, the corresponding clinical question was considered not addressed. the agreement between responses to clinical questions provided by the two investigators who independently interpreted the tte study at bedside was used as an indicator of effectiveness of the tested curriculum. proportion of graduates to work within a ''critical care'' setting. the level of support available to trainees may vary with local resources but risk management and national guidelines stipulate that close supervision is provided to junior doctors in high stake decisions and procedures until deemed competent at the relevant tasks . furthermore, substantial ongoing reduction in working hours places further limitations on training; both majors can impact adversely on junior doctors service output and experience. a modified delphi method was used years ago to design a task focused single-day course on the theoretical basis of critical care and provide lab-based training in delphi identified high risk procedures and interventions . objectives. assess the impact of the course on the following: trainee confidence and the start of the ''novice'' critical care post trainee performance in comparison to peers perceived educational benefit from their training post compared to peers methods. junior doctors attending the course were enrolled in the study and matched for graduation year and medical school to junior doctors who did not attend similar training prior to commencing their post. data was collected through anonymous standardized forms on the day of the course, first day of the job, end of week , week and months into the post. trainee confidence and self perceived competence were assessed on a ten point scale. in addition, trainees were requested to maintain a log of interventions: -ultrasound guided central venous catheter insertion, -arterial catheter insertion, -ventilation problem solving. candidates attending the course demonstrated greater confidence at multiple points within their post as well as higher performance, satisfaction and educational value scores. conclusions. critical care trainees benefit from a task focused orientation to the fundamentals of critical care before commencing first post in this setting. . enrolled patients in each group. no differences in age and gender. incidence of vap-study group . % compared to control group . % p value . . vap per , hospital days: control- . % compared to study- . % p value . ; average days in icu control- . compared to study- . , p value . ; average ventilated days, control- . compared to . , p value . ; average antibiotic use in days control- . compared to study- . , p value . . introduction. nosocomial infections are the most common in-hospital complications with high morbidity and mortality. educating healthcare professionals is an important prevention measure. objective. to analyze the impact of a nurse consultant team on nosocomial infections prevention in the icu, the improvement in prevention knowledge of the nurse staff, and its impact in the application of the prevention measures in the daily practice. methodology: the nurse referent team was constituted by nurses. the study subjects were all the staff icu nurses and all the patients admitted during pre and post-intervention phases. the study was conducted in our medical-surgical icu ( beds) in phases: pre-interventional ( / / - / / ) observational. record of the accomplishment of cdc recommended variables about mechanical ventilation associated pneumonia (vap) and catheter related bloodstream infection (cr-bsi) prevention measures. interventional ( / / - / / ) eight educational meetings with the nurses staff groups to teach the most important aspects of the nosocomial infections prevention. before and after lectures every nurses answered an anonymous questionnaire about their knowledge in those subjects. a poster with the most important reminders was place in every icu patient room. post-interventional ( / / - / / ) observational. new record of the same cdc pre-interventional variables. we compared the accomplishment of these variables before and after the interventional phase as well as the number of correct questionnaire answers. statistics were made with spss software. results. during the interventional phase % of the staff nurses attended the educational meetings. the number of correct answers increased significantly after the conference ( . vs. . % p \ . ). regarding to the daily practice, we observed a significant increase in the accomplishment in most of the variables (see table below), while in of them no improve was observed and in the improvement was not statistically significant. during the study period we observed a decrease in the incidence of vap ( . - . episodes/ , mv days) and cr-bsi ( . introduction. glucose variability has been found to be associated with mortality in critically ill patients, independent of mean glucose concentration [ ] . objectives. the aim of this analysis was to assess the impact of real time continuous glucose monitoring (cgm) on glucose variability in critically ill patients receiving intensive insulin therapy (iit). methods. this is the post-hoc analysis of a prospective, randomized, controlled trial [ ] . data of patients admitted to the icu either receiving iit according to a real time cgm system (guardian Ò , medtronic, northridge, ca, usa) (n = ) or according to an algorithm (n = ) with selective arterial blood glucose measurements (simultaneously blinded cgm) for h were analysed. insulin infusion rates were guided according to the same algorithm in both groups. mean glucose and standard deviation, as a marker of glucose variability, were calculated for the first h (glumean , glusd ) and for the whole study period (glu sd ). statistical comparison of parameters between study groups and between icu survivors (n = ) and non-survivors (n = ) was performed using student's t test. results. the variability of sensor glucose during the entire study period was comparable between the real time cgm group and controls ( . ± . vs. introduction. in the gastrointestinal tract, the gut flora which comprises several hundred grams of bacteria is crucially involved in host homeostasis through their metabolic, trophic, and protective activities. however, the immediate changes in the gut flora in critical illness following severe insults are unknown. objectives. to investigate the changes in the gut flora at an early phase of severe insult in critically ill patients. methods. fifteen patients who experienced a sudden and severe insult including trauma, out-of hospital cardiac arrest, and cerebral vascular disease were studied, along with healthy volunteers as the control group. two fecal samples were acquired from the subjects by swabs of the rectum within h after admission to the emergency room (day ). samples were serially collected from patients on day , , , , , and . samples were collected from control subjects. results. total bacterial counts, especially various obligate anaerobes and total lactobacillus, significantly decreased in comparison to those of the control subjects on day . in addition, on day , the total organic acid levels of the patients were significantly lower than those of the control subjects; particularly acetic acid, propionic acid, and butyric acid. the levels of these acids remained low throughout the days period of study. the total bacterial counts did not recover to normal levels during the day study period. obligate anaerobe counts of the patients did not improve until day . total lactobacillus counts were low on day and increased gradually thereafter, but did not attain the levels found in controls. the counts of pathogens (enterococcus and pseudomonas) increased during the study period. conclusions. gut flora in critically ill patients can change drastically immediately after a severe insult, and may not recover for up to days. at the same time, the number of harmful bacteria can increase. total bacteria . ( . - . ) . ( . - . ) . obligate anaerobes clostridium cocades group . ( . - . ) . ( . - . ) . clostridium leptam subgroup . ( . - . ) . ( . - . ) . bacteroides fragilis group . ( . - . ) . ( . - . ) . bifidobacterium . ( . - . ) . (\ . - . ) . atopobium cluster . ( . - . ) . (\ . - . ) . results. mean serum (oh)d level was . ± . ng/ml. by current definitions the majority of patients ( . %) were vitamin d deficient (\ ng/ml) and . % were vitamin d insufficient (c and \ ng/dl). normal (oh)d levels ([ ng/ml) were present in . %. table provides information on clinical and laboratory findings in the three (oh)d groups. both lower (oh)d tertiles were associated with increased hospital mortality after adjustment for age, sex and saps ii. for patients both (oh)d and pth levels were available. adjusting the cox regression analysis also for pth and dialysis status increased the hr for hospital mortality to . ( . - . ) and . ( . and . ) for the two lower (oh)d tertiles. in addition tertiles of pth and serum calcium levels suggested higher mortality rates for patients in the highest pth (p = . ) and those in the lowest calcium tertile (p = . ). our results demonstrate that independent of baseline saps ii, age and sex, critically ill patients with low (oh)d levels seem to be at increased risk for hospital mortality. whether a rapid correction of vitamin d status may be beneficial in the icu setting remains to be further explored in randomized controlled trials. • the autonomic storm after brain death must be early diagnosed and treated with a standardized protocol including hormone therapy introduction. the use of filling pressures of the right atrium and left atrium is normal in the monitoring of critically ill patients undergoing mechanical ventilation. this monitoring is done through an invasive catheter placed in the superior vena cava and pulmonary artery, which is not free of complications. the ability to make measurements of these parameters in a non invasive way, makes the echocardiography an useful and essential tool when monitoring critically ill patients objectives. we focus the study on validate the reliability of noninvasive measurements by echocardiography and invasive measurement catheters of filling pressures methods. we conducted a prospective observational study relating the filling pressures, between central venous pressure (cvp) with the diameter of the inferior vena cava and left atrial pressures with the values of the ratio e/e . the filling pressure variables were only discriminated as high or low. low values were accepted when invasive measurement of cvp was \ and \ mmhg in the lap; and by echocardiography when the diameter of the ivc was\ mm and the ratio e/e \ . high values were accepted when the measurement of cvp was higher than and mmhg in lap and in echocardiography when the diameter of the ivc [ mm and the ratio e/e [ . we collected data from patients in the immediate postoperative period, under mechanical ventilation (vt - ml/kg, fio %, peep ), sinus rhythm, good cardiac function and without postoperative drug support. all of them had a central venous line and right atrium catheter as habitual monitoring of postoperative cardiac patients. we performed an echocardiography when the patient presented hypotension, with low values of cvp and lap, and we repeated the measurements after the infusion of the habitual fluid protocol ( ml hes % in - min). the data we record were: diameter of ivc and ratio e/e by echo and cvp and lap values by invasive catheters. rd esicm annual congress -barcelona, spain - - october s introduction. an attenuated cardio-hemodynamic response to dobutamine is associated with a poor outcome in established human sepsis [ , ] . establishing a sensitive method to identify early cardiac dysfunction in both experimental and human sepsis would be a useful tool to explore timesensitive mechanisms further. objectives. to assess myocardial responsiveness to dobutamine in early sepsis. methods. all procedures were in accordance with uk home office laboratory animal legislation. under isoflurane anaesthesia, male adult wistar rats underwent left common carotid and right internal jugular venous cannulation for blood sampling/continuous bp monitoring and fluid administration respectively. rats received either . ml caecal slurry (sepsis; n = ) or . ml saline (sham; n = ) ip, before fluid resuscitation ( . % saline ml/kg/h) and conscious monitoring was commenced. after h, rats were re-anaesthetized with isoflurane and transthoracic echocardiography was performed. stroke volume was optimised with saline boluses prior to an incremental dobutamine infusion ( . - mcg/kg/ min). data are presented as mean (sd); analyzed with -way anova and post-hoc tukey test. results. figure summarizes hemodynamic changes after sepsis, fluid resuscitation and dobutamine infusion. baseline parameters were similar after echocardiography-guided fluid resuscitation, with contractility and stroke volume restored in septic rats to sham values. septic rats demonstrated an enhanced chronotropic response to dobutamine compared to sham (p \ . ). both peak velocity and cardiac output were attenuated by c % in sepsis (p \ . ). in sepsis, baseline map was higher but neither sham nor septic maps were affected by dobutamine infusion. conclusions. dobutamine stress echocardiography is a sensitive, reproducible, dynamic physiological probe that reveals early cardiac dysfunction in septic rats with apparently similar baseline cardiovascular physiology. introduction. the evaluation of right ventricular (rv) function is clinically useful in patients with acute respiratory distress syndrome (ards) because the presence of rv failure has large prognosis implications. the purpose of the current study was to compare right ventricular myocardial strain imaging parameters with conventional echocardiographic indices evaluating right ventricular function during ards. objectives. we hypothesized that peak systolic strain would be more sensitive than conventional echocardiographic parameters in detecting subclinical right ventricular systolic dysfunction in patients with ards. methods. in total, patients with ards and with normal right ventricle function assessed by two dimensional echocardiography and age matched subjects under mechanical ventilation without heart or pulmonary disease were included in the present study. conventional echocardiography parameters for rv function assessment like rv fractional area change (rvfa) or the tricuspid annular plane systolic excursion (tapse) were measured and compared to tissue doppler imaging parameters with strain value obtained from the right ventricle free wall. . strain values were reduced in the rv free wall of the patients with ards compared with the control group ( . % ± . vs. . % ± . p = . ) moreover no significant difference was observed in conventional two dimensional parameters evaluating rv systolic function between these two groups of patients. in patients with ards a significant relationship was shown between peak systolic strain at basal free wall and arterial carbon dioxide tension (rho = - . p = . ) and with the end inspiratory pressure (rho = - . p = . ). conclusions. during the ards, doppler tissue imaging parameters can determine rv dysfunction that is complementary to conventional echocardiographic indices and is correlated with respiratory parameters. on doppler tissue imaging, patients with ards exhibit abnormal rv systolic function even in patients with normal rv function assessed with conventional echocardiographic parameters. objectives. studying the effect of olv on rv outflow impedance during inspiration and expiration using transesophageal echo-doppler in a trial to differentiate the rv consequence of increasing lung volume from those secondary to increasing airway pressure during mechanical ventilation. methods. thirty stable patients on mechanical ventilation because of different causes were enrolled prospectively in this single center, cross sectional clinical study. each patient was firstly subjected to conventional ventilation (cv) with volume controlled ventilation, followed by open lung concept (olc) ventilation by switching to pressure controlled mode, then recruitment maneuver applied until pao /fio [ torr. hemodynamic (mean arterial pressure ''map'', central venous pressure ''cvp'' and heart rate ''hr'') and respiratory (total and intrinsic peep, peak, plateau and mean airway pressure and total and dynamic lung compliance) measurements were recorded before, min after a steady state of cv and min after a steady state of olc ventilation. also, transesophageal echo doppler was performed at end of inspiration and end of expiration to calculate the mean acceleration (ac mean ), as a marker of the rv outflow impedance, min after a steady state of cv and min after a steady state of olc ventilation. results. during inspiration, ac mean was significantly lower during cv compared to olc ventilation (p value . ). inspiration didn't cause a significant decrease in acmean compared with expiration during olv (p value. ) but did do so during cv. in comparison to baseline and cv, olc ventilation was associated with a statistically significant higher cvp (p value . for both), higher total quasi-static lung compliance (p value . for both) and dynamic lung compliance (p value . for both). moreover, pao /fio ratio of olv was significantly higher than in baseline and cv (p value . for both). conclusions. olc ventilation does not change rv afterload during inspiration and expiration as rv afterload appears primarily mediated through the tidal volume. moreover, olc ventilation provide a more stable hemodynamic condition and better oxygenation and lung dynamics. introduction. among indices provided by the analysis of aortic blood flow through esophageal doppler, mean acceleration (acc) is supposed to reflect the left ventricular (lv) systolic function, but this has been poorly validated. in particular, acc could be influenced by loading conditions of the lv. objectives. to test whether acc actually behaves as an indicator of lv systolic function by testing if . it increased with inotropic stimulation, . it was not altered by fluid loading, . it correlated with the echographic lv ejection fraction (lvef) and it reliably tracked the changes in lvef during therapeutic intervention. in patients with cute circulatory failure (sapsii ± , age ± years, receiving norepinephrine), we administered either a volume expansion ( ml saline over min in patients) or dobutamine ( lg/kg/min in patients). we simultaneously measured acc (cardioq, deltex medical) and lvef at baseline and after therapeutic intervention. results. volume expansion significantly altered neither lvef (from ± to ± %) nor acc (from . ± . to . ± . cm/s ) while dobutamine infusion significantly increased lvef by ± % and acc by ± %. considering the acc/lvef pairs of measurements, an acc \ . cm/s predicted a lvef b % with a sensitivity of % ( % ci [ - %]) and a specificity of % ( % ci [ - %]). the changes in lvef and in acc during fluid and dobutamine administration were significantly correlated (r = . , p \ . ). conclusions. acc fulfilled the criteria required from a clinical indicator of lv global systolic function. a given value of acc allowed detecting a low lvef with a modest accuracy. by contrast, the treatment-induced relative changes in acc were reliable for tracking the treatment-induced relative changes in lvef. objectives. to compare the relationship between systolic or diastolic dysfunction at icu admission and the incidence of cardiologic complications and mortality at sixth months. methods. prospective study of forty consecutive patients diagnosed of acute myocardial infarction (ami) ( nstemi, stemi) who were admitted in the icu of university hospital puerto real (cadiz, spain) from st may to th september . studied variables: age, gender, type of ami (nstemi, stemi), left ventricular ejection fraction (lvef) by biplanar simpson's rule, diastolic function (ratio e/e of the mitral annulus included), incidence of cardiac complications (acute pulmonary oedema, atrial fibrillation with hemodynamic instability and cardiogenic shock) and mortality at sixth month. echocardiographic studies were performed with a ge vivid pro(r) by an intensivist who had performed up to doppler studies in critical patients. all studies were remeasured by a second observer in an echocardiographic workstation with no statistical difference in measured velocities. patients were classified according to their lvef in (a) preserved ([ %), (b) mildly depressed ( - %), (c) moderately depressed ( - %) and (d) severely depressed (\ %); and according to their e/e ratio in (a) normal e/e ratio (\ ) and (b) elevated e/e ratio (c ). the results were statistically analysed with chi-square test and odds ratio calculus. results. diastolic dysfunction measured with e/e ratio was associated with high incidence of cardiac complications (chi test cl % p \ . , or ). systolic dysfunction measured by lvef was also associated with more complications but with less strength of statistical association (chi test cl % p \ . , or . ). there were no significative statistical difference between lvef and e/e ratio in mortality at sixth month. conclusions. in our study, diastolic and systolic dysfunctions in patients with ami at icu admission were associated with high incidence of cardiac complications, with more strength of statistical association in patients with diastolic dysfunction. the small sample volume didn't allow us obtaining significative statistical differences in mortality at sixth months. a new method has been developed to assess global end-diastolic volume (gedv) and extravascular lung water (evlw) from a transpulmonary thermodilution curve. our goal was to compare this new method to the established method currently in clinical use, over a wide range up to extreme pathophysiological conditions. objectives and methods. anesthetized and mechanically ventilated pigs ( - kg) were instrumented with a central venous catheter and a right ( f pulsiocath, pulsion, munich, germany) and a left ( f volumeview, edwards lifesciences, irvine, ca) thermodilution femoral arterial catheter. the right femoral catheter was connected to a picco monitor (pulsion) and used to measure cop, gedvp and evlwp using the old method based on the equation: gedv = cop (mtt -dst). the left femoral catheter was connected to the new ev monitor (edwards) and used to measure coe, gedve and evlwe using the new method based on the equation: gedve = f (s /s ) coe mtt, where s and s are respectively the maximum up-and down-slopes of the dilution curve, respectively. measurements were done during inotropic stimulation (dobu), during hemmorhage (hypo), during fluid overload (hyper), and after inducing oleic acid-acute lung injury (ali). overall, cop and coe ranged from . to . and from . to . l/min, respectively. cop and coe were closely correlated (r = . ), mean bias (± sd) was . ± . l/min and %error was %. gedvp and gedve ranged from to , and from to , ml. gedvp and gedve were closely correlated (r = . ), mean bias was - ± ml and %error was %. evlwp and evlwe ranged from to , and from to , ml. evlwp and evlwe were closely correlated (r = . ), mean bias was - ± ml and %error was %. parameters over the study period are presented in the table (*p \ . intervention vs. base or hyper). introduction. fluid resuscitation is a major therapy in icu. various mechanisms are involved in the regulation of the microcirculation and the macrocirculation. objectives. the goal of this study is to assess the sublingual microcirculatory changes in response to fluid challenge in preload-responsive and non preload-responsive patients. after approval by our local institutional review board, patients in surgical icu have been included in an observational study. each patient was monitored by an arterial catheter and an oesophageal doppler. the decision of fluid infusion was taken by the physician in charge of the patient. preload-responsive patients were defined by variations in cardiac index (ci) c %. sublingual microcirculation videos were obtained using the orthogonal polarized spectral (ops) imaging technology. functional capillary density (fcd, cm cm - ) and microcirculatory flow index (mfi) were collected. the macrocirculatory and microcirculatory measurements were obtained before, during and after the infusion of ml of saline. five sublingual sites were recorded before and after the fluid resuscitation. the ventilator settings and sedative and vasoactive drugs infusion rates were kept constant throughout the procedure. results. patients were admitted in icu for acute brain trauma (n = ), hemorrhagic shock (n = ), septic shock (n = ), acute brain hemorrhage (n = ) and acute pancreatitis (n = ). the average age of the patient was ± . the mean values of ci and mean arterial pressure (map) before the fluid therapy were respectively . ± . l/min/m and ± mmhg. nine patients responded to fluid infusion (ci c %.). about the microcirculation, there was no significant difference between responders (r) and non-responders (nr) concerning the variations of mfi ( . introduction. passive leg raising (plr) was shown to discriminate hemodynamically unstable patients who will benefit from subsequent fluid administration or not. concerned by the possibility of harmful hypotension starting the plr maneuver from a °semirecumbent position, in a previous study, we found that raising patients' legs from a supine position, we were not able to predict fluid responsiveness in a heterogeneous cohort of medical intensive care unit (icu) patients. objectives. to investigate whether starting plr maneuver from a °semirecumbent position would better predict volume responsiveness without harmful hypotension in spontaneously breathing critically ill medical icu patients. methods. fluid responsiveness was tested in consecutive patients ( sepsis, respiratory failure, heart failure, others) with a mean arterial pressure (map) \ mmhg and/or a cardiac index (ci) \ . l/min/m . heart rate (hr), mean arterial pressure (map), global end-diastolic volume index (gedvi), cardiac index (ci) and stroke volume index (svi) were recorded using the picco method. patients were stable in a semirecumbent ( °) position when first measurements were taken (baseline ). for the plr maneuver, patient's bed was tilt to have the lower limbs raised to a °angle while the patient's trunk was then in a supine position. changes after min were recorded. the patient was then brought into a supine position, and heamodynamic measurements were recorded when stable (baseline ). thereafter, ml of . % nacl were administered over min. positive predictive values (ppv) and negative predictive values (npv) of the plr maneuver were calculated using a cut-off value of % increase for ci and svi and % increase for map. results. patients' median age was ( - ) years and their saps score ( - ). all patients received vasopressors and/or inotropes. baseline hemodynamics and changes after plr and fluid challenge are shown in table . results are given as median (range); n/a = not available, *p \ . versus baseline. ppv and npv for ci were and %, for svi and % and for map and %, respectively. conclusions. in our hands, plr was not useful identifying fluid responders in this heterogenous population of severely ill medical icu patients, the starting semirecumbent position being associated with a potentially harmful decrease in map. however, it was helpful to detect patients who will not benefit (or even suffer harm) from further fluid administration. recently, some studies suggested that an impaired diastolic function is a predictive factor of mortality in patient with shock. it is not already known whether fluid infusion could improve diastolic function. objectives. the aim of the study was to determine the impact of rapid fluid infusion on diastolic function. after acceptance by the local ethic committee, icu patients were prospectively included. volume expansion (ve) by ml of saline was performed by the intensivist in charge. transthoracic doppler echocardiography was performed before and after fluid infusion. stroke volume (sv), early diastolic transmitral velocity (e), early diastolic mitral annular velocity (ea) and e/ea ratio (reflect of lv filling pressure) were studied. patients were divided in groups according to their sv' increase: responders (r) (those who increased their sv by at least %) and non-responders (nr). wilcoxon rank sum test was performed to compare data before and after ve. data are presented in median (iqr) results. fifty-three ( %) patients were r and ( %) were nr. in the overall population, ea increased significantly with ve [from . ( . ) to . ( . ) cm/s, p = . ]. in the r group ea increased significantly [from . ( . ) to . ( . ) cm/s, p = . ] and e/ea did not change significantly [from . ( . ) to . ( . ), p = . ]. however in the nr group, ea did not change significantly [from ( ) to . ( . ) cm/s, p = . ] while e/ea increased significantly [from . ( . ) to . ( . ) cm/s, p = . ]. conclusions. according to these results, adequate fluid infusion seemed to enhance lv relaxation without increasing lv filling pressure while inadequate fluid infusion did not affect relaxation but increased lv filling pressure. objectives. the aim of our study is to compare the rapid variation of co measured by vigileo-flotrac Ò with doppler-echocardiography which is considered as a reference method. during the first hours of hospitalisation, we studied mechanically ventilated patients receiving norepinephrine who underwent arterial pressure monitoring via a radial artery catheter. the flotrac Ò pressure sensor and the vigileo Ò monitor were connected to the arterial line. at each fluid expansion or norepinephrine dose modification a transthoracic doppler-echocardiography was performed and co was calculated. variations for co measured by each method were compared. results are presented as median (iqr). linear regression and the bland-altman method were used for statistical analysis. methods. for the in vitro experiments blood of healthy donors was incubated (in the ratio : ) with one of the following solutions: ringer solution, ringer-lactate solution, modified gelatin (gelofusin); hydroxyethyl starch (hes) / . . after incubation, the following parameters of erythrocyte aggregation were measured: t and t -characteristic times of spontaneous erythrocyte aggregation; b-hydrodynamic strength of aggregates; i . -index of strength of the largest aggregates at shear rate . s - . rbc deformability at various shear stresses was determined by ektacytometry. in vivo study on patients with trauma treated randomly with either only crystalloids (group ; n = ), or crystalloids + hes / . (group ; n = ) or crystalloids + gelofusin (group ; n = ) over days, the same parameters as in vitro study were determined at day - . twenty healthy men and women were included as controls. for statistical analysis the statistical package spss version . was used. statistical significance was considered at p \ . . in vitro study in the final analysis effects of different colloids on rbc aggregation and deformability were considered as increasing impact (:), decreasing impact (;) and no impact (-) ( table ) . in vivo study significant microrheological disturbances were detected at day after admission. deformability index was lower in patients compared with controls ( . ± . vs. . ± . ; p = . ). simultaneously, the patients showed erythrocytes hyperaggregation compared with control (;t , ;t ; :i . , :b). in the first group (crystalloids) described violations persisted throughout the study time. in group (crystalloids + hes), the deformability was higher than in the st group, from days till the end of the study, attaining the normal range, and also higher than in the third group (crystalloids + gelofusin). in the third group, deformability index was not significantly different from group . according aggregatometrical data in the first group hyperaggregation syndrome remained the entire period of observation. hes adding (group ) decelerated aggregate formation (:t , :t ; ;i . ). in contrast, modified gelatin adding enhanced erythrocyte aggregation (;t :i . , :b). conclusions. crystalloid solutions are not able to improve microrheological parameters. hes / . increases rbc's deformability and reduced rbc's aggregability. gelofusin increases erythrocyte aggregation and no effect on deformability. introduction. trauma patients often require norepinephrine (ne) infusion and fluid challenge to keep normal blood pressure values. the reliability of dynamic predictors of fluid responsiveness during vasopressors therapy is under debate. we investigated the impact of norepinephrine (ne) infusion changes on pulse pressure variation (ppv) assessed with the mostcare system (vytech health, laboratoires pharmaceutiques vygon, ecouen, france) in intensive care unit patients. this device is a pulse contour method that provides cardiac output and fluid responsiveness variables and does not need any kind of calibration or preloaded data. methods. trauma patients ( female, male, mean age ± ) admitted to a -bed university hospital medico-surgical icu were prospectively enrolled. inclusion criteria were: mechanically ventilated patients (tidal volume [ ml/kg and constant respiratory rate); invasive arterial blood pressure monitoring; ne infusion. ppv values were recorded continuously during three different haemodynamic states: at baseline (t ), min after a . lg/kg/min ne increase (t ), min after a further . lg/kg/min ne increase (t ), min following the reduction of ne to t dosage (t ) and min after setting ne to baseline value (t ). during the study neither fluid challenge nor other vasoactive/inotropic drug changes were done. anova test was applied. results. see data in table . at t ne mean dosage was . lg/kg/min (range . - . lg/kg/min). the mean ppv was: at t . ± . %, at t . ± . %, at t . ± . %, at t . ± . %, at t . ± . % (p \ . ). conclusions. our findings demonstrated that ppv was significantly affected by changes in ne: the higher the ne dosage the lower the ppv. changes in arterial tone due to ne infusion can impair ppv reliability in assessing fluid responsiveness in trauma patients. introduction. in mechanically ventilated patients respiratory variation in the arterial pulse pressure (dpp) is a reliable predictor of fluid responsiveness . respiratory variation of pulse oximetry plethysmographic waveforms correlate to dpp and can be calculated automatically in real time (heart-lung index [hli Ò ] from hamilton medical). this prospective study evaluates the relationship between dpp and hli Ò to predict fluid responsiveness. mechanically ventilated patients were investigated; all connected to an hamilton g ventilator and ventilated in adaptive support ventilation (asv), paralyzed and none had severe cardiac dysrhythmia. were eligible for fluid expansion. dpp, hli Ò (obtained from a finger probe pulse oxymeter integrated to the ventilator) and cardiac index (ci from transthoracic echo-doppler), were obtained before and after fluid expansion ( ml/kg of hea over min). ci-responders were defined by % increase from baseline. results. out of the patients were ci-responders and had significantly higher hli Ò before volume expansion ( % ± vs. % ± , p \ . ). before fluid expansion hli Ò was correlated with dpp (r = . , p \ . , fig. ). hli and dpp were significantly correlated with change in ic induced by fluid expansion (r = . and r = . , respectively). objectives. the primary end point of this study was to evaluate the rvd of the ivc in icu patients with spontaneous breathing. methods. icu patient with spontaneous breathing and signs of hypoperfusion (oliguria, mottles, serum lactate level [ mmol/l) were eligible after the approval of the local ethics committee. we excluded patients with acute heart failure with pulmonary edema, moribund and arrhythmic patients. the trans thoracic echocardiographic (tte) evaluation was done by confirmed intensivists (level [ in echocardiography). the aortic diameter measured at the lv outflow chamber and the tvi were measured. the vena cava inferior diameters at inspiration and at expiration were measured on the sub costal view. the rvd of the ivc was defined as the (maximal ivc diameter -minimal ivc diameter)/maximal ivc diameter. these measures were realized at t , before fluid challenge, and after a fluid challenge of ml of hes % ( . / ) over min (t ). patients with an increase of tvi of more than % were considered as responders to the fluid challenge. the measures of tvi and of the rvd of the ivc were validated by an experimented intensivist and echographist (level ) after blinding the patient' name and of the times of measurement. roc curves were constructed, and the cut off was determined as the closest point of the roc curve to the ideal point (sensibility = specificity = ). the values are expressed as median and extremes. objectives. our objective was to test whether non invasive assessment by trans thoracic echocardiography of sub aortic velocity time index (vti) variation after a low volume of fluid infusion ( ml of hydroxy ethyl starch, hes) can predict fluid responsiveness. methods. sub aortic vti was measured by transthoracic echocardiography before fluid infusion (baseline) in sedated patients with acute circulatory failure and low tidal volume mechanical ventilation in whom volume expansion was planned. then, vti was recorded after ml of fluid infusion over min, and after an additional infusion of ml of hes over min. we measured the variation of vti after ml of fluid (dvti ) for each patient. receiver operating characteristic (roc) curves were generated for dvti in all patients. when available, roc curves were also generated for pulse pressure variation (ppv) and central venous pressure (cvp). , volumes (gedvi) and variabilities (svv, ppv) have been suggested to predict volume responsiveness (vr). the final classification of a patient as ''volume responsive'' is usually made by a volume challenge (vc) with an infusion of a pre-defined amount of fluid over a certain time. among many variations of vcs, the infusion of ml crystalloid over min is one of the most established. despite superior predictive capabilities of svv, ppv and gedi compared to cvp and pawp in a number of studies, they fail to predict vr in a substantial number of patients. furthermore, the use of these parameters is limited due to femoral access of the cvc (gedi; cvp) or the absence of controlled ventilation and/or sinus rhythm (svv, ppv). repeated ''exploratory'' vcs with ml/kg might result in volume overload in some patients. objectives. therefore, we investigated the usefulness of a ''small vc'' with . ml/kg crystalloid over min compared to a standard vc with ml/kg over min. in patients equipped with picco hemodynamic monitoring we performed a min vc with ml/kg of crystalloid. during the vc transpulmonary thermodilution (td) was performed at , and min to obtain td-derived ci (ci td ). additionally pulse contour ci (ci pc ) was recorded in intervals of min. introduction. the prevalence of obesity, defined as a body mass index (bmi) c kg/ m , reaches epidemic proportions. it is not only a risk factor for health problems, but also exacerbates illness progression. consequently, the number of obese patients on the intensive care unit (icu) has increased enormously. caring for obese patients can be quite challenging due to the weight and size of this person. the extent of and specific problems associated to the care of obese icu patients are unknown. the aim of this study is to identify and quantify problems nurses face in caring for obese patients on the icu. this study was performed on the icu at the radboud university nijmegen medical centre and contained two parts. in the first part a selection was made of obese patients admitted between and ; these patients were matched with normal weight patients (bmi . - . kg/m ). patients were matched on gender, age, length of icu stay and apache-ii score. all patient files were screened for the presence and intensity of problems in caring for these patients. in the second part nurses were asked in a survey to share their experiences in caring for obese patients. they were asked about the nature, frequency and intensity of the problems they faced. in total, problems were identified in the screened patient files. seventy-two problems ( . %) occurred in care for obese patients and ( . %) in care for normal weight patients. in both groups, most of the problems were related to activities of daily living (adl) such as (re)positioning in bed, transfers and personal care. surprisingly, the intensity of the problems was similar in both groups. most of the problems were moderate (hardly to solve by one person) or severe (only to solve with two persons or special equipment). moderate problems occurred in . % of normal weight patients and in . % of obese patients; severe problems . and . %, respectively. this result was also confirmed by the survey. the nurses qualified most of the problems they were asked about as moderate or severe, and the frequency of the experienced problems was much higher. from the files it appeared that in . % of the obese patients nurses had adl problems. strikingly, in the survey nurses reported that they frequently ( . %) or even always ( . %) experienced adl problems in obese patients. nurses reported and experienced more problems in daily care for obese icu patients compared to normal weight icu patients. although the intensity of the problems with obese patients did not differ from normal weight patients, the frequency in which they occur was much higher. differences between reported problems and the survey suggest an underestimation of problems that can be solved by performing a prospective study. nevertheless, based on these results, and taking into account that obesity will increase in the future, we recommend anticipating to the needs of the nurses whenever possible. introduction. worldwide the number of obese patients (bmi [ ) is increasing rapidly ( ); this also includes patients admitted to the intensive care units (icu). this raises special demands on the staff, the surroundings and the equipment ( ) . often the obese patient is not mobilised according to the clinical standard this causes complications to breathing, circulation and skin etc. furthermore the length of stay in the icu increases and the mortality rises. objectives. the aim of this study therefore was to make clinical guidelines and recommendations for mobilisation of the obese icu patient based on evidence. this will increase the knowledge and importance of mobilisation between staff and on longer term improves the daily average number of mobilisations performed with these patients. a secondary aim is that increased knowledge on this topic will improve the interdisciplinary work between the different professions based on the same overall aim. a systematic review of the literature concerning mobilisation of the obese icu patients was made in the year - . the study is still work in progress analysing the literature to make guidelines and recommendations based on evidence. furthermore evidencebased education of special trained staff in mobilisation has been conducted in january/ february to improve their knowledge of the impacts mobilisation has on the respiration, circulation and skincare etc. the education was planned to aiming at a interdisciplinary audience. results. the preliminary results shows that it is more difficult to care for and mobilise the obese icu patient, because there is lack of space, non-availability of the correct equipment, too few available staff members and a significant negative attitudes among the staff towards the obese patient. recommendations are made within airway, breathing, circulation, nutrition, pain, equipment and patient experience according to the procedure of mobilisation of the obese icu patient. the recommendation was implemented in the already performed education and resulted in a changed attitude among the participant and improved the status of mobilisation in the daily prioritization. this knowledge was obtained in the evaluationinterview conducted approximately one month after the seminar. conclusions. according to the literature mobilisation of the obese icu patient needs special attention towards a safe clinical practise based on evidence with focus on both the patient and the staff. special attention towards this group of patient is created by performing evidence based research resulting in clinical guidelines that has to be implemented through theoretical and practical education on an interdisciplinary level. nurses are constantly exposed to the pain and suffering of those in their care . the primary aim of this study was to investigate the risk of secondary traumatic stress/compassion fatigue (sts/cf-the trauma suffered by the helping professional) and burnout (bo-emotional exhaustion, depersonalization, and reduced sense of personal accomplishment), and the potential for compassion satisfaction (cs-the fulfillment from helping others and positive collegial relationships) among nurses working in icu. an additional goal was to test the relationship of these three constructs to each other. ( ) . the use of closed suction circuits has been suggested beneficial as a prophylactic measure ( ) . objectives. the aim of this study was to compare the incidence of vap and the occurrence of desaturation during suction using either oss or css. we also investigated contamination of the closed suction circuit and the occurrence of adverse events. methods. css were a new product in our clinic. all staff underwent a user course supervised by the manufacturer of the closed circuit. after this, data were collected during four periods in , month css followed by months oss which was repeated twice. during the summer period css were used without any data collection and then followed by two periods of css and oss. all mechanical ventilated patients were consecutively included. a culture of deep endotracheal aspirate and a blind microbiology brush was taken in association with the intubation, after h and every monday. after changing css and in case of extubation, the tip of the catheter was sent for culture. demographic data were retrieved from the hospital database. data were analyzed with descriptive methods. results. the incidences of vap were higher in the css group (table ) . both suction systems showed almost no desaturation during and after suctioning. positive cultures were obtained in % of all the retrieved css catheters. the microbiological flora resembled the species found in the airway cultures. there were no inter patient contamination and neither did the bronchoscopy frequency differ between oss and css patients. in the css group six adverse events were seen; three tube occlusion and three incidences with secretion clogging. conclusions. the use of a css did not prevent vap, in our study. there were no benefit with css other than maybe to protect the staff and our finding of positive culture in % of the cases is in line with earlier studies. objectives. the aim of this study was to determine which intensive care patients the nurses defined as 'difficult' and their experiences in coping with such patients. the study was carried out as a qualitative design with voluntary nurses employed in five intensive care units of a research and training hospital. the data were collected using demographic characteristics form and a semi-structured interview form. interviews with nurses were made individually and face to face. the data were evaluated by using colaizzi's phenomenological data analysis method. as a result of data analysis into two categories and two themes were identified. the categories were ( ) difficult patient definition of the nurses, ( ) the effect of difficult patients on their care, and ( ) how the nurses are affected and cope with difficult patients. the nurses listed their reasons for defining some persons as difficult as difficult physical care of the patients, and the difficulty in communicating due to dementia, agitation, alzheimer's disease or the patient's personal characteristics. the nurses said that they found taking care of patients they found difficult physically and psychologically demanding. they used methods such as finding out the patient's problem and taking appropriate measures, increasing communication with the patient and providing explanations, trying to obtain spiritual satisfaction and transferring the patient's care to another nurse when communication problems were impossible to overcome. intensive care nurses have difficulty in caring for and communicating with some intensive care patients due to the characteristics of the disease, physical/psychological factors and personal characteristics. we found that nurses continued the care of these ''difficult'' patients by focusing on solving their problems, transferring the care to another nurse when necessary or by trying to obtain spiritual satisfaction. methods. teams of three delirium experts visited ten icu's in the the netherlands in which the cam-icu was incorporated in daily practice, twice. these teams consisted of two consultants in either psychiatry, clinical geriatrics or neurology, and either a research-physician (mmjve) or a research-nurse (mvdb). based on cognitive testing, inspection of the files and dsm-iv criteria for delirium, the teams classified patients as awake and not delirious, or delirious or comatose. this classification served as gold standard to which the cam-icu as performed by the bed-side nurses was compared. a simple table was used to calculate the sensitivity and specificity. results. delirium experts performed assessments. ( %) of these patients were assessable for delirium, ( %) patients were excluded because the level of consciousness was too low, and ( %) patients were non-assessable due to other reasons. overall, we found a sensitivity of % ( % ci - %) and a specificity of % ( % ci - %). the strengths of this study include the large numbers, the multicentre design, the extensive evaluations by teams of various delirium experts and the independent assessments of delirium experts and bed-side nurses. a limitations is the time interval between the expert assessment and the administration of the cam-icu (mean min; standard deviation min). there were striking differences in implementation strategies of the cam-icu between the centres. tables , . rd esicm annual congress -barcelona, spain - - october s introduction. presence of expiratory ineffective efforts in mechanically ventilated patients is a common problem associated with increased duration of mechanical ventilation, length of stay and also a higher cost and mortality. nowadays, identification and categorization of expiratory asynchronies can only be done at the bedside with the continuous observation of the ventilator interface. nurses must be skilled to understand non appropriate situations of anomalous patient-ventilator interactions. objectives. we tested the hypothesis that after specific training nurses would acquire enough skills to detect expiratory efforts as intensive care expert physicians would do. training phase: nurses were provided with selected bibliography on patient ventilator interaction and afterwards trained by intensivists with expertise on mechanical ventilation ( h/day during days) on airway pressure, flow and volume waveforms identification and eye interpretation of early and late ineffective expiratory efforts during expiration. validation phase: airflow and airway pressure waveforms were obtained from different icu mechanically ventilated patients using and acquisition and processing biomedical signal software (better care Ò ). one thousand and seven breaths were randomly selected from a total of , , breaths. subsequently, selected breaths were blindly analyzed by trained nurses and intensivists to identify ineffective expiratory efforts. introduction. several publications indicate that manual hyperinflation is a widely used measure in the icu, but more important is the fact that there is no uniformity in the implementation of this measure. this is also on my ward. in literature there are a number of reasons given to start manual hyperinflation: abolish mucus retension, improve oxygenation and removal of atelectasis. the positive effects are improved compliance, improved oxygenation and a decrease in the number of vap's (ventilator associated pneumonia). the negative effects are a decrease in cardiac output due to high peak pressures, an increased risk of baro-/volutrauma and the risk of giving too much tidal volumes. the risk of barotrauma increase with pressures above cmh o. other side effects include the development of a pneumothorax and increased icp (intra cranial pressure). objectives. creating more awareness of the procedure with lower peak pressures as a result. methods. through literature review, clinical courses and the introduction of a pressure gauge achieve greater uniformity and awareness of the procedure. we used a flow analyzer of imt medical, a laptop with flowlab software version . . and an artificial lung to demonstrate how much pressure and volume is generated during manual hyperinflation. conclusions. compliance with bts guidelines could be improved. unsurprisingly co-morbidities were frequent, but did not seem to affect outcome. use of a pneumonia severity assessment tool was sub-optimal, however mean curb- score didn't correlate with that recommended to prompt critical care assessment. apart from functional status, we are unable currently to identify any factors in this age group which can be used to guide critical care admission decision making. conclusions. in our study the incidence of complicated pneumonia was / , patients admitted in picu. in necrotizing pneumonias the blood cultures were more positive than in non-necrotizing patients. although the surgical approach in necrotizing pneumonia is controversial, it resulted in a insignificantly lower mortality rate, comparing with non-necrotizing pneumonias. background. community-acquired pneumonia (cap) of mixed etiology has frequently been described in the literature, but its clinical significance remains unknown. the aim of this study was to describe the prevalence, clinical characteristics, and outcome of severe cap of mixed etiology in icu patients. a -year prospective study was conducted on consecutive patients with severe cap admitted to icu in whom an extensive microbiological investigation was performed. results. patients were included. a single pathogen was detected in ( . %) cases, while two or more pathogens in ( . %) cases. the most frequent pathogens' combinations were those of two bacteria ( . %) and bacterium plus virus ( . %). compared with patients with monomicrobial pneumonia, patients with mixed pneumonia were older, had higher severity score (psi) and were more likely to have previous chronic pulmonary disease (see table below). moreover, mixed cap patients showed similar clinical and analytical data at admission but increases in the frequency of respiratory distress and in length of stay and a trend to higher orotracheal intubation and mortality rates. a mixed etiology was detected in % of cases with cap requiring icu hospitalization and was associated with older age and increased severity. despite similar radiological features (n of involved lobes, pleural effusion) at admission, cap with mixed etiology showed a trend to worse clinical course and outcomes than monomicrobial pneumonia. objectives. to assess the incidence and aetiology of pneumonia in a mixed medicalsurgical icu, in order to develop local epidemiologically guided protocols to reduce antibiotic resistance selection in patients with pneumonia. methods. retrospective observational study on prospectively collected data in a mixed medical-surgical icu of a secondary care italian hospital. at our institution, epidemiological data on infections and data on antibiotic use are recorded since ; in a new electronic recording of icu infections was introduced. type of infection, germ characteristics, clinician diagnosis and antibiotic use were prospectively collected in an electronic database and retrospectively reviewed. antibiotic exposure index was calculated as each antibiotic total amount administered divided by its defined daily dose times total days of admission. between and a total of patients were admitted to our icu. pneumonia was the commonest infectious disease at admission ( cases, % of patients), and the commonest infectious complication during icu stay ( new occurrences, % of total pneumonia patients). table shows major epidemiological findings in the study population. the incidence of acquired pneumonia was remarkable: . cases every , days of mechanical ventilation. the most frequent isolated organisms were s. aureus ( patients) and p. aeruginosa ( patients). methicillin-resistant s. aureus (mrsa) accounted for % of pneumonia caused by s. aureus, and its prevalence matched closely the exposure index to vancomycin. such a high incidence of mrsa is consistent with other records in mediterranean countries. carbapenem-resistant p. aeruginosa was somewhat less of a problem ( % of pneumonia by p. aeruginosa), and was not apparently associated with antibiotic exposure, at least within the unit. conclusions. in our retrospective observational study we found a high incidence of pneumonia at our institution, as well as a high percentage of mrsa, the latter with strong relationship with exposure to vancomycin. new protocols for infection containment and antibiotic usage are urgently needed. introduction. community-acquired pneumonia (cap) carries a high morbidity and mortality. a major problem is the insufficient monitoring of cap by standard chest radiography, as the evaluation depends highly on the observer and the extent of pulmonary infiltration cannot be assessed properly ( ). objectives. the aim of our study was to compare the process of inflammation in cap measured by alveolar nitric oxide (no)-analysis ( ) in exhaled breath and the extent of the inflammatory infiltration by electrical impedance tomography (eit) ( ) in spontaneously breathing patients. after approval of the local ethic committee and obtained written informed consent patients with cap were included in the study. all patients showed an acute pulmonary infiltration in chest x-ray, pulmonary symptoms (coughing, shortness of breath), positive findings in auscultation, leukocytosis, elevated crp and a pneumonia severity index c . no analyses (analyser cld sp, eco medics, dürnten, switzerland) were performed at t (up to h after admission), t ( days after admission) and t ( days after admission. eit measurements (eit evaluation kit, dräger medical, lübeck, germany) were performed at t and t and inhomogeneity of ventilation was assessed by offline analysis. all measurements were made at beside in sitting position. data were compared by t test and regression analysis. results. there was no significant correlation between the alveolar no concentration and the extent of inhomogeneity of the local infiltration measured by eit. also during the study the time course of the inhomogeneity index was not correlated with change in exhaled no. the right/left distribution of the pulmonary infiltration in the chest x-ray and the eit measurement showed a positive correlation (p \ . ; r = . ). conclusions. pulmonary regional infiltration in cap measured by eit can not predict the actual alveolar process of inflammation in the lung. nevertheless the monitoring devices give additional information to better evaluate the time course of inflammation and the dimension of the respiratory dysfunction in diseased lung. organizing pneumonia (op) presenting as acute respiratory failure (arf) is a relatively rare disease, and was only previously specifically reported in small series [ , ] , with mortality up to %. these studies were performed before the publication of international consensus classification of idiopathic interstitial pneumonias in [ ] . objectives. to compare clinical features and prognosis of patients with op with those of patients presenting diffuse alveolar damage (dad), during arf. design: retrospective monocentric study in a university hospital conducted during an yr-period. to determine predictors of niv failure in patients who were intubated for respiratory failure and extubated directly to niv. methods. this is a retrospective analysis of prospectively collected data from january to dec . patients with respiratory failure were mechanically ventilated in a university hospital's medical intensive care unit (icu) and subsequently extubated to niv. physiological and biochemical parameters, using arterial blood gas measurements, were collected at the end of the spontaneous breathing trial and h after the application of niv. failure of niv was defined as respiratory failure requiring re-intubation within h. out of patients, . % were successfully extubated to niv. success rates were . % in patients with chronic obstructive pulmonary disease (copd) and . % in other patients (p = . ). patients who failed niv were more tachypnoeic, acidaemic and hypercapnic pre-niv, and more tachycardic, hypotensive, acidaemic, hypercapnic and hypoxaemic post-niv (p all. ). on logistic regression analysis, three physiologic parameters predicted niv failure: pre-niv respiratory rate (or . , % ci . - . per breaths increase), post-niv heart rate (or . , % ci . - . per beats increase) and post-niv systolic blood pressure (or . , % ci . - . per mmhg decrease). conclusions. physiologic parameters, including the respiratory rate pre-niv, and heart rate and systolic blood pressure post-niv, independently predict niv failure post-extubation. these parameters should be taken into account in the decision to extubate directly to niv. introduction. discontinuation of mechanical ventilation in critically ill patients is a challenging task and involves a careful weighting of the benefits of early extubation and the risks of premature spontaneous breathing trial (sbt). only a few studies have explored indices derived from both heart rate and breathing pattern variability analysis for the estimation of weaning readiness. objectives. to investigate heart rate (hr) and respiratory rate (rr) complexity in patients with weaning failure or success, using both linear and nonlinear techniques from signal processing theory. methods. forty-two surgical patients were enrolled in the study. there were who passed and who failed a weaning trial. signals were analyzed for min during two phases: despite of passing the protocol the decision to extubate was postponed in some patients. to gain insight on the physicians reasons for continuing mechanical ventilation after passing the wean screen protocol. a wean screen protocol was introduced at a mixed medical (neuro-)surgical icu of a teaching hospital in december to april . ventilation practitioners assessed ventilated patients and recorded the physicians reasons for continuing mechanical ventilation despite of passing the wean screen protocol. . patients were ventilated in this period. daily screens were performed, screens were successful. only passed wean screens resulted in extubation. the rate of extubation was %. % screens did not lead to liberation from mechanical ventilation. the extubation rate does not correspond with the findings of the abc trial with an extubation rate of %. table shows the physicians' reasons to continuing mechanical ventilation. it should be noted that all patients with an unsafe airway were patients with a glasgow coma scale (gcs) of b [intracerebral haemorrhage ( %), cerebral infections ( %), post-cpr encephalopathy ( %) and severe brain injury ( %)]. we accomplished a reduction in the use of sedatives (- % midazolam and - % propofol) and morphine (- %) ( table ). the amount of time spend on ventilators decreased, albeit not significantly (p = . ). this was probably due to the vap-ventilatorbundle (introduced last year), the heterogeneity of our cohort and the already short mv-duration. . non-invasive ventilation (niv) has been utilized in selected patients with hypoxemic arf to avert endotracheal intubation, which is related to life-threatening complications. niv has been also proposed to facilitate weaning and extubation in patients with hypercapnic arf. so far, no controlled randomized study has investigated the potential role of niv in weaning patients with hypoxemic arf. objectives. we designed this pilot study to assess safety and feasibility of niv to wean hypoxemic arf patients. twenty mechanically ventilated patients with hypoxemic arf were randomized to receive early extubation followed by niv application via helmet (helmet group) or conventional weaning through the endotracheal tube (tube group). primary outcomes were the duration of invasive mechanical ventilation and the adherence to the study protocol. secondary outcomes were protocol failure (i.e. need for re-intubation), icu and hospital mortality, rate of tracheotomy, duration of continuous intravenous sedation, weaning time, and septic complications. table . weaning through helmet by niv application following early extubation was safe and feasible. overall the adherence to the study design was %. in addition, in the helmet group, there was a significant reduction in the rate of tracheotomy and a trend toward a lower rate of protocol failure, and fewer days on invasive ventilation. there was no difference with respect to days of continuous sedation, icu and hospital mortality, weaning time and septic complications. ( ) . delirium is a common occurence on the icu and is associated with increased length of stay (los) and poor outcomes ( ) . objectives. we developed a combined daily sedation hold, delirium management, and weaning (sdw) protocol and implemented this to reduce icu los and improve outcomes. methods. a sdw protocol was implemented in . we prospectively audited all patients from january to march . delirium was measured using the icdsc. data was analysed using graphpad statistical software. results. consecutive patients were analysed. the incidence of delirium was % ( pts). of these, % ( ) had risk factors for delirium. there was no difference in onset of delirium between sexes, age, type of admission, or severity of illness. however, in patients with delirium, duration of mechanical ventilation (mv) and icu los were significantly longer and there was a trend towards increased hospital los ( conclusions. measuring the linear dependence of variables through time by k and ø may be used to determine non-linear behavior between the variables of the emmv. non-linear behavior during weaning perhaps indicates the dependency of, either the resistance or compliance of the respiratory system, on the ventilatory support (i.e. pi). accordingly, k and ø, estimated at the frequency interval form to (h) - , can provide information concerning to the dynamics of the respiratory system that can be used as a complement to determine the suitability of the mv withdrawal. objectives. to study the potential superiority of aprv on cmv in a subgroup of patients with severe ards. methods. retrospective observational study on patients severe ards who were admitted between july and january to mafraq hospital icu in uae. the diagnosis of ards was based on presence of bilateral infiltrates in cxr and p/f ratio of less than in absence of evidence of elevated left atrial pressure. all patients were managed according to ardsnet guidelines using low tidal volume cmv and iv steroids. criteria for transition to airway pressure release ventilation (aprv) included failure to wean down fio below % after h, hemodynamic instability due to high peep, and failure to maintain plateau airway pressure below cmh o. initial settings of aprv were ph , pl , th , and tl . with titration of fio as required keeping pao more than mmhg. we compared the outcome of cmv and aprv groups with special concern to the duration of mechanical ventilation, requirement for tracheostomy, and survival to icu discharge. twenty four male and females were included in the study with a mean age of years (± ). fourteen out of them fulfilled the criteria and were shifted to aprv within h of initiating mechanical ventilation. ten out of ( %) patients in the aprv arm survived to icu discharge versus out of ( %) patients in cmv group (p . ). survivors in aprv group spent significantly shorter periods of mechanical ventilation compared to survivors in cmv group ( . vs. . days p . ). while out of ( %) survivors in cmv required tracheostomy for prolonged intubation or recurrent lavage, only out of ( %) survivors in aprv group required tracheostomy tube placement (p . ). we concluded that aprv can be effectively used as rescue measure of ventilation in patients with severe ards. although our study does not show any mortality benefit of using aprv over cmv, there was a shorter ventilation days and icu stay using aprv. we strongly recommend further studies to investigate the probability of using aprv as initial mode of ventilation in this subset of patients. weaning from mechanical ventilation is a common daily procedure when caring for critically ill patients, and a lifesaving practice on which nurses are taking an increasing role with the introduction of nurse-led protocols. the literature supports that nurse-led protocols facilitate weaning and increase nurses' input in decision-making. on the other hand, decision-making is a complex function affected by the nature of the task, the decision environment and the characteristics of the decision maker. although the cognitive process of clinical decision-making has been investigated with many different methodologies, little is known about the decision environment and its impact on decisions' during the weaning process. objectives. this paper aims to address one of the factors of the clinical environment and its impact on the decisions when discontinuing mechanical ventilation. methods. this paper is part of a large comparative ethnographic study looking at nurses' input during the weaning process of mechanically ventilated patients. participant observation of critical care nurses took place in an -bedded icu in greece and an -bedded icu in scotland for months each to examine nurses' involvement in the decisions made. in-depth semi-structured interviews with the nurses followed focusing on how nurses perceived their participation in the decisions made. data from field notes and interview transcripts were analysed thematically using the qualitative data analysis software nvivo, version . inter-personal and inter-professional relationships were considered revealing influences of nurses' input in decision-making. clinicians' personality played a significant role in their involvement in decisions, whereas trust and appreciation, the sense of support and the sense of accountability were also considerable dynamics of inter-professional relationships and predisposed decision-making. clinical decision-making is a multi-dynamic process specifically in complex clinical long-term situations such as weaning. aspects of the decision environment, such as the interprofessional relationships should be acknowledged when introducing methods to enhance nurses' role in teamwork and collaborative decision-making in order to improve the weaning process of ventilated patients and their outcome. objectives. the objective of our study was to analyze the temporal trends and outcomes of two cohorts of patients ventilated with psv and pav+. a cohort of consecutive patients who were ventilated with pav+ and another cohort of consecutive patients who were ventilated with psv were compared. all patients had the same inclusion criteria (gas exchange, ventilatory mechanics, peep level, resolution/stabilization of the cause leading to invasive mv and appropriate level of consciousness). both modes were adjusted to predefined clinical criteria (psv to reach a respiratory rate about bpm and pav+ to reach a physiological inspiratory effort introduction. presence of expiratory asynchronies (ea) (ineffective efforts, cough and continued contraction of inspiratory muscles) is a common problem associated with increased duration of mechanical ventilation, longer stay, higher costs and increased mortality. because of the lack of systems that automatically detect and report ea, their identification is currently done by examining ventilator interface at the bedside or by applying dedicated algorithms in investigational conditions. validate the accuracy of linear mathematical algorithms to automatically detect ea built in a new computerized system that grabs and process data from different bedside icu monitors and mechanical ventilators. observational and prospective study in a general icu of beds. two beds were equipped with a software (better care Ò ), a technological platform responsible for data acquisition and synchronization, processing, storing-as non static and processable dicom objects-and also for integrating all this data with health information systems. by using the better care Ò platform, a total of , , breaths from consecutive adult patients were collected with at least h of mechanical ventilation. algorithm # : the ea algorithm consisted in a mathematical analysis of the airflow and airway pressure waveform variations during expiration not followed by a mechanical breath. algorithm # : designed to select , breaths out of the total number. this algorithm sorted and classified the breaths by the percentage of deviation from the expected expiratory curve. the result was , breaths covering most of the shapes the expiratory curve could have. five expert attendant physicians independently analyzed the , selected breaths and classified them as ea or not. the ea algorithm processed the same , selected breaths and assigned a percentage to each one, according to the variation in the shape and direction of the expiratory airflow and airway pressure curves. the expert criterion against the ea algorithm scores was used to construct a logistic regression model. we calculated sensitivity, specificity, positive predictive value and negative predictive value. the predictive performance of ea algorithm was evaluated using roc curves. optimal sensitivity and specificity were achieved by setting the cut-off point at a ea algorithm score of %. a variation in the shape and direction of the expiratory airflow and airway pressure curves [ % compared to the theoretical curve identified an ea with a sensitivity of . %, specificity of . %, a positive predictive power of . % and a negative predictive power of . %. introduction. near-infrared spectroscopy (nirs) in combination with a vascular occlusion test (vot) has been proposed to assess and identify metabolic and microcirculatory alterations during sepsis and shock in critically ill patients. however, to automatize repeated measurements at the bedside, this technique can potentially cause discomfort to the patient. vascular arterial occlusion performed in the finger may be a more attractive method to execute repeated measurements at the bedside because of more tolerability from the patient. we have previously showed in healthy volunteers that nirs can be used on finger to assess the sto response to vot and that min was an adequate occlusion time to provide the best curve fit for nirs dynamic variables . objectives. we aimed to investigate whether sto response to vot obtained from the finger could predict conventional sto response measurements obtained from the thenar of critically ill patients. parameters of sto response were measured with an inspectra spectrometer model (hutchinson technology inc.) equipped with a -mm or a -mm probe. the mm probe was placed over the thenar eminence and the -mm probe was place over the ventral face of the middle finger. we performed in each patient a series of two vascular occlusion tests (vot): one on the finger ( min) followed by one on the arm ( min). the measurements were obtained within h of intensive care admission and every h thereafter until day . vot-derived sto traces were analyzed for baseline, ischemic (rdecsto , %/min) and reperfusion (rincsto , %/s) parameters. we performed paired of nirs measurements in critically ill patients (age ± ; m/ f). although sto did not differ significantly between thenar and finger ( % ± vs. % ± ; p = . ), rincsto and rdecsto were statistically lower in the finger ( . %/s ± . vs. . %/s ± . , p = . ; . %/min ± . vs. %/min ± . ; p = . ). we performed bivariate linear model with correlated errors in which sto outcomes on thenar and on finger were treated as responses. the correlation was significant for sto and rincsto , but not for rdecsto (table ) . furthermore, mixed model analysis showed that thenar-sto as dependent variable could be significantly predicted by finger-sto parameters with estimation coefficient (± se) of . ± . (p = . ), . ± . (p = . ) and . ± . (p = . ) for sto , rincsto and rdecsto , respectively. correlation of sto response: finger vs. thenar a prospective randomized clinical trial performed in icu's of an university and teaching hospital during a . year period, involving septic and non-septic patients, randomized (after stratification) to hemodynamic monitoring, by picco tm or pac with both techniques allowing cardiac output and central/mixed venous o saturation monitoring. methods. hemodynamic management was guided by extravascular lung water index (evlwi) and global end-diastolic volume index (gedvi) in the picco tm group and by the pulmonary capillary wedge pressure (pcwp) in the pac group for consecutive days. primary outcome measures were ventilator-free days (vfd), for which the study was powered, and lengths of stay in icu and hospital. secondary measures were the course of cardiorespiratory parameters, fluid and vasopressor requirements, lactate levels, organ functions and mortality. in the study period, septic and non-septic patients were included. patients received a picco tm and a pac catheter. monitoring arms were comparable at baseline, although sepsis differed from non-sepsis in hemodynamics and severity of lung injury. premorbidity was greater in non-septic patients. the fluid infusions and balances did not differ between monitoring arms, except at t = h when the picco tm group had a more positive balance (p = . ). cardiac index and central venous o saturation increased more in the course of time in the picco tm than in the pac group. the decrease in norepinephrine requirements strongly tended to favor the picco tm group (p = . ). the course of lactate levels and organ failure did not differ between monitoring arms. vfd did not differ among monitoring arms. picco tm monitoring was associated with relatively fewer mechanical ventilation and icu days in sepsis but more in non-sepsis (after day ). the changes in respiratory parameters, sofa and number of catheter-related complications did not differ among the arms of the study. overall, patients ( %) died in the picco tm group before day and ( %) in the pac group (p = . ). conclusion. hemodynamic management guided by picco tm monitoring is safe and results in better tissue oxygenation than guidance by pac, without inducing pulmonary overhydration, in septic and non-septic, critically ill patients. this was associated with fewer mechanical ventilation and icu days in patients with sepsis but more days in patients with non-sepsis (after day ), partly attributable to greater cardiovascular premorbidity in the latter. the major primary and secondary endpoints, vfd and mortality, were not affected. introduction. non-invasive evaluation of endothelial function may be easily accomplished by ultrasound assessment of flow-mediated vasodilation (fmd) of the brachial artery, but this technique has not been fully explored in septic patients. objectives. this prospective study aims to investigate the role o fmd analysis on intra hospital prognosis of patients with severe sepsis and septic shock. adult patients admitted to the intensive care unit with a diagnosis of severe sepsis or septic shock (\ h of duration) were consecutively included. fmd of the brachial artery was measured upon admission and after and h using a high-frequency linear transducer ( . - mhz) according to internationally accepted protocols. a group of apparently health subjects paired for gender and age was used as controls for fmd analysis. patients were followed up to discharge or death. we studied adult patients mean age ± years, females, % on vasopressors with sepsis predominantly of abdominal or respiratory etiology ( %). apache ii risk score was ± and intra hospital mortality rate was %. fmd was similar in patients with or without use of vasopressors at baseline (p = . ). fmd in septic patients was significantly lower than in health controls ( . ± vs. ± %; p \ . ). we observed that survivors depicted a gradual improvement on endothelial function, so that h after sepsis onset fmd was significantly lower in nonsurvivors (- . ± vs. . ± %; p \ . ; time-group interaction p value = . ). conclusions. brachial fmd is altered in septic patients with hemodynamic instability and its improvement may be an early marker of favorable prognosis. introduction. change in pulse pressure variation (dpp) and respiratory variation of the pulse oxymetry plethysmogram (pop) may predict the hemodynamic effect of peep in mechanically ventilated patients [ , ] . reported comparisons [ , ] between pop variations (popv) and co or dpp are based on selection of - consecutive breaths (dpp b) during a ''stable'' period of pop. recently, a fully automatic ventilation mode (intellivent Ò , hamilton medical, switzerland) that incorporates an automatic and continuous popv calculation (hli Ò ) using a dedicated algorithm has been developed. the present study was designed to compare dpp b, dpp calculated with the algorithm as hli Ò (dppalg) and hli Ò. . . sedated icu patients ventilated with hamilton medical s ventilator (with integrated pulse oxymetry (po)) were included (age = ± years, saps ii = ± , no arrhythmia, norepinephrine: . ± . mg/h in patients, map = ± mmhg, vt = . ± . ml/kg). waveforms of po from a finger sensor and of blood pressure from a radial catheter were recorded for - h. from the waveforms, breath by breath (using respiratory flow signal), without pre-selection of stable periods and using known formula [ ] dpp b (averaging breaths without any filtering), dppalg and hli Ò were automatically obtained (matlab Ò ). dpp b was compared to dppalg ( pairs) using mann-whitney t test. pairs of hli Ò and dppalg values (see fig. below) were compared using linear regression and bland-altman method. a dppalg threshold value of % was used to generate hli Ò roc curves. results. dpp b and dppalg were significantly correlated (r = . , p \ . ), but standard deviation of dpp b were higher than the standard deviation of dppalg ( . ± . vs. . ± . %, p \ . ). dppalg and hli Ò were correlated (r = . , p \ . ), mean difference was ± %. hli Ò above % predicted dppalg above % with a sensitivity of % and specificity of % (roc: . ). conclusions. dpp b should be interpreted with caution due to the high variance of this index. in real conditions and during long time monitoring dppalg and hli Ò are in acceptable agreement and hli Ò may help estimating continuously the hemodynamic effects of ventilation. introduction. transthoracic echocardiography (tte) is supposed not to be useful in ventilated patients (pt). echocardiography is usually performed transesophageally in ventilated pt and is thought to be independent of the examiner's skills. we want to demonstrate that tte in ventilated pt could be learned even by medical students with reasonable results and that tte could add useful informations for interpretation of the hemodynamic status. objectives. in a prospective observational study consecutive patients (pt) were enrolled in a -bed medical intensive care unit of a university hospital. inclusion criteria was septic shock according to actual guidelines. transthoracic echocardiography (acuson cv , siemens, germany) was performed by a medical student in each subject on day , day and survival was reported on day . tte-examination was reduced to an apical -chamber view for interpretation of left ventricular global function and calculation of left ventricular ejection fraction (ef) with the simpson method and to a subcostal view in order to examine the diameter of the inferior caval vein (ivc) and to rule out pericardial effusion. each examination was digitally recorded and was interpreted by an experienced cardiologist. every single pt was mechanically ventilated. cardiac output (co) was measured with the transpulmonary thermodilutional technique (picco-catheter, pulsion, germany). the insertion of the picco-catheter took place due to an individual physician's decision. crp was measured as an parameter of inflammation. results. pt, mean age years ± . , male ( %), pt with known coronary artery disease ( %), pt with known dilated cardiomyopathy ( %). mean apache ii-score . ± . . pt died within days ( %). picco-catheter was inserted in pt ( %). tte could be successfully performed in pt ( %). the following values are expressed as mean values ± sd, student's t test, p \ . denotes statistic significance. ef on day . % ± . , ef on day . % ± . , p = . . ivc on day . mm ± . , ivc on day . mm ± . , p = ns. co on day . l/min ± . , co on day . l/min ± . , p = . . crp on day . mg/dl ± . , crp on day . mg/dl±, p\ . . pericardial effusion in no pt. in older pt coronary artery disease is common and ef is at the start of septic shock severely diminished. ef decreased slightly in the early course of septic shock, may be as an expression of septic cardiomyopathy. the ivc diameter did not change and may not be useful as a predictor of preload in ventilated pt. co decreased over time as the hyperdynamic circulation in septic shock is getting normalised. tte adds useful hemodynamic information and should be performed in each ventilated pt. tte could be performed in almost each ventilated pt and is easily learned even by medical students. ( , ) , which can often be caused by anaemia. in current guidelines the transfusion trigger is haemoglobin (hb) \ g/dl, but there is no recommendation for scvo ( ). objectives. the aim of this retrospective study was to evaluate the change in scvo before and after transfusion and to reveal whether co -gap reflects it. methods. over a month period hb, scvo , co -gap and o -extraction ratio (o er) were recorded before and after transfusion. data are presented as median [interquartile range], for statistical analysis wilcoxon, mann-whitney tests and pearson correlation were used as appropriate. results. out of transfusion events the scvo was measured in cases. after transfusion hb increased significantly: . [ . - . ]- . [ . - . ] g/dl, p \ . . the median scvo was %, therefore two groups were created: ''low'' (scvo \ %, n = ); ''high'' (scvo c %; n = ). hb increased significantly in both groups (p \ . ), but scvo conclusions. in the high-group the low hb levels did not cause oxygen debt, as after transfusion hb increased significantly but scvo did not, and o er and co -gap were within the normal range. our results give further support that not only the hb level should serve as a transfusion trigger, but measures of oxygen debt such as scvo and co -gap should also be considered, hence unnecessary transfusions could be avoided. introduction. intellivent Ò is a fully closed loop ventilation designed to keep the patient within target ranges of etco and spo . the system includes an automatic adjustment of peep and fio following the ardsnetwork tables [ ] . if required peep is changed by cmh o every min with a maximal possible value set by the user or depending on an automatic and continuous calculation of the respiratory variations of the plethysmogram from an integrated pulse oxymeter (hli Ò ), i.e. the higher the hli Ò the lower the maximal peep allowed by the system. the present study was designed to estimate whether changes in peep are reflected in hli Ò changes. in sedated icu patients ventilated for min in fully closed loop ventilation with intellivent Ò (hamilton medical s ventilator), episodes of significant changes in peep (c cmh o) were selected and hli Ò values within min before and after peep changes were collected. statistics were done using sigmastats with p \ . as significant. results. changes in peep and in hli Ò are shown in the table ± cmh o ± cmh o ± % ± % p \ . the correlation between change in peep and change in hli Ò is shown on the fig. . conclusions. based on these preliminary data changes in peep are reflected hli Ò changes and may help estimating continuously the hemodynamic effects of ventilation. objectives. we have tested a axis accelerometer sensor for detection of regional left ventricular ischemia. in pigs a -axis accelerometer was sutured to the left ventricular (lv) apical region in left descending coronary artery (lad) supply area accelerometer x-axis measured longitudinal-, y-axis circumferential-and z-axis radial epicardial motions. epicardial displacements were calculated from the acceleration signals and systolic displacements within ms after peak r on ecg was measured. lad was occluded for s to induce regional lv dysfunction. myocardial circumferential strain (shortening) measured by echocardiography in the lv apical anterior region was used to confirm ischemia. the ecg st-segment in lead ii was also monitored. data are presented as mean ± se. early systolic displacement at baseline was ± mm, ± mm and ± in circumferential, longitudinal and radial directions, respectively. lad occlusion induced akinesia in circumferential ( ± mm, p \ . ) and radial ( ± mm, p = . ) directions, whereas longitudinal displacement changed less to ± mm (p = . ). ischemia was confirmed by echocardiography strain, showing lengthening in systole (p \ . ). no significant changes were observer in the ecg st-segment during coronary occlusion (p = . ). introduction. there is increasing evidence to suggest perioperative complications are predictive of long term survival and that reducing them may improve survival rates . goal directed therapy has been shown to reduce mortality and morbidity perioperatively, with those unable to increase oxygen delivery perioperatively having demonstrably worse outcomes. the advent of non invasive tissue oxygenation monitors using near infrared spectroscopy has allowed further study of oxygen flux during goal directed therapy. objectives. to observe changes in tissue oxygenation during an h oxygen delivery targeted post surgical optimisation program and provide long term mortality followup of a surgical cohort of high risk patients. methods. patients undergoing high risk surgery and postoperative optimisation (targeting of oxygen delivery index of [ ml/min/m ) on the tensive care unit at a london teaching hospital were enrolled. each patient underwent a protocolised haemodynamic optimisation protocol as per our standard unit policy for h with consecutive recordings of tissue oxygenation at the thenar eminence using an inspectra monitor. additional variables relating to global and tissue perfusion were measured concurrently. patients were followed up for survival status at . years using routinely available information held within our hospital records. in hospital mortality was . % (n = ), whilst at . years this had increased to % (n = ). there was no significant difference between apii scores ( ) versus . ( ), age . ± . versus . ± . or operation type for survivors and non-survivors at . years respectively. significant differences between groups were found however for admission and mid optimisation protocol ( h) hr and sto (see table there were no significant differences in measured variables for day mortality. conclusions. there appears to be a statistical and clinical difference in hr and tissue oxygenation between the long term survivors of high risk surgery who undergo monitored postoperative goal directed optimisation. introduction. bronchoscopic bronchoalveolar lavage (b-bal) is today the gold standard for sampling of inflammatory markers in the distal airways. nonbronchoscopic bronchoalveolar lavage (n-bal) by ordinary suction catheter has been investigated as a more easily accessible method for alveolar sampling in the setting of acute respiratory distress syndrome (ards). the results, however, were disappointing, probably due to more proximal sampling by the n-bal. to investigate wether n-bal by a catheter with physical properties similar to those of the bronchoscope is comparable to b-bal. methods. b-bal and n-bal by cook's airway exchange catheter was performed with ml normal saline on opposite sides min apart at nine different occasions on anesthetized and intubated pigs. the volume of the recovered lavage was noted, after which the fluid was analyzed for albumin, total cell count, viability and differential cell count. statistical analysis was performed using wilcoxon's rank-sum test. results. n-bal yielded significantly higher albumin content than b-bal ( . ± . vs. . ± . mg/l, p = . ). in all other measurements there were no significant differences between n-bal and b-bal (recovered volume . objectives. we hypothesized that collagen synthesis and degradation are disturbed in acute respiratory failure. in the finnali-study we defined acute respiratory failure as need of noninvasive and/or invasive ventilatory support for more than h ( ). after informed consent we collected blood samples for serum procollagen propeptides i and iii (pinp, piiinp) and ictp levels at study admission, day , and . patients with all four blood samples were included in this substudy. multiple organ dysfunction (mod) was defined as two or more individual organ sofa scores of - at any day during the first week. results. the study population comprised of finnali patients ( ). the mean (sd, range) age was years ( , - ) and the majority were male %. on admission the mean sapsii score was ( , - ). patients ( %) developed mod during the first days. over time piiinp/pinp-ratio first increased and then decreased to baseline by day while pinp/ictp-ratio decreased and then decreased to baseline by day (p \ . and p = . , respectively) ( fig. ). there were no statistical differences in the ratios between patients with or without mod. conclusions. we found that in patients with acute respiratory failure the balance of collagen synthesis was towards degradation of type i collagen and production of collagen type iii. ± ng/ml in the ards group, and significantly higher than the . ± . ng/ml in the ali (not ards) group. the difference in hmgb values in the early stage between the group that died up to the by th day and the surviving group was not significant, but the hmgb values were significantly higher in the group that died until the th day and th day than in the survival group. it was concluded that differences in hmgb values in the early stage after the onset of ali (not ards)/ards are useful as outcome determining factors after days of onset. an inverse correlation was observed between the hmgb values and lung oxygenation, suggesting the possibility that hmbg is involved in the development of respiratory failure. s. shibata , g. takahashi , n. shioya , s. endo akita city hospital, anesthesiology, akita, japan, iwate medical university, emergency medicine, morioka, japan, iwate medical university, critical care medicine, morioka, japan sivelestat sodium hydrate (sivelestat) is a selective polymorphonuclear leukocyte elastase (pmn-e) inhibitor and has also been shown to be effective for pulmonary disorders associated with sirs in clinical patients. blood levels of inflammatory cytokines have been shown to be decreased in patients treated with sivelestat. however, since patients with sirs have already received other drugs, it remains indefinite whether or not sivelestat might suppress the production of cytokines. moreover, it is difficult to clarify any cells releasing cytokines. in the experiment using cells isolated from the blood, intercellular mutual actions and cytokine networks were blocked and the experiment failed to faithfully reproduce the in-vivo condition. objectives. the possibility of sivelestat suppressing the production of cytokines from granulocytes and monocytes was assessed by intracellular cytokine staining using the whole blood culture method and flow cytometry to faithfully reproduce the in-vivo condition. methods. blood samples were collected from healthy volunteers. a vehicle (control group), lipopolysaccharide (lps; lps group), or lps + sivelestat (sivelestat group) was added to the whole blood, followed by the addition of a protein transport inhibitor in each group. after incubation, they were subjected to staining of the cytokines retained in the cells by the addition of an anti-interleukin (il- ) or anti-tumor necrosis factor a (tnf-a) antibody and analysis by flow cytometry. the data were analyzed by the kolmogorov-smirnov test. values obtained [d/s(n)] result from the comparison of the fluorescence histograms of each sample with a control one. addition of sivelestat at low concentrations ( and lg/ml) significantly (p \ . ) suppressed the production of il- from granulocytes induced by a low concentration ( ng/ml) of lps. on the other hand, the granulocytic production of tnf-a induced by a high concentration of lps ( ng/ml) was significantly (p \ . ) suppressed by treatment with sivelestat at high concentrations ( and lg/ml). with regard to the monocytic production of tnf-a and il- induced by lps, there was no significant suppression of either tnf-a or il- production by sivelestat. conclusions. sivelestat, a neutrophil elastase inhibitor, suppressed granulocytic production of il- and tnf-a, suggesting the potential usefulness of sivelestat for the treatment of various morbid conditions involving il- and tnf-a in their onset. introduction. coagulation, fibrinolysis and extravascular fibrin deposition are the hallmarks of the pathogenesis of acute lung injury (ali). pai- has a central role in antagonizing fibrinolysis by decreasing the plasminogen turnover to plasmin. pai- has been suggested as a clinical severity marker of ali. in previous studies it was associated with higher mortality and morbidity in the critically ill. upar is a cell surface receptor activating the serine protease upa. increased expression of upar is found in various stages, including inflammation, tissue remodelling and malignancies, indicating poor prognosis. pai- antagonizes the proteolytic activities of upa and plasmin. objectives. we sought to evaluate the prognostic value of supar and pai- for -day mortality of patients with acute respiratory failure (arf). the finnali-study patients needed invasive or non-invasive ventilation for more than h ( ). blood samples were collected from patients at baseline and on day after baseline. healthy volunteers were also analyzed. sera were frozen at - °c until analyses. concentrations of supar and pai- in blood serum were measured by enzyme linked immunosorbent assay (elisa). data are presented as median (iqr). the prognostic value of supar and pai- for -day mortality was determined with roc analysis. in the critically ill, supar and pai- were . ( . - . ) ng/ml and . introduction. acute lung injury is a common disease in intensive care, associated to various septic or inflammatory diseases. inflammation is part of the defense mechanisms of innate immunity, occurring after tissue injury. objectives. the aim of the project was to decipher the transcriptional changes occurring after the onset of an inflammatory injury by intravenous injection of oleic acid. experimental study of the lung transcriptome after oleic acid injection. thirtysix c bl/ j mice, aged of weeks, were sacrificed at h, h , h, h, h and h after physiological serum or oleic acid injection ( ll) in the caudal vein. left and right lung were separated for mrna extraction and pathological examination. labelled cdna were hybridized on cdna nylon microarray (tagc, marseilles, france) and raw data were extracted from scanned images with bzscan software. raw data were normalized with the quantile method, and supervised analysis was conducted with significance analysis of microarray algorithm within the r statistical suite and bioconductor libraries. after the administration of oleic acid, the mice were tachypneic and prostrated. all survived during the first hours. the pathological analysis of lung tissue revealed an early inflitration of the lung tissue by polynuclear cells, as well as a pulmonary edema. these alterations were not observed after h. the time course analysis of transcriptional lung data identified a thousand genes which expression is modulated after injury. hierarchical clustering identified major groups of genes. the first one ( genes) is composed of genes transiently up-regulated between h and h after oleic acid injection. th second group ( genes) is composed of genes expressed between h and h. the third group ( genes) is composed of genes expressed at the later time points ( h- h). the functional annotation linked these signatures with keywords related to pro-inflammatory response, vascular endothelium modification and lipid metabolism, respectively. rt-pcr analysis of pro-(tnf, il ) and anti-inflammatory (il , il ) markers related the pro-inflammatory phase to the earlier time points ( h- h ) and the anti-inflammatory phase to the late points (after h). conclusions. oleic acid injection in mice induced a transient acute lung injury. this is confirmed by clinical, pathological and transcriptional modifications. the modulation of gene expression after the oleic acid injection revealed an early pro-inflammatory response, followed by an anti-inflammatory response and lipid metabolism modificiations. this model could now be used to describe the specific modulation occuring during pulmonary infection and critical injuries like acute respiratory distress syndrome. introduction. ventilator associated lung injury (vali) is influenced by tidal volumes, airway pressure and cyclic opening of alveoli during mechanical ventilation. preserved spontaneous breathing during partial ventilatory support may be protective, but it is not known whether the transpulmonary pressure generated by spontaneous breathing has the same effect on vali as if generated by the ventilator. to determine whether hemodynamics, respirtory function and vali are influenced by the amount of support provided by pressure support ventilation. after approval from the institutional animal care committee, acute lung injury was induced in anesthetized sd rats by acid aspiration. ten animals each were then ventilated with positive end-expiratory pressure cmh o in pressure control (pc), pressureregulated assist control (ac) or pressure support mode with % (ps ), % (ps ) or % (ps ) pressure support of initial distending pressure needed to maintain tidal volume. pc animals were paralyzed. after h animals were killed and vali determined. results. there were no differences in baseline characteristics. acute lung injury was characterized by a decrease of the p/f ratio from ± to ± mmhg and of the dynamic compliance from . ± . to . ± . ml/cmh o. conclusions. compared to controlled ventilation, preserved spontaneous breathing activity improved hemodynamic stability, respiratory function and lung edema clearance. the reduction in pressure support did not lead to reduced tidal volume, but transpulmonary pressure was preserved by muscular activity of the chest wall. no difference was observed between full or % of pressure support, but further reduction in pressure support resulted in increased wet-dry ratio. objectives. we studied the effects of metabolic acidosis on enzymatic and non-enzymatic no-production in hypoxic and hyperoxic lung regions in a pig model. eighteen healthy anesthetized pigs were separately ventilated with hypoxic gas to the left lower lobe (lll) and hyperoxic gas to the rest of the lung. six pigs received hcl infusion (hcl group), six pigs received n w -nitro-l-arginine methyl ester (l-name) and hcl (l-name + hcl group) and six pigs received buffered ringer's solution (control group). no concentration in exhaled air (eno), no synthase (nos) activity in lung tissue, and regional pulmonary blood flow were measured. results. metabolic acidosis, induced by infusion of hcl, decreased the relative perfusion to the hypoxic lll (q lll /q t ) from (± ) to (± )% in the hcl group (p \ . ), and from (± ) to (± )% in the l-name + hcl group (p \ . ), without any measurable significant changes in eno from hypoxic or hyperoxic lung regions there were no significant differences between the hcl and control groups for ca + -dependent or ca + -independent nos activity in hypoxic or hyperoxic lung regions. metabolic acidosis augmented the hypoxic pulmonary vasoconstriction, without any changes in pulmonary enzymatic or non-enzymatic no-production. when acidosis was induced during ongoing nos-blockade, the perfusion of hypoxic lung regions was almost abolished, indicating acidosis-induced pulmonary vasoconstriction was not no dependent. assessing and monitoring biomarkers in acute lung injury (ali) may improve knowledge of its pathogenesis, early recognition, and management and predict remote organ injury and multiple organ failure. objectives. early consents for research are difficult to obtain in patients with or at risk of ali because of the emotional burden of the severity and sudden onset of the disease. however, study samples may be obtained from left-over clinical blood draws, which are readily available if processed adequately. the aim of this study was to compare fresh and ''waste'' blood samples prospectively in a series of consecutive critically ill patients. the hypothesis is that ''waste'' blood samples if appropriately processed provides accurate and reliable results comparable to the gold-standard, which is immediate collection and processing of fresh blood samples. prospective study comparing biomarkers of epithelial injury (srage) and inflammation ( different cytokines/chemokines) in critically ill patients measured on fresh blood or waste blood, kept at degrees celsius for h. an automated system performed a daily screening of adults in the icu with an increased risk for ali (lung injury prediction score, lips) within h of admission and/or on recognition of the diagnosis of ali, using the american-european consensus conference criteria. risks factors for ali include pneumonia, sepsis, pancreatitis, shock, aspiration, high risk surgery and high risk trauma. irb approved the protocol and written consent was obtained from patients or their surrogates. statistical measurements were performed using the bland-altman analysis for correlation between fresh and waste blood sample data. between may and december , patients were enrolled. one patient was excluded due to lack of sample. samples were obtained either at one time point (n = ) or two, on consecutive days (n = ). female/male patient ratio was / . seven of the patients had ali. twenty two patients had risk for ali with a median lips score of (iqr . - . ). sepsis was the most common risk factor, present in patients. in-hospital mortality was % ( / ). the bland-altman plot (mean bias ± se, limits of agreement) showed good correlation for il- ra (- ± . pg/ml, - . to . pg/ml), il- ( . ± . pg/ml, - to . pg/ml), il- (- . ± . pg/ml, - . to . pg/ml), il- (p ) (- . ± . pg/ml, - . to . pg/ml), mcp- (- . ± pg/ml, - . to . pg/ml) and srage (- ± pg/ ml, - to pg/ml) between fresh blood and ''waste'' blood samples. in patients with ali, properly stored blood, drawn for clinical purposes, can be processed within h for research purposes. however, the stability of each biomarker of interest needs to be individually validated before using stored blood introduction. pulmonary surfactant inactivation following acute lung injury might promote alveolar derecruitment and reduce the airspace available for ventilation, making the lung more prone to ventilation-induced lung injury (vili). our aim was to test the potential for a protective effect of exogenous surfactant treatment in a model of acid aspiration and vili. methods. male c /bl mice were anesthetized, mechanically ventilated (vt ml/ kg; rr /min; peep ± . cmh o; fio . ) and immediately subjected to intrabronchial (right) instillation of . ml/kg hcl . m. mechanical ventilation went on for min. min after the acid instillation, mice were treated with exogenous surfactant ( mg of phospholipids/ml) given as bolus of ml/kg in the right bronchus (surf group). we measured oxygenation, lung compliance (measured every min throughout the experiment), macrophage inflammatory protein (mip) in broncho-alveolar lavage (bal) fluid. . pao at the end of the experiment was significantly higher in the surf than in control group ( ± vs. ± mmhg, p \ . ). although surfactant bolus caused a reduction in lung compliance measured and min after treatment, in the surf group compliance restored to ± % of the post injury level, while it decreased in control group to ± % (p \ . ). there were no differences between groups in the dosage of mip- in bal neither in right or left lung. conclusions. exogenous surfactant treatment improved lung function in a murine model of two hit lung injury. grant acknowledgment. introduction. ventilator induced lung injury significantly contributes to the mortality in patients with acute respiratory distress syndrome, the most severe form of acute lung injury. understanding the molecular basis for response to cyclic stretch and its derangement during high volume ventilation is of high priority. objectives. to identify specific molecular regulators involved in the development of ventilator induced lung injury. we undertook a comparative examination of cis-regulatory sequences involved in the coordinated expression of cyclic stretch responsive genes using microarray analysis. analysis of stretched vs. non-stretched cells identified significant enrichment for genes containing binding sites for the transcription factor atf (activating transcription factor ). to determine the role of atf in vivo, we compared the response of atf gene deficient mice to wild type litter mates in an in vivo model of ventilator induced lung injury. results. atf deficiency results in increased sensitivity to mechanical ventilation alone or in conjunction with inhaled lipopolysaccharide ( mg/kg) as determined by assessment of lung and bronchoalveolar lavage cell infiltration and pro-inflammatory mediator release, pulmonary edema and indices of tissue injury. the expression of genes containing an atf cis-regulatory region was significantly altered in gene deficient animals. atf protein expression and nuclear translocation is increased after mechanical ventilation. conclusions. atf deficiency confers increased sensitivity to mechanical ventilation alone or in combination with inhaled endotoxin. in our model, atf acts to ''counterbalance'' cyclic stretch and high volume-induced inflammation, limiting its potential to cause additional lung injury and consequently protecting animals from injurious cyclic stretch. objectives. our aim was to evaluate the role of the alveolar macrophages in a murine model of ali, by selective depletion of this type of cells from the air space achieved by clodronate administration. mice were treated (it) with ll of clodronate (clo)-or pbs (pbs)-liposomes. after h mice were anesthetized and ventilated (vt - ml/kg, rr min - , fio . ); in order to induce lung injury ml/kg of hcl ( . m) or air bolus (sham group) was instilled in the right bronchus. mice were ventilated for min, and extubated after awakening. h after injury, animals were sacrificed and broncho-alveolar lavage (bal) and blood gas analysis (fio = . ) were performed. . h after lung injury animals with alveolar macrophages depletion, showed a better oxygenation versus pbs-treated group. however, recruitment of neutrophils in bal was not statistically different between clo_hcl and pbs_hcl group. results. high levels of oc were found in patients treated by mg of ot bid. oc levels ranged from , to , ng/ml in these patients. concentrations of oc were five-to tenfold higher than concentrations reported in healthy volunteers. lesser levels were found in patients treated by mg of ot bid. nevertheless, the patient with the moderate renal failure seemed to accumulate oc (levels ranged from to ng/ml) whereas concentrations reported in the patient with a normal renal clearance were below ( - ng/ml). conclusions. ecmo seemed not to have any influence on oc concentrations while renal insufficiency seemed to be the parameter leading to oc accumulation. as ic was very low and reached even with usual dosage, increasing ot dose to mg bid appeared to be unnecessary. objectives. aim of our study was to evaluate the effect of nursing care on patients undergoing venous-venous ecmo for acute respiratory distress syndrome (ards). methods. we recorded physiological and ecmo parameters (heart rate, arterial blood pressure, mixed venous saturation (svo ), arterial oxygen saturation (spo ), body temperature and extracorporeal blood flow (bf)) before and during daily nursing in patients undergoing vv-ecmo for several days (each patient was followed on average for . days, cases in total). arterial blood gases were also collected before and after nursing care. daily nursing was performed following defined steps (sponge bath, oral hygiene, change position of endotracheal tube, elevation with scooping stretcher for sheets replacement and back hygiene, dressing replacement) in agreement with a standard protocol in use in our department. (expressed as mean ± standard deviation). all patients were affected by ards h n -related. patients were sedated with propofol ( ± mg/h) or midazolam ( . ± . mg/h) plus an opioid drug (fentanyl ± mcg/h or remifentanil . ± . mcg/kg/min or sufentanil . ± . mcg/kg/min). ramsey score before nursing was . ± . . in cases patients were paralysed. in table we summarized the adverse events observed during nursing care, divided into hypertensive or tachycardic episodes, blood oxygen desaturation, reduction in svo or reduction in bf. forty-nine sedative bolus were administered during nursing (mean request for each patient: . ± . ), always after an episode of hypertension or tachycardia (most frequently during elevation with scooping stretcher and changing position of endotracheal tube). although in cases preventive bolus of sedation were administered before nursing, in of those cases ( %), additional bolus were required. we found an inverse correlation between bf and the increase in heart rate, drop in arterial saturation and svo . despite active warming, we observed a drop of . ± . °c (p \ . ) in body temperature. nursing care may have a significant impact on physiologic parameters of patients during vv-ecmo. tachycardia, hypertension and reduction in oxygenation were commonly recorded and were not prevented by pre-nursing bolus of sedation but were attenuated in patients with higher bf. introduction. prone position has been used in cases of ards with refractory hypoxemia but some physiological effects are still unknown. prone position could increase intraabdominal pressure (iap) and could lead to acute renal failure (arf). acute kidney injury in icu is associated with increased mortality. objectives. the aim of this study was to determine whether prone position could increase intraabdominal pressure and possibly promote arf. we studied all adult ards patients who were ventilated using the protective strategy defined by ards network criteria and who needed prone position to improve oxygenation. we collected respiratory data (ventilator parameters and gas exchange) and hemodynamic variables (heart rate, systolic, diastolic and mean arterial pressure). iap was measured using the abdo-pressure tm bladder transducer following world society of acute compartment syndrome recommendations. abdominal perfusion pressure was calculated as mean arterial pressure minus iap. main renal parameters were: filtration gradient (fg), creatinine clearance, fractional excretion of sodium (fena) and urea (feurea). patients were classified according to rifle score after each manoeuvre. all data were recorded in prone and in supine position at least once per day. results. the study included patients ( male) admitted to a medical-surgical icu over a one-year period. their mean age was . ± . and length of icu stay was ± days. all patients had primary ards and had received nephrotoxics. icu mortality reached %. we recorded at least manoeuvres per patient (a, b, c). prone positioning improved pafio ratio from . ± to ± (p = . ). iap showed a small increase from . ± . to . ± . mmhg (a; p = . ), from . ± . to . ± . mmhg (b; p = . ) and from . ± . to . ± . mmhg (c; p = . ). there were no statistically significant changes in hemodynamic parameters or abdominal perfusion pressure. renal function parameters (fg, creatinine clearance, fena and feurea) showed no modification after each prone positioning. in contrast, when patients were classified according to rifle score, we observed a trend towards worsening, though this was not statistically significant. conclusions. prone positioning improved arterial oxygenation in primary ards patients and was associated with an increase in iap. however, creatinine clearance and glomerular filtration remained unchanged. percutaneous extracorporeal life support system (p-ecls) including ecmo becomes widely used in medical and surgical emergent situation, such as refractory cardiogenic shock, cardiac arrest and acute respiratory failure. patients requires highly specialized intensive care and monitoring system. we reviewed our ecls experience and tried to analyze the clinical outcomes, factors for survival and frequently faced problems during management for improving weaning and survival rate (medical vs. surgical patients). introduction. in spite of the huge efforts spent over the last years, conventional treatment of acute hypoxemic respiratory failure (ahrf) is often inadequate and alternative procedures must be instituted. icus skillful in extracorporeal membrane oxygenation (ecmo), as recently shown [ ] , may improve survival of these patients. since we developed a treatment algorithm for ahrf which encomprises: ( ) low flow venous-venous ecmo (lf-ecmo) consisting in a relatively low initial blood flow (bf, - . l/min) to maximize extracorporeal co removal while providing partial oxygenation (if needed, bf can be increased up to . - l/min to keep arterial po above mmhg); ( ) femoral-femoral percutaneous cannulation with - fr cannulas to allow free movements of the neck and increase patient's tolerance; ( ) early institution of spontaneous assisted ventilation (sb) and weaning from sedation and mechanical ventilation (mv) while on ecmo. objectives. to review our last years lf-ecmo activity. methods. study period was january - . lf-ecmo entry criteria were: potentially reversible acute hypoxemic respiratory failure, lis c , no evidence of intracranial bleeding and no absolute contra-indications to heparinization. ecmo was performed with different type of heparin coated hollow-fiber artificial lungs. . we treated patients (mean ± sd, ± . years old, % males, bmi ± , sofa . ± , oi ± ). % of these patients were placed on ecmo at other hospitals and transported to our icu by a dedicated ecmo team. ventilation days before ecmo were ± (range - ). before ecmo vt/kg was ± . and rr was ± : after ecmo beginning vt/kg was unchanged while rr decreased to ± (p\ . ). ecmo was set at bf . ± l/min, gf . ± . l/min, fio . ± . introduction. ventilating patients with acute lung injury (ali) in supine position potentially leads to an impaired pulmonary gas exchange. prone position (pp) is an attractive means to improve ventilation-perfusion (v/q) ratio [ , ] but has several contraindications and showed no improvement in survival so far [ ] . another therapeutical option is an upright position, which is easy to perform and has theoretical advantages over pp: the upward shift of the abdominal compartment is less pronounced, thus increasing thoracoabdominal compliance [ ] . however, to date regimes of an upright position did not tilt patients more than ° [ ] . objectives. we hypothesised that a °standing position (sp) during mechanical ventilation may improve respiratory function. furthermore, we aimed to determine the feasibility of a sp for h during mechanical ventilation. we studied adult patients, receiving mechanical ventilation for more than h in the intensive care unit of an university hospital. after recording baseline data, patients were placed in a °sp with the body entirely straight. further data sets were recorded during h in sp, and after patients position was readjusted to supine position. functional residual capacity (frc) increased immediately after reaching sp (p \ . ) and remained elevated after repositioning to supine position. pao /fio ratio and compliance decreased initially during sp, but increased (p \ . ) after patients were retransferred to supine position. haemodynamic variables remained stable under a moderate increase of doses of catecholamines during the study period. conclusions. changes in respiratory function during sp are probably explained by a downward shift of the diaphragm due to gravitational forces leading to an increased frc but not altering v/q ratio as demonstrated by the pao /fio ratio. after reaching the initial supine position the opening of the lung proved by the elevated frc is the predominant effect now associated with an increase in oxygenation as reflected by the pao /fio ratio due to an optimised v/q ratio. our results are confirmed in a subgroup analysis for patients meeting ali criteria. ventilating patients in sp may be a new therapeutical approach to improve respiratory function in patients with ali. ( ) . there are several clinical trials investigating the efficacy of the free radical scavenger n-acetylcysteine (nac) in ards, but its advantage remains uncertain. objectives. critically appraise and summarize all randomized clinical trials involving intravenous nac administration in adult patients suffering from ards. we included trials involving participants with ards according to the american-european consensus conference criteria ( ) regardless of the underlying cause, and where one of the groups was treated with intravenous n-acetylcysteine in bolus intravenous doses or as continuous infusion, or combination of the two, and the other group was given placebo or standard treatment. conclusions. the main finding of this meta-analysis is that intravenous nac is ineffective in reducing mortality, length of stay or duration of mechanical ventilation in ards. we also found that late administration of nac may be associated with adverse outcome. the mechanism of this potentially deleterious effect remains unclear, but dosing and timing of nac appear to be critical issues. objective. to evaluate if extubation during ecls is harmful or beneficial. a -year-old woman was admitted to our intensive care unit (icu) after removal of a left ventricular assist device. this device was implanted as bridge to recovery for postpartum cardiomyopathy and ventricular function seemed to have recovered sufficiently. however, shortly after icu admittance she developed massive left and right ventricular failure. therefore a centrally cannulated veno-arterial ecls (maquet permanent life support) was implanted as a bridge to transplant. four days later she was extubated while on full ecls support, in order to reduce the risk of ventilator associated pneumonia. while on ecls, the patient was mobilized, practiced with an ergometer and chatted with her family. three days later the patient underwent cardiac transplantation. the postoperative period was characterized by temporary pulmonary failure, due to the combination of lung edema and atelectasis. eventually she made a full recovery. discussion. ecls provides a valuable means as bridge to transplantation, bridge to bridge or bridge to recovery. with the increasing use of ecls for circulatory failure, debate about the necessity of mechanical ventilation during this treatment ensues. ecls is usually applied under deep sedation and controlled mechanical ventilation. discontinuation of sedation possibly prevents intensive care acquired weakness. extubation during ecls may provide better pulmonary perfusion due to negative intra-thoracic pressure. furthermore, the awake and extubated patient is able to mobilize and exercise which may reduce the risk of atelectasis and ventilator associated pneumonia. our patient however developed pulmonary edema and atelectasis after discontinuation of ecls. the edema was probably a consequence of reperfusion injury, due to severely decreased pulmonary flow while on ecls. an absent ventilatory drive while on ecls may have led to hypoventilation while the patient was extubated, resulting in atelectasis. an extensive medline search resulted in one other case report describing an extubated patient on ecls. intermittent non-invasive positive pressure ventilation was used to prevent atelectasis, but the patient developed pneumonia after days of ecls. our patient was successfully extubated while on ecls. however, we conclude that there is insufficient evidence to recommend or oppose extubation of patients on ecls for circulatory failure. severe ards and refractory hypoxemia were defined with a pao / fraction of inspired oxygen (fio ) ratio of b , or uncompensated hypercapnea with a ph of \ . despite receiving optimal conventional treatment. the ecmo can be used as a rescue treatment in these case. objectives. evaluation of severe ards treated with extracorporeal oxygenation (ecmo). all these ards were due to bacterial pneumonia or h n influenza. over the last year (december -january ), the recourse to extracorporeal oxygenation (ecmo) was used in ten patients with severe ards and severe hypoxemia. two groups were defined: bacterial pneumonia with ards (bp group, n = ), and h n influenza with ards (h n group, n = ). all ecmos were implanted at the bedside to facilitate intra-hospital or inter-hospital transfer, because of severe hypoxemia or hemodynamic instability making impossible patient mobilization before ecmo. results. data sets of patients of consecutive patients treated with ecmo were complete and included into analyses. we had no clinical or radiological evidence for thrombosis or clotting within ecmo-circuit with a target-ptt of s. one patient with systemic aspergillosis died because of intracranial hemorrhage. one ecmo circuit had to be replaced due to insufficient oxygenator function after days. further data are presented in tables and . conclusions. in this retrospective analysis of patients who underwent ecmotreatment, ac with low-dose heparin (target-ptt of s) was safe and without any observation of macroscopic thrombosis or clotting within the circuit. transfusion requirements and intracranial hemorrhage were low as compared with previous reports [ , ] . therefore our data suggest that it is possible and safe using ecmo-therapy with low-dose heparin. introduction. in response to h n pandemy, italy and lombardy created a national and a regional icu network, respectively, for treatment of ards patients. our hospital policlinico san matteo of pavia participated with a team for inter-hospital ecmo implantation and subsequent patient transport. objectives. description of the pavia ecmo team and activity analysis. methods. our team is composed by a cardiac surgeon, two intensivists, a perfusionist, an icu nurse, two emergency rescue technicians and a driver. all necessary aids for implantation and intensive care are ranged in three trolleys and three transport bags. equipments are firmly mounted on a two-level steel bridge connected to a spinal board. a portable ultrasonograph is also available. the ecmo team was alerted by the national call center. each mission used two ambulances, and in one case the ambulances were embarked on a hercules c j. from october to december , four patients were implanted and transported, three suffering from h n influenza (including a -kg body weight patient) and one from acute mitral valve rupture. all patients, already mechanically ventilated with maximal support, had veno-venous ecmo implanted by femoro-femoral percutaneous cannulation. the median mission duration was of . h (range - h). all patients were transported to our icu, where the median ecmo duration was of days (range - days). no major managing issue occurred during the ecmo missions, and patient hospital survival was of %. a multispecialist team with good knowledge of ecmo can provide an effective support in severe respiratory failure, with ecmo implantation in peripheral hospitals and subsequent patient transport, thus realizing a fast and safe continuum between phone call activation and admittance to the reference center. introduction. when patients with sever respiratory failure are treated with v-v ecmo the right heart sometimes fails. this is a serious complication with a high mortality. in our unit these patients have been converted to v-a ecmo, although it is not fully agreed upon in the ecmo community due to previously depressing results. objectives. to evaluate the results of conversion to v-a from v-v ecmo in case of right heart failure. retrospective analyses of all patients with severe respiratory failure, treated between and at the karolinska ecmo centre. patients who were converted to v-a ecmo due to right ventricular failure were evaluated. a total of patients ( adults, peadiatric, neonatal) were treated on v-v ecmo for severe respiratory failure. of them ( adults, peadiatric, neonatal) needed conversion to v-a ecmo due to right ventricular heart failure demonstrated clinically by multiorgan failure and verified by echo cardiography. the survival after conversion to v-a ecmo was / ( %) in the adult age group, / ( %) in the peadiatric age group and / ( %) among the neonates. conclusions. given the high risk of fatality if not treated, conversion to v-a from v-v ecmo should be considered when the right ventricle fails. patients on v-v ecmo with right ventricle heart failure have very bad prognosis. it is concluded from the present results that conversion to v-a ecmo can save some of these patients. cardiac surgery and regional hemodynamics: objectives. to test whether tapse and right ventricular systolic (sm) and diastolic (em and am) tissue doppler imaging velocities are related with pulmonary artery systolic pressure (pasp) and length of the weaning process in mechanically ventilated patients with acute heart failure (ahf). methods. rv fractional area change (rvfac), left ventricular ejection fraction (lvef), pasp, tapse, sm, em, am rv tdi velocities, early diastolic mitral e wave and e maximal tdi velocities of the mitral annulus at the lateral wall were obtained at admission by doppler echocardiography in a cohort of patients with ahf, presented with pulmonary oedema, who required positive-pressure ventilation for more than h in the intensive care unit (icu). echo-derived measures were compared between patients with and without pulmonary hypertension, whereas their association with duration of mechanical ventilation and length of the weaning process was tested with multivariate linear and logistic regression analysis. and increased e/e ratio ( . ± . vs. . ± . , p \ . ) compared with subjects with normal pasp (n = ). these variables were negatively associated with duration of mechanical ventilation (r = . , beta slope = - . for tapse, r = . , beta = - . for sm, r = . , beta = - . for em/am, p \ . ) and were proven to successfully discriminate patients with (n = ) and without (n = ) prolonged weaning ([ days of weaning after the first spontaneous breathing trial failure, p \ . for all comparisons). conclusions. we suggest that in critically ill patients with ahf presented with pulmonary oedema, low tapse and rv tdi velocities upon admission are associated with pulmonary hypertension and prolonged length of the weaning process. objectives. the aim of the study was to study changes in cerebral blood flow (cbf), as determined by tcd, during the early postoperative course of cvs and to correlate such changes with post-operative nc. we studied patients undergoing extracorporeal circulation cvs (coronary by-pass, valve replacement or both) between march and march . cbf was assessed by measuring bilateral mca flow velocities by tcd before and , and h after cvs. changes c % between consecutive tcd results were considered significant. demographic and clinical variables, co morbidities, euroscore, sofa, type and duration of surgery and type and severity of nc were also recorded. patients were assigned to groups according to cbf changes from baseline: a) changes b %; b) cbf increases c %, c) cbf decreases c %. nc were classified as major (stroke, tia and coma) and minor (delirium, encephalopathy, transient cognitive impairment). we used descriptive statistics and inference by v , anova and pearson's correlation. of the patients, were excluded ( early post-operative death and due to technical difficulties or incomplete tcd recordings). of evaluable patients, ( %) had no cbf changes (group a), ( %) had increases c % (group b) and ( %) had decreases c % after cvs (group c). a positive correlation was found between cbf changes and duration of circulatory arrest (p \ . ), maximum sofa score (p \ . ), respiratory dysfunction (p \ . ) and duration of mechanical ventilation (p \ . ). neurological complications occurred in patients ( %), of which ( %) were major and were minor ( % introduction. the sole monitoring of macrohemodynamic variables is not always sufficient in the early detection of tissue hypoperfusion, especially in cardiac surgical patients that frequently present with microcirculatory derangements. near infrared spectroscopy (nirs) is an easily applicable non invasive technique that has been used to provide an estimate of tissue oxygenation at the bed side. objective. the aim of our study was to evaluate the effect on outcome of guiding hemodynamic therapy and specifically inotrope titration in cardiac surgical patients postoperatively with nirs. methods. patients operated on with cardiopulmonary bypass were assigned, after stratified randomization (gender, euroscore-cutoff of ), to an intervention (ig) and a control group (cg). postoperatively, following cardiac intensive care (cicu) admission, after initial resuscitation according to cicu protocol, sto (%) was measured in patients of the ig in muscle sites: thenar, masseter and deltoid. if it was less than % in / sites, dobutamine was administered in incremental doses ( . lg/kg/min), with the sto (%) measured every half hour. the interventional period began upon cicu admission and lasted for h, after which both groups were treated according to cicu protocol. primary outcome measured was the oxygen consumption rate at the end of the h intervention period as assessed with nirs vascular occlusion technique. . patients were included in the study ( in the intervention group and in the control group). the groups did not differ statistically significantly regarding age, euroscore, and macrohemodynamic variables postoperatively (with the exception of cvp). microcirculatory parameters upon admission to the cicu also did not differ, excluding masseter sto (%). the oxygen consumption rate and the reperfusion rate increased in the h study period in both groups, without differing statistically significantly between the groups at any time point (cg oxygen consumption rate . ± . upon cicu admission and . ± . h later, ig . ± . and . ± . respectively) (cg reperfusion rate ± upon cicu admission and ± h later and ig ± and ± respectively). as far as outcome parameters were concerned, the groups did not differ statistically significantly in the total hours and total dose of vasopressors ± inotropes received, in the hours of mechanical ventilation, in the duration of cicu or hospital stay, and in sofa scores the days following the operation. conclusion. nirs guided titration of inotropes did not lead to a greater improvement in the microcirculation h postoperatively, or to a better outcome. the limited power of the study prevents definite conclusions on the role of nirs in hemodynamic therapy in cardiac surgery patients. objectives. to estimate the prevalence of pulmonary embolism among mv patients in icu and its association to deep vein thrombosis (dvt). in a monocentric prospective observational study, we included all the patients requiring mechanical ventilation with no previously diagnosed pe, who underwent a thoracoabdominal ct contrast scanner for any medical reason. we used a modified protocol for pe diagnosis with a -multidetector row ct scan read by two independent radiologists. the association with a dvt was explored by performing venous compression ultrasound of four limbs. objectives. the aim of this animal study was to evaluate the effect of intraabdominal hypertension on left ventricular diastolic function. after approval by an institutional animal care committee, rabbits were anesthetised before mechanical ventilation. an intraperitoneal infusion of . % glycine solution was used to increase intraabdominal pressure to mmhg. the right common carotid artery was catheterised in the neck in order to introduce a millar mikro-tip catheter (millar instruments inc., houston, usa) into the left ventricle. heart rate, arterial pressure, central venous pressure, oesophageal pressure and intraabdominal pressure were measured. the s time constant of relaxation which is considered as best index of relaxation was calculated using the derivative method ( ). all haemodynamic measurements were registered at baseline and after inducing intraabdominal hypertension. data are presented as mean (iqr) and were compared using a wilcoxon rank sum test. results. heart rate (from ± to ± beat/min, p = . ), mean arterial pressure (from ± to ± mmhg, p = . ) and dp/dt max (from , ± to , ± mmhg/s, p = . ) were not significantly modified by intraabdominal hypertension. however, the s time constant of relaxation increased significantly (from ± to ± ms; p = . ). conclusions. in this animal model, intraabdominal hypertension impairs left ventricular relaxation. these changes in the condition of the microcirculation have been related to the degree of organ dysfunction and thus patient outcome ie hospital length of stay. near infrared spectroscopy (nirs) is an easily applicable non invasive technique that has been used to provide an estimate of tissue oxygenation at the bed side. objectives. the aim of our observational study was to examine whether impaired tissue oxygenation as assessed with nirs immediately postoperatively correlates with hospital length of stay. patients undergoing a planned cardiac surgical procedure on cpb were included in the study. patients' thenar tissue oxygenation (sto %) was assessed with nirs postoperatively in the cardiac intensive care unit (cicu). results. patients undergoing cardiac surgery on cpb ( male/ female) (age: ± years, euroscore: . ± ; mean ± sd) were enrolled in the study. patients length of stay was . ( - ); median(range). the haemodynamic parameters of our patients upon admission to the cicu were: map ± mmhg, cvp ± mmhg, pcwp ± mmhg, mpap ± mmhg, ci . ± . l/min/m , svr ± dyne x s/ cm , pvr ± dyne x s/cm , hr ± bpm, hb . ± . g/dl, lactate . ± . mg/dl; (all variables expressed as mean ± sd). upon admission to the cicu all patients were mechanical ventilated, under vasopressor ± inotrope support and their central temperature was . ± . ; mean ± sd. the thenar sto % was ± ; mean ± sd. thenar sto % correlated statistically significantly with hospital length of stay (r = . , p = . ). discussion. tissue oxygenation as assessed with nirs reflects the balance between regional oxygen delivery in relation to oxygen utilization. an elevated sto in the presence of normal macrohemodynamics may reflect impaired oxygen consumption and thus an impaired microcirculation. conclusion. patients with impaired tissue oxygenation immediately postoperatively have a longer hospital length of stay. further studies are needed to confirm these results and to investigate the potential benefit from incorporating this information regarding tissue oxygenation in the treatment algorithm. objectives. the goal of this study was to compare two different sedative agents for implantation of crt-ds related to incidence of adverse events and patient's satisfaction. methods. the study included forty-two, asa iii-iv patients, undergoing transvenous implantation of crt-ds under local infiltrative anesthesia with to ml of % lidocaine. intraoperative sedation was established with intermittent boluses of midazolam ( - mg) to achieve desirable level of sedation. before the induction of ventricular fibrillation in order to test the defibrillator function of the crt-d device, patients received an additional bolus of either propofol ( . - . mg kg - , p group, n = ) or etomidate ( . - . mg . kg - , e group, n = ) targeting bis values in the range - . the incidence of apnea, hypotension, nausea, myoclonus, pain at injection site, allergic reactions as well as patient's satisfaction with anesthesia described as feel of well being were registered and compared between groups. results. in subjects ( %) no complications were recorded. myoclonus was registered in patients from e group ( %) and in none from p group (p \ . ). no patients receiving etomidate reported pain at injection site compared to patients ( %) receiving propofol (p \ . ). there was no significant difference in incidence of apnea between two groups ( vs. %, p = . ). two patients in p group ( %) and in e group ( . %) became hypotensive after delivering the hypnotic agent (p = . ). also, there was no statistically significant difference between groups considering the frequency of nausea ( % vs. %, p = . ). all the patients whom propofol had been delivered ( %) reported feel of well being and only four of them filed the same after etomidate ( %) (p \ . ). no allergic reactions and major adverse events were registered. conclusions. implantation of crt-ds and its testing can be successfully performed with administration of both propofol and etomidate as a safe procedure with low per operative morbidity and shorter complication rates. still, treating with propofol tends to be more satisfactory for the patients. introduction. ultra-short-acting b selective adrenergic antagonists are now widely used to control tachycardia and tachyarrhythmia perioperatively. among them, landiolol, a new ultra-short-acting b -blocker, has been reported to exert a more potent negative chronotropic effect with little effect on blood pressure than esmolol ( ). however, detailed mechanisms underlying different cardiovascular actions are still unknown. objectives. in this study we evaluated direct effects of landiolol on cardiac performance and single cell electrophysiology in comparison to those of esmolol. methods. the present study composed of two parts. the first part of the study used isolated guinea-pig hearts which were perfused in the langendorff mode at constant flow with oxygenated tyrode solution at °c. the coronary perfusion pressure (cpp) was continuously monitored throughout the experiment, and intrinsic heart rate (hr) and isovolumetric left ventricular contraction were measured with a thin saline-filled balloon inserted into the left ventricle. the second part of the study was to measure action potentials and ionic currents in ventricular myocytes isolated enzymatically from guinea-pig hearts. comparison of data was conducted by repeated-measure anova with post hoc test (bonferroni's correction). conclusions. esmolol had a more potent negative inotropic effect than landiolol. this effect is, at least in part, derived from shortening of apd. in addition, increase of the coronary resistance would facilitate the negative chronotropic action of esmolol in vivo. conclusions. nma moderates hpv in the conscious spontaneously breathing beagle, but not to the same degree as acz. as compared to acz, the additional methyl-group in nma may impair its capability in vivo to act on a non-ca acz-sensitive cellular receptor or channel or that both, ca-dependent and ca-independent actions of acz yield a greater effect. introduction. tee with bubble test is considered as the ''gold standard'' method to detect a pfo with right to left shunt. tcd is a non-invasive method which has been shown to be as accurate as tee for pfo detection. we conducted a multicenter trial to estimate the prevalence of pfo, the influence of the size of the heart chambers on the prevalence of pfo and the accuracy of tcd as a non invasive method for pfo detection in mechanically ventilated icu patients. one hundred icu patients ( m and f) under mechanical ventilation who needed a tee study for hemodynamic assessment were included in the study. in each patient, the presence of a pfo was detected by tee and tcd. three bubble tests with agitated haemacel Ò were performed by each method, with tee probe at and rotation and with tcd the gate of pulse wave doppler (pwd) at the m segment of the middle cerebral artery (mca). patients without temporal acoustic window to perform tcd were excluded from the study. the size of pfo was classified as grade i, ii and iii according to the number of microbubbles passing from the right to the left atrium and the number of hits (high intensity transient signals) detected with pwd in the mca (grade i: \ microbubbles or hits, grage ii: [ and \ and grade iii: more than microbubbles or hits). for each patient included in the study we measured and correlated the presence of pfo with the tidal volume (v t ), the plateau pressure (p plat ), the compliance of the respiratory system (c rs ) and the size of the right (rv) and left (lv) ventricle. results. mean p a o /fio was (min , max ), mean c rs was ml/cmh o (min , max ), mean v t was ml (min , max ) and mean p plat was cmh o (min , max ). the prevalence of pfo detected with tee was % and with tcd %. there was no pfo detected with tee and missed by tcd. tcd was more sensitive than tee in detecting pfo of grade i ( with tee, with tcd) and ii ( with tee, with tcd), while for grade iii the two techniques had equal sensitivity ( with tee, with tcd). no correlation was found between p plat , c rs , v t and the presence of pfo. on the contrary, a strong correlation was found between rv dilatation and the presence of pfo (p \ . ). conclusions. the prevalence of pfo detected by tcd is very high in mechanically ventilated icu patients and this may have important clinical implications. tcd is more sensitive than tee in detecting a small pfo. the presence of rv dilatation increases the prevalence of pfo. objectives. the aim of our study was to identify in mechanically ventilated patients for ali/ards the prevalence of pfo and to evaluate the factors that may influence the prevalence of pfo. methods. two groups of mv patients, one with ali/ards and one without respiratory failure (rf), were enrolled in the study. all patients underwent a tee study for hemodynamic assessment. in each patient three consecutive bubble tests with agitated haemacel Ò were performed at and rotation of the tee probe. the bubble test was performed through a central line in the inferior or superior vena cava (ivc, svc). a pfo was diagnosed by the presence of microbubbles in the left atrium within five cardiac cycles following the injection. furthermore, in ali/ards patients in whom a pfo was not detected at baseline mv, three consecutive bubble tests during recruitment maneuver at cmh o for s were performed. the compliance of the respiratory system (c rs ), blood gas exchange and the ventilatory settings (p plat , v t ) were recorded in both groups. o, respectively. the presence of rv dilatation was a strong predictor for the fo opening (p \ . ); on the contrary, no statistical significant difference was found between the site of injection (svc vs. ivc), the c rs , v t , and p plat and the presence or absence of a pfo. a high prevalence of pfo was found in ali/ards patients. rv dilatation seems to be the reason of this high prevalence. rv dilation may be due to the lower c rs and higher p plat of the ards patients. introduction. the clinical evaluation of arterial tone is mainly based on the calculation of total systemic vascular resistance (tsvr). however, given the pulsatile nature of arterial flow, this parameter provides an inadequate assessment of vascular tone. another approach proposed would take account of changes in pulse pressure and blood flow, relationship known as arterial elastance (ea). so, for a given stroke volume, the blood pressure generated in the circulatory system will depend on ea ( ). to assess the ability of the dynamic arterial elastance (ea dyn ), defined as the relationship between pulse pressure variation (ppv) and stroke volume variation (vvs), to predict the hemodynamic response in mean arterial pressure (map) to a increase in stroke volume (sv) in hypotensive preload-dependent patients with acute circulatory failure. we performed a prospective clinical study in a -bed multidisciplinary intensive care unit, including patients with controlled mechanical ventilation and monitored with the vigileo Ò monitor, for whom the decision to give fluids was taken due to the presence of circulatory, including arterial hypotension (map b mmhg or systolic arterial pressure \ mmhg), and preserved preload-responsiveness condition, defined as svv c %. dynamic arterial elastance (vpp/vvs ratio), arterial pulse pressure to sv ratio, map/sv ratio, tsvr and map were compared to predict a map increase c % after volume expansion (map-responders). results. at baseline, only ea dyn was significantly different between map-responders and nonresponders. ve-induced increase in map was strongly correlated with baseline ea dyn (r = . , p \ . ) and changes in ea dyn after ve (r = . ; p \ . ). the only predictor of map increase was ea dyn (auc . ± . ; % c.i.: . - ). a baseline ea dyn value [ . predicted an increase c % in map after fluid administration with a sensitivity of . % ( % c.i.: . - . %) and a specificity of % ( % c.i.: - %). conclusions. dynamic assessment of arterial elastance by pvv to svv ratio during controlled mechanical ventilation could be used to predict mean arterial pressure increase after volume loading in hypotensive preload-dependent patients. severe sepsis is one of the major reasons for intensive care unit (icu) admission and leading causes of mortality. some of these score systems have been customized for patients such as apache ii, apache iii, sasp ii and mods. this study is to assess the validity of mortality prediction systems in severe septic patients. objectives. the aim of this study was to compare and evaluate four severity scoring systems in intensive care unit (icu), including apache ii, apache iii, sasp ii and mods in severe septic patient. methods. fifty-six severe septic patients were divided into two groups. one was survival group and the other was non-survival group. besides general data, the continuous surveillance of apache ii, apache iii, sasp ii and mods were recorded by st, rd and th day. results. compared with survival group, mods was significant difference in non-survival group only in st day ( . ± . vs. . ± . , p \ . ) but apache ii, apache iii and sasp ii were significant difference through st, rd and th day(p \ . ). in seven-day comparison, p value of apache iii in non-survival group was the minimum (p = . ) and p value of mods was the maximum (p = . ). in optimal survival evaluation, it seemed that apache iii was the best (apache iii [ apache ii = saspii [ mods). conclusions. in order to evaluate the critical condition and prognosis of severe septic patients, apache iii was the best and apache ii and sasp ii were followed and mods was the worst. objectives. to assess compliance with the cem standards for management of severe sepsis across three ed sites in the west midlands. methods. data was collected retrospectively over months. patients presenting to the ed within this period were assessed for likelihood of severe sepsis by the diagnostic code given to each patient upon leaving the ed. data was analysed using a scanned copy of the ed clerking. patients' notes were assessed for sirs criteria and signs of new infection. if these criteria were met, and organ dysfunction was present, they were included in the audit. results. patients with severe sepsis were identified. of these % were documented as septic by ed staff. the cem standards of care were received in % of patients with a documented diagnosis of severe sepsis in the ed, and % of patients overall. % of patients received the 'treatment' aspects of care: oxygen, iv antibiotics (with blood culture) and iv fluids. % of severely septic patients had no documented consideration of icu referral. conclusions. early recognition of severe sepsis in the ed led to greater performance in meeting the cem standards. although % of patients received observations and % received the treatment interventions, we performed poorly in meeting the remaining cem standards. the trust has developed a severe sepsis proforma which incorporates the cem standards to accurately record the completion of each intervention. a sepsis course for staff has been launched trust wide, and a formal referral process to icu for all severely septic patients is being implemented. objectives. to observe association of body temperature (bt) and antipyretic use with mortality in the critically-ill. a prospective multi-national, multi-center observational study. consecutive patients whose icu stay were expected to be more than h were recruited from centers in japan and centers in korea. patient's bt was prospectively recorded every h until patient's death, discharge from the icu or up to days. information including patient's clinical characteristics at admission, presence of infection, and use of steroids, extracorporeal circuit, and antipyretics were recorded. ( ). while blood culture results take time, treatment for bloodstream infection should be provided swiftly, usually before results are available ( ) . prior treatment with antimicrobials increases the chances of false negative results. haste, poor technique and alteration in commensal flora may increase the chances of falsely identifying pathogens. objectives. we have investigated the utility of blood culture tests in our general critical care unit over year in terms of results yielded and actions prompted. methods. the indication for blood culture was clinician's discretion. all critical care sourced blood cultures for the period oct to sept were reviewed from the microbiology laboratory database. blood culture specimens were collected in bact/alert Ò bottles (biomerieux, durham, nc, usa ). notes review was made of the positive blood culture episodes to determine actions after the results were known. consideration was given to the source of the blood sample: clean stab versus from an intravascular device. categoric data was analysed using the chi-squared test and p value of . was accepted as significant. objectives. we hypothesized that in the emergency department of our hospital many patients with sepsis are not recognized as such. methods. in a retrospective design, patients of an age of years and older who were admitted to the emergency department during a period of months between january-april and diagnosed as having an infection were included. the diagnose infection was made on admission by the emergency department nurse. the included patients were either classified as having sepsis or not having sepsis, according to the sirs criteria. conclusions. h n infection was associated with significant morbidity and mortality. it occurred mainly in young pts with co-morbidities and was associated with severe hypoxemia, a trigger for prolonged mechanical ventilation and frequent use of lung rescue therapies. a significant delay in hospital admission and start of antiviral therapy should also be noted. admission to administration time difference between cycles was . h, with a mean reduction of . h between clinician assessment and prescription time in cycle two. we identified delays against the standard after both cycles of the audit. we demonstrated that the method of prescription should be taken into consideration when prescribing antibiotics in patients with suspected sepsis. there are a multitude of factors that could contribute to a reduction in the clinician assessment to prescription time, which may be investigated in further audits. conclusions. despite high levels of resistance among psa and ab from these icus, cfr for most carbapenem dosing regimens were above the reported susceptibility. doripenem provided greater cfr than meropenem, which was superior to imipenem against these isolates. while higher doses combined with prolonged infusions significantly improved cfr against psa, alternative therapeutic strategies will be required to address these highly resistant ab. grant acknowledgment. the passport study is supported by a grant from janssen-ortho-mcneil. introduction. drug interactions are common, and the effects of these interactions can range from innocuous to deadly. critically ill patients often receive a variety of potent drugs, including antimicrobials, making this population extremely susceptible to drug-drug interactions. therefore, physicians must be familiar not only with the antimicrobial drugs capable of producing adverse drug events, but also their potential drug-drug interactions. there are scarce data about the incidence of these types of drug interactions and the how frequently it might cause adverse events. objectives. the purpose of this study is to evaluate the incidence of potential drug interactions involving antimicrobials and the possibility to cause adverse events. the clinical pharmacist has prospectively analyzed icu prescriptions between january and december with the purpose to identify potential drug-drug interactions involving antimicrobials. the screening was done with the relief from a software (epocrates rx Ò drug reference). the interactions detected were classified in eight groups according to the affected system (neurological, cardiovascular, gastrointestinal, renal, endocrine, hematological, musculoskeletal and others) and through the type of interaction (pharmacokinetic, pharmacodynamic and others). we have identified the most common potential effects, the medications involved and have observed the incidence of adverse drug events. results. the icu admitted patients during the study period. we have analyzed physician orders with prescribed items. we have identified antimicrobial drug interactions ( different interactions) which compound % of the total drug interactions (n = ). the cardiovascular system and the pharmacokinetic interaction were the most potentially affected ( %; %). the most common medications involved were: fluconazole ( %), clarithromycin ( %), levofloxacin ( %); linezolid ( %). the clinical pharmacist has made an intervention regarding medication safety in % (n = ) and the acceptance rate by the medical icu staff was %. we have not been able to identify any adverse drug event caused by drug interaction even with our active search and the spontaneous reports. however, sub notification must be taken into consideration. conclusions. clinicians should be aware of potential drug-drug interactions when making therapy selections for critically ill patients. antimicrobial drugs are susceptible to interact with other drugs, which may increase the risk of adverse drug events. the clinical pharmacist interventions may improve clinical outcomes by optimizing medication use, monitoring potentially preventable adverse drug events and promoting information about this important issue to the icu multi-professional team. introduction. cefazolin is one of the most frequently administered antimicrobial agent for prophylaxis in ''clean'' surgery. its broad spectrum against gram + micro-organisms and its pharmacological characteristics make it an easy-to-use choice to prevent infections caused by staphylococcus aureus and coagulase-negative stapylococci. objectives. the aim of this study is the evaluation of the plasma concentrations of cefazolin administered as a prophylactic antimicrobial agent during cardiac surgery with cpb. adequate cefazolin plasma levels can maintain a tissue concentration high enough to prevent the risk of developing post-operative infections. after obtaining ethical committee approval and personal written consent, two groups of patients were enrolled in this prospective study. the first group, patients, received cefazolin, g, - min before skin incision and g adjunctive dose after h. then, three g doses were administered every h. in the second group of patients the adjunctive g cefazolin dose was given at the beginning of the cpb. blood samples were collected immediately before the first dose and every hour for the whole time of surgery, and, only in the second group, after surgery, at th, th and th hour. plasma cefazolin concentration was determined with a biological radial diffusion assay. results. plasma cefazolin was constantly higher than the mic of the most involved micro-organisms (according to clsi). in the first group, cefazolin concentration suddenly decreased after starting cpb. the g adjunctive dose immediately restored it. the earlier administration of this dose in the second group prevented this sudden fall. plasma cefazolin was maintained at effective inhibitory levels for the whole time of surgery in all patients ([ mcg/ml). during the postoperative period cefazolin decreased slowly, but inhibitory plasma levels were always maintained. the rate of cefazolin clearance was found equal to the creatinine clearance in all patients. perioperative plasma cefazolin concentration conclusions. the administration of cefazolin g every h can guarantee effective inhibitory plasma concentrations during surgery and during the first h after surgery. cpb causes a sudden fall in cefazolin plasma levels. this can be avoided administering an adjunctive g dose immediately before starting cpb. objectives. vancomycin dose regimen was adjusted based on trough plasma levels in burn patients that were distributed according to the extension total burn surface area (tbsa); also pharmacokinetics changes were compared. methods. twenty seven adult burn patients of both sexes, requiring antimicrobial therapy with vancomycin for the control of sepsis were investigated. pharmacotherapeutic follow up was performed in a serial of periods ( observations) for all patients investigated by collection of blood samples, ml each from the venous catheter as follows: st blood sample collection, h after the beginning of drug h infusion and a nd sample blood collection at the trough, immediately before the next dose. if necessary, additional sample blood collections were performed based on the laboratorial data for patients any time, for dose adjustment purpose and optimization of drug therapy. vancomycin plasma concentrations were determined by highperformance liquid chromatography. plasma curve decay was plotted, and pharmacokinetics was analyzed by one-compartment open model against the reference data reported. results. burn patients receiving the empiric dose regimen showed trough plasma level lower than the minimum effective concentration, consequently dose adjustment was required. vancomycin adjusted dose regimen showed statistical significance differences according to tbsa (p \ . ) as follows for daily dose normalized to body weight and expressed by mean ± sd: . ± . mg/kg/day were required for patients with tbsa below %, . ± . mg/kg/day for tbsa - % and . ± . mg/kg/day were required for tbsa above %. relevant changes on pharmacokinetics were observed by drug plasma clearance increased according the increase of tbsa (p \ . ), while the apparent volume of distribution and also the biological half-life remained unchanged. additionally, a weak correlation was observed between vancomycin plasma clearance and creatinine clearance (r = . ; p = . ), probably due to the contribution of the extra-renal clearance on total drug elimination. on the basis of data obtained in the present study and to prevent therapeutic failure and also to reduce the risk of bacterial resistance, dose adjustment in burn patients is recommendable based on vancomycin plasma monitoring and also on the extension of total burn surface area. introduction. the importance of early antibiotic therapy has been recently demonstrated. regarding a rapidly increasing number of obese patients, appropriate drug dosage in these patients is an important challenge of critical care since it has been shown that not only early start of antibiotics but also correct target concentrations decrease mortality. vancomycin is administered according to body weight (bw). nevertheless, little is known about the percentage of obese patients achieving pre-defined target serum levels within h after initiation of vancomycin therapy compared to patients with normal bw. objectives. therefore, it was the aim of our study to analyze the appropriateness of serum vancomycin levels in patients with a bw between and kg. vancomycin is almost entirely excreted by the glomerulus and may be responsible for nephrotoxicity [ ] . however, there is a lack of definitive evidence linking concentrations to either outcome or toxicity [ ] . few reports exist comparing intermittent dosing and continuous infusion. ingram [ ] suggested that whilst associated with a slower deterioration in renal function, there was no difference in the prevalence of nephrotoxicity. similarly, hutschala [ ] demonstrated worsening creatinine in patients following cardiac surgery with both intermittent and continuous infusion but infusion tended to be less nephrotoxic despite receiving higher doses. we wish also to report our experiences with vancomycin infusion in critically ill cardiac patients. methods. we examined retrospective data from , patients treated with vancomycin. we perform adjusted and un-adjusted analysis using sofa on the day of starting vancomycin and total dose received. to assess the differences in either an initial pulmonary or non pulmonary presentation. methods. prospective, observational, multi-center study conducted in intensive care (icu). we reviewed demographic and clinical data for all pandemic h n influenza a infections reported in the esicm h n registry. results. patients were screened from the registry. patients with completed data entry for pulmonary and non pulmonary with outcomes were identified and analysed. all patients had either suspected, probable or confirmed pandemic h n influenza a infection and were being cared for in an icu. % of the patients were male with a median age of (iqr - ) years. the admission mean saps score was ± and the apache ii score was ± . % of the patients subsequently received non invasive ventilation and % received invasive mechanical ventilation. the icu mortality rate was %. the hospital mortality was %. % of patients presented with a pulmonary presentation. % of these were admitted with ards and/or bacterial pneumonia and % with an acute bronchospastic exacerbation. % of patients were admitted to the icu with a non pulmonary presentation. the main reasons for admission in these patients were: cardiovascular instability ( %), altered level of consciousness ( %), renal failure ( %) and acute coronary syndromes ( %). patients with a pulmonary presentation were older, had a increased history of asthma or copd and were more likely to be ventilated. they had a higher mortality rate in the icu. non pulmonary presentations were more likely to suffer from chronic renal impairment. a total of episodes of pandemic influenza a (h n )v infections in critical care setting were analyzed: with bacterial pneumonia ( males and females) and with wheezing or viral pneumonia ( males and females). the mean age was (± ) years in patients with bacterial pneumonia and (± ) in patients viral pneumonia. the mean apache ii score was (± ) and (± ), with a corresponding probability of death of (± )% and (± )%. comorbidities were common, but without significant differences between the two groups (only exceptions pregnancy-more prevalent in patients without bacterial pneumonia-and dialysis dependence-more prevalent in patients with bacterial pneumonia). at icu admission shock and acute renal failure were more common in patients with bacterial pneumonia. in patients without pneumonia; severe hypoxia and ards did not presented significant differences between groups. aims. evaluation if an isocaloric beginning of artificial nutrition in critically ill medical patients is associated with increased nutritional related side effects compared to a hypocaloric start. methods. critically ill medical patients with an expected need for artificial nutrition of [ days were included into this prospective, randomized clinical study. artificial nutrition was started either isocalorically right from the beginning (group a; n = ) or hypocalorically ( % of the energy demands) followed by a stepwise increase over the next days (day : %); day : %) (group b; n = ). nutrition related side-effects were defined as the occurrence of hyperglycemia, hyperlactatemia, hypertriacylglycerolemia, upper digestive intolerance, cholestasis, or diarrhea as well as disturbances of serum electrolytes and were assessed on a daily basis. patients were randomized to receive either an artificial nutrition started isocalorically (group a) or hypocalorically followed by a stepwise increase (group b). of the patients, patients completed the study (group a: n = ; group b: n = ). the calculated, cumulative energy requirements of patients of group a and b were , ± , and , ± , kcal, respectively (p = ns). patients of group a received ± % and patients of group b ± % of the calculated energy requirements (p \ . ). the incidence of nutritional related side effects was not different comparing both groups, except for hypophosphatemia, which was more pronounced in group a. additionally, exogenous phosphate needs were higher in patients of group a. the number of interruptions of the artificial nutrition did not differ between groups. conclusions. an isocaloric start of artificial nutrition provided more energy during the first days of their icu stay than a hypocaloric beginning. there was no difference in the number of interruptions and in the incidence of nutritional related side effects, except hypophosphatemia suggesting the presence of refeeding syndrome. in studies carried on to demonstrate positive effects of glutamine (gln) that has innumerable biological features, the main point of discussion isn't whether gln has positive effects in sepsis but rather the effect difference between different administration routes. only enteral (en.) or parenteral (pn.) administration was analyzed in this respect and no studies on combined administration were performed. the primary endpoint in this study was to analyze the effects of administration of en. and pn. gln together or separately on intestinal mucosa + immune system in the experimental sepsis model. for this purpose villus atrophy, bacterial growth in blood and tissue, levels of blood gln, tnfa and il were examined. the secondary endpoint was to evaluate the different administration models in terms of cost. wistar, adult female rats were used. they were fed standard. sepsis was developed in groups (all rats) by injection of intraperitoneal(ip.) ml ( cfu/ml) e. coli. grup c (n = ):en./pn. isotonic saline ( ml/day; ml/d); grup e (en., n = ):en. gln ( . g kg - day - ) + pn. saline ( ml/d); grup p (pn., n = ):pn. gln ( . g kg - day - gln) + en. saline ( ml/d); group ep (en. ± pn., n = ):pn. gln ( . g kg - day - ) ala-gln = . g kg - day - gln) + en. gln ( . g kg - day - ); were administered. feeding of rats began h (h) after administration of ip e. coli. blood gln (with spectrophotometer), tnfa and il concentrations(with elisa) were examined at the start (baseline levels) and at - h after the experiment started. samples of tissue from mesenteric lymph node, liver, lung, blood and small intestine were collected. ala-gln = . g kg. . rates of reproduction of the strain administered were found lower for group ep than group c (p \ . ). rates of villus atrophy in ileum of group ep, p and e were lower than group c (p \ . ).plasma gln levels were found lower in groups ep and p at h, and higher at h than other groups (p \ . ). when plasma gln levels at h were compared with their baseline levels, significant increases were detected in groups ep and p and significant decreases were detected in groups c and e (p \ . ). serum tnfa and il levels were found lower for groups ep and p at and h when compared between groups (p \ . ). when serum tnfa and il levels at h were compared with their baseline levels, more distinctive increases were detected in groups c and e than other groups (p \ . ). significant positive correlation was determined between tnfa and il levels at h (p \ . ) and h (p \ . ). cost of simultaneous administration of en. and pn. gln was higher than en. administration but close to pn. administration at these doses. methods. medline and embase were searched. hand citation review of retrieved guidelines and systematic reviews was undertaken and academic and industry experts were contacted. only methodologically sound randomised controlled trials (rcts) were eligible for inclusion in the primary analysis. the primary analysis was conducted on clinically meaningful patient oriented outcomes, which included mortality, functional status and quality of life. secondary analyses considered vomiting/regurgitation, pneumonia, bacteremia, sepsis and multiple organ dysfunction syndrome. meta-analysis was conducted using the peto analytic method, which is known to minimize bias in the presence of sparse events. the impact of heterogeneity was assessed using the i metric. results. , unique abstracts were identified, resulting in the retrieval of papers for detailed eligibility review. four rcts were identified to be on topic however one rct reported excessive loss to follow-up such that an intention to treat analysis could not be conducted. analysis based on the three methodologically sound rcts demonstrated the provision of early en was associated with a significant reduction in mortality (or = . , % confidence interval . to . , i = ). no other outcomes could be pooled. sensitivity analysis including all four on-topic rcts (or = . , p = . , i = ), and a simulation analysis conducted using a different analytical method. (or exact = . , % ci . to . ), confirmed the presence of a mortality reduction. conclusions. although the detection of a statistically significant reduction in mortality is promising, overall trial size was small. the results of this meta-analysis should be confirmed by the conduct of a large multi-center trial. reference(s). results. the mean ibp was . ± . and mean igp was . ± . . correlation between the ibp and igp was significant however moderate (r = . ). analysis according to bland and altman showed a bias and precision of . and . mmhg respectively, however the limits of agreement (la) were large and ranged from - . to . mmhg. the median grv proto was ml ( - , ) and median grv classic was also ml ( - , ). correlation between the methods was excellent (r = . ). analysis according to bland and altman showed a bias and precision of - . and . ml respectively and the limits of agreement (la) ranged from - to mmhg. the median drainage time and return times were min ( . - ) and . min ( - ) for grv proto compared to min ( . - ) and min ( - ) for grv classic. a preliminary cost effectiveness analysis shows that the price of measuring grv with the classic method ranges from . € to . € per day, depending on the grv size. price of measuring grv with the gastro pv system is independent of grv size and is estimated at . € per day. the gastro pv system if priced at . € could become cost effective at grv of cc and more. conclusions. the interim results of an ongoing multicentre pilot study show that the gastro pv is a good alternative to the standard method for measuring grv. because the nurse can perform other tasks during drainage and return of the grv, and the fact that the system remains closed during measurement, this could be a major step forward in standardisation of grv measurement. furthermore it allows screening for intra-abdominal hypertension via igp estimation. acknowledgment. the gastro pv devices were provided by holtech medical, free of charge. introduction. the importance of early enteral feeding of the critically ill patient has been well documented. it is the more physiological approach, which is associated with lower rates of infectious complications. early enteral nutrition within h is recommended by the espen guidelines on enteral nutrition. a recent meta-analysis revealed that mortality and the incidence of pneumonia were significantly reduced in patients with enteral nutrition within h. parenteral nutrition may be associated with higher mortality. objectives. evaluation of a new technique for the placement of postpyloric feeding tubes by intensive care physicians. methods. prospective cohort study in critically ill patients subjected to transnasal endoscopy and intubation of the pylorus. attending intensive care physicians were trained in the handling of the new endoscope for transnasal gastroenteroscopy for days. a jejunal feeding tube was advanced via the instrument channel and the correct position assessed by contrast radiography. primary outcome measure was successful postpyloric placement of the tube. secondary outcome measures were time needed for the placement, complications like bleeding and formation of loops and the score of the placement difficulty graded from (easy) to (difficult). data are given as mean values and standard deviation. out of attempted jejunal tube placements, tubes ( %) were placed correctly in the jejunum. the duration of the procedure was ± min. the difficulty of the tube placement was judged as follows: grade : patients, grade : patients, grade : patients, grade : patients. in cases, the tube position was incorrect, and in another cases, the procedure had to be aborted. only in one patient, bleeding occurred that required no further treatment. conclusions. fast and reliable transnasal insertion of postpyloric feeding tubes can be accomplished by trained intensive care physicians at the bedside using the presented procedure. this new technique may facilitate early initiation of enteral feeding in intensive care patients. grant acknowledgment. the authors acknowledge the support of pentax, hamburg, germany, who provided the endoscope used in the study and of fresenius kabi, bad homburg, germany who provided the feeding tubes. a well-nourished condition before prolonged endotoxemia results in a better ability to adapt to endotoxin-induced metabolic deterioration of arginine-nitric oxide metabolism than does reduced caloric intake before endotoxemia ( ). the role of individual organs in the arginine-citrulline metabolism during malnutrition and sepsis is unknown and may be key to direct future interventions. to study the effects of reduced caloric intake and endotoxemia on the citrulline-arginine metabolism in the gut-liver-kidney axis. organ arginine-nitric oxide metabolism was measured by using a primedconstant stable-isotope infusion of [ n ]arginine and [ c- h ]citrulline during conditions; a -day reduced caloric intake feed regimen (starv; n = ), normal control feed regimen (co; n = ), endotoxemia alone (ce) and reduced caloric intake and endotoxemia (re) in. catheters for blood sampling were placed in the abdominal aorta, which, in combination with the catheters in the portal, hepatic and renal veins, served for metabolic measurements across the portal-drained viscera, liver and the kidneys, respectively. results. interestingly, re animals had similar citrulline appearance from the gut ( ± nmol/kg/min) compared to control and animals during ce, but higher in endotoxemia alone ( ± , p \ . ). this was related to a significantly higher no production from the gut in the re group ( , ± vs. ± , p \ . ). in the kidney arginine appearance from citrulline decreased significantly during re compared the control animals ( ± vs. ± nmol/kg/min, p \ . ). in contrast, the liver disposed more arginine in the re group compared to the other conditions, while no production was not higher. conclusions. despite reduced caloric intake prior to endotoxemia, the gut remains capable of increasing release of citrulline, although the capability of the kidney for the de novo production of arginine is severely compromised. metabolic control of the citrullinearginine metabolism in the gut-liver-kidney axis should focus on increasing de novo arginine production from citrulline. objectives. the aim of this study was to measure duodeno-caecal transit times of enteral feed in this patient group using a scintigraphic technique. a prospective observational study was performed in mechanically ventilated critically ill patients ( m, age ± yr, bmi ± kg/m , icu admission day ± , apache ii on study ± ; mean ± sd) and healthy subjects ( m, age ± year, bmi ± kg/m ). after a h fast a ml enteral feed (ensure kcal/min), labelled with mbq m tc-sulphur colloid, was infused into the distal duodenum over min. dynamic anterior scintigraphic images were recorded in min frames for min and the time of first appearance of activity in the caecum was recorded by two blinded operators (kj, ar). data were assessed using mann whitney u test and are presented as median (iqr). introduction. erythromycin, a macrolide antibiotic is widely used as a prokinetic agent in intensive care unit (icu) despite the lack of data supporting its prolonged effectiveness in enteral nutrition (en) intolerant critically ill patients. to evaluate impact on clinical outcome of erythromycin prescription as prokinetic agent in icu. all patients consecutively admitted from january through december mechanically ventilated for more than days and receiving en were included in an observational cohort study. en intolerance was defined clinically as a -hourly gastric residual volume (grv) c ml or vomiting. successful en was defined as a grv\ ml with a feeding rate c ml/h. erythromycin prescription was left to practician appreciation. objectives. this study aims at evaluating the relationship between diarrhoea and en in icu patients. methods. during month, the days with and without diarrhoea (c liquid stools/day) and the characteristics of nutritional support of all patients staying in our icu were recorded. patients staying \ h or presenting an intestinal stomy were excluded. we compared, between days with and without diarrhoea, total energy coverage and energy coverage by en as % of needs, en energy intake and en volume for each patient. needs were estimated as - kcal/kg body weight for women and men, respectively. the relationship between antibiotics, laxative treatment and diarrhoea was also analysed. results are presented as mean ± sd. comparisons were made by mann-whitney test. the risk of diarrhoea with en was calculated by odds ratio and confidence intervals (ci). the study included days of hospitalisation of patients ( ± years, bmi ± kg/m , sofa score at admission ± ). en was present in days of diarrhoea and days without diarrhoea. determining the small bowel function is of great concern in icu patients, because a malfunctioning small bowel may predispose to malnutrition and may increase the risk of sirs. a recently developed test, the citrulline generation test (cgt), measures the enterocytes' capability to convert glutamine into citrulline. the production of citrulline exclusively takes place in functioning enterocytes, therefore this conversion represents small bowel function. objectives. we aimed to define the cgt reference values in 'stable' icu-patients to assess small bowel function. secondly, we wanted to compare four different cgt methods; enteral and iv administration of dipeptiven and measurement of citrulline in both arterial and venous samples. we performed the cgt on stable icu-patients, defined as having respiratory failure but not dependent on vasopressors. they had a normal renal function and were able to tolerate enteral nutrition. a h fast was followed by administration of g of glutamine-alanine (dipeptiven Ò ) either intravenously or enterally, randomly determined. the next day the same test was performed by using the other route. after each administration of dipeptiven, citrulline levels, both arterial and venous, were measured at fixed time points using reverse-phase high performance liquid chromatography (hplc). results. nine females and males were admitted to the icu with either a medical ( ) or a surgical ( ) diagnosis. they had a mean (± sd) age and bmi of . ± years and . ± , kg/m respectively. their median apache ii score was . (iqr = . - . ). on the day the cgt was performed their median sofa score was . (iqr = . - . early post-pyloric feeding has been shown to improve clinical outcomes [ ] . commonly used methods for placing a nasojejunal tube (njt) are blind, endoscopic or fluoroscopic placement. the later two methods are relatively invasive, expensive and can cause delay to feeding, whereas blind placement is often unsuccessful. electromagnetic sensor guided njt insertion is a bedside technique able to confirm successful placement without the need for abdominal x-ray. the system incorporates a liquid crystal display and a receiver unit. the receiver is placed over the patient's xiphoid process and picks up the signal from an electromagnetic transmitter located at the tip of the feeding tube. the screen provides a visual aid to enable the operators to trace the route of the tube tip and identify its' location according to anatomical markers. objectives. we were interested to determine the suitability of electromagnetic sensor guided njt insertion especially in relation to success rate and procedure time. methods. fifty patients were referred for electromagnetic njt insertion on units at the leeds teaching hospitals. insertion time was measured from oesophageal visualisation until post-pyloric placement. various positional manoeuvres were employed along with administration of sedatives, prokinetics and air insufflation when applicable. all insertions were carried out by experienced investigators. all njt insertions were confirmed by abdominal x-ray. data collection included patient demographics, hospitalisation and procedural information. results. forty male and female patients, mean age (range - years), bmi mean ( - ), had attempted electromagnetic njt placement. patients had been hospitalised for a median of days ( - ). indication for njt insertion was either large aspirate and/or reflux ( %). seventy six percent of patients had an artificial airway and % of patients were receiving sedation. forty six percent of patients received metoclopramide and % air insufflation. thirty six percent of patients were moved into either left or right lateral position. successful post-pyloric placement was achieved in % of patients confirmed by additional abdominal x-ray. procedural time varied from to min (mean ). two of the placement failures were due to patient intolerance. conclusions. bedside electromagnetic guided njt placement technique is an acceptable method of placing post pyloric feeding tubes with a high success rate. gastrointestinal failure (gif) score has been suggested ( ). the gif score defines gi failure as the occurrence of feeding intolerance (fi) and intra-abdominal hypertension (iah) simultaneously. to compare the outcome of patients with primary vs. secondary gif. methods. all consecutive, mechanically ventilated (mv) patients treated for at least h during january to december in two icus were studied. gif was defined as gif score equal or above points according to the gif score ( ). points = fi and iah simultaneously; points = abdominal compartment syndrome (acs). fi was defined as the need to stop enteral feeding for any clinical reason (vomiting, high gastric residuals, bowel distension etc). iah was defined as mean intra-abdominal pressure (iap) c mmhg on any day. acs was defined as iap [ mmhg with the new onset organ failure. when gif developed in a patient with primary pathology in abdomino-pelvic region it was classified as primary gif, when occurred without previous pathology in abdomino-pelvic region it was taken as secondary. objectives. in this study the biochemical quality and prion safety of the pharmaceutically licensed plasma octaplaslg Ò was evaluated. the prion reduction factor achieved by western blot was confirmed by animal studies. eighteen consecutive batches of octaplaslg Ò (octapharma ppgmbh, vienna, austria) were tested on global coagulation parameters, fibrinogen levels, activities of coagulation factors and protease inhibitors, activation markers, as well as von willebrand factor multimers. in parallel studies, plasma pool was spiked with exogenous spike material, derived from brains of hamsters infected with hamster-adapted scrapie k, and a down-scale of the octaplaslg Ò manufacturing process was performed. the prp sc reduction factor for the resin was investigated in both western blot and hamster bioassay studies. a reduction factor of c . log prp sc was found for this process step by western blotting. the outcome of the hamster bioassay confirmed that the high level of removal prp sc seen during octaplaslg Ò manufacturing was equivalent to a removal of infectivity ( . log ). in octa-plaslg Ò , a parallel reduction of the s/d virus inactivation step led to significantly higher activities of plasmin inhibitor. our studies demonstrated that the same amounts of prp sc and prion infectivity bind rapidly and with a very high affinity to the chromatography resin. octaplaslg Ò has the same clinical safety and efficacy profile compared to that demonstrated by octaplas Ò over the last years, except for the increased safety margin in terms of prion disease transmission and the possible effect of a significantly increased plasmin inhibitor activity. uniplas Ò is a second generation solvent/detergent (s/d) treated, coagulation active plasma for infusion produced with an implemented prion removal step. it was developed as an alternative to the blood group specific s/d plasma products, octaplaslg Ò and octaplas Ò , in order to obtain an universally applicable (i.e. blood group independent) plasma that can be used without taking into account the blood group of the recipient. due to an initially controlled, optimal mixing of plasma of different blood groups prior to s/d treatment, in uniplas Ò , the blood group specific antibodies (anti-a and anti-b of both igm and igg type) are neutralised and/or removed by free a and/or b substances and red blood cells (rbcs) to a clinical acceptable level with very limited or no complement activation. objectives. in this study an extensive biochemical characterisation of the first uniplas Ò validation batches was performed. methods. three batches of uniplas Ò were produced by octapharmappgmbh (vienna) under production conditions in [ ] [ ] . uniplas Ò batches were tested on all important coagulation factors, protease inhibitors, activation markers, adamts and factor h levels, as well as von willebrand factor multimers. in addition, anti-a and anti-b titres of igm-and igg-type were investigated. finally, complement activation products, as well as key components of the complement system, were measured. results. in uniplas Ò batches, all coagulation factor activities were higher than . iu/ml and all protease inhibitor activities, including protein s and plasmin inhibitor, were higher than . iu/ml. uniplas Ò contained standardised levels of adamts and factor h, within the normal ranges for single-donor freshfrozen plasma. there was no activation of fvii obtained during manufacturing, thrombin-antithrombin (tat)-complex, prothrombin fragments (f + ) and d-dimer levels were within the normal ranges. anti-a and anti-b titres were within the uniplas Ò specification, i.e. anti-a igm and anti-b igm\ : as well as anti-a igg and anti-b igg \ : , respectively. uniplas Ò did not contain an increased amount of immune complexes and the manufacturing of uniplas Ò associated with more complement activation than the one seen for octaplaslg Ò . conclusions. the present study confirmed that uniplas Ò displays the same high quality and clinical efficacy as the s/d treated blood group specific plasma octaplaslg Ò , but with the additional advantage in being a blood group independent universally applicable plasma. most pts received more fluids than calculated by parkland formula ( ± . ml/kg %tbsa). interestingly, nonsurvivors received less ( . ± . vs. . ± . ml/kg %tbsa). gastric decompression, ascites drainage and the implementation of a stool protocol with rectal enemas ( interventions in pts) was able to remove . ± . l of body fluids and this was related to a significant decrease in iap and cvp and an improvement in oxygenation and urine output ( conclusions. pris is a difficult condition to diagnose and routine monitoring of the adverse effects of high-dose propofol remains sub-optimal. hypothermia has been reported to alter propofol pharmacokinetics and we propose that active cooling may increase the risk of developing pris. this may be particularly relevant in patients with tbi who are on high doses of propofol to control icp in addition to concomitantly administered catecholamines to maintain cerebral perfusion pressure. we recommend that further research is required in this area in view of the increasing use of induced hypothermia in icu. objectives. to compare differences in fluid resuscitation based on direct or indirect admissions to the london burns unit. methods. admissions to the burns unit with [ % burned surface area (%bsa) were identified over years. were excluded from analysis due to palliation or death within the first h. sets of notes were randomly selected for analysis of fluid balance in the first h period of fluid resuscitation after the burn injury. results. mean (sd) time from burn injury to arrival at the burns unit was lower for patients transferred direct to the burns hospital rather than via another hospital ( . ± . vs. . ± . min p = . ). mean (sd) error in burn size estimation was lower for patients initially treated by burns specialists versus non-burns specialists ( ± . vs. . ± . %, p = . ). all patients were resuscitated according to the parkland formula calculated at one of , or ml/kg/%bsa. the mean (sd) actual fluid volume differed from the target by . % (± . %); the lower the calculated fluid target, the greater the error between actual and planned resuscitation volumes; there was no difference in accuracy of fluid resuscitation at h between patients initially managed by burns specialists versus non-burns specialists ( . ± . vs. . ± . % respectively, p = . ). conclusions. burned patients transferred directly to specialist burns care receive a faster and more accurate assessment of their burn injury. despite this, we found no difference in fluid targeting errors at h, though this may reflect corrective fluid management on arrival at the specialist centre. echocardiography is an useful and minimally invasive tool that allows to know the heart filling pressures, also it has proven highly accurate in predicting the response to volume in critically ill patients. we try to determinate the response to fluid infusion by static variables as cvp or lap, comparing with the variation of ivc. methods. an observational prospective study with patients undergoing coronary cardiac surgery ( patients were excluded by a no presenting a good echo views), in the postoperative period under mechanical ventilation (vt ml/kg, fio %, peep ). we performed an echocardiography if the patient presented hypotension, just before the habitual fluid load protocol were started ( ml hes % in - min). we collected data before and after the infusion, and determine the responsiveness to volume if the cardiac output increased more than %. data in the report included invasive cvp and lap, and echo measures, ratio e/e', diameter and variations of inferior vena cava (ivc) and variations of stroke volume by echocardiography (Ølvot x vti lvot) and with vigileoÒ system. . the correlation between low values of cvp/lap and volume response was poor, the relationship between cvp below mmhg with increased cardiac output had a correlation (pearson correlation - . ) with a significance ( -tailed) . , and the relationship between lap \ mmhg and an increase in cardiac output had a correlation (pearson correlation . ) with a significance of ( -tailed) . . the measurement of the variation of the inferior vena cava, led us to calculated a cutoff point more sensitive to determine which patients were responders to volume. through the roc curves (sensitivity/specificity), with the area under the curve of . % (se = . %) and with a confidence interval of % (p significance of . ), resulted in a % variations of ivc with a sensibility of % and specificity of % (younden's index of . %). the same calculation, based on kraemer's quality indices (qi) gave us a % of variation in ivc, with a w = . specificity rather than sensitivity (qi . ), and with a w = . sensitivity rather than specificity (qi . ) objectives. to ascertain whether postoperative hypothermia is linked to high or low risk surgical patients. we conducted a prospective systematic analysis looking at the incidence of postoperative hypothermia in adults who underwent general anaesthesia. children age \ , pregnant women and patients undergoing regional anaesthesia were excluded from the survey. to identify the current level of doctors' knowledge on perioperative fluid management. methods. the survey was conducted at george eliot hospital, nuneaton, uk in may . questionnaires consisting of ten multiple-choice questions on basic sciences and clinical scenarios were devised by a consultant anaesthetist. these were personally distributed to doctors of all grades working in anaesthetics and the surgical specialties. doctors were asked to complete the questionnaire within min. of the questionnaires distributed, were completed. results. the mean questionnaire score varied between specialties from % in the anaesthetics department to % for doctors in surgical specialties. the mean score of registrars and fy doctors in surgical specialties was found to be and % respectively. the overall mean score was %. of all doctors surveyed, the daily maintenance water requirement was known by only %, % knew the daily maintenance sodium requirement and % knew that of potassium. the electrolyte contents of . % sodium chloride and hartmann's solution was answered correctly by % and % respectively. there is a significant deficiency in doctors' knowledge on perioperative fluid management. more emphasis on optimal perioperative fluid management is required in undergraduate and postgraduate training. increased awareness of the british consensus guidelines on intravenous fluid therapy for adult surgical patients would aid training. based on this survey, a regional online survey of junior doctors is planned to further identify gaps in perioperative fluid management training. optimal fluid management could also help to reduce prolonged hospital stay which can result from fluid-related complications. objectives. to evaluate dynamic echocardiographic parameters as predictors of volume responsiveness in surgical patients. methods. patients were included in the study after laparotomy surgery performed on the same day ( breathing spontaneously and mechanically ventilated in volume controlled mode with tidal volume of ml/kg). a fluid challenge was performed in spontaneously breathing patients by passive leg raising and infusing saline ( ml/kg). echocardiographic analysis of respiratory changes of inferior vena cava diameter (ddivc) and aortic blood flow (dabf) was performed in all patients. a threshold of % for ddivc was used for classifying patients as volume responders or non-responders. age, sex, gender, bmi, cvp, iap, map, left ventricular ejection fraction, left ventricular systolic and diastolic area, and stroke volume in all patients, as well as itbvi, ci, ppv and svv in patients were measured. a positive correlation with ddivc was established for itbvi (r = . , p = . ), iap (r = . , p = . ) and ef (r = . , p = . ). a positive correlation with dabf was not established for any variable measured. patients ( %) were classified as volume responders and ( %) as non-responders. responders had overall higher iap than non-responders ( . ± . mmhg vs. . ± . mmhg respectively, p = . ). respiratory changes of ivc diameter showed positive correlation with itbvi. so, conclusions about itbvi could be indirectly made from ddivc values in patients who are not being invasively monitored. ppv and svv did not show positive correlation with itbvi. surprisingly, we confirmed a positive correlation between ddivc and iap. we detected patients with high iap, while all the volume responders had overall higher iap. although further investigations are needed to establish how longer duration of high iap may influence ddivc, it seems that ddivc is a good parameter of volume responsiveness during first h after laparotomy surgery. unlike from other studies, we could not establish a positive correlation between dabf and any variable measured. these studies were performed in hypovolemic septic patients, so this could be the reason for such different results. more studies are needed in a larger set of patients undergoing laparotomy surgery to evaluate dabf. introduction. fluid optimization after major cardiac surgery was shown to improve patients postoperative outcome significantly. several hemodynamic parameters were proposed for the guidance of therapy but never compared in a head to head trial. objectives. in this prospective randomized trial patients scheduled for elective cardiac surgery underwent early goal directed fluid therapy guided either by stroke volume variation (svv) or by oxygen delivery index (do i). we hypothesized that while svv is easier to obtain it will not be inferior to do i in outcome parameters. methods. following ethics committee approval and signing of a written informed consent, patients were randomized in two groups to undergo either fluid optimization guided by do i or svv in the first postoperative hours in the icu following elective cardiac surgery (cabg). following a standardized egt protocol the parameters were collected by using hemodynamic monitoring based on a pulse contour analysis and a transpulmonary lithium dilution (lidco plus, lidco,uk). we compared amount and type of volume infused, need and amount of inotropic or vasopressor substances, time spent on ventilator, los in the icu and postoperative complications. statistics were evaluated by using a t test for unpaired samples. table . compared to the do i group fluid optimization using svv showed reduced ventilator times (p = . ) and less complications (p = . ) in the first days after surgery. no differences between the groups were detected concerning the type and amount of volume infused, need for inotropes or vasopressors or the los in hospital conclusions. while svv is less invasive, cheaper and easier to be obtained than do outcome was at least not inferior and even showed improvements in postoperative cardiac surgery patients. rd esicm annual congress -barcelona, spain - - october s introduction. over the years, there have been concerns over incompatibility of transfused blood with various intravenous fluids during blood transfusion, especially related to increased levels of haemolysis. it is often impractical, particularly in an emergency situation, to flush through a giving set with a so-called ''safe'' fluid prior to and after delivering blood. we wanted to investigate whether this is actually necessary and whether the usual fluids used in the perioperative period really do cause any demonstrable alteration in the composition of transfused blood. objectives. the purpose of this study was to expose packed red cells to a variety of different intravenous fluids commonly used during the perioperative period and to measure a number of parameters in the blood following their contact with each different fluid, including a blood film to examine for clumping of cells or haemolysis. a unit of a positive blood was passed through blood giving sets which were primed with various intravenous fluids. after adequate mixing of blood with fluids, samples were collected for full blood count, urea and electrolytes and blood films. one millilitre of mixed blood was taken in each bottle at a time. the intravenous fluids used in this study were normal saline, hartmann's solution, % dextrose, % dextrose, starch and gelatin. there was no significant rise in blood parameters suggestive of haemolysis. the potassium and ldh levels were not significantly different with various fluids. the haemoglobin and haematocrit levels were also comparable to one another. there was no demonstrable changes in blood parameters suggestive of haemolysis, nor were there any change in electrolyte values. this suggests that all of the fluids investigated during this study would be suitable to be used via the same giving set before and after the transfusion of pack red cells. objectives. to assess the compliance with the national guidelines in avoiding inadvertent peri-operative hypothermia in an acute district general hospital in england. we prospectively studied our local practice on maintaining normothermia in consecutive adult surgical patients { men, mean age . years, patients with asa grade ( . %), emergency surgical patients ( . %), patients with significant cardiac disease . %}. we used a questionnaire that was filled pre-operatively by anesthetic nurses, intra-operatively by anesthesiologists, and post-operatively by recovery nurses. patients were recruited from the following surgical subspecialties: general surgery ( %), gynecology ( %), trauma ( %), breast surgery ( %) and orthopedics ( %). day surgery patients were excluded. peri-operative hypothermia was defined as temperature \ °c as per the nice guidelines. results. less than half of our patients ( . %, n = ) had their temperature measured preoperatively, on whom incidence of hypothermia was . % (n = ). only one of these patients was warmed prior to induction. patients requiring emergency surgery and those with asa grade had increased incidence of preoperative hypothermia ( . % and . % respectively, p \ . ). based on nice guidelines, patients needed intraoperative forced air warming but only ( . %) patients received it. intraoperative temperature measurement was made on patients, of whom . % (n = ) were hypothermic. incidence of intraoperative hypothermia was high in surgical procedures lasting longer than min (p \ . ) but was not affected by the use of regional anesthetic techniques. patients had their temperature measured on arrival to recovery of whom ( . %) were hypothermic. patients ( . %) had their temperature measured every min (nice recommendation) and the mean time interval for temperature measurement in recovery was min. patients were still hypothermic on leaving recovery. conclusions. majority of our surgical patients did not receive adequate perioperative care on maintaining normothermia. consequently, the incidence of hypothermia was significant pre-, intra-and post-operatively. we are currently analyzing the data to investigate the effect of hypothermia on duration of recovery stay, length of hospitalization and mortality in our patients. we completed a double-blind randomized trial in patients undergoing cardiac surgery in which we compared fluid resuscitation with a hydroxyethyl starch (hes, % mw pentastarch) and saline. use of hes resulted in markedly less use of catecholamines the morning after surgery. an underlying design principle was that assessment of cardiac index (ci) is essential for a proper fluid protocol. in this analysis we examine that supposition. all subjects had pulmonary artery catheters. patients were consented preoperatively, but randomized post operatively to receive up to blinded ml boluses for predefined hemodynamic targets; ci \ . l/min/m , blood pressure (bp) set by admitting team, cvp \ mmhg, or urine output \ ml/h. hemodynamic measurements were made before and after each bolus. after the study boluses, only saline was used. results. patients received fluids, hes and saline. there were study boluses, hes and saline. of these, boluses ( %) could not be assessed for this hemodynamic analysis (but were still used for the primary outcome) because of protocol violation or missing data. of the rest, ( %) of boluses were given for a low ci; in bp and cvp were also low so that ci was the only trigger in %. a low bp was a trigger in ( %). low cvp was the trigger in ( %). only hes and saline patients required the maximum allowed blinded boluses. at the th bolus, low ci was the trigger for ( %) of hes but ( %) of saline patients. there were that could be evaluated for hemodynamic response based on four possible outcomes of cvp and ci. objectives. the aim of our study was to evaluate the predictive value of cvp with regard to gedi, and to correlate these parameters to cardiac index (ci). conclusions. volume depletion according to gedi was found in more than half the patients. the predictive values of cvp with regard to volume depletion were low gedi and its changes significantly correlated to ci and its changes, which was not observed for cvp. therefore, gedi appears to be more appropriate for volume management during mayor liver resections. introduction. regional anticoagulation with citrate is an effective and established anticoagulation strategy during crrt in critically ill patients, especially in surgical patients with a high risk of bleeding and in case of a heparin-induced thrombocytopenia ( ). however, citrate crrt could be associated with major metabolic derangements such as metabolic alkalosis, hypocalcemia, hypernatremia and citrate toxicity. objectives. the aim of our study was to investigate efficacy, safety and metabolic stability during citrate crrt in critically ill patients with acute kidney injury. methods. the retrospective study was performed in a mixed surgical and trauma icu in a university hospital. patient charts were reviewed for demographic data, the period and dosage of citrate crrt and metabolic parameters. reasons of admission, comorbidities and severity of illness were also evaluated. citrate crrt was performed using commercially available equipment and fluid solutions (multifiltrate Ò with integrated ci-ca Ò -system; fresenius medical care; germany). to maintain stable metabolic and haemodynamic conditions we used an internal standard protocol for citrate crrt. statistical analysis was performed using descriptive methods (mean, median and standard deviation) and a mann-whitney u test where appropriate. p \ . was regarded as statistically significant. conclusions. although minor metabolic imbalances were observed, none led to a termination of citrate crrt and all of them could be managed by adjustments of blood flow and dialysate rates according to a preset protocol. our findings suggest citrate crrt to be a safe and effective strategy for crrt even in patients with hepatic dysfunction. nevertheless, metabolic parameters need to be monitored regularly to avoid severe metabolic derangements. introduction. the liver is central to ammonia metabolism, being the main site of urea cycle enzyme pathways. in acute liver failure (alf) and decompensated chronic liver disease (cld) ammonia dysmetabolism results in hyperammonaemia, thought to be of central importance in the pathogenesis of hepatic encephalopathy and, in alf cerebral oedema [ ] . continuous renal replacement therapy (crrt), commonly used in critically ill patients may be an effective method of clearing ammonia. little is known of the efficacy such techniques have on ammonia clearance. objectives. to quantify the clearance of ammonia using an aquarius haemofilter (ahf) using different renal replacement doses and techniques. methods. patients with a circulating ammonia level[ lmol/l due to commence crrt were enrolled. the ahf was programmed to run in either pre-or post-dilution modes at a blood flow rate of ms/min using a . or . m filter depending on the crrt ultrafiltration (uf) dose, which included , or ml/kg/h (adjusted for ideal body weight). ml of blood and effluent fluid were collected, on ice into lithium/heparin and serum separation tubes, from pre and post filter access points and effluent tubing to calculate urea and ammonia clearance using the cordoba formula [ ] . delta whole body ammonia clearance was determined by measuring arterial ammonia at and min. ammonia measurements were performed using a pocketchem Ò blood ammonia bedside testing machine. results. patients ( alf and cld) were recruited (mean age years, sd ( ), with mean arterial ammonia lmol/l, sd ( ). min whole-body ammonia clearance was - lmol/l, p = . , paired t test). ammonia and urea clearance were correlated (r = . , p = . ); uf rate correlated negatively with filtrate ammonia (r = - . , p = . ) and positively with ammonia clearance (r = . , p = . ). filter ammonia clearance was not dependent on filter size for the standard blood flow rate. pre or post dilution modes did not affect ammonia clearance (p = . , student's t test). a constant filter size and blood flow rate achieved ammonia clearance of ml/min/m for ml/kg/h, ml/min/ m for ml/kg/h and ml/min/m for ml/kg/h (p = . , one way anova). conclusions. ml/kg/h based on ideal body weight appears to be the optimum dose of crrt for ammonia clearance when using a blood flow rate ml/min and a . m filter. filter and delta whole body ammonia clearance may be increased further using the combination of a higher dose ( ml/kg/h) with a larger filter size and higher blood flow rates. introduction. malnutrition is common in intensive care following the catabolic state induced by critical illness. patients who progress from enteral nutrition back to oral feeding are usually in an energy deficit. espen guidelines recommend increasing calorie delivery during the recovery period to cover this anabolic phase. oral nutritional supplements (ons) are widely used to facilitate calorie delivery within the hospital setting however the effectiveness of this strategy is dependent on patient compliance with the products. compliance among the elderly ward-based population has been considered ( ) however that of intensive care patients has not been reported. to evaluate compliance to ons in a mixed medical and surgical adult intensive care unit (icu) in a district general hospital. prospective observational study was conducted over a month period with data compiled from fluid chart analysis and discussions with nursing staff. all adult icu patients prescribed, or offered without prescription, an ons were included until the point they were discharged to the ward. the supplements studied, resource Ò energy, . fibre, fruit and dessert (nestlé nutrition), were selected based on their availability within the trust. patients were offered a choice of flavour. results. data was collected and analysed for patient days. a total of supplements were prescribed. of the prescribed supplements, . % were offered to patients and . % consumed. % were offered the same at nursing discretion based on clinical need and . % were consumed. resource Ò energy was the most frequently prescribed and offered product ( . and . % respectively). most common flavours selected by patients were strawberry and vanilla. resource . fibre was better tolerated ( . %) than resource energy, resource fruit and resource dessert ( . , . and . % respectively). across all products the best tolerated flavours were apricot, chocolate and coffee ( %). the highest calorie supplement, resource Ò . fibre, resulted in the best compliance in both tested flavours. compliance with ons demonstrated here is higher than previous studies ( ) partly attributable to one-on-one nursing of icu patients enabling active encouragement with feeding. nursing staff discretion had better uptake than routine prescription of ons. however, difficulties with ons still remain. interestingly in our study the highest calorie density supplement was tolerated the best and thus giving the most benefit to the patient. despite the difficulties associated with ons uptake we would recommend its regular use on icu with a drive towards the highest calorie supplements being offered. introduction. cirrhosis is a chronic disease and the patient's quality of life is affected in a negative way due to the problems like ascites, jaundice, nutrition deficiency, fatigue, activity intolerance, itching, pain, insomnia, anxiety, hopelessness, work loss and depression. objectives. the aim of this study is to examine the changes in patient's lives that diagnosed with cirrhosis of the liver disease owing to the symptoms they experienced. methods. this research is a qualitative study that has been carried out with inpatients diagnosed with liver cirrhosis in the gastroenterology clinic of a teaching and research hospital. average age of patients was (ranging - ). descriptive characteristics form and semi-structured interview form were used in the data collection. interviews with patients have been performed individually and face to face. the data were evaluated by using colaizzi's phenomenological data analysis method. as a result of the data analysis, three categories and six themes were identified. categories include: (i) problems of symptoms related to the physical limitations (ii) psychosocial issues. patients suffer mostly from fatigue and malaise ( patients), while those in the later stages suffer from, additionally, physical ailments caused by acid. inability to sleep due to anxiety and increase in tendency to sleep in advanced stages have been identified after being diagnosed. the majority of patients were identified to have undergone an anxiety besides having a fatal disease due to concern for the future, being forced to quit the job and being affected by the experiences of the patients in advanced stages. it also has been discovered that the patients had experienced social isolation because of fatigue and weakness in particular. as the result of this study it has been determined that patients with cirrhosis have mainly problems of fatigue, weakness, sleep disorders, anxiety and associated problems. rd esicm annual congress -barcelona, spain - - october s [ ] . while in patients with acute liver failure, elevation of arterial ammonia levels has been linked to cerebral complications and increased mortality, the role of arterial ammonia in hh patients is unknown. our study aims at evaluating arterial ammonia levels in patients with hh. furthermore, we wanted to elucidate the potential consequences of high ammonia levels in these patients. arterial ammonia levels were measured and documented in hh patients without liver cirrhosis who were admitted to the medical icu. icu mortality and overall day-survival were documented. cox regression was performed to describe the impact of ammonia levels on mortality. mann-whitney test was used for comparison of metric variables. results. overall median arterial peak ammonia level in our patients was lmol/l ( . - . lmol/l), whereas median arterial peak ammonia value was significantly higher in icu non-survivors compared to survivors ( ( - . ) vs. . ( . - . ); p \ . ). saps ii and sofa score were significantly higher in icu non-survivors (p \ . and p \ . , respectively). cox regression revealed that arterial peak ammonia levels were significantly associated with higher -day-mortality (p \ . ), even after adjustment for saps ii. median arterial peak ammonia levels in patients with verified brain edema were significantly higher than in patients without ( . lmol/l ( - . lmol/l) vs. . lmol/l ( . - . lmol/l); p \ . ) after exclusion of patients following cardiopulmonary resuscitation with consecutive hypoxic brain damage. our results suggest that increased levels of ammonia are associated with high mortality and can lead to brain edema in patients with hh. % of patients had a diagnosis of sepsis and % of patients were admitted under the neurosurgical team, the latter of which may have contributed to the relatively low anticoagulant use of %. systemic heparinisation was the sole anticoagulant used, but compliance with local protocols was poor with % of appts below the therapeutic range and % of infusions commenced at the wrong rate. % of filter changes were due to clotting and mean filter life was h. despite this, dose delivery was acceptable, with % of prescribed dose delivered. conclusions. as previously reported , our demographic data confirm the relatively poor outcome of patients needing crrt. we have identified areas where care for these patients could be optimised and endeavour to do this locally via improved protocol design and an ongoing educational programme. many of the components of crrt could be incorporated into care bundles, but certain aspects of treatment remain controversial which may be a barrier to their adoption. given the high numbers of neurosurgical patients in our unit, consideration should be given to the use of regional anticoagulation such as citrate. introduction and objectives. accurate prognostic indicators of patient survival in an intensive care unit (icu) help guide clinical decision making. factors known to portend poor prognosis in acutely ill cirrhotics in icu include the need for mechanical ventilation, development of shock, renal failure and sequential increase in the number of failing organs. while serum lactate is now an established marker of survival and/or the need for transplantation in fulminant liver failure, its impact on critically ill cirrhotics is less well known. methods. we retrospectively studied consecutive acutely ill cirrhotics admitted to the icu between and at the royal free hospital, a tertiary referral centre in liver diseases and transplantation. data were collected on demographic variables, aetiology of liver disease, liverspecific prognostic scores [child-turcotte-pugh (ctp), model for end-stage liver disease (meld), united kingdom model for end-stage liver disease (ukeld)], and acute illness scores [acute physiological score and chronic health evaluation (apache ii), sequential organ failure assessment score (sofa) ]. in addition, serum lactate levels at , and h were also recorded. multivariable logistic regression analysis was performed, and the discrimination ability of each of the above-mentioned scoring models in predicting icu and hospital survival of these patients was evaluated using the area under the receiver operating characteristic (roc) curve. conclusions. one third of lt recipients present a documented bacterial infection within year after surgery. we found a high prevalence of ciprofloxacin resistance and a low incidence of s.aureus witch was often resistant to methicillin. non fermentative gram negative bacilli represent % of the pathogens and should be taken in account for treatment of the most severe patients. extracorporeal liver support therapy is in its infancy but is valued as a detoxification treatment option for patients with cirrhosis who have rapid worsening of their liver function. we report the use of prometheus Ò , a new extracorporeal liver support system allowing the removal of protein bound and water soluble toxins by fractionated plasma separation and absorption (fpsa) in a patient with wilson's disease (wd) who developed rapid worsening of their liver function. a -year-old female patient, diagnosed with wd since the age of , was initially treated in an irregular pattern with penicillamine. therapy was discontinued. now, years later, she developed acute decompensated liver failure with hepatic encephalopathy with a meld . liver transplantation (lt) was the treatment option for this patient. but, in this case, the rapid and adverse evolution of the liver failure with renal failure and the unknown waiting time for a emergency liver donor in our country led us to use the extracorporeal liver support therapy. after h min of therapy we reduced the amount of bilirrubin for less than a half, we increase the urinary output and next day the patient went to liver transplant, stable, with a renal function improved. conclusions. acute liver failure due to wd is most of the time fatal without emergency lt. this case report highlights discontinuation of chelants treatment in a patient with wd. as the patient progressed to decompensated liver cirrhosis with encephalopathy, lt was the only treatment option but while we don't get a donnor, we can use, for a short period of time, an extracorporeal liver support therapy as a very useful bridge. results from two studies presented at the recent easl congress have shown that treatment with extracorporeal devices may not confer a survival advantage for severe liver failure patients, despite positive dialysis effects. however, results among a small sub-group of patients show promise like severely ill patients with hepatorenal syndrome type or a meld score over . ( ) . metoclopramide is used to stimulate the upper gi tract and seems to have no effect on colonic motility. objectives. the aim of this in vitro study was to compare the prokinetic potency of those substances. a tissue bath with guinea pig colonic segments fixed on a polyacrylic tray allows the evaluation of the transit time (tt), the time necessary for a wooden pellet to perambulate. a decrease of the tt reflects stimulation, and an increase inhibition of peristalsis. after stable peristalsis activity the effect of increasing concentrations of prucalopride, neostigmine or metoclopramide on tt were evaluated. dose response curves were constructed, two way anova (sigma stat) was used for statistics, p values b . were considered to be significant. effect of prucalopride and neostigmine on motility results. prucalopride stimulates normal peristalsis in vitro only in the highest tested concentration of lm (p \ . ). neostigmine's prokinetic effect was limited to a small concentrations range ( . lm, p \ . ), the concentration of . lm had a moderate, but not statistically significant prokinetic effect and the highest tested concentration ( lm) lead to a complete block of peristalsis (fig. ) . metoclopramide, as expected, was devoid of any effect on colonic motility. conclusions. this experimental setting is a reliable method to evaluate the effect of different substances on colonic motility in vitro. prucalopride's prokinetic activity is concentrations dependent and limited. neostigmine is well known to improve colonic motility, but it seems imperative that the drug's effective dose range be use-higher concentrations have inhibitory effect on peristalsis. objectives. robotic radical prostatectomy involves extreme changes in patient position and often associated with a longer operative time than other commonly performed laparoscopic procedures. this review discusses the anesthetic considerations in robotic radical prostatectomy while analyzing potential risk factors related to pulmonary complications. we retrospectively reviewed the medical records of all the patients who had undergone robotic radical prostatectomy at our institution. among the total patients of , aged to years, patients were capable of spontaneous respiration at the end of surgery (group i) whereas patients needed assist ventilation (group ii). the demographic characteristics, coexisting diseases, anesthesia and operation time, anesthetic agents, the amounts of blood loss, infused fluid and transfused blood products were compared between the groups. results. the mean age of the patients was . ± . years. the mean operation times were . ± . min (range, - min). age, body mass index (bmi) and asa status did not differ significantly between the two groups, whereas operation time, the amount of blood loss and the incidence of transfusion were significantly higher in the group ii. although patients with subcutaneous emphysema and atelectasis needed prolonged ventilator care for h, the incidence of atelectasis and subcutaneous emphysema was similar between the groups. conclusions. prolonged laparoscopic surgery in a steep trendelenburg position has a high possibility of postoperative respiratory insufficiency and the possible contributing factor is a long operation time. objectives. we examined the frequency of postoperative cough reflex and its effect on postoperative clinical outcome retrospectively. we examined the patients who admitted into the icu after the esophagectomy with lymphadenectomy during the period from september, , to february, . in addition to usual criteria for extubation we removed their tracheal tube if the cough reflex was identified when one milliliter of half saline was distilled into their trachea. if the cough reflex was absent until days after the operation the patient underwent tracheostomy and after that they weaned from the ventilator. results. there were patients (f/m / ), and their mean age was . ± . . cough reflex were confirmed by seventh postoperative day in patients ( %) but residual patients underwent tracheostomy because of absence of cough reflex ( introduction. the technique of laparoscopic cholecystectomy carried with carbon dioxide pneumoperitoneum may lead to adverse events in mechanical, hemodynamic and respiratory systems as a consequence of physiopathological changes such as increased intraabdominal pressure. _ it may cause hypoxemia, hypercapnia, hemodynamic instability and impairment of oxygenation. decreased functional residual capacity, ventilation/perfusion imbalance and sympathetic stimulation effects of co that is absorbed from peritoneum are basic problems. in perioperative period, application of mechanical ventilation and anesthesia should be reviewed because of these physiopathological mechanisms. in this study, we aimed to investigate the effects of cmh o peep application on etco , minute ventilation and arterial oxygenation during laparoscopic cholecystectomy operations. for this reason, the study included total patients and they were randomly divided into two groups. same anesthetic protocol was applied in both groups. for general anesthesia induction; mg/kg dose of fentanyl, mg/kg dose of propofol were administered. following this procedure endotracheal intubation was applied with . mg/kg dose of cisatracurium. patients received % o -% n o (mixture with equal amounts) with . - . mac end-tidal sevoflurane for anesthesia maintenance. before co insufflation, respiratory parameters were recorded on the respiratory apparatus adjusting etco - mmhg, respiration rate /min., inspiration/expiration rate : , vt: - ml/kg. patients were ventilated by volume controlled mechanical ventilation. heart beats, mean arterial blood pressure and peripheric o saturation (spo ), etco , minute ventilation(v) and peak airway pressure(p _ ip) values of all patients were recorded just before insufflation (t ). after recording, cmh o peep was applied to the first group (group ). peep wasn't applied to the nd group (group ). these parameters were repeated in periods such as (t ) and (t ) minutes after insufflation, preexsufflation (t ) and postexsufflation (t ) in both groups. before insufflation, respiration rate ( /min) and etco ( - mmhg) values were adjusted as planned in both groups and minute ventilation was also adjusted. at the same time, total insufflated amount of co for distending abdomen was recorded. arterial blood gas analyses were made just before induction (while patients were breathing normal room air, t ), min after induction (t ) and just before the end of the operation (t ). in our study, we found that minute ventilation to stabilize etco - mmhg was significantly increased in group in which peep was not applied (p \ . ). none enhancement was needed in minute ventilation in group and arterial oxygenation was significantly increased in group (p \ . ). aside from the cholesterol lowering effects of statins, as a class of drugs they have been shown to exert anti-inflammatory effects and have the potential to be therapeutic in neuroinflammatory disorders . we tested the hypothesis that atorvastatin improves memory retrieval post unilateral nephrectomy in a murine model. methods. c /bl mice were randomly allocated into groups (n = - /group): control plus placebo, control plus atorvastatin, nephrectomy plus placebo and nephrectomy plus atorvastatin. animals were given either a placebo ( . ml normal saline) or lg in . ml normal saline of atorvastatin by gavage once a day for days. on day all animals underwent fear conditioning training using a conditional stimulus of a db tone and an unconditional stimulus of a . ma electric shock. on day the surgical animals underwent unilateral nephrectomy, whilst the control animals received no surgery. at post-surgical day all animals were tested for hippocampal dependent memory retrieval using the fear conditioning paradigm, with freezing response to the db tone as a marker of memory retrieval. all animals were then terminated. results. surgery evoked a reduction in hippocampal dependent memory retrieval in the nephrectomy plus placebo group as measured by % freezing time (mean ± sd: ± ) when compared to the control plus placebo group ( ± ; p \ . ); a situation mimicking pocd. this change was obviated in the nephrectomy plus atorvastatin group ( ± ; p [ . vs. control plus placebo). conclusions. our data suggested that atorvastatin has the potential to improve postoperative cognitive performance in a murine model of pocd. the proven safety of the drug along with its already widespread use and cost effectiveness would permit rapid instigation of a human randomized controlled trial to explore efficacy in the clinical setting. a. puxty , r. docking glasgow royal infirmary, department of anasethetics, glasgow, uk hypotension in the post-operative period is common but guidelines recommend its prevention/treatment [ ] . epidurals are common practice following major surgery in many institutions and can prevent pulmonary complications [ ] but have also been associated with falls in blood pressure when compared to other analgesic techniques [ ] . fluids therapy is a common intervention for hypotension but fluid overload has been associated with worse outcomes in surgical patients [ ] . we decided to audit the incidence and management of hypotension in the surgical high dependency unit of a large tertiary referral hospital. to determine the incidence and management of hypotension in the surgical high dependency unit in pancreatic, upper gi and lower gi patients. we prospectively looked at patients who underwent major upper gi, lower gi or pancreatic surgery involving epidural analgesia. the first h of care from onset of anaesthesia was closely looked at with regards to fluid management, epidural management and actions taken on episodes of hypotension or severe hypotension (defined as systolic blood pressure of \ and \ respectively). each episode of hypotension was looked at to determine the actions taken at that point. of the patients looked at, were major pancreatic, lower gi and upper gi patients. ( %) had at least one episode of hypotension, with ( %) having at least one episode of severe hypotension. mean fluid in during the first h was ml, with a mean fluid balance of ml. there was no difference between the doses of epidural local anaesthetic in h between the hypotensive and non hypotensive groups (p = . ). management of hypotensive episodes was variable, but the most common intervention at episode one was fluid bolus ( %) and discontinuation of epidural was most common at episode two ( %). use of vasopressors for hypotension was very low with only two infusions being started altogether. conclusions. hypotension is very common in our high dependency unit. fluid balance in our patients was far more positive that we had expected. management of hypotension was variable. we plan to institute a protocol for hypotension and fluid administration to determine if improvements can be made. objectives. to identify predictive factors associated with the need for relaparotomy in patients with ssp. adult ssp patients undergoing laparotomy between and included within a single-center peritonitis registry (perit) were collected. patients subjected to relaparotomy were studied. we excluded patients with severe peritonitis secondary to appendicitis. apache ii and sofa score at icu admission after the initial laparotomy were recorded. variables with a p value. in a bivariate analysis were included in a multivariate logistic regression for further analysis of predictors for need for re-laparotomy. results. two-hundred forty-seven patients were obtained from perit registry. a total of patients with spp were included in the analysis. eighty seven patients ( %) required relaparotomy. median number of re-laparotomies was . most spp were associated to colon (n = , . %), small intestine (n = , . %) and biliary tract (n = , . %) perforations. cultures were positive in . % of first laparotomy: gram negative bacteria were isolated in . %, gram positive bacteria in . % and fungi in . %. hospital mortality was % (n = ). multivariate analysis is described in the table . conclusions. in obese patients scheduled for surgery, the previous use of cpap has not shown an improvement in blood gas parameters. the use of cpap in the hours before and immediately after surgery has not been associated with better postoperative oxygenation. combined icu-surgery dpt. action in these cases seem to contribute to better patient outcomes. objectives. we set out to quantify the intensive care workload and changes to that workload over the first years following the transfer of a specialist bariatric service to our hospital. a prospectively collected bariatric surgical database was cross-referenced to the itu database (ward-watcher) to identify admissions to the -bedded critical care unit of all patients who had undergone any bariatric procedure. for each patient identified; demographics, reason for admission, level of support, length of stay and outcome were recorded. data were grouped into -month periods for trend analysis. research in emergency situations and especially in resuscitation field raises important ethical and regulatory issues. the globalization of the resuscitation science through multicentric trials for example highlights the need for a more consistent approach to regulatory aspects to enable the science to grow while protecting human rights. objectives. the purpose of this analysis is to compare the different regulations approaches in emergency research in north america (canada, usa) and in europe (european directive, france). conclusions. this analysis emphasizes the lack of international standardization of regulatory measures and ethical decisions. however some countries like the us seem to advance in the democratic process by mandating additional regulatory measures (community consultation, public disclosure to the communities) prior to initiation of clinical investigation; nonetheless, there is little evidence of their effectiveness. many challenges are raised. firstly, the variability in regulations, and consequently in local board's assessments, is problematic, pleading for international regulations. secondly, the current heterogeneous ethical review process and demanding unsubstantiated regulatory measures poses a risk to all when it is not evidence based and it is applied inconsistently between countries, within a country and worse at the level of each individual hospital review board. it puts the investigator at risk for unnecessary criticism and the community at risk as it is unknown if we truly consult or inform our target communities about waiver of consent research through our current ethical and regulatory processes. globalization and evaluation of the ethical and regulatory processes are urgently needed; regulatory community has to work towards a standardized evidence-based process upon which to base regulatory decisions. introduction. in research outside the intensive care field it is known that a high score for the psychological factor ''perceived hopelessness'' experienced by healthy individuals increases risk of death several fold. objectives. the aim of this study was to examine if the score of the psychological factor ''perceived hopelessness'' may predict long term mortality (mean or high perceived hopelessness score) when assessed post icu care in former icu patients. methods. prospective, multicenter study in three mixed icu's in sweden. questionnaires, including the -item hopelessness scale, demographic data and previous illnesses, were sent months after discharge to all former adult icu patients who thereafter were followed for another years. a reference group of individuals from the uptake area of the hospitals served as controls. results. ( %) patients returned the questionnaires. the icu patients reported significantly higher mean scores in perceived hopelessness score compared with the general population, . (sd . ) compared with . (sd . ) (p \ . ), and % (n = ) of the icu patients perceived a mean or high hopelessness score compared with % of the general population (p \ . ). the icu patients who died during the follow-up period reported a significantly higher perceived hopelessness score (n = ) . (sd . ) (p \ . ) as compared with those who survived up to years after discharge (n = ) . (sd . ). in a logistic regression model the long term mortality for the icu group was found to be affected by: pre-existing disease [odds ratio (or): . ], age (or: . ) and perceived hopelessness score (or: . ). the new and interesting finding of this study is that icu patients score higher on ''perceived hopelessness'' than a control population and this increase is predictive for the post icu mortality. furthermore, the size of this effect is significant and only exceeded by pre-existing disease and age. we performed a retrospective observational study to evaluate what proportion of met calls was associated with lomt issues. to estimate the proportion of met reviews involving patients with a not-forresuscitation (nfr) order and the timing of met calls in relation to admission and death or discharge from hospital. to compare the patient characteristics and outcome for met calls associated or not associated with lomt issues. we obtained hospital research ethics committee approval. we performed a retrospective observational study involving five-year (august -april ) in a single tertiary australian hospital. we obtained information on demographics, on the met review and hospital outcome. lomt included nfr orders, not for met orders and palliative care plans. results. we analysed met reviews in patients. table and fig. summarize major findings for overall population and the two subgroups of patients with or without lomt. patients with lomt care plan were older, more likely to have medical diagnoses, were reviewed later during their hospital stay and closer to their hospital discharge or death. fewer lomt patients were admitted to icu. hospital length of stay was shorter, mortality in lomt care patients was double that of non-lomt patients. however, more % of patients with lomt were discharged alive from the hospital. conclusions. more than one third of met activations deal with lomt issues. although the mortality of these patients is high, a large proportion survives to hospital discharge. evaluation of the patient experience in intensive care (icu) frequently depends on reports from surrogates such as relatives. there is a concern regarding the validity of the surrogate opinion which might not represent the values of the incapacitated patient and treatment decisions therefore maybe biased [ ] . others have found that there is a strong preference within a population for utilizing relatives as surrogate decision-makers in the event of admission to icu and this attitude is not influenced by ethnicity, religion or education level [ ] . objectives. the objective was to measure the ability of the relative to answer on behalf of the patient. a further wish was to determine the validity of their surrogate responses. a retrospective study, which surveyed relatives of patients who had died within a critical care service during a -year period ( , ) . the item questionnaire allowed for the collection of quantitative and qualitative data with respect for each item to overcome the limitations of the quantitative format which may not be sensitive to all the issues which can surround the provision of end-of-life care [ ] . for items, relatives were asked specifically to grade their capacity to represent the patient. results. quantitative data from the items designed to test the relatives' perception of their ability to act as surrogates indicates that relatives considered they could respond to these items for % (average) of instances. when the relative did answer on the patient's behalf, the level of concordance between the surrogate (relative) and the patient's perceived opinion was % suggesting that when the relative is willing to act as surrogate the response is likely to have validity. (table ) . results from the qualitative data indicates that the low ( %) level of willingness to answer these questionnaire items reflected a reluctance to answer on behalf of a sedated or ventilated patient, rather than an inherent inability to represent the patient. conclusions. the response rate to the items vindicates concerns regarding the ability of relatives to represent the patient in icu settings and supports a need for further study. where the relative is willing to act as surrogate, concordance does exist. qualitative data clarified quantitative results and was instrumental in promoting a better understanding of the concerns of relatives who have a family member admitted to icu. . the majority of patients that died in icu were provided some kind of therapy restriction. an important conflict strains between clinical practise, bioethical principle and jurisdiction laws; the solution of this conflict is more and more urgent. therapy restriction has also important economical aspects since the number and cost of available treatments constantly increase. our survey studied therapy restriction procedures in hungary for the first time. in we performed a survey with questionnaire among intensive care physicians. questionnaires were sent out electronically to registered members of the hungarian society of anaesthesiology and intensive care. respecting anonymity we have statistically evaluated replies ( %) with t test and anova. we grouped intensive care physicians based on gender, years spent in work, religion and type of department they were working, and we compared data from these groups. intensive care physicians generally make their decisions alone, based on the patient's long-term life prospects and physical status ( . / points). they are slightly influenced by the opinion of the patient ( . ), the relatives ( . ) and other medical personnel ( . ). if the physician sees any chance of recovery but the patient or relative requests treatment restriction then . % of physicians that completed the forms would continue therapy against the will of the patient or relative. only . % would accept the patient's/relative's opinion and autonomy in such a case and would stop therapy. in fact . % of physicians would make their decisions without considering or even against the opinion of patient if they think therapy is useless. if there is no chance of recovery despite medical treatment % of physicians stop the treatment, . % would continue it without informing the patient or the relatives, . % informs the relatives but continues useless treatment irrespective of the will of the patient or relative. having analyzed the groups we found two significant differences. in case of useless treatment physicians working in university hospitals more often choose treatment restriction without informing relatives (p \ . ) then those working in non-university hospitals. physicians who declare themselves as atheist rather choose the continuation of treatment without informing relatives (p = . ). conclusions. the hungarian practise of end of life decisions among intensive care specialists is paternalistic, physicians make their decisions alone, do not consider the requests of the patient or relatives. our goal is to strengthen patient autonomy and to support their opinion by training icu physicians. on the other hand it is inevitable to define what useless medical treatment exactly is and to introduce this category in medical ethics and also in jurisdiction practise. objectives. to determine the frequency and processes of eol care at our centre. between october and december , / ( %) patients staying in the icu for more than day, underwent some form of eol care in the icu. icu staff notified investigators whenever an eol decision was made. we recorded demographic details, documentation of the eol care process in the case notes, and interviewed icu staff to determine the eol care processes involved. results. patients ( %) were male, ( %) were females. mean age was . ± years. icu stay was . ± . days, admission apache ii score was . ± . which increased to . ± . on the day of eol care decision. % patients had metastatic cancer. reasons for initiating eol care were refractory acute illness in %, advanced cancer in %, brain death in %, and lack of finances in %. eol discussions were initiated by the family in %, and by the icu medical team in % patients. families wanted to take the patient home to die. the icu consultant was involved in all discussions with the family, the primary consultants in % and primary team residents in %. nurses were involved in only patients. agreement on eolc was reached after discussion in %, discussions in %, and discussions in % of cases. documentation of the eol care process was not done in % cases. withholding of life support (wh) was practised in / patients ( %) and withdrawal of life support (wd) in %. intubation was withheld in . % patients, cardiopulmonary resuscitation in %, inotropes in % and dialysis in %. regarding wd, only / patients were extubated and the ventilator withdrawn in another / patients. inotropes were withdrawn in patients ( %). reduction of fio . without discontinuing mechanical ventilation was the commonest mode of wd, in patients ( %). all patients received morphine infusions during lols/wols. family members were present by the bedside in % cases. conclusions. wh is preferred over wd. documentation of the eol process does not occur in a significant proportion of cases. nurses are rarely involved in the eol care decision making process. legal issues may be barriers to good eolc in our icu, and perhaps in india. objectives. to know the point of view of the staff is essential to understand their beliefs, attitudes and decisions. brazilian private general icu with beds. the following items were analyzed: profile of the interviewed; their opinion about end of life questions: fear of death, fear of experience pain before death, the best place to die, advanced directives, decision-making process, therapeutic withhold of mechanical ventilation, nutrition, fluid management, antibiotics, vasoactives drugs, sedation and analgesia in patients which death is imminent and irreversible. results. about . % of our icu team answered the research (n = ). the mean age is . years (sd . ), . % of female, . % married, . % protestants and . % catholics and icu professional experience of . years (sd . ). using a visual analog scale ( , no fear to , the worst fear possible) the team pointed . as their fear of death; the fear of suffering pain before death was . . for . % of the responders, the best way to die would be with their lovely ones, no matter if at home or at hospital. only . % would prefer to die an icu. the majority of the team ( . %) would share the eol decision-making process with the family instead only by the medical staff ( . %). about . % would leave an advanced directive with their therapeutic preferences like do not resuscitation orders. the icu team agreed on the withdrawal of vasoactives drugs ( . %), antibiotics ( . %), nutrition ( . %) and mechanical ventilation ( . %) in patients out of treatment. our results showed the staff vision about their own death and their opinion about the end-of-life care issues. in developing country as brazil there is a still gap between everyday practice and the current legislation. fortunately, the debate about eol issues has increased in last years. the end-of-life discussions and decisions should begin by respect to points of view of all involved: patients, family, medical staffs with a legal support of the society's beliefs and expectations. prospective observational study conducted in greek multidisciplinary icus. we studied all consecutive icu patients who died, excluding those who stayed in the icu \ h or were diagnosed with brain death. patients comprised the study population [mean age ± (sd) years, mean apache ii score on admission ± ]. results. of patients studied, % received full support including unsuccessful cardiopulmonary resuscitation (cpr). % died after withholding of cpr, % after withholding of other treatment modalities besides cpr, and % after withdrawal of treatment. patients in whom therapy was limited had a longer hospital (p = . ) and icu (p \ . ) stay, a lower admission gcs score (p \ . ), a higher apache ii score h prior to death (p \ . ), and were more likely to be admitted with a neurological diagnosis (p \ . ). patients who received full support were more likely to be admitted with either a cardiovascular (p = . ) or trauma diagnosis (p = . ), and to be surgical rather than medical (p = . ). the most important factors affecting the physician's decision to provide full support were reversibility of illness and prognostic uncertainty; the physician's religious beliefs and legal concerns had minimal impact. the main factors guiding the decision to limit therapy were unresponsiveness to treatment already provided, prognosis of underlying chronic disease, and prognosis of acute disorder; old age was not a determinant, while economic cost and lack of icu beds seem to play no role. relatives' participation in decision-making occurred in % of cases and was more frequent when a decision to provide full support was made (p \ . ). the principal reason for not discussing end-of-life dilemmas with relatives was the fact that the family was thought not to understand ( %) advance directives were rare ( %). icus. however, in a large majority of cases, it involves the withholding of cpr only. withholding of other therapies besides cpr and withdrawal of support are infrequent. physician has a dominant role in decision-making. objectives. the primary objective of this study is to determine the prevalence of inappropriate or non-beneficial care in icu patients as perceived by their icu healthcare providers, as well as the reasons for this perception. second, we want to determine which factors are associated with the perception of inappropriate care. a descriptive survey design is used. a single-day cross-sectional evaluation of perceptions of inappropriate care among , icu healthcare providers in icu centres in european countries will take place on may th . questionnaires will be administered to icu healthcare providers (nurses, head nurses, junior and senior icu physicians) providing bedside care to adult icu patients on that particular day. in this study, inappropriate care is defined as a patient care situation that is similar to one or more of seven scenarios. these scenarios were created based on the literature and a multidisciplinary conference attended by experts in intensive care, geriatrics, and palliative care. . the cross-sectional study will take place on may th . preliminary results will be given at the esicm conference. we have designed a one-day cross-sectional study to record inappropriate or non-beneficial care in european icu's. results will be available for the esicm conference. grant since the introduction of the mental capacity act in the uk in , the impact within research in the intensive care environment has not been elucidated. since many of the patients are incapacitated and therefore unable to consent, it is now stipulated by the ethics committee that the researcher must make reasonable attempts to identify a consultee, failing this, nominate a person unrelated to the research project to be consulted. in order to comply with the mental capacity act, retrospective consent must be obtained, once the patient regains capacity. objectives. the aim of the study was to highlight the difficulties in obtaining retrospective consent, evaluate the methods used and demonstrate the adaptations made to increase retrospective consents. methods. this explorative analysis investigated the process of obtaining consent in patients enrolled in an observational study on critically ill patients. consent was obtained on admission if the patient had capacity. assent from the patient's next of kin or a legal professional representative was obtained before enrolment in patients who lacked capacity. after discharge from icu, a member of the research team re-visited these patients to explain their involvement in the research, its purpose, procedures, implications and any further participation required by the subject. at this point, the patient could consent or withdraw from the study. if the patient decided to withdraw from the study, all data collected and samples stored were destroyed. the researcher visited the patient for a minimum of two visits; firstly to explain the study; secondly to establish if the patient has retained the information and to gain retrospective consent. results. patients were recruited within the time period of which ( . %) died. in ( . %), consent was obtained on admission as the patients had capacity, ( . %) were discharged prior to obtaining retrospective consent, ( %) lacked capacity on the researcher's visits, and patient ( . %) withdrew from the study. patients ( . %) were successfully consented retrospectively. overall, the researchers performed visits to obtain from the patients for whom retrospective consent was required. conclusions. the process of recruiting patients who lack capacity within the intensive care unit is challenging and time consuming. stipulations set by the ethics committee to seek retrospective consent once the patient has regained capacity, has a major impact on research staff time and finances. detailed recommendations as well as guidelines how to assess capacity in the post-icu patient and how the assessment of capacity has to be applied to intensive care research are needed to fully comply with ethical and legal requirements. objectives. we wanted to know if patients expressed to surrogate decision makers, after icu discharge, specific resuscitation directives, and we have investigated any factors related to the patients and their illness or care process that might be associated with this. we reviewed patients admitted in the icu between december and may . a random sample of survivor patients has been defined. seven patients were excluded ( for language barrier, died, were no more reachable). fifty three patients took part in semistructured interview at - month post icu discharge. the questionnaire discussed in detail the aspects of advance directives. patients had also completed a quality of life questionnaire (euroqol d), and we calculated the eq- d visual analog scale. we reviewed medical records in icu data base: age, gender, length of stay, saps ii, bmi, length of ventilator support and central venous catheterization as well as prescription of transfusion, hemodialysis or adrenergic agonist. multivariate logistic regression was practiced to investigate any factor associated to expression of specific resuscitation directives after icu discharge. after icu discharge, % of interviewed survivors expressed specific resuscitation directives to an appropriate identified surrogate (written ''living will'' or oral statement). eq- d visual analog scale was ± . on multivariate regression analysis, only one studied variable was significantly associated to the post-icu expression of specific resuscitation directives: age (odds ratio = . , z = - . , p = . ). conclusions. after icu discharge, a majority of our patients expressed to surrogate decision makers specific resuscitation directives, especially the younger patients. our findings suggest that surviving to icu is an opportunity to specify oral or written directive, and both may help to illuminate future decision making from the patient's perspective. objectives. to explore the issues around eolc provision for cancer patients in a critical care unit through family, professional and patient experiences. to explore how a diagnosis of cancer impacts upon eolc provision for critically ill patients. a heideggerian phenomenological interview approach was undertaken, in order to gain personal experiences. families of those patients who died after decisions to forgo lifesustaining treatment (dflsts) were interviewed. patients who were seriously critically ill (apache ii [ or had received cpr) who experienced critical care were also interviewed, since patients' views about eolc provision are very rarely explored. doctors and nurses also contribute their vision for, and experiences of, eolc in a cancer critical care unit. thirty seven participants were interviewed. tensions between treating families versus treating patients impacted on timeliness of eolc. achieving a good death was possible through caring activities that made best use of technology to prevent prolonged dying. decision-making and eolc could be difficult to separate out which, in turn, affects prospects for eolc. three main themes included: dual prognostication; the meaning of decision-making; and care practices at eol: choreographing a good death. these themes outlined the essence of moving along a continuum toward patients' deaths and the impact that had on opportunities for care and a good death. conclusions. cancer affected the trajectory in unexpected ways. the trajectory could be very quick, especially in unexpected death and some newly diagnosed cancers. even in the face of a life-limiting and serious disease like cancer, death could be unexpected. the rapidity of trajectory related to cancer diagnosis, prognosis, withdrawal and patient demise significantly impacted on the potential for, and timing of, eolc. a sentiment of moving on from historical practices around critical care for cancer patients, and related poor prognoses, was overwhelmingly agreed on but important caveats in cancer prognostication remains. conclusions. these data suggest that oscillation settings of and hz provided more optimal pef/pif ratio ([ . ). our data also suggests that airway clearance using hfcwo may facilitate improved gas exchange in mechanically ventilated patients. further study is required to confirm these results grant acknowledgment. partial funding support in the form of devices was provided by hill-rom inc. a. esquinas , m. folgado , j. serrano hospital morales meseguer, intensive care unit, murcia, spain, hospital virgen de la concha, zamora, spain, hospital reina sofia córdoba, intensive care unit, cordoba, spain objectives: we hypothesized that the use of intrapulmonary percussive ventilation (ipv) could effect hypercapnia/acidosis and airway secretions control during treatment with noninvasive mechanical ventilation (nippv) in exacerbations of copd associated with bronchial secretions. prospective multicenter study. the study was performed in the medical icu of spanish university hospitals members of the spanish ipv working group. we enrolled copd exacerbation patients with secretions and the need for nippv in icu. criteria of exacerbations of copd are: a respiratory frequency c /min, a pao [ mmhg and ph b . . we define two ipv strategies as complementary treatment during nippv to evaluate the effects of ipv. strategy group i: nippv at first line and combination of ipv in early periods without nippv in spontaneous breathing and ph c . . strategy group ii: first line of ipv with mouthpiece/face mask and oxygenation previous to the application of nimv with ph \ . . in both groups daily sessions ipv were applied by for min/ day by mouthpiece or face mask during stay in icu. nippv was applied with bipap ventilator (respironics) and face mask with bipap mode. cardiopulmonary monitoring, clinical and arterial blood gases were evaluated. therapy was considered as successful when patients did not need nippv support and clinical and arterial blood gases returned to baseline. results. patients with copd exacerbation were admitted in icu for nimv, age ± years, male ( %) were excluded for severe hypoxemia (pao :fio b ) associated with pneumonia ( / ) and cardiac insufficiency ( / ). fifty patients were enrolled in the study. -up tilt-table rehabilitation better than sitting in a chair for ventilated adults in intensive care in terms of improving lung function? j. manners , a. thomas , s. boot , g. mandersloot barts and the london school of medicine and dentistry, london, uk physiotherapy intervention is a fundamental part of the patient stay in an intensive care unit (icu) and treatment is often aimed at maintaining/improving respiratory function. physiotherapists use the upright posture to elicit these improvements and sitting in a chair and standing with a tilt-table are commonly used interventions. to date there are no published reports comparing the efficacy of these interventions in ventilated subjects. • to compare the effects of these two positioning techniques employed with icu patients. • to measure changes in respiratory rate, tidal volume and minute volume during these positioning interventions. • to measure functional residual capacity during positioning interventions. • to measure the change in metabolic demand during positioning interventions. methods. convenience sampling of ventilated subjects meeting the inclusion criteria was employed. subjects acted as their own controls undergoing sitting in a trauma chair and standing on a tilt table at degrees in random order on the same day. respiratory rate (rr), tidal volume (v t ), ventilation (v e ) and oxygen consumption (vo ) were measured at minute intervals during baseline and intervention for min. functional residual capacity (frc) was measured once at rest and following each intervention. measurements were recorded using the ''e-covx'' module for the ''ge carestation ventilator''. results. subjects were recruited. no adverse events occurred during interventions. significant increases from baseline rr (p \ . ), v e (p \ . ) and vo (p = . ) occurred during the tilt table intervention. there was an increase in frc during tilting of . l which failed to reach significance. significant increases from baseline rr (p \ . ), vo (p = . ) and a decrease in v t (p = . ) occurred with the chair intervention. conclusions. these interventions are safe in a critical care population. increased muscular activity associated with upright interventions elicited expected elevations in vo . the tilt-table produced an increase in v e driven by an increased rr at the expense of v t . v e was not elevated during chair sitting despite an increased vo and was accompanied by an unexpected decrease in v t. introduction. uk guidelines about rehabilitation after critical illness highlight the need for outcome measures to determine patient progress and efficacy of treatment [ ] . there is no consensus about the most appropriate measures of patient function. the austoms [ ] tool was designed by therapists in australia to measure activity and function across nine scales assessing structural and functional difficulties and ability to perform activities. scales are split into four domains (impairment, activity limitation, participation restriction and distress/wellbeing) and scored from to with . intervals allowed. acceptable inter-rater variation is defined as an absolute difference of . . austoms has not been appraised in patients recovering from critical illness. objectives. to prospectively determine the inter-rater reliability of the austoms physiotherapy scales in adult patients who had undergone cardiothoracic surgery and required critical care admission for over days. methods. the therapy (physiotherapy and occupational therapy) team underwent a h teaching session using the austoms handbook prior to commencing the trial. austoms was then used over eight consecutive weeks during the weekly therapy goal setting meeting. each week a patient was selected to be scored using the most appropriate functional scales. the clinical history was presented to the team by the therapist leading the patient's care. therapists were then asked to independently score patients across the four domains for each scale. reasons underlying differences in scores were explored by group discussion. the difference between the th and th centiles of the initial scores was calculated for each domain as a measure of inter-rater variability. results. - therapists were present at each meeting. respiratory function and musculoskeletal movement related function were the most common scales used. the mean difference between th and th centiles was greater than . (± . ) for all domains. none of the scales/domains showed consistent inter-rater reliability over the week period. overall the activity limitation domains of each scale showed the least inter-rater variance of scores. clinical experience of therapist did not appear to influence scores. conclusions. the austoms outcome measure showed poor inter-rater reliability when evaluated over an week period on our intensive care unit. further work is ongoing to evaluate the ability of austoms to reveal changes over time when scored by therapists. introduction. uk guidelines on the rehabilitation of patients after critical illness highlight the importance of establishing and reviewing individualised rehabilitation goals for all patients that are at risk of developing physical and non-physical morbidity [ ] . our institution's practice is to create objective goals that are smart-specific, measurable, achievable, realistic and timed [ ] . objectives. the aim of this audit was to prospectively collect data regarding the setting of rehabilitation goals in a group of patients admitted to a cardiothoracic intensive care unit. methods. all consecutive patients admitted under the intensive care team in november were included. data regarding the timings of initial physiotherapy assessment, goal setting, and concomitant sedation were collected using a structured questionnaire completed by the treating physiotherapist. results. patients were admitted under the critical care team. patients were assessed by a physiotherapist within h of admission. of these , had smart goals set within a median of days of initial assessment (range - days). there was a correlation between level of consciousness and the number of days taken to set goals. patients who were fully conscious or drowsy on initial contact (n = ) had a smart goal set in a median of days. by contrast patients who were sedated/paralysed on initial assessment (n = ) had goals set in a median of days. initial goal setting did not include other therapists or the family. goals fell in to categories, range of movement, hoisting out to chair for periods of time, sitting on the edge of the bed, transferring out to the chair by standing and mobility goals-i.e. walking set distances. the maximal interval between reviews of the patients' goals was days. most patients had smart goals defined and regularly reviewed. however, despite physiotherapy assessment within h of admission, there was often a delay in setting these objective goals. the need for continuous sedation acted as a barrier to explicit setting of goals. the results emphasised the need to improve patient and family/carer involvement with initial goal setting in order to be compliant with uk standards. objectives. investigation of ems effects on muscle strength and exploration of issues in relation to handgrip dynamometry in icu patients. one hundred seventy two consecutive patients with apache ii score c , were randomly assigned to the ems (n = , age: ± years, apache ii: ± ) or the control (n = , age: ± years, apache ii: ± ) group. ems sessions applied daily in muscles of both lower extremities. the strength evaluation of various muscle groups of the upper and lower extremities was made clinically upon awakening with the mrc scale, ranging from to (normal strength) for each group. the same scale was also employed in the diagnosis of cipnm (mrc \ / ). a subgroup of these patients also performed handgrip dynamometry. results. fifty seven patients (ems: , control: ) were finally evaluated. ems patients scored higher than controls (p b . ) in wrist flexion, knee extension, ankle dorsiflexion and right side hip extension, while they tended to perform higher in all other muscle groups (p: . - . ) ( table ) . grant acknowledgment. this project has been co-financed by e.u. and the greek ministry of development. background. secretion removal is major aim of respiratory physiotherapy in intensive care. manual hyperinflation provides a tidal volume to the lungs that is greater than baseline. it is effective in secretion clearance and is frequently used [ , ] . there is a limited evidence that addressed the effects of combining rib-cage compression and suctioning on oxygenation, ventilation, and airway-secretion removal in mechanically ventilated patients [ ] . objectives. the aim of this study was to investigate the effects of manual hyperinflation administered in combination with expiratory rib-cage compression on lung compliance, gas exchange, and secretion clearance in mechanically ventilated patients. methods. twenty-two intubated, mechanically ventilated, and hemodynamically stable patients were studied. the patients received manual hyperinflation, with or without expiratory rib-cage compression, with a minimum -h interval between the two interventions. manual hyperinflation with or without expiratory rib-cage compression was performed for min before endotracheal suctioning. respiratory mechanics and hemodynamic variables were measured min before (baseline) and then and min after the interventions. arterial blood gases were determined min before (baseline) and min after the interventions. secretion clearance was measured as sputum weight. the two measurements were obtained on the same day. results. no significant differences were observed in gas exchange and secretion clearance between the two interventions (p [ . ). in each case, static lung compliance and tidal volume improved significantly at min post-intervention (p \ . ), whereas at min postintervention, only static lung compliance had improved significantly above baseline (p \ . ). our results suggest that the addition of expiratory rib-cage compression to manual hyperinflation does not improve lung compliance, gas exchange, or secretion clearance in mechanically ventilated critically ill patients. recently, there has been an interest in mobilization of acutely ill patients who are in an intensive care unit (icu). in the literature, the major safety issues while mobilizing critically ill patients has been outlined. cardiac reserve [(cr) (% of age predicted maximal heart rate)] and respiratory reserve [(rr), ratio of partial pressure of oxygen in arterial blood to the inspired fraction of oxygen (pao /fio )] are the important factors that can affect the ability to tolerate the mobilization. patient who has rr more than and cr lower than % is considered to have sufficient reserve to tolerate mobilization [ , ] . objectives. the aim of this study was to compare the effects of mobilization on respiratory and hemodynamic parameters in patients with sufficient and insufficient respiratory and/or cardiac reserve. mobilization events are divided into two groups (sufficient, insufficient) according to the pre-mobilization cr (sufficient, \ %; unsufficient, [ %) and rr (sufficient, [ ; insufficient, \ ). heart rate (hr), systolic/diastolic/mean arterial blood pressure (sbp, dbp, mabp), respiratory rate (rsr) and percutaneous oxygen saturation (spo ) were recorded from the monitor. respiratory and hemodynamic parameters were collected just prior to the mobilization, just after the completion of the mobilization when the patient had been returned the supine position and min of the recovery period and compared between the groups. a total of abdominal surgery patients ( male, female) received mobilization treatments in icu. the mean age was . years, mean body mass index (bmi) was . kg/m , mean apache ii score was . and mean icu stay was . days. mobilization events included ( %) sitting on the edge of the bed, ( %) standing, ( %) walking to chair and sitting in the chair. % ( ) of mobilization events had insufficient rr and % ( ) of mobilization events had sufficient rr. . % ( ) of mobilization events had insufficient cr and . % ( ) of mobilization events had sufficient cr. all respiratory and hemodynamic parameters were found similar in sufficient rr and insufficient rr group at all stages of the mobilizations (p [ . ). spo was higher, while hr and rsr was lower at all stages in sufficient cr group compared to insufficient cr group (p \ . ). resting hr and cr may affect the safety of mobilization, for this reason it is important to consider respiratory and hemodynamic parameters prior to and while mobilizing the icu patients. introduction. obesity is a chronic disease and a major health problem. obesity in critically ill patients is associated with a prolonged duration of mechanical ventilation and intensive care unit (icu) length of stay [ ] . objectives. the aim of this study was to investigate the effects of mobilization on respiratory and hemodynamic parameters in the critically ill obese patients. [ . kg/m )] were included as soon as their cardiorespiratory stability allowed mobilization protocol. mobilization was defined as sitting in the bed, sitting on the edge of the bed, standing, walking to chair and sitting in the chair. heart rate (hr), systolic/diastolic/mean arterial blood pressure (sbp/dbp/mabp), respiratory rate (rr) and percutaneous oxygen saturation (spo ) were recorded from the monitor. respiratory and hemodynamic parameters were collected just prior to the mobilization (supine position), just after the completion of the mobilization when the patient had been returned the supine position and min of the recovery period. all parameters were compared with initial values. the ratio of partial pressure of oxygen in arterial blood to the inspired fraction of oxygen (pao /fio ) was calculated from the arterial blood gas samples before and after the mobilization. introduction. the use of respiratory therapy for patients with a variety of lung disease is a standard in medical care [ ] , including in the intensive care unit (icu) setting [ ] . in this context, it is widely accepted the routine use of physical therapy in several situations in the intensive care, such as the care of critically ill patients not requiring ventilatory support, assistance during the postoperative recovery and the assistance to critically ill patients requiring ventilatory support [ ] . at present definitive recommendations cannot be made regarding the use of respiratory physiotherapy for decreasing relevant clinical outcomes in critical ill patients requiring mechanical ventilation. objectives. this study aimed to determine the impact of providing chest physiotherapy on the duration of mechanical ventilation, intensive care length of stay, intensive care and hospital mortality in mechanically ventilated patients. single-centre, randomized, controlled trial in a university hospital general intensive care unit (icu). were included in the study patients aged more than years, admitted to the icu needing mechanical ventilation for longer than h. physiotherapists provide group intervention (p) with the intensity and frequency of therapy they felt appropriate based on their assessment of the likely treatment benefit. control patients (group c) only received suctioning, decubitus care and general mobilization. results. primary outcomes were icu and hospital mortality regardless of the cause of death. secondary outcomes were length of icu and hospital stay, length of mechanical ventilation, weaning and extubation failure. patients in the p group more frequently achieved parameters to start weaning, but there were no significant differences between p and c groups on weaning and extubation failure, length of mechanical ventilation and length of icu stay. there was fewer hospital, but not icu, mortality in the p group. conclusions. we demonstrated that respiratory physiotherapy decrease hospital mortality and suggest that this effect was, in part, secondary to the effect of the intervention on weaning from mechanical ventilation. introduction. critical illness can cause diverse cerebral dysfunctions ranging from unconsciousness to minor cognitive impairments (mci). severe cerebral dysfunction, as delirium, is known to affect outcome after critical illness but it is uncertain whether minor impairments affect mortality or morbidity [ ] . objectives. the primary aim of this study was to estimate the incidence of mci in a group of general icu survivors immediately after icu stay and three and months after discharge. secondary we wanted to explore if type of cerebral dysfunction after icu discharge affected mortality and morbidity. methods. patients admitted to our general icu were included prospectively. we included patients. / ( %) were delerious and / ( %) were not delerious but had mmse \ after icu stay. of the patients with mmse c , were possible to classify as having mci or not. / ( %, % ci: - %) were found to have a mci after icu discharge. on and months these numbers were respectively: % ( % ci: - %) and % ( % ci: - to %) there was an increased risk of both death and being institutionalised at both and months regarding delirious patients and patients with mmse \ compared to patients with mmse [ . no such differences were found regarding patients with or without mci. (tables and ) . conclusions. the incidence of mci after critical illness is high on discharge but drops on and months after. severe cognitive impairments affect mortality and morbidity, but minor cognitive impairments do not. objectives. this study analyzes mid-term survival and risk factors associated with survival of patients undergoing cardiac surgery in son dureta hospital. methods. patients were consecutively operated from november to december . patients who were discharged alive from hospital were followed until december . we did kaplan-meier survival analysis and logistic regression study of variables associated with mid term mortality. results. in-hospital mortality was . % ( % ci: . - . %). information was available on , ( %) of , patients who survived until hospital discharge. at the end of the follow-up period, observed mortality was . % (ci %: . - . %). survival probability at , and years of follow-up was , and %, respectively. the mean time of follow-up was . years (range . - . ). patients c years showed a lower survival rate than patients \ years of age (log rank \ . ). age c years, history of severe ventricular dysfunction (ef \ %), diabetes mellitus, preoperative anemia and hospital stay were independently associated with mid-term mortality. conclusions. mid-term survival of patients alive after hospital discharge was very satisfactory. mid-term mortality varied according to age and several preoperative chronic diseases. a closed-ended questionnaire was developed by the nurse congress commission of the société de réanimation de langue française (srlf). an invitation to complete it online was sent by email to caregivers registered on the srlf push-list. results were analyzed by icu or by respondent. results. caregivers working in icus completed the questionnaire ( % were nurses, % were doctors, % were nurse's aides, % worked in adult icus and % in pediatric icus). % of adult icus (n = ) had unrestricted policy but % had a visiting time of less than h per day. at the opposite, % of pediatric icus (n = ) had unrestricted policies. % of the respondents working in icus with a visiting time \ h per day considered very useful or essential to enlarge visiting periods but % of them considered this enlargement as unhelpful. at the opposite, % of the respondents working in icus with unrestricted policy found very useful or essential to reduce visiting periods. % of caregivers working in icus with unrestricted policy but only % of caregivers working in other icus thought that an unrestricted policy was able to improve often or systematically the relations with families. moreover, only % of caregivers working in icus with unrestricted policy but % of caregivers working in other icus thought that an unrestricted policy disturbs the organization of care. % of respondents found very useful or essential to give information in a dedicated room whereas it was often or systematically done in only % of icus. identically, % of respondents found very useful or essential to give information to proxies with the patient's nurse whereas it was often or systematically done in only % of icus. some cares were often or systematically programmed for family participation in % of pediatric icus but in only . % of adult icus. indeed, proxies often or systematically participated in nursing in % of pediatric icus but never in adult icus. at the opposite, proxies often or systematically participated in tracheal aspirations in only % of pediatric icus and in . % of adult icus. conclusions. more than half of respondent's adult icus are closed but caregivers working in icus with unrestricted policy perceive it favorably. some improvements are also expected by caregivers on the use of dedicated rooms for information and on the participation of nurses in meetings with families. finally, participation of families to care is not a practice of french adult icu caregivers. methods. included: patients with dysfunction of two or more organs in the first h, admitted and discharged from icu during . excluded: neurocritical and politrauma patients. contact year following discharge; questions were asked concerning symptoms related to a period in intensive care that presented following discharge and which were not present prior to admission. in the case that the patient was not contacted, the next of kin was asked. results. patients included. general characteristics during admission to icu: % male; age . ± . years; sofa* ± . ; apache** ii . ± . ; apache** iv ± . ; length of stay in icu: . ± . days; . % were on invasive mechanical ventilation and . % on non-invasive mechanical ventilation. data collection was carried out over ± . months, on average months (range: - months). . % ( patients) had died at the time of contact. the person contacted was the patient in . % of the cases, the spouse in . % and immediate family (patient's parent/child/sibling) in . % of the cases. . % had difficulty sleeping following discharge from icu with an average time since discharge of . ± . months; . % suffered feelings of sadness and difficulty in finding enjoyment which had persisted for . ± . months; . % had experienced difficulty in concentrating over an average of . ± . months; . % had suffered some form of memory loss after discharge over an average period of . ± . months; . % presented with asthenia over an average of . ± . months; . % had arthromyalgia over a period of . ± . months; . % had experienced changes in appetite over an average of . ± months; . % had changes in intestinal habit over an average of . ± months; of which . % had diarrhoea, . % constipation, and . % both symptoms; . % presented with headache over a period of . ± . months; . % had tremors, that had not previously been present, over an average of ± . months; . % had experienced reduced vision, over an average period of . ± . months; . % presented with speech/ language problems, over an average period of . ± . months; . % exhibited newly presenting changes in micturition, over ± . months. another less frequently occurring symptom was loss of hearing ( . %). conclusions. severely ill patients that are admitted to icu frequently present with ''residual'' symptomatology following discharge, most notably arthromyalgia and asthenia. many of these conditions persist for months. intensive care unit (icu) readmission rates range from to %, in spite of initial recovery from critical illness. previous researches report that the revised acute physiology and chronic healthy evaluation (apache ii) score at either admission or discharge is an important predictor for readmission after icu discharge. however, there are a few papers concerning the association of discharge apache ii score with readmission after discharge from surgical intensive care unit. objective. we compared the ability of the discharge apache ii score with that of the admission apache ii score in predicting readmission, especially early readmission within h, after discharge from icu. conclusion. this study showed that both discharge apache ii score and admission apache ii score are useful predictors for readmission after icu discharge, but discharge apache ii score is only independent factor in predicting early readmission within h after icu discharge. introduction. health related quality of life (hrqol) is decreased in former icu patients. in research outside the intensive care field it is well known that the psychosocial factors, coping strategies and perceived hopelessness affect hrqol. however, the influence of coping and hopelessness on hrqol after intensive care is unknown. objective. the aim of this study was to examine how coping strategies and perceived hopelessness among former icu patients compares to corresponding in a reference group. we also evaluated the effect of coping and hopelessness and icu related factors on hrqol. methods. prospective, multicenter study in three mixed icu's in sweden. patient demographics, length of stay, apache ii score, reason for admission and time on ventilator were collected for all adult patients. questionnaires, including the coping instrument pearling-schooler mastery scale (pms), the -item hopelessness scale, sf- , demographic data and previous illnesses were sent months after discharge from hospital to the patients. the reference group (n = , ) was a random selection of persons from the same catchment area as the study patients. . ( %) icu-patients, - years, returned the questionnaires. the patients reported significantly lower mean scores in coping . (sd . , p \ . ) and higher perceived hopelessness . conclusions. this study indicates that coping strategies and perceived hopelessness are important for the hrqol of previous icu patients. however, the magnitude of these effects are smaller than that of pre-existing diseases. introduction. mortality on a medical intensive care unit (icu) is estimated to occur in about % of patients. its association with age, severity of illness and comorbidities is well established. for other diseases like coronary artery disease it has been shown that pre-existing depression is a risk factor for worse outcome. the role of depression regarding the outcome of icu patients has not been investigated so far. we studied the association between pre-existing depression and mortality in medical icu patients and present preliminary data of this ongoing study. objectives. assessment of a possible association between mortality of icu patients and prevalent depressive mood at time of icu admission. the primary endpoint was -day mortality. methods. prospective cohort study. all patients admitted to a medical -bed icu in a university hospital, older than years, were eligible. postoperative patients and patients who had an expected length of stay below h (survey) were excluded. patients whose cognitive function allowed appropriate comprehension and response answered the hospital anxiety and depression scale (had). prevalent depressive mood at admission was defined by a score c in the depression dimension. all other patients were assessed by observer rating by next-ofkin. in this case the hammond scale, a validated instrument for observer rating of depressive mood (cut-off c ), and a modified version of the had for observer rating (cut-off c ) were used. in addition apache ii, saps ii, sofa, age, sex, comorbidities, reason for admission, length of icu stay and ventilator days were recorded. . by now patients had complete follow up data. of these patients ( %) were classified to have depressive mood at icu admission. in total patients had died by day ( %). the -day mortality was % ( / ) in patients with depressive mood and % ( / ) in patients without (p = . ). patients with and without depressive mood did not differ with respect to age, sex, apache ii, saps ii or sofa score at admission. multiple logistic regression analysis with -day mortality as the dependent variable revealed that prevalent depressive mood at the time of icu admission was an independent risk factor for mortality (table ) . conclusions. pre-existing depressive mood is an independent risk factor for mortality in medical icu patients. introduction. some classical post-icu discharge predictors of death are described, such as age, severity of disease and level of nursing care [ ] . besides these factors, some laboratorial data at icu discharge are potential predictors of post-icu death. objectives. the aim of this study was to investigate whether standard base excess (sbe), ph, lactate, hemoglobin level, creatinine, platelets, leukocytes and albumin at the icu discharge as well as the % decrease on c-reactive protein concentrations (crp [ %) from the day pre-icu discharge to the day of icu discharge may be useful predictors of in-hospital outcome. patients discharged from the icu after at least h of stay were retrieved from our prospective collected data base. a multivariate analysis was performed using a backward-lr binary logistic model taking in-hospital death as a dependent variable and the cited data as independent variables. results. patients were retrieved. the average age was ± years old, mean apache ii score was ± , and the main causes of admission were septic syndromes and respiratory failure. the in-hospital mortality after icu discharge was %. the icu length of stay was ± days. at the time of icu discharge ph was . ± . , sbe was - . ± . mmol/l, lactate was . ± . mmol/l, hemoglobin . ± . , creatinine was . ± . g/dl, albumin was . ± . g/dl, platelets was , ± , /mm , leukocytes was , ± , cells/mm and the number of patients who lowered crp at least % were ( % conclusions. this study demonstrated that sbe, lactate, hemoglobin and albumin concentrations on the day of icu discharge are independent predictors of in-hospital mortality. moreover, the reduction on crp levels above % in the last h of icu stay is a strong predictor of better in-hospital clinical outcome. we suggest that these variables together with the clinical judgment may be taken into account on the icu discharge decision process. readmissions to the intensive care unit (icu) are usually associated with increased morbidity and mortality, and they may evidence the quality of patients' care. the risk for icu readmission varies across studies, and is generally analyzed just before icu discharge, leading to deviation of icu team and patients' daily goals. early prediction may improve the care for patients in risk for icu readmission, and help developing mechanisms for its prevention. objectives. to analyse risk factors for readmission in intensive care unit looking at the first h data after unit admission. methods. the first intensive care unit admission of patients was analyzed from january to december in a medical-surgical unit. readmission to the unit was considered those during the same hospital stay or within months after intensive care unit discharge. deaths during the first admission were excluded. demographic data, acute illness and comorbidity prognostic scores, and use of mechanical ventilation were submitted to uni and multivariate analysis for readmission. numeric variables were expressed as median or percentage. conclusions. age, medical admission, sofa score and respiratory-and/or sepsisrelated admission are early associated with increased icu readmission risk. objectives. the aim of this study was to examine patient perceived hrqol in former icu patients that die in the period from month up to years after discharge from intensive care unit and the hospital. methods. prospective, multicenter study in three mixed icu's in sweden. questionnaires, including hrqol (sf- ), demographic data and previous illnesses, were sent out six, , and months after discharge to all former adult icu patients. data for this study were only collected among those dying before the months post-icu follow-up. of the patients who returned the questionnaires ( . %) died, ( . %) between and months, ( . %) between and months, and ( . %) between and months. the most frequent admission diagnoses were respiratory problems n = ( . %) and gastrointestinal diseases n = ( . %). examining hrqol in the former icu patients the following observations were made: (see fig. ). a pronounced and quantitatively large decrease in hrqol is seen for the surviving patients with pre-existing disease as compare to the previously healthy survivors. although already at a very low value further decreases in hrqol for the patients dying before years post icu is significantly less as compared to the icu patients with pre-existing disease that survives. the decrease is mainly in physical function, role physical function and role emotional function (marked in the figure). conclusions. yes, health related quality of life is extensively affected, mainly in the dimensions physical function, role physical function and role emotional function. importantly, in these two affected physical dimensions a shorter time to death increases such a decrease. the finding further stresses the importance of pre-existing diseases for the final hrqol outcome of former icu patients. introduction. despite initial recovery from critical illness requiring icu admission, many patients remain at risk of subsequent deterioration and death [ ] . recent studies have shown readmission rates ranging between and % [ ] ; this population had mortality rates six times higher and were eleven times more likely to die in hospital [ ] . . to calculate the readmission rate in our mixed icu unit over a months period . to identify risk factors associated with readmission into the icu . to study the outcomes of these readmissions methods. a retrospective observational study, data was collected from an icu computer database (metavision) and analysed manually results. the total number of admissions in this period was , average patient age was ± with . % being males. readmissions constituted . % of the total admissions with . % of those readmitted within h of their initial discharge. % of the initial discharges from the unit were made out of hours i.e. unplanned, presumably due to heavy demand on beds. readmissions were particularly associated with patients discharged to surgical wards . % and the hepatobiliary hdu . %, the latter might reflect the proportion of that particular patients population received. . % of the readmissions required to stay h or less in icu. the overall mortality of the patients requiring more than one admission in this months period was . %. there is an urgent need for expanding icu services in our hospital, i.e. extra beds, staff, outreach teams, etc in addition to investing in nursing capacity building especially in surgical wards. we agree with others studies that compared with the general population, icu survivors report lower hrqol. moreover, a relationship between several factors like sepsis, renal failure, sofa (first and second day score), critical illness polyneuropathy, mechanical ventilation, sedation time, previous psychiatric history and blood products transfusions were found in our study population. conclusions. according to our data, subclavian vein was the most common insertion site used, especially as nd and rd placement and was related with the lower incidence of becteremia episodes. although the risk of placing a cvc for inflection complications is against the risk for mechanical complications, we have to improve our cvc policy, preferring the subclavian or the jugular site of insertion, in order to minimize the infection risk for a nontunneled cvc. objectives. objectives for this study were to determinate the frequency and the risk factors associated with bos. secondarily, we searched several variables as civil status, age, sex, work seniority as potential risk factors. inclusion criteria were to work in critical care unit (ccu) the hospital clínico universidad de chile (hcuch). this unit included subunits: intensive care unit (icu), middle care unit (mcu). the mbi Ò instrument was applied between april to july of . all staff of ccu were asked to response the instrument. as previously reported, bos was defined with high ee, high dp and low pa. risk of bos was anything of the three dimensions positive for bos. we gave information on specifics objectives and the schedule of a future intervention programme. for analysis, comparisons were made based on student t test, chi-square test with yates corrections or fisher exact test as corresponded. for all tests we used confidence interval % with p \ . . a total of mbi Ò tests that included all sub-units in ccu. this is a % of all personal working in the ccu. bos was found in . % of cases. women ( %), unmarried ( %), with an average of age . years old. ( - years old) and with a work seniority younger than years ( %). ee is high ( . %), for nurse and paramedical personals. dp was . and . % to middle level, for nurse and medical doctor, and low pa in % for paramedical personal, with longer work seniority (more than years). risk factors were female gender, unmarried status, childless, middle aged ( - years old) and recent start in the job (stay younger than years). introduction. burnout is a prolonged response to chronic emotional and interpersonal stressors on the job, and is defined by three dimensions: exhaustion, cynism (depersonalization), and inefficacy. icu physicians are exposed to several stress factors and are particularly predisposed to this syndrome. to describe the prevalence of burnout syndrome among intensivists and its relation to their quality of life. methods. an epidemiological cross-sectional survey conducted to evaluate all adult icu physicians in salvador, ba (brazil), from october to december . the quality of life and burnout syndrome were evaluated respectively by the whoqol-bref instrument and the maslach burnout inventory (mbi). burnout was classified into low, moderate and high levels for the three studied dimensions, according the mbi classification, and it was defined by the presence of a high level in at least one dimension. the quality of life was evaluated in four domains: physical, psychological, social relationships and environment, graduated from to , with higher scores denoting higher quality-of-life. [ ] ) has been successfully used to measure nursing workload on an intensive care unit over a -h period. in contrast to intensive care, the nursing care workload on mc is not evenly spread over a twenty four period, but tends to vary between shifts. objectives. the aims of this pilot study were ( ) to assess the fitness of nas as an accurate reflection of nursing workload on an mc unit. ( ) to determine the nursing work load, per patient, per h shift. prior to the commencement of the study all thirty one nurses taking part received instruction in the content and registration of nas. at the end of each h shift, each nurse retrospectively scored their patient(s) using nas. this consists of a check list containing twenty three items giving a possible score between and , where equates to . full time equivalent (fte) intensive care nurse. the nas were entered in to a database and the average scores, per patient, per shift were calculated. three hundred patients were retrospectively scored over a -month period in october and november . not all patients were scored on all three shifts as some patients had been transferred out of the unit before shift end. in addition any incorrectly completed forms were discarded and excluded from the study. methods. this multicenter pilot study included doctors working at (pediatric) intensive care units (icu). subjects were randomly assigned to two groups: one was first tested during day, then during night, while the other was tested in reverse order. the d test of attention [ ] was used to assess attentional performance. total performance (tn-f) score, standardized for age and level of education, was used to express attentional performance. subjective, -to- scores were gathered in two questionnaires. results. figure displays standardized total performance scores of doctors. measured attentional performance showed high intra-and interpersonal variability and did not differ between both shifts (p [ . ). in contrast, doctors expected alertness to be decreased ( . ± . and . ± . (mean ± sd) on subjective -to- scale during day and night shifts, respectively; p \ . ) and the chance of making errors to increase (from . ± . to . ± . (mean ± sd); p \ . ) during night shifts. conclusions. physicians working at icu are aware of the risk of making errors during night shifts. however, we showed that doctors perform equally during night and daytime when confronted with a short-time challenging task. consequently, a discrepancy between measured attentional performance and expected alertness was observed. these results suggest nocturnal alertness might be comparable to daytime during short-lasting tasks that elicit a high level of stress and motivation (e.g. testing, medical emergency). further research is needed to elucidate if longlasting (routine) tasks reflect decreased sustained attention and contribute to medical errors. we studied physicians, the majority of whom were male ( %). mean age and time since graduation were . and years, respectively. high levels of emotional exhaustion, depersonalization, and reduced personal accomplishment were found in . , . , and . %, respectively. prevalence of burnout syndrome, defined as a high score in at least one dimension, was . %, while prevalence was . % for all three dimensions. in conclusion, burnout syndrome was common in this sample of icu physicians. aims. our goal was to assess the physician's opinion about potential competencies of a triage nurse. a representative cross sectional study design was applied with self-fill-in questionnaire about physician's attitude related to skills of triage nurses. the questionnaires were distributed between september and november in (out of ) eds. in this survey physicians' questionnaires were processed. chi-square and student-t test was used for comparison of variables. p values less than . were considered statistically significant. results. . % of physician would support the special training of triage nurse. . % of physician suggests that the nurses use the patient's physical examination regularly in eds. the full time (ft) emergency physician significantly would reduce the basic competencies of nursing (e.g. dressing, feeding of patient, p = . , and p \ . , respectively) than parttime (pt) emergency physicians. significantly greater part of the ft physician would widen the competency of triage nurses in the field of physical examination of nervous system (p \ . ) and cardiovascular system (p = . ) than the pt physician. conclusion. hungarian emergency physician would widen the competency of triage nurse, but only half of physician would like to that nurses apply physical patient examination in practice. the full time physician would give more competencies for triage nurse than part time ones, but the final field of competency will be depended on other factors. healthcare-associated infections (hcai) are estimated to affect . million people worldwide, causing longer hospital stay, increasing hospital costs and excess mortality [ ] . hand hygiene represents the single most effective way to prevent healthcareassociated infections. compliance with hand hygiene amongst healthcare workers (hcw) has been demonstrated to be quite low at % [ ] . to quantify the degree of compliance to hand hygiene norms in the icu and to assess the short term success of strategies to improve hand hygiene compliance. setting. bedded medical-surgical icu in a tertiary care centre. design. prospective observational. method. unobtrusive observer (single person). observed over sessions of h. the compliance was calculated as :number of times the staff performed hand hygiene/number of hand hygiene opportunities. the number of hand hygiene opportunities was based on the who tools [ ] : before touching a patient, before clean/aseptic procedures, after body fluid exposure risk, after touching a patient and after touching patient surroundings. introduction. icu delirium represents a form of brain dysfunction that in many cohorts has been diagnosed in - % of patients receiving mechanical ventilation. delirium is a common but complex clinical syndrome characterized by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course and is associated with poor outcomes. and yet, it can be diagnosed and treated. in the uk, reporting of delirium is generally considered to be poor. in light of updated nice guidelines on delirium due out this year, specialist clinical assessment will soon become gold standard as a means of diagnosing and reducing the prevalence of this condition in the icu setting. nice recommends that cam-icu (confusion assessment method) be used by healthcare professionals who are trained and competent in the diagnosis of delirium. on our -bed unit, we are currently implementing cam-icu assessments to be performed twice daily (at the commencement of each nursing shift) as well as rass (richmond agitation and sedation scale) scoring on an hourly basis for all patients. objectives. to implement training of all our icu nursing staff in the use of cam-icu and rass scoring. to periodically validate and reinforce earlier training, so as to improve assessment and reporting of delirium. methods. our 'delirium group' comprising both nursing and medical staff, taught cam-icu and rass to staff members using multimedia presentations in small groups and/or individual teaching sessions over weeks. scoringofcam-icu andrasswassubsequentlyauditedon occasions post training. discrepancies were discussed and post-audit retraining provided where necessary. results. the following audit and validation data were generated on our unit as documented in table . no statistical analysis was undertaken. we anticipate focusing on the challenges encountered and strategies used in managing this change in our icu practice. methods. the factors causing resistance to change based on multisource data. qualitative technical methods were used: brainstorming and focal groups. the data collection elaboration was created by the collaboration of icu nurse, quality department nurse and external reviewers. finally, the main factors were classified in different categories. each category was scored by to according to gravity and prevention possibility. finally, priority was given to more serious and easier prevention problems. results. the most serious problems for icu professional was the historical factors. the easier solution problems were ''the lack of information'' and all evaluators were agree with it. we arranged the factors in order to the next classification (tables and ). discussion. all investigators were agreed with the low importance of problems with payments and low prevention probability of low organisational flexibility, so they were agreed on not to work about them. the icu professionals were more pessimistic and have lower confidence in prevention possibilities but they showed more confidence about the capacity to learn new skills. they weren't worried about resistance to do experimental things. probably, historic factors play an important role in this pessimistic attitude. on the other side, quality and safety experts have more experience in prevention programs and they put all their trust in its. after doing the analysis, we chose the ''lack of information problem'' to plan prevention activities. we consider it is a serious and real problem but at the same time, easy of prevent. conclusions. the implementation of the patient safety program in the icu means a real cultural change. the priority analysis could help to plan strategies in order to avoid the program failure. objectives. we concerned about whether medical personnel could recognize management of the cuff of artificial airway or not. we asked to doctors and nurses working in intensive care unit of konyang university hospital, daejeon, republic of korea. we asked questions with contents of questionnaire that was composed of methods of set initially, maintenance and appropriate pressure of cuff. results. of medical personnel replied to us. most of them had worked in intensive care unit, so they had placed of artificial airway. . % of them used manometer to adjust the cuff. we could find that nurses had more cognition compared to doctors for it ( vs. %). only . % of doctors described pressure of the cuff in medical record. of medical personnel replied that they knew the appropriate range of cuff pressure. % ( / ) of them replied that the range of cuff pressure was kept with - mmhg and % ( / ) was - mmhg. % of nurses in the icu knew that range of cuff pressure was - mmhg. most of them knew complications of high and low pressure of the cuff. . % of medical personnel monitored the cuff balloon during receiving mechanical ventilation and they used manometer to adjust it. % of nurses knew that the cuff should be adjusted continuously, but % of doctors did. interval measuring the cuff pressure was % of once a day, % of three times a day, % of more than four times a day conclusions. most of the medical personnel knew to keep appropriate cuff balloon to prevent various complications of artificial airway. they had insufficient cognition about maintaining the cuff balloon and appropriate level of cuff pressure. that was more prominent in doctors than nurses interhospital transfer is occasionally required as a consequence of limited therapeutic options or because of a need for a higher intensity of medical care that cannot be given in rural intensive care units. along with the potential benefit for the to be transferred patient, transport may also lead to hemodynamic and pulmonary deterioration. in order to minimize additional risk of interhospital transport of critically ill patients, a mobile intensive care unit with a specialized retrieval team was established in our university hospital-based intensive care unit. from march , transport of the critically ill patients in our adherence region are performed by micu. objectives. in this prospective audit adverse events and patient stability during micu transfers were assessed and compared to our previous data on transfers performed by standard ambulance [ ] . results. interhospital transfers over a -month period were evaluated. systolic blood pressure, glucose and haemoglobin were significantly different at arrival compared to departure, although never significant values for major deterioration were reached. an increase of total number of variables beyond threshold at arrival was found in % of patients, percent exhibited a decrease of one or more variables beyond threshold and thirty percent showed an equal number of trespassed thresholds. there was no correlation between the patients status at arrival and the duration of transfer or severity of disease. icu mortality was %. compared to standard ambulance transfers of icu patients performed in , there were far less adverse events: . vs. %, which in the current study were merely caused by technical (and not medical) problems. although mean apache ii score was significantly higher, patients transferred by micu showed less deterioration in pulmonary parameters during transfer than patients transferred by standard ambulance. conclusion. transfer by micu imposes less risk to critically ill patients compared to transfer performed by standard ambulance and has therefore resulted in an improvement of quality of interhospital transport of icu patients. introduction. previous studies in adult intensive care units (icus) reported rates of pre-mortem to post-mortem discrepancies ranging between and % depending on the population studied. and, most of them were retrospective studies, which included small number of patients. to compare clinical and pathological diagnoses and to determine the types of errors in a large and multidisciplinary icu-patient population. we conducted a prospective study of all consecutive autopsies performed on patients who died in the icu of the hospital universitario de getafe, madrid, spain, between january and december . the diagnostic errors were classified in two categories: class i errors that were major misdiagnoses with direct impact on therapy, and class ii diagnostic errors which comprised major unexpected findings that probably would not have changed therapy. conclusions. this study found significant discrepancies between clinical diagnoses before death and post-mortem findings. this reinforces the importance of the post-mortem examination in detecting otherwise unexpected diagnoses and improving the quality of care of critically ill patients. introduction. unplanned extubation is associated to a high risk of reintubation end correlates with increased risk of nosocomial pneumonia. on the other hand, reintubation significantly increases morbidity and mortality in critical ill patients, increasing the incidence of ventilator associated pneumonia (vap) rate and makes the airway management risky. objectives. the aim of our study was to test the rate of unplanned extubation as well as the reintubation rate in our icu, in order to evaluate the efficiency of our airway and weaning time protocols. methods. during a nearly year's period, patients admitted to the icu, mean age: . years, mean apache ii score: . , mean los: . days, with predicted and actual mortality: . and . % respectively. from these, were intubated and included retrospectively in our study. patients were extubated, while the others either underwent bedside percutaneous tracheostomy or died. we concerned that the number of days of mechanical ventilation were about equal to the number of days of intubation. reintubation was defined as the need to reintubate during the first h after extubation. we recorded four episodes of unplanned extubation. three of them caused by malfunction of the tube due to secretions and airway obstruction and one of them was undesired extubation caused by the patient himself. the total number of days of intubation was , , mean ± sd: . ± . , min: , max: days. therefore the rate of unplanned extubation was . %, while the standard limit is below %. the total number of reintubations was , while the total number of scheduled extubations was . therefore, the reintubation rate was . %, while the standard limit is below %. conclusions.the recorded rate of unplanned extubation was low in our icu patients, below the acceptable limit, assuming that our sedation and airway management policy is effective. on the other hand, the recorded rate of reintubation was high in our study, above the acceptable limit. although a low rate of reintubation might indicate excessively long mechanical ventilation times, this did not recorded to our study. nevertheless, our data suggest that we have to improve further our weaning time protocols, making the extubation procedure safer, and avoiding risk factors for vap. . pvs such as inappropriate enrollment of patients with a contraindication to the study treatment may lead to excess harm in the active intervention group [ ] and failure to deliver the study intervention according to the study protocol may underestimate true treatment efficacy [ ] . full reporting of pvs may aid in the interpretation of rct results however there are no published reviews on this topic [ ] . objectives. to determine reporting rates for key types of pvs and to investigate study characteristics that may be related to reporting. publications were excluded because they were subgroup or economic analyses of a previously published rct [ ] , not a rct [ ] , not published in the target journal [ ] , systematic reviews [ ] , or other reason [ ] . median trial size was participants (range: to , ). / ( %) of rcts were single centre, / ( %) were industry funded and / ( %) reported negative findings. overall / ( %) of rcts reported some form of pv, these included: / ( %) patient compliance; / ( %) discontinuation of study intervention due to safety; / ( %) study intervention-related researcher error; / ( %) inappropriate enrollment and; / ( %) technical errors in randomisation. multi-centre rcts may be more likely to report study intervention-related researcher errors ( % of multi-centre trials vs. % of single centre trials, p = . ). academic trials were less likely to report discontinuation of study intervention due to patient safety ( % of academic trials vs. % of industry trials, p = . ) and were less likely to report technical errors in randomization ( % of academic trials vs. % of industry trials, p = . ). conclusions. multi-centre trials are accepted to be organizationally complex. on-site education may be required to reduce errors in study intervention delivery attributable to the research team. it is possible the apparent excess harm attributable to industry trials is a reporting artifact however, if it is real, it must be addressed. additional research is required to investigate patient safety-related pvs and technical randomization errors, which may be lower in academic trials. to determine the occurrence of harmless incidents and ae related to physician's competences in icus, disclosing their potential risk factors. conclusions. this prospective study was essential to identify the proportion of our icu admissions affected by md-inc and md-ae, disclosing their nature. our md-ae rates, affecting more than % of admissions, were higher than those described in prior general studies, including not only icus. among the detected md-ae, hypoglycemic episodes not related to insulin administration predominated, indicating important deficiencies regarding nutritional support. severity on admission and length of stay were important risk factors for the occurrence of at least one md-ae. a systematic measurement and analysis of unintended events (ue) have been recommended for patient safety and improvement of quality of care in critically ill patients. however, a spontaneous reporting system may be inefficacious in intensive care unit (icu) because of a poor data collection, particularly by physicians staff. objectives. the aim of this study was to evaluate the reliability of a staff spontaneous event report by comparison with events collected by an external observer in a surgical intensive care unit (icu). to facilitate the reporting and the analysis, we identified a series of events with a serial number and a colour code related to their for each of the following macro-phases: icu bed booking, admission procedures, patient stay, discharge and emergency procedures. a specific structured form including ue's code and colour, date and hour of the event and type of patient has been prepared and proposed to staff -week for each month after a proper phase of education. the report was voluntary and anonymous and the data collected during the morning shift from september to december have been compared to those collected from an external observer. in the studied period, healthcare staff reported ues: % collected by nurses, % occurred during the morning shifts and % were classified as moderate or severe. the rate of ue in the morning shift was ues per patient days. the external observer identified events in morning shifts with an incidence of ues per patient days. the violation of isolation rules for patient with multi-drug resistant bacteria infection both by icu staff and surgical consultant was the ue observed more frequently by the staff ( %) and by the external observer ( %). conclusions. the above data indicated that: . in our icu the incidence of ue is very high, particularly for compliance to isolation of infected patients and . the spontaneous reporting system under-estimated largely the real incidence of ues. introduction. importance of renal assessing in intensive care unit (icu) patients is unquestionable for a correct drug dosing, fluid requirements or decisions for renal replacement therapies. serum creatinine (sc) is a very common biochemical parameter in clinical practice for assessment of renal function. many equations have been designed to estimate creatinine clearance based on sc, but their capacities for providing a correct estimate of glomerular filtration rate (gfr) are suboptimal. this is even worse in critically ill patients due to malnutrition and/or immobilization. in clinical practice, despite its limitations, h-urine creatinine clearance (crcl h ) is used as a reference method to determine gfr. data show that cystatin-c could be promising as an endogenous filtration marker in icu settings. objectives. to assess in a medical icu population whether the arnal-dade formula of cystatin-c clearance (cc) developed from serum cystatin-c (scc) shows better predictive performance of gfr than sc-based formulae, as regards to patients' renal function: crcl h c ml/min . m or crcl h \ ml/min . m . results. all formulae showed notable bias from the reference method. interestingly, all equations based on sc-values clearly overestimated crcl h (cg: . %; mdrd: . %; fv-mdrd: . %), whereas cc showed underestimation of these crcl h (cc: - . %). in the crcl h c ml/min . m group (n c = ; patients), cc showed the best correlation indexes (cc-crcl h ; r = . , r = . ), the second most biased (- . %) and the worst precision ( . %). in this group, mdrd was the least biased (- . %) and the most precise ( . %). in the crcl h \ ml/min . m group (n \ = ; patients), cc was the worst correlated with crcl h (r = . , r = . ), in contrast to mdrd (r = . , r = . ). in terms of precision, mdrd showed again better results than cc: . % vs. . %, respectively. conclusions. in our icu population, cc did not demonstrate a clear improvement on the remainder sc-based formulae in either of the two groups according to crcl h . however, in a patient with high mdrd values and suspicion of low gfr, cc could be useful as guidance before obtaining the definitive confirmation by crcl h . introduction. there are well established and robust techniques for measuring and categorizing renal function in people with chronic kidney disease (ckd). a number of rapid bedside estimates of renal function have been devised incorporating routine daily measurements, such as serum creatinine, in combination with demographic data (e.g. cockroft-gault, the mdrd series). the addition of serum cystatin c measurements to some equations may also improve accuracy of estimation. the current and accepted categorical classification of acute kidney injury (aki: akin/rifle) has been useful epidemiologically but does not provide a continuously variable measure of severity of aki which would be valuable for both clinical management and research. objectives. previously published abstracts have suggested a role for egfr in describing renal function in the critically ill but a more comprehensive analysis was needed. methods. ( male) (mean age range - ) critically ill patients with aki were recruited. a h creatinine clearance ( crcl) (previously validated as a measure of renal function in critically ill patients) was measured and simultaneous blood sampling was done for creatinine, urea, albumin and cystatin c. various equations used to estimate gfr were compared to crcl with regression and bland-altman analysis. all patients had a crcl of\ ml min per . m introduction. epithelial-mesenchymal transition (emt), a key process in tissue development and repair, has also been identified as a major mechanism in fibrogenesis. the cytokine tgfb has been shown to induce transformation of epithelial cells into matrixforming and smooth muscle actin (sma)-expressing myofibroblast (mf) via emt. the other prerequisite is an injury-induced loss of intercellular contact, including adherens junctions (ajs). the classical experimental method to induce aj disruption is the uncoupling of e-cadherin-mediated contacts by low calcium medium (lcm). this concept has been termed as the two-hit model of emt ( ). b-catenin, a scaffold protein of the aj, released by cell contact injury, can act as a transcription factor and has been shown to facilitate emt. however, the mechanism whereby cell contact injury promotes emt is not understood. our recent studies have shown that smad , one of the main signal transducers of the tgfb pathway is a strong inhibitor of epithelial sma expression, by interfering with myocardinrelated transcription factor (mrtf) [ ] . the latter is the main driver of the sma promoter, through it association with serum response factor (srf). intriguingly, b-catenin can bind to smad . to clarify the mechanisms whereby aj injury promotes sma expression. methods. ajs were manipulated in kidney tubular cells, either by sirna-mediated downregulation of e-cadherin, b-catenin or through chemical uncoupling of ajs by lcm. protein expression was detected by western blotting and immunofluorescence microscopy, proteinprotein interactions were monitored by co-immunoprecipitation, and the activity of the sma promoter was determined by luciferase reporter assays. knockdown of e-cadherin promoted b-catenin translocation to the nucleus and induced a threefold rise in the tgfb-triggered sma expression. conversely, silencing of b-catenin strongly suppressed the two-hit (tgfb + lcm)-induced activation of the sma promoter, and inhibited sma protein and mrna expression by %. the same stimuli induced strong association of b-catenin with smad . transfection of cells with a b-catenin expression vector dose-dependently prevented the inhibitory action of smad on the mrtfinduced activation of sma promoter. moreover the active (myogenic) mrtf-srf complex was restored, as b-catenin preempted smad 's inhibitory effect on the complex. these studies define a novel mechanism whereby epithelial injury activates the myogenic program, a central process in organ fibrosis. our results imply that b-catenin, liberated from the injured ajs, facilitates the activation of the myogenic program by preventing or mitigating the inhibitory action of smad on mrtf. these hitherto unknown interactions among smad , b-catenin and mrtf represent novel targets to lessen fibrogenesis. introduction. in intensive care unit (icu) patients, kidney function is monitored by the creatinine clearance (crcl). it can be measured by two methods. urinary crcl (ucrcl) is directly measured, using the urinary and serum creatinine. but commonly crcl is estimated from serum creatinine (scr) alone, as estimated glomerular filtration rate (egfr); using equations validated in chronic kidney diseases. there is paucity of literature on validation and comparison of these methods in icu (hoste) . objectives. we compared -h timed ucrcl and egfr in the newly admitted critically ill. we also sought to ascertain the incidence of high crcl and the agreement between methods in this subgroup. conclusion. the use of rifle criteria gives a high incidence of aki in the icu setting. in this unselected population of critically ill pts, cysc seems to be superior to cre in predicting pts who will develop aki and will need rrt during their hospitalization in the icu. early identification of high risk patients may allow potentially beneficial therapies to be initiated early in the disease process, before irreversible injury occurs. introduction. the contrast-induced nephropathy (cin) is consider to be the most frecuence reason of acute renal failure in hospitalized patients. they are defined by a fixed increase ( . mg/dl) o a % rise serum creatinine level after to be exposed h to the contrast. the main complications are kidney and cardiac problems and this will lead to longer hospitalization and increased mortality. objectives. to compare cin occurrence after a injecting a iso-osmolar contrast (ioc, idixanol) or a low-osmolar contrast (loc, iohexol) to a group of patients submitted to coronary angiography, with o without percutaneous coronary intervention (pci). to establish unrelated cin markers and to evaluate the efficiency of the kidney protection protocol used in our hospital. conclusions. the loc was associated to a greater number of cin than ioc. patients who developed cin were significantly longer hospitalized. the use of point giving system that includes cin's predictors like dm, hematocrit \ %, ami, and treatment with diuretics helps us to classify cin risk and use a correct kidney protection protocol. introduction. the incidence of acute renal failure in the intensive care unit (icu) is around % of cases and is related to increase in mortality in patients who required dialysis as far as %. early detection of acute kidney injury (aki), after damage is not on set could be crucial to develop therapeutic strategies to modify the course of injury. blood and urinary concentrations of ngal are early biomarkers of aki ; to date, little information exists regarding ngal usefulness in critically ill patients. objectives. to analyze: . the capacity of urine ngal (ungal) to predict akievaluated by rifle score-in critically ill patients and, . the ungal values in patients with sirs, sepsis or septic shock. methods. ngal was measured in urine sample by an automatic analyzer device (architect ci Ò ; abbott diagnostics) at admission and h later in patients admitted to a general icu. patients were classified both by rifle score at admission and and h later and by ungal concentrations at admission. to the later classification, the cut-point for aki prediction was obtained by roc curve analysis. ungal values at admission were compared in patients with sirs, severe sepsis or septic shock. clinicians were blinded to ngal results. the study included consecutively-admitted patients ( female) with mean age . ± . years, and length of icu stay of . ± days. fifty-four sirs, severe sepsis and septic shock. thirteen patients developed rifle f score, of them at icu admission; extracorporeal renal therapies were required in cases. when patients were classified according to their rifle score at h of admission, ungal values at admission were: ( - ) ng/ml in patients with rifle , ( - ) ng/ml in with rifle r, ( - ) ng/ml in with rifle i and ( - ) ng/ml in with rifle f (p = . ). five patients were excluded, three died before h with ungal ( - , ) ng/ml and two were discharged before h with ungal ( - ) ng/ml. the area under roc curve of ungal at admission for aki prediction was . ( % confidence interval . - . , p \ . ), with an optimal cutoff value of ng/ml with % sensitivity and % specificity. forty-seven patients have ungal b ng/ml. ungal concentrations at admission were ( - ) ng/ml in patients with sirs, ( - ) ng/ml in patients with severe sepsis and ( - ) ng/ml in patients with septic shock (p = . ). conclusions. urine ngal concentrations measured at icu admission appeared as a useful predictor of aki in critically ill patients; in addition, ungal concentrations showed an increasing pattern from sirs to severe sepsis and septic shock. rd esicm annual congress -barcelona, spain - - october s introduction. two previous studies using the rifle criteria in intensive care patients have found the incidence of acute kidney injury (aki) to be and %. however, these studies used calculated basal value of creatinine in a considerable proportion of their patients, which is a possible source of error. objectives. the aim of this study was to investigate the incidence and severity of acute kidney injury in intensive care patients using true baseline creatinine values. objectives. the aim of this study was to define the status of hcy and b vitamins at admission and days of icu stay in critically ill patients, and to evaluate its relationship between them. a prospective study was done on critically ill consecutive patients with inclusion criteria: c years old, sirs and apache ii [ . hcy, b and folic plasma levels were measured by enzymoimmunoassay and enzymatic method. for b , b and b in erythrocyte. permission was obtained from an institutional ethical committee and written informed consent was asked. results. at and days of icu stay and % of patients were b deficient, respectively. and % were b deficient on both times, respectively. folic levels show significant differences between and days of icu stay. we found association between b vitamin and hcy at admission and days. no differences were found between and days hcy values. introduction. cytochrome p a (cyp a), the most abundantly expressed cytochrome p enzymes in liver, are responsible for the metabolism of over % of drugs used across several therapeutic classes. in adults, cyp a is represented primarily by the major isoform, cyp a , and a polymorphically expressed isoform, cyp a . individuals with at least one wild-type cyp a * allele synthesise functionally active enzyme while homozygotes for the * allele are functional non-expressers of the enzyme. the presence of functional cyp a increases the hepatic metabolism of cyp a substrates such as tacrolimus. ckd is known to reduce the hepatic metabolism of drugs via the cyp a enzyme system and we have shown, recently, that aki has a similar effect and that the length of time with aki is the most important variable. we hypothesise that expression of functional cyp a may reduce the impact of aki on hepatic drug metabolism as has been shown to be the case for drug interactions with the imidazole antifungals. methods. ( male) (mean age range - ) critically ill patients with no aki and varying degrees of severity of aki were recruited. midazolam concentration was measured h after intravenous administration as a probe-drug for hepatic cyp a / enzyme activity (t [midazolam] ). this is a validated method for testing cyp a activity in critically ill patients. patients were excluded if they were on any known cyp a / inhibitors. results. two patients with severe aki had unexpectedly high t [midazolam] . figure demonstrates the following: without a cyp a * allele, the rate of midazolam metabolism increased with duration of aki (r = . ; p \ . ) (solid line). patients who had at least one * allele (dashed line) were protected from the inhibitory effect that aki has on hepatic drug metabolism (significant difference between the correlation lines p = . ). if the two major outliers are removed (dotted grey line) from the * /* group (r = . ; p \ . ), the correlation lines remain statistically different (p = . ). conclusions. the presence of an allele which codes for functional cyp a protects critically ill patients from the inhibitory effect of aki on the hepatic metabolism of midazolam. thyroxine replacement therapy has become commonplace in the management of organ donors to reverse hemodynamic instability and homeostasis, yet the pharmacokinetics of thyroxine are unknown in this patient population [ , ] . since t is only available in oral form, we studied the pharmacokinetics of oral versus intravenous t to determine if oral administration is suitable. objectives. ( ) to study the pharmacokinetics of oral versus iv t therapy; ( ) to determine if oral thryoxine therapy is suitable. with ethics approval and signed consent from the substitute decision maker, patients who were determined to be neurologically dead and consented for organ donation, were randomized to receive either an oral or intravenous dose of t ( mcg/kg). all patients received an oral and iv preparation; one of which was a placebo. this study was also double blinded and randomization occurred in blocks of - . free serum levels of t and t were measured hourly until the time of organ procurement. the area under the curves (auc) were determined and compared using. results. there were patients ( males) in the oral versus patients ( males) in the iv group, with an average age of ± vs. ± , respectively. there was no significant difference at baseline or h between groups for hemodynamic variables, free t , free t or tsh levels. the only exception was map where it was higher at baseline in the oral group and there was a significant increase at h in the iv but not the oral group ( - vs. - in the oral). the auc for t was greater for the iv group ( pmol/l/ h) compared to the oral group ( pmol/l/ h). there was no statistically significant difference in any of the levels from to h between the oral and iv groups. oral bioavailability of t was %. conclusions. administration of iv t resulted in a slightly greater auc compared to oral administration. however, oral bioavailability of t in our population was very high, at %. t is currently the recommended thyroid replacement in neurologically dead organ donors. however, intravenous t is unavailable in many jurisdictions. iv t has been used as a substitute. our study shows that in this select population, oral bioavailability is high suggesting that oral t may be a reasonable alternative. further work is needed to determine whether there was a difference in the number and rate of organ retrieval in the oral versus intravenous groups. introduction. specific characteristics of metabolic derangements occurring in critical illness is domination of developing catabolic state particularly in acute necrotizing pancreatitis. as a result, we faced such a problem as developing a clinically apparent protein-calorie deficiency which is resistant to standard nutritional support. the treatment of acute necrotizing pancreatitis in chronic abuse patients is difficult to handle for the clinician and should include sufficient energoplastic supply. objectives. in our research we aimed to assess the efficacy of adding of ornithineaspartate complex in carbohydrate metabolism in chronic abuse patients with acute necrotizing pancreatitis. methods. comparable chronic abuse patients with acute necrotizing pancreatitis (control group n = , mean age . ± . ; ornithine group n = , mean age . ± . ) received early parenteral nutrition from the moment of admission to hospital with universal system ''three-in-one''. ornithine group also received ornithine-aspartate complex by parenteral administration ( g/day). on the second day the patients were admitted parenteral nutrition and tube feeding h/day. the volume of parenteral nutrition was gradually decreasing. biochemical and metabolic endpoints were measured at baseline and on th day (nitrogen balance, amino acids spectrum, plasma whole protein, transferring concentrations, glucose and insulin levels) at the clinical laboratory in all patients metabolic disturbances with protein status and carbohydrate metabolism shifts were revealed. dynamic of the whole protein, albumin/protein ratio and nitrous balance in both group showed similar tendency of metabolic improvement. dynamic of essential and nonessential amino acids concentration remained normal showing adequate energoplastic supply in both groups. glutamine concentration in ornithine group remained stable and even increased by the th day of nutritional support, while in control group glutamine concentration was decreasing, and by the th day of nutritional support it was below normal values. in ornithine group higher levels of endogenous insulin at normal values of glucose and faster fisher index improvement were detected. conclusions. administration ornithine-aspartate complex in therapy of acute necrotizing pancreatitis in chronic abuse patients, probably, may influence on disease outcome. in ornithine group duration of delirium tremens causes was ± days versus control group ( ± days). restoration of metabolic activities confirms adequate nutritional support in both groups but ornithine-aspartate complex adding provides faster improvement of protein and carbohydrate metabolism. objectives. this study was designed to evaluate the nutrition indexes including serum prealbumin level as prognostic indicators of patient recovery in critically ill patients with comparing severity scoring systems. we selected patients over years old, supplied with total parenteral nutrition (tpn) for more than days in surgical intensive care unit, ajou university hospital, suwon, korea. the serum prealbumin, albumin levels and total lymphocyte count were measured at the first, rd, , , , th days of nutrition support care by tpn. we checked apache (acute physiology and chronic health evaluation) ii score, saps (simplified acute physiology score), mods (multiple organ dysfunction score) and sofa (sequential organ failure assessment) score of patients. results. there were male patients and female patients with mean age . years. the mean day of sicu staying was . days. we compared two groups; survivor group (n = ) and non-survivor group (n = ). there were significant statistical differences in icu staying days (p = . ), apache ii score (p \ . ), saps (p \ . ), mods (p = . ) and sofa score (p = . ) between two groups. however, serum prealbumin level (p = . ), albumin level (p = . ) and total lymphocyte level (p = . ) did not showed significant difference between two groups. receiver operating characteristic curve showed low accuracy of serum prealbumin level as a prognostic factor (area = . ). prealbumin level showed correlation with albumin (r = . ), however did not show correlation with apache ii (r = - . ), saps (r = - . ), sofa (r = - . ) and mods (r = - . ). conclusions. nutrition indexes including prealbumin did not correlated with clinical outcome of critically ill patients. introduction. physical function is impaired following critical illness [ ] . anaemia is a common complication of critical illness and has the potential to influence physical function [ ] . it is not known whether anaemia affects the physical components of quality of life, the ability to carry out the activities of daily living (aodl) or the actual physical function of patients during recovery from critical illness. to determine the physical quality of life, ability to perform activities of daily living and actual physical function in a cohort of icu survivors dichotomised on the presence of anaemia at months following icu discharge. one other organ failure were recruited from a general icu population. patients with a preexisting haematological condition were excluded. baseline and characteristics of icu stay were recorded. the patients were assessed with the sf- quality of life questionnaire (pcs), the frenchay activities index (fai) of aodl recalled for pre-morbid status and at and months, and the min walk test ( mwt) for actual physical function at and months following discharge from icu. organotopic measures of haemaglobin, creatinine, serum c-reactive protein and albumin concentration were also recorded. the results were dichotomised on the presence of anaemia at months for statistical analysis. baseline characteristics were compared with student's t test. a way anova was performed on the pcs and fai score as well as comparisons with t test between each time-point. the distance walked as part of the mwt was compared with mann-whitney u test. patients who remained anaemic at months were older, had a longer icu stay and had a greater requirement for inotropes during their icu stay. the pcs score of quality of life and the fai score was significantly impaired in both groups during follow up, but there was no effect of anaemia. the results of the t tests showed that there was a significant difference between the groups at months for pcs but not for fai scores. the distances walked were severely impaired compared to the normal population ( and m at and months for anaemic group and and m for non-anaemic) in both groups was not significantly different between the two groups. the non-anaemic group did increase the distance walked significantly from to months. there was no difference between albumin, crp and creatinine concentrations between the groups. methods. this experiment was divided into two procedures. the first procedure is to choose two kinds of cell strains, including jurkat cell strain (comes from leukemia) and ccrf-cem cell strain (comes from acute lymphocyte leukemia).we cultivate this two kinds of cell strains to mature stage, then inoculate every kind of cell strain into four culture dishes, two culture dishes was stimulated by lg/ml lipopolysaccharide(study group), and the other two culture dishes serve as blank control(not stimulated by lg/ml lipopolysaccharide). eight hours later, we extracted the microrna in each culture dish. the second procedure is to use the technique of gene microarray to analysis the difference expressions of microrna. in the context of a high altitude expedition human subjects can safely be submitted to prolonged hypoxia and the resulting changes in mitochondrial function can be explored in a controlled fashion. the effect of hypoxia on immune cells-key players in the pathophysiology of sepsis-is of particular interest. to measure mitochondrial function of monocytes during prolonged hypobaric hypoxia. methods. serial blood samples were collected and oxygen saturation was measured in twelve climbers before and throughout a high altitude climbing expedition to pik lenin ( , m). measurements were performed at m (baseline) and at the altitudes of , m (day ), m (day ) and , m (day ) above sea level. pure monocytes were isolated by the use of an antibody-antigen mediated immunomagnetic cell isolation procedure and lysed for determination of activities of mitochondrial enzymes cytochrome c oxidase and citrate synthase. repeated measurements anova followed by least significant difference (lsd) post hoc test were used to compare results on different altitudes. mean oxygen saturation was ± % on , m, and decreased to ± % on , m and ± % on , m (p = . ). we observed an increase in citrate synthase activity on all altitudes compared to baseline levels (p = . ). compared to the baseline, prolonged hypobaric hypoxia induced an increase in the mitochondrial respiratory chain enzyme cytochrome c oxidase enzymatic activity only at , m (p = . ). normalization of cytochrome c oxidase enzymatic activity by citrate synthase activity (relative enzymatic activity) yielded a decrease in relative cytochrome c oxidase enzymatic activity during hypoxia on , and , m (fig. ) . expressing cytochrome c oxidase enzymatic activities as a ratio to citrate synthase is intended to act as a safeguard for potential differences in mitochondrial enrichment. conclusions. the data demonstrates that prolonged hypobaric hypoxia leads to a decrease in relative cytochrome c oxidase activity. this is due to an increase in citrate synthase activity as a marker enzyme for the mitochondrial matrix representing mass and/or number of mitochondria which is not counterbalanced by a corresponding increase of cytochrome c oxidase activity. results. glycocalyx degradation was increased in the lps-treated animals ( . lm, p \ . ) compared to controls. intracellular tissue no concentrations were two-to threefold higher in the lps-treated mice compared to controls (liver, kidney, heart, gut). the number of infiltrating mpo-positive cells increased significantly during endotoxemia. levels of both plasma arg and cit were significantly lower in lps-challenged mice than in controls, whereas plasma ornithine levels were significantly higher. conclusions. in this new developed murine sepsis model, the prolonged infusion of lps resulted in increased glycocalyx degradation and associate endothelial leakage. the enhanced no levels correlated with decreased plasma levels of arg and cit. our murine model with prolonged infusion appears applicable as a model for the human clinical situation, enabling adequate investigation of the influences of the arg-no metabolism on endothelial dysfunction in sepsis. critical illness polyneuromyopathy is a muscular weakness occurring in intensive care unit. one of the major risk factor is sepsis. an early decrease in membrane excitability was described [ ] but corresponding mechanisms are imperfectly known. tnfa is released in the first time of sepsis and could be involved in the physiopathology. objectives. the aim of our study was to investigate tnfa effects on muscular voltage gated sodium channels (nav) in an in vitro model. early effects of tnfa on nav were analysed by macro-patch clamp on muscular fibers isolated from rat peroneus longus. measurements were performed on control fibers and after addition of tnfa at concentrations ranging from . to ng.ml - . the effects of chelerythrine, a specific inhibitor of protein-kinase c (pkc), were also tested. experimentations were realised in a laboratory with permission of experimental research on animals and under the supervision of an authorized person (no - ). tnfa produced a concentration-dependant inhibition of nav currents (fig. ) . maximal inhibition ( % of control current) was observed with concentrations from ng ml - and above. this decrease was fast: % of maximum inhibition was observed in less than min. moreover, chelerythrine inhibited tnfa action on nav. conclusions. in our experimental model, tnfa induce a rapid and concentration dependant decrease of muscular nav currents like observed in chronic sepsis [ ] . as this effect is too quick to be a transcriptional one, and as it is blocked by chelerythrine, it can be assumed that tnfa action is mediated by a nav phosphorylation secondary to pkc activation. in conclusion we evidenced that tnfa reduce muscle excitability in the early stages of sepsis. further studies are needed to obtain a precise description of tnfa mechanisms. may also contribute to cell signaling and regulation of the immune response. nad(p)h oxidase in leukocytes and the vascular wall is a major regulated source of o . we hypothesized that mice deficient in the p phox (ko) component of nad(p)h oxidase would have less pulmonary inflammation than wild type (wt). we treated wt or ko mice with iv saline or lps and assessed lung injury by: . wet-dry-weight ratio; . leak of evans blue (eb) labeled albumin; and . histological score for edema. we used myeloperoxidase activity to indicate neutrophil (pmn) accumulation in lungs, and measured accumulation of macrophages and neutrophils in bronchial alveolar lavage (bal). apoptosis was assessed by tunnel staining. we also expression of icam- , an adhesion molecule, and nitric oxide synthase (nos) enzymes, enos and inos (western and northern analysis) as well as nitrotyrosine formation. results. lung injury was increased in both groups. surprisingly there was greater eb leak in ko than wt at h and a greater edema score at and h. pmn and macrophage accumulation in bal were the same in both groups at h but greater in ko mice at h. myeloperoxidase activity was similar at h post lps in ko and wt indicating that similar accumulation of pmn in the lungs. apoptosis was increased in both groups at h, but resolved in wt at h and persisted in ko. nitrotyrosine was increased in both groups but appeared higher in ko. expression of enos and inos increased in both groups but was greater in ko than wt. conclusions. in contrast to our prediction, lung injury was greater in p phox ko mice which indicates that this complex is not essential for lung injury. however, the injury was more severe and prolonged in ko mice indicating that o may regulate the inflammatory response. introduction. septic shock remains the main cause of mortality in the icu, thus a persistent challenge. recently, dna and mrna analysis by microchip and gene expression by real time pcr highlighted proteins s a , s a and their complex, known as the calgranulins, as potential key prognostic markers for this disease: those two proteins, whose expression seems to be restrained to phagocytes cells are newly recognized components in sepsis-induced inflammation. moreover, they were shown to be at significantly higher concentrations in the plasma of septic shock patients that were going to die. in the contrary, those who were to survive saw their plasmatic concentration decrease, all severity scores in between the population being the same. objectives. the aim of this study was to determine the repartition of these proteins in immune cells, their intracellular variation, at baseline and after cell activation and finally to understand the relation between their intracellular and extracellular expression. we used an in vitro model close to the immuno-inflammatory aggression that is septic shock. we stimulated in vitro for , and h whole blood from healthy volunteers using agonists found in the inflammatory storm that is septic shock (lps, fmlp, gmcsf, ifng). we also induced death cell, either using an apoptotic agonist, or by necrosis technics. we then analysed the intracellular variation of the calgranulins using flow cytometry technics. the extracellular quantification was made using elisa methods. all the statistic analysis were made using a mann-whitney test. we showed in this work for the first time that the intracellular repartition of the calgranulins is different depending on the type of cell: the complexe is the main form in the monocyte cytoplasma, whereas s a is the main intracellular form of the pmn. this repartition remains after cell activation. we also checked the absence of calgranulins in lymphocytes. after cell activation we showed that intracellular s a , s a and s a a increased, but at different levels depending on the cell and the agonist used. extracellular s a also raised after cell stimulation, but the concentration found were very low compare to those found in the plasma of septic shock patients. conclusions. together, these results suggest a different regulation depending on the form of the protein and of the cell and thus of proper distinct function of each monomer and of the complex. in the limits of our model the increased concentrations found in the plasma of patients with a septic shock can't be explained by immune cell activation. objectives. although there is no specific antidote for these potent toxins, drugs like penicillin g and silibinin have been used with conflicting evidence. we successfully managed two patients with mushroom poisoning by using silibinin and nac. methods. two members of a family, a mother years old, and her son years old were admitted to our icu h after the ingestion of wild mushrooms. they presented with abdominal cramps, vomiting, profuse diarrhea ([ /day), myalgias, confusion and agitation. the clinical examination showed severe dehydration, tachycardia, oliguria with grade i-ii hepatic encephalopathy. laboratory exams revealed elevation of liver enzymes sgpt: / u/l, sgot: / u/l. coagulation parameters were as following: prothrombin time . / . , factor v \ %/ %, factor vii \ / %. high ammonia levels were noted, reaching and ng/dl, respectively. metabolic acidosis was also present with mild renal dysfunction. the ultrasound performed in both patients showed hepatosplenomegaly. aggressive fluid and electrolyte replacement started upon admission. silibinin was given at a dose of mg/kg/day intravenously, in four divided doses, for three consecutive days, while nac was given as a continuous infusion at a dose of mg/kg for the first hour, mg/kg for the next h, and thereafter mg/kg/day for the following four days. hepatic encephalopathy, mild jaundice and renal dysfunction resolved within h, and liver function tests returned to normal within days. the patients recovered fully and were discharged to a medical ward. recent experimental and clinical studies have shown a strong protective and antioxidant effect against hepatic cell injury in amanita toxicity by the administration of nac and silibinin, either as monotherapy or as a combination therapy. although further clinical research is required to confirm their efficacy in reducing mortality and transplantation rate, nac has been used in our icu in hepatic dysfunction of different etiologies with promising results. we have recently shown that in patients with lactic acidosis due to metformin intoxication (serum drug level = ± lg/ml; therapeutic level is b lg/ml) systemic oxygen consumption (vo ) can be abnormally low despite a preserved global oxygen delivery (do ) ( ). the study, however, suffered from being retrospective. objectives. to prospectively clarify whether metformin primarily impairs vo . methods. eight sedated, paralyzed and mechanically ventilated pigs received a continuous i.v. infusion of metformin, at a rate of . g/h. the amount of metformin administered to each animal ranged from and g. the experiment always finished h after the initiation of drug infusion. use of sedative and neuromuscular blocking drugs, as well as ventilatory setting, were always kept constant. serum metformin concentration was measured at the end of the experiment, using high performance liquid chromatography (hplc). arterial ph, lactatemia, vo (indirect calorimetry) and do (computed from cardiac output measured by pulmonary artery thermodilution) were recorded hourly. data are presented as mean ± sd. statistical testing was performed using the one-way repeated measure anova and the linear regression analysis. metformin infusion produced toxic serum drug levels ( ± lg/ml; n = ). arterial ph drop from . ± . (prior to infusion) to . ± . (end of the experiment) (n = ; p \ . ) and lactatemia rose from ± to ± mmol/l (n = , p \ . ). vo progressively decreased (from ± to ± ml/min; n = , p \ . ) while do did not significantly change over time (from ± to ± ml/min; n = , p = . ). the decrease in vo was proportional to the dose of metformin administered (r . ; n = , p = . ) and to the serum drug level reached by the end of the experiment (r . ; n = , p = . ). conclusions. lactic acidosis develops during metformin intoxication in the presence of a diminished vo but in the absence of any clear evidence of inadequate do . this finding suggests that impaired oxygen utilization, rather than availability, may have a role in the pathogenesis of metformin-induced lactic acidosis. : min) . death was consequent to multiorgan failure, anoxic encephalopathy or capillary leak syndrome if ecls was performed under cardiac massage. four patients presented with documented brain death, allowing organ donation in cases. among these patients, the heart of one flecainide-poisoned patient was successfully transplanted, after normalization of ecg and myocardial function as well as toxicant elimination under ecls. prognostic factors in ecls-treated poisoned patients were as follows: qrs enlargement on admission (p = . ), saps ii score on admission (p = . ), ecls performance under massage (p = . ), arterial ph (p \ . ), lactate concentration ( . [ . - . ] versus . mmol/l [ . - . ], p = . ), as well as red cell (p = . ), fresh plasma (p = . ), and platelet (p = . ) transfusions within the first h. conclusions. to our knowledge, this is the larger series of ecls-treated poisoned patients ever reported. ecls appears to be an efficient salvage technique in case of refractory toxic cardiac failure or arrest, with a % survival rate. our series clearly demonstrate that toxic refractory cardiac failure remains the best indication with a % survival rate. objectives. aim of the study was to investigate the incidence of infections in patients treated with hypothermia while receiving sdd. in this retrospective case control study patients treated with prolonged hypothermia (cases) were identified and patients with severe brain injury were included (controls). propensity score matching was performed to correct for differences in baseline characteristics and clinical parameters. primary outcome was the incidence of infection. the secondary endpoints were the micro-organisms isolated from surveillance cultures and during infection. the demographic and clinical data indicated that the cases and controls were well matched. the length of stay in the icu and duration of mechanical ventilation were comparable between the groups. the overall risk of infection during icu stay was % in the hypothermia groups versus . % in the normothermia group (p = . ). pneumonia was diagnosed in . % of patients in both groups (p = . ). the incidence of meningitis, wound infection, bacteremia, and urinary tract infection was low and comparable between the groups. staphylococcus aureus was most frequently identified as the causative infectious microorganism in both the hypothermia ( . %) and normothermia ( . %) group (p = . ), followed by coagulase negative staphylococci ( . % in the hypothermia and . % in the normothermia patients, p = . ) gram-negative bacteria were isolated from the surveillance cultures in . % of patients treated with hypothermia and . % of patients in the control group (p = . ). colonization of the rectum with gram-negative bacteria was significantly more frequent in patients treated with hypothermia compared with normothermia ( . vs. . % respectively, p = . ). in contrast, colonization of the upper gastrointestinal tract and sputum was comparable between the groups with an incidence of . % in the hypothermia patients versus . % in the normothermia patients (p = . ). use of sdd mitigates the increased risk of infection in patients treated with hypothermia. based on the surveillance cultures, it seems that oropharyngeal decontamination is the most effective part of the sdd regimen in the prevention of pneumonia. introduction. prognostic scores specific for critical patients were developed in order to predict mortality based on physiologic and laboratorial variables. on the other hand, specific scores for burn patients are calculated taking into consideration inhalation injury, age and total burned surface area (tbsa), among others. however, scores utilized in general icu have not been evaluated in burn patients. objectives. therefore, the aim of the present work was to validate apache ii, saps as well as initial sofa in a population of patients with massive burn. these scores were compared to some specific burn patient scores, including absi (abbreviated burn severity index) and estimates of the probability of death. retrospective study employing data collected prospectively from may to february ( months) at an icu specialized in burn patients at a teaching hospital which is considered a reference centre in trauma care. all patients admitted during this period were included. one hundred and fifty-four consecutive patients were studied (male: %; female: %), with averaged age of . ± . years and a hospital stay of . ± . days. mortality rate of our sample was . %. incidence of inhalation injury was % and total burn surface area (tbsa) was the following: . % of patients had % or less; . % had - % of tbsa whereas . % showed % or more. area under curve of receiver operating characteristic (roc) of evaluated indexes is displayed on table . computerized head tomography is routinely performed as a diagnostic tool after the occurrence of neurologic deterioration in the icu adult patients. however, the ct findings in this setting are rarely reported. we hypothesized that the analysis of a series of cranial cts would help to understand the neurologic conditions of the critically ill patients and improve their management. objectives. to analyze, over a three-month period, the head ct scans performed in the adult icu in the albert einstein hospital in são paulo, brazil. methods. all cranial cts performed in the icu patients during the studied period were analyzed by two radiologists from the albert einstein hospital staff from may st to august st, , according to a pre-established protocol: . presence of acute cerebral ischemia; . presence of previous cerebral ischemia; . presence of acute cerebral hemorrhage; . presence of cerebral edema; . cerebral aneurisms; . cerebral tumors and . normal cerebral tomography. we studied ct scans from ( . %) males and ( . %) females, mean age . ± . years. the head ct findings were the following: ( ) presence of acute cerebral ischemia = ( . %); ( ) presence of previous cerebral ischemia = ( . %); ( ) presence of acute cerebral hemorrhage = ( . %); ( ) presence of cerebral edema = ( . %); ( ) cerebral aneurisms = ( . %); ( ) cerebral tumors = ( . %) and ( ) c years c , abc (assessment blood consumption) cp: c and ets (emergency transfusion score) cp: c , c years c . these scales handle the following combinations of variables for calculation: age, sex, type of admission, mechanism, blood pressure, focussed assessment for the sonography of trauma, hemoglobin, orthopedic or pelvic trauma, heart rate. mt was defined as the transfusion of units or more of packed red blood cells in the first h. we study the sensitivity (s), specificity (sp), positive and negative predictive value (ppv, npv), likelihood ratios positive and negative (lhr+ , lhr-) and area under the receiver operating characteristic curve (auroc) of different scales for the predictive power of tm validated in the literature. patients were available for analysis ( . % men, iss ± , blunt trauma . % objectives. we measured patient-reported outcome following surgical management with dc using a quality of life instrument. methods. survivors discharged between and months after severe tat were contacted after obtaining approval by our institutional irb. we excluded patients with neurotrauma. we applied self-response version euroqol questionnaire (eq- d) and visual analog scale (eq-vas: (worst health)- (best health). euroqol it is based on a descriptive system that defines health in terms of dimensions: mobility, self-care, usualactivities, pain/discomfort and anxiety/depression. each dimension has levels of response: no problems (level ), some problems (level ) severe problems (level ). results. thirty four patients were contacted. mean ± sd age was . ± . yrs, male were . % and penetrating trauma occurred in . %. mean ± sd in severity scores were: ati . ± . , iss . ± . and apache ii ± . the median time from discharge was months (iqr - months). the eq- d dimensions in which the largest proportion of patients reported severe problems were usual-activities (work, study) and pain/discomfort . % and . % respectively as shown in the conclusions. survivors of severe trauma and dc, reported acceptable quality of life with minimal limitations with social functioning. a prospective study should assess quality of life in these patients from hospital discharge and systematically over time. introduction. brain tumors surgery is one of the main causes of admittance to the nicu. it is important to know the risk factors associated to hospital mortality of patients admitted to nicu due to this reason. to identify perioperative factors associated to higher hospital mortality in a series of patients admitted to nicu immediately after a bt elective resection. methods. data of patients operated for bt elective resection and consecutively admitted to nicu at imss umae bajío were prospectively obtained. nicu bt database includes perioperative items. we divided the series in two groups: surviving and deceased patients. then, we analyzed the perioperative behavior differences between both groups. either student's t test or chi-square test was used, as it corresponded, for the analysis of differences observed between both groups. values of p lower than . were considered significant. results. the hospital mortality observed in this series of patients was . % ( / ). data of the nine variables showing significant differences between surviving and deceased patients groups are shown in table . even if hypoxic brain injury has been reported as the strongest factor affecting the poor outcome of near-drowning patients, little has been known about prognostic factors affecting the outcomes of those patients receiving mechanical ventilation. to define prognostic factors affecting the outcomes of patients mechanically ventilated after near-drowning. , white blood cell counts (or, . ; % ci, . - . ; p = . ), serum creatinine (or, . ; % ci, . - . ; p = . ), and serum lactic acid (or, . ; % ci, . - . , p = . ) were associated with favorable outcomes, respectively. however, only higher body temperature as a clinical parameter and the level of serum lactic acid as a laboratory parameter were significant predictors of favorable outcomes in multivariate analyses; the or were . ( % ci, . - . ; p = . ) and . ( % ci, . - . ; p = . ), respectively. conclusions. initial body temperature and the level of serum lactic acid were two most important clinical and laboratory prognostic factor in nearly drowned patients. the outcomes were not affected by the degree of initial hypoxemia. to determine the use of automated external defibrillators (aed) and manual defibrillators deployed in the various hospital wards (unmonitored areas) in a university hospital. a prospective study was performed according to utstein style of all cardiac arrests occurred in the hospital during the first months after the implantation of a new protocol of care for hospital cardiac arrest. because of this plan automated external defibrillators were located for hospital wards and common service areas (radiology areas, outpatients, …) where one would expect a lower incidence of cardiac arrests, according to the risk map elaborated previously. in areas of greatest risk manual defibrillators previously existed. all resuscitation attempts in these areas were analyzed, excluding the emergency department because of a separate protocol against the rest of the hospital. special attention was given to the use of aeds by wards staff before the arrival of resuscitation team. also a comprehensive volunteer training program was designed, but it began after the analyzed period was finished. results. during the first months we collected a total of pcr in hospital wards and public areas, with a median age of years and predominantly male ( patients). the most common origin was respiratory ( patients) followed by cardiac ( patients). the most frequent rhythm detected was non-shockable ( patients), only in was shockable and unknown in . before the resuscitation team arrival only two patients had been manually defibrillated and were never used the new aeds. conclusions. the aeds provided in the hospital were completely useless in the first months after placement, probably due to the lack of a comprehensive training plan associated to the population goal. methods. descriptive longitudinal study. patients were studied by encephalic death, as potential donors of organs, alerted to the network of regional transplant (cdtot), by units of intensive care, for months, in barranquilla's city. it was applied qualifying each of the variables in agreement to the vital opposing signs and biochemical tests brought in this moment. . . % of the subjects were male; the average of age was . years (±sd: . ). the values of blood sugar, sodium, osmolaridad, tonicidad, po , fc, pam, and glasgow, determined a score of , qualification that there had patient with encephalic death with the scale mbcm, as a test of certainty of the scale to diagnose encephalic death in total absence of reflections of stem. conclusions. there is recommended the application of mbcm's scale to every neurological patient by diagnosis of encephalic death in proof of certainty, in absence of others. by the high specificity of the already demonstrated scale there is recommended that scores lower than they should restate the qualification. a score of is an encephalic death in absence of reflections of stem. grant acknowledgment. clínica general del norte-cdtot introduction. prospective analysis of tracheostomies performed in patients admitted to a neurotrauma icu, the reasons for its implementation, and intraoperative complications in the first week. methods. all patients admitted to the icu of neurotrauma, which underwent a tracheostomy after admission. data were collected: affiliation, cause of admission, average stay, cause for realization of tracheostomy, tracheostomy time delay from its indication, place of performance of the procedure (icu or operating room), perioperative complications (event at transfer to operating room or during surgery: hypoxia, hypotension, arrhythmia, bleeding, premature extubation, false cannulation, cardiac arrest, pneumothorax or death), and postoperative complications in the first week (bleeding, difficulty in changing cannula, stomal infection, pneumothorax, death). introduction. the s- b protein is a brain-specific protein release from astroglial cells into the circulation after traumatic brain injury (tbi). researches indicate that the s- b serum level could be a useful indicator of tbi severity, however there is not evidence enough about the role of s- b in nonsevere head trauma. the hypothesis that s- b is a useful screening tool to detect brain injury in patients with a normal level of consciousness after a head trauma was tested. a total of patients with the diagnosis of mild tbi without decrease of consciousness (according to the gcs) with at least one neurological symptom or finding like amnesia, headache, dizziness, convulsion and vomits, were prospectively included. we recorded the clinical data on admission and a blood sample before h after tbi, for s- b inmunoluminescence analysis. a routine cranial computed tomography scan (ct) was obtained within h after the injury (categorized in normal or pathological). the diagnostic properties of s- b serum levels. lg/l, for prediction of intracranial lesions revealed by ct were tested with receiver operating characteristic (roc) analysis. seventy of the patients ( . %) were men, with a mean (sd) age of . ( . ) years (range, - years). a total of patients ( . %) had intracranial lesions. serum s- b levels were significantly higher in patients with intracranial lesions than in the remaining patients. the average value of the protein in patients without intracranial lesion was . lg/l with a ci % ( . - . lg/l), and in those with pathological findings in ct was . lg/l with a ci % ( . - . lg/l). significant differences were found between levels of s b protein and the presence of pathological findings in the ct (p = . ) (fig. ) . the roc curve analysis showed that s b protein is a useful tool to discriminate the presence of intracranial injury in ct (auc, . , % ci, . - . , p \ . ). s b analyses with a cut-off level of . lg/l showed a sensitivity % but a specificity . %. we evaluated different cut off values and in our series, the best cut off of the s b protein is at . lg/l with a sensitivity of % and specificity %. (fig. ) conclusion. determination of serum protein s- b is a useful biochemical indicator of brain damage in head trauma. our results show that an increase in the cut-off point of s- b to . lg/l increases its accuracy in the prediction of the existence of macroscopical lesions. key words. protein s- b, brain injury, minor head trauma, cranial computed tomography. critically ill patients with systemic inflammatory response syndrome frequently suffer muscle weakness due to critical illness myopathy (cim) and polyneuropathy (cip). several in vitro studies have shown that the cause of muscle weakness is a loss of membrane excitability accompanied by membrane depolarization [ ] . objectives. we investigated membrane polarization and excitability parameters in muscle and motor nerve in vivo within the first week after intensive care unit (icu) admission. methods. the study was approved by our local ethics committee. patients with sofa scores c on consecutive days underwent nerve conduction studies including direct muscle stimulation to categorize patients as icu-control, cim-(dmcmap \ mv) and/or cippatients (reduced snap amplitude) within the first days after icu admission. to assess excitability parameters we recorded stimulus-response behaviour, threshold electrotonus, current-threshold relationship and recovery cycle from abductor pollicis brevis muscle following stimulation of the median nerve [ ] . data are shown as median and %/ % percentile. conclusions. we describe for the first time that critically ill patients in general show muscle-and nerve membrane depolarization, whereas patients later suffering from muscle weakness due to cim or cim/cip feature additionally reduced membrane excitability. this suggests that membrane depolarization in critically ill patients is caused by energy failure leading to dysfunction of the na-k pump, the motor of membrane repolarisation-whereas reduced membrane excitability in cim or cim/cip needs an additional dysfunction of voltage gated sodium channels for example occurring in the presence of endotoxins [ ] . in intensive care patients with central nervous system (cns) disease, the systemic inflammatory response syndrome (sirs) criteria are often unreliable as a basis for identifying the inflammatory process. even with the presence of some infection they could be signs of the diencephalons-catabolic syndrome. diencephalons-catabolic syndrome like sirs constitutes of hyperthermia over °c, tachypnea of over per minute, tachycardia, and arterial hypertension. thus, sirs symptoms may occur after antibacterial treatment even if there is no infection or inflammation. we suggest a more precise method which could help to avoid the excessive antibacterial therapy and to control it in patients with cns disease-a procalcitonin test. objectives. reduce the use of wide specter antibiotics makes the control over antibacterial therapy in patients with cns diseases more precise; reduce the number of complications related to unnecessarily long antibacterial treatment. after obtaining the informed concern, in our investigation we included patients with different neurological disorders, who had recently transferred neurosurgical operations. all of them demonstrated sirs symptoms on different postoperative terms. when sirs symptoms occurred, we checked the level of procalcitonin in the patient's serum by a semi quantitative method on a disposable brahms pct-q system. the procalcitonin level was determined against a color scale. procalcitonin level over . ng/ml ( patients) considered a sign of infection and in such cases we prescribed antibacterial treatment , mg of selenase for - days. if the test result was negative ( patients) we repeated it in h and in cases with the same results, no antibacterial treatment was administered even if there were sirs symptoms. if pct-q test was negative patients were sedated (fentanyl . - . lg/kg/h and clonidine . - . lg/kg/h) to achieve autonomic stability and attenuate clinical manifestation of sirs. we had not observed any cases of sepsis in both groups of patients. by mince of pct, we had managed to reduce the quantity of wide specter antibiotics, used in neurosurgical patients for . %. conclusions. procalcitonin test in neurosurgical clinic let us determine the necessity of antibacterial treatment reduce the use of wide specter antibiotics, medical costs and prevent the forming of polyresistant infection. l. combe , r. appleton , c. gilhooly , j. kinsella university of glasgow, department of anaesthesia and critical care, glasgow, uk intensive care unit-acquired weakness (icuaw) is increasingly recognised as a common complication of critical illness with potentially prolonged debilitating sequelae. the estimated incidence is % in patients with sepsis, multi-organ failure or prolonged mechanical ventilation [ ] and suggested risk factors include: the systemic inflammatory response syndrome (sirs), sepsis, higher severity of illness, hyperglycaemia, renal replacement therapy and parenteral nutrition. objectives. the aims of this study were to determine the incidence, risk factors and outcomes for patients diagnosed with icuaw in glasgow royal infirmary's (gri) icu. the study was undertaken in two parts, firstly as a case-control study [matched for age (within years), sex and admission apache ii score (within points)] and secondly by comparing identified cases of icuaw to a -month cross-sectional sample ( / / - / / , patients) of gri's icu patients. data for both parts of the study was obtained from two electronic databases, wardwatcher and carevue. carevue was searched to identify patients with icuaw and wardwatcher was used to identify the controls. data collected included: patient and illness characteristics, severity of illness scoring, organ support and treatments provided, laboratory results and outcomes. minitab software was used for statistical analysis. conclusions. the incidence of icuaw was very low, we hypothesise this to be explained by the absence of systematic evaluation of patients for icuaw. the risk factors and outcomes for icuaw were consistent with some of the published literature. prospective study is now planned to systematically evaluate this condition. with increasing age, comorbidity, and socioeconomic deprivation being associated with higher risk pregnancies, there comes a potential higher risk of complications. neurological and neurosurgical complications, which can be particularly devastating during the peripartum period, include those due to medical conditions of pregnancy (hypertensive disease, sepsis, thromboembolic disease, hypoxic-ischaemic brain injury), iatrogenic complications secondary to anaesthetic or obstetric interventions, incidental illness or injury (pharmacological alterations, trauma, tumour), and deliberate self-harm and violence. objectives. to ascertain the frequency of neurocritical care admissions in the west of scotland, the nature of the admission diagnoses, the impact they have on our service (length of stay), and maternal and foetal outcome. methods. using the scottish intensive care society audit group wardwatcher patient database, female patients aged - years old who were admitted to the neurocritical care unit were identified (january -december ). we manually reviewed the electronic admission note for each of these women in order to gain diagnoses; a targeted case note analysis ensued. within the month study period there were a total of admissions to neurocritical care, of whom fulfilled the age and gender criteria; admissions ( . % of total) were for neurological complications in the peripartum period. the age range was to years (median years). three women ( %) were intrapartum ( - weeks gestation) at the time of their admission, and three were postpartum ( day- months). half of admissions were due to incidental illness or injury, a third to pregnancyrelated medical complications, and one case was iatrogenic in nature. length of stay in icu was to days (median . days). one patient sustained a residual facial nerve weakness and deafness. conclusions. this survey provided insight into the incidence and nature of pregnancyrelated pathology requiring acute referral to a regional neurosciences centre. as highlighted in other surveys, there may be many more peripartum patients with neurological complications who are cared for in general critical care units, and do not require admission to a tertiary referral centre [ ] . further work is underway to ascertain the true numbers of neurological complications of pregnancy countrywide. our approach represents a paradigm for the continuing audit of pregnancy-related critical care resource use in scotland. introduction. hypertonic saline has an osmotic effect on the brain because of its high tonicity and ability to effectively remain outside the blood-brain barrier. there may be a minimal benefit in restoring cerebral blood flow, which is thought to be mitigated through local effects of hypertonic saline on cerebral microvasculature. most comparisons with mannitol suggest almost equal efficacy in reducing icp but not compared their effects on eeg. objectives. we aimed to compare the effects of % mannitol, % or % hypertonic saline on hemodynamic parameters, intracranial pressure and electroencephalography in experimental head trauma. bilateral craniotomy were carried out in the parietal region and head trauma was applied for all rabbits. the rabbits were randomly divided into four groups. in group i rabbits were only observed. in group ii: % mannitol, in group iii: % hypertonic saline and in group iv: % hypertonic saline was administered intravenously to achieve similar osmolar load. electroencephalography, mean arterial pressure, heart rate, intracranial pressure were recorded before trauma and and min after trauma. results. increased intracranial pressure was significantly decreased by mannitol, and % hypertonic saline solutions at the end of study (p \ . ). but intracranial pressure values of mannitol and % hypertonic saline groups were lower than the other groups (p \ . ). the electroencephalography scores decreased after trauma in all groups (p \ . ). at end of the study, and % hypertonic saline groups had similar electroencephalography scores with pretrauma scores (p [ . ). the mean arterial pressure and heart rates increased after trauma in all groups (p \ . ). mean arterial pressure values were found lower only in mannitol group at end of the study (p \ . ). our study showed that when used in intracranial hypertension treatment, % hypertonic saline solution is as effective as mannitol, and preserves hemodynamic parameters, and normalizes traumatic electroencephalography abnormalities better than mannitol. objectives. to identify the causes of new onset seizures in patient admitted in medical icu. methods. all the patient admitted in icu and who had new onset seizures were evaluated. the patients were evaluated for metabolic profile. imaging (ct/mri) was done whenever needed. patients with preexisting seizure history were excluded from study. . ( males, females) patients, who had first seizure during hospitalization in icu were included. patients had generalised and one had focal seizures. patients had metabolic abnormalities. ( . %) had evidence of hepatic encephalopathy. ( . %) had only hepatic encephalopathy while rest had associated uremia, hyponatraemia, hypophosphatemia and hypomagnesemia. out of patients, who had renal failure, had evidence of uremia while rest had associated hyponatraemia or hypophosphatemia. only one patient had evidence of hypocalcemia. imaging was done in patients. ( %) had abnormal ct scan results. ( . %) had intracranial hemorrhage, ( . %) had infarct, ( . %) had brain metastasis, had evidence of hydrocephalus and one each had evidence of extradural hemorrhage and tuberculoma. csf analysis was done in ( . %) patients. ( . %) had evidence of tuberculosis and ( . %) had evidence of pyogenic infection. to study the role of various investigations and ct in evaluating these patients. all patients admitted with new onset seizures within h prior to presentation were included. all the patients were questioned and an attempt was made to assign an electroclinical syndrome to seizure. patients were evaluated for metabolic profile, neuroimaging. csf examination was done in those who had persistently altered mental status, infectious symptoms and fever. results. patients were admitted ( . % of total patients who came to emergency) with history of new onset seizures. . % patients were diagnosed to have acute symptomatic seizures and were placed in ilae category . and three patients were placed in ilae category of remote symptomatic seizures. the cause of seizures was established in ( . %) patients and remained unestablished in ( . %) patients. ( . %) patients were diagnosed to have neurocysticercosis. other important causes were acute infarct, uremia, hyponatremia, hypernatremia, viral encephalitis, post partum eclampsia, pyogenic and tubercular meningitis. alcohol withdrawal seizures were seen in . % patients. metabolic derangements were seen in ( . %) patients. computed tomography was done in patients and % had abnormal findings. mri was done in patients and had abnormalities. conclusions. neurocysticercosis was found to be most common cause of seizure activity in our part of country. though metabolic derangement can cause significant proportion of new onset seizure patients routine imaging of brain should be performed in patients with new onset seizures. work environment and organisational issues: - subjective and objective research into the working conditions and their effect on the health and safety of people working in icu, focusing mainly on the natural factors of temperature, humidity, ventilation, lighting and noise (part ) n. karachalios , e.c. katsilaki , d. sfyras general hospital of lamia, icu, lamia, greece the aim of the project is the subjective and objective investigation of the conditions of work and the relation repercussions on the health and safety of people working in the icu, focusing mainly on the natural factors that are likely to cause the sick building syndrome. for this purpose a protocol of research in two phases has been planned. the first included objective measurements, with the use of suitable equipment, of the natural factors of temperature, humidity, ventilation, lighting and noise. the second phase included the subjective estimation of the working people about their own health and conditions of their work, in the particular area of the hospital with the use of substantiated anonymous questionnaire. after the subjective and objective study and analysis of questionnaires and measurements of natural factors, we found that the medium temperature of the icu was °c. the mean relative humidity of the icu was % (highest . % and lowest . %). the mean ventilation rate of the icu was m /h (highest . and lowest \ . m /h). the mean sound pressure was . db (highest and lowest . db). the average lighting was . lux ( lux lowest and lux highest). the objective data seem to keep pace with the subjective opinions of the working people, as they were impressed in the questionnaires of subjective estimate. the objective data were compared with the subjective. the results of the research were also compared with data from the existing bibliography and current legislation, leading to a line of conclusions. ( ) insufficient and bad quality ventilation. ( ) the existing temperature of the environment contributes to the appearance of sick building syndrome. ( ) the working environment is noisy. ( ) the environment of work has problematic or insufficient lighting. ( ) the icu under study is a building area which can be characterized as ''sick'' if immediate action is not taken. background. up to % of critical care nurses test positive for (symptoms of) post traumatic stress disorder (ptsd) [ , , ] . it is assumed that these symptoms are caused by professional involvement in life-threatening events [ ] . in a sample of intensive care nurses, we investigated which work related incidents were perceived as most distressing. method. in interviews, nurses ( % female) were asked to memorize and tell about their most traumatic work related event. all interviews were recorded. after verbatim transcription, the 'most critical events' were extracted and categorized bij two independent psychologists. . none of the nurses reported major life-threatening events such as trauma-related injuries, massive bleeding or seeing patients die as their 'most critical incident'. conclusion. not the major life-threatening events but relatively 'normal work related events' under unusual circumstances are mentioned as most critical by nurses. in contrast to major life-threatening events, these 'normal events' are usually underestimated by colleagues, and thus potentially compromise peer-support. a care bundle refers to evidence based interventions and information grouped together to improve outcomes and consistency of provided care [ , ] . at the icus charge nurses and intensivists as shift leaders are responsible for daily management of unit activities. several immediately made decisions by shift leaders are made under time pressure and high information load with inadequate information. though we have evidence of structure and process based factors such as material and human resources, admission and discharge decisions or bed utilization, the support for information transfer and integration is poor in organizational decision-making concerning these factors. objectives. to identify immediate information needs of charge nurses and intensivists during the management of daily activities at the icu and evaluate how necessary this information is for their decision-making. from september to november , all charge nurses (n = ) and intensivists (n = ) of university affiliated icus providing comprehensive care in finland were surveyed with an on-line questionnaire using statements. the questionnaire was developed based on our previous observation study and statements of our survey regarded information needs related to the icu care activities. a rating scale from to (completely unnecessary-absolutely necessary) was used to assess the necessity of the information. for each statement, a response with mean or over was regarded as necessary information for immediate decisions. results. the response rate was . % (charge nurses . %, intensivists . %). the working experience varied from to years (mean . , sd . ). over % of respondents worked as a shift leader once a week or more often. statements of were valued as a necessary (mean [ or more) for immediate decision-making. absolutely necessary information (mean [ or more) for immediate decision-making were assessed related to the statements. these statements concerned isolations, mechanical ventilation, admissions and discharges, special treatments, patient's condition, and scheduled dates or times for surgery or other procedures. conclusions. both icu charge nurses and intensivists identified several information needs that are crucial for immediate decision-making during the whole icu care process. information needs of the shift leaders differed and they were strongly connected to the needs of one's professional requirements. an integrated overview and summarization of immediately needed information-a care bundle for organizational decision-making-at the icus is highly needed for icu shift leaders. the common interests of both professionals, charge nurses and intensivists, should be emphasized when new technology-based systems are developed. background. the nursing shortage is an international problem that is expected to worsen in the coming years. studies show that one of the main reasons nurses leave the profession is their dissatisfaction with their work environment. structural empowerment and nurse-physician collaboration are two elements of the nurses' work environment that are potentially related to one another according to kanter's theory ( ) . in addition, a nurse's clinical specialization has been found to influence perceptions related to these two concepts. to examine the level of perceived structural empowerment, the perceptions of nurse-physician collaboration and the relationship between these two variables, among intensive care unit (icu) nurses and general ward nurses in israel, and to compare the groups. a descriptive, correlational, comparative study design was used on a sample of icu nurses and nurses from internal medicine and general surgery wards in a large university hospital in israel (response rate %). a three section, self administered questionnaire was used to measure the study variables: the condition of work effectiveness scale-ii (cweq-ii), the collaboration with medical staff scale (cmss) and demographic-professional background. results: perceived structural empowerment was found to be moderate (m = . , sd = . , range = - ). nurses tended to agree that there was nurse-physician collaboration (m = . , sd = . , range = - , = strongly disagree, = strongly agree). a correlation was found between structural empowerment and the nurse-physician collaboration (r = . , p \ . ). a significant difference was found between icu nurses and general ward nurses on their perceptions of nurse-physician collaboration (t ( ) = - . , p \ . ; general wards: m = . , icu: m = . ). no significant differences were found between nurse specialization on perceived level of structural empowerment. conclusion. nurses in this study tended to agree that there was nurse-physician collaboration on their unit/ward. nurses who perceived themselves as having a higher level of structural empowerment, felt that there was a higher level of nurse-physician collaboration. general ward nurses had more positive perceptions about nurse-physician collaboration on their ward as compared to icu nurses. no difference was found between the two groups on the level of structural empowerment. recommendation. the findings of this study can be used as the basis for the design of interventions, aimed at enhancing structural empowerment and nurse-physician collaboration, in order to improve nurses' work environment, as one of strategy to decrease the nursing shortage. further study of additional hospitals in the country is also recommended. teams have expanded and in some hospitals h cover has been instituted. researchers are questioning the validity of outreach services and its impact on patient outcomes. as cco has been viewed as the panacea to all problems, data collection and analysis is fundamental in proving its financial and clinical benefits. objectives. this comparative study aims to evaluate retrospective data from month in and month in . data does not encapsulate patient outcomes; it will compare frequency of referrals and interventions. this data provides an indication to the extent cco has participated in the care of the acutely ill over a given time period. methods. data was collected from the d medicus database collating intervention data. analysis occurred using key interventions using excel software conclusions. whilst the validity of services has been questioned, the data itself indicates that more patients are referred and frequency of interventions has increased. various system changes occurred during this time period such as a change of mews trigger scores, the advent of h cco and courses such as alert and survive sepsis were introduced into the basic training of staff. it must be noted that the intention in the uk for cco was a service that empowered staff through education to undertake this care themselves; therefore the increase in interventions could indicate that the educational approach hasn't made progress. although the study compares interventions, an increase in the type of interventions was also noted such as ward based cco supervised cpap and establishing a picc line service. therefore this highlights the changing application of interventions. further analysis is required to look at the appropriate skills required for the delivery of safe care to the acutely ill in the ward environment. whilst ward staff are increasingly under resourced, both in skills and manpower, cco do provide the skills, knowledge and time to meet the shortfall in safe timely care. introduction. working as a critical care nurse involves situations where teamwork is essential and rapid, effective communication is of importance [ ] . the education to become a specialist icu nurse gives skills and knowledge to manage patients who are critically ill with rapidly changing conditions [ ] . experimental research is one way of contributing to the acquisition of such knowledge. to describe how icu nurses may contribute and perform in the experimental research process, an environment usually unfamiliar to them. we describe our experiences with regard to clinical contribution and our subjective evaluation of involvement in animal experimental research. method. three icu nurses in a swedish hospital were asked to participate in a research project investigating myocardial metabolism in porcine models of shock. the tasks were anaesthesia and pain management, assisting with catheter insertion and haemodynamic monitoring the pigs during the process results. although the situation was new, the nursing role and function in the team were at once similar and different to the daily work situation in the icu. one major skill learnt was the rigour of experimental measurements and sources of error, which is sometimes neglected in clinical care. being able to observe changes due to shock in a controlled setting, we improved our ability to critically 'think ahead' in anticipation of clinical deterioration [ ] . our first-hand experiences at the animal experimental laboratory allayed many anxieties and misconceptions with this type of research. conclusions. the critical care environment demands skills such as the ability to accurately define and change priorities rapidly, good communication and teamwork [ ] . we believe that the experimental research setting is one way of enhancing this ability. in these units patients condition may change rapidly and they may need close inspection as well as emergency response. early warning scoring (ews) system may make early recognition of and response to bad condition possible by observation based on systematic parameters. ews was developed as a simple scoring system to be used at ward level utilizing routine observations taken by nursing staff. ews is based on five physiological parameters; systolic blood pressure, pulse rate, respiratory rate, temperature and avpu score (alert; reacts to voice; reacts to pain; unresponsive). objectives. the aim of this study was to evaluate ews among patients admitted to pacu. methods. ews parameters were recorded four times from patients after their admission to pacu. the first record was taken during the first admission to pacu (ews ), the second (ews ) after min, the third after (ews ) and the fourth record after min. the correlation between variables like differences of four ews, patients age, the asa score, duration of operation were statistically examined. early treatment and recognition of sepsis is a stated aim of the surviving sepsis campaign [ ] but in busy clinical environments the delivery of antibiotics and fluids can often be delayed. we describe the implementation of an audit proforma, based on the survivesepsis.org [ ] resuscitation bundle, as a tool to deliver six aspects of management within h of recognition sepsis. . improve the early recognition and treatment of sepsis in acute medical patients. . provide a sustainable change in the management of septic patients . improve mortality and length of hospital stay methods. the proforma consist of six treatment management steps, based on the survivesepsis.org ''septic six'': oxygen, blood cultures, antibiotics, lactate, iv fluids, strict fluid management. it is triggered by patients satisfying two or more of the systemic inflammatory response syndrome criteria. all management steps should be implemented within h of the trigger time stated on the form. the forms are collected and analysed every month and the results are displayed for staff working on the medical admissions unit and accident and emergency. a total of forms have been collected, % diagnosed with severe sepsis. the progress on all six parameters is shown below. over the initial seven month period we have demonstrated a sustained improvement in the rapid delivery of all six of the management parameters. introduction. the early goal-directed resuscitation has been shown to improve survival in patients presenting with septic shock. a recent systematic review demonstrated the inability of central venous pressure (cvp) to predict the hemodynamic response to fluids infusion, and it should not be used to make clinical decisions regarding fluid management in critical patients. the clinical implication of this fact in septic shock is not well-known. objectives. the aim of this study is to determine if the resuscitation with fluids guided by cvp has clinical implications in patients with septic shock. post-hoc analysis of a patients' cohort with septic shock admitted in the medical intensive care unit since june to june . all of them were treated on basis of a bundle for severe sepsis management. chi-square analysis was used to compare categorical data. continuous data were compared using student's t test. we used multiple logistic regression model to assess the association between the independent variable and mortality, after adjustment for possible confusing factors (we considered variable to be confounding if the estimate of the coefficient changed by more than %). eighty-five patients were studied. % were male. their average age was ± and % had previous chronic diseases. severity scores: apache ii ± , sofa ± and % of patients had multiorganic dysfunction. infectious focus was respiratory in %. cvp mean was ± mmhg, scvo ± % and the mean amount of fluids provided was ± cc. % of patients needed mechanical ventilation. hospital-stay middle was days ( - ) and days in icu conclusions. in our patients' cohort with septic shock treated under the basis of the early goal-directed resuscitation, the volume of fluids infused was associated independently with mortality. a lower fluid administration in the resuscitation probably could be caused by the early reach of a high central venous pressure. blinding of study interventions is necessary to prevent bias in randomized controlled trials (rct). since normal saline and % albumin are packaged in bags and bottles, respectively and they have different color and texture, a blinding procedure is necessary to ensure the fluids appear identical for comparative rcts. objectives. to describe the blinding procedure and evaluate sterility and stability involved in the transfer and storage of study fluids in the precise pilot rct. a standard operating procedure for concealment, meeting pharmacy guidelines and good manufacturing practices was developed by the manufacturing pharmacist at the coordinating centre and used by all participating sites. fluids were transferred with aseptic technique into identical ml bottles under a sterile hood by the pharmacy or transfusion medicine technician then covered with an opaque wrapping. average time to transfer of study fluids from their original packaging was recorded to understand labor involved with creating each study fluid package. yellow intravenous tubing was manufactured to also conceal the fluid color. six blinded bottles of normal saline and % albumin from the participating centers were stored at room temperature for at least months. cultures of the fluids using blood culture media and/or endotoxin levels (measured by commercial assay) were obtained to document sterility of the study fluids. protein electrophoresis was used to assess albumin stability. results. transfer of the study fluids was the responsibility of the research pharmacist/ technician and blood bank at and sites, respectively. average time to transfer containers of normal saline and % albumin into bottles was ± and ± min, respectively. sterility (culture negative and/or endotoxin undetectable) of study fluids was confirmed from all bottles of normal saline and albumin that underwent testing. protein electrophoresis of albumin samples showed a single band suggesting no degradation of albumin during transfer and storage. conclusions. the standardized blinding procedure developed for transfer of study fluids in this pilot rct confirmed sterility and stability of our study fluids for months. these data are important when considering the length of allowable storage time for these study fluids. due to the resources and time involved with the transfer of these fluids for individual sites, this transfer method needs to be incorporated into budgeting and may not be feasible in the context of a large rct. grant acknowledgment. the precise pilot rct was funded by a grant from canadian blood services. covidien, singapore, singapore, yong loo lin school of medicine, national university of singapore, biostatistics unit, singapore, singapore introduction. the surviving sepsis campaign recommends a -h resuscitation bundle and a -h management bundle to improve outcomes in severe sepsis. compliance with and relevance of these recommendations to asian intensive care units (icus) are unknown. objectives. the primary objective of the present study was to assess the compliance of asian icus and hospitals to these bundles. the secondary objectives were to evaluate the impact of compliance on mortality, and the organisational characteristics of asian hospitals which are associated with higher compliance. methods. this was a prospective observational study of patients with severe sepsis who were admitted to the participating icus in july . we recorded the organisational characteristics of participating centres, the patients' baseline characteristics, and the achievement of targets within the resuscitation and management bundles. results. sixteen countries and icus participated, enrolling patients. hospital mortality was . %. achievement rates for the bundle targets were: lactate measurement, . %; blood cultures, . %; broad-spectrum antibiotics, . %; fluids ± vasopressors, . %; central venous pressure, . %; central or mixed venous oxygen saturation, . %; low-dose steroids, . %; drotrecogin alfa, . %; glucose control, . %; lung-protective ventilation, . %. compliance rates for the entire resuscitation and management bundles were . and . % respectively. on logistic regression analysis, achievement of the targets for blood cultures, antibiotics, and central venous pressure independently predicted decreased mortality. high-income countries, university hospitals, icus with an accredited fellowship programme, and surgical icus were more likely to be compliant to the resuscitation bundle. conclusions. compliance to the resuscitation and management bundles is generally poor across asia. given the resource limitations in asia, the most appropriate strategy to improve outcomes in severe sepsis may be to concentrate on ensuring early administration of antibiotics after blood cultures, and appropriate fluid therapy. cerebral oxygen desaturation predicts cognitive decline and longer hospital stay after cardiac surgery monitoring brain oxygen saturation during coronary bypass surgery: a randomized, prospective study the work is supported by departmental sources. clinical features and prognosis of organizing pneumonia pre-senting as acute respiratory failure in icu reference(s). . webster nr. ventilation in the prone position prone position in acute respiratory distress syndrome effect of prone positioning on the survival of patients with acute respiratory failure acute effects of upright position on gas exchange in patients with acute respiratory distress syndrome this study was funded by arjo international ag, florenzstrasse d metabolic acidosis and fatal myocardial failure after propofol infusion in children: five case reports longterm propofol infusion and cardiac failure in adult head-injured patients mild hypothermia alters propofol pharmacokinetics and increases the duration of action of atracurium intermittent haemodialysis versus crrt for arf in the intensive care unit dialysis dose in acute kidney injury: no time for therapeutic nihilism cirrhotics admitted to icu, and when added to the liver-specific scores of meld or ukeld, improves their respective predictive value intensive care, london, uk, royal free hospital epidural anesthesia, hypotension and changes in intravascular volume intraoperative fluid restriction improves outcome after major elective gastrointestinal surgery surrogate designation: can we trust our relatives? does chest physical therapy work? physiotherapy in intensive care: towards an evidence-based practice fisioterapia no paciente sob ventilação mecânica this research was supported by grants from the following brazilian funding agencies/programs: cnpq, capes, fapesc and unesc readmission to surgical intensive care increases severity-adjusted patient mortality physiological scoring systems and audit predicting death and readmission after intensive care discharge a case-control study of patients readmitted to the intensive care unit severity of illness and risk of readmission to intensive care: a meta-analysis a comparison of admission and worst -h acute physiology and chronic health evaluation ii scores in predicting hospital mortality: a retrospective cohort study learning from the past to inform the future-a survey of consultant nurses in emergency care assessing emergency nursing competence post-traumatic stress among swedish ambulance personel levels of mental health problems among uk emergency ambulance workers partial and full ptsd in brazilian ambulance workers: prevalence and impact on health and on quality of life ambulance personnel and critical incidents impact of accident and emergency work on mental health and emotional well being artemis health institute, director, critical care, pulmonology and sleep medicine, gurgaon, india, artemis health institute, nursing, gurgaon, india reference(s) the australian incident monitoring study in intensive care: aims-icu. the development and evaluation of an incident reporting system in intensive care adverse events in critical ill patients ministry of health and social policy communication: a key factor in the patient safety? anemia of the critically ill: acute anemia of chronic disease impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient high dose recombinant human erythropoietin stimulates reticulocyte production in patients with multiple organ dysfunction syndrome: the journal of trauma: injury, infection and critical ca to the staff of the critical care department, faculty of medicine injury severity and quality of life: whose perspective is important? quality of life and persisting symptoms in intensive care unit survivors: implications for care after discharge variations in health-related quality of life in critical patients funded in part by fogarty international center nih grant no. d tw - and clinical research institute-fundacion valle del lili glasgow coma score, use of mechanical ventilation and vasoactive agents, and the occurrence of severe sepsis (according to bone's criteria- ). the causes of admission were divided as: ischemic stroke, hemorrhagic stroke, subarachnoid hemorrhage, status epilepticus, traumatic brain injury, elective neurosurgeries, and miscellanea. the foci of infection, microbiological data and bacteremia were analyzed from septic patients. numeric data were expressed as median and interquartiles, while categorical data were calculated as percentage. univariate and multivariate (logistic regression) analysis was carried out to point factors associated with hospital mortality. results. we included patients, with median age years (iq range - ) and % were male %) patients, while it occurred during icu stay on ( %) patients. hospital mortality was associated with age, the admission cause (higher for hemorrhagic stroke, traumatic brain injury and status epilepticus), apache ii score, glasgow coma score and severe sepsis on the univariate analysis cnpq perioperative factors associated to higher mortality in patients admitted to the neurological intensive care unit (nicu) immediately after brain tumor (bt) resection saldívar umae (high-specialty medical unit no ) el bajío, imss and nicu, hraeb (high-specialty regional hospital of el bajío) anaesthesiology and intensiv care medizin anaesthesiology and intensive care unit charité universitätsmedizin-berlin, department for anesthesiology and intensive care medicine after approval of the local ethics committee, the pdr icg was measured within h post injury (day ) using the non-invasive limon system (pulsion medical systems of pdr icg to supranormal values higher sofa scores were indirectly associated with lower pdr icg values, particularly for sofa scores[ . when patients were grouped by icu length of stay (\ , c days, corresponding to the mean icu los of the german trauma registry), logistic regression analysis identified pdr icg consumables were provided by pulsion medical systems influence of apoe polymorphism on cognitive and behavioural outcome in moderate and severe traumatic brain injury genetic variation of the apoe promoter and outcome after head injury effects of apolipoprotein e genotype on outcome after ischaemic stroke, intracerebral haemorrhage and subarachnoid haemorrhage the association between apoe « , age and outcome after head injury: a prospective cohort study decreased cerebrospinal fluid apolipoprotein e after subarachnoid hemorrhage correlation with injury severity and clinical outcome « association of ventilation rates and co concentrations with health and other responses in commercial and industrial buildings « sensitivity to noise, personality hardiness, and noise-induced stress in critical care nurses recommended lighting level for offices » the chartered institution of « sick building syndrome, sensation of dryness and thermal comfort in relation to room temperature in an office building: need for individual control of temperature silent misery: most severe critical incidents post traumatic stress disorder in the emergency room: exploration of a cognitive model trauma exposure and post-traumatic stress disorder in intensive care unit personnel increased prevalence of post-traumatic stress disorder symptoms in critical care nurses drivers of quality in health services: different worldviews of clinicians and policy managers revealed systems thinking, system dynamics the fifth discipline: the art and practice of the learning organisation the development of system dynamics as a methodology for system description and qualitative analysis finnish funding agency for technology and innovation nursing activities score tradução para o português e validação de um instrumento de medida de carga de trabalho de enfermagem em unidads de terapia intensiva: nursing activities score (nas) nursing activities score in the intensive care unit: analysis of the related factors the self-perceived health between medical-surgical and crit-ical care nurses in hungary deutsch , i. boncz , a. sebestyen , a. olah university of pecs faculty of health sciences a longitudinal study design was used to explore the self perceived health of inhospital nurses in acute care settings (surgery, casualty, internal medicine, intensive, coronary care, emergency room) in two hungarian factors predicting team climate, and its relationship with quality of care in general practice nurse working conditions, organizational climate, and intent to leave in icus: an instrumental variable approach critical care nurses' work environments: a baseline status report quality of practice in an intensive care unit (icu): a mini-ethnographic case study vasps/intv ). medicinska fakulteten, lunds universitet critical thinking and clinical decision making in critical care nursing assessing and developing critical-thinking skills in the intensive care unit gulhane military medical academy, haydarpasa training hospital, istanbul, turkey, gulhane military medical academy technology as a catalyst to transforming nursing care devices and desire: gender, technology and american nursing surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock division of pulmonary and critical care medicine, seoul, republic of korea, peking union medical college hospital, department of critical care medicine mai hospital, intensive care department, hanoi, viet nam, king saud bin abdulaziz university for health sciences, king abdulaziz medical city, intensive care department dr soetomo general hospital, department of intensive care republic of china, ripas hospital, intensive care unit surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock the surviving sepsis campaign: results of an international guideline-based performance improvement program targeting severe sepsis great differences in compli-ance with surviving sepsis campaign bundles surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock delayed diagnosis is associated with increased morbidity, mortality and cost in the icu. as the mortality rate of severe sepsis remains unacceptably high, a group of international expert developed guidelines in , termed the surviving sepsis campaign (ssc). the ssc group has introduced the ''sepsis care bundles surviving sepsis campaign guidelines for severe sepsis and septic shock implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality improving outcomes for severe sepsis and septic shock: tools for early identification of at-risk patients and treatment protocol implementation observational, prospective follow-up. patients who were admitted into the intensive care unit in university hospital complex a coruña (chuac) during the months of hospital mortality was surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock early goal-directed therapy in the treatment of severe sepsis and septic shock associated with decreased mortality translating research to clinical practice: a -year experience with implementing early goal-directed therapy for septic shock in the emergency department improvement in process of care and outcome after a multicenter severe sepsis educational program in spain duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock delta co (pvco -paco ) as a prognostic factor in septic shock septic shock using the new device inspectra : relation to macro-and microhemodynamic and outcome c. luengo , , f. vallée , c. damoisel , m. resche-rigon among the techniques assessing microperfusion, near infrared spectroscopy (nirs) gained interest. more than baseline sto values, the reperfusion slope after a vascular occlusion test (vot) nirs parameters, especially the reperfusion slope scvo or svo ); metabolic (ph, base excess and lactate) parameters were collected. microperfusion data consisted in: nirs (baseline sto , occlusion and reperfusion slopes (%/s), automated software); skin laser doppler microflow (baseline flow (tpu), peak flow (tpu) and slope during reperfusion (tpu/s), measured during and after a min vot. survivors (s) and non-survivors ] differed between s and ns at day . macro-hemodynamic and metabolic data did not differ between s and ns plan quadriennal ea svo does not predict fluid responsiveness in critically ill septic patients supported by msm research grant: replacement of and support to some vital organs years) were studied. apache ii and sofa score at study entry were (range: - ) and (range: - ) respectively. the septic syndrome was due to sepsis (n = ), severe sepsis (n = ) or septic shock (n = ). sites of infection included the lung reference(s). . ungerstedt u: microdialysis: principles and applications for studies in animals and man the pathophysiology and treatment of sepsis management of sepsis surviving sepsis campaign guidelines for management of severe sepsis and septic shock relation between muscle na + k + atpase activity and raised lactate concentrations in septic shock: a prospective study long-term continuous glucose monitoring with microdialysis in ambulatory insulin-dependent diabetic patients whether it is worth to correct acidemia by infusion of alkaline solutions is a matter of discussion. there are a number of evidences against the use of alkalinization therapy with respect to the benefits of reversing ph and the side effects of sodium bicarbonate infusion [ ]. nonetheless, as recently shown by means of an on line survey, % of critical care physicians administer base to patients with lactic acidosis mmol/l), animals were randomized to min of: a) sustained lactic acid infusion, a + b) sustained infusion + sodium bicarbonate, o) transient infusion, b) transient infusion + sodium bicarbonate. in the transient infusion (group o and b), at randomization lactic acid was replaced with normal saline. acid-base status and lactate levels were measured over time. in a number of animals phosphofructokinase (pfk) enzyme's activity was also measured. results. following lactic acid infusion blood lactate rose unnecessary use of alkali perturb acid-base status and lactate metabolism potentially overcoming metabolic adaptive strategies. reference(s). . boyd jh, walley kr. is there a role for sodium bicarbonatein treting lactic acidosis from shock? use of base in the treatment of acute severe organic acidosis by nephrologists and critical care physicians: results of an online survey strong ions gap (sig) quantifies unmeasured blood anions and it is calculated by the difference between strong cations and strong anions (all of them, dissociated in blood plasma) retrospective, observational study of all patients with septic shock as defined by the american-european consensus, admitted to the icu from arterial blood gases, albumin, lactate and electrolytes were obtained at admittance and h later; apache and sofa score, central venous saturation and lactate comparison of acid base models for prediction of hospital mortality following trauma forty-five sepsis patients [median age, (iqr, - ) years; admission saps ii, ( - ) pts; severest multiple organ dysfunction syndrome score interaction of vasopressin infusion, corticosteroid treatment, and mortality of septic shock comparing two different arginine vasopressin doses in advanced vasodilatory shock: a randomized, controlled, open-label trial lambert university of leicester, division of anaesthesia, leicester, uk blood samples were taken: at induction of anaesthesia, at and - h post-cpb. neutrophils were isolated, mrna extracted, dna cleaned and reverse transcribed supported by a grant from the association of anaesthetists of great britain and ireland, and the british journal of anaesthesia/royal college of anaesthetists secretoneurin (sn), a neuropeptide, is specifically expressed in endocrine elevated nucleosome levels in systemic inflammation and sepsis extracellular histones are major mediators of death in sepsis rd esicm asymmetric and symmetric dimethylarginines (adma, sdma) are protein-breakdown markers; both compete with arginine for cellular transport and are excreted in urine. moreover adma, sdma, their ratio (marker of adma catabolism), arginine, interleukin- (il- ), tumor-necrosis-factor-a (tnf-a), c-reactive-protein(crp) on day , , , , and at discharge in consecutive severely-septic patients were measured sdma were higher than normal, adma/sdma ratio was halved, arginine was low. adma was related to total sofa and arginine, inversely related to il- and crp; sdma was related to saps ii, sofa, blood urea, creatinine, arginine. adma/sdma ratio was inversely in non-survivors, creatinine, il- , tnf-a, crp and adma were stable, sdma increased, adma/sdma ratio remained low figure: time course of adma and sdma blood levels (mean ± standard error) during icu stay and the last icu day protein-hmgb- levels as predictors of outcome in patients with sepsis and septic shock hmgb as a predictor of organ dysfunction and outcome in patients with severe sepsis early low dcs counts may be correlated to disease severity and could predict fatal outcome. however, little is known about dc number in other shock than septic. objectives. to evaluate and compare the circulating dcs number in patients with severe sepsis, septic or cardiogenic shock. methods. in a prospective multicentric study ( icu), consecutive immunocompetent patients with severe sepsis (ss), septic shock, cardiogenic shock were included. peripheral blood dc counts, measured by flow cytometry, were evaluated and compared between the three populations at admission and h later. correlation to disease severity evaluated by clinical scores and day mortality was studied. results. patients were included (age ± years, male, sofa d . ± . , saps ii ± ): septic shock, severe sepsis and cardiogenic shock. mortality at d was respectively , and %. patients presented a sepsis associated to cardiogenic shock. at baseline and at day , a dramatic diminution in the numbers of total dcs either myeloid (mdcs) or plasmacytoid (pdcs), was observed in sepsis (severe sepsis or septic shock) compared to cardiogenic shock patients. no difference was seen between severe sepsis and septic shock patients (fig. ). we did not observe any correlation between the number of total dcs at admission or at day and severity of illness scores dc reduced number is a valuable marker of severe sepsis in shock and is not affected by hemodynamic changes. it could not be used as a prognostic marker in severe septic patients. preliminary results from a prospective study assessing the relationship between standard laboratory coagulation and global tests of clot-formation using thromboelastography in patients with fulminant hepatic failure v the routine use of international normalized ratio (inr) to establish the coagulation status in patients with fulminant hepatic failure (fhf) may be misleading. anecdotally, fhf patients, despite a significantly deranged inr, may display a normal or even hypercoagulable state, as recently shown, albeit in an extracorporeal setting, with frequently clotted circuits, despite raised pt we prospectively studied coagulation, demographic, survival and outcome measures of fhf patients (defined by de-novo liver failure, coagulopathy-inr [ . , and encephalopathy) admitted to the royal free hospital liver and/or intensive care unit(s) (icu), a tertiary referral centre in liver diseases and transplantation we present the standard clotting tests and teg results from (of a required ) patients currently enrolled, demonstrating variable degrees of encephalopathy and coagulopathy effect of norepinephrine on cardiac output and preload in septic shock patients apparent heterogeneity in splanchnic vascular response to norepinephrine during sepsis aggressive use of high-dose norepinephrine in the treatment of septic shock norepinephrine requirement is not an independent variable to predict outcome in severe septic shock patients aim. the aim of this study was to measure the level of ptsd among hungarian ambulance workers, and explore factors which can influence it.sample and methods. hungarian ambulance workers were involved to this crosssectional study ( ambulance drivers, ambulance nurses, and ambulance team leaders: medical doctors and ambulance officers). self filling questionnaire were used for data collection, including briere's trauma symptom checklist, and socio-demographic questions. chi square test, independent t test and variance analysis were used for comparison of variables.results. the average ptsd-points of ambulance workers was . there was significant association between level of ptsd and gender: women's average , men's average ptsd-points (p = . ). there were no correlations between level of ptsd and type of settlement, location of ambulance station and level of education. those who would need psychological support (p = . ), and those who had psychologically traumatic experiences in the last years have significantly higher ptsd-points (p = . ).conclusions. hungarian ambulance workers are exposed with many effects which can lead ptsd. professional psychological support is needed in order to cope with ptsd successfully.the results were presented and discussed in our weekly meeting on patient safety and healthcare for all icu personnel. by the end of this year all the recommendations will be implemented in our icu.conclusions. we improved the safety and quality of in hospital transportation of icu patients by performing a prospective risk analysis. bow-tie is a good instrument to identify health care risks. to determine the incidence of phrenic neuropathy associated with the catheterization of internal jugular and subclavian veins, without ultrasound support, in patients admitted to an icu. a prospective study was performed by following patients admitted in the icu between october and may . a normal neurography of both right and left phrenic nerves at the moment of their admission was the main inclusion criteria. after this baseline study, a new neurography was repeated weekly (chen and resman method, sinergy medelec), during their stay and at the moment of being discharge from icu. simultaneously, all vascular subclavian and internal jugular vein catheterization were registered. a final neurography and a fluoroscopy study were performed after being discharged from hospital. results. patients were included and two hundred and ten neurographies of both right and left phrenic nerves were performed. patients did not receive any vascular punctures in the cervical region during the follow up period, acting as control group. patients underwent a total of vascular catheterization, in subclavian vein ( . %) and in internal jugular vein ( . %). a phrenic neuropathy was diagnosed in patients. this represented an incidence of % ( / ) of phrenic neuropathy per patient and % ( / ) related to subclavian and internal jugular vein catheterization. in relation to patients without phrenic nerve injury who underwent subclavian and internal jugular vein catheterization, patients affected of phrenic neuropathy had longer mechanical ventilation time ( ± days vs. ± , p = . ) and longer average stay time in icu ( . ± days vs. ± , p = . ), although these differences have not statistical significance. we did not find significantly differences related to age ( ± vs. ± , p = . ) and apache ii index ( ± . vs. . ± . , p = . ) between both groups (wilcoxon two-sample test). we performed a control neurography of case patients after being discharged from hospital. we checked the cmap phrenic nerve reappearance after weeks and months of being diagnosed its neuropathy, respectively. conclusions. we found an incidence of phrenic neuropathy of % per patient and % related to subclavian and internal jugular vein catheterization, during the follow-up period. the time of reappearance of phrenic cmaps after being detected its neuropathy points to a neuroapraxia or partial axonotmesis as pathogenic type of injury.discussion. phrenic neuropathy has to be considered in cases of difficult weaning of unclear etiology. the catheterization of subclavian and internal jugular veins should be recommended employing ultrasound support. p. merino , m.c. martin-delgado , j. alvarez , i. gutiérrez-cía , Á . alonso-ovies , syrec hospital can misses, icu, ibiza, spain, isde, Á rea de salud, madrid, spain, hospital de fuenlabrada, icu, madrid, spain, hospital clínico universitario, icu, zaragoza, spain introduction. syrec project aims to improve icu patient safety. the project includes an epidemiological study. we present the main results.objectives. to estimate the near miss (nm) and adverse events (ae) rate in spanish intensive care units (icus). we study the incidence and nature. finally, we classify and analyze its severity.methods. multicenter prospective observational cohort study. inclusion criteria: patients admitted to the participant icus during the -h observation period. during this period, nm and ae detected and reported inside and outside icu were included. only outside icus were considered when its were the reason for admission. we evaluate the kind of incident, severity and preventability. data collection studied under the distribution of frequencies.results. , patients were included. , incidents were reported in patients, were nm and ae. risk: the median risk of nm was % versus ae %. . incidents per patient admitted. incidence rate: the incident rate median was . per patients per hour icu stay, the nm of . per patients per hour icu stay and that of ae, . per patients time of stay in icu. the % of the incidents reported have been nm and % ae. this incidents causing temporary damage in the . % of occasions and in the . % permanent damage, compromised the patient's life or contributed to death. classification of incidents (table ) . conclusions. our study shows a high individual risk. our icus services present a highrisk environment. therefore we have to go into the developement of epidemiological studies depth, in order to create further strategies supporting patient safety. restore cardiovascular performance in severe lactic acidotic rats a. kimmoun , n. sennoun , n. ducrocq , b. levy , inserm u , groupe choc, vandoeuvre-lès-nancy, france, chu nancy brabois, intensive care unit, vandoeuvre-lès-nancy, france introduction. lactic acidosis during shock is responsible for myocardial failure, vascular hyporesponsiveness and a decrease in sensitivity to vasopressor agents. sodium bicarbonate is a proposed treatment to correct acidosis, although with deleterious cardiovascular effects. indeed, hypocalcemia and hypercapnia, both powerful myocardial depressants, are the main side effects of the administration of this therapy [ ] . objectives. already studied in experimental models of isolated lactic acidosis, the cardiovascular effects of sodium bicarbonate administration have never been explored after correction for hypocalcemia and hypercapnia. methods. we therefore compared, in a rat model of severe lactic acidosis (ph \ . , hyperlactatemia[ mmol/l) induced by a state of controlled hemorrhagic shock, the cardiovascular effects of: ( ) standard resuscitation plus administration of sodium bicarbonate with correction for calcemia and paco (''adapt'' group, n = ); ( ) standard resuscitation plus administration of sodium bicarbonate without correction for paco and calcium (''nonadpat'' group, n = );( ) standard resuscitation; (''stand'' group, n = ); ( ) standard resuscitation plus calcium administration (''calc'' group, n = ). evaluation at steady and shock state, min and min was focused in vivo on arterial gas and myocardial contractility (emax) by conductance catheter. ex vivo vasoreactivity was tested on mesenteric arteries ( lm) by myography. sodium intakes were equivalent between groups. results. our model displayed a profound acidosis from . to . ± . (p = . ) and hyperlactatemia from . ± . to . ± . mmol/l (p \ . ). emax decreased from . ± . to . ± . mmhg/ll p = . . in the adapt group, at min, ph was normalized at . ± . (p = . ). furthermore, emax was enhanced at ± % (p \ . ) (stand: ± %, nonadapt: ± %, calc: ± %). the cumulative dose of infused norepinephrine was significantly lower in the adapt group ± lg/kg compared to other groups (stand: ± lg/kg, nonadapt: ± lg/kg, calc: ± lg/kg, p = . ). ex vivo mesenteric vasoreactivity in the adapt group was normalized (graph ).mesenteric vasoreactivity to phenylephrine conclusions. in severe lactic acidosis, infusion of sodium bicarbonate after correction of its side effects improves myocardial function and vasoreactivity. [ ] . the prevalence and significance of -hydroxyvitamin d deficiency in the intensive care unit have not been fully determined. a recent study of an unselected group of itu patients [ ] has suggested low itu admission -hydroxyvitamin d levels are common. objectives/hypotheses to be tested. royal free hospital intensive care unit patients exhibit low circulating levels of -hydroxyvitamin d. circulating levels of -hydroxyvitamin d decrease further during the course of hospital admission. admission circulating levels of -hydroxyvitamin d affect itu morbidity and mortality methods. all itu admissions were assessed within h of presentation and patients who were deemed to have the potential to require admission for at least week were included. demographic and clinical data were obtained in a prospective manner. results were recorded from samples obtained at admission, days and days. standard itu nutrition protocols were used. no interventions were performed. results. clinical and outcome data were obtained for patients. no significant differences between apache , saps or apache scores for survivor and non-survivor groups at either itu or hospital discharge were noted. further patients await complete data analysis. % ( of for whom results were available) achieved an adequate ([ nmol/l) circulating hydroxyvitamin d level. patients ( . %) demonstrated levels within the insufficient range ( - nmol/l). patients ( . %) did not have any detectable -hydroxyvitamin d. the remaining patients ( . %) were either in the deficient ( . %, - nmol/l) or severely deficient ( . %, - nmol/l) ranges. admission -hydroxyvitamin d levels in survivors and non-survivors were compared at itu and hospital discharge. no significant differences between the four groups (p [ . , anova) were observed, indicating that in this data set, admission -hydroxyvitamin d levels do not appear to alter or determine clinical course. mean -hydroxyvitamin d levels were compared at admission, day and at day . no significant differences between the three groups (p [ . , anova) were identified. no significant differences between the mean -hydroxyvitamin d levels of the survivors and non-survivors at day or day were apparent (small numbers). admission [ , ] and patients undergoing surgical procedures [ ] . patients with neurological illness can receive significant quantities of ns, chosen primarily for its iso-osmolar properties. objectives. ns is commonly used as maintenance and resuscitation fluid by the anaesthetist, and as intravascular flushes by the radiologist during prolonged interventional neuroradiological (inr) procedures. this pilot feasibility study aimed to ascertain the effect of ns infusion on acid-base measurements in patients undergoing inr procedures under propofol-remifentanil anaesthesia. methods. we collated routine electrolyte, albumin and acid-base data of patients who underwent coil/glue embolisations of intracranial aneurysms and vascular malformations, both before and after the procedure. base excess (be) was partitioned into the effects of sodium chloride difference (na-cl), albumin, lactate and unmeasured anions (uma), using the stewart-fencl-story approach [ ] . all values are reported as medians (ranges objectives. to investigate the erythropoietic response to hight dose of a weekly schedule of recombinant human erythropoietin (rhuepo) in critically ill anaemic septic patients. a total of patients admitted to the intensive care unite (icu) were enrolled in this study, patients were randomized to receive either rhuepo or not, patient did to form the rhuepo group, did not to form the control group.results. the epo treated group of patients showed significant increase in reticulocyte count compared with baseline p \ . , as well as with the control group p \ . . the epo treated group exhibited also a significant increases in hb concentration compared with baseline p \ . as well as the control group . . all patients in the control group received rbc blood transfusion %, while only . % of the epo group did. the epo treated group showed significant decreases in their apache ii score during the study period compared with baseline p \ . as well as with the control group p \ . . the epo treated group showed no significant difference in their sofa score compared with baseline p \ . , however the control group exhibited continuous and significant increase in their sofa score throughout the study period compared with their baseline p \ . , there was no significant difference in the final outcome recovery, mortality or morbidity p . , p \ . respectively.conclusions. the administration of rhuepo to critically ill anaemic septic patients is effective in raising their reticulocytic counts, hb concentrations and in reducing the total number of units of rbcs they require. in addition there was a trend toward better in hospital clinical course, increased recovery and decreased mortality in the rhuepo group.conclusions. anaemia is common following critical illness but does not appear to affect the physical aspects of recovery during medium term rehabilitation. this may be due to an overwhelming degree of symptom burden from other complications of critical illness impairing physical function to such a degree that the effects of anaemia are negligible in the medium term. although decreases in number and function has mainly been described in skeletal muscle, also other organs seem to be affected and it has been hypothesized that mitochondrial dysfunction might be involved in the development of organ failure. to study the effect of plasma of patients with septic shock on mitochondrial function in vitro to potentially later on identify a central factor affecting mitochondria in all tissues during sepsis and leading to multiple organ failure.methods. after sacrificing - week old sprague-dawley rats, mitochondria from soleus muscle were isolated through homogenization and a series of centrifugations. mitochondrial function was assessed by measuring of oxygen consumption, using an oxygraph containing a clarke-electrode, after addition of adp. before these measurements, mitochondria were incubated with plasma from septic patients or healthy volunteers, respectively, for min. in our second series, the mitochondria were incubated with different concentrations of il- , tnf-a or buffer. respiration rates were measured in the presence of adp (state ; a measure for the oxidative capacity to produce atp) and without the presence of adp (state ; a measure for the amount of uncoupling). respiratory control ratio (rcr; a measure for the respiratory efficiency of the mitochondria) was calculated by dividing state by state activity. all measurements were related to citrate synthase activity to compensate for the amount of mitochondria. statistical differences between the groups were analyzed using a student's t test.results. adp dependent (state ) respiration was % higher and rcr % higher in the mitochondria incubated with plasma from the septic patients compared to those incubated with plasma from healthy volunteers (table) . there were no significant differences between the groups incubated with preservation buffer or the different cytokines (table) . introduction. microvascular fluid loss from the intravascular to the interstitial space generates tissue edema and is one of the major challenges in emergency and intensive care medicine. isolation of interstitial fluid (if) from skin makes it possible to study the microcirculation and proteins in this environment both during normal as well as pathophysiological conditions such as acute inflammation.objectives. by studying bio-markers from proteomic analysis by mass spectrometry in an inflammation model, we wanted to find proteomes that could be important in explaining inflammation. we have applied a recently described centrifugation method in a porcine model and compared it with implanted wicks. in nine anesthesized piglets we compared the methods and evaluated the if, by overhydrating the pigs with ml of acetated ringer's solution for h, and thereafter continuously supplemented for h according to fluid losses. if was isolated from implanted dry wicks, wet wicks and by centrifugation of excised skin. the methods were evaluated by the ability to reflect overhydration and to show the expected composition of plasma proteins in if by use of hplc. the if was also processed further with mass spectrometry to find possible tissue degradation or inflammation due to overhydration. statistics: by spss v . and graphpad instat (version . ). significance level: p = . . colloid osmotic pressure in if was significantly lowered after overhydration for all the tree methods. wet wicks p = . , dry wicks p = . , skin samples p = . . hplc of if collected with centrifugation after overhydration, identified peaks representing molecules smaller than albumin. mass spectrometry of the same if identified several proteins associated with inflammation: alpha- -antichymotrypsin and lumican, the latter a protein identified as a modulator of inflammation. we have introduced a new centrifugation method for isolation of if from the skin of pigs. by further analysis of if isolated by centrifugation we were able to distinguish proteins found only in the if of the pigs overhydrated with ringer's acetate. these proteins could be associated with an inflammatory condition in the skin caused by massive overhydration, again causing tissue degradation. identification and validation of proteomic biomarkers can be a useful tool in future treatment of inflammation in general, and in sepsis in special. objectives. to define the pattern of change in metabolites by mrs in experimental sepsis. male sd rats (weight - g) underwent cecal ligation and puncture or sham procedure (n = per group), and h after surgery were euthanized. pulmonary tissue was extracted for magic angle mrs (hr-mas) and processing by the r metabonomic package. a supervised statistical analysis of main components (mc) was performed on the processed spectra.results. the mc analysis discriminated both group (septic and nonseptic) indicating a different metabolite profile. in addition, the analysis of mc loading revealed displacement positions in the discrimination between groups with a variation in the signal intensity of %.conclusions. metabolomic analysis of pulmonary tissue by mrs is a potentially useful technique for the detection of biomarkers in sepsis.grant acknowledgment. introduction. cd + cd + neutrophils are a key subset of phagocytes associated with severe bacterial sepsis [ ] . their characteristics, and potential neuro-immunomodulation, have not been explored in humans neutrophils exposed to septic plasma from icu patients. to assess the effect of adrenergic/cholinergic neurotransmitter molecules on human neutrophil adhesion and activation markers following exposure to human septic plasma. with irb approval, neutrophils were isolated from healthy volunteers (ficoll density gradient separation) and incubated for h with either plasma from healthy volunteers or septic patients plus pathophysiological concentrations of epinephrine (e), norepinephrine (ne) or acetylcholine (ach) and nicotine (nic) to assess potential parasympathetic-related neuro-immunomodulation. flow cytometry (dako cyan) measured expression on neutrophils of cd , cd , cd antibody markers and viability. median values are shown; analyzed by anova.results. neutrophils were unaffected by ne, e, ach or nic after incubation with plasma from healthy volunteers. after incubation with septic plasma, marked neutrophil activation occurred (p = . ). however, nic reduced cd + cd + activation (* fig. a ) by % (median ( - %; th- th centiles); p = . ). nic also attenuated cd expression, suggesting reduced neutrophil adhesion (* fig. b) . neutrophil viability was similar across drug and plasma treatments. conclusions. these preliminary data suggest that nicotine attenuates both the activation and adhesion of human neutrophils exposed to human septic plasma, but does not affect viability. objectives. the aim of this study was to evaluate the potential impact of lag between sepsis initiation and start of treatment on mitochondrial respiration. methods. animals [ . ± . kg] were randomized (n = /group) to a control group (group i) and three groups resuscitated at (group ii), (group iii), and (group iv) hours, respectively, after fecal peritonitis induction. fecal peritonitis was induced with instillation of . g/kg of autologous feces via intra-peritoneal drain. resuscitation was performed according to the ssc and esicm sepsis guidelines for h. respiration of permeabilized skeletal muscle fibers and their isolated mitochondria was assessed at baseline and after , , , and h, when applicable, or before death occurred, if earlier. at the end of the experiment, also isolated brain, hepatic and myocardial mitochondrial respiration was measured using high resolution respirometry (oxygraph- k, oroboros instruments, innsbruck, austria). results. mortality ( %, each) and organ dysfunction was highest in groups iii and iv. in these two groups, different pattern of changes of skeletal muscle mitochondrial complex i-dependent respiratory control ratio (rcr) were observed (table ) . no significant differences between groups were observed for complex i-and ii-dependent rcr values of hepatic, myocardial and brain mitochondrial respiration (fig. ). there were no significant differences between the groups for any of the complexes in permeabilized skeletal muscle fibers mitochondrial respiration (data not shown). conclusions. despite the high mortality observed in groups resuscitated at later time points after induction of sepsis, end organ mitochondrial function assessed using physiological substrates was preserved. despite significant changes in skeletal muscle mitochondrial respiration efficiency in the two groups with the highest mortality, our findings do not support the view that mitochondrial dysfunction plays a major role in the pathogenesis of multiorgan dysfunction in experimental sepsis. grant acknowledgment. swiss national fund, nr: - ; stiftung für die forschung in anästhesiologie und intensivmedizin. adipose tissue is an endocrine organ which produces signalling proteins involved in inflammation and glucose homeostasis [ ] . one of these proteins, adiponectin, promotes glucose utilisation and fatty acid oxidation and thus improves insulin sensitivity via its two receptors, adipor and adipor [ ] . adiponectin expression has been shown to be reduced in type ii diabetes, obesity and endotoxaemia [ , ] . adiponectin also exhibits antiinflammatory properties [ ] . in this study, we have examined whether adiponectin and its receptor gene expression changes in murine adipocytes stimulated by lps. methods. t --l adipocytes were grown in culture media (dmem with % fetal calf serum) until confluent. pre adipocytes were differentiated with the addition of mg/ml insulin, mm dexamethasone and mm ibmx. media was changed every h. cells were treated on day with ng/ml, or mcg/ml lps (escherichia coli, sigma-aldrich). cells were harvested at and h. mrna levels were determined by rt pcr in a . ll reaction volume consisting of . ng of reverse transcribed cdna mixed with optimal concentrations of primers and probe and qpcr tm core kit (eurogentec, uk) in -well plates on a mx p detector. results. cell response to lps was confirmed using il as a reference gene. expression of adiponectin mrna was significantly reduced in cells treated with lg/ml lps harvested at h ( . fold p = . ). there were no changes in cells treated with lower concentrations of lps. there were no changes at h. r gene expression was significantly reduced following treatment with ng/ml lps at h ( . fold p = . ), but treatment with higher concentrations did not change expression. there were no changes at h. r expression levels were significantly reduced at h in the and the mcg/ml groups ( . fold p = . and fold p = . ) respectively. there were no changes at h. discussion. our results add to the evidence that changes occur in the adiponectin system during inflammation. in this model, we observed rapid reduction (at h) in adiponectin at high dose lps, r at low dose lps and r at medium and high doses. there were no changes in expression levels at h. this suggests that a rapid change in the adiponectin system may occur in response to lps but this change is not maintained at h. in a previous study, our group has shown reduced adiponectin gene expression in adipose tissue depots in lps induced endotoxaemia [ ] . it is interesting that different concentrations of lps induce different changes within the adiponectin system. further studies are needed to elucidate whether reductions in both adiponectin and its receptor may contribute to the inflammatory changes and hyperglycaemia commonly observed during sepsis including all co poisoned patients treated with hyperbaric oxygen. following parameters were seized: age, sex, date of admission, sofa, the source of the intoxication, the gravity co score, the initial clinical examination (realized by first aid), biology, the rate of hbco, the murray score and the rate of complication. results. patients were included in the study. the sex ratio was %, the mean age was ± years and the global mortality was , %. among the patients % were poisoned by smoke (s group), % by pure co (c group) and % by exhaust fumes. more than % of the exhaust fumes victims were suicide origin. this characteristic is associated with neurological impairment induce by ingested drugs. then, their neurological status is impossible to link to the co poisoning. we have therefore decided to exclude this group. the sofa score was higher in the s group compared with the c group ( . - . ; p \ . ). a co score equal to was present in versus % respectively in s versus c group (p \ . ). in the under group of patients having a co score at , % ( / ) of co poisoned patients versus . % ( / ) of smoke poisoned patients were ventilated (p \ . ). these patients were intubated either during transport or in the intensive care and none of them received hydroxycobalamine during the first aid (before intubation). the laboratory data showed in the s group a higher lactates level ( . vs. . mmol/l; p = . ) and lower initial pao /f i o ratio ( vs. ; p = . ). nine percent of the s group present a murray score at versus % for c group (p \ . ). pneumonia, shock and death were significantly more frequent in the s group (respectively . vs. . %, p \ . ; . vs. . %, p \ . ; and . vs. . %, p \ . )conclusions. as expected the smoke poisoned group has a higher mortality than pure co group (mortality % vs. overall mortality . %). at equivalent co gravity score, mortality and complications are always more frequent in the smoke poisoned group. the smoke poisoned group has a high risk of degradation. those patients require specific monitoring and support and probably early administration of hydroxycobalamine. hypothesis. at administration and maintaining higher plasma levels of at can reduce the need for inotropes in burn shock patients. we performed a retrospective cohort study of burn shock patients admitted to a single tertiary care center over years period. patients were eligible for inclusion if they were received fluid resuscitation with ringer's solution and colloid according to clinical guidelines. data were abstracted including demographic, burn injury characteristics, resuscitation fluid volume, the type of colloid and the average of plasma at levels within h after burn injury. administration of fresh frozen plasma and/or recombinant human at was defined as at administration. the decisions of at administration and inotropic support (dopamine or dobutamine) were made by the attending intensivists. primary outcome measure was the need for inotropes within h after burn injury. cox regression model was used to estimate the risk reduction by at administration and average of at levels. [ ] . argon, another member of the noble gas family has been reported previously to have a neuroprotective property [ ] . the aim of this study was to investigate whether it attenuates neuronal injury in a rat model of neonatal asphyxia. methods. seven-day-old postnatal sd rats underwent right common carotid artery ligation and then recover with their dim for h. thereafter, they were exposed to % o balanced with nitrogen for min. after h, they were treated with % argon or % nitrogen (positive control group) for min. the cohort pups without intervention served as naïve control. they were perfused days later and their brains were sectioned and stained with . % cresyl violet. microphotographs were taken from ca area of the hippocampus near - . bregma relative to adult brain at magnification. healthy cells were counted in a blind manner and their mean value was used for data analysis. results. the thickness of healthy layers in the right ca area of the positive control group was remarkably reduced compared with other groups (fig. ). quantitative analysis revealed that argon treatment significantly increased healthy cell numbers in the right ca area of hippocampus from . ± . in the positive controls to . ± . (p \ . ) (fig. ). grant acknowledgment. this study was supported by a grant from action medical research, uk. objectives. our objective was to study the mechanisms of death following high-dose citalopram administration in rats. experimental study in sprague dawley rats with intraperitoneal (ip) citalopram administration; determination of the median lethal dose (mld)using the dixon and bruce upand-down method; clinical descriptive study of citalopram-induced features and measurement of alterations in respiratory pattern (arterial blood gases and plethysmography) and biological parameters including blood lactate (scout Ò , ekf diagnostic), plasma and platelet serotonin concentrations (high-liquid performance chromatography-fluorometry); determination of the preventive activity on seizures and death of diazepam, cyproheptadine, and propranolol pretreatments with the determination of their minimal effective dose; comparisons using anova for repeated measurements followed by bonferroni post-test.results. citalopram ip-mld was determined as mg/kg in rats. seizures were significantly increased in rats receiving and % of citalopram mld versus controls (p \ . and p \ . , respectively), while death rate was only significantly increased in rats treated with % of citalopram mld (p \ . ). significant decrease in body temperature was observed after min in rats treated with doses[ % mld in comparison to controls (p \ . ). occurrence of serotonin behavioural syndrome was comparable in all groups. citalopram administration did not result in significant hypoxemia, hypercapnia, and lactate elevation, thus not supporting the hypothesis of the occurence of any significant deleterious cardiovascular effect in citalopraminduced toxicity. however, a significant moderate increase in the inspiratory time (p \ . ) accompanied with an expiratory braking was observed. a significant decrease in platelet serotonin and increase in plasma serotonin concentrations were measured (p \ . ). pre-treatment with diazepam ( . mg/kg) and cyproheptadine ( . mg/kg) of rats receiving a lethal citalopram dose prevented seizures and death, while propranolol was ineffective.conclusions. citalopram respiratory toxicity remains mild, while deaths result from seizures probably related to serotonin toxicity. our observations may be helpful to better understand and manage human citalopram poisonings. objectives. to define the population pharmacokinetics (pk) of phenytoin in the critically ill, in addition to risk factors for sub-therapeutic dosing.methods. free and total ptn concentrations were measured in serum by means of high performance liquid chromatography following microfiltration, two to three times in the first h after a loading dose. population pk modelling, including intra and interindividual variability, were determined using nonmem (r) . in the netherlands the use of diazepam is advised as first line treatment although evidence is not established and mainly provided through case-reports [ ] . to compare the effect of diazepam on mortality in (hydroxy) chloroquine intoxication to standard therapy. we performed an extensive medline search ( -april ) with a manual reference search of identified papers. (hydroxy) chloroquine intoxication studies and case reports in english, dutch or french were evaluated. patients older than years with severe intoxications, based on measured concentrations or life-threatening symptoms, were included. pooled relative risk (rr) for mortality with corresponding % confidence interval (ci) were calculated by means of a fisher exact test. our results were compared with two retrospective and one prospective study.results. there were case reports identified from which case reports met our inclusion criteria. thirteen patients received diazepam of whom two died, compared to twelve patients who did not get diazepam of whom one died. statistical analysis demonstrated that treatment with diazepam was not associated with a lower mortality rate (rr: . ci . - . ; p = . ).although pooling of case reports is debatable, these results were comparable to the retrospective and prospective studies that didn't show any benefit from diazepam in chloroquine intoxication [ , , ] . the positive effect of diazepam may have been underestimated, due to the fact that it has been given only as rescue therapy.conclusions. based on our analysis there is a lack of evidence concerning any antidotal effect of diazepam. good supportive treatment is pivotal. if the clinical manifestations of (hydroxy) chloroquine intoxications require sedation or treatment of seizures, diazepam is a good choice based on its pharmacological profile. a prospective study which compares diazepam to sedativa with similar pharmacokinetic and dynamic profile is required to prove that diazepam has any antidotal effect. introduction. brain is one of the first organs affected in sepsis and evaluation of brain function is difficult since patients are under sedation. it has been shown that mitochondrial dysfunction may play a significant role in the pathogenesis of septic encephalopathy. here we investigated inflammatory and metabolic parameters in a model of polymicrobial sepsis in mouse. methods. sepsis was induced by intraperitoneal injection of feces. animal received imipenem h after the procedure. control animals received intraperitoneal saline and imipenem after h. blood cytokines and serum lactate were measured. the animals were sacrificed by cervical dislocation. brain slices of mcm were used to measure oxygen consumption and glucose uptake.results. interleukin , mip a and interleukin b significantly raised in the first h after sepsis induction (p = . ; p = . ; p = . respectively). in h only mip a was significant higher (p = . ). lactate was elevated and h after sepsis induction (p \ . and p \ . respectively). oxygen consumption increased after h of sepsis and drops under control values h after the induction of sepsis. glucose uptake, measured by the nbdg fluorescence, was higher after h (p = . ) and h after sepsis induction.conclusion. in a murine model of abdominal sepsis, inflammatory markers, lactate production, and brain glucose uptake increased and were parallel to alterations in the mitochondrial oxygen metabolism. introduction. the royal bournemouth hospital has one of the highest out-of-hospital cardiac arrest admission rates in the uk. in , following ilcor/aha guidelines [ ] , a cooling protocol was developed for patients with return of spontaneous circulation after advanced life support for ventricular fibrillation or pulseless ventricular tachycardia. in preparation for potential new ilcor/aha guidelines in , the prospective database of outcomes for these patients was analysed.objectives. to evaluate the outcomes of therapeutic hypothermia for patients with return of spontaneous circulation following cardiac arrest. outcome data from our prospective registry of cooled patients are summarised.results. sixty-three patients were cooled in years (median age years; mode ; range - years). % survived to itu discharge and % to hospital discharge. % of these were discharged home ( % to a rehabilitation hospital before home and one patient to a long term care facility). ninety-five percent of survivors were alive at months and % alive at year with seven status results still pending. median itu length of stay was . days (range - ). six patients required temporary percutaneous tracheostomies for airway protection and weaning from ventilation. median duration from itu to hospital discharge was days (range - ).conclusions. this series is large by comparison to other uk centres. survival to hospital discharge, at months and year were better than other published results. although neurological outcomes were not formally assessed, we believe that the capacity to discharge home is a desirable patient outcome and represents the beneficial neurological effect of our cooling protocol. selection bias will have undoubtedly affected our results. however the age of our patients was higher than in published trials and in other reports is considered an adverse outcome predictor. our data would not support restricting induced hypothermia on the basis of age alone. we consider the itu and hospital lengths of stay required to discharge these patients to be long. these data were not reported in original trials. discharges may obviously be delayed for non-clinical reasons. this aside, neurological recovery progresses for months after cardiac arrest and discharge home may still prove possible if time is allowed. however, post-itu resource implications should be considered when introducing a cooling protocol. introduction. acute ischaemic stroke (ais) is the third largest cause of mortality and the leading cause of chronic disability in the industrialized world. in some parts of europe and the united states - % of patients with ais may be admitted to a neurological intensive care unit (icu) for supportive therapy with - % receiving mechanical ventilation [ , ] . there are currently no agreed uk criteria for the admission of ais patients to critical care.objectives. to review the incidence and outcome of ais in our tertiary icu over the last five years. november and november . ais was classified as thrombo-occlusive or embolic. subarachnoid haemorrhage and primary intracerebral haemorrhage were excluded. demographic and outcome data were recorded and compared against a mean value of all icu admissions.results. ais comprised . % of icu admissions during the study period. demographic data is presented in table as mean ± standard deviation or median (interquartile range) as appropriate. in % ( / ) of hospital ais admissions were admitted to icu. patients had surgical procedures including decompressive craniectomies. % of survivors had a discharge gcs of / . mortality for unselected medical admissions over the study period was %. there are differences of significance in the mortality according to the age, classified by age groups with an age cut off of years (\ years . vs. c years %, p \ . ). apart from the gcs, the rest of the variables analyzed in the ich score are not of significance; supra and infratentorial, presence of intraventricular blood neither on the divided volume over or under cc although, in the latter, a p \ . can be observed and if we only analyze the supraventricular, it comes out as significant. other analyzed data are the time of the surgery, which is not significant, the need for mechanical ventilation, which is ( . vs. . %, p \ . ), and the days of ventilation with a mortality clearly higher on those patients with\ days of ventilation ( %) and on those of shorter stay (lesser then days %).conclusions. let be remarked that the samples have been taken from patients admitted in the intensive care unit, losing a possible sample of less serious patients, and with a higher level of consciousness, what might explain why supra or infratentorial location and the volume don't come out as forecasting factors, since its likely that there are many small infratentorial outside the intensive care unit. we highlight also that the high mortality in the first few days can be caused by those patients who are admitted as donors, developing an encephalic death in the first days, conditioning also the data regarding the mortality on fewer days with ventilation. the finish up, we have to point out the fact that the presence of previous hypertension during the treatment might be a bad forecasting factor that should be deeper studied. to determine whether a delay exists between the time of diagnosis of intracranial haemorrhage and the time of reversal of anticoagulation, in patients presenting within our region. following approval by all audit and haematology departments a month retrospective analysis was performed. we reviewed consecutive patients who received reversal of anticoagulation with pcc and vitamin k having presenting with intracranial haemorrhage whilst on warfarin. time of diagnosis was obtained from the time of scan and time of pcc issue was obtained from the blood bank database. case note analysis was performed to obtain further information.results. patients were identified, in the neurosurgical centre and in peripheral hospitals. the median time from scan to issue of pcc was min. patients were reversed within min and patients waited longer than min to have pcc issued. no adverse thromboembolic events were encountered.conclusions. avoidable delay exists between ich diagnosis and pcc issue. pcc could be stored in the emergency department and a stat dose administered immediately after diagnosis facilitating rapid correction of inr. repeat audit will be required to assess safety and efficacy. objectives. the aim of this study was to compare the functional ability and muscle strength between these two groups of patients. twenty-nine patients were evaluated (m: , f: ) (age: ± years).the diagnosis of critical illness polyneuromyopathy was based on muscle strength measurement according to the medical research council (mrc) of muscle strength methodology. nine patients were diagnosed with critical illness polyneuromyopathy during their icu stay (mrc \ / ).the patients were evaluated with mrc and hand-grip dynamometry (hgd) every days until their discharge from the hospital. the fim scale (functional independence measure) was used to evaluate the functional ability ( - ).the first evaluation was done at the discharge from the hospital and the second one ± months afterwards.results. the patients who developed critical illness polyneuromyopathy had statistically significantly lower mrc ( ± vs. ± , p \ . ) and hgd at icu discharge (left ± kg vs. ± , and right ± kg vs. ± , p \ . ) compared to those who did not. the muscle strength as assessed with the mrc days after icu discharge had statistically significantly lower ( ± vs. ± , p \ . ), just as the second hgd evaluation (left ± kg vs. ± and right ± vs. ± kg, p \ . ).compared to those who did not develop critical illness polyneuromyopathy, the patients who did, had statistically lower fim values during their discharge from the hospital ( ± vs. ± , p \ . )and months afterwards ( ± vs ± , p \ . ).conclusions. the patients who developed critical illness polyneuromyopathy had significantly inferior muscle strength at their discharge from the icu. these patients also had lower functional ability. this functional ability remained defected even months after their discharge from the hospital. these initial findings are suggestive that the appearance of critical illness polyneuromyopathy affects the patients mobility after their discharge either from the icu or from the hospital and persists for several months after icu discharge. further studies are needed to evaluate the effect of this impairment on the quality of life of these patients and also to evaluate therapeutic tools for critical illness polyneuromyopathy. introduction. this poster presents a qualitative system dynamics (sd) analysis of the factors which influence the care of acutely unwell ward patients in new zealand. this systems thinking approach is commonly used in organisational research and offers a way to make sense of complex relationships between variables. this approach has previously been used in health care to demonstrate differences in mental models between policy makers and clinicians (cavana et al., ) . since the factors which influence the care of acutely unwell ward patients are complex and multi faceted the qualitative sd method becomes an ideal analytic approach (e.g. see wolstenholme and coyle, ; senge, ; vennix, ; or maani and cavana, ) .objectives. the aim of this study was to examine the factors which influence the care of acutely unwell ward patients from an organisational perspective. key objectives were to determine the enablers and barriers to care from a nursing, medical and managerial (at ward and executive level) perspective.methods. using a multiple case study approach in four wards in two new zealand hospitals, focus groups and one to one interviews were conducted with key stakeholders identified as nurses, doctors and managers. initial coding of the data generated themes. these themes were then clustered to provide variables which were mapped to generate separate causal loop diagrams (clds) for each of the stakeholder groups to provide the basis for analysis. the clds were compared for characteristics and world views. preliminary results demonstrate a difference between clinical and managerial staff in characteristics and world view regarding the factors which affect the care of acutely unwell ward patients.conclusions. the qualitative sd approach has offered a novel and helpful way to make some sense of the complexity associated with caring for acutely unwell ward patients. organizational responses that may improve care delivery to these patients should be based on frank and open discussions between staff at all levels to ensure a shared mental model as the basis for change. objectives. the aim of the study is to explain the nursing in the technologicallyadvanced intensive care units. in this phenomenologically-designed study, a face-to-face in-depth interview was performed with nurses, who were experienced for - years in the intensive care unit of cardiovascular surgery clinics. during the interviews, a semi-structured form was used. data were analysed using colaizzi's method of data analysis. the study was approved by the ethics committee of the institution.results. according to the nurses, nursing in technologically-advanced environment has three stages. these stages constituted three themes of the study: technology shock (first stage), understanding the technology-supported care (second stage), competency in technological environment (last stage). in the first stage, the nurses focus on themselves and technology; perceive the environment as frightening and complex. in the second stage, nurses gain control on technology, feel themselves safe and recognize their responsibility. in the last stage, the nurses experience anxiety related to their accountability. this anxiety may be motivating but also may be wearisome.conclusions. the nurses passes through three stages in a technologically-advanced environment. helping nurses to pass through these three stages appropriately will increase the contribution of technology to the patient care, more utilization of technology by nurses and more job satisfaction. unexpectedly, the compliance rate with the recommendations was significantly better over night. although the number of nurses is constant in the h, the number of doctors is lower and less differentiated in the night shift. in an attempt to find an explanation for these findings we looked at the patient flow and time span until the first medical observation in the different time periods and we found that over night admissions (between : a.m. and : a.m.) corresponded only to % of all admissions and were seen sooner, which might explain our findings. a. objectives. the purpose of the study was to assess whether the completion of the sepsis resuscitation bundle within the first h after icu admission, but beyond the specific time limit of the various bundle interventions, is related to an improvement in survival in patients with severe sepsis/septic shock. this was a single-center prospective observational study of patients admitted to the medical-surgical icu of an urban tertiary care teaching hospital with severe sepsis/septic shock. patients were recruited from june to november . we assessed the compliance with the different tasks included in the -h resuscitation bundle. furthermore, we ascertained within the first h after icu admission the compliance with those tasks not carried out within their specific time limits; we have called this variable ''bundle improvement at the icu''. results were stratified by the number of tasks of the bundle completed before admission at the icu, and the lag time between the beginning of severe sepsis and admission to the icu. these late completed tasks at the icu were related to hospital mortality by a cox regression model. objectives. the aims of this study were to assess the compliance rate with h bundle as defined in the surviving the sepsis campaign guidelines in patients diagnosed with sepsis regardless of severity and whether compliance affects the rate of mortality and/or hospital stay. we conducted a prospective observational study. we randomly recruited adult patients from acute admissions unit and intensive care in an acute district general hospital in england who met the diagnostic criteria for sepsis. for each patient, compliance with sepsis care bundle was obtained from medical notes. the following components of the h sepsis bundle were assessed: obtaining blood cultures, initiating antibiotic therapy, measuring serum lactate and in the event of septic shock administration of fluid therapy. conclusions. long and unacceptable delays in admission to iccu were identified despite evidence of significant organ dysfunction in many of these patients. with all bundle elements being met for only patient it is apparent that evidence based endpoints aimed at reducing mortality from severe sepsis are not being met despite all the bundle elements being practically deliverable. poor compliance with taking blood cultures prior to antibiotic administration and lack of scvo measurement are areas requiring particular attention. further work is recommended to identify potential contributing factors to non-compliance. introduction. international guidelines recommend that cardiac output measurement is required in addition to arterial pressure monitoring in patients with persistent shock after initial therapy [ ] . nevertheless, these recommendations are not supported by any comparison of arterial pressure and cardiac output for monitoring the effects of the most current treatments like fluid therapy. objectives. to evaluate in which extent monitoring the haemodynamic effects of a standardized fluid challenge with the sole arterial pressure could help for detecting the fluidinduced changes in cardiac index (ci). in critically ill patients with acute circulatory failure deemed at receiving a -ml saline infusion over min, we measured the systolic (sap), diastolic (dap), mean (map) and pulse (pp) arterial pressure and transpulmonary thermodilution ci before and after volume expansion.results. volume expansion significantly increased ci, sap, dap, map and pp by ± %, ± %, ± %, ± % and ± %, respectively. the fluid-induced changes in pp, sap and map were significantly correlated with the fluid-induced changes in ci (r = . , . and . , respectively). the changes (in %) in pp were significantly related to the changes (in %) in stroke volume for all quartiles but with different coefficients of correlation: r = . for the st quartile ( - years), r = . for the nd quartile conclusions. pp and sap were the best arterial pressure values for detecting the fluidinduced changes in ci. using the sole pp for assessing fluid responsiveness led to a non negligible proportion of false negative cases. this supports the recommendation that when a precise monitoring of fluid resuscitation is required, like in refractory shock, a direct assessment of cardiac output is required. objectives. aim of our study is to show that it is possible to reduce high catecholamines in previous improper volume resuscitated patients by forced volume resuscitation combined with active dose reduction and generate the hypothesis of an avoidable catecholamine induced circulation injury. introduction. the sialic acid content of the red blood cell (rbc) membrane decreases early in sepsis [ ] , and this alters the rbc shape and metabolism [ ] . an increased ratio of the rbc proteins band /alpha spectrin was observed in a mouse model of septic shock, suggesting a possible alteration of the rbc membrane integral/peripheral proteins ratio [ ] . as there are interspecies differences in membrane composition, these observations need confirmation in humans. we studied rbcs from patients with (n = ) and without (n = ) sepsis at icu admission and on day in the septic patients. exclusion criteria were recent rbc transfusion, hematologic diseases, cirrhosis and diabetes mellitus. procedures included screening for rbc membrane protein alterations by cryohemolysis test and separation of the rbc membrane and skeletal proteins by polyacrylamide gel electrophoresis in the presence of sodium dodecyl sulfate [ ] . comparison between groups was made by the student's t test or the mann-whitney test. a p value . was considered as statistically significant.results. the hemogram, including reticulocyte count was similar in septic and non-septic patients at icu admission. no significant difference was observed for cryohemolysis test results and the amount of the rbc proteins (table ) . objectives. our purpose was to compare a new method (patrol fr - ) with the reference method (randox tm ) during cbp. patients scheduled for coronary artery bypass (cb) and aortic valve replacement (avr) under cbp were enrolled after written informed consent in this protocol approved by local ethics committee. anesthesia protocol was standardized with systematic use of tranexamic acid. three blood samples were harvested: t = induction; t = min. after cross aorta clamping; t = h after induction. the patrol method was performed after serum exposition to a photosensibilizer agent then to a laser irradiation leading to the formation of free radicals. oxidation by those free radicals of a fluorometric sensor allowed an indirect measure of tas. this measurement in arbitrary unit (au) corresponded to area under curve compared to a control value from a pool serum. a value higher than indicated a lower capacity for the given serum to neutralize free radicals whereas a lower value indicated a higher capacity. the same sample allowed tas determination (lmol/l) with randox tm method. results were expressed as absolute numbers, mean ± sd. tas were compared with anova test; p \ . was significant.results. the seven patients ( male, female; ± years old) enrolled underwent cardiac surgery ( cb and avr) without any problem. there was no variation in tas determination with the randox tm method: t : . ± . ; t : . ± . ; t : . ± . lmol/l. conversely a two fold significant increase was measured during cpb with the patrol method: ti: . ± . ; t : . ± . *; t : . ± . au. *p \ . versus t .conclusions. oxidative stress due to overwhelming release of reactive nitrogen/oxygen species (rn/os) is held largely responsible for sepsis-induced organ failure and mortality [ ] . up-front and/or ongoing distortion of the pro-oxidant/anti-oxidant balance is likely to play an important role in this situation and in ischemia-reperfusion. therefore the patrol test which appeared to be more sensible than the randox tm method could a good tool in these cases and for evaluation of new anti-oxidant treatments in critical care medicine. these results have to be confirmed in a larger population. introduction. sepsis is the leading cause of death in critically ill patients. despite attempts to improve standardized strategies in resuscitation and treatment of sepsis, the morbidity and mortality remain unacceptably high. early diagnosis and stratification of the severity of sepsis is the key to start timely the appropriate treatment. sepsis is the systemic inflammatory response syndrome to infection; it can lead to hypoperfusion and organ dysfunction and at the cellular level to aerobic mitochondrial dysfunction. lactate is the product of anaerobic metabolism and thus may serve as a prognostic factor in this subset of patients.objectives. the authors propose to test the association of the first serum lactate at hospital admission with shock and icu mortality in patients with community-acquired severe sepsis. during the study period , patients were admitted in the unit, of those ( %) had severe community-acquired severe sepsis (cass). crude icu mortality rate among cass was %. considering the model previously described in methods and when the variables were adjusted only gender, age, saps ii, severity of sepsis and serum lactate were retained in the final model for icu mortality and saps ii nad serum lactate for shock (see table ). a first blood lactate level was independently associated with shock and icu mortality in patients community-acquired severe sepsis admitted in intensive care. objectives. the objective of this study was to test whether svo can predict fluid responsiveness in these patients. we studied patients who were monitored with a pulmonary artery catheter for severe sepsis and septic shock. hemodynamic measurements were obtained before (baseline values) and after a fluid challenge with colloids or crystalloids. responders were defined as those with a[ % increase in cardiac index (ci). no additional interventions were performed during the test. student's t test and linear correlation were used for the statistical analysis.results. mean patient age was ± years and the mean sofa score ± . mean arterial pressure was ± mmhg, cardiac index . ± . l/min/m , pulmonary artery balloon-occluded pressure ± mmhg, and heart rate ± bpm. thirty-four patients ( %) responded to the fluid challenge. responders and non-responders had similar baseline svo ( ± vs. ± %, p = . ). baseline svo was[ % in responders ( %) and in non-responders ( %). there was no correlation between changes in ci (%dci) and the baseline svo (fig. ) . sepsis is a disorder of microcirculation [ , ] . although the pathogenesis of microvascular dysfunction in sepsis is extremely complex, neutrophil activation and their interaction with endothelial cells are considered central features of sepsis-induced microcirculatory alterations. to our knowledge, however, no study evaluated the microvascular pattern of septic patients with chemotherapy-induced severe leukocytes depletion.objectives. to assess early microcirculatory response to sepsis in patients with and without drug-induced neutropenia.methods. demographic and hemodynamic variables together with sublingual microcirculation recording (ops-sdf videomicroscopy) were collected in four groups of subjects: septic shock (ss, n = ), septic shock in neutropenic patients (nss, n = ), neutropenia without inflammation (neutr, n = ) and healthy controls (crtl, n = ). except for controls, all measurements were repeated after complete resolution of septic shock and/or neutropenia (tp ). collected video-files were processed using appropriate software tool and semi-quantitatively evaluated (functional capillary density, fcd (cm/cm ); mean flow index, mfi [ ] ) [ ] . conclusions. microvascular derangements in sepsis did not differ between non-neutropenic and neutropenic patients. surprisingly, neutropenia per se without measurable systemic inflammation was also associated with alterations of the sublingual microcirculation. although we cannot exclude the role of residual neutrophils, our data could indicate that leukocytes are not the only and exclusive modulators of septic microvascular dysfunction. in addition, the role and mechanisms of microvascular changes associated with chemotherapyinduced neutropenia warrants further investigation. multiple organ failure is a leading cause of death in critically ill patients. improvements in outcome will most rely on our capacity to measure rapidly accessible biomarkers.objectives. to investigate if the time sequence of reactive oxygen metabolites (roms) production with sofa score could be prognostic for outcome. the study included critically ill patients (from september to december ) who had roms measured (hydroperoxides) during icu stay, when the diagnostic criteria for sepsis (observed n = ), severe sepsis (observed n = ) and septic shock (observed n = ) were present, - days and weeks after the diagnosis (samples n = ); on the same days, the sofa score was calculated. the plasma roms values were assayed by a diacron-italia kit, applied to an automatic instrument (olimpus au ). statistical analysis was performed used mann-whitney test and the linear regression analysis. the roms values and sofa score were inversely correlated (r = . for sepsis; r = . for severe sepsis; r = . for septic shock). the droms (the difference between the first and the last measurement of roms levels in each individual patient) was significantly different between survivors and non-survivors. clinical characteristics of the patients are presented in table . values are presented as median and interquartile rangers. a p value . was considered as statistically significant.conclusions. the plasma roms values decreased when the critically conditions rapidly evolved towards organ failures with higher sofa. to explore: (a) stress neuropeptides (acth, cortisol, prolactin, neuropeptide y (npy) and substance p (sp)) in critically ill subjects and controls, (b) potential association between levels of stress neuropeptides, disease severity and pain. a prospective correlational study, with repeated measurements and cross-sectional comparisons. fifty-three critically ill patients with diverse primary diagnoses and -age and gender-matched healthy controls were studied for days. serum neuropeptides were quantified by elisa (npy, sp) and chemiluminescence immunoassays (acth, cortisol, prolactin). pain levels were assessed by payen and puntillo scales. clinical severity was quantified by multiorgan failure scoring system (mof) and the multiple organ dysfunction score (mods). results. we observed: (a) statistically significant differences between critically ill and control subjects in regard with cortisol (p \ . ), npy (p \ . ) and sp (p \ . ) levels throughout the study. specifically, cortisol levels were higher and npy and sp levels were lower in patients compared to controls, (b) significant bivariate associations between stress neuropeptides (p \ . ), (c) statistically significant associations between acth and pain intensity levels assessed by payen (r = . , p = . ) and puntillo (r = . , p = . ) scales. there was also a constant but not statistically significant (p = . ) trend for lower sp levels in patients receiving opioids than in controls. moreover, npy levels were significantly lower in patients receiving analgesia (p = . ), (d) lower acth and cortisol levels in survivors (p \ . ) (e) at the day of least severity, a significant association between sp levels and mof was observed (r = . , p \ . ).conclusions. (a) despite the fact that npy and sp are stress neuropeptides, their levels appear to be decreased in mods patients. it is worth-exploring whether critical illness may be a state of suppressed activity of some neuropeptides, (b) the observed association between stress neuropeptide levels and survival in critical illness needs to be explore further, (c) bedside measurement of selected neuropeptides in the future may provide an estimation of pain in uncommunicative patients.hence, the study of stress neuropeptides may provide new insight for the management of the critically ill. objectives. the objective of this study was to compare septic and non-septic inflammatory process in critically ill patients with respect to paraoxonase activity, lipid profile and lipid peroxidation markers. methods. analyzed were serum paraoxonase activity, lipid profile, oxidized low density lipoproteins and conjugated dienes in critically patients with sepsis n = ), age/sex/ap-acheii matched critically ill controls with non-septic sirs (n = ) and age/sex matched outpatient controls without inflammation (n = ).results. the activity of pon was lower in septic patients ( . ± . u/ml) as well as in patients with non-septic sirs ( . ± . u/ml) compared to healthy controls ( ± . u/ml). the decrease in paraoxonase activity, high density lipoprotein cholesterol and apolipoprotein a- concentrations was closely followed by the counter increase of serum amyloid a in both groups of patients. there was no difference in paraoxonase activity between septic and non-septic critically ill patients. the concentration oxidized low density lipoproteins and conjugated dienes as markers of lipid peroxidation, were raised in both septic and non-septic sirs critically ill patients as compared with healthy controls. however there was no difference between both critically ill patient groups.conclusions. the decreased activity of paraoxonase in negative correlation with lipid peroxidation markers offers a potentially useful nonspecific marker of inflammation in critically ill patients.grant acknowledgment. objectives. in the present study, we studied the short-term and direct effects of ivig with sepsis.methods. patients was investigated. following the administration of g of ivig for h, we took blood samples immediately following ivig treatment and at h after ivig treatment. blood samples taken at h and just prior to ivig administration were used as controls. while there was no difference between h before and just prior to ivig treatment, statistically significant decreases were observed in the levels of il- after the administration of ivig. no significant changes were observed in the levels of tumor necrosis factor-a and high mobility group box- .changes in serum tnfa, il- , hmgb we confirmed the results of previous animal studies. while we reported that the administration of ivig directly reduces the levels of il- in patients with sepsis, a further prospective study of the ant-cytokine effects following ivig treatment will be conducted in the near future. objectives. to investigate the levels of nucleosome in septic patients and to determine whether nucleosome could serve as a biomarker for sepsis. sixty-four consecutive patients who were newly admitted in surgical intensive care unit at two university hospitals were enrolled in this study. whole blood samples were drawn within h of admission and on the third, fifth and seventh days. a last blood sample was drawn after recovery at icu discharge in survivors or at imminent death in the cases of non-survivors. plasma levels of nucleosome as well as cytokines il- and il- were detected by means of enzyme linked immunosorbent assay. . fifty patients were diagnosed as sepsis and the other fourteen patients were classified as controls. plasma levels of nucleosome were significantly higher in septic patients than in controls (two-way anova, p \ . ), while the levels of il- and il- were comparable between septic patients and controls. the septic patients presented the highest levels of nucleosome on the admission day, which was significantly different from the admission levels of nucleosome in controls ( . ± . vs. . ± . , p \ . ). the plasma levels of nucleosome between survivors and nonsurvivors showed no statistical significance.conclusions. plasma levels of nucleosome may serve as a valuable biomarker for sepsis.introduction. high mobility group box protein (hmgb- ) is a cytokine that can mediate inflammatory response in different conditions included rheumatoid arthritis, infections, sepsis and septic shock. hmgb- released by activated macrophages/monocytes acts as a late mediator of sepsis. studies have shown that serum hmgb- concentrations were elevated in patients with severe sepsis.objectives. in the present study, we evaluated the role of the hmgb- levels at the time of admission at the intensive care unit (icu) as predictor of outcome in patients with sepsis and septic shock.methods. forty-four patients admitted to the icu with sepsis and septic shock was recruited. serum samples were obtained at the time of admission for the determination of hmgb- levels. the results were correlated with the origin of sepsis, severity, organ dysfunction, requirements of mechanical ventilation and vasoactives, days at the icu, comorbidities and mortality at the icu and days after admission. twenty-six patients were male ( . vs. . %). septic shock was present in patients ( . %). the mortality rate at the icu was . % (n = ) and . % (n = ) at day th. hmgb- levels were . ng/ml ± . ( . - . ng/ml). hmgb- levels were significantly higher in non-survivors at the icu than in survivors ( . ng/ml ± . vs. . ± . , p \ . ). higher levels of hmgb- in serum at the admission were correlated with a higher mortality rate in the icu (p \ . ) but not at day th (p = . ). these levels were not correlated with days at the icu, requirements of vasoactives, mechanical ventilation, and apache score.conclusions. the determination of hmgb- levels at admission at the icu in patients with sepsis and septic shock is a good predictor of worse outcome and lethality.introduction. recent experimental and clinical data ( , ) support the hypothesis that costimulatory molecules, such as cd , play an essential role in the innate immune response during sepsis. expression of cd on the surface of monocytes could represent an important pathway in the modulation of the production of several key inflammatory mediators.objectives. to investigate whether the expression of cd molecule on the surface of plasma monocytes differs among the various stages of sepsis. a total of participants ( icu patients with sepsis, icu patients with septic shock and healthy controls) were included in the study (male patients . %, mean age . ± . years). inclusion criteria: icu patients on mechanical ventilation with first episode of sepsis or septic shock during current hospitalization. exclusion criteria: immunosuppression, neoplasia, autoimmune disease, cardiovascular disease. age, gender and comorbid conditions were recorded. a blood sample for quantification of cd expression was obtained at the time of enrollment (day ), and on the fifth day after the onset of sepsis; measurement was made on the same day. cd expression on the surface of plasma monocytes (on days and ) was assessed by flow cytometric analysis. statistical analysis: kruskal-wallis test to identify difference of cd expression among the groups was performed. post-hoc analysis was made by mann-whitney u test between independent groups, using bonferroni correction for multiple comparisons. roc curve analysis was used to determine the accuracy of cd in identifying patients with sepsis or septic shock. patients with sepsis had significantly higher levels of cd (day ) compared with healthy controls subjects ( . ± . vs. . ± . , p b . ). on the contrary, patients with septic shock did not show any significant difference compared with controls. a roc curve analysis for cd (day ) (auc = . , p b . ), revealed that a cut-off value of . could predict patients with sepsis with a sensitivity of % and a specificity of %.conclusions. upregulation of cd expression may reflect a protective phenomenon during sepsis. on the contrary, low cd expression could represent impaired immune function associated with more severe disease. in order to increase the cardiac output in the septic shock patients, according to surviving sepsis campaign team, norepinephrine (ne) or dopamine administration was recommended. the both agents increase the sympathetic tone which antagonize against parasympathetic activity used for gastrointestinal motility (involved gastric emptying). then, it is raised a question whether ne delayed the gastric emptying or not.objectives. this study was aimed to evaluate the gastric emptying in the septic shock patients with norepinephrine. a prospective observational study involved adult septic shock patients, who received ne continuously in icu sardjito general hospital (yogyakarta, indonesia). patients with any head pathologies (trauma, surgical procedures for tumor or bleeding), any gastrointestinal or abdominal pathologies (diarrhea, trauma, surgical procedures for cancer, peritonitis, ileus etc.), and administrations of metochlopramide or alinamin were excluded. nutrition fluids ( ml) was given passively via nasogastric tube, then after min the tube was aspirated. the volumes of aspirates were recorded in % as a gastric residue. once measurement was done with time randomly for every patient. at the measurement time were recorded the dose of ne and the vital signs.results. the gastric residues were . ± . % ( patients), . ± . % ( patients) and . ± . % ( patients) for the doses of ne of . , . and . lg/kg b.w./ min respectively. at the ne doses of . , . and . lg/kg b.w./min, all of the gastric residues were zero ( patients). the correlation between the ne doses and the gastric rescues was statistically significant (p: . ). the mean arterial pressures (map) were . ± . mmhg (ranges from to mmhg. there was no significantly correlation between map and the gastric residues.conclusions. the gastric emptying in the septic shock patients was not disturbed by administration of ne. introduction. anemia is a frequently encountered problem on the intensive care unit. several factor lead to anemia, among which are traumatic blood loss and the drawing of blood for routine laboratory tests. it's not known how this may affect innate immunity. hepcidin is a central regulator of iron homeostasis. it is induced in response to iron and inflammation and reduced in response to anemia and hypoxia. the suppression of hepcidin leads to the internalization and degradation of the iron exporter ferroportin on intestinal cells and macrophages, leading to the uptake of iron from the gut and the release of iron from the macrophages from the reticulo-endothelial system (res). these cells are central to the innate immune response and the altered iron status of these cells due to suppression of hepcidin may affect the inflammatory response of these cells. we tested the hypothesis that phlebotomy in human volunteers would lead to a suppression of the innate immune response. this abstract provides data of a pilot study carried out in subjects. to investigate the effect of phlebotomy on the innate immune response of whole blood in human volunteers.methods. three volunteers were subjected to the letting of ml of blood by phlebotomy. blood for the determination of hemoglobin and iron parameters, leucocyte count and differential, and hepcidin- was drawn at day , and after phlebotomy. further whole blood stimulation was carried out at each time point by adding . ml heparin anticoagulated whole blood to a prepared tube containing endotoxin, pam cis or rpmi as a control. final concentrations of lps and p c were ng/ml and lg/ml respectively. these tubes were incubated at °c for h and centrifuged for min at , g. the supernatant was frozen at - until the measurement of tnf-alfa and il- by elisa. cytokine production was corrected for the number of monocytes present. data are expressed as mean ± sem. hemoglobine decreased from . ± . mmol/l at baseline to . ± at day . it returned to normal at day . there were no apparent changes in serum iron levels. there was however a clear decrease in serum ferritin levels from ± at baseline to ? at day . leucocyte count and differentiation did not show any significant changes. hepcidin was clearly suppressed from to day after phlebotomy (from ± to ± ). tnf-alfa production dropped from to ng/ monocytes at day . il- production dropped from to ng/ monocytes. hepcidin levels correlated well with cytokine production (r . for tnf-alfa, r . for il- ).conclusions. phlebotomy leads to suppression of the innate immune response in whole blood. this could be a result of the intracellular decrease of iron in immune cells due to the systemic suppression of hepcidin. these findings are relevant to critical care patients that are subject to the repeated drawing of blood while their immune system is often compromised. introduction. hypothermia and hyperthermia occur in many pathological states presenting to the emergency department. both these processes are known to significantly impair coagulation pathways but as yet there is little evidence to show what affect they have on the evolving clot structure. previous studies have attempted to determine the effect of temperature on whole blood coagulation using techniques such as thromboelastometry (teg) but its ability to provide meaningful outcomes in terms of clot quality and structure remains elusive. recent studies have highlighted the potential of a new technique, gel point (gp) and fractal dimension (d f ), as a functional biomarker in haemostasis. to explore both the changes in coagulation pathways and their associated effect on clot structure and quality based on the new biomarkers, gp and df. following full ethical approval, healthy whole blood samples were obtained from individuals and tested at temperatures of °c (n - ), °c (n - ), °c (n - ), °c (n - ), °c (n - ). an oscillatory shear technique [ ] using an ar-g instrument (ta instruments) was applied to each sample. the gp, which indicates the formation of the fibrin network, was obtained for each sample using the chambon-winter gel point criterion [ ] . this method provides the basis from which d f can be determined [ ] to interpret the structural properties of the clot network. the results were compared with the standard teg analysis. firstly, results showed a significant progressive change in the clot structure by this new biomarker across the whole temperature range ( - °c). secondly, it also highlighted a significant and meaningful correlation between coagulation pathway change (time to gp, tgp) and the eventual clot outcome (fractal dimension). the tgp of the incipient clot was prolonged and the corresponding d f decreased with reduced temperature values. although, the changes in the coagulation pathway of the teg (r time) and the rheometer (tgp) correlated, the new biomarker, d f , provided additional structural data on the fibrin network formed and highlighted the relationship between coagulation pathway changes and the eventual fibrin clot structure.conclusions. in this study, we describe and quantify for the first time how temperature affects the coagulation pathways and how this impacts on the fibrin clot network, morphology and strength by using the new biomarkers, gp and d f . the potential of these new biomarkers in determining the effects of temperature change in critical illness and injury needs to be evaluated clinically. key: cord- -j cecioe authors: fager, edward w. title: determination and analysis of recurrent groups date: - - journal: ecology doi: . / sha: doc_id: cord_uid: j cecioe nan the primary information available from an ecological survey usually consists of a mass of sampling results involving many localities and many species. in order to investigate the interspecific processes which may be involved in controlling the abundance and distribution of the species found, it is useful to be able to group together those species which frequently occurred together in the samples, which were in this sense a nearly constant part of each other's biological environment. the grouping will be most valuable as a classificatory device if it consists of defined units obtained by a procedure which can be repeated. whatever the method of grouping employed, the sampling procedure is certain to introduce subjective elements; the size of sample, the number and selection of sampling sites and the sampling methods used will always be influenced by the judgment of the person doing the study and they will in turn influence the composition of the groups. if, however, the sampling conditions are explicitly given, the probable extent and character of these influences can be taken into account and a meaning given to the groupings in this context. some of the methods of grouping which have been suggested will be briefly reviewed (see also macfadyen, ) and a new method will be outlined which overcomes some of the difficulties review of some methods of grouping animals have often been grouped on the basis of vegetation or of various physical or chemical factors in the environment, but many difficulties are involved in vegetational classification or in deciding what is a critical limit in respect to a certain physical or chemical factor. furthermore, animal groupings do not always conform to vegetation or other factors ; a group may extend over several recognizable vegetation or soil divisions or there may be several distinct assemblages of animal species within an environmental complex which is uniform in many other respects. the characterization of the habitat in which an animal group is often found must include the associated plants and other factors, but it seems better to use the animals as the primary basis for their grouping. gisin ( gisin ( , gisin ( , has suggested a procedure using what he has called "differential" species. in the hands of an experienced worker this method can lead to useful groupings, but the choice of the species which will be designated as "differential" is so subjective that comparison between groupings by different workers, even if based on the same material, may be impossible. moreover, using this method groups may be suggested the constituent species of which so seldom occur together that it seems unlikely that they could have any relation to each other. for example, gisin ( ) in his rearrangement of agrell's ( ) swedish lapland collembola suggested four groups. members of three of these were found together moderately often. the fourth group contained four species, representatives of which were recorded in a total of thirty-one samples ; no sample contained all four, one sample contained three, five samples contained different pairs and twenty-five samples contained only one of the species. the subjective element can be reduced if the grouping is based on a defined index of affinity. perhaps the simplest expressions which might be used for this purpose are those proposed by jaccard ( ) and sprenson ( ) as measures of the similarity between floras. as given, however, neither differentiates between a coefficient based on ten samples and one based on one thousand samples, though the latter would surely be a more reliable estimate. the expressions also fail to take account of changes in the relative number of total occurrences of the two species; as long as the sum of the total occurrences remains constant, the proportions can change without affecting the value of the coefficient. a method based on correlation between pairs of species is precisely definable but, as cole ( ) has pointed out, product moment correlation cannot be used directly because sampling results for most species are not normally distributed in regard to numbers of individuals per sample; there are qsually a few outsize samples which will have a disproportionate effect on the calculations. transformation of the data or the use of rank correlation could overcome this difficulty, but any method which involves a measure of abundance may, in certain cases, not lead to the desired results : two species may always occur together and never separately and yet, unless there is a nearly constant relation between the relative numbers of individuals of the two species, a correlation coefficient will indicate no relationship even though they are a constant part of each other's biological environment. for this reason it seems best to base species groupings upon presence and absence alone and to consider abundance relations within such groupings after they have been determined. in his paper, cole ( ) discussed the coefficients of association which had been proposed up to that time and indicated the deficiencies of each. he then proposed a new coefficient using only presence and absence and based on a x con-ti~ig-ency table for which a chi-square test of sigmficance can be calculated. a basic assumption of his expression is that all samples taken should be included; i.e., the probabilities of occurrence of the two species being tested for association are assumed to be uniform throughout the area sampled. under this assumption, the chi-square indicates the significance of the departure of the observed number of joint occurrences from the number expected on the hypothesis of independent distribution of the two species over all the samples. although cole did not use his coefficient for grouping species, it has been so used several times since. the following example shows that it is not a satisfactory criterion for grouping if the groups are to be composed of species which form a nearly constant part of each other's biological environment: species and show no evidence of association when examined by cole's method and yet they nearly always occur together-over % of the occurrences of each are in company with the other -and should be considered together in any grouping based on this set of samples. on the other hand, species and are significantly associated by cole's criterion even though their affinity is rather low-less than % of the occurrences of each are in company with the other. in general, two species which occur in most of the samples taken will show little or no evidence of association and two species with a low percentage of joint occurrences can show significant evidence of association if they are rare enough or if a large enough number of samples in which they could not occur are included. bray ( s ) has recently noted these difficulties connected with the use of cole's index and has attempted to overcome them by considering only quadrats within plots in which both species occurred. macan ( s ) using the method without modification found a very large number of positive associations in his analysis of collections of corixidae, a finding which, as he indicated, was unsatisfactory because the objective analysis produced a less well-defined picture than that which could be obtained from a subjective technique based on a knowledge of habitat features. an expression of the sort suggested by cole has certain desirable properties; in particular, it is sensitive to changes in the relative frequency of occurrence of the two species and a "significance a t-test is preferred to chi square because it can be used as a one-tailed test [ . s ,....., p (.os) ] for positive affinity; negative affinity, being based on the failure to find a species, seems potentially subject to too many unavoidable errors. there are both mathematical and biological reasons for setting an upper limit on the value of nn which will be considered with a given na: the closer the ratio nnjna is to , the closer the normal approximation will be to the true value; keeping the ratio close to ensures that whenever evidence of affinity is obtained the number of joint occurrences will be a considerable proportion of the total number of occurrences of both of the species. this is a desirable property for an index to be used as a basis for grouping if the purpose is to put together organisms which are a nearly const·mt part of each other's biological environment. an upper limit of for the ratio nn/na is therefore sug-level" can be defined for use as an objective criterion of the presence of affinity. it can be adapted for use as an index of affinity if it is assumed that the probability of finding species a is najna + nb and of finding species b is nbjna + nb, where na is the total number of occurrences of species a and nb is the total number of occurrences of species b; i.e., the probalilities of occurrence of the two species are related to the sum of their occurrences (na + nb) rather than to the total number of samples taken. the use of this assumption removes the premium on rarity and also makes it possible to find evidence of affinity between two species which occur in most of the samples taken. it seems neither more nor less arbitrary than the use of the total number of samples for the latter is usually determined arbitrarily by the person doing the work, often mainly on grounds of practicality or subjective judgment that the number taken is sufficient. if the preceding assumption is used and the species are assigned to the letters so that na is less than or equal to ne, the number of joint occurrences (j), on the hypothesis of independent distribution, will have a hypergeometric distribution with expected j equal to nanejna + ne and variance equal to (nanb) j(na + ne) (na + ne- ). for values of na greater than and p and q not too different from j , a normal approximation can be used to test the significance of the deviation of the observed number of joint occurrences from the expected number. for this purpose, the following expression can be taken as a normal deviate with mean and unit variance (pearson ): gested. the use of such a limit has the disadvantage of preventing the finding of affinity between such a pair of species as a rare parasite and its relatively abundant host, but the existence of a relationship of this kind can, in any case, probably be satisfactorily established only by field observation and breeding studies. minimum values of j which are significant at the .os level have been calculated for values of na from s to using exact probabilities obtained by leslie's method ( ss) . similar values have been calculated for each tenth value of na from to using the normal approximation. both sets are given in table in the appendix. these values and intermediate ones which can be estimated by interpolation will make it possible to quickly sort pairs of species into those which certainly show evidence of affinity, those which cer-tainly do not and those which are doubtful and require calculation. when applied to the examples used in the discussion of cole's coefficient, the index proposed above indicated significant evidence of affinity between species and but none between species and . it is, therefore, a better index of the pro-portion of occurrences which are joint occurrences and should provide a more satisfactory basis for grouping. it may be repeated that cole did not develop his index as a basis for grouping and that the two indices measure different things: cole's index measures the departure of the two species from independence of distribution on the assumption that the probability of occurrence of each is constant over all the samples taken ; the index proposed in this paper provides an objective measure for the word "frequently" in the statement "these species frequently occurred together." the procedure to be outlined for the determination of recurrent groups may appear complicated but with a little practice it can be gone through at least as rapidly as the "fitting by eye" of a trellis diagram. it has the virtue of repeatability ; given the same primary information, two workers will always arrive at the same groups. this means that if several workers using similar sampling methods make studies in different localities and find different recurrent groups, there is some assurance that the differences are real and not the result of differences in judgment or emphasis. any dichotomous index of relationship between species can be used as a basis for grouping by this procedure; the meaning of the groups will be determined by the nature of the attributes measured by the index. in this paper, a recurrent group is defined as one which satisfies the following requirements : ( ) the evidence for affinity is significant at the . level for all pairs of species within the group. ( ) the group includes the greatest possible number of species. ( ) if several groups with the same number of members are possible, those are selected which will give the greatest number of groups without members in common. ( ) if two or more groups with the same number of species and with members in common are possible, the one which occurs as a unit in the greater number of samples is chosen. these requirements are to be taken in order; i.e., the group or groups which fulfill requirements and are determined and then, if there are several possible combinations, a choice is made on the basis of , followed, if necessary, by . such groups will represent the largest, most frequent, separate units within which all the species formed a nearly constant part of each other's biological environment. they would be a likely choice if one wished to make an intensive study of interspecific processes which are quantitatively important in the habitats sampled. the following procedure will give a recurrent group or groups as defined above. the affinity information for the species concerned may be set out in a trellis diagram as shown for the example (table i) . if there are many species, it has been found more convenient to record the information for each species on a separate card. . =non-affinity the species are put in order in terms of the number of other species with which they have affinity. in the example this order is a, b, c, . . . p, q. starting with the species with the largest number of affinities, species are counted in the direction of decreasing number of affinities until the number of species counted (x) exceeds the number of affinities ( y) of the last species counted. in the example this occurs at species h where x = and y = . two possible relationships between x and y must now be considered: if this is true, as it is in the example, the largest potential group will contain y + species ; species in the example. it cannot contain more because species h has affinities with only other species and can, therefore, only form a group of species satisfying requirement ( ). if species h is omitted, only species are left. because the species were put ecology, vol. , no. in order in terms of the number of other species with which they had affinity, the species beyond h will either have the same number of affinities as h, in which case they are also potential members of a group of species, or fewer affinities than h, in which case they cannot be included in a group of species satisfying requirement ( ). if species h had had affinities with other species, the largest potential group would have contained the first species, a to h. [x > y + ] if this is true, the largest potential group will contain the x - species preceding the last one counted. for example, if species h had had affinities with or fewer other species, the largest potential group would have been composed of the species, a to g, for h and any species beyond it could only form a group containing or fewer species. the counting procedure thus selects those species which are potentially members of a group satisfying requirements ( ) and ( ). these must be further examined to determine whether such a group can be formed. two preliminary tests of the possibility of its formation can be applied. the first test can be stated as follows : in order to form a group of z members from v potential members, there must be at least z of these with more than z- affinities with others of the potential group. for this test the affinities of each of the selected species with all others of the potential group are tabulated. this tabulation for the example is shown below : a b c d e f g h v = ;z = . there are only species which have more than affinities and, therefore, a group of species cannot be formed. passing the preceding test is a necessary but not sufficient condition for the formation of a group as can be seen by consideration of the following : if the interrelationships among the potential members had been such that there was affinity between all species except the four pairs, a-b, c-d, e-f, and g-h, the tabulated affinities would have all been and yet no group containing species and satisfying requirement ( ) could have been formed. on the other hand, if the species a to g had had affinity with all others except h, the tabulated affinities would have been seven 's and one and a recurrent group of species could have been formed. in general, the affinities lacked by the species needed to form the group must be accounted for by species which are not necessary for its formation. the second test determines whether this condi-tion is met. it can be expressed algebraically as follows : in order to form a group of z members from v potential members the following inequality must hold: (v- ) ( z-v) < + ~ z largest affinities -~ the rest of the affinities. applied to the two cases discussed in the preceding paragraph, it gives the following results: incorrect, a group of cannot be formed. ( - ) ( [ ] - ) < + ( )- ( ); correct, a group of can be formed. this is a necessary and sufficient condition for the formation of a recurrent group when v = z or z + ; it is necessary but not sufficient when v = z + or more for in this case the two sums on the right hand side of the expression can vary independently to some extent, the more so as there are more possible pairs of species within the category "rest." although passing these tests does not make the potential group a certainty in all cases, the two tests will prevent unnecessary work in many instances in which no group can be formed. returning now to the example, no group of species could be formed so the possibility of the next smaller group, species, is investigated. two additional species, j and k, must now be considered for, having affinities with other species, they could be members of a group of . the affinities within the group of species are shown in the first line of the tabulation below. both tests indicate that it may be possible to form a recurrent group of species : there are over species with more than affinities; ( - )( [ ] - ) is less than + ( + + + + + ) -( + + + ). the affinity interrelationships must now be examined in detail in order to make the final determination. perhaps the easiest way to do this is to eliminate those species which do not have more than z - affinities, g and k in the example ; repeat the tabulation as shown in the second line below, eliminate species which now do not have more than z - affinities and repeat until no more species can be eliminated. if at the end of this process v is less than z + , the second test can be applied as a both necessary and sufficient condition for the formation of a recurrent group. v=lo z= v= z= v= z= v= z= in the last line ( - ) ( [ ] - ) is less than + ( ) - and as v = z this is a necessary and sufficient condition for the formation of a recurrent group. therefore, the species a-e, j constitute the group. the presence of j in the group emphasizes the necessity of considering all species which, on the basis of the number of other species with which they have affinities, might be part of the group. the initial counting procedure takes care of this automatically for the largest potential group, but the appropriate species must be added if this group cannot be formed and the next smaller must be considered. as there were no alternative groups of satisfying requirements ( ) and ( ), requirements ( ) and ( ) do not have to be considered. the species not included in the group are now examined to see if any have affinities only with members of the recurrent group. this is true of l and q. such species are considered associates of the recurrent group. the procedure is repeated on the remaining species, omitting their affinities with members of the first recurrent group (table ii) . the largest potential group contains species; x = and y = at species n. when the affinities within this group of are tabulated, however, p and n have only and a group of species cannot be formed. all of the species must be included when the next smaller group, species, is considered. none can be eliminated on the basis of the first test and as ( - ) ( [ ] - ) is less than + ( + + ) -( + + + ) a group may be possible. when the interrelationships are examined in detail, the following groups are found to satisfy requirements ( ) and ( ) : fgn, fgp, fhp, fkp, gmn. requirement ( ) will be satisfied if gmn and either fhp or fkp are selected. in order to decide between the latter two, the original sampling results would have to be investigated on the basis of requirement ( ) . it will be assumed here that fhp occurred as a unit more often than did fkp. the relation- ships between the species might be set out as shown in figure . this method has been applied to several studies reported in the literature and to an unpublished survey of the invertebrate fauna of decaying wood done by the author. in all cases the groups determined were consistent with what was known of the species' requirements, preferences, etc. the invertebrates from decaying wood were grouped using code numbers for the species in order to eliminate the possibility of bias ; the groups found were in general agreement with impressions gained during sorting and counting. recurrent groups based on the index of affinity proposed in this paper and determined by the procedure outlined above are composed of species which very frequently form a part of each other's biological environment. such interspecific concepts as dominance, concordance and correlation should, therefore, be particularly meaningful when examined within these groups. the several methods of analysis suggested below use ranking procedures which, as kendall ( ) has shown, are very useful for detecting general trends in material which includes some extreme values, as sampling results from natural populations nearly always do. before the analytical methods can be applied, samples representative of each recurrent group must be selected. for groups containing only a few species, selection can be based on the requirement that all species in the group are present in the sample. for groups containing many species, this may too greatly reduce the number of samples and some compromise must be accepted. the requirement should be set at a high percentage present but the exact value to be used will depend on the sampling results which are available. it should be explicitly stated in any case. table iii presents some sampling results, related to actual observations but somewhat modified in order to show the different results which dominance numerical dominance is often expressed as a mean percentage of total individuals, obtained from the summed percentages of the samples considered separately. such an expression, using percentages calculated for samples with different total numbers of individuals, is hard to interpret and gives no information about the constancy of the relation. the difficulties of interpretation are increased if the species are dissimilar in size, activity, etc. it is, therefore, suggested that determinations of dominance be restricted to species within recurrent groups which are, or appear to be, similar in regard to size, activity, food requirements, etc. and that the determination be based on ranks within samples, summed over the set of samples. this is equivalent to n things (species) ranked m times (number of samples in the set). the concordance among the rankings can be tested by the statistic w (kendall , pp. - ) , which can range from to ; from no agreement to perfect agreement among the rankings. details of the calculation of w and of an f-test of its significance are given in the appendix. the use of ranks within samples gives every sample an equal voice in the decision and eliminates the bias which one or two samples with exceptionally large or small percentages may impose on the per cent method. rankings within samples for the species a, b and c and d and e are shown in the second part of table iii. for the value of w is significant at the . level showing that there is concordance among the samples; i.e., the dominance relations between the species tend to be constant over the set of samples. the sum of ranks is for each species the best estimate, in the sense of least squares, of the over-all rank of that species and if there is significant evidence of concordance the species may be ordered by these sums. the results may be stated as c >a, b; i.e., c is constantly dominant to a and b, and a is probably dominant to b but their sums of ranks are so nearly equal that the relative positions are less certain. the value of w[w = . ; f(n = . ; n = . ) = . (p > . )] is not significant for d and e indicating that dominance relation between these two species is not constant. relative abundance over all the samples is related to but not the same as numerical dominance. for example, assume that the numbers of individuals of two species found in samples were as follows: species x would be found to be constantly dominant to species y and yet their relative abundances would not be significantly different. the difference between the relative abundances could be tested by the usual t-test of the difference between the means, but if there were any outsize samples they would exert a disproportionate influence. as these are often present among samples taken from natural populations, it is probably better to use the distribution-free statistic u and a t-test based on it (hoel , pp. - ). this tests the hypothesis that the distributions of the two populations of values are the same against the alternative that one distribution is situated to the left (lower valued) of the other. it is not affected by outsize samples. details of the calculation will be found in the appendix. in the case of species a and b the observed value of u is not significantly different from the expected value. there is, therefore, no evidence that the distribution of abundances of a was different from that of b. as is apparent by inspection, c was significantly more abundant than either a or b. the observed value of u is significant at the .os level, indicating that e was significantly more abundant than d even though determination of dominance had shown that it was not constantly dominant to d. the concordance among the species of a recurrent group on what constitutes a good habitat can be tested by the same methods ( w) as were used in examining numerical dominance except that in this case ranking is done within species and the meaning of n (number of samples in the set) and n (number of species) are the reverse of those used in the previous test. if the observed number of individuals of a species is taken as an estimate of the goodness of a sample for that species, the samples can be ranked in regard to each species ; this eliminates difficulties due to differences between species in average abundance, efficiency of collection, etc. the sum of these ranks over all species of the group is for each sample the best estimate, in the sense of least squares, of the rank of that sample among the samples selected as representative of the group. if there is significant evidence of concordance, the samples can be put in order. rankings within species are shown in the third part of table iii. for the recurrent group considered as a unit; showing that there is agreement among the species on what constitutes a good or bad habitat. the samples can be put in order of decreasing goodness as follows: > , > , , , , , > . an examination of the other characteristics of these samples, especially the extremes, might reveal a good deal concerning the preferences and requirements of the group as a whole. rank correlations between species should also be calculated because the preceding generalization may miss significant relations: if, in a group consisting of four species two rankings are alike and the other two are exactly the opposite, the concordance will be zero although the six possible pairs of species will give four perfect negative correlations and two perfect positive correlations. because of the possibility of parent correlations, nonsense correlations, etc., the interpretation of correlation analysis must always be viewed with reservations. if, however, correlation coefficients are calculated only for those pairs of species for which there are other reasons for expecting interrelationships, they may serve as useful guides to the mature and constancy of the relations. kendall's ( , pp. - , ) the nearly significant positive correlation between the two species of poduromorph collembola, ac, might be due to chance, might indicate that the species have a favourable effect on each other, or might result from their liking the same conditions and not interfering. the significant positive correlation shown by the presumed prey-predator pair, cj, indicates that the predator did tend to congregate in those places where its prey was abundant. the absence of significant negative correlation between similar species means that in none of the pairs of species was an increase in the number of individuals of one always accompanied by a proportionate decrease in the number of individuals of the other. more evidence than the presence or absence of correlation is necessary before biological relationships can be claimed, but such an analysis will suggest those which might best repay further investigation. this paper presents a defined, repeatable method for grouping together species which are frequent components of each other's biological environment. such a method makes it possible to compare groups found in different habitats or at different times or localities. as the composition of these recurrent groups is influenced by the method of sampling used and by the "level of significance" required of the index of affinity, the groups are abstractions. it has, however, been found that if sampling is related to the size, activity, etc., of the organisms and the significance requirement is made stringent, the groups formed have ecological unity in the sense of significant intragroup agreement on what constitutes a good or bad habitat. it seems reasonable, therefore, to consider them as natural assemblages, somewhat artificially delimited but nonetheless real. because the recurrent groups are composed of species which very often occur together, they represent particularly appropriate units within which to examine interspecific relationships. the analytical procedures suggested for this examination have two purposes; the provision of a summary description of relationships and the suggestion of working hypotheses upon which to base further field and laboratory work. the use of methods employing ranking gives each species an equal voice in the analyses, removes many of the difficulties due to non-normality of distributions and makes it possible to determine the constancy of general trends. a new index of affinity between species, based on presence and absence, is proposed and a table is provided from which the significance of an observed number of joint occurrences can be estimated. using this index and a four-part definition of a recurrent group, a procedure is outlined which leads to the largest, most frequent, separate groups within which all species formed a nearly constant part of each other's biological environment. ranking methods are suggested for the examination of interspecific concepts such as numerical dominance, relative abundance, concordance and correlation within these groups. the essentials of the methods of testing for con-cordance ( w) and correlation ( -rb) and of the u test are given below for the convenience of those to whom the texts may not be readily available. the expressions given for the first two tests include the corrections required when tied ranks are present. in both cases, t or u represent the extent of ties present; e.g., if a ranking has members with one rank and others with another rank, the summation is ( - ) + ( - ) in the case of wand ( - ) + ( - ) in the case of "b· for the calculation of w all ties are considered together ; for the calculation of 'rb the extent of ties in one ranking is represented by t and that in the other by u. when tied ranks are absent, the summations are and the expressions are considerably simplified. concordance (kendall ) : if n things are ranked m times, the ranks for each of the n things are summecl and the sum of the squares of the deviations of these sums from their mean is represented by s, the concordance between the rankings ( w) is given by the following expression : w- s m n(n - )ml'jt(t - ). this does not have to be modified for tied ranks unless the number and extent of ties is large. to determine significance the usual table of the variance ratio (f) is entered with degrees of freedom n and n • correlation (kendall ) : the rankings are arranged so that one is in the natural order- , , , ... n. following this arrangement, scoring is based entirely on the other ranking. starting with the lefthand member, + is scored for every larger rank and - for every smaller rank to the right of it. after this has been done for each member of this ranking, -rb is calculated from the sum of the scores ( s) as follmvs : s 'rb = y'[n(n- )l'jt(t- ) ][n(n- )l'ju(u- )] . t is the sum of ranks of the y's when the x's andy's are ranked together. these expressions can be used in a one-tailed t-test of the hypothesis that the distributions of the two populations are the same against the alternative that the x population is situated to the left (lower valued) of the y population. for m and n equal to or more, the following expression may be taken as a normal deviate with mean and unit variance : this test is nearly as efficient as the usual t-test when applied to normally distributed populations ; as it is distribution-free, it is applicable to nonnormal distributions. example: if na = and nb= , a j of at least is necessary for significant evidence of affinity; if na= and nb= (nb/na= . ), minimum significant j can be zur okologie der collembolen: untersuchungen im schwedischen lappland a study of mutual occurrence of plant species the measurement of interspecific association vegetationsforschung auf soziationsanalytischer grundlage analyses et syntheses biocenotiques . l'ecologie introduction to mathematical statistics nouvelle recherches sur ia distribution florale rank correlation methods a simple method of calculating the exact probability in x contingency tables with small marginal totals a contribution to the study of the ecology of the corixidae (hemipt the invertebrate fauna of the choice of statistical tests illustrated on the interpretation of data classed in a x table a method of stabilizing groups of equivalent amplitude in plant sociology based on the similarity of species content and its application to analyses of the vegetation on danish commons key: cord- -sow k m authors: an, jisun; kwak, haewoon title: multidimensional analysis of the news consumption of different demographic groups on a nationwide scale date: - - journal: social informatics doi: . / - - - - _ sha: doc_id: cord_uid: sow k m examining , news articles that are the most popular for different demographic groups in daum news (the second most popular news portal in south korea) during the whole year of , we provided multi-level analyses of gender and age differences in news consumption. we measured such differences in four different levels: ( ) by actual news items, ( ) by section, ( ) by topic, and ( ) by subtopic. we characterized the news items at the four levels by using the computational techniques, which are topic modeling and the vector representation of words and news items. we found that differences in news reading behavior across different demographic groups are the most noticeable in subtopic level but neither section nor topic levels. demographics play an important role in news consumption. what women in their fifties read is very different from that of men in their twenties. understanding such differences in news consumption can potentially help journalists to pitch news articles better, help editors to decide which ones to put on the front page, and help computer scientists design new algorithms for recommending articles. that is the reason why news consumption of demographic groups has been actively studied in both the domains of journalism study and computer science [ , , , , , ] . the previous literature regarding news consumption in the study of journalism has mainly focused on the gender differences in the consumption of news genres [ , , ] primarily due to the lack of other detailed data. on the other hand, in computer science, previous studies have mainly focused on developing models for predicting clicks and for news recommendations at an individual level with large-scale data [ , , ] . in this study, we attempt to bridge these two worlds and uncover the differences in news consumption across demographic groups by large-scale news consumption data. specifically, we aim to quantify such differences in four dimensions: actual news items, sections, topics, and subtopics. while the existence of the "differences" is expected, our multidimensional analysis shows how such differences can be differently captured in each dimension. for this study, we collected and analyzed the daily top news items for each gender (male and female) and age group ( s, s, s, s, and s) in daum news, the second most popular news portal service in south korea, for the entire year of . the number of the unique news items collected is , . daum news can have the accurate, not self-reported, information on the user's age and gender based on one's social security number. this practice is not common in the western web services. in south korea, to join a website, it is mandatory for identity verification to provide the social security number that contains your birth year and gender. also, daum news has a strong user base that reads news with a logged-in status mainly because daum news offers a wide range of services, which include e-mail, internet community, or messenger, for example, based on the logged-in status. sex-typed media preference has long been investigated for various types of media. regarding movie and tv genres, studies have found that women are more likely to watch tragedies, soaps, dramas, medical serials, and romances; men, on the other hand, tend to prefer horror, sports, and action and adventure content [ , , , , ] . psychological research suggests that such sex-typed media selections might well be rooted in societal gender stereotypes -men are expected to achieve more, and women are expected to interact more [ ] . scholars of the study of journalism have examined how demographics, such as sex or age, relate to news-seeking behavior and news preferences [ ] . when attending to news, the sexes typically pursue remarkably different interests -in terms of topics, men tend to follow news on politics, sports, and business and finance, whereas women turn to news about community and health issues [ , ] . also, women read more about social/interpersonal issues than men, and men read more about achievement/performance than women [ ] . scholars suggested that the origin of gender difference in news consumption is not considered from biological differences but from the psychological traits led by the sex-typed socialization [ ] . while news preferences have been extensively studied for the news section, little is known about the topic or subtopic preferences of different demographic groups' news consumption. the key reason for this oversight is mainly due to a lack of data. most of the previous work is based on surveys or experiments in the laboratory setting [ , , ] . by contrast, our work relies on the longitudinal data collection where a huge number of korean internet news readers are unobtrusively monitored. since news sites have been publishing online, we now have access to large-scale data of individual news consumption with detailed personal profiles. computer scientists have addressed news-related questions but with different interests and approaches from scholars in journalism or communication studies. news-related research by computer scientists has predominantly focused on modeling news sharing behavior [ ] [ ] [ ] , news diffusion [ , , , , , , , , ] , and modeling the relative prominence of items or topics [ , , , , , ] . computer scientists also have exploited news consumption patterns of individuals mainly for building a better news recommendation system to give readers a personalized experience when reading the news. systems that make recommendations according to demographic classes were initially introduced [ ] . more recently, the demographic information has often been used as a feature of those models [ , ] . however, the demographic differences in news consumption have not been fully uncovered, particularly in different dimensions of news such as topic or subtopic. online news consumption in south korea has increased drastically. about % of south korean people access news online at least once a week . given the % internet and % smartphone penetrations, such a drastic increase makes sense. web portal sites such as naver and daum are especially popular digital news platforms. due to the extreme popularity of these portals, news providers in south korea have been eager to publish their content via portals for years. in , naver and daum formed the committee for the evaluation of news partnership, complete with a set of ethical standards to help decide which providers should be eligible to supply news to portals. as a result, we can reasonably say that news providers and the news readers of daum news are representative of the general south korean news media and population, respectively. daum is the second largest web portal in south korea, followed by naver. daum plays a significant role in providing a place for accessing online news to south korea; % of south koreans ( . m users) access daum news on a weekly basis. daum news provides different ways to explore news articles, for example, by its recency, by current issues, by regions, or by popularity based on the number of views or the number of comments. a unique feature of daum news is that it provides the top most popular news articles on a particular day for each gender and age group, which are [male or female] and [ s, s, s, s, and s and above]. we note that naver does not provide a ranked list of news articles by different demographic groups, and thus, we focus on daum news data even though it is the second largest news portal in south korea. we crawled the top most popular articles for different age and gender groups of each day for a one-year period ( / / − / / ). we carefully designed our crawlers not to degrade the performance of daum's web servers. in our data set, we have , listed news items with , unique news titles. for each news item, we have its unique item id, demographic group, rank in the group, title, summary, news source, and published date. we note that news articles about entertainment and sports are not included in the lists due to daum news's policies. we need to determine the section, topic, and subtopic of the news items we collected. next, we will briefly describe the methodology that we adopt for the analysis. defining the operational coding scheme for news has been a central issue for communication studies. in this study, we introduce four dimensions of news (sections, topics, subtopics, and individual news items) by which we investigate news consumption patterns. the diagram of the four dimensions of news is illustrated in fig. . the first dimension is the news section (e.g., society, politics, etc.), which is a category of news often adopted in newsrooms and which has been popularly used for sex-typed news preference studies. next, a news topic refers to a specific happening (e.g., a mers outbreak in south korea or child abuse case in a daycare center). within a topic, we further explore subtopics by distinguishing different aspects of a topic. finally, there is a dimension where all individual news items are aligned. we then can characterize the entire news collection (e.g., a news collection of south korea in ) according to the four dimensions. the most common way of categorizing news is perhaps to use a news section as defined by the news media. especially for online news, which news section a news article belongs to can be inferred from the meta information embedded in the news urls. for example, the url http://media.daum.net/society/labor/ newsview?newsid= l is categorized as "society." we parsed all of the collected urls and extracted the section information. figure shows the proportion of news items for each demographic group for each news section. in our dataset, daum news has seven different news sections, which are culture, digital, economic, foreign, life, politics, and society. we note that the entertainment and sports sections are not included in the dataset. we observe that female groups are more alike than male groups in terms of news section preference. for female groups, society and culture were the two most popular news sections. for age male and age male groups, society, foreign, and politics were more popular than the others. then, for the age male and age male groups, their interests were digital (i.e., technology news), economics, and politics. we also find one noticeable behavior of the age male group: % of their top most popular news items over a year are about politics. these news section preferences align well with previous work on sex-typed news consumption observed internationally [ , ] . the news section category provided by daum news abstractly captures the high-level topic of a news item. in this study, we go beyond a mere news section preference and examine whether the gender-or age-specific topic or subtopic preferences exist. to do that, we need to understand the semantic content of the news articles. for example, news about "violence at daycare" and "a killer of his family" are both categorized under society, but they are two different topics. we automatically discover a topic-specific categorical structure from a set of titles and classify each news article based on it. topic modeling techniques such as probabilistic latent semantic indexing (plsi) [ ] , latent dirichlet allocation (lda) [ ] , and hierarchical dirichlet processes (hdp) [ ] can be employed to induce topics from the set of news titles. we manually compare the three methods in terms of the interpretability of the induced topics and the quality of the clustered news titles for each of the included topics. for two slices of subsets, may and october , we examined the top topics resulting from the three methods with their top words. for our dataset, plsi's top topics were mapped more clearly with news events in the corresponding month than lda's and hdp's topics were. one possible reason is that lda and hdp were penalized more for modeling topics with short titles than plsi was. thus, we use plsi to detect candidate topics. there are also specialized topic models for short texts, such as a biterm topic model (btm) [ ] , and we leave it as a future work to improve our topic categorization method. one problem with these topic modeling techniques is that they are not timesensitive. the following two news titles, "anyang killer -a man killed his family" and "wife killer -a man killed his wife but did not show any grief," are likely to be categorized as the same topic even though one event happened in january , and the other happened in october . to handle this problem, we first split our dataset by month, and then we build a plsi model for each of the monthly datasets. each plsi model induces topics, giving us , candidate topics in total. each topic is represented by word distributions. we then aggregate similar candidate topics by examining the representative keywords for topics (words with the highest probabilities). in our case, we aggregate topics if they share more than three top words. after this, we classify each news title as one of these candidate topics based on the score given by the plsi model. finally, we split every candidate topic further into multiple topics by considering the publication times of news items. only news items published for days in a row are tagged as the same topic, resulting in , topics. news titles without any matching candidate topic are considered stand-alone topics. altogether, we have , topics. across all topics, the most popular news event is the middle east respiratory syndrome (mers) outbreak in south korea. we find , matching news items regarding mers. the most frequent words are mers, a vice prime minister, confirmed patients, infected, hospital, daejeon, tourists, etc. validation of topic categorization. for the purpose of validation, we crossmatched the set of news items extracted by the topic-model-based clustering method with the set of news items extracted by a keyword-based method. we focus on one particular news topic, mers outbreak in south korea. the outbreak lasted for a month and a half starting on may th. a total of cases occurred during the outbreak, with a death toll of . due to the outbreak, , schools were temporarily closed, and , people were quarantined. mers was the most sensational news event in south korea in . we extract news items whose title contained the word "mers", which results in news items. by including more keywords, we may be able to extract more news items. however, we use a single word to be sure that all the retrieved news items are relevant to the news event. we find that % of news items about the mers outbreak ( out of news items) overlap with those by the topic modeling based method. then, to examine the relevance of those articles without the word "mers," we randomly select articles that do not explicitly include the word "mers" and examine what they are about. we find that all are relevant to the mers. this indicates that our method can extract news items even when the title of news does not include a key topic word. however, a set of topic words (not one word) will also be able to retrieve all relevant news items. once we have a set of news articles on a certain topic, we further need to group them by subtopic. to this end, we train our data to represent each news item on a vector space and then cluster news items. semantic vector space models of language represent each word with a real-valued vector. firstly introduced by hinton [ ] , the methods have been extended using neural network [ , ] and applied for the practical uses. in recent years, milkolvo's skip-gram and distributed bag-of-word (dbow) models [ ] are popularly used for learning vector representation of words and documents due to its computational efficiency. in the skip-gram model, the objective is to predict a word's context given the word itself, whereas the objective in the dbow model is to predict a word given its context. more recently, the concept of embeddings has been extended beyond words to a number of text segments, including phrases [ ] , sentences and paragraphs [ ] , and documents. adopting the document representation method, we learn distributed representations of news items in our daum news collection. each of news items is represented as low-dimensional vectors and are jointly learned with distributed vector representations of words using a dbow model explained in [ ] . in this vector space, two news items of semantically similar meaning are located nearby. in our news embeddings (henceforth news vec), every news item is mapped to a unique vector in a matrix that represents news items, and every word is mapped to a unique vector in a matrix that represents words. we denote by n v the s × f matrix of s which is the sum of n news items (n , n , . . . , n n ) and f dimensions (f , f , . . . , f f ). a great advantage of learning distributed representation vectors for news in this way is that the algorithm is not sensitive to news item length and does not require specific tuning for word weights. the row of the matrix n v, n i , is a vector of f dimensions representing the i-th news item. the dimension of vector f is set to , and the model is trained with epochs. once we have news vec, we apply the hierarchical clustering method using ward's method [ ] to this resulting matrix to cluster news items of the same subtopic. the hierarchical clustering method builds a dendrogram among entities. then, one can cluster entities based on the dendrogram. its main advantage is that the dendrogram is computed only once regardless of the number of clusters of interest. once the dendrogram is built, we can simply choose the number of clusters (k) of our interest. validation for subtopic categorization. to evaluate the news vec based subtopic clustering method, we prepared a corpus in which each news item is labeled by two authors. we used news items about mers extracted by the keyword-matching method. then, we manually classify news items by subtopics. we conduct a qualitative content analysis to develop a taxonomy of subtopics for mers news. following an open-coding method [ ] , we identify the subtopics of mers news in a two-phase process. we first read titles and descriptions of news items to develop an initial coding scheme and then used an affinity diagramming technique [ ] to iteratively develop a classification scheme for subtopics until a new subtopic did not emerge. table lists the resulting subtopics. the individual authors manually classified all news items into one of the subtopic categories. using the delphi method [ ] , after each researcher independently coded the titles, we then iteratively compared and recoded the news items as necessary until we came to an agreement. the ten subtopics regarding the mers with the number of corresponding news items are listed in table . st "reporting new cases" was the most popular subtopic with news articles in our data set, followed by st "responsibility of government" with news items and st "economical consequences" with news items. we then use this labeled data for the evaluation of our subtopic categorization method. we first learn news vec using entire daum news data. then, we cluster those news items into ten groups (k = ) using vectors from the resulting news vec. we evaluate the resulting subsets of news items with manually tagged clusters. for each detected subset, we find the best matched manual cluster based on the proportion of matching news items. across ten subsets, our news vec subtopic classification achieved an . % matching rate on average where the maximum matching rate is . % and the minimum is . %. in our method, selecting the k is challenging. here, we propose one possible solution to assist in the k selection procedure. the idea is that the average similarity scores for all pairs of news items within the same subtopic (s within ) should be smaller than across the subtopics (s across ). when news items are in vector representation, one can use any distance measures, such as euclidean distance or cosine similarity, to measure the similarity score between two news items. those two values, once found empirically, can play a role as thresholds for selecting the k for different topics. in our evaluation data set, s within is . and s across is . when using cosine similarity. for further evaluation, we use these two values to find the subtopics of another topic, "daycare child abuse." for news items regarding the topic, we find k equals five. the manual inspection reveals the following five subtopics emerged: ( ) what the teacher did to a child; ( ) how cruel the teacher is; ( ) investigation and prosecution; ( ) a new regulation on cctv installation at daycare centers; and ( ) other cases of child abuse. we now quantify differences in news consumption across demographic groups in four dimensions: ( ) by actual news item, ( ) by section, ( ) by topic, and ( ) by subtopic. as a first attempt to compare the news consumption of different groups, we look at actual news items. we measure the similarity among groups based on commonly consumed news items (by their unique news ids) among the top articles consumed by each group over a one-year period. we use jaccard similarity to compute group similarity. for the two sets, a and b, the jaccard similarity is given by : j(a, b) = |a∩b| |a∪b| . in our case, let a and b be sets of news items corresponding to the two groups to be compared. strictly, |a ∩ b| would translate to the count of the news items matched across the sets of a and b. figure (a) shows the jaccard similarity among groups as a heatmap. for example, the pair of age female and age female has a jaccard score of . . this means that, among the union set of all their consumed news items, % are common. the higher the similarity score is, the more news items are viewed in common between the two groups. we find that within same-sex groups, the similarity generally increases as the age difference decreases, with female groups have a stronger tendency of it than male groups (the average similarity score among all pairs of female groups is . while that of male groups is . ). however, we observe two exceptions, age female and age male. they are more similar to the age or age than the age same-sex groups. in fig. , we can see that the age groups have more politics and foreign news items in the top lists, indicating their similarity to older groups. we then find strikingly low similarity scores between different sex groups. age male and age male have almost no news items in common with the female groups, and the same happens for the age female and age female groups. with these results, we can conclude that the set of popular news items that females consume is very different from what males read. we have shown that there is a striking difference between the popular news items for the male groups and those of the female groups. now, we will examine the news consumption of those groups in terms of sectional interests. this analysis will tell us whether the existing framework of news consumption based on sex or age is also found in korea. for each group g, we created a vector s g = (w ,g , w ,g , . . . , w s,g ) in which each dimension corresponded to a predefined section from daum news where s = in our case (see sections in fig. ) . the weight w s,g was computed by the proportion of the news items in the section s for the group g. we then computed the cosine similarity between two vectors to compare the sectional interests of two groups. the results are shown in fig. (b) as a heatmap. for female groups, we find high similarity scores between all pairs (> . ), showing that the proportion of news items in each section is similar in each group. a similar pattern is also observed for male groups but to a lesser extent, and with one exception, age male, which shows a very different sectional interest. the reason is that they exclusively read political news - % of the top news items for a one-year period are about politics (see fig. ). male groups are further split into two groups, as age male and age male are more similar to female groups, but age male and age male have sectional interests distinct from those of female groups. this partly supports the traditional sex-typed news consumption theory -our data set also shows different sectional preferences in different gender groups. however, we find such differences are driven more by age male and age male and less by age male and age male. in summary, the sectional interests seem to be alike across all groups except age male. considering that news consumption largely depends on current, local issues, this could make sense. however, given the striking differences in common news items, the fact that groups largely share sectional interests is still surprising. we now move onto the similarities in the topics that different groups consume. given that sectional interests are similar among groups, but not the actual news items, it is intuitive to think that even if two groups are visiting the same news section, such as society, they might consume different topics -older people might read more about "baby killer" while young people read more about "violence at school." to investigate such topic-specific differences in news consumption, we map each news item to a specific topic. the topics are identified by the method we described in sect. . . then, we quantify the importance or the level of attention to a specific topic for a group by computing the lifespan. we define the lifespan of a topic as the longest period of time when that topic appeared on the top list for each group. we then measure the similarities between groups based on the importance of the different topics. we select topics that are consumed by at least two groups, resulting in , topics and compute each topic's lifespan for each group. this gives us a ranked list of topics for each group, and we use spearman's rank correlation coefficient (ρ) to compare the two ranked lists. figure (c) shows the results as a heatmap. all pairs of rankings are statistically significantly different (p < . ). in this heatmap, we compare pairs of values. for example, a value of . between age female and age male is hard to interpret by itself. comparing one similarity score to other entries, one observes that this value is higher to that for the 'age male' -'age male' pair or 'age male' -'age male' pair. simply put, one could claim that gender differences lead to more strongly pronounced news consumption than years of age difference. by comparing pairs of values, we observe that age differences play important roles in news consumption -a similar pattern was also found when looking at common news items in sect. . . given that a pair of different sex groups have few common news items consumed, the high similarity between two ranked list of topics (ρ > . ) is striking. this means that all users of daum news are interested in similar topics, but what they read is different; less than % of news items on average were in common for those pairs of different sex groups while the average ρ is . for these pairs. we also find that two groups, age male and age female, are generally more different from other groups, confirming the existence of an age gap between -year-olds and others. we also note that while the age male group has very different sectional interests, it has similar topic preferences to those of other groups. we firstly observed that demographic groups show such different news consumption patterns at news item level. then, the high similarity scores at section and topic levels tell us that the overall news consumption is largely driven by current issues. however, groups still have distinct news consumption patterns. this suggests that news consumption even for one particular topic may be very different across groups. for this analysis, we use our evaluation data set and focus on the subtopic consumption regarding the mers outbreak. the mers outbreak was a deviant event, and all ten demographic groups have at least one news item about mers. however, the volume of news items about mers is different across groups. news items about mers are more popular in female groups than in male groups-on average, the female group has . popular news items about mers while that of the male group is . . we then quantify the differences in mers news consumption in terms of the content between two groups. to do this, for each group, we rank the subtopics of mers outbreak in table by the number of news items. then, we test the similarity between two groups by computing the spearman's ranking correlation coefficient. this will tell us which two groups have the most similar consumption of subtopics about mers. figure (d) shows the results as a heatmap. all pairs of rankings are statistically significantly different (p < . ). from the heatmap, we observe that ( ) the popular news is more similar within the same sex groups than within the different sex groups; ( ) female groups are more similar to each group than male groups are; and ( ) age differences matter, except in the age male and age female groups. interestingly, all three of these observations are also found in our previous analysis that compares actual news items in sect. . . all these results lead us to conclude that all groups are generally interested in similar news sections or topics; however, for the same topic, they are attracted to different subtopics, leading to the big differences in popular news among groups. to gain insights into how popular news items about mers differ between different demographic groups, we extract the most discriminative words in news titles for each group. we focus on the group-specific words of news titles, specifically on those with a high phi score, the chi-square test statistics [ ] , for discriminating between one group and others (e.g., age female vs. non-age female (all other groups)). table shows the top words ranked by phi. two authors of this work translated korean words to english words. some interesting differences were observed. overall, female groups are likely to check the status of the mers outbreak, such as how many people are infected (the number of patients, death, this week), the symptoms of mers (high fever, cytokine storm), and the protection against mers (mask, gloves). the age female group showed an interest in news about pregnant women who had been diagnosed with mers and other women's cases. the age female group, in particular, was more interested in the status of closed schools and other education-related topics. on the other hand, the male groups were more interested in the political issues surrounding the mers outbreak, the accusations towards the government's response to the mers outbreak (e.g., ruling and opposition parties, the lack of a proper response, misreporting, false propaganda), and the responsibility of politicians. news vec offers an opportunity to visualize each news item in the vector space by applying t-sne, a widely-used dimensionality reduction based on manifold learning [ ] . figure shows where each news item (colored circle) consumed by each gender (fig. (a) ) or age ( fig. (b) ) group is located in the vector space. in the figure, closed circles are that news items have similar representations in the vector space and thus fall in similar subtopics. for the clarity of the visualization, we focus on the news items consumed by a single demographic gender or age group. figure (a) shows a better clustered structure than fig. (b) , meaning that gender difference is well aligned with the difference of vector representation of news items than age difference. in fig. (b) , we can also see some clustered structures, such as groups of green circles (news on patients' deaths read by s), blue circles (news on choongbuk-daejeon regions read by s), red circles (news on the closing of schools read by s), and purple circles (news on the prime minister read by s) from the top to the bottom, while colored circles are mostly dispersed over the space mostly. this is another evidence that gender difference is more noticeable than age difference at the subtopic level. to the best of our knowledge, this is the first study to conduct a multidimensional analysis of the news consumption of different demographic groups on a nationwide scale. differences in news consumption between different demographic groups exist among south koreans. we look into news consumption at different levels and find that section and topic preferences are similar across groups, but subtopic preferences are not. this means that only the behavioral differences in the subtopic level can explain the strikingly low numbers of common news items across different demographic groups, whereas the differences in the news section or topic levels cannot. in summary, while different demographic groups are interested in similar topics, they read news articles belonging to different subtopics, indicating that subtopics make the news consumption of the different groups different. for the following studies, our work suggests that the differences between demographic groups should be examined at the appropriate level. one potential limitation is that we analyze a single news portal service, even though it is an extremely popular service in south korea. to the best of our knowledge, daum is the only data source where ( ) the user-registered demographic information is credible, and ( ) the user base spans all generations and parties. we are willing to extend our approach to new data sources that satisfy above two conditions so that we can find demographic differences in news consumption. we note that all the users are exposed to the same layout and the same items if they visit the website at the same time. thus, the ways to show news, such as news clustering or adaptive layout, cannot selectively influence on a certain user segment. while the differences in news consumption between demographic groups can be explained partly by different interests on subtopics, there could be other latent factors such as sentiments or frames of news. for instance, grabe and kamhawi found that men recognize and respond more to negatively framed messages, while women are more aroused by and engaged with positively framed messages [ ] . by adding another dimension to our news dimensions, we can understand human behavior on consuming news in depth. in this work, we examined the most critical aspects of news, which are section, topic, and subtopic, and saved the other dimensions for the future work. our results also bring the practical implications for news organizations. our characterization of user behavior allows them ( ) to gain a better understanding of what people consume and ( ) to produce more relevant and engaging content for different demographic groups. such demographic-based profiling can help tackle the cold-start problem for new users. by simply knowing the gender and age of a new user, one can provide a better user experience when reading online news. the opposite direction of the inference can also be useful. given the first few sets of news articles, one can infer the demographics of the reader. this will be particularly useful if the demographics of users are not readily available on news sites. tracking information epidemics in blogspace a peek into the future: predicting the evolution of popularity in user generated content icwsm : proceedings of the th international aaai conference on weblogs and social media sharing political news: the balancing act of intimacy and socialization in selective exposure partisan sharing: facebook evidence and societal consequences trends in social media: persistence and decay the role of social networks in information diffusion the pulse of news in social media: forecasting popularity a neural probabilistic language model contextual design: defining customer-centered systems latent dirichlet allocation statistical inference can cascades be predicted? personalized recommendation on dynamic content using predictive bilinear models online news consumption: a structural model linking preference, use, and paying intent models of the self: self-construals and gender the anatomy of large facebook cascades news in online and print newspapers: differences in reader consumption and recall the structural virality of online diffusion hard wired for negative news? gender differences in processing broadcast news music and music videos distributed representations probabilistic latent semantic indexing the gender news use divide: americans' sextyped selective exposure to online news topics prediction of retweet cascade size over time what is twitter distributed representations of sentences and documents using a model of social dynamics to predict popularity of news meme-tracking and the dynamics of the news cycle the delphi method: techniques and applications personalized news recommendation based on click behavior visualizing data using t-sne gender as a social category efficient estimation of word representations in vector space distributed representations of words and phrases and their compositionality information diffusion and external influence in networks exploring the paradox of the enjoyment of sad films the respondent gender gap a framework for collaborative, content-based and demographic filtering news audiences increasingly politicized-online news audience larger, more diverse: biennial media consumption sensation seeking, television viewing motives, and home television viewing patterns selective viewing: cognition, personality and television genres clustering methods differences in the mechanics of information diffusion across topics: idioms, political hashtags, and complex contagion on twitter continuous space language models sharing clusters among related groups: hierarchical dirichlet processes qualitative research: analysis types and software tools a biterm topic model for short texts modeling information diffusion in implicit networks key: cord- -o e na authors: nan title: scientific session of the th world congress of endoscopic surgery, jointly hosted by society of american gastrointestinal and endoscopic surgeons (sages) & canadian association of general surgeons (cags), seattle, washington, usa, – april : poster abstracts date: - - journal: surg endosc doi: . /s - - - sha: doc_id: cord_uid: o e na nan purpose: to evaluate the efficacy of single-incision laparoscopic surgery for totally extraperitoneal repair (sils-tep) of incarcerated inguinal hernia. patients and methods: clinical setting a retrospective analysis of patients undergoing sils-tep for incarcerated hernia from may to august at kinki central hospital was performed. exclusion criteria sils-tep was contraindicated for the following conditions in our hospital: a history of radical prostatectomy; a small indirect inguinal hernia in a young patient; and unsuitable for general anesthesia. surgical procedure laparoscopic abdominal exploration through a single, . -cm, intraumbilical incision was performed. the incarcerated hernia content was gently retracted from the hernia sac into the abdominal cavity. in some cases, simultaneous manual compression on the incarcerated hernia from the body surface was required. if no bowel resection was needed, a standard sils-tep using mesh was performed following laparoscopic abdominal exploration and incarcerated hernia reduction. if bowel resection was required, inguinal hernia repair using mesh was not performed to avoid postoperative mesh infection, and two-stage sils-tep was performed - months after the bowel resection. results: fourteen patients ( men, women) with irreducible inguinal hernias, including with unilateral hernias and with bilateral hernias, underwent surgery. the patients' median age was years (range, - years), and median bmi was . kg/m (range, . - . kg/m ). of the patients, had acute incarceration, and had a chronic irreducible hernia. seven patients with acute incarcerated hernias underwent emergency surgery, and two of the seven patients needed singleincision laparoscopic partial resection of the ileum, followed by two-stage sils-tep. twelve patients, excluding two patients who required single-incision laparoscopic partial resection of the ileum, underwent laparoscopic exploration with hernia reduction followed by sils-tep. one case of chronic incarceration out of the twelve patients who underwent sils-tep after hernia reduction required conversion to kugel patch repair. the median operative times were min (range - min) for unilateral hernias and min (range - min) for bilateral hernias. the median blood loss was minimal (range - ml). the median postoperative hospital stay was day (range - days). the median follow-up period was months (range - months). a seroma developed in % ( / ) of patients and was managed conservatively. no other major complications or hernia recurrence were noted during the follow-up period. conclusions: sils-tep, which offers good cosmetic results, could be safely performed for incarcerated inguinal hernia. objective: introduction of mis in pediatric age group has been proved feasible and safe. there is considerable evolution with introduction of a number of invovation in mis pediatric inguinal hernia repair. high ligation of sac is the basic premise of surgical repair in pediatric inguinal hernias. there are different mis techniques broadly grouped into intracorporeal or intracorporeal with extracorporeal component namely the suturing. every techniques has its own complications. the main objective of our study was to focus on different anatomical pointers which can lead inadverent complications mainly bleeding and recurrence. methods and procedures: prospective review of hernias ( male and female) ( months- years) performed laparoscopically between september and june . under laparoscopic guidance, the internal ring was encircled extraperitoneally using a - non-absorbable suture and knotted extraperitoneally. data analyzed included operating time, ease of procedure, occult patent processus vaginalis (ppv), contralateral inguinal hernia, complications, cosmesis and recurrence. results: sixteen right ( %), left ( %) and bilateral hernia ( %) were repaired. five unilateral hernias ( . %), all left, had a contralateral ppv that was repaired (p= . ). mean operative time for a unilateral and bilateral repair were . ( - ) and . min ( - min) respectively. one hernia repair still recurred ( . %) even with all precautions and another had a post operative hydrocoele ( . %). one case ( . %) needed an additional port placement due to inability to reduce the contents of hernia completely. because of our techinique we could not find any adverent peroperative bleeding. there were no stitch abscess/granulomas, obvious spermatic cord injuries, testicular atrophy, or nerve injuries. conclusion: the results confirm safety, efficacy and cost effectiveness of laparoscopic inguinal hernia repair. during our per-operative analysis we focus to address the anatomical landmark to minimize future recurrence and peroperative surgical complications. we identified and named a point as j. point at the tip of triangle of "doom". that is most important point to address peroperatively. there is high chance of recurrence if that point is not encircled well or inadequately circled because of fear of iliac vessels injury. we aslo concluded that 'water dissection technique' is effective techniques in un-experienced hand and in early stages of laparoscopic hernia repair to prevent inadvertent iliac vessels injury. medstar georgetown university hospital, georgetown university school of medicine, introduction: incisional hernias following abdominal surgery can be associated with significant morbidity leading to decreased quality of life, increase in health care spending and need for repeat operations. patients undergoing gastrointestinal and hepatobiliary surgery for malignant disease may be at higher risk for developing incisional hernias. identifying these risk factors for incisional hernia development can help decrease occurrence. this will be the largest multi-institutional study looking at incidence of symptomatic hernia rates for major abdominal operations including colectomy, hepatectomy, pancreatectomy, and gastrectomy. methods and procedures: an irb-approved retrospective study within the medstar hospital database was conducted, incorporating all isolated colectomy, hepatectomy, pancreatectomy, and gastrectomy procedures performed across hospitals between the years of to . all patients were identified using icd- and icd- codes for relevant procedures and then subdivided into either having benign or malignant disease. exclusion criteria comprised of patients who had concomitant organ resection, or those undergoing organ transplant. data validation was performed to verify the accuracy of the data set. the rate of symptomatic incisional hernia rates (ihrs) were determined for each cohort based on subsequent hernia procedural codes identified and repairs performed. descriptive statistics and chi squared test were used to report ihrs in each group. results: during this -year span, a total of , major abdominal operations were performed at all institutions, comprising of , colectomies, , hepatectomies, , pancreatectomies, and gastrectomies. malignancy was the indication for surgery in , ( . %) colectomies, ( . %) hepatectomies, ( . %) pancreatectomies, and ( . %) gastrectomies. ihr in each cohort for benign vs malignant etiologies, respectively, are as follows: ( . %) vs ( . %) in colectomy (p= . ), ( . %) vs ( . %) in hepatectomy (p= . ), ( . %) vs ( . %) in pancreatectomy (p= . ), and ( . %) vs ( . %) in gastrectomy (p= . ) patients. conclusion: symptomatic incisional hernia rates following major gastrointestinal and hepatobiliary surgery ranges from . to . %. there was no significant increase in hernia rates in patients undergoing surgery for malignancy. patients undergoing colectomy for benign disease had a high incidence of symptomatic ihrs. introduction: prosthetic infections, although relatively uncommon, are a major source of cost and morbidity. the study aimed to evaluate the influence of mesh structure including the polymer type and mean pore size on bacterial adherence in a mouse model. methods: three commercially available hernia meshes were included in the study. for each mesh type, a cm square was surgically placed intraabdominally in mice. one mouse served as a control while an enterotomy was made in the subsequent mice to introduce a bacterial load onto the mesh. after hours the meshes were harvested. the inoculated meshes were then plated on agar plates and bacterial counts were counted after hours. the bacterial counts were compared between the various mesh types. results: the mean bacterial adherence was increased in the large pore mesh was colonies, for the small pore mesh was colonies, and in the biologic mesh group it was colonies. conclusions: through the use of a mouse model, the influence of mesh type and pore size on bacterial adherence was evaluated. meshes that have larger pores with a lower prosthetic load and the biologic mesh interestingly had lower early bacterial colonization after hours following an enterotomy. further evaluation with a longer incubation time could be helpful to determine the effect of bacterial colonization of mesh. hrishikesh salgaonkar, raquel maia, lynette loo, wee boon tan, sujith wijerathne, davide lomanto; national university hospital, singapore laparoscopic repair of groin hernias is widely accepted approach over open due to lesser pain, faster recovery, better cosmesis and decreased morbidity. however, there is still debate on its use in large inguino-scrotal hernias, recurrent hernias and history of lower abdominal surgery anticipating adhesions and difficulty in dissecting extensive hernia sac. retrospective analysis of prospectively collected data was done of patients undergoing laparoscopic repair of large inguino-scrotal, incarcerated groin hernia, recurrent cases after open or laparoscopic repair and history of previous lower abdominal surgery. between january to july , patients with large inguino-scrotal hernias, recurrent hernia, history of lower abdominal surgery, incarcerated femoral hernia underwent laparoscopic inguinal hernia repair. patient characteristics, operating time, surgical technique, conversion rate, complications and recurrence up to months recorded. patients had large inguino-scrotal hernia, recurrent hernia ( previous open, previous lap) , history of lower abdominal surgery ( lscs, appendectomy, prostatectomy, midline laparotomy), incarcerated femoral hernia, meshoma removal. patients underwent total extraperitoneal (tep) repair, transabdominal pre-peritoneal (tapp), needed conversion to open. mean operation time was min for unilateral and min for bilateral hernia. seroma formation seen in patients, minor wound infections treated conservatively. we conclude that the laparoscopic approach can be safely employed for the treatment of complex groin hernias; surgical experience in laparoscopic hernia repair is mandatory with tailored technique in order to minimize morbidity and achieve good clinical outcomes with acceptable recurrence rates. mesh fixation in ventral incisional hernia is a topic of ongoing debate. permanent and absorbable tacks are acceptable and widely used methods for mesh fixation. the purpose of this study was to compare outcomes of permanent tack fixation versus absorbable when used alone or with suture fixation in laparoscopic incisional hernia repairs. a retrospective review of all patients undergoing laparoscopic ventral hernia using tack fixation (absorbable/permanent) alone or in conjunction with suture fixation was queried from the ahsqc database. outcome measures included hernia recurrence rate, pain, quality of life, wound related issues, and hospital length of stay. propensity match scoring was performed to compare patients undergoing tack only fixation versus tack and suture fixation with a p-value of . considered significant. a total of patients were identified after propensity match scoring with who underwent repair with permanent tacks alone or with sutures and who underwent repair with absorbable tacks alone or with sutures. following matching there were no differences in bmi, age, hernia width/length, or baseline pain/ quality of life. there were no significant differences found in outcome measures including recurrence rates, pain and quality of life outcomes at days, months, and year, surgical site infection (ssi), and postoperative length of stay (p[ . ). there was a significant increase in any post op complication in the permanent tack fixation group compared to the absorbable tack fixation group ( % vs %, p. ) which is likely due to the increase in surgical site occurrences noted in the permanent tack fixation group ( % vs. %, p. ). based on this large data set, there are no significant differences in postoperative outcomes in permanent versus absorbable fixation in laparoscopic hernia repair except in surgical site occurrences. further study is needed to evaluate but at the present time, there is no convincing evidence that one type of fixation is superior to another in laparoscopic ventral hernia repair. introduction: inguinal hernia repair is the most common procedure in general and visceral surgery worldwide. laparoscopic transabdominal preperitoneal mesh hernioplasty (tapp) has been also popular surgical method in japan. single incision laparoscopic surgery is one of the newest branches of advanced laparoscopy, and its indication has been spread to not only simple surgery such as cholecystectomy, but also complex surgery. we report our experience with single incision laparoscopic tapp (s-tapp) for japanese patients with inguinal hernia. case description: a consecutive series of patients ( male, female) who underwent s-tapp during june to september in a single institution. twenty eight of the patients had bilateral inguinal hernia. the mean follow-up was days. the average age of the patients was . ± . years. establishment of the ports: a -mm vertical intra-umbilical incision is made for port access. one -mm optical port and two -mm ports were placed side-by-side through the umbilical scar. surgical procedure: the procedure was carried out in the conventional fashion with a wide incision in the peritoneum to achieve broad and clear access to the preperitoneal space, and an appropriate placement of polypropylene mesh ( dmaxtm light, bard) with fixation using the tacking device (absorbatack®, covidien). the hernia sac is usually reduced by blunt dissection, or is ligated and transected with ultrasound activated device. the peritoneal flap is closed by one suture with - pds and the - tacks using absorbatack®. discussion: in one patient, we encountered a large sliding hernia on the right side having sigmoid colon as content of the sac, which required conversion to the conventional laparoscopic procedure. there were nine recurrence cases after surgery of laparoscopic or anterior approach, and two cases after prostatectomy. there was no intra-operative complication. the mean operative time was . ± . min, and blood loss was minimum in all cases. the average postoperative stay was . ± . days. there was one recurrence case ( . %) months after the surgery. there was no severe complication after the surgery, but there were seromas ( . %) and one hematoma ( . %). two patients had blunt tactile sense in the area of the lateral femoral cutaneous nerve ( . %), which improved in two months. conclusion: our results suggest that s-tapp is a safe and feasible method without additional risk. moreover, cosmetic benefit is clear. however, further evaluation for postoperative pain and longterm complications compared to standard laparoscopic tapp mesh hernioplasty should be required. manuel garcia, md, daniel srikureja, md, marcos j michelotti, md, facs; loma linda university health introduction: prosthetic mesh use has become standard practice during ventral hernia repair to reduce the risk of recurrence. the ideal mesh is macro-porous which favors rapid cellular ingrowth and tissue integration, has limited tissue reactivity, low profile and weight, and has high tensile strength to add resilience to the repair. additionally, the material is expected to have good handling characteristics. currently, there is a wide variety of options for mesh. biosynthetic material (poliglycolic acid/trimethylene carbonate -pga/tmc) has been shown to behave well in terms of early vascularization and ingrowth as well as adequate long term tissue generation. gore® synecor® biomaterial is a composite mesh including two layers of absorbable biosynthetic material (pga/tmc) with one tridimensional non-absorbable macro-porous knit of dense ptfe mesh. it has shown good vascularization and ingrowth at days in animal examination. however, there is still no evidence of long term behavior of this mesh in human tissue. we present the first histologic analysis of this mesh year after placement in a human. objective: to perform a histologic analysis of the gore® synecor® biomaterial one year after placement in the human body. methods: after incidentally finding incorporated gore® synecor® mesh in a patient with prior ventral hernia repair year ago, during open bilateral inguinal hernia repair, a sample of mesh was taken and sent to pathology lab for analysis. tissue healing, vascularization, and ingrowth of the composite mesh were analyzed. results: histologic findings significant for a biomaterial consistent with a knitted ptfe material surrounded by mature fibrovascular tissue and foreign body inflammation consistent with expected healing response for this time frame. no evidence of any other biomaterial (pga/tmc) or evidence of infection. conclusion: gore® synecor® biomaterial has shown to be well integrated into appropriately healed tissue, with pronounced vascularization and ingrowth. the pga/tmc layers have been seen to be completely absorbed and replaced by collagen. these findings, in a human months sample, replicate what had been shown in animal specimens. method: from to , patients came to hospital with renal paratransplant hernia. they were evaluated for this study. the following data were collected from their records: age, gender, weight, age at graft rejection, surgical complications, treatment method and the treatment results with composite ptfe mesh. results: for laparoscopic repair of incisional hernia after renal transplant, the median interval between kidney transplantation and developing of incisional hernia was (range to ) days. predisposing factors were obesity, age over fifty years, and female gender. in six patients, hernia was large, and the repair was performed with using composite ptfe mesh. one patient had developed serous collection in surgical site, which was managed successfully with multiple punctures. hernia recurrence or infection was not noted in these patients during to months follow-up periods. conclusion: incisional hernia is not a rare entity after kidney transplantation. predisposing factors, such as obesity, age over years, and female gender have a role in its development. repeated surgeries in kidney recipients can increase the risk of incisional hernia. managing this complication by laparoscopic approach is a safe and effective method. sujith wijerathne, raquel maia, hrishikesh salgaonkar, wee boon tan, lynette loo, davide lomanto; national university hospital, singapore introduction: a femoral hernia is a less common type of hernia. it is estimated to account for less than % of all abdominal wall hernias. only about in every groin hernias are femoral hernias. they are found more commonly in females due to wider shape of pelvis. laparoscopy by offering magnification and better vision provides us the opportunity for clear visualization of the myopectineal orifice. laparoscopy seems to be a safe and feasible approach for femoral hernia repair in an asian population. case description: between and , consecutive patients with femoral hernia who underwent laparoscopic hernia repair were prospectively studied. patient demographics, hernia characteristics, operating time, conversion rate, intraoperative, postoperative complications and recurrence were measured. discussion: total of femoral hernias were repaired, on right and on left groin. this included patients with bilateral and unilateral hernia. concomitant obturator hernia were found. there were male and female patient. no conversion was reported. one patient had injury to bowel at the mm port entry site, without contamination, identified and managed immediately. patients developed seroma, all were managed conservatively except one who needed aspiration. peri-port bruising was noticed in patients and patients had hematoma. one patient with hematoma underwent excision of the organised hematoma. of the hematoma patient was on aspirin pre-operatively. no wound infection, chronic groin pain or recurrence was documented during follow up till date. conclusion: laparoscopic repair offers accurate diagnosis and simultaneous treatment of both inguinal and femoral hernia with minimum morbidity and good clinical outcomes. better visualisation and magnification gives us an opportunity to identify occult hernias which can be repaired during the same setting, thereby reducing the chance of recurrence and possible need for second surgery. laparoscopic repair has become the procedure of choice for the treatment of the majority of groin hernia at our institution. introduction: totally extraperitoneal (tep) repair that does not require peritoneal incisions is a good procedure that involves minimal visceral damage. however, balloon-or camera-assisted blunt dissections that are performed in a haphazard manner do not follow precise dissection of the fascia layer. furthermore, they have a disadvantage in that they are difficult to understand anatomically. we therefore developed a novel preperitoneal approach to resolve this issue. methods: a -mm trocar is inserted into the rectus abdominis sheath cavity after a small incision is made below the umbilicus and the posterior rectus sheath is exposed. a -mm trocar is inserted cm towards the pubic bone from the umbilicus. using forceps from this position, narrow branches that enter the posterior rectus sheath from the inferior epigastric vessels are dissected, thereby broadly exposing the anterior surface of the posterior rectus sheath. the third mm-trocar is inserted near the lateral margin of the rectus abdominis. on the outside, local anesthetic is injected beneath the posterior rectus sheath and the preperitoneal cavity is separated in fluid so that the peritoneum is not injured during posterior rectus sheath incision. a small incision is made to the posterior rectus sheath or attenuated posterior rectus sheath at one finger width higher than the expected upper margin of the prosthetic mesh. due to the effects of local injection, a sharp incision to the fascia can be made with an electric scalpel. utilizing this mechanism, the posterior rectus sheath aponeurosis and the lining transverse fascia and superficial preperitoneal layer are individually identified. once the preperitoneal cavity is reached, the peritoneal margin is determined in the lateral direction, and the peritoneum that is pulled due to pneumoperitoneum is separated from the preperitoneal fascia on the outside from the cranial side towards the deep inguinal ring. on the inside, the pneumoperitoneum pressure pushes the peritoneum inferiorly, leading to enlargement and increased visibility of the posterior rectus sheath deep fascia, which is dissected one layer at a time from the outside. the umbilical prevesical fascia is dropped inferiorly, and the dissection of the preperitoneal cavity necessary for mesh deployment is performed. results: by individually dissecting each fascia using emphysema through pneumoperitoneum and enlargement through local injection, the method for reaching the preperitoneal cavity could be successfully completed by following the dissection of the fascia layer without proceeding with the operation blindly, thereby resulting in the elimination of intraoperative bleeding and postoperative hematoma. introduction: in the field of abdominal wall reconstruction, the utility of drain placement is of debatable value. we present outcomes evaluating drain placement vs no drain placement at the time of robotic transversus abdominis release (rtar) technique with placement of mesh in the retromuscular position, a currently understudied subject. methods: retrospective review of a prospectively maintained hernia patient database was conducted identifying individuals who received either drain placement or no drain placement during abdominal wall reconstruction via the rtar technique from august to june at a single high volume hernia center. perioperative data and postoperative outcomes between the two groups are presented with statistical analysis for comparison and quality of life (qol) measures assessed using the carolina comfort scale. results: thirty-five patients were identified for this study, of which had drains placed intraoperatively in the retromuscular position at the conclusion of rtar (drn) and underwent rtar without the placement of draining devices (nd). the drn cohort had a mean bmi, defect area, mesh area, and operative time of . , cm , cm and minutes, respectively, compared to . , cm , cm , and minutes in the nd group. all cases utilized medium weight macroporous polypropylene synthetic implantable mesh materials in both the drn and nd subgroups. there were no reported postoperative complications, including no development of hematoma, seroma, or surgical site infections in either group. hernia recurrence was not identified in either the drn or nd cohorts through a mean follow up of days ( . months). there were no statistically significant differences in postoperative qol outcomes. conclusion: our series review suggests that the use of intraoperative drains may not afford any benefits with the rtar technique when mesh is placed in the retromuscular position. additional postoperative management associated with drain care may be unnecessary. surg endosc ( ) :s -s background: appendectomy is one of the most common operations performed during emergency surgery. although laparoscopic appendectomy (la) has become the treatment of choice, there is still a debate regarding the use of la for treating complicated appendicitis. in this retrospective analysis, we aimed to clinically compare la and open appendectomy (oa) for treating complicated appendicitis. methods: we retrospectively identified patients who underwent an operation for complicated appendicitis at our hospital; these patients were operated on between and july . [editor ] in total, patients underwent conventional appendectomy and patients were laparoscopically treated. outcomes included operation time, blood loss, length of hospital stay, and postoperative complications. logistic regression analysis was performed to analyze the concurrent effects of various factors on the rate of postoperative complications. objective: small bowel perforation has conventionally been dealt with open exploration, which frequently leads to many wound-related complications. wound infection is the major reason for increasing morbidity in these patients and delay recovery. laparoscopic surgery has various benefits over open surgery like, smaller wound, lesser pain and faster recovery. the aim of this study was to relay the advantages of minimally invasive surgery (mis) to patients with small bowel perforation to decrease postoperative wound complications and duration of hospital stay. methods: it is a retrospective study, including patients with small bowel perforation from to . of these , had traumatic etiology, had typhoid-related perforation and the remaining had a duodenal perforation. of them were male, and the average age was . years. only patients who presented within hours of perforation were included in the study. laparoscopic exploration was done on introducing camera from -mm infraumbilical port after intraperitoneal carbon dioxide insufflation. the remaining two -mm working ports were then introduced depending on the site of perforation once identified. the perforations were then repaired using intracorporeal single-layer suturing using polydioxanone - suture. the peritoneal cavity was given thorough lavage and abdominal drain placed in the pouch of douglas. fecal contamination was found in all the patients. a total of patients underwent conversion to open surgery due to inability to find the site of perforation laparoscopically. of the operated patients, patients developed port-site infection, and there were no major postoperative complications in the -week follow up period. conclusion: we conclude from our study that laparoscopic intervention in early small bowel perforation is a safe approach with favorable outcomes, especially with regards to wound complications, that are a major factor in increasing the morbidity in such patients postoperatively. laparoscopic approach leads to early discharge and recovery postoperatively. with the emerging era of laparoscopic surgery, leading to its easy accessibility, more patients can advantage from this technique when they arrive in emergency with intestinal perforation. s surg endosc ( ) :s -s introduction: pneumatosis intestinalis (pi), or gas in the bowel wall, can be seen on various imaging modalities. the pathophysiology behind pi is unclear. one theory proposes a mechanical cause (e.g. small bowel obstruction) while another proposes a bacterial etiology. management of pi in adults is difficult as often there is a benign clinical course. however, when paired with specific clinical features such as hepatic portal venous gas (hpvg) on imaging, the course of management changes as the suspicion of bowel ischemia increases. hpvg alone has been associated with a high mortality rate and a poor prognosis. management in this case becomes surgical. case presentation: we present a case of -year-old latino male who presented to the emergency room with abdominal pain and altered mental status. focused physical examination revealed a non-rigid abdomen, no rebound tenderness, no guarding, and diffuse tenderness only to deep palpation. ct scan of the abdomen and pelvis demonstrated moderate portal venous gas in the right and left hepatic lobes, an upper midline dilated small bowel loop with pneumatosis intestinalis, and a moderately distended stomach with gas and fluid. laboratory studies revealed metabolic acidosis and a lactic acid level of . mmol/l. due to these findings, bowel ischemia was suspected, and the patient was taken to the operating room for a diagnostic laparoscopy. the laparoscopy was converted to an exploratory laparotomy due to extensive adhesions. intraoperatively, there was no small bowel compromise and no identifiable transition point. extensive lysis of adhesions and repair of iatrogenic enterotomy were performed. patient tolerated the procedure well, clinically improved, and was discharged from the hospital. discussion: this case illustrates the difficulty in management of a patient with pneumatosis intestinalis and, specifically, hepatic portal vein gas seen on ct imaging. hpvg has traditionally been a harbinger of morbidity and mortality, but exploratory laparotomy revealed only diffuse abdominal adhesions and the absence of bowel ischemia despite high clinical suspicion. background: ventral hernia repair is one of the most common surgical procedures facing the general surgeon. there is little consensus as to the best surgical technique for complex scenarios. often these patients have complicating co-morbid conditions such as radiation therapy, that has an inevitable effect in the abdominal wall structures, which can lead to non-traditional repairs. case report: we present a case of a year-old female who underwent a tah/bso and right hemicolectomy which was complicated by wound dehiscence. she underwent primary repair and adjuvant whole pelvis radiation for her squamous cell carcinoma. subsequently, the patient developed acute obstructive symptoms do to a stricture within her small bowel and a large ventral hernia measuring cm with non-reducible abdominal contents below the level of the fascia more prominent in the suprapubic area. the patient's bmi was . . various considerations are important in planning a surgical repair in a previously irradiated field with loss of domain which include, minimal dissection, and the use of an atraumatic surgical techniqueque with either external oblique release or transversus abdominis muscle release (tar). we chose a a tar, as it provides wider myofascial release and dissection below the arcuate line towards the space of retzius and bogros allowing for a larger sublay mesh placement. also it avoids the need of skin flaps reducing the risk for wound complications in under-perfused tissue. the tar was performed successfully and there were no intraoperative and postoperative complications. her follow-up at months revealed no wound complications or hernia recurrence. conclusion: for patients with compromised tissue and loss of domain a tar technique may be useful when reconstructing complex abdominal wall hernias. it provides the core principals of hernia repair such as primary fascial closure, wide mesh overlap, and finally it provides a reliable approach for the under-perfused tissue without need of skin and soft tissue flap creation. outcomes in the management of cholecystectomy patients in the setting of a new acute care surgery service model: impact on hospital course larsa al-omaishi, bs, william s richardson, md; ochsner medical clinic foundation introduction: the acute care surgery (acs) model, defined as a dedicated team of surgeons to address all emergency department, inpatient, and transfer consultations, is quickly evolving within hospitals across the united states due to demonstrated improved patient outcomes in the non-trauma setting. the traditional model of call scheduling consisted of one senior attending and one senior resident on call per -hour shift. attendings were responsible for consults, previously scheduled operations, as well as clinic time. multiple recent studies have shown statistically significant improvements in several parameters of patient care by using acs including but not limited to . time from emergency department to surgical evaluation . time from surgical evaluation to operating room . operative time . percent laparoscopic . length of hospital stay . intra-operative complications (blood loss, perforation rates) . post-operative complications (fever, infection, redo) . cost. one study demonstrated a statistically significant cost savings for the acute care surgery model with respect to appendectomies, but not cholecystectomies. study design: a retrospective analysis of patients who underwent cholecystectomy in the setting of non-traumatic emergent cholecystitis was performed to compare data from two cohorts: the traditional model and the acs between january , and dec , at ochsner medical center, a -bed acute care center in new orleans. parameters gathered included . time from emergency department to surgical evaluation . time from surgical evaluation to operating room . operative time . percent laparoscopic . length of hospital stay . intra-operative complications (blood loss, perforation rates, conversion to open) . post-operative complications (fever, infection, redo). demographics were also collected including age, weight, height, ethnicity, asa, etc. inclusion criteria included: age[ and having undergone cholecystectomy between jan , and december , . exclusion criteria included choledocholithiasis, gallstone pancreatitis, ascending cholangitis, gangrenous cholecystitis, septic complications precipitating further procedures and delays, or researcher discretion. results: patients were initially identified as having undergone cholecystectomy within the allotted time period [ - , - , - , - ] . were excluded due to one of the reasons above. median patient age was years old and the average patient encounter was . days. conclusion: the acs model is better suited to manage emergent non-traumatic cholecystectomies than the traditional call service at our institution, as evidenced by several parameters. s surg endosc ( ) :s -s he nailed it background: nail guns are powerful tools and are widely used. injuries with these devices may be devastating due to the significant force they can deploy. patients and methods: we herein report a first case of a self inflicted abdominal injury with a nail gun. results: a year old male with history of coronary artery disease, type dm and early signs of dementia attempted to refill a nail gun. he lodged the device against his right abdomen while the air hose was still attached and then accidently fired nails into his abdomen. after he unsuccessfully tried to pull the nails out he drove himself minutes to our emergency room. he was hemodynamically stable on arrival; pain control was achieved, antibiotics were given and he received tetanus immunization. ct-scan showed the two foreign bodies penetrating from the ruq with one reaching the transverse colon. on emergency laparoscopy, the nails were found to have penetrated the thick omentum and the puncture site of one nail into the colon was identified. the omentum was resected off the colon and the right colon was completely mobilized. no additional injuries were found. the entrance area of the nails was then used to create a loop colostomy. the postoperative course was initially uneventful but the patient developed a severe posttraumatic inflammatory reaction of the fat tissue in the right upper quadrant and had to be readmitted for pain control and antibiotics were again administered. he recovered and was discharged with a plan for laparoscopically assisted colostomy closure after weeks. discussion: to the best of our knowledge this is the first reported isolated colonic injury by a nail gun. given the tremendous force of the device with unknown collateral damage to the surrounding tissue it was decided to manage the accident with a laparoscopic assisted colostomy using the entrance point of the nails for fecal diversion. introduction: it is difficult to diagnose obturator hernias by routine physical examination. obturator hernias are frequently complicated by ileus and the diagnosis is often first made from abdominal ct. obturator hernias are difficult to reduce, and often necessitate emergency surgery. they are common in elderly people, and they often had bad general condition. so it was high in the death rate. at our hospital, we first attempt to reduce the hernia from the body surface under ultrasonographic guidance. after relieving the strangulation, we perform radical operation electively in patients who are for possible for surgery under the general anesthesia. we perform laparoscopic repair for obturator hernias. obturator hernias are often complicated by other types of hernia. in these cases, we perform total repair. herein, we present a review of the patients who underwent surgery for obturator hernia at our hospital. methods: we review the data of cases of obturator hernia encountered by us from february to december . we performed total repair in three of the cases. however, it is difficult to procure a mesh that would be adequate for all the defects (inner inguinal ring, femoral ring, obturator). no single mesh can fit, because the inguinal and pelvic curves present opposing curves near the obturator. therefore, we placed two pieces of mesh available at our hospital ( d max [bard] and onlay sheet of kugel patch [bard] ) together in the patientswe could successfully cover all the defects using these two pieces of mesh and could fit the mesh to the pelvic shape by devising an appropriate connection between the meshes. results: we reviewed a total of operated cases for obturator hernia. the hernia was bilateral in cases, and complicated by other hernias in cases. we first determined the appropriate approach for the repair. we performed total repair in cases. they were no complications and no cases of recurrence. conclusion: our approach to the repair of obturator hernias was very useful. we can use the exact area and shape of the mesh needed in individual patients by this method. we show the method of shaping the mesh to fit the pelvic form. demin aleksandr, do, ajit singh, do, noman khan, do; flushing hospital introduction: internal hernias are known complications that are well documented to involve peterson's defect. in bariatric patient's post gastric bypass there is a high index of suspicion for internal hernias as well as a low threshold to operate. there have been some debates around the closure of the potential peterson's space with several studies advocating closure versus some which show that there is no difference in the rate of symptomatic internal hernias. we present a case of an unusual cause of small bowel obstruction due to internal hernia caused by a cecal volvulus. it is an atypical presentation however the patient was triaged and brought to the or within hours of admission. although it is rare there have been reports of internal hernias caused by other structures like congenital bands or natural potential spaces. there have been reports of unusual presentations of the cecum herniating through the foramen of winslow. the anatomical rearrangements after bypass create potential areas where an internal hernia can occur. in this case a bowel resection was undertaken due to the anatomical variation of the cecal bascule and cecal volvulus due to high rate of recurrence of this cecal pathology. majority of internal hernias do not require bowel resection especially when detected earlier and prompt surgical exploration is undertaken. mortality as direct consequence internal hernia is extremely rare. however late diagnosis of internal hernias can lead to catastrophic gut loss and may require lifelong tpn and/or visceral transplantation or autologous reconstruction. conclusion: careful history and physical of our bariatric patient can elicit the signs and symptoms of internal hernias and prevent the morbidity and mortality that can come with the complications of this condition. unusual presentations and causes are reason for prompt diagnosis and complete exploration. shingo ishida , naotsugu yamashiro , satoshi taga , koichi yano ; shinkomonji hospital, shinmizumaki hospital symptomatic cholelithiasis is common disease performed with laparoscopic cholecystectomy (lc). we will hesitate to operate if the patient is pregnant in the third trimester. pregnant patients undergoing laparoscopic surgery have been reported increasingly. however, most case reports are confined to patients in the first and second trimester. we report a patient who underwent lc in the third trimester and review the relevant literature. a -year-old woman in the third trimester ( w d) of pregnancy was seen in the emergency department of our hospital with a history of upper abdominal pain. there was no problem in the course of pregnancy. the result of the examination proved to be attack of gallstone colic. she was hospitalized the same day and underwent lc the next day. the base of pregnancy uterus was cm above the navel. we needed to consider the surgical approach, for example inserting the first trocar under left hypochondrium. operative duration was minutes. she complained abdominal distension at postoperative day (pod) and but there was no abnormality in the fetus. she was discharged on pod . after that she gave birth to a healthy baby. lc in third trimester of pregnancy was safely performed with obstetrics back up. weekday or weekend hospital discharge: does it matter for acute care surgery? ibrahim albabtain , roaa alsuhaibani , sami almalki , hassan arishi , hatim alsulaim ; kamc, background: hospitals usually reduce staffing levels over weekend. this raises the question of whether patients discharged over a weekend may be inadequately prepared and possibly at higher risk for adverse events post-discharge. the aim of this study was to assess the outcomes of common acute care surgery procedures for patients discharged over weekend, and identify the key predictors of early readmission. methods: this retrospective cohort study was conducted at a tertiary care hospital between january and december . surgical procedures included were cholecystectomy, appendectomy, and hernia repairs. patients' demographic, co-morbidities, complications, readmission and follow-up details were collected from the electronic medical records. predictors and post-operative outcomes associated with weekend discharge were identified by multivariable analysis using univariable and multivariable logistic regression models controlling for potential confounders. results: a total of patients were included. overall median age was years (iqr: , ). the majority of patients were female (n= , . %). patients ( . %) underwent a cholecystectomy, ( . %) an appendectomy, and ( . %) hernia repairs. weekend discharge was . % vs. . % of weekday discharge. patients discharged during weekend were younger ( . vs. , p-value. , mean) . post-discharge -day follow-up visits were significantly lower in the weekend discharge subgroup ( . % vs. . %, p-value . ). overall, -day readmission rate was . % (n= ), and did not differ between those of weekend and weekday discharge (or= . , % ci . - . ). conclusions: patients discharged on weekends tended to be younger in age and less likely to have chronic diseases. patients discharged over the weekend were less likely to follow up compared to weekday discharge patients. however, the readmissions rate did not differ between the two groups. intrauterine device (iud) migration out of the uterine cavity is a serious complication. its incidence in the us has been reported to be about . % annually. previously published systematic review supports the use of laparoscopic surgery for elective removal of migrated iucds from the peritoneal cavity. we present the safety and efficacy of the laparoscopic approach to this complication in the acute care setting. depicted is an otherwise healthy year old female with no previous surgical history who presented to the ed with worsening abdominal pain for one week with no associated symptoms. on physical exam, patient was non toxic. abdomen was moderately distended with guarding and rebound tenderness to palpation, no rigid. patient had been seen shorlty prior to ed admission by her obgyn and recent work up with abdominal/pelvic x-ray and ultrasound has revealed a misplaced iud in the transverse position (side ways). pregnancy test was negative. based on patient clinical presentation and recent radiologic findings, we decided to proceed with diagnostic laparoscopy. after systematic review of cavity, the foreign body was found to be incorporated within the greater omentum. we procceded, laparoscopically with omentectomy+foreign body removal. there were no perioperative complications, patiet was discharged on the following day. the use of laparoscopy in elective iud retrieval within in the abdominal cavity has been considered standard of care in surgical management to date. this poster demonstrates its use as an effective approach for safe removal of intra-abdominal foreign bodies also in the acute setting. symptomatic inguinal and umbilical hernias in the emergency department: opportunity lost? andrew t bates, md, jie yang, phd, maria altieri, chencan zhu, bs, salvatore docimo, jr., do, konstantinos spaniolas, md, aurora pryor, md; stony brook university hospital introduction: patients with symptomatic inguinal and umbilical hernias often present to the emergency department (ed) when their symptoms change or increase, usually not requiring emergent surgery. however, little is known about how often these patients present prior to eventual repair and whether they undergo surgery at the initial presenting institution. the aim of this study was to assess the clinical flow of patients presenting in the ed for inguinal and umbilical hernia. methods: all patients presenting to eds in new york state from to with symptomatic inguinal and umbilical hernias were identified using the new york state longitudinal hospital claims database (sparcs). patients were followed for records of hernia repair and subsequent inpatient and outpatient visits up to . results: , patients presenting to the ed for symptomatic inguinal hernia were identified. . % ( , ) of ed presentations resulted in inpatient admissions. , ( . %) had repair later and their average time from ed presentation to inguinal hernia repair was (± ) days. . % of patients who did not have subsequent surgery had only one ed visit. of those that underwent interval repair, . % had only one ed visit prior to surgery. for those patients with only one ed visit before repair, . % had repair at a different hospital, as opposed to . % if multiple ed visits were made. , umbilical hernia patients presenting to the ed were identified. . % ( , ) resulted in inpatient admission. , ( . %) had interval repair, with the average time from ed presentation to umbilical hernia repair being (± . ) days. % of patients who did not record of later repair presented to the ed once. of those patients who underwent repair, . % did so after one ed visit. for those patients with only one ed visit before repair, . % had repair at a different hospital, as opposed to . % if multiple ed visits were made. conclusion: a majority of patients with symptomatic inguinal and umbilical hernias that present to the ed do so once with no subsequent follow-up or repair. for those patients that undergo interval repair, a significant portion willnopt for surgery at other hospitals. a significant proportion of patients with acutely symptomatic inguinal/umbilical hernias who undergo interval repair after a previous ed visit, will opt for definitive surgery at another hospital facility. this represents a missed opportunity for continuity of care for providers and healthcare systems. nikhil gupta, dr, himanshu agrawal, dr, arun k gupta, dr, dipankar naskar, dr, c k durga, dr; pgimer dr rml hospital, delhi introduction: peritonitis is the inflammation of the serous membrane that lines the abdominal cavity and the organ contained therein and is one of the most common infections, and an important problem that a surgeon has to face. reproducible scoring system that allows a surgeon to determine the severity of intra-abdominal infections are essential to prognosticate the patient. this study was done to compare apache ii scoring and mpi score to assess prognosis in perforation peritonitis. methods: all patients admitted with hollow viscus perforation from st november till st march was included in the study. it was a cross sectional observational study. apache ii and mannheim peritonitis index (mpi) scoring systems were calculated in all the patients in order to assess their individual risk of morbidity and mortality. the outcome variables were studied postoperatively -post-operative wound infection, wound dehiscence, anastomotic leak, respiratory complications, duration of hospital stay, need of ventilator support and mortality. the inferences were drawn with the use of appropriate tests of significance. results: the study comprised of patients. neither apache ii nor mpi could predict postoperative wound infection. the mean apache ii score of subjects included in the study was . ± . with range of to and the mean mpi score of subjects included in the study was . ± . with range of to . apache ii was able to predict postoperative respiratory complications, post-operative need for ventilatory support, hospital stay duration and mortality while mpi was able to predict post-operative wound dehiscence, post-operative respiratory complications, post-operative need for ventilatory support and mortality. neither apache ii nor mpi could predict postoperative anastomotic leak and postoperative wound infection. conclusion: mannheim peritonitis index is a useful and simple method to determine outcome in patients with peritonitis. mpi is comparable to apache ii in assessing the prognosis in perforation peritonitis and can well be used in emergency setting in place of apache ii scoring when time is a definite constraint. microrna- and the prognosis of human carcinomas: a systematic review and meta-analysis chengzhi huang, mengya yu; guangdong general hospital (guangdong academy of medical science) muhammad nadeem , julian ambrus, md , steven schwaitzberg, md , john butsch, md ; university at buffalo, introduction: mitochondria is a small energy producing structure of a cell. mitochondrial myopathy (mm) is mixed disorder clinically, which can affect various systems besides skeletal muscle. mm starts with muscle weakness or exercise weakness. mm patients have decreased skeletal muscle mitochondrial function than the healthy person, because of weakened intrinsic mitochondrial function and decreased mitochondrial volume density. no one has studied the mm role in gerd and constipation so far. this study is aimed to see effects of mm on the gastrointestinal system specifically gastroesophageal reflux disease (gerd), gall bladder issues, and constipation. methods: between may and june , mm diagnosed patients at buffalo general hospital were included in this retrospective study. we assessed their demeester score for gerd and wexner's constipation questionnaire for constipation. demeester score[ and constipation score[ were set points for gerd and constipation respectively. data was analyzed by using spss version . mitochondrial enzymes were assessed by using their muscle biopsy report. results: out of ( . % female, . % male) mitochondrial myopathy patients, . % and . % were suffering from gerd and constipation respectively. . %, . % and . % patients had gall bladder issues, obstructive sleep apnea (osa) and fatigue respectively. mm gerd patients ( . % female, . male) had mean demeester score . (sd: . ) more than normal although . % patients were on gerd medications and . % patients had nadh cytochrome c reductase, cytochrome c oxidase and citrate synthase abnormal mitochondrial enzyme in mm associated gerd but . % mm patients had abnormal cytochrome c oxidase enzyme only. mm along with constipation had mean wexner's constipation score . (sd: . ) more than the normal although . % were taking enema, medications or digital assistance. % patients had cytochrome c oxidase and nadh cytochrome c reductase enzymes were abnormal in those patients. . % mm associated gall bladder issues patients had cytochrome c oxidase abnormal. . % mm associated gerd and constipation patients had gall bladder issues. conclusion: in this present study, we found that mm had effects on gastrointestinal system causing gerd, constipation and gall bladder issues. gerd, constipation and gall bladder problems are common in mm patients even patients are taking medications for gerd and constipation. cytochrome c oxidase, citrate synthase and nadh cytochrome c reductase are the most commonly impaired mitochondrial enzyme in mm patients and mm associated gerd, constipation and gall bladder issues patients. objectives: gulf war illness (gwi) is a chronic, multisymptom illness marked by cognitive and mood dysfunction and disrupted neuroendocrine-immune homeostasis affecting % of gw veterans. after + years, useful treatments are lacking and its cause is poorly understood, although exposures to pyridostigmine bromide and pesticides are consistently identified among the strongest risk factors. previous work in our laboratory using an established rat model of gwi identified persistent elevation of microrna- (mir- ) levels in the hippocampus whose gene targets are involved in cognition-associated pathways and neuroendocrine function, suggesting that mir- inhibition is a promising therapeutic approach to improve the complex symptoms exhibited by gwi. the purpose of this study was to identify broad effects of mir- inhibition in the brain by profiling the expression of genes known to play a critical role in synaptic plasticity, glucocorticoid signaling, and neurogenesis in gwi rats administered a mir- antisense oligonucleotide (mir- inhibitor). methods and procedures: nine months after completion of a -day exposure regimen involving gw-relevant chemicals and stress, rats underwent intracerebroventricular infusion of mir- inhibitor (n= ) or scrambled negative control oligonucleotide (n= ) and were implanted with -day osmotic pumps delivering . nmol/day. intranasal delivery of oligonucleotides was performed on additional rats (n= per group; daily for days) to determine whether mir- inhibition is achievable using a noninvasive procedure. hippocampi were harvested and quantitative pcr arrays were used to profile the expression of focused panels of genes important for ) synaptic alterations during learning and memory, ) signaling initiated by the glucocorticoid receptor (known mir- target), and ) neurogenesis. hippocampi were also analyzed by quantitative pcr to examine expression levels of endogenous mir- . results: upregulation ([ . fold change, p. ) of synaptic plasticity genes, glucocorticoid signaling genes, and neurogenesis genes was observed in the hippocampus of gwi rats infused with mir- inhibitor compared to scrambled control, consistent with a significant reduction (p\ . ) in mir- levels detected in rats receiving mir- inhibitor. altered gene expression and a reduction in mir- levels were not observed in rats after intranasal delivery. conclusion: mir- antagonism in the hippocampus upregulates the expression of several downstream targets involved in synaptic plasticity, glucocorticoid signaling, and neurogenesis and is a promising therapeutic approach to improve cognition, emotion regulation, and neuroendocrine dysfunction in gwi. further testing is being pursued to discover the optimal dose for intranasal administration to test viability of this option for ill gw veterans. nikhil gupta, dr, ananya deori, dr, arun k gupta, dr, dipankar naskar, dr, c k durga, dr; pgimer dr rml hospital, delhi background: the ultrasonic dissector, commonly known as the harmonic scalpel, has been in use for achieving haemostasis in surgery for almost yrs. its advantages in breast surgery, especially in the dissection of axilla, have been a matter of debate as previous studies have shown inconsistent results. this study compares the outcomes of the ultrasonic dissector in axillary dissection with that of the conventional electrocautery. methods: patients who were undergoing mrm and bcs with axillary dissection from november till march were included in the study. patients were randomized into two groups, group a undergoing axillary dissection with ultrasonic dissector and group b with electrocautery. the operative time, intra-op bleeding, post-op pain, post op drain volume, hospital stay and any other complications were noted in the two groups. results: the numbers of patients in both groups were each. group a had a significantly shorter operative time, both for axillary dissection ( . min vs. . min, p. ) and the total duration ( . vs. . min, p= . ). the blood loss was significantly less in group a, as measured by the mop count. there was significant reduction in the total post-op drainage volume, which resulted in fewer days of drain in-situ and the total number days stayed in the hospital. there was no significant change in the post-op complications such as haematoma, seroma, flap necrosis, oedema, etc. conclusion: with the use of ultrasonic dissector, the operative time, blood loss and the axillary drainage was significantly reduced. the axillary drainage in turn, reduced the hospital stay. there was no significant difference in terms of complications like haematoma formation, seroma formation, skin flap necrosis or oedema. for the statistical analysis, χ or fisher's exact tests to compare proportions and the nonparametric mann-whitney u test for analysis of values with abnormal distribution were used. discussion: the study included patients. all preoperative laboratory indicators were elevated. the laboratory tests do not demonstrate any statistical significance between these two groups. the group of the patients without stones in the cbd diagnosed by ioc was also divided in patients with diameters. ?mm and with diameters≥ . ?mm of the cbd. also in these two groups, the statistical analysis of the laboratory tests does not demonstrate significant difference. all patients underwent ioc. ioc showed stones in / patients ( . %) . a comparison of patients with and without stones at ioc showed similar mean times from hospitalization to surgery ( . background: housed in a high volume tertiary referral center, our division receives a large amount of transfers and referrals from outside institutions for patients who require completion cholecystectomies. in this study "completion cholecystectomy" refers to patients that meet one of three criteria: . previous subtotal cholecystectomy, . previously aborted cholecystectomy, or . previous cholecystectomy with incidental finding of cancer on pathology. traditionally, exploration of a reoperative field in the right-upper quadrant mandates an open approach due to dense adhesions and inflammation. over the past few years, we have found that robotic-assisted surgery has allowed us to perform these completion cholecystectomies in a minimally invasive fashion. methods: case logs and operating room billing logs were reviewed from to to identify all robotic-assisted cholecystectomies performed at our institution. review of all reports identified completion cholecystectomies. all additional variables including demographics, operative variables, and postoperative outcomes were determined from manual chart review of all consultation notes, operative reports, anesthesia records, progress notes, discharge summaries, and postoperative office visits. results: of the identified robotic-assisted completion cholecystectomies, patients had a previous subtotal cholecystectomy, patients had an aborted cholecystectomy, and patients had an incidental finding of t gallbladder carcinoma on pathology. fifteen patients ( %) underwent preoperative ercp either for choledocolithiasis or to determine biliary anatomy. average time from original procedure was months with . % of previous procedures performed in an open approach. average or time was . minutes, average ebl was . cc, and average length of stay was . days. one patient ( . %) was readmitted within days for nausea that resolved with antiemetics. three patients ( . %) had minor postoperative complications (clavien-dindo grade or ) which resolved with pharmacologic therapy. no patients suffered a -day mortality. all cases were completed in minimally invasive fashion without a conversion to an open procedure. conclusions: although rare, completion cholecystectomies present a challenging surgical scenario. although traditionally performed in an open approach, we have had success in recent years at our institution with a robotic-assisted approach to completion cholecystectomy. we feel that the robotic approach offers certain advantages in a hostile, reoperative field which allows us to perform these procedures in a minimally invasive fashion with no conversions to an open procedure to date. previously limited to case reports, this report of procedures represents the largest case series of robot-assisted completion cholecystectomies to our knowledge. s surg endosc ( ) :s -s background: percutaneous cholecystostomy tube (pct) has been used as a bridge treatment for grade ii-iii moderate to severe acute cholecystitis (ac) to "cool" the gallbladder down over several weeks and allow the inflammation to resolve prior to performing interval cholecystectomy (ic) and removal of the pct, often laparoscopically. the aim of this study was to assess the impact of timing of ic after pct on operative success and outcomes. methods: a retrospective review of electronic medical records of patients who were treated for ac with a pct, and subsequently underwent ic at our institution between january to december was performed. the patients were divided into three groups (n= each), based on the duration of the pct prior to ic, and these groups were comparatively analyzed. a comparative sub-analysis of clinical outcomes between patients who underwent surgery within the first week vs. third week or later after pct was also performed. results: a total of patients met the study criteria. each group had patients. there were no statistically significant differences between the groups in regards to age, gender, bmi, imaging findings, and indications for cholecystostomy tube placement. overall, there was no statistically significant difference in outcomes between performing ic within the first weeks, - weeks and [ weeks after pct placement. the length of stay, overall morbidity, clavien-dindo grade of complications and mortality were similar between the time intervals. however, a sub-analysis showed that patients who underwent ic within the first week of pct placement had statistically significant higher mortality rate (p= . ) compared to those who underwent ic[ weeks of pct placement. the two patients who died in our sample had ic within a week after pct placement. even though there was a statistically significantly higher morbidity rate in those who had ic[ weeks after pct, the clavien-dindo grade of these complications was lower than. conclusion: delaying ic to [ weeks after pct placement for ac is not associated with any improvement in patient morbidity, length of stay or rate of conversion from laparoscopic to open cholecystectomy. cholecystectomy within the first week of pct placement is associated with higher mortality rate than after weeks likely due to associated sepsis. introduction: the effect of intraoperative bile spillage during laparoscopic cholecystectomy (lc) on operative time (or time), length of stay (los), postoperative complication rates, and day readmission rates was analyzed. laparoscopic cholecystectomy is the gold standard operation for gallbladder disease in the united states. number of studies have shown that same day discharge in elective laparoscopic cholecystectomy is feasible and safe. bile spillage during this procedure can be a common occurrence in teaching institutions, however, data on the effects of operative outcomes is lacking. methods: this is a retrospective study analyzing all of the laparoscopic cholecystectomies performed at the brooklyn hospital center (tbhc), both emergent and elective, from to . patient data was collected on demographics, comorbidities, bile spillage, operative findings, complications, los, and day readmission rates. statistical analysis was performed using imb spss statistics v. . covaried analysis of variance (ancova) was performed on continues variables and significance levels were calculated. pearson's chi square significance level was calculated for all binomial variables. results: of the patients who underwent lc during this time period, intraoperative bile spillage was encountered in patients. interestingly, bile spillage was significantly more likely to be seen in elective cases over acute cases ( . % vs . %, p. ). there was a statistically significant increase in or time in cases where intraoperative bile spillage was encountered vs. cases where no bile spillage was encountered ( vs. min, p= . ). there was a significant increase in rate of conversion to open procedure when bile spillage was encountered ( . % vs. . %, p. ). drain placement rates increased, not surprisingly, when bile spillage was encountered ( . % vs. . %, p. ). there was no statistically significant difference in los between cases with bile spillage and cases without ( . days vs. . days). there was no significant increase in complication rate or day readmission rates. conclusions: intraoperative bile spillage significantly increases or time, conversion to open procedure, and drain placement. however, there was no significant effect observed of intraoperative bile spillage on length of stay, complication, and day readmission rates. thus, intraoperative bile spillage appears to have little clinical significance on surgical outcomes. however it may have an impact on overall healthcare costs. larger prospective studies evaluating the effect of intraoperative bile spillage on los, or time, complication rates, and day readmission rates are needed to analyze these effects further. tariq nawaz, md; rawalpindi medical university study design: prospective and observational study. place and duration: from january, to july . surgical unit ll, holy family hospital, rawalpindi. patients and methods: thousand patients with a diagnosis of cholithiasis were included. exclusion criteria are patient younger than year and older than year. calot's triangle dissection was done meticulously. cystic artery and hepatic artery anomalies and variations were observed and analyzed on spss . results: the age varies from to years. on the basis of distributional variation the cystic artery was single in % cases, branched in % cases and absent in % cases. on positional variations the cystic artery was superomedial to the cystic duct in % cases, anterior in % cases, and posterior in % cases and low lying in % of the cases. on the basis of length variation results showed that ( %) cases had a normal cystic artery. a short cystic artery was found in ( %) cases and a long cystic artery was present in ( %) cases. other arterial variations are of hepatic artery i.e moynihan's hump ( %) and and right hepatic artery present in calots triangle in % conclusions: for the safety of laparoscopic cholecystectomy one should be well aware of the anatomical variations of the cystic and hepatic artery. keywords: cholelithiasis, cholecystitis, laparoscopic cholecystectomy. as small as it gets: micro-invasive laparoscopic cholecystectomy using only two mm trocars and a needle grasper background: the majority of surgeons use four ports including for laparoscopic cholecystectomy (lc). multiple efforts have been made to reduce number and size of ports. left upper quadrant (luq). patients and methods: of lcs performed from / - / , ( %) were done using three instruments including cases in which trocars and the teleflex needle grasper were used. in cases only two mm trocars were (left upper quadrant (luq) and umbilicus) with the minigrasper being placed between the two. the gallbladder (gb) serosa was incised on both sides and a window was created behind the gb midportion and widened towards fundus and infundibulum. cystic artery (ca) and cystic duct (cd) were dissected out obtaining the critical view and after the last fundus adhesion was cut, ca and cd were secured with clips or endoloop. results: median age of women and men was . (range . - . ) years. lc was done for acute cholecystitis (n= ), chronic cholecystitis (n= ), biliary dyskinesia (n= ), choledocholithiasis (n= ). three patients had an ercp with bile duct clearance prior to the lc. in one case a keith needle was used to suspend the gb fundus for better exposure. twelve patients had additional procedures together with their lc (wedge liver biopsy ( ), lysis of adhesions ( ) , umbilical hernia repair ( ) , mesenteric/lymphnode biopsies ( ) . median or time was (range - ) minutes. the specimen was removed through the luq port site in patients. there were no vascular or bile duct injuries in this series. % of cases were done as outpatient procedures, % of patients required hours observation only three patients were hospitalized for medical reasons. conclusion: in selected cases with either small stones or biliary dyskinesia, lc with only two mm ports and a needle grasper is possible. the teleflex minigrasper can completely replace a port based grasper. introduction: the standard treatment for lithiasic acute cholecystitis remains the laparoscopic cholecystectomy despite the timing of surgery is still controversial. the aim of this prospective study is to evaluate the advantages and limitations of early laparoscopic cholecystectomy in a district hospital. methods and procedure: all patients undergoing laparoscopic cholecystectomy at the surgical department of "carlo urbani" hospital in jesi (italy) from may to september were consecutively enrolled. clinical data such as gender, age, bmi, comorbidity, previous abdominal surgery, previous acute cholecystitis were collected. subsequently, the patients were arranged in two groups according to the timing of intervention (early versus elective surgery). for each group, we compared data concerning surgery, such as operative time, intraoperative and postoperative complications, length of hospital stay and cost analysis. results: this study is a part of an ongoing research. so far, we collected laparoscopic cholecystectomies. ten ( %) of them were admitted with acute cholecystitis and were operated during the hospital stay (group a). group b included patients scheduled for elective surgery (n= ; %). the two groups were comparable with respect to clinical data. conversion to open approach was performed in cases, all of them in group b. mean surgical time was . ± . minutes in group a and . ± . minutes in group b (p= . ). no significant differences in intraoperative and postoperative complications rates were seen in the two groups, just a few in both of them. mean overall length of hospitalization was . ± . days in group a and ± . days in group b (p= . ), whereas the difference in length of postoperative hospitalization was not statistically significant. due to the extended hospitalization for group a, the cost increase as compared to group b was statistically significant, too. conclusions: early laparoscopy is comparable to delayed laparoscopy in terms of postoperative hospitalization and complications in the management of acute cholecystitis. a longer hospital stay among patients scheduled for immediate surgery may be associated with a more time-consuming diagnostic work-up before surgery. however, in future research we expect to enhance our cost analysis with more data regarding the costs incurred in the first hospitalization reserved to nonoperative treatment of group b inpatients with acute cholecystitis. s surg endosc ( ) introduction: with improvements in healthcare access and technology, admissions of octogenarian population with acute cholangitis (ac) are increasing. octogenarians are vulnerable to inferior outcomes. there is no study to evaluate factors predicting outcomes of ac in octogenarians. the aim of our study is identify factors predicting outcomes, and to evaluate the quick sequential organ failure assessment (qsofa) score and tokyo guidelines (tg ) severity grading for octogenarian patients with ac. methods: a retrospective review of octogenarian patients admitted with ac from january to december was performed. demographic profile, clinical presentation and discharge outcomes were studied. systemic inflammatory response syndrome (sirs), qsofa and tg severity grading scores were calculated. mortality is defined as death within days of admission or in hospital mortality. statistical analysis was performed using spss version . results: there were a total of patients admitted for ac, of which ( %) were octogenarians. majority (n= , %) were female, with a mean age of (range - ) years. majority were secondary to gallstones (n= , %), and ( %) were due to malignancies. ( %) and ( %) patients fulfilled sirs and qsofa criteria of severity respectively. ( %) and ( %) of patients had a tg severity grading of moderate and severe respectively. nine ( %) patients required inotropic support in the emergency department (ed) and ( %) patients were admitted to critical care unit (ccu). ( %) patients underwent endoscopic retrograde cholangiopancreatography (ercp) and ( %) underwent percutaneous transhepatic biliary drainage (ptbd) for biliary decompression. patients underwent index cholecystectomy. length of stay was . (range - ) days and -day mortality of %. multivariate analysis performed showed that an abnormal glasgow coma score (p= . ) and malignancy (p. ) predicted -day mortality. the use of ed inotropic support predicted ccu admission (p= ). a positive blood culture (p= . ), presence of malignancy (p. ), use of ed inotropes (p= . ), and index cholecystectomy (p= . ) predicted a longer length of stay. qsofa (p. ) and tg severity grading (p= . ) were predictive of -day mortality. sirs criteria did not predict -day mortality. conclusion: reduced consciousness and malignancy predicted -day mortality in octogenarian patients with ac. qsofa and tg severity grading system is superior to sirs criteria in predicting mortality of octogenerians with ac. our group has performed needlescopic grasper assisted silc (nsilc) to overcome these problems. we evaluate the technical feasibility, safety and benefit of nsilc versus three-port laparoscopic cholecystectomy (tplc). methods and procedures: this prospective randomized control study was conducted to compare the advantages if any between the nsilc and tplc. one hundred and forty eight patient were randomized into two groups, with one group underwent n slic ( patients) and a control group underwent tplc ( patients). basic information about the patient and diagnosis was collected. the surgical outcome that was composed with critical view of safety (cvs) time, major procedure time and total operation time, and the comparison of postoperative complication was made. result: nsilc group was consisted of male ( . %) and female ( . %), and tplc group was consisted of male ( . %) and female ( . %) (p= . ). the average age of nsilc group was . ± . years old, and tplc group was . ± . years old (p= . ). cvs time of tplc group was shorter than silc group (nsilc: . ± . min, tplc: . ± . min, p= . ), major procedure time (skin incision to gb removal from liver bed) of tplc group was shorter than nsilc group (silc group: . ± . min, tplc: . ± . min, p= . ). however, there was no significant difference in postoperative complication (nsilc: , tlc: , p= . ). conclusion: although cvs time, major procedure time, and operation time of silc were longer than tplc, overall clinical results were similar. nsilc is feasible and safe surgical procedure in patient with benign gallbladder disease. introduction: management of malignant biliary obstruction not amenable to surgery is usually by means of ercp or pthc. however, on occasions, these routes are not accessible and the alternate decompressive technique of percutaneous cholecystostomy (pc) has to be adopted. the aim of this study was to evaluate the efficacy and outcomes of pc in a highly selected series at a tertiary referral center. methods: we retrospectively reviewed all patients that had undergone pc from to . data collected included baseline demographics, comorbidities, details of pc placement and management, etiology of mbo, and post-procedure outcomes. the charlson comorbidity index (cci) was calculated for all patients at the time of pc. results: four hundred and eight patients underwent pc placement of which patients including ( %) males and ( %) females, with malignant biliary obstruction. the mean age at the time of pc placement was . ± . years of age, and the mean cci was . ± . for all patients. of mbo in all patients was due to pancreatic malignancies (n= ), cholangiocarcinoma (n= ), primary hepatic malignancies (n= ), secondary hepatic tumors (n= ), and ampullary carcinoma (n= ). pc tube complications were reported in ( %) patients. mean number of tube exchanges was . ± . . mean duration from pc tube placement to death was ± . days. total deaths were recorded. conclusion: pc placement appears to be a viable option in mbo in elderly and frail patients. in this cohort, pc may be a potential definitive management to improve quality of life. melanie boyle, daivyd palencia, philip leggett; houston northwest medical center background: there are very few studies assessing the relationship between gastroesophageal reflux and biliary disease. this is surprising as they share presenting symptoms as well as risk factors, particularly obesity. our group previously produced a review of patients in our practice who had undergone some type of reflux procedure. conclusions showed that the prevalence of gallbladder disease in our severe reflux population is much higher compared to that found in the general population. our goal of this study is to expand on that data to include a larger sample size to investigate the incidence of biliary disease in our reflux population and decide if this should influence our pre-operative algorithm for anti-reflux surgery patients. methods: we expanded on our previously performed retrospective review of patients that underwent laparoscopic fundoplication for reflux disease. we previously reviewed data from to . we are now looking at data from to . our expected sample size will include approximately patients, of which have currently been reviewed. our previous study included only . the surgery preformed was either a toupet or nissen fundoplication, and one underwent a dor. demographic data, imaging studies, and pathology results were reviewed. results: we looked at whether each patient who underwent antireflux surgery had a prior cholecystectomy either remotely or recently, underwent concomitant cholecystectomy, or had no biliary disease in their workup. the groups had similar age and were predominantly women. we once again demonstrated that the prevalence of gallbladder disease in our severe reflux population is much higher than the general population. when approaching a patient with gastroesophageal reflux disease, attention should be paid to gallbladder symptomatology as well. we recommend that it may be beneficial to include gallbladder ultrasound in pre-operative workup for antireflux surgery so that concomitant cholecystectomy can be performed if indicated. steven schulberg, do, jonathan gumer, do, matt goldstein, vadim meytes, do, george ferzli, md; nyu langone hospital -brooklyn introduction: acute cholecystitis is a common surgical disease with roughly , cholecystectomies performed in the us annually. the current dogma revolves around the " hour rule" advocating early cholecystectomy if within the window, and if beyond hours, conservative treatment and interval operation. in patients beyond the hour window, as well as with multiple comorbidities, advanced age, and other complicating factors, cholecystostomy has become an acceptable treatment as a bridge to interval cholecystectomy. while this has become an appropriate treatment modality, it does not come without its own set of complications. we aim to evaluate the rate of complications in our institution. methods: this is a retrospective review of all patients at our institution who underwent cholecystostomy placement between and . we evaluate the comorbidities, readmission rate, overall rate of complication associated with cholecystostomy tubes, and eventual definitive cholecystectomy. results: our cohort includes patients, % of whom were male, with a mean age of . we had an overall complication rate of . %, including tube dislodgements, leaking tubes, and misplaced tubes. all cause readmission rate was % and only % of patients who had cholecystostomy drains underwent interval cholecystectomy. conclusion: there has been much interest in treatment of acute cholecystitis in patients with multiple comorbidities. in review of our data, a surprisingly large number of patients had mechanical complications involving the cholecystostomy drain. in an era focused on decreasing readmission rates and their associated costs, drains carry a high risk of malfunction which will in turn, lead to increases in these two metrics. while there is more work to be done in the evaluation of early cholecystectomy versus cholecystostomy in this subgroup of patients, we suspect that early cholecystectomy in the medically optimized patient will lead to reduced length of stay and hospital costs as well as increased patient satisfaction. does selective use of hepatobiliary scintigraphy (hida) scan for diagnosis of acute cholecystitis, following equivocal nondiagnostic gallbladder ultrasonography, affect outcomes fahad ali, ba, amir aryaie, md, eneko larumbe, phd, mark williams, md, edwin onkendi, md; texas tech university health sciences center introduction: acute cholecystitis (ac) is diagnosed by characteristic gallbladder ultrasonographic findings (high specificity, low sensitivity). hepatobiliary scintigraphy (hida) may be needed to confirm ac (higher sensitivity and specificity). the aim of this study was to assess the impact of the current selective use of hida scan for sonographically equivocal cases of ac on outcomes. methods: a retrospective chart review of patients treated for ac at our institution ( / to / ) was performed. patients were divided into groups: the ultrasound only group (us-only) and the ultrasound-hida group (us-hida). timing of us and hida, and intervention for ac since presentation to emergency room (er), and their impact on outcomes were analyzed. ac severity was graded per the tg -tokyo guidelines. results: a total of patients were analyzed. the groups were statistically similar with regards to age, body mass index, asa class ii, iii and iv, extent of leukocytosis at presentation and liver functions test levels at presentation. in the us-only group, diagnostic ultrasound was obtained sooner, [median of (interquartile range, iqr . - . ) hours] from presentation to the er compared to the us-hida group, ) hours], p= . . hida was obtained after a median delay of . (iqr . - ) hours from a nondiagnostic ultrasound. majority of patients ( %) in the us-only group had mild (tg grade i) to moderate (tg grade ii) ac, while % of the us-hida group had moderate (tg grade ii) to severe (tg grade iii) ac (p= . ). despite this, more patients in the us-hida group ( %) had a "normal" non-diagnostic ultrasound compared to the us-only group ( . %), p. . seven patients in the us-hida group had no intervention due to normal hida scan ( ) , ac misdiagnosis due to liver cirrhosis ( ) , and severe medical comorbidities ( ) . more patients ( %) in the us-only group underwent laparoscopic cholecystectomy, compared to % in the us-hida group (p= . ). between the two groups, there was no significant differences in -day morbidity, mortality and reoperations. however, the length of stay was longer by a median of . days in the us-hida group (p= . ). conclusion: patients with moderate to severe ac are more likely to need hida scan due to a "normal" non-diagnostic ultrasound, have a delay in diagnosis, not have intervention for ac due to severe medical comorbidities and have lower chance of laparoscopic cholecystectomy. the length of hospital stay is significantly longer for these patient by a median of . days. introduction: benign gallbladder disease is commonly treated with laparoscopic cholecystectomy (lc). gallbladder cancer (gbc) is a rare malignancy characterized by high invasiveness and poor survival. in our institution, all gallbladder specimens are routinely sent to pathology, to rule out gbc. the purpose of our study was to assess the efficacy for routine histopathology of gallbladder specimens after cholecystectomy (cly) for all gallbladder disease. methods and procedures: after obtaining approval from our institutional review board, a retrospective review was conducted on all patients who underwent cly from june of to may were included in the study. the data obtained include gender, age, american society of anesthesiologist score (asa), body mass index (bmi), comorbidities, length of stay (los), radiological imaging and pathology results. independent t and chi-square tests were performed using ibm® spss® software. results: there were cly performed at our institution, of which ( %) were lc. females composed of ( %) patients and the median age was . ( %) gallbladder specimens were found to be cancerous. ( %) gallbladder specimens were benign. majority ( %) were chronic cholecystitis, ( %) were acute cholecystitis and ( %) were gangrenous cholecystitis. ( %) were found to be acalculus cholecystitis and ( %) were cholelithiasis. ( %) were found to be adenomyositis, and other. conclusion: in our institution, less than % ( ) of all gallbladder specimens were found to be cancerous. it would decrease cost and work load if gallbladder specimens are selectively sent to pathology. emanuel a shapera, md we sought to determine clinical factors associated with recurrent cholangitis in two las vegas community hospitals to aid providers in management of this disease. methods and procedures: retrospective, multi-center study. over ercps were analyzed between and . patients were identified as having multiple ( ) admissions for cholangitis per tokyo criteria. univariate and multivariate analysis was conducted. results: patients with a significantly (p. ) higher albumin level on admission ( . ) were discharged home more often than patients discharged to a facility or hospice ( . ). on multivariate analysis, non-home discharge was associated with lower albumin level at admission (p= . ) and greater maximum temperature prior to decompression (p= . ). increased hospital stay was associated with lower albumin level at admission (p= . ). a majority ( / ) of recurrent episodes involved stent placement, exchange or removal. patients ( %) had either biliary malignancy, gallbladder or both. blood cultures were drawn in % of all episodes and positive in %, e coli being the most common pathogen isolated. all patients had low hdl levels ( - , mean ) . conclusions: high fevers and poor nutritional status was associated with increased length of hospital stay and fewer home discharges. tumors, gallbladders and malfunctioning stents contribute substantially to morbidity. close follow up for indicated gallbladder removal, stent management and nutritional optimization is critical to reduce the burden of this disease. we compared the surgical method in neonate choledochal cyst between oec and lec. the perioperative and surgical outcomes that were reviewed included age, operative time, postoperative hospital stay, time to diet, and surgical complications. the patients were followed up for months (range, - months) . results: there was no difference in range of bile duct excision and manner of roux-en-y hepaticojejunostomy between oec and lec groups. there was no intraoperative complication in both groups and no open conversion in the lec group except one case which was ruptured choledochal cyst. the median age of oec and lec groups were days (range, - ) and . days (range, and median body weight at the time of operation were . kg (range, . - . ) and . kg (range, . - . ) , respectively. the median operative time was minutes (range, - ) in oec and . minutes (range, in lec groups and there was no significant difference between oec and lec groups (p= . ). intraoperative bleeding was minimal in both groups. the postoperative hospital-stay, time to start diet, and time to return to full feeding had no significant differences in both groups. after discharge, of ( %) oec patients experienced readmission due to cholangitis and ileus, while there were none in the lec group. conclusions: this study revealed that lec had better prognosis compared to oec. lec provided an excellent cosmetic result. so we suggest lec could be the treatment of choice for neonatal choledochal cyst. this is a small series, therefore future studies will have to include a larger number of patients and evaluate long-term follow-up. keywords: choledochal cyst, laparoscopy, neonate. laparoscopic narrow band imaging for intraoperative diagnosis of tumor invasiveness in gallbladder carcinoma: a preliminary study yukio iwashita, hiroki uchida, teijiro hirashita, yuichi endo, kazuhiro tada, kunihiro saga, hiroomi takayama, masayuki ohta, masafumi inomata; oita university faculty of medicine introduction: determining tumor invasiveness before operation is one of the most important unsolved issues in the management of gallbladder cancer. we hypothesized that the assessment of irregular vessels on the gallbladder wall may be useful for detecting subserosal infiltration. we present an initial report on the clinical usefulness of laparoscopic narrow band imaging (nbi) for the intraoperative diagnosis of tumor invasiveness in gallbladder carcinoma. methods: thirteen patients with gallbladder cancer were included in this study. patients with tumors located in the liver bed and those with definitive invasion observed on computed tomography findings were excluded from this study. gallbladders were observed using nbi and the microvasculature was evaluated. according to previous reports of endoscopic nbi, we defined four findings as positive: vessel dilatation, tortuousness, interruption, and heterogeneity. the nbi findings were compared with postoperative pathological findings. the study protocol was approved by the institutional review board of the oita university. results: the serosal surface of the tumor site and its microvasculature were successfully observed in all patients. laparoscopic nbi detected at least one abnormal finding in seven patients, and postoperative pathology showed subserosal infiltration accompanied by vessel invasion. on the contrary, six patients with no positive nbi findings showed mild or no subserosal infiltration and no vessel invasion. conclusions: our study indicated that laparoscopic nbi may be useful for diagnosing subserosal infiltration accompanied by a vessel invasion. shuichi iwahashi, mitsuo shimada, satoru imura, yuji morine, tetsuya ikemoto, yu saito, hiroki teraoku; department of surgery, tokushima university introduction: laparoscopic cholecystectomy (lap-c) is the standard operation for the benign diseases. we have reported reduced port lap-c (rpl-c) was safely and comparable method to sils-c and conventional lap-c (sages ) . in this time, we examined the utility of rpl-c containing the post-operative adverse event. procedures: the adjustment is the benign illness including the cholecystolithiasis, and advanced obesity and the cases of the inflammation remaining have been excluded. the incision is put and cut open the abdomen to the umbilical region, and camera port was inserted. we used mm flexible scope. mm forceps for holding of the gallbladder bottom and left hand of operator were inserted directly with no port. methods: rpl-c has been introduced in this department since july, . we performed cases of lap-c, containing sils-c and american style conventional lap-c, and we performed rpl-c has been performed already cases. we compared the patient background and the operation factor between rpl-c, sils-c, conventional lap-c. operators were young surgeons, they were not specialists of gastroenterological surgery or endoscopic surgery. results: the difference was not admitted in the age, gender, the physique, and the disease, and the difference was not admitted in hospital stay after the operation (rpl-c:sils-c:conventional lap-c= . ± . days: . ± . days: . ± . days) and the amount of blood loss (rpl-c:sils-c:conventional lap-c= . ± . ml: . ± . ml: . ± . ml) and operation time (rpl-c:sils-c:conventional lap-c= ± min: ± min: ± min). and surgical wound after rpl-c was cosmetically acceptable. regarding as the post-operative adverse event, there were no patients of bile duct injury. conclusion: in the patients on reduced port lap-c, there were no bile duct injuries of postoperative adverse event. reduced port lap-c is safely for young surgeons and comparable method. introduction: acute cholangitis is an ascending infection of the biliary tree secondary to obstruction and can be severe if proper intervention and treatment are not performed in a timely fashion. the most common management of cholangitis with ductal obstruction due to choledocholithiasis is intravenous hydration, empiric antibiotic therapy, endoscopic retrograde cholangiopancreatogram (ercp) with sphincterotomy and stone extraction with or without stent placement, followed by a delayed laparoscopic cholecystectomy. we present the case of a patient with blood clot obstruction of a common bile duct (cbd) stent after ercp with sphincterotomy and stone extraction. case presentation: a year old male presented to the emergency department with jaundice, right upper quadrant abdominal pain, truncal pruritis, nausea, vomiting, and fever. biochemical analyses and liver profile demonstrated an elevated white blood cell count, hyperbilirubinemia, and elevated liver enzymes consistent with cholestasis. biliary ultrasound demonstrated multiple gallstones and dilation of the cbd with a distal obstructing calculus. he proceeded to ercp where biliary cannulation was achieved, sphincterotomy performed, and a large amount of sludge and pus was drained. an mm stone was removed from the cbd by balloon sweep with completion cholangiogram demonstrating no filling defects. a stent was then placed in the cbd with adequate flow. following the procedure, the patient continued to have increasing hyperbilirubinemia. a repeat ercp revealed a large blood clot and continued bleeding at the previous sphincterotomy that resolved with epinephrine injection. the former stent was visualized in the proper position, removed with a snare, and found to be fully occluded with blood clots. after retrieval of additional clots, a new stent was placed with adequate return of bile. the patient recovered with resolution of his symptoms and hyperbilirubinemia with laparoscopic cholecystectomy. discussion: cholangitis is characterized by charcot's triad of right upper quadrant abdominal pain, fever, and jaundice due to an ascending bacterial infection of the biliary tree coinciding with obstruction of biliary flow most commonly from gallstones. cholangiography via ercp with associated sphincterotomy, stone extraction, and stenting is both diagnostic and therapeutic. while debated by endoscopists, stent placement has shown to reduce recurrent biliary complications, decrease length of hospital stay, and lessen morbidity. although pancreatitis is the most common cause of hyperbilirubinemia post-ercp, stent occlusion secondary to stones or blood clots should be considered to effectively treat patients. proper hemostasis is important in any procedure and close patient follow-up should be performed to prevent further complications. sarrath sutthipong, md, panot yimcharoen, md, poschong suesat, md; bhumibol adulyadej hospital background: choledochal cyst (cc) is a rare disease, characterized by dilatations of the extra-or/ and intrahepatic bile ducts. ccs occur most frequently in asian and female populations. cc is associated with biliary lithiasis and considered at risk of malignant transformation. todani's classification dividing cc into types is the most useful in clinical practice. the current standard treatment is complete cyst excision with roux-en-y hepaticojejunostomy and cholecystectomy for the extrahepatic disease (todani type i and iv). in this report we present our experience using a total laparoscopic technique to treat adult patients with cc in -year period. methods: a retrospective review of the records of the patients above years who underwent laparoscopic cyst excision and roux-en-y hepaticojejunostomy in our hospital between january and may was carried out. the data included the clinical presentation, investigation, perioperative details and complication. the type of cc was classified according to todani's classification. results: seven cases of cc were reviewed, females and male with mean age years (range - years). these included cases of todani type ib and cases of type a. the predominant symptoms were chronic abdominal pain and jaundice. a case of both pancreatitis and cholangitis were also seen. investigations included ultrasound with mrcp in cases and ercp in case. the mean operative time was hours and minutes ( hours minutes to hours range) with mean intraoperative blood loss ml (range - ml). all the resected specimens showed chronic inflammation. malignancy was not seen in any patients. the early postoperative complications included bile leakage with intra-abdominal collection in patients, which were managed conservatively (evidenced by clinical status and imaging study), re-operation was not required. the median duration of hospital stay was days (range - days). there was no perioperative mortality. all patients were followed up at , , and months postoperatively, late complication were not detected during each visit. conclusion: in our opinion, laparoscopic cyst excision and hepaticojejunostomy could offer more feasible and safe methods of treatment for ccs in adult patients with potentially less postoperative morbidity, a shortened length of stay and a lower blood loss when compared to the preferred open approach. however, we would need to study this on a larger sample of patients to report the efficacy and safety of laparoscopic approach. endoscopic trans-papillary gallbladder drainage (etgbd) in acute cholecystitis: a single center experience arun kritsanasakul, chotirot angkurawaranon, jerasak wannapraset, thawee rattanachu-ek, kannikar laohavichitra; rajavithi hospital background: surgery is the mainstay of treatment for cholecystitis, however, it may not be safe or feasible in some circumstances such as severe cholecystitis or cholecystitis in extremely high-risk patients. gallbladder drainage may be an appropriate alternative or a bridging option prior to cholecystectomy. endoscopic trans-papillary gallbladder drainage (etgbd) has been proposed as a modality that is feasible and effective in cholecystitis. objective: the primary outcome of this study is to evaluate the effectiveness of etgbd. the secondary outcome is to evaluate the safety, early experience outcomes, and complications of this procedure. methods: retrospective medical records review between january -december from a single tertiary referral hospital center, rajavithi hospital, bangkok, thailand. a total of patients who was diagnosed with cholecystitis and underwent etgbd. the procedure was performed at the endoscopic suite under light sedation via total intravenous anesthesia. the patient demographic data and procedures were collected. the technical success of etgbd was defined as decompression of the gallbladder by successful cystic duct stent placement. the clinical success was defined as resolution of symptoms and/or improved laboratory data or ultra-sonographic findings. results: a total of patients underwent etgbd. among these patients, were high risk for surgery due to age or comorbidity, had concomitant jaundice and was failure of medical treatment. both technical and clinical success of etgbd was achieved in of cases ( %). the two patients that did not achieve technical success were due to failure to cannulate guidewire through cystic duct and the other had trans-cystic guidewire perforation that needed surgical intervention. there were two intra-operative complications ( %). one was the patient who had trans-cystic guidewire perforation and another had anesthesia-related complication (hypoventilation requiring endotracheal intubation). there were no -day mortality. conclusion: endoscopic trans-papillary gallbladder drainage is an alternative treatment modality for patients with cholecystitis who are at high-risk for surgery and or those who are unsuitable for percutaneous gallbladder drainage. the technique is feasible, however, careful case selection and high endoscopic skill is needed. julia f kohn, bs , alexander trenk, md , woody denham, md , john linn, md , stephen haggerty, md , ray joehl, md , michael ujiki, md ; university of illinois at chicago; northshore university healthsystem, northshore university healthsystem introduction: subtotal cholecystectomy, where the infundibulum of the gallbladder is transected to avoid dissecting within a heavily inflamed triangle of calot, has been suggested as a method to conclude laparoscopic cholecystectomy while avoiding common bile duct injury. however, some case reports have suggested the possibility of recurrent symptoms from the remnant gallbladder. this retrospective case series reports a minimum of two-year follow-up on patients who underwent subtotal cholecystectomy within one four-hospital system. methods: a retrospective chart review database containing randomly selected cholecystectomies, all of which occurred between and , was reviewed to identify all instances of subtotal cholecystectomy. charts for these patients were reviewed through / , including any documentation from other providers, including primary care. results: six patients who underwent subtotal cholecystectomy with a remnant of infundibulum left following surgery were identified. surgical approach and the choice to perform subtotal cholecystectomy were dependent on the attending surgeon; all decisions were made intraoperatively. there was an average of months of follow-up for these patients within our institution. discussion: this case series adds six cases to the literature surrounding long-term outcomes in patients who underwent subtotal cholecystectomy. although one patient was lost to follow-up, no patient had recurrent biliary colic or other complications arising from the remnant gallbladder. this may be encouraging to surgeons who feel that subtotal cholecystectomy with an infundibular remnant is the safest way to proceed with cholecystectomy in patients with severe inflammation. objective: this study aims to evaluate the utility and efficiency of icg as an alternative to routine intraoperative cholangiogram in patients undergoing cholecystectomy. introduction: common bile duct injury is an uncommon, but serious complication associated with laparoscopic cholecystectomy. current guidelines state that when used routinely intraoperative cholangiogram (ioc) can decrease biliary injury, however it is not routinely used due to increased time of operation, and inaccessibility of equipment. indocyanine green (icg) has been found to be effective for identification of biliary anatomy during cholecystectomy, however has not yet been widely adopted. we aim to assess if icg is able to overcome the obstacles of ioc, while still effectively assessing biliary anatomy. methods: we performed a retrospective analysis of laparoscopic cholecystectomies performed in a single institution from january to september . elective and emergent cases were included. we stratified patients into icg and non-icg groups. patients who had concomitant procedures performed were excluded. we analyzed patient demographic information, as well as bmi, asa classification and comorbidities in both groups. our primary outcome was operation time (skin to skin), and laparotomy conversion rate. secondary outcomes were effectiveness of icg in visualizing biliary anatomy, and cost. results: patients were included in our study, in the non-icg arm and in the icg arm. both groups were similar in background. there were no statistical differences in patient demographics, asa classification, bmi, or comorbidities. there was no statistical difference in operation time ( . vs . minutes; p. ) or conversion rate ( . vs %; p. ). icg was able to delineate biliary anatomy in % of the patients. the cost of a mg/vial kit of icg is approximately $ . conclusion: the use of icg does not increase operating time during laparoscopic cholecystectomy. icg is an inexpensive and effective tool used to delineate biliary anatomy without the inherent burden and limitations of ioc. benefsha mohammad, md , michele richard, md , steve brandwein, md , keith zuccala, md ; danbury hospital, danbury hospital department of gastroenterology, introduction: obesity is a prevalent issue in today's society, which has increased the number of gastric weight loss surgeries. this presents an anatomical challenge to biliary disease requiring endoscopic retrograde cholangiopancreatography (ercp). in gastric bypass patients, traditional ercp via the mouth in these patients is technically more challenging, requiring a longer endoscope with a reported success rate of less than %. a solution is laparoscopic assisted ercp (la-ercp) via gastrostomy. this minimally invasive technique has become increasingly more prevalent and safe. we present our experience with la-ercp at our teaching community hospital in a large cohort of patients. methods and procedures: retrospective chart review was performed on all patients with a history of prior laparoscopic gastric bypass surgery who underwent la-ercp from april to april . the procedure was performed by two different general surgeons and one gastroenterologist. a pursestring suture and transfacial stay sutures were used to bring the gastric remnant to the abdominal wall. a gastrostomy was then created and accessed by the duodenoscope to perform the ercp. biliary sphincterotomy, papillary or biliary dilation, lithotripsy, stent placement, and/or stone removal were performed as indicated. we observed the incidence of postoperative outcomes, including acute pancreatitis, reoperation, post-procedure infection, pain control, hospital re-admission and bile leak. results: thirty-two patients met inclusion criteria. six patients were male and twenty-six were female, with mean ages of (std dev ) and years (std dev ), respectively. indications for la-ercp included suspected choledocholithiasis ( / ), cholangitis with choledocholithiasis ( / ), acute pancreatitis ( / ), abdominal pain with abnormal lft ( / ), cholangitis with cholecystitis ( / ), and bile leak ( / ). la-ercp was successfully performed in all thirty-two patients. biliary cannulation, sphincterotomy and stone extraction were performed on / patients, and one patient underwent sphincterotomy and stent placement for bile leak after recent laparoscopic cholecystectomy. one patient developed acute pancreatitis with elevated pancreatic enzymes which resolved after conservative treatment. one patient required a second la-ercp for stent replacement due to a persistent bile leak. the median length of stay was days (range - days). conclusions: la-ercp is a safe and feasible alternative to open surgery, and can be safely implemented at community hospitals with adequately trained providers. obesity is a growing burden on society, increasing the incidence of weight loss surgery. our large study proves that in this minimally invasive era, la-ercp provides gastric bypass patients a safe alternative with less pain and increased satisfaction. ahmed elgeidie, elsayed adel; gastrointestinal surgery center background: endoscopic sphincterotomy (es) is an effective therapeutic procedure for common bile duct (cbd) stone clearance but it carries a substantial risk of recurrent stones at long-term outcome. aim of the study: to evaluate the rate of cbd stones recurrence after primary complete endoscopic clearance, and to identify the risk factors of recurrence. methods: between january and december , patients with cbd stones who underwent successful es and complete stone clearance were studied retrospectively. recurrent cbd stone, was defined by the confirmation of the presence of cbd stone at least months after previous complete cbd stone clearance by es. the risk factors for recurrent cbd stones and mean time interval between initial es and stone recurrence were analyzed. results: in total, patients we included. the median follow up period was months. recurrent cbd stones appeared in / ( . %) patients after a median time interval of ( - ) months following es. stone recurrences were observed on multiple occasions in patients ( . %). on the univariate analysis, the significant risk factors related to recurrent cbd stone were male sex (p= . ), previous history of cholecystectomy (p= . ) multiple cbd stones (p= . ), large cbd stone (p= . ) the presence of periampulary diverticulum (p= . ) and stone crushing using mechanical lithotripsy (p= . ) conclusion: recurrence of cbd stones is an identified long-term risk after es and stone clearance. background: laparoscopic cholecystectomy during advanced pregnancy is challenging due to the limited intraabdominal space. patients may be at increased risk for developing trocar site hernia. case report: a year old hispanic female in her th week of pregnancy came to the er with acute right upper quadrant pain. due to lack of accessibility she had poor prenatal care. she had mildly elevated amylase but normal lfts and ultrasound showed some gallbladder wall thickening suggestive for acute cholecystitis and no dilated biliary duct. fetal ultrasound was normal. she was admitted to the hospital and started on antibiotics, obstetrics was consulted. her amylase peaked at [ u/l but then normalized and indication for laparoscopic cholecystectomy was made. mrcp and ercp were not performed as it was assumed that the patient had passed a stone. five mm trocars were placed in the luq and the umbilicus and a teleflex minigrasper between the tow. the uterus was found at the umbilical level. the gb was pulled out and the serosa was incised on both sides and a window was created behind the gb midportion and widened towards infundibulum and fundus. there was gb wall thickening and edema. the critical view was obtained and the cystic artery and duct were clipped and divided. the common bile duct appeared normal and no ioc was done. the specimen was retrieved through the luq port site using a mm endobag after dilatation to . cm due to the presence of two large stones. the port site fascia was closed using a suture passer. the postoperative course was uneventful and both mother and baby were well at the two weeks follow up. discussion: in case of biliary pancreatitis during pregnancy, lc should be performed and if ultrasound shows a normal biliary system and amylase/lipase normalize, mrcp/ercp and ioc may be avoidable to protect the baby. lc with two ports is feasible during pregnancy. removal of the specimen through a lateral abdominal wall site may help prevent an umbilical port site hernia in this patient population. s surg endosc ( ) :s -s introduction: splenic abscess is a rare, potentially lethal condition, with autopsy studies showing incidence rates between . - . %. mortality rates ranging from to % making early diagnosis and prompt intervention vital. several case reports have documented post surgical splenic abscess, most notably after laparoscopic sleeve gastrectomy. to the best of our knowledge, there has not been any reported cases of splenic abscess arising after laparoscopic cholecystectomy. it is important to remember this disease process for expeditious targeted treatment in future cases. case presentation: a year-old female with past medical history significant for cholilithiasis, hypertension, and hyperlipidemia presented to the emergency department (ed) with a chief complaint of abdominal pain for two days. labs and imaging were obtained which confirmed the diagnosis of choledocholithiasis and pancreatitis. ercp was performed which showed a . cm stone causing obstruction, with several other smaller filling defects. the stones were removed after sphincterotomy. post procedurally, the patient underwent an uncomplicated laparoscopic cholecystectomy on hospital day (hd) # . post operatively, the patient had persistent leukocytosis peaking at . thousand on postoperative day (pod) # . a ct scan was performed which showed a rim-enhancing splenic collection measuring . . cm suggestive of an abscess. interventional radiology was consulted and aspirated ml of purulent fluid. cultures grew out klebsiella pneumoniae and enterobacter cloacae complex, and the patient was discharged home on zosyn. discussion: laparoscopic cholecystectomy has become the cornerstone in treatment of symptomatic biliary colic and acute cholecystitis. of the many recognized complications of laparoscopic cholecystectomy, splenic abscess has not yet been reported in current literature. the nonspecific signs and symptoms of splenic abscess make clinical diagnosis difficult. the classic triad of fever, palpable spleen and left upper quadrant pain are only seen in about two-thirds of patients. ct scan has been shown to be the most sensitive imaging modality for diagnosis of splenic abscess. current treatment options for splenic abscess are broken down into two subsets: percutaneous and surgical intervention. percutaneous treatment includes image guided aspiration with or without placement of drainage catheter. surgical intervention can be either laparoscopic or open and includes drainage of abscess with splenectomy or splenic conservation. the best treatment option remains unclear, and there is lacking prospective data demonstrating which modality is superior. introduction: laparoscopic subtotal cholecystectomy is widely accepted as a safe alternative to the conventional laparoscopic cholecystectomy in case of acute cholecystitis with frozen calot's triangle. the remnant stump of the gallbladder may be either sutured or looped. however, there are limited studies comparing the outcomes of the two techniques. the present study is aimed at comparing loop and suture closure of the gall bladder stump. methods: a retrospective analysis of our prospectively maintained database revealed that between january and december . patients underwent laparoscopic subtotal cholecystectomy for acute cholecystitis, chronic cholecystitis or empyema gallbladder with frozen calot's triangle. the decision to use endoloop or sutures for stump closure was made intra-operatively after dividing the gallbladder through the infundibulum. a no. sized drain was kept in all the cases. the patients were discharged with drain in situ, and were reviewed on post-operative day during which an ultrasound was done and drain removed if the progress was satisfactory. the intra-operative and post-operative data between the two groups were recorded and analyzed. results: endoloop closure was performed in patients and suture closure using . ethibond was done in patients. three patients from the sutured group had post operative bile leak among which one patient underwent endobiliary stenting. the other were managed conservatively while the drain had to be retained for weeks. two patients in the endoloop group were detected to have retained stone in the remnant gallbladder cuff among which one had recurrent cholecystitis requiring laparoscopic completion cholecystectomy. none of the patients had bile duct injury or surgical site infection. mean post operative stay was . + . days, did not significantly vary between the groups. suturing needed more surgical expertise and had prolonged operative time than endoloop ( + min versus + min, p= . ). conclusion: suture or loop closure of the remnant gallbladder after subtotal cholecystectomy are equally effective. suturing the stump may be associated with increased incidence of biliary leak while endoloop may have higher incidence of retained gallstones. the choice between the two may be made intra-operatively based on the surgeon's expertise and preference. background and aim: in recent years, due to the spread of laparoscopic cholecystectomy, bile duct injury as its complication has been reported at a certain frequency. current surgical treatments include ) suturing and closing the injured part laparoscopically during surgery, ) transitioning to laparotomy and closing the suture, ) inserting a tube such as t-tube under the laparotomy, ) bile duct-intestinal anastomosis under the laparotomy, etc. are taken into consideration. regardless of which treatment method, it is not a definite ideal treatment. we have developed a bioabsorbable material (caprolactone: lactic acid ( : ) polymer reinforced with polyglycolic acid fiber and designed to be absorbed in about weeks). at this conference, we would like to talk about the current state and problems of development of minimally invasive therapy for biliary damaged area using bioabsorbable materials we developed. method: in order to overcome the problem of the current bile duct injury cure method, we have been developed, a) a method of closing a perforation part endoscopically from the luminal side of a bile duct (a covered stent using a bioabsorbable material in the damaged part), b) develop a method of closing the biliary duct injury under the laparoscope from the outside of the bile duct (adhering the bioabsorbable sheet to the bile duct perforation using a biocompatible adhesive). results: experimental results of suturing the bioabsorbable material in the biliary duct in surgery of laparotomy were able to regenerate the bile duct without stenosis in the damaged area. however, various adhesives were tried to bond the sheet of this bioabsorbable material and the native bile duct under the endoscope, but at the moment, there is no glue that will allow the sheet to be adhered readily and reliably where there is moisture to a certain extent. a tool for delivering the sheet from the bile duct into the injured part is under development and good results are obtained at present. conclusion: it is possible to regenerate the bile duct without constriction using a bioabsorbable material. it is difficult to laparoscopically adhere to the injured part of the bile duct, but we hope that it will be possible in the near future to develop further adhesives. s surg endosc ( ) , - kg/m (c) and more than kg/m (d). we made a . -cm longitudinal skin incision within the umbilicus. a wound retractor and a surgical glove were applied at that incision. we used the three -mm ports technique. after retracting the gallbladder upward, the cystic duct and artery were divided and identified using pre-bending forceps through the flexible port and laparoscopic coagulating shears (lcs). the cystic artery was dissected using the lcs and the cystic duct was also dissected after clipping. the gallbladder was freed from the liver bed using the lcs, and the specimen was retrieved from the umbilical wound. results: there were conversions to open laparotomy in cases ( . %) and requirement of additional ports in ( . %). the mean age (years), operation time (min), blood loss (ml) and postoperative hospital stay (days) in group a, b, c and d were . , . , . and . (p= . [), . , . , . and . (p= . ), . , . , . and . (p= . ) , and . , . , . , and . (p= . ), respectively. there was a significant difference in age only. the complications were bile duct injury in one case ( . %) and pneumothorax in two ( . %). conclusion: obesity had no influence of surgical outcomes for performing silc. introduction: recent studies have reported mixed outcomes when comparing surgeon case volume and laparoscopic cholecystectomy (lc) outcomes. formal minimally invasive surgical training (mist) has been shown to be associated with shorter post-operative length of stay (los), but no difference in major adverse events such as bile leak, bile duct injury, intra-abdominal abscess formation, and death. we aim to determine -day rates of major adverse events after lc in a university hospital setting, to identify significant associated risk factors, and to determine if mist or surgeon volume are associated with differences in los and major adverse events. methods: we conducted a single-center retrospective review of , cholecystectomies performed over a seven-year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . characteristics and outcomes were compared using chi squared or rank sum tests. multivariable regression modeling was used to determine independent associations with the two main outcomes, major adverse events and los. results: we identified , adults who underwent lc during the study period, with a median age of , and % women. about % (n= ) of patients had a los[ day and . % (n= ) were re-admitted within the first days after surgery for any reason. within days of lc, . % (n= ) of patients suffered from one or more major adverse events. this includes . % (n= ) of patients with bile duct injury, . % (n= ) of patients with bile leak, . % (n= ) of patients with intra-abdominal abscess, and . % (n= ) of patients died for reasons related to their procedure or post-operative recovery. table shows the characteristics of the patients and procedures with a comparison of the patients with an adverse event versus those without one. in univariate analysis, high annual surgical volume ( + cases/year) and procedure urgency were found to be significant predictors of adverse events and los, however, mist was not. in multivariable analysis, controlling for significant univariate predictors, urgent or emergent cases were associated with a -fold increase in odds of an adverse event (or= . introduction: laparoscopic cholecystectomy is an extremely common procedure in the united states, with over , cases performed annually. despite the procedure's overall safety, there has been some evidence that tobacco use is associated with increased risk of wound infection after lc. this retrospective chart review sought to examine whether tobacco use is associated with increased complications following laparoscopic cholecystectomy within a high-volume healthcare system. methods: after irb approval, of approximately , cholecystectomies performed within one four-hospital system between and were randomly selected, and patient charts were retrospectively reviewed. pre-, intra-, and postoperative data were collected, including all complications within days. tobacco use cohorts were defined as follows: never, former (any historical tobacco use), and current (active tobacco use within year of surgery) per the acs nsqip surgical risk guidelines. following preliminary data analysis, multivariable logistic regression models were generated to identify whether tobacco use was predictive of outcomes of interest. of the cases analyzed, patients ( . %) were never smokers; . % were former smokers, and . % were current tobacco users or had quit less than months prior to surgery. there were surgical site infections, one wound dehiscence, one port site hernia, three common bile duct injuries, and medical complications requiring prolonged hospitalization or readmission within days. current tobacco users were significantly more likely to undergo urgent surgery (following emergency admission or direct admission to the hospital) than former or nonsmokers. however, there was no difference between cohorts for prolonged duration of surgery, conversion to an open procedure, surgical site infection, wound dehiscence or hernia, common bile duct injury, or other medical complication. there was no significant difference between cohorts when all postoperative complications were pooled. conclusions: there does not appear to be a significant difference in -day surgical outcomes or complications in active tobacco users vs. former or non-users. although studies in other surgical settings have indicated a possible reduction in complications if patients abstained from smoking prior to surgery, this may not be beneficial in laparoscopic cholecystectomy. moreover, as current tobacco use appears to be associated with higher rates of urgent surgery, these patients may not be able to stop smoking prior to an elective procedure. prospective studies to further clarify whether there is any benefit towards tobacco cessation prior to lc may be valuable. , [ , [ respectively ( - ) , cyfra were . , . , . respectively ( - . ) . afp and cea were negative. as for this patient, he is of high risk of hepatobiliary system diseases. introduction: thymoma is one of the rare tumor entity benign or malignant arsisng from the epithelial cells of thymus gland, frequently associated with neuromuscular disorder myasthenia gravis. so, we are presenting this rare case of thymoma with myasthenia gravis in our institute. methods: we operated a single patient of thymoma in a case of myasthenia gravis by video assissted thoracoscopic approach. results: operative time- min, intraoperative blood loss − ml, post operative analgesia requirement in form of nsaids is for days, no ventilatory support required post operatively, with follow up reduction in achr ab from nmol/l to nmol/l and reduction in symptoms in form of reduced ptosis. conclusion: thoracoscopic thymectomy is feasible and safe in terms less operative time, less post operative pain and analgesia requirement and no post operative ventilatory support requirement. carter c lebares, md, stanley j rogers, md; ucsf background: duodenal fistulas are uncommon but morbid complications of acute necrotizing pancreatitis. if percutaneous drainage fails, surgical correction via roux-en-y diversion or pancreaticoduodenectomy can be required. while self-expanding metal stents have been tried, complications like migration and perforation have limited such use. endoscopic transmural stents have successfully treated fistulas of the stomach, particularly post-sleeve gastrectomy. here we present a case of endoscopic transmural stents used to treat a non-resolving duodenal fistula following acute necrotizing pancreatitis. methods: under general anesthesia, using a standard adult gastroscope, the fistula was identified in the second portion of the duodenum (fig. ) . a flexible-tipped guide wire was used to identify the fistula tract and two fr cm double pigtail biliary stents were deployed ( fig. ) with positioning verified under fluoroscopy. two weeks later these were removed and a single stent deployed into the visibly smaller tract (fig. ). two weeks after that, the single stent was removed and contrast medium was injected under fluoroscopic visualization, demonstrating resolution of the fistula (fig. ) . case: this patient is a year old woman with hypertension and congenital hearing loss who underwent a cholecystectomy for biliary colic and subsequent ercp with sphincterotomy for retained stone. this was complicated by acute pancreatitis which progressed to severe necrotizing pancreatitis with infected retroperitoneal necrosis. percutaneous drainage yielded initial improvement but a persistent moderate collection ( cc per day) lead to the identification of a fistula in the second part of the duodenum. repositioning and exchange of percutaneous drains over weeks did not hasten resolution. endoscopic transmural pigtail stents were tried after visualization of a large ( - mm diameter) fistula tract. stents were utilized as described in methods, with a total of three endoscopic interventions, at week intervals, resulting in resolution of the fistula as evidenced by contrast injection into the duodenum under fluoroscopy and subsequent ct scan with oral contrast. the patient's symptoms resolved and she was tolerating a normal diet. she remained thus at month follow-up. conclusion: this case demonstrates the benefit of endoscopic transmural stents for the resolution of duodenal fistulas, expanding the utility of this technique to address leaks and fistulas of the upper gastrointestinal tract. further study is warranted to clarify the timing and adjuncts to optimize the use of this promising approach. totally laparoscopic alpps combined with the microwave ablation for a patient with a huge hcc hua zhang; department of hepatopancreatobiliary surgery, west china hospital, sichuan university introduction: associating liver partition and portal vein ligation for staged hepatectomy (alpps) is a novel technique for resecting hepatic tumors that were previously considered unresectable due to the insufficient future liver remnant (flr) which may result in postoperative liver failure (plf). the procedure has been accepted and modified in many medical centers worldwide. but reports about the laparoscopic alpps were rare. this study aimed to report a totally alpps combined with microwave ablation for a patient with huge hcc and confirm the feasibility of laparoscopic alpps. methods: a -year-old man had complained of -year history of right upper abdominal pain, and the syndrome was worsened in recent month. abdominal enhanced computed tomography (ct) imaging revealed a cm solid mass in right lobe of liver with non-uniform and unclear boundary, the right posterior branch of the portal vein was invaded. in addition, a small lesion was simultaneous found in left lateral lobe of liver. the tumor was evaluated as unresectable due to the flr was only ml ( %). we decided to perform the laparoscopic alpps procedure. first stage including microwave ablation of the lesion in left lobe, cholecystectomy, ligation of the portal vein and transection of liver parenchyma. the second stage was done days later and consisted of laparoscopic right hemihepatectomy. results: the two stages were underwent by laparoscopy successfully. the operation duration was and minutes, respectively. estimated blood loss was and ml. the hospitalization time in intensive care unit was and days. there was no need for transfusion in both stages. the patient was discharged days after the second stage and the total hospitalization time was days. recovery of the patient was uneventful in addition to the incision infection after the second stage which recovered with conservative management. the patient did not show any signs of liver failure. the ct scan before the second stage showed an enlargement of left lobe, the flr was ml ( . %). there was no signs of residual liver disease in the ct scan days after the operation. the patient showed no signs of recurrence or liver failure in the following up period of six months. conclusion: totally laparoscopic alpps combined with microwave ablation is safe and feasible for the multiple hcc which was not resectable. the hypertrophy of remaining liver was fast and can achieve an adequate volume in a short time. introduction: chronic pancreatitis is a benign, irreversible inflammatory disorder characterized by the conversion of the pancreatic parenchyma into fibrous tissue. initial management should be conservative, surgery is applied in case of failure of medical treatment. the development of minimally invasive techniques has made it possible to perform these highly technical procedures in a laparoscopic manner. materials and method: we have the history of patients with and years with chronic pancreatitis and pancreatic lithiasis of difficult handling but intractable pain to those who decided to surgical management. we performed the procedure under general anesthesia, epidural analgesia catheter was placed. neumoperitoneum technique of cali, at mmhg and approach using a mm umbilical port, working ports of and a of mm port,. the pancreas was exposed by a section of the gastrocolic ligament with a mm ultrasonic scalpel, with cephalic retraction of the stomach, opening of a smaller sac and approaching the transpavity of omentum. the ventral surface of the pancreas was exposed from the neck. an incision was made in a pancreas body with a monopolar hook. primary pancreatic duct lumen was identified and the incision was extended longitudinally from the neck to the tail of the pancreas ( cm). roux's y loop was prepared cm from the treitz ligament, with a jejunum section with a mm stapler, roux's loop was transmecoscopically retrocollic, closing the gap of the mesocolon with monocryl. a -cm jejunum-jejunal anastomosis was performed with endo-gia stapler and closure of enterotomy with - polypropylene intracorporeal suture. jejunal (roux) isoperistaltic loop was placed longitudinally at the opening of the main pancreatic duct, and enterotomy was performed with monopolar in antimesenteric segment. the intracorporeal pancreatico and jejunum anastomosis was performed using a lower and an upper plane, with single points of total thickness with ethnobond - . closed drains were placed towards each anastomosis. this procedure was performed in the patients reported. operative time - min complications none operative time - days minimal bleeding drains no retired in both cases at days year follow-up of patients improved pain\ conclusions: minimally invasive surgery is a fundamental tool for the approach and management of patients with biliopancreatic pathologies. the establishment of multidisciplinary groups, offer an excellent alteranativa in the integral management of the patients. surg endosc ( ) gallbladder anatomy is highly variable, and surgeons must be prepared to identify anomalies of form, number, and position. variants include gallbladder agenesis, diverticulum, duplication, bilobed, multiseptate, phrygian cap, ectopic, and hourglass gallbladder. the hourglass gallbladder has been described from the earliest days of cholecystectomy, as morton described a congenital case in , and else thoroughly described the acquired and congenital strictures leading to the hourglass deformity in . we describe a case of an hourglass gallbladder found during one-step endoscopic retrograde cholangiopancreatography (ercp) and laparoscopic cholecystectomy. this year old male presented to an outside hospital with one day of nausea, and constant, severe, epigastric pain that radiated to his back. he endorsed a history of similar pain several times in the past. his abdomen was soft, nontender, and without murphy sign. laboratory evaluation revealed total bilirubin . mg/dl, alkaline phosphatase u/l, ast u/l, alt u/l, and no leukocytosis. ct abdomen and pelvis revealed cholelithiasis, distal choledocholithiasis, intra-and extra-hepatic ductal dilation, and a . centimeter left liver hemangioma. he was transferred for management of choledocholithiasis, and an abdominal ultrasound revealed cholelithiasis, without gallbladder wall thickening or pericholecystic fluid, and a . millimeter common bile duct without choledocholithiasis. he was taken to the operating room for a one-step ercp and laparoscopic cholecystectomy. upon laparoscopy, dense adhesions to the gallbladder were found. after initially attempting to obtain the critical view of safety, we then embarked on the retrograde "top down" dissection. this isolated a spherical structure measuring . . centimeters. two very thin tubular structures were identified, clipped, and transected after we found they were too small to place a cholangiocatheter. the common bile duct appeared to be pulled anteriorly by surrounding inflammation, though this was later found to be the proximal segment of gallbladder. the intra-operative ercp identified a remnant gallbladder with cholelithiasis and no extravasation of contrast. given the unusual anatomy, we completed the operation, ordered a post-operative ct liver and mrcp, and consulted a hepatopancreatobiliary surgeon. a small remnant gallbladder was identified on ct liver, though not on mrcp. completion laparoscopic cholecystectomy with intraoperative cholangiogram and ultrasound was performed on hospital day . this hourglass gallbladder variant likely occurred secondary to chronic fibrosis from cholecystitis, leading to a proximal and distal gallbladder lumen. in anatomic uncertainty, the "top down" dissection, intraoperative cholangiography, ct liver, and expert consultation are safe methods to avoid iatrogenic injury. introduction: endoscopic entero-enteral bypass could change our approach to small bowel obstruction in patients with prohibitively high operative risk. magnetic compression anastomoses have been well-vetted in animal studies, but remain infrequent in humans. isolated cases of successful use in humans include treatment of biliary strictures and esophageal atresia. while endoscopic gastro-enteric magnetic anastomoses have been described, the associated multicenter cohort study was terminated due to serious adverse events. since then, the technology has evolved and recently our own institution reported results of the first in-human trial of magnetic compression anastomosis (magnamosis), deployed through an open approach. here we present the first case of endoscopic delivery of the magnamosis device and the successful creation of an enteroenteral anastomosis for chronic small bowel obstruction in a patient with prohibitively high operative risk. methods: the magnamosis device has previously been approved by the food and drug administration (fda) for use in clinical trial. our institutional review board approved emergency compassionate endoscopic use of the device in this patient due to a non-resolving small bowel resection and prohibitively high operative risk. case: this is a year old man with advanced liver disease, chronic obstructive pulmonary disease, and history of emergent right colectomy with end ileostomy for cecal perforation. he presented with multiple acute on chronic episodes of small bowel obstruction with a stable transition point in the distal ileum, radiographically estimated at centimeters proximal to the ileostomy. endoscopic evaluation through the ileostomy revealed a traversable obstruction with proximally dilated small bowel. the magnets were delivered via endoscopic snare under fluoroscopic guidance and positioned in adjacent loops of bowel on either side of the obstruction (image ). by days post-procedure, healthy villi were visible through the central portion of the mated magnetic rings (image ). by days the magnetic rings were mobile and the anastomosis was widely patent allowing easy passage of the gastroscope (image ), and the patient's symptoms were completely resolved. the rings passed through the ileostomy days post-procedure. at month follow up, the anastomosis was unchanged (image ). conclusion: this case demonstrates the benefit of an endoscopically created magnetic compression anastomosis in a patient with small bowel obstruction and high operative risk. further studies are indicated to evaluate the use of this technique in similar patients or those with malignant obstruct, ion. desiree raygor, md, ruchir puri, md; university of florida health jacksonville cholecystectomy is one of the commonest operations in general surgery [ ] . occasionally chronic cholecystitis can lead to a small contracted gallbladder. this diagnosis can be misleading as it may represent congenital agenesis of the gallbladder [ ] . a -year-old female with a past history of pancreatitis presented with a three day history of right upper quadrant pain associated with nausea and vomiting. upon exam she exhibited tenderness in the right upper quadrant. her leukocyte count and liver function tests were within normal limits. ultrasound revealed a poorly visualized, contracted gallbladder without stones and a dilated common bile duct (cbd). cholescintigraphy revealed non visualization of the gallbladder after two hours, which was suggestive of acute cholecystitis. decision was made to proceed with a laparoscopic cholecystectomy. the abdomen was entered by an open hasson technique and standard trocar placement for a cholecystectomy was performed. on initial inspection, the gallbladder was not readily visible. a structure appearing to be the cbd was present and was mobilized circumferentially (fig. ) . a gauge butterfly cannula was utilized and multiple cholangiographic images were obtained (fig. ). no cystic duct or gallbladder was identified which was suggestive of congenital agenesis of the gallbladder. the patient did well postoperatively, and was discharged home on postoperative day two. the patient's symptoms resolved and she continues to be pain free one month postoperatively. congenital agenesis of the gall bladder is a rare disorder. a high index of suspicion is required especially in the setting of a small contracted gall bladder. if preoperative imaging is inconclusive then diagnostic laparoscopy should be the next step. cholangiogram should be performed routinely to confirm the diagnosis and to rule out an ectopic gall bladder. conversion to open does not offer any distinct advantage, and laparotomy should be avoided if possible given its associated morbidity. there are many reports upper abdominal major arterial aneurysms. however, an aneurysm of left inferior phrenic artery had never been reported. a -year-old woman with liver cirrhosis associated with hepatitis b viral infection was referred to department of surgery for treatment of aneurysm of left inferior phrenic artery. she underwent trans-arterial chemoembolization (tace) for treatment of hepatocellular carcinoma three times, previously. on months after last tace, mm sized highly enhancing nodular lesion of gastric fundus was found on follow-up abdomenpelvis computed tomography (a-p ct). one year later, the size of this lesion increased to mm, and an aneurysm was diagnosed. she underwent angiography and attempted embolization with an aneurysm of the left inferior phrenic artery, but access failed. we performed a laparoscopic vessel ligation. she recovered with no complication and discharged on the th postoperative day. s surg endosc ( ) :s -s yousef almuhanna, vatsal trivedi, fady balaa; university of ottawa a years old female, g and weeks pregnant, was brought to the hospital by ems, after being found on the floor in her toilette surrounded by vomitus and urine. mother-inlaw, who happens to be at the house that time, have heard severe retching followed by a loud bang sound. firefighters have found no pulse and therefore started cpr. return of spontaneous circulation was achieved, yet unfortunately, she had arrested again minutes prior to arrival to er. pocus assessment showed large rvot, and therefore tpa was started on the assumption of pulmonary embolism. upon arrival of blood work, it was found that her hemoglobin had dropped from to . fast was repeated showing moderate to severe amount of free fluid in the morrison's pouch and pelvis. she was then taken to the operating theatre, had undergone laparotomy showing liver segment ii injury. pringle's maneuver and aortic clamping did not control the bleed, therefore finger fracture and venous clips were used to temporary minimize the bleed, and head to interventional radiology suite. after multiple attempts to control the bleed, and the massive transfusion, she vital signs were not maintained, and had arrested afterwards. sarrath sutthipong, md, chumpunut chuthanan, md, chinnavat sutthivana, md, petch kasetsuwan, md; bhumibol adulyadej hospital, bangkok, thailand background: mesenteric panniculitis (mp) is a rare, benign and chronic fibrosing inflammatory disease that affects the adipose tissue of the mesentery of the small bowel and colon. the specific etiology is unknown and no clear information about the incidence. the diagnosis is suggested by ct and is usually confirmed by surgical biopsy. treatment is based on some selected drugs. surgical resection is sometimes attempted for definitive therapy, although the surgical approach is often limited. we reported a case of the mp diagnosed with ct and surgical biopsy by laparoscopic approach. case report: -year-old woman with months history of chronic abdominal pain, mainly localized in the sub-epigastrium, intermittent and mild. she had anorexia but no weight loss or change in bowel habits. no history of medical illness or surgery. the physical examination was unremarkable, except for palpation of ill-defined mass about cm at mid-abdomen, firm, smooth surface with mild tenderness. the laboratory profile and tumor marker were normal. ct of the abdomen, which showed focal heterogeneous enhancement of the mesenteric fat with stranding ( . . cm) with multiple internal subcentimeter lns in the supraumbilical area, which was probably inflammatory in origin and suggestive of mp. f-fdg pet/ct showed faint fdg uptake in multiple mesenteric lns. the patient was subsequently underwent diagnostic laparoscopy with biopsy. intra-operative finding showed a fat-like surface of yellowish mass at mesentery of jejunal segment, incisional biopsy was performed laparoscopically. the histology showed adipose tissue with areas of fat necrosis, fibrosis, foamy macrophages infiltration and predominant chronic inflammation, no evidence of malignancy. ihc studies (including cd , s- , cd and cd ) were performed and the result was compatible with reactive process. treatment was started with mg prednisone once daily and planned for follow-up with repeated ct scan. discussion: mp involves the small bowel mesentery in over % of cases. the diagnosis is made by pathologic findings: fibrosis, chronic inflammation and fatty infiltration. the differential diagnosis is broad and has been associated with malignancies such as lymphoma, well-differentiated liposarcoma and melanoma. the imaging appearance varies depending on the predominant tissue component. a definitive diagnosis is biopsy but open biopsy is not always necessary. no data of laparoscopic biopsy, which has been reported previously. treatment has been reserved for symptomatic cases with a variety of drugs. our case was started on oral corticosteroid treatment and waited for responsive evaluation. background: laparoscopic appendectomy is the gold standard for treatment of acute appendicitis. stapled closure of the appendiceal stump is often performed and has been shown to have several advantages. few prior cases have been reported demonstrating complications from free staples left within the abdominal cavity after the laparoscopic stapler has been fired. case report: a previously healthy year old female initially underwent laparoscopic appendectomy for acute uncomplicated appendicitis during which the appendix and mesoappendix were divided using laparoscopic gastrointestinal anastomosis (gia) staplers. her initial postoperative recovery was uncomplicated and she was discharged home the same day. the patient returned to the emergency department on postoperative day with one day of sharp mid-abdominal pain, obstipation, and emesis. her abdomen was distended and mildly tender but not peritoneal. she was afebrile but was found to have a leukocytosis of . . ct demonstrated twisted loops of dilated small bowel in the right lower quadrant with two transition points, suggestive of internal hernia with closed loop bowel obstruction. diagnostic laparoscopy was performed through the three prior appendectomy incisions. an adhesion was noted between the veil of treves and the mesentery of a more proximal loop of ileum caused by a solitary free closed staple, remote from the staple lines, resulting in an internal hernia containing several loops of ileum ( fig. ). the hernia was reduced, and the small bowel was noted to have early ischemic discoloration. the adhesion was lysed by removing the staple from both structures to prevent recurrence. through the remainder of the procedure, the compromised loops of bowel began to peristalse and the color normalized. the procedure was concluded without resection. the patient recovered on a surgical floor and was discharged home on postoperative day one. conclusion: gastrointestinal staplers are commonly used secondary to ease of use and low complication rate. it is not uncommon to leave free staples in the abdomen during laparoscopy as retrieval can often be more difficult and time consuming. our case is only the second in the literature reporting an internal hernia with closed loop bowel obstruction as a complication of retained staple. choosing the most appropriate size staple load, to reduce the number of extra staples after the fire, and removing as many free staples as possible can prevent potentially devastating complications. video-assisted thoracoscopic pulmonary wedge resection in a patient with hemopytsis and intralobar sequestration: a case report mary k lindemuth, md, subrato j deb, md; the university of oklahoma health science center case report: a -year-old male with history of noonan's syndrome, bronchitis, and asthma presented with acute hemoptysis. while chest x-ray was unremarkable, a computed tomography angiogram of his chest was significant for intralobar pulmonary sequestration in the right lower lobe. the aberrant pulmonary artery originated from the abdominal aorta, immediately proximal to the celiac axis, and coursed through the hiatus in the retroperitoneum. flexible, fiberoptic bronchoscopy revealed blood within the right lower lobe bronchus with no appreciable source. a right video-assisted thoracoscopic approach was taken for wedge resection of the sequestration. twoportal technique was utilized with the patient on single lung ventilation. the sequestration was easily identified; the anomalous pulmonary artery coursed directly to a large, focal area of hemorrhage noted within the lower lobe pulmonary parenchyma, as seen in image [rectangle marking the aberrant artery and oval marking the sequestration]. pathologically, the specimen was noted to be benign lung parenchyma with bronchiectasis and abundant, acute hemorrhage. discussion: pulmonary sequestration (ps) is a rare, congenital bronchopulmonary foregut malformation. literature describes the incidence of ps to be only . - . % of all pulmonary malformations. as ps is most frequently diagnosed during childhood, the occurrence of diagnosis during adulthood is estimated to be less than per , adults. two types (intra-and extralobar) are described, with intralobar sequestration most common and contained within the normal visceral pleura. both types have aberrant systemic arterial blood supply, most frequently from the thoracic aorta. likewise, both types are nonfunctioning lung tissue, as there is no direct communication with the bronchopulmonary tree. the most common presentation is pneumonia, and often patients will have had recurrent symptoms before diagnosis. it is rare to present with hemoptysis, which is understood to be secondary to elevated capillary pressure within the sequestration and then communication through the pores of kohn. while endovascular embolization of the aberrant pulmonary artery has been described as a safe alterative for surgical intervention, the subjects of these studies have primarily been children and long-term outcomes are unknown. the definitive treatment of ps continues to be surgical intervention. the surgeon should strive to leave as much normal lung parenchyma as possible. video-assisted thoracoscopic resection is well tolerated by patients when compared to thoracotomy. however, it is vital for the surgeon to be aware of the potential risk of life-threatening hemorrhage secondary to the sequestration having systemic blood supply that must be controlled and ligated. case report: a years-old female patient with history of an increased mass and weight loss of kilograms in months, associated with vomiting and nausea for eight months. abdominal ultrasound showed an irregular cyst, without solid projections and without signs of flow in doppler, measuring cm. investigation continued with ct scan that showed a large homogeneous cystic lesion with no septum in the abdominopelvic region, possibly mesenteric, measuring . . cm. a laparoscopic approach for resection of the cyst was then performed. the surgery was performed with a patient in the dorsal decubitus, using three trocars: one in the umbilical region ( -mm) for the camera, and where the pneumoperitoneum was created by the hasson open technique under direct vision; and another two located in the epigastrium ( -mm) and in the right upper quadrant ( -mm) . in addition to the mesenteric cyst, a simple cyst in the right ovary and a solid nodule with a lipomatous characteristic of approximately cm in the abdominal cavity were visualized. total resection of the mesenteric cyst with periprancreatic fibrous tissue was performed. the cyst was punctured and its contents fully aspirated. resection of the right ovarian cyst was also performed. at the end of the procedure the mesenteric and ovarian cysts, the nodule, part of the omentum, and the peripancreatic tissue were removed through the -mm trocar at the umbilicus. patient had no further complications, being discharged four days after the procedure. histopathologic result showed a serous cyst in the right ovary, serous cyst in peripancreatic mesentery with chronic inflammatory process and signs of calcification; no signs of malignancy were observed in any specimen. we aimed to present the succesul therapeutic approach utilizing laparoscopy for safely removing a gastrointestinal stromal tumor. depicted is a year old jehova's witness female who presented to the emergency department for evaluation of bitemporal headache and dizziness and found with profound anemia with hemoglobin . and hematocrit . upon arrival to ed. the patient refused blood transfusion as her religious beliefs, jehovah's witness, preclude her from taking blood products. as part of her work up, endoscopy was performed and revealed a large, approximatelly cm, prolapsed, ulcerated, nodular lesion with active bleeding in the cardia of the stomach. this was temporized but the friable tissue, with no single identifiable lesion for clip placement, left the patient at high risk for re-bleeding. she was taken to the operating room and laparoscopic partial gastrectomy with intraoperative esophagogastroduodenoscopy were succefully perfomed, with minimall blood loss and no intra operative complications. patient was discharged on post op day . we present the case of a -year-old male with a history of morbid obesity with an initial bmi of . , who underwent an elective laparoscopic single anastomosis duodenal-ileal bypass with sleeve gastrectomy (sadi-s). postoperatively he developed an anastomotic leak at the duodeno-ileal anastomosis that would not resolve despite reoperation. he was then converted to a roux-en-y gastric bypass (rygb). postoperative imaging failed to reveal any signs of anastomotic leak and the patient was discharged tolerating an oral diet. he returned to the emergency department days later with a cm sub-hepatic collection arising from the duodenal stump from the surgical conversion. interventional radiology percutaneously drained the collection and found a connection between the cavity and the duodenum. using this connection, a percutaneous decompressive duodenostomy drain was successfully inserted into the duodenum using a guidewire through the abscess cavity along with an extra-enteric drain placed within this cavity. the collection was obliterated and the duodenal leak was controlled successfully with percutaneous drainage, bowel rest with parenteral nutrition and broad-spectrum intravenous (iv) antibiotics. the patient was reintroduced to a bariatric clear diet after a week of bowel rest and the abscess drain was then discontinued during the same hospital admission. the patient was discharged with the percutaneous duodenostomy tube which was removed in clinic days later, after the patient tolerated capping trials and imaging failed to reveal any further collections, oral contrast extravasation or distal obstruction. in this article we analyze notable imaging from the case and review current literature on the different management options for a duodenal stump blowout. we also discuss the basics of the sadi-s procedure and conversion of a sadi-s procedure to a rygb. keywords: anastomotic leak, duodenal stump blowout, sadi-s, duodenostomy tube. pancreatopic heterotopia is often an incidental finding on autopsy, but in some cases can lead to abdominal pain, obstruction, or intussusception. we present a case of pancreatic herterotopia mimicking an internal hernia on radiologic imaging. a year old female with seven month history of chronic abdominal pain treated for low back pain and recurrent urinary tract infections. she was found to have a computed tomography (ct) scan concerning for internal hernia and labs consistent with acidosis. she was taken for a laparotomy and did not have an internal hernia, but an exophytic mass in the proximal jejunum. the mass was resected and a stapled side to side jejunojejunostomy was created. on pathologic review, the specimen was found to be pancreatic heterotopia. her post operative course was complicated by an ileus, but was discharged post op day three. at her two week follow up she had minimal incisional pain and at one year follow-up she had resolution of her left upper quadrant abdominal pain. prior to this report, pancreatic heterotopia has never been described as presenting on ct scan as an internal hernia. although uncommon it should remain in the differential when evaluating a patient presenting with abdominal pain and radiologic evidence of obstruction or internal hernia. case report: a -year-old male patient who was diagnosed with high blood pressure at years-old and presented tetraparesis and intense asthenia for six months. blood tests showed hypokalemia, hypernatremia, and suppressed renin activity. ultrasound of the urinary tract was normal. ct scan of the abdomen showed a hypodense nodule with regular margins, measuring . . cm with a density of hu in the non-contrast phase and heterogeneous uptake after the injection of the contrast in the left adrenal gland. thus, the diagnosis of hyperaldosteronism secondary to the left adrenal nodule was confirmed, and surgical resection was indicated. the procedure was performed with the patient in the right lateral decubitus. two -mm and one -mm trocars were used on the left flank, as well as the -mm portal for the camera in the lower right quadrant under direct vision. the pneumoperitoneum was created by the hasson open technique in the transumbilical incision. the procedure consisted of the dissection, isolation and electrocautery of the left renal capsule and the left adrenal region with ultrasonic device, as well as the periadrenal vessels, adjacent lymph nodes and periadrenal and adrenal fat tissue. the surgery was uneventful and the patient had no further complications, being discharged the next day. histopathologic result showed a completely excised adrenocortical adenoma. conclusions: the hybrid minimally invasive approach proved to be safe and effective for this procedure, and the known advantages of minilaparoscopy such as less trauma, better visualization, better dexterity, better aesthetics, and reduced hospital stay were observed. s surg endosc ( ) background: coccidioidomycosis is a fungal infection endemic to the southwestern united states, central america and south america. coccidioides is ubiquitous in many of these endemic regions, with near % seroconversion in some communities. two-thirds of these mycotic infections may be asymptomatic. the most common presentation of coccidioidomycosis consists of "flu-like" symptoms or pneumonia. less than five percent of symptomatic cases progress to disseminated coccidioidomycosis which may involve any organ system. very rarely infection may include the peritoneum. we report a case of coccidioidomycosis with peritoneal involvement in an immunocompetent individual. case: a -year-old male presented to the emergency department with progressive abdominal pain. he was seen and treated for pneumonia in the emergency department one week prior. the patient worked outdoors in arizona and was otherwise healthy with a family history of malignancy and blood disorders. fever, leukocytosis and ascites on computed tomography scan prompted a diagnostic laparoscopy which revealed peritoneal granulomas positive for coccidioides. the patient was treated outpatient with fluconazole. discussion: since this is the th reported case of peritoneal coccidioidomycosis to our knowledge. the patient described in this case report was an otherwise healthy -year-old male; this is incongruent with many of the previously recorded cases which involved disseminated disease in immunocompromised patients. the patient's family history of malignancy and blood disorders suggests a potential underlying genetic predisposition that could account for this abdominal presentation. possible mutations include genes coding for the interleukin- β receptor and the signal transducer and activator of transcription which have been implicated in increased coccidioidomycosis susceptibility. peritoneal infection presents a unique challenge in diagnosis. in these cases coccidioidomycosis may not be suspected due to nonspecific symptoms and imaging, the infrequency of this extra-pulmonary manifestation and clinical characteristics that mimic the presentation of tuberculosis and malignancy. abdominal infections have been misdiagnosed as appendicular abscesses, iliopsoas abscesses, adnexal abscesses and pancreatic masses. consequently, the diagnosis of peritoneal coccidioidomycosis is often made after laparoscopic exploration of the abdomen and histopathology, as it was in this case report. conclusions: coccidioidomycosis incidence is on the rise in endemic areas and it often falls on the surgeon to make the diagnosis in extra-pulmonary cases. the peritoneal subset of coccidioidomycosis should be considered in endemic areas when a young, otherwise healthy patient presents with abdominal pain. failure to recognize the possibility of coccidioidomycosis may lead to unnecessary treatments and procedures. indocyanine green cholangiography to detect anomalous biliary anatomy steven d schwaitzberg, md, gabrielle yee, ms; university at buffalo jacobs school of medicine introduction: common bile duct injury is the most feared complication of cholecystectomy. imaging with indocyanine green (icg) is a safe and effective technique to detect biliary anatomy in open, laparoscopic and robotic surgery. several studies report detecting aberrant biliary anatomy with the use of icg in laparoscopic cholecystectomy with high success rates. by identifying the cystic duct-common hepatic duct confluence before dissecting calot's triangle, icg allows surgeons to perform "virtual" cholangiography at the start of procedures to identify either normal anatomy or possible anatomic variants. it is clear that icg use is an effective tool to achieve the critical view of safety. however, no reports have suggested icg cholangiography as the last operative step in cholecystectomy to identify hidden biliary anomalies and avoid postoperative bile leak complications. case report: we report a novel use of icg cholangiography in visualizing anomalous biliary anatomy prior to closing, thus avoiding potential bile duct leakage. in our case, icg cholangiography was used to fluoresce the common hepatic duct, common bile duct and cystic duct. the cystic duct was transected, and the gallbladder was removed using electrosurgery. at the completion of the gallbladder removal, the liver was elevated to inspect the clips on the cystic duct and artery. at this point, near infrared imaging was reinitiated, and a small mm structure was noted to fluoresce next to the cystic artery. this structure was identified using white light and subsequently clipped. discussion: the use of icg in this context after the completion of the cholecystectomy facilitated the identification of a small hepatocystic or aberrant duct, which would have likely leaked bile sometime in the postoperative period. based on our experience, we recommend one additional routine near infrared viewing to identify small structures or potential leaks at the completion of cholecystectomy. improved visualization of the extrahepatic biliary anatomy by icg has the potential to translate into improved clinical outcomes. solitary fibrous tumors (sft) are uncommon fibroblastic mesenchymal neoplasms that display a wide range of histologic behaviors. these tumors, which are estimated to account for % of all soft tissue neoplasms, typically follow a benign clinical course. however, it is estimated that - % of sfts are malignant and demonstrate aggressive behavior with local recurrence and metastasis up to several years after surgical resection. we report a case of sft arising from the stomach, which is an exceptionally rare finding and has been reported only six times in the literature. additionally, this tumor was associated with dedifferentiation into undifferentiated pleomorphic sarcoma. to our knowledge, there are no documented cases of a malignant sft arising from the stomach to demonstrate dedifferentiation into an undifferentiated pleomorphic sarcoma. a -year-old male presented to the emergency department with vague complaints of right-sided flank pain. the patient had a history of nephrolithiasis and underwent a ct abdomen. this scan revealed a large heterogeneous mass in the left upper quadrant. the patient underwent endoscopic ultrasonography with fine needle aspiration of the mass, which stained strongly for cd . gastrointestinal stromal tumor (gist) was the favored diagnosis as it is by far the most common mesenchymal neoplasm of the stomach, especially cd positive spindle cell neoplasm. accordingly, the patient began treatment with imatinib; however, after four weeks of therapy, there was no significant radiologic regression. a second biopsy was performed and the specimen was sent for stat immunohistochemistry, which revealed diffuse strong nuclear positivity. a diagnosis of solitary fibrous tumor was provided. surgical resection of the tumor was performed, which measured . cm. the patient was to undergo surveillance imaging every to months post-operatively. surveillance scan showed solitary metastatic disease in the left lateral segment of the liver. he underwent left lateral segmentectomy with an uneventful recovery. our case was complicated by diagnostic dilemma with gist, highlighting the challenges of diagnosing and characterizing sfts. dedifferentiation, or the abrupt transition from a classic sft into a high-grade sarcoma, is a particularly concerning finding in our case, as it is associated with a worse prognosis than classic malignant sft. the stat marker by immunohistochemistry is very specific for sft and may have aided in the diagnosis earlier. therefore, it is imperative to keep solitary fibrous tumor, albeit exceedingly rare, in the differential diagnosis of mesenchymal neoplasms of the stomach. appendiceal diverticulitits is an uncommon pathology that can clinically mimic acute appendicitis. some radiographic distinctions have been reported, but final pathologic examination of the surgical specimen is required to confirm the diagnosis. symptoms are often more mild, which can lead to a delayed diagnosis, and increases the risk of severe complications such as perforation. a year old female presented with a three day history of right lower quadrant pain. she described the pain as constant and radiating to the left lower quadrant. associated symptoms included nausea and vomiting, and decreased appetite; she denied fevers or diarrhea. the patient had no significant past medical history, and surgical history was significant for a total nephrectomy for living donor kidney transplant to her mother. on physical exam she was tender in the right lower quadrant with rebound and a positive rosving's sign. all laboratory results were unremarkable, and she was hemodynamically stable. ct scan was performed and demonstrated a dilated fluid filled appendix with surrounding inflammatory change without abscess or free intra-peritoneal air. she was subsequently admitted to the hospital, made npo, started on iv antibiotics, and was taken to the operating room where she underwent an uncomplicated laparoscopic appendectomy. post-operatively, her hospital course was unremarkable. pathology revealed acute suppurative appendicitis secondary to an acutely inflamed appendiceal diverticula, consistent with a final diagnosis of acute appendiceal diverticulitis. appendiceal diverticulitis should be considered in patients presenting with acute right lower quadrant abdominal pain. although some consider appendiceal diverticulitis a variant of acute appendicitis, it is important to distinguish between the two diagnoses. appendiceal diverticulitis has a higher rate of complications, including perforation, and is associated with a higher risk of neoplasm, particularly mucinous adenomas and carcinoid tumors. appendectomy should be performed in all cases in order to obtain appropriate pathological examination and rule out coexistent neoplasms. laparoscopic appendectomy is a safe and appropriate approach to treatment of appendiceal diverticulitis. upper gi endoscopy and biopsy showed a gastrointestinal stromal tumor (gist) in the stomach. a videolaparoscopic partial gastrectomy was then proposed. the surgery was performed with the patient in the right lateral decubitus. two -mm minilaparoscopic trocars, a -mm conventional trocar for an ultrasonic instrument and a -mm trocar in the umbilical region for the camera were used. pneumoperitoneum was created using the hasson open technique under direct vision. trans-operatory endoscopy was perfomed to identify the tumor easily. initially, the ultrasonic device released the large omentum, and, then, the tumor was resected in the body of the stomach. the gastric wall was manually sutured with a - vicryl, and the tumor was removed in an endobag through the -mm incision in the umbilicus. the surgery was uneventful, with a total time of minutes. the patient had no further complications, being discharged two days after the procedure with good clinical conditions. histopathological result showed a free margins gist. conclusion: the minimally invasive approach proved to be safe and effective for this procedure. the known advantages of video-surgery such as less trauma, better visualization, increased dexterity, better esthetics, and less postoperative recovery time were confirmed. the upper gi endoscopy contributed to improve the safety and efficacy of the procedure, allowing a more precise resection of the gist, as well as the intragastric review of the suture line at the end of the surgery. background: portal vein thrombosis (pvt) is a rare post-operative complication, which has been associated with a wide range of precipitating factors. most commonly described associated conditions include; cirrhosis, bacteremia, myeloproliferative disorders and hypercoagulable states. pvt most frequently occurs as a complication after hepatobiliary surgery, and although possible, very few cases have been documented occurring after laparoscopic surgery of the gastrointestinal tract. herein, we describe a case of pvt in a patient who underwent elective laparoscopic right hemicolectomy and was treated successfully at our center. case: a year-old female with past medical history of depression, migraines and endometriosis underwent an uncomplicated laparoscopic right hemicolectomy at our facility, for recurrent rightsided diverticulitis. she had suffered previous episodes of diverticulitis and desired definitive surgical treatment. her hospital course was uneventful and she was discharged to home on postoperative day . on post-operative day , she presented to the emergency department complaining of severe abdominal pain, back pain and nausea. computed tomography of abdomen and pelvis revealed pvt. she was initiated on therapeutic anticoagulation with heparin. hematology was consulted for hypercoagulable workup. further investigation revealed that she had a family history of a brother who had had a lower extremity deep venous thrombosis, with negative hypercoagulable workup. she had also previously been taking leuprolide and conjugated estrogen and medroxyprogesterone for her endometriosis. she was ultimately found to have a heterozygous prothrombin g a gene mutation. her anticoagulation was bridged to coumadin and she was discharged home. she has recovered as expected, without any further complications. discussion: although more common in patients with cirrhosis after hepatobiliary surgery, pvt is a rare complication that can occur after virtually all types laparoscopic surgeries, including elective right hemicolectomy. patients may be completely asymptomatic, or present with a broad spectrum of symptoms including; severe abdominal pain, fever, diarrhea, or gastrointestinal bleeding. physicians should be aware of this possible complication, since early diagnosis and treatment is imperative to prevent life-threatening complications, such as intestinal ischemia and perforation. a detailed medical and family history is imperative, and all patients with post-operative pvt should undergo complete hypercoagulability workup. this is a case of a year old male with a previous history of a redo-hiatal hernia years prior who presented with two episodes of upper gastrointestinal bleeding with no identifiable source noted on both endoscopy and angiography. during his second admission, initial hemoglobin was . g/dl and endoscopy performed showed massive amount of blood in the stomach. continuous oozing was seen originating in the fundus area but no clear source could be identified. empiric epinephrine was injected to the area but failed to achieve hemostasis. angiography was also negative. repeat endoscopy performed showed no active bleeding, however, distention of the wrap into the gastric cavity was observed. the patient re-bled and was taken to the operating room emergently after failed attempt at endoscopic control. the patient underwent proximal gastrectomy after intra-operative gastrostomy and exploration was unable to identify a bleeding source. the patient was left with an open abdomen and in discontinuity while resuscitation was performed in the surgical intensive care unit. he subsequently underwent a roux-en-y reconstruction and gastrostomy tube placement via the distal gastric remnant. upper gastrointestinal series performed demonstrated absence of leak, and the patient was started on a liquid diet supplemented with tube feeding. his recovery was uneventful and he was discharged home in stable condition. pathology revealed gastric ischemia at the base of the wrap making it impossible to visualize through endoscopy. on reviewing the literature, gastric ulcers and ischemia have been previously described. incidence was up to % and their onset of presentation ranged from the early post-operative period up to years. most were located in the lesser curvature. the exact pathophysiology for its occurrence is not completely understood. factors hypothesized include technical aspect of the fundoplication causing inappropriate tension, vessel disruption and ischemia, and injury to the vagus nerve affecting gastric emptying which was thought to increase gastrin secretion. treatment includes medical management with proton pump inhibitors; however, few cases describe antrectomy with inclusion of the bleeding ulcer. our case presents failed medical and endoscopic management. we recommend take down of the fundoplication in hemodynamically stable patients to completely evaluate the gastric mucosa, identify, and address the source of bleeding. otherwise emergent cases will require staged gastrectomy including the wrap followed by roux-en-y reconstruction. acalculous cholecystitis associated with a large periampullary duodenal diverticulum: a case report peng yu, md, phd, austin iovoli, aaron hoffman, md; department of surgery, suny buffalo, kaleida health system, buffalo, ny introduction: periampullary diverticulum (pad) could compress common bile duct (cbd), and consequently cause obstructive jaundice and cholangitis as few publications have documented. here we first report an acalculous cholecystitis associated with a pad-related cbd obstruction. case: the patient was a -year-old female with a past surgical history of laparoscopic sleeve gastrectomy who presented at the emergency room with upper abdominal pain and vomiting for one day, associated with leukocytosis and left shift. serum total bilirubin raised up to . mg/dl on hospital day (hd) . ct, ultrasound, and mrcp images confirmed a distended, wall-thickening gallbladder with pericholecystic fluid, and a significantly dilated cbd at . cm of diameter ( fig. ) , without cholelithiasis or choledocholithiasis. ercp was unable to be completed due to the post-gastrectomy anatomy and the failure in cannulation into the ampulla which embedded in a large foodimpacted pad (fig. ). on hd , the patient underwent a diagnostic laparoscopy and an intra-operative cholangiogram which confirmed a mildly inflamed edematous gallbladder, and a . . cm large pad with a narrow neck that was distorting the distal cbd (fig. ). since the patient's bilirubin level had been improving, we decided to only do a laparoscopic cholecystectomy. intraoperatively an anatomic variation of the cystic artery encircling the cystic duct ( fig. ) was also identified. postoperatively the patient recovered well during the thereafter inpatient course and at the postoperative -week outpatient follow-up. the pathology of the excised gallbladder confirmed cholecystitis without cholelithiasis. discussion: lemmel's syndrome is defined, in the absence of cholelithiasis or other detectable obstacle, by obstructive jaundice due to pad. since lemmel described this duodenal-diverticulum-obstructive jaundice in , there still have been very few cases reported or investigated. to date there is no report describing the association of acalculous cholecystitis with lemmel's syndrome. this patient's mild acalculous cholecystitis probably attributed to the biliary obstruction and consequent gallbladder hydrops. her symptoms could be from either acalculous cholecystitis or intermittently worsening biliary obstruction. in this case, the contribution of the anatomic variation of the cystic artery is unclear. in the future, if this patient's symptoms recur, the treatment plans for her will be sphincterotomy, removal of the impacted food in the pad, or diverticulectomy. accidental fish bone ingestion masquerading as acute abdomen aim: to report a case of fish bone ingestion masquerading as acute abdomen. case report: a years old female patient presented with complaints of severe abdominal pain since days. there was no history of associated nausea or vomiting, fever or altered in bowel habits. on examination patient had tenderness and guarding localized to the right iliac fossa. blood investigations revealed raised inflammatory markers. ultrasound whole abdomen and contrast enhanced computed tomography (cect) were normal. patient was managed conservatively but in view of persistence of symptoms a triple puncture diagnostic laparoscopy was performed on day of admission. omental inflammation with soapy appendix was found and appendicectomy was performed. on further assessment a foreign body was also found in the ileum which was removed and identified as a fish bone. patient had a satisfactory post operative recovery and was discharged in stable condition. discussion: acute abdomen due to fish bone ingestion is not a very common occurrence. unfortunately the history is often non-specific and these people can be misdiagnosed with acute appendicitis & other pathologies. ct scans can be useful to aid diagnostics. it is however not fully sensitive in detecting complications arising from fishbone ingestion. conclusion: any patient with acute abdomen, with non-specific history and normal imaging may still benefit from a diagnostic laparoscopy. discussion: this patient presented with a bowel obstruction, partial cecal necrosis and neuroendocrine carcinoma. literature suggests that cecal necrosis in the majority of cases is caused by a vascular event, occlusive or non-occlusive. the patient had atherosclerosis and an underlying malignancy which can be associated with prothrombotic states and contributes to an overall risk of thrombosis. the cecum can sustain ischemic ischemic injury in the presence of severe or prolonged hypotension. most frequent causes being decompensated heart failure, hemorrhage, arrhythmia or severe dehydration, only of which was present in this patient. the midgut neuroendocrine tumor is generally located in the terminal ileum, as a fibrotic submucosal tumor cm or less. mesenteric metastases are often larger than the primary tumor and associated with fibrosis which may entrap loops of the small intestine and cause bowel obstruction. this may eventually encase the mesenteric vessels with resulting venous stasis and ischemia in segments of the intestine as seen in this patient. conclusion: cecal necrosis is a rare entity, but its incidence increases with age. isolated cecal necrosis may manifest as a ct-negative appendicitis or a small bowel obstruction in the absence of past surgical history. s surg endosc ( ) laparoscopic transection of the falciform and triangular ligament successfully released the entrapped loop with successful reperfusion by the end of the surgery. in the absence of any prothrombotic comorbidity, the patients were discharged asymptomatic without further anticoagulation. to date only few similar cases have been reported, and most of them described in neonates and pediatric patients. to our knowledge, this cases reporteds in the elderlys. in this patients laparoscopic approach was both diagnostic and therapeutic with the transection the ligament. roberto javier rueda esteban , andres mauricio garcia sierra , felipe perdomo ; universidad de los andes, fundacion santa fe this is a patient´s rare case of spontaneous splenic rupture associated to chronic myeloid leukemia as an uncommon complication. the case report and review of the relevant literature on symptomatology and clinical management is presented. emphasis is made about the importance of including splenic rupture as differential diagnosis for acute abdominal pain, especially in a patient with neoplastic hematopathology, since early treatment increases patient survival and prognosis. esophagectomy is a complex operation associated with serious immediate complications and long term chronic complications. gastric ulcers are a common chronic complication after esophagectomy with gastric conduit reconstruction. these are rarely complicated by significant bleeding or perforation. we report a case of delayed diagnosis of a fistula forming between a gastric conduit and right bronchial tree years after esophagectomy. this was successfully treated using multiple therapeutic approaches including endoscopic localization and resection through a right thoractomy. to the best of our knowledge, our patient is the only survivor from a chronic gastric conduit bronchial fistula. a year old male with type diabetes mellitus, dyslipidemia, asthma and smoking history presented years after an ivory-lewis esophagectomy for a gastrointestinal stromal tumor (gist) with a chronic cough starting years after his esophagectomy followed by multiple episodes of hematoptysis over the next years. the patient was known to have ulcers in his gastric conduit with a massive bleed year after his esophagectomy. repeat endoscopy revealed two large chronic ulcers that had increased in size based on comparison of pictures from endoscopies to years after his esophagectomy despite maximal medical management. the patient presented to numerous specialists at tertiary care centers in canada and the united states. ultimately, in a clinic the patient was observed to cough immediately after the ingestion of water, but not solids leading to a provisional diagnosis of a gastrobronchial fistula. a barium swallow failed to show a fistula (fig. ). however at endoscopy, instillation of saline directed at an ulcer immediately induced a cough, but this was not reproduced when the saline was directed away from the ulcer. the fistula was ultimately demonstrated by placing a wire through the ulcer and visualizing it bronchoscopically in the right superior segmental bronchus . in an effort to pursue a minimally invasive approach two attempts were made to close the fistula with over-the-scope clips (otsc). unfortunately, the patient's symptoms persisted. a wire was placed through the fistula and delivered through the patient's mouth and endotracheal tube. a right thoracotomy allowed access to the conduit, which was opened and the fistula localized using the wire. the fistula was resected and the bronchus closed. at twelve month follow up the patient did not have a recurrent cough or hemoptysis while tolerating a full diet. introduction: roux en-y gastric bypass (rygb) is one of the initial and most studied weight reduction procedures and remains the gold standard for comparison in bariatric surgery clinical outcomes. although rygb is an effective procedure for weight loss, it has been less popular over last several years because of increased morbidity compared to the more utilized vertical sleeve gastrectomy (vsg). early complications of rygb include bleeding, perforation, or leakage. late complications include internal hernias, small bowel obstruction, anastomotic stenosis, marginal ulcers, and gastrogastric fistulas. case report: a -year old female with a past medical history of morbid obesity, diabetes mellitus type , hypertension, gerd, peptic ulcer disease, cholelithiasis, liver dysfunction with ascites, asthma, and a past surgical history of rygb ( years ago) presented to our institution with acute on chronic abdominal pain associated with nausea, vomiting, dysphagia, inability to eat and maintain hydration, and an additional weight loss of about lbs. over the last year. in addition, the patient was a chronic opioid and nsaid user, had an extensive smoking history, and had not followed with her surgeon for years. at the time of presentation, the patient weighed lbs (bmi: . ), had normal vital signs, and appeared cachectic. an upper gastrointestinal study followed by an upper endoscopic examination demonstrated complete obliteration of the gastrojejunal anastomosis and revealed a -cm long gastrogastric fistula originating from the distal end of the gastric pouch to the lesser curvature of the excluded stomach. after conservative measures were initiated to hydrate and metabolically stabilize the patient, the decision was made to proceed with diagnostic laparoscopy and surgical placement of a gastrostomy tube to the gastric remnant. the patient was discharged after tolerating a full liquid diet and gastrostomy tube feedings, for plan of future revision of gastrojejunostomy when optimal nutritional status is achieved. conclusions: late complications of rygb occur at a rate of - %. major risk factors for anastomotic complications include non-compliance, smoking, and opiate and nsaid abuse. though abdominal pain, anastomotic stenosis, marginal ulcers, and fistulas are relatively common late complications of rygb, complete obliteration of the gastrojejunal anastomosis has not been well described in the literature. this case demonstrates the importance of long term follow up post rygb for early diagnosis of late complications and brings attention to this rare, but possible sequele that can arise in patients after rygb. contrast radiograms and upper endoscopic photographs will be presented. introduction: retroperitoneal sarcoma represents approximately - % of all sarcomas and less than . % of all neoplasia. radiotherapy and chemotherapy still do not represent valid therapeutic alternatives; therefore complete surgical resection is the only potential curative treatment modality for retroperitoneal sarcomas. the ability of complete resection of a retroperitoneal sarcoma with tumor grading remains the most important predictor of local recurrence and disease-specific survival. in a patient with a large fibrosarcoma and associated hypoglycemia, assays for insulin-like activity (ila) were found to be high in the extract of tumor tissue, while insulin was not detected in significant concentration neither in the same extract nor in his serum. laparoscopic surgery represents an alternative technique for radical resection of such tumors as a minimally invasive rather than traditional surgery. only few cases were reported in the literature. introduction: roux-en-y gastric bypass (rygb) is a frequently performed bariatric procedure, of which internal hernia (ih) is a known complication. we discuss a rare finding of occult gastric remnant perforation as a result of an obstructed ih in a post bypass patient. methods: we present a case report of a single bariatric surgeon's experience at a tertiary care hospital. literature review of pubmed confirms the unique presentation and operative findings in our patient, as few similar cases have been published. a -year-old male s/p rygb years ago presented to the ed with right upper quadrant pain, nausea, vomiting, and a leukocytosis of , . bmi was . ; weight was lbs. workup included an abdominal ultrasound showing gallbladder distention without signs of cholecystitis. liver function tests were normal. further imaging included a ct scan, remarkable for a paraesophageal hernia (peh) containing the gastric pouch, and an elevated left hemidiaphragm. the scan showed no evidence of ih or bowel obstruction. an upper gi series was additionally obtained, which was also negative for small bowel obstruction. due to unclear etiology for this patient's symptoms or source of leukocytosis, diagnostic laparoscopy was planned. results: intraoperative findings were significant for ih containing dilated small bowel with twisted and incarcerated omentum through the jejunojenunostomy site, as well as a distended gallbladder without acute inflammation. ih was reduced and closed without bowel resection. cholecystectomy was completed. subsequent inspection of the diaphragmatic hiatus revealed uncomplicated herniation of the gastric pouch. in attempts to dissect the left diaphragmatic crus, a large pocket of purulent material was encountered below the left diaphragm in the region of the remnant stomach fundus. methylene blue test and intraoperative endoscopy did not demonstrate any connection to gastric pouch. the purulence was attributed to an occult remnant stomach perforation related to distal obstructed ih. a drain was left in the abscess and the peh was not surgically addressed. patient was discharged on postoperative day . he has not suffered any further complications or recurrent complaints. conclusion: gastric perforation following rygb is an uncommon complication resulting from ih. this diagnosis was missed by preoperative imaging and was only found after thorough laparoscopic investigation. surgeons should maintain a high clinical suspicion of ih in post rygb patients with otherwise unexplained abdominal symptoms, fever, and leukocytosis, even in the absence of confirmatory diagnostic testing. threshold for operative exploration in this clinical setting should remain low. alejandro garza, md, robert alleyn, md, jose almeda, md, ricardo martinez, md; utrgv obesity is an epidemic condition worldwide carrying significant morbidity and mortality. surgical therapy is the only proven effective method to sustain weight loss. among the different surgical procedures gastric bypass is the most effective. during this surgery, most of the stomach is excluded from the upper gastrointestinal tract which makes future evaluation of the same very challenging. this could potentially lead to delay in diagnosis of any pathology in the bypass stomach. gastric cancer is the th most common cause of cancer and cause of cancer death in the united states. we present a case report of a patient who underwent a roux-en-y gastric bypass and went on to developed adenocarcinoma in the gastric remnant year after her surgery. she underwent an exploratory laparotomy, extended antrectomy, subtotal gastrectomy including the gastro-colic ligament, and incidental appendectomy. pathology showed grade undifferentiated adenocarcinoma that penetrated the visceral peritoneum with clear margins. there was angiolymphatic invasion and perineural invasion along with metastatic carcinoma in out of lymph nodes. introduction: polyarteritis nodosa (pan) is a systemic transmural inflammatory vasculitis that affects medium-sized arteries. inflammation of the vessel wall and intimal proliferation creates luminal narrowing which can lead to stenosis and insufficiency. the same inflammatory process causes disruption of the elastic lamina leading to aneurysm formation and possible spontaneous rupture with life-threatening bleeding. multifocal segments of stenosis and aneurysm formation are characteristically identified as a "rosary sign" or "beads on a string". unlike other vasculitides, pan does not involve small arteries or veins, and is not associated with anti-neutrophil cytoplasmic antibodies. we present the case of a year old female with a significant intra-abdominal bleed that was explored and repaired primarily. she was subsequently found on angiogram and postmortem pathology to have findings consistent with pan. case presentation: year old female who presented to the emergency department with abdominal pain followed by hemorrhagic shock and found to have a ruptured left hepatic artery aneurysm during exploratory laparotomy. this aneurysm was suture ligated with a successful outcome. a mesenteric arteriogram was performed the following day and demonstrated lesions consistent with pan including aneurysms of the left gastric branches, right and left hepatic arteries, and beaded appearance of the iliac artery. however, days after hospital discharge she developed massive pulmonary embolism from which she did not recover. postmortem examination confirmed rupture of the left hepatic artery aneurysm in addition to gross anatomical and histological findings consistent with pan. discussion: polyarteritis nodosa is a systemic inflammatory vasculitis that causes intimal proliferation and elastic lamina disruption. this multifocal disruption of the vessel results in aneurysm formation alternating with stenosis creating a characteristic "rosary sign" on imaging. spontaneous rupture of these aneurysms is rare and almost always fatal due to life-threatening hemorrhage. with acutely ruptured aneurysms, prompt diagnosis, aggressive resuscitation, and hemostasis through transarterial embolization or surgery is paramount for patient survival. while acute rupture of an aneurysm as the result of pan is exceedingly rare, it must be considered as a differential diagnosis in the setting of acute abdominal pain and hemodynamic instability. in a patient known to have a medical history of pan and aneurysm formation, routine monitoring and disease progression should be followed. introduction: , surgeries are done annually in the us for small bowel obstruction, which is most commonly caused by intraabdominal adhesions, malignancy, and hernias. . to . % of small bowel obstructions are due to paraduodenal hernias. paraduodenal hernias carry a % lifetime risk of incarceration with a mortality of to %. case report: the patient is a year old male who presented with severe upper abdominal pain for one day. he was passing flatus and had had a bowel movement the previous day. on examination, the patient was tender over the upper abdomen. computed tomography (ct) scan with iv contrast showed a mesenteric swirl sign. the decision was made to perform diagnostic laparoscopy with possible small bowel resection. intraoperatively, a mesenteric defect was noted posterior and to the right of the duodenum, through which bowel was herniating. the herniated bowel and its mesentery were edematous. the defect was sutured closed, taking seromuscular and mesenteric bites through the stomach, jejunum, and mesentery. the patient had an uneventful recovery postoperatively and was discharged on postoperative day . he returned on postoperative day with periumbilical pain which resolved with conservative management. he was followed up weeks postoperatively and was doing well. discussion: paraduodenal hernias are the most common internal hernias. they are seen more often in males. they are caused by failure of the counterclockwise rotation of the prearterial segment of the embryonic midgut in weeks to of embryonic development. paraduodenal hernias usually present with chronic intermittent abdominal pain, weight loss, nausea, and vomiting. they may present acutely with symptoms of bowel obstruction. peritoneal signs are often not appreciated due to retroperitoneal position of the hernia. ct scan of the abdomen often shows clustering of bowel loops, which cannot be displaced on repositioning the patient. if imaging is equivocal, diagnostic laparoscopy may be undertaken. surgical correction consists of reducing the bowel, resecting nonviable segments, and either closing the defect or opening the sac laterally into the general peritoneal cavity. in summary, paraduodenal hernias are a rare cause of bowel obstruction and as such present a challenge in diagnosis and early intervention. diverticulosis of the appendix is a rare disease found in . - . % of appendectomies, first described in . the clinical presentation may be acute inflammatory with or without appendicitis or it may be an incidental finding in an uninflamed appendix. the congenital type is rare and it has all the bowel wall layers. it most frequently represents as pseudo diverticulum which lacks the muscularis layer. the pathogenesis of appendiceal diverticula is not completely elucidated. its symptoms are similar to and often misdiagnosed for that early acute or chronic appendicitis. while appendectomy is curative for both entities, it is important to distinguish diverticulum of the appendix from appendicitis as it is four times more likely to perforate and may be a sign of an underlying neoplasm. we reported a very rare giant pseudo diverticulum of the appendix in a -year-old male presenting with chronic abdominal discomfort for months. abdominal x-ray showed abnormal gaseous finding. physical exam was significant for a soft rubbery mass in the periumbilical region. blood work revealed slight elevation of c-reactive protein. preoperative ct and mri showed a -centimeter-large cavity composed of thin wall, located at the tip of the appendix with peri appendicular fat stranding. in the concern of pending obstructive symptom and chronic abdominal pain, we decided to perform the resection laparoscopic. the soft mass arose from the tip of the appendix. there were dense adhesions between the appendix, mesentery, and sigmoid colon. after adhesiohedlysis, laparoscopic appendectomy was performed with endogia. the specimen was extracted through a small incision without spillage. hospital course was uneventful and the patient was discharged on post-operative day . the pathological finding was consistent with a pseudo diverticulum of the appendix which lacked muscularis layer and the inner wall of the cavity was lined with a scattered cubital epithelial layer in the continuity with the appendiceal mucosal membrane. here we report a successful laparoscopic resection of an extremely rare giant chronic pseudo diverticulum of the appendix. yvette farran, ms, jorge a miranda, ms, benjamin clapp, md, elizabeth de la rosa, md; texas tech university health sciences center introduction: sigmoid colon intussusception is rarely encountered and given its vague symptomatology diagnosis and management can be difficult. the treatment of an intussusception in adults is different than in children. lipomas as the causative etiology for intussusception are encountered up to . % of the times and up to %- % of the patients require surgical resection for treatment. methods: this is a case report about a year old male that presented with two weeks of worsening abdominal pain and distention. physical exam was only pertinent for abdominal pain on light palpation, guarding and moderate distress. ct scan of abdomen and pelvis demonstrated a lipomatous mass causing complete obstruction of the sigmoid colon with intussusception. this was managed with laparoscopic sigmoidectomy. the patient had an uncomplicated post-operative period and was discharged on post-operative day . pathology of the lipomatous mass confirmed a benign lipoma. discussion: intussusception is rarely encountered in clinical practice in adults and constitutes % of all cases. lipoma induced sigmoid intussusception with complete obstruction is rare. symptoms can be non-specific as in this case. this case report highlights the importance of timely diagnosis and treatment of an intussusception in adult patients. ct scan is the gold standard for diagnosis and often shows a "target sign". other imaging techniques like ultrasound have shown adequate results but remain less effective than ct scan. the treatment in adults is not a reduction by enema like in pediatrics but rather resection of the lead point. this can be appropriately done with a laparoscopic technique in most cases. conclusion: colonic intussusception is rare. surgery is the only treatment for an intussusception in adults since the lead point needs to be removed, and can be attempted safely with a laparoscopic approach. surg endosc ( ) :s -s joshua smith, md, kern brittany, md, amie hop, md, amy banks-venegoni, md; spectrum health case report: year-old female with no significant past medical history presents with a -year history of nocturnal cough that had worsened over the past months and had associated regurgitation. she underwent esophagogastroduodenoscopy (egd) that showed a tortuous esophagus and tight lower esophageal sphincter that required dilation. she received an upper gastrointestinal (ugi) contrast study that showed a dilated, tortuous esophagus with 'bird's beak' tapering, consistent with achalasia, as well as a large epiphrenic diverticulum measuring cm. esophageal manometry confirmed "pan-esophageal pressurization" consistent with type ii achalasia. given her symptoms in the presence of these findings, she elected to proceed with surgery. she underwent laparoscopic, trans-hiatal epiphrenic diverticulectomy, heller myotomy and dorr fundoplication. extensive dissection allowed for approximately cm of retraction down from the chest and we were able to come across it with a single blue load of a mm linear cutting stapler. post-operatively, she tolerated the procedure well with immediate improvement in her symptoms. her ugi on post-operative day showed no evidence of leak, she tolerated a soft diet and was discharged home. she was seen at -week and -year follow-up appointments with complete resolution of symptoms. discussion: epiphrenic diverticula in the presence of achalasia has an occurrence rate of %. large diverticula ([ cm), are even more rare with only a handful of case reports in the literature. historically, thoracotomy or, more recently, thoracoscopic approaches are required for resection. however, thoracic approaches are associated with a % increase in morbidity, namely due to staple line leak and the resulting pulmonary complications. only a single case report exists on our review of the literature that demonstrates successful trans-hiatal laparoscopic resection without post-operative complications of a diverticulum of this size. the shortest documented length of hospital stay postoperatively for similar cases is days, while the average is - days or longer for those with complications. our patient was able to go home on post-operative day after a normal ugi and was tolerating a soft diet. not only does this case show that a large epiphrenic diverticulm can be successfully resected via the trans-abdominal laparoscopic approach, this case makes the argument that patients undergoing any minimally-invasive epiphrenic diverticulectomy and myotomy, with or without fundoplication, may be successfully managed with early post-operative contrast studies and dietary advancement, thus decreasing their length of hospitalization and overall cost of treatment. kazuma sato, shunji kinuta, koichi takiguchi, naoyuki hanari, naoki koshiishi; takeda general hospital background: situs inversus totalis (sit) is a rare congenital condition in which the abdominal and thoracic organs are located opposite to their normal positions. few cases of laparoscopic surgery for gastric cancer with sit have been reported. we report a case of laparoscopic distal gastrectomy with d lymph node dissection performed for gastric cancer in a patient with sit. case description: an -year-old woman was admitted to our hospital for treatment of gastric cancer that was diagnosed by esophagogastroduodenoscopy (egd) at a local clinic after she experienced anemia and nausea. egd identified an irregularly shaped gastric ulcer located at the anterior side of the lesser curvature of the antrum. a biopsy revealed a moderately differentiated adenocarcinoma. she was then diagnosed with sit by chest radiography and abdominal computed tomography (ct). the abdominal ct showed that all organs were inversely positioned and that the wall of the antrum had thickened; it also showed the lymph nodes in the lesser curvature of the stomach, without distant metastasis or an abnormal course of vascularity. the patient was clinically diagnosed with t n m stage iiia gastric cancer according to the japanese classification of gastric carcinoma. a laparoscopic distal gastrectomy with d lymph node dissection in accordance with the japanese gastric cancer treatment guidelines as well as a roux-en-y anastomosis due to an esophageal hiatal hernia were performed. the surgery was safely and successfully performed, although it required more time than usual because the inverted anatomic structures were repeatedly examined during the surgery. the postoperative course was positive, and the patient was discharged on postoperative day without any complications. the final stage of this case was pt bn m stage ia. currently, the patient is doing well without recurrent gastric cancer. conclusion: gastric cancer with sit is an extremely rare occurrence. we experienced a case of laparoscopic distal gastrectomy with d lymph node dissection performed for gastric cancer in a patient with sit. we simulated the operation for sit by viewing left-right reversed ordinary surgical videos. the abdominal ct angiography with a three-dimensional reconstruction helped reveal any variation and confirmed the structures and locations of vessels before the surgery. the operation could safely be performed following the standardized surgical technique by reversing the surgeon standing position and trocar position. sternum or chest wall resection is performed for a variety of conditions such as primary and secondary tumors of the chest wall or the sternum. sternum reconstruction has been a complex problem in the past due to intraoperative technical difficulties, surgical complications, and respiratory failure caused by the chest wall instability and paradoxical respiratory movements. advances in the fields of surgery and anesthesia result in more aggressive resections. nowadays neither the size nor the position of the chest wall defect limits surgical management, because resection and reconstruction are performed in a single operation that provides immediate chest wall stability. chest wall resection involves resection of the ribs, sternum, costal cartilages and the accompanying soft tissues and the reconstruction strategy depends on the site and extent of the resected chest wall defect. here i'll present, the youngest ever case reported, years old girl with rhabdomyosarcoma involving the sternum. i will present the management challenges and the reconstruction options. introduction: neuroendrocrine malignancies constitute . % of all cancers. the gastrointestinal tract is the commonest site, followed by the lung. the last decade has seen a steady increase in their incidence. this is a case series of twenty five such tumours and their clinicopathological characteristics. materials and methods: twenty five patients with neuroendocrine tumours of the gastrointestinal tract were studied with reference to their demographic and clinicopathological characteristics. apart from routine pathological examination, these tumours were also checked for e cadherin expression as an independent marker of aggressive disease. results: the age of our patients ranged from to years. we had female and male patients, contradicting a female preponderance in literature. the vast majority of the tumours we encountered were from the stomach and duodenum, with and patients, respectively. two tumours were at the gastroduodenal junction, two from the appendix, small intestine and pancreas, each, and one each from the rectum and gall bladder. this is in contrast to literature that shows that neuroendocrine tumours of the git most commonly arise from the appendix and small bowel, followed by the rectum, stomach and duodenum. two of these tumours were functional. the diagnosis was confirmed by immunohistochemistry staining for chromogranin a and synaptophysin. grading was done using who criteria that takes into account the mitotic count, ki index and necrosis. of our cases were grade i. further, immunohistochemistry for e cadherin showed that absence of expression correlated with more aggressive clinical behavior. out of twenty five patients were operable at presentation and standard resections depending on the organ of origin with adjuvant therapies were given as required. could only be given palliative care. the functional tumours were treated with radiolabelled somatostatin analogues following uptake studies. conclusion: as neuroendocrine tumours are relatively rare, information about them is not as abundant as with other malignancies. absence of e cadherin expression is associated with more aggressive disease. more studies are required that document the pathological characteristics and clinical behavior in order to offer well rounded treatment protocols that treat not only the primary, but also the generalized effects of the secretions produced by them. targeted chemotherapy is gaining prominence, but more specific drugs directed at the plethora of receptors these tumours express, could potentially revolutionize treatment. ( ) . unfortunately there are no publications from denmark. we would like to present first to our knowledge reported case of double gallbladder in denmark. double gallbladder is a rare anomaly with a prevalence of : in autopsy studies, described first by boyden in ( ) . there are several classifications of double gallbladder that are based on relation between gallbladder, cystic duct and common bile duct ( , ) . non-specific symptoms and inadequate imaging are possible causes of lack of awareness of the condition. removal of all gallbladders, preferably laparoscopic with special attention to the biliary anatomy, is recommended ( ). method: case report with review of the literature. a -year-old female patient of polish origin was hospitalized due to upper right quadrant pain. on admission clinical manifestations and paraclinical abnormalities of pancreatitis were present. ultrasound scanning of the abdomen showed bile stones, ultrasonic manifestations of acute cholecystitis and normal intra-and extrahepatic bile ducts. because of elevated liver enzymes mrcp was performed and showed double gallbladder, double cystic duct and signs of pancreas anulare. scheduled ercp confirmed bile stones in cbd, double gallbladder with double cystic duct, h-type according to harlaftis classification ( ) . because of minor retroperitoneal perforation second ercp was needed for removal of all stones. the patient was then scheduled to laparoscopic cholecystectomy with perioperativ cholangiography. conclusion: anatomical variations of the gallbladder such as double gallbladder are rare and often remain unnoticed. they are most often identified because of clinical manifestations symptoms, diverse imaging studies, during surgery or autopsy. as most of them are not expected, they can contribute to complications during surgery. careful preoperative imaging is very important to prevent accidental bile duct injury. looking at the number of case reports, double gallbladder seems to be slightly more common than expected. the interesting question is whether a gallbladder discovered during an unrelated radiological investigation in a patient that previously underwent a cholecystectomy can represent undetected case of double gallbladder. we would like to present a review of the literature as well as images from mrcp, ercp and laparoscopy. michael jaroncyzk, md, courtney e collins, md, ms, vladimir p daoud, md, ms, ibrahim daoud, md; st. francis hospital; hartford ct introduction: several decades ago, surgical training was saturated with procedures to treated peptic ulcer disease. since the introduction of histamine- blockers and proton pump inhibitors, these procedures have dwindled significantly. however, there are still instances where patients require surgical intervention for peptic ulcer disease. perforation is one of the indications for surgery. the surgical options to treat a perforated peptic ulcer are numerous. one of the most common options is a graham patch. we are presenting a case of a patient with a perforated ulcer that did not have available omentum for the repair. methods and procedures: recently, a -year-old female with a past history of an open total abdominal hysterectomy and bilateral salpingo-oophorectomy presented as an outpatient with chronic lower abdominal pain. she underwent a work-up and imaging that did not reveal any pathology. at diagnostic laparoscopy, she had diffuse lower abdominal adhesions, which were lysed. she was discharged on the same day, but presented to the emergency department two days later with severe abdominal pain and fevers. the work-up revealed tachycardia, diffuse abdominal tenderness with peritoneal signs, leukocytosis and a large amount of free air on imaging. she was emergently brought to the operating room for a diagnostic laparoscopy. during laparoscopic exploration, the lower abdominal cavity appeared normal for a recent lysis of adhesions. attention was turned to the upper cavity to find the pathology. bile-stained free fluid and peri-gastric exudates were identified, but no perforation was visualized. intra-operative endoscopy revealed the site of perforation in the antrum on the lesser curvature. a biopsy was performed and the decision was made to perform a graham patch. however, the omentum was already densely involved with the lower abdominal cavity from the enterolysis. due to the close proximity of the falciform ligament, it was mobilized laparoscopically and the pedicle was used as a graham patch. the patient recovered without any additional issues. the biopsy was reported as a chronic gastric ulcer. conclusion: surgical history has given us many options to treat peptic ulcer disease that are not nearly as common as they were decades ago. perforated ulcers can be managed laparoscopically and graham patches are a common choice for repair. however, the lack of the omentum for a proper pedicle flap can pose a problem in some patients. we have shown in this patient that a falciform pedicle flap can be successfully used as a substitution. laparoscopic management of boerhaave's syndrome after a late presentation: a case report and literature review tahir yunus, hager aref, obadah alhallaq; imc background: boerhaave's syndrome involves an abrupt elevation in the intraluminal pressure of the oesophagus, causing a transmural perforation. it is associated with high morbidity and mortality. having a nonspecific presentation may contribute to a delay in diagnosis and results in poor outcomes. treatment is challenging, yet early surgical intervention is the most important prognostic factor. case presentation: we present a case of a thirty-two-year-old male with a long medical history of dysphagia due to benign oesophagal stricture. he presented with acute onset of epigastric pain after severe emesis. based on computed tomography scan, he was diagnosed with boerhaave's syndrome. presenting with signs of shock, mandated immediate surgical exploration. for which he was taken for laparoscopic primary repair with uneventful postoperative recovery. the golden period of the first hours of insult still applies for cases of oesophagal perforation. the rarity of these cases makes a comparison between the various treatment methods difficult. our data support that the use of laparoscopic operative intervention with primary repair as the mainstay of treatment for the management of oesophageal perforation. lipomas of the gastrointestinal tract are rare benign soft tissue tumors that are often discovered incidentally. these lesions are often asymptomatic, but have occasionally been reported to have clinical significance as will be described in this case report. a year old male initially presented to his primary care physician's office with a three week history of vague intermittent abdominal pain. his pain was located in the mid epigastrium and was associated with mild nausea. past medical history was significant for hyperlipidemia and a right-sided goiter, and he denied any previous surgeries. outpatient work up revealed a microcytic anemia, intermittent melena and hemoccult positive stools. the patient was referred to hematology and gastroenterology. endoscopies revealed gastritis, and small internal and external hemorrhoids. he underwent an outpatient ct scan which demonstrated a . . cm mass within the lumen of the jejunum causing long segment non-obstucting intussusception. subsequently, the patient was referred to surgery and underwent a diagnostic laparoscopy. at the time of surgery, an approximately twelve centimeter segment of proximal jejunum was identified intussuscepting into a distal limb. this segment was attempted to be reduced laparoscopically, however there was significant mesentery within in the intussusceptum and the segment could not be safely reduced. therefore, the section of bowel was delivered through a small periumbilical incision. the intussusceptum was then able to be manually reduced from the intussusception. at this point a large mass was palpated inside the lumen of the jejunum. a small bowel side to side, functional end to end resection and anastomosis was preformed. the bowel was returned to the abdomen and the abdomen was re-insufflated. the remainder of the small bowel was run and no additional lesions were identified. final pathology revealed a . . . cm submucosal partially obstructing lipoma with ulceration at the tip. the patient recovered uneventfully and was discharged home on the second post operative day. this case report describes a submucosal jejunal lipoma that was acting as a lead point for intermittent non-obstructing small bowel intussusception, while simultaneously causing a microcytic anemia due to ulceration at the tip of the lipoma. laparoscopic assisted reduction and small bowel resection is a safe and effective treatment for gastrointestinal tract lipomas that are unable to removed endoscopically. percutaneous endoscopic gastrostomy (peg) is an alternative to laparotomy for open gastrostomy tube placement to provide enteral nutrition for those who are unable to pass nutrition orally. despite being less invasive, the procedure is not without its complications, one of which includes the formation of a gastrocolocutaneous fistula. the case describes a year old female who presented with a peg placed months prior with reports of leakage of tube feeds from the gastrostomy site. as there was concern for possible ileus or obstruction, an upper gi series was completed which seemed to indicate dislodgement of the g-tube. the g-tube was replaced and a follow-up gastrograffin study was repeated which now indicated that the g-tube was within the lumen of the colon. soon thereafter fecal matter was noted to be draining around the g-tube site; however, patient was without clinical signs of peritonitis. the patient was managed non-surgically as she was a poor surgical candidate with multiple prohibitive co-morbidities. the g-tube was removed bedside by cutting it flush at the skin level with the anticipation that the remainder of the tube would be excreted with bowel movements. the decision was then made to attempt closure of the gastric fistula endoscopically which was accomplished with hemoclips. a follow up upper gi study hours later showed no extravasation of contrast through the gastric fistula. the colocutaneous fistula had self-resolved over the next couple days as well. placement of the peg tube through the transverse colon can present with varying ill effects including diarrhea, pneumoperitoneum, peritonitis, gram negative pulmonary infection or feculent vomiting with the formation of a gastrocutaneous fistula. treatment historically for a gastrocolocutaneous fistula has been exploration and excision of the fistula tract with resection of the involved colonic segment. however, there currently is no gold standard for the management of, and really ranges from conservative management to surgical and is dependent on the presenting symptoms. if the peg becomes dislodged with resultant spillage from the colon with resultant peritonitis, surgical exploration is needed with removal of the g-tube and repair of the stomach and colon. on the other hand, non-surgical management has been suggested in management of a well-established fistula. fistula closure may be spontaneous; however, can be inhibited due to delayed gastric emptying or leakage of gastric secretions through the fistula. endoscopic clipping of the fistula tract employing the hemoclips is a treatment option. median arcuate ligament syndrome (mals) is a rare etiology of abdominal pain caused by narrowing of the celiac artery at its origin by the median arcuate ligament with relative hypoperfusion downstream. patients suffer from post-prandial abdominal pain, abdominal pain associated with exercise, nausea, and unintentional weight loss. diagnosis is historically made by demonstrating elevated celiac artery velocities and respiratory variation on dynamic vascular studies. standard of care for mals patients is laparoscopic celiac artery dissection with release of the median arcuate ligament. at our institution, we have encountered fourteen patients (eleven female, three male) diagnosed by elevated peak velocity in the celiac artery by duplex ultrasound in conjunction with ct angiogram, mr angiogram, arteriogram, or multiple modalities. all but one patient had multiple diagnostic imaging modalities, with the most common being ct angiogram; eight patients had invasive imaging. the mean age at presentation was . years in men and . years in women. on average, male patients presented with a longer duration of symptoms, . years (range - years), as compared to women, . years (range - years). symptoms were fairly consistent between genders and included nausea, emesis, abnormal bowel habits, early satiety, post-prandial pain, and weight loss. all male patients reported at least two symptoms, most commonly nausea and post-prandial pain. in female patients, % reported having three or more symptoms. notably, post-prandial pain was universal among men and women, while weight loss was exclusive to female patients as reported by %. pre-operative peak velocities were recorded in all but one patient, with mean values more elevated in female patients as opposed to male patients, cm/s versus cm/s. post-operative duplexes were obtained in seven patients; pooled data show a mean change of negative cm/s for an average of cm/s after decompression. in all cases, the celiac artery trifurcation was visualized and noted to have a distinct change in artery caliber after division of the ligament. in total, % of patients reported significant improvement with return to normal diet and healthy weight gain post-operatively. of the three without complete resolution, two were diagnosed with motility disorders and one was lost to follow-up. our experience demonstrates that laparoscopic release of the median arcuate ligament in patients with significant flow limitation of the celiac artery on dynamic and anatomic imaging can be a successful treatment option for patients with recalcitrant pain and gastrointestinal dysfunction with no alternative diagnosis. matthew a goldstein, ma, kirill zakharov, do, sharique nazir, md; nyu langone brooklyn adhesions are fibrotic bands that form between and among abdominal organs. the most common cause of abdominal adhesions is previous surgery in the area as well as radiation, infection and frequently occurring with unknown etiology. these bands occur among abdominal organs, commonly the small bowel, and can lead to obstruction or remain asymptomatic, akin to the patient discussed here. congenital abdominal adhesions are rare and have received little attention in research and field of study. the patient described in this case is a -year-old female with a past medical history of morbid obesity, bmi of , hypertension and no past abdominal surgical procedures. the patient presented in august for bariatric surgical consultation and was ultimately taken for an attempted laparoscopic sleeve gastrectomy. upon entering the abdomen, significant adhesions were encountered and an additional attending was called to assist in identifying the stomach. the splenic flexure was found to be plastered to the diaphragm and the descending and transverse colon were adhered to the anterior surface of the stomach. additionally, small bowel adhesions encased the area between the right and left hepatic lobes as well as the caudate lobe. after extensive enterolysis, the pylorus remained the only identifiable portion of the stomach. the patient also demonstrated significant hepatomegaly and a wedge resection was performed. the amount of adhesion and matting of the small and large bowel obscured the view of the stomach and the procedure was deemed too dangerous and terminated. this case represents the uncommon scenario in which an abdomen with no prior surgical history presents with extensive, obscuring adhesions. one such recent study describes the influence of cytokines and proinflammatory states as contributors to obstruction and malrotation in children, but this patient demonstrated no significant history. further investigation is needed to determine potential etiologies of symptomatic and non-symptomatic congenital adhesions among bariatric patients who fail conservative treatment. today the patient is doing well and the surgical team will attempt to complete the procedure in the coming months. laparoscopic spenulectomy: an interesting case report riva das, md , daniel a ringold, md , thai q vu, md ; orlando health, abington jefferson health introduction: spenules, or accessory spleens, are a rare disease entity. most often, they are asymptomatic, and found incidentally during radiographic workup for an unrelated problem. torsion can cause a splenule to not only become symptomatic, but also confound the results of usual diagnostic studies. case description: a -year-old female patient with history of uncomplicated hypertension, hyperlipidemia, hysterectomy, cholecystectomy, spinal surgery, and partial left nephrectomy, presented to the hospital with a two-week history of intermittent left upper quadrant abdominal pain. she denied any similar episodes in the past, or any associated symptoms. further investigation with a ct scan of the abdomen and pelvis showed an acute inflammatory process in the left upper quadrant in same location as some colonic diverticulosis, as well as a . cm soft tissue mass. this indeterminate soft tissue mass was described as having decreased attenuation compared with the spleen. differential diagnosis for this mass included malignancy, an atypical splenule, or an infectious/inflammatory mass. an mri was recommended for further evaluation, but did not reveal any additional significant findings. nuclear medicine liver/spleen scintigraphy was performed, which showed no focal activity associated with the indeterminate left upper quadrant mass, therefore making it unlikely to reflect a splenule, and making malignancy the diagnosis of exclusion. following a period of observation with analgesia, intravenous antibiotics, and bowel rest, her abdominal pain did not resolve, and the decision was made to proceed with operative exploration. diagnostic laparoscopy revealed an approximately cm spherical mass in the left upper quadrant located just below the inferior aspect of the spleen. the superior aspect of the mass gave rise to a vascular pedicle, which upon tracing, seemed to originate from the splenic hilum. this pedicle was easily ligated, and the mass removed. pathology revealed an extensive infarcted hemorrhagic nodule with organizing thrombus and attached thrombosed artery, consistent with an infarcted splenule due to torsion along its own axis. the patient had an uncomplicated postoperative course. discussion: this case report demonstrates the unusual presentation and workup of a patient that was ultimately diagnosed with an infarcted splenule, despite imaging findings that did not correlate, and may even have confused her diagnosis. scintigraphy, which is normally the gold standard for diagnosing and localizing accessory splenic tissue, was in this case unrevealing, due to inability of the tracer to traverse the torsed vascular pedicle. operative exploration was both diagnostic and therapeutic. patients which was treated with antibiotics suggested by culture and sensitivity report and local wound care. one patient died due to sepsis at presentation. conclusion: chikungunya virus was found circulating in rodents in pakistan as early as . duodenal ulcer perforation which is a common surgical emergency in our part of the world usually presents with pinpoint perforation in ant wall of first part of duodenum unlike in already diagnosed cases of chikungunya disease where a slit like duodenal perforation is noted in the anterior wall of first part of duodenum. literature and consensus relate this perforation with the excessive use of nsaids due to usual presentation of arthritis in chikungunya disease but the unusual presentation is still to be answered. introduction: bouveret's syndrome is a rare form of gallstone ileus in which an impaction of a gallstone in the duodenum results in a gastric outlet obstruction. gallstone ileus accounts for approximately - % of all cases of small bowel obstruction. the terminal ileum is the most common location for a calculus to cause obstruction followed by the proximal ileum, jejunum and duodenum/stomach respectively. open and laparoscopic surgery has previously been the mainstay of treatment for bouveret's syndrome, however with the advent of new endoscopic techniques and instruments there has been increasing success in endoscopic management. this case report looks at a patient with a gastric outlet obstruction from a gallstone, and discusses the current literature regarding diagnosis and management. case: year old male presented with several day history of epigastric abdominal pain and multiple episodes of nonbloody, nonbilious emesis. he had previously been diagnosed with cholelithiasis, however had refused surgery at that time. on admission the patient was found to have a leukocytosis of . . an ultrasound was performed in which the images were limited due to pneumobilia. a subsequent ct scan revealed pneumobilia, and a large cm gallstone impacted in the first portion of the duodenum causing a gastric outlet obstruction. the patient underwent failed endoscopic attempts at removal and ultimately required a laparotomy, enerotomy with stone extraction. discussion: bouveret's syndrome is a rare variant of gallstone ileus. with newer endoscopic techniques and electrohydraulic lithotripsy, there has been increasing success with endoscopic retrieval of the impacted gallstones. there is some controversy in regards to the need for definitive operative management. stone extraction, without cholecystectomy and fistula repair, has been shown to have less postoperative complications as well as lower mortality rates compared to when a cholecystectomy and fistula repair has been performed. total mesorectal excision (tme) with neoadjuvant chemoradiotherapy (nacrt) is standard treatment for rectal cancer, which has resulted in a decrease in local recurrence. however, nacrt has shown no significant overall survival and some adverse effects mainly caused by radiation therapy. recently, the usefulness of neoadjuvant chemotherapy (nac) has been reported. we retrospectively assessed the efficacy and safety of the neoadjuvant mfolfoxiri compared with nacrt followed by laparoscopic surgery. a total of patients undergoing laparoscopic surgery for lower rectal cancer (clinical stage: ii or iii) from july to february in our department were retrospectively evaluated. patients underwent nac, and patients underwent nacrt. the following data were collected: pathological complete response (pcr), histological grade, down staging, radial margin (rm) and postoperative complications. histological grade was defined as follows: tumor cell necrosis or degeneration is present in less than one third of the tumor area (grade a), between one and two thirds (grade b), more than two thirds but viable cells remain (grade ), and complete response (grade ). these two groups were demographically comparable. down staging did not differ between the two groups. histological grade (?grade b) and pcr were significantly higher in the nacrt than in the nac group (p. ). rm had no significant difference in both groups, but tended to be able to secure negative rm in the nac group ( % vs. . %, p= . aims: increasing evidence suggest that cme may improve overall and disease free survival in colon cancer. our aims were to investigate the safety and efficacy of single incision laparoscopic cme colectomy (silcc) compared to multiport cme laparoscopic colectomy (mpclc) providing the first meta-analytical evidence. methods: pubmed, scopus and cochrane library were searched. studies comparing the silcc to mpclc in adults with colon adenocarcinoma were included. the studies were critically appraised using the newcastle ottawa scale. statistical heterogeneity was assessed with x and i . the symmetry of funnel plots was examined for publication bias. results: one randomized and four case control trials were included ( silcc vs sl introduction: obesity has been associated with increased morbidity following total proctocolectomies with ilealpouch anal anastomosis (tpc-ipaa). however, the incremental added risk of increasing obesity class is not known. the aim of this study was to evaluate the additional morbidity of increasing obesity class for tpc-ipaa. methods: after ethics board approval, the acs-nsqip database ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) was accessed to identify patients who underwent elective tpc-ipaa. body mass index (bmi, kg/m ) was classified as normal ( . - . ) , overweight ( . - . ), obesity class-i ( - . ), obesity class-ii ( - . ) and obesity class-iii (≥ ). primary outcomes were overall surgical site infection (ssi) and organ-space infection (osi). secondary outcomes were -day major morbidity and length of hospital stay (los aim: in curatively intended resection of sigmoid and rectal cancer, many surgeons prefer to perform ligation of the root of the inferior mesenteric artery (ima), high tie, because of oncological reasons. however, ligation of the ima has been known to decrease blood flow to the anastomosis. there are few reports of patients undergoing the reduced port laparoscopic approach (rps) including single-incision laparoscopic approach (sils) even among those undergoing laparoscopic lymph node dissection around the ima with preservation of the left colic artery (lca). our objective was to evaluate the quality of this procedure regarding application of rps for the treatment of sigmoid and rectal cancer. methods: the feasibility of this procedure was evaluated in consecutive cases of rps for sigmoid and rectal cancer. a lap protector (lp) was inserted through a . cm transumbilical incision, and an ez-access was mounted to lp and three -mm ports were placed. almost all procedures were performed with standard laparoscopic instruments using a flexible scope (sils). a mm port was inserted in right lower quadrant mainly in rectal cancer surgery (sils + ). our method involves peeling off the vascular sheath from the ima and dissection of the ln around the ima together with the sheath. results: lymph nodes around the ima were dissected with preservation of the lca in cases (group a). the ima was ligated at its root in cases (high tie, group b). in group a, patients were treated with sils and patients were treated with sils+ . in group b, patients were treated with sils and patients were treated with sils+ . median operative time was . , and . min for group a, and b, respectively. the operative time was significantly longer in group a. estimated blood loss was . and . g, and mean numbers of harvested ln were . , and . . none of the other operative results of groups a and b were different statistically. in this series, there was only one anastomotic leakage in group b. conclusion: our method allows equivalent laparoscopic lymph node dissection to the high tie technique. the operative time tends to be longer, however this procedure has a possibility to reduce an anastomotic leakage. introduction: the routine mobilization of the left colonic flexure in colorectal surgery is still a matter of debate. we present our surgical approach with data. this technique may increases the surgical expertise/confidence when the surgical maneuver is necessary. up to % of all splenectomies are for surgery-related injuries; % of those splenic injuries are treated by splenectomy. the iatrogenic splenic injury rate during colorectal surgery is . %. iatrogenic splenic injuries create: increased risk of mortality/morbidity, extended operative time/patient in-hospital stay and increased healthcare costs. risk factors for iatrogenic splenic injury are: advanced age, adhesions, underlying pathology. obesity is not a risk factor. it is debated if the left colonic flexure mobilization is a risk factor for splenic injury. the ligament over-traction is the most frequent damage mechanism. the most dangerous surgical manuever is the spleno-colic ligament surgical dissection. moreover, laparoscopy descreases by almost , times the splenic injury risk. some surgeons are reluctant to routinely take down the splenic flexure. materials and procedures: robotic left colonic/rectal cases with routine splenic flexure mobilization technique have been performed: left colectomy (n= ), rectal surgery (n= ), transverse-colectomy (n= ) and pancolectomy (n = ). conversion rate , %, ebl\ ml, postop-leak ( . %) and % iatrogenic splenic injuries. results: in our approach, there are pathways that need to be mastered for the splenic flexure mobilization:a) medial to lateral dissection (underneath the inferior mesenteric vein); b) lateral to medial (from the lateral peritoneal reflection); c) access to the lesser sac with omental detachment from the transverse colon; d) access to the lesser sac with the gastrocolic opening, following the inferior border of the pancreas. the dissection should be closer to the colon rather than to the spleen. in our experience the routine mobilization of the splenic flexure may have some advantages: a) better (without tension) distal anastomosis formation; b) better perfusion of the proxiaml stump; c) wider oncological dissection; d) no need of going back to the flexure when the proximal stump is too short; e) mastering a surgical manuver useful in other procedures (e.g. distal pancreasectomy). the theoretical drawbacks of routine splenic flexure mobilization can be:a) longer operative time, which is on average increased by minutes; b) risk of splenic injuries, in our experience, no splenic injuries have been registered. conclusions: technical accuracy with cautious dissection/visualization can reduce iatrogenic splenic damages rate. laparoscopy decreases splenic injury rate. robotic surgery may have the potential to further reduce this complications. our data suggest that the routine mobilization of the splenic flexure, has more advantages than drawbacks and it can reduce the iatrogenic splenic injury rate. more trials are needed in order confirm our findings. introduction: the robotic stapler with the endowrist™ technology (intuitive surgical, inc.) includes a larger range of motion and articulation compared to the laparoscopic device, and may provide some benefits in difficult areas like the pelvis. to date, few studies have been published on the application of robotic endowristed stapling. we present our preliminary experience using the robotic stapler in low anterior rectal resection (larr) with total mesorectal excision (tme) for rectal cancer. methods and procedures: between march and september , patients underwent elective robotic larr with tme and primary colorectal anastomosis within the eras program. patient demographic, intra-operative data and post-operative outcomes were compared between the endowrist™ robotic stapler group (rs group) and the laparoscopic stapler group (ls group). results: the two groups were homogeneous in terms of demographic and clinical characteristics. thirteen ( males) and patients ( males) were included in rs and in ls group, respectively. seven patients received preoperative chemoradiation in rs group, in ls group. there was no difference in intra-operative blood loss and total operative time. the median number of stapler fires for patients in rs group and in ls group was (range, - ) and (range, - ), respectively. loop-ileostomy was fashioned in patients in rs group ( . %) and patients in ls group ( . %). the days mortality was nil. two cases of anastomotic leaks have been detected in rs group ( . %), cases ( . %), occurred in ls group, all treated conservatively. the mean length of postoperative stay was . ± . days in rs group, . ± . days in ls group. conclusions: in our preliminary experience the application of robotic stapler during larr with tme has shown to be safe and feasible with acceptable morbidity. even if our case series is pretty small, fewer stapler fires were required in the rsg compared to lsg. we believe that the robotic stapler might lead to a more precise firing during pelvic surgery: it can explain the trend toward a decreased number of fires, that has been well documented in literature to be related to a lower risk of anastomotic leak. further high quality studies are required to confirm these findings. background and objectives: the present study was aimed at investigating the safety and feasibility of laparoscopic ultra-low anterior resection (l-ular) with total mesorectal excision (tme) and transanal specimen extraction for rectal cancer located at lower one-third rectum, and specifically understanding the oncological outcome of the operation. patients and method: a prospective designed database of a consecutive series of patients undergoing laparoscopic ultra-low anterior resection for rectal malignancy with various tumornode-metastasis (tnm) classifications from to at the texas endosurgery institute was analyzed. in this study ultra-low anterior resection is defined as low anterior resection for the malignant lesion at distal / of rectum. results: ultralow anterior resections were completed laparoscopically with tme and transanal specimen extraction. the operating time for the surgery was . ± . minutes, and estimated blood loss during the procedure was . ± . ml. the length of the lesion from the anal verge measured with intraoperative colonoscopy ranged from . cm to . cm, and shortest distance of colorectal anastomosis from the anal verge is cm. since diverting ileostomy was routinely installed after l-ular, none was found to have anastomotic leakage, however patients developed anal stenosis within -month follow-up. therefore the overall rate of postoperative complication is . %. moreover patients were reported to have local recurrence in -year followup with the rate of . %. conclusions: l-ular is safe and effective procedure for the rectal cancer at distal / rectum with comparable local recurrence and postoperative complication rates, thereby suggesting l-ular can be considered as a procedure of choice for rectal cancer at very low location in the rectum. for rectal cancer, however, local full-thickness excisions are fraught with high local recurrence rates -even if limited to early and best selected lesions. this corroborated observation is likely caused by a combination of missed nodal disease and direct implantation of tumor cells into the mesorectum, which upstages even early t lesions to at least a t lesion. the treatment of choice for invasive adenocarcinoma consists of an oncological total mesorectal resection, possibly with other modalities. rectal tumors of uncertain behavior can present a treatment dilemma between over-treatment vs under-treatment. concept: if the nature of a lesion is not certain or if contradictory results have been obtained, we propose a superficial local excision as a mucosal excisional biopsy to establish the diagnosis while avoiding interference with subsequent definitive treatment modalities by preserving the integrity of the external rectal wall and mesorectum. a benign final pathology concludes the treatment, whereas a detection of invasive cancer will be managed with a subsequent oncological resection. methods: this is a case report of a -year-old woman found to have a . cm villous lesion in the mid to distal rectum without proven or disproven invasive cancer. a tems-guided mucosal resection of the rectal mass at cm above the anal verge was performed whereby the lesion was dissected off the underlying muscularis. results: with preoperative discrepant erus and mri staging ut - vs ct lesion, a technically successful mucosal resection of the large rectal mass was carried out. pathology revealed a tubulovillous adenoma without high grade dysplasia or malignancy and a complete resection. conclusion: tems mucosal excisional biopsy of rectal tumors of uncertain behavior allows for a less invasive diagnostic approach that may (a) be definitive treatment if the lesion is proven benign, or (b) confirm the need for more aggressive treatment without having burned any treatment bridges or upstaged an early tumor by violating the mesorectal plane. an oncologic resection with appropriate (neo-)adjuvant chemotherapy can be carried out while preventing the potential for tumor seeding at initial operation. background: adequate visualization of the entire lumen of the large bowel is essential in detecting pathology and establishing diagnoses during colonoscopies. patients are provided dietary instructions and medications in order to achieve adequate bowel preparation. given the extensive amount of preparation required, some patients may be unable to adhere to the prescribed routine, resulting in rescheduling or repeat procedures and misallocation of limited resources. a number of previous quality-improvement efforts have been implemented to ensure adequate preparation prior to colonoscopy. objective: the objective of this study was to develop and assess the feasibility of a novel smart phone application in the delivery of bowel preparation instructions. methods: a novel smart phone application was developed to deliver bowel preparation instructions to patients undergoing colonoscopy for the first time. patients were included in the pilot phase of this project if they were undergoing a colonoscopy for the first time. we included patients who had access to a smart phone, had not previously had a bowel preparation for any reason. we excluded patients with a previous diagnosis of inflammatory bowel disease or colorectal cancer. patient surveys were administered at the time of colonoscopy. patients were questioned regarding the completeness of bowel preparation and adherence to bowel preparation instructions. patient questionnaires were completed to ascertain the ease of use of the smart phone application and any concerns that arose. quality of bowel preparation was assessed by the colonoscopist using the validated ottawa bowel preparation score. this is the pilot study results for the "coloprep" trial (nct ). results: a total of patients were enrolled in the pilot phase of this study. patient satisfaction, adherence to instructions and ease of use of the smart phone application were ascertained. bowel preparation, as assessed by the colonoscopist, was reported. conclusions: this study assessed the feasibility of using a novel smart phone application for delivery of bowel preparation instruction. this pilot study is the initial phase of a randomized controlled trial to compare smart phone application vs. written instructions in the delivery of bowel preparation instructions. the . median follow-up was months. there were no statistically significant differences found in clinical features and laboratory findings between the two groups. no statistically significant difference was found regarding the overall success rates and the complication rates between the conservative and the surgical arms (success rates: . % and . % (p= . ) and complication rates: . % and . % (p= . ), respectively). however, surgical treatment was better than conservative treatment in preventing recurrent diverticulitis (recurrence rates: % and . % (p= . ), respectively). conclusion: conservative management with bowel rest and antibiotics is a safe and effective treatment for right-sided colonic uncomplicated diverticulitis and may be considered as the initial option. on the other hand, laparoscopic diverticulectomy is also safe, effective and adequate. surgery is advocated to decrease the recurrence rate. introduction: it has been hypothesized that the structural and functional changes that develop in the defunctioned segment of bowel may contribute to the development of postoperative ileus (poi) after loop ileostomy closure (lic). as such, longer intersurgery interval between ileostomy creation and lic may increase poi. methods and procedures: after institutional review board approval, all patients who underwent lic at a single institution between - were identified. the primary endpoint, primary poi, was defined as either a) being kept nil-per-os on or after postoperative day for symptoms of nausea/vomiting, distension, and/or obstipation or b) having a nasogastric tube (ngt) inserted, without postoperative obstruction or sepsis. secondary endpoints included length of hospital stay (los) and non-poi related morbidity. patients who left the operating room with a ngt, had a planned laparotomy with a concomitant procedure at the time of lic, had a total proctocolectomy as their index operation, or had secondary poi, were excluded. patients were then divided into two groups based on timing from the index operation to lic (\ months vs. objective: fecal incontinence can be a debilitating problem significantly diminishing productivity and quality of life. sacral neuromodulation has emerged as a first line surgical option treatment in patients with fecal incontinence. though its efficacy has been rigorously evaluated in adult populations there is scant data available for its use in the pediatric pateints with fecal incontinence. this case study discusses the management of fecal incontinence in a pediatric patient with a history of hirschsprung's disease utilizing sacral nerve stimulation. methods: our patient is a -year-old female with a history of hirshsprung's diagnosed in infancy and treated surgically with coloanal pull through at the age of who presented with complaints of fecal incontinence. the patient was wearing pads daily, noting frequent uncontrolled bowel movements as well as having frequent missed days of school due to these symptoms. despite maximal medical management and pelvic floor physical therapy the patient continued to have - episodes of fecal incontinence daily. a ct scan with rectal contrast was used to establish her postoperative anatomy. anal manometry showed low rest/squeeze pressures, absent resting anal inhibitory reflex, and abnormal sensation. furthermore, during balloon expulsion testing the patient failed to pass device. the patient was deemed a candidate for stage testing with sacral nerve neuromodulation. during follow-up, the patient was noted to have resolution of her episodes of fecal incontinence and the second stage was completed. the patient continues to note % continence and dramatic improvement in her quality of life. conclusion: in this patient with a history of severe fecal incontinence due to hirschsprung's disease, sacral neuromodulation has had a significant impact on her quality of life. post-operatively she continues to have marked improvement in her symptoms with - bowel movements a day with no recurrence of fecal incontinence. the use of sacral neuromodulation is a promising treatment for fecal incontinence in the pediatric population. future research investigating the longterm efficacy of this treatment modality in the pediatric population is needed. cases of bowel obstruction caused by colorectal cancer recurrence and progression were excluded. surgical cases ( . %) were considered to be early bowel obstruction and ( . %) were classified as late bowel obstruction. left hemicolectomy (n= , . %) was a significantly more frequent procedure in early bowel obstruction, and abdominoperineal resection (n= , . %) was significantly more common in late bowel obstruction (p. ). both early and late bowel obstruction included adhesive small bowel obstruction (n= ), internal hernia (n= ), and strangulation obstruction (n= ). internal hernia (n= ) and strangulation obstruction (n= ) occurred after left hemicolectomy and abdominoperineal resection, respectively. there is no apparent relationship between surgical procedures and adhesion regions (abdominal wall, intestinal tract, and pelvic cavity). the incidence rate of postoperative small bowel obstruction remained low, and laparoscopic colectomy had been safely performed. however, countermeasures are needed because of the high frequency of both early and late bowel obstruction which occurred after left hemicolectomy and abdominoperineal resection, respectively. improved utilization of resources as an improvement introduction: nowadays, treatment decisions about patients with rectal cancer are increasingly made within the context of a multi-disciplinary team (mdt) meeting. the outcomes of rectal cancer patients before and after the era of multi-disciplinary team was analyzed and compared in this paper. the purpose of the present study is to evaluate the value of discussing rectal cancer patients in a multi-disciplinary team. methods and procedures: in our health institute, weekly mdt conferences were initiated in january . meetings were attended by surgeons, radiologists, radiation and medical oncologists and key nursing personnel. all rectal cancer patients diagnosed and treated in - in the general surgery division of the "carlo urbani" hospital in jesi (an, italy) were included. then, the data from rectal cancer patients in were evaluated, before the adoption of mdt and in year , after the adoption of meetings. datasets regarding demographics, tumor stage, treatment, and outcomes based on pathology after operation were obtained. during an mdt discussion patient history, clinical and psychological condition, co-morbidity, modes of work-up, clinical staging, and optimal treatment strategies were discussed. a database was created to include each patient's workup, treatments to date and recommendations by each specialty. ''demographic variables'' consisted of age at diagnosis, sex, body mass index, comorbidities, american society of anesthesiologists physical status classification system, clinical stage and pathological stage. other analyzed variables included baseline carcinoembryonic antigen (cea), the type of imaging, use of neoadjuvant chemo-radiation, restaging following neoadjuvant therapy, distance from the anal verge, operation type and use of adjuvant chemo-radiation. ''outcome variables'' consisted in a comparison for each group between clinical and pathological stage. results: sixty-five patients were included in this study: thirty patients in (pre-mdt) and thirty-five patients in . demographic variables did not differ significantly between groups. preoperative clinical stages with baseline preoperative cea and postoperative pathological stage were analysed, too. thanks to the mdt and the increased use of the neoadjuvant therapy, a statistically significant difference in reduction of the stage between the clinical and pathological stage in the patients of the mdt group was verified. conclusions: the vast majority of rectal mdt decisions were implemented and when decisions changed, it mostly related to patient factors that had not been taken into account prior to the adoption of multi-disciplinary team. analysis of the implementation of team decisions is an informative process in order to monitor the quality of mdt decision-making. purpose: in japan, lateral pelvic node dissection (lpnd) is the standard treatment for locally advanced lower rectal cancer. there are few reports of patients undergoing single-incision plus one port laparoscopic (sils+ ) lpnd even among those undergoing laparoscopic lpnd. the aim of this study is to describe our initial experience and assess the feasibility and safety of sils+ lpnd for patients with advanced lower rectal cancer. methods: a lap protector (lp) was inserted through a . cm transumbilical incision, and an ezaccess was mounted to lp and three -mm ports were placed. a mm port was inserted in right lower quadrant. a single institutional experience of sils+ lplnd for rectal cancer are presented. inclusion criteria was indications for lld were lower rectal cancer with t - , or t - rectal cancer with metastasis of lateral lymph node, as described by the japanese society for cancer of the colon and rectum (jsccr) guidelines for the treatment of colorectal cancer. perioperative outcomes including operative time, operative blood loss, length of stay, postoperative complications, and histopathological data were collected prospectively. introduction: endoscopic stenting with a self-expandable metallic stent (sems) is widely accepted procedure for malignant colorectal obstruction. we assessed the safety and efficacy of insertion of a sems followed by elective surgery as 'bridge to surgery (bts)' in our institute. methods: this study was a retrospective study in our institute. the data was collected from medical charts from january to june . results: a total of consecutive patients underwent radical surgery for colorectal malignancy during this period. in this series, patients ( . %) were diagnosed malignant colorectal obstruction and intended to a bts. the stent was successfully placed in patients and all the patients were planned to undergo radical surgery. the failed patients underwent stoma creation ( patients) and hartmann's procedure. the technical success rate was % and the clinical success rate was %. the median time from sems to surgery was days ( - days) . open and laparoscopic surgery was performed in and patients, respectively, except for one patient refused radical surgery because of a great age. the tumor could be resected in patients (bts patients) with primary anastomosis. however, diverting stoma creation was needed in patients and decompression rectal tube was placed in patient. the entire patient laparoscopically was no conversion to open surgery. there was no anastomotic leakage in bts patients. the median duration of postoperative hospital stay was days ( - days). the overall postoperative complication was % ( / ) including bowel obstruction and anastomotic stricture. the median follow-up period was days. during the follow-up period, patients were relapsed peritoneal dissemination, ovarian metastasis, and liver and pulmonary metastases, respectively. former patients were diagnosed stage iva at the time of primary surgery. one patient died from sudden death. conclusions: our data suggested that routine use of sems insertion was safe and effective procedure for malignant colorectal obstruction as a bts. moreover, laparoscopic procedure was useful procedure in bts patient. the short-and long-term surgical outcomes were also acceptable. introduction: serpin e , also known as plasminogen activator inhibitor- (pai- ) is an inhibitor of urokinase type plasminogen activator (upa) and tissue-type plasminogen activators (tpa ). pai- plays a role in the regulation of angiogenesis, wound healing, and tumor cell invasion; over expression has been noted in breast, esophageal, and colorectal cancer (crc). pai- is also a potent regulator of endothelial cell (ec) proliferation and migration in vitro and of angiogenesis and tumor growth in vivo. the plasminogen/plasmin system plays a key role in cancer progression by mediating extracellular matrix degradation and tumor cell migration. surgery's impact on plasma pai- levels is unknown. this study's purpose was to measure plasma pai- levels before and during the first month after minimally invasive colorectal resection (micr) for crc. objectives: retroflexion in the rectum at the end of a colonoscopy is a requirement for a complete endoscopic evaluation. retroflexion helps to visualize and detect polyps which would be missed otherwise. currently new endoscopes are available which can do retroflexion in the caecum. aim: our study aims to compare the rate of polyp detection rate in cecum and ascending colon with and without retroflexion in cecum. methods: this is a single center, single operator, retrospective study. a total of two hundred patients were involved. a single center irb waiver was obtained. patients were divided into two groups based on the presence/absence of retroflexion in caecum during their colonoscopy. the data was obtained from records. group a (n= ) had colonoscopy without retroflexion in caecum group b (n= ) had colonoscopy with retroflexion in caecum inclusion criteria: patients undergoing screening colonoscopy between the age of and . results: group a: total of patients were screened. a total of polyps were detected in group a. number of cecal polyps were ( . % of total polyp count). number of ascending colon polyp were ( % of total polyp). on analyzing the pathology % of the cecal polyps were tubular adenoma, % hyperplastic polyps % and % lymphoid aggregate. number of ascending colon polyps were , of which % were tubular adenoma, % tubular adenoma and % tubulovillous adenoma group b: total of patients were screened. a total of polyps were detected. number of cecal polyps detected were ( . % of total polyp count). number of ascending of ascending colon polyps were ( %). on analyzing pathology, % cecal polyps were tubular adenoma and % were sessile serrated. out of the ascending colon polyps % were tubular adenoma, % sessile serrated, % tubulovillous and % hyperplastic polyp. side events: two mass lesions were noted in both group a and b. there was incomplete colonoscopy in group a and b. conclusion: this retrospective analysis reveals a small increase in polyp detection in the cecum with retroflexion, especially in detecting sessile polyps which have more malignant potential. however, a large multicenter analysis will be required to validate the above observation. background: while uncommon, rectal prolapse is a disabling condition affecting older females. in a small subset of patients, concomitant organ prolapses with or without incarceration can lead to significant morbidity. as the field of laparoscopy has evolved, minimally invasive surgical options for rectal prolapse have led to improved quality and reduced morbidity for patients suffering this debilitating disease. methods: the - acs-nsqip databases was queried for patients undergoing a traditional or minimally invasive rectopexy based on cpt codes ( , , , and ) . emergent cases and patients with preoperative infections or inflammatory states were excluded. the primary outcome of interest was a -day postoperative composite morbidity score. statistical analysis incorporated multivariate analysis and binomial logistic regression with p. holding significance. results: these inclusion and exclusion criteria identified patients undergoing traditional ( ) and minimally invasive ( ) rectopexy for prolapse between and . patients undergoing traditional rectopexy were older (p. ), had a higher body mass index (p= . ), more comorbid conditions (diabetes, copd, hypertension) and less functional independence (p= . ). patients undergoing a traditional rectopexy had a higher composite morbidity incidence of . % vs. % for minimally invasive rectopexy (p. ). specifically, minimally invasive rectopexy patients had a . % reduction in wound complications (p= . ) and a shorter hospital stay ( . days vs. . days, p . ) compared to a traditional rectopexy. readmission rates were also . % lower in the minimally invasive group (p= . ). after controlling for the differences in the cohorts, a minimally invasive approach was a significant protective factor against the incidence of -day postoperative morbidity (or . , p. ). conclusion: a minimally invasive rectopexy has improved -day postoperative morbidity compared to a traditional rectopexy and should be strongly considered for the treatment of rectal prolapse. objectives: the short-term safety and efficacy of a self-expandable metallic stent (sems) placement followed by elective surgery, "bridge to surgery (bts)", for malignant large-bowel obstruction (mlbo) have been well described. the aim of this study was to investigate the risk factors for postoperative complications and optimal interval between sems placement and surgery in patients with mlbo. methods: retrospective examination of patient records revealed that the bts strategy was attempted in patients with mlbo from january to march in our institution. two of these patients were excluded because they had undergone emergency surgery for sems migration; thus, patients with mlbo who had undergone sems placement followed by elective surgery were included. of these patients, eight had developed postoperative complications (clavien-dindo grading≥ii) (postoperative complication: poc group) whereas patients had no such complications (no poc group). results: univariate analyses showed that the factors of asa score, number of lymph nodes resected, interval between sems and surgery, and preoperative albumin concentration were associated with postoperative complications. multivariate analysis identified only the interval between sems and surgery as an independent risk factor. furthermore, a cut-off value of days for interval between sems and surgery was identified by roc curve analysis. conclusions: an interval of ≥ days from sems placement to surgery is an independent predictive factor for postoperative complications in patients undergoing elective surgery in a bts setting. thus, an interval of over days is recommended for minimizing postoperative complications. haseeb kothar, ronan cahill; mater misericordiae university hospital current clinical advances in operative near-infrared visualisation of cells, tissues and structures are predicated on the use of commercial available near-infrared cameras to excite and visualise emission energy from non-selective, approved compounds (predominantly indocyanine green (icg)). it is expected that new generation compounds wholly selective for specific cellular components are now needed for further advance and a variety of molecular targets have been proposed and are being developed primarily for oncological imaging purposes. recent publications have however suggested icg itself is retained within malignant tissue differently to its uptake and clearance from surrounding non-malignant tissue which is important for two reasons. firstly, it exploits and makes visual the increased vascular permeability and disordered clearance associated with carcinogenesis which is a common endpoint of a variety of mediators including but not limited to vegf. this raises the useful option of targeting downstream effects of cancer compounds on a metabolic basis as opposed to tagging individual cell or antigen components. this means that a single agent could be used to target a variety of cancers rather then needing a specific one for each specific sub-type as well as obviating the issue of cancer cells heterogeneity even in a single cancer deposit. second, it is very likely that some or all of the "localisation" effect of proposed selective compounds may well be due to a similar phenomenum rather then cell-specific binding and may make distinction from other areas of similar metabolic behaviour (ie inflammatory regions) difficult. the crucial step-advance for such agent development so may well relate to timing of compound delivery and "visualisation window" at the region of interest rather then highly selective oncocellular-targeting. to illustrate this in more detail, we have been examining the tissue-specific effects and actions of near-infrared excitation in patients (n= ) with localised malignant colorectal primaries receiving an aliquot of icg before such examination at the time of resection. icg can be selectively apparent in the colorectal primary minutes after its systemic administration likely due to altered vascular dynamics. additional dose-related work has shown that early administration ( - minutes before examination) does not give useful information related to tumour fluorescence. interestingly none of these patients had fluorescence seen within their regional lymphatics but none also had malignant lymph nodes associated with their large primaries on pathological examination. however, this procedure is not usually performed in laparoscopic apr for its technique difficulty, which may lead to increased rates of complications ( fig. ) . here, we compared the feasibility and peri-operative outcomes of the laparoscopic apr with and without pelvic peritoneum closure (ppc) for lower rectal cancer. introduction: there are reports of increased operative duration, blood loss and postoperative morbidity, caused by difficulties in obtaining good visualization and in controlling bleeding when laparoscopic resection is performed in obese patients with colon cancer. purpose: the aim of this study was to investigate the impact of obesity on perioperative outcomes after laparoscopic colorectal resection performed by various operative methods in our department. patients and methods: we conducted a retrospective analysis of patients with colorectal cancer who underwent laparoscopic surgery between january to december . right colectomy was performed in patients, sigmoidectomy in patients, and low anterior resection in patients. the surgical outcomes were compared between non-obese (body mass index [bmi]\ kg/m ) and obese (bmi ? kg/m ) patients. results: right colectomy cases: the amount of blood loss was significantly increased in the obese group compared with the non-obese group, but operation time did not differ significantly between the groups. there were no significant differences between the two groups in the rate of postoperative complications and duration of post-operative hospitalization. sigmoidectomy cases: there were no significant differences between the two groups in operation time and amount of blood loss. even though the preoperative asa score and the rate of postoperative complications were higher in the obese group, the mean postoperative hospital stay did not differ significantly between the two groups. low anterior resection cases: there were no significant differences between the obese group and the non-obese groups in operation time, amount of blood loss, rate of postoperative complications, and duration of post-operative hospitalization. discussion: although there are some reports of increased operative times in obese patients, the operative procedure was not extended in any of the present study patients. the amount of blood loss was significantly increased in the obese group compared with the non-obese group when right colectomy was performed. among the patients undergoing sigmoidectomy, the postoperative rate of complications was higher in the obese group; however, the preoperative asa status was also higher in the obese group than non-obese group, indicating that factors other than obesity may be involved. conclusion: we concluded that laparoscopic colorectal resection appeared to be safe and feasible in both obese patients and non-obese patients. however, bmi may not accurately reflect the amount of visceral fat present. background: for the complete rectal prolapse (basically longer than cm), we thought sling rectopexy was most reasonable to hang up and fix the rectum, which drooped down and prolapsed due to the relaxation of supporting tissue. we considered ripstein method had enough fixed power of rectum to sacrum. however, complications of rectal stenosis, constipation, mesh infection and mesh penetration were reported. therefore, we modified ripstein method to conquer such complications. aim: a prospective study beyond the randomized control trial (rct) between our modified ( introduction: the results of the japan clinical oncology group (jcog) study suggested that total mesorectal excision (tme) and lateral lymph node dissection (llnd) could become the standard treatment for lower rectal carcinoma. however, llnd must also be performed laparoscopically if surgery for lower rectal carcinoma is to be carried out as a completely laparoscopic procedure. transanal tme (tatme) is expected to provide better results than the conventional tme, both oncologically and in terms of pelvic function, and its use has recently been spreading in japan. we started performing laparoscopic tatme+llnd in our department in july and here report the short-term outcomes. subjects and methods: we used laparoscopic tatme+llnd to treat men and women with ct or deeper rectal carcinoma in whom the inferior margin of the tumor was on the anal side of the peritoneal reflection. this was a retrospective study of short-term postoperative outcomes. surgical procedure: laparoscopic surgery was started simultaneously by two teams, one working transabdominally and the other working transanally. the transabdominal team performed the standard proximal llnd and mobilization of the splenic flexure via five ports. they then dissected the bilateral lateral lymph nodes, mainly in the obturator (# ) and internal iliac (# ) groups. during this time, the transanal team performed laparoscopic tatme. finally, both dissection layers were connected and the cancer was excised. results: six patients had clinical stage ii and two had clinical stage iii lower rectal carcinoma. all the patients underwent preoperative chemotherapy with s- +l-ohp. five underwent a sphincterpreserving surgery, and three underwent rectal amputation. the mean operating time was minutes (range, - minutes), and the mean amount of hemorrhage was g ( - g). the mean number of lymph nodes dissected was , and r resection was performed in all the cases. the mean length of hospital stay was days, and a postoperative complication of clavien-dindo grade iii or higher occurred in one patient (anastomotic failure). conclusions: laparoscopic tatme+llnd performed by two teams simultaneously is an extremely useful procedure that not only reduces operating time, but also is less invasive than laparoscopic surgery. it may also be effective for improving curative nature, nerve preservation, and anal function. objective: in laparoscopic appendectomy, the base of the appendix is usually secured by applying a roeders knot. the aim of this study was to compare the advantages of using staplers and hem-olocks for securing the base of the appendix. method: the study included patients between age of to years with acute appendicitis randomly divided into two groups. in the first group, the base of the appendix was secured using roeders knot. in the second group, mesoappendix was not dissected and was included in the endostapler jaws. the primary outcome was overall morbidity. secondary outcomes were total duration of surgery, total length of stay and ease in difficult cases. result: no morbidity was recorded in any group. the time of the operative procedure was significantly longer in the cases with roeders knot than in the stapler group (p. ) as mesoappendix was not dissected in the later. cases with unhealthy base were progressed to laparoscopic quadricolectomy. apart from the ease of applying a stapler, cases of second group with gangrenous base were easily tackled using endostapler, avoiding the need of a hemicolectomy. conclusion: all forms of closure of the appendix base are acceptable, but endostapler technique apart from providing a secure base, reduces operative time and is an essential tool in cases of gangrenous base. introduction: accurate staging is essential to estimate the prognosis of patients with colorectal cancer (crc) and lymph node evaluation is key to determine it. in non-metastatic crc, the number of harvested lymph nodes is the strongest prognostic factor for outcome and survival. additionally, it is thought that a higher lymph node yield may be representative of a higher quality of surgical care. due to the importance of the association between lymph node evaluation and outcome in crc, it is necessary to evaluate factors which may affect lymph node harvest. introduction: hatmann's procedure is commonly done in treating complicated diverticulitis, negleccted rectal trauma with sepsis and sometimes malignancy. the traditional techniques to restore the intestinal continuity after hartmann's procedure were for many years the standard of care in these operations, but in fact they carry many morbidity and even mortality and failure. laparoscopic techniques is not only carry the advantage of minimal invasive surgery, but also of better visualizationn and magnification. the aim is evaluating the outcome of using the laparoscope in reversal of hartmann's procedure as regard feasibility and safety. patients and method: forty patients were subjected to laparoscopic reversal of hatmann's procedure in tanta university hospital, there ages ranged between to years, the time elapsed after the original operation ranged from months to years, excluding advanced malignany. conversin occurred in cases due to extensive adhesions and bleeding. results: no mortality, or major morbidity in our study and only single leak treated by covering ilestomy. conclusion; laparoscopic hartmann's procedure is feasible, promising tehnique with minimal morbidity. background: minimal invasive surgery has been well established in the elective colorectal surgery and it has been proven better clinical outcome compared with open surgery. in the emergent setting, laparoscope is used mostly in the colecystectomy, appendectomy but laparoscopic emergent colorectal surgery is limited for it's complexity and difficulity. the aim of this study was to envaluate the feasibility of laparoscopic emergent colorectal surgery. methods: this study is prospective collected, observational single center study of patients undergoing laparoscopic emergent colorectal surgery from to . the patient demographics, surgery indication and detail, complication, clinical outcome and hospital stay were collected and analyzed. results: there are total emergent colorectal operations and patients were managed with minimal invasive method. among these laparoscopic emergent surgery, there are male patients and female patients. mean age of the patients was . years (range - years). the main indication for operation: perforation . % ( / ), leakage after elective colorectal surgery . % ( / ), obstruction . % ( / ), ischemia colitis . % ( / ,), bleeding . % ( / ). there are cases in asa , cases in asa , cases in asa . the qsofa score for sepsis: cases was , cases was , cases was , case was . there are cases undergoing laparoscopic lavage with diverting stomy, cases were hartmann procedure, cases were anterior resection, cases were right hemicolectomy, cases were perforation repair, cases were redo anastomosis. there are cases coversion to open method including cases were due to bowel adhesion, cases were due to bowel distension, case was due to severe shock status. mean operative time is . minutes. the overall mortality rate was . % and major complication rate (clavien-dindo grade above ) was . %. re-operation rate was . %. the mean hospital stay was . days. conclusions: this study presents evidence of an initially clinical outcome in emergent laparoscopic colorectal suregry. in the absence of large case series, the benefits of a laparoscopic approach should befall to at least a minority of these patients. confocal laser endomicroscopy (cle) can provide real-time observation of the cell structure and tissue morphology. in our study, we aim to assess the situation of anastomotic perfusion using cle. method: the experimental rabbits were separated into two groups: group a (good anastomotic perfusion, n= ), group b (poor anastomotic perfusion, n= ). the partial colectomy and anastomosis was performed for group a and b. then detection for anastomotic perfusion using cle was carried out after the surgery. during the continuous scanning, we counted the number of blood cells that cross over the certain point of anastomotic stoma in the same period. results: assistant with fluorescein sodium, the blood vessels are highlighted. we can see significant difference of imaging effect between group a and group b. the average number of blood cells are . /min of group a and . /min of group b (p. ), which has significant difference. conclusion: cle can allow real-time observation of the blood flow of anastomotic stoma in vivo. therefore, it is feasible to assess the anastomotic perfusion using cle in colorectal surgery. cigdem benlice, ahmet rencuzogullari, james church, gokhan ozuner, david liska, scott steele, emre gorgun; cleveland clinic background: intraoperative colonoscopy (ioc) is an adjunct in colorectal surgery (crs) especially in patients with malignancies in order to detect location of the primary or synchronous lesions as well as assessing anastomotic integrity. however, effects of intraoperative colonoscopy on short term outcomes during crs is a concern. this study aims to evaluate safety and feasibility and post-operative outcomes of intraoperative colonoscopy in left-sided colectomy patients for colorectal cancer patients by using the nationwide database. patients and methods: patients undergoing elective left-sided colectomy with low pelvic anastomosis without any proximal diversion for colorectal cancer were reviewed from the american college of surgeons national surgical quality improvement program (acs-nsqip) proceduretargeted database ( ) ( ) ( ) according to their primary procedure current procedural terminology (cpt) code. subsequently, patients who underwent intraoperative colonoscopy were identified from concurrent cpt codes and divided into two groups based on the simultaneous intraoperative colonoscopy. demographics, comorbidities, -day postoperative complications were evaluated and compared between the groups. multivariate logistic regression was conducted adjusting for significant factors between the groups. results: a total of patients were identified and ioc was performed for ( . %) patients. objective: laparoscopic ileostomy commonly performed for the patients with colorectal obstruction due to cancer, peritonitis with perforation of colon or the other reason. reduced port surgery is a novel technique that may be performed when considering minimally invasive surgery and desiring a cosmetic benefit. the aim of this study was to evaluate safety and feasibility of reduced port laparoscopic ileostomy for the patients with advanced colorectal cancer before chemotherapy. methods: between july and august , patients who underwent reduced port laparoscopic ileostomy were included ( male and female, age: years old. the outcomes were evaluated in terms of operation time, intraoperative blood loss and perioperative complications. sugical procedures: the patients were placed in the supine position and the operator stood left side. an access device with the wound-protector (ez access, hakko, nagono, japan) was inserted on the future ileostomy site in the right lower abdomen, inserting two of -mm trocars, maintaining pneumoperitoneum at mmhg with carbon dioxide. a -mm trocar was inserted in the left lower abdomen. a -mm flexible laparoscope was inserted from access device port. after exploring abdominal cavity, ileum end was identified. then the marking using dye was put on the ileum of cm proximal from the ileum end. the ileum marked by dye was grasped, and extracted through the access devise. then a blooke ileostomy was created. results: reduced port laparoscopic ileostomy was performed for patients with colorectal obstruction due to cancer before chemotherapy. the mean operative time was minutes, the mean blood loss was . ml. three patient received one additional port. there were no intraoperative complications. five patients ( . %) experienced postoperative complications (two of deep surgical site infection, one of pneumonia, one of outlet obstruction and one of renal dysfunction). there were no other intraoperative or postoperative complications. conclusion: reduced port laparoscopic ileostomy is a safe and feasible procedure for the patients with advanced colorectal cancer before chemotherapy. methods: we performed elective lcr on patients for primary colorectal cancers between june and june . seventy-two patients were excluded in this study following reasons: patients underwent multiple organ resection, and colorectal cancer was diagnosed with stage iv in patients. accordingly, patients were eligible for comparative analysis, with in group po (post operation) and in group c (control). in group po, past operative procedures were as follows: appendectomy ( %), digestive tract ( %), hepato-billiary-pancreatic ( %), gynecologic ( %), urologic surgery ( %), and others ( %). results: there were no significant differences between two groups in asa (grade≤ : vs. %, p= . ), bmi ( introduction: the treatment of rectal cancer requires highly skilled practice by the entire multidisciplinary team. important aims of treatment are: to reduce the risk of residual disease in the pelvis, with lower morbidity and to preserve good sphincter function. the tata procedure is transanal transabdominal radical proctosigmoidectomy with coloanal anastomosis. this technique was first developed in by dr. gerald marks to avoid a permanent colostomy for low-lying rectal cancer. this study reports the long-term results of tata procedure for low rectal cancer. methods and procedures: a prospective study was on patients with low rectal cancer between april and july in a tertiary referral university-affiliated center specializing in laparoscopic surgery. all resections were carried out by a team of dedicated colorectal surgery and standard protocol was used for all pre-and-post-operative care. all the patients underwent total mesorectal excision. results: consecutive patients ( male, female, mean age ) underwent tata procedure, of them ( , %) after neoadjuvant radiochemotherapy. the mean operation time was min (range - ) and the mean estimated blood loss was ml (range - ). the overall incidence of morbidity was , % ( / ) and the mean hospital stay was , days. the mean follow-up period was , (range, - ) months with a recurrence rate of , % ( / ), overall estimated -year survival , % and the disease-free survival rate , %. conclusion: laparoscopic total mesorectal excision with tata procedure is safe with excellent local recurrence and disease-free survival rate. jacek piatkowski, md, phd, marek jackowski, prof; clinic of general, gastroenterological and oncological surgery introduction: more than years ago, laparoscopic technique was considered to be a fully accepted surgical method for treatment of rectal cancer. the following years are a further search for a new surgical method that reduces invasiveness and improves treatment outcomes. it seems that such a method is transanal total mesorectal excision. the aim of this study was to evaluate the new method of rectal cancer surgery (tatme) after years of its use. methods: radicality of treatment (r resection, local recurrence), outcome of surgical treatment and quality of life of patients after surgery were evaluated. results: in the period from . . . - . . . patients ( men, women) were operated in the clinic. in cases the indication for surgery was lower and middle rectal cancer and in cases high grade dysplasia. all patients underwent laparoscopic rectal proctectomy with transanal access (tatme). in all cases, complete oncological radicalization (resection r ) was obtained. the average operation time was minutes. we had used two teams approach (cecil approach) with laparoscopic sets -abdominal and perineal starting at the same time. in the postoperative course, patients had signs of anastomosis leak ( of them required reoperation). the follow-up period is - months. none of the patients had any recurrence of cancer. conclusions: . transanal tme for rectal cancer surgery is an alternative method to conventional laparoscopic surgery. . in a large proportion of patients with lower and middle tumors, the rectum can avoid abdomino-perineal resection with permanent colostomy. background: the double stapling technique (dst) has widely spread colorectal anastomosis especially for anastomosis after low anterior resection. as for the colorectal cancer treatment, heald reported total mesorectal excision (tme) in , and has been accepted as the standard technique for rectal resection due to the decreased local recurrence rate and improved functional results. with advent of dst, there is a background that it has become possible to preserve anus, even in the case with the lesion at lower rectum. laparoscopic surgery for colon cancer was introduced in the s, and has had promising results including long-term outcomes. according to the spread of laparoscopic surgery, laparoscopic surgery had been applied to the rectal resection, with technical difficulty. one of the reasons for the difficulty is that the high rate of anastomotic leakage, a critical adverse effect of low anterior resection (lar). thus, risk factors for anastomotic leakage were widely discussed, including technical factors such as pre-compression and number or firing. the decisive difference in conventional lar and laparoscopic lar in dst, is the stapler used for transection of the rectum. the laparoscopic staplers which are currently available are thought to be not ideal, and there is little evidence of specific specifications of stapler for laparoscopic surgery. materials and methods: all method described in this study was approved by the institutional ethical review committee. we reviewed the colon and rectal wall thickness according to histological examination using h&e staining of distal margin of resected specimen of the patients who conclusions: rstc for severe acute uc is at least as safe as the laparoscopic approach. although the robotic cohort had more comorbidities, major postoperative complications, readmissions, and reoperation rates were less when compared to lstc. rstc was also associated with an earlier return of bowel function and shorter length of stay. a prospective study with larger numbers is needed to see if the superiority of robotic versus laparoscopic approaches is reproducible. s surg endosc ( ) introduction: complete mesocolic excision (cme) has been advocated based on oncologic superiority, but is not commonly performed in north america. furthermore, many data are limited to case series with few comparative studies. therefore the objective was to systematically review studies comparing the short-and long-term outcomes between cme and non-cme colectomy for colon cancer. methods: a systematic review was performed according to prisma guidelines of medline, embase, healthstar, web of science, and cochrane library. studies were only included if they compared conventional resection (non-cme) to cme for colon cancer. quality was assessed using the methodological index for non-randomized studies (minors). the main outcome measures were short-term morbidity and oncologic outcomes. study eligibility, data extraction and quality assessment was performed by two independent reviewers, and disagreements resolved by consensus. weighted pooled means and proportions with %ci were calculated using a randomeffects model when appropriate. results: out of citations, studies underwent full-text review and met the inclusion criteria, of which were unique series. mean minors score was . (range - ). the mean sample size in the cme group was (range - ) and (range - ) in the non-cme group. in the unique studies, included only right-sided resection, and . % ( % ci . - . ) of the remaining were right-sided colectomies. of the studies that reported surgical approach, . % ( %ci . - . ) of cme were performed laparoscopically. there were papers reporting plane of dissection, with cme plane achieved in . % ( . - . ). mean or time in cme group was minutes (range - ) and in non-cme group minutes (range - ). perioperative morbidity was reported in studies, with pooled overall complications of . % ( %ci . - . ) for cme and . ( %ci . - . ) for non-cme resections. anastomotic leak occurred in . % ( %ci . - . ) of cme versus . % ( %ci . - . ) in non-cme colectomies. cme surgery consistently resulted in more lymph nodes retrieved, longer distance to high tie, and specimen length. there were studies that compared -or -year overall or disease-free survival, or local recurrence. only studies reported statistically significant higher disease-free or overall survival in favour of cme. local recurrence was lower after cme in of reported studies. conclusions: the quality of the current evidence is limited and does not consistently support the superiority of cme. more rigorous data are needed before cme can be recommended as the standard of care for colon cancer resections. gilberto lozano dubernard, md, facs, ramon gil-ortiz, md, gustavo cruz-santiago, md, bernardo rueda-torres, md, javier lopez-gutierrez, md, facs; hospital angeles del pedregal introduction: to assess the feasibility of a single-stage colorectal laparoscopic re intervention without ostomy. colonic laparoscopic interventions on patients that previously underwent a minimally invasive procedure, constitutes the current boundary in the management of the acute colorectal pathology. that includes, patients with fecal peritonitis due to diverting procedures already treated surgically. the outcome of our patients could significantly improve if the surgical procedure is performed in one time, with no stoma. method and procedures: from september to june , one hundred thirty-two patients underwent colorectal laparoscopic surgery. five of these patients developed complications: three perforations due to colonoscopy and two due to dehiscence of the anastomosis. these five patients underwent a second laparoscopic procedure that included resection and anastomosis. no stoma required. results: all five patients underwent a second laparoscopic procedure due to an anastomosis leak. no stoma was required. the procedure consisted on resection of the previous anastomosis, re anastomosis, abdominal lavage, aspiration and drains placement. all of them supported with parenteral nutrition. there were no surgical complications. only one patient developed pneumonic symptoms that were solved. conclusion: the reported results, regarding no conversion rate, nor mortality, on our series of patients, suggest that single stage laparoscopic re intervention is feasible, despite fecal peritonitis. introduction: total mesorectal excision is known to be a gold standard surgical procedure for the rectal cancer. subsequently complete mesocolic excision (cme) is recognized as an essential surgical procedure for the colon cancer. the transverse colon is relatively minor location for colon cancer. variety of vessels and mobilization of splenic flexure and dissection close to pancreas make operations for the transverse colon cancer complicated. laparoscopic transverse mesocolic excision in our hospital is presented. method: laparoscopic surgery is conducted with five trocars under the lithotomy position. inferior mesenteric vein is cut after dissection of the descending colon with medial approach. the lower edge of pancreas is exposed near the inferior mesenteric vein and is dissected along toward the tail of pancreas. the splenic flexure is mobilized with lateral approach and the dissection between transverse mesocolon and the lower edge of pancreas is continued in the direction to the pancreas head. coming to the exposure of superior mesenteric artery and vein, the origin of middle colic artery and vein are cut. the transverse mesocolon is separated from the pancreas head and the duodenum with preserving the gastrocolic trunk of henle and the right gastroepiploic vein. the hepatic flexure is mobilized and cme for the transverse colon is finished. this method, the 'tail to head of pancreas' approach, we called, was performed from september . this method is well performed with one series of surgical view, and seems to be a simple procedure as cme with central vascular ligation for the transverse colonic cancer. there were no intraoperative complications, and one postoperative pancreatitis with grade ? of clavien-dindo classification of surgical complications. conclusion: our method, the 'tail to head of pancreas' approach, with transverse mesocoloc excision is simple, safe and feasible. the introduction: anastomotic complication after stapled anastomosis in colorectal cancer surgery is a considerable problem. there are various types of anastomotic complication and they have different severity. this study was aimed to evaluate the impact of intraoperative colonoscopy on detection of anastomotic complication, and its effectiveness in treatment of anastomotic complications after anterior resection (ar) and low anterior resection (lar) for colorectal cancer intraoperatively. methods: from dec. to jul. , a total of patients who underwent anastomosis between sigmoid colon and rectum after colorectal resection were reviewed retrospectively. intraoperative colonoscopy was performed routinely since december in our hospital after anterior resection and low anterior resection. to identify effectiveness of intraoperative colonoscopy, we compared postoperative complications with non-intraoperative colonoscopy group during previous months. intraoperative colonoscopy was performed after anastomosis to visualize the anastomosis line and to perform an air leakage test. if anastomotic defect and moderate bleeding were found in intraoperative colonoscopy, it was managed by means of reinforcement suture or transanal suture repair. we used logistic regression to analyze anastomotic complication between two groups with or without intraoperative colonoscopy. results: of the patients who were performed intraoperative colonoscopy after ar (n= ) and lar (n= ), abnormal findings including bleeding and air leak were found in patients ( . %). among those, cases were observed without any procedure, additional procedures were performed in patients ( . %, transanal suture ( ), lembert suture ( )). postoperative complication was developed in patients; patients had anastomosis bleeding ( . %), patients had ileus ( . %), patient had pneumonia ( . %), patients had minor complication ( . %, acute urinary retention, chylous drainage, laparoscopic port site bleeding). among patients who had anastomosis bleeding, patients were treated by endoscopic clipping, patients were cured by conservative treatment. there was no postoperative anastomotic leakage. the cases of ar and lar were and in non-intraoperative colonoscopy group, there was no significant difference between two group (p= . ). the proportion of laparoscopic surgery was . % and . % on intraoperative colonoscopy and non-intraoperative colonoscopy group, respectively, there was significant difference statistically (p= . ). however, there was no significant difference in anastomotic complication rate between two groups. (rr= . , % ci, . - . ). conclusions: although there was no significant difference in postoperative anastomotic complication rate between two groups, intraoperative colonoscopy may be valuable method for decreasing postoperative complication by visualizing anastomosis line and performing additional procedure. conclusion: it was suggested that lymph node dissection of both middle and left colic regions is necessary for splenic flexure colon cancer, because lymph node metastasis was recognized in both region. surg endosc ( ) :s -s the aims: laparoscopic right hemicolectomy became the standard of care for treating cecum, ascending and proximal transverse colon cancer in many centers. most centers use laparoscopic colectomy with extracorporeal resection and anastomosis (lc). single-incision laparoscopic colectomy with intracorporeal resection and extracorporeal (sc) remains controversial. the aim of the present study is to compare these two techniques using propensity score matching analysis. methods: we analysed the data of patients who underwent laparoscopic right hemicolectomy with lc or sc between december and december . the propensity score was calculated from age, gender, body mass index, the american society of anesthesiologists score, previous abdominal surgery and d lymphnode dissection. short-term outcomes were recorded. postoperative pain was evaluated using a visual analogue scale (vas) and postoperative analgesic use as outcome measure. results: the length of skin incision in the sc group was significantly shorter than in the lc group: median (range) ( . - ) cm verses ( - ) cm (p= . ). the vas score on day and day after surgery was significantly less in the sc group than in the lc group: median (range) ( - ) verses ( - ) on day (p= . ) and median (range) ( - ) verses ( - ) on day (p= . ). significantly fewer the number of requiring analgesia in the sc group on day and day after surgery: median (range) ( - ) times verses ( - ) times on day (p= . ) and ( - ) times verses ( - ) times on day (p= . ). there were no significant differences in operative time, intraoperative blood loss, the number of lymph nodes removed and postoperative courses between the groups. conclusions: sc for right colon cancer is safe and technically feasible. sc reduces the length of skin incision and postoperative pain compared with conventional lc. patients were divided into the following groups: cephalo-medial-to-lateral approach group (cml group, n= ) and medial-to-lateral approach group (ml group, n= introduction: laparoscopic technique has been widely used in the treatment of colorectal cancer, while playing its minimally invasive advantages, but also achieved a good effect of radical oncology. however, t colorectal cancer is not recommended laparoscopic surgery. methods: retrospectively collected pt colorectal cancer data from to in guangdong general hospital, all cases were undergoing radical surgery. results: a total of cases were enrolled in the pt group, including cases of laparoscopic group, cases of open group, conversion rate was . %. there was no difference in baseline data (age, sex, bmi, asa, etc.)(p. ). there was a significant difference between the two groups (p. ) in blood loss, postoperative complications and postoperative recovery index. in the pathologic t a/b, combined-organ resection, postoperative recurrence, the laparotomy group had more cases, and there was a statistically significant difference between the two groups (p\ . ). the -and -year overall survival rates were . % and . % for the lap group and . % and . % for the open group (p= . ). meanwhile, the -and -years disease-(p= . ). iiic stage, lymph node status, ca - and adjuvant chemotherapy were independent prognostic factors affecting overall survival. the age, pt a/b, iiic stage, ca - and adjuvant chemotherapy were independent influencing factors of disease-free survival. conclusions: laparoscopic surgery for pt colorectal cancer surgery, it is not only in the play of its minimally invasive but also obtained with the similar long-term effect. but we need more multicenter, prospective, and large sample clinical studies to validate our findings. introduction: lymph node (ln) retrieval after surgery is important. in the present study we evaluated the efficacy of the fat dissolution technique using fluid containing collagenase and lipase to avoid staging migration after laparoscopic colorectal surgery. methods: seventeen patients who underwent laparoscopic ln dissection for colorectal cancer were evaluated. first, unfixed lns within the resected mesentery were explored by visual inspection and palpation immediately after the operation by the surgeon, which is the most common practice in japan. subsequently, the fat dissolution technique was used on remnant fat tissue, and the lns were evaluated again. the primary endpoint was whether the second assessment increased the number of lns evaluated. results: the median number of lns identified at the first and second assessments was and , respectively, resulting in a significant increase in the total number of lns evaluated ( vs. , p\ . , paired t-test). one positive node was identified among all the additional lns identified ( . %; / ). although staging was not altered in any patient, the second assessment resulted in an increase in the originally insufficient number of lns evaluated (\ for stage ii) in three patients, whose treatment may be altered. tumor cells detected after the fat dissolution technique were stained with carcinoembryonic antigen and cytokeratin- . conclusion: using the fat dissolution liquid on remnant fat tissue of the mesentery of the colon and rectum enabled identification of additional lns. this method should be considered when the number of lns identified is not sufficient after conventional ln retrieval, and may avoid stage migration. aim: the aim of this study is to evaluate the pathological resection margin after laparoscopic intersphincteric resection for low rectal cancer. method: from to , there were eight laparoscopic intersphincteric resection cases for low rectal cancer. we evaluated the clinicopathological findings and the positivity of pathological resection margin. results: the median distance from the anal verge to the tumor was mm (range, - ), and the median diameter of the tumor was mm (range, - ). there was no case with neoadjuvant therapy. the estimated tumor depth were ct in cases ( . %) and ct in cases ( . %), and the actual tumor depth were ptis in cases ( . %) and pt in cases ( . %) and pt in cases ( . %). the median distal resection margin was mm (range, - ). pathological resection margin, such as the proximal, distal and circumferential margin was negative in all cases ( %). there was no mortality, but morbidity occurred in two cases (one case of anastomotic leakage and one case of small bowel obstruction). no recurrence nor distant metastasis was observed in the follow up period. conclusion: there was no positive resection margin case in the series. our patient selection, indication and the technique were considered to be precise and appropriate. introduction: the fistulas of the intestine to the vagina or the bladder include a highly morbid entity, with several functional limitation and loss of the quality of life, its diagnosis is complex and more than its treatment, which include a wide range of possibilities that go from the simple derivative colostomy in search of the spontaneous closure of the fistula, under the complete correction of the pathology with resections, anastomosis and mini-vasive reconstructions. give to know our experience in the minimally invasive treatment of whole vaginal and whole vesicial fistules by laparoscopic via, for the last years. results: a total of patients were operated in this period, women and men, all those by laparoscopic via, with intestinal resection, in thick intestine cases, in one small intestine and in another case with the commitment of the two, everyone restriction and intestinal anastomosis and in no matter were colostomy, primary closures of the fistula in patients were required, conversion to open surgery in a case and there was no recurrence, patients had prolonged hospitalization for localized infections, a requirement reintervencion for revision. a patient suffried a umbilical eventration for the extraction site, which was corrected one year after laparoscopy. conclusion: minimally invasive surgery in patients with this type of pathology becomes an excellent strategy for the integral management of these patients. group work guarantees good results. robbie sparks, dr, ronan cahill; mater misericordiae university hospital background: precise preoperative localisation of colonic cancer is a prerequisite for correct oncological resection. effective endoscopic lesional tattoo is vital for small, radiologically unseen tumors planned for laparoscopic resection but its practice may be imperfect. methods: retrospective review of consecutive patients with preoperative endoscopic lesional tattoo who underwent laparoscopic colonic resection identified from our prospectively-maintained cancer database with supplementary clinical chart and radiological, histological, endoscopic and theatre database/logbook interrogation. results: patients ( males, mean age years, median bmi . kg/m , left sided lesions, screen detected, benign polyps, % conversion rate). in operations ( %) tattoo visibility was documented with tattoo absence noted in ( . %) although tattoo was identifiable in the pathological specimen in four. in those with "missing tattoos", six of the lesions were radiologically occult and in three the tumor was found in a different colonic segment then had been judged at colonoscopy. four patients had on-table colonoscopy and five were converted to laparotomy ( % conversion rate, p. ). mean postoperative length of stay was . (range - ) days. one patient's segmental resection contained only benign pathology requiring a second operation to remove the cancer. on univariate analysis, time between endoscopy and surgery (but not patient age, gender, bmi, endoscopist or surgeon seniority, tumor size or location) was significantly associated with absence of tattoo intraoperatively (p= . ). conclusion: recording related to tattoo is variable but definite lack of gross tattoo visualisation significantly impacts the procedure. the mechanism of tattoo absence is multifactorial needing careful consideration but solvable. the aim of the present study was to perform a systematic review of the literature to determine the role of antibiotics in the management of acute uncomplicated diverticulitis (aud). diverticular disease is the most common disease of the large bowel and poses a significant burden on healthcare resources. in the united states alone, the cost of diverticular disease has been estimated to be over $ billion making it the fifth most important gastrointestinal disease economically. the use of antibiotics in the management of aud, however, is primarily based on expert opinion as current high-quality evidence is lacking. recent studies have not only questioned the optimal type and duration of antibiotic regimens, but whether antibiotics provide any benefit in the treatment of aud. conclusions: antibiotic use in patients with acute uncomplicated diverticulitis is not associated with a reduction in major complications, readmissions, treatment failure, progression to complicated diverticulitis, or need for elective and emergent surgery. however, it increases the length of hospital stay. given the risk of selection bias in included studies, further randomized trials are needed to clarify the need for antibiotics in uncomplicated diverticulitis. laparoscopic para-aortic lymph node resection for colorectal cancer aim: we want to highlight the feasibility of a sigmoidectomy using total laparoscopic with a transanal extraction of the specimen. methods: it is a -year-old female patient, obese (bmi= kg/m ) to the antecedents of laparoscopic cholecystectomy and chronic constipation. she was treated three months ago for a sigmoidal diverticulitis complicated with a pelvic abscess. the evolution has been favorable under antibiotic therapy and percutaneous drainage of the abscess. the colonoscopy showed a multiple diverticula located between and cm from the anal verge. prophylactic sigmoidectomy was performed laparoscopically using trocars ( mm supra ombilical, mm fid and mm right flank). the specimen was extracted transanally, thus avoiding a pubic incision. the steps of the intervention were: -mobilisation of left colon -closing of distal left colon stump -rectal stump lavage -opening on the rectum -transanal introduction of the anvil -specimen transanal extraction -closing og rectal stump -colonic positioning of the anvil -coloractal anastomosis. results: the intervention was minutes. no perioperative incidents. the liquid regime was authorized on the night of the intervention. the operating procedures were favorable with an exit to j post operative. the anapath examination of the surgical specimen confirmed the presence of sigmoidal diverticula. conclusion: laparoscopic sigmoidectomy with transanal extraction of the specimen for benign desease is a seductive technique with satisfactory results. it avoids a pubic incision with its parietal and aesthetic complications. chengzhi huang; guangdong general hospital (guangdong academy of medical science) background: colorectal cancer (crc) is one of the most common malignant diseases over the world. of the causes of the death of crc, metastasis to liver or lung are the major factors. however, there is still lack of precise tumor biomarker that precisely predict the clinical outcome of crc. the salt-inducible kinase (sik ) encodes a serine kinase of amp-activated protein kinase (ampk) family, which may play critical roles in tumorigenesis and tumor progression. this study aimed the study the expression and clinical significance of sik and crc patients. methods: the expression of sik protein was measured by western-blot and analysis of immunohistochemistry. sik mrna expression in cancerous tissue was measured by rt-pcr. results: the expression level of sik was correlated with the following factors: tumor invasion (t stages), lymph node metastasis, clinical stages (tnm) and tumor location. the down-regulated sik implies poor clinical outcome measured by kaplan-meier analysis (p-value. ), and may act as an independent risk factor of crc patients. background: surgical specimens for resected colon cancer vary in quality and there remains no universally accepted technique to guide resection margins. a minimum of lymph nodes provides some quality assurance, however this remains a crude marker of optimal oncological surgery. a tool to precisely identify lymphatic drainage within the mesentery could improve the oncologic quality of resection and better guide adjuvant treatment through more optimal mesenteric lymphadenectomy. while fluorescence imaging (fi) has been described to identify nodal disease in several other cancers, feasibility and best practices have not been established in colon cancer. we describe a novel technique of fi using indocyanine green (icg) to identify lymphatic spread and potentially guide optimal mesenteric lymphadenectomy in colon cancer. methods: three consecutive patients with colon cancer undergoing a laparoscopic resection had peritumoral subserosal injection of icg for fi after extracorporealization of the mobilized specimen. three concentrations of icg were injected − mg/ ml, mg/ ml, and mg/ ml. a total of ml was given for each patient. using a modified laparoscopic camera, the icg was excited by light in the near-infrared (nir) spectrum, for real-time visualization of the lymphatic drainage. the main outcome measure was identification of lymphatic drainage. results: three patients with right-sided primary colon cancer were evaluated. all three patients had successful identification of the lymphatic drainage pattern along the mesentery. the most successful protocol was ml (concentration mg/ ml) subserosal injection at points within close proximity ( cm) of the tumor with a -gauge needle, then waiting minutes for complete mapping. no intraoperative or injection-related adverse effects occurred with -day follow-up. the median lymph node yield was . all specimens had tumor-free margins. conclusion: from this small series, fluorescence imaging with icg is a potentially safe and feasible technique for identifying mesocolic lymphatic drainage patterns. this proof of concept and protocol will lead to future studies to examine the utility of fluoresence imaging to guide more precise surgery in colon cancer. introduction: anastomotic leakage in colon/rectal surgery is a dangerous event with an occurance rate ranging from to %. the associated mortality rate is between - %. the white-light intraoperative subjective surgical assessment (the most frequently used approach) underestimates the actual anastomotic leakage rate. intraoperative tissue perfusion assessment by indocyanine green (icg)-enhanced fluorescence has been reported in multiple clinical scenarios in laparoscopic/ robotic surgery, as well as for for bowel perfusion assessment. this technology can detect microvascular impairment, potentially preventing anastomotic leakage. we reviewed the literature and present our data to evaluate the feasibility and usefulness of icg-enhanced ?uorescence in the intraoperative assessment of vascular peri-anastomotic tissue perfusion in colorectal surgery. methods and procedures: a pubmed literature narrative review has been performed. moreover, out of a total of robotic colorectal cases, we retrospectively analyzed icg-enhanced fluorescence robotic colorectal resections ( left colectomies- rectal resections- right- transverse- pancolectomy). results: after icg-technology use, the biggest (n[ ) case-series showed a rate of . - % of cases in which they changed the level of resection based on icg. icg technology may variably reduce the anastomotic leak rate from to %. however, the threshold values to define the actual sub-optimal perfusion are still under investigation. in our experience, out of icg cases performed: the conversion, intraoperative complication, dye allergic reactionand mortality rates were all %. post-op surgical complications: case of leak ( , %) and sbo for incarcerated hernia ( . %). in cases, with normal white-light assessment, the level of the anastomosis was changed after icg showed ischemic tissues. despite the application of icg, anastomotic leak has been registered. conclusions: icg-enhanced ?uorescence may intraoperatively change the white-light assessed resection/anastomotic level, potentially decreasing the anastomotic leakage rate. our data shows that this technology is safe, feasibile and may prevent anastomotic leakage. however, the decision making is still too subjective and not data driven. at this stage icg, beside being a promising technique, doesn't have high level of evidence (most of the reports are retrospective). some randomized prospective trials with an adequate statistical power are needed. a precise injection dose and timing standardization is required. the main challange is to develop a method to objectively obtain a real-time intensity assessement. this may provide objective metric tresholds for an intraoperative evidence/data-based surgical decision making. introduction: according to the world health organization, colorectal cancer is the rd most commonly diagnosed cancer in the world. one of the main risk factors for the development of colorectal cancer is obesity. obesity is seen to increase the risk of colorectal cancer by % in women per kg/m and % in men per kg/m . bariatric surgery is one of the treatments that is considered to achieve and sustain a significant amount of intentional weight loss in patients. considering that fact that bariatric surgery decreases obesity, this intentional weight loss would seem to provide a favorable outcome in terms of diagnosis and prognosis of colorectal cancer. a systemic review of the literature was conducted via pubmed to identify relevant studies from january through may . the main outcome for this study is to assess whether patients who underwent bariatric surgery (restrictive and malabsorptive procedures) had an increased or decreased risk of colorectal cancer. all studies included in this meta-analysis are retrospective cohort studies. results were expressed as standard difference in means with standard error. statistical analysis was done using fixed-effects meta-analysis to compare the mean value of the two groups between bariatric surgery and non-surgery in patients with colorectal cancer. (comprehensive meta-analysis version . . software; biostat inc., englewood, nj). results: four out of studies were quantitatively assessed and included for meta-analysis. among the four studies, , underwent bariatric surgery and , did not undergo bariatric surgery. there is a significant decrease ( . ± . ; p= . ) in the risk in patients developing colorectal cancer in patients who underwent bariatric surgery compared to those who didn't get surgery. conclusion: bariatric surgery patients appear to have a decreased risk of colorectal cancer compared to patients who did not have bariatric surgery. guh jung seo, hyung-suk cho; department of colorectal surgery, dae han surgical clinic, gwangju, south korea introduction: the incidence of rectal carcinoid tumors is increasing due to the widespread use of screening colonoscopy. endoscopic mucosal resection (emr) is a useful method for small rectal carcinoid tumors (≤ mm) because of its simplicity, quick procedure and low complication rates. we aimed to describe our experience and evaluate the outcomes of emr for rectal carcinoid tumors. the patients enrolled in this study were patients with small rectal carcinoid tumors who underwent emr using a submucosal injection technique of epinephrinesaline mixture between august and october . all medical records, including characteristics of the patients and tumors, complications, were retrospectively reviewed. results: the patients were men and women, with a mean age of . years (range, - years). en block resection was performed by emr in all cases. the endoscopic mean size of tumors was . mm (range, - mm). the pathologically measured mean size of the resected specimens was . mm (range, - mm). the mean size of resected carcinoid tumors was . mm (range, . - mm). the tumor shape was submucosal tumor in and polyp in . histological examination revealed that cases had resection margin positive of tumor and case had undetermined resection margin of tumor. of the patients, patients underwent endoscopic treatment and patients underwent transanal excision. no residual tumor was found in additionally removed tissue. there were cases with emr-related complications: early postprocedural bleeding and postpolypectomy syndrome. there was no significant bleeding requiring blood transfusion or perforations. conclusion: endoscopic mucosal resection is considered to be a relatively safe and useful method for treatment of small rectal carcinoids in selected patients. background: disturbance of sexual function after an operation for rectal cancer has often occurred. the relationship between autonomic nerves and arteries in pelvis was examined. methods: clinical studies of male patients with resected rectal cancer were performed using snap gauge method, penile-brachial index and evoked bulvo-cavernous reflex. in canine experiments, pelvic splanchnic nerve (psn) electric stimulation, arterial flow measurement, corpus cavernosum pressure measurement and muscle strip study using drugs were evaluated. results: in clinical studies of male patients, transection of the hypogastric nerve (hgn) and the sympathetic trunk did not affect the erectile function in the postoperative course. in animal experiments transection of these nerves did not affect the increase in inner pressure of the penis cavernosum. in postoperative cases in which only one side of the lower grade branches of the psn (s ) were preserved, the erectile function was preserved. in animal experiments in which the psn of one side was disturbed, the ipa flow of the same side decreased, while the flow of the other side increased. we have evaluated the role of adrenergic components in the psn on the erectile function in the dog. the effect of norepinephrine hydrochloride on canine vascular smooth muscle was examined in vitro. vascular smooth muscle strips from the ipa relaxed longitudinally. electrical stimulation of the psn increased blood flow in the ipa and also elevated the cavernous pressure. these increases were blocked in part by phentolamine, but not by propranolol or atropine. the effects of cholinergic and adrenergic agonists and antagonists on mechanical responses were also examined in muscle strips obtained from various arteries in the intra-pelvic region including the ipa. norepinephrine induced contraction in the iliac artery and relaxation in the ipa, and both the contraction and relaxation responses were blocked by phentolamine but not by propranolol. these findings suggest that in the dog, α-adrenergic components projected through the psn may contribute to penile erection. conclusion: blood flow in the ipa was controlled significantly by the same side psn, but compensatory by the other side psn. it is also conceivable that the erectile function through the psn is controlled by the sympathetic nerve, not by the parasympathetic nerve. in postoperative cases in which only one side of the lower grade branches of the psn (s ) were preserved, the erectile function was preserved. introduction: currently, neoadjuvant chemo-radiotherapy (ncrt) followed by low anterior resection or abdominoperineal resection are the standard treatments for locally advanced rectal cancer. ncrt can improve resecability, achieve better sphincter preservation and reduce local recurrence. although total mesorectal excision is the standard treatment for advanced rectal cancer, recent trends in minimally invasive treatments led to an increase in local excision or "watch and wait" in patients with an excellent response to ncrt. the purpose of this study, part of an ongoing research, is critically evaluating the feasibility of "non-operative treatment" for rectal cancer in a district hospital. methods and procedures: a total of patients with rectal cancer, who where treated with ncrt from january to august at "carlo urbani" district hospital in jesi (italy), were retrospectively reviewed. all patients had histologically-confirmed primary adenocarcinoma of the rectum located within cm from the anal verge. the involved patients completed ncrt and had no recurrence disease, distant metastasis, synchronous malignancies. they were classified according to the mandard's tumor regression grade (trg) into two clusters: group a (trg - ) and b . results: the average age of people is . and were male. five patients underwent abdominoperineal resection and % fell within group a. six patients had lymph nodes involved. four patients suffered relevant complications, such as wound complication, anastomotic leak, operative reintervention and death. univariate analysis showed that the main predictors of tumor regression were the absence of lymph-nodes involvement from initial imaging (p. ), normal initial carcinoembryonic antigen level (p. ) and tumor downstaging in imaging (p. ). in addition, most relevant complications occurred to elderly patients although they observed a good clinical response. besides, % of patients were found to be complete pathologic responders upon examination of the surgical specimen. conclusions: the oncologic feasibility of non-operative management for the patients with complete clinical response after ncrt has been growing, but some studies have suggested lack of oncologic safety in these patients. the patients with a complete clinical response expect good survival, but they may still harbor residual disease. no consensus on "watch and wait" policy in the field of rectal cancer was obtained, yet. our data did not entirely support this policy although it might be the best strategy, based on the predictors of tumor regression, to avoid the complications associated with surgery in elderly patients with significant medical comorbidities and fear of a permanent stoma. introduction: conventional incision laparoscopic surgery procedure for rectal cancer is widely accepted as a successful alternative to laparotomy now, bestowing specific advantages without causing detriment to oncological outcome. evolving from this, single-incision laparoscopic surgery (sils) has been successfully utilized for the removal of colonic tumors, but the literature lacks sufficient data analyzing the suitability of sils for rectal cancer especially for total resection mesorectal excision (tme), particularlyon oncological outcome. we report the short-term clinical and oncological outcomes from a large cases retrospective analysis of observational study of sils for tme procedure of rectal cancer. methods: rectal cancer patients who underwent transumbilical single incision laparoscopic tme surgery were recruited in the current study. short-term perioperative clinical parameters and oncological outcomes were observed and all patients were followed up after surgery. then summarize the preliminary application results. results: operations were accomplished successfully with single incision laparoscopy, patients were converted to multiport approach, and was converted to laparotomy, no diverting ileostomy was performed. the average operative time was ( . ± . ) min, with an average blood loss of ( . ± . ) ml, the median postoperative hospital stay was ( . ± . ) days. all patients received a r resection and the surgical margin were conformed negative in all cases, the median number of harvested lymph node is ( . ± . ), the specimens met the requirement of tme. there were postoperational complications, no operation-related mortality or postoperative anastomotic leakage was observed. no patient appeared recurrent in a median follow up of months. conclusions: total mesorectal excision surgery for rectal cancer can be safely performed using transumbilical single incision laparoscopic technique, with acceptable short-term clinical and oncological outcome. surg endosc ( ) background: any surgical trauma induces an inflammatory response, which is considered as a negative factor in the general immune response, specially in malignant disease. the c-reactive protein (crp) is an acute phase protein often used as a marker of surgical trauma. stent treatment has been used as a treatment option for colonic obstruction in palliative cases for many years, and also as a bridge to surgery in selected cases. in a pilot study we compared the inflammatory response after acute stent treatment or surgery for malignant colonic obstruction. method: we compared two consecutive series of treatment of acute malignant colonic obstruction, stent treatment or emergency surgery during - . all patients were admitted with acute colonic obstruction due to colorectal cancer. choice of treatment was based on attending senior colorectal surgeons' preference, patient comorbidities and disseminated disease was considered. patient age, crp, time to first defecation and length of stay was recorded. results: a total of patients were identified in a retrospective analysis. patients had acute stent treatment and had acute surgical treatment for colonic obstruction, all due to colorectal cancer. median age was y ( - ) with no difference between the groups. there was no difference in metastatic disease between the groups. median time until first defecation after treatment was significantly shorter for the stented patients ( h ( - )) compared with those operated ( h ( - )) (p, ). median hospital stay was also shorter in the stent group, days ( - ), versus days ( - ) in the surgical group (p= , ). crp did not differ between the groups before treatment. both treatments resulted in increased crp levels at postoperative days and , but the crp levels were significantly higher in the surgical group than in the stent group at both time points (pod p= , , pod p, ) conclusion: acute stent treatment in colonic malignant obstruction seems to induce a less pronounced inflammatory response compared with surgery, as shown by a significantly reduced increase in postoperative crp resulting in shorter time to first defecation and a shorter hospital stay. introduction: meckel's diverticulum is the most common congenital abnormality in newborns, present in about - % of them. diagnostic of meckel's diverticulum requires a high index of suspicion, and even with the use of modern imaging technologies, they are often diagnosed intraoperatively. what to do when an asymptomatic diverticulum is found incidentally during surgery for other causes is a matter of discussion. objective: the aim of this article is to report symptomatic and asymptomatic incidentally found cases seen in a fourth-level hospital in colombia. the reports of the histopathologic examinations carried out in the hospital in the last years were reviewed searching for those containing meckel's diverticulum in their diagnosis. patients were divided in asymptomatic and symptomatic groups. the asymptomatic group was defined as patients who were operated for a different indication and a meckel's diverticulum was found incidentally. morbidity was divided in early and late complications after the initial surgery. results: from january to june , a total of pathology reports included the diagnosis meckel's diverticulum. a total of adult patients were retrieved. all of those patients with meckel's diverticulum a total of patients were symptomatic, being sbo the most common complication and required the surgical remove incidentally. conclusion: the correct approach of the patients with diverticular pathology allows the early identification and the appropriate management of the surgical complications that can be presented. robert j czuprynski, md, grace montenegro, md; saint louis university hospital presacral masses are a rare entity, with an incidence of . % and can be classified in several categories, including inflammatory, neurogenic, congenital, osseous and miscellaneous. in this case, a neuroendocrine tumor was identified with concern for iliac chain lymphatic and gluteal metastasis. the patient underwent abdominoperineal resection, excision of presacral mass, lymph node biopsy and omental flap. final pathology returned as a grade ii neuroendocrine tumor arising from a tailgut cyst. a year old female with a ten year history of recurrent perianal, ischiorectal and deep postanal abscesses presents with a presacral mass biopsy proven well-differentiated neuroendocrine tumor. octreotide scan demonstrated avidity for presacral mas as well as left intergluteal lymph node and two internal iliac lymph nodes. chromogranin a, neuron-specific enolase and serotonin markers were all negative. the patient was taken to the operating room and underwent abdominoperineal resection, resection of presacral mass and internal iliac nodes with an omental flap. neuroendocrine tumors arising from tailgut cysts of the presacral space are rare in nature. in a retrospective study from great britain, four of thirty one tailgut cysts had malignant transformation, so it is generally recommended to resect the cysts. in this case, the patient's tumor was a moderately differentiated, grade ii with extensive lymphovascular and perineural invasion. there are no prospective studies showing neoadjuvant therapies in neuroendocrine tumors of the presacral space. according nccn guidelines, patient is currently asymptomatic with low tumor burden. recommended treatment at this time is observation with surveillance tumor markers every - months or octreotide. anastomotic leakage has been commonly regarded as one of the toughing postoperative complications in laparoscopic mid/low rectal cancer surgery, attenuating the short-term clinical benefits. the left colic artery (lca) has been routinely central-ligated in dissection process to guarantee the oncological effects, which may potentially attribute to the postoperative ischemia-induced anastomotic leakage in the patients with left-colic vessel variation, e.g. bypass or absent of riolan arch. however, no specific study focuses on the surgical benefits of lca preservation compares to conventional ones. herein, we conduct a single center randomized controlled trial, demonstrating that lca-preserving technique shows significant reduction rate of postoperative leakage as well as overall complications comparing to the traditional central-ligation group. no difference in survival rate and recurrence in short term is found between the two groups. the lca-preserving strategy is proven to be repeatedly safe and feasible, potentially reduce the risk of anastomotic leakage with comparable short-term outcomes. further investigation is required for both the oncological safety and long-term prognosis for this innovative technique. background: three-photon imaging (tpi), which was based on the field of nonlinear optics and femtosecond lasers, has been proved to be able to provide the -dimensional ( d) morphological feature of living tissues without the administration of exogenous contrast agents. the purpose of this study is to investigate whether tpi could make a real-time histological d diagnosis for colorectal cancer compared with the gold standard hematoxylin-eosin (h-e). methods: this study was conducted between january and august . a total of patients diagnosed as colon or rectum carcinoma by preoperative colonoscopy were included. all patients received radical surgery. the fresh, unfixed and unstained full-thickness cancerous and the corresponding normal specimens in the same patient, were immediately prepared to receive tpi after surgery. for d visualization, the z-stacks were reconstructed. all tissue went through routine histological procedures. tpi images were compared with h-e by the same attending pathologist. results: the schematic diagram of tpi is shown in fig. a . peak tpi signal intensity excited at nm was detected in living tissues. the field of view (fov) was µm and the imaging deep was µm in each specimen. in normal specimens, glands lined regularly and characterized as a typical foveolar, which was comparable to h-e images ( fig. b and d ). in cancerous specimens, irregular tissue architecture and shape were identified by tpi, which was also validated by corresponding h-e images ( fig. c and e ). tpi images can be acquired with a view of d visualization. based on rates of correlation with pathological diagnosis, the accuracy, sensitivity, specificity, positive predictive value, negative predictive value were %, %, %, %, . %, respectively. conclusions: it is feasible to use tpi to make a real-time d optical diagnosis for colorectal cancer. with the miniaturization and integration of colonoscopy, tpi has the potential to make a real-time histological d diagnosis for colorectal cancer in the future, especially in low rectal cancer. erica pettke , abhinit shah , vesna cekic , daniel feingold , tracey arnell , nipa gandhi , carl winkler, md , richard whelan ; mount sinai west, columbia university introduction: alvimopan (alvim) is a peripherally acting µ-opioid receptor antagonist used to accelerate gastrointestinal functional recovery postoperatively (postop) after bowel resection. the purpose of this retrospective study was to compare the time to first flatus and bowel movement (bm) as well as length of stay (los) following elective minimally invasive colorectal resection (crr) in a group of patients (pts) who received alvimopan perioperatively (periop) vs a group that did not get this agent. methods: a data review from to from irb approved databases was carried out. operative, hospital and office charts were reviewed. routine use of alvim for elective crr cases was stared in . besides gi data, preoperative comorbidities and day postop complication rates were assessed. the results with periop alvim were compared to a no-alvim group. the students t and chi-square tests were used. results: a total of pts underwent elective crr. alvim was administered periop to pts ( %). the breakdown of indications between groups were similar. alvim pts were younger ( . vs. . years old, p= . ) and, as regards comorbidities, less likely to have heart disease (cad . % vs . %, other heart disease . % vs . %) but were otherwise similar. the rate of laparoscopic-assisted (alvim, . %; no alvim, %) and hand assisted or hybrid operations (alvim, . %; no alvim, %) were similar. alvim pts had significantly earlier return of flatus ( . vs . days) and first bm ( . vs . , p. for both) than the no alvim group. there was also a trend toward a shorter los ( . vs . days, p= . ) for the alvim group. overall complication rates were similar, however, alvim pts had lower rates of post-operative ileus ( . % vs . %, p. ), sssi's ( . vs %, p= . ), and blood transfusion ( . vs . %, p= . ) than the no alvim group. conclusion: the two groups compared were largely similar (most co-morbidities, indications, crr type) with the differences in age and cardiac issues noted. the impact of the higher rates of sssi's, blood transfusion, and mi in the no alvim group on gi function is unclear. pts who received alvim periop had an accelerated return of bowel function, decreased postoperative ileus and shorter length of stay. these results suggest that alvim is effective in reducing the postoperative ileus but further study is warranted. background: laparoscopic total proctocolectomy (tpc) is selected for minimally invasive surgical treatment of familial adenomatous polyposis (fap) and ulcerative colitis (uc). our policy of tpc is no diverting ileostomy for fap and creating ileostomy for ibd because most of the patients received steroid therapy. objective: we examined the outcome of laparoscopic tpc according to disease of fap and ibd (uc and crohn's disease). methods: twenty-three consecutive patients who underwent laparoscopic tpc between april and march were examined. the patients were divided into fap group and ibd group. results: seven patients of fap and patients of ibd (uc , crohn's disease ) underwent laparoscopic tpc or total colectomy. among them, patients (fap , ibd ) were cancerassociated cases. the procedures of the fap group was tpc with iaca in patients and hals total colectomy with ira in patient. the procedures of ibd group were tpc with iaca in patients, tpc with iaa in patients, total colectomy with ira in patients, of which hals cases. the mean operative time and blood loss were minutes, . g in the fap group and minutes, . g in the ibd group, respectively. diverting ileostomy was constructed in patients of only uc group. early complications of fap group were observed in cases (postoperative ileus , anastomotic leak with conservative treatment ), and those of ibd were observed in cases (ileus , anastomotic leak with conservative treatment , abdominal abscess , wound infection ). the median postoperative hospital stay was days in the fap group and days in the ibd group. complications requiring reoperation were cases (fap : intestinal obstruction, ibd : inflammation of stoma-closure site). no cancer recurrence and mortality were observed. one case of fap underwent additional transanal mucosal resection due to new lesion of adenoma. conclusions: laparoscopic total proctocolectomy for fap and ibd was performed safely, especially less complications occurred in fap patients without diverting ileostomy. in addition, followup of remaining mucosa is important in iaca and ira patients. treatment of complex anal fistula has always been a nightmare for surgeonsby conventional means. even the lowest and simple looking fistula at times comes out to be a complex one with high incidence of recurrence above %. most of the availability diagnostic including mri is nit conclusive and many a times the surgeon remains in a state of confusion as to what is going to come at the operation table. the conventional treatment modalities also usually leave the patient wounded needing almost to weeks to heal with a risk of sphincter damage and a high risk of recurrence. we would be presenting the technical details and results of our series of cases of complex anal fistula treated by video assisted endoscopic therapy. jun higashijima, phd, mitsuo shimada, professor, kozo yoshikawa, phd, takuya tokunaga, phd, masaaki nishi, phd, hideya kashihara, phd, chie takasu, phd, daichi ishikawa, phd; department of surgery, the university of tokushima background: one of the important causes for anastomotic leakage (al) in anterior resection is an insufficient blood flow of the stump. the hems (hyper eye medical system) and spies (laparoscopic icg system) can detect the blood flow of fresh organ intraoperatively by injection of indocyanine green (icg). and thermography also can evaluate the bloodflow less invasively. the aim of this study is to evaluate the usefulness of icg system and thermography in laparoscopic anterior resection. patients and methods: this study retrospectively included patients who underwent laparoscopic anterior resection for colon cancer with double stapling anastomosis procedure. blood flow evaluation of oral stumps was performed with measurement of fluorescence time (ft) using hems and spies. and bloodflow was also evaluated by thermography. result: evaluation by icg system: in all cases, the al rate was . % ( / cases). over ft cases, the al rate was %, higher than that of under s cases and these patinets need additional management, covering stoma or additional resection. and in border cases, ft * sec, al rate is . %, higher than under s cases. in these borderline cases, if covering stoma was performed in patinets with more than three well known risk factors, the al rate reduced to . % and false positive was . %. and under s cases, they need no additional management. evaluation by thermography: in residual intestine, the temperature was siginificantly higher than resected intestine ( . vs . ?, p. ). and the temperature in ft under s cases was significantly higher than over ft over s cases ( . vs . ?). the temperatue and ft was tended to be oppositely correlated (r = . ). conclusion: both icg system and thermography may be useful to avoid anastomotic leakage. introduction: some patients who undergo neoadjuvant chemoradiation therapy (crt) for rectal cancer achieve a pathologic complete response (pcr) in which no tumor cells are discovered during pathologic analysis of the resection specimen. achievement of pcr is correlated to improved prognoses relative to non-pcr counterparts. such correlations are not well established in the context of a community-based hospital. the study sought to examine response rates, recurrences, and survivals in locally advanced rectal cancer patients and compare patient outcomes to those achieved at major academic institutions. methods and procedures: a single-center retrospective chart review was performed at a local, community-based hospital. study population consisted of patients with locally advanced rectal cancer treated with neoadjuvant crt followed by surgical resection. patients with a history of metastasis, inflammatory bowel disease (ibd), hereditary cancer syndromes, concurrent or prior malignancy, and emergent surgery were excluded. results: patients ( . %) achieved pcr in the test population. across both groups, mean age (p =. ), gender (p=. ), and ethnicity (p=. ) were found to be comparable. mean interval between crt and or (p=. ), pre-op stage (p=. ), number of nodes (p=. ), radiation dose (p=. ), tumor location (p=. ), and days of follow-up (p=. ) presented statistically insignificant differences between groups. at years, non-pcr patients ( . %) had a recurrence with zero recurrences in the pcr group. -year mortality presented non-pcr patients ( . %) compared to pcr patient ( . %). conclusion: a multidisciplinary approach to rectal cancer consisting of standardized preoperative treatment and surgical resection can achieve patient outcomes and survival similar to those of larger academic institutions, even in the context of a community-based hospital. objective: the aim of this study was to assess safety and feasibility of total mesorectum excision (tme) within the holy plane based on embryology for rectal cancer. methods: prospectively collected data of consecutive patients with rectal cancer who underwent tatme from november to august were enrolled. surgical outcomes including tme completeness, operative time for tme completion, blood loss, complications, pathological findings and length of hospital stay were assessed. surgical procedure: after performing ractal lavage, self-retaining anal retractor was set, and anal dilators were used for an atraumatic introduction of the transanal access devise (gelpoint path). three of -mm trocars and one of -mm trocar were inserted through the gelpoint path in a quadrant shape. then the gelpoint path was introduced through the anal to rectum. after rectosigmoid colon was temporally clamped using an atraumatic endo bulldog clip, pneumoperitoneum was maintained at mmhg with carbon dioxide via an air seal platform. a purse-string suture using a polypropylen with -mm rounded needle was performed clock-wise to tightly occlude the rectum with a cm margin distal to the tumor. after irrigation with saline and marking dissection line with tattooing the rectal mucosa distal to the mucosal folds, a mucosal transection of rectum was initiated. then a full-thickness rectal transection was performed circumferentially. after dissection of rectococcygeal muscle at o'clock and rectourethral muscle in the anterior wall, circumferential sharp dissection within the holy plane was performed. dissection proceeded between the endopelvic fascia and the prehypogastric nerve fascia in the posterior plane, between the denonvilliers's fascia and the anterior mesorectum in the anterior plane, and between pelvic nerve and the mesorectum with recognition of the neurovascular bandle in the lateral plane. then the dissection connected to the abdominal plane via laparoscopic team with working together until tme completed. results: tme completion performed in ( . %) patients. thirty five ( . %) patients had negative of circumferential resection margin. mean of tme completion time and blood loss were min and g, respectively. one ( . %) patient had an intraoperative complication and ( . %) patients had postoperative complications. no other complications occurred. the length of hospital stay was days. conclusions: tatme within the holy plane on based on embryology is a safe and feasible procedure for rectal cancer. abstract: acromegaly is a debilitating condition marked by excessive production of growth hormone. this leads to disfiguration, cardiopulmonary complications, and increased risk for cancer. with up to a two-fold increased risk of developing colon cancer and worse prognosis for diagnosed patients, earlier and more frequent screening has been recommended. we present a case of a -year-old hispanic male with acromegaly who presented to our hospital with hematochezia and weight loss. a near-obstructing rectal adenocarcinoma with metastasis to the liver was discovered. after completing neoadjuvant chemoradiotherapy, he underwent laparoscopic low-anterior colon resection and simultaneous open hepatic trisegmentectomy. in this case report, we review the literature and current guidelines in screening this high-risk group of patients. introduction: in this study, we discovered that in cme for laparoscopic right hemi-colectomy starting at the ileocolic vessel and proceeds along the superior mesenteric artery (sma) achieved a better oncologic outcome compared with the conventional ones proceeding along the superior mesenteric vein (smv). methods and procedures: patients admitted to a shanghai minimally invasive surgical center were included from september to january and were randomly divided into two groups: study group (n = ) and conventional group (n = ). operation time, blood loss during surgery, liquid intake time, postoperative hospital stay, postoperative complications within days after surgery, specimen length, and number of lymph nodes harvested as well as the positive lymph node rate were observed and studied. results: there was no statistical difference between the two groups with the exception of number of lymph node dissected and the positive lymph node rate for stage iii colon cancer. the study group had more lymph node retrieved and also a higher positive rate compared with the conventional group. the mean number of lymph node retrieved of study group was . ± . , while the conventional group was . ± . (p. ). and the positive lymph node rate for study group was . %, the conventional group was . %. conclusion: when performing the laparoscopic right hemi-colectomy, dissecting the lymph node along with the left side of sma could be achievable and there were no differences of surgical outcomes compared with the conventional ways, while there was a higher number of lymph nodes dissected and positive rate probably leading to a better oncologic outcome. aims: we describe laparoscopic surgery for rectal cancer using needlescopic instruments performed at our department. methods: from to , cases of rectal cancer underwent surgery using needlescopic instruments: cases at rectosigmoid colon, at upper rectum, and at lower rectum. an umbilical camera port ( -mm) and two needlescopic instruments (endorelieftm) were directly punctured into the assistant surgical site. we started with port sites. in low rectum cancer cases, we kept the good pelvic visualization to lifting the peritoneum of the bladder onto the ventral side using the lone star retractor staystm. results: the median age was years ( - years), with males and females, and body mass index was . kg/ m ( - kg/m ). anterior resection was performed in cases, low anterior resection in cases, intersphincteric resection in cases, abdominoperineal resection in cases, hartmann's procedure in cases, and lateral lymph node dissection in case. in addition, one case of t b (bladder) was converted from laparoscopic to open surgery. however, there were no cases in which needlescopic instruments were replaced with conventional forceps. moreover, intraoperative complications related to the forceps were not observed. conclusions: in rectum cancer surgery, needlescopic instruments leave a small postoperative wound; healing is rapid and the cosmetic result is excellent. surgical safety is comparable to that using conventional forceps. there is no problem with the rigidity of needlescopic instruments. however, where the shaft is curved, operative control requires attention to mobility and directionality. in low rectum surgery, use of needlescopic instruments is limited due to the curvature of the shaft during the dissection of the anterior rectum wall, but it is possible to maintain a good field of view by using auxiliary equipment. therefore, more cases could be considered for surgeries using needlescopic instruments with the help of auxiliary equipment. introduction: anastomotic leaks are devastating complications of colorectal operations that lead to significant morbidity and potential mortality. inadequate tissue perfusion is considered a key contributor to anastomotic failure following colorectal operations. currently, clinical judgment is the most commonly used method for evaluating adequate blood supply to an anastomosis. more recently intraoperative laser angiography using indocyanine green (icg) has been utilized to assess tissue viability, particularly in reconstructive plastic surgery. this technology provides a real-time evaluation of tissue perfusion and is a helpful tool for intra-operative decisions, particularly in deciding to revise an intended colorectal anastomosis. our study aimed to determine if there is a statistical significance in colorectal anastomotic leak or abscess rate using icg compared to common clinical practice. methods and procedures: patients undergoing left-sided colorectal operations, between march and february , were retrospectively reviewed. patients' colorectal anastomoses were evaluated using icg angiography (icga) to qualitatively assess tissue perfusion (icg group). peri-operative and post-operative outcomes, including anastomotic leak and abscess rates, were compared to patients who had colorectal operations without icga (control group). the primary outcomes of intra-abdominal leak rate and intra-abdominal abscess rate were compared using exact chi-square tests. the secondary outcomes of -days or return, mortality, and readmission rate were compared using chi-square tests. all statistical analyses were performed using sas software. results: two leading indications for surgery included malignancy (n = ) and diverticulitis (n = ). the majority of patients either had a low anterior resection (n = ) or sigmoidectomy (n = ). all operations were primarily minimally invasive. no statistically significant difference was seen between the two groups in regards to patient demographics, rate of proximal diversion (p = . ), and splenic flexure mobilization (p = . ). patients in the icga group were more likely to have high ima ligation than in the control group ( . % vs. . %, p-value. ). of the icga group, of the patients underwent additional colonic resection while of the did not undergo additional colonic resection. there was no statistically significant difference in primary or secondary outcomes between the two groups. conclusion: icg angiography has become a helpful adjunct in determining adequate perfusion to an intended colorectal anastomosis. this data is unable to support any difference in patient outcome utilizing this technology over surgeons' visual and clinical assessment. our results may contribute to larger studies to determine if there is a true difference in anastomotic leak or abscess rate using this technology. objective: to investigate the feasibility and surgical strategy of complete mesocolic excision (cme) with completely medial access by "page-turning" approach (cmapa) for the laparoscopic right hemi-colectomy. the cmapa is a modified medial approach of cme, which focus on the exploration of surgical plane instead of the recognition of vessels. surgical procedures: ( ) start point: the anatomy projection of ileocolic vessel; ( ) expose the whole trunk of smv to the level of inferior edge of pancreas before ligating any branches, for the purpose of high tie and verifying their location; ( ) enter the intermesenteric space (ims) and right retrocolic space (rrcs) with cranial and right extension through transverse retrocolic space (trcs); ( ) complete mobilize the mesocolon and remove the tumor en-bloc. see figure ? . clinical outcome: from september to march , there were patients underwent cmapa in shanghai ruijin hospital. the average operation time was . ± . minutes, average blood loss was . ± . ml, number of lymph node was . ± . , average specimen length was . ± . cm, flatus time was . ± . days, fluid intake time was . ± . days and average hospital stay was . ± . days. the overall complications rate was . % ( / ). compared to traditional medial approach of cme performed in our center, the blood loss, operation time and hospital stay were significantly reduced by performing cmapa for laparoscopic right hemi-colectomy. conclusion: the advantage of the cmapa ( ) to avoid the laparoscopic "leverage effect" and "tunnel effect". ( ) to make the branches of superior mesenteric vessels more easily recognized. ( ) to offer surgeons an alternative route entering the trcs, ims and rrcs. ( ) to avoid repetitive flipping of the colon complying with the "no touch" principle, and to lower the requirements of assistants. figure : anatomy and surgical planes concerning cmapa. aim: we have reported a possibility of "one-stop shop" simulation for liver surgery by mri using gadoliniumethoxybenzyl-diethylenetriamine pentaacetic acid (eob-mri) (emerging technology, sages )., which is characterized by ( ) one-time examination, ( ) no-radiation exposure, ( ) demonstration of liver vasculatures including biliary tract, ( ) diagnosis of tumors, ( ) volumetry and ( ) estimation of liver functional reserve in each segment. the aim of this study is to investigate usefulness of "one-stop shop" simulation for liver surgery using eob-mri. methods: accuracy of liver vasculatures: d-reconstruction of dynamic eob-mri imaging was done by synapse vincent software (fujifilm medical co., ltd., japan), using a manual tracing method. visualization of hepatic vessels in eob-mri was compared with that in dynamic ct in patients. assessment of liver functional reserve: the standardized signal intensity (si) of each segment was calculated by si of each segment divided by si of the right erector spine muscle. the standardized total liver functional volume (tlfv) was calculated by ∑ [k= to ] (standardized si of segment (k) volume of segment (k)) divided by body surface area. the following formula of resection limit was established using normal liver cases ( % of the liver is resectable) and unresectable cirrhotic patients such as recipients of liver transplantation ( % of the liver is resectable). the estimated resection limit (%)= % (the standardized tlfv of the patient - )/ , . this formula was validated using other patients who underwent hepatectomy. results: accuracy of liver vasculatures: the liver simulation by eob-mri succeeded in demonstrating hepatic vasculatures including biliary tract, diagnosis of hepatic tumors, and volumetry without any radiation exposure. regarding the vessel anatomy at hilar area, biliary tract was more clearly visualized in eob-mri. regarding the hepatic artery, right and left hepatic arteries were well visualized in all cases, however, small-sized middle hepatic artery was visualized in only one out of patients. assessment of liver functional reserve: as a result of validation of the patients, one patient having resection volume with over the resection limit died of liver failure, however, the other cases within their resection limits did not suffer from liver failure. conclusion: "one-stop shop" liver surgery simulation could contribute to safety of liver surgery such as laparoscopic hepatectomy, because of no radiation exposure, accurate assessment of anatomical variations especially biliary tract, and helping decision making of resection volume. showing key steps of the procedure to be viewed. the in-studio program was hosted by an education specialist from the science center and a surgical resident from our institution, with laparoscopic instruments available for manipulation by participants. participants then viewed a video highlighting the roles of all healthcare providers involved in the specialty to be featured, including nurses, physicians, dietitians, psychologists, technologists, etc. live questions and answers were then encouraged between students and surgeons during the surgery broadcast. the program also expanded from high schools to vocational-technical colleges and nursing schools. results: during the - academic year there were sessions presented to schools, with student participants. by the - year this increased to sessions presented to schools, with participants. in sum, throughout the first years of the program, there were schools attending, with a total of , participants. of polled high school participants, % of responders acknowledged considering a career in healthcare after this experience. conclusion: over years, our program has grown steadily in popularity such that schools from several counties attend and regularly return, and we have been asked to expand the program to create a surgical summer camp for students interested in science and technology. live broadcast surgery in an elective, minimally invasive format provides unique visibility and access to surgical procedures for student audiences and promotes future interest in healthcare careers. surg endosc ( ) :s -s p improving trainees' self-assessment through gaze guidance introduction: effective learning to become competent in surgery depends on a trainee's ability to accurately recognize their strengths and weaknesses. however, a surgical trainee's self-assessment is poorly correlated with expert assessment. this study aimed to improve self-assessment by the visual gaze guidance provided through telestration in laparoscopic training. we hypothesized that visual conveyance of where to look or perform actions on the laparoscopic video enhances the trainees' awareness of the gaps in their skills and knowledge. methods and procedures: a lab-developed telestration system that enables the trainer to point or draw a free hand sketch over a laparoscopic video was used in the study (fig. ). seven surgical trainees ( surgical fellow, research fellow, pyg- and pyg- ) participated in a counterbalanced, within subjects controlled experiment, comparing standard guidance with telestration-supplemented guidance. the trainees performed four laparoscopic cholecystectomy tasks -mobilizing cystic duct and artery, clipping the duct, clipping the artery, and cutting the duct and artery, on a laparoscopic simulation. performance assessment, adapted from the global rating scale (grs) instrument, was completed by the trainers and trainees at the end of each task. the mean self-assessment scores were compared with the trainers' scores by the linear mixed model, where the trainees' performance indicated by the trainers' scores was control. the assessment alignment was evaluated by spearman's rho. results: the trainers' scores were significantly lower than the self-assessment scores in the standard guidance, while the scores of the trainers and trainees were much more similar (fig. ) . the correlation between the trainers' and trainees' assessment in telestration guidance was high (r= . , p. ), compared to the standard guidance (r= . , p= . ). the correlation comparison for each grs criterion shows a significant increase (p= . ) in the assessment alignment for depth perception in telestration guidance (r= . , p. ), compared to the standard guidance (r= . , p= . ) (fig. ) . the visual gaze guidance improved the alignment of assessment between the trainer and trainees, especially for the assessment alignment in depth perception. for visual gaze guidance to become an integrated part of the training, further work needs to be conducted to understand how gaze guidance change the nature of the training process. applying to surgical residency: what makes the best candidates? yann beaulieu, beng, louis guertin, md, frcsc, ariane p smith, md, margeret henri, md, frcsc, facs; university of montreal objective: while quotas for canadian surgical residency programs are at their lowest point in ten years, the number of canadian graduating medical students is at an apogee. this year, only spots in surgical residency programs were available for students applying to carms. undergraduate medical students individually collect anecdotal information regarding what influences admission to their surgical subspecialties of interest, as scarce literature covers the topic. we thus surveyed surgeons and residents to analyze the relative importance of modifiable factors and innate attributes in the selection of new surgical residents. methods: an electronic survey was sent to all surgeons and surgical residents affiliated with the university of montreal. participants were asked to specify their surgical subspecialty, their status, their level of experience and whether they were an active member of a residency selection committee. the subjective importance of predefined application elements and candidate qualities was assessed using -point likert-type items. results: of the surgeons and residents to whom the survey was sent, ( . %) and ( . %) completed the survey. evaluations of elective rotations and evaluations of core rotations were considered very important by . % and . % of responders respectively. regarding letters of recommendation, the content was rated very important ( . %) more often than the notoriety of the author ( . %). networking with key surgeons was considered the least important element to prioritize with % of negative assessments. with regards to the fundamental qualities of surgical candidates, the extremes were "clinical judgement" with . % and "innate technical ability" with . % of responders rating them very important. no significant differences in responses were observed between staffs and residents, between members and non-members of selection committees, between different levels of surgical experience and between surgical subspecialties. conclusion: clinical judgement and performance in core and elective rotations along with strong personalized letters of recommendation should be prioritized by medical students aiming for a surgical career. kazuhiko shinohara, phd, md; school of health science, tokyo university of technology background and objective: many types of training devices had been proposed since the early days of endoscopic surgery. however, they are too expensive for daily training of novices. we developed a simple and economical training device made of frozen fruit and agar. material and methods: to make this device, g of agar powder was added to ml of boiling water and boiled for min. the solution was then poured into a stainless steel tray containing frozen blueberries and lychees and refrigerated for h. basic maneuvers required during endoscopic dissection and resection of a tumor with laparoscopic forceps and electrosurgical devices were then performed using this agar model in a conventional laparoscopic training box. results: using this model, endoscopic dissection and enucleation of a tumor with an electrosurgical device could be practiced repeatedly with minimal expense and preparation. background: situs inversus totalis (sit) is a rare congenital anatomy and a challenging condition for laparoscopic surgeries because standardized strategy to overcome such anatomical difficulties. mirror-reversed video images of laparoscopic surgeries for patients with normal anatomy could help to develop surgical strategies for patients with sit. we had a chance to evaluate this idea with a treatment of a patient of early gastric cancer, and describe the surgical results of the case. patient and methods: seventy-two-year-old women with a history of sit was referred to our department for the treatment of early gastric cancer, and laparoscopic distal gastrectomy with d + lymphadenectomy was scheduled. a video record of the same surgery for a patient with similar physical attribute performed before then was retrieved, and was edited with a computer into full length, totally mirror-reversed images of the surgery. designated operator and assistant simulated the operation using the video several times before surgery. results: laparoscopic distal gastrectomy was performed with d + lymphadenectomy while the operator was on the left side of the patient and the assistant on the other side, being opposite positions as usual. laparoscopic b- reconstruction was followed using "delta anastomosis" technique reported by kanaya et al. total laparoscopic procedures were completed with the operation time of minutes and the blood loss below measurable limits. no appreciable complications were observed after surgery and the patient was discharged on postoperative day . no recurrence of the disease was detected until years after surgery, conclusion: although further validation is unlikely because of a rare incidence of this anatomy, the same technique would be recommended for one of the preoperative preparations for similar cases. background: surgical simulation is thought to provide a basis for improvement of resident surgical skill training, in the safety of a simulation setting. it is unclear whether surgical skills learned in a simulation curriculum actually contribute to the improvement of surgical skills when transferred to the or. methods: a ten question online survey was sent to attending surgeons and residents. the questionnaire focused on domains: confidence, independence, transferable skills, improvement of skills/knowledge and time spent on the simulation curriculum. evaluation data was collected and anonymously analyzed. background: minimally invasive surgery poses a unique learning curve due to the requirement for non-intuitive psychomotor skills. programmes such as the fundamentals of laparoscopic surgery (fls) provide mandatory training and certification for many residents. however, predictors of fls performance and retention remain to be described. this single-centre observational study aimed to assess for factors predicting the acquisition and retention of fls performance amongst a surgically naïve cohort. methods: laparoscopically naïve individuals were recruited consecutively from preclinical years of a medical university. participants completed five visuospatial and psychomotor tests followed by a questionnaire surveying demographics, extracurricular experiences and personality traits. individuals completed a baseline assessment of the five fls tasks evaluated by fls standards. subsequently, participants attended a -minute training-course over week one and two on inanimate box trainers. a post-training assessment was performed in week three to evaluate skill acquisition. participants were withdrawn from laparoscopic exposure and retested at four onemonth intervals to assess skill retention. introduction: bipolar energy can cause thermal injury to adjacent organs when used improperly. sages fuse curriculum provides didactic knowledge on principles and best practices for safety, but there is no hands-on component to practice these skills. the objective of this study is to compare the effectiveness of the vest™ bipolar training module in addition to the fuse curriculum. methods and procedures: the study was a mixed design with two groups, control and simulation. after a pre-test that assessed their baseline knowledge, the subjects were randomized to two groups. both groups were given a min presentation, reading materials from the fuse manual and an online didactic module on bipolar energy. the simulation group also practiced on the simulator for one session that consisted of five trials on the effect of activation time on thermal damage and the importance of providing a margin of safety by sealing short gastric vessels. after one week the performance of both groups was assessed using a post-questionnaire. one week after the post-test both groups performed sealing of vessels on an explanted porcine mesentery with vessels perfused. their performance was videotaped and their activation times were recorded. a total safety score was calculated by assessing the proximity of the location of activation to the intestine by two independent raters. wilcoxon -signed rank and mann-whitney u tests were used to assess difference within and between groups. results: a total of residents ( in each group) participated in this irb approved study. median test scores for both groups increased (simulation, p= . and control, p= . ). no difference was found between the two groups in their pre-test (p= . ) and post-test (p= . ) scores indicating learning. the median total activation time for control group was higher ( . s) compared to simulation ( . s) but was not statistically significant (p= . ). there was a moderate agreement between two raters for margin of safety (kappa= . , p. ). total safety scores showed no difference between the two groups (p= . ). conclusions: subjects with simulation training had lower activation time compared to control. training for margin of safety requires more simulation refinement. small sample size and variations in the explanted models contributed to variability in data but even with small sample size, simulation training along with the fuse curriculum trended towards being more beneficial than the fuse curriculum alone. the general, that aims to build educational infrastructure and standardize training and education in laparoscopy throughout mexico. ilap participants engage in didactic and hands-on modules in educational theory, laparoscopic techniques, and simulation based education (sbe), and then develop and implement a -day sbe course for local trainees. the purposes of this study were to understand the existing educational environment at a single institution in mexico and measure the changes in perceptions, attitudes, and engagement in surgical education after an intensive training course. methods and procedures: all faculty and of general surgery resident participants completed a survey that contained items designed to assess the existing educational environment at a large, public hospital in mexico. using a -point likert scale, residents self-rated the quality of faculty feedback and the learning environment within their institution ( =strongly disagree, = neutral, =strongly agree). faculty rated their perceptions of the same educational themes. upon completion of a faculty-lead simulation course, residents rated the educational environment during the course. faculty provided additional qualitative feedback. descriptive analyses were performed. irb-exemption was obtained through lurie children's hospital. results: discordance existed in perceptions of the existing educational environment. the greatest disparity between resident and faculty perceptions included "faculty provide sufficient feedback in the operating room" ( % vs. %), "faculty promote an active learning environment" ( % vs. %), and "residents may ask questions without fear of negative evaluation" ( % vs. %). faculty and residents agreed with "residents are sometimes afraid to speak up in the operating room for fear of retaliation" ( % each). post-course evaluations (n= ) revealed universal improvement in all educational themes during the simulation course. qualitative feedback revealed most faculty plan to incorporate open communication and safe learning into their practice. residents were equally positive, with % optimistic that they will see changes within the educational environment. conclusions: significant discordance exists in resident and faculty perceptions of the educational environment at a large teaching hospital in guadalajara, mexico. after participation in the ilap course, residents noted demonstrable change in the faculty approach to education and feedback, and both faculty and residents expressed optimism for increased engagement in education. the immediate successes of the ilap initiative should be followed over time, as the ultimate measure of success is sustainability and scalability throughout mexico. background: laparoscopic anterior resection is technically challenging and the learning curve is long. well-designed formative assessments can provide trainees effective and constructive feedback, an important element in efficient learning. previously reported assessments for laparoscopic colorectal procedures were developed for summative assessment. we aimed to develop a formative assessment tool to evaluate competence and provide trainees with effective feedback in laparoscopic anterior resection. methods: the assessment tool was developed by an expert panel from mcgill university affiliated hospitals. the procedure was deconstructed into a series of sequential steps including general domains, surgical principles, injury prevention and technical skills specific to laparoscopic anterior resection. the tool contains discrete items with global rating scales for each step of the operation; each domain was scored using a -point likert scale, with anchors for scores of , and . each operation was assessed through direct observation in the operating-room by the attending, a trained observer, and trainees themselves. intraclass correlation coefficients (iccs) were calculated to estimate interrater reliability for ( ) attending surgeon and trained observer, ( ) attending surgeon and self-assessment, and ( ) trained observer and self-assessment. internal consistency was measured using cronbach's alpha. comparison between training levels was done using mann-whitney u-test. the global operative assessment of laparoscopic skills (goals) was also used to assess trainees' general laproscopic skills. spearman's correlation was used to determine association between goals and this procedure-specific tool. overall usefulness of this tool was evaluated using a cm visual analog scale. results: in this pilot study, fourteen operations, performed by experienced surgeons and trainees were assessed. the icc between ( ) attending surgeon and observer was . ( % ci . to . ) ( ) observer and self-assessment was . ( % ci . to . ), and ( ) attending surgeon and self-assessment was . ( % ci - . to . ). the internal consistency of the items was excellent (cronbach's α= . ). there was a significant difference in median total score between experienced surgeons and trainees ( . ± . vs. . ± . ; p= . ). there was strong correlation (r= . ) between goals and this procedure-specific score. overall usefulness of this assessment tool was rated as . ± . . all assessments were completed in about minutes. conclusions: we present a new procedure-specific formative assessment tool for laparoscopic anterior resection and provide preliminary evidence of its reliability and validity. this formative assessment tool could be used for constructive feedback and tracking performance in competencybased surgical training. cullen introduction: one of the key challenges to the proliferation of endoscopic submucosal dissection (esd) in the west has been a lack of training platforms. therefore, the virtual endoluminal surgery simulator (vess) is being developed as a training tool for esd. the aim of our study is to inform the design of vess using cognitive task analysis (cta), which is a human factors engineering framework to describe practitioners' mental models and cognitive processes and incorporate insights into the simulator's design. methods and procedures: cta-based interview questions were developed to probe the cognitive challenges and strategies employed at each stage of the esd procedure. six esd practitioners were interviewed for varying lengths of time. two of these interviews were conducted simultaneously during an observation of a training workshop where the cta participants were instructors (total observation time was five hours, and interview time was * minutes). another interview was conducted during observation of esd procedures (total observation time was hours, and interview time was * minutes). participants had varying levels of experience in esd, with of them being 'super-experts' (exclusively esd exponents), an 'expert' and a fellow. a cta of the data is currently being conducted to systematically inform design of functionalities in the simulator. results: analysis of our data highlights a few prominent themes at each stage of esd: goals, challenges (e.g., avoiding perforation of muscularis); points of decision-making (e.g., partial or full incision for boundary demarcation); skills involved (e.g., dissection); and ambiguity (e.g., unclear lesion boundaries). participants also described risks associated with each stage of esd and strategies to prevent or overcome the same. conclusions: qualitative data for a cta were collected through observations and interviews of esd practitioners. preliminary analysis has indicated prominent themes to consider in the design of the training simulator. the next step in the study is to conduct a full-scale cta of esd based on the current data. the ultimate benefit of the cta would be to incorporate the results into informing the design of vess in a way that is compatible with the mental models of esd trainees, thus enhancing the fidelity and effectiveness of the simulator. background: colonoscopy is an important diagnostic and therapeutic procedure in the management of colonic disease; achieving competence during residency is an integral part of performing high-quality colonoscopy in-practice, regardless of specialty. there is debate and controversy however, regarding what, if any, number of procedures achieves said proficiency. furthermore, there is significant heterogeneity in the current guidelines and studies published to-date on the definition of competence in colonoscopy. objective: to determine individualized learning curves as an alternative to 'number of procedures' for assessing colonoscopy competence. methods and procedures: this is a multi-institutional prospective cohort study involving eleven surgical trainees (novice endoscopists). the main outcome, colonoscopy competence, was assessed by determining the independent colonoscopy completion rate (iccr), the number of procedures required to reach % independent colonoscopy completion and polyp detection rate. individual and overall iccr were calculated using moving average analysis. conclusions: while a benchmark for a minimum number of procedures may be necessary to allow supervisors to adequately assess performance, it is difficult to determine what number is optimal. there appears to be significant heterogeneity in both overall number of colonoscopies completed by each resident, as well as the mean iccr and the number of procedures required to reach the current benchmark for competency. the use of learning curves allows real-time tracking of progress and training tailored to the individual, as we move forward in the era of competency-based medical education. background: with the growing popularity of robotic-assisted surgery, new methods for evaluation of technical skill are necessary to determine when a surgeon is qualified to perform an operation independently. current evaluation methods are limited to point likert scales which require a degree of subjective scoring. surgeons in training need an objective method of evaluation to view progress and target areas for improvement. one method of objectively evaluating surgical performance is a cumulative sum control chart (cusum). by plotting consecutive operative outcomes on a cusum chart, surgeons can view their learning curve for a given task. another method of objective evaluation is the dv logger®, or "black box," which records objective measurements directly from the da vinci® system. methods: we followed two hpb fellows during dry lab simulation of robotic-assisted hepaticojejunostomy reconstructions using biotissues to model a portion of a whipple procedure. we simultaneously recorded objective measurements of dexterity from the da vinci® system and performed cusum analyses for each procedural step. we modeled each variable using machine learning (a self-correcting and autoregressive modeling tool) to reflect the fellows' learning curves for each task. statistically significant objective variables were then combined into a single formula to create an operative robotic index (ori). results: variables that significantly improved over the course of the simulation included completion time (p= . ), economy of motion in arm (p= . ), number of times head was removed from the console (p= . ), total time left master manipulator was active (p= . ), total time right master manipulator was active (p. ), and total time that any arm was active (p\ . ). the inflection points of our cusum charts and plots of objective variables both showed improvement in technical performance beginning between trials and [ fig. and fig. ]. the operative robotic index showed a strong fit to our observed data and improved with additional trials (r = . ). [ figure ]. conclusions: in this study we identified objective variables recorded by the da vinci® system which correlated with the technical dexterity of fellows during a robotics dry lab. we broke a complex procedure down in stepwise fashion with cusum analyses to determine targets for improvement. using variables which correlated with the improved performance of the fellows, we effectively modeled the learning curve with the creation of an operative robotics index (ori). this study successfully models the learning curve of novice robotic surgeons using a novel combination of objective measures. georg wiese, md, paula veldhuis, steve eubanks, md, facs, scott w bloom, md, frcsc, facs; florida hospital institute for surgical advancement introduction: robotic surgery is a specialized skill which requires time and resources to master. in a general surgery residency program that seeks to train competent surgeons in both open, laparoscopic and endoscopic techniques it is difficult to see where adding robotic training will be of benefit and at what cost this will be to the remaining surgical skills. we therefore sought to ascertain robotic surgery's current role in the training of new general surgeons by soliciting the opinions of current general surgery program directors on the role of robotic surgery at their respective institutions. methods: an irb approved survey was created and sent to general surgery program directors across the country to assess how robotic surgery training is being integrated into current surgical training. the survey was sent via email to publicly available email addresses from the acgme website of program directors. it was voluntary in nature and consisted of questions regarding current status of robotic training in residency as well as future goals. results: overall response from our pd survey were at % of the surgical programs with addresses available via acgme, though responses continue to be submitted at the time of this abstract. approximately % of all respondents are from independent, university based programs. % felt that robotics was an emerging skillset important for residents to master versus % feeling that it was more appropriate for fellowship. all respondents noted that robotic surgeons were present at their institution, % within the core faculty, and % indicated that they were actively recruiting robotically trained surgeons. additionally, % of programs indicated that residents were exposed to robotic surgery, % of these on core general surgery rotations. % of respondents indicated that they had a formal robotic training curriculum with % of programs taking measures to integrate robotics into the future curriculum though % lacked specific milestones for such training. finally, opinion was evenly divided among respondents as to whether one could sign off on residents to perform robotic assisted cases upon completion of pgy year with % agreeing with that statement and the remainder indicating some additional training would be necessary. conclusions: our study highlights the emerging field of robotic assisted mis surgery and its increasing role in residency training. it is evident from the data, that robotic surgery is a growing part of residency experience. importantly, however, milestones were significantly lacking for determining resident progress in robotic training. introduction: in chile, medical students have the opportunity to undertake a month-long medicine elective (me) in a community hospital, primary care center or emergency department within the country at the end of their first clinical year. due to the lack of opportunities to practice suturing in the first years, students usually do not have an optimal performance in this type of medical procedure during the me. simulation training programs in suturing improve technical skills, selfconfidence and patient safety in the medical internship. the objective of this study is to evaluate the impact of implementing a simulated suture training program earlier in the medical curriculum, before the me. methods: we conducted a prospective, randomized controlled trial with medical students at the end of their first clinical year. they were randomized into two equal groups. the intervention group received an intensive suture training program consisting in one theory class, four practical sessions and effective feedback from an expert surgeon. the control group did not receive training, remaining with the classic opportunistic learning approach during the me. after the me, all students undertook an electronic survey. statistical analysis was performed on the answers of both groups. per protocol analysis was applied. results: there were no statistical differences between groups in terms of age and sex. four students did not complete the training program. one student in the control group did not reply to the survey. higher self-confidence with regards to suturing was reported in the intervention group in comparison with the control group [ / ( %) vs / ( %), p, ]. also, a greater student desire to carry out suture-related procedures was reported in the intervention group than the control group [ / ( %) vs / ( %), p, ]. in addition, a lower rate of overseeing physician intervention was reported in the intervention group [ / ( %) vs / ( %), p, ] ( table ) . a greater number of patients requiring sutures were treated by the intervention group than the control group, with a median of patients ( - ) against ( ) ( ) ( ) ( ) . the intervention group performed a higher number of sutures with a median of ( - ) vs ( - ), with a statistically significant difference (p, ) in both cases (fig. ) . conclusion: a simulated suture training program prior to the me generates a positive impact on medical students by improving self-confidence and desire to attend patients that require sutures. this leads to a higher rate of both exposure to suture techniques and suture execution. introduction: measuring performance in the operating room (or) is challenging. performance is a multifaceted construct a complex interaction of many behaviors and actions that reflect an individual's knowledge and skill. no assessment tool to date provides an expertise-based, comprehensive evaluation of the various aptitudes necessary to excel in the or, especially with respect to advanced cognitive skills. using qualitative methodologies, we previously defined behavioral themes that guide surgeons' behaviors, decisions, and actions, within a universal framework of domains that reflect intra-operative performance. the purpose of this pilot study was to use this framework to derive a comprehensive assessment tool and to obtain evidence for its validity as a measure of intra-operative performance. methods: an assessment tool was developed by a panel of surgeons and surgical trainees based on the five-domain model of intra-operative performance: ) psychomotor skills; ) declarative knowledge; ) interpersonal skills (two items); ) personal resourcefulness, and ) advanced cognitive skills (ten items). all items were rated on an ordinal scale of (inadequate) to (expert) and equally weighted. surgical residents and surgeons from a single academic center were evaluated on their performance during standard general surgery operations, for example, open inguinal hernia repair and laparoscopic cholecystectomy. for residents, there were evaluators -the attending surgeon and an observing surgeon. attending surgeons evaluated their own performances and were also assessed by observing surgeons. internal consistency, inter-rater reliability, and correlation of total scores with training level (junior residents, senior residents, staff surgeons) were calculated. likert scale questionnaires were administered to evaluate the tool's usability, feasibility, and educational value. results: fifteen subjects ( junior residents, senior residents, surgeons) participated. the total score on the assessment demonstrated significant differences between training levels ( figure) . inter-rater reliability was high (interclass correlation coefficient= . ), as were internal consistency between each domain score (cronbach's alpha= . ), internal consistency amongst items in the advanced cognitive skill domain (cronbach's alpha= . ), and internal consistency amongst items in the interpersonal skills domain (cronbach's alpha= . ). all assessments required less than five minutes to complete. overall, evaluators agreed that the assessment tool was easy to use, was comprehensive, and should be used routinely throughout training to track performance and provide formative feedback. conclusion: in this pilot study, we developed a comprehensive assessment tool for intra-operative performance and provide preliminary validity evidence for the score. surg endosc ( ) introduction: the purpose of this study was to evaluate the validity of our developed system for assessing suturing skills in laparoscopic surgery (fig. ) . we have updated numbers of participants and a comparison method compared with the last year report. methods and procedures: fig. shows our developed computerized system for objective assessment of suturing skills by using a laparoscopic intestinal suturing model, e-lap. the system includes a new artificial intestinal model that mimics living tissue and pressure-measuring and image-processing devices. each examinee performs a specific skill using the artificial model, which is linked to a suture simulator instruction evaluation unit. the model uses internal air pressure measurements and image processing to evaluate suturing skills. five criteria, scored on a five-grade scale, were used to evaluate participants' skills ( fig. ) . the volume of air pressure leak was determined by the volume of air inside the sutured artificial intestine. for example, for the criterion "air pressure leakage", the approximate midpoint of the acceptable range was grade . values lower than the minimum acceptable value received lower grades and those above the midpoint of the acceptable range higher grades. we enrolled surgeons who participated a simulator competition event at the th annual meeting of the japan society for endoscopic surgery (jses houston methodist hosptial, baylor college of medicine introduction: the sages flexible endoscopy course for minimally-invasive surgery (mis) fellows has been shown to improve confidence and skills in performing gi endoscopy. this study evaluated the long-term retention of these confidence levels and investigated how fellows have changed practices within their fellowships as a result of the course. methods: participating mis fellows completed surveys six months after the course. respondents rated their confidence to independently perform sixteen endoscopic procedures ( =not at all; =very). while the pre-and post-course surveys identified anticipated endoscopy uses and barriers to use, the -month follow-up survey evaluated actual usage and barriers to use in each fellow's practice. respondents also noted participation in additional skills courses and status of fundamentals of endoscopic surgery (fes) certification. comparison of responses from the immediate postcourse survey to the -month follow-up survey were examined. mcnemar and paired t-tests were used for analyses. results: twenty-three of ( %) course participants returned the -month survey. % had passed the fes skills examination and % had attended another flexible endoscopy course. no major barriers to endoscopy use were identified. in fact, fellows reported less competition with gi providers as a barrier to practice compared to their original post-course expectations ( % versus %, p. ). in addition, confidence was maintained in performing the majority of the endoscopic procedures, although fellows reported significant decreases in confidence in independently performing snare polypectomy (− %; p. ), control of variceal bleeding (− %; p. ), colonic stenting (− %; p. ), barrx (− %; p. ), and tif (− %; p. ). fewer fellows used the gi suite to manage surgical problems than was anticipated post course ( % versus %, p. ). fellows without fes certification reported loss in confidence to independently perform barrx (− %; p. ) and colonic stenting (− %; p. ), and also a % decrease in the use of gi suite to manage surgical problems (p. ) fellows who passed fes noted no significant loss of independence, changes in use, or barriers to use. % of fellows made additional partnerships with industry after the course. % stated flexible endoscopy has influenced their post-fellowship job choice. % would recommend the course to other fellows. the sages flexible endoscopy course for mis fellows results in long-term practice changes with participating fellows maintaining confidence to perform the majority of taught endoscopic procedures six months later, and over % reporting that flexible endoscopy influenced their career choice. additionally, fellows experienced no major barriers to implementing endoscopy into practice. the materials and methods: at our center, we formulated a laparoscopic mentorship program where a senior consultant was paired with a particular trainee resident for a period of weeks. consultants & residents were a part of the study. the or schedules were rearranged to accommodate these pairs. an evaluation of the residents' views was performed prior to the study and once at its completion, using a simple questionnaire with each parameter scored between & . results and discussion: continuous, consistent evaluation by a consultant over an extended period of time allowed them to assess their assigned resident's laparoscopic skill set. all pairs observed an increased frequency of errors being noticed & improved upon. the consultants stressed upon shedding undesirable operative habits. there was a significant improvement in residents' scores at the end of the short study. conclusion: we found that the short-term mentorship program was easy to incorporate within our or schedule and was well received by the participants. continuous short rotations under senior consultants appear to allow residents to not only fully observe and imbibe correct operative techniques, but also helps shed unfavorable habits. we are currently amid the second cycle of our study & looking forward to the results at the end of this academic year. introduction: colorectal cancer is one of the most common cancers in the united states. endoscopic submucosal dissection (esd) is an emerging minimally invasive technique that allows complete en-bloc resection and a much lower recurrence rate at long-term follow-ups. however, performing colorectal esd is technically demanding since the colorectal wall is thin and constantly moving, and potentially higher rates of complications (e.g., bleeding and perforations). hence, an adequate training for colorectal esd is needed to acquire basic proficiency with minimum complications. objectives: a virtual reality (vr)-based simulator with visual and haptic feedback for training in colorectal esd is being developed, which the aim to allow trainees to attain competence in a controlled environment with no risk to patients. in this work, a newly developed application of the virtual simulator that promotes the endoscopists to perform and assess technical skills in esd is developed. training tasks are built based on physics-based computational models of human anatomy with tumors. methods: the main modules of the vr-based simulator for colorectal esd involve: ( ) rendering; ( ) haptic interface; ( ) physics-based simulation; and ( ) performance recording and assessment metrics. the rendering engine allows surgical tasks to be performed in the three-dimensional virtual environment. haptic feedback mechanisms allow users to physically feel the interaction forces. physics-based simulation technologies are employed to enable the complicated simulation for performing virtual surgical tool-tissue interactions. the simulator can also collect learners' performance data to offer feedback based on the built-in metrics. results: four training tasks involving marking, injection solution, circumferential cutting, and submucosal dissection are designed to practice skills with different surgical tools. the marking task aims to identify the lesion. the injection solution task minimizes the risk of bleeding and perforation to protect the muscularis. in the circumferential cutting task, the objective is initial incision of the lesion with the surgical tools. the objective of the dissection task is to remove the tumor from the connective tissue of the submucosa under the lesion. conclusions: the vr-based simulator enables realistic esd tasks to provide a possibility for developing, validating and objectively evaluating the performance metrics in colorectal esd training, and offers an opportunity to rise up the learning curve before application to patients. background: the virtual translumenal endoscopic surgery trainer (vtest) simulator is a virtual reality system that was designed to train the hybrid-notes technique. transfer of skill acquired while training on the vtest was measured in a near-real cholecystectomy procedure staged in the easie-r model. methods: sixteen medical students were divided randomly and evenly into groups: control, training. all subjects performed the cholecystectomy procedure on the vtest simulator to establish a baseline (pre-test). the training group received training sessions, over a period of consecutive weeks, consisting of trials per session or as many trials as can be accomplished in one hour, whichever was achieved first. at the end of the training period, all subjects performed one trial on the vtest simulator (post-test), and again to weeks later (retention test). two months after that, subjects performed the hybrid-notes cholecystectomy procedure on an easie-r model. performance with the easie-r simulator was video-recorded, and three tasks within the cholecystectomy procedure were isolated for evaluation: clipping, cutting, and dissecting the gallbladder. objective performance measures, such as time and error, were extracted from the videos by two independent reviewers, while subjective performance was scored by four expert surgeons who were blinded to the training conditions. expert reviewers used a modified version of the operative performance rating system by the american board of surgery and the objective structured assessment of technical skills (osats) tool. results: there was no difference in task completion time between the control and training groups, (t( )= . , p =. ) in the cutting and clipping tasks. however, there was a significant difference in the number of errors, t( )=- . , p=. . there was no difference in subjective performance between the training groups for the clipping and cutting tasks. in the gallbladder dissection task, however, there was a statistical significance in "instrument handling" based on one of the surgeons' ratings (t( )= . , p=. ), and a statistical significance in "time and motion" based on another surgeon's rating (t( )= . , p=. ). conclusions: results indicate that weeks of training on the vtest simulator did not allow the subjects to transfer their learned skills equally to the near-real environment, even though they retained the skills when tested for retention. this new insight suggests that modification of the training method for different types of surgical skills may be warranted to optimize their transfer to the real environment. examining conclusions: this study provides evidence to suggest that for bariatric surgeons, experience and skills acquired in performing non-bariatric surgery may not translate to improved outcomes in bariatric surgery. as seen in this study, improvement in bariatric surgical outcomes is likely more dependent on experience specifically performing bariatric procedures. as there may be no benefit acquired from performing surrogate procedures, this may have implications in the design of subspecialty training programs and for accreditation purposes. . a universally adjustable cellphone holder was used where smartphones could be placed inside the fls box in order to capture the task from a similar angle as the onboard camera. residents were able to use their own smartphones to record their performance on each of the five fls tasks in high definition (hd) quality. after each practicing session, they would upload their videos to a designated folder on a password-protected computer in the simulation lab. this folder was linked to a cloud-based storage system that fls instructor had exclusive access. the faculty was able to review each video in the next hours and provide immediate feedback to the residents via email, over the phone or in-person. the video library of performance also allowed the instructor to track the progress of the residents and whether they reached proficiency level in all five tasks to take the fls examination. this program was offered to all surgical trainees. results: utilization of simulation lab to practice fls tasks increased significantly across all postgraduate years after implementation of this model. six residents took the fls examination. the passing rate of the residents remained the same ( % before and after) but their scores in fls manual skills improved significantly compared to the group prior to implementation. the residents evaluated this change positively and reported that the use of videos and immediate feedback by faculty was a valuable intervention in their learning experience. conclusions: the smartphone cameras are readily available and can be used for telementoring. incorporation of telementoring in standard proficiency based fls training can promote self-directed learning and improve the access to experts for immediate feedback as a crucial element of effective training in acquisition of laparoscopic skills. background: it is important that making individual procedures a language, and an objective qualitative evaluation for the laproscopic training. recently, task training and the sham operation using the virtual simulator are carried out for medical students as the basic laparoscopic maneuver training, but there are few reports of objective qualitative evaluation for the training. in this study, we investigated rubric evaluation as the qualitative evaluation for laparoscopic training. materials and methods: one hundred and six students in th grade of tokushima univ. were participated. basic laparoscopic task training (gummy band ligation, beads transfer, delivery of beads, gauze excision) with training box and sham laparoscopic cholecystectomy with virtual simulator were performed. task execution time and rubric evaluation which includes the evaluation standard that became a language for each maneuver were performed before and after basic task training and sham operation. the group who are bad at laparoscopic maneuver was decided by time exceeded in tasks more than two from before practice. relationship between the group who are bad at laparoscopic maneuver and the group which self-evaluation was higher in a rubric evaluation was investigated. results: in basic task training, average task execution time in all students was shortened after practice compared with before practice, but investigated individual, students exceeded in more than two tasks. rubric evaluation in basic task training showed no difference between self-evaluation and evaluation by tutor before and after practice. in sham laparoscopic cholecystectomy, all students and tutor showed high score by rubric evaluation after practice compared with before practice. some students showed higher score than tutor, especially in part of extension of operation field by elevation of the gall bladder, exposure of triangle of calot, and exposure of cystic duct. students who showed high score by self-evaluation in many maneuver of sham laparoscopic cholecystectomy also exceeded in more than two basic tasks. conclusions: as rubric evaluation showed the point of the maneuver is made a language definitely, it was useful for an objective qualitative evaluation for laparoscopic training. pre introduction: bariatric surgery candidates have the opportunity to research bariatric surgeons and hospitals prior to scheduling their elective surgery. pre-operative information sessions are important tools for bariatric surgeons to provide patient education while increasing their patient population. online education is becoming increasingly popular, but its utility over in-person education is uncertain. our objective was to compare patients attending the two most commonly used educational formats: online (webinars) and in-person (seminars) and determine which were more likely to undergo bariatric surgery. methods: we conducted a retrospective cohort study of , patients who attended pre-operative information sessions from january to december by reviewing data maintained by the obesity, prevention, policy and management (oppm) database from our institution. the patients were divided into two groups: those who attended an in-person session (n= ) and those who attended an online session (n= , ). the proportion of patients who went on to have bariatric surgery was compared between the two groups. to categorize the study sample, patient demographics, surgeon providing the information session, and procedure performed were compared between groups. multivariate logistic regression model was applied to compare the effectiveness of in-person session and online session. results: of , patients analyzed, % attended online information sessions ( % female, mean age ). the remaining % attended in-person information sessions ( % female, mean age ). analysis found that . % of patients who attended online information sessions went on to have a bariatric surgical procedure, while . % of patients who attended in-person sessions went on to have a bariatric surgical procedure. after controlling for differences in age and gender, results of multivariate logistic regression analysis indicate that patients who attended inperson sessions were % more likely to have a bariatric surgical procedure than patients who attended an online session ( introduction: knot security is the ability of knots to resist slippage as force is applied, and the optimal number of throws to ensure a secure knot improves efficiency and outcome. the literature on the accepted number of throws per type of suture material has been largely anecdotal, often referring to throws for silk, for polyglactin (vicryl), five for polydioxanone (pds), and six for polyproprolene (prolene). we report a pilot knot-tying study of four suture types to determine optimal numbers of throws. materials and methods: four senior general surgery residents (pgy- and above) and four attending surgeons participated. participants viewed a standardized instructional video and a one-handed knot-tying tutorial. they were instructed to tie one-handed knots, beginning each knot with two throws in the same direction, and square the third and subsequent throws in the opposite direction. each surgeon tied knots, using differenttypes of - suture material: silk, polyglactin, polydioxanone, and polyproprolene. suture types were evaluated using , , , or throws. the participants were randomized to both suture type and order of throw numbers. the knots were then tested on the f.a.s. t knot tester (sawbones, vashon island, wa) for slippage (insecure knot) or breakage (secure knot). generalized estimating equation (gee) analysis was used to determine optimal throw number. results: knots were individually tested on the knot tester for slippage and recorded as % slipped (see table) . the percentage of slipped knots varied by participant and ranged from to %. generalized estimating equation analysis suggested that the only significant variable when determining knot security was number of throws (p= . ), not suture type or participant training level. the optimal number of throws for - silk, polydioxanone, and polypropylene was five, whereas six throws was optimal for polyglactin. conclusion: knot security is dependent on the number of throws placed, and these optimal numbers were higher in our study than the commonly accepted number of throws. evaluation of take introduction: laparoscopic skills can be learned using portable simulators and these skills are transferrable to the operating room. several training regions within the uk have therefore developed and delivered home-based laparoscopic training programmes for junior surgical trainees. although performance improved in some, overall engagement has been poor. similar results have been observed in north america. the aim of our study was to uncover the reasons for poor engagement with home-based simulation with a view to developing a future, more successful, programme. methods: this was a qualitative study utilising focus groups. interviews were undertaken with key stakeholders involved in various laparoscopic home-based simulation programmes through the uk. training equipment comprised the eosim portable simulator paired with online training tasks. the tasks were similar to those used in the fundamentals of laparoscopic surgery programme (fls). basic metric feedback was provided (eg time to complete task). a total of individuals were interviewed, including surgical trainees, consultant trainers, training directors and programme faculty. this generated approximately hours of data which was coded using nvivo software. a basic thematic analysis was performed. results: trainees cited multiple competing professional commitments as a barrier to engaging with home-based simulation. they tended to focus on scoring 'points' which contributed toward career progression rather than tasks which were interesting, or associated with personal development. this approach is perpetuated by the surgical training system, which rewards trainees with points for publications and exams, but not for operative skill. this leads to conflict between trainers and trainees, the former expecting trainees to instead focus upon developing their technical abilities. trainees were unsatisfied with metric feedback and wanted individual feedback from consultant trainers (attending equivalent). trainees generally perceived consultants as lacking interest toward the programmes and training in general. however, some consultants were in fact unaware of the programmes being delivered and others felt lacking in confidence to deliver necessary training to trainees. conclusions: our findings are widely generalizable and have implications for any institution delivering a similar programme. as a means of improving engagement, the the inception of scheduled simulation study days, providing trainees with the opportunity for personalised feedback from consultants, has been suggested. equipping trainers with the necessary competencies to deliver training can be achieved by ensuring attendance at the necessary professional development courses. tackling the 'box ticking' culture is more challenging and may involve a move toward restructuring the current surgical training scheme. introduction: to provide evidence for the face and content validity of a hybrid active-shooter team training simulation and the impact of a hybrid curricular model on learner's engagement and performance. the following study was conducted because hospitals are increasingly threatened by active-shooter incidents, and no active and noticeable training is currently available to train hospital staff members. methods: thirty-five volunteers (medical students, residents and other allied health providers) from the university of minnesota affiliated medical centers were randomly selected and divided into control and experimental groups. the control group (n= ) was given a traditional lecture-style presentation. the experimental group (n= ) participated in the hybrid curriculum which included augmented reality, kinesthetic simulation, and debriefing components. following both curriculum styles, nasa task load index (tlx) surveys were completed by each group member. a final active shooter simulation experience was presented and evaluated by active-shooter trained raters using a checklist of critical actions from the department of defense. a post-simulation nasa tlx survey and post-test were provided. to assess face and content validation of a hybrid team-training simulation exercise to prepare healthcare personnel in the event of a hospital-related active-shooter crisis, a -point likert-scale survey determined the realism, utility, and applicability of this type of training while engagement and performance during the simulation were measured using a nasa-tlx survey and contrasted with the rater's evaluation. our study provided evidence to support the face and content validation of an active-shooter simulation team training curriculum as a useful adjunct to health care institutional safety planning. we demonstrated that this type of training requires an optimal level of cognitive activation to increases learner's engagement and performance. we concluded that the hybrid design of our curriculum was successful in delivering these optimal levels of cognitive stimuli by producing engaging team training simulation experience capable of motivating our learners to acquire the tactical skills and life-preserving behaviors consistent with better survival opportunities during a hospital related active-shooter crisis. the introduction: the virtual electrosurgical skill trainer (vest) provides surgeons and trainees with a hands-on approach to learning the best practices in electrosurgery. it is comprised of five modules covering tissue effects, stray currents, bipolar tools, monopolar tools and or fire safety. the module in this study teaches the origins of stray currents and shows the learner how they can cause damage to non-target tissues via direct and capacitive coupling. the aim of this study was to assess learning using the vest system. methods: the irb approved study followed a single group pretest-posttest design and was conducted at the sages learning center. thirty-eight subjects participated and out of these, % were attending surgeons while the rest were medical students, residents and fellows. % of subjects had prior fuse exposure, while the remaining had none. subjects were asked to complete a five-question multiple choice questionnaire before and after using the simulator. it assessed their knowledge in topics such as direct coupling, capacitive coupling and insulation failure. participants then used the simulator to complete three tasks. first, the subject used direct coupling to seal a vessel and observed the desired effects and potential pitfalls. in the second task the subject was immersed inside the peritoneal cavity and was directed to use the active electrode to observe how the activation of energy can cause capacitive coupling. in the third task the subject practiced evaluating the insulation of electrosurgical tools for defects. wilcoxon's signed rank test was used to differentiate between pre-and post-test scores, and the mann-whitney u test was used to differentiate between the groups of subjects as a function of fuse experience. results: the median score on the pre-simulator assessment was % and the post-simulator median score was % (p = . ). there was no statistically significant difference in pre-assessment scores between attending surgeons and the others (p= . ). subjects with prior fuse exposure scored significantly higher on the pre-module assessment compared to those that had no prior fuse exposure ( % vs %, p= . ). in the post-assessment their median scores were % and %, respectively (p= . ). conclusions: the vest simulator module successfully increased the overall participants' knowledge of coupling in electrosurgery regardless of level of surgical experience. participants with prior exposure to the fuse curriculum had increased knowledge on this topic at baseline as compared to participants without any fuse exposure. introduction: the objective of this study was to assess the reliability of a modified notechs rating scale for the evaluation of medical students' non-technical (nt) skills. the importance of physician nt skills for the safe care of patients is receiving increasing attention in the literature. tools to assess nt skills such as notechs that addresses communication, situation awareness, cooperation, leadership, and decision-making have been shown to be valid and reliable. despite its importance, the assessment of nt skills of medical students, our future physicians, has received little attention. methods and procedures: twenty-seven medical students participated in of acute care simulated scenarios, each approximately minutes long. video recordings of student performance were reviewed and assessed using a modified notechs rating tool adapted for these scenarios with input from a team of clinicians, nurses, and human factors specialists. the rating scale ranged from to , representing very problematic behavior (e.g., not vocalizing concerns or decision process) and representing model behavior (e.g., identifies future problems and remains calm to unexpected events). two reviewers rated all videos independently on the notechs domains and specific subscales. student scores in each nt skill domain and interrater reliability were assessed. results: a summary of the scores of each notechs domain is shown in table . the highest overall average score of a participant was . while the lowest was . . the intra-class correlation (icc; two-way random model) was . , and the cronbach's α coefficient was [ . . the lowest icc agreement was in the situation awareness domain ( . ) while the highest agreement was in leadership ( . ). conclusion: medical student nt skills during acute care simulated scenarios vary significantly using a modified notechs assessment. this newly developed tool provides a framework for educators to evaluate medical students' nt skills during simulation training. it further identified domains where students scored lower, such as situation awareness, and could be targeted for education. the moderate icc, between the . - . range, shows that further refinement of the tool is needed to reliably assess the constructs. future steps to obtain validity evidence include additional raters and applying the tool in non-simulated settings. introduction: a general misperception of the real concept of robotic surgery seems to be revealed in our clinical practice. despite its introduction almost years ago, robotic surgery is still related to many myths and beliefs. before designing a trial to see if these false awareness could impact on outcome, we measured this misperception by a survey. moreover we tested if medical school is able today to give to the future doctors a necessary knowledge about robotic surgery. with the same survey we explore the feelings about the introduction of the artificial intelligence in medicine and the perception of the consequences of a larger use of technology in medicine. methods and procedures: a multiple choice survey was designed and anonymously administered via the platform surveymonkey (http://www.surveymonkey.com). a total of questions were selected from the research team and included in the survey. the questionnaire was divided in three parts: the first was to get information on participants' population; the second asked specific questions about robotic surgery; the third focused on technology use in medical education. results: we received and analyzed questionnaires, of which totally filled. many undergraduates consider robotic surgery as "experimental", will prefer open surgery on themselves and see a risk for robotic surgery in damaging the patient-surgeon relationship. this situation is better for medical students, but still a great diffidence were encountered. % of ug consider robotic surgery as "experimental" vs only . % of ms (q ). most thought robotic surgery had been used for only years or less (q ). . % of ug and . % of ms gave the right answer (p=. ). almost % of ug see robotic surgery as a risk in damaging the patient-surgeon relationship. this is not seen among ms (q ) (p=. ). % of ug are fearful of robots used to operate them. this fear is significantly reduced among medical students (p=. ). ug were less familiar with the indications and uses for robotics. ms gave a correct response more frequently (q , . % vs . %, p= . ). conclusions: our results indicates that nowadays, the robotic surgery is related a lot of misperceptions and a generally low level of information. this general picture is partially mitigated during the medical school, but the level of knowledge is still low. a big effort seems mandatory in clarify every technical aspect and an ethic debate about robotics, technology and ai as part of medical curriculum is advisable. background: learning theory states that a certain level of physiological stress or cognitive activation is required to achieve optimal task engagement and performance by the learners. our study will seek to determine if a hybrid team training curriculum inclusive of a task-oriented interactive virtual environment could help achieve the optimal level of cognitive activation required to result in a higher task engagement and performance. methods: a total of thirty-five medical professionals from the university of minnesota participated in several team training simulations. participants were randomly selected to an experimental and control groups. the experimental group (n= ) was exposed to a hybrid team training module, consisting of a task-oriented augmented reality phase followed by a second and third phase consisting of a kinesthetic simulation scenario and debriefing, respectively. the augmented reality phase presented the trainees to an interactive -degree image of the same clinical room where the simulation would take place allowing for ''situated-learning'' to take place. during the learning phase, trainees were encouraged to interact and communicate with each other while completing the tasks allowing for ''social-learning'' to effect. the control group (n= ), educational component consisted of a traditional audiovisual lecture-style introductory presentation, a simulation, and debriefing. after completing their respective educational components, each group completed a nasa task load index survey to assess the cognitive load experience of the individual educational models. subjects were then exposed to a final simulation (test simulation) similar in content and structure to the initial simulation. this was followed by a second nasa tlx survey. raters evaluated both group level of engagement and performance using a validated checklist of critical actions. results: the experimental groups showed higher weighted overall nasa cognitive load index scores than the control group (p= . ) prior to the test simulation. the weighted nasa score remained elevated in the experimental participant groups following the test simulation, whereas in the control group the post-simulation nasa assessment revealed a decrease in cognitive load (p= . ). expert raters using a validated checklist determined that . ± . % of the experimental (hybrid curriculum) group and . ± . % of the control group appeared to be more engaged and performed better during the simulation. conclusions: pre-simulation task-oriented augmented reality learning environments designed to incorporate situated, and social learning virtual experiences can provide the optimal level of cognitive boost that can result in a higher participant engagement and performance during team training simulation scenarios. introduction: despite the huge importance of laparoscopy, medical students have a brief contact with this surgical specialty during medical school in brazil. usually, they get in touch with this specialty during the surgery clerkship in the last years of medical school. therefore, few students perform clinical research or develop interest for this area during graduation. objective: to awaken the interest in laparoscopy of medical students early in medical school, improving the development of clinical research projects, and to prepare new generations of minimally invasive surgeons. discussion: the academic league of videolaparoscopy was created in under the guidance of dr. gustavo carvalho from the university of pernambuco, brazil. an academic league is a group of medical students who are guided by a tutor to develop three areas: research, teaching, and clinical practice. every year new students join the league after being selected with a multiple question test and an analysis of the curriculum vitae. the students are stimulated to participate in laparoscopic procedures as observers, learning about the techniques and instruments. moreover, there are minimally invasive surgery lectures and courses during the year. general surgery residents can also be part of the program as tutors. they are encouraged to present lectures, and to assist with research projects. medical students participated of this program in years. % pursued a surgical specialty after graduation. % did minimally invasive surgery as a fellowship. conclusions: the students who participate in several activities provided by the league have an increased interest in pursuing the path to become a laparoscopic surgeon. background: surgical education is an active and adaptive process of developing knowledge, technical and non-technical skills. the rise of social media has created a paradigm shift in surgical education, with online learning platforms offering exposure to real-time content, expert instruction, and global collaboration. while these disruptive technologies evolve, their influence on surgical education has not been investigated. our goal was to evaluate the growth and impact of an online surgical education model-the advances in surgery (ais) channel. our hypothesis was that utilization and engagement with the platform continues to grow, providing novel methods of measuring successful education. methods: assessment of the platform's membership demographic, user activity, and engagement was performed from inception in to quarter . the ais channel uniquely provides free, high quality, innovative content from elite surgeons in scheduled and continuously available formats across colorectal, bariatric and endocrine surgery service lines. users login to access content, with demographics, time spent, and content accessed recorded as measures of active account utilization and engagement. the main outcome measures were overall membership trends, utilization patterns by region, content type, and surgical specialty for the platform. results: users were predominately male ( . %), surgeons ( . %), and ranged in age from to years ( . %). the main surgical subspecialty represented was colorectal ( . %). active account usage/weekly recurrence was . % ( % industry benchmark), with users engaged for a mean minutes/session (excluding live events). since inception, steady exponential growth was seen across several dimensions. registered users and unique ip addresses increased from over , and , in to over , and . million in , respectively. the number of countries represented increased to reach across continents. at present, over live surgeries and live congresses have been broadcast from countries, with over , surgical videos available on demand to facilitate surgical education. the greatest engagement is seen with live surgical broadcasts. conclusion: our analysis demonstrated proof of concept for a unique, online surgical education model to provide effective surgical education. success was validated through the increase in overall users, sustained active account usage, and global penetration. user preferences for live surgical broadcasts were seen. knowing the utilization and preference patterns, the platform can continue to evolve and enhance the learners' experience. with this growth and penetrance, there is the potential to globally improve patient outcomes and the quality of care provided. background: a realistic simulator for transabdominal preperitoneal (tapp) inguinal hernia repair would enhance the surgeons' training experience before they enter the operating theater. the purpose of this study was to evaluate the efficacy of d-printed tapp simulator in evaluating preoperative skill before entering operative theater. methods: surgeons in our institution were enrolled in this study. they performed simulation tapp and the performance score was measured using tapp check list. the tapp simulator allows for the performance of all procedures required in tapp. the correlation between post -graduate years (pgys), age, experienced a number of laparoscopic surgery (more than , less than ), experienced number of tapp and the performance score was evaluated. results: strong correlation between experienced member of tapp inguinal hernia repair and the performance score was evaluated in this study (r= . ). however, the correlation between pgy, age and score was weak ( introduction: as the field of laparoscopic surgery grows, the need for standard measures of complex laparoscopic surgical skills is apparent. fundamentals of laparoscopic skills (fls) testing is required to complete general surgery residency, but there is no standard metric to convey expertise in advanced laparoscopic procedures. in an effort to develop a standardized assessment of laparoscopic suturing expertise, a group of experts was surveyed using delphi methodology to reach consensus on observed laparoscopic suturing skills reflective of performing at an expert level. methods: expert laparoscopic surgeons participated in serial surveys via redcap (research electronic data capture). experts included surgeons who perform[ /year laparoscopic procedures that involve intra-corporeal suturing, obtained from the authors' personal and professions networks. using a point likert scale, participants were asked to agree/disagree if different observed laparoscopic suturing skills indicate performing at an expert level. these skills were chosen from prior assessment instruments in the literature and the authors' previously published work. tasks were considered to meet criteria for consensus and eliminated from the next round of the survey after reaching % consensus as "strongly agree." results of the previous round of surveys were shared with participants at the start of the next round. the predefined endpoint for the delphi was set as maximum of rounds, reaching % consensus on each skill, or if[ % of initial respondents fail to return for subsequent surveys. results: after the first round of the delphi survey, respondents met inclusion criteria. preliminary data demonstrated skills that reached consensus ([ % of respondents chose "strongly agree"): forehand suturing, avoiding tissue trauma, having a technically acceptable final product (ie. tight closure), and tying a secure knot at the end of suturing. items did not approach consensus (\ % of respondents chose "strongly agree" or "agree"): alternating hands for each throw while tying, never missing a target when grabbing needle/suture, alternating direction of throws when tying, and backhand suturing. data from all four rounds of surveys as well as the final draft of the assessment instrument will be available at time of presentation. conclusion: preliminary data of this delphi study allowed us to reach consensus amongst a group of expert laparoscopic surgeons on the characteristics of expert laparoscopic suturing, which will allow creation of a comprehensive assessment tool for this domain. validation of such a tool will help advance the surgical field towards true competency-based credentialing and promotion. the study was designed to assess the knowledge of scp among european surgeons (specialists and residents). additionally, surgeons' opinion on usefulness of each of the rules of scp was gathered. the data were analyzed in terms of differences between residents and specialists. this is to set ground for and an educational program and increase the safety of elective laparoscopic cholecystectomy by minimizing the occurrence of cbdi. methods: the data on the knowledge of scp and opinion on usefulness of its rules were gathered in form of an anonymous questionnaire distributed among participants of several surgical conferences in poland. the questionnaire then asked about the surgeon's experience in terms of cholecystectomies performed and the number of complications in form of cbdi. it then listed the scp rules and asked the surgeon about their opinion on usefulness of each of the rules on a -point scale. gathered data were subject to statistical analysis and a comparison between specialists and residents was performed. the study has been registered in the clinicaltrials.gov-nct . , although these numbers are still low. significant differences in the mean usefulness score between residents and specialists were observed in regard to two rules: rule was found more useful by residents (mean score , vs. , , p= . ), whereas rule was found more useful by specialists (mean . vs. . , p= . ). the awareness of the sages safe cholecystectomy program in poland is still low and needs to be promoted. both surgical residents and specialists consider the rules of scp to be useful during surgery, although there are slight differences in the usefulness scores between the groups. an educational program to promote and further implement the scp should be established. introduction: transanal total mesorectal excision (tatme) has attracted substantial interest amongst colorectal surgeons throughout the world. technical challenges of the technique however have been acknowledged by early adopters and this may underpin the early reports of visceral injuries which occurred during the perineal phase. evidence from previous surgical training programs suggest that a structured proctorship programme can shorten the learning curve, operative time and most importantly reduce major complications. the aim of this study was to report on the first national pilot training initiative which was developed in the uk to ensure safe introduction of this technique. methods: a pilot training programme for the uk has been established in partnership with the healthcare industry, and supported by the association of coloproctology of great britain and ireland. the programme consists of three phases: (i) development of a consensus process on the optimum training curriculum of tatme from all relevant stakeholders, including experts, early adopters, and potential learners, to guide the training of this technique (ii) piloting of this training curriculum and (iii) assessment and quality assurance mechanisms to monitor training and measure outcomes. results: a cohesive multi-modal training curriculum has been developed providing clear guidance on case selection, supporting multi-disciplinary and multimodal training including online modules, dry-lab, purse-string simulators, cadaveric training and formal clinical proctoring programme. the uk pilot programme opened for applications in may and, after a rigorous selection process, the initiative was launched in september with trainers mentoring consultant colorectal surgeons from five centres. the selection of learners was based on suitable case volume and prior experience in laparoscopic rectal surgery. objective assessment tools were applied to an unedited video of a laparoscopic rectal surgery case for each applicant. for the selected centres, access to the ilapp tatme app was provided to access educational content including operative video footage, prior to attending a bespoke cadaveric workshop. each learner will then benefit from a structured, centrally organised and funded proctorship programme at their own institutions. a global assessment score form has been specifically designed to monitor training and a formal accreditation process will be used to sign off each learner using competency assessment tool. data on the cadaveric workshop and initial outcomes of the clinical mentorship will be presented at the conference. conclusion: a competency-based pilot training programme for transanal total mesorectal excision has been launched in the uk to support safe introduction of this technique. practicing on a fls trainer box is effective but requires large amount of consumables and is scored subjectively. the purpose of this study is to evaluate the face validity of the intracorporeal suturing task on a virtual fundamentals of laparoscopic surgery simulator (virtual fls). we hypothesize that the virtual fls will demonstrate face validity. methods and procedures: after a video demonstration and a practice period, twenty-three medical students and residents completed an evaluation of the simulator. the participants were asked to perform the standard intracorporeal suturing task on each of the virtual fls and the traditional fls box trainer. the presentation order of the devices was balanced. the performance scores on each device were calculated based on time (seconds), deviations to the black dots (mm), and incision gap (mm). the participants were then asked to finish a -question questionnaire regarding the face validity of the simulator. participants answered questions with ratings from (not realistic/useful) to (very realistic/ useful). a wilcoxon signed ranks test was performed to identify differences in performance on the virtual fls compared to the traditional fls box trainer. results: responses to of the questions ( . %) averaged above a . out of . those questions that rated the highest were the degree of realism of the target objects in the virtual fls compared to the fls ( . ) presently, most training methods for thoracoscopic esophagectomy use live porcines; this presents several problems including cost, long preparation times, and ethical issues. these problems further prevent frequent training. currently, no alternative models for thoracocopic esophagectomy training. we report, for the first time, the development and use of a non-biomaterial training model for thoracoscopic esophagectomy. methods: we collaborated with sunarrow co., ltd. (tokyo, japan) to develop the training model. we created organ models for esophagus, trachea, bronchus, aorta, vagus nerve, recurrent nerve, bronchial artery, lymph node, vertebrae, azygos vein, and thoracic duct, and filled the models with a polyvinyl alcohol hydrogel. the gaps between organs were filled with a filler material mimicking connective tissue. we chose a synthetic resin that closely mimics the characteristics (rigidity or elasticity) of each organ. after each organ was fixed, the model was covered with a filler to create a pleural membrane to allow training in peeling operations. in addition, because a patient plate was attached to the rear of the training model, excision with an energy device was possible and more closely simulated surgical conditions. results: using the training model resulted in a highly satisfactory level of experience in three trainees. the trainees were able to learn anatomical positions and sequence of surgical procedures, including endoscope handling. centre for rural health, aberdeen university introduction: as doctors become expert in a complex procedure, they develop automatic nuances of performance that are difficult to explain to a peer or a trainee (so called 'unconscious competence'). traditional methods which aim to allow sharing of expertise have limitations: concurrent reporting alters the flow of the task at hand while retrospective reporting is subject to bias and often incomplete. iview expert is a technique validated in the aerospace domain which externalises an expert's cognitive processes, without disrupting the task at hand. the aim of this project is to assess the feasibility of adapting the technique to medical training. methods: this was an observational case study in which an expert endoscopist wore a head mounted camera to capture a complex procedure (colonoscopy). captured video was reviewed during a facilitated debrief which externalised the expert's cognitive processes. the debrief was recorded and formed an audio commentary. the video and accompanying audio commentary formed a learning package which was watched by a specialty trainee. the technique differs from standard procedural videos in that it provides a more detailed insight into cognitive processes of the expert. this is achieved through the debrief, which encourages reflection upon kinaesthetic (head movement) as well as auditory and visual cues, resulting in a higher level of experiential immersion. questionnaires examined acceptability and educational value of the technique using likert scales and free text answers. quantitative data were presented using basic descriptions in terms of agreement with statements. qualitative data from free text responses were coded in order to identify key themes. results: the expert agreed that wearing the camera was acceptable and did not interfere with the procedure, nor usual decision making processes. qualitative analysis revealed the debrief process to be associated with a high level of experiential immersion: "as if they were there". both the expert and the trainee strongly agreed that the process was educationally valuable and that they learned something new. qualitative analysis demonstrated that the technique revealed useful and unique nuances of the procedure. the intervention could represent a powerful adjunct to existing training methods, especially amongst more experienced practitioners. we are currently undertaking a larger study involving a greater range of procedures with more learners. introduction: endoscopy is an important skill for general surgeons to possess. however, there is lack of training within surgery residency programs. we implemented a one-day endoscopic surgery course with the aim of improving the confidence of surgical residents in performing endoscopic procedures. we also aimed to examine the effect of the exposure to this course on self-reported confidence in performing endoscopic procedures. methods and procedures: the fundamental of endoscopic surgery course at texas tech university health science center is a one-day course consisting of both didactic training and lab training. the didactic part of the course is taught by attending physicians and focuses on the basics of endoscopy, management of upper and lower gastrointestinal (gi) bleed, and techniques to perform a variety of gi endoscopic procedures on swine esophagus and stomach explant. the lab portion of the course allows residents to perform different endoscopic surgical procedures with the attending physicians providing guidance. residents from pgy- to pgy- participated in the course. a -item questionnaire that measured the self-reported confidence in performing several endoscopic procedures on a - likert scale was administered before and after the course. results: twenty-two participants successfully completed the training and the questionnaires. a significant improvement was observed in the overall confidence in performing a variety of endoscopic procedures ( . ± . , p. ). the improvements remained significant even after controlling for the years of postgraduate surgical training (p. ). conclusion: the one-day fundamental of endoscopic surgery course enabled residents to be more confident with endoscopic procedures. overall, the residents felt that the course was helpful and would like to attend more than one session per year. this course should be held, at least, annually to allow the general surgery residents to become even more confident with this important skill. by being more confident in their surgical endoscopy skills, they will ultimately be able to provide better care for patients. introduction: a course evaluation study on the effectiveness of improving laparoscopic skills of surgical residents using swine models was evaluated through a self-report questionnaire administered before and after course completion. the purpose of the training is to provide surgical residents opportunities to practice and advance their laparoscopic proficiencies. methods and procedures: participating residents in all post-graduate year levels (pgy through pgy , n= ) were provided anesthetized pigs with which to perform a variety of simple to complex laparoscopic cases. prior to training, residents were given a questionnaire composed of eleven questions requiring the subjects to rate their confidence in performing various laparoscopic procedures on a - likert scale. after completion of the course, an identical questionnaire was distributed with two additional questions relating to the overall impact of the course. all statistical analyses were conducted using r statistical software (version . conclusion: overall, one-day hands-on training using swine models improved resident's skills, confidence, and understanding of laparoscopic surgery. the information acquired through the questionnaire emphasized the importance of providing a laparoscopic training course as a standard requirement at all medical institutions. allowing opportunities for surgical residents to practice their laparoscopic skillset will not only help in their individual academic advancements, it will allow them to provide optimum care for their patients. background: learning laparoscopy is difficult and many educational tools including simulation training are required. feedback plays a crucial role for motor skill training but require expert tutors and its time consuming. e-learning increases knowledge acquisition through a more interacting multimedia experience and reduces de costs of learning. in the last decade multiple applications (apps) have been developed for mobile medical training. a new ios app was developed using specially designed educational videos that explain the main technical aspects in advanced laparoscopy through simulation training. the aim of this study is to present the first results of its incorporation in a surgical simulation lab as a complement of effective feedback. methods: twenty-five consecutive residents were trained in our simulation lab through a session validated training program for the acquisition of advanced laparoscopic skills needed for the performance of a laparoscopic hand-sewn jejuno-jejunostomy. every session had written instructions and a basic tutorial video. the app consist two main sections, the first one explains the essential techniques needed for intracorporeal suturing and the second is a complete walkthrough of the validated training program. the trainees were divided in two groups, the first was trained without using the app (napp) and the second group was trained using the app (yapp). both groups of trainees could ask for feedback anytime they needed. trainees were assessed before and after the training program using validated rating scales and the number of necessary tutor-feedback sessions were registered. finally the yapp group answered a survey about the strengths and weaknesses of the app for learning advanced laparoscopic skills. results: twenty-five residents completed the training program; yapp and napp. both groups finalized their training with no statistical significant differences in their scores (p: . ). the number of tutor-feedback needed to complete the training in the yapp vs napp was of [ ( - ) vs ( - ) (p. )] respectively. in the questionnaire all participants considered that the app was effective for learning advanced laparoscopy. over downloads have been registered since the app was published in the apple app store in . we present a novel smartphone app that guides laparoscopic training using simulation-based educational videos with very good results. the use of app guided learning reduces de need of expert tutor feedback reducing the costs of simulated training. jemin choi, young-il choi; kosin university gospel hospital purpose: laparoscopic appendectomy (la) has been widely performed for acute appendicitis. in addition, minimally invasive surgery such as la is common surgical technique to the surgical residents. however, single incision laparoscopic surgery (sils) is a challenge to inexperienced surgical residents. we described our initial experience in teaching sils procedure for appendectomy in our medical center. methods: twenty nine cases of single incision laparoscopic appendectomy (sila) were performed by single surgical resident and cases of la were performed by surgical residents and boardcertified surgeons. a study was reviewed retrospectively. ( ) clinical stressors (i.e., vitals of patient coding). we developed a stress simulator testbed by integrating an fls box trainer with a linux computer, running custom c++ code. the code generated various stressor conditions, while recording sensor data from the trainer and human operator. we tested groups of participants in an irb approved trial including: novices (non-medical students), intermediates (medical students), and experts (pgy residents and fellows). the study consisted of subjects performing the peg transfer and the pattern cut six times (baseline, four randomized stressors, posttest). after each task, the nasa-tlx survey was administered to determine the overall workload of that stressor condition. an analysis of variance was conducted to identify significant trends in terms of stressor type. results: when compared to baseline nasa-tlx scores, the intermediate group had the greatest changes in overall workload than novices and experts (p= . ). additionally, the change between baseline and post-test workload was significantly lower than for the environmental, negative evaluative, and clinical stressors (p= . ). for pattern cutting, subjects reported a significantly lower perception of failure (p= . ) in both the positive evaluative (mean= . ) and post-test conditions (mean= . ), yet, though not statistically significant (p= . ), the measured accuracy in the task during the positive evaluative condition was actually worse ( . %), second only to the pre-test accuracy ( . %). the best accuracy for pattern cutting across all expertise levels was % for the post-test followed by . % in the negative evaluative condition. these results are interesting as they show that despite perceived improvements in performance with a positive feedback condition, performance actually degrades and is better in the negative feedback condition, which is perceived to be more difficult. these results were not found in the peg transfer task, which is arguably an easier task. conclusion: from the evidence gathered in the study, it is clear that there is a correlation between distractors and performance. further analysis is needed to identify the relationship between the type of stressor, and inherent difficulty of the tasks, in terms of which type of stressor best improves learning and outcomes. surg endosc ( ) each received credentials to perform diagnostic and therapeutic ercp from their respective hospitals in nevada, minnesota, and idaho. one continues to teach ercp to general surgery residents, and another taught the skill to fellows in an advanced endoscopy fellowship. all three continue to use ercp in their practice ( to times per month), as they each specialized in a field that utilizes ercp routinely. choledocholothiaisis is the most frequent indication, though ercp is also performed for iatrogenic biliary duct leaks, traumatic biliary or pancreatic duct leaks, chronic pancreatitis, and malignancy. conclusions: training in esophagogastroduodenoscopy and colonoscopy is required for general surgery residents, but the addition of ercp to select residents' training enables them to completely manage their patients' surgical disease. the training of select general surgery residents in this skill has been successful, evidenced by the continued use of ercp in the practices of three residents who completed this training program at our institution. the decision to train residents in this skill should be left to individual program directors and department chairs. we recommend that residents selected for this additional training should plan to practice in specialties where ercp can be implemented. conclusion: same-day discharge after nissen fundoplication and hiatal hernia repair is feasible for select patients. one major challenge for same day discharge is the current insurance provisions required for hospital reimbursement. within the parameters of this study, bmi and asa score did not differ between discharged and admitted patients, while older age and increased procedure duration were associated with need for admission. premkumar anandan, ms, facs; bangalore medical college and research institute introduction: minimal access surgery is an imperative element of enhanced recovery program and has significantly improved the outcomes. enhanced recovery program (erp) synonym "fast track" surgery "was first conceived by dr henrich kelhet. largely described for colorectal surgery and reported to be feasible and useful for maintaining physiological function and smooth the progress of recovery. most of the patients who present for surgical emergency are not adequately prepared and many are not in normal physiological state. the feasibility of enhanced recovery programs protocol in such emergency minimal access surgery remains indistinct. this study was designed to validate an enhanced recovery program in patients who undergo emergency minimal access surgery. introduction: pathways for enhanced recovery after surgery (eras) have been shown to improve length of stay and postoperative complication rates across various surgical fields, however there is a relative lack of evidence-based studies in bariatric surgery. the objective of the current study was to determine if starting a bariatric full liquid diet on postoperative day (pod) zero was associated with shorter length of stay (los) for patients who underwent laparoscopic sleeve gastrectomy (lsg) or roux-en-y gastric bypass (rygb). methods: retrospective review of a prospectively collected dataset was conducted at a single institution before and after implementation of a new diet protocol for lsg and rygb. postoperative diet orders were changed from full liquid diet on pod to pod . length of stay and -day readmissions were reviewed from june to august . independent samples t-tests were used to compare continuous variables and chi-squared tests for categorical variables before and after diet change was implemented. patients were excluded if they were undergoing revision surgery, were discharged directly from pacu, or had significant intraoperative complications or required reoperation within the same admission. introduction: data suggests value in using tap (transversus abdominis plane) neural blockade in abdominal surgical procedures. we deploy tap blockade using liposomal bupivacaine via ultrasound (us) as part of a narcotic sparing pain management pathway for patients undergoing abdominal surgery in our rural community setting. our goal was to evaluate adequacy of postoperative discomfort and the success in avoiding narcotic usage. methods and procedures: records of patients undergoing abdominal surgical procedures performed by one surgeon over an month period were reviewed under irb approval. patients taking narcotics prior to the procedure (except for discomfort due to the condition being surgically treated) were excluded from analysis, as were those admitted to the hospital for postoperative treatment. us guided lateral tap blocks were performed by the surgeon using mg of liposomal bupivacaine and mg of bupivacaine in the or prior to the incision. unilateral block was performed for unilateral procedures (e.g. inguinal hernia) and bilateral for laparoscopic or midline procedures. incisional sites were treated with a field block of mg of bupivacaine. prescriptions for medications included , mg of acetaminophen qid and mg of naproxen sodium tid for days. a prescription for tramadol ( to mg prn up to times daily; tablets with no refill) was given. patients were seen in followup two weeks postoperatively. data (following standard scales/metrics) for patient-reported-outcomes e.g. pain, nausea-vomiting, & fatigue will be analyzed with the above data and the analysis with conclusions will be presented & discussed. federico sertic, md, ashwin gojanur, dr, ahmed hammad, md; guy's and st thomas' hospital introduction: the aim of this project is to assess the quality of post-operative pain relief in colorectal surgery and identify patients in whom pain management has not been effective, in order to improve the quality of post-operative care. effective management of post-operative pain has long been recognised as important in improving the post-operative experience, reducing complications and promoting early discharge from hospital. standards: all patients should be pain free at rest, % of elective patients should be told about what analgesia they will have post-operatively, % of patients should be satisfied with their pain management and % of patients should feel staff did everything they could to control their pain. methods and procedures: questionnaires were given to patients on the day prior to discharge. questions about pre-operative and post-operative pain experience were asked. data regarding post-operative analgesia were collected from medication charts and medical notes. data were collected over a period of two months (august/september ). range of procedures: elective laparoscopic abdomino-perineal-excision-of-rectum with igap flaps, elective laparoscopic right hemicholectomy, laparotomy+bowel resection/stoma formation ( elective, emergency), elective repair of parastomal hernia, appendicectomy ( laparoscopic elective, laparoscopic emergency, laparotomy emergency) and elective reversal of ileosomy. pain scores ( - ): immediately post-operative pain, day post-operative pain, post-operative pain after day and pain on moving/coughing/straining. results: mean immediate post-operative pain score was . ( % of patients with score +), mean day post-operative pain score was . , mean post-operative pain score after day was . , mean pain score on moving was . ( % of patients with score +), mean pain score on coughing/ straining was . ( % of patients with score +). % of patients were satisfied with their post-operative pain management and felt that the staff had done everything they could to manage their pain. % of patients were not aware of their post-operative analgesia regimen and % did not know how regularly they could request analgesia. conclusions: effective management of post-operative pain is a key part of post-operative care and an important component of enhanced recovery programmes. patient satisfaction with pain management has been found to correlate with received pre-operative information. increasing ward nurses' and acute pain teams' knowledge is important in improving patients' pain experiences. interestingly, those patients who had a background of long-term opioid requirements reported that they were satisfied with their pain management. methods and procedures: a patient undergoing a standard ultrasound guided ql block by an anesthesiologist established the baseline anticipated response, and procedure time. the procedure, performed under sedation preoperatively, required over minutes. for this study, patients undergoing laparoscopic colorectal surgery were administered a lateral ql block (modified ql ) under ultrasound guidance by the operating surgeon. ml of a mixture ( ml injectable liposomal bupivacaine suspension, ml . % bupivacaine hydrochloride and ml normal saline) was injected bilaterally, after induction, skin preparation, draping, and prior to the operation. postoperative narcotic use and pain vas scores were documented. results: six patients were administered a bi-lateral ql block intraoperatively. procedures were: laparoscopic sigmoid colectomies, one end ileostomy reversal, laparoscopic completion proctectomy with ileal pouch anal anastomosis, and a laparoscopic descending colectomy. of the narcotic naïve patients, mean pain vas on post op days , and were . , . and . respectively within a multimodality pain management/enhanced recovery program, where standing orders prompting narcotic administration by nursing staff is pain vas . all were discharged on pod or without narcotic prescriptions. two of the patients were chronic narcotic users, and they were discharged on their baseline narcotics, i.e. without additional narcotics. all intraoperative blocks were performed in less than minutes. conclusion: a novel, surgeon-administered lateral ql block under ultrasound guidance, is feasible and provides post-operative pain control. patients are discharged home on no/baseline narcotics. a randomized controlled trial is being constructed based on these striking findings. keywords: lc-laparoscopic cholecystectomy, ga-general anaesthesia, sa-spinal anaesthesia. nikhil gupta, rachan kathpal, dr, arun k gupta, dr, dipankar naskar, dr, c k durga, dr; pgimer dr rml hospital, delhi introduction: cholecystectomy have shown some advantages when done under spinal anaesthesia (sa) and associated with less intra operative and post -operative morbidity and mortality. laparoscopic cholecystectomy (lc) under regional anaesthesia alone included patients with coexisting pulmonary disease, who are deemed high risk for ga. the aim of the present study is to assess the efficacy and safety of laparoscopic cholecystectomy under sa. materials: this prospective, interventional study was conducted on patients with chronic calculous cholecystitis attending general surgery out-patient department of our institution. results: in our study, intraoperative complications recorded were hypotension, bradycardia, intra op shoulder tip pain, bleeding from the liver bed, bile spillage, post-op pain and vomiting. % patients had intraoperative pain, % had shoulder tip pain, . % had bradycardia, . % had hypotension, . % had bile spillage and . % had bleeding. laparoscopic cholecystectomy under spinal anaesthesia should be promoted more even in developing countries but we need to establish well evaluated safety guidelines that could be followed faithfully for minimizing the risk of complication. background: the "opioid crisis" has taken over headlines with increasing public attention brought to the drastically increasing rates of addiction to prescription narcotics. in , the american society of addiction medicine reported million americans with an addiction to prescription pain relievers and a four-fold increase in overdose related deaths. in a medical setting, increased opiate use is associated with increased rates of delirium, ileus, urinary retention, and respiratory depression. these risks are increased in the obese/bariatric population. transversus abdominis plane (tap) block is a safe and effective approach to achieve optimum pain control. it reduces the use of opiates in patients undergoing major abdominal surgery. however, there is currently no data in the literature examining its use in the bariatric population. our study examines the use of liposomal bupivacaine for tap block in patients undergoing laparoscopic sleeve gastrectomy (lsg). methods: sixteen patients undergoing lsg with tap block were compared with historical cohort of sixteen patients undergoing lsg without tap block (standard group). the primary outcome measured was post-operative in-hospital opiate use (morphine equivalents). statistical analysis was performed using student's t test for continuous variables and fisher's exact test for categorical variables. results: both groups were well matched in regards to bmi, age, and asa class. there was a significant decrease in the post-operative use of opiates with the use of the tap block ( . mg in the tap block group vs. mg in the standard group; p . ). there was no difference in the mean length of stay between the two groups. there was an increase in the mean operative time with use of the tap block ( minutes in the tap block group vs. minutes in the standard group; p. ) conclusions: the use liposomal bupivacaine for tap block provides substantial analgesia, allowing for significant reduction in post-operative opiate use in our bariatric patients. this can be an important adjunct in pain control for the bariatric population and aid in post-operative complication risk reduction. introduction: the objective of this study was to identify variation in weight and demographics in the distribution of pre-operative clinical characteristics between super obese females compared with males who were about to undergo bpd/ds surgery. as the american obesity epidemic increases, morbidly obese patients have become integral to every surgical practice; they are no longer limited to bariatric surgeons. every clinical insight helps the surgeon to optimize outcomes when operating on and managing these medically fragile individuals. in this context, however, clinically and statistically significant differences in demographics, body mass, and in the distribution of weight-related medical problems between super-obese women and men are unknown. introduction: a transversus abdominis plane (tap) block is an ultrasound-guided injection of local anesthetic in the plane between the internal oblique and transversus abdominis muscles to interrupt innervation to the abdominal skin, muscles, and parietal peritoneum. currently there are incongruent findings on the benefit of this regional anesthetic to surgical patients, particularly the obese population. we hypothesized the addition of a tap block in an enhanced recovery pathway (eras) for bariatric patients would decrease opioid use and shorten hospital length of stay. methods: a retrospective review of all patients who underwent bariatric surgery at a single institution from january to december was performed. patients were identified as: no tap block (no tap), tap blocks that were performed after induction either pre-surgery (pre-tap) or post-surgery (post-tap). the primary outcome was time to first opioid (min) and total morphine (mg) equivalents in pacu. objective: prolonged postoperative ileus increases hospital length of stay and therefore impacts healthcare costs. although many surgeons recommend ambulation in the postoperative period to hasten return of bowel function, little evidence exists to support this practice. our hypothesis is that early ambulation does reduce the time to return of bowel function after intestinal surgery. methods: a subset of patients undergoing intestinal surgery from an ongoing, prospective trial evaluating perioperative physical activity was analyzed. preoperatively, patients wore an activity tracker for a minimum of three days to establish a baseline activity level, measured by daily steps. postoperatively, steps were recorded for days. patients were included in this study if they underwent an operation on the small bowel, colon, or rectum. resolution of postoperative ileus was defined as the postoperative day when patients were noted to meet all of the following criteria on review of nursing documentation: passing flatus, stooling or having ostomy output, and tolerating a regular diet without intravenous fluids. "early" postoperative activity was defined as the average number of daily steps during the first two postoperative days. discussion: these results suggest the patients who received an intraoperative block laparoscopically were more likely to be able to spend less time in the post anesthesia care unit and be discharged home the same day. based on these results, additional process improvement ideas will be implemented in an attempt to improve outcomes. riley d stewart, md, msc, frcsc, james ellsmere, md, msc, frcsc; dalhousie university division of general surgery introduction: oropharyngeal and gastrointestinal (gi) perforations from bbq brush bristles are being reported in the literature with increasing frequency. media attention to this problem has increased awareness by the public. most commonly, bbq bristles lodged in the gi tract can be removed endoscopically or pass without complication. rarely, surgical intervention is required for removal of the bristle or drainage of an associated abscess. we report a case of gastric perforation by a bbq bristle leading to a pancreatic abscess. case report: a -year-old male presented to a regional center with epigastric pain and malaise. his medical history included: hypertension, dyslipidemia, gerd, and smoking. his surgical history included: a tonsillectomy, excision of bronchial cleft cyst, and an umbilical hernia repair. on presentation, his laboratory investigations where unremarkable aside from an elevated white blood cell count. investigations including an abdominal x-rays and an abdominal ultrasound were unremarkable. he was initially treated with a proton pump inhibitor for presumed peptic ulcer disease. he returned to the local emergency room, no better than before. a ct scan was arranged which demonstrated a foreign body at the pylorus consistent with a bbq bristle and a peripancreatic fluid collection (figs. & ) . a gastroscopy failed to identify the bristle. he was admitted, placed on iv antibiotics and referred to our center. despite several days of antibiotics prior to arrival, the collection size on repeat ct scan had increased and the patient had ongoing pain. we repeated the endoscopy with a side viewing endoscope. the perforation was identified posteriorly at the pylorus. the bristle had migrated into the peripancreatic space. the perforation was cannulated with a jagtome. fluoroscopy was used to confirm the position of a wire in the fluid collection (figs. & ) . pus was drained from the collection into the stomach by placement of a french pigtail catheter (fig. ) . the patient was discharged pain free the following day. the patient was asymptomatic at weeks' follow-up. a repeat ct scan showed resolution of the abscess and safe migration of the bristle and stent out of the gi tract (fig. ) conclusion: to our knowledge, this is the first reported transgastric endoscopic drainage of a peripancreatic abscess caused by a bbq bristle gastric perforation. this case is a demonstration of the ever-expanding role of therapeutic endoscopy in a surgical practice. andrew w white, md, carl westcott, md; wake forest baptist medical center introduction: endoscopic balloon dilation of the gastroesophageal junction (gej) is generally limited to mm in diameter. in many stenotic or spastic disorders of the gej mm is just not big enough. larger balloon sizes are available ( and mm), although these are deployed under fluoroscopy without endoscopy. thus, these larger dilations are often not feasible at the time of the diagnostic endoscopy because different facilities and/or equipment are needed. also, fluoroscopic mm balloon dilations are associated with a percent perforation rate. to address these shortcomings we present an experience with a retroflexed "against the scope" balloon dilation of the gej. in detail, the gej is visualized while retroflexed and a balloon is then placed through the scope. the gej is cannulated next to the scope and deployed. please see the attached image for example. methods and procedures: a retrospective chart review was performed for a single surgeon during the past five years. we identified those who had retrograde dilations and evaluated the indications, repeat dilations, complications and symptomatic response. results: a total of retrograde dilations were performed on patients with gej related dysphagia. the average age was . years. of dilations were with a mm balloon while other dilations used as small as a mm balloon. dilations were performed for persistent dysphagia after cardiomyotomy between and days after surgery. other indications for dilation were dysphagia after fundoplication ( / ), dysphagia after paraesophageal hernia repair ( / ) and achalasia during pregnancy ( / ). patients required a total of repeat retrograde dilations at an average time of days after previous dilation. there were instances reported where the dilation did not improve symptoms. there was mucosal breakdown noted in instances although there were no perforations. bleeding was noted in instances although this was always minimal and selfresolving. conclusions: retrograde endoscopic dilation is safe and effective in this small series. the mm balloon against a mm scope gives a mm diameter, but a different shape and a decreased total circumference. there is a possible added safety advantage given that the balloon is inflated under visualization. it can be inflated in steps or stopped if it appears too aggressive. in addition these larger dilations were provided at the time of the initial diagnostic egd without extra equipment. more studies are needed to compare retrograde endoscopic dilation to other methods of management of gej stenosis. introduction: robot-assisted surgery allows surgeons to perform many types of complex laparoscopic surgical procedures. more and more patients are treated with this sophisticated system. however, all the instruments used in the currently available surgical robot system is rigid. therefore, there exists a limitation in the extent of reach to the deeper surgical fields. in order to overcome this difficulty, we are developing a novel flexible endoscopic surgery system (fess) which has flexible single port platform of cm in diameter, independently controlled endoscope and instruments, open architecture that is compatible with existing flexible devices and a magnified d hd camera that has sensors of both rgb and infrared. furthermore, the system is smaller and would be more cost-effective than existing robotic surgical system. a preliminary experiment was performed in surgical procedures using porcine model to evaluate effectiveness and feasibility of fess. methods and procedures: experimental protocols were approved by the animal research committees of our institution. we used a female swine of kg. an assistant forcep lifted up the fundus of gallbladder to create good visualization of surgical field. the cystic duct was ligated by laparoscopic clip device from assistant port. blunt dissection was performed by pushing the forceps and sharp dissection by monopolar electrocoagulation. results: the fess accomplished the dissection of the gallbladder from the liver bed successfully. two mm forceps had enough grasping and dissecting force and dexterity. the gallbladder was removed from single port site easily. conclusions: this experiment showed that it is feasible to intuitively operate single-site cholecystectomy with fess. in order to realize a pure fess procedure, an additional novel device to create good visualization of the surgical field is necessary for the fess platform. a prototype has already been developed for evaluation in securing the surgical field. the optimal working range, or "sweet spot" of fess is not relatively large. in addressing this issue, the feature of easy setup is being improved to enable more efficient positioning and shifting of the sweet spot for the surgical field. this mechanism could enhance the expansion of procedures suitable for fess. the target procedures of fess are those specifically suitable for single port surgery, such as transanal surgeries and transcervical mediastinoscopic surgeries. intraluminal procedures and natural orifice translumenal surgery (notes), which are not considered suitable for rigid surgical robot, are also good applications of fess. regression of anal and scrotal squamous cell carcinoma (hpv related) with imiquimod index patient is a year old hiv positive homosexual man with anal-scrotal condylomas (ain) initially resected in , then treated with radiation in for recurrence. recurred in with changes severe enough to ''…consider diagnosis of invasive squamous cell carcinoma…''. patient elected trial of imiquimod % cream three times per week to defer recommendation of abdominoperineal resection. imiquimod has no antiviral effect but stimulates interferon and cytokines to suppress hpv subtypes and , among other immune effects. no data exists as to systemic effects of imiquimod. after three months of therapy, lesions had largely regressed with only one specimen showing ''…concern for squamous cell carcinoma in situ…''. patient has elected to continue treatment pending further biopsy. this report is typical of a number of other reports of small numbers of cases of neoplasia regression with imiquimod % cream to include melanoma-in-situ, basal cell cancer of skin and other cutaneous malignancies as well as vin. a second female patient, years old, hiv+ with hpv lesions (ain ) including urethral lesions, is being treated with vulvar application of imiquimod to determine if urethral lesions will regress. there is no fda-approved indication for mucosal application of imiquimod. biopsies are pending at completion of six month trial of imiquiimod. surg endosc ( ) introduction: training in flexible endoscopy remains a critical skill for surgeons, as therapeutic endoscopy procedures continue to evolve and to supplant standard surgical operations. the role of endoscopy across surgical subspecialties is shifting, as endolumenal procedures (like per-oral endoscopic myotomy and endolumenal bariatric interventions) have become commonplace. while surgical residency minimum case volumes are mandated, little is known about the volume of endoscopic procedures surgical fellows participate in. we aimed to characterize the volume of flexible endoscopy cases logged by surgical subspecialty fellows as a measure of endoscopic platform use by surgeons. methods: operative case logs for fellows enrolled in post-graduate training programs participating in the fellowship council were de-identified (no patient or program specific information) and provided for analysis. the case log is an online, mandatory, self-reported collection of all surgeries, procedures and endoscopies performed during fellowship year. all cases listed within the category of "gi endoscopy" in which the fellow designated their role as "primary" surgeon for the procedure were further sorted based on subcategory and linked to the year of fellowship graduation. rigid endoscopy, trans-anal endoscopic procedures, and those in which the fellows roll was "first assistant" were excluded. introduction: complex pancreatic and duodenal injuries due to trauma continue to present a formidable challenge to the trauma surgeon with a described mortality of - % and morbidity of - %. duodenal fistula formation subsequent to failure of attempted primary repair is associated with significant morbidity and mortality. we present the first reported series of four patients with complex trauma-related duodenal injuries who had failure of primary repair which were managed with duodenal stenting. we compared outcomes to a matched case control cohort of patients with trauma related duodenal injuries. the aim of this study is to document our experience with enteral stents in patients with complex duodenopancreatic traumatic injuries. methods: a retrospective review at a level i trauma center identified patients who underwent endoscopically placed indwelling covered metal stents after failure of primary duodenal repair in the form of high output duodenal fistulas. a matched case control cohort was identified including patients with duodenal fistulas who were not treated with stents. drainage volumes were collected and classified according to source and phase of intervention (i.e. admission to fistula diagnosis, to stent insertion, after removal, and until discharge). results: there was a decrease in the mean combined drain output of ml/day (p= . ) after stent placement. when comparing the sum of all output sources, there was a statistically significant difference across phases (p= . ) and "after removal" was significantly less when compared to the reference phase (p= . ). there was also a change in the directionality of the slope for the sum of all drain outputs with an increase of ml/day prior to stent placement compared to a decrease of ml/day (p= . ) after stent placement. the stenting group demonstrated a decrease in mean drain output ( ml/day vs ml/day, p= . ) and increase in distal gastrointestinal output ( ml/day vs ml/day, p= . ). one patient in the stent group required later operative repair. all other patients in the stenting and control group had resolution of their fistulas over time. there were late mortalities in the control group. the stent treated patients demonstrated diversion of approximately ml/day of enteral contents distally. while all patients eventually healed their fistulas, the stent treated patients demonstrated an accelerated abatement of drain outputs when compared to the control cohort, but did not reach statistical significance. indwelling enteral-coated stents appear to be an effective rescue method for an otherwise inaccessible duodenal fistula after failure of primary repair. kevin l chow, md, hassan mashbari, md, mohannad hemdi, md, eduardo smith-singares, md; university of illinois at chicago introduction: esophageal trauma represents an uncommon but potentially catastrophic injury with a reported overall mortality of up to %. the management of iatrogenic and spontaneous perforations have been previously described with well-established guidelines which have been mirrored in the trauma setting. esophageal leaks are the most feared complication after primary surgical management and present a challenge to salvage. there has been increasing reports in the literature supporting the use of removable covered metal stents to treat esophageal perforations and leaks in the non-trauma setting. we present the first reported case series of four patients presenting with external penetrating trauma induced esophageal injuries, complicated by failure of initial primary surgical repair and leak development, successfully managed with the use of esophageal stents. materials and methods: a retrospective review was performed at a level i trauma center identifying four patients who underwent endoscopically placed removable covered metal stents, either by a surgical endoscopist or an interventional gastroenterologist, after failure of primary surgical repair of esophageal traumatic injuries. demographic information, hospital stay, additional interventions, complications, imaging studies, iss scores, and outcomes were collected. results: our cohort consisted of patients with penetrating injuries to the chest and neck with esophageal injuries ( thoracic and cervical esophageal injuries) managed with esophageal stenting after leaks were diagnosed following primary surgical repair. their initial esophageal injuries included grades , and . leaks were diagnosed on average post-operative day . two patients underwent an additional attempted surgical repair and subsequent leak development. esophageal stents were placed under endoscopic and fluoroscopic guidance within days of leak diagnosis. there was resolution of their esophageal fistulas with all patients resuming oral intake (averaging days after stent placement). three patients ( %) required further endoscopic interventions to adjust the stent due to migration or for dilations due to strictures. mortality was %, all patients survived to be discharged from the hospital with average icu length of stay of days. conclusion: the use of esophageal stenting has progressed over the last few years, with successful management of both post-operative upper gastrointestinal leaks as well as benign, spontaneous, or iatrogenic esophageal perforations. while the mainstay of external penetrating traumatic esophageal injuries remains surgical exploration, debridement, and repair with perivisceral drainage; our case series illustrates that the use of esophageal stents is an attractive adjunct that can be effective in the management of post-operative leaks in the trauma patient. results of the ovesco-over-overstitch technique for managing bariatric surgical complications introduction: since , the preferred method of enteral access has been the percutaneous endoscopic gastrostomy tube (peg). accidental removal is a common complication associated with excessive cost and possible significant morbidity. removal prior to days is considered ''early removal.'' early removal has more significant risk associated with it, and can necessitate emergent operation to prevent peritonitis and sepsis. some patients, who do not exhibit signs of peritonitis, may be simply observed. for these patients, peg replacement would typically be delayed - days to ensure closure. this delay results in prolonged npo status and worsened nutritional status. presented below is a case of early accidental removal followed by endoscopic clip closure, and immediate peg replacement. case report: a -year-old male presented after a large left middle cerebral artery infarct. a peg placement was completed without complication. eleven hours after the procedure the patient had pulled the peg tube out of the abdominal wall. at this time the patient appeared to have no abdominal pain and no signs of peritonitis. twelve hours following the accidental removal of his peg tube, the patient was taken back to the endoscopy suite, and an egd was performed. the previous peg site was identified and appeared closed and ulcerated. the mucosal defect was closed with two endoscopic metallic clips. a peg tube was then placed at an adjacent site. the following day, the patient was restarted on trickle feeds and advanced to regular tube feeding over a period of hours. since that time, his peg has been functioning well. discussion: we propose that in the case of early accidental peg removal, the patient should be examined first for evidence of peritonitis. if initial physical exam and radiographic investigation do not reveal peritonitis or significant pneumoperitoneum, the patient should undergo urgent repeat endoscopy. at this time, the gastrotomy can be closed endoscopically via metallic clips and peg can be replaced immediately. tube feeds can be initiated after a - hour period of dependent drainage with serial abdominal exams. introduction: since its inception in , poem has become a viable procedure for the treatment of achalasia and esophageal dysmotility disorders. however many institutions are in the beginning stages of implementing the procedure into their programs. in view of training, we report the successful ability to dissect and identify common landmarks during a poem procedure performed by trainees under supervision in a high volume poem center. methods: posterior poem procedures performed by trainees with experienced proctor guidance during the period between february to july were evaluated for the frequency of identifying the perforating vessels, the presence of sling fibers, and position on the lesser curvature of stomach evaluated by double scoping method during the creation of the tunnel and myotomy for procedure. results: all poem procedures were successfully completed by trainees (gi and surgery fellows). the average length of procedure was minutes. indication for procedure included patients with type achalasia ( %), with type achalasia ( %) and des ( %). average length of myotomy for all procedures was . cm. during these procedures or perforator vessels were identified in ( %) of patients, sling muscle was identified in patients ( %) of patients. myotomy extended to anterior lesser curvature of stomach on double scope exam in % of patients. no patient had a serious complication requiring intervention. conclusion: trainees performing a posterior poem procedure were able to correctly dissect and identify the sling muscle and/or perforating vessels in approximately % and % respectively of procedures. however the myotomy position was correctly placed in all procedures. this indicates that while ideally the sling fibers and perforating vessels should be identified, a correctly positioned myotomy can still be successfully performed by trainees without identification of these landmarks. introduction: gastroparesis is a rapidly increasing problem with sometimes devestating patient consequenses. surgical treatments, particularly laparoscopic pyloroplasty, have recently gained popularity but require general anesthesia, advanced skills and create risk of leaks. peroral pyloromyotomy (pop) is a less invasive alternative but is technically demanding and not widely available. we propose an hybrid laparo-endoscopic collaborative approach using a novel gastric access device to allow a endoluminal stapled pyloroplasty as an alternative treatment option for functional gastric outlet obstruction. methods and procedures: under general anesthesia six female pigs (mean weight kg) had endoscopic placement of or mm intragastric ports (taggs, kansas, usa) using a technique similar to percutaneous endoscopic gastrostomy. a mm laparoscope was used for visualization. endoflip (crospon, inc., galway, ireland) was used to measure cross sectional area (csa) and compliance of the pylorus before intervention, immediately after and at week survival. pyloroplasty was performed using a mm articulating laparoscopic stapler (dextera microcutter). after removing the taggs ports, the gastrotomies were closed by either endoscopic clip, endoscopic suture or suture under laparoscopic vision. the animals were survived for week. after - days, a second laparo-endoscopic procedure was performed to verify healing of the pyloroplasty as well as intraluminal dimensions. at the end of the protocol, animals were euthanized. results: six endoluminal linear stapled pyloroplasty were performed. the mean operative time was min. in all cases, this technique was effective in achieving optimal pyloric dilatation. median pyloric diameter (d) and median cross-sectional area (csa) pre-pyloroplasty were mm ( . - . mm) and . mm ( - mm ). after the procedure, these values were increased to . mm ( . - . mm) and . mm ( - mm ) respectively (p= . the quality of endoscopic examination depends on the quality of endoscopic equipment, experience of the endoscopist and preparation of the patient. contemporarily electronic endoscopes make feasible to transfer image directly to external device which is subsequently linked to computer network and can be transferred further. dynamic image viewed in real time is more accurately interpreted by a physician than a static one. the possibility of simultaneous voice contact makes teleconsultation sterling. the aim of this study was to present our own experience regarding endoscopic teleconsultations. materials and methods: analysis enrolled examinations performed in endoscopic centers located in lesser poland district and in denmark. consultations took place in real time, consulting physicians had more than years of experience in endoscopic procedures and over colonoscopies and therapeutic procedures performed. there were teleconsultations via standard internet connection mb/s. endoscopic centers were equipped with olympus and series linked to video card. each card had its own ip address, and the image was accessible through internet login from anywhere. consulting physicians used computers connected to internet for tracing the image synchronously and giving advice. results: teleconsultations were undertaken in . % of all endoscopic procedures. teleconsultations concerned difficulties in endoscopic image interpretation in cases and decisions regarding further treatment in cases. the consulting physician solved all problems concerning proper endoscopic image interpretation. in cases the elective procedure was rejected. the elective treatment was continued in remaining cases. patients had a complication of polypectomy that was endoscopically treated. conclusions: the opinion of independent consulting physician in difficult clinical cases regarding endoscopic procedures helps to understand the endoscopic image in real time and implicates a decrease in complications after endoscopic procedures. michelle ganyo, md, robert lawson, md; naval medical center san diego introduction: a presacral phlegmon is a contained collection of infected fluid and inflammation within the bony pelvis, posterior to the rectum and anterior to the sacrum, that usually arises as a complication of surgery, malignancy, inflammatory bowel disease, ischemic colitis or perforated viscous. symptoms include low-back pain, pelvic pain and fevers. antibiotics and supportive therapy are the mainstay of treatment. however, if abscess develops, drainage is required usually by trans-gluteal percutaneous and/or surgical methods, both of which are associated with significant morbidity and mortality. endoscopic ultrasound (eus) -guided drainage of perirectal and presacral abscesses is a well described minimally-invasive approach that permits clear definition of anatomy, real-time access to the abscess and creation of an internalized fistula through placement of one or more transluminal stents. however, to date there is no published report describing endoscopic treatment of the more complicated, clinically challenging presacral phlegmon. here we present a case of a symptomatic presacral phlegmon recalcitrant to medical management that was successfully treated with an endoscopically placed retrievable, transmural, lumen-apposing metal stent. case report: this is a case-report of a -year-old, post-partum female who presented with fevers and recurrent lower back pain radiating to her rectum and vagina. her spontaneous vaginal delivery was notable for a second-degree laceration that was primarily repaired at the time of delivery months prior to presentation. her past medical history was otherwise unremarkable. radiographic imaging revealed several perirectal and presacral abscesses that were considered too small for percutaneous drainage. iv antibiotics were started and the largest abscess was targeted for eusguided aspiration. unfortunately, her pain became constant and progressed in severity. a follow-up mri a week later revealed a -cm presacral phlegmon. results: colonoscopy revealed a luminal bulge in the rectum but was otherwise normal. to permit drainage and multiple sessions of endoscopic necrosectomy, a mm lumen-apposing metal stent (lams) was placed transrectally under eus-guidance into the presacral phlegmon. endoscopic debridement with forceps and copious irrigation was performed. over the following weeks the patient reported purulent rectal drainage and resolution of her fevers and pain. repeat endoscopy revealed a normal rectum and no sign of the stent. a follow up mri showed a -cm area of heterogenous tissue in the presacral area. conclusions: although not previously described for management of a presacral phlegmon, lams appears to be a safe and effective, minimally-invasive treatment option. introduction: flexible endoscopy has evolved to include multiple endoluminal procedures such as anti-reflux procedures, pyloromyotomy, and mucosal and submucosal tumor resections. however, these remain technically demanding procedures as they are hindered by the state of flexible technology which has difficult imaging, limited energy devices, no staplers, and cumbersome suturing abilities. an alternative approach is transgastric laparoscopy, which for almost decades has been shown to be a good procedure for pancreatic pseudocyst drainage and full-thickness and mucosal resection of various lesions. we propose to expand the indications of transgastric laparoscopy by using novel endoscopically placed transgastric laparoscopy ports (taggs, kansa, usa) to replicate endoscopic procedures such as endoluminal antireflux surgery. methods and procedures: under general anesthesia female pigs (mean weight . kg) had endoscopic placement of mm-intragastric ports (taggs, kansas, usa) using a technique similar to percutaneous endoscopic gastrostomy. a mm laparoscope was used for visualization. endoflip, (crospon, inc., galway, ireland) was used to measure cross sectional area (csa) and compliance of the gastroesophageal junction (gej) before and after intervention. laparoendoscopic-assited suture plication of the gej was performed using - sutures (polysorb®). once the taggs ports were removed, the gastrotomies were closed by using endoscopic clip. at the end of the protocol, animals were euthanized. results: five laparoendoscopic-assited sewing plication were performed. the mean operative time was , min (endoscopic evaluation: . min, tagss insertion: min, endoflip evaluation+ gej plication: , min, gastric wall closure: min). in all cases, this technique was effective in achieving adequate gej plication. median gej diameter (d) and median cross-sectional area (csa) pre-plication were . mm ( . - . mm) and . mm ( - mm ). after the procedure, these values were decreased to . mm ( . - . mm) and . mm ( - mm ) respectively (p= , ). median distensibility (d) and median compliance (c) pre-plication were . mm /mmhg ( . - . mm /mmhg) and . mm /mmhg ( , - , mm /mmhg). after the procedure, these values were decreased to , mm /mmhg ( . - . mm /mmhg) and . mm /mmhg ( . - . mm /mmhg) respectively (p= , ). no intraoperative events were observed. conclusion: a hybrid laparoendoscopic approach is a feasible alternative for performing intragastric procedures with the assistance of conventional laparoscopic instruments; especially in cases where the location of the intervention limits the access of standard endoscopy or where endoscopic technology is inadequate. further evaluation is planned in survival models and clinical trials. introduction: due to previous manipulation or submucosal invasion, colonic lesions referred for endoscopic mucosal resection (emr) frequently have flat areas of visible tissue that cannot be snared. current methods for treating residual tissue may lead to incomplete eradication or not allow complete tissue sampling for histologic evaluation. our aim is to describe dissection-enabled scaffold assisted resection (descar): a new technique combining circumferential esd with emr for removal of superficial non-lifting or residual "islands" with suspected submucosal involvement/fibrosis. methods: from to , lesions referred for emr were retrospectively reviewed. cases were identified where lifting and/or snaring of the lesion was incomplete and the descar technique was undertaken. cases were reviewed for location, prior manipulation, rates of successful hybrid resection and adverse events. results: lesions underwent descar due to non-lifting or residual "islands" of tissue. patients were % m, % f, and average age (sd ± . yrs). lesions were located in the cecum (n= ), right colon (n= ), left colon (n= ) and rectum (n= ). average size was mm (sd ± . mm). previous manipulation occurred in / cases ( % biopsy, % resection attempt, % tattoo). the technical success rate for resection of non-lifting lesions was %. there was one delayed bleeding episode but no other adverse events. approximately % of patients have been followed up endoscopically to date with no evidence of residual adenoma. conclusions: descar is a feasible and safe alternative to argon plasma coagulation and avulsion for the endoscopic management of non-lifting or residual colonic lesions, providing en-bloc resection of tissue for histologic review. further studies are needed to demonstrate long-term eradication and for comparison with other methods. results: patients underwent fully covered stent placement procedures. indications for stent placement were leak in patients ( sleeve; bypass) and stricture in patients ( bypass, sleeve). five patients had stent migration. three required surgical removal, one patient endoscopic repositioning and one passed the stent per rectum. all eight patients with enteric leak successfully underwent stent placement in conjunction with diagnostic laparoscopy and drainage. all but one of these patients developed an enteric leak perioperative to index procedure. the average duration of stent treatment in these patients was days ( - days). of the patients treated for a stricture, patients ( sleeve, bypass) failed treatment and required subsequent definitive operative revision. average length of time of stent treatment in these patients was days (range, - days) and five had severe intolerance. conclusions: endoscopic stent placement of leak may require multiple procedures and carries the risk of migration; however, this therapy seems to be an effective treatment. failure rates are higher with strictures and are not as tolerated by patients. background: colonoscopy is the most commonly performed endoscopic examination worldwide and is considered the gold standard for colorectal cancer screening. the quality of examination and endoscopic treatment is affected by a number of factors that are verified by recognized parameters such as cecal intubation rate and time (cir, cit), withdrawal time, adenoma detection rate (adr) and polyp detection rate (pdr). advanced endoscopic imaging improves accurate recognition of the nature and variety of pathologic lesions, while the endoscope tips, third eye retroscope and wide-angle endoscopy allow detection of lesions located on the proximal side of the intestinal folds. the aim of the study was to assess the suitability of wide-angle colonoscopy for the detection of colorectal lesions and to analyze the functionality of a special endoscope series regarding cir, cit and withdrawal time. introduction: leak is an uncommon but serious complication of gastrointestinal surgery. when identified post-operatively, percutaneous drains are used to manage abscesses and prevent further peritoneal contamination. if drain position is suboptimal, however, the consequences of persistent leak may necessitate a formal surgical intervention in a hostile abdomen. in select situations, we have utilized natural orifice transluminal endoscopic surgery (notes) methods to enter the abdominal cavity and place/reposition drains under direct endoscopic visualization a part of our comprehensive endoscopic management algorithm for leaks. methods and procedures: a prospectively collected database was queried for patients who had undergone transluminal endoscopic drain repositioning (tedr) as part of multimodal endolumenal therapy for leak (including interventions like defect closure, enteral feeding access, or endolumenal stent placement). inadequate drainage was identified pre-procedurally by undrained fluid collections in conjunction with clinical signs of sepsis. translumenal access was obtained via the leak site and carbon dioxide insufflation was used in all cases. the peritoneal cavity was surveilled and cleared of gross debris by irrigation and suction. intraabdominal drains were located endoscopically and fluoroscopically, grasped with an endoscopic snare or grasper and repositioned adjacent to the leak site to ensure better drainage. results: four patients ( female), average age (range - ), average body mass index (range - ) were managed with tedr as a component of endoscopic treatment of full-thickness gastrointestinal leak. two patients developed leak following revisional bariatric surgery. one patient had an acutely dislodged gastrostomy tube with intraperitoneal leak after multiple laparotomies recently closed with a granulating vicryl mesh. one patient developed a leak at an esophagojejunostomy following total gastrectomy. three patients had adequate drainage after the initial tedr, while one patient required tedr on two occasions. all patients had improved drainage demonstrated by resolution of clinical signs of sepsis and resolution of fluid collections. drains were removed as clinically indicated. conclusion: intraabdominal drains are an essential element in the management of full-thickness gastrointestinal leaks, but are not always able to be adequately positioned percutaneously. transluminal endoscopic drain repositioning via a gastrointestinal defect is a viable option to avoid surgical intervention in an otherwise hostile field and is a novel practical notes application. background: epiphrenic diverticula (ed) arise from increased intraluminal pressures, often secondary to achalasia or another underlying esophageal motility disorder which causes "pulsion" physiology. ed are traditionally thought to contribute to patients' symptoms of regurgitation and dysphagia, and are frequently resected at time of heller myotomy and fundoplication done for treatment of the primary motility disorder. ed excision carries significant risks (staple line leak, pulmonary complications, mortality), and little is known regarding patients with ed and esophageal motility disorder who undergo surgical myotomy without ed resection. the goal of this study was to compare outcomes of patients with ed and esophageal motility disorder who did and did not undergo diverticulectomy at time of myotomy and fundoplication. methods: retrospective analysis of prospectively collected database from to was performed. patients with diagnosis of ed undergoing surgical treatment of symptomatic esophageal motility disorder were included. all patients underwent laparoscopic heller myotomy with toupet fundoplication by a single surgeon at a tertiary referral hospital. patients were stratified according to whether ed was excised or not excised at time of primary surgery. patient-reported symptoms were obtained from pre/post-operative clinic evaluations and mailed surveys during the follow-up period. independent samples t-test and fisher's exact test were used to compare continuous and categorical variables respectively. results: ed was identified in patients prior to surgery. primary diagnoses included achalasia (n = ), nutcracker esophagus (n= ), and diffuse esophageal spasm (n= ). ed was excised in five patients ( . %) and not excised in ten patients ( . %), with no significant difference in frequency of preoperative dysphagia ( % vs. %, p= . ) or regurgitation ( % vs. %, p= . ) between groups respectively. reasons for non-resection included ed was too proximal (n= ), patient/surgeon preference (n= ), and small ed size (n= ). the resection group did not experience any leaks and there were no mortalities in either cohort during the follow-up period. at mean clinic follow-up of days, there was no difference in frequency of residual dysphagia in patients who did or did not undergo ed resection ( % vs. %, p= . ) and neither cohort reported residual regurgitation symptoms. conclusions: this study suggests that leaving ed in place during surgical treatment of an esophageal motility disorder may achieve similar rates of postoperative symptom control. while ed excision in this study did not cause significant excess morbidity, ed resection introduces risk of leak and requires more extensive surgery that may not provide significant benefit to patients. introduction: median arcuate ligament syndrome (mals) has been described in the literature as presenting with a constellation of symptoms including nausea, vomiting, weight loss, and post-prandial epigastric pain. while many of these symptoms are consistent with foregut pathology, a cohort of patients with mals presenting with delayed gastric emptying has not been described in the literature. in this study we report on the possible association of mals with delayed gastric emptying. methods: cases of mal release were collected between and . eight patients were identified who presented with mals and underwent subsequent mal release. all patients underwent laparoscopic or robotic surgery. patients were compiled into a retrospective database and their demographic, symptomatic, imaging, and outcomes data were analyzed. background: laparoscopic fundoplication (lf) is often performed to treat paraesophageal hernia and/or gerd. care is taken to select the right patients for the operation. some patients may not improve, and others experience dysphagia or bloating after surgery. factors associated with patient satisfaction after fundoplication would be helpful during the patient selection process. methods: a retrospective review of a prospectively collected database was performed. queried patients underwent lf from to . non-elective operations and fundoplications after heller myotomy were excluded. of this cohort, patients were included only if they responded to a two-year postoperative quality of life survey. surveys were distributed preoperatively, at three weeks, at one year, and at two years. the surveys include the reflux severity index, gerd-hrql, and dysphagia score. the gerd-hrql asks about patient satisfaction with their current state ( = dissatisfied, = somewhat satisfied, = very satisfied). the cohort was divided according to their answer to this question at two years. demographics and preoperative factors were compared between the groups with kruskal-wallis and fisher's exact tests. univariable and multivariable ordinal logistic regression was performed to identify preoperative symptoms associated with satisfaction at two years. scores on the surveys over time were were also analyzed. results: a total of patients were included in the analysis (dissatisfied = , somewhat satisfied = , very satisfied = ). the only significant demographic or preoperative difference was a high number of paraesophageal hernias in the 'very satisfied' cohort (p = . ). on univariable regression, younger age and paraesophageal hernia predicted satisfaction. several variables negatively predicted satisfaction with an or \ . multivariable regression, controlled for age and hernia type, identified throat clearing, post-nasal drip, and globus sensation as preoperative symptoms less likely to result in patient satisfaction (p = . , . , and . , respectively). subgroup analysis of patients with paraesophageal hernias revealed that patients with bloating preoperatively are less likely to be satisfied at two years. survey scores over time showed all groups improving over three weeks, but while satisfied patients continued to improved, dissatisfied patients symptomatically worsened over time. conclusion: this study confirms previous reports stating atypical symptoms of gerd are less likely to improve after lf. it also shows individuals with paraesophageal hernia tend to do quite well, unless they report bloating preoperatively. patient-centered analysis such as this can be useful when discussing postoperative expectations with patients, and may reveal opportunities to individualize operative approach. objective: the study was performed to assess whether sutured crural closure or mesh reinforcement for hiatal closure yields better results with regards to symptom resolution and recurrence post-operatively. material and methods: a prospective randomized controlled trial was carried out at grant medical college and sir j. j. group of hospitals, mumbai, india. patients were randomized to receive either sutured repair or mesh reinforcement of hiatal closure. outcomes of interest were symptom resolution, quality of life scores and recurrence in the postoperative period. results: patients were recruited for the trial ( -sutured repair, -mesh reinforcement). the two groups were comparable in terms of demographic profiles, symptom severity and findings at esophagogastroscopy and manometry in the pre-operative period as well as size of the hiatal defect measured intra-operatively. post-operatively the mesh repair group had significantly better symptom resolution in terms of early satiety, chest pain and regurgitation (p\ . ) while with respect to heartburn, dysphagia and post-prandial pain there was no significant difference between the improvements demonstrated. improvement in quality of life scores after either procedure was not significantly different. recurrence was higher in the suture repair group ( vs , p. ). recurrence lead to poorer symptom severity scores as well as quality of life scores and one patient underwent re-operation. the change in the symptom severity score from baseline after the procedure at months in the subgroup population. conclusion: mesh reinforcement results in a reduced rate of recurrence and offers excellent symptom control in the short-term without a rise in complications when compared to sutured repair for the closure of hiatal defects in laparoscopic hiatal hernia repairs. material and methods: in a period from to , patients underwent laparoscopic resection ( -gastric resection, -duodenal resection), using different techniques. all patients were investigated with upper gi endoscopy, eus and abdominal contrast-ct, which allows us to get the complete evaluation of tumor, including size, location, type of growth and the gi layer. based on the findings the decision on the type of resection was made. the majority of resections were wedge or partial resections, performed using endoscopic steplers or using ultrasound scissors followed by double-suturing of gatro/duodenotomy. in the cases of tumor location on the posterior gastric wall we mobilized the the greater curvature to get a direct approach to the tumor with extraluminal growth. in the cases with intraluminal growth we used transgastric approach with small , cm incision on the anterior gastric wall for endoscopic stepler. technically the most complex procedures were in the cases of tumor location close to anatomically narrow places and muscle sphincters (gastroesophageal junction, pylorus, duodenal bulb, duodenal flexure), with high risk of stenosis and dysfunction of anatomical sphincters. in such cases we used «lifting-technique» in which we dissect serous and muscle layers circumferentially around the tumor making partial enucleation of lesion followed by total resection preserving almost all normal tissue with minimal suturing and deformity at the site of surgery. ( : ), mean age was . years (sd ± . ), patients ( %) had mis. the type of reconstruction was predominantly with a "pull-up" technique (n = , . %) followed by the kirschner-akiyama procedure (n = , . %), stapled gastroplasty was performed in patients. all the anastomosis were performed at the level of the neck and only one of the patients had a stapled anastomosis, mean operative time was min (sd ± min) including resection of the specimen. primary neoplasms were predominantly hypopharynx (n = , . %), distal esophagus (n = , %), cervical esophagus (n = , . %) and thoracic esophagus (n = , . %). histologic types were mainly squamous cell carcinoma (n = , . %) and adenocarcinoma (n = , . %). mean of hospitalization days was . (sd ± . ). no complications were observed in patients and major complications (dindo-clavien ≥iiib) were found in patients. anastomotic leak was present in patients ( . %) and perioperative mortality ( days) was . %. progressive shift to laparoscopic surgery was evidenced through the years ( - : . %, - : . % and - : . %; p = . ) and reduction in major complications (p = , ) was observed. anastomotic leaks (p = , ) and perioperative mortality (p = . ) did not show significant differences in the present study. conclusions: results in our center show that major complications decrease with time after application of minimally-invasive surgery and no differences in anastomotic leaks and mortality were seen. current data has lead us to abandon open total esophagectomy as a first-choice procedure. introduction: minimal invasive three-fields esophagectomy for minimal invasion is the surgical standard for oncological procedures and benign diseases. cervical dissection has a risk of to % in some series, of, lesion or paralysis of the rnl, but the standard in mckeon approach is %. a high level of suspicion is needed because this type of lesion has an impact on postoperative evolution and the hospital stay. main: to describe three cases of rnl post esophagectomy paralysis in three planes by least invasion. methods: in a period of years, january to june , esophagectomies for bening disease were performed. three patients ( males female) with diagnosis of terminal achalasia and stenosis secondary to caustic ingestion consulted at the minimal invasion service fundcacion valle del lili. they were schedualed for minimal invasive three fields esophagectomy, one patient without complications and early discharge ( postoperative day) but occasional dysphagia, the other two required early reintubation after de surgery with ards, patient requiered tracheostomy, the second patient could be extubated after days but with occasional dysphagia. all three had mild hoarseness after surgery. the patient who required tracheostomy was decannulated at days without complication. results: the three patients underwent endoscopy without complication in the cervical anastomosis stenosis or disorder in the emptying of the gastric tube, swallowing study without alteration and laryngoscopy with paralysis of the left vocal cord. these patients went to speech therapy with total paralysis recovery at months corroborated with laryngoscopy, without dysphagia or hoarseness. conclusion: rnl innervates the larynx and upper esophageal sphincter, therefore lesion or paresis causes symptoms such as hoarseness, dysphagia, difficulty swallowing, aspiration, difficulty in coughing, pneumonia and ards. injury has a predecessor factor in pulmonary complications and prolongation of the hospital stay. % of these patients may require some surgical procedure to restore the function of rnl. noninvasive monitoring of the laryngeal nerve decreases the risk of injury. philip case report: multiple esophageal diverticula associated with achalasia introduction: achalasia is well defined disorder of increased lower esophageal sphincter tone ( ). epiphrenic esophageal diverticulum are a rare disorder believed to result from increased intraesophageal pressure often in conjunction with a motility disorder causing functional outflow obstruction. they are a pulsion-type pseudo-diverticulum with mucosal bulging most frequently from the right posterior esophageal wall ( ) . we present a very rare case of achalasia associated with multiple esophageal diverticula successfully treated with laparoscopic heller myotomy with dor fundoplication. case presentation: a year old woman presented with years of dysphagia, chest discomfort, regurgitation, and weight loss. esophagoscopy showed a patulous esophagus with multiple esophageal diverticula (figure ). barium esophogram demonstrated esophageal diverticula in the distal esophagus and delayed clearance of esophageal contrast (figure ). high resolution monometry revealed a hypertensive mean les, an aperistaltic body on of wet swallows, and panesophageal pressurization in of wet swallows -consistent with type ii achalasia by chicago classification ( ). we performed a laparoscopic heller myotomy with dor fundoplication. the myotomy was extended cm above the gasgtroesophageal junction and cm onto the gastric cardia. an anterior diaphragmatic defect with a moderate type hiatal hernia was repaired with two sutures, ensuring to not impinge the esophagus (figure ). at weeks post operatively the patient reports excellent results. her dysphagia and chest discomfort have entirely resolved. her eckhardt score improved from seven preoperatively to one post operatively. discussion: type ii achalasia is successfully treated in the majority of cases with laparoscopic heller myotomy and partial fundoplication ( ). however, esophageal diverticula typically require both myotomy as well as diverticulectomy for successful treatment ( ) . there is little experience with the surgical management of multiple esophageal diverticula. we propose a two stage surgical approach for these patients. we reason that the risk of esophageal leak or stenosis in the case of multiple esophageal diverticulectomies out weighs the proposed benefit. indeed epidemiologic studies indicate that the majority of esophageal diverticula are asymptomatic ( ) . in the event the patient remains symptomatic after myotomy a second stage operation with diverticulectomies would be possible. this single experience suggests that diverticulectomy may not be necessary in the case of multiple diverticula associated with achalasia. instead, treatment may be directed at relieving the functional obstruction responsible for the symptoms by performing laparoscopic heller myotomy with dor fundoplication. takahiro kinoshita, md, facs, masanori tokunaga, md, akio kaito, md, masahiro watanabe, md, shizuki sugita, md; national cancer center hospital east, japan objective: the optimal surgical approach for siwert type ii cancer is still controversial due to the anatomical complexity of the region. potential advantages of laparoscopic transhiatal approach have not been fully investigated. methods and procedures: we retrospectively analyzed consecutive patients with siewert type ii cancer who underwent laparoscopic transhiatal resection. indication of surgery is patients with siewert type ii cancer with less than cm esophageal invasion. regarding the extent of resection, basically proximal gastrectomy with the lower esophageal resection was selected, aiming at preservation of gastric reservoir function. in terms of reconstruction after proximal gastrectomy, double-tract method was performed. intraoperative peroral endoscopy was routinely employed for determination of the appropriate resection level of the stomach. esophagojejunostomy was employed by overlap method using a mm linear stapler. in order to obtain a wider operative field in the lower mediastinum, the diaphragmatic crus was dissected to widen the esophageal hiatus. results: in patients ( males and females), median operation time was minutes, and estimated blood loss was g. the rate of surgical morbidity was %, and that of anastomotic leakage was %. there was no mortality. the mean length of proximal margin was mm, and no positive margin was recorded. the -and -year overall survival rate was . % and %, respectively. conclusions: laparoscopic transhiatal resection for siewert type ii cancer is technically challenging, but appears feasible and safe when performed by an experienced surgical team. a largescale prospective study is necessary for final conclusion. introduction: mesh use for reinforcement of primary crural closure is controversial. synthetic mesh use poses a risk of erosion but there is no evidence that non-synthetic mesh is useful to minimize the risk of hernia recurrence. we evaluated a fully bioresorbable mesh made from poly- -hydroxybutyrate (p hb) for crural reinforcement after para-esophageal hernia (peh) repair. the aim of this study was to evaluate the safety and efficacy of p hb mesh at the hiatus in patients undergoing peh repair. this was a review of prospectively collected data on consecutive patients that had repair of a peh with reinforcement of the crural closure with p hb mesh. to be considered a peh at least % of the stomach was herniated into the chest. a collis gastroplasty or crural relaxing incision was added for short esophagus or crural tension when necessary. routine follow-up consisted of esophagogastroduodenoscopy (egd) at months for patients that had a collis gastroplasty and a barium upper gi study (ugi), high resolution manometry (hrm) and ph test in all patients at months. a hernia of any size identified during objective follow-up testing was considered a recurrence. overall, there was a significant difference in mean measured tension between the three subjective suture ratings by the surgeons. however, there was substantial variability and overlap amongst the surgeon's ratings (figure) . the tension necessary to approximate the crura during peh repair can be objectively measured and as expected increases progressively with anterior movement up the hiatus. while there was some correlation between a surgeon's subjective assessment of the tension necessary to bring the crura together and actual measured tension, there was wide variability and imprecision from one stitch to another. objective tension measurement may provide a more reliable assessment of when excessive force is being used to re-approximate the crura and potentially improve peh recurrence rates. ahmed introduction: paraesophageal hernia repairs are increasing in prevalence, and unfortunately carry a high recurrence rate. consequently, reoperation is expected to increase in frequency. published data on the outcomes of recurrent paraesophageal hernia (rpeh) repair is very limited. because of the technical difficulties of revisional surgery, we hypothesize that laparoscopic revisional paraesophageal hernia repairs are associated with high perioperative morbidity and poor patient outcomes. methods: all rpeh repairs performed by the foregut surgical service at our institution from to were reviewed. patients were included if their index operation was a true pehr (initial type hiatal hernia repairs were excluded, as well as multiply recurrent hernias). demographics, medical and surgical history, and operative notes from the index surgery were reviewed. details from standardized pre-operative symptom assessment, objective testing and operative details for the revisional surgery were collected. patients were routinely offered month post-operative upper gastrointestinal contrast evaluation. postoperative outcomes included a standardized symptom assessment and results of objective testing at any time after surgery. results: twenty six patients were identified who underwent repair of rpeh. demographic, operative and perioperative data was available for all patients (table ) . twenty four patients underwent followup symptom evaluation (two were lost to follow-up after the initial hospitalization). sixteen patients underwent follow-up objective testing by radiographic evaluation with contrast, endoscopy or both. these subgroups were used to calculate symptomatic and objective outcomes (table ) . conclusion: reoperative laparoscopic surgery for recurrent paraesophageal hernias is technically challenging as evidenced by long operative times. despite this, perioperative outcomes at a high volume center are good, with low morbidity and no mortality. importantly, symptomatic outcomes for this difficult problem are excellent. introduction: hypotension of the lower esophageal sphincter (hles) and the presence of hiatal hernia (hh) have both been associated with gastroesophageal reflux disease (gerd). the exact likelihood with which a hles or a hiatal hernia predict gerd continues to be defined. we hypothesize a synergistic interaction in those with hles and hh in predicting gerd as defined by a positive ph study. methods and procedures: between and , consecutive patients presenting to a surgical practice with symptoms most concerning for gerd, without prior antireflux surgery were evaluated by high resolution manometry (hrm), esophagogastroduodenoscopy (egd), videoesophagography (veg) and an ambulatory ph study. hles was defined as residual les pressure of\ mmhg, hh was defined as having been noted and measured by the radiologist, these were further categorized into any hh, - cm, [ - cm background: while clinical outcomes have been reported for antireflux surgery, there is limited data on postoperative outpatient encounters and their associated costs. the aim of this study is to evaluate the utilization of healthcare and its associated costs during the -day postoperative period following antireflux surgery. methods: we analyzed data from the truven health marketscan® research databases. patients ≥ years with an icd- procedure code or cpt code for antireflux surgery and a primary diagnosis of gerd during - were selected. only patients with continuous enrollment six months prior to the date of surgery and -days after surgery were analyzed. patients with a diagnosis of esophageal cancer or achalasia during the six-month period prior to antireflux surgery, a length of stay [ days following index procedure, a capitated plan, or patients who underwent emergency surgery were excluded. outpatient endoscopy was defined using icd- and cpt codes, and related readmission was defined by clinical classification software. introduction: the development of postsurgical gastroparesis following nissen fundoplication is poorly understood. in this study, we analyze the development of gastroparesis requiring intervention and other subsequent procedures following fundoplication and paraesophageal hernia (peh) repair procedures in the state of new york. methods: using a comprehensive state-wide administrative database (sparcs), we examined all in-patient and outpatient records for adult patients who underwent fundoplication or peh repair as a primary procedure for the treatment of gerd between the years of - . patients with an initial gastroparesis diagnosis were excluded from the analysis. through the use of a unique identifier, each patient was followed until for the subsequent diagnosis of gastroparesis or reoperation. surgical procedures for the treatment of gastroparesis included pyloroplasty, pyloromyotomy, or gastroenterostomy procedures. multivariable logistic regression models were used to identify independent predictors for having subsequent reoperation. results: a total of , patients were analyzed. this included , fundoplication patients ( . %) and , ( . %) with peh repair. in the fundoplication group, ( . %) patients had a follow-up diagnosis of gastroparesis or secondary procedure. ( . %) of the patients who underwent a primary peh repair procedure had a follow-up procedure or gastroparesis diagnosis (table ) . mean time to follow-up procedure or diagnosis was . years for the fundoplication group and . years for the peh repair group. the majority of the follow-up procedures in the fundoplication group were revisional procedures (fundoplication or peh repair) (n = , . %), while ( . %) patients were newly diagnosed with gastroparesis and/or underwent a secondary procedure for its treatment. conclusion: fundoplication and peh repair procedures have a relatively low post-operative incidence of gastroparesis following initial procedure for treatment of gerd. secondary fundoplication or peh repair was more commonly performed compared to any of the surgical procedures for gastroparesis for both procedures. further analysis of association with subsequent procedures is needed. during this procedure, gastro-esophageal reflux was evaluated and assigned to severe, moderate and slight category. if the reflux was observed slightly up to cervical esophagus, the case was assigned to moderate category. if the reflux was observed intensely up to cervical esophagus, the position was returned to head high position for the safety and the case was assigned to severe category. the anti-reflux surgery was considered in the moderate and severe categories. results: we have performed laparoscopic nissen procedure in cases. the mean operation time was min. the outcome was assessed by reflux test performed on - postoperative day, and the results showed the reflux was disappeared in every cases. median follow-up period of this study was months ( - months). in cases ( . %) ppi was restarted before months after the anti-reflux surgery. in cases ( . %) ppi was restarted after the anti-reflux surgery during the whole follow-up period of this study. the bmi of the patients had no relationship to the needed restart of ppi. to evaluate the degree of esophagitis objectively before and after the anti-reflux surgery we designed "the esophagitis score". in this scoring method, a number from - was assigned according to the degree of esophagitis along with the la classification. the results of the study have shown that the reflux esophagitis was improved obviously after the anti-reflux surgery even in the ppi restarted group (p. ). discussion: the number of gerd patients who needed anti-reflux surgery seems to be so high. to extract the patients who needed it remarkably is important. the anti-reflux surgery is most effective for the patients who really have the obvious reflux. reflux test is feasible because of its convenience and visual effects for the patients. the results of the laparoscopic nissen fundoplication were good and satisfied by the patients mostly. surg endosc ( ) :s -s introduction: fundoplication at the time of giant paraesophageal hernia repair is controversial. the proposed advantages are better reflux control and lower recurrence. disadvantages include fundoplication specific complications, might be unnecessary and may not decrease recurrence. we retrospectively reviewed giant paraesophageal hernia repairs (peh) with two point gastropexy in the fundus and body, and no antireflux procedure. data collected is postoperative gerd symptoms, postoperative proton pump inhibitors (ppis) therapy and recurrence. methods: a retrospective review of patients who underwent repair of giant peh from to december of . giant was defined as a hernia with % or more of the stomach above the diaphragm. follow up consisted of upper gi (ugi) study one year postoperatively and reflux symptom questionnaire. patients were followed every months in the surgery clinic and a ppi wean was initiated at the second postoperative visit. the primary outcome we evaluated was discontinuation of ppis. in addition, we utilized a standardized reflux scale and recurrence rates collected. chi-squared was used for statistical analysis. background: gastroesophageal reflux disease (gerd) is a highly prevalent disorder with a multitude of treatment options ranging from lifestyle modifications and medical management to surgical options. despite the numerous treatments available, there is still debate over which approach is most appropriate and effective for patients. this study aims to examine the effect of robotic hiatal hernia repair (rhhr) with the novel addition of esophagopexy in patients with gerd. methods: a single institution, single surgeon, prospectively maintained database was used to identify patients who underwent rhhr with a partial fundoplication and concomitant esophagopexy for gerd from november to july . patient characteristics, operative details and postoperative outcomes were analyzed. primary endpoint was resolution of subjective gerd symptoms and discontinuation of proton pump inhibitor (ppi). recurrence of hiatal hernia was a secondary endpoint. results: eleven patients were identified meeting the inclusion criteria (rhhr + esophagopexy) with a mean follow-up of . weeks ± . weeks. in regards to the rhhr, % underwent a partial fundoplication and the additional % underwent a re-do wrap. this patient cohort was . % female with a mean age of . ± . years. preoperative esophagogastroduodenoscopy (egd) was performed in % of patients with the study showing a hiatal hernia in . %, gastritis in . % and esophagitis in . % of patients. manometry was performed in . % of the patients showing % of these patients with esophageal dysmotility. esophagograms and ph studies were performed preoperatively in . % and . % of patients respectively. preoperatively, % of patients had a documented diagnosis of gerd and were taking a ppi and/or h blocker. after rhhr with esophagopexy, . % of patients had resolution of their gerd symptoms while . % (n = ) remained symptomatic. however, one of two patients reported a subjective decrease in symptom severity following the procedure. despite resolution of symptoms, . % remained on ppis. another % switched to h blockers and one patient discontinued all antisecretory therapy. none of the patients experienced recurrence of their hiatal hernia. conclusion: based on our data, rhhr with esophagopexy results in resolution gerd symptoms in over % of symptomatic patient. in patients with hiatal hernias and gerd, rhhr with esophagopexy does lead to resolution of symptoms, however, the majority of patients remained on ppis. long-term follow up is needed to investigate whether these patients are able to discontinue ppis and remain symptom free. chaya shwaartz, nadav zilka, mustapha siddiq, yuri goldes, md; sheba medical center, israel background: d gastrectomy for gastric carcinoma is a well-established procedure in patients undergoing surgery for gastric cancer and is the standard of care in our institution. reduced pain, early ambulation, and better cosmetics are some of the benefits of minimally invasive surgery for early gastric cancer. we aimed to describe our experience in laparoscopic d gastrectomies undertaken by a single surgeon in our institution. methods: this is a single-center retrospective review of prospectively collected d gastrectomies performed by a single surgeon. between november and february , laparoscopic subtotal/total gastrectomies were performed at sheba medical center, a tertiary center for forgut cancer. clinicopathological characteristics of the patients, surgical performance, postoperative outcomes and pathological data were collected. results: forty-five patients underwent laparoscopic gastrectomy. of these, had subtotal gastrectomy and had total gastrectomy. the median age in our series ( - ). most of the patients in our series had early gastric cancer (t - ) ( %). the mean average of dissected lymph nodes was ± . the mean operative time was ± . the postoperative complications, classified using the clavien-dindo classification. severe complications ([ cd iiia) rate was %. conclusions: laparoscopic d gastrectomy for invasive gastric cancer is safe and feasible when carried out in high-volume centers by an experienced surgeon as part of a multidisciplinary team with careful case selection and appropriate high-quality postoperative support. minimally invasive management of diaphragmatic hernias after esophagectomy: a case report introduction: esophagectomy is a common treatment for both benign and malignant pathologies of the foregut. hiatial paraconduit hernias are rare complications following esophagectomy. in this study, we review our experience with these rare diaphragmatic hernias. methods: a retrospective analysis of all patients presenting with hiatial hernia after esophageal resection at the university of oklahoma health science center between and was performed. data was abstracted from the medical record for evaluation and included demographics, symptoms, repair techniques and outcomes. no patients were excluded. results: a total of ten patients were identified to have paraconduit hernias. during this time interval, there were a total of esophageal resections performed. all patients had esophagectomy for malignant disease. seven of the patients have undergone surgery. two patients are asymptomatic and are being followed at their request, and one patient is pending elective correction. of the seven patients who underwent surgery, the median age was , with males and two females. six of the seven patients underwent minimally invasive ivor lewis esophagectomy and one had an open mckeown procedure. the median time from esophagectomy to hernia repair was months, with range from month to months. the most common presenting complaint was abdominal pain and nausea. one patient was noted to have a paraconduit hernia on postoperative day and taken to surgery for repair during the hospitalization. there was one death in a patient who presented with necrosis of the small bowel. the remaining patients all had laparoscopic approach. one patient required a hand port to reduce incarcerated colon and one patient was noted to have a cecal perforation during port closure requiring repair. all patients had herniated colon, with small intestine or pancreas herniation noted in three. repair was performed by reducing the viscera, a left phrenic relaxing incision, closure of the hiatus around the conduit and then closure of the diaphragmatic defect with mesh. at median follow up of months, there are no recurrences. conclusion: hiatal paraconduit hernias are becoming a frequent finding among survivors of esophageal cancer surgery. our study demonstrates that there is a propensity for patients who undergo minimally invasive esophagectomy to develop these hernias. the vast majority of patients can undergo laparoscopic repair. our recommendation is to perform a diaphragmatic relaxing incision and liberal use of mesh. early results appear to be favorable regarding recurrence. aim: there have been several reports illustrating the safety and efficacy of various surgical techniques in performing laparoscopic esophagojejunostomy (ej). this study aims to compare two established methods of ej anastomosis -circular stapling with purse-string suture ("lap-jack") and linear stapling technique -in laparoscopic total gastrectomy. methods: patients diagnosed with gastric cancer underwent intracorporeal ej anastomosis in laparoscopic total gastrectomy from january, to october, . cases used the circular stapler with purse-string "lap-jack" method, and patients used the linear stapling method for ej anastomosis. were matched using propensity scores, and retrospective data for patient characteristics, surgical outcome, and post-operative complications was reviewed. the two groups showed no significant difference in age, bmi, or other clinicopathological characteristics, and there was no conversion to an open procedure. after propensity score matching analysis, the linear group had significantly shorter operating time ( . ± . vs . ± . , p≤ . ) and more sufficient proximal margin ( . ± . vs . ± . , p = . ). no significant difference was found in estimated blood loss, retrieved lymph node, hospital stay, and time for first flatus. there was no postoperative mortality. early postoperative complication of the circular and linear group occurred in ( . %) and ( . %, p = . ) patients respectively. ej leakage occurred in ( . %) cases from each groups, with ( %) case from both group needing radiologic or surgical intervention. no other significant difference in early complication was found. late complication was observed in ( . %) cases (circular = linear = , p = . ) with ej anastomosis stricture in the linear group, but there was no statistical significance. conclusion: both circular stapling and linear stapling techniques are feasible and safe in performing intracorporeal ej anastomosis during laparoscopic total gastrectomy. linear-stapling technique had more sufficient proximal margin and shorter operating time. there was no significant difference in anastomosis related complication between the two groups. masahiro watanabe, masanori tokunaga, akio kaito, shizuki sugita, takahiro kinoshita; national cancer center hospital east, gastric surgery division background: although the current standard treatment for advanced gastric cancer (agc) is open gastrectomy, laparoscopic gastrectomy (lg) is increasingly performed, especially in the east. however, it is a technically demanding procedure, and the feasibility remains unclear. the aim of the present study was to clarify the feasibility of lg for agc. patients and methods: the present study included patients who underwent lg for agc between and . the indication of lg has gradually expanded in our institute, and is currently any stage gastric cancer except for gastric cancer obviously invading adjacent organs or gastric stump carcinoma. we retrospectively reviewed short-and long-term surgical outcomes of the patients. results: male/female ratio was : , and median age (range) was ( - ) years. distal gastrectomy was most frequently performed ( %), followed by total gastrectomy ( %). median operation time and intraoperative blood loss was ( - ) minutes and ( - ) g, respectively. clavien-dindo grade iii or more complication rate was . %. with a median followup period of months, the -year recurrence free survival rates of pstage ii and iii patients were % and %, respectively. conclusion: the outcomes of lg for agc are satisfactory, provided that an experienced team performs the surgery. introduction: the present study aims to evaluate the predictive value of indocyanine green (icg) for the detection and prevention of anastomotic leak following esophagectomy. anastomotic leak is a highly morbid and potentially fatal complication of esophagectomy. ensuring adequate perfusion of the gastric conduit can minimize the risk of postoperative leak. intraoperative evaluation with fluorescence angiography using icg offers a dynamic assessment of gastric conduit perfusion, and can guide anastomotic site selection. methods: a search of electronic databases medline, embase, scopus, web of science and the cochrane library using the search terms "indocyanine/fluorescence" and esophagectomy was completed to include all english articles published between and august . articles were selected by two independent reviewers based on the following major inclusion criteria: ( ) esophagectomy with gastric conduit reconstruction; ( ) use of fluorescence angiography with indocyanine green to assess perfusion; ( ) age ≥ years; ( ) sufficient outcome data for the calculation of leak rates and ( ) sample size ≥ . the quality of included studies was assessed using the quality assessment of diagnostic accuracy studies- . results: our literature search yielded potential studies, of which studies were included for meta-analysis after screening and exclusions. there were eleven prospective and three retrospective studies. the pooled anastomotic leak rate when icg was used was found to be %. pooled sensitivity and specificity for leak detection were . ( . - . ) and . ( . - . ), respectively. when studies involving intraoperative modifications were removed, pooled sensitivity and specificity were only marginally changed to . ( . - . ) and . ( . - . ), respectively. the diagnostic odds ratio was found to be . ( . - . ) across all studies and . ( . - . ) when intraoperative interventions were excluded. only three trials included a control group, giving a sample size of . in studies with a comparator group, icg was associated with an % reduction in the risk of anastomotic leak [or: . ( . - . )]. conclusions: in non-randomized trials, the use of icg as an intraoperative tool for visualizing vascular perfusion and conduit site selection, is promising. however, poor data quality and heterogeneity in reported variables limits cross-study comparisons and generalizability of findings. randomized, multi-center trials are needed to account for independent risk factors for leak rates and to better elucidate the impact of icg in predicting and preventing anastomotic leaks. objective: robotic assistance for bariatric surgery represents a novel application of a rapidly emerging technology. its safety and efficacy remains primarily characterized by smaller, singleinstitution studies. in this investigation, the influence of robotic assistance on short-term perioperative outcomes is contrasted with the more established primary multi-port laparoscopic approach for patients undergoing roux-en-y gastric bypass (rygb), using data from a national bariatric database. methods: a retrospective analysis of , robotic-assist and , laparoscopic rygb patients from the metabolic and bariatric surgery accreditation and quality improvement program national database were reviewed for differences in patient characteristics and short-term outcomes. on bivariate analysis, variables associated with primary outcomes of -day reoperation, readmission and reintervention were imputed into multivariate analyses to determine independent significance. results: robotic-assist bypass patients were older (p\. ), had a higher prevalence of comorbidities and had concomitant operations more frequently performed during surgery (p\. ). on bivariate analysis, robotic-assist patients had a higher rate of readmission than laparoscopic patients ( . % vs. . %; p=. ), but no differences in -day reoperation ( conclusion: robotic-assistance does not confer an increased rate of morbidity and mortality after rygb, and represents a feasible surgical modality for the surgeon willing to adopt the technology and accept its limitations. alicia m bonanno, md, brandon tieu, md, farah husain, md; oregon health and science university introduction: marginal ulcer is a common complication following roux-en-y gastric bypass with incidence rates between and %. most marginal ulcers resolve with medical management and lifestyle changes, but in the rare case of a non-healing marginal ulcer there are few treatment options. revision of the gastrojejunal (gj) anastomosis carries significant morbidity and mortality with complication rates ranging from to %. thoracoscopic truncal vagotomy (ttv) may be a safer alternative with decreased operative times. the purpose of this study is to evaluate the safety and effectiveness of ttv in comparison to gj revision for treatment of recalcitrant marginal ulcers. methods and procedures: a retrospective chart review of patients who required surgical intervention for non-healing marginal ulcers was performed from st september to st september . all underwent medical therapy along with lifestyle changes prior to intervention and had preoperative egd that demonstrated a recalcitrant marginal ulcer. revision of the gj anastomosis or ttv was performed. data collected included operative time, ulcer recurrence, morbidity rate, and mortality rate. statistical analysis was performed using t-test and fischer's exact test. results: a total of fifteen patients were identified who underwent either gj revision (n= ) or ttv (n= ). there were no -day mortalities in either group. mean operative time was significantly lower in the ttv group in comparison to gj revision ( . ± vs. . ± minutes respectively, p= . ). recurrence of the ulcer was not significant between groups and occurred following gj revisions and ttv. overall complication rate was not significantly different with % in the gj revision group and % in the ttv group. complications included anastomotic leak ( gj), anastomotic stricture ( gj), aspiration ( ttv), dysphagia ( gj and ttv), and dumping syndrome ( gj). conclusions: our results demonstrate that thoracoscopic vagotomy may be a better alternative with decreased operative times and similar effectiveness. however, further prospective observational studies with a larger patient population would be beneficial to evaluate complication rates and ulcer recurrence rates between groups. we present a case of a -year-old female with a history of thyroid cancer who initially presented to an outside hospital complaining of reflux, abdominal pain, early satiety, and -pound unintentional weight loss. endoscopy demonstrated a cm pre-pyloric mass; with initial biopsies of the mass demonstrating only gastric mucosa. endoscopic ultrasound and fna of the lesion also failed to elucidate its pathology. due to the pyloric location of the mass and inability to rule out invasive malignancy, we recommended a robotic-assisted transgastric submucosal resection with possible distal gastrectomy. intraoperatively we found a -degree circumferential pre-pyloric exophytic sessile tumor. frozen sections suggested a benign papillary tumor therefore we proceeded with submucosal resection. the resulting mucosal defect and gastrotomy were closed primarily with absorbable suture. final pathology showed the tumor to be a tubulovillous adenoma with high grade dysplasia arising against a background of intestinal metaplasia. the resection margins were negative for dysplasia. the postoperative course was complicated by a minor leak which did not require operative intervention and subsequent gastric outlet narrowing which required endoscopic dilation and feeding tube placement. however, the patient has recovered well and has advanced to diet as tolerated. gastric adenoma has a prevalence of . - . % in the western hemisphere. the risk of carcinomatous transformation in gastric adenomas is related to size, degree of dysplasia, and villosity. gastric adenomas are considered precancerous lesions. pre-operative pathologic diagnosis of dysplasia is often elusive as biopsies will often miss or under-grade the lesion. guidelines advocate for complete resection with either endoscopic submucosal dissection or surgical resection depending on surgeon preference and local expertise. endoscopic resection has been shown to be safe and efficacious in the removal of adenomas with good long-term outcomes. in this case the pathology of the lesion was unclear after multiple unsuccessful biopsies and required a surgical diagnosis to rule out invasive malignancy. management of gastric adenomas, while rare, may require a multidisciplinary approach between surgical endoscopy, minimally invasive surgery, and surgical oncology to achieve local control in an oncologically sound manner. we show that transgastric submucosal resection can be achieved in a minimally invasive fashion using robotic assistance. objective: parahiatal hernia is a rare type of diaphragmatic hernia with incidence of . - . %. para-hiatal hernias arises lateral to the left crural musculature adjacent to but separate from the oesophageal diaphragmatic hiatus. in view of its rare occurance and little clinical suspicion, it is almost never diagnosed clinically. the current case report is intended to depict the clinical profile of an intraoperatively diagnosed para-hiatal hernia and feasibility of laparoscopic repair of parahiatal hernias. method: laparoscopic fundoplication is frequently performed at grant medical college and sir j. j. group of hospitals, india. during one such case intraoperatively para-hiatal hernia was diagnosed. discussion: primary or true parahiatal hernias occur as a result of a congenital weakness and secondary defects follow hiatal surgery. the primary treatment of para-hiatal hernia is mesh-plasty. this is coupled with fundoplication in cases of large hernia and those symptomatic for gastroesophageal reflux disease. laparoscopic repair of these uncommon hernias is safe, effective and provides all of the benefits of minimally invasive surgery. conclusion: due to its rare occurrence, knowledge about this condition among laparoscopic surgeons is important to avoid diagnostic dilemma. knowledge about its management aids intraoperatvely to avoid performing incomplete procedure. introduction: extended indications of endoscopic resection for early gastric cancer (egc) have been widely accepted. according to current japanese guidelines, additional gastrectomy with lymph node dissection (lnd) is recommended for patients proven to have potential risks of lymph node metastasis (lnm) on histopathological findings. on the other hand, the frequency of lnm in these patients is exteremely low. the aim of this study was to elucidate the accurate risk of lnm based on the number of risk factors (rf) for possible lnm, and to compare the stratified risk of lnm with predicted risk from additional radical resection. methods and procedures: we enrolled egc patients who did not meet absolute or extended indications of endoscopic resection, and investigated the risk stratification of lnm according to the total number of lnm rfs described below; ( ) sm , ( ) lymphatic vessels invasion, ( ) undifferentiated adenocarinoma and [ mm in diameter, and ( ) [ mm in diameter and ulcer formation. we compared the stratification risk to the surgical risk that was calculated based on the japanese national clinical database (ncd) risk calculator in patients with additional gastrectomy after esd. results: the total number of lnm rfs and frequency of lnm were significantly correlated ( / rf; . %, rfs; . %, rfs, . %, rfs, . %; p. , fischer exact test). the estimated frequency of lnm was found to be lower than the predicted value of in-hospital mortality rate based on ncd in . % of / rf-patients who underwent additional gastrectomy with lnd after esd. the present study suggested that some patients must be over-indicated for additional gastrectomy with lnd, and no additional surgical treatment or less invasive surgery, such as local lnd (sentinel node navigation surgery or lymphatic basin resection), might be indicated for some patients with low number ( / rf) of lnm risk factors after esd. aims: laparoscopic proximal gastrectomy has been applied for early gastric cancer in upper third. we previously reported outcomes of laparoscopic total gastrectomy in managing this condition. in this study, we applied this modified technique for upper third early gastric cancer with double tract reconstruction. it is expected that our technique could be useful for treating these cases. methods: from april of to june of , consecutive patients with upper third early gastric cancer were assigned to undergo surgical treatment with proximal gastrectory at our hospital. we had cases of total gastrectory for upper third early gastric cancer in the same study period. background: laparoscopic total gastrectomy for remnant gastric cancer is much more difficult than common laparoscopic total gastrectomy due to severe adhesions to adjacent organs, displacement of anatomical structure. purpose: the aim was to analyze cases of laparoscopic total gastrectomy for remnant gastric cancer at the department of surgery of juntendo university urayasu hospital between november and april . method: we analyzed outcome and feasibility of laparoscopic total gastrectomy surgery for remnant gastric cancer. and we compared with laparoscopic total remnant gastrectomy ( cases) versus laparoscopic total gastrectomy ( cases) in our hospital. results: in the previous laparoscopic surgeries. we performed laparoscopic distal gastrectomy in cases, laparoscopic proximal gastrectomy in pcases, and open distal gastrectomy in cases. all cases were performed laparoscopic total gastrectomy with r-y reconstruction. case of them had been converted to open surgery due to severe adhesions. the mean operative time was min and the mean blood loss was ml. there were no intraoperative complications, and there were postoperative complications as a pancreatic fistula and a bowel obstruction. however, there were no intra-operative complications more than grade according to the clavien-dindo classification. the mean postoperative hospital stay was . days. all cases were without recurrence. thus, there were no significant differences in operative time, bleeding volumes, intra and postoperative complications and hospital stay compared with laparoscopic total gastrectomy. conclusions: laparoscopic total remnant gastrectomy can be performed with similar short-term outcomes to laparoscopic total gastrectomy, and may be feasible and safe procedure, and can become an option of therapeutic strategy. although this study was not powered to show lower recurrence rates with synthetic absorbable as compared to biologic, the . % recurrence rate is consistent with other series utilizing this mesh. it is interesting to note the difference in time to recurrence. these results suggest that while synthetic absorbable mesh may result in lower recurrence rates, recurrence seems to occur earlier. the results also suggest that deconditioning (lower bmi), and difficult cases and/or recovery may predispose to recurrence. these findings can help inform lf mesh selection and predict which patients are at higher risk of recurrence. introduction: little discussion of gastroparesis (gp) following laparoscopic paraesophageal hernia repair (lphr) has been reported in the literature. we wished to examine the incidence in our institution, and identify potential risk factors for development of gastroparesis following lphr. methods and procedures: a single institution retrospective chart review was preformed using cpt codes corresponding to paraesophageal hernia repair and fundoplication to identify patients undergoing laparoscopic paraesophageal hernia repair over a five year period ( / / - / / ) by three surgeons. emergency procedures and reoperations were excluded. in total, patients undergoing non-emergent first time lphrs were identified. size of the hiatal defect was identified when able, via either measurement between the diaphragmatic crura on ct or by medical record documentation. data obtained included sex, age, hernia type, mesh usage, and existence of specific comorbidities associated with gastroparesis. presence of gastroparesis was identified either by documentation of diagnosis via clinical judgment, or by results of gastric emptying nuclear medicine studies, with timing being no longer than months from date of surgery. independent students t-test and fisher exact test were used to determine statistical differences between the groups. results: patients undergoing non-emergent first time lphrs were identified. of these, we were able to obtain the size of the hiatal defect in patients. patients overall were diagnosed with gastroparesis, with an overall incidence of . %. when comparing all patients who developed gastroparesis to those who did not, only females comprised the group which did develop gastroparesis ( males/ females with gp, males/ females without gp, p= . ). age was also found to be greater in the group which developed gastroparesis. for patients in which the size of the hernia defect was identified, the average age was years older in the group diagnosed with gastroparesis ( step under laparoscopic view, left part of the lesser omentum was cut with preserving the hepatic branch of vagus nerve. the right crus of the diaphragma has been dissected free from the soft tissue around the stomach and abdominal esophagus. in this step the fascia of the right crus should be preserved and the soft tissue should not been damaged to avoid bleeding. after cutting the peritoneum just inside the right crus, the soft tissue was dissected bluntly to left side. then the inside margin of the left crus of the diaphragma was recognized from the right side. in this part of the procedure, laparoscope uses trocar (a), the assistant uses trocar (b) to pull the stomach to left lower side and the operator's right hand uses trocar (c). step the branches of left gastroepiploic vessels and the short gastric vessels were divided with ultrasonic coagulation and dissection device. the left crus of the diaphragma was exposed and the window at the posterior side of the abdominal esophagus was widely opened. in this part of the procedure, laparoscope uses trocar (a) at the beginning of dividing left gastroepiploic vessels, trocar (b) when dividing short gastric vessels. step the right and left crus are sutured with interrupted stitches to reduce the hiatus. from the right side, the fundus of the stomach is grasped through the widely opened window behind the abdominal esophagus. then the fundus of the stomach is pulled to obtain a degree ''stomach-wrap'' around the abdominal esophagus (fundoplication). using - non-absorbable braided suture, stitches are placed between both gastric flaps. purpose: laparoscopic gastrecomy has been widely adopted as the treatment of choice by many countries and institutions. internal hernia is a well-known complication after rouxen-y gastric bypass in the field of bariatric surgery. however, there were only a few reports of internal hernia after gastrectomy in gastric cancer patients. the purpose of this study was to analyze the incidence and clinical features of internal hernia after gastric cancer surgery in a high-volume center. method: , gastric cancer patients who underwent curative gastrectomy at seoul national university bundang hospital between january and december were retrospectively reviewed in this study. internal hernia was classified into two types, mesenteric hernia and petersen's hernia. result: patients who underwent distal gastrectomy (dg) with reconstruction by billroth ii, rouxen-y gastrojejunostomy and uncut rouxen-y gastrojejunostomy, total gastrectomy (tg) with esophagojejunostomy, and proximal gastrectomy with double tract reconstruction (pg dtr) with esophagojejunostomy and gastrojejunostomy had potential space for internal hernia. among these patients, ( . %) were determined as internal hernia by computed tomography and patients ( . %) underwent surgical treatment of internal herniation. two patients were conservatively managed. all patients suffered from abdominal pain and / ( %) patients showed nausea and vomiting. the median interval between the initial gastrectomy and surgery for internal hernia was days. mesenteric hernia was observed in cases and petersen's hernia in cases. since we started closing the mesenteric and petersen's defects from may of , there were only cases ( %) observed afterwards but there were cases ( %) before closure of the defects. conclusion: internal hernia after gastrectomy is likely underreported. although we analyzed patients with internal hernia, there might be more patients with mild symptoms who were managed conservatively by their own. a high degree of suspiciousness for internal hernia should be maintained in patients presenting symptoms like nausea, vomiting and abdominal pain after gastrectomy with potential space for internal hernia. with our experience, closure of the mesenteric and petersen's defect is helpful in reducing internal hernia. however, due to low incidence, a multicenter retrospective study is necessary. introduction: the increased incidence of anemia in patients with a hiatal hernia (hh) has been clearly demonstrated, as has resolution of anemia after hh repair in these patients. despite this, the implications of preoperative anemia on postoperative outcomes have not been well described. in this study, we aimed to identify the incidence of preoperative anemia in patients undergoing hh repair at our institution and sought to determine whether preoperative anemia had an impact on postoperative outcomes. methods and procedures: using our irb-approved institutional hh database, we retrospectively identified patients undergoing hh repair between january and april at our institution. we identified all patients with anemia, defined as serum hemoglobin levels less than mg/dl in men and mg/dl in women, measured within two weeks prior to surgery, and compared this cohort to those that had normal hemoglobin values preoperatively. specific perioperative outcomes analyzed included: estimated blood loss (ebl), operative time, need for blood transfusion, failure to extubate postoperatively, intensive care unit (icu) admission, postoperative complications, length of stay (los), and -day readmission. results: we identified patients undergoing hh repair, of which had preoperative bloodwork available for review. the average age was years and the majority of patients were female ( %, n= ). most were treated electively ( %, n= ) and with a minimally invasive approach ( %, n= ). patients ( . %) had preoperative anemia. compared to patients without anemia, patients with anemia had increased rates of failed extubation postoperatively ( . % vs. . %, p= . ), increased icu admissions ( . % vs. . %, p= . ), increased need for perioperative blood transfusions ( . % vs %, p= . ), and increased rates of postoperative complications ( . % vs. . %, p. ). although mean los ( . days vs. . days, p . ), mean operating time ( mins vs. mins, p= . ), and ebl ( ml vs ml, p= . ) were greater in the anemic group, they did not reach statistical significance, and there was no significant difference in -day readmission rate ( . % vs . %, p= . ). conclusions: anemia diagnosed on preoperative bloodwork appears to be associated with increased failure to extubate postoperatively, need for icu admissions, need for perioperative blood transfusion, and increased overall complication rate after hh repair. however, we found no significant difference in los or -day readmissions between anemic and non-anemic patients. since the majority of patients in this analysis underwent elective repairs, these results would support the preoperative treatment of anemia in patients undergoing hh repair. few studies have compared the procedures' long-term effectiveness with none looking beyond years. this study sought to characterize the efficacy of laparoscopic toupet versus nissen fundoplication for types iii and iv hiatal hernia using a telephone survey. methods and procedures: with irb approval, a review of all laparoscopic hiatal hernia repairs with mesh reinforcement performed over seven years at a single center by one surgeon was conducted. patient demographics and perioperative characteristics were recorded. hiatal hernia was classified per published sages guidelines as type iii or iv using operative reports and preoperative imaging. patients with type i or ii or recurrent hiatal hernia and patients receiving concomitant procedures were excluded. the gerd-health related quality of life survey was administered by telephone no earlier than months postoperatively. patients responded to items concerning symptom severity using a -point scale ( =no symptoms to =symptoms are incapacitating to do daily activities). symptoms surveyed included heartburn ( items), difficulty swallowing ( item) and regurgitation ( items introduction: as the thoracic esophageal carcinoma has a high metastatic rate of upper mediastinal lymph nodes, especially along the recurrent laryngeal nerve (rln), it is crucial to perform complete lymph node dissection along the rln without complications. although intraoperative neural monitoring (ionm) during thyroid and parathyroid surgery has gained widespread acceptance as the useful tool of visual nerve identification, the utilization of ionm during esophageal surgery has not become common. here, we describe our procedures focusing on a lymphadenectomy along the rln utilizing the ionm. methods and procedures: we first dissect ventral and dorsal side of the esophagus preserving the membranous structure (meso-esophagus), which contains tracheoesophageal artery, rln and lymph nodes. we next identify the location of the rln which runs in the meso-esophagus using ionm before visual contact. after that, we perform lymphadenectomy around the rln preserving the nerve. this technique was evaluated in consecutive cases (neural monitoring group; nm) of esophagectomy in prone positioning, and compared with our historical cases (conventional method group; cm background: laparoscopic hiatal hernia repair, particularly large type and type hernias, is associated with high recurrence rates. various use of overlay mesh reinforcement have been described in an attempt to improve outcomes. unfortunately, overlay use of biologic mesh continues to result in high recurrence rates, and more effective repairs employing permanent mesh raise serious erosion concerns and are therefore rarely used. we theorize that employing an interlay technique with permanent mesh (positioned between both crura) will help enhance crural closure and improve rates of hiatal hernia recurrences with minimal risk of erosion. methods: we reviewed all patients who underwent a laparoscopic hiatal hernia repair from april to august by a single surgeon from a prospectively maintained database at a tertiary care referral center (n= ). patients who underwent surgery for achalasia with concurrent hiatal repair were excluded. during this time frame, a new interlay technique of polypropylene mesh was employed upon suture closure of the crura. outcomes of repair were retrospectively reviewed. recurrence of hernia was identified by positive work up of patient's symptoms (new onset dysphagia, gerd, pain). results: a total of consecutive laparoscopic hiatal hernia repair were reported in a period of months. interlay polypropylene mesh was utilized in all repairs. patients were majority females ( . %), had a median age of and had a mean bmi of . . eleven ( . %) patients were redo repairs. majority of patients received a nissen fundoplication (n= , . %) followed by a toupet fundoplication (n= , . %). median length of stay after surgery was day. median follow up was days (range: - days). there were zero reported recurrences. conclusion: laparoscopic hiatal hernia repair with interlay polypropylene mesh appears in the short term to be a safe and durable technique to reduce the incidence of hiatal hernia recurrences. further studies are needed to assess more long term outcomes of this novel technique. zia kanani , melissa helm , max schumm , jon c gould, md ; introduction: laparoscopic fundoplication remains the current gold standard surgical intervention for medically refractory gastroesophageal reflux disease. studies suggest that on average - % of patients undergo reoperative surgery due to recurrent, persistent, or new symptoms. the primary objective of this study was to characterize the long-term symptomatic outcomes of primary and reoperative fundoplications in a clinical series of patients who have undergone one or more fundoplications. methods: patients who underwent laparoscopic primary or reoperative fundoplication between and by a single surgeon were retrospectively identified using a prospectively maintained database. patients undergoing takedown of a failed fundoplication and conversion to roux-en y gastric bypass (for morbid obesity, severe gastroparesis, or or more prior failed attempts) were excluded from the current analysis. all procedures were performed laparoscopically. patients were asked to complete the validated gerd-health related quality of life (gerd-hrql) survey prior to surgery and postoperatively at standard intervals to assess long-term symptomatic outcomes and quality of life. gerd-hrql composite scores range from (highest disease-related quality of life) to (lowest diseaserelated quality of life, most severe symptoms conclusions: patients who need to undergo reoperative fundoplication have more severe gerd-related symptoms at years post-op compared to patients undergoing primary fundoplication. however, good outcomes and morbidity rates of laparoscopic reoperation that approximate that of a primary fundoplication are possible in the hands of an experienced surgeon. adenocarcinoma of duodenum: surgical or endoscopic treatment? introduction: it is well known that the adenocarcinoma of the duodenum (adc) is a quite rare lesion infact represents % of cancer of the small bowel and % of these are localized in the periampullary area: % affect the sub-papillary tract and only % the supra-papillary segment of the duodenum. the adc may arise from duodenal polyps (familial polyposis, or gardner's syndrom or be associated with coeliac disease). until now the treatment was the pancreatoduodenectomy (for anatomo-surgical reasons and for the possibility of regional lymphonode resection). infact in my series of of such procedures, where performed for duodenal cancer. in this last years patients with adc of supra-papillary segment of the duodenum underwent endoscopic submucosal dissection (esd). the purpose of this study were to check the feasibility of the esd in treating such cases. in our experience this kind of endoscopic operation was feasible with high complication rate; perforation in cases ( . %); and bleeding occurred in case ( . %). all the complications were successfully treated endoscopically and the long-term outcomes was favorable. consitering the high rate of complications, the difficult and long procedure, the compliance of patients (c ), the general anesthesia, a very very skilled endoscopist is needed. conclusions: the esd represent a new endoscopic approach enstablished in clinical practice: end is performed following the intraluminal path ( rd space) wich, unlike the others, remain virtual and has to be created by dissecting and expanding the tissues layer between the mucosa and the muscolaris propria allowing the endoscope to gain access. the benefit of esd for treating the adc of the supra-papillary segment of the duodenum, according to our experience, must be validate in the future; a pre-operative pet-tac scan examination must be performed in order to demostred the lesion of the duodenum and if there is any limphatic involvement and no infiltration of the head of the pancreas. yoontaek lee, md, sa-hong min, md, young suk park, md, sang-hoon ahn, md, do joong park, md, phd; seoul national university bundang hospital purpose: this study summarizes the single institution experience of laparoscopic gastrectomy in advanced gastric cancer and evaluates the postoperative morbidities and long-term oncologic outcomes. methods: a total of , laparoscopic gastrectomy for advanced gastric cancer were performed at seoul national university bundang hospital between may and may . the characteristics of patients, surgical techniques, postoperative morbidities, and long-term oncologic outcomes were retrospectively reviewed using electronic medical records. results: patients required conversion to open surgery. the reasons of conversion to open surgery were advanced stage (n= ), intraoperative bleeding (n= ), adhesion due to previous abdominal operation (n= ), small abdominal cavity (n= ), associated disease (n= ), and intraoperative pleural injury (n= ). the mean hospital stay was . days for distal gastrectomy, . days for total gastrectomy, . days for proximal gastrectomy, and . days for pylorus preserving gastrectomy. the mean number of collected lymph nodes was . for distal gastrectomy, . for total gastrectomy, . for proximal gastrectomy, and . for pylorus preserving gastrectomy. the rates of postoperative complications of grade ii or more were . %. there was one case of postoperative mortality due to delayed bleeding after discharge. old age was the only independent predictor of surgical morbidities. background: intrathoracic gastric volvulus is a life-threatening condition of paraesophageal hernia. the therapeutic is a challenge because in acute volvulus it may lead to gastric strangulation and necrosis. most patients are elderly and with a significant associated medical illness which has higher morbidity and mortality of major surgery. we present a laparoscopic surgery is safe in paraesophageal hernia with acute intrathoracic gastric volvulus in a high-risk patient. case presentation: an -year-old woman with underlying of diabetes mellitus and hypertension was transferred from an outlying hospital with anemia, dysphagia, urinary tract infection and aspiration pneumonia. she had severe recurrent emesis after admission. ct scan of the chest and abdomen revealed a large esophageal hiatal hernia, and most of the stomach was in the inferior mediastinum with organoaxial gastric volvulus. endoscopy revealed flat pigmented spot gastric ulcer which compatible with cameron lesion and twisting of gastric folds without evidence of ischemia. the endoscopic reduction was unsuccessful. a laparoscopic surgery was performed and the herniated stomach was successfully reduced. the hernial sac was excised. the crura were approximated and reinforced with composite mesh. nissen fundoplication was performed along with gastropexy of the greater curve of the stomach to the abdominal wall. there was no perioperative complication. she tolerated enteral diet on a postoperative day . she had an uneventful recovery and discharged in weeks after treatment of her associated medical illnesses. she had no relapse of previous symptoms at her six-month follow-up assessment. discussion: endoscopic reduction of acute gastric volvulus may be the first option in a patient with severe comorbidities. however, if there is evidence of ischemia or failure of endoscopic reduction, surgical treatment should be considered. laparoscopic reduction and gastropexy may be a lessinvasive and viable alternative to the more aggressive surgical procedure but definitive surgery with repair hiatal hernia can be done in a selected patient. conclusion: minimally invasive treatments of acute gastric volvulus with paraesophageal hernia, either endoscopic or laparoscopic offer the option for reducing morbidity and mortality in elderly with significant comorbidities. the definitive laparoscopic surgery can be accomplished successfully and safely when it is performed with meticulous attention to the surgical technique and perioperative care. reid fletcher, md, mph, emily ramirez, rn, alfonso torquati, md, philip omotosho, md; rush university medical center introduction: the objective of this study was to evaluate the impact of an enhanced recovery after surgery (eras) program on post-operative length of stay following laparoscopic sleeve gastrectomy. eras programs have been demonstrated to improve outcomes and decrease length of stay in multiple surgical disciplines however relatively little has been published regarding the impact of eras programs in bariatric surgery. methods: an eras program for all patients undergoing bariatric surgery was implemented in february at a single institution. we retrospectively reviewed all patients undergoing laparoscopic sleeve gastrectomy between february and august . as a pre-eras historical control, we also reviewed all patients undergoing laparoscopic sleeve gastrectomy between january and december . baseline patient characteristics, additional concomitant operative procedures as well as -day readmission and complication rates were reviewed. logistic regression analysis was used in univariate and multivariate models to identify factors that predicted early post-operative discharge. data analysis was completed using stata se software (statacorp lp; college station, tx). results: eighty-five patients underwent laparoscopic sleeve gastrectomy after implementation of the eras program while patients were included in the pre-eras control group. there were no statistically significant differences in the baseline characteristics between the two groups and there were no differences in the rate of concomitant procedures performed. there was a statistically significant decrease in post-operative length of stay following implementation of the eras program from . it has been reported that laparoscopic redo surgery is effective for recurrent gerd and/or hiatal hernia after surgery. however, there has been very few reports from japan. we report an initial experience of laparoscopic surgery for japanese patients with recurrent gerd and/or hiatal hernia. among patients who had undergone laparoscopic fundoplication in our hospital from to , patients with recurrent gerd/hiatal hernia underwent redo surgery. preoperative work-up included upper gi series, endoscopy, ct, h ph-impedance and manometry. the patients consisted of women and men with a mean age of . years. the interval from the initial surgery was . months ( days- months). the types of initial fundoplication were nissen: , toupet: , anterior: . the types of recurrence were sliding hernia: and paraesophageal hernia: . one patient with recurrent sliding hernia had poor gastric motility. laparoscopic redo surgery was performed on patients. redo surgery included crural repair with mesh reinforcement: , refundoplication: (nissen-nissen: , nissen-toupet: , toupet-toupet: , toupet-lateral: ) and reduction of the incarcerated paraesophageal hernia: . additional procedure included mesh reinforcement: and pyloroplasty: . open partial gastrectomy was performed for one patient with incarcerated and strangulated hernia. operation time was min. patients was converted to open surgery. oral intake was started on the st pod and postoperative stay was . days. two patients recurred after redo surgery, one of whom underwent re-redo surgery. during the surgery, ivc was injured but rescued by open surgery. eleven patients had good outcome and patients required ppi after redo surgery. our morphological fundoplication score significantly improved after redo surgery. symptom score and acid exposure time were also significantly improved after redo surgery. laparoscopic redo surgery for recurrent gerd and/or hiatal hernia after surgery is safe and effective, although attention should be paid during surgery to avoid injury of the adjacent organs. surg endosc ( ) introduction: cameron ulcers (cu) are linear erosions or ulcerations in the gastric mucosa at the level of the diaphragmatic hiatus in patients with a hiatal hernia (hh) and are frequently associated with anemia. perioperative outcomes of patients with cu undergoing hh repair are not well described. we sought to identify the incidence of cu in patients undergoing hh repair at our institution and determine whether the presence of cu impacted postoperative outcomes. methods and procedures: using our irb-approved institutional hh database, we retrospectively identified patients undergoing repair between january and april . we identified all patients with cu found on preoperative esophagogastroduodenoscopy (egd). we compared patients with and without cu to determine if they differed in terms of preoperative anemia (defined as hemoglobin levels less than mg/dl in men and mg/dl in women). lastly, we compared outcomes between the cu group and the non-cu group, focusing on need for perioperative blood transfusion, failure to extubate postoperatively, intensive care unit (icu) admission, postoperative complications, length of stay (los), and -day readmission. conclusions: the presence of cu on preoperative egd is associated with increased rate of preoperative anemia, increased los, and increased icu admission after hh repair. although the cause of anemia in patients with hh is commonly attributed to cu, only % of cu patients were anemic, indicating that differences in outcomes may not only be attributed to a higher incidence of anemia in cu patients. the implications of cu in patients undergoing hh repair need to be further elucidated. laparoscopic heller myotomy as treatment for achalasia objective: aim of this stud was to review our experience with laparoscopic heller dor myotomy. disphagia constitutes the main symptom. diagnosis is performed by means of esophageal manometry. materials and method: over a period of years, patients were treated with heller myotomy plus dor fundoplication laparoscopically. all patients had lost weight, and there was a prevalence of females with an average age of . twenty five patients had chagas disease. they were all assessed with serial x-rays, endoscopy, esophageal manometry, and their symptoms were assessed with a - score, being the most severe. results: there was no conversion or mortality. in patients the mucosa was perforated during myotomy. the mucosa was sutured without altering the result of the treatment. average hospital stay was hours. one patient had to be reoperate because of esophageal perforation with peritonitis. sixty patients were followed up with manometric control and ph-probe testing, and only % of those had pathologic reflux. conclusions: laparoscopic treatment of achalasia is possible and reproducible, while reducing the morbility of laparotomy with relieve of patients symptoms. introduction: stent treatment in the gastrointestinal tract is emerging as a standard therapy for overcoming strictures and sealing perforations. we have started to treat patients with perforated duodenal ulcers using a partially covered stent and external drainage achieving good clinical results. stent migration is a serious complication that may require surgery. pyloric physiology during stent-treatment has not been studied and mechanisms for migration are unknown. the aims of this study were to investigate the pyloric response to distention mimicking stent-treatment, using the endoflip, investigating changes in motility patterns due to distention at baseline, after a pro-kinetic drug and after food ingestion. methods: a non-survival study in five pigs was carried out, followed by a pilot study in one human volunteer. a gastroscopy was performed in anaesthetized pigs and the endoflip was placed through the scope straddling the pylorus. baseline distensibility readings were performed at stepwise balloon distention to ml, ml, ml and ml, measuring pyloric cross sectional area and pyloric pressure. measurements were repeated after administration of a pro-kinetic drug (neostigmin) and after instillation of a liquid meal. in the human study readings were performed in conscious sedation at baseline and after stimulation with metoclopramide. results: during baseline readings the pylorus was shown to open more with increasing distention, together with higher amplitude motility waves. reaching maximum distention-volume ( ml), pyloric pressure increased significantly (p= . ) and motility waves disappeared. after prokinetic stimulation pyloric pressure decreased and motility waves increased in frequency and amplitude at , and ml distentions. after food stimulation pyloric pressure stayed low and motility waves showed increase in amplitude at distentions of , and ml. during both tests the pylorus showed higher pressure and lack of motility waves at maximum probe distention of ml. similar results were found in the human study. the pylorus seems to acts as a sphincter at low distention but when further dilated starts acting as a peristaltic pump. when fully distended, pyloric motility waves almost disappeared and the pressure remained high, leaving the pylorus open and inactive. stent placement in the pylorus results in pyloric distention, possibly changing motility. this study indicates that a duodenal stent placed over the pylorus should have a high radial force in the pyloric part in order to dilate the pylorus and diminish the contraction waves, this might reduce stent migration. introduction: cutting-edge technology in the field of minimal invasive surgery allows the application of singleincision laparoscopic surgery on gastric cancer. however, single-incision distal gastrectomy (sidg) is still technically difficult due to limited range of motion and unstable field of view-even in the hands of an experienced scopist. solo surgery using a passive scope holder may be the key in allowing sidg to be safer and efficient. we report our initial experience of consecutive cases of solo sidg. methods: prospectively collected database of patients clinically diagnosed as early gastric cancer who underwent solo sidg from october until july were analyzed. all the operations were held by a single surgeon and a scrub nurse. a passive laparoscopic scope holder was controlled by the surgeon to fix the field of view. results: the mean operation time (sd) was . (± . ) min, and the average estimated blood loss was . ± . ml. average body mass index was . ± . kg/m . the median hospital stay (range) was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) days, and the mean number of retrieved lymph nodes was . ± . . there was no conversion to multiport or open surgery. early postoperative complication occurred on % with three delayed gastric emptying, two postoperative pneumonia, one pancreatitis, and one wound complication. conclusion: solo sidg using a passive scope holder allows sidg to become more feasible by providing a stable field of view. there were no peri-operative deaths in either group. in the elective group, age was not an independent risk factor for complications (or . , % ci . - . ). conclusions: the incidence of major complications and mortality in this series were much lower than those previously reported for elective lpehr, while morbidity after emergency repair remains high. the paradigm of watchful waiting for elderly and/or minimally symptomatic patients with giant peh should be revisited. the impact of vagal nerve integrity testing in the surgical kamthorn yolsuriyanwong, md, eric marcotte, md, mukund venu, bipan chand, md; loyola university chicago, stritch school of medicine background: thoracic and gastric operations can cause vagal nerve injury, either accidentally or intended. the most common procedure, which can lead to such an injury, includes fundoplication, lung or heart transplantation and esophageal or gastric surgery. patients may present with minimal symptoms or some degree of gastroparesis. gastroparetic symptoms of include nausea, vomiting, early satiety, bloating and abdominal pain. if these symptoms occur and persist, the clinician should have a high suspicion of a possible vagal injury. investigative studies include endoscopy, esophageal motility, contrast imaging and often nuclear medicine gastric emptying studies (ges). however, ges in the post-surgical patient have limited sensitivity and specificity. if a vagal nerve injury is encountered, subsequent secondary operations must be planned accordingly. methods: from january to august , patients who had a previous surgical history of a foregut operation, with the potential risk of a vagal nerve injury, had vagal nerve integrity (vni) test results reviewed. vni test was measured indirectly by the response of plasma pancreatic polypeptide to sham feeding. the data collected and analyzed included age, gender, previous surgical procedures, clinical presentation, results of vni testing and the secondary procedure planned or performed. vni testing was compared to other testing modalities to determine if outcomes would have changed. results: eight patients ( females) were included. the age ranged from to years. two patients had prior lung transplantation and six patients had prior hiatal hernia repair with fundoplication. seven patients presented with reflux and delayed gastric emptying symptoms. one lung transplantation patient had no symptoms but his lung biopsy pathology showed chronic micro-aspiration with rejection. the vni testing results were compatible with vagal nerve injury in patients. according to these abnormal results, the plans for nissen fundoplication in patients were modified by an additional pyloroplasty and the plans for redo-nissen fundoplication in patients were changed to redo-nissen fundoplication plus pyloroplasty in patient and partial gastrectomy with roux-en-y reconstruction in patients. the operative plans in patients with a normal vni test were not altered. all patients that had secondary surgery had improvement in symptoms and or improvement in objective tests (ie signs of rejection). conclusion: the addition of vni testing in patients with previous potential risks of vagal nerve injury may help the surgeon select the appropriate secondary procedure. . we present a single-center experience with a "myotomy first" approach for all patients, regardless of diverticular size. the hypothesis is that cardiomyotomy alone will provide satisfactory symptom abatement in some patients. and mis cardiomyotomy causes minimal scarring, so a staged mis diverticulectomy is feasible at a later date if diverticular retention/stasis continues. in order to discuss this treatment algorithm we present our experience with cardiomyotomy alone for patients with epiphrenic diverticula. methods: the electronic medical record was queried for patients with esophageal diverticula who were managed with cardiomyotomy and dor fundoplication alone. pre and post-operative reflux/dysphagia questionnaires were gathered; imaging studies, operative data, complications and follow up were reviewed. results: from march of until the present, patients with esophageal diverticula were treated using the "myotomy first" approach. intraoperative esophagoscopy was done to internally visualize the elimination of the inciting spastic esophageal muscle. preoperatively, all patients complained of regurgitation, followed by dysphagia in ( %) and weight loss ( %). postoperatively, dysphagia and weight loss resolved in all subjects. regurgitation symptoms resolved in ( %) patients. the average size of the diverticula was . cm , the range was - cm . post operative esophagream's showed persistent diverticual, however most had decreased in size. there were no perioperative complications, average length of stay was . days and there were no icu admissions or returns to the or. the average length of follow up for these patients was days where all patients reported being satisfied with their results and none of them have yet desired to pursue diverticulectomy. discussion: a "myotomy first" approach resulted in excellent short term symptomatic control. none of the have retained or re-experienced symptoms of diverticular retention worthy of surgical intervention. in the age of laparoscopic surgery, an esophageal epiphrenic diverteculectomy should be staged. this step wise approach seeks to assure surgical necessity for a morbid endeavor. surg endosc ( ) :s -s the background: the two-stage oesophagectomy (ivor-lewis procedure) remains the mainstay of curative surgery for oesophageal cancers in the uk. gastro-oesophageal anastomotic leak is a potentially devastating complication of this procedure affecting perioperative morbidity and mortality. although the leak rates have improved over the years, it still remains widely variable. intraoperative reinforcement of gastro-oesophageal anastomosis with an 'omental wrap' has been proposed as a measure to reduce anastomotic leak rates. there is some data to suggest that this additional technique reduces anastomotic leak. we reviewed our single institution data to assess if the omental wrap indeed had a 'cocoon' effect in maturing the anastomosis and reducing leak rates. methods: data for all cancer oesophagectomies (ilog) performed in our institute since april - was retrospectively analysed from a prospectively maintained database. the patients were categorised into two groups. masafumi ohira; department of gastroenterological surgery, hokkaido university graduate school of medicine background: in laparoscopic surgery, both surgical technique and adequate support and traction by an assistant are highly important. this study assessed the impact of the first assistant on shortterm outcomes of laparoscopic distal gastrectomy (ldg) and laparoscope-assisted distal gastrectomy (ladg). methods: patients who underwent ldg or ladg for gastric cancer at our hospital, between november and august , were included. ldg and ladg cases of billroth i reconstruction, performed by a single surgeon accredited in endoscopic procedures, were analyzed. the cases were categorized into the following groups according to the first assistant's postgraduate years (pgy) of experience: group a, - years; group b, - years; group c, - years; and group d, [ years. short-term outcomes were compared between the groups. results: we examined cases. operative time was significantly longer in group a than in group b (p= . ). no significant differences in operative time were found between groups b, c, and d. the cases were recategorized into groups as follows: group a, the young assistant group (group y, n= ), and groups b, c, and d, the senior assistant group (group s, n= ). significant differences in operative time and method of anastomosis (circular stapler or delta anastomosis) were observed between the groups (p= . and p= . , respectively), but no significant differences in complication rates were found (p= . ). the unadjusted analysis revealed that the group, method of anastomosis, and body mass index (bmi) were significant factors associated with longer operative time. multivariate linear regression analysis with stepwise model selection using akaike's information criterion (aic) revealed that bmi and group were significant factors associated with longer operative time (p= . and p= . , respectively). multivariate analysis using these variables and the method of anastomosis confirmed the significance of bmi and group for longer operative time, but no significance was found in the method of anastomosis (p= . , p= . , and p= . , respectively). conclusions: our study showed that operative time tended to be longer when the first assistant had experience of less than pgy, but the morbidity did not increase. as with the operator, the first assistant needs adequate training to ensure a smooth operation. steven g leeds, md, marc ward, md, brittany buckmaster, pa, estrellita ontiveros, ms; baylor university medical center at dallas background: gastric contents can reach beyond the esophagus into the larynx and pharynx causing an increasingly prevalent disease called laryngopharyngeal reflux (lpr). magnetic sphincter augmentation (msa) has been used as an alternative treatment for gerd with good success, but there is no data to support its use in lpr. methods: forty-five patients with msa implants for symptomatic relief with both gerd and lpr symptoms were examined. all patients experienced at least one typical gerd symptom as well as at least one extra-esophageal symptom. this was assessed using the gerd-hrql which is questions graded - on each question, and reflux symptom index (rsi) which is questions graded - on each question. patients filled out questionnaires preoperatively, one month postoperatively (early follow up), and at months to year postoperatively (late follow up). the responses on the gerd-hrql were clustered into questions inquiring about heartburn ( ), dysphagia ( ), and regurgitation ( ) like all surgical fields there is a push towards standardization of the post operative course while maintaining safe practices. other surgical fields have streamlined recovery processes in an effort to standardize care and minimize costs. laparoscopic hiatal hernia repair is a complex procedure, but with experience and a team approach, this operation can become a streamline process. methods: a retrospective review was done for over laparoscopic hiatal hernia repairs at a single institution. aspects of post operative care such hospital floor, nursing ratio utilized, pain medication, diet advancement, use of foley catheters and length of hospital stay were tracked. statistical analysis was done to compare utilization of resources as years went on along with complications and readmissions. results: a total of hiatal hernias were performed between and . improvements were noted in nearly every field over time, including faster foley removal, decreased length of hospital stay, decreased use of patient controlled analgesics (pcas) and faster advancement of diet. furthermore these patients are now treated on a surgical floor rather than the intensive care unit or step down with a higher nurse to patient ratio, decreasing hospital cost. there were no changes in complications, reoperations or readmissions over the course of the study. conclusions: cost, length of stay and so called "advanced recovery pathways" are all the rage in the surgical literature. anytime a procedure and its post operative course can become less of a "major undertaking" and more routine, the more streamline it becomes. this comes from making a standard protocol that deescalates treatment based on what is actually needed. nearly every aspect of post operative care was simplified; length of stay and cost to the hospital was decreased while no additional complications or readmissions were accrued. the foundation of a formalized advanced recovery pathway will be implemented from these factors which were studied. background: the obesity epidemic continues to worsen. bariatric surgery remains the most effective way to achieve weight loss and resolution of comorbidities. laparoscopic sleeve gastrectomy has become the most common bariatric operation due to excellent efficacy and low morbidity and mortality. the most common complication of sleeve gastrectomy is gastroesophageal reflux disease (gerd), which can adversely impact the quality of life and lead to additional esophageal complications. recently, esophageal magnetic sphincter augmentation (linx®) has become an acceptable alternative to fundoplication for certain patients with gerd. the use of linx® in patients who previously underwent laparoscopic sleeve gastrectomy was described in a case series in . the known complications of these devices include dysphagia, need for endoscopic dilation, and device erosion. the complication profile of linx® in the setting of sleeve gastrectomy has not been reported heretofore. methods: we present a case of a patient with prior sleeve gastrectomy who received a linx® device one year after her bariatric operation due to severe gerd refractory to medical management. initial evaluation demonstrated a hypotensive lower esophageal sphincter and hiatal hernia, but no evidence of stricture or twisting. soon after linx® implantation, the patient developed progressive dysphagia and worsened reflux. repeat evaluation showed esophagitis, a moderate stricture with angulation at the incisura, and a large amount of retained food. discussion: the patient was recommended conversion to roux-en-y gastric bypass, but was deemed to be a poor candidate due to heavy smoking. thus, laparoscopic removal of the linx® device was performed with hiatal hernia repair and gastric stricturoplasty. post-operative fluoroscopic evaluation revealed improvement in the stricture, but persistent gastroesophageal reflux. the patient experienced a significant improvement in her symptoms of dysphagia, nausea, and vomiting. however, once smoking cessation is achieved, she may still need a conversion to roux-en-y gastric bypass in order to address persistent gerd. conclusion: conversion to roux-en-y gastric bypass remains the standard approach to treatment of gerd post sleeve gastrectomy. new approaches to this problem, including placement of linx®, are promising but have not been evaluated for long-term safety and efficacy in the setting of prior bariatric surgery. careful diagnostic evaluation prior to placement of magnetic sphincter augmentation device should be routinely undertaken. postoperatively, close long-term follow up is imperative, particularly in patients with prior sleeve gastrectomy. presence of linx® in a patient with prior bariatric surgery may lead to worsening symptoms if complications of initial operation are present. kazuto tsuboi, md , nobuo omura, md , fumiaki yano, md , masato hoshino, md , se-ryung yamamoto , shunsuke akimoto, md , takahiro masuda , hideyuki kashiwagi, md , norio mitsumori, md , katsuhiko yanaga, md ; fuji city general hospital, shizuoka, japan, nishisaitama-chuo national hospital, saitama, japan, the jikei university school of medicine, tokyo, japan background: esophageal achalasia is one of the primary esophageal motility disorders, and the patients suffer from dysphagia, vomiting and chest pain. timed barium esophagogram (tbe) is a convenient method to assess esophageal clearance, which we usually performed before and after surgery. meanwhile, laparoscopic heller-dor operation (lhd) has been considered worldwide as a gold standard for the surgical management of esophageal achalasia. the aim of this study is to examine the effect of preoperative clearance rate at the lower part of the esophagus on surgical outcomes in patients with esophageal achalasia. patients and method: between august and april , patients who underwent lhd at our institution were extracted from the database. out of patients, patients met our inclusion criteria; such as the patients who underwent lhd as an initial operation with complete evaluation with preoperative esophageal clearance by tbe. these patients were divided into three groups by the degree of esophageal clearance (group a: clearance rate \ %, group b: %? clearance rate \ %, and group c: %? clearance rate). patients' background, pre-and post-operative symptom scores, and surgical results were compared. before and after surgery, the standardized questionnaire was used to assess the degree of frequency and severity of symptoms (dysphagia, vomiting, chest pain and heartburn). moreover, satisfaction with operation was evaluated using the standardized questionnaire. statistical analysis was performed by using krasukal-wallis test or chi-square test, and p-value less than . was defined as statistically different. results: their mean age was . years and of them were male ( . %). one hundred and sixty-eight patients ( . %) were in group a, ( . %) in group b, and ( . %) in group c. the maximum width of the esophagus in group c was smaller than that in other groups (p= . ). as to the pre-operative symptom score, the frequency score of dysphagia was significantly lower in group c (p= . ), whereas the severity score of chest pain was significantly higher in group c (p= . ). surgical outcomes including the incidence of mucosal injury were not different among the groups. moreover, the patient satisfaction with lhd was excellent regardless of preoperative esophageal clearance. conclusion: preoperative clearance rate at the lower part of the esophagus in patients with esophageal achalasia did not affect the surgical outcomes of lhd, but the characteristics of preoperative symptoms in patients with poor esophageal clearance was low dysphagia and high chest pain. surg endosc ( ) ( . cm . cm) was made by dissecting between submucosal and muscular layers at the anterior remnant gastric wall. after creation of the double flap, the posterior esophageal wall ( cm from the edge) and the anterior gastric wall (superior edge of the mucosal window) were sutured for fixation, and . cm from the inferior edge of the mucosal window was opened, and the wall of the esophageal edge and the opening of the remnant gastric mucosa were sutured continuously. the anastomosis was fully covered by the seromuscular flaps with suturing. in latg, roux-en-y reconstruction was performed through a small incision using a circular stapler. introduction: the purpose of this study was to clarify the long-term and short-term outcomes of consecutive patients who underwent thoracoscopic esophagectomy in the prone position using a preceding anterior approach for the resection of esophageal cancer at a single institution. this method was established to make an esophagectomy easier to perform and to achieve better outcomes in terms of safety and curativity. methods and procedures: we retrospectively reviewed a database of patients with thoracic esophageal cancer who had undergone a thoracoscopic esophagectomy (te, patients) or an esophagectomy through thoracotomy (oe, patients) between january and august . to compare the long-term outcomes of te and oe, we used a propensity score matching analysis and a kaplan-meier survival analysis. to analyze the short-term outcomes of te, patients were chronologically divided into three groups: a first period group ( patients), a second period group ( patients), and a third period group ( patients). as for thoracoscopic procedure, the esophagus was mobilized from the anterior structure during the first step and from the posterior structure during the second step. the lymph nodes around the esophagus were also dissected anteriorly and posteriorly. the intraoperative factors, the number of dissected lymph nodes, and the incidence of adverse events were compared among the three period groups using a one-way anova or chi-square test. results: one hundred and twenty-three patients from each group, for a total of patients, were completely selected and paired. background: it is also difficult to anastomose using circular stapler in the narrow neck field. to overcome the problem we modified circular stapling for anastomosis. gastric juice reflux is frequently observed at the esophagogastric anastomosis. we develop and report trapezoidal tunnel method to reduce the incidence reflux. ( ) patients one hundred thirteen cases ( in left lateral and in prone position), with esophageal carcinomas underwent vats-e, respectively. esophago-gastric anastomosis is performed for cases by modified circular stapling and cases by trapezoidal tunnel method. ( ) methods at first the patients are fixed at semi-prone position and esophagectomy is performed in prone position that can be set by rotating and ports are used at the intercostal space (ics). esophagectomy and the l.n. dissection are performed with pneumothorax by maintaining co insufflation. esophago-gastric anastomosis is performed as following, i) trapezoidal tunnel method sero-muscular layer of anterior wall in the near top of gastric conduit is peeled from submucosal layer after parallel horizontal incision of sero-muscular layer, and then trapezoidal tunnel of sero-muscular layer is created. the edge of the proximal esophagus is drawn into the tunnel and esophago-gastric submucosa anastomosis is performed. to wrap anastomosis distal side of parallel line is closed. ii) modified circular stapling at first the circular stapler is introduced into the gastric conduit and joined to an anvil, and close a little. and then a joined anvil is placed into the proximal esophagus and secured by means of a pursestring suture. the gastric conduit opening is closed by a linear stapler. purpose: mesh utilization and its impact on postoperative hernia recurrence following paraesophageal hernia repair remains a polarizing topic. this analysis evaluates the recent trends in laparoscopic paraesophageal hernia repairs and analyzes the impact of operative time on postoperative morbidity. methods: the - acs-nsqip database was queried for primary cpt code for laparoscopic paraesophageal hernia repair with and without mesh ( / ). only elective cases performed by a general surgeon were included. operative time was grouped into quartiles ( - , - , - , - min) and statistical analysis was performed using anova univariate with post-hoc testing and multivariate regression modeling controlling for age, diabetes, renal disease and weight loss. this analysis was powered to detect a greater than % difference in outcomes based on mesh utilization. the outcomes of interest were composite morbidity scores and readmission rates within days of surgery. results: the database identified a cohort of , laparoscopic paraesophageal hernia repairs performed between and . average patient age was years and average patient body mass index was . mesh was utilized in % of cases per year and did not change over the study period (p= . ) however mesh utilization was %, %, %, and % within operative time quartiles - respectively (p. ). postoperative morbidity and readmission rates for each operative time quartile were . %, . %, . %, and . % (p. ) and . %, %, . %, and . % (p= . ), respectively. post-hoc testing indicated statistically significant differences in postoperative morbidity and readmission rates between quartiles and / . multivariate regression analysis documented operative time as a risk factor for postoperative morbidities and readmission, even after controlling for covariates. mesh utilization was only significant for a reduction in the rate of venous thromboembolic complications (or . , p= . ) but did not impact other morbidities or readmission rates. conclusion: this analysis suggests that patients with higher operative times have increased postoperative morbidity and readmission while mesh utilization does not impact postoperative outcomes, after accounting for the longer operative time of a paraesophageal hernia repair with mesh. introduction: gastroparesis is a chronic gastric motility disorder defined by delayed gastric emptying and symptoms such as nausea, vomiting, bloating and abdominal pain. surgical options for refractory gastroparesis include pyloroplasty, gastric stimulator insertion, and gastrectomy. the palliation from a pyloroplasty and gastric stimulator may be synergistic, however concerns remain regarding the possibility of stimulator infection when performing both procedures simultaneously. we present our initial experience of combined laparoscopic pyloroplasty and insertion of gastric stimulator. methods: gastroparesis patients diagnosed by solid gastric scintigraphy or endoscopic evidence of retained food after prolonged npo status who underwent combined laparoscopic heineke-mikulicz pyloroplasty and gastric stimulator insertion between july and july were reviewed. patient demographics, pre-and post-operative symptom scores and outcomes were collected. results were analyzed using statistical tests as appropriate. p value . were considered significant. results: seven patients underwent the simultaneous pyloroplasty and gastric stimulator insertion. six patients ( %) were idiopathic and one patient ( %) was diabetic. one patient was male and six patients were female. charleen yeo, enming yong, danson yeo, kaushal sanghvi, aaryan koura, jaideepraj rao, myint oo aung; tan tock seng hospital introduction: gastric cancer is one of the most common cancers in the asian population, with recent literature supporting the laparoscopic approach in early disease. however, the minimally invasive approach in advanced disease is still controversial. the outcomes of laparoscopic gastrectomy in the elderly have also not been extensively studied. we aim to evaluate our institution's short term outcomes of laparoscopic versus open gastrectomy for gastric cancer-with particular focus on advanced disease and elderly patients. methodology: we prospectively collected the data of all patients who underwent gastrectomies for stomach cancer from to . all patients underwent a partial or total gastrectomy with d lymphadenectomy. the decision for open or laparoscopic approach was decided between surgeon and patient. we excluded patients who underwent palliative resection. all patients were followed up for at least one year post-operatively. introduction: it was an eye-opener when the lancet brought the attention about global surgery. it is estimated that the deaths due to lack of access to surgery is far greater than deaths due to malaria, tuberculosis and hiv/aids put together. there is greater need to stress the importance in developing countries. there is a responsibility at the medical schools to enlighten students about this necessity and arouse interest in concept of global surgery. the students or surgical residents in the future are a great resource to solve this major problem. the first step would be to educate surgical residents. we need to assess the existing awareness about global surgery problem among surgical residents. we can plan a program to train the next generation surgeons. methods and procedure: all the surgical residents in our institution (victoria hospital, bangalore, india) were enrolled for this study. a total of residents were enrolled. a multiple-choice questionnaire regarding global surgery was designed. the received questionnaire was analyzed to assess the depth of knowledge about global surgery. there were multiple choice questions (mcq) and an option was provided at the end for feedback and suggestion to improve the global surgery in our country. each question carried one mark. score more than was considered the cutoff for pass and those students were termed 'informed'. results: ( . %) students cleared the cut off score of and were termed 'informed'. among this group ( %) residents scored marks. ( . %) students did not cross the cut off and were termed 'non-informed'. among these ( . %) students scored marks and did not know anything on the topic. students provided relevant suggestions and opinions to improve global surgery issue. conclusion: there is a great lacuna in knowledge about global surgery among surgical residents. we need to plan a program integrating global surgery in the syllabus of surgical training. the awareness among residents would arouse interest and participation in the future. introduction: minimally invasive surgical techniques (mists) could have tremendous applications and benefits in resource poor environment. these include but are not limited to short hospital stay, reduced cost of care, and reduced morbidity, especially related to post operative infections. there is growing interest in mists in most low and middle income countries (lmic) but its adoption has remained limited largely due to high cost of initial set-up, lack of technological backup and limited access to training among others. one of the most limiting factors is the maintenance of the vision system. an affordable laparoscopic set-up as an example will therefore go a long way in improving access to mists. methods and procedures: a common zero-degrees mm scope is attached on the camera of a low price smartphone (samsung galaxy j , samsung®, seoul, south korea). two elastic bands are used to fix the scope right in front of the main camera on the smartphone. the device is covered with sterile transparent drapes (tegaderm®, m corporate, st. paul, mn, usa). a light source is connected with a fiber optic cable for endoscopic use. the image can be seen in real time on a common tv screen through an hdmi connection to the smartphone, with a sterile drape. holding the vision system through the scope would guarantee to keep the camera in place without issues. to operate in full screen the vision was digitally zoomed at . , without losing quality (that is more related to the intensity of the light). as a collateral project we built a low cost simulator training box with the same camera to train the surgeon, obtaining a high fidelity and affordable simulation setting. results: we were able to perform the tasks of the fundamentals of laparoscopic surgery curriculum using our vision system with proficiency. in a pig model, we performed a tubal ligation to simulate an appendectomy and we were able to perform basic laparoscopic suturing. no major issue were encountered and small adjustment only were required to have an acceptable, stable and clear view. conclusion: there is growing interest in minimally invasive surgeries among surgeons in lmic, but its adoption has remained limited due to reasons such as high cost of initial set-up, lack of technological backup and limited access to training among others. an affordable laparoscopic camera system will therefore go a long way in improving access to mis in such settings. open. there were no deaths or bile duct injuries in our series. two patients undergoing laparoscopic approach were converted to open ( . %). complications, los, and gender were similar between the two groups. the laparoscopic group were significantly younger and had a significantly longer operative duration (table) . long term outcomes were not available for analysis. laparoscopic and open cholecystectomy appear safe in the setting of short term surgical missions. neither group suffered major complications. both had similar immediate outcomes. los for both groups was surprisingly similar and shorter than larger series which may possibly due to patient selection. given similar immediate outcomes and large burden of disease, the open approach should be considered. however, this cost may be extracted in terms of greater pain or longer recovery time for patients, which may outweigh the benefits. further data is needed to study pain, long term outcomes, and return to work. introduction: minimally invasive surgery relies on optimal camera control for the successful execution of operations. one disadvantage of laparoscopic surgery is that camera control is dependent on a surgical assistant's interpretation of visual cues and ability to predict the next field of focus in addition to verbal commands from the operating physician to provide the optimal view. robot-assisted minimally invasive surgery provides the operating surgeon the advantage of dictating their field of view. this study aims to utilize a video processing algorithm to determine the incidence of improperly centered field of view in laparoscopic vs. robot-assisted surgery. methods: in this study, recordings of minimally invasive resection of rectal cancer ( laparoscopic and robot-assisted surgery) were evaluated. recordings were input into matlab® video processing to generate single frames at each second interval. a single reviewer would indicate the pixel which best determined where the camera should be centered based on positioning of instruments, current action (dissection/hemostasis/traction) depicted in the frame, and previous review of recordings. pixel locations were recorded for subsequent analysis. centered views were determined as those with the identified centered position pixel lying within the center quadrant when frames were split into a uniform grid. in addition, distance of each point to the absolute center of the frame was calculated based on the pixel's x and y positions. results: individual operation data was analyzed for percent of centered pixel locations and pixel distance from the center pixel of the frame. robot-assisted surgery demonstrated higher percentage of centered views over laparoscopic surgery ( . ± . vs. . ± . ; p. ). robot-assisted surgery also demonstrated shorter distances to frame center than laparoscopic surgery ( . ± . vs. . ± . ; p. ). conclusion: robot-assisted surgery aims to resolve conflicts of cooperation that occur between surgeon and assistant in laparoscopic surgery by enabling manual visual control of the operative field by the operating surgeon. this study demonstrates that by eliminating such conflicts, optimal surgical view is more frequently obtained. surg endosc ( ) background/objective: valveless laparoscopic insufflator systems are marketed for ability to prevent loss of abdominal collapse and desufflation during laparoscopy. however, community surgeons raised concern for possible entrainment of room air, including oxygen ( ), with these systems. this study seeks to quantify o and non-medical air entrainment by a laparoscopic valveless cannula system to understand the risk of intraoperative air embolism. a communityuniversity collaborative was created to design a model and test this hypothesis. methods: an artificial abdomen was developed and calibrated to equivalent compliance and intraoperative volume of an average adult abdomen. it was connected to a flow meter, oxygen concentration sensor, and commercially available laparoscopic valveless cannula system. background: further advance of near-infrared (nir) imaging capability into greater clinical usefulness will be helped by the development of new targetable agents. to avoid issues related to dose timing and contamination, compounds that become fluorescent only at the site being targeted would be a significant advance. here we build on earlier laboratory work to show step-wise advance of the agent towards clinical trialling. methods: a novel agent (nir-aza) was tested in ex vivo colorectal specimens using two commercially available systems to determine characteristics in biological tissue. it was then trialled in a large animal cohort (n= ) to determine its performance for both intestinal perfusion assessment and lymph node mapping (both stomach and colon) using again a commercially available optical imaging system and including a direct comparison with indocyanine green. results: the novel agent was easily detectable in biological tissue in the near infrared wavelength relevant to commercial instrumentation both as a local depot tattoo and as a lymphatic tracing agent. porcine model trialling again showing excellent detection and tracking characteristics both in the circulation and in gastrointestinal tissue with clear tracking to relevant lymph nodes within minutes evident with the latter. while these studies were non-survival, there was no evidence of local tissue or systemic system toxicity in any case. direct qualitative and quantificative comparison between in situ nir-aza and icg at both intestinal and lymph basin regions showed similar levels of fluorescence. conclusion: the trial compound underwent successful testing indicating proof of earlier projected potential. this is encouraging for further work to advance to first in human testing. introduction: enhanced imaging systems have been developed to alter laparoscopic camera output to facilitate visualization during laparoscopic surgery using several novel imaging modes: clara mode reduces overexposure and reflections while brightening darker areas of the image; chroma mode intensifies color contrast to more clearly delineate blood vessels; and a combined chroma-clara mode. the ies also allows the surgeon to change imaging modes throughout the procedure as needed to facilitate different portions of the operation. we hypothesized that this technology would enhance visualization of critical structures during laparoscopic cholecystectomy (lc) compared to standard laparoscopic imaging. methods: videos and still images from an ies (karl storz endoscopy) were assessed in patients undergoing lc using the four imaging modalities. three time points were assessed: ) after adhesions were taken down but before any other dissection; ) after partial dissection of the hepatocystic triangle; and ) after establishment of the critical view of safety (cvs). seven surgeons blinded to the imaging modalities ranked each modality from (best) to (worst) for each of time points ( dissection points for cases). structures identified on achievement of the cvs were also analyzed. all statistics were performed using spss. rank data was analyzed with the friedman and wilcoxon signed rank tests. results: the median ranks of the chroma and chroma-clara imaging modalities (median [iqr] [ ] [ ] [ ] vs ( - ), p= . ) were not significantly different from each other, but both ranked significantly higher than the clara and standard modalities (median rank [iqr] [ ] [ ] and [ ] [ ] , respectively, p. ). individual surgeon preferences varied; four surgeons preferred chroma-clara, two preferred chroma, one preferred clara, and none preferred the standard mode. in addition, the cystic artery and cystic duct were visible in all cases after achieving the cvs, but the common bile duct was visible in only % of cases. conclusion: enhanced imaging system technology provides modalities that were significantly preferred over standard laparoscopic imaging on retrospective review of still and video images during lc. enhanced imaging modalities should be evaluated further to assess their impact on outcomes of lc and other laparoscopic procedures. introduction: cholangiocarcinoma is often diagnosed at an unresectable stage. endoscopic stent placement is generally performed to release the tumor-induced biliary obstruction. however, stents misplacement and migration, tumor tissue ingrowth and cholangitis are relatively frequent complications. energy-based techniques (radiofrequency ablation and photodynamic therapy) have been proposed as alternatives or in addition to the stent placement, showing controversial results. the use of laser sources in the ablation of the biliary wall has not been investigated so far. this study aims at the evaluation of the optimal power and exposure time to achieve a controlled circumferential intraluminal laser ablation of the common bile duct (cbd). methods: through a laparotomy access, the cbd of pigs was exposed and a small choledocotomy was made. a confocal endomicroscopy (ce) scanning (cellvizio) was performed through the choledocotomy, after injection of ml of sodium fluorescein. the . mm diameter circumferentiallyemitting diode laser probe ( nm wavelength) was introduced in the cbd. laser ablation was performed at w during s (n= ) or s (n= ). the power setting was predetermined on preliminary ex-vivo tests on porcine liver specimen. local temperature control was monitored through a fiber bragg grating, embedded in the laser probe. ce scanning was then repeated. the extent of the ablation was measured on hematoxilin-eosin and nadh stained slides. results: the diameter of the probe was too small to enable a single-shot circumferential ablation. there were no full-thickness perforations. after s from turning laser on, the temperature at the application site reached a plateau with minimal oscillations, and remained at mean values of . ± . °c during both and min. histology revealed that the mucosa ablation, at the contact areas, induced a consistent cellular necrosis (nadh-). ce scanning provided real-time images with a specific aspect of the post-ablation mucosa, including an alteration of the normal glandular structure and a general lack of enhanced imaging. the local application of a circumferential laser source induced a precise and safe mucosa ablation with a long-standing increase in temperature in the cbd, in this experimental trial. however, there is a need of an adapted probe, better fitting the diameter of the cbd to enable a single-shot circumferential treatment. goutaro katsuno, md, phd , yasuhiko nakata, md, phd , nobuyuki kubota, md, phd , teruo kaiga, md, phd , takao mamiya, md , masahiro yan, md , naoaki shimamoto, md , shuichi sakamoto, md, phd ; department of gastrointestinal and minimally invasive surgery, mitsuwadai general hospital, introduction: recently major developments in video imaging have been achieved for performing complete mesocolic excisions (cme) or total mesorectum excisions (tme). indocyanine green (icg) fluorescence imaging is already contributing greatly to making intraoperative decisions for keeping an intact visceral fascial layer, making suitable mesentery division lines and identifying anastomotic perfusions. the aim of this study is to present our experience with laparoscopic procedures for colo-rectal cancers using icg fluorescence imaging (lap icg-fi). patients and methods: we usually use the near-infrared (nir) laparoscopy (stryker corporation, michigan, usa) for lap icg-fi. [indocyanine green fluorescent imaging] visualization of lymph flow: icg ( . mg/ . ml) was injected into the submucosal layer around the tumor at points with a -gauge localized injection before the lymph node dissection. visualization of blood flow: after complete colorectal mobilization, the mesocolon was completely divided at the planned proximal or distal transection line. indocyanine green was injected intravenously and the transection location(s) and/or distal rectal stump, if applicable, were re-assessed in fluorescent imaging mode. results: we experienced lap icg-fi cases with colo-rectal cancer patients. tumor was located at the rectum in of them, at the sigmoid colon in , at the transverse colon in , at the descending colon in , at the ascending colon in , and at the cecum in . tnm stage was -i in patients, ii in , iii in , and iv in . the median (range) age of the patients was ( - ) years with a median (range) bmi of . ( - . ) kg/m . the lymph flow was visualized in patients ( %) intraoperatively. however, a high-quality intraoperative icg lymphangiogram was achieved in patients ( %). in high-quality lymphangiogram, the lymphatic ducts and lymph nodes were clearly visualized in real time, and this proved useful in keeping an intact visceral fascial layer as well as in making a suitable mesentery division line even in the bmi[ patients. a high-quality intraoperative icg angiogram was achieved in all patients. anastomotic perfusion was satisfactory in all cases. in patients ( . %), the use of nir+icg resulted in revision of the proximal colonic transection point before formation of the anastomosis. there were no postoperative anastomotic leakages. no injection-related adverse effects were reported. conclusion: lap icg-fi is a simple, safe and useful tool to help us complete lap cme or tme and check real-time anastomotic tissue perfusion. introduction: recently, the spread of laparoscopic surgery as a standard treatment and the development of information & communication technology have yielded abundant video data of laparoscopic procedures. these data have been accumulated and we can access them anytime, anywhere. however, the direction of how to use the abundant video data are still unclear. conventionally, surgical procedures have been performed based on surgeon's subjective decisions and skills, so called "tacit knowledge". for the purpose of objective analysis of laparoscopic procedures in video data, automatic recognition of surgical tools and understanding of surgical workflow must be the first critical step. we used convolutional neural network (cnn) which is the current trend in machine learning and computer vision tasks. methods: using video database of laparoscopic sigmoid colectomy in our institute, we performed annotation of tools and phases in every frame of the operating videos. for the tool detection, we annotated bounding boxes for both left and right tools in the videos. furthermore, phase annotation was performed by watching the videos in consultation with laparoscopic surgeons. the laparoscopic sigmoid colectomy operation passes through phases; -placement of ports and preparation, -dissection of retrorectal space, -medial approach to ima, -isolation and division of ima, -medial-to-lateral retromesenteric dissection, -lateral mobilization of left colon, -rectosigmoid mobilization, -division of mesorectum, -rectosigmoid resection and anastomosis, -finishing. we used cnn architecture to perform surgical tool detection and workflow recognition. results: we totally labeled tools used in the procedures of laparoscopic sigmoid colectomy and successfully developed tool detection system by cnn. as for surgical workflow, average times of phase - were . , . , . , . , . , . , . , . , . , . min, respectively. workflow recognition system using cnn was also successfully developed, while we needed to extract pure operating scenes in advance for efficient recognition outcomes. we've developed tool detection and phase recognition systems using cnn. we need more datasets to improve the detecting ability for future clinical uses. introduction: surgical environments require special aseptic conditions for direct interaction with the preoperative images and surgical equipment, which hampers the use of traditional input devices. we presented the feasibility of using a natural user interface (nui) for gesture control combined with voice control to directly interact in a more intuitive and sterile manner with the preoperative images and the integrated operating room (or) functionalities during laparoscopic surgery. in this study, efficiency and face validity of using this nui for medical image navigation and remote control during the performance of a set of basic tasks in the or will be assessed. methods and procedures: twenty experienced laparoscopic surgeons participated in this study. they performed basic tasks in the or focused on the interaction with a medical image viewer (osirix; pixmeo) and with the functionalities of the integrated or (or ; karl storz). these tasks were carried out by means of traditional manual interaction, using a computer keyboard and mouse and a touching screen, and using a gesture control sensor (myo armband) in combination with voice commands. this nui is controlled by the tedcube system (tedcas medical systems). time required to complete the tasks using each interaction method was recorded. at the end of the tasks, participants completed a questionnaire for face validation and usability assessment. results: the use of the nui required significantly less time than conventional manual control to show preoperative studies and information for surgical support. however, the interaction with the medical image viewer was significantly faster using the traditional input devices. participants evaluated the nui as an intuitive, simple and versatile tool that improves sterility during surgical activity. seventy-five percent of the participants would choose the gesture control system as a method of interaction with the patient's preoperative information during surgery. conclusions: the presented gesture control system allows surgeons to directly interact with preoperative imaging studies and the functionalities of an integrated or during surgery maintaining the aseptic conditions. for the traditional manual interaction, it is necessary to take into account the possible reaction time and displacement time of the technician to execute the surgeon's requests. a more personalized medical image viewer is required and with higher integration with the capabilities of the presented gesture control system. emma k gibson, bs, jacqueline j blank, md, timothy j ridolfi, introduction: following a generous left hemicolectomy an anastomosis between the transverse colon and rectum may be required. extensive mobilization and retroileal routing is sometimes necessary to create a tension-free anastomosis. retroileal routing is a technique in which a window is created in the ilieocolic mesentery. the colon is routed through this window, beneath the ileum, prior to entering the pelvis. retroileal routing is uncommon and there is no data on this technique when performed in using a hand-assisted laparoscopic technique. the aim of this study was to review our experience with hand-assisted laparoscopic left sided colon resections including retroileal routing of the proximal colon to the rectum. methods and procedures: we performed a retrospective review of a single surgeon's experience with hand-assisted laparoscopic left sided resections over a seven-year period from - . indication for operation, basic demographics, bmi, procedure time, short-and long-term morbidity, and mortality were recorded. results: a total of patients underwent a hand-assisted laparoscopic left sided resection with a colorectal or coloanal anastomosis. of these, underwent hand-assisted laparoscopic procedures with retroileal routing of the proximal colon. in each case, operations included a midline hand port incision and two mm ports in the lower abdomen. the indications for operation were diverticular disease and neoplasm in nine and four patients respectively. procedures took an average of . ( - ) minutes to complete. postoperative morbidity included intubation for co retention in one patient and a rll effusion in another patient. there were no anastomotic leaks and there were no -day or -day mortalities. conclusion: retroileal routing of the colon following left hemicolectomy occurs infrequently. a hand-assisted laparoscopic approach appears to be a safe and efficient in these technically challenging cases. objective: approximation of the diaphragmatic crus pillars is a key step in hiatal hernia repair. the dogma of successful hernia repair requires tension free approximation of tissue. there are no techniques described to measure tension across the crus closure. aim of this study is to describe a novel technique for measuring the tension exerted on crural sutures and report initial findings. methods: data was collected at institutions by the same surgeon. after hiatus dissection was complete the crus defect was measured both anterio-posterior and transverse dimension. the crus closure sutures were placed posterior and then lateral to the esophagus. the initial suture is started posteriorly with a figure of eight fashion (# ). with each subsequent stitch placed anteriorly (# and # ) or laterally (l , l ) till adequate hiatus closure is achieved. we measured tension on each suture placed as follows. conclusions: the autolap system provides improved image stability, staff interactions, and enhanced ergonomic comfort for the surgical team. it also offers cost-savings from decreased staffing requirements for hospitals that routinely use staff camera holders. the system set up of - min was less variable after cases, representing the learning curve. in addition, our approach identified problems with the system that require improvement by the manufacturer. notably, we identified significant ergonomic problems for human camera holders, which has been previously described and can be addressed by this device. background: gastric leaks continue to be a troubling predicament for physicians and patients alike. they are especially concerning after bariatric surgery. electrolyte abnormalities and dehydration continuously pose a life threatening problem in these patients. methods: this is an irb approved retrospective review of our experience with a biologic tissue mesh plug closure of gastric leaks. our interventional radiology colleagues percutaneously accessed the perigastric collection with a wire and a straight catheter was guided through the gastric wall defect and advanced over the wire until it was intraluminal. the surgeon then placed an endoscope down to the level of the gastric defect. the wire was then retrieved by the endoscope achieving percutaneo-oral wire access. the biologic tissue matrix was then measured and cut to a square and inverted into a cone like structure with a flat straight piece on the open end. the cone patch was then secured to the wire with braided polyglactin suture loop. the wire was then withdrawn back through the gastric defect pulling the plug and patch into position and placement was confirmed by endoscopy. results: we attempted closure of a gastric leak arising after bariatric surgery in six patients. five underwent successful deployment while one had premature disconnection of the plug from the wire and could not be deployed. the five who had successful deployment had immediate success and within days resumed enteral intake of liquids and resolution of the leak. two of the six patients additionally underwent covered stent placement to stent a stenotic area at the incisura angularis from the esophagus to the antrum. this stent was typically removed - weeks later. there were no complications related to the procedure or the plug. only one patient has undergone repeat endoscopy to evaluate the status of the plug. in that patient an ulcer at the plug site was visualized one month after the procedure. three months later endoscopy showed the clean ulcer had shrunk to half of the original ulcer size. conclusion: this novel minimally invasive technique utilizing ir and endoscopic placement of a biologic mesh plug into gastric leaks after bariatric surgery has been highly successful in treating chronic and subacute gastric leaks. we recommend that these endoscopic techniques be used to close gastric defects prior to operative intervention. introduction: laparoscopic surgery has spread worldwide and become a standard procedure among many abdominal surgical fields. the incidence of postoperative adhesion, which is a typical postoperative complication, is considered low compared with that after laparotomy, but once complications develop, such as adhesion-induced intestinal obstruction and chronic abdominal pain, the low-invasiveness of laparoscopic surgery may decrease markedly. while we have previously used a sheet-type absorbable barrier to prevent adhesion, it requires a technique in many cases when it is applied in the abdominal cavity. in this study, we used a spray-type absorbable barrier, which is considered simple to apply, as an adhesion-preventing absorbable barrier following laparoscopic surgery. subjects and methods: a spray-type absorbable barrier for prevention of adhesion (ad spray type l®) was applied to the dissected surface, port region, and beneath the small incised wound in patients who underwent laparoscopic surgery of the large intestine after february . the nozzle is long ( mm in length) and the angle of the tip is adjustable to some extent, so that the spray could be applied easily to the target region, even in areas in which it would be difficult to secure a work space, by rotating the shaft and finely adjusting the angle of the tip. in order for the barrier to remain in the target region, this preparation must remain viscous after application. discussion: approaches for the insertion and affixing of a conventional sheet-type absorbable barrier for the prevention of adhesion has been reported previously by various researchers. the adhesion-preventing absorbable barrier used in this study was a spray type with a long nozzle, which may have been useful because it made the laparoscopic application easy. however, its application requires some experience and time for preparation compared with the use of the sheet type, which could be disadvantageous. further accumulation of cases, including evaluation of prevention of adhesion after use of the adhesion-preventing absorbable barrier may be necessary. christopher g yheulon, md, priya rajdev, md, s. scott davis, md; introduction: evidence has demonstrated that biosynthetic glue for laparoscopic inguinal hernia repair results in decreased pain. however, the two glue sub-types (biologic-fibrin based; synthetic -cyanoacrylate based) have never been compared. this study aims to assess the outcomes of those subtypes. method and procedures: a systematic review of the medline database was undertaken. randomized trials assessing the outcomes of laparoscopic inguinal hernia repair with penetrating and glue fixation methods were considered for inclusion and data analysis. thirteen trials involving patients were identified with eight trials utilizing fibrin and five trials utilizing cyanoacrylate. results: there were no differences in recurrence or wound infection between the glue subtypes when compared individually to penetrating fixation alone or indirectly to each other. there was a significant reduction in urinary retention with fibrin glue when compared to penetrating fixation (or . , % c.i. . - . ). no studies utilizing cyanoacrylate analyzed urinary retention as an outcome. there were non-significant trends in reduction of hematoma and seroma for both glue subtypes when compared to penetrating fixation (or . , % confidence interval . - . ). conclusions: glue fixation in laparoscopic inguinal hernia repair reduces the incidence of urinary retention and may reduce the rate of hematoma or seroma formation. as there are no differences in outcomes when comparing fibrin or cyanoacrylate glue, surgeons should choose the glue that is available at the lowest cost at their respective institution. however, improvement of the optical system is necessary to further utilize this advantage. we are developing an optical lens system covering the range from macroscopic to microscopic. methods: we developed a handheld prototype created by combining the objective lens system of an optical microscope and a telescope lens. a feasibility study using a porcine model was conducted. macroscopic observation was done at a distance followed by microscopic observation in contact with tissue. first, we observed the operative field macroscopically. we then observed the serosa of the small intestine microscopically, and effects of blood flow occlusion were studied. results: ( fig. and fig. ) the same visual field as ordinary laparoscopy was achieved during macroscopic observation, while using microscopic observation it was possible to observe the complex peristaltic movements of the intestine. the minute blood vessels of the visceral peritoneum and larger, deeper blood vessels were also observed. when the mesenteric vessels were occluded, changes in peristaltic movement were seen directly. congestion in blood vessels in the deep layers of the serosa was observed. improvement in peristalsis and congestion were confirmed by restoring blood flow. this system enables direct visual observations not possible with conventional optics. this system can be utilized in both laparoscopic and open surgery. the microscopic visual information obtained by this system may help with intra-operative decision making and serve to facilitate safe and precise surgery. introduction: accurate, real-time visualization is critical for efficient, effective and safe surgery. although optical imaging using near-infrared (nir) fluorescence has been used for visualization of anatomic structures and physiologic functions in open and minimally invasive surgeries, its efficacy and adoption remain suboptimal due to the lack of specificity and sensitivity. herein, we report a novel class of compounds, which are exclusively metabolized in liver or kidney, rapidly excreted into to biliary or urinary systems, and emitted two different nir fluorescence spectrums. methods: novel, water-soluble heptamethine cyanines; compound x (biliary) and compound y (urinary), unreactive towards gluthathione and the cellular proteome were synthesized, and visualized using real-time, dual-color nir imaging device. sprague-dawley rats (n= ) and yorkshire pigs (n= ) were used to demonstrate and validate its usefulness, distributed into a control group (icg; rat n= , irdye cw rat n= ), a biliary group (compound x; rat n= , pig n= ), a urinary group (compound y; rat n= , pig n= ), and dual-labeling group (compound x&y; rat n= , pig n= ). each rat and pig received one or two of the compounds at optimized dose of . -mg/kg intravenously, fluorescence signals and bio-distributions were monitored and recorded over time. the target to background ratio (tbr) was calculated in each target systems and compared to assess sensitivity and specificity. results: compound x was rapidly cleared from liver within min after intravenous injection while the fluorescence signals in biliary system lasted up to h both in rats and pigs. compound y showed significant renal excretion up to h and the urinary signals remained up to h. they were both highly specific to target organs with tbr values of . (biliary), . (urinary) and . (cf. icg) at peak signals. these new compounds have approximately - times higher quantum yields than icg and . - . times higher specificity to kidney and liver than irdye cw. one-way anova showed significant differences between control, biliary, and urinary group (p. .) dual-labeling results also showed a complete separation of these two metabolic systems (p= . ) and a real-time display of these two systems were clearly visualized with pseudo-colored labeling inside the animal body. conclusion: we report a new generation of organ-specific, real-time fluorescent markers for intraoperative visualization, navigation and potential geo-fencing. these new compounds have significantly higher quantum yields and higher specificity to visualize kidney and/or liver than any currently available reagents. background: porcine models have been widely accepted for gastrointestinal surgery studies, due to their similarities to human anatomy, histology and physiology. devices such as laparoscopic staplers have been widely used in bariatrics and are currently the cornerstone of bariatric. there are currently few published articles regarding surgical stapler testing in porcine models by means of a survival design. the purpose of this study is to present a new model for stapler testing in porcines. we present the following study in which we asses a novel stapler's feasibility and safety, and its compatibility to currently used stapler reloads. this novel stapler, the aeon™ endoscopic linear stapler (lexington medical inc., billerica, ma. pending fda approval), has been previously tested in-vitro and in-vivo by the lexington medical engineering department in matters of mechanical function, staple line bursting pressure, staple formation and hemostasis. duffy et al. used this instrument for small bowel anastomoses in a two-week survival study in porcine models. methods and procedures: four porcine animal model was used under iacuc protocol for a -day survival study held at the fiu (doral, fl, u.s.a) research facility. all animals underwent sleeve gastrectomy using the novel stapler handle, combined with the endo gia™ (medtronic, mansfield, ma) mm-staple reloads in two of the animals and aeon™ mm-staple reloads in the remaining two. no reinforcements or oversewing of the staple line was done. these procedures were performed by two bariatric surgeons. animals were monitored perioperatively by the facility staff as per protocol. the animals were euthanized at day . post-mortem assessments were done blindly. gross evaluation and comparison of the gastric tube and their staple lines was done, as well as patency, strictures, and staple line integrity. results: stapler function was equivalent with both reload brands, no technical issues were encountered. - firings were used per animal. no intraoperative complications related to stapler function ensued. no postoperative complications were encountered. all animals survived the full length of the study- days. all sleeves were patent, no strictures or bowel obstruction were present. conclusions: in an animal survival study, a follow-up period of weeks appears to be a good benchmark for stapler testing. the use of the novel stapler for gastric resections appears feasible and safe. further studies such as microscopic examination of the staple lines, might help confirm equivalence, safety and feasibility of these products for the sleeve gastrectomy procedure. jason m samuels, md , peter einersen, md , krzysztof j wikiel, md , heather carmichael , douglas m overby , john t moore , carlton c barnett , thomas n robinson, md , teresa s jones , edward l jones, md ; university of colorado denver, denver va medical center introduction: the purpose of our study was to evaluate the impact of smoke evacuation devices on operating room fires caused by surgical skin preps. surgical fires are rare but preventable events that cause devastating injuries. alcohol-based surgical skin prep serves as the fuel for a fire ignited by electrosurgical instruments. we hypothesized that increasing air exchanges near the tip of the active electrode will reduce the concentration of alcohol thus reducing the incidence of surgical fires. methods: a standardized, ex vivo model was created with a cm section of clipped, porcine skin. surgical skin preparations tested: % isopropyl alcohol with % chlorhexidine gluconate (chg-ipa) and % isopropyl alcohol with . % iodine povacrylex (iodine-ipa). based upon previous studies, a high-risk situation was replicated with immediate energy activation in the presence of pooled alcohol-based prep. the site was draped to simulate a small surgical procedure with approximately square cm exposed. (figure ) a standard and smoke evacuating electrosurgical pencil was activated for s on w coagulation mode in the presence of % oxygen. a standard wall suction was also tested with the tip held cm from the tip of the electrosurgical pencil. a chi-square test was used to compare differences between groups. results: surgical fires were created in % ( / ) of the tests with the chg-ipa and % ( / ; p= . ) of the tests with iodine-ipa. continuous wall suction did not change the incidence of fire. the smoke evacuation electrosurgical pencil significantly decreased the incidence of fire when compared to the standard pencil and continuous wall suction for both preparations (table ) . with chg-ipa, the smoke evacuation electrosurgical pencil decreased the frequency of fire by % (figure , p. ). similarly, when using iodine-ipa, the electrosurgical pencil with integrated smoke evacuation demonstrated a % decrease in fires (figure , p. ). conclusion: alcohol-based skin preps fuel surgical fires. the use of a smoke evacuator electrosurgical pencil reduces the occurrence of surgical fires. elimination of alcohol-based preps and the use of smoke evacuation devices decrease the risk of operating room fires. brian bassiri-tehrani, md, netanel alper, md, jeffrey s aronoff, md, yaniv larish, md; lenox hill hospital ureteral stents have historically been used in pelvic surgery when anatomical or clinical considerations warrant urological expertise to aid in identifying the ureters. in the colorectal and gynecologic surgery literature, prophylactic ureteral stents appear to increase the ability to detect ureteral injuries while not being shown to prevent such injuries. with the increasingly widespread use of laparoscopy and the robotic platform in complex colorectal and pelvic surgery, the utility of stents remains unclear. one of the limiting factors regarding the use of ureteral stents in minimally invasive surgery is the lack of tactile feedback; the inability of the surgeon to directly palpate the stents. one proposed method to overcome this deficiency has been the use of lighted ureteral stents. increased operating time, increased cost, and need for specialized equipment are potential drawbacks of lighted stents. an alternative to using lighted stents in minimally-invasive surgery is to directly inject indocyanine green (icg) into the ureters after cystoscopy-guided placement of ureteral stents. intraoperative visualization of the ureters is acheived by using either the pinpoint endoscopic fluorescence imaging system in laparoscopy, or firefly integrated with the robotic platform. it is hoped that the risk of inadvertent ureteral injuries during colorectal and pelvic operations will be minimized using this technique, due to improved visualization of the ureters throughout the procedure. in this case presentation, we describe a novel use of icg in a patient undergoing a laparoscopic surgery for resection of a . . . cm pelvic mass abutting the bladder, sigmoid colon and left ureter. preoperatively, there was concern that the mass would be intimately adherent to, or even invading, the bilateral ureters based on ct scan findings. after ureteral injection of icg, visualization of both ureters was easily achieved at the time of operation, and the procedure proceeded with careful and safe dissection of the mass with visualization of the ureters at all times. though there is a paucity of studies evaluating the use of icg in the laparoscopic modality, this technique was safe, easy to employ, inexpensive and very useful to visualize the ureters intraoperatively. indeed, larger studies with appropriate sample sizes would help to further validate this novel use of icg. university of colorado -denver, va eastern colorado healthcare system introduction: operating room fires are "never events" that expose the patient to the risk of devastating complications. our group has previously demonstrated that alcohol-based surgical skin preparations fuel operating room fires. manufacturer guidelines recommend a three-minute delay after application of alcohol-based preps to decrease the risk of prep pooling and surgical fires. the purpose of this study was to evaluate the efficacy of the three-minute dry time in reducing the incidence of surgical fires. methods and procedures: a standardized, ex vivo model was used with a cm section of clipped, porcine skin. alcohol-based surgical skin preparations tested were % isopropyl alcohol (ipa) with % chlorhexidine gluconate (chg) and % ipa with . % iodine povacrylex (iodine-ipa). nonalcohol-based solutions included % chlorhexidine gluconate and % povidone-iodine "paint." an electrosurgical ''bovie'' pencil was activated for seconds on watts coagulation mode in % oxygen, both immediately and minutes after skin preparation application, with and without solution pooling. results: no fires occurred with immediate testing of nonalcohol-based preparations ( / ). alcohol-based preps created flames on immediate testing in % ( / ) of cases when pooling was present. without pooling, flames occurred in % ( / ) of cases on immediate testing. after a -minute delay, there was no difference in the incidence of fire when pooling was present ( / vs. / , p [ ) . similarly, there was no difference when pooling was not present ( / vs. / , p= ). (table ) conclusions: alcohol-based surgical skin preparations fuel surgical fires. waiting minutes for drying of the surgical skin prep did not change the incidence of surgical fire (regardless of whether there was pooling of the prep solution). the use of nonalcohol-based skin preps eliminated the risk of fire. introduction: laparoscopic port sites are associated with a significant incidence of long-term hernia formation. in addition, closure with closed loop suture may lead to increased post operative pain thereby limiting patient mobility. the development of novel trocar closure systems could offer a pathway towards quality improvement and warrants investigation. we performed a randomized controlled trial comparing a novel anchor based system (neoclose®) versus standard suture closure. methods: a prospective randomized controlled trial of patients undergoing port site closure following robotic assisted laparoscopic sleeve gastrectomy or gastric bypass was completed ( with neoclose® device and with standard laparoscopic suture closure). each patient had both the camera port and stapling port closed ( port sites in each group). primary outcome measures included the incidence of hernia ( week ultrasound), time for port site closure, and depth of needle penetration. secondary outcome measures were analog pain scoring at post op day , week and week . results: physical exam as well as ultrasound evaluation showed no hernias in either group at weeks. when compared to suture closure, the neoclose® device was associated with shorter closure times ( . ± . versus . ± . s, p. ) and needle depth penetration ( . ± . versus . ± . cm, p\ . ). the neoclose® device was associated with decreased pain at week after the operation (analog pain score . ± . versus . ± . , p. ). no difference in pain scoring was observed on post operative day or at week . conclusions: trocar site closure with the neoclose® device is associated with decreased closure times and needle depth penetration. no difference in the incidence of hernias was identified very early after operation. the neoclose® device led to decreased pain week after trocar closure which is potentially secondary to decreased tension when compared to closure with closed loop suture. long term hernia data ( year) is pending with patients scheduled for follow up physical exams and ultrasounds. federico gheza, md, mario a masrur, md, simone crivellaro, md; uic introduction: robotic instruments provides a better ergonomics during suturing compared to standard laparoscopy. minimally invasive procedures with limited need of few suture may benefit from an economically affordable device able to overcome some limitations of laparoscopic suturing. flexdex surgical recently obtained the fda approval for human use of its articulated laparoscopic needle driver. the official training provided by the company (available at https://flexdex.com/register-for-training) is a h basic dry lab. the training curriculum as well as the accreditation process is not well structured. no literature is available today on this matter. our goal was building a dedicated training, to allow a safe and predictable early use in humans. methods and procedures: the training module design and implementation was done in our minimally invasive laboratory. in the preliminary phase we define with a small group of residents and research specialists a short list of mandatory concepts to detail showing the instrument. a simple suturing task was then performed by the same group with the new device, laparoscopically and with the robot, available in our lab for training only. a more complex task, based on a dedicated self-designed high-fidelity model of urethral anastomosis was then proposed, exploring different options (one flexdex only vs two flexdex, surgeon vs assistant holding the camera). lastly, we applied the new device in animals to evaluate the usefulness of including simple tasks or entire procedures in the training curriculum. results: we were able to define a multilevel, adaptable training module including a basic information session, a dry lab with inanimate low-and highfidelity models and a pig lab. subjects with different level of expertise (medical student, resident, fellow, expert and very expert surgeon) were involved to have an extensive feedback. however, our main focus was to design a training module for laparoscopic and robotic surgeons, to safely introduce the flexdex in their practice. the only outcome for this preliminary work was collected through a "post exposure" survey. the expert surgeon that did the entire training was able to give feedback after his first application of the device in humans as well. conclusions: flexdex is a promising device, available in the united states in approved facilities only. a minimally invasive lab with high laparoscopic and robotic training experience is the ideal setting to build a curriculum. a first adaptable, multilevel, original, high-fidelity training is proposed to be validated with further studies and could be implementable for accreditation purposes. surg endosc ( ) :s -s augmenting spatial awareness in laparoscopic surgery by immersive holographic mixed reality navigation using hololens objectives: endoscopic minimally invasive surgery provides a limited field of view, thus requiring a high degree of spatial awareness and orientation. because of a d field of endoscopic view, a surgeon's spatial awareness is diminished. this study aims to evaluate the efficacy of our novel surgical navigation system of immersive holographic mixed reality (mr) using a head-mounted smart glass display hololens to enhance spatial awareness of the operating field in laparoscopic surgery. the authors describe a method of registering and overlaying the preoperative mdct imaging localization of tumors, vessels, and organs onto the real world in the operating theatre through holographic smartglasses in augmented reality (ar). methods: in this study we included laparoscopic gi, hpb, urology, and gynecologic surgeries using this system. we developed a ct-based patient-specific holographic mr surgical navigating application using hololens, that is a pair of see-through monitors built-in head-mounted display. by reconstructing the patient-specific d surface polygons of tumors, vessels, and organs out of the patient's mdct, mr anatomy was displayed on the see-through grasses three-dimensionally during actual surgery. the hololens features an inertial measurement unit which includes an accelerometer, gyroscope, and a magnetometer for environment understanding sensors, an energy-efficient depth camera, a photographic video camera, and an ambient light sensor. results: the accurate surgical anatomy of size, position, and depth of the tumors, surrounding organs, and vessels during surgeries could be measured using build-in dual infrared light sensors. the exact location between surgical devices and patient's anatomy could be traced on the pair of mr smart-glasses by satellite tracking. the gesture controlled manipulation by surgeons' hands with surgical groves was useful for intraoperative anatomical references of tumors and vascular position under sterilized environment. it allowed the user to manipulate the spatial attributes of the virtual and real anatomies. this system reduced the length of the operation and discussion time. this could support complex procedures with the help of pre-and intra-operative imaging with better visualization of the surgical anatomy and spatial awareness with visualization of surgical instruments in relation to anatomical landmarks. conclusions: the immersive holographic mr system provides a real-time d interactive perspective of the inside of the patient, accurately guiding the surgeon. this helps spatial awareness of the surgeons in the operating field and has illustrative benefits in surgical planning, simulation, education, and navigation. enhancing scene visualization is a feasible strategy for augmenting spatial awareness in laparoscopic surgery. francisco miguel sánchez margallo, phd , juan a. sánchez-margallo, phd , andreas skiadopoulos, phd , konstantinos gianikellis, phd ; minimally invasive surgery centre, cáceres, spain, university of nebraska at omaha, university of extremadura, spain introduction: new handheld devices have been developed in order to address the technical limitations and ergonomic issues present in laparoscopic surgery. the aim of this study is to analyze the surgeon's performance and ergonomics using the radius r drive instruments (tubingen scientific medical, germany) during the execution of laparoscopic cutting and suturing tasks. methods and procedures: three experienced laparoscopic surgeons performed both an intracorporeal suturing task and a cutting task on a box trainer. both tasks were repeated three times. a maryland dissector and a pair of scissors were used for the cutting task. for the suturing task, a maryland dissector and needle holder were used. conventional laparoscopic instruments and their equivalent r drive instruments were used. the order in the use of the type of instruments was randomized. execution time and surgeon's ergonomics were assessed. for the latter, surface electromyography (trapezius, deltoid and paravertebral muscles) and the nasa-tlx index were analyzed. for the cutting task, the percentage of the area of deviation from the cutting pattern (% of error) was assessed. the suturing performance was assessed by means of a task-specific validated checklist. results: surgeons required more time to perform both laparoscopic tasks using the r drive instruments. the use of both instruments had a similar percentage of deviation from the exterior part of the cutting pattern. however, the deviation from the inner part was significantly higher using the r drive instruments (conv: . ± . % vs r drive: . ± . %; p\. ). needle driving was scored lower using the r drive instruments, but quality of knot tying was similar to conventional instruments. the use of r drive increased the muscle activity of the trapezius muscles bilaterally for both laparoscopic tasks. this muscle activity also increased for the left deltoid muscle during the cutting task. surgeons stated that the use of r drive instruments leads to a higher mental and physical workload when compared to traditional laparoscopic instruments. conclusions: despite the novel and ergonomic design of the r drive laparoscopic instruments, the results of this study suggest that an improvement in surgical performance and physical workload is required prior their use in an actual surgical setting. further studies should be done to analyze the use of these instruments during other laparoscopic tasks and procedures. we believe that surgeons need a longer and comprehensive training period with these laparoscopic instruments to reach their full potential in laparoscopic practice. background/objectives: d printing has been shown to be a useful tool for preoperative planning in various surgical disciplines. however, there are only several single case reports in the field of liver surgery. this is because of problematic visualization of anatomy, difficulties in methodology and-most importantly-high costs limiting implementation of d printing. the goal of this study is to evaluate the utility of personalized d-printed liver models as routinely used tools in planning and guidance of laparoscopic liver resections. materials and methods: contrast-enhanced computed tomography images of consecutive patients who underwent laparoscopic liver resections in a single centre were acquired and processed. proper segmentation algorithms were used to obtain virtual models of anatomical structures, including vessels, tumor, gallbladder and liver parenchyma in stl (stereolithography) format. after processing files, models in parts were subsequently printed with desktop ultimaker + (ultimaker, netherlands) d printer, using polylactic acid filaments as printing material. all parts were matched together to create a mold, which was later casted with transparent silicone. models were delivered to surgical teams prior to the surgery as well as used in patients' education. results: up to now, six full-sized, transparent, personalized liver models were created before laparoscopic liver resections and used as a tool for preoperative planning and intraoperative guidance. usefulness of these models has been evaluated qualitatively with surgeons. operative data was obtained for each patient and it will be used for quantitative analysis in further study phases. costs of one model varied between $ and $ and whole process of development took approximately days in every case. conclusions: d-printed models allow precise planning in complex cases of minimally invasive liver surgery by providing high-quality visualization of patient-specific anatomy. implementation of this technology might potentially lead to clinical benefits, such as reduction of operative time or improvement of short-term outcomes. having said that, more data is needed to decisively prove these hypotheses. introduction: modern laparoscopic graspers may risk inadvertent injury to tissues, and have been shown to produce crush and puncture injuries. in addition, the force transmitted to the tissues by grasper handles can be highly variable, dependent on the orientation and amount of tissue engaged by the grasper. we have developed a novel vacuum-based laparoscopic grasper designed to reduce tissue injury from grasping. the aim of this study is to compare the incidence and severity of tissue trauma caused by vacuum-based graspers versus standard compressive graspers while manipulating tissue. we performed an in vivo surgical porcine study to assess gross and histologic tissue injury after grasping trials. grasping trials were divided equally between two adult porcine models; samples of small bowel were grasped with a standard atraumatic laparoscopic grasper (aesculap double-action atraumatic wave grasper) and were grasped with our novel vacuum grasper with varying vacuum head designs ( for head a, each for heads b and c). following grasping, the porcine model was allowed to dwell for hours prior to harvest. gross injury was graded as follows: ) no injury, ) ecchymosis only, ) serosal injury, ) seromuscular injury, and ) perforation. histologic injury was graded as follows: ) serositis, ) partial-thickness injury to the muscularis propria (mp), ) full-thickness mp injury, and ) full-thickness mp and mucosal injury. mann-whitney u test was performed to compare both gross and histologic injury scores between the groups. results: on gross assessment, no samples were noted to have injury more severe than ecchymoses following grasping. the vacuum grasper was found to cause more ecchymosis (median= ) than the compressive laparoscopic grasper (med.= , u= , p. ). on histologic assessment, the compressive grasper caused significantly more severe injury (med.= ) compared to the vacuum grasper (med.= , u= , p= . ). subgroup analysis showed that heads a (med.= , u= . , p= . ) and b (med.= , u= , p= . ) caused significantly less injury compared to the compressive grasper. head c (med.= , u= . , p= . ) also showed less injury but did not reach statistical significance. conclusion: this study demonstrates that our novel laparoscopic vacuum grasper produces less tissue trauma than standard compressive graspers. vacuum-based grasping is a viable alterative for reducing inadvertent tissue injury in laparoscopy. minimally invasive surgery centre, cáceres, spain, university of nebraska at omaha, university of extremadura, spain introduction: the aim of this study is to analyze the surgeon's performance, workload and ergonomics using an ergonomically designed handheld robotic needle holder during laparoscopic urethrovesical anastomosis in an animal model, and comparing it with the use of a conventional laparoscopic needle holder. methods and procedures: six experienced surgeons performed an urethrovesical anastomosis in a porcine model using a handheld robotic needle holder and a conventional laparoscopic axialhandled needle holder (karl storz gmbh). the robotic instrument (dex®, dextérité surgical) has an ergonomic handle and a flexible tip with unlimited rotation, providing seven degrees of freedom. the use of the surgical instrument was randomized. for each procedure, an expert surgeon evaluated the surgical performance in a blinded fashion using the global operative assessment of laparoscopic skills rating scale. besides, the quality of the intracorporeal suture was assess by a validated suturing-specific checklist. the surgeon's posture was recorded and analyzed using the xsens mvn biomech system based on inertial measurement units. the surgeon's workload was evaluated by means of the nasa task load index, a subjective, multidimensional assessment tool. the patency of each anastomosis was assessed using methylene blue. results: all urethrovesical anastomoses were completed without complications. only one anastomosis with the robotic device failed the patency test. surgeons showed similar surgical skills with both instruments, although they presented greater autonomy with the conventional instruments (p =. ). for the suturing performance, the use of the robotic device led to an increase in the number of movements during the needle driving and lower tendency to follow its curvature during the withdrawal maneuver (p=. ). the level of workload increased with the robotic device. however, the surgeon's satisfaction with the surgical outcome did not differ using both instruments. the use of the robotic instrument led to similar posture of the shoulder and wrist and better posture of the right elbow (p=. ) when compared to the conventional instrument. conclusions: the use of the robotized needle holder obtained similar results for the surgical performance and surgical outcome of the urethrovesical anastomosis when compared to the conventional instrument. we consider that aspects such as the surgeon's autonomy, dexterity in driving the needle and workload could be improved with a comprehensive training with the new device. inertial sensors can be an alternative for actual and crowded surgical environments. surgeons acquired a better body posture using the novel robotic needle holder. surg endosc ( ) :s -s introduction: temporal and spatial tissue temperature profile in electrosurgical devises, such as ultrasonic scissors and bipolar vessel sealing system, was experimentally measured, and the incidence of postoperative complications after thoracoscopic esophagectomy was assessed according to the electrosurgical devises used. methods and procedures: experiment of thermal spread: sonicision (sonic) was used for ultrasonic scissors and ligasure (ls) was used for bipolar vessel sealing system. each device was activated in order to cut porcine muscle at room temperature. temperatures of both the device blade and porcine tissues beside the device were measured using a temperature probe. each experiment was performed at least three times. room temperature was degrees. clinical analysis: the patients who underwent thoracoscopic esophagectomy with -field lymph node dissection in the prone position were selected in the study. incidence of postoperative complications after thoracoscopic esophagectomy was compared according to electrosurgical devises. bronchoscopy was used for diagnosis of recurrent laryngeal nerve paralysis (rlnp). sonic and ls was employed in and patients, respectively. material: we compared consecutive cases using d laparoscopic surgery versus cases of d conventional laparoscopic surgery from january to june . all surgical procedures were performed by experienced laparoscopic surgeons using d (einsteinvision system) and hd conventional laparoscopic optic. d-laparoscopic surgery offers the depth perception of the surgical field that is lost with the conventional ( d) laparoscopic surgery, and in many series is reported to be better in terms of surgical performance. outcome measures was operation time, surgical performance, blood looses, complications and surgeon satisfaction with the procedure. results: cholecystectomy was the most frequent surgery performed with cases ( %); hernia surgery cases ( %); fundoplication cases ( %), appendectomy cases ( %), left colon excison with colo-rectal anastomosis cases( %), and other cases ( %) wich included ovarian cyst excision, liver biopsy, prostatectomy and pediatric surgery. we compared each d procedure with a standard laparoscopy case performed by the same surgeon during the time of the study. d vs d surgical procedures outcome measures are shown in table . we found better results in operation time, surgical performance and less blood looses in favor of three-dimensional laparoscopy (. ). conclusion: d laparoscopy reduces operation time related to better performance during the procedure. depth perception facilitates dissection, intracorporeal knotting, mesh placement and colo-rectal anastomosis. surgeons reported better surgical performance and comfort during d laparoscopy; there were any reported side effects such as headache or dizziness. background: social media (some) uniquely allows international collaboration, with immediacy and ease of access and communication. in areas where surgical management is contentious, this could be a valuable tool to frame the current state, propose best practices, and possibly guide management in a rapid, cost-effective, global scale. our goal was to determine the ability to use twitter-a some platform-as an alternative surgical research tool. methods: twitter was used to host an online poll on a pre-selected controversial topic with no current consensus guidelines-pathological complete response in rectal cancer. an influential colorectal surgeon published the survey "t n rectal cancer undergoes a complete response" on two separate occasions. both polls were open for duration of three days. two methodologies were tested to increase exposure and direct towards relevant participants: first, tagging several worldwide experts, then using the well-established hashtag #colorectalsurgery and publishing during an international surgical conference. the main outcome measure was the feasibility, validity, reproducibility, and methods to further participation of a twitter survey. results: the tweet polls were posted three weeks apart. there was no cost and the time required for the process was three minutes, demonstrating the feasibility. providing three closed options to select from facilitated validity. the poll's anonymity limited knowledge of the participant's qualifications, but public comments and "retweets" came from surgeons with experience ranging from trainee to department chair. a robust volume of respondents was observed. the st post received votes, "likes", "retweets", and comments from a diverse international group ( countries). all tagged members participated in the forum. the nd received votes, "likes", "retweets", and comments. the results were reproducible, with the majority favoring option on both occasions ( % and %, respectively; p= . ). treatment recommendations, their rationale, and open questions were identified in the thread. conclusions: some can be used as a research tool, with valid, reproducible, and representative survey results. while exposure was comparable across the two methods, tagging specific members guided experts to provide more opinions than using conference and specialty hashtags. this could expand awareness, education, and possibly affect management in a transparent, cost-effective method. the anonymous nature of respondents limited the ability to make conclusions, but interest and opinion leaders for further study can be easily identified. this demonstrates the potential for some to facilitate international collaborative research. background: despite the technological advancement of a minimally invasive approach to pylorus -preserving pancreaticoduodenectomy (pppd), the morbidity is still high. among the many complications, postoperative pancreatic fistula (popf) is reported in high incidence rate, which varies from researcher to researcher, and a fistula risk score (frs) has been developed to predict the popf. the aim of this study is validate the fistula risk score in minimally invasive approach of pppd and find the other meaningful parameter for prediction of popf. method and materials: from january to august , laparoscopy attempted right-sided pancreas resection was performed on patients including robotic reconstruction in the division of hepatobiliary and pancreas at yonsei university health system. among them, patients were excluded due to total pancreatectomy (n= ), open conversion (n= ), pancreaticogastrostomy and hybrid manual anastomosis (n= ), non-measurable drain and missing datas (n= conclusions: fistula risk score is significant prediction factor of popf including biochemical leaks. in addition to the previously known frs variables, our data showed that bmi is an important predictor of popf with clinical relavancy in a minimally invasive approach of pppd. laparoscopic hemi-hepatectomy for liver tumor satoru imura, hiroki teraoku, yuji saito, shuichi iwahashi, tetsuya ikemoto, yuji morine, mitsuo shimada; tokushima university introduction: with progress of surgical technique and devices, laparoscopic liver resection became a realizable option for patients with liver tumor. major liver resection such as anatomical left or right hemi-hepatectomy has also been introduced in many centers. herein, we evaluate surgical results of laparoscopic hemi-hepatectomy for liver tumor. patients and methods: until march , consecutive patients who underwent laparoscopic or laparoscope-assisted hemi-hepatectomy (left: , right: ) were reviewed and the surgical data such as operation time, blood loss, postoperative complications were analyzed retrospectively. results: of the patients underwent left hemi-hepatectomy, cases were primary liver cancer, cases were metastatic tumor, and cases were benign tumor. pure laparoscopic surgery was performed in cases. the mean blood loss was ( - ) ml, mean operating time was ( - ) minutes and mean postoperative hospital stay was ( - ) days. the rate of postoperative complications was . % (wound infection; n= ). all right hemi-hepatectomy was performed by laparoscope-assisted method. of the patients underwent right hemi-hepatectomy, cases were primary liver cancer, cases were metastatic tumor, and cases were benign tumor. the mean blood loss was ( - ) ml, mean operating time was ( - ) minutes and mean postoperative hospital stay was ( - ) days. the rate of postoperative complications was . % (biliary stenosis; n= ). the patients with hepatocellular carcinoma were followed up for a median of ( - ) months. recurrence occurred in cases and none of them had died at the time of follow-up. conclusion: laparoscopic hemi-hepatectomy is a safe and effective procedure for the treatment of benign and malignant liver tumors. ibrahim a salama, professor; department of hepatobiliary surgery, national liver institute, menoufia university abstract background: iatrogenic biliary injuries are considered as the most serious complications during cholecystectomy. better outcome of such injuries have been shown in cases managed in a specialized center. objective: evaluatation of biliary injuries management in major referral hepatobiliary center. patients and methods: four hundred seventy two consecutive patients with post-cholecystectomy biliary injuries were managed with multidisciplinary team (hepatobiliary surgeon, gastroenterologist and radiologist) at major hepatobiliary center in egypt over years period using endoscopy in patients, percutaneous techniques in patients and surgery in patients. results: endoscopy was very successful initial treatment of patients ( %) with mild/moderate biliary leakage ( %) and biliary stricture ( %) with increased success by addition of percutaneous (rendezvous technique) in patients ( . %). however, surgery was needed in ( %) for major duct transection, ligation, major leakage and massive stricture. surgery was urgently in patients and electively in patients. hepaticojejunostomy was done in most of cases with transanastomatic stents. one mortality after surgery due to biliary sepsis and postoperative stricture was in cases ( . %) treated with percutaneous dilation and stenting. conclusion: management of biliary injuries was much better with multidisciplinary care team with initial minimal invasive technique to major surgery in major complex injury encouraging for early referral to highly specialized hepatobiliary center. introduction: simple liver cyst is the solitary non parasitic cystic lesion of the liver. teatment of symptomatic liver cyst varies from simple aspiration to hepatic resection. each treatment has its own merits and associatied complications. laparoscopic unroofing (fenestration) offers the best balance between efficacy and safety. polycystic liver disese (pcld) treatment by this method are less clear because of high failure rate. liver resection though more effective carries higher risks. treatment of hydatid disease are controversial. materials and method: simple cyst may be asymptomatic and picked up as incidental findings on ultrasound examination for other abdominal complaints. few cyst have symptoms of mass effect or with complication effect due to haemorrage, rupture, infection. on examination liver is palpable. compression over bile duct give rise to jaundice. the commonest symptoms are pain, early satiety, nausea and vomiting. simple cyst are more common in female after years of age. the cyst located antriorly inferiorly and laterally are the ideal case. investigation like ultrasonography is important. it will helps us to detect the cyst nature, will help to differentiate bet ween simple cyst from poly cystic liver disease, from neoplastic liver. in endemic area of hydatid liver disease serological test is mandatory. ct scan is important regarding details information about to localise the cyst, to identify the liver tissue arroud the cyst, relationship of cyst with the nearby vital structures, number of cyst, calcification and carcinomatous changes in its wall. aspiration of cystfluid, biological and cytological examination to rule out the presence of infection, biliary communication and malignancy. recently, ca - estimation is helpful for the differentiating the simple cyst from the cystadenoma or carcinoma. for jaundice patient ercp is impotant to locate the intraductal polyp causing the biliary obstruction or cyst causes the compression of the biliary tree. for bleeding in cyst mri is helpful. carcinoma at epithelial lining may occur. result: laparoscopic de-roofing (fenestration) less radical procedure ensures adequate drainage of cyst content into the peritoneal cavity. the cyst wall can be removed using harmonic scalpel so smoked produced and fogging of lens can be minimized. the interior surface inspected with care to exclude neoplastic growth and biliary communication. whole operative procedure, duration of postoperative recovery, hospital stay is much shorter in this procedure. large cevron incision can be avoided. no recurrence in two years follow up period. liver resection and total cystectomy theoretically minimizes the recurrence risk but invoke the a real risk of postoperative complications and death. conclusion: careful case selection and meticulous surgical skills are the two major determinants of the outcome. in the llr group, the first port was placed with an alexis® wound retractor (applied medical, usa) and free access® (top corporation, japan) at the abdominal defect made by previous sc. an additional or trocars were placed as needed. results: all patients in the llr group were treated using the laparoscopic approach. there were no other significant differences in patient background and characteristics. operative duration was similar for these groups. blood loss, complication rate, and hospital stay in the llr group were significantly decreased compared with the olr group. conclusion: in concurrent liver resection and sc, the open approach may require multiple large incisions, but the laparoscopic approach can complete procedures with a stoma wound and a few port wounds. additionally, use of a platform on the wound for sc enhances safety and efficacy for dissection of intraabdominal adhesions and a clear operative view. primary hepatic lymphoma: the importance of liver biopsy diego t enjuto , carlos ortiz , laura casanova , jose luis castro , pablo sánchez , jaime vázquez , norberto herrera , benjamín tallon , carmen jimenez ; hospital severo ochoa, hospital san rafael, hospital henares primary hepatic lymphoma (phl) is a very uncommon lymphoproliferative malignancy. it accounts for only . % of all extranodal non-hodgkin lymphoma and . % of all cases of non-hodgkin disease. the diagnosis is made when there is only liver involvement or when there is minimal non-liver disease. bone marrow, spleen, or hematologic affection should be excluded to confirm the diagnosis. we present our experience with two phl's that were correctly diagnosed thanks to laparoscopic liver biopsy. -year-old male admitted because of a -month history of right upper quadrant pain and nonmeasured weight loss. liver function tests and cholestasic enzymes showed normal values. serologic tests showed negative results for both hbv (hepatitis b virus) and hcv (hepatitis c virus). ct (computed tomography) scan showed three intrahepatic lesions in segments v, vi, and vii. ct-guided fine needle did not reach the diagnosis so a laparoscopic hepatic biopsy was performed. the final diagnosis was burkitt-like lymphoma. chemotherapy with r-chop (rutiximab, cyclophosphamide, adriamycin, vincristine, and prednisone) modality was started and completed after cycles. it is currently years since the patient was diagnosed and there are no clinical or radiological signs of recurrence. -year-old male who complained of diarrhoea and abdominal pain. chronic hb infection with no viral charge was detected. ultrasound showed heterogeneity of the whole left hepatic lobe and an mri was performed. a ten by segen centimeters lesion occupying the left hepatic lobe enhanced in arterial phase was seen suggesting adenoma. laparoscopic hepatic biopsy was completed to reach a definitive diagnosis. non-hodgkin lymphoma follicular type has just been confirmed with the histology and immuno-histochemistry. chemotherapy with r-chop should be started in the following weeks. phl's diagnosis is hard to achieve. fine needle biopsies are frequently negative because of the large area of necrosis. surgical biopsies are sometimes indispensable to get enough tissue to reach the diagnosis. phls are sometimes misdiagnosed as hepatocellular carcinoma because of its relation to hcv meaning a major hepatic resection. that is the reason why we consider that all diagnostic measures should be undertaken to rule out a different type of tumor. surgical resection is normally not needed in phls; as they are chemosensitive lesions. surgical options usually add unnecessary morbidity and mortality to these patients. chemotherapy standard treatment for phl consists on r-chop combination. pancreatic neoplasm enucleation -when is it safe? case report and review of the literature elaine jayne buckley , k molik , j mellinger ; siu-som, hshs pediatric surgery introduction: solid pseudopapillary tumors are rare neoplasms accounting for - % of pancreatic malignancies with a low risk of recurrence and metastasis. pancreatic malignancies are less common in pediatric populations, though small case series have identified that pseudopapillary tumors comprise between and % of pediatric pancreatic neoplasms. as these tumors have a low risk of metastasis, the mainstay of treatment has remained surgical excision. several surgical approaches have been described from extensive resections such as pancreaticoduodenectomy to local enucleation. we present a case of enucleation of a large pseudopapillary tumor from the pancreatic head complicated by pancreatic fistula. a literature review was performed given the rarity of this tumor to review surgical approaches, to compare complications and long-term outcomes, and to identify specific strategies to decrease the risk of pancreatic fistula. case description: a year-old female presented with months of abdominal pain. computed tomography identified a right upper quadrant mass felt to be consistent with a lipoma. follow up ct at months suggested the mass was more likely a gastrointestinal stromal tumor (gist), and surgical resection was recommended. enucleation of the mass was chosen in view of a wellcircumscribed appearance, clear operative tissue planes, and concern for long-term morbidity of a more extensive resection given the patient's young age. pathology demonstrated an . cm pseudopapillary tumor with negative margins. her post-operative course was complicated by a grade b pancreatic fistula, managed with nutritional support, external drain maintenance, and endoscopic stenting. the patient achieved healing of the pancreatic fistula after four months. results: our literature review demonstrates no difference in recurrence, mortality or morbidity between types of surgery. pancreatic fistula contributed to the majority of postoperative morbidity in all cases. recommendations for enucleation include small ( - cm) tumors with between and mm margin from the main pancreatic duct. techniques identified to minimized post-operative pancreatic fistula include preoperative imaging of the duct anatomy, preoperative pancreatic stent placement, and intraoperative ultrasound to identify the pancreatic duct. some literature supports preservation of pancreatic parenchyma, particularly in younger patients, to reduce endocrine and exocrine dysfunction given the low rates of recurrence and metastasis with this rare neoplasm. conclusion: our case demonstrates complications of enucleation of a large pseudopapillary tumor with successful multidisciplinary post-operative management. with the risk reduction strategies identified, we suggest that enucleation may be considered for pseudopapillary tumors in younger patients to preserve pancreatic parenchyma and long-term pancreatic function. introduction: recent advancements in minimally invasive techniques led to increased effort and interest in laparoscopic pancreatic surgery. laparoscopic distal pancreatectomy is a widely accepted procedure for left-sided pancreatic lesions. in other cases, the adoption of laparoscopic pancreaticoduodenectomy has been hindered by the technical complexity of laparoscopic reconstruction. hybrid laparoscopy-assisted pancreaticoduodenectomy (hlapd) in which pancreaticoduodenal resection is performed laparoscopically, while reconstruction is completed via a small upper midline minilaparotomy, is combines the efficacy of open approach, and the benefits of laparoscopic approach. the purpose of this study is to report our experience of hlapd and to define the learning curves. methods: patients with benign and malignant periampullary lesion underwent hlapd by a single surgeon between july and may were retrospectively reviewed. the clinicopathologic variables were prospectively collected and analyzed. the learning curve for hlapd was assessed using cumulative sum (cusum) and risk-adjusted cusum (ra-cusum) methods. results: the most common histopathology was pancreatic ductal adenocarcinoma (n= , . %), followed by intraductal papillary mucinous neoplasms (n= , . %), ampulla of vater cancer (n= , . %), and common bile duct cancer (n= , . %). the median operation time was min (range, - min) and the median estimated blood loss was ml. based on the cusum and the ra-cusum analyses, the learning curve for hlapd was grouped into four phases: phase i was the initial learning period (cases - ), phase ii was the technical stabilizing period (cases - ), phase iii was the second learning period (cases - ) and phase iv represented the second stabilizing period (cases - ). there was a statistical difference in terms of surgical indication between phase ii and iii (p= . ). conclusions: hlapd is a technically feasible and safe procedure in selected patients. this procedure has benefits of both open and minimally invasive procedure, and could be a stepping-stone for transition from open to purely minimally invasive pancreaticoduodenectomy. in silico investigation of the background: wilson's disease is a rare autosomal recessive genetic disorder of copper metabolism, which is characterized by hepatic and neurological disease. the gene atp b (on chromosome ) leads to wilson's disease is highly expressed in the liver, kidney, and placenta and encodes a transmembrane protein atpase (atp b), which functions as a copper-dependent p-type atpase. methods: here, the rare codons of atp b gene and their location in the structure of atp b protein was studied with rare codon calculator (racc) (http://nihserver.mbi.ucla.edu/racc/), atgme (http://atgme.org/), latcom (http://structure.biol.ucy.ac.cy/latcom.html) and sherlocc program (http://bcb.med.usherbrooke.ca/sherlocc.php). racc server identified arg, leu, ile, and pro codons as rare codons. results: results showed that cyp a gene have single rare codons of arg. additionally, racc detected two rare codons of leu, single rare codons of ile and rare codon of pro. atp b gene analysis in minmax and sliding_window algorithm resulted in identification of and rare codon clusters, which shows the difference features of these algorithms in detection of rcc. analyzing the d model of atp b protein show that arg residue constitute hydrogen bonds with glu and glu that with mutation of this residue to ser this hydrogen bonds were disrupted and may interfere in the proper folding of this protein. moreover, the side chain of arg don't forms any bond with others residues that with mutation to thr form new hydrogen bond with the side chain of arg . these addition and deletion of hydrogen bonds effects on the folding mechanism of atp b protein and interfere with the proper function of the atp b position. his forms the hydrogen bonds with the his and it seems that this hydrogen bond close together two region of this protein and it seems that has a critical role in the final folding of atp b protein. conclusions: computational study of diseases such as wilson's disease and involved genes (atp b) help us in understanding of disease's physiopathology and finding new approaches for detection and treatment. pancreatic stump leak and fistula formation are significant causes of morbidity in patients undergoing distal pancreatectomy (dp), with incidence of % to as high as % in a large systematic review. we present a case of a year old female, four months status post distal pancreatectomy and splenectomy for pseudopapillary neoplasm of pancreatic tail. patient presented to our institution with day history of left upper quadrant pain and general malaise. differential diagnosis on admission was abdominal wall abscess vs incarcerated incisional hernia. physical exam was positive for severe tenderness to palpation over a * cm cm non reducible mass in left upper quadrant with surrounding skin erythema. patient underwent a diagnostic laparoscopy and intraoperative findings revealed extensive adhesions to the anterior abdominal wall and a loop of small bowel was found adhered to the previous incision site in left upper quadrant. upon further dissection we entered a large cm cavity with saponified caseous material. the saponified material and thick tan fluid were evacuated into an endocatch bag and two large bore jackson pratt drains were left within the cavity. further examination showed that the small intestine was normal with no signs of obstruction or ischemia. fluid studies and cultures were sent and showed yeast like organisms and negative for acid fast bacillus. we report an unusual presentation of a distal pancreatectomy stump leak in the formation of an intra-abdominal saponified fluid collection four months after the primary procedure. given the high incidence of pancreatic stump leak and fistula formation after distal pancreatectomy, much effort has been made to identify factors associated with higher incidence of leaks and their usual and unusual presentations, which will be reviewed in this report. initial concerns regarding healthy donor's safety and graft integrity, need for acquiring surgical expertise in both laparoscopic liver surgery and living donor transplantation (ldlt) have delayed the development of laparoscopic donor hepatectomy in adult-to-adult ldlt. however, decreased blood loss, less postoperative pain, shorter length of stay in hospital, and excellent cosmetic outcome have well been validated as the advantage of laparoscopic hepatectomy. hence, the safety and feasibility for laparoscopic donor should be further investigated. we present initial experiences and safety for totally laparoscopic living donor right hepatectomy. in cases who received elective living donor right hepatectomy for adult-to-adult ldlt, totally laparoscopic approach was applied from may up to august . the anatomical variation of portal vein was not considered as an exclusion criteria, but all donors were with type i portal vein variation. the bile duct anomaly was preoperatively evaluated with magnetic resonance cholangiopancreatography (mrcp) and was never excluded for totally laparoscopic approach. d conventional rigid º rigid laparoscopic system was used in cases and the remaining cases used d flexible laparoscopic system. in about %, hepatic duct anomalies (type , a, b) were identified. the operation time was from hours to hours. and the time for the graft removal was within minutes. the hepatic duct transection was performed under operative cholangiography via a cystic duct and the patency of left hepatic duct was also confirmed by operative cholangiography. however, during postoperative period, bile leakage was identified in only case and resolved after the biliary stent insertion by ercp. during operation, there was no transfusion and the inflow control like pringle maneuver was not used at all. v or v were reconstructed in cases and large right inferior hepatic vein was prepared for anastomosis in cases. all grafts were removed through the suprapubic transverse incision. most donors were discharged at days after hepatectomy. during the short-term follow-up period in the donors except this case, complications were not identified. conclusively, totally laparoscopic right donor hepatectomy in elective adult-to-adult ldlt can be initially attempted after enough experiences of laparoscopic hepatectomy and ldlt. however, the true benefits of totally laparoscopic living donor right hepatectomy should be fully assessed through various experiences from multi-institutes. background: the role of neoadjuvent chemotherapy on the treatment of pancreatic cancer remains widely controversial. studies have evaluated its effect on resectability and survival; however, few have studied the consequence of neoadjuvent therapy on surgical outcomes and complications. methods and procedures: a retrospective analysis was performed utilizing the targeted pancreas module of the national surgical quality improvement project (nsqip) for patients undergoing pancreaticoduodenectomy. neoadjuvent therapy was defined by chemotherapy and/or radiation in the -days before surgery. patient demographics, operative characteristics, and -day outcomes were compared amongst patients undergoing neoadjuvent chemotherapy, radiation, chemoradiation, and no neoadjuvent therapy. both univariable and multivariable analysis were completed. results: pancreaticoduodenectomy was completed in , patients. , patients had no neoadjuvent therapy; underwent both chemotherapy and radiation; underwent chemotherapy alone, and underwent radiation alone. there were no differences in demographics or comorbidities. no difference in -day mortality was found; however pancreatic fistula formation was affected by neoadjuvent therapy. neoadjuvant radiation increased fistula formation (or: . , % ci: . - . ) while neoadjuvent chemotherapy (or: . , % ci: . - . ) was protective. conclusion: neoadjuvent therapy significantly impacts surgical outcomes following pancreaticoduodenectomy. given that pancreatic fistula formation can delay post-operative chemotherapy, it may be reasonable to refrain from neoadjuvent radiation therapy for patients with resectable and borderlineresectable disease. the influence of thickest background: the use of stapling devices for distal pancreatectomy remains controversial, due to concerns about the development of postoperative pancreatic ?stula (popf). pancreas thickness might be associated with popf, but suitable thickness of stapler remains also inconclusive in view of reducing popf. methods: we routinely use thickest endo gia™ reloads with tri-staple™ (covidien, north haven, ct) for pancreas closure during laparoscopic left side pancreatectomy (lp) since . we compared short term surgical results of the consecutive ten patients underwent lp using new stapler (ns) and patients with lp using other type of stapler (os) focusing on popf. results: no patients developed clinically relavent (cr)-popf in ns group and two patients ( . %) with os group experienced cr-popf. however, there was no difference of cr-popf between two groups. pancreas thickness on stapling point were not different between two groups ( . mm vs . mm, p= . ). in ns group, patients ( . %) developed a popf, whereas in os group, patients ( . %) developed a popf. there was also no difference of popf between groups. conclusion: the gia™ reloads with the thickest tri-staple™ allows effective prevention of cr-popf after distal pancreatectomy. however, there was no advantage over thinner stapler for lp. introduction: single-incision laparoscopic hepatectomy (silh) has been showed feasible and safe in experienced hands for selected patients with benign or malignant liver diseases. there were only small series reported and most of the procedures were minor liver resections. we herein present our experience of silh during a period of months. methods and procedures: consecutive patients underwent silh which were performed by two experienced laparoscopic surgeons with straight instruments. patient characteristics and surgical outcomes were analyzed by reviewing the medical charts. results: the patient age was . ± . ( - ) years with male predominance ( patients, . %). six patients ( . %) had liver cirrhosis proved by pathologic examinations. nine procedures ( . %) were indicated for malignancy. four major hepatectomies (over two segments) and nine minor ones were performed including seven anatomical resections. the abdominal incisions were para-or trans-umbilical except one which was along the old operative scar at lower midline, while most of them (n= , . %) was within cm in length. inflow control was carried out by either individual hilar dissection or extraglissonian approach instead of pringle maneuver. the operations were all accomplished successfully without additional ports or open conversion. the operative time was . ± . ( - ) min and the estimated blood loss was . ± . ( - ) ml. five ( . %) patients encountered complications and four of them were classified as clavien-dindo grade i. the postoperative length of hospital stay was . ± . ( - ) days. there was no mortality. conclusion: silh can be performed safely and efficaciously for selected patients with benign and malignant liver diseases including cirrhosis. not only minor but also major liver resections are feasible. this innovative procedure provides low postoperative pain and fast recovery. before adopting this demanding technique, surgeons should be familiar with both single-incision laparoscopic surgery and laparoscopic hepatectomy. better outcomes after the learning curve could be anticipated. background: laparoscopic distal panreatectomy (ldp) has been replacing the open procedure for benign or malignant diseases of the pancreas. however, it is often difficult to apply ldp for pancreatic ductal adenocarcinoma (pdac) because its aggressive invasion to adjacent organs or major vessels. objectives: the objective of this study was to report our experiences for laparoscopic extended pancreatectomy with en-bloc resection of adjacent organs or major vessels for left-sided pdac. methods: we reviewed data for all consecutive patients undergoing ldp for left-sided pdac at asan medical center (seoul, south korea) between april and december . the patients who underwent laparoscopic extended panreatectomy with en-bloc resection of adjacent organs or major vessels were included in analyses. results: of total patients, underwent laparoscopic extended pancreatectomy. there were male and female patients with a median age of . years. resected adjacent organs or vessels were as following: stomach in , duodenum in , colon in , kidney in , superior mesenteric vein in , and celiac axis in . median operative duration was minutes, and median length of hospital stay was days. pathological reports revealed the following: a median tumor size of . cm, the tumor differentiation (well differentiated in , moderately differentiated in , and poorly differentiated in ), t stages (t in , t in , and t in ) , and n stages (n in and n in ). r resection was achieved in patients, and most r resection were tangential retroperitoneal margins. postoperatively, clinically relevant postoperative pancreatic fistula was occured in patients, and there was no -day mortality. median overall survival was . months and year survival rate was . %. conclusions: although laparoscopic surgery has limitations in treating extensive diseases, some selected patients can be applicable for laparoscopic extended pancreatectomy with acceptable complication and survival rates. who underwent hepatic resection was included. these patients were divided into llr or olr. demographics, tumor characteristics, recurrence rates and over-all survival were compared between the groups. results: patients were included and grouped into llr (n= ) and olr (n= ). the average tumor number was ± for both groups, while the mean tumor size was . cm and . cm for the llr and olr group, respectively. when compared with olr, llr had lower post-operative complication rates ( . % vs . %, p= . ) and shorter hospital stay ( vs days, p= . ), although the difference was not statistically significant. overall, recurrence-free and disease-free survival was comparable between llr and olr. introduction: single port surgery has been described since with cholecystectomy, colectomy, gastrectomy, and others. nevertheless, few cases are still reported in field of hbp surgery. herein, we report single port pancreatic surgery developed from our previous experience. we had started single port surgery in , since then we have done more than cases of single port surgery using surgical glove port including cholecystectomy, appendectomy, and colectomy. because we consider this experience should develop to pancreatic surgery, cases of single port staging laparoscopy for potentially resectable and borderline resectable pancreatic cancer and cases of single port plus one port distal pancreatectomy (spop-dp) have been done in our institution. single port staging laparoscopy for pancreatic cancer. resectability was proved in ( %) out of patients while patents had unresectale factor such as small liver and peritoneal metastases that was not able to detect pre-operatively. the length of hospital days were . ± . days and the days to chemotherapy were . ± . days. single port plus one port distal pancreatectomy (spop-dp) spop-dp starts with . cm skin incision on umbilicus. subsequently, a wound retractor is installed at umbilical wound. then, a non-powdered surgical glove ( . inches) is put on the wound retractor through which three -mm slim trocars and one -mm trocar are inserted via each finger tips. a semi-flexible laparoscopic camera is inserted via the middle finger port. -mm port is used when laparoscopic us, mechanical stapler, endo intestinal clip or retrieval bag were needed. an additional -mm port is inserted at left subcostal lesion mainly used for surgeon's right hand instrument. gastric posterior wall is fixed to abdominal wall by suture instead of manual retraction. pre-compression before transection of the pancreas was done using endo intestinal clip before firing. discussion: as we have seen in these two decades, surgery has dramatically been changed by laparoscopic surgery or robotic surgery. nevertheless, because of technical difficulty and relatively high post-operative complication rate, introduction of reduced port surgery to hbp surgery has just started. spop-dp using endo intestinal clip, glove port and gastric wall hanging method is feasible. but its advantage is not clear so far, multicenter rct is highly desired to clear the benefit of reduced port surgery for pancreas. introduction: scoring systems (ss) are an essential pillar of care in acute pancreatitis (ap) management. we compared six ss (acute physiology and chronic health examination (apache-ii), bedside index for severity in ap (bisap), glasgow score, harmless ap score (haps), ranson's score and sequential organ failure assessment (sofa) score) for their utility in predicting severity, intensive care unit (icu) admission and mortality. methods: ap patients treated between july and september were studied retrospectively. demographic profile, clinical presentation and discharge outcomes were recorded. predictive accuracy of six ss was assessed using areas under receiver-operative curve (auc) with pairwise comparisons. results: patients were treated for ap. twenty-two ( . %) patients were excluded for insufficient data. / ( . %) were male and mean age was . ( - ) years. most common aetiology was gallstones ( . %). mean length of stay was . ( - ) days. ( . %) patients had severe ap, ( . %) required icu admission and ( . %) died. table below shows positive predictive value (ppv), negative predictive value (npv) and auc of six ss in predicting outcomes. pairwise comparisons revealed ranson's (p. ) and sofa (p. ) scores were superior than other ss in predicting all three outcomes. auc of sofa was greater than ranson's score in predicting severity (p. ), but similar in predicting icu admission (p= . ) and mortality (p = . ). conclusion: sofa score is superior to classical ss in predicting severity, icu admission, and mortality in ap. introduction: necrotizing pancreatitis is often a devastating sequelae of acute pancreatitis. historically several approaches have been described with variable outcome. open necrosectomy is associated with higher morbidity ( %) and mortality ( %). endoscopic necrosectomy often is tolerated well but associated with stent migration and multiple procedures. video-assisted retroperitoneal debridement is tolerated well but associated with severe bleeding if adjacent blood vessels are injured during the procedure leading to severe complications. methods: in our series, we perform a step up approach by involvement of a multidisciplinary group consisting of general surgeons, gastroenterologists, infectious disease physicians, critical care internalist, interventional radiologist and nutritional services to formulate a management plan. the necrotized pancreas is initially drained with an ir guided drain, fluid cultures sent for microbiology and treatment with appropriate antibiotics if deemed necessary. the drain is gradually upsized to a fr sized drain to form a well-defined tract for surgical debridement; a preoperative ct scan of the abdomen with iv contrast to access the location and proximity of the vasculature around the necrotized pancreas. a collaboration with the interventional radiologist to discuss possible ir embolization of splenic artery prior to surgical debridement. the patient would then undergo video assisted retroperitoneal pancreatic necrosectomy and a sump drain left in-situ at the pancreatic fossa. post-operative management in the surgical icu would be lead by the critical care internalist. results: three patients were managed by this multidisciplinary approach with excellent outcomes. one patient underwent preoperative ir embolization followed by surgical debridement; second patient underwent embolization immediately following debridement; one patient did not require any embolization but had ir on standby if needed to intervene. post-operatively all three patients recovered well. they all were tolerating good oral intake and were discharged to rehabilitation facilities. conclusion: our preliminary experience demonstrates that an early multidisciplinary plan by various subspecialties can result in a pragmatic and successful approach to this potentially catastrophic condition. introduction: liver resection with preservation of as much liver parenchyma as possible is called parenchymal sparing hepatectomy (psh). psh has been shown to improve overall survival by increasing the re-resection rate in patients with colorectal liver metastases (crlm) and recurrence. the caudal-cranial perspective in laparoscopy makes the cranial segments ( , a, , and ) more difficult to access. the objective of this systematic review is to analyze feasibility, safety, morbidity, and oncologic outcomes of laparoscopic psh. methods: a systematic review of the literature was performed. medline/pubmed, scopus, and cochrane databases were searched. a search strategy was published with the prospero registry. a systematic review was conducted on all cases reported, they were categorized by area of resection and quantitative meta-analysis of operative time, blood loss, length of hospital stay, complications, and r resection was performed. results: of the studies screened for relevance, studies were selected. because interventions or endpoints were noncontributory or reporting incomplete, were excluded. only publications remained, reporting data from patients who underwent laparoscopic psh. the highest oxford evidence level was b and selective reporting bias was common due to single center and noncontrolled reports. among them, ( . %) resections were in the cranial segments ( . %), a ( . %), ( %), and ( . %), which previously would have required laparoscopic hemi-hepatectomies or sectorectomies. the most common tumor type was crlm ( %) and the second most common tumor type was hepatocellular carcinoma ( %). feasibility of laparoscopic psh was %, conversion rate was %, and complications were seen in % of cases. no perioperative mortality was reported. no standardized reporting format for complications was used across studies. meta-analysis revealed a weighted average operating time of minutes, estimated blood loss of cc, and length of stay of days. r resections were achieved in % of cases. conclusion: laparoscopic psh of difficult to reach liver tumors are feasible with acceptable conversion and complication rate, but relatively long operating times and relatively high blood loss. in future studies, data on long term survival and specific tumor type recurrence should be reported and bias reduced. yangseok koh , eun-kyu park , hee-joon kim , young-hoe hur , chol-kyoon cho ; chonnam national university hwasun hospital, chonnam national university hospital purpose: laparoscopic surgery has become the mainstream surgical operation due to its stability and feasibility. even for liver surgery, the laparoscopic approach has become an integral procedure. according to the recent international consensus meeting on laparoscopic liver surgery, laparoscopic left lateral sectionectomy ( conclusion: this study showed that laparoscopic lls is safe and feasible, because it involves less blood loss and a shorter hospital stay. for left lateral lesions, laparoscopic lls might be the first option to be considered. keywords: laparoscopy, left lateral sectionectomy. outcome analysis of pure laparoscopic hepatectomy for hcc and cirrhosis by icg immunofluorescence in.-a propensity score analysis introduction: in laparoscopic hepatectomy, the surgeon cannot use their hand to palpate the liver lesion and estimate margin of resection. the use of icg immunofluorescence technique can show up the liver tumour and has the potential to facilitate a throughout assessment during the operation. method: between and , there were patients undergone pure laparoscopic liver resection for hcc in our hospital. patients had undergone surgery by the conventional laparoscopic approach. patients had laparoscopic hepatectomy with additional icg immunofluorescence augmented technique. the surgical outcome was compared with propensity score analysis in a ratio of : . result: patients had icg immunofluorescence assisted laparoscopic hepatectomy (group ). patients using conventional laparoscopic liver resection with propensity-matched were selected for comparison (group ). the median operation time was minutes vs minutes p= . , the median blood loss was ml vs ml (p= . ). additional tumours were identified by icg technique. patients had suspicious lesion picked up by icg technique but proven to be benign pathology on frozen section examination. the sensitivity of tumour detection by group was %. % r resection was achieved in group and group respectively. hospital stay was days vs days (p= . ), post-operative complication was ( %) vs ( . %) (p= . ) none of the patient developed icg related complication. conclusion: in the current study, the new technique showed equally good short-term outcome when compared with conventional laparoscopic hepatectomy. icg immunofluorescence augmented reality is a promising technique that might facilitate easier identification tumour during laparoscopic hepatectomy. surg endosc ( ) :s -s taking the training wheels off: transitioning from robotic assisted to total laparoscopic whipple introduction: there is a substantial learning curve to performing minimally invasive pancreatoduodenectomy (mis-pd) for surgeons who are trained in open pd. the learning curve to transition from robotic assisted pd (rapd) to total laparoscopic pd (tlpd) is not well established. methods: mis-pds performed between january and june performed by sc as a surgeon or co-surgeon were included for analysis. mis-pds were performed using a robotic assisted technique prior to august , and tlpds were performed subsequently. rapds performed prior to were excluded to limit the comparison to rapds after the initial learning curve. demographics, clinical and pathologic outcomes, operative and post-operative outcomes were compared. results: a total of rapds and tlpds were scheduled during the study period. there was no statistically significant difference in age, body mass index, or prior abdominal surgery. median time from initial clinic consultation to surgery was days for the rapd group versus days in the tlpd group (p= . ). conversion to laparotomy was required in of patients ( there were no operative complications or mortality. the mean hospital stay was ± . hours. there was no postoperative jaundice, bile leak, intra-abdominal collections or mortality. conclusion: when surgery is indicated for difficult acute calculous cholecystitis, laparoscopic subtotal cholecystectomy with control of the cystic duct is safe with excellent outcomes. however, if the critical view of safety can't be achieved due to obscured anatomy at calot's triangle, conversion to open surgery or cholecystostomy must be performed to prevent bile duct injury. scott revell, md , joshua parreco , rishi rattan, md , alvaro castillo, md ; u. miami -jfk gme consortium, university of miami, miller school of medicine introduction: over the last two decades the increasing incidence of benign liver tumors has led to the expanded need for clinicians to make therapeutic decisions regarding the utilization of open, minimally invasive and ablative techniques. the purpose of this study was to compare outcomes of the management of benign liver disease based on operative approach and pathology. methods: patients aged years or older who underwent liver surgery for benign liver tumors from to were identified in the nationwide readmissions database. patients were compared based on liver pathology, resection versus ablation, and an open versus laparoscopic/robotic approach. the outcomes of interest were in-hospital mortality, prolonged length of stay (los) [ days, and readmission within -days. univariable analysis was performed for these outcomes and multivariable logistic regression was performed using the variables with a p-value . on univariable analysis. results were weighted for national estimates. results: there were , patients undergoing surgery for benign hepatic tumors in the us during the study period. the most common pathology was benign neoplasm ( . %) followed by hemangioma ( . %), and congenital cystic disease ( . %). resection alone was performed in . %, ablation alone in . %, and resection with ablation in . %. a laparoscopic/robotic approach was used in . % of cases. the overall mortality rate was . %, a prolonged los was found in . %, and readmission within days occurred in . %. an increased risk for mortality was found with hemangioma (or . , p= . ) and congenital cystic disease (or . , p= . ). resection with ablation was associated with an increased risk of prolonged los (or . , p. ), while a laparoscopic/robotic approach was a protective factor for prolonged los (or . , p. ). patients treated with ablation alone were at decreased risk for readmission (or . , p. ). omar m ghanem, md , desmond huynh, md , tomasz rogula, md ; mosaic life care, cedars sinai, introduction: laparoscopic sleeve gastrectomy is the most commonly weight loss procedures performed worldwide. as such, there is great diversity in the techniques utilized. this study aims to identify and categorize the differences in techniques and assess the need for guidelines in this field. case description: surgeons were surveyed on the techniques they employ on biweekly basis using the international bariatric club facebook group. the survey included sleeve staple line reinforcement, preoperative work up, intraoperative hiatal dissection, bougie size, distance from pylorus to distal staple line, and intraoperative leak testing. surveys were conducted between may and july . each survey was active for weeks after which data was collected. participants were required to select a single answer per question. discussion: when surveyed on staple line reinforcement (n= ), surgeons used no reinforcement, over-sewed, buttressed, clipped as necessary, over-sewed as necessary. for preoperative work up (n= ), utilized routine endoscopy, routinely obtained upper gi series, routinely obtained both endoscopy and upper gi, and employed endoscopy or upper gi series only in patients who were symptomatic. for hiatal dissection (n= ), surgeons dissected the hiatus routinely, dissected only when obvious hernias intraoperatively, dissected only if the hernia was detected on preoperative work up, and dissected in the setting of gerd symptoms. for sleeve caliber sizing (n= ), bougie \ f was used by surgeon, bougie size f, f, f were utilized by , bougie size f and f were utilized by , bougie[ f were used by , and gastroscopes ( f) were used by . with regards to distance from pylorus to where the sleeve staple line was initiated (n= ), participants started \ cm away from pylorus, between and cm, and started [ cm from pylorus. finally, for preferred intraoperative leak test during sleeve (n= ), methylene blue was used by surgeons, air leak test by , used both, and opted for none. conclusion: this study characterizes the wide varieties in the techniques used during sleeve gastrectomy. a great number of variations exist in every parameter surveyed; however, there is little evidence comparing the effectiveness and safety of these variations. in this setting, further randomized controlled trials are necessary and should be used to construct guidelines to best optimize outcomes in this extremely common and necessary operation. yen-yi juo, md, mph, yas sanaiha, md, yijun chen, md, erik dutson, md; ucla introduction: bariatric surgeries are commonly performed in accredited centers of excellence, but no consensus exists regarding the optimal readmission destination when complications occurred. our study aims to examine the impact of care fragmentation on post-operative outcome and evaluate its causes and consequences among patients undergoing -day readmission after bariatric surgery. methods: the metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip) database was used to identify patients who experienced -day unplanned readmission following bariatric surgery. non-index readmission was defined as any readmission occurring at a hospital other than the one where initial surgery was performed. primary outcome was -day mortality after surgery. logistic regressions were used to identify risk factors for nonindex readmission and to adjust for confounders in the association between non-index readmission and -day mortality. results: a total of , patients were identified as experiencing -day unplanned readmission following bariatric surgery, among whom ( . %) were non-index readmissions. occurrence of postoperative complication during initial hospitalization was the most significant risk factor for non-index readmission (or . , % ci . - . , p= . ) in our multivariate logistic regression. the three most common reasons for readmission were similar within the two comparison groups, including nausea/vomit, abdominal pain and anastomotic leakage. similar proportion of patients underwent reoperation among the two comparison groups ( . vs . %, p= . ). even after adjusting for occurrence of complications, being readmitted to a non-index facility was still associated with a . -fold odds of -day mortality ( % ci . - . , p\. ). conclusion: non-index readmission significantly increases the risk of -day mortality following bariatric surgery. patients were more likely to visit a non-index facility if complications occurred during their initial hospitalization. further patient education is required to re-inforce the importance of continuity-of-care during management of bariatric complications and guide patient's decision making in choosing readmission destinations. introduction: sleeve gastrectomy has become the most performed bariatric surgery. removing part of the stomach causes weight loss by restricting food intake and regulating the production of incretins, particularly ghrelin. however, prognostic factors to weight loss after sleeve gastrectomy have been difficult to find. the goal of this research was to study the correlation between the volume of resected stomach and weight loss. methods and procedures: volume of resected stomach of patients undergoing sleeve gastrectomy was measured. a standard laparoscopic technique was used. calibration was performed tightly around a fr bougie, and stapling started - cm from the pylorus. the standardized technique for measurement involved insufflation with a g catheter with saline solution to a pressure of cm h o immediately after removal of the specimen. resected stomach's volume, gender, age, bmi, height and % of total weight loss (%twl) at months and year were prospectively recorded. correlation between variables was analyzed with pearson's test and linear regression models. conclusion: removed stomach was larger on men than women and its size slightly correlated to height. however, volume of resected stomach did not seem to have an incidence on short termweight loss. gastric size should not be considered as a prognostic factor for weight loss in patients undergoing sleeve gastrectomy. revisional bariatric surgery after initial laparoscopic sleeve gastrectomy: what to choose salman alsabah, eliana al haddad, ahmad almulla, khaled alenezi, shehab akrouf, waleed buhamid, mohannad alhaddad, saud al-subaie; amiri hospital introduction: bariatric surgery has been shown to produce the most predictable weight loss results, with laparoscopic sleeve gastrectomy (lsg) being the most performed procedure as of . however, inadequate weight-loss may present the need for a revisional procedure. the aim of this study is to compare the efficacy of laparoscopic re-sleeve gastrectomy (lrsg), laparoscopic roux-en-y gastric bypass (lrygb) and gastric mini-bypass surgery (mgbp) in attaining successful weight loss following initial lsg. methods: a retrospective analysis was performed on all patients who underwent lsg at amiri and royale hayat hospital, kuwait from to . a list was obtained of those who underwent revisional bariatric surgery after initial lsg, and their demographics were analyzed. introduction: the aim of this study is to identify potential risk factors or early indicators, specifically related to perioperative blood pressure, and its association with perioperative hemorrhage in the bariatric population. laparoscopic bariatric surgery in the united states has been steadily increasing over the past several years. between and , the annual number of cases has increased by %. although rare, hemorrhagic complications (hc) occur at a rate of - % and can lead to significant morbidity and mortality. by identifying factors which may place a patient at higher chance of hc, surgeons can potentially mitigate those risks. these modifications could reduce morbidity and limit the requirement of transfusions or reoperations. methods and procedures: a retrospective case-control series was performed to include all patients who underwent either laparoscopic sleeve gastrectomy (sg) or laparoscopic roux-en-y gastric bypass (gb) in at a single bariatric center of excellence. a total of patients were identified with perioperative hc. each patient was matched : for procedure, body mass index, and medical comorbidities. peak systolic, diastolic, and mean arterial pressures were compared between groups at time of admission, intraoperative, and during remainder of initial hospital stay. welch's t-tests were used for comparison between groups. results: a total of procedures were performed with de novo sg, and de novo gb. revisional bariatric cases were excluded from the study. hc occurred in ( . %) total patients, gs and gb. four patients required operative treatment for hc, were treated laparoscopically and required laparotomy. the mean diastolic pressures at time of arrival on day of surgery was higher in patients who develop hc (p= . ) and mean peak diastolic pressure intraoperatively was lower in patients who develop hc (p= . ). there was no statistical difference in peak systolic or mean arterial pressures throughout the hospital stay. conclusions: bariatric surgical patients with elevated preoperative diastolic blood pressures are at an increased risk of postoperative hc. additionally, decreased peak diastolic blood pressures may be an early indication of an hc in bariatric patients. introduction: bariatric surgery in the adult population is recognized as one of the most effective treatments for obesity and its comorbidities. nonetheless, the safety, efficacy, and substantial outcomes of bariatric surgery in young adults are still not well documented. the aim of our study is to evaluate the safety and efficacy of laparoscopic sleeve gastrectomy (lsg) in young adults (\ years old) versus older adults (≥ years old). methods: we retrospectively reviewed all patients who underwent bariatric surgery at our institution from to. propensity score matching was used in order to balance covariates, matching for common demographics and comorbidities between the younger patient population (\ years old) and the control group ([ years old). all tests were two-tailed and performed at a significant level of . . statistical software r, version . . ( - - ) was used for all analyses. results: of patients, . % (n= ) met our inclusion criteria after matching. we found . % (n= ) patients under years old and . % (n= ) patients greater or equal to years old (control group). we observed that our younger population distribution was predominantly caucasian and female, . % (n= ) and . % (n= ) respectively. the mean age was . ± . years with a preoperative body mass index (bmi) of . ± . kg/m in the younger group compared to . ± . years and a bmi of . ± . kg/m in the control group. diagnosis of diabetes and hypertension were present in . % (n= ) and . % (n= ) of our younger group, respectively. no statistical significance was found when assessing the percentage of bmi loss (% ebmil) at and months follow-up as shown in table . when comparing the % ebmil at months follow-up, the younger group had . % more ebmil than the control group (p= . ). when assessing post-operative complications we observed no statistical significance. conclusions: bariatric surgery is equally effective and safe in young adult population demonstrating a significant better %ebmil at months following bariatric surgery. following prospective studies are needed to elucidate the resolution and behavior of comorbidities in a younger bariatric population. minimally invasive conversion of sleeve gastrectomy to rouxen-y gastric bypass for intractable gastroesophageal reflux disease: short term outcome background: surgical management recommendations for intractable gastroesophageal reflux disease (gerd) after sleeve gastrectomy (sg) remain controversial. this case series demonstrates our experience with treatment of post-operative intractable gerd using minimally invasive conversion of sg to roux-en-y gastric bypass (rygb). patients and methods: this is a retrospective review of a prospective data registry (mbsaqip) from jan through sept . eleven patients, female and male, were evaluated. of the surgeries, were laparoscopic, assisted with xi da vinci robot, and assisted with si da vinci robot. all patients presented with intractable reflux on high dose ppi. three had a history of aspiration pneumonia. ± . %, respectively. one was omitted due to pending results. conclusion: several solutions exist for operative management of intractable gerd after sg including redo-sleeve gastrectomy, combined gastrectomy with fundoplication, conversion to gastric bypass or anti-reflux procedures such as linx. reports remain small in series and require further study to evaluate the consistency of results. we found minimally invasive conversion of sg to rygb is a highly effective and safe option for treatment of intractable gerd. setthasiri pantanakul, chotirot angkurawaranon, ratchamon pinyoteppratarn, poochong timrattana; rajavithi hospital background: obesity is an important health problem affecting more than million people worldwide. esophageal dysmotility is a gastrointestinal pathology associated with obesity; however, its prevalence and characteristics remain unclear. esophageal dysmotilities have a high prevalence among obese patients regardless of gastrointestinal symptoms. objective: to identify the prevalence of esophageal motility disorder in asymptomatic obese patient. materials and methods: prospective study was performed between june and march . a total of of morbid obese patients who visited the bariatric and metabolic clinic at rajavithi hospital (bangkok, thailand) underwent preoperative evaluation with high resolution esophageal manometric test with manoscantm eso (smith medical). tracings were retrospective analysis and reviewed according to chicago classification criteria for esophageal motility disorders. results: among asymptomatic obese participants, twenty five of them were female. the mean age was . ( - ) years old. most of the participants were classified as class three obesity or over. the mean bmi was . kg/m . no hiatal hernia was found and the anatomy of esophagus was normal in all patients. the mean irp was . mmhg. twenty-one patients ( . %) demonstrated high irp over normal limit ([ mmhg) . four patients demonstrated premature contraction (dl\ . second). hypercontractile esophagus was identified in patients and ineffective motility disorder was found in patients. two patients were diagnosed as distal esophageal spasm (des). two patients were compatible with type achalasia and patients ( . %) have esophageal outflow obstruction. none of the patient demonstrate incomplete bolus clearance even high irp or abnormal motility. conclusion: this study reveals a high prevalence of esophageal dysmotility in asymptomatic thai obese patients. the most common abnormality were esophageal outflow obstruction and ineffective motility. the chicago classification of esophageal motility disorder may not suitable among obese population. sitembile lee, ms , chike okolocha , aliu sanni, mdfacs ; philadelphia college of osteopathic medicine ga campus, eastside bariatric and general surgery introduction: roux-en-y gastric bypass (rygb) is the most popular bariatric procedure performed worldwide, accounting for % of all bariatric procedures. however, in patients with a body mass index (bmi) ≥ kg/m (super-super obese) the rygb procedure can be technically challenging. this has led to the adoption of a single-stage treatment such as one anastomosis (mini) gastric bypass (oagb/mgb) in the super-super obese patients. proponents of the oagb/mgb claim the clinical outcomes are comparable to the rygb. the aim of this study is to compare the outcomes of the two procedures by examining the literature. methods: a systematic review was conducted through pubmed to identify relevant studies from to with comparative data on rygb versus oagb/mgb on super-super obese populations. the primary outcome was the percentage excess weight loss (%ewl). other outcomes include operative times, complication rates and length of hospital stay. results were expressed as standard difference in means with standard error. statistical analysis was done using randomeffects meta-analysis to compare the mean value of the two groups (comprehensive meta analysis version . . software; biostat inc., englewood, nj introduction: obesity is becoming more prevalent in patients with inflammatory bowel disease (ibd). the obese body habitus increases the complexity of surgeries that are often needed to treat ibd. some surgeons may delay definitive surgical treatment because of obesity. little data exists on bariatric surgery in the obese patient with ibd. methods: we retrospectively identified patients who had known diagnosis of ibd who underwent bariatric surgery from to . demographics and post-operative outcomes were assessed. results: patients were identified: with ulcerative colitis (uc) and with crohn's disease (cd). of the uc patients, none of the patients had surgery for uc and only one was on a biologic. of the uc patients, had adjustable gastric band (agb), had gastric bypass and had sleeve gastrectomy. one patient with agb had it replaced for slip and subsequently removed for dysphagia. uc preoperative bmi average was . . postoperative bmi was . with excess weight loss (ewl) of %. average follow up was months. of the cd patients, patients had ileocolic resections and one had total proctocolectomy with end ileostomy. one was on remicade and one on mp. of the cd patients, had agb, had gastric bypass and had sleeve gastrectomy. one agb patient had conversion to gastric bypass because of dysphagia and poor weight loss. a second abg patient had band removal because of dysphagia. cd patients' preoperative bmi average was . . postoperative bmi was . with average ewl of %. average follow up was months. overall, agb patients had % ewl, sleeves % and gastric bypass %. two uc patients had post-operative flares, one immediately post op and one month post-operative. four of the band patients had dysphagia, with one replacement, two removals and one conversion to bypass. there were no leaks, intraabdominal infections, fistulas or wound infections. conclusions: uc patients appear to have higher excess weight loss compared to crohn's patients; ewl % compared to % but was not statistically significant. agb had poor results in both uc and cd patients. sleeve gastrectomy and gastric bypass results in effective weight loss for obese patients with ibd. gastric bypass in ibd patient is controversial, but may be appropriate in the right clinical setting. introduction: previous studies suggest that modest preoperative weight loss is associated with improved weight loss following bariatric surgery. however, there remains a need to investigate factors which may successfully predict preoperative weight loss among bariatric patients. methods and procedures: this analysis included patients who underwent laparoscopic roux-en-y gastric bypass (rygb), sleeve gastrectomy, or gastric banding at an academic medical center in california. data were measured at patients' consult and preoperative clinical visits. preoperative weight loss outcomes were categorized as follows: no weight loss, lost weight, or gained weight. associations between categorical sociodemographic and surgical characteristics and preoperative weight loss outcomes were assessed using the chi-square test of association. associations between continuous measures and preoperative weight loss outcomes were assessed using anova. a sub-group analysis was completed among participants who lost weight prior to bariatric surgery. wilcoxon-rank-sum and kruskal-wallis tests were used to evaluate associations between patient characteristics and the number of pounds lost. results: patients (n= , ) were predominately ages - ( %), female ( %), white ( %), and privately insured ( %). patient race was significantly associated with weight loss outcomes (p = . ): whereas % of white patients lost weight prior to surgery, only % of black patients lost preoperative weight. among privately insured patients, % lost weight. in contrast, % of patients insured by medi-cal/medicaid lost weight (p= . ). on average, lower baseline excess body weight was associated with no weight loss. patients who lost preoperative weight (n= , ) were included in the sub-group analysis. male sex (p\. ), black race (p. ), undergoing laparoscopic rygb (p= . ), no previous abdominal surgeries (p= . ), upper tertile baseline weight (p. ), waist circumference (p\. ), percent body fat (p\. ), bmi (p. ), excess body weight (p. ), and systolic blood pressure (p= . ) were associated with more pounds lost. conclusions: this study demonstrates various associations between sociodemographic and clinical patient characteristics and preoperative weight loss. given previous literature indicating the positive relationship between preoperative and postoperative weight loss following bariatric surgery, the results of this study suggest an opportunity to improve preoperative weight loss among specific groups. yen-yi juo, md, mph , usah khrucharoen, md , yijun chen, md , yas sanaiha, md , peyman benharash, md , erik dutson, md ; background: besides rate and extent of weight loss, little is known regarding factors predicting interval cholecystectomy following bariatric surgery, which are important factors in a surgeon's consideration during decision-making regarding whether to perform prophylactic cholecystectomy. in addition, no previous studies have quantified the incremental costs associated with ic. we aim to identify risk factors predicting interval cholecystectomy (ic) following bariatric surgery and quantify its costs. methods: a retrospective cohort study was performed using the national readmission database - . cox proportional hazard analyses were used to identify risk factors for ic. linear regression models were constructed to examine associations between cholecystectomy timing and cumulative hospitalization costs. background: patient-reported outcomes after bariatric surgery are important in understanding the longitudinal effects of surgery. the impact of hospital practices and surgical outcomes on followup rates remains unexplored. objective: to assess the effect of hospital-level practices and -day complication rates on -year follow-up rates of a standardized patient-reported outcomes survey. methods: bariatric surgery program coordinators in a statewide quality improvement collaborative were surveyed in june about their practices for obtaining patient-reported outcomes data one year after surgery. hospitals were ranked based on their follow-up rates between and (accounting for overall performance and improvement). univariate analysis was used to identify hospital practices associated with higher follow-up rates. multivariable regression was used to identify independent associations between -day outcomes and follow-up rates after adjusting for patient factors. results: overall, follow-up rates improved from ( . %± . ) to ( . %± . ) though there was wide variability between hospitals ( . % vs . % in ) . coordinator survey response rate was %. sixty-one percent of all surveyed coordinators perceived that surgeons prioritize high follow-up rates. when asked how long were their patients followed for, % of coordinators noted their programs provided lifelong follow-up. patient reminders about the -year survey were used by % of programs, mostly during clinic visits ( %). most programs ( %) had implemented strategies to improve follow-up rates, such as handing out the survey ( %) during clinic visits. follow-up providers included surgeons ( %), nurse practitioners ( %), and/or registered dietitians ( %). patient disinterest ( %), loss to follow-up ( %), survey length ( %), and lack of staff/ resources ( %) were the factors most commonly perceived as barriers to high follow-up rates. when compared to programs in the bottom quartile of follow-up rates, those in the top quartile were more likely to hand out the survey to patients during clinic visits ( % vs . %; p= . ) and had lower rates of risk-adjusted severe complications ( . % vs . %; p= . ), readmissions ( . % vs . %; p= . ), and reoperations ( . % vs . %; p= . ). conclusions: hospitals vary considerably in their -year follow-up rates when seeking patientreported outcomes data after bariatric surgery. there were also significant differences in programspecific practices for obtaining these data. hospitals with higher -year follow-up rates were more likely to physically hand surveys to patients during a clinic visit and had lower -day severe complication, readmission, and reoperation rates. improved -year patient-reported outcomes follow-up after bariatric surgery may be a proxy for higher quality perioperative care. david merkle , kazim mohommed , danielle r rioux , dilendra weerasinghe, md, facs ; nova southeastern university, herbert wertheim college of medicine, bariatric surgery is gaining popularity not only for its weight loss benefits, but also for its metabolic effects. we present a -year-old female patient with symptoms of neuroglycopenia, occurring -years post roux-en-y gastric bypass surgery. during one of her syncopal episodes, her blood sugar was noted to be mg/dl. continuous glucose monitoring demonstrated post prandial hypoglycemia, averaging episodes per day, with a maximum of episodes in one day. upon further evaluation, the lab results of the hba c, chromogranin a, somatostatin, and urinary sulfonylurea levels were all normal, with the c-peptide level within the upper limit of normal. ct scan of the abdomen and pelvis did not show any obvious masses in the pancreas, and since the chromogranin a level was normal, it lead to the empiric diagnosis of nesidioblastosis by exclusion. we placed the patient initially on medical management which included a carbohydrate restricted diet of g per meal, eating - small meals per day, and taking mg of acarbose three times per day. overall, symptoms have improved, and she has - episodes per month, compared with about episodes per day. we will also present the data with regards to other invasive treatment options, which are available when medical treatment options have failed, such as gastric bypass reversal versus distal gastrectomy. vertical banded gastroplasties (vbgs) were a common bariatric procedure in the s but have largely fallen out of favor due to unsatisfactory weight loss and a relatively high incidence of longterm complications such as dysphagia and severe gastroesophageal reflux disease (gerd). one of the ways to address these undesirable effects is to convert to a roux-en-y gastric bypass (rygb). the aim of this study was to assess the safety and efficacy of vbg-to-rygb conversion. outcomes of vbg revisions performed at an academic center between and were reviewed. of the vbg revisions, gastrogastrostomies were created in two patients, two underwent a planned -stage conversion, and vbgs were converted to rygbs. patients were operated on an average of years after their initial vbg. presenting symptoms were weight regain (n= , . %), dysphagia (n= , . %), or severe gerd (n= , . %). fourteen patients ( %) had a gastric staple line dehiscence. of the vbg to rygb conversions, were laparoscopic, were converted to open, were open, and were robotic-assisted. average operative time and length of hospital stay were . minutes and . days, respectively. within the first months post-operatively, twelve ( %) patients required readmission directly related to surgery, while eight ( %) visited the emergency department. eight patients ( %) required at least one unplanned operation due to complication(s) during the entire follow-up: small bowel obstruction (n= , at -week, -months, and -months), necrosis/leak of remnant stomach requiring remnant gastrectomy (n= ), tracheostomy for prolonged respiratory failure (n= ), bleeding (n= ), anastomotic leak (n= ), and hemothorax requiring vats (n= ). four patients ( %) had a contained perforation that was medically managed and five ( %) developed a gastrojejunal anastomosis stricture requiring endoscopic intervention. one patient ( . %) developed pulmonary embolism. there was no mortality directly related to surgery. complete resolution or improvement of gerd/dysphagia was appreciated in all patients in the short term follow-up. patients who presented with weight regain had a mean bmi loss of . ± . points in the median follow-up time of . months up to a year after conversion to rygb. in summary, reoperative bariatric surgeries after vbgs are complex, requiring longer operative times and length of stay. our study found % risk of severe complications requiring reoperations, compared to the previously cited % in short and long-term complications. conversion of vbg to rygb provides excellent relief of severe gerd and dysphagia and is a viable option for significant weight reduction. introduction: bariatric surgery is a safe and effective treatment for severe obesity and its comorbidities. however, concomitant splenectomy is sometimes required due to uncontrolled bleeding during the surgery. limited literature exists regarding the effects of concurrent splenectomy on outcomes of bariatric surgery. this study aimed to determine these outcomes. methods: adult patients with obesity who underwent primary, elective laparoscopic roux-en-y gastric bypass (lrygb) or laparoscopic sleeve gastrectomy (lsg) with concomitant splenectomy were identified from the metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip, ) and national surgical quality improvement program (nsqip, (nsqip, - datasets. using propensity scores (based on baseline variables), patients who underwent primary bariatric surgery were matched : to a control group (primary lrygb/lsg without concomitant splenectomy) and thirty-day postoperative outcomes were compared. continuous variables and categorical variables were categorized as medians with interquartile range (iqr) and counts with percentages, respectively. background: several previous studies have suggested a correlation between weight loss and age after bariatric surgery. objective: the aim of our study is to further address age as a preoperative factor to determine the amount of weight loss after bariatric surgery. materials and methods: we performed a retrospective analysis of outcomes of a prospectively maintained database of , obese patients who underwent either sleeve gastrectomy (sg) or roux-en-y gastric bypass surgery (rygb) at our hospital between and . we analyzed the -month, -month, and -year postoperative percent total body weight loss (%tbwl) of obese patients who underwent bariatric surgery based on their preoperative age. results: the average age of patients included in the study was years old with a range of - years. an inverse relationship between preoperative age and postoperative weight loss was observed. younger patients achieved a higher % tbwl than older patients at the -month, -month, and -year postoperative follow-up. the average %tbwl for all patients at the -month, -month, and -year postoperative follow-up periods were . %, . %, and . %, respectively. at the -year follow-up, for every decade increase in age (above the average age of ), patients lost % less tbwl. conclusion: in our study, younger patients tend to lose a greater amount of %tbwl than older patients after bariatric surgery. results: patients participated in the survey. the median age was yo (iqr: - ) and . % were females. the following responses were encountered when asked about the importance of surgery-related factors: the study population indicated the following responses regarding expectations from magnetic surgery compared to conventional laparoscopy: there was no significant evidence of different responses by demographic groups. additionally, . % of the population indicated that a surgeon performing magnetic surgery should be more skillful than a surgeon performing conventional laparoscopy. conclusion: this study represents the first report of bariatric patient's perception regarding surgery-related factors. notably, nearly % of the cohort indicated that cosmesis after surgery is an important factor, whereas the responses regarding the rest of the factors were indicated as expected. the bariatric population included in this study had a positive perception of magnetic surgery. furthermore, the population perceived that this technique is associated with better outcomes, better cosmetic results, and higher surgeon dexterity. introduction: although much is known regarding medical outcomes of metabolic surgery, less is known regarding quality of life outcomes. we hypothesized that the collection of patient-reported outcomes (pros) could help us understand quality of life in this patient population. we chose to primarily use patient reported outcomes measurement information system (promis) instruments because of their broad applicability, low cost, and ability to use computer-adapted technology to survey. methods: we implemented the routine collection of pros as part of clinical care in december, . patients were offered tablets in clinic, and were asked to complete the surveys at most of their visits. we used computer-adapted technology to decrease the length of time needed to survey. we collected the following promis instruments: depression, pain interference, physical function, and satisfaction with social roles. we also collected the gerd-hrql, a general health question, and a current health visual analog scale (vas). we retrospectively reviewed our results from december through september . results: our response rate was % over the last year of collection. in total, assessments were completed by patients. the mean scores in our total patient population were as follows: vas , gerd-hrql , general health , depression , pain , physical function , and social roles . for promis instruments, the mean for the national population is , with as the standard deviation. for the depression and pain scores a higher score is worse, while a higher score indicates better quality of life for social roles and physical function. conclusions: routine collection of patient reported outcomes can be implemented in a metabolic surgery clinic. health-related quality of life appears to be decreased in this patient population compared to the general public. further work is ongoing to learn about postoperative trends, as well as differential effects of metabolic procedures. the effect of peri-operative antibiotic drug class on the resolution rate of hypertension after roux-en-y gastric bypass and sleeve gastrectomy. results: in total, rygb and sg were included in our analysis. no significant differences were found between cefazolin and clindamycin regarding hypertension resolution rates after sg. there was a significant difference in the resolution of hypertension after rygb with the use of prophylactic clindamycin or cefazolin. as shown in figure , patients who underwent rygb and received clindamycin had a significantly higher rate of hypertension resolution compared to cefazolin. this effect started at weeks post-operatively ( . % vs . % respectively, p= . ) and persisted up to the -year ( . % vs . % respectively, p= . ). we found no significant differences in patient age, sex, number of pre-operative hypertensive medications, pre-operative bmi, or %bmi change after year to account for the significant effect of antibiotic choice on hypertension resolution. conclusion: this study represents the first clinical report to suggest an impact of the type of antibiotic administered at the time of rygb on co-morbidity resolution, specifically hypertension. future studies will be needed to confirm that the mechanism of action for this novel finding is due to the differing modifications of the gastrointestinal microflora population based on the specific peri-operative antibiotic administered. introduction: laparoscopic adjustable gastric band with plication (lagbp) is a novel bariatric procedure which combines the adjustability of the laparoscopic adjustable gastric band (lagb) with the restrictive nature of the vertical sleeve gastrectomy (vsg). the addition of plication of the stomach to lagb should provide better appetite control, more effective weight loss, and greater weight loss potential. objective: the purpose of the study was to analyze the outcomes of lagbp at months. setting: this is a retrospective analysis from one surgeon at a single private institution. methods: data from all patients who underwent a primary laparoscopic lagbp procedure from december to june were retrospectively analyzed. data collected from each patient included age, gender, weight, body mass index (bmi), and excess weight loss (ewl). results: sixty-six patients underwent lagbp. the mean age and bmi was . ± . years and . ± . kg/m, respectively. all patients were beyond the -month postoperative mark. no patient was lost to follow-up. the patients lost an average of % and . % excess weight loss (ewl) at months ( . % follow-up) and months ( . % follow-up), respectively. also, the patients lost a mean bmi of . kg/m and . kg/m at months and months, respectively. the total number of fills during the study period was , and the mean fill volume was . ± cc. dysphagia was the most common long-term complication. the mortality rate was %. conclusions: lagbp is a relatively safe and effective bariatric procedure. in light of recent studies demonstrating poor outcomes following lagb, lagbp may prove to be the future for patients desiring a bariatric procedure without resection of the stomach. the median interval between (lrygb) and reoperation is months in group a and months in group b. the median percentage of excess weight loss (%ewl) is % vs %, respectively (p= . ). patients % ( in group a) were admitted in an emergency with an acute abdomen pain. ct scan was performed in patients % and has shown signs of occlusion in all cases. the most common symptoms were abdominal pain and vomiting. the surgery was performed by laparoscopy in patients % and by laparotomy or conversion in patients %. in all cases internal hernia was reduced and closed all defects. in only one patient in (group a) small bowel at jja was resected. there was no mortality and one patient had pneumonia with acute respiratory distress which was treated medically. conclusions: the closure of mesenteric defects at (lrygb) by tight non-absorbable continued sutures is recommended because it is associated with a significant reduction in the incidence of internal hernia. introduction: laparoscopic roux-en-y gastric bypass (rygb) is a common and effective form of bariatric weight loss surgery. however, a subset of patients will fail to achieve the expected total body weight loss (tbwl) greater than % after months or experience significant weight regain despite dietary, psychiatric, and behavioral counseling. although alternative procedural interventions exist for operative revision after suboptimal rygb weight loss, laparoscopic adjustable gastric banding (lagb) provides an option with short operative time, low morbidity, and effective results. we have previously demonstrated that short-term ( -month), and mid-term ( -month) weight loss is achievable with lagb for failed rygb. the objective of this study is to report the long term year outcomes of lagb after rygb failure. methods and procedures: a retrospective review of prospectively collected data before and after rygb when available, and before and after revision with lagb was performed. background: saline filled intragastic balloons have become a common outpatient procedure for the treatment of obesity. acute dilation, ischemia and necrosis of the stomach has been described in the medical literature. gastric necrosis from acute gastric dilation is a rare but life-threatening condition, which requires timely diagnosis and management. we present a case of partial gastric ischemia with necrosis hours following placement of a saline filled intragastric balloon. postoperative complaints of bloating, nausea and vomiting are common complaints following placement of saline filled intragastric balloons and can lead to a delay in diagnosis. early diagnosis and management is essential in avoiding this life threatening complication. case report: a year old woman, bmi , comorbid conditions of diabetes mellitus underwent uncomplicated placement of a saline filled intragastric balloon for treatment of obesity. hours after placement the patient complained of cramping and bloating. hours following placement the patient developed vomiting and presented to an emergency room for evaluation. she was found to have blood glucose exceeding and a severely dilated stomach with pneumotosis on ct evaluation. ng tube decompression and icu management of the severe hyperglycemia was initiated. removal of the intragastric balloon was delayed - hours until an appropriate endoscopic retrieval kit could be obtained. endoscopic retrieval was performed without incident and near complete necrosis of the gastric mucosa was noted. the antrum was the only area spared. hours after retrieval a laparoscopic evaluation of the stomach revealed full thickness necross of the entire fundus and greater curve. indocyanine green (icg) fluorescent dye was used to assess vascular integrity of the remaining stomach and to define lines of resection. resection of the greater curvature was performed using icg florescent dye to ensure that the angle of hiss was viable and well perfused. the patient had a full recovery and subtotal gastrectomy was avoided. conclusions: spontaneous gastric distension exacerbated by gastric outlet obstruction following placement of a saline filled intragastric balloon can occur. unrecognized this condition can lead to ischemia, necrosis and perforation of the stomach. appropriate evaluation of patients following placement of intragastric balloons is essential. recognition of this condition can be delayed due to the complaints of cramping, bloating and vomiting which are typical following placement of saline filled intragastric balloons. untreated, gastric ischemia and necrosis can lead to early perforation which is associated with a high mortality rate. introduction: morbid obesity has become a growing health risk in the united states with up to % of americans suffering with obesity. bariatric surgery remains the best treatment for morbid obesity. the recent use of laparoscopic sleeve gastrectomy (lsg) as a single stage procedure has met with great success because of its quick learning curve and minimal postoperative complication rates. however, there are concerns if the lsg is an effective procedure for long-term weight loss. although criticized at first, the mini-gastric bypass (mgb) surgery has become a great option for morbidly obese patients because of the ability to lose weight with minimal post-op complications. the aim of this review is to assess the outcomes of lsg as it compares to mgb for the management of morbid obesity. introduction: we hypothesize that a jejunoileal anastomosis and partial diversion using magnamosis, a novel magnetic compression device, is technically feasible and will improve insulin resistance and metabolic syndrome similarly to patients who underwent bariatric surgery. metabolic surgery has demonstrated improvements in various parameters including insulin resistance, triglyceride levels, and cholesterol. it may be technically feasible to perform a less-invasive operation through partial diversion, and thereby stimulate an increase in incretins from the l-cells of the ileum to glean these benefits. methods and procedures: we performed a laparotomy and jejunoileal partial diversion using magnamosis in five rhesus macaques with induced insulin resistance through dietary modifications. after surgery, weight was monitored and a metabolic laboratory evaluation was performed weekly. timed tests were performed at baseline and again at and weeks postoperatively for triglyceride levels, glp- , insulin, glucose, and bile acids. the primates were followed for weeks prior to euthanasia. results are represented as mean±sem and all p-values were calculated using a two-sample students' t-test. introduction: many studies concerning individuals seeking bariatric surgery indicate a higher prevalence of psychiatric disorder in this population, both before and after surgery, however results are not conclusive. the aim of this study was to investigate changes in psychiatric health after gastric bypass surgery. methods: patients within the catchment area of the department of psychiatry of the south alvsborg hospital, operated with gastric bypass surgery during - were identified through the scandinavian quality registry (soreg). patients files were examined and psychiatric diagnoses and alcohol/drug abuse were recorded preoperatively and with a follow up time of years. results: a total of operated patients were identified. of these patients had been in contact with the psychiatric department before or after surgery. patients had attempted suicide preoperatively, but no attempts were made postoperatively, all women. patients attempted suicide postoperatively without a previous history of suicidal attempts, men woman. four patients with a preoperative history of alcohol abuse were identified, all women. these individuals did not seem to abuse alcohol/drugs postoperatively. postoperatively patients with an alcohol/drug abuse were identified, men, women. none of them had a former history of abuse. of the patient performing suicidal attempts postoperatively, men woman, had a postoperatively emerging alcohol/drug abuse. conclusion: preoperatively known alcohol/drug abuse or suicidal attempts do not seem to predispose for postoperative abusive problems or suicidal behavior. preoperative identification of individuals prone to alcohol/drug abuse or suicidal attempts seems difficult. introduction: in the past, our group has popularized models for gastric bypass, sleeve and gastric imbrication. there are currently no models to predict weight loss following single anastomosis duodenal switch. surgeons who offer this procedure are left to guess based on their limited experience how their patients will do following surgery we have developed a simple office based algorithm to predict weight loss following this procedure. method: patients met the criteria for this study. these patients underwent surgery at a single institution from june to december . non-linear regression analysis was performed to interpolate weight loss at one year. a multilinear regression was run to determine the significant variables. a model was then constructed to predict weight loss after single anastomosis duodenal switch. results: bmi, htn, gender, and the interaction between htn and dm were found to affect weight loss. the model achieved a r value of . and the average error of prediction in the model was . %ewl. conclusion: today too many surgical practices offer procedures tailored to surgeon instead of the needs of the patient. using our models predicting postoperative weight loss can be a straightforward process using easily gathered data. all surgeons should be doing this currently in their own practice to allow patient to choose targeted healthcare interventions based on patient's personal goals. surg endosc ( ) introduction: there is a long-standing practice of testing anastamosis both in upper and lower gi surgery. post-operative leaks in bariatric surgery are an uncommon but serious compilation increasing morbidity and risk of mortality. the present study looks at the practice of performing an intra-operative leak test during roux-en-y gastric bypass (rygb) and sleeve gastrectomy (sg). methods and procedures: the study was divided in two independent phases of six months and months. data was collected from all patients undergoing sg, rygb or revision rygb within those two periods. to confirm the integrity of the staple line all patients underwent a methylene blue and air test intra-operatively. this was followed by a gastrograffin swallow the morning post procedure. results: total number of patients in the study was . there were four positive intraoperative tests. one patient was a primary rygb and three patients were undergoing revision rygb. all were reinforced and subsequent recovery and gastrograffin swallow showed no leak. one revision rygb had an undetected small bowel injury distal to jejuno-jejunostomy that was not identified on intraoperative or next day imaging. we used multivariate statistical analysis to study our population sample and classified the impact of each factor or their combination with the use of principal component analysis. we used systematic clustering to identify subpopulations that have significant differences in statistical distribution. result: the main determinant of total operative time was the surgeon and the level of his assistant. prior surgeries, bmi and smoking history had a statistically significant impact on the laparoscopic time (p value. ). removing the impact of various surgeons, we detected four clusters of patients based on more than patient characteristics. we noticed total or time had two different clusters: one with a standard-deviation of - min while the other had over min. conclusion: this study may have practical implications on improving scheduling. the different comorbidities of these bariatric patients helped to stratify patients into these main cluster groups. better predictability on length of operative procedure can lead to more efficient use of or time and staff, thus ultimately leading to savings for the hospital. in addition, we used automated noninvasive tracking methods to identify phases of bariatric procedures that will allow more accurate estimated or time to efficiently schedule cases. the smart or, which is equipped with multiple noninvasive sensors, allows for error free tracking and monitoring without human interference. objectives: successful outcomes after bariatric surgery (bs) require a comprehensive educational program (cep) focused on post-surgical dietary and lifestyle changes. at our institution, patients must comply with a -week life-after-surgery program prior to surgery. since many patients are not able to participate in-person, an online cep was created to improve accessibility. to evaluate comprehension, a -question test is administered at the last preoperative visit to participants of both classes. the primary objective of this study is to evaluate the effectiveness of online versus inperson cep in terms of comprehension and post-operative weight loss. methods: patients who underwent bs from august -may were retrospectively reviewed at a single institution. all patients who underwent the in-person or online cep, completed the -question test, and had post-operative follow-up for at least months were included. baseline demographic, operative, and weight data were obtained using the electronic medical record. background: body weight loss after bariatric surgery is affected by several factors. diabetes status or preoperative body mass index (bmi) would affect the body weight loss after surgery. age and sexuality may also be the predictor. furthermore, the malabsorptive procedure is considered more effective for body weight loss than the restrictive procedure alone. we investigated the contribution of preoperative background data and procedures to the body weight loss after surgery. methods: this was a multicenter, retrospective study to validate the efficacy of bariatric surgery for morbidly obese patients in japan. patients underwent sleeve gastrectomy (lsg) or lsg with duodenal-jejunal bypass (lsg/djb) in each institution from january to december , and whose bmi was kg/m or more at the first visit were included in this study. we investigated the percent excess body weight loss (%ewl) at months after surgery. univariate and multivariate analyses were done to evaluate the predictive factors of body weight loss. we defined that %ewl more than % as well response (wr background: despite its known safety and efficacy, bariatric surgery is an underutilized treatment for morbid obesity in the united states. objective: our goal was to identify factors associated with failing to proceed with surgery despite being considered an eligible candidate by a bariatric surgery program. methods: this is a retrospective study that includes all patients (n= ) who attended a bariatric surgery informational session (bis) at a single center academic institution in . eligible candidates were identified after clinical evaluation and multidisciplinary candidacy review (mcr). we compared patients who underwent surgery to those who did not (i.e. dropped out) by evaluating patient-specific, insurance-specific, and bariatric surgery program-specific variables. univariate analysis and multivariable regression were performed to identify risk factors associated with failing to undergo surgery among eligible candidates. introduction: the elderly are a special subset of the population due to their limited physiological reserve with aging. revisional bariatric surgery is becoming more common with increase in primary bariatric procedures. data on safety, weight loss, and metabolic effects of revisional bariatric surgery in elderly is limited. the aim of this study was to assess the safety and efficacy of revisional bariatric surgery in the elderly. methods: clinical data of all elderly patients ( years and above) who underwent elective revisional bariatric surgery at an academic institute between and were reviewed. demographic data, perioperative variables, and postoperative outcomes were studied. results: a total of patients were identified with a female predominance ( : ). mean age was ± . years. mean bmi at the time of revisional surgery was . ± . kg/m . the primary indication for revisional surgery included management of postoperative adverse events (n= , . %) and weight recidivism (n= , . %). in patients with postoperative complications, the most common indications for revisional surgery were dysphagia (n= , . %), marginal ulcer (n= , . %), gastric outlet obstruction (n= , . %), and fistula formation (n= , . %). the most common type of revisions included conversion of vertical banded gastroplasty to roux-en-y gastric bypass (rygb, n= ), revision of rygb (n= ), conversion of adjustable gastric banding to sleeve gastrectomy (sg, n= ), and sg to rygb (n= ). two out of seven ( . %) patients with -day postoperative readmissions had serious complications that required reoperation. one of them underwent small bowel resection for ischemia and the other had thoracotomy for hemothorax evacuation developing secondary to a gastropleural fistula. while there was no mortality over the first days postoperatively, two patients died months after surgery due to infectious complications. in the median follow-up time of (interquartile range, - ) months, mean weight and bmi changes of − . kg and − . kg/m were observed. twenty-three ( . %) patients had diabetes at time of revisional surgery. a mean reduction of . mg/dl in fasting blood glucose and . % in glycated hemoglobin were noted between baseline and last follow-up. conclusion: revisional bariatric surgery in elderly is associated with high complication rates. our data indicate that revisional bariatric surgery can potentially alleviate symptoms and resolve complications of primary bariatric surgery. elderly patients should have their risk stratified and weighed against the benefits of surgery. anne-marie carpenter, bs, alexander l ayzengart, md, mph; university of florida introduction: bariatric surgery is the most effective treatment for morbid obesity. of all available procedures, laparoscopic sleeve gastrectomy (lsg) is now the most popular worldwide. common complications of lsg include gastroesophageal reflux, stricture, and staple-line leak. although rare, portomesenteric venous thrombosis (pmvt) and liver retractor-induced injuries are increasingly reported. we present a case of isolated left portal vein thrombus after routine lsg that was likely caused by prolonged compression of left liver lobe by the nathanson retractor. case presentation: a -year-old female with a bmi of and biliary colic due to cholelithiasis underwent lsg with hiatal hernia repair and cholecystectomy. she tolerated the procedure without complication and was discharged home on the following day. on postoperative day , she presented to the emergency department with fever and epigastric pain. contrast ct revealed an isolated filling defect within the proximal left portal vein; abdominal doppler demonstrated an acute thrombus occluding the left portal vein with normal flow in the main and right portal veins. the patient was treated with a -month course of therapeutic anticoagulation with lovenox. a complete hematologic workup did not uncover any hypercoagulable conditions. the patient recovered well and remained asymptomatic at her follow-up visit weeks after operation. discussion: pmvt is a rare surgical complication with multifactorial etiology. in bariatric surgery, evidence suggests lsg elicits more frequent pmvt compared with roux-en-y gastric bypass. a systematic review cited the incidence rate of pmvt as . - % after lsg. the mechanisms are thought to be due to pneumoperitoneum, procoagulant obese state, manipulation of portomesenteric venous system during division of the gastrocolic ligament, and postoperative dehydration. liver retraction is paramount during laparoscopic bariatric surgery to provide adequate visualization of the upper stomach and diaphragmatic hiatus. most methods of liver retraction produce significant pressure on the liver parenchyma by compressing it against the diaphragm. three types of liver injury have been documented in literature: minor congestion, traumatic parenchymal rupture, and delayed liver necrosis. uniquely, we propose an additional type of injury-left portal vein thrombosis due to compression of left liver lobe with the nathanson retractor. conclusion: the case described herein represents the first documented report of isolated left portal vein thrombosis after lsg. this is a unique presentation of retraction-related liver injury causing pmvt by mechanical compression of liver parenchyma. as surgical procedures increase in duration, intermittent release of liver retraction should be performed at regular intervals. introduction: up to % of patients experience internal hernia (ih) after laparoscopic roux-en-y gastric bypass (rygb). studies have shown that antecolic roux limb orientation, and closure of the mesenteric defect reduce, but do not eliminate, the incidence of ih. we hypothesize that despite operative differences, ih occur more frequently in patients who experience significant weight loss. this study aims to determine whether those patients who present with ih following rygb experience greater than % excess body weight loss (ebwl). methods: a retrospective chart of all patients who underwent ih repair following rygb at our institution between sept and sept was performed. all applicable cpt codes to encompass ih repair were reviewed (n= ). patients with ih repair after rygb were identified. results: of the patients, were female. the mean pre-rygb weight was lbs (sd± . ), bmi . kg/m (sd± . ). all procedures but one were performed in an antecolic configuration; the other retrocolic-antegastric. fifteen cases were laparoscopic and two were open; nine had the jejunal mesenteric defect closed, eight did not. the average weight loss from the time of rygbp to ih presentation was . lbs (sd± . ) and %ebwl from rygb to the nadir weight was % (sd± ). when evaluated by t-test, there was no statistical difference in bmi at the time of program initiation, rygb, or ih presentation, as well as number of pounds lost, %ebwl, or time to ih presentation, when comparing patients for whom the mesenteric defect was closed or not. average time from rygb to ih presentation was . years (range - days) . conclusion: in our limited cohort of patients who have presented with internal hernia after rygb, there was an average of % ebwl. this is greater than the average expected %ebwl at our institution and others, suggesting that ih may occur in patients with greater weight loss at a higher frequency. mesenteric defect closure did not appear to have any influence in this limited cohort, suggesting that weight loss is a stronger factor in ih development. we plan a more extensive evaluation in a larger cohort of patients to determine if greater %ebwl is a predictor of ih formation in patients undergoing rygb. introduction: introduction of enhanced recovery after surgery (eras) pathways has led to early recovery and shorter hospital stay after laparoscopic roux-en-y gastric bypass (lrygb) and laparoscopic sleeve gastrectomy (lsg). this study aims to assess feasibility and outcomes of postoperative day (pod) discharge after lrygb and lsg from a national database. methods: patients who underwent elective primary lrygb and lsg and were discharged on pod and were extracted from metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip) dataset. a : propensity score matching was performed between cases with pod vs pod discharge, and the -day outcomes of the propensity-matched cohorts were compared. high risk patients were excluded from the analysis. purpose: the aim of this study was to evaluate a large volume, multi surgeon bariatric surgery center producing the largest sample size to date proving efficacy (% weight loss) and safety of sleeve gastrectomy following band removal in one or two step procedures. methods: all patients undergoing conversion of lagb to lrygb ( ) and lsg ( ) regardless of one step vs two step conversion from january to january were included. a retrospective analysis of our prospectively maintained database was performed to compare outcomes in patients undergoing conversion to lrybg vs lsg after lagb to identify the outcomes. introduction: the purpose of the study was to describe the use of intraoperative indocyanine green (icg) fluorescence angiography to identify the blood supply patterns of the stomach and gastroesophageal junction (gej). we hypothesized that identifying these vascular patterns may help modifying the surgical technique to prevent ischemia-related postoperative leaks. methods: patients underwent laparoscopic sg and were examined intraoperatively with icg fluorescence angiography at an academic center from january to september . prior to the construction of the sg, ml of icg was injected intravenously and pinpoint® technology was used to identify the blood supply of the stomach. afterwards, the sg was created with attention to preserving the identified blood supply to the gej and gastric tube. finally, ml of icg were injected and pinpoint® technology was used again to ensure that all the pertinent blood vessels were preserved. results: patients successfully underwent the procedure with no complications. the following blood supply patterns to the gej were found: the incidence of overall accessory blood supply to the right-side dominant pattern was more common than expected. in about half of the cases where an accessory vessel was found in the gastrohepatic ligament, the blood flow was toward the stomach (and not the liver). furthermore, the incidence of accessory blood supply from the left side was found in % of the cases. % of patients had both the left side accessory and accessory gastric artery pattern. in these particular patients, if a concurrent hiatal hernia repair is performed, these accessory blood supplies are at risk of being injured if care is not taken to preserve them, rendering the gej relatively ischemic. conclusion: icg fluorescence angiography allows determining the major blood supply to the proximal stomach prior to any dissection during sleeve gastrectomy so that an effort can be made to avoid unnecessary injury to these vessels. background: morbid obesity, a common medical concern with significant health risks, has a prevalence of . % among u.s. adults. bariatric surgery provides effective weight loss for morbidly obese patients with improvement in their comorbid conditions. traditionally, routine intraoperative drain placement (idp) and postoperative esophagram (ugis) were thought to identify early postoperative complications. recently, these interventions have been scrutinized for their effectiveness. we hypothesized that idp and postoperative ugis do not alter outcomes in bariatric surgery and only increase hospital length of stay (los). methods: two cohorts, each consisting of patients from either or were analyzed from our institution. in the cohort, all patients had idp and an ugis on postoperative day , prior to starting a clear liquid diet. in the cohort, no patients had idp or ugis, but instead were started on a clear liquid diet on postoperative day , in the absence of vomiting. all patients in each cohort underwent either a laparoscopic sleeve gastrectomy or a roux-en-y gastric bypass. a retrospective study was performed to analyze whether there was a significant difference in postoperative complications, length of stay, and operating room time between these two cohorts. those who underwent t dm remission were less likely to be vdd at all time points. the rates of vdd appear to be slightly higher in rygb at each time points. the rates of macrocytic anemia, microcytic anemia and hypoalbuminemia were low and varied depending on surgical procedure, with no relevant increase following surgery (see figure ). conclusions: vitamin d deficiency is prevalent among diabetic patients with obesity presenting for bariatric surgery. the postoperative management was successful in addressing vdd following surgery; those who experienced t dm remission after surgery were less likely to be vdd. further prospective studies are needed to explore this relationship. surg endosc ( ) :s -s introduction: it is well known that morbid obesity is strongly associated with high blood pressure. cardiovascular risk reduction is a well studied and described result of bariatric surgery. the objective of this study is to quantify hypertension resolution in patients who underwent bariatric surgery at our institution. methods: we retrospectively reviewed all the patients who underwent either laparoscopic sleeve gastrectomy (lsg) or laparoscopic roux en y gastric bypass (lrygb) at our institution between and . we selected those patients who were on antihypertensive medical treatment and had a -month follow-up. hypertension resolution was defined as the interruption of any blood pressure medications within the follow-up period. we compared the patients who had resolution of hypertension (group ) with patients who did not (group ), based on demographics, comorbidities, and outcomes. chi-square and student t-test were used for categorical and continuous variables respectively. results: out of patients, ( . %) patients met the inclusion criteria, out of which, ( . %) had a complete resolution of hypertension within months. the patient population included in group was predominantly female n= patients ( . %), diabetic (n= , %), with a mean bmi of . ± . kg/m , a mean age of . ± . years, and a preoperative systolic blood pressure mean of ± . mmhg. the most common procedure performed was lsg with n= ( %). comparison between group and group based on age, gender, bmi, and diabetes showed no statistically significant difference. estimated bmi loss % at months, type of procedure and % ebmil showed no statistically significant difference between the groups. conclusions: rapid weight loss is associated with a drastic reduction of blood pressure. besides weight loss, we did not identify a clear correlation between risk factors when we compared patients who had resolution of hypertension with patients without resolution. further prospective studies should be done for better understand these findings. the mount sinai hospital, university of chicago introduction: for many patients, hiv has transformed from a life-threatening illness into a manageable chronic disease. reflecting trends in the general population, obesity is increasingly prevalent among hiv-positive patients. surgical intervention has shown the greatest effectiveness in treating obesity. it is unknown, however, whether physician attitudes reflect the changing trends in obesity care for hiv-positive patients. methods and procedures: medical students from the first, second, and fourth years of training were invited to participate in an irb-approved survey, handed out during didactic sessions, which was designed to assess their knowledge and attitudes regarding bariatric surgery in hiv-positive patients. self-reported demographic information of respondents was also collected. the outcome of interest was the proportion of correct responses. univariate and multivariate regression analyses were performed. results: surveys were completed by medical students. demographic covariates included the following: age, sex, race, bmi, and year of training. age, sex, race, and bmi were not statistically significant in the multivariate model. however, in both univariate and multivariate models, each additional year of training was associated with a significant increase in the proportion of correct responses (multivariate model beta coefficient= . , p. ). conclusions: obese and hiv-positive patients suffer from well-documented stigma in health care. these findings suggest that medical training corrects common misperceptions of obese and hivpositive patients, and may lead to a better understanding of the appropriateness of bariatric surgery for hiv patients. whether these attitudes are predictive of referral practices remains to be seen. introduction: obesity is a common problem worldwide with numerous associated comorbidities and is associated with an increased risk of developing some cancers. despite bariatric surgery being associated with a risk reduction for cancer development, some will develop cancer after surgery and little is known about complications which might arise during multimodality cancer treatment. here we report the case of a year-old female who developed an unusual giant marginal ulcer (mu) post laparoscopic roux-en-y-gastric bypass (lrygb) while receiving systemic chemotherapy for an early stage breast cancer. case report: in summary, a year-old female with a preoperative bmi of kg/m had an uncomplicated lrygb one year prior to her presentation. she was a non-smoker, was abstinent of alcohol and did not use nsaids, steroids or other ulcerogenic medications. eight months post procedure with a bmi of . kg/m she was diagnosed and treated with bcs plus slnb for a pt n m er/pr +ve her −ve breast cancer. one week following her third cycle of docetaxel and cyclophosphamide, she presented with two days of melena, small volume hematemesis and abdominal discomfort. the patient was resuscitated with prbc, started on a ppi infusion and had free air ruled out on a cxr. upper endoscopy was complete showing a giant mu at the gastrojejunal anastomosis, biopsies ruled out malignancy and h. pylori. subsequent ct abdomen/pelvis identified contrast extravasation from the anastomosis confirming a free perforation. broad spectrum antibiotics were started and a diagnostic laparoscopy complete. a graham patch repair utilizing omentum and abdominal washout were complete with placement of surgical drains. the patient was supported with parenteral nutrition while npo. diet was advanced after an upper gi series on post operative day showed no ongoing leak. the patient was discharged on post operative day , recovered and although further chemotherapy was discontinued she completed whole breast radiotherapy. conclusion: leaks and hemorrhage are early postoperative complications that are not seen intraoperatively in our experience. furthermore, endoscopy significantly increases mean operative time. routine use should be left to the discretion of the surgeon but should not be considered an essential step of the sleeve gastrectomy. the objective of the study: surgical site infection (ssi) following bariatric surgery contributes to patient morbidity and additional use of health care resources. we investigated whether a ssi quality control initiative in the form of a refined preoperativeantimicrobial protocol affected the rate of ssi following laparoscopic roux-en-y gastric bypass (lrygb). we reviewed all lrygb procedures performed between june and december at a single bariatric surgery centre of excellence. two preoperative antimicrobial protocols were compared. patients undergoing surgery prior to february received g of cefazolin whereas patients undergoing surgery after february , received a new antimicrobial protocol consisting of g cefazolin, mg metronidazole and ml oralchlorhexidine rinse. the primary outcome was day ssi including superficial ssi, deep incisional ssi and organ/space infection as defined by the centre for disease control. clinic charts and provincial electronic medical records were reviewed for emergency department visits, microbiology investigations and physician dictations diagnosing ssi. outcomes were assessed using a students t-test. results: two hundred seventy six patients underwent lrygb of which received the refined antimicrobial protocol and received cefazolin. the refined antimicrobial protocol significantly decreased the rate of deep incisional ssi compared to cefazolin (n= , . % vs n= , . %; p\ . ). the refined antimicrobial protocol resulted in an insignificant overall reduction in the rate of superficial ssi (n= , . % vs n= , . %; p[ . ) and organ/space infection (n= , . % vs n= , . %; p[ . ) respectively. conclusions: a preoperative antimicrobial protocol using cefazolin, metronidazole and chlorhexidine oral rinse appears to reduce the rate of ssi following lrygb. this protocol may be most effective to prevent deep incisional ssi. additional patient cases or alternative study design including a randomized control trial is required to better understand the efficacy of this protocol. background: for many years, the roux-en-y gastric bypass (rygb) was considered a good balance of complications and weight loss. according to a several short-term studies single anastomosis duodenal switch or stomach intestinal pylorus sparing surgery (sips) offers similar to weight loss to rygb with fewer complications and better diabetes resolution. however, no one has substantiated complication and nutritional differences between these two procedures over the midterm. this paper seeks to substantiate previous studies and compare complication and nutritional outcomes between rygb and sips. methods: a retrospective analysis of patients who either had sips or rygb from to . complications were gathered for each patient. nutritional outcomes were measured for each group at , , and years. regression analysis was applied to interpolate each patient's weight at , , , , , , and months. these were then compared with t tests, fisher exact tests, and chi squared tests. results: rygb and sips have statistically similar weight loss at , , , , and months. they statistically differ at and months. at months, there is a trend for weight loss difference. there were only statistical differences in nutritional outcomes between the two procedures with calcium at and years and vitamin d at year. there were statistically significantly more long term major complications, minor complications, reoperations, ulcers, small bowel obstructions, nausea, and vomiting with the rygb than sips. conclusion: with comparable weight loss and nutritional outcomes, sips has fewer short and long-term complications than rygb and better type diabetes resolution rates. introduction: the purpose of this study is to determine the risk factors that contributed to increased postoperative complications, as noted in prior studies within the publicly funded insurance population undergoing bariatric surgery. methods and procedures: data was collected via a retrospective review of the medical records of patients who underwent laparoscopic roux en y gastric bypass or laparoscopic sleeve gastrectomy from to at a single institution. for each patient, data was collected in the following categories: baseline demographics, insurance status, medical comorbidities, immediate complications, re-admissions and associated complications, and follow up out to years. results: a total of patient charts were reviewed, patients were categorized as private insurance and patients were categorized as public insurance. there was no statistically significant difference in mean patient age (private . years vs public years), sex (male:female %: % for both groups), or bmi ( vs ). there was a statistical significance in relationship status in the categories of single ( % vs %), married ( % vs %) or living with a partner ( % vs %), as well as employment status ( % vs %). when comparing comorbid conditions preoperatively there was no difference except for diabetes which was less common in the private insurance group % vs %. readmission rates for complications were significantly different as well at % vs % with public insurance patients having increased complication rates and readmissions. there was no difference in follow up percentages at each time point for the two groups. interestingly postoperative bmi was significantly different in the two groups until year out ( vs ) when the difference disappears. conclusions: our current data set confirms prior research that documented higher complication rates in public insurance patient populations without differences in long term results in regards to weight loss. it also shows that the public insurance group is possibly at higher risk for complications and readmissions postoperatively due to the lack of social support at home given that a much higher percentage of them are single or divorced, and lack employment. it is likely that this lack of support at home prompts more frequent readmissions and associated complications. introduction: gastric bypass has been an acceptable treatment for the morbidly obese patient, with proven efficacy on weight loss and remission of co morbidities, especially diabetes (t dm). laparoscopic sleeve gastrectomy (lsg) is gaining momentum as an alternative procedure for the morbidly obese patient. the aim of this study is to assess the resolution of t dm by examining hba c, bmi, fat %, and % excess weight loss in t dm patients in our lsg patients. methods: we performed a retrospective chart review of t dm patients before and after lsg, analyzing hga c, bmi, % weight loss, fat %, and diabetic medications. data was analyzed by using spss version . paired t-test was applied to see the significance of bmi, weight, fat % and hba c before and after the procedure. introduction: gastroesophageal reflux disease (gerd) is a known risk following laparoscopic sleeve gastrectomy (lsg), with up to % of patients affected by the disease postoperatively. of these patients, an unknown number progress to medically refractory gerd. due to their postsurgical anatomy, these patients have limited options for intervention. while endoluminal therapies are available, surgical revision to roux-en-y gastric bypass (lrygb) has become an accepted revisional treatment. despite this therapeutic option, many payors deny coverage for this treatment. in this study, we report outcomes of revision of lsg to lrygb and difficulties in obtaining insurance approval for the operation. methods: we conducted a retrospective review of all patients who underwent a revisional bariatric operation at a single institution between january and august . we analyzed all patients who underwent conversion of lsg to lrygb. we collected data on -day mortality and morbidities, pre-and postoperative antacid use, and the insurance approval process. results: within the study period, we identified patients undergoing revisional bariatric surgery. seventeen patients had undergone conversion of lsg to lrygb. all of these patients underwent revision due gerd refractory to maximal medical therapy. the average body mass index was kg/m , and our average operative time was minutes. one patient required laparoscopic cholecystectomy within days due to acute cholecystitis, and another patient required reoperation for control of staple line bleeding. there were otherwise no -day morbidities or readmissions. fifty nine percent stopped all antacid medication by six months, and % stopped by months. of the % percent of patient still on proton pump inhibitor therapy, none of those patients complained of reflux symptoms. of non-medicare patients, % were initially denied insurance coverage for revision. only one plan accounted for all initial approvals. twenty five percent of denied patients eventually paid out of pocket, and the remaining % ultimately secured coverage after an appeal process. with no significant differences in mortality or hospital stay. significantly shorter operative times were observed in the adolescent group ( . ± vs . ± , p. ). in univariate analysis blood transfusions and vte rates were significantly lower in the adolescent group but there was no difference after risk-adjusted logistic regression analysis. analysis of readmission data showed lower rates in adolescents compared to young adults ( . % vs . % p= . ). however, adolescents are more frequently readmitted secondary to gallstone disease ( . % vs . %, p. ). the most common reason for readmissions in both groups was nausea and vomiting with fluid/electrolyte depletion, followed by abdominal pain. conclusion: adolescent bariatric surgery is feasible and safe, with outcomes similar to that of young adults. lsg is currently the most common bariatric procedure performed in adolescents which is reasonable given the relative lack of co-morbid conditions within this group. nausea and vomiting are the most common reason of readmission in both groups, but gallstone disease is significantly higher in adolescents, suggesting that this population should be carefully screened for gallbladder disease preoperatively. further studies regarding long-term results are needed to elucidate long-term outcomes, such as the durability of comorbidity resolutions in adolescent patients. introduction: revision bariatric surgery is always considered to be associated with higher complication rates. there is currently controversy in the literature regarding one stage and two stage revisions. methods: the present study is ongoing longitudinal prospective analysis of data of revision surgery in a single unit. the revision surgery was offered after initial failed or complicated gastric band, sleeve gastrectomy and roux-en-y gastric bypass (rygb). results: there were forty-two individuals who had revision bariatric surgery. the age of the cohort of patients ranged from twenty-six to seventy-five years. thirty-three were females and nine males. all patients who were hypertensive or diabetic at the time of their initial bariatric operation had a relapse of their co-morbidity prior to their revision surgery. the two stage revisions patients had their band removed at another facility, had a compilation from the band itself or did not wish for revision surgery initially. of the two failed bypasses one had a large pouch and very short limbs. the other had a gastro-gastric fistula and ultra short limbs. there were no deaths in this study. one patient who underwent one stage revision of a gastric band to bypass had an iatrogenic small bowel injury that required a second operation. amelioration of diabetes and hypertension was seen in all who had relapsed. weight loss was good in all patients except for the those undergoing revision from short limbed to long limbed bypass. conclusion: there is enough evidence that revision surgery is feasible, and can ameliorate metabolic co-morbidities after failed band and sleeve. two staged surgery is not necessarily safer compared to one stage revision. in the present study an inadvertent iatrogenic injury occurred in one stage revision group but is not true reflection of increased complications. the association between preoperative endoscopic esophagitis and post operative gerd in sleeve gastrectomy patients samer elkassem, md; medicine hat regional hospital introduction: gerd is a common complication after sleeve gastrectomy (sg). the purpose of this study is assess the relationship between pre-operative findings of endoscopic esophagitis and postoperative gerd in sg patients. the hypothesis of this study is that patients with pre-op esophagitis are more likely to have gerd post-op than patients with no esophagitis pre-op. methods: a retrospective review of sg patients who had pre-operative endoscopy and followed prospectively for at least one year was preformed. patients were divided into two groups based on pre-op endoscopic findings: those with no findings of esophagitis (ne), and those with endoscopic esophagitis, including barretts (ee). patients were followed for at least one year, and assessed for usage of a proton pump inhibitor (ppi) usage. the two groups were compared using both student t-test and chi square test. results: a total of patients did not have any findings of esophagitis on pre-op endoscopy (ne group), and patients had findings of endoscopic esophigitis (ee). there was no difference in preoperative demographics and post-op weight loss at one year (table i) . follow-up ranged from one to years post-op. the dependency on ppi usage and de novo reflux are shown in table ii . introduction: patients with "super-super obesity", defined as a bmi≥ , are at higher risk of weight-related health problems and might benefit more than others from metabolic and bariatric surgery. however, these benefits need to be weighed against the potential for increased operative and perioperative risks. accurate data regarding these patients is critical to guide procedure choice and informed, shared decision-making. the metabolic and bariatric surgery accreditation and quality improvement program (mbsa-qip) is a national accreditation and quality improvement program, which captures clinically-rich specialty-specific data for the majority of all bariatric operations in the united states. this is the first analysis of the mbsaqip participant use file (puf) focusing on this at-risk subpopulation. introduction: sleeve gastrectomy represents one of the most common surgical procedure used in bariatric surgery. the most feared complication following laparoscopic sleeve gastrectomy is the leak that occurs at the staple line. one method to reduce the risk of leak is the use of reinforcement material at the suture line. in this study, the efficacy of sutures and fibrin glue in the prevention of staple leak has been compared retrospectively. materials and methods: a total of patients undergoing lsg between october and august at the medical faculty of firat university were retrospectively assessed using the hospital database system records. results: there were males ( %) and ( %) females, with a mean age of years (range: - y), and body mass index of kg/m . while no reinforcement material was used in patients ( %) at the suture line, reinforcement sutures or fibrin glue were used in ( %) and ( %) patients, respectively. postoperative leak occurred in patients ( . %), and ( . %) of these had no use of reinforcment material for leak prevention, while additional sutures or fibrin glue had been used in patients, one in each group ( . %). one patient died due to leak and the consequent development of sepsis ( . %). discussion: lsg is increasingly more frequently used in bariatric surgery practice. however, an increase also occurs in the rate of complications. a discrepancy exists in the published literature regarding the benefit of reinforcment the suture line on the risk of leak risk. in our patient series, patients without the use of additional material in the staple line had a significantly increased risk of leak. conclusion: despite some controversy, strong evidence exists on the effectiveness of fibrin glue in the prevention of leaks in patients undergoing laparoscopic sleeve gastrectomy. background: laparoscopic bariatric surgery has been performed safely since . in a persistent search for fewer and smaller scars, single port and acuscopic surgery or even notes have been implemented. the goal of this study is to analyze the safety and feasibility of using a low cost incisionless liver retraction compared to a standard laparoscopic retractor for sleeve gastrectomy. methods and procedures: candidates for sleeve gastrectomy that fulfilled nih criteria for bariatric surgery were selected. those younger than and/or with prior upper-left quadrant surgery were excluded. all patients signed written consent. patients were randomized : to either a standard port technique with a fan-type liver retractor through a mm port (group a); or a port technique with the liver retracted by a polypropylene suture passed through the right crura and retrieved at the epigastrium with the use of a fascia closure needle (group b). all surgeries were performed by the same surgeon. surgery length from insertion of first port to withdrawal of the last was the primary endpoint. anthropometric data, % of pre-surgical total weight loss (%ptwl), visualization of the surgical field, complications inherent to liver retraction and postoperative morbidity were recorded. background: comprehensive web and hospital based preparative patient education allow the morbidly obese patients to understand weight loss surgery, its benefits, the necessity of follow up and the risk of weight regain. while the inhouse seminars provide a face-to-face interaction with the bariatric program staff, the online seminars are easily accessible and more cost effective. the primary objective of this study is to compare demographics and weight loss surgery outcomes between patients who participated in the online vs in-house preparative seminars. methods: after obtaining institutional review board approval, a retrospective chart review was performed involving patients who underwent bariatric surgery between january and december at a tertiary care center. the patients were divided into two groups based on their choice of educational seminar, online or in-house, prior to their initial consult with a surgeon. data was collected on age, type of insurance, length of stay (los), longest follow up and change in bmi to assess weight loss. results: one hundred and eighteen patients were included in this study. eighty patients attended in-house seminar while completed online seminar. the various types of surgery (laparoscopic gastric bypass, sleeve gastrectomy, and band) were similarly represented between the two groups. there was no difference in the type of insurance policy between the groups. patients who elected to take the in-house seminar were on average years older than those who chose the online course, which was statistically significant (p. ). there were no differences in los, longest follow up after surgery, and weight loss at months between the groups. conclusions: based on mbsaqip registry data, patients age or over did not have higher odds of a -day readmission compared to younger patients after lsg or lrygb. rates of -day readmission, reoperation, and death were similar, but rates of complications (e.g. pneumonias, unplanned intubations) were higher in the older group. bariatric surgery in the elderly should therefore be performed only after careful and patient-centered selection processes. introduction: revisional bariatric surgery has become more common in recent years. it is to address short and long-term complications of primary bariatric surgery as well as the issue of weight regain. the aim of this study was to retrospectively analyze the indications for reoperation and short-term outcomes in our institution. methods and procedures: between and , patients who underwent bariatric surgery in our center were included in a prospectively collected database. demographic data, primary and revisional bariatric procedures, reasons for revisions and outcomes were recorded and reviewed retrospectively. results: a total of patients underwent bariatric surgery at our institution and % of these (n= ) were revisional bariatric surgery. we identified groups of patients according to their primary procedures: adjustable gastric band (agb), roux-en-y gastric bypass (rygbp), vertical band gastroplasty (vbg), and sleeve gastrectomy (sg). of the patients, ( %) had abg as primary procedure. of those, % had their band removed due to food intolerance and severe dysphagia and % had a conversion to either rygbp or sleeve gastrectomy (sg) due to weight recidivism. in the rygpbp group (n= ), % of the patients presented with late complications. of these, % had an acute presentation (small bowel obstruction, internal hernia, or perforated marginal ulcer) requiring emergency surgery. only % patients needed gastric bypass takedown due to severe hypoglycemia. weight recidivism was noted in % of the patients that necessitated either revising the anastomosis, trimming of the gastric pouch or gastrogastric fistula takedown. in the vbg group (n= ), % of the patients experienced weight recidivism that required conversion to rygb and % of the patients required the vbg to be taken down due to obstructive symptoms. in the sg group (n= ), % of the patients experienced early complications needing a second procedure. weight recidivism was found as the most common reason for conversion ( %) to rygbp. twenty nine percent of the patients in this group underwent conversion to a rygbp due to severe de novo gerd. introduction: our aim was to systematically review the literature to compare weight loss outcomes and safety of secondary surgery after sleeve gastrectomy (sg), particularly between roux-en-y gastric bypass (rygb) and biliopancreatic diversion with duodenal switch (bpd-ds). sg was originally developed as the first part of a two-stage procedure for bpd-ds. however, it is now the most common standalone bariatric surgery performed in the united states. the majority of sg are done as the sole bariatric operation but in %, a second operation is necessary, due to insufficient weight loss, weight regain or reflux. the most common second-stage operations are rygb at % and bpd-ds at %. there are a few small case series comparing rygb to bpd-ds as a secondary surgery after sg. these studies suggest that after failed sg, bpd-ds results in greater weight loss but higher early complication rates than rygb. we had one mortality, related in part to supra-therapeutic anticoagulation perioperatively. one patient underwent successful heart transplantation and additional patients were reactivated on the transplant list. conclusion: laparoscopic sleeve gastrectomy is effective in advanced heart failure patients for meaningful weight loss, reactivation to the transplant wait list, and ultimately cardiac transplantation. however, this complex population carries a high perioperative risk and close multidisciplinary collaboration is required. more data is needed to best optimize perioperative management of these patients. the introduction: bariatric surgery is a highly effective treatment for severe obesity. while its effect on improvement of the metabolic syndrome is well described, its effect on intrinsic bone fragility and fracture propagation is unclear. therefore, the aims of this systematic review of the literature were to examine ( ) the incidence of fracture following bariatric surgery, ( ) the association of fracture with the specific bariatric surgical procedure ( ) conclusion: it appears that the overall risk of sustaining a fracture of any type after undergoing bariatric surgery is approximately percent after an average follow up of . years. the greatest risk of fractures is associated with the bpd, with the rygb being the most favorable. fractures following bariatric surgeries tend to follow osteoporotic and fragility patterns. post-operative supplementation of vitamin d, calcium and weight bearing exercises need to be optimized, and long term follow-up studies will be needed to confirm that these interventions will indeed reduce fracture risk following bariatric surgery. background: the effect of sleeve gastrectomy on gastroesophageal reflux (gerd) remains controversial. it is currently common practice to perform a hiatal hernia repair (hhr) at the time of the sleeve gastrectomy, however, there are few data on the outcomes of gerd symptoms in these patients. the aim of this study was to evaluate the effect of performing an esophagopexy hiatal hernia repair on gerd symptoms in morbidly obese patients undergoing robotic sleeve gastrectomy (rsg). methods: a single institution, single surgeon, prospectively maintained database was used to identify patients who underwent rsg and concomitant esophagopexy for hiatal hernia repair from november to july . patient characteristics, operative details and postoperative outcomes were analyzed. primary endpoint was subjective gerd symptoms and recurrence of hiatal hernia. results: thirty-seven patients were identified meeting the inclusion criteria (rsg+hhr+esophagopexy) with a mean follow-up of . over the past years there have been several bariatric surgeries cancelled secondarily to abnormal pre-operative test results within eastern health. these surgeries are often cancelled the day before their scheduled surgery, which does not provide sufficient time to book other patients. the end result is that the or gets underutilized and the bariatric surgery waitlist grows. prior to any major surgery patients are often subjected to a routine screening process, which includes a history and physical along with diagnostic screening tests and screening blood work. a preliminary analysis was done of the first patients through the bariatric surgery program at eastern health assessing the coagulation study results and outcomes. analysis showed that out of the first patients % were found to have a history of bleeding, % were using anticoagulants preoperatively, another % were noted to have a family history of bleeding. in the preoperative blood work that was done, % were found to have an elevated ptt/ inr for which hematology ended up being consulted in % of the patients. overall this did not change the preoperative management of these patients and they went on to have their surgery. intraoperatively patient was noted to have excessive bleeding and this was found not be associated with any preoperative elevation in their coagulation studies or family history of bleeding disorders. post operatively there was bleeding in patient which required transfusion, however this too was found not to be associated with any preoperative elevation in their coagulation studies or family history of bleeding disorders. overall this initial analysis showed no difference in operative management or delay in surgery secondarily to abnormal preoperative assessment findings. further analysis of a larger population of the bariatric surgery program patients is needed in order to determine whether any changes should be made to the preoperative assessment protocol. introduction: patients undergoing bariatric surgery frequently present with various obesity-related psychiatric comorbidities, including depression. furthermore, previous literature has demonstrated a positive association between depression and cardiovascular disease, and obesity serves as an independent risk factor for cardiovascular disease. however, the relationship between preoperative depression and cardio-metabolic risk factors following bariatric surgery remains unknown. methods and procedures: this retrospective analysis utilized data obtained from patients (n= , ) who underwent bariatric surgery at a single academic medical center in california. patients underwent either laparoscopic roux-en-y gastric bypass or sleeve gastrectomy. using medical record data, patients were preoperatively categorized as follows: not depressed, history of depression but not currently on anti-depressive medication, and history of depression and presently taking anti-depressive medication. patient demographic characteristics were obtained preoperatively. clinical and biochemical risk factors for cardiovascular disease were evaluated preoperatively and and months following bariatric surgery. anova, kruskal-wallis, and chisquare tests were applied where appropriate. results: in this sample, % of patients were not depressed, % had a history of depression but were not taking anti-depressive medication preoperatively, and % had a history of depression and were taking anti-depressive medication preoperatively. at baseline, depressive history was positively associated with female sex (p\. ), older age (p\. ), white race (p\. ), medicare insurance (p\. ), previous abdominal surgery (p\. ), length of stay (p\. ), requiring an inferior vena cava filter (p=. ), total cholesterol (p\. ), and triglycerides (p =. ). on average, patients with a history of depression taking anti-depressive medication weighed less than patients with a history of depression not on medication and patients without depression preoperatively (p=. ) and (p=. ) and (p=. ) months after surgery. after six months of follow-up, preoperative depressive history was positively associated with total cholesterol (p=. ), triglycerides (p\. ), hba c (p=. ), and fasting serum concentrations of insulin (p=. ). after months of follow-up, preoperative depressive history was positively associated with higher levels of total cholesterol (p=. ), ldl cholesterol (p=. ), and triglycerides (p= . ). conclusion: a history of depression prior to surgery was associated with higher levels of total cholesterol and triglycerides at baseline and and months postoperatively. after months, preoperative depressive history was also associated with higher levels of ldl cholesterol. this study suggests that, on average, bariatric patients with comorbid depression have worse lipid profiles prior to-and up to one year after-bariatric surgery relative to counterparts without depression. yen-yi juo, md, mph, yas sanaiha, md, erik dutson, md, yijun chen, md; ucla introduction: anastomotic leak is one of the most morbid complications of roux-en-y gastric bypass (rygb), yet its risk factors are ill-defined due to the rarity of the complication. we aim to identify both patient-and operative-level risk factors for anastomotic leak after rygb using a national clinical database. methods: a retrospective cohort study was performed using the metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip) database. all adult patients who underwent laparoscopic or open rygb were included. multivariate logistic regression models were used to identify patient-and operative-level variables associated with development of anastomotic leakage. clinically relevant anastomotic leakage is defined as those that required readmission, intervention, or reoperation. introduction: hyperammonemia secondary to ornithine transcarbamylase (otc) deficiency is a rare and potentially lethal disorder. the prevalence of otc deficiency is reported to be : , to : , in the general population. otc deficiency has been reported in patients presenting with neurological symptoms after roux-en-y gastric bypass (rygb), and less than cases have been reported in the literature. the aims of this study are to examine the apparent incidence of this uncommon disorder in patients after bariatric surgery and to examine potential predictors of mortality. methods and procedures: this is a single center, retrospective study in a large, urban teaching hospital of postbariatric surgery patients who developed hyperammonemia from january to august . elevated plasma ammonia with an elevated urinary orotic acid level is accepted as consistent with a diagnosis of otc deficiency. all patients in our program are instructed on a post-operative diet containing grams/day of protein. descriptive and correlative statistics are calculated for all variables. results: between january and august , bariatric surgical procedures were performed at this single medical center. seven women with neurological symptoms had plasma ammonia levels above the upper limit of normal range. their average bmi is kg/m . two patients underwent vertical sleeve gastrectomy (vsg), underwent vsg with duodenal switch, and underwent rygb. all patients were hospitalized. the mean peak plasma ammonia level is umol/l (range: - ). the mean urinary orotic acid level is . mmol/mol creatinine (range: . - . ). there were patients with no orotic acid level checked, secondary to demise. no patient had clinical features or findings of progressive hepatic failure. there are four mortalities ( . %). serum folate and peak lactic acid levels are predictors of mortality with p-values of . and . respectively. the apparent incidence of otc deficiency is : in post-operative patients. conclusions: in our post-operative population, hyperammonemia results in a high mortality. its apparent incidence, secondary to otc deficiency, amongst bariatric surgery patients is higher than that reported in the general population. since otc deficiency is identified after multiple bariatric surgical procedures, further investigation will be important to examine potential mechanisms for its development which may include a genetic predisposition (possibly triggered by nutritional deficiencies), upper gut bacterial overgrowth (supported by elevated serum folate levels), or preexisting, subclinical hepatic dysfunction. introduction: the use of closed suction drains is associated with poor outcomes in many anastomotic operations and routine use is not recommended. in this context, intraoperative drain placement for primary bariatric surgery remains controversial. recent studies demonstrate that drains confer no benefit to patients; however, data are limited to descriptive single center experiences with low sample size. in order to characterize this practice gap, and implement evidence based recommendations, we sought to evaluate the use of closed suction drain and outcomes following primary bariatric cases using the mbsaqip registry. methods: we used data from the metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip) public use file for patients who underwent a non-revisional laparoscopic roux-en-y gastric bypass (rygb), laparoscopic sleeve gastrectomy (lsg), or laparoscopic adjustable gastric banding (lagb). we excluded patients with asa status greater than or conversion to an open procedure. we analyzed demographics, preoperative comorbidities, procedure type for patients who did and did not undergo drain placement. adjusted rates of postoperative complications and mortality were then compared based on receipt of postoperative drain placement. results: of the , included patients who underwent laparoscopic bariatric surgery, , ( . %) underwent intraoperative drain placement. drains were more often placed in patients who underwent lrygb, were older, had higher preoperative bmi, had higher preoperative asa status, and had more comorbid conditions. after patient level risk adjustment, there was no difference in rates of leaks requiring intervention ( . % versus . %, p= . ) or mortality ( . % versus . %, p= . ) for patients with and without drains. in patients who underwent drain placement, there were higher rates of transfusion ( . % versus . %, p. ), reoperations for bleeding ( . % versus . %, p= . ), all reoperations ( . % versus . %, p. ), and surgical site infections (ssi) ( . % versus . %, p. ). conclusion: our analysis demonstrates that nearly one quarter of all laparoscopic bariatric surgery patients undergo drain placement. we found that drain placement is more common in preoperatively higher risk patients and following higher complexity procedures as suggested by associated increased rates of transfusion and reoperations for bleeding. we found no benefit to drain placement in terms of interventions for clinically significant leaks or mortality. finally, patients who underwent drain placement were more likely to develop ssi suggesting routine placement is not without risk. although further prospective studies are warranted, our analysis demonstrates that drains have the potential for harm with minimal protective benefit for patients after primary bariatric surgery. sleeve gastrectomy ( % n= ) and laparoscopic roux-en-y gastric bypass ( % n= ) were the two types of surgeries done in our population. the risk of developing atrial fibrillation was calculated preoperatively and found a -fold higher risk in females and -fold greater risk in males when compared with the ideal risk for each category. at months follow-up the preoperative risk was . ± . % with an absolute risk reduction of . % corresponding to a relative risk reduction of . % with males having a more significant change at months follow-up. these findings and the electrocardiographic changes at months follow-up are better described in background: the sleeve gastrectomy (lsg) is the most popular procedure worldwide to treat obesity. among those that are obese, gerd has a prevalence of . percent. many surgeons do not perform lsg in these patients because only . percent of symptomatic patients showed resolution of gerd-like symptoms after concomitant sleeve gastrectomy with hiatal hernia repair. many surgeons perform the gastric bypass on gerd patients with hiatal hernias because they believe its superior for the resolution of gerd. when they do this they overlook the many long term complication associated with gastric bypass. also, many patients do not want the gastric bypass under any circumstances. surgeons need to be open to finding better way to reduce the high recurrent rates of gerd after lsg. materials and methods: this is a single institution, multi-surgeon, retrospective study involving morbidly obese patients in a prospectively kept data base from january of through july of . these patients all had gerd with preoperatively identified hiatal hernias on egd. all patients were dependent on anti-reflux medications. there were ( . %) males and ( . %) females. bmi ranged from to . hiatal hernias measured from cm to cm. all lsg patients received a primary crural closure, with or without gore bio a mesh placement, at least weeks prior to the sleeve gastrectomy. post-operatively, patients were interviewed for gerd symptomatology and anti-reflux medication dependency. results: of the patients, ( . %) patients had resolution of gerd-like symptoms and off all anti-reflux medications after the staged hiatal hernia repair and sleeve gastrectomy. patients ( . %) had improvement of gerd but still dependent on anti-reflux medication. patients ( . %) had no resolution or improvement of gerd. there was one post-operative complication of laryngospasm with pulmonary edema status post extubation. there were no mortalities in the series. conclusions: in this study, staged hiatal hernia repair, at least weeks prior to sleeve gastrectomy, doubled the published rate of gerd resolution from % to %. % showed improvement in symptoms at one year. this rate is comparable to gerd resolution after gastric bypass. this may be an alternative approach to hiatal hernias in the morbidly obese patient with gastroesophageal reflux disease who do not want a gastric bypass. background: bariatric surgery is a common procedure in general surgery. gastric bypass has been performed laparoscopically for over two decades and multiple techniques are described. the circular stapled anastomosis, one of the earliest methods for gastrojejunostomy, is performed in two ways: a transoral method to introduce the anvil and a transabdominal approach developed later. the former technique requires passing the anvil of the circular stapler through the mouth, down the esophagus, and into the gastric pouch. in the latter method, a gastrotomy is made, the anvil is introduced, and the gastrotomy is stapled off, creating the gastric pouch. this study aims to objectively compare the two methods of circular stapled gastrojejunostomy in terms of surgical site infection (ssi) rate. methods: a retrospective chart review of patients undergoing laparoscopic roux-en-y gastric bypass with one of two surgeons at a bariatric center of excellence in an academic hospital from january introduction: laparoscopic sleeve gastrectomy (lsg) has become the most commonly performed procedure in the treatment of morbid obesity, but there is significant variability in its performance. from national database analysis, more restrictive sleeve construction, based on smaller bougie size, has not correlated with greater weight loss. we hypothesize that bougie size is not reflective of actual restriction, or that sleeve restriction does not correlate with weight loss. we performed qualitative and volumetric analysis of immediate post-sleeve contrast studies to determine the association of sleeve restriction with post-operative weight loss and complications. methods: between and , patients underwent immediate post-sleeve contrast studies. based on standardized vertebral body height assessment by preoperative chest radiograph, sleeve diameter at intervals (including the narrowest point) was measured in mm, and the volume above the narrowest point of the sleeve was calculated. sleeve shape was assumed as dual-tiered or simple truncated cone based on morphology. sleeve restriction, morphology and volumetric analysis were associated with clinical outcomes including complications, post-op symptoms, and weight loss at months. background: variability in surgical technique resulting in narrowing at the incisura angularis, twisting along the staple line, and retention of the gastric fundus has been implicated in increased gastroesophageal reflux disease (gerd) following laparoscopic sleeve gastrectomy (lsg). standardizing creation of the sleeve based on anatomic landmarks may help produce more consistent sleeve anatomy and improve outcomes. methods: a retrospective review of all patients undergoing lsg from january to november at a single institution specializing in bariatric surgery was performed (n= ). patients underwent either traditional lsg with use of a f suction bougie to guide creation of the sleeve (n = ) or anatomy-based sleeve gastrectomy (abs, n= ). abs was performed using a gastric clamp to maintain predetermined distances from key landmarks ( cm from gastroesophageal junction, cm from incisura angularis, cm from pylorus) during stapling. patient demographics, perioperative characteristics, and post-operative outcomes were compared using chi-square and student's t-tests as required. helicobacter pylori (hp) is prevalent in up to % of the population worldwide with increased rates observed in the bariatric population. bariatric surgery has seen a rapid expansion over the last years with the growing rates of severe obesity. higher hp rates are thought to be associated with increased rates of postoperative complications including increased marginal ulceration and leak rates. accordingly, some bariatric centers have adopted routine pre-operative screening and hp eradication programs. yet, while hp correlation with gastritis and malignancy has now been well defined, its impact on patients undergoing bariatric surgery remains unclear. background: the risk of developing a hiatal hernia in the obese population is . fold compared to patients with a bmi \ . most hiatal hernias after bariatric surgery are asymptomatic and when symptoms are present they may be difficult to differentiate from overeating or maladaptive eating habits. the aim of this study was to define the risk and symptoms associated with a hiatal hernia in the post-bariatric surgery cohort. methods: a retrospective review of prospectively collected data for patients who underwent laparoscopic hiatal hernia repair who previously had primary roux-en-y gastric bypass (rygb) or sleeve gastrectomy (sg). data collection spanned a five-year interval ( / - / ). preoperative and follow up data were collected from medical records and questionnaires in the clinic or by telephone. variables obtained include age, gender, psychiatric history, pre-index procedure bmi, pre-hiatal hernia repair bmi, post-hernia repair bmi, pre and post operative symptoms, and associated morbidity. all hiatal hernia repairs were done laparoscopically, with posterior cruroplasty after circumferential hiatal dissection. results: we identified patients with a symptomatic hiatal hernia who had previously (range: - years) underwent bariatric surgery. fourteen rygb patients presented at a mean of . years compared to sg patients who presented at a mean of . years after index procedure. diagnosis was by a combination of ugi ( %), ct scan ( %) and egd ( %). mean follow up was . months (range: - months). laparoscopic hiatal hernia repair was successfully performed in all patients with % mortality. dysphagia and regurgitative symptoms markedly improved in [ % of patients however, nausea, vomiting and abdominal pain were not changed in - % of patients ( figure) . conclusion: hiatal hernia following bariatric surgery is a rare but important cause of bloating manifested as nausea and vomiting, abdominal pain, regurgitation or reflux, and food intolerance or dysphagia (barf)-and should be further evaluated with imaging or endoscopy when present. laparoscopic repair of hiatal hernia is warranted and results in resolution of symptoms in the majority of symptomatic patients. mid-term outcomes of sleeve introduction: obese patients suffer from multiple organ comorbidities which contribute to a shortened lifespan. one of the effects of obesity is thought to be pseudotumor cerebri, which is secondary to increase in intracranial pressure (icp) in the absence of an obstruction. over the past two years, we have measured icp after insufflating with a laparoscopy device. we found that icp increases dramatically and it correlates with the amount of insufflation in the abdomen. over the years, there have been studies in obese patients and intra-abdominal pressure. these studies have shown that some obese patients have an intra-abdominal pressure of - mmhg. increasing intraabdominal pressure is thought to escalate intracranial pressure (icp). the objective of this pilot study was to observed change in icp after the raising intra-abdominal pressure. method: in this retrospective chart review preliminary study, pressure in each of the patients either normal pressure hydrocephalous or high pressure hydrocephalous receiving a ventricle shunt were measured by manometer. once the shunt was placed into the ventricle, we attached a manometer to measure the opening pressure. after we accessed the abdominal cavity using the standardoptiview technique, we created a pneumoperitoneum. after achieving an intraabominal pressure of mmhg, were measured the icp using the manometer. spss software version was used for data analysis. paired t-test was applied on icp before and after the procedure. introduction: postoperative bleeding represents an infrequent, yet serious complication after bariatric surgery. differences in the rate of postoperative bleeding reported for the two most common weight loss procedures-laparoscopic roux-en-y gastric bypass (lrygb) and laparoscopic sleeve gastrectomy (lsg)-are ostensibly confounded by patient and surgeon specific preoperative, intraoperative and postoperative factors, in particular, by the utilization of staple line reinforcement or oversewing. with this understanding, we aim to use a large national database to definitively characterize differences in bleeding rates between lsg and lrygb. conclusions: after appropriate risk-matching, lsg patients have a reduced likelihood of a postoperative bleeding event compared to those undergoing lrygb. this difference is likely more pronounced with intraoperative securing of the staple line via oversew, buttress or an alternative method. these findings from a large national database represent an important consideration for surgeons and patients alike when evaluating the appropriate bariatric operation. background: bariatric surgery has shown to be the most effective treatment, with documented improvement in obesity-related comorbidities. the type of health insurance coverage plays an important role in the access to bariatric surgery, but might also affect postoperative outcomes. the objective of this study is to determine whether there is a difference in outcomes based on the type of insurance months after bariatric surgery. methods: we retrospectively reviewed all the patients that underwent bariatric surgery at our institution from to . we divided the patients into two groups, based on the type of insurance, private (group one), and public (group two). we compared demographics and months outcomes between the groups, using t-test for continuous variables and chi-square for categorical variables. we also compared months estimated bmi loss between different private insurances using anova. introduction: bariatric surgeons are now performing primary and revisional procedures on the extremes of age. there is controversy surrounding the safety and effectiveness of bariatric surgery among older age groups compared to younger age groups. to address this knowledge gap, we designed a study assessing short-term bariatric surgery outcomes among various age groupings across a large national database. methods and procedures: de-identified patient data across from the mbsaqip registry was used. age groupings were organized into young, middle-aged, and older adults (in years) as follows: \ , - , and [ , respectively. the following -day outcomes were evaluated between all possible pairwise age groupings: mortality, surgical site infection (ssi), and readmission; logistic regression was used to compare outcomes between age groupings controlling for primary vs. revisional index operation, patient factors, and procedure factors. a p value of . was deemed statistically significant. results: a total of , patients were identified (age range: to [ ); % (n= , ) underwent primary bariatric operations while % (n= , ) underwent revisional cases. older adults had significantly worse outcomes than middle-aged and younger adults, respectively, for over comparisons across all outcomes; in contrast, younger adults had significantly worse outcomes than middle-aged adults for only comparisons across ssi and readmission. for primary bariatric cases, older adults had significantly higher mortality rates than middle-aged and younger adults, respectively, in the following categories: asa , laparoscopic sleeve gastrectomy (lsg), or laparoscopic roux-en-y gastric bypass (lrygb). for revisional cases, older adults had significantly higher mortality rates than middle-aged and younger adults, respectively, in the setting of female gender, caucasian race, or asa . regarding ssi, older adults undergoing primary lrygb had significantly higher organ space infections compared to younger adults. in addition, older adults who had revisional lrygb had significantly higher deep surgical site infections compared to middle-aged adults. following primary bariatric cases, older adults had significantly higher readmission rates compared to younger adults in the presence of male gender, caucasian race, asa , copd, or after lsg. following revisional cases, older adults had significantly higher readmission rates than middle-aged and younger adults, respectively, in the setting of pre-operative chronic steroid use. conclusions: overall, older adults had worse short-term outcomes compared to their younger counterparts following primary and revisional cases. further research is required to investigate these findings with the goal of targeting interventions to improve outcomes among bariatric surgical patients. background: the obesity epidemic in the united states has been accompanied by surge in bariatric surgery. nearly , bariatric procedures were performed in the us in , % of which involved roux-en-y gastric bypass (rnygb). while rnygb has proven an effective tool in combating obesity, it also alters a patient's anatomy in a way that makes traditional ercp a difficult, if not impossible option for interrogating the common bile duct. one way to approach the post-rnygb patient with obstructive jaundice is to access the peritoneal cavity via a laparoscopic/ robotic approach followed by direct cannulation of the gastric remnant with a laparoscopic port, allowing passage of an endoscope. the aim of this study was to evaluate our single center experience with minimally-invasive transgastric ercp (tg-ercp) from to . methods: we compiled a list of all patients who underwent laparoscopically or robotically assisted tg-ercp at our institution from - . we then examined patient demographics, procedural details, postoperative outcomes, and success rate, with success defined as cannulation of the ampulla, clearance of obstruction if present (stones/sludge/stenotic ampulla), and completion imaging of the biliary and pancreatic ducts. results: patients were included in the study. cases were performed robotically ( %), and laparoscopically ( %). ercp was successful in cases ( %). all unsuccessful attempts were aborted when the endoscopist was unable to pass the scope through a tight pylorus. median time of operation was minutes ( minutes if concomitant cholecystectomy was performed, minutes if not). median length of stay after operation was days (range - days). median estimated blood loss (ebl) was ml. post ercp pancreatitis occurred in patients ( . %), and was mild and self limited in all cases. patients had postoperative bleeding requiring transfusion. both of these had concomitant cholecystectomy. discussion: in patients with biliary obstruction and anatomy not suitable for traditional ercp, tg-ercp is a viable option. it can be performed with in a minimally invasive fashion (either laparoscopically or robotically) with a high success rate and low morbidity. as the population of patients who have undergone rnygb continues to grow, so does the likelihood of encountering one with obstructive jaundice. tg-ercp, therefore, should be thought of as an essential tool in the armamentarium of the general surgeon. introduction: primary palmar hyperhidrosis (ph) is a pathological condition of over perspiration caused by body produces an excessive amount of sweat. this disorder affects to decrease quality of life of patients. thoracoscopic sympathectomy is minimally invasive and an effective procedure to treat hyperhidrosis. different of level of sympathectomy has been debate for the best outcomes. many researchers studied about short term outcomes but no empirical research evidences long term outcomes of thoracoscopic sympathectomy in thailand. this study purposed to evaluate and compare the long term clinical outcomes between patients who underwent t and t thoracoscopic sympathectomy for ph with particular attention to patient satisfaction and quality of life. methods and procedures: sixty patients with ph underwent thoracoscopic sympathectomy. patients were divided into two groups by the level of thoracoscopic sympathectomy as t group and t group. they were investigated the improvement of sweating, compensatory sweating, satisfaction and quality of life. the long-term investigation was designed to examine clinical outcomes at before surgery, six months after surgery, year after surgery, years after surgery, and last follow up days were compared within group and between of t and t group. they were subjected to telephone interview using multiple questionnaires to investigate surgery outcomes, degree of satisfaction, and quality of life improvement. results: sixty patients responded to the telephone interview. patients demographic data and also recurrence rate of ph between t and t group was not significant different (p= . ). both groups improved severity of sweating without any statistical significant. but the t thoracoscopic sympathectomy led to significantly lower incidence of compensatory hyperhidrosis when compared with t group at back and trunk sites. the t group had higher overall satisfaction than t group with was not significantly different. long term result are followed after years. conclusions: there was no difference in decreasing severity of sweating between t and t level of thoracoscopic sympathectomy. both group equally archived patient satisfaction. but the t level of thoracoscopic significantly had lower severity of ch and better quality of life in long term period. introduction: acute pancreatitis due trauma is commonest cause of pseudocyst in pediatric age. due to limited literature available and under diagnosis by pediatricians, the true incidence of pseudocyst in - age group is not known. material and methods: retrospective analysis of pediatric age ( - years) patients who underwent laparoscopic cystogastrostomy at distric teaching hospital was done. patients data, presentation, investigations, opetation done and post operative course was studied. result: total of patients ( males & females) had mean age of . years, mean weight of kg. etiollogies included blunt abdominal trauma ( ), idiopathic ( ), gallstones ( ) . average cyst diameter was . cm. laparoscopic cystogastrostomy by transgastric approach was successfully possible in cases with no conversion. cystogastrostomy was performed using sutures in patients and ultrasonic energy device in patients. gastrotomy was closed with sutures in all cases. mean operative time was minutes. post operative imaging at months revealed no persistence or recurrence of cyst. conclusion: minimally invasive laparoscopic approach for chronic pancreatic pseudocyst in pediatric age group is safe and effective strategy and should be adopted as primary modality of treatment. introduction: videoscopic neck surgery is developing despite the fact that only potential spaces exist in the neck. gagner first described the endoscopic subtotal parathyroidectomy with constant co gas insufflations for hyperparathyroidism in . the cervical approach utilizes small incisions in the neck thus making it cosmetically unacceptable and cannot be used for lesions greater than cm. the axillary approach makes it difficult to visualize the opposite lobe. the anterior chest wall approach utilizes port access at various positions on the anterior chest wall depending on the surgeon. this technique also allows bilateral neck exploration. hence we have been able to perform total thyroidectomies with central compartment clearance for papillary carcinoma and near-total thyroidectomies for large multinodular goiters, materials and methods: three incisions subplatysmal plane pneumoinsufflation with carbon dioxide (co ) ports creating a subplatysmal palne dissection begins at the inferior pole posterior dissection clipping superior thyroid vessels specimen freed up thyroid lobectomy was performed in the twenty cases. the average blood loss was ml mean operative time was min there were no complications and no cases were converted to open. there were no cases of recurrent laryngeal nerve injury or postoperative tetany. no subcutaneous emphysema, ecchymosis or hypercarbia was observed in any patient. all patients were discharged on the second postoperative day except the first on the fifth day. in conclusion this approach seems to be safe in case of unilateral lobectomy but early to say it is superior to conventional thyroidectomy especially in total thyroidectomy. introduction: laparoscopic sleeve gastrectomy (lsg) is one of the most commonly performed weight loss surgeries. prolonged hospital admissions are associated with both increased morbidity and mortality and increased strain on the health care system; studies are now investigating the safety and feasibility of outpatient lsg. this study examined a single surgeon's postoperative admission trends for patients who underwent lsg. the patients were divided into two cohorts based on the date of surgery, and we hypothesize institutional experience has a significant impact on postoperative stay and hospital readmission rate. methods: this is a retrospective study on lsgs performed by a single surgeon in a tertiary center from - . inclusion criteria: patients [ years old, bmi [ with comorbidities or bmi [ , and patient approval by the bariatric surgical program in victoria, british columbia. patients with prior weight-loss surgery were excluded. patients were discharged home on a care plan involving: nurse and surgeon telephone follow-ups within one week post-surgery. patients were divided into two cohorts: cohort a (procedures between - inclusive) and cohort b (procedures between - inclusive). results: patients were included in this study: females ( . %) and males ( . %). the mean preoperative age was . ± . years, and the mean preoperative bmi was . ± . kg/m . the average postoperative discharge day for the population was day . ± . and the average or time was . ± . minutes. one patient in cohort b was re-admitted pod with a diagnosis of postoperative edema managed conservatively and is included in the analysis as pod . a second patient in cohort b returned to hospital (pod ) for abdominal pain and was managed conservatively as outpatient. conclusion: there was a significant difference in the average postoperative discharge day between patients in cohort a and cohort b who underwent lsg with patients in cohort b requiring a shorter average admission time. this study suggests that with increasing institutional experience and a postoperative discharge plan, patients undergoing lsg may be discharged on postoperative day one safely. surg endosc ( ) introduction: minimally invasive techniques have revolutionized the art of the surgical practice. the laparoscopic approach to cholecystectomy has become the gold standard and is the most common laparoscopic general surgery procedure worldwide. in an effort to further enhance the advantages of laparoscopic surgery, even less invasive methods have been attempted, including smaller and fewer incisions. the objective of this study was describing our results of years of needlescopic cholecystectomy. methods: since march all patients that underwent to needlescopic cholecystectomy micro-laparoscopic procedure with instruments of mm were included in this study in a prospective database and the information was analyzed. results: between march and september , needlescopic cholecystectomies have been done at texas endosurgery institute in san antonio, texas by a single surgeon. % of the patients were female. the average age was . (range of - years old). average operating time was . minutes (range of - minutes). the minute operation required laparoscopic cbd exploration, accounting for the extended time. average estimated blood loss (ebl) was cc (range of - cc). % of cases required conversion to standard mm cholecystectomy and was completed without incidents. all patients were followed up at weeks, weeks, and months after the procedure. only patient presented with a hernia at the umbilical site. otherwise no wound, bile duct, bile leak, bleeding or thermal injury complications were identified. conclusions: micro-laparoscopic procedures with mm instruments in this specific procedure of needlescopic cholecystectomy is safe and feasible, and is a cosmetic alternative to the standard laparoscopic cholecystectomy. there's still less report about thyroid cancer cases in toetva. this study reviews all cases of thyroid cancer which surgery were performed. there were cases of toetva in thyroid cancer and cases of opened thyroidectomy. objective: to review and report in terms of surgical outcome, complication, post-surgical treatment and recurrence in all cases of thyroid cancer surgery, especially in toetva technique. material and methods: from march -july in police general hospital, a total of patients underwent toetva with cases of toetva in thyroid cancer and cases of opened thyroid surgery in thyroid cancer. all patients were recorded in multiple parameters. results: this study have total of thyroid cancer cases which cases ( %) were male and cases ( %) were female, with an average age of . most clinical presentation was thyroid mass or nodule which was at cases ( . %), case ( . %) was non-toxic goiter and case ( . %) was grave disease. the clinical presentation mean time was . years ( weeks- years). there were cases ( . %) with a mass at right lobe, cases ( . %) with a mass at left lobe, and cases ( . %) with mass at both lobes. the size of thyroid mass was . ± . centimeters ( - centimeters). there were cases ( . %) had euthyroid, case ( . %) had subclinical hyperthyroid, cases ( . %) had subclinical hypothyroid, and cases ( . %) had hyperthyroid. for type of surgery, there were cases ( . %) of toetva surgery and cases ( . %) of opened total thyroidectomy. most patients at cases ( . %) didn't have any post-operative complication. and there were hypothyroid cases ( . %), transient hypocalcemia with no symptom cases ( . %), and transient hoarseness cases ( . %). after toetva surgery performed, cases ( . %) were redo completion thyroidectomy, cases ( . %) were transaxillary completion thyroidectomy, cases ( . %) were redo toetva, and case ( . %) deny for reoperation. and cases ( %) didn't have any complication after redo surgery, cases ( . %) were hypothyroid, cases ( . %) were hypocalcemia and hypoparathyroid, and case ( . %) was transient hoarseness. after did thyroidectomy, ultrasound neck shown that cases had no residual or recurrence thyroid mass, cases had residual thyroid tissue. all cases received radioactive iodine ablation. radionuclide total body scan showed no evidence of distant functioning metastasis. conclusion: three-year short-term followed up toetva in thyroid cancer has shown less complication and no recurrence cancer. objective of the study: sentinel node navigation surgery (snns) in gastric cancer has been investigated for almost two decades in an effort to reduce operative morbidity. indocyanine green (icg) with enhanced infrared visualization is one technique with increasing evidence for clinical use. we are the first to systematically review and perform metaanalysis to assess the diagnostic utility of icg and infrared electronic endoscopy (iree) or near infrared fluorescent imaging (nifi) for snns exclusively in gastric cancer. methods and procedures: a search of electronic databases medline, embase, scopus, web of science and the cochrane library using search terms "gastric/stomach" and "tumor/carcinoma/cancer/neoplasm/adenocarcinoma/malignancy" and "indocyanine green" was completed in may . all human, english language randomized control trials, non-randomized studies, and case series were evaluated. articles were selected by two independent reviewers based on the following major inclusion criteria: ( ) diagnostic accuracy study design; ( ) indocyanine green was injected at tumor site; ( ) iree or nifi was used for intraoperative visualization. the primary outcomes of interest were identification rate, sensitivity and specificity. titles or abstracts were screened after removing duplicates. the quality of all included studies was assessed using the quality assessment of diagnostic accuracy studies- . results: ten full text studies were selected for meta-analysis. a total of patients were identified with the majority of patients possessing t tumors ( . %). pooled identification rate, diagnostic odds ratio, sensitivity and specificity was . ( . - . ), . ( . - ), . ( . - . ) and . ( . - . ) respectively. the summary receiver operator characteristic for icg+iree/nifi demonstrated a test accuracy of . %. subgroup analysis found improved test performance for studies with low risk quadas- scores, studies published after and submucosal icg injection. iree had improved diagnostic odds ratio, sensitivity and identification rate compared to nifi. heterogeneity among studies ranged from low (i \ %) to high (i [ %). conclusions: the idea of snns in gastric cancer is intriguing because of the potential to limit operative morbidity. we found encouraging results regarding the accuracy, diagnostic odds ratio and specificity of the test. the sensitivity was not optimal but may be improved by a carefully planned and strict protocol to augment the technique. given the limited number and heterogeneity of studies, our results must be viewed with caution. objective: to evaluate the feasibility, cost effectiveness and safety of single incision laparoscopic surgery using routine laparoscopy instruments. method: cases of acute appendicitis and cases of symptomatic gallstone disease were included in study. cases were enrolled in study and prospective observational study was performed. ruptured appendicitis/abscess formation were excluded from study. similarly empyema gallbladder/gallbladder perforation were also excluded. results: total cases included; cases of appendicitis and cases of symptomatic cholelithiasis. mean age of appendectomy group was . ± . years and mean age of cholecystectomy group was . ± . years. in our study, mean operative time for sil appendectomy was . ± . min. post-operative fever was noted in cases ( . %). mean post-operative pain as per vas score taken after hours, on pod was . . average post op stay in hospital was . days, port site infection occurred in one case ( . %). patient satisfaction score obtained on the scale of - on one month follow up was . , while scar cosmesis score was . . in our study, cases underwent sil cholecystectomy, of which were male ( . %) and were females ( . %), and mean age of patients was . yrs. mean operative time in our study was . min, mean post-operative pain taken on pod as per vas score was . , mean post-operative hospital stay was . days, port site infections occurred in cases. post-op fever was noted in cases, post-operative patient satisfaction score obtained at month follow up was . and scar score of . on the scale of - . no case required drain placement and conversion. conclusion: sils can be performed using conventional laparoscopic instruments especially in a government setup where per capita economic burden to patient will be less. though it has more operative time, it has comparably less post-operative hospital stay, causes less pain, and has significantly more patient satisfaction regarding post-operative scar and cosmesis. since sils has more patient acceptance and satisfaction, it can be offered to all patients undergoing laparoscopic surgery. it is very useful in government setup where lower economic class of patients will also benefit, irrespective of unavailability of special instruments and financial constraints, as it can be performed using routine laparoscopic instruments. in the year we started to practice the pericardic window by laparoscopy to diagnostic of head injury hidden in precausal trauma, although lucketally for our society, this type of injury has decreased considerably, we have achieved an important number of patients and in the last year we have performed the procedure for another type of pathologies and also diversified the approach route according to the case. objective: sharing accumulated experience in years in the pericardic window practice by laparoscopy or thoracoscopy. material and methods description of cases results: during this period, we have accomplished cases of laparoscopic pericardal window with two unique ports for the diagnosis of head injury in trauma precordial, additionally there were practiced windows through traumatic trauma of which have been derived in treatment of cardiac injury on this way, without performing open approach. in another scenario, we have performed pericardial spill treatments for different causes by minimally invasive via. no complication or mortality associated with the procedure has been presented. conclusions: the pericardic window performed by a minimally invasive surgery is an effective, replicable strategy for the management of diagnosis and the medical and traumatic treatment of this pathology. patient selection is key and work in multidisciplinary groups guarantees good results. introduction: for the transabdominal preperitoneal repair (tapp) for groin hernia, single port surgery (sps) has been reported to reduce the abdominal wall damages. to reduce the length of the umbilical scar and to keep the view of triangulation, we use one needle forceps plus sps. patients and methods: from may to july , consecutive tapp patients were retrospectively investigated. there were male and female. we use two mm ports ( for the scope and for the operator's right hand forceps) through an umbilical multi-channel port and additional mm needle instrument is pierced above the pubic bone. a mm flexible scope allowed us to keep the triangular formation easily. we studied the safety and usefulness of this method from the viewpoints of operation time and the complications. results: median operation time of single side hernia ( cases) was min ( - ) and the bilateral case ( cases) was min ( - ). five cases needed one or two additional mm ports, and one case with severe preperitoneal adhesion due to the previous prostate cancer surgery was converted to open method because of the venous bleeding. other complications were spermatic cord injury and postoperative seroma that required the percutaneous puncture. umbilical scars and the pierced needle instrument scars became gradually invisible within or months. there were no incisional hernia nor wound infections in our series. these data was comparable to the conventional laparoscopic hernia repairs. conclusions: operation scars of this method had better cosmesis than the conventional tapp or sps tapp, and there were no differences between our sps-tapp with one needle foerceps and conventional method in operation time and the complication rate. our method was demonstrated as a less invasive approach for laparoscopic groin hernia repair. clinical application: fj clip is a stainless steel that can be used to hold organs in the abdominal cavity. it is available in two sizes: mm and mm. the device is short, it has a strong grasp, and it causes no or only negligible organ damage. we have used fj clip in the performance of local gastric excision (n= ), colectomy (n= ), and cholecystectomy (n= ) with no resulting difficulty. f loop plus is a g stainless steel loop-like device into which we can insert φ . mm nt alloy thread, which we draw out extracorporeally via simple puncture. laparoscopic total and proximal gastrectomy. we made a small incision at the umbilicus and inserted a -mm camera port and -mm metal cannula. we placed two (left and right) epigastric ports. retraction of the left hepatic lobe was easy with use of the -mm fj clip and a -mm penrose drain. for # lymph node dissection, we used the fj clip to grasp the upper part of the stomach, inserted the f loop plus from the upper right abdomen. for # dissection, we grasped the pyloric vestibule and pulled it leftward. for dissection of the upper edge of the pancreas, we grasped the left gastric arteriovenous pedicle and pulled it toward the abdomen. the fj clip's grasp and traction exerted on the stomach wall were strong and effective, and there was little organ damage. reconstruction (roux-y) or double tract were performed within the abdominal cavity by hand-sewn purse string suture of the esophageal stump, insertion of an anvil, and use of an automated anastomosis device. we have experienced total and proximally cases to date, but there have been no complications, and both intraoperative bleeding and operation time were within normal limits. conclusion: we believe the fj clip and f loop plus will replace conventional forceps for various tasks in reduced port gastrectomy. introduction: pulmonary anatomical resection is considered as standard treatment for early staged lung cancer. uniportal video-assisted thoracoscopic surgery (uvats) has recently showed favorable surgical outcomes, but remains technically demanding, especially in a complex procedure such as anatomic segmentectomy. needlescopic instruments facilitates complex laparoscopic surgeries with nearly painless and scarless postoperative outcomes, however, its utilization of thoracoscopic surgery were mostly for minor procedures such as bullectomy and sympathectomy. we presented our initial experience of lung cancer surgery performed by uniportal vats and additional needlescopic instruments, and we also compare the operative results with conventional uniportal vats. methods: from december to august , consecutive patients with lung cancer undergoing anatomical lung resections including lobectomies and segmentectomies were reviewed retrospectively. of these patients, patients received conventional uniportal vats (uvats), and patients received needlescopic-assisted uniportal vats (na-uvats). we compared the peri-and post-operative outcomes in these groups. results: there was no significant difference in demographic, anesthetic, or operative characteristics in two groups except for age. the mean operation time was statistically less in the na-uvats group ( . ± . min vs . ± . min, p= . ). the intraoperative blood loss was significantly less in the na-uvats group ( . ± . ml vs . ± . ml, p= . ). there were two major pulmonary arterial bleeding events and one conversion to thoracotomy in the uvats group. the hospital stay, duration of chest tube drainage and post-operative pain scale were comparative in the two groups. conclusion: under the assistance of additional needlescopic instruments, uniportal vats can be performed more efficiently and safely without compromising its benefit in less postoperative pain and early recovery. purpose: we applicated the v-loc into abdominal wall closure in single incision laparoscopic appendectomy (sila) from . the aim of our study is to present our experience of abdominal wall wound closure technique using barbed suture in sila and comparision of perioperative outcomes with conventional method of layer by layer abdominal wall closure after sila. methods: from august to june , sila was performed on patients with acute appendicitis at the department of surgery, hallym sacred heart hospital. under approval of institutional review board, data concerning demographic characteristics, operative outcomes, postoperative complications were compared between both v-loc closure group and conventional layer by layer closure procedures. in v-loc closure group, after removing the appendix, divided linear alba was closed using unidirectional absorbable barbed suture v-loc - with continous running fashon. begins at the end of incision, and coming back with reinforced running. subcutaneous closure was also done using same thread, and the subcuticular suture along incision line was performed with remaning portion of v-loc. results: the demographic data of patients's characteristics were similar between the two groups. the use of barbed suture significantly reduced the suturing time for abdominal wall closure (p= . ) compared with conventional suture. the postoperative incision length was significantly shorter in v-loc group than conventional group (p= . ). the rate of surgical site infection were similar in both group. no incisional hernia were noted in both group with median follow up periods of . months. the total costs of the procedure were comparable in both group under korean drg system. the use of barbed suture in abdominal wall closure in single port laparoscopic appendectomy is safe, and feasible method, reduces the suturing time, thereby decreasing the total operation time, and incision length with cosmetic effect. angela m kao, md, michael r arnold, md, julia e marx, paul d colavita, md, b todd heniford; carolinas medical center introduction: morgagni hernia is an anteromedial congenital diaphragmatic hernia seen in approximately in live births and rarely identified in adulthood. patients may be asymptomatic, have intermittent symptoms, or present acutely with incarceration/obstruction. given this, surgical repair is recommended, but a standardized technique has not yet been described. methods: a prospectively collected hernia-specific database was queried for all adult morgagni hernias performed at a tertiary hernia center. demographics and peri-operative data were compared. ( ) repair. the most common ( . %) method of repair included suturing mesh to the diaphragmatic portion of the defect and securing the anterior-inferior edge to anterior abdominal wall with transfascial sutures and/or tacks. four patients ( . %) underwent primary repair. average defect and mesh size was . cm and . cm , respectively. three patients ( %) underwent a concomitant paraesophageal hernia repair. mean ebl and length of stay was ml (range - ml) and . days (range - days). postoperative morbidity included transient postoperative hypoxemia ( patients) and pleural effusion ( ) . there was no mortality, mesh complications or recurrences with a mean follow-up of months. conclusions: morgagni hernias patients were more often older, obese, and women. these hernias remained unrepaired in % of patients despite their having had previous abdominal surgery. a laparoscopic or robotic approach offers an effective hernia repair with minimal complications, short hospital stay, and excellent long-term results for both elective and acute operations. mesh repair, sutured to the diaphragm and sutured/tacked to the abdominal wall, appears to be a very successful means to repair larger defects. introduction: hydatidosis is a zoonotic disease caused by echinococcus granulosus. it is endemic in the mediterranean, south america and middle east. it is a systemic disease wherein lungs are the second most common organ involved, after liver. radio-imaging plays an important role in diagnosing and determining the extent of the disease. surgical enucleation of cyst has been the classical treatment for this disease. bilateral lung involvement has been traditionally treated by median sternotomy or a bilateral thoracotomy. video assisted thoracoscopic surgery (vats) is an effective surgical approach in such settings. materials and methods: at our center, we have operated cases of pulmonary hydatidosis thoracoscopically over the past years. in all cases, area around the cyst was cordoned off with . % cetrimide soaked gauze pieces. a pericystotomy is performed with ultrasonic shears & the germinal membrane is delivered en masse into an endo-bag. an air leak test after saline instillation into the cavity, is a standard part of the procedure. for those cases with cysto-bronchiolar communications, the defect was sealed by either suturing or glue application. traditionally, bilateral cases & cysts larger than cm in size were tackled by an open approach. but, in our experience, cyst size, bilaterality & presence of complications are not contraindications for vats. all cases are administered perioperative albendazole ( mg twice a day, administered for three cycles of days each, with a gap of days in between) which helps in preventing recurrence and also takes care of any inadvertent intra-operative spillage. introduction: minimally invasive surgery (mis) is the standard approach for most of the surgical procedures performed by general surgeons. traditionally the majority of operations for trauma are performed open due to the complexity of the cases, however, trauma surgeons are expanding their armamentarium to include mis in a variety of acute procedures. we report our experience with the application of laparoscopy in a variety of trauma cases. methods: a retrospective review of trauma cases performed between / - / . during that time laparoscopic cases were performed after traumatic injury. patient demographics, injury severity (iss), injury mechanisms, the types of procedures and outcomes will be described. means and standard deviations were calculated and t test were performed. a p value of . was statistically significant. results: demographics-a total of trauma cases were performed laparoscopically during the study period. the majority were male, n= and the age was sd . obesity was documented in %, hypertension or cad was in %, and substance abuse was in %. blunt trauma was in % and penetrating %. the iss was sd . surgical procedures-the majority, %, of the procedures were completed laparoscopically. non-therapeutic laparoscopy was performed in %. repair of diaphragmatic or traumatic abdominal wall hernias were %. hematoma evacuation and control of bleeding was %. control of solid organ bleeding and repair was performed in %. intestinal repair occurred in %. for the cases that required open conversion iss was sd vs. laparoscopic cases iss was sd , p= . . outcomes: the overall length of stay was days sd . there was n= late death in a poly-trauma patient that required open conversion for complex solid organ and intestinal injuries. there was n= case of a community acquired pneumonia, and n= case of a recurrent pneumothorax. conclusions: a descriptive series of trauma operations approached with mis techniques is described. this cohort had high injury severity and a predominance of comorbid conditions. laparoscopy was successfully applied in the majority of cases for a variety of therapeutic procedures and mortality and morbidity was low. mis is safe and is gaining momentum for application in traumatic injury. objectives: laparoscopic distal gastrectomy for early gastric cancer is a standard treatment in japan described in guidelines. the surgical procedure has been shifting from laparoscopic assisted to complete laparoscopic surgery. in this study, we evaluated the outcomes and safety of the laparoscopic assisted distal gastrectomy. methods: for the marking of the oral side transecting line, the clipping at oral side of cancer lesion was performed by gastro-endoscopy before surgery. the lymph node dissection (d +/d ) is performed laparoscopically. as the dissection of the pancreatic superior region, the assistant hold the left gastric artery and keep the good view by retracting the pancreas. the common hepatic artery and proximal side of splenic artery are exposed. both sides of the left gastric artery and vein are exposed. left gastric vein and left gastric artery are cut after clipping and sealing. lymph node dissention of hepato-duodenal ligament is done and right gastric artery is cut after clipping and sealing. minor curvature of upper gastric wall is exposed (no , dissection). billroth i reconstruction by the circular stapler (cdh) is performed. through the upper median incision with cm, operator pulls out the stomach and transects the oral side of stomach with linear stapler after palpating the clips. duodenum is transected after purse string suture. gastroduodenal anastomosis is performed by cdh. results: two hundred cases were analyzed. the operation time, blood loss and the conversion to open surgery rate were minutes, ml, and . %, respectively. as postoperative complications, anastomotic failure, pancreatic fistula and postoperative bleeding were %, . % and %, respectively. the reoperation rate was %. one surgical death due to cerebral infarction was experienced. there were no patients with ppm (pathological proximal margin) positive and too much pm distance. frequency of abdominal wall incisional hernia and ileus were % and %, respectively. conclusion: although there is the disadvantage that small laparotomy can be made in the upper abdomen, laparoscopic assisted distal gastrectomy with billroth i reconstruction in our procedure is enough good from the viewpoint of the precision of proximal margin, and the incidence of serious complications. introduction: minilaparoscopy (mini) is a modality of minimally invasive surgery that attempts to produce less surgical trauma to the abdominal wall by reducing the diameter of surgical instruments to mm. searching for better outcomes in inguinal hernia repair, surgeons have looked for new and less invasive alternatives such as single-incision surgery, single-port surgery and mini. minilaparoscopic transabdominal preperitoneal hernia repair (mini-tapp) demonstrates some of the known advantages of mini general surgery procedures such as enhanced visualization, improved dexterity and great cosmetic outcome. it is safe and reproducible since it does not differ from standard laparoscopy. introduction: the celiac plexus is a structure located in the retroperitoneum, at the level of the lumbar vertebra, which is located in the prevertebral region and has sympathetic fibers. patients with advanced gastrointestinal cancer and associated pain, one of the management strategies is pain control. neurolysis of the celiac pleural by laparoscopy was first reported in humans in in patients with advanced pancreatic adenocarcinoma with excellent results. experience will be shown in the simplification of the technique for the procedure. method: neurolysis of the celiac pleura was performed in patients with advanced gastrointestinal cancer, stomach %, pancreas % liver % other %, no complications associated with the procedure, pain improvement was achieved in % of patients after process. the standardization of the technique by laparoscopy and its simplification, has made this procedure that is replicable and safe. description of the technique: patient in french position, technique of trocars, umbilical trocar mm and trocars of mm paraumbilical, staging laparoscopy is performed and sampling if necessary, is identified in the region of the lowercurvature of the stomach, the celiac trunk and the emergence of the left gastric artery are identified and cc of % alcohol diluted to the medium in the lateral fatty bearing are instilled through a pericranial under direct vision, verifying the non-arterial instillation of the alcohol. there were no complications related to the procedure. results: we report the experience of one group who underwent celiac pleura neurolysis in patients with advanced gastrointestinal cancer, gastric cancer %, pancreatic cancer %, liver cancer % and another %. the most frequent pathology report was adenocarcinoma, % of the patients were managed at hours with sustained effects, up to months of follow-up. with a significant decrease in pain medication. only patient required new laparoscopic neurolysis because of difficult-to-manage pain. the operative time of this procedure was minutes. the standardization of the technique, the use of low cost inputs, makes this type of procedure easily replicable with goodresults in pain management in cancerpatients. conclusions: mis is offered as one of the fundamental tools for the management of palliative procedures in gastrointestinal cancer. neurolysis of the celiac pleura with standardization of the technique, use of low cost elements, and the surgeon's skills make this procedure an option of management and control of pain in patients with advanced gastrointestinal cancer, is easily replicable, economical and insurance. background: the non-absorbable polymer clip offers a solution to the disadvantage of traditional metallic clip. due to its metallic property, it is not only expensive but also causes artifacts on imaging studies and often migrates into cbd. this study compares the traditional standard metallic clip with hem-o-lock used in laparoscopic cholecystectomy (lc) in regard of the safety and efficacy?. material and methods: this study includes patients who underwent lc implementing metallic clip (mc) and patients implementing hem-o-lock clips (h )?. both clips were applied to cystic duct and artery, then the gallbladder was dissected from the liver bed by diathermy. the intraoperative and postoperative parameters were collected including duration of the operation and complications?. results: the median operative time was not statistically different between the mc and the hc group ( . vs . minutes, respectively; p= . ) with no significantly less incidence of bile spillage ( vs. , p= . ) . no statistically significant difference was found in the incidence of postoperative complications between both groups ( vs. , p= . ). no postoperative bile leakage was encountered in both groups. conclusion: hem-o-lock clip provides a complete hemobiliary stasis and a secure cystic duct and artery control. its cost effectiveness is also attractive while provides efficacy equivalent to that of the standard metallic clip. introduction: most of the blunt thoracoabdominal injury patients always have multiple organ injuries. plan of definite treatment depends on the preoperative diagnosis. in isolating diaphragmatic traumatic injury without others organ injury laparoscopic approach is helpful, decrease a length of hospital stay as well as decrease a wound complication. authors describe the laparoscopic treatment of the patient who had rupture of a diaphragm from blunt trauma in an emergency setting. methods and procedures: a years old man presented with motor vehicle accident and mechanism of injury was blunt thoracoabdominal injury. he complains about chest tightness and tachycardia. complete evaluation and ct scan ware performed. stomach was herniated to the left chest and diaphragmatic ruptured was found neither others great vessels nor solid organs injury. the laparoscopic approach was desired and left diaphragm was repair by non-absorbable sutured without intraoperative complication. results: the patient has been discharged days post-operative with full recovery. chest x-ray was taken before discharge, in out-patient department weeks as well as months after discharge which shown no diaphragmatic herniation. conclusion(s): laparoscopic approach in isolated traumatic ruptured diaphragm patients is safe and should be considered. short-term outcome of laparoscopy-assisted distal gastrectomy with roux-en-y reconstruction through mini-laparotomy for gastric cancer since , we have introduced laparoscopy-assisted distal gastrectomy (ladg) with b-i reconstruction through mini-laparotomy. regarding to reconstruction, roux-en y reconstruction are also one of the choice in ladg, however, the technical feasibility has not been well documented so far. the purpose of this study was to compare the short-term outcome of ladg with roux-en-y reconstruction through mini-laparotomy compared to that of ladg with b-i anastomosis. between and , patients who underwent ladg for gastric cancer in oita university were enrolled in this retrospective study. since , the roux-en-y reconstruction has been performed as a standard method in our department. these patients were divided two groups based on anatstomosis; roux-en-y (r-y) group (n= ) and billroth i (b-i) group (n= ). baseline characteristics, operative results (including complications) and pathological results were evaluated. there were a considerably greater number of patients with advanced clinical stage and having ≥t invasion in the r-y group. estimated blood loss was lower in r-y than in b-i (p. ) and operative time was longer in r-y than in b-i (p. ). there were no significant differences in all grade intra-operative complications (p= . ). in addition, there were no significant differences in all grade post-operative complications between the two groups except internal hernia. hospital mortality was % in each group. ladg with r-y reconstruction through mini-laparotomy was technically feasible as well as ladg with b-i anastomosis. utilization of laparoscopy associated with blunt abdominal trauma: the nationwide inpatient sample - kenneth w bueltmann , marek rudnicki ; advocate illinois masonic medical center, chicago, il, university of illinois introduction: the incidence of trauma and its heavy burden upon the healthcare system remain strong. paradigm shifts in the management of these cases has, however, improved the mortality in such cases. it can be expected that improvements in management, when combined with the benefits of laparoscopy, will demonstrate positive impacts upon treatment outcomes. methods: the nationwide inpatient sample was referenced for inpatient stays for the years to . abdominal trauma cases were selected and identified as hollow (ho) or solid organ (so) type, and as blunt or penetrating. the trauma subset was then scanned for the presence of discrete laparoscopic procedures, laparotomy, and converted cases, and flagged accordingly. conclusion: utilization of laparoscopy in treatment of intraabdominal solid and hollow organs injury increases over time. although current analysis based on available hcup nis data include any procedures done during post-traumatic hospitalization, its results can lead to conclusion that minimally invasive technique is being utilized in increased fashion. introduction: single incision laparoscopic (sil) surgery is a laparoscopic procedure which leaves a single small incision in navel, and has been reported to be less invasive than and as safe and efficient as the conventional multiport laparoscopic (mpl) surgery. the long-term rate of incisional hernia after sils colectomy is unknown, and the risk factors of incisional hernia formation is not fully elucidated. methods and procedures: this is a retrospective from a prospectively collected database. the investigation took place in a high-volume multidisciplinary tertiary private hospital in japan. introduction: laparoscopic approach in the acute surgical care setting continues to be underutilized. we aim to report the successful diagnostic and therapeutic use of laparoscopy in the management of a nontoxic patient presenting with acute abdomen and to highlight the benefits of a minimally invasive approach without added morbidity. case report: presented is a -year-old male with history of cad s/p cabgx two years prior and no abdominal surgical history who presented to the ed with sudden onset severe, diffuse, abdominal pain of six-hour duration with n/v. there was no trauma to the abdomen. he had mildmoderate hypertension, but was otherwise hemodynamically stable. on examination, the patient was in severe distress and writhing in pain. fast exam was unable to be performed secondary to pain. cta of the abdomen revealed mesenteric abnormalities with associated small bowel edema in the rlq suspicious for small bowel ischemia. he was taken to the or for diagnostic laparoscopy. he was found to have an omental adhesive band to the abdominal wall with herniation of the small bowel through the small opening. approximately cm of ischemic, nonviable small bowel was resected and anastomosed intracorporeally. he tolerated the procedure well and was discharged home on post-operative day . discussion: primary omental related internal herniation of small bowel is exceedingly rare. there have been only few cases reported in the literature ( , , , ) . two were diagnosed on exploratory laparotomy, one on diagnostic laparoscopy and one at autopsy. the one who underwent diagnostic laparoscopy did not require bowel resection. in presenting this case, we hope to illustrate the role of laparoscopy in the management of acute abdominal pain due to bowel compromise. introduction: morgagni hernias are a rare finding in the adult population, and represent - % of all congenital diaphragmatic hernias. multiple approaches to these rare hernias have been described in the literature. here we present a novel technique of laparoscopic trans-abdominal repair using a combination of the endo-close device (medtronic, minneapolis, mn) and the ti-knot (lsi solutions, victor, ny.) methods: in a patient with a large left anterior diaphragmatic defect we performed trans-abdominal suturing utilizing the endo-close to perform primary closure of the defect, using the ti-knot to secure the pledged sutures along the anterior fascia. due to the size of the defect ( cm) this primary repair was buttressed with polyester mesh. in a second patient with a smaller ( cm) classic right-sided anterior diaphragmatic defect we similarly performed laparoscopic trans-abdominal suturing using the endo-close to traverse both the anterior and posterior fascia and the ti-knot to secure the sutures in order to perform a primary repair of the hernia. both patients presented had an uneventful postoperative course and no indication of recurrence at months. conclusions: morgagni hernias present unique technical challenges. in our experience the combined use of trans-abdominal suture with laparoscopic knot replacement device allowed for completion of both cases laparoscopically with minimal tension on the repairs. feasibility of concomitant laparoscopic splenectomy and cholecystectomy in situs inversus totalis: first case report worldwide ibrahim a salama, md, phd; department of hepatobiliary surgery, national liver institute, menoufia university introduction: situs inversus totalis is a rare anomaly characterized by transposition of organs to the opposite site of the body. combined laparoscopic splenectomy and cholecystectomy in those patients is technically more demanding and needs reorientation of visual-motor skills. presentation of case: herein, we report a year old girl presented with yellowish discoloration and left hypochondrium and epigastric pain diagnosed as hereditary spherocytosis (hs). the patient had not been diagnosed as situs inversus totalis before. the patient exhibit a left sided "murphy's sign" and spleen palpable in right hypochondruim. diagnosis of situs inversus totalis was confirmed with ultrasound, computerized tomography (ct) and magnetic resonant image (mri) with enlarged right sided spleen and presence of multiplegall bladder stones with no intra or extrabiliary duct dilatation. the patient underwent combined laparoscopic splenectomy and cholecystectomy as treatment of hereditary spherocytosis (hs). discussion: feasibility and technical difficulty in diagnosis and treatment of such case pose challenge problem due to the contra lateral disposition of the viscera. difficulty is the laparoscopic technique encountered in skelatonizing the structures in calot's triangle, which consume extra time than normally located gall bladder with right sided standing surgeon and the position changed to left sided standing surgeon during splenectomy. in review up to date medical literature this is the first case reported worldwide. conclusion: provided that the technique is performed by an experienced surgical team, concomitant laparoscopic splenectomy and cholecystectomy in situs inversus totalis is a safe and feasible procedure and may be considered for coexisting spleen and gallbladder disease as in hereditary spherocytosis (hs) as changes in anatomical disposition of organ not only influence the localization of symptoms and signs arising from a diseased organ but also imposes special demands on the diagnosis and surgical skills of the surgeon. objective: to identify the preference among medical students of the following surgical approaches: open surgery, conventional laparoscopy, minilaparoscopy (mini), single incision laparoscopic surgery (sils), natural orifice transluminal endoscopic surgery (notes), and robotic surgery. methods: an online google questionnaire was filled by medical students of different years in medical school. before answering the questionnaire, they watched an online video showing the different techniques, its advantages and disadvantages. the questionnaire consisted of questions about the hypothetical situation where the participants were going to be submitted to an elective cholecystectomy and they could decide which technique they would prefer. all statistical analysis was performed using the r software program, version . . . the chi-squared test was performed for categorical variables where appropriate. a p value . was statistically significant. results: one hundred and eleven medical students answered the survey. ( . %) were female and men. most of the students were between to years old ( . %). they were in the first four years of medical school. when asked if they would consider notes or single incision even if they know that they are new procedures and with not completely established security standards, . % ( ) answered that they wouldn´t consider with no difference between gender (p= . ). when asked if only conventional laparoscopy, robotics or mini were offered, which one they would choose: % of women and . % men chose mini first (p= . ). about the factors that they would consider the most important when choosing the surgical technique, they answered safety first ( . %), followed by the surgeon´s experience with the procedure ( . %), with no statistically significant result between genders (p= . ). when asked if they would consider an open technique even with the other techniques available and compared according to their year in medical school, students closer to finishing medical school would not consider it, with a statistically significant result (p= . ). regarding the most important factors they would consider and compared by year in medical school, safety and experience of the surgeon performed best, with a statistically significant result (p. ). conclusion: among the available surgical approaches, minilaparoscopy tends to be the preference among women medical students who considered safety the most important aspect. the closer they get to the end to medical school, the less they consider the open technique. background: extension of the single incision for the purpose of specimen removal in singleincision plus one additional port laparoscopic surgery (sils+ ) can undermine the merits of sils + , either by increasing wound-related morbidity or by destroying cosmesis. methods: we retrospectively analyzed the clinical outcomes of patients underwent elective sils + anterior resection, either with transanal specimen extraction (tase, n= ) or transumbilical specimen extraction (tuse, n= ), for colorectal cancer from january to june . this study included patients with a tumor diameter less than cm, measured by preoperative computer tomography. results: both groups were similar in patient's basic information and oncologic condition. most surgical data and postoperative clinical variables were comparable between tase and tuse group, except for increasing operative time in tase ( . + . vs. ± . min, p= . ) and reducing wound complications in tase ( % vs . %, p= . ). dosage requirement of narcotic analgesics was not inferior in tase group compare to tuse group. no significant differences were observed in conversion rate, perioperative and overall morbidity between the two groups. conclusion: although sils+ with tase prolonged operative time compare to with tuse, implement of tase is expected to provide benefit of reduced wound-related morbidity in patients with a tumor diameter less than cm. medhat ibrahim, md; al-azhar university, naser city, cairo, egypt purpose: morgagni hernia (mh) is a rare condition. mh is less than % of surgically treated diaphragmatic hernias in infants. there is no specific symptom for the maorgagni hernia. open surgical repair was the golden stander before the introduction of the laparoscopic surgery in the children and infant. there are many different laparoscopic techniques for mh repair have been reported. i report laparoscopic repair of mh in five infants using primary sutures closure with inrta-corporeal knot tying and ethicon secure strap device. this study is an evaluation of the safety and efficacy of this new laparoscopic technique of mh repair in infants with it is short-term outcomes follow up. patients and methods: five infants with mhs underwent laparoscopic repair by hernia sac excision then two primary sutures, non-absorbable proline through the full thickness of the anterior abdominal wall and the posterior rim of the defect, intra corporeal sutures knot tying, ethicon secure strap device which was used to complete the colures of the defect. there was no insertion of chest tube or drain. results: five infants with mh were operated upon. there were males and female. all cases were left side mh, male-female ratio was : . intraoperative and postoperative analgesia requirement was minimal (paracetamole mg/kg/rectal suppository/ hours for the first hours). ceftriaxone mg/kg single dose at the anesthesia induction. all operations were completed laparoscopic. all infants started and tolerated oral regular feeding with in hours from surgery. none of the patients developed intraoperative or postoperative complications. the maximum follow-up was months (mean, months). all patients are in good health without recurrence or port site compilation. conclusion: this easy save technique of mh repair is reducing the operative time and postoperative hospital stay. it is minims the need of postoperative analgesia, anti biotic. the early oral feeding is also a good benefit. the introduction: transumbilical single port laparoscopic appendectomy (tspla) is the most popularized single port surgery in the world. it provides more cosmetic benefits than conventional laparoscopic surgery. however, single port appendectomy requires longer operation time and advanced surgical skills. we aimed to investigate the learning curve for tspla. material and methods: data were collected from patients who underwent tspla by single surgeon between march and february . the learning curve were analyzed using a cumulative sum control chart (cusum) for operation time and complication. results: a total of patients were included in this study. mean operation time is . ± . minutes. there was no open or multi-port conversion. based on cusum for operation time, learning curve were cases. conclusions: tspla is a safe and effective alternative procedure. the learning curve could be overcome safely without major complications. our results suggest that the cases are sufficient to achieve surgical skills for tspla. introduction: anastomotic leakage (al) is a life threatening complication after minimally invasive ivor lewis esophagectomy (tmie ile) and has diverse treatment strategies such as conservative treatment, endoscopic treatment and surgery. however, there is no consensus on which treatment strategy is best. the aim of this study was to analyse various therapeutic strategies for al and their outcomes. methods and procedures: this retrospective multicentre study was performed in three highvolume hospitals. all patients that developed al after tmie ile in the period of january -july were included. the different endoscopic (stenting, clipping and suction-drainage) and surgical treatments and their success-rate were described; success was defined as clinical improvement after primary treatment. primary endpoint was the time until oral feeding was resumed. secondary endpoints were hospital stay and the total amount of surgical, endoscopic and radiologic interventions. results: in total patients that developed al were identified; four patients received antibiotics only. in the remaining patient, endoscopic treatment was performed as primary treatment in %; % received primary surgical treatment. basic variables were similar in these groups. median postoperative day of diagnosis of al was day in the endoscopic-group and day in the surgical-group (p= . ). admission to the icu as a result of the leakage was necessary in % in the endoscopic-group versus % in the surgical-group (p. ). however, median icu-stay was significantly shorter in the endoscopic-group ( days versus days, p= . ). success-rate of the primary treatment was similar; % and % respectively (p= . ). primary and secondary endpoints were comparable for both the endoscopic-and surgical-group; median time until oral feeding was resumed was days and days respectively (p= . ), median total hospital stay days and days respectively (p= . ) and the median number of interventions was in both groups (p= . ). conclusion: endoscopic treatment appears to be a safe and efficient therapy for al after tmie ile. a patient-tailored approach based on the condition of the patient and the morphology of the leak can be adapted to avoid surgery in a selection of patients. this may prevent surgical reoperations and reduce icu admissions. background: lymph node (ln) dissection around recurrent laryngeal nerve (rln) is one of the most important and difficult procedure in esophageal cancer surgery because of high rate of ln metastasis and risk of rln palsy. especially around left rln, the surgical area is far and narrow by thoracic approach which tends to results in insufficient ln dissection. therefore, we tried to remove this ln by imaging lymphatic chain to dissect sufficient ln. surgical procedure: we perform thoracoscopic esophagectomy by semi-prone position using - mmhg thoracic air pressure. after dissection of right rln ln, middle and lower esophagus, encircle the esophagus at the level of bifurcation of bronchus and pull toward right side by tape to dissect the dorsal and left side of upper esophagus. dissect the tissue including left rln ln from trachea by pulling esophagus up to dorsal side and try to move this tissue toward dorsal side of left rln so that this rln ln tissue can recognize as the "lymphatic chain". to increase the mobility of esophagus, cut the esophagus at the level of aortic arch and pull further up this upper esophagus to dorsal side. cut the esophageal branch of rln and separate this lymphatic chain from rln. at the end of thoracic procedure, this lymphatic chain is attached to upper esophagus. after the upper esophagus has pulled out from cervical site, lymphatic chain can easily recognize at the esophageal wall. result: we performed this lymphatic chain procedure in cases. to evaluate this procedure, cases of conventional method by same prone positioned esophagectomy was used for control. there was no statistical difference between these two groups in amount of blood loss (lymphatic chain: conventional= ml: ml, p= . ), rate of rln palsy ( . %: . %, p= . ). although the thoracic operation time was extended in some degree ( min: min, p= . ), number of dissected ln was increased ( . : . , p= . ) and recurrence along left rln has been relatively fewer by this method ( . %: . % p= . ). conclusion: ln dissection around left rln would be easy and sufficient by imaging lymphatic chain. further improvement is needed to secure this procedure and further evaluation should be done to support this data. introduction: to evaluate the role of robotic assisted surgery as part of an appropriate patient work-up and treatment of ipmn and its consistency in terms of perioperative and long term results. few reports described singular minimally invasive procedures for ipmn. this study aims to describe a comprehensive, oncologically adequate treatment of ipmn in a minimally invasive unit with an extremely high robotic penetrance. methods and procedures: we retrospectively analyze our database of resected ipmn between and . this case series includes consecutive, unselected patients: all candidates with a preoperative diagnosis of ipmn were approached robotically. results: among robot assisted pancreatic resections, we identified patients with ipmn. one was excluded for having less than months follow-up, so patients were included and analyzed. they underwent duodenopancreatectomy in cases, distal pancreatectomy in cases and central pancratectomy in . all but one indications followed the most updated available guidelines (sendai from to and fukoka from to ; american gastroenterology association guidelines were used for comparison only). one patient was operated even if the guidelines were suggesting to follow up, because of a strong familiar cancer history. the final pathology for this patient was high grade dysplasia. in another patient we were inside fukoka's recommendations, but outside aga guidelines and the final pathology was adenoma in chronic pancreatitis. postoperative morbidity was . ( low grade complications, one grade a pancreatic fistula, now considered a biochemical leakage only) and mortality was zero. one conversions to open surgery occurred only: a dp in jehowah's witness with a bulky mass behind the portal vein. the mean follow up was months (range: - ), with only one loss to follow up after months for a high grade dysplasia. conclusion: in hepatobiliary pancreatic minimally invasive centers the treatment of ipmn can be grant following the same principles of major cancer centers, with comparable results. large unbiased studies are needed to evaluate if a minimally invasive approach could modify the ratio between operated and surveilled patients. reducing the use of catheters, tubes and imaging after hiatal hernia surgery significantly reduces length of hospital stay sophia s oswald, candice l wilshire, md, brian e louie, md, ralph w aye, md, alexander s farivar, md; swedish medical center introduction: historically, standard post-operative management of patients undergoing laparoscopic hiatal hernia surgery has been placement of a foley catheter and nasogastric tube (ngt) at the time of surgery with removal early on postoperative day (pod) one, at which time an upper-gastrointestinal series study (ugi) would be performed. we initiated a quality improvement project, seeking to assess if we could safely forego placement of foley and ngt along with the ugi, unless clinically indicated. our aim was to determine if this decreased overall length of stay (los), and how often and which demographic of patients needed placement of foley or ngt postoperatively. methods and procedures: we reviewed patients who had undergone laparoscopic hiatal hernia surgery between and under a single thoracic surgeon. patients were excluded for poor esophageal motility (peristalsis \ %), previous esophageal surgery, and presence of a paraesophageal hernia (peh) with over % of the stomach contained in the chest. eligible patients were further stratified into two groups: fast track and non-fast track. fast track was defined as patients who left the operating room (or) with no foley or ngt, and did not receive a routine ugi on pod one. non-fast track was defined as patients who left the or with a foley and ngt and received a routine ugi on pod one. los was measured in hours from the start of surgery to the time of discharge. results: of the patients included, were categorized as fast track and as non-fast track. the two groups were similar in terms of age, gender, bmi and asa; however, the fast track group had fewer paraesophageal hernias and shorter surgery times [table] . the hospital los, however, was significantly shorter in the fast track group, even though there were more postoperative urinary catheters utilized. no patients in fast track group needed an ngt placed or ugi ordered during initial stay. conclusion: in more straightforward laparoscopic hiatal hernia surgery, surgeons can safely forego ngt and foley placement, as well as ugi evaluation the following morning. these initiatives may translate to a quicker discharge from the ward, and may allow safe transition to performing these cases in hour ambulatory outpatient setting. further evaluation of additional interventions and patient education to decrease los are underway. the conclusion: laparoscopic surgery seems to be a safe and feasible option, with long-term benefit for primary tumor resection with metastatic colorectal cancer, but optimal treatment has yet to be defined. the canadian association of gastroenterology (cag) has implemented the colonoscopy skills improvement (csi) program across canada with a goal of improving colonoscopy quality. the programs' efficacy has not yet been formally assessed. this retrospective cohort study was performed on fourteen endoscopists practicing in a tertiary referral center who have undergone csi training between october and december . procedural data were collected before and after csi training. data were extracted from the electronic medical record (emr) and entered into spss version . for analysis. student's t-test was used to compare groups for continuous data; chi-squared tests were used for categorical data. data were collected for a total of procedures; were done before csi training and procedures since csi training. our sample size provided % power to detect a mean difference in adr improvement of %. the most common indication for colonoscopy was family history of colorectal cancer in ( . %) patients. while age ( . yrs v. . yrs, p. ) and gender ( . % male v. . % male, p= . ) were similar, they were statistically different between groups. groups were comparable in terms of indication, and completion rate ( . % v. . %). adr improved significantly after completing the course ( . % v. %, p. ). an improvement was also noted in both polyp detection ( . % v. . %, p. ) and polyp removal ( . % v. . %, p\ . ). we have seen a significant increase in adr at out institution since implementing the csi program. gastric stomach cancer is a rapid major cause of cancer-related death globally, have higher incidence in men and it is noticeable by its heterogeneity. a lot of studies have expressed out the molecular basis of this cancer, include pathogenesis, invasion and metastasis. the invention of new technologies has help to bring out several novel biomarkers that have diagnostic and prognostic value. therefore, this review centers on biomarkers for the early diagnosis, treatment and prognosis of gastric cancer, elaborate the clinical important of serum tumor markers in a patient with this cancer as well as checking the growths, prognosis together with epigenetic changes and genetic polymorphisms. a deep and rigorous search was carried out in pub med/medline using specific words; "gastric cancer", with "tumor marker". our search yielded important reports about related topic from books and articles that were published before the end of september . conclusively, scientists are utilizing time and resource to salvage this nemesis which is of global burden. classical and novel biomarkers are important for treatment as well as pre-post diagnosis of gc. major causes for this disease are cigarette smoking, infection by helicobacter pylori, atrophic gastritis, male sex, and high salt intake. the treatment of which early diagnoses is of important to the management, after pathological diagnoses by stage prognosis and metastatic setting, although the outcome proved not so good includes chemotherapy, and oral medication are oxaliplatin, capecitabine, cisplatin and -fluorouracil ( -fu). introduction: emergent appendectomy is the standard of care in usa based on tradition rooted in theory that delaying surgery allows for progression of disease and poorer outcomes. antibiotic treatment alone has been shown feasible in the treatment of uncomplicated appendicitis. in clinical practice surgical treatment can be delayed due to a multitude of medical and logistical reasons. this study evaluates the relation between timing of surgery to outcomes. methods and procedures: consecutive adult patients undergoing appendectomy in a teaching community hospital were risk stratified using the acs risk calculator. time from imaging to incision defined early and delayed groups. statistical analysis was used to determine association between risk level, timing of surgery and outcomes. results: % of patients in this study were considered high risk. average time to incision was . hours. shorter time to incision was associated with a statistically significant lower length of stay (p. ). for every hours in surgery delay, one day was added to the length of stay. no statistical difference was found between time to incision and other outcome variables of clinical complications, conversion to open appendectomy or frequency of complicated appendicitis. length of stay was longer than predicted by acs risk calculator in both high and low risk groups. a multidisciplinary, obesity-focused approach improves diagnosis of obesity-related illnesses: a new paradigm for the care of patients with obesity roderick olivas, aaron brown, md, racquel s bueno, md, cedric s lorenzo, md; university of hawaii -department of surgery introduction: patients suffering from the burden of obesity are at significant risk for medical problems that lead to premature death and disability. we hypothesize that a multidisciplinary bariatric team will be better equipped to recognize and diagnose these conditions. this study hopes to quantify that a patient focused approach leads to increased recognition of obesity-associated comorbidities, thus improving quality of care and surgical outcomes. methods and procedure: a retrospective medical chart review of patients who underwent bariatric surgery from / / to / / was performed comparing patient problem lists obtained from their primary care providers upon entry into the bariatric program, and the final problem list generated after evaluation by the program's multidisciplinary team. the total number and specific comorbidities identified before and after multidisciplinary team evaluation was analyzed with a paired t-test and manova, respectively. comparison of the number of comorbidities identified against specific patient demographics was conducted using paired t-test. results: a total of patient charts were selected and met inclusion criteria. the sample consisted of % women and % men; the mean age was . ; the mean bmi was . ; % were morbidly obese (bmi ) and % were obese . the total number of comorbidities identified after evaluation by a multidisciplinary team was significantly greater (p=. ), with the average number of comorbidities diagnosed before and after being . and . , respectively. a significant increase (p. ) in the identification of comorbidities before and after evaluation were noted for all demographics, and no disparities regarding gender, age, marital status, employment status, bmi, or ethnicity where identified. conclusion: patients with obesity unknowingly suffer from many obesity-associated comorbidities simply because their health care providers have failed to recognize the existence of these conditions. surprisingly, this include diseases that are highly associated with obesity, such as osa and t dm, for which obese patients should be screened. although the root of this dereliction is yet to be determined, insufficient obesity-focused education and inherent weight bias among providers must be considered. assessment by a multidisciplinary bariatric team resulted in the identification and treatment of an increased number of comorbidities in this patient population. increased recognition of obesity-related comorbidities improves quality of care, which can translate into improved surgical outcomes. introduction: it is known that surgical residents suffer from sleep deprivation. no recent study evaluated the type and number of calls received at night. lately, burn out, depression and suicide have been the subject of interest in studies and media because of the higher rate among the residents compared to general population. the objective of our study is to evaluate junior resident's level of fatigue and the quantity and quality of calls received during on-call nights in general surgery at chus. methods and procedure: transversal study conducted on junior residents that were on-call in general surgery at the chus between april and august , . the participants detailed all the calls received between pm and am on an database created on the application handbase and completed a daily calendar of their on-call night noting all the tasks they did every half hour (surgery/consultation/sleep). the level of fatigue was evaluated at the end of the night at am with a visual analog of sleep scale on a score over points. results: the level of fatigue / (tired) or / (exhausted) was reached in closed to % of the oncall nights. the median number of calls by night was and the median duration of sleep was only . hours. the median lenght of uninterrupted sleep was . hours by night. among the total nights and calls analyzed, % were ''not pertinent'' and % were ''reportable in the morning''. more than % of the nights had at least one call ''not pertinent'' or ''reportable in the morning'' that have interrupted the junior resident's sleep. the level of fatigue was significantly correlated to the number of calls received during the night (spearman's rho=+ . , p. ) and to the number of uninterrupted hours of sleep (spearman's rho=− . , p. ). conclusion: the level of fatigue is very high among the junior residents in general surgery. many of the calls received during the night are not pertinent or could have been delayed to the morning. our results lead us to the conclusion that interventions and recommendations should be made to raise nurses and resident's awareness about the situation to reduce the unnecessary calls and the level of fatigue of the residents. we hope that on-call resident sleep will be better preserved and that will result in fewer health issues for them (burn out, depression, suicide). without interruptions: does twitter level the playing field? heather j logghe, md , laurel milam, ma , natalie tully, bs , arghavan salles, md, phd ; thomas jefferson university, washington university, introduction: frequent interruption of women in conversation has long been noted anecdotally, and studies confirm that women are interrupted more often than men. such interruptions can diminish perceptions of authority and compromise women's self-confidence. on twitter, users cannot be interrupted in the same way they can be in live conversation. thus the platform may provide a means for women to overcome this obstacle. to determine the degree to which women surgeon leaders utilize twitter compared to their male colleagues, we examined the twitter accounts and activity of the leaders of three national surgical societies. methods and procedures: lists of surgeons holding leadership positions in three surgical societies; the american college of surgeons, the academic association of surgery, and the society of american gastrointestinal and endoscopic surgeons, were obtained and duplicate names were deleted. table details the organizations and leadership positions included. the twitter accounts of these leaders were then identified and confirmed by reviewing the accounts for surgical content. account duration was calculated from the join date. the number of tweets, accounts following, followers, and likes were recorded for each account. outliers were defined as two standard deviations from the mean. results: one hundred sixty-eight men and women surgeon leaders were identified. forty-nine percent of the men and % of the women were found to have twitter accounts. mean account durations for men and women were similar, . years and . years, respectively. outliers for total tweets ( men, women), accounts following ( men), followers ( men), and likes ( men) were excluded from analyses. almost all positive outliers were men. there were no negative outliers. overall, excluding the outliers, there were no significant differences between men and women in any metric. conclusion: among leaders in the surgical organizations analyzed, a higher percentage of women than men have twitter accounts. those with the greatest number of tweets, accounts following, followers, and likes, however, are overwhelmingly male. thus, although women in this sample were more likely than the men to have twitter accounts, men were more likely to gain influence through their accounts. increasing women's influence in this public forum may position them as much-needed role models for the current and next generations. surgical societies may help reduce the disparity in women's representation in surgical fields through education of their members on how to use social media. introduction: the aim of this study was to report the perioperative morbidity and short-term outcomes of a case series of robotic-assisted laparoscopic transabdominal preperitoneal (tapp) inguinal hernia repairs. methods and procedures: a retrospective review (january through december ) of patients who underwent either unilateral or bilateral robotic-assisted laparoscopic tapp inguinal herniorrhaphy by two attending surgeons was performed. patient demographics, perioperative morbidity, operative time, and follow-up data were analyzed. results: patient demographics are summarized in table . mean operative times for unilateral and bilateral inguinal herniorrhaphy were . ± . and . ± . minutes, respectively. mean robot console times for unilateral and bilateral inguinal herniorrhaphy were . ± . and . ± . minutes, respectively. postoperative complications included urinary retention ( . %), conversion to open repair ( %), and delayed reoperation ( . %). no major bleeding, surgical site infection (ssi), or mortality was observed. at first follow-up visit ( ± days), symptoms/signs included groin/scrotal swelling ( %), seroma ( %), groin pain ( %), burning ( %), numbness ( %), and persistent urinary retention ( %). % of patients required a second follow-up visit. two patients underwent reoperation for suspected recurrence but instead a cord lipoma was found without a hernia defect. conclusions: robotic-assisted tapp inguinal herniorrhaphy can be performed with operative times and short-term outcomes similar to those published for open technique. the robotic-assisted tapp inguinal herniorrhaphy is a safe and an efficient minimally invasive surgical option with lower ssi risk and better cosmetic results. gunnar nelson, nathan lau, phd; virginia polytechnic institute & state university introduction: the fundamentals of robotic surgery (frs) and fundamentals skills of robotic surgery (fsrs) are universal curriculums covering a range of topics to assure a high level of surgical skills for optimal patient outcomes. this assurance of skills should include management and response to adverse events. thus, we reviewed frs and fsrs to identify any gaps in educational contents pertaining to how surgical teams are trained to handle adverse events in robotic surgery. methods and procedures: we conducted a literature search through google scholar, journal of robotic surgery, and plos one on frs and fsrs from to . we reviewed articles on preparing medical professionals in handling adverse events during robotic surgeries. besides the two curriculums, we also surveyed the literature on the characteristics of the adverse events and responses of the medical team. this literature survey provided a basis for recommending additional education contents to frs and fsrs. results: in our review, the frs contains modules consisting of an introduction to robotic surgery, with cognitive, psychomotor, and team training/communication skills. meanwhile, the fsrs contains different tasks, half of which on human-machine interaction and another half on operative interaction. both curriculums appear to lack contents on managing adverse events in robotic surgery. according to fda data, , adverse events were reported per , surgeries, of which (i) % relates to broken pieces of surgical instruments falling into patients, (ii) . % pertains to burning holes in tissue from electric arching, and (iii) . % relates to unexpected operations of the instrument such as power outage and issues with electrosurgical units. thus, medical professionals should be trained to manage common adverse events in robotic surgery. for frs, augmenting the five current scenarios in the communication section with common adverse events (i.e., broken pieces falling into patients) would minimize complications under abnormal circumstances. for fsrs, the most logical method would be augmenting the operative interaction tasks with adverse events to train medical professionals. conclusion: we discovered universal curriculums on robotic surgery lack education contents for training medical professionals to manage adverse events and out of the , procedures, ( . %) pertained to device malfunction. to protect the patient's health, universal curriculums must incorporate contents preparing medical professionals in responding to adverse events, particularly device malfunctions, during robotic surgeries. introduction: this retrospective study was performed to evaluate the safety and feasibility of the new senhance robotic system (transenterix) for laparoscopic cholecystectomies. we report the first single-institutional experience utilizing this new robotic platform. methods: approximately robotic cholecystectomies were performed using the senhance robotic system. the senhance surgical system is a new robotic platform that consists of a cockpit, manipulator arm and a connection node ( figure ). this new system provides robotic surgery with numerous advantages including eye-tracking camera control system, haptic feedback, reusable endoscopic instruments, and a high configuration versatility due to total independency of the manipulator arms. patients were between and years of age, eligible for a laparoscopic procedure with general anesthesia, had no life-threatening disease with a life-expectancy of less than month and a bmi\ . a retrospective review of a variety of prospectively collected pre-, peri-and postoperative data including but not limited to patient demographics, intraoperative as well as postoperative complications was performed. cholecystectomies were performed by expert level laparoscopic surgeons. results: the standard laparoscopic technique and setup was easily applicable to the senhance robotic system for this particular surgery. operative time and perioperative complications were comparable to reports of standard laparoscopic cholecystectomies. there was no significant learning curve detected in our case series. conclusion: we report the first experience with laparoscopic cholecystectomies using the new senhance robotic system. there were no major perioperative complications and operative time was comparable to standard laparoscopic cholecystectomies well reported in the literature. this case series suggests that the senhance robotic system can be safely and easily used for laparoscopic cholecystectomies by experienced laparoscopic surgeons. background: the ergonomic benefits or robotic surgery for the health of the surgeon are widely touted as benefits of this technique, though concern remains over a perception of increased risk of injury to patients, particularly in the novice robotic surgeon. injury to the bedside surgeon and assistants due to robotic movement can also occur, though not previously reported. we describe a finger fracture to the bedside surgeon due to entrapment between robotic arms and discuss potential risks to the surgeon in robotic procedures. procedure: a distal pancreatectomy and splenectomy was performed utilizing the davinci si system (intuitive surgical, inc., sunnyvale, ca). during the operation, hemorrhage was encountered which required an instrument exchange that was delayed by self-testing failures. after the instrument was validated and advanced into the field by the bedside surgeon, the operator abruptly took control of the device to reposition. the external portion of the active arm was then rapidly and forcefully propelled laterally toward a stationary retracting arm. the bedside surgeon's hand was still engaged on the instrument being inserted and became trapped between the two arms, leading to a right middle finger crush injury. results: the bedside surgeon sustained a fracture to the distal phalanx at the insertion of the flexor tendon with significant hyperextension of the joint. there was temporary paresthesia of the fingertip. while flexor tendon function was preserved and surgery was not required, the surgeon was required to maintain continuous splinting and was unable to return to full duty for a total of weeks. the surgeon has mild residual hyperextension. conclusions: while complications to the patient have previously been attributed to the robotic platform, this case demonstrates that there are other inherent hazards to members of the operative team. as is natural with all indirect visual surgical techniques, the operator becomes intensely focused on the internal view and instruments in the field. this spatial separation is accentuated on the robotic platform as the isolated console provides a complete visual field immersion, no tactile feedback, and a disconnect between the rapid, sizeable outward arm motions need to produce small internal movements. given the need for maximum dexterity internally, the device doesn't have external proximity sensors to prevent arm-arm or arm-operator collisions. while many bedside operators report anecdotes of collisions with the device, this case reveals the forces involved at the human-machine interface can lead to more significant injuries. robtic approach to non-midline abdominal wall hernias: a single institution experience from a high volume center emily benzer, do, j. stephen scott, md, facs; university of missouri introduction: the objective of our study was to evaluate our experience with robotically repaired non-midline abdominal wall hernias at a high-volume robotic surgery program. we also will discuss the technical advantages of the use of robotic technology in repair of these unusual hernias which have typically had higher recurrence rates then midline hernias. laparoscopic approach for lateral ventral abdominal wall hernia (spigelian) and lumbar hernia has been described, however the success of robotic assisted repair for these hernias has yet to be determined. methods: a retrospective case analysis of all robotic abdominal hernia cases between june and june at an academic institution with a single high volume robotic surgeon was performed. the operative details of robotic repair of non-midline abdominal hernias, patient demographics, length of stay and smoking status were recorded and analyzed. the technical advantages of the use of robotic technology for example circumferential fixation of the mesh, ease of intracorporeal suturing, and the use of wristed instruments to gain better angles for posterior fascial release were evaluated. results: a total of cases were identified. the average age of the patients was . years (range - years) and patients were predominantly female ( %). spigelian hernias represented % (n = ) and lumbar hernias % (n= ). all patients had primary closure of their defect and patients ( %) had a posterior myofascial release performed. mesh types placed included polypropylene uncoated (n= ), polypropylene coated (n= ), and biologic (n= ). with uncoated polypropylene mesh placed had peritoneum closed over the mesh. the average length of stat was . days (range - days). there were no recurrences identified over a mean follow up period of . months (range . - . months). conclusion: robotic assisted repair of non-midline abdominal wall hernias is a viable option in the elective setting with no recurrences noted in this case series. the technical advantages of using robotic technology were identified and discussed in detail. these advantages theoretically improve outcomes in these patients however further analysis on long-term outcome and costs will have to be determined in future studies. the inguinal hernia repair has seen several critical improvements in recent times due to the implementation of new techniques, including laparoscopic repair, as well as robotic repair. with over , inguinal hernia repairs performed annually, it is important to identify the safest and most patient-friendly method. for surgeons, robotic assisted laparoscopic surgery is gaining in popularity for its dexterity and d visualization. but despite the growing interest in robotic hernia repairs, there is a scarcity of literature to support its superiority over open inguinal hernia repair. this study hypothesizes that patients who undergo robot assisted laparoscopic inguinal hernia repair will have decreased immediate post-operative pain, shorter recovery room stays, decreased narcotic requirement, and overall decreased pain at follow up compared to open inguinal hernia repair. in this study, we performed a retrospective analysis of patients who underwent either an open or robotic assisted laparoscopic inguinal hernia repair at stamford hospital, from july -july . the following characteristics were analyzed for both subsets of patients: gender, bmi, type of repair, operative time, recovery room time, immediate post-operative pain, and post-operative pain at follow up. our study demonstrated longer average operative time for patients undergoing robotic hernia repair compared to open repair, which was statistically significant (p value=. ). patients who underwent robotic inguinal hernia repair spent less time in the recovery room compared to patient who underwent open repair. in addition, patients in the robotic hernia group required less narcotics in the recovery room compared to patients who underwent open repair (p value = . ). there was no statistically significant difference between lengths of hospital stay between the two groups. this study highlights several possible advantages of robotic inguinal hernia repair, including lower post-operative pain scores, less narcotic usage required in the post-operative period, as well as shorter recovery room time. the results from this study should increase interest in investigating the superiority of robotic inguinal hernia repair. future plans for study involve comparing robotic to laparoscopic repair. in addition, we plan to continue to follow the study patients to look at additional qualitative metrics, including time to return to work and time to return to daily activities. introduction: buccal mucosal grafts (bmg) are traditionally used in urethral reconstruction. there may be insufficient bmg for applications requiring large amounts of graft, such as urethral stricture after gender affirming phalloplasty. rectal mucosa is an alternative with less post-operative pain, no impairment in eating and speaking, and larger graft dimension. laparoscopic transanal minimally invasive surgery (tamis) has been described by our group. due to the technical challenges of harvesting a sizable graft within a confined space, we adopted a new approach using the intuitive da vinci xi® system. we demonstrate the feasibility and safety of a novel technique of robotic tamis (r-tamis) in the harvest of rectal mucosa for the purpose of onlay graft urethroplasty. methods and procedures: irb approval was obtained. three female-to-male transgender adults (age range: - years) presenting with post-phalloplasty urethral strictures underwent robotic rectal mucosal harvest. the procedure was first rehearsed on an inanimate model using bovine colon. the surgery was performed under general anesthesia with the patient in lithotomy position. the gelpoint path transanal access platform was used. the rectal mucosa was harvested by the robotic instruments after submucosal hydrodissection. specimen size harvested correlated with clinical surface area needed for urethral reconstruction. following specimen retrieval, flexible sigmoidoscopy was used to ensure hemostasis. the rectal mucosa graft was placed as an onlay for urethroplasty. results: there were no intraoperative or postoperative complications. average graft size was cm (range: - cm). every case had excellent graft take for reconstruction. all patients recovered without morbidity or mortality. they reported minimal postoperative pain and all regained bowel function on the first postoperative day. all reported significantly less postoperative pain and greater quality of life in comparison to prior bmg harvests. the procedure has been refined to increase efficiency and decrease operative time by maintaining adequate insufflation, retraction of the mucosal graft, and maintaining graft integrity. conclusions: to our knowledge, this is the first use of r-tamis for harvest of rectal mucosal graft. our preliminary series indicates the robotic approach is feasible and safe. it constitutes a promising minimally-invasive technique to employ in urethral reconstruction. demonstrated feasibility and avoidance of the challenging recovery associated with bmg harvest warrants further application and long-term evaluation of this procedure. prospective studies evaluating graft success, donor site morbidity and long-term outcomes are needed. introduction: the proportion of robotic minimally invasive procedures that are being performed annually is growing rapidly, specifically in the field of general surgery. a robotic approach to minimally invasive procedures potentially confers a number of benefits ranging from a magnified viewing field to greater attenuation and translation of hand movements leading to improved stability and maneuverability. it is paramount that a robust curriculum is designed for training surgical residents in robotic techniques. the aim of this project is to assess the current state of robotic surgery training at the ohio state university, with specific regard to whether it is currently temporally effective in addition to establishing a baseline against which the robotic surgery curriculum can be compared. methods and procedures: data were obtained for cases performed at the ohio state university hospital east, between january and september of . case time, date, type, and attending surgeon were recorded and tracked for review. of the cases, were cholecystectomies, were unilateral inguinal hernia repairs, and were bilateral inguinal hernia repairs-for a total of procedures included in the analysis. chief residents were trained in two-month blocks, beginning in january of . mean console operative times for the first and second months were compared for cholecystectomies as well as unilateral and bilateral inguinal hernia repairs. results: mean console time decreased for cholecystectomies (− . %; n= ), bilateral (− . %; n= ) and unilateral (− . %; n= ) inguinal hernia repairs from month one to month two. there was a large amount of variance across training blocks, but there was a systematic improvement in operative time across the training period. average operation length was shortest for cholecystectomies (m= . min), followed by unilateral inguinal hernia repairs (m= . min), and finally bilateral inguinal hernia repairs (m= . min). discussion: this preliminary data suggests that residents are able to decrease their robotic operation time over the course of the two-month rotation. although sample sizes were relatively small for each block, the consistency of the trend supports this conclusion. further data collection will allow for more precise estimates in the future, and stronger conclusions to be drawn. these results show that rapid improvement is possible and provide motivation to establish robotic surgery curricula for general surgery residents nationally. robotic pancreas-sparing treatment of pancreatic neuroendocrine tumors: three case reports and review of the literature alessandra marano, giorgio giraudo, stefano giaccardi, desiree cianflocca, diego sasia, felice borghi; santa croce e carle hospital introduction: pancreas-sparing resections would be the ideal procedure in case of small pancreatic neuroendocrine tumors (p-nets) reducing the risk of exocrine and endocrine insufficiency. compared to standard resection, this type of surgery is safe and feasible without increasing the risk of postoperative complications except the overall rate of clinical pancreatic fistula (pf), which did not result in higher mortality or overall morbidity. robotic surgery for pnets enucleation has been rarely described but initials experiences have shown that this approach is associated with favorable outcomes. the aim of this study is to describe three cases of dv®si™ pancreatic enucleation for p-nets located in the uncinate process, in the body and in the posterior aspect of the tail of the pancreas, respectively. a brief review of the literature regarding the application of robotics for pnets enucleation is also included. methods and procedures: this study includes patients undergoing dv®si™ enucleation for pnets with a maximum diameter no more than cm and a distance between tumour and main pancreatic duct (mpd) greater than mm. at surgery, exposure of the pancreas was achieved by separation and traction of the gastrocolic and gastropancreatic ligaments. the pancreas was explored: an intraoperative ultrasound was used ensuring negative margins and leaving the mpd intact. thus, a cross-stitch through the tumour was made routinely in order to pull the tumour. enucleoresection was carried out with monopolar scissors and bipolar forceps. the tumour was placed into a specimen bag and removed from the trocar port. a drain was always left. results: median total operative time was min. no conversion neither intraoperative complications occurred. median length of stay was . days. two patients presented a pf grade a (classification isgpf) while a pf grade b occurred in case of pancreatic tail net enucleation. final pathology revealed two insulinomas and one non-functioning net of the pancreatic body. at a median follow-up of months no pancreatic insufficiency, reoperation or tumour reoccurrence was observed in all cases. the robotic approach for the treatment of p-nets is safe and feasible and, in selected cases, it may extend the indications of minimally invasive pancreatic-sparing surgery. in particular, the robotic approach provides a more precise dissection and may ensure negative margins and the mpd intact. these preliminary results are consistent with literature data about over robotic pancreatic enucleations for p-nets that shows favourable surgical outcomes, especially if compared with those of open surgery. introduction: rectal cancer continues to be a surgical challenge. new technologies must be incorporated into practice and, at the same time, oncologic surgery and overall outcomes must be improved. the use of da vinci robotic surgery systems has spread rapidly in the field of rectal cancer treatment showing several technical advantages and favorable outcome compared to laparoscopy. since the introduction of the robotic platform in our institution in , we have adopted a single-docking robotic technique for rectal resection. the aim of this study is to present our standardized technique and to analyse the clinical outcomes of the first robotic rectal procedures. methods and procedures: prospectively collected data reviewed from consecutive patients who underwent single docking totally robotic (da vinci® si™) dissection for rectal cancer resection between june and august under eras program. robotic rectal surgery was performed without changing the position of the robotic cart but only the robotic arms are repositioned between two phases: ) vascular ligation, and sigmoid colon to splenic flexure mobilization; and ) pelvic tme. results: there were men ( %) and the median age was years (range- - ). thirty-five patients had neo-adjuvant chemoradiotherapy whilst patients had bmi [ . procedures performed included anterior resection (n= ) and abdominoperineal resection (n= ). protective ileostomy was performed in patients. the median operating time was min (range- - ). there was one conversion and two intra-operative complications (one bladder lesion and one ureteral lesion, respectively). median length of stay was . days (range, , and readmission rate was %. thirty-day mortality was zero. anastomotic leak rate was %, and all patients except by one were managed conservatively. the mean lymph node harvested was (sd± . ). radial margin was negative in all patients. at median follow-up of months, there were no local recurrences. the single docking robotic technique is a safe and feasible approach for rectal surgery: in our study it has demonstrated favourable clinical outcomes and the adoption of a standardized stepwise approach was useful especially during the initial learning phase. to the best of our knowledge, this is the largest series from italy to report this standardized approach and the short-term clinical and oncological outcomes. in the complex laparoscopic surgical procedure, there is a problem such as that the laparoscope and the surgical instruments interfere with each other because multiple instruments is concentrated in one place. this problem is significantly appear in the laparoendoscopic single site surgery. therefore we suggested multi degrees of freedom (dof) manipulator with mantle tube for assisting laparoendoscopic surgery, which manipulator has two flexion and one telescopic mechanisms actuated by wire. it is possible to insert any thin surgical instruments such an endoscope the mantle tube of the multi dof manipulator, which the manipulator can let those surgical instruments access the operative field from different axis with other instruments. the use of this manipulator has two advantages, one of which is avoidance of fighting between instruments and laparoscope. the other is that become possible to ensure a satisfactory field of vision in the operative field. in this report, we assumed that this multi-dof manipulator is used as laparoendscope. in order to evaluate the performance of this manipulator, the operation time of the test in the abdominal cavity simulator (fasotec inc.) was measured. the test is a contact test to multiple-targets, which is a test that bring a forceps contact multiple-targets in the abdominal cavity simulator according to the defined pattern. as a general comparison and evaluation target for this measurement result, it is compared with the case using the same access method as the conventional rigid endoscope. in this test, the number of contacts between forceps and laparoendoscope were recorded by using electrical device. subjects (n= ) are adult men who trained the peg transfer in the above simulator. it was compared of total operating times of the test and the field of vision obtaining each device. from these results, using the suggested manipulator device rather than using rigid laparoscope a satisfactory field of vision is obtained, and it is possible to short the operating time approximately seconds, and to small the number of contacts significantly. therefore it was shown that the effectiveness using the suggested manipulator device. for this reason, use of this device is expected to facilitate the complex surgical operation. additionally, it is performed para ablative operation of swine liver tissue in the abdominal cavity simulator, as previous step of clinical test. the operative field in this test was surveyed, the refinements of this manipulator for improvement performance were described in this report. yoshiyuki usui, md, phd, ichiro akiyama, md, phd, hironori kunisue, md, phd, hideaki mori, md, phd, tetsuya ota, md, phd; okayama medical center background and methods: we have performed approximately cases of gasless endoscopic thyroid surgery since for years. this surgery was performed through a small subclavian incision and using a wire traction and inserting an endoscope. we have modified and improved our surgical techniques by inventing various surgical instruments. here we introduce four newly invented surgical instruments, chronologically. results: we made u-retractor ( ), u-trocar ( ), u-kelly forceps ( ), and u-suction tube retractor ( ). all surgical instruments were modified from conventional surgical instruments. the u-retractor was a piercing retractor, each end of which had a sharp tip and a retractor. this retractor was inserted from the -cm working port outside the body and retracted the muscles effectively. the u-trocar was reversely set from inside to outside to make the working space wider. the u-kelly forceps which had a special ratchet were made to dissect loose connective tissue around the thyroid gland avoiding injury of the recurrent laryngeal nerve. the u-suction tube retractor facilitated a wider working port and eliminated the mist created by the ultrasonically activated scalpel effectively. recent data showed no difference of operative time, hoarseness, blood loss and hospital stay between conventional thyroid lobectomy and gasless endoscopic lobectomy. conclusion: gasless endoscopic thyroid surgery has been improved in the last years. this procedure made the excision of not only benign thyroid tumors but also small thyroid carcinomas. this operation is still cost effective, because almost all surgical instruments are reusable and is a satisfactory experience to both the patients and surgeons. objective: to put forward the importance of complete (r ) resection for the treatment of retroperitoneal tumors increasing overall survey. methods: in this study; patients having the diagnosis of retroperitoneal tumors with different histopathological subtypes whom were hospitalized in emergency surgery department of istanbul medical faculty between the years of and were evaluated retrospectively. the database of the department was analyzed. operational backgrounds, histopathological results, radiological evaluations, and assesments about relapses, and overall survey were obtained from the medical archieve. results: the average follow-up time was , years. all of the patients included into the study were undergone operations. the average time of hospital stay was calculated as days. of the patients were found to have positive surgical margins in their histopathological evaluations. overall mortality rate of the study was % ( / ). we have observed a direct correlation between complete (r ) resection and disease-free survival. patients having relapses had worse prognosis in terms of overall survey ( % mortality rate). after having done the statistical evaluation, surgery was found to be the main determining factor for the assesment of overall survey. conclusion: reference to an experienced and multidisciplinary surgical center after an early diagnosis has upmost importance for the treatment of retroperitoneal tumors. surgical approach constitutes the main element in the management. overall survey is directly correlated with complete (r ) resection. novel fluorescent dyes for real-time, intraoperative, organ-specific visualization of biliary and urinary systems using dual-color near-infrared imaging ; children's national health system, nih/nci p multidisciplinary approach for management of necrotizing pancreatitis: a case series prabhu senthil-kumar university of alberta, centre for the advancement of minimally invasive surgery introduction: the objective of this study was to systematically review the bariatric surgery literature to understand how weight loss is reported. the incidence of obesity has increased globally. according to the world health organization more than million were obese in . in the last decade, bariatric surgery has been increasingly utilized as an effective treatment option for severely obese patients. currently, bariatric surgeries are among the most commonly performed operations. the primary outcome of such procedures is weight loss which has been shown to vary according to the type of surgery. however, there are different methods used to report weight loss which makes it difficult to directly compare outcomes between studies. a previous review by dixon et al. in revealed a wide heterogeneity in weight loss reporting. however, there have been no recent reviews on the reporting of weight loss in bariatric surgery. methods: a search of the medline electronic database was performed for studies published in using search terms gastric bypass/sleeve gastrectomy, weight, human, and english. articles were selected by two independent reviewers based on the following inclusion criteria: ( ) adult participant ≥ years predictive factors for excess body weight loss after bariatric surgery in japanese obese patients takeshi naitoh hypertension resolution after rapid weight loss: a single institution experience cristian milla matute reoperative bariatric surgery: analysis of indications and outcomes: a single center experience iman ghaderi objective: to observe the effects of duodenal-jejunal transit on glucose tolerance and diabetes remission in gastric bypass rat model. method: in order to verify the effect of duodenal-jejunal transit on glucose tolerance and diabetes remission in gastric bypass, twenty-two type- diabetes sprague-dawley rat model established through high fat diet and low dose streptozotocin (stz) administered intraperitoneally were assigned to one of three groups: gastric bypass with duodenal-jejunal transit (gb-djt n= ), gastric bypass without duodenal-jejunal transit (rygb n= ) and sham (n= ). body weight, food intake, blood glucose, as well as meal-stimulated insulin, and incretin hormones responses were assess to ascertain the effect of surgery in all groups. oral glucose tolerance test (ogtt) and insulin tolerance test (itt) were conducted three and seven weeks after surgery. results: comparing our gb-djt to the rygb group, we saw no differences in the mean decline in bodyweight, food intake, and blood glucose -weeks after surgery. gb-djt group exhibited immediate and sustained glucose control throughout the study outcomes with sham operation did not differ from preoperative level. conclusion: preserving duodenal-jejunal transit does not impede glucose tolerance and diabetes remission after gastric bypass in type- diabetes sprague-dawley rat model is bariatric surgery effective for comorbidity resolution in super obese patients? methods: a retrospective analysis of outcomes of a prospectively maintained database was done on obese patients with a diagnosis of at least one or more of the following comorbidities-t dm, htn, osa, or hld-at the time of initial visit who had undergone either a sleeve gastrectomy (sg) or a roux-en-y gastric bypass (rygb) at our hospital between and . the patients were stratified based on their preoperative body mass index (bmi) class: bmi methods: we retrospectively reviewed all patients that underwent laparoscopic sleeve gastrectomy (lsg) at our institution from - . common demographics and comorbidities were collected as well as creatinine, preoperatively and up to hours after surgery. the renal function was calculated using the ckd-epi formula, derived and validated by levey et al. acute kidney injury was defined as an increase in serum creatinine by ≥ . mg/dl within hours after surgery. all tests were two-tailed and performed at a significant level of . . statistical software r, version . . ( - - ) was used for all analyses. results: of the patients reviewed conclusion: the impact of laparoscopic sleeve gastrectomy in renal function is evident within the first hours after surgery. patients undergoing lsg, especially patients with baseline chronic kidney disease stage ≥ are at increased risk of developing acute kidney injury in the perioperative setting the body mass index (bmi), fasting plasma glucose (fpg), glycosylated hemoglobin (hba c), serum triglyceride, serum cholesterol and blood pressure of all patients were measured before and at months after surgery. the results were collected and analyzed. results: patients suffered from metabolic disease undertook lsg surgery successfully (a mean age of years), were male and were female. all of patients suffered from obesity and the mean bmi of them was . ± . kg/m before surgery. among them, patients had type diabetes mellitus (t dm), patients had hypertriglyceridemia (htg), patients had hypercholesterolemia (hc) and patients had hypertension. the mean bmi of patients at months after surgery was . ± . kg/m and decreased significantly (p. ). the mean excess weight loss (ewl%) of patients was . %± . %( %* %) at months after surgery. the average levels fpg, hba c of t dm patients at months after surgery were . ± . mmol/l, . %± . % methods: we retrospectively reviewed all patients who underwent bariatric surgery from to . we assessed kidney function using the chronic kidney disease epidemiology collaboration (ckd-epi) and cardiovascular risk using framingham risk score (frs) equation pre-operatively and at and months of follow-up. our population was divided into two groups: patients with ckd stage ≥ (gfr\ ml/min) and patients with normal gfr. significance. results: of the , patients reviewed, . % (n= ) met the criteria for ckd-epi glomerular filtration rate (gfr) and framingham risk score (frs) calculations. after matching, patients ( . %) were left to analyze, % (n= ) of which had a laparoscopic sleeve gastrectomy. eighty-six patients ( %) had an impaired kidney function (ckd≥ ) (group ) and patients ( %) had a normal gfr (group ). common demographics and comorbidities after matching are described in table . the mean creatinine in group was . ± . mg/dl versus . ± . mg/ dl in group (p
). glomerular filtration rate was . ± . ml/min in group and ± . ml/min in group . furthermore, when the frs was calculated at months follow-up, patients with impaired kidney function had an absolute risk reduction of . % corresponding to a relative risk reduction (rrr) of group . the percentage of estimated bmi loss was found to be similar in both groups ( . ± . and . ± . respectively p= . ). conclusions: bariatric surgery, especially lsg, has a positive impact on kidney function particularly in patients with chronic kidney disease stage or greater. despite these patients having a higher preoperative cardiovascular risk, they showed similar risk reduction when compared to patients with normal kidney function at months of follow-up the impact of socioeconomic factors and indigenous status jerry t dang only ( . %) patients underwent urgent conversion for management of complications after sg. three patients had intraoperative complications necessitating blood transfusion. fourteen ( . %) patients required readmission within days postoperatively. six patients ( . %) required surgical interventions including for gastrointestinal leak, for hemodynamic instability, for a cecal perforation, and for a small bowel obstruction. there were no mortalities within the first year of revisional surgery. in patients with bmi[ kg/m at the time of revisional surgery, at the median postoperative follow-up of (interquartile range, - ) months, a median (interquartile range, - ) kg/m reduction in bmi was observed. overall, ( . %) patients had persistent type diabetes at time of revisional surgery. improvement of diabetes was observed in patients ( . %) after conversion of sg to rygb. among patients with gerd symptoms, subjective symptomatic relief was reported at the last follow-up. conclusion: weight recidivism is the most common indication for revision of sg objective: to evaluate laparoscopic mini-gastric bypass in the treatment of morbid obesity. method: three hundred patients with a mean bmi of . . kg/m underwent a laparoscopic mini-gastric bypass between to . a laparoscopic approach with five trocar incisions was used to create a long narrow gastric tube; this was then anastomosed ante-colically to a loop of jejunum cm. distal to the ligament of treitz peri-operative and short-term follow-up results up to does age or preoperative bmi influence weight loss after bariatric surgery? one-way anova or the kruskal-wallis test was used to compare continuous data across all groups. subsequent analysis of categorical data was achieved by chi-square or fisher's exact test. statistical significance was accepted as p. . results: a total of patients ( % male) were analyzed. average age and preoperative bmi were . ( . ) years and . ( . ) kg/m , respectively. preoperative comorbidities included: diabetes ( . %), hypertension ( . %), hyperlipidemia ( . %), previous myocardial infarction ( . %), obstructive sleep apnea ( . %), chronic obstructive pulmonary disease ( . %), gastroesophageal reflux ( . %), tobacco use ( . %). the asa classes of patients undergoing sg were ii ( . %), iii ( . %), and iv ( . %). the follow up rate at , and months was . %, . %, and . %, respectively. the -day mortality and readmission rate were % and . %, respectively. the %ewl was not different among age groups at , or months for the total, male, or female cohorts. among preoperative bmi groups, %ewl was not different in any cohort at or months, but was different at months for the total cohort (p. ) and female cohort (p\ . ), and trended toward significance in the male cohort (p= . ). the highest %ewl was found to be in patients with preoperative bmi of - . there was no difference in -day mortality or readmissions among groups a crp≥ mg/dl had a sensitivity for a complication of % and a specificity of %. primary bariatric surgery patients with a post-operative complication had higher crp levels compared to those who did not ( . ± . mg/dl vs . ± . mg/dl; p= . ). there was no difference in crp levels for patients with a -day reoperation or readmission. there were no mortalities. conclusions: bariatric surgery patients with elevated post-operative crp levels are at increased risk for -day complications. the low sensitivity of a crp≥ mg/dl suggests that a normal crp methods and procedures: the patients, who formed the previously published cohort, were contacted and their charts were reviewed. follow-up visits, symptom severity scores, and any subsequent medical or surgical interventions were collected. symptoms were assessed using the symptom severity score (sss) and the gastroparesis cardinal symptom index (gcsi) questionnaires. success was defined as a sss of or less. results: out of original patients, patients ( males, females) were available for follow-up ( patients declined participation, were lost to follow-up, patient was deceased, and was excluded after undergoing esophagectomy for unrelated indication) mbbs ; grant government medical college and sir jj government hospitals methods and procedures: twenty-six nh patients with dm were prospectively randomized to undergo either lrygb or lsg. patients were followed for -years with primary end points consisting of total weight loss (twl), percent excess body weight loss (%ebw) and impact on dm as measured by fasting blood glucose (fbs) and hba c. in addition, baseline, week, and , , , , and months post-operative levels of glucagon-like peptide (glp- ), peptide yy (pyy), leptin, and ghrelin were collected. results: a total of / patients completed follow-up. the %ebw at year for lrygb and lsg were % and %, respectively. resolution of dm occurred in / patients, the remaining three subjects were in the lgs arm. pre-operative fbs in lrgyb and lsg groups, were and , respectively. pre-operative hba c in the lrygb and lsg groups, were . and . , respectively. fbs at year for lrygb and lsg were and , while hba c for lrygb and lsg were . and . , respectively. a consistent post-operative decrease in fbs was only seen in lrygb. lrygb ghrelin percentages increased at , , and months, while levels decreased in lsg. leptin percentages decreased in both groups. the ppy levels remained relatively unchanged in both groups. lrygb glp- levels increased at week, , , and months. lsg glp- trends were similar except at months where glp- levels decreased. conclusion: lrygb and lsg resulted in equivalent post-surgical weight loss and resolution of dm in the nh population video assisted thoracoscopic thymectomy (vats) has emerged as a minimally invasive alternative to the standard transsternal approach. we present herewith the surgical and neurological outcomes after vats their operative time, blood loss, conversion rate and post operative parameters like intensive care unit (icu) stay, inter-costal drainage (icd) indwelling time, hospital stay were recorded. neurological outcomes were assessed based on myasthenia gravis foundation of america (mgfa) post intervention status classification. statistical analysis was done using stata software. results: ninety patients underwent thoracoscopic thymectomy during the study period. vats was done through right approach in ( . %), left approach in ( %) bilateral approach in patients ( %) and subxiphoid approach in ( . %). there was conversion to open approach in ( . %) patients due to dense adhesions at westchina hospital of sichuan university were included. all of the operations were performed by a single skilled surgeon. we divided our patients into two groups based on whether isao was used. of them, patients received isao for lps and patients received lps without isao. surgical skills and safety were evaluated. results: there were no significant differences in preoperative patients characteristics of the two groups. significantly less intraoperative blood loss( . ± . ml vs . ± . ml; t=− . , p= . ) were observed in group of isao conclusions: isao is technically feasible, safe surgical skills for patients reveived lps, and its represents an effective method to decreased intraoperative blood loss. p modular laser-based endoluminal ablation of early cancers: in-vivo dose-effect evaluation and predictive numerical modelling giuseppe endoscopic submucosal dissection enables en-bloc removal of early gastrointestinal neoplasms. however, it is technically demanding and time-consuming. laser-based ablation (la) techniques, are limited by the lack of depth penetration control and thermal damage (td) prediction. our aim was to evaluate a predictive numerical modelling (pnm) of the td to preoperatively select the optimal power and exposure time enabling a controlled ablation down to the submucosa (sm). additionally, the ability of confocal endomicroscopy (ce) to provide information on the td was assessed at the histology, there was an increased damage depth per higher j applications. the r value at . j was . ± . , and was significantly lower when compared to energies from j (r= . ± . ; p. ) up to j ( . ± . ; p\ . ). safe m and sm ablations were achieved applying lower p settings ( . and w), at different t values, leading to an mp impairment only in and % of the cases, respectively. ce provided relevant images of the td, consisting in architecture's distortion and disappearance of the gland's contours. the predicted damage depth we also analyzed early gastric cancer patients who received lpg-ip with cm jejunal interposition. anastomosis procedure was overlap method for eshophagojejunostomy and gastrojejunostomy, feea for jejuno-jejunostomy. results: the comparison between otg/opg-ip shows no significant difference in perioperative complications and qol scores, significant smaller body weight loss in opg-ip group. lpg-ip group also shows good result in short term outcomes. consideration: as comparison in open surgery implies superiority in jejunal interposition, we have introduced lpg-ip. esophagogastrostomy after proximal gastrectomy is simple but has a risk for sever gerd symptoms, no optimal procedure for reconstruction after proximal gastrectomy has yet been established. although laparoscopic jejunal interposition is relatively complicated in procedure, we can safely perform in combination with common anastomosis techniques. conclusion: body weight loss in otg-ip group is smaller compared to otg group consecutive patients with early gastric cancer underwent solo spdg (n= ) and mldg (n= ) performed by same surgical team. solo spdg can be defined as practice in which a surgeon operates alone using camera holder. mldg usually requires two or three surgical assistants. the inclusion criteria in this study were (i) pathologic proven stage i-ii gastric cancer (ii) no other malignancy (iii) more than d lymph node dissection (iv) r surgery. one-to-two propensity score matching was performed to compensate for the differences between two groups. results: after the propensity score matching, solo spdg (n= ) and mldg (n= ) patients were selected. mean operation time ( ± . vs ± . mins, p= . ) and estimated blood loss (ebl) ( . ± . vs . ± . ml, p= . ) were significantly lower in the solo spdg group than in the mldg group. the hospital stay and the use of pain control were similar between the two groups. although the initiation of semi fluid diet was similar, the time to first flatus was earlier in the solo spdg adhesional omental hernia: a case report an unexpected cause of small intestinal obstruction in crohn's disease strangulation inguinal hernia due to an omental band adhesion within the hernia sac: a case report omental adhesion, intestinal herniation, and unexpected death in the elderly small bowel obstruction secondary to greater omental encircling band-unusual case report the median operative time was min. the median postoperative hospital stay was . d. histological examination of the tumors revealed carcinomas, adenomas, and carcinoid. complications occurred in ( %) patients, viz., ssi (two patients), pancreatic fistula (two patients), bleeding (two patients), passing failure (one patient), and cholangitis (one patient). however, no severe postoperative complications (clavien-dindo classification grade or higher) were reported in these cases. conclusion: our cases showed that duodenal tumor resection using lecs enables curability through a minimally this study aimed to compare the outcomes of tltg with those of latg by using a meta-analysis. methods: we searched pubmed, embase, and cochrane library in may, to locate prospective or retrospective studies on surgical outcomes of tltg versus latg. the outcome measures were postoperative complications such as anastomosis leakage and anastomosis stenosis, operation time, blood loss, time to flatus, time to first oral intake, and postoperative hospital stay endoscopic thyroid lobectomy: our early experience at tertiary care hospitals of lahore univariate analysis was performed followed by logistic regression to identify independent predictors for the primary outcome. results: forty-six out of ( %) patients referred for gp required jt insertion to treat malnutrition. etiology of gp included: % idiopathic, % diabetic, % post-surgical. thirty-six patients ( %) reported severe daily symptoms. twenty-five patients ( %) had successful return to oral intake while ( %) required prolonged feeding access, reinsertion of a jt or tpn initiation. on multivariate analysis patients who had a pyloroplasty (p= . , or . ) and those who were married (p= . , or . ) were found to be independent predictors of successful discontinuation of tube feedings. on subgroup analysis -hour gastric emptying time normalized after pyloroplasty (p= . ) in patients which had a successful re-initiation of oral intake while persistent gastric emptying refractory to pyloroplasty was associated with failure. the group of patients who underwent pyloroplasty did not differ in terms of demographics, marital status (p= . ) and preoperative gastric emptying (p= . ) from those who did not. gp etiology (p= . ) psychiatric conditions (p= . ) and substance abuse laparoscopic transabdominal repair of morgagni hernia rebekah macfie average procedure length was . minutes. average hospital length of stay was . days, with all patients tolerating a regular diet prior to discharge. our -day readmission rate was / ( . %). / ( . %) patients required repeat egd evaluation for either recurrence of symptoms or impacted food bolus. at week follow-up, / patients ( %) complained of dysphagia and / patients ( %) had eliminated ppi from their daily medication regimen. at month follow-up, / patients ( %) complained of dysphagia and / patients ( %) had eliminated ppis. at year follow-up, / patients ( %) complained of dysphagia and / patients ( %) had eliminated ppis. conclusion: as a recently introduced surgical option, no long-term data exists detailing the linx procedures ultimate success rates and complication profile mini-laparoscopic vs traditional laparoscopic cholecystectomy: preliminary report deniz atasoy since the introduction of minilaparoscopic cholecystectomy (mlc) in , it gained little interest that could be attributed to decreased durability of the reduced size instruments, poorer optical resolution and smaller jaws of the instrument tips. our aim was to compare the outcomes of mlc with traditional laparoscopic cholecystectomy (tlc) one developed choledocholithiasis on postoperative day one and after ercp the course was uneventful. the other patient developed choledocholithiasis and acute pancreatitis on the sixth postoperative day and was treated conservatively. the stone in the ampulla had fallen by itself without a need for ercp single-incision plus one additional port laparoscopic surgery for colorectal cancer with transanal specimen extraction: a comparative study two patients had a previous attempt of hernia repair, one with mesh. one patient did not have any immunosuppression due to hiv infection, whereas the other were on cyclosporine, tacrolimus and/or mycophenolate mofetil. there were two laparoscopic and two open cases, mean operative time was . minutes ( - ), mean blood loss was ml ( - ). mesh used were biological porcine dermis in one case, polypropylene with absorbable hydrogel barrier in three cases. mean mesh length and width were cm ( - ) and . cm ( - ) respectively. one patient underwent a component separation, though none of the patients had the fascial defect closed. there were no intra-operative complications. three patients were readmitted for hyperkalemia, abdominal pain, and seroma respectively. neither recurrences nor reoperations were reported. mean follow-up was . days ( - ) conclusion: post liver transplant incisional hernia repair is feasible either laparoscopic or in an open fashion. because of the size and location of the defect, fascial closure is unlikely achievable. the use of standard techniques and materials give a similar result of the non-transplant population. p technique of esophagojejunostomy using orvil after laparoscopy assisted total gastrectomy for gastric cancer shinichi sakuramoto there was a significant difference in mortality between the two time-periods, / patients died during - and / died during - (p= . ). those who died were significantly older ( years ( - )) than the survivors ( y ( - )) (p= . ). five of the patients who died in the previous group died without any intervention. / of those who had an acute open necrosectomy died. surgical necrosectomy correlated significantly with mortality (p= . ). the only patient who died in the recent group died without any intervention. none of the patients receiving minimal invasive drainage in this group died until now only cases in adults and fewer than cases in children have been reported in world literature, with surgical management being the only option. an innovative, minimally invasive laparoscopic excision of the abdominal sac was performed and the scrotal component was managed by jaboulay's procedure. this is probably the first case report in world literature describing laparoscopic management of hydrocele-en-bissac. case report: a year old male presented with complaints of bilateral hydrocele and swelling in right lower abdomen since one year. computed tomography of the abdomen revealed an encysted hypodense lesion with enhancing walls along the right side of pelvis, anterior to the psoas muscle and extending through the internal ring into the right inguinal region upto the scrotal sac; measuring . cm . cm suggestive of an encysted hydrocele of cord associated with hydrocele of both scrotal sacs excessive gastric resection may result in postoperative deformity of the stomach, with consequent gastric stasis in food uptake. to minimize the resection of stomach tissue, especially for lesions close to the esophagogastric junction or pyloric ring, we have developed laparoscopic wedge resection (lwr) with the serosal and muscular layers incision technique (samit) for gastric gastrointestinal stromal tumors. this samit is simple and does not require special devices. purpose: the purpose of this study was to clarify whether lwr with samit for gastric gists is technically feasible in term of short-term outcome methods: all patients who went through lsg in our department between / to / have been evaluated for bleeding complications, after implementation of anti-bleeding policy: blood pressure was controlled to mmhg during stomach resection and staple line was reinforced throughout it's length with a running - absorbable v-lock suture. drains were used selectively. results: out of patients who went through the procedure ( . %) suffered hemorrhagic complications: patients had? hb[ gr%. patients received - red blood pc's. no patients were re-operated for bleeding. patients were readmitted for infected hematoma and had ct guided drainage. one patient ( . %) suffered from leak. conclusion: implementation of anti-bleeding policy in lsg is very effective. there is no need to use expensive buttress material to achieve these results. drains can be used selectively. the impact of this policy on leak rate needs to be fifty procedures immediately prior to, immediately after, and eight months after completion of training were included for each endoscopist. data were extracted from the electronic medical record and entered into spss for analysis. student's t-test was used to compare groups for continuous data, and chi-squared tests were used for categorical data. data were collected for procedures. patient groups pre, post, and eight months after csi training were comparable in terms of age ( . yrs, . yrs, and . yrs), sex ( it's in the bag; can stoma output predict acute kidney injury in new ostomates? robert fearn colostomy output stabilised rapidly, whilst ileostomy output increased progressively throughout the first postoperative days as can be seen in chart . twelve patients ( %) developed aki during index admission. length of stay was significantly greater in the aki group at ( % ci - ) days vs ( - ) days. highest daily stoma output was non significantly higher in the aki group ml ( % ci - , ml) vs , ( - , ml) as was mean daily stoma output at ml ( - , ml) vs ml ( - ml) (chart ). seventeen patients ( %) were readmitted for any reason, ( %) specifically for aki. in total patients ( %) developed aki within three months of their stoma surgery only of whom had developed aki during their index admission. all patients who developed aki following their index admission were ileostomy patients. conclusion: acute kidney injury in new stoma patients is associated with prolonged hospital stay and readmissions with associated morbidity and healthcare costs consecutive laparoscopic bariatric operations were performed, including primary roux-en-y gastric bypasses (lrygb), primary adjustable gastric bands (lagb), primary sleeve gastrectomies (lsg) and secondary bariatric surgeries and revisions. all bariatric procedures were approached laparoscopically ( procedures were stapled and were nonstapled). the mean patient age was years ( - ), females represented % and mean bmi was . kg/m ( - ). there were no perioperative mortalities, no conversions to open surgery and no intraoperative blood transfusions. there we two major intraoperative complications (hypopharyngeal perforation- , malignant hyperthermia- ). mean hospital stay was . days ( - days). eleven patients ( . %, in gastric bypass group and one in lsg group) required -day reoperations for postoperative complications (staple line gastrointestinal bleeding- , anastomotic leak- , strangulated port site hernia- , unexplained severe abdominal pain- , intestinal obstruction- , and intraabdominal abscess- ). there were no long term ( -year) mortalities in patients that required reoperation. there was one transfer to another institution. the dynamics of further improving safety was such that there was no complication on the recent consecutive stapled procedures and the mean hospital stay was . days ( - days). detailed subgroup analyses will be provided. conclusions: with well-controlled and structured pre-, intra-, and post-operative care, laparoscopic bariatric surgery can be performed with minimal reoperations and zero mortality in a teaching institution does concomitant placement of a feeding jejunostomy tube during esophagectomy affect quality outcomes? md, facs; icahn school of medicine at mount sinai background: placement of a feeding jejunostomy tube (fj) is often performed during esophagectomy. few studies, however, have sought to determine whether concomitant placement affects postoperative outcomes of esophagectomy of these, ldg was performed patients and odg was performed . we compared elderly patients (aged years or more) with younger patients in each operative procedure. (ldg: elderly , younger ; odg: elderly , younger ) preoperative comorbidity and surgical results were analyzed. multivariate analysis was performed to detect predictive factors for postoperative complications. results: in both ldg and odg groups, the operative time and amount of blood loss did not differ, while comorbidity was more common in elderly patients than in the nonelderly, and there were fewer retrieved lymph nodes in elderly patients. the incidence of all postoperative complications did not differ between both groups in each procedure, and there were no significant differences in the time to first flatus or postoperative hospital stay. however, in terms of specific postoperative complications, respiratory complications were more frequently observed in eldery group with odg significantly (p= . ), while not with ldg group. in multivariable analysis, age was not independent predictor of postoperative complications. conclusion: odg for eldery patients requires attention particularly in postoperative respiratory complications. ldg is a safe and less invasive treatment for gastric cancer in elderly patients who have greater comorbidity. p examining the role of preoperative ineffective esophageal motility in laparoscopic fundoplication outcomes tyler hall there were no significant differences in complications or recurrence rates. preoperative quality of life measures did not vary between the cohorts nor did postoperative scores at three weeks or six months. patients with % ineffective clearance exhibited worse gerd-hrql scores one and two years postoperatively conclusion: preoperative ineffective esophageal motility was shown to result in comparable short-term quality of life following ars. however, gerd-hrql scores at one and two yearsshowed worse outcomes in patients with preoperative iem robotic surgery as part of oncologically adequate ipmn treatment: indications, short and long term results federico gheza eligible patients who had minimally invasive surgery were stratified in multiport laparoscopic and robotic cohorts, and included if they had poi/sbo after surgery. comparative analysis assessed the demographic, perioperative, and postoperative outcomes. the main outcome measures were the incidence rate, associated variables, and time to ileus/ sbo across the mis platforms. results: during the study period total patients were reviewed- laparoscopic and robotic. postoperatively, ( . %) laparoscopic and ( . %) robotic patients suffered from poi/sbo laparoscopic sbo occur significantly later after the index procedure than robotic sbo ( conclusions: the rate of poi/ sbo is considerable and comparable across laparoscopic and robotic approaches. however, there are distinct differences in the severity, time to occurrence, and impact on quality measures, such as los and readmissions between laparoscopic and robotics. this information could be an important factor in which approach the surgeon choses laparoscopic surgical procedure was standard with using laparoscopic linear stapler. responses to surgery were evaluated a month after the operation based upon the american society of hematology evidence-based practice guidelines for itp. results: there was no open conversion in this study. the mean operation time and blood loss were min and g, respectively. there was no case using blood transfusion during and after operation. with regard to complications, one patient ( %) had a postoperative pancreatic fistula that did not require percutaneous drainage. positive responses, including the complete and partial remissions, were achieved in % ( / ). the mean follow-up duration was months, and the -, -, and -year relapse-free survival rates were % for all three time points. conclusions: the present study demonstrated that ls for itp can provide good long-term outcomes two cases of conversion from sp-c to open surgery were excluded. all procedures were followed postoperatively for a minimum of months, and wound complications such as bleeding, fat lysis, infection, or hernia were recorded. patients were classified as having a wound complication or not. results: pure transumbilical sp-c was completed . %, additional trocars were used in . %, and the rate of conversion to open surgery was . %. after a median follow-up of . (range, - ) months few cases performed with hand assist, notes, or single-incision. utilization of robotics was highest for bpd/ds ( of , cases, . %). the greatest number of robotic-assisted cases were sleeve gastrectomy ( , of , , . %) and gastric bypass ( , of , cases, . %). relatively few operations were converted to a different approach (see table). operative time was longer when using robotic approaches for both sleeve ( . vs . minutes, p. ) and bypass ( . vs . , p\ . ). postoperative los was no shorter when using robotic-assistance (see table). unadjusted -day outcomes revealed slightly higher rates of readmission for both operations when using robotic-assistance (see table), and slightly higher rates of complications after robotic sleeve gastrectomy p comparision of perioperative and survival outcomes of laparoscopic versus open gastrectomy after preoperative chemotherapy: a propensity score-matched analysis adjustment for potential selection bias in the surgical approach was made with propensity score-matched (psm) analysis. perioperative and survival outcomes were compared between the lag and og groups. results: in total, patients were identified from the database. after psm analysis, patients who underwent og were one-to-one matched to patients who underwent lag in the setting of nact. these two groups had similar outcomes in terms of intra-and postoperative complications and -year overall survival. however, the lag group had a longer operation time (p= . ) and lower estimated blood loss (p= . ). moreover, compared with patients in the og group, those in the lag group had fewer days until first ambulation conclusion: the present study indicates that lag performed by well-qualified surgeons for treatment of locally advanced gastric cancer after preoperative chemotherapy is as acceptable as og in terms of oncological outcomes. p outcomes of laparoscopic antireflux surgery for gastroesophageal reflux disease: effectiveness and economic benefits kyung won seo, phd; kosin university college of medicine purpose: laparoscopic antireflux surgery (ars) is an alternative treatment option for gastroesophageal reflux disease (gerd) in the world. however, the effectiveness and economic feasibility of ars versus medical treatment is unknown. this study was performed to evaluate the effectiveness and economic benefits of ars. methods: nine patients with gerd were treated using laparoscopic ars between and . surgical results and total cost for surgery were reviewed. results: seven men and women were enrolled. preoperatively, typical symptoms were present in patients, while atypical symptoms were present in patients. one patient underwent partial fundoplication due to absent peristalsis and the other underwent nissen fundoplication. postoperatively, typical symptoms were controlled in of patients, while atypical symptoms were controlled in of patients. overall, at months after surgery, reported partial resolution of gerd symptoms, with achieving complete control. the average cost of ars for nine patients was usd. conclusion: laparoscopic ars is effective for controlling typical and atypical gerd symptoms. the cost of ars may be more economical over the long term compared to medical treatment since laparoscopic surgery is reported to affect respiration and circulation, we should take indication of lag for elderly patients into consideration carefully. indication of lag for elderly patients, however, is still controversial. the aim of this study is to assess the safety and validity of lag for elderly patients. method: medical records were retrospectively reviewed for patients who underwent lag for gastric cancer between and . in this study, patients over years of age were defined as elderly patients. patients were divided into two groups according to age; group a (age ≥ , n= ), group b (age \ , n= ). preoperative characteristics and postoperative outcomes were analyzed. two-tailed student's test and/or pearson's chi-square test were used for statistical analysis. results: there were no significant differences in male/female ratio and body mass index between two groups. number of patients whose asa physical status was ≥ , and/or performance status was ≥ did not differ total gastrectomy ( . vs . %, p= . ), proximal gastrectomy ( vs . %, p= . ). intra-operative blood loss, operating time, and number of harvested lymph nodes did not differ between the two groups. as for postoperative complications such as intra-abdominal abscess ( . vs . %, p= . ), anastomotic leakage ( vs . %, p= . ), significant difference was not observed between the two groups. in addition, respiratory and cardiovascular complication was not observed in elderly patients. incidence of clavien-dindo classification ≥grade ( . vs . %, p= . ), and postoperative hospital stay ( . vs . days, p= . ) did not differ. conclusion: short-term outcomes of lag in elderly patients were not different from those in young patients the essential role of the transcystic duct tube (c-tube) during laparoscopic common bile duct exploration (lcbde) towakai hospital introduction: laparoscopic common bile duct exploration (lcbde) is a standard surgical procedure for the treatment of common bile duct stones (cbds). however, there are some problems associated with cbd drainage after operations even if performing with the primary closure. therefore, we developed a new drainage tube, c-tube, which contributes to shorter drainage periods and reduces perioperative complications. method: c-tube is a type of bile drainage tube which is fixed to the cystic duct with an elastic band. closing the duct with an elastic band as soon as c-tube is removed prevents bile leakage from the stump of the cystic duct. the essential roles of this tube include: . assisting suturing during operations, . use during intra-and post-operative cholangiograpy, . assisting post-operative endoscopic sphincterotomy when necessary we included patients from -years prior to our intervention and compared this with patients who had follow-up after implementation. we excluded patients having revisions, gastric banding, and patients whose primary surgeon had left during the data collection period. we analyzed demographics and follow-up rates at , , , , and months. chi-square test was used to evaluate for significance, and results were corrected for multiple comparison. results: patients met inclusion criteria in the pre-intervention group, and in the postintervention group. of those, were analyzed for the year follow-up visit. the pre-intervention group had males, females, and an average age of . approximately / of the surgeries performed were sg, / were rygb. the post-intervention group had males, females, average age of . approximately half of the post-intervention cases were sg while the rest were rygb. conclusion: bariatric surgery is a useful tool in aiding weight loss and improving comorbidities. it is essential that patients receive long-term follow-up and monitoring to achieve these goals. our program now uses a system of phone call reminders for scheduled visits, as well as calls and letters for annual visits surgeon's evaluation of an intraoperative microbreaks web-app workload questions were modified nasa task load index (physical demand, mental demand, and complexity) and procedural difficulty on - ( =maximum impact) scales. primary outcomes were the impact of microbreaks on surgeons' physical performance, mental focus, pain/discomfort and fatigue with checkboxes for improved, no change and diminished. secondary outcomes were microbreaks impact on distraction level and workflow disruption using a - ( =maximum impact) scale. descriptive statistics were calculated for median and interquartile ranges (iqr) of these responses. results: seven surgeons ( male, female), with a median (iqr) surgical experience of ( . , ) years, completed ten surgical days with a median (iqr) operative duration of ( , ) minutes/surgical day. the median number of microbreaks/surgical day was . the median (iqr) for mental demand, physical demand, surgical complexity and difficulty are shown in table . following each surgical day, surgeons reported / improved physical performance situs inversus totalis (sit) is inherited in an autosomalrecessive fashion with complete abnormal transposition of thoracic & abdominal viscera. its incidence varies from in to live births. for those undergoing surgery, laparoscopic approach is preferred as it avoids inappropriate incisions. however, due to mirroring of the viscera, the surgeon faces constant visio-spatial disorientation during laparoscopy. p ''how to be a surgeon and not dying trying'' control of basic physiological parameters in perioperative phase second main variable: blood pressure (bp) with manual measurement sleeve. preoperative bp and immediate postoperative bp were measured, we were not able to measure intraoperative bp due to the lack of consent of the surgeons involved for the use of other devices different from the heart rate band. secondary variables: years from graduation, years of practice, age, body mass index (bmi), number of medical co-morbidities, number of jobs, sleeping hours the night before. we took measurements to surgeons during a laparoscopic cholecystectomy. results: the mean preoperative heart rate was . bpm. the mean minimum intraoperative heart rate was bpm. the mean maximum intraoperative heart rate was . bpm ( % with tachycardia at the surgery). the mean immediate postoperative heart rate was . cpm. the mean heart rate minutes after the postoperative phase was . cpm. at the immediate preoperative phase % of surgeons had elevated bp level (usual normotensives) articles were randomly selected and the gender of the first and last authors determined. results: of the bariatric surgery publications reviewed, only % of first authors and . % of last authors were female surgeons. even though the proportion of female authors has increased over time, this is not proportional to the increase in the number of female surgeons or surgery residents (figure ). discussion: female surgeons are under-represented in bariatric surgery research. the number of female surgeons and residents has a continuous up trend over the last few decades our survey also included the validated quick-dash (disabilities of the arm, shoulder, and hand) questionnaire for upper-limb symptoms and the ability to perform certain physical activities. the quickdash is scored into two components: disability/symptom score, and the optional work module, which represent the impact of disability on daily activities and work responsibilities, respectively. both scores range from - , with a higher score indicating greater disability. surgeons were grouped according surgical focus (open, lap, or ra), and comparisons were made between groups. surveys with more than % of responses missing were excluded. statistical analysis were done using spss . , with α= . . results: completed surveys were evaluated (open: n= , lap: n= , ra: n= ). the survey response rate was %. . % of respondents were general surgeons, and mean age was ± . years. surgeons reported an average of ± . cases performed per month ra: . %, p= . ). likewise, there were no differences in the mean disability similarly, there was a positive correlation between mean work scores and reported pain in the upper-limb for lap and ra, both p. . conclusions: this nationwide survey revealed a similar prevalence of pain in the upper-limb among surgeons performing open, laparoscopic and robotic-assisted procedures. likewise, similar disability scores were reported between the three surgical groups. older surgeons performing laparoscopic and robotic-assisted approaches reported a higher impact of upper-limb problems interfering with their daily activities, unlike open surgeons. among all surgeons who reported pain in the upper-limb, laparoscopic and robotic surgeons were more likely to report that this pain interferes with their work activities an analysis of subjective and objective fatigue between laparoscopic and robotic surgical skills practice p d laparoscopic versus robotic gastrectomy for gastric cancer: comparisons of short-term surgical outcomes lin chen, xin guo patients who underwent d-lag (n= ) or rag (n= ) for gastric cancer were enrolled. the clinicopathological factors and short-term surgical outcomes were compared with retrospectively analysis. results: the clinicopathological factors between the two groups were well matched. postoperative recovery factors including the days of first flatus, days of eating liquid diet and hospital stay were similar. the rate of postoperative complications between the two groups were with no statistical differences in the subgroups of patients with total gastrectomy, d-lag had less blood loss and shorter operative time than rag (p= . and p. ), while for distal gastrectomy, blood loss and operative time showed no statistical differences. conclusions: this study suggests that d-lag is a novel and acceptable surgical technology in terms of surgical and oncological outcomes. d-lag is a promising approach for gastric cancer therapy methods: patients underwent robotic surgery between the beginning of to first half of in turkey were included. data were obtained from a prospectively maintained database. patient, surgeon and hospital identifiers were encrypted. parameters were operation type, operation year, robotic system used (s, si, xi), hospital volume and surgeon volume. high volume robotic colorectal hospital and surgeon was defined as the caseload within the forth interquartile ( th- th) based on the median value. results: there were colorectal procedures. surgeons performed robotic colorectal surgery at hospitals. ( . %) and ( . %) procedures were performed with the s-si and xi platforms respectively. hospitals have both of the si and xi platforms. hospitals are the si, hospitals are the xi hospital currently. the number of robotic colorectal operations increased gradually by years (figure ). the median numbers of colorectal procedures were (range - ) and (range - ) per hospital and per surgeon respectively among those hvrcs, the numbers of si and xi users were and respectively. the surgeons who performed more than procedures continued to use robot in their practice except one surgeon who stopped at . only left colectomies and no right colonic resection were performed before introduction of the xi platform first robotic cases and implementation of a robotics curriculum in a general surgery residency domenech asbun armonk ny) and utilized student's t test and chi-square. we also performed a linear regression analysis to determine the effect of or time, robotic surgery, and diagnosis on operating room costs and postoperative length of stay. results: laparoscopic and robotic cholecystectomies were performed. demographic parameters (age, gender, medical comorbidities, preoperative albumin and bmi, surgical history and smoking) were comparable. primary diagnosis was significantly different (chi-square . ), driven by more acute cholecystitis in the laparoscopic group. / robotic cases and / ( . %, p = . ) laparoscopic cases were converted to open ( for adhesions, for failure to progress, and for visualization of anatomy after adjusting for or time and diagnosis, robotic surgery was associated with a $ increase in costs robotic surgery is independently associated with increased or cost, but individual hospital systems must decide if this additional cost outweighs increased robot utilization and training benefits for physicians and staff robotic abdominal wall hernia repairs: technical considerations and lessons learned inguinal hernia repairs (ihrs) comprised the majority ( . %) of cases ( . % male, mean age . , mean bmi . ). there were unilateral ihrs with an average operative time of . ± . min and an average ebl of . ml. there were bilateral ihrs with an average operative time of . ± . min and average ebl of . ml. thirteen ihrs were combined with umbilical hernias and two with incisional hernias. average operative time for combined procedures was . min and average ebl was . ml. fifty-five incisional hernias were repaired robotically ( . % male, mean age . , mean bmi . ), four of which were retrorectus and two of those required transversus abdominis release. median hernia size was cm ( - cm). mean operative time was . ± . min and average ebl was . ml. twenty-three ventral/umbilical hernias were repaired robotically ( . % male, mean age . , mean bmi . , median size . cm ( - cm), mean operative time . ± . min, average ebl . ml). one spigelian hernia (operative time min, ebl ml) and one parastomal hernia (operative time min, ebl ml) were repaired robotically. there were no major complications and only groin seroma requiring percutaneous aspiration. nine patients required conclusion: this study demonstrates improved outcomes of robotic inguinal hernia repair compared to an open or laparoscopic approach. robotic hernia repair showed overall lower -day complication and readmission rates, and shortened los. while open approach had the highest rate of opiate use we retrospectively investigated consecutive overweight gc patients (bmi≥ ) underwent distal gastrectomy with d lymphadenectomy ( for rag and for lag) performed by two surgeons. the clinicopathological and surgical features were compared between groups. the cutoff point for initial phase (phase i) and stable phase (phase ii) were determined by cumulative sum (cusum) curve of operation time. results: generally, the surgical outcomes including postoperative complication rate, duration of postoperative hospital stay and lymph nodes harvest in the overweight patients have comparable results between rag and lag groups. the cutoff determining phase i and ii according to the cusum figure for rag group was and cases for surgeon a and b, respectively. and comparison analysis showed that the operation time of phase ii rag was significantly shorter robotic-assisted transabdominal preperitoneal inguinal herniorrhaphy: a single-center experience including perioperative morbidity and short-term outcomes patient factors, treatment factors, and outcome measures were collected in an attempt to gain insight and to generate ideas to potentially improve outcomes. results: there were no operative complications. six patients ( %) had failed gastric pacemaker placement prior to intervention. nine patients ( %) reported improvement in their symptoms and overall quality of life. four patients ( %) reported no improvement in symptoms and required additional intervention for symptom control and supportive care (one underwent roux-en-y gastric bypass, three underwent laparoscopic jejunostomy feeding tube placement to maintain nutrition). conclusion: robotic-assisted pyloroplasty is a safe option that improves symptoms and quality of life in % of our patients patients were matched into cohorts by procedure type. outcomes were analyzed using unpaired t-test and fisher's exact test. results: cost data was available for patients undergoing ras or la procedures. significant increases in equipment, labor, and overhead costs resulted with ras vs. la. variable-labor and variable-overhead costs were significantly higher in la procedures. higher supply costs and longer procedure time was seen with ras in all cohorts however, total -day costs were not significantly different in any group. conclusion: ras led to significant increases in fixed clinical, operative and pathologic factors were reviewed and analyzed. results: seventy patients underwent robotic surgery for rectal cancer during the study period. the locations of tumor were upper rectum, lower rectum. the procedure were as follow, high anterior resection in , low anterior resection in , isr in , apr in patients. eight patients underwent bilateral lymph nodes dissection (llnd). the procedures were performed successfully in all cases. mean age was . years, and % of the patients were men, and the mean body mass index was . (range, . - . ) kg/m . median operative duration was ( - ) minutes. median blood loss was ( - ) ml. median postoperative stay was ( - ) days. mean harvest lymph node number was . ( - ). surgical margins were negative in all cases. there was one conversion due to bleeding during the llnd and anastomotic leakage occurred in two patients. morbidity was %. there was no mortality postoperatively in this series. conclusion: in early series of the selected patients, this technique appears to be fesible and safe when performed by surgeons skilled in laparoscopic colorectal surgery the inactive electrode was placed touching small bowel to simulate accidental thermal injury. the bowel tissue at the site of temperature change was immediately resected and examined histologically for tissue injury. student t-tests were used for all comparisons with a p-value less than . considered statistically significant. results: comparison of the laparoscopic and robotic techniques are displayed in table . energy transfer was quantified using energy leak (per ma), which in these tests averaged . degree celsius change ( % ci . - . ) at the inactive electrode. surface temperature heated to a maximum of . degrees celsius, more in the robotic system than laparoscopy but still clinically negligible. pathology results from in vivo testing showed only thermal injury to the serosa without deeper mural injury. conclusions: stray energy transfer occurs in both laparoscopic and robotic surgery in amounts that are measurable but without clinical relevance. the average change in tissue temperature is less than degrees celsius laparoscopically and less than degrees robotically. while the robotic surgery appears to transfer more stray energy, no significant bowel injuries were caused in either group. p robot assistance can improve the performance of laparoscopic extensive concomitant adhesiolysis: results from a large observational study federico gheza outcomes compared were operative time, conversion rate, overall complications, gastrointestinal (gi) related complications (wound infection, abdominal abscess, anastomotic leak, ileus and small bowel obstruction), hospital length of stay, and -day re-admission rate. two sample t-test was used and p. was considered statistically significant. results: fifty-five robotic colectomies were matched with laparoscopic counterparts based on type of operation: right colectomy (n= ), sigmoidectomy (n= ), low anterior resection (n= ), proctocolectomy (n= ), transverse colectomy (n= ), abdominoperineal resection (n= ), and total abdominal colectomy (n= ) we assessed if technical obstacles of laparoscopic suturing were decreased and if laparoscopic skills overall were improved. surgical outcomes were compared relative to our historic values; we assessed procedure time and operating room efficiency, including set up and turn-over times. results: overall, the d/flexdex system permitted a greater improvement in working speed, superior optical visualization, and better suture handling compared to standard laparoscopy. all surgeries were completed without any complications. historically, we considered laparoscopic suturing to be complicated and inefficient. we relied on tacking devices for mesh fixation, suturing was previously completed with large cumbersome straight laparascopic devices. however, with flexdex and endoeye flex d, tacking devices have been eliminated and suturing technique improved. the mean total procedure times remained comparable for inguinal and hiatal hernia surgeries, and slightly longer for ventral hernias. operating room efficiency, including mean set up and turn-over times also remained unchanged. the acquisition cost for both the olympus endoeye flex d laparoscopic imaging system we performed a cost analysis which showed an average total cost of $ , for laparoscopic sleeve gastrectomy and an average of $ , for robotic assisted. the total reimbursements were $ , for laparoscopic sleeve gastrectomy and $ , for robot assisted. this translated to an average contribution margin of $ , for laparoscopic vs $ , for robot assisted. we analyzed these differences for bypasses as well. laparoscopic bypasses averaged minutes laparoscopically vs robotically. we found an average cost of laparoscopic $ , vs robot assisted $ , , with a contribution margin of $ , laparoscopic vs $ , robot assisted. conclusions: in our study we noted increased operative times with robot assisted operations, especially bypasses which could be explained by increased use of the robotic system for difficult cases such as revisional bypasses. the impact of cost is especially important in this financial climate, and judicious use of resources becomes important when determining surgical approach average or time for rih was minutes compared to lih which was minutes. average intraoperative cost for rih was $ , compared to lih which was $ . of note, one lih was converted to open, whereas none of the rih required conversion. average los was . hours for rih compared to . hours for lih. postoperative pain at one week follow up was the same between both groups. two postoperative surgical site occurrences (sso) occurred in the lih group ( groin seromas), whereas no ssos occurred in the rih group. eleven ventral hernia repairs were examined, were robotic (rvh) and were laparoscopic (lvh). average or time for rvh was minutes compared to minutes for lvh. average intraoperative cost for rvh was $ , compared to lvh which was $ , . no procedure from either group required conversion to open. average los was . hours for rvh, and . hours for lvh. again, postoperative pain was the same at one week follow up for both groups. there were no postoperative complications noted in either cohort. conclusion: operative time and procedural costs for rvh and rih repairs were shown to be longer and more expensive when compared to their laparoscopic counterparts. however, with increased operative experience using the robotic platform, surgical time did show a decreasing trend does robotic system have advantages over laparoscopic system for distal pancreatectomy? results: a total of consecutive patients underwent minimally invasive distal pancreatectomy (ldp n= ; ra-ldp n= ). most common pathologic finding was pancreatic ductal adenocarcinomas ( cases). there was no in-hospital mortality or cases of conversion to open surgery in this study. spleen-preserving approach was performed more often in the ra-ldp ( %) than in the ldp ( . %) groups (p= . ) both groups showed no significant differences in the total number of lymph nodes, number of positive lymph nodes, tumor differentiation, tumor stage, and resection margins. conclusions: ra-ldp is a safe and feasible approach that has an advantage of performing spleenpreserving distal pancreatectomy, with perioperative and short-term oncologic outcomes comparable to those of ldp. p robot-assisted alpps technique mike fruscione right portal vein embolization was not feasible secondary to the proximity and size of the right hemi-liver tumor burden relative to the right portal vein. the pre-operative planned procedure was a right trisectionectomy and microwave ablation of the segment lesion. results: using the da vinci xi surgical system (intuitive surgical, inc.) the right portal vein was dissected, doubly-ligated, and divided. the liver parenchyma was split from the inferior edge to the dome mm medial to the falciform ligament and down to the middle hepatic vein which was preserved to maintain adequate venous outflow. the patient was discharged home on post-operative day two. on post-operative day six, ct volumetrics demonstrated a flr of %. on post-operative day seven, a second stage alpps procedure was performed where the right hepatic artery, middle and right hepatic veins and right hepatic duct were ligated and divided. segments a/b, , , and were removed. the patient was discharged home on post-operative day five they were asked to answer demographic questions and rate their comfort level ( =not comfortable, =very comfortable) with aspects of robotic surgery. paired t-tests and wilcoxon tests were used to assess whether there were changes in comfort level before and after labs, and chi-square goodness of fit tests were used to assess whether dry lab (using inanimate objects), wet lab (using a porcine model), or simulator modules were thought to be most helpful in obtaining specific robotic skills. results: the survey response rate was % (n= ). ninety-one percent of residents felt that robotic surgery is not intuitive. prior to simulation, % of residents felt inadequately prepared to safely operate on the robotic console. following simulation, % felt better prepared and more confident to participate in robotic surgery for the first patients whom we treated (the first-stage group), we invited a visiting expert from a high-volume center to perform the procedure jointly with our hospital's surgeons by using a dual console. for the subsequent patients (the second-stage group), the procedure was performed by our hospital staff alone. in this report, we describe our experience of introduction of robotassisted colectomy and discuss issues for the future. patients and methods: the operative procedure was sigmoid colectomy, low anterior resection, and intersphincteric resection. the median number of lymph nodes dissected was . . the mean operating time was minutes for the first-stage group and minutes for the second-stage group. the median console time was minutes for the first-stage group and minutes for the second-stage group, with no significant differences between the two groups. the mean operating time other than console time was minutes for the first-stage group and minutes for the second-stage group, significantly longer in the latter group. the mean amount of hemorrhage was . g in the first-stage group and g in the second-stage group. no significant differences were found between the two groups in the mean length of postoperative hospital stay. none of the patients in either group developed a complication of clavien-dindo grade iii or higher. conclusions: the use of dual console system was particularly useful for the introduction of robotassisted surgery in our hospital. for the patients whom we treated, we found almost no difference in console time between the first-and second-stage groups. the high-quality instruction received via the dual console was considered to have had a beneficial effect on the operators' learning curve. however, the operations that were set up other than console time, such as roll-in and docking, took significantly longer in the second-stage group when the proctor was not present select specimens from each trial were immediately resected and evaluated for histologic thermal injury. experiments were repeated times based to detect an expected difference of five degrees. student t-tests were used for all comparisons with significance set at . . results: stray energy transfer was higher in the single incision setup compared to the traditional setup (figure ). stray energy in the assistant grasper caused . ± . °c of temperature change in the standard configuration, and . ± . °c in the single incision configuration (p= . ). doubling energy output to w amplified the same finding robotic single-site cholecystectomy of cases: surgical outcomes and comparing with laparoscopic single-site procedure jae hoon lee incisional hernia occurred one case in each group. rssc is safe and feasible procedures. with accumulating of experience, rssc had more short operative time than sslc. comparing to sslc, rssc is relatively suitable to acute gallbladder disease and high bmi and requires a minimal learning curve to transition from traditional multiport to single-port robotic cholecystectomy. p initial experience using da vinci xi robot in colorectal surgery anna r spivak, do, john marks, md; lankenau medical center introduction: the xi robot has been developed to facilitate multiquadrant abdominal surgery. this report presents initial experience to evaluate feasibility and safety of xi robot in colorectal surgery. methods: all cases performed on xi robot were prospectively entered into a robotic database that was queried for colorectal cases performed from intraoperative complications were encountered in cases ( . %), requiring conversion to laparoscopy. none were converted to open. mean length of largest incision . cm. median ebl ml. there was no mortality. there were ( . %) immediate postoperative morbidities: postoperative abscess, bowel perforation, two postoperative bleeds, two hernias, two hematomas, smv thrombosis, small bowel obstruction. perioperative blood transfusions were required in . % of cases. there was one anastomotic leak. median time from surgery to low residue diet and discharge was days. conclusion: initial experience shows robotic colorectal resection with da vinci xi learning curve for robotic sleeve gastrectomy and roux-en-y gastric bypass: achieving equivalence to laparoscopy residents and fellows participated in an analogous fashion in both arms of the study, and patients undergoing re-operative bariatric surgery were excluded. results: a total of patients undergoing rsg (n= ) or rrygb (n= ) were included. for the overall robotic cohort, median age was (range - ), % were american society of anesthesiologists (asa) score , % were asa score , and mean body mass index (bmi) was ± with no differences between procedures. there were no conversions to open. there was one patient with portal vein thrombosis after rsg which occurred in the th rsg and one patient who underwent re-operation in the immediate post-operative period for hemorrhage at the gastro-jejunal anastomosis in the rrygb group; this occurred in the th rrygb. there were no leaks, strictures, or mortalities in either group. mean length of stay was days± for rsg with no difference based on number of procedures performed. in the rrygb group, los decreased after the first five procedures from days± to days±(p= . ). for both procedures, operative time decreased by number of procedures performed (figure). equivalence to lsg in operative time ( minutes± ) was reached after eight robotic procedures were included. the da-vinci xi® was used for the operations. age, gender, body mass index (bmi), asa score, indication for surgery, urgency of procedure, type of procedure, docking number, operation time, estimated blood loss, complications, short (≤ days) and long term ([ days) complications were evaluated. results: patients ( females) were included. median age was . median bmi was , median asa score was . total and completion rrp-ipaa were performed for and patients respectively. the indications were as follows: medical refractory uc (n= ), cancer/dysplasia (n= ), fulminant colitis (n= ), toxic megacolon (n= ), medical treatment resulting in growth retardation (n= ), medical treatment refractory bleeding (n= ). patient with toxic megacolon had an emergent operation. the median docking number was and for completion and total rrp-ipaa respectively. median operative time was minutes. median blood loss was ml. all patients had a stapled ileal j pouch anal anastomosis. all patients had a diverting loop ileostomy at the time of ipaa creation. no intraoperative complications were observed. no conversion to open surgery was needed. the median time to flatus was day. the median time to oral intake was day. patient had a laparotomy on postoperative day due to intra-abdominal bleeding. patient had a bleeding from ileostomy which was treated endoscopically. superficial surgical site infection was observed in patients. patient had a pouchitis managed with oral antibiotics. patient had an ileus responded to conservative treatment. patient had a per-anal bleeding stopped spontaneously. patient had a urinary tract infection responded to antibiotics. patients had pouchitis, patient had a perianal fistula requiring a loop ileostomy and a parastomal hernia was developed in another patient in long term follow up ) were significantly different between the two groups. , pairs undergoing primary and pairs undergoing revisional procedures were successfully matched. robotic gastric bypass was associated with a significantly longer operation length than laparoscopic gastric bypass for both primary (median difference minutes, p. ) and revisional (median difference minutes, p. ) procedures overall, there were no significant differences in anastomotic/staple line leak, -day readmission, reoperation, re-intervention, total event, and mortality rates between matched cohorts. conclusion: when controlling for patient characteristics, those undergoing primary and revisional lrygb and rrygb had no difference in early morbidity. despite the prolonged operative duration, the robotic approach was not associated with any clinical benefit or increased complications for primary or revisional gastric bypass surgery preoperative risk factors were collected. we focused on perioperative outcomes and in hospital complication rate. results: thirty-three patients underwent robot assisted giant hiatal hernia repair at our institution. patients ( %) were years and older and patients ( %) had a bmi higher then. there were no significant differences in patient characteristics between the groups. no patient underwent conversion to open or standard laparoscopy. no mortality was observed and no transfusions were needed. four patients ( %) had a complication, two of them were older than years old. three of the four patient ( %) that had a complication were obese. there were no statistical differences in mortality % and . % of them were with s-si and xi platforms respectively. the median numbers of procedures were (range - ) and (range - ) cases per hospital and per general surgeon respectively. the high volume surgeons (higher than th percentile) performed ( %) of the cases. the xi platform has been the main tool for colorectal surgery only (figure ). conclusions: while xi platform significantly increased caseload in general surgery by facilitating performance of colorectal surgery, its preference in other general surgical fields is not superior to si laparoscopic inguinal hernia repair (tapp) -first experience with the new senhance robotic system robin schmitz ; intuitive surgical inc, loma linda university medical center introduction: crohn's disease is an incurable inflammatory disorder that can affect the entire gastrointestinal tract. while medical management is considered first-line treatment, approximately % of patients with crohn's disease require surgery within years of their initial diagnosis. traditionally, surgery has been performed via an open approach with poor adoption of minimally invasive technique. the aim of this study is to demonstrate the feasibility of robotic-assisted approach as a minimally invasive option for surgical management of crohn's disease and compare the perioperative outcomes with traditional laparotomy. methods: patients who underwent elective resection of the intestine for crohn's disease by roboticassisted or laparotomy approach from to q were identified using icd- codes from premier healthcare database. all the procedures were performed by either general surgeons or colorectal surgeons. since hospital characteristics were comparable between the two cohorts before propensity-score matching, : matching was performed using patient characteristics such as age, gender, race, charlson index score and year of the surgery to create comparable cohorts. sample selection and creation of analytic variables were performed using instant health data (ihd) platform (bhe methods: we conducted a retrospective analysis of , mis inguinal hernia repairs ( , robotic, , laparoscopic) from through with data collected in the premier hospital database. patient, surgeon, and hospital demographics of robotic and laparoscopic inguinal hernia repairs were compared. the adjusted odds ratio of receiving a robotic procedure was calculated for each of the demographic factors using a multivariable logistic regression model. statistical significance was defined as p. . sas software version . was used for statistical analysis. results: the odds of a procedure being robotic increased from inguinal hernia repair is one of the most common general surgery procedures with over , performed annually in the united states. when compared to traditional open inguinal hernia repair (oihr), laparoscopic inguinal hernia repair (lihr) has been associated with faster postoperative recovery rates and lower postoperative pain. with advances in the robotic platform, robotic inguinal hernia repair (rihr) is an available technique that is currently being explored. this study examines lihr and rihr as described in literature to see if one is superior to the other. study design: search terms: ''inguinal hernia repair surgical complications including hematomas ( . %), seromas ( . %), and trocar site infection ( . %) resolved with antibiotics, with a . % postoperative complication rate. conclusion: rihr repair is a safe alternative to lihr, with fewer postoperative complications and a faster recovery time. however, operative time as well as or room time is significantly longer, which may increase overall cost laparoscopic or robotic approach were chosen on a schedule availability basis. data was collected prospectively and it involved anthropometric data, presence of type diabetes mellitus (t dm), % of preoperative total weight loss (%ptwl), surgical time, postoperative length of stay, -day complications, and need for readmission or reoperation. comparison between groups was carried on with t-test for continuous data and with chi-square test for dichotomous variables. a p lower than . was considered significant. results: overall sagb were performed, laparoscopic and robotic. a long and thin gastric pouch was created calibrated by a fr bougie and a . cm antecolic antegastric gastrojejunal (gj) anastomosis was groups (laparoscopic vs robotic) were comparable regarding age ( vs . years, p= . ), bmi ( . vs kg/m , p= . ), %ptwl ( . vs . %, p= . ) and % with t dm ( vs there were fewer men in the laparoscopic group ( . vs % there were ( . %) major complications in the laparoscopic group: bleedings from the gj anastomosis, one of which required reoperation, severe dumping syndrome, gerd requiring revision and gj stricture that underwent relaparoscopy. the only complication ( %) in the robotic group was an acute pancreatitis. readmission rate was % in both groups and reoperation rate was % for laparoscopic and % for robotic surgeries. conclusions: totally robotic sagb with manual gastro jejunal anastomosis was safe and feasible in this early experience compared to laparoscopic approach multi degrees of freedom manipulator with mantle tube for assisting endoscopic and laparoscopic surgical operations masataka nakabayashi, phd , yuta hoshito, masters student p step by step anatomic mapping during laparoscopic transabdominal adrenalectomy lateral flank approach ranbir singh steps analyzed were: right adrenalectomy: step ) mobilize liver; ) medial dissection; ) adrenal vein isolation; ) inferior dissection; ) adrenal off kidney; ) detachment. left adrenalectomy: step ) division splenorenal ligament; ) develop plane pancreas/kidney; ) mobilization medial/lateral borders adrenal; ) adrenal vein isolatoin; ) dissection adrenal off kidney; ) detachment. structures were identified as yes/no and results expressed as percentage total n of cases seen at each step. results: structures identified at each step are shown (table) incisions were made at the oral vestibule under the inferior lip. a -mm trocar was inserted through the center of the oral vestibule with two -mm trocars above incisors. the subplatysmal space was created down to the sternal notch, and carbon dioxide was insufflated at pressure mmhg to maintain the working space. parathyroidectomy was performed using laparoscopic instruments. intraoperative parathromone levels were measured minutes after excision of gland. primary end-points were the success rate in achieving the cure from hyperparathyroid state and hypocalcemia rate. secondary end-points were operating time, scar length, pain intensity assessed by the visual-analogue scale, analgesia request rate, analgesic consumption, quality of life within postoperative days (sf- ), cosmetic satisfaction, duration of postoperative hospitalization, and cost-effectiveness analysis. result: one patient experienced a transient recurrent laryngeal nerve palsy which was spontaneously resolved within month. no permanent recurrent laryngeal nerve injury was found no mental nerve injury or infection was found. conclusion: with highly sensitive localising sestamibi and ct scans, focussed exploration is the current standard of treatment. among all minimally invasive surgeries, toepva is a feasible, safe, and almost pain-free surgical option when combined with intraoperative parathormone monitoring for patients with hyperparathyroidism indocyanine green is a water soluble nontoxic compound exhibiting near infrared renal function and long-term survival. indocyanine fluorescence helps in assessing vascular flow, tissue perfusion and aberrant anatomy and thereby leads to lower conversion rates in partial nephrectomy. we aim to present our experience in patients who underwent partial nephrectomy over years. materials and methods: of the partial nephrectomies performed at our institution, were done by laparoscopic approach alone and rest by patients who underwent llr for whole hepatoma in our facility, underwent llr for a solitary hepatoma and were divided into "before standardization" (bs; n= ) and "after standardization" (as) groups (n= ). patient background, characteristics, and perioperative outcomes were compared between these groups. procedure: we chose the devices according to phases of liver transection. a soft-coagulation monopolar device was used for marking surface. an ultrasonically activated device was used for transection of the liver surface within a -cm depth. crash and sealing with biclamp were indicated for deep-phase transection. the cavitron ultrasonic surgical aspirator was used if the lesion was close to the major glisson's sheath or the major hepatic vein. results: no significant differences in the patients' background were found between the two groups. the operative durations were min ( - min) and min ( - min) in the as and bs groups, respectively, with a significant difference (p. ). the blood loss volumes were cc ( - cc) and cc ( - cc), respectively (p= . ). the lengths of hospital stay after llr were days (range, - days) and days ( - days), respectively, with a significant difference iwao kitazono, phd , kentaro gejima , hizuru kumemura , akira hiwatashi , yuichiro nasu , fumisato sasaki , akio ido , yutaka imoto ; cardiovascular and gastroenterological surgery, kagoshima university graduate school of medical and dental science, digestive and lifestyle disease, kagoshima university graduate school of medical and dental science introduction: in locally-treatable gastrointestinal tumors, laparoscopic endoscopic cooperative surgery (lecs) is a minimally-invasive technique that can avoid excessive resection of the gastrointestinal tract. objective: to share our therapeutic guidelines and surgical technique of lecs for gastroduodenal tumors. subjects: nineteen patients who underwent lecs for gastroduodenal tumors ( patients with gastric tumor and patients with duodenal tumor).[results] ) gastric tumors ( gist, glomus): . site of lesion was u ( patients), m ( ), or l ( ), . operative procedure was acquired in a stepwise manner from classical lecs ( patients) to inverted lecs ( ) to non-exposed endoscopic wall-inversion surgery: news ( ). . operative outcome revealed no postoperative complications. ) duodenal tumors ( adenoma, m cancer, ectopic pancreas): . site of lesion was bulbus duodeni ( patient), superior part ( ), or descending part ( ); . operative procedure was esd followed by laparoscopic continuous suture in a single seromuscular layer for patients with preoperatively confirmed or suspected cancer, or full-thickness resection followed by albert-lembert suture along the short axis for patients unable to undergo esd. in all cases, c-tube was placed to prevent bleeding and perforation at the site of resection due to exposure to bile; . operative outcome included successful endoscopic hemostasis upon bleeding from exposed vessel on postoperative day in patient and anastomotic leak in patient. the event of anastomotic leak resolved after days of bile drainage through c-tube and conservative therapy. compared with patients who underwent esd alone, those who underwent lecs had significantly larger diameters of resected specimens and tumors (p. ) but no significant difference in the incidence of postoperative bleeding and delayed perforation. conclusion: for gastroduodenal tumors, lecs is a minimally-invasive and safe therapeutic option as it combines advantages of both laparoscopy and endoscopy. in particular, c-tube placement for bile drainage was effective in reducing exposure of the suture site to bile as well as supporting drainage after anastomotic leak. introduction: in japan, transurethral balloon catheters (tuc) are currently inserted in most surgical patients to maintain a urine outflow route and to measure the urine output both intraoperatively and postoperatively. however, tuc insertion not only causes postoperative pain but can also lead to urinary tract infections. temporary suprapubic catheters (spc) are used in the field of obstetrics and gynecology as a method of postoperative management to avoid performing transurethral procedures. in the field of surgery, especially in laparoscopic surgery, spc also considered how it would be a useful way to reduce patient suffering. here we report our prospective study on whether an spc can be safely inserted as a substitute for tuc during laparoscopic-assisted colectomy. subjects and methods: the subjects in this study were patients who underwent laparoscopic surgery for primary colorectal cancer from to , and who would normally have had their urinary balloon catheter removed early after surgery. during surgery, an angiomed cystostomy set was installed for patients who gave their consent to participate in this study as an alternative to a urinary balloon catheter. we prospectively collected patient information including sex and age, in addition to other perioperative data, such as, time required for cystostomy, complications accompanying cystostomy, sense of discomfort or pain associated with the vesical fistula after surgery, the time of the removal of the vesical fistula, the frequency of releasing the vesical fistula, postoperative complications. results: our subjects included cases who gave their informed consent to have an spc inserted. an spc was inserted into the remaining case. the mean surgical duration was min, and the spc insertion was performed at a mean of min after the start of surgery. insertion required a mean duration of . s. the bladder of one case ( . %) was perforated, and hematuria was observed at the time of insertion in two cases ( . %), but surgery completed without any incident. six out of cases ( . %) demonstrated neither urinary urgency nor independent urination on the day the catheter was clamped. however, the clamp was released two to four times, and draining of an average of ml urine, urinary urgency, and independent urination were confirmed - days later. conclusion: spc is a procedure that avoids crossing the urethra and its associated disadvantages. here we were able to demonstrate that the procedure can be safely used in laparoscopic surgery patients.our objective is to devise methods for proper port placement to overcome the ergonomic challenges. procedure: patients with sit were operated laparoscopically in our hospital in the period of may to november , males suffering from cholelithiasis without cholecystitis and female with acute appendicitis. after thorough review of literature and proper planning, the patients were posted for surgery. for laparoscopic appendectomy, a thorough initial diagnostic survey is performed on introducing a scope through the umbilical port and confirming the exact location of the appendix. the two working ports are introduced accordingly, which is usually a mirror image of the standard port sites. the appendix was visualised in the left iliac fossa and after meticulous dissection, the appendix and mesoappendix were divided using an endostapler. the operative time was minutes and there were no intraoperative or postoperative complications.the port placement for laparoscopic cholecystectomy in such a case is trickier as the anatomical variation and the contralateral disposition of the biliary tree demand an accurate dissection and exposure of the biliary structures to avoid iatrogenic injuries. it is important to conform to the principles of triangulation during port placement. the mirror image of -port placement is convenient for left-handed surgeons. whereas, to make the procedure comfortable for right-handed surgeons, the working ports need to be shifted caudally with the surgeon standing between the patient's legs. the mean operative time was minutes and there were no minor or major intraoperative or postoperative complications.conclusion: ergonomic comfort is vital to a smooth procedure. while mirroring ports suffices for appendectomy, all other procedures require forethought for port placement. it should be noted that ambidexterity is a desirable skill in the operating room for a laparoscopic surgeon.priscila r armijo, md, chun-kai huang, phd, gurteshwar rana, md, dmitry oleynikov, md, ka-chun siu, phd; university of nebraska medical center introduction: the aim of this study was to determine how objectively-measured and self-reported fatigue of the upper-limb differ between laparoscopic and robotic surgical training environments. methods: surgeons at the sages conference learning center, and at our institution were enrolled. two surgical skills practical environments were utilized: ) a laparoscopic training-box environment (fls) and ) the mimic® dv-trainer (mimic). two standardized surgical tasks were chosen for both environments: peg transfer, and needle passing. each task was performed twice. objective fatigue was evaluated by muscle activation and fatigue, and comparisons were made between fls and mimic, for each surgical task. muscle activation of the upper trapezius, anterior deltoid, flexor carpi radialis, and extensor digitorum were recorded during practice using surface electromyography (emg; trignotm, delsys, inc., boston, ma). the maximal voluntary contraction (mvc) was obtained to normalize muscle effort as %mvc. the median frequency (mdf) was calculated to assess muscle fatigue. subjective fatigue was self-reported by completing the validated -scale score piper fatigue scale- (pfh- ) before and after practice. statistical analysis was done using spss v . , with α= . . results: this abstract represented the performance of trainees (fls: n= , mimic: n= ) as part of larger cohort of the study. for peg transfer, emg analysis revealed that mimic had a significant increase in mean muscle activation for the upper trapezius and anterior deltoid, both p\ . . conversely, practice with fls led to significantly more muscle fatigue than mimic for the same muscle groups (upper trapezius: p= . , anterior deltoid: p= . ), represented by a significantly lower mdf. similarly, for needle passing, mimic had a significant increase in mean muscle activation for the upper trapezius (p= . ) and anterior deltoid (p= . ), but practice with fls significantly induced more muscle fatigue effort for anterior deltoid (p= . ). survey analysis revealed a significant decrease in self-reported fatigue after performing fls tasks (before: . ± . , after: . ± . , p= . ), but no difference after mimic tasks (before: . ± . , after: . ± . , p= . ). conclusions: although different muscle groups are preferentially required in the performance of fls and mimic, our analysis for both surgical tasks showed practice with mimic required more activation of shoulder muscles, whereas practice with fls could lead more muscle fatigue for the same muscle groups. interestingly, surgeons reported improved or no change in perceived fatigue after the tasks, despite of having an increase in muscular activation and effort. subjective selfreport fatigue might not truly reflect the level of fatigue when trainees practice surgical tasks using fls or mimic. objective: to investigate the prevalence of musculoskeletal (msk) injuries in bariatric surgeons around the world. background: as the popularity of bariatric surgery increases, efforts into improving its patient safety and decreasing its invasiveness have also been on the rise. however, with this shift towards minimal invasiveness, surgeon ergonomic constraints have been imposed, with a recent report showing a - % prevalence of physical complaints in surgeons performing laparoscopic surgeries. methods: a web-based survey was designed and sent out to bariatric surgeons around the world. participants were queried about professional background, primary practice setting, and various issues related to bariatric surgeries and msk injuries. results: there were responses returned from surgeons from countries around the world. . % of the surgeons have had more than years of experience in laparoscopic surgery, . % in open and . % in robotic surgery. % of participants reported that they have experienced some level of discomfort/pain attributed to surgical reasons, causing the case load to decrease in . % of the surgeons. it was seen that the back was the most affected area in those performing open surgery, while shoulders and back were equally as affected in those performing laparoscopic, and the neck for those performing robotic, with . % of the surgeons reporting that this pain has affected their task accuracy/surgical performance. a higher percentage of females than males reported pain in the neck, back and shoulder area when performing laparoscopic procedures. supine positioning of patients evoked more discomfort in the wrists, while the french position caused more discomfort in the back region. only . % sought medical treatment for their msk problem, of which . % had to undergo surgery for their issue, and . % of those felt that the treatment resolved their problem. conclusion: msk injuries and pain are a common occurrence among the population of bariatric surgeons, and has the ability to hinder performance at work. therefore, it is of importance to investigate ways in which to improve ergonomics for these surgeons as to improve quality of life.introduction: the use of robotic technology is rapidly increasing among general surgeons but is not being routinely taught in general surgery residency. we aimed to evaluate our first robotic cases during which time we developed a robotic surgery curriculum incorporating residents. methods: the first robotic cases performed at our institution from - by two surgeons were analyzed. a residency curriculum was developed and instituted after the first months. it consisted of online modules offered by intuitive surgical resulting in certification, simulator training, hands on workshops for cannula placement, docking, instrument exchange, camera clutching and other introductory tasks. patient demographics, type of procedure, resident involvement, total operative and console times, comorbid conditions and complications were evaluated. unpaired t tests were performed for statistical analysis. results: females and males comprised this series with an average age of years ± . the majority of patients, % had comorbidities, with a predominance of hypertension, % and diabetes, %. the bariatric patients had an average bmi of ± . a variety of procedures were performed including hernias, foregut and bariatric. residents participated in % of cases. there were no differences in total operative and console times in cases with residents except bariatric procedures. there were complications in this series; postoperative ileus, gallbladder fossa hematoma and an enterotomy. there was one early conversion to open in a complex foregut case and no deaths in this series.conclusions: we report our initial experience of robotics in a variety of general surgery and complex foregut cases. the implementation of a robotic surgery program and residency curriculum was safe with similar outcomes related to operative times and complications. as mis expands with the application of robotics in general surgery, residency curriculums will need to be revised. further data is needed to determine residency learning curves between robotics and laparoscopy.background: robotic surgery has made a large impact in the fields of urology and gynecology. its use is significantly increasing in the fields of general and bariatric surgery. evidence remains unclear as to the clinical impact on outcomes, and significant questions remain as to the impact of cost. our goal was to evaluate the economic impact of robotic surgeries in general and bariatric surgery at our institution. methods: this study is a retrospective analysis of minimally invasive general and bariatric procedures done at a single institution from january through june . we performed a cost and reimbursement analysis of robotic versus conventional laparoscopic surgery. the cost evaluation included operative time, operating room costs, length of stay and overall hospital expenses. in addition, we looked at reimbursement and the contribution margin per cpt code. results: our study included a total of patients who underwent laparoscopic and robot assisted general and bariatric surgeries. the average time duration for laparoscopic surgeries was minutes vs minutes for robot assisted. we performed a cost analysis which showed an average total cost of $ , for laparoscopic and an average of $ , for robot assisted. the total reimbursements were $ , for laparoscopic and $ , for robot assisted. this translated to an average contribution margin of $ , for laparoscopic vs $ , for robot assisted. for general surgery we found an average cost of laparoscopic $ , vs robot assisted $ , , with a contribution margin of $ , laparoscopic vs $ , robot assisted. for bariatric surgeries we found an average contribution margin of $ , for laparoscopic vs $ , for robot assisted. conclusions: robotic surgery has been associated with higher costs and longer operative times. in this economic climate of increased cost awareness with institutions under increasing financial pressures, judicious use of resources becomes important when determining surgical approach. although cost of robot assisted surgery may decrease with time, other quality factors may be important in patient selection. although there is no clear evidence that institutions lose money with robot assisted surgery, in our experience the contribution margin is lower with robot assisted surgery as compared to conventional laparoscopy.introduction: this retrospective study was performed to evaluate the safety and feasibility of the new senhance robotic system (transenterix) for inguinal hernia repairs using the transabdominal preperitoneal approach. our series is the first experience in the field of general surgery utilizing this new robotic platform. methods: from march to september , inguinal hernia repairs in patients were performed using the senhance robotic system. the senhance surgical system is a new robotic platform that consists of a cockpit, manipulator arm and a connection node (figure ). this new system provides robotic surgery with numerous advantages including eye-tracking camera control system, haptic feedback, reusable endoscopic instruments, and a high configuration versatility due to total independency of the manipulator arms. patients were between and years of age, eligible for a laparoscopic procedure with general anesthesia, had no life-threatening disease with a life-expectancy of less than month and a bmi \ . a retrospective chart review was performed for a variety of pre-, peri-and postoperative data including but not limited to patient demographics, hernia characteristics, intraoperative and postoperative complications. results: male and female patients were included in the study. median age was . years (range - years), and median bmi was . (range . - . kg/m ). median docking time was minutes (range - minutes), and median operative time was minutes (range - minutes). two cases were converted to standard laparoscopic surgery due to robot malfunction and intraoperative bleeding respectively. one patient developed a postop seroma that did not require any further intervention. conclusion: we report the first series of laparoscopic inguinal hernia repairs using the new senhance robotic system. compared to previously published conventional laparoscopic or robotic tapp hernia repairs these data suggest similar outcomes in operative time and perioperative complications. additionally there was no significant learning curve detected due to its intuitive applicability. therefor the senhance robotic system can be safely and easily used for tapp hernia repairs by experienced laparoscopic surgeons. this is a video presentation of years old female, who presented with suprapubic pain and mass to gynecology office. she has a history of robotic hysterectomy and sbladder sling operation years ago. this was complicated with peritonitis and long icu stay, due to what she was called ''bowel injury'' but treated only conservatively with antibiotics and subsequent abscess drainages at that time. she has occasional appearing nodule and pain at the left suprapubic region. ct ordered by gynecology read as abdominal wall hernia with long sigmoid diverticuli in hernia. also there was small amount of subcutaneous air at the tip of herniated diverticuli. after antibiotic treatment and improvement, colonoscopy shows, actually the diverticuli is the limb of the sling going through the simoid and anchored in subcutaneous fat on abdominal wall ahich represents clocutaneous fistula as gets infected. clip was placed on sling and repeat imaging comfirmed that the localion of this sling fits to location of so called ''hernia'' the sling limb was resected robotically and colon was repaired with side stapling of clolonic wall. the abdominal wall defect is repaired with long term absorbable suture. as far as we have found, the presentation and treatment of this complication is unique and could not find a similar case to guide us for the plan. background: robot-assisted surgery using da vinci surgical system (dvss) is thought to have many advantages over conventional laparoscopic surgery. it was reported that the use of the surgical robot might reduce surgery-related complications, then a multi-institutional historically controlled prospective cohort study on the feasibility, safety, effectiveness and economical efficiency of robotic gastrectomy (rg) for resectable gastric cancer was conducted in japan. this study evaluated the safety of rg using dvss xi. methods: this single-center, prospective phase ii study included patients with resectable gastric cancer (umin ). the primary endpoint was the incidence of post-operative complications greater than grade iii according to clavien-dindo classification during one month after surgery. the secondary endpoints included all adverse events and completion rate of robotic surgery. results: from oct to jan , patients were enrolled for this study. the incidence of post-operative complication greater than grade iii was %. the overall incidence of adverse events was . % (grade i; . %, grade ii; . %). no patient required conversion to laparoscopic or open surgery; thus, the rg completion rate was %. conclusion: this study suggested the introduction of rg using dvss xi for gastric cancer seems to be safe and feasible. priscila r armijo, md , dmitry oleynikov, md , sages robotic task force* ; university of nebraska medical center, sages robotic task force introduction: while robotic companies continue to aggressively market and promote the use of robots in general surgery, little is known about how this technology is employed by general surgeons, and what is expected of this technology from both novice and experts in the field. the aim of this study is to evaluate the needs of general surgeons who are new to robotic surgery and the needs of established robotic surgeons. methods: the sages robotic task force survey, a one-page survey, was designed and sent electronically to all sages members. questions regarding fellowship training, area of expertise, robotic simulation and in clinical case use, services offered in the current hospital, mentorship, likelihood of switching to a different approach, and expectations for the robot were included in the survey. two groups were created based on previous use of davinci® system in a clinical scenario, or not. statistical analysis was conducted using ibm spss v. . . , using fischer's exact and pearson's chi-squared tests where appropriate. results: sages members answered the survey. surprisingly, respondents ( %) had used the davinci® in a clinical setting. among these, ( %) had additional fellowship training, compared to ( %) in the non-clinical use group, p= . . of all surgeons with additional fellowship training, the great majority ( %) had specialization in advanced gi, mis and bariatric surgery, followed by colorectal ( %). most surgeons are performing less than cases per month using the robotic system, and with the majority of cases performed using the platform being hernia repairs ( %), followed by foregut-related procedures ( %). interestingly, from all the surgeons who replied the survey, only . % are planning to switch from open procedures to its robot counterpart, whereas . % are planning to adopt robotic-assisted procedures rather than laparoscopy. conclusions: the majority of sages members who responded to the survey have used the davinci® in a clinical setting in the past. surgeons who stated they perform mainly laparoscopic procedures were likely to continue to adopt robotic techniques, whereas those who perform open hernia repair for example were not very likely to switch to robotic approach. while the use of the robot may be enabling surgeons who used to perform mostly open procedures in the urology or gynecology fields, laparoscopic skills predict robotic utilization in general surgery. hernia and foregut appear to be the most common procedures that are being utilized.aim: while conventional multiport laparoscopic splenectomy has become gold standard for some hematological or splenic diseases, reduced-port laparoscopic splenectomy (rpls) including singleincision laparoscopic splenectomy (sils) is regarded as highly challenging. herein, we describe the technical refinements for safe rpls especially for patient with splenomegaly. methods: in all cases, access was achieved via a . -cm mini-laparotomy at the umbilicus into which a sils tm port or e-z access ® with three -mm trocars was placed. a -mm flexible scope, an articulating grasper, and straight instruments were used. our rpls is characterized by the followings: a) early ligation of the splenic artery to shrink the spleen, b) application of our original "tug exposure technique," which provides good exposure of the splenic hilum by retracting (tugging) the spleen with a cloth tape, and c) safe introduction of stapler under the guidance with a flat drain into the splenic hilum. results: rpls patients ( men and women, ± years old) comprised hematological disorder (n= ), splenic disease (n= ), and liver cirrhosis (n= ). in patients ( %), rpls was successfully completed: sils in and sils plus one additional port only in patients. conversion to open surgery was necessary in patients including liver cirrhosis with remarkable collateral varicose veins around the spleen. operation time and blood loss were ± min and ± g, respectively. weight of the extracted spleen was heavier than normal and ± g (maximum g). no intra-or postoperative complication occurred. the postoperative scar was nearly invisible. conclusions: rpls might safely be performed even for splenomegaly (up to , g). however, care should be taken for cirrhotic patient with collateral veins. rpls can be the procedure of choice even in the patients with splenomegaly and who are concerned about postoperative cosmesis. the aim of this feasibility study was to evaluate laparoscopic sn biopsy for laparoscopic snns in early gastric cancer patients. subjects and methods: this study includes patients with ct n m (primary tumor \ cm) gastric cancer who underwent laparoscopic sn biopsy in conjunction with radioisotope and dye methods between jan. and jul. . first, we looked for green-dyed sns after injection of indocyanine green (icg) without near-infrared light system, and then tried to detect the radioactivity of sns using a hand-held gamma probe inserted through a small incision at the umbilical port. after the areas where sns were distributed were resected, a gastrectomy with prophylactic lymphadenectomy was performed according to the gastric cancer treatment guidelines of the japanese gastric cancer association. we looked for undetected sns in the resected specimen at the back table. results: among cases, there were ( %) in which sns were not detected in the resected specimen. there were cases in whom sns were detected in the resected specimen. in both cases, the primary tumors were located in the middle and greater curvature of the stomach. in case , laparoscopic sn biopsy identified the left ( sb) and right ( d) greater-curvature lymph node (lns) as sns, however, lesser-curvature ( ) and infrapyloric ( ) lns remained as sns in the resected specimen. in case , the left ( sb) and right ( d) greater-curvature lns were identified as sns intraoperatively, while the lesser-curvature ( ) ln remained as an sn in the resected specimen. the sns overlooked with laparoscopic sn biopsy method were detected by radioisotope only. no cases had ln metastasis, and the -year relapse-free survival rate of these patients was %. conclusions: our feasibility study of laparoscopic sentinel node biopsy for early gastric cancer showed that we should search for sns of the lesser curvature carefully even if the primary lesion is located at the greater curvature. key: cord- -sizuef v authors: nan title: ectes abstracts date: - - journal: eur j trauma emerg surg doi: . /s - - -y sha: doc_id: cord_uid: sizuef v nan the gertality-score: a feasible and adequate tool to predict mortality in geriatric trauma patients introduction: a large number of prediction models and subsequent outcome scores for trauma mortality have been developed over the last decades. however, feasible scoring systems for the severely injured geriatric patient are lacking. the aim of this study was to develop a new mortality prediction model for severily injured geriatric patients. materials and methods: the german trauma registry was utilized and all geriatric individuals (c years) admitted between and with an iss [ ] c were included. patient and trauma characteristics, diagnostics, therapy and outcome data were gathered. the specific odds of all variables for mortality were calculated. relevant variables were added to the novel gertality-scoring system. subsequently, this score as a sole predictor for mortality was compared with the geriatric trauma outcome score , iss, patient's age and max ais. results: a total of . trauma patients with a mean age of years were included. based on the univariable analysis, the following five variables were included in the gertality-score: age c years, pbrc-transfusion requirements from admission to ward, asa-score c , gcs b , ais c . the values of a given parameter are added to reach the total gertality-score (range - points). the auc found in the novel gertality-score was . , whereas the geriatric trauma outcome score had an auc of . . conclusions: the novel gertality-score is a simple and feasible scoring system that enables an adequate prediction of the probability of mortality in severely injured geriatric patients by using only five specific parameters. references: . champion hr, et al. the major trauma outcome study: establishing national norms for trauma care. j trauma. ; : - . . zhao fz, et al. estimating geriatric mortality after injury using age, injury severity, and performance of a transfusion: the geriatric trauma outcome score. j palliat med. ; ( ) : - . the longer the better! 'extending thawed plasma shelf life to days' introduction: major bleeding is one of the most common causes of death after severe polytrauma. one of the most recent interventions that aims for bleeding control is resuscitative balloon occlusion of the aorta (reboa). this study aims to compare macro-and microcirculatory changes of intraabdominal organs and the lower extremity during the use of reboa. materials and methods: six pigs were anesthesized and received a median laparotomy. the reboa catheter (reliant balloon, medtronic) was inserted via the inguinal artery and occluded in zones , and . the occlusion of the reboa was vizualized with fluoroscopy. the balloon was inflated for min per zone. during this time the local microcirculation was measured with oxygen to see (o c, lea). between each zone the balloon was deflated for min. blood pressure was measured at the carotis artery and the femoral artery. results: baseline values of microcirculation differ significantly among organs. the flow rate is significantly higher in intraabdominal organs (colon . a.u., stomach . a.u.) compared to the extremity ( . a.u., p \ . ). blood pressure measured at the carotic artery increased significantly after inflation of the balloon (p \ . ). this increase depends on the zone of inflation (increase of ? mmhg in zone compared to baseline). the increase of blood pressure after inflation in zone is comparable to the baseline value. the colon is most sensitive to changes of microcirculation whereas the stomach and the extremity are most robust. conclusions: reboa is a new device to control for massive bleeding. different organ systems react differently to the same occlusion of the aorta. the systemic blood pressure does not mirror the local microcirculation of the abdominal organs. during emergency resuscitation with reboa these changes should be kept in mind. none of the authors have any conflicts of interests to declare. investigation of coagulopathies and its relevance with mortality and transfusion rates using thromboelastography in trauma patients introduction: fibrinolysis shutdown after injury is a common and lethal coagulopathic phenotype. patients with polytrauma, especially those with brain hemorrhage, require delayed initiation of prophylactic or therapeutic anticoagulation despite a measurable hypercoagulable state. to understand and modulate the post-trauma coagulation milieu, we assess patients with daily thromboelastography(teg). we hypothesized that persistently high clot strength and low dissolution is associated with thrombotic adverse outcomes in severely injured patients. materials and methods: adult patients with blunt or penetrating injuries admitted to the icu of a level i urban trauma center from jan-jul were included. adverse outcomes were defined as death, ventilator-free-days (vfd) = , acute lung injury (ali), acute kidney injury (aki), and venous thromboembolic events (vte). we assessed trends of clot dissolution (fibrinolysis, ly %) and strength (maximum amplitude, ma) in the first icu days using linear mixed models to account for repeated measures and missing observations. ly % was box-cox power-transformed to approximate normality. significance for pairwise comparisons at each time was adjusted by false-discovery-rate. results: patients: median age -years, % female, iss (iqr - ), % blunt mechanism, median icu days . overall, % developed one or more of the following; %vfd = , %ali, %aki, %vte, %death. ly was persistently lower in patients with adverse outcomes compared to those without (interaction time*adverse_outcomes p = . ), with fdr-adjusted significant differences at icu days and (fig ) . conversely, ma did not differ significantly by adverse outcome status(interaction time*complications p = . , fig ) . conclusions: low clot dissolution, not clot strength, is associated with adverse outcomes in severely injured trauma patients. additional work is underway for earlier identification of sd phenotypes and strategies to mitigate impaired fibrinolysis. introduction: angioembolization (ae) is can be both diagnostic and therapeutic in management of a hemodynamically unstable trauma patient. however, patients who would benefit from ae typically require emergent surgery for their injuries. the critical decision of transferring a patient to the operating room versus the interventional radiology suite can be bypassed with the advent of intra-operative angioembolization (ioae) . while the ability to perform such an intervention was previously limited by the availability of costly rooms termed raptor (resuscitation with angiography, percutaneous techniques and open repair) suites, it has been suggested that using c-arm digital subtraction angiography (dsa) is a comparable alternative. this case series aims to establish the feasibility and safety of ioae. materials and methods: we conducted a retrospective anlaysis of all trauma patients at our level trauma centre who underwent ioae with a concomitant surgical intervention from january to april . results: a total of patients ( . % male, . ± . years, . % blunt) underwent ioae using the c-arm dsa. all but one patient underwent exploratory laparotomy, . % of which underwent an additional surgical procedure (ex. exploratory thoracotomy, orthopaedic). either gelfoam ( . %), coils ( . %), or a combination of both ( . %) were used for embolization. internal iliac embolization was performed in . % of cases ( . % bilateral) and five patients ( . %) required hepatic embolization. ae was successful in all but one case, inferior vena cava filters were placed in . % of cases, and . % of patients required a second ae. the -day mortality was . %. conclusions: our results suggest ioae is a feasible and safe management option in severe trauma patients with the advantage of concurrent operative intervention and ongoing active resuscitation with good success in hemorrhage control. introduction: partial resuscitative endovascular balloon occlusion of the aorta (reboa) is a new concept of aortic occlusion to reduce the ischemic injuries below the occlusion level. it is, however, difficult to determine when the occlusion is partial in a clinical setting. end-tidal carbon dioxide (etco ) is a product of aerobic metabolism and its production is reduced during ischemia and anaerobic metabolism. the aim of this study was to investigate if etco is a good predictor of the degree of aortic occlusion during normovolemia and hemorrhagic shock in a porcine model. methods: nine pigs, - kg, were anesthetized and surgically prepared. then, gradual zone aortic occlusion by %, % and % was induced, during first normovolemia and then controlled hemorrhagic grade iv shock. hemodynamic/respiratory variables, blood gases, aortic/mesenteric blood flow, blood pressure of common femoral artery and etco were measured continuously. oxygen consumption and carbon dioxide production were calculated for each timepoint for correlation measurement to different methods for partial occlusion determination. background: acute appendicitis is one of the most common surgical emergencies worldwide. the aim of this meta-analysis of randomized controlled trials was to compare the safety and efficacy of antibiotic treatment versus appendicectomy as the primary treatment for patients diagnosed to have acute appendicitis. methods: a systematic online search was conducted using the following databases: pubmed, scopus, cochrane database, the virtual health library, clinical trials.gov and science direct. only randomized controlled trials (rcts) that compared antibiotics treatment (a) versus surgical treatment (s) as primary treatment of appendicitis were included. results: eight rcts with . patients were included: in the antibiotics group and in appendicectomy group. higher rate of treatment success was noted in appendicectomy group . % versus only . % in the antibiotics group (p \ . ) (fig. ). follow up period for recurrence was one year in all studies and the recurrence at year was reported in . % ( / ) of patients treated with antibiotics and . % ( / ) of them underwent appendicectomy. moreover, rate of overall were . % in a group and . % in s group (odd ratio . [ . - . ], ci %, p-value: . ) (fig. ) . a longer length of hospital stay was reported among antibiotics group ( . ± . in a group versus . ± . in s group, p . ). conclusions: appendicectomy has significantly higher efficacy rate but higher complications rate when compared to antibiotics treatment. most of the studies included in this meta-analysis conveyed a high risk of bias, hence more well-designed rcts are recommended. introduction: post-operative adhesions are associated with increased risk of morbidity and mortality. up to date no effective measures has been introduced to decrease intra-abdominal adhesions following laparotomy. oxiplex-ap gel has been used in extra-abdominal surgical procedures to prevent adhesions. in the current study oxiplex-ap was tested in a mural animal model to investigate its efficacy in reducing post-surgical intra-abdominal adhesions. materials and methods: forty rats subjected to laparotomy were randomly divided into groups of . a serosa injury was made on the small intestine and three different treatments were applied: simple suture, simple suture ? oxiplexap, and oxiplex-ap only; the last group received no treatment of the injury before closure of the abdomen. all animals were kept alive for days, and a second laparotomy was done to measure the intra-abdominal adhesion by the nair classification. results: at second look laparotomy a significant difference in adhesion was noticed between the simple sutures and simple suture ? oxiplex-ap were the latter had developed less adhesions. there was also a trend towards less adhesion development between the simple sutures and oxiplex-ap only group, with less adhesions in the latter. conclusions: the use of oxiplex-ap was associated with decrease adhesion formation in the current animal model particularly without suturing. further investigations into these findings are needed. introduction: emergency abdominal surgery is known to result in high morbidity and mortality. furthermore, evidence suggests that unplanned admissions to the intensive care unit (icu) are associated with higher in-hospital mortality than those patients with planned icu admissions . the aim of the study was to describe the patient population who required an unplanned admission to icu following emergency laparotomy at the royal melbourne hospital. materials and methods: a single-centre retrospective observational study was performed using prospectively collected data between and . patients who underwent an emergency laparotomy and experienced an unplanned icu admission were included. patients who underwent a trauma laparotomy were excluded from the study. results: emergency laparotomies were performed. of these, ( . %) required an unplanned admission to icu. fourty-two patients ( %) were female, and patients ( %) were aged years and above. sixty-three ( %) were admitted due to single organ dysfunction (clavien-dindo iva). the median time to icu admission was days in patients classified to have experienced clavien-dindo iva, while it was days in patients who experience multi-organ dysfunction (clavien-dindo ivb). thirty-seven patients ( %) were admitted to icu due to complications classified as cardiopulmonary. conclusions: recognising that emergency laparotomy is a high risk procedure, with the elderly patients accounting for the majority of unplanned icu admissions, it is imperative to utilise risk stratification methods to guide optimal peri-operative management. this should result in improved utilisation of critical care resources and overall patient outcomes. introduction: the way of reconstruction following intestinal resection in the emergency settings is still controversial. the question which is better between hand-sewn and stapled anastomosis in trauma and emergency surgery occasionally arises; however, there have been few reports comparing these methods. materials and methods: a record-based retrospective study was performed to compare hand-sewn with functional end-to-end anastomoses in trauma and emergency operations from october to october in one of the largest trauma and emergency centers in japan. the patients who had intestinal resection with functional endto-end or hand-sewn anastomosis in an emergency surgery were included. the patients who had covering ileostomy or colostomy, or who underwent surgery as an elective operation were excluded. the primary outcome is the rate of complication associated with anastomosis. the statistical analyses were performed using a chi introduction: injuries are the fourth leading cause of death in europe. laparotomy is the standard treatment for penetrating abdominal wounds. because of the morbidity and the high rate of negative laparotomies, the nonoperative treatment is effectively developing. the aim of this study is to analyze the complications and the quality of life of the patients after laparotomy for this kind of wounds. materials and methods: a retrospective cohort of patients was studied between and at the laveran military teaching hospital in marseille. one hundred and eighty-six trunk gunshot or stab wound were recorded, including abdominal wounds. thirtyfour patients were managed by laparotomy and included in this study. the patients and their referring general practitioners were contacted to complete missing data and the sf- quality of life score. results: among the patients included, the average age was years and most of them were men. the indication for laparotomy was mainly based on the hemodynamic instability, then according to the results of the computed tomography in case of suspicion of specific lesions: bowel injuries, major vascular injury, mesenteric or mesocolic vascular injury, diaphragmatic injury and intraperitoneal bladder rupture. only laparotomies were negatives. eleven complications after laparotomy were found ( , %), including early (within the days) and late. no complication was found after negative or non-therapeutic laparotomies. the quality of life of the patients after one year is similar to those of the general population. conclusions: the most common indication for laparotomy for abdominal penetrating trauma is hemodynamic instability. the rate of laparotomy complications for penetrating abdominal trauma is similar to those of scheduled surgeries. the quality of life after this care remains unchanged. these results may insist on the fact that the ''gold standard'' treatment for penetrating abdominal injury remains the laparotomy objectives: splenic artery embolization (sae), a routinely used adjunct in the non-operative management (nom) of splenic injuries(si), was widely adopted in trauma about two decades ago. we examined complications that occurred with this modality at a level trauma center over a recent -year period and compared this to the prior years. methods: patients who had sae for si between - were identified. sae complications were noted. splenic abscess, splenic infarction and contrast-induced renal insufficiency were considered major complications. coil migration, fever and pleural effusions were regarded ''minor'' complications. the results were compared with data from a prior study examining similar indices at the same trauma center between and . fishers exact test was used for comparison. results: there were patients admitted with si in the recent period, of which ( %) underwent immediate splenectomy. sae was performed in ( . %) of the patients who underwent nom. of these sae patients, % had a contrast blush and . % were either aast grade or . five sae patients ( . %) had splenectomy for continued bleeding. the overall complication rate was . %. major complications occurred in patients ( . %) and minor in patients ( . %). embolization location in the splenic artery was proximal in . %, distal in . % and in both in . %. there was no association between complications and coil location by logistic regression. differences between the two periods shown in table . conclusion: sae continues to be a useful adjunct in nom of si and has seen increased utilization. complications continue to occur,although fewer minor complications were noted in the second period. no association between embolization location and complications was noted in the recent period. judicious utilization of sae is imperative given the complications that continue to be noted from this procedure. the effect of the time spent in the emergency department on the mortality rates and cause of death in patients who underwent emergent laparotomy introduction: the purpose of this study was to a) examine the effect of the time spent in the emergency department (ed) on hypotensive patients in need of emergent laparotomy and b) to determine the mortality rates and cause of death in these patients. materials and methods: between - , patients were included ( men and women, mean age . years) who underwent laparotomy less or equal to min from ed admission. of the patients, (group ) had a systolic blood pressure (sbp) greater than mmhg and had a sbp less or equal to mmhg. all patients had abdominal injuries with an injury scale score (iss) between and . the in-hospital mortality represented the primary outcome, while secondary outcomes included cause of death and time to death. results: in this study both groups spent a median of min in the ed, but the time from the ed to the operating theatre was shorter in the group ( min versus min). in total, the mortality rate was %, but in the group the mortality was %. the sbp on arrival in the ed was strongly associated with the risk of death. furthermore, we observed significant positive correlation between the probability of death and the time spent in the ed, with an increase of probability of death equal to . % per minute spent in the ed. in both groups the hemorrhage was the commonest cause of death ( %). the results of this study indicate that, in patients with abdominal injuries requiring emergent laparotomy, the probability of death is proportional to both extent of hypotension and the length of time spent in the ed. especially, in patients who were presented with a sbp inferior of equal of mmhg, this probability increased as much as % for each min. despite many advances in trauma surgery, half of hypotensive patients are going to die in the first h. introduction: injury to the pancreas may lead to significant morbidity and mortality. we studied the prevalence of pancreatic endocrine and exocrine functions and evaluated the morphological regenerations in pancreas following partial pancreatectomy. materials and methods: patients with pancreatic trauma were recruited ambispectively from january to december . endocrine functions were assessed at the time of admission and at months follow up with g oral glucose tolerance test (ogtt), serum insulin and c-peptide levels, hba c estimation and exocrine functions were assessed with faecal elastase test. pancreatic volumetry was done with imaging studies at -and -months post discharge. results: twenty patients were studied with a median age of years at the time of injury. all the patients were normoglycemic on admission; only one patient who underwent pancreatic resection developed diabetes mellitus requiring insulin on follow up. patients ( %) were found to have prediabetes by american diabetes association (ada) criteria. patients ( %) had pancreatic exocrine insufficiency. pancreatic volume increment, from mean pancreatic volume of . cm to . cm , was noted in partial pancreatectomy patients. conclusions: overt endocrine and exocrine insufficiency is rare in pancreatic trauma patients. but subsets of patients are biochemically predicted to have higher risks of endocrine dysfunction and exocrine insufficiency. hence, while dealing with pancreatic trauma patients, one should remember the possible metabolic disorders associated and the need for specific investigations. pancreatic volume increment is a new finding which opens up more opportunities for further research. hospital de santo espírito da ilha terceira, general surgery, angra do heroísmo, portugal, hospital de santo espírito da ilha terceira, orthopedics and traumatology, angra do heroísmo, portugal introduction: rope bullfights are traditional events in the azores islands, where a bull is set on the streets, arrested by a rope on its neck. around events happen every year and it is already part of the island's touristic attractions. inevitably, every year, people get injured either from direct trauma with the bull or from falls when trying to escape from the animal. the aim of this study was to characterize the type of injuries that occur in these bullfighting events, as to their incidence, mechanism of injury, anatomical affected area and severity. materials and methods: we prospectively registered all cases of injured people who suffered any type of trauma during rope bullfights and received emergency therapy in the local hospital, between and . results: patients recured to the emergency department, . % female, with mean age of . years. regarding the mechanism of injury, . % occured due to direct trauma to the animal while in the remaining . % resulted from falls during escape or handling of the rope. the most commonly affected anatomical areas were the limbs ( . %) followed by the head and neck ( . %) and thorax ( . %). in , % of the cases, patients suffered from multiple traumas. in . % of the cases the treatments performed were wound care, wound closure and/or symptomatic therapy. in total, patiens were hospitalized, patients required interventions in the operating room ( closed fracture reductions and exploratory laparotomy with splenectomy) and patients were hemodynamically unstable upon admission (hypovolemic shock due to splenic fracture and cet). conclusions: the rare articles published describe the mechanisms of injury associated with bullfights in spanish centers and injuries resulting from wild cow accidents in indian cities. this is the first local descriptive study on the prevalence of traumatic injuries associated to this specific type of rope bullfights. introduction: the two-stage splenic rupture is seldom, its risk is unpredictable and a precise diagnosis of a ct and/or mri imaging unexpectable or unexcludable. generally, and due to our experience and current literature a two-stage rupture occurs within one week after trauma. though dramatic courses after two or three weeks are known. therefore, it is suggested to perform a prophylactic angioembolization in (still) hemodynamically stable patients. materials and methods: a retrospective study in a level-one trauma centre of switzerland did analyse all patients that underwent a prophylactic angioembolisation after an explicit diagnose by ct and/or mri of a splenic parenchymal lesion after trauma between and . further inclusion criteria were hemodynamical stability (sys rr [ mmhg) and missing indication for immediate laparotomy. results: patients ( f, m) with an average age of ± years underwent preemptive angioembolisation after traumatic lesions of the spleen. the ais abdomen was in and in patients. besides a splenic injury patients did also have a kidney injury. the overall iss was ± points. patients suffered additional thoracic or head trauma. in patients the angioembolisation was performed on admission, in on the st, in at the nd and respectively in the rd and th day of. in case an uncomplicated selective embolization of a main duct of the splenic artery was performed. in patients the trouble-free proximal embolization of the splenic artery was done. the average stay was ± . days. no deaths or complications seen due to angioembolisation or splenic rupture. there were no complications or operative introduction: traumatic abdominal wall hernias (tawhs) are uncommon, and the optimal management is debated. tawhs most often result from blunt trauma and are associated with severe intraabdominal injuries. our institutional protocol mandates primary repair only if the patient undergoes laparotomy for other reasons and is without mesh. since , primary repair of lumbar hernias included bone anchors when indicated. we wanted to describe the tawh patients treated operatively during initial hospitalization focusing on injury mechanism, diagnosis, associated injuries, operative techniques, early complications and outcomes. materials and methods: we performed a retrospective, descriptive cohort-analysis of data from the institutional trauma registry from - . all operatively managed tawhs were identified based on ais codes, ncsp codes and relevant key words. results: of the identified patients, ( %) were women. median age was years (range - ). median iss was and patients had iss [ . injury mechanism was blunt except for one explosion. patients ( %) had been in a mvc, and of these ( %) had seat belt injuries. of these patients had a disruption of the muscle from the iliac crest, and one had a hernia through a fractured iliac wing. bicycle falls and fall from height had hernias in the anterior abdominal wall. two meshes were placed, with no known complications. bone anchors (twinfix Ò , mm) were used in patients. no recurring hernias were identified in the patients with routine follow-up ( - months) . conclusions: surgery for tawh is uncommon in our institution. tawh is often associated with severe torso injuries and primary repair is only done when laparotomy for other reasons is indicated. primary suture of the muscle, including use of bone anchors seems to be adequate treatment, as we have identified no recurrences. a longterm follow-up study is warranted for operated and non-operated patients with tawh. a comparison of sub-specialty operative adolescent patient outcomes in adult and pediatric trauma centers introduction: adolescent trauma victims may be treated at either an adult (atc) or pediatric trauma center (ptc). these centers have different resources, surgeon training and overnight in-house coverage. it is not known how outcomes compare with regards to the very small subset of patients that actually undergo a surgical trauma intervention. we hypothesized that presentation to a ptc would yield increased mortality when subspecialty intervention was required and that this would be most pronounced at night when in-house attending coverage is absent at all state ptcs. materials and methods: a review of the pennsylvania trauma outcome study (ptos) database was performed to capture patients aged - who underwent any non-orthopedic trauma surgery. cohorts were created for cranial, thoracic, abdominal or vascular surgery from - . trauma centers were divided as adult level (atc ), adult level (atc ) or pediatric (ptc). groups were created based on time of arrival with am- pm being dayshift and : pm- am being night shift. age, race, mechanism of injury, vital signs, gcs, iss, los and mortality were evaluated. ancova was utilized to control for iss variation. spss was used for all analyses. results: patients met initial criteria. atc s saw more minority patients and more males than other center types. atc s saw an overall older cohort ( . years vs . years in atc and . years in ptc, p \ . ). despite this age difference, presenting systolic blood pressure was lowest at the atc s ( . mmhg vs . mmhg at atc and . mmhg at ptc, p \ . ). iss and triss and overall mortality were not different and this included when grouped by day or night shift. of note, trauma thoracotomy was more likely to be performed at night in adult centers. hospital length of stay was significantly lower for atc ( . days vs . in atc vs and . in ptc). conclusions: adult and pediatric trauma centers see different patients. operative trauma cases are surprisingly low at our state's ptcs and trauma thoracotomy was more likely to be performed at night in atcs than ptcs. broader study is needed to uncover differences in operative care and outcomes. treatment of dislocation of the patella as a result of sports injuries in children. forecast and consequences in adulthood k. furmanova , o. loskutov , a. naumenko medinua clinic and lab, ortopedics, dnepr, ukraine introduction: dislocations of the patella with a rupture of the medial patellofemoral ligament (mpfl) account for - % of acute injuries of the knee joint [ , ] . inadequate therapeutic tactics of these injuries in childhood and youth, as a result of sports injuries, are fraught with complications in the form of the instability of the knee joint, residual deformities and contractures in patients in adulthood [ , ] . materials and methods: in the period from to cases of rupture of mpfl among children aged - years who were involved in sports were observed. the examination included conducting a clinical examination, axial radiography with flexion of the joint at angles of °and °, mri of the knee joint. results: in . % ( cases) the integrity of the mpfl(with a reduced number of sutures) was restored using a yamamoto suture, and in cases ( . %), the autoplasty of the mpfl was performed. excellent medium-term ( years) clinical and functional results according to the ikdc scale were noted in . % of cases, good in . %, satisfactory in . %. in patients ( . %) there was a relapse of dislocation after performing an mpfl suture during the first year after surgery mainly due to noncompliance with the recommendations. conclusions: injury to the knee joint with the patella dislocation in childhood and adolescence, associated with a sports injury is an indication for surgical treatment in order to adequately restore the integrity of the mpfl and prevent disabling complications. our yamamoto suture technique is more optimal for treating young patients with instability of the patella and is recommended for widespread use in pediatric orthopedists due to its undeniable clinical advantages. osteotomy with a defect cm placed cm below tibial plateau. types of fixation have been simulated: plate fixation of only a medial pillar, plate fixation of only a lateral pillar, plate fixation of both pillars, and locking intramedullary nailing. results: in case of plate fixation of only a medial pillar, the injury to an interosseal membrane causes an expressed valgus deformation at axial loading, leading to a reasonable ( . mpa) overload of the fixator in the osteotomy area. the use of a lateral plate leads to excessive loading on an external pillar, while the medial pillar remains unsupported. this causes overloads of the fixator in the osteotomy area ( . mpa). the double plate fixation is typical of the lowest extent of bone fragments displacements ( . mm) . this is a super-rigid type of osteosynthesis, able to cause a stress-shielding syndrome in the adjacent bone. it has been estimated that the method of im nailing is an optimal fixation method, with minimum loading of the fixator ( . mpa) and the best distribution of changed elastic strains in the bone-implant system. conclusions: the mathematical simulation demonstrates that fixation by a medial plate is possible only if support functions of the ligament system and interosseal membrane remained intact. if an injury is a high-energy one, nailing is preferable. introduction: treatment of large bone defects is one of the great challenges in contemporary orthopedic and traumatic surgery. grafts are necessary to support bone healing. a well-established allograft is demineralized bone matrix (dbm) prepared from donated human bone. a recent development is a new fibrous demineralized bone matrix (f-dbm) with a high surface-to-volume ratio. in this study we examine toxicity of an innovative dbm fibers preparation. materials and methods: f-dbm was transplanted to a mm, platestabilized, femoral critical-size-bone-defect of mm in sprague-dawley (sd)-rats (n = ). healthy animals were used as control. after months histology, hematological analyses as well as serum biochemistry was performed. were measured as indicators of free radical exposure. there were no significant differences between the control group and animals receiving f-dbm. hematology as well as biochemistry did not differ between operated animals and control. histologically no evidence of damage to liver and kidney and a good bone healing could be observed in most cases. conclusions: taken together, these results provide evidence for no systemic toxicity of the bone allograft. i have received no significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services or financial support related to this abstract. • i hereby confirm that my abstract is based on previously unpublished data and that i own the rights to the written summaries of research or observations presented in the abstract, or that i have obtained permission for the acknowledged sources for other excerpts taken from copyrighted works. • in submitting an abstract i hereby agree that the copyright of my abstract is transferred to the european society of trauma and emergency surgery. • i hereby confirm that i will present my abstract at the congress in case it is accepted. sponsor: german institute for cell and tissue replacement (dizg, gemeinnützige gmbh), berlin, germany. intramedullary nailing through suprapatellar approach in distal tibia fractures: a retrospective study evaluating clinical and radiographic results d. bustamante recuenco , a. gómez , j. m. pardo garcía , e. garcía , p. castillón , p. caba doussoux hospital de octubre, madrid, spain, madrid, spain, hospital mutua terrasa, orthopaedics, barcelona, spain introduction: distal tibia fractures (dtf) can be operated either by intramedullary nailing (imn) or by orif with plates. the current literature shows a higher rate of malalignment and consolidation delay with imn when compared to plates. in these studies, an infrapatellar approach for the imn is performed. recent studies show a better alignment in dtf treated with imn by suprapatellar approach, though functional and biological outcomes have not been analyzed yet. our goal is to assess the clinical and radiographic results of the treatment of dtf with imn using a suprapatellar approach. materials and methods: a two-center retrospective study was performed, collecting the cases with dtf treated with suprapatellar imn from / to / . results: a total of patients were obtained, with a mean age of . years. the average follow-up was months. % of the fractures were ao type a, presenting the remaining % intra-articular involvement. patients presented complications, corresponding in of them to superficial infections. as for clinical results, complete mobility in the knee and ankle was obtained in almost all cases. at the radiographic level, a total of % ( ) of distal malalignment cases were detected, defined as more than °deviation from normal axis in the coronal and sagittal planes. most of the fractures consolidated in a period of - months. there were cases of delayed consolidation, from which developed pseudoarthrosis. conclusions: intramedullary nailing through a suprapatellar approach for dtf offers good clinical and radiographic results, with low rates of malalignment and lack of consolidation. more studies are required to compare the results obtained with other fixation methods for these fractures. reference: avilucea fr, triantafillou k, whiting ps, perez ea, mir hr. suprapatellar intramedullary nail technique lowers rate of malalignment of distal tibia fractures. j orthop trauma. ; ( ) : - . the clinical consequences of follow-up radiographs in ankle fractures are unclear and indications for these radiographs are seldom well-defined. routine radiographic imaging in the follow up of patients with an ankle fracture adds to treatment costs, although retrospective studies dispute its usefulness. the aim of this study was to assess if a protocol with a reduced number of routine radiographs would lead to cost savings, without compromising clinical outcomes. materials and methods: a multicentre randomized controlled trial was conducted. patients were randomly assigned in a : ratio to usual-care (consisting of routine radiography at one, two, six and twelve weeks) or reduced-imaging (radiographs only obtained for a clinical indication at six and twelve weeks). functional outcome was assessed using the omas and aaos ankle questionnaires, quality of life was measured with eq- d- l and sf- questionnaires. other outcome measures included complications, pain, the number of radiographs, health perception and self-perceived recovery. costs were measured with self-reported questionnaires results: the study group consisted of participants, of which ( %) received operative treatment. patients in the reduced-imaging group received median radiographs, whilst patients in the usual care group received median radiographs (p \ . ). omas, aaos scores, quality of life, pain, health perception and self-perceived recovery did not differ between groups. we observed complications in the reduced imaging group. this did not differ significantly from the usual care group ( complications p = . ). a significant reduction in radiographic imaging costs was observed (-€ per patient, % ci - to - ). overall costs per patient were comparable ( [ % ci - to ]). conclusions: implementation of a reduced imaging protocol in the follow up of ankle fractures leads to cost savings and more importantly does not lead to worse functional outcomes. results after percutaneous and arthroscopically assisted osteosynthesis of calcaneal fractures w. grün , m. molund , f. nilsen , a. stødle oslo university hospital, orthopaedic department, ullevål, oslo, norway, Østfold hospital, orthopaedic department, grålum, norway introduction: operative treatment of calcaneal fractures using the extensile lateral approach is associated with high rates of soft tissue complications. during the last years there has been a trend towards less invasive fixation methods. percutaneous and arthroscopically assisted calcaneal osteosynthesis (paco) combines the advantages of good visualization of the posterior facet of the subtalar joint with a minimally invasive approach. materials and methods: we conducted a clinical and radiographic follow-up of patients with calcaneal fractures treated by paco with a minimum follow-up of year. there were sanders ii and sanders iii fractures. the mean follow-up period was . months (sd . ). our primary outcome was the american orthopaedic foot and ankle society (aofas) ankle-hindfoot score. secondary outcomes were the calcaneus fracture scoring system (cfss), the manchester-oxford foot questionaire (moxfq), the visual analog scale (vas) for pain and the incidence of complications. radiographs were obtained to evaluate the reduction of the fractures as well as the presence of subtalar osteoarthritis. results: the median aofas score was (range, - ), the cfss score ( - ), the moxfq score . ( - . ). the vas pain score was ( - . ) at rest and . ( - . ) during activity. the böhler angle improved from mean . degrees (sd . ) preoperatively to . degrees ( . ) postoperatively. however, the follow-up radiographs showed subsidence of the fractures and a böhler angle of . degrees ( . ). % of the operated feet showed signs of posttraumatic subtalar osteoarthritis. there were no wound healing complications. two patients were reoperated with screw removal due to prominent screws. conclusions: our results suggest that paco gives good clinical results and a reduced risk of complications in selected calcaneal fractures. prospective longterm studies will be necessary to better evaluate the potential advantages and limitations of paco. with the nascent state of microsurgical services in the region the application of negative pressure wound therapy (npwt) has proven to be very helpful. an improvised npwt has made it locally available to patients. this report aims to show how this has improved the management of open fractures of the lower limb in a resource restricted setting. materials and methods: a -month review of cases of lower limb open fractures managed at a regional trauma centre in nigeria was done. the type of wounds were classified based on region and need for soft tissue coverage. results: a total of cases were reviewed approximately % of these case were gustilo and anderson type iii. of these had npwt as part of their management. some of the benefits of observed were; reduced frequency of wound dressings, and shorter time to optimize wound for closure. conclusions: the locally improvised npwt has proven to be an affordable and cost-effective tool in the management of open lower limb fractures. it remains an invaluable alternative of care in the absence of microsurgical skills and patented device with are far from reach owing to financial constraints. references: . hussain a, singh k, singh m. cost effectiveness of vacuum assisted closure and its modifications: a review. isrn plast surg. ; : - . . isiguzo c, ogbonnaya i, uduezue a. modification of negative pressure wound therapy in the economically constrained region: a preliminary report. vol. , nigerian j plast surg. joytal printing press; . p. - . . mba u, nevo a. challenges of limb salvage in a resource limited environment: case report and review of literature. niger j plast surg. ; ( ): . . novak a, wasim sk, palmer j. the evidence-based principles of negative pressure wound therapy in trauma and orthopedics. open orthop j. ; : - . introduction: lower extremity vascular trauma may result in limb loss or mortality. this study examined outcomes of lower extremity vascular trauma (levt) and potential associations to amputation/mortality. materials and methods: a retrospective cohort study of patients (n = ; limbs) with levt between and in a single trauma center. only patients requiring a vascular procedure were included. data were extracted from the swedish vascular registry (swedvasc) and the swedish trauma registry (swetrau). results: mean age ± years; men % ( / ); trauma mechanism % ( / ) blunt and % ( / ) penetrating. % of patients underwent preoperative cta; % of patients ( / ) were transferred to hybrid operating room. arterial injury was present in / limbs ( %) and venous injury in / limbs ( %). the most frequently injured artery was popliteal artery ( / ; %) followed by superficial femoral artery ( / ; %). most common vascular operative procedure was arterial bypass/interposition graft ( / ; %). a vascular shunt was used in % of cases ( / ). fasciotomy was performed in % ( / ) of limbs. four patients were lost to follow-up after less than five days. there were eleven limbs ( / ; %) amputated within -day postoperative follow-up. all amputations were caused by blunt trauma. % ( / ) of arterial injuries below-the-knee led to amputation. thirty-day mortality rate was . % ( / ) . univariate analysis showed that fractures (p \ . ), soft tissue injury (p \ . ), multiple injuries (p = . ), and blunt mechanism (p \ . ) were associated with amputation and mortality after levt. conclusions: this study showed that amputations after levt are caused by blunt trauma. also levt combined with fractures, soft tissue injury, or multiple injuries increased the risk of amputation and mortality. multi-center study enabling multivariate analysis to adjust for potential confounding factors is imperative to confirm these findings. incidence, treatment and financial burden of tibial plateau fractures in belgium between and describe the incidence, evolution in management and financial burden of tpf in belgium between and . we compare national data with data from uz leuven (uzl), the largest university hospital in belgium. materials and methods: this study includes all tpf treated in belgium between and . we identified . tpf, of which fractures were treated in uzl. despcriptive statistics were used to analyze the data. results: the annual incidence increased from . to . / , /y. an increase in number was true for both operatively treated patients (otp) and non-operatively treated patients (notp), but was more pronounced in the latter ( % vs. % increase). the rate of surgery (ros) decreased from . % to . %. the mean ros for uzl was . %. the total financial burden in belgium increased with %, mainly driven by increasing costs in otp. hospitalisation rates for notp decreased from % to %, as day hospital admission occured more commonly. the mean hospitalisation cost was € , for otp and € , for notp. costs for uzl inpatients were € , and € , . nursing days accounted for % of the cost in otp and % in notp. the mean los was . days for otp and . days for notp. uzl patients had a mean los of . and . days. conclusions: tpf are associated with increasing hospital related healthcare costs. as nursing days determine the majority of the financial burden, measures should be taken to avoid prolonged los. introduction: rotational malalignment (rm) is a common postoperative complication after intramedullary (im) nailing of tibial shaft fractures. computed tomography (ct) is commonly used for detection of malrotation, however reliability is frequently questioned. the purpose of this study is to evaluate the intra-and inter-observer reliability of low-dose protocolled bilateral postoperative ct-assessment of rotational malalignment after im nailing of tibial shaft fractures. materials and methods: a total of patients were prospectively included with tibial shaft fractures that were treated with imn in a level-i trauma center. all patients underwent postoperative bilateral low-dose ct-assessment (effective dose of . - . mgy) as per hospital protocol. four observers performed the validated reproducible measurements of tibial torsion in degrees, based on standardized techniques. the intra-class coefficient (icc) was calculated to evaluate intra-and inter-observer reliability. the intra-and inter-observer reliability was categorized according to landis and koch. results: intra-observer reliability for quantification of rotational malalignment on postoperative ct after imn of tibial shaft fractures was excellent with . ( % ci = . - . ). the overall inter-observer reliability was . ( % ci = . - . ), also excellent according landis and koch. discussion and conclusion: first, bilateral postoperative low-dosesimilar radiation exposure as plain chest radiographs-ct assessment of tibial rotational alignment is a reliable diagnostic imaging modality to assess rotational malalignment in patients following imn of tibial shaft fractures and it allows for early revision surgery. second, it may contribute to our understanding of the incidence, predictors, and clinical relevance of postoperative tibial rotational malalignment in patients treated with imn for a tibial shaft fracture, and facilitates future studies on this topic. the trauma emergency laparotomy audit (tela) t. collaborators , m. marsden , p. vulliamy , r. carden , o. najiuba , n. tai , r. davenport tela collaboration, natric, n/a, united kingdom, queen mary university of london, centre for trauma science, london, united kingdom introduction: mortality for shocked trauma patients undergoing emergency laparotomy remains unchanged for years. the tela study aimed to describe the contemporary peri-operative management and patient outcome following abdominal injury. materials and methods: a prospective multicentre observational study of all patients undergoing emergency abdominal surgery within h of injury was performed in the uk and ireland for six months from the st january . shock was defined as the receipt of blood transfusion, with clinical or biochemical evidence of hypoperfusion. results: the study included patients from hospitals, of whom ( %) were shocked and received a median of units red blood cells. shocked patients were more likely to have a blunt mechanism of injury ( % vs %, p \ . ) and had a % mortality ( / ). half of these deaths occurred in the operating room (or). patients that died were more severely injured (injury severity score (iqr - ) vs (iqr - ), p = . ) and had a greater degree of shock at hospital arrival (base deficit . (iqr . - . ) vs . ( . - . ) , p \ . ). processes of care were equivalent or better among non-survivors, with a higher proportion of patients that died undergoing laparotomy within min of arrival in the emergency department ( % vs %, p = . ) and a lower proportion receiving crystalloid in the or ( % vs %, p \ . ). however, delays to achieving definitive haemorrhage control and delivering balanced blood transfusion ratios were observed among both survivors and non-survivors. conclusions: damage control resuscitation principles are followed most closely in patients that die. despite better processes of care, in shocked patients died in this study justifying the continued search for novel therapeutic approaches. pre-operative temporary haemorrhage control and pharmacological mitigation of the effects of shock may be productive avenues of research to improve patient outcomes. introduction: tranexamic acid (txa) has been shown to reduce mortality in bleeding trauma patients, with greater effect if administered early. normally administered intravenously, txa can also be administered intramuscularly, which could be advantageous in low resource and military settings. intramuscular use has only been tested in healthy patients, and it is likely that shock will reduce intramuscular uptake. materials and methods: in a prospective experimental study norwegian landrace pigs ( - kg) utilised in a surgical course in haemostatic emergency surgery were subjected to various abdominal and thoracic trauma. after h of surgery the pigs were injected with mg/kg txa either intravenously or intramuscularly. blood samples were drawn at , , , , , , and min. the samples were centrifuged and analysed with liquid chromatography-mass spectrometry (lc-ms/ms). results: preliminary results from animals in the intramuscular and animals in the intravenous group. mean plasma concentration with sd of txa as a function of time is shown in figure . plasma concentration in the intramuscular group was near ug/ml min after administration, and rose above ug/ml after min. conclusions: plasma concentrations reported to inhibit fibrinolysis in vitro is - . ug/ml ( , ) . if this extrapolates to the clinical situation intramuscular administration would yield plasma levels within the lower end of therapeutic range after min. in ongoing haemorrhagic shock plasma concentrations of txa after intramuscular administration were considerably lower than after intravenous administration, but within therapeutic range . introduction: fallowing laparoscopic cholecystectomy(lc), patients suffer from postoperative pain, especially in the abdomen. intraperitoneal local anesthesia (ipla) reduces pain after laparoscopic cholecystectomy(lc). acute cholecystitis(ac)-associated inflammation, increased gallbladder wall thickness, dissection difficulties, and a longer operative time are several reasons for assuming a benefit in pain scores in urgent lc with ipla application. the aim was to determine the postoperative analgesic efficacy of high-volume lowdose intraperitoneal bupivacaine in urgent lc. materials and methods: fifty-seven patients, american society of anesthesiologists(asa) physical status i or ii were randomly assigned to receive either normal saline(group a) or intraperitoneal bupivacaine(group b) at the beginning or at the end of the surgery in urgent lc. the primary outcome was the scores of postoperative pain by visual analogue scale score (vas) after surgery. results: postoperative vas scores at st and th hours were significantly lower in group b than group a (p \ . ). postoperative vrs scores at st, th and th hours were significantly lower in group b than group a (p \ . , p: . , p: . ). anelgesic use was significantly higher in group a at st postoperative hour than group b (p \ . ). shoulder pain was significantly lower in group b than in group a (p \ . ). patient satisfaction was significantly higher in group b than in group a (p \ . ). conclusions: high-volume low-concentration intraperitoneal bupivacaine instillation resulted in better postoperative pain control along with reduced incidence of shoulder pain and analgesic consumption in comparison to control group in urgent lc. introduction: in-hospital resuscitative thoracotomy is an established procedure for patients with penetrating cardiac injuries. the survival rate is dismal in patients with cardiac arrest prior to admission. prehospital resuscitative thoracotomy (prt) was introduced by the london hems with the highest published survival rate of %. we aimed to identify the number of patients who could potentially benefit from prt in our major trauma center catchment area. materials and methods: data from to were collected from the institutional trauma registry and electronic records. we included patients [ years, with penetrating cardiac injury, or penetrating chest trauma and cardiac arrest, or penetrating chest trauma and sbp \ mmhg. commonly used criteria for prt are tamponade with cardiac arrest lasting \ min at the time of ambulance arrival and with [ min remaining transportation time to hospital. results: cardiac injury was found in of included patients. of these , arrived at the hospital with signs of life and survived. of the patients who died had tamponade. criteria for prt were not met in of patients with tamponade. two patients could have been eligible for prt. one patient was found in oslo with cardiac arrest lasting min. the patient had multiple stab wounds to the chest and had several perforations of the right atrium, not technically manageable in a prehospital setting. the second patient was injured outside our primary catchment area and arrested with prehospital personnel present. prt was performed and the tamponade relieved, but compression of the aorta was necessary. the patient was declared dead shortly after hospital admission. conclusions: in years in a population of . million, two patients met london hems criteria for prt. prt was performed in one patient who was declared dead shortly after hospital admission while one patient suffered from injuries which are unmanageable in a prehospital setting. isolated tissue injury leads to fibrinolytic shutdown, tpa resistance and alterations in clot structure in a porcine model introduction: trauma-induced coagulopathy includes a spectrum of hypo-to hypercoagulable phenotypes with differing levels of fibrinolysis and tpa sensitivity. fibrinolysis shutdown is associated with increased late mortality and shown in small animal studies to be driven by tissue injury. utilizing a novel method of clot structure analysis, we hypothesize that isolated tissue injury provokes fibrinolysis shutdown, tpa resistance and is associated with altered clot structure resulting in enhanced clot stability. materials and methods: all male pigs (n = ) underwent anesthesia, intubation, femoral artery cannulation and mini-laparotomy. tissue injury (n = ), was inflicted with bilateral chest wall muscular cutdowns and bilateral femoral fractures using a captive bolt pistol. mean arterial pressure was maintained at [ mmhg. timed blood samples analyzed using tpa challenged and citrated native teg to evaluate tpa resistance and fibrinolytic shutdown respectively. after mm punch biopsy induced splenic injury, clot was collected, washed, and chemically fractioned by strong cation exchange chromatography. tandem mass spectrometry and bioinformatic analysis were used to evaluate clot structure and factor xiiia cross-linking patterns and covalently associated proteins. results: tissue injury pigs showed increased tpa resistance (change tpa-teg ly : - . % vs - . % p = . ) and a trend of fibrinolytic shutdown evidenced by teg compared to control (fig. ) . splenic clot structure analysis demonstrated altered clot structure (fig. ) and identified elevated levels of protease inhibitors such as alpha macroglobulin and alpha antiplasmin at h post tissue injury compared to baseline. conclusions: in a porcine model, isolated tissue injury provokes fibrinolysis shutdown and tpa resistance resulting in altered clot structure with an increased incorporation of anti-protease proteins resulting in enhanced clot stability. there is a high incidence of rotational malalignment after intramedullary nailing of tibial shaft fractures: a prospective cohort series of patients n. j. bleeker amsterdam medical centre, flinders university, department of orthopedics and trauma surgery, amserdam, netherlands introduction: intramedullary nailing (imn) is the treatment of choice for most tibial shaft fractures due to its minimalistic surgical approach, superior fracture healing, and rapid recovery. however, an iatrogenic pitfall is rotational malalignment (rm). the aim of this prospective cohort study was to determine the incidence of rm and to evaluate the efficacy of protocolled bilateral postoperative computed tomography (ct) assessment of rotational tibial alignment. materials and methods: between and we prospectively included patients ( male ( %)), with a mean age of years, with a unilateral tibial shaft fracture. as per hospital protocol, patients underwent a routine low-dose bilateral postoperative ct to assess rm. forty-two patients ( %) suffered open injuries; ( %) were involved in a multi-trauma sustaining more than one injury. according to the ao/ota classification, there were simple ( %), wedge ( %), and complex fractures ( %). fracture location within the tibial shaft varied with six patients ( %) being within the proximal third, ( %) middle third, and ( %) distal third. there were segmental ( %) fractures that involved more than one third of the tibia. results: fifty-five patients ( %) had post-reduction rm including patients ( %) between °- °, seven patients ( %) with a rm between °- °, and two patients ( %) with a rm greater than °w hen compared to the uninjured side. of the patients with rm, the tibia was externally malrotated in patients ( %). three patients ( % of cohort or % of those with rm) underwent revision surgery to correct the rm as detected on ct scan. conclusions: this study reveals a high incidence of rm following tibial nails ( %) with a surprisingly low revision rate ( % of those with rm). a subsequent study should aim to assess clinical relevance of rm in terms of functional outcome and gait analysis. for now ctrotational-profiling provides a platform for early recognition and correction of rm secondary to tibial imn. level of evidence: therapeutic level ii -prospective cohort study. materials and methods: the tarn database was analysed retrospectively to quantify the number of trauma team activations, patients with major trauma (mt), causes of injury, and subspecialty-specific trauma procedures. crude and risk-adjusted mortality rates, observed to expected (o/e) mortality ratio, and risk-adjusted rates of survival from mt were also calculated. results: the number of trauma team activations has risen by a factor of . the predominant injury mechanism that resulted in mt was a fall from less than m. there has been a fivefold increase in the overall number of trauma surgical procedures. orthopaedic surgeons have performed % of trauma procedures, followed by neurosurgeons, oral and maxillofacial surgeons, and visceral trauma surgeons. the rate of trauma laparotomies per consultant fluctuated between . and . per month. a fall from less than m, road traffic accident and a fall from more than m were the three leading causes of death from mt. the overall o/e mortality ratio was . . conclusions: aintree trauma profile has significantly changed since . this change highlights the potential need for a review of how mt services are offered at aintree to reduce the o/e mortality ratio. this may be achieved through more co-ordinated provision of trauma care, prevention, audit and research programmes. the role of visceral trauma surgery should be reconsidered within the context of the surgical patients' needs and demands, and fundamental requirements of the profession. inter-hospital variation in surgical intensity for trauma admissions: a multicenter cohort study l. moore , m. p. patton , i. farhat , p. a. tardif , c. gonthier , a. belcaid , f. lauzier , a. turgeon , j. clément université laval, social and preventive medicine, québec, canada, chu de québec-université-laval, québec, canada, introduction: guidelines for trauma patients are increasingly moving away from surgical management towards less invasive procedures but there is a knowledge gap on how these recommendations are influencing practice. we aimed to assess inter-hospital variation in surgical intensity for trauma patients and identify determinants of surgical intensity. materials and methods: we conducted a retrospective multicenter cohort study based on the trauma centers of an inclusive canadian provincial trauma system. we included adults admitted for major trauma between and . analyses were stratified for orthopedic (n = , ), neurological (n = , ) and thoracoabdominal surgery (n = ). surgical intensity was quantified with the number of surgical procedures during the first h. inter-hospital variation was assessed with the intra-class correlation coefficient (icc) from multilevel poisson regression models. relative risks (rr) were generated to identify determinants. results: moderate inter-hospital variation was observed for orthopedic surgery (icc = . %, % confidence interval [ci]: . - . ) whereas variation was low for thoracoabdominal surgery (icc = . %, % ci: . - . ) and neurosurgery (icc = . %, % ci: . - . ). level iv centers had similar surgical intensity for thoracoabdominal injuries (rr: . , % ci: . - . ) but lower intensity for orthopedic injuries (rr = . , % ci: . - . ) than level i/ii centers. during the study period, we observed a decrease in intensity for neurosurgery (rr for (rr for - versus . , % ci: . - . ) and thoracoabdominal surgery (rr = . , % ci: . - . ). conclusions: the observed inter-hospital variation in risk-adjusted surgical intensity suggests that there may be opportunities for quality improvement in surgical care for injury admissions. a better understanding of how surgical intensity influences clinical outcomes is needed to inform quality improvement activities. pre-hospital injury diagnosis a. easthope , m. marsden , g. grier barts and the london medical school, london, united kingdom, royal london hospital, centre for trauma science, london, united kingdom introduction: accurate pre-hospital diagnosis of a patient's injuries may improve care by facilitating effective intervention at the scene and reducing time to definitive treatment in hospital . we sought to assess the diagnostic accuracy of injuries by london's air ambulance (laa) clinicians and identify conditions in which clinical accuracy may deteriorate. materials and methods: a retrospective review was undertaken of all patients conveyed to the royal london hospital by laa from october for six-months. pre-hospital injury scores, coded using the abbreviated injury score (ais) were compared to hospital discharge ais. patient outcomes were evaluated in the case of underscored injuries. results: during the study period patients were seen and met eligibility. mean clinical sensitivity and specificity was % and % respectively. chest injury identification was most sensitive ( %) and pelvic injury least sensitive ( %). the relative risk (rr) of underscored injuries to the chest, abdomen and pelvis increased with decreasing glasgow coma scale (gcs) peaking at . (iqr . - . ). the average accuracy of injury identification was % with a negative predictive value of %. no overt patient morbidity resulted from a missed, or under-scored injury. all missed injuries were subsequently identified in the emergency department. conclusions: the pre-hospital diagnosis of injuries has reasonable sensitivity and excellent specificity. accurate pelvic injury diagnosis is more challenging than chest or abdomen. with decreasing gcs, the risk of missing injuries increases. clinicians should be aware of the potential for error when treating trauma patients with impaired conscious levels. comorbidities, injury severity and complications predict mortality in severe thoracic trauma: a retrospective analysis from the norwegian national trauma registry of epidemiology, clinical factors and risk factors for mortality of patients with thoracic injuries. materials and methods: adult patients treated for severe thoracic trauma (injury severity ais c ), between and at haukeland university hospital were included. data were extracted from ( ) the haukeland university hospital local trauma registry, and ( ) the norwegian trauma registry. additional data on comorbidities and complications was collected from patient records. the factors age, gender, comorbidities [charlson comorbidity index (cci)], anticoagulant use, injury severity [revised trauma score (rts)], [injury severity score (iss)] and complications [clavien-dindo scale (cds)] were analyzed for being predictive of in-hospital mortality. multivariate logistic regression analyses with backward selection methods were used. results: data of patients were analyzed, of which ( %) patients died. median iss was in the non-survivors (iqr , ) and (iqr , ) in survivors (p = . ). data of patients were used in the risk factor for mortality analysis. two or more comorbidities measured by cci (or: . , p = . ), injury severity measured with the rts (or: . , p = \ . ), and grade c complications on the cds (or: . , p = . ) were significant predictors for mortality. conclusions: severe comorbidities significantly decreased the chances of survival after thoracic trauma. injury severity was also found to be a significant predictor of mortality. physiological injury severity, measured by rts, appeared to be a stronger predictor of mortality than iss after thoracic trauma. finally, severe complications led to considerably higher risk of mortality following thoracic trauma. the psychosocial impact of e-bike accidents and changing values of older patients in the netherlands, a qualitative study s. berben , l. vloet , e. c. t. tan , m. edwards , , a. brants , , , g. olthuis , , , , a. oerlemans , , , , f. haverkamp , , introduction: the mechanical impact of e-bike accidents, increasingly used by older persons, has shown to be higher compared to regular bike accidents. however, the psychological impact of e-bike accidents in older trauma patients, their experiences in emergency and follow-up care, and the possible change in values and beliefs in response to the accident is still unknown. materials and methods: we used a qualitative design and included older patients ( ? years) with a variety of (severe) injuries, who were admitted to the emergency department after an e-bike accident (n = ) and their relatives (n = ). they were interviewed within one month (t ) and after three months (t ) of the date of accident. interviews were transcribed verbatim and analyzed via a thematic analysis approach using an ethical perspective. results: many patients required (in)formal care after hospital discharge. in general patients were satisfied with the provided emergency surgical care, although some patients reported limited and insufficient information on rehabilitation and homecare support. the analysis yielded impaired physical condition, anxiety, increased vulnerability and dependency of care givers as psychosocial impact. freedom impairment, shifting relational autonomy, and confrontation with vulnerability and mortality were reported changes in values. central values as mobility and freedom, vitality and health, social participation and recreation were put under pressure and needed to be negotiated again after the accident in order to decide whether to use the e-bike again. conclusions: follow-up information of surgeons and emergency physicians after initial hospital care for older trauma patients with an e-bike accident shows room for improvement, with more specific consideration for the psychological impact of trauma and changes in values after e-bike accidents. eur j trauma emerg surg. . https://doi.org/ . /s - - - . traumatic subaxial cervical fractures: functional prognostic factors and survival analysis introduction: the main goal of this study is to identify the risk factors for poor functional outcomes and to analyze the overall survival (os) and complications rate in patients with traumatic cervical spinal cord injury (sci) and subaxial cervical fracture (sacf) treated with open surgical fixation. materials and methods: the authors retrospectively reviewed sixtyfive consecutive patients from one single center with traumatic unstable sacf and associated sci treated surgically between and . we exclude cervical fractures with concomitant severe head injury, brachial plexus injury, lumbar plexus injury, superior or inferior limb fractures and patients who were lost during the followup period. statistical analysis using a chi square test, student's t-test and logist regression were used to identify factors associated with poor functional outcomes after surgical treatment. os analyses were performed using kaplan-meier curves. results: the -year survival rate was . %. four patients died in the first days after surgery and , % need a reoperation. the median time from injury to surgery was . days. the complication rate was %, being respiratory failure the most common one. preoperatively, % had an asia \ c. about % of the patients with asia between a-d had improve one or more asia grades. logistic regression analysis show that older age, sacf above c , asia \ c pre-surgery and long time from injury to surgery were related with poor prognosis. the os rate was higher in patients with neurological improvement, without signs of neurogenic shock at presentation and in sacf bellow c . conclusions: our results suggest that sacf should be treated as soon as possible in order to improve the os rates and functional outcomes. older patients, lower asia at presentation and sacf above c are related with worst functional outcomes. introduction: compression fractures of multilevel vertebral bodies are common in children. due to segmental plasticity, several adjacent vertebral bodies are compressed to a lesser degree at each body. plain ap and lateral x-ray is the first diagnostic examination in the emergency department (ed), but a proper diagnosis is often delayed or missed. materials and methods: this is a retrospective, monocentric study in children falling on their back who showed up at the orthopedic ed, between december and september . nine children ( f, m) with an average age of . years were included. trauma occurred playing games and doing sports in all cases. all children were subjected to x-ray, followed by mri scans for doubtful findings on the plain x-ray or persistent mild pain (t , t , t -stir sequences). results: cuneiform vertebral fracture or vertebral body height reduction was diagnosed with x-ray in five vertebrae while mri showed fractures in vertebrae including compression and edema of adjacent vertebrae in the t -stir sequence. therefore only . % vertebral fractures have been detected by plain x-ray. the injured vertebral bodies were so distributed: t n = , t n = , t n = , t n = , t n = , t n = , t n = , t n = , t n = , t n = , l n = , l n = , s n = , s n = . the most involved spine section was between t and t with fractures. conclusions: vertebral fractures are not always related to hyperflexion or forward hinging mechanism. mri showed vertebral compression fractures and the t -stir sequence showed edema as post-traumatic evidence that had not been detected by x-ray. in absence of a radiologically visible lesion, the persistence of pain should be investigated by performing mri scans. the middle thoracic spine level appeared to be the most involved one in pediatric vertebral fractures. introduction: occipitocervical fixation (ocf) is an effective surgical method to treat various craniovertebral junction (cvj) pathologies. a rigid fixation achieved from ocf displaces other techniques of cvj stabilization unfortunately during procedure deep and wide wound is performed. aim of this study is to share our experience in ocf and lately performed percutaneous ocfs with intraoperative ct guided navigation system. materials and methods: of patients who underwent ocf were performed percutaneously. o-arm ct scans were used to illustrate and measure radiologic parameters. screws were implanted in c lateral masses ( ) , isthmus of c ( ) and c pedicles ( ) and assessed according gertzbein robbins (gr) in modification of bredow classification from a to e. results: a total screws were implanted, of them was performed in open surgery and percutaneously. outcome in gr classification for screws implanted in open surgery was: a ( , %), b ( , %), c ( , %), d ( , %) and e ( , %) while in percutaneous: a ( , %) and b ( , %) . in open surgery one screw was revised. conclusions: percutaneous occipitocervical fusion seems to be a good option to achieve desirable effect in cervical pedicle screws implantation. during procedure whole nuchal muscles are preserved. ct guided surgery and microscope view are necessary to perform percutaneous ocf. introduction: studies have found higher risk of traumatic deaths in rural areas in norway combined with a paradoxically decreased prevalence of severe, non-fatal injuries ( ) . this study investigates the risk of fatal and non-fatal injuries among all adults in norway in the period - . materials and methods: all traumatic injuries and deaths among persons with residential address in norway from - were included. data was collected from the norwegian patient registry and the norwegian national cause of death registry. all cases were stratified according to six groups of centrality based on statistics norway's classification of centrality . mortality-and injury rates was calculated per , inhabitants per year. results: the mortality rate differed significantly according to the levels of centrality (p \ . ). the mortality rate in the most urban group ( ) was . and in the most rural group ( ) . . the lowest mortality rate was found in centrality group ( . ). there was an increased risk of death between centrality group and group with a relative risk of . (ci: . - . , p \ . ). the most common cause of death was transport injuries, self harm, fall injury and other external causes. the highest urban-rural gradient was seen in transport injuries with a relative risk of . (ci . - . , p \ . ) comparing group to group . group had the lowest risk of nonfatal injuries ( ) and group the highest ( ). the risk of nonfatal injuries increased with higher grade of rurality, comparing group and revealed a relative risk . (ki . - . , p \ . ). conclusions: the more rural the higher risk of traumatic deaths and non-fatal injuries. transport injuries had the highest urban-rural gradient. references: . bakke hk, hansen is, bendixen ab, morild i, lilleng pk, wisborg t. fatal injury as a function of rurality-a tale of introduction: virtual fracture clinics (vfcs) are an alternative to conventional fracture clinics for management of musculoskeletal injuries. they have been shown to be a safe and effective model for upper and lower limb injuries. there is limited data to support their use for specialist thoracolumbar fracture follow-up. materials and methods: lean methodology including process mapping was applied to identify a safe virtual alternative for the pathway. first cycle analysis of consecutive referrals to a traditional specialist thoracolumbar fracture clinic. second cycle analysis of consecutive referrals six months after introduction of a vfc. results: mean time to first outpatient review in first cycle was days. referrals led to booked outpatient appointments and were missed ( % non-attendance). % of referrals had or more scheduled appointments. / were ao type a - and all of these received non-operative treatment. / were ao type a or b and of these received non-operative treatment. patient received operative stabilisation (ao type b). process mapping identified two pathways-virtual review with advice letter and physiotherapy referral (outcome a-ao type a - ) or face to face review (outcome b-ao type a or b). mean time to outpatient review in second cycle was days. / received outcome a. / ( %) made a telephone call for advice and only / ( %) asked for a face to face appointment. / received outcome b and all were discharged after one visit. patients in cycle required operative stabilisation. statistically significant reduction in number of scheduled face-to-face reviews ( versus ; p \ . ) and mean time to first review ( days versus days; p \ . ). conclusion: virtual thoracolumbar fracture clinics are a safe and clinically effective alternative to traditional fracture clinic models. lean methodology can be uses to extend virtual clinic pathways to specialist trauma clinics. treatment prognosis of cases of fragility fracture of pelvis m. yoshida fujita health universityhospital, emergency, aichi, japan introduction: the number of cases of fragility fracture of pelvis in the elderly has been increasing in recent years, but there are still not enough reports of surgical treatment as a treatment method, but there is still no certainty how to treat. so we investigated prognosis of cases of fragility fracture of pelvis. materials and methods: subjects were fragility fracture of pelvis treated at a single center from april to april , males, females, average age ± . years. only cases that had ct scan were included. we examined rommens classification, the presence of injury, presence of hip implants, functional prognosis, and -year mortality. results: the breakdown of rommens classification is type ia cases, ib cases, iia cases, iib cases, iic cases there were cases of iiia, cases of iiic, case of iva, cases of ivb, and cases of ivc. surgical treatment was indicated in cases ( . %) (iic case, iiia cases, ivb cases, ivc cases) there were cases ( . %) with no injury mechanism and cases ( %) with hip implants. cases ( %) were able to follow up for more than year including telephone surveys, and . % of them did not recover to functional level before injury. the one-year mortality rate was . %. conclusions: in the cases studied here, cases ( . %) were indicated for surgery. the prognosis and mortality rate are almost the same as those reported overseas, and as with proximal femoral fractures, there is a possibility that it may be greatly involved in adl decline in the elderly. we think that further study is needed in the future. conclusions: patients with a femoral neck fracture who received a hip hemiarthroplasty and used anticoagulation had no significant longer delay to surgery and had a higher mean loss of hemoglobin points. as a clinical consequence of this, more packed cells were supplemented. also more postoperative hematomas were found in the population with anticoagulation. no differences were found in mortality rates at -days and one year. results: on all eight patients the easy-approach was applied without adverse events. in four cases the plate osteosynthesis was done completely endoscopically with excellent results for the patients regarding pain relief and scar development. in the remaining four cases the endoscopic stabilization was not performed for the following reasons: in the first overall case primarily only the endoscopic approach was planned. in the fourth overall case, ventilation showed high end-expiratory co -levels after endoscopic situs preparation, so we converted to the open plating. in the fifth overall case, the easyapproach was applied to evacuate a retrosymphyseal hematoma in a patient with a stable pubic rami fracture. in the eighth overall case, the anterior pelvic ring injury was a bilateral multifragmentary pubic rami fracture in combination with a disruption of the symphysis. after endoscopic situs preparation with clipping of the corona mortis vessel, reduction of the displaced symphysis could not be done endoscopically. conclusions: we demonstrated that the endoscopic plate osteosynthesis of the anterior pelvic ring is feasible with existing standard laparoscopic instruments. the evaluation of the easy-approach in the clinical setting is going on, while the development of suitable reduction tools is one major goal of future studies. introduction: retrograde intramedullary pubic ramus screw fixation is less invasive method and biomechanically stable compared to the plate fixation. the purpose of this study is to examine the feasibility of screw insertion using computed tomography (ct). materials and methods: we analyzed sixty ct data ( cases in male and female each). by using ct analyzing software, the virtual column with . mm diameter was inserted so that we analyzed the feasibility of the screw insertion. and the intramedullary diameter of the pubic ramus at the parasymphyseal area, base, and acetabulum were measured. results: the virtual . mm diameter screws could be inserted in % ( / ) in male and . % ( / ) in female. the cause that screws insertion was impossible was penetration to the hip joint in all cases. the screw inserting point was . mm and . mm from the medial border of the pubic symphysis and . mm and . mm from the upper border of the pubic symphysis in male and female respectively (p [ . ). the intramedullary diameter of pubic ramus was . mm, . mm and . mm at parasymphyseal area, . mm, . mm and . mm at the base of pubis, and . mm. . mm and . mm at the acetabulum in male, female who had the screw corridor and female who didn't have the screw corridor respectively. the diameter of the pubic ramus of the female who didn't have the screw corridor was significantly small compared to male and pubic ramus in three measuring points (p \ . ). , % of the screws were revised. there were no neurovascular or urologic complications. radiographic nonunion was observed in % with a minimum follow-up of months, this correlated with a peri-implant infection (p . ), operation [ months after trauma (p . ) and non-significantly with implant loosening (p . ). there was no correlation of nonunion with patient's age, the fracture mechanism or a non-excellent reduction. in total, . % of the patients were re-operated, in . % a re-osteosynthesis was conducted. conclusions: retrograde trans-pubic screws show good clinical results with lower or similar complication rates compared to alternative methods as plate fixation or external fixator. fracture union did not depend on fracture mechanism or age. hence, this minimal-invasive method is especially attractive in elderly patients with an ffp. because it is an internal fixation of the superior pubic ramus with relative stability, an anatomic open reduction is not necessary to achieve fracture union. the need for extraperitonal pelvic packing -finally confirmed to be vanishing? introduction: the presence of cerebral venous thrombosis (cvt) is increasingly recognized in traumatic brain injury (tbi), but its complication rate and effect on outcome remains undetermined. in this study, we characterize the complications and outcome-effect of cvt in tbi patients. materials and methods: in a retrospective, case-control study of patients included in the oslo university hospital trauma registry and radiology registry from - , we identified patients with cvt (cases) and without cvt (controls). groups were matched regarding abbreviated injury severity (ais) head region score - . cases were identified by ais or icd-code for cvt and a ct/mr venography confirmed to be positive for cvt, whereas controls had no ais or icd-code for cvt and a ct/mr venography confirmed to be negative for cvt. risk of mortality was assessed using multivariate logistic regression adjusting for initial gcs, iss and rotterdam score. results are also reported for subgroups according to cvt location ( fig. introduction: the aims of this prospective cohort study were (i) to identify trajectories of recovery in patients with mild traumatic brain injury (mtbi) during the first two years after trauma and (ii) assess patients and injury characteristics for these trajectories. materials and methods: all adult trauma patients with mtbi (aisseverity or and an injury severity score \ ) who were admitted to a hospital in a region of the netherlands from august to november were asked to complete questionnaires. the questionnaires could be completed at week, and , , , and months and included the euroqol- -d for health status, including a cognition dimension, the hospital anxiety depression scale (hads-d and hads-a for symptoms of depression and anxiety respectively) and the impact of event scale (ies) (for post-traumatic stress symptoms). latent class trajectory analysis was used to determine trajectories of recovery in latentgold . , patient and injury characteristics of the classes were assessed in ibm spss . . results: a total of patients ( % of total) completed at least one follow-up questionnaire. the number of classes (trajectories) ranged from for cognition to for depression. poor recovery classes of cognition and health status consisted of mostly females, patients with low education, higher age, longer length of stay at the hospital and frail patients. the class with full recovery consisted of young patients, with most recovery occurring during the first six months after injury. patients who reported poor health status before injury scored significantly lower health status after injury and showed no recovery over time. conclusions: different recovery patterns were present in patients with mild traumatic brain injury. especially frail elderly patients who reported poor health status before injury have poor outcome up to months after injury. post-concussive symptoms in children and adolescents with traumatic brain injury: a center-tbi study introduction: acute respiratory is associated with high morbidity and mortality. in addition, its etiologies are heterogeneous and the outcome depends on the underlying cause. the aim of the present study is to analyze, whether the mortality of posttraumatic ards is affected ( ) over time, ( ) attributable to geographic distribution, ( ) related to the used definition and ( ) introduction: many factors of trauma care have changed in the last decades. this review investigated the effect of these changes on overall and cause-specific mortality in polytrauma patients admitted to the intensive care unit (icu). moreover, changes in trauma mechanism over time and differences between continents were analyzed. materials and methods: a systematic review of literature on overall mortality in polytrauma patients admitted to the icu was conducted. overall and cause-specific mortality rates were extracted as well as the trauma mechanism of each patient. linear regression on changes in overall and cause-specific mortality rates was performed. results: thirty studies, which reported mortality rates for , observed patients, were included and showed a decrease of . % in overall mortality per year ( fig. ). brain-related death has become more common over the years, whereas multiple organ dysfunction syndrome (mods), acute respiratory distress syndrome and sepsis became less prevalent (fig. ) . mods was the most common cause of death in north america and brain-related death was the most common in asia, south america and europe (fig. a) . penetrating trauma was most often reported in north and south america and asia (fig. b) . conclusions: overall mortality in polytrauma patients admitted to the icu has been decreasing as a result of the improvements in trauma care. a shift from mods to brain-related death could be observed. more research on preventative measures for the latter is required to ensure a further decline in mortality. moreover, we have shown geographical differences in cause-specific mortality, which may provide learning possibilities between similar trauma centers resulting in improvement of trauma care introduction: aim of the current study was to assess an association between trauma patient volume of the intensive care unit and inhospital mortality. materials and methods: from data of the japan trauma databank, this retrospective cohort study selected adult (c y) trauma patients hospitalized in the intensive care unit with the injury severity score of c . after applying a multiple imputation on all the study variables, a logistic regression generalized estimating equation after adjustment for age, sex, mechanism of trauma, and the injury severity score as covariates and hospitals as a cluster assessed an association between quartile of patient volume in intensive care unit and hospital mortality. introduction: quality and content of early fracture hematoma (fh) dictate the healing process in long bone fractures. different reaming protocols for intramedullary nailing (imn) are available. however, the impact of reaming strategies on immune cell characteristics of early fracture hematoma is unclear. we hypothesized that the application of reaming irrigation and aspiration (ria) techniques optimizes cellular content of fracture hematoma. materials and methods: twenty-four pigs underwent standardized femur fracturing. then, animals were exposed to different protocols of imn. group a underwent no reaming prior to imn. group b was treated with conventional reaming plus imn and group c composed of animals treated with ria and subsequent nailing. fracture hematoma was collected h after reaming. fh-immune cells were isolated and studied by flowcytometry. cell viability was tested by annexin-v-labelling. neutrophil activation was determined by mac- /cd bcell surface expression levels, whereas fcyriii/cd -receptor expression was utilized to investigate neutrophil maturation. results: all animals survived the observation period. propertions of white blood cell subtypes in fh did not differ between conditions. however, the percentage of viable fracture hematoma immune cells was significantly higher in the ria-group, compared with conventional reaming (respectively mean . % vs. . %, p = . ). additionally, both neutrophil cd -expression (- %) and cd bexpression (- %) were significantly lower in those animals treated with ria compared with the conventional reaming condition. conclusions: this experimental study reveals that reamed irrigationaspiration (ria) prior to imn is associated with increased immune cell viability and less neutrophil senescence/activation in early fracture hematoma. this underlines the important role of imn in optimizing local cellular immune homeostasis during the formationphase of early fracture hematoma. introduction: the study and determination of the traumatic pattern in bicyclists-delivery employees. the recording of personal protective equipment and evaluation of the selection criteria of their self protection. materials and methods: a total of patients ( men and woman) with mean age of . years ( - years) were included over a study period from january to march . twenty-one patients admitted to the hospital with a total of injuries treated operatively, whereas injuries were treated conservatively. we recorded and evaluated the use of adequate personal protective equipment of these delivery employees. results: the mean hospitalization time was . days ( - days) . a total of thoracic injuries, traumatic brain injuries, spine injuries, lower extremity injuries and upper extremity injuries were recorded. surgical treatment concerned patients with upper extremities and patients with lower extremities injuries and the anatomic regions involved were the distal radius ( ), pelvic ring injury ( ), femoral fractures ( ), tibial plateau fractures ( ), patella fractures ( ), diaphyseal tibial fractures ( ), and ankle fractures ( ) . conclusions: the lack of an adequate personal protective equipment due to their low financial status in combination with the absence of driving professional education among workers in this category of delivery employees results in lower extremity injuries with the majority requiring hospitalization and surgery. further investigation is needed, as well as constant training and setting right criteria for the pursuit of such employment. results: a total of nine rct's ( patients) and the sixteen observational studies ( patients) were included. the pooled nonunion rate did not differ significantly between both treatment groups (risk difference: %; or . , % ci . - . ). more patients treated with nailing required re-intervention (risk difference: %; or . , % ci . - . ) with shoulder impingement being the most predominant indication. more patients treated with pate fixation developed radial nerve palsy compared to nailing (or . , % ci . - . ). notably the absolute risk difference is small ( %) and during follow-up the palsy resolved spontaneously in the majority of patients. nailing lead to a faster time to union (mean difference: . week, % ci . - . ), lower infection rate (risk difference: %, or . , % ci . - . ) and shorter operation duration (mean difference: min, % ci . - . ). functional scores were comparable in both groups (standardised mean difference: - . , % ci - . to . ). there was no difference between effect estimates form observational studies and rct's. conclusion: there appears to be no difference between plate fixation and nailing for humeral shaft fractures with regard to non-union rate and functional outcome. patients treated with plate fixation have a higher risk for infection and radial nerve palsy, but lower risk for reintervention. the absolute differences, however, are small. nailing does differ significantly from plate fixation in terms of shorter operation duration and time to union. the pooled estimates from randomised clinical trials did not differ significantly from estimates obtained from observational studies. post-traumatic complications are more often after medial clavicle injuries compared to lateral clavicle injuries introduction: medial clavicle injuries (mci) are widely unexplored, especially in contrast to lateral clavicle injuries (lci). current research concerning mci assumes a higher severity of mci, e.g. concerning concomitant injuries. our aim is to evaluate by big data analysis if these rare injuries would also lead to a higher number of post-traumatic complications. materials and methods: we focused on the mci subgroup consisting of medial clavicle fracture and sternoclavicular joint dislocation. the lateral clavicle fracture and the acromioclavicular joint dislocation were summarized to the subgroup of lci. the midshaft clavicle fracture was analyzed for comparison. the data are based on icd- codes of all german hospitals as provided by the german federal statistical office. anonymized patient data from to were evaluated. the retrospective analysis addresses the fracture healing in dislocation, delayed union and non-union. results: the proportion of all patients suffering from complications was . %, which were attributed to one of the three post-traumatic complications. each complication rate for the single injury and the single complication was rather low with a maximum of %. mci were more likely to be affected by post-traumatic complications than lci with a ratio of . to . times (p \ . ). the midshaft clavicle fracture was similarly frequently affected by complications with . % of all complications as the mci ( . %). the lci accounted for the smallest proportion at . %. conclusions: we proved that mci are more often associated with post-traumatic complications than injuries of the other parts of the clavicle. this is another hint that mci appear to be more complex than lci. this could be due to a missing standard procedure and the higher number of concomitant injuries in mci. further representative clinical studies are required since miscoding is a frequent issue in research concerning clavicle injuries, especially in a big data analysis. quantification of trauma center accessibility using gis-based technology introduction: there is no generally accepted methodology to asses trauma system access and optimal geographical trauma center distribution. the goal of this study is to determine the influence of trauma center(tc) distribution during high and low traffic density using geographical-information-system(gis)-technology. methods: using arcgis-pro, we calculated differences in transport time (tt) and population coverage in seven scenarios with , , or tcs during rush [r]-and low traffic [l] hours in a densely-populated region with tcs in the netherlands (fig. ) . results: in the seven scenarios, the population that could reach the nearest tc within (\) min, varied between - % ( fig. ) in the three-tc-scenario, roughly % of the population could reach the nearest tc \ min in [r] and [l] . the hypothetical scenarios with two geographically well-spread tcs showed similar results as the current three-tc-scenario. in the one-tc-scenarios, the population reaching the nearest tc \ min decreased by - % in both [r] and [l] compared to the three-tc-scenario. in the three-tcscenario the average tt increased with about . min to almost min in [r] , in comparison to min during [l] (fig. ) . similar results were seen in the scenarios with two geographically well-spread tcs. in the one-tc-scenarios and the geographically close two-tcscenario the average tt increased by - min [l] and - min [r] in comparison to the three-tc-scenario. conclusion: this study shows that a gis-model for trauma center access offers a quantifiable and objective method to evaluate trauma system configuration in areas with different geography and demography. applying this technology to one of the most densely populated areas in the netherlands shows that the transport time from accident to trauma center would remain acceptable if the current situation with three trauma centers would be changed to a scenario with two geographically well-spread centers. classifying posttraumatic stress disorder courses in physical trauma patients: an observational prospective cohort study introduction: the aim was to identify different courses of posttraumatic stress disorder (ptsd) in physical trauma patients. then, to examine whether these classes could be characterized by sociodemographic, clinical, psychological, and personality outcomes. methods: patients completed the impact of event scale-revised (ies-r), m.i.n.i.-plus after inclusion, , , , and months after injury to examine different courses. the hospital anxiety and depression scale, neo-five factor inventory, state-trait anxiety inventory-trait, and the whoqol-bref were completed after inclusion only. latent class analysis, chi square tests, and anova were performed to analyze the aims. results: in total, patients were included. the mean age was . (sd = . ) and % were male patients. the ies-r (see figure ) and the m.i.n.i-plus had five classes ( : moderately, : little bit, : worse, : none, : quite a bit of ptsd symptoms). patients in class are diagnosed with ptsd (cut-off score c ). on both questionnaires, patients (proportion & %) in class or , scored higher on anxiety, depressive symptoms, neuroticism, and trait anxiety compared to the other classes over months after trauma. lower scores on all domains, except for social domain on the ies-r, were found compared to the other classes (ies-r; physical domain: class vs. (mean ± sd): . ± . vs. . ± . , p-value = \ . ). psychological and personality outcomes were significantly different on all courses. also, patients in class or were younger compared to the other classes (ies-r; class vs. : . ± . vs. . ± . , p-value = \ . ). no medical outcomes for ptsd were found. conclusions: about % suffer from ptsd symptoms months after trauma. different courses were defined by sociodemographic, psychological, and personality characteristics. professionals can, short after trauma, recognize patients at risk for ptsd when they focus on these characteristics. then, an intervention can be offered. six meter, the criterion for severe adult trauma to falls from heights in cdc field triage needs to be lowered introduction: trauma is one of major public health care issue which is costly to society. differences vary from region to region, but blunt trauma accounts for a large part of the total trauma, and the rates of the falls from heights among the blunt trauma is getting higher. it is serious that falls from heights is often accompanied by severe multiple trauma. therefore, authors studied the relationship between the height of the fall/other related factors and outcomes including hospital stay/mortality. materials and methods: retrospective cohort study of the adult falls-from-heights patients visited a regional trauma center for years (from . . to . . ). results: of total patients, the number of d.o.a patients were . the height from falls of the deceased patients was statistically significantly higher than that of the survived patients. ( . ± . m vs. . ± . , p \ . ) the auc of the roc curve of the height from fall to mortality was . . (figure) the sensitivity of . m was . % and . m was . %, respectively. the traumatic brain injury, pelvis fracture, visceral organ injury, age, and the height from fall were statistically significant risk factors in multivariate analysis for mortality (p = \ . , . , , , . , and . respectively). conclusions: the height from the fall is closely related with mortality. we think the current height for the severe fall injury in cdc field triage for trauma is high and needs to be lower to . introduction: operative management of severe trauma is a team effort, requiring excellent communication skills. surgeons, anesthesiologists and nurses need to coordinate effectively in order to ensure an excellent clinical outcome. the definitive surgical trauma care (dstc), definitive anesthesia trauma care (datc) and definitive perioperative nurses trauma care (dpntc) courses provide an excellent opportunity to train efficient teamwork. we aimed to study the impact of the joint dstc-datc-dpntc courses in candidates' perceptions and skills in perioperative communication. materials and methods: study population of candidates ( surgeons, anesthesiologists and nurses) participating in a joint dstc-datc-dpntc course in coimbra, portugal. median age of years (range - ). female gender in ( %) of cases. all participants attended joint lectures, case discussions and surgical skills session, emphasizing intraoperative communication. postcourse survey on several aspects of peri-operative communication, with responses on a likert scale. participants were also asked which aspects of intraoperative communication they valued the most. statistical analysis with spps, . (wilcoxon signed rank test, significance with p-value \ . ). results: all participants responded to the survey. results displayed an increase in the self-assessed importance of team briefing and intraoperative communication, particularly routine periodic communication, rather than only at critical moments (p \ . ). postoperative team debriefing was also valued as highly relevant. closed-loop and direct, by-name communication were highly rated (p \ . ). self-reported communication skills improved significantly during the course (p \ . ). conclusions: joint training in the dstc-datc-dpntc courses provides a unique opportunity to improve candidates' self-awareness and skills in intraoperative communication. a public health approach to knife related trauma in liverpool: a geospatial study r. shellien , n. misra , , j. germain , m. whitfield aintree university hospital, emergency general surgery and trauma unit, liverpool, united kingdom, liverpool john moores university, public health institute, liverpool, united kingdom introduction: liverpool is a city that has undergone recent rapic socioeconomic change. despite reductions in overall deprivation, incidents of stabbings have increased by % in the last years. this study will describe the trend in knife crime, drawing on governmental data and policies to conclude the reasons behind the trend. materials and methods: a retrospective cohort study of patients presenting to north-west ambulance service (nwas) with a penetrating injury in liverpool between and . data collected included patient demographics, geography and timing of incidents and correlation to datasets of multiple indices of deprivation and knife crime prevention outreach education programmes. results: incidents of stabbings have increased by % between and . victims were more likely to be males ( %) between the ages of and ( %). the peak rate was between : - : ( . %) and trough between : - : ( . %). there is a spike in incidents of stabbings of - year olds from : to : , correlating with school closure. there appears to be statistically poor correlation between deprivation of lower super output areas and stabbings (r = . , . and . for , and respectively). however, when the data is split into larger areas, middle super output areas (msoas), deprivation appears to be a further risk factor. this study has identified certain geographical areas as high risk. conclusions: this study allows for targeted public health interventions at populations most at risk of knife trauma, including geographical mapping of high-risk areas, so that interventions can be distributed appropriately. references: ministry of housing, communities and local government ( government ( , government ( , introduction: trauma teams treat complex patients with injuries posing significant resuscitative and management challenges. effective teamwork is essential to optimise patient outcomes and improve survival, with failure contributing to adverse events [ ] . the role of multidisciplinary (mdt) trauma training has been demonstrated by the military operational surgical training course (most) [ ] . it is imperative that civilian trauma training adopts similar methodology to optimise team work. materials and methods: the three-day multidisciplinary trauma course comprised cadaveric-based skills teaching supplemented by lectures and real-life scenario discussion. delegates were senior surgical and anaesthetic registrars and consultants, alongside trauma team leaders (ttl), scrub staff and operating department practitioners (odp). pre-and post-course questionnaires assessed perceptions of multidisciplinary trauma simulation and confidence in specialty specific skills. results: all delegates reported mdt simulation clarified each role, including their own, in the trauma team. post-course, scrub staff and odps felt confident gaining intraosseous access (p \ . ), surgical delegates had improved confidence performing all skills (p \ . ), with anaesthetists and ttls more confident in haemorrhage control and performing resuscitative thoracotomy (p \ . ). conclusions: mdt trauma training improves team understanding of role and effectively teaches skills. mdt courses with experienced faculty are one way of improving mdt trauma team function. further careful evaluation is required to assess performance of trauma teams in real scenarios. introduction: despite a dramatic rise in youth knife crime, the factors associated with it remain underexplored, especially in the critical pre-college years, which hinders effective counter-knife carrying interventions. the current research is the first to addresses this deficit. materials and methods: british male school students (mean age = . , sd = . ) coming from four different schools completed a short -min survey. they indicated their standing on a number of dimensions (school-adapted and shortened-scale-based predictors) derived from theories of violence, developmental psychology and related research (i.e. violence acceptance, need for respect, belief in self-defence, belief in a just world, narcissism, psychopathy, impulsivity, sensation seeking, and need for closure). results: for perceived knife harmfulness (i.e., the knife's assumed value in inflicting injury and death)-the total variance explained by the model was . %, r = . ; f( , ) = . . the only statistically significant predictors were: right-wing authoritariamism (b = . , p = . ) and need for respect (b = . , p = . ). the other factors were not statistically significant. for the perceived value of knife defence (i.e., its assumed defensive worth in violent confrontations) -the total variance explained by the model was . %, r = . ; f( , ) = . , pviolence acceptance (b = . , p = . ), followed by need for closure (b = . , p = . ), narcissism (b = . , p = . ) and psychopathy (b = . , p = . ). conclusions: this study provides evidence for future knife-carrying prevention interventions, such as talks in schools or social media videos, to focus more on how to increase self-esteem, stimulate empathy for and better understanding of other people, and approach problems from multiple (rather than just two) perspectives, emphasizing the ultimate superiority of the human intellect over brute force. introduction: the physician's response unit (pru) is a novel service that operates from the royal gwent hospital's emergency department (ed), in newport, south wales. it involves an emergency medicine consultant and a paramedic responding to calls in a rapid response vehicle. their aim is to treat and, hopefully, discharge patients at the scene, reducing ed admissions. the pru can also refer patients on to other departments, e.g. the medical assessment unit, allowing patients to bypass the ed. methods: the author spent six weeks out in the pru and in the ed to observe and speak to patients. to assess whether ed admissions were reduced, the dispositions of patients seen by the pru were recorded on a daily log sheet. the service users' satisfaction with the pru was evaluated using simple questionnaires. this included both patients and paramedics, who can request the pru for support with a patient. results: the pru saw patients during the project's timeframe. % (n = ) of these patients were discharged at scene, while % (n = ) were sent to the ed. % (n = ) of patients asked described the care they received from the pru as equal to or better than care they have received previously. % (n = ) of patients rated their overall satisfaction with the pru as / . conclusions: the pru is very well received by both patients and paramedics and has been shown to reduce the number of patients attending the ed. this system excellently implements the principles of prudent healthcare introduction: in germany reducing alcohol related harms in youth is still a priority, because adolescents and young adults still have the highest accident risk in road traffic. therefore, the p.a.r.t.y.-project aim to increase awareness of alcohol and risk-related issues. the purpose of this study was to analyse the risk behaviour of adolescents before and after a prevention project in two different hospitals in germany. materials and methods: during a one-day prevention project, young people within the age of to years got an overview of the route an accident victim go through from the ambulance until the rehabilitation. before and after the prevention day, a structured written survey was completed by the adolescents. results: students participated in the p.a.r.t.y. program between and . the gender distribution of the participating students were balanced. the average age of the adolescent was years. according to the program, the risk assessment and risk behaviour improved through the project significantly (\ . ). the evaluation of the students' satisfaction was rated as good. the majority of students prefer to repeat the project day after years. conclusions: the prevention program shows that the program increase for short-term the awareness for risk related trauma in youth. nevertheless, long-term studies are necessary to receive data regarding the long-lasting effect. references: the present study is funded by the ministry for energy, infrastructure and digitization of the country mecklenburg-vorpommern, germany. development of a claims-based risk adjustment model for trauma introduction: duodenal injury is rare. the diagnosis requires a high index of suspicion which might result in delayed treatment. there is limited data on the delayed diagnosis group, especially high grade duodenal injuries. the purpose of this study is to determine the characteristics and outcomes of delayed high grade duodenal injuries. materials and methods: charts of all patients from - who had history of small bowel injuries are reviewed. the inclusion criteria were age between - years old, diagnosis with duodenal injuries at least grade with delayed operation at least h after injuries. baseline characteristics and postoperative outcomes were recorded. results: of the small bowel injuries, ( %) were duodenal injuries. the overall mortality was %. delayed diagnosis more than h with at least grade of duodenal injuries were cases. the overall in-hospital mortality rate of the delayed group was . % ( / ) who had concomittent hemorrhagic shock and low initial systolic blood pressure. cases ( . %) were diagnosed within h and had better outcomes without leakage. they could step diet within days and had shorter length of hospital stay (mean = days). patients ( . %) presented with delayed diagnosis more than h (the maximum was h after injuries). all these patients had anastomosis leakage and need reoperation. they had initial low level of serum albumin (mean . mg/dl), high white blood cell count, low serum bicarbonate and presented with preoperative acute kidney injury. conclusions: delayed diagnosis and surgical treatment of high grade duodenal injuries lead to poor outcome. low initial blood pressure associated with mortality and delayed treatment more than h had higher morbidity. references: gary sa, frederick am, charles sc, et al. delayed diagnosis of blunt duodenal injury: an avoidable complication. acs meeting. ; ( ) : - . routine follow-up imaging has no advantage in the non-operative management of blunt splenic injury in adult patients modality. the aim of this study was to investigate the incidence and time to failure of nom as well as to evaluate the relevance of follow-up imaging. materials and methods: all adult patients with bsi admitted to our level i trauma center, including two associated hospitals, between / / and / / were retrospectively analyzed. demographic data, injury severity score, splenic injury grade, modality, results and consequences of follow-up imaging were retrospectively analyzed. results: a total of patients with a mean age of . ± . years ( - years) met inclusion criteria. patients ( . %) underwent immediate intervention. patients ( . %) were treated by nom. failure of nom occurred in patients ( . %). failure was significantly associated with active bleeding (or . , % ci . , . , p = . ) , and liver cirrhosis (or , % ci . , . , p = . ) . patients ( . %) in the nom-group received followup imaging by ultrasound (us, n = ) or computed tomography (ct, n = ). in cases, routine imaging examinations were conducted ( us and ct scans) without prior clinical deterioration. ( . %) of these imaging results revealed no new significant findings. every failure of nom was detected following clinical deterioration. conclusions: to our knowledge this study includes the largest monocentric patient cohort undergoing ultrasound as first-line followup imaging modality in the nom setting of bsi in adult patients. the results indicate that a routine follow-up imaging, regardless of the modality, has no therapeutic advantage. indication for radiological follow-up should be based on clinical findings. if indicated, a ct scan should be used as preferred imaging modality. the association between bmi and mortality of renal injuries in adult trauma patients introduction: the role of body mass index (bmi) on solid organ injuries remains debatable. while some studies have shown no association between bmi and hepatic or splenic injuries, others have reported that severe hepatic injuries were more common in pediatric patients with bmi [ . the aim of this study is to examine the association of bmi and mortality, as well as any significant differences between operative vs. non-operative management. materials and methods: this was a retrospective study using the american college of surgeons-trauma quality improvement program database to identify all adult patients (ages to \ ) with traumatic renal injuries. the primary analysis showed a different pattern of mortality between patients with bmi \ and those with bmi c kg/m . then, the study population was divided into patients with bmi \ and those with bmi c kg/m . multivariable logistic regression was conducted to assess any association of mortality with age, gender, bmi, and injury severity score (iss). results: adult trauma patients were identified. a greater proportion of males ( . %) and females ( . %) had bmi \ kg/m (p = . ). the average age of patients with bmi \ kg/m was . (sd = . ) years which was significantly younger than that in patients with bmi c kg/m , . (sd = . ) years (p = . ). patients with bmi \ kg/m were found to have a significantly higher mortality rate of . % vs. . % in patients with bmi c kg/m (p = . ). however, there was no significant difference in type of operative or nonoperative management between patients with bmi \ vs. bmi c kg/m . after multivariable logistic regression, mortality was associated with age, bmi and iss. no effect modification of sex was observed in the relationship of mortality and bmi. conclusions: adult patients with renal injuries and bmi \ kg/m have significantly higher rates of mortality compared with adult patients with renal injuries and bmi c kg/m . introduction: trauma is an ever-evolving surgical discipline. trauma remains a major source of global mortality. the operative and non-operative options for trauma patients has steadily increased. the development of trauma protocols, advancement in transport to trauma centres and radiological techniques has seen a shift in trauma surgery caseload. observing and understanding this shift from operative management to an increasing non-operative management of trauma cases will better prepare the acute medical team in this setting. materials and methods: prospective trauma registry data was collected and analysed retrospectively. patients presenting to a tertiary referral hospital between jan to dec with an injury severity score of [ were reviewed. patients who were transferred to another facility for management were excluded. the demographic data and surgical outcome data were collected and analysed. trend analysis of the operative cases performed for each specialty. results: major trauma patients presented to the john hunter hospital between january to dec . there was a non-statistically significant increase in the number of presentations ( pt in vs in , p = . ). there was a decreasing rate of operations performed for trauma patients ( % in vs % in , p \ . ). there was an increasing rate of orthopaedic surgery cases and operative time compared to other specialties ( in vs in , p \ . ). general surgical major trauma operating cases noted a significant decline over the study time ( in vs in , p \ . ). conclusions: there is a sizeable shift in the caseload of different surgical specialties in regard to major trauma patients over the course of years from to . orthopaedics has seen a significant increase in operative caseload and surgical time required to adequately manage major trauma presentations. the workload and experience of general surgical teams will likely be affected by these changes. the distribution of resources needs to be reflected in the changing work demands of each surgical subspecialty. traumatic internal hernia with delayed small bowel strangulation after pelvic ring injury hospitalization, follow up abdomen ct checked. there was no other specific change than increased thigh hematoma. eight days after hospitalization, ct was re-examined due to abdominal pain with abdominal distraction. an ct showed peritonitis with pneumoperitoneum and small amount of ascites. small bowel herniation through right pubic bone fracture site with ischemic change also noted. diagnosis: diagnosis was traumatic pelvic hernia with delayed small bowel strangulation. therapy and progressions: an emergency operation was performed. ileal loop was hernitated and perforation was found. emphysematouns change and fluid collection was exsited at perineal area and left high. after small bowel loop segmental resection, wound vac was applied at thigh area. comments: traumatic pelvic hernia is rare. diagnosis is challenging in the acute setting and often delayed due to lack of awareness. when diagnosed, efforts should be made to look for other serious injuries as traumatic pelvic hernia usually associated with concomitant intraabdominal injuries. the optimal management of traumatic hernia should be individualised based on the mechanism and severity of injury, presence of concomitant injuries, size of defect, and presence of incarceration. delayed treatment may read to fatal outcomes. careful inspection of the patient is important. references: vincent k, cheah sd. traumatic abdominal wall hernia-a case of handlebar hernia. med j malaysia. ; ( ): - . angio-embolization in pediatric trauma patients with blunt splenic injury: a systematicreview t. nijdam , r. spijkerman , l. hesselink , t. hardcastle , l. leenen , f. hietbrink umc utrecht, traumasurgery, utrecht, netherlands, inkosi albert luthuli central hospital, trauma, durban, south africa introduction: non-operative management (nom) for children with blunt splenic injury (bsi) is nowadays a commonly used treatment in pediatric trauma departments. in adult trauma departments the addition of splenic angio-embolization (sae) is suggested to decrease the failure rate of nom in high grade splenic injuries. however, the use of sae in pediatric trauma departments is very uncommon and it is unknown if sae is of additional value in pediatric trauma patients. therefore, the aim was to analyze the available literature on sae in pediatric trauma patients with bsi. materials and methods: a literature search was performed to find eligible studies that analyzed sae in pediatric patients with bsi. the primary outcome was failure of treatment in these patients. secondary outcomes were the success rate of sae, length of stay and mortality. the relative risk (rr) was calculated to compare primary outcome between study groups. results: in total studies were identified through the search, a total of studies matched our inclusion criteria and were selected for this review. studies included a total of . pediatric patients, of whom underwent sae. patient age ranged from &lt; year to years, mean age was . years. both injury severity score and spleen injury grade were higher in the sae group compared to the nom group. failure rate of sae was %. no spleen related morality was observed in the sae group. conclusions: the literature suggests that sae might be of added value in a very selective group of pediatric trauma patients with high grade splenic injures. however, since limited evidence is available concerning the use of sae in pediatric trauma patients with bsi, no firm conclusions can be drawn about safety and effectiveness. introduction: the management algorithms for trauma have changed with the development of specialised trauma centres. the aim of this study was to review the management and outcomes of patients with traumatic small bowel (sb) and colonic injuries. material and methods: patients treated for sb and colonic injuries between - at aintree university hospital (liverpool) were identified using the prospective trauma audit and research network database. the management and outcomes of the patients included were analysed. results: patients sustained sb and colonic injuries. there were ( . %) sb injuries and ( . %) colonic injuries ( patients had a sb and colonic injury). patients ( . %) of injuries were due to knife stabbing wounds, ( . %) patients were due to gunshot wounds, and ( . %) patients were due to road traffic accidents/ blunt blows. damage control surgery was performed in ( . %) patients. colonic injuries included ( . %) haematomas and ( . %) perforations. a resection and stoma (rs) procedure was performed in patients ( . %), primary repair (pr) in patients ( . %) and resection with anastomosis (ra) in patients ( . %). sb injuries included ( . %) haematomas and ( . %) perforations. pr was performed in ( . %) cases and ra in ( . %) cases. the overall complication rate after sb and colonic injury was % ( patients) with a significant complication rate ( patients, p value = . ) for patients undergoing rs in colonic trauma. the -day mortality rate was . % ( patient). conclusions: pr in sb and colonic injuries appears safe. in our dataset, rs appeared to have a higher complication rate. our study highlights that such injuries are uncommon with a high complication rate. surgeons need to provide individualised treatment. introduction: nowadays, patients with high grade bsi are preferably treated using spleen preserving treatments (spt). it is assumed that patients with low grade bsi treated with spt have a good splenic function after recovery. however, there is no consensus on splenic function after high grade bsi. in several institutions, asplenic/hyposplenic infection prevention protocol will be executed in all patients who had spt after high grade bsi, where other institutions evaluate splenic function first. scintigraphy is believed to be the best flow/activity test to approximate splenic functionality. the aim of the study was to analyze whether spleen injury grade is associated with diminished splenic function. secondarily, we aimed to evaluate whether splenic function testing is necessary in pediatric patients after bsi. material and methods: a retrospective study was performed from january to january . in our institution patients with bsi grade iv of v are assumed hyposplenic and will receive a splenic function test. we included all patients with a minimum follow-up test period of days. all tests were analyzed by the radiology specialist. for each patient we furthermore collected clinical data, including the date of trauma, gender, age, mechanism of injury, ais of splenic injury and iss. results: patients consisted of male and female, with a median (iqr) age of . ( . - . ) . median iss was . ( - . ) and the median spleen ais was ( ) ( ) . nom was used in patients, sae in five patients and two patients were treated with surgical mesh technique. the median follow-up time of all performed tests was ( - ) days. a total of patients ( %) had a grade iv or v splenic injury. scintigraphy was utilized to test most patients. a total of out of patients had an adequate splenic function, including all sae patients. conclusions: even high grade splenic injuries show adequate splenic function in the follow-up of pediatric trauma patients after bsi. therefore routine diagnostic follow-up by scintigraphy is not necessary in this specific patient group. evaluation of abdominal injuries treated at stavanger university hospital: occurrence, severity and mortality j. w. larsen , k. søreide , , j. a. søreide , , k. tjosevik , k. material and methods: retrospective evaluation of data recorded prospectively in the hospital's trauma registry between january and december . patients with abbreviated injury scale (ais) code for abdominal injury were included. descriptive analyzes are presented for demographic data, injury type, mechanism, and severity, as well as -days mortality. results: a total of patients with abdominal injuries were included ( . % of all trauma patients). % where men. median age was . the injury mechanism was blunt in %. transport accidents were the most frequent cause of injury ( %). median iss was , and median niss . overall -days mortality was . %, with a median trauma injury severity score (triss) of , . multiple abdominal injuries were recorded in % of the patients. % had associated injuries in other body regions, most frequently in the thoracic region ( . %). solid organ injury occurred in % of the patients, with liver injury ( %), splenic injury ( %), and kidney injury ( %) encountered most frequently. an ais score c was found in % of liver injuries, % of splenic injuries, and in % of patients with kidney injuries. hollow viscus injuries were found in % of the patients. injuries to the small intestine ( %) and colon ( %) were most frequent. abdominal vessel injuries were encountered in %, and % of these had an ais score c . conclusions: abdominal injuries are dominated by solid organ injuries following blunt injury mechanism and are often associated with concomitant thoracic injury. patients who dies within days from admission are characterized by a low probability of survival shown by triss. pancreatic trauma management in a third level centre a. gonzález-costa , r. gracia-roman , s. montmany-vioque , a. campos-serra , r. lobato-gil , c. zerpa-martin , f. j. garcía-borobia , p. rebasa-cladera , s. navarro-soto management. the aim of the study is to review the management and describe the most frequent complications of pancreatic trauma in our centre. material and methods: observational study with prospective collection of data, from march to march . inclusion criteria: trauma patients older than admitted to the emergency department who were admitted to icu or died before admission. demographic data has been collected, also vital signs, iss, mechanism of action, mortality, complications, and lesions. results: between and , polytraumatic patients were registered. only had pancreatic trauma ( . %). the male: female ratio was : ; with an average age of . years (sd . ) . mean iss of . (sd . ), mean ais of . (sd . ) and mortality of . % ( patients). the most frequent pancreatic lesion was at the head of the pancreas ( patients; . %), followed by body-tail ( patients; . %) and two patients with full section ( . %). . % of patients were treated with non-operative management. five patients required urgent surgery ( %), requiring corporocaudal pancreatectomy in cases and drainage in patients. an embolization of a gastroduodenal artery aneurysm was performed in patient. respiratory complications were the most frequent. patients developed a pancreatic fistula ( . %), although in surgical patients this complication was much higher ( % in our series). one of them required puestow pancreaticojejunostomy and patient developed necrotizing pancreatitis ( . %). conclusions: pancreatic trauma is very uncommon. its management can be difficult, depending on the degree of injury (aast), with a high rate of complications. therefore, combined management and monitoring by the surgery and intensive care team will be very important. introduction: the aim of this retrospective study was to evaluate and compare the clinical outcomes of conservative versus surgical treatment in a series of patients with liver injury. material and methods: between - , there were included patients. according the treatment chosen, the patients were subdivided in two groups. non-operative management was considered in hemodynamically stable patients. the failure of conservative treatment was defined as need to resort to operative management after a period of strict monitoring when the reason was related to the liver or associated injuries or need for late angioembolization. all hemodynamically unstable patients were subjected surgical treatment. results: conservative treatment was selected for patients and only in of them was failed due to associated delayed bleeding and small bowel injury. patients underwent emergent surgery which included packing, lobectomy and splenectomy. operative findings revealed grade iii liver injuries in % and grade iv in %. pneumonia, sepsis and ards were the most frequently associated complications. the overall mortality rate was . %. in patients of conservative group, non-surgical treatment failed with surgery being required. the mortality in the group of patients who underwent emergent laparotomy on admission was of patients. conclusions: conservative treatment of blunt traumatic hepatic injuries is applicable in patients presenting hemodynamic stability with mild hepatic injuries and it could be successful even in high graded injuries with low morbidity and mortality. surgical treatment is indicated in grade v injuries. nevertheless, failure of conservative treatment does not necessarily lead to an increase in the incidence of complications or mortality. with the trend towards more conservative management strategies, surgeons' exposure to laparotomies for blunt injuries in rtas has decreased. the aim of this study was to examine surgeons' exposure to laparotomies following blunt trauma which remains important to maintain low patient morbidity and mortality rates. material and methods: data was collected for adult patients admitted to mater dei hospital (malta) following rtas with ctproven intrabdominal injuries between january and january . results: patients ( ( . %) males vs. ( . %) female (p value \ . ), mean age = . years) were included in the study. patients ( . %) were car occupants whilst patients ( . %) were pedestrians. ( . %) patients had single intraabdominal organ injury, whilst ( . %) had multiple intraabdominal organ injuries. the -day mortality rate was . % ( patients). liver injuries occurred in ( . %) patients, splenic injuries occurred in ( . %) patients, kidney injuries in ( . %) patients and other organs were injured in ( . %) patients. conservative management was followed in ( . %) patients, angioembolisation was utilised in ( . %) patients and operative management was performed in ( . %) patients during the -year period. this resulted in trauma laparotomies following rtas per year. conclusions: only a minority of patients require operative management after rtas. surgeons in small countries have limited exposure to complex rta's. in view of the low exposure to emergency laparotomies following rtas, changes to our local training programme was done. trauma courses, lectures and fellowships in eu have been implemented to maintain surgical skills to an optimal level. references: european commission, annual accident report. european commission, directorate general for transport june . case history: a year old female presented to the accident and emergency department h post colonoscopy with complaints of left sided abdominal pain. this colonoscopy was requested under a -week wait for a history of chronic diarrhoea. this was a complete and uneventful examination ath the time, with random colonic and ileal biopsies taken. she attended a ? e with left sided abdominal pain increasing in severity. clinical findings: she was found to have an exquisitely tender abdomen, experienced more in the left upper quadrant. she was clinically shocked with a marked hypotension and tachycardia. investigation/results: a ct of her abdomen and pelvis showed free fluid within the abdomen and pelvis, with active bleeding and large haematoma adjacent to the spleen. the grade of splenic injury however was not commented upon by the reporting radiologist. interventional radiological embolism was considered but unfeasible as patient not stable haemodynamically. diagnosis: she was diagnosed with a splenic injury post-colonoscopy, with internal bleeding and haemodynamic instability. therapy and progressions: she underwent an emergency splenectomy overnight and was transferred to the intensive care unit for postoperative care. she recovered well, was stepped down to ward level care and was discharged with post splenectomy protocols, including all necessary vaccinations. comments: splenic rupture post-colonoscopy is a very rare event, with less than cases reported worldwide since . however, it still should be considered as a cause of a ? e presentation in patients with upper abdominal pain and haemodynamic instability after recent colonoscopy. we wanted to present this rare case to the international audience of estes congress to raise awareness of this rare complication. clinical findings: hemorrhagic shock and consciousness disorder were observed. her abdomen was distended, and she was intubated in the emergency room. investigation/results: ct revealed massive intra-abdominal bleeding. diagnosis: massive intra-abdominal bleeding due to hepatic laceration. therapy and progression: damage control surgery (dcs) and transcatheter arterial embolization (tae) were performed. she was transported to a hybrid operating room. she experienced cardiac arrest before operation. cardiopulmonary resuscitation was immediately initiated, resulting in the return of spontaneous circulation. laparotomy with perihepatic packing (php) was performed, but she experienced two more episodes of cardiac arrest during operation. then, tae was performed for right hepatic artery extravasation. after physiological function restoration, including rewarming, coagulopathy correction and hemodynamic stabilization in the intensive care unit. she gradually became hemodynamically stable. however, incomplete hemostasis was obtained at second-look laparotomy h later. because of bleeding, we repeated php. we performed cholecystectomy and abdominal closure after confirming complete hemostasis ( h post-accident). she was discharged ambulatory without neurological deficit (day ). comments: prognosis of traumatic cardiac arrest is generally poor, and survival without considerable neurological deficit is very rare. we reported a surviving patient with severe hepatic laceration. sharing of strategies and tactics, such as blood transfusion, tae, trauma team approach to surgery, early decision of dcs improves outcome of patients with severe abdominal trauma. references: resuscitation. ; : - . introduction: the spleen is the most commonly injured organ after blunt trauma. non operative treatment (nom) of splenic injuries has gained wide acceptance. transcatheter embolization of the splenic artery is considered a useful adjunct in aast lesions c without active bleeding. we report a retrospective review of all patients admitted to a level trauma center with blunt splenic injury from to and compare their treatment and outcome with a previous series from to , when angioembolization was performed only in case of contrast blush at ct scan. patients and results: from to june , patients with blunt splenic injuries were admitted to the ed of a level university hospital in milan, italy. men to female ratio was : ,the mean age . ± years (range - ), and the iss ± . (range - ). eight patients ( . %) underwent emergent splenectomy due to hemodynamic instability. of the stable patients treated with nom, those with aast lesions c (n = ) were submitted also to angiography and to embolization of the spleen ( %), either proximally ( ) or distally ( ). two nom failed, and the patients were submitted to splenectomy or distal embolization. the median hospital stay was . ± . days. the total spleen salvage rate was %. no associated abdominal injuries were missed in the nom group. in the previous series of patients (mean age . ± . years, range - , #:$ = : , iss ± , range - ), underwent emergency splenectomy ( %), and ( %) were treated conservatively, with only embolization ( , %) in case of aast c at ct scan. failure of nom were , and the spleen salvage rate . %. liver injury following multiple cardiopulmonary resuscitations case history: this is a case of a year old woman who presented to the emergency department (ed) due to worsening dyspnea complicated by two lengthy cardiac arrests. after the first resuscitation and return to spontaneous circulation (rosc), echocardiography was done and showed severely dilated right ventricle with strain, suggestive of massive pulmonary embolism, for which rtpa was given. arrest occurred again, and post rosc, heparin was started and the patient was transferred to the icu. extracorporeal membrane oxygenation (ecmo) was initiated but complicated by severe hemodynamic instability and a third cardiac arrest, so cardiopulmonary resuscitation (cpr) was performed till rosc and massive transfusion protocol was started for suspected intraperitoneal bleeding. clinical findings: after ecmo cannulation, abdominal distention was noted with a severe drop in hemoglobin and an increased intraabdominal pressure ( mmhg). abdominal bedside ultrasound showed significant amount of dense free fluid. the decision for an urgent exploratory laparotomy was made and the patient was taken to the operating room. therapy and progressions: deep liver laceration over the right hepatic dome with rupture of the capsule and an estimated hemoperitoneum of l were found intra-op. controlling the bleeding was difficult due to the laceration site and the patients coagulopathic status, so packing was done and the patient was transferred to icu for correction of the coagulopathy and re-evaluation in h. the liver was unpacked after h, bleeding sites were cauterized and sutured and the liver was wrapped with a mesh with an attempt for a tamponade effect. the patient's stay in icu was complicated with kidney injury requiring chronic dialysis but otherwise recovered well. comments: liver injury is a rare but serious complication after cpr that should be considered in case of persistent hemodynamic instability along with bedside findings. this case is intriguing due to the right sided liver injury with no overlying rib fractures. blunt renal trauma after electrical injury: a series of curious events. a. nixon , e. falidas , d. davris , a. botou , g. sofos chalkida general hospital, department of surgery, chalkida, greece case history: a yr old patient was referred to the emergency department (ed) of our hospital from a primary health center after sustaining an electrical injury ( v ac). the patient experienced loss of consciousness (loc) and promptly fell to the ground in a supine position. the patient arrived approximately h after the incident. clinical findings: vital signs: bp: / mmhg, hr: bpm. the patient's major complaint was left flank and abdominal pain. no obvious thermal injuries were observed or any other signs of external trauma. a left abdominal mass developed which was evident on physical examination. in addition, examination of urine revealed gross hematuria. investigation/results: ekg monitoring documented sinus tachycardia without evidence of cardiac arrhythmias. fast indicated the presence of a massive retroperitoneal hematoma. the fast exam indicated the left kidney as the probable source of hemorrhage. the initial hematocrit (hct) from the primary health facility was % while results from the ed recorded a hct of %. diagnosis: grade v renal trauma. therapy and progressions: a massive transfusion protocol was initiated. the patient underwent an emergency laparotomy and a left nephrectomy was performed. subsequent imaging did not reveal other injures. comments: the history of electrical injury could have misdirected investigation efforts towards cardiogenic shock. this case suggests that even in the absence of a high energy impact, sustained hemodynamic instability should always be attributed to hemorrhagic shock until disproven. in addition, the management of grade v renal trauma in blunt injury remains a controversial topic, however we believe that in cases of class iv shock, surgical management is imperative. case history: y.o. female with a history of chagas' disease of years duration and esophageal involvement in the last few months. she's admitted for a first endoscopic balloon dilatation due to dysphagia, which is performed according to protocol, and a tear of the mucosa layer is observed during it. clinical findings: she's stable for the first h but with continuous thoracic pain of moderate intensity according to the gi specialist. on the second day there's a general worsening of the patient's condition, with dyspnea, fever, desaturation and tachycardia. results and diagnosis: she develops leukopenia and elevations of acute phase reactants, and a ct scan reports a distal esophageal perforation with free extravasation of contrast in the mediastinum and bilateral pleural effusions. therapy and progressions: emergency surgery is performed through a midline supraumbilical laparotomy which shows peritonitis around the epigastric area. after opening the hiatus, a very long transmural esophageal tear with devitalized tissues and severe contamination are observed. a trans-hiatal esophagectomy was decided and, given the hemodynamic stability, a gastroplasty is performed and brought up to the neck without anastomosis, along with a terminal cervical esophagostomy and feeding jejunostomy. the patient did well in the postop period. we were able to do the esophagogastric anastomosis in the neck days later, during the same admission. comments: the surgical technique in esophageal perforation depends mainly on the time elapsed since the perforation, and on the condition of the patient. esophagectomy is sometimes unavoidable, and a gastroplasty can be brought up to the neck at the same time in selected cases, with reconstruction of the upper gi tract during the same admission. introduction: the spleen is one of the most frequently injured abdominal organ. the anatomy of the lesion defines the degree according to aast, ranging from grade i to v in increasing complexity. the diagnosis of splenic trauma may be difficult, as % of patients may show no signs or symptoms at primary survey. the approach involves two main strategies: conservative or surgical. the strategy should take into account four aspects: hemodynamic status, anatomy of the lesion, associated injuries and organizational structures of the evaluation site. this study aims to evaluate the type of approach performed on different degrees of splenic trauma during years in a portuguese trauma center. material and methods: we conducted a retrospective study including all patients diagnosed with splenic trauma during a period of seven years. by consulting the patient's clinical files we evaluated and compared: demographic data, trauma kinetics, degree of splenic injury and the approach taken as well as morbidity and mortality. results: of the patients studied, most were male with blunt trauma. in patients the inicial approach was surgery and in the option was conservative treatment. in grade iii or iv lesions conservative treatment failed in % of patients. patients in whom the surgical approach was first chosen had predominantly grade iv lesions, with total splenectomy being the preferred approach. in grade iii lesions, the option was mainly conservative surgery of the spleen. conclusions: the initial approach of splenic trauma results essentially of the experience of emergency teams and support structures for surveillance and intervention (intervention radiology and -h operating room availability). the attempt to try conservative strategy is increasing over time. introduction: for decades, helicopter emergency medical services (hems) contribute greatly to prehospital trauma patient's care by performing advanced medical interventions on scene. unnecessary dispatches, resulting in cancellations, cause these vital resources to be temporarily unavailable. these cancellations contribute to overtriage and provide additional costs to society. an earlier study showed a cancellation rate of % in our trauma region. however, little empirical knowledge exists about reasons for cancellations for different mechanisms of injury (moi) and type of dispatch. this study aims to examine the current cancellation rate in our trauma region over a -year period. additionally, insights in cancellation reasons for different moi and type of dispatch are evaluated. methods: a retrospective study was performed, using data derived from the hems database of trauma region north west netherlands, between april st and april st . information regarding patient's characteristics, date and time of day, moi, type of dispatch, and cancellation reason were compared. results: in total, , patients were included. hems was cancelled in . % of dispatches. the majority of dispatches ( . %) were cancelled because the patient was physiologic-and neurologically stable. dispatches simultaneously activated with ems were cancelled . % of times, compared to . % when hems assistance was additionally requested by ems on scene. no differences were found between dayand night-time dispatches. trauma related dispatches were cancelled more frequently compared to non-trauma related dispatches. conclusions: this study found a considerable-and increased cancellation rate compared to previous research. an explanation for this finding could be better adherence to dispatch protocols. furthermore, a great variety in cancellation rates was found among different moi's. therefore, continuous critical evaluation of hems triage is important and dispatch criteria should be adjusted if necessary. case history: two separate cases of high speed road traffic collision. the first is years old female without significant past medical history. the second is years old male who had short extremitis due to history of spastic quadriplegic cerebral palsy alongside congenital kyphosis and postural scoliosis. clinical findings: on examination the first patient was hemodynamically stable with soft abdomen and bruising over the left pelvic area. the second patient had left side neck and right side chest bruises; furthermore, he was tachycardic with normal blood pressure, but he was generally pale, getting clammy and significantly sweaty. investigation/results: fast scan for both patients showed free fluid in the abdomen and ct scan was uncertain of the source in the first patient. in the second, a large mesenteric haematoma was evident on ct with contrast extravasation with corresponding significant drop in hemoglobin and raised lactate levels. diagnosis: case : hemodynamically stable blunt abdominal trauma. case : hemodynamically unstable blunt abdominal trauma. therapy and progressions: the first patient was managed conservatively initially but worsened overnight with a drop in haemoglobin and increase in lactate mandating emergency laparotomy. hemoperitoneum and cm of ischaemic bowel with tear in the mesentery was found. she had an uneventful recovery after resection and primary anastomosis. the second patient underwent immediate emergency laparotomy. there was evidence of hemoperitoneum ( l) and similar mesenteric tear with ischemia involving cm of the terminal ileum. resection with end to end anastomosis was done. patient was then transferred to itu; however, he developed chest infection which prolonged hospital stay. comments: hemodynamic instability is a major factor in mandating urgent exploratory laparotomy in bat and bucket-handle injury is not uncommon following road traffic accidents. introduction: incisional hernias are one of the most common complications post-abdominal surgery, affecting between - % of patients undergoing a laparotomy. a number of risk factors are associated with their development such as age, bmi, type of surgery and co-morbidities. these risk factors also affect their levels of recurrence which is why the technique undertaken to repair these is of such interest. the primary purpose of this meta-analysis was to examine which repair technique is associated with the lowest level of recurrence whilst a secondary aim was to examine whether the frequency of common complications was dependent on the type of repair utilised. material and methods: this systematic review and meta-analysis was conducted by both co-authors. the following information sources were utilised; cochrane/embase/google scholar/pubmed/scopus. in relation to the eligibility criteria-papers that were published from onwards and in the english language were included with any length of follow-up. study selection was as per the inclusion/exclusion criteria below and only cohort studies/rcts/systematic reviews/ meta-analyses and case control studies were included. inclusion criteria: abdominal incisional hernias, all types of repairmesh/open/laparoscopic/sutured repair/primary repair etc. in terms of the exclusion criteria-any hernia repair that was not incisional was excluded. results and conclusions: in terms of the primary question posed by this repair, meta-analysis shows that there is a significant difference between open vs laparoscopic technique and recurrence rates in relation to the primary question posed by this paper whilst the use of mesh impacts negatively on post-operative wound infection rates. this invites an interesting debate on the merits of each technique whilst demonstrating the need for a multicentre randomised controlled trial. laparoscopic approach in penetrating abdominal trauma: case study and review of the literature b. vieira , v. taranu , a. silva , d. galvão , a. soares hospital de santo espírito da ilha terceira, general surgery, angra do heroísmo, portugal introduction: laparoscopy(ls) has greatly improved surgical outcomes in many elective abdominal procedures. the use of ls in acute care is becoming widely accepted. however, a number of safety issues have limited its application in abdominal trauma. notwithstanding with the reports and studies of the past decade proving its safety and accuracy, ls is slowly replacing the need for exploratory laparotomies. case report: a yo male sustained with penetrating stab wound on the left flank. he was hemodynamically stable. ct confirmed intraperitoneal positioning of the knife, without free fluid or air nor any evidence of organ injury. an exploratory ls was performed and confirmed the intraperitoneal positioning of the knife. abdominal exploration revealed a jejunal transfixating lesion about m from treiz's angle that was manually closed. the patient maintained a favorable po evolution and was discharged on the thpo day. discussion/conclusion: a number of concerns have limited the use of ls in abdominal penetrating trauma. initially, it resulted in high rates of missed injury, mainly of the small bowel, generating considerable criticism. the development of systematic abdominal explorations in ls, as described by choi and kawahara, resulted in a rate of missed injuries close to zero. moreover, direct visualization using ls has shown superior specificity and sensitivity in identifying peritoneal penetration, hollow viscus injuries and diaphragmatic lesions when compared to ct. in the case reported here, ct didn't show any image suspected of perfuration such as free air or fluid, and yet ls showed a small bowell injury. besides its advantages as a diagnostic tool avoiding negative laparotomies in more than % of the cases, thanks to evolving techniques and improved practice, it may also be therapeutic and allow safe definitive treatment for many types of injuries as described here. method: this is a monocentric retrospective study from a database entered prospectively. all patients admitted to the university hospital in nice with splenic trauma between / / and / / were included. the primary endpoint was performing splenectomy as a failure of a nom. results: patients were included in our study. the majority of splenic lesions were severe grades, that is to say greater than . in total, splenectomies were performed urgently, i.e. % of patients; angio-embolizations were performed, i.e. % of patients with a success rate greater than %; . % of patients who had not anterior angio-embolization required secondary splenectomy; . % of the patients who had anterior angio-embolization required secondary splenectomy. in the patient group with successful angio-embolization, the mean age was years vs . years in the nom failure group (p = . ). a decrease in hemoglobin between admission and h after admission was found in the nom failure group compared with the successful embolization group (p = . ). conclusion: hemoglobin monitoring in the hours following admission of a patient with splenic trauma may be an important factor in the surveillance of hemodynamically stable patients. prospective studies could confirm these results. missed ureteric injuries in gunshot injuries of the abdomen: how to avoid? introduction: traumatic ureteral injuries are uncommon. penetrating rather than blunt trauma is the most common cause of ureteral injuries. the aim of this study is to make a strategy to avoid missing ureteric injuries in gunshot injuries of the abdomen. material and methods: patients were operated in our hospital in years period. all patients were managed according to atls guidelines. for stable patients, full radiological work up was done, while hemodynamically unstable patients were shifted to or immediately for laparotomy and exploration. all patients demographic and clinical data were recorded these include :patient age, sex, mechanism of injury, hemodynamic state on arrival to the rr, anatomical site of gunshot injury, associated injuries, ureteric injuries detected early or late, early repair, delayed presentation and morbidly associated with delayed discovery. results: ureteric injuries were found in patients out of patients who underwent laparotomy for gunshot injuries had ureteric injury in an incidence of . %. ureteric injuries were missed in the first laparotomy in patients. associated injuries of other abdominal viscera include; colon injuries affecting ascending and descending colon in all the patients. conclusions: ct and pyelogram are the modalities of choice in stable patient but in unstable patients the early recognition of ureteric injuries depends on high index of suspicion leading to surgical exploration of the ureter along its course. case history: we present a case of a year old man, who was injured by his agricultural machine in the abdomen. clinical findings: he was transferred in the emergency department and he was hemodynamically stable. he had several traumas in his abdominal wall. from the largest one, in the left iliac fossa, omentum, transverse colon and loops of the small intestine were protruded out of the abdominal wall. the small bowel was ischemic and ruptured. investigation/results: computed tomography investigation, revealed small amounts of liquid and air in the abdominal cavity. diagnosis: the patient was immediately operated. the destroyed loop of the small bowel was resected with the use of a stapler and the field was washout. then with a midline incision the abdomen was opened. there were no other injuries inside the abdomen cavity. there was an extensive injury with a creation of a large gap in the anterolateral abdominal wall. it was impossible to identify the left rectus abdominis muscle as also the lateral muscles (external and internal oblique and transversus abdominis). therapy and progressions: a side to side entero-enteric anastomosis was created and a meticulous observation and washout of the abdomen were performed. for the closure of the abdominal wall a double-sided mesh from polypropylene coated with silicone on one side ( cm) was placed and the operation was completed. all the other wounds of the abdominal wall were closed with loop nylon stitches no . a closed suction drain was placed above the mesh. the patient had a very good postoperative course. he was dismissed from the hospital after days in a very good condition. comments: the usage of mesh was very useful for the reconstruction of the abdominal wall. there is no conflict of interest. strategy shift from damage control surgery to primary radical surgery improve the outcome of blunt hepatic injury involving inferior vena cava introduction: the diagnosis of abdominal trauma is a real challenge even for surgeons experienced in trauma. clinical findings are usually unreliable, and abdominal examination is made up of various factors. diagnostic tools that help the attending physician make critical decisions, such as the need for laparotomy or conservative treatment, are mandatory if we propose a favorable outcome. material and methods: the study was performed in the clinic i surgery, the county clinical emergency hospital craiova, between - and analyzed a number of abdominal traumas hospitalized, investigated and treated in the clinic. the methods of paraclinical diagnosis are evaluated comparatively, the study analyzing the evolution and the tendencies during the studied period, from , to . results: the study allowed an evaluation of the diagnosis and treatment methods compared to the data in the literature. conclusions: thus ct scan remains the standard criterion for detecting solid organic lesions. in addition, a ct scan of the abdomen may reveal other associated lesions. fast ultrasound is an important and valuable alternative for diagnosing abdominal trauma, especially for patients who are hemodynamically unstable and cannot be mobilized. there is a tendency in the treatment of abdominal trauma, as evidenced by the literature data on the use of conservative versus surgical treatment for a larger number of cases introduction: antiplatelet agents and anticoagulant drugs are widely used in prevention of cardiovascular incidents, which poses a challenge in surgical emergencies. the drafting of a multidisciplinary protocol for the treatment of pharmacological induced coagulopathy in patients who require urgent surgery standardizes management and increases patients' perioperative safety. material and methods: aims of the study were to describe the results from the protocol implementation. a retrospective study was conducted by examining reports of every patient presenting pharmacological induced coagulopathy and undergoing emergent surgery, recorded in our center from to inclusive. different algorithms used were explained and data such as need of transfusion, reintervention rate and perioperative complications were analyzed. results: data from patients were analyzed, median age of , ( %) men. patients ( %) used anticoagulant drugs. fresh frozen plasma transfusion and/or prothrombin complex concentrates were used according to the guideline. ( %) patients used antiplatelet agents. % of them underwent a delayed h surgery directly. tirofiban therapy was established in patients on dual therapy due to medium-high risk of cardiovascular event. regarding surgical approach, ( %) were laparoscopic, ( %) open and conversion occurred in ( %) cases, but only of them due to intraoperative hemorrhagic complication. only cases of postoperative hemorrhagic complications led up to reintervention and only one isolated case of thrombotic complication was reported. finally, ( %) mortality cases were reported, but none was caused by hemorrhagic nor thrombotic complications. conclusions: establishment of a guideline on management of pharmacological induced coagulopathy in emergent surgery is crucial in all surgical emergency units and has proven to be effective and safe. introduction: digestive haemorrhage is a frequent pathology. most of the episodes are self-limited, but in some cases massive haemorrhage occurs, leading to a % mortality rate. severe problems occurs when endoscopic treatment is not effective, requiring emergent surgery with poor prognosis. the aim of this study is to evaluate the implementation of interventional radiology techniques on short-term results. methods: a retrospective descriptive study was performed reviewing patients who underwent radiological embolization after failure of endoscopic conventional treatment between - in our hospital. a total of patients were included. results: patients were male. cases were from lower gi track and were from the upper gi with a similar death rate between them, with a higher rebleeding rate in upper gi ( . % vs . %). % of the arteriographies did not show any bleeding site, of them developed a new bleeding episode. overall patients who undergo embolization, urgent surgery was avoided in of the patients diagnosed as upper gi haemorrhage and in of the patients diagnosed as lower gi haemorrhage. patients died, those death occurred later on the recovery of the acute bleeding episode and embolization, all of them related to patients comorbidities. conclusions: arterial embolization has become an important tool in order to treat massive haemorrhages of the gastrointestinal tract. it seems to decrease the mortality and morbidity rate, but some complications can be associated such as rebleeding or bowel ischaemia. massive transfusion protocol with early administration of platelet and fresh-frozen plasma along with packed red cells in the initial phase of resuscitation is associated with improved outcomes introduction: massive transfusion (mt) in a ratio of : : (prbc:platelet:ffp) is the standard of care in hemorrhaging trauma patients. the aim of our study was to compare the outcomes of patients who receive near balanced resuscitation (nbr) compared to unbalanced resuscitation (ubr) during the initial phase of resuscitation. material and methods: we performed a -year analysis of the acs-tqip. all adult patients (age [ ) who received mt (defined as transfusion of prbc c units in -h) were included. patients were stratified into two groups: nbr defined as prbc:platelets:ffp in : [ . : [ . and ubr ( : \ . : \ . ) in the first h of resuscitation. primary outcome measure was mortality. secondary outcome measures were complications, and hospital length of stay. propensity matching was performed to match the two groups. results: a total of , patients received mt. mean age was ± years, median iss was [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . overall h mortality was . %. only % patients received nbr while % received ubr in the first -h. using propensity score matching, patients were matched for demographics, ed vitals, iss, ais and injury parameters. patients who received nbr in the early resuscitation phase had lower mortality ( % vs. %, p = . ), lower overall complications ( % vs. %, p = . ), with no difference in hospital length of stay ( days vs. days, p = . ) compared to the ubr group. conclusions: only one-third of patient receiving massive transfusion receive prbc, ffp and platelet in a ratio closer to : : in the initial -h and they have lower mortality and complications compared to patients with unbalanced resuscitation. material and methods: the goal is to assess mtp strategies in level- trauma centres in the netherlands and compare these with each other and (inter) national guidelines. a trauma surgeon or anaesthesiologist involved in compiling the mtp in each level- trauma centre in the netherlands and dutch ministry of defence was approached to share their mtp and comment on their protocol in a survey or oral follow-up interview. results: all eleven level- trauma centres responded. content of the packages and transfusion ratio (red blood cells/plasma/platelets) was : : , : : , : : , : : , : : , : : , : : and : : . tranexamic acid was used in all centres and an additional dose was administered in eight centres. fibrinogen was given directly (n = ), with persistent bleeding (n = ), based on clauss fibrinogen (n = ) or rotem Ò (n = ). standard coagulation monitoring are used in all centres, but most hospitals use also rotational thromboelastometry (rotem Ò ) (n = ), thromboelastography (teg Ò ) (n = ) or both (n = ). all centres used additional medication for patients using anticoagulants, but its use was ambiguous. conclusions: mtps in dutch level trauma centres differs from (inter) national guidelines in transfusion ratio and additional medication, which could be explained by misinterpretation of the : : ratio, changes in components and following an outdated dutch national guideline. whether these differences in mtps actually leads to different patient outcomes will follow from data that is currently being collected. this study is sponsored by the dutch ministry of defence. anastomotic bleeding after colorectal surgery: incidence, management and complications introduction: postoperative anastomotic bleeding (pab) is a frequent minor complication ( - %) that usually resolves by a conservative approach. hemodynamic instability and anemization may develop requiring urgent management. the aim of our study is to describe pab and its treatment. material and methods: observational retrospective cohort study of patients with pab collected between july and september . pab was defined as an episode of lower gi bleeding after colorectal surgery with at least one anastomosis. characteristics of patients, surgery, length of hospital stay, morbidity and mortality, and management of pab were reviewed. results: a total of ( . %) patients with pab was collected. median age was of years (iqr - ), with a median estimated asa grade of . the most common procedure was a right hemicolectomy ( %), followed by sigmoidectomy ( %). % of surgeries were laparoscopic. only cases were converted to an open approach. % of patients had the first episode of pab during the first h after surgery, while % after the third postoperative day. pab was treated conservatively in % of the cases. the remaining % required urgent endoscopic management identifying the bleeding through the anastomosis line, using clips in patients and hemospray in patient to control it. no complications were recorded after endoscopic treatment. just case required surgical reintervention. a total of ( %) patients required blood transfusion with a median of (iqr - . ) units. length of hospital stay was . days. no mortality related to pab was registered. conclusions: pab is a mild complication after colorectal surgery. most of the patients respond to conservative management. urgent endoscopic treatment seems to be effective and safe to control pab even during the first postoperative day. introduction: hemorrhagic shock and associated reperfusion injuries are davastating situations during the treatment of polytrauma patients. the aim of this study was to analyze and compare alterations of the local circulatory changes of various body regions during hemorrhagic shock and after fluid resuscitation. material and methods: this study was conducted on male pigs. they suffered a standardized polytrauma including femoral fracture, blunt thoracic trauma and liver laceration. further, the suffered a hemorrhagic shock for h (aimed map mmhg). fluid resuscitation with three times drawn blood volume after hemorrhagic shock. retrograde nailing for femoral fracture and chest tube in case of pneumothorax liver packing. measuring circulation at liver, colon, stomach, and extremity. results: inclusion of animals. local circulation at the extremity decreased significantly compared to baseline values during hemorrhagic shock ( . a.u. versus . a.u., p \ . ). after resuscitation the flow rate at the extremity was comparable to baseline values. the stomach was least sensitive to hemorrhagic shock, whereas the oxygen delivery rate at the colon decreased during shock phase and remained decreased during fluid resuscitation (p \ . ). conclusions: different body regions react differently to hemorrhagic shock. the colon appears to be most vulnerable to changes based on hemorrhage. the delayed improvement of circulation in liver, colon, and extremities may represent a trigger for systemic hyperinflammation and subsequent sirs and sepsis. none of the authors have any conflicts of interest to declare. massive transfusion in penetrating trauma: the search for a specific prediction system introduction: prediction systems of massive transfusion (mt) were developed from cohorts with a small proportion of penetrating trauma. some of them required laboratory tests. we aimed to evaluate abc score and to identify independent predictors of mt in a cohort of torso penetrating trauma (tpt) material and methods: adults with tpt, managed in a level-i trauma center, who received one or more packed red blood cells (prbc), were included. variables obtained during the evaluation in the trauma bay were registered prospectively. the ability to predict mt was evaluated with simple, multiple logistic regressions and roc curves. results: we included patients; . % were male, and . % received fire-arm wounds. twenty-one ( %) received mt. mt patients were intubated more frequently in the pre-hospital, had lower sbp, higher hr, lower gcs, and received more frequently vasopressors (p \ . ) when compared with the no-mt patients. trauma mechanism, number or localization of the wounds, and positive fast could not discriminate mt (p [ . ). hypotension, tachycardia, and alteration of the glasgow coma scale or its motor response behaved as independent predictors of mt. models created with these variables showed better discriminative ability than abc score, with adequate goodness to fit. conclusions: prediction models of mt, based on heart rate, systolic blood pressure, and neurologic alteration outperformed abc score in a tpt cohort. introduction: rectus sheath hematoma presents with abdominal pain and anterior abdominal wall mass. it can be followed conservatively and rarely causes mortality ( ) . in this study we aimed to review rectus sheath hematoma cases consulted to our department and to present our management. material and methods: the data of patients admitted with rectus sheath hematoma between and was collected using hospital database. treatment modalities, demographic data and complications were reviewed retrospectively. results: all the cases presented with abdominal pain and/or with a palpable abdominal mass. . % of the patients (n = ) were receiving anticoagulant therapy at the time of admission. the mean inr value was . . patients were followed up with es&ffp transfusion and conservative treatment. patients not eligible for conservative care underwent inferior epigastric artery embolization and hematomas in patients were evacuated via a percutaneous drainage catheter. patient went through laparotomy for an infected hematoma and one patient underwent laparotomy plus packing. the patient who had laparotomy plus packing died due to intraabdominal hematoma and sepsis. conclusions: rectus sheath heamatoma is a rare cause of acute abdominal pain. the patients diagnosed early and have suitable indications can be treated conservatively ( ) . rectus sheath hematoma should be considered in the differential when a patient with a history of anticoagulant drug use presents with acute abdominal pain in order to prevent unnecessary surgery and complications. introduction: an early delivery of blood products when massive transfusion protocols (mtp) are triggered is mandatory to improve trauma patients survival. scores predicting massive transfusion (mt) have already been described ( ) . the aim of our study is to compare scores for predicting mt and identify the best trigger for mtp. material and methods: multicentric retrospective study from the trauma registry of the spanish surgeons' association. severe trauma patients (injury severity score [iss] c ), admitted to different level trauma centers, from january to september were included. demographic and clinical information was recorded, and predictive scores for mt were assessed. results: patients were included. medium age was . ± . years, ( . %) were male. median iss was (iqr ). in % of the patients a mt (defined as c units of packed rbc) was necessary, while a mtp was triggered in . %. surgery was performed in . %. the overall mortality was of . %. predictive scores for mt were compared: gap (glasgow coma scale, age, systolic blood pressure), shock index (si), assessment of blood consumption (abc) and mabc (modified abc). auroc for gap was . ± . , si . ± . , abc . ± . and mabc . ± . , showing differences between gap (the worst score) and the others, p \ . . no differences were found between si, ab and mabc. best cut-off points were calculated. si c . better predicts mt with a sensitivity %, specificity . %, positive and negative predictive values . % and %. conclusions: si, abc and mabc are all good scores for predicting mt in our population. appealing by its simplicity, we recommend si as the best trigger for mtp. protocols should be standardized to improve the accuracy of mtp activation for trauma patients. introduction: the prevalence of knife-related offences is rising in the uk. successful management of trauma patients requires the co-ordinated response of specialist services, including transfusion. we aimed to assess the impact of knife-crime on transfusion support within a uk adult major trauma centre (mtc). material and methods: retrospective review of patients admitted to a uk mtc following knife injuries resulting from interpersonal violence during a three-year period (may -april ). source material included electronic patient records, tarn database and massive transfusion protocol (mtp) logbook. patient characteristics, resource utilisation including transfusion, mtp activation and outcome were collated. results: patients were identified, ( %) were male. median age was years. ( %) were under the age of . patients ( %) presented with circulatory compromise (sbp \ ). patients ( %) had attended our hospital previously for violencerelated trauma. % arrived at hospital between h to h. ( %) required one or more surgical procedures. median length of stay was days. patients ( %) received blood transfusion. median units transfused were prbc, ffp, platelets (atd). mean component use was pbrc (range - ), . ffp ( - ), platelets . ( - ), cryoprecipitate . ( - ). annual mtp activations increased from to during the study period (total ). stabbings accounted for . % of these ( patients), of which ( %) were transfused. conclusions: knife crime presents a burden to blood transfusion, accounting for a quarter of mtp activations. patients typically present out of hours with implications for service planning and delivery. patient profile together with repeat healthcare attendance and surgery requiring transfusion has implications for red cell allo-immunisation. we recommend timely baseline blood grouping and triage to optimise the safe use of rhd positive cellular components. introduction: spontaneous intramural small bowel hematoma is a very rare complication of anticoagulant therapy. nowadays, the prevalence is increasing due to the widespread use of computerized tomography and the increasing number of patients receiving anticoagulant therapy. material and methods: patients admitted to our center between january and june and treated with the diagnosis of intramural hematoma were retrospectively evaluated. results: the median age of the patients was years ( - ) and ( %) were male. at the time of appeal, warfarin intoxication was present in cases ( %) and the median inr was . ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . one patient had known factor deficiency. diagnosis was made by computerized tomography in all cases. one intramural hematoma was localized in the duodenum ( . %), nine in the jejunum ( %), and five in the ileum ( . %) six patients ( %) had ileus findings. all patients underwent fresh frozen plasma replacement due to high inr levels and bleeding. median tdp transfusion was units ( - ). only patients ( %) required erythrocyte suspension replacement. all cases were followed up conservatively and there was no need for intensive care. the median hospital stay was ( - ) days. conclusions: due to the limited number of studies in the literature with a large number of cases, retrospective evaluation of singlecenter cases may be helpful. spontaneous intramural small bowel hematoma should be considered in the elderly population under warfarin therapy who present with abdominal pain, especially if inr values are above therapeutic limits spontaneous regression is seen in the majority of cases. non operative management and correction of coagulopathy with fresh frozen plasma replacement is the preferred approach. references: abbas ma, et al. spontaneous intramural small-bowel hematoma: clinical presentation and long-term outcome. arch surg. ; ( ) : - . pre-hospital decision-making: identifying the challenges assessing and managing traumatic haemorrhage and coagulopathy m. marsden , r. bagga , k. gillies , r. lyon , s. kellett , r. davenport , n. tai expert pre-hospital clinicians in making decisions about the diagnosis and treatment of patients with major haemorrhage and suspected tic. methods: semi-structured interviews were conducted with senior pre-hospital consultants from london's air ambulance and air ambulance kent, surrey and sussex. interviews probed clinicians on how they make decisions relating to the pre-hospital assessment of major haemorrhage and tic and subsequent blood product transfusion. the interviews were analysed using descriptive thematic analysis. results: all clinicians agreed that identifying and treating major haemorrhage was vital. half of the clinicians reported making no conscious assessment for tic and six reported tic should be managed in a hospital setting. four broad themes were identified: collation of information, weighing utility of different approaches, influence of experience and evaluation of unknowns. collating information from multiple sources drove clinical decision-making. decisions on blood product transfusion were made after weighing potential benefits (e.g. improve microvascular perfusion) against harms. clinical experience was reported as key to nuance clinical assessment, detect subtle signs and identify patterns. uncertainty complicated clinical decision-making in two domains; incomplete knowledge of a patient's injury and uncertainty of best clinical practice. conclusion: the pre-hospital identification and treatment of major haemorrhage was recognised as challenging and fundamental. necessity of pre-hospital tic diagnosis and treatment divided opinion. identifying these four themes allows for a greater understanding of the factors involved in making these decisions and will guide the creation of more accurate decision support tools to aid pre-hospital clinicians. nothing to declare. introduction: massive transfusion (mt) is defined as the administration of c packed red blood cells (prbc) in h. alternative definitions have been proposed; however, there is little understanding about the discriminative ability of different mt definitions with regards to mortality and multiorgan failure (mof). we aim to assess and compare the discriminative ability of different definitions of mt concerning mortality and mof. material and methods: we included patients who arrived to the emergency department and required trauma team activation at a level i trauma center in the city of cali, colombia between - . demographics and trauma characteristics were evaluated. the following mt definitions were measured: units of blood products in h (t ), u prbc in (t - ), u prbc in h (t - ), prbc in h (t - ), the combination of t - and t (t-combi), prbc in h (t - ), prbc in h (t - ) and units of prbcs in min. the operative characteristics were calculated for each definition. mof was defined as a sofa score of c points. results: we included subjects, . % male. trauma mechanism was penetrating in . %. the median and interquartile range (iqr) of age was years iqr ( - ) and of iss ( - ). lesions were located in the torso in . % of patients, and . % had a positive abc score. a total of ( %) received at least unit of prbc. tables and presents the operative characteristics of definitions of mt with respect to mortality and mof, respectively. conclusions: although all definitions showed an association with higher odds with the outcomes of interest, none of them showed an accurate diagnostic capacity regarding mof and mortality. thus, we advise caution when relying on the classical definition of mt ([ rbc units in h) to guide the flow of care of severely injured patients. trauma and coagulation: trends in coagulation factors in the severely injured trauma patient introduction: trauma-induced coagulopathy (tic), affects about - % of the major trauma patients. in the past, tic was considered as a consequence of the coagulation factors' dilution after a highvolume colloid administration. today tic is seen as a phenomenon that can arise after trauma; the first event is the c-protein activation by the tissue damage and hypoperfusion, resulting in the subversion of the hemostatic process. material and methods: the patients of the pilot study ''trauma and coagulation'' run in irccs san raffaele scientific institute have been reviewed and analyzed using a suite of experimental coagulation factors including rotem parameters, activated protein c (apc), thrombomodulin, endothelial protein c receptor, thrombin-antithrombin complex (tat), plasminogen activator inhibitor (pai- ), seselectin, interleukin- (il- ), interleukin- (il- ), d-dimer (xdp), antithrombin iii (atiii), and prothrombin fragment f ? (f ? ). new patients have been enrolled to validate the results of the pilot study. results: there is a statistically significative correlation between clinical scores of severity of trauma and risk of massive transfusion (iss, abc and tash) and some of the experimental coagulation factors analyzed. case history: to evaluate the role of negative pressure wound-care systems applied to the pleural cavity in case of severe acute empyemas and frail patients not amenable to conventional surgery. clinical findings: we report the case of a yrs old male critically ill patient suffering from complications of cardiac surgeries who developed a severe right empyema with broncho-pleural fistula through the site of a previous pulmonary hernia. investigation/results: we review the actual indications of negative pressure therapy in thoracic surgical emergencies especially in septic patients unfit for surgery. in our case the repeated application of negative pressure with dedicated dressings through the initial thoracotomy was the chosen damage control approach because of the sepsis and poor conditions. diagnosis, therapy and progressions: air leaks were later found to originate from a subsegmentary branch of middle lobe bronchus. subsequent video-assisted debridement procedures followed by negative pressure therapy managed to ( ) control the infection, ( ) reduce the thoracotomy incision into a thoracoscopic access and ( ) heal the pleural cavity, restoring eventually better general conditions of the patient. the closure of the bronchial fistula required further procedures after the acute phase when sepsis was overcome. comments: negative pressure systems can be applied to the pleural cavity with many advantages in selected critically ill patients. they allow to contain, treat and resolve infections both of chest wall and pleural cavity in case of severe empyemas reducing also wound pain and eliminating the need of chest drains. air leaks may also be managed by negative pressure therapy with adequate indications and particular attention to its settings. references: sziklavari z. mini-open vacuum-assisted closure therapy with instillation for debilitated and septic patients with pleural empyema. eur j cardiothorac surg. . flail chest: the renaissance of rib osteosynthesis c. leite , a. oliveira , a. lemos , b. barbosa , c. casimiro centro hospitalar tondela-viseu, general surgery, viseu, portugal case history: we present the clinical case of a male patient of years old. injury mechanism: fall from his own height over the right hemithorax. clinical findings: rib fractures with flail chest and significant displacement of bone edges. symptoms: intense thoracic pain. diagnosis: rib fractures with flail chest. therapy and progressions: multimodal analgesia. on the th day, he presented a tension pneumothorax. after adequate intercostal drainage, the pneumothorax relapsed. on the th day, he underwent a right posterolateral thoracotomy, open reduction and internal fixation of ribs with plates and screws and intercostal drainage. evolution: he received respiratory kinesiotherapy and was discharged on the th pos op day. follow-up at st and th months, without functional impairment and with preservation of quality of life. comments: rib fracture is the most common injury in the setting of thoracic trauma and is associated with a higher morbimortality. in the last years, positive pressure mechanical ventilation was the first line treatment of respiratory insufficiency caused by rib fractures. however, severe complications associated with prolonged mechanical ventilation, have elicited the rising implementation of open rib reduction and internal fixation techniques. the most consensual indications are: flail chest with fracture of at least ribs, significant displacement of bone edges or uncontrolled pain. rib osteosynthesis is a simple method but requires clinical experience in thoracic approaches and handling of specific instruments and material. its implementation in non-ventilated patients reduces the need for mechanical ventilation, pain, length of stay and allows preservation of quality of life. yokohama city university medical center, advanced critical care and emergency center, yokohama, japan, saiseikai yokohama-shi nanbu hospital, department of surgery, yokohama, japan, yokohama city university, department of general surgery, yokohama, japan, yokohama city university, department of emergency medicine, yokohama, japan introduction: although americans and europeans report emergency room thoracotomy (ert) is of value in penetrating trauma patients, most of ert is performed for blunt trauma in japan. after the establishment of the local government-directed major trauma center in the city of yokohama, the unexpected trauma survivor rate increased in the single center study. we report our experience in ert and surveyed the effect of the establishment. material and methods: patient characteristics (backgrounds, mechanism of injury, indication for ert, anatomic injuries, interventions and survival) of those who underwent emergency thoracotomy compliant with the guideline of western trauma association, between october and september were analyzed. results: fifty-eight patients ( males) underwent emergency thoracotomy. median age was . ( - ) years. fifty-seven were performed for blunt trauma ( %) and only for penetrating injuries. twenty-three patients presented with cardiac arrest on arrival, while thirty-five had deep and refractory hypotension. overall, survival rate improved from ( / ) to % ( / ) (p = . ) after the establishment of the trauma center. of patients presenting with cardiac arrest, only one survived. conclusions: the establishment of major trauma center seemed to affect the survival rate of the patient edt was performed. introduction: more than % of polytrauma events involve chest injuries. one third of these patients sustain thoracic instability due to serial rib fractures. thanks to numerous innovations in implant development several approaches currently exist for surgical rib stabilization (srs). however, no consensus exists regarding patient selection for srs to date. material and methods: retrospective single center cohort analysis in trauma patients. serial rib fracture was defined as three consecutive ribs confirmed by chest ct. cohort includes patients that were treated conservatively and patients that underwent srs by plate osteosynthesis. demographic patient data, trauma mechanism, injury pattern, injury severity score (iss), glasgow coma scale (gcs) and hospital course were analyzed. two matched pair analyses stratified for iss ( pairs) and gcs ( pairs) were performed to minimize selection bias. results: the majority of patients was male ( %) and aged ± years. serial rib fractures were located left/right/bilateral in %/ %/ % of cases. other thoracic bone injury included sternum ( %), scapula ( %) and clavicula ( %). visceral injury consisted of pneumothorax ( %), lung contusion ( %) and diaphragmatic rupture ( %). average iss was ± . . overall hospital stay was . and icu stay . days. in hospital mortality was %. srs did not improve hospital course or postoperative complications in the complete study cohort. however, patients undergoing srs had significantly reduced gcs ( . ± . vs . ± , ; p = . ). matched pair analysis stratified for gcs showed a reduced need for blood substitution and shorter icu stays ( vs days; p = . ) including shorter respirator time ( vs h; p = . ) and reduced in hospital mortality ( vs %). conclusions: patients with serial rib fractures and simultaneous severe cerebral injury benefit from surgical rib stabilization. tracheal and bilateral recurrent laryngeal nerve disruption injury secondary to accidental strangulation by dupatta case history: year old female brought to trauma emergency with a/h/o accidental strangulation injury with dhupatta at farm field while working with thresher machine after h of injury. patient had severe dyspnoea, dysphagia, paining neck clinical findings: primary survey revealed threatened airway with extensive surgical emphysema, rr- /min, spo - % on high flow oxygen mask, hemodynamically stable, and had no neurological deficits. patient was immediately intubated, however ventilation could not be maintained and surgical emphysema worsened hence immediate tracheostomy was established. investigation/results: computed tomography (ct) head and ct angiography of neck with venous phase study of neck and chest with ct esophagogram revealed complete disruption of cricotracheal junction with extensive cervical and upper thoracic surgical emphysema and no other injuries. diagnosis: disruption of trachea from cricoid cartilage with crushed trachea with loss of approximately cm, cricoid and thyroid cartilage fracture, complete avulsion of bilateral recurrent laryngeal nerves and serosal tear of esophagus. therapy and progressions: neck exploration with debridement of tracheal margins and anastomosis between trachea and cricoid cartilage with repair of cricoid, laryngeal cartilage and esophageal serosal repair was performed. comments: post-operatively patient underwent fibreoptic bronchoscopy and revealed paramedian location of vocal cords. at present patient is with tracheostomy tube in situ undergoing speech therapy and is able to generate comprehensible sounds. further laryngeal framework surgery is being planned. introduction: emergency resuscitative thoracotomy (ert) is a lifesaving procedure in selected patients and it is often considered a controversial ''last chance'' method of resuscitation. objectives of ert are to resolve pericardial tamponade, to repair heart injuries, to perform an open cardiac massage, to cross-clamp the aorta to redistribute blood flow to the myocardium and brain, to control intrathoracic bleeding and air embolism in the bronchial venous system. outcome mostly in blunt trauma is believed to be poor. material and methods: we retrospective reviewed patients c years who underwent ert at san camillo-forlanini hospital (rome, italy) between january and september with traumatic arrest for blunt or penetrating injuries. results: of ert, ( . %) were for blunt trauma, ( . %) were for penetrating trauma. . % of patients were male. the collectively reported overall survival was % (n = ). when including erts designated as done in the emergency department for blunt mechanism, only patient survived ( . %). survival after erts for penetrating trauma was % ( of ). conclusions: our experience suggests that ert is a technique that should be utilized for patients with critical penetrating injuries. the reported outcome after ert in european civilian trauma populations is favorable with an overall survival of %. multicenter, prospective, observational data are needed to validate the modern role of ert in blunt or penetrating trauma. references: narvestad jk, et al. emergency resuscitative thoracotomy performed in european civilian trauma patients with blunt or penetrating injuries: a systematic review. eur j trauma emerg surg. ; ( ) case history: an -year-old male driving a car collided with a wall at a speed of km/h and was brought to a hospital near the scene. he was diagnosed with right multiple rib fractures and hemopneumothorax, and transferred to our emergency center for definitive care. clinical findings: the patient's consciousness was clear and his heart rate, blood pressure, respiratory rate, and o saturation (room air) on arrival were /min, / mmhg, /min, and %, respectively. subcutaneous emphysema was identified on the right side of his chest and his right breathing sound decreased on auscultation. there was no tenderness and rebound on abdominal examination. investigation/results: an enhanced whole-body computed tomography scan revealed a small disruption on the right diaphragm behind the sternum and free air in the abdomen. diagnosis: the diagnosis was right traumatic diaphragmatic injury, sternum fracture, and right multiple rib fractures with pneumohemothorax. there was free air in the abdomen but without evidence of perforation of the digestive tract as there was no finding of peritonitis on physical examination. thus, pneumoperitoneum from the thorax was strongly suspected. therapy and progressions: laparoscopic observation revealed a . cm-length of disruption on the diaphragm in the right sternocostal triangle. this was covered with falciform ligament using extracorporeal knot tying method because there was little seam allowance in front of the disruption on the sternum side, and direct suture was not possible. prognosis was good following surgery, and the chest drain was removed on postoperative day and the patient was discharged on postoperative day . comments: laparoscopic repair of the diaphragm using extracorporeal knot tying method is often used for retrosternal (morgagni) hernias. however, the method was also useful in this case because the diaphragmatic injury occurred in the sternocostal triangle. rib fractures associated with pneumo-and/or hemothorax; does everyone need a chest tube? v. snartland , p. a. naess , c. gaarder , m. hestnes , p. majak , , faculty of medicine, university of oslo, oslo, norway, oslo university hospital, department of traumatology, oslo, norway, oslo university hospital, trauma registry, oslo, norway, oslo university hospital, department of cardiothoracic surgery, oslo, norway introduction: pneumo-and/or hemothorax are often seen in trauma patients with rib fractures (rfs). standard treatment for pneumothorax (ptx), hemothorax (htx) and hemopneumothorax (hptx) is tube thoracostomy (tt). however, a non-operative approach can be applied in selected patients. we wanted to assess our practice in patients with rib fractures and associated ptx, htx or hptx. material and methods: all adult patients (c years) with rf, admitted by a trauma team at oslo university hospital in were identified retrospectively and those with associated ptx, htx or hptx were then included in the study. patients who underwent tt prior to arrival and those who died were excluded. spss v was used for statistical analysis. results: of the patients with rfs, a total of patients had ptx, htx or hptx. fifty-one percent ( / ) of these patients were treated with tt and % ( / ) of the patients underwent tt within h after arrival. the presence of opacification (p \ . ), chest wall deformity (p \ . ) and pneumothorax size (p \ . ) were significantly higher on chest x-ray in the tt group compared to the nonoperative group. intubation at arrival was also significantly more common in patients treated with tt (p \ . ). there was no difference in the presence of subcutaneous emphysema between the groups. the tt group was sicker than the non-operative group (had a significantly lower systolic blood pressure, a lower gcs and a higher lactate on arrival). oxygen saturation, heart rate, respiratory rate, ph and hemoglobin did not differ significantly between the groups. conclusions: in trauma patients with rf concurrent ptx, htx or hptx should be suspected. in our study only half of these patients were treated with tt, and % of tubes were inserted within h after admission. size of the ptx, radiological presence of opacification and deformity of the chest wall should be addressed when choosing treatment strategy. introduction: emergency department thoracotomy (edt) is a potentially life-saving surgical procedure performed in the emergency department (ed) in patients presenting with cardiac arrest following penetrating thoracic trauma. however, it is not clear if all surgeons are prepared or motivated to perform this procedure. furthermore, not all institutions are equipped, either in terms of logistics or team training, to perform edt. our purpose was to perform a pilot study in a cohort of polish surgeons of various specializations, in order to ascertain who would and who would not (and why) perform edt in their departments. material and methods: study population of surgeons ( specialists, residents) from various hospitals in poland, mean age: - years, . % men, . % women. study respondents were asked to fill in a questionnaire on the indications and motivation to perform edt in their clinical practice. results: most respondents (n = , %) correctly recognized the indications to perform edt. however, only ( %) declared they would perform it. the reasons for not performing edt were: lack of team training ( . %); lack of equipment ( %); lack of motivation among ed personnel ( . %); the ed is not prepared ( . %); the respondent is not prepared ( %). only participants ( . %) declared that their institutions had the edt protocol. conclusions: this survey demonstrates that, although most surgeons agree on the indications for edt, the level of preparedness in its execution is lacking. the main reasons are the lack of team training, the lack of equipment and the lack of motivation among ed personnel. other relevant reasons were the lack of preparation of either a surgeon or a department. these results demonstrate that improvements in institutional logistics as well as in team and individual training can translate into improved care. we strongly advise the performance of a pan-european survey on edt to address other unrecognized issues. mediastinum widening: how to manage it? a. gonzález-costa , r. gracia-roman , s. montmany-vioque , m. s. santos-espi , r. lobato-gil , m. pascua-solé , a. campos-serra , a. luna-aufroy , p. rebasa-cladera , s. navarro-soto parc tauli hospital universitari, trauma and emergency general surgery department, sabadell, spain, parc tauli hospital universitari, esofagogastric general surgery department, sabadell, spain, parc tauli hospital universitari, angiology and vascular surgery, sabadell, spain case history: a -year old male was admitted to our emergency department as a polytrauma code, because of a gunshot wound in the neck. clinical findings: his airway was compromised with expansive cervical hematoma. intubation was difficult. he was hemodynamically unstable with cervical bleeding, in which manual compression was applied. results: chest x-ray showed mediastinal widening without pneumo or hemothorax. diagnosis: urgent sternotomy while maintaining manual compression on the cervical bleeding, followed by left antero-lateral cervicotomy. injuries: section of left jugular vein and left carotid artery, lesions of unnamed vein. free cervical chylous fluid. left pleura and pericardium were opened without identifying major injuries. therapy and progressions: jugular vein was repaired with continuous suture and carotid artery with patch sutured. unnamed vein was sectioned between ligatures. thoracic duct was ligated. after surgery, ct scan showed cervical and mediastinal hematomas without signs of active bleeding, and correct permeability of the vessels, with no cranial lesions. the patient was admitted to the intensive care unit. tracheostomy was performed. fibrobronchoscopy, fibrogastroscopy and esophagogastricoduodenal discarded airway and esophageal lesions. he presented the following complications: • small mediastinal collection • right diaphragmatic paralysis. • paralysis of vi left cranial nerve (mononeuritis of vascular origin). the patient was discharged on the th postoperative day. comments: in this kind of trauma is essential the airway management with intubation when necessary. it is important that mediastinal widening visualized in the chest x-ray in a traumatic patient, should be an indication of surgery. in our case, it was essential to start it with sternotomy while maintaining manual neck compression, and in a second time, perform the cervical approach since that prevented the patient from suffering a greater blood loss. background: clavicular fracture is very common in childhood. otherwise, the medial third of the clavicle is the less affected. the current report describes a new pattern of clavicular injury, in which a medial third clavicular fracture and posterior sternoclavicular joint (scj) dislocation occur together in a skeletally immature patient. clinical findings: an -year-old boy sustained a direct impact to his left shoulder resulting from the fall of a sofa. at admission, he complained of severe pain in the clavicular and shoulder associated with functional limb impotence. physical examination revealed deformity of the proximal third clavicle, with swelling and tenderness to palpation along the medial left clavicle. no signs of skin pression or neurovascular impairment were found. the anteroposterior radiograph of the left clavicle showed a fracture of the proximal third shaft and an asymmetry of the scj. computed tomography confirmed the association of a greenstick fracture of the proximal third clavicular shaft, accompanied by a mild posterior scj dislocation. therapy and progressions: the left limb was immobilized with a sling during weeks, after which physical therapy was initiated to improve range of motion using active and gentle active-assisted exercises. at the months medical consultation, he presented asymptomatic, with good bone healing, full range of motion of the shoulder and absence of relevant aesthetic deformity. comments: in the immature skeleton, scj dislocation and epiphyseal fracture of the proximal clavicle are very rare entities due to the multiple strong ligaments that stabilize the scj. trauma in the proximal third of the clavicle typically results in fractures in the region of the physis and only more rarely culminate in dislocations of the scj. these injuries warrant a high index of suspicion, and early ct scanning is recommended. although treatment may be conservative, in situations of major displacement, surgery should be considered. use of rib fracture scoring systems in a uk major trauma unit: a retrospective audit and lessons learnt introduction: rib fractures are detected in % of trauma patients [ ] . significant morbidity and admission to intensive care units (itu) is common [ ] . rib fracture scores do not have strong validity as a predictor, but are a useful screening tool to identify patients at higher risk, of morbidity. the aim of this study was to audit the use of rib fixation scores in a single major trauma centre. material and methods: a retrospective audit of trauma patients with rib fractures presenting to a single major trauma centre over a -year period subsequently admitted to itu was performed. demographics, length of itu stay, rib fracture score (rfs) and ribscore were recorded and comparisons made between patients who had surgical rib fixation and those who did not. results: patients with traumatic rib fractures were admitted to itu over -year, of whom had rib fixation. mean age of patients undergoing surgery was compared to in the non-surgical cohort. average rfs was higher in the surgical cohort ( vs ; p = \ . ), as was average ribscore ( vs ; p = \ . ). incidence of flail segment was higher in surgical cohort ( % vs %; p = \ . ), as was number of rib fractures ( vs ; p = \ . ) and incidence of st rib fracture ( % vs %, p = \ . ). rib fractures treated surgically had a longer itu stay ( . days vs . ; p = \ . ). conclusions: surgical rib fixation patients were older and had longer itu stay. higher rib fracture scores correlated with need for surgical intervention. this highlights the need for careful patient selection for rib fixation, as they appear to fall in a more vulnerable patient demographic. there is a need for a score combining ribscore and rfs, ensuring the nature of fractures and presence of flail segments are interpreted in the context of patient age, to ensure this vulnerable patient group undergoes surgical fixation only when necessary. jichi medical university, shimotsuke tochigi, japan case history: an -year-old female individual hurt her back while walking during a hospital rehabilitation program after experiencing a brain stroke. her hemoglobin level gradually decreased to . g/dl on the th day after injury. a non-enhanced abdominal ct scan revealed a burst fracture of the lumbar spine. the patient was brought to our emergency center for a thorough examination. clinical findings: her vital signs on arrival were gcs: e v m , hr: , bp: / , rr: , and bt: . . her back presented a severe kyphotic spine. the palpebral conjunctiva was anemic and there were no injuries on her surface. no abnormalities were detected upon auscultation of the thorax and no tenderness and rebound was detected upon physical examination of the patient's abdomen. investigation/results: hemoglobin level was . g/dl and lactate . mmol/l on arrival. an enhanced chest and abdominal ct scan revealed a burst fracture of the th lumbar spine, a large hematoma around it, and a pseudoaneurysm of the lumbar artery. diagnosis: a pseudoaneurysm of the lumbar artery and a burst fracture of the th lumbar spine was diagnosed. therapy and progressions: the angioembolization of the lumbar artery was abandoned because the distance between the abdominal aorta and the aneurysm was \ mm. endovascular aneurysm repair (evar) was finally performed. after the successful completion of the surgery, the patient was discharged on the th day after evar. comments: slight injury caused the fracture of the lumbar spine, possibly yielding pseudoaneurysm of the lumbar artery. such pseudoaneurysms are rare and employing evar for its treatment is equally rare. blunt lumbar artery injury may be a differential diagnosis for the elderly patients who present burst spine fractures with extreme anemia or shock, even if it results from a minimal injury. case history: a year old co-driver was hit by another car on her side. air rescue found the patient with gcs and right tension pneumothorax. oral intubation, decompression with chest tube and transportation to the nearest level one trauma center was undertaken. clinical findings/investigation/results: on presentation in the emergency room the patient was hemodynamically instable with free fluid in efast-sonography and a haemoglobin of . g/dl. she was immediately taken to the operation room where laparotomy was performed. liver rupture and right diaphragm rupture was found. diagnosis: right hilar bronchial disruption. therapy and progressions: despite packing of the liver the patient remained instable. due to continuous bleeding from diaphragm rupture side right anterolateral thoracotomy was performed. bronchial disruption close to the hilus was detected leading to total pneumonectomy. after surgery the patient recovered under intensive care. six weeks after initial trauma the patient presented with ileus. a gastric tube was placed without complications. chest x-ray was performed showing intrathoracal displacement of the gastric tube. in an emergency operation the insufficient bronchus trunk was covered with an intercostal muscle flap. comments: this case shows the rare necessity of total pneumonectomy after blunt chest trauma and its typical complication with insufficiency of the bronchial trunk. after total pneumonectomy surgery covering the bronchial trunk should be performed as soon as possible to prevent insufficiency. in these patients gastric tubes should only be placed under endoscopic vision. because of the high complication rate total pneumonectomy should only be performed as a last resort procedure in the context of damage-control surgery. introduction: multiple rib fractures continue to be a challenging problem as the associated pain leads to a compromise in respiration. proper analgesia is required for physiotherapy, and to prevent development of respiratory failure. ultrasound-guided serratus plane block (spb) has recently been described as a regional anesthetic technique to provide analgesia to a hemithorax by blocking the lateral branches of the intercostal nerves. material and methods: from sept we applied the serratus plane block for pain control in patients with multiple rib fractures. we administered . - . % bupivacaine solution with easypump for - days, the infusion rate was ml/h. after admission we measured pulmonary function of patients and recorded the forced vital capacity (fvc). we repeated the test after the catheter insertion on the - - days. in our control group ( patients introduction: rib fractures are the most frequent injury after blunt thoracic trauma. it is very important to choose the most appropriate interventions to minimize or prevent complications. but who will benefit most of those interventions remains a challenge. material and methods: a retrospective study with a prospective data collection from march to december . there have been included all traumatic patients older than years old, that were admitted to the icu or who were died before the admission and had a plain chest radiograph (cxr) and thoracic or thoraco-abdominal scan (ct scan) in the first h. demographic data has been collected, vital signs, iss, mechanism of action, need of ventilation or intubation, lesions, complications, cause of death. a total of cxr were reevaluated by one general surgeon (one of the authors) and one radiologist, who were blinded to the results of the subsequent chest ct scan, the written radiology report and the patient's outcome. rib fractures, pneumothorax, hemothorax, pulmonary contusion, laceration and atelectasis were described. results: attending to the number of fractures, the kappa between the radiologist, the surgeon and the ct report is very low: surgeon-ct k = . , radiologist-ct k = . , and radiologist-surgeon k = . . both radiologist and surgeon under-diagnosed rib fractures. we tried to predict respiratory failure and pneumonia using the number of fractures, and scores (chest trauma score, ribscore and rib fracture score). results are shown on the table. conclusions: plain radiography seems not to be a good diagnostic method for rib fractures. both radiologists and surgeons under-diagnosed rib fractures. scores based on radiography seem un-useful given that this under-diagnoses rib fractures; but with a precision of % by the surgeon evaluating cxr and using a score like rfs perhaps it is enough to decide which patients require a ct scan or more specific treatment in the icu. surgical experience of traumatic diaphragm injury in a single regional trauma center for years introduction: this study is a retrospective review of the experience with the management of traumatic diaphragm injury in our trauma center from to . material and methods: we identified a total of patients with the traumatic diaphragm injury coded from the institutional trauma registry. we reviewed the radiographic finding of radiologists and the electronic medical record (emr). results: the mean of injury severity score (iss) was . ± . . except for case, the plain chest x-ray was evaluated in the patients before surgery, only patients were revealed positive finding for diaphragm injury (n = / , %). the computed tomography (ct) was performed for patients, the positive finding was . % (n = / ). according to the clinician impression before surgery, the diagnosis for diaphragm injury was showed . % (n = / ). approaches were laparotomy in patients ( . %), thoracotomy in ( . %), thoracoscopy in ( . %), laparoscopy in ( . %), open conversion after thoracoscopic or laparoscopic exploration in ( . %), median sternotomy in ( . %). the occurrence of herniation was ( . %). the mean of the calculated rupture size in the operation field was . ± . cm. in our study, the herniated peritoneal organ was observed in more than cm size rupture of the diaphragm. patients were performed surgical management of diaphragm rupture after h. conclusions: without herniation of organs, the radiologic evaluation was difficult to detect diaphragm injury. and, detect of diaphragm injury with herniation of organ, the injury of the diaphragm was predicted a larger than cm. case history and clinical findings: a -year-old man presented to the emergency room with a single self-inflicted left chest gunshot wound at the level of nd rib. on arrival patient was conscious, with systolic blood pressure mmhg and heart rate bpm. extremities were pale, cold. jugular veins distended. investigation/results: fast scan was negative. chest radiograph revealed a metal foreign body with the size of mm at the projection of heart. a ct scan of chest and abdomen demonstrated bullet inside the dorsal wall of the left ventricle and blood in pericardium and left pleural cavity (figs. , ) . therapy and progression: patient was taken to the operation room for median sternotomy. due to severe deterioration of patient's condition, ml of blood was aspirated from the pericardium prior to sternotomy. during subsequent pericardiotomy ml of blood was evacuated. main pulmonary artery wall gunshot injury was detected above the pulmonary valve. the wound was sutured, after which the hemodynamics stabilized. cardiac surgeon was consulted about the air gun bullet inside the myocardium. it was decided that removal of the bullet is not indicated. the patient was observed in the icu for the next h, later transferred to the thoracic surgery ward. the postoperative course was uneventful. an echocardiogram demonstrated a perforation of the anterior leaflet of mitral valve with a mild to moderate regurgitation, otherwise no abnormalities. patient was discharged on day . patient has been followed up on an annual basis for the last years. patient's exercise tolerance and cardiac function according to repeated echocardiography remains unchanged with no evidence of dyskinesia or other abnormalities. bullet is retained in the same location (fig. ) . comments: this case illustrates a successful management of usually lethal injury of main pulmonary artery and reflects that retained myocardial foreign body does not necessarily cause any complications. profile of penetrating chest injuries in hostile environment: a three year study introduction: penetrating chest injuries are one of the leading causes of death and major morbidity in operations involving high energy weapon systems. this study aimed at assess the profile of penetrating chest injuries suffered during armed combat operations in a hostile environment over a three year period. material and methods: a retrospective and prospective, non-randomized study designed to assess the profile of chest injuries in armed combat operations over years. all patients with penetrating chest injuries were included in the study. results: there were trauma cases out of which patients suffered penetrating chest injuries. the age range of patients was - years and all were male. a total of casualties were brought dead ( . %). there were lung injuries and two diaphragmatic injuries. thoracotomy was required in patients ( . %) and intercostal chest drainage (icd) in patients ( . %). average blood loss was ml and duration of hospital stay ranged from to days. conclusions: ballistic injuries to the chest are frequently fatal due to injuries to the heart, major vessels and tracheobronchial tree. prompt and efficient pre hospital treatment, expedient evacuation to a surgical facility and swift management by critical care specialists and surgeons can be instrumental in reducing mortality and morbidity. the cornerstone of management is bedside intercostal chest drain insertion as a formal thoracotomy is seldom needed. penetrating chest injuries can be managed by general surgeons with training in thoracotomy and repair of intra-thoracic structures does the number of a-or low symptomatic but intervention requiring complications justify regularly chest x-ray controls after less than rib fractures? c. deininger , , f. wichlas , , s. deininger , v. hofmann , university hospital of salzburg, orthopedics and traumatology, salzburg, austria, universitätsklinikum salzburg, klinik für orthopädie und traumatologie, salzburg, austria, universitätsklinikum salzburg, universitätsklinik für urologie und andrologie, salzburg, austria introduction: fractures of less than ribs may still cause delayed complications ( ) . the aim of this retrospective study is to determine whether standardized control imaging in a-or low symptomatic patients reveals a significant number of intervention requiring complications and therefor should be recommended. material and methods: all patients with less than rib fractures presenting in our emergency department after any trauma mechanism in the study period of years ( - ) and available for follow up were included retrospectively in the study. results: we included patients in this study, ( . %) of which were male, female ( . %), with a median age of . ± . years. in patients ( . %) rib was affected, in patients ( . %) , the fractured ribs being true ribs ( - ) in cases ( . %), false ribs ( - ) in cases ( . %) and both in cases ( . %). the affected thorax half was the left side in cases ( . %), the right side in cases ( . %) and both thorax halves in cases ( . %). the trauma mechanisms were falls at home, traffic accidents, sporting accidents, work accidents, fighting related and minor trauma in ( . %), ( . %), ( . %), ( . %), ( . %) and ( . %) cases, respectively. the median follow up time was ± days. patients ( . %) required delayed intervention: case of hemopneumothorax and cases of pneumothorax all treated with chest tube. conclusions: planned chest x-ray controls seem not to be necessary. symptom triggered reappearance for patients after rib fractures in hospitals seems to be sufficient and more economical compared to regularly re-imaging ( ) is computed tomography a first line modality in stable blunt chest trauma elderly patients? a. becker , , y. berlin , , d. hershko , emek medical center, department of surgery a, afula, israel, technion-israel institute of technology, haifa, israel, emek medical center, surgery, afula, israel introduction: adult older, patients aged [ years, represent up to - % of all trauma patients admitted to the trauma centers. chest trauma in older patients have been recognized to strongly influence mortality. the estimated of % mortality and pneumonia rate for these patients was observed ( , ) . based on low diagnostic accuracy of cxr, interpretation difficulties due to aging chest wall deformities, we hypothesized that ct chest should be the first imaging modality in stable elderly blunt chest trauma patients. patients and methods a retrospective analysis of all blunt trauma admissions at emek medical center between - years was performed in order to identify patients with blunt chest trauma. only stable trauma patients with abbreviated injury score (ais). results: among patients that met inclusion criteria, there were ( %) patients aged - years old and ( %) patients aged c . in the first group of patients ( - ), had ct chest on arrival. in the second group of patients (aged c ), there were ( . %) patients with missed injuries. in this group, patients who had ct chest on arrival, of ( . %) patients had missed injuries. eleven of ( %) patients who had no ct chest on arrival, diagnosed with missed injuries (p- . ). readmission rate in the first group of patients ( - ) was of ( %) who had ct chest on arrival, and of ( %) who had cxr on arrival only (p- . ). in the second group (c ), readmission rate was of ( . %) patients with ct chest on arrival, and of who had cxr on arrival only ( %) (p- . ). conclusions: based on our study result we conclude that ct chest should be a first imaging tool in stable elderly patients with blunt chest trauma. no disclosures. efficacy and safety of small-bored tube thoracotomy for chest trauma: large-bored chest tubes will no longer be needed introduction: tube thoracostomy drainage is an important treatment for traumatic pneumothorax and hemothorax. traditionally, largebored chest tubes have been recommended for successful drainage and prevention for clogging by clots. however, there is little evidence that large-bored tubes are more effective than smaller ones. in consideration of invasiveness, in our emergency room (er), we use fr chest tube for all trauma patients when chest thoracotomy is indicated. the aim of our study is to investigate the efficacy and safety of small-bored tubes for chest trauma patients. material and methods: we conducted a retrospective observational study. we included the adult patients ([ years old) who had undergone tube thoracostomy with fr chest tubes for chest trauma during the years from october to september in our er. the patients with cardiopulmonary arrest on contact or on arrival were excluded. we evaluated tube-size related complications defined as obstruction and worsening of pneumothorax/hemothorax due to ineffective drainage. results: there were eligible patients, % were male, mean age was . and the average injury severity score was . (± . ). sixty-six tube thoracostomies were performed by emergency physicians and were performed by thoracic surgeons. the average duration of tube placement was . days (± . ). there were not any tube-size related complications nor any patients who required additional tube insertion. case history, clinical findings: different stable hemodynamic cases with thoracoabdominal penetrating trauma and negative fast evaluation were enrolled in study. subsequent hemo/pneumothorax was managed initially by tube thoracostomy. investigation/results: hence laparoscopic investigation is an effective method for evaluation of diaphragmatic injuries in thoracoabdominal penetrating trauma, patients underwent diagnostic laparoscopy. in case , classic approach was done by open technique mm port insertion in sub umbilical. two mm ports inserted in lower abdomen at the level of midclavicular line. then mm port was added in subxiphoid area and by introducing zero-degree camera through it a better exposure was obtained. in case , mm sub umbilical port, mm port in subxiphoid and another mm working port at the level of umbilicus and right midclavicular line were applied. a -degree camera used. exposure, working space and exploration maneuvers were much easier to perform in compare with case . in case , port placement was identical to case but zerodegree camera was used. due to poor exposure, subxiphoid port was replaced by a mm one and used for camera insertion, then an acceptable exposure was obtained. in case , port placement of case was used by using -degree camera which resulted in a great exposure. diagnosis, therapy, progressions: patients tolerated the operation well and underwent appropriate management according to their intra operation findings; post-op courses passed without any complications. comments: in patients with suspicious diaphragmatic injury and according to available facilities in our centers, in unilateral injuries we suggest that a mm port in subxiphoid area can be used instead of contralateral midclavicular mm port. in bilateral injuries, if enough exposure doesn't achieve, a mm port in subxiphoid can be added. in absence of degree cameras, mm port use in subxiphoid can give surgeons better exposure. hemodynamic instability in patients with extremity injuries: motor vehicle accidents and shot wounds vs. explosions a. mahamid , i. ashkenazi hillel yaffe medical center, hadera, israel introduction: we previously reported that hemorrhagic instability (hs) was a complication of extremity injuries in as many as of of patients treated in one medical center following explosions. the objective of this study was to evaluate whether the prevalence of hs in patients with other high energetic injuries such as motor vehicle accidents and shot wounds (mva/sw) is different or not. material and methods: victims following mva/sw with extremity injuries and hs treated in one medical center during were identified with the aid of the national trauma registry and the center's blood bank. hs was defined as tachycardia (pulse [ /min) and/or hypotension (systolic pressure \ mmhg) in need of blood transfusions to reverse instability. patients in whom hs could be attributed to injuries other than the extremity injury were excluded. these were compared to patients treated following bomb explosions ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) conclusions: the proportion of patients in need of blood transfusion is much higher in patients whose extremity injury was caused by an explosion. the relative risk for hs is almost times higher in these patients. new technologies in soft tissue wound management limit reconstruction complexity and enhance recovery introduction: large soft tissue losses are associated with infection, increased morbidity and mortality, increased costs and poor outcome functionality. the purpose of this study was to evaluate the efficacy of a combination treatment of combined topclosure Ò tension relief system (trs) and administration of regulated oxygen and antibiotic irrigation negative pressure-assisted wound therapy (roi-npt) in the treatment of patients suffering from significant soft tissue loss. patients with open abdomen, large infected wounds, and extensive soft tissue loss treated with trs and roi-npt. results: full wound closure was achieved in [ patients treated without skin grafts or flaps. primary failure was successfully followed with secondary closure with the same system. the trs system allowed early postoperative physiotherapy with good to excellent functional results. limitations and complications will be discussed. . trs is a novel device for stretching, and securing wound closure, applying stress relaxation and mechanical creep for primary closure of large skin defects that otherwise would have required closure by skin grafts, flaps or tissue expanders. . irrigation may accelerate the evacuation of infectious material from the wound and may provide a novel method for antibiotic administration. . supplemental oxygen to the wound reverses reduced o levels in the wound's atmosphere inherent to the conventional negative pressure-assisted wound therapy restricting vacuum use in anaerobic contamination. moris topaz is the inventor and patent holder of the topclosure Ò and vcarea Ò . attendees' perceptions about tourniquet safety use aboard, easiness of application, and preference among four devices tested assessed. material and methods: the descriptive study design assessed employing a post-seminar survey, participants' perceptions of tourniquet safety use, application easiness, and preference among the four devices tested (cat, sam-xt, swat-t, and rats). the first two variables measured on a one-to-ten scale (being ten the easiest or safest, and one the least easy or least safe), while preference was measured by frequency count, with only one device to select as the preferred. frequencies and percentages for categorical variables and averages calculated and compared using the anova test (p \ . ). results: a total of sailors, ( %) females, and ( %) males, aged between and , participated in the workshop and completed the survey. the mean for the perception of safety regarding onboard usage was . . as for application easiness, cat and sam-xt ranked equally high ( . ), followed by swat ( . ) and rats ( . ), and the only statistical difference found was for rats (p \ . ). cat was reported as preferred by participants ( %), followed by sam-xt ( %), swat-t ( %), and rats ( %). conclusions: jse crewmembers (non-medical personnel) considered safe the use of tourniquets on board. of the four devices assessed, cat and sam-xt were regarded as equally easy to use and rats the least of all. cat was reported as preferred by almost three out of every four respondents. introduction: surge capacity is the ability to manage the increased influx of critically ill or injured patients during suddenly onset crisis, like a mass-casualty incident (mci) or disaster. during such an event all ordinary resources are activated and used in a systematic, structured and planned way. there are, however, situations where conventional healthcare means are insufficient and additional resources must be summoned. this study investigates the possibility of using community resources such as primary health care centers, nonmedical professionals and non-standardized facilities together with educational initiatives to increase surge capacity in a flexible manner. purpose: to investigate the possibility of an increased and flexible surge capacity during a crisis, disaster or mass casualty incident (mci) by examining the main components of surge capacity (sc) (staff, stuff, structure, and system) in the västragötaland region of sweden. method: this thesis uses a mixed methods research approach with an explanatory sequential design. a literature search was performed by using standard search engines utilizing relevant keywords, questionnaires and semistructured interviews were used for data collection from primary health care centers, dental and veterinary clinics, schools, hotels and sports facilities to determine capabilities, barriers, limitations and interest to be included in a flexible surge capacity system. results: preliminary findings indicate that there is interest, capacity and capability in the investigated municipalities to partake in a fscplan: primary healthcare centers can be toned up with drills and exercises, civilians can be educated in advanced first aid procedures (immediate responders) and focused leadership (scene management), schools, hotels and sports facilities can be prepared with advanced first aids kits and be used as alternative care facilities. these alternatives together represent the concept of flexible surge capacity. conclusion: flexible surge capacity can be a possible approach to create extra resources in disaster situations, mci's, or whenever supporting infrastructure is not intact. new educational initiatives, drills and exercises, laymen empowerment and organizational and legal changes might be needed to realize a flexible surge capacity. introduction: a hospital may need partial or total evacuation because of internal or external incidents, such as in natural disasters and or armed conflicts. an evacuation aims either to transport a large number of patients to other medical facilities or to prepare enough space to receive a large number of victims. despite many publications and reports on successful and unsuccessful evacuations, and lessons learned, there is still no standardized guide for such an evacuation, and many hospitals lack the proper preparedness. we aimed to analyze the preparedness of hospitals for a total evacuation by looking into some key parameters necessary for a successful performance. material and methods: a literature search was performed by using the standard search motors in the related fields, and by using relevant keywords. eleven questions were sent to representatives from euand non-eu countries. results: our findings indicate that there is neither a full preparedness nor a standard guideline for evacuation within the eu or other non-eu countries included in this study. some countries did not respond to our questions due to the lack of relevant guidelines, instructions, or time. conclusions: hospitals are exposed to internal and external incidents and require an adequate evacuation plan. there is a need for a multinational collaboration, specifically within the eu, to establish a standardized evacuation plan. references: nero c, Ö rtenwall p, khorram-manesh a. hospital evacuation; planning, assessment, performance and evaluation. j acute dis. ; ( ): - . introduction: the importance of and the need for medical management during any armed conflict is a fact. many medical achievements have been accomplished due to wars and armed conflicts. the world is, however, divided into countries with and without related military healthcare services. there is a need for joint structure with the civilian in the former, while in the latter the civilian healthcare is responsible for offering services to the military. this study aims to identify the needs of military healthcare system and military medicine as an independent specialty. material and methods: a literature search was performed by using the standard search motors in the related fields, and by using relevant keywords. relevant professionals were asked about the pros and cons of having established military healthcare. the data was collected and analyzed. results: although our findings indicate a need for military medicine/ healthcare as a professional specialty, the organizational divisions between military and civilian healthcare systems seems to be changing. the current security issues worldwide, the pattern of injuries and resource scarcity indicates a need for improved collaboration and maybe a fusion between these entities. conclusions: new security threats, modern technology, the pattern of medical injuries, and the lack of adequate surge capacity may indicate a very close collaboration between military and civilian healthcare systems. such a close collaboration may develop to fusion and a total defense healthcare system that can act both in peace and during conflicts. references: ringel js. the elasticity of demand for health care. a review of the literature and its application to the military health system. https://apps.dtic.mil/docs/citations/ada khorram-manesh, a. facilitators and constrainers of civilian-military collaboration: the swedish perspectives. eur j trauma emerg surg. . https://doi.org/ . /s - - - . alternative methods of mandibular comminuted fracture fixation in severe maxillofacial injured patients introduction: severe maxillofacial injuries refer to significant facial trauma with communitive bony fractures and soft tissue loss. they result in violent trauma as firearm injuries (wartimes injuries, terrorist attack, suicide attempt) and high velocity motor vehicle accidents. the initial management consist of fighting hemorrhage, fighting asphyxia, wounds debridement and suture, and fractures stabilization, especially mandibular fracture stabilization. our study aims to share thoughts on the alternative methods of comminuted mandibular fracture fixation within the context: kind of injury, multitrauma patients, mass-casualty situation, precarious situation or hostile environment. material and methods: based on our experience (clinical cases), on senior surgeons questioning and on medical literature data, we sought to identify, to evaluate and to compare the different available methods to stabilize comminuted mandibular fractures in severe facial injured patients. results: open reduction and stable internal fixation (using macro plate), external pin fixation and closed reduction with maxillomandibular fixation are the methods of treatment which are the most classically used and described. however, some methods using kirschner wires are reported: in cross extrafocal pinning ( fig. ) , external fixation and handmade splints. all these methods differ in their complexity of use, in their availability, and in their possibilities to treat one kind of mandibular fracture or another. conclusions: the stabilization method of comminuted mandibular fracture will be choose depending on material availability, on surgeon's abilities, on the time available (mass-casualty situation) and on the patient's overall condition. even if stabilization methods using wires are less commonly used, they appear to us to be useful in the initial management of the severe maxillofacial injured patient with comminuted mandibular fracture, especially in austere conditions. causes of combat casualties' death at medical treatment facilities (mtf) in modern conflicts: russian experience i. samokhvalov , v. badalov , k. golovko , t. suprun , v. chupriaev material and methods: data including mechanism of injury, physiologic and laboratory variables, staged surgical treatment and cause of death were obtained from the combat trauma registry of the kirov military medical academy war surgery department. the combat trauma registry includes russian wounded in military conflicts over the past decades, of them ( . %) dead of wounds (dow) at the mtf. results: . % of the total dow number died at the role ii field medical units, . % died at the forward military role iii hospitals, and . % died at the role iv hospitals. the causes of dow patients delivered to the mtf were nonsurvivable traumatic brain wound ( . %), life-threatening consequences of injuries-mainly massive blood loss due to external and internal bleeding and acute respiratory failure ( . %), as well as the late septic complications ( . %). terms of death depended on the cause of dow. so for nonsurvivable traumatic brain injuries, they amounted to . ± . days, for lifethreatening consequences of wounds- . ± . days, and in the development of complications- . ± . days. conclusions: there is a high mortality rate among the combat casualties delivered to mtf in modern asymmetric warfare ( . %). moreover, half of these patients ( . %) die at role ii field medical units mostly from nonsurvivable injuries and from acute irreversible blood loss that occurred at the prehospital stage. the main cause of hospital combat mortality is severe septic complications of combat trauma. in consideration of the present counterterrorism practices, prevention and initial treatment for primary blast injury by shock waves constitute a particularly urgent subject because blast injuries and gunshot wounds account for the majority of terrorism deaths. in japan, due to strict ethical standards in animal experiments, there is no appropriate animal model of blast injury. we established an original small animal model of blast injury using a laser-induced shock wave at the national defense medical college (ndmc). however, since the experiments were conducted using only small animals, such as mice and rats, it was necessary to establish a medium-sized animal model aimed to test the applicability in human patients in the long term. correspondingly, we established a blast tube, which was authorized globally as a shock wave-generating device that causes blast injury based on air pressure differences, in the ndmc research institute using the budget of advanced research on military medicine of japan in . this allowed us to conduct scientific studies on blast injury using mediumsized animals. in this presentation, we will introduce the structure and function of the blast tube installed in the ndmc and present some of the results of our research thus far. this research is financially unfortunately, even if hospital and their staff are an essential key for successful response to mcis, the plan are seldom well-known and, above all, exercises are quite neglected at local and national levels. due to mci rarity, simulation exercises are the only way to achieve proficiency in mci response. therefore, we tested an original mci training system (macsim Ò ) adapted to the pemaf of a large university hospital in milan (italy). material and methods: the original mci training format called macsim-pemaf (emergency plan for massive influx of casualties)was developed for the italian society for trauma and emergency surgery (sicut) in . it uses macsim Ò , a simulation tool scientifically validated for training and assessment of healthcare professionals in mci management. between and the course was held for the emergency department staff of a single university hospital of milan (italy) (foundation cà granda-ospedale maggiore policlinico). macsim Ò was used to reproduce the hospital resources, with different mci scenarios. during the simulation the participants had the opportunity to test the local pemaf, in adjunct to their knowledge and skills. course effectiveness was evaluated by a pre-and post-course self-assessment questionnaire. results: macsim-pemaf was tested in seven courses, for a total of participants. pre-and post-test questionnaires showed a significant improvement in hospital staff self-perception of knowledge and skills in mci management. on a - scale, the improvement value was from . ± . to . ± . (p \ . ). conclusions: macsim-pemaf is a useful tool to test single hospital pemaf. it is versatile enough to adapt to specific realties, mimicking different traumatic scenarios. participants, acting in their usual professional roles, can increase their self-perception to be able to respond to a mci with in-hospital resources. introduction: emt are field health facilities, specifically structured to operate in case of disaster, where local healthcare resources are insufficient. there are types of emt. ''emt regione piemonte'' is the first italian emt to be certificated by who. it's a type , meaning that more than triage and stabilization of emergency cases it's provided with an icu, a / working operation room, a test lab, radiological and ultrasound devices. it can admit up to inpatients. cyclone idai made landfall on / / in the district of dondo in mozambique. it brought torrential rains and strong winds and had heavy impacts on the city of beira and surrounding areas resulting in loss of communication and access. in addition important damage and destruction to shelter, settlements, health and wash facilities occurred. on / italian government approved the aid mission, from march st to th three italian military aircraft transported the medical staff and the boxes containing the hospital to maputo and then in beira. on / , the hospital began working, treating an average of patients and performing - surgeries per day, involving mozambican staff who immediately well integrated with the italian colleagues. results: days of activities. surgeries ( orthopaedic, general surgery, gynaecology, plastic surgery). . % of the cases related to cyclone. mean tiss: ( - ). mean age ( - ) females, males. types of anaesthesia: % locoregional, % general, % analgosedation. conclusions: our first experience in a mass casualties' scenario showed how important is to refresh team skills through periodic drills. the leadership is of paramount importance to keep the team united and to support collaboration with other nations' teams and with the local population. adaptability and open-mindedness are fundamental. emts do not arrive in loco immediately so that longer periods of mission and integration with local medical staffs should be programmed. introduction: in utrecht, the netherlands, a worldwide unique major incident hospital is continuously standby to receive multiple victims during mass casualty events. each year, different types of mass casualty events are simulated with a varying number of victims, to train command and control under extreme circumstances. in utrecht, on march th , a terrorist opened gunshot fire in crowded public transport. the aim of the study is to compare our experiences in simulation versus reality. material and methods: an internal evaluation was performed by questionnaires completed by participants and an external evaluation was performed by interviews. results: all five victims were brought to the major incident hospital, of whom two were dead on arrival, one died seven days after due to multiple organ failure and two survived after multiple surgical procedures. all victims arrived within min after the major incident hospital was activated. a sufficient number of medical staff was alarmed for these five victims, however, since the event occurred during office hours, at least a double amount of staff showed up. among some medical staff on commanding key positions fear arose about their own safety and of relatives outside the hospital. this was exaggerated by incomplete and incorrect provided information from the scene. although medical care of the victims was not affected at all, occasionally the anxiety negatively influenced the command and control structure. conclusions: the combination of anxiety and a surplus of awaiting and benevolent curious medical staff resulted in occasional insufficient performance of the existing command and control structure, despite proper training. however, simulation of fear in a training is very difficult. nowadays, with the increasing threat of terror attacks, one should be aware of the influence of fear and anxiety on personnel, even with low numbers of victims. ethic and law issues during mass casualties management operations in foreign countries introduction: mass casualties incidents occur even more frequently during the last years globally. international help in order to manage them, when needed and asked, has to take into consideration special aspects of ethics and local law status in order to successfully fulfill its expectation. purpose: to demonstrate the ethic and law issues that arise during mass casualties management operations in foreign countries. material and method: literature review from recent management operations in syria, iran and sub saharan africa. results: during such operations a lot of ethical and law issues arise. the knowledge of ethics and laws in the country that these take place is essential and critical for the successful result of them. special care must be taken for the management of women, children and dead people. traditions and religion status of the local populations also must be taken into consideration and actions must take place in accordance to respect of the local authorities and social conditions. conclusions: mass casualties management operations in foreign countries is a challenging mission. ethic and law issues arise and must be taken into consideration for the success of the mission. western surgical experience is one thing, but surgical practice in countries in conflict zones is another. the pathologies are different, the thermal conditions are often difficult and the follow-up of the patients is fundamentally modified. humanitarian surgery is becoming more professional and most organizations are setting up a training program for new surgeons embarking on the humanitarian adventure. international committee of the red cross (icrc) has implemented an onboarding-surgeon experience, before to become a fully icrc surgeon. i hereby present my personal onboarding experience in south sudan: how to learn a new type of surgery, how to come with an helicopter to collect patients in the bush and then, how much you learn about yourself. conflict of interest: i only represent my own experience and i do not represent icrc. surgical clinical reasoning during the war in the period between and , i was the head of operating rooms and icu at the clinic for orthopedic surgery and traumatology, in sarajevo. working in the operating room whose walls are shaking because of the sniping and shelling was not remembered by any other generation of surgeons. there were around traumatized citizens of sarajevo. thousands of injured, dying patients were seeking for help from a small number of surgeons. the duty of a surgeon working in the war conditions, without water, electricity, medicines, or heat, is not easy at all, and there were a lot of difficult situations. for example, one day, operated children were again wounded by direct shelling on the walls of pediatric department of our clinic. after we re-operated the children, we also operated the injured nurses. th may, , th february, , and th august, were the most painful experiences in the surgical treatment of disaster in the center of sarajevo, with a large number of massively traumatized patients. while you were helping one casualty, others were pulling our arms or legs. while you were helping one patient, others were dying in the cramp of pain. during the war, a series of traumatic events happened. above many thousands of them, i admitted a -year-old girl, severely injured, with traumatic lower leg amputation of the leg, and severe injuries of the thigh, pelvis, and neck. we operated on her through the night. during the surgery, she received whole blood transfusions. following the surgery, she was stabilized on pediatric department of our clinic. one day, i saw her mother brought her a gift, immensely valuable in those days, a small canister of pure water. in the , one girl approached me, and asked me if i remembered her. i remembered the canister of pure water. she was happy to show me how she can walk now, and told me she lives in canada and works as a university assistant. i was more than happy to see her walk proudly, as she was leaving. she injury pattern of earthquake in athens, greece: the panic-effect introduction: earthquakes are devastating events. greece is known to be in the first place of seismicity in europe and sixth worldwide. lately, a . richter earthquake shook the greek capital, and fortunately no substantial construction damage was sustained. the aim of the study is to evaluate the classification and severity of all injuries, as well as the type of orthopedic surgical procedures performed, in addition to the role that panic plays on the occurrence of these kind of trauma material and methods: prospective case-series study, conducted in the emergency department of our hospital after the july th, earthquake. the study included patients treated by our department, who sustained injuries in their attempt to run away from the scene. age range was from to years old (mean . y.o), were female and were male. results: a total of injuries reviewed. upper extremities were involved in of all cases, lower extremities in and one patient suffered minor head trauma. four patients required hospitalization and all of them underwent surgical treatment. open reduction and internal fixation performed in patients ( calcaneus fracture and olecranon fracture), patient underwent intramedullary nail fixation (tibial shaft fracture) and external fixation was applied to another (distal tibia fracture). six patients were conclusions: panic is an independent contributing factor in natural disaster associated trauma. prior education, preparedness and combined team effort are clearly needed, in order to reduce the incidence of these injuries. regardless of age, panic may result in various types of fractures, even in cases there are no substantial construction damages after an earthquake. digital and analogue record system for mass casualty incidences at sea: results, reliability and validity introduction: mistriage may have serious consequences for patients in mass causality incidences (mci) at sea. therefore, an exercise was conducted to compare the reliability and validity of an analogue and tablet based recording system for triage of sample patients. material and methods: volunteers were asked to triage with the start-algorithm (black, red, yellow and green) patients in a given time using an analogue and tablet based system. triage score distribution and agreement between the two triage methods and a predefined standard were reported. the present study assessed the triage results as well as the reliability through cronbachs alpha and kappa. for testing of validity and internal consistency, the sensitivity, specificity and predictive value was measured. results: forty-eight participants completed a total of triages. while the number of triaged patients in the given time was significantly higher with the analogue system compared to the digital system (p-value . , t-test), the validity measured with the cronbachs alpha and unweighted cohens kappa was higher with the digital system. for each triage category, higher values were gained with the digital system. the sensitivity, specificity and predictive value for the digital system was higher than for the analogue system. conclusions: this study gives reliable and valid results comparing a digital versus an analogue triage system for a mci at sea. significant differences could be found for the number of triages and the number of under triage. the results of the study show that the used digital system has a slightly higher reliability and validity than the analogue triage system. references: the present work is part of the project improved emergency treatment and organization in the event of a mass casualty of casualties at sea (venomas), planned within the framework of the research network ''kompetenz und organisation für den massenanfall von patienten in der seeschifffahrt'' (kompass) and funded by the federal ministry of education and research (grant number: n ). predicting outcome for extremity wounds in pediatric casualties of war introduction: during the early s, the international committee of the red cross (icrc) implemented the red cross wound classification (rcwc) for penetrating wounds. wound grades of , and describe the amount of kinetic energy transferred to the tissue (low, high and massive, respectively). currently, this classification system mostly serves as a descriptive tool, but it is hypothesized it could also support clinical decision making. the aim of this study is to assess whether the wound grade of a pediatric patient's extremity wound correlates with patient outcomes. material and methods: this study included pediatric patients (age \ years), who have been treated by the icrc for conflictrelated extremity injuries between and . the correlation of the following variables with the wound grade were analyzed: number of surgeries required, length of stay, and in-hospital mortality. results: the study cohort consisted of pediatric patients. the higher the wound grade, the more surgeries were performed per patient (p \ . ), with a mean of surgeries per patient if they had a wound grading of . there were no significant differences in mortality rates between any of the wound grades, which were . % ( / ), . % ( / ) and . % ( / ) for wound grade , and respectively. pediatric patients with wound grade were hospitalized for the longest period (mean . days), followed by wound grade (mean . days) and wound grade (mean . days; all with p \ . ). conclusions: the wound grade of pediatric patients' extremity wounds appears to correlate with some patient outcomes, but not with mortality. grading of extremity wounds according to the rcws could support clinical decision making in pediatric patients. introduction: during the last few decades, french armed forces have regularly deployed in asymmetric conflicts. surgical support for casualties of these conflicts occurs in nato role and medical treatment facilities (mtf); definitive surgical care occurs in france following a strategic medical evacuation. the aim of this study was to describe the combat injury profile of these soldiers who presented with either non-exclusively orthopedic and/or non-exclusively brain injuries. material and methods: this descriptive study is a retrospective analysis of the surgical management of french casualties performed in role or mtf in afghanistan, mali, niger, djibouti and the central african republic between january and december . results: one hundred patients were included. forty had fragment wounds. the most severe lesions were of the head, neck or thorax. the average injury severity score (iss) was . (ic % . - ). damage control procedures were performed. thirty patients died with a mean iss of (ic % - ); deaths were considered as preventable deaths. the most frequent surgical procedures in the mtf were digestive (n = ) and thoracic surgery (n = ). thirty patients needed second-look surgery in france; eleven had severe complications. no patient died following medical evacuation to france. conclusions: results from this study indicate that the mortality following non-exclusively brain or orthopedic injuries remains high in modern asymmetric conflicts. introduction: telemedicine has been applied to disasters and extreme environments for more than years, however, despite the many lessons learned so far, telemedicine is still not a common part of the immediate disaster response. for this reason, a review of the literature was conducted to investigate whether telemedicine technology can be used to address medical and non-medical needs in extreme environments. material and methods: this systematic review included studies published in the period - , originating from literature search bases medline, scopus, cinahl and pubmed. the case of neemo project were studied so to evaluate the diagnostical and surgical care of the patients regarding the emergency response in a remote and constricted area, with limited human medical resources and using the telecommunications and telerobotic technologies. results: the majority of the included studies have highlighted the importance of telemedicine interventions in extreme environments, stressing that it is a viable solution to health care provision. in addition, it has been found that telemedicinal technology provides the possibility of virtual collaboration between healthcare professionals with various specializations. projects neemo , , engaged to eliminate the challenges of telesurgery. conclusions: future studies such as large multicentre randomized trials will have to be conducted that will lead to safe conclusions on the usefulness and efficiency of telemedicine applications in extreme environments. introduction: tourniquets are a critical tool in the immediate response to life-threatening extremity hemorrhage. the optimal tourniquet type and effectiveness of non-commercial devices is unclear, and the aim of this study. material and methods: this prospective observational cadaverbased study was performed using a perfused cadaver model with a standardized superficial femoral artery injury bleeding at ml/ min. five devices were tested: cat (combat application tourniquet), rats (rapid application tourniquet system), swat-t (stretch, wrap, and tuck tourniquet), a triangle bandage and a stick and a leather belt. volunteer medical students with no prior clinical tourniquet experience participated. each student underwent a practical hands-on demonstration of each of the tourniquets, prior to the test. using a random number generator, they then placed all tourniquets in random order. outcomes measures included time to hemostasis, total time to secure devices, estimated blood loss (ebl) and difficulty rating. a one-way anova repeated measures was used to compare efficacy between the tourniquets in achieving the outcomes. results: participants' mean age was ± . years and ( %) were male. all participants were able to stop the bleeding with of the tourniquets. with the rats there was a % failure rate. among the five types of tourniquets, time to hemostasis and ebl were not statistically significantly different (p [ . ). the swat-t required the longest time to be secured ( . ± . ), while the belt was the fastest ( . ± . ; p \ . ). conclusions: all five tourniquets, including the non-commercial devices, were effective in achieving hemostasis. a standard leather belt was the fastest to place and able to stop the bleeding. however, it required continuous pressure to maintain hemostasis. nevertheless, in an emergency setting where commercial devices are not available, improvised tourniquets may be an affective lifesaving bridge to definitive care. hospital preparedness for mass gathering events and mass casualty incidents in matera, european capital of culture for introduction: mass casualty incidents (mci) may occur during mass gathering events (mge). lack of preparedness of health system increases mortality. education and training are crucial. hospital mci plans are mandatory in italy, but they are poorly known. on , matera was declared italian host of european capital of culture for : the local hospital decided to revise the hospital plan for massive influx of injured (pemaf) and to start a program to train the staff. material and methods: the pemaf was reviewed through simulations that involved all the staff. a partnership with mrmi-italia (italian chapter of the international association medical response to major incident and disaster-mrmi&d) leaded to the support of experts and to the organization of residential courses based on the macsim Ò (mass casualty simulation) simulation tool. educational capacity of the residential events was tested through a self-assessment tool. results: alert, coordination and command sequences were defined. all the available resources were recorded and the functional areas identified. the communication network was improved. documentation and registration system was prepared. standard operational procedures (action cards) were created for the key positions. residential educational events of macsim-pemaf were organized. the educational capacity was tested through self-evaluation: knowledge of participants resulted improved. conclusions: mge are a great opportunity for the hosting community but they also represent an increased risk of mci. preparedness is mandatory for health system. the format macsim-pemaf seems to be adequate to review the existing plans and transfer skills to attendants. introduction: the cruise industry is facing a constantly growth of infectious diseases. some of them are reaching the extent of mass casualty incidences (mci), which are overwhelming the capacity of the local rescue system. our aim was to improve the ability to act in a mci due to an infectious emergency regarding the situation at sea/in the port. hamburg, as one of the largest ports in europe, was chosen for analysis. material and methods: the collaborative project ''adaptive resilience management in the port'' (armihn) is funded by the german federal ministry of education and research. scenarios due to an infectiological emergency were developed together with the university central department of occupational medicine and maritime medicine and the hamburg port health center in hamburg, germany. these scenarios were specified with all key stakeholders in the port. the organizational structure of the current emergency management was analyzed and a new concept was developed. results: for the ship and the port, emergency strategies dealing with mass casualties of injured persons are available. nevertheless, current concepts regarding this special situation of an infectiological mci were missing. we developed a new concept, which based on the models concerning mass casualties of injured persons. for this purpose, emergency surgeons can be recommended as experts regarding coping with a major emergency and for developing adaptive training concepts. conclusions: new operational concepts coping with mci of infectious patients were developed. in a second step, an emergency plan and a training concept for relevant stakeholders in the port will be developed. these will be evaluated in a full exercise in the port of hamburg and tested for their suitability. the results will be transferred to comparable infrastructures to cope with a major case incident with infected people in the port area. emergency surgeons should be involved in these steps due to their expertise. the work was funded by the german federal ministry of education and research ( n ). no further significant relationships. war surgery training, the use of swine model in military simulation center introduction: due to the international instability, our forces are deployed in many place and our military surgeons have to deal with ballistics trauma and improvised explosive devices related trauma. in order to be well prepared and effective in these isolated situation, the val de grace school (our military health service academy) provide a years course to train the young surgeon. this year surgical courses ended with war trauma surgery simulation on a swine model. material and methods: this use of the swine alive model is incorporated in the cesimco (military surgical simulation center) and also use for the training of our fully registered surgical team. this laboratory responds to all civilian authorizations and ethical considerations as enacted by european rules (felasa). results: the aim of this presentation is to show the different procedures and the teaching provided in this structure to improve surgical skills in war condition. all procedures are approved by the ministry in charge of the animal experimentation and respond to the animal welfare regulation. the number of swine used in these teaching is reduced to the minimum. we think that this animal model and its use in military forward surgical facilities, is the end point of the years military surgical course provided by the val de grace school. conclusions: this model is actually the most reliable and ethically acceptable teaching procedure we've found. during these teaching the students have to deal with open trauma and hemorrhagic lesions in damage control situation. we try to follow the different type of war related lesions observed in french military in order to stick to the reality of the field. this teaching is now mandatory before being deployed as a military surgeon on field. case history: -year-old male, previously healthy, admitted to the er due to shotgun injury to the right hip. during transport, the bleeding open wound was covered, two iv catheters were introduced, and saline and painkillers were administered. on admission, the patient was conscious, eupneic and normotensive, with a gcs score of . clinical findings: after the primary survey and exclusion of cranial, thoracic and abdominal lesions, the limb injury was addressed, showing a cm oval-shaped wound. the right leg was shortened and externally rotated. pulses were present but the patient referred calf and foot hypoesthesia. investigation/results: x-rays showed a comminuted pertrochanteric fracture and the presence of metallic foreign bodies. diagnosis: open right pertrochanteric fracture. therapy and progressions: initially, the wound was covered, and iv antibiotics and supportive therapy were given. in the or, irrigation, surgical debridement, and foreign body removal were performed, followed by orif with one dall-miles cable and a cephalomedullary femoral long nail. after surgery, the patient maintained lower limb hypoesthesia and had plantar flexion and foot dorsiflexion grade motor deficit. during follow-up, soft tissues recovered uneventfully and bone healing successfully occurred. full weight-bearing was tolerated at weeks post-op but the neurological deficits persisted despite physiatric treatment. electromyography confirmed severe partial lesion of the sciatic nerve. comments: generally, clean wound, fracture stability, restoration of circulation and skin closure of neurovascular structures are a priority and should be a reason for delayed nerve repair. introduction: despite mass casualty incidents (mci) are becoming a common concern, particularly regarding the care of paediatric victims, pure paediatric trauma centres (ptc) are still rare in europe. the purpose of this study is to assess the capacity of the hospitals in the metropolitan area of milan in case of mci involving the paediatric population, with focus on the pre-impact planning phase. material and methods: relevant literature and existing guidelines were reviewed by the representatives of four referral centres for the management of either trauma or paediatric patients. minimum standard requirements of care of paediatric trauma and consequently the maximal surge capacities for each hospital were defined based on the severity of injuries and personnel/equipment availability. results: overall, the four hospitals are able to treat patients with the highest priority (t ), to patients with intermediate priority (t ), and patients with deferrable priority (t ). severely injured patients \ years old should be preferentially transported to the hospitals with paediatric expertise, whereas patients between to years of age can be managed in multi-speciality structures. conclusions: in case of mci it is not always possible to rely on the availability of a ptc. hospitals with paediatric trauma care expertise can work in synergy with ptcs, or offer an alternative if there is no ptc, and should therefore be included in disaster plans for mci involving paediatric victims. case history: we present a case of a -year-old male with a proximal radius and ulna gunshot fracture associated with a complete lesion of the brachial artery, which was urgently repaired by grafting in his native country. a partial proximal radius excision was also performed. three months later, after soft tissue recovery, the ulna fracture was fixed with a dcp plate plus iliac crest bone graft. at months follow up x-rays showed hardware loosening, so the plate was removed and an external fixator was implanted. in this situation the patient attended to our clinic months after the initial injury. clinical findings: findings included proximal pin purulence, an elbow varus deformity and a limited joint motion: flexion °, extension °, supination/pronation °. investigation/results: x-rays and ct scan showed proximal ulna pseudoarthrosis. diagnosis: proximal ulna pseudoarthrosis after a gunshot fracture. therapy and progressions: a two-stage procedure was performed. initially we performed a wide debridement and external fixator removal. an ulna nail combined with gentamicin and vancomycin pmma spacer was implanted. s. aureus was identified in intraoperative cultures. in a second stage, year after, the nail and spacer were removed and a vascularized fibula graft with saphenous loop was implanted and fixed with a va-lcp plate. the central band of the interosseous membrane was repaired with a prosthetic device. currently, the patient presents full flexion range, hyperextension of °, active pronation of °and supination of °. x-rays show graft consolidation. comments: gunshot fractures are complicated lesions with significant soft tissue damage and high risk of vascular and nervous injury. a thorough study and initial systematic approach is mandatory in order to avoid later complications. introduction: the purpose of our study was to independently analyze pediatric trauma data, especially that of preschool-aged children, including demographics, injury patterns, the associated mechanism of injury, and outcomes, at a single institution in korea to gain a better understanding of current trends in non-regional trauma centers. material and methods: we conducted a retrospective review of preschool-aged children with trauma, who presented to the emergency department a single center between march and december . results: overall, there were pediatric patients who experienced trauma admitted during this study period. the frequency of admissions was similarly high in all seasons except winter. falls were the most common mechanism of injury at all ages, except , , and years of age, according to comparative analysis by age and mechanism. the most common place of trauma at - years of age was at home, and outside the home at the age of years or older. the most common injury region was to an extremity ( . %). mean injury severity score was ± . , and the mean hospital stay was . ± . days. conclusions: although mortality from trauma is low in pediatric patients, we must continue to improve treatment outcomes for children. it is unlikely for a hospital to have a pediatric trauma specialist, such as a pediatric orthopedic surgeon or plastic surgeon, due to manpower constraints. in order to further improve the outcome of treatment with insufficient resources, it is necessary to recognize agespecific characteristics. question: the new safety situation in europe and the lessons learnt civilian events of damage show that hospitals have to be prepared for mass casualties. the shift of the operational mode to ''emergency medicine'' have to be planed and practiced. the reporting tool for this is the hospital action plan (hap) that every hospital should have. the efficiency of the existing plan is already proven in different largescale exercises. in germany the legislator obligates the hospitals to enable there staff to properly perform the different tasks of the hap. in addition, the have to develop and evaluate proper training and exercises. goal of this study was to establish along the hap of a level one trauma center an modular mass casualty training (manv ) that would help to analyze the tasks to face and to deepen the existing structures of communication. method: we set a scenario with casualties and evolved the different shifting phases of the trauma center (alarming-, mobilization-, constitution phase). setting the concept of training outside the regular service period we took in account that there will be a lack of resources and material. we did not exercise in a large-scale but trained in small groups modular. we also did a screen adaption of the hap of the trauma center to have a mind set for the staff and a starting point to the scenario. to teach our operative procedure we simulated our '' columns concept'' (medical, personal and infrastructure) to the staff. specific to the different task groups (medical doctors, technicians, nurses) we exercised and the different sectors (er, triage, or, command etc.) and the necessary shifts of the different hospital sectors when a mass casualty occurs. before and after we did a query of the staff to see how much impact the modular exercise would have on the hap-knowledge of our staff. results: we were able to simulate realistically an identical mass casualty scenario to different staff groups of our hospital. knowledge about the hap increased significant from to % after the trainings. % of the staff see a clear improvement of information about the hap. also, the specific shifting-phases and the enrolment of the plan to move in an ''emergency medicine mode'' understand % better. % of the staff fell now a much better preparedness than before. % think that through modular exercises and small group training the communication in between working groups improved. conclusion: we could manage to improve a significant increase of knowledge about the hap in our staff. all the small group modular training in the different sector can be easily but together in large-scale exercise and other teams like police, military or fire-department can easily be added. introduction: dstc course focusses on surgical skills for trauma care. it is designed to teach surgical techniques for the definitive treatment of severe trauma. currently, it has evolved into an international trauma team course. our objective was to assess faculty members' opinion regarding course content, educational methods, and incorporation of non-technical skills. material and methods: a descriptive study was designed using an anonymous online survey issued from may to august , . senior international faculties' opinion from countries assessed. the survey inquired views of courses content, duration, adequacy of hands-on practice, need for updates, and usefulness of incorporating non-technical skills to the course. results: from the surveys issued, were ( %) answered. the course content was valued as very satisfactory by %; % were very satisfied or satisfied with courses educational method. % considered the time devoted to lectures, case discussions, and skills lab very adequate or adequate. course duration ( days) was valued suitably by % of responders. the inclusion of non-technical skills was considered as very important by %, important %, of some importance %, of little importance by %, and unimportant by %. this result reflects the insufficient sense of significance, among some, of the importance of trauma team dynamics. course content updates were seen as convenient by % of the surveyed population, suggesting them at least every - years. conclusions: dstc international faculty response to the online survey tool was inadequate, receiving % of the targeted study population. of the assessed faculty, most were satisfied with course content, duration, and educational methods. the surveyed population lacked a uniform perception of the importance of incorporating nontechnical skills. introduction: dstc is an iatsic course emphasizing on teaching surgical skills for trauma care. in many countries, it is an essential course focused on the ''second hour'' beyond atls and teamwork. initially centered on the surgeon, it currently seems to be adopting a trauma team training (ttt) model, incorporating the anesthetist to the program (ds-datc). our objective was to review this changing trend in three countries: spain, portugal, and brazil. material and methods: a descriptive study was designed by faculty from the three countries examining course records and analyzing its evolution during the last five years. number and types of courses delivered in each country from to reported, and the proportion of dstc to ds-datc scrutinized. frequencies and percentages calculated for categorical variables and the proportion of course types also determined. results: during the -year studied period, dstc courses were issued: ( %) in spain, ( %) in brazil, and ( %) in portugal. a total of ( %) ds-datc courses in the three countries, and the percentage of total delivered in each country was as follows; spain ( %), portugal ( %) and brazil ( %). overall ds-datc to dstc ratio was : , detailed as follows: portugal : , spain : , and introduction: thailand is a disaster-prone country with a high dependency on tourism. it has been affected by both natural and manmade emergencies. the thai emergency healthcare system consists of emergency physicians working at hospitals and prehospital levels, emphasizing their essential role in emergency management of any incident. we aimed to investigate the thai emergency physicians' level of preparedness by using tabletop simulation exercises and three different scenarios. material and methods: using the lc (three level collaboration) method, two training sessions were arranged for over thai emergency physicians, who were divided into three groups of prehospital, hospital, and incident command staff. three scenarios of a terror attack and explosion, riot and shooting, and high building fire were discussed in the groups. results: our findings indicate that the initial shortcomings in command and control, communication, coordination, and the ability of situation assessment increased in all groups step by step and after each scenario. new perspectives and innovative measures were presented by participants, which improved the whole management on the final day. conclusions: tabletop simulation exercises increase the ability, knowledge, and attitude of thai emergency physicians in managing major incidents in strategic, tactical, and operative managerial levels, and should be included in their professional curriculum. introduction: non-operative management of traumatic injuries has led to decreased surgical exposure for trauma trainees [ ] . while simulation using cadavers may improve exposure to damage control techniques, tissue handling realism is variable depending on embalmment and perfusion techniques [ ] . objective: to evaluate the feasibility of perfused thiel cadaver use for trauma surgery simulation. material and methods: thiel cadavers were cannulated in the ascending aorta and right atrium to create a left-to-right perfusion system. a magnetic pump was used to achieve a pulsatile flow with a gelatin-based solution, aiming for a flow of l/min. peripheral circulation was improved with arteriovenous fistulas (carotid-jugular, femoro-femoral and brachio-brachial). a left common iliac vein injury was performed laparoscopically through the sigmoid mesentery. the surgical trainee was blinded to the initial injury and assisted by a staff surgeon. results: a trauma laparotomy was performed. the small bowel was eviscerated and all four quadrants were packed with gauze. a left, expanding zone iii hematoma was detected. the left sigmoid colon was mobilized to achieve proximal control of the left iliac vessels. the left common iliac vein was actively bleeding and ligated according to damage control principles. the left ureter was uninjured. the sigmoid mesentery was closed, without active bleeding. the remaining of the abdominal cavity was explored without other injuries. time from laparotomy to closure was min. tissue handling and circulation dynamics were highly realistic due to thiel embalmment and pulsatile perfusion. conclusions: pulse-perfused thiel cadavers represent a realistic simulation option for surgical trainees. widespread implementation may provide accurate simulation for lifesaving procedures rarely performed in an era of non-operative management of traumatic injury. a new concept of intra-operative performance monitoring and self-assessment in hepato-pancreato-biliary surgery and other surgical specialties s. kharchenko , , m. yanovsky colmar civil hospital, university of strasbourg, department of general surgery, colmar, france, hepato-biliary institute henri bismuth, paris, france, interceg, kharkiv, ukraine introduction: currently, the majority of learning curve studies for surgical interventions associated with simple chronometric estimation in a whole: from incision to closure. a selective approach for step-bystep time fixation of all hpb interventions (hepatectomy, others) or other surgical specialties can bring a new vision of correlation between intra-operative timing and the clinical outcome. material and methods: every operation can be divided into step items so standardized worldwide, for example, planned or urgent laparoscopic cholecystectomy e.g. incision to port placement, exposure, dissection to cholangiography, cholangiography, extraction, closure. results: the prototype named chronoi of infrastructure for automated monitoring (simulator of time tracking activities, web-service for request processing, database and knowledge base collection subsystems, learning curve representative and analytics software) is designed and to be implemented. individual self-assessment is available in a real-time fashion. the learning curve changes are shown per procedure. up to our knowledge, we can firstly in the world describe the surgeons, incl. in hpb, as speedy, standard or nonstandard depending on the surgeon's ''individual speed'' in operative performance. it's to be documented in their e-logbooks according to the current fellowship standards or practice re-certification. conclusion: the intra-operative monitoring and worldwide standardization give a new vision of the surgical practice in hpb surgery meaning an introduction of monitoring-based clinical outcomes (timing with morbi-mortality or other). only new trials will approve the role of the presented concept in hpb surgery as well as in general, emergency and trauma. introduction: the management of patients victims of war weapons and collective emergencies represents a major public health issue in france, but also abroad. terrorist events in recent years on the national territory have highlighted the need for training the population and caregivers in the management of these injuries. because of his experiment in the domain, the french military medical service (fmms) was requested to cooperate with the french prehospital teams in order to improve knowledge and teaching in this area. today, a continuing medical education, easily available and free access is needed in this area. material and methods: development of video podcasts (infographics) of a few minutes on the theme of management of patients victims of war weapons and collective emergencies. the working group ensures the production and quality of educational messages. production is provided by the communication establishment of defense. the broadcast is displayed on the channel you tube of the fmms. results: the title of the traum'cast podcast is the contraction of trauma and podcast. twelve episodes are scheduled on a -weeks rhythm. the podcast program is as follows: conclusion: fmms knowledge and experiment in managing patients victims of war weapons is unique. teaching can take various forms, theoretical, practical, academic, or through publications. traum'cast is a major innovation in the dissemination of this knowledge and each episode focuses on a specific skill. traum'cast will highlight the applicability of military medicine concepts in a civilian environment. traum'cast will be translated in an english version. project was supported by grants of french ministry of defense (innovation department). splenectomy in current surgical practice: a tricky and elusive procedure for the surgical resident? introduction: splenic rupture and oncologic resections are the most common indications for splenectomy, but technical expertise is progressively being taken over by non-operative and more conservative approaches. material and methods: retrospective review of all total splenectomies performed between february and january at an italian academic hospital, assessing demographics, diagnosis, operating surgeon, surgical approach, complication rate, postoperative critical care admission, and -day mortality. results: over years, consecutive splenectomies were performed by different surgeons, of whom surgical trainees, with unplanned (i.e. emergency/iatrogenic injury) and planned (i.e. benign/malignant disorders) procedures and an average of . and . procedures per year respectively. over the study period, only surgeons performed at least procedures and only performed at least procedures. laparoscopy was performed in . % of cases, predominantly during planned procedures, with an overall . % conversion rate mostly related to technical difficulties (i.e. spleen dimension, difficult vascular visualization). overall major postoperative complication rate (clavien-dindo c ) was . %, slightly higher in emergency procedures although not significantly different ( . % vs. . %, p = . ). reintervention rate was . %, due to hemorrhage in more than half of cases. overall -day mortality rate was . %, with elective -day mortality rate of . % (p = . ). conclusions: splenectomy may be required ever more rarely but potential risks are not irrelevant. competence for surgical trainees should be achieved elsewhere (e.g. simulated/cadaveric training case history: an year old femal patient underwent changing of the components of the tha because of aseptic loosening. due to circumstances the surgeon decided to implant a cemented femoral component. the procedure was without any significant abnormalities. the first postoperative radiograph was planned after recovery-as usual. the x-ray imaging showed a misplaced femoral component. therefore a ct-scan was performed additionally and the malposition of the cemented femoral component was confirmed. the patient had to undergo another surgery-removing of the cemented femoral component and implantation of a new well placed one. therapy and progressions: after prompt resuscitation, an emergency laparotomy was performed and an anastomotic leak was found, requiring re-do ileo-ileal anastomosis. postoperative course was complicated by intra-abdominal collection treated by antibiotics alone (clavien-dindo grade ). the patient was discharged on th pod. at pathological report, segmental absence of intestinal musculature (saim) was diagnosed. the revision of past specimens confirmed the same finding. comments: usually recognized in neonates/premature infants, saim is generally an incidental finding in adults [ ] , often undiagnosed and more frequently described in the colon [ ] . in such scenario, main differential diagnosis is ischemia. etiology is unclear and can be classified as either primary/congenital or secondary. the former is characterized by acute onset of symptoms, whereas in the latter a longer history of intestinal symptoms is usually present [ , ] . most authors agree upon a congenital pathogenesis. generally, saim is associated with hollow viscus perforation and treated with surgical resection. contrary to our experience, no recurrence of intestinal perforation has been reported [ ] virgen del rocío university hospital, general surgery, seville, spain, hospital regional de málaga, general surgery, málaga, spain, hospital de estella, general surgery, navarra, spain, hospital gregorio marañón, general surgery, madrid, spain, complejo hospitalario de jaen, general surgery, jaen, spain introduction: specific training in the management of trauma patients is essential for surgeons. training through courses in this area (atls, dstc, musec) directly impacts the care of these patients. the aim of this study is to know the specific training in trauma care of spanish surgeons. materials and methods: a national survey has been sent to all member surgeons of the spanish surgeons association. it has evaluated their degree of participation in emergency surgery acute care, and therefore the possibility of attending trauma patients, their participation in the initial care at their hospital, as well as their specific training in this area. results: the survey has been completed by surgeons from spanish regions, and most surgeons who responded were from catalonia and andalusia. ( . %) of those surveyed take calls for the ed. only ( . %) report having a hospital registry of trauma patients. . % of surgeons answer that in their hospital the general surgeon is not involved in the initial care of trauma patients. . % have taken the atls course, . % the dstc course, and . % the musec course (or another course on e-fast). despite this, . % consider the atls course should be mandatory during residency, and . % of those surveyed consider trauma care in their hospital as very bad or deficient. conclusions: according to this survey, specific training in trauma care is still deficient in spain and with many aspects that can be improved. only % of those surveyed have received specific training in definitive surgical management of severe trauma. despite this, a large percentage of surgeons take calls for the ed routinely, and face the challenge of managing these patients. exploring team leaders' decision-making challenges in civilian and military complex trauma introduction: in the nordic countries professionals may work in both civilian and military trauma care. timely and effective decisionmaking in complex trauma is essential in improving survival benefits. the mindset and management priorities differ among medical professionals, and correlate with different experience levels. trauma leaders are usually senior surgeons with extensive experience and well-developed decision-making skills. simulation training has been shown to be effective in practicing decision-making. the aim of this study is to explore the team leaders' decision-making challenges in complex trauma care and structure them with the activity theory framework (at). material and methods: video recordings at a trauma center in johannesburg and live observations of complex trauma training in gothenburg focusing on team leaders' decision-making challenges were analyzed and systemized using the at. results: the team leaders' activities were mapped onto the main elements of at ( fig. ) whereby the decision making challenges were classified into six categories (table ) . conclusions: the at framework may benefit and inform the design of educational interventions by structuring key issues of complex activities. introduction: trauma is one of the main causes of mortality worldwide and prevention stands out as one of the main ways to modify its incidence. a prime example of such initiatives is the prevent alcohol and risk-related trauma in youth program (p.a.r.t.y.). it aims to raise awareness of the population most at risk for trauma, young people from to years. the study objective was to evaluate the program impact on students' knowledge and behavior. material and methods: a quantitative, uncontrolled intervention cohort study was conducted through the responses of the p.a.r.t.y. in and . data collection occurred through the application of a questionnaire to participating and non-participating students of public schools in the city of campinas, after a few months of participation in the program. results: among answers, . % were male, . % between and years, and . % program participants. time between participation and answers was . (± . ) months. regarding the first conducts when facing traffic trauma, . % of those who participated chose the correct answer, against . % of those who did not. about the first care while the service does not arrive, . % of the first group answered correctly, compared to . % of the second. concerning about the service that should be called in the event of a trauma, . % of participants would call correctly against . % of non-participants. in questions related to traffic laws, . % of participants opted for the correct answer as to what should be done in the face of a running over, against . % of non-participants. conclusions: students who had participated in the program had a higher rate of correct answers, a few months after the event, compared with students who did not attend. thus, it is concluded that there is a impact over the time caused by it. introduction: currently, intraosseous (io) devices are necessary for the resuscitation of severe trauma patients. however, opportunities to learn io device insertion are limited for residents. the aim of this study was to conduct a simulation of io device insertion for residents and to evaluate its effectiveness. material and methods: in this simulation, residents inserted io needles into the sternum of pigs under general anesthesia with the instructor's guidance. comprehension tests and questionnaires about satisfaction level and self-efficacy were conducted before and after the simulation. the objective evaluation was the io access success rate, and the subjective evaluation was obtained from points on comprehension tests and questionnaires. results: thirty-six residents participated in this study. just one resident had successfully obtained io access clinically. success rate of establishing io access in the simulation was %. the rate of test completion was % and that of questionnaire with survey response was %. the comprehension test results improved from . ± . to . ± . (mean ± standard deviation, p = . ) out of points. the questionnaires concerning satisfaction level changed from . ± . to ± . (p \ . ) out of points. the questions specifically concerning self-efficacy dramatically increased from . ± . to . ± . (p \ . ) out of points after the simulation. conclusions: the simulation in this study improved the knowledge, satisfaction level, and self-efficacy of the residents for io access. the success rate of confirmation of io access in this study was %. this experience may positively affect their clinical performance in trauma care. case history: case . a -year-old white man presented to the ed complaining of intense abdominal pain and vomiting. he referred at least two previous episodes with associated fever which resolved spontaneously. case . a years old white man consulted at the ed for intense abdominal pain, nausea, anorexia and constipation for the last h. none history of abdominal surgery were registered. clinical findings: in both cases, the abdomen was distended without bowel sounds. investigation/results: case . abdomen xr: distended small bowel loops localized at the right side. ct scan: an encapsulated cluster of dilated small bowel loops into the ascending mesocolon. case . ct scan: an encapsulated nonrotated small bowel in the right side of transverse mesocolon and mesenteric vascular pedicle displaced. diagnosis: intestinal obstruction secondary right paraduodenal hernia therapy and progressions: emergency midline laparotomy that evidenced a rpdh which was reduced before closing the mesentery defect. the postoperative was uneventful. comments: paraduodenal hernias are a type of internal hernia and a rare cause of intestinal obstruction accounting for about . % of all hernias. right paraduodenal hernias are far less common than left ones. symptoms of paraduodenal hernias are nonspecific. preoperative diagnosis of pdh by imaging techniques is difficult. contrastenhanced ct scan is highly recommended as the most specific method of diagnosis for pdh. with the increased use and improved enhancement of ct scans, paraduodenal hernias currently can be diagnosed preoperatively. this advancement in diagnostics coupled with increasing experience and facility of general surgeons in using laparoscopic techniques has led to the initiation of laparoscopic repair of internal hernias. case history: a -year-old female patient who goes to the emergency department due to vomiting and abdominal pain. since the accident, the patient reported post-prandial discomfort and gastroesophageal reflux, as well as self-limited abdominal cramps. clinical findings: soft, depressible abdomen. bowel sounds on left hemithorax. investigation/results: cxr: right hemidiaphragm elevation. lab test: leukocytosis. thorax and abdomen ct: right anterior diaphragmatic hernia and passive atelectasis secondary to ascent of dilated small intestine and colon. diagnosis: intestinal obstruction secondary post trauma diaphragmatic hernia. therapy and progressions: emergency laparotomy due to symptoms compatible with intestinal obstruction secondary to incarcerated diaphragmatic hernia. it is right diaphragmatic chronic rupture chronic with omental incarceration, antrum, small bowel and ascending colon with reversible signs of suffering. chelotomy and content reduction, herniorrhaphy with loose spots with non-absorbable material are performed. endothoracic drainage is left removed at h. the postoperative course is uncomplicated. comments: trauma events should be considered in the diagnostic process to avoid delayed treatment. case history/clinical findings: we present a -year-old male patient with a history of large pelvic mass in the rectum-prostate space under study, since months. he were admitted into the emergency unit, days after the mass biopsy, with fever up to °c and rectorrhagia. the patient rapidly developed septic shock with hemodynamic instability and elevation of acute phase reactants. abdominal ct was performed: pelvic mass of . . cm, of heterogeneous content, with areas of blood density. we decided doing an emergency surgical exploration of this mass as the only suspected origin of infection. investigation/results: in the surgical exploration the mass was protruding on the anterior rectum wall. the mass was drainaged with an output of ml of purulent material mixed with clots and necrotic tissue. foley no. probe was placed inside the cavity. in the postoperative period, the patient showed significant hematochezia, so he was reoperated performing hemostasis and rectal tamponade. it was effective and a new foley catheter was replaced at h. when the purulent drain gave way, the catheter was removed and the patient evolved favorably. diagnosis: cytology analysis: mesenchymal type lesion, morphologically and immunophenotypically compatible with gist (gastrointestinal stromal tumor). ihq profile: cd , dog , c-kit positive. therapy and progressions/comments: the complications of gist are usually acute abdomen due to peritonitis secondary to perforation or hemorrhage. however, the formation of intratumoral abscesses is very inusual, although is described in the literature. emergency surgery is often necessary due to the significant affectation of the general condition of the patient and the difficulty of the diagnosis. fournier's gangrene (fg) is a surgical emergency defined by an obliterating endarteritis of the subcutaneous tissue arteries of infectious etiology, with progressive necrotizing fasciitis of the perineal, abdominal, thoracic or lower limbs, which can lead to multiorgan failure. a years old woman was admitted in our er presenting with a week worsening vulvar pain. clinical exam showed vulvar and mons venus erythema, without lesions, bp was / mmhg and she had a fever of . °c. blood work showed leukocytosis ( . /ll), neutrophilia ( . /ll) and crp of mg/ l. past medical history of obesity, right thp and total thyroidectomy. vulvar cellulitis was the initial diagnosis and empirical atb was implemented. on d , due to an evolution into septic shock and spread of an emphysematous inflammatory process to the right thigh and buttock, the diagnosis of fg was made. during emergent surgery we observed extensive fascial and tissue necrosis from the asis and suprapubic region to the proximal third of the right thigh and perineum. extensive necrosectomy, drainage of purulent exudate and transversostomy were performed. empirical second-line broad-spectrum atb was started. she underwent new necrosectomies and surgical debridements on po days and and needed icu stay for days. daily dressing changes were performed with povidone iodine and later with octenidine. microbiology sample showed polymicrobial infection with gram positive and negative organisms as well as anaerobes, thus confirming the diagnosis of fg type i of vulvar origin. after surgical and hd stabilization, the patient underwent plastic reconstructive surgery, with local flaps and partial skin graft. the postoperative period was uneventful and the outcome was great. introduction: appendicitis is not uncommon in the elderly but may often be mis-diagnosed [ ] . the aim of this study was to explore the specific traits and treatments of this group in a swedish context to better understand where to optimize the management. material and methods: all acute appendectomies registered in the southern general hospital registry between january and june constituted the cohort (n = ). patients were stratified into two groups; c and \ years of age. significances were computed with pearsons chi and anova. results: the older group made up % of the study population (n = ). the elderly population was female to a larger extent (or . , p \ . ), triaged higher in the emergency department (p \ . ) and had higher asa classifications (p \ . ). the elderly were also perceived as sicker at the time of decision for surgery, expressed as having higher priorities for surgery (p \ . ). no significant difference between the groups in time from arrival to decision for surgery was found, nor for the time from arrival to surgery. there was a higher rate of perforations in the elderly group ( . % vs . %, p \ . ), twice the length of hospital stay (p \ . ) but no significant differences in complication rates ( . vs . %, p = . ). twenty-eight day mortality rate was % in the younger group and . % in the older group (p \ . ). conclusions: this study shows that an elderly group of appendicitis patients are more frail and more acutely sick when presenting to the hospital. in spite of higher priority for surgery, the elderly experience longer hospitalization and higher mortality rate, but not more complications. the findings are consistent with antecedent research. introduction: existing evidence points towards the notion that patients undergoing emergency surgery receive a poorer consenting quality when compared to their elective counterparts. with , cholecystectomies in england a year, cholecystectomy is one of the most frequently performed procedures both in the emergency and elective settings. however, to date, no studies have explored the relationship between consenting quality and the setting of cholecystectomy. we aimed to measure the quality of informed consent (ic) for patients who underwent emergency vs elective cholecystectomy. material and methods: the final review included the analysis of ic forms completed between - . percentage proportions were calculated to demonstrate the degree of completeness of consenting against a total of components of information. binary regression was utilised for subgroup analysis. results: patients undergoing emergency surgery were more likely than elective patients to be warned of severe perioperative complications such as cardiac disorders ( . % vs . %, p = . ), fluid collection ( . % vs . %, p = . ), and infected bile spillage ( . % vs . %, p = . ). elective patients were more likely to be counselled about the risk of less serious side effects of cholecystectomy such as diarrhoea ( . % vs . %, p = . ). patients in asa - group were more likely to be counselled about the occurrence of pulmonary embolism. interestingly, patients were more likely to receive a patient information leaflet if they were females and under . conclusions: the results of this study demonstrate multiple inconsistencies in the level of disclosed information to patients undergoing cholecystectomy. the results suggest that the consenting physicians make assumptions regarding the information that the patient would like to receive based on patient demographics and clinical factors, highlighting the need for more consistent consenting procedures. acute calculous cholecystitis and the timing of cholecystectomy: advocating early surgery i. moutsos , r. lunevicius liverpool university hospitals nhs foundation trust, general surgery, liverpool, united kingdom introduction: cholecystectomy cures acute calculous cholecystitis (acc) in nearly all patients and, according to nice, augis, tokyo and wses guidelines, should be conducted at the earliest opportunity, within days of the diagnosis. the present audit aimed to measure whether the care of patients with acc meets the standards of best practice and to assess whether early cholecystectomy was a more beneficial and safer intervention as compared to delayed cholecystectomy. material and methods: a ''snapshot'' sample of patients operated on between / and / with an index admission diagnosis of acc was reviewed. the selected patients were divided into three subgroups according to the timing of their surgery: - (early), - , and[ days. the other measures used in this audit were the rates of conversion to open surgery, subtotal cholecystectomy (stc), perioperative complication-specific morbidity, secondary interventions, and admission to intensive therapy unit (itu). results: nine patients ( %) underwent early cholecystectomy-laparoscopic (n = ) or primary open (n = ); of the other patients-delayed laparoscopic cholecystectomy. the rates of stc were similar in both subgroups- . % ( / ) vs . % ( / ). delayed cholecystectomy was related to five side effects: higher rates of postoperative collections (three patients, . %), external bile leak (one patient, . %), ercp ( . %), emergency re-operations (two patients, . %), and admission to itu ( . %). they all occurred in the delayed [ weeks surgery subgroup of patients. conclusions: although no significant associations were found when comparing early to delayed cholecystectomy, this analysis shows that postoperative morbidity, the rates of secondary interventions and admissions to itu were higher when surgery was delayed. this audit advocates that early cholecystectomy should become a standard of practice as per national and international guidelines. esophagopericardial fistula following primary repair for chronic esophageal ulceration presenting with pericardial tamponade: a case report and outline of management and treatment case history: a -year-old man with chronic esophageal ulcerations presented with substernal pain, fever, and shortness of breath. a radiograph revealed a right pleural effusion and pneumomediastinum consistent with an esophageal perforation (fig. ). he underwent a right thoracotomy, primary esophageal repair with intercostal muscle flap buttress, and gastrojejunostomy feeding access. a post-procedural gastrograffin study demonstrated an anastomotic leak (fig. ) . a right thoracostomy drain was placed for diversion. the patient was discharged home and returned days later. clinical findings: he presented with substernal pain, hypotension, and fatigue. thoracic computed-tomography (ct) revealed a pneumopericardium and an esophagopericardial fistula (epf) manifesting as pericardial tamponade (fig. ) . diagnosis: epf. therapy and progressions: the patient underwent a subxiphoid pericardial window and mediastinal drain placement for decompression. an esophagogastroduodenoscopy revealed an exposed right atrium, thus precluding esophageal stenting. sepsis and antibioticassociated clostridium difficile colitis complicated his post-operative course. once resolved, the patient underwent a partial esophageal resection, epf ligation, and esophagogastrostomy. the postoperative gastrograffin study did not demonstrate an anastomotic stricture or leak. the patient tolerated a regular diet and was discharged home. comments: esophagopericardial fistula is a rare clinical entity most often caused by benign disease. prompt diagnosis and treatmentpericardial decompression and fistula ligation-is critical. due to wide use of proton pump inhibitors and development of interventional radiology (ir), causative reasons are changing. introduction: secondary peritonitis yields high morbidity and mortality rates. besides rapid source control, adequate antimicrobial therapy is essential to improve outcomes. thus initial empiric therapy has to take suspected germ spectrum as well as possible resistance rates into account. microbial selection and resistances may pose problems during prolonged administration of antibiotics. however, a possible negative effect of multi-resistant germs on mortality has not yet been clarified. the choice of a suitable antibiotic and the relevance of its efficacy on isolated germs as well as the relationship between germ spectrum and clinical condition of the patients need to be clarified. material and methods: intraabdominal swabs from consecutive patients from to requiring intensive care due to secondary peritonitis were evaluated retrospectively. patient characteristics and outcomes, germ spectrum and resistance rates were collected. changes over the course of therapy and development of resistance as well as influences on the clinical course were analyzed. introduction: complicated intra-abdominal infections (c-iai) represent challenging diseases with high mortality rates. depending on different selection criteria and therapy strategies the reported mortality rates vary between . and %. usually a distinction between community (cap) and hospital acquired peritonitis (hap) is made. hap can further be classified as postoperative peritonitis (pop) or non-postoperative peritonitis (hap-non-pop). we conducted a retrospective analysis of patients with c-iai requiring intensive care therapy. material and methods: all patients with c-iai requiring surgery and intensive care treated at the danube hospital in vienna from to were retrospectively analyzed. a total of patients where included into the study and grouped as cap, hap-non-pop or pop. for each group comorbidity and patient characteristics, source and cause of infection, hospital and icu stay, apache ii, saps ii and sofa-scores, mortality and outcome were calculated and compared to each other, using fisher exact test or mann-whitney-u-test. results: a total of c-iai were treated, consisting of . % cap, . % hap-non-pop and % pop. concerning the patient characteristics and comorbidities no significant differences were seen between the groups, except for malignant diseases which were significantly higher in pop. the postoperative (source control) apache ii and saps ii values did not differ between cap and pop (apache ii mean: cap . , pop . ) whereas both were significantly higher in hap-non-pop (apache ii mean: . ). mortality rates were not significantly different in cap and pop ( . % vs. . %): however, hap-non-pop was complicated by a nearly doubled death rate ( . %). conclusions: although patients with pop are described to have a higher mortality in the literature, this could not be shown in our study. postoperative survival was comparable between cap and pop patients. hap-non-pop demonstrated a significantly higher mortality. acute appendicitis and acute diverticulitis presenting concurrently treated surgically and conservatively clinical findings: on examination the abdomen was soft but there was tenderness and guarding in the right iliac fossa and suprapubic region. her observations were stable on admission and she was afebrile. investigation/results: laboratory tests demonstrated a wcc . ( /l) and crp of . (mg/l). urinalysis was normal. a ct of the abdomen and pelvis with intravenous contrast demonstrated acute appendicitis with non-perforated sigmoid diverticulitis (fig. , fig. ). diagnosis: concurrent acute appendicitis and non-perforated sigmoid diverticulitis. therapy and progressions: the patient underwent a laparoscopic appendicectomy. intraoperative findings included a retrocaecal inflamed appendix and diverticulitis in the pelvis which was not disturbed. there was no pus in the pelvis. she recovered well postoperatively and was discharged home to complete one week of oral antibiotics the following day. the histology demonstrated acute appendicitis. comments: there are very few reports in the literature of concurrent appendicitis and sigmoid diverticulitis despite these two pathologies being amongst the most common presentations of abdominal pain. this case demonstrates the value of cross sectional imaging, ct imaging is a helpful diagnostic tool and is highly sensitive and specific for both diverticulitis and appendicitis.the challenge in this case is balancing the two differing managements of these two conditions. most cases of diverticulitis are managed conservatively with dietary modification and antibiotics. operative management is only usually considered if there are associated complications such as intraabdominal perforation. this is in contrast to appendicitis where the standard treatment is to undergo surgery. references millions of people die from major trauma annually. - % of these deaths are due to exsanguination, with nearly half dying prior to hospital arrival. when properly managed, these deaths are preventable. this paper summarizes data relating to the extent of hemorrhage as a cause of mortality in the traumatic arena. an overview of the pathophysiological steps occurring during massive bleeding and their clinical implication is presented. a variety of treatment options, both historical and current, is then discussed, including vascular occlusion methods and hemostatic dressings, along with their limitations and complications. finally, woundclot, a new hemostatic gauze, is introduced, which not only requires no compression when it is applied, but allows the first responder to rapidly and effectively treat more than one casualty within seconds. additionally, it is adaptable to a wide array of clinical applications, both traumatic and surgical, including situations where vascular occlusion methods are not practical or are contraindicated. i am the clinical research administrator for core scientific creations treating acute colonic diverticulitis with extraluminal pericolic air; a multi-centre retrospective cohort study background: since the emergence of acute care surgery as an entity encompassing trauma and emergency general surgery there have been several studies evaluating patient outcomes noting a higher unexpected survivorship and expedited operative times, shorter hospital stays, and fewer complications for patients undergoing procedures such as appendectomy; however, these superior outcomes have not been demonstrated across the array of emergency surgical cases. the aim of this investigation is to determine whether patients operated on by acute care surgeons in a trauma center benefit from the trauma model of in-house availability, earlier availability of surgical care, and care dictated by evidence-based protocol. we examined our health care system's data to determine if trauma centers were to able to provide more timely care with improved outcomes, by focusing on truly emergent general surgery cases. this was examined by identifying and quantitatively comparing time to operative intervention, need for re-operation, hospital length of stay, duration of stay spent in intensive care unit, and patient disposition at time of discharge. methods: this is a retrospective cohort study. patients presenting with emergency general surgery conditions (incarcerated hernia, perforated viscus, sbo, necrotizing soft tissue infection) who underwent surgery within h of presentation were selected. outcomes were compared between patients presenting to our two trauma centers versus our two non-trauma centers. n = results: at this time we are nearing the finalization of our data interpretation. we are examining mean time to operation, los, icu los, need for re-operation, and disposition at discharge. discussion: although our data analysis is not complete we feel that the results of our data will shed valuable and needed light onto the care delivered to emergency general surgery patients by surgeons in this increasingly complex population. anastomosis leakage after hartmann removal, with conservative treatment at the beginning but after, bad evolution, a surgery was performed with colostomy and vac system. patient. after h, he develop a compartmental syndrome and a vac system was applied. investigation/results: patient. after the first change the distance between the two layers was cm and botulinum toxin was applied. pat. the distance between the two layers of abdomen was cm and botulinum toxin was applied. patient. the distance between the two layers was cms and toxin was applied. unfortunately, he suffered from a hepatorenal syndrome and died. diagnosis: open abdomen with distance between the two layers: cm, and cm. therapy and progressions: we have added botulism toxin with doses of units in each side of abdominal wall. patient. three changes after, the abdomen wall was closed. months later, the abdominal wall is ok. patient. a reduction of % was got. comments: the use of open abdomen in patients suffer from septic shock or after an abdominal compartment syndrome often poses a challenge in the abdomen closure. we have developed a protocol, dividing our patients according to the distance between the two layers in two group: more than cm or cm or less. in the first group ([ ), we present our first cases in our protocol. conclusions: botulinum toxin can make easier abdomen closure when the distance between the two layers is more than cms incidentally discovered splenic peliosis in a patient with no comorbidity clinical findings: a -year-old man with no comorbidities visited our emergency medical center based on a complaint of chest pain. the chest and abdomen radiographs, electrocardiogram, and cardiac markers showed no abnormalities; therefore, he was discharged from the hospital. two months later, he returned to our hospital with abdominal pain and distension. he was hemodynamically stable, and there were little tenderness and rebound tenderness on his abdomen, although he complained a slight abdomen discomfort investigation/results: no abnormalities were found on the laboratory examinations, including complete blood cell count, cardiac markers, and coagulation profile. an abdomen computed tomography revealed multiple hemorrhagic cysts on spleen with moderate amount of hemoperitoneum. diagnosis: ruptured splenic peliosis with hemoperitoneum. therapy and progressions: laparoscopic splenectomy was done because recurrent rupture of hemorrhagic cysts was strongly anticipated. on histologic examination, the blood-filled cysts were welldemarcated, distributed in red pulp congestion. no vascular-endothelial cells were observed, and normal lining cells were disappeared in the wall. comments: a peliosis is a rare disorder characterized by widespread, blood-filled cystic cavities within the parenchymatous organs. the liver is the most commonly involved organ, and an isolated splenic peliosis is extremely uncommon. patients are often asymptomatic; therefore, early recognition and withdrawal of offending agents is crucial. in cases with the rupture of surface lesions, which can occur spontaneously or by the minor trauma, prompt surgical management is necessarily required. splenectomy offers the advantage of a definite histological diagnosis with the complete elimination of the risk of recurrent hemorrhage. introduction: despite an evident success and advantages of endoscopic surgery, the discussion on reasonability of endoscopic surgeries in children with acute appendicitis is still going on. purpose: to assess the effectiveness of laparoscopic techniques for treating appendicular peritonitis in children. material and methods: children with appendicular peritonitis were operated in our hospital ( ) ( ) ( ) . they aged - years ( ± . ); . % of boys, . % of girls. appendicular peritonitis was registered in . % cases of acute appendicitis. three ports were used for the approach: appendectomy was performed by the ligature technique with roder loop. results: laparoscopic surgery is indicated in all forms of appendicular peritonitis, except appendicular abscess stage , and total abscessing peritonitis. in appendicular abscess stage , we perform a puncture and drainage under ultrasound control. - months later appendectomy is made. total abscessing peritonitis is an indication for laparotomy. laparoscopic surgery in patients with peritonitis has the following stages: diagnostic laparoscopy; sanation of the abdominal cavity by the aspiration of purulent exudate; ligature appendectomy; in diffuse and combined peritonitis a pelvic aspiration drainage is made. in appendicular abscess stage , we additionally put the aspiration drainage in the cavity of destructed abscess. conclusions: laparoscopic technique applied for surgeries in children with acute appendicitis has considerably improved outcomes introduction: nighttime emergency surgery is associated with increased postoperative morbidity and mortality [ ] , and delayed appendectomy due to acute appendicitis is not linked to a higher rate of postoperative complications (pc) [ ] . the aim of this study was to determine whether appendectomy on-call (oc) was associated with higher risk of pc. ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . two patients underwent major thigh amputation. negative pressure wound therapy and hyperbaric oxygen therapy were used in and patients, respectively. three patients died (mortality rate = %). conclusions: the mortality and major amputation rates ( % and %, respectively) were lower than those reported previously. in this study, even when patients had multiple organ failure or septic shock, major amputation was not always needed because of effective communication between the infection control team and intensive care specialists, resulting in radical debridement without amputation. material and methods: a systematic search in pubmed/medline, embase, cinahl and central was performed. the primary outcomes were mortality and amputation. these outcomes were related to the following time related variables ( ) time from onset symptoms to presentation; ( ) time from onset symptoms to surgery; ( ) time from presentation to surgery; ( ) duration of the initial surgical procedure. for the meta-analysis, effects were estimated using random-effects meta-analysis models. results: a total of studies ( patients) were included for qualitative analysis, of which patients died ( . %). a total of studies ( nsti patients) were included for the different quantitative analyses performed. mortality was significantly lower for patients with surgery within h after presentation compared to when treatment was delayed more than h (or . ; % ci . - . ). surgical treatment within h resulted in a % mortality rate compared to % when surgical treatment was delayed more than h. also, surgery within h reduced the mortality compared to surgery after h from presentation (or . ; % ci . - . ). patient delay (time from onset of symptoms to presentation or surgery) did not significantly affect the mortality in this study. none of the time related variables assessed reduced the amputation rate. conclusions: average mortality rates reported remained constant (around %) over the past years (fig. ) . surgical debridement as soon as possible lowers the mortality rate for nsti with almost %. thus, a sense of urgency is essential in the treatment of nsti. altemeiers procedure in an emergency setting case history: three patients with irreducible incarcerated rectal prolapsed were referred to our department for treatment. all patients were female and their age was , and years old. all patients suffered from severe co-morbidities. clinical findings: all patients presented with incarcerated rectal prolapse. in one patient there was macroscopic evidence of mucosal necrosis, whereas the other two patients had evidence of ischemia. the former patient was febrile whereas the latter did not exhibit signs or symptoms indicative of sepsis. investigation/results: blood panels demonstrated leukocytosis and elevated levels of c-reactive protein (crp) in all patients. apart from routine imaging upon admission (e.g. chest radiography), no other imaging modalities were performed. diagnosis: irreducible incarcerated rectal prolapse. therapy and progressions: initially manual reduction of the prolapsed was attempted without success. all patients were evaluated as high risk surgical candidates. altemeier's procedure was selected as a safer alternative to an abdominal approach. all patients were successfully discharged after resumption of bowel function. comments: incarcerated rectal prolapse is a rare clinical condition. initial management involves manual reduction of the prolapse. when this is not feasible, urgent surgical management is mandatory. in patients with severe co-morbidities, altemeir's procedure is a safe and effective treatment when performed by an experienced practitioner. introduction: treatment options for sigmoid volvulus are decided by its severity. uncomplicated cases are usually treated by endoscopic detorsion followed by elective surgery and complicated cases or cases can't be detorsioned are treated with emergency surgery. in this study we aim to review a single center experience in long term management of sigmoid volvulus cases. material and methods: data of the sigmoid volvulus cases between - were collected using hospital database. files of patients were reviewed for treatment modalities, demographic info and complications. patients were dropped from the study due to inadequate long term follow-up. results: were men and were women. mean age was , . endoscopic detorsion was attempted in cases. success rate was % (n = ). of these patients were followed up with elective surgery. patients with complicated cases and unsuccessful detorsion patients were managed by emergency surgery. hartman procedures, anterior resections, left hemicolectomies, subtotal colectomy and transverse loop colostomies were done. a stoma was created in cases. patients had their stoma created in the primary surgery and an additional of stomas were created due to anastomosis leakage. mortality rate in the first days was % (n = ) in patients with a stoma (n = ). asa and charlson co-morbidity scores were exceptionally high in the mortality group. in the remaining patient group, stoma closure rate was . %. conclusions: endoscopic detorsion is a powerful and highly successful management option in uncomplicated cases when done by an experienced staff. emergency surgery shouldn't be delayed in complicated cases or after unsuccessful detorsion attempts. introduction: esophageal perforation has high mortality rates when not treated aggressively. treatment options are conservative approach, endoscopic intervention and surgery. purpose of this study is to review cases of esophageal perforation in a single center and to evaluate types of diagnosis and treatment options. material and methods: using hospital database we collected data of patients diagnosed with esophageal perforation between - . we reviewed treatment modalities, demographic data and complications. patient was removed from the study due to insufficient long term data. results: were female and were male. average age was . . average time between the onset of symptoms and admission was . days. the most common etiology was iatrogenic (n = ) followed by consumption of corrosive substances in patients, spontaneous perforation in patients, esophageal tumour in patients and foreign body ingestion in patients. patients were treated surgically, patients were treated with endoscopic stenting and patient was treated with surgery following stenting. patients were managed conservatively with antibiotherapy. average time in intensive care was . days and average hospital stay was . days. mortality was seen in patients treated with surgery and patients treated with stents. conclusions: esophageal perforations are mainly iatrogenic but also can be caused by multiple reasons. especially in cases developed after endoscopy, rapid intervention can be a significant factor that can decrease both mortality and morbidity rates. introduction: spontaneous rupture of liver tumors (rlt) is a rare but potentially life-threatening condition. damage control techniques, namely perihepatic packing (php), is a resource for the most physiologically compromised patients, with more stable patients undergoing transarterial embolization (tae) or immediate resection. decision algorithm depends on patient status, available resources and liver function. the authors present their center experience in managing rlt and propose a management algorithm. material and methods: eighteen consecutive patients who underwent surgery for rlt in our department (january -october ). inclusion criteria: spontaneous rupture and evidence of intraperitoneal bleeding. fourteen patients were male. mean age of . years ( - ). thirteen patients ( %) presented in hemorrhagic shock. mean tumor size was . cm ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . most frequent pathological diagnosis were: hepatocellular carcinoma in cases ( %); adenoma in three cases ( %); metastases in two cases ( %); liver sarcoma in one case ( . %). median of seven units transfused by patient ( - ). statistical analyses with spss tm version . results: six patients ( %) needed immediate surgery (php in three and resection in three). five ( %) underwent urgent ([ h and \ h) and seven ( %) delayed ([ h) resection. hepatectomy was performed on all (fifteen minor and two major) but one patient php only. eight patients ( %) underwent tae prior to resection, two of them ( %) between php and hepatectomy. median length of stay days . major morbidity in three patients ( %); mortality in three patients ( %). number of transfused units associated with increased risk of complications (p = . ). conclusions: rupture of liver tumors is a severe complication. although hepatic resection, with or without preoperative tae, should be considered gold standard, damage control techniques such as php are the only option for physiologically compromised patients (fig. ) . seasonal variability of cellulitis: a five year retrospective cohort study introduction: it is commonly purported that the incidence of cellulitis is highly seasonal but there is little empirical evidence supporting this assertion. this year retrospective cohort study set out to identify whether there is a statistically significant relationship between an increase in temperature and incidences of cellulitis. as a corollary to this proposition, length of hospital stay for cellulitis was examined in relation to the level of inflammatory markers upon admission and micro-organism identified on culture. material and methods: this is a year retrospective single centre cohort study of all patients admitted with cellulitis to tallaght university hospital from to inclusive. the patient cohort was identified via the use of a prospectively managed database of all surgical admissions and corroborated via examination of clinical chart records. dates of admission were correlated with the average temperature of dublin as provided by the meteorological office of ireland. site of infection, inflammatory markers and the prevalent micro-organism were also identified whilst the length of admission was extrapolated from hipe (hospital inpatient enquiry) records. results: there were admissions for cellulitis with cases of necrotising fasciitis. there was a statistically significant (p \ . ) relationship between temperature and cellulitis with admission peaking in late summer/autumn. age correlated significantly with readmission. furthermore, the level of crp had a statistically significant prognostic value as an independent predictor for the length of hospital stay with a high level resulting in a prolonged admission. conclusions: there is a statistically significant relationship between a rise in temperature and the incidence of cellulitis. furthermore age is an independent risk factor for re-admission with same whilst inflammatory markers at time of admission can be used as a prognostic marker for length of stay. case history | clinical findings: a -year-old female patient, with history of type ii diabetes, high blood pressure and major depressive syndrome, was admitted in the emergency room department complaining of abdominal pain. based on the patient's history and physical examination, a presumptive diagnosis of renal colic was initially made. however, after days, the patient showed signs of fever, aggravated abdominal pain and vomiting. investigation/results | diagnosis | therapy and progressions: a ct scan showed the presence of a radiopaque foreign body near the duodenum, the presence of air bubbles outside the intestinal lumen and an hepatic abscess. we agreed to perform a laparoscopy, drainage of hepatic abscess and fish bone removal after successfully identification. after days, the laboratory findings showed persistent leukocytosis and raised cpr, which led to a second ct scan with maintenance of the hepatic abscess. the decision was to perform a percutaneous drainage. after the second drainage, the patient had an uneventful recovery. comments: foreign body ingestion into the gastrointestinal (gi) tract is rare and typically accidental in adults. most ingested foreign bodies pass through the gastrointestinal tract without the need for any intervention. gi perforation is rare and can occur at any site. surgical intervention is required in less than % of the cases. fish bones are the most commonly ingested objects. preoperative diagnosis, when possible, is made with ct scan, identifying a linear high-density structure. high level of suspicion is of paramount importance. in cases of delayed diagnosis, perforation may lead to intraperitoneal abscess formation. reports of hepatic abscess secondary to fish bone perforation has been limited to isolated case reports in the literature. case history: description of two cases of appendicular goblet cell carcinoid tumors, which debuted as acute appendicitis. patient a was a -year-old woman with a -h evolution of classic symptoms of acute appendicitis. patient b was a -year-old female that consulted for chronic abdominal pain in rlq that recently increased pain intensity and fever. clinical findings: patient a had pain and defense in rlq without a fever. patient b had a chronic painful fluctuating mass in rlq, with fever over °c. investigation/results: patient's a lab test showed leukocytosis and us findings of acute appendicitis. the patient's b ctscan showed an intra-abdominal abscess fistulized to the abdominal wall, along with formation of a phlegmonous mass related to appendicular plastron. diagnosis: the anatomopathological reports for both patients were informed as appendicular goblet cell carcinoid tumor. therapy and progressions: both underwent laparoscopic exploration. after appendicectomy in patient a, when the diagnosis of gcct was made, the case was discussed at our mdt meeting and a right hemicolectomy was indicated and performed shortly after. in the patient b a right hemicolectomy was performed in the initial surgery due to the magnitude of tissue involvement. currently, both are receiving chemotherapy with xelox without signs of recurrence or tumor spread on follow up. comments: the gcc is a rare entity of appendicular tumors with a less favorable prognosis than the appendicular pure neuroendocrine tumors. it behaves like a low-grade adenocarcinoma and often presents as disseminated disease. therefore, sometimes surgical treatment with appendicectomy is not enough, needing the right hemicolectomy to avoid recurrence. this is recommended for tumors [ cm, pt or t and higher grade histology. introduction: among the post-pancreatoduodenectomy complications post pancreatoduodenectomy hemorrhage (pph) is the least common complication, but severe form may be life-threatening without an urgent treatment. late pph are more likely due to a complex physio-pathological pathway secondary to different etiologies. the understanding of the etiology and such a pathway could therefore be of great interest to guide the treatment of potential lifethreatening late severe pph. results: during the aforementioned period patients underwent pd, of whom ( . %) developed pph. early pph was reported in one patient ( . %) with severe bleeding from the gastric stapler line. late pph were reported in of these patients ( . %). the most common causes were bleeding from a vascular pseudoaneurysm reported in patients of which, one had mild and had severe hemorrhage and bleeding from gastro-enteric anastomosis marginal ulcer in patients, all with mild hemorrhage. no etiology was fond in patients with mild hemorrhage. a significant association was found between the severity of late hemorrhage and the vascular pseudoaneurysm as a cause of bleeding (p \ . ). all pseudoaneurysm bleeding occurred in cases complicated by a postoperative pancreatic fistula (popf) with a significant statistical association (p \ . ). conclusions: the most common cause of pph was bleeding from a vascular pseudoaneurysm, most of them were severe bleeding with late presentation and all were associated with a popf. in these cases, early detection by cta is mandatory, allowing an urgent treatment by angiography of such a bleeding vascular complication following pd. ventral hernia in hostile situation introduction: there is no consensus about the benefit or harm derived from adding a mesh hernioplasty at the same time as an urgent intraperitoneal surgery for another cause. the use of a prosthesis in contaminated fields is controversial, but suture repair has a high risk of recurrence. the main objective has been to analyze the impact of the simultaneous repair of uncomplicated midline hernias at the same time as emergency surgery for another cause, in relation to the presentation of complications, the surgical site infection rate (isq) and recurrences. material and methods: retrospective, observational study of all urgently operated patients (surgery open and laparoscopic) in the period between - who underwent a simultaneous midline primary ventral hernioplasty. the background, circumstances of the surgery and postoperative complications during the first month and long term through the basis of prospective data of emergency surgery and complications of our surgery department. results: a total of patients ( female) met the inclusion criteria with a mean age of . years (sd = . ), average bmi of . kg/ m (sd = . ). the most frequently performed interventions were: appendectomy ( . %); cholecystectomy ( . %); and lysis of adhesions ( . %). the . % of all interventions were performed by laparoscopic approach. they presented associated peritonitis in . % of the cases. the . % of patients presented some complication, in . % surgical site infection ( . % organ space). during the followup three recurrences were detected ( . %), no patient has presented chronic infection related to the use of prostheses. conclusions: in our series the simultaneous performance of hernia repair of the midline in the context of emergency surgery for another cause has been safe and not associated with long-term complications and low recurrence rate. the open abdomen: our experience introduction: ''open abdomen'' refers to a solution in which the abdominal content is left deliberately exposed under a temporary cover for a variable amount of time. since this method has been used more and more for the treatment of severe intra-abdominal infections. starting from the s the concept has been also applied in trauma surgery. material and methods: between / we have treated patients with this technique. in cases the etiology was traumatic, in the remaining cases the abdominal pathology was inflammatory. in the last years we also started to use it in some cases of treatment of surgical complications. the techniques we used were different and changed during the time. at the beginning of the experience we've completed drainages of the abdominal cavity according to mickulizt, laparostomies with mesh, bogota bags. these techniques have been abandoned since the negative pressure therapy came out. we started with the barker vacuum pack ( cases), followed by the vac (vacuum assisted closure) and ab thera kci Ò ( patients) systems and in the last three years we used the cnp suprasorb Ò of lohmann and raucher ( patients case history: year old lady presented at the a&e with few days history of constipation, faeculent vomiting, abdominal distension and pain in the lower abdomen. she had hysterectomy many years ago through a lower midline incision. her urgent ct scan of the abdomen and pelvis confirmed an incarcerated right obturator hernia containing a small bowel loop causing bowel obstruction. clinical findings: elderly, frail patient with mild tachycardia, distended abdomen and lower abdominal tenderness with guarding in the left iliac fossa. per rectal examination was unremarkable. investigation/results: inflammatory markers were raised, lactate, liver and kidney function was in normal limits with only mild hypokalaemia and hyponatraemia. ct abdomen and pelvis confirmed small bowel obstruction at the mid ileal level due to right obturator hernia. diagnosis: incarcerated right obturator hernia causing small bowel obstruction. therapy and progressions: patient was taken to the operating theatre for urgent laparotomy. dilated small bowel loops and incarcerated right obturator hernia was found with proximal ileal loop in it. after blunt stretching and dilatation of the obturator foramen, the involved ileal loop was reduced. it was deemed viable, therefore no bowel resection was required. the defect at the right obturator foramen was closed with suture. post-operatively the patient was transferred to the intensive care unit for further management. comments: obturator hernias are a rare type of pelvic hernias. their real incidence is unknown but it is thought to be less than % of all hernias worldwide and due to its non-specific symptoms and late diagnosis, they require bowel resectional surgery in nearly % of the cases. howship-romberg sign is helpful in diagnosing such a hernia, but the ultimate diagnostic choice is ct scanning which is the only way to find this condition early and avoid bowel ischaemia. case history: a -year-old woman without previous medical history presented to the emergency department with abdominal pain and dysphagia associated with nausea, vomiting and absolute constipation. during previous months, she reported having ingested hair. clinical findings: abdominal examination revealed a distended abdomen with rebound tenderness and tinkly bowel sounds. investigation/results: ct-scan showed a distended stomach with a mussel-shaped, heterogeneous and non-enhancing mass. an esophagogastroduodenoscopy revealed hair inside the lower esophagus and the stomach. diagnosis: high intestinal obstruction due to a gastric trichobezoar. therapy and progressions: the patient underwent laparotomy, gastrotomy and trichobezoar removal (fig. ) . the postoperative period was uneventful and she was discharged home on the th pod with a psychiatric evaluation scheduled. comments: bezoars are rare conditions consisting of compacted material that is unable to pass through the gastrointestinal tract. this condition usually involves the stomach; rarely, it can extend into the small bowel and even the colon, giving the so-called rapunzel syndrome. bezoars could be composed by vegetable material (phytobezoars), hair (trichobezoars), drugs (pharmacobezoars), or other materials. , a trichobezoar is the result of trichotillomania, trichophagia or other psychiatric disorders. always consider bezoars in differential diagnosis. introduction: the effectiveness of different step-up approaches is increasingly evaluated but results are controversial. we assessed the results of a standardized step-up approach protocol in the treatment of acute severe necrotizing pancreatitis, with a special focus on patient stratification to obtain an early identification of those deserving a more aggressive strategy. matherials and methods: this is a retrospective analysis of patients with acute severe pancreatitis over a period of years. the variables taken into account were: etiology and severity of the disease, sepsis, organ failure, hemodynamic stability, treatment, los, morbidity, mortality. since , patients with infected necrosis underwent a standardized step-up approach: percutaneous drainage only; percutaneous and endoscopic procedure; surgery. the results were compared with the standard care delivered from to . results: among patients, ( . %) were identified as affected by severe necrotizing disease. overall mortality was . %. the initial management was non operativein all patients. mortality in the step-up group was % ( / ) vs % ( / ) in the standard care group. conclusion: a standardized step-up approach protocol offers better results than standard care in the management of acute severe necrotizing pancreatitis. however, a better stratification of patients. introduction:the appendix stump closure in complicated appendicitis has been widely practiced in different ways such as metal clip, hem-o-lok clip, endoloop and endostapler. the treatment of complicated appendicitis with necrosis and perforation of the appendix base is controversial. we aimed evaluate the efficacy of laparoscopic partial caecum resection with endostapler in complicated appendicitis with necrosis and base perforation. material and methods:from january to october , we evaluated consecutive patients who underwent a laparoscopic partial caecum resection in complicated appendicitis with necrosis and perforation of the appendix base. partial caecum resection was performed with the endostapler to close the appendix base at ileocaecal junction. results:the laparoscopic partial caecum resection with endostapler was used in % . of the cases. the mean operative time was . ± . min. there were necrosis of appendix base in , perforation of appendix base and diffuse peritonitis in , perforation of the appendix base and localized peritonitis in of the patients. the wound and intra-abdominal infection rates were . % and . %, respectively. there were no operative complications and the conversion rate was . %. the average length of hospital stay was . ± . days. there was no leakage on the stapler line. conclusions:the laparoscopic partial caecum resection with endostapler in complicated appendicitis with necrosis and perforation of the appendix base, is a safe and effective technique. introduction: the term ''''volvulus'''' comes from the latin ''''volvere''''meaning twist. if left unattended, sigmoid volvulus can compromise the blood supply of the involved segment,leading to ischemia,gangrene,perforation and death. the mainstay of sigmoid volvulus management has been through proctoscopic or colonoscopic decompression when feasible, followed by surgery either during the same admission or electively. the aim of our study is to identify patients which can benefit of immediate surgical approach and prognostic factors associated with failure of conservative/endoscopic treatment. materials and methods: charts of patients admitted for sigmoid volvulus to our institute were retrospectively analysed. we revised ct scan images and laboratory tests of all the patients to identify risk factors for conservative treatment failure. results: patients underwent surgical procedures; in cases after a failure of an initial conservative approach; patients were managed with endoscopic approach only. elective surgery was performed in patients. case history: we report a -year-old male case presenting left hand middle finger pain after pressured paint gun shot in volar proximal phalanx clinical findings: on physical examination swelling and tenderness on the volar side of the hand was observed (fig. ) investigation/results: pain was remarkably more intense with passive finger extension. distal nerurovascular status was unscathed. there was no fracture reported on radiography. leukocytosis and acute phase reactants rise was observed on laboratory examination diagnosis: after physical, radiological and laboratory examination the diagnosis of acute flexor tenosynovitis was made. therapy and progressions: open debridement and irrigation following bruner incisions on middle finger was undertaken within h of injury. paint impregned in tissues could be observed in subcutaneous tissue, palmar fascia and flexor tendon sheath. paint affected tissues samples were analysed in microbiology laboratory (fig , ) after checking nerurovascular indemnity, g drainage was left in deep tissues and skin suture was performed with - monofilament non absorbable suture. the patient followed days intravenous antibiotical therapy followed by weeks oral treatment. he attended physiotherapy program postoperatively, reporting no functional disability or wound complications after weeks. comments: chemical flexor tenosynovitis is an important emergency which must be correctly diagnosed and treated due to quick progression and potential morbidity if not treated effectively ( ) in our experience, case was managed by open debridement and irrigation but different treatments can be followed depending of patientsclinical situation, such as iv antibiotics with serial examinations or percutaneous drainage. it should also be noted that australia does not have a specific subspecialty in emergency surgery. the acute surgical unit at the tch was set up in in order to provide a dedicated acute unit to service the ever increasing demand acute surgery. previous model was that the acute surgical service was integrated into the elective work. additional beds were provided to the unit including the positions of a dedicated director and chief nurse. the achievement of the unit has been the decreased time to theatre, less after-hours operating, standardised treatment approaches, and dedicated emergency surgery medical staff. the difficulties have included clinician engagement, competing resources with elective surgery, emergency surgical presentations increasing by - % each year, and the unit''s beds being used for non-acute patients as the hospital approaches regular %. the acute surgical unit has evolved into a specialised acute care that enables rapid assessment and treatment of patients with staff dedicated with skills in this area. treating pyogenic liver abscesses secondary to diverticulitis in a patient using immunosuppressants for crohns disease by performing a sigmoid colectomy introduction: pyogenic liver abscess (pla) formation due to microbial contamination of the liver parenchyma is often seen secondary to intra-abdominal infections. pla formation due to crohn''s disease (cd) is a rare complication and not well-documented in current literature. as symptoms often mimic a cd exacerbation, diagnosis is often delayed and severe disease may develop. optimal treatment for this group of patients remains debatable. case presentation: a -year-old man was admitted to the hospital with a -week history of overall malaise, fever and night sweats. patient''s history solely stated a -year treatment of cd that was stable over the past period with infliximab and azathioprine. investigations and treatment: biochemical analysis revealed a c-reactive protein of mg/l and a white blood cell count of . /l. an abdominal ct scan showed multiple abscesses in the right lobe of the liver and a thickening of the wall in the transition of the descendent colon to sigmoid. the patient''s immunosuppressants were paused, intravenous antibiotics were administered and a percutaneous drainage of the biggest pla was performed. however, the clinical condition of the patient did not improve. colonoscopy and pet-ct scan did not reveal any other sites of infections. as patient remained septic and previous imaging revealed mild diverticulitis rather than active cd, an emergency hartmann''s procedure was performed. hereafter, the patient recovered rapidly and the plas resolved completely. conclusion: diverticulitis of the sigmoid colon should be considered as causative pathology in patients presenting with multiple pyogenic liver abscesses and a history of crohn''s disease that is in full remission with immunosuppression. when the abscesses exceed cm in size and are multilocular, resection of the inflamed colon can be a treatment option of value. clinical findings: epigastric pain and recent episode of hematemesis. pain at deep palpation of the epigastrium, no signs of peritoneal irritation investigation/results: abdominal x-ray and ct showing a large right sided strangulated paraesophageal peh, with pneumatosis of the gastric wall diagnosis: right sided strangulated peh therapy and progressions: emergent laparotomy. peh reduced, ischemic portion of the stomach recovering viability. closure of diaphragmatic defect with non-absorbable suture, reinforcement of lower esophageal sphincter with round ligament (ligamentum teres hepatis) and anterior partial fundoplication (dor). postoperative course uneventful, patient discharged on th pod. comments: peh are mediastinal displacements of abdominal organs, most often the stomach, associated with laxity or a hole in the phrenoesophageal membrane, large enough to allow the gastric fundus to herniate. because the stomach is attached to the gastroesophageal junction, it tends to rotate around its axis leading to organoaxial volvulus. occurrence and size increases with age. peh account for - % of all diaphragmatic hernias. in patients without prohibitive operative risk, they should be surgically corrected, avoiding the risk of acute and potentially life-threatening complications when emergent surgical repair is required. the risk of developing these complications is less than %/yr and associated mortality rate is approximately %. case history: patient was a previously healthy -year-old female with an unremarkable past medical history, non-smoker with a high body mass index (bmi [ ). she first presented to a level medical facility with acute left upper leg pain and swelling. one week prior to this she had a progressive cough, swinging fever, and malaise. clinical findings: patient was transferred to our hospital haemodynamically unstable, acidotic, hypoxemic and delusional. tachypnea and oliguria were present. she continued to deteriorate clinically with pyrexia (t , oc), resistant shock, and toxaemia. on examination her left leg was found to be paresthetic below the femoral-inguinal fold. investigation/results: abg samples showed lactic acidosis with a ph of . and lactate of . mmol/l. hypoxia and hypocapnea were present.her biochemical profile showed acute kidney injury (aki) with raised creatinine kinase (cpk) and serum creatinine (cr) . . chest x-ray illustrated bilateral lung infiltrations (ards image). diagnosis: patient was urgently referred to a ct scan of the left femur with i.v. contrast for suspected necrotising fasciitis. ct findings highlighted a deep muscular femoral abscess with multiple regional fluid collections and necrotizing inflammation from the femur diaphysis to the patella. therapy and progressions: the patient was immediately transferred to or for emergency surgical exploration and debridement. almost the entire anterior compartment of the femur was necrotic and hence an extensive excision of the dead tissues and packing with npwt was performed. comments: severe snm can cause marked systemic toxic effects, namely, the streptococcal toxic shock syndrome (stss). stss secondary to snm is a life-threatening host response to gas superantigens with a mortality rate as high as %. clinical findings: patient had a diffusedlty tender abdomen and had not passed flatus proceeding his admission to the a ? e department and was vomiting. investigation/results: ct abdomen showed small bowel dilatation with abrupt cut-off point proximal to the icv diagnosis: a diagnosis of small bowel obstruction was made based on the clinical and ct findings. therapy and progressions: patient was taken to theatre for laparoscopy ? -proceed and a 'slipped' bowel lopp was noted within the peritoneal flap that had been created a week prior during the original hernia repair. the 'v lock'' suture line was found to be loose which is thought to have led to this complication. the bowel loop was reduced, deemed viable and an internal hernia repair was performed. post-operative period was unremarkable and the patient was discharged day posy-operatively. comments: during lap tapp hernia repair, there are currently at least options avaiable for peritoneal flap closure; (sutures, tackers and glue.) suregons prefernce prevails over the chosen approach. when sutures are chosen, most surgeons prefer the self-locking v-lock stitch. by adopting this technique, meticulous periotneal closure is impoartan, as loose suturing of the peritoneum can lead to post operative complications of internal herniation and small bowel obstruction, as described in this case. a multi-centre prospective study would be welcomed, to compare efficacy and safety of all types of peritoneal closure devices. introduction: peer review assessment of medical treatment has been shown to be a robust way of improving quality of care in trauma in our institution and globally. in we introduced regular morbidity and mortality meetings at the department of gastrointestinal surgery. severe complications (revised accordion classification [ ) after surgery were identified on a weekly basis, evaluated and data included in a local quality registry with the aim of revealing suboptimal surgical quality and continuously improving our results. material and methods: retrospective analysis of collected data from the described quality registry. all adult patients who had undergone gastrointestinal surgery in were assessed. results: of surgical procedures performed, % were emergency procedures. a total of % ( / ) experienced a severe complication after surgery and % ( / ) required reoperation. in the group of upper gastrointestinal surgery [n = ( %)] % were emergency procedures. anastomotic leak (al) was identified in % ( / ) undergoing thoraco-laparoscopic esophagectomy and in % ( / patients) after gastrectomy. of laparoscopic cholecystectomies, % were emergency procedures with % ( / ) reoperation. of hernia repairs, % required reoperation. in the group of lower gastrointestinal surgery [n = ( %)] % were emergency procedures. al was diagnosed in % of colonic resections and % of patients after rectal resection. in emergency colorectal resections(n = ) there were no al. of appendectomies, patients ( %) required reoperation. the most frequent cause of reoperation was revision of stoma ( ), followed by reoperation for al ( ), abscess ( ), and wound dehiscence ( ). patients died after surgery of which were emergency surgical patients. conclusions: systematic assessment of all severe complications helps reveal surgical procedures which can be improved but also to identify surgical procedures with low complications rates. plans are being developed to improve the quality of the identified procedures. all surgical departments should have regular and thorough assessment of their activity. acute surgical patients operated by emergency surgeons has less risk of post-operative complications and mortality d. gumaa east kent hospitals university nhs foundation trust, general surgery, ashford, united kingdom introduction: in england and wales, we perform over , emergency laparotomy every year. days mortality rate is around - %. in our study we are trying to demonstrate if have dedicated emergency surgery service will make a difference in the outcome of emergency laparotomy. material and methods: retrospective study on prospectively collected data from nela database done in a large district general hospital. all patients over years old who underwent emergency laparotomy for acute surgical condition between november and january were included in the study. mortality and post-operative complications were the primary outcomes. results: total of patients were included in the study, operations were performed by emergency surgeons (es). days mortality rate was %, while it was . % for the none emergency surgeons group (nes) post-operative complications were . % compared to % for patients operated by nes. there was shorter itu stay with average of . days, while the itu stay for the other group was . days, but the es group had higher chance of unplanned return to theatre. . % of the patients went back to theatre compared to % of the other group. reasons of unplanned return to theatre was mainly post-operative collection or wound dehiscence. conclusions: emergency surgeons has better outcomes when they perform emergency laparotomy, may be because they perform higher number of laparotomy compared to their peers. emergency surgery has been a growing subspeciality recently, and with no doubts having surgical emergency units has improved the patient's care around uk. the advantage of g over g of prophylactic cefazolin in surgical site infections in trauma surgery below the knee introduction: the rate of surgical site infections(ssi) after foot/ankle surgery remains high, despite the implementation of antibiotic prophylaxis ( ) . recently guidelines suggest a single dose of g instead of g of cefazolin for implant surgery, this decision is largely based on pharmacokinetic studies ( ) . however, the clinical effect of this higher dose has never been investigated in this region. this retrospective cohort study therefore investigated the effect of g compared to g of prophylactic cefazolin on the incidence of ssis in foot/ankle surgery. material and methods: all patients undergoing trauma-related surgery of the foot, ankle or lower leg between september and march were included. primary outcome was the incidence of a ssi. ssis were compared between patients receiving g and g of cefazolin as surgical prophylaxis. results: a total of patients received g and patients received g of cefazolin. the groups did not differ in gender, age, weight, co-morbidities or intoxications. the overall number of ssis was ( . %) in the g group and ( . %) in the g group. corrected for the confounders ''age'', ''smoking'' and ''blood loss'' this was not statistically significant (p = . ). conclusions: even though the decrease in ssi rate from . to . % was found not to be statistically significant, it might be clinically relevant considering the reduction in morbidity, mortality and healthcare costs. research linking pharmacokinetic and clinical results of prophylactic cefazolin is needed to establish whether or not the current recommendations and guidelines are sufficient for preventing ssis in foot/ankle surgery. introduction:right-sided colonic diverticulitis (rd) is much rarer than left-sided (ld) and subsequently, controversies concerning the most appropriate treatment remain unsolved. our experience let us believe that mild rd can benefit from an outpatient management. material and methods: we performed a single center retrospective comparative study in which we included all our diverticulitis patients that were treated as inpatient in our unit. we divided in two groups:rd and ld group. the ld group was created by randomization from a prospective ld patients database. results: we included rd and ld patients treated in our unit from july to july . median age was . in rd and . in ld, with a . % of females in rd vs . % in ld. asa classification was significantly lower in rd (asai: . % vs %, asaii: . % vs , , asaiii: vs . %, asaiv: vs . % p = . ). the presence of neumoperitoneum in ct scan was significantly higher in ld . % vs . % p = . ) surgery was performed in . % of the left-sided diverticulitis compared to of the rd group (p = . ). antibiotics of third line (imipenem and meropenem) were only required for ld ( vs . % p = . ). length of hospital stay was significantly shorter (p = . ) in rd ( . ± . ) than in ld group ( . ± , ) conclusions: in our series, patients with right diverticulitis had fewer perforations in the ct scan, they required lower spectrum antibiotics and did not required any surgical treatment with a shorter length of hospital stay. we consider that mild right diverticulitis could benefit from an outpatient treatment with oral antibiotic following similar recommendations to those followed for mild ld patients. when surgery should not be immediate, a night of hospitalization in a specialized environment is performed and surgery deferred overnight. in some selected patients, a return home is possible with a scheduled emergency surgery the next day. the pa.r.c.o.ur protocol is set up in the surgical emergencies of the university hospital of lille after a suitable medical treatment and enlightened information. this retrospective study assesses whether this deferred surgical management allows a return home on the day of the operation. methods: between / / and / / , records of patients operated for an abscess, appendicitis, cholecystitis or symptomatic inguinal hernia were reviewed. patients who did not have criteria for immediate surgical management (peritonitis, occlusion, sepsis, cellulitis, intravenous treatment need) agreed to return to their home for an os the next day. results: / % interventions were performed in os and allowed a return home at day , within a median time of h [iqr - ]. conclusions: the pa.r.c.o.ur protocol makes it possible to reserve the availability of the entire technical platform (operating rooms and beds) to the most serious pathologies with a failure rate of %. the medico-economic benefits, the efficiency in the management of the beds and the satisfaction of the patient and medical staff of this protocol must be evaluated prospectively. a years old woman was admitted in our er presenting with a h sharp epigastric and ruq pain, fever, nausea and vomiting, hd stable. the patient had a past medical history of tachyarrhythmia, open-angle glaucoma and lower limb venous insufficiency. her past surgical history included an hysterectomy and bilateral salpingooophorectomy, appendectomy and left inguinal hernioplasty. during clinical examination, signs of peritoneal irritation were present. ct scan revealed a small pneumoperitoneum in the luq and multiple small and large bowel diverticula, without free peritoneal fluid. blood work showed mild leukocytosis and neutrophilia. we performed an urgent exploratory laparoscopy in which dozens of small intestine diverticula were found, increasing proximally in number. one of them, cm distally from the treitzs angle, showed signs of perforation, with a small abscess and surrounding fibrin. the affected bowel was externalized through a cm laparotomy for segmental resection and a manual double-layer terminoterminal jejunojejunostomy was performed. in the perforated jejunal diverticulum, a mm cod fishbone was identified as the cause of the perforation. the histopathological examination of the extracted cm tissue sample, found several diverticular structures of the muscular wall, one of which with a mm perforation and a granulocytic infiltrate with serosa involvement. complicated cases of small bowel diverticulosis are best managed by segmental resection surgery. despite being quite rare, every surgeon should be aware of such acute abdomen presentation. asymptomatic cases benefit from a watch-and-wait approach. case history: a -year-old female consulted to the emergency department for a h epigastric pain. it was accompanied by nausea without vomiting. clinical findings: the patient was hemodynamically normal and the abdomen was soft with minimal distention. investigation/results: x-rays showed large gastric dilation. the abdominal ct scan showed mesenteric axial gastric volvulus with minimal free fluid. suddenly, the patient presented diffuse abdominal pain with diaphoresis, mucocutaneous pallor, hypotension and tachycardia. diagnosis: a gastric volvulus with gastric ischemia was suspected. broad-spectrum antibiotic therapy and resuscitation measures were started. emergency surgery was indicated. therapy and progressions: a decompressive gastrostomy, gastric reduction and devolvulation, transverse colon resection due to ischemia and splenectomy were performed. after h, she required total gastrectomy and right hemicolectomy due to ischemia secondary to severe septic shock associated with disseminated intravascular coagulation. comments: the gastric volvulus is an uncommon entity, being the mesenteric-axial type so rare. there are very few cases described whose manifestation is accompanied by hypovolemic shock secondary to splenic laceration, which occurred due to the great gastric distention. early diagnosis is the key to start treatment as quickly as possible, due to high mortality the main mechanism of death is usually vascular involvement, perforation and multiorgan failure. results: we analyzed , pediatric ogis, and . % of pediatric cases occurred in the - age group, . % in - , . % in - , and . % in - . the average age of the cohort was . years and . % of cases occurred in boys. racial distribution revealed . % of cases in caucasians, . % in african americans, and . % in hispanics. most ( . %) cases were documented in the southern united states. of our , cases, . % underwent vitrectomy, . % underwent enucleation, and . % developed endophthalmitis. the rate of endophthalmitis development after ogi was highest ( . %) in the asian/pacific islander group. the average length of stay for the entire cohort was . days, and the average cost per day was $ , . . table contains a breakdown of our statistics. conclusions: as documented in the nis, ogi occurs more commonly in boys than in girls at a ratio of approximately : . the rates of vitrectomy and enucleation are higher in boys. we noted a higher of rate of enucleation in asian/pacific islanders and african americans. the plurality of ogis occur in the - age group; this age group also has the highest relative rate of enucleation. with respect to location, ogis occurring in the western united states had the highest average cost per day of inpatient stay. autologous tissue from intramedullary channel parietes for femur nonunions management introduction: a reamer-irrigator-aspirator (ria) method is deeply reliable for getting high volumes of bone graft/mscs. high rates of successful outcomes have been reported after the use of ria bone fragments to cure non-unions. material and methods: being supported by histomorphological examination of the material acquired while drilling intramedullary channels of patients with femur nonunions ( -hypertrophic, oligotrophic), we have discovered that nevertheless, expressions of the dystrophy and necrosis in bone tissue and marrow in pseudoarthrosis areas depend on time since fracture occurrence, the microscopic study of the material cm above and below a fracture line has demonstrated ordinary structures of bone tissue and marrow in all cases. introduction: this study aimed to evaluate the outcomes of ankle fractures with posterior malleolus fragments (pmfs) involving \ % of the articular surface treated with or without screw fixation. material and methods: among patients with ankle fractures and pmfs who underwent surgery between march and february , with type pmfs involving \ % of the articular surface were included. of these patients, underwent screw fixation for pmfs and lateral and/or medial malleolar fracture fixation (group a) and underwent internal fixation for malleolar fractures without screw fixation for pmfs (group b). ankle joint alignment and fracture healing were measured using plain radiography and computed tomography (ct). clinical outcomes were determined using the american academy of orthopaedic surgeons foot and ankle questionnaire, short form- , and american orthopaedic foot & ankle society scale. results: nonunion was not noted in either group. however, we detected union with a step-off of mm or more in cases from group b. with regard to ankle joint alignment, case in group a and cases in group b showed mild asymmetry of the medial and lateral clear spaces on ct at months. clinical outcomes at and months after surgery were better in group a than in group b. conclusions: screw fixation of pmfs was effective for fracture healing and maintaining ankle alignment. additionally, it improved short-term clinical outcomes, which we believe was due to stabilization of ankle fractures with pmfs involving\ % of the articular surface. references: level ii, prospective comparative study. how accurate can gaps and step-offs be determined in acetabular fracture treatment? introduction: the assessment of gaps and steps in acetabular fractures is challenging. studies evaluating the value of various imaging techniques to enable accurate quantification of acetabular fracture displacement are limited. this study aimed to assess the inter-and intraobserver variability of gap and step-off measurements using pelvic radiographs, intraoperative fluoroscopy and computed tomography (ct). material and methods: sixty patients, surgically treated for acetabular fractures, were included. five observers measured the gap and step-off on all the pre-and postoperative pelvic radiographs and ct scans. intraoperative fluoroscopy images were reassessed to determine the presence of gaps and/or step-offs. the inter-and intraobserver variability were calculated for the measurements using pelvic radiographs or ct scans. kappa was calculated for the intraoperative fluoroscopy assessment. results: for the preoperative displacement, the intraclass correlation coefficient (icc) was . (gap and step-off) using pelvic radiographs, and . (gap) and . (step-off) using ct scans. for the postoperative displacement the icc was . (gap) and . (step-off) using pelvic radiographs and . (gap) and . (step-off) using ct scans. the average kappa for the intraoperative gap and/or step-off assessment using fluoroscopy was . (- . to ) both for the inter-and intraobserver assessment. conclusions: there is little agreement between the observers regarding the measurements of the preoperative displacement, the presence of gaps and step-offs intraoperatively and the measurements of the postoperative displacement. a possible explanation for this is that the acetabulum has a three-dimensional spherical shape with multiple fracture lines and fragments going in different directions. single radiographic or ct-based gap or step-off measurements do not seem to be representative for the fracture characteristics, therefore the use of d measurements should be considered. introduction: long-term intake of glucocorticoids leads to pathologic changes in bone and cartilage tissues. material and methods: to understand how to prevent the occurrence of the pathology, we studied the use of vitamin d, vitamin e and a combination thereof on the background of the intake of prednisolone, . mg/ g of body weight. the experiment involved male rats of wistar linear breed. the animals were months old and weighted . ± . g. the experiment included series of animals, rats in each, namely: the first group-intact animals; the rest of the animals received prednisolone, . mg/ g of body weight. the rats of the third series received additionally iu of vitamin d . the animals from the fourth group also received . iu ( . mg) of vitamin e. results: long-term administration of prednisolone to the experimental animals has caused significant structural and functional disorders in their bone and cartilage tissues. they can be construed as simulated glucocorticoid-induced osteochondropathy. the combination of the vitamins d and e has demonstrated its ability to promote restoration of histomorphologic features of bone and articular cartilage in proximal femur epiphysis and epiphyseal cartilage of proximal femur epimetaphysis in animals with simulated glucocorticoid-induced osteochondropathy. the combination of the vitamins d and e has demonstrated a better effect on the background of the glucocorticoid-induced osteochondropathy, compared to the vitamin d alone. conclusions: preventive administration of the vitamins d and e while treatment with prednisolone leads to avoidance of the majority of pathologic changes, resulting otherwise from glucocorticoid-induced osteochondropathy. konyang university hospital, orthopaedic, deajeon, south korea introduction: the purpose of this study was to evaluate clinical, radiological and functional outcomes of patients had osteochondral autograft harvested from the ipsilateral femoral head for a femoral head defect after posterior hip fracture dislocation material and methods: this study was approved by irb at our institution. a retrospective chart review of a prospectively performed operation was performed at two university hospital between march , , and june , . all fracture was classified by the ao/ota classification. we included the patients had minimum months of follow up periods. ten displaced head fractures were addressed through posterior surgical dislocation and two patients had no posterior dislocation was operated using smith-peterson approach. an osteochondral graft was harvested from inferior non-weight bearing articular surface and grafted to osteochondral defect. all patients were full weight bearing by months results: we had femoral head fracture dislocation. patients were excluded due to lost to follow up. twelve of with type i/ii pipkin fracture dislocation with the articular defect and reduced within h of injury was identified for review. the patients were followed up for a mean of . months. there was no osteonecrosis. decreased joint space was identified in two patients. all fractures achieved union. the mean harris hip score of last follow up was . ( - ) one patient who operated using the smith-peterson approach had femoral nerve palsy. conclusions: the clinical and radiological results after treatment of femoral head fracture dislocation with articular defect by osteochondral autograft harvested from its own non-weight bearing articular surface show good outcomes. hospital universitario fundacion jimenez diaz, madrid, spain, hospital universitario de octubre, madrid, spain, hospital universitario la paz, madrid, spain introduction: preoperative computerized tomography scan provides important information about ankle fractures associating posterior malleolus, helping us distinguishing fractures affecting distal tibiofibular joint. the aim of our paper is to describe our series of patients suffering an ankle fracture with posterior malleolus involvement. methods: fifty-two consecutive patients, with ankle fracture involving posterior malleolus were evaluated prospectively. all of them were assed with a preoperative ct scan, demographic data, fracture mechanism, surgical approaches, posterior malleolus size measured classification and treatments were analyzed. results: most frequent posterior malleolus pattern according to bartonicek classification was type ii, twenty-two patients ( . %). an alternative surgical approach was performed in thirty-three patients ( %) as a consequence of information provided by ct scan. no statistical differences were observed when measuring posterior malleolus in conventional x-rays or ct scan. analysis of variance showed a p value less than . when comparing pm size and haraguchi and bartonicek classifications. discussion and conclusion: ct scan is required to perform an adequate preoperative study of ankle fractures involving posterior malleolus, using this information to provide a better outcome to our patients. effect of atorvastatin and losartan on gene expression and cell count in a rat model of posttraumatic joint contracture of the knee-a blinded and randomized animal study introduction: myofibroblasts have been associated with increased posttraumatic joint contracture, which has a massive impact on articular function. atorvastatin and losartan have shown to reduce the proliferation of cardiac, hepatic and pulmonary myofibroblasts. the aim of this study was to evaluate the effect of atorvastatin and losartan on gene expression, cell count and collagen deposition in the posterior joint capsule , and weeks after trauma in a rat model of posttraumatic joint contracture of the knee. material and methods: posterior capsular injury and kirschner-wire immobilization of the knee were performed in sprague-dawley rats. atorvastatin, losartan, or placebo was administered daily orally. the rats were sacrificed at either (n = ), (n = ) or (n = ) weeks after initial surgery. rats euthanized at week had their k-wire removed at week , followed by a remobilization period of another weeks. the results were evaluated via qpcr and immunohistochemistry. results: losartan reduced the number of myofibroblasts in comparison to the control at week and , whereas atorvastatin lowered myofibroblasts only at week (p \ . ). atorvastatin reduced the collagen deposition at week , whereas losartan had no effect on collagen deposition. losartan decreased gene expression of connective tissue growth factor (ctgf) at week and of tgf-b at week . clinical findings: positive anterior drawer test, grade iii valgus instability, and a palpable gap below the patella were assessed. no neurovascular alterations were found and ankle-brachial index scored [ . . investigation/results: initial immobilization with a splint was performed. radiographs showed a high patella with no other lesions. mri revealed a complete rupture of the patellar tendon and a complex multiligamentous injury with complete anterior cruciate ligament (acl) tear, avulsion of distal medial colateral ligament (mcl), and a complex rupture of both meniscus. diagnosis: knee dislocation with patellar tendon rupture. therapy and progressions: definitive treatment was performed days after the initial lesion, with arthroscopic resection of the posterior horn of the external meniscus and reconstruction of the acl with posterior tibial tendon allograft, as well as open repair of the patellar tendon and the internal meniscus, with subsequent mcl distal reinsertion. immediate partial weight-bearing with an extension orthosis was allowed. the patient is currently progressing with rehabilitation. comments: knee dislocation is a rare injury, and most cases are due to highenergy trauma. concomitant rupture of the patellar tendon is very unusual, and most cases are described in the context of open injuries. surgery is mandatory in order to restore full stability of the knee, with either one intervention or a staged surgery, including repair of the collateral ligaments and the patellar tendon followed by arthroscopic reconstruction of the cruciate ligaments. postoperative management consists on early rom restoration and weight-bearing as tolerated. introduction: apophyseal anterior inferior iliac spine (aiis) fractures are rare injuries. they most commonly occur in athletes in adolescence period. because the ossification of pelvis is not completed, apophyses are the weakest part of musculo-tendinous unit during this period, thus avulsion fractures are more frequent than muscle ruptures. aiis avulsions are the result of sudden and forceful contraction of rectus femoris muscle concentrically or eccentrically. material and methods: we report a clinical case of a aiis avulsion fracture in a young male football player, after being misdiagnosed as muscle strain. results: our patient was treated with conservative treatment including bed rest, analgesia, using crutches and toe-touch weight bearing, progressing to full weight bearing as tolerated and nonsteroidal anti-inflammatory drugs. at follow-up, he showed relief from his pain and mechanical symptoms and regained full range of motion and returned to his previous levels of activity. conclusions: diagnosis requires careful attention to the physical examination and imaging. in this case, the fracture was managed successfully with a conservative approach. good results and return to previous levels of activity can be achieved with conservative treatment. when misdiagnosed as a simple strain, the late diagnosis may cause chronic pain with decreased sportive performance in the future. therefore, a carefully taken anamnesis and physical examination with comparative anterior-posterior pelvic x-rays are needed not to miss avulsions in adolescents; also in some instances, more advanced scanning methods must be considered. introduction: the problem of meniscus damage in children is due to unsatisfactory treatment results, which is associated with the frequent execution of meniscectomies. amount of unjustified meniscectomies and the incidence of osteoarthritis can be reduced if menisci are repaired. material and methods: during the period january -august children with injuries of the meniscus were treated in morozov children's clinical hospital. children underwent meniscus repair by suturing using three techniques: ''all inside'', ''inside out'' and ''outside to inside''. meniscus suture decision was made taking into account the assessment of the severity of the damage. the period from the moment of injury wasn't taken into account. the technique of meniscus suture was determined depending on the location and type of damage. we met children with damage to the discoid meniscus who underwent partial resection and meniscus suture. children underwent a meniscectomy due to severe traumatic and degenerative changes. children had mri of the knee after months and x-ray after months. results: children achieved a satisfactory functional result; operated children are at the rehabilitation stage. we faced a complication-limitation of flexion in the knee joint in child. in all children on the control mri, the absence of synovitis, the safety of the reconstructed meniscus contour and the decrease in the intensity of the hyperechoic signal in the gap zone in dynamics are determined. conclusions: the introduction of a technique for repair meniscus integrity in the daily practice of an arthroscopist makes it possible to reduce the number of meniscectomies, which will reduce the number of unsatisfactory treatment results for this pathology and prevent the development of early osteoarthritis of these, children revealed a fracture-dislocation of the patella. in children, a tangential fracture of the lateral condyle of the femur was noted. in children, the dislocation was repeated. we met children with bilateral damage. all children with complete damage to the medial patellofemoral ligament, fracture-dislocation of the patella and dysplastic dislocation were performed tendon plastic using the quadriceps femoris tendon. the technique includes: transplanting a graft quadriceps tendon graft without cutting off the patella. next, the transplant is subfascial carried out in the medial direction and is fixed with a bio-integrated screw in the femur. results: the rehabilitation period was months. % of children have a satisfactory result (there is a limitation of flexion in the knee joint to °). % have an excellent clinical result: the full range of motion in the knee joint, the absence of pain and a return to sports. none of the operated children had relapses of dislocation. conclusions: it is recommended to consider the technique of tendon plasty of the medial patellofemoral ligament using the quadriceps femoris tendon as a method of choosing the treatment for patellar dislocation in children. case history: a -year-old boy who was injured while playing baseball. he was playing as a catcher and was bumped into the runner, therefore his ankle got twisted. he was immediately taken to the hospital. clinical findings: x-ray the distal tibial epiphyseal growth plate was irregular. although the ankle joint was not dislocated. in the ct, the proximal fibular fragment was caught behind the posterior edge of epiphysis of the distal tibia and was trapped there. investigation/results: the patient must be operated in order to repair the ankle. but the reduction of the entrapped distal tibia epiphysis was not easy without open. diagnosis: we diagnosed with bosworth like fracture. therapy and progressions: reduction was not easy, however we performed it by the pulling the fibula towards to outside, pulling out the curled anterior tibiofibular ligament, and then pushing into the tibia. we performed screw fixation after reduction of distal tibial epiphysis. furthermore, we fixed the fibula with plate. we made him to do range of motion exercise and toe touch gait from next day, and full weight bearing from weeks. we removed the implant months after the surgery. he did well subsequently, and at years after injury, he had normal function of the ankle, and normal x-ray. and he has returned to sports without pain. introduction: judo is the most popular martial art in the world and the first martial art recognized since as an olympic sport. worldwide, the international judo federation has registered countries with about million judo practitioners. like martial arts, judo mainly involves grip and throwing techniques. the competition rules in judo have been subject to constant adjustment and optimization in recent years. injuries prevalence is an important factor in the contact martial arts. material and methods: a prospective cohort study of all registered international athletes ( ) at three different european judo contests in germany were accomplished with the aim to investigate the injury rate as well as the pattern of injury. the age of the athletes ranged between and years. injury incidence rates were calculated per athlete-exposures (iirae) and per min of exposure (iirme). independent variables were sex and weight division. subgroups were compared by calculating the injury incidence rate ratio. results: severe injuries by judo tournaments are rare. the most frequently injured regions were the hand and head. the fights of the main block are riskier than the finals. the incidence of injury in heavyweight division differed with lightweight competitors. the risk of injury for female and male competitors differed slightly. conclusions: further studies are needed to determine a judo specific injury patterns and factors especially in the pre-competitional phase. investigation of prevention-strategies like the adaptation of competition rules etc. makes sense. does garden''s classification of femoral neck fracture match between orthopedic specialist and clinical resident? t. inoue , s. inoue , t. muraoka prefectural miyazaki hospital, orthopedics, miyazaki, japan introduction: garden''s classification is the most popular classification of femoral neck fractures. femoral neck fracture should be operated^ h; however poor agreement make waiting time longer because it takes more time to prepare implants and biological clean room. we investigate the agreement of the garden''s classification (non-displacement type or displacement type) between clinical resident and orthopedic specialist. material and methods: the examiner are a clinical resident ( nd year) and an orthopedic specialist ( th year). the subjects were cases of femoral neck fractures treated at our hospital between january and december . first, the examiners classified them into a non-displacement type and a displacement type (test ). second, the examiners studied the literature about unclassifiable type. third, the examiners classified cases month later once more (test ). finally, we compared the first test with the second test using the agreement (the number of matched patients/total) and kappa coefficient. results: the test showed that the agreement and kappa coefficient were . % and . . the test showed agreement was . %, . . the intra-observer agreement of clinical resident was . % and kappa coefficient was . . the orthopedic specialist was . %, and kappa coefficient was . . at test , cases did not match. cases of those were unclassifiable type, which were valgus type with medial fracture line. with slight displacement, agreement will get lower; some doctors consider it displacement type. conclusions: unclassifiable type makes us confused. it makes agreement better to discuss about unclassifiable type. introduction: the aim of this retrospective study was to describe the profile of missed hand and foot fractures in multitrauma patients and to elucidate risk factors for the delayed diagnosis. material and methods: from to , there were included patients. missed fractures were defined as fractures, which were not diagnosed during primary and secondary survey. patients were assessed for age, sex, glasgow coma scale, injury severity score, and length of stay in hospital (los). timing of hand or foot diagnosis related to admission date (measured in days) was noted. results: overall, . % of patients had a delayed diagnosis of hand fracture, . % ha a delayed diagnosis of foot fracture. the mean gcs for patients with delayed diagnosis was , whereas patients with diagnosis the day of admission had and mean gcs of (p \ . ). patients with delayed diagnosis had a mean iss of . versus . for those diagnosed the day of admission (p \ . ). furthermore, patients with delayed diagnosis had a mean los of . days, whereas those diagnosed at the time of admission had a mean los of days (p \ . ). concerning delayed diagnosis hand fractures, metacarpal and phalangeal fractures were the most common injuries overall ( . % and . %, respectively). concerning delayed diagnosis foot fractures, metatarsal fractures ( cases) and calcaneus fractures were the most common injuries overall, followed by talus fractures and toe fractures. conclusions: this study revealed that with a decreased gcs and increase in iss, polytrauma patients are increasingly at risk for delayed diagnosis of hand and foot fractures with a concomitantly increased los. as a delayed diagnosis has significant impact on the final functional outcome, correct and careful primary, secondary and tertiary survey is essential. introduction: the aim of this study was a) to determine the methods of hemorrhage control currently being used in clinical practice and b) to analyze pelvic fracture mortality rates before and after initiation of a multidisciplinary pelvic fracture protocol. material and method: between and , we included trauma patients with pelvic fractures (group ). a similar retrospective examination was performed on a number of trauma patients without pelvic fractures (control group). there were collected injury severity score (iss), the highest abbreviated injury scale (ais) score in each anatomic region and methods of pelvic hemorrhage control. there were also recorded hospital lengths of stay (los) and in-hospital mortality. results: the average follow-up was -months. the average iss in group and group was respectively . and . . in both groups the commonest mechanism of injury was motor vehicle crash ( . %). in group , angioembolization and external fixator placement were the commonest used method of hemorrhage control. patients underwent diagnostic angiography with contrast extravasation noted in patients. patients with pelvic fracture had a mean hospital los of . days. the overall in-hospital mortality rate of patients with pelvic fractures was . %, while in group the overall in-hospital mortality was . %. age, shock, severe head injury and increasing iss, are all significantly associated with mortality in the pelvic fracture group. conclusions: the findings from this study demonstrate no clear relationship between the choice of hemorrhage control intervention used and the patient's clinical status. in healthier patients with unstable pelvic fractures, the mortality rate was similar to that of patients with stable fracture patterns. introduction: various percutaneous screw placement for pelvic and acetabulum fractures is often difficult because of complex anatomical morphology, however, it becomes very beneficial to set enough fixation stability if we can insert the long screws. d-ct navigation system for the screw placement is beneficial for precise screw insertion. we investigated the accuracy of screws with d-ct navigation. material and methods: our retrospective case series were assessed by the accuracy of screws with d-ct navigation for pelvic and acetabulum fractures. twenty-six patients who sustained pelvic fractures and thirteen patients who sustained acetabular fractures were included in this study and . mm cortical screws or . mm cannulated screws were inserted with d-ct navigation. we investigated the number of screws and screw positions which is measured by postoperative ct scan and classified by smith criteria. results: we inserted tits (transiliac-transsacral) screws and is (iliosacral) screws for pelvic fractures. of screws ( . %) were placed in correct position (grade or ). screw for s lesion was placed in incorrect position. meanwhile we inserted antegrade pubic screw, anterior column screws, posterior column screws and infra-acetabular screws. of screws ( . %) were placed in correct position (grade or ). screws were in incorrect position and they were all cortical screws. and there was no complication related to screw insertion. conclusions: our study highlights that d-ct navigation system reduced the malposition rate of screw insertion for pelvic and acetabular fractures. however, we sometimes had difficulty in inserting tits screw for s lesion and cortical screw for acetabular fractures. we assumed that this was caused by narrowness of s corridor and flexibility of drill or inserting cortical screws in wrong position manually. we should pay much more attention even using d-ct navigation. is operative therapy still warranted for dislocated acetabular fractures in elderly patients? introduction: the incidence of acetabular fractures in elderly patients is increasing. there is no consensus about the right treatment for the impaired elderly patient with an acetabular fracture. the aim of study was to investigate acetabular fractures in the elderly patient and the risk of a secondary tha. material and methods: a retrospective study was performed from till in the radboudumc nijmegen. all patients with an acetabular fracture were reviewed. they were divided into two groups, younger than and or older. ct scans were used for classification according to letournel and for the quality of the reduction according to matta. there was a follow-up of minimal years. results: in total, patients attended at the radboudumc with an acetabular fracture, of which were years or older. in the younger group, patients received surgery and elderly patients. according to matta, an anatomical reduction was achieved in % of the young patients and % of the elderly patients. imperfect reduction was achieved in % of the younger patients and % of the elderly patients. thirteen percent of younger group and % of the older group needed a tha based due to the posttraumatic arthritis, the younger group after months and the older group after months on average. one younger patient with anatomical reduction needed a tha, none of the elderly patients. twenty-three percent of the younger patients and % of the elderly patients, all with a poor reduction, needed a tha. age, the complexity of the fracture and the quality of the reduction were important factors leading to a secondary total hip arthroplasty. conclusions: elderly patients are two times more likely to need a secondary total hip arthroplasty. after an anatomical reduction, the risk is very low, even in the elderly. surgery for dislocated acetabular fractures is a good option when there is a possibility for a good reduction. references: letournel e. matta jm. introduction: in japan, as a definition of basicervical fractures of the proximal femur, a fracture line is placed into and out of the joint capsule of the hip joint. however, in fact there are various fracture types.we classified these fracture types based on treatment methods and reported on these results. material and methods: cases of proximal femoral fractures treated in our hospital from january to december . basicervical fractures occurred in cases ( . %). all cases diagnosed with x-ray and d-ct, and observed for months or more after surgery. results: there are two types of basicervical fractures: the fracture line exists around the just inside of the intertrochanteric part: normal type(n type); cases ( . %), and fracture line exists subcapital at ventral side, the coronal plane in the center of the neck and the trochanteric fossa at the dorsal part: coronal shear type(c type); cases ( . %).c type was further classified by treatment method depending on existence of posterolateral fragment and anterior wall fracture. c type without comminution ( part:c- type) was cases ( . %). with posterolateral fragment ( part:c- type) was cases ( . %), with posterolateral fragment and anterior wall fragment ( part:c- type) was cases ( . %).n type and c- type were treated by sliding hip screw (shs) with anti-rotation screw. c- type: shs with trochanteric stabilizing plate, c- type because of the bony contact area is very small: hemi-arthroplasty with calcar replacement was performed. cut out occurred in cases of c- type and case of c- type, but others obtained union.. one case of c- type occurred peri-prosthetic fracture intraoperatively. conclusions: we classified cases of basicervical fractures, and according to its classification, treatment method was decided and good clinical results were obtained. strategies aimed at preventing chronic opioid use after trauma: a scoping review c. cô té , m. berube université laval, faculty of nursing, québec city, canada, chu de quebec research center, université laval, trauma, emergency, critical care medicine, québec city, canada introduction: a high incidence of chronic opioid use (up to %) has been documented after trauma. solutions are urgently needed considering the importance of this public health issue. we aim to identify strategies to prevent chronic opioid use in the trauma population and to assess their level of evidence. material and methods: we initiated a scoping review of literature to identify research articles and guidelines on preventive strategies. several databases and websites of trauma were searched. strategies were classified according to their types and targeted trauma populations. the level of evidence was summarized according to an adaptation of oxford center for evidence-based medicine classifications and strategies effectiveness. results: close to items have been screened until now from which studies - and one guideline were found eligible. two studies - combined education with mandatory limit of opioid prescriptions (level iii) in the orthopaedic trauma population and the other study used tailored physical training after whiplash injury (level i). findings showed reduction of opioid use or complete weaning at and weeks after trauma, however the effect was not maintained beyond weeks. guidelines on orthopaedic trauma made the following recommendations: prescribe the lowest effective dose for the shortest period (strong, high-quality evidence), avoid long-acting opioids in the acute setting (strong, moderate-quality evidence), and prescribe precisely (avoiding ranges of dose and duration) (strong, low-quality evidence). conclusions: chronic opioid use is an important issue in trauma patients. findings highlighted the need for more research to reduce the burden associated with chronic opioid use in this population. references material and methods: we analyzed clinical cases: men- and women- , mean age years. trauma circumstances: habitual trauma- cases, traffic accident- , precipitation- , sport- , aggression- . for cohort analize schatzker classification was used: especially type i was meet in cases, ii- , iii- , iv- , v- , vi- ; close, open. for paraclinic examination were used x-ray and ct. surgical management consisted of: close reduction, internal fixation- cases ( -percutaneus canulated screws arthroscopic assisted, -external fixator), open reduction, internal fixation- cases. bone graft was done in cases. results: postoperative follow up was performed at , , , weeks. patients were evaluated according to the lysholm knee scoring scale, obtaining an average score of points. bone healing was achieved in a period of between to weeks. postoperative complication developed in cases. results were depending on the stability of osteosynthesis, precocity, rightness of functional reeducation and patient compliance. conclusions: favorable functional results and less complication were met in cases of individual approach of surgical management, a good choice of implants and minimally invasive surgical techniques. fractures of the shoulder processes-a case report case history, clinical findings and diagnosis: -year-old male, low-speed motorcycle crash with subsequent polytrauma. he presented with right shoulder pain, swelling and pain to the touch. articular ct revealed a type i fracture of the coracoid base, type iii acromion fracture and scapular body fracture without displacement. results, therapy and progressions: he was submitted to surgical treatment days later. a superior ''sabercut'' approach with open reduction and osteosynthesis of the coracoid process was performed with a cancellous screw and washer and fixation of the acromion with k-wires and tension band wire. fracture of the scapular body followed a conservative treatment. immediate postoperative period was uneventful and he presented with favourable evolution in the subsequent -week, -week and -month follow-up. at present time, at -month follow-up, maintained anatomical reduction in radiological control, complete arm abduction and no limitation with efforts. comments: conservative treatment is generally indicated for all shoulder body fractures without displacement. fractures of the coracoid or acromion with [ cm displacement are described as an indication for surgical treatment. fractures of the acromium without displacement may follow conservative treatment with sling immobilization. surgical fixation can be achieved with screws, plate and screws or tension band wire. although controversial, surgical treatment for coracoid fractures is preferred, especially in active young patients with open reduction and fixation with screws or, if necessary, with plate and screws. the treatment applied in the present case, all approaches described in the literature as being effective and with good results, is in agreement with the options described in the literature and constitutes a corroborative example of its efficient results. case history: a -year-old male, hand worker, attended to our emergency department after a traffic accident complaining about pain and swelling in his left wrist. initial radiographs revealed an isolated dorsal dislocation of the lunate that went unnoticed. two and a half months later he was referred to our clinic. clinical findings: findings included dorsal wrist deformity and pain. he presented a decreased passive wrist flexion and extension range of motion, with normal finger tendinous function. investigation/results: plain x-rays showed persistence of the lunate dorsal dislocation without any associated injuries. diagnosis: chronic isolated dorsal dislocation of the lunate therapy and progressions: open reduction was performed using a dorsal approach. the scapholunate, lunotriquetal and scaphocapitate spaces were stabilized with a compression screw and kirschner wires respectively. the patient persisted with pain and functional limitation after the surgery, showing an insufficient reduction of the scapholunate space on the x-ray. nine months after the initial surgery, he developed a purulent fistula on the ulnar edge of the carpus. after it was resolved, a total wrist arthrodesis was performed using the mannerfelt technique. at the months follow up, he was clinically stable, consolidation of the arthrodesis was documented and he had returned to his previous normal activities. comments: isolated dorsal dislocation of the lunate is a rare lesion. the delay in the diagnosis of carpal dislocations is frequent. this compromises the final outcome of reconstructive techniques and the risk of residual instability, hence increasing the risk of chronic pain associated with posttraumatic osteoarthritis. in the case of chronic lesions, treatment with palliative techniques such as proximal carpectomy or joint arthrodesis should be taken into consideration. references: siddiqui n., sarkar s. isolated dorsal dislocation of the lunate. open orthop j. ; : - is ultrasound-guided regional anesthesia safer than landmark technique? one-hospital experience introduction: according to the literature the application of ultrasound (us) in performing regional anesthesia had a significant impact on patient safety by increasing the success rate [ ] . in a donated ultrasound device became available in the institute of emergency medicine, chisinau, republic of moldova. due to lack of equipment both us guided and landmark techniques have been performed. the aim of this study was to analyze the two methods of performing regional anesthesia, in order to estimate the potentials benefits of of us guided techniques (succes rate and doses). results: the bivariate analysis showed that, out of anesthetics in lmg, a number of were reported as unsuccessful, compared with a number of in usg. the v test with corrections for continuity did not determine significance (test value . , df = , p = . , effect size = . ), rr being . ( % ci . - . ). linear regression for dose (lidocaine) modeling, in patients included in the research, showed a decrease of the dose by mg in lmg, the confidence interval being quite wide ( % ci -. , -. ). that is, the actual decrease is within the limits of and mg. conclusions: the tendency towards higher failure rate in successfully performing an us guided regional anesthesia and relative ''uncertain'' decreasing of dosage are in contradiction with the international statistical data. this in turn evidenced probable deficiencies in the training of the practitioners in field of ultrasound guided techniques in our country. the prospective research to confirme/infirme these results and estimate the complication rate follows. references: . barrington mj, uda y. did ultrasound fulfill the promise of safety in regional anesthesia? current opinion in anaesthesiology ; ( ) results: average age years old ( - ).all were active labour patient. the most frequent mechanism was high energy trauma (traffic accident), of who presented gustilo grade iiib open fractures operated in the country of origin. most frequent pattern of fracture was -c. ( cases) and -c. ( cases). initial conservative treatment was performed in of the cases. one persistent pseudoartrhosis with osteosynthesis material failure. in every case, preoperative ct and early surgical intervention were carried. in cases, an additional procedure was associated at the radioulnar distal joint. in all cases consolidation occurred. one patient required reintervention for persistent pseudoarthrosis. average consolidation time months ( ) ( ) ( ) ( ) ( ) ( ) ( ) .average follow-up of months ( - ). average active joint balance: flexion °( °- °), extension °( °- °), pronation °( °- °), supination °( °- °). average dash . ( - . ).force reduction greater than % compared to contralateral in of the cases. radiological parameters:radial height . mm ( - ),radial inclination °( - °),volar angulation . °( . °- °), ulnar variance . mm ( ) ( ) ( ) ( ) ( ) . conclusions: malunion of the distal radius is an uncommon and severe complication with increasing incidence that requires early and personalized surgical treatment to achieve the correction of the deformity, preserving mobility acquiring consolidation with acceptable functional results case history: isolated ulnar translocation of the carpus is unusual. when the translation occurs without injury of the radius, ulna or carpal bones are often misdiagnosed. early diagnosis is key, to avoid further complications such as redislocation of the carpus ( ). clinical findings: in our case a young male patient suffered a high energy motorcycle accident. he had no a b c d problem investigation/results: the ulnar translation of the left carpus was evident but comparison x-rays were taken on both wrist for further evaluation. the distance between the line, drawn through the axis of the radius and the center of the capitate bone was measured bilaterally. the results were . mm vs . mm. diagnosis: isolated, open ulnar translocation of the radiocarpal joint, dumontier type i, was diagnosed. treatment: the primary treatment was debridement, reposition and fixation with ex fix. after the wound healing on th days we made reconstruction. volar approach was used, we re-reponate the carpus and fixated the position with two mm smooth kirschner wires. the radioscaphocapitate and long radiolunate and radioscaphoid ligaments were reattached to the volar margins of radius using mitek mini anchors. we put the ex fix and left the bended wires percutaneously. after weeks the ex fix and the k wires were remove. wrist motion exercises were initiated under supervision of physiotherapist. comments: after weeks the wrist was in good alignment, the flexion-extension were - , the deviations were - °. the radiographic signs of this injury are unusual and often misdiagnosed. it can be useful to compare with contralateral x-rays. the radiolunate and radioscaphocapitate ligaments is considered crucial in prevention of ulnar translation. in our opinion the radiolunate arthrodesis can be reserved for failed ligament repairs. introduction: within the orthopaedic paediatric population, there is a distinct paucity of literature in regard to post-operative paediatric analgesic regimes. supracondylar humeral fractures account for % of all paediatric limb fractures and there has been a marked divergence in recent literature concerning the most appropriate choice of analgesia for this cohort with recent studies recommending the routine inclusion of an opioid agent post-operatively on prescription. opioids have deleterious side effects pertinent to paediatrics. in our institution, patients'' only receive a prescription for acetaminophen and nsaids upon discharge. our study assessed postoperative analgesic satisfaction rates in all paediatric patients who underwent crpp for supracondylar humeral fractures in our institution from january to december . material and methods: this is a retrospective multi-surgeon case series of all paediatric patients who underwent crpp from january to december . patient data was extrapolated from theatre records and clinical charts. for each patient, all analgesic agents given were identified, the dosage, route and frequency of administration in addition to the length of their hospital stay and time from injury to operation. following discharge, patients'' guardians were contacted retrospectively and a questionnaire was administered which ascertained the efficacy and duration of analgesia used by the patient postoperatively. results: fifty patients were identified for inclusion within the study who met the inclusion and exclusion criteria. there was a % satisfaction rating amongst the responders with the analgesic regime recommended-acetaminophen & nsaids. conclusions: in stark contrast to papers which we discuss throughout our paper, our study conclusively demonstrates that opioid prescriptions are not required upon discharge for supracondylar fractures within a paediatric population case history: a -year old man suffered an isolated injury of his right hand in a motorcycle accident. clinical findings: the patient presented with a swollen hand, a subtotal amputation of the middle finger at the level of the middle phalanx and lacerations to the other fingers (fig. ) . investigation/results: after excluding injuries to other body regions, radiographs and a ct of the hand were performed (fig. ) . diagnosis: closed fracture dislocation of cmc joints from ii. to v. finger, comminuted fracture of the middle phalanx of the middle finger, closed fracture of the proximal phalanx of the middle finger, other lacerations to the iv. and the v. finger. therapy and progressions: urgent open reduction and internal fixation (orif) with k wires of the cmc joints. exploration of the middle finger reviled heavy contamination and comminution of the phalanx, with injury to one neurovascular bundle. a phalangectomy with acute finger shortening was performed with creation of a new ip articulation (distal to proximal phalanx) (fig. , ) . progression after the surgery was uneventful. there was no sign of infection. the shortened finger was sufficiently perfused and the patient reported a sense of touch. k wires were removed after weeks and physical therapy was started. the patient has limited rom in his neo ip joint with minimal pain (vas - ) (fig. ) . comments: middle phalangectomy of the hand was described in the literature only in two papers which report treatment of chronical or congenital diseases. the authors propose this method as an alternative to amputation in selected trauma cases. results: patients ( m, f, mean age y) with fractures were included. kidney-tpl, lung-tpl, liver-tpl, heart-tpl, kidney/pancreas-tpl. all patients got treated with at least two immunosuppressive drugs. cause of accident: . % sports/leisure, % work/household, . % traffic accidents, % without trauma. the operation was performed under perioperative long-term antibiosis, often with a combination of two or three drugs. patients were hospitalized for an average duration of . days and were also examined by the particular organ specialists. osteosynthesis: in % primary operative fracture treatment, in % two-step procedure. plates distal radius and ulna [healing period (h) conclusions: the fracture healing was possible but significantly delayed. the wound healing took longer. the immunosuppressive therapy may be responsible for these problems. the rehabilitation of movement and weight bearing has to be adapted to the slowed fracture healing. introduction: the prevalence of fragility fractures of the pelvis (ffp) increases, including in up to % a lesion of the posterior pelvic ring. an operative therapy is indicated in cases of prolonged or immobilizing pain or in a displaced dorsal fracture. methods: patients suffering an ffp treated with a minimal-invasive trans-sacral bar through s from to were included. the patients or their relatives were contacted to ask about mortality, the present mobility and place of residence. % of all patients still alive could be included in follow-up. results: females and males with a mean age of . ± . years ( - ) were included. concomitant stabilization of the anterior pelvic ring was performed in %. . % underwent an operative revision ( % evacuation of hematoma, % peri-implant infection, % hardware removal-combinations possible). the trans-sacral bar was removed in one case due to malpositioning. the length of stay was ± days. at discharge, % were mobile on the ward, % in their room, % for transfer to sitting position and % were bedridden. % were discharged to their home, % in geriatric rehabilitation unit, the remaining to other rehabilitation or to a nursing home. during follow-up, mortality was %, one patient died during hospital stay. the patients died in average ± weeks after discharge. after a follow-up of ± weeks, % lived at their home, thereof one-third with assistance. % needed a walking aid, % were mobile without walking aid, % were bedridden or only mobile to sitting position. conclusion: the trans-sacral bar in s is a valuable minimal-invasive stabilization method to recover mobility in elderly with an ffp. a relatively long in-hospital stay could be explained by the initial trial of conservative treatment and due to intra-and inter-departmental cogeriatric services. the high mortality and need for assistance reflects this geriatric, multi-morbid patient collective. case history: a -years-old woman was admitted in the emergency room after being run over by a bus. clinical findings: at the emergency room, she was conscient and hemodynamic stable. head, thoracic or abdominal trauma were excluded. the patient presented with an open wound in left popliteal area with massive bleeding with exposure of gastrocnemius and soleus muscles and achilles tendon investigation: radiologic images didn't show any fracture. a limb angiography showed complete perfusion of the leg, without any lesion on major arteries. diagnosis: open aquilles tendon avulsion through the popliteal fossa therapy and progressions: the patient was taken to the operating room. we approach the popliteal area and found a small laceration of popliteal vein, which was sutured with prolene / . then, we reference the achilles tendon, and tunneled the posterior face of the leg, and passed the tendon through the tunnel. a distal approach, above the insertion of achilles tendon was done, and two suture anchors preloaded with sutures were inserted in the medial and lateral sides of the calcaneal tuberosity, then we did an krackow suture. we also did a fasciectomy on the lateral side of the leg, to prevent compartmental syndrome. the patient was put in a posterior cast with of flexion for weeks. the immediate post-operative time was in an intermedia unit care, to control possible multiorgan failure. in days, she was discharged to orthopedics nursery. due to the degloving of subcutaneous tissue, she evolved with some blisters which made her stay inpatient about weeks. after some time, she developed some areas of skin necrosis, which needed some intervention by plastic surgery with skin graft. now, she has skin completely healed, some loss of strength in the leg, with loss of plantarflexion, and is under prolonged rehabilitation program. therapy and progressions: she was rushed into the or and submitted to external fixation of the humerus and bones of the forearm, debridement, and primary closure of the forearm and hand. successive dressings and debridement was maintained and, at th postoperatory day(po) the external fixator of the left humerus was removed and a nailing was performed as well as an osteosynthesis of the clavicle fracture with anatomical plate. at thpo the external fixator of the forearm bones was removed and an open reduction and internal fixation of the radius with lcp plate and closed reduction and internal fixation of the ulna with an anterograde ten nail was performed. at thpo, she underwent an autologous skin graft of the forearm and hand wounds. good clinical evolution of the wounds and fractures, all of which evolved to consolidation, although m fracture malunion was verified as well as deficit of thumb abduction and extension of rd- th fingers. uefi of / . comments: the approach of polytrauma patients should be sequential, according to the atls protocol, preserving life, limb and function. treatment of these lesions is complex and, if poorly managed, can be associated with high morbidity, as most patients combine severe and contaminated lesions, extensive skin loss, open fractures, postoperative infection. a sequential approach is required, which involves injury assessment, infection prevention, soft tissue treatment and fracture stabilization. introduction: pelvic fractures, though rare ( - %), are often associated with high mortality ( - %). the factual outcomes in polytrauma patients with the additional burden of pelvic fractures are unknown. the purpose of this study is to provide an in-depth analysis of pelvic fractures in seriously injured patients. material and methods: this is a retrospective analysis of prospectively maintained trauma registry from to . we included all trauma patients with iss c . group i, which had an additional burden of pelvic fractures, was compared with group ii, consisted of patients without pelvic fractures. a double-adjustment propensity score match (psm) analysis was utilized to minimize confounding and unbiased estimation of the impact of pelvic fractures. . ± . , asmd = . ).patients in group i had higher number of genitourinary surgery (p = . ), exploratory laparotomy (p = . ). therequirement of angio-embolization was similar in between two groups (p = . ). while there were no difference in mortality (or . , % ci . - . , p = . ), group i had higher odds of severe sepsis (or . % ci . - . , p = . ) and ventilator-associated pneumonia (or . , % ci . - . , p = . ) conclusions: pelvic fractures in polytrauma patients did not translate into higher mortality. however, there was an increased risk of sepsis and vap. evidence-based management at tertiary care specialized centers can further enhance the outcomes. investigation/results: ap pelvis x-ray reveals a complex left proximal femur fracture with neck and trochanteric extension. a ct-scan was obtained and showed a complex fracture pattern with subcapital and trochanteric extension. blood analysis showed a hemoglobin of . g/dl. diagnosis: therapy and progressions: at admission, patient refused erythrocytes'' concentrate transfusion and was hospitalized for pain control and hemodynamic stabilization. despite alternative measures such as intravenous iron supplementation and erythropoietin, hemoglobin values remained lower than . g/dl, thus preventing any surgical procedure. at day , patient finally decided to accept packed red blood cells and was then transfused. at day and with a hemoglobin of . g/dl, the patient was finally submitted to a total hip arthroplasty with an uncemented revision femoral stem. at day , the patient initiated the rehabilitation protocol with hospital discharge at day with a hemoglobin of . g/dl. comments: proximal femur fractures arise as one of the major problems of present traumatology. comorbidities frequently prevent surgical treatment within the golden hour (first h) and thus limiting the postoperative results. in this particular case, a timely surgical approach would have made it possible to try a more conservative procedure with femoral osteosynthesis. the surgical delayed due to low hemoglobin values limited the surgical options and forced a more aggressive procedure. routine versus on demand removal of the syndesmotic screw; a multicenter randomized controlled trial on functional outcome introduction: syndesmotic injuries are common, being present in approximately - % of surgically treated ankle fractures . one of the most commonly used ways of fixation is the syndesmotic screw (ss). traditionally, this screw is removed after - weeks as it is thought to hamper ankle function and cause pain. however, a recent study showed that implant removal does not always result in improvement of functional outcome . with the relatively high complication rate of implant removal in mind, retaining sss could be beneficial. we therefore aimed to investigate the effect of retaining the ss on functional outcome. material and methods: in this multicenter rct, patients were randomized between routine and on demand removal (upon patients request). the primary outcome was functional outcome at months after ss placement, measured by the olerud-molander score (omas) with a non-inferiority limit of points ( % power, a = . ). secondary outcomes include quality of life, range of motion, complications and costs of ss removal. results: a total of patients were randomized, of which for routine removal and for on demand removal. the mean age was years old and % was male. follow up of all participants will be completed in march . results of the primary outcome analysis are therefore not yet available, but will be at the conference. conclusions: if on demand removal of the ss is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care. this means that patients will not have to undergo a secondary procedure, resulting in fewer complications and subsequent lower costs. introduction: treatment options for pertrochanteric fractures of the hip are extra-or intramedullary fixation. the aim of this study is to identify risk factors for the development of complications: varus deformity, neck shortening, revision and cut-out. material and methods: retrospective cohort study in which radiographs of patients with pertrochanteric fractures, treated at the uz brussel between and , were reviewed. fracture type, type of the device, cut-out and revision where noted. measurements for the centrum-collum-diaphyseal angle (ccd) of the two hips, impaction, tip apex distance (tad), parker''s ratio were realized. statistical analyzes were made with logistic and multiple linear regression analyzes. results: patients were included. bmi (p = , ), type of osteosynthesis (p = , ), dhs ? plate (p = , ), short nail (p = , ) and the tad (p = , ) are independent risk factors for the development of varus deformity after consolidation. for impaction are bmi (p = , ), short nail (p = , ), long nail (p = , ) and fracture type a (p = , ) independent risk factors. we identified a marginal statistical significant risk factor for cut-out: tad (p = , ). conclusions: , % of the patients had varus deformity after consolidation. the risk of varus deformity rises with a higher bmi and a higher tad. the risk for this complication was higher when using a nail. neck impaction was shown more together with a high bmi and less in fracture type a and with the use of a short or long nail. in the prevention of cut-out, it is important to keep the tad low. case history: -year old female with previous distal femoral plating ( years ago) and ipsilateral proximal femoral nailing ( months ago) presented with a diaphyseal femur fracture. clinical findings: extremity was swollen, painful, neurocirculatory intact, no shortening or external rotation was seen. she was unable to lift her leg. scars showed no sign of infection. investigation: x-ray revealed a spiral fracture including distal pfna locking screw, unhealed proximal femur fracture without loss of reduction, protruding pfna blade and a healed distal femoral fracture. diagnosis: peri-implant fracture classification proposed by the singapore group presented a discrepancy between nail type subtype b and plate type subtype. by simplification, we disregarded the distal (healed) fracture to choose the first option. therapy: firstly, the distal femoral plate was removed as the preoperative simplification dictated. secondly, pfna distal locking screw was removed and the pfna blade shortened. after open reduction cerclage wires were applied. a long lcp plate was initially fixed through the plate and pfna locking hole, adjusted in line, fixed proximally with screws through a locking attachment plate and cerclage, distally locking screws were used. comments: distal femoral callus prevented the use of a long nail. as the proximal fracture was not yet healed, we avoided full implant removal. as the pfna was unstable, fixation through the plate and pfna distal locking hole enabled implant coupling to strengthen the construct. the plate covered the entire bone to bridge the possible loci minori left by the plate removal and minimize stress risers. background: we have been reported the usefulness of intra-medullary antibiotics perfusion (imap) and intra-soft tissue antibiotics perfusion (isap) for suppressing open fracture and bone infection. imap and isap was a method of antibiotics delivery with the continuous administration of high-dose aminoglycosides. however, the best dose was not obviously. the purpose of this study was to evaluate translation of aminoglycosides from imap or isap. as follows: males and females, average age was . years old, intramedullary nails and plates. one dialysis patient was including. we measured concentration of gentamicin from imap, isap and in blood, outflow. results: average administration concentration of all cases was . lg/ml. average blood concentration of all cases was lg/ml and outflow concentration were . lg/ml. average blood and outflow concentration of each dosage were shown as follows: lg/ ml: . lg/ml, lg/ml, lg/ml: . lg/ml, . lg/ml, lg/ml: . lg/ml, lg/ml, lg/ml: . lg/ml, . lg/ml. in dialysis patient case, lg/ml administration lead concentration of blood as . lg/ml, outflow as lg/ml. side effect were not observed. discussion: local antibiotic administration using imap and isap showed increasing blood concentration depend on administration dose. under lg/ml administration dose showed safe blood concentration(\ lg/ml). on the other hand, lg/ml administration dose achieve trough concentrations over - times of minimum inhibitory concentration. furthermore, we need to pay attention for administration dose in dialysis patient case. conclusion: lg/ml administration dose achieved safe and effective local concentration. introduction: distal radius fractures and supracondylar humerus fractures are two of the most common fractures seen in children. most can be treated with non-operative treatment but a small number require operative reduction and surgical stabilisation, often with percutaneous kirschner wires. this study aims to identify whether an early review is required before planned removal of the wires. materials and methods: retrospective review of paediatric patients undergoing surgical reduction and stabilisation with percutaneous kirschner wires for upper limb injuries. data collected over threemonth period (june-august ). number and type of outpatient reviews, imaging episodes and clinical interventions recorded. results: consecutive patients with mean age years (range - ). distal radius fractures and supracondylar humerus fractures. patients transferred to another unit. / patients received a week check and then a second review where the wires were removed. mean time to first outpatient review . days (sd . ). at initial appointment all patients had a change of cast and a satisfactory radiograph. mean time to second outpatient review was . days (sd . ). at the second appointment / patients had the wires and cast removed and subsequent satisfactory radiograph. / required a further period of casting. / had a third appointment. / required formal physiotherapy after cast removal. there was one transient anterior interosseous nerve palsy after supracondylar fracture stabilisation. clinical union of the fracture and good functional outcome was seen in all cases. conclusion: the initial outpatient review at - weeks allows a lighter weight cast to be applied but in this series the radiograph taken after the cast was changed did not alter management. our findings support a cast change alone at weeks and then clinician review with radiographs at the time of wire removal. introduction: the aim of this study was to describe surgical technique, report on patient-based functional outcomes and complications following open reduction and internal fixation in patients with scapular fractures. methods: the study comprised patients who were treated with open reduction and internal fixation (orif) of a scapular fractures between september and july . surgical indications were as follows: medial/lateral displacement greater than mm; shortening greater than mm; angular deformity greater than °; intraarticular step-off greater than mm and double shoulder suspensory injuries (including fracture of clavicle, coracoid or acromion with displacement greater than mm). all patients underwent x-ray examination (true ap, y scapular view) and computed tomography (ct) scans. fractures were classified according to the revised (ao/ota) classification system. functional outcome were measured using the constant-murley score. results: seven patients had glenoid fossa fracture, six patients had scapular body fracture and one patient had acromion process fracture. all glenoid fossa and scapular body fractures were exposed via the judet approach. eleven of patients were reviewed with constant-murley score at the final follow-up examination, three patients were lost for follow-up. the mean follow-up after injury was months ( - months). we found in four patients infraspinatus muscle hypotrophy. mean constant-murley score was . (± . ) for injured arm and . (± . ) for uninjured arm. mean score between injured and uninjured arm was . (± . ) which is excellent functional outcome according to grading the constant-murley score. conclusions: open reduction and internal fixation of displaced scapular fractures is a safe and effective treatment option that results in reliable union rate and good to excellent functional outcome. introduction: the aim of this study was to evaluate clinical and radiological results of intramedullary radius and ulna nails in treatment of adult forearm fractures. methods: the retrospective study included patients who were treated with intramedullary nailing of forearm fractures between january and september . the medical records and radiographic images of all patients, taken preoperatively and postoperatively, were reviewed. fractures were classified according to the ao/ota classification system by reviewing the radiographs. we analayzed time to union, union rate, clinical outcome and complications. results: primary intramedullary osteosynthesis were performed in patients with forearm diaphyseal fractures. the average time to union was months (range, - months) in primary osteosynthesis cohort. secondary intramedullary osteosynthesis were performed in four patients following removal of plates and screws due to pseudoarthrosis. the average time to union was months (range, - months) in secondary osteosynthesis cohort. overall union rate was , % in forearms with fractures or pseudoarthrosis of the radius, ulna, or both bones, which were treated with intramedullary nail with compression screw. overall complications were one nonunion, one postoperative rupture of the extensor pollicis longus tendon and one postoperative transitory radial nerve palsy. conclusions: intramedullary nailing of adult forearm fractures is a safe and effective treatment option that results in reliable union rate and good to excellent clinical outcome. key words: forearm fractures, intramedullary nailing, biological fixation, union rate results: transverse or short oblique fractures of the middle third of the humeral shaft were treated using a retrograde approach. spiral fractures of the middle third of the humeral shaft were treated through the antegrade approach. comminuted fractures of the proximal third of the humeral shaft were treated mostly through the antegrade approach. comminuted fractures of the distal third of the humeral shaft were usually treated using the retrograde approach. whenever possible, we prefer retrograde insertion because the approach through the shoulder joint is avoided. reduction with retrograde nailingnis easier because upper arm was placed on the radiolucent operating table extension. interlocking screw insertion by freehand techique is also easier to perform because there is no danger of radial nerve injury. nonunion was found in eight patients ( , %). there were five patients ( , %) with postoperative transitory radial nerve palsy that fully recovered within months. conclusions: the choice of approach to the medullary canal depends on the fracture type and the fracture site. therefore, antegrade nailing should be performed for proximal third humeral shaft fractures and complex middle third humeral shaft fractures, while retrograde nailing should be perforemd for distal third humeral shaft fractures and simple transvese or short oblique middle third humeral shaft fractures. keywords: humeral shaft fractures, intramedullary nailing, radial nerve palsy, nonunion the diaphyseal aseptic tibial nonunions after failed previous treatment options managed with the reamed intramedullary locking nail i. kostic , m. m. mitkovic clinical center nis, university hospital, orthopaedics and traumatology, nis, serbia, university of nis, serbia, orthopaedics and traumatology, nis, serbia introduction: in this article, we present our approach to the surgical treatment of noninfected tibial shaft nonunions. material and methods: between and , patients with aseptic diaphyseal tibial nonunion was treated by reamed intramedullary nailing and were retrospectively reviewed. all patients, preoperatively, were evaluated for the signs of the infection, by the same protocol. results: the time that elapsed from injury to intramedullary nailing ranged from to months (mean months).open intramedullary nailing was unavoidable in cases ( , %), while closed nailing was performed in patients ( , %). all patients were followed up in average period of years postoperative (range - years), and ( , %) patients achieved a solid union within the first months. conclusions: in conclusion, a reamed intramedullary nail provides optimal conditions for stable fixation, good rotational control, adequate alignment, early weight-bearing and a high union rate of tibial non-unions. percutaneous figure of suture as a novel technique for treating closed tendinous mallet injuries following failed splinting therapy. t. eltantawy , a. yousif , k. maheshwari , a. hartpinto bedford hospital, plastic surgery, bedford, united kingdom introduction: mallet injuries are common injuries affecting the hand. majority of them are managed using conservative method, however a small percentage of patients that do not do well on conservative treatment need an operative intervention. we wish to evaluate the efficacy of percutaneous figure of suture as a new technique for treating closed tendinous mallet injuries resistant to splinting therapy, as a minimally invasive treatment option. material and methods: we present a case series of patients who had persistence of more than degree extensor lag, despite splinting minimally for weeks. all of these were treated with a percutaneous figure of suture placed across the dorsum of dipj, which provided splinting for further weeks. this technique provides fixation for the dipj in hyperextension position by going through the periosteum on both sides and was done under local anaesthesia. results: the mean age of our patients was years, with a single digit involved in all patients. all the five cases had nearly fully straight dipj with less than °extensor lag following weeks of percutaneous stitch placement. there was no further recurrence with mobilisation or overlying skin necrosis. conclusions: percutaneous figure of suturing technique can be an effective, minimally invasive and safe technique to treat closed tendinous mallet injuries not responding well for conservative splinting. introduction: osteosynthesis of pertrochanteric fractures (pf) is a frequently performed procedure in orthopaedic trauma care. dynamization of the osteosynthesis during fracture healing can lead to dynamization of the lag screw. which can cause debilitating complaints. a spontaneous femoral neck fracture (sfnf) after implant removal was seen in patients over a month period. based on these cases we evaluate the different aspects of the pathophysiological and mechanical mechanisms of lag screw dynamization, complaints and complications in pf healing. material and methods: pubmed search on incidence of chronic pain, gait impairment associated with dynamization of osteosynthesis, risk factors for dynamization and complications after implant removal. based on research data preventive recommendations are suggested. results: literature describes complaints as reduced mobility, gait impairment and chronic pain in association with lag screw dynamization. an important risk factor is the ao-classification of pf, a type fractures are significantly associated with more dynamization and the onset of trochanteric pain and gait disturbances. partial implant removal can reduce complaints in the majority of symptomatic patients, and induce symptoms in % of asymptomatic patients. literature study shows a sfnf after lag screw removal with an incidence of %, affecting mostly vulnerable elderly patient resulting in a high mortality rate. risk factors associated with an increased risk of this complication are pre-existing systemic osteoporosis, stress-shielding, pre-loading of the implant. most importantly the removal itself, a sfnf with the implant in situ is very uncommon. conclusions: the clinical indications for implant removal in healed pf are not well established, and should be restricted to specific cases. after removal, partial weight bearing and good patient counselling is extremely important. replacement with shorter lag screw should be considered. metal osteosynthesis of pathological bone fractures with metastatic lesion of plates with a spray on their surface of hydroxyapatite and % silver v. protsenko , a. abudayeh , v. chornyi , y. solonitsyn institute of traumatology and orthopedics of nams of ukraine, onco-orthopedics, kiev, ukraine, bogomolets national medical university, kiev, ukraine introduction: surgical intervention in the case of pathological bone fracture against the background of metastatic lesion involves performing osteosynthesis. for more effective integration of the metal plate with the bone, a material based on bioactive glass was sprayed on their surface. bioactive glass-based material is an osteoinductive and osteoconductive biomaterial that integrates quickly with bone, forms a bone-ceramic complex, and is transformed into bone over time. material and methods: metal osteosynthesis of pathological bone fractures with metastatic lesion of plates with spraying on their surface of hydroxyapatite and % silver was performed in patients. the functional result of the operated limb was calculated on the msts scale. evaluation of pain was performed on the scale of r.g. watkins. the quality of life of patients was evaluated using the eortc qlq-c system. the evaluation of the integration of the plate with the bone was performed by radiological examination and by osteoscintigraphy. results: postoperative complications were found in ( , %) patient, recurrence of metastatic tumor was noted in ( , %) patients. the functional result of the operated limb after metal osteosynthesis was , %. the degree of pain decreased from , % to , %. the quality of life of patients after metal osteosynthesis improved from to points. x-ray examination revealed the formation of callus within a shorter timeframe, as evidenced by the more intense accumulation of radioisotope during osteoscintigraphy. introduction:the aim of this study was to evaluate the results in patients who had heal intertrochanteric fracture but did not receive adequate mobilization and rehabilitation support. material and methods:sixty patients over years old age were included in our study. the rehabilitation emphasized pain relief, muscle strength, range of motion, endurance, balance challenges, and proprioceptive enhancement for all patients. it started postoperative first day and was delivered twice a day by the physical therapist until discharge. patients were discharged on average . days ( - days) after surgery. the mobilization of patients was evaluated with the parker and palmer mobility scoring system, the clinical evaluation was performed with the haris hip scoring and daily living activities were evaluated with the barthel life index before and at the end of the fracture. results: female male patients were included in our study. the mean age was , ( - ) years and the mean follow-up period was , ( - ) months. patients had a type, patients had a type intertrochanteric femur fracture. in the last follow-up, all patients had fracture union. patients' mobility, daily life activity and clinical evaluations were found to be statistically significantly worse in the last control than before surgery. conclusions:the success of the surgical treatment and the union of the fracture after fixation are not sufficient for the successful mobility,daily life activity,and clinical results.the success in the functional results are significantly related with the ambulatory ability.although early mobilization and rehabilitation support are important in intertrochanteric femur fractures after surgery,the continuity of mabilization and rehabilitation support after hospital discharge is more important.the rehabilitation which administered by the patient''s ralations after hospital discharge is not sufficient.therefore,the importance of home-based rehabilitation is increased. the prognostic value of the hip screw position in trochanteric fractures i. gárgyán , î csonka , t. ecseri university of szeged, department of traumatology, szeged, hungary introduction: in our study, we analyzed one of the hungarian population's most frequent injuries, the hip fracture, focusing mainly on the lateral femoral neck and the pertrochanteric fractures. according to the classification of the swiss association for ostheosynthesis (ao), we focused on -a and -a fractures, the incidence of which increases by ageing. material and methods: between and , we analyzed the data of patients. all of the fractures were stabilized with intramedullary nails. patients received stryker gamma Ò , whereas patients' fractures were solved with synthesis pfna Ò nail. in all cases, closed reduction method was used with fluoroscopy on an extension table. the surgeries were done in general or epidural anesthesia and performed by traumatology residents or specialists using standard lateral exploration. data were collected using gepacs software and statistical analysis was done with ms excel. results: cut-out occurred in cases ( , %): out of that ( . %) were left sided and were ( , %) right sided. ( . %) patients were treated with gamma nail, and in ( , %) cases pfna nail was used. the average tad-index was mm. conclusions: according to recommendations of the tad-index value, when using dynamic hip screw, it should be mm or lower. the average index value was mm which was equal in the complicated and non-complicated groups. our study shows that the cutout is independent from the tad-index value, thus this recommendation cannot be applied for intramedullary nails. oita university hospital, acute trauma, emergency, and critical care center, yufu, japan, oita university, orthopaedic surgery, yufu-city, oita, japan introduction: dome impaction fragments (difs) in acetabular fractures are typically accompanied with anterior column fragments and recognized as the gull sign on plain radiographs. meanwhile there are some difs which do not fit into typical difs. the aims of this study were to define atypical dif and describe tips for diagnosis and intraoperative visualization. material and methods: this study was a retrospective case review. we defined atypical difs as the fragments which were independent of anterior column fragments and did not show the gull sign on plain radiographs. from jan to july , there were patients of acetabular fractures, and patients ( . %) had difs. among them, patients ( . %) were identified as the cases with atypical difs. all of them were male. the ages were from to . results: the atypical difs were not obvious on x-rays (fig. ) . all three atypical difs were located at posteromedial weight bearing zones of the acetabulum. case and were displaced in accordance with posterior column fragments, and were visualized clearly on the sagittal view of ct images (fig. ) . case was impacted posteriorly into a posterior part of the ilium as a free fragment, and well visualized on ct sagittal and coronal views. anterior intrapelvic approach was chosen in all patients to treat atypical difs. the iliac oblique view was useful to visualize the atypical difs intraoperatively in case and . in both cases, the reverse gull sign appeared after reduction of posterior column fragments (fig. ) . in case , the inlet view was useful to visualized the atypical dif intraoperatively.the fragments were reduced and fixed with supra-acetabular screws (fig. ) . results: we found prospective two to years after acetabular osteosynthesis , % complications. avn of the femoral head was present in , % of the hips reduced within h and , % of the hips reduced more than h after the injury [p = , ; = , ; or = ( % ci = , - , ) ]. post-traumatic oa of the hip we found in , % (fig. ) infections we found in , % ( deep, superficial), iatrogenic nerve palsy in ( , %), traumatic nerve palsy in , % ( ), dvt in , % ( ) , and ho in , % ( ) cases. in one case ( , %) revision surgery was done. conclusions: acetabular fractures are followed with complications. some complications depend on surgery, meanwhile others cannot be affected on (type of fracture, impaction of acetabulum, injury of the femoral head, dislocation of femoral head). good knowledge of acetabular anatomy, surgical technique, experienced surgical team, early surgery, anatomical reduction and stable orif, early mobilization, can significantly influence excellent/good functional outcomes and reduce possibility for complications. introduction: reduction is one of the important factors in surgical treatment of femoral trochanteric fractures. in this study, postoperative reduction status was examined and the relationship between this reduction status and unsatisfactory cases was investigated. material and methods: cases of femoral trochanteric fractures over years treated with pfna-ii were investigated. postoperative reduction status was evaluated in ap and lateral view of x-ray and ct. anatomical reduction means medial or anterior cortex is reduced anatomically (abbreviation am and aa). intramedullary reduction means medial or anterior cortex of proximal fragment is inside the shaft (im, ia). extramedullary reduction is medial or anterior cortex of proximal fragment is overlapped to cortex of shaft (em, ea). unsatisfactory cases were ununited cases until months and excessive sliding cases over mm. reduction status of these cases was evaluated. results: postoperative status was classified with combination of medial and anterior reduction status. so there are nine groups and number of each group are as follows; im-ia: case, im-aa: cases, im-ea: case, am-ia: cases, am-aa: case, am-ea: cases, em-ia: cases, em-aa: cases, em-ea: cases. non-united cases until months were cases. reduction status of non-united cases were; im-ia: cases, im-ea: cases, am-ia: cases, am-aa: cases, em-ia: cases, em-aa: cases. there was no case in extramedullary reduction of anterior cortex. excessive sliding of blade over mm was cases. there was also no case of extramedullary reduction of anterior cortex in these cases ( cases were cut out). conclusions: our results show there are no ununited cases and excessive sliding cases in extramedullary reduction of anterior cortex. this means extramedullary reduction of anterior cortex is important to reduce unsatisfactory results in surgical treatment of femoral trochanteric fractures. male injured open lateral condyle fracture of femur by to be bitten by a pig. after months from initial debridement, i confirmed the size of bone defect was cm( ) cm in depth. the same size of bone was harvested from iliac crest and transplanted in the bone defect area of lateral condyle of the femur. after months from bone transplantation, i confirmed bone union and two . mm diameter osteochondral grafts and . mm diameter osteochondral graft were transplanted for the chondral defect lesion. case ; seventy year old male injured open lateral condyle fracture of femur by traffic accident. after months from first debridement, i confirmed the bone defect (size cm( ) cm in depth) and the same size of bone was harvested from iliac crest and transplanted in the bone defect area. and simultaneously two mm diameter osteochondral grafts were transplanted for the chondral defect lesion. case ; year old male injured open lateral condyle fracture of femur by traffic accident. i confirmed the size of bone defect was cm( ) cm in depth. the same size of bone was harvested from iliac crest and transplanted in the bone defect area of lateral condyle of the femur. after month from bone transplantation, he had undergone autologous chondrocyte implantation. investigation/results: at last follow-up, average flexion angle of knee was degrees. in all cases, lysholm knee scoring scale was good. diagnosis: large traumatic osteochondral defect of the weightbearing articular surface of the knee comments: treatment of large traumatic osteochondral defect of the weight-bearing articular surface of the knee is a difficult condition to treat. combination of bone transplantation and osteochondral autograft transfer or autologous chondrocyte implantation is useful strategy for the injury. references: tegner y., lysholm j., clin orthop relat res., , - , pr treatment of double tension band wiring method with ai wiring system for transcondylar distal humeral fractures m. uchino hakujikai memorial general hospital, orthopaedic surgery, tokyo, japan introduction: as ai wiring system is united the pin with the cable due to compressed sleeve, the pin is never deviated. we review the treatment of transcondylar distal humeral fractures with ai wiring system in geriatric patients. patients and methods: were identified as receiving this surgery. all patients were female and their mean age was years. they were assessed union rate, range of motion for elbow joint, postoperative complication and functional outcome for japanese orthopedic score. results: union rate was %. the mean arch of motion was °at latest follow-up. the complications were detected cases which were temporary ulnar palsy for cases and hardware failure for case. the average of functional outcome was points ( / ). conclusion: tension band wiring of transcondylar distal humeral fractures with ai wiring system provides stable fixation for osteoporotic bone and tiny fragment. introduction: the purpose of this study was a comparative evaluation of the complications related to the treatment of trochanteric fractures using -screw proximal femoral nail (pfn) versus proximal femoral anti-rotational blade nail (pfna). material and methods: a retrospective review was conducted between march and march . the study included patients treated surgically for trochanteric fractures. the mean age was , ± , ( - ) years. patients were treated by pfn ( patients, , %) or by pfna ( patients, , %). implant related complications were the primary objectives. infection and revision surgery were also recorded. results: complications were observed in ( . %) patients in pfn group and ( , %) patients in pfna group (p = . ). screw backout (n = ) and cut-out (n = ) occurred in , % patients treated with pfn. in the pfna group, cut-out occurred in , % (n = ) of cases. infection (n = ) represented , % in pfna patients and , % (n = ) in pfn group. there were no statistically significant differences in both groups considering implant-related complications (p = , ) and infections (p = . ). revision surgery was performed in ( , %) patients. soft tissue problems are more likely in fractures due to high energy impact than low energy type fractures. high energy type present with horizontal fractures of tibia and fibula (i.e. on the same level), whereas in low energy type tibia fractures they present with spiral or oblique fracture patterns often associated with concomitant fractures of the posterior rim of the distal tibia (i.e. volkmann's triangle). posterior malleolus fractures occur regularly but are often missed and seen only on ct scans obtained either for preoperative planning or to verify postoperative rotation. in literature these mostly undisplaced fractures are treated with screw fixation mostly from anterior. but is this really necessary? material and methods: we retrospectively analysed consecutive tibia shaft fractures operatively treated over the past years at our regional hospital analysing the fracture pattern. results: out of patients with tibia shaft fractures patients presented with a posterior rim fracture of the tibia. no routine stabilisation of the volkmann fragment was performed, in all cases the posterior rim fragments healed uneventful. angles of °and above seem to present themselves with a concomitant fracture of the posterior malleolus. they are mostly undisplaced and the trauma mechanisms is low energy and torsion. none out of the patients had known osteoporosis. conclusions: low energy and torsion-type tibia fractures with an angle of [ °seem to have an accompanying undisplaced fracture of the posterior malleolus. these fractures are usually undisplaced and do not need to be addressed. as a consequence there seems to be no need to actively rule them out with ct scans prior to surgery. concomitant ankle fractures including posterior rim fractures should be addressed like isolated ankle fractures. the dangers of bouncing: a prospecive cohort study of injuries associated with trampolines and bouncy castles over a month period in a paediatric population. introduction: within the orthopaedic paediatric population, there is an increasing incidence of presentation of fractures associated with both trampolines & bouncy castles. whilst this phenomenon has been depicted frequently within the media in recent years given the dramatic upsurge in trampoline and bouncy castle usage, there have been few studies documenting either the incidence of fractures associated with either. materials and methods: this was a prospective cohort study conducted within our institution over a month period june to august inclusive . all paediatric patients who sustain a fracture and present to the national childrens'' hospital are referred to the orthopaedic department either whilst as an inpatient or as an outpatient depending on the assessment of the severity of injury. a standardised mixed questionnaire was given to all parents''/guardians which recorded the type of injury, type of trampoline/bouncy castle, inherent awareness of safety precautions governing the usage of either and application of same was recorded. the type of fracture was corroborated via examination of x-ray in addition to the recording of any complications via examination of clinical chart records. results: there were patients who sustained a fracture directly related to the usage of either a trampoline or bouncy castle for which the majority required operative intervention. there was wide variability in the nature of injuries recorded; supracondylar/radial fractures were the most common whilst more complex injuries such as an open fracture of the femur was rarer. conclusions: awareness and application of necessary safety precautions was low ( %) amongst parents'' supervising parents''/guardians highlighting the need for greater public awareness of same. furthermore, the incidence of severe injury relating to usage of trampolines/bouncy castles is not uncommon highlighting the high risk activity that trampolining is. introduction: conventional plate fixation (pf) of distal fibular fractures in elderly patients is associated with a high risk of wound and implant related complications. intramedullary fixation (imf) using a fibular nail is a minimally invasive alternative to pf that provides superior biomechanical strength and allows immediate full weight-bearing postoperatively. aim: to compare the postoperative complications of minimally invasive intramedullary nail fixation to conventional pf for lauge-hansen supination external rotation type fractures in patients aged years or older treated in a single geriatric trauma unit in the netherlands. methods: a retrospective cohort study was performed including unstable ankle fractures in patients aged years or older treated with either imf or pf between january to january . the primary outcome measure was the total number of wound related complications. results: a total number of patients were included with a mean age of . years (range to ). the imf-cohort (n = ) had a significantly higher mean age ( . versus . years, p = . ) and charlson co-morbidity index ( . versus . , p = . ) compared to the pf-cohort (n = ). the total number of postoperative complications was lower after imf ( %) compared to pf ( %), although this relative difference was not statistically significant (p = . ). all complications observed in the imf-cohort were wound related but demanded no debridement or implant removal. wound related complications did not differ significantly from pf ( % versus %, p = . ). no implant related complications, hospital-acquired complications or mortality were observed after imf. conclusion: despite the higher mean age and co-morbidity status of patients treated with a minimally invasive intramedullary nail, the total number of postoperative complications was lower after imf compared to pf. this technique might be a promising alternative in a selected group of patients. the authors declare that they have no commercial associations that might pose a conflict of interest. no funding or other compensation was received for the research, authorship or publication of this article. gustilo type ii and gustilo type iii fractures. the treatment protocol was external fixation at admission and definitive osteosynthesis with plate at ± days. a single approach to the tibia was performed in patients, and a combined anterior and posterior approach was used in . the incidence of complications was %: cases of poor soft tissue evolution, of which were infections. patients evolved to nonunion. osteoarthritis appeared in % of patients ( . % grade ), and only one patient needed arthrodesis. . % had a valgus ldta (\ °) and . % a varus deformity ([ °). we found a significant relationship between the history of open fracture and the development of complications (p \ . ). we found no relationship between the incidence of complications and the approach. conclusions: tibia ao c fractures have a high percentage of complications and evolve to well-tolerated osteoarthritis. open fracture seems to significantly influence the poor postoperative outcomes of these patients. clinical findings: a -year-old male, who suffers a closed chest trauma with pneumothorax, right pulmonary contusion and poor pneumoperitoneum. also a grade iiia open fracture of the right femur, with a cm bone defect. investigation/results: upon arrival at the hospital, he needs orotracheal intubation, as well as blood transfusion with red blood cell concentrates. external fixator is placed on the right femur. diagnosis: a iiia grade diaphyseal open fracture of the right femur with cm bone defect, bearing external fixator with one broken proximal pin and positive culture for s maltophila in the distal pin. therapy and progressions: antibiotic treatment and medical optimization are performed, cemented intramedullary nailing (t -stryker) with antibiotic (vancomycin-tobramycin), as well as cement spacer with antibiotic (masquelet's first stage) in the defect area. in second time, withdrawal of spacer and contribution of ria autograft of contralateral femur and allograft respecting membrane. the patient begins the protected weight bearing with two crutches immediately, without using them months after the surgery. bone consolidation without pain or limitation after year. comments: the induced membrane technique is a simple and effective technique for the reconstruction of segmental bone defects and can be used as a first time technique together with the initial stabilization, leaving the defect ready for graft delivery in the second time. introduction: carpal metacarpal dislocation is a rare entity that accounts for less than % of all carpal injuries. dorsal dislocations are the most common and occur most frequently after violent trauma in young individuals and are easily overlooked and may lead to longterm sequelae. material and methods: we present the case of a carpal metacarpal dislocation from d to d . male, years old, no relevant personal history. brought to the emergency service after a motorcycle accident with projection. he had a symphysis pubis diastasis, a distal radius fracture on the right wrist and a fracture of the left forearm bones. no other apparent injuries associated. at week , he presented edema and dorsal deformity of the left hand associated with limited finger movements. neurovascular assessment was normal. the radiological evaluation showed a carpal metacarpal dislocation from m to m . it was an unstable reduction so open reduction was performed, with debridement of fibrous material, until exposure of the articular surfaces, and reduction and fixation with k wires of the three metacarpals (from d to d ). similarly, m was stabilized with a k-wire due to clinical instability observed intraoperatively. results: it is necessary to reduce and stabilize these lesions to avoid vasculonervous compression and skin distress. open reduction is indicated in irreducible cases allowing debridement and excision or os of small osteochondral fragments and fixation of associated fractures. conclusions: combined dislocation of multiple metacarpals is a rare lesion that compromises the functional prognosis of the hand in the absence of adequate treatment. instability and post traumatic arthrosis are among the sequelae of this lesion. identify the lesion to allow the appropriate treatment usually leads to good results. case history: -year-old suffered direct trauma to his right hand after falling off his bicycle. clinical findings: on physical examination showed edema and bruising from the base of the thumb and thenar eminence, tenderness over the cmc joint and functional disability speacialy in pincer grasp. no neurovascular injuries investigation/results: the x-ray revealed a comminuted fracture of the base of the thumb metacarpal. diagnosis: we identifed a rolando fracture. therapy and progressions: on the day after the trauma, he was submited to open reduction and osteosinthesis with lateral-palmar plate and screws, through radiopalmar aproach of the thumb base. intra operatively no dorsal fragments werefound to be left undisplaced. two months after surgery, the patient went back to the hospital for sudden pain and inability to extend the thumb. clinically with rupture of the long extensor of the thumb. on the x-ray, the fracture was aligned. the latero-lateral tenorrhaphy with kessler suture was preformed and intraoperatively a bony spicule was identified in the proximal stump of the tendon, which was removed. months after the initial trauma, the patient has a consolidated neck and no limitation of the mobility of the thumb. comments: rollando fracture is relatively rare in adolescents. the aim of treatment should be exact reduction usually with open technics. the main complications are stifness and early arthrosis. there are also records of conflicts with the plates and even rupture of the extensor tendon, so the radiopalmar placement of the plate was chosen. nevertheless, the rupture occurred due to conflict with an unidentified bone fragment during surgery causing an unexpected complication in this case. the immobilization necessary after tenorrhaphy could have caused joint stiffness, but in this case the teenager fully recovered after physical therapy case history: periprosthetic and periimplant femoral fractures are an increasingly frequent pathology. in many cases they are a challenge with limited or too aggressive therapeutic options. it is important to investigate new approaches that increase the arsenal of the orthopedic surgeon. the recently described mipo (minimally invasive plate osteosynthesis) approach for the medial aspect of the femur may seem like a dangerous procedure because of the anatomical structures that run along the medial aspect of the thigh, but it is a viable and useful option in selected cases. clinical findings: we present the case of a -year-old patient with a total hip replacement who presented a first periprosthetic vancouver b fracture of the femur that was treated with a lateral blocked plate. subsequently the patient presented a second supracondylar femur fracture below the first plate (vancouver c). investigation/results: after thinking over the possible therapeutic options, we decided to treat our patient by means of the medial femoral mipo approach with a long medially placed blocked plate, managing to stabilize the fracture and superimpose the plate on the previous implants without the necessity of removing the previous lateral plate. diagnosis: periprosthetic and periimplant supracondylar left femoral fracture. therapy and progressions: we used the surgical technique of the medial femoral mipo approach as described by apivatthakakul . comments: we consider that the medial femoral mipo approach is a useful therapeutic tool to consider. it seems a safe and low-invasive option for the resolution of cases in which the lateral mipo approach is not a feasible option. references: c. jiamton y t. apivatthakakul, « the safety and feasibility of minimally invasive plate osteosynthesis (mipo) on the medial side of the femur: a cadaveric injection study » , injury, vol. , n.o , pp. » , injury, vol. , n.o , pp. - » , injury, vol. , n.o , pp. , nov. . posterior knee dislocation with neurovascular injury associated-a case report case history, investigation and diagnosis: a -year-old male was brought in after h following a heavy straw bale fall. he presented with a posterior knee dislocation that had already been reduced and an open wound in the popliteal fossa. the limb was flushed and pale on the extremity, with absence of the pedis and posterior tibial pulses. stability tests revealed unstable knee in all axes. an anterior shoulder dislocation was diagnosed and reduced. therapy and progressions: an emergent surgery was performed, involving a transarticular external knee fixation and a femoro-popliteal bypass above the knee (angiogram revealed a stop sign at the level of the interarticular popliteal artery). he developed circulatory shock and was admitted to the intensive care unit. on the stpostoperative day(po) was diagnosed a compartment syndrome that was treated with fasciotomies. these incisions showed a slow but progressive evolution, that required vacuum dressings and underwent autologous skin graft on the thpo day. the external fixator was removed on the stpo day and rehabilitation was started. on a -month follow-up, the patient had a good evolution of the wounds, but a knee with valgus and anteroposterior laxity and severe complete peroneal, tibial and sural neurological injury, confirmed with electromyography, and neuropathic pain. introduction: isolated iliac wing fractures represent only a small part of all pelvic fractures. these fractures are associated with severe injuries, but are considered benign. the literature lack information about the function and quality of life of these patients. our objective was to evaluate the long-term effects of isolated iliac wing fractures. material and methods: patients with pelvic fractures treated at oslo university hospital, ullevaal, in the time period - , were extracted from the local fracture registry. patients were registered in this period. a search was also made in the hospital''s administrative electronic database for patients registered with diagnose code s . in icd- in the same period. patients were identified. in total, patients had an isolated iliac wing fracture, and these were invited to a follow-up examination, including proms (eq- d- l and majeed score), clinical examination, and pelvic x-ray. results: nine patients agreed to participate in the study, median years after the fracture (range - ). all of them were injured from high energy trauma, with mean niss , (range - ) . four of the fractures were open, and seven of the patients had associated injuries. five were treated with internal fixation. the mean eq- d vas was (range - ). five patients reported pain, one of them related to the pelvic fracture. the mean majeed score was (range - ). seven patients had sensory deficit in the lateral thigh. one patient had difference in range of motion between the two hips. the x-rays showed healed fractures in all the patients. eight of them showed ectopic ossification. conclusions: our study confirms previous studies that isolated iliac wing fractures are results of high energy trauma with severe associated injuries. however, the majority of this group of patients seem to have a good general state of health, which is in accordance with the general assumption of the injury as a benign one. fenton's syndrome-a case report of a common underdiagnosed entity case history: a right handed -year-old male, construction worker, was admitted in our emergency department, after a meters fall. the authors report a case of fenton's syndrome in a politrauma scenarium. clinical findings: both right elbow and left wrist were painful, swollen and with a remarkable restriction of the range of motion (rom). patient also reported lower back pain. no neurovascular injuries were detected. investigation/results: x-ray and ct scan confirmed a fracture of a lumbar vertebra, fracture of the right olecranon and, on is left wrist, a carpal fracture-luxation mayfield of both scaphoid and capitate associated with rotation of the last one proximal pole-fenton''s syndrome. diagnosis: this syndrome is an atypical presentation of perilunate fracture dislocation and, therefore, difficult to diagnose. few reports were found in literature. after an open reduction of the fractures, a definitive fixation with headless herbert screws was achieved. percutaneous kw and immobilization of the wrist were performed to further stabilization of the lunotriquetral joint. weeks later consolidation was noted. a decrease of °in extension and flexion were detected when compared with the contralateral wrist. grip strength test was similar on both hands. osteosynthesis of the right olecranon was also realized. comments: a careful neurovascular assessment is important. although it is rare, injuries of median nerve were already reported associated to this complex fractures. open reduction and osteosynthesis are necessary due to the great instability and the risk of nonunion and osteonecrosis of the rotated proximal segment. introduction: intramedullary nailing has been popularly applied for the femoral shaft fractures. the current study aimed to analyze the femur geometry for development of implant design with dimensional skeletonization. material and methods: we acquired computed tomography (ct) images of both femur reviewed in a single center from to . the total participants were enrolled and they were divided into subgroups according to age (decades) and gender. each subgroup included persons, respectively. these images are used to produce d samplings. with the skeletonization, we obtained the geometry parameter; ( ) femur shaft length from the tip of the greater trochanter to the bicondylar line, ( ) the minimum diameter of the medullary canal and its location, ( ) anteroposterior (ap) diameter and lateral diameter of the entire femur, ( ) radius of curvature (roc) of the femur (bowing). we compared all parameters according to sex and age. results: the average age of the participants were . years (range - years) and the number of each gender was exactly same. the femur length was . ± . mm (range, . - . mm) and the femur shaft length was . ± . mm (range . - . mm), both of them were longer in male (p = . , \ . ). the minimum diameter of the medullary canal was . ± . mm (range . - . mm). the roc was . ± . mm (range . - . mm) . the rate of the minimum diameter less than mm and mm was . % and . %, respectively. the rate of roc with less than mm and mm was . % and . %, respectively. conclusions: this geometry analysis showed that there are mismatch problem between the current nail and the medullary canal in . % and the roc of the femur was smaller than that of the current nail systems ( - mm). the result indicates potential mismatch problem in clinical cases and the problem can be resolved with newly designed nail system. the study was funded by national reserach foundation of korea (nrf- r d a b ). safe zone of the infracacetabular screw: virtual mapping of three-dimensional hemipelvises for quantitative anatomic analysis introduction: an infra-acetabular screw can provide increased stability in fixating acetabular fracture. we conducted this study to define the incidence of the safe corridor for infra-acetabular screw and to determine the correlation between the safe corridor and other demographic factors such as age, sex and height. material & methods: pelvis computed tomography (ct) of participants was extracted with evenly age-and sex-allotted. virtual three-dimensional ( d) model was generated. a search was performed to find the maximum-with corridor connecting two points. the entry and exit point was displaced in the template. the maximum diameter of each corridor was measured in automatic procedure. a minimum mm corridor diameter, sate corridor, was defined as a cutoff for placing a . mm cortical screw in clinical setting. all data were presented as mean and range or mean and standard deviation. two-sample t test and regression analysis were used to compare difference between groups based on sex, age, and height. results: among hemipelvis, hemipelves ( . %) satisfied a minimum safe corridor diameter of mm. when divided into a subgroup by the patient's gender, the incidence of the safe corridor of a male group was statistically higher than a female group ( . % vs . %), with the mean corridor diameter of . mm ( % ci, . ) and . mm ( % ci, . ), respectively (p \ . ). in correlation analysis, only the height showed a positive correlation with the diameter of the safe corridor of a total population (r = . ; p \ . ). conclusions: the study provided the safe corridor was found in % of male and % of female, and the taller had the higher incidence of the safe corridor. the patient''s height was correlated with the corridor diameter of the infra-acetabular screw, whereas the patient''s age did not correlate with the corridor diameter. introduction: femoral neck fractures in middle-aged and older patients represent one of the most common orthopedic conditions. osteosynthesis, as a primary treatment option for femoral neck fractures has shown to have successful outcomes. however, this is not the case for old fractures. the purpose of this study was to evaluate the outcomes of treatment of femoral neck fractures in which cementless total hip arthroplasty was indicated. the aim of our study was to analyze the prosthetic failure, i.e., the reasons for unsuccessful outcome, in order to suggest the indications for primary osteosynthesis which could guide the femoral neck fracture management. material and methods: a total of patients were analyzed in this study, with femoral neck fracture treated with osteosynthesis. reviewing the radiological findings, as well as the course of the treatment, we set up the criteria, on the basis of which we could advice the immediate implantation of total hip prosthesis for the femoral neck fracture. results: old fractures, varus deformity of the femoral head and neck, dislocation, as well as the comminuted fractures, are all factors affecting the surgical outcomes of osteosynthesis. additionally, medical and technical equipment of medical institution, personnel competence, and minutious surgical technique affect the treatment outcomes. introduction:proximal ulnar fractures are usually osteosynthesized by means of angle stable plate osteosynthesis. despite good functional results of this procedure, complications such as high access morbidity and disruptive osteosynthesis material with a high rate of material removal are described. the aim of our study was the development of a new locking nail and test setup for comparison with a plate osteosynthesis on artificial bones. material and methods: in our biomechanical laboratory, a jupiter b fracture of the proximal ulna was standardized on sawbones and stabilized by means of the newly developed nail or anglestable posterior plate osteosynthesis. a servopneumatic testing machine, the specimens were flexed under a cyclic load ( - n) in the physiological range of movement of the elbow from °to °.the maximum elastic deformation of the specimens and the loosening of the implants were evaluated after test cycles. results: the primary stability of the constructs at the anterior cortical bone after nail osteosynthesis was significantly greater ( . ± . mm) than in the angle-stable plate osteosynthesis ( . ± . mm, p \ . ).after passing through the test cycles, both implants showed a low loosening rate. in the area of the anterior cortex, the locking nail showed a significantly lower rate of loosening (nail . ± . mm, plate . ± . mm, p \ . ). at the dorsal cortex, there were no differences between plate and nail in both series of measurements. conclusions: intramedullary implants provide biomechanical benefits in fracture stabilization. good biomechanical results have already been shown in the literature after nailing olecranon fractures . nevertheless, due to the complex anatomy and the resulting difficult implantation technique, ulnar nails could not prevail in practice. the presented nail allows a safe stability with simple surgical technique. introduction: adequate treatment of tibial plateau fractures is crucial to minimize patient disability, development of posttraumatic arthritis and subsequent need for a total knee arthroplasty (tka). however, due to the complexity of the fracture, adequate reduction cannot always be achieved which could result in the early conversion to a tka. in this study we introduce a quantitative d fracture assessment method and investigate whether it could help to identify patients that are at risk of conversion to a tka. material and methods: we retrospectively included patients, who were treated for a tibial plateau fracture between and . patients developed severe posttraumatic arthritis and underwent conversion to a tka. from all patients, d models were created using the pre-operative ct-scans. for each patient, the d gap area between the fracture lines, representing an innovative combined gap and step-off measurement in d, was determined in order to quantify the displacement (figure ). roc curve analysis was performed to determine a critical cut-off value for the d gap area. kaplan-meier survival curves were created to assess the association between d fracture anatomy and risk on a tka at follow up. results: a critical cut-off value of mm was found to give highest combined sensitivity and specificity for d gap area and the risk of tka at follow-up. kaplan-meier survival curves showed . % knee survival (no tka) at year follow up in the group with a gap area of \ mm , whereas in the group with a gap area of c mm a knee survival of . % was found. at year follow up knee survival was . % and . %, respectively, for the two groups (\ mm and c mm ). conclusions: we developed an innovative method to quantify the amount of displacement in d. pre-operative d fracture assessment could be used as an addition to the current fracture classification methods to help identify patients who have a high risk on conversion to tka at follow-up. introduction: soft tissue sarcomas (sts) in the anterior compartment of the thigh are frequent. the extent of quadriceps resection is controversial. the aim of the present study is to communicate our results in complete quadricectomies due to high-grade sts. material and methods: we present sts, in stage iiib of the ajcc, with a mean craniocaudal diameter of cm ( - ). there were women and men, with a mean age of years ( - ). six were undifferentiated pleomorphic sarcomas, myxofibrosarcoma and clear cell sarcoma. in every case, total quadricectomy was performed with wide margins. posterior reconstruction with local muscle transfers was performed, expect for the younger patient, who received a vascularized contralateral vastus lateralis transplant. in all cases, complementary radiotherapy was indicated, and in patients adjuvant chemotherapy. results: three patients required friedrich due to necrosis of the edges of the surgical wound. one patient died months after the intervention as a result of multiple metastasis, and two due to medical complications after week and months, respectively. the average follow-up time for the rest was months , with no local recurrence. as for functional outcomes, mean msts score was ( - ), with deficit of active knee extension in most of them. the functional result of the patient with the vascularized muscle transplantation was excellent. all of them were satisfied with the results of the treatment. conclusions: quadricectomy provides good functional and acceptable cancer results, although it is not exempt from complications in frail patients. vascularized muscle transplantation, though complex, can improve functional results, especially in younger patients. introduction: operative treatment is a valuable option in displaced proximal and/or middle one-third diaphyseal humeral fractures. although plate osteosynthesis is preferred to intramedullary nailing, surgery can be complicated by radial nerve palsy. a helical plate could avoid this high-impact complication. to date there is however a lack of published evidence in literature, although recent asian case reports show promising results. material and methods: we retrospectively reviewed patients who were treated with open reduction and internal fixation with a helical plate consecutively from october until august at az groeninge, kortrijk. a deltopectoral approach was used in combination with a distal anterolateral incision, whether or not in continuity. a self-molded long philos plate was used in the first patients, while in our last patients the a.l.p.s plate (zimmer Ò ) was used. standard radiographs were obtained pre-and postoperatively. we retrospectively searched for complications, e.g. radial nerve palsy, infection and/or loosening. in autumn , patients were reassessed. patient''s general health status was evaluated using the eq- d- l score. constant-murley scores and dash scores were used for evaluating shoulder function and disability measures consecutively. results: all humeral fractures consolidated at months. there were no radial nerve palsies due to surgery. one plate was removed after year due to a late infection. with a minimum follow up of year, the mean dash score was ( - ) and the mean constant-murley score was ( - ). the dash score was inversely proportional with the constant-murley score and patient''s general health status. conclusion: a helical plate avoids neurological complications with similar healing rates and good to excellent shoulder function at year follow up in the treatment for proximal and/or middle one-third diaphyseal humeral fractures. the use of antibiotic-impregnated cancellous bone grafts in onestage surgery for chronic orthopaedic infection: preliminary clinical results k. dendoncker , g. putzeys , az groeninge, tissue bank, kortrijk, belgium, az groeninge, orthopaedic center, kortrijk, belgium introduction: the use of cancellous bone allografts is an established technique in reconstructive orthopaedic surgery. unfortunately, its use is generally avoided in the presence of a local infection. antibiotic impregnated cancellous bone grafts has shown its effectiveness as an local antibiotic delivery system [ ] [ ] [ ] . in this clinical study, we report our first personal experience with the use of vancomycin-impregnated cancellous bone grafts in one-stage surgery for periprosthetic joint infections (pji) and fracture-related infections (fri). material and methods: between december and march nine patients were treated during a one-stage surgery with vancomycinimpregnated cancellous bone grafts, containing g vancomycin per cc bone. regular clinical, laboratory and radiographic follow-ups were performed for at least months after surgery. results: the procedures included revision of pjis (hip and humerus) and fris (tibia, femur and clavicula). one tibia required further revision because of recurrent infection and one hip has an uncertain infection state, however the remaining patients stayed free from infection during a follow-up of at least months. interestingly, in one patient the vancomycin concentration could be determined in the drainage fluid from the wound. radiographic examination revealed no signs of osteolysis or loosening, good incorporation of the bone graft and progressive consolidation. conclusions: within the limits of the study, the use of vancomycinimpregnated cancellous bone grafts in one-stage surgery to treat pji and fri yielded positive outcomes in terms of clinical, laboratory and radiographic follow-up. this technique might offer new treatment strategies in often devastating injuries. references: . putzeys g., et al. orthopaedic proceedings. ; -b:supp_ , - . with the modified arthroscopic approach (group b). the prospective follow-up included the lysholm score, the subjective questionnaire of the ikdc score and the specifically extended oak score for clinical evaluation. the rolimeter Ò was used to test the translational mobility of the knee joint. the statistical significance level was set at %. results: the follow-up was . ± . months and . ± . months postoperatively in group a and b, respectively. the subjective scores were tested. group a and b achieved a mean lysholm score of . ± . and . ± . points respectively. in the subjective ikdc assessment, group a achieved . ± . points and group b . ± . points. the clinical oak score was . ± . points in group a and . ± . points in group b. the following values could be recorded for the stability of the posterior cruciate ligament: the side difference in the rear drawer test was . ± , mm in group a and . ± . mm in group b. in the reversed lachman test, a difference of . ± . mm and . ± . mm was measured in group a and b, respectively. all values mentioned were comparable between the two evaluated groups. conclusions: the results of the two surgical techniques were comparable. therefore the arthroscopic approach is the preferred method in our institute. simple correction technique of femoral malrotation after pfn-a osteosynthesis of trochanteric fracture k. pavotbawan , p. stillhard , c. sommer kantonsspital graubünden, department of trauma surgery, chur, switzerland introduction: malrotation after intramedullary nailing in femoral shaft fractures are well known. but malrotation after nailing of trochanteric fractures is an underestimated problem. during surgery the axial alignment can easily be evaluated by fluoroscopy in both planes. but the torsional alignment is difficult to assess especially with the patient placed on the traction table. in literature a malrotation after pfna is described in up to % of the cases. a revision with replacement of the blade, especially in patients with poor bone quality, may result in a reduced stability. to our knowledge there is no publication till to date to give a treatment pathway for this problem. we developed a rather easy technique to derotate a malrotated femur after pfna fixation. material and methods: the basic idea is to leave the usually well placed blade insitu in the femoral head, just rotating the distal main fragment around the nail. therefore, a small u-shaped osteotomy with a chisel is performed in the femoral cortex just anterior of the entry site of the blade. the length (l) of this osteotomy can be calculated, following the formula: l = d x p x a/ (d = diameter of femur, a = angle of malrotation). then the distal locking bolt is removed, the leg derotated and finally locked again. the procedure is controlled by two schanz''screws separately inserted in both main fragments angulated to each other in the angle ''a''. results: since patients were detected with a clinically relevant femoral malrotation. all patients had an internal malrotation from to degrees confirmed and measured by ct scan. all of them were successfully revised in the above described technique - days after initial fixation. conclusions: first, we believe that malrotation after trochanteric fracture fixation is an underestimated problem. and second our method is a simple salvage procedure for malrotated trochanteric fractures after pfna, leaving the blade in situ in the femoral head. optimal intramedullary nailing for trochanteric fractures: the importance of distal locking screw and reduction position t. waki , t. yano , k. ito , s. matsushima akashi medical center, orthopaedic surgery, akashi, japan introduction: distal locking issue for trochanteric fractures is still controversial. therefore, the purpose of this study was to investigate the complications between distal unlocked group and distal locked group. further, the relationships were evaluated between these complications rates and their reduction positions after operation. material and methods: operations were performed for trochanteric fracture (ao a ?a ) from to . of these, patients with f/u periods [ month were . gamma im nailing system (stryker) was used for all patients. patients (unlocked group) from to operated without distal locking screw. patients (locked group) from to operated with distal locking screw. we retrospectively analyzed those patients who suffered complications such as delayed healing and postoperative periimplant fractures and cut-out of the lag screw. further, in lateral view of their radiographs, we evaluated the position of the proximal fragment compared with distal fragment. the reduction positions were divided into groups: anterior (subtype-a), neutral (subtype-n), and posterior (subtype-p). results: in unlocked group, complication was shown in patients (complication group). delayed healing was shown in / ( . %) in unlocked group and / ( . %) in locked group. peri-implant fracture was shown in / ( . %) in unlocked group and / ( %) in locked group. cut-out of the lag screw was shown in / ( . %) in unlocked group and / ( . %) in locked group. in complication group, subtype-p was more than non-complication group. conclusion: in the current study, higher number of complications was seen in the distal unlocked group. and, our study showed the reduction position might be associated with post-operative complications. we concluded that nailing without distal locking screw might be dangerous and subtype-p should be avoided. introduction: heterotopic ossification (ho) after acetabular fracture surgery has been one of the common complications and often limits function with the range of motion severely. surgical resection is challenging and only effective treatment for established ho. we herein report four cases who underwent surgical resection and mobilization for ho after acetabular fractures surgery. material and methods: four cases with severe ho after acetabular fracture surgery were included in this study. the mean age at operation was years old, and all patients were males. in judet-letournel classification, there were three cases classified as posterior wall fracture, and one case as transverse and posterior wall fracture. two of four cases were combined with posterior dislocation of the hip. in all cases, the first operation was performed using with the kocher-langenbeck (kl) approach. results: surgical resection of ho was performed using with the kl approach at . months (range - months) after the first operation. the median operating time and intraoperative bleeding were respectively . h and ml. intraoperative d navigation was used in one case. as postoperative complications, one case developed sciatic nerve palsy and another case sustained the iatrogenic femoral neck fracture. all cases have no recurrence with a follow-up of . years after the surgical resection. conclusions: surgical resection is the only treatment for symptomatic ho. but that requires preoperative planning and must be performed carefully because the extent of resection is still controversial and that may develop severe complications such as nerve palsy and iatrogenic fractures. by using navigation, we can determine the extent of resection easily and operated safely. case history: -year-old male, previously healthy, turned to the hospital after a motorbike crash, resulting in high energy direct trauma of the right wrist. clinical findings: upon admission, cranial, thoracic, abdominal and other traumatic injuries were excluded. the patient presented with pain, swelling and visible deformity of the right wrist and hand, hypoesthesia of the th finger, and no perfusion deficits. investigation/results: x-rays showed volar perilunate carpal dislocation with associated comminuted scaphoid fracture, radial styloid avulsion, and metacarpal phalangeal dislocation of the th digit. under sedation, closed reduction of the metacarpal phalangeal joint was accomplished, and reduction of the carpal dislocation was attempted unsuccessfully. the wrist was temporarily immobilized in a cast and taken to the or. diagnosis: transcaphoid-transradial-styloid-perilunate volar dislocation therapy and progressions: surgical treatment comprised loose bodies removal, reduction of the perilunate dislocation, orif of the scaphoid using a herbert screw, and stabilization of the carpal rows using two percutaneous kirschner wires. after surgery, a thumb spica cast was applied. post-operatively, neurovascular status was normal. at weeks, x-rays showed signs of bone healing, the cast and k wires were removed, and physical therapy was initiated. at months, scaphoid fracture consolidation was achieved. the patient remained with a mild deficit in wrist extension but reported no pain nor important limitation in daily living activities. comments: perilunate injuries with displacement or dislocation usually require surgery. persistent instability is a described complication, often progressing to secondary post-traumatic arthritis of the wrist and carpus, termed scapholunate advanced collapse. introduction: this study was conducted to study the patient characteristics, classification, treatment, complications and functional outcome of operatively treated displaced intra-articular calcaneal fractures (diacf) in a level trauma center in the netherlands material and methods: patients with an diacf, classified as sanders c and operatively treated with percutaneous screw fixation (psf) or open reduction and internal fixation (orif) between january and december were identified. pre-and postoperative radiological assessment was performed. functional outcome, range of motion and change in footwear were evaluated with the use of the american orthopaedic foot & ankle society (aofas) score and the maryland footscore. general health and patient satisfaction was assessed using the short form- (sf- ) and the visual analogue scale results: in total, patients with an operatively treated diacf were identified. patient with diacf completed the questionnaires. there were males and females, mean age at trauma was years. average follow up was years. were classified as sanders type , and as respectively type and . were joint depression and were tongue-type fractures. there were no differences in sanders classification between the group treated with orif and psf. for orif and psf there were ( - %), ( - %) and ( - %) for respectively sanders type , and fractures. mean aofas, mfs, sf- and vas was ( - ), ( - ), ( - ) and ( - ) for respectively orif and psf. mean pre-and post-bohler angle was ( - ) and ( - ) for respectively psf and orif. underwent an ankle arthrodesis. surgical site infection and deep infection occurred in ( , - %) and ( , - %) in respectively psf and orif conclusions: long-term comparison shows no significant differences between orif and psf in treatment of sanders fracture type, bohler angle reduction, on functional outcome or complication rates introduction: the prevalence of hand injury in the pediatric population is attributed to their curiosity, limited fear of pain and diminuted motor coordination. the seymour fracture, which was first reported by seymour in , represents a transverse extra-articular open fracture of the distal phalanges associated with nail bed injuries. the fracture includes salter-harris type i and ii fractures as well as juxta-epiphyseal injuries. material and methods: the aim of this report is to present a case of a seymour fracture in a young boy and describe the injury mechanism associated with misuse of the newly emerging vehicle, the hoverboard. results: our patient was treated promptly and provided with appropriate management following the standard of care in our hospital for such injuries: disimpaction and repair of the nail bed, reduction of the fracture, and k-wire fixation across the distal interphalangeal joint. the patient was discharged with a volar slab and was prescribed an oral antibiotic. the patient recovered well with no major deficits. conclusions: the timely recognition and management of seymour fractures is crucial. the surgical treatment has good results however, conservative management can be an option in some specific cases. antibiotics are always required. we report a case of a fracture pattern resulting from the improper use of an hoverboard. although improper use was a factor, design fault also plays a role in causing the injury. hoverboards are a new transport technology that has been introduced in recent years. because of the number of injuries that have resulted from hoverboards, they should be used in the most controlled way possible to prevent any unnecessary injuries. case history: we report the case of a years old male from bangladesh, with months of progressively increasing pain, limited range of motion and swelling on his left knee, with kg of weight loss and inguinal lymph nodes. clinical findings: knee radiography and mri of the knee demonstrated a voluminous soft tissue mass surrounding the distal femur with intraarticular and posterior extension. a toracic-abdominal-pelvic ct showed supra and infradiaphragmatic lymph nodes. c-reactive protein level was , mg/dl. investigation/results: the clinical picture suggested a lymphoproliferative syndrome. a biopsy was performed, revealing cm of purulent material. synovial fluid had leucocytes/ul, % of polymorphonuclear cells, % of mononuclear cells and undetectable glucose. acid-alcohol resistant bacilli test and pcr test for mycobacterium tuberculosis were positive. diagnosis: mycobacterium tuberculosis knee arthritis therapy and progressions: the patient was treated with polytherapy consisting on rifampin, isoniazid, pyrazinamide and ethambutol. months later, the patient reports no pain, and tumor size has decreased. comments: mycobacterium tuberculosis infection is not a common disease in developed countries. however, the incidence in europe is increasing due to immigration. even though the lung is the most affected organ, osteoarticular tuberculosis represents around % of extra-pulmonary cases. tuberculosis simulates several diseases. because of non-specific symptoms and radiological signs, it can be difficult to diagnose. in a patient with chronic knee pain and limited range of motion, tuberculosis infection should be kept in mind, among other differential diagnoses, such as fibromatosis, pigmented villonodular synovitis or soft tissue sarcomas. clinical findings: the patient presented with a valgus deformity of the knee, the medial femoral condyle protuding on the medial side of the knee. neurovascular status was intact. investigation/results: xray revealed lateral dislocation of the knee. mri revealed mcl, pcl and acl rupture. diagnosis: knee dislocation (kd) grade iii (schenck). therapy and progressions: the patient underwent emergent closed reduction. neurovascular status was intact after resuction. due to important oedema and blisters, the lower limb was immobilized with a brace to allow for skin surveillance. after weeks, the brace was replaced by a long leg cast for more weeks. after months, the patient maintained residual pain, rom - / and minor instability. comments: kd are unusual injuries, associated with high energy trauma, therefore they often result in disruption of at least major ligaments and associated injuries, from soft tissue to vascular structures. emergent reduction is mandatory, and definitive treatment can be conservative, or early/late surgical repair/reconstruction of the ruptured ligaments. there is a lack of large prospective clinical studies comparing the different types of treatment. even so, data tend to associate early surgical treatment with better functional outcomes, though there is no statistic evidence supporting its improvement of the range of motion or stability. long term complications most frequently include residual pain, instability or rigidity. rarely the knee returns to its pre-injured state, independently of the treatment used. references: dwyer, t., et al. ( ) . outcomes of treatment of multiple ligament knee injuries. the journal of knee surgery, ( ), - . advising a reduction after a fracture of the distal radius, reliability with and without use of expert based criteria introduction: distal radius fractures (drf) are common, however many aspects of its management remain subject of debate . this study assessed the interobserver reliability of surgeons concerning the recommendation for a reduction and the improvement of expert based criteria for reduction. material and methods: we sent out surveys to members of the science of variation group. the first survey divided participants in groups, each rated - radiographs of drf. resulting in rated fractures by participants. each observer indicated whether they would advise a reduction or not. the second survey randomized participants ( surgeons) to either receive or not receive criteria for reduction and participants indicated if they would recommend reduction. results: the reliability for advising a reduction was poor, kappa . ( % ci . - . ). multivariable linear regression analyses indicated that each additional degree of dorsal angulation increased the change of recommending a reduction by % (beta . , % ci . - . p \ . ). criteria for reduction did not increase interobserver reliability for recommending reduction (no criteria kappa . % ci . - . vs. criteria . % ci . - . ). the likelihood of recommending a reduction was higher in the group using the criteria ( . vs . , p = . ). conclusions: poor interobserver reliability is associated with greater practice variation. dorsal angulation is the main drive for recommending a reduction. the liberal use of the criteria in combination with a specific focus on dorsal angulation leads in our opinion to less variation in treatment recommendation for distal radius fractures. this is something future study could assess for distal radius fractures in actual practice introduction: the number of pertrochanteric hip fractures increases proportionally to the increase in life expectancy. currently, the most used treatment in these fractures is the antegrade nailing. suffering a second fracture in the same femur around an antegrade nail is an uncommon complication, but it has a great impact on the patient. the aim of this study is to describe the type of perinail femoral fractures observed in our center, the treatment performed and the medium-term results. material and methods: between and , patients presented a perinail femoral fracture. were women and one was male, with an average age of . initial fractures were classified according to the ao classification: were a , were a and were a . of them were synthesized by short pfn-a (synthes), with short pfn (synthes) and with gamma (stryker). the average time since osteosynthesis of the proximal femur fracture and the perinail fracture was . years ( month- years). results: of the peri-implant fractures occurred at the level of the nail tip or the distal locking screw. the remaining fractures occurred in the distal femur. these supracondylar fractures and of the fractures at the level of the nail tip were synthesized with a va condylar plate (synthes), overlapped with the nail. in the rest of the fractures around the tip of the nail, the short nail was removed and replaced by a long pfn-a nail. one of the patients died in the immediate postoperative period. two patients died during the first year. in the rest of the patients, a complete consolidation of the fracture was observed, and their previous baseline situation was recovered. conclusions: peri-implant femur fracture is a rare but very severe condition, which requires good surgical planning, and is not without complications. gamagori city hospital, department of orthopedics, gamagori, japan, nagoya daini redcross hospital, department of orthopedics, nagoya, japan introduction: hip fracture is a leading worldwide health problem for the elderly. a missed diagnosis of hip fracture on radiography leads to a dismal prognosis. the application of a computer-aided diagnosis (cad) system using artificial intelligence (ai) to detect hip fracture can potentially improve the accuracy and efficiency of hip fracture diagnosis. material and methods: cad system using ai was trained using cases, plain frontal pelvic radiographs (pxrs) between and from each institution. the accuracy, sensitivity, falsenegative rate, and area under the receiver operating characteristic curve (auc) were evaluated on independent pxrs. the authors mixed resnext as classification algorithm and ssd as object detection algorithm to train cad system. results: the algorithm achieved an accuracy of . %, a sensitivity of . %, a false-negative rate of %, and an auc of . for identifying hip fractures. the visualization algorithm showed an accuracy of . % for lesion identification. conclusions: our cad system using ai not only detected hip fractures on pxrs with a low false-negative rate but also had high accuracy for localizing fracture lesions. the cad system using ai might be an efficient and economical model to help clinicians make a diagnosis without interrupting the current clinical pathway. medical faculty university of nis, orthopaedic surgery, nis, serbia, clinical center nis, orthopaedic and traumatology clinic, nis, serbia, orthopaedic word of medical center, cuprija, serbia introduction: bone reconstruction and limb lengthening usually refers to application of ilizarov or other ring external fixation devi-ces . we present here series of posttraumatic reconstruction and limb lengthening, by the use of new concept of d unilateral external fixation device. material and methods: as a clinical material, we present series of patients with different posttraumatic deformities ( ) and limbs discrepancy ( ) as a result of severe traffic accidents and wars. all patients have been treated by specially designed unilateral d external fixation system. that system is not bulky and it is more comfortable in comparison to ring fixators. procedure is relatively simple, so patients handle the device by themselves. during biomechanical testing, it was found that stability of this device is similar to ring systems. the last version of the device includes computer program and two sensors. results: all deformity corrections have been achieved successfully. sliding graft procedure has successfully been performed in all patients with bone defect reconstruction from to cm. in one patient with complex deformity and shortening, correction couldn''t be achieved during one procedure, so additional operations, by the use of the same system have been performed and correction completed. superficial pin tract infection rate was . % and we didn''t have deep infection. there were no other complications including dvt, joint stiffness, neurovascular injuries. conclusion: unilateral external fixation device with balanced d stability provides the same success of bone reconstruction and limb lengthening as ring fixators, but it is more comfortable and more easy for handling. references: treatment principles in bone reconstruction and limb lengthening of the lower extremity. olesen uk, nygaard t, kold sv, hede a. ugeskr laeger. nov ; ( ) at this moment author has licence agreement with the producer of external fixation devices. all patients were classified into the isolated hip fracture and the concomitant fracture. we analyzed these patients'' characteristics such as age, gender, bone mineral density (bmd), body mass index (bmi), korean version of mini-mental state examination (mmse-k), injury mechanism, and length of hospital stay. results: the most common site of upper extremity fracture was distal radius fracture of patients ( . %), followed by proximal humeral fracture of ( . %). concomitant fractures occurred on the same side in patients ( . %). the mean age of patients with a concomitant fracture was younger than that of patients with an isolated hip fracture (p \ . ). mean preinjury mmse-k was . in isolated hip fracture and . in concomitant fracture patients (p \ . ). mean length of hospital stay was statistically significant different between two groups (p \ . ). according to fracture site of hip, there was no statistically different prevalence of upper extremity fracture in femoral intertrochanteric fracture compared to the neck fracture. conclusions: we found a . % prevalence of concomitant hip and upper extremity fractures. it was found that the younger the age with preserved cognitive ability in elderly patients with a hip fracture, the higher the prevalence of upper extremity fracture. in addition, it is important to keep in mind that patients with a concomitant fracture have a longer hospital stay and difficulty in rehabilitation. on the other hand, the amount of bleeding was ml in group e and ml in group l, and there was no significant difference between the two groups. poor cases on postoperative images were % in group e and % in group l, and the joa hip score was . (groupe) and . (group l). in clinical results is significantly improved in group l. conclusions: the treatment results improved significantly in group l. as the number of experienced cases increased from these results, the reduction accuracy and treatment results improved, so experience was considered important for improving the treatment results of acetabular fractures. the additional value of the weight-bearing and gravity stress radiograph in determining stability of isolated type b ankle fractures introduction: the goal of the current study is to investigate whether the weight-bearing and gravity stress radiographs have additional value in determining stability in isolated type b fibular fractures. this in order to make the important distinction between fractures that need surgical treatment and fractures that can be safely treated conservatively. material and methods: patients with an isolated type b ankle fracture, without medial or posterior fracture, and a medial clear space (mcs) \ mm on the regular mortise radiograph were included. in the emergency room, a gravity radiograph was performed (in accordance with out protocol). within week, an additional mri scan was made. at this moment, in patients a weight-bearing radiograph was performed too. the mcs measurements of these regular mortise, gravity and weight-bearing radiograph were compared with the mri findings. the mri scan was set as reference standard to detect injury of the deltoid ligament in order to determine (in)stability. results: mean mcs on mortise radiograph was . mm (range . - . ); in ( . %) patients the mcs was [ mm and in patients ( . %) the superior clear space (scs) was [ mcs ? mm. in ( . %) patients, the scs [ mcs ? mm. on the gravity stress radiograph, . % of the patients had a mcs [ mm. the weight-bearing radiograph showed a mcs [ mm in ( . %) patients. in ( . %) patients, the mri showed a complete rupture of the deltoid ligament. in ( . %) patients a partial rupture was seen. patients ( . %) received surgical treatment. in all conservatively treated patients, no secondary dislocation occurred and there was no need for postponed surgical treatment. conclusions: the gravity stress view has a tendency to overestimate the mcs. thus, potentially too many stable fractures are incorrectly diagnosed instable and receive unnecessarily surgical treatment (with additional costs and risks). the weight-bearing radiograph, on the contrary, does not overrate the medial injury and can safely be used in the decision making process of treating conservatively and weightbearing (for example by using a brace) introduction: the purpose of this study was to identify the effect of the intravenous iron supplementation on demand of perioperative blood transfusion and post-operative hemoglobin recovery in geriatric hip fractures. material and methods: a retrospective cohort study was performed on patients who underwent surgery with proximal femoral nail for hip fracture and age years old or older between jan and may in a single center. the participants were divided into groups according to preoperative intravenous iron supplementation (iron isomaltoside, monofer Ò , pharmacosmos, holbaek, denmark); group (n = ) with monofer mg before surgery and group (n = ) without monofer. transfusion was preformed when the hgb was less than mg/dl). primary endpoint was incidence of perioperative transfusion. secondary endpoints were various hemoglobin (hgb) levels. results: the average age of the participants were . years old, and average body mass index (bmi) was . . demographic data including age, sex, bmi, comorbidity (charlson comorbidity index) of each group showed no difference. the complications from intravenous iron administration were not occurred. the preoperative hgb was . mg/dl (group . ± . vs, group . ± . , p = . ). the hgb at the postoperative day was . mg/dl (group . ± . vs group . ± . , p = . ). the average hgb at the postoperative month was . mg/dl (group . ± . vs group . ± . , p = . ). transfusion rate was . % ( / ) and the rate showed no difference between groups ( . % vs . %, p = . . the recovery of hgb between postoperative month and preoperative state showed statistically difference (group . vs group -. , p = . ), and iron supplementation group had more recovery. conclusions: intravenous iron supplement before the hip fracture surgery in elderly helped to recover hgb at postoperative month. comminuted subtrochanteric femur fractures-our experiences introduction: subtrochanteric femoral fractures account for approximately % of all the hip fractures and their treatment represents a challenge because of the short proximal fragment and highenergy forces. material and methods: a total of patients with subtrochanteric, highly comminuted fractures, were included in this study, with age range from to years. the mechanism of injury in all patients was high-energy trauma. in each case we applied a long gamma nail (limma lto) without focus opening. results: in all patients, good clinical and radiologic results were accomplished, in addition to early weight-bearing, without shortening of the legs, or consequences on the state of the hip and morbidity in general. conclusions: although the comminuted subtrochanteric femur fractures represent a challenge for the orthopedic surgeons, osteosynthesis using long gamma nail without the focus opening provides outstanding results. introduction: this study analyzed the association between the postoperative reduced position obtained on using short femoral nails (sfns) and the amount of sliding after fixation in unstable trochanteric fractures. material and methods: this retrospective study included patients with unstable trochanteric fractures with posterolateral support deficiency who underwent osteosynthesis with sfns and were followedup for months or longer. the study included men and women with a mean age of . years at the time of fracture. closed or open reduction was performed to achieve anatomical to medial type position on frontal view and anatomical to extramedullary type position on lateral view, followed by fixation with sfns. immediately and extramedullary type in patients immediately after surgery. three months after surgery, the reduced position worsened from the anatomical to intramedullary type in patients. according to the reduced positions at months after surgery, the mean amount of sliding was . mm in patients with intramedullary type, . mm in those with anatomical type, and . mm in those with extramedullary type. the amount was larger in those with intramedullary type than in those with anatomical and extramedullary types. moreover, excessive sliding was observed in patient with intramedullary type. conclusions:to prevent excessive sliding by ensuring anteromedial bony support in unstable trochanteric fractures with posterolateral support deficiency, open reduction should be aggressively performed to overcorrect to the extramedullary type when reduction performed on a traction table results in either anatomical or intramedullary type positioning. in this paper, we report patient previously studied for osteomyelitis caused by high-energy missile trauma, in . that study involved a total of patients with osteomyelits, divided into two groups, according to the treatment protocol applied. the group included patients treated using classic surgical methods, including debridement, curretage, forage, perfusion drainage and sequestration. the group included patients treated using recommended surgical methods and used pmma antibiotic beads. years after, we tried to contact all of the patients, for the purpose of follow-up. however, only patient was available for analysis. among patients we followed-up, were treated using recommended surgical protocol, while the remaining patients were treated using classic surgical methods. we present the patients' general status, as well as the local surgical status and radiographic analysis, years after. we obtained long-term results of both treatment protocols applied. from the group , patients developed chronic recurrent osteomyelitis, while only one patient from the group developed such condition. introduction: the aim of this study was to evaluate the treatment results using anterior subcutaneous internal fixation(infix) for the pelvic fractures and to consider an improvement strategy for the complications. material and methods: from to , pelvic fractures were enrolled. there were two males and females. the average age was years. there were fragility fractures and five high energy fractures. our operative procedure was as below: the connection between screws and rod was just above the fascia of the sartorius muscle. the connection bar was pre-bended before the operation using the initial axial ct scan. we assessed bone union, additional fixation, the distance between the femoral artery and connection rod (dar), the distance of protruded bar lateral to the connection (dpb), and complications. results: bone union achieved in out of cases. there was one nonunion and three early deaths because of medical complications. seventeen out of cases required additional posterior fixations. the average dar was . ( . - . mm) , and the dpb was . ( - ) mm. thirteen out of cases ( . %) had complications. there were seven lateral femoral cutaneous nerve (lfcn) symptoms ( required implant removal (ir)), two infections ( required ir), one hematoma (ir), one irritation (ir), one heterotopic ossification, one loosening (re-operation). there were no femoral vessels and nerve-related symptoms. to release lfcn and surrounding soft tissues decreased the nerve symptoms. conclusions: to connect the screws, and the rod just above the sartorius fascia could avoid major vessels and nerve complications, and also irritations. although this study found a high complication rate of infix, to release the lfcn and around soft tissue could decrease the complications. introduction: several studies have reported that posterior or anterior tilt increases the risk of reoperation in undisplaced femoral neck fractures (garden i/ii) after internal fixation performed using nonangular stable devices such as pins and multiple screws. however, to the best of our knowledge, there is limited research involving angular stable devices. the present study aimed to investigate the clinical outcomes in undisplaced femoral neck fractures after internal fixation using angular stable devices. material and methods: this retrospective study included patients (mean age, . [range, - ] years) who underwent internal fixation using angular stable devices between january and january . undisplaced femoral neck fractures with garden alignment index (gai) b °(posterior tilt angle c °) or gai b °( anterior tilt angle c °) were included (posterior: , anterior: ) in this study. patients were followed up for at least months (mean, . months). we analyzed the preoperative and last-followed gai on lateral radiographs, non-union, and late segmental collapse (lsc). results: among the patients, non-union was identified in ( . %) and lsc was observed in ( . %). the mean preoperative gai was . °(range, °- °), and the mean last-followed gai was . °( °- °). the overall complication (non-union and lsc) rate was . % ( / patients). among patients with gai c °, lsc occurred in ( . %). conclusions: in undisplaced femoral neck fractures, preoperative posterior c °is a risk factor for postoperative complications even when internal fixation is performed using angular stable devices; thus, primary arthroplasty may be considered. case history: the patient is a -year-old female who had undergone lumpectomy at the age of when she was diagnosed with breast cancer. she had antiresorptive drug therapy for bone metastasis, since years after the lumpectomy. she fell down from standing height and was diagnosed as right femoral subtrochanteric fracture. her femur was fixed with short femoral nail. she complained left hip pain at age .she complained left hip pain from july . clinical findings: she could walk with crutch.rom of left hip was normal. investigation/results: breast surgeon took mri and there was metastasis in the proximal part of femur. he thought the cause of pain was this metastasis. however, there was fracture line at the height of lesser trochanter when she visited our department. diagnosis: atypical fracture was strongly suspected, however, fracture line was little higher as normal atypical fracture. therapy and progressions: osteosynthesis with long femoral nail was performed months after first visit to our department because of increasing pain. pathological findings were metastasis and fracture. after surgery, radiation to femur was performed. she can walk without pain by crutch and fracture line is almost disappeared on months after surgery. comments: atypical femoral fractures (affs) are recently observed as a complication of antiresorptive drugs for bone metastasis. however, there were metastasis and atypical fracture in this case. introduction: in the present study we aim to evaluate the articular surface reduction quality by means of postoperative computer tomography (ct), in complex tibial plateau fractures, treated with an illizarov frame. materials and methods: this retrospective case series covers the period from - to - . forty-four patients with a mean age of years (range - years), with a complex intrarticular proximal tibia fracture were included. fracture types iii to vi according to schatzker's classification were included. the majority were closed injuries, apart from cases (a gustilo anderson type a and a type ). all patients were placed on a fracture table. a mini-open reduction of the articular surface was followed by application of a knee spanning illizarov frame. post-operatively all patients were subject to ct of the injured knee. outcomes were measured using the american knee society score. results: mean outpatient follow up was of at least months (range of - months). mean time for fracture consolidation . weeks (ranging from to weeks). according to the degree of postoperative articular surface depression patients were grouped as follows: had under mm, had - mm and over mm of depression. those with less than . mm of collapse had % chances of an excellent result according to akss. on the contrary, those with more than . mm of articular surface collapse had % chances for low scores and functional results. the achievement of a mechanical axis within °of the contralateral limb was positively correlated with good functional results but did not have a correlation with the akss. conclusions: complex tibial plateau fractures may be treated successfully with mini open reduction and the application of an illizarov frame. post-operative ct denotes the exact degree of displacement of the articular surface, which is prognostic regarding outcome. postoperative x-rays may be misleading, since they can underestimate articular surface collapse. introduction: a new trauma center building was constructed in march , and the process from the trauma bay to the operation room is faster. we hypothesized that this process improved the survival rate of trauma patients in need of trauma laparotomy. material and methods: the new trauma center separates the trauma bay from the emergency room, and the trauma team exam patients initially. it also has a separate operation room that is always available for emergency surgery. therefore, the decision to perform laparotomy and time to operation has been shortened. from january to december , trauma patients who underwent emergency laparotomy were included. those younger than years, who had delayed operation, underwent surgical observation, delayed admission by patient, or underwent angiography first were excluded. patients were dichotomized to the before-trauma-center (bc) and after-traumacenter (ac) groups, and their characteristics and clinical outcomes were compared. results: of patients, were included in the bc group and were included in the ac group. the times from admission to operation introduction: acute care is a growing worldwide burden with increasing visits to the emergency department (ed). the acute care system in the netherlands is almost overloaded and costs are increasing. almost % of ed visits have surgical disease. there is no nationwide acute care surgery (acs) model implemented yet, and resources and infrastructure are organized differently in almost every hospital. this study provides an overview of the existing systems nationwide, and basis for a national uniform model. material and methods: an online survey was distributed through the dutch surgical society and sent to all dutch hospitals. after sending a reminder, the survey was closed and results were analyzed. results: thirty-two hospitals ( %) participated in the survey. in % a surgeon (trauma, vascular or gastro-intestinal) was assigned as consultant and responsible for ed admissions, emergencies in-house, and in some cases also emergency surgeries. % of hospitals have an ed observation unit (edou). a dedicated emergency surgery operating room (esor) is available in % ( / available in %), and used efficiently in % primarily due to the following challenges: elective surgery scheduled at esor ( %), necessary stop of esor when elective programs are delayed ( %). in hospitals without an esor, the emergency surgeries are scheduled in between elective surgeries resulting in extending programs into the evening. finally, % of respondents was familiar with acs, with % being positive about exploring options of implementing such a model in our country, and % of the respondents opts for more focus on acs in surgical residency. conclusions: in the netherlands the organization of acute care varies. the main common bottleneck is the logistics around the or. implementation of a dedicated esor and unconditional availability / of this or seem to be the most important factors for optimal efficiency. although there needs to be more focus on acs in general, implementing a uniform model nationwide seems challenging at this moment. trauma team activations (tta) at an european trauma center: cases analyzed s. saar , , e. lipping , h. vospert , r. volmer , h. k. laas , j. lepp , k. g. isand , p. talving , north estonia medical centre, division of acute care surgery, tallinn, estonia, university of tartu, tartu, estonia, north estonia medical centre, tallinn, estonia introduction: the north estonia medical centre (nemc) is the largest trauma center in estonia with evolving capabilities. however, studies scrutinizing trauma team activations (tta) are currently lacking. thus, we initiated an investigation to document tta profile and outcomes. material and methods: all tta patients admitted to the nemc between / and / were retrospectively identified. data collected included demographics, injury severity score (iss), management, hospital length of stay (hlos), and in-hospital outcomes. primary outcome was -day mortality. results: overall, patients were included. mean age was . ± . years and . % were male. penetrating and blunt trauma accounted for . % and . % of the cases, respectively. non-ground level falls were the predominant mechanism of injury constituting . % of the admissions. mean iss was . ± . and . % of the patients were severely injured (iss [ ). blood alcohol level (bal) was positive at . %. a total of . % of the patients had an emergent operation. mean hlos was . ± . days.overall -day mortality and mortality of severely injured patients was . % and . %, respectively. conclusions: the current investigation documents comparable outcomes with established european trauma facilities [ , ] . blunt injury patterns predominate, however, high penetrating trauma incidence for european settings was noted. high rate of positive bal in tta patients warrants national preventive measures. introduction: the acute care surgery (acs) model was initially developed as a dedicated service for the provision of high quality / non-trauma emergency surgical care. after implementation in the united states (us), the model has been adopted in several variations around the world.in this systemic review we investigated which components are essential for a potential uniform acs model, by giving an overview of the current available acs models worldwide and their state of implementation. material and methods: a literature search ( - ) was conducted using pubmed, medline, embase, cochrane library and web of science databases following the prisma guidelines. all relevant data of acs models were extracted from included articles. results: sixty-five articles describing acs models in different countries were included in this review. the majority consist of a dedicated surgical service, providing non-trauma emergency surgical coverage, with daytime on-site attending coverage by an attending surgeon who is cleared from elective duties, and / in-house resident coverage. emergency department coverage and access to an acute care operating room varied widely across countries. critical care is fully embedded in the original us model as part of the acute care chain (acc), while in most other countries it is still a separate unit. while in most european countries acs is not a recognised specialty yet, there is a tendency towards more structured acute care, with training and separation from elective practice. conclusions: acs is gradually implemented worldwide. however, large national and international heterogeneity exists in the structure and components of the model. critical care is still a separate unit and specialty in most systems while it is essential to be part of the acc in order to provide the best peri-operative care of the physiologically deranged patient. universal acceptance of one global acs model seems challenging, however a global consensus on essential components would benefit any healthcare system. introduction: the recent financial crisis in greece is coped mainly with reformations towards cost effectiveness and rationality in the management of public expenses. the goal of the study is to evaluate the cost and time effectiveness in the management of the surgical patients admitted in emergency department (ed). methods: for a period of h/day in consecutive days, surgical cases presented in the ed of a tertiary university hospital of athens were followed. inclusion criteria were need for laboratory tests or imaging examinations or an immediate resuscitative intervention. data recorded regarding demographics, vitals, critical time points, disease and management. physician related data and cost of examinations were also collected. case severity was calculated by early warning score [ ] . results: she average waiting time for each patient was min and the average total time until final decision was : h. blood tests costs reached an average of , € per case and imaging an average of , €. the striking finding was that only one out of patients was of medium clinical risk, while all the others were of low. thus, substantial symptoms and clinical findings were lacking and as the ''tertiary care'' character of the hospital was mandating conclusive diagnosis, exams were ordered. this approach absorbs time and funds putting at risk the very few severe cases which are the target population for the magnitude of the facility. the current study indicates that the use of a tertiary hospital as a primary health care center by the public, is disorganizing the system, and increase the cost in time, funds, and preventable morbidity and mortality. a pre-hospital triage and management of the low severity cases system is pending to be established in our environment and becomes top priority in an era of prolonged financial crash. for years, surgical emergencies in ecuador have been managed without significant standardization. scarce numbers of specialists, lack of a constant presence of full-time teaching faculty versed in emergency surgery and lack of continuity with surgical trainees led to variability in clinical and surgical decision-making. to address these issues, the regional hospital vicente corral moscoso (hvcm) adapted and implemented a model of ''trauma and acute care surgery'' (tacs) to the reality of cuenca, ecuador. a cohort study was carried out, comparing trauma and acute care surgery patients exposed to the ''traditional care model'' before the implementation of the tacs model. variables assessed included: surgical wait times, number of hospital visits, number of surgical interventions, number of surgeries performed per surgeon and inhospital mortality. higher mortality was found in the traditional care model (rr of . , p b . ) compared to the tacs model. we observed a statistically significant decrease in surgical wait time ( . - . h for emergency general surgery, . - . h for trauma, p b . ). lengthof-stay decreased in trauma patients ( - days p b . ). the total number of surgical interventions increased ( , . - , . , p b . ) ; by extension, the total number of surgeries performed per surgeon also increased ( . - . , p b . ) . the implementation of tacs model in a typical resource-restrained, tertiary care hospital in latin america had a positive impact by decreasing surgical waiting time in trauma and emergency surgery patients, and length-of-stay in trauma patients. we also noted a statistically significant decrease in mortality. while cost could not be objectively evaluated with the available data, savings to the overall system and patients can be inferred by decreased mortality, length-ofstay and surgical wait times. to our knowledge, this is the first implementation of an tacs model that has been described in latin america. introduction: traumatic injuries constitute one of our major public health challenges. the most effective means to reduce the impact trauma has on individuals and society is primary injury prevention, reducing the incidence of traumatic events, which relies on detailed knowledge of risk factors. the aim of this study is to facilitate targeted injury prevention through improved data collection and analysis on impairing substances as risk factors for traumatic injuries. material and methods: idart is a national prospective observational study including analyses of the toxicological profile of all patients c year of age admitted via trauma team activation to any norwegian trauma hospital (n ) during a month study period. residual blood from routinely drawn blood samples at trauma admission is analyzed for alcohol, illegal and psychoactive drugs. toxicological data will be linked to clinical data from the national trauma registry. results: the study period started march st, , and during the first months patients were included from trauma hospitals. more than % of the included patients tested positive for psychoactive substances according to preliminary data. data on the prevalence of different psychoactive substances disaggregated by mechanism of injury, demography and geography from the month study period will be presented. conclusions: the idart study will provide a detailed descriptive analysis on the prevalence of alcohol, illicit and medicinal drug use among all patients admitted to a norwegian hospital with suspected severe injury. subgroup analyses will include prevalence of alcohol and other substances in subgroups analyses on patient and injury characteristics and geographical variations. analyses will aim to identify high risk groups according age, gender, circumstances of the injury, geographical location and type of psychoactive substance. the dutch nationwide trauma registry: the value of capturing all acute trauma admissions m. driessen , l. sturms , l. leenen lnaz/umcu, trauma surgery, nijmegen, netherlands introduction: twenty years ago the dutch government decided to reform the trauma care system and designated level regional trauma centers (rtcs). these centers, in collaboration with ambulance services and regional hospitals, have managed to set up regionalized inclusive trauma systems. moreover, they set up the dutch national trauma registry (dntr) as a quality evaluation and epidemiology resource. in this resource all acute hospital admissions were included, in order to measure the hospital and prehospital processes and outcomes. in the current study we demonstrate its current status and compare it with national trauma registries from the uk and germany. material and methods: the dntr includes all injured patients treated at the ed of % of all hospitals in the netherlands within h after the trauma followed by direct admission, transfer to another hospital or death at the ed. a representative descriptive analysis of extracted data from is demonstrated. results: between and a total of , trauma cases have been registered in the dntr. hospital participation has increased from % up to %. in alone, a total of . patient were included, % concerned males, the median age was years. % of all admissions had an iss c , of which % was treated at a rtc. from this cohort, in comparison, only % and % of the dntr patients met tr-dgu or tarn inclusion criteria. particularly children, elderly and patients admitted at non rtcs are not captured in the tr-dgu or tarn. also, part of iss c and fatal cases do not meet tr-dgu or tarn inclusion criteria. conclusions: the dntr has evolved into a comprehensive wellstructured nationwide population-based trauma register, with an annual number of , cases being entered in the database the dtr has grown to be one of the largest trauma databases in europe. the registry enables studies on the injury burden and quality and efficiency of the entire trauma care system encompassing all traumareceiving hospitals. introduction: trauma mortality is not distributed evenly. rural areas have higher incidence rates of trauma mortality than urban areas. the rural northern part of the nordic countries have common challenges with sparsely populated areas, long distances, and an arctic climate. the aim of this study was to compare the cause and rate of fatal injuries in the northernmost area of the nordic countries over a fiveyear period. material and methods: in this retrospective cohort we used the cause of death registries and collated all deaths from to with an external cause of death (icd- , v -y , except y - and t - ). the study area was the three northernmost counties in norway, the four northernmost counties in finland and sweden and the whole of iceland. we used % confidence intervals (ci ) to test for differences between the countries. results: there were deaths in the study area during the -year period. low energy (le) trauma constituted % and high energy (he) trauma % of deaths. northern finland had the highest incidence for both high energy trauma and low energy trauma. iceland had the lowest incidence for high-, and low energy trauma. iceland had the lowest prehospital share of deaths at % and the lowest incidence of injuries occurring in a rural location. the incidence rates for he trauma death was , / . /year in northern finland, , / . /year in iceland, , / . /year in northern norway and , / . /year in northern sweden. conclusions: there were significant and unexpected differences in the epidemiology of trauma death between the countries. the differences suggest that a comparison of the trauma care systems and preventive strategies in the countries is required. the diurnal and seasonal relationships of pedestrian injuries secondary to motor vehicles in young people introduction: there remains a significant morbidity and mortality in young pedestrians that are hit by motor vehicles, even in the era of pedestrian crossings and speed limits. the aim of this study was to compare incidence and injury severity of motor vehicle-related pedestrian trauma according to time of day and season in a young population. we hypothesised that injuries in young people would be more prevalent during dusk and dawn and during autumn and winter. material and methods: data was reviewed from patients in the - year old age group in the trauma audit and research network (tarn) national database, who had been involved as a pedestrian in a motor vehicle accident between and . the incidence of injuries, their severity (using the injury severity score [iss]), hospital transfer time and mortality were analysed according to the hours of daylight, darkness and seasons. results: . % of injuries occurred during time of darkness post sunset, while . % occurred during daylight. the incidence of injuries in motor vehicle accidents, in absolute terms, was highest during - , with a second peak at - . the greatest injury rate (number of injuries/hour) occurred during - and - with respective rates of . and . injuries scoring an iss over occurred . % at - and a further . % until . mortality was greatest during - involving out of the total deaths. autumn was the predominant season and lead to . % of injuries, with a further . % in winter. this demonstrated a clear difference to . % and . % in spring and summer. conclusions: we have identified a relationship between reduced daylight and the frequency and severity of pedestrian trauma in young people suggesting that reduced visibility may play a significant role which could be addressed through a targeted public health approach to implement change. enhancing cost effectiveness in a system in crisis: a , patient study a. tsolakidis , c. christou , p. smyrnis , a. prionas , a. tooulias , g. tsoulfas , v. n. papadopoulos aristotle university of thessaloniki, st department of surgery, papageorgiou general hospital, thessaloniki, thessaloniki, greece introduction: to date, there is no national trauma database in greece. the goal of our study is to record and evaluate trauma management at our university hospital as well as to measure the associated healthcare cost, while laying out the foundations for a national database. material and methods: retrospective study of trauma patients (n = , ) between and . demographic information, injury patterns and severity, outcomes and cost were recorded. results: the proportion of patients that were transferred to the hospital by the national emergency medical services was , %, whereas ( %) of our trauma patients did not meet the us trauma field triage algorithm criteria. over-triage of trauma patients to our facility ranged from . to . %, depending on the criteria used. ( . %) of our patients received operative management and % ( ) of them had postoperative complications. an iss [ was seen in ( %) of our patients and their mortality was , %. the overall non-salary cost for trauma management was . . euros. the cost resulting from the observed over-triage ranged from . to . . euros. furthermore ( . %) of our patients underwent at least one ct scan that did not show any significant traumatic lesion. the cost of hospitalization of these patients was . euros. conclusions: the prehospital triage of trauma patients in the greek national health system is ineffective, with significant over triaging, leading to excessive costs. appropriate use of criteria for diagnostic procedures and algorithms may lead to a, much-needed, reduction of these costs. introduction: in japan, there are emergency and critical care centers nationwide (one center for approximately every , people), and a system is in place to accept local critically ill patients h a day, irrespective of whether their conditions are intrinsic or extrinsic. however, manpower and medical care systems differ depending on the emergency and critical care center, and the establishment of a system for consolidating severe trauma patients has been particularly problematic. material and methods: this study examined cases where the patient had some sign of life when encountered by ambulance teams of the cases of traffic accident deaths that occurred in chiba prefecture between and . thirteen emergency and critical care center representatives in chiba prefecture met to verify each case based on data from the police, fire department, and medical institutions. the cases were classified into ( ) preventable trauma death (ptd) cases, ( ) suspected ptd cases, and ( ) non-life-saving cases; the problems (causes of ptd) in each case were examined. result: there were cases ( %) of ptd and suspected ptd. sixty-eight of these cases were transported to emergency and critical care centers. the most common cause of death was bleeding, accounting for cases and the locations where the problems that caused ptd occurred were outside of the hospital (n = ) and in the hospital (n = ). the problems that occurred in the hospital (including duplications) include circulatory management (n = , %), the treatment plan (n = , %), delay of lifesaving surgery (n = , %), and delay of diagnosis (n = , %). most of these occurred in the initial emergency care room. conclusion: this study clarified that ptd still occurs in relation to bleeding control in the current trauma care system in chiba prefecture. it is vital to establish a national ''trauma center'' and to thoroughly consolidate trauma cases to eradicate ptd. analysis of the impact of the implementation of a trauma team in a trauma center from an upper-middle-income country introduction: trauma teams (tt) improve the care process and the outcomes. a multidisciplinary tt was conformed in september to achieve a rapid response by specialists in emergency medicine, trauma surgery, diagnostic imaging services, and blood bank in a level i trauma university hospital in southwestern colombia. objective: to evaluate the impact of a tt implementation in terms of times of attention and mortality. material and methods: retrospective study. all the patients with the highest level of tt activation treated in the months after the tt implementation were included. the subjects triaged to the trauma center in the months pre tt were taken as controls. four hundred sixty-four patients were included, before the implementation of the tt (btt) and after (att). demographic data, trauma characteristics, times to tomography, and trauma surgery and mortality were recorded. the analysis was made on stata , Ò . categorical variables were described as quantities and proportionscontinuous variables as mean and standard deviation or median and interquartile range (iqr). categorical variables were compared by chi or fisher's test. continuous variables with student's t or wilcoxon-mann-withney. a multiple logistic regression model was created to evaluate the impact on mortality if being treated att, adjusted by age, trauma severity, and physiologic response on admission. results: the time from admission to the ct scan was min (iqr - ) in the btt group and min (iqr - ) in the att group, p &lt; . . the time to trauma surgery was min (iqr - ) in the btt group and min iqr - ) in the att group, p &lt; . . mortality in the btt group was . % and . % in the att group. adjusted or was . ( . - . ) p = . conclusions: the implementation of a multidisciplinary trauma team associated with a reduction of the times to tomography and surgery and with a decrease in mortality risk. no prediction of an unfavourable outcome after surgical treatment of chronic subdural hematoma patients using machine-learning l. riemann , a. younsi , c. habel , j. fischer , a. unterberg , k. zweckberger university hospital heidelberg, neurosurgery, heidelberg, germany introduction: chronic subdural hematomas (csdh) are expected to become the most frequent neurosurgical disease by the year . although often perceived as a ''benign'' condition, considerable rates of mortality and poor outcome have been reported. we therefore evaluated factors associated with an unfavorable outcome after surgical treatment of csdh patients by developing a predictive model using machine-learning. material and methods: consecutive patients treated for csdh with surgical evacuation between and at a single institution were retrospectively analyzed. potential demographical, clinical, imaging and laboratory predictors were assessed and a decision-tree predicting unfavorable outcome (gos - ) was subsequently developed using the classification and regression tree (cart) algorithm. out-of-sample model performance was evaluated using repeated cross-validation (fivefold with repetitions). results: eligible patients were analyzed. median age was (iqr - ) years and % were males. mortality rate was . % and rate of unfavorable outcome was . %. the developed decision-tree to predict unfavorable outcome had splits and included the following clinical variables (in descending order of calculated importance): gcs, comorbidities, hb, and age. after cross-validation, the following model performance metrics were obtained: a model accuracy of . ( . - . ), sensitivity of . ( . - . ), and specificity of . ( . - . ). conclusions: gcs, comorbidities, hb, and age were identified as the most important clinical predictors for an unfavorable outcome in csdh patients after surgery. the developed model was simple and still displayed a high accuracy and very high specificity, the sensitivity was however rather low. our results might help clinicians to better assess the prognosis in patients with csdh. introduction: in most developing countries access to tertiary care neurosurgical setup is uncommon. majority trauma including neurotrauma & medical conditions requiring emergency neurosurgical interventions present to a general surgeon. this study is an attempt to highlight the importance of emergency neurosurgery as a skill amongst general surgeons & also focus on the challenges in managing such cases in austere environments material and methods: this study was a retrospective analysis of progressively collected data of trauma patients with a specific focus on head injuries & emergency neurosurgical interventions for both traumatic & non traumatic indications in a level trauma centre in a semi urban area over a period of years from august to september results: a total of patients of trauma were analysed out of which were head injuries. road traffic accidents accounted for nearly % of head injuries. atypical trauma especially in rural setup e.g. train collision, animal related causes were also seen. males accounted for majority (m:f = . : ). mean age was yrs. patients had imaging findings suggestive of severe head injury. acute sdh was the commonest post traumatic finding and mca territory infarct in non traumatic group. patients underwent emergency neurosurgical intervention with a survival of %. factors associated with poor outcome were delayed presentation (p \ . ), sdh with diffuse axonal injury. alcohol consumption was a significant factor. conclusions: emergency neurosurgery is an essential skill for general surgeons. performing such cases in a low resource environment in absence of modern day facilities for imaging, icp monitoring & powered equipment presents a significant challenge. general surgeons should be able to perform operative interventions with basic handheld instruments. operative management whenever indicated should be done & helps improve outcomes. head trauma in polytraumatized patient. analysis of risk factors and neurological prognosis b. castro , , , m. morote gonzález , , , l. cebolla , , , a. sada , , , l. seisdedos , , , , , j. gil , c. rey valcárcel , , f. j. turégano fuentes , , c. tristan , c. ruiz moreno hgugm, surgery, madrid, spain, hospital, madrid, spain, hospital, madrid, spain, hospitall, madrid, spain, hospital, madrid, spain, hospital, madrid, spain, hospital, madrid, sri lanka introduction: severe trauma is one of the most frequent causes of death and disability and traumatic brain injury (tbi) in polytrauma is the main cause of death and disability in survivors. the aim of this study is to analyze mortality associated to tbi in the last years, prognostic factors associated with it and neurological outcomes in survivors with tbi. methods: retrospective observational study that includes risk factors and functional neurologic evaluation in polytrauma patients attended in gregorio marañon hospital between - . inclusion criteria were severe trauma patients (iss c ) with a tbi and abnormal ct of the head. we analyzed mortality trend in two periods : - and - , and neurological evolution and outcome at discharge with functional scores (ramkin scale and gos) in the second one. results: from to , severe trauma patients were admitted, ( , %) with brain or central nervous system injuries visible on head ct. median age was ' ; . % were men. the global mortality of the cohort has been , %, . % of them for neurological causes. ischemic heart disease, anticoagulation, abnormal pupils or eye opening, the need for surgery, shock, gos, iss, niss, cranial ais are significant associated with higher mortality (p \ , ).the mortality rate due to neurological causes decreases in the second period from , to , %, this descent being statistically significant (p = , ). between and , % patients died from cnsi, and , % of tbi survivors had a vegetative status at discharge, , % had major disability, and , % had a good neurological recovery. conclusions: mortality due to tbi decreased in the last years, but this improvement after tbi was at the expense of a high rate of vegetative status and great disability, showing the need for continuous research in this area. introduction: severe traumatic brain injury (tbi) constitutes one of the most frequent causes of intensive care unit admissions and is a major cause of death and disability among young people. decompressive craniectomy (dc) is a life-saving measure used to relieve intracranial pressure (icp). this procedure is related with low mortality rates and poor functional outcomes. the aim of this study is to analyze the survival rates and prognostic factors related with functional outcomes after dc for severe tbi. material and methods: retrospective, single center study of patients with severe tbi in whom a dc was performed between the years and . demographic features, clinical parameters, radiological findings and clinical outcomes were included in the study. for the statistical analysis we used anova, chi-square, kaplan meyer, cox regression and logistic regression. a p value of less than . was considered to indicate statistical significance. results: the mean initial glasgow coma scale was , ± , and the mean initial motor response (imr) was , ± , . the mean icp after dc was , ± , . the -day survival after dc was %. twenty percent of the patients improve ate least point in the glasgow outcome scale (gos) between and months after surgery. twelve patients improve from unfavorable gos to favorable gos. at -month follow-up, % of the patients has gos [ . younger age, high irm a post-operative icp were the factors significantly associated with a higher chance of outcome improvement. conclusions: dc is useful for the management of refractory intracranial hypertension related to severe tbi, and in selected patients is associated with good functional outcomes. introduction: antiplatelets and anticoagulation, commonly referred to as antithrombotic therapy, are frequently used in patients c years. the use of antiplatelets and anticoagulation are associated with increased incidence of intracranial bleeding ( , ) . there are two research questions addressed in this study: ( ) does preinjury antithrombotic therapy affect survival in elderly patients with tbi? ( ) are direct oral anticoagulants (doacs) associated with better survival than vitamin k antagonists (vka) in tbi patients on anticoagulation? materials andmethods: retrospective cohort study based on data extracted from the oslo tbi registry. included in the study are tbi patients c years admitted to ouh with cerebral-ct showing signs of acute trauma (hemorrhage, fracture, vascular injury) in the time period - . the impact of age, comorbidity, antithrombotic medication and antithrombotic reversal protocol for survival will be explored. results: the patient inclusion is ongoing. preliminary data will be presented at the st ectes in april . the estimated number of tbi patients c years with cerebral-ct showing signs of acute trauma in the study period is * . in this patients group, the expected preinjury use of antiplatelet and anticoagulation medication is * % and * %, respectively. conclusions: the knowledge regarding impact of preinjury antithrombotic therapy on survival in elderly tbi patients is clinically relevant, and may improve patient management in the acute phase of injury. references: introduction: traumatic acute subdural hematoma (asdh), especially the large ones in need of surgical evacuation, is associated with high mortality. contemporary population-based series of surgically treated asdh are sparse. the two main aims of this single-center study from oslo university hospital (ous) were to estimate incidence of surgery for asdh in the population of helse sør-Øst, and estimate in-hospital and -month survival of these patients. treatment of tbi at ous adheres to the brain trauma foundation guidelines, with icp controlled therapy and evacuation of asdh when gcs \ and hematoma volume c cm or midline shift c mm or hematoma width [ mm. the goals of tbi treatment for adults have been to maintain icp \ mmhg and cerebral perfusion pressure (cpp) c mmhg. methods: from . . all patients with traumatic brain injury (tbi) with positive head ct, admitted to ous, living in helse sør-Øst ( . million inhabitants) and having a norwegian social security number, have been included in our approved tbi-quality register. included in the present study are all patients with asdh undergoing evacuation of the hematoma within days of trauma. the following data were extracted from the register; demographic variables, date of injury and trauma mechanism, severity of head injury according to hiss grade, rotterdam ct score, surgical procedures, multitrauma, glasgow outcome scale at discharge and date of death. results: asdh patients were operated in the -year period - , % males, mean age was years ( - ), the most frequent trauma mechanism was falls ( %), % were under influence of ethanol, % had severe tbi and % had multitrauma. the incidence of surgically treated asdh in helse sør-Øst was / . /year. in-hospital and -month mortality was . % and %, respectively. conclusion: the presented data for incidence and mortality will be compared with earlier reports. age-related difference in impacts of coagulopathy in patients with isolated traumatic brain injury: an observational cohort study w. takayama , a. endo , y. otomo tokyo medical and dental university hospital of medicine, trauma and acute critical care, tokyo, japan background: age and trauma-induced coagulopathy (tic) have been reported to be the predictors of poor outcome following traumatic brain injury (tbi). whether the impact of brain injury induced coagulopathy on outcomes have age related differently is unknown. objectives: we evaluated the age-related difference in the impact of tic on outcomes in patients with isolated tbi. methods: a retrospective observational study was conducted in two tertiary emergency critical care medical centers in japan from to . the patients with isolated tbi [head abbreviated injury scale (ais) c , and other ais \ ] were included. we evaluated the impact of coagulopathy (international normalized ratio c . , and/or platelet count \ /l, and/or fibrinogen b mg/dl) on the outcomes [glasgow outcome scale-extended (gos-e) scores, inhospital mortality and ventilation free days (vfd)] in both group using univariate and multivariate models. furthermore, we visualized the impact of coagulopathy on gos-e according to age, by using a generalized additive model. results: of the patients studied, they were divided based on their age: non-elderly group (n = , - years) and elderly group (n = , age c years). although, in the multivariate model, age and coagulopathy were significantly associated with lower gos-e, in-hospital mortality and shorter vfd in the non-elderly group, significant impact of coagulopathy was not observed for all the outcomes in the elderly group. the correlation between coagulopathy and lower gos-e decreased with age after round years old. conclusions: in patients with isolated tbi, impact of coagulopathy on functional and survival outcomes was lower in geriatric patients. no difference in mortality between isolated tbi and polytrauma with tbi: it is all about the brain introduction: despite improvements in trauma and critical care mortality caused by traumatic brain injury (tbi) remains high. [ ] as polytrauma is naturally associated with increased mortality, this study compared mortality rates in isolated tbi (itbi) patients and polytrauma patients with tbi admitted to icu. material and methods: a -year retrospective cohort study included both consecutive trauma patients with itbi with ais head c (ais of other body regions b ) and polytrauma patients with ais head c admitted to a level-i trauma center icu. patients \ years of age, injury caused by asphyxiation, drowning, burns and transfers from and to other hospitals were excluded. patient demographics, shock and resuscitation parameters, denver multiple organ failure scores and acute respiratory distress syndrome (ards) data were collected. [ ] data is shown as medians with interquartile ranges. p-values \ . were statistically significant. results: a total of patients were included. the median age was ( - ) years, ( %) patients were male, median iss was ( - ). seventy-nine ( %) of all patients died. polytrauma patients developed more often ards ( % vs % p = . ) but had similar mods rates ( % vs % p = . ). polytrauma patients stayed longer on the ventilator ( vs. days p b . ), longer in icu ( vs. days p b . ) and longer in hospital ( vs. days p b . ). there was no distinction in in-hospital mortality of itbi and polytrauma patients ( % vs. % p = . ). tbi contributed to all deaths in itbi patients and all but three deaths ( %) in polytrauma patients. conclusions: tbi was the main cause of death in both groups. there was no difference in mortality rates between polytrauma patients with tbi and itbi patients, even though polytrauma patients were more severely injured. references: [ ] dewan mc et al. estimating the global incidence of traumatic brain injury. j neurosurg. ; ( ): - . no significant relationships or conflict of interests. how modeling the brain ventricles could help brain trauma understanding ( ). in pathological cases as in hydrocephalus, or in brain trauma, it is likely that each patient's ventricle structure has an impact on the way they behave. for instance, a shock wave may turn out differently according to the ventricle's shape. this can explain why for a same shock, the clinical translation is not the same. the aim of the study is to implement a finite element model of the cranio-cerebral system and to analyse the impact of a trauma simulation. material and methods: this is amonocentricretrospective study from . the database contains ct scans of healthy patients. we used itk-snap software to segment the ventricles and matlab to implement the model. results: the mean volume of the total ventricles is ml (sd = ). the median is ml (table ) .to identify the correlation between the parameters acquired we performed a pearson test. we found multiple significant correlations and one of the most relevant one is between the ventricular volume and the width of the third ventricle ( table ). showing that the total ventricular volume is statistically correlated to the width of the third ventricle is clinically interesting. we could potentially simplify our analysis of the ventricular system in head trauma by measuring less coordinates and yet come up to an accurate prognosis. the ventricle volumes are used as neuroimaging marker of brain changes in health and brain trauma. to our knowledge, it is the first time they are studied in vivo on ct-scan. this study and the existing correlations are relevant for the configuration of the finite element model on going. it can surely help the comprehension of the interaction between the structural parts of the cranio-cerebral system during brain trauma. (excitatory-glutamate, and inhibitory-c-aminobutyric acid, gaba), is crucial for the normal cerebral functioning. gaba concentrations vary in different cerebral zones [ ] responsible for different cerebral tasks. in this study, [gaba] is measured in the posterior cingulate cortex (pcc) of children with acute mtbi. material and methods: acute mtbi patients (\ h since injury, . ± . y.o) and healthy controls ( . ± . y.o). mri scanner philips achieva t was used. standard mri protocol for tbi revealed no pathological lesions in brain of any subject. magnetic resonance spectroscopy (mega-press [ ] ) was applied to obtain gaba signal without macromolecules. spectroscopy voxel is demonstrated on fig. . intensities of gaba, glutamate ? glutamine, creatine and water signals were calculated in gannet program [ ] . absolute concentrations were calculated. mann-whitney was used to reveal the statistical significance of between-group differences. results: typical gaba spectrum processing in gannet is demonstrated on fig. . no changes in glx were found. the values of [gaba] in pcc are demonstrated on fig. : the increase in gaba is not statistically significant. conclusions: this is the first study of [gaba] in pcc of children with acute mtbi. the result of current work disagrees with our previous study, where gaba was increased (p \ . ) in the anterior cingulate cortex of children with mtbi [ ] . this indicates to a necessity of further data collecting in order to reveal any [gaba] alterations in various cerebral loci. this would help to identify the causes of an inhibition/excitation imbalance and to predict possible dysfunctions of cns following mtbi. results: tnaa and naag concentrations along with stable naa concentration were found to be reduced in patient group. reduced asp and elevated mi concentrations were also found. the main finding of the study is that tnaa signal reduction in wm after mild traumatic brain injury is associated with the drop of the naag concentration rather than of naa one, as it was thought previously. this highlights the importance of separation of these signals at least for wm studies to avoid misinterpretations of the results. naag plays an important role in its selective activation of the mglur receptors, thus providing neuroprotective and neuroreparative function immediately after mtbi. it might have potential for the development of new therapy strategy for patients with injuries of various severity. introduction: traumatic brain injury (tbi) is globally recognized as a major health and socioeconomic issue. however, reported numbers vary and often represent subgroups. the number of hospital-admitted tbi has an important impact on hospital resources. thus, the monitoring of hospitalized tbi patients is needed. in , oslo neurosurgical tbi registry was established and includes patients admitted to oslo university hospital (ouh) with traumatic intracranial injury identified by neuroimaging. the aim is to introduce the registry; describe the patient group and volume. material and methods: descriptive study from oslo neurosurgical tbi registry. results: patients from south-east region were included in - (population million). mean age was years (sd ), % were males. most frequent cause of injury was falls ( %), increasing with age. % was influenced by alcohol at time of injury. preinjury antithrombotic therapy was common ( %). most of the patients had multiple pathologies on ct caput, e.g. simultaneous cranial fracture, sdh, tsah and brain contusion (four most frequent). accompanying injuries were found in %. % was transported to ouh directly form accident scene. % was classified as severe tbi upon arrival ouh, % was intubated, and trauma team was activated in %. median annual and monthly numbers of cases were (range - ) and (range - ), respectively. no clear change in case load between years and months, except a slight decline in march. admission rate peaked during the weekend. patients were continuously admitted throughout day and night, [ % between : and : . conclusions: patients included in the registry were older than those included in previous tbi studies. the numbers of cases admitted were stable across the months and years. however, the majority of patients were admitted during weekends and nights; thus handled by duty staff. relationship between brain-body temperature difference and neurologic outcomes in patients with severe head trauma introduction: brain is one of the most vulnerable organ to temperature. the association between core body temperature(ct) and neurologic outcomes in patients with post-cardiac arrest, severe head trauma and stroke has been reported. there were few reports comparing brain temperature(bt) with ct and peripheral temperature(pt). we investigated the association of differences among bt, ct and pt with neurologic outcomes in patients with severe head trauma. material and methods: we retrospectively reviewed data for patients with severe head trauma who underwent monitoring intracranial cerebral pressure(icp), bt, ct and pt simultaneously between january and december . results: we evaluated patients with a median age of years (range - years). glasgow outcome scale(gos) at discharge were as follows: good recovery(gr) , severely disabled(sd) , vegetative state(vs) , death(d) . table showed the average values of icp, cerebral perfusion pressure(cpp), bt, ct, pt, differences between each temperature (bt-ct, ct-pt, bt-pt) and gos in each patients. there was remarkable difference between bt and ct in the dead patient, whereas less differences were found in the other alive patients. we found greater difference between bt/ct and pt in the vs patients than gr patients. conclusions: greater differences between bt/ct and pt can be related to poorer neurologic outcomes introduction: minor head traumas are difficult to assess even with guidelines, hence head cts are often requested. as head cts are increasingly accessible, the demand on the radiology department often exceeds its capacity. there has been an increase in head cts at the oslo emergency department (oed), norway. the scandinavian guidelines for initial management of head injuries in adults (sg) is standard practice in the oed when assessing patients with head trauma.the aim of this study is to assess the number of patients with traumatic brain injury, evaluate guideline compliance and false negative initial reports by junior radiologists. material and methods: a consecutive cohort of patients from jan-june who received a head ct at oed due to minor head trauma was assessed. data was gathered from the ct request form, radiology report and ct images. the data points analyzed were: type of trauma, gcs, anticoagulants, loss of consciousness, nausea and vomiting, positive traumatic ct findings, and number of head cts within a year period. results: intracranial bleeds were reported in ( %) patients, ( . %) required neurosurgical intervention. skull fractures were reported in ( . %) patients, however no intracranial bleeds were present. it was impossible to assess guideline compliance because % of the referrals lacked adequate clinical information. ten bleeds were missed, however no further action was needed. % received more than head cts in years conclusions: head injury guidelines can improve clinical practice and reduce unnecessary ct scans; thus minimizing radiation exposure. based on the low number of positive findings, we hypothesize that sg compliance can be improved at oed. compliance was not assessable for nearly half of the patients, due to vital clinical factors missing. implementation of a standardized ct referral form based on the sg and educating junior ed doctors may decrease the number of unnecessary head cts. introduction: to date, there is no ideal allograft that provides local antibiotic release. along with this, existing fillers are expensive material, which complicates their application in practice. all this leads to the need to look for new ways to solve this problem. material and methods: gentamicin was used as an antibacterial drug because of its wide spectrum of action and thermal stability. for the study, staphylococcus aureus attc was used as a microbial strain. the antibiotic release from the studied materials was determined by equilibrium dialysis over the entire observation period. gentamicin antibiotic concentration was determined by hplc. results: an allograft impregnated with an antibiotic, prepared according to the marburg system in the area of the subcortical part of the bone, suppresses the staphylococcus aureus attc strain twice as much as perossal. when comparing bone allografts impregnated in various ways, the longest release time showed a perforated allograft.a bone graft impregnated with an antibiotic by incubation showed a % longer release time compared to perossal granules (p \ . ).when in vitro incubation of the antibiotic gentamicin with the drug ''perossal'', the dissociation rate is more than % in the first two days. when the antibiotic gentamicin with a bone allograft is incubated in vitro on the second day, dissociation into the extracellular space makes up more than % of the drug from the previously bound (p \ . ), which also indicates a longer release time from the bone allograft. conclusions: in vitro, a bone allograft impregnated with an antibiotic is able to reversibly bind the antibiotic gentamicin and gradually release it over a period of days. the use of a bone allograft impregnated with an antibiotic suppresses the growth zones of staphylococcus aureus strains. references: rudenko a., impregnation of the bone allograft: comparison of heads coloring. european journal of trauma and emergency surgery (suppl) p. acute appendicitis and pregnancy: from incidence to modern management: literature review and proposal for consensus estes experts guidelines a. l. bubuianu , a. mihailescu , g. pokusevski tameside general hospital, general/emergency surgery, ashtonunder-lyne, united kingdom introduction: acute abdominal pathology during pregnancy has historically been a challenging decision for the emergency surgeon, that had to deal with patients at same time. acute appendicitis has probably the highest prevalence of all. early involvement of the gynaecological team was considered paramount and the ongoing debate laparoscopic versus open intervention, has been more recently challenged by case reports where antibiotics alone have been a successful strategy. material and methods: literature review has been conducted by the investigating team, using the following search algorithm: reviewers screened pubmed portal to conduct a thorough search of the most important medical databases, cochrane's library, medline and embase. case reports and low quality case series have been excluded from the literature review. results: there is currently no general consensus in regards to operative strategy in acute appendicitis during pregnancy, but most authors described safety of laparoscopic intervention in the first trimesters and favoured open approach in a mother closer to term. the antibiotic treatment alone can only be considered in presumed early appendicitis, where there are no features of pending perforation, presence of phlebolith or established peritonitis and should be done under the close monitoring of experienced general surgeons. conclusions: an expert consensus is required in first instance, (set of questions submitted to audience at end of presentation for their expert opinion) regarding optimal treatment strategy in acute appendicitis during pregnancy, followed by a multicenter prospective randomised control trial, which we are hopeful to engage with help of numerous european hospitals where estes members activate. introduction: deep tissue pressure injuries (dtpi) are complex and difficult to treat. the higher prevalence is observed in paraplegic and elderly populations. primary closure of large, stage- dtpis is rarely feasible and flap closure is customarily applied. presented is a technique using tension relief system (trs; topclosureÒ tension relief system) and regulated oxygen and irrigation negative pressure wound therapy (roi-npt; vcareaÒ) to facilitate simple primary wound closure of dtpis. methods: large, stage- dtpis were closed by a limited surgical procedure entailing conservative debridement, en-bloc primary wound closure based on the application of trs and roi-npt. results: details of the closure of consecutive large dtpis in patients is presented. immediate primary closure was achieved in cases, while three others were closed over - days. surgery time ranged between . and h and hospitalization between and days. following a median follow-up of months (range - months), all wounds healed with one late recurrence. post-operative wound infection observed in one patient was successfully treated with systemic antibiotics. minor skin damage inflicted by the tension sutures at the anchoring sites healed spontaneously. gradual return to partial loading of the operated area was enabled within - weeks and full weight-bearing was achieved within - weeks. introduction: chronic pain is a disabling condition affecting - % of trauma patients. considering the burden of chronic pain, interest in interventions to prevent this disorder after trauma has grown. a descriptive review of literature was undertaken to assess the evidence on these interventions. material and methods: medline, cinahl and cochrane library databases were searched to identify interventional studies published up to august . websites of injury, critical care and pain organizations were also consulted to retrieve relevant guidelines. the literature search used combinations of medical subject headings and keyword under the themes of pain, trauma, surgery and preventive interventions. results: many knowledge syntheses relevant to the population of trauma published between and were found. low to moderate level of evidence was reported for pharmacological interventions such as the administration of ketamine, neuropathic pain medication and multimodal analgesia. local or regional nerve block in the presence of factures was associated with a high level of evidence. very low to low evidence was described for nonpharmacological interventions including cryotherapy and early mobilization. finally, psychological interventions were associated with a low to moderate level of evidence and multimodal pain management interventions (pharmacological and non-pharmacological) with a high level of evidence. conclusions: research is still needed to define the role of interventions to prevent chronic pain in trauma patients. thus far, multimodal pain management interventions involving multidisciplinary team management appear to be the most promising. implementing such interventions could reduce the negative consequences associated with chronic pain. introduction: chronic use of opioids has been documented % of trauma patients. accordingly, the tapering opioids prescription program in trauma (topp-trauma) was developed. the aim of this study was to assess the feasibility of topp-trauma and explore the efficacy of topp-trauma in reducing opioid use. material and methods: a -arm pilot rct was conducted in patients presenting a high risk for chronic opioid use. we aimed to recruit participants to receive either topp-trauma or an educational pamphlet. topp-trauma comprised educational and counseling sessions. the feasibility assessment of topp-trauma was based on the ability to provide its components. the morphine equivalent dose (med) per day as well as pain intensity and pain interference with activities were measured at and weeks following discharge. results: preliminary findings based on data collected in participants showed that counseling sessions were most frequently needed to completely taper opioids. sessions attendance reached %. nearly % of eligible patients accepted to participate and an attrition rate of % was found. even though the experimental group consumed a higher med h prior to hospital discharge compared to the control group ( . vs . ), its med/day intake was lower at weeks ( . vs . ) and weeks ( vs . ). these self-reported data were validated by the total med delivered by participants'' pharmacy at both time points ( . vs . at weeks; . vs . at weeks). minimal mean score differences were observed in both groups with regard to pain intensity and interference with activities. conclusions: data collected until now provided evidence on the feasibility of topp-trauma and on the program potential efficacy. challenges that will require to be addressed in future rct include the acceptance to take part in the study and participants' drop out. introduction: head preserving surgical treatment for ao-type b fractures with little to no dislocation consists of three canullated screws or a dynamic hip screw (dhs). there is a new alternative: the femoral neck system (fns). the fns has some advantages over dhs. the anti-rotation screw provides extra rotational stability because of the diverging design. furthermore, the incision is smaller in fns and only one locking screw is necessary for plate fixation. we present the first results of this new surgical fixation of femoral neck fractures with fns. material and methods: during the period of november until october , all patients with femoral neck fractures treated with fns, were included in this prospective single center cohort study. patient characteristics, fracture classification (ao, garden, pauwel), perioperative parameters and postoperative complications were registered. patients were allowed to mobilize based on the principle of permissive weightbearing. follow up was planned after weeks and weeks. primary outcome measure was cut-out rate within months. results: twenty-four patients with a femoral neck fracture (ao-type b) were surgically treated with fns. median age was , (range - ). median operation time was mins (range - ). mean duration of in hospital stay was days (range - days). twentytwo ( , %) patients completed the regular follow up of weeks. one patient ( %) had a reoperation due to a cut-out. during follow up one patient developed a wound-infection ( %) which was treated with intravenous antibiotics conclusions: femoral neck system as surgical treatment for femoral neck fractures shows promising first results. low cut-out rate, limited operation time, low mortality and short duration of in-hospital stay make this device a possible alternative for dhs of canullated screws. definitive conclusions should be made after studying long term results in larger cohorts. references: none. new personalized approach to enteroatmospheric fistulas using d bioprinting device introduction: enteroatmospheric fistula is a challenge for surgeons. it presents a great clinical variability. this diversity means that, despite having tried multiple devices and techniques to achieve local control of the intestinal effluvium over the rest of the wound, there is currently no technique that can solve this problem in all patients. d printing is a novel therapy that allows the customization of the devices according to the needs of each patient. the aim of this study is to describe the technique of manufacturing a custom device designed by bioscanner imaging and manufactured using a d printer for use in the management of enteroatmospheric fistula. we describe our initial results. materials and methods: we present four patients with enteroatmospheric fistula. the intestinal segment involved, the dimensions of the wound, the intestinal debit and the size of the exposed intestinal surface are substantially. all require an average of - daily cures by the nurse. after obtaining images of each fistula with a bioscanner, a personalized device was designed and made by a d printer. the polycaprolactone device was placed including inside the fistulous orifices and surrounding it with npwt in order to accelerate the healing of the wound to ostomize the fistula or achieve its definitive closure. results: four devices with different designs have been manufactured. the wound remained isolated from the intestinal contents after placement, favouring the granulation of the surrounding tissue with npwt and thus avoiding contamination of the wound. the system remained without leaks for an average of h, reducing the need for daily cures, improving patient comfort and avoiding complications. conclusions: the use of a manufacturing model using d bioprosthesis printing in order to create a personalized device that fits the characteristics of the patient's wound is feasible and offers promising results in the management of enteroatmospheric fistulas. new approaches in bone tissue engineering: innovative scaffold design for principle unlimited size bone substitutes introduction: in bone tissue engineering (bte), autologous boneregenerative cells are combined with a scaffold for large bone defect treatment. microporous, polylactic acid scaffolds showed good healing results in bone defects in small animals. transfer to large animal models, however, is challenging and not easily achieved simply by upscaling the design. increasing diffusion distances has a negative impact on cell survival and nutrition supply. this can lead to cell death and ultimately implant failure.this approach focuses on scaffold architectures, that meet all the requirements for a modern bone substitute. biological-functional, porous subunits in a loadbearing, compression-resistant frame structure characterise the innovative design. an open, macro-and microporous internal architecture provides optimal conditions for oxygen and nutrient supply in the inner areas of the implant by diffusion. material and methods: during the design process, prototypes (temple (figure a) , grid (figure b) , onion (figure c)) were dprinted (fused filament fabrication) using polylactic acid (pla). -after incubation with saos- (sarcoma osteogenic) cells for days (measurements on days , , and ), cell morphology, distribution and survival (fluorescence microscopy, ldh-based cytotoxicity assay), metabolic activity (mtt test) and osteogenic gene expression were determined. results: all designs not only showed cell colonization, but cells also sustained their ability to differentiate (already after days) and to divide. the open, hierarchical-structured design, with its innovative porous structure, provides a good basis for cell settlement and proliferation. the modular design allows easy upscaling and offers potential solutions to previous limitations scaffold developement in bone tissue engineering. references: the value of d reconstructions in determining post-operative reduction in acetabular fractures: a pilot study introduction: in patients with acetabular fractures, the reconstructed three-dimensional ( d) model of the contralateral acetabulum could be used as a mirrored template for the anatomic configuration of the affected joint. this has not been validated. material and methods: computer tomography (ct)-scans of twenty patients with unaffected acetabula were used. the symmetry of the generated d models was evaluated through; ( ) mirroring of the acetabulum; ( ) initial rough matching; ( ) automatic optimisation of the matching via surface-based matching; ( ) calculation of distances between surfaces by evaluating the euclidean (straight-line) error distance between the closest points between left and right. the percentages of surface-points of the left and right acetabulum with a distance smaller than . , . , . and . mm were calculated and evaluated, in relation to matta's criteria, for acetabular fracture reductions. the analysis was performed using the mirrored left acetabulum matched onto the right original structure (left mirrored to right original; ''lm ro'') and the right mirrored to left original (rm lo). to determine the inter-observer agreement the procedure was repeated by a second assessor for the first ten patients. results: patients had a mean ± sd age of . ± . years, % was male. the mean distance deviation was less than . mm in all comparisons. the calculated distances in . % of the surface points of the left and right acetabulum were below the tolerance threshold of . mm, based on matta's anatomical reduction critera (table ). absolute differences between assessors were\ . mm per patient with an overall moderate agreement of %. conclusions: d reconstructed models of healthy left and right acetabula are highly similar and could potentially be used as mirrored duplicates. the next step will be to investigate these results in patients with reduced acetabular fractures. : matta, j. ( ).j bone joint sur am. : - pr minimally invasive plate osteosynthesis technique for distal humeral fracture: a cadaveric study v. hofmann , c. deininger , t. freude , f. wichlas university hospital salzburg, orthopedics and traumatology, salzburg, austria introduction: in our study we want to evaluate the feasibility of minimally invasive plate osteosynthesis (mipo) technique for distal humeral fracture using anatomically precontoured double plate osteosynthesis. material and methods: eight elbows from four thiel fixed cadavers were included. on unfractued cadavers we tested the minimally invasive approach with two separate incisions, one at the lateral and one at the medial epicondylus. the preformed plates were inserted directly into the bone on sides and fixed with percutaneous screws. then we created an ao type a and c fracture. the reduction was performed under x-ray control and stabilized with k-wires. then we also inserted the plates in mipo technique. in the case of an intraarticular fracture, an olecranon osteotomy was additional performed in a minimal invasive way to control the distal humeral joint surface. after finishing reduction and fixation the approach were extended to control the fracture alignement, position of the plates and to expose the ulnar nerve. results: the plate position was satisfactory and we could not detect any major soft tissue damage or ulnar nerve injury by using the minimally invasive plate osteosynthesis technique. in the extraarticular fractures, reduction was achieved with k-wires and was acceptable in all cases. the intra-articular fractures were controlled by an additional olecranon osteotomy using the mipo technique with a good view on the joint surface of the distal humerus. conclusions: the findings of the present study show that mipo technique in distal humerus fracture is feasible and save especially for ao type a fractures. in ao type c fractures the olecranon osteotomy provided enough visibility to evaluate the distal humeral joint surface. the surgical technique is demanding, and care must be taken not to injure the ulnar nerve. never the less it is an effective surgical treatment method and an alternative option to open techniques. correlation between pelvic incidence and acetabular orientation in anteversion and inclination-an analysis based on a d statistical model of the pelvic ring introduction: the pelvic ring is a complex bony structure with a central role for the human''s mobility building the connecting part between the upper body and the lower extremities. pelvic incidence and acetabular orientation are two important parameters used in the description of pelvic anatomy and are of central importance for understanding the biomechanical interaction of spine, pelvis and hip joints. the objective of the study was the analysis of a potential correlation between pelvic incidence and acetabular orientation. material and methods: a d statistical model of the pelvic ring consisting of individual ct scans of european adults without bony pathologies was used to analyse pelvic incidence and acetabular orientation in anteversion and inclination. an additional analysis on the correlation between those parameters was performed using the software spss. results: a slight positive correlation between pelvic incidence and acetabular anteversion could be shown (r = . ; p = . ) as well as a strong positive correlation between anteversion and inclination (r = . ; p \ . ). pelvic incidence and acetabular inclination showed none statistically significant correlation (r = . ; p = . ). conclusions: the results of the study might contribute to a better understanding of the biomechanical interaction between the axial skeleton and the lower extremities and deliver valuable information concerning preoperative planning in orthopaedic and trauma surgery of the lumbar spine, the pelvis and the hip joints like for example reconstructive surgery after trauma, operative treatment of congenital or acquired deformities or total joint arthroplasty. references: boulay et al., ''pelvic incidence: a predictive factor for three-dimensional acetabular orientation-a preliminarystudy. '' anat res int. ; : . doi: . / . epub . introduction: the majority of distal clavicle fractures (dcfs) are displaced fractures and are prone to delayed-or non-union. there are several options for surgical reconstruction, open reduction and fixation or hook plate, but in patients with a comminuted or small fracture they are known to have a high complication and failure rate, and secondary surgery for removal is often necessary. we hypothesize that resection of the distal fracture fragment and subsequent stabilization with the lockdown device, is an alternative for selected patients with dcfs. methods: eleven patients with a comminuted dcf were treated with a lockdown device. data on pain and range of motion were documented and the constant shoulder score (css), oxford shoulder score (oss) and nottingham clavicle score (ncs) were assessed at one year follow-up. results: eight patients underwent surgery within weeks, compared to patients where the surgery was delayed ([ weeks) due to persisting pain and delayed-union. none of the patients had postoperative complications. in months after treatment, patients were complaint-free. one patient had hardware removal due to pain at the site of the screw head. four patients were assessed after one year follow-up. the mean pain score was . . the mean flexion , °, abduction , °, exorotation °and extension °. the css had a mean of . , oss . and the ncs a mean of . conclusions: all patients had a good short-term clinical outcome and hardware complications did not occur. we are the first to describe the use of the lockdown device in dcfs. this device is not dependent on fracture healing and secondary surgery is not necessary, therefore it can be an alternative in the treatment of dcfs. a larger series and longer follow-up is necessary to confirm this conclusion. in this ongoing study, the remainder seven patients will be included and presented at the estes. moore type i tibial head fractures are one of the most challenging fractures to treat. material and methods: we performed the following approaches on eight thiel fixed cadavers: the anterolateral (with an osteotomy of the tuberculum gerdyi, a subcapital fibula-osteotomy and an osteotomy of the tuberositas tibia), the medial approach (with submeniscal arthrotomy and a dissection of the medial collateral ligament) and the posterior approach with a submeniscal athrotomy. the reachable borders of the articular joint surface have been marked by a k-wire. the visual joint surface has also been radiographically documented by inserting k-wires into the tibia head. finally the results have been photo documented on the exarticulated joints. results: the reachable areas of the articular surface have been defined and documented. the combination of the subcapital fibulaosteotomy and the submeniscal arthrotomy showed the most increase in accessibility to the articular surface in the dorsal part. an additional osteotomy of the tuberculum gerdyi increased the vision on the entire lateral and anterior articular surface. the submeniscal arthrotomy, at the medial approach, has not a good view on the surface. the posterior approach showed only a limited view on the lateral and medial articular surface at the dorsal part. none of the surgical approaches sufficiently visualizes the intercondylar region. conclusions: a fracture-specific approach strategy is critical for the preoperative planning of complex tibia-head fractures. subcapital fibula osteotomy is the most efficient surgical approach to reach the posterior and lateral articular surface. for the anterior articular surface, the best overview was achieved by an osteotomy of the tuberculum gerdyi. it was not possible to see and control the intercondylar region with any approach. introduction: osteosarcoma (os) is the most common bone carcinoma in humans. at the time of the first diagnosis are already in about % metastases present. the current treatment strategies include above all radical surgical resection and chemotherapy. in the search for alternative therapy methods. treatment with cold atmospheric plasma (cap) shows promising prospects. at the cellular level, this leads to various cellular mechanisms and finally to induction of anticancerogenic effects such as growth inhibition, apoptosis, and changes in the cell-cell interactions. the impact of cap on the integrity of the cell membrane of os cells, however, is unknown. material and methods: suspended cells from two human osteosarcoma cell lines (u -os, mnng) were treated for s, s, and s with cap. cell proliferation was determined after h, , , , and h using casy cell counter. dye loss assay was performed by using fluorescein diacetate (fda). this was followed by indirect treatment with cap for s. in the cell-free supernatant was determined by tecan multireader the dye emission. flow cytometry assay was used after cap treatments and incubation with fda. the mean fda fluorescence intensity of individual cells in the flow cytometer was measured. results: cell kinetics showed significant inhibition of cell proliferation in both cell lines after cap treatment. the assays for determination of the dye level showed a significantly increased membrane permeability of both cell lines after cap treatment. the significant effect on the membrane integrity correlated with treatment duration. conclusions: this confirms a modulating influence of cap on the functionality of the cell membrane and may support the anti-proliferative effect of the cap treatment. thus, cap is a promising therapy option, especially for chemotherapy-resistant entities introduction: osteosarcoma (os) is the most common bone cancer in humans. standard therapy includes radical surgical resection and chemotherapy, but due to strong toxic effects, new treatment options are urgently needed. currently, there is a discussion about expanding the oncological therapy spectrum and treat with cold atmospheric plasma (cap). it is a reactive ionized gas rich in radicals, photons, and electromagnetic rays. its biological effects are primarily mediated by reactive oxygen and nitrogen species (rons). due to its low temperature, cap is suited for medical applications. in vitro studies have shown the antitumoral effect of cap also for pancreatic cancer, melanoma, ovarian, breast, and colon cancer. material and methods: human os cell lines u -os and mnng/ hos were used. proliferation assay. the growth of cap-treated cells was examined using a casy cell counter. caspase / assay. following cap treatment, the activities of caspase- and caspase- were measured using a specific substrate peptide coupled with a fluorescent dye (cellevent tm ). single-cell gel electrophoresis comet assay. dna damage after cap treatment was identified using alkaline microgel electrophoresis. dna migration was measured using comet score software. the percentage of tail dna was used to indicate the relative fluorescence intensity of the head and tail. tunel assay. after cap treatment tunel analysis was performed. results: the results revealed that the cap treatment of os cell lines leads to significant inhibition of cell growth. subsequently, the activation of caspases and the induction of apoptotic dna fragmentation was demonstrated. the treatment of os cells with cap leads to an induction of apoptosis and a reduction of cell growth. introduction: extra peritoneal packing (epp) is a quick and highly effective method to control pelvic hemorrhage. we hypothesized that this procedure may be as safely and efficiently performed in the emergency room (er) as in the operating room (or). methods: retrospective study of patients who underwent epp in the er or or in two trauma centers in israel between - . material and methods: retrospective study of patients who underwent epp in the er or or in two trauma centers in israel between - . results: patients were included in our study, in the er-epp group and in the or-epp group. the mean injury severity score (iss) was . ± . . following epp, hemodynamic stability was successfully achieved in of patients ( . %). a raise in the mean arterial pressure (map) with a median of mmhg (mean . ± . , p = . ) was documented. all patients who did not achieve hemodynamic stability after epp had multiple sources of bleeding or fatal head injury and eventually succumbed. the overall mortality rate was . % ( / ) with no difference between the or and er-epp groups. patients who underwent epp in the er showed higher change in map (p = . ). no differences were found between er and or epp in the amount of transfused blood products, surgical site infections and length of stay in the hospital. however, patients who underwent er epp were more prone to develop deep vein thrombosis (dvt): % ( / ) vs % ( / ) in er and or-epp groups respectively (p = . ). conclusions: epp is equally effective when performed in the er or or with similar surgical site infection rates but higher incidence of dvt. level of evidence: retrospective cohort study, level iv. introduction: application of supraacetabular schanz screws is usually performed under image intensifier guidance. the aim of this study was to perform it without imaging, with the hypothesis that, respecting anatomical landmarks, pre-and intraoperative fluoroscopy can be avoided. material and methods: insertion of the supra-acetabular schanz screws was performed in human adult cadavers. with cadavers placed in supine position, the anterior superior iliac spine (asis) was palpated. starting from this landmark, cm were measured in a distal and cm in the medial direction. at this point, a cm long oblique skin incision was performed. through this approach, mm schanz screws were drilled bilaterally into the supra-acetabular corridor with an angulation of °to distal as well as °to medial. combined obturator oblique-outlet views (cooo) were taken bilaterally to prove the screw position. six of the specimens underwent a d-ctscan. images were evaluated concerning correct screw positioning. skin and subcutaneous tissues were removed in the ilioinguinal region and possible lesions to the lateral femoral cutaneous nerve (lfcn) or to the joint capsule were evaluated. results: during radiographic evaluation of the cooo-scans ( specimens) and the d-scans ( specimens), the schanz screws were placed inside the supra-acetabular corridor in all specimens ( / ). during dissections, no intracapsular screw placements or lfcn lesions were found. conclusions: using our technique, all schanz screws could be sufficiently inserted without intraprocedural x-ray imaging. references: . karaharju, e. and p. slätis, external fixation of double vertical pelvic fractures with a trapezoid compression frame. inhury, . : p. - . . mears, d. and f. fu, external fixation in pelvic fractures. orthop clin north am, . : p. - . . mears, d. and f. fu, modern concepts of external skeletal fixation of the pelvis. clin orthop, . : p. - . pr epidemiology of self-inflicted major trauma r. stoner , n. misra , l. mason aintree university hospital, liverpool, united kingdom introduction: in the united kingdom, severely injured patients are taken directly to a major trauma centre (mtc). whilst deliberate self harm (dsh) is a known mechanism for this, there is limited prior research. - % of major trauma is thought to be self inflicted , . our aim was to describe the epidemiology of presentation to our mtc resulting from dsh. material and methods: retrospective review of patient records in our mtc for adult trauma team activations between / / and / / . data was collected on patient demographics, location type, injury severity score (iss), mechanism of injury and mortality. results: episodes of dsh made up . % of all trauma cases, involving patients; . % re-attended. z-scores show no change in incidence over time, but significant variability month by month, with / months [ sd from mean. mean patient age years (range - ). . % were male. . % came from residential location and . % from prison. most common mechanism was penetrating trauma ( . %). in-hospital mortality was % ( . % in males vs . % in females, chi p = . ). conclusions: this is the largest review of self inflicted trauma cases in a uk mtc, with a similar incidence to prior studies. there was no observed correlation with season or trend over time. mortality was higher in male patients, in keeping with national statistics on suicide, whilst dsh in females was linked to less severe injury; severity is related to mechanism of injury. injury from self stabbing/cutting was most common in patients from residential locations, whilst hanging was more common in prisoners. this study identifies preventable risk factors for major self inflicted injury. introduction: the distribution of trauma deaths was classically described following a trimodal pattern. during the last decade improvements in trauma care as damage control resuscitation (dcr) have minimized resuscitation injury. we hypothesized that the implementation of dcr in severely injured trauma patients is associated with less mortality and modifies mortality pattern. material and methods: we performed a -year ( - ) retrospective cohort analysis of all severely injured trauma patients (niss c ) who underwent surgery at our level trauma center. since , dcr was implemented including damage control surgery, minimizing crystalloids and increasing the use of blood products. our patients were stratified into two phases: pre-dcr ( - ( ) and post-dcr ( . results: a total of patients were identified. there were patients ( . %) in the pre-dcr group and patients ( . %) in the post-dcr group. mean age ( . vs . , non significant (ns)), mechanism of injury (blunt trauma: . % vs . %, ns) and shock on admission ( . % vs . %, ns) were similar between groups. there is a significant reduction in the rate of overall mortality ( . % vs . %, p \ . ). while early deaths from traumatic brain injury ( . % vs . %, ns) and hemorrhage ( . % vs . %, ns) are alike, mortality secondary to multisystem organ failure (msof) is lessened ( . vs . %, p \ . ). conclusions: dcr has helped in reducing overall mortality and mortality due to msof in our severely injured trauma patients. introduction: the mangled extremity severity score (mess) was constructed as an objective quantification criterion for limb trauma. a mess of or greater than was proposed as a cut-off point for primary limb amputation. opinions concerning the predictive value of the mess vary broadly in the literature. the aim of this study was to evaluate the applicability of the mess in a contemporary civilian central european cohort. material and methods: all patients treated for extremity injuries with arterial reconstruction at two centres between january and december were assessed. the mangled extremity severity score (mess) and the amputation rate were determined. results: seventy-one patients met the inclusion criteria and could be evaluated for trauma mechanism and injury patterns. the mean mess was ). seventy-three percent of all patients ( / ) had a mess b and % ( / ) of c . eight patients ( %) underwent secondary amputation. patients with a mess c showed a higher, but statistically not significant secondary amputation rate ( . %; / ) than those with a mess b ( . %; / ; p = . ). the area under the roc curve was . (ci . ; . ). conclusions: based on these results, the mess seems to be an inappropriate predictor for amputation in civilian settings in central europe possibly due to therapeutic advances in the treatment of orthopaedic, vascular, neurologic and soft tissue traumas. introduction: in polytrauma victims the acute respiratory distress syndrome (ards) is a major cause of morbidity and mortality. it presents a complex pathophysiology that is characterized by pulmonary activated coagulation and reduced fibrinolysis. due to the fact that the pulmonary endothelium is considered a key modulator of ards and that tpa in plasma is predominantly synthesized and secreted by vascular endothelial cells, we hypothesized that the time courses of serum tissue-type plasminogen activator (tpa) and its main inhibitor, the plasminogen activator inhibitor type- (pai- ), might indicate a clinical approach to preventing ards in polytrauma victims. material and methods: twenty-eight consecutive polytraumatized patients with concomitant thoracic trauma, age c years, iss c , who were directly admitted to our level i trauma center, were evaluated. blood samples were taken initially and on day , , , , , , and during hospitalization. luminex multi-analyte-technology was used for analysis of tpa and pai- antigen levels. results: both levels were particularly high at admission. although they significantly declined within three and seven days, respectively, they remained elevated throughout three weeks. throughout this observation period mean tpa antigen levels were higher in polytrauma victims suffering ards than in those without ards, whereas mean pai- levels were higher in polytrauma victims sustaining pneumonia than in those without pneumonia. noteworthy, in each patient, who developed ards, the tpa antigen level raised up to the onset of the syndrome and declined afterwards. conclusions: the development of ards has to be expected in a polytrauma victims if the tpa antigen level continues to rise after admission. potentially, in patients with a low risk of excessive bleeding the onset of the syndrome might be prevented by the timely administration of recombinant profibrinolytic proteins. motocross is a dangerous business: small bowell perforation case report case history: a year-old male, previously healthy, was admitted to the ed after being involved in a motorcross accident. he suffered blunt abdominal trauma. clinical findings: at admission, patient presented pale but haemodinamically stable. physical examination was unremarkable except for an evident abdominal wall hematoma and abdominal guarding over the left quadrants. investigation/results: abdominal ultrasound showed an intestinal loop with decreased peristalsis with a small amount of liquid adjacent (fig ) . due to the patient's haemodynamic stability, ct scan was performed (fig . ) which showed liquid in the left flank and iliac fossa, but without an identifiable intrabdominal lesion. diagnosis: the patient was admitted to the operating theatre with acute abdomen. therapy and progressions: intraoperatively fecal peritonitis was evident from a cm-hole on the antimesenteric border of the jejunum, the enterotomy was closed and profuse lavage was done; the abdominal wall closed without drainage. the patient went through an empirical antibiotic cycle. liquids per os were started on the first postoperative day and the patient progressed without issues. he was discharged at the th postoperative day. the remaining follow-up was uneventful. comments: small bowel perforation after blunt abdominal trauma is rare. sbmi has a high morbidity and mortality that increase with delayed diagnosis; however, clinical and radiographic signs of perforation are often absent, like in the case presented. ct is considered the gold-standard. in our specific situation, the small bowel perforation did not produce any pneumoperitoneum in a young patient with very good physiologic status that kept him hemodynamically stable. the prognosis of pelvic injury is closely related to the severity of vascular injury rather than the complexity of bony fracture y. wu , c. hsieh , c. fu chang gung memorial hospital, trauma and emergency surgery department, taoyuan city, taiwan introduction: pelvic injuries are among the most dangerous and deadly trauma. although complex pelvic fractures are often associated with vascular injuries, it is still unclear regarding the impact of the severity of vascular injury to the outcome of patients. we hypothesized that, in addition to the complexity of bony fracture, the severity of pelvic vascular injury plays a more decisive role to the patients'' outcome. material and methods:medical records of patients with pelvic fracture in a single trauma center between jan and dec were retrospectively reviewed. those who had an abbreviated injury scale (ais) c other than pelvis were excluded. based on ct results, the type of pelvic fracture was classified according to young-burgess classification, and the severity of vascular injury were recorded as minor (fracture with or without hematoma) or severe (hematoma with contrast pooling or extravasation). the patient demographics, clinical parameters, and outcome measures were compared between the groups. results: among the patients, severe vascular injury were noted in patients. patients with severe vascular injuries had significantly increased amount of red blood cell transfusion (rbct) ( . vs. . units, p = . ), longer icu stay (is) ( . vs. . days, p = . ) and total hospital stay (hs) ( . vs. . days, p = . ) compared to minor vascular injuries. on the other hand, those with complicated pelvic fracture (lc type ii/iii, apc type ii/iii, vs and combined type) had similar amount of rbct and is compared to that of simple pelvic fracture (lc type i, apc type i) except a longer hs ( . vs. . days, p = . ). conclusions: our results indicated that the severity of vascular injury is more closely correlated to the outcome of patients with pelvic fractures than the type of bony fracture does. in addition to the type of bony fracture, the grade of vascular injury should be considered as an important part of pelvic injury classification. associated abdominal injuries do not influence reduction quality in operatively treated pelvic fractures-a multicenter cohort study from the german pelvic registry results: . patients with pelvic injuries were treated during this period. . % had a concomitant abdominal trauma. the mean age was . ± . years. comparing the two groups, patients with a combination of pelvic and abdominal trauma were significantly younger ( . ± . vs. . ± . years; p \ . ). both, complication rates ( . % vs. . %; p \ . ) and mortality ( . % vs. . %;p \ . ) were significantly higher. in the subgroup of acetabular fractures, the time until definitive surgery of the pelvis was significantly longer in the group with the combined injury ( . ± . vs. . ± . days; p \ . ) . the grade of successful anatomic reduction did not differ between the two groups. conclusions: patients with a pelvic injury have a concomitant abdominal trauma in about % of the cases. the clinical course is significantly prolonged in patients with a combined injury, with increased rates of morbidity and mortality. however, the quality of the postoperative results is not influenced by a concomitant abdominal injury. a. martins rangel , r. pozzi , j. alfredo cavalcante padilha , s. sardinha , f. eduardo silva , d. teixeira rangel heat, trauma center, são gonçalo, brazil f.f.c., male, years old, was admitted to the trauma center about h after a stabbing wound in the neck. upon examination the patient was mechanically ventilated and hemodynamically stable, with an exposed sectioned trachea, which had a tracheostomy tube applied. the penetrating injury itself was mostly allocated in zone ii. he had a ct angiography and was referred to the or for surgical treatment. the cervicotomy found that both the external and internal right jugular veins had been injured alongside the sternocleidomastoid, sternohyoid and homohyoid muscles, the thyroid cartilage, just above the vocal cords, which had exposed the anterior larynx and the epiglottis the right anterior jugular vein and smaller tributaries of the right internal jugular vein, were ligated; a tracheostomy was performed and the thyroid cartilage and anterior laryngopharyngeal wall were reconstructed with the epiglottis implantation, sternoid, homohyoid and sternocleidomastoid muscle sutures, after which the platysma was closed but not the skin, left to secondary healing. patient was extubated within h, discharged from icu on the fifth postoperative day. thickened oral diet was introduced on the th day, and by the th day he was discharged without the tracheostomy tube, with a normal diet. comments: the cervical region is an area susceptible to serious injury due to the presence of vital structures, with massive hemorrhage, airway obstruction, cervical spine injuries and cerebral ischemia as the leading causes of death. initial management of penetrating injuries follows the principles of trauma care with airway control initially. references: bhatt nr-penetrating neck injury from a screwdriver: can the no zone approach be applied to zone i injuries? bmj yan wang-penetrating neck trauma caused by a rebar-a case report. medicine ( ) introduction: annually, approximately , people decease as a result of a fall in the netherlands, according to the statistics netherlands. the aim of this study is to evaluate the demographic parameters, fall characteristics and resulting injury patterns of this group in the region of amsterdam. methods: all patients deceased as a result of injury due to a fall in the period july st until july st in the region of amsterdam were included. data were collected from the database (formatus) of the department of forensic medicine (public health service amsterdam). results: during the study period , patients deceased after a fall. the mean age was years ( - years) and % was male. a psychiatric disease was diagnosed or suspected in % of the population of which cognitive impairment, including dementia, was encountered in most of the cases ( %). the majority of the falls happened at home ( %) or at nursing facilities. a minority ( . %) was work related. over % of the falls was from standing position, . % was not from standing position of which . % regarded falls from stairs, the majority was male. multitrauma patients accounted for . % of the population. from the remaining , patients, . % sustained one or more injuries to the pelvis or extremities. central nervous system (cns) injuries were described in . % of the patients. mortality was in . % of the cases due to primary cns injury, . % was due to complications of which clinical deterioration ( . %) and infection ( . %) were the most common. conclusions: in the region of amsterdam the majority of deaths due to a fall regards the geriatric population. fall from standing position and mortality due to complications, mainly clinical deterioration, accounted for the majority of deaths. intervention to prevent falls and thereby complications need more awareness to reduce mortality. results from a multidisciplinary blunt splenic injury protocol introduction: the majority of splenic injuries are currently managed non-operatively. failure of non-operative management includes grade iv or v splenic injury or vascular abnormalities that are suitable for embolization. the primary indication for operative management of blunt splenic injury is hemodynamic instability. in our center, the last twenty splenic injuries, admitted during two years, were not managed according to published guidelines. ten patients ( %) underwent splenectomy, being unstable only of them ( % of the whole sample). material and methods: staff from anesthesiology, interventional radiology and trauma surgery came up with a joint protocol. grade iii splenic injury non-operatively management, including fluid responsiveness (achieving shock index (ht/bp) below . after a bolus of colloids) and, focus placed only on hemodynamic stability instead of on vascular abnormalities are our principal modifications regarding already published protocols. results: seventeen patients with blunt spleen trauma were admitted after starting up our protocol. six ( grade iii, grade ii and grade i) splenic injuries were successfully managed non-operatively. prophylatic embolization was performed in five patients: were grade iv spleen trauma and were grade iii spleen trauma with vascular abnormalities. one grade iii splenic trauma was embolized due to a pseudoaneurysm detected in ct scan performed h post injury. five grade v spleen trauma required urgent surgery. of them presented with shock index [ . . conclusions: our multidisciplinary protocol has helped in improving outcomes in blunt splenic injuries. we have achieved an almost full compliance to our protocol. case history: -year old male experienced severe blunt trauma after a bus accident. clinical findings: he is found alert (gcs = ), hemodynamically stable and with a patent airway. he presented catastrophic lower left limb where tourniquet was applied. gram of tranexamic acid (txa) and ml of crystalloids were administered. he was intubated in the site of injury and transfered to our center, being always hemodynamically stable. on hospital admission he was normotensive (bp = / mmhg, sinus rithm ppm), shock index \ . . he suffered uneventfully amputation of the limb with no need for blood products transfusion. his past medical history was only pertinent for hypertension. investigation/results: following urgent damage control surgery, ct scan was performed where acute bilateral pulmonary embolism was diagnosed. diagnosis: asymptomatic acute bilateral pulmonary embolism therapy and progressions: during icu stay, the patient kept hemodynamically stable. endotracheal tube is removed one day later and he is successfully transfered to the ward three days later. comments: hypercoagulability can occur after severe tissue injury, that is likely related to tissue factor exposure and impaired endothelial release of tissue plasminogen activator (tpa). in contrast, when shock and hypoperfusion occur, activation of the protein c pathway and endothelial tpa release induce a shift from a procoagulant to a hypocoagulable and hyperfibrinolytic state with a high risk of bleeding. it can be inferred that a patient presenting with severe tissue injury without shock is at high risk of perioperative thrombosis and txa might not be administered. ( ) . it signifies high energy force, representative of severe overall trauma. study reported mortality of blunt pelvic trauma to reach . - % ( ) . injury severity score (iss), hypotension, head injury, posterior fracture & haemorrhage have been implicated ( ) . however, there is a paucity of data in developing countries. this study identifies the problem burden, management outcomes and factors predicting mortality. material and methods: patients had pelvic trauma, retrospectively from jan to dec and prospectively from may to april . patients was included after excluding less than years and coagulation disorder results: majority were males ( . %),with a mean age of . . mechanism was rti ( . %) followed by fall from height ( %), railway accidents ( . %). mean iss & rts was . and . respectively. associated injury were long bone fractures ( . %), chest injuries ( . %).head injury ( . %). lateral compression ( . %), was the most common followed by anteroposterior compression ( %) & combined ( . %).majority underwent operative intervention ( . %) for pelvis or associated injury. the mortality rate was . % secondary to haemorrhagic shock ( . %) and sepsis ( . %). the factors were male gender, age, iss, rts, head injury, unstable pelvis. however, no association with haemoglobin, long bone fracture, and massive transfusion protocol was found conclusions: our study showed a mortality of . % which is comparing with previous study introduction: the number of patients admitted to oslo university hospital (ouh) due to bicycle trauma is increasing. we aimed to identify possible predictors of serious and fatal bicycle injury. material and methods: the ouh trauma registry was searched for patients treated for bicycle trauma between and . data extraction included putative predictors of serious and fatal injuries, defined as iss c and death within days, respectively. univariate analyses were performed and reported as odds ratios (or). p \ . was regarded as statistically significant. results: bicyclists were admitted, % were males, median age was years (range - ). injury mechanisms were single bicycle crash in %, collision with a motorized vehicle in %, bicycle vs. bicycle in % and others in %. serious injuries were seen in % and . % died. predictors for serious and fatal bicycle trauma are presented in figure . conclusions: we identified age c , high comorbidity and loss of consciousness (gcs b ) as predictors for both serious and fatal injury after bicycle trauma. single bicycle crash was the most common cause of serious bicycle injury in our trauma center. diagnosis, investigation and results: all case reports represent polytrauma patients with clinical worsening and admission to the icu, with subsequent development of acute respiratory distress syndrome (ards) refractory to primary measures. therapy and progressions: different mechanisms led to the development of ards in the different cases. on a primary approach, standard measures such as curarization, recruitment maneuvers, prone positioning and peep increase were applied whenever possible. an absence of improvement led to an almost inevitable need of extracorporeal membrane oxygenation (ecmo) rescue therapy. all patients responded positively to this treatment without major complications and were eventually discharged from the icu. comments: ards is a major cause of respiratory failure in polytrauma patients. among the many therapeutic options, ecmo emerges as a powerful tool as rescue therapy in respiratory failure refractory to all other measures, being the present case reports corroborative examples of its efficiency. introduction: nowadays when cities are improving fast and significantly, including transportation system, even more we encounter with high energy trauma . still the most vulnerable on the roads are pedestrians. material and methods: the analysis of the data collected prospectively from january to october was performed including the mechanism and diagnosis of polytrauma, patient demographics and the main outcomes. results: in total, patients were assessed according to the polytrauma protocol. the median age of the cohort was years (iqr - ), male patients, . % vs. . % females, p = . . the most frequent mechanism was a pedestrian struck by a vehicle in . % cases, and falling from a height of over m in . %. of those patients who had musculoskeletal injuries, in . % the trauma mechanism was a fall from a height and in . % pedestrians were struck by a vehicle, . % of patients who fell from a height and . % of those struck by a vehicle suffered visceral injuries. the most common cause of neurotrauma was a fall from a height in . %, and pedestrians involved in car accidents in . %. from the whole cohort, patients were not saved, resulting in a . % mortality rate. most patients ( ) who died had iss [ . the mortality reached . % among pedestrians struck by a vehicle and . % among patients who fell from a height of over m. conclusions: the most common mechanism in the cohort was a pedestrian struck by a vehicle, followed by falling from a height, with a predominant involvement of male patients. similarly, the most frequent cause of musculoskeletal injuries and visceral injuries was falling from a height and pedestrians struck by a vehicle, demonstrating an important direction for polytrauma prevention. introduction: recent reviews of uk trauma data show altering demographics. patients are increasingly older and sustain lower energy injuries, with falls \ m being the most common ( ) . material and methods: data collected over years in a major trauma centre was used to calculate injury specific admission rates, case fatality rates and injury specific mortality attribution. data on patient age, footwear, lighting, alcohol intoxication and previous admissions were collected in falls \ m resulting in mortality. results: patients sustaining falls \ m represented % of admissions and % of mortalities. all falls represented % of admissions and % of mortalities. case fatality of falls of \ m and [ m was . % and . %. all fall case fatality was . %. this was significantly higher than the case fatality of stabbings ( . %) and rtas ( . %). in falls \ m causing fatality, mean patient age was . years. % of patients aged - were under the influence of alcohol when falling, with % aged - , but only % patients aged - . % aged - who died when falling were wearing slippers. this increased to % in those aged - , and % aged - . % of falls occurred under daylight/full light. % of patients aged - who died after falling had been admitted to hospital within the last year, although this increased to % in those aged - , and % aged - . conclusions: falls were the most common cause for hospital admission, had the highest case fatality of injury mechanisms and caused the most patient mortality. alcohol intoxication was associated with falls in younger patients who died after falling, but this was less common in older patients. wearing slippers was less common in the young but significantly associated with fatal falls in older patients. these results offer a range of therapeutic targets when developing fall prevention strategies. introduction: the treatment of splenic lesions is determined by the hemodynamic situation, the degree of injury and the presence of bleeding. arterial embolization has expanded the indications of the conservative treatment. retrospective observational study on splenic traumatism and its therapeutic options. material and methods: a total of patients with splenic injury have been treated at our centre between and . patients were hemodynamically stable: were embolized and received a conservative treatment. patients were hemodynamically unstable: had a good response to the resuscitation treatment so they were embolized, but there was one patient who deceased because of other causes. from these patients, patients received splenectomy. results: the main objective of this study is to review the management of the trauma patient with splenic injury. of the total of patients with splenic trauma, average iss of , underwent splenic embolization, underwent urgent splenectomy and were treated with conservative treatment. the embolized, were hemodynamic unstable at arrival but responded to the fluid therapy, had a splenic lesion grade iv, a grade iii, grade ii and another a grade i. the success rate of embolization was % in the embolized patients. patient died, only one of them in the embolization group and was not related to the splenic trauma nor embolization, were in the urgent splenectomy group due to severity of trauma, died before receiving any treatment and in the conservative treatment group due to other complications. conclusions: patients who respond to volume or are hemodinamically with high-grade lesions, arterial embolization would be less aggressive treatment options with excellent results. haukeland university hospital, surgical unit/ regional traumacenter, bergen, norway, norwegian university of science and technology, trondheim, norway, haukeland university hospital, physical and rehabilitation medicine, bergen, norway, university of bergen, bergen, norway, st olavs hospital, physical and rehabilitation medicine, trondheim, norway introduction: during the past decades acute trauma care has improved through the development of highly specialized trauma centres and teams. since patients are considerable young when being affected, trauma may lead to life-long physical, cognitive and emotional constraints interfering with an independent self-determined life ( , ) . in , a revised national plan for the treatment of trauma patients in norway was published ( ) . the plan emphasizes the importance of rehabilitation and the need for early interdisciplinary rehabilitation. this study will examine in which extent patients receive rehabilitation in early phase after trauma as recommended in the norwegian national plan. in addition we will examine what follow-up patients receive after trauma, quality of life, functional level and use of health care and next-of kin resources. material and methods: patients admitted to regional trauma center in mid-or western norway in with niss c are recruited to participate. data will be collected from national trauma register, the norwegian patient register, the municipal patient and user register, data from statistics norway, the electronic patient record (epj) and the patient/relatives questionnaire. discussion: the results will be useful in the preparation of patient courses that comply with strong recommendations in the national trauma plan, ensuring equal treatment and raising awarness about rehabilitation for trauma patients. introduction: diaphragmatic lesions involve wounds and rupture of the diaphragm, through penetrating wounds or thoraco-abdominal trauma. their incidence is - %. the diagnosis may be late, despite the technical advances made by medical imaging. the choice of surgical approach and technique is still controversial. mortality is usually related to the associated injuries. the present paper analyzes the incidence of diaphragmatic lesions that occur in thoraco-abdominal trauma, their epidemiology, diagnosis and treatment. material and methods: we performed a retrospective study over a -year period ( - ) , in the surgical units of the emergency county hospital of braila, including all patients diagnosed with diaphragmatic lesions. results: during the study period, patients had thoracic-abdominal trauma. there were cases of blunt trauma and thoracic-abdominal trauma. our study involved cases of diaphragmatic injuries ( . %), by road accident and by white weapon. the sex ratio was : . the average age was years. chest radiography was a contributory preoperative diagnosis in cases. the diaphragmatic wound was on the left side in cases, and its average size was cm. the surgical procedure involved the reduction in the abdomen of the herniated viscera and the monoplane suture of the diaphragm by nonabsorbable ''x'' points in all cases. chest aspiration was the rule. there was only one death in a complex polytrauma case. case history: we report the one case which performed tae, angioplasty, thoracotomy, laparotomy and preperitoneal pelvic packing (ppp) in the hybrid emergency room (h-er). the patient was male in the s, who was riding on his motorcycle and fell from a m height. clinical findings: he was in shock state. diagnosis: we scanned cect and diagnosed subdural hematoma, traumatic subarachnoid hematoma, lt hemopneumothorax, lung contusion, multiple costal bone fracture, intercostal artery injury, splenic injury (gradeiii), pelvic bone fracture. therapy: we inserted the drainage tube to the hemopneumothorax and did the tae for the pelvic bone fracture and splenic injury. after tae, he was in still shock state. the bleeding volume from the lt drainage tube increased, so trauma surgeons did the emergency thoracotomy and thoracic endovascular aortic repair (tevar) for intercostal artery injury. we suspected he also had abdominal compartment syndrome due to recanalization of tae, and they performed the emergency laparotomy and did ppp for the pelvic bone fracture. comments: we install an ivr-ct system in our trauma resuscitation room in october . we named it h-er, as it enables us to do all examinations (sonography, ct and fluoroscopy) and treatments (ir, operation) required for trauma in a single room. we have to perform prompt diagnosis and treatment, especially in cases of severe polytrauma cases. a retrospective study proved that the h-er had shortened the time of ct initiation and emergency procedure and that lead to improve mortality ). h-er is a novel trauma resuscitation room to do all treatments required in the only one room for severe traumatic patients introduction: according to the previous advanced trauma life support (atls) guidance, the early assessment of trauma patients with haemorrhage were classified upon the vital signs. recently, national trauma registry analyses suggested to extend the assessment criteria with the base deficit (bd), referring to the metabolic status. our objective was to investigate the relevance of bd and to explore new prognostic factors in the early assessment of the severely injured. material and methods: our study included patients registered between . . and . . on our emergency ward for whom the trauma team was activated. they were grouped into severity groups (i-iv) according to either the vital signs (classical) or the extended criteria with bd. the data were extracted from medical documentations of the early phase of treatment. as primary outcome, we compared the -h mortality rate of the patient groups. we studied the need for massive transfusion and intensive care unit care as secondary outcomes. results: according to the classical assessment, % of the patients were assigned to group i (lowest risk for haemorrhagic shock) and % to group ii. the remaining % were grouped into groups iii and iv (higher risk). with taking bd into consideration, % were reassigned to a higher risk group; however, this change affected only groups i and ii. the -h mortality changed only in group i ( . % vs . %; p = . ). bd did not affect the need for massive transfusion. in groups i and ii, . % of the patients, in groups iii-iv % needed intensive care unit treatment. conclusions: bd is an effective prognostic factor in the early assessment of trauma patients. however, compared to the vital signbased evaluation, it provides extra informaton only in less severe cases. according to our findings, it may help to assess the need for the administration of blood products. grants: nkfi k ; ginop- . . - - - ; efop- . . - - - . complejo hospitalario de jaén, servicio de cirugía general y del aparato digestivo, jaén, spain, complejo hospitalario de jaén, servicio de anestesiología y reanimación, jaén, spain case history: years old male, with history of hypertension and dyslipidemia, suffered a backhoe accident and was admitted in a regional hospital. on initial assesment he presented contusion and two laceration wounds in left chest and in lumbar region. body ct informed subcutaneous emphysema and left rib fractures from th to th, left hemidiaphragm edema, laminar left pneumothorax and contusive lung. posterior lumbar hematoma and no intra-abdominal free fluid. laceration wounds were partially sutured, with drainages through the wounds clinical findings: he was transferred to our emergency department, presenting dyspnea, tachycardia, sweating, painful luq and left hemithorax worsening with breathing investigation/results: reviewed by our radiologist, tc images showed herniation of abdominal organs into the chest diagnosis: traumatic hernia in left costophrenic recess. multiple rib fractures therapy and progressions: the hernia contents (left colonic flexure and omentum) were reduced and defect closed with primary repair in emergency surgery. rib fractures treated by osteosynthesis.on th pod left renal artery dissection and renal infarction were evidence in a new ct. comments: diaphragmatic injuries are caused by blunt or penetrating thoraco-abdominal trauma. potentially life-threatening due to the herniation of abdominal organs and severe associated lesions. clinical suspicion is important as prompt diagnosis and treatment are necessary for good outcomes. in our case, the initial clinical assessment was incorrect and the transfer put the patient in danger as an emergency surgery should have been performed before transfer. this enhances the importance of a correct initial management of polytrauma patients. introduction: the fractures of the calcaneus account for about - % of all fractures of the human skeleton. the majority of these fractures ( %) are intra-articular and surgical intervention is a widely accepted way of treatment material and methods: the aim of this study was to evaluate the results of open reduction and internal fixation for di-afc.in a period of years ( - ) patients ( patients with bilateral fractures) with age range from to years old, were treated surgically using the lateral extensile approach. follow-up was - years. the results were evaluated based on x-ray parameters (calcaneal morphology, bohler''s and gissane''s angles), active range of motion, footwear problems and time needed to return to work. the sf- health survey was used for outcome assessment. results: fracture mean healing time was , weeks. the outcome was excellent in cases, good in cases and poor in cases. the complications were malposition of fixation in patients, superficial wound slough in patients, reflex sympathetic dystrophy in patients, deep infection in patients who were treated with antibiotics and metalwork removal following union of the fracture. one patient resulted in metal breakage with consequent pseudarthrosis. finally one patient developed chronic osteomyelitis and is under treatment. the treatment with open reduction and internal fixation for di-afc is indicated, provided that the restoration of calcaneal shape, alignment and height is achieved. long term functional results with mild pain, few alterations in activities of daily living or work, and essentially no footwear problems, can be expected from a properly performed open reduction and internal fixation. extraperitoneal rectal injury in emodinamically unstable patient treated after dcs with external traction applied in an endorectal balloon r. somigli hospital, general and emergency surgery, pistoia, italy case history: a -year-old man was crushed between two vehicles while he was working. he arrived in er hemodynamically unstable, so he underwent to emergency surgery. clinical findings: at rectal examination there was evidence of almost complete antero-lateral anorectal laceration. at abdominal examination there was evidence of anorectal full-thickness laceration and urethra full laceration. investigation/results: no diagnostic was required in preop because of patient instabilty. diagnosis: pelvic fracture with hemodynamic instability, severe rectal injury and complete prostatic urethra transection. therapy and progressions: el, lateral colostomy, pelvic paking, cistostomy and hip external binder. damage control surgery was performed. on pod second look was carried out and an almost complete extraperitoneal rectal injury was found during pelvic depaking. properitoneum was drained and a baloon probe was introduced in the rectum to allow the proximal rectal flap to advance to the distal rectum. stomal washes were performed with no rectal leak and rectal baloon traction mantained for days. radiological and endoscopic check haven't shown any leak and a good mucosal reconstruction. mri no sphincteral anatonical defects. waiting for emg before stoma reversal. comments: the optimal managment for extraperitoneal rectal injuries remains controversial. an approach with lateral colostomy and conservative treatment of rectal lacerations with rectal trac-tion baloon, could represent a safe treatment alternative in those cases with sphincter preservation, with a lower risk of complication. exploring differences between iss and niss scores for -day mortality in adult and elderly trauma patients in a norwegian national trauma cohort m. introduction: injury severity score (iss) and new injury severity score (niss) with a threshold over is commonly used to define severe injury and to define the study population in trauma registrybased studies for both adult and elderly trauma patients ( ) . for elderly patients (c years) this might be unreasonably high and might lead to exclusion of significantly injured elderly with increased risk of mortality. the aim of this study was to assess whether there were significant differences in -days mortality between adults and elderly trauma patients for different frequently used iss and niss thresholds material and methods: the norwegian trauma registry was interrogated to identify all adult (c years) trauma patients included in the registry from january through december . data were dichotomized to age groups ''adult'' and ''elderly'' ( - and c respectively) with -days mortality as primary endpoint. mortality rates were assessed for iss and niss thresholds of [ , [ and [ . we applied descriptive statistics and chi-squared test for comparisons. results: patients with available information about age, -days mortality and iss and niss scores were included in the analysis, of which patients were - years old and patients were c years. adult and elderly patients died, giving overall mortality rates of . % and . % respectively. for iss and niss [ there was a significantly higher -days mortality in elderly trauma patients ( . % and . % respectively) than adult patients ( . and . % respectively) (p \ , ), as for all other iss and niss thresholds tested. conclusions: this study demonstrates that elderly trauma patients has a significantly higher mortality risk than adult trauma patients at all iss or niss-thresholds analysed. this group has a significant mortality even at iss and niss above . introduction: the trauma tertiary survey (tts) is a widely accepted tool in the prevention of missed injury. existing literature on its effectiveness focusses on multitrauma patients. this study investigates the yield of the tertiary survey in trauma who are admitted for tts, without having any significant injury. material and methods: a single center retrospective cohort study was performed in a level ii trauma center. trauma patients without any clinically significant injury at the primary and secondary survey were included. the primary outcome was missed injury found during tts (type ). secondary outcomes were missed injury found after tts but during admission (type ), mortality and hospital length of stay [ days. results: from included patients, patients ( . %) had a type missed injury. alcohol consumption was associated with an increased risk for type missed injuries (odds ratio = . , % ci: . - . ) . a type missed injury was only found once, it concerned the only case of trauma related mortility. out of nonoperated patients, ( . %) were admitted for more than two days. these patients were significantly older ( vs. years, p \ . ) and had a higher asa classification, - vs. - ( . % vs. . %, p \ . ). conclusions: tts showed missed injuries in only . % of trauma patients who had no clinical significant injury found during primary and secondary survey. high costs of admission, together with a low yield found for this study's population the cost benefit of hospitalizing these patients is for discussion. future research should therefore focus on the identification of predictors of a positive tertiary survey. references: . advanced trauma life supportÒ student course manual. . keijzers, et al., the effect of tertiary surveys on missed injuries in trauma: a systematic review. . enderson et al., the tertiary trauma survey: a prospective study of missed injury. the -h rule in the emergency department and its association with surgical mortality in one public hospital in israel: retrospective study i. ashkenazi hillel yaffe medical center, hadera, israel introduction: in order to improve patient treatment the -h rule in the emergency department (ed) was introduced in many countries as well as in israel. within four h, patients attending the ed must be seen, treated, and a decision must be reached whether these patients are to be admitted or discharged. though a popular performancebased measure, whether the -h rule in ed is associated with a decrease in mortality is controversial. the primary objective of this study was to evaluate the association between time in the ed and surgical mortality in one public hospital in israel. material and methods: included in this retrospective study were patients admitted to the ed of hymc during . patients dying on the first day were excluded. . results: included in this study were , patients. of these, , ( . %) patients were hospitalized and the rest were discharged. overall, patients died. general surgery accounted for , patients of which died ( . % of hospital deaths; . % of all surgical patients; . % of patients hospitalized in general surgery). internal medicine together with general surgery and orthopedic surgery accounted for . %, . % and . % of the mortalities observed in patients with decisions made within - h, in patients with decisions made beyond h and in all the patients respectively. forty-five patients with decisions made within h died compared to with decisions made beyond h. these represent . % and . % of all surgical patients in the ed (whether hospitalized or discharged) and . % and . % of those hospitalized. conclusions: general surgery is the second largest contributor to hospital morality. in both absolute terms and relative terms, mortality was not increased by delays in decisions made beyond h. the adoption of this performance-based measure should be questioned. introduction: trauma is an important cause of mortality [ , ] . researchers are looking for optimal death/survival predictive models in trauma population. one way is to validate traumatic scores for different medical systems [ ] . the aim of our study was to validate the new injury severy score (niss) in severe trauma ( introduction: the international classification of diseases-based injury severity score (iciss) has been proposed as a reliable tool to measure trauma system performance especially in countries where a trauma registry has not been yet established. the purpose of this study is to assess the predictive capability for in-hospital mortality of iciss with international and adjusted survival risk ratios (srrs) in greek trauma population. material and methods: this single center, retrospective cohort study was conducted in a greek tertiary care hospital between january to december . the trauma population was defined as hospitalized patients with a principal hospital discharge diagnosis in the range icd- s -t . duplicated injury icd codes, readmissions, transfer to another hospital and missing data were excluded. the primary outcome was in-hospital mortality. adjusted srrs was calculated from patients with multiple injuries and the following two iciss scores were evaluated: multiplicative-injury (iciss) and singleworst-injury (swi). the models were assessed in terms of their discrimination, measured by receiver operating curve (roc) analysis and calibration measured using calibration curves. results: a total of patients were included in the study. median age was ± years and mortality rate was , %. based on international srrs, the area under the curve was , ( % ci . - . ) for iciss-multiplicative and , ( % ci . - . ) for iciss-worst injury. both modes had statistically significant better performance with adjusted greek srrs (aur = , % ci . - . and aur = , % ci . - . , respectively). conclusions: this analysis has demonstrated the validity iciss model for in-hospital mortality prediction in greek trauma population. further research is warranted to confirm the performance of iciss using a sufficiently sized sample to define national srrs. introduction: the occurrence of intra-abdominal abscesses is the most serious post-operative infective complication after appendectomy. a significant amount of research has been conducted in an attempt to identify those patients at greatest risk. pct is initially described as an early, sensitive and specific marker for sepsis associated with bacterial infection. we hypothesize that pct could serve as a predictor of the development of intraabdominal abscess and postoperative infective complication material and methods: the present study is a prospective, single centre, observational cohort study involving patients undergoing emergency appendectomy. all patients admitted to the acute care surgery ward for appendicitis were screened for study eligibility. pct poc samples will be obtained preoperatively (t ) and post procedure (t ) at h (t ), h (t ), and days (t ) post procedure. the primary objective of this study was to assess the diagnostic accuracy of point-of-care testing for pct in identifying post appendectomy abscess. the secondary objective was to determine the diagnostic accuracy in identifying any infective complication conclusions: we expect the incidence of abscess and infective complication to be increased in the pct elevated group compared with the control group. previous investigations indicate the overall morbidity related to infective complication is approximately - % of patient undergoing laparoscopic appendectomy. our pilot study revealed that the incidence could be as high as % in patients with prolonged elevated pct levels. introduction: hand trauma is a common cause for attendance to the accident and emergency (a&e), accounting for nearly - % of all patients . it is essential that accurate treatment and management is done as the implications of mismanagement are long term, which may lead to disability, loss of work and income, livelihood, and even psychological issues . the presence of a specialised hand surgeon is essential for management of these injuries , but in the a&e setting it is not always possible to have such specialised care and there is a need for an efficient triage system. materials and methods: we did an audit in our department and found a delay in the referral of patients from a&e to our trauma clinic, which was quite expected due to a high patient inflow. we devised a trauma pathway for the a&e, known as the d-system which outlines for them till what day from trauma is a particular hand patient safe to be sent to the hand clinic or who needs an urgent referral to a higher trauma centre, based on urgency of need of intervention. the pathway is in the form of a simple flowchart, which is easy to understand even for junior members of the team. we intend to do another audit after implementation of the pathway to assess change in practice. conclusion: it is essential to have simplified pathways for non-specialist areas in order to streamline treatment and offer the best care, in the limited availability of resources, especially at smaller hospitals. our aim is to develop one such system and assess it's effective in delivering better care. introduction: a quantitative method for measuring trauma severity has many potential applications. the intent of this study was to evaluate the accuracy of the mgap score and its components in prediction of in-hospital mortality versus the accuracy of the revised trauma score rts at a trauma center. material and methods: this study included patients with trauma. data regarding age, mechanism of injury, systolic blood pressure, glasgow coma score and respiratory rate were collected at trauma center of alberto torres hospital. mgap and rts scores were calculated, and their accuracy to predict survival/death outcome. results the study included patients, ranging in age from to years, % male. from the total sample, patients who suffered from penetrating trauma and patients who suffered from blunt trauma were observed. in the comparison of the scores, rts and mgap, there was no significant superiority in any of them for predicting the outcome -which in our study was hospital discharge or death -even when compared by trauma mechanism. the gcs proved to be a very sensitive criterion in both scores, especially in patients with traumatic brain injury, totaling patients in our statistical analysis, of which , % had a negative outcome. rts was slightly superior than mgap in patients classified by the score as high chance of mortality, with % versus % of assertiveness. conclusions: up to the moment, there is no evidence to support the superiority of one of the analyzed scores as a predictor of mortality in the patients evaluated. although the rts score is more widely used in trauma centers, the application of the mgap score is more feasible in pre or in-hospital care of polytrauma patients, since it does not use respiratory rate in its parameters. validation of d-dimer for screening for venous thromboembolism in pelvic and lower extremity trauma patients t. uehara , , t. noda , t. yumoto , n. kobayashi , a. nakao , t. ozaki okayama university, emergency healthcare and disaster medicine, okayama, japan, okayama university, orthopaedic surgery, okayama, japan, okayama university, musculoskeletal traumatology, okayama, japan, okayama university, emergency and critical care medicine, okayama, japan, okayama saidaiji hospital, okayama, japan introduction: venous thromboembolism (vte) is a life-threatening complication after major trauma patients. we previously reported that the patients with higher injury severity score (iss) and lower extremity trauma had high risk for vte. additionally, high d-dimer levels (cut-off d-dimer value, . lg/ml) on day were useful for screening for vte in major trauma patients. we validated d-dimer levels for vte screening for patients with pelvic and lower extremity trauma. material and methods: a retrospective study was undertaken between april and august at the okayama university hospital. patients with pelvic or lower extremity trauma were included (median iss, ). we collected following data; age, sex, iss, the number of operation times, value of d-dimer in screening, incidence of vte and use of anticoagulants. results: eleven patients showed high d-dimer levels in screening, furthermore, six patients were diagnosed vte using contrast-enhanced computed tomography. symptomatic pulmonary embolism was not occurred. patients with vte had undergone orthopaedic surgeries two or more times. fourteen patients received therapeutically or prophylactic anticoagulation therapies. conclusions: measurements of d-dimer levels after pelvic or lower extremity trauma patients were useful for screening of incidence of vte. direct oral anticoagulants were convenient for treatment to vte. trauma patients often needed several times of surgeries, heparin was also useful in perioperative period. introduction: early assessment of the clinical status of severely injured patients is crucial for guiding surgical treatment. several scales are available to differentiate between risk categories. we compared four established scoring systems in regard to their predictive abilities for early versus late in-hospital complications. methods: database from a level i trauma center. the following four scales were tested: the clinical grading scale (cgs; covers acidosis, shock, coagulation, and soft tissue injuries), the modified clinical grading scale (mcgs), the polytrauma grading score (ptgs), and the early appropriate care protocol (eac; covers acid-base changes). admission values were selected from each scale and the following endpoints were compared: mortality, pneumonia, sepsis, death from hemorrhagic shock, and multiple organ failure. results: in total, severely injured patients were included (mean age, . ± years; mean iss, . ± . points; incidence of pneumonia, . %; incidence of sepsis, . %; death from hem. shock, . %; death from multiple organ failure (mof), . %; mortality rate, . %). istinct differences in the prediction of complications, including mortality, for these scores (or ranging from . to . ). the ptgs demonstrated the highest predictive value for any late complication (or = . ), sepsis (or = . , p = . ), or pneumonia (or = . , p = . ). the eac demonstrated good prediction for hemorrhage-induced early mortality (or = . , p \ . ), but did not predict late complications (sepsis, or = . and p = . ; pneumonia, or = . and p = . ) cgs and mcgs are not comparable and should not be used interchangeably (krippendorff a = . ). conclusion: our data show that prediction of complications is more precise after using values that covers different physiological systems (coagulation, hemorrhage, acid-base changes, and soft tissue damage) when compared with using values of only one physiological system (e.g., acidosis). none of the authors have any conflicts of interest to declare. mortality rate related to trauma mechanisms in trauma center at alberto torres hospital from january to july r. p. pereira , r. adriana martins , j. a. c. padilha , f. e. silva , , d. rangel alberto torres hospital, trauma center, são gonçalo, brazil, federal university of rio de janeiro, niterói, brazil introduction: to demonstrate the healthcare services of the trauma center of rio de janeiro based on epidemiological data and on the specificity of the type of initial care delivered to multiple trauma patients, comparing the mortality rate at the second peak of death with the worldwide literature. materials/methods: retrospective study extracted from ''ct heat'' database. polytraumatized patients of both sexes were included and the mortality rate was calculated taking into account the second peak of death from trauma, gender, age and primary mechanisms of injury. discussion: the data collected show % mortality in the second peak, with firearm projectiles ( %) followed by traffic accident and fall as the primary causes of death. conclusion: because of the structural and health care profile of this trauma center, it was possible to reach the desirable mortality rate according to the worldwide literature (less than %). introduction: trauma patients are sometimes in critical condition upon arrival and need aggressive treatments to survive. despite all efforts many end up dying. it seems necessary to try to identify those patients with a very high risk of death to avoid futile treatments. the aim of our study was to develop a simple clinical tool to predict mortality in trauma patients that can be easily calculated in the ed. material and methods: we analyzed data from all trauma patients arriving at a spanish trauma hospital from june to june . patient demographics, physiologic trauma scores, vital signs, and glasgow coma scale (gcs) were recorded. our primary outcome was mortality. logistic regression analysis (lra) was performed using three variables (age, shock index (si), and gcs) to determine the appropriate weights for predicting mortality. using them, we constructed a simple score to calculate mortality. results: patients were studied. the mortality rate was . %. our score was constructed using weights derived from lra for age [ y ( points), si [ ( points) , and gcs conclusions: our score is easy and quick to calculate and could be a useful tool to predict mortality using early available parameters upon arrival in the ed. acknowledging the ethics involved in this topic, this score could sort out patients with a very high risk of death and in whom aggressive therapeutic measures could be limited early or withdrawn in agreement with family members references: haider a, et al ( ) ( ) ( ) states the average cost for an a&e attendance and non-elective inpatient stay is £ and £ , respectively highlighting the importance for schemes to reduce hospital admissions. assess impact of ambulatory care, surgical emergency assessment unit (seau) and ''emergency surgeon of the week'' (esw) on hospital admissions for surgical referrals (gp/ a&e). material and methods: retrospective analysis of prospectively collected data of hospital admissions from the patient centre database before and after implementation of seau (in november ) and esw (in november ), including the units'' activities. emergency general surgeon followed : (monday-thursday, - ) rota based at seau. results: since ( months), seau has reviewed (new ; follow ups ) patients. surgical admissions (sa) pre and post implementation seau were * and */month respectively, a drop by %. esw helped a further drop by another % to */month. % of new referrals were admitted and overall % of all patients reviewed were admitted. juniors (st /st ) and seniors (st - /staff grades/consultants) admitted % and % of the referrals respectively. uss and ct were performed in dedicated seau slots. % attending seau were likely to recommend the unit to friends or relatives. conclusions: in the face of unprecedented demand for hospital beds (more so in the winter), ''emergency surgeon of the week'' based at seau could be the answer to relieving the capacity, financial pressures and providing high quality safe patient care for our already strained nhs. surgical emergencies, an educational and medico-economic challenge introduction: surgical emergencies are a frequent reason for consultation in the emergency department and are responsible for significant morbidity and mortality. our study aims to present the number of patients admitted for a surgical emergency in a french level trauma-center and the volume of patients operated in emergency depending on the different specialties. method: we conducted a retrospective, single-center study of the hospital emergency department (uas) of the university hospital center of nice between january and december . we studied the volume represented by surgical emergencies according to the different specialties. results: the emergency department welcomed , patients, of which , surgical emergencies patients accounted for % of the total activity; patients were operated on urgently, which represents % of all surgical procedures in our hospital. conclusion: surgical emergencies are an important part of the activity of our hospitals. an academic definition is difficult to achieve. a regional organization is needed for the management and optimal care of these patients. the creation of regional centers, as for the trauma centers, seems indispensable, especially for the most serious patients, allowing both a better medico-economic and educational management of surgical emergencies. introduction: every new admission to the icu prompts a handover from the referring department to the icu staff. this step in the patient pathway provides an opportunity for information to be lost and for patient care to be compromised. mortality rates in intensive care have fallen over the last years, however, % of patients admitted to an icu will die during their admission ( ) . communication errors contribute to approximately two-thirds of notable clinical incidents; over half of these are related to a handover ( ) . nice have concluded that structured handovers can result in reduced mortality, reduced length of hospital stay and improvements in senior clinical staff and nurse satisfaction ( ) . material and methods: a checklist was created to review to score the handover. this was created with doctors and nurses and is relevant for handovers between all staff members. information was gathered prospectively by directly observing handovers on the icu. results: there is a notable discrepancy in the quality of handovers of new patients. this is true of handovers between doctors, nurses and a combination of the two. % (n = ) of patients weren't handed over to a doctor. the most commonly missed pieces of information were details of the patient's weight ( %, n = ), their height ( %, n = ), whether the patient has previously been admitted to an icu ( %, n = ) and whether the patient has any allergies ( %, n = ). conclusions: the handover of new patients to the icu is often unstructured and important information is missed. this can be said for all staff members and grades, and for handovers from all hospital departments. introduction: bowel resection for acute mesenteric ischaemia (ami) in elderly is associated with significant morbidity and mortality, and increasing age and frailty are associated with increased risk. this study aims to assess the short-term outcomes for elderly patients undergoing surgery for ami, and to assess the accuracy of surgical risk calculators in this population, to determine their utility in preoperative discussions. introduction: intertrochanteric femoral fracture of the super-elderly is often difficult to treat because good surgery does not always lead to good functional prognosis. we investigated the factors affecting the functional prognosis in patients with intertrochanteric fracture over years old. material and methods: cases of intertrochanteric fracture over years old who had undergone surgical treatment at our hospital between december and september were examined. nine men and women, age at injury ranged from to years, with a median of years. the average postoperative follow-up period was . months. for these cases, the mobility was classified into independent walking, assisted walking (cane, walker), wheelchair, bedridden, and the transition of pre-and postoperative mobility was analyzed. the significance test was performed using the mann-whitney u test, and p \ . was considered significant. results: by fracture type, when jensen classifications i and ii were stable, iii, iv, and v were unstable, mobility of unstable type was significantly reduced (p = . ). when the waiting period for surgery is divided by the median of days, there was no difference in mobility reduction between groups of less than days and groups of more than days (p = . ). although there was no significant difference in the presence or absence of preoperative rehabilitation intervention (p = . ), there was a tendency for less decline in mobility when preoperative rehabilitation intervention was performed. conclusions: in the treatment of this fracture, early surgical treatment after injury is recommended, but in the case of very elderly people, waiting is often required due to existing diseases and poor general condition . this study suggests the importance of preoperative rehabilitation intervention during the waiting period for surgery to prevent disuse disorders. references: . kelly-pettersson et al. waiting time to surgery is correlated with an increased risk of serious adverse events during hospital stay in patients with hip-fracture: a cohort study international journal of nursing studies ( ) - . older patients with traumatic shock exhibited lower pulse pressure compared with younger patients; an analysis of nationwide trauma data base in japan introduction: the study purpose was to assess the effect of age on the relationship between pulse pressure (pp) and systolic blood pressure (sbp) in patients with traumatic shock. material and methods: in this retrospective cohort study using nationwide trauma data base in japan from april to may , trauma patients years of age and older with sbp \ mmhg were selected. patients with severe traumatic brain injury (the abbreviated injury scale on head [ ) and cardiac arrest (hr = and sbp \ mmhg) were excluded. linear regression analysis assessed association between pp and sbp interacted by age group dichotomized as \ or c years old. results: during the study period, patients were included. the linear regression analysis indicated the significant association between pp and sbp in overall population (ec, estimated coefficient = . %ci [ . , . ], p \ . ). association between pp and sbp was significantly interacted by the age group (ec = . %ci [ . , . ] introduction: high rates of trauma in south africa (sa) predominantly affect the youth, yet the geriatric population is not exempt. in addition to inherent challenges of age, elderly trauma patients are further compromised by resource constraints. we aimed to assess injuries and outcomes in elderly patients admitted to a tertiary trauma unit in sa. material and methods: a retrospective record review was done of all patients years and older, admitted to the trauma unit over an -month period. injury severity score (iss), mechanism of injury (moi), in-hospital complications and length of hospital stay were documented. results: patients (mean age: years; % female) were included with mean iss of . the most frequent mois included nontraumatic falls ( %), falls from height ( %), motor-vehicle collisions ( %), pedestrian vehicle collisions ( %), and blunt injuries ( %, % intentionally inflicted). eighty patients ( %) experienced at least one in-hospital complication. the mortality rate was %. the mean length of hospital stay was days. conclusions: despite the known vulnerablities of the elderly, the mortality rate and isss of this cohort were relativley low. however, when compared to first world literature, intentionally inflicted injuries and certain preventable mois (e.g. fall from height and pedestrian vehicle collisions) were common, [ ] [ ] introduction: the majority of new colorectal cancer is diagnosed in people [ years, yet the elderly are less likely to undergo curative surgery. chronological age is poorly correlated with post-operative outcomes and is not an acceptable measure of risk. conversely, frailty is a strong predictor of poor outcomes following surgery and presents an opportunity for patient optimisation. the aim of this systematic review is to assess the available evidence between frailty and outcomes in patients of all ages undergoing surgical resections for colorectal cancer. material and methods: pubmed was searched for articles reporting outcomes for patients deemed frail undergoing elective or emergency colorectal cancer resection up until august . the primary outcome was mortality ( and day). secondary outcomes; length of stay, readmission, reoperation & post-operative complications. results: studies identified, studies were deemed eligible for inclusion. study types, frailty assessments & outcomes measured were variable. despite this heterogeneity, categorisation of ''frailty'' was associated with higher rates of post-operative mortality, complications, readmission, and length of stay. conclusions: based on current evidence, frailty is a strong predictor of poor clinical outcomes in patients undergoing surgery for colorectal cancer. standardisation of frailty assessment and measure of outcomes is needed for more robust analysis. accurate risk stratification of patients will allow us to make informed treatment decisions and identify patients who may benefit from prehabilitation and intensive tailored post-operative care. introduction: pneumatosis intestinalis (pi) and hepatic portal venous gas (hpvg) are two radiological findings associated with a broad range of medical conditions. pi can be primary ( % of cases),usually with a benign course, or secondary ( % of cases),which results from obstructive or ischemic gastrointestinal diseases. only a minority of pi is associated to free abdominal air. in literature there is no consensus on radiological and biochemical markers of favourable outcome nor on treatment options-medical or surgical. we tried to identify prognostic markers in a series admitted to a single university hospital. material and methods: the medical records of patients with pi and/or hpvg admitted to ospedale maggiore policlinico (milan, italy) in the period - were collected the ct scan were reviewed by a single radiologist. results: mean age was . ± years ( - ). pi was primary in , % of the patients (n = ), and secondary in , % (n = ). at ct, pi was associated to portal gas in patients ( %) ( dead, alive) and to free air in patients ( %) ( dead, alive). linear or rounded gas collections were equally distributed in primary and secondary pi. the colon was involved in patients ( %), followed by the small intestine in ( , %),and the stomach (n = ). in patients serum lactate was [ , and died. leucocytosis (wbc [ , /mm ) was present in patients ( alive).four patients had peritonitis and abdominal tenderness. laparotomy was performed in primary (alive) and secondary pi ( deaths).in two patients it was diagnostic; in and associated to right or left colectomy, in to ileal resection and in to other procedures.surgery was judged futile in patients; all died a few hours after emergency department access. conclusions: we could not found any relationship between clinical, biochemical and radiological findings and outcome of pi. mesenteric and portal gas is a ominous finding, but did not reach significant value. successful transcatheter arterial embolization for a giant pseudoaneurysm of gluteal muscle due to ground level fall in elderly woman with direct oral anticoagulants t. kadoya , r. nakama , k. arakawa , t. ogura , k. kase saiseikai utsunomiya hospital, department of emergency medicine and critical care medicine, utsunomiya, japan, saiseikai utsunomiya hospital, department of radiology, utsunomiya, japan case history: a 's year-old woman using apixaban fell on the ground and was transferred to previous hospital. magnetic resonance imaging was taken and she was diagnosed as gluteal hematoma. she was treated conservatively but hemoglobin (hb) level was gradually decreased. although she was administered red blood cell as needed, anemia progressed. contrast-enhanced ct showed expanding hematoma of gluteal muscle. she transferred our hospital for advanced treatment including surgery on th day on hospital. clinical findings: vital signs were stable on arrival at our hospital. extensive subcutaneous hematoma was found in the right thigh and gluteal lesion. investigation/results: laboratory test showed that hb . g/dl and normal coagulation status. contrast-enhanced ct showed a giant pseudoaneurysm inside the gluteal muscle. therapy and progressions: angiography showed a giant aneurysm of peripheral branch of internal iliac artery. we performed transcatheter arterial embolization (tae) for it by gelatin sponge. after tae, there was no complication and progressive anemia was stopped. she was transferred to another hospital for rehabilitation six days after tae. comments: increase use of direct oral anticoagulants in elderly people could induce severe hemorrhagic trauma by minimal mechanism. tae is minimal invasive and safety procedure for such trauma case. introduction: the number of elderly people will increase during the next few decades. more importantly, the number of people aged or above are projected to increase % in developed countries. in spain, people over age were . % of the population in , and this will increase to . % in . that has implications in the health services and in the management of trauma patients. material and methods: we did a retrospective cohort analysis of trauma patients c y.o. admitted to our level i trauma center during the time-period of - . demographic data, icu care, and mortality were assessed. results: trauma patients c y.o. were admitted during that period. this is a % increase compared with the number of patients admitted during the previous decade ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . mean age was . ± . years, and median new injury severity score (niss) was (interquartile range to ). % were male. the mechanism of injury was % falls, and % pedestrian runovers. patients were admitted to icu, with median niss of and mortality rate of %. among severely injured trauma patients (niss c ) the hospital mortality rate of those c years was %, much higher than in the age group of - years ( %), with a significant difference (p \ . ). no differences mortality rates between - years and youngers with the same niss. conclusions: the geriatric trauma patient population is on the rise worldwide. this should be taken into account in our trauma centres in order to be able to adapt and try to improve trauma care in these patients. introduction: frailty is a geriatric syndrome which has been considered as a risk factor in the elderly, increasing adverse events in terms of global health, as hospitalization, increase of falls, need of institutionalization, and mortality. the aim of this study is to evaluate relationship between frailty, and the presence of major complications in the postoperative course of patients older than years undergoing emergency surgery. material and methods: prospective, longitudinal, cohort study, using four different scales of frailty as a predictor of risk for short-term adverse events, for patients during the postoperative course of emergency surgery (may -september ). the sample is categorized according to four frailty scales (clinical frailty scale, frail score, trst and share-fi) . we analyze the variables regarding diagnoses, clinical examination at admission, surgical procedures, and postoperative outcomes during the first days. clavien-dindo classification was used in order to graduate the severity of complications. results: patients were included with a mean age of , years (sd , ) . , % of the simple are women. frailty prevalence ranges, according to the frailty scales, from , % to %. median hospital stay was days ( iqr , ) . all four frailty scales show statistical differences to predict major complication in our simple. trst and frail scales show the strongest measure of association (or , and , , respectively). the frail phenotype, is also related to an increased of mortality, and frail scale is the frailty scale with largest or (or = , ).only frail show association with longer hospital stay ([ days), and reoperation rate. conclusions: frailty represents a predictive marker of major complications and mortality, for patients older than years undergoing emergency surgery. frail score, shows the strongest relationship with mortality and complications. introduction: age has been identified as a predictor of trauma mortality [ ] and it is known that even low energy trauma may cause severe injuries in the elderly [ ] . the aim of this study was to explore how the elderly trauma patients, and the care thereof, differ from the younger ones in a swedish context. material and methods: the swedish trauma registry (swetrau) was used. consecutive recorded trauma cases that presented at one level ii trauma hospital during december -august were included (n = ). patients were stratified into groups; those c and those results: in the c years group, sex distribution was more even (female . vs . %, p \ . ), physical status according to pretrauma asa classification was higher (mean . vs . , p \ . ) and the trauma mechanism was predominantly low-energy (falls from no height) as opposed to the conclusions: the trauma among elderly swedish patients are more often of low energy compared to the younger population. in spite of this, the elderly are more severely injured, require more surgical interventions, and their short term mortality is increased -fold. measures aimed at prevention of low energy trauma of the elderly are therefore much needed. introduction: there are intramedullary or extramedullary methods in internal fixation od trochanteric fractures. seldynamisalbe internal fixator with two sliding screws (sif), as an extramedullary method, and gamma nail (gn), as an intramedullary method, are in routine trochanteric fractures treatment at our institution for last two decades. material and methods: health related quality of life and hip function were assesed at least two years after surgery, in the series of patients with a surgically treated ao a or a fracture type. there were two groups of patients: group treated by sif and group treated by gn. examination had been performed using sf- test, with its physical component score (pcs) and mental component score (mcs), and harris hip score (hhs) tests. results: in sif group, mean pcs was , , mean mcs was , and mean hhs was , . in gn group mean pcs was , , mean mcs was , and mean hhs was , . there was no significant difference regarding all these parameters between the groups of patients (p [ , ). there was correlation between all evaluated parameters, both in groups of patients particularly and in all patients (p \ , we identified undertriage in , % ( / ). falls from own height ( - m) was found in patients with iss [ , / ( %) of them was found to have been undertiaged (p . ). we found an association between gcs \ and undertriage (p = . ). % ( / ) falls between - m and % ( / ) of these without trauma team. falls between - m , % ( / ) without trauma team. all with fall [ m had trauma team. mortality was % ( / ), no association between height of fall and mortality (p . ). undertriage was not associated with increased mortality (p = , ). median age in mortality group was years versus years in surviving group (p \ . ). in univariate analysis there was association between prehospital bp \ (p . ), gcs \ (p \ , ), iss (p \ . ), prehospital rr [ , rts \ (p \ . ) asa score [ (p \ . ) and mortality. conclusions: we found significant undertriage in the geriatric trauma population with fall injuries. gcs \ and low energy falls was associated with undertriage but not with mortality. laparoscopic direct repair of an incarcerated spigelian hernia c. bergamini , v. iacopini , r. de vincenti , a. bottari , g. alemanno , p. prosperi aou-careggi, emergency surgery, firenze, italy spigelian hernia occurs through a defect in the anterior abdominal wall adjacent to the semilunar line. it is in itself very rare and more over it is difficult to diagnose clinically. it has been estimated that it constitutes . % of abdominal wall hernias. the majority of patients present with symptomatic incarceration of preperitoneal fat or intraabdominal viscera. radiographic studies are beneficial in confirming the diagnosis. the high rate of incarceration with or without strangulation mandates operative repair once the diagnosis is confirmed. the spigelian hernia has been repaired by both conventional and laparoscopic approach. laparoscopic management of spigelian hernia is well established. most of the authors have managed it by transperitoneal approach either by a direct repair or by placing the mesh in intraperitoneal position or raising the peritoneal flap and placing the mesh in extraperitoneal space. there have also been case reports of management of spigelian hernia by total extraperitoneal approach. we present the case of an obese eighty-four y.o patient. complaining for a sudden onset abdominal pain in the right low quadrant, mimicking an appendicitis. the ct scan demonstrated a typical picture of a spigelian hernia containing an intestinal loop. the loop showed classical signs of parietal wall ischemia. the video describes the surgical laparoscopic approach of this case which was able to confirm the diagnosis e to reduce the loop into the abdomen. the loop initially appeared diffusely ischemic, but after the intra-abdominal reduction some signs of vitality started to be noticed. however, they were incomplete; thus the loop was resected. the hernia defect was successively repaired in a direct way because of the small caliber (\ cm of diameter) and the possible contamination coming from the intestinal resection. post-operative course was particularly benign and the patient was discharged on the seventh post-operative day in good health. introduction: trauma audit & research network (tarn) data shows older persons falling from standing height and sustaining significant injury has become the commonest trauma presentation in england and wales . we aimed to assess whether frailty predicts poor outcomes in the elderly. material and methods: retrospective database review of tarn eligible patients [ years old admitted in a week period with documented rockwood clinical frailty score . age, injury severity score (iss), length of stay (los) and mortality were noted. the inhospital mortality group was sub-analysed. logistic regression was performed (stata v ), odds ratios and % ci reported. results: older age was associated with higher cfs in the patients studied. increasing cfs was associated with increased overall mortality (cfs - vs cfs - or . ; % ci . - . ), decreased likelihood of pre-hospital trauma alert and increased length of stay (cfs - stayed days more than cfs - ). all deaths had cfs [ and head or chest injury. adjusting for age and cfs those with chest injury were . times more likely to die (or . %ci . - . ). mortality in those with rib fracture was times higher in cfs - vs cfs - (or . %ci . - . ). conclusions: increasing age and cfs (especially - ) are associated with poor outcomes in elderly trauma, thus cfs is a useful prognostic tool in severely injured elderly patients. chest injuries are a major cause of mortality in this group, especially with increasing frailty. major trauma centres must develop practice management guidelines to appropriately manage these patients. introduction: major trauma causes activation of the complement system, which plays a key role in development of systemic inflammatory response syndrome and multiple organ failure. complement is known to be activated early after trauma , but the relationship between outcome and the extent of complement activation during the first critical hours after injury is unknown. we hypothesized that complement activation in the first hours after trauma displays a highly dynamic pattern which is associated with outcome. material and methods: complement activation was assessed by plasma terminal c b- complement complex (tcc) using elisa in a prospective cohort of trauma patients. samples were obtained at admission, after , , and h, and daily in the intensive care unit. the extent of complement activation was assessed as area under the concentration curves - h after injury (tcc-auc - ). the relative contribution of complement activation, base excess (be) and new injury severity score (niss) to outcome was analyzed by multivariable analyses. results: niss and be were associated with tcc-auc - in bivariate analyses (spearmans rho (p) was respectively , (p = . ) and - . (p = . )). in multivariable analyses, niss and initial tcc alone predicted % of the variability in ventilatorfree days (vfds), whereas initial tcc and tcc-auc - predicted %. tcc auc - alone contributed with % to the model. tcc-auc - was also significantly higher in patients deceased at day ( . ; . - . (median; quartiles) vs. . ; . - . , p = . introduction: massive transfusion protocols [mtp] have been widely adopted for the care of bleeding trauma patients but their actual effectiveness is unclear. this study aims to conduct an updated meta-analysis to evaluate the effect of implementing an mtp on the mortality of trauma patients. material and methods: medline, pubmed, google scholar and cochrane library databases were systematically searched for relevant articles published from january , to july , using a combination of key words and additional manual searching of reference lists. three reviewers independently screened the articles for potential inclusion. eligible articles were original articles in english, included trauma patients and compared mortality outcomes before and after institutional implementation of a mtp. primary outcomes were h and overall mortality. results: nineteen studies met inclusion criteria, analyzing outcomes from , trauma patients. there was a wide range of outcome and process indicators utilized by the different authors. mtps significantly reduced over-all mortality, pre-mtp- . % and post-mtp . % [or . ( . - . )] for trauma patients. -h mortality was not significantly reduced [or . ( . - . )]. conclusions: the institution of an mtp has a significant over-all mortality reduction for trauma patients. we encourage that researchers use standard nomenclature and indicators, provide more details regarding protocols and patient populations and incorporate advances in the management of bleeding trauma patients in all future mtp studies. introduction: when resuscitating patients with hemorrhagic shock following trauma, fluid volume restriction and permissive hypotension prior to bleeding control are emphasized with good outcomes for penetrating trauma patients. however, evidence that these concepts apply well to the management of blunt trauma is lacking. this study aimed to assess the impact of vasopressor use in patients with blunt trauma in severe hemorrhagic shock. material and methods: in this single-center retrospective study, we reviewed records of blunt trauma patients with hemorrhagic shock and included patients with a probability of survival \ . . patient's characteristics, examinations, severity and administrated therapies were compared between survivors and non-survivors. data are described with median ( - % interquartile range) or number. results: thirty patients were included and median injury severity score in survivors vs non-survivors was ( - ) vs ( - ) (p = . ), with no significant difference in probability of survival. despite no significant difference in injury severity, non-survivors were administered vasopressors significantly earlier after admission and at significantly higher doses. total blood transfusion amount administered within h after admission was significantly higher in survivors ( [ conclusions: vasopressor administration and high-dose use for hemorrhagic shock following severe blunt trauma are significantly associated with increased mortality. although the transfused volume of blood products tends to be increased, early termination of vasopressor should be considered. all authors have no significant relationships with regard to this study. early amplitudes of citrated functional fibrinogen in thromboelastography to predict massive transfusion introduction: this study aims to evaluate the role of early amplitudes of the thromboelastography measure of citrated functional fibrinogen (cff) to predict massive transfusion (mtx) defined as transfusion of c of any blood products within an hour of arrival to a major trauma centre. material and methods: trauma patients c years requiring activation of the major haemorrhage protocol with teg performed on a tegÒ s hemostasis analyser were eligible for inclusion. exclusion criteria were arrival [ h after injury, pregnancy, bleeding disorder or anticoagulant use. patient demographics and transfusion requirements were obtained from medical notes. teg manager was accessed to extract amplitudes at min (a ), min (a ) introduction: hyperfibrinolysis, remains a significant characteristic of acute traumatic coagulopathy induced mortality. s a , a cell surface protein, when shed creats an occult hyperfibrinolytic subtype. annexin a (a ), a multicompartment protein that co-localizes with s a and contains a tissue plasminogen activator (tpa) binding site has been shown to enhance tpa activity -fold and thus behaves as marker of hyperfibrinolysis. we hypothesize that increased concentrations of a in blood will enhance tpa fibrinolysis. material and methods: blood was collected from ( ) healthy volunteers. recombinant a in concentrations , , , , , lg/ ml was added blood and then combined with tpa ng/ml. samples were assessed using thromboelastography (teg). blood samples were collected from trauma activations from -current at a single, urban, level- trauma center. samples were assessed using a combination of rapid, citrated native and tpa challenge teg. a levels were established via proteomic analysis. results: a - (lg/ml) significantly increased tpa mediated ly % vs tpa alone (a ? tpa [ - ] median . % vs tpa . % p \ . ). a without tpa had no significant effect on ly % and was similar to the lysis of control (a lg/ml . % vs control . % p = . ). a - (lg/ml) significantly increased r time from control and tpa alone (control normalized to vs a median . -fold increase in minutes p \ . and tpa . -fold decrease vs a median . -fold increase p \ . ). rapid teg for patient vs patient in our ongoing study was . % vs . % and . % and . % respectively on tpa challenge teg. proteomic analysis of a relative activity found a . -fold a activity in patient compared to patient . conclusions: exogenous cell free a significantly increases tpa mediated fibrinolysis measured by teg. preliminary data from our ongoing trauma study evaluating a levels and hyperfibrinolysis coincide with our in vitro study. introduction: massive transfusion protocol can be activated to mobilize the blood products resource in a timely and effective manner. blood products, however, are still wasted or overused. we aimed to study what proportion of patients who met the abc criteria for massive transfusion received or more units packed rbc (prbc). material and methods: a retrospective study all level i trauma patients admitted with arrival systolic blood pressure of or less (july to may ) was recruited. transfusion was complied with stts. all clinical and laboratory findings, and management procedures were populated from the data registry. results: of admitted trauma patients met the inclusion criteria. of patients who where admitted with hypotension, of patients ( . %), who met the abc criteria for receiving or more prbc were stabilized with or units. in other words, stts enabled us to save units of prbc. arrival data, i.e. blood pressure (cut of point: mmhg and p value: . ), shock index (cut of point: . and p value: . ) and pulse rate (cut of point: beat/min and p value: . ) were significantly different in patients prescribed or more units prbc. after initial resuscitation, blood pressure (cut of point: mmhg and p value: . shock index cut of point: . and p value: . ), pulse rate(cut of poinan beat/min and p value: . ) presence of pelvic fracture, positive fast,and base deficit [ were significantly different in the group received or more units prbc. conclusions: massive transfusion protocol with abc criteria may lead to wasted or overused blood products.consideration of dcr continuation strategy complied with stts along with the findings of this study has resulted in a refined protocol characterized by more effective and efficient blood product resource allocation. references: -chang r, holcomb jb. optimal fluid therapy for traumatic hemorrhagic shock. critical care clinics. jan ; ( ) case history: we present the clinical case of a female patient of years old who had been taking aspirin. mechanism of injury: a fall from her own height, resulting in head trauma. clinical findings: dysphonia and stridor, having underwent an immediate orotracheal intubation. investigation/results: she had a head ct done that was normal; and a cervical column and neck ct that showed a large retropharyngeal hematoma, without an associated vertebrae fracture. diagnosis: large retropharyngeal hematoma. therapy and progressions: she was admitted to the intensive care unit for mechanical ventilation. on nd day, she underwent a surgical tracheostomy. on th day, underwent weaning from mechanical ventilation. on h day, was transferred to the ent ward, had the tracheostomy tube removed and was discharged from hospital. comments: a hematoma in this potential space may constitute an immediately life threatening emergency due to airway compromise. in , thomas et al found only cases described in the literature since . the most common cause is the blunt cervical trauma (in % of the cases). other causes are the cervical hyperextension injury, cervical vertebrae fracture, cough, sneeze, strain, blunt head trauma, swallow a foreign body, retropharyngeal infection, carotid artery aneurism, internal jugular vein puncture, metastatic disease, coagulopathy, anticoagulants, etc. in the setting of trauma, the mechanism of injury generally permits explaining the presenting injuries. in this case, the clinical severity expressed by the patient seemed to be disproportional to the resultant injury. however, the presence of haemorrhage contributing factors associated with the existence of fascial spaces in the neck, should warn us of the possibility of formation of deep cervical hematomas that may cause an occult airway obstruction. case history: a -year-old male with a personal history of consumption of alcohol, cannabis, smoked cocaine and heroin. he was found in decubitus position and in a situation of cardiac arrest. the last time he was seen in his baseline situation was h before. after performing cpr and administration of naloxone and flumacenyl, sinus rhythm was achieved. clinical findings: h after admission, increased tension was observed in left leg, thigh and gluteal region. absence dorsalis pedis, tibialis posterior and popliteal pulse was observed in a doppler examination. investigation/results: intracompartmental pressure measurement revealed a result of mmhg in the deep posterior compartment and mmhg in the superficial (diastolic bp mmhg). at admission k levels were . meq/l, creatinine . mg/dl and ck u/l. diagnosis: opioid-related compartment syndrome. therapy and progressions: urgent fasciotomies of the leg and thigh were performed h after diagnosis with a posteromedial and anterolateral approach in the first case and with a lateral approach in the latter. herniation and signs of poor viability in all the compartments were observed. after the surgery, he persisted with anuria and a ck peak of , u/ l, which was next normalized. debridements were performedfor the next days. subsequently, after the isolation of p. stutzeri and mucor in the wound and the absence of signs of vitality, a supracondylar amputation was performed. after, hemodynamic status improved. weeks after the amputation it was possible to withdraw hemodialysis, which he had required since admission. comments: opioid misuse is a topic of growing interest. recent works have reported a worse prognosis in the case of opioid-related compartment syndrome. a high level of suspicion is necessary to make a prompt diagnose in these patients. introduction: the pelvic binder is a mechanical device designed to compress instable pelvic ring fractures and minimize dead space in order to limit blood loss. it is generally recommended to apply a pelvic binder if an unstable injury is suspected and the patient presents with a ''c-problem''. the effectiveness remains questionable though. material and methods: a total of trauma patients between and were retrospectively evaluated regarding instable pelvic injury. patients were admitted with a pelvic binder applied. the correct application was evaluated using ct scout. four groups were generated: group with correct pelvic binder application, group with incorrect placement, group with no pelvic binder at time of admission, group with pelvic binder applied in er. total outcome was determined based upon iss, age, preclinical time, time to ct, shock index, hemoglobin at admission, survival rate, administration of blood products as well as total hospital and icu days. results: % of all pelvic binders were applied incorrectly. patients ( %) suffered an instable pelvic fracture. patient survival was not influenced by the preclinical application of a pelvic binder ( % group vs. , % group , p = , ). no significant statistical difference was found for total icu days , vs. , , p = , ; total hospital days , vs. , , p = , ; rbc transfusion , vs. , , p = , ; iss , vs. , , p = , . conclusions: the correct application of a pelvic binder seems to pose problems preclinically. while the need to minimize blood loss is crucial, our collective did not benefit from this device. additionally, survival rates of the patients that suffered an instable pelvic fracture were unaffected. the iss remains the strongest predictor of total patient survival in pelvic trauma. trauma resuscitation times in a level trauma center in the netherlands: a prospective overview introduction: in trauma, time is considered to be an important factor influencing patient's outcome. in the first hour after injury, appropriate care has the greatest effect on trauma patient's survival. previous research showed that measuring in-hospital trauma resuscitation times, contributes to insights and improvement of the resuscitation process. however, despite developments of atls guidelines, no recent empirical knowledge regarding resuscitation times exists. the aim of this study is to examine in-hospital trauma resuscitation times in a level trauma center in the netherlands. material and methods: a prospective study was performed in level trauma center amsterdam umc location vumc, between may and august . trauma patients, aged c , presented during daytime at the trauma resuscitation room were included. information regarding patient's characteristics, trauma-and injury type, handover duration, duration till start of diagnostics and intervention, total resuscitation time, patient's disposition and survival were compared. results: in total, patients were analyzed. motorized traffic accident ( %) and blunt injury ( %) were the most common mechanism-and injury types. median prehospital to in-hospital handover time was . min (iqr . ) . median duration till start of diagnostics and intervention were . (iqr . ) and . min (iqr . ) respectively. median total resuscitation time showed to be . min (iqr . background: terrorist attacks and civilian mass casualty events are frequent, and some countries have implemented tourniquets for uncontrollable extremity bleeding in civilian settings. we summarized current knowledge on the use of pre-hospital tourniquets in civilian settings to assess whether their use increases the survival rate in civilian patients with life-threatening hemorrhages from the extremities. methods: using the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines, we searched medline (ovid), embase (ovid), cochrane library, and epistemonikos in january . all types of studies that examined the topic in a pre-hospital setting published after january , , were included. the protocol was registered in prospero (crd ). results: among screened records, studies were identified as relevant. due to a lack of relevant civilian studies, military studies were also included. the studies were highly heterogeneous, with low quality of evidence. most studies reported increased survival in the tourniquet group, but few had relevant comparators, and the survival benefit was difficult to estimate. most studies reported a reduced need for blood transfusion, with few and mainly transient adverse effects from tourniquet use. conclusion: the data suggest that the use of commercial tourniquets in a civilian setting to control life-threatening extremity hemorrhage is probably associated with improved survival, reduced need for blood transfusion, and few and transient adverse effects. the effect of venous infusion by emergency medical service personnel on the prognosis of severe traffic accident patients: a nation-wide study in japan y. katayama , t. kitamura , , t. hirose , y. nakagawa , t. shimazu osaka university graduate school of medicine, department of traumatology and acute critical medicine, suita, japan, osaka university graduate school of medicine, environmental and population science, suita, japan introduction: in japan, the law of paramedic was revised in , and it became possible for paramedic in japan to secure an infusion route before cardiac arrest for severe patients. however, the effect of this treatment on the prognosis of severe trauma patients has not been assessed. we assessed this effect on the prognosis of severe traffic accident patients with using population-based ambulance record and nation-wide hospital-based trauma registry in japan. material and methods: this study was a retrospective observational study and the study periods was years between january to december . we linked the nation-wide hospital based trauma registry (jtdb) and the population-based ambulance record in japan in case. in this study, we included the traffic accident patients with iss score more than and excluded cardiopulmonary arrest patients on the arrival of ems on the scene and missing data cases. the main outcome was cardiopulmonary arrest on hospital arrival. mcnemar's test and conditional logistic regression analysis were used to assess the association between the securing a infusion route by ems personnel and the primary outcome after one-to-one propensity score matching for securing a infusion route or not. results: traffic accident patients were eligible for analysis and patients were dripped by ems personnel. after one-to-one propensity score matching, the proportion of cardiopulmonary arrest on hospital arrival were . % ( / ) in patients dripped by ems personnel and . % ( / ) in patients not dripped by ems personnel, respectively (p = . ). the adjusted odds ratio for securing a infusion route was . [ % confidence interval; . - . , p = . ]. conclusions: in this study, there was no association between the securing a infusion route and outcome of traffic accident patients. the association between trauma patient characteristics and adverse laboratory values: which patient characteristics are most predictive? introduction: in more than countries worldwide, laboratory testing is protocol driven since when it was included in the practice guideline of the advanced trauma life support course (atls). however, it is not clear yet which patient characteristics are associated with unfortunate laboratory values. the aim was to create an overview of the characteristics that were associated with adverse laboratory values. material and methods: this cohort study was performed at amsterdam umc, location amc (level trauma center), including patients during a period of years. data concerning age, gender, asa scores, injury severity scores (iss), glasgow coma scores (gcs), mechanism of injury, type of injury (blunt or penetrating) and the presence of helicopter emergency medical services (hems) were obtained. the hematology panel included hemoglobin, hematocrit, mcv, leucocyte and thrombocyte values. the coagulation panel included inr, pt, aptt, fibrinogen and d-dimer values. other panels include arterial blood gas, kidney and liver panels. the association between trauma patient characteristics and laboratory values were determined by using binary and multinomial logistic regression. results: a total of patients were included, consisting of predominantly men ( %) with a mean age of years old. an increase in age and iss was correlated with abnormal laboratory values (p = . ). additionally, male gender, iss [ , blunt trauma and the absence of hems was associated with a deviation in laboratory values (p \ . ). other patient characteristics did not show a significant correlation with adverse laboratory values. case history: a -year-old man presented with a classic case of pituitary apoplexy with a history of headache, nausea and vomiting. clinical findings: he was found to have a sellar and suprasellar mass with internal cystic and hemorrhagic component consistent with a pituitary macroadenoma. investigation/results: he underwent transsphenoidal sugery for a pituitary macroadenoma. because the tumor was invaded to left cavernous sinus, we left small portion of the tumor. eighth day after surgery, he underwent gamma-knife surgery (gks) for residual tumor. after two weeks, he complained of left ptosis. we considered the rd nerve palsy to be a post-radiation reaction at first. after months, the symptoms had been continuous and mri showed increased size of cystic lesion involving left cavernous sinus. diagnosis: ct angiogram demonstrated a saccular aneurysm at left distal ica. endovascular coil embolization was performed. therapy and progressions: after months of the intervention, the rd nerve palsy was partly improving. comments: our case report emphasizes the necessity of cerebrovascular imaging before surgery for pa. mr angiography/ct angiography is not currently obligatory in patients with pituitary adenoma, but in cases with the symptoms of displacement of the neuro-vascular structures it can be of great value. even in patients without such presentations, it may be helpful to evaluate the vascular involvement. case history: a -year-old boy during the preparation for a fishing session was pierced to the left orbitary region by a high-speed spearfishing steel. clinical findings: upon arrival the patient was conscious and responsive with a gcs of , he followed commands appropriately and there were no motor of sensory deficits. investigation/results: plain skull radiographs showed the spear crossing the skull from the left orbit to the posterior part of the parietal bone. diagnosis: the patient was immediately intubated to prevent involuntary movement of the foreign body. ct scan showed the fracture of the left orbitary roof where a centimetres long metallic object crosses the cerebral parenchyma of the left hemisphere and perforates the left parietal skull. therapy and progressions: under direct visualization via transorbital approach the foreign body was removed together with bone fragments, hemostasis was done and orbitary roof repaired. serial cranial ct scan showed progressive reduction of frontal and parietal hematoma. the movement of the eye improved after a few days, normalizing with the regression of periorbital edema. upon discharge at th postoperative day the patient had a gcs score of , no motor deficit and minimal visual loss. comments: penetrating injury of the skull and brain are relatively uncommon events, representing about , % of all head injuries. orbital roof is relatively thinner part of the skull that can provide easy access to projectile objects, which can penetrate into cranial cavity and damaging the brain parenchyma. the principles of treatment are removal of bone fragments and foreign body, control of persistent bleeding and intracranial hypertension, prevention of infection though debridement of all contaminated and necrotic tissue and at the same time preservation of as much nervous tissue as possible. multitraumapatients whith severe head injury (ais ‡ ) are more quickly carried out ct scan on than a patient without severe head injury v. giil-jensen , k. andersen , t. k. helle haukeland univercity hospital, sugical department, bergen, norway, haukeland univercity hospital, ambulance service, bergen, norway introduction: trauma patients who are prone to severe head injuries during trauma may profit from obtaining a rapid clarification of the injury magnitude when using ct examination. in the case of a delayed ct examination, the consequence of the head injury could be more extensive. in this study, we wanted to see if those with severe head injury (ais c ) received a faster ct survey than those who had no severe head injury. material and methods: retrospective registry study of severely injured patients (iss [ ) which had been hospitalized as a trauma patient at haukeland university hospital in the period - . in the study, we have excluded all patients entered as multitrauma but who have iss \ and all patients who have not defined ct time. it turns out that over half of the patients lacked the registration of accurate time for the ct survey in the national trauma register. the number is still considered large enough to find a result. results: patients were received as multitraumatic at haukeland university hospital during the period. of these, was severely injured. of these, patients had severe head injuries and they again had head injuries as the only serious injury (ais c ). median time from arrival receipt to start ct, for this group was min. in the control group that was severely injured but without severe head injury is the same time min. there was patients in the control group. conclusions: for the patients in this study who had severe injuries (n: ), the median time from the arrival in the emergency department to the ct starts was min shorter for severe head injuries than for the group without severe head injuries. introduction: the patients with severe traumatic brain injury (stbi) who needs surgical intervention often experience acute traumatic coagulopathy (atc). earlier transfusion with high blood product ratios (plasma, platelets, and red blood cells via : : ratio) is recommended for severely injured patients. however, recommended blood product ratio for stbi is still controversial. material and methods: we retrospectively reviewed successive adult stbi who underwent surgical treatment in our hospital between january and december . we have transfused plasma aggressively to maintain blood fibrinogen above - mg/dl. we evaluated the total amount of transfusion and mortality. we exclude cases administered fibrinogen concentrate. results: patients were enrolled. the amount of transfusion for h is rbc . units, ffp . units, pc . units . stbi with severe other trauma needs higher ratio of plasma. discussion: tissue injury of stbi causes severe coagulopathy and : : transfusion was thought to be insufficient for stbi in order to maintain fibrinogen. we agressively transfused plasma but we achieved fibrinogen value above only in % of stbi with severe other trauma. agressive plasma transfusion had limitation for hyperfibrinolysis so we expect other product, for example fibrinogen concentrate. introduction: traumatic brain injury (tbi) remains a leading cause of hospital admission and mortality amongst trauma patients. intracranial hemorrhage (ich) can occur with tbi and presents a severe complication. low complication tolerance in developed countries and uncertainty on actual risk cause excessive diagnostics and hospitalization, considered unnecessary and expensive. methods: tbi cases indicated for cranial computer tomography (ct) according to international guidelines, at our level i trauma center between - were retrospectively included. multivariate logistic regression was performed for ich, progression and mortality predictors. results: tbi patients (m: . ; age at trauma: . ± . ), were included. ct was performed in . %, skull fracture diagnosed in . %, ich in . %, ich progression in . %. in patients \ a, chronic alcohol consumption (p = . ) and neurocranial fracture (p \ . ) were significant ich risk factors in a multivariate analysis. in patients between - a, chronic alcohol consumption (p \ . ) and skull fracture (p \ . ) revealed as significant ich predictors. in patients [ a, age (p = . ), anticoagulation (p = . ) and neurocranial fracture (p \ . ) were significant risk factors for ich, age (p = . ) was an independent risk factor for mortality. late onset ich only occurred in cases with at least of factors: age [ , anticoagulation, neurocranial fracture. overall hospitalization might have been reduced by . % via low risk cases. conclusions: triggered by decreasing error tolerance, international guidelines for mild tbi focus on safety maximization. repeated ct in initially ich negative cases should only be considered in high risk patients. non-ich cases aged \ years do not gain safety from observation or hospitalization. recommendations from our data might, without impact on patient safety, reduce costs by unnecessary hospitalization and diagnostics. references: to be added by the authors. evaluation of low-value clinical practices in acute trauma care: a multi-center retrospective study l. moore , k. soltana , j. clément , a. turgeon , î mercier , r. krouchev , p. a. tardif , s. bouderba , a. belcaid université laval, social and preventive medicine, québec, canada, chu de québec-université-laval, québec, canada, université-laval, québec, canada, introduction: low-value clinical practices have been identified as one of the most important areas of excess healthcare spending and are associated with adverse health outcomes. the objectives of this study were to estimate the frequency low-value practices in injury care and assess inter-hospital variations. material and methods: we identified low-value clinical practices from internationally recognized clinical guidelines. we conducted a population-based retrospective cohort study using data from an inclusive canadian trauma system ( - ) to calculate frequencies and assessed inter-hospital variations with intra-class correlation coefficients (icc). results: we identified low-value practices of which could be measured and validated using trauma registry data. the three lowvalue clinical practices with the highest absolute and relative frequencies were pelvic x-rays in hemodynamically stable patients with a negative physical exam for pelvic injury ( . %), head ct in adults with minor head injury who were negative on a validated clinical decision rule ( . %) and chest x-ray in hemodynamically stable patients with a normal physical exam ( . %). we observed high inter-hospital variation for surgical management of penetrating zone ii neck injury without hard signs (icc = %), and moderate variation for head ct in adults with minor head injury who were negative on a validated clinical decision rule (icc = . %). conclusions: we have developed and validated algorithms to evaluate nine potentially low-value clinical practices using trauma registry data. highest frequencies were observed for imaging in the emergency department and the highest inter-hospital variation was observed for inappropriate surgical management. these data can be used to advance the agenda on low-value care for injury admissions. dysfunction of functional connectivity between default mode network and cerebellar structures in patients with mtbi in acute stage. rsfmri and dti study introduction: mild traumatic brain injury (mtbi) occupies one of the first places in children injuries. among all brain networks at the resting state, the default mode network (dmn) is the most widely studied network. the aim of this study is to examine functional connectivity in normal-appearing cortex in acute period of mtbi using rsfmri. material and methods: mr negative participants were studied in age from to years (mean age- . years). group of patients consisted of children with mild traumatic brain injury in acute stage. age-matched healthy volunteers comprised control group. all studies were performed at phillips achieva . t mri scanner using -channel head coil. fmri data were processed using functional connectivity toolbox conn. seed-based analysis was performed in order to reveal disturbances in functional connectivity. statistical processing was performed using statistica . results: dti analysis didn't show any changes in values of apparent diffusion coefficient (adc) and fractional anisotropy (fa) between two groups (see fig. ). no statistically significant differences in correlation strength between dmn parts were observed in two groups (see fig. ). intergroup seed-based analysis revealed statistically significant (p \ , ) difference in neural correlations between dmn parts and vermis (cerebellum structural part): positive link in control group and negative link in group of patients. conclusions: one of the most common symptoms of mtbi is dizziness as a result of impaired movements coordination. vermis as an essential cerebellum part plays an important role in the vestibuloocular system which is involved in the learning of basic motor skills in the brain. vermis aids in the synchronization of eye and motor functions in order for the visual field and the motor skills to function together.our results show that mtbi appears to be a possible reason of connectivity malfunction in normal-appearing vermis. references: predictors of developing post-traumatic endophthalmitis introduction: h magnetic resonance spectroscopy ( h mrs) allows to study structural and metabolic brain disorders in various pathological conditions in vivo. non-invasive method determines its advantage for use in children in serious condition with acute cerebral injuries. this determined the purpose of the study: to identify criteria of irreversible brain damage based on the h mr spectra analysis in comatose children with acute traumatic brain injury (tbi) or anoxia. material and methods: patients ( months- years) were examined in the acute period of severe cerebral injury (gcs score - ): six were in acute and subacute period of severe tbi, one patient was examined on the seventh day after drowning, and one-a day after acute cerebral blood flow (hemorrhage). all patients died in - days after the study. control group included healthy children aged from to years. single voxel h mrs and d h mrs was performed on t scanner. h spectroscopic voxel (te/tr = / ms, voi = cm , nsa = ) was oriented on mri intact areas: cortex of frontal, parietal and occipital lobes (fig. ) , thalamic nuclei (fig. ) , cerebellum, brainstem (fig. ) . for d h mrs a spin-echo point-resolved spectroscopy (press) sequence was used (te/tr = / ms) with the spectroscopic voi of cm on frontal lobes. results: in all spectra lactate (lac) signal, dominating all other signals, was detected. n-acetylaspartate (naa) was reduced by % and creatine/phosphocreatine (cr)-by %. conclusions: h mrs is a non-invasive prognostic method in patients with acute cerebral brain damage in coma. the cause of patients' death is the shift of cerebral glucose metabolism to an anaerobic type, as evidenced by the accumulation of lac. disturbance of energy metabolism causes a decrease of cr and a decrease in the neuronal marker naa. the combination of these patterns in acute cerebral injury, regardless of etiology indicates irreversible brain tissue damage. introduction: scalds and contact burns are the most common burn injuries both in children and adults. data are conflicting regarding which type of burns are more severe. we compared scalds, contact, and flame/fire burns at our burn center to determine which type were more likely to result in full thickness injuries and prolonged length of stay (los). material and methods: we conducted a structured retrospective medical record review of all patient admissions to a regional burn unit over a -year period between and . data included demographic, clinical, and specific burn characteristics. the association between patient predictor variables and outcomes (full thickness burns, los) was explored using chi-square and stepwise logistic regression. results: there were , patients with either scald (n = , %), fire/flame (n = , %) or contact burns (n = , %). burn depth was not available for cases ( %). mean (sd) age was ( ), % were male. mean (sd) total body surface area (tbsa) was ( )%. % of burns contained areas of full thickness injury. patients with scalds were younger than those with contact or fire burns ( ± vs. ± vs. ± years respectively, p \ . ). the percentage of burns that were full thickness by etiology were contacts ( %), fire/flame ( %) and scalds ( %); p \ . . after adjusting for age, location, and tbsa, scalds were less likely to result in full thickness injuries than contact burns (odds ratio . , %%ci, . - . ). adjusting for multiple testing, univariate analysis (as well as the multivariate analysis) showed no difference in % rd degree burns between fire and contact burns, but scalds were significantly lower than each of those. los for scalds ( ± ) and contact burns ( ± ) was significantly shorter than for fire/flame ( ± days, p \ . ). conclusions: while less common, contact and flame burns were more likely to result in full thickness injuries than scalds. references: epidemiology, treatment, costs, and long-term outcomes of patients with fireworks-related injuries (rocket); a multicenter prospective observational case series introduction: the aim of this study is to provide detailed information about the patient and injury characteristics, medical and societal costs, and clinical and functional outcome in patients with injuries resulting from fireworks. material and methods: a multicenter, prospective, observational case series performed in the southwest netherlands trauma region, which reflects % of the netherlands and includes a level i trauma center, a burn center, and an eye hospital. all patients with any injury from consumer fireworks, treated at a dutch hospital between december , and january , , were eligible for inclusion. exclusion criteria were unknown contact information or insufficient understanding of dutch or english language. the primary outcome measure was injury characteristics. secondary outcome measures included treatment, direct medical and indirect societal costs, and clinical and functional outcome until one year after trauma. results: out of patients agreed to participate in this study. the majority was male (n = ; %), % were children \ years, and % were bystanders. injuries were located to the upper extremity or eyes and were mostly burns (n = ; %) of partial thickness (n = ; %). fifteen ( %) patients were admitted and ( %) patients needed surgery. the mean total costs per patient were € , ( % ci € , to € , ). patient-reported quality of life and functional outcome was not significantly different during follow-up compared with pre-trauma. conclusion: the most common injuries afflicted by consumer fireworks were burns, mostly located to the upper extremity, and eye injuries. fireworks can result in severe injuries, for which ( %) patients needed hospital admission and ( %) patients needed surgical treatment. although some injuries resulted in permanent disability, year after trauma it in general did not have major or longlasting impact on patients'' self-reported quality of life or functional abilities. persistent inflammation, immunosuppression and catabolism syndrome after polytrauma: a rare syndrome with major consequences. l. hesselink , r. spijkerman , r. hoepelman , l. koenderman , l. leenen , f. hietbrink umc utrecht, trauma surgery, utrecht, netherlands, wilhelmina children's hospital, center for translational immunology, utrecht, netherlands introduction: more severely injured patients survive the critical first phase after trauma nowadays. a substantial portion of these patients require long-term critical care support and suffer from recurrent infections. this clinical condition fits in a syndrome referred to as ''persistent inflammation, immunosuppression and catabolism syndrome'' (pics). the aim of this study was to investigate the incidence of pics and clinical outcomes of trauma patients with pics in a level one trauma center. material and methods: all trauma patients c years admitted to the intensive care unit (icu) for c days between and , were included. patients with isolated neurological injuries were excluded. pics patients were identified by icu stay c days, c infectious complications and increased catabolism. infectious complications included infections during hospitalization and readmissions due to an infection. increased catabolism was defined as weight loss [ %, a body mass index. results: of the , polytrauma patients, patients had an icu stay c days. after exclusion of patients with isolated neurological injuries, patients were included. of these patients, developed pics. pics patients sustained infectious complications on average (compared to in the non-pics group, p \ . ) and . % of the pics patients developed sepsis. also, pics patients had a longer hospital stay (mean of days versus days, p \ . ) and sustained more surgical procedures (mean of versus per patient, p \ . ). infectious readmissions occurred until years after the initial trauma. conclusions: patients who develop pics experience long-term inflammatory complications that lead to frequent readmissions and surgical procedures. therefore, despite its low incidence, this clinical condition forms a burden on patients and a substantial financial burden on society. hyperbilirubinemia as a risk factor of the trauma icu patient introduction: hyperbilirubinemia is common in the intensive care unit (icu). hyperbilirubinemia has been considered as a risk factor of the icu patient. hyperbilirubinemia can have various causes. the hyperbilirubinemia has never been studied for the trauma icu patient. the aim of this study is to elucidate the incidence and effects of the hyperbilirubinemia for the trauma icu patient. material and methods: retrospective review of the trauma icu patients from . . to . . . initial bilirubin serum level, h bilirubin level, day bilirubin level, highest bilirubin level, overall morbidity and mortality and other clinical variables were identified and evaluated. the patients who have highest bilirubin level c . mg/dl were defined as hyperbilirubinemia group. results: a total patients were enrolled in this study. hyperbilirubinemia above serum bilirubin c . mg/dl were appeared in patients. the mortality of the hyperbilirubinemia group was higher than the other group ( . % vs . %, p = . ). the icu stay of the hyperbilirubinemia group was longer than the other group ( . day vs . day, p = . ). the hyperbilirubinemia group had more incidences of pneumonia, acute kidney injury, and sepsis than the other group ( . % vs %, p = . / . % vs . %, p = . / % vs %, p \ . ). conclusions: the hyperbilirubinemia is a risk factor of the trauma icu. if the hyperbilirubinemia is appeared, the cause of the hyperbilirubinemia should be evaluated and make an effort to correct hyperbilirubinemia for the each cause of the hyperbilirubinemia. case history: we present the clinical case of a male patient of years old. injury mechanism: a firework burst on his right forearm. clinical findings: injury: a large area of carbonization of the muscles of the flexor compartment. signs and symptoms: intense pain in the hand and forearm with local oedema and tension. diagnosis: deep burn of the forearm. therapy and progressions: surgical debridement and fasciotomy of this compartment; followed by deferred and progressive primary closure by means of rubber bands that were tightened as the oedema diminuished-shoelace technique. evolution: discharged from hospital on the th pos op day; follow-up at rd and th month without functional impairment, with a good healing evolution. comments: deep burns that reach the subfascial planes of the limbs, increase the pressure in the muscular compartments, and may progress to a compartment syndrome. there is no specific cutoff value of pressure for this diagnosis; consequently, the final decision to proceed with a fasciotomy relies on the clinical experience. surgical debridement and fasciotomy may result in large wounds, sometimes difficult to close. grafts and flaps result in another wounds and carry a risk of pain, infection, scar shrinking and necrosis. the diagnosis of a limb compartment syndrome is almost always a clinical one and requires a high index of suspicion so as to the fasciotomy is done in time. the shoelace technique is a simple, reproducible and cost-effective method of deferred closure of a large wound, preserving functionality and resulting in a good final cosmesis. references: johnson ls et al, management of extremity fasciotomy sites prospective randomized evaluation of two techniques, am j surg. . the use of propranolol in the management of acute thermal burn injury: evaluation of the effect of fixed dosages in african patients c. jac-okereke , i. onah , esut teaching hospital, surgery, enugu, nigeria, national orthopaedic hospital, enugu, nigeria introduction: propranolol has been shown to improve outcomes in burn patients. its effects are achieved at doses that reduce the heart rate by - %. africans have a different propranolol pharmacogenetic profile as compared to other races. there is paucity of literary works on the use of propranolol in africans with burns. in our study, we explored the effectiveness of fixed dosages of propranolol in nigerian patients. material and methods: this was a prospective comparative study of adult burn patients; two test groups received propranolol mg/day and mg/day respectively. the average daily pulse rate prior to and after the administration of propranolol were compared. results: patients in the control group had no effective reduction in their pulse rate. patients who received propranolol at a dose of mg/day had a reduction c %. no adverse events were observed. conclusion: it is important to establish the effective dosage of propranolol in burn patients of african-descent and explore its potential benefits in their treatment. although we cannot draw strong case history: the authors present in their paper three cases of blunt abdominal injury caused by seat belt in car accident. in the first two cases there was no diagnostic problem thanks to clear clinical finding. in the third case there was no clinical correlation and even repeated auxiliary examinations did not indicate the need for surgical intervention of the abdominal cavity. clinical findings: case no. -male y. old, haemodynamic stability, thoracic an abdominal pain, fast positivity, on ct free fluid in abdominal cavity, small spleen laceration, positivity of peritoneal symptomatology. case no. -male y. old, haemodynamic stability, bilateral hypogastric pain without peritoneal symptomatology, fast with small perihepatic fluid, on ct fluido-pneumoperitoneum. case no. -female y. old, haemodynamic stability, thoracic pain, massive oedema on the right side of the neck and supraclavicular area, without abdominal symptomatology. fast with small subhepatal fluid collection- mm, ct scan with large neck haematoma and fracture of st rib, apical pneumothorax- mm. intraabdominal only subhepatal fluid stripe- mm, suspected of small hepatic laceration. after days the clinical status rapidly changed, during h peritoneal symptomatology occured. on control ct scan fluido-pneumoperitoneum was detected. investigation/results: all patients underwent surgical procedure diagnosis: bowel mesenteric injury therapy and progressions: the first patient underwent ileo-caecal and hartmann resection, by the second patient was small intestine and col. sigmoideum resection needed, and the last one underwent ileal resection and npwt. comments: despite the current diagnostic methods blunt abdominal injuries, unlike the penetrating ones, can present a certain diagnostic problem especially when they are accompanied by other serious conditions such as manifest chest injuries. introduction: patients with hypertension and peritonitis must undergo a laparotomy. in isolated parenchymal lesions of the liver, the spleen or kidneys interventional or conservative approaches are more frequently used. to miss a hollow viscus organ lesion, that would need an operative procedure, is a constant fear. it is the aim of this study to identify significant predictors of the simultaneous presence of a hollow viscus lesion in patients with parenchymal organ lesions. material and methods: data of over ' inpatients of a levelone-trauma centre between and were analysed. only hemodynamically stable patients with a splenic-, liver-, or kidney injury (independent of grade) after blunt abdominal trauma were included. significant predictors were detected in bi-and multivariant analysis. results: of the patients with an average age of ± years % (n = ) had a splenic-, % (n = ) a liver-and % (n = ) a kidney rupture. the total iss was ± points. in patients ( %) a hollow viscus injury could be found (stomach n = , small bowl n = , colon n = , rectum n = ). injuries of the thorax ( %), the extremities ( %), the head ( %), the vertebra column ( %) and the pelvis ( %) were diagnosed as concomitant injuries. due to multivariant analysis neither age, gender, heart frequency at admission, gcs, base excess, the coagulation parameters, the hemoglobin value nor the separate injury regions could be identified to be predictive factors for the presence of a hollow viscus lesion. conclusions: clinical parameters taken at admission are not useful to predict hollow viscus injuries. the ct-scan is currently seen to be the best possible imaging modality, but it can be false negative, especially within the first min after trauma. repetitive clinical examination is necessary. in doubt a diagnostic laparoscopy or even laparotomy has to be performed. introduction: a heavy abdominal trauma is associated with a high morbidity and mortality. it is the aim of this study to show injury patterns in the abdomen and concomitant injuries in polytraumatized patients as well as to identify risk factors of the decease. material and methods: data of over ' inpatients of a level-one trauma centre between and were retrospectively analysed. only patients with a relevant abdominal trauma (ais abdomen c ) were included. the ais score was determined either with a contrast enhanced computed tomography or intraoperatively. significant risk factors were detected in bi-and multivariate analysis. results: patients with an averaga age of ± years were included. % (n = ) had an ais abdomen of , % (n = ) of and % (n = ) of . the overall iss was ± points. the mechanism of injury was mainly blunt ( %). a splenic rupture was present in % (n = ), a liver rupture in % (n = ) and a kidney rupture in % (n = ). hollow viscus injuries were present in % (small bowl n = , colon n = , stomach n = , rectum n = , bladder n = ). concomitant injuries were determined in % of the patients. of these % were diagnosed a thoracic injury, % injuries at the extremities, % head injuries. % spinal injuries and % pelvic injuries. the mortality was % (n = ). a liver rupture (p = . , or . ), pelvic injuries (p = . , or . ), age (p = . , or . ), hypotension (systolic blood pressure \ mmhg) (p = . , or . ) and a low gcs at admission (p \ . , or . ) were determined to be significant risk factors. conclusions: in our trauma department life threatening abdominal traumata are treated about every days. lethal abdominal injuries were mostly associated with serious liver ruptures or pelvic injuries. due to our experience we recommend the use of an early ct-scan as thereby the injury severity can be fast and precisely assessed. case history: a yo female was tranferred to our icu on day of a severe acute necrotizing alchoolic pancreatitis with mof. crrt with cytosorb was immediately started. on day after onset (dao ) an acs with a new organ failure (lung) showed up. open abdomen (oa) and tac with mesh-mediated/npwt got a temporary improvement. clinical findings: on dao (oa ), reopening of the mesh entailed a sudden fascial retraction of cm. a new larger mesh was positioned. on dao (oa ) the fascial defect measured both on ct slices and in or was cm. provision of a longterm oa was done. therapy and progressions: a new fascial traction device (fas-ciotensÒ, germany) was positioned on dao (oa ), with a continuous traction weight of - kg. revision was scheduled any - days, according to clinical needs, including combined anterior and retroperitoneal necrosectomy. progressive traction allowed to get a cm fascial gap under traction on dao (oa ). anterior cst was thus performed and fascia primarily closed. completion of necrosectomy was done through the bilateral lumbar incisions and npwt. comments: early fascial closure is a goal in oa. mesh-mediated traction/npwt is the most effective strategy, but primary fascial closure is sometimes impossible. the duration of oa is a key point. fasciotensÒ allowed to overcome the failure of mesh-mediated option and avoided fascia retraction in a longterm oa. it was quickly managed by the nurse staff, allowed a easier access to the abdomen and a proper positioning of the protective film. its effectiveness in this demanding case makes it an interesting option for shortening fascial closure in septic oa too. background: small bowel obstruction (sbo) caused by intra-abdominal adhesions is one of the main surgical emergencies. in most of the time, adhesions are created by previous abdominal surgeries. without any severity signs, the medical treatment is first proposed to avoid superfluous surgery. we noticed that the failure of medical treatment is frequently seen in patients previously operated of appendicectomy. the purpose of this study is to determine the eventual relation between a previous appendicectomy and failure of medical treatment in sbo. methods: we conducted a retrospective data collection using a diagnostic code for bowel obstruction in patients who have consulted in emergency from . . to . . at the salengro university hospital in lille. using the administrative database, patients were identified. we excluded all children, patients with wrong diagnosis and those whose outcome was not known. finally, patients with sbo on intra-abdominal adhesions confirmed on ct-scan were reviewed. the patients were separated in two groups. the group (g ) included patients who required surgical management during hospitalization ( patients) and group (g ) patients with successful medical treatment ( patients). we compared the rate of previous appendectomy in these two groups using a pearson's chi-squared test. in a second step, we tried to find out if there were others factor associated with failure of medical management. results: there was significant difference between the two groups with a higher rate of appendectomy in the surgical management group g (p = . ). this difference was even more pronounced if appendectomy was the only surgical history. in the subgroup analysis of patients with previous appendicectomy, the laparoscopic approach or laparotomy didn't influence the outcome of the management of the sbo. conclusion: this study shows the difference between the two groups of sbo, with more surgery sanction in the group of patients previously operated of appendicectomy. perhaps because this surgery involves the very distal part of the small bowel and decrease the efficiency of a proximal nasogastric aspiration. these results should not change the initial management of sbo by medical treatment in absence of severity signs. however, knowing this data, we have to consider that a history of appendicectomy is a risk factor of failure of medical treatment in this situation. introduction: diaphragmatic injuries are a rare consequence of closed thoraco-abdominal trauma that could be difficult to detect due to paucity of clinical signs and frequent erroneous interpretation of radiological images. the overall incidence of diaphragmatic injury is , - , % in blunt trauma. if the injury is not recognized it could lead to considerable risk of late morbidity and mortality. this study reviews our years experience in the management of this patients. material and methods: a retrospective review of trauma registry of our tertiary referral centre was performed. preoperative, intraoperative and postoperative data were analysed to assess determinants of mortality, morbidity and effect of therapeutic delay by univariate analysis models. penetrating injuries were excluded from the study. results: over years patients with diaphragmatic injury due to blunt trauma were identified: had a simple laceration of the diaphragm without hernia, had acute and chronic diaphragmatic hernia. the mean patient age was years (range -- years). overall mortality was %. the site of injury was the left diaphragm in cases, the right diaphragm in cases and bilateral in case.the hernia content was stomach ( ), colon ( ), spleen ( ), liver ( ), omentum ( ) and multiorgan ( ). all acute patients were managed with primary suture repair via laparotomy except for two patients that required additional thoracotomy; chronic patients were treated laparoscopically in cases ( , %), in which a synthetic or a biosynthetic mesh was used to reinforce the suture. higher morbidity and mortality was seen in multiple associated injuries, head injuries associated, right diaprhagm injury, age [ years and treatment delay [ h. conclusions: delayed treatment of diaphragmatic injuries could be dramatic: it is importnat not to misinterpreter the radiological findings and to reassess the patient mantaining a high level of suspicion of these injuries. trauma opposing vector forces resulting in distal avulsion of internal oblique muscle: a case report p. spada , p. fransvea , g. altieri , m. di grezia , v. cozza , g. pepe , a. la greca , g. sganga fondazione policlinico universitario agostino gemelli irccs, catholic university of rome, division of emergency surgery, roma, italy case history: abdominal muscle injuries after blunt trauma are rare but increasingly recognized. here we report a case of blunt trauma resulting in a complete disinsertion of the distal part of the internal oblique muscle. case report: y.o. male, was involved in a roll over motor vehicle accident. primary survey was carried out according to atlsÒ approach with good response. he had a seatbelt sign. according to the dynamic of the trauma he underwent a ct. diagnosis: a ce-mdct revealed complete disinsertion of the oblique muscles of the left abdomen from their iliac insertion, with herniation of adipose tissue and hematoma of the soft tissues without active blushing. no other traumatic injuries were identified. therapy progressions: a conservative treatment of the hematoma of the left abdominal wall was adopted. the patients was then ischarged from hospital after days. no late complications were observed. comments: the overall incidence in all traumatic admission is . - . %. a deep knowledge of vector force involved in trauma and their influence in the specific anatomical changes of the abdominal wall muscle can lead to suspicious of this rare injuries even if no other lesion are detected. in our opinion this trauma case is useful in reminding us to look for it because the radiologist or a no well experienced trauma surgeon may miss it fondazione policlinico universitario agostino gemelli irccs, catholic university of rome, division of emergency surgery, roma, italy introduction: the best and correct management of patients with open abdomen (oa) is nowadays still unclear. our algorithm consists of using an intra abdominal negative pressure wound therapy device plus an early medial mesh mediated fascia traction (''step by step'' procedure). the aim of this study was to asses outcomes of this algorithm technique based on patient conditions and open abdomen technique performed. materials and methods: we performed a retrospective analysis of patients treated with open abdomen technique from / / to the / / . variables taken into account were: initial diagnosis, open abdomen technique used, number of surgical interventions, abdominal wall closure technique, length of stay in the icu, inhospital morbidity and mortality rates. we collected also data on the post-operative development of incisional hernias and entero-atmospheric fistula. results: / of open abdomen were done after trauma. in the remaining cases open abdomen was done for non-traumatic disease. patients have been treated following our algorithm (with negative pressure wound therapy abthera device and step by step approach with medial mesh mediated fascia traction). in this group fascial retraction was significant lower and definitive direct abdominal wall closure rate was statistically higher. conclusion: an early fascia traction mediated with a mesh lead to an earlier fascia closure with a lower need of mesh positioning for definitive closure; the rate of post incisional hernia is similar among the two groups references: case history: a year old male presented in the er with malaise, fatigue and loss of appetite. he was recently hospitalised due to a peritonsillar abscess and during investigations he was first-diagnosed with non-hodgkin lymphoma. his medical and surgical history were otherwise unremarkable. clinical findings: on admission the patient was febrile and tachycardic (hr bpm) but remained hemodynamically stable (bp: / mmhg). clinical examination revealed abdominal distention and rebound tenderness in the right abdomen. investigation/results: blood tests were significant for leukocytosis (wbc: . /ll-neut: %), acute kidney injury (urea: mg/dl, cr: . mg/dl), elevated crp ( mg/l) and ldh ( iu/l), hyponatremia (na: mmol/l) and hypoalbuminemia. chest and abdominal x-rays were non-diagnostic, while abdominal ultrasound showed increased air presence along the medial line. investigations concluded with an abdominal ct scan that revealed pneumoperitoneum, small bowel distention and multiple enlarged mesenteric lymph nodes. diagnosis: the patient was transferred to the or for an explorative laparotomy. he was diagnosed with ileo-cecal intussusception causing bowel ischemia and perforation at the ileocecal valve. enlarged lymph nodes were observed along the mesentery. therapy and progressions: the affected ileus and colon were removed and a subtotal colectomy with end ileostomy was performed. the pathology report confirmed infiltration of the dissected bowel and lymph nodes by lymphoma cells. the patient continued treatment in the icu. he was discharged on the th postoperative day. comments: intussusception is rare in adults and, contrary to children, is highly associated with malignancies. resection without reduction has been advocated-wherever possible-in order to ensure better oncological outcomes. introduction: emergency surgeries are oftenly related to contaminated/infected fields, where the implantation of non reabsorbable meshes for reconstruction of the abdominal wall may not be recomendable. we aim to evaluate the results of polyvinylidenfluoride (pvdf) meshes used for complicated ventral hernia in the acute setting material and methods: retrospective analysis of patients with vh undergoing emergency surgery on which a pvdf mesh was required, in a third level hospital (november -september ). we analyzed early and late postoperative complications and -year recurrence rates. association between grade of contamination, mesh placement and infectious complications and recurrences was investigated using binary and multiple regression. results: we collected patients with a mean age of '' years, mean bmi of '' kg/m and mean cedar index of '' . '' % of patients had a grade - ventral hernia according to rosen''s index. concomitant procedures included al least one organ resection in '' % of surgeries and previous contamined mesh explantation in '' %. a pvdf mesh was placed using an intraperitoneal onlay mesh (ipom) technique in '' % of cases and an interposition location in '' %. readmission rate was '' %, one-month recurrence '' % and recurrence after a year '' %. overall mortality rate was . %. risk of recurrence was related with patients with a rosen score over (p \ . ) and also with postoperative ssi (p = . ). higher recurrence rates were not found regarding the pdvf meshes placement. postoperative seroma and hematoma rates were '' % and '' %. enteroatmospheric fistula rate was '' %. conclusions: pvdf prosthesis seems to be an useful material for complicated ventral hernia repair, specially in the acute setting, showing similar recurrence and infectious complication (fistula, chronic mesh infection, surgical site infection) rates with regard to different prosthesis used in the literature. operative vs non-operative management in liver trauma patients in a uk major trauma centre conclusions: the airs can predict the histologic severity and the intra operative findings in patients with a high clinical suspicion of aa. airs could be useful to reduce negative appendectomy and predict the postoperative stay to evaluate the deformity progression in spine injuries (dorsal, dorsolumbar, lumbar) managed by internal fixation. introduction: there continues to be controversy surrounding the management of thoracolumbar burst fractures. numerous methods of fixation have been described for this injury, but to our knowledge, spinal fusion has always been part of the stabilising procedure, whether this involves an anterior or a posterior approach. material and methods: patients with spinal injury (dorsal, dorsolumbar, lumbar) were included. all patients had dorsal, dorsolumbar, lumbar spine injuries managed with posterior short segment pedicle screw fixation and were followed up for at least one year after surgery. preoperative, post operative and follow up lateral radiographs were examined for cobb''s angle, anterior wedge compression angle and upper and lower adjacent intervertebral disc heights anteriorly, middle and posteriorly. results: at final follow up, the mean improvement in cobb''s angle post operatively was . °. the mean loss of correction of cobb''s angle was . °with sd of . °compared to post operative. the mean improvement in anterior wedge compression angle was . °post operatively. the mean loss of reduction in anterior wedge compression angle was . °with sd of . °. the increase in cobb''s angle was statically significant (r = . , p = . ) with the loss of reduction of anterior wedge compression angle at follow up and loss in intervetebral disc height at upper intervetebral disc anteriorly only(r = . , p = . ). the mean period at which sitting and standing was initiated was . months and . months respectively and mean periods for which brace was used was . months. conclusions: pedicle screw fixation is good but related to loss in reduction of anterior wedge compression angle and decrease in upper intervertebral disc height anteriorly. references: p. l. sanderson:short segment fixation of thoracolumbar burst fractures without fusion. introduction: with the newly implemented ao upper cervical spine classification system a modern, pragmatic system has been established. to what extent the simplification is helpful or whether an adjustment of the new ao classification may be discussed, forms the question of this work. material and methods: retrospective analysis of upper cervical spine injuries with ct/mri diagnostics presented to trauma surgeons with several years' experience to do classification and suggest treatment. results: the classification according to the known systems showed a relatively good agreement in the exact classification and therapy. the classification according to the new ao upper cervical spine was simple and consistent but revealed different treatment recommendations for two subtypes (iii type a and iii type b). conclusions: the new ao upper cervical spine classification system leads to a simplification. uncertainties remain with the most frequent fractures on the upper cervical spine, the c fractures. these will be managed under iii type a. however, just these injuries require completely different treatment concepts. further adaptation is required for type iii b because there uncertainties regarding the therapy also remain. case history: a -year-old woman, on treatment with acenocoumarol due to atrial fibrillation, and interatrial communication, suffered a compression fracture of the vertebrae l to l after a lowenergy trauma. due to poor pain control, she underwent a percutaneous transpedicular kyphoplasty, with no intraoperative complications. clinical findings: during the immediate postoperative period, she developed dysarthria and claudication of barré in her right upper limb. investigation/results: an angio-ct scan was performed, showing endovascular material in the left middle cerebral artery (mca) and within the lungs, compatible with cement emboli. mri showed cortico-subcortical ischemic areas in mca territory. cement-embolism stroke after percutaneous kyphoplasty therapy and progressions: conservative treatment was chosen due to the high number of emboli and the favorable evolution of the patient, with resolution of the neurologic symptoms in h without sequelae. days later, she suffered a transient ischemic attack, with no changes in the ct-scan compared to the previous images, which also solved with no residual deficits. one month after this episode, the patient died due to a spontaneous cerebellar hemorrhage related to acenocoumarol overdose. comments: kyphoplasty is a safe technique performed to treat vertebral compression fractures in elderly patients, with good clinical results and a low complication rate. its main complications are related to the leakage of cement from the vertebral body, usually well tolerated. other complications are exceptional, such as cerebral strokes, cardiac perforation, or death. the present case, although infrequent, shows us the need to assess the risk-benefit balance when operating fragile patients, as life-threatening complications may happen in these procedures. references: . marden fa, putman cm. cement-embolic stroke associated with vertebroplasty. ajnr am j neuroradiol. nov; ( ): - . survival rate and application number of total hip arthroplasty in patients with femoral neck fracture: an analysis of clinical studies and national arthroplasty registers g. hauer , a. heri , s. klim , p. puchwein , a. leithner , p. sadoghi medical university of graz, department of orthopaedics and trauma, graz, austria introduction: total hip arthroplasty (tha) is an increasingly popular treatment option for fractured neck of femur (nof) [ , ] . the aim of this study was to systematically review all literature on primary tha after fractured nof to calculate an overall revision rate. furthermore, we wanted to compare primary tha implantations after fractured nof between different countries in terms of tha number per inhabitant. material and methods: all clinical studies on tha for femoral neck fractures between and were reviewed and evaluated with a special interest on revision rate. revision rate was calculated as ''revision per component years'' [ ] . tha registers were compared between different countries with respect to the number of primary implantations per inhabitant. results: twenty-two studies showed a mean revision rate of . % after ten years. we identified eight arthroplasty registers that revealed an annual average incidence of tha for fractured nof of . per , inhabitants (table ) . conclusions: we found similar annual numbers of thas for fractured nof per inhabitant across countries. revision rates in clinical studies are higher compared to registry data [ , , ] . the results of this analysis can be used to rank present and future national tha numbers within an international context. early clinical predictors of pneumonia in patients with acute spinal cord injury without bone injury: a retrospective study t. sakamoto , s. kanezaki , n. notani oita university, oita, japan introduction: pneumonia is still significant complication that associates with mortality and duration of hospitalization in patient with acute spinal cord injury without bone injury (sciwobi). the purpose of this retrospective study is to clarify early clinical predictors of pneumonia in patients with sciwobi. material and methods: we reviewed the medical records of patients with sciwobi who admitted between january and november . spearman's rank-correlation coefficient was used to test the relationship between each parameter. multiple logistic regression analysis was performed to determine the factors that influenced pneumonic morbidity. results: a total of patients with acute sciwobi, who were evaluated for neurological impairment within h after injury, were reviewed. pneumonia occurred in patients ( %), seven patients injured at c and four at c . according to spearman's rank method, asia motor score, beginning period of nutrition, ventilator use, neurological level of injury (nli) ] c , low prognostic nutritional index (pni) were correlated with onset of pneumonia. logistic regression found ventilator use to be most predictive of pneumonia (odds ratio [or] = . , % confidence interval [ci] . - ), followed by nli ] c (or . , % ci . - . ), beginning period of nutrition (or . , % ci . - . ), pni (or . , % ci . - . ). conclusions: in addition nli, low pni increases the risk of pneumonia. we consider that improving nutritional status, especially early initiation of enteral nutrition, decrease the incidence of pneumonia. bicycle-related cervical spine fractures e. helseth , j. ramm-pettersen , s. f. eng , i. naess , m. mejlaender-evjensvold , h. linnerud oslo university hospital, neurosurgery, oslo, norway introduction: the incidence of traumatic cervical spine fractures (cs-fx) in the norwegian population is / , /year, and % of these injuries are bicycle-related ( , ) . materials and methods: prospective cohort study of all bicyclerelated cs-fx in the south-east norwegian population ( . million) in the time period - . the data were retrieved from our quality control database for traumatic cs-fx in south-east norway. in the database all cs-fx patients (c (occipital condyle) to c /th ) are prospectively registered. results: during the four-year study period patients with bicyclerelated cs-fx were registered, ( %) were males, and mean age was years (range - ). the cs-fx was located in the upper cervical segment (c -c ) in ( %) patients, lower cervical segment (c -th ) in ( %), and at both segments in ( %). the most common fx subtype was c -fx. spinal cord injury secondary to cs-fx was registered in patients ( %). fracture stabilization was achieved with open surgery in ( %), external immobilization with a stiff collar alone in ( %,) and without treatment in ( %). conclusions: severe bicycle-related cervical spine injuries are not uncommon. the increasing political desire to move commuting from motorized vehicles to bicycles warrants a heightened focus on road safety. introduction: the need for cervical immobilization is predicted by the atls, the standard of care in trauma since , because cervical trauma is a important cause of disability. however, its discontinuation was linked to x-rays, a fact that has been changed thanks to the development of two algorithms that assess the severity of cervical trauma: the canadian c-spine rule (ccr) and the national emergency x-radigraphy utilization study (nexus). material and methods: this study aims to compare the reduction values in the number of ct scans required after the application of both algorithms in a level- trauma center and to verify the degree of adherence of residents in the use of each. cohort study with randomized application by residents of the algorithms in all patients suffering from blunt trauma with cervical collars who were admitted from august to october . the conducts had their frequencies analyzed to obtain an inference about the efficacy of each method in the abstention of x-rays and case resolution, in addition to verifying if the indicated conduct was followed by the resident, inferring on the confidence in the algorithm. results: cases were evaluated during this period, of which were by the ccr algorithm and by the nexus. the indication rate for ccr imaging was . % and nexus was . %, showing no statistical difference between them (p = , ; ci = %). in the evaluation of the effective conduct, which evaluated the reliability of the algorithm, there was no disagreement between them (p [ , ; ci = %). conclusions: neither method demonstrated superiority to the other in reducing the indication of imaging exams and its uses had equal adherence by resident physicians. panacek case history: a year old lady presented with severe neck pain following a fall and cervical hyper-extension injury. she had previously undergone anterior cervical discectomy and fusion at c / with placement of artificial interbody bone graft. postoperatively, the patient reported an excellent clinical outcome and later imaging confirmed interbody fusion. clinical findings: on examination, the patient was neurologically intact but reported severe mid-cervical neck pain with reduced range of movement. investigation/results: imaging included ct and mri of the whole spine diagnosis: imaging revealed an unstable hyper-extension injury of the cervical spine. a fracture extended through the caudal end of the fused graft-vertebral interface at c / with disruption of the posterior elements. therapy and progressions: given the severity of the injury surgery was recommended. the patient underwent uneventful c -t posterior instrumentation and fusion with excellent outcome (follow up two years). comments: this is the first report of a cervical spine fracture through the site of an anterior cervical discectomy and fusion. it is hypothesised that the fused cervical segment resulted in increased stress at the fused caudal graft-vertebral interface during hyper-extension, this combined with reduced tensile strength at the graft-vertebral interface resulted in this unusual transverse fracture pattern. the clinician should be aware that patients presenting with cervical spine trauma in the context of previous cervical spine surgery are prone to greater mechanical forces. there should be a high index of suspicion for serious injury prompting thorough assessment and investigation. pr s -screw-fixation: computer aided study prevent unguided missile r. krassnig , w. pichler , e. viertler , a. schwarz , r. wildburger , g. hohenberger auva rehabilitation clinic tobelbad, tobelbad, austria, boldin und pichler og, graz, austria, medical university graz, graz, austria, auva unfallkrankenhaus, graz, austria, medical university graz, orthopaedics and trauma, graz, austria introduction: transiliosacral screw fixation of unstable dorsal pelvic ring fractures is not much present neither in literature nor in practice. in cause of the complex anatomy and the varying narrow safe bony corridors its a demanding procedure. limited information is available on optimal placement and the geometry of safe zones for screw insertion in the pelvis. material and methods: d-reconstructions of consecutive ct scans of polytraumatic injured patients ( female, male) were the basis to insert two virtual cad bolts (representing screws) into the first two sacral segments as performing during screw fixation. results: in s the narrowest point was reached after a mean of . mm respectively . mm, depending on the selected way of measurement. for s the mean distance to the tricky constriction area amounted to . mm, respectively . mm. the average height in s measured . mm and the average width . mm. according, the average height for s was . mm and the average width . mm. the measurement results didn't show a significant difference between male and female pelvis bones for any distance of interest. conclusions: an optimal screw position is very important, because in the areas of bony narrowing are the exit points of the sacral nerves, which exit through the foramina anteriorly and posteriorly. damage to this nerve structures can cause severe long-term consequences such as numbness or paralysis. knowledge of predefined distances may aid in preoperative planning, decrease operative and radiation times and may prevent unguided missiles. clinical findings: there were absent breath sounds on the right side of the thorax, ultrasound showed an extensive pleural effusion. a chest tube was inserted and l of bloody-milky fluid was drained. investigation/results: ct scan showed fractured c -c and th -th vertebral bodies, fractured lateral osteophytes of th - and probable injury of the thoracic duct at th - level. pleural effusion analysis showed raised cholesterol and triglyceride levels. diagnosis: traumatic chylothorax; fractures th -th , th -th , c -c therapy and progressions: patient was kept on ventilatory support for days. primarily she was treated with total parenteral nutrition followed by no fat and hypolipidemic diet. the chest tube was removed after days. she was discharged in stable condition the following day. at the month check-up she was stable and eupnoic. comments: traumatic chylothorax caused by blunt chest trauma is extremely rare. there are hypotheses that injuries to the thoracic duct are caused by hyperextension of the spine or by increased thoracic/ abdominal pressure (seat-belt injuries). in our case, chylothorax probably resulted from fractured lateral osteophytes. patients are usually successfully treated with pleural drainage and total parenteral nutrition. if there is no improvement after weeks or if drainage exceeds . l/day or l/day for more than days, thoracic duct ligation should be considered. conservative treatment resulting in t-l or lumbar kyphosis can worsen the quality of life of the patient whereas traditional open surgery may be an overtreatment in some cases, considering blood loss, possible complications, hospital stay and delayed functional recovery. in this setting, a good option can be a percutaneous minimally invasive surgery. the advantages of percutaneous pedicle screw fixation are: preservation of posterior musculature, less blood loss, shorter operative time, lower infection risk, less postoperative pain, shorter hospital stay and easier implant removal after bone union. limitations such as inability to achieve direct spinal canal decompression can be dealed by combination with open techniques. the objective of this study was to report the results of ppsf on these fractures and the technical problems we had to overcome. methods: patients are included, treated with percutaneous transpedicular fixation and stabilization with minimally invasive technique from december to october . patients were males, females; average age was , years (range from to ). in all cases, system pathfinder-nxt (zimmer) was used. results: most of the patients presented an early post-operative mobilization with amelioration concerning pain and a low complication rate. limitations in mobilization were mainly due to coexistent injuries, polytrauma or non-reversible neurological deficit. conclusion: ppsf is a reliable and safe procedure which does not replace the open technique but adds to treatment options by restoring a good sagittal alignment similar to those reported for open surgery. removal of hard material is advocated after fracture healing to preserve the lumbar spinal mobility and avoid zygapophyseal joint osteoarthritis. critical surgery within the first hour of presentation: is it a feasible intervention for better trauma care outcomes in low and middle income countries? introduction: in low and middle-income countries (lmic) golden hour care concept is almost nonexistence due to resource constraints. in this study, we analyzed one novel concept of critical surgery within the first hour of admission as a possible intervention which could be applied in the existing scenario in these countries without much resource requirement. material and methods: a retrospective analysis of a prospectively maintained data registry under a project named titco (towards improved trauma care outcome) was done. registry data from a level - trauma centre in india were analyzed from october to september . all patients who admitted and underwent critical surgical interventions within the first hour of presentation were analyzed. these patients were divided into two groups depending upon primary presentation or referred from another facility. statistical analysis was done between these two groups to compare the outcome. results: sixty-one ( . %) patients were directly admitted from the site of the incident whereas forty-five ( . %) were transferred from other hospitals for surgical needs. the median time from injury to presentation for primary patients was min with interquartile range (iqr) of . in the referred patient median time gap between the injury to our center (not referring center) was min with iqr of . this difference was statistically significant. major outcome indicators in the form of median icu and total stay, as well as mortality, were not significantly different conclusions: proposed concept might be a useful hospital-based intervention in existing trauma system in lmic to improve the outcome of injured patients along with improving prehospital services. oslo university hospital, ullevål, orthopedic department, oslo, norway, extrastiftelsen, oslo, norway introduction: it is well-known that physical activity is good for us. although the skeletal muscle is the main organ which is directly affected, exercise affects the whole body. the mechanisms responsible for these beneficial effects are gradually becoming known to us through extensive research. this might make it easier for physicians to prescribe exercise as a therapy equally and even more beneficial than drugs regarding effect and risk profile. the aim of this thesis was to review the current literature on the molecular mechanisms of exercise-induced health benefits. material and methods: a search in medline and embase resulted in articles. they were sorted by title and abstract, then by reading the full text. relevant articles from the reference-lists were included. sources were found outside of the search. results: when we exercise, the skeletal muscle is subjected to several mechanical and chemical stimuli, which in turn activate a set of kinases and phosphatases. these are molecules that regulate transcription-factors and co-activators, and this leads to adaption of the muscle-cells. i addition, the muscle secretes a number of proteins called myokines, which conduct the effect of exercise to other organs and tissues. some lead to increased cerebral neuroplasticity, hypertrophy and angiogenesis (bdnf, vegf and igf- ). several interleukins have also been identified as myokines, and they mediate an anti-inflammatory effect which is favorable in the prevention and management of conditions like atherosclerosis and type diabetes. lastly, we found that exercise leads to epigenetic changes, altering the genetic expression in several types of tissues. some studies suggest that the epigenome is affected by exercise even before we are born, giving babies born to physically active mothers a favorable epigenetic expression. conclusions: we should use this knowledge to support the implementation of physical activity in treatment and preventive health care. impact on undertriage and mortality after changing from a twotiered to one-tiered trauma team activation protocol costs. prognostic factors may assist in identifying high cost groups with potentially modifiable factors for targeted preventive interventions, hence reducing costs and increase rtw rates. evaluation of long-term follow-up and consequences of gunshot and stab wounds in a french civilian population introduction: the data concerning long-temr follow-up of patients and consequences of gunshot wound (gsw) and stab wound (sw) are almost inexistent in the literature. in finland, a study showed that % of patients with trunk wounds died secondarily from alcohol-related or violent problems [ ] , highlighting the secondary importance of long-term care for these patients. the main objective of our study was to analyze the hospital and posthospital follow-up of patients with gsw or sw and to evaluate late complications and the consequences of these traumas. material and methods: from january to january , patients were hospitalized for gsw or sw management in laveran military hospital. hospital data were collected via informatic patient file and post-hospital data via a telephone questionnaire with the general physician (gp). results: median hospital follow-up was days . seventy-six patients had a follow-up visit with their gp ( %). median follow-up was mois . twenty-four patients were totally lost to follow-up ( . %). global follow-up identified patients with longterm consequences ( . %), psychiatrics and organics. seventeen cases of recurrence were found ( . %). high iss, age, gsw and gp identified in patient medical file were significantly linked to long-term consequences occurrence. conclusion: this study showed a high number of long-term consequences occurrence among patients with gsw or sw. however, the extra-hospital follow-up seems insufficient. it is therefore imperative to strengthen the compliance and adherence to the care network of these patients. awareness and involvement of medical, paramedical teams and gp role seems essential to screening and management of these consequences. introduction: focused assessment with sonography for trauma(-fast) is an effective tool for assessments of severely injured patients, especially in the settings of helicopter emergency medical service(hems) because of limited devices and time. the objective of this study is to investigate accuracy of trauma ultrasound in helicopter emergency service compared with enhanced ct scan. material and methods: we investigated the trauma patients in years which was demonstrated fast and delivered to the advanced critical care center in gifu university by hems. accuracy of the fast was determined by comparison to the presence of injury, primarily determined by computed tomography, and to required interventions. results: patients were included in this criteria. there were and patients in which we found fluids in thoracic or abdominal cavity by enhanced ct scans and ultrasounds in hems, respectively. sensitivity and specificity, positive predictive value, negative predictive value, accuracy were . , . , . , . , . . if we limited the data for abdominal fluids, each data were . , . , . , . , . . in the patients of negative fast with positive ct, no patient died due to hemorrhage in thoracic or abdominal cavity. conclusions: it has been reported that sensitivity of fast in hems was lower compared with in er. in the settings of prehospital trauma care, advantages of portable ultrasound could be limited because of peculiar environments. and also, the thoracic or abdominal fluids could increase with time by organ injuries and it causes fast negative in acute phases.in this series, we could not find cases which has possibility of death because of negative fast and might influence the treatment. repeated fast or careful assessment of patients based on the other findings could be beneficial. references: the sensitivity of fast in hems was low and demonstrating fast for several times could be effective to detect the thoracic or abdominal hemorrhage. pre-hospital trauma care in switzerland and germany: do they speak the same language? los angeles county ? usc medical center, department of surgery, divison of acute care surgery and surgical critical care, los angeles, united states introduction: field amputation can be life-saving for entrapped patients requiring surgical extrication. under these austere conditions, the procedure must be performed as rapidly as possible with limited equipment, often in a confined space, while minimizing provider risk. the aim of this study was to determine the optimal saw for a field amputation. material and methods: this was a prospective cadaver-based study. four saws (gigli, hand pruning, electric oscillating and reciprocating) were tested in human cadavers. each saw was used to transect four separate long bones (humerus, ulna/radius, femur and tibia/fibula). the time required for each saw to cut through the bone, the number of attempts, slippage, quality of proximal bone cut and extent of body fluid splatter as well as the physical space required by each device during the amputation were recorded. univariate analysis (fisher's exact and kruskal-wallis or mann-whitney u-test) was used to compare the outcomes between the different saws. results: the fastest saw was the reciprocating followed by oscillating ( . [ . - . ] sec vs . [ . - . ] sec, p = . ). the number of attempts required to amputate ( . [ . - . ] , p = . ) and the amount of slippage ( . [ . - . ], p = . ) were highest with the pruning saw. the reciprocating saw had the worst proximal bone cut quality ( % poor, p = . ) and the largest blood splatter ( . [ - ] , p = . ). the physical space required to perform an amputation ranged from cm with the oscillating to cm with the reciprocating saw. overall, the oscillating saw outperformed the others in number of attempts, slippage and quality of bone cut and physical space requirements, and was the second fastest ( table ) . conclusions: the speed, precision, safety, space required, as well as the highly adjustable blade in the oscillating saw make it ideal for a field amputation. a gigli saw is an excellent backup for when electrical tools cannot be used or fail. impact of air medical transport on the survival of major trauma patients in thailand e. surakarn , w. siriwanitchaphan bangkok hospital headquarters, bangkok trauma center, bangkok, thailand introduction: air medical transport is an alternative mode of interfacility transfer for injured patients who required a higher level of trauma care in thailand. this study assessed the impact of air medical transport on the survival of major trauma patients transferred from local hospitals to a tertiary care hospital. material and methods: trauma registry of - was reviewed. major trauma patients transferred by air ambulance were identified. injury severity score (iss), predicted mortality and actual survival to hospital discharge were studied and compared between two subgroups, the seriously injured patients (iss - ) and the severely injured patients (iss [ ) . the predicted mortality was calculated from the probability of survival (ps) of trauma and injury severity score (triss). results: there were major trauma patients (iss [ ) transferred by air ambulance in five years period. patients were severely injured (median iss = ), and patients were seriously injured (median iss = ). the range of flight time was - min. the overall survival rate was . %. the predicted mortality in the severely injured group was cases ( . %), but the actual mortality was nine ( . %), . % lower than predicted mortality. the predicted mortality in the seriously injured group was one case ( . %), while the actual number was two ( . %). the eleven deaths in this study were eight cases of severe traumatic brain injury(tbi) patients, two cases of massive bleeding with subsequent multi-organ failure and one drowning. conclusions: air medical transport significantly improved the survival of severely injured patients who need higher level of trauma care. severe tbi and the presence of multi-organ failure associated with unfavorable outcomes. however, a detailed analysis of the trends and epidemiology of rtis affecting the most vulnerable children in qatar, under years of age, has not been conducted. this study's primary objective of is to describe the epidemiology of rtis and deaths in young pediatric patients in qatar. material and methods: data, for all young pediatric [under years] victims of rti''s and rti deaths from january , , through december , , from the trauma registry of the hamad trauma center [htc], the national level trauma referral center of qatar, was analyzed. this data was correlated and compared with data from the hamad general hospital mortuary and vital statistics data from the qatar ministry of development planning and statistics, the vital statistics annual bulletin, for the years - . results: the htc attended to patients, under years, with severe rtis and in-hospital rti deaths were reported during the study period. males made up . % of the injured and % of fatalities.the average age of the injured was years and for fatalities was it was . years. the rti incidence rate per , for both sexes, under years, has been unchanged ( in and in ) . the road mortality rate, per , , has decreased significantly, from . in to . in . since , the proportion of pre-hospital deaths has been increasing, - %, and the in-hospital death rates has been reduced to %. conclusions: rapid improvements in pre and in-hospital post-crash care in qatar have resulted in marked reductions in in-hospital deaths for young children with rtis. the emergence of pre-hospital road deaths of under ''s must be made a priority for road safety in qatar. the implementation of proven prevention programsshould be fast tracked in order to directly address this issue. introduction: despite improving survival of patients in prehospital traumatic cardiac arrest (tca), initiation and/or discontinuation of resuscitation of tca patients remains a subject of debate among prehospital emergency medical service providers. the aim of this study was to identify factors that influence decision making by prehospital emergency medical service providers during resuscitation of patients with tca. methods: twenty-five semi-structured interviews were conducted with experienced ambulance nurses, hems nurses and hems physicians individually, followed by a focus group discussion. participants had to be currently active in prehospital medicine in the netherlands. interviews were encoded for analysis using atlas.ti. using qualitative analysis, different themes around decision making in tca were identified. results: the causes of bleeding were grouped into several categories.the most frequent cause with cases in a row is attributed to diverticular bleeding,other causes of bleeding were angiodysplasia,post polypectomy bleeding,gist tumor,rectal ulcers and inflammatory disease.no case presented mortal or serious complications,secondary to the procedure. only cases presented a mild complication: focal mucosal ischemia of the embolized intestinal segment that was resolved with conservative treatment.lesions in charge of bleeding in those cases in which the angiographic treatment failed,were:ulcer in cases,a case of bleeding after endoscopic polypectomy, a case of diverticular bleeding and bleeding secondary to a coagulation disorder.among these patients, the definitive treatment was the following: -a second angiographic treatment was effective in the case of bleeding due to coagulation disorder. -a case of self-limited bleeding. -surgical treatment was the definitive treatment in both cases of bleeding in the context of and patient with bleeding after polypectomy. we have not observed a significant relationship neither the type of lesion or its location with the probability of failure of the angiographic treatment. nor do we observe a significant relationship between the type of material used for embolization and the risk of treatment failure. comments: our data show that angioembolization is an effective and safe technique to treatment lgi bleeding. references: clin endosc . endoscopic therapy for acute diverticular bleeding introduction: the use of resuscitative endovascular balloon occlusion of the aorta (reboa) as adjunct for temporary hemorrhage control in patients with major torso hemorrhage is increasing. specifications and characteristics of available aortic occlusion balloons (aob) are diverse. in order to minimize the risk of failure and complications it is important to choose a device that fits the requirements per medical situation. the aim of this study is to provide guidance in the choice of an aob in a specific situation. material and methods: aob were assessed for characteristics and different properties of each are outlined. the bending stiffness was measured with a three-point bending device. results: although all aob tested are small caliber devices ranging from (er-reboa tm ) to french (codaÒ ), some need large bore access sheaths up to french (fogarty Ò and lemaitre tm ) or even insertion via surgical cut-down (equalizer tm ). the bending stiffness of the aob varied from . n/mm (± . sd) with the codaÒ to . n/mm (± . sd) with the russian prototype. guidewire-free devices are generally stiffer than over-thewire catheters. the tokai rescue balloon tm showed kinking of the shaft at low bending pressures. the er-reboa tm , fogarty Ò , lemaitre tm , reboa balloon Ò , and rescue balloon tm are the only catheters with external length marks to assist blind positioning. the only aob using a non-compliant balloon is the reboa balloon Ò . conclusions: specifications of available aob are diverse. in resource-limited settings, reboa should be performed with a rather stiff device that can be placed without wire and fluoroscopy, such as the er-reboa tm , fogarty Ò , and lemaitre tm . of these aob, the er-reboa tm is the only catheter compatible with a small french sheath. use of non-compliant balloons without real-time fluoroscopy is not advised given the potential risk of aortic rupture. when fluoroscopy is available, a guidewire can be considered. case history: year old male patient presenting with an initially uncomplicated pertrochanteric fracture, treated by an intramedullary nailing system (figs. and ) . days after the operation and mobilization without any adverse events the patient was readmitted. clinical findings: massive swelling, hematoma and pain. investigation/results: sudden fall of hb values down to , g/dl, ct scans showed the lesser trochanter located directly to the deeper femoral artery after mobilization (fig. ) . diagnosis: perforation of the deep femoral artery and several veins by the dislocated lesser trochanter therapy and progressions: blood transfusion, intraoperative cardiopulmonary resuscitation, several revision surgeries to stop the bleeding by oversewing the deep femoral artery and ligation of the veins, removal of the lesser trochanter fragment (fig. ) . admission to intensive care unit. subsequent plastic coverage. comments: according to literature, bleeding complications and injuries of the deep femoral artery can occur even several days after an initially uncomplicated pertrochanteric hip fracture. besides acute life-threatening bleeding, false aneurysm can occur ( ) ( ) ( ) . even if those late complications are very rare, the consequence for the patient can be devastating. these rare cases show the clear obligation to a thorough follow up treatment and regularly dressing changes. investigation/results: arterial colour doppler of the popliteal artery showed hypoechoeic contents and narrowed lumen. biphasic flow was seen in both popliteal and posterior tibial arteries. diagnosis: popliteal artery injury with delayed repair therapy and progressions: two incision and four compartment fasciotomy was done under regional block the next day which revealed a non contractile posterior compartment. superficial and deep muscles of the posterior compartment had doubtful viability. left distal sfa to infragenicular popliteal artery bypass graft was placed on day post injury. blood flow was established upto the ankle and foot, confirmed on check angio. however, foot drop of the patient persisted. after appearance of a healthy granulation tissue at the wound site ( days), a split thickness skin graft was placed to give coverage with % uptake of the graft. comments: blunt popliteal artery injury has been reported to result in amputation rates of nearly - %.the importance of a detailed vascular examination of a blunt trauma patient is emphasized as a limb can be salvaged if timely intervention is done. in this case even with an unfavourable mess score. case history: a healthy -year-old male, with no history of interest, suffers a high-energy trauma as a water bottle rushes over his left knee. clinical findings: go to the emergency room with pain and functional impotence in the left knee, with its anatomical deformity. knee x-ray pa and l are performed and the distal pulses that are present are taken. ankle-brachial index [ . . closed reduction is performed in emergencies under sedation and control x-ray is requested, aiming at correct reduction. it was decided to keep under observation for - h before discharge from hospital to schedule regulated ligament reconstruction surgery after studying with mri. therapy and progressions: at h of evolution after the accident and after having reduced the dislocation, the patient who has the leg with a temperature equal to the contralateral is reassessed, however, there is no palpable dorsal pedis pulse or posterior tibial palpation in the affected leg. it is decided to urgently request an angiotc and it is objective thrombosis of popliteal artery. vascular surgeon is contacted and emergency surgery is decided. a by-pass is performed with vena safena. diagnosis: traumatic knee dislocation and popliteal artery injury comments: in the st century, complementary tests in diagnosis are becoming increasingly important. however, in this case we want to management of aseptic tibial nonunion anastasios g. c. reamed interlocking intramedullary nailing for the treatment of tibial diaphyseal fractures and aseptic nonunions. can we expect an optimum result? results of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunion management of tibial non-union using reamed interlocking intramedullary nailing the radiographic union scale in tibial (rust) fractures: reliability of the outcome measure at an independent centre pelvic trauma: wses classification and guidelines damage control orthopaedics in unstable pelvic ring injuries references: beuran, m. trauma scores: a review of the literature glasgow coma scale, age, and arterial pressure (mgap): a new simple prehospital triage score to predict mortality in trauma patients. critical care medicine. champion hr. a revision of the trauma score proximal femoral nail antirotation versus gamma nail for intramedullary nailing of unstable trochanteric fractures. a randomised comparative study results of the femur fractures treated with the new selfdynamisable internal fixator (sif) dhs helical blade for elderly patients with osteoporotic femoral intertrochanteric fractures the hypermetabolic response to burn injury and interventions to modify this response racial differences in propranolol enantiomer kinetics following simultaneous i.v. and oral administration propranolol dosing practices in adult burn patients the hypermetabolic response to burn injury and modulation of this response: an overview. wound heal south africa management strategies and outcome of blunt traumatic abdominal wall defects: a single centre experience blunt traumatic abdominal wall hernias: a surgeon's dilemma blunt traumatic abdominal wall hernias: associated injuries and optimal timing and method of repair traumatic abdominal wall herniation: case series review and discussion trauma patients with open abdomen: do they differ from others? a single center experience h. fagertun , a. seternes department of circulation and medical imaging, trondheim, norway introduction: treatment with open abdomen is demanding for patients, staff and hospital. a multidisciplinary approach is mandatory. the aim of this study was to compare trauma patients with open abdomen (oa) and patients treated with oa for other reasons, regarding outcome and resources spent. material and methods: retrospective study of patients treated with oa in a tertiary hospital in norway. ten were trauma patients vacuum-assisted wound closure and mesh-mediated fascial traction for open abdomen therapy-a systematic review prospective study examining clinical outcomes associated with a negative pressure wound therapy system and barker's vacuum packing technique thoracic-abdominal trauma with diaphragm lesions n. vlad , i. streanga , a. morar , i st. spiridon'' hospital iasi. we have analyzed clinical data, trauma mechanism, pathology of the lesion, time trauma-diagnostic, associated lesions, treatment, and follow-up. results: there have been patients ( men, women), mean age . location of diaphragmatic tears has been on the left hemidiaphragm ( cases), on the right hemidiaphragm ( cases), or bilateral ( cases). the trauma mechanism has been blunt ( cases) or penetrant ( cases). all patients had associated visceral lesions and had been operated right diaphragmatic injury and lacerated liver during a penetrating abdominal trauma: case report and brief literaturereview traumatic diaphrag-matic ruptures: clinical presentation, diagnosis and surgicalapproach in adults traumatic rupture of the diaphragm: experiencewith patients % ( / ) were aast grade or . in the total group, median age was years, . % were male and . % were blunt injuries. median iss in the nom group was and in the om group. median iss for those with grade or injury was . . % ( / ) underwent nom, compared to . % ( / ) of those with aast grade or . for each mmhg increase in systolic blood pressure, patients with grade or injury were % less likely to have an operation (or . , p = . ) and for each beat increase in heart rate intra-operative grade i was revealed in patients ( , %), grade ii in ( , %), grade iii in ( , %) grade iv in ( , %) and grade v in ( , %). histologic finding of catarral appendicitis was found in ( , %) patients, ( %) had phlegmonous appendicitis and ( , %) had gangrenous appendicitis. the airs difference was statistically significant with histological findings quality of publications regarding the outcome of revision rate after arthroplasty swedish hip arthroplasty register annual report joon yung lee: risk factors for failure of nonoperative treatment for unilateral cervical facet fractures in , patients were included in the trauma registry. median iss was and patients had an iss [ . of these patients / ( %) were undertriaged with a mortality of / ( %). the total mortality in was , % ( / ). i , median age was years for the patients with no tta vs years for those patients who did receive a tta (p \ . ) prognostic factors for medical and productivity costs, and return to work after trauma: a prospective cohort study l results: a total of trauma patients ( % of total study population) responded to at least one follow-up questionnaire. mean medical costs per patient (€ , ) and mean productivity costs per patient (€ , ) varied widely. prognostic factors for high medical costs were higher age, female gender, spine injury, lower extremity injury, severe head injury, high injury severity, comorbidities, and pre-injury health status. productivity costs were highest in males, and in patients with spinal cord injury, high injury severity, longer length of stay at the hospital and patients admitted to the icu. prognostic factors for rtw were high educational level, male gender, low injury severity swiss and german (pre-)hospital systems, distribution and organisation of trauma centres differ from each other [ , ]. it is unclear if outcome in trauma patients differs as well. therefore, this study aims to determine differences in characteristics, therapy and outcome of trauma patients between both german-speaking countries. material and methods: the traumaregister dguÒ (tr-dgu) was between - and - were included if they required icu care or died. trauma pattern trauma care in germany trauma systems in europe practical assessment of different saw types for field amputation: a cadaver-based test study these themes were: factual information (e.g., electrocardiography rhythm)educational programs and future guidelines. references: rosemurgy as, prehospital traumatic cardiac arrest: the cost of futility blunt vertebral vascular injury in trauma patients: atlsÒ recommendations and review of current evidence treatment-relater outcomes fron blunt cerebrovascular injuries. importance of routine follow-up arteriography provided the catheters used for this study. no other support was provided diagnosis: the probe had perforated the ivc wall. therapy and progressions: open repair was performed through a xifopubic laparotomy and the cattel-braasch maneuver to expose the ivc (fig. ). a retroperitoneal hematoma was observed anteriorly to the infrarenal ivc, without active bleeding. the ivc was dissected out sufficiently to permit proximal and distal vascular control (fig. ), the probe was then removed and the laceration on the infrarenal ivc closed with a running suture. the postoperative course was uneventful. comments: to our knowledge this is the first reported case of symptomatic ivc laceration by an ice probe during ca. references: enriquez a. use of intracardiac echocardiography in interventional cardiology complications of catheter ablation for atrial fibrilla iatrogenic percutaneous vascular injuries: clinical, presentation, imaging, and management vascular complications during catheter ablation of cardiac arrhythmias: a comparison between vascular ultrasound guided access and conventional vascular access false aneurysm of the profunda artery resulting from intertrochanteric fracture. a case report profunda femoris arterial laceration secondary to intertrochanteric hip fracture fragments. a case report with major thoraco-abdominal vascular injuries (aorta, inferior vena cava and main branches). data on demographic, clinical status and imaging was recorded. descriptive and kaplan meir survival analysis was performed. results: patients were included. median age was years (iqr - ), ( . %) were male. aorta was the most frequently damaged vessel ( , %) the median iss was (iqr - )interventional procedure. overall mortality was %, with % of deaths during the first hour, . % in the first h and . % afterwards. median survival was days (ic - ). we compared survival curves in periods abdominal vascular trauma. trauma surg acute care open history: popliteal artery injuries are frequently seen with fractures, dislocations, or penetrating injuries. a thirty one year old pathologies. references: natsuhara, k.m. et al, what is the frequency of vascular injury after knee dislocation knee dislocation and vascular injury: -year experience at a uk major trauma centre and vascular hub can vascular injury be appropriately assessed with physical examination after knee dislocation? introduction: this retrospective cohort study investigated the prevalence of and risk factors for preoperative venous thromboembolism (vte) in patients with a hip fracture and a delay of [ h from injury to surgery. material and methods: this observational study included patients with a hip fracture surgically treated at university hospital. patients underwent indirect multidetector computed tomographic (mdct) venography for preoperative vte detection after admission. overall vte risk and median time from injury to ct scan were calculated. age, sex, fracture type, time from injury to ct scan, body mass index, preinjury mobility score, previous anticoagulation treatment, previous hospitalization for vte, varicose veins, and medical comorbidities were considered potential risk factors. results: the prevalence of preoperative vte was . % ( of patients). the mean time from injury to ct scan was . days. the delay from the time of injury to ct scan averaged . days for patients who developed preoperative vte, compared with . days for patients who had not developed vte. in the adjusted models, female sex, subtrochanteric fracture, pulmonary disease, cancer, previous hospitalization for vte, and varicose veins were risk factors for vte. the final multivariate logistic regression analysis introduction: vertebral compression fractures constitute a large percentage of traumatic injuries of spine. the initial management plays an important role in the final outcomes. the present study aims to study the profile of vertebral injuries in rural & semi urban population & to analyse the role of level two hospitals in initial management of vertebral injuries. material and methods: this study was a retrospective analysis of progressively collected data of patients presenting with vertebral injuries in a level two hospital catering to semi urban & rural population in india. the initial presentation along with the age & sex profile was noted. etiological factors leading to compression fractures were noted. any neurological deficit either at the time of admission or transfer to a tertiary care neurocentre was noted as per asia scale. initial management was carried out in accordance with the atls guidelines. results: a total of out patients admitted with complaints of back pain were diagnosed to have compression fractures of the spine. the mean age was . years. male: female ratio was approx : . the lumbo sacral spine region was the most comply affected region. two patients were incidentally detected to have vertebral fractures as a result of metastatic malignancy. a due note was made regarding patients who had deteriorated during the transfer in terms of neurological deficit & evidence of spinal shock. conclusions: road traffic accidents contribute a significant portion of vertebral trauma . smaller hospitals & general surgeons have an important role to play in terms of initial stabilisation of such patients particularly the ones presenting with neurogenic shock. a good initial management has sigificant bearing on outcomes. analysis of risk factors for tracheostomy in cervical spinal cord injury without bone injury n. notani , s. kanezaki , t. sakamoto , h. tsumura oita university, orthopaedic surgery, yuhu, oita, japan introduction: there are many cases that require tracheostomy in the acute phase of cervical spinal cord injury, and various risk factors have been reported so far. however, there has been no report on cervical spinal cord injury without bone injury. the aim of this study is to evaluate risk factors for tracheostomy in patients with cervical spinal cord injury without bone injury. material and methods: we conducted a retrospective observational study. patients who were treated for cervical spinal cord injury without bone injury in our hospital were divided into groups: tracheostomy (tc) group and no tracheostomy (no tc) group. we compared variables, including age, sex, asia impairment scale (ais), neurological level of injury (nli), injury severity score (iss), vital signs, blood gas analysis, tracheal intubation, chest complication, smoking history between two groups. results: there were patients in tc group, and patients in no tc group. on univariate analysis, there were significant differences in age, ais a, tracheal intubation, nli ] c . on multivariate analysis, nli ] c was an independent predictor of tracheostomy. conclusions: in this study, we demonstrated that nli ] tc could be useful to predict tracheostomy in patients with cervical spinal cord injury without bone injury. case history: many fractures of the articular processes of the cervical spine are associated with displacement and instability, approximately % of all traumatic cervical spine injuries involve isolated fracture of the articular processes non-displaced or minimally displaced. [ ] this case demonstrates a isolated facet fracture of the cervical spine with c radiculapathy treated with minimally invasive spine surgery techniques clinical findings: a -year-old male was admitted to the neurosurgery department due to severe neck pain (vas / ). the pain radiating to the right upper extermity along dermatome c . neck and trunk rotation worsened the pain. investigation/results: furthermore, physical examination revealed hyperaesthesia in the right index finger without muscle weakness. ailments suddenly appeared weeks earlier after getting up in the morning. imaging demonstrated isolated, unilateral fracture of the right superior articular process of c diagnosis: imaging demonstrated isolated, unilateral fracture of the right superior articular process of c therapy and progressions: the patient was treated by microsurgical c decompression and fusion of c - under navigation guidance. intraoperative ct scans were performed to evaluate sufficient bone removal.after the surgery, the neck and upper extremity pain subsided. the patient had returned to his usual job and sport activities. comments: this case illustrates the value of the navigation and intraoperative ct in the evaluation of bony decompression, anatomy and location of implants. navigation minimized iatrogenic injury resulting in reducing postoperative complications like chronic pain, kyphotic deformity and muscular atrophy.introduction: resuscitative endovascular balloon occlusion of aorta (reboa) is a technique initially developed in the military for trauma patients injured in combat . recently, there has been much debate on its role in civilian trauma cases in controlling non-compressible torso haemorrhage (ncth) . this review aims to provide an update on current literature on the outcomes and concerns of this procedure. material and methods: a systematic literature search according to prisma guidelines was performed over the period of january to august across embase, medline and cochrane databases. patient characteristics, mechanism and severity of injury, survival rates and post-reboa complications between survivors and non-survivors were compared. results: a total of studies were included in this review. % and % of the reboa cases were penetrative and blunt cases respectively. the survival rates ranged from to % across the studies. systolic blood pressure (sbp) was significantly elevated post-procedure, from . to . mmhg in the survivor group (p \ . ) and . to . mmhg in the non-survivor group (p = . ). the injury severity score (iss) was lower in the survivor group ( . vs . ; p \ . ) whereas their glasgow coma scale (gcs) was higher ( . vs . ; p = . ). the survivors also had a shorter duration of aortic occlusion ( . vs . min; p = . ). common complications noted following the procedure include renal injury, lower limb ischaemia and thrombosis. conclusions: pre-reboa sbp, iss, gcs and duration of aortic occlusion were found to be associated with survival. complications directly due to the procedure were difficult to ascertain. a prospective study in a multiple trauma centre is needed for further evaluation of the indications, feasibility and complications involved in reboa. references: introduction: traumatic vertebral artery injury (vai) is a wellknown complication of cervical spine injury and often causes posterior circulation stroke. we report preventive effect of acute phase endovascular intervention for traumatic vai. material and methods: all patients with cervical spine injury were surveyed with post-contrast computed tomography for vai. when vai was diagnosed, the affected vertebral artery (va) was occluded with endovascular intervention before spine reduction and fixation. brain ischemic lesion was evaluated before and after the treatment. results: forty-one patients with vai associated with cervical spine injury underwent endovascular intervention. the affected va was occluded with endovascular coils before cervical spine reduction and fixation in patients, and after treatment in one patient. va stenting was done for another two. six presented new brain infarctions after spine surgery. of these, two had endovascular intervention after spine reduction. out of patients who had endovascular embolization before spine reduction, four had newly developed infarctions after spine surgery, of which two were symptomatic. there were no complications related to the endovascular procedure. conclusions: in conclusion, endovascular embolization for traumatic vai before spine reduction and fixation was found to be effective to prevent symptomatic brain infarction. introduction: the use of drug coating balloons (dcb) in primary or secondary angioplasty for peripheral vascular disease is a new tendency. the use of paclitaxel decelerates the growth and hyperplasia of neo-intima tissue which can cause re-stenosis and total occlusion in the spot of pta is a very promising technique in long lasting results of balloon ptas. purpose: to demonstrate our experience and results of the technique of dcb pta with the use of drag coating balloons. material and method: in the period between march and september , patients with sfa lessions were treated with pta with dcb for acute limb ischemia. were males and females. mean age was , y.o (± . ). patients were examined pro operationally and immediate post operationally in abi difference and their post operational follow up included measurement of abi and u/s triplex scan on the st, rd, th and th month(where chronically available) after pta. results: the mean immediate post operative increase of abi was , (± , ). were chronically available the increase of abi remained to , in the months follow up, , in the months and , in the th month follow up while patency of the artery treated remained in all patients. of the patients suffered from acute complications during or short after the pta ( with peripheral embolization and with retroperitoneal hematoma) which were treated immediately and left no consequences. conclusions: the use of dcb for pta in acute ischemia is a quite new, promising technique for maintaining patency of treated arteries for long time post operative period. the medium time results from its use in our clinic seem to be satisfactory. jichi medical university hospital, tochigi, japancase history: a -year-old male hit his neck hard against the fence. thereafter, he experienced difficulty in breathing and severe neck pain. he was brought to the emergency center by ambulance. clinical findings: his vital signs on arrival were gcs: e v m , hr: , bp: / , rr: , spo : ( lo ). significant neck edema and tracheal deviation were noted. inspiratory stridor was not heard with no signs of retracted breathing or subcutaneous emphysema. investigation/results: an enhanced ct scan of the neck revealed tracheal deviation and compression with ruptures of the left thyroid lobe. a large hematoma and arterial extravasation from a branch of the inferior thyroid artery were noted. diagnosis: rupture of the left thyroid lobe and injury around the distal portion of the left inferior thyroid artery. therapy and progressions: after securing the airway by intubation, angiography of the neck was performed; extravasation from a branch of the left inferior thyroid artery was suspected. angioembolization was continued for hemostasis using gelatin sponge. neck edema improved in the intensive care unit. following extubation on the hospital day , the patient was discharged on the th day with no complication. comments: thyroid injury due to blunt neck trauma is rare and surgical intervention such as hemithyroidectomy is generally prescribed. the patient''s condition, in this case, improved by angioembolization without any invasive surgical procedures. catheter procedure may, thus, be effective for hemostasis on thyroid injury after the confirmation of airway placement. introduction: the indication for resuscitative endovascular balloon occlusion of the aorta (reboa) is hemodynamically unstable patients in life-threatening hemorrhage below diaphragm. it was unclear that the difference of indications for reboa affects mortality in trauma.material and methods: this study used data from the japan trauma data bank (jtdb) ( - ), a nationwide trauma registry, to describe the epidemiology of reboa. adult trauma patients used reboa were included. patients were excluded if they had cardiac arrest at the scene or dead on arrival, or had an unsurvivable injury of any region of the body as defined by the abbreviated injury scale. patients were classified by whether patients had indications for reboa. the indications for reboa were defined by indications for hemostasis to intraabdominal, retroperitoneal, pelvic or extremity hemorrhage. the indications were decided by the delphi method with the cooperation of experts in trauma for this study. the contraindications were defined by brain injury needed intervention and hemorrhage above diaphragm. the logistic regression was used to assess the mortality after adjustment for injury severity score. as a sensitivity analysis, a generalized linear mixed model with random effects of a facility was performed. results: of , patients registered in the jtdb, patients underwent reboa. had indications for reboa and underwent reboa without indications. the physiological variables were similar, but the consciousness was worse in the no-indications group. injury severity of brain and chest were higher in the no-indications group. the indications group had . % and the no-indications group had . % contraindications for reboa. the mortality was similar ( . % versus . %, or . , %ci . - . ). a sensitivity analysis showed the same result as the primary analysis (or . , %ci . - . ). introduction: most incident first responders have a primary nonmedical role, but are frequently the only professionals initially at the scene. early hemorrhage control via advanced techniques such as resuscitative endovascular balloon occlusion of the aorta (reboa) can save lives. training first responders these techniques has therefore the potential to improve outcomes. this study evaluates the ability to train quick response team fire fighters (qrt-ff) to gain percutaneous femoral artery access and place a reboa catheter, using a comprehensive theoretical and practical training program. material and methods: six qrt-ff participated in the training. sof medics from a previous training served as control group. a formalized training curriculum included basic anatomy and endovascular materials for percutaneous access and reboa catheter placement. key skills were: ( ) preparation of an endovascular toolkit, ( ) achieving vascular access in the model and ( ) placement and positioning of the reboa catheter. results: qrt-ff had significantly better baseline knowledge of surgical anatomy (p = . ) compared to medics. they also scored significantly better on using endovascular materials (p = . ), performing the procedure without unnecessary attempts (p = . ) and overall technical skills (p = . ). the median time from start to reboa inflation was : min for qrt-ff and : min for medics. procedure times improved in all qrt-ff and of the medics in a second attempt of gaining vascular access and reboa placement. conclusions: our comprehensive theoretical and practical training program proves suitable for percutaneous femoral access and reboa placement training of qrt-ff without prior ultrasound or endovascular experience. repetition reduces procedure times. training in the use of advanced hemorrhage control techniques such as reboa, as a secondary occupational task, has the potential to improve outcomes for severely bleeding casualties in out-of-hospital settings. prytime medical tm devices, inc. provided the reboa access task trainer (ratt) and the catheters used for this study. no other support was provided.the authors declare that there are no conflicts of interest that could inappropriately influence (bias) their work. introduction: angioembolization (ae) has become an important component in the management of bleeding from severe pelvic fractures. timely availablity of ae is required for both, level and trauma centers. the aim of this study was to assess the utilization of this procedure in level and trauma centers and effect on oucomes. material and methods: retrospective, -year ( - ) study using the the american college of surgeons tqip database, including adult patients with isolated severe pelvic facture (ais [ ] [ ] [ ] . patients who underwent laparotomy or preperitoneal packing within h from admission were excluded, operative management for bleeding control between and h was considered as failure. univariate analysis was used to compare patients in level vs centers, multivariate regression analysis was performed to determine factors predictive for mortality and overall complications.results: patients ( in level ; in level centers) met the criteria for inclusion. overall, ( . %) underwent ae, with a trend toward higher ae rate in level centers ( . % vs . %, p = . ). no significant differences were observed in timing and failure rate of ae between the levels. particulary in the ae subgroup there was a significantly lower blood product utilization in the first h in level i centers (prbc . vs . units, p = . ; plasma . vs . units, p = . ). mortality and overall complication rates were similar. table the level of trauma center was not a predictive factor for mortality (or . , p = . ) and overall complications (or . , p = . ). conclusions: in isolated severe pelvic fractures, there was a trend toward higher ae rate and significantly lower utilization of blood products in level centers. there were no significant differences in mortality or complications. the ae subgroup in level centers had a higher blood products use without outcome benefit, suggesting more restrictive transfusion policy may be considered. portal vein thrombosis after distal splenopancreatectomy: successful recanalization using fogarty balloon catheter case history: intraoperative lesion of smv during distal splenopancreatectomy is repaired using peritoneal patch harvested from anterior abdominal wall clinical findings: postoperative increase in serum lactate and d-dimer without signs of peritonitis prompts bedside doppler us showing no blood flood within portal vein (pv) investigation/results: ct angiography is performed suspecting acute mesenteric ischemia, but no abnormal bowel enhancement/ thickness is seen despite complete pv thrombosis. anticoagulation with unfractioned heparin is started, but clinical conditions deteriorate diagnosis: at reintervention, bowel is viable, so the surgeon performs fogarty balloon catheter thrombectomy successfully reestablishing blood flow within pv. no intestinal resection is required therapy and progressions: pv patency is regularly evaluated with us. anticoagulation with low molecular weight heparin is prosecuted for months and then suspended since no recurrence is recorded meanwhile comments: pv thrombosis is uncommon but can follow injury to portal venous axis during surgery. anticoagulation with heparin should be started as soon as the diagnosis is made and maintained for at least - months postoperatively to prevent recurrence. patients with persisting/worsening symptoms - h after initiation of anticoagulation, or those with peritonitis who are poor surgical candidates may be considered for interventional radiological treatment. otherwise, surgical intervention is required and may encompass resection of necrotic bowel. thrombectomy and/or balloon dilation/vascular stent placement may be helpful in recently developed pv thrombosis since risk of recurrence seems to be decreased references: acute mesenteric ischemia: guidelines of the world society of emergency surgery (world j emerg surg ); mesenteric venous thrombosis (j clin exp hepatol ); contemporary management of acute mesenteric ischemia in the endovascular era (vasc endovascular surg ) key: cord- - xvzvdg authors: nan title: national scientific medical meeting abstracts date: journal: ir j med sci doi: . /bf sha: doc_id: cord_uid: xvzvdg nan zero months months months months group a . . * . ** . "* . ** zero months group b . . ** values are means; *p< . and **p< . l~ most other studies show neutral effects on insulin sensitivity, with minimal incidence of glucose intolerance. this may be partly explained by the diversity of age, diagnosis (whether insufficiency or deficiency state), other pituitary deficiencies and replacement therapy, and possibly by dosage ofgh utilised in these studies. clostridium difficile-associated disease (cdad) is primarily a nosocomial condition. community-acquired disease has been described but the incidence is low "). during a recent outbreak, we prospectively reviewed all new cases of cdad to determine what proportion of cytotoxin positive cases were community or hospital acquired. during a month study period, cases were identified. history of diarrhoeal episodes were recorded for each case. selected isolates were typed using pyrolysis mass spectrometry (pms). community-acquired cdad was defined as diarrhoea, on or within hours of admission, in association with a positive stool cytotoxin test for c.difficile and in the absence of hospitalisation within days. sixty-five cases ( %) were hospital acquired. fifteen patients ( . %) had cdad on admission; ( %) were community acquired, ( . %) had been recently hospitalised ( at st. james's hospital, at other hospitals). pms typing of faecal isolates revealed that predominant strains were responsible for the hospital outbreak; one of these strains was also isolated in community-acquired cases. this study suggests that the incidence of communityacquired cdad may be higher than previously reported. we suggest that all newly admitted or transferred patients with diarrhoea should be screened for this organism. several studies have confirmed that activated protein c resistance (apc-r) occurs in - % of thrombosis patients and is therefore more common than congenital deficiencies in the inhibitors of coagulation such as atii , proteins c and s. homozygosity for the factor v (fv) gene mutation is associated with a - fold increased risk of venous thrombosis while heterozygosity is associated with a - fold increased risk. the mutation, however, is highly prevalent in the general population, a prevalence of % has been reported in several european countries. its frequency in the population of northern ireland (ni) has not yet been reported. we screened a group of generally healthy elderly individuals (av. age . ; range - yr on several occasions for apc-r using an assay based on the prolongation of activated partial thromboplastin time by the addition of apc. a mean ratio of . (range . - . ) was measured. seven individuals ( . %) had ratios < . (av. . ; range . - . ). these subjects were then analysed for the fv mutation by pcr amplification and restriction analysis. the individuals with the lowest ratios (av. . ; range . - . ) were found to be heterozygous for the mutation. none of these individuals were deficient for protein c, protein s or atiii. the frequency of apc-r ( . %) within this ni elderly group is similar to that reported by others in the uk whose studies would have included a generally younger population. the successful ageing of these individuals perhaps underlines the low risk associated with heterozygosity. alternatively a higher prevalence of the mutation may exist in the general population of ni, where the incidence of heart disease is one of the highest worldwide. the insulin-like growth factor ii gene (igf ) is imprinted. thus, in contrast to most genes where both maternal and paternal copies (alleles) are transcribed into rna and expressed, gf is normally only expressed from the paternal copy (monoallelic expression). alterations causing biallelic expression of igf may lead to excess growth factor production, and thus, to tumourigenesis. this study evaluated igf expression in a series of childhood cancers. to date tumours have been evaluated using pcr based methodology ( wilm's tumours, rhabdomyosarcomas, miscellaneous). dna was extracted and a polymorphic site apal within the igf gene was amplified and digested. this identified samples as heterozygous for igf , meaning that separate maternal and paternal alleles were distinguishable. rna from these informative samples was extracted, pcr amplified and restriction digested, to identify monoallelic versus biallelic profiles at the expression level. samples with normal imprinting (monoallelic) displayed allele a ( bp) or allele bl/b ( / doublet). biallelic samples displayed both alleles. using this approach / informative wilm's tumours and / rhabdomyosarcomas demonstrated biallelic expression. in conclusion, biallelic expression of igf was detected in a significant number of wilm's tumours and rhabdomyosarcomas, and should be considered; with other genetic alterations, as a candidate mechanism in tumourigenesis. the proinflammatory cytokines, tnf~, il and il- , may mediate host metabolic and immune responses to cancer possibly leading to paraneoplastic phenomena such as cachexia. the cellular origin of these cytokines in the cancer patient, in many cases, remains unknown. we examined proinflammatory cytokine levels intracellularly, using flow cytometry, in pbmcs from oesophageal cancer patients (n= ) and age and sex matched controls (n= ). tnf~ and il- levels were significantly increased (p< . ) in pma stimulated t cells and monocytes from the cancer patients when compared to the healthy controls. these results were confirmed using standard elisa assays. following cotlagenase digestion, increased levels of tnfa and il- ,were detected in oesophageal tumour infiltrating t cells when compared to cells from normal mucosa. there was also increased production of tnf~ and il- , but not il-ib, in malignant epithelial cells when compared to normal and halothane and maintained by % nitrous oxide-oxygen, . - . % halothane, with spontaneous ventilation. tc rose marginally in group and fell in group (not significant, ns). tp in groups and at induction and and minutes were, respectively, (mean + sem, celsius) . + . vs . + . , ns; . + . vs . + . , ns and . + . vs . + . , (p< . ). overall incidence of shivering-was .%, but not significantly different between the groups. the data suggests that preemptive application of the space blanket increases tp in paediatric patients during general anaesthesia and tends to conserve tc. chronic actinic dermatitis (cad) an uncommon, eczematous, photosensitive eruption is diagnosed on history, clinical examination, skin biopsy and abnormal light tests. drug induced photosensitivity may look identical clinically, have a similar history and patients with cad may be treated with potentially photosensitising drugs. we therefore reviewed all patients with cad and compared their monochrumator light tests with patients who had drug induced photosensitivity. phototesting was performed on unaffected skin of the back with an irradiation monochromator; the minimal erythema dose (med) determined for a series of wavelengths between and nm, in patients with drug induced photosensitivity and patients with cad. of ten females, four males with drug induced photosensitivity, age range - (mean yrs), ten ( %), were photosensitive in the uva range ( - nm), the implicated drugs including, quinine, sparfloxacin, amiodarone, doxycycline, mefenamic acid, nalidixic acid, fenbrufen, diclofenac, enalpril and prochlorperazine maleate. three patients with rosacea were photosensitive to doxycycline. the re/nainder ( %), were tested after discontinuation of the drug and their light tests were normal. in the cad group, (four males and three females), age range - (mean . yrs), three patients ( %), were sensitive to uva, uvb and visible light, four ( %) to uva and uvb. in conclusion, uva dissociated from uvb photosensitivity seems a relative but not absolute sign of drug induced photosensitivity. this pattern of light tests should prompt a detailed drug history to elucidate the causative agent. phototesting should be performed while on the offending drug as testing days or weeks after discontinuation will give normal results. patients at risk of bone fractures by measuring bone mineral density (bmd) and markers of bone turnover and to assess the correlation of these with the severity of cld. twenty three patients with cld had bmd measured by dual-energy x-ray absorptiometry scanning of hip and lumbar spine. bone formation was assessed using serum levels of procollagen type peptide, osteocalcin and bone alkaline phosphatase, and bone resorption was assessed using hour urinary excretion of hydroxyproline, pyridinoline and deoxypyridinoline. % and % of patients had evidence of osteoporosis at the lumbar spine and femoral neck respectively. biochemical results showed that % of patients had an increase in all bone resorption markers and % had an increase in markers for bone formation. bmd at the lumbar spine was lower in patients with cholestatic liver disease compared to patients with other types of'liver disease (p= . ). no correlation was found between bmd and patient age, bilirubin, albumin, inr or duration of liver disease. conclusions: osteopenia occurs in up to % of patients with cld due to a high bone turnover state where bone resorption exceeds formation. osteoporosis is most severe in those patients with cholestasis. a detailed profile is presented of all leukaemia and multiple myeloma (icd-o code ) patients registered by the southern tumour registry during the -year period / "). annual age-adjusted rates of . and . per , were seen for males and females respectively. these levels indicate a lifetime (up to yr) risk of in for males and in for females. the main morphological sub-types registered were multiple myeloma ( %), cll ( %), aml ( %) cml ( %) and all ( %). one, two and five-year survival rates were examined; age at diagnosis and lesion type were extremely significant factors in relation to patient outcome. the overall incidence levels indicate that irish rates were relatively high by internatiomil standards r we assessed effects of reducing the volume of hyperbaric bupivacaine by giving half the volume as isobaric bupivacaine. when using . % hyperbaric bupivacaine for spinal blockade, the segmental spread and cardiovascular effects of the block have been shown to be dependent on the volume of local anaesthetic injected. patients undergoing elective surgery were studied in a prospective, randomised, double-blind trial: group ( patients) received their local anaesthetic as two equal aliquots of . % hyperbaric bupivacaine and . % isobaric bupivacaine respectively; group ( patients) received their local anaesthetic as two equal aliquots of . % hyperbaric bupivacaine. there was no significant difference found between the two groups with regard to maximal height of block (group , mean (range), t (t -ti ); group , t (ts-t )), rate of onset of blockade, or time to maximal blockade (group , mean (sem), . ( . ) rain; group : . ( . ) min). there was no difference found between each group in either cardiovascular stability or vasopregsor usage. the administration of a mixture of . % isobaric bupivacaine and . % hyperbaric bupiv/~caine confers no advantages over administration of the same volume of . % hyperbaric bupivacaine alone. propofolis used as a sedative during regional anaesthesia. providing titrateable sedation, it can compromise haemodynamic stability. a propofol ketamine combination provides stable haemodynamics during total intravenous anaesthesia, avoiding emergence phenomena m. we compared two sedative regimes in patients having spinal anaesthesia. following informed consent, patients, asa i-ii, undergoing spinal anaesthesia were randomized to one of two groups (n= ). group i (propofol-ketamine) received loading doses of . mg/kg propofol, . mg/kg ketamine followed by an infusion of . mg/kg/h and . mg/kg/h respectively. group ii (propofol) received bolus . mg/kg and infusion . mg/kg/h. subsequent infusion rates were titrated to effect using a sedation score. heart rate, blood pressure, oxygen saturation, end tidal c and oxygen requirements were recorded. observation continued for the recovery period and patients visited the following day. data were analysed using t-test, chi test and anova. groups were demographically comparable. sedative and respiratory indices were similar for both groups. there was no difference in total propofol requirements between the groups; group i - _+ mg, group ii - _+ : mg (mean _+ sd). there was a large difference in mean arterial pressure, being much lower in the propofol only group. both groups had an uneventful recovery without emergence phenomena. our results do not confirm the described additive effect of andketammc . ketamine.with propofol for sedation propofol ' =~ ) confers haemodynamic stability during spinal anaesthesia. we designed a controlled study to investigate whether there is a direct relationship between the degree of postoperative pain and the development of negative middle ear pressure in adults following tonsillectomy. middle ear pressure was measured by tympanometry. pressures were classified as type a (o to - mmh ), type b (flat) or type c (- to - mmh ) tympanograms. patients with type a tympanograms, undergoing tonsillectomy were enrolled in the study. patients had daily tympanometry whilst in hospital and then weekly until amrmalisatign. a questionnaire incorporating visual analogue pain scores was filled in at the same time. a control group of patients with type a tympanograms, undergoing appendicectomy and endotracheal intubation was used. follo~v up was available on patients. patients ( %) developed type c tympanograms, patients %) type b and ( %) patients remained unchanged. no member of the control group developed any change in middle ear pressure (chi squared = . , p < vol. , irish journal of supplement no. medical science . ). there was no relationship between pain scores for throat pain or otalgia and the development of negative middle ear pressure. patients recorded higher pain scores for throat pain at day then day , only of this group had negative middle ear pressure. middle ear pressure reverted to normal at day in / patients and in the remaining / it was normal at day . this study demonstrates the development of transient negative middle ear pressure following tonsillectomy in % of patients. this change is unrelated to the degree of postoperative pain nor is it associated with otalgia. postoperative ward analgesia remains suboptimal. this may be partially related to inadequate early use of opioids to attain minimum effective analgesic concentration (meac). we examined the incidence and predictors of severe postoperative pain on admission and discharge from our postoperative recovery room (rr). verbal pain scores were obtained in a pilot study of patients on rr admission and discharge. procedures were classed as open cavitary, laparoscopic, orthopaedic, ent or body surface surgery. intraoperative use and dosage of narcotics and nonsteroidal (nsaid) analgesics, anaesthetists' experience (prefellowship or post-fellowship nchd, consultant) were noted, and rr opioid usage recorded. pain scores and analgesic use were examined using mann-whitney, ~ analysis and logistic regression. moderate or severe pain was experienced by % of patients on either arrival or discharge. median intraoperative morphine dosage was mg. opioid use was slightly (median morphine dosage mg, p < . ) higher in patients undergoing cavitary surgery; these patients had the highest pain scores on rr arrival and departure. patients ( %) received > mg morphine intraoperatively. discharge scores of / or higher occurred in patients ( %). opioid usage and pain scores were unrelated to level of training. nsaid use/nonuse was unassociated with differences in opioid use or rr pain scores. no morbidity attributable to analgesic use (desaturation, slow respiratory rate) occurred. nonattainment of meac is frequent after open cavitary surgery. conservative opioid dosages continue to be employed despite inadequate early postoperative pain relief; this does not change with increasing experience. reporting such findings in departmental audit may help to alter perioperative management; such data may serve as a baseline for future interventional studies. diclofenac is frequently used for analgesia after tonsillectomy. recently concern has been expressed about the effect of diclofenac on prolonging bleeding time. one recent retrospective study found its use in tonsillectomy was associated with an increase in reactionary haemorrhage. we designed a randomised controlled study to compare the effects of rectal diclofenac and im pethidine given at induction with pethidine alone, in children undergoing tonsillectomy. fifty nine patients were entered into the study. there were males and females, mean age years, range ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . patients were randomised according to chart number. thirty five patients received rectal diclofenac after induction. twenty four patients acted as controls. there were no significant differences in operating time or operative blood loss between the two groups. in the recovery room the diclofenac group was significantly less restless than tl~e control group (p < . , chi squared test), with less crying, movement and agitation. there was no difference in postoperative recovery and no primary or reactionary haemorrhage. one patient in the diclofenac group developed a secondary haemorrhage. this study demonstrates a significant reduction in restlessness in the recovery room in children receiving rectal diclofenac. no increase in reactionary haemorrhage was demonstrated. diclofenac remains a safe and effective analgesic agent in children undergoing tonsillectomy. elderly patients have decreased dose requirements for many drugs compared to the young. few studies have examined dose requirements of opioids in the elderly when administered via patient controlled analgesia (pca) . we compared the pca morphine requirements between young and elderly patients. records were retrospectively analysed from , consecutive patients receiving pca for post-operative pain. inclusion criteria (i) age less than years or greater than years, (ii) upper abdominal surgery, and (iii) morphine pca usage. patients fulfilled the inclusion criteria. patients were young and were elderly. the mean age in the young was years and in the elderly was years. % were female in the younger group, % were female in the older group. pain scores at rest and on movement were similar in both groups . and . respectively in the young, . and . in the elderly. (p > . , students t-test). morphine usage over hours was + . mg in the young, and + . in the elderly. (mean + s.d.) (p.< . , students t-test). elderly patients required significantly less morphine via pca to achieve the same pain scores as the young. these findings are consistent with studies showing decreased requirements of other drugs in elderly. the erythrocyte sodium-lithium countertransport (slc) is abnormal in essential hypertension and some other forms of cardiovascular disease (cvd) but the considerable overlap in its activity in patients with these conditions and in normotensive healthy subjects remains a strong point against its possible utility as a marker for cvd. we sought to address this issue in greater detail. twenty-nine hypertensive patients ( with family history of cvd) aged . + . years (mean + se) and normotensive subjects ( with family history of cvd) aged . + . years, participated after informed consent. slc were determined in , , , and mm sodium chloride; and the vmax and km of the transporter determined. hypertensive and normotensive individuals with family history of cvd (n = ) had higher slc activity ( . + . vs . + . , p < . ), greater vmax ( . + . vs . + . mmol/lcell.h, p < . ) and lower km . mm (median) vs . (p < . ) than hypertensive and normotensive subjects without such a history (n = ). however, none of these parameters was sufficiently discriminatory as evidenced by the considerable overlap in the scattergrams for the two groups. on the other hand not only was the median quotient vmax/km significantly different . vs . (p < . ), but also the scattergram separated the two groups. this may reflect an effect of hereditary factors on the identified rate-limiting step in the transport system. capsaicinadministration results in depletion of substance-p sensitive nerves. this study was carried out to observe the impact on the morphology of mitral valve endothelium. the experimental group received capsaicin i.p. on day four of life; control animals received drug vehicle only. animals were anaesthetised by chloral hydrate and hearts were removed following perfusion of % glutaraldehyde, and were routinely processed for scanning electron microscopy. normal endothelial morphology showed an ordered and structured pattern, with large raised nuclei covered in discrete microappendages: no zoning was observed over the valve surface. following capsaicin administration, valves were seen to be torn and possessed a denuded endothelium. nuclear bulges changed in both apparent height and area, with the surface partially denuded of microappendages. one month following systemic administration of capsaicin to neonatal rats, a serious alteration of mitral valve endothelium morphology and integrity had occurred. depletion of substance-p may have resulted in mechanical insufficiency of the mitral valve. this study was funded by the health research board. with expanding applications and increasingly aggressive stress protocols, concerns about the safety of dobutamine stress echocardiography (dse) have arisen. the purpose of this study was to analyse prospectively the safety, adverse event profile, and complication rate of dse. prospective data was recorded in a consecutive series of patients undergoing dse for diagnostic evaluation of chest pain, for risk assessment following myocardial infarction or for detection of hibernating myocardium. the maximum dose of dobutamine used was mcg/kg/min in . % of patients and mcg/kg/min in . %. atropine was used in . % long-term outcome following coronary artery bypass grafting may be related to the prevalence of major risk factors and their treatment following surgery. we aimed to establish the prevalence and current management of coronary risk factors in a group of consecutive patients attending our hospital. this is a report of the first patients. data was collected by a structured patient interview, chart review, physical measurements and blood sampling. there were male and female patients, average age . years. the mean length of time since surgery was . years. thirty-nine patients had a recurrence of angina and this occurred on average ll months after surgery. as regards risk factors, were active smokers, were ex-smokers and only had never smoked. two thirds of the patients were taking regular exercise; only took no exercise at all. seventy-two percent of patients had a cholesterol greater than . mmol/l, yet only of the patients were on lipid lowering drug therapy and a further were on a lipid towering diet. twenty-nine patients had a systolic bp > or a diastolic bp > and of these were on antihypertensive therapy. seventy-seven patients were overweight but most of these had received specific advice regarding weight reduction in the preceding year. our results show a high prevalence of treatable risk factors in this high-risk group with inadequate treatment in many cases. new combined primary and hospital care strategies for cardiac rehabilitation and long-term secondary prevention of coronary heart disease are required. if the goal of modern therapy of acute myocardial infarction (ami) is preservation of myocardium, the occurrence of cardiac failure could be regarded as a treatment failure. in recent studies of iv thrombolysis and primary ptca the frequency of left ventricular failure (lvf) following ami has been as low as . %. this very low rate might be explained by selection bias in patients recruited to randomized trials. the purpose of this study was to examine the frequency of lvf in a consecutive alterations in nitric oxide (no) synthesis have been implicated in cardiomyopathy, ischaemic heart disease and septic shock. recent work has suggested a possible role for nitric oxide in cardiac arrhythmogenesis. the effects of inhibiting no synthesis with l-name (n c -nitro -l -arginine methyl ester) on cardiac electrophysiology have not been fully determined. the dominant frequency of electrically induced ventricular fibrillation was determined in l anaesthetised pigs ( - kg) using a fourier transform. the dominant frequency ( . _+ . hz in lead ii) was not altered by treatment ( . _+ . hz) with l-name in a group of pigs ( - kg) the effect of l-name ( mg/kg) was assessed in relation to energy required to defibrillate. there was no significant difference in the energies required to achieve successful defibrillation on % of attempts between the l-name group ( . _+ . j) and the control group ( . _ . j), and on % of occasions, l-name ( . + . j) and control ( . _+ . j). the results show that inhibition of no synthesis has no significant effect on the dominant frequency of ventricular fibrillation or on the efficacy of defibrillation in the pig heart. received either mg ( pts) or mg ( pts) oral flecainide followed by a maintenance dose of mg bd. all pts were euthyroid. none had significant hypertensive, valvular or ischaemic heart disease. pts had normal echocardiograms, had mildly dilated atria. of the pts ( %) converted to sinus rhythm, within hrs and at and days respectively. subsequently, he was found to have paralysis of all the muscle groups of his right upper limb apart from some flexor movements in his fingers with areflexia and sensory loss over the c /c dermatomes. the findings were thought to be in keeping with a brachial plexus.lesion. an mri scan showed a "haematoma" or "fibrosis" around the brachial plexus~ emg studies revealed a complete lesion from c /c with evidence of partial function at c and a good function at c . despite physiotherapy, at follow up months later there was no improvement in the emg findings. though brachia~ plexus injury has always been considered a complication of central venous line insertion <l), there have been no cases described, in the literature in the last years. central lines are mandatory irt major surgical cases but one must always be aware of the possible complications caused by them. body weight (bw) in icu patients fluctuates due to alterations in body mass ( ) and water ( ) and is usually estimated rather than measured. we hypothesised that (i) estimated weights are inaccurate and (ii) changes in true body mass (tbm) are masked by changes in water content. on admission, icu patients whose expected length of stay (los) was > days were placed on a bed incorporating load cells (accuracy of _ . kg). bw was estimated by icu staff. mbw was then recorded hourly under standard conditions. changes in mbw due to pack insertion/dressing changes were excluded. we calculated tbm as mbw minus cumulative fluid excess, corrected for insensible losses c ~. patients received standardized nutritional support from day and urinary nitrogen on day was calculated we studied patients whose mean (sd) age, mbw, los and apache ii score were . yr ( . ), . kg ( . ), . days"( . ) and ( . ) respectively. mean error in estimated weight on admission was . % (nurses) and . % (doctors). mean protein and calorie intake was g and kilocals/day. mean decrease in mbw during icu stay . kg/day (range . kg (gain) to . kg). mean reduction in tbm was . kg/day (range . - . kg/ day) and this correlated with urinary nitrogen loss (r= . ). in icu, (i) estimated weight is significantly inaccurate and should not be used in physiological calculations and (ii) rapid and significant decreases in body mass occur which may be underestimated due to fluid accumulation. dopamine appears to influence pituitary function and is associated with decreased circulating human growth hormone and insulin-like growth factor i m which could exacerbate catabolism, and therefore wasting, during critical illness. at hrly intervals from admission, patients whose expected length of stay exceeded days, were weighed (measured body weight, mbw) under standardized conditions,-using a bed incorporating electronic load cells (accuracy + o. kg). standard demographics, apache ii score and use of dot~amine by infusion was recorded. changes in weight due to removal./ insertion of prostheses, packs/dressings were excluded mbw was converted to true body mass (tbm) using measurements of cumulative fluid balance ( ml = kg) and insensible lossr patients received nutritional support, starting on day , based on their admission mbw. there were no significant differences in mean age, weight, length of icu stay, admission apache ii scores and mean daily protein/calorie intake between patients who had received dopamine by infusion (group d) and who had not (group nd). mean (sd) decreases in mbw during icu stay were . ( . ) kg/day (group d) and . ( . ) kg/day (group nd) (p< . i). mean decrease in tbm was . ( . ) kg/day and . ( . ) kg/day respectively (p< . ). thus group d were losing an additional . kg body mass per week relative to group nd. the use of dopamine by infusion is associated with an accelerated loss of lean body mass during critical illness. adhesion of polymorphonuclear leucocytes (pmns) to pulmonary endothelial cells is an initial step in the inflammatory process characterising the adult respiratory distress syndrome. previous studies using human umbilical vein endothelial cells (huvecs) have suggested that lipopolysaccharide (lps) is a potent stimulus for pmn adhesion to endothelial cells. the aim of this study was to investigate the effect of lps on pmn adhesion to human pulmonary artery endothelial cells (hpaecs). human pmns were coincubated with hpaecs _+ lps ( . - mg/ml) with % serum for hour. the effect of phorbol myristate acetate (pma) ( ng/ml) was also examined. percentage adhesion stimulated by pma was + sd. lps did not significantly increase adhesion at any of the concentrations used. to confirm the activity of lps pmns were incubated at ~ with . - mg/ml lps + % serum for hour and labelled with flourescent antibodies to the mac adhesion molecule complex (cd /cd lb). facs analysis indicated upregulation of both cd and cdllb. thus in the system used, lps did stimulate pmn adhesion molecule expression, indicating that the lack of adhesion reflects a difference in hpaec response to lps compared to that reported for huvecs. this work was supported by the health research board ireland. although inhaled corticosteroid therapy is of undoubted benefit in the management of asthma, dysphonia is a recognised sequela. this study was designed to examine longitudinally the effect of inhaled steroids on the voice and vocal cords of newly diagnosed and previously untreated asthmatics. twenty subjects were recruited and underwent voice and vocal cord assessment prior to and months after starting inhaled steroid treatment. the assessment consisted of ) rating dysphonia using a visual analogue scale, ) acoustical analysis of the voice and ) videostroboscopic examination of vocal cord activity. prior to commencing inhaled steroid therapy for their asthma subjects had normal voices, subjects were mildly hoarse and one was moderately hoarse. vocal cord pathology was noted in subjects, patients had vocal cord nodules and the remainder were noted to have mildly oedematous cords together with a glottic chink. at month follow up, improvement in voice was noted in subjects, one patient felt more dysphonic but there was no change in vocal cord appearance. one subject was noted to have developed a mid glottic chink with no associated change in voice. one subject had clearing of mild vocal cord oedema and improvement in voice. this study demonstrates that % of subjects commencing inhaled steroid therapy for asthma have mild vocal cord pathology. voice is more likely to be improved following use of inhaled steroids for months then made worse. although the relationship between elastin degradation and emphysema is well known, recent evidence suggests that a more complex process of pulmonary remodelling occurs within the emphysematous lung. the aim of this study was to assess the extent of extracellular matrix remodelling by ultrastructural examination of its two major components, elastin and collagen. emphysema was induced in rats by the intratracheal administration of porcine pancreatic elastase ( . u/g body weigh and human lungs were obtained at surgical resection for lung carcinoma. emphysema was confirmed histologically in both animal and human samples by measurement of the mean. linear intercept. matching sections were immersed in . m naoh and % formic acid to digest elastin and collagen respectively. scanning electron microscopy with stereo-pair imaging allowed -d visualisation of elastin and collagen frameworks. the distribution of emphysema was primarily panacinar in rat lungs a'nd centriacinar in human lungs. as expected in both types of emphysema, elastic lamellae were disrupted and perforated with multiple fenestrations. accompanying this disintegration was a marked increase in thickness of collagen fibrils which in some cases coalesced irish journal of medical science imparting a sheet-like appearance to the airspace walls. unique to human centriacinar emphysema, collagen formed helices which spiralled around alveolar septae to form bulky walls between adjacent airspaces. in conclusion, these findings lend support to the novel concept of aberrant collagen remodelling in the pathogenesis of emphysema. small cell lung carcinoma (sclc) is the most aggressive of the four common cell types of lung carcinoma. less than % of patients with sclc are alive two years after diagnosis. staging procedures, treatment regimens and survival results were reviewed in a small regional centre to make a comparison with larger treatment centres. thirty-one cases of sclc seen by one physician from to were reviewed. staging was clinical. treatment was undertaken in conjunction with the local oncology and radiotherapy services. % of patients had limited disease where as % had extensive disease at diagnosis. in patients with limited disease, % were alive at months and there was a % long term survival rate i.e. greater than three years. average length of survival in limited disease was days. survival results were comparable with those treated with chemotherapy alone and combination chemotherapy and radiotherapy. in patients with extensive disease the best results were from those treated with a combination of chemotherapy and radiotherapy with art average survival of days. these figures compare favourably with those from larger multidisciplinary centres. the factors contributing to our relative success may relate to continuity of care achieved in a smaller centre. nasal cpap is a very effective therapy for osa, but is cumbersome, and compliance varies. we prospectively evaluated consecutive osa patients treated with ncpap, who were asked to complete questionnaires before, and to months after starting therapy. this stttdy intended to examine both the patient's subjective response to ncpap and their bed-partner's impressions also. replies were received in ( %) patients. patients were divided i~to groups depending on whether they had a bed-partner, and according to their response to an initiat question assessing overall improvement in sleep quality and daytime al'ertness with ncpap, ranging from (minimal/none) to + (excellent). patients were called responders if they scored > . group a ( pts, %) were responders with bed-partners; group b ( pts, %) non-responders with bed-partners; group c ( pts, %), were responders ( pts, %) and nonresponders ( pts, %) without bed-partners; and group d ( pts, %) had stopped ncpap. nine questions were directed at the bed-partner, and assessed their perception of changes in both the patient's and their own sleep quality, daytime alertness, mood and quality of life, and also to changes in the relationship between patient and bed-partner following institution of ncpap. these questions scored from - (worse) to + (marked improvement). significant improvement in all parameters for the patient (mean + sd = . + . ) were noted in group a. in addition, group a bed-partners reported ~ubjective improvement in the same parameters ( . + . ). group b improvements were less, ( . + . in patients, and . + . in partners). overall, the data indicate a subjective success of therapy in % of patients, but the bed-partner's replies indicate this figure underestimates the true response rate. furthermore, the results show significant improvements in the bed-partner's sleep quality, daytime alertness, mood and quality of life, indicating that successful treatment of osa patients with ncpap also gives significant benefits to their bed-partners. vincent's hospital, dublin. neutrophil collagenase (mmp ) is a member of the matrixmetalioproteinases (mmps), a family of highly homologous zinc endopeptidases which play a crucial role in many physiological processes. the aim of this project was to develop a purification system for mmp from purulent sputum and raise polyclonal antibodies. after initial extraction, contaminating proteins were removed with a zinc chelate affinity column. mmp was then separated, from another closely related mmp, gelatinase b, on a q sepharose ion exchange column using a nacl gradient. the final purification step was carried out with an orange sepharose affinity column. sds-page analysis indicated the presence of purified protein with bands corresponding to latent neutrophil collagenase ( kd) and products of coll~igenase autodegradation at lower molecular weights ( kd & kd). a fold increase in specific activity was observed, with a % final yield, which provided mg quantities of pure enzyme. this work is funded by forbairt and the. irish american partnership. cd is a protein first described as a surface marker on hodgkin's lymphoma cells. recently cd has been demonstrated on th -type t lymphocytes (produce il- , , , l and ), which have a pro-inflammatory cytokine profile. but is not found on thl-type t lymphocytes (produce il- and ifn-gamma). its ligand, cd l, has also been described, cd -cd l interaction has been shown to aid the development oft lymphocyte clones into a th rather than a th phenotype. th -type cytokines are inextricably linked to the aetiology of inflammatory airway disease. firstly we investigated serum cd levels in various patient groups. we have demonstrated significant differences in serum cd levels in the following groups, atopic asthmatics (mean = iu/l, n = ), non-atopic asthmatics (mean = iu/l n = ) and atopic rhinitis/dermatitis (mean = iu/l n = ) and normal controls (mean = iu/l, n = ). secondly we cultured peripheral blood mononuclear cells from allergic individuals and normals. when these cultures were stimulated with house dust mite antigen (der p ) and il- or der p with both il- and i - , surface expression of cd on t lymphocytes could be demonstrated using fluorescent staining and flow cytometric analysis, after days culture in the allergic individuals but not in normals. the presence of i - in the culture increased the degree of surface cd expression. these results are important as they show that allergic individuals have an expandable population of memory t lymphocytes which respond to allergen by expressing cd and developing th- phenotype. most work on cd and th- cytokines has hitherto been carried out an t cell clones. we have developed a relatively simple in vitro system of looking at t lymphocyte response to allergen which will allow the testing of novel therapeutic interventions with a view to modulating the immune response in allergic disease. our work also suggests that even non-allergic patients with inflammatory airway disease may have increased th activity, which has not been shown previously. scimitar syndrome is a rare congenital disorder consisting of a spectrum of abnormalities including hypoplasia of the right pulmonary artery, dextroposition of the heart, anomalous pulmonary venous drainage of the right lung into the inferior vena cava and anomalities of the right diaphragm. bronchiectasis and respiratory tract infections on the right side are the usual clinical presenting features. a year old male patient was referred to the outpatient clinic with a history of recurrent chest infections which were slow to resolve following antibiotic therapy. physical examination revealed decreased air entry, coarse crepitations and a prolonged expiratory wheeze in the right lower lobe. the only abnormalities on routine biochemical and haematological screening were an elevated esr of and a slightly raised white cell count of . a chest x-ray revealed hypoplasia of the right lung when compared to the left. in addition to this there was a vascular shadow present in the right lower robe representing an anomalous pulmonary vein which appeared to drain to below the diaphragm on the night side. bronchoscopy showed a normal left bronchial tree. on the right, no apical segment was detected in the right lower lobe. otherwise no endobronchial lesion was seen. a dynamic computerised axial tomographic scan of the thorax was performed. this showed a dilated anomalous right lower pulmonary vein which was clearly seen to enter the inferior vena cava below the diaphragm. in addition the right lung was again noted to be hypoplastic when compared to the left. these findings were pathognomonic of the scimitar syndrome. "the patient was treated symptomatically and is presently stable. conclusion: scimitar syndrome, with its wide spectrum of abnormalities should be considered when reviewing plain chest x-ray in patients with recurrent right lower lobe respiratory tract infection. recent studies indicate that the ability of circulating neutrophils to regulate surface levels of adhesion molecules may be altered in disease situations. the aim of this study was to determine if changes in neutrophil responsiveness accompanies chronic inflammation in cf. neutrophils in blood samples from cf patients and age-matched control subjects were analysed by flow cytometry for expression of l-selectin and mac- (cd lb) following stimulation by interleukin- (il- ) and fmlp. as expected, both il- and fmlp provoked a decrease in surface levels of l-selectin and an increase in cdi lb levels. however, the magnitude of these changes was significantly lower in cf patients than in control subjects (table) . these results suggest that chronic exposure to inflammatory stimulii in vivo may alter neutrophil responsiveness in cf. given the emphasis on rational prescribing, we reviewed drug use in a bedded long-stay unit. prescribing patterns were analysed on an appointed day thereby obtaining a "snapshot" of prescribing practices. one hundred and ninety four long-stay residents, with a mean age of , were on drugs, the maximum number of drugs per patient was , the minimum and the average . . sixty percent of prescriptions fell within one of the following therapeutic categories:-central nervous system (cns) preparations ( prescriptions), analgesics ( ), gastrointestinal preparations ( ) and cardiovascular preparations (i ). there were ,prescriptions for respiratory drugs and only prescriptions were for antibiotics. the most commonly prescribed cns preparations were anti-psychotics ( ), benzodiazepincs ( t ), anti-depressants ( ). % of all analgesics prescribed ( ) were nsaids. the most commonly prescribed h blocker was cimetidine ( ). nuseals aspirin ( ), digoxin ( ) and captopril ( ) were the most commonly prescribed cardiovascular drugs. % of drugs were issued on an as required basis, i.e. "prn". the most commonly prescribed prn therapeutic classes were analgesics ( prescriptions) followed by gastrointestinal ( ) and cns preparations ( ). these results contrast with prescribing patterns in hospitals and general practice and may provide an insight into the challenges and realities of management in long-stay units. supported by the health research board. evaluation of physician requests to hospital based clinical pharmacist for ( ) drug information, ( ) possible adverse drug reaction (adr) was undertaken over a two year period from jan ' to dec ' (admissions - , , opd attendances - , ). overall requests were made. ( ) drug information: advice/information on new drugs, formulation, dosage, safety consideration prior to drug prescribing was given in cases. ( ) suspected adr: a total of suspected adverse drug reactions were investigated. in cases, no adr link was established, after extensive literature/data base search. adr's were confirmed in cases of which were reported to n.d.a.b. regular on-going interaction between physicians and clinical pharmacy allowed critical analysis of new drugs and heightened awareness of, potential adverse drug reactions in current clinical practice. we previously demonstrated that commonly prescribed medications are not easily identified by patients, doctors or nurses in the hospital setting o, ~. we then investigated the ability of hospital pharmacists, in all, to identify the same commonly prescribed branded and generic drugs. correct identification as follows:-bendrofluazide k ( / ), cimetidine ( / ), diazepam mg ( / ), diazepam mg generic ( / ), digoxin ( / ), ferrous sulphate ( / ), frusemide ( / ), mefenamic acid ( / ), paracetamol ( / ), prednisolone ( l/ ), temezepam ( / ), theoph /lline ( / ). pharmacists had % correct answers compared with % for nurses and % correct for doctors. the pharmacists had no difficulty recognising drugs with brand names written on them e.g. cimetidine, but like nurses and doctors had difficulty identifying the plain white tablets e.g. prednisolone. generic drugs were tess well recognised. a number stated that they were unwilling to definitively identify medication with no clear marking. pharmacists were also asked to list the top prescribed drugs, l got / correct and got / correct. in contrast out of doctors got / correct, got right and only got right. we conclude that hospital pharmacists are generally better than doctors or nurses at identifying commonly prescribed drugs but their knowledge of the top prescribed drugs is not as good at that of doctors. all professionals need assistant in this important task. suggesting reduced activity or more iranians with inherited variants of cholinesterase. one iranian subject with very low activity (dibucaine number below , atypical) had a history of apnea. these data indicate that the frequency of atypical and heterozygote genes for cholinesterase activity leading to prolonged apnea with succinylcholine (suxamethonium) is much higher in iranian than irish populations. this study emphasises the importance of ethnic pharmacology. it is has been advocated that funding for the prescibing of methadone in general practice should be provided separate from the indicative drugs budgeting scheme on the assumption that this may act as a disincentive to g.p.s to take on care of drug addicts. the objective was to analyse the current level and cost of methadone prescribing in general practices in the eastern health board over a six month period. there was a review of methadone prescriptions for gms patients from jan. to jun. . , persons received prescriptions. , scripts were issued. the age-specific prescribing rate for the total population was / , (males /i , , females / , ). males aged - years had the highest age specific rates ( / , ). the cost of methadone prescriptions amounted to s for the six months there was a trend towards an increase in the number of g.p.s who prescribed methadone over the period. only four of the g.p.s ( . %) who prescribed methadone issued in excess of scripts for the period studied. for a small number of g.p.s methadone prescribing is a significant cost item on their budget. in the light of this, government policy should be reviewed with a view to excluding methadone from the indicative drug budgeting scheme. sciences, mashhed, lran. there is increasing evidence that some of the wide variation in the response to medicines has a genetic origin which may be expressed on a racial basis. to further study inter-ethnic differences in pharmacology we compared the activity of an enzyme responsible for the breakdown of endogenous substances and drugs -serum cholinesterase (pseudocholinesterase), dibucaine and fluoride numbers -in irish and iranian healthy subjects. irish subjects had significantly higher serum cholinesterase activity ( . + . vs . + . u/ml, mean + sem, p < . drug prescribing data may reflect changes in therapy and disease pattern. we reviewed current drug use among patients (n = ) in a dublin teaching hospital in "snapshot" fashion on a designated day, and compared it with that obtained in . in , patients received an average of . different drugs each, with % on or more and % on none. by , the average was . (range i - ), with % on or more. the percentage of patients receiving heparin fell from % to %, due mainly to a reduction in use on the medical side. the proportion of patients prescribed hypnotics fell from % to %, while ssri's are now the most used anti-depressants. antibiotic choice changed from amp/amoxicillin to coamoxiclav and the cephalosporins. diuretics remained the most frequently used cardiovascular agents, accounting for % of all drugs used and prescribed for around one quarter of patients. digoxin use remained constant, and by , % of patients were on anti-platelet doses of aspirin. at least four different agents were in use in each of calcium antagonist, beta blocker and ace inhibitor classes. some of these changes in therapy reflect therapeutic advances, changes in disease management, greater choice of therapy and amendment of less than desirable therapeutic practices. on the other hand, some may reflect fashion or pharmaceutical promotion, rather than change as a consequence of evidence-based practice. acknowledgements: pharmacy staff, st. james's hospital and the health research board. studies of in vivo endothelial function in humans have usually involved intraarterial cannulation and the subsequent administration of substances that stimulate the endothelium to produce nitric oxide (no). such techniques are invasive and potentially hazardous. an alternative non-invasive method would be of benefit. animal studies have indicated that reactive dilation of vascular beds may be at least partially endothelium dependent. this study aimed to determine whether reactive hyperaemia in the human forearm was an endothelial dependent process with the potential to be used as a non-invasive method of stimulating the endothelium. ten volunteers underwent brachial artery cannulation and randomly received either placebo or n-monomethyl-l-arginine (l-nmma) ( ~mol/min), an no synthase inhibitor, for minutes. following this reactive hyperaemia was induced by the inflation of an arm cuff to mmhg for minutes and the response to this was measured by strain-gauge plethysmography. when flows had returned to baseline the process was repeated with the remaining substance. results were analysed by repeated me~isures anova. l-nmma resulted in significant reduction of basal forearm blood flow (p< . ). there was no significant difference in reactive hyperaemia with either l-nmma or placebo. in conclusion, no does not contribute to reactive hyperaemia in the human forearm. dublin . home-based infusion therapy has been widely recognised as the optimum for treatment of disease states that require daily intravenous therapy from a patient-care aspect. conditions necessitating intravenous therapies in hiv disease include: cmv retinitis, intractable cryptosporidial diarrhoea, azole-resistent candidosis, nutritional support with total parenteral nutrition, chemotherapy for aids-related malignancies and palliative care in the terminal phase of the disease. the need for such therapies is increasing as patient survival improves. in , the home-infusion service was set up in recognition of the need to treat patients, requiring intravenous therapy, in the home environment. this has been brought about by the development of small, light-weight pumps suitable for ambulatory use, the development of a service for aseptic compounding and the availability of permanent in-dwelling venous catheters. we describe the impact of this service on our patient cohort. to date, sixty-five hiv positive patients have received parenteral therapy at home. patients' age, sex, risk group, cdc stage, cd count, indication for therapy, complication rate and response to treatment are described. the provision of this service has reduced the number and length of patient admissions with associated improvement of quality of life. in addition, it recognises that patients prefer to be treated in the home environment aided by a co-ordinated multidisciplinary approach. since blood alcohol levels over mg/ ml are now illegal for vehicle drivers we have investigated if the commonly held "safe" limit of two drinks will bring the young adult over the legal limit and if this amount of alcohol will affect their psychomotor skills. following informed consent healthy volunteers, nonhabitual drinkers on no medication ( male, female), with a median age of (range - ) years participated and refrained from alcohol for at least days. each drank within minutes two standard drinks ( . ml each ) of . % vodka ( . units of alcohol) plus ml of orange juice at about minutes after a standard mid-day meal. their psychomotor performance was estimated by the number connecting technique at minutes after alcohol consumption and they were also asked to rate their feelings (which included alertness, clear-headedness, competence and attentiveness) using a visual analogue scale of to . blood samples at one and two hours later were collected from the antecubital vein and analysed on the same day for alcohol content using enzymatic methods. mean (+ sem) blood concentrations of alcohol at and hours respectively were . + . and . + . mg/ ml. in males and . + . and . + . mg/l- ml in females. values were significantly higher in females. blood concentrations in females were also higher (p < . ) than in males when expressed per kg body weight. while the blood alcohol in both the genders was considerably lower than the current legal limit in ireland their psychomotor skills as estimated from their task completion time and their answers to questionnaires were indicative of an impaired cns function. thus while drinks may keep many subjects below the legal limit, there is considerable inter-individual variation with females showing higher concentrations and both genders have evidence of impaired performance at these lower levels. a non-linear approach was used to develop an hrv parameter, robust to both data non'-st~itionary and missing data points. unlike the standard chaos approach, using higher dimensional embeddings and time-delays, we employed a onedimensional correlation integral plot. the parameter thus obtained, allows an estimate of the spatial spreading of the attractor (ssa) or spatial variation of rr intervals along a straight line. heart rate data from volunteers ( : to : hr), ~ifter oral placebo or propranolol mg, investigated the ability to detect drug effect. vitamin e (~-tocopherol) is the most important dietary antioxidant in lipid and cell membranes and its intake reversely relates to the incidence of coronary heart disease and certain cancers. estrogen regenerates oxidized tocopherol radical in vitro m but such interaction has not been investigated in postmenopausal women receiving estrogen containing hormone replacement therapy (hrt) although estrogen containing oral contraceptive may reduce plasma vitamin e levep. we studied healthy post-menopausal women (aged - ) ammenorrheic for at least one year. fifteen subjects took a combination of harmogen provera therapy and acted as a control group. blood samples were taken from all subject at baseline and after weeks. in the hrt group, serum fsh levels were greatly reduced ( . + . vs . + . iu/ , p < . , mean + sd, after hrt) with an increased serum oestradiol level (< - . vs . + . umol/ , p < . ). no change occurred in the control group. vitamin e status, measured either as plasma or red cell ~-tocopherol respectively showed no change in both groups (hrt group . + . vs . + . , . + . vs . + . gmol/ , p > . ). we conclude that in post-menopausal women, weeks estrogen containing hrt did not alter vftamin e concentrations in vivo. we assessed the clinical benefit of the newer markers of bone formation: osteocalcin (oc), procollagen carboxyterminal peptide (picp), bone alkaline phosphatase (balp), and bone resorption: carboxyterminal telopeptide of type collagen (ictp) and urinary deoxypyridinoline crosslinks (dpd) over traditional assays such as total alkaline phosphatase (talp) and urinary hydroxyproline (oh/pr) in patients with primary hyperparathyroidism (phpt). patients were sampled basally, then at , , , and hours post surgery and again at . , , and months post op. the mean basal p cp level was + ug/l (normal: - ) this increased to a peak at h ( +_ ug/l), then declined to normal at weeks ( + ug/l). mean basal urinary dpd levels were raised at . + . nm/mm cr. (normal . - , ), they had normalised by months to . -+ . nm/mm cr. mean balp levels were always normal, although normal the yearly mean oc level was significantly lower than the basal value. mean ctp, oh/pr and talp levels were always normal. therefore bone turnover in phpt is best assessed by the newer markers picp and dpd. we have previously described seasonal variation in fibrinogen with higher levels in winter. as fibrinogen is an acute phase reactant, the winter rise may be a response to seasonal infections. the present study investigates this hypothesis by examining seasonality infibrinogen and markers associated with infection: white cell count (wcc), interleukin- ( l- ), human herpes virus (hhv ) and herpes simplex virus (hsv) antibodies. monthly blood samples from healthy volunteers age and over were measured for fibrinogen, wcc, il- , hsv and hhv reactivation over a year time period. a rhythmometric method was used to examine the data for seasonality. statistical significance was measured using the fstatistic. a highly significant seasonal variation (sv), peaking in mid-february, was found for fibrinogen (n= ; sv= . g/ ; f= . ; p< . ). no significant seasonal variation was present for measures of wcc (n= ; sv= . e /l; f= . ; p> . ), hhv (n= ; sv= . au; f= . ; p> . ), hsv (n= ; sv= . au; f= . ; p> . ) or il- (n= ; sv= . pg/ml; f= . ; p> . ). the present investigation does not support the hypothesis that seasonal variation in fibrinogen is a direct effect of the acute phase response, initiated by a seasonal variation in level of infection. the explanation for the seasonal changes in fibrinogen remains unknown. increased plasma homocysteine and reduced plasma antioxidants are risk factors in the development of vascular disease. design: subjects drawn from elderly people living in the community (median age yr, range - yr; female). total plasma homocysteine, vitamin c, gamma tocopherol, retinol and beta carotene were measured by high pressure liquid chromatography. homocysteine levels in elderly males [median (range) = . um ( - . ), n= were significantly higher than in vol. , supplement no. irish journal of medical science elderly females [ . um ( . - . ), n= ]. these values were also higher than in a younger ( - years) male cohort [mean = . um, n= ]. no correlations to vitamin concentrations were found, nor was there a correlation to age within the elderly cohort. within the elderly females, a significant negative correlation with age was found in vitamin c, gamma tocopherol and beta carotene (p< . ). however a significant increase in retinol was noted. a very strong correlation between vitamin c and gamma tocopherol levels was noted in the elderly population sample (p< . after multiple regression). conclusion. homocysteine levels in the elderly are higher than in samples of a younger population. a gender difference is maintained in the elderly. the provision of extended care forms one part of a spectrum of health care for older people. in the eastern health board area all patients over the age of must be assessed by the multidisciplinary geriatric team prior to placement. we report on the experience of the total number of referrals for assessment for extended care to one department of geriatric medicine in a bed teaching hospital. ninety-eight patients listed for extended care in . the mean number of days between listing for long term care and placement was _+ days (range to ). almost one quarter of patients died while in hospital awaiting long term care: this underlines the frailty of patients who are admitted to hospital and request long term care. two patients were transferred to other institutions and patients were able to get home. of the remaining patients ( %) were placed in statutory or voluntary long term care accommodation and only % were eligible (usually financially but in some cases due to significant disability) for nursing home care using the terms of the nursing home act. patients who are listed for long term care through a general hospital are in general very frail, they tend to have a very extended length of stay and the provisions of the nursing home act only apply to a minority. these findings underline the need for provision of adequate statutory and voluntary extended-care places within the eastern health board area. there are over screening assessments for cognitive function and choosing the most appropriate may be difficult. increasingly the importance of behavioural dysfunction is recognised. can any of the cognitive assessments help to predict behavioural dysfunction.'? we compared and contrasted the folstein mini mental state examination (mmse) and the cognitive assessment schedule (cas) of the clifton assessment procedures for the elderly (cape) and compared them with the behavioural rating scale (brs) of the cape. the study was carried out on a total of referrals to the occupational therapy departments by geriatricians in the meath hospital and st. james's hospital. all subjects were over and medically stable. the time scale involved was may-july . the mmse and the cas were administered within the one sitting and each was timed. brs was rated the same day by either a staff or family, member. the average time to complete the mmse ( + s) was longer than the cas ( + s) but this was not statistically significant. the mmse and cas were significantly correlated (r = , p < . ). the cas was significantly correlated with the behaviour scale (r = , , p < . ) whereas the mmse was not. these results suggest that equivalent assessments of cognitive function may be made with the mmse or cas, but a low cas score will be a better prediction of behavioural dysfunction. a spectrum of neurological and myopathological changes are associated with patients in intensive care units. we observed several patients post discharge from icu who presented with unexplained dysphagia which we suspected may be associated with the neurological complications of sepsis. the particular complication of dysphagia as a neurological manifestation of sepsis has not been documented. our descriptive study presents a series of three patients with persistent dysphagia which may represent a similar phenomenon. we selected patients for the study ranging from - years of age and on the basis of medical history including icu stay, sepsis, and intubation. all patients presented with dysphagia as observed on videofluoroscopy. we studied the video findings in-depth in order to ascertain if similar swailow patterns were present in these patients and if this could be correlated with their medical history. each of the three patients presented with similar dysphagia signs. the oral phase of the swallow was moderately atypical but the pharyngeal phase was significantly atypical. it was felt that intubation alone was not the sole causative factor of this dysphagia. the polyneuropathy associated with sepsis in icu may explain the atypical swallow patterns observed in these patients. the severity of the persistent dysphagia can cause serious respiratory and medical consequences. there is a need for further investigation of this phenomenon to identify patients who are at risk. little attention has been paid to the prevaience and phenomenology of behavioural disturbances among medical patients despite awareness of the high prevalence of cognitive vol. , supplement no. impairment in this patient population. we screened consecutive admissions to a department of acute geriatric medicine. patients were evaluated over a week period using a modified version of the brief agitation rating scale. medication use, cognitive function and impact on nursing time were also measured. the prevalence of behavioural disturbance in this population was / ( %). the most frequent behavioural abnormalities were restlessness ( ), complaining ( ) and screaming ( ). the most common underlying disorders were dementia, stroke disease, personality disorder and paranoid psychosis. the behavioural disturbance was only documented in the medical notes in patients ( %) and in only cases was a psychiatric consultation sought. these findings demonstrate that behavioural disturbances are not only common but also under-documented in elderly medical patients and there is a need for training in the detection and management of behavioural symptoms in this patient group. in lower limb trauma where there is severe compound fracture, the successful treatment of this depends on adequate bone and soft tissue debridement. as a result, subsequent bone defects can lead to instability and often require large amounts of bone grafts, and major soft tissue reconstruction is reaquired to obtain skin cover. large soft defects can by reduced bv primary bone resection and shortening of the limb. this will improve the chance of bone healing if performed in the presence of an external fixator, then lengthening at a site away from the traumatised area can gradually restore limb length. two cases are presented to demonstrate .the effect of compression / distraction techniques on soft tissue and bone injuries in these difficult situations. wegener's granulomatosis -wg ( ), churg strauss syndrome -css ( ), polyarteritis nodosa -pan ( ) and unclassified ( ). using the chc definitions, the diagnoses were wg ( ), microscopic polyangiitis -mpa ( ), pan ( ) and undefined ( ). there was concordance in only patients (all wg). there is significant discordance between these two criteria sets. since the acr criteria does not recognise mpa, they tend to overdiagnose wg. in addition, the chc criteria cannot be applied without a biopsy and therefore surrogate features which predict the underlying histology are required to allow more practical application of the chc definitions. the objective was to determine the value of examination of dried freshly produced saliva, under light microscopy, in patients with xerostomia related to secondary sjogrens syndrome. ten patients with known connective tissue disease or rheumatoid arthritis attending rheumatology clinic were enrolled into the study, all with symptomatic xerostomia and dry eyes. all had an abnormal schirmer's test. five normal patients were enrolled, all of whom were without clinical evidence of rheumatological disease. control patients were enrolled who had no clinical evidence of rheumatological disease, a salivary sample was collected and examined by light microscopy. serum was also examined for the presence of anti-ro/la, rheumatoid factor, and anti-nuclear factor. all ten patients demonstrated 'reindeer horn' type ferning of saliva, a pattern of shorter thicker clubbed branches of crystallised mucus, in contrast to the normal ferning pattern of the healthy subjects. conclusion: we have shown in this preliminary report that light salivary microscopy is a simple test easily performed in an outpatient setting which could be a useful diagnostic procedure in sjogrens syndrome. recently, two sets of criteria have been proposed for the nomeclature of primary vasculitides, the american college of rheumatology (acr) classification criteria and the chapel hill consensus conference (chc) definitions. the aim of this study was to determine the concordance of these two systems in a cohort of patients with primary systemic vasculitis. patients with systemic vasculitis were recruited who had a biopsy proven diagnosis or, who had typical clinical features associated with a postive antineutrophil cytoplasmic antibody (anca). the case notes were reviewed and patients were classified according to both sets of criteria. twenty-six patients were recruited, of whom had a positive biopsy. applying the acr criteria, the diagnoses were, primary pulmonary hypertension (pph) typically affects young individuals, and has a high morbidity and mortality. secondary pulmonary hypertension complicating connective tissue diseases likewise carries a poor prognosis. we evaluated the acute and chronic effects of ketanserin, a selective serotonin type- receptor antagonist in patients with pulmonary hypertension in the acute study ketanserin was administered as a peripheral venous infusion during right heart catheterisation. following encouraging results during catheterisation oral administration of ketanserin mg daily in divided doses was instituted. in patient , a year old female with probable pph, serial cardiac catheterisations over a year period showed a significant, sustained reduction in both mean pulmonary artery pressure from mmhg at baseline to mmhg at year (normal - mmhg) and pulmonary vascular resistance units at baseline to units at year (normal < units). in patient , a year old female with limited scleroderma (crest) echocardiography after month's oral ketanserin showed a reduction in estimated peak right ventricular systolic pressure from mmhg at baseline to mmhg (normal range - mmhg). the acute and long term response to ketanserin with improyement in pulmonary haemodynamics in these patients suggests that if a beneficial effect is detected during catheterisation long term oral therapy may be worthwhile. levels were low (< . iu/ ); normal though above average (>- -< iu/l) and moderate high (> -< iu/l) respectively. gonadotrophins for ovarian stimulation were commencing initially at iu for group a & b and at iu for group c. ivf performance was poor in most aspects (total follicles, oocytes & embryos transferred) in group b comparing with group a or c; the cumulative ongoing pregnancy rate (pr) over ivf cycles in group b; was % comparing with . % in group a (p < . ) however there was no significant difference in pr in group c ( %) comparing with other two groups. cycle day fsh screening is predictive of follicular development in ivf. high initial dose of gonadotropins help to improve the pregnancy rate in the presence of moderate high level of fsh. the purpose of this study was to evaluate patient satisfaction with antenatal care provided in the perinatal day centre (pndc). a self administered questionnaire was administered to consecutive patients. the main indications for referral were suspected small-fordates ( %), non-proteinuric hypertension ( %), glucose tolerance testing ( %), reduced fetal movements ( %) and post-term evaluation ( . %); % were nulliparae. thirty-two percent of patients were reviewed in the pndc on the day of referral; the rest within days. twenty eight percent of patients lived more than miles from the hospital and % spent more than minutes in travelling there. eighty five percent of patients scored their level of satisfaction with the service provided in the pndc as > out of ; only . % would have preferred admission; % said that they would prefer to visit the pndc times per week to avoid admission. the main area of dissatisfaction related to the waiting time for review prior to discharge, with . % of patients waiting over hours. patients attending the pndc report a high level of satisfaction; changes to reduce the visit duration have been introduced. to examine the change of taking-up the essential preconceptual measurements; rubella immune status, cervical cytology and prophylactic folic acid intake; following specific advice and publicity through general public meetings with new patients prior to in vitro fertilization (ivf) programme. in we studied new couples for ivf for the presence of some specific pre-conceptual data (group a). in this study we follow-up the same intake in another new women interviewed to commence ivf programme from january till september (group b). in group (b) the taking-up measurements were dramatically improved. however, % and % stilldid not have rubella immunity test and cervical cytology performed; compared to % and % in group (ai respectively (p< . ). while folic acid intake was sustained at > % in both groups. following specific advice the rate of taking-up of preconceptual measurements prior commencing ivf programme was improved. there is a future need for continuous enhancement of the publicity and advice regarding the importance of preconceptual measurements. the aim of this study was to introduce icsi to ireland for treatment of specific cases of male factor infertility. following an introductory proving period using the bovine model, thirtyeight couples with infertility attributed to the male were selected for an icsi attempt. ovulation induction, oocyte retrieval and luteal management were as described for conventional ivf tm. the average age of patients selected for icsi were . + . years and . + . years for the female and male respectively, with an average duration of infertility of . + . years. a year old woman presented with a three day history of parasthesia in her lower limbs and difficulty walking. neurological examination revealed sensory loss in her limbs and truncal ataxia. rombergs sign was positive. pelvic examination revealed a large pelvic mass that was distinct from the uterus. routine blood investigations were normal. csf culture, ct brain and serum electrophoresis were negative. anti-purkinjie cell antibodies were not present. ca- levels were elevated at micrograms/litre. laparotomy revealed a cm left ovarian tumour. a total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy was performed. histology revealed a poorly differentiated clear cell adeno-carcinoma of the left ovary. the capsule was intact and peritoneal washings were negative. she made a good postoperative recovery. she received six courses of carboplatin without ill effect. her neurological symptoms resolved. subacute cerebellar degeneration can occur as a paraneoplastic disorder in ovarian carcinoma. the mechanism by which cancer can cause neurological disorders is not fully understood. paraneoplastic cerebellar degeneration occurs with or without the presence of purkinjie cell antibodies. the aim was to review all red cell transfusions in gynaecological surgery in . a retrospective review of blood bank records and individual charts was carried out. patients underwent gynaecological surgery; ( %) were cross matched and ( . %) were transfused. units were transfused. there were no single unit transfusions. the mean number of units transfused per patient was . this accounted for % of all units transfused this year. % of patients were undergoing elective surgery. the overall cross match/transfusion ratio was . intraoperative difficulty was recorded in % of cases. % of patients were transfused perioperatively and % postoperatively. the percentage of patients requiring blood transfusions in the the main individual operation categories was as follows: radical surgery: %; total abdominal hysterectomy and salpingo-oopherectomy, %; vaginal hysterectomy and repair, %; subtotal abdominal hysterectomy, %; vaginal hysterectomy alone . %; and total abdominal hysterectomy alone %. adverse reactions to transfusions were seen in % of patients. conclusion: the majority of patients transfused were undergoing elective surgery. vaginal hysterectomy was associated with greater blood loss than abdominal hysterectomy. only half of all units cross matched were transfused. dilatation and curettage (d+c) is the most common operation performed in the u.k. the liberal use of d+c has been criticised. the objective of this study was to evaluate the use of outpatient endometrial pipelle biopsy and determine its safety in terms of detecting abnormalities. complications and financial costs were also evaluated. data was reviewed from an active gynaecological unit from february to january , using theatre and outpatient records. a total of d+cs and endometrial pipelle biopsies were performed in this period. malignancies were detected by d+c and by pipelle biopsy. a total of and benign abnormalities were detected by each method respectively. there was a higher complication rate in the d+c group but the failure rate was higher in the endometrial pipelle biopsy group. the monetary savings over this period is estimated at s there were no missed malignancies to our knowledge over the year period since endometrial pipelle bioposy was introduced to this hospital. our study indicates that outpatient endometrial pipelle biopsy appears to be safe, efficacious and economical. while ultrasound findings may sometimes be in conflict with clinical examination, it is the case that there are instances when ultrasound findings have, following subsequent laparotomy, been found to be wholly incorrect. it is therefore not surprising that there remain some gynaecologists who view ultrasound with scepticism, preferring to rely solely of their clinical findings. there have been few studies that directly compare clinical, ultrasound and surgical findings in the detection of pelvic masses. the objective of the study was firstly to directly compare the reliability of clinical and ultrasound examination findings in the detection of pelvic masses proven by subsequent laparotomy and secondly to determine the accuracy of ultrasound in detecting malignancy. this was as a retrospective review of women who underwent a laparotomy because of a pelvic mass between january to february . information was obtained from theatre and patient records. real time abdominal ultrasound was used. findings at laparotomy were correlated with clinical and ultrasound findings. the sensitivity and specificity of ultrasound in detecting a uterine mass was % and % respectively. this contrasts sharply with clinical examination (sensitivity = % and specificity = %). similar findings were obtained when ultrasound was compared to clinical examination in detecting ovarian masses. ultrasouud is capable of predicting benign disease with reasonable confidence but the prediction of malignancy is less reliable. in conclusion, ultrasound is more sensitive and specific in detecting pelvic masses compared to clinical examination. vincent's hospital, dublin. osteoporosis occurring during pregnancy or lactation is a rare event despite the homeostatic demands of the foetus for calcium. we investigated the case of a year old woman who, immediately following vaginal delivery of her first child, developed severe back pain due to a vertebral compression deformity of the second lumbar vertebrae. bone mineral density (bmd) was measured by dual-energy x-ray absorptiometry. calcium metabolism and bone turnover were studied. there was a severe reduction in bmd in the spine (z-score = - . ) and f e m o r a l neck ( z -s c o r e = - . ); but, serial measurements showed no further reduction in bmd. indices of calcium metabolism and bone turnover were normal. pregnancy-induced osteoporosis is a severe but self-limited disorder in calcium homeostasis of unknown aetiology. women with low bmd prior to pregnancy may be at increased risk. in view of increased demand, supplemental calcium and vitamin d should be considered during pregnancy and lactation. crumlin, dublin . the aim of this study was to assess the clinical status on admission and the critical care m a n a g e m e n t of children p r e s e n t i n g with m e n i n g o c o c c a l i n f e c t i o n . t h i s was a retrospective study of the charts of consecutive admissions. mean age was . years (+ . ). the average duration of symptoms prior to admission was . hours (+ . ). on admission . % were hypotensive, . % had clinical signs of haemodynamic instability and . % of cases that had a wood gas analysis on admission had a metabolic acidosis (bases excess < - . ). the mortality rate was . %. % of deaths were hypotensive on admission and all had a metabolic acidosis. of the survivors . % were hypotensive on admission, % had clinical signs of cardiovascular compromise, % were admitted to the high dependency unit, % required invasive pressure monitoring and . % were ventilated and received inotropic support. in this study children presenting with m e n i n g o c o c c a l infection have a high incidence of cardiovascular instability. successful management is dependent on early presentation and initiation of therapy and on aggressive intensive care monitoring and support of the cardiovascular i and vital organ systems. the normal crying curve and incidence of colic for term infants are well known. we studied prospectively the crying pattern and the incidence of colic in preterm'infants to determine if prematurity influenced these behaviours. the subjects were consecutive preterm infants admitted to the cork neonatal units for two and a half months from july . a continuous hour diary was completed on each infant by the neonatal nurses, when the babies were on full oral feeding and no longer required intensive care. the parents completed the diaries 'after discharge. colic was defined according to wessel's rule of threes. two unwell babies were excluded. the duration of follow up was from to weeks. fifty infants were recruited and completed the study ( lost to follow up and one withdi'awn due to sepsis). their mean (range) gestational age was ( - ) weeks and birthweight was . ( . - . ) kg. the mean (range) age of crying onset was x(y-z) weeks; crying, peak 'was x(y-z) weeks and crying offset was x(y-z) weeks. one baby developed colic in the period of follow up. conclusions: the incidence of wessel's colic was less than expected in these preterm babies. the crying pattern according to chronological age was different from that clescribed in term babies. in general preterm babies had a delayed onset of crying, but the pattern became similar to term babies when allowance was made for gestational age. the findings'suggest that the crying patterns of early infancy have a developmental basis. we re-evaluated children who had had rs ( - ), with their closest-age siblings using the wechsler scales, coopersmith self esteem inventory and achenback child behaviour checklist (acbc) (duffy j. et al ). the rs patients' means were consistently lower than that of their sibs. however, comparison of mean raw data, using "t-tests", yielded significant differences only in the acbc scores, in that rs children exhibited significantly more problem behaviours than their sibs (p= . ). after categorisation of iq data, further comparisons between the groups (using x ), found rs patients were significantly more likely to score "below average" in tests of verbal iq compared to their sibs (p= . ). age of onset and clinical stage were also found to be more important predictors of outcome. children less than year of age at onset of rs had significantly lower iq scores on all measures of cognitive ability (p= . ) and more problem behaviours (p= . ) than children over year of age. no significant differences were found in comparison with sibs. clinical stage to which rs progressed affected only verbal iq scores. children in whom consciousness had been impaired had significantly lower iq scores than both their sibs and rs children in whom consciousness was less impaired (p= . ). in conclusion outcome remains cautiously positive, with / rs children attending mainstream schools or in employment without apparent difficulties. a national breastfeeding policy was introduced by the department of health in . factors identified for promotion of breastfeeding were based on the who/unicef "ten steps for successful breastfeeding". we present clinical cases which suggest that one step may need to be modified. the charts of breastfed babies admitted to the special care baby unit were reviewed for one year following the introduction of the national breastfeeding policy to this hospital. thirteen term breastfed babies were admitted because of fever and dehydration. none of the babies had water or bottle feed supplements. ten of the thirteen mothers were primigravida. eleven babies were admitted in the six months following the introduction of an exclusive breastfeeding policy. the nursing staff were then alerted to the risk of dehydration, but two further babies of mums committed to exclusive breastfeeding were admitted in the subsequent six months. routine biochemistry, haematology and a limited septic screen was performed in all babies. three of the thirteen babies had lumbar punctures. the mean (range) weight loss on admission was . ( . - )%. the mean (range) plasma sodium level was . ( - )meq/ and the mean (range) urea was . ( . - . )meq/t. there was no growth from the cultures of the blood, urine, csf and swabs. all the babies were given intravenous fluids and parenteral antibiotics for hours. the outcome was satisfactory in all babies and breastfeeding was reestablished in eleven of the thirteen babies. conclusions: the common factor to these babies was inadequate fluid intake prior to admission associated with stricl~ adherence to the policy, and avoidance of all supplements including water. we conclude that the who/unicef step "not to give food or drink other than breastmilk unless medically indicated" is too restrictive in the immediate postpartum period. . % of children reported headache in the previous months . % of girls and . % of boys reported headache (p < . ). . % of children reported daily headache . % of children reported weekly headache . % of children reported monthly headache . % of children reported headache less often than monthly the percentage of children with headache at each frequency, other than daily, increased with increasing age. in girls headache showed a marked rise at ages , and years. reported prevalence of headache in the past year in to year old aberdeen children was % and % was recorded for swedish children aged , , and years old. this study is the first community based prevalence study of headache in irish schoolchildren. our aim was to test the hypothesis that there is no correlation between the type of feeding & swallowing disorder the child has with the neurological diagnosis or the radiological findings. a further purpose was to develop a classification of the feeding & swallowing disorders which would guide us towards a management plan. a retrospective analysis of the data collected between the years - from the feeding & swallowing clinic at booth hall children's hospital was done. children were included in our study ages ranged from months to yrs. all the children were assessed by the members of the feeding & swallowing team and had videofluroscopic assessment by the same radiologist. neurological signs, speech therapy assessments & videofluroscopy findings were compared between children with spastic quadriparesis & those without. significant differences were noted. a clinical classification was devised using cluster analysis. we conclude that there is no causal relationship between the neurological diagnosis & the type of dysphagia. there are three distinct groups of children who require different strategies of clinical management. surveillance commenced in january to continuously monitor the incidence of surgical site infections (ssi). employing modern optical scanning technology (formic for windows version . , formic limited, london) a questionnaire was designed, which required minimal completion time. the questionnaire includes relevant data based on the american national nosocomial infections surveillance system for ssi including the ssi risk index. surveillance commences at the time of surgery and continues until the patient's discharge. optical scanning technology allows rapid reading of surveillance questionnaires thereby bypassing the bottleneck of manual data entry. by october , details of , procedures had been recorded. the crude ssi rate for these patients was . %. the patient risk index used demonstrated that there were increased chances of developing ssi in certain patient groups. seventy-nine per cent of ssi had presented by the th post-operative day. the length of stay increased by an average of days in patients developing ssi. regular feedback to individual surgeons, theatre and ward staff maintains awareness and highlights possible problems. we recommend optical scanning technology to all those engaged in surveillance work. this system would be especially useful were data collected is transported from outlying hospitals to a central receiving centre for collation and analysis. in francis crumpe published a paper ~ in which he described the therapeutic effect of poisonous mussels (psp) on a case of tetanus. he obtained the mussels from tralee ship canal on the occasion of its infrequent emptying, and entertained the idea of using them in tetanus after treating a young girl with psp who recovered after hours. prior to the use of psp he described it's paralytic effect in two cockrels who both recovered. in concluding his successful use of psp he speculated as to the clinical nature and role of the toxin tralee ship canal was opened in . the water was relatively stagnant and would have contained plenty of nutrients. as such it would have been an ideal habitat for toxic algae which may have been brought across the atlantic as spores in bilge water . the emptying of the canal may well have been done at times of algal blooming. this is the first irish report of psp and a most remarkable use of saxitoxin (?) in the treatment of tetanus, antedating the current management by seventy years. this study was carried out to quantify the published research on smoking in irish medical journals; to ascertain the type of research carried out; and to identify the authors of that research. during the years under study, papers explicitly dealing with smoking were published. only papers appeared in forum. there was a decline in published papers in the eighties with a resurgence in the early nineties. of the papers, a majority were observational and ten were editorials. only one paper dealt with smoking cessation, and one with preventive work. general practitioners were poorly represented as authors. one doctor (prof. r. mulcahy) published at least one paper on smoking in each quinquennium since . this study underlines the relative insignificance of smoking as a topic for research in ireland. a major sea change in attitude will be required if the government's targets for smoking cessation are to be realised, particularly if they are to be achieved by relying on the medical profession. radiology represents a major cost centre within a hospital. lack of awareness of cost amongst doctors may result in the inappropriate requesting of radiology services. this study assesses doctors knowledge of the cost to a tertiary referral hospital of commonly performed radioj'ogical procedures and investigations. doctors were asked to estimate the cost of items namely -chest,x-ray, arch aortogram, ultrasound abdo., lumbosacral spine, barium enema, ct brain, ct abdo., ultrasound abdomen, i.v.p. and percutaneous gastrostomy tube insertion under radiological screening. doctors in st. vincent's hospital were surveyed. doctors as a group overestimated the cost of all individual tests, by margins ranging from % (i.v.p. & gastrostomy insertion) to % (ct brain/ct abdo.) the total cost to the hospital of all items was s consultants'overestimated this total cost by %, followed by registrars, interns and s.h.o's who overestimated the total cost by margins of %, % and % respectively . conclusion: doctors tend to overestimate what radiological procedures and investigations cost a public hospital, often by quite wide margins. thus, any excessive requesting of radiology services by docto.rs is not due to a lack of awareness of their true cost to the hospital. (ded) in dublin. secondly, to identify the major cancers contributing to years of potential life lost (ypll) for the ehb, each cca and ded in males and females. in ireland little work has been done to date on disease specific premature mortality. crude death rates weight all deaths equally; in comparison, ypll emphasise deaths among younger persons and provide a measure of the burden of premature mortality. premature mortality for the deds in dublin for the years and was estimated using ypll, which was calculated by subtracting the date of death form . ypll due to each of the major disease groups were ranked for each ded. seventy-one thousand four hundred and sixty-eight & ) years of potential life were lost in dublin in the and . . % of ypll was due to injury and poisoning, . % to cancer, . % to circulatory disease. however, when the major cause of ypll was established for each ded, injury and poisoning was the number one cause of death in . % of the deds; cancers %, congenital and perinatal conditions . % and circulatory disease %. by emphasising deaths in younger individuals ypll is a valuable tool for planning and monitoring local health promotion initiatives. serum total homocysteine (thcy) levels are inversely associated with dietary intake of folic acid and b vitamins and raised levels have been linked with chd. we have examined the association between thcy concentration and the risk of chd in middle-aged men in british towns. we used a nested case control study design, within an ongoing prospective study, thcy concentration was measured in serum samples, stored at entry to the study, from incident cases of myocardial infarction and controls. cases and controls were frequency matched by town and age group. levels of homocysteine [geometric mean ( %c ) were significantly higher in cases than'controls: homocysteine . ( . - . )gmol/l vs . ( . - . )lamol/l; p = , . there was a graded increase in the relative risk (odds ratio; or) of chd in the nd, rd and th quartile of thcy (or . , . , . ; trend p = . ) relative to the first quartile. adjustment for age, town, social class, body mass index, smoking, physical activity, alcohol intake, hypertensive status, serum cholesterol and serum creatinine did not attenuate this association, (or . , . , . ; trend p = . ). the findings suggest that thcy is an independent risk factor for chd with no threshold level. in summer , a diagnosis of cryptosporidiosis was made in a child who had visited a pet farm. this child had participated in a summer project involving children and nine adults. reports of a similar illness among other project members, prompted an outbreak investigation. a cohort study consisting of two phases was initiated. % ( / ) of project participants responded to a self-administered questionnaire in the first phase. thirteen children met the case definition, of whom seven had cryptosporidium detected in their stools. illness was significantly associated with having visited a pet farm. (p< . ). % of those ill sought medical attention, of whom two were hospitalised the second phase of the cohort study was conducted among those who had visited the pet farm. % ( ) were interviewed. illness was significantly associated with play in sand, to which animals had access, at a stream's edge beside a picnic area (p< . ). contact with various animals was not statistically significantly associated with illness. however the small numbers involved may have obscured such an association. this outbreak highlights a potential hazard for children visiting pet farms and also that cryptosporidiosis is a significant but often overlooked cause of morbidity in healthy children. managers of pet farms need to be aware of the potential for transmission of disease to visiting children. strict implementation of hygiene measures is essential to minimise risk. the mrc vitamin trial highlighted the importance of folic acid in the prevention of neural tube defects(l). since , the department of health has recommended periconceptional folic acid supplements. the objective of this study was to document the knowledge and behaviour of women in child bearing years to periconceptional folic acid. a cross sectional community survey was conducted using an interviewer administered questionnaire in dublin. three hundred and thirty five women took part in the study. approximately two thirds / ( . %) had heard of folic acid. knowledge was significantly associated with higher social class and higher education (p< .o ). few / ( . %) had been advised to take folic acid before pregnancy. only / ( . %) of the women in the study were currently taking folic acid supplements. three quarters of the group ( . %) would be willing to take periconceptional folic acid supplements if they knew it would reduce the risk of malformations. the majority ( . %) would prefer to take folic acid in tablet form. this study clearly shows that few women in childbearing years have been advised on folic acid. however, if advised appropriately the majority would be willing to take periconceptional folic acid in tablet form. future publicity campaigns involving all health professionals should address these issues. unstable intra-articular fractures with or without dislocation of the phalangeal joints often lead to joint stiffness ana loss of function. nine patients with comminuted intra-articular phalangeal fractures were treated in our unit by dynamic external fixator using "pins and rubber bands traction system". the mean age was . years, and the follow-up average was . months. five patients had full and good range of motion in the involved joints. three patients had poor results, and one patient underwent open reduction one week following the original procedure. the technique and our results are discussed. this dynamic frame is compact, comfortable for the patient, easy to apply and allows early mobilisation. careful selection of patients and close follow-up in the first few weeks are needed. this study examines how gp's store and handle vaccines. all gp's in a health board region were invited to take part. gp's were interviewed in their practice premises about how they dealt with vaccines fridges were examined and temperature recorded post interview. oral polio was taken from randomly selected fridges for potency testing. cold chain monitors and freeze watch indicators were used to monitor batches of vaccine stored. of the gp's, ( . %) agreed to participate, used fridges to store vaccine, store vaccine at room temperature. of the fridges, ( . %) had the power supply safeguarded, ( . %) had thermometers, ( . %) had vaccine only stored therein. during defrosting, vaccine was inadequately protected in ( . %). of the gp's who use multi-dose vaccine vials, ( . %) keep them for further use at the end of a day/session, store them at room temperature. ( . %) fridges had temperatures outside the recommended range. ( . %) coldchain monitors indicated vaccine exposed to more than ~ ( %) of the oral polio samples showed a reduction in total titre of live virus, however, none were below the minimum acceptable. this study indicates that vaccine potency could be seriously compromised due to breaks in the cold-chain and suggests the need for guidelines to be drawn up, implemented and monitored to ensure the integrity of immunisation schemes. comparison was made with a study carried out in . in addition the range of antimicrobial agents tested included new oral cephalsporins and quinolones that were not then available. three hundred microorganisms isolated from mid stream urine (msu) samples were examined by standard microbiological techniques. antimicrobial susceptibility testing to antimicrobial agents was performed on significant pathogens (> organisms per ml) by disc diffusion test, and minimum inhibitory concentrations of antibiotics was carried out by e test on organisms found resistant by disc testing. by comparison with resistance amongst e.coli, the most commonly isolated pathogen, had increased for the following: ampicillin by % to %, co amoxyclav by . % from %, trimethoprim by % to % and nitrofuradantin by % from %. no increase in resistance occurred to cephradine ( %), or nalidixic acid ( . %). resistance to cefixime, ofloxacin and ciprofloxacin, was %, no resistance was encountered to cefotaxime. for proteus species resistance to ofloxacin, ciprofloxacin and cefotaxime was %, and for enterobacter sp %. enterococci were sensitive to ampicillin and augmentin but the numbers were small. pathogens isolated from patients domiciled in the inner city were significantly more resistant to nalidixic acid ( %), cefotaxime ( %), cefixime ( %), ofloxacin and ciprofloxacin ( %) than those isolated from patients in rural areas. the purpose of this study is to examine the relative importance of obstetric complications ( c%) in the aetiology of schizophrenia and mania. using the dublin psychiatric case register, birth records of patients with an icd- diagnosis of schizophreniaor mania were obtained. these records were evaluated, for obstetric complications using two scales, the lewis, owen and murray scale (lom) it~ and the parnas scale . the mothers of those going on to develop schizophrenia did not differ from those going on to mania as regards maternal age, parity, social class, or period of pregnancy. however, males who developed schizophrenia when compared to males developing mania, experienced significantly more oc's when rated by the lom scale (p= . ) and.more frequent oc's on the parnas scale (p< . ) of greater severity (p= . ). no significant differences were found between females with schizophrenia and those with mania. dublin. the aim was to evaluate the diagnosis, symptomatology and level of functioning of patients presenting with a first episode of psychosis to a catchment area service and a private psychiatric hospital. all patients presenting with a first episode of psychosis were assessed using the scid-p,,the positive and negative syndrome scale (panss) and the global assessment of functioning scale (gaf). fifty-eight patients ( male, female) ranging in age from to years (mean + sd = . + . ) were included in the study. the mean total panss score was . (sd + . ) and was strongly correlated with the gaf score (p < . ) but independent of age (p = . ). males had a significantly lower gaf score compared to females (p = . ) but there was no gender difference in the total panss score (p = . ), twenty-five patients ( %) had a lifetime prevalence of drug abuse or dependence but only patients ( %) had signs of drug abuse or dependence in the month prior to presentation. level of functioning was strongly influenced by the severity of psychopathology. substance abuse is common in individuals presenting with a first episode of psychosis. the aim was to evaluate the presence of involuntary movements in patients presenting with first episode psychosis to a catchment area service and a private psychiatric hospital. patients presenting with first episode schizophrenia and schizophreniform psychosis were assessed for involuntary movements using the involuntary movements scale (a.i.m.s.). patients ( m., llf.), age range - years (mean= . years.) were included in the study. one patient ( . %) satisfied the strict criteria of schooter and kane for spontaneous dyskinesia. patients ( m., if.), had minimal involuntary movements in at least body areas, predominantly orofacial. the total a.i.m.s. score was positively correlated with the number of days spent in hospital per year of follow up (p= . ). the group with involuntary movements were found to have spent more days in hospital per year of follow up, v. days (p= . ). for patients with first episode schizophrenia or schizophreniform disorder spontaneous dyskinesia is not common. however involuntary movements at presentation may be a predictor of poorer outcome. psychiatry has moved from custodialcare towards care in the community. adequate reprovision will have to be made in order to discharge the remaining continuously hospitalized patients. the objectives of this study were to describe a.n entire long-stay hospital population, to examine the differences between the old and new long stay groups within this populatian and to evaluate the needs for community residential and day care facilities in order for hospital closure to take place. the study group consisted of the total long-stay population of st. davnet's hospital, monaghan. the patients were assessed using the community placement questionnaire (cpq) one hundred and twenty four patients were included in the study. fifty-six were female and % were single. the mean age of the total group was . years. the majority suffered from schizophrenia. the assessment revealed a globally disabled group with multiple handicaps. the new long-stay group were disabled as the old long-stay group. the patients were characterised into four groups with regard to placement recommendations. these were a specialist unit for chronically disturbed geriatrics, a geriatric unit, a high support hostel and a medium support hostel. the remaining population of this hospital were highly dependent with multiple handicaps but would live in community with adequate support. there is little difference between the needs of the old long-stay and those of the new long-stay. failure of the immune system to identify self peptides is likely to lead to the development of an autoimmune reaction. susceptibility to autoimmunity is strongly influenced by genes clustered in the hla region (chromosome p) particularly class i (a, b and c) and class ii (d, q and p). it has been suggested that there is an autoimmune component in the aetiology of schizophrenia. of many conflicting reports from case/control studies using hla antigens the most consistent finding has been an increased frequency of hla-a (now split into a /a ). additionally, a susceptibility locus for schizophrenia has been reported near the hla locus. to attempt to confirm the hla a hypothesis, we have genotyped a preliminary sample of familial schizophrenic probands and unrelated controls at the hla-a region, using a pcr-ssop technique. the frequency of hla-a (the major component of a ) in patients and controls respectively was . % vs . %. these findings do not support the hypothesis. some of the discrepancy may be due to unspecific cross-reactions produced by commercial antisera used in the microlymphocytotoxicity method of previous studies. however it is also possible that the hla associatton with schizophrenia may reflect linkage disequilibrium with unidentified gene(s) within the hla region which is less strong in the irish population. schizophrenia is a common mental disorder affecting about % of the general population with a devastating disturbance of mind and personality. family, twin and adoption studies have demonstrated that the disease is largely genetic with a polygenic mode of: transmission. dopamine receptors have been implicated in the aetiology of the disease. as yet dopamine genes have been identified (d -d ). in particular the d receptor is expressed in the limbic regions of the brain, implicated in the control of emotions. association studies of a d polymorphism (glycine to serine substitution at position ,) with schizophrenia have produced conflicting findings, many of which, however, have demonstrated a significant excess of homozygosity, or excess of the -l genotype at this polymorphism. in this study, familial schizophrenics and irish unrelated controls were genotyped. the result show a small increase in the frequency of the - genotype which did not attain statistical significance (patients, . % vs. controls, . %). homozygosity (alleles - and - ) was also slightly increased in the patients (patients, . % vs. controls, . %). the small increase in the frequency of the - genotype and of homozygosity in the patients is in keeping with earlier findings but suggests that the effect, if any, of d sequence variation in the development of the disease is small. lack of information about general practitioners' (gp's) ability to prescribe psychotropic medication may affect patients' compliance. in this study, out of patients attending a psychiatry out-patient clinic completed a questionnaire which documented how many had run out of medication, the steps taken if they had and the role each patient thought their gp played in their treatment. % indicated that their gp knew what their current medication was but only % thought that their gp could provide them with a prescription if they did not have one from the clinic. this figure was similar in those who had ( %) and had not ( %) run out of medication in the past. on running out of medication, % of patients waited until their next appointment, % attended their gp and the remainder either contacted the department or went to a chemist. in conclusion, many patients do not appreciate the entitlement of their gp's to prescribe psychotropics for them. literature regarding whether or not the social class distribution of patients with psychiatric illness may differ from the general population remains controversial. we sought to clarify this by examining social class at the time of birth, to see whether patients with serious psychiatric illnesses (schizophrenia and mania) differ from the general population. paternal occupation of schizophrenic patients, and manic patients, from the dublin psychiatric case register, were obtained from birth registration details and categorised according to central statistics office criteria, the same-sex previous live birth was used as a matched control. there was no difference between the social class of patients with schizophrenia or mania (p= . ). neither patients with schizophrenia (p=b. ) nor mania (p= . ) differed from controls in social class distribution. paternal social class was found to be related to amount of time spenr in hospital (p< . ', mean= . ), and educational age (p< . , mean= . ) and "age at onset of the illness" (p= . , mean= . ). these results suggest that social class of origin may not be related to the development of either schizophrenia or mania. however, social class of origin may be relevant in terms of presentation of schizophrenia for treatment. cognitive function is widely recognised to be impaired in schizophrenia but there is an ongoing debate as to whether this impairment is generalised or localised, progressive or static, similar in both sexes, or related to symptoms. using the positive and negative syndrome scale (panss)'we measured psychopathology in chronic in-patients ( m, f; mean age . + . ) who satisfied feighner criteria for schizophrenia. subsequent to this, we assessed their global cognitive function using the mini-mental state examination (mmse) and their frontal cognitive function using a new instrument, the executive interview (exit). poor performance on the exit was associated strongly with increasing severity of negative (r=- . , p< . ) but not positive (r=-- . , ns) symptoms,'in both males (r=-- . , p< . ) and females (r=-- . , p< . ). overall exit performance declined modestly with increasing age (r=-- . , p< . ) but this phenomenon was co'nfined to females (r=-- . , p< . ; males: r=-- . , ns). mmse performance was also associated with negative symptoms (r=-- . , p< . ) but decreased mm:e prominently with age (r=-- . , p< . ) and showed no gender difference. frontal dysfunction in schizophrenia appears to be intimately related to negative symptoms over the course of severe chronic illness, and may reflect among males a more static' trait deficit than is accessed by the mmse. this study was supported by the stanley foundation. while determinants of the course of schizophrenia are unclear, emerging evidence suggests that the longer psychosis proceeds unchecked before initiation of anti-psychotic therapy, the poorer may be long-term outcome. we have reported that, among older in-patients, increasing duration of initially untreated psychosis in the pre-neuroleptic era was associated with a deterioration to a state of muteness (after controlling for intervening variables). the current survivors of this population have now been examined more extensively using the positive and negative syndrome scale (panss), the mini-mental state examination (mmse) and the executive interview (exit). among these patients (mean age . + . ), after controlling for age and for the duration and continuity of subsequent antipsychotic treatment, increasing duration of initially untreated psychosis was associated with greater severity of negative symptoms (p< . ) and with lower scores on the mmse (p< . ) but not with executive dysfunction on the exit (p= . ). increasing duration of initially untreated psychosis appears to be associated with the evolution of more prominent negative symptoms and cognitive impairment in a manner consistent with an active, morbid process in schizophrenia that can be ameliorated by anti-psychotic drugs. this study was supported by the stanley foundation and the health research board. patients who are selected and who agree to participate in the royal college examinations play an important role. as psychiatrists and exam organisers, we should be aware of the potentially stressful experience which this might present. the purpose of our study was to elicit attitudes to the exam, and also knowledge of the examination procedure. a questionnaire comprising questions was circulated to patients who had participated in the royal college examinations. responses were received from ( %) of the patients. there were males and females in the responding group. none of the patients had previously participated in the examinations. all of the respondents (n= ) felt that the candidate had been polite towards them during the interview. % (n= ) of the patients were nervous prior to the examination, and this group was predominantly female (n= ). % of the patients (n= ) did not know that they would receive payment for their participation. % (n=l ) did not know that they might be physically examined as part of the examination procedure. % (n= ) of the patients described experiences which had been upsetting for them the results of our study suggest that on the whole patients tolerate the exam procedure quite well. one of the central issues concerning physiotherapists in stroke rehabilitation is the emergence of abnormal tone. rehabilitation involves re-establishing a normal postural control mechanism (ncpm)"~. abnormal tone may develop in the presence of severe sensory and proprioceptive loss. the patients' attempts to move and find a stable base can lead to compensatory movement patterns and asymmetrical postures. positioning is used by physiotherapists to influence the distribution of muscle tone and facilitate symmetrical postures. it is essential that the patient is made aware of his 'position in space' as failure to do so presents no feedback regarding movement resulting in inertia ~ ~. standardised positioning charts have been used in hospitals. the physiotherapist liaises with nursing staff regarding correct use on a hour basis. this study looked at the role of a more individualised approach to positioning in the form of a photograph. patients were randomised to two positioning groups group a standard vs group b photograph, and their positioning was scored by a 'blinded' research physiotherapist over an eight week period. the results of a pilot study on a small number of patients revealed that nursing staff preferred a positioning chart individually tailored to the patient's problems. from a physiotherapy perspective, improved postural awareness correlated with better positioning scores in group b. the prevention of compensatory movements, posture is critical in stroke rehabilitation, the use of an individualised positioning chart requires further evaluation. we discuss the case of a fourteen year old boy who presented with bilateral ptosis present since birth, microcephaly and pigmentory retinopathy"!. he was found to have mild facial and proximal limb weakness. creatinine kinase and ldh were raised. muscle biopsy showed ragged red fibres consistent with a mitochondrial myopathy ~ ~. electron microscopy showed abnormal mitochondria. the term mitochondrial myopathy describes a diverse range of clinical disease ~ ~ and this is discussed. she developed a vasculitic skin rash with pruritis and oedema associated adenopathy, low grade fever and mouth ulcers. lab tests showed leucocytosis, eosinophilia and abnormal liver function. skin biopsy indicated an inflammatory picture without vasculitis. ct thorax confirmed axillary and para-aortic adenopathy. lymph node biopsy confirmed a reactive lymphadenopathy. the aim of. this study was to assess the characteristics of patients referred for pudendal nerve studies over a one year period. consecutive patients were asked a standard questionnaire and nerve studies were performed as described by kiff and swash m and swash and snook~ k of the patients, only were male. the age range was from to (mean ). presented with constipation and with faecal incontinence. two had both symptoms. bladder incontinence was presented in of patients. of these, faecal incontinence was the cardinal symptom in patients, constipation in . patients were nulliparous. of the remaining , had a history of complicated births involving forceps ( ), caesarean section ( ), post partum haemorrhage ( ), breech without forceps ( ) . patients had pelvic surgery and one had major trauma. of patients had bilaterally delayed pudental nerve terminal motor latency (pntml). of people had unilaterally delayed pntml, were right sided, were left sided. had normal studi~s. the range of measurements was . - . ms with a mean of . ms. in conclusionl delayed pntml was seen in of patients with constipation and of with faecal incontinence. pelvic surgery and a complicated obstetric history were significant. urological symptoms were also a common association. the p component of the middle latency-auditory evoked potential is attenuated in response to the second of paired clicks in a normal population. in schizophrenia, this attenuation is minimal. in alzheimer's disease (ad), the results have varied between centres depending on the frequency of the stimuli and the interclick interval. we studied ad patients, elderly controls (ec) and young controls (yc) using a paradigm of sets of paired clicks. in contrast to previous studies, our study demonstrates significantly larger absolute p generation and recovery amplitudes in ad patients compared to elderly controls and young controls. the purpose of study was to establish a simple screening vol. , irish journal of supplement no. medical science test to identify asymptomatic intracranial aneurysms (icas). an association between atherosclerosis and icas is recognised. elevated serum lipoprotein (a) [lp(a)] is an independent risk factor for atherogenesis. we aimed to assess the degree of correlation between serum lp(a) and the occurrence of sporadic ruptured aneurysms and familial asymptomatic aneurysms. lp(a) levels were measured in (a) patients with icas and normal controls, (b) first degree relatives of patients with familial subarachnoid haemorrhage (sah). icas were detected by cerebral angiography. patients with sporadic icas had significantly elevated lp(a) levels when compared with matched controls. mean level was . mg/dl in patients and . mg/dl in controls. in the familial studies, out of i subjects with asymptomatic icas had elevated lp(a) levels. one young female with elevated lp(a) had a pre-aneurysmal dilatation at operation. six out of subjects without icas had elevated lp(a) levels; four of these were in the second or third decade of life and may yet develop aneurysms. conclusions: lp(a) has potential as a biological marker for icas. follow-up studies are required on angiographically negative subjects. we have begun a genetic case-control study to establish if particular apoprotein (a) gene polymorphisms can be correlated with the occurrence of icas. post mastectomy breast reconstruction has undergone several changes in the recent years. attitudes have changed towards the problem from both the patient and the reconstructive surgeon, as aesthetic outcome receives a greater emphasis than previously. there is a shift towards using autologous tissue as a means of reconstruction; these new technically difficult procedures entail a longer learning. centralization of this type of reconstruction in highly specialized centres only will serve the patient better. we share our experience of post mastectomy breast reconstruction spread out over the past five years. seventy-eight consecutive cases of breast reconstruction are included in the study. different techniques of breast reconstruction were used with a recent switch to transverse rectus abdominis myocutaneous (tram) flap; we feet that tram flap is the gold standard of breast reconstruction as far as the ultimate cosmetic result is concerned. ours is only a moderate sized study compared to some published, yet it is representative of the experience of most of the plastic surgery units in the british isles. clinically significant paraneoplastic neurologicaldisorders are rare, most are associated with small cell lung, female genital tract and breast carcinoma. the malignancy is often silent and the neurological manifestations vary from encephalomyelitis, cerebellar degeneration, sensory neuropathy to neuromuscular block. prognosis is usually poor. pathogenesis is thought to be related to cross reaction with neurons of antibody produced to tumour antigens. detection of these antineuronal antibodies in serum has assisted diagnosis of paraneoplastic encephalomyelitis in which anti-hu antibodies are present and cerebellar degeneration, in which anti-yo are found. in our lab, we used avidin-biotin-complex immunocytochemistry to detect anti-hu (cortical neuron antibodies) and anti-yo (purkinje cell antibodies) in patients' sera. tests were performed on human frontal cortex and cerebellum, at in and in , dilutions, with positive and negative controls. of sera, were positive. two patients had repeat positives; in one, antibody titre rose in the second sample. subsequent patient review showed positives ( patients) had identifiable carcinoma with paraneoplastic cns signs, had no identifiable malignancy but had no other cause of their cns disorder and are being followed up; details of one patient were unavailable. these results are similar to other centres. the proliferation of tumour cells despite the presence of tumouricidal mediators could be due induction of a heat shock response, a universal cellular defence mechanism in host cells and possibly tumour cells. protection may be mediated either by increasing intracellular levels or surface expression of heat shock proteins (hsp). the aim was to assess the effect of heat shock induction on tumour cell protection against host effector cells. the heat shock response was induced in sw colorectal cells by either sodium arsenite ( - ~tm for hr) or by hyperthermia ( ~ for rain). monocyte (m )-mediated cytotoxicity or flow cytometry to evaluate surface expression of hsp and hsp were assessed. cytotoxicity showed a significant decrease in all treated groups (p< . ) when compared to the control value. there was also a significant decrease in all groups (p< . ) when compared to the ~ value. no significant alteration in surface expression of either hsp or hsp was seen. conclusion: heat shocking tumour cells significantly protects them from m -mediated tumour cell lysis. since the flow cytometric data indicate that there is no concomitant increase in surface expression of hsp and hsp on the tumour cell following heat shock, it can be inferred that induction of intracellular hsp levels are responsible for the protective effect on the tumour cells. a week qol study in consecutive advanced cancer patients was undertaken to compare the subjective question fact-g with simple subjective global tools (visual analog, categorical scales: vas, cas), objective tools (spitzer qli and ecog performance status) and verbatim patient description. we anticipated the high drop out rate enrolling to achieve complete study patients for statistical purposes. the study sample appeared representative of the advanced cancer population in the usa. generally qol was satisfactory despite the severity of illness. there were significant differences in all measures between those who described qol in verbatim responses as positive and negative, particularly cas, vas, and qli (p< . ). there were significant intercorrelations between qli and ps (observer rated), vas and cas (subject rated) respectively (p< . ). taking patient description as the gold standard, simple, global qol measures e.g. vas or cas are as effective as multidimensional ones (fact-g and qli). irish journal of medical science males had more dysphagia. survival from diagnosis was greater for females </= years (female median months, male median months, p< . ). anorexia was associated with reduced survival since diagnosis in the total population and in males. anorexia anddysphagia were associated with reduced survival from referral. advanced cancer patients were polysymptomatic. symptom prevalence differed with age, gender and cancer site. the pattern of g symptoms was related to gender and severe weight loss. specific symptoms were associated with reduced survival. there was a gender difference in survival favoring females. the administration of recombinant interleukin- (rll- ) is limited by the induction of increased microvascular permeability. the in vivo antineoplastic effects of taurine in combination with rll- were investigated and its impact on the associated vascular leak was examined. lung metastases were established in mice via tail vein injection. ten days after injection mice were randomized into treatment groups. on day the mice were sacrificed; lungs were removed, weighed and metastases counted. treatment of tumour-bearing mice with rll- alone resulted in a significant reduction in tumour nodule incidence compared to a control group, while the~group recei'~ing rll- + taurine showed an even fuither reduction in the incidence of lung nodules. animals receiving rll- showed a significant increase in mean wet lung weight compared to control lung weight, while mean wet lung weight of the rll- + taurine group was significantly less than that of the rll- group.and comparable to control values. animals receiving ril- + taurine in vivo demonstrated significantly enhanced splenocyte-mediated antimelanoma activity ex vivo compared to animals receiving rll- alone. thus taurine may have an important role in modulating both metastatic growth and the associated toxicity of rll- immunotherapy. a prospective analysis of symptoms in , patients on initial referral to the palliative care service of the cleveland clinic was made using the paradox relational database. the median number of symptoms per patient was (range - ). the most frequent symptoms were pain %, easy fatigue %, weakness %. anorexia %, > % weight loss %, lack of energy %, dry mouth %,'eonstipation %, dyspnea % and early satiety %. patients years and under had more pain, sleep problems, depression, anxiety, vomiting and headache (all p< . ).'the prevalence of early satiety, nausea, vomiting and anxiety were greater in females; dysphagia nd hoarseness in males. patients with >/= % weight loss had more gi symptoms; of these females had more nausea, early satiety; the progn.o'stic significance of abnormalities in the p tumour suppressor gene and in the expression of its protein in colorectal carcinoma may be influenced by the method of analysis used. we studied p abnormalities in patients with colorectal cancer followed for more than years. single-strand conformation polymorphism analysis (sscp) was used to detect alterations in exons - of the p gene. paraffin sections were examined immunohistochemically for p overe,xpression with the monoclonal antibody do- (dako) both with and without microwave antigen retrieval. abnormalities of the p gene were found in % of cases by sscp analysis but were unrelated to age, sex, tumour size or differentiation. outcome was unrelated to sscp abnormalities (p= . ). overexpression of p protein was seen in % of cases by immunohistochemistry without microwave antigen retrieval and in % of cases with microwaving. poor long-term survival was related to immunohistochemical expression of p protein either with (p= . ) or without (p= . ) microwave antigen retrieval. these results suggest that immunohistochemical detection of the p protein product may be more useful than sscp analysis of the encoding p gene in identifying those at high risk of colorectal cancer recurrence and death. dublin . the anti-tumour activity of tumour infiltrating lymphocytes (tils) is known to be poor and therapeutic manipulation of these cells has met with little success. suppressor macrophages (smo) influence t cell cytotoxicity and proliferation. we hypothesized that smo are a component of the lymphoreticular infiltrate and that these cells may be related to lymphocyte numbers within the tumour. tgf-b may influence macrophage phenotype. colorectal and breast tumours were obtained within an hour of resection. tumours were dissaggregated with collagenase and dnase for three hours. antibodies was used to identify smo (rfd and rfd ) and t cell subsets (cd and cd ) by flow cytometry on the resulting cell suspension. pre-op blood was collected from patients and tgf-b levelsdetermined by elisa. conclusions: we have shown for the first time that smo, defined by the antibodies rfd and rfd , are present within breast tumours. we have also shown that the balance of t cell subsets is different in these tumours and may be related to smo content. circulating tgf-b levels are increased in breast cancer and associated with greater smo numbers. this was not found to be the case in colorectal cancers. these results imply the existence of a fundamental difference in the make-up of the lymphoreticular infiltrate between these cancers. swelling of the upper limb is an uncommon but well irish journal of medical science recognised complication of breast cancer treatment. in severe cases, patients have limited arm function and feel disfigured. in a pilot study, the incidence of arm swelling following complete axillary clearance in the immediate post-operative period and at long term follow-up was investigated. arm volume measurements were performed using an opto-electronic volometer (bosl medizintechnick, hamburg). both ipsilateral and contralateral arm volumes were assessed. the expected volume of the ipsilateral arm volume was calculated using the formula vr = v = mls for right handed people and v = vr = mls for left handed people (vr and v = volume of the right and left arms respectively). the difference between the expected and actual volume of the ipsilateral arm was expressed as a percentage of the expected volume. twelve patients undergoing axillary clearance for breast cancer were prospectively evaluated pre-operatively, hours and days post-operatively. a second group of patients who had had axillary clearance at least months previously (range to months) were also evaluated. there was no significant change in arm volume in the immediate post operative period. clinically detectable arm welling was found on patients who had undergone axillary clearance at least months previously but none had any impairment of arm function. we conclude that axillary clearance can be performed safely and that arm swelling is an uncommon complication. a larger study is planned to investigate factors such as the influence of pectoralis minor division, duration of the operation and the number of axillary nodes retrieved on upper limb volume. epidermal growth factor (egf) is a potent mitogen and has been shown to accelerate healing of epithelial damage both in the skin an.d the gut. in the skin egf is not produced locally as the requisite mrna is not present but egf receptors are present on the surface of basal keratinocytes. egf is produced in various sites in the gi tract including the submandibular salivary glands. we have hypothesised that as there is upregulation of salivary egf production in some enteropathies a similar situation may occur in disorders of the skin with an associated enteropathy. using a sensitive radio-immunoassay, egf activity was estimated in stimulated saliva from patients with various skin disorders, patients with gastrointestinal disease, patients with mixed dermatological and gut disease and normal healthy volunteer controls. elevated egf activity was found in the following groups of patients : skin cancers, psoriasis, acne, oesophagitis and ulcerative colitis. the hypothesis of up-regulation of salivary egf production in skin associated enteropathy was rejected but the discovery of elevated egf activity in skin cancers and psoriasis may have aetiological and therapeutic implications. the malignant fibrous histiocytoma (mfh) is considered an uncommon malignancy. its potential for invasion, metastasis and death of patient has been reported in literature. it can be confused with other tumours including fibrosarcoma. salient histologic features include cells of both the fibrocytic and histiocytic series. mfh with its high recurrence rate and lethal potential merits an aggressive evaluation and treatment. we present unusual case of recurrent mfh treated in our unit with an open question as to what qualifies to be adequate primary surgical excision. the recommended management of localised merkel cell carcinoma has been wide surgical excision, combined with adjuvant radiotherapy in selected cases. the risk of recurrent regional disease is reported to be between % and %. a year old woman with merkel cell tumour on the cheek is presented; this patient was treated exclusively with radiotherapy to a total dose of gy over days. the tumour regressed rapidly during the treatment, and there were no signs of local or regional recurrence. the patient is still alive and free of disease for months. immune in origin with a heightened cutaneous immune response to ultraviolet light. the coexistence of cad and pbc is a new association which has not previously been documented and may not be fortuitous given the similar pathogenesis of both diseases. chronic actinic dermatitis (cad) is a rare photosensitive disorder which primarily affects elderly men resulting in an eczematous reaction to ultraviolet-radiation and sometimes visible light. the pathogenesis has been attributed to an autoimmune process, possibly in response to a photoallergen which has yet not been identified. we report a year old female patient who developed cad four years after being diagnosed with primary biliary cirrhosis (pbc). abnormal monochromator irradiation tests were detected with narrow band ubv, uva and in addition visible light wavelengths. phot provocation tests induced florid vesicular eczema and multiple patch and photo-patch tests were positive, findings typical of cad. immunoglobulin g was elevated at mg/dl and liver histology was typical of pbc with an elevated anti-mitochondrial antibody. routine biochemical and immunological tests were ~ormal and porphyrin screen was negative. azathioprine mg/day induced remission of cad. pbc is an auto-immune disorder where cell-mediated immunity is impaired, suggesting that sensitized t lymphocytes may cause damage to bile ducts. the pathogenesis of cad may be auto- we present two cases of cutaneous polyarteritis nodosa (pan) associated with seronegative arthritis: the first patient, a year old male presented in complaining of a year history of pain, stiffness and swelling affecting his right ankle. he also noted intermittent tender nodules on the dorsum of his foot and over his ankle over the preceding three years. the second patient, a year old male, presented .in complaining of a month history of tender nodules on his shins, and pain and swelling of his right ankle. skin biopsies of the nodules in both cases showed medium vessel vasculitis consistent with polyarteritis nodosa. neither patient had any symptoms or signs to suggest systemic involvement. the only abnormality. n laboratory investigations for vasculitis was elevated esr. x-rays showed periosteal elevation and new bone formation in case , and were normal in case. . bone scan demonstrated increased uptake at the talo-navicular joint in case and at the fight ankle in case . synovial biopsy and mri confirmed the presence of an inflammatory arthropathy in patient . joint involvement has been a prominent feature throughout the course in both cases requiring aggressive treatment with vol. , irish journal of supplement no. medical science cyclophosphamide and systemic corticosteroids in case . cutaneous pan is a localised cutaneous vascular disorder with a benign chronic relapsing course. in one reviewl, of patients had arthralgias but an association with arthritis has not been emphasized in the literature to date. we conclude that this condition may present as a seronegative arthropathy in which the joint symptoms may be the most prominent feature and aggressive immunosuppresive therapy may be required for control. cardiac transplantation patients have an increased risk of skin disease. in our centre, heart transplants were performed with a year survival of %. eighty three patients are now alive and have required dermatological assessment. the mean age of patient was . years, (range - years); males, females. skin infections were diagnosed in of patients. drug side effects, including sebaceous hyperplasia and steroid acne, were common. in the patients who developed skin cancer, mean time from transplant to development of lesions was . years. eleven of patients had non melanoma skin cancers (nmsc), squamous cell carcinomas (scc), basal cell carcinomas (bcc), giving scc/bcc ratio of : . three of patients had multiple skin cancers, one had tumours. nine of patients had actinic keratoses, two thirds of whom had sccs. nineteen of patients had viral warts, two of whom had sccs. viral warts, premalignant and malignant lesions were located on sun exposed sites. skin complications of cardiac transplantation though mild were very common. the observed incidence of nmsc in age matched cardiac transplant recipients, appears much higher than the expected incidence of . per , population (national tumour registry ). regular dermatological assessment of cardiac transplant patients is necessary to detect skin disease and early skin cancer. the increased incidence of warts and skin cancer in renal transplant recipients {rtr} is well known. the oncogenic potential of unusual human papilloma virus {hpv} types has been postulated from warts and in both premalignant and nonmelanoma skin cancer (nmsc). the possible etiological role of sun-exposure in facilitating the development of hpv associated skin disorders is also suggested. a clinical study to assess the risk factors for development of these lesions in rtr attending the dermatology servic& age and sex matched haemodialysis patients were similarly examined as controls. male and female patients with a mean duration of transplant of . years, range to years. a total of nmsc (range to ), scc and bcc, ratio . : , were excised from rtr of which over % had viral warts, mosle commonly occurring on sun exposed sites and always predated the development of neoplastic lesions. both were associated with mean duration from transplantation, years for warts and . for skin cancer and not the type of immunosuppressive treatment. none of the control patients had similar findings. conclusions: the close clinical association of viral wart lesions and development of skin cancer in these patients suggests a close relationship to immunosuppression, in addition to exposure to ultraviolet radiation. this study highlights the high rate of nmsc in rtr. these patients justify early and regular skin assessments soon after transplantation with advice on sun protection. sensitivity to ultraviolet (uv) light may be established by exposure to broad band uva and uvb radiation. the minimal erythema dose (med) can be determined at individual wavelengths using a monochromator. uv action spectra of photosensitive disorders may thus be constructed. we examine the value of this process in distinguishing two clinically similar photosensitive disorders. the radiation from a xenon arc is separated into component wavelengths using the monochromator. each wavelength is focused on unaffected skin, on the patient's back. the patient is exposed to a range of doses of w radiation. the med is determined for a series of wavelengths from to nm. chronic actinic dermatitis (cad) and drug induced photosensitivity are photosensitive disorders which may have similar clinical history and presentation. ten cad and drug induced photosensitivity patients were tested. uva photosensitivity was seen in % of the latter group. the remaining % had normal mlts as the implicated drug had been discontinued prior to testing. cad patients were sensitive to both wa and wb radiation. forty-three percent of these patients were also sensitive to visible light ( to nm). monochromator light test (mlt) results show that uva photosensitivity dissociated from wb photosensitivity is indicative of a drug induced light sensitive disorder. sensitivity to both wa and wb however indicates a diagnosis of cad. mlts can therefore distinguish between clinically similar photosensitive disorders. bartholomew's hospitals, london. patients with mpd have an increased incidence of both thrombosis and haemorrhage suggesting a pivotal role for; platelets in these conditions. this study aimed to examine platelet activation antigen expression in stable patients with mpd and to examine the predictive value of these antigens prospectively. patients with mpd had p selectin and gp measured using a refined minimally manipulative flow cytometric technique. expression of p selectin -median . % (inter quartile range . - . ), control . % ( . .- . ) and gp -median . % ( . - . ), control- . % ( . - . ), were significantly elevated p< . . patients were followed for a median of months. % experienced thrombosis and % bleeding during follow up. at entry to the study % of patients had previously experienced thrombosis, median disease duration deaths, of which were caused by thrombotic events in which the mpd was a major risk factor. increased expression of p selectin or gp expression failed to predict thrombosis or bleeding in this study. nor was any significant retrospective relationship demonstrated. however, previous thrombotic events were strongly associated with future events (p< . ). this association was independent of disease, duration, age and medication. not surprisingly disease duration was also correlated with thrombotic/bleeding events. taurine levels fall in gut mucosal cells during critical illness. however, taurine transport into human intestinal cells is poorly understood. the aim was to establish the efficiency of taurine uptake by enterocytes, and to examine uptake under stressful conditions. to investigate efficiency of taurine uptake, confluent caco- cells were incubated for time points up to h. in a second study, cells were incubated for h with medium containing dexamethasone and / or cytokines. media for both studies was supplemented with [ h]-taurine. radioactivity was related to mg/ml protein to calculate rate of taurine uptake for each time point. study : uptake exhibited a steady linear response which approached saturation at h. maximal uptake occurred at h after which the rate levelled off. study : dexamethasone alone reduced taurine uptake by . % (p< . ) and in combination with tnf-c~ and ifn ~/ it decreased transport by . %. (p< . ). lps alone impaired uptake by % (p< . ). conclusion: we have established the time course over which taurine transport reaches its maximum rate in caco- cells, and that corticosteroids and cytokines significantly impair uptake of taurine in these cells. elderly individuals have an increased risk of infection suggesting that immune responsiveness is altered with age. changes in the level of proinflammatory cytokine production may be an important indication of any such age related change. using flow cytometry we examined intracellular tnfet, il-lf~ and il- in pbmcs from normal healthy volunteers of different ages ranging from up to yr (n= ). tnf and il levels from pma stimulated cd positive cells (t cells) were shown, using this technique, to increase in an age dependent manner (p< . ). no il- was detected in any t cell sample. no significant differences were observed between the different age groups for tnfa, il- g or il- in cd + cells (monocytes). the age related changes detected by flow cytometry have been confirmed using conventional elisas. this novel method of proinflammatory cytokine detection has detected increased tnf and il levels in t cells from elderly healthy volunteers which may help explain some of the exaggerated inflammatory responses seen in elderly patients. detection of proinflammatory cytokines by conventional elisa or bioassay is problematic due to the presence of naturally occurring biological inhibitors. flow cytometry allows the simultaneous detection of both intra and extracellular antigens thus intracellular cytokine levels can be quantified while cell surface markers allow cell type identification. a range of monoclonal antibodies were examined for tnfcx, il-lg and il- using saponin permeabilisation oft cells (cd ), monocytes (cd ) and epithelial cells (ber-ep ). t cells and monocytes were grown in ~culture, t~p :to hr with or without pma activation, and intracellular cytokine levels were shown to increase with time, with the stimulated samples producing more cytol<ine than the spontaneous.samples (p< . ). elisas performed on these same samples (n--: ) correlated well with the flow cytometric results (r= . ). tnf~x, il- and il- are detectable !n monocytes while only tnfa and il- have been detected in tcells and epithelial cells using this methodology. this novel technique will allow us to identify the cytokine producing cell while also avoiding the influence of the extracellular millieu, thus being useful for a number of research and diagnostic applications. all the viral hepatitides are said to be common in the middle east. hepatitis a viru s (hav) seroprevalence is said to be % in the adult population of gulf countries. hepatitis b, c and d seroprevalence are taken from blood banks data which are biased by selection criteria and the background of blood donors. very little is known about hev in the uae. vol. , supplement no. irish journal of medical science the aim was to investigate the seroprevalence of hav, hbv, hcv, hdv & hev in the uae. we prospectively recruited volunteers drawn from all the uae, socioeconomic classes and from different age groups in both sexes. each donated ml. of venous blood and using an indirect enzyme immunoassay were tested for total ig to hav; hbsag using monoclonal antibody t.o hbsag; for hcv antibodies using recombinant antigens hc- , hc- , c- and ns- , ( rd generations); for total ig to hdv and for total ig to hev. positive samples were retested in duplicate for confirmation. this large sero-epidemiological study clearly shows that hav is decreasing in the uae. hbv is low but significant, hcv is similar to southern european countries, hev is lower than expected and hdv does not exist in hbsag carriers in the uae. reactive oxygen and nitrogen species produced by inflammatory cells plays a role in tissue injury and inflammation. taurine, a bamino acid present in high concentrations in leukocytes functions as an anti-oxidant by scavenging the mpo derived oxidant, hypochlorous acid, to form taurinechloramine. experimental colitis was induced in male sprague-dawley rats and randomised into two groups. one group received tap water whilst the second group was supplemented with taurine ( %). these groups were sub-divided into those receiving tnbs/ ethanol (n= ) or saline (n= ). an increase in wcc count, particularly neutrophils was found in colitis. tat~rine was found to reduce the severity of the disease (ns) usin.g a colon macroscopic score. in the first group, respiratory burst activity was reduced in animals that had developed colitis (p< . ) although mpo activity was augmented (p< . ). nitric oxide production was . and . fold respectively higher in inflamed and non-inflamed areas of the colon than that by normal colonic mucosa. animals supplemented with taurine demonstrated attenuated m po activity (p= . ). administration of taurine did not lead to a reduction in nitric oxide production. thus, taurine appears to have a beneficial role in reducing the severity of disease. a reduction in mpo and respiratory burst may be beneficial in reducing tissue damage. to women subsequently identified by a national screening programme which revealed to be positive for rna of hepatitis c, type lb. were referred to this centre for evaluation. had moderate activity by modified knodell index, mean (_+ . ), bridging fibrosis and a mean alt of ( - ). six months dual therapy was administered. two patients withdrew due to depression ( ) and hyperthyroidism ( ). one patient di d not respond. seven responded with normalisation of alt and negative pcr. eight patients showed improved histology (kai +_ . ), fibrosis was unchanged. adverse reactions in the treated group included marrow suppression ( ) and thyrotoxicosis ( ) . at six months follow up four remain in remission with normal alt negative pcr, three have relapsed, (pcr positive, mean alt ( - ). we conclude that despite adverse prognostic indicators in this homogenous group with chronic hepatitis c, lb and long disease duration, dual therapy with interferon and ribavirin achieved results comparable to prolonged high dose interferon in patients with more favourable initial prognoses. the aim of the study is to evaluate a day course of azithromycin in combination with omeprazole in eradication of h.pylori. twenty-four patients with proved h.pylori infection and peptic ulcer disease were treated with omeprazole mg daily for months plus azithromycin mg daily for days. h.pylori was diagnosed on the basis of clo test and histology. this was done at the beginning and months after the treatment. eradication was defined as negative clo test as well as negative histology. out of patients, patients were lost to follow-up. only patients were analysed. sixteen patients responded to treatment and had successful eradication as well as healing of their ulcers. these included patients with gastric ulcers ( . %), patients with duodenal ulcers, patients with gastric and duodenal ulcers and patients with non-ulcer dyspepsia. five patients did not respond including with non-ulcerative dyspepsia. duodenal ulcers and gastric ulcer. however their ulcers have healed and symptoms relieved and they were treated with other h.pylori eradication regimes. conclusion. in this small study we have shown that azithromycin mg oncedaily for days is an alternative safe effective and well tolerated monotherapy for eradication of h.pylori. it has been suggested that hepatitis c virus (hcv) infection is associated with a high prevalence of autoimmune disease, but that this risk may be diminished in patients who received a low viral load at initial infection. the aim was to determine the prevalence of symptoms, signs and markers of autoimmune disease in a group of women vol. , irish journal of supplement no, medical science infected with hcv contaminated anti-d immunoglobulin. patients, mean age . years (range - yrs) were examined. patients ( %) were rheumatoid factor positive. ana was positive in patients ( %) but titres were / in / . thyroid globulin antibodies were found in patients ( %) with also being tm positive. further patients were positive for thyroid microsomal ab. prevalence of apa, ara, sm were %, % and % respectively. one patient had cryoglobulins detected while antibodies against mitochondria and lkm-i were not found only one patient of was symptomatic. these levels of antibodies are no greater than levels in the general population and similar to other groups infected with hcv contaminated anti-d. these results further support the hypothesis that either low viral innoculum or long duration of infection may in some way result in a low level of autoimmunity. a previous study (ilan et al, arch int. med., ; : - ) suggested that lga deficiency disposes towards hepatitis c virus (hcv) infection in some patients. it has also been suggested.that iga deficiency may occur as a result of the viral infection as a secondary event. the aim was to determine the prevalence of selective and partial lga deficiency in patients with hcv infection using a radio-immunodiffusion technique. serum lgg and igm levels were also examined. immunoglobulin levels were measured in patients, women and men, mean age . years (range - years) infected with blood between and . none of the patients were found to have selective or partial iga deficiency. mean iga = . g/l (range . g. - . g/l). furthermore no patient exhibited deficiency of igg or igm. conclusion : no evidence of iga or other immunoglobulin deficiency exists among this group of patients with hcv infection. while it may be possible that lga levels decrease following infection, no evidence exists that this phenomenon persists in the long term. hereditary non-polyposis colorectal cancer (hnpcc) is the most common form of hereditary colon cancer and accounts for up to % of the overall cancer incidence. the disease is inherited in an autosomal dominant manner andis characterised by predominantly right-sided tumours. hnpcc is caused by mutations in one of four mismatch repair genes. these genes are homologues of the bacterial mismatch repair systerfi and their function is to detect and correct defects in dna. the hmsh gene is reported to account for up to % of cases, hmlhi, hpms and hpms account for %, % and % of cases respectively. we have collected eighteen irish hnpcc families which satisfy the amsterdam criteria for the disease. we have screened the entire hmsh gene in eight of these families. a combination of single strand conformational analysis (sscp) followed by dideoxy sequencing was used to detect defects in the dna. sequence analysis revealed the presence of a novel polymorphismin exon in one family and a possible splice site mutation in the remaining ten families, using a novel mutation detection technique. departments of medicine and immunology, university college hospital, galway. serial iga gliadin antibody (igaga) studies are used as a surrogate for repeated small intestinal biopsy to monitor dietary compliance in treated coeliac patients. we have correlated igaga levels with indices of hyposplenism (platelets and erythrocyte "pits") to determine if either index can be used to monitor adherence to a gluten free diet. the study population of biopsy proven coeliacs was stratified according to dietary status into gluten free diet (groups a) and normal diet (group b). the iga gliadin antibody titres were significantly lower in group a than group b ( . : units p = . ). in group a gliadin antibody titres showed a statistically significant correlation with both platelet (p = . ) and pits count (p -- . ) ; in group b gliadin antibody titres correlated with platelet counts only (p - . ). those ona gluten free diet were further subdivided according t ~ reported degree of adherence to the diet (strict diet -sgfd, lax'diet -lgfd). significantly higher gliadin antibody titres were found in lgfd than sgfd ( . ; . p = . ), but the ptatelet and.pit counts were similar in the two groups. igaga is superior to platelet or pit coums in monitoring dietary'compliance in coeliac disease. hospital, galway. iga endomysial antibodies (igaea) are said to be more specific and sensitive indicators of coeliac disease than iga gliadin antibodies (igaga). initially the igaea substrate was monkey oesophagus and more recently umbilical cord. a new commercial product has becomeavailable using primate smooth muscle (accu track -diagnostic slides). we have undertaken a preliminary study to compare the performance of this lgaea assay and igaga elisa in treated and untreated coeliacs, coeliac relatives and controls. the study population consisted of biopsy-proven coeliacs who were stratified according to "reported" dietary status into good gluten free diet (group a), poor gluten free diet (group b) normal diet (group c) and unaffected coeliac relatives (group d) and controls (group e). elevated igaga (> units) were found in the following groups : a %, b %, c %, d %. igaea were positive in a %, b %, c %. with respect to igaga positivity, there were false positive igaeaa %, b . %, c % and false negative -a %, b %, c %, d %. in this preliminary study in untreated coeliac patients the performance of the igaea test was on a par with the igaga assay. alt and fibrosis may be associated with a non-alcohol steatohepatitis and these processes may be synergistic. finally, number and type of riba bands is not a predictor of inflammatory activity. ~stepping hill hospital, stockport, uk sk je. royal oldham hospital, rochdale rd., oldham ol jh. we investigated upper gut bleeding in patients aged years and over. a proforma addressing demography, drug therapy, clinical status, timing of endoscopy / surgery, and outcome was used. consecutive patients (median age years, range - ) were studied over months. ( %) underwent gastroscopy with a % diagnostic yield. patients had severe oesophagitis, had oesophageal malignancy, had gastric ulcers - of which are malignant and had duodenal ulcers. ulcerogenic drugs were implicated in patients. patients were referred for surgery, operated upon with one postoperative death. had haemoglobins of g/dl or less. all malignant lesions were inoperable. the overall mortality was % reducing to % if neoplasla were excluded. co-morbidity influenced mortality. patients were discharged with a median hospital stay of days. information on cause of bleeding greatly influenced management. the prognosis of gut haemorrhage in the very old need not be so poor. a few require surgery but the majority respond to active medical resuscitation which is a key factor in determining outcome. we advocate low threshold for endoscopy, judicious use of ulcerogens and adherence to guidelines on management of upper gut haemorrhage. haemochromatosis (hh), a common recessively inherited disorder of iron metabolism is closely linked to the hla-a locus on chromosome . linkage studies have demonstrated a close association between (hh) and the hla alleles, a and b ("ancestral haplotype"). heterogeneity at the molecular level may account for the variance in clinical phenotypic expression. the aim was to evaluate phenotypic expression of hh in the presence/absence of the a -b ancestral haplotype. probands ( m: f) from unrelated irish families were investigated. phenotypic variability was assessed with regard to l) age; ) % trans.sat.; ) serum ferritin; ) liver bx iron grade; ) body iron stores and )symptomatology. three males were homozygous for a b , were heterozygous for a b and were non-a b . symptomatology, trans, sat., serum ferritin and liver bx grade were not influenced by homozygousity or heterozygousity for a b . conclusion: there were no significant differences in phenotypic expression on comparison of the three haplotype groups. no predominant genotype appears to be responsible for phenotypic severity in irish families indicating the possibility of multiple mutagenicity of the hh gene. of riba positive anti-d associated chronic hepatitis c patients, were pcr positive but had surprisingly mild disease. the disease status of the pcr negative patients was hitherto uncertain and is the subject of this study. / riba positive patients referred to this centre were biopsied because of elevated alt ( ) or florid symptoms which dated from inoculation ( ). histological activity index * , , , , , (f), (f), , (f), , , , , , , , no bile duct damage, lymphoid follicles or aggregates was observed. / had mild periportal fibrosis (f), of these had steatohepatitis with obesity ( ) and impaired glucose tolerance ( ) suggesting dual pathology. we conclude that riba positive, pcr negative patients have minimal disease activity. elevated the association between the hla locus and haemochromatosis (hh) has allowed early identification of affected siblings. it is unclear what proportion of subjects who are predicted to be homozygous or heterozygous for the disease by hla typing develop the disease. studies correlating clinical features with hla type in families from ireland -a putative source of this celtic trait have not been described. the aim was to correlate clinical, biochemical and pathologic features of hh with hla typing in first degree relatives of probands. initial analyses identified homozygous (hh), heterozygous (hn) and normal (nn) individuals. however, / hn individuals had stainable iron on liver biopsy, confirming hh. further hla analysis revealed homozygous x heterozygous matings and identification of all disease haplotypes within each pedigree allowed final classification of hh, hn and nn individuals. vol. . supplement no. conclusion: this study demonstrates the importance of hla typing in the clinical management of families with hh, furthermore, in multiply affected families the incidertce of homozygous x heterozygous matings is high indicating the high degree of "pseudodominance" in the irish population. the degree of acute hepatic failure after severe trauma and sepsis is related to the extent of hepatocyte (hc) damage and cell death resulting from either necrosis or apoptosis. we have previously demonstrated that tnf-ct and lps can directly lead to hc necrosis, but not apoptosis. recent, studies have shown that reactive oxygen intermediates (roi) and nitric oxide (no) are capable of inducing apoptosis in eukariotic cells. however, it is unclear whether roi or no are involved in hc cell death. the aims of this study were to evaluate the role of no and roi in hc cell death (apoptosis vs necrosis). hcs were isolated from sprague-dawley rats, and cultured with the no donor, sodium nitroprusside (snp) or the roi generation system, hypoxanthine-xanthine oxidase (hx-xod) and h . the effect of lps, tnf-t~, and ifn-y alone or in combitmtion with different antioxidants and the no synthase inhibitor, n-methyl arginine (nma) on hcs was also assessed. snp caused a dose-dependent increase in hc apoptosis. roi generated by hx-xod and h did not induce hc apoptosis, but were responsible for hc necrosis. tnf-ct alone failed to induce hc apoptosis, but when ~combined with antioxidants resulted in increased hc no production and apoptosis. this effect was attenuated by nma. snp also induced hc damage and hc necrosis. moreover, tnf-ct-mediated hc damage and necrosis could be further reduced by the combination of antioxidants and nma. these results indicate that roi preferentially induce hc necrosis, but not apoptosis. induction of no resulted in both hc apoptosis as well as hc necrosis, which suggest that overproduction of no may be detrimental during the sirs. irish journal of medical science intervention was not uniform. mean albumin was . g/ . mean weight was . kg. poor cognitive status greatly increased the requirement for dietetic consultation time. lack of dietetic resources results in inadequate monitoring of these patients following discharge. this study highlights the need for a dedicated clinical nutrition service, for medical services for older people. periconceptual consumption of folic acid has been shown to decrease the incidence of neural tube defects. the preventative strategy of universal food fortification with folic acid presents the possible risk of masking the diagnosis of cobalamin deficiency in pernicious anaemia. in addition, the ultimate longterm effect of universal exposure of adult or foetal cells to a synthetic substance, ie. folic acid, is unknown. in this study, the threshold oral dose of folic acid in a number of foods above which metabolically-unaltered vitamin appeared in serum postprandially was determined in a young and elderly population by microbiological assay of serum pre-fractionated by hplc. subjects on a five-day regime of fortified cereal and bread along with their normal unfortified diet. were shown to have a threshold level of ~g/d, abovewhich unaltered folic acid appeared in the serum. individuals given folic acid in either isotonic saline, milkor white bread exhibited a threshold level of ~tg per serving. from patterns of food consumption in ireland, even moderate levels of fortification are likely to lead to some population groups being exposedto excessive amounts of un-altered folic acid in serum. many older people are nutritionally compromised. there is clear evidence that: nutrition intervention reduces morbidity m and mortality in older patients. to identify the spectrum of nutritional abnormalities referred for dietetic intervention and the problems associated with nutritional assessment, elderly patients were alphanumerically selected from files of the department. of nutrition and dietetics. the most common dietetj.c interventions were: use of supplements %; high protein high calorie diet %; nasogastric feeding %; reduction fat %; iron/thiamine assessment %; high fibre diet %; diabetic diet %; nutrition swall w programme %; lipid lowering diet %. some % referred required nutritional supplements, but the profile of an increase in oxidative stress in cystic fibrosis patients has been suggested. activated neutrophjls in the presence of chronic lung inflammation in addition to increased activity of the electron transport chain in cfmay. increase free radical generation. antioxidant protection against free radical attack is likely to be compromised as a i'esult of deficiencies in fat soluble antioxidants vitamins. in the present study stimulated thiobarbituric aoid reacting substances (tbars) were measured to determine the ability of plasma to withstand lipid peroxidation. copper was used to in!tiate the breakdown of lipids to lipid hydroperoxides and eventually to aldehydes, mainly malonyldialdehyde (mda). pooled cf plasm a and pooled control plasma were incubated for , , , , and min. mda complexes with thiobarbituric acid which absorbs at approximately rim. there is a lag phase where antioxidartts vol. , irish journal of supplement no. medical science in the plasma or tissue protect against lipid peroxidation, then a log phase where the protective effect is overcome and finally the reaction reaches a plateau when lipid peroxidation is complete. absorbance at nm was measured in all samples and zero order and first derivative spectra were obtained. the lag phase appears to be longer in the pooled cf plasma compared with controls. plasma t~-tocopherol levels were within the normal range in both groups, indicatin~ an alternative protective effect in cf. mild hyperhomocysteinaemia is an established risk factor for heart disease. a source of homocysteine in humans is the essential amino acid methionine found in protein of animal origin. in an -week study weekly fasting plasma homocysteine levels were examined in a group of healthy male subjects (n= ) under normal dietary conditions (weeks to ) and in response to graded increased methionine intakes (weeks , , ). nutrient intakes, including methionine, were calculated from x -day food records. under normal dietary conditions weekly mean plasma homocysteine levels were not significantly different (anova) from each other ranging from . + . to . + . ~tm/ . doubling daily methionine intakes (supplementing with mg/ kg/d) did not result in a significant increase in plasma homocysteine ( . + . ~m/ ), however, significant increases were achieved when diets were supplemented with methionine at levels of and mg/kg/d resulting in mean plasma homocysteine levels of . + and . am/ + . , respectively. mean plasma homocysteine levels returned to baseline ( . + . ~tm/l) days post supplementation. we conclude that supplementary methionine results in a significant increase in plasma homocysteine only when levels of five times the normal dietary intake are reached. this study is evaluating the use of a synthetic construct which encompasses primer binding sites for lpl and a variety of cytokine and other transcripts, to quantify lpl expression in cultured human monocyte-derived macrophages. following isolation of total rna at various times during cell culture, its reverse transcription (rt) using random hexamer primers generating first strand cdna and specific amplification of lpl cdna targets by polymerase chain reaction (pcr), generates products identifiable on gel electrophoresis. quantitation of message is obtained by incorporating the pawl construct in the rt assay in varying quantities as an internal standard with known amounts of monocyte-macrophage rna (l~tg). pcr amplification of this construct yields size distinguishable products from that produced by the monocyte-macrophage lpl cdna transcript. pcr conditions for the assay have been optimised at cycles of denaturation (tmin @ ~ annealing ( . min@ ~ and extension (lmin@ ~ lpl mrna has been detected in cultured monocytes and macrophages throughout their differentiation. also increased expression of monocyte lpl mrna has been observed following hr incubations with chylomicrons ( t~g/ x mononuclear cells/ ml)-when compared with controls. interestingly, little or no lipase mrna was detectable in circulating monocytes using identical pcr conditions to preparations of mrna from the day and day cultured cells. this methodology will now permit investigation of the factors controlling lpl expression in cultured human monocytic cells. replacement growth hormone (gh) therapy in adult hypopituitarism is attracting increasing interest. in markussis (l) detected premature atherosclerosis by ultrasonography in the untreated patient we have shown plaque regression with patients on replacement gh (norditropin) in a -month trial. females and males were recruited, mean age . years. at each timepoint plaque characteristics were measured by duplex ultrasound. patients showed a large reduction in plaque size (mean %) after four months treatment (p value < ~ l). similarly, highly significant values in cholesterol, hdl and ldl and apo a are achieved. chol hdl ldl apo a pretreatment . . . posttreatment . w . w . w ~ w achieve a high degree of statistical significance (p< . ). the significant reductions achieved in plaque characteristics in six patients studied who showed plaque formation correlates with other parameters traditionally accepted as reducing cardiovascular risk. hypertension is found in approximately % of patients with cushing's syndrome, but the mechanism is poorly understood. previous studies in our unit have examined levels of exchangeable sodium, plasma renin and angiotensin ii and cardiac sensitivity to phenylephrine. one previous study has demonstrated enhanced pressor responsiveness to noradrenaline in a group of patients with cushing's syndrome due to adrenal adenoma. we have investigated the blood pressure response to noradrenaline in patients with pituitary dependent cushing's syndrome and in controls matched for age, sex and bmi. noradrenaline was infused for minute intervals at five different concentrations between . and . mcg.kg.min -~ multiple systolic and diastolic readings were recorded and the infusion was stopped if the systolic pressure became > mmhg, diastolic _> l mmhg or the systolic pressure rose > mmhg. basehne blood pressure in the patients with cushing's disease (cd) was / + / compared with / + / mmhg in the normal controls (nc). in of the patients with cushing's disease, the test had to be stopped before completion of the protocol, whereas this was necessary in only one control subject the change in blood pressure from basehne to the blood pressure value recorded either at the time the test was stopped or at the peak blood pressure reading during equivalent noradrenaline infusions was compared between the matched pairs. the mean change in diastolic pressure was + mmhg in cd compared with + in nc (p< . ). there was no statistically slgmficant difference in either systolic pressure ( + vs + mmhg) or mean arterial pressure ( + vs + mmhg). these results demonstrate an increased diastolic pressor response to noradrenahne tn cushing's disease. increased pressor sensitiwty to uoradrenaline may contribute to the elevated blood pressure seen in cushing's disease. increased plasma homocysteine (thcy) is an independent risk factor for premature vascular disease. patients with insulindependent diabetes have an increased prevalence of cardiovascular disease. accordingly, we measured plasma thcy concentration in such patients ( - y), randomly selected, and in control subjects. in controls, thcy was higher in males than in females (supine: geometric mean ( % ci): , . ( . , ) v . ( . , . ) i.tmol/l, p< . ), as previously described, but there was no gender difference in patients. male patients, without microvascular complications, had lower thcy than controls (supine: . ( . , . ) v . ( . , ) ~mol/l, p< . ), but values in female patients without complications were similar to those of female controls, thcy significantly correlated with age in diabetics but not in controls, thcy increased in patients with increased severity of microvascular complications, partly due to the effect of age. thcy was higher when standing.than when supine in both controls ( ( . , . ) v ( . , . )lalmol/l, p< . ) and patients ( . ( . , . ) v . ( . , . )l.tmol/l, p< . ). the absence of gender difference, the association between thcy and age, and higher levels with increasing microvascular complications suggest thcy could be of pathogemc significance in iddm patients, despite unexpectedly low levels in male patients without complications. differences.between supine and erect samples may be due to haemodilution of albumin-hound thcy in the latter a review of the treatment outcome of thyrotoxicosis with standard dose/doses of radio-active iodine (sdrai) in consecutive patients presented to the endocrinology department, uchg, from december -december was analysed. the mean pre-treatment levels of free thyoxine (ft ) was correlated with the treatment outcome. there was statistically significant difference in the pre-treatment ft between responders and nonresponders to the first dose rai (p = . ). response with hypothyroidism and/or euthyroidlsm was considered successful treatment / ( %) responded to a single dose rai; / ( . %) and / ( %) responded with euthyroldism and hypothyroidism respectively / ( . %) and / ( . %) responded to the second and third doses of rai respectively giving a total response rate of . % and % respectively. interestingly, / ( . %) patients failed to respond even to the fourth dose rai / ( . %) patients with t toxicosis ( females and male). two responded to the first dose (one with hypothyroidism and the other with euthyroidism), the remaining required a second dose, which produced the same results. no statistically significant difference in the response rate between t and t toxicosis (p = . ) was observed. inherent in the st. vincent declaration targets is the need for continuous data collection and audit. we present preliminary information from the mater database, the first prospective audit of patients from a homogenous irish population. , iddms ( m: f) were identified with the following characteristics (mean + sd), age . + . years, duration of dm + . years, bmi . + . (males) and . + . kg/m (females), hbalc . + . % (n< . %). no male:females differences existed in the above nor in macrovascular complication rate . % (predominantly peripheral vascular &sease and lschaemic heart disease). however, males were more likely to be current smokers ( % vs %, p = ). hypertension rates ( . m vs . %f), cholesterol > . mmol/ ( . m vs . %f) were similar but more males had cholesterol < . mmol/l ( . m vs . %f, p < . ). clinical nephropathy was present in . % of males vs . % in females (p< ) . % had clinical peripheral neuropathy. retinopathy will be described elsewhere. . % of females and . % of males had a history of hyperthyroidism and . % of females vs . % of males of hypothyroidism. . % had history of psychiatric disease. conclusion although not a population based study, care of iddm in ireland is almost totally hospital clinic based cigarette smoking is identified as the major problem to be addressed patients with diabetes meltitus (dm) are at a higher risk of developing vascular complications, including coronary artery disease (cad). we performed a detailed analysis of predictors of cad and its seventy in patients with dm and chest pain patients in total single vessel cad (svd) in , double vessel (dvd) in , and triple vessel (tyd) in on cine contrast angiography clinical, biochemical and dobutamme stress echocardiographic findings are tabulated below for patients with angiographically proven coronary artery disease. patients with tvd had a longer duration of dm ( years) and were more likely to have retinopathy ( %) the sensitivity of dse was excellent for severe disease. conclusion' duration of dm, retinoapthy, and a positive dse were the best predictors of severe cad in a diabetic population with chest pain the haemodynamic hypothesis for the pathogenesis of diabetic microangiopathy argues that an initial increase in microvascular flow leads to sclerosis and disturbed microvascular autoregulation. we have recently demonstrated impairment of vasoconstrictor responses to endothelin- , a potent endothelium-derived constrictor substance, in niddm and have suggested that this could contribute to the initiation of microangiopathy the purpose of this study was to determine whether responsiveness to endothelin-i is also impaired in iddm. non-specific vascular smooth muscle contraction was assessed using high dose serotonin eleven patients with iddm and control subjects underwent forearm blood flow (fbf) measurement by venous occlusion plethysmography in response to local infusions of endothelin- ( pmol/min for minutes) and serotonln ( la g/min for minutes) control subjects showed slow onset vasoconstriction in response to endothehn- reaching maximum at minutes (p< . ) the diabetic group did not respond to endothelin-i group differences were significant (p= . ). the two groups showed similar vasoconstriction in response to serotonln. in conclusion, vasoconstriction in response to endothelin-t is impaired m iddm non-specific vascular smooth muscle contraction is preserved. impaired vascular responsiveness to endothehn-i is a possible common mechanism for the pathogenesls of microanglopathy in ddm and niddm. we measured total corrected (tca) and standardised ionised calcium (lca) in a population of intensive care ( cu) patients (with a mean age of + years, % male) to determine the prevalence of abnormalities in circulating calcium and its possible determinants severity of illness was measured by the apache ii score (acute physiological and chronic health evaluation). for comparison of ica we examined subjects undergoing arterial gases which proved to be normal and non-critically hypoxlc subjects ica was measured on arterial gas samples and corrected for ph % of icu patients had a total ca (unadjusted) of < mmol/l. after adjustment for serum albumin, % of icu patients had an tca < mmol/ % of icu patients had a serum phosphate of < . mmol/ ica in controls was . + . mmol/ and . + . mmol/ in hypoxlc non icu patments (ns) ica in icu was lower: . + . (< . ). tca and lca were not slgmficantly related. tca and ica did not sigmficantly differ between patients who died and who survived in the icu, and they were not related to apache ii score. belfield, dublin . from july to june there was a -fold increase m the annual number of specimens submitted to the virus reference laboratory because of a perceived risk of contracting hiv through a needlestick injury, blood splash, human bite, or through occupational exposure. needlestick-associated specimens also comprise an increasing proportion of 'at-risk' specimens, rising from . % m the year july -june to . % in the year july -june . between july and june a total of patients had specimens submitted for hiv antibody testing after a perceived'exposure to hiv of these only patients had more than specimen taken. although the time of putative exposure is rarely avadable, the median interval between st and nd postexposure specimens for these patients is months with / ( %) lying between to months. if the risk of hiv refection from a needlestlck injury is assessed as sufficient to warrant serological investigation, the timing and number of blood samples are important. a negative report from a single early specimen may not indicate an absence of infection a basehne specimen and follow-up specimens at weeks, months and at a minimum of months post-exposure are recommended appropriate serology for other viral mfections (hepatitis b and hepatitis c) should also be considered. since the beginning of a significant sustained increase in the numbers of hepatitis a cases has occurred. the number of cases m was against in . this reverses the continuous fall observed over previous years. the reason for this increase remains unidentified at present this increase has occurred following a dramatic increase in the total number of hepatitis a igm tests carried out by the vrl since february/ march the increase in the number of tests carried out since this time is primarily attributable to increased hepatitis testing following receipt of hepatitis c-contaminated rhesus anti-d immunoglobuhn. analysis of the age profiles of the positive patients and of all the referrals indicates that . % of positive results were found m patients aged yr or less whdst % of all hav igm tests were performed on individuals aged yr or greater. this raises the question whether greater selectivity should be employed when requesting hepatitis a tests studies report compliance rates ranging from to % in hiv negative patients there has been no comprehensive study of compliance in hiv positive patients. accurate measurements of compliance are not easy; easy measurements of comphance are not accurate "). to determine the compliance rate in hiv posmve patients attending st. james hospital, dublin, one hundred consecutive patients attending the service were interviewed (homosexual , ivdu , heterosexual ). the questionnaire was divided into three sections. firstly, a medical review was completed by the clinicmn which included demographic data, cd count, cdc staging, karnofsky index and prescribed medication. secondly, the pharmacy detailed the medication dispensed to each patient. the third section comprised a patient interwew to determine adherence to, and understanding of prescribed drug therapy. we report an overall comphance rate of %. this was unevenly distrtbuted between the two main patient groups ( % in homosexuals, % in ivdu) the following factors were found to mfluence compliance: number of medications, cdc stage, karnofsky index, dysphagia, educational and socio economic factors. we also found that poor patient understanding of the prescribed therapy significantly affected compliance. the aim was to determine the incidence of stds in patients presenting for hiv testing at the department of genito-urinary medicine, saint james's hospital. a retrospective analysis of all patient notes who presented for hiv testing between july ' and december ' was undertaken. according to clinic policy all patients had been screened for the following stds; neisseria gonorrhoea, chlamydia trachomatls trlchomonas vagmalis, candida, human papilloma virus, herpes simplex virus syphilis and hepatitis b in addition intravenous drug users (ivdus) were also screened for hepatttls c all patients underwent pre test counselhng. sex, age, risk groups and diagnoses were noted. patients presented for hiv testing, of whom % were male, % female, wtth an average age of . years. of the total, % were, or had previously been ivdus. of the total ivdus, were heterosexual males were bisexual and were females . % of the male patients were homosexual and % btsexual there were posmve hiv tests ( % of total); males and female. in this group there were patients with hepatitis c, all of whom were ivdus. no other stds were detected in the hiv negative group hepatitis c was diagnosed in , hepatttis b in , anogenital warts in , herpes gemtalis in , syphilis in , n. gonorrhoea in , t. vagmalis in i, c. trachomatls m , g vaginalis in and candldlasis in . this study confirms the importance of std screening in all patients requesting a hiv test. of the total testing for hiv, % had a concurrent std diagnosis although no stds were identified in the hiv positive group this may be more a reflection on the makeup of the irish hiv positive population, the majority being ivdus, rather than a difference m the mode of sexual toxoplasmosis is the most common opportumstlc infection of the central nervous system in aids patients. in clinical practice the diagnosis depends on clinical, radiographic and serological findings coupled to chnical response to therapy brain biopsy is not routinely performed. in this retrospective review, we describe our experience with diagnosing toxoplasmosis we examined (a) the clinical demographics and presentation, radiographic findings, response to therapy and patient outcome (b) role of polymerase chain reaction (pcr) in detecting toxoplasma gondii from blood and csf samples (c) the usefulness of serology in diagnosing acute infection. all cases diagnosed as toxoplasmosls based on the above criteria were reviewed. pcr to detect toxoplasma gondn dna used primers to the b gene giving a bp amphficatton product serological tests used were sabln-feldmen dye test and latex agglutination. there were cases diagnosed ( m, f, cd - ; cdc iv ). panents unknown to be hiv posmve presented with cerebral toxoplasmosis patients were not receiving continuous systemic prophylaxis against pce diagnostic value oft gondii pcr in blood and csf showed a sensmvlty of %, specificity of %, ppv was % and npv was % determination of lg subtype was of limited value % ( ) of patients were seronegatlve of whom % ( ) had histologically proven disease of these latter cases were pcr negative the dye test was of poor predictive value this review confirms the need to combine all parameters in making a diagnosis of toxoplasmosis in lmmunocompromlsed hosts. the performance of the newly developed, rapid and fully automated m~croparticle enzyme immunoassay abbott imx hiv- /hiv- rd generation plus assay for the detection of antibody to hiv- and hiv- including subtype o m human serum or plasma was assessed the assay was evaluated by testmg specimens from blood donors, diagnostic populations and hospitalized patients, hiv seroconverslon panels confirmed hiv-positive specimens, and potentially interfering specimens. the abbott imx hiv- /hiv- rd generation plus assay showed an overall apparent specificity of . % (lower limit of % ci . %) in the tested blood donor populations (n= t). this comparable to the specificity found for the abbott imx hiv-i/hiv- rd generation plus eia ( %) and the axsym h v- /hiv- assay ( %). the apparent sensitivity of the abbott imx hiv-i/hiv- rd. generation plus assay is at least equivalent to that of the abbott imx hiv-i/hiv- rd generation plus eia and the axsym hiv-i/hiv- assay. of hiv-i seroconversion panels tested, the abbott imx hiv- /hiv- rd generation plus assay detected seroconverslon earlier on up to panels, depending on the comparison assay. among specimens from asymptomatic and symptomatic hiv patients, the abbott imx hiv- /hiv- rd generation plus assay detected ( ) including specimens characterized as hiv- subtype o. the abbott imx hiv- /hiv- rd generation plus assay is an extremely sensltlve and highly specific assay for the early detection of antibody to hiv- /hiv- and shows at least an equivalent performance to the abbott imx hiv-i/hiv- rd generation plus eia and the axsym hiv- /hiv- assay. the fully automated imx instrument system offers ease of use and rapid results on a widely accepted and reliable platform. streptokinase (sk), a kd protein produced by group c b hemolytic streptococci, is a widely used thrombolytic agent. anti-sk antibodies arise either as a result of therapeutic administration of sk or following natural mfection with streptococci although the clinical significance of antl-sk antibodies is not clear, there is evidence that some anti-sk antibodies arising from natural infections can interfere with sk activity tn vtvo, resulting in thrombolytlc failure. to facilitate further investigations of these antibodies, we have developed and validated a highly sensitive functional assay, which measures sk neutralisatlon activity of serum independently of other circulating inhibitory factors in the sample, and a rapid and convenient enzymeimmunoassay for the detection of anti-sk antibodies. analysis of over random serum samples from the local blood bank with the enzymeimmunoassay showed the prevalence of antl-sk antibodies to be approximately %. all the positive samples and an equal number of the negative samples randomly selected were analysed by the functional assay the agreement between the results of the two assays was excellent indicating that our enzymelmmunoassay was a convement method for detection of anti-sk antibodies which could neutrahse sk activity m vitro irish journal of medical science tuberculosis drug therapy, isolation precautions and prophylaxis. conventional methods of detection such as microscopy and culture either lack sensitivity and specificity or are timeconsuming. in this study we investigated the use of a pcr based diagnostic assay for the detection of m. tuberculosis in sputum samples this assay has been developed by bioresearch ireland (bri) and raggio italgene. sputum samples were lysed and pcr amplified using an m. tuberculosis complex-specific primers. the results obtained using the bri/c-trak tm technology were initially compared to the amplicor system (hoffman la roche). both probe detection methods represent fast and reliable methods for the detection of m. tuberculosts in clinical samples. this test is designed to eliminate the possibility of obtaining false negatives. strongyloldes stercoralis infection in humans ts endemic in the tropics. as travel is becoming more common, it will be seen more frequently. two cases of this infection in irish people are described. case i. a year old women had travelled and worked in poor rural areas of mexico for one month, three years before presentation. two and a half years later she developed abdominal discomfort, anorexia and sore throat. myalgia, arthralgta and a transient skin rash began to appear in the next month. eosinophilia, mild anaemia and raised liver blood tests were noted. elisa test for strongyloides was positive but parasites were not seeri in the faeces. ivermectin was given and the patient feels better. case ii. a year old nurse had arthralgia, fatigue and some weight loss for months'. on two occasions in the last four years, she had been travelling extensively in s.e. asia for a total of four months. she was admitted to hospital because of acute fever and loin pain. a urinary tract infection was diagnosed. absolute eosinophil count was i'aised . x ^ / . esr was mm/hr. strongyloides elisa was positive and treatment administered as above. strongylotdes is the most important nematode in the returned tropical traveller. it can multiply and persist within the body for long periods of time and it can cause hypertnfection syndrome, a protean fulminating infection of bowel, lungs, blood stream and brain, in those who are lmmunocompromised. diagnosis can be difficult by stool microscopy. thlabendazole has side effects but ivermectin is safe and effective. june , there was an outbreak of c.difficde-associated diarrhoea (cdad) at st. james's hospital. the aims of this study were to determine the incidence and outcome of cdad in hiv positive and negative patients we prospectively reviewed all patients with diarrhoea, a positive c.difftcile cytotoxin assay, and in whom no other infectious cause for diarrhoea was identified demographic data, history of diarrhoeal episodes, risk factors and outcome were recorded. the incidence of cdad in hiv negative patients was . per hospital admissions, compared to per admissions m hiv positive patients. the average number of courses of antibtotlcs received, in hiv negative patients prior to the onset of symptoms was . , and % of this group were exposed to third generation cephalosporins. hiv positive patients received an average of . courses of antibiotics and no patients received third generation cephalosporins. there were no deaths due to cdad in hiv positive patients however hiv negative patients died from severe pseudomembranous colitis in conclusion we documented a unexpectedly low incidence and complication rate of cdad in hiv positive patients this is surprising considering their multiple hospital admissions and exposure to ant~microbial and chemotherapeutic agents. the number of new positive hiv specimens detected at the virus reference laboratory has risen from a cumulative total of m july of to in september of . we examined our data to determine the proportional make up of these positives by major risk group. in august . % of positive specimens were from intra venous drug abusers (ivda) by september ivda made up % of the total positive hiv specimens. positive specimens from homosexual individuals rose fro.m l % of total positives in august to . % in september there were no recorded positive specimens from heterosexual exposure in august but in september . % of positive specimens recorded heterosexual exposure. a further category which includes blood donors, haemophiliacs, transplant patients and organ donors made up % of total positives in august and in september made up . % of total positives. we further examined our data in order to show when these changes occurred by ascertaining how many new positive patients have been discovered per year in each of the main risk groups. see in the united kingdom echovlrus type (echo- ) is regularly isolated, with nearly reports annually to the central public health laboratory. reports increased during - and overall it is the second most commonly reported echovlrus in the u.k. echo- epldemiology is different to that of other enteroviruses; over % of patients with echo- tsolated are less than years of age echo- shows distinctive and unique cytopathogenic features in tissue culture, and based on sequence analyses, it seems to belong to a separate subgroup of picornaviruses. echo- has been associated with respiratory symptoms in premature infants, myocarditis and severe encephalitis. in an outbreak of acute flaccid paralysis associated with echo- was described in jamaica in six patients, four of whom died. we describe three cases of sudden death in infants associated with echovirus type infection case i: s d. born / / ; birth asphyxia and death at two days of age; echo- isolated on from spleen. this study assessed the antibiotic sensitivity of organisms causing urinary tract infections (uti) among genito-urinary medicine (gum) clinic attenders in order to determine whether it is worthwhile giving tetracycline for dipstick (nitrite) positivity, even in the absence of clinical features of uti. we looked retrospectively at laboratory confirmed uti's diagnosed among gum clinic attenders over a period of eight months. we assessed antibiotic sensitivities of the organisms involved, and determined how many dipstick positive urines which were left untreated turned out to be real uti's. % of uti's were due to coliforms and % of these were sensitive to tetracycline. % of uti's were due to staphylococcus saprophyticus, % due to beta haemolytic streptococcus group b, % due to enterococcus, % due to proteus species and % due to coagulase negative staphylococci. % of nephur positive urines were left untreated. % of these were nitrite positive. failure to treat a positive urine dipstick which turned out to be a uti necessitated a further clinic visit for adequate treatment. nitrite positive urines should be treated as a uti, even in the absence of clinical features of uti, either with trimethoprim or tetracycline. the number of untreated uti's and unnecessary extra visits to gum clinics would have been reduced with the use of judicious antibiotic therapy for nitrite positive urines. strains of enterococci resistant vancomycin have been reported with increasing frequency. in , we investigated an increase in the frequency of vancomycin-resistant enterococcus faecium (vref) among patients in the haematology/oncology unit using pulse-field gel electrophoresis (pfge) to genotype these isolates and to assist in establishing the source of these vref. eighteen clinical isolates of vref from blood, urine sputum and-faeces and two environmental isolates were collected from separate patients between march and july . minimum inhibitory concentrations (mics) to several antibiotics including teicoplanin and vancomycin were determined by agar dilution. pfge were performed following smal restriction endonuclease digestion. antimicrobial susceptibility testing revealed high level resistance to vancomycin and teicoplanin; mics > mg/ l and > mg/l respectively. this antibiogram is consistent with the van a phenotype. pfge of all isolates revealed identical patterns indicating clonal spread of vree subsequent implementation or infection control measures reduced the frequency of vref isolation. pfge proved useful in demonstrating clonal spread of vref and.in emphasising the need for infection control measures. a prospective audit of baeteraemia in our bed teaching hospital was carried out from february to march . clinical and microbiological data were collected on episodes of bacteraemia in patients. of these ( %) were hospital acquired and ( %) community acquired. urinary tract and respiratory tract sources were implicated in % and % of community acquired episodes, making e. coli and s. pneumoniae the commonest community acquired isolates ( % and % respectively). other gram negative bacilli accounted for % and s. aureus for %. coagulase negative staphylococci were the commonest hospital acquired isolate ( %) followed by s. aureus ( %), e. coli (i %) and enterococcus spp. ( %). enterobacter spp. were the second commonest gram negative isolate ( %). central venous cannulae were implicated in % of hospital acquired cases. urinary tract infections accounted for %. % of which were catheter related. invasive diagnostic procedures (angiography, prostate and liver biopsies, sinography) were implicated in t episodes. gentamicin resistance was found in % of hospital acquired aerobic gram negative bacilli and mrsa accounted for % of hospital acquired s. aureus. these figures are higher than expected but may be explained by outbreak of mrsa and gentamicin resistant entercobacter spp. which occurred during the study period. the past severalyears have seen a significant increase in the recognition of moraxella (branhamella) catarrhalis as a respiratory pathogen (~). the pathogenic mechanisms employed by the organism are largely unknown, but adherence may play a role ~ ~. in our investigation the haemagglutinating ' activity of isolates of m. catarrhalis was determined by a microtitre method. no isolate agglutinated horse, chick or sheep red blood cells (rbc). seventeen isolates agglutinated human rbc, x~hile of these isolates also agglutinated rabbit red. blood cells. haemagglutination of human and rabbit red blood cells was inhibited by porcine mucin. galactose inhibited the haemagglutiriating activity of the isolates which agglutinate both human and rabbit rbc and yet bad no effect on the haemagglutinating activity of the isolates which haemagglutinate human rbc alone. .electron microscopy studies of the bacteria demonstrated a diffuse outer fibrillar layer on the surface of haemagglutinating positive isolates, thislayer was subsequently removed following trypsin treatment, as was the haemagglutinating activity. a kda trypsin sensitive protein appears to be associated wfth haemagglutinating properties. mrsa is an increasingly important cause of morbidity, and is spreading from large hospitals to smaller community-based facilities and nursing homes. the objective of this survey was to obtain an indication of the size of the mrsa problem in ireland prior to introducing national mrsa control guidelines. a survey of all microbiology laboratories in ireland was carried out over two weeks in spring . for patients from whom mrsa was isolated during the study period standard demographic and clinical data were requested and period prevalence/ discharges was calculated. all microbiology laboratories surveyed responded. mrsa was isolated from patients during the week period. the period prevalence of mrsa/ , discharges was . . males aged + had the highest rate of infection ( / discharges). half of all isolates were from patients in surgical or medical wards, but % were from community-based sources e.g. gps, nursing homes, hospices. thirty-two percent of mrsa patients were infected rather than colonised. mrsa is clearly a substantial problem in ireland. while it is largely a hospital problem at present, the increasing trend for day procedures and shorter stays means that infection will increase in the community. a survey in a university hospital in the usa revealed % of mrsa cases to be communityacquired. tonsil core specimens were cultured for bacteria including mycoplasma, chlamydia and ureaplasma urealyticum in children undergoing tonsillectomy for recurrent acute tonsillitis. serology for chlamydia and mycoplasma pneumoniae was obtained in of the children. the polymerase chain reaction (pcr) was used to investigate the presence of chlamydia pneumoniae in core tonsil tissue. ureaplasma urealyticum was cultured in three children ( . %) and mycoplasma salivarium in two children ( . %). culture was negative for chlamydia pneumoniae and mycoplasma pneumoniae. the complement fixation test for chlamydia species was positive in / children ( %) indicating previous infection. specific immunofluorescence testing for c. pneumoniae was positive for lgg (titre> ) in / ( %). igm antibody to c. pneumoniae and antibodies to c. trachomatis and c. psittaci were not detected. ninechildren ( %) had titres > to m. pneumoniae. pcr failed to demonstrate c. pneumoniae. aerobic and anaerobic bacteria were cultured from all specimens. the culture of ureaplasma urealyticum in . % of our patients indicates a higher rate of colonisation then previously thought. this study irish journal of medical science demonstrates past infection with c. pneumoniae in % and with m. pneumoniae in % of children with recurrent tonsillitis. however c. pneumoniae and m. hominis do not play a significant role in childhood recurrent tonsillitis. multiply resistant enterococci are increasingly common causes of serious infection in hospitalized patients. high level gentamicin resistance (mic > mga) in enterococci further compromises the therapy of such infections. we have identified seven clinical isolates of enterococcus hirae demonstrating high-level gentamicin resistance (hlgr: mic > i mg/ ). to our knowledge this is the first report of hlgr for this enterococcus species. plasmid analysis has demonstrated the presence of a single, large plasmid in all seven isolates, as well as several smaller plasmids in some of the isolates. filter mating experiments have revealed that in all seven cases, hlgr was transferred to a laboratory recipient e. faecalis jh- by conjugation. plasmid analysis of transconjugant strains confirmed transfer of the large plasmid in all cases. based on restriction enzyme profiles, two distinct conjugative plasmids were identified for the e. hirae isolates investigated. at present we are using southern blot techniques with oligonucleotide probes designed to hybridise to the hlgr determinant found in other species of enterococcus. the results will confirm whether or not the same resistance determinant is responsible for the dissemination of hlgr in the genus enterococcus. dublin . aminoglycosides remain commonly used in the treatment of severe gram negative infection and have conventionally been given on a twice or thrice daily basis. single daily dosing offers advantages with respect to less nephrotoxicity, better bactericidal activity, convenience, nursing time, cost and should avoid subtherapeutic dosing which has a significant impact on outcome. we reviewed serum gentamicin assays from january to december to assess potential toxicity and subtherapeutic dosing in patients who received once daily gentamicin and those who received multiple daily dosing. assays were performed in the study period. of those were random assays and not included. there was a trend towards significantly less potentially toxic levels in the once daily group compared to the multiple daily group (p< . ). once daily dosing produced significantly less subtherapeutic dosing (p< . ). over % of peak assays in the once daily group were in the recommended range. we conclude that current practice of multiple daily dosing of gentamicin leads to significant underdosing and more potentially toxic trough levels. measurement of trough assays only in patients who are treated with once daily aminoglycosides is sufficient and will have considerable cost savings. respiratory, syncytial virus (rs virus) is a major respiratory pathogen of infants less than year old. it occurs in annual epidemics during the winter and early spring in temperate climates. during rs virus epidemics a significant number of infants less than months old are hospitalised with symptoms of bronchiolitis and pneumonia. rs virus exists in two antigenically distinct subgroups, a and b which are known to cocirculate in the same community during the same rs virus season. there is much debate regarding the virulence of one strain over the other. using a panel of monoclonal antibodies specifically directed against the two rs virus strains, rs virus isolates from specimens sent to the virus reference laboratory, university college dublin, over seven consecutive rs virus seasons ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) were typed and the rs virus subgroup predominance monitored. subgroup a was the most predominant of the rs virus isolates accounting for . % of the total and was found to be the predominant rs virus strain in six out of the seven rs virus seasons studied. subgroup b predominated in a season in which the number of rs virus detections peaked much later than normal. treatment of fungal infections in patients in intensive care unit (icu.) is usually empiric. the aim of this study was to identify candida species isolated from i.c.u. patients and to test their susceptibility to antifungal agents to enable more directed therapy. forty candida sp. from patients in i.c.u. were isolated from the following sites, blood culture ( ), central venous catheter ( ), chest drain fluid ( ), wounds ( ), catheter urine ( ), bronchial lavage ( ), sputum ( ). strains were identified by standard procedures. minimum inhibitory concentrations of amphotoeracin b, -flucytosine and fluconazole were obtained by agar dilution test and e test. the isolates were identified as c.albicans ( ), c.glabrata ( ), c.krusei ( ), c.tropicalis ( ), c.parapsilosis ( ), c.kefyr (i). all the candida species were sensitive to amphoteracin b (mic = -< mg/l), and flucytosine (mi c= < mg/l). c.albicans and c.parapsilosis were fluconazole sensitive (mic = - mg/l). four of eight c.glabrata were fluconazole resistant (mic = > mg/l). c.krusei, c.tropicalis and c.kefyr were also resistant (mic = > mg/l). wbilst there were no major discrepancies between the agar dilution test and the e test, the agar dilution test was laborious and required a high degree of skill. the e test was easier to read and more reliable results were obtained provided the inoculum was carefully standardised. this study shows that azole antifungals should not be ganglion is probably the commonest tumour encountered in the hand and the wrist. it often arises from tendon sheath or lining of a joint capsul. the treatment can be surgical or nonsurgical, the latter includes aspiration with or without injection of steroids. surgical treatment of ganglion can pose a difficult situation to deal with. it requires hand surgeon to deal with one such problem, we present a year old man with tender mass in the hypothenar eminence. during surgical exploration it was obvious that the ganglion was infiltrating the wall of the ulnar artery, and the histology proved this later. the clinical features, management arid the outcome of this unusual case are discussed. ischaemic preconditioning (ipc) of the myocardium with repeated brief periods of ischaemia and reperfusion (i-r) prior to prolonged ischaemia significantly reduces subsequent infarction. following ipc two "windows of opportunity" (early and late) exist during which prolonged ischaemia can occur with reduced myocardial infarction, we investigated if ipc of skeletal muscle prior to flap creation improved subsequent flap survival and perfusion in either early or late windows. the latissimus dorsi muscles (ldm) of sprague-dawley rats were used. group : (control, n= ). the ldm was elevated as a thoracodorsatly based island flap group : (early ipc, n= ). the ldm was preconditioned with two minute episodes of normothermic global ischaemia with intervening minute episodes of reperfusion prior to elevation. group : (late ipc, n= ). the ldm was elevated hours after ipc ischaemia was created by occlusion of the thoracodorsal artery and vein and the intercostal perforators having previously isolated the muscle on these vessels. muscle perfusion was assessed by a laser doppler perfusion imager. one week after flap elevation the percentage of muscle necrosis was measured by computer-assisted planimetry ipc significantly reduced muscle flap necrosis (table) in both early and late windows. muscle flap perfusion was similar in all groups. this study compares the biochemical, serological and histopathological findings in women with chronic hepatitis c virus (hcv) infection with age-matched women with established autoimmune hepatitis (aih). there is increasing evidence of autoimmunity in hcv liver pathology. because of different treatment regimens for hcv (d-interferon) and aih (steroids, immunosuppression), clear distinction between the two diseases is desirable. liver enzymes (alt, ast, alkaline phosphatase), antinuclear factor (anf), anti-smooth muscle (asm) and antimitochondrial (ama) antibodies are compared for both groups of patients. liver biopsies from all women were compared using the grading and staging system of ishak et al ( ) . the results show that while some women in both groups show elevated liver enzymes, positive anf and asm autoantibodies, the values are much higher in aih. similarly aih patients show overall more severe disease on liver histology. both groups demonstrate poor correlation between histological features and autoantibody titre. we conclude that distinction between hcv and a!h is usually possible with liver histology and serology. some women with chronic hcv and positive autoantibodies however," demonstrate a histological and serological picture suggesting that chronic hcv may be mediated by an immunopathogenic mechanism. irish journal of medical science terminal changes only, showed lymphocytic meningitis and of these also had perivascular lymphocytic inflammation (cd positive) in the subependymal regions, brainstem and choroid plexus. two brains showed purulent meningitis and one case had central pontine myelinolysis probably related to profound metabolic disturbance. basal ganglia mineralization, hiv encephalitis (hive) or hiv leucoencephalopathy (hivl) were not present. these findings differ considerably from those described in us cases, in whom the majority have evidence of hiv within the cns. relatively early death from systemic infection may account for the lack of hive/hivl in these cases. the lymphocytic meningitis and perivascular inflammation may represent an immuno-allergic reaction, previously reported as "early" changes, regarded as important in inducing vascular damage which allows subsequent entry of h v into the brain. the aim of this study is to assess apoptosis in areas of interface hepatitis and spotty necrosis in hepatitis c virus (hcv) infected liver biopsies, and to correlate the degree of apoptosis with severity of histological activity. liver biopsies were randomly selected from a group of type lb hcv positive women. these patients were diagnosed by recombinant immunoblot assay (riba) test and the presence of hcv rna was confirmed using the polymerase chain reaction (pcr). apoptosis was demonstrated in the biopsies by the oncor apoptag in-situ hybridisation technique. the average number of apoptotic hepatocytes per portal tract, and within the parenchyma per x objective, was determined. the modified histological activity index (h.a.i.) was used to score each biopsy. comparison of the results shows that increasing numbers of apoptotic hepatocytes are consistently associated with increasing scores for interface hepatitis and spotty necrosis. it is concluded that apoptosis occurs in hcv infected livers and that it correlates with increasing histological activity .indicating a significant role for apoptosis in the pathogenesis of hcv liver disease. and university of edinburgh, scotland. paediatric aids represents only % of cases worldwide, in most published series parental iv drug use was the main risk factor, cns pathology was a late feature of the disease and antiretroviral treatment had been given. we studied eleven brains from romanian children with probable postnatal hiv infection using standard neuropathological stains and immunostains for lymphocyte markers and hiv p antigen. death was due to systemic infection, mostly pneumonia or gastroenteritis; antiretroviral treatment had not been given. three cases showed we studied the role of the p and bcl- genes in the pathogenesis of post-transplant lymphoproliferative disease (ptl). ten cases were examined by immunohistochemical and molecular methods. immunohistochemistry was performed using standard and antigen retrieval methods, with the p do- and the bcl- oncoprotein clone antibodies. dna was extracted from paraffin blocks and subjected to pcr, and single-strand conformation polymorphism (sscp) analysis searching for mutated p genes. samples showing any evidence of aberrant migrations were further analysed by direct sequencing. pcr was also used to detect bcl- gene rearrangements. we employed a technique called representational difference analysis to search for previously undescribed translocations or deletions which may be involved in breast carcinogenesis. dna was isolated from both invasive ductal carcinoma of the breast and normal tissue from the same patient. following restriction enzyme digestion and tigation of oligonucleotide linkers, pcr was carried out on both tumour and normal dna using oligonucleotide specific primers to obtain a representation of each genome (amplicons). digestion with the same restriction enzyme removed the original linkers, and a second set of oligonucleotides were ligated to normal amplicons only. the tumour derived amplicons were subtractively hybridised to the normal and subsequent pcr was used to isolate fragments unique to the normal dna (difference products). this was possible since oligonucleotides were ligated to normal dna only. following a series of further subtractive hybridisations and subsequent amplifications, purified difference product was obtained. difference products in the size range - bp were obtained. following further rounds of subtractive hybridisation and amplification, purified difference product will be sequenced and characterised by comparison with known gene sequences. the chromosomal location of the affected gene will be established by in-situ hybridisation and somatic ceil hybridisation, using the difference product as probe. protein s is secreted by osteoblasts and case reports of reduced bone mineral density in patients with total protein s deficiency have lead to the hypothesis that this inherited disorder is associated with generalised osteoblast dysfunction predisposing to osteoporosis ~. we have assessed bone formation in patients ( male and female) with total protein s deficiency and controls ( male and female) using two recently available sensitive markers; serum osteocalcin (oc) and serum procollagen carboxyterminal peptide (p cp), both secreted by the osteoblast. the mean total protein s level amongst the patients was _+ % (ref range - %), mean oc was . ng/ml (ref ~'ange . - ng/ml) and the mean picp was . + uga (ref range - ug/ ). in the control group, mean oc was . _+ ng/ml and the picp was + ug/ . there was no statistical difference between both groups using either marker. in conclusion bone formation as assessed by serum osteocalcin and p cp appears to be normal in patients with total protein s deficiency. hereditary spastic paraparesis (hsp) is a variably expressed neurodegenerative disorder which exhibits clinical and genetic heterogeneity. hsp can be inherited in an autosomal dominant (ad), autosomal recessive (ar) or x-linked manner. ad-hsp has been linked to a number of loci. we have ruled out linkage to these loci in a large irish family affected with ad-hsp. the aim of this study was to determine whether ad-hsp is linked to spinocerebellar ataxia loci (sca), sca-i & sca-ii. ad-hsp can be clinically similar to sca. dna was extracted from blood taken from co-operating family members. microsatellite markers spanning the sca-i and sca-ii loci were amplified by pcr. individuals were genotyped and linkage analysis was carried out using the linkage set of programs. significantly negative lod scores were obtained for both sca-i and sca-ii loci. d s gave maximum exclusion of cm on either side of the sca-i locus with a lod of - . at a recombination fraction of . . d s gave maximum exclusion of cm on either side of the sca-ii locus with a lod of - . at a recombination fraction of . . other markers examined also outruled linkage to these loci. we conclude that the gene for ad-hsp is unlinked to the major sca loci. serum vitamin b is frequently measured in the investigation of anaemia, and in screening neurological and other disorders. frequently, patients are found with low serum vitamin b level with a normal hb and without clinical abnormalities relevant to vitamin b deficiency. this study was carried out to determine the significance of a low serum vitamin b level. vitamin b measurements were carried out over an month period using a chemiluminescence method (abbott imx). clinical data was obtained retrospectively. of the samples ( . %) representing patients had a low serum vitamin b level (> pg/ml) with a mean of pg/ml ( - ). data was available on patients. ( %) had a hb below the normal range with median serum vitamin b level of pg/ ml ( - ). ( %) had a normal hb, mcv and mchc with a median serum vitamin b of pg/ml ( - ), and had a normal hb with an abnormal mcv or mch. lft's, autoantibodies, schillings test and bone marrow examination data will be presented. in conclusion in patients with a low serum vitamin b level, there was no significant difference in the b levels in those patients with a normal or a low hb concentration. it would appear that serum vitamin b is a poor discriminatory test but that changing the normal range may not help in screening. low serum vitamin b on its own may not appear to provide adequate grounds for lifelong replacement therapy. of in for males and in for females. as expected the overall incidence of hodgkin's was lower with one third of male and one quarter of female lymphoma cases affected by the disease. a distinct age specific pattern is evident depending on lesion type. marked variation in incidence levels were noted throughout the study region. an extremely varied pattern is evident in the survival rates for lymphoma patients. the cork and kerry rates for malignant lymphoma are relatively low when compared with international levelstzl obstetric complications and schizophrenia: methodology and mechanisms perinatal complications and clinical outcome within the schizophrenia spectrum ) negative symptoms, cognitive impairment and duration of initially untreated psychosis in schizophrenia davnet's hospital, monaghan, and royal college of surgeons in ireland retinal pathology in kearns sayre syndrome mitochondrial dna and disease mitochondrial myopathies: clinical features, investigation, treatment and genetic counselling phenytoin induced pseudolymphoma. a report of a case and review of the literature cutaneous reactions in head injured patients receiving phenytoin for seizure prophylazis hydantoin induced pseudopseudolymphoma branhamella catarrhalis: an organism gaining respect as a pathogen correlation between branhamella catarrhalis adherence to oropharyngeal cells and seasonal incidence of lower respiratory tract infections ) epidem ology and survival rates for all lymphoma patients registered in cork and kerry over the eight year period an indepth review of all lymphoma (icd -o code ) patients registered by the sourthern tumour registry during the eight year period / ~l annual age adjusted rates of . . and . per , were seen for males and females respectively. these levels indicate a lifetime (up to yr) risk references . cancer, the irish experience cancer incidence in five continents volume v immunohistochemistry for bcl- oncoprotein without antigen retrieval gave negative results, but with antigen retrieval, showed positive staining in out of cases. no bcl- rearrangements were detected by pcr. the combination of sscp and sequencing confirmed only wild type dna in all cases, p immunohistochemistry by standard methods revealed positive staining in only one out of nine samples analysed. when the antigen retrieval method was employed for this antibody, positive staining was seen in > % of tumour cells in four further cases.our results suggest that p does not play major role in ptld. bcl- overexpression but not rearrangement may contribute to the development of ptld. transplant arteriopathy (ta) is the major cause of death in cardiac allograft recipients. the pathogenesis is unclear. we have previously shown a plasma cell predominance in the infiltrate of ta, leading us to hypothesise a role for epstein-barr virus (ebv) infection in its pathogenesis. an association between cytomegalovirus (cmv) and ta has previously been suggested. the aim of the study was to investigate the role of epstein-barr virus (ebv) and cytomegalovirus (cmv) in the pathogenesis of ta.we performed pcr for cmv and ebv dna and protein (lmp) in seven cases of ta, involving cardiac allografts. restriction mapping was used to confirm that pcr products were either cmv or ebv dna respectively.cmv dna was found in four cases. ebv dna was found in six of the seven cases and ebv lmp staining was present in six cases. ebv was detected in all cases by either pcr or ihc.our results suggest that ebv infection may play a pathogenic role in transplant arteriopathy. the evidence for a similar role for cmv ~s less strong. st. vincent's hospital. hereditary spastic paraplegia (hsp) is a neurodegenerative disorder characterised by progressive spasticity, primarily of the lower limbs. it can be inherited in an autosomal dominant (ad), autosomal recessive or x-linked manner~ we have identified a large irish family (family a) affected with ad hsp that cosegregates with dementia. three. loci have previously been identified that are linked to ad hsp in families of different ethnic origin. the locus on chromosome is reported to be the major hsp locus. the aim of the present study was to examine family a for linkage to the chromosome hsp locus.dna has been extracted from blood taken from all co-operating family members for genotyping. polymorphic microsatellite markers from chromosomal region p - have been amplified by pcr, electrophoresed on a denaturing polyacrylamide gel and detected by silver staining. linkage analysis was carried out using the linkage series of programs. linkage analysis excluded the hsp gene from the chromosome p locusl the most significant marker was d s , with a lod score of- . for recombination fraction . , thereby excluding approximately cm either side of this marker. negative lod scores were also obtained for the other markers chosen (d s , d s , d s , d s ) excluding cm, cm, cm and cm respectively.the current study has therefore successfully excluded linkage of ad hsp in family a to the major locus on chromosome p. further studies are underway to exclude linkage of hsp in this family from other candidate loci, prior to carrying out a genome wide search. the presence of dementia in this family in association with hsp suggests that a new and as yet unidentified gene is responsible. vincent's hospital. eye and ear hospital, dublin. ched is a corneal endothelial dystrophy characterised by diffuse bilateral corneal opacities resulting in impaired vision. both autosomal dominant and autosomal recessive modes of inheritance have been described. another endothelial dystrophy, posterior polymorphous dystrophy (ppmd) has been linked to qll.we have used homozygosity mapping to analyse a pedigree with autosomal recessive ched for linkage to ql. . all affected individuals are offspring of consanguinous matings. homozygosity mapping is based on the principle that these offspring would be homozygous for genetic markers near the disease gene. homozygous regions would be random between different offspring of these matings, except at the di-sease locus shared by affected offspring.dna was extracted from blood taken from family members, of which have ched. allele frequencies were determined in pooled dna from affected individuals. pooled dna from unaffected individuals was used as a control. at the disease locus, a shift in allele frequencies towards a single homozygous allele would be observed in the affected dna pool. pooled dna was genotyped by pcr for polymorphic microsatellite markers in the region of qll. pcr products were separated on a polyacrylamide gel and visualised by silver staining. similar allele frequencies were observed at these loci in both dna pools demonstrating independent assortment of alleles. in addition, affected and unaffected family members were individually genotyped at these loci and no significant loss of heterogeneity in the affected individuals at these loci was observed. these data indicate exclusion of linkage of the ched gene to qll. key: cord- -m n r authors: sole-violan, j; sologuren, i; betancor, e; zhang, s; pérez, c; herrera-ramos, e; martínez-saavedra, m; lópez-rodríguez, m; pestano, j; ruiz-hernández, j; ferrer, j; rodríguez de castro, f; casanova, j; rodríguez-gallego, c title: lethal influenza virus a h n infection in two relatives with autosomal dominant gata- deficiency date: - - journal: crit care doi: . /cc sha: doc_id: cord_uid: m n r nan introduction acute myocardial depression in septic shock is common [ ] . myocardial depression is mediated by circulating depressant substances, which until now have been incompletely characterized [ ] . the aim of our study was to observe the eff ects of tnfα on the model of perfused rat heart. methods after profound anesthesia with pentothal, the wistar rats were killed by exsanguination. after sternotomy, the heart was taken and connected to the langendorf column. the apex of the heart was hooked to a strength sensor. biopac student laboratory software was used to record and analyse heart contractions. contractions were recorded every minutes during periods of minutes. control measurements were fi rst recorded. we measured four parameters: heart rate, contraction force, speeds of contraction and relaxation for control, during tnfα ( ng/ml) exposure and after removal of tnfα. we express the variations of parameters as percentage of the control ± sem. a paired t test was used to compare heart rate, contraction amplitude, speeds of contraction and relaxation with tnfα and control measurements and after removal of tnfα. results eight rat hearts wistar (weight = ± g) were studied. see table . heart rate ± * ± introduction traditional whole blood experiments suggest that sepsis causes abnormal red blood cell (rbc) deformability. to investigate this at the cellular level, we employed a novel biophysical method to observe individual rbc membrane mechanics in patients with septic shock. methods we collected blood samples from patients with septic shock until either death or day of admission. thermal fl uctuations of individual rbcs were recorded allowing a complete analysis of rbc shape variation over time. mean elasticity of the cell membrane was then quantifi ed for each sample collected. we recruited nine patients with septic shock. table shows mean rbc thermal fl uctuation and sofa scores. conclusion rbc thermal fl uctuation analysis allows variations in rbc elasticity during sepsis to be quantifi ed at a cellular level. we could not identify any specifi c trend between sepsis severity and erythrocyte elasticity. cells demonstrated both increases and decreases in fl uctuation independent of sofa score. this is contrary to current evidence that suggests rbc deformability is reduced during sepsis. reference introduction whole blood experiments suggest that cardiopulmonary bypass (cpb) causes red blood cell (rbc) trauma and changes in deformability that may contribute to postoperative microcirculatory introduction neutrophil gelatinase-associated lipocalin (ngal)/ lipocalin , known as a sensitive biomarker of acute kidney injury, prevents bacterial iron uptake, resulting in the inhibition of its overgrowth [ ] . we previously demonstrated that this protein was discharged into gut lumen from crypt cells in septic conditions, and inhibited the growth of escherichia coli [ ] . however, it remains unclear which pathway is associated with the upregulation of ngal. we therefore designed the present study to reveal whether the patternrecognition receptor of bacteria, the toll-like receptor (tlr) family, plays a pivotal role for ngal secretion from gut crypt cells. methods with our institutional approval, the ileum and colon of male c bl/ j mice ( to weeks) were everted and washed by ca + and mg + free pbs buff er fi ve times. tissues were incubated with ca + and mg + free pbs containing mm edta for hour to isolate crypt cells of gut. the cell suspension was fi ltered through a cell strainer ( μm) twice, and deposited the crypt cells by centrifugation at ×g. the isolated crypt cells were resuspended in pbs and stained with . % amido black for labeling paneth cells. the × crypt cells were resuspended in ml hbss containing . % fetal bovine serum and % penicillin-streptomycin. the crypt cells were incubated at °c with or without tlr ligands: lipopolysaccharide (tlr ligand, μg/ml) and cpg-dna (tlr ligand, μg/ml). after a -hour incubation period, the crypt cells were deposited and eluted mrna to measure the expression of both ngal and tlr mrna using real-time pcr. results more than to % of collected cells were stained by amido black. lps signifi cantly upregulated the expression of ngal and tlr mrna in ileum and colon crypt cells (p < . ). although the cpg-dna did not upregulate ngal and tlr mrna in ileum crypt cells, the apparent expression of ngal and tlr mrna was found in colon crypt cells (p < . ). conclusion bacterial stimulation of tlr and tlr pathways plays a pivotal role in the expression of ngal mrna in gut, suggesting that ngal, derived from gut crypt cells, could contribute to the regulation of the intraluminal microfl ora in the critically ill. references introduction most individuals infected with the pandemic h n infl uenza a virus (iav) (h n pdm) experienced uncomplicated fl u. however, in a small subset of patients the infection rapidly progressed to primary viral pneumonia (pvp) and a minority of them developed ards. inherited and acquired variability in host immune responses may infl uence susceptibility and outcome of iav infection. however, the molecular nature of such human factors remains largely elusive. methods we report three adult relatives with the autosomal dominant gata- defi ciency. p and his son p had a history of myelodysplastic syndrome and a few episodes of mild respiratory infections. they developed pvp by h n pdm which rapidly evolved to ards. they died at the age of and , respectively. results patients were heterozygous for a novel r l mutation in gata . like other patients with gata- defi ciency, the three relatives had absence of peripheral nk and b cells and monocytopenia. however a high number of plasma cells, which were found to be pauciclonal, were observed in peripheral blood from p during h n pdm infection. p and p had normal levels of immunoglobulins and igg antibodies against common viruses. microneutralization test showed that p produced normal titers of neutralizing antibodies against h n pdm and against the previous annual h n strain. our results suggest that a few clones of long-living memory b cells against iav expanded in p ; and that these cells produced cross-reactive antibodies against h n pdm, similar to those recently described. during the fl u episode p had a strong increase of ifnγ-producing t cells and of ifnγ production. the th -related chemokines cxcl and cxcl , as well as ifnγ, mcp- and il- , were strongly elevated in serum from p and p in the course of h n pdm infection. conclusion gata- defi ciency is the fi rst described mendelian inborn error of immunity underlying severe iav infection. primary immunodefi ciencies predisposing to severe iav infections may debut, even in adults without a history of previous severe infections. the massive ifnγ-mediated cytokine storm may explain the fatal course of h n pdm infection in our patients. introduction adenosine exerts anti-infl ammatory and tissue protective eff ects during systemic infl ammation. while the anti-infl ammatory properties may induce immunoparalysis and impede bacterial clearance, the tissue protective eff ects might limit organ damage. the eff ects of a common loss-of-function variant of the adenosine monophosphate deaminase gene (ampd ), which is associated with increased adenosine formation, in patients with sepsis are unknown. methods in a prospective cohort, genetic-association study, the eff ects of the presence of the ampd gene on immune function, multiorgan dysfunction and mortality in septic patients was studied. pneumosepsis patients (n = ) and controls without infection (n = ) were enrolled. results in pneumosepsis patients and controls, a similar prevalence of the c>t (rs ) mutation in the ampd gene was found. univariate logistic regression analysis showed a tendency of increased mortality in patients with the ct genotype, compared with patients with the cc genotype (or . ; % ci . to . ). moreover, carriers of the ct genotype tended to suff er more from multiorgan dysfunction, or . ( . to . ) and . ( . to . ), for ct and tt, respectively (p = . ). in septic carriers of the ct genotype, the ex vivo production of tnfα by lps-stimulated monocytes was attenuated (p = . ), introduction hypogammaglobulinemia has been frequently found in adult patients with severe sepsis and septic shock. furthermore, it seems that at least a low serum level of igm is correlated with higher mortality in sepsis. the mechanisms of hypogammaglobulinemia in septic shock have not yet been explained. it has been hypothesized that outfl ow of immunoglobulins into the extravascular space due to increased capillary permeability could reduce immunoglobulin serum concentrations. angiopoietin- , which directly disrupts the endothelial barrier, is markedly elevated in sepsis and other infl ammatory states and its serum level has been correlated with microvascular leakage, end-organ dysfunction and death in sepsis. methods in the prospective, noninterventional study, we assessed the correlation between the capillary leakage marker angiopoetin- and serum levels of igg and igm in patients with community-acquired severe sepsis or septic shock on admission. blood samples were obtained during the fi rst hours after admission to hospital. results mean age of patients ( females) was years. median apache ii and sofa scores at admission were and , respectively. the mortality rate was %. thirty-four percent of all patients had level of igg < mg/dl. the median concentration of angiopoietin- in the hypo-igg group was , pg/ml, which was not statistically diff erent (mann-whitney; p > . ) than in the rest of patients with normal levels of igg ( , pg/ml). the concentration of igm < mg/dl was found in only four patients ( %) and all died. pearson's correlation test showed that the correlation between the concentrations of angiopoietin- and igg (correlation coeffi cient . ) or igm (correlation coeffi cient . ), respectively, were not statistically signifi cant (p < . ). conclusion at present the hypothesis that increased microvascular leakage is responsible for hypogammaglobulinemia in septic patients could not be accepted. studies on larger number of patients are needed. in addition, it is necessary to further explore other possible mechanisms, such as increased catabolism and consumption of antibodies or inadequate synthesis of immunoglobulins, which could also be responsible for hypogammaglobulinemia in sepsis. introduction septic encephalopathy is a frequent complication in severe sepsis but its pathogenesis and mechanisms are not fully understood. oxygen supply and utilization are critical for organ function, especially for the brain, a tissue extremely dependent on oxygen and glucose. disturbances in oxygen utilization are common in sepsis and a number of mitochondrial dysfunctions have been described in diff erent tissues in septic animals as well as in septic patients. our group described mitochondrial dysfunctions in the brain during experimental sepsis. methods experimental sepsis was induced by endotoxemia (lps mg/ kg i.p.) in sprague-dawley rats and by polymicrobial fecal peritonitis in swiss mice. brain glucose uptake was observed in vivo in endotoxemic rats using positron emission tomography with [ f]fl uorodeoxyglucose and autoradiography with -deoxy- c-glucose. results mice with polymicrobial sepsis present hypoglycemia, hyperlactatemia and long-term cognitive impairment. we observed a rapid increase in the uptake of fl uorescent glucose analog -deoxy- -(( -nitro- , , -benzoxadiazol- -yl)amino)-d-glucose in brain slices from septic mice in vitro. a similar increase in brain glucose uptake was observed in vivo in endotoxemic rats. remarkably, the increase in glucose uptake started hours after lps injection, earlier than other organs. the brains of mice with experimental sepsis presented neuroinfl ammation, mitochondrial dysfunctions and oxidative stress, but mitochondria isolated from septic brains generated less ros in vitro in the fi rst hours. this led us to investigate the role of nadph oxidase, an enzyme induced during innate immune response, as a potential source of reactive oxygen species in experimental sepsis. inhibiting nadph oxidase with apocynin acutely after sepsis prevented cognitive impairment in mice. our data indicate that a bioenergetic imbalance and oxidative stress is associated with the pathophysiology of septic encephalopathy. we are observing a new metabolic phenotype in the brain during sepsis, characterized by a rapid increase in glucose uptake and mitochondrial dysfunctions that may be secondary to infl ammation and hypoxia. introduction pathophysiology of brain dysfunction associated with sepsis is still poorly understood. potential mechanisms involve oxidative stress, neuroinfl ammation and blood-brain barrier alterations. our purpose was to study the metabolic alterations and markers of mitochondrial dysfunction in a clinically relevant model of septic shock. methods twelve anesthetized (midazolam/fentanyl/pancuronium), invasively monitored, and mechanically ventilated pigs were allocated to a sham procedure (n = ) or sepsis (n = ), in which peritonitis was induced by intra-abdominal injection of autologous feces. animals were studied until spontaneous death or for a maximum of hours. in addition to global hemodynamic and laboratory assessment, intracranial pressure and cerebral microdialysis were assessed at baseline, , , and hours after sepsis induction. after death, brains were removed and brain homogenates were studied to assess markers of mitochondrial dysfunction. introduction identifying a group of patients at high risk of developing infectious complications is the fi rst step in the introduction of eff ective pre-emptive therapies in specifi c patient groups. quantifying cytokine gene expression also furthers our understanding of trauma-induced immunosuppression. our group has already demonstrated that a predictive immunological signature derived from mrna expression in elective thoracic surgical patients accurately predicts pneumonia risk [ ] . methods in total, ventilated polytrauma patients were recruited. mrna was extracted from paxgene tubes collected within hours of the initial insult, at and hours. t-helper cell subtype specifi c cytokines and transcription factors mrna was quantifi ed using qpcr. ten healthy controls served as a comparator. results the median injury severity score (iss) was . time bloods demonstrated a reduction in tnfα † , il- § , il- ‡ , rorγt* and t bet § , and an increase in il- * and il- † mrna levels in comparison with the control group (*p < . , † p < . to . , ‡ p < . to . , § p < . to . ). there was a positive correlation between iss and il- ‡ whilst both il- § introduction measurement of biomarkers is a potential approach to early assessment and prediction of mortality in septic patients. the purpose of this study was to ascertain the prognostic value of proadrenomedullin (padm), measured in all patients admitted to the icu of our hospital with a diagnosis of severe sepsis or septic shock during year. methods a cohort study of patients > years with severe sepsis according to the surviving sepsis campaign, in an icu of a university hospital. demographic, clinical parameters and padm, c-reactive protein and procalcitonin were studied during year. descriptive and comparative statistical analysis was performed using the statistical software packages statistica stat soft inc . and medcalc . . . . results we analyzed consecutive episodes of severe sepsis ( %) or septic shock ( %) in the icu. the median age of the patients was introduction sepsis results from complex interactions between infecting microorganisms and host responses, often leading to multiple organ failures and death. over the years, its treatment has been standardized in early goal-oriented therapies, which may benefi t from circulating biomarkers for early risk stratifi cation. we aimed to evaluate the prognostic value of presepsin (scd -st), a novel marker of bacterial infection. methods we performed a nested case-control study from the randomized controlled albumin italian outcome sepsis (albios) trial, enrolling patients with severe sepsis or septic shock from icus in italy. fifty survivors and nonsurvivors at icu discharge were selected, matched for age, sex, center and time of enrollment after inclusion criteria were present. edta-plasma samples were collected at days , and after enrolment for presepsin (immunechemiluminescence assay pathfast presepsin, url pg/ml, cv %; mitsubishi chemicals) and procalcitonin assay (pct, elecsys brahms cobas® pct, url . ng/ml, cv . %; roche diagnostics). results clinical characteristics were similar between the two groups, except for a worse sofa score at day in decedents. presepsin at day was signifi cantly higher in decedents ( , ( , to , ) pg/ ml, median (q to q )) than in survivors ( , ( to , ) pg/ml, p = . ), while pct did not diff er ( . ( . to . ) vs. . ( . to . ) ng/ml, p = . ). presepsin decreased over time in survivors, but remained elevated in decedents ( ( to , ) vs. , ( , to , ) pg/ml at day , p = . for time-survival interaction); pct decreased similarly in the two groups (p = . ). patients with early elevated presepsin had worse sofa score, higher number of mofs, hemodynamic instability (lower mean arterial pressure at baseline and after hours), and mortality rate at days ( % vs. %, logrank p < . ). the association between presepsin and outcome was more marked in patients with late enrollment ( to hours), and in septic shock. early presepsin had better prognostic accuracy than pct (auroc . vs. . , p = . ), and improved discrimination over sofa score, especially in septic shock. conclusion early presepsin measurements may provide important prognostic information in patients with severe sepsis or septic shock, and may be of crucial importance for early risk stratifi cation. introduction infections are a major complication during the postoperative period after heart transplantation (ht). in our hospital, nosocomial pneumonia is the most frequent infection in this period. the objective of this study is to determine the epidemiological and microbiological characteristics of this disease in our centre. methods a descriptive retrospective study of all medical records of ht performed in a single institution from to followed until june . clinical and microbiological variables were considered. centre for diseases control (cdc) criteria were used to defi ne nosocomial infections. invasive aspergillosis was considered if there were criteria for probable aspergillosis according to idsa criteria. results in hts there were infectious episodes in patients ( . %). eighty-fi ve patients ( . %) died during hospitalization. infection is the second cause of mortality during the postoperative period ( . % of dead patients). the most common locations of infections were pneumonia (n = , . % of infection episodes), bloodstream (n = , . %), urinary tract (n = , . %), surgical site (n = , . %) and intraabdominal infections (n = , . %). patients with pneumonia were treated according to knowledge in a specifi c moment, thus diff erent antibiotics were used. the duration of antibiotic therapy was ± . days. in nine episodes of pneumonia according to the cdc no germ was isolated in the cultures. six of the episodes were polymicrobial infections. the most frequent microbes isolated were e. coli (n = , . % of pneumonia cases), a. fumigatus (n = , . %), s. aureus (n = , . %), p. aeruginosa (n = , . %), p. mirabilis, k. pneumoniae, e. cloacae, e. faecalis, c. glabrata, and s. marcescens (one case each, . %). pneumonia was suspected but not confi rmed in patients. despite this, antibiotic treatment was maintained for a media of . ± . days: wide-spectrum treatments and targeted therapy after knowing the antibiogram. the length of icu stay was . ± . ( to ) days, of hospital stay was . ± . ( to ) days and of mechanical ventilation was . ± . ( to ) days. the mortality of patients with pneumonia was . %. conclusion nosocomial pneumonia is the most frequent infection in our series. despite when infection was not confi rmed, antibiotic therapy was maintained in suspect cases. we found a high incidence of aspergillosis. limitations because of wide duration of this study should be considered. that numbers of cvc, intubation and surgery, the use of muscle relaxant and steroid were independent risk factors for developing vap. ventilator days and icu length of stay were longer in the vap group ( vs. and vs. days, respectively). lastly, the hospital mortality rate was signifi cantly higher in the vap group ( % vs. %, p = . ). conclusion the incidence of vap was . % in the sicu of siriraj hospital, which was comparable with previous reports. bundles of care to prevent vap should include weaning from a ventilator. muscle relaxant and steroid should be administered according to strong indication. meticulous care of the airway should be implemented as protocol in order to prevent complications that can result in the development of vap. reference introduction this is a -year prospective study to determine the incidence, source and etiology of hospital-acquired bloodstream infection (habsi) in the indian context. the resistance pattern was also reviewed. methods a single-centre prospective study in a -bed icu. habsi was defi ned according to current cdc guidelines. hcap, catheterassociated uti (cauti) and skin-related infections causing bsi was also defi ned according to recent guidelines and analysed. results out of positive samples, samples (n = ) were habsi. the microbiological analysis showed % were gram-negative, % were candida and % were gram-positive. the commonest isolate was klebsiella and mrsa was commonest in gram-positive. the source of habsi showed crbsi was the commonest cause at %, which correlates with international data. ventilator-associated pneumonia and cauti caused . % bsi respectively. the resistance pattern among gram-negative bacteria showed multidrug-resistant (mdr) and extreme drug-resistant (xdr) isolates were highest. see tables and . introduction catheter-related bloodstream infection (crbsi) is a complication of central venous catheters (cvcs) with an attributable morbidity, mortality and cost [ ] . we examined patient risk factors for crbsi in an adult parenteral nutrition (pn) population. the study was carried out in a -bed tertiary-referral teaching hospital over a -year study period ( to ). all inpatients referred for pn via cvcs were included. prospectively collected data were recorded in a specifi c pn record. the crbsi audit group met quarterly to review all sepsis episodes, assigning a diagnostic category (crbsi or non-crbsi). patient risk factors for development of crbsi were examined using a logistic regression model to take account of the dichotomous nature of the outcome. odds ratios from a model incorporating demographic and clinical data were tested for statistical signifi cance. introduction many patients develop infections following operations. decreased immune competence has been demonstrated in acute neurological conditions. a strong cytokine-mediated antiinfl ammatory response was observed in stroke patients at infection, although infection due to the decreased proinfl ammatory mediators can be expected as well. to investigate this question the following experiment was performed. methods twenty-two urinary bladder cancer patients with radical cystectomy and lymphadenectomy were studied. blood samples were taken on day (before) and days , , , and after operation as well as on days , , and during follow-up. tnfα, soluble tnfα receptor i and il- levels in sera were determined by hs elisa and/or elisa. plasma acth and cortisol values were measured by ria kits. results from patients, eight deep wound and urine infections were found in days and six urine and wound infections in days after surgery, all survived. all patients were bacterially contaminated, as wound samples taken at the end of operation demonstrated. on day the circulating tnfα values were lower in infected patients. tnf started to increase from day to day , never reaching values of the uneventful healing group. soluble tnf receptor i, il- , acth, and cortisol concentrations did not demonstrate any diff erence on day but from day started to increase transiently, reaching higher levels in septic patients. conclusion a low proinfl ammatory response is a key facilitating factor for the development of infection. measuring serum tnfα levels before and after operations can thus predict the outcome. evaluation during days in may including direct observation of hand hygiene compliance by control nurses and hand cultures of healthcare workers (hcw). based on the who guidelines on hand hygiene in health care [ ] , cleaning of hands with alcohol-based hand rubs (sterillium) was prescribed before touching a patient and before aseptic procedures, after body fl uid exposure risk and after touching a patient and touching his/her surroundings. promotion of the hand hygiene program consisted of lectures and web-based self-learning, posters located near points of care and verbal reminders by control nurses. new observations of hand hygiene by control nurses during days and hand cultures of healthcare providers were performed in september . consumption of alcohol-based hand rub (product volume use per patient-days) was used as a surrogate marker of hand hygiene over time. the diff erence in hand hygiene compliance during the two periods was examined using a chi-squared test. diff erences in hand cultures were examined using a student's t test. time trends in the consumption of alcohol-based hand rub were examined using linear correlation. p < . was considered statistically signifi cant. the study was approved by the institutional ethics review board. results during the survey, in may opportunities to observe hand hygiene were presented and in september. overall compliance improved from . % ( / ) to % ( / ), χ = . (p < . ). in may, hcw had a mean of . ± . colony-forming units (cfu) on their hands compared with . ± . cfu on the hands of hcw in september (p = . ). we also observed an initial increased use of alcohol-based hand rubs from ml per patient-day in may to a maximum ml per patient-day in june, but a decline to ml per patient-day in september, pearson correlation coeffi cient = . (p = . ). conclusion implementation of a new hand hygiene program at our icu resulted in improved hand hygiene compliance and less cfu on the hands of hcw. there was no signifi cant increased use of alcohol-based hand rubs over time. the results indicate that constant awareness is vital for success. reference introduction icu-acquired infection is directly related to hospital mortality. hand hygiene is an eff ective, low-cost intervention that can prevent the spread of bacterial pathogens, including multidrugresistant organisms. historical compliance with hand hygiene guidelines by physicians, nurses and other care providers is poor. methods present expectations by the infection control committee are to 'pump in, pump out' of every room, using % isopropyl alcohol. we performed , observations of hand hygiene in the surgical icu from march through october , and intervened to change behavior by providing monthly feedback to specifi c provider groups and services. we made use of the unit coordinator to measure compliance of all individuals in the icu. results overall compliance by physicians was . %, for nonphysicians was . %. feedback to physicians, individually and by service, dramatically increased hand hygiene compliance, defi ned as both on entry and exit from the patient room, over the study period. see figure . conclusion physician behavior is responsive to monthly feedback that is specifi c to the individual or surgical service. use of the unit coordinator was very eff ective at gathering a very large sample size in a short period of time. introduction the benefi ts of universal glove and gowning (bugg) study is a cluster-randomized trial to evaluate the use of wearing gloves and gowns for all patient contact in the icu. the primary outcome is vre and mrsa acquisitions; secondary outcomes include frequency of healthcare worker visits, infection rates, hand hygiene compliance and adverse events. methods we enrolled icus in states. icus collected nasal and perianal swabs on all patients at admission and discharge/transfer. after a -month baseline period, units were randomized to the intervention arm and required to wear gloves and gowns for all patient contact. an intervention toolkit was created based on site feedback and compliance reports. swab collection compliance was fed back and discussed during site conference calls on a weekly basis. site coordinators monitored compliance with gloves and gowns, hand hygiene and frequency of hcw visits and reviewed patient charts for adverse events. results during the -month study period, , swabs were collected. after the baseline period, we were able to achieve and maintain swab compliance rates between and %. monthly discharge compliance increased by % by the beginning of the intervention period ( figure ). observers found % compliance with universal glove and gowning over , -minute observation periods ( figure ). ninety charts at each site were reviewed for adverse events. conclusion over a diverse group of us hospitals, we achieved high compliance with surveillance cultures and implementing universal gloving and gowning was achieved quickly with high compliance. introduction sepsis accounts for a very high mortality. the surviving sepsis campaign recommends a fi rst hours resuscitative bundle to improve patient outcome. despite this, the bundle is poorly performed because of several organizational and cultural barriers. in recognition of this, we guess that an educational and organizational intervention out of the icus could impact on septic patient outcome. in order to test our hypothesis we carried out, in hospitals, a pre-intervention survey of the human and organizational resources (hor) available in the management of septic patients. the aim is to seek any barrier potentially aff ecting correct guidelines implementation. methods thirty-nine medical wards (mw) and emergency departments (ed) were enrolled. every unit was asked to fi ll in a pre-agreed hor checklist focused on the main requirements suggested by the guidelines. results analysing the human resources available, we see that the bedto-doctor ratio signifi cantly (p < . ) increases from the day to the night shift: from to beds per doctor on the mw (median). otherwise, the ed staff remains roughly the same: from . to . doctors on duty (median). the analysis of the organizational tools (table ) points out a low percentage of hospitals having: a diagnostic and therapeutic protocol for sepsis management ( . %), some hospital empirical antibiotic therapy guidelines ( %) and an infective source eradication protocol ( . %). moreover, just % of hospitals involve an infectious diseases expert in every case of severe sepsis or septic shock. conclusion we guess that the poor availability of hor showed by the hospitals could have a role in the guidelines implementation and in the patient's outcome. only a comparison between these results and data collected from a clinical checklist, focused on sepsis bundle compliance, and from a patient's outcome summary could confi rm our hypothesis. this is the aim for our next part of the study. reference introduction the incidence of patients carrying esbl-positive bacteria in our icu ( in admissions in ) was not considered problematic. however, routine cultures had identifi ed esbl-negative patients who had become colonized with esbl strains during their icu stay. self-disinfecting siphons, preventing bacterial growth by antibacterial coating and intermittent heating, and biofi lm formation by electromechanical vibration, were placed in all sinks in the icu. the aim of the present study was to evaluate the eff ect of this intervention. methods an intervention study in a -bed icu. the intervention involved placement of self-disinfecting siphons (biorec). all patients with an expected icu stay of days or more between january and december were studied. samples of throat, sputum and rectum were taken at admission and twice weekly, and cultured for esbls. between june and october , sinks in patient rooms were cultured regularly for esbls. after the intervention in april , multiple repeat cultures were taken. whenever the species and antibiogram of bacteria cultured from patients and sinks matched, they were typed by aflp. results before intervention multiple esbl-forming strains were found in sinks of all patient rooms. eighteen patients who were esbl-negative on icu admission became colonized with diff erent esbl strains, that were present in sinks of their admission rooms ( figure ). four contaminations were proven by aflp-tying. one patient died of esblpositive e. cloacae pneumonia. after intervention all sinks were negative for esbl strains. no further patients became esbl colonized during the icu stay. conclusion wastewater sinks were the likely source of esbl colonization for icu patients. after placing self-disinfecting siphons introduction the present study investigated the eff ects of a single dose of intraperitoneal (i.p.) igg and iggam administration on various behavioral alterations in a cecal ligation perforation (clp)-induced sepsis model in rats. methods female wistar albino rats ( to g) were divided into fi ve groups (n = ): a naive control group, a sham operated group receiving conventional antibiotic treatment, a clp group receiving clp procedure and conventional antibiotic treatment, and igg and iggam groups which were also applied g/kg, i.p. igg and igam therapy minutes after the clp procedure. ten, and days after the surgery, animals underwent three behavioral tasks: an open fi eld test to evaluate the locomotor activity, an elevated plus maze test to measure the level of anxiety, and a forced swim test to assess the possible depressive state. the results acquired from these tests were used to estimate the eff ect of immunoglobulin therapy on behavioral changes in clp-induced sepsis in rats. in the open fi eld test, the clp group showed a signifi cant decrease in total squares passed on days and . similarly, total numbers of rearing and grooming were dramatically decreased in the clp group in comparison with control and sham groups (p < . ). in the elevated plus maze test, the number of entries to open arms decreased in the clp group. in the forced swim test, there was a tendency for increase in immobility time in the clp group, although the data were statistically insignifi cant. all of these values which were indicating the importance of behavioral alterations were improved on day . immunoglobulin therapy prevented the occurrence of these behavioral changes. especially, animals in the iggam group conserved the values quite near to those of the control group in measured parameters. conclusion sepsis, even though it has been treated with conventional antibiotics, caused a negative eff ect on behavioral parameters. in this study, igg and iggam treated animals in the presence of clp did not show these behavioral changes. therefore our results suggest that a single dose of i.p. igg and iggam treatment, which was applied immediately after the sepsis procedure, prevents behavioral defects observed following sepsis. introduction thrombomodulin is an endothelial cell cofactor and glycoprotein for thrombin-catalyzed activation of protein c. a recombinant human soluble thrombomodulin (rhstm) has been recently developed, and this new agent has a unique amino-terminal structure exhibiting anti-infl ammatory activity including sequestraction and cleavage of high-mobility group box (hmgb- ). methods in this study, patients with septic disseminated intravascular coagulation (dic) were treated with rhstm, which is recomodulin® inj. (asahi kasei pharma co., tokyo, japan). patients with septic dic were treated with to u/kg/day. results there were signifi cant results for improvement of apache ii score and dic diagnostic criteria score for critically ill patients after treatment using rhstm (p < . ). improvement for platelet count and d-dimer level were also observed in this study (p < . ). activation of antithrombin (at) also was signifi cantly increased after treatment (p < . ). hospital mortality was . % in this study. conclusion the rhstm might be one of most important endogenous regulators of coagulation, acting as the major inhibitor of thrombin as well as at iii. this new agent may play an important role in treatment for septic dic. introduction antithrombin iii (at iii) has been known to contribute to anti-infl ammatory response as well as its anticoagulation. our previous introduction sepsis and septic shock are complex infl ammatory syndromes. multiple cellular activation processes are involved, and many humoral cascades are triggered. presumably, endothelial cells play a pivotal rule in the pathogenesis of sepsis, not only because they may infl uence the infl ammatory cascade but also because, upon interaction with excessive amounts of infl ammatory mediators, the function of these cells may become impaired. it is likely that a general dysfunction of the endothelium is a key event in the pathogenesis of sepsis [ ] . hmg-coa-reductase inhibitors have been shown to exhibit pronounced immunomodulatory eff ects independent of lipid lowering. most of these benefi cial eff ects of statins appear to involve restoring or improving endothelial function [ ] . we hypothesize that statins can improve endothelial dysfunction in septic patients. methods a double-blinded, placebo-controlled, randomized trial was undertaken. we enrolled adult patients within hours of severe sepsis or septic shock diagnosis and randomized them to placebo or atorvastatin mg/day for a short term. endothelial dysfunction was assessed measuring plasmatic levels of il- , et- , vcam- by elisa and measuring fl ow-mediated vasodilatation of the brachial artery at basal, and hours after randomization. results we studied patients, in the placebo group (mean age ± years, . % male; apache ii risk score . ± . ) and in the statin group (mean age . ± years, . % male; apache ii risk score ± . ). the baseline characteristics of the placebo group were similar to statin patients as well as the mean length of stay in the icu ( . ± . and . ± days, respectively) and the time on vasopressors ( . ± . and ± . hours, respectively). no signifi cant diff erence was observed on the temporal variation of biomarker levels (il- , vcam- , et- ) between treatment and control groups. the intrahospital mortality rate was % in the statin group and % in the placebo group (p = . ). introduction a novel sorbent hemoadsorption device for cytokine removal (cytosorbents, usa) was developed and successfully tested in animal models of sepsis. the experience in the clinical setting is still limited to case reports. in this fi rst clinical trial, we tested the hypothesis that treatment with sorbent hemoadsorption could safely and eff ectively reduce cytokines in septic patients with acute lung injury (ali). methods ventilated patients fulfi lling the criteria for severe sepsis and ali were enrolled in this multicenter randomized, controlled, openlabel study comparing standard of care with or without hemoperfusion treatment. primary endpoints were safety and il- reduction. treated patients underwent hemoperfusion at fl ow rates of ~ to ml/ minute for hours per day for consecutive days. the overall mean reduction in individual plasma cytokines for the control and treatment groups during the treatment period was calculated using a generalized linear model. results forty-three patients ( treated, control) completed the study and were further analyzed. incidence of organ dysfunction at enrollment (treatment vs. control) was: septic shock ( % vs. %, p = . ), acute respiratory distress syndrome ( % vs. %, p = . ), and renal failure ( % vs. %, p = . ). during treatments no serious device-related adverse events occurred. on average, there were no changes in hematology and other blood parameters except for a modest reduction in platelet count (< %) and albumin (< %) with treatment. hemoperfusion decreased il- blood concentration signifi cantly (- . %, p = . ), with similar reductions of mcp- (- . %, p = . ), il- ra (- . %, p = . ), and il- (- . %, p = . ). the -day mortality ( % vs. % control, p = . ) and day mortality ( % vs. % control, p = . ) did not diff er signifi cantly between the two studied groups. conclusion in this fi rst clinical study of a novel sorbent hemoadsorption device in patients with severe sepsis and ali, the device appeared to be safe and decreased the blood concentration of several cytokines. further research is needed to study the eff ect of the device on the clinical outcome of septic patients. response; and the changes of endotoxin and proinfl ammatory molecules. methods forty septic/septic shock patients with renal failure were enrolled in the study. all patients had preoperative endotoxin > . level/units (eaa spectral d) and were submitted to high-volume hemodiafi ltration ( ml/kg/hour, prismafl ex; gambro) with a new treated heparin-coated membrane (oxiris; gambro). at t (pretreatment) and t ( hours) the main clinical and biochemical data were evaluated. all data are expressed as mean ± sd. one-way anova test with bonferroni correction was used to evaluate the data changes. p < . was considered signifi cant. results table presents the main results of this study. conclusion in septic/septic shock patients with renal failure, crrt with a new treated heparin-coated membrane (oxiris; gambro) is clinically feasible, and has a positive eff ect on renal function and hemodynamics. an adsorbing eff ect on proinfl ammatory mediators may have a role in these results. these data and the trend toward a decrease of endotoxin during the treatment warrant further investigation. reference introduction endotoxin, a component of the outer membrane of gramnegative bacteria, is considered an important factor in pathogenesis of septic shock [ ] . the aim of our study was to determine whether endotoxin elimination treatment added to the standard treatment would improve organ function in patients with septic shock. methods adult patients with septic shock who required renal replacement therapy (rrt), with a confi rmed endotoxemia, and suspected gram-negative infection were consecutively added to the study within the fi rst hours after diagnosis. all patients received full standard treatment for septic shock. endotoxin elimination was performed using the membrane oxiris (gambro, sweden), a medical device for continued rrt with the unique feature of endotoxin adsorbtion. an endotoxin activity assay was used to monitor endotoxin elimination therapy at baseline (t ), hours (t ), hours (t ), hours (t ), hours (t ), and hours (t ). our key indicators were the improvement in hemodynamics and organ function, and decrease of endotoxin activity (ea) in blood. continuous variables are presented as mean values with standard deviations. results high ea level at baseline ( . ± . endotoxin activity units (eau)) signifi cantly decreased during rrt with oxiris membrane to . ± . (t ), . ± . (t ), . ± . (t ), . ± . (t ), . ± . (t ) eau (p < . ). map increased from baseline ± to ± , ± , ± , ± , ± mmhg (p < . ), and the mean norepinephrine use decreased from . ± . to . ± . , . ± . , . ± . , . ± . , . μg/kg/minute (p < . ) at t , t , t , t , t , t , respectively. the sofa score had decreased from ± to ± , ± , ± points (p < . ), and the procalcitonin level declined from ± to ± , ± , ± ± ng/ml (p < . ) at t , t , t , t . conclusion rrt with oxiris membrane resulted in the eff ective elimination of endotoxins from the blood. the therapy was associated with an increase in blood pressure, a reduction of vasopressor requirements, and an improvement of organ function. the application of the endotoxin activity assay was useful for bedside monitoring of endotoxemia in icu patients. introduction severe sepsis and septic shock remain the most serious problem of critical care medicine with a mortality rate of to % [ ] . several studies have demonstrated positive eff ects of selective adsorption of lps on blood pressure, pao /fio ratio, endotoxin removal and mortality [ , ] . the purpose of the study was to evaluate the effi ciency of using the selective adsorption of lps, toraymyxin -pmx-f (toray, japan) and alteco® lps adsorber (alteco medical ab, sweden), in the complex treatment of patients with severe sepsis. methods forty-six patients with gram-negative sepsis in the postoperative period were enrolled into the study. toraymyxin -pmx-f was used in the pmx-f group (n = ), while alteco lps adsorption was used in the alteco lps group (n = ). the clinical characteristics are listed in table . the sofa score, pao /fio , procalcitonin (pct), c-reactive protein (crp), endotoxin activity assay (eaa) was noted before, and hours after the selective adsorption of lps. results at hours after pmx-f, signifi cantly decreased pct from . ( . ; . ) to . ( . ; . ) ng/ml, p = . , decreased crp from ( ; ) to ( ; ) mg/l, p = . and sofa score from . ( , ; . ) to . ( , ; . ), p = . . at hours after alteco lps, signifi cantly decreased pct from . ( . ; . ) to . ( . ; . ) ng/ml. the -day mortality rate was . % (n = ) in the pmx-f group and . % (n = ) in the alteco lps group. introduction corticosteroid (cs) therapy in sepsis remains controversial and was fi rst introduced in sepsis management for its antiinfl ammatory property. cs has found a role in septic shock amelioration with inconsistent outcomes. the surviving sepsis campaign (ssc) includes cs as a level c recommendation in septic shock [ ] . adapting and practicing ssc guidelines vary between critical care units. accordingly, a survey was conducted to elucidate the usage of cs for septic shock by uk critical care physicians (ccps). methods following approval by the uk intensive care society (ics), the survey was publicised on the ics website and its newsletter. results a total of intensivists responded to this online survey. seventy-four ( . %) ccps prescribed cs only if the septic shock is poorly responsive to fl uid resuscitation and vasopressor therapy. six ( . %) initiated cs at the same time as vasopressor therapy. none initiated cs for patients with severe sepsis. no cs other than hydrocortisone is being used. the most commonly used intravenous regimen is mg hourly ( %) followed by mg hourly ( %). only % of ccps would prescribe it by infusion. less commonly used regimens were mg hourly ( %) and mg hourly ( %). only % would consider adding fl udrocortisone. prior to initiating cs, % of ccps would perform a short synacthen test, while % would not. the majority ( %) of ccps would stop cs after resolution of shock state or when vasopressor infusion is terminated whilst % after a fi xed duration. withdrawal of cs also diff ered, in that % tapered/weaned steroids, % stopped it abruptly and % of ccps would base their cs cessation pattern on the clinical context. only % of ccps believe that cs is benefi cial whereas % were unsure of the benefi ts in septic shock. only ( %) responders indicated that their critical care unit had a written protocol for cs in septic shock. conclusion the perceptions, usage and cessation of cs in septic shock vary but do appear to have shifted in the last decade. a uk survey in identifi ed that only % of icus used cs for septic shock and over % perform a short synacthen test [ ] . it appears that many intensivists are using cs for septic shock, despite confl icting outcome data. we all strive to practice evidence-based medicine but until we have a robust, reliable and methodical randomised control trial that attempts to resolve the cs debate, practice will remain diverse on this subject, as refl ected by our survey. references introduction from december to december , patients in scotland presented with confi rmed anthrax infection manifested by soft tissue disease related to heroin injection. these cases represent the fi rst known outbreak of a recently recognized form of anthrax, termed injectional anthrax, which appears to be associated with a high mortality rate ( % in confi rmed cases from the uk outbreak). while epidemiologic data from this outbreak have been published, no report has systematically described fi ndings in patients at presentation or compared these fi ndings in nonsurvivors and survivors. methods to better describe injectional anthrax, we developed a questionnaire and sent it to clinicians who had cared for confi rmed cases during the outbreak. completed questionnaires describing patients, nonsurvivors and survivors, were returned. results in preliminary analysis of categorical data, a signifi cantly (fisher exact test) greater proportion of patients with compared with without the following fi ndings did not survive; history of alcohol use (p = . ); the presence of lethargy (p = . ), confusion (p = . ), nausea (p = . ), abdominal pain (p = . ), or the need for vasopressors (p = . ), oxygen, mechanical ventilation, or steroids (all p = . ) at presentation; and excessive bleeding at surgery (p = . ). initial analysis of continuous data demonstrated that, compared with survivors at presentation, nonsurvivors had signifi cantly (one-way anova) increased respiratory rate, percent neutrophils on complete blood count, hemoglobin, inr, c-reactive protein, and bilirubin and signifi cantly decreased temperature, systolic blood pressure, platelets, sodium, albumin, calcium (corrected for albumin), base excess and bicarbonate (all p ≤ . ). conclusion the implications of the apparent diff erences noted between nonsurvivors and survivors in this survey of cases from the fi rst known outbreak of injectional anthrax require further study. however, these diff erences might inform the design of research during future outbreaks or of methods to identify patients most in need of anthrax-specifi c therapies such as toxin-directed antibodies. introduction based on the results of our previous studies [ ] we have identifi ed clinical risk factors for the emergence of gr(+) infections in our icu and we have developed a new algorithm for combating them. the choice of the particular antibiotic drug is guided by additional risk factors for severity of illness and data on the infectious focus. the response to therapy and its duration are also stated. the aim of the current study was to evaluate the effi cacy and safety of this preemptive approach. methods a randomized prospective controlled trial was carried out from september to september . patients were submitted to block randomization and stratifi ed on the basis of their initial saps ii exp score. antibiotic therapy was started on the day of inclusion in the treatment group and only with proven gr(+) pathogen in the control group. initial data were gathered on demographics, diagnosis, proven risk factors for sepsis-related mortality, severity of infl ammatory response, ventilator-associated pneumonia and organ dysfunction. dynamics of sirs, cpis and sofa scores, subsequent infectious isolates, ventilator-free days, length of icu stay and outcome were followed for each patient. results a total of patients were enrolled. no statistically signifi cant diff erences in their basal characteristics were found. the subsequent score values, length of icu stay and the number of ventilator-free days were also comparable between groups. the majority of gr(+) pathogens were isolated between and days of inclusion. no diff erences were found regarding the concomitant gr(-) fl ora and the related antibiotic therapy. the new organ dysfunction severity was similar in both groups (p = . ). the in-hospital mortality was . % in the treatment group versus . % in the control group (p = . ). signifi cant diff erences between the kaplan-meier estimates of survival were also not found (log-rank test p = . ). no major adverse reactions were observed. conclusion the implementation of this new policy failed to reduce the degree of organ dysfunction severity and was not associated with signifi cant survival benefi t. moreover, even though it did not reach statistical signifi cance, a second peak of gr(+) isolates was observed as a possible complication of the preemptive therapy. whether this approach could lead to vancomycin mic creep or there could still be a niche for it later in the course of treatment and/or in nontrauma patients remains to be further explored. reference introduction acinetobacter baumannii (a. baum) is a leading cause of septicemia of patients hospitalized in the icu with high mortality rates. the aim of our study is to investigate the risk factors associated with a. baum bacteremia and its mortality rates. introduction the french military hospital at the kaboul international airport (kaia) base provides surgical care for international force and afghan national army soldiers, and also local patients. the development of multiresistant bacteria (mrb) nosocomial infections has raised a major problem complicating the care of combat casualties [ ] . the aim of this study is to assess the prevalence of mrb carriage on admission to the icu in this combat support hospital. methods we used a prospective observation study on patients admitted to the french military icu in kaia over months (july to september ). all hospitalized patients were assessed for the presence of colonization with mrb: nasal and rectal swabs were performed to identify, respectively, methicillin-resistant staphylococcus aureus (mrsa) and extended-spectrum β-lactamases bacteria (esblb). the following data were recorded for each patient on admission: demographic characteristics, bacteriological results, length of stay, type of previous hospitalization. results sixty-three patients were admitted. the mean length of stay (mls) was ± days, and the mean age was ± ( patients < years). patients were hospitalized for combat-related trauma ( %), noncombat-related trauma, medical pathologies ( %), and postoperative care ( %). they were afghans ( %) or westerners ( %). swabs were not realized for eight patients. forty-three percent revealed an esblb colonization: escherichia coli ( patients), klebsiella pneumoniae (one patient), acinetobacter baumanii (one patient). no patients were colonized with mrsa. ten patients ( %) were directly admitted to the icu, ( %) had been hospitalized before admission, ( %) were transferred after resuscitative and stabilization care in a level unit. for the two last categories, the mls (for previous hospitalization) was respectively ± days and ± hours. among patients transferred after care in a level unit, mls was no diff erent between colonized and noncolonized patients: ± versus ± hours (p = . , mann-whitney test). conclusion in this study, prevalence of colonization with esblb at admission is very high, suggesting a high prevalence of mdr colonization in the local population in afghanistan. it remains important to intensify the prevention policy against mrb cross-transmission in the deployed icu. critical care , volume suppl http://ccforum.com/supplements/ /s introduction the aim of this study is to describe the clinical and epidemiological profi le of icu patients receiving tigecycline (tgc) and to evaluate the potential benefi ts of tgc higher doses. methods all patients admitted to our icu between june and may who received tgc were evaluated. cases were excluded when infections were not microbiologically confi rmed. results over the study period, patients fulfi lled the inclusion criteria: in the sd group ( mg every hours) and in the hd group ( mg every hours). the sd group and the hd group were not signifi cantly diff erent in terms of age, severity of disease, duration of tgc therapy, rate of concomitant other active antibiotic use and of inadequate empirical antimicrobial therapy (iiat) (p = ns). mdr a. baumannii and k. pneumoniae were the main pathogens isolated. the percentage of germs other than a. baumannii and k. pneumoniae was higher in the sd tgc group (p < . ). otherwise infections due to less susceptible germs (tgc mic value ≥ μg/ml) were mainly treated with tgc higher doses (p < . ). no signifi cant diff erences were found in terms of icu mortality (p = . ). the rate of abnormal laboratory measures during tgc treatment was similar between the two groups (p = ns). no patients required tgc discontinuation or dose reduction because of suspected adverse events. in the vap subpopulation ( patients: received sd and hd), the clinical cure rate and microbiological eradication percentage were higher when tgc was used at higher doses ( . % vs. . %; p = . and . % vs. . %; p = . ). table shows multivariate analysis of clinical cure predictors in the vap subgroup. conclusion in critically ill patients, hd tgc use seems to be safe and, combined with other active antibiotics, may increase the rate of mdr germ vap clinical success. iiat and the severity degree of patients' clinical condition still remain major determinants of vap treatment failure. reference introduction amikacin inhale (nktr- , bay - ) is a drugdevice combination in clinical development for adjunctive treatment of intubated and mechanically ventilated patients with gram-negative pneumonia. the product uses a proprietary vibrating mesh nebulizer system (pdds clinical) with amikacin sulfate formulated for inhalation ( . ml of mg/ml amikacin solution) for a -day twice-daily course of therapy. it is designed for use with two delivery systems: one system for intubated patients (on-vent; figure ), and a second handheld (hh) system for patients who are extubated before completing the course of therapy ( figure ). we investigated in vitro the amikacin lung dose delivered by pdds clinical. methods an estimated lung dose (eld) for on-vent setting was measured in vitro after collecting aerosolized amikacin from a fi lter at the end of an endotracheal tube during ventilation. the eld for the hh device was calculated from the fi ne particle fraction (fpf < μm) postmouthpiece, multiplied by the in vitro delivered dose post-mouthpiece. fpf < μm refl ects lung deposition observed during phase clinical trials [ ] . eighty-one nebulizers with volume median diameter (vmd) introduction recent studies demonstrate that a loading dose of mg/kg (total body weight) of amikacin in septic patients is required to reach a suffi cient peak concentration. this study examines parameters infl uencing the relation between amikacin dose and peak concentration. methods in this retrospective study we looked at patients ( peak levels) between and . multivariate linear regression analysis was done for several parameters: administered dose calculated with total body weight, ideal body weight, adjusted body weight, type of intensive care patient, bmi, daily fl uid balance, sofa score and apache score, and patient characteristics were analyzed. results a linear correlation between dose and amikacin peak level was confi rmed (figure ) . a total . % of all amikacin administrations did not result in a therapeutic peak level. the multivariate linear regression analysis showed the best linear correlation with adjusted body weight and sofa score. the comparison of variables between four patient groups, based on the deviation between measured peak level and predicted peak level (according the linear correlation), showed new variables that may infl uence peak level. conclusion this confi rms that low doses (< mg/kg) of amikacin in intensive care patients seldom result in a therapeutic peak level. the proposed loading dose of mg/kg is good for reaching a therapeutic level, although . % remains subtherapeutic. due to the linear correlation, more therapeutic levels may be reached with higher doses ( to mg/kg). new variables need further investigation to explain the high variability in achieved peak level. introduction antibiotic-associated diarrhoea (aad) occurs in as many as % of patients receiving antibiotics, often leading to increased morbidity, prolonged in-hospital stay and additional healthcare resource utilisation. age, antibiotics and prolonged postoperative ward and icu stay have been suggested to be independent risk factors. in such patient populations, probiotics may be used to prevent antibioticassociated diarrhoea, yet they are not routinely recommended as a component of perioperative care. the aim of this study was to model the long-term costs associated with aad and to assess the eff ectiveness of probiotics as a preventive strategy. we developed a simulation model to determine clinical costs and outcomes attributable to aad. to assess the cost-eff ectiveness of probiotics, as part of a perioperative regime, we constructed a decision critical care , volume suppl http://ccforum.com/supplements/ /s s tree. the model observes long-term costs and outcomes of probiotics as compared with conventional therapy, from a societal perspective. input parameters, extracted from meta-analysis, clinical trials and national databases, include incidence numbers, costs and qualityadjusted health states for the remaining life (qalys). outcomes assessed were overall costs attributable to add and the cost-eff ectiveness of probiotics, described as costs/qaly. our results indicate an estimated incremental lifetime cost of £ , . per add patient, largely driven by increased icu length of stay and readmission rates. the addition of probiotics to the standard perioperative regime is associated with a small survival benefi t of . months, yet a cost reduction of £ . /add patient. the main cost was increased duration of icu stay and readmissions, which contribute to % of total expenses. conclusion aad is associated with a signifi cant increase in costs from a societal perspective. the provision of probiotics can achieve substantial cost savings and can be recommended as a cost-eff ective regime in the perioperative setting. preventing add off ers a potentially signifi cant reduction of in-hospital costs and resource expenditures. introduction novel treatment strategies for invasive candidiasis (ic) are constantly emerging. nevertheless, diffi culties in diagnosis pose a challenge on their reliability, effi cacy and safety. we have previously developed and approbated in our icu an algorithm for empirical antimycotic therapy, combining the most signifi cant risk factors for ic with three major clinical criteria for persistent nonbacterial sepsis [ ] . on the other hand, preemptive therapy, based on identifi cation of mycotic antigens and/or anti-mycotic antibodies in serum, is regarded as more reliable, even though it is known for its low sensitivity. the aim of the current study was to compare and evaluate the possible outcome benefi t of our protocol implementation versus detection of galactomanan in patient's serum as a trigger for antimycotic treatment initiation. methods a randomized prospective controlled trial was carried out from september to september . after the implication of the inclusion and exclusion criteria, patients were submitted to block randomization and stratifi ed on the basis of their initial saps ii exp score. antimycotic therapy was started on the day of inclusion in the control group and only with positive galactomanan serum test in the preemptive therapy group. initial data were gathered on demographics, proven risk factors for ic-related mortality, severity of infl ammatory response and organ dysfunction. dynamics of sirs and sofa values, candida colonization index, ventilator-free days, length of icu stay and outcome were followed for each patient. results a total of patients were enrolled. no statistically signifi cant diff erences in their basal characteristics were found. the subsequent sirs and sofa scores showed fi rm dynamics in the control group, although the new organ dysfunction severity was insignifi cantly lower. the length of icu stay and the number of ventilator-free days were comparable. the in-hospital mortality was . % in the preemptive therapy group versus . % in the control group (p = . ). a total of seven adverse reactions were observed among treated patients, yet not associated with higher mortality risk. conclusion the choice of empirical versus preemptive therapy led to earlier and more stable reduction in the degree of organ dysfunction severity. it showed to be at least not inferior if not equal; in terms of survival benefi t and expediency of treatment. moreover, galactomanan detection fails to guide the choice of the individual antimycotic, based on the expected candida spp. reference introduction invasive candidemia is a major cause of increased mortality among icu patients. antifungal agents like liposomale amphotericin b and azoles could not accomplish the claim to be fi rst choice in the treatment of invasive fungal infection (ifi) because of side eff ects and eff ectiveness. especially, cardiothoracic surgery patients as a group of high-risk patients are in a focus for new strategies and agents. a new class of antimycotic agents, the echinocandins, with a low profi le of side eff ects, low interactive potential and high eff ectiveness in the treatment of candidemia, is a powerful option in the treatment of ifi. we report our single-center experience with a modifi ed clinical treatment approach based on clinical score of leon and using echinocandins as fi rst-line therapy for proven and suspected fungal infection. methods from may to october , , patients were treated on our cardiothoracic icu. we evaluated cardiothoracic postoperative patients with proven or suspected ifi or prophylaxis ( figure ). the records were evaluated for cardiothoracic procedures, microbiological and yeast date, cardiothoracic surgery score (casus), icu and clinical data. mean age was . years with % male patients. most patients had combined cabg and valve procedure (n = ), other groups were htx and ltx (n = ), assist therapy (n = ), tavi (n = ) and other procedures. mean predicted mortality using the logarithmic casus score at the onset of ifi was %. c. albicans was isolated in %, c. glabrata in %. length of antifungal treatment using micafungin in cases was ± days. eradication of yeast was successful in % but mortality of all patients remains high at . % but was lower than predicted in the casus score. mortality was not yeast related. conclusion our described treatment approach shows encouraging results for the treatment of ifi especially in high-risk cardiothoracic patients. with fungi [ ] . the relationship between colonization and invasive fungal infection (ifi) in severely ill icu patients with a vad support is not described. this study analyzes the incidence and outcome of fungal infection and colonization in vad patients in bridge to transplantation or in destination therapy. methods we conducted a retrospective review of all vad implantations in our surgical icu between and . the incidence of fungal colonization, antifungal prophylaxis, bacterial sepsis and the mortality of ifi versus no ifi patients were compared. results in the study period, patients with severe heart failure or cardiogenic shock were selected for a vad implantation (nine in destination therapy). the overall mortality rate was % during mechanical assistance. confi rmed (n = ) and highly suspected (n = ) ifi occurred during the icu stay in % of patients who were treated with echinocandins, voriconazole and/or liposomal amphotericin b. the isolated fungi were: six candida albicans, two parapsilosis, one glabrata and one invasive pulmonary aspergillosis. antifungal prophylaxis with fl uconazole was administered to % of patients at mean for days mainly in the more recent implantations. in the no ifi population, % (n = ) had a systemic or vad bacterial sepsis with a mortality rate about %. the mortality without any sepsis was reduced to %. fungal colonization was signifi cantly more present ( % vs. %) before ifi in vad patients. the mortality rate was dramatically higher with ifi ( % vs. %) in accordance with the literature [ ] . see table . conclusion in our center, we observed a high incidence of ifi in icu patients with vad that was associated with a mortality rate of %. screening of fungal colonization appears to be very important during the icu stay for vad patients. trials are needed for investigating the use, the drug choice and the timing of antifungal prophylaxis for such high-risk patients. reference introduction echinocandins are recommended fi rst-line treatment for candidaemia [ ] . a cost-eff ectiveness model developed from a uk perspective examined costs and outcomes of antifungal treatment for candidaemia and other forms of invasive candidiasis based on european clinical guidelines [ ] . methods costs and treatment outcomes with the echinocandin anidula fungin were compared with caspofungin, micafungin, fl uconazole, voriconazole and amphotericin b. the model included non-neutropenic patients aged ≥ years with confi rmed candidaemia/ another form of invasive candidiasis receiving intravenous fi rst-line treatment [ ] . patients were categorised as a clinical success or failure (patients with persistent/breakthrough infection); frequency data for each outcome were taken from a mixed-treatment comparison [ ] . successfully treated patients switched to oral therapy. clinical failures switched to a diff erent antifungal class. it was assumed that second-line treatment duration was equivalent to that of fi rst-line treatment and only two lines of therapy were required to treat infection. other inputs were all-cause -week mortality, cost of treatment-related adverse events (aes) and other medical resource use costs. life-years were calculated using a published model [ ] . antifungal agent-related aes were taken from the product label/literature. resource use was derived from the literature and discussion with clinical experts. drug acquisition/ administration costs were taken from standard uk costing sources. results first-line anidulafungin for treatment of candidaemia was cost-eff ective per life-year gained versus fl uconazole (incremental cost-eff ectiveness ratio £ ). anidulafungin was cost saving versus caspofungin and micafungin in terms of life-years gained due to lower icu costs and a higher rate of survival combined with a higher probability of clinical success. conclusion anidulafungin was cost-eff ective compared with fl uconazole for treatment of candidaemia and was cost saving versus other echinocandins in the uk. european guidelines recommend echinocandins as fi rst-line treatments for candidaemia [ ] ; this model indicates that anidulafungin marries clinical eff ectiveness and cost-eff ectiveness. introduction invasive fungal infections (ifi) aff ect % of icu patients and are increasing in incidence. ifis are associated with a poor prognosis, which is further complicated by diffi culties in identifi cation of fungal organisms by traditional culture methods and the emergence of candida species resistant to triazole therapy [ , ] . this study aimed to assess the prevalence of ifis, the organisms responsible and outcomes of patients aff ected. the majority of patients ( %) were treated with echinocandins, whilst of the nine patients who were initially treated with fl ucanazole, six ( %) required therapy escalation to an echinocandin. the results of our study are consistent with other published data, in that whilst ifi prevalence is low, they are associated with increased morbidity in critically ill patients. this study has led to a change in hospital policy regarding antifungal use in the icu, with echinocandins being fi rst-line in the pre-emptive treatment of ifi. we keenly await the results of the fire study, which will provide important insights to identifi cation of patients at risk of ifis and optimal drug therapy. introduction the aim of this study was to compare self-reported beliefs with actual clinical practice of oxygen therapy in the icu. hyperoxia is frequently encountered in ventilated patients and prolonged exposure has repeatedly been shown to induce lung injury and (systemic) toxicity. methods an online questionnaire for icu clinicians was conducted to investigate beliefs and motives regarding oxygen therapy for critically ill patients. furthermore, arterial blood gas (abg) samples and corresponding ventilator settings were retrieved to retrospectively assess objective oxygenation between april and march in the icus of three teaching hospitals in the netherlands. results analyzable questionnaire responses were received from icu physicians and nurses. the majority of respondents believed that oxygen-induced lung injury is a concern, although barotrauma and volutrauma are generally considered to impose a greater risk in mechanical ventilation. frequently allowed minimal saturation ranges in the questionnaire were to % and to kpa ( figure ). selfreported fio adjustment in hypothetical patient cases with variable saturation levels was moderately impacted by the underlying clinical condition. to study actual clinical practice, a total of , abg samples with corresponding ventilator settings, covering , patient admissions, were retrieved. analysis showed a median (iqr) pao of . kpa ( . to . ), median fio was . ( . to . ), median peep was ( to ). a total . % of all pao registries were higher than previously suggested oxygenation goals ( . to . kpa) [ ] . in . % of cases with pao higher than the target range, neither fio nor peep levels had been lowered when the next abg sample was taken. conclusion most clinicians acknowledge the detrimental eff ects of prolonged exposure to hyperoxia in the icu and report a low tolerance for high saturation levels. however, the self-reported intention for conservative oxygen therapy is not consistently expressed in our objective data of actual clinical practice and a large proportion of patients was exposed to high and potentially toxic oxygen levels. introduction during mechanical ventilation, oxygenation can be infl uenced by adjusting fio and positive end-expiratory pressure (peep). there have been recommendations for how the fio and peep should be set [ ] . however, in a recent audit we found that the compliance of doctors of these recommendations is very low [ ] . conclusion implementing an fpi ≤ -based algorithm signifi cantly reduced the fio and increased the peep applied in mechanically ventilated within the fi rst hours. whether this has any impact on earlier weaning due to reaching the weaning criteria of fio sooner, and as a result shortening the duration of mechanical ventilation, has to be investigated in the future. references system) were applied with the humidifi er to optimize humidication. typeb was used in three patients and typev in four patients. the fl ow was started at l/minute. this fl ow rate was titrated upwards to a maximum of l/minute ( , , , , , l/minute) and the agfr was measured. intratracheal pressure tracing was done over minute. airway pressure measurement was repeated and the maximal expiratory pressure was measured in mmhg. the agfr in the respiratory circuit was almost same in typeb, but there was obvious decrease in the agfr in typev ( . ± . , . ± . , . ± . , . ± . , . ± . , . ± . l/minute at assumed fl ow, , , , , , l/minute, respectively). hfnc signifi cantly increased maximal expiratory pressure in both groups, . ± . , . ± . , . ± . , . ± . mmhg for typev and . ± . , . ± . , . ± . , . ± . mmhg (maximum mmhg) for typeb, when agfr was set at , , , l/minute. higher agfrs were found to result in larger increase in maximum expiratory pressure. the data indicate that hfnc are associated with an increase in intratracheal expiratory pressure. because it was diffi cult to determine end-expiratory pressure, we chose maximal expiratory pressure for a substitute. the reason why agfr in typev was lower than assumed fl ow may be the resistance generated by nc. the larger increase in expiratory pressure in our study than previously reported may be due to the eff ect of high respiratory resistance of japanese who have relatively small airway structure compared with western people. conclusion hfnc are eff ective in providing higher expiratory pressure. it is important to know the fl ow rate is lower than expected when the venturi type is used. results a weaning-induced pulmonary edema was diagnosed in instances (paop signifi cantly increased from . ± . to . ± . in these cases). evlwi, bnp, plasma protein and hemoglobin concentrations signifi cantly increased in these instances ( . ± . %, . ± . %, . ± . % and . ± . %, respectively) while they did not signifi cantly changed in cases without weaning-induced pulmonary edema. the increase of evlwi ≥ . % (+ . ml/kg), an increase in bnp ≥ . % (+ pg/ml), an increase in plasma protein concentration ≥ % and in hemoglobin concentration ≥ % exhibited good areas under the roc curves to predict weaning-induced pulmonary edema ( . ± . , . ± . , . ± . and . ± . , respectively). these areas under the roc curves were not statistically diff erent. the baseline values of evlwi, bnp, plasma protein and hemoglobin concentrations did not predict weaning-induced pulmonary edema. conclusion the increases in evlwi, in plasma protein and hemoglobin concentration and in bnp are valuable alternatives to the pulmonary artery catheter for diagnosing weaning-induced pulmonary edema. the primary aim of this study is to assess the impact of pressure support ventilation (psv) on the rate of pneumothorax and mortality in critically ill patients with lung injury. the secondary aim is to evaluate pressure-volume (p-v) relationships. spontaneous modes of ventilation have been associated with lower rates of atelectasis, less muscle atrophy, better airfl ow distribution and importantly lower sedation requirements, which relates to lower mortality. accordingly, we hypothesized that the use of psv in patients with moderate/severe lung injury would have rates of pneumothorax and mortality within the standard of care. we further hypothesized that given its spontaneous nature, set pressures (peep and ps) but not tidal volume (vt) would be related to airway pressures. methods all adult patients admitted to two surgical/medical icus subjected to invasive mechanical ventilation (mv) were enrolled. patients were stratifi ed by lung injury score (lis) in two groups: < . (lisl); ≥ . (lish). exclusion criteria included pneumothorax on admission, use of other ventilatory strategies, and inability to trigger ventilation. patients were ventilated with psv, and treated only with pro re nata haldol, morphine and clozapine. airway pressures and conclusion we demonstrate that psv in minimally sedated patients with severe lung injury is safe as it is associated with low incidence of barotrauma, atelectasis and mortality, and with ppl and duration of mv within standard of care. we also demonstrate in psv that p-v relationships may diff er and that in this setting higher vt may not be deleterious. introduction the aim of this study is to compare two ventilation strategies, the ardsnet protocol and open lung management, using computer control for hours. the standard therapy for patients with ards does typically apply a mechanical ventilator to support breathing. the cost of therapy is high and it requires much attention from physicians to adjust the proper ventilation settings in a timely manner. a closed-loop ventilation concept has therefore been developed and tested with two induced ards pigs. methods the hardware system is composed of a ventilator (servo ), a spectrophotometry (cevox), a capnography device (co smo+), an electrical impedance tomography device (goe mf ii) and a patient monitor (sirecust). the software is developed with labview . . with approval from the ethical committee, two kg pigs were exposed to surfactant depletion with a warm saline washout to induce ards (pao / fio < mmhg). one pig model was ventilated with an automatic ardsnet protocol and another was automatically ventilated with open lung management. blood gas analysis (bga) was carried out every half an hour. results artifi cial ventilation using the auto ardsnet protocol successfully stabilized oxygenation, minimized plateau pressure (< cmh o), and controlled the ph value for acidosis and alkalosis management. on the other hand, auto open lung management off ers a distinctive result of ventilation. a signifi cant improvement of oxygenation and lung compliance was observed within a few breaths after the recruitment maneuvers. both subjects were ventilated at the same tidal volume of ml/kg and the comparative results of automatic ventilation settings and bga are provided in table for every hours. conclusion the auto open lung management concept gave much better gas exchange than the auto ardsnet protocol. these preliminary results showed a necessity to evaluate the two diff erent ventilation strategies. therefore, further experiments with pig models will be implemented in the near future to obtain results with statistical signifi cance and to ensure the safety of automation in a mechanical ventilation system. intellivent-asv has been developed to provide fully closed loop mechanical ventilation using a ventilation controller keeping etco and spo within expert-based ranges. ventilation of ards patients focuses on delivering adequate oxygenation and allowing elimination of co while protecting the lung. the objectives were to compare intellivent-asv with conventional ventilation on safety and effi cacy, and to compare the number of manual adjustments between the two ventilatory modalities. methods a randomized, controlled study including all consecutive patients receiving mechanical ventilation for at least hours. patients were randomly ventilated either with intellivent-asv or conventional ventilation, with a s (hamilton, bonaduz, switzerland). parameters were adjusted by the clinician in charge of the patient. ventilatory and oxygenation parameters were recorded cycle by cycle during hours and blood gases were performed every hours. results twenty-four patients with ards were included, female, male, median age ( to ) years, apache ii score ( to ), pao /fio at inclusion ( to ). eleven were ventilated in the conventional group and in the intellivent-asv group. the study was stopped for one patient from the intellivent-asv group because of a pneumothorax not caused by ventilation. the delivered vt was slightly higher during intellivent-asv ( . ( . to . ) vs. . ( . to . ) ml/kg, p = . ). the time spent by the various parameters in the suboptimal zone (safety) is the same for the two ventilation modes. the time spent in the optimal zone (effi cacy) is the same for the two ventilation modes, introduction ventilator-induced lung injury (vili) is a well-known side eff ect of mechanical ventilation. the pressures and volumes needed to induce vili in healthy animals are far greater than pressure and volumes applied in clinical practice [ ] . a possible explanation may be the presence of local pressure multipliers (stress raisers). methods we retrospectively analyzed ct scans of patients with ards and ct scans of healthy subjects. a homogeneous lung would have the same gas/tissue ratio in all its regions. if a lung region expands less than the neighbour regions these will be more strained to vicariate the non/less expanding region. we measured the stress raisers by computing the ratio between the gas fraction of the region of interest and the neighbouring regions: if the infl ation would be the same (homogeneity), the ratio will be equal to one; if the infl ation of the surrounding regions would be greater than the region of interest (that is, more strained), the ratio between the two will be greater than one and was taken as a measure of stress raiser. we considered pathological stress raisers as the regions showing infl ation ratio greater than the th percentile of the control group ( . ) and defi ned as the extent of the stress raisers the fraction of lung volume above this threshold. the extent of stress raisers increased with the severity of ards ( ± , ± , ± % of lung parenchyma in mild, moderate and severe ards, p < . ). the extent of stress raisers correlated with the dead space fraction (r = . , p < . ), with the fraction of poorly aerated tissue (r = . , p < . ) and also has a negative correlation with the fraction of well infl ated tissue (r = . , p < . ). the response to peep, passing from to cmh o is minimal (average decrease of stress raiser extent ± %) and inter-individual variability is great (in patients, stress raisers increased passing from peep to peep ). stress raisers turn out to be greater in nonsurvivor patients than in survivor patients ( ± vs. ± % of lung volume, p = . ). the art strategy did not increase the risk of barotrauma (relative risk (rr) = . , % ci = . to . ) in the fi rst days after randomization or the need to initiate or increase vasopressors or mean arterial pressure < mmhg (rr = . , % ci = . to . , p = . ) hour after randomization. however, the art strategy increased the risk for severe acidosis (ph < . ) hour after randomization (rr = . , % ci = . to . , p = . ). conclusion art is feasible. the incidence of adverse events was similar between groups except for severe acidosis hour after randomization. hence we adjusted the study protocol, increasing the respiratory rate (from to /minute) during msarm. introduction cardiac surgical procedures are associated with a high incidence of postoperative complications, increasing costs and mortality. the purpose of this study is to evaluate prospectively the impact of two protective mechanical ventilation strategies, both using low-tidal volume ventilation ( ml/kg/ibw) after cardiac surgery. conclusion the reliability of pressure measurements and also of compliance estimation via the tested catheters is high. only in two catheters was the fi lling volume a critical point for a precise measurement of pressure or for estimation of compliance. immediately after unpacking, adhesion of the balloon material might prevent reliable pressure measurement, therefore before the fi rst measurement overfi lling of the balloon and retention of the excess gas seems strongly recommended. introduction low tidal volume (vt) ventilation in intensive care patients without lung injury attenuates the systemic infl ammatory response [ ] . the contribution of the specifi c organ infl ammatory responses to the systemic picture remains to be elucidated. we investigated the eff ect of low vt ventilation compared with medium high vt on hepatic, splanchnic and cerebral cytokine responses in an experimental large animal postoperative sepsis model. methods twenty pigs, group protective ventilation (pv), were ventilated with low vt ( ml/kg) and peep cmh o while pigs, group control (c), were ventilated with a vt of ml/kg and peep cmh o. catheters were introduced into an artery, the jugular bulb, the hepatic vein and the portal vein. laparotomy for hours simulated a surgical procedure after which baseline ensued and a continuous endotoxin infusion was started at . μg/kg/hour for hours. diff erences were analyzed with anova for repeated measures. results tnfα levels were higher in the hepatic vein than in the artery, the jugular bulb and the portal vein. il- levels were higher in the artery and the jugular bulb compared with the portal and hepatic veins. il- levels were higher in the portal vein compared with the jugular bulb and hepatic vein. the organ-specifi c il- concentrations were all higher than the arterial concentration. comparison between the ventilation groups showed that tnfα, il- and il- in the hepatic vein were higher in group c compared with group pv at the end of the experiment. peak concentrations of tnfα and il- in the portal vein were higher in group c compared with group pv. in this experiment tnfα was mainly generated in the liver while the results point to signifi cant nonhepatic il- and il- production. ventilation with low vt and medium-high peep attenuated hepatic and splanchnic cytokine production compared with mediumhigh vt and lower peep. reference introduction airway pressure release ventilation (aprv) allows spontaneous breathing throughout the ventilation cycle. it increases venous return and cardiac index, which will signifi cantly improve organ perfusion. this is important in septic shock patients to prevent extrathoracic organ system failure secondary to poor perfusion. benefi ts of aprv with cardiovascular changes are noticed in patients with acute lung injury and acute respiratory distress syndrome. it is not well established whether applying aprv will improve the survival outcome for septic shock patients. the primary outcome is whether the use of aprv in septic shock patients restores hemodynamic stability earlier than the cmv mode. the secondary hypothesis is whether the use of aprv in septic shock patients improves their survival in the icu. methods after institutional review board approval, we retrospectively analyzed the clinical data of septic shock patients who received ventilator support between january and december at a tertiary care hospital. the cox proportional hazards model was used in adjusting potential confounding factors. the nonparametric wilcoxon rank sum test was used to assess signifi cant outcome diff erences between groups. time to event/survival data will be analyzed using kaplan-meier methods. these analyses were accomplished using sas, version . . results among the patients, were excluded as per the exclusion criteria: incomplete data (n = ), do not resuscitate (n = ), icu readmission (n = ) and head injury (n = ). finally, patients were included, from these received cmv and received aprv. at the beginning of the study, there were no diff erences between the groups in relation to hemodynamic parameters. reversal of shock achieved in less than hours was statistically signifi cant between the groups (aprv, n = ( %) and cmv, n = ( %), p = . ). the proportion of patients recovering from septic shock after initiation of ventilator therapy was higher in aprv than the cmv group ( % vs. %, respectively, p < . ). the mortality rate was signifi cantly higher in cmv (n = , %) as compared with aprv (n = , %) (p = . ). conclusion the use of aprv in septic shock patients restores hemodynamic stability earlier than the cmv mode. there was a signifi cant improvement in icu survival using aprv over cmv. early initiation of aprv in ventilated septic shock patients was associated with a decrease in icu mortality. obese patients are at risk of developing atelectasis and acute respiratory distress syndrome (ards) [ ] . the prone position (pp) may reduce atelectasis, and improves oxygenation and outcome in severe hypoxemic patients in ards [ ] , but little is known about its eff ect in obese ards patients. introduction protective mechanical ventilation (mv) in ards is based on reduced stretch of pulmonary tissue, sometimes resulting in severe hypoventilation that can be avoided when using high respiratory rate. high-frequency positive-pressure ventilation (hfppv) has not been fully explored, especially when associated with other strategies aiming to avoid hypercapnia. methods we induced ards in eight pigs by lung lavage with saline plus hours of injurious mv with low peep and high driving pressure (dp). we then performed a recruitment maneuver (rm) followed by peep titration using the amount of alveolar collapse in electrical impedance tomography (eit). then stabilization during hours with tidal volume (vt) at ml/kg, respiratory rate (rr) breaths/minute and peep selected with the peep-fio table (arma study), which was kept constant during two steps of hfppv with a rr : one without an inspiratory pause (hfppv- ), and one with a pause of % of inspiratory time (hfppv- w/p %). in another hfppv step, we used peep titrated with eit after rm (hfppv- w/rm). during each hfppv step, vt was set to reach a paco of ± mmhg. distribution of regional ventilation was analyzed using eit. equilibrium was considered if paco was stable (< % of variation) for > minutes. results hfppv allowed reduction in paco levels: ( , ) versus ( , ), ( , ), ( , ) mmhg, besides using lower vt: . ( . , . ), . ( . , . ), . ( . , . ) and . ( . , . ) ml/kg during stabilization, hfppv- , hfppv- w/p % and hfppv- w/rm, respectively. it had no signifi cant diff erent results comparing hfppv- with and without an inspiratory pause. hfppv- w/rm allowed a better alveolar homogenization and improvement in oxygenation, shunt, dead space and dp compared with the other steps. see table . conclusion hfppv with a conventional mechanical ventilator is able to maintain stable paco in clinically acceptable values, allowing reductions in vt. hfppv- w/rm and peep titration using eit allowed further physiologic benefi ts in a severe ards model. high-frequency percussive ventilation (hfpv) is a rescue technique for most severe acute lung injury/acute respiratory distress syndrome (ards) patients [ ] , especially with smoke inhalation or respiratory burns [ ] . this study aimed at characterizing hfpv as delivered by percussionnaire vdr ® and at evaluating how hypobarism interferes with hfpv, in order to assess its usability at altitude. methods using a mechanical test lung mimicking ards (compliance ml/cmh o) with two resistance levels ( and cmh o/l/second) and ventilated with vdr ® in a hypobaric chamber, ascents/descents between and , and then and , ft were performed. adjustable vdr ® parameters were modifi ed one at a time at each altitude. besides these parameters (cross-measured with standalone hardware), oxygen consumption of the respirator and three calculated parameters were studied: low-frequency tidal volume (vt, integrated from instantaneous fl ows measured with a fleisch pneumotachograph), end-inspiratory (pmei) and end-expiratory (pmee) mean pressures. pmei and pmee in hfpv refl ect plateau pressure and positive end-expiratory pressure in conventional ventilation. the correction of altitude-induced off set with the modifi cation of working pressure was also tested. results data displayed by vdr ® overestimated pulmonary pressures by more than %, but were reliable for other parameters. during ascent, an off set appeared for all respiratory parameters: vt increased by % and pmei by % between and , ft. during descent, the off set was reversely directed with a % decrease in vt and a % decrease in pmee between , and ft. modifying working pressure adequately corrected pmei and pmee, but not vt. in all cases, manually correcting vdr ® parameters to their ft level also corrected these off sets. multivariate analysis further established that, adjusting for other parameters, vt, pmei and pmee did practically not depend on altitude. oxygen consumption of the respirator was high, l/minute at ft, and stable with altitude. it was reduced with percussive rate and with fio . conclusion hfpv can be safely used at altitude, provided that vdr ®displayed parameters are used to manually adjust settings in order to avoid exposing patients to volutrauma or barotrauma during ascent, and to major hypoventilation and alveolar collapse during descent. the high oxygen consumption is currently the main limit to its use for longrange aeromedical evacuations. the application of peep is commonly used in acute respiratory distress syndrome (ards) and has been shown to improve oxygenation. to identify patients that most benefi t from the application of peep, the discrimination of recruiters and nonrecruiters has been postulated by gattinoni and colleagues [ ] . recently, dellamonica and colleagues [ ] presented a method to predict alveolar recruitment. we hypothesised that the amount of recruitable volume allows the discrimination between ards patients and patients with healthy lungs (hl). methods we recalculated the recruited volume (rv) in patients with ards [ ] according to the method proposed by dellamonica and colleagues during an incremental peep manoeuvre (peep increased until the plateau pressure reached cmh o). rv was calculated as the change in end-expiratory lung volume minus total respiratory system compliance times the peep change (rv = Δeelv -ctot×Δpeep). for comparison, patients with hl undergoing elective surgery in general anaesthesia were measured using the same protocol. results both ards and hl patients exhibited typical p-v curves and stepwise recruitment ( figure ). by raising peep from to cmh o, ards patients recruited ± ml (mean ± sd) and hl patients ± ml. there was a strong correlation (r = . ) of the total rv with the end-inspiratory volume at a plateau pressure of cmh o in both groups; that is, recruitment was found to the same extent in both groups ( figure ). conclusion the relative contribution of rv to lung volume gain is similar in ards and in patients with healthy lungs. our results question the relevance of recruitability as defi ned by dellamonica and colleagues as a typical phenomenon of ards, but support the baby lung concept, as the recruited volume was closely related to the size of the lung. introduction venovenous extracorporeal membrane oxygenation (vv-ecmo) for respiratory failure in the icu is used in a variety of clinical situations and has been demonstrated to signifi cantly improve survival without disability in adult respiratory distress syndrome [ ] . ecmo has been presented as a risk factor for bloodstream infection although recently published data do not support this view or the use of antibiotic prophylaxis [ ] . we aimed to examine vv-ecmo as a risk factor for nosocomial bloodstream infection. a larger study is needed to confi rm such fi ndings and to assess the need for specifi c intervention, namely routine antibiotic prophylaxis. introduction aptt is a common tool for anticoagulation monitor ing during extracorporeal membrane oxygenation (ecmo). thromboelasto graphy (teg) is another available option in this setting. methods a prospective observational study on consecutive patients during venovenous ecmo. anticoagulation was provided critical care , volume suppl http://ccforum.com/supplements/ /s s with unfractioned heparin titrated to an aptt ratio target of . to . kaolin-activated teg (k-teg) was contemporarily measured but did not guide heparin infusion. baseline k-teg reaction time (r) > minutes is accepted for anticoagulation but when it exceeds minutes anticoagulation may be too great [ ] . results mean ecmo duration was ± days. a total of k-tegs were collected. comparison between aptt and k-teg r is reported in table . four patients ( %) had hemorrhagic complications. neither aptt nor k-teg r were signifi cantly diff erent in patients with hemorrhagic events compared with patients without hemorrhagic events but the latter received a signifi cantly lower total heparin dose (p = . ). conclusion anticoagulation was excessive in more than one-half of the samples according to teg monitoring, while negligible based on aptt. reference introduction the usefulness of extracorporeal membrane oxygenation (ecmo) is being rediscovered in the wake of the pandemic of h n infl uenza. however, it has been reported that patients who received ecmo often developed virus-associated hemophagocytic syndrome (vahs), compared with those without ecmo support. although there is ample evidence that extensive cytokine activation is a key factor in vahs, ecmo itself could be a potential trigger to exacerbate the pathology by amplifying cytokine activation. in this study, we investigated whether mediators such as cytokines may be produced by ecmo. methods patients with severe respiratory failure who were placed on ecmo were enrolled between june and july . this study was approved by the ethics committee. blood specimens were drawn from the blood circuit at the inlet of the centrifugal pump (before) and outlet of the hollow fi ber oxygenator (after) at a frequency of three to four times per day. blood il- β, il- , il- , il- , il- , il- , il- , il- , il- (p ), il- , il- , g-csf, gm-csf, ifnγ, mcp- , mip- β, and tnfα were measured globally using a multiplex cytokine bead array system (bio-plex; bio-rad, tokyo, japan). hmgb was measured using an elisa kit (shino-test, tokyo, japan). results two patients with interstitial pneumonia were studied. the ecmo system consisted of a rotafl ow centrifugal pump (maquet japan, tokyo, japan), a biocube tnc coating (nipro, osaka, japan), and a percutaneous cardiopulmonary support system (capiox ebs; terumo, tokyo, japan). the blood fl ow rate was . ± . l/minute. a total of blood sets were collected. in most cases, blood levels of il- β, il- , il- , il- , il- (p ), il- , il- , gm-csf, ifnγ, and tnfα were below the detection limit and did not increase during ecmo. the other mediators were detected at the inlet (before), but no signifi cant increase was observed at the outlet (after) (hmgb , p = . ; il- , p = . ; il- , p = introduction during severe exacerbation of chronic obstructive pulmonary disease (copd) tachypnea, as a consequence of respiratory acidosis, and airfl ow limitation, due to small airway obstruction, lead to lung hyperinfl ation, respiratory distress and gas exchange impairment. invasive mechanical ventilation could worsen lung hyperinfl ation and produce a vicious circle. we investigated whether increasing extracorporeal carbon dioxide removal (ecco cl) could reduce the respiratory rate (rr), so prolonging time for lung emptying and allowing resolution of hyperinfl ation. methods six patients with copd exacerbation with respiratory acidosis (paco ± mmhg, ph . ± . ) and tachypnea (rr ± ) despite maximal non-invasive ventilation underwent venovenous extracorporeal membrane oxygenation (vv-ecmo). all patients were awake and spontaneously breathing an adequate air-oxygen mixture to correct hypoxemia (pao ± mmhg). while keeping the blood fl ow stable ( . ± . l/minute), we changed the gas fl ow of the artifi cial lung to modify the extracorporeal co clearance as a percentage of total patient co production (% ecco cl/total vco ) and we observed the variations of rr. we recorded rr at three levels of gas fl ow in each patient ( figure ) . in all patients rr decreased with the increase of extracorporeal co removal and a negative correlation was found between rr and ecco cl/total vco (r = . , p < . ). in all patients we were able to obtain a reduction of rr below ( ± vs. ± , rr at low gas fl ow vs. rr at maximal gas fl ow, p < . ). the selected maximal gas fl ow was variable between diff erent patients ( . ± l/minute), corresponding to diff erent levels of ecco cl/total vco ( ± %, range to %) and rr response ( ± , range to ). conclusion in patients with copd exacerbation, who failed noninvasive ventilation, vv-ecmo allows one to maintain spontaneous breathing. titration of extracorporeal co removal leads to control rr. this approach could interrupt the vicious circle of dynamic hyperinfl ation and allow the defl ation of lung parenchyma. table presents the main results. the co removal by membrane oxygenator ranged from to ml/minute. all patients survived to the treatment and / were weaned from the ventilator at the end of ecco removal. only one oxygenator was used for every patient without clotting of the circuit or any major bleeding problem. we have previously shown, in an ex vivo porcine model, that lung elastance calculated as the peep change divided by lung volume increase (Δpeep/Δeelv) is closely correlated to conventionally measured lung elastance using oesophageal pressure [ ] . in this study we hypothesize that the successive change in lung volume during a peep-step manoeuvre could be predicted from Δpeep and lung elastance as Δpeep/el. the objective of the study was to validate this hypothesis in patients with acute respiratory failure (arf). methods thirteen patients with arf were studied during an incremental peep trial, - - - - cmh o. Δeelv was determined as the change in expiratory tidal volume following each peep step. conventional calculation of lung elastance was obtained from tidal variation in airway pressure minus tidal variation in oesophageal pressure divided by tidal volume. position of the oesophageal catheter was verifi ed according to baydur [ ] . the measured change in end-expiratory lung volume during the peep-step manoeuvre using spirometry was compared with the end-expiratory lung volume change calculated from el and stepwise changes in peep as Δpeep/el. results there was a close correlation between the measured build-up of end-expiratory lung volume during a peep-step manoeuvre and Δpeep/el where el was conventionally determined using oesophageal pressure measurements (see figure ). conclusion esophageal pressure measurements are diffi cult to perform [ ] and rarely used in routine clinical practice. our fi ndings indicate that a change in peep together with measurements of the resulting change in end-expiratory volume by spirometry in the ventilator could be used to determine lung elastance separately, the relation between lung and chest wall elastance as well as the transpulmonary pressure. references introduction long-term use of mechanical ventilators may lead to ventilator-induced diaphragmatic dysfunction (vidd) and increase the duration of weaning from mv [ ] . it was hypothesized that stimulating the diaphragm during mv may prevent vidd and may lead to early weaning [ ] . in this study, the feasibility of generating coordinated contraction of both diaphragms was investigated using a novel transvenous diaphragmatic pacing system. methods two juvenile pigs were anesthetized with propofol ( to μg/kg/minute) and ventilated (vent) with an assist control mode mv (nellcor puritan bennett ). using fl uoroscopy, a novel multipolar neurostimulation catheter (inspirx rl picc ; respithera, bloomington, mn, usa) was threaded into the left internal jugular vein and advanced to the junction of right atrium and the superior vena cava using a modifi ed seldinger technique. the successful capture of the right and left phrenic nerves was confi rmed by fl uoroscopic visualization. peak airway pressures (pawp) and blood gases were determined after minutes mv (mv), mv and stimulation applied together (mv+stim) and stimulation only (stim). no animal-ventilator dyssynchrony during stimulation (mv+stim) was noted while peak airway pressures were reduced. during stim there was no discernible paradoxical movement of the diaphragm. in addition, pco and po confi rmed that adequate ventilation and oxygenation can be provided by the system, while pawp could be reduced (table ) . introduction retrospective studies suggest that cardiac troponin levels are often elevated in patients with acute exacerbation of chronic obstructive pulmonary disease (aecopd) indicating a poor survival. novel high-sensitivity cardiac troponin (hs-ctnt) assays have better analytical precision than standard troponin (ctnt) assays. we elaborated a prospective cohort study to investigate the prognostic value of this novel biomarker in patients with aecopd. methods fifty-six patients (mean age years, % male) with the fi nal diagnosis of aecopd were enrolled. those who were diagnosed with acute coronary syndromes were excluded. we measured cardiac troponin t with a standard fourth-generation assay and a highsensitivity assay. clinical, electrocardiographic and echocardiographic data were collected at admission and the primary prognostic endpoint was death during days of follow-up. introduction british thoracic society guidelines on communityacquired pneumonia (cap) advocate icu referral for patients with curb score of and . a recently developed scoring system, smart-cop, designed to identify patients at need of intensive respiratory or vasopressor support (irvs), has been validated in a variety of settings. it predicts the need for icu admission (defi ned as need for irvs) with greater accuracy than curb , but is not used routinely in our uk institution. methods we retrospectively analysed critical care admissions of patients with a diagnosis of cap in a uk district general hospital -icnarc-coded diagnoses of pneumonia (bacterial, viral, no organisms isolated) over a -month period (august to january ). we ascertained the curb and smart-cop scores on referral to the icu and matched them in relation to the need for irvs, length of inotropic and ventilatory support and icu length of stay. results our search revealed potential matches. five patients were excluded (not cap) and the notes for seven patients were not available for analysis. we analysed the notes of patients matching our criteria. in this small sample, there was a strong association between increasing smart-cop score and the need for irvs (correlation coeffi cient r = . ). there was also a strong correlation with longer inotropic support (r = . ) and longer ventilatory support (r = . ) with increasing smart-cop scores but a weaker correlation with length of icu stay (r = . ). moreover, none of the patients admitted to the icu had curb score higher than at the time of icu referral. conclusion in our small sample, higher smart-cop score was associated with increased likelihood of irvs. this suggests that a further study with a larger sample size should be performed to investigate whether smart-cop is an improvement on curb in predicting the need for irvs in uk intensive care patients. introduction streptococcal pneumonia remains the most common cause of community-acquired pneumonia (cap), bacterial meningitis and bacteremia. severe pneumonia caused by streptococcal pneumonia frequently exists in the emergency room or icu. we performed this study to evaluate the eff ect of steroid therapy for severe streptococcal pneumonia patients with mechanical ventilation retrospectively. methods we enrolled adults of streptococcal pneumonia patients who required mechanical ventilation. seven of patients (s group) were administered with steroid (hydrocortisone to mg/day), and the remaining six patients received no steroid therapy (ns group). as the conventional therapies, mechanical ventilation was commenced when a patient's pao /fio showed less than or they clinically complained of being short of breath. all patients received appropriate fl uid therapies, vasoactive agents and blood transfusion according to the protocol of early goal-directed therapy in the surviving sepsis campaign guidelines , and also were treated with antibiotics, immunoglobulins ( g/day for days) and sivelestat sodium hydrate ( . mg/kg/day for days). the apache scores in the s group and ns group were ± and ± , sequential organ failure assessment scores were ± and ± , respectively. these scores showed no signifi cant diff erence between the groups. procalcitonin (pct) in the s and ns groups was . ± . and . ± . ng/ml, respectively, and there was no signifi cant diff erence between the groups. pct declined signifi cantly in both groups. pao /fio of the ns group was signifi cantly higher than the s group on icu admission and days after admission, but no signifi cant diff erence on days after icu admission. il- of the ns group declined signifi cantly after icu admission, and the s group also tended to decline. conclusion steroid therapy for severe streptococcal pneumonia patients with mechanical ventilation may have a potential to maintain oxygenation of the lung, but no signifi cant eff ects on changes of infl ammatory markers (il- , crp). introduction electrical impedance tomography (eit) is a non-invasive and nonradiating imaging technique, which can be used to visualize ventilation distribution of the lungs and could distinguish between the dependent (dorsal) and nondependent (ventral) parts. methods the aim of this study was to observe ventilation distribution between dependent and nondependent lung regions, for the individual patient, during three diff erent levels of support during pressure support (ps) and neurally adjusted ventilatory assist (nava) ventilation. ten mechanically ventilated patients in the icu were included. the ratio for dependent/nondependent distribution of ventilation is signifi cantly higher at lower support levels compared with higher support levels in both ps and nava. however, during nava there was signifi cantly less impedance loss between the diff erent levels of assist compared with ps. tidal volumes decreased when decreasing assist levels during ps whereas not during nava ventilation. the electrical activity of the diaphragm decreased in both ps and nava with higher levels of assist. three patients showed an increase in dependent tidal impedance variation (tiv) after lowering the assist level from to cmh o. this increase in tiv did not occur during nava ventilation. conclusion there is more ventilation in the dependent part of the lung, compared with the nondependent part, at lower levels of assist. this could indicate that at higher support levels the contribution of the diaphragm is reduced. during nava ventilation, there is an autoregulation in which the patient is adjusting his tidal ventilation to maintain homogeneous ventilation distribution. in status asthmaticus. our purpose was to analyze bipap use and outcomes for children with status asthmaticus and obesity in our ped. methods patients placed on bipap in the ped for status asthmaticus from january to august were included in the analysis. subjects were divided into moderate and severe exacerbations and then further subdivided into the following growth curve-based weight subgroups: < percentile, to percentile and > percentile. subjects received standard asthma therapies in addition to bipap. data were obtained at the bedside by the respiratory therapist or collected retrospectively by study investigators. data were stored and analyzed using a redcap database. results three hundred and fi fty-nine subjects were analyzed. table shows the time on bipap per visit. children whose weight was > percentile revealed trends towards longer treatment times on bipap compared with the other two groups. we explored the feasibility, reliability and physiological signifi cance of diaphragm thickening on ultrasound. methods five healthy subjects participated. we monitored inspiratory fl ow, volume, esophageal and gastric pressures, and diaphragm electrical activity (by esophageal and surface electromyography) while subjects performed a series of inspiratory maneuvers: tidal breathing, threshold-loaded breathing, a muller maneuver, and inspiration to various lung volumes above functional residual capacity. at the end of each inspiratory eff ort, subjects were instructed to close the glottis and relax the respiratory muscles (so as to maintain lung volume while eliminating diaphragm activation). sonographic images of diaphragm thickening during these maneuvers were obtained using m-mode with a mhz linear array probe placed in the right ninth, th, or th intercostal space between the middle and anterior axillary lines. results diaphragm thickening in the zone of apposition was readily visualized by ultrasound in all fi ve subjects. mean end-expiratory diaphragm thickness was . mm (sd = . mm). during tidal breathing, the diaphragm thickened by a mean of % (sd = %). the bland-altman coeffi cient of reproducibility was . mm; approximately % of measurement variability arose from caliper positioning on the ultrasound machine; diaphragm thickness measurements changed as the probe was placed in diff erent intercostal interspaces. diaphragm inspiratory thickening increased signifi cantly with increasing inspiratory eff ort but also varied with lung volume independent of eff ort. at inspiratory volumes below % of inspiratory capacity, lung volume change contributed minimally to diaphragm thickening. conclusion visualizing diaphragm thickening in the zone of apposition by ultrasound provides a feasible non-invasive technique for monitoring diaphragm activation in healthy subjects. diaphragm thickening primarily refl ects muscular eff ort rather than altered muscle conformation induced by changes in lung volume, especially at lower inspiratory volumes. the theoretical advantages of monitoring the electrical activity of the diaphragm (eadi) and neural triggering of support breaths (nava-maquet) have not yet been shown to translate into signifi cant clinical benefi t [ ] . here we assess the eff ect of eadi monitoring, in patients at risk of prolonged weaning, on outcomes. introduction emergency endotracheal intubation results in accidental oesophageal intubation in up to % of patients often with disastrous consequences. we have previously published a highly specifi c and sensitive novel method to detect endotracheal intubation based on diff erences in ventilation pressure waveforms in the oesophagus and in the trachea in patients with healthy lungs [ ] . a detection algorithm, based on diff erences in compliance/elasticity between the lung and the oesophagus, generated a d-value indicating tracheal intubation if d > . and oesophageal intubation if d < . . the aim of the current study was to validate the algorithm in patients with lung disease. methods after obtaining institutional approval, intubated and ventilated icu patients were included. inclusion criteria were controlled mechanical ventilation and at least mild to moderate lung injury according to a murray lung injury score > . . a connecting piece was placed between the endotracheal tube and the ventilation bag. this piece comprised a thin air-fi lled catheter inserted through the tube lumen at cm from the distal end, and a second catheter located at the proximal end of the tube. we performed three consecutive manual bag ventilations while recording the pressure curves through both catheters. for each ventilation, a d-value was calculated. results mean age (sd) of the patients was ( ) years, % were male. the mean (sd) murray score was . ( . ). pathologies included pulmonary oedema, pneumonia, atelectasis and traumatic lung injury. all d-values are represented in figure . the median (iqr, range) d-value was ( to , . to , ). our algorithm therefore confi rmed a high sensitivity to detect correct endotracheal intubation also in patients with lung disease. under the hypothesis that oesophageal compliance does not increase signifi cantly in patients with lung disease, the specifi city of our algorithm will not be aff ected. the aim was to compare two novel endotracheal tubes (ett), mallinckrodt taperguard (tg, tapered polyvinyl chloride (pvc) cuff ) and kimvent microcuff (mc, cylindrical polyurethrane cuff ), with conventional portex (pt, globular pvc cuff ) in leakages across cuff s (microaspiration) under simulated clinical situations. it has been shown that globular pvc cuff s protect poorly against leakages due to microchannels formed from infolding of redundant cuff material [ ] . we hypothesized that tg and mc better prevent microaspiration, which is a major mechanism of ventilator-associated pneumonia (vap the most common cause of ventilator-associated pneumonia (vap) is aspiration of oral secretion through the endotracheal tube (et). subglottic suction drainage (ssd) has been recommended as a safety measure against aspiration due to its high eff ectiveness. currently, two types of cuff shape -spindle and tapered -are predominant in high-volume, low-pressure (hvlp) ets with ssd. however, the shape most suitable for preventing dripping onto the subglottis has not been determined. the purpose of this study was to determine whether an et with tapered-type cuff can reduce the incidence of vap. methods after approval from the appropriate ethics committee, we conducted a single-institutional prospective randomized clinical trial on the eff ectiveness of using an et with a diff erent cuff type. introduction national audit project (nap ) highlighted the need to improve airway management in icus and key recommendations were the continuous use of end-tidal carbon dioxide (etco ) monitoring, pre-intubation checklists and diffi cult airway trolleys [ ] . this complete cycle audit aimed to quantify the current state of airway management on our icu and the eff ectiveness of implementing the nap recommendations. methods data collection was carried out prospectively for both phases and included documentation of intubation, use of etco and the incidence of serious adverse events (saes). the contents of the intubation boxes were compared against the diffi cult airway society (das) guidelines [ ] . the re-audit was carried out months following the introduction of a pre-intubation checklist, a documentation sticker, a diffi cult airway trolley and standardization of the basic bedside airway boxes with a checklist of contents. a training program in airway management for all icu staff was also introduced. micro-ct scan (skyscan ; bruker, belgium) was performed using a resolution of μm. axial sections of the cm above the cuff were reconstructed, and the volume of secretions was assessed by a density criterion. microbiological cultures of the ett lavage fl uid were then obtained. patient's demographics and clinical data were recorded. in a diff erent set of bench experiments, we injected ml water-based polymer into new etts of diff erent sizes. we measured resistance to airfl ow before and after using an ett cleaning device (airway medix closed suction system; biovo technologies, tel aviv, israel). we also obtained resistance values of intact etts as controls. the studied etts remained in place for a median of days (iqr range to ). the amount of secretions assessed by ct scan was . ± . ml (range . to . ml). secretion volumes were not related to patient severity at admission (saps , p/f ratio) or days of intubation; an inverse correlation with patient's age was present (p = . , r = . ). bacterial growth was present in / ( %) ett fl uids cultures and candida spp. showed an elevated prevalence ( / , %). in the bench tests, the cleaning device reduced resistance to airfl ow (diff erence before and after cleaning . ( % ci = . to . ) cmh o/l/second, p = . ). after cleaning, resistance resulted higher than intact etts, although with a clinically negligible diff erence (diff erence . ( % ci = . to . cmh o/l/second), p = . ). conclusion micro-ct scan is a feasible and promising technique to assess secretions volume in etts after extubation. the use of an ett cleaning device decreases resistance to airfl ow in bench tests; the eff ectiveness of such a device in the clinical setting could be properly assessed by post-extubation ct scan. [ , ] . the objective was to develop and validate a simplifi ed score for identifying patients with di in the icu and to report related complications. methods data collected in a prospective multicenter-study from , consecutive intubations from icus were used to develop a simplifi ed score of di, which was then validated externally in consecutive intubation procedures from other icus and internally by bootstrap on , iterations. in multivariate analysis, the main predictors of di (incidence = . %) were related to the patient (mallampati score iii or iv, obstructive sleep apnea syndrome, reduced mobility of cervical spine, limited mouth opening), to pathology (severe hypoxia, coma) and to the operator (non-anesthesiologist). from the β-parameter, a sevenitem simplifi ed score (macocha score; introduction in mechanically ventilated neonates the fl ow-dependent resistance of the endotracheal tube (ett) causes a noticeable pressure diff erence between airway and tracheal pressure [ ] . this may potentially lead to retardation of the passive driven expiration and dynamic lung infl ation consecutively but more importantly increases . the aim of this study was to evaluate the correlation between nt-probnp and cce and the potential usefulness of such variables during the weaning process from mv. methods twenty-two long-term (> hours) mechanically ventilated patients capable of performing a weaning trial of spontaneous breathing (sbt) were enrolled in the study. inclusion criteria were: age > years and equipment with a standard arterial catheter line. exclusion criteria were: neuromuscular disease, tracheotomy, renal failure, and traumatic brain injury. during the weaning process, nt-probnp plasma levels, cce, and standard hemodynamic and ventilatory data were collected minutes before extubation (t ), hours (t ) and hours later (t ). after removal of tracheal tube, patients with a history of heart failure received continuous positive airway pressure (cpap group). patients with normal cardiac function were maintained with spontaneous breathing (sb group). results sixty-six paired nt-probnp and cce values were obtained. patients in the sb group and in the cpap group were and , respectively. in both groups there was a trend towards an increase in nt-probnp values after extubation, an opposite trend was observed regarding cce values (p < . ). nt-probnp levels showed an increase after extubation (t , t ) compared with t ; conversely, cce showed an inverse trend. overall, a negative correlation was found between nt-probnp and cce values (r = - . , p < . ). signifi cant inverse correlations were found between nt-probnp and cce at t , t , and t (r = - . , - . and - . respectively; p < . ). the overall correlation between nt-probnp and cce was - . in the sb group and - . in the cpap group. standard hemodynamic and ventilatory data did not show signifi cant changes during the study. conclusion nt-probnp correlated well with cce. the latter seems to be an additional attractive index of cardiovascular state that, in association with nt-probnp changes, may provide information about cardiac function on a beat-by-beat basis during weaning process from mv. comparison of outcomes between early and late tracheostomy for critically ill patients k suzuki , s kusunoki , t yamanoue , k tanigawa introduction tracheostomy is one of the more commonly performed procedures in critically ill patients requiring long-term mechanical ventilation. however, the optimal timing or method of performing tracheostomies in this population remains to be established. in the present study, we compared outcomes of early and late tracheostomy in critically adult patients with diff erent clinical conditions. methods all patients needing tracheostomy in the critical care medical center of hiroshima prefectural hospital from january to december were surveyed. patients with tracheostomy who were not indicated for mechanical ventilation were excluded from the subjects. early tracheostomy (et) was defi ned as < days after tracheal intubation and late tracheostomy (lt) was defi ned as ≥ days after intubation. we compared patient characteristics, type of tracheostomy procedure, length of weaning from ventilator and outcomes between the groups. data are shown as the mean ± sd, with unpaired t test and mann-whitney u test used for statistical analyses. statistical signifi cance was accepted at p < . . results one hundred patients were surveyed. the et and lt groups included and patients, respectively. tracheostomy was performed using a percutaneous procedure in patients (et: , lt: ) and a surgical procedure in patients (et: , lt: ). sixty-two patients (et: , lt: ) survived to discharge and patients died in the icu (et: , lt: ). fifty-six patients (et: , lt: ) were weaned from ventilator support and tracheostomy cannula was removed in patients (et: , lt: ). there were no signifi cant diff erences in type of tracheostomy procedure, period from tracheostomy until icu and hospital discharge, rate of patients who could be weaned from ventilator and removed tracheostomy cannula, and icu and hospital mortality between the groups. the length of mechanical ventilation and the time to removal of tracheostomy cannula were signifi cantly shorter in the et group ( ± vs. ± and ± vs. ± days, respectively). conclusion in this retrospective study, early tracheostomy reduced the length of weaning after tracheostomy and the time to removal of tracheostomy cannula, while there were no diff erences in the length of icu stay and patient outcome. in critically ill adult patients who require mechanical ventilation, a tracheostomy performed at an earlier stage may shorten the duration of artifi cial ventilation. a further randomized clinical trial is essential to determine the eff ectiveness and safety of early tracheostomy. reference s variability in the course of blood vessels in the pre-tracheal area. a % risk of clinically relevant bleeding was recently reported for patients undergoing pdt [ ] . we conducted a systematic review of reports evaluating clinical outcomes following use of ultrasound scanning (us) for pdt. methods two investigators performed a search of the literature using the following databases: central, embase, medline and scopus. the following eligibility criteria were used: population including adults > years managed in the icu; use of ultrasound to guide decisionmaking pre-pdt or guide pdt performance; report of clinically relevant outcome measures. nonrandomised controlled trials were classifi ed according to cochrane non-randomised study methods group criteria [ ] and evaluated for risk of bias. results an initial search identifi ed , reports, of which studies met eligibility criteria: eight case series, one randomised controlled trial (rct) and one prospective cohort study, incorporating patients. two studies specifi cally reported data on patients with obesity (n = patients) and one study reported data for a group of patients with spinal cord fi xation (n = ). us was used to guide decision to perform pdt or surgical tracheostomy in fi ve studies, with decision to perform surgical tracheostomy ranging from to % of cases. us was used to guide insertion point in seven studies, and used real-time in four studies. times to perform us-guided pdt were reported in four studies (ranging from to minutes). no studies compared time taken with or without us. data on complications of procedure were reported in nine studies. minor bleeding was reported for eight cases ( . % overall). prolonged bleeding was reported in two cases ( . %). there were no episodes of catastrophic bleeding among cases. high risk of bias was identifi ed in fi ve studies in terms of patient selection. an intervention protocol was not defi ned in three reports. no attempt was made at blinding any aspect of the studies. conclusion use of us guidance could theoretically help minimise risk of haemorrhagic complications during pdt and perhaps reduce time taken to perform pdt. however, there is currently inadequate evidence from controlled cohort studies or rcts to suggest that routine use for pdt in selected or unselected groups improves clinically relevant outcome measure. introduction failed airway situations are potentially catastrophic events and require a correct approach with appropriate tools. recently, ventrain has been presented as a manual device for emergency ventilation through a small-bore cannula, which can provide expiratory assistance by applying the venturi eff ect. methods we used the simularti human patient simulator to evaluate ventrain. initially, we studied the eff ectiveness and security in ventilating and oxygenating the patient. in a second phase, the ventrain performance was compared with what is considered to be the present gold standard (quicktrach ii, portex mini-trach ii seldinger kit, melker emergency cricothyrotomy catheter set). seven anesthesiologists performed an emergency transcricoid ventilation with each device in the same setting. results ventrain provided an average tidal volume of ml and an average minute volume of . l in the considered situation, with a modifi cation of pao from to mmhg and of paco from . to . mmhg. in the second phase, the time needed to obtain an eff ective oxygenation with ventrain was found to be shorter than other devices (median diff erence; vs. minitrach - seconds; vs. melker - seconds; vs. quicktrach - seconds) ( figure ); the ability to remove co resulted bigger (average diff erence: vs. minitrach - . ; vs. melker - . ; vs. quicktrach - . ) ( figure ) and moreover the users judged it more favorably. conclusion in this manikin study, ventrain seemed to be able to appropriately oxygenate and ventilate a patient in a cicv situation. when compared with the best available choices, it has shown not to be inferior. introduction eff ective delivery of aerosolized bronchodilators for patients with asthma is crucial for adequate therapy in critical care and emergent settings. often administered with pressure-metered dose inhalers (pmdis), bronchodilator delivery depends on the correct patient technique during administration [ ] and the ability to measure treatment response, which are diffi cult to monitor at the point of care and particularly so in resource-poor settings where standard inhospital monitoring is unavailable [ ] . methods a point-of-care device for airfl ow measurement during bronchodilator delivery was designed and tested for use in resourcelimited settings. the handheld device was constructed from a clinical aerosol delivery tube with a bidirectional sensor for pressure diff erential detection about the aerosol element ( figure ). the custom low-cost introduction protocol-based care of the tracheostomised patient is important, as adverse events confer a high rate of mortality. little is known regarding the existence of formal evidence-based guidelines on tracheostomy care. the aim of this study was to perform a systematic review for evidence-based guidelines on adult tracheostomy care. methods a systematic search of pubmed, medline, guideline clearinghouses, centres of evidence-based practice, and professional societies' guidelines relating to care of adult patients with a tracheostomy was performed by two reviewers. in addition, a google search of publicly available tracheostomy care guidelines was performed. search terms: (tracheostom* or tracheotom*) and (protocol* or guideline* or standard* or management or consensus or algorithm*). filters: english language, human, from january to date, adult patients. guideline appraisal criteria: the quality of guidelines retrieved was assessed using the appraisal of guidelines research and evaluation ii (agree ii) instrument [ ] . the search results are summarised in table . a total of guidelines were identifi ed. five were found to satisfy the agree ii criteria and only three related to the entire spectrum of tracheostomy management. the majority was informal and was not published or evidence based. conclusion five evidence-based guidelines on adult tracheostomy management were identifi ed. this may represent a paucity of evidence on the subject, suggesting that further clinical trials on the topic are needed to contribute to the evidence base. this also highlights the need for international consensus on the topic, to reduce duplication of eff orts, standardise practice, and improve outcomes. [ ] concluded that the majority of airway-related signifi cant complications in icus resulted from displaced or blocked tracheostomies and recommended together with the intensive care society and the national tracheostomy safety project that each icu in the uk should have an emergency airway management plan and guidelines [ ] . the aim of this survey was to establish whether such guidelines exist and are familiar to those working within the icus of the east of england (eoe), their ease of availability in an emergency and the degree of emergency tracheostomy training within the region. methods data collection was via a telephone survey of icus in the eoe training region during july with one senior icu nurse and one icu trainee questioned per hospital. questions related to the existence and accessibility of guidelines for tracheostomy emergencies, and to the respondent's degree of emergency tracheostomy training and their perceived availability of formal training. results all icus questioned perform and manage tracheostomies. of respondents, knew of guidelines covering all of the emergencies described above and their location. four respondents thought that these guidelines were accessible in an emergency setting, one-half of which were on computer systems requiring a login and search function. with regards to emergency management, respondents felt competent in a tracheostomy emergency; almost exclusively through experience and in-house teaching. no respondents were aware of any formal emergency tracheostomy management courses. conclusion despite national guidance within the uk this survey highlights that implementation and awareness of emergency tracheostomy guidelines in icus in the eoe region is poor, and when present they are not readily accessible in an emergency. emergency training has largely been informal and the availability of formal training courses has not been recognised. in order to improve patient safety there is a need to ensure that emergency tracheostomy management including guidelines, equipment and formalised tracheostomy emergency training are adopted and embraced universally. references introduction a fatal incident related to a blocked tracheostomy tube prompted a review in our trust. to provide safe tracheostomy care, changes in staffi ng, education and operational policies were recommended. training of potential fi rst responders to tracheostomy or laryngectomy emergencies remains outstanding. we aim to quantify the training defi cit. tracheostomies are common in critical care but these patients require ongoing management of an artifi cial airway on discharge to the ward and even the community. in our critical care unit cared for tracheostomy patients, of which were transferred to the wards. the th national audit project highlighted complications including hypoxic brain injury and death [ ] and the national patient safety agency recognised a number of avoidable aspects [ ] . existing guidelines for management of these patients including emergencies are not widely known. methods an anonymous online survey was sent to all trainees who may respond to a tracheostomy emergency in our organisation. trainees in anaesthesia/critical care, general medicine, general surgery, ent, thoracics and a&e were approached. all completed forms were included. we achieved a response rate of % ( / ). respondents comprised: % anaesthesia/critical care, % medicine and % surgery. over one-half ( / ) had managed tracheostomy/laryngectomy emergencies, with % ( / ) of these incidents occurring on the wards and one in an outpatient clinic. only % ( / ) had received any formal training on management of a blocked/misplaced tracheostomy tube and only % ( / ) were aware of any guidelines. one-third of responders lacked confi dence in management of these emergencies and % felt they would benefi t from formal training including simulation. conclusion the population of patients with exteriorised tracheas is increasing and represents a high-risk group. management of airway emergencies in these patients is not part of standard life-support courses. according to our trainees, these scenarios are relatively common and a signifi cant proportion of fi rst responders are poorly equipped to deal with them. our trust will be including specifi c training on the emergency management of neck breathers as part of in-house resuscitation training. we would contend that national resuscitation courses should consider doing the same. introduction usually percutaneous tracheostomy is accomplished via the tracheal tube. some severe complications during percutaneous dilatational tracheostomy (pdt) may be related to poor visualization of tracheal structures. the alternative implies extubation and reinsertion of a laryngeal mask (lma). an accidental extubation as well as an injuring of the vocal cords (because of the infl ated cuff during dislocation) appears impossible in this method. subjectively, the bronchoscopic view obtained via a lma seems to be better than that obtained with an endotracheal tube (et) [ , ] . methods in this prospective observational study, the bedside pdt was performed using the ciaglia blue dolphin method in critically ill patients. the patient's tracheal tube was exchanged for a lma fastrach™ before undertaking pdt. the insertion of the lma, the quality of ventilation, the blood gas values, the view of the tracheal puncture site, and the view of the balloon dilatation were rated as follows: very good ( ), good ( ), barely acceptable ( ), poor ( ), and very poor ( ) . results pdts with lma were successful in . % of the patients (n = ). the ratings were or in % of cases with regards to ventilation and to blood gas analysis, in . % for identifi cation of relevant structures and tracheal puncture site, and in . % for the view inside the trachea during pdt. a rating of was assigned to one patient requiring tracheal reintubation for inadequate ventilation. there were no damages to the bronchoscope or reports of gastric aspiration. conclusion the blue dolphin pdt using a lma showed defi nite advantages regarding inspection of dilation process. this method improves visualization of the trachea and larynx during a video-assisted procedure and prevents the diffi culties associated with the use of an et such as cuff puncture, tube transection by the needle, accidental extubation, and bronchoscope lesions. the lma results as an eff ective and successful ventilatory device during pdt. this may be especially relevant in cases of diffi cult patient anatomy where improved structural visualization optimizes operating conditions. the intensivist performing pdt should be scrupulous when deciding which method to use. in our icu the blue dolphin pdt with lma has become the procedure of choice. introduction acute cor pulmonale (acp) is associated with increased mortality in patients ventilated for acute respiratory distress syndrome (ards). interventional lung assist (ila) allows a lung-protective ventilatory strategy, whilst allowing co removal, but requires adequate right ventricular (rv) function. rv restriction (including presystolic pulmonary a wave) [ ] is not routinely assessed in ards. methods a prospective analysis of retrospectively collected data in patients with echo during ila was performed. data included epidemiologic and ventilatory factors, lv/rv function, evidence of rv restriction and pulmonary hemodynamics. data are shown as mean ± sd/median (interquartile range). results thirty-two patients ( ± years), male ( %), sofa score . ± . were included. pulmonary hypertension (pht) was %, and hospital mortality %. mortality was not associated with age, days on ila, length of icu stay, inotropic support, nitric oxide or level of ventilatory support, but was associated with pressor requirement (p = . ), a worse pao :fio ratio ( . ( . to . ) vs. . ( . to . ), p = . ) and higher pulmonary artery pressures ( . mmhg ( to ) vs. . ( . to . ), p = . ). no echo features of acp were found, with no signifi cant diff erence between rv systolic function, pulmonary acceleration time and pulmonary velocity time integral between survivors and nonsurvivors. the incidence of rv restriction was high ( %), and independent of pht, rv systolic function and level of respiratory support, but correlated with co levels (restrictive . kpa ( . to . ) vs. . ( . to . ), p = . ). see figure . conclusion typical echo features of acp were not seen in this study, possibly because of the protective ventilatory strategies allowed by use of ila. the incidence of rv restriction may refl ect more subtle abnormalities of rv function. further studies are required to elucidate rv pathophysiology in critically ill adult patients with ards. reference introduction global left ventricular electromechanical dyssynchrony (glvd) is uncoordinated lv contraction that reduces the extent of intrinsic energy transfer from the myocardium to the circulation leading to a reduction in peak lv pressure rise, prolonged total isovolumic time (t-ivt) and fall in stroke volume [ ] . this potentially important parameter is not routinely assessed in critically ill cardiothoracic patients. methods a prospective analysis of retrospectively collected data in cardiothoracic icu patients who underwent echocardiography was performed. in addition to epidemiological factors, echo data included comprehensive assessment of lv/rv systolic and diastolic function including doppler analysis of isovolumic contraction/ relaxation, ejection time (et) and fi lling time (ft). t-ivt was calculated as ( -(total et + total ft)) and the tei index as (ict + irt) / et. t-ivt > second/minute and tei index > . were used to defi ne glvd [ ] . data are shown as mean ± sd/median (interquartile range). results a total of patients ( . ± . years), male ( %), apache ii score ( . ± . ) were included. the prevalence of glvd was high ( / , %) and associated with signifi cantly increased mortality, . % vs. % (p = . ). there was no diff erence in requirement for cardiorespiratory support between the two populations, but there were signifi cant diff erences (no glvd vs. glvd) in requirement for , p = . ), mitral regurgitation ( . % vs. . %, p = . ), or any other measures of lv systolic or diastolic function between the two groups. there was good correlation between the two methods used to assess dyssynchrony (lv t-ivt:lv tei index correlation coeffi cient = . , p < . ). conclusion glvd that limits cardiac output is common in the cardiothoracic icu, and signifi cantly related to mortality. when diagnosed, the underlying cause should be sought and treatment instigated to minimize the t-ivt (pacing optimization/revascularization/ inotrope titration/volaemia optimization). references introduction correction of coagulopathy before central venous catheter (cvc) insertion is a common practice; however, when ultrasound guidance is used this is controversial as mechanical complications are rare. studies in oncology patients suggest that cvc placement without prior correction of coagulopathy is safe but no studies are available for critically ill patients and guidelines do not give recommendations [ , ] . we do not routinely correct coagulopathy, even if severe, when ultrasound guidance is used and the purpose of this retrospective study was to evaluate the safety of this practice. methods data for all ultrasound-guided interventions, including complications, are prospectively collected in our department for audit purposes; in this study we involved only cvc insertions in the icu between february and november . electronic medical and laboratory records and paper-based nursing charts were retrospectively studied for all interventions, specifi cally looking for blood results, coagulation abnormalities and intervention-related complications. in the study period, ultrasound guidance was employed for a total of central line insertions in icu patients. coagulopathy was detected in cases at the time of cvc placement ( . %). on the day of cvc insertion, coagulation abnormalities were corrected in cases ( . %); out of patients with severe coagulopathy ( . %) and out of patients with coagulopathy of moderate severity ( . %) had no correction at all. correction was started only after cvc insertion for reasons unrelated to cvc placement in a further eight and two patients with severe and less severe coagulopathy ( . % and . %), respectively. no bleeding complications were observed. conclusion in patients undergoing cvc insertion in our icu, coagulopathy is common. we observed uncomplicated cvc placement in all patients with severe uncorrected coagulopathy and in a further patients with coagulopathy of moderate severity. when combined with other studies, our data suggest that ultrasound-guided cvc placement without routine correction of coagulation abnormalities may be safe in the icu. introduction early bleeding from the exit site after cvc or picc placement is a very common event that causes diffi culties in the patient's care and logistical problems. in our experience, the rate of signifi cant local bleeding after placement of piccs without reverse tapering may be as high as % at hour and % at hours, while the rate of bleeding after placement of a large-bore dialysis catheter is above % at hour. methods the aim of this pilot study was to verify the effi cacy of a cyanoacrylate glue in reducing the risk of early bleeding at the exit site after cvc or picc placement. we studied a group of adult patients consecutively undergoing placement of polyurethane cvcs or piccs without reverse tapering in a non-intensive ward of our hospital. all lines were inserted according to the same protocol, which included % chlorhexidine antisepsis, maximal sterile barriers, ultrasound guidance, ekg guidance and securement with sutureless device. two minutes after placement of the glue, the exit site was covered with a temporary gauze dressing, which was replaced by transparent membrane at hours. all patients were assessed at hour and at hours. results in consecutive patients ( piccs, dialysis catheters and nine cvcs), there was no signifi cant local bleeding at hour or at hours after catheter placement. no local adverse reaction occurred. no damage to the polyurethane of the catheters was detected. conclusion glue is an inexpensive and highly eff ective tool for avoiding the risk of early bleeding of the exit site after catheter placement. we also suggest that in the next future the glue might prove to have benefi cial collateral eff ects on the risk of extraluminal contamination (by reducing the entrance of bacteria in the space between the catheter and the skin), as well as on the risk of dislocation (by increasing the stability of the catheter inside the skin breach). introduction about years ago the use of chest radiographs as the golden standard to ensure correct positioning of central venous catheters (cvc) was questioned. the frequent use of cvcs was also challenged. we decided to retrospectively evaluate our routines in a large surgical unit in a swedish university hospital. methods all x-rays were centrally registered. chest x-ray performed in our unit is almost entirely used to confi rm cvc positioning. the certofi x cvc set for the seldinger technique in combination with certodyn -universaladapter (b braun, germany) is now used as the routine equipment and the right jugular vein is our standard approach. in the total number of x-rays performed in patients at our unit was , , which corresponds to the approximate number of inserted cvcs at that time, since a confi rmatory x-ray was routine. x-rays were rarely performed on other indications in our unit. x-ray costs were at that time approximately € , (~€ /each). the year after, , chest x-rays were performed, refl ecting both the use of intracardiac confi rmation of correct cvc position and also a reduced use of cvcs. this trend has continued over time. in approximately cvcs were inserted at our unit. x-rays were performed in about % of these cases. the cost for a chest x-ray is today ~€ , meaning that x-ray costs were approximately € , . we have not experienced any medical problems when intracardiac ecg was used for positioning confi rmation. on the contrary, aspiration of venous blood without apparent p-waves in a patient with sinus rhythm may suggest improper placement of the cvc; for example, the right brachial vein. conclusion if we had continued to use cvcs at the same frequency as we did years ago, and used x-ray confi rmation in practically all cases, we would have paid approximately € , annually. reduced use of cvcs, in combination with intracardiac confi rmation of cvc positioning, has not only allowed us to reduce costs associated with cvc insertion by more than € , , corresponding to a reduction rate of more than %, but also decreased the patient's exposure to x-ray irradiation. introduction in cases of arrhythmia, the beat-to-beat variation of arterial pressure (ap) may impair the accuracy of automated cuff measurements. indeed, this oscillometric device relies on the detection of arterial wall oscillations. our aim was to determine, in icu patients, whether brachial cuff measurements are really less reliable during arrhythmia than during regular rhythm. methods patients with arrhythmia and carrying an intra-arterial catheter were prospectively and consecutively included in this multicenter study. after each arrhythmic inclusion, a regular rhythm patient was included. a second inclusion was possible in case of change in the cardiac rhythm. three pairs of invasive and brachial cuff (philips® mp monitor) measurements of mean arterial pressure (map) were respectively averaged. some patients underwent a second set of measurements, after a cardiovascular intervention (passive leg raising, volume expansion, initiation of/increase in catecholamine infusion) allowing the assessment of map changes. introduction signifi cant changes in haemodynamics occur after brain stem death (bsd) and there is evidence that yield of transplantable organs may be decreased in donors who remain preload responsive prior to donation [ ] , suggesting that optimisation of the cardiac output (co) may be benefi cial in potential organ donors. we describe current uk practice with regard to co monitoring in this group. methods we reviewed a database of brain-stem-dead potential organ donors collected by specialist nurses in organ donation (sn-od) over a -month period ( april to october ) across multiple uk centres. the database contained data on donor management in the period from initial sn-od review to immediately prior to transfer to the operating theatre. we analysed data on co monitoring and vasopressor/inotrope use. where information was missing/not recorded in the dataset, the treatment referred to was interpreted as not given/not done. fifty-three patients ( . %) had evidence of co monitoring. lidco was the most popular method ( figure ). a total of ( %) patients received treatment with vasopressors and/or inotropes. co data were utilised in a variety of ways ( figure ). conclusion the majority of potential donors require vasopressors and/or inotropes post bsd, but it seems only a minority currently have their co monitored. there is variation in how co data are utilised to direct haemodynamic management. we welcome the development of standardised bundle-driven donor management. reference the indocyanine green plasma disappearance rate (icg-pdr) is a dynamic liver function test that can be non-invasively measured by pulse densitometry. icg-pdr is associated with mortality and other markers of outcome. due to predominant use of icg-pdr in the icu setting, the normal range is based on scarce data available outside the icu and given with to %/minute. methods to prospectively re-evaluate the normal range and to analyze the potential impact of biometric data on icg-pdr, we measured icg-pdr (i.v. injection of . mg/kg icg; limon, pulsion, munich, introduction mixed venous oxygen saturation (svo ) represents a well-recognized parameter of oxygen delivery (do )-consumption (vo ) mismatch and its use has been advocated in critically ill patients in order to guide hemodynamic resuscitation [ ] and oxygen delivery optimization. nevertheless, the pulmonary artery catheter (pac) is not readily available and its use is not devoid of risks. furthermore, its use has been decreasing in recent years in surgical and cardiac surgical patients as the benefi t of guiding therapy with this device is unclear [ ] [ ] [ ] . central venous oxygen saturation (scvo ) has been suggested as an alternative to svo monitoring due to its feasibility in several settings. unfortunately concerns arise from its capability to correlate with svo , the relationship being infl uenced by several factors, such as hemodynamic impairment and pathological process. hemodynamic instability and shock often complicate cardiac surgery, and the svo -scvo relationship has not been specifi cally investigated in this setting. the aim of this study is to compare svo and scvo values in patients with cardiogenic shock after cardiac surgery. methods a prospective observational study was designed and conducted. inclusion criteria were: patients who had underwent elective or urgent/emergent cardiac surgery, with cardiac index (ci) < . l/minute/m estimated by means of a pac, left ventricle ejection fraction (lvef) < %, lactate > mmol/l, age > years. a central venous catheter (cvc) and a pac were inserted for each patient before surgery in the same right internal jugular vein in accordance with standard procedure. proper position of the pac was confi rmed with pressure tracings and chest x-ray. mixed and central venous blood samples were collected from the distal ports of the pac and cvc respectively minutes after icu admission, and every hours for a total of three samples in a -hour period for each patient. all blood samples were analyzed by a co-oximeter (radiometer abl fl ex; radiometer, copenhagen, denmark). statistical analysis was performed by stats direct (ver. . . , cheshire, uk) and graphpad (vers. prism . ; san diego, ca, usa). all data were tested for normal distribution with the kolmogorov-smirnov test. statistical analysis was performed by linear regression analysis. the agreement between absolute values of scvo and svo were assessed by the mean bias and % limits of agreement (loa) ((mean bias ± . )×standard deviation) according to the method described by bland and altman [ ] . results a total of patients were enrolled. in out of cases all three blood samples were collected. in two patients only two blood samples were drawn as they exited the inclusion criteria. linear regression analysis between the two variables resulted in an r of . . bland-altman analysis ( figure ) for the pooled measurements of svo and scvo showed a mean bias and loa of . % (sd of bias . ) and - . to + . % respectively. conclusion scvo has been advocated as an attractive and simple indicator of do -vo mismatch [ ] . its role as a surrogate of the wellestablished svo has been investigated in several settings, and it has been purposed in the hemodynamic resuscitation of critically ill septic patients [ ] . nevertheless, the svo -scvo relationship can be infl uenced by several factors due to scvo dependency from global blood fl ow redistribution that can occur during hemodynamic impairments. it has been shown previously that in healthy people scvo values tend to underestimate svo values, due to the higher oxygen content from inferior vena cava [ ] . during circulatory shock, not homogeneous oxygen extraction and regional blood fl ow methods we assessed the benefi t these tee data provided in the assessment of fi ve domains: hypovolemia, right ventricular dysfunction, left ventricular dysfunction, sepsis, and valvular abnormality. bedside practitioners listed their diagnoses before and after seeing primary tee images perform by trained physicians. we used a to likert scale to assess diff erential diagnosis before and after the tee, comparing changes using a paired t test. results all requests for tee were to access hemodynamic instability. a total of patients were screened and nine were eligible, in which total tee studies were performed. there were no complications with tee and all patients tolerated the long-term placement of the probe well. of the fi ve diagnostic domains studied, right ventricular failure was the most commonly underdiagnosed contributor to the hemodynamic instability among patients prior to tee (p = . ) (figures and ). introduction echocardiography is increasingly utilized by inten sive care physicians in everyday practice. standardization of echocardiographic studies and reporting, quality assurance and medicolegal requirements necessitate establishment of a dedicated system within the critical care setting. we describe the process of setting up a critical care echocardiography (cce) laboratory based on our experience from three separate icus. methods a retrospective review and analysis of the process involved in establishment of echocardiography laboratories within icus. results creating a cce service involves a number of stages and takes several years to achieve. major components include staffi ng, equipment, quality control, study archiving and networking capability. for staffi ng the objective is to identify and recruit staff with adequate training and expertise in cce, providing / specialist cover in addition to supporting and training junior medical and nursing staff . there is further a need to acquire funding for high-quality ultrasound machines and related hardware as well as long-term dicom-based archiving and reporting systems. this should be based on projections of annual volumes of echo studies and corresponding digital storage. networking connectivity is highly desirable, including obligatory back-up solutions and site allocations. a business case incorporating all the above should precede any development as identifi able funding sources and administrative approval are essential. the implementation stage requires the presence of a project leader who can organize the trialing of scanners, archiving, reporting and research systems, ensure compatibility with existing hospital and cardiology networks, and who can assist in individualizing archiving and reporting software refl ecting institutional and icu specifi cs. coordination with the it department is very important. clear contractual vendor obligations for service, maintenance and future upgrades of hardware and software need to be specifi ed. training and credentialing of staff is best achieved within a systematic framework that includes ongoing competency review, education and qa programs. partnership with cardiology may benefi t both groups. major pitfalls are associated with poor initial training, lack of expertise and leadership, and bad vendor contracts. conclusion establishment of a cce laboratory requires careful planning, and allocation of adequate human and fi nancial resources. many potential problems can be identifi ed and prevented in advance. strong expert leadership plays an important role. introduction contrast-enhanced ultrasonography (ceus) is a dynamic digital ultrasound-based imaging technique, which allows quantifi cation of the microvascularisation up to the capillary vessels. as a novel method for assessment of tissue perfusion it is ideally designed for use in the icu. ceus is cost-eff ective and safe and can be repeatedly performed at the bedside without radiation and nephrotoxicity. critical care , volume suppl http://ccforum.com/supplements/ /s methods the frequency of ceus use in the multidisciplinary surgical icu was retrospectively evaluated for the period from september to september . furthermore, contributions of this novel method to the management of critically ill icu patients as well as its accuracy were assessed. results in total, ceus studies were performed in critically ill icu patients. the most frequent indications included: assessment of the liver perfusion, assessment of the pancreas and kidney perfusion after pancreas and kidney transplantation, assessment of the renal perfusion in acute kidney injury (aki), assessment of active bleeding and assessment of the bowel perfusion. in all studies, the correct diagnosis was achieved and the transport of critically ill patients to the radiology department for further diagnostic procedures as well as application of iodinated contrast agents was avoided. in cases signifi cant new fi ndings were detected. twelve of them were missed by conventional standard doppler ultrasound prior to ceus. in assessment of seven cases with aki, impaired or delayed perfusion and microcirculation of the kidney was observed in six patients. in three patients urgent surgical intervention was performed because of ceus results. in three cases active bleeding was excluded at the bedside due to absence of contrast agent extravasation into hematoma (thigh and perihepatic) or into abdominal cavity, without need for complementary ct imaging or angiography. in one case the regular perfusion of intestinal anastomosis was confi rmed with no need for surgical exploration. none of patients undergoing ceus manifested any adverse reactions or developed any complications associated with the imaging technique. conclusion contrast-enhanced ultrasonography clearly improves visualization of the perfusion in various tissues. it is very likely to be superior to standard doppler ultrasound, and is safe and well tolerated in critically ill patients. promising indications for the use of ceus in the icu may be the assessment of kidney microcirculation and assessment of liver perfusion in liver transplant and liver trauma patients. introduction even though invasive hemodynamic devices are usually used for assessment of septic shock victims, they cannot evaluate the heart function. lv dysfunction as well as right heart syndrome are not uncommon in sepsis and critical patients. intensive care ultrasound discloses these data and leads to appropriate treatment. methods the study was a prospective cross-sectional study. the measurement was performed within hours of icu admission. we excluded patients with history of copd and pulmonary hypertension from any diseases. only good-quality images acquired from subjects were included for analysis. the primary objective was to disclose how the hemodynamic changed in septic patients by icu-us. introduction thermodilution (td) is considered a gold standard for measurement of cardiac index (ci) in critically ill patients. the aim of this study is to compare intermittent bolus td ci with intermittent automatic calibration ci (autoci) and two continuous cis obtained by pulse contour analysis with picco (picci) and pulsiofl ex (pucci). methods interim results of an ongoing prospective multicentre study in patients. age . ± . , saps ii score . ± . and sofa score ± . . all patients underwent picco monitoring via a femoral line whilst a radial line was kept in place during four -hour time periods (in the fi rst two periods, the pulsiofl ex was connected to a radial line; in the last two it was connected to a femoral line). in the fi rst and third periods, the pulsiofl ex was calibrated with tdci, for the second and fourth periods pulsiofl ex was calibrated with autoci. simultaneous picci and pucci measurements were obtained every hours while simultaneous tdci and autoci were obtained every hours. we also looked at the eff ects of interventions. in total, cci and tdci values were obtained: paired picci and pucci; paired autoci-tdci measurements. tdci values ranged from . to . l/minute/m (mean . ± . ), autoci from . to . ( . ± . ), picci from . to . ( . ± . ) and pucci from . to . ( . ± ). pearson's correlation coeffi cient comparing mean pucci and picci values per patient had an r of . . comparison between autoci and tdci had an r of . . changes in autoci correlated well with changes in tdci (r = . , concordance coeffi cient = . ), as did changes in pucci versus changes in picci (r = . , cc = . %). changes in picci and pucci induced by an intervention correlated well with each other (r = . , cc = %). the percentage error (pe) obtained by bland and altman analysis and r for the diff erent comparisons are presented in table . the preliminary results indicate that in unstable critically ill patients, ci can be reliably monitored with pulsiofl ex technology via a femoral line. pulsiofl ex was also able to keep track of changes in ci. interim results of an ongoing study on the use of non-invasive hemodynamic monitoring with nexfi n in critically ill patients introduction perioperative goal-directed therapy (pgdt) can substantially improve the outcome of high-risk surgical patients [ ] . but the approach needs an initial investment and increases the staff workload. economic factors might participate in the weak adherence to the pgdt concept. some model studies support pgdt cost-eff ectiveness, but real economic data based on a recent clinical trial are lacking. we performed an economic analysis of hemodynamic optimization using the stroke volume variation trial [ ] in order to elucidate this issue. methods the hospital care invoices of all patients included in the trial were retrospectively extracted. due to the nature of the data we have adopted the healthcare payer's perspective. we performed a comparison of induced costs between the vigileo (n = ) and control (n = ) groups and constructed a cost tree using the study group and complications occurrence as distributive parameters. the incremental cost-eff ectiveness ratio per complication avoided was calculated and, fi nally, diff erent reimbursing categories were assessed as potential cost drivers. results a decreased rate ( vs. patients) and number of complications ( vs. ) were observed in the original trials vigileo group. the mean cost of intervened patient was lower (€ , ± , vs. € , ± , ; p = . ). according to the cost-tree analysis, patients with complications (n = ; %) consumed signifi cantly more resources (€ , ; %). a gain of € per avoided complications confi rms that the lower complications rate was the most important cost driver. both the clinical care for patients costs (€ vs. ; p = . ) and ward stay costs (€ vs. ; p = . ) were decreased by the intervention. on the contrary, the intervention increased anaesthesia costs (€ vs. ; p = . ). conclusion intraoperative fl uid optimization with the use of stroke volume variation and the vigileo/flotrac system showed not only a substantial improvement of morbidity, but was also associated with an economic benefi t. this observed benefi t highly exceed the increased monitoring costs in our trial. introduction hemodynamic monitoring is important in high-risk surgical patients in order to detect and correct circulatory instability, thereby improving outcome [ ] . the extravascular lung water index (evlwi) refl ects pulmonary edema [ ] . the new ev /volumeview (edwards lifesciences) can accurately measure evlwi corrected for the actual volume of lung parenchyma (evlwic). the aim of our study is to prove a stronger correlation between evlwic and pao /fio compared with evlwi in patients undergoing pulmonary resection. methods a prospective observational study. seven patients with lung cancer undergoing pulmonary resection were monitored using the ev plathform. evlwi was assessed by thermodilution at the following time points: after intubation (t ); during single-lung ventilation (t ); after lung resection (t ); after icu admission (t ); hours (t ) and hours after icu admission (t ). evlwic values were also collected at t and t . pao /fio was measured at the same time points. results no signifi cant correlation was found between evlwi and pao / fio (r = - . , p > . ), while a signifi cant correlation was seen between evlwic and pao /fio (r = - . , p = . ; figure ). conclusion despite the small sample size, this study shows that in patients undergoing pulmonary resection the evlwic is more strongly correlated to pao /fio than evlwi. therefore, the ev may be a valuable tool for more reliable hemodynamic monitoring in this subgroup of patients. references or extracardiac arteriopathy) were allocated to gdt or conventional hemodynamic therapy. we excluded patients with endocarditis, previous use of dobutamine, need for iabp, high dose of vasopressors and emergency surgery. the gdt protocol involved hemodynamic resuscitation aimed at a target of a cardiac index > l/minute/m through a three-step approach: fl uid therapy of ml lactated ringer's solution, dobutamine infusion up to a dose of μg/kg/minute, and red blood cell transfusion to reach a hematocrit level above %. results twenty patients from the gdt group were compared with control patients. both groups were comparable concerning baseline characteristics and severity scores, except for a higher prevalence of hypertension and heart failure in the gdt group. intraoperative data showed no diff erence regarding length of extracorporeal circulation, fl uid balance, transfusion or inotropic requirement. patients from the gdt group were given more fl uids within the fi rst hours as compared with the conventional group ( , ml vs. ml, p < . ). gdt patients showed a median icu stay of days ( % ci: to ) compared with days in control patients ( % ci: to ). moreover, hospital stay was less prolonged in gdt patients ( days vs. days, p = . methods sixteen patients were divided into two groups: one group was treated with a restrictive approach (≤ ml/kg/hour), and the other with a liberal approach (> ml/kg/hour). patients were randomly allocated using sealed envelopes. during the thoracic part of the surgical procedure, all patients received one-lung ventilation (olv). in the group treated with a restrictive volume approach, patients received fl uids at the rate of . ± . ml/kg/hour. pao /fio was ± after intubation and ± before extubation. in the group treated with a liberal volume approach, fl uids were replaced at . ± . ml/kg/hour. pao /fio was ± after intubation and ± before extubation. surgery combined with olv was found to signifi cantly aff ect the pao /fio value (anova, f , = . a, p = . , partial η = . ). the average pao /fio level was signifi cantly higher in the restrictive-replacement group than in the liberal-replacement group (anova, f , = . , p = . , partial η = . ). there was no interaction between the groups (anova, f , = . a, p = . , partial η = . ). mean length of stay in the icu was similar between the restrictive-replacement group ( . ± . days) and the liberalreplacement group ( . ± . days) (anova, f , = . a, p = . , partial η = . ). conclusion results from this small sample indicate that esophageal carcinoma surgery by itself had a detrimental eff ect on the pao /fio value, which restriction of perioperative volume did not signifi cantly aff ect. volume restriction also did not aff ect length of stay in the icu. we hypothesized that goal-directed therapy (gdt) is not associated with an increased risk of cardiac complications in high-risk, noncardiac surgical patients. patients with limited cardiopulmonary reserve are at risk of mortality and morbidity after major surgery [ ] . augmentation of the oxygen delivery index (do i) with a combination of intravenous fl uids and inotropes (gdt) has been shown to reduce the postoperative mortality and morbidity in high-risk patients [ ] . however, concerns regarding cardiac complications associated with fl uid challenges and inotropes used to augment cardiac output may deter clinicians from instituting early gdt in the very patients who are more likely to benefi t. methods systematic search of medline, embase and central databases for randomized controlled trials of gdt in high-risk surgical patients. studies including cardiac surgery, trauma, and pediatric surgery were excluded to minimize heterogeneity. we reviewed the rates of all cardiac complications, arrhythmias, acute myocardial ischemia, and acute pulmonary edema. meta-analyses were performed and forest plots drawn using revman software. data are presented as odd ratios (ors) ( % cis), and p values. and compared with those calculated with the echocardiographic standard formulation (stroke volume = cross-sectional area×velocity time integral; coecho = sv×heart rate). in every patient co was measured twice: at baseline (t ) and after volume loading ( ml lactate ringer solution) (t ). agreements between covig, comc, and coecho were evaluated by means of simple linear regression (r ) and bland-altman analysis. results twenty patients were enrolled in the study. values of r , bias and limit of agreement at t and t are summarized in table . co values ranged from . and . l/minute (echo), from . to . (vigileo) and from to . (mostcare); the pearson's and bland-altman methods showed poor agreement between coecho and covig, demonstrating a tendency to overestimation (see figure ). the percentage of error (pe) was . % at t and . % at t . on the contrary, mostcare measures showed good agreement with echocardiography (see table ) with a pe of . % at t and of % at t . conclusion vigileo did not prove to be a substitute to the reference system; pre-loaded data, necessary for vascular impedance estimation, may be one of the main limitations that made vigileo measurements less accurate than the mostcare ones. on the contrary, mostcare, an uncalibrated totally independent system, was shown to properly estimate the vascular impedance in these hemodynamically stable patients. further comparisons in unstable conditions are needed to confi rm our observations. references previous studies have found an association between severity of acute infl ammatory states and increased arterial stiff ness but it is not known whether non-invasive pulse waveform analysis could predict development of multiple organ failure in septic patients. the purpose of this study was to evaluate the photoplethysmographic brachial artery pulse wave transit time and augmentation index and their changes in response to induced forearm ischemia in septic icu patients and correlate these indices to the development of subsequent end organ damage. methods a prospective observational study in patients with sepsis within hours of admission. severity of sepsis was assessed with apache ii score (median . ) and sofa score (median . ). threeminute signal recording was done concurrently from the brachial artery at the elbow and the radial artery at the wrist with an originally designed photoplethysmograph at rest and after minutes of induced forearm ischemia. recordings were analyzed to obtain the pulse wave transit time and augmentation index at rest and seconds after induced ischemia. the sofa score was recalculated at hours post recording. results we studied consecutive general icu patients. there was a negative linear relationship between the pulse wave transit time (median . ms) at rest and increase in sofa score in hours (p = . , r = . ). the postischemic pulse wave transit time increased in all patients (median . ms) but no association was found between the proportion of increase and subsequent change in sofa. correlation between rest (median . ) and postischemic (median . ) augmentation index and -hour sofa scores was not statistically signifi cant (r = . , p = . ). conclusion this study indicates that in early sepsis pulse waveform characteristics could predict the risk of developing end organ failure. the pulse wave transit time is more robust than the augmentation index and could be easier to use in patients with poor perfusion. vascular reactivity indices do not seem to have predictive value in this context. reference in clinical practice, blood volumes (bv) are typically measured by thermodilution. recently, contrast-enhanced ultrasound (ceus) has been proposed as an alternative minimally invasive approach for bv assessment [ ] . this method measures bv using a single peripheral injection of a small bolus of ultrasound contrast agent (uca) detected by an ultrasound scanner. by measuring the acoustic backscatter, two indicator dilution curves (idcs) can be derived from two diff erent sites in the circulatory system. idc analysis permits deriving the mean transit time (mtt) the bolus takes to travel between the injection site and two measurement sites. assessment of the bv between these sites is obtained by multiplying the diff erence in mtt (Δmtt) by the blood fl ow. in this study, we compare diff erent volumes in an in vitro set-up by ceus with true set-up volumes and thermodilution acquired volumes. methods the in vitro set-up consisted of a centrifugal pump, a network of tubes with variable volumes, an electromagnetic fl owmeter to measure and adjust the generated fl ow, heating devices to maintain constant temperature ( °c), two thermistors for thermodilution measurement, an ultrasound transducer and a pressure stabilizer. a small bolus of uca diluted in cold saline ( mg sonovue® in ml saline at °c) was injected into the system. the cold uca passage through a fi rst and a second region of interest (roi) was measured simultaneously with the ultrasound transducer and the thermistors. the measurements were performed at diff erent fl ows and volumes. bvs were estimated using the two diff erent approaches, namely ceus and thermodilution. the idcs were processed and fi tted separately with a dedicated model to estimate the Δmtt of the cold uca bolus between the two rois and the two thermistors. all the measurements were repeated three times. results a linear relation between bvs estimated by the two techniques was observed with a correlation coeffi cient of . . the bias of ceus with respect to the true volumes was - . ml; the bias of thermodilution was . ml. the most prominent diff erences between the two techniques were observed in case of high volume and low fl ow, possibly due to diff erent transport kinetics between ucas and heat. the use of cardiac output monitoring has been shown to be benefi cial in the setting of perioperative medicine and critical illness [ , ] . more recently, its application in the setting of major trauma has been described [ ] . here, we describe our preliminary experience of embedding bioreactance fl ow monitoring within the major trauma primary survey of severely injured patients and the subsequent eff ect on patient management. methods institutional ethical approval was obtained. intubated major trauma patients were sequentially enrolled. exclusions included major thoracic burns and children. bioreactance fl ow monitoring (nicom; cheetah) was applied at the same time as ecg leads and the calibration step performed during handover from the prehospital team. time to availability of oxygen delivery data was recorded and trauma team members surveyed regarding for perceived benefi ts and concerns from this monitoring. the infl uence of fl ow monitoring on fl uid resuscitation, time to ct and defi nitive disposal (to or/icu) was measured and compared with a control population matched for injury severity score, age and sex. results cardiac index was available at mean . minutes (median minutes; sd . ), fl uid responsiveness at mean . minutes (median ; sd . ) and oxygen delivery calculation at mean . minutes (median ; sd . ). passive leg raise was not performed in % of patients due to concerns about pelvic or brain injury. volume of fl uid infused (mean vs. ml; p = . ), time to ct (mean . vs. . minutes; p = . ), and time to defi nitive disposal (mean . vs. . minute; p = . ) were all reduced in the fl ow monitored group, although not signifi cantly diff erent when compared with a matched control group (mann-whitney u rank sum). eighty-four percent of trauma team members surveyed felt the fl ow monitoring data to be useful, and only % felt it may impair clinical management. conclusion cardiac index, fl uid responsiveness and oxygen delivery data can be obtained inform a primary survey. rather than introducing delays, the use of fl ow monitoring was associated with a trend towards decreased time to imaging; less fl uid use pre-damage control point and reduced time to defi nitive disposal. further research is required to confi rm benefi ts and mechanism. references introduction pulse pressure variation (ppv) is a dynamic indicator of fl uid responsiveness, which is known to have a low sensibility and specifi city in patients ventilated in pressure support (ps) [ ] . we aim to investigate patient-ventilator asynchrony as a potential source of hemodynamic interference in ps. methods we performed a prospective study including ps ventilated patients who met inclusion criteria for fl uid depletion [ ] . patients who showed an asynchrony index (ai) exceeding % were included in the asynchrony group (ag). the remaining patients were included in the synchrony group (sg) [ ] . beat-to-beat hemodynamic variables were recorded through pram (mostcare; vytech health srl, padova, italy). ppv cutoff of % was used to identify fl uid responders/nonresponders. a fl uid challenge of ml normal saline was given in minutes. an increase of % of cardiac index after minutes indicated fl uid responsiveness. results so far, eights patients showed an ai > % while did not. overall sensitivity was . % versus % in sg; overall specifi city was . % versus . % in ag. overall cohen's k was . % versus . % in ag (see figure ). however, because none of the responders in the ag group was detected by ppv, statistical analysis was not feasible within this subgroup. the mini-fl uid challenge is a widely used strategy to manage fl uid loading in the icu and or. although it might be a rational strategy, data on the mini-fl uid challenge and its reliability are very limited. we investigated the value of changes in pulse contour cardiac output as a result of a mini-fl uid challenge of and ml to predict fl uid loading responsiveness. methods we measured the eff ects after the administration of , and ml bolus colloid infusions on co (modelfl ow (com) and lidco (coli)), cvp and map in patients on mechanical ventilation after elective cardiothoracic surgery. from the data we analysed the smallest volume that was predictive for the eff ects of ml on cardiac output. results coli and com increased after , and ml fl uid loading. best results are observed for changes in com after ml fl uid loading (area under the roc . , % ci between . and . ). a change in modelfl ow co of at least . % has a sensitivity of % and a specifi city of % after ml fl uid loading. sensitivity is % and specifi city % for a similar cutoff in co measured with the lidco device after ml fl uid loading. in our patient population, map and coli did not predict responsiveness with more accuracy than mathematical chance. see figure . conclusion changes in pulse contour co can be used in a mini-fl uid challenge to assess fl uid responsiveness in our postcardiac surgery patients. introduction fluid responsiveness is defi ned based on an arbitrary increase of cardiac output (co) or stroke volume (sv) of to %. we hypothesise that the variation of heart effi ciency (eh) and the slope (s) defi ned by the relative increase of co over the relative increase of mean fi lling pressure (pmsa) can be used as alternative defi nitions of fl uid responsiveness. introduction fluid overload is associated with poor outcome in the critically ill. thus, an accurate predictor of a positive haemodynamic response (increase in stroke volume) to fl uid challenge is vital. methods we studied the predictive value (positive response defi ned as change in stroke volume > % after ml/kg fl uid bolus) of a range of haemodynamic variables: static (cvp, active circulating volume, central blood volume, total end diastolic volume), dynamic (systolic pressure variation, stroke volume variation) and contactility (dp/dt), in a group of ventilated children (median weight kg). variables were measured using transpulmonary ultrasound dilution and pram (an arterial pulse contour method). we performed paired measurements (pre-fl uid and postfl uid challenge), with a sv response rate of %. overall predictive values were poor, but slightly better for static versus dynamic variables (table ) . when sv response was analysed as a continuous variable, the two predictive multivariable variables were change in tedvi and baseline dp/dt (r = . , both p < . ). conclusion the predictive ability for typical static and dynamic haemodynamic variables, when taken in isolation, is poor. however, improved prediction is seen when baseline contractility is taken into account. pressure (map)-guided fl uid therapy on microcirculatory perfusion in patients undergoing abdominal surgery. methods patients undergoing elective abdominal surgery were randomized into a ppv/ci-guided group (n = ) or a map-guided (n = ) group. ppv, ci and map were measured using the non-invasive fi nger arterial blood pressure measurement device ccnexfi n (edwards lifesciences bmeye, amsterdam, the netherlands). tidal volumes were ≥ ml/kg with peep ≥ mmhg. in both groups, map of mmhg was maintained. in the ppv/ci group, an intraoperative algorithm was used keeping the ppv under % and ci above . l/minute/ m using fl uid therapy and dobutamine and noradrenaline infusion, respectively. sublingual microvascular perfusion was measured after anesthesia induction, and every subsequent hour using sidestream dark-fi eld imaging (microscan; microvision medical, amsterdam, the netherlands). the perfused small vessel density (pvd) values were offl ine quantifi ed. the fi rst hour during surgery, the ppv/ci-guided group tended to receive more fl uids than the map-guided group ( , ± ml vs. ± ml; p = . ). at this time point, the pvd was slightly lower in the ppv/ci-guided group ( . ± . mm/mm ) when compared with the map-guided group ( . ± . mm/mm ; p = . ). in both groups the pvd remained stable during the fi rst hours of surgery. however, hours after the start of surgery, the pvd in the ppv/ci group restored and tended to be higher than in the map-guided group ( . ± . vs. . ± . mm/mm ; p = . ). after hour of surgery, the administered fl uid volume correlated inversely with pvd (r = - . , p = . ). conclusion goal-directed fl uid management resulted in a higher administered fl uid volume in the beginning of surgery, and this was associated with a slightly reduced microcirculatory perfusion when compared with map-guided fl uid management. microcirculatory perfusion tended to improve as surgery progressed in the goal-directed fl uid therapy group. our fi ndings suggest that goal-directed and mapguided fl uid management are associated with distinct patterns in fl uid resuscitation, which may be of consequence for microvascular perfusion. introduction previous studies demonstrate that loss of glycocalyx integrity is associated with impaired microvascular function. we investigated whether glycocalyx dimensions are reduced in patients undergoing cardiac surgery with or without cardiopulmonary bypass (cpb), and are paralleled by loss of microcirculatory perfusion using in vivo microcirculation measurements. methods patients undergoing on-pump surgery with nonpulsatile (n = ) or pulsatile (n = ) cpb or off -pump surgery (n = ) underwent sublingual sidestream dark-fi eld imaging at baseline, during coronary grafting and upon icu admission to assess perfused microvascular vessel density. glycocalyx integrity was evaluated using the glycocheck measurement software, and expressed as the perfused boundary region (pbr). an increase in pbr represents deeper penetration of erythrocytes into the glycocalyx, and is indicative for compromised glycocalyx thickness. introduction cold exposure can be adapted for exercise or therapeutic purposes, but its impact on microcirculation in healthy humans has not been well defi ned. we hypothesize that whole body cold stress may impair microcirculation. methods seven volunteers were recruited for the water immersion procedure. during the cooling protocol the volunteers every minutes of immersion were asked to step out from the bath and rest for minutes in a room environment and then return to the water bath for the next minutes of immersion. this head-out immersion procedure in bath water at °c continued until the rectal temperature was dropped to . °c or the time of minutes was terminated. maximum cold water immersion time was minutes. before, at the end of whole body cooling and hour after cooling was ended, systemic hemodynamics and direct in vivo observation of the sublingual microcirculation were obtained with sidestream dark-fi eld imaging. assessment of microcirculatory parameters of convective oxygen transport (microvascular fl ow index (mfi), proportion of perfused vessels (ppv)), and diff usion distance (perfused vessel density (pvd) and total vessel density (tvd)) was done using a semiquantitative method. results during cooling and hour after cooling was ended, a signifi cant increase in cardiac output (p = . and p = . ) was observed, but there were no changes in heart rate or mean arterial pressure in comparison with baseline variables. there were no signifi cant changes in ppv, mfi, pvd and tvd of small vessels in comparison with baseline variables during all observational time. conclusion defined cold exposure had no effect on the microcirculation. introduction vasodilation and increased skin blood fl ow (also sweating) are infl uential in heat dissipation during heat exposure and exercise. it is unclear how heat stress infl uences microcirculation. side dark-fi eld imaging visualizes the blood fl ow at the capillary level and helps to assess perfusion heterogeneity. clinical and experimental data show that the sublingual region is clinically relevant for detecting microcirculatory alterations and more represents central microcirculation than cutaneous perfusion. we hypothesize that whole body heat stress may increase capillary density. methods eight healthy men with no history of cold and/or heat injury were recruited to this study. passive body heating was performed by continuous immersion up to the waist in the water bath at °c and continued until rectal temperature reached . °c. before, at the end of whole body heating and hour after heating was ended, systemic hemodynamics and direct in vivo observation of the sublingual microcirculation were obtained with sidestream dark-fi eld imaging. assessment of microcirculatory parameters of convective oxygen transport (microvascular fl ow index (mfi), proportion of perfused vessels (ppv)), and diff usion distance (perfused vessel density (pvd) and total vessel density (tvd)) was done using a semiquantitative method. vessels were separated into large (mostly venules) and small (mostly capillaries) using a diameter cutoff value of μm. results whole body heating resulted in signifi cantly increased heart rate (p = . ) and cardiac output (p = . ) in comparison with baseline variables. one hour after heating was ended, the heart rate introduction serial measurements of lactate over time may be a better prognosticator than a single lactate concentration [ ] . early lactateguided therapy also reduces icu length of stay and icu and hospital mortality [ ] . this study aims to assess the prognostic value of the lactate clearance (lc) in the fi rst hours in surgical patients. methods in a prospective cohort during year, we followed consecutively enrolled patients admitted immediately postoperative to the surgical icu of hospital santa luzia, brasília, brazil. patients were assigned to two groups: lc > % and lc ≤ %. the primary outcome measure was mortality at and days. the secondary outcome included hospital and icu length of stay (los). results a total of patients were followed. in total, . % were male and % underwent elective surgery. the mean age was ± , apache ii score ± , saps ± . the mortality at days was . % (n = ) and the mortality at days was . % (n = ), respectively. hospital mortality was . % (n = ). sixty-one percent (n = ) of the patients had lc > % versus % (n = ) with lc ≤ %. those who had lc ≤ % were older ( ± vs. ± , p = . ) and had greater apache ii score ( ± vs. ± , p = . ) and saps ( ± vs. ± , p = . ). there was no diff erence in icu los ( ± vs. ± days, p = . ) and hospital los ( ± vs. ± days, p = . ). initial lactate levels were lower in the group with lc ≤ % ( . ± . vs. . ± . , p = . ); however, mean lactate was higher in hours ( . ± . vs. . ± . , p = . ). all of the patients who died in the fi rst days had lc ≤ % ( . %, n = , p = . ); this group also had a higher mortality at days ( . %, n = vs. . %, n = ; p = . ). the relative risk for mortality lc ≤ % in and days was . ( % ci: . to . ) and . ( % ci: . to . ), respectively. signifi cant diff erence was observed in the kaplan-meier survival curves for and days (p = . and . , respectively). the sensibility of lc ≤ % was % ( % ci: to %) for -day mortality and % ( % ci: to %) for -day mortality. the specifi city was % ( % ci: to %) for -day mortality and % ( % ci: to %) for -day mortality. conclusion despite initial lactate levels, lactate clearance ≤ % proved to be a good predictor of mortality in and days in surgical patients admitted in the postoperative period to the icu. references introduction the use of peripheral perfusion objective parameters to anticipate successful resuscitation in septic shock has been recently investigated [ ] . the mottling score, a perfusion parameter used for decades, has been proposed to correlate with septic shock survival [ ] , and was tested in this study as a clinical tool in predicting mortality. methods a prospective observational study was conducted, with patients consecutively admitted to a tertiary hospital icu in brasília, brazil. from july to may , all patients diagnosed with septic shock were enrolled. demographic data, diagnoses, shock origin and severity scores were recorded. after initial resuscitation, the score was registered in the fi rst days by the same observer, considering the score on the lower limb without an arterial catheter, or the worst between the lower limbs, and the worst in the days. exclusion criteria were terminal illness with no intervention decision and incomplete methods pigs ( to kg) were randomized into one of the groups: sham (n = ), hs (n = ), lr ( × volume bled; n = ) or terli ( mg bolus; n = ). hs induced to target map of mmhg was maintained for minutes. brain tissue oxygen pressure (pbto ), intracranial pressure (icp), cerebral perfusion pressure (cpp), haemodynamics and blood gas analyses were assessed prior to hs (baseline) up to minutes after treatment. tissue markers of brain oedema (aquaporin- (aqp ) and na-k-cl cotransporter- (nkcc )), apoptosis (pre-apoptotic protein (bax)) and oxidative stress (thiobarbituric acid reactive substances (tbars)) were also measured. results sham animals had no signifi cant changes in the variables assessed. hs resulted in a signifi cant decrease in cpp (mean varied from to mmhg), pbto (from . to . mmhg), icp (from to mmhg) and haemodynamics (map from to mmhg; ci from . to . l/minute/m ), and a signifi cant increase in blood lactate (from . to . mmol/l) and cerebral aqp (mean ± se; ± % of sham), nkcc ( ± % of sham), bax ( ± % of sham) and tbars. fluid resuscitation was followed by an increase in icp (from to mmhg) and a decrease in cpp (from to mmhg), with an increased expression of cerebral aqp ( ± % of sham), nkcc ( ± % of sham) and bax ( ± % of sham introduction shock induces mitochondrial damage, which can lead to tissue injury and infl ammation. resuscitative adjuncts to limit mitochondrial injury may be eff ective to reduce tissue injury and protect against the sequelae of hemorrhagic shock (hs). others and we have demonstrated the protective eff ects of inhaled carbon monoxide (co) or nebulized sodium nitrite (nano ) in models of hs. our aim was to test the hypothesis that co and nano protect against hemorrhagic shock-induced tissue injury/infl ammation by limiting mitochondrial damage and preventing bioenergetic failure. methods twenty anesthetized female yorkshire pigs were subjected to severe hemorrhage until unable to compensate or minutes, and were then resuscitated with volume/pressors. muscle and platelet samples were obtained at baseline (bl) and hours after resuscitation (endobs). animals were randomized to: standard of care (hsr, n = ); hsr+co (co; ppm× minutes, n = ); or hsr+nano (nano ; mg in pbs× minutes, n = ), and sham (n = ). co or nano were initiated ~ minutes before resuscitation. primary endpoints were changes in muscle and platelet mitochondrial respiration between bl and endobs, quantifi ed by muscle respiratory control ratio (rcr, traditional respirometry), and by the change in proton-leak respiration (plr) and mitochondrial reserve capacity in platelets. secondary endpoint was mortality at endobs. results skeletal muscle rcr decreased in the hsr group (p = . ) but not in sham. decrease in rcr was primarily due to decreased adpdependent respiration, without change in state respiration. hsr also resulted in platelet mitochondrial dysfunction as demonstrated by increased plr and decreased reserve capacity. this correlated with increased platelet activation (%cd p+ by fl ow cytometry) in hsr. co or nano treatment prevented these deleterious changes in both muscle and platelet mitochondrial respiration, as well as limited hsr-induced platelet activation. co treatment also improved reserve capacity compared with baseline. mortality was higher in hsr than in co or nano ( vs. and %, respectively). conclusion in severe hs, mitochondrial injury in platelets and muscle was limited by co or nano . although not powered for a secondary endpoint, mortality was double in hsr versus adjunctive therapies. this suggests that co and nano may protect mitochondrial function by maintaining atp-coupled respiration and reserve capacity, and that this may confer a survival advantage. however, further investigations are required. introduction norepinephrine has been widely used in septic shock. however, its eff ect remains controversial. we conduct a systematic review and meta-analysis to compare the eff ect between norepinephrine and other vasopressors. methods the pubmed, embase, and cochrane library databases from database inception until october were searched. we selected randomized controlled trials in adults with septic shock and compared norepinephrine with other vasopressors. the quality of each study included was assessed with jadad score. after assessing for heterogeneity of treatment eff ect across trials using the i statistic, we used a fi xed eff ect model (p ≥ . ) or random-eff ects model (p < . ) and expressed results as the risk ratio (rr) for dichotomous outcomes or the standardized mean diff erence (smd) for continuous data with % ci. results eighteen trials (n = , ) met inclusion criteria, which compared norepinephrine with fi ve diff erent vasopressors (dopamine, vasopressin, epinephrine, terlipressin and phenylephrine). the mean jadad score was . . overall, there was no diff erence in mortality in the comparisons between norepinephrine and vasopressin, epinephrine, terlipressin and phenylephrine (p > . , respectively). however, norepinephrine had a trend in decreasing mortality compared with dopamine (rr, . ; % ci, . to . ; p = . ). there were a decreased heart rate (hr) (smd, - . ; % ci, - . to - . ; p = . ), cardiac index (smd, - . ; % ci, - . to - . ; p = . ) and an increased systemic vascular resistance index (svri) (smd, . ; % ci, . to . ; p < . ) with the treatment of norepinephrine compared with dopamine. conclusion there is not suffi cient evidence to prove that norepinephrine is superior to vasopressin, epinephrine, terlipressin and phenylephrine in terms of mortality. however, norepinephrine is associated with a decreased hr, cardiac index and an increased svri, and appears to have a greater eff ect on decreasing mortality compared with dopamine. introduction vasoplegic syndrome is a common complication after cardiac surgery, with negative impact on patient outcomes and hospital costs. pathogenesis of vasodilatory phenomenon after cardiac surgery remains a matter of controversy. loss of vascular tone can be partly explained by the depletion of neurohypophyseal arginine vasopressin stores. vasopressin is commonly used as an adjunct to catecholamines to support blood pressure in refractory septic shock, but its eff ect on vasoplegic shock is unknown. we hypothesized that the use of vasopressin would be more eff ective on treatment of shock after cardiac surgery than norepinephrine, decreasing the composite endpoint of mortality and severe morbidity. methods in this prospective and randomized, double-blind trial, we assigned patients who had vasoplegic shock to receive either vasopressin ( . to . u/minute) or norepinephrine ( . to μg/ kg/minute) in addition to open-label vasopressors. all vasopressor infusions were titrated and tapered according to protocols to maintain a target blood pressure. the primary endpoint was major morbidity according to sts ( -day mortality, mechanical ventilation > hours, mediastinitis, surgical re-exploration, stroke, acute renal failure). secondary outcomes were time on mechanical ventilation, icu and hospital stay, new infection, the time to attainment of hemodynamic stability, occurrence of adverse events and safety. results a total of patients underwent randomization, were infused with the study drug ( patients received vasopressin, and norepinephrine), and were included in the analysis. patients who received vasopressin had a lower rate of morbidity ( . % vs. %, p = . ) as compared with the norepinephrine group. the -day mortality rate was . % in the norepinephrine group and . % in the vasopressin group (p = . ). there were no signifi cant diff erences in the overall rates of serious adverse events ( . % and . %, respectively; p = . ). results patients in the two groups were statistically comparable with respect to sex (p = . ) and age (p = . ). the causes of the syndrome of tako-tsubo were: subarachnoid hemorrhage (six patients) after coronary artery bypass graft (four patients), and polytrauma (two patients). all patients had low cardiac output. in the levosimendan group the ejection fraction at entrance was ± %, after hours ± %, and ± % after hours. in the control group the ejection fraction at entrance was ± %, after hours ± % and after hours ± %. comparing the two groups we reached statistical signifi cance, p = . . conclusion comparing the two groups, we noticed that both started from a low cardiac output. however, in the group who used the drug therapy based on levosimendan we saw a return of systolic function of the left ventricle to near-normal levels within hours, while in the control group there remains a dysfunction in systolic function. we have shown the drug therapy based on levosimendan contributes to improving the systolic function of the left ventricle compared with treatment with dobutamine despite the initial cardiac stunning. reference introduction in the critically ill, the incidence of raised cardiac troponin t (ctnt) levels is high. although the mechanisms of myocardial injury are not well understood, raised ctnt levels are associated with increased mortality. the aim of our study was to determine the incidence, prevalence and outcome of silent myocardial injury as determined by raised ctnt levels and concomitant ecg changes in critically ill patients admitted for noncardiac reasons. methods ecgs were taken and ctnt was measured daily during the fi rst week and on alternate days during the second week until discharge from the icu or death. after completion of the study, all ctnt levels and ecgs were analysed independently and patients were classifi ed into four groups: defi nite mi (ctnt ≥ ng/l and defi nite ecg changes of mi), possible mi (ctnt ≥ ng/l and ischaemic changes on ecg), troponin rise alone (ctnt ≥ ng/l with no ischaemic ecg changes), or normal. all medical notes were reviewed independently by two icu clinicians. results a total of patients were included in the analysis ( % female; mean age . (sd . ); mean apache ii score . ). in total, patients ( %) had at least one ctnt level ≥ ng/l during their stay in the icu. twenty patients ( %) fulfi lled criteria for a defi nite mi, of whom % were septic and % were on noradrenaline at the time (icu and hospital mortality: % and %, respectively). thirty-nine patients ( %) had a possible mi, of whom % were septic and on noradrenaline (icu and hospital mortality: % and %, respectively). sixty-two patients ( %) had a raised troponin without ecg, of whom % were septic and . % were on noradrenaline (icu and hospital mortality: % and %, respectively). twenty-three patients had normal ctnt results and serial ecgs, of whom % had sepsis. icu and hospital mortality was %. only % of defi nite mis and % of possible mis were recognised by the clinical teams at the time. conclusion eighty-four per cent of critically ill patients had a raised ctnt level at some stage during their stay in the icu. more than % of patients fulfi lled criteria for a possible or defi nite mi, of whom only % were recognised clinically. icu and hospital outcome were signifi cantly worse in patients with a ctnt rise. the proportion of patients with sepsis was similar between the patients with a defi nite, possible or no mi. the grace risk score for predicting death within months of hospital discharge was validated and can be used in patients with acs. it would be perfect in the future to include the grace risk score in the medical records of this type of patients. also it would be very interesting to validate this in a multicentric study. figure ). patients in group had more prolonged length of stay in the icu and in hospital than patients in group . after recovery from septic shock we notice a huge accumulated fl uid balance. a more positive fl uid balance was associated with a more prolonged length of stay in the icu and in the hospital. ugib patient needs an intervention or not. however, the intervention which the gbs mentions includes not only endoscopy but also blood transfusion. therefore, we cannot determine whether a ugib patient needs urgent endoscopy or just blood transfusion by gbs alone. we hypothesized that high lactate clearance (clac) would decrease the likelihood of sustained ugib. methods this is a retrospective study. ugib patients, who visited the emergency department (ed) of the national center for global health and medicine from april to march and received urgent endoscopy in the ed, were enrolled. we collected for each patient the gbs, the blood lactate value on arrival in the ed, the blood lactate value after bolus administration of to ml/kg ringer's acetate (initial fl uid therapy) and the report of urgent endoscopy. we classifi ed the severity of ugib according to gbs. a score ≤ was classifi ed as moderate, and a score ≥ was classifi ed as severe. clac was defi ned as the percentage decrease in blood lactate from the time of arrival in the ed to the time when an initial fl uid therapy was fi nished. clac < % was defi ned as low, and clac ≥ % was defi ned as high. whether a patient had sustained bleeding or not was determined based on the report of urgent endoscopy. the relationship between clac and sustained bleeding was examined by fisher's exact test, and p < . was considered statistically signifi cant. results seventy-nine patients were enrolled. fifty-one patients were with moderate ugib, and patients were with severe ugib. as indicated in tables and , there was a signifi cant relationship between clac and sustained bleeding in moderate ugib (p = . ). on the other hand, there was no signifi cant relationship between clac and sustained bleeding in severe ugib (p = . ). introduction the aim of our study was to assess the muscular glucose by microdialysis and its association with mortality in septic shock patients. we conducted a preliminary prospective study. we included septic shock patients hemodynamically optimized according to international recommendations. a microdialysis catheter was inserted in the femoral quadriceps. interstitial fl uid samples were collected every hours for days. the determination of muscular glucose was performed by the cma analyzer (cma/microdialysis ab, sweden). we also performed a dosage of concomitant blood glucose. the study population was divided into two groups according to hospital mortality. statistic analysis: mann-whitney test and chi-squared test: comparisons between groups. quantitative variables were expressed as mean ± standard deviation or median (interquartile range) as appropriate. results we included patients with septic shock. the mortality rate was %. demographics were comparable between groups except for age ( ± vs. ± , dead patients vs. survivors, respectively; p = . ). pneumonia was the major cause of septic shock ( patients). we analysed blood samples and muscular glucose samples. we found a positive association between muscular glucose, blood glucose and mortality. tissue glucose was signifi cantly higher among dead patients compared with survivors at the th hour. comparing all data, muscular glucose (p = . ) and blood glucose (p = . ) were signifi cantly higher in dead patients (table ) . conclusion our data suggest that muscular glucose assessed by microdialysis and blood glucose are associated with mortality in septic shock patients. therefore, muscular glucose may refl ect the metabolic alterations and microcirculatory dysfunction induced by septic shock. methods the audit had the trust audit committee's approval. the existing protocol was used as the benchmark. patients were studied prospectively to assess compliance with the local bowel protocol, incidence of constipation and relationship to weaning from respiratory support and feeding. all hdu and all mechanically ventilated icu patients who stayed on the ward for more than days were included, except for patients after bowel surgery and patients with encephalopathy. results among the hdu and icu patients audited in the royal liverpool university hospital, % and % respectively were constipated. laxatives were prescribed when patients had not opened their bowels for days in % hdu and % icu cases. taking into consideration that the median age, apache ii score and length of stay for constipated and nonconstipated patients were similar, the relationship to feeding and respiratory support were assessed. introduction it was noted on our unit that dislodgement of nasogastric tubes occurred commonly. this can lead to an increased risk of aspiration, interruptions in nutritional support, skin breakdown and radiographic exposure [ ] . it is recommended that the position of nasogastric tubes should be confi rmed by aspiration and ph testing, with radiographic confi rmation used only when this is not possible [ ] . methods we performed a retrospective review of chest x-ray (cxr) requests for the -month period june to august using the trust radiology information system. the proportion of cxr requests for confi rmation of position and patient demographics were measured with an estimation of the fi nancial cost performed. results there were patients admitted to the critical care area in the study period. in total, out of , ( . %) cxrs performed were for confi rmation of position. repeated x-rays were required in some patients (see table ); these patients were older and tended to have a longer length of stay. a mobile cxr costs £ in our trust, if one cxr is accepted per patient with a nasogastric tube; there was an excess of images with a cost of £ , in the -month period. conclusion an excess of cxrs were performed for confi rmation of nasogastric tube in our patient population. the recommended methods for position confi rmation were reinforced amongst medical staff . the high number of repeated imaging for some patients indicates that dislodgement of tubes was also a problem. we propose that nasogastric tubes should be bridled after fi rst dislodgement or at tracheostomy insertion to minimise dislodgement in the future. methods mechanically ventilated, not enterally fed icu patients (n = ) were recruited from an interdisciplinary icu. healthy, overnight-fasted volunteers (n = ) served as reference. a primed constant i.v. infusion of h-labeled phenylalanine (phe) and tyrosine was used to quantify whole-body protein metabolism. patients remained on parenteral nutrition (pn) as clinically indicated; controls received pn starting . hours before starting enteral feeding. intrinsically c-phe-labeled casein was infused for hours by nasogastric tube at . g protein/ hour, together with maltodextrin at . g/hour. protein breakdown, synthesis, net balance, and phe splanchnic extraction were calculated before and at the end of the enteral feeding period, using equations for steady-state whole-body protein kinetics. comparisons were made by wilcoxon matched pairs and mann-whitney u tests; values are reported as mean ± sd. results protein net balance was lower in patients than in the reference group at baseline (- . ± . vs. . ± . mg/kg bw/hour, p = . ), and after enteral feeding (- . ± . vs. . ± . mg/kg bw/hour, p = . ). recovery of labelled phe from enteral feeding into the systemic circulation was higher in the reference group as compared with patients ( . + . % vs. . + . %, p = . ). enteral feeding did not aff ect protein metabolism in the reference group. in patients, protein breakdown became slightly lower during enteral feeding ( . ± . vs. . ± . mg/kg bw/hour, p = . ) and protein net balance became slightly higher (- . ± . vs. - . ± . mg/kg bw/ hour, p = . ). conclusion intrinsically isotope-labelled casein can be used to quantify dietary contribution to protein metabolism in critically ill patients. hypocaloric enteral feeding marginally improved protein balance in these patients. the low recovery of enterally administered labelled amino acid underlines the need to quantify uptake from the gastrointestinal tract when protein turnover measurements are performed in critically ill patients on enteral nutrition. methods this small-scale study of ngt placements during a -week period collated data supplied by questionnaire by healthcare workers responsible for ngt placements. results analysis of adverse incident reports identifi ed no never events of misplaced ngts within the previous years. this audit revealed that the commonest type of ngt was a radio-opaque tube with stylet (corfl o) ( % of placements), with occasional use of the electromagnetic placement system (cortrak) ( % of placements). sizes ( %) and ( %) were most common. tube placement was confi rmed by: x-ray ( %); ph of aspirates ( %); electromagnetic tube placement (one patient). the time taken from decision to place ngt to use varied (range to minutes). little distinction was seen in the time taken to use and ngt confi rmed by aspirate alone ( minutes) or by x-ray ( minutes), although the shortest interval was seen in electromagnetic ngt placement ( minutes). the cost of ngts confi rmed by aspirate alone was low (approximately £ . ), higher with x-ray confi rmation/electromagnetic placement (approximately £ . ). conclusion despite the small dataset the results demonstrate a concerning delay in the application of enteral feeding and/or drug administration. whilst reassuring in the steps taken to avoid never events, this study demonstrates that there may be delays in time-critical administration of enteral medicine or optimal nutritional practices. this study reveals a signifi cant problem with aspirating gastric contents for ph testing, necessitating a large number of x-ray position confi rmations. even if the frequency and volume of gastric aspiration were greater, there is a belief that ph testing may not be suffi ciently accurate (since many factors alter patients' gastric ph). it is possible that new technologies such as electromagnetic ngt placement may allow faster/equally safe practices. further study including cost/benefi t analysis will be needed to confi rm this. reference . eighteen readings were from newly placed ng tubes and readings from old ng tubes. fiftythree per cent of routine ph readings were falsely high; that is, ph or above despite the ng tube being in the stomach (figure ). twentyeight per cent of newly placed ng tubes had falsely high ph readings ( figure ). conclusion in this population of icu patients, routine/daily checks of ng ph aspirate appear to be limited. this is almost certainly due to the use of continuous ng feed together with ppis. the usefulness of ph testing in newly placed ng tubes, however, appears more reliable. introduction sepsis is the most common cause of death in icus [ ] . destruction of intestinal barrier function and increased translocation of bacteria to systemic blood fl ow can lead to sepsis [ ] . probiotics may have benefi cial eff ects in improvement of critically ill patients by modulating intestinal barrier and reduction of infl ammation [ ] . the aim of this trial was to determine the eff ect of probiotic on infl ammatory biomarkers and mortality rate of sepsis in critically ill patients in the icu. methods this double-blind, randomized controlled trial was conducted on critically ill patients admitted to the icu. they were randomly assigned to receive placebo or probiotic for days. the apache score, sequential organ failure assessment (sofa) and systemic concentrations of il- , procalcitonin (pct) and protein c were measured before initiation of the study and on days and . also, day mortality was evaluated for each patient. results il- and pct levels decreased and protein c levels increased signifi cantly in probiotic group over the treatment period (p < . ). there was a signifi cant diff erence in il- , pct and protein c levels of the th day between two groups (p = . , . and < . , respectively). compared with controls, probiotic was eff ective in improving apache and sofa scores in days (p < . ). there was signifi cant diff erence between the probiotic and control group in the -day mortality rate ( % vs. % respectively, p = . ). conclusion probiotics reduce infl ammation and mortality rate in critically ill patients and might be considered as an adjunctive therapy to sepsis. introduction the aim of this study is to establish whether diff erent types of sepsis have an impact on selenium levels. selenium is an essential trace element involved in antioxidant and immunological reactions. selenium levels have been shown to be low in patients with systemic infl ammatory response syndrome and sepsis. selenium replacement has been recommended in patients with sepsis [ , ] . greater than days of supplementation may also help to prevent the development of new infections on icus [ ] . methods this is a prospective survey where selenium levels were collected from patients admitted with septic shock to a tertiary icu, for months from october to march . results selenium levels were measured in patients with septic shock. abdominal and chest sepsis were the main sources of infection. those with an abdominal source of sepsis had the lowest levels, as shown in table . all septic shock patients who had selenium levels taken within the fi rst days of admission had subnormal levels (< . mg/dt), and after days had levels within the normal range, as shown in figure . introduction glutamine regulates many biological functions in preserving the cell, acts as a key respiratory fuel and nitrogen donor for rapidly dividing cells, and modulates the expression of many genes associated with metabolism, cell defences and repair, and cytokine production. in severe thoracic trauma, glutamine supplementation is essential because the body consumes more than it produces and glutamine eff ects become dependent on its route of delivery. methods fifty-two patients to years old with surgery for severe thoracic trauma were assessed in two groups: group a received . to . g/kg/day i.v. glutamine + g enteral glutamine for days, supplementation to enteral nutrition; group b receive only i.v. glutamine supplementation to enteral nutrition . to . g/kg/day for days. weaning time, the duration of p.o. ileus, incidence and time to resolution of vap, glycemic level and the percentage decrease of crp at hours were assessed in both groups. results weaning time and the duration of p.o. ileus were signifi cantly lower in group a; although the incidence of vap is similar in both groups, the time of vap resolution is lower, the glycemic control is better in group a. the percentage of crp decrease is higher in group a. see figure . conclusion glutamine becomes an essential amino acid in severe thoracic trauma and when the patients are fed other than tpn (enteral, oral); although hard evidence is lacking, both administration routes may be effi cient as soon as possible. results total cholesterol (tc) and low-density lipoprotein-cholesterol (ldl-c) levels were less changed signifi cantly in the low ratio group ( ± vs. ± mg/dl, p = . for tc, ± vs. ± mg/dl, p = . for ldl-c) compared with the high ratio group in postoperative patients. other laboratory parameters and adverse events did not show statistically signifi cant diff erences between the groups. see table . introduction the optimal feeding of critically ill patients treated in the icu is controversial. present guidelines for protein feeding are based on weak evidence obtained with suboptimal methods. whole body protein kinetics is an attractive technique to assess optimal protein intake by measuring the eff ect of protein feeding strategies on protein synthesis rates, protein degradation rates and protein balance. here protein kinetics were measured in critically ill neurosurgical patients during hypocaloric and normocaloric parenteral nutrition. methods neurosurgical patients on mechanical ventilation (n = ) were studied. energy expenditure was measured with indirect calorimetry. after that, the patients were randomized to receiving hours of % of measured energy expenditure followed by hours of % or % before %. whole body protein kinetics were measured during the last half hour of the feeding periods using stable isotope-labeled phenylalanine as a tracer. during a continuous infusion of labeled phenylalanine and tyrosine, plasma samples were obtained and later analyzed for the content of the labeled amino acids using mass spectrometry. protein kinetics were calculated using standard steady-state kinetics. in addition, amino acid concentrations were analyzed by hplc. student's t test was used for statistical analyses. the patients received . ± . and . ± . g amino acids/ kg/day (p < . ) on the days with and % of measured energy expenditure respectively. energy expenditures were . ± . and . ± . kcal/kg/day (p = . ) on the and % days respectively. plasma amino acids concentrations were . ± . and . ± . mm (p = . ) on the days respectively. whole body protein synthesis was % lower when % of energy expenditure was given, . ± . versus . ± . mg/kg/hour (p = . ), whilst protein degradation was unaltered . ± . versus . ± . mg/kg/hour (p = . ). also protein oxidation was unaltered . ± . versus . ± . mg/kg/hour (p = . ). this resulted in a % higher whole body protein balance with the normocaloric nutrition, - . ± . versus - . ± . mg/kg/ hour (p = . ). conclusion the protein kinetics measurements and the protocol used were useful to assess the effi cacy of nutritional support in critically ill patients. in the critically ill neurosurgical patients treated in the icu, hypocaloric feeding was associated with a more negative protein balance, while the amino acid oxidation was not diff erent. controlled trial (epanic: clinicaltrials.gov: nct ) [ ] showed that withholding parenteral nutrition during the fi rst week of icu stay whereby tolerating substantial caloric defi cit (late pn) accelerated recovery and shortened weaning time as compared with early parenteral substitution for defi cient enteral feeding (early pn). we examined the impact of late pn, as compared with early pn, on incidence and recovery of icuaw. methods a preplanned subanalysis of adult patients included in the epanic trial. the study was performed between october and november and included those patients who required intensive care for ≥ days as well as a computer-generated, admission categorymatched, random sample of short-stay icu patients, the latter to correct for possible bias evoked by earlier icu discharge in one of the two study groups. assessors blinded for treatment allocation evaluated muscle strength clinically three times weekly from awakening onward and performed nerve conduction studies and electromyography (ncs and emg) weekly. the primary outcome was the incidence of icuaw, diagnosed clinically by the medical research council (mrc) sum score (< / ) [ ] at fi rst evaluation. secondary outcomes included icuaw at worst and last mrc evaluation, recovery from icuaw and incidence of abnormal fi ndings on ncs and emg. all analyses were performed on the total dataset and on a for-baseline characteristics propensity score-matched sample to correct for possible imbalances between the groups. [ ] . plasma total bilirubin was quantifi ed in all patients daily while in the icu. liver enzymes alt, ast, ggt and alp were quantifi ed twice weekly in all patients while in the icu. in a random predefi ned subset of patients, circulating bile salts were also quantifi ed with ms-hplc at baseline and on day , day and the last day in the icu (n = ). gallbladder sludge was evaluated by ultrasound on icu day by blinded assessors (n = ). results from day after randomization until the end of the -day intervention window, plasma bilirubin was higher in the late pn than in the early pn group (all p < . ). in the late pn group, as soon as pn was started on day , plasma bilirubin also fell and the two groups became comparable. maximum levels of ggt, alp and alt during the icu stay were higher in the early pn group (all p < . ). compared with baseline, the circulating glycine and taurine conjugated primary bile salts were elevated on day , day and last day of the icu stay (p < . for all). however, there was no diff erence between the two groups. more patients in the early pn than in the late pn group had gallbladder sludge on day ( % vs. %; p = . ). conclusion tolerating substantial caloric defi cit by withholding pn until day of critical illness increased circulating levels of bilirubin but reduced the occurrence of gallbladder sludge and lowered ggt, alp and alt levels. these results suggest that hyperbilirubinemia during critical illness dies not necessarily refl ect cholestasis and instead may be an adaptive response. additional analyses on a propensity scorematched patient population are ongoing. reference the duration of renal replacement therapy (rrt) [ ] . the impact of the intervention on early markers of catabolism has not been investigated. methods we studied the impact of early versus late pn on daily markers of catabolism in the icu in the total study population and in propensity score-matched subgroups of long-stay patients. in addition, we calculated the net incorporation rate of the extra amino acids supplied by early pn. results plasma urea, the urea/creatinine ratio and nitrogen excretion increased over time in the icu. early pn further increased these markers of catabolism, from the fi rst day of amino acid infusion onward, and only marginally improved the nitrogen balance. also in the group that received pn only after the fi rst week in the icu, ureagenesis was increased by infusing amino acids. over the fi rst weeks, approximately two-thirds of the extra amino acids supplied by early pn were net wasted in urea. the above fi ndings were confi rmed in propensity scorematched subgroups of long-stay patients. the higher urea levels with early pn, rather than the kidney function as such, may have driven the observed longer duration of rrt, as supported by multiple regression analysis. conclusion the extra amino acids supplied by early pn appeared ineffi cient to reverse the negative nitrogen balance, not because of insuffi cient amino acid delivery, but rather because of insuffi cient incorporation with, instead, increased degradation into urea. the substantial catabolism of the extra amino acids, leading to pronounced urea generation, may have prolonged the duration of rrt in the early pn group. introduction muscle weakness of critical illness is associated with prolonged dependency on ventilatory support and delayed rehabilitation. muscle wasting related to poor nutrition has long been considered a major determinant, whereas the importance of myofi ber integrity only recently emerged [ ] [ ] [ ] [ ] . we hypothesized that nutrient restriction early during illness aggravates atrophy while preserving myofi ber integrity by activating the crucial cellular quality control pathway autophagy. the latter could be important to preserve muscle function. methods critically ill patients (n = ) were randomized to early (early-pn) or late (late-pn) initiation of parenteral nutrition to complete failing enteral nutrition, while maintaining normoglycemia ( to mg/ dl) with insulin, in the epanic study [ ] . vastus lateralis biopsies were harvested after week and compared with matched controls (n = ). results as compared with controls, muscle from critically ill patients showed reduced myofi ber density, a shift to smaller (especially type i) myofi bers, lower myosin and actin mrna, upregulated mrna of the ubiquitin ligases muscle-ring-fi nger- and atrogin- , a small increase in the autophagosome formation marker lc -ii/lc -i, and increases in the autophagic substrates ubiquitin and p (all p ≤ . ). late-pn, resulting in a larger caloric defi cit than early-pn, had no substantial impact on atrophy markers. in contrast, late-pn increased lc -ii/lc -i (p = . ), which coincided with less accumulation of ubiquitinated proteins/aggregates (p = . ). fewer patients on late-pn developed muscle weakness as compared with early-pn ( % vs. %, p = . ). in multivariable analysis, a lower lc -ii/lc -i ratio (p = . ) and higher myofi ber density (p = . ) were independently associated with muscle weakness. conclusion early-pn did not counteract muscle atrophy whereas it suppressed autophagy and aggravated weakness. statistically, muscle weakness was not explained by atrophy or wasting but rather by impaired autophagy and preservation of muscle density. thus, tolerating nutrient restriction early during critical illness may preserve myofi ber integrity by activating autophagy. introduction closure of an acute hospitals emergency department (ed) has important ramifi cations for those centres expected to take up the resultant workload. the continued reconfi guration of emergency care is likely to produce an increasing number of these scenarios. little evidence is available to support planning of such initiatives and thus the implications are diffi cult to anticipate. this study aims to demonstrate one hospital's experience of the rationalisation of emergency care and its eff ect on workload. methods this retrospective study was conducted in a large teaching hospital. activity data were analysed for a -month period following the closure of a neighbouring ed. the results were subsequently compared against the year prior to closure. attendance, triage data, admission rates and waiting times were compared across the two periods, as were workload data for all grades of physician. the chisquared test was used to examine diff erences between groups. results in the period studied, the gross attendance fi gure increased by , ( . %), whilst the admission rate rose from to %. following closure of the neighbouring ed, the proportion of highacuity patients attending our institution increased dramatically, with the proportion of category one and two patients (manchester triage scale) increasing by . % (p = . ) and . % (p < . ), respectively. likewise, ambulance arrivals increased out of proportion to the total increase in attendances (p = . ). admissions from the ed to the icu increased by . %. consultants workloads now include % more category and patients (p = . ). conclusion reconfi guration of emergency care can have dramatic implications for existing services; these may not always be anticipated. rationalisation of ed's may result in a concentration of high-acuity patients accompanied by a downturn in the numbers of patients whose presentations are amenable to care delivered in other settings. this abrupt change in case mix requires a re-examination of existing workforces and their seniority. overcrowding estimation in the emergency department: is the simplest score the best? introduction emergency department (ed) overcrowding is a major international problem with a negative impact on both patient care and providers. among validated methods of measurement, emergency physicians have to choose between simple and complex scores [ , ] . the aim of the present study was to compare the complex national emergency department overcrowding scale (nedocs) with the simple occupancy rate (or) determination. we further evaluated the correlation between these scores and a qualitative assessment of crowding. methods the study was conducted in two academic hospitals and one county hospital in liège, chênée and verviers; each with an ed census of over , patient visits per year. samplings occurred over a -week period in january , with fi ve sampling times each day. results ed staff considered overcrowding as a major concern in the three eds. median or ranged from to , while the nedocs ranged from . to . . we found a signifi cant correlation between introduction it is evident that accident and emergency departments are overloaded with patients, which results in delays in healthcare provision [ ] . a large proportion of patients consist of patients with minor illness that can be seen by a healthcare provider in a primary care setting. the aim of the study was to determine the characteristics of patients using gp walk-in services, patients' satisfaction and the eff ect on emergency department (ed) services. methods the survey was conducted in sheffi eld and rotherham walk-in centres over weeks during september and october . a self-reported, validated questionnaire was used to conduct survey on the patients presenting at these centres. we estimated that a sample size of around patients from each centre was required to achieve statistically robust results. a post-visit, short questionnaire was also sent to those who agreed for the second questionnaire and provided contact details. ed data were also obtained from april to march , year before and year after the opening of the gp walk-in centre. data were entered and analysed in pasw statistics . ethical approval of the study was obtained from the nhs ethical review committee. results a total of , patients participated in the survey (rotherham ; sheffi eld ). the mean age of the participants was . years at sheffi eld and . years at rotherham. a higher proportion of users were female, around % at both centres. most of the patients rated high for convenience of the centre opening hours and location (above %, apart from the location of sheffi eld centre, which was rated high by around % of the research participants). overall % patients were satisfi ed with the service at rotherham centre and around % at the sheffi eld centre. based on the estimation of the monthly counts of patients attending ed and the gp walk-in centre, around % monthly reduction in minor attendances at ed was expected. however, ed routine data did not show any signifi cant reduction in minor attendances as a result of the opening of the gp walk-in centre. conclusion these walk-in centres have been shown to increase accessibility to healthcare service through longer opening hours and walk-in facility. although the eff ect on the reduction of patients' load at the ed is not visible as these centres cover a fraction of the population, the centre has a potential to divert patients from the ed. reference overcrowding in emergency departments (eds) is a widely known problem. it causes problems and delays in the ed and has a negative impact on patient safety [ ] . the aim of this study was to analyse whether a reform of emergency care can reduce patient fl ow into the ed. methods a substantial reform of emergency care took place in the province of kanta-häme in southern finland. three separate out-ofhours services in primary healthcare (phc) and one ed in the hospital were combined into one large ed in april . basic principles of the new ed were: the ed is only for those patients who are seriously ill or injured, and need immediate care; phc (healthcare centres) take care of acute ordinary illnesses and nonserious injuries during offi ce hours. to achieve these principles a regional fi ve-scale triage system was planned and implemented. the information plan was established. citizens were systematically informed about the principles of the new ed by mail, articles in the newspapers and interviews in the radio and television. the ed's internet pages were planned and established. the number of patient visits (hämeenlinna region) was analyzed years before and after establishing the new ed. results during the -year period before the establishment of the new ed the mean number of gp patient visits was , ± /month. during the -year period after the reform the number was diminished to , ± /month. this change was not associated with the increase of the patient visits taken care of by specialists and hospital residents. see figure . conclusion an extensive reform of the emergency services can notably reduce patient fl ow into the ed. reference abdominal pain in adolescent females has undergone recent changes with regards to its management under various specialities. the authors report a single-centre audit looking at the correct investigation and management of -year-old to -year-old girls with abdominal pain in the emergency department setting. methods a single-centre audit and retrospective analysis of patients took place using case notes and computerised records. documentation was analysed using statistical analysis and minimum standards were set and reviewed. results after exclusion criteria females between the ages of and presented to the paediatric emergency department in leicester with abdominal pain as the predominant admission symptom during a -month period. documentation of the gynaecological history was poor (menstrual history %, sexual history %, contraception %), as was the performance of basic investigations (urine dipsticks %, pregnancy test %). documentation was analysed with regard to discharge diagnosis. ultrasound investigation was performed on seven of the patients but only once admitted to various specialities. no ultrasound was undertaken upon admission. conclusion improvement in documentation of minimum standards for these patients is needed. a multidisciplinary care pathway could improve outcome. consideration should be given to whether early ultrasound investigation is appropriate and there is a further need for investigation as to whether this would improve longer term outcomes. introduction bipap utilization for the treatment of severe refractory status asthmaticus patients has become an accepted therapy but is not well described for moderate exacerbations. we sought to analyze outcomes from our bipap quality database for children presenting in status asthmaticus at varying levels of severity. methods ped status asthmaticus patients requiring bipap from january to august had a bedside interview and documentation of information at the time therapies were given. incomplete data were collected retrospectively. all data were stored and analyzed using a redcap database. subjects were stratifi ed into severity groups based on asthma score at the time of bipap placement. results there were subjects in the moderate severity group and in the severe group. table shows the groups were well matched and compares other pertinent data. children with severe presentations were placed on bipap sooner (p < . ) and remained on bipap longer (p < . ). the moderate group had a longer wait until bipap placement. tables and demonstrate higher initial bipap (ipap/epap) settings with increasing age and severity. figure trends initiation and termination asthma scores stratifi ed by severity at bipap we present a case series of toxicity due to a novel substance in the uk: eric- . novel drugs of abuse are becoming more common throughout the world, and they represent particular diffi culties in their acute management. a recent report from the european monitoring centre for drugs and drug addiction and europol has reported new psychoactive substances reported via its early warning system. methods this was a retrospective case-note review over a -month period. patients were included if their presentation was due to recent ingestion of eric- . physiological data, symptoms, outcome and destination of the patient from the emergency department were collected. postmortem toxicological analysis was obtained for one of the two patients who died. results forty-one attendances were identifi ed from patients. two patients died and fi ve were admitted to the icu. heart rate and temperature on arrival tended to be above normal (mean heart rate was bpm, with an sd of ; mean temperature was . °c with an sd of . ). in total, . % of attendances included agitation and . % choreiform movements. α-methyltryptamine and -/ -fl uoroephedrine were found in the blood of one of the patients who died. conclusion in this outbreak in the uk, eric- gave symptoms similar to other stimulants known as legal highs, including death. it may have been a novel substance, -/ -fl uoroephedrine. this underlines the need for prospective data collection and early national and international information sharing. introduction thallium is an odorless, tasteless, heavy metal that has been often used for intentional poisonings. in severe patients, thallium poisoning produces neuromuscular symptoms such as extreme pain and muscle weakness. methods five case reports. results all patients worked at a pharmaceutical factory. they joined a tea party held at their workplace at the end of april . the fi ve patients drank tea from a teapot someone had put thallium in. a few days later, they complained of femoral numbness and pain caused by pressure. about a week later, three of fi ve patients had profound hair loss. three weeks after the party, they came to our er. we thought that their symptoms might be caused by some chemicals. we searched the keywords: 'lower extremity pain' , 'hair loss' and 'poison' in the internet. as a result, thallium, mercury, lead, and so forth, were suspicious metals. in those metals, thallium was most likely because it was used in their factory. we immediately examined the blood concentration of several metals and ordered iron(iii)hexacyanoferrate(ii) that is known as the antidote for thallium poisoning. only thallium was positive in the blood metal concentration test. three patients consented to oral administration of an antidote. two patients rejected administration because their symptoms were mild and getting better. all symptoms of all patients gradually disappeared by august. we also followed up the course of blood concentration of thallium. the concentration in three patients who took the antidote was reduced more rapidly than the two patients who did not take it. conclusion all patients recovered without any sequelae. three patients' hair started to grow months from ingestion of thallium, and after half a year their hair was restored to their former state. we had diffi culty ordering iron(iii)hexacyanoferrate(ii) because this is also known as an antidote for cesium. on march a megathrust earthquake and tsunami hit japan and the giant tsunami gave rise to an accident at a nuclear power generation plant. because the rumor of radioactive substances including cesium might be spread was the talk in the city near the nuclear power plant, the authorities put the antidote under heavy supervision. we could also collect the data for the course of thallium concentration. thallium concentration of the patients who had an antidote was reduced more rapidly but these patients had a loose stool, thought to be a side eff ect of this antidote. reference . ± sd . . ± sd . drugs aff ects the central nervous and cardiovascular systems, resulting in severe arrhythmia and death. heart rate variability (hrv) analysis is a non-invasive assessment method that allows evaluation of the cardiac autonomic (sympathetic and parasympathetic) activity. the aim of this study was to evaluate hrv in children requiring icu stay due to tca poisoning. methods twenty children with isolated tca poisoning aged between and years who were hospitalized in the pediatric icu, between march and july , and healthy children as a control group were enrolled. clinical and electrocardiographic (ecg) fi ndings were noted in the tca poisoning group. in both groups, -hour time domain hrv analysis (sdnn, sdann, sdnni, rmsdd, nn , and pnn ) was performed. we also recorded frequency domain analysis results at the fi rst minutes and the last minutes of the -hour record (vlf, nlf, nhf, lf/hf ratio). the average level of tca in the study group was , ± and tca levels were positively correlated with the duration of qrs interval (p < . ). in time-domain nonspectral evaluation, sdnn (p < . ), sdnn (p < . ), rmsdd (p < . ), and pnn (p < . ) were found signifi cantly lower in the tca intoxication group compared with the control group, while nn (p < . ) was signifi cantly higher in value. the spectral analysis (frequency domain) of data recorded at fi rst minutes after intensive care admission showed that the values of the nlf (p < . ) and lf/hf ratio (p = . ) were signifi cantly higher in the tca intoxication group than the controls, while nhf (p = . ) values were signifi cantly lower. the frequency domain spectral analysis of data recorded at the last minutes showed a lower nhf (p = . ) in the tca intoxication group than the controls, and the lf/hf ratio was signifi cantly higher (p < . ) in the intoxication group. sdnn (p < . ), rmsdd (p < . ), sdnni (p < . ), and pnn (p < . ) levels were higher in patients with positive ecg fi ndings than those without positive ecg fi ndings. the lf/hf ratio was higher in seven children with seizures (p < . ). conclusion existing fi ndings give us an idea about hrv's value to determine arrhythmia and predict convulsion risk in tca poisonings. hrv can be used as a non-invasive method in determining the treatment and prognosis of tca poisoning. results hmmd receives an average of cases of stroke monthly, and thrombolysis did not occur before the implementation of the tm project, because of the lack of neurologists available to conduce the cases. after implementation of the tm program, six cases of ischemic stroke were thrombolyzed with alteplase; only one case ( %) progressed to death from septic shock, and one case ( %) presented symptomatic intracranial hemorrhage. conclusion thrombolysis in ischemic stroke reduces % the risk of disability and % the mortality rate. this procedure has been only feasible to be done in the community setting because of the implementation of the tm project, which permits the presence of a real time consultation with a specialized neurological team from a tertiary center. analyses, and then returned home. in total, . % of patients were hospitalized in a medical or surgical department, and . % in the short-term hospitalised unit of the emergency department (stay duration < hours). some . % of patients worsened and were oriented in the icu. a total . % of patients in a cardiac icu. in total, . % of patients had stay duration less than hours in the ed, . % < hours. forty percent of patients supported by fi remen and % supported by private ambulance left the hospital after a single medical consultation. conclusion nearly % of patients calling the french emergency medical dispatching centre are sent to hospital. those transportations are supported for two-thirds of cases by a private ambulance or fi remen ambulance. one out of two patients only receive a simple medical consultation in the ed, and go back home. this may concur to the defi ciency of using general medicine in town. they prefer using emergency services for free. only one patient out of four was hospitalized more than hours. introduction early onset eff ective care in the emergency department (ed) has been reported to have a great infl uence on the intensive care patients' morbidity and mortality [ ] . little is known about the infl uence of the reorganisation of the ed on patient intake to the icus. the aim of this study was to analyse monthly intake of patients from the ed to the cardiac care unit (ccu) and icu before and after the reform of emergency services. methods in kanta-häme central hospital, a new ed started on april . four older emergency rooms were combined into one bigger emergency department and an observation ward was introduced with continuous follow-up of vital signs. this study is a retrospective analysis of the patient intake to the ccu and icu year before and after the reorganisation. using as data the finnish intensive care quality consortium (intensium, finland) database and the cardiac database of the hospital, patient transfer from ed to the icu and ccu was collected and analysed. monthly pre/post comparisons were carried out statistically by a nonparametric wilcoxon signed-rank test. the total decrease in monthly patient infl ow from ed to the icu and ccu was . % (p = . ); that is, from the mean of . ± . to . ± . patients (figure ) < . ) . the result is longer overall hospitalization of patients having wi (p < . ) and a higher number of surgeries (p < . ). after the er, % of patients with wi were hospitalized in the icu ( % of them after surgery) but only % of patients involved in a ca ( % after surgery). as many patients with wi as involved in a ca ( %) were admitted to the ward ( % of patients with wi after surgery but only % of patients with injuries due to a ca). thirty-three per cent of patients involved in a ca returned home and one was transferred, whereas only three patients with wi returned home after being in the er, three patients were transferred and one died in the operating room. observed paediatric mortality in our medical treatment facility was . % ( children out of ): three children died of wi, three due to a ca and one of septic shock due to a medical cause. conclusion war injuries are more prone to cause polytrauma than ca. according to the pts, iss, niss, triss and ascot, children experiencing wi have higher severity scores and predicted mortality rate than others, stay longer in the hospital and have more surgeries. our research indicated that disaster medicine should be established systematically or it is necessary to compile a compendium of disaster medicine from a broad perspective or from a bird's-eye and long-term view. the japanese version was tentatively completed with volumes as of the fi nancial year , of which nearly three-quarters are written in japanese. although this worked partly during the aboveshown catastrophe in japan , several problems are left to be solved; that is, the insuffi cient operation system of the japan dmat or disaster medical assistant team that seemed to have caused a large number of preventable deaths. conclusion the large number of casualties during a major disaster is a global problem, even in the developed countries. when the role of the intensivist is reviewed, many roles were verifi ed to be important; that is, as a leader of a medical team or triage offi cer as well as a professional in the fi eld of specifi c intensive care. however, there are many problems to be solved in the fi elds of disaster medicine. in order to solve the diversifi cation or the various medical problems, it is necessary to compile or systematize a disaster medicine of the world version. the concept of the compendium and our process of trial are shown in relation to intensive care. there are distinct diff erences in the pathophysiology between medical cardiac arrests and tca. traumatic pathologies associated with an improved chance of successful resuscitation include hypoxia, tension pneumothorax and cardiac tamponade [ ] . the authors believe a separate algorithm is required for the management of out-of-hospital tca attended to by a highly trained physician and paramedic team. methods a suggested algorithm for tca was developed based on the greater sydney area helicopter emergency medical service's standard operating procedures and current available evidence. results an algorithm for the general management of tca can be seen in figure . in tca, priority should be given to catastrophic haemorrhage control (tourniquets, direct pressure, haemostatic agents, pelvic and long bone splintage) and volume resuscitation. simultaneous oxygena tion optimisation should occur with proactive exclusion of tension pneumothoraces with bilateral open thoracostomies. cardiac ultrasound (us) should be used to help exclude cardiac tamponade and assist in prognostication. the us presence of true cardiac standstill versus low pressure state/pseudo-pea, and an etco < . kpa carries a grave prognosis in tca. given the high incidence of hypovolaemia, hypoxia and obstructive shock prior to tca, the role of adrenaline and chest compressions are limited. figure shows a suggested algorithm for the management of penetrating tca requiring prehospital thoracotomy. conclusion the suggested algorithm is designed for a highly trained physician-led prehospital team and aims to maximise the number of neurologically intact survivors in out-of-hospital tca. little is known about the benefi t of physician winching in addition to a highly trained paramedic. we analysed the mission profi les and interventions performed during rescues involving the winching of a physician in the greater sydney area hems (gsa-hems). methods all winch missions involving a physician from august to january were identifi ed from the prospectively completed gsa-hems electronic database. a structured case-sheet review for a predetermined list of demographic data and physician-only interventions (poi) was conducted. we identified missions involving the winching of a physician, of which case sheets were available for analysis. the majority of patients were traumatically injured ( %) and male ( %) with a median age of years. seven patients were pronounced life extinct on the scene. a total of poi were performed on patients. administration of advanced analgesia was the most common poi making up . % of interventions. patients with abnormal rtsc scores were more likely to receive a poi when compared with those with normal rtsc (p = . ). the performance of poi had no effect on median scene times ( vs. minutes; p = . ). see tables and . conclusion our high poi rate of % coupled with long rescue times and the occasional severe injuries supports the argument for winching doctors. not doing so would deny a signifi cant proportion of patients time-critical interventions, advanced analgesia and procedural sedation. the aim was to assess the content and state of repair of equipment carried for transfer of critical care patients to other hospitals. by chance, several items of date-expired stock were identifi ed in the transfer kit whilst moving a patient to a tertiary centre. this raised the possibility of a more extensive problem with the equipment bags. due to the geographical location of our district general hospital we undertake around transfers of critical care patients to other hospitals per year ( % by air) and it is clearly important that our equipment is well maintained for these journeys. methods we maintain two identical sets of equipment (syringes, fl uid, airway management items, and so forth) and drug bags to take on transfers; one equipment and one drug bag taken on each trip. the contents of all four bags were checked and itemised. by careful consideration of the aims of the bags (to provide emergency equipment and drugs for managing one patient during an en-route emergency) a new inventory was devised. excess items were removed to lighten the bags and improve accessibility to the essential items. expired stock was removed. a daily checking procedure and tamper-proof seals on the bags were instigated and the bags were reassessed months later. results a total of . % of drug items and . % of equipment items had expired or would do so within days of the initial assessment. the combined weight of one equipment and one drug bag was reduced from to kg ( % reduction) by introducing the new inventory. at reassessment in november , only items of equipment ( . %) were expired or near to expiry and there were no expired drug items ( . % near to expiry). in total, . kg ( small items) of extraneous equipment had been added through over-restocking and was removed. conclusion these bags are designed for a clinician to manage a patient when an emergency arises during transfer of a critical care patient. by the introduction of simple measures, the risks posed by expired items or cluttered equipment bags have almost been eradicated. signifi cant weight savings have been made; this off ers improved ergonomics for staff and is also an important consideration for aeromedical operations. our department was surprised to discover the extent of decline of our equipment and it may be that other departments would fi nd themselves in a similar position. the anaesthetic registrars who routinely escort the transfer patients have a vested interest to maintain this equipment and this has secured their buy-in to the new checking procedure with clear results. conclusion prehospital hyperoxemia did not infl uence the functional neurological outcome. one of the reasons for this fi nding could be the short arrival time to the trauma center where repeated analyses of arterial blood gases were performed. therefore, correction of fraction of inspired oxygen according to the arterial blood gas analysis shortens the time of hyperoxemia, thus reducing neuronal brain damage. introduction severe burn patients are often noted to have subsequent neurocognitive problems. experimentally, we have found striking, prolonged elevations of infl ammatory markers in the brain (for example, il- ) even when the injury occurs in a remote anatomic location. this neuroinfl ammatory response can also be signifi cantly blunted by a single post-burn dose of estrogen. sonic hedgehog (shh), an important signaling protein found in the brain, controls and directs diff erentiation of neural stem cells, infl uencing brain regeneration and repair by generating new neurons throughout life. as estrogens not only blunt infl ammation but also exert an infl uence on a variety of stem cells, we hypothesized that β-estradiol (e ) might aff ect levels of shh in the post-burn rat brain. methods male rats (n = ) were assigned randomly into three groups: controls/no burn (n = ); burn/placebo (n = ); and burn/e (n = ). burned rats received a % ° tbsa dorsal burn, fl uid resuscitation and one dose of e or placebo ( . mg/kg intraperitoneally) minutes post burn. eight animals from each of the two burn groups (burn/placebo and burn/e ) were sacrifi ced at hours and at days, respectively (sham group at days only), with four each of the two burn groups sacrifi ced at days. brain tissue samples were analyzed by elisa for shh. results mean levels of shh levels were signifi cantly elevated within hours as much as days post injury in burned animals receiving the β-estradiol (> , pcg/mg) as compared with the placebotreated burned animals (< pg/mg) and controls (< pcg/mg). see figure . conclusion early, single-dose estrogen administration following severe burn injury signifi cantly elevated levels of shh in brain tissue. this fi nding may represent an extremely novel and important pathway for both neuroprotection and neuroregeneration in burn patients. introduction many proposed resuscitative therapies for cardiac arrest and trauma will require the earliest possible intervention and would occur under volatile circumstances, making true informed consent for clinical trials unfeasible. the purpose here was to report our experience using exception to informed consent during the inaugural pilot study of infusing estrogen for acute injury, the so-called rescue shock study. methods fifty patients were enrolled in rescue shock in which estrogen or placebo was infused as soon as possible in the emergency department for trauma patients with a low systolic blood pressure (< mmhg) at two level i trauma centers. they were all treated with a single-dose estrogen or placebo infusion within hours using exception from informed consent following us federal guidelines. results investigator-initiated exception from informed consent studies is feasible, with our fda ind approval obtained in days, irb approval in days, and irb approval in days. community consultation/notifi cation was successfully accomplished with no one opting out and / enrolled patients or their legal representatives were notifi ed of participation (one died unidentifi ed, two died with no known contact). the average number of days to verbal notifi cation of patients or advocates was . days (range to days) as the study team began notifi cation only after the patient or family was able to reasonably understand information about the study. no one decided against continued follow-up. overall, patients and their families were very enthusiastic about participation and the data safety monitoring board had no safety concerns after reviewing all study data. conclusion although delayed notice of participation occurs for many justifi able reasons, the use of exception from informed consent for novel, time-sensitive resuscitation studies is not only crucial, but can be feasible, and well accepted by patients, their advocates and communities at large. introduction patients with severe burn injury experience a rapid elevation in multiple circulating proinfl ammatory cytokines, with the levels correlating with both injury severity and outcome. in animal critical care , volume suppl http://ccforum.com/supplements/ /s s models, accumulations of these cytokines have been observed in remote organs, including the heart, brain and lungs. however, data are lacking regarding the long-term levels of cytokines in the heart following severe burn injury and also how infusion of parenteral estrogen, a powerful anti-infl ammatory agent, would aff ect these levels. using a rat model, we studied the eff ects of a full-thickness thirddegree burn on cardiac levels of il- and tnfα over days with and without β-estradiol infusion. methods a total of male rats were assigned randomly to one of three groups: ( ) conclusion following severe burn injury in an animal model, an early single dose of estrogen can decrease the prolonged let alone the early onset of cardiac infl ammation. based on these data, clinical studies of estrogen infusions should be seriously entertained as estrogen may not only be an inexpensive, simple adjunctive therapy in burn management, it may also obviate the need for many subsequent interventions altogether and even diminish mortality. conclusion the results of this study highlight the risk factors for the development of complications following blunt chest trauma. a risk stratifi cation tool has also been developed that could assist in the prediction of poor outcomes in this patient group. the next stage is to complete a prospective validation study. reference introduction we have reported the risk of chest drain insertion inferior to the diaphragm when using current international guidelines [ ] . another complication is damage to signifi cant peripheral nerves, such as the long thoracic nerve causing winging of the scapula [ ] . we assessed these risks using: the european trauma course method, a patient's handbreadth below their axilla just anterior to the midaxillary line; the british thoracic society safe triangle [ ] ; and the advanced trauma life support (atls) course guidance [ ] . methods we used the above guidelines to place markers (representing chest drains) in the thoracic wall of cadavers bilaterally ( sides), cm anterior to the midaxillary line. subsequent dissection identifi ed the course and termination of the long thoracic nerve, the site of lateral cutaneous branches of intercostal nerves, and their relation to the markers. the long thoracic nerve was found in the fi fth intercostal space in of cases, always in or posterior to the midaxillary line. contrary to the description in grays' anatomy ( th edition) it terminated before the inferior border of serratus anterior. most commonly it was found to end by branching in the fourth (right) or fi fth (left) intercostal space (range third to sixth). lateral cutaneous branches of intercostal nerves were found in the fi fth intercostal space in of cases. contrary to the description in last's anatomy ( th edition) they always passed anterior to the midaxillary line (and marker). conclusion placement cm anterior to the midaxillary line minimises risk to the long thoracic nerve and lateral cutaneous branches of intercostal nerves. we therefore conclude that not all areas of the british thoracic society safe triangle are indeed safe, and anteroposterior placement should follow the european trauma course and atls guidelines: just anterior to the midaxillary line (for example, cm). introduction whole body computed tomography (wbct) appears to be useful for the early detection of clinically occult injury, although its indications have been controversial. the purpose of this study was to develop a clinical prediction score to clarify the indications for blunt trauma patients with multiple injuries (mi) who require wbct. methods we conducted a retrospective study of patients with blunt trauma who underwent wbct at our emergency center between june and july . we chose the presence or absence of mi (injury severity score ≥ ) in need of surgical intervention as the outcome variable. we used bivariate analyses to identify variables potentially predicting the presentation of mi. the predictor variables were confi rmed by multivariate logistic regression analyses. we assigned a score based on the corresponding coeffi cients. results among the patients enrolled, were in the mi group. four predictors were found to be independently signifi cant by the logistic analysis: ( ) body surface wound ≥ regions, ( ) positive focused assessment with sonography for trauma, ( ) white blood cell count ≥ , /μl, and ( ) d-dimer ≥ μg/ml. score was assigned to predictor ( ), score was assigned to predictors ( ), ( ) and ( ). a prediction score was calculated for each patient by adding these scores. the area under the receiver operating characteristic curve was . . no patients with a score of or less had mi (figures and ) . conclusion in patients with a score of or , the presence of mi is less likely. these patients may not require wbct, and selective ct scans of body parts based on clinical presentation should be considered. (figure ) . the most common intervention as a result of the ultrasound was initiation of a pressor infusion ( . %), of which . % were ionotropes. additional therapies included blood transfusion ( . %), heparin ( . %), tpa ( . %), cardiac catheterization ( . %), and surgery ( . %). rosc was achieved in . % of patients; average time to rosc was minutes. a total . % of patients who underwent als were alive at hospital discharge and . % at year. conclusion focused cardiac ultrasound is a feasible adjunct to als resuscitation and may assist in the early identifi cation of reversible causes of cardiac arrest. care must be taken to ensure no interruptions to cardiac compressions are made by performance during pulse checks. further studies are needed to examine the outcomes associated with its integration into resuscitations. introduction in this case report, we describe a patient who presented with a cardiac arrest as a result of an obstructive shock, which progressed into cardiac arrest, caused by an acute para-esophageal gastric herniation. methods our patient, with a medical history of a laparoscopic repair of a symptomatic diaphragmatic hernia months prior, presented herself at the emergency department with pain in the upper abdomen and nausea. the physical examination, laboratory tests and x-ray of the thorax were normal and she was sent home. twenty-four hours later paramedics were summoned to our patient because of increased complaints. on arrival of the paramedics she had a normal electrocardiogram (ecg) and during the transfer from her bed to the stretcher she collapsed due to pulseless electric activity (pea), for which cardiopulmonary resuscitation was started. sinus rhythm and output was regained after several minutes and the patient was transported to the hospital. at arrival in the hospital, the x-ray of the thorax showed an intrathoracic stomach and a signifi cant mediastinal shift to the right. results after emergency laparotomy, which concerned correcting the gastric herniation and resection of an ischemic part of stomach, the patient remained hemodynamically stable. cardiac ischemia was ruled out based on ecg, laboratory fi ndings, cardiac ultrasound and cardiac computed tomography. the ultrasound in the emergency department did show a distended right ventricle and normal left function, which disappeared later (after repositioning the stomach), which is evidence for the mediastinal shift as a cause for the pea. conclusion we are the fi rst to describe a patient requiring cardiopulmonary resuscitation for progressive obstructive shock, due to an intrathoracic stomach. especially after a laparoscopic repair of a diaphragmatic hernia, this is a rare cause for shock and cardiac arrest, which requires a diff erent medical approach. is a key factor in improving survival from out-of-hospital cardiac arrest (ooh-ca). the alert algorithm, a simple and eff ective compression-only telephone cpr protocol, has the potential to help bystanders initiate cpr. this study evaluates the eff ectiveness of the implementation of this protocol in the liege dispatching centre. methods we designed a before-and-after study based on a -month retrospective assessment of the adult victims of ooh-ca in , before the implementation of the alert protocol in the liege dispatching centre, and the prospective evaluation of the same -month period in , immediately after the implementation of this protocol. data were extracted from ambulance, paramedical and medical intervention teams fi les, as well as the audio recordings of the dispatching centre. conclusion in ohca patients with unshockable initial rhythm, prehospital epinephrine administration signifi cantly increased the rate of survival at month after cardiac arrest. the best single predictor for favorable neurological outcomes at month following prehospital epinephrine administration after cardiac arrest was age (< years) followed by total dose of epinephrine ( mg) and then by call-response time (< minutes). [ ] . methods this was a single-center retrospective cohort study of patients who suff ered ohca and were transported to our hospital between april and march . we investigated the patients' characteristics, whether they met the tor criteria, and their outcome at the time of hospital discharge. results a total of patients (mean age, years), % of whom were male, were transported to our hospital after suff ering ohca. cardiopulmonary arrest was witnessed in cases ( %). the aha guidelines for cpr and ecc regarding the criteria for tor were applied in cases ( %), of whom ( %) were dead on arrival, and were successfully resuscitated and admitted. the outcomes for these patients were as follows: died in the hospital, two patients were discharged with a glasgow pittsburgh cerebral performance category (cpc) score of , and one patient was transferred to another hospital with a cpc score of . conclusion in our study, % of the patients who were transported to the hospital after ohca met the criteria for tor. outcomes for patients who met the tor criteria were signifi cantly worse than those who did not meet the criteria ( . % vs. . %, p < . ). in japan, eff orts are made to resuscitate almost all individuals who suff er ohca, but % of those patients die within a day. in light of the fact that even the medical cost for each of these patients who die within a day amounts to us$ , [ ] , the introduction of tor will have a particularly strong impact in japan. introduction detection and treatment of cardiopulmonary arrest and their antecedents may be less eff ective at night and weekend than weekdays because of hospital staffi ng and response factors [ ] . early detection and resuscitation of cardiopulmonary arrest are crucial for better clinical outcome. we conducted our study to evaluate event survival of in-hospital cardiopulmonary arrest after regular working hours in nonmonitored areas of a tertiary-care center. = ) , hypoxia (n = ), cardiac other (n = ), sepsis (n = ), arrhythmia (n = ) and pe (n = ). in two ihca patients more than one likely cause of arrest was reported and in cases no cause was identifi ed. the presenting rhythm was ventricular fi brillation (vf) in . % (n = ), pulseless electrical activity in . % (n = ) and asystole in . % (n = ). a total of . % (n = ) were thrombolysed and one ( . %) patient was referred for emergency pci. conclusion as previously reported [ ] , ihca was associated with a worse prognosis than ohca. the ohca survival rate was better than reported elsewhere [ ] . the percentage of ihca attributed to mi was low. only one ohca patient was referred for emergency pci. routine coronary angiography with ad hoc pci in vf ohca has been associated with increased survival [ ] . greater availability of pci post ohca could further improve mortality in patients with a primary cardiac pathology. further investigation should include management of noncardiogenic cardiac arrest. introduction mild therapeutic hypothermia (mth) is the most powerful therapy to improve survival and neurologic outcome after out-ofhospital cardiac arrest. such benefi t may also occur for unconscious patients after in-hospital cardiac arrest. the aim is to compare -year evolution of neurological outcomes of patients treated with mth after in-hospital versus out-of-hospital cardiac arrest. methods a prospective study of patients treated with mth after cardiac arrest in a community hospital in são paulo, brazil. after return of spontaneous circulation, unconscious survivors received mth using topical ice and cold saline infusions in order to achieve a to °c goal temperature, within hours of cardiac arrest, and maintained in the management of out-of-hospital cardiac arrest (ohca) is not clear cut [ ] . it has historically been used in patients with st elevation on post-resuscitation electrocardiogram (ecg) although this is a poor predictor of acute coronary occlusion after cardiac arrest [ ] . this study investigates the benefi t of pci regardless of post-resuscitation ecg. benefi t is widely claimed for therapeutic hypothermia, so cooling parameters were included. methods we analysed all consecutive adults admitted post ohca to a university hospital icu between january and december . patients received pci regardless of ecg changes. a cox proportional hazards model was used to determine the relationship between pci, cooling and survival to discharge. routinely collected data such as demographics and details of resuscitation (ohca utstein data) were also included. results survival to hospital discharge was % with % of survivors discharged to a neurological rehabilitation centre. multivariate analysis using a cox proportional hazards model showed pci to be an independent predictive factor of survival, unrelated to ecg (hazards ratio, . ; % ci, . to . ). cooling had no signifi cant impact on patient survival. see figure . conclusion in this small retrospective study primary pci appears to be an independent predictor of survival after ohca. this is consistent with other studies suggesting benefi t for primary pci regardless of the post-resuscitation ecg [ ] . cooling was not found to improve survival to discharge but further analysis is required to determine impact on neurological function. introduction sedation and therapeutic hypothermia (th) modify neurological examination and alter prognostic prediction of coma after cardiac arrest (ca). additional tools, such as eeg and evoked potentials, improve prediction of outcome in this setting, but are not widely available and require signifi cant implementation. methods using a new device for infrared pupillometry, we examined the value of quantitative pupillary light reactivity (plr) to predict outcome in comatose post-ca patients treated with th. twenty-four comatose ca patients treated with th ( °c, hours) were prospectively studied. the percentage variation in plr was measured during th ( hours from ca), using the neurolight algiscan® (idmed, marseille, france). for each patient, three consecutive measures were performed and the best value was retained for analysis. the relationship of plr with survival and neurological outcome (cpc scores) at months was analyzed, and the predictive value of plr was compared with that of standard clinical examination (motor response and brainstem refl exes) performed at hours from ca. results quantitative plr was strongly associated with survival (median left-eye plr % ( to %) variation in survivors vs. . % ( to . %) in nonsurvivors, p < . ) and -month neurological outcome ( % ( to %) in patients with cpc to vs. . % ( to . %) in those with cpc to , p < . ). comparable fi ndings were obtained using right-eye plr. a plr > % was % predictive of patient prognosis, with false-positive and false-negative rates of % for outcome. clinical examination was signifi cantly associated with outcome; however, motor response (mr) and brainstem refl exes (brs) yielded higher falsepositive and false-negative rates than plr (table ) . conclusion quantitative plr appears highly accurate and superior to standard neurological examination to predict outcome in patients with post-ca coma. further study is warranted to confi rm these promising fi ndings. acknowledgements supported by grants from the swiss national science foundation (fn _ ) and the european critical care research network (eccrn). figure . mv was associated with a signifi cant reduction of scto from baseline ( % ( to ) to % ( . to . ), p < . ). no signifi cant changes in scto were found after ih ( ( to ) vs. ( to . ), p = . ). conclusion moderate hv was associated with signifi cant reduction in cerebral saturation, whilst ih may be detrimental after ca and th, whilst increasing map to supranormal levels with vasopressors does not improve cerebral oxygenation. these data stress the importance of strict control of paco following ca and th to avoid secondary cerebral ischemic insults. introduction after cardiac arrest, microcirculatory reperfusion dis orders develop despite adequate cerebral perfusion pressure. increased blood viscosity strongly hampers the microcirculation, resulting in plugging of the capillary bed, arteriovenous shunting and diminished tissue perfusion. the aim of the present study was to assess blood viscosity in relation to cerebral blood fl ow in patients after cardiac arrest. methods we performed an observational study in comatose patients after cardiac arrest. patients were treated with hypothermia for hours. blood viscosity was measured ex vivo using a contraves ls viscometer. mean fl ow velocity in the middle cerebral artery (mfvmca) was measured by transcranial doppler (tcd) at the same time points. < . ) . there was a signifi cant association between viscosity and the mfvmca (p = . ). see figure . conclusion viscosity decreases in the fi rst days after cardiac arrest and is strongly associated with an increase in cerebral blood fl ow. since viscosity is a major determinant of cerebral blood fl ow, repeated measurements may guide therapy to help restore cerebral oxygenation after cardiac arrest. in preliminary data, we report that sr > might correlate with bad outcome and that combining nse and sr might improve the predictive value. also, low nse and good initial bis values correlate with preserved cerebral potential and should encourage the clinician. introduction accurate prediction of neurological outcome after cardiac arrest is desirable to prevent inappropriate withdrawal of lifesustaining therapy in patients who could have a good neurological outcome, and to limit active treatment in patients whose ultimate neurological outcomes are poor. established guidelines to predict neurological outcome after cardiac arrest were developed before the widespread use of therapeutic hypothermia. the american association of neurology guidelines [ ] currently recommend that absent or extensor motor scores on day post arrest are reliable indicators or poor neurological outcome with a false positive rate of to %. methods a review of existing literature was undertaken to examine whether the utility of motor scores to predict poor neurological outcome is infl uenced by the use of therapeutic hypothermia. results six studies were identifi ed [ ] [ ] [ ] [ ] [ ] [ ] that investigated the use of motor scores on day post cardiac arrest in patients who had received therapeutic hypothermia. false positive rates (defi ned as -specifi city) for predicting poor neurological outcome were calculable in fi ve of the six studies [ ] [ ] [ ] [ ] [ ] and were %, %, %, % and % respectively. in all studies the fpr for motor scores of extension or worse were signifi cantly higher than the % ( to % % cis) in the aan guidelines. conclusion motor scores at day post cardiac arrest of extension or worse do not reliably predict poor neurological outcome when therapeutic hypothermia has been used. clinical neurological fi ndings may not be valid predictors of poor neurological outcome after therapeutic hypothermia. introduction it has been reported that the young are much more resistant to transient cerebral ischemia than the adult. methods in the present study, we compared the chronological changes of calcium binding proteins (cbps) (calbindin k (cb-d k), calretinin (cr) and parvalbumin (pv)) immunoreactivities and levels in the hippocampal ca region of the young gerbil with those in the adult following minutes of transient cerebral ischemia induced by the occlusion of both the common carotid arteries. in the present study, we examined that about % of ca pyramidal cells in the adult gerbil hippocampus died at days post ischemia; however, in the young hippocampus, about % of them died at days post ischemia. we compared immunoreactivities and levels of cbps, such as cb-d k, cr and pv. the immunoreactivities and protein levels of all the cbps in the young sham were higher than those in the adult sham. in the adult, the immunoreactivities and protein levels of all the cbps were markedly decreased at days post ischemia; however, in the young, they were apparently maintained. at days post ischemia, they were decreased in the young; however, they were much higher than those in the adult. conclusion in brief, the immunoreactivities and levels of cbps were not decreased in the ischemic ca region of the young days after transient cerebral ischemia. this fi nding indicates that the longer maintenance of cbps may contribute to a less and more delayed neuronal death/ damage in the young. delay in reaching target temperature [ ] . we hypothesize that early and rapid induction of hypothermia will mitigate neuronal injury and improve survival in a swine model of tbi. methods twenty domestic cross-bred pigs ( to kg) were subjected to a atm ( ms) lateral fl uid percussion tbi. the brain temperature and icp were measured using camino®. serum biomarkers for neuronal injury -s- β, neuron-specifi c enolase, glial fi brillary acid protein (gfap), and neurofi laments heavy chain -were measured daily using enzyme-linked immunosorbent assay. twelve of the injured animals were rapidly cooled to °c within minutes of the injury using a transpulmonary hypothermia technique [ ] . hypothermia was maintained for hours. eight injured control animals were maintained at °c. in both groups, anesthesia (isofl urane %) was discontinued and the animals were weaned off the ventilator after hours. five days post injury, the surviving animals were euthanized and necropsied. the data were analyzed using a log-rank (mantel-cox) test, and anova. results ten of the hypothermia and four of the eight normothermia animals survived to the end of the -day study (χ = . , df = , p = . ). although the probability of type i error between survival curves was %, the study was clinically signifi cant and showed a clear trend toward improved survival with hypothermia. the intracranial pressures were signifi cantly (p < . ) lower in the hypothermia group. both interventions -that is, general anesthesia and hypothermiamitigated the rise of serum biomarkers following tbi. however, the suppression of biomarkers was sustained during the recovery period only in the hypothermia group. with the exception of the gfap levels, the curves of all biomarkers were signifi cantly diff erent between the groups. conclusion our preliminary fi ndings show early initiation, rapid induction, and prolonged maintenance ( hours) of cerebral hypothermia to lower intracranial pressure, blunt the rise in serum biomarkers, and improve survival following tbi. references introduction traumatic brain injury (tbi) is a contributing factor to approximately one-third of all injury-related deaths in the usa annually. updated statistical records for tbi in egypt are lacking. the current research is aiming to estimate the prevalence of tbi in egypt in order to develop a comprehensive tbi prevention program. methods a -year period (one calendar month every quarter of ) descriptive epidemiological study of moderate and severe tbi cases admitted to the emergency department, cairo main university hospital. the data collection sheet included personal data (age, sex and residency), incident-related data (cause, nature and time of injury) and both clinical and radiological fi ndings. introduction one of the most used prognostic models for traumatic brain injury is the impact-tbi model, which predicts -month mortality and unfavorable outcome. our aim was to study whether adding markers of coagulation improves the model's predictive power when accounting for extracranial injury. methods patients with a tbi admitted to a designated trauma center in / were screened retrospectively and included according to the impact study criteria. the predictive outcome was calculated for included patients using the full impact-tbi model. to assess coagulopathy and extracranial injury we used the prothrombin time percentage (pt), platelet count ( ), and injury severity score (iss introduction evidence suggest that endogenous lactate, produced by aerobic glycolysis, is an important substrate for neurons, particularly in conditions of increased energy demand. this study aimed to examine brain lactate metabolism in patients with severe traumatic brain injury (stbi). methods a prospective cohort of stbi patients monitored with cerebral microdialysis (cmd) and brain tissue oxygen (pbto ) was studied. brain lactate metabolism was assessed by quantifi cation of elevated cmd lactate samples (> mmol/l). these were matched to pyruvate and pbto , and dichotomized as hyperglycolytic (cmd pyruvate > μmol/l) versus nonhyperglycolytic or as hypoxic (pbto < mmhg) versus nonhypoxic. data were expressed as percentages per patient. global brain perfusion (categorized as oligemic, normal or hyperemic) was assessed with ct perfusion (ctp). results twenty-four patients (total , cmd samples) were studied. samples with elevated cmd lactate were frequently observed ( ± % sem of individual samples). brain lactate elevations were predominantly hyperglycolytic ( ± . %), whilst only ± . % of them were hypoxic. trends over time of both lactate patterns are shown in figure . on ctp (n = ; average hours from tbi) hyperglycolytic lactate was always associated with normal or hyperemic ctp, whilst hypoxic lactate was associated with oligemic ctp (table ) . our fi ndings suggest predominant nonischemic lactate release after tbi and identify, for the fi rst time, an association between cerebral hyperglycolytic lactate production and normal to supranormal brain perfusion. our data support the concept that lactate may be used as energy substrate by the injured human brain. in the prehospital setting, it is diffi cult to use the glasgow coma scale (gcs) to evaluate the consciousness state using in pediatric patients with severe trauma. the japan coma scale (jcs) is a consciousness scale used widely in japan and, with its four grades, is simpler and quicker to use than the gcs. this study examined whether our study identifi ed a moderate relation between peep and osnd and a weaker one between ppeak, pm and osnd. thus, in selected cases osnd could serve as a bedside marker of eff ect of airway pressure to icp. yet, larger studies are needed to come to a safer conclusion. reference introduction following primary neurological insult, initial manage ment of traumatic brain-injured (tbi) patients has a clearly defi ned pathway [ ] . however, after arrival at tertiary centers, further manage ment is not standardized. intracranial hypertension (ich), systemic hypotension, hypoxia, hyperpyrexia and hypocapnia have all been shown to independently increase mortality [ ] . despite numerous studies, there is currently no level evidence to support any specifi c management [ ] . our objective was to provide an overview of the current clinical management protocols in the uk. methods thirty-one icus managing patients with severe tbi were identifi ed from the rain (risk adjustment in neurocritical care) study, and a telephone survey was conducted. results a total % of units used a cerebral perfusion pressure protocol for the initial management, with % targeting pressures of to mmhg and % aimed for > mmhg. ninety-one percent of units monitored co routinely with % targeting co of . to kpa (figure ). regarding osmotherapy, mannitol was still the preferred agent, with % of units using it as fi rst line; % used hypertonic saline, while % of units used either depending on clinicians' preference. sixteen percent questioned were currently enrolled on the eurotherm hypothermia trial, while % never used hypothermia and one unit used prophylactic hypothermia routinely. the remaining % of units used hypothermia only to manage refractory ich. conclusion there is no clear consensus on the initial targets used. the surviving sepsis campaign showed that protocol-led care can reduce mortality [ ] . perhaps it is time for a similar approach to be adopted, with specialists coming to together to review the evidence and formulate guidelines that can then be tested. introduction traumatic brain injury (tbi) is a major cause of permanent disability and death in young patients. controversy exists regarding the optimal cerebral perfusion pressure (cpp) required in tbi management. a tool for monitoring autoregulation and determining an optimal cpp is the pressure reactivity index (prx), defi ned as a moving correlation coeffi cient between the mean arterial blood pressure (map) and intracranial pressure (icp) at a frequency of at least hz. this requirement of high frequency has constrained its use to a few academic centers. an association was shown between outcome and continuous optimal cpp based on hours of prx [ ] . we present a novel low-frequency autoregulation index (lax), based on correlations between icp and map at a standard minute-by-minute time resolution. methods a total of patients from the brain-it [ ] multicentre european database had registered outcome and icp and map for the fi rst icu hours. twenty-one tbi patients admitted to the university hospitals of leuven, belgium and tubingen, germany were continuously monitored using icm+ software (cambridge enterprise) allowing for continuous prx calculation. autoregulation indices versus cpp plots for prx and lax were computed to determine optimal cpp every minute during the fi rst icu hours [ ] . results on the brain-it database, lax resulted in an optimal cpp for % of the fi rst hours. table shows recommendations with respect to outcome. in the leuven-tübingen database, prx and lax resulted in % and % recommendations respectively. the average diff erence between methods was . mmhg. conclusion the diff erences in optimal cpps derived from prx and lax were not clinically signifi cant. lax allowed for recommendations to be computed for longer periods. signifi cantly better outcome (table ) was observed in patients for whom optimal cpp derived from lax was maintained. introduction pediatric patients with altered mental status (ams) present with poor histories resulting in delayed testing and potential poor outcomes. non-invasive detection for altered cerebral physiology related to tbi would improve resuscitation and outcome. cerebral rso (r c so ) studies demonstrate its utility in certain neurological emergencies. methods a retrospective analysis of r c so utility in ams. rcso data were collected every seconds for ams patients who had a head ct. patients with a negative head ct were compared with those with an abnormal head ct. roc analysis was performed to fi nd the auc for each summary statistic and performance characteristics. subgroup analysis was done to determine whether r c so predicted injury and location. results r c so readings across , , , and minutes were stable (figure ). r c so readings with one or both sides < % or a wide diff erence between l and r cerebrum was predictive of an abnormal ct scan. a mean diff erence of . was % sensitive for detecting a ct lesion with % specifi city, % ppv, and % npv; a mean diff erence of . was % specifi c for an abnormal head ct. lower mean r c so readings localized to the ct pathology side, and higher r c so readings trend toward the edh group. conclusion cerebral rcso monitoring can non-invasively detect altered cerebral physiology and pathology related to tbi as the cause for pediatric altered mental status. the utility of r c so monitoring has shown its potential for localizing and characterizing intracranial lesions among these altered children. further studies utilizing r c so monitoring as an adjunct tool in pediatric altered mental status evaluation and management are ongoing. introduction fever is a dangerous secondary insult for the injured brain [ ] . we investigated the cerebral and hemodynamic eff ects of intravenous (i.v.) paracetamol administration for the control of fever in neurointensive care unit (nicu) patients. methods the i.v. paracetamol ( g in minutes) was administered to nicu patients with a body temperature (temp.) > . °c. its eff ects on mean arterial pressure (map), heart rate (hr), intracranial pressure (icp), cerebral perfusion pressure (cpp), jugular venous oxygen saturation (sjvo ) and temp. were recorded at the start of paracetamol infusion (t ) and after (t ), (t ) and (t ) minutes. interventions for the maintenance of cpp > mmhg or icp < mmhg were recorded. (figure ). in fi ve cases norepinephrine infusion was started for cpp < mmhg. in another two cases, for the same reason, the norepinephrine dosage was augmented. the proportion of patients who had infusion of norepinephrine increased from . % at t to . % at t (p = . , chi-square for trends). conclusion use of i.v. paracetamol is eff ective in the maintenance of normothermia in acute brain-injured patients. however, adverse hemodynamic eff ects, which could represent a secondary insult for the injured brain, must be rapidly recognized and treated. reference introduction evaluating resource utilization is paramount in critically ill patients with traumatic brain injury (tbi), but little is known on readmissions after hospital discharge. we evaluated rates and determinants of unplanned readmission following tbi. methods we conducted a multicenter retrospective cohort study from april to march . data were obtained from a canadian provincial trauma system, based on mandatory contribution from trauma centres, and a hospital discharge database. patients aged ≥ years with tbi (icd- or icd- codes of - and s , respectively) were included. patients who died during the index hospitalization, who lived outside the province, who could not be linked with the hospital discharge database were excluded. we collected baseline and trauma characteristics, hospital admissions in the months preceding index admission, and readmissions in the following months. primary outcome was unplanned readmission days, months and months post discharge. we evaluated sociodemographic and clinical factors associated with readmissions using a logistic regression model. results among , adult patients with tbi identifi ed in the registry, , patients were included among which , had severe, , moderate and , mild traumatic brain injury. most patients were young (mean age: ± years) and had no comorbidity ( . %). overall, , patients ( . %) were readmitted within days, . % within months and . % within months. at days post discharge, ( . %) were readmitted for a complication. the median length of stay was days (q to q : to ). more than % of patients aged ≥ years with ≥ comorbidity or with ≥ admission prior to index hospitalisation were readmitted. the severity of the tbi was not an independent predictor of readmission. age, highest ais, number of comorbidities, number of admissions prior to index hospitalization, level of index trauma center and discharge destination were associated with readmissions on multivariate analysis. conclusion readmissions in the months following tbi are frequent, but were not found to be associated with the tbi severity. further studies evaluating reasons for readmission are warranted in order to develop strategies to prevent such events. introduction pituitary disorders following traumatic brain injury (tbi) are frequent, but their determinants are poorly understood. we performed a systematic review to assess the risk factors of tbiassociated pituitary disorders. methods we searched medline, embase, scopus, the cochrane library, biosis, and trip database, and references of narrative reviews for cohort, cross-sectional and case-control studies enrolling at least fi ve adults with tbi in whom ≥ pituitary axis was tested and one potential predictor reported. two independent investigators selected citations, extracted data and assessed the risk of bias. we pooled the data from all studies assessing a specifi c predictor, regardless of the pituitary axis being evaluated. when more than one pituitary axis was assessed, we used the data related to hypopituitarism or the data from the most defective axis. when a pituitary axis was evaluated several times, we used assessment farthest from the injury. a meta-analysis was performed using random eff ect models and i was used to evaluate heterogeneity. introduction prevention of secondary neurologic injuries is paramount for improved neurologic outcomes after traumatic brain injury (tbi). evidence suggests that although therapeutic hypothermia (th) lowers intracranial pressure and attenuates secondary cerebral insults after tbi [ ] , it also induces hypotension. brief episodes of mild hypotension in brain-injured patients can trigger secondary injuries, which have been associated with increased mortality in patients with tbi [ ] . vasopressin mitigates hypotension in septic shock and improves coronary perfusion in hypothermic cardiac arrest models [ ] . we hypothesized that a lowdose vasopressin infusion may reduce the cumulative epinephrine dose in hypothermic, brain-injured swine. methods six domestic cross-bred pigs were subjected to epinephrine infusion after general anesthesia, standardized tbi and transpulmonary hypothermia ( °c for hours). all animals received the same care, aiming for a mean arterial pressure > mmhg. at hour , animals received additional vasopressin infusion at . units/minute. we measured the cumulative epinephrine dose for each animal pre and post vasopressin infusion ( figure ) and performed a twosample wilcoxon rank-sum test, comparing the median cumulative epinephrine doses in the two groups. the median cumulative epinephrine dose in the animals that received the vasopressin infusion was mg with a th to th interquartile range (iqr) of to mg. the median cumulative epinephrine dose in the control group was , mg (iqr , to , mg). this was statistically signifi cant (p = . ), based on the wilcoxon rank-sum test. conclusion a low-dose infusion of vasopressin can signifi cantly reduce vasopressor requirements and improves hemodynamics in hypothermic, brain-injured swine. this hemodynamic stability may improve neurological outcomes. introduction severe traumatic brain injury (tbi) is a major cause of death and of severe neurologic sequelae. long-term functional outcome of tbi and its best timing of assessment are not well understood, and may be evaluated too prematurely in clinical studies because of resources required to do so without too much missing data. hence, we conducted a systematic review of studies in severe tbi patients to evaluate the long-term functional outcome. we hypothesized that functional impact measured by the glasgow outcome scale (gos), or the extended version (gose), may plateau after several months in patients with severe tbi. methods we performed a systematic review of randomized controlled trials and cohort studies (prospective and retrospective) in patients with severe tbi. we searched medline, embase, cochrane central, biosis, cinahl and trip database from their inception to december . references of included studies were searched for additional studies. two reviewers independently determined study eligibility and collected data. the primary outcome measure was the proportion of unfavourable functional outcome (gos to or gose to ) at to months, to months, to months and more than months after severe tbi. we calculated freeman tukey-type arcsine squareroot transformations and pooled data using random-eff ect models. heterogeneity was assessed with the i test and sensitivity analyses were based on a priori hypotheses. in total, , studies were assessed for eligibility; studies (n = , ) were included. in the studies using the gos, a poor functional outcome was observed in . % ( % ci = . to . %, i = %), . % ( % ci = . to . %, i = %), . % ( % ci = . to . %, i = %) and . % ( % ci = . to . %, i = %) of patients at to months, to months, to months and beyond months, respectively. in the studies using gose, a poor functional outcome was observed in . % of patients at to months ( % ci = . to . %, i = %) and . % at to months ( % ci = . to . %, i = %). heterogeneity was present in most analyses and was not entirely explained by the planned sensitivity analyses. conclusion considering that the incidence of patients with an unfavourable outcome remained constant at diff erent assessments, a follow-up of severe tbi patients longer than months does not provide incremental information. functional outcomes measured longer than months after the injury may not be warranted in clinical studies. introduction prevention of secondary brain injury is the cornerstone in the management of patients with severe traumatic brain injury (tbi) and raised intracranial pressure (icp). although a variety of monitoring methods are available, due to lack of strong evidence their use varies considerably [ ] . the objective of this survey was to provide an overview of the current practice in monitoring of patients with severe tbi in all neuro-icus across the uk. introduction pulmonary complications are frequently occurring medical complications after aneurysmal subarachnoid hemorrhage (asah) [ ] . early respiratory deterioration (erd) may be associated with delayed cerebral ischemia (dci) or outcome and would then be a potential target for therapeutic interventions. we investigated whether respiratory deterioration within the fi rst hours after admission predicted dci or poor outcome. methods we conducted a retrospective study in consecutively admitted patients with asah, admitted between october and october to the icu of a university hospital. erd was defi ned as increased need for ventilatory support the second or third day after admission (table ) . elective intubation for a surgical procedure was not included as erd. inclusion criteria were availability of detailed information on respiratory status and level of support, admission within hours after hemorrhage and age ≥ years. multivariable survival analysis was used to investigate associations of dci, death and glasgow outcome scale (gos) with erd adjusted for condition on admission, hijdra score, treatment of ruptured aneurysm and pulmonary comorbidity. gos was assessed at to months after the bleed. dci was defi ned as described recently [ ] . results mean age of the patients was . (± . ) and . % was female. a total . % of the patients developed dci. mortality was . %. forty percent of the patients were classifi ed as having erd. erd was not associated with dci (adjusted hr = . ; % ci = . to . ; p = . ). erd showed a trend towards an association with mortality (adjusted hr = . ; % ci = . to . ; p = . ; additionally adjusted for age, and rebleed). a clear association was found between absence of erd and functional outcome with ordinal logistic regression analysis ( . point increase in gos score at to months; % ci = . to . ; p = . ; additionally adjusted for age and rebleed). conclusion erd within hours after admission is associated with increased risk of poor functional outcome after asah, but not dci. further investigations are required to assess whether prevention of erd may improve outcome. introduction elevated intracranial pressure (icp) may have deleterious eff ects on cerebral metabolism and mortality after aneurysmal subarachnoid hemorrhage (sah) [ , ] , but its relevance has not yet been well explored. aims of this study are to track icp changes after sah, to identify clinical factors associated with it and to explore the relationship between icp and outcome. methods a total of consecutive sah patients with icp monitoring were enrolled. episodes of icp > mmhg for at least minutes and the mean icp value for every -hour interval were analyzed. the highest mean icp collected in every patient was identifi ed. icp values were analyzed in relation to clinical and ct fi ndings; -month outcome and icu mortality were also introduced in multivariable logistic models. results eighty-one percent of patients had at least one episode of elevated icp and % had a highest mean icp > mmhg. the number of patients with highest mean icp > mmhg or with episodes of hicp was maximum at day after sah and decreased only after day . neurological status, aneurysmal rebleeding, amount of blood on ct and ct ischemic lesion occurred within hours from sah were signifi cantly related to highest mean icp > mmhg in a multivariable model. patients with highest mean icp > mmhg showed signifi cantly higher mortality in icu. however, icp is not an independent predictor of months unfavorable outcome. conclusion elevated intracranial pressure is a common complication in the fi rst week after sah. it is associated with early brain injury severity and icu mortality. . we systematically reviewed their prevalence, aiming particularly at studies with low risk of bias. methods we searched embase, medline, the cochrane library, trip database, references of included studies and narrative reviews. we included cohort studies, cross-sectional studies and rcts published in any language that tested the integrity of ≥ pituitary axis in adults with asah. studies including more than % of non-aneurismal sah were excluded. studies were considered at low risk of bias if the authors defi ned inclusion/exclusion criteria, avoided voluntary sampling, and tested > % of included patients with proper detailed diagnostic criteria. studies testing all pituitary axes were considered as evaluating hypopituitarism, which was defi ned as the dysfunction of ≥ axis. we used a freeman tukey-type arcsine square-root transformation and pooled prevalences using the dersimonian-laird random-eff ect method. we determined the degree of heterogeneity with i values. results among , citations, we included studies ( , patients). patients were mostly female ( %) aged . ± . . sixteen studies reported the severity of asah, reported the procedure for securing the aneurysm and reported the location of aneurysm. overall, hypopituitarism was observed in . % of patients at shortterm (< months), . % at mid-term ( to months) and . % at long-term (> months) ( table ). there was an insuffi cient number of studies with low risk of bias to perform sensitivity analyses according to study quality. conclusion the exact prevalence of pituitary disorders following asah remains uncertain, mainly due to high heterogeneity and the small number of studies with low risk of bias. however, the prevalence seems to decrease during the recovery phase. the prevalence, risk factors and clinical signifi cance of pituitary disorders in asah will require further rigorous evaluation. is associated with a high morbidity and mortality. although uk anaesthesia guidelines advocate early coiling or clipping of the aneurysm within the fi rst hours of admission for all grades of asah, the optimal timing of treatment and whether this is linked with better neurological long-term outcome are a subject of debate [ ] . we aimed to investigate whether the timing of the occlusion of the aneurysm translates into better outcome. methods a retrospective analysis of prospective collected data in a tertiary neuroscience centre from january to september . all patients were managed according to the local guidelines for the management of asah. outcome was assessed at months using the extended glasgow outcome scale (gose) defi ning good recovery as a gose ≥ and poor outcome as gose ≤ . results a total of patients were included within the study period. three patients were not expected to survive the fi rst hours and were not included in the study. seventeen patients were classifi ed as good grade asah (wfns i to iii) and eight as poor grade (iv to v). twenty-two patients underwent successful coiling while the other three required clipping due to unsuccessful coiling. we did not fi nd any correlation between the timing of coiling/clipping and the -month gose (figure ) . a total % of the patients had a poor -month gose while % had a good long-term functional outcome. the overall mortality rate was %. conclusion overall mortality in patients with asah is low when aneurysm is treated early post rupture of aneurysm. we did not fi nd any correlation between the timing of occlusion of aneurysm and the -month functional outcome. patients underwent neuropsychological evaluation at early (< days, days) and delayed time points ( month, months). patients were tested for language, verbal fl uency, short-term and long-term memory, attention, executive functions, praxis, and neglect. impairments in activities of everyday life were assessed using the activities of daily living scale and the instrumental activities of daily living scale. the sf- was used to assess the quality of life at months. since complications of aneurysm treatment in addition to asah severity may signifi cantly aff ect cognitive status, patients were evaluated according to the world federation of neurological surgeons score after treatment (wfnspt). all wfnspt to patients completed neuropsychological tests at each time point. wfnspt and wfns patients were testable in % and % of the cases respectively at early time points. wfns patients were not testable at any time point. in all testable patients, cognitive functions were severely impaired at early time points. at months in wfns to a good recovery of language defi cits while only a partial recovery of attention, memory and executive functions were observed; at the same time point % of wfns patients became testable, but they had a worse recovery of all cognitive functions. at month after sah less than % of patients return to work, at months approximately %. despite a good recovery of everyday life activities at months, for all patients quality of life was lower than a normal population. conclusion cognitive dysfunction has diff erent time courses after asah: signifi cant defi cits in diff erent cognitive domains, worse quality of life and diffi culties in return to work persist in more than % of patients at months following sah. results pretreatment with mg/kg, but not mg/kg, of asa-da protected against ischemic neuronal death and damage, and its neuroprotective eff ect was much more pronounced than that of asa or da alone. in addition, treatment with mg/kg asa-da reduced the ischemia-induced activation of astrocytes and microglia. conclusion our fi ndings indicate that asa-da, a new synthetic drug, prevents against transient focal cerebral ischemia, which provides a resource for the development of its clinical application for stroke. introduction acute neurological injury is a leading cause of morbidity and mortality in children. global prevalence and regional disparities of etiology, interventions, and outcomes are unknown. the aim of this point-prevalence study was to measure the burden of pediatric neurological injury and to describe variations in interventions and outcomes in icus. methods one hundred and three icus on six continents enrolled subjects on specifi c days in a -year period. included subjects were between ages days and years who were diagnosed with acute traumatic brain injury, stroke, cardiac arrest, central nervous system infection or infl ammation, status epilepticus, spinal cord lesion, hydrocephalus, or brain mass. sites completed a secure web-based case report form that included subject and hospital demographics, details about the neurological disease, interventions, length of stay, and pediatric cerebral performance category (pcpc) score (good outcome = pcpc to ) and mortality at hospital discharge. results of , subjects screened, , ( %) met enrollment criteria. the mean number of subjects enrolled per site for each study day was . . most sites were dedicated pediatric icus with a mean number of icu beds (range to ). icus had resources to invasively monitor intracranial pressure ( %), continuous electroencephalography ( %), invasive and non-invasive brain tissue oxygenation ( % and %), and somatosensory evoked potentials ( %). there were on average icu faculty and six fellows per site, and nearly one-half reported a neurocritical care icu team. subjects were % male and % white, and % had normal pre-admission pcpc scores ( %). status epilepticus and cardiac arrest (both %) had the highest prevalence. sixty-one per cent of subjects were mechanically ventilated during icu admission. icu length of stay was a mean days (median days) and hospital los was a mean days (median days). survival at hospital discharge was % with % of subjects discharged home and % to inpatient rehabilitation. conclusion acute neurological disease is a signifi cant pediatric health issue. these data suggest a vital need for increased research and healthcare resources to assist in the challenge of improving outcomes for these children. the newly approved oral anticoagulant dabigatran has no eff ective antidote. we therefore suspected an overall increase in mortality in patients presenting to the emergency department (ed) with a bleeding complication on dabigatran compared with warfarin or aspirin. methods we conducted a post hoc analysis on a database of all patients admitted to a tertiary-care ed with any kind of bleeding or suspicion of one from march to august who were taking dabigatran, warfarin, or aspirin. the primary endpoint was long-term survival. patients were censored at death or at the end of the study period ( december ). we performed a cox proportional hazard model, controlled for age, to calculate the hazard ratio (hr) for dabigatran versus warfarin and one for warfarin versus aspirin. statistical signifi cance was set at α = . and results are presented with % ci. results in total, patients met the inclusion criteria with a mean follow-up period of year. the mean age was . years and . % were men. a total of deaths ( . %) were recorded within the follow-up period; eight ( %) for dabigatran compared with ( . %) for warfarin and ( . %) for aspirin. the mortality risk for patients on dabigatran was signifi cantly higher than for patients on warfarin: hr = . ( % ci: . to . ), p = . after controlling for age. aspirin had a lower (but not statistically signifi cant) mortality risk compared with warfarin; hr = . ( % ci: . to . ), p = . after controlling for age. the results showed higher overall mortality in patients who presented to the ed with a bleeding complication and were taking dabigatran compared with warfarin or aspirin. physicians should be aware of the potential higher mortality with dabigatran over warfarin when treating a bleeding patient. however, this was a singlecentre retrospective analysis with a small number of patients taking dabigatran (n = ), and further studies are needed to corroborate the results. introduction dose adjustments of low molecular weight heparin (lmwh) based on daily anti-xa measurement by chromogenic assay remain controversial in daily clinical practice. one of the major obstacles is the cost of such a test. an aff ordable and reliable bedside test could change practice to an individual tailored dosing of lmwh. the aim of our study was to evaluate whether a prophylactic dose regimen of mg enoxaparine in cardiac surgical patients increases the anti-xa activity to the level necessary for effi cient prevention of a thromboembolic event [ ] . secondarily we tested whether there was a reliable correlation between a bedside anti-xa measurement compared with a two-stage chromogenic assay at the laboratory [ ] . this was an open, single-centre, prospective, nonrandomized clinical trial at a university hospital. all patients that needed prophylactic dosing of enoxaparine after cardiac surgery were duly informed and after giving written consent we included patients with a mean euroscore of . . the demographic specifi cations, medical and surgical history of all patients were collected. anti-xa activity was measured at three diff erent points in time. we determined baseline, peak and trough anti-xa activity: preoperatively, and respectively hours after the third dose of enoxaparine and minutes before the fourth dose. each measurement was done with both techniques, the two-stage chromogenic assay at the laboratory (biophen®) and the bedside assay (hemochron® jr). results our dose regimen of enoxaparine achieved in one-half of the included patients a suffi cient anti-xa activity for prevention of thromboembolic events. one-half of the patients with insuffi cient anti-xa activity had a body mass index over kg/m . comparison of the bedside assay with the two-stage chromogenic assay by means of the pearson's correlation coeffi cient showed correlation of the two tests if no variables were taken into account. in the bland-altman analysis we could not confi rm this correlation. conclusion the bedside anti-xa activity assay with a hemochron device tends to show some correlation with the two-stage chromogenic assay, but insuffi cient to be used as an alternative, in this small but uniform patient population. use of a standard dosing protocol for enoxaparine administration is prone for underdosage in post-cardiac surgery patients and may increase postoperative morbidity. references introduction we hypothesized that higher doses of enoxaparin would improve thromboprophylaxis without increasing the risk of bleeding. critically ill patients are predisposed to venous thromboembolism, leading to increased risk of adverse outcome [ ] . peak anti-factor xa (anti-xa) levels of . to . iu/ml, hours post administration of enoxaparin, refl ect adequate thromboprophylaxis for medico-surgical patients. methods the sample population consisted of patients, randomized to receive subcutaneous (s.c.) enoxaparin: mg × (control group), versus mg × , mg × or mg/kg × (test groups) for a period of days. anti-xa activity was measured at baseline, and at , , and hours post administration on each day. patients did not diff er signifi cantly between groups. results on day of administration, doses of mg × and mg × yielded similar mean peak anti-xa of . iu/ml and . iu/ml respectively, while a dose of mg × resulted in subtherapeutic levels of anti-xa ( . iu/ml). patients receiving mg/kg enoxaparin achieved near-steady-state levels from day with mean peak anti-xa levels of . iu/ml. steady-state anti-xa was achieved for all doses of enoxaparin at day . at steady state, mean peak anti-xa levels of . iu/ ml and . iu/ml were achieved with doses of mg × and mg × respectively. this increased signifi cantly to . iu/ml and . iu/ml for doses of mg × and mg/kg enoxaparin respectively (p = . ) (figure ) . a dose of mg/kg enoxaparin yielded therapeutic anti-xa levels for over % of the study period. there were no adverse eff ects. introduction unfractionated heparin is preferred over lmwh in icu patients but lmwh is used more frequently in many european icus. thromboprophylaxis with standard doses of nadroparin and enoxaparin has been shown to result in signifi cantly lower anti-xa in icu patients when compared with medical patients [ , ] . methods icu patients (saps ± , mv, n = ; pressors n = ) received , iu (group , n = ) or , iu dalteparin s.c. (group , n = ). twenty-nine medical patients receiving , iu dalteparin served as controls (group ). results group had signifi cantly lower areas under the xa curve (auc) compared with groups and (table ) . diff erences were not signifi cant between groups and . peak anti-xa activities (c max -anti-xa) were delayed (t max -anti-xa) in group compared with groups and (table ) . conclusion in icu patients a s.c. dose of , iu dalteparin results in signifi cantly lower xa activities when compared with normal ward patients. a s.c. dose of , iu dalteparin in icu patients resulted in kinetics and peak anti-xa activities comparable with medical patients receiving , iu dalteparin. introduction anemia is very frequently encountered on the icu. increased hepcidin production is one of the cornerstones of the pathophysiology of anemia of infl ammation. the fi rst-in-class hepcidin antagonist nox-h , a pegylated anti-hepcidin l-rna oligonucleotide, is in development for targeted treatment of anemia of infl ammation. we investigated whether nox-h prevents the infl ammation-induced serum iron decrease during experimental human endotoxemia. methods a randomized, double-blind, placebo-controlled trial in healthy young men. at t = hours, ng/kg e. coli endotoxin was administered intravenously (i.v.), followed by . mg/kg nox-h or placebo i.v. at t = . hours. blood was drawn serially after endotoxin administration for measurements of infl ammatory parameters, cytokines, nox-h pharmacokinetics, total hepcidin- , and iron parameters. the diff erence of serum iron change from baseline at t = hours was defi ned as the primary endpoint. results endotoxin administration led to fl u-like symptoms. infl ammatory parameters (crp, body temperature, leucocytes, and plasma levels of tnfα, il- , il- , and il- ra) peaked markedly and similarly in both treatment groups. nox-h was well tolerated. plasma concentrations peaked at . ± . hours after the start of administration, after which they declined according to a two-compartment model, with a t / of . ± . hours. in the placebo group, serum iron increased from . ± . μg/l at baseline to a peak at t = hours, returned close to baseline at t = hours and decreased under the baseline concentration at t = hours, reaching its lowest point at t = hours. in the nox-h group, serum iron concentrations rose until t = hours and then slowly declined until t = hours. from to hours post lps, the serum iron concentrations in nox-h -treated subjects were signifi cantly higher than in placebo-treated subjects (p < . , ancova). conclusion experimental human endotoxemia induces a robust infl am matory response and a subsequent decrease in serum iron. treatment with nox-h had no eff ect on innate immunity, but eff ectively prevented the infl ammation-induced drop in serum iron concentrations. these fi ndings demonstrate the clinical potential of the anti-hepcidin drug nox-h for further development to treat patients with anemia of infl ammation. the association between haemoglobin concentrations and mortality has been studied in patients with various comorbidities [ , ] . this study aims to determine the association between haemoglobin levels on admission to intensive care and patient length of stay and mortality. methods a retrospective collection of data from patient admissions to a single fi ve-bed icu over a -year period identifi ed , patients between april and november . patients were split into groups according to haemoglobin concentration on admission. the data were analysed to determine whether there was any relationship between haemoglobin concentration at icu admission and any of our outcome measures (unit and hospital mortality, unit and hospital length of stay). results patients with haemoglobin concentrations ≤ g/dl and > . g/dl were used in mortality comparisons. patients with a haemo globin concentration ≤ g/dl had an increase in icu mortality compared with those with haemoglobin levels > g/dl (or = . , % ci = . to . , p < . ). a similar diff erence was seen with hospital mortality (≤ g/dl . % vs. > g/dl . %, p < . ). unit length of stay was signifi cantly longer in patients with admission hb ≤ g/ dl ( . days) compared with an admission hb > g/dl ( . days), p < . . hospital length of stay was also signifi cantly longer in patients with hb ≤ g/dl versus hb > g/dl ( . days vs. . days, p < . ). there was seen to be an inverse correlation between haemoglobin concentration and patient age (r = - . ; p < . ). conclusion haemoglobin concentrations ≤ g/dl on admission to the icu are associated with an increase in icu mortality, hospital mortality, unit length of stay and hospital length of stay when compared with patients admitted with haemoglobin concentrations > g/dl. introduction according to many authors, acute necrotizing pancreatitis (anp) still remains one of the diffi cult problems of abdominal surgery. the complexity of the pathogenesis of the disease, features of the pancreas pathomorphology, abdominal hypertension, and high mortality ( to %) necessitate a search for new ways to treat this disease. the study was conducted in patients with anp, who were divided into two groups according to type of analgesia: epidural or opioids. patients from the fi rst group (n = ) had epidural analgesia by ropivacaine to mg/hour during to days, and from the second group (n = ) opioid analgesia by trimeperidine mg three times a day during the same period. we monitored the level of septic and thrombohemorrhagic complications by clinical and instrumental data, during the month after treatment starting. the hemostatic system was evaluated using indicators of hemoviscoelastography (mednord- m analyzer). results it was found that all patients with anp initially have hypercoagulation and fi brinolysis inhibition. levels of hemostatic disorders correlate with the level of septic complications, treatment in the icu, and mortality. in the fi rst group we noted a deep vein thrombosis, two pneumonia, seven pseudopancreatic cysts and abscesses, two deaths and time of stay in the icu as . days. in the second group: three cases of deep vein thrombosis, four pneumonia, pseudopancreatic cysts and abscesses, two episodes of gastroduodenal bleeding, fi ve deaths and time of stay in the icu as . days. conclusion using epidural anesthesia in patients with anp reduced the number of septic complications on . %, and reduced the mortality rate from . % (second group) to . % (fi rst group). we think that violations of blood coagulation and microcirculation are the basis for ischemia, necrosis in tissues and septic complications. epidural analgesia is an eff ective method to decrease the level of septic and thrombohemorrhagic complications and mortality in anp patients. methods after ethics approval and informed consent, we studied the functional state of hemostasis in a group of healthy volunteers, who were not receiving drugs aff ecting coagulation, and patients with postphlebothrombotic syndrome (ppts). in the ppts patients we conducted baseline studies of coagulation state and daily monitoring of dynamic changes in the functional state of hemostasis, a comparative evaluation of performance low-frequency piezoelectric vibration hemoviscoelastography (lpvh) and platelet aggregation test (pat), standard coagulation tests (sct), and thromboelastogram (teg). we found that lpvh correlated with sct, pat and teg. however, our proposed method is more voluminous: indexes icc (the intensity of the contact phase of coagulation), t (the time for the contact phase of coagulation), and ao (initial rate of aggregation of blood) are consistent with pat; indexes icd (the intensity of coagulation drive), cta (a constant thrombin activity) and cp (the clot intensity of the polymerization) are consistent with sct and teg. in addition, the advantage of this method is to determine the intensity of fi brinolysiswith the indicator iris (the intensity of the retraction and clot lysis). conclusion lpvh allows one to make a total assessment of all parts of hemostasis: from initial viscosity and platelet aggregation to coagulation and lysis of clots, as well as their interaction. these fi gures are objective and informative, as evidenced by close correlation with the performance of traditional coagulation methods. prophylaxis in orthopedics or in cases of acute coronary syndromes. the main drawback of fond is that routine monitoring is not currently available. this could be a problem during the management of critical and surgical patients, especially in cases of old patients and renal failure. the aim of this study is to evaluate the ability of thromboelastography (teg) to determine the level of anticoagulation due to fond in a surgical population. we prospectively analyzed all patients to whom elective major orthopedic surgery was consecutively performed in a -month period. all the patients received fond . mg in the postoperative period according to accp guidelines. native and heparinase (hep) teg (haemoscope corporation, niles, il, usa) tests activated with kaolin were performed using whole blood citrated samples at four times: t , before fond administration; t , hours after administration; t , hours after administration (half-life); t , hours after administration. the following native and hep teg parameters were analyzed: reaction time (r), α angle, maximum amplitude (ma) and coagulation index (ci). these parameters were compared with levels of anti-xa. unvariate analysis and spearman's test were applied to our data. results eighteen patients were analyzed. ten patients met the inclusion criteria. the mean r value increased from t to t . the mean r parameter was in the normal range at any phase of the study and there was no signifi cant diff erences between the r mean value at the diff erent phases. the lowest value of r was at t , which coincides with plasmatic peak concentration of fond. this value did not correlate with anti-xa mean value at t , which showed the highest value at that time. there was signifi cant diff erence between the mean native and hep r value only at t (p < . ), native and hep α angle at t , ma and ma hep at t (p < . ) and ci and ci hep at t (p < . ). only the parameter ma had signifi cant variation over time (p < . ). conclusion r represents the time necessary to thrombin formation and in the presence of fond we hypothesized a prolonged r time. in our population, teg performed with citrated kaolin-activated whole blood was not able to detect prophylatic doses of fond in every phase. on the contrary, levels of anti-xa were able to reveal the exact pharmacokinetics of the drug. further studies including a large number of patients are necessary. introduction coagulopathy, particularly a trend toward hypercoagula bility and hypofi brinolysis, is common in critically ill patients and correlates with worse outcome. available laboratory coagulation tests to assess fi brinolysis are expensive and time demanding. we investigated whether a modifi ed thromboelastography with the plasminogen activator urokinase (ukif-teg) [ ] may be able to evaluate fi brinolysis in a population of critically ill patients. methods ukif-teg was performed as follows: fi rst urokinase was added to citrate blood to give fi nal concentrations of ui/ml, then thromboelastography (teg) analysis was started after kaolin activation and recalcifi cation with calcium chloride. basal teg (no addition of urokinase) was also performed. fibrinolysis was determined by the loss of clot strength after the maximal amplitude (ma), and recorded as ly (percentage lysis at minutes after ma) and as ly (percentage lysis at minutes after ma). results ukif-teg was performed on healthy volunteers and critically ill patients. ly was predicted by ly according to an exponential function, so we used ly as an indicator of clot lysis. basal teg showed increased coagulability and a trend toward less fi brinolysis in critically ill patients compared with healthy volunteers (reaction time . ± . minutes vs. . ± . minutes, p < . ; α-angle . ± . vs. . ± . , p < . ). this reduction of fi brinolysis was more evident at a urokinase concentration of ui/ml (figure ). conclusion ukif-teg could be a feasible point-of-care method to evaluate fi brinolysis in critically ill patients. methods we performed a randomized, double-blind study in patients who underwent cesarean section. patients were divided into two groups: the fi rst group (n = ) received preoperative ( minutes before operation) tranexamic acid mg/kg; the second group (n = ) received preoperative placebo. the condition of hemostasis was monitored by haemoviscoelastography. results all patients included in the study before surgery had moderate hypercoagulation and normal fi brinolysis: increasing the intensity of clot formation (icf) to . % compared with normal rates; the intensity of the retraction and clot lysis (ircl) was . ± . in both groups. at the start of the operation in patients (group ), icf decreased by . % (p < . ), and ircl decreased by . % (p < . ) compared with preoperatively. in group , there was icf decrease by . % (p < . ), and ircl increase by . % (p < . ) compared with preoperatively. at the end of the operation, the condition of hemostasis in both groups came almost to the same value -moderate hypocoagulation, depressed fi brinolysis. in both groups there were no thrombotic complications. intraoperative blood loss in the fi rst group was ± . and in the second was ± . . conclusion using of tranexamic acid before surgery signifi cantly reduces intraoperative blood loss by %, without thrombotic complications. introduction rotational thromboelastography (rotem) can detect dilutive and hypothermic eff ects on coagulation and evaluate corrective treatments. the aim of this in vitro study was to study whether fi brinogen concentrate alone or combined with factor xiii could reverse colloid-induced and crystalloid-induced coagulopathies in the presence and absence of hypothermia. methods citrated venous blood from healthy volunteers was diluted by % using / . hydroxyethyl starch or ringer's acetate. rotem was used to evaluate the eff ect of addition of either fi brinogen concentrate corresponding to g/ kg, or this fi brinogen dose combined with factor xiii equivalent to iu/kg. blood was analyzed at or °c with rotem extem and fibtem reagents. results a signifi cant dilutive response was shown in both groups: hypocoagulation was greater in the starch group. hypothermia lengthened the following: extem clotting time (ct), clot formation time and α angle; fibtem maximal clot formation (mcf). irrespective of temperature, fi brinogen overcorrected ringer's acetate's eff ects on all rotem parameters and partially reversed starch's eff ects on extem ct and fibtem mcf. fibtem demonstrated that factor xiii provided an additional procoagulative eff ect in the ringer's acetate group at both temperatures but not the starch group. the only extem parameter to be improved by addition of factor xiii was mcf at °c. conclusion rotem shows that fi brinogen concentrate can reverse dilutive coagulation defects induced by colloid and crystalloid at both and °c. some additional reversal was provided by factor xiii: higher doses of both fi brinogen and factor xiii may counteract starch's eff ects on clot structure. introduction natural colloid albumin induces a lesser degree of dilutional coagulopathy than synthetic colloids. fibrinogen concentrate has emerged as a promising strategy to treat coagulopathy, and factor xiii (fxiii) works synergistically with fi brinogen to correct coagulopathy following haemodilution with crystalloids. objectives were to examine the ability of fi brinogen and fxiii concentrates to reverse albumininduced dilutional coagulopathy. high and low concentrations of both fi brinogen and fxiii were used to reverse coagulopathy induced by : dilution in vitro with % albumin of blood samples from healthy volunteers, monitored by rotational thromboelastometry (rotem). results haemodilution with albumin signifi cantly attenuated extem maximum clot fi rmness (mcf), α angle (aa), clotting time (ct) and clot formation time (cft), and fibtem mcf (p < . ). following haemodilution, both doses of fi brinogen signifi cantly corrected all rotem parameters (p ≤ . ), except the lower dose did not correct aa. compared with the lower dose, the higher dose of fi brinogen signifi cantly improved fibtem mcf and extem mcf, aa and cft (p < . ). the lower dose of fxiii did not signifi cantly correct any of the rotem parameters, and the high dose only improved extem ct (p = . ). all combinations of high/low concentrations of fi brinogen/ fxiii signifi cantly improved all rotem parameters examined (p ≤ . ). fibrinogen concentration generally had a greater eff ect on each parameter than did fxiii concentration; the best correction of rotem parameters was achieved with high-dose fi brinogen concentrate and either low-dose or high-dose fxiii. conclusion fibrinogen concentrate successfully corrected initiation, propagation and clot fi rmness defi cits induced by haemodilution with albumin, and fxiii synergistically improved fi brin-based clot strength. results iocs was used in severe pphs and severe pph controls were managed without iocs. placenta accreta can be selected as the best indication for rbc restitution. in the , to , ml pph, allogeneic transfusion was decreased in the iocs group: . versus . % (p = . ); prbc: ( to ) versus ( to ) (p = . ). iocs spared blood bank prbc ( , ml); that is, . % of the total transfusion need. no amniotic fl uid embolism has been observed in the group with iocs whereas one case appeared in the control group without iocs. conclusion regarding the literature [ ] [ ] [ ] [ ] and our study, iocs could be used safely in pph during cs. a leukocyte fi lter for retransfusion has been recommended and rhesus isoimmunization must be precluded and monitored by repeated fetal rbc testing. bleeding with the use of a protamine infusion and an abolishment of heparin rebound [ ] . the aim of this study was to see whether the use of postoperative protamine infusions in our cardiac itu was associated with a reduction in heparin rebound and blood loss. methods data from cardiac surgery patients were retrospectively analysed. of these, had routine management with a bolus of protamine to correct the activated clotting time and then expectant management of subsequent bleeding, and had the same but also a protamine infusion of to mg/hour for between and hours postoperatively. blood loss was measured at , , and hours. in all, excessive bleeding was investigated using thromboelastography (teg). rebound heparinisation was determined by a ratio of r-times (heparinase/plain) < . . the mann-whitney u test and the chi-squared test were used to assess statistical signifi cance. results there was no signifi cant diff erence in blood loss between the two groups. blood loss at hour in the infusion and non-infusion group was and ml, respectively (p = . ); at hours: and ml (p = . ); at hours: and ml (p = . ); and at hours: and ml (p = . ). there was also no signifi cant diff erence in those getting heparin rebound with % in the infusion group and % in the non-infusion group (p = . ). conclusion unlike teoh and colleagues [ ] , we did not fi nd an advantage in using protamine infusions. that there were still cases of heparin rebound in the infusion group suggests that the infusion was not as eff ective as expected and/or the dose was inadequate. however, previous studies assessed heparin rebound using isolated clotting parameters [ , ] . here, we used teg. as teg measures the thrombodynamic properties of whole blood coagulation, perhaps it is a more reliable indicator of heparin activity? as a retrospective study, there are limitations; namely, the nonstandardised management of the patients and the potential bias in the anaesthetists' selection of patients for an infusion. this group may be inherently higher risk for bleeding. however, heparin rebound is common and protamine is a simple, relatively safe and low-cost intervention compared with transfusion and so further study is needed. introduction the purpose of this study was to evaluate whether a restrictive strategy of red blood cell (rbc) transfusion was superior to a liberal one for reducing mortality and severe clinical complications among patients undergoing major cancer surgery. methods the trial was designed as a phase iii, randomized, controlled, parallel-group, superiority trial. the inclusion criteria were adult patients with cancer who were undergoing major abdominal surgery requiring postoperative care in an icu. the patients were randomly allocated to treatment with either a liberal rbc transfusion strategy (transfusion when hemoglobin levels decreased below g/dl) or a restrictive rbc transfusion strategy (transfusion when hemoglobin levels decreased below g/dl). the primary outcome was a composite endpoint of death or severe complications. the patients were monitored for days. results a total of , patients were screened for eligibility and met the inclusion criteria. after exclusions for medical reasons or a lack of consent, patients were included in fi nal analysis, with allocated to the restrictive group and to the liberal group. the primary composite endpoint -all-cause mortality, cardiovascular complications, acute respiratory distress syndrome, acute kidney injury requiring renal replacement therapy, septic shock or reoperation at days -occurred in . % of the patients in the liberal strategy group and in . % in the restrictive group (p = . ). the liberal strategy group had a signifi cantly lower -day mortality rate as compared with the restrictive group ( . % ( % ci, . to . %) vs. . % ( % ci, . to . %), respectively, p = . ). the occurrence of cardiovascular complications was lower in the liberal group than in the restrictive group ( . % ( % ci, . to . %) vs. . % ( % ci, . to . %), respectively, p = . ). the restrictive strategy group had a higher day mortality rate as compared with the liberal group ( . % ( % ci, . to . %) vs. . % ( % ci, . to . %), respectively, p = . ). conclusion the liberal rbc transfusion strategy with a hemoglobin trigger of g/dl was associated with fewer major postoperative complications in patients undergoing major cancer surgery compared with the restrictive strategy. introduction red blood cell (rbc) transfusion is associated with morbidity and mortality in critically ill patients. congenital cardiac surgeries are associated with high rates of bleeding and consequently with high rates of allogeneic transfusion. we aimed to evaluate the association of transfusion with worse outcomes in children undergoing cardiac surgery. methods we performed a prospective cohort study of patients undergoing cardiac surgery for congenital heart disease. we recorded baseline characteristics, rachs- score, intraoperative data, transfusion requirement and severe postoperative complications as need for reoperation, acute kidney injury, arrhythmia, severe sepsis, septic shock, bleeding, stroke, and death during days. we performed univariate analysis using baseline, intraoperative and postoperative variables. selected variables (p < . ) were included in a forward stepwise multiple logistic regression model to identify predictive factors of a combined endpoint including -day mortality and severe complications. results one hundred and thirty-six patients ( . %) were exposed to rbc transfusion. in the intraoperative room, . % of patients received at least one rbc unit, and in the icu, . % of children were transfused. from all patients, ( . %) presented the combined endpoint. patients with complications had higher rachs- score, were younger ( months ( to ) vs. months ( to ), p < . ), had a lower weight ( kg ( to ) vs. kg ( to ), p < . ), a longer time of surgery ( minutes ( to ) vs. ( to ), p < . ), a longer duration of cardiopulmonary bypass ( minutes ( to ) vs. minutes ( to ), p = . ), a lower svo at the end of surgery ( % (iqr to ) vs. % ( to ), p < . ), a higher arterial lactate at the end of surgery ( . mmol/l ( . to . ) vs. . mmol/l ( to ), p = . ), a lower intraoperative hematocrit ( . ± . % vs. . ± % (p < . )) and a lower hematocrit at the end of surgery ( . ± . % vs. . ± . % (p < . )) as compared with patients without complications. patients with complications were more exposed to rbc transfusion in the intraoperative room ( % vs. %, p = . ) and in the icu ( % vs. . %, p = . ). in an adjusted model of logistic regression, rbc transfusion is an independent risk factor of combined endpoint (or . ( % ci, . to . ), p = . ). conclusion blood transfusion after pediatric cardiac surgery is a risk factor for worse outcome including -day mortality. avoiding blood transfusion must be a goal of best postoperative care. introduction we do not have enough criteria to make a judgment of the need for a massive transfusion (mt) in severe blunt traumatic patients. as a scoring system to predict the need for a mt, we usually use the assessment blood consumption score (abcs) and/or the trauma-associated severe hemorrhage score (tashs). however, for these scoring systems, the procedure is slightly complicated. the aim of this study was to establish a predictor of a mt using coagulation or fi brinolysis markers. methods a retrospective analysis of mt was conducted in patients with severe blunt traumatic injury, which was defi ned as injury severity score (iss) of or more admitted to the icu between june and december . blood samples were collected from patients immediately after arriving at our level i trauma center. we defi ned the patients who received more than unit packed red blood cells (prbcs) within the fi rst hours as a mt group and who received less than units prbcs as a non-mt group. after the demographic data, number of units of prbcs and the need for massive transfusions were recorded and analyzed in each groups, we compared data between two groups. results there were patients who met the inclusion criteria. fifty patients received blood transfusions ( . %; / ). there were patients in the mt group ( . %; / ) and in the non-mt group. the mt group was signifi cantly higher in the ratio of females (p < . ), iss (p < . ), pt-inr (p < . ), aptt (p < . ), abcs (p < . ) and tashs (p < . ) than in the on-mt group. on the other hand, the mt group was signifi cantly lower in ps (p < . ) and fi brinogen level (p < . ) than the non-mt group. in the receiver operating characteristics (roc) analysis, the area under the curve (auc) to distinguish a mt was the highest for tashs ( . , p < . ), followed by fi brinogen ( . , p < . ), and abcs ( . , p < . ). fibrinogen was only a predictor of a mt without a scoring system such as abcs and tashs, and the optimal cutoff value was mg/dl. conclusion we found that the level of fi brinogen was the most valuable predictor of a mt in the coagulation or fi brinolysis markers. it is certain that the level of fi brinogen at admission was not as useful as the tashs about predicting a mt in this study. whereas the scoring systems require the assessment of several factors, the measurement of fi brinogen is simple, easy and quick. we strongly suggest that the level of fi brinogen will be a useful predictor of a mt at in severe blunt traumatic patients. introduction red blood cell (rbc) transfusions are frequent in critically ill children. their benefi ts are clear in several situations. however, issues surrounding their safety have emerged in the past decades. it is important to identify the potential complications associated with rbc transfusions, in order to evaluate their risk-benefi t ratio better. methods a single-center prospective observational study of all children admitted to the pediatric intensive care unit (picu) over a -year period. the variables possibly related to rbc transfusions were identifi ed before the study was initiated, and their presence was assessed daily for each child. in transfused cases (tcs), a variable was considered as a possible outcome related to the transfusion only if it was observed after the fi rst transfusion. results during the study period, admissions were documented, of which were included in the study. among them, ( %) were transfused. when comparing tcs with nontransfused cases (ntcs), the odds ratio (or) of new or progressive multiple organ dysfunction syndrome (npmods) was . ( % ci = . to . , p < . ). this association remained statistically signifi cant in the multivariate analysis for children with admission prism score ≤ (or = . , % ci = . to . , p = . ). tcs were ventilated longer than ntcs ( . ± . days vs. . ± . days, p < . ). this diff erence was still signifi cant after adjustment using a cox model. moreover, we observed an adjusted dose-eff ect relationship between rbc transfusions and length of mechanical ventilation. the picu length of stay was signifi cantly increased for tcs ( . ± . days vs. . ± . days, p < . ), even after multivariate adjustment (hazard ratio of picu discharge for tcs: . , % ci = . to . , p < . ). we also observed an adjusted dose-eff ect relationship between rbc transfusions and picu length of stay. the paired analysis for comparison of pre-transfusion and posttransfusion values showed that the arterial partial pressure in oxygen was signifi cantly reduced after the fi rst transfusion (mean diff erence . mmhg, % ci = . to . , p < . ). the paired analysis also showed an increased proportion of renal replacement therapy, while the proportions of sepsis, severe sepsis and septic shock did not diff er. conclusion rbc transfusions were associated with prolonged mechanical ventilation and prolonged picu stay. the risk of npmods was increased in some transfused children. moreover, our study questions the ability of stored rbcs to improve oxygenation in critically ill children. these results should help to improve transfusion practice in the picu. introduction microcirculatory alterations during sepsis impair tissue oxygenation, which may be further worsened by anemia. blood transfusions proved not to restore o delivery during sepsis [ ] . the impact of storage lesions and/or leukocyte-derived mediators in red blood cell (rbc) units has not yet been clarifi ed [ ] . we compared the eff ects of leukoreduced (lr) versus nonlr packed rbcs on microcirculation and tissue oxygenation during sepsis. methods a prospective randomized study. twenty patients with either sepsis, severe sepsis or septic shock requiring rbc transfusion randomly received nonlr (group , n = ) or lr (group , n = ) fresh rbcs (< days old). before and hour after transfusion, microvascular density and fl ow were assessed with sidestream dark-fi eld imaging sublingually. thenar tissue o saturation (sto ) was measured using near-infrared spectroscopy and a vascular occlusion test was performed. results the de backer score (p = . ), total vessel density (p = . ), perfused vessel density (p = . ), proportion of perfused vessels (p = . ), and microvascular fl ow index (p = . , figure ) increased only in group . the sto upslope (figure ) during reperfusion increased in both groups (p < . ). in group the baseline sto and sto downslope during ischemia increased, probably refl ecting a lower o consumption. conclusion unlike nonlr rbcs, the transfusion of fresh lr rbcs seems to improve microvascular perfusion and might help to restore tissue oxygenation during sepsis. introduction obstetric haemorrhage remains a leading cause of maternal mortality and severe morbidity. cardiovascular and haemostatic physiology alters in pregnancy and massive transfusion protocols have been implemented for obstetric haemorrhage based on limited evidence. the objective of this study was to examine the pattern and rate of blood products used in massive transfusion for obstetric haemorrhage in a tertiary obstetric hospital. methods massive transfusion was defi ned as or more units of red blood cells within hours in accordance with the australian massive transfusion registry defi nition. following ethics approval, all cases fi lling this criterion were identifi ed in the hospital's birthing and blood bank systems. data were extracted from the medical histories and analysed using spss. p < . was considered statistically signifi cant. results twenty-eight women in three years ( to ) underwent a massive transfusion for obstetric haemorrhage, with nine receiving more than units of rbcs in hours. eleven ( %) were admitted to the icu and underwent a hysterectomy, of which six were admitted to the icu. the median estimated blood loss was , ml (iqr , to , ). median blood product delivery was rbc units (iqr to ); ffp units (iqr to ); platelets units (iqr to ) and cryoprecipitate units (iqr to ). one-half of the women received the fi rst four units of rbcs in less than minutes. other blood products were started a median of minutes, minutes and minutes after the rbc transfusion commenced, respectively. eight women had a fi brinogen level < . g/l on the initial coagulation test during the haemorrhage. the remaining women had a median fi brinogen level of . g/l (iqr . to . ). there was no diff erence in the transfusion of rbcs (p = . ), ffps (p = . ) and platelets (p = . ) in women who showed an initial low fi brinogen and those who did not, although there was a diff erence in the number of units of cryoprecipitate (p < . ). the median lowest hb during the haemorrhage was g/l (iqr to ) and median discharge hb was g/l (iqr to ). no blood product reaction was noted and there was one death. conclusion massive transfusion for obstetric haemorrhage involved rapid blood product administration with no consistent pattern in the ratio of products administered. introduction blood transfusions are associated with longer icu and hospital inpatient durations, and an increase in mortality [ ] . this study was undertaken to investigate whether the practice of packed red cell critical care , volume suppl http://ccforum.com/supplements/ /s s (prc) transfusions in the icu was in accordance with the best clinical evidence. a number of studies, most notably the tricc study [ ] , have shown that indications for icu blood transfusions are a haemoglobin (hb) level of < g/dl or evidence of acute haemorrhage [ ] . these criteria were therefore employed. methods this study prospectively examined episodes of prc unit transfusions over a -month period in the icu of a large level trauma centre and a tertiary cardiac unit. the number of prc units transfused in each episode was recorded by nurses, along with the proposed indication and concurrent hb level. the data were analysed to assess the number of transfusions administered contrary to the guidelines, along with the average hb level at which a prc unit was transfused and the average number of units administered per episode. results a total units of prc were transfused in the icu, over episodes during the -month period (excluding immediately postoperative transfusions). ninety-four units ( . %) administered in transfusion episodes ( . %) occurred contrary to the guidelines. in . % of these cases the recorded reason for transfusion was an apparently low hb level. the median (iqr (range)) hb level at which patients were transfused: within guidelines was . g/dl ( . to . ( . to . )); within guidelines, excluding cases of acute blood loss, was . g/dl ( . to . ( . to . )); and outside the guidelines was . g/dl ( . to . ( . to . )). one unit of prc was transfused in episodes ( . %), units of prc were transfused in episodes ( . %), and to units were transfused in episodes ( . %), with two-thirds of the latter due to acute haemorrhage. our results indicate a liberal transfusion threshold currently exists in the icu. patients are frequently receiving excessive prc transfusions for hb levels above the recommended concentration. in the -month study period, these were associated with a cost of approximately £ , . we recommend increased staff awareness of the guidelines to reduce the number of unnecessary transfusions. this would decrease exposure of icu patients to unnecessary risks of blood transfusion, reduce cost of treatment and help to preserve a valuable resource. introduction transfusion-related acute lung injury (trali) has a high incidence in critically ill and surgical patients and contributes to adverse outcome, while specifi c therapy is absent. recently it was demonstrated that complement activation plays a pivotal role in trali. we aimed to determine whether a c inhibitor is benefi cial in a two-hit mouse model of antibody-mediated trali. methods balb/c mice were primed with lipopolysaccharide (lps, from e. coli :b ) that was administered intraperitoneally in a dose of . mg/kg, after which trali was induced by injecting mhc-i antibody against h kd (igg a,k) at a dose of mg/kg. mice infused with pbs or lps served as controls. concomitantly, mice infused with the mhc-i antibody were treated with c inhibitor (cetor®; sanquin, amsterdam, the netherlands) in a dose of iu/kg intravenously. after infusion, mice were mechanically ventilated with a lung-protective pressurecontrolled mode for hours and then sacrifi ced, after which a bronchoalveolar lavage (bal) was done. statistics were analyzed by one-way anova, values expressed as mean and standard deviation. results injection of lps and mhc-i antibodies resulted in trali, indicated by increased levels of protein in the bal fl uid, wet/dry ratios and levels of kc, mip- and il- . c inhibitor cetor® signifi cantly reduced total protein in bal fl uid from ( ) to ( ) μg/ml (p < . ) and tended to reduce the wet/dry ratio from . ± . to . ± . (p = . ). cetor® also reduced balf levels of mip- from ( ) to ( ) pg/ml (p < . ). kc and il- levels were not aff ected. conclusion in a model of antibody-mediated trali, c inhibitor attenuated pulmonary infl ammation. c inhibition may be a potential benefi cial intervention in trali. introduction transfusion-related acute lung injury (trali) is a syndrome that presents as a sudden onset of respiratory distress hours after transfusion of blood products. the diagnosis is based on clinical and radiographic fi ndings. particularly at risk for trali are cardiac surgery patients. however, specifi c patient risk factors and data on outcome are largely unknown. the aim of this study was to investigate incidence, risk factors and outcome of trali in cardiac surgical patients on cardiopulmonary bypass. methods all thoracic surgery patients from a university hospital in the netherlands of years and older admitted to the icu from january until december were screened. included patients were observed during surgery and the fi rst hours on the icu for the onset of possible trali. the canadian consensus conference trali defi nition was used. two independent physicians blinded to the predictor variables scored the chest radiographs for the onset of bilateral interstitial abnormalities on k monitors. when interpretation diff ered, chest radiographs were reviewed by a third physician to achieve consensus. the european system for cardiac operative risk evaluation (euro score) and the american association of anesthesiology (asa) were scored before surgery. by calculating the acute physiology and chronic health evaluation (apache) ii and iv scores the severity of illness was determined on arrival in the icu. in total, , cardiac surgical patients were included. a total of ( . %) patients developed trali within hours following surgery. patients developing trali were older compared with patients not developing trali, mean age respectively and years (p = . ). furthermore, patients developing trali had higher apache ii, apache iv, euro and asa score (p = . , p = . , p = . and p = . introduction volume resuscitation is essential to restore normovolemia during hemorrhagic shock, burns and sepsis. however, synthetic colloids cause dilutional coagulopathy. the aims were to determine whether the natural colloid albumin induces a lesser degree of coagulopathy compared with synthetic colloids, and the comparative eff ectiveness of fi brinogen concentrate to reverse coagulopathy following dilution with these solutions. methods rotational thromboelastometry-based tests were used to examine coagulation parameters in samples from healthy volunteers, in undiluted blood and samples diluted : with saline, was seen for samples diluted with synthetic colloids (p < . ) but not albumin (p = . ). following addition of fi brinogen, fibtem mcf, extem mcf and extem aa were signifi cantly higher, and extem cft was signifi cantly shorter in samples diluted with albumin versus those treated with hes or dextran (p ≤ . ). conclusion hemodilution using albumin induced a lesser degree of coagulopathy compared with the synthetic colloids hes and dextran. in addition, albumin-induced coagulopathy was more eff ectively reversed following addition of fi brinogen concentrate compared with coagulopathy induced by synthetic colloids. comparative assessment of the diff erent fl uid modalities is hampered by a paucity of direct trials. we present a network meta-analysis for assessing the relative eff ectiveness of two fl uid treatments in sepsis when they have not been compared directly in a randomized trial but have each been compared with a common treatment. methods a systematic review of trials sepsis yielded trials for assessment in network meta-analysis. the indirect comparison between albumin, hes and crystalloid was conducted using bayesian methods for binomial likelihood, fi xed-eff ects network meta-analysis with a monte carlo gibbs sampling method. studies in septic patients with crystalloid as a reference treatment compared with any formulation of the colloid treatments albumin or hes were included, as were direct head-to-head trials between the two colloids. results odds ratios between the diff erent treatments were obtained ( figure ). ranking the interventions [ ] demonstrated that albumin ranked highest in lowering mortality at a . % probability compared with . % and . % for crystalloid and hes, respectively. conclusion albumin as a fl uid therapy in sepsis is associated with the lowest mortality of the three modalities studied. (sap), sv and co were recorded directly before the administration of any colloid (t ) and every minutes for the next hour (t to t ). kolmogorov-smirnov was used to test normal distribution of data and anova was used for the statistical analysis. p < . was considered statistically signifi cant. results demographic data and asa classifi cation did not diff er statistically signifi cant among the six groups of the study. co, sv, hr and sap did not show any statistically signifi cant evolution compared with their baseline value during the study period. moreover, there were no statistically signifi cant diff erences among the six study groups with regard to any of the recorded parameters. conclusion according to our results, volume replacement with the six colloids tested in our study did not result in any hemodynamic response. within comparison of these six colloids did not reveal any statistically signifi cant diff erence in any of the parameters recorded according to our protocol. the biochemical characteristics of infused fl uids may be important in regulating acid-base balance, by modifying plasmatic volume and strong ion diff erence. in vitro and animal studies [ , ] have shown that volume and strong ion diff erence of infused fl uids (sidin) as well as the arterial baseline bicarbonate concentration (hco -a) infl uence acid-base variations. our aim was to verify these changes in critically ill patients after surgery. methods an electronic-dedicated database was created to retrospectively collect volume, type of fl uids infused and plasmatic acidbase balance variations in postoperative icu patients from admission to : am of the day after. sidin was calculated as the average sid of all fl uids infused during the whole study period (crystalloids, colloids and blood products). arterial base excess variation (Δbea) was computed as the diff erence between values at : am on the day after and those at entry. we report data from all patients admitted in and ( patients). results nine patients not receiving intravenous infusions were excluded. the remaining population was divided into three groups according to sidin distribution (group , ± ; group , ± ; group , ± meq/l). we observed a progressive increment in Δbea between the groups ( . ± . vs. . ± . vs. . ± . mmol/l, p < . ). we further subdivided each group by the median value of baseline hco -a ( . ( . to . ) mmol/l) and we analyzed the Δbea: we observed a greater increase in patients with lower baseline hco -a (group , . ± . vs. . ± . , mmol/l, p < . ; group , . ± . vs. . ± . , mmol/l, p < . ; group , . ± . vs. . ± . mmol/l, p < . ), as compared with those with higher baseline levels. when the study population was divided into quartiles of the diff erence between sidin and hco -a, Δbea appeared to increase with the rise of such diff erence (p < . ). conclusion sidin aff ects the acid-base status per se and in relationship with hco -a. we verifi ed this hypothesis in critically ill patients, highlighting the importance of the diff erence between sidin and hco -a, which better describes and predicts the acid-base modifi cations to fl uid therapy. introduction fluid resuscitation should improve tissue oxygenation in hypovolemia, besides restoring macrohemodynamic stability [ ] . we evaluated the microvascular response to fl uid challenge with diff erent colloid solutions and its relation to macrohemodynamics. methods an observational study of patients receiving a fl uid challenge ( ml colloids in minutes) according to the attending physician's decision. before and after the infusion, sublingual microcirculation was evaluated with sidestream dark-fi eld imaging (microscan; microvision medical, amsterdam, the netherlands). microvascular fl ow and density were assessed for small vessels [ ] . the cardiac index (ci), intrathoracic blood volume index (itbvi) and extravascular lung water index (elwi) were measured in seven patients with picco (pulsion medical system, munich, germany). results ten patients (two sepsis, four trauma, three intracranial bleeding, one post surgery) received either saline-based hydroxyethyl starch (hes) / . (amidolite®; b.braunspa; n = ) or balanced hes / . (tetraspan®; b.braunspa; n = ). the ci (p = . ) and itbvi (p = . ) tended to increase, the evlwi did not change. microvascular fl ow and density improved in the whole sample. no correlation was found between macro-circulatory and micro-circulatory parameters. balanced hes led to a greater increase in capillary density than nacl hes (figure ). conclusion balanced hes may be more effi cacious than saline-based hes in recruiting the microcirculation, thereby improving tissue o delivery. introduction are safety guidelines being followed when administering procedural sedation in the emergency department? between november and november , the npsa received alerts of patients being given the wrong dose of midazolam for procedural sedation [ ] . in the fi rst years of midazolam use there were deaths, most related to procedural sedation [ ] . methods we searched through the controlled drugs book in resuscitation over a -month period and found a list of patients who had received midazolam or fentanyl. from this, we could make a search for the relevant a and e notes for these patients. from these notes, we looked for (see shorthand in table ): verbal consent documentation (consent), past medical history recorded (pmhx), safe initial dose of midazolam (midaz), pre-procedure monitoring (pre), post-procedure monitoring (post), and monitoring for hour before discharge ( hr). following introduction of a reminder in the controlled drugs book/ sedation room and staff education, the case notes were analysed over another -month period ( sets of notes) to assess practise against safety guidelines. results see table (key for shorthand in methods). conclusion the re-audit notices within the procedural sedation room and controlled drug book front cover served as a reminder of good practise. the visibility of this reminder (within the cd book) helped ensure better adherence to the audit standard. this reminder will now be kept within the cd book. introduction daily sedation interruption and protocol implementation have been recommended to reduce excessive sedation; however, their use has been inconsistent. we hypothesized that the use of an age, kidney and liver function adjusted sedation protocol would be associated with reduced doses and improved outcomes compared with a standard protocol. methods this was a prospective cohort study comparing months of a standard protocol (control group) with months of an adjusted protocol (intervention group). in the adjusted protocol, patients were divided into three categories: category (age < years, and normal kidney and liver function), category (age = to years, or moderate kidney or liver function impairment), and category (age > years, or severe kidney or liver function impairment). the upper limits of analgesics and sedatives doses were determined by age, and kidney and liver function, being lowest in category , and lower in category than category . all consecutive adults mechanically ventilated patients who required infusion of analgesics and/or sedatives for > hours were included in the study. we compared the main outcomes of both groups including average daily doses of analgesics and sedatives; average sedation-agitation scale (sas), pain and gcs scores; mechanical ventilation duration (mvd); sedation-related complications during icu stay; icu and hospital length of stay (los), and icu and hospital mortality. results two hundred and four patients were included in the study (control group = ; adjusted protocol group = ). there was no diff erence in baseline characteristics between the two groups. the adjusted protocol group, compared with the control group, received signifi cantly lower average daily doses of fentanyl ( , ± , μg vs. , ± , μg, p = . ), nonsignifi cant lower average daily doses of midazolam and dexmedetomidine, and a trend toward higher average daily doses of propofol. pain score was higher in the adjusted protocol group ( . ± . vs. . ± . , p < . ) with no diff erence in sas or gcs scores. sedation-related complications during icu stay were not diff erent between the two groups; however, agitation (sas = ) was less frequent in the adjusted protocol group ( % vs. %, p < . ). icu mortality was signifi cantly lower in the introduction the aim of this research was to provide clinically relevant evidence for y-site compatibility of drug infusion combinations used in the picu. pharmacists and clinicians regularly have to interpret limited published data, particularly when more than two drugs are y-sited. the risk of potential incompatibility must be balanced against that of additional line insertion. methods a full -factorial design (total combinations) was used to investigate chemical and physical compatibility of fi ve drugs (clonidine, morphine, ketamine, midazolam and furosemide). the drugs were studied at their highest commonly infused concentrations and exposed to three variations in environmental conditions (diluent: sodium chloride . % or glucose %; temperature or °c; and normal room lighting or blue light phototherapy). chemical stability was assessed using hplc; > % reduction in concentration indicated incompatibility. physical incompatibility was confi rmed by precipitation, ph or colour change. results environmental conditions had no eff ect on the drug mixtures. the precipitation observed in incompatible combinations was due to either a change in ph, or with ketamine the presence of benzethonium chloride. of possible drug combinations, were incompatible. a further three combinations were incompatible at extreme ph, or were of concern and so should be avoided. the incompatible formulations all contained furosemide. all combinations of the sedative agents studied were chemically and physically compatible. conclusion this work provides evidence for y-site compatibility of morphine, midazolam, clonidine and ketamine in any combination, which will potentially reduce the need for extra intravenous lines. furosemide is incompatible with any of these sedative drugs and must be infused via a separate line. these results will aid clinical decisionmaking and help satisfy the requirements of recent uk department of health legislation relating to the mixing of medicines. reference introduction in light of the interest in the relationship between glycemia control in critically ill subjects and outcome, we set up a study to investigate whether benzodiazepine, commonly used in anesthesia and icus, interferes with glucose metabolism and to explore the mechanism. methods a total of sedated and paralyzed sprague-dawley rats ( ± g) were investigated in four consecutive studies. ( ) to investigate the eff ects of diazepam on blood glucose, rats were randomly assigned to intraperitoneal anesthesia with tiopenthal mg/kg (dzp ), tiopenthal mg/kg + diazepam mg/kg (dpz ) or tiopenthal mg/kg + diazepam mg/kg (dzp ). blood levels of glucose (gem premier ; il) were measured at time intervals over hours. ( ) ten animals randomized to dzp or dzp underwent an intravenous glucose tolerance test with glucose bolus ( . g/kg). acute insulin response, the mean value of blood insulin (insulin elisa kit; millipore) from to minutes after glucose bolus, was measured as index of insulin secretion. ( ) a hyperinsulinemic euglycemic clamp obtained by a continuous intravenous infusion of insulin ( mui/ kg/minute) was run in animals randomized to dzp or dzp and the glucose infusion rate (gir, mg/kg/minute) was assessed [ ] . ( ) introduction we report our experience in the use of isofl urane for prolonged sedation in severe ards patients. prolonged sedation in the icu may be diffi cult because of tolerance, drug dependence and withdrawal, drug interactions and side eff ects. inhaled anesthetics have been proposed for sedation in ventilator-dependent icu patients. anaconda is a device that allows a safety and easy administration of inhaled anesthetics in the icu. methods from january to june , patients were sedated with isofl urane by means of the anaconda device. we consider administration of isofl urane as a washout period from common sedative drugs in patients with (at least one of ): high sedative drug dosage (propofol ≥ mg/hour or midazolam ≥ mg/hour) to reach the target richmond agitation sedation score (rass) or inadequate paralysis; two or more hypnotic drugs to reach the target rass (propofol, midazolam, hydroxyzine, haloperidol, diazepam, quetiapine); and hypertriglyceridemia. during isofl urane administration previous hypnotic drugs were interrupted. we retrospectively collected data before, during and after administration of isofl urane: hemodynamic parameters, renal and hepatic function, level of sedation (rass) and sedative drug dosage. all data are reported as mean ± standard deviation, otherwise as median (minimum to maximum). results mean age was ± years and saps ii was . ± ; patients were treated with ecmo for severe ards and four had a history of drug abuse; median icu length of stay was ( to ) days and they were ventilated for ( to ) days. due to severe critical illness, target rass was - for all patients, most of which were also paralysed. isofl urane was administered in nine patients because of a high level of common sedative drugs, in fi ve patients due to the use of two or more hypnotic drugs and in one patient because of hypertrigliceridemia. isofl urane administration lasted . ± . days. during isofl urane administration no alteration in renal function or hemodynamic instability was recorded. after the isofl urane washout period we observed a reduction in sedative drug dosage in patients while two patients were quickly weaned from mechanical ventilation and the target rass raised to . in two patients isofl urane was precautionarily interrupted because of concomitant alteration of liver function and suspected seizures respectively. conclusion inhaled anesthetics could be successfully used in the icu especially in case of an inadequate sedation plan; for example, in patients with a history of drug abuse or young severe ards patients that required deep sedation and paralysis for a long period. introduction pharmacological agents used to treat critically ill patients may alter mitochondrial function. the aim of the present study was to investigate whether fentanyl, a commonly used analgesic drug, interacts with hepatic mitochondrial function. methods the human hepatoma cell line hepg was exposed to fentanyl at . , or ng/ml for hour, or pretreated with naloxone (an opioid receptor antagonist) at ng/ml or -hydroxydecanoate ( -hd; a specifi c inhibitor of mitochondrial atp-sensitive k + (katp) channels) at μm for minutes, followed by incubation with fentanyl at ng/ml for an additional hour. the mitochondrial complex i-dependent, ii-dependent and iv-dependent oxygen consumption rates of the permeabilized cells were measured using a high-resolution oxygraph (oxygraph- k; oroboros instruments, innsbruck, austria). the respiratory electron transfer capacity of intact cells was evaluated using fccp (carbonyl cyanide p-trifl uoromethoxyphenylhydrazone) to obtain the maximum fl ux. results incubation of hepg cells with fentanyl ( hour, ng/ml) induced a reduction in complex ii-dependent and iv-dependent respiration ( figure ). cells pretreated with -hd before the addition of fentanyl exhibited no signifi cant changes in complex activities in comparison with controls. pretreatment with naloxone tended to abolish the fentanyl-induced mitochondrial dysfunction. treatment with fentanyl led to a reduction in cellular atp content ( . ± . in controls vs. . ± . μmol/mg cellular protein in stimulated cells; p = . ). we did not observe any diff erence in basal or fccp-uncoupled respiration rates of cells treated with fentanyl at ng/ml compared with controls (data not shown). conclusion fentanyl reduces cultured human hepatocyte mitochondrial respiration by a mechanism that is blocked by a katp channel antagonist. in contrast, antagonism with naloxone does not seem to completely abolish the eff ect of fentanyl. introduction endothelial dysfunction during endotoxemia is responsible for the functional breakdown of microvascular perfusion and microvessel permeability. the cholinergic anti-infl ammatory pathway (cap) is a neurophysiological mechanism that regulates the infl ammatory response by inhibiting proinfl ammatory cytokine synthesis, thereby preventing tissue damage. endotoxemia-induced microcirculatory dysfunction can be reduced by cholinergic cap activation. clonidine improves survival in experimental sepsis [ ] by reducing the sympathetic tone, resulting in the parasympatheticmediated cap activation. the aim of this study was to determine the eff ects of clonidine on microcirculatory alterations during endotoxemia. methods using fl uorescent intravital microscopy, we determined the venular wall shear rate, macromolecular effl ux and leukocyte adhesion in mesenteric postcapillary venules of male wistar rats. endotoxemia was induced over minutes by intravenous infusion of lipopolysaccharide (lps). control groups received an equivalent volume of saline. clonidine μg/kg was applied as i.v. bolus in treatment groups. animals received either (i) saline alone, (ii) clonidine minutes prior to saline administration, (iii) clonidine minutes prior to lps administration, (iv) clonidine minutes prior to lps administration, (v) clonidine minutes after lps administration or (vi) lps alone. results all lps groups (iii to vi) showed a signifi cantly reduced venular wall shear rate compared with the saline group after minutes. there were no signifi cant diff erences between the numbers of adhering leukocytes in the clonidine/lps groups (iii, iv, v) and the lps group after minutes. macromolecular effl ux signifi cantly increased in all groups over the time period of minutes. after minutes there was no diff erence between the lps group and the clonidine minutes prior to lps administration group (iv) whereas all other groups (i, ii, iii, v) showed a signifi cantly reduced macromolecular effl ux compared with the lps group. conclusion clonidine has no positive eff ect on microhemodynamic alterations and leukocyte-endothelial interaction during endotoxemia. the reduction of capillary leakage in clonidine-treated groups depends on the time interval relative to the initiation of endotoxemia. endothelial permeability and leukocyte activation are regulated by diff erent pathways when stimulated by clonidine during endotoxemia. we conclude that clonidine might have an important time-dependent anti-infl ammatory and protective eff ect on endothelial activation during infl ammation. introduction delivering analgesics via conjunctival application could provide rapid and convenient pain relief in disaster medicine. there are sporadic reports from the usa concerning inhalation administration of aerosol with various drugs producing a wide variety of eff ects from anxiolysis, sedation, and loss of aggressiveness to immobilisation. we attempted to determine in an animal experiment whether conjunctival administration of s+ketamine could produce signifi cant eff ect without side eff ects. methods after ethic committee approval, rabbits were administered conjunctival s+ketamine . mg/kg. measured parameters were spo , blood pressure (bp) and heart rate (hr) before administration and in -minute intervals and immobilisation time (loss of righting refl ex [ ] . we can speculate that the reason for stability of cardiorespiratory parameters was due to the sympathoadrenergic eff ect of ketamine or due to the method of administration. there were no signs of conjunctival irritation in any animal (s+ketamine is a preservative-free solution). conclusion conjunctival s+ketamine . mg/kg in rabbits produced rapid onset without changes in cardiorespiratory parameters and without signs of irritation of the eye. the results of our project warrant further research to increase the variety of drugs and methods of their administration for anxiolysis, sedation and analgesia in disaster medicine. introduction procedural sedation is used in the emergency department (ed) to facilitate short but painful interventions. many patients are suitable for discharge after completion. ideally, the agent used to achieve sedation should not have a prolonged eff ect, allowing safe discharge in the shortest time frame. we hypothesised that propofol, with its short onset and off set, may reduce length of stay (los) in comparison with traditional benzodiazepines. methods data from a prospective registry were analysed for the period august to january . patients who underwent procedural sedation and who were discharged from the ed were identifi ed. individuals were grouped as having received propofol, midazolam or a combination of the two. all were discharged when fully alert and able to eat and drink. demographic details and the type of procedure undertaken were extracted. anova was performed to identify diff erences in the length of stay between groups, in addition to descriptive analysis. results during the study period patients underwent procedural sedation and were discharged from the ed. the median age was years and % were male. the commonest procedure performed was shoulder reduction ( %). in the propofol group (n = ) the mean los was minutes compared with minutes in those receiving midazolam (n = ) and minutes in those receiving a combination (n = ), p = . . there was no diff erence in adverse events between groups. see figure . conclusion propofol is increasingly used in eds for procedural sedation due to its short duration of action. this study suggests that a shorter duration of action and faster recovery may result in a reduced los in the ed. the use of propofol for sedation in intensive care has been associated with the propofol infusion syndrome (pris) characterised by cardiac dysfunction, metabolic acidosis, renal failure, rhabdomyolysis and hyperlipidaemia. we prospectively monitor biochemical markers that we believe demonstrate early signs of this dangerous, often fatal syndrome. when this pre-pris state is identifi ed, propofol is withdrawn whilst the syndrome is still reversible. methods we prospectively audited our monitoring of these markers over a -month period in propofol-sedated patients: propofol infusion rate, creatine kinase (ck), triglycerides (tg), creatinine, lactate, ph and base defi cit. we defi ned the criteria for pre-pris as requiring a ck ≥ mmol/l that had doubled from its base level and a rise in tg ≥ . iu/l; both that followed a trend with propofol dose. conclusion we propose that a paired rise in ck and tg that can be attributed to propofol alone represents a pre-pris state that is at risk of developing into full pris. we noted this in % of our patients, all on modest doses of propofol. it is unclear what proportion of patients will develop the full syndrome as it is not ethically possible to continue propofol in this situation. we advocate daily monitoring of ck and tg to identify pre-pris so that propofol can be reduced or substituted to avoid the morbidity and mortality of the full syndrome. introduction until recently there were no guidelines for the reporting of adverse events (aes) during procedural sedation [ , ] . a consensus document released in by the world siva international sedation task force proposed a benchmark for defi ning aes [ ] . we analysed , cases of procedural sedation in the emergency department. methods the study is based on , patients who received procedural sedation with propofol in the emergency department between december and march . patients were selected and sedated to a strict protocol by ed consultant staff . we applied the ae tool by performing a search through patient records, discussion with consultants performing the sedation and consensus opinion. results from , cases we identifi ed sentinel (six of hypotension, fi ve cases of hypoxia), moderate, minor and three minimal risk adverse events. the study shows a % adverse event rate. this supports use of propofol sedation by emergency physicians but within the limits of a strict governance framework. our safety analysis using the world siva adverse events tool provides a reference point for further studies. introduction physical restraints are used to facilitate essential care and prevent secondary injuries. however, physical restraint may be regarded as humiliating. it may lead to local injury and increase the risk of delirium and post-traumatic stress syndrome. research on physical restraint is scarce. the aim of this study is to investigate the scope of physical restraint use. methods twenty-one icus ranging from local hospitals to academic centres were each visited twice and patients were included. we recorded characteristics of restrained patients, motives and awareness of nurses and physicians. results physical restraint was applied in ( %) patients, ranging from to % in diff erent hospitals. frequent motives for restraint use were 'possible threat to airway' ( %) and 'pulling lines/probes' ( %). restrained subjects more often had a positive cam-icu ( % vs. %, p < . ), could less frequently verbally communicate ( % vs. %, p < . ), and received more often antipsychotics ( % vs. %, p < . ), or benzodiazepines ( % vs. %, p = . ). the use of physical restraint was registered in the patient's fi les in % of cases. of the interviewed nurses, ( %) were familiar with a physical restraint protocol and ( %) used it in any situation. thirty percent of the interviewed physicians were aware of the physical restraint status of their patients. conclusion physical restraint is frequently used in dutch icus, but the frequency diff ers strongly between diff erent icus. attending physicians are often not aware of physical restraint use. introduction physical restraint (pr) use in critically ill patients has been associated with delirium, unplanned extubation, prolonged icu length of stay, and post-traumatic stress disorder. our objectives were to defi ne prevalence of pr use, and to examine patient, treatment, or institutional factors associated with their use in canadian icus. measures aimed at delirium prevention (psychohygiene and early mobilization) were carried only in a small minority or were not documented. to implement protocolled delirium care in the region at study, a multifaceted tailored implementation program is needed. introduction the objective of this study is to investigate the eff ect of intraoperative administration of dexamethasone versus placebo on the incidence of delirium in the fi rst four postoperative days after cardiac surgery. methods within the context of the large multicenter dexamethasone for cardiac surgery (decs) trial [ ] for which patients were randomized to mg/kg dexamethasone or placebo at induction of anesthesia, a monocenter substudy was conducted. the primary outcome of this study was the incidence of delirium in the fi rst four postoperative days. secondary outcomes were duration of delirium, use of restrictive measures and sedative, antipsychotic and analgesic requirements. delirium was assessed daily by trained research personnel, using the richmond agitation sedation scale and the confusion assessment method. medical, nursing and medication charts were evaluated for signs of delirium and use of prespecifi ed medication. analysis was by intention to treat. results of eligible patients, complete data on delirium could be collected in patients. the incidence of delirium was . % in the dexamethasone group and . % in the placebo group (odds ratio = . , % ci = . to . ). no signifi cant diff erence was found on the duration of delirium between the intervention (median = days, interquartile range to days) and placebo (median = days, interquartile range to days) group (p = . ). the use of restrictive measures and administration of sedatives, haloperidol, benzodiazepine and opiates were comparable between both groups. conclusion intraoperative injection of dexamethasone seems not to aff ect the incidence or duration of delirium in the fi rst days after cardiac surgery, suggesting this regimen is safe to use in the operative setting with respect to psychiatric adverse events. reference introduction the beliefs, knowledge and practices regarding icu delirium among icu professionals may vary. this may interfere with the implementation of the dutch icu delirium guideline. we aimed to get insight into potential barriers and facilitators for delirium guideline implementation that may help to fi nd an eff ective implementation strategy. methods an online survey was sent to healthcare professionals from the six participating icus. respondents included icu physicians, nurses and delirium experts (psychiatrists, neurologists, geriatricians, nurse experts). the survey consisted of statements on beliefs, knowledge and practices towards icu delirium. agreement with statements by more than % of respondents were regarded as facilitating items and agreement lower than % as barriers for implementing protocolled care. of the surveys distributed, were completed ( . %). the majority of respondents were icu nurses ( %). delirium was considered a major problem ( %) that requires adequate treatment ( %) and is underdiagnosed ( %). respondents considered that routine screening of delirium can improve prognosis ( %). however, only a minority ( %) answered that delirium is preventable. only % of the respondents had received any training about delirium in the previous years and % of them found training useful. the mean delirium knowledge score was . out of (sd = . ). when all groups were mutually compared, nurses scored lower than delirium experts (anova, p = . ). the respondents ( %; n = ) from three icus indicated that cam-icu assessment was department policy. however, % (n = ) of these respondents felt unfamiliar with cam-icu and only % (n = ) of them indicated that a positive cam-icu was used for treatment decisions. haloperidol was the fi rst-choice pharmacological treatment. only % of all respondents knew that a national icu delirium guideline existed, but in-depth knowledge was generally low. conclusion our survey showed that healthcare professionals considered delirium an important but underdiagnosed form of organ failure. in contrast, screening tools for delirium are scarcely used, knowledge can be improved and protocolled treatment based on positive screening is often lacking. these results suggest that the focus of implementation of icu delirium management should not be on motivational aspects, but on knowledge improvements, training in screening tools and implementation of treatment and prevention protocols. introduction delirium is an acute disturbance of consciousness and cognition. it is a common disorder in the icu and associated with impaired long-term outcome [ , ] . despite its frequency and impact, delirium is poorly recognized by icu physicians and nurses using delirium screening tools [ ] . a completely new approach to detect delirium is to use monitoring of physiological alterations. temperature variability, a measure for temperature regulation, could be an interesting parameter for monitoring of icu delirium, but this has never been investigated before. the aim of this study was to investigate whether temperature variability is aff ected during icu delirium. methods we included patients in whom days with delirium could be compared with days without delirium, based on the confusion assessment method for the icu and inspection of medical records. patients with conditions aff ecting thermal regulation, including infectious diseases, and those receiving therapies aff ecting body temperature were excluded. twenty-four icu patients were included after screening delirious icu patients. daily temperature variability was determined by computing the mean absolute second derivative of the temperature signal. per patient, temperature variability during delirious days was compared with nondelirium days using a wilcoxon signed-rank test. with a linear mixed model, diff erences between delirium and nondelirium days with regard to temperature variability were analysed adjusted for daily mean richmond agitation and sedation scale scores, daily maximum sequential organ failure assessment score, and within-patient correlation. results temperature variability was increased during delirium days compared with days without delirium (mean diff erence = - . , % ci = - . ; - . , p < . ). adjusting for confounders did not alter our fi ndings (adjusted mean diff erence = - . , % ci = - . ; - . , p < . ). conclusion temperature variability is increased during delirium in icu patients, which refl ects the encephalopathy that underlies delirium. opportunities for delirium monitoring using temperature variability should be further explored. particularly, in combination with electroencephalography it could provide the input for an objective tool to monitor delirium. in icu patients, little research has been performed on the relationship between delirium and long-term outcome, including health-related quality of life (hrqol), cognitive functioning and mortality. in addition, results seem to be inconsistent. furthermore, in studies that reported increased mortality in delirious patients, no proper adjustments were made for severity of illness during icu admission. this study was conducted to investigate the association introduction we aimed to clarify the diff erences between primary and secondary acute gi injury. methods a total of , consecutive adult patients were retrospectively studied during their fi rst week in the icu. pathology in the gi system or laparotomy defi ned the primary gi insult. if gi symptoms developed without primary gi insult it was considered secondary gi injury. absent bowel sounds (bs), vomiting/regurgitation, diarrhoea, bowel distension, gi bleeding, and high gastric residuals (grv > , ml/ hours) were recorded daily. results in total, , patients ( . % male), median age years (range to ), were studied. eighty-four per cent of them were ventilated, % received vasopressor/inotrope. median (iqr) apache ii score was ( to ) and sofa on the fi rst day was ( to ). a total . % had primary gi pathology. during the fi rst week % of patients had absent bs, % vomiting/regurgitation, % diarrhoea, % bowel distension, % high grv and % gi bleeding. all symptoms except diarrhoea occurred more often (< . ) in patients with primary gi insult. eighty-fi ve per cent of patients with primary gi insult versus % without developed at least one gi symptom. the incidence of gi symptoms was signifi cantly higher in nonsurvivors. icu mortality was lower in patients with primary than secondary gi injury ( . % vs. . %, p = . ). nonsurvivors without primary gi insult developed gi symptoms later (figure ). conclusion primary and secondary acute gi injury have diff erent incidence, dynamics and outcome. ventilation with relative risk of to % and with mortality of to % [ , ] . one of the promoting factors of vap is the increased ph of the gastric acid, which occurs when h -receptor antagonists (h ra) or proton pump inhibitors (ppi) are used for stress ulcer prophylaxis. the results of this pilot study suggest that there may be no diff erence in the incidence of vap and gi bleeding if stress ulcer prophylaxis is performed by h ra or ppi. as the latter is more expensive, its use as fi rst choice in critical care should be questioned. conclusion depending on resection size liver resection acutely increases portal venous pressure and induces neurohumoral activation resulting in compromised renal function and increased risk of developing aki. introduction severe acute pancreatitis (sap) requiring admission to an icu is associated with high mortality (hospital mortality reached %) and long lengths of stay [ ] . survival among patients with predicted sap at admission has been shown to correlate with the duration of organ failure (of) [ ] . the systemic determinant of severity in a new classifi cation of acute pancreatitis (ap) is also based on identifi cation of patients with transient or persistent of [ ] . methods the aim of the study was to retrospectively determine the predictors of early persistent of in icu patients with sap. the analysis involved patients. the median time interval between the onset of ap and admission was ( ; ) hours. the patients were divided into two groups: the fi rst group (n = ) had transient of and the second group (n = ) had persistent of. the ability of the apache ii score, total sofa score and number of organ/system failure to discriminate transient from persistent of was explored with receiver operating characteristic (roc) curves. results hospital mortality was signifi cantly higher in the second group as compared with the fi rst group ( % vs. %, p = . ); while infectious complications were % versus % (p = . ) and median lengths of icu stay were ( ; ) days for the second group and ( ; ) days for the fi rst group (p = . ). optimum cutoff levels (by roc curve analysis) were apache ii score ≥ (sensitivity . ; -specifi city . ), total sofa score ≥ (sensitivity . ; -specifi city . ), and failure ≥ organs/systems (sensitivity . ; -specifi city . ). see table . introduction the aim of this study was to evaluate the accuracy of thrombopoietin (tpo) plasma levels as a biomarker of clinical severity in patients with acute pancreatitis (ap). tpo is a humoral growth factor that stimulates megakaryocyte proliferation and diff erentiation [ ] . furthermore, it favors platelet aggregation and polymorphonuclear leukocyte activation [ ] . elevated plasmatic concentrations of tpo have been shown in patients with critical diseases, including acs, burn injury and sepsis [ ] . in particular, clinical severity is the major determinant of elevated tpo levels in patients with sepsis [ ] . ap is a relatively common disease whose diagnosis and treatment are often diffi cult, especially in the clinical setting of the emergency department (ed introduction renal ischemia-reperfusion injury (iri) is a common cause of acute kidney injury and occurs in various clinical conditions including shock and cardiovascular surgery. renal iri releases proinfl ammatory cytokines within the kidney. atrial natriuretic peptide (anp) has natriuretic, diuretic and anti-infl ammatory eff ects [ ] and plays an important role of regulating blood pressure and volume homeostasis. the hypothesis was that renal iri induces infl ammation not only in the kidney but also in remote organs such as the lung and heart and anp attenuates renal injury and infl ammation in the kidney, lung and heart. methods male sprague-dawley rats were anesthetized with pentobarbital. tracheostomy was performed and rats were ventilated at vt ml/kg with cmh o peep. the right carotid artery was catheterized for blood sampling and continuous blood pressure measurements. the right femoral vein was catheterized for infusion of saline or anp. rats were divided into three groups; iri group (n = ), left renal pedicle was clamped for minutes; iri+anp group (n = ), left renal pedicle was clamped for minutes, anp ( . μg/kg/minute, for hours minutes) was started minutes after clamp; and sham group (n = ), the shamoperated rats. hemodynamics, arterial blood gas, and plasma lactate levels were measured at baseline and at hour, hours and hours after declamp. the mrna expression of il- in the kidney, lung, and heart were measured. the kidney, lung and heart were immunostained to examine the localization of il- and nf-κb and assigned an expression score. the wet/dry ratio of the lung was also measured. results renal iri induced metabolic acidosis, pulmonary edema, mrna expression of il- in the kidney, lung and heart. renal iri increased immunohistochemical localization of il- in the proximal convoluted tubule of the left kidney and nf-κb in the bronchial epithelial cells of the lung. anp attenuated metabolic acidosis, pulmonary edema and expression of il- mrna in the kidney, heart, and lung. anp decreased immunohistochemical localization of il- in the left kidney and nf-κb in the lung. conclusion these fi ndings suggested that infl ammation within the kidney after renal iri was extended into the lung and heart. anp attenuated metabolic acidosis and infl ammation in the kidney, lung and heart in a rat model of renal iri. anp may attenuate organ crosstalk between the kidney, lung and heart. reference increase in urinary ngal in patients receiving bicarbonate infusion was observed compared with control (p = . ). the incidence of postoperative rrt was similar but hospital mortality was increased in patients treated with bicarbonate compared with chloride ( / ( . %) vs. / ( . %), or . ( . to . ), p = . ). see figure . conclusion on this basis of our fi ndings we do not recommend the use of perioperative infusions of sodium bicarbonate to reduce the incidence or severity of aki in this patient group. figure ). an excellent predictive value was found for ungal/uhepcidin ratio (auc . , figure ). this ratio combines an aki prediction marker (ngal) and a marker of protection from aki (hepcidin), potentiating their individual discriminatory values. contrarily, at icu admission, none of the plasma biomarkers was a good early aki predictor with auc-roc ≥ . . conclusion several urinary markers of acute tubular damage predict aki after cardiac surgery and the biologically plausible combination of ngal and hepcidin provides excellent aki prediction. introduction furosemide is one of the most employed diuretics in the icu for its ability to induce negative water balance. however, one common side eff ect is metabolic alkalosis [ ] . we aimed to describe the time course of urinary excretion and changes in plasmatic acid-base balance in response to the administration of furosemide. methods we connected the urinary catheter of icu patients to a quasi-continuous urine analyzer (kidney instant monitoring®), allowing measurement of ph (phu), sodium, chloride, potassium and ammonium concentrations (na+u, cl-u, k+u, nh +u) every minutes. the study period lasted hours after a single intravenous bolus of furosemide (time ). in patients receiving two or more administrations over a longer period ( ( to ) hours), according to clinical needs, we reviewed data on fl uid therapy, hemodynamics and acid-base balance from the beginning to the end of the observation. results ten minutes after furosemide administration, na+u and cl-u rose from ± to ± and from ± to ± meq/l respectively, while k+u fell from ± to ± meq/l (p < . for all electrolytes vs. time ) with a consequent increase in urinary anion gap (agu = na+u + cl-u -k+u). urinary output increased from ( to ) to ( to ) ml/ minutes (p < . ). after the fi rst hour cl-u remained higher than na+u, which progressively decreased, leading to a reduction in agu and phu over time. in parallel, a progressive increment in nh +u was observed. in patients receiving more than one administration we observed an increase in arterial base excess ( . ± . vs. . ± . mmol/l, p < . ) and plasmatic strong ion diff erence (sidpl) ( ( to ) vs. ( to ) meq/l, p = . ) during the study period. these changes were due to a decrease in plasmatic clconcentration ( . ± . vs. . ± . meq/l, p = . ). plasmatic sodium and potassium concentrations did not change. in these patients, considering the total amount of administered fl uids and urine, a negative water and chloride balance was observed (- ± ml and - ± meq, respectively). conclusion furosemide acts immediately after administration, causing a rise in urinary output, na+u and cl-u concentrations. loop-diureticinduced metabolic alkalosis may be due to an increased urinary chloride loss and the associated increase in sidpl. reference introduction given the signifi cant morbidity and mortality associated with acute kidney injury (aki), there is a need to fi nd factors to help aid decision-making regarding levels of therapeutic support. as a prognostic biomarker, the red cell distribution width (rdw) has attracted interest in the setting of critical care when added to existing scoring systems [ ] . by examining rdw in a previously studied aki cohort, we aimed to evaluate the utility of this routine blood test. methods a cohort of mixed critical care patients who received renal replacement therapy for aki had their demographic and biochemical data retrieved from electronic databases. outcomes were gathered for icu and hospital mortality. incomplete datasets were discarded, leading to complete sets. rdw data were taken from the fi rst sample after admission to the icu, as were all other biochemical values apart from pre-rrt creatinine and potassium. overall cohort characteristics were gathered, and two groups were created: those with a rdw value within normal range (≤ . %) and those with a greater than normal value (> . %). we then further subgrouped rdw to assess the correlation between rising levels and icu mortality. results a total . % of our cohort had a rdw greater than the normal laboratory range at time of icu admission. key baseline characteristics (age, apache ii score, length of stay, icu mortality) did not diff er signifi cantly between patients with normal and abnormal rdw. when subgroup analysis was performed, no statistically signifi cant correlation between rising rdw and icu mortality was found (spearman correlation = . , p = . ). conclusion in this cohort of critically ill patients with aki, rdw was not found to be a predictor of mortality. our results contradict those of recent studies [ , ] . however, both groups of rdw patients in our study suff ered a higher icu mortality than in other studies. to further explain these fi ndings, we intend to perform multivariate logistic regression analysis and assess the eff ect of social deprivation on rdw. introduction intra-abdominal hypertension (iah) is an independent predictor of renal impairment and mortality [ ] . organ dysfunction caused by the pressure eff ect of iah is well understood, but how this is modifi ed in the presence of bowel obstruction is unclear. the aim of this study was to determine how diff erent iah models cause renal dysfunction in a pig model. methods twenty-four pigs were divided into three groups; a control group (n = ), a pneumoperitoneum (pn) (n = ), and an intestinal occlusion (oc) model (n = ). iap was maintained for hours at mmhg during which time creatinine, urea, urine output, potassium, and glomerular fi ltration pressure (gfp) were measured. statistical analysis was performed using repeated-measures anova. results over the fi rst hours there was a statistically signifi cant diff erence between the control group and both iah models for conclusion as expected the iah models resulted in signifi cantly worse renal function after hours. this early renal dysfunction may be as a result of an early infl ammatory process that has been associated with the pathophysiology of acute kidney injury. potassium was signifi cantly elevated in the pn group as compared with the oc group. early changes in potassium levels with iah may be a marker of early renal dysfunction and the usefulness of other renal biomarkers, such as ngal, prompts further investigation. reference introduction oliguria is common in septic patients and is frequently therapeutically addressed with loop diuretics; that is, furosemide. diuretic treatment in shock and hypovolemia is not rational, but can be tried in oliguric patients with normovolemia or hypervolemia and without hypotension. in such patients it still does not always increase dieresis and can also be harmful. the resistive index is a measure of pulsatile blood fl ow that refl ects the resistance to blood fl ow caused by the microvascular bed distal to the site of measurement. it can refl ect functional status of the tissue distal to the point of measurement. we investigated whether measuring the renal resistive index (ri) could be helpful in determining which patients will respond to furosemide treatment. methods we included medical icu patients with sepsis and oliguria (urine output < ml/kg/hour) who were prescribed i.v. furose mide. patients with known chronic renal failure, hypovolemia (cvp < mmhg) or severe hypotension (map < mmhg) were excluded. resistive index ( − (end diastolic velocity / maximum systolic velocity)× ) was measured in at least three segmental arteries of both kidneys, the average of all measurements was reported as the result. repeated assessments were viewed as independent if separated by more than hours. furosemide was given intravenously in the dose of mg after ri measurement. positive response to furosemide was defi ned as doubling of hourly dieresis or achieving urine output > . ml/kg/hour after drug administration. we included patients with a total of measurements. in cases patients had positive response to furosemide. median ri in responders was . (range . to . ) and in nonresponders . (range . to . ); p = . . construction of receiver operating characteristic curve showed % sensitivity and % specifi city for the cutoff ri . . no other measured patient characteristic was found to be predictive of response to diuretic treatment. conclusion our results show that the ri could be used to guide diuretic treatment in nonhypovolemic, nonhypotensive septic patients. further studies are needed to confi rm those preliminary results. introduction as a proof of concept, the potential added value of chitinase -like (chi l ) as a more early and specifi c diagnostic parameter for acute kidney injury (aki) was investigated in adult icu patients that underwent elective cardiac surgery. . conclusion sdma appears to be an accurate and precise estimate of gfr and a more sensitive biomarker of renal dysfunction than scr. we predict sdma will perform better than scr as a biomarker of aki. this forms the basis of a future study. introduction growing evidence hints that bidirectional interaction between heart failure and kidney disease and renal insuffi ciency is a strong predictor of mortality as well as causally linked to the progression of heart failure. neutrophil gelatinase-associated lipocalin (ngal) is an early predictor of acute kidney injury (aki). we evaluated the impact of ngal on morbidity and mortality in patients with acute heart failure. methods seventy-six patients presenting with symptoms consistent with acute heart failure (median age years, % male) were enrolled. plasma ngal levels were measured by an elisa at admission and compared with the glomerular fi ltration rate (egfr) and b-natriuretic peptide (bnp) levels. the primary outcome was aki development defi ned by rifle criteria (fall in gfr > % or creatinine rise ≥ % from baseline, or a fall in urine output < . ml/kg/hour) and secondary outcomes were duration of hospital stay and in-hospital mortality. conclusion ngal is emerging as a promising biomarker of aki in the setting of acute heart failure and elevated ngal levels indicate a poor prognosis in this population regarding morbidity and mortality. introduction aki is a common occurrence in sick hospitalized patients, in particular those admitted to intensive care. published data suggest that to % of all critically ill patients develop severe aki and require initiation of renal replacement therapy (rrt) [ , ] . such patients have high mortality rates often exceeding % [ ] . we aimed to review the outcomes of patients admitted to the icu and required renal replacement therapy for aki. we examined whether aetiology of aki, comorbidity burden, hospital length of stay and treatment in icu had any signifi cant association with survival in the study cohort. methods during , patients were identifi ed to have received rrt with aki who were admitted to the icu at the royal wolverhampton hospitals nhs trust. computerised and paper-based case records were examined for these patients to collect the data. akin classifi cation was used to classify the severity of aki. conclusion individuals who develop dialysis-dependent aki in the icu setting in general terms either die or recover. sepsis is the most common association with death. the need for mechanical ventilation and inotropic therapy are both associated with increased incidence of death. introduction this study was to evaluate the effi ciency of the early start of intermittent substitutive renal therapy in patients with polytrauma complicated by multiple organ failure syndrome. methods forty-two patients with polytrauma complicated by multiple organ failure syndrome were included in the study. the age of the patients was from to years ( . ± . years average). all patients were divided into two equal groups. in the control group (cg) the criteria for the start of the substitutive renal therapy were: hyperkalemia ≥ mmol/l, plasma creatinine ≥ μmol/l, diuresis ≤ ml/hour. in the investigation group (ig) there were subtests to carry out the substitutive renal therapy, allowing one to start it in the earlier period of the multiple organ failure progression. these are increase of na + > mmol/l, osmolarity > mosm/l, elevation of the plasma toxicity according to the average molecule concentration ≥ . , diuresis decrease ≤ ml/hour. these were examined: lethality, quantity of the substitutive renal therapy procedures, mechanical lung ventilation duration (mlv), intensive care and hospital duration. the substitutive renal therapy was carried out by ak- -ultra apparatus (gambro, sweden). the statistical analysis was realized using statistica . and the mann-whitney u test. the average quantity of the substitutive renal therapy procedures in the cg was . ± . , in the ig it was ± . (p < . ). the recuperation of the renal excretory functions was on ± day in patients of the cg, and on ± . day in the ig, from the moment of substitutive renal therapy start (p < . ). lethality in the cg was % (nine patients), and in the ig it was % (six patients, p < . ). the duration of the mlv in the cg and ig was ± . days and ± . , respectively (p < . ). in the ig the duration of the icu was lower by %, hospitality duration was lower by % (p < . ). conclusion the effi ciency of the substitutive renal therapy depends directly on the hydroelectrolytic and metabolic changes and toxicosis degrees in the polytrauma complicated by multiple organ failure syndrome. the early start of the dialysis methods treatment allows one to achieve the earlier recuperation of the renal functions and to decrease the lethality level by %. can treatment with the molecular adsorbent recirculation system be the solution for type- introduction it has been suggested that fl uid balance is a biomarker in critically ill patients [ ] . there is a paucity of randomized trials examining the eff ect of daily fl uid balance on outcomes in patients on continuous renal replacement therapy (crrt). the renal trial did not fi nd mortality diff erence with higher crrt dose [ ] , but did not investigate the eff ect of daily fl uid balance on patient outcomes. a post hoc analysis suggested survival benefi t in patients with negative fl uid balance [ ] . in this study, we hypothesize that daily fl uid balance is an independent predictor of mortality in critically ill patients. we conducted a retrospective cohort study in eight icus of a tertiary academic center. we constructed a robust clustered linear regression model of daily fl uid balance and all-cause hospital mortality among critically ill patients receiving crrt. we adjusted the model for the charlson comorbidity score, the daily sofa scores in the fi rst week after initiation of crrt as well the type of icu. results after adjusting for the type of icu and the daily severity of illness, patients who died had on average ml higher daily fl uid balance compared with patients who survived (p < . , % ci = to , ml, figure ). severity of illness predicted daily fl uid accumulation; each additional point of the sofa score predicted an additional ml of extra daily fl uid (p = . ). balance and intradialytic hypotension with mortality and recovery of renal function. methods we conducted a retrospective cohort study among patients aged ≥ years who had rrt initiated and continued for ≥ days in a level or icu at two academic centres, and had fl uid balance data available. patients with end-stage kidney disease, within year of a renal transplant or who had rrt initiated to treat a toxic ingestion were excluded. we used multivariable logistic regression to determine the relationship between mean daily fl uid balance over the fi rst days following rrt initiation and the outcomes of mortality and rrt dependence in survivors. introduction acute kidney injury (aki) is a common complication of critical illness and sepsis [ ] . dosing of antibacterial agents in septic patients is complicated by altered pharmacokinetics due to both acute renal failure and critical illness [ ] . current dosing regimens for administration of gentamicin and vancomycin to septic patients with aki on continuous venovenous hemofi ltration (cvvh) at a fi ltration rate of ml/kg/hour are missing. methods seventeen septic patients with aki treated with vancomycin and seven patients with gentamicin on cvvh were included. in the vancomycin group, patients received the fi rst dose of . g intravenously followed by . g/ hours if not adjusted. in the gentamicin group, patients received a loading dose of mg followed by a maintenance dose every hours. the vancomycin maintenance dose was optimized to achieve auc - /mic ≥ (cmin > mg/l), gentamicin target was cmax/mic of to . maintenance doses were adjusted according to drug level simulation using a pharmacokinetic programme. the median vancomycin total clearance (cltot) was . and . ml/minute/kg on the fi rst and second day of the study. crrt clearance accounted for about to % of vancomycin cltot found in a population with normal renal function ( . ml/minute/kg). vancomycin serum concentrations after the fi rst dose were below the required target of mg/l as early as hours in patients. auc - / mic ≥ ratio was achieved in % of patients on the fi rst day. the median gentamicin cltot was . and . ml/minute/kg on the fi rst and second day of the study. crrt clearance accounted for about % of gentamicin cltot found in a population without renal impairment ( . ml/minute/kg). the target cmax/mic ratio was achieved in % of patients after the fi rst dose. conclusion cvvh at a fi ltration rate of ml/kg/hour leads to high removal of both antibiotics. due to rapid change in patient's clinical status it was impossible to predict a fi xed dosage regimen. we recommend administration of unreduced loading dose and: blood sampling as early as hours after fi rst vancomycin dose; blood sampling to minutes after gentamicin administration and before the next dose; and the maintenance dose should be based on druglevel monitoring. crrt. the aim was to evaluate the eff ects on electrolyte and acid-base status of a new rca-cvvh protocol using an mmol/l citrate solution combined with a phosphate-containing replacement fl uid, compared with a previously adopted rca-cvvh protocol combining a mmol/l citrate solution with a conventional replacement fl uid. methods until september , rca-cvvh was routinely performed in our centre with a mmol/l citrate solution and a postdilution replacement fl uid with bicarbonate (hco - , ca + . , mg + . , k + mmol/l) (protocol a). in cases of metabolic acidosis, not related to inappropriate citrate metabolism and persisting after optimization of rca-cvvh parameter setting, bicarbonate infusion was scheduled. starting from september , in order to optimize buff er balance and to reduce the need for phosphate supplementation, a new rca-cvvh protocol has been designed using an mmol/l citrate solution combined with a recently introduced phosphate-containing replacement fl uid with bicarbonate (hco - conclusion protocol b provided a buff er balance more positive than protocol a and allowed one to adequately control acid-base status without additional bicarbonate infusion and in the absence of alkalosis, despite the use of a standard bicarbonate concentration replacement solution. furthermore, the combination of a phosphate-containing replacement fl uid appeared eff ective to prevent hypophosphatemia. introduction the aim of this study was to establish the intraobserver and interobserver variation of ultrasonographic measurements of the rectus femoris muscle cross-section area (rf-csa). muscle wasting is frequent in the icu, aff ecting more than one-half of the patients with severe sepsis [ ] . muscle mass reduces rapidly, and to % is lost within the fi rst week [ ] . to monitor muscle mass, ultrasound has the benefi ts of being both readily available in the icu and non-invasive. ultrasonographic measurement of rf-csa has an almost perfect correlation with mri (mean interclass correlation (icc) = . ) [ ] and rf-csa is linearly related to maximum voluntary contraction strength in both healthy subjects and copd patients (r = . ) [ ] . methods the study had two purposes: to determine the intraobserver variation for rf-csa by one observer scanning healthy adult volunteers three times each at -day intervals; and to determine the interobserver variation for rf-csa by two observers each scanning adult icu patients on the same day. patients were in a supine position, legs in passive extension. the transducer was placed perpendicular to the long axis of the right thigh over the rf, two-thirds of the distance from the anterior superior iliac spine to the superior patellar border [ ] . rf-csa was calculated by planimetry. at each scan, three measurements were made. for intraobserver variation, the × scans were analyzed using the interclass correlation coeffi cient. for interobserver variation, the three measurements from each observer were averaged and compared using bland-altman statistics. results intraobserver variation: healthy adults, age . ± . years, weight . ± . kg, sex three male/ female. icc: . ( % ci: . to . ). interobserver variation: icu patients, age: ± . years, weight: . ± . kg, sex nine male/six female. bland-altman: bias: - . cm , % limits of agreement - . to . cm . conclusion ultrasonographic measurement of rf-csa is easily learned and quickly performed. it has a very low intraobserver and interobserver variation and can be recommended as a reliable method for monitoring muscle wasting in the icu. in artifi cially fed critically ill patients, adipose tissue reveals an increased number of small adipocytes and accumulation of m -type macrophages [ ] . we hypothesized that nutrient-independent factors of critical illness explain these fi ndings, and also that m macrophage accumulation during critical illness may not be limited to adipose tissue. methods we performed a randomized investigation in a septic mouse model of critical illness and a study of icu patient biopsies. in the critically ill mouse, we compared the eff ect of parenteral nutrition (n = ) with fasting (n = ) on body composition, adipocyte cell size, and macrophage accumulation in adipose tissue, liver and lung. fed healthy control mice (n = ) were studied for comparison. in vivo adipose tissue was harvested after week of illness from human patients (n = ) who participated in a rct on early parenteral nutrition versus tolerating nutrient restriction [ ] , adipose tissue morphology was characterized and compared with healthy controls (n = ). results irrespective of nutritional intake, critically ill mice lost body weight, total fat and fat-free mass. part of the fat loss was explained by reduced ectopic fat accumulation. adipocyte cell number and the adipogenic markers peroxisome proliferator-activated receptor γ and ccat/enhancer binding-protein β increased with illness, again irrespective of nutritional intake. macrophage accumulation with predominant m -phenotype was observed in adipose tissue, liver and lungs of critically ill mice, further accentuated by fasting in visceral tissues. macrophage m -markers correlated with chemoattractant factor expression in all studied tissues. in human subcutaneous adipose tissue biopsies of critically ill patients, increased adipogenic markers and m macrophage accumulation were present irrespective of nutritional intake. conclusion adipogenesis and accumulation of m -macrophages are hallmarks of critical illness, irrespective of nutritional management in humans and mice. critical illness evokes macrophage polarization to the m -state not only in adipose tissue but also in liver and lungs, which is further accentuated by fasting. introduction intravenous magnesium sulfate is commonly used in obstetric patients with pre-eclampsia. following a case of acute symptomatic hypocalcemia we retrospectively examined a cohort of patients to investigate the frequency of hypocalcemia. methods obstetric patients were identifi ed from the icu admissions database and divided into two groups -those treated with magnesium (for suspected pre-eclampsia) and those admitted for other obstetric indications (postpartum hemorrhage, infection, etc.). the baseline calcium values were compared, as well as the lowest and discharge values. albumin and magnesium values were also compared. all comparisons used student's t test. results data were collected on parturients admitted over years including ( %) who received magnesium and ( %) who did not. magnesium-treated women were younger (age: ± vs. ± years, p = . ). the baseline calcium concentrations were similar for the two groups ( . ± . vs. . ± . mmol/l, p = . ). patients receiving magnesium had signifi cantly higher magnesium concentrations ( . ± . vs. . ± . mmol/l, p < . ), and signifi cantly lower calcium concentrations during therapy ( . ± . vs. . ± . mmol/l, p < . ). at discharge, the calcium levels were closer (magnesium treated . ± . vs. untreated . ± . mmol/l, p = . ). the albumin concentrations did not diff er between the two groups (magnesium treated ± vs. nontreated ± g/l, p = . ). normal values: calcium . to . mmol/l, magnesium . to . mmol/l, albumin to g/l. conclusion magnesium therapy was associated with hypocalcemia. potential causative mechanisms include a renal excretion interaction and magnesium-induced suppression of parathyroid hormone secretion. physicians should be aware of the potential for symptomatic hypocalcemia during magnesium therapy. introduction disorders of sodium (na + ) and water homeostasis are common in hospitalised patients. hyponatremia in particular has been associated with worse hospital outcome and length of stay [ ] . we aimed to defi ne the incidence of hyponatremia (serum na + ≤ mmol/l) in our intensive care population and to determine whether it was associated with icu outcome or length of stay. methods demographics, apache ii score, outcome data and admission sodium were retrieved from the ward watcher system in the victoria infi rmary icu for , consecutive admissions from january to present. we divided patients into three groups depending on serum na + (≤ mmol/l, to mmol/l, ≥ mmol/l) and compared apache ii score, length of stay and icu outcome between patients with a low versus a normal serum na + . data were analysed using the chi-squared test, student's t test and the mann-whitney test where appropriate. results of the , patients studied, , had apache ii data and serum na + recorded and so were included for analysis. in total, patients ( . %) had a serum na + ≤ mmol/l and , patients ( . %) had a serum na + of to mmol/l. patients with a low na + had a higher mortality (or = . , % ci = . to . , p < . ), a higher apache ii score ( vs. , p < . ) and higher mean age ( years vs. years, p < . ) than patients with a normal serum na + . mean length of stay of patients with low serum na + was also longer ( . days vs. . days) although this was not statistically signifi cant (p = . ). conclusion in summary, hyponatremia is a useful index of severity of illness in our icu population. whether this is a direct adverse eff ect of low serum sodium levels, or if hyponatremia is simply a marker for 'sicker' patients, is not known. reference introduction the anion gap (ag) is used routinely in the assessment of metabolic acidosis, but can be misleading in patients with hypoalbuminemia and other disorders commonly encountered in intensive care. this approach to acid-base analysis relies on assessment of ph, pco , sodium, bicarbonate and chloride, and can lead to underestimation or overestimation of the true electrochemical status of a patient, as it does not include important ions such as lactate, calcium, magnesium, and albumin. the strong ion gap (sig) is an alternative to the ag and is based upon stewart's physical chemistry approach. however, the sig is cumbersome to calculate. as such, a number of shortcut equations have been developed in an eff ort to approximate the sig. we sought to compare three such equations, the kellum corrected anion gap (kellagc), the moviat equation, and ezsig, in an eff ort to evaluate precision and accuracy [ ] [ ] [ ] . methods we conducted a retrospective chart review of consecutive patients admitted to the icu of george washington university medical center from september to march . of the , patients screened, met inclusion criteria, which included availability of all laboratory components to calculate the sig, obtained within hour of each other. demographic data and serum values for ph, pco , albumin, lactate, sodium, potassium, chloride, bicarbonate, magnesium, phosphate, and calcium were collected. the ag, sig, kellagc, ezsig, and moviat equations were subsequently calculated and compared using pearson correlation and bland-altman analysis. results the mean sig was . ± . . mean values for kellagc, moviat, and ezsig were . ± . , . ± . , and . ± . , respectively. pearson correlation coeffi cients for kellagc, moviat, and ezsig when compared with the sig were r = . , p = . ; r = . , p = . ; and r = . , p = . , respectively. in bland-altman analysis, the mean bias for the test equations versus the sig were: kellagc ( . ), moviat (- . ), and ezsig ( . ). conclusion while all three equations correlated highly with the sig, the ezsig and moviat outperformed the kellagc in pearson and bland-altman analysis. the ezsig had a smaller bias than the moviat equation and a slightly better correlation ( . vs. . ). in the assessment of critically ill patients, ezsig is a candidate scanning equation for the measurement of the sig when all sig components are not available. university-affi liated teaching hospital in tunis. patients admitted within the fi rst hours post burn with greater than % total body surface area (tbsa) burned were enrolled in this study from january to june . exclusion criteria were pregnancy, history of adrenal insuffi ciency, or steroid therapy within months prior to burns. a short corticotrophin test ( μg) was performed, and cortisol levels were measured at baseline (cs t ) and minutes post test. adrenal insuffi ciency was defi ned by a response ≤ μg/dl. relative adrenal insuffi ciency was further defi ned by a baseline cortisol > μg/dl. results patients were assigned into two groups: g (rai, n = ) and g (absence ai, n = ). comparative study of the two groups shows the results presented in table . conclusion rai is common in severely burned patients during the acute phase, and is associated with shock. further prospective controlled studies will be necessary to establish risk factors of rai in severely burned patients and its impact on their prognosis. albumin-adjusted calcium concentration should not be used to identify hypocalcaemia in critical illness t steele , r introduction hypocalcaemia is common in critical illness and accurate assessment is crucial. small studies have shown that albumin-adjusted calcium (adjca) does not accurately predict the ionised calcium (ica) concentration in critically ill patients, yet adjca continues to be widely used [ ] . we investigated the reliability of using adjca to identify hypocalcaemia in a large, diverse population requiring intensive care. methods in a retrospective study of patients admitted to the icus of a tertiary care hospital between january and , ica and ph were extracted from routine blood gas results and total calcium, albumin and phosphate from routine biochemistry results. adjca was calculated using a formula derived from and validated on the local population [ ] . sensitivity, specifi city, positive and negative predictive values (ppv and npv) and area under the curve (auc) of adjca for predicting hypocalcaemia (ica < . mmol/l) were calculated. results in total, patients were included. the mean age was ± years, mean weight ± kg, apache ii score ± and most patients suff ered from pneumosepsis. on the fi rst day of intubation, total and free testosterone levels were extremely low in most patients and remained low during the fi rst week (figure ). β-estradiol levels were elevated on day and decreased during the fi rst week. lh and fsh levels were inappropriately low. all lipoprotein fractions and their apo-proteins were reduced as well as -oh-progesterone, dhea and dheas. in contrast, androstenedione (adione) levels were elevated. this suggests preferential and stimulated synthesis of androstenedione ( figure ). the high β-estradiol levels indicate that androstenedione is shunted into the estrogen pathway, a process that requires high aromatase activity. the high estradiol/total testosterone ratio supports this conclusion. conclusion hyperestrogenic hypotestosteronemia is a frequent fi nding in the acute phase of severe sepsis in male patients with respiratory failure. it is suggested to be caused by decreased androgen production and shunting of androgen to estrogen synthesis as a result of increased aromatase activity. the clinical relevance of gonadal hormone substitution needs further study. introduction melatonin could have a meaningful role in critically ill patients, because of its immunomodulatory, antioxidant and sleep regulation properties; it is reduced in critical illness. the purpose of this study is to describe the endogenous blood melatonin values in icu patients and their correlation with clinical parameters. methods seventy-three high-risk critically ill patients mechanically ventilated for > hours were enrolled. blood samples for melatonin assay were collected between the rd and the th day of the icu stay. melatonin was determined by radioimmunoassay and elisa. the peak and the area under the curve (auc) calculated for each patient were correlated with the clinical parameters using the regression for quantiles test. results endogenous melatonin was found lower in critically ill patients compared with healthy subjects (figure ) , although it showed a great individual variability and it generally maintained a night-time increase. in the univariate analysis the peak was found related to: blood creatinine (p = . ); patients in coma (p = . ); hospital mortality (p = . ). the auc was found related to: saps ii (p = . ); creatinine (p < . ); ast (p < . ); alt (p < . ); hospital mortality (p < . ). peak and auc were found higher in nonsurvivor patients. in accord with previous studies, the endogenous blood melatonin was found reduced in icu patients. the higher melatonin peak in renal failure may be due to an increased distribution volume; greater auc in patients with liver failure could be due to a less effi cient removal of the hormone from the systemic circulation. the fi nding of increased peak and auc in nonsurvivor patients could be due to a hormonal response increased by the body stress reaction, potentially similar to cortisol [ ], or to a higher production of a physiological antioxidant [ ] with a decreased ability to use it. introduction metformin intoxication inhibits mitochondrial complex i and oxygen consumption (vo ). succinate bypasses complex i by donating electrons to complex ii. the aim of this study was to clarify whether succinate ameliorates mitochondrial vo of metforminintoxicated human platelets. methods platelet-rich-plasma was incubated for hours with metformin at a fi nal concentration of mg/l (control), . mg/l (therapeutic dose) or mg/l (toxic dose). platelet vo was then measured with a clark-type electrode, in the presence of glutamate plus malate (complex i electron donors) (fi nal concentration: mmol/l for both) or succinate (complex ii electron donor) ( mmol/l), before and after adding cyanide ( mmol/l). mitochondrial (cyanide-sensitive) and extra-mitochondrial (cyanide-insensitive) vo were corrected for platelet count. the main results, from four preliminary experiments, are shown in figure . in the presence of glutamate plus malate, only platelets incubated with a high dose of metformin had a mitochondrial vo signifi cantly lower than controls. in the presence of succinate, mitochondrial vo of controls did not change signifi cantly whereas that of platelets incubated with metformin did. the eff ect of succinate tended to become larger as the dose of metformin was increased from up to mg/l ( . ± . vs. . ± . vs. . ± . nmol/minute* cells) (p = . ). even so, mitochondrial vo of platelets incubated with the highest dose of metformin did not return to the levels of controls. extra-mitochondrial vo was always the same. introduction metformin, widely used as an antidiabetic drug, activates the amp activated protein kinase, a key regulator of the metabolism providing protection under fuel defi ciency. chronic metformin therapy has been shown in long-term follow-up clinical studies to reduce cardiovascular mortality [ ] . in animal experiments, acute metformin pretreatment has been shown to reduce ischemia-reperfusion injury on cardiomyocytes [ ] . we want to evaluate whether outcomes are aff ected in coronary artery bypass grafting (cabg) surgery. introduction metformin, an oral hypoglycemic drug, belongs to the biguanide class and is now generally accepted as fi rst-line treatment in type diabetes mellitus, especially in overweight patients [ ] . in some predisposing conditions, the use of metformin may result in metforminassociated lactic acidosis (mala), a rare adverse event associated with a high mortality rate [ ] . the aim of this study is to assess risk factors and prognostic factors in patients with mala. [ ] . in our study, a higher plasma concentration of lactate represents the main negative prognostic factor, as pointed out by other studies [ ] . the prothrombin activity, which is considered to be a decisive prognostic factor in the study of peters and colleagues [ ] , was not impaired in patients with poor outcome. introduction stress hyperglycemia in the critically ill is a complex process in which insulin signaling is systematically hijacked to provide energy substrate for metabolic priorities such as cell healing or infection containment. fluctuating levels of plasma glucose are associated with increased mortality in the icu [ ] . we develop a multiscale mathematical model that can characterize the severity of stress hyperglycemia based on a fundamental understanding of the signaling molecules involved. methods insulin resistance following insult has been shown to be driven primarily by the immune response via the cytokine il- [ ] . we created a multiscale mathematical model that links circulating glucose and insulin concentration dynamics from the extended minimal model [ ] to a cellular insulin response model [ ] that captures insulinmediated glucose uptake in an insulin-responsive cell. results inhibitory dynamics driven by il- were incorporated into the cellular model to attenuate an insulin signaling intermediate (insulin receptor substrate ) according to the proposed biological mechanisms. the percentage reduction in glucose uptake as a function of il- concentration was fi t to data from patients who underwent elective abdominal surgery [ ] , shown in figure . the overall multiscale model captures decreased insulin signaling as a result of increased il- levels and the subsequent hyperglycemia that may ensue. introduction hyperglycemia is frequently encountered in critically ill patients, and associated with adverse outcome. improvement of glucose protocol adherence may be accomplished using electronic alerts. we confi gured a non-intrusive real-time electronic alert, called a glyc sniff er, as part of our intensive care information system (icis) that continuously evaluates the occurrence of persistent hyperglycemia and hypoglycemia. conclusion a real-time electronic persistent glycemia sniff er resulted in a signifi cantly higher proportion of normoglycemia, without increasing the variability. furthermore, hypoglycemic events occurred less frequently, and were resolved more timely. smart alerting is able to improve quality of care, while diminishing the problem of alert fatigue. introduction a recent study showed that hyperglycaemia (blood glucose ≥ . mmol/l) in nondiabetic patients hospitalised in a medical icu is associated with increased risk of diabetes [ ] . we investigated a large mixed icu population to confi rm these results. methods this study retrospectively included patients with negative history of diabetes admitted to icus during the year . we excluded patients receiving steroids, with newly diagnosed diabetes and those with end-stage disease. patients were followed-up years after index admission. diagnosis of diabetes within months from the index admission was presumed as revealing dm at inclusion, which excluded the patient. patients who were taking glucocorticoids during the followup period were excluded. diabetics were identifi ed from icd- documentation. propensity score for death (pdead) was computed from either sap (mimicii) or apache iii (hidenic) to assess the risk of death. hypoglycemia was defi ned as avg ≤ mg/dl. avg was computed as the area under the glucose curve throughout icu admission. mortality was examined within bins (each bin is categorized by a mg/dl increase in avg) and was compared between adjacent categories using a chi-square test. the same method was repeated among diabetics, nondiabetics, patients with lower (pdead greater than median) and higher (pdead lower than the presence of decubiti on admission to the icu is associated with longer hospitalizations even after adjusting for age, acuity, and organ supportive therapies. du on admission to icu provide a unique, unambiguous marker of increased resource utilization. introduction the aim was to analyze the prognosis of aids patients with organ dysfunctions at icu admission. methods a prospective cohort study, including all patients with hiv/ aids diagnosis, who were admitted to a specialized icu from november until may . patients with less than hours of icu stay were excluded. demographics and nutritional status were collected. the organ dysfunctions were classifi ed according to the sofa score, and categorized as absent ( sofa point), mild ( to points) and severe ( to points). we expressed numeric variables as median and interquartile interval ( % to %). we performed a multivariate analysis of possible variables associated with hospital mortality (p < . ), and we explored the -day, -day and -day survival of patients with and without independent risk factors. we included patients with hiv/aids admitted to the icu. median age was ( to ) years and % were male. severe malnutrition was common ( %). the cd cell count was ( to ) cells/mm and viral load was , ( to , ) copies/ml; % had at least one opportunistic infection; % had used antiretroviral therapy previous to icu admission. mechanical ventilation was used by % of patients and hospital mortality was %. total sofa score was ( to ) points. cardiovascular dysfunction was the most common on the fi rst day of stay ( %), followed by respiratory ( %), neurological ( %), renal ( %), hematological ( %) and hepatic ( %). cardiovascular and renal dysfunctions presented with higher rate of severe dysfunction ( % and %, respectively). rates of neurological (p = . ), renal (p = . ) and hematological (p = . ) dysfunctions were higher in nonsurvivors. age, cd cell count, malnutrition, and opportunistic infections were included in the multivariate analysis. neurological dysfunction was the independent risk factor for hospital mortality (odds . ( . to . )). the presence of neurological dysfunction was dichotomized: associated or not with primary neurological diagnosis; survival was lower in the patients with neurological dysfunction and without primary neurological diagnosis (log-rank test . in the -day and . in the -day analysis). sixty-day survival was similar in primary and secondary neurological dysfunction, but it remained lower than in patients without neurological impairment. conclusion neurological dysfunction was independently associated with hospital survival, mainly in those aids critically patients without primary neuropathy. results a total of charts were reviewed. in total, were categorized into a (n = ), b (n = ) or c (n = ). d (n = ) consisted mainly of patients with hematological malignancies (n = ) and patients with chemotherapy or immunosuppressive treatment (n = ). the groups diff ered in length of stay with a< b< c. during the fi rst days the sofa score was higher in a compared with c and in b compared with c. the duration of antibiotic therapy was longer in both b and c compared with a. there were no diff erences in -day mortality (a: / = %, b: / = %, c: / = %); however, the proportions of patients dying between days and were higher in b ( / = %) and c ( / = %) compared with a ( / = %). conclusion in this retrospective material it was possible to categorize . % of all patients as having primary, secondary or tertiary sepsis. the categories diff ered in clinical picture at presentation as well as in outcome. a prospective study is warranted to validate the results of this study. conclusion older people represent a growing proportion of the population although their representation in the critical care population remained constant in this -year study. these patients had a slightly higher median apache ii score and . % greater critical care mortality than the younger patients. the majority of survivors were able to go home; however, % died within months with signifi cant life expectancy curtailment, surviving on average only . months after discharge; this has not changed in the last years. those who survived this initial period ( %) had a much better outlook. this information may be vital to patients and physicians when discussing admission to critical care. reference methods potential risk factors for psychological problems were prospectively collected at icu discharge. two months after icu discharge icu survivors received the questionnaires post-traumatic stress symptom scale- (ptss- ) and hospital anxiety and depression scale (hads) to estimate the degree of post-traumatic stress, anxiety and depression. of the responders, % had adverse psychological outcome, defi ned as ptss- > and/or hads subscales ≥ . after analysis, six predictors with weighted risk scores were included in the screening instrument: major pre-existing disease, being a parent to children younger than years of age, previous psychological problems, in-icu agitation, being unemployed or sick-listed at icu admission and appearing depressed in the icu. each predictor corresponded to a given risk score. the total risk score, the sum of individual risk scores, was related to the probability for adverse psychological outcome in the individual patient. the predictive accuracy of the screening instrument, as assessed with area under the receiver operating curve, was . . when categorizing patients in three risk probability groups -low ( to %), moderate ( to %) and high ( to %) risk -the actual prevalence of adverse psychological outcome in respective groups was %, % and %. conclusion the preliminary screening instrument may aid icu clinicians in identifying patients at risk for adverse psychological outcome after critical illness. prior to wider clinical use, external validation is needed. the multiorgan dysfunction syndrome (mods) is a dynamic process involving simultaneously or consecutively two or more organ systems [ ] . the organ dysfunction's degree can be assessed by three severity scores (sofa [ ] , mods [ ] , lods [ ] ), but they have some limitations: they do not allow the evaluation of the clinical course of a patient, they are not reliable in populations diff erent from the reference one, and they do not support clinicians' decisions. because mods implies a systemic infl ammatory reaction leading to microcirculatory dysfunction, our hypothesis was that organ failures follow a predictable sequence of appearance. our aims were to verify the presence of more likely organ failure sequences and to assess an online method to predict the evolution of mods in a patient. the high mortality and morbidity rate of mods in icus can in fact be reduced only by a prompt and well-timed treatment [ ] . methods we selected patients consecutively admitted to the icu of sant'andrea hospital from january to june . the inclusion criteria were at least two organ systems with sofa ≥ , icu length of stay > hours. for each patient we calculated the sofa since the beginning of the inclusion criteria and daily for days. for the statistical analysis we used dynamic bayesian networks (dbns) [ ] . dbns were applied to model sofa changes in order to identify the most probable sequences of organs failures in a patient who experienced a fi rst known failure. we created a dbn for the analysis of mods studying the relations between organ failures at diff erent times. the dbn was made so that each organ failure is dependent on the previous one. we also considered a corrective factor to take account that not all patients completed the observation. using software (genie) we obtained the probabilities of the organ failure sequences. conclusion the use of dbns, although with our limited set of data, allowed us to identify the most likely organ dysfunction sequences associated with a fi rst known one. capability to predict these sequences in a patient makes dbns a promising prognostic tool for physicians in order to treat patients in a timely manner, or to test a treatment effi cacy. introduction assessing whether a critically ill patient should be admitted to an icu remains diffi cult and mortality amongst icu patients is high. to render intensive care with no prospect of success is an immense emotional burden for both patient and relatives, and a great socioeconomic burden for society as well. therefore, validated strategies that can help identify patients who will benefi t from intensive care are in demand. this study seeks to investigate whether preadmission quality of life can act as a predictor of mortality amongst patients admitted to the icu. methods all patients (> years) admitted to the icu for more than hours are included. in order to assess preadmission quality of life, the patient or close relatives complete the short-form (sf- ) within hours after icu admission. mortality is evaluated from icu admission until days hereafter. logistic regression and receiver operating characteristic analyses are employed to assess predictive value for mortality using fi ve models: introduction long-term compromise after traumatic injury is signifi cant; however, few modifi able factors that infl uence outcome have been identifi ed. the aim of this study was to identify acute and early post-acute predictors of long-term recovery amenable to change through intervention. methods adults (> years) admitted to the icu, princess alexandra hospital, australia following injury were prospectively followed. data were collected on demographics, pre-injury health, injury characteristics and acute care factors. psychosocial measures (selfeffi cacy (se), illness perception (ip), post-traumatic stress disorder (ptsd) symptoms and psychological distress) and health status (sf- ) were collected via questionnaire , , , and months post injury. outcomes of interest were the physical function (pf) and mental health (mh) subscales of the sf- . regression models were used to estimate predictors of physical function and mental health over a -year period. a subject-specifi c intercept in a mixed model was used to account for repeated data from participants over time. results participants (n = ) were young (median , iqr to years), predominantly male ( %) and spent on average days in the icu and weeks in hospital. response rates were over % at each follow-up, with responders similar to nonresponders except for being generally older. pf and mh scores improved over time, although the averages remained below the australian norms at months. predictors of pf included ip (β = - . , % ci = - . to - . , p < . ), se (β = . , % ci = . to . , p < . ), hospital length of stay (β = - . , % ci = - . to - . , p < . ), never having been married (β = . , % ci = . to . , p = . ), and having injury insurance (β = - . , % ci = - . to - . , p < . ). predictors of mh included ptsd symptoms (β = - . , % ci - . to - . , p < . ), psychological distress (β = - . , % ci = - . to - . , p < . ), se (β = . , % ci = . to . , p < . ), and unemployment (β = - . , % ci = - . to - . , p = . ). conclusion trauma icu patients experience compromised physical function and mental health months after injury. psychological distress, self-effi cacy and illness perception infl uence outcomes and are potentially amenable to change in response to interventions initiated during hospital stay. introduction swiss diagnosis related groups (swissdrg) have been eff ective since january . the infl uence of this new system on patients' discharge characteristics from a large icu is not known. with the introduction of the drg we expect patients to be discharged after a shorter length of stay on the icu and with higher severity of illness. methods the icu of the city hospital triemli in zurich has an interdisciplinary organization with surgical and internal medical patients, with a maximum occupancy of beds and a center function for the surrounding hospitals. in this ongoing prospective observational study, we collect and analyze the anonymized data of all patients discharged from our icu prior to and after the introduction of the swissdrg. the primary endpoint was the length of stay on the icu in hours. the secondary endpoints were the severity of illness of the patients at the time of discharge, detected by the scoring system saps ii as well as measured by the number of readmissions to the icu. initially all patients were analyzed and in a second step only patients within percentiles to were considered. we also analyzed the subgroups of patients referred internally, patients sent back to referring hospital and patients regionalized to a homebase hospital. the statistics have been done with spss and p < . was considered signifi cant. results we present the results of an -month period, months prior to and months after the introduction of the swissdrg. data of , and , patients were analyzed, respectively. when all patients were included, we found prior to and after the introduction of the drgs a comparable length of stay on the icu (mean ± sd of . ± . hours vs. . ± . hours), no diff erence in the severity of illness at discharge detected by the saps ii (mean ± sd of . ± . vs. . ± . ) and the number of readmissions ( vs. ). there was also no signifi cant diff erence when only percentiles to were included or when the three subgroups were analyzed. conclusion up to now, the introduction of the swissdrg has no infl uence on patients' discharge characteristics from a large icu. data assessment will continue and further data analysis has to be performed. there are only few data on the infl uence of drg on icu patients [ , ] . we expect that the introduction of the drg in switzerland will change the number of admissions from external hospitals to a large icu with a centre function and will infl uence the severity of disease of the admitted patients. the icu of the triemli city hospital in zurich has an interdisciplinary organisation with surgical and internal medical patients, with a maximum occupancy of beds and a centre function for the surrounding hospitals of the region. in this prospective ongoing observational study, we collect and analyse the anonymised data of all patients admitted to our icu from an external hospital during months prior to ( january to december ) and after ( january to december ) the introduction of the drg in switzerland. exclusion criteria are admissions by the emergency department, self-assignments into the hospital and internal relocations. the primary endpoint is the number of admissions from an external hospital to our icu. secondary endpoints are the severity of the disease of the admitted patients, detected by the scoring systems saps ii and apache ii as well as the length of stay in external hospitals before admission. the statistical analysis is descriptive. results we present the preliminary data for months (in each case january to october) before and after the introduction of the drg. we observed an increase of . % ( vs. patients) of admissions to our icu after the introduction of the drg. the severity of disease determined by the saps ii score is unchanged (mean . vs. . points, p = . ). the severity of disease determined by the apache ii score is signifi cantly lower ( . vs. points, p = . ). we also noted that after the introduction of the drg the patients were earlier transferred from an external hospital to our icu (mean time until transfer . vs. . hours), but this value was not signifi cant (p = . ). conclusion up to now the introduction of the drg in switzerland has had a complex infl uence on the number and the kind of patients (lwp, n = ); and patients whose waiting time was equal to or less than that period, short waiting period (swp, n = ). results in total, patients were included, of which belonged to the lwp group ( . %). for the entire cohort, the mean apache ii score was ± , the mean age was ± years, and patients were male ( . %). the lwp group did not show diff erence in the apache ii score ( ± vs. ± , p = . ), but was older ( ± vs. ± , p = . ). lwp also had a higher incidence of primary bloodstream infection ( . % vs. . %, p = . ) and catheter-associated urinary tract infection ( . % vs. . %, p = . ). lwp patients had higher mortality ( . % vs. . %, p = . ) and longer icu los ( ± vs. ± days, p = . ). relative risk for death in the lwp was . ( % ci: . to . ). conclusion despite showing no signifi cant diff erences on apache ii scores from the swp group, patients from the lwp group presented greater incidence of primary bloodstream infection, catheterassociated urinary tract infection, higher mortality outcomes and longer icu los. references intensivists are expected to have many roles during and after a major disaster/catastrophe; that is, triage, intensive care, education for people, and so forth. the roles of intensivists against special disaster or nuclear disaster are studied based on actual experiences. methods several disasters are studied. the fukushima daiichi nuclear plant explosion after the higashinihon earthquake was medically reviewed based on the total -day stay on-site in addition to several days around the site. the chernobyl incident was inspected years after the incident. other nuclear disasters are included. results many serious problems were revealed in the medical teams, which are as follows: inappropriate basic preparedness against large special disasters, including nuclear disaster; lack of appropriate education and training for medical teams against nuclear disasterthat is, most members of japan dmat or the disaster medical assistance team are still laypersons; incorrect standard/rules of japan dmat, which were excessively focused upon cure of the usual type of injury and planned short period or nearly hours, which should be abandoned; and insuffi cient consideration to the weak/vulnerable people or cwap, children, (pregnant) women, aged people, and the poor people/sicker patients. many of them died because of an insuffi cient emergency transportation system from their contaminated houses or hospital. conclusion in order to cope with the special disasters, such as nbc or nuclear, biological and chemical disaster, it is insuffi cient to take makeshift measures or use cheap tricks. working out the systematization of disaster medicine, based upon the academic viewpoints and philosophy/reliability, is essential to protect the people and the nation. variation in acute care burden and supply across diverse urban settings s murthy , s austin , h wunsch , nk adhikari , v karir , k rowan , st jacob , j salluh , f bozza , b du , y an , b lee , f wu , c oppong , r venkataraman , v velayutham , d angus the world bank has warned that the rapid growth of the world's urban population can only be accommodated safely if cities adequately develop key infrastructure, such as the provision of acute care resources. yet, even basic descriptive information on urban acute care supply and demand is extremely limited. we therefore conducted a pilot assessment across seven diverse urban settings across the world. we selected a convenience sample of seven large cities with varying geographical and socioeconomic characteristics: boston, paris, bogota, recife, liaocheng, chennai, and kumasi. to estimate acute care supply, we developed an instrument to collect data on acute and critical care infrastructure. we collected data from municipal authorities and local research collaborators. we expressed the burden of acute disease as the number of deaths due to acute illnesses, estimated from the global burden of disease study. results were expressed as acute care supply and acute deaths per , population and acute care supply per acute deaths. the supply of hospital beds varied from . / , population in kumasi to . / , in boston. icu beds with capacity for invasive mechanical ventilation and intensive nursing services ranged from . / , in kumasi to / , population in boston. the number of ambulances varied -fold between cities. the gap between cities widened when demand was estimated based on disease burden, with a -fold diff erence between cities in icu beds/acute deaths. in general, most of the data were unavailable from municipal authorities. conclusion the provision of acute care services, a key aspect of urban infrastructure, varied substantially across the seven diverse urban settings we studied. furthermore, the local municipal authorities generally appeared to have little knowledge of their acute care infrastructure, with implications for future planning and development. resources may not always be allocated by severity of illness, but by custom or habit, particularly if diff erent groups administer bed control and triage. specialty-specifi c diff erences may exist even when a single team controls triage. variability in resource utilization has important implications for cost-containment and triage. methods patients admitted to a single, closed medical/surgical icu with full-time intensivists and unifi ed triage control in a large, university-affi liated hospital were evaluated during to . patients who died in the icu were excluded. the day of discharge (d/c) and severity using apache iv and its related acute physiology score (aps) component were calculated daily for the fi rst days. trend was assessed across days by cuzick's test. results a total of surgical and medical patients met inclusion criteria. in total, . % of surgical and . % of medical patients had an icu los < ; p = . . admission severity was correlated with length of stay, p = . for both medical and surgical patients. medical patients are sicker on admission and d/c from the icu than surgical patients (p < . ) (figure ). conclusion icu utilization diff ered by patient type even with unifi ed triage control within a single unit. surgical patients were less severely ill on admission to and d/c from the icu. a signifi cant percentage of medical and surgical patients are d/c within day and may be more effi ciently served in a less resource-intensive environment. the reasons for the diff erences in icu utilization for surgical versus medical patients require clarifi cation and may have implications for both resource utilization and cost. introduction interest in safety and clinical outcomes of inpatients has been growing in japan, because the , lives campaign was introduced under the japanese patient safety act in . in this act, an introduction of the rapid response system (rrs) was one of the mainstreams to inpatients' care. however, many japanese healthcare providers cannot understand how to achieve the introduction of the rrs, because there are few who have knowledge of the system. therefore, we developed a new introductory training course for the rrs. the educational eff ectiveness was analyzed through the surveillance questionnaires after the course. methods the educational program includes a lecture series con cerning the outline and management methods, introduction of facilities that have already deployed, small group discussions, and teaching methods-of-training for the medical emergency team using a simulator. evaluation was made in the fi ve-point scale by participants ( physicians, nurses and eight other professions) throughout seven courses. the questionnaires are: a. understanding of rrs, b. knowledge acquisition about patient safety, c. expectation for decreasing the cardiopulmonary arrest by rrs, and d. expectation for decreasing the psychological burden by rrs. results seventy-three participants ( . %) answered the questionnaires. the numbers of participants who scored more than four points were as follows: a. was ( . %), b. was ( . %), c. was ( . %), and d. was ( . %), respectively. the majority of participants obtained the correct knowledge, and had a solid understanding for the rrs. it was evident that providing abundant material and didactic lectures traced from the introduction to management, and collecting and resolving the questions, promoted comprehension. however, there is a limitation of whether or not the participants introduce the rrs into their own institutions. it is essential to improve the course and continue to support the activities of the participants. conclusion our training course may promote the introduction and dissemination of the rrs in japan. introduction teaching of medical ethical issues including confi dentia lity and consent have long been a small part of the medical curriculum. these issues are more complex in an icu where patients may lack capacity. documents such as good medical practice , confi dentiality and the mental capacity act give guidance to medical professionals in these matters in the uk. methods a questionnaire was distributed amongst staff in four icus in south london. results were analysed according to level of experience and background (medical/nursing or allied health professional (ahp)). of questionnaires distributed, the response rate was % ( % doctors, % nurses and % ahp). staff with either less than year experience or greater than years experience had the greatest exposure to the mental capacity act and data protection act, suggesting a gap in knowledge in staff with intermediate experience. knowledge of the caldicott principles were unaff ected by experience, with many experienced respondents having 'no idea' . the majority of respondents (unaff ected by experience) felt that when giving information to relatives face to face, relatives should be kept fully informed. when giving information over the telephone, most doctors felt the response should be tailored to the knowledge of the person being spoken to whilst nurses were split between tailoring the response, giving full information, setting up a password system and not giving any information at all. most respondents felt date of birth and hospital number constituted 'patient identifi able information' . however, experienced staff did not appreciate the importance of unusual diagnosis and clinical photographs as also being able to identify patients. similarly, the majority knew that the patient themselves identifi ed the 'next of kin' but % (unaff ected by experience) felt this was decided by the family and felt the family could decide on resuscitation status. when consent is required for an elective procedure in a patient who lacks capacity, doctors tended to have a better understanding of the need to delay the procedure where possible than nurses, the majority of which felt this could be decided by the next of kin or two consultant doctors. most doctors felt that 'acting in the patient's best interests' would mean doing what would give the patient the best outcome rather than doing what the patient would have wanted (unaff ected by experience). the majority of staff , on answering this questionnaire, felt that they lacked suffi cient knowledge on the subject and most felt annual reminders would be useful. the icu is an environment where issues of consent, confi dentiality and disclosure of information occur daily. staff feel they lack knowledge in these areas that is unaff ected by their experience. we need to ensure that all staff have the necessary knowledge to deal with these situations. introduction alcohol-related hospital and icu admissions are known to have a huge impact on healthcare resources in the uk. excessive use of alcohol is independently associated with sepsis, septic shock and hospital mortality among icu patients. this study assesses the relationship between alcohol abuse and intensive care resource utilisation in a mixed medical, surgical and neurosurgical icu. methods a prospective survey of emergency alcohol-related admissions over a -year period was undertaken at a tertiary university adult general and neurosurgical icu. all patients were screened for acute and chronic alcohol abuse on admission. acute alcohol abuse was defi ned as being intoxicated with alcohol at the time of admission and chronic alcohol abuse was defi ned as chronic alcohol use exceeding recommended uk national guidelines on consumption. the amount of alcohol consumption was obtained, diagnosis on admission, icu and hospital mortality, length of stay, and total cost were recorded. all patients were screened for alcohol-related comorbidities. comparative retrospective data were obtained for the same time period for nonalcohol-related emergency icu admissions. data were analyzed using spss. results in total, . % of patients were admitted with a history of acute/chronic alcohol excess. sixty-seven per cent of alcoholrelated admissions were due to acute alcohol excess. neurosurgical patients admitted due to alcohol excess had higher itu mortality than nonalcohol-related neurosurgical patients: . % versus . % (p = . ), respectively. ninety-three per cent of alcohol-related neurosurgical admissions were caused by acute alcohol intoxication. the intensive care cost was signifi cantly higher for alcohol-related (£ , per patient) compared with nonalcohol-related neurosurgical admissions (£ , per patient). of the medical patients admitted, % of these admissions were due to acute alcohol excess. the cost of intensive care treatment was lower for alcohol-related medical admissions. conclusion this is one of the largest studies of alcohol-related admissions to critical care. our survey confi rms that alcohol-related admissions to the icu are commonplace; however, our frequency is signifi cantly less than previously reported. our study reveals interspecialty variations in demographic data, apache ii scores, mortality and cost of admission. neurosurgical alcohol-related admissions bear higher mortality and result in greater resource utilisation relative to nonalcohol-related neurosurgical admissions. alcohol continues to burden both our patients and critical care. during the fi rst three postoperative days, preoperative ahi > was associated with a prolonged weaning time, a reduced oxygenation index (arterial po /fio ), an impaired kidney function, an augmented infl ammatory response and an overall increased length of stay in the icu. the observed association of high preoperative ahi values with postoperative clinical characteristics remained statistically signifi cant throughout the fi rst three postoperative days. conclusion undiagnosed sdb is highly prevalent among cardiac surgical patients. clinical trajectories of individuals with severe sdb are described by a prolonged recovery of pulmonary function, delayed weaning and a pronounced infl ammatory response after surgery. screening for sdb might identify patients that are susceptible for a complicated postoperative course. introduction a literature review was performed to assess whether massage benefi ts patients postoperatively following coronary bypass grafts (cabg) and or valve replacement/repair. a case study on a patient who had suff ered a hypoxic brain post cardiac arrest was conducted. methods a review on medline and cochrane using search terms massage, cardiac and icu identifi ed nine research papers on the benefi ts of massage postoperatively for the aforementioned patient group. other papers were listed but unrelated to cardiac surgery. none of the nine papers identifi ed for this review were icu specifi c in the title but the icu was mentioned in the main text body. for the purpose of this review the selected papers are researching the eff ects of massage on physiological parameters, anxiety, pain, calm and perceived stress indicators in the cabg and/or valve repair/replacement. out of these nine papers, one is british ( ). five are american ( to ), two are brazilian ( ) and one is an indian paper ( ). all papers are randomised control trials (rcts). papers written prior to were excluded from this literature review. introduction vap has continued to be a major cause of morbidity and mortality in critically ill patients in thailand for decades. previous research found that the implementation of vap care bundles and the educational program can reduce vap incidence in the icu [ ] . in this research we aimed to observe the reduction of vap incidence after the implementation of vap care bundles to icu medical personnel. methods inclusion criteria: all adult surgical patients (> years old) who are on ventilatory support in the surgical icu at siriraj hospital. there are two groups, divided into pre-educational group (group i) and post-educational group (group ii) (n = /group). we also observed the adherence rate to vap care bundles according to the educational program. the pretest and post-test to determine the effi cacy of the educational program were done. the vap care bundles consisted of weaning according to weaning protocol, sedation vacation, headof-bed elevation, measurement of cuff pressures four times/day, % chlorhexidine use for mouth care and emptying of ventilator circuit condensate. results there were . and . episodes of vap per , ventilatordays in group i and group ii, respectively (p = . ). the incidence of vap was . % in group i and . % in group ii (p = . ). there was signifi cant reduction in the length of ventilatory support per person (group i = , group ii = (median), p = . , % ci = . to . ) and mortality rate (group i = . %, group ii = . %, p = . ). there was no signifi cant diff erence in loi, loh and atb cost. the pretest scores were . and . on average from medical personnel in group i and group ii, respectively (p = . ). the head-of-bed elevation adherence rate was improved after the educational program (group i = . %, group ii = . %, p = . ). but the adherence to other bundles was not improved. see tables and . introduction following our study of severe sepsis care across three centres [ ] , we aimed to introduce a rapid feedback mechanism into our rolling audit programme. whilst previous audits raised awareness of severe sepsis, only whole organisation performance was reported and no feedback was given to individual clinicians. it is recognised that such feedback loops can improve clinical practice [ ] . methods patients admitted to critical care ( beds, four units) with a primary admission diagnosis of infection were screened for severe sepsis. pre-icu care was then audited against the surviving sepsis guidelines [ ] . time zero is defi ned as when criteria for severe sepsis were fi rst met. an individualised traffi c-light report was then generated and emailed to the patient's consultant and other stakeholders involved in care (figure ). we aimed to report cases within days of critical care admission. a cumulative report is generated monthly to track organisation-wide performance. since november , cases of severe sepsis have been audited and reported back to clinicians. compliance with antibiotics in < hour has risen from to % and compliance with the pre-icu elements of the resuscitation bundle has risen from to % ( figure ). feedback from clinicians has been encouraging as our reports highlight both positive and negative examples of practice. conclusion individualised feedback on sepsis care has led to substantial improvements in guideline compliance. this concept could be translated to other time-dependent patient pathways. introduction when we talk about safety culture, we speak of being aware that things can go wrong. we must be able to recognize mistakes and learn from them, sharing that information fairly and impartially to try to prevent its recurrence. organizations such as the agency for healthcare research and quality (ahrq) have developed tools to help organizations measure their safety culture and there is little information about our country. methods a descriptive survey study. we sent the spanish version of the questionnaire on patient safety culture (ahrq) to the nursing staff of a polyvalent icu of beds in a tertiary hospital. the questionnaire was sent to nurses, receiving correctly answered surveys (response rate of . %). on a scale of to , . points was obtained to estimate the safety climate for staff respondents. the item best scored was teamwork in the unit ( . %). detected as a fortress, 'communication between nurses at shift changes' ( . % positive responses). the worst rating was obtained in the section on human resources, followed by management support in the fi eld of patient safety. conclusion the perception of safety culture in an icu by nursing staff is far from optimal levels. the team work dimension was identifi ed as the most valued by workers, with the transmission of information on shift changes the most valued item. methods to compare our number of admissions, related activity and case-mix indicators year before and after the geographical change was done. we analyzed our whole number of patients admitted to the icu. we used the chi-square test for categorical variables and one-way analysis of variance for quantitative data. minitab and statbas statistical programs were used. we plotted activity data using the barber-johnson diagram. results a total of , cases ( % males; mean age years) were admitted to our icu during the period ( year before and after the transfer). no diff erences between both groups were founded in demographic data, knaus score and nyha status. regarding their origin, we found more patients admitted from other hospital centers ( vs. %; p < . ). apache ii score increased from . to . % (p < . ) and a slight increase change in saps score was also found ( . to . ; p < . there are several defi nitions of level (l ) care, all refer to a group at risk of clinical deterioration on the ward [ ] [ ] [ ] . there is evidence that ward patients who become acutely unwell often receive suboptimal care [ ] . a regional study commissioned by norfolk, suff olk & cambridgeshire critical care network (nscccn) found that a majority of ward patients may be of l dependency and death rates appear to be correlated with l status. we aim to examine the relationship between the ward distribution of illness acuity, staffi ng and patient outcome. methods data were collected as part of nscccn's observational prevalence study in . ward surveys included acuity of illness, staffi ng levels and skill mix. secondary data were obtained from the patient administration system. emergency, oncology, paediatric and maternity units were excluded. results complete datasets were obtained from , patients in wards in our university hospital over two seasons. this constitutes . % of inpatients from those wards. the mean ward occupancy rate was % ( th to th percentile: % to %). at least one l acuity criterion was scored by ( %) patients, with % from geriatrics followed by orthopaedics ( %) and general surgery ( %). each ward had an average of eight qualifi ed nursing staff (range: to ) equating to an average staff :patient ratio (spr) of . . there was no correlation between ward occupancy and nursing staff (pearson correlation, corr: . ), nor between prevalence of l criteria and staffi ng (corr: . ). the admission rate to intensive care was noted to be higher if the patients were nursed in a ward with lower than average spr compared with higher spr ( . % vs. . %, p = . fisher's exact), but this was not statistically signifi cant. senior nursing (band ) staff were part of the skill mix on only nine of ward surveys. conclusion better outcome with improved spr may be unsurprising, although if proven conclusively would signifi cantly inform workforce planning. lack of correlation between staffi ng levels and occupancy or acuity is also interesting given that we know l criteria are associated with worse outcome. introduction prolonged shifts, workload, stress, and diff erent confl icts are associated with burnout, loss of psychological wellbeing, and probably with an inadequate sleep quality (isq). this relevant disturbance leads to deterioration of the work performance, may impair quality of care provided to patients and increases the incidence of serious adverse events. the objective was to determine the prevalence of isq and sleepiness among uruguayan icu workers, and to evaluate risk factors associated with isq. methods a survey was conducted in six uruguayan icus. the sleep quality was evaluated on the basis of the pittsburgh score (ps), and the sleepiness was identifi ed by the epworth scale. isq was defi ned as ps greater than points and sleepiness by an epworth scale higher than points. icu's, patient's, and clinician's characteristics were assessed for their association with the prevalence of isq. all variables with p < . in univariate analysis were included in a model of ordinal regression. p < . was considered statistically signifi cant. results the survey was completed by icu workers. the global prevalence of isq in icu was . %. isq was observed in % of physicians and % of nurses and nurses assistant (p < . ). sleep medication was used by . % of the icu team. univariate analysis showed that isq was signifi cantly associated with sex ( % vs. %, p = . in women and men, respectively), marital status ( % vs. %, p = . in single and couple workers, respectively), more than hours working in the last week ( % vs. %, p = . ) and less than sleeping hours ( % vs. %, p < . ). multivariable analysis demonstrated that a sleep duration less than hours was independently associated with isq (or = . ; % ci = . to . ; p < . ). furthermore, pathologic sleepiness was present in . % of icu workers. sleepiness was independently associated with use of sleep medication (or = . ; % ci = . to . ; p = . ). conclusion the prevalence of isq and sleepiness is very high among icu workers. those disturbances are independently associated with a sleep duration less than hours, and sleep medication use, respectively. these results highlights that strategies to decrease isq and sleepiness in icu clinicians are urgently needed to improve work performance, improve quality of care provided and prevent adverse events. introduction work-related stress is a potential problem among doctors and is associated with anxiety, depression, reduced job satisfaction, days off work, errors and near misses [ ] . to compare stress levels between diff erent groups of doctors and identify causes of stress, we conducted a survey at university hospital lewisham using the uk health and safety executive's management standards (hsems). hsems is a validated tool developed to identify work conditions that warrant interventions to reduce stress levels across organisations [ ] . methods we conducted an anonymous survey of doctors working in anaesthetics, intensive care, general medicine and accident and emergency (a&e) departments over weeks using the hsems question naire. we also surveyed awareness of the trust's stress management services and whether staff had a designated supervisor or mentor. results were analysed using the hsems analysis tool, which rates stressors with a score from to ( represents the lowest amount of stress). we compared the trust's results against hsems national standards. results seventy-two doctors completed the survey. lowest stress levels were found in doctors working in intensive care (n = , mean . , sd . ). this was followed by medicine (n = , mean . , sd . ), anaesthetics (n = , mean . , sd . ), and a&e (n = , mean . , sd . ), which had the highest stress levels. there was no signifi cant diff erence in stress levels between diff erent grades of doctors. when compared with hsems targets, staff relationships and peer support exceeded national standards. however, management of organisational change and demands at work need improvement. the majority of doctors ( %) had no idea what stress management services were provided by the trust. seventy-nine per cent of doctors had an allocated supervisor or mentor, % of those felt able to approach their supervisor. conclusion these survey results provide reassurance that stress levels in intensive care compare well, despite critically unwell patients and higher mortality rates. we identifi ed areas that need improvement within the trust and will present these results to all relevant departments. with the support of hospital management we will initiate hsems-validated measures to reduce stress. introduction although recent reports show an improvement in outcomes for pediatric hematology patients requiring intensive care [ , ] , respiratory failure remains one of the major risks of pediatric mortality. this study was conducted to assess our hypothesis that mortality associated with respiratory failure is higher than that for other organ failures in pediatric hematology patients admitted to our icu. methods a retrospective study analyzed children with hematological disorders admitted to our icu between april and june . all of the included children required emergency admission and invasive mechanical ventilation. those who did not need intubation, or required intubation only for therapeutic intervention and died within hours of icu admission were excluded. the survival group was defi ned as patients who were discharged from the icu, and the nonsurvival group was defi ned as those who died in the icu or within days after discharge from the icu. the pelod score and pim-ii were applied as morbidity scoring systems results twenty-seven patients, including males and nine females, with a median age of . years (range, . to . years) were analyzed. sixteen patients had leukemia, fi ve had hemophagocytic syndrome, six had solid tumors. the average predicted mortality rate was . % in pim-ii. the survival group included patients ( %) and the nonsurvival group included patients ( %). when the survival group was compared with the nonsurvival group, there were no signifi cant diff erences in the systolic blood pressure ( . ± . mmhg vs. . ± . mmhg; p = . ), the proportion of patients requiring continuous renal replacement therapy ( . % vs. . %; p = . ), and pelod score ( . ± . vs. . ± . ; p = . ). in the nonsurvival group, the pim-ii was higher than that in the survival group ( . ± . vs. . ± . ; p = . ); the pao /fio ( . ± . vs. . ± . ; p = . ) and oxygenation index ( . ± . vs. . ± . ; p = . ) were signifi cantly worse in the nonsurvival group than in the survival group. conclusion the data show that respiratory failure is more strongly associated with mortality than other organ failures in pediatric hematology patients requiring intensive care. these results also suggest that mechanical ventilation intervention in patients with respiratory failure must occur earlier to improve the outcomes for these patients. introduction critically ill patients with haematological malignancies (hm) have high hospital mortality [ ] . severity of illness scores may underestimate mortality in such patients [ ] . methods data collection was conducted at three hospitals from to . patients with any active hm condition were matched with two control patients at two hospitals and with one control at christie hospital. control patients had the same apache ii (within points) and admission diagnosis, but no hm. readmissions and planned surgical cases were excluded. results a total of patients with hm were compared with control patients. seventy-four admissions with hm were identifi ed at two hospitals, and each was matched with two control patients. eightynine admissions with hm from christie hospital were identifi ed. these were matched with controls. patients with hm spent signifi cantly longer in hospital before icu admission (table ) . unit and hospital mortality rates were not statistically diff erent between patients with hm and without hm ( table ) . conclusion unit mortality of critically ill patients with hm was similar to those without hm. hospital mortality in patients with hm was higher than those without hm, although not statistically signifi cant. severity of illness at presentation to critical care is the main determinant of outcome in patients with hm. group when requiring emergency admission to the icu in a tertiary cancer centre. methods a retrospective review of medical notes between and . results a total of patients were admitted, of whom had more than one admission. there were episodes in total. leukaemia n = ; lymphoma n = ; myeloma n = . we compared the characteristics of those who survived icu admission with those who failed to survive to discharge from icu. the two populations were similar (age vs. ; males % vs. %). those who survived had a lower apache ii score on admission ( vs. ; p < . ), lower mean organ failure scores ( vs. ; p < . ), lower requirements of inotropes ( % vs. %; p = . ), ventilation ( % vs. %; p = . ) and fi ltration ( % vs. %; p = . ). there was no diff erence in the prevalence of sepsis at the time of admission ( % vs. %). both groups included patients with prior bone marrow transplant ( % vs. %). of note, icu and -month survival were % and %, respectively. these values are lower than those reported in the literature to date. conclusion icu and -month mortalities were % and %, respectively. patients with haematological malignancy stand to benefi t from intensive care, and should be off ered admission based on clinical need. introduction many evidence-based interventions are not delivered to patients [ ] . this may not be due to a clinician's intentional decisions. the aim of this project was to compare the use of starch before and after removing it as an option from an e-prescribing template. methods our e-prescribing software enables users to prescribe intravenous fl uids from a series of menus. one of these is a template that has several fl uids available to use as a bolus when instructed by a clinician. we removed starch as an option from the template in april . starch could still be prescribed elsewhere on the prescribing system. data on the use of starch from november to november were analysed as the mean volume of starch infused per patient per month. the mean of each set of parameters was then compared using a student's t test. results the mean volume of starch per patient administered before and after electronic prescription options were altered was ml and ml, respectively (p = . ). see figure . conclusion despite clinicians intending to reduce the use of starch it was still regularly administered on our icu. the removal of a default prescribing option dramatically reduced the volume of starch used whilst not restricting the ability to make a conscious choice to prescribe it. adjusting default options has potential to infl uence clinical decisions and ensure more reliable, evidence-based care. introduction early detection of sepsis is important for a suffi cient treatment to reduce mortality. we hypothesized that using modifi ed systemic infl ammatory response syndrome criteria over hour using an electronic software program facilitates the clinical diagnosis of sepsis. methods after irb approval and informed consent we enrolled in this prospective, observational, single-center study , consecutive patients (age . ± . , female/male / ) admitted over a -month period to a surgical icu. a total of them met modifi ed systemic infl ammatory response criteria. patients were monitored by an electronic software program using live data from the laboratory and bedside monitors to detect modifi ed systemic infl ammatory response syndrome criteria persisting over hour. the physicians were blinded to the software program alerts that notifi ed in real time when modifi ed systemic infl ammatory response syndrome criteria were detected and persisted over hour, but did not provide treatment recommendations. results there was a total of modifi ed systemic infl ammatory response syndrome criteria alerts. seventy-four were confi rmed as true sepsis cases by physicians. the overall incidence of sepsis was %. patients were categorized into length of stay < hours, to hours and > hours. the overall sensitivity of our system for detecting sepsis was % and the specifi city was %. the positive predictive value is % and the negative predictive value is %. conclusion real-time alerts using an automated, electronic monitoring of modifi ed systemic infl ammatory response syndrome criteria facilitate the clinical diagnosis of sepsis. beds. intentional rounds or proactive patient rounds were recognised by the royal college of physicians and the royal college of nursing [ ] as structured, evidence-based processes for nurses to carry out regular checks with individual patients at set intervals. the senior nursing team decided to adapt this initiative to the intensive care setting in order to address clinical challenges and provide guidance for shift leaders to focus on key elements of care. methods our intentional rounds, performed once per shift (twice daily), include two components. first, pressure area care -this component involves the shift leader checking whether key elements of pressure sore prevention have been performed. these include completion of the waterlow risk assessment tool [ ] , noting the frequency of repositioning, use of lateral positioning and pressure-relieving pads. second, renal replacement therapy rates -this element was identifi ed as an area for focus after we established that our haemofi ltration fl uid use per hour of therapy was twice that of a near identical clinical setting. this pattern continued even after adopting similar therapy guidelines. the shift leader was guided to check whether therapy rates had been adjusted in line with latest biochemical results. the incidence of pressure ulcers in the months since the initiative began has averaged . per month compared with . per month prior to commencement of intentional rounding. added to the rounding tool at the end of september , rrt rates in the preceding months averaged . ml/kg/hour over hours, an . % reduction from the previous average of . ml/kg/hour. if the pattern of rrt was to continue, this could equate to a cost saving of uk£ , per annum. conclusion the use of a modifi ed targeted intentional rounding tool by the nursing shift leader can help ensure that best practice guidelines are adhered to. this strategy can improve patient outcomes and provide potentially signifi cant fi scal benefi ts. references introduction handovers are often associated with poor communi cation. icu patients with multiple complex problems are ideal to study naturally occurring handovers. however, few studies have been conducted in the icu. methods we conducted questionnaires of physicians and nurses involved and observed handovers in real time of medical icu patients over month. we interviewed of physicians and nurses involved ( . %) and observed real-time handovers ( patients, . %) of patients. mean duration of handover was . (± . ) seconds, . % were face to face and . (± . ) distractions per handover were noted, person-to-person calling being the commonest mode of distraction ( . %). nurses received training during induction in signifi cantly higher numbers, covered allied specialties more and reviewed the patients early (all p < . ). perception of the relative importance of diff erent components of the handover varied signifi cantly between donors, recipients, physicians and nurses. both physicians and nurses seldom ( . %) reviewed the available electronic past medical records of the patient before handover, which in addition to training in handover and overall confi dence level in the management following handover are signifi cantly associated with better satisfaction in univariate analysis; only the confi dence level in patient management remained signifi cant after multivariate analysis. however, agreement between donor and recipient on overall satisfaction was poor (p > . ). nursing handovers were signifi cantly longer than physicians' ( . ± . vs. . ± . seconds, p < . ) but are also associated with higher distractions particularly during evening shifts. conclusion a higher percentage of nurses received handover training; nursing handovers are longer and more inclusive of other components of patient management; perceived importance of components of handover varies among healthcare professionals; distractions are common during handovers and associated with longer duration, by nurses and in the evening shifts; and higher confi dence level in patient's management following the handover is associated with better satisfaction. using telemedicine to provide acute burn and critical care consultation on pediatric and adult burn patients in lviv, ukraine, as well as in triage and transport of critically ill patients from lviv to a tertiary-care facility in the usa for further management. methods using a new telemedicine learning center established at city hospital # in lviv, ukraine, consultations regarding acutely injured burn victims occurred between physicians in ukraine and physicians at shriners hospital and massachusetts general hospital in boston. after the initial presentation, each patient was reviewed on a daily basis by physicians in boston. skype, an internet-based communication tool, was used in communication with the burn center in lviv. radiographic images were scanned and digitalized using an electronic scanner, and jpeg image compression was used to facilitate the transmission of radiographic images and patient charts. informed consent and hippa guidelines were followed in transmitting any patient-related information. results since we have provided consultation on patients in lviv, ukraine, ranging in age from months to years. each patient had an average of six consultations. we present two of these cases as examples of the capabilities of our telemedicine program. the fi rst case involved a -month-old female with % tbsa from scald injury, where telemedicine was instrumental in the primary assessment as well as to arrange a direct assessment from a nearby burn surgeon. the second case resulted from a house fi re with multiple casualties, where physicians in boston were able to utilize telemedicine to guide the initial resuscitation and airway management of three critically burned children, as well as to arrange for transport of one of the victims, an -year-old male with % tbsa, from ukraine to the usa for acute management. multiple diffi culties were overcome in implementing the system between the two countries including: time zone diff erences, language barrier, and diff erent approaches to patient care. conclusion we have established a telemedicine program linking physicians in boston, ma, usa with city hospital # in lviv, ukraine to improve care in pediatric and adult burn patients. our program has provided consultation on patients since , and it highlights the capabilities of telemedicine for acute consultation as well as triage and transport of critically ill patients to tertiary-care facilities. introduction during the last few years the frequency of end-oflife decisions (eold) signifi cantly increased in icus. the method of nurse involvement in making eold is diff erent worldwide [ , ] . the purpose of this study was to analyze opinions of nurses about therapy restriction. we have examined with a multicenter study the opinions of the medical stuff about end-of-life care in hungarian icus. methods we performed a questionnaire evaluation among physicians and nurses of icus about infl uencing factors of therapy restriction, the method of the decision-making process, and the frequency of diff erent eold. the questionnaire, containing questions, was delivered electronically to hungarian icus, and then we analyzed the responses anonymously. the retrieved answers ( physicians, nurses) were analysed using a nonparametric student's test. results a total % of the nurse responders work in university clinics, % in regional centrum, % in municipal hospital, % in other icus. the nurses found both human ( . / vs. . / ) and material ( . / vs. . / ) resources more restrictive factors during patient admission than physicians (p = . , p = . ). nurses working in municipal hospital were more strongly infl uenced by lack of material and human resources ( . / , . / ) than nurses working in university clinics ( . / , . / ), p = . , p = . . younger nurses (working between and years) were more interested in the patient's or surrogate's wishes than older nurses (working more than years). religion did not infl uence patient admission and forego therapy; however, religious nurses compared with atheists and nonpracticing believers preferred to prolong therapy against the patient's will (p = . ). nurses felt that physicians slightly involved them in the end-of-life decision-making process ( . / vs. . / p = . ). conclusion we found that the workplace, level of medical attendance, godliness, work experience, and position in medical staff strongly infl uenced making eold. while limitation of the therapy should be team work, nurses felt their opinions were hardly taken into consideration, although nurses seemed to be more realistic in the decision-making process. introduction more than one in fi ve people admitted to an icu will die there. research has highlighted concerns about support for patients and families and decision-making in this context [ , ] . here, we describe the development and evaluation of a tool to improve palliative care in a -bed general icu in a central london teaching hospital. methods medical research council guidance for complex interventions phase to i comprised literature review, theoretical modelling, observation and qualitative interviews and focus groups with staff and families exploring concerns and views of interventions identifi ed in the literature review. phase ii comprised intervention development, implementation and evaluation of tool feasibility and eff ects using staff survey, observation, audit of records and relative survey. results phase i: staff and family members were interviewed. the short time between decisions for treatment withdrawal and death, plus concerns for support management, communication and decision-making, highlighted a need to ensure excellent psychosocial assessment for all. phase ii: as part of integrated care guidelines, we developed the king's psychosocial assessment and care tool (k-pace). k-pace is used for all patients entering the icu, completed within hours of admission. it contains psychosocial assessment of the family and patient needs, and identifi es key individuals for contact. educational training was supported by k-pace and was implemented in two waves. post-implementation survey of icu staff found that most ( %) were aware of k-pace. eighty-two per cent of nurses but only % of doctors had completed the tool. in total, / ( %) family members responded to the survey (additionally three patients responded). there were high levels of satisfaction for symptom control and psychosocial care but concerns continued regarding explanation of treatment and care. conclusion k-pace is a feasible tool to improve the palliative care of patients and their families in the icu. further refi nement is needed and planned, with consideration of roll-out into the wider medical centre. be concerned involving the family's will. especially, stopping or withdrawing therapy is a quite diffi cult operation in japan because of legal issues. our hypothesis is that some diff erence exists in thoughts between physicians and nurses for terminal patients in the icu. the aim of this study is to know their real thoughts. methods a questionnaire survey was performed on physicians and nurses in our medico-surgical icu. the questionnaire consists of questions with fi ve optional answers related to the thoughts of participants about treatment of hopeless or brain death patients. concretely, the questions were; whether to withhold therapy or not, whether to accept to withdraw therapy or not and with family's will, whether to accept to immediately stop therapy and with family's will, whether to positively or not donate organs from a brain death patient, necessity of icu care for brain death patients, and feeling guilty and stress for stopping or withdrawing therapy. the optional answer has fi ve gradations from 'yes' to 'no' for all questions. the participants were asked to answer the questionnaire by expressing themselves without regarding legal issues or the consensus. it was guaranteed to be anonymous for them in the data analysis. the answers were compared between physicians and nurses. the mann-whitney u test was used for statistical analysis. p < . was considered statistically signifi cant. results there were in total participants (response rate . %) with physicians and nurses. withdrawing therapy was signifi cantly accepted in nurses than in physicians ( % vs. %, p = . ), when the family well understood. withholding therapy should not be operated for brain death patients for physicians ( %), while it seemed a diffi cult judgement for nurses ( %, p = . ). icu care for brain death patients is less necessary for physicians than nurses ( % vs. %, p = . ). there were no signifi cant diff erences in other questions between physician and nurses such as feeling guilty or stress for stopping or withdrawing therapy. conclusion some of end-of-life thoughts in the icu showed diff erences between physicians and nurses. introduction optimal patient evaluations of icu rehabilitation therapy remain unclear. methods one hundred icu patients with acute respiratory failure were randomized to receive early rehabilitation (er) or usual-care (uc). cohort (n = ) received er as one physical therapy (pt) session/day versus uc; cohort (n = ) received er as pt/day with the second session resistance training, versus uc. uc was without er. blood was drawn for cytokines through day . cohort underwent strength and physical functional assessments using the short physical performance battery (sppb), a valid and reliable measure of physical function consisting of walking speed, balance, and repeated chair stands. it is a well-studied composite measure in older persons, but has not been used in icu survivors. small changes of . to . points in the sppb have been shown to be clinically meaningful. conclusion in this pilot study, early icu rehabilitation was safe, and was associated with numerically although not statistically shorter hospital stay, greater strength and improved functional scores. particularly, the sppb demonstrated discriminatory ability in groups of icu survivors with low physical function. future early icu rehabilitation studies should consider icu survivor assessments using the sppb due to its ease, reproducibility and discriminatory ability following icu and hospital discharge. of the demographic variables such as sex, age, education, race and length of stay had an eff ect on perceived quality of care. conclusion the cqi 'r-icu' turned out to be a valid, reliable, sensitive and feasible instrument. large-scale implementation is recommended. actual incidence of global left ventricular hypokinesia in adult septic shock sepsis and the heart cardiovascular biomarkers in the icu plasma endothelin- levels in septic patients the role of endothelium and endogenous vasoactive substances in sepsis nicotinic acetylcholine receptor α subunit is an essential regulator of infl ammation cholinergic agonists inhibit hmgb release and improve survival in experimental sepsis thrombocytopenia in patients in the medical intensive care unit: bleeding prevalence, transfusion requirements, and outcome infl ammation, stress, and diabetes procalcitonin increase in early identifi cation of critically ill patients at high risk of mortality post-operative hypoalbuminaemia and procalcitonin elevation for prediction of outcome in cardiopulmonary bypass surgery enhanced oxygen delivery by perfl ubron emulsion during acute hemodilution iv perfl ubron emulsion versus autologous transfusion in severe normovolemic anemia: eff ects on left ventricular perfusion and function effi cacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (cesar): a multicentre randomised controlled trial nosocomial infections in a cohort of extracorporeal life support patients the epidemiology and outcome of medical emergency team call patients treated with non invasive ventilation early prehospital use of non invasive ventilation improves acute respiratory failure in acute exacerbation of chronic obstructive pulmonary disease bts guidelines for the management of community acquired pneumonia in adults: update smart-cop: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia the smart-cop score performs well for pneumonia risk stratifi cation in australia's tropical northern territory: a prospective cohort study application and comparison of scoring indices to predict outcomes in patients with healthcare associated pneumonia eff ects of continuous positive airway pressure in acute asthma noninvasive positive pressure ventilation in status asthmaticus eff ect of nasal continuous positive airway pressure on methacholine-induced bronchoconstriction the royal college of anaesthetists [www.rcoa.ac.uk/nap ] . diffi cult airway society equipment list cochrane handbook for systematic reviews of interventions. version . . . the cochrane collaboration proceedings book of th congress of the society of critical care medicine early goal-directed therapy in the treatment of severe sepsis and septic shock oxygen transport in cardiogenic and septic shock evidence based of the use of the pulmonary artery catheter: impact data and complications the eff ectiveness of right heart catheterization in the initial care of critically ill patients statistical methods for assessing agreement between two methods of clinical measurement use of central venous oxygen saturation to guide therapy comparison of central-venous to mixed-venous oxygen saturation during changes in oxygen supply/demand systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients intraoperative fl uid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study accidental catheter removal in critically ill patients: a prospective and observational study national patient safety agency: reducing harm caused by the misplacement of nasogastric feeding tubes. npsa/ /psa . nhs national patient safety agency: reducing the harm caused by misplaced nasogastric feeding tubes. npsa/psa ./psa . npsa epidemiology of severe sepsis in the usa: analysis of incidence, outcome, and associated costs of care post-injury multiple organ failure: the role of gut probiotics in the intensive care unit measures of crowding in the emergency department: a systematic review measuring and forecasting emergency department crowding in real time promoting global research excellence in severe sepsis (progress): lessons from an international sepsis registry interhospital transfer of critically ill patients: demographic and outcomes comparison with nontransferred intensive care unit patients outcomes of patients admitted to tertiary intensive care units after interhospital transfer: comparison with patients admitted from emergency departments outcome of critically ill patients undergoing interhospital transfer brain tissue oxygen monitoring and hyperoxic treatment in patients with traumatic brain injury association between early hyperoxia and worse outcomes after traumatic brain injury both hypoxemia and extreme hyperoxemia may be detrimental in patients with severe traumatic brain injury focused assessment with sonography in trauma (fast): should its role be reconsidered? it's higher than you think: chest drains and the th ics tube thoracostomy: complications and its management bts guidelines for the insertion of a chest drain american college of surgeons committee on trauma: advanced trauma life support for doctors, course manual. chicago: american college of surgeons american heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care heart rate response to hemodialysis-induced changes in potassium and calcium levels survival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: a meta-analysis acute intrathoracic gastric herniation as a rare cause of cardiac arrest dw hoelen references . kern kb: optimal treatment of patients surviving out-of-hospital cardiac arrest immediate coronary angiography in survivors of outof-hospital cardiac arrest immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest hypothermia for neuroprotection in adults after cardiopulmonary resuscitation investigation and early management of head injury. london: national collaborating centre for acute care updates in the management of intracranial pressure in traumatic brain injury guidelines for the management of severe traumatic brain injury bundled care for septic shock early prognosis in traumatic brain injury: from prophecies to predictions one-year extended glasgow outcome scale and hospital mortality predictors in patients with severe traumatic brain injury in brazil r turon , fr ferreira , d prado bioavailability of subcutaneous low-molecular-weight heparin to patients on vasopressors prophylactic anticoagulation with enoxaparin: is the subcoutaneous route appropriate in the critically ill? s -s . p massive blood transfusion for obstetric haemorrhage s simmons graphical methods and numerical summaries for presenting results from multiple-treatment meta-analysis: an overview and tutorial the rule regulating ph changes during crystalloid infusion in vivo conditioning of acid-base equilibrium by crystalloid solutions: an experimental study on pigs mixing of medicines prior to administration in clinical practice: medical and non-medical prescribing procedural sedation goes utstein: the quebec guidelines barriers to propofol use in emergency medicine international sedation task force: adverse event reporting tool to standardize the reporting and tracking of adverse events during procedural sedation: a consensus document from the world siva international sedation task force mediators infl amm acute kidney injury in an infant after cardiopulmonary bypass predictive power of serum cistatin c red cell distribution width improves the simplifi ed acute physiology score for risk prediction in unselected critically ill patients red blood cell distribution width is an independent predictor of mortality in acute kidney injury patients treated with continuous renal replacement therapy incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiplecenter epidemiological study eff ect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients acute renal failure in critically ill patients: a multinational, multicenter study impact of etiology of acute kidney injury on outcomes following liver transplantation: acute tubular necrosis versus hepatorenal syndrome cirrhotics admitted to intensive care unit: the impact of acute renal failure on mortality hyponatraemia as a risk factor for hospital mortality albumin-adjusted calcium is not suitable for diagnosis of hyper-and hypocalcemia in the critically ill derivation and internal validation of an equation for albumin-adjusted calcium conclusion succinate ameliorates (but does not return to normal) references . uk prospective diabetes study group p root cause analysis of hypoglycemic events in critically ill patients a mcdonald offi ce of national statistics population data sccm/esicm/accp/ats/sis international sepsis defi nitions conference the sofa (sepsis-related organ failure assessment) score to describe organ dysfunction/failure. on behalf of the working group on sepsis-related problems of the european society of intensive care medicine multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome the logistic organ dysfunction system: a new way to assess organ dysfunction in the intensive care unit visualizing multiple organ failure: a method for analyzing temporal and dynamic relations between failing systems and interventions modelling gene expression data using dynamic bayesian networks disaster medicine compendium team japan critical care university of toronto, canada; intensive care national audit & research centre oswaldo cruz foundation, rio de janeiro, brazil; peking union medical college hospital standards for consultant staffi ng of intensive care units. ics & ibticm standards eff ectiveness of an educational program to reduce ventilatorassociated pneumonia in a tertiary care center in thailand: a -year study multi-departmental system analysis is needed for evaluation of severe sepsis care: a multi-centre study audit and feedback: eff ects on professional practice and health care outcomes surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock levels of critical care for adult patients acutely ill patients in hospital. nice guideline . nice an acute problem? ncepod hse management standards and stress-related work outcomes references . centre for maternal and child enquiries: saving mothers' lives: reviewing maternal deaths to make motherhood safer: - . the eighth report on confi dential enquiries into maternal deaths in the united kingdom % in non-infected patients, p = . ) and . % were under haart ( . % in patients admitted without infection, p = . ). mean cd count at admission: . ± . cells/mm (vs. . ± . , p = . ) ) and . % renal replacement ( . % in no septic patients, p = . ). mean icu and hospital los was ± . days (p = . ). icu mortality: . % ( % in nonseptic patients, p = . ) conclusion sepsis is a common reason for admission to the icu in hiv patients and is accompanied by high mortality. pneumonia is the most frequent source of infection. septic patients are less frequently under haart and have a worse inmune status (lower cd count and higher viral load). despite a higher apache ii, and a higher need for hemodynamic and respiratory support, there is no statistically signifi cant diff erence in icu and hospital mortality between septic and nonseptic patients p survival of critically ill patients with haematological malignancies compared with patients without haematological malignancy r pugh the outcome of haematological malignancy in scottish intensive care units intensive care unit admission in patients with haematological disease: incidence, outcome and prognostic factors intensive care management of patients with haematological malignancy comorbidity as a prognostic variable in multiple myeloma: comparative evaluation of common comorbidity scores and use of a novel mm-comorbidity score icu and -month outcome of oncology patients in the intensive care unit assessing the quality of interdisciplinary rounds in the intensive care unit uni-and interdisciplinary eff ects on round and handover content in intensive care units perspective: physician leadership in quality rcn: ward rounds in medicine. principles for best practice. london: royal college of physicians, royal college of nursing the importance of accurate risk assessment and appropriate intervention in tissue viability handover in the emergency department: defi ciencies and adverse eff ects communicating in the 'gray zone': perceptions about emergency physician hospitalist handoff s and patient safety a national survey of end-of-life care for critically ill patients nurse involvement in end-of-life decision making: the ethicus study p alternative to improve palliative care for all patients and families in critical care units: development and preliminary evaluation following mrc guidance of the king's psychosocial, assessment and care tool i higginson, c rumble half the families of icu patients experience inadequate communication with physicians confl icts between physicians' practices and patients' wishes improving the quality of end-of-life care in the pediatric intensive care unit: parents priorities and recommendations on speaking less and listening more during end-of-life conferences evaluating end of life in ten brazilian pediatric and adults intensive care units parents' perspectives on physician-parent communication near the time of a child's death in the pediatric intensive care unit ) and sepsis (p = . ) were signifi cantly diff erent between responders and nonresponders. responders had a lower mean gcs ( ± vs. ± ), lower amount of edema and were less likely to have had sepsis. in a multiple regression analysis, sepsis, edema, bmi and age explained % of the variance conclusion in patients with a better neurological condition, sepsis and/ or leg edema it was more diffi cult to obtain an adequate quadriceps contraction with nmes. nmes is safe to apply on the icu. references . dh and modernisation agency: the national outreach report. london: nhs modernisation agency pilot study of early rehabilitation strategies in acute respiratory failure d files physical rehabilitation following critical illness long term outcome from critical illness cg critical illness rehabilitation: guideline public health resource unit: critical appraisal skills programme. questions to help you make sense of qualitative research quality measurement at intensive care units: which indicators should we use? handboek cqi ontwikkeling: richtlijnen en voorschriften voor de ontwikkeling van een cqi meetinstrument using the commissioning for quality and innovation (cquin) payment framework -guidance on national goals for refi nement, scoring, and validation of the family satisfaction in the intensive care unit (fs-icu) survey our data showed no benefi t with the use of a potent statin acutely in patients with sepsis or septic shock with regards to improvement in endothelial function. references conclusion the use of the lps-selective adsorption (particularly pmx-f) in patients with severe sepsis leads to improvement of systemic infl ammation and organ dysfunction. references s on these data we will continue to the next phase of this project and test pfc in the prevention of ards alone, and in combination with hs. references conclusion pp seems safe in obese patients and may improve oxygenation more than in nonobese patients. obese patients could be a subgroup of ards patients who may benefi t most from pp. references long-term functional outcome in adults with severe tbi: a meta-analysis m asselin , y lachance , g lalonde introduction two previous classifi cations of acute kidney injury (aki) that are known as rifle criteria and akin criteria have shown that aki is associated with increased morbidity and mortality. diff erences in predicting ability for prognosis, however, have been reported. in , kidney disease improving global outcomes (kdigo) created the new aki criteria, combining rifle and akin criteria. however, such a combination might cause inconsistency among each defi nition in the criteria. we have investigated all of the defi nitions in the new kdigo criteria in detail. methods this is a retrospective historical cohort study including adult patients admitted to the icu (jikei university, tokyo, japan) between january and october . patients undergoing chronic dialysis were excluded. kdigo criteria were applied to all patients to diagnose aki. hospital mortality of patients with aki diagnosed by the defi nitions in the criteria was compared. results a total of , patients were evaluated. aki occurred in . % with standard defi nition of kdigo; . % with creatinine criteria alone; . % with urine output alone. by multivariable analysis, each aki stage was associated with hospital mortality: . %, odds ratio . , for stage ; . %, odds ratio . , for stage ; . %, odds ratio . , for stage . crude hospital mortality stratifi ed by the defi nitions showed increasing trends with stage progression. mortality of the three defi nitions in stage was from . % to . %. stage had two defi nitions and their mortality was . % and . %. stage had fi ve defi nitions and their mortality was from . % to . %. conclusion aki defi ned by the new kdigo criteria was associated with increased hospital mortality. in addition, defi nitions in the kdigo criteria seem to be appropriate because of clear relations between mortality and stage progression. introduction to evaluate whether urinary neutrophil gelatinaseassociated lipocalin (ungal) detects acute kidney injury (aki) earlier than the estimated glomerular fi ltration rate (egfr) in cardiac surgery patients. methods two-hundred and seventy-four adult patients undergoing cardiac surgery were consecutively included from february to december . exclusion criteria were absence of diuresis due to end-stage renal disease or chronic renal failure and a previous cardiac catheterism with i.v. contrast use the week before surgery. four serial blood and urine samples immediately before (pre) and after (post) surgery, and day ( d) and days ( d) after surgery were obtained. ungal was measured in an architect (abbott diagnostics). akin criteria were used to diagnose aki. the study was approved by the local ethics committee and all patients gave informed consent. delta ungal was defi ned as the diff erence between the pre and the posts concentrations. results one-hundred and eighty-one patients ( . %) were men; mean age was . ± . years. valve replacement was performed in , coronary artery bypass graft (cabg) in , valve surgery + cabg in , cardiac transplant in fi ve, aorta aneurism surgery in nine, and other procedures in eight patients. icu and hospital stays were . ± . and . ± . days, respectively. renal replacement therapy (rrt) was required in patients ( . %) within hours of icu stay and in patients ( . %) within weeks. mortality at days was . %. eighty-six patients ( . %) were diagnosed with aki within hours of surgery. area under the roc curve of post ungal for aki diagnosis was . ( . to . ) (p < . ) at an optimal cutoff value of μg/l, introduction acute renal failure (arf) is a common complication in patients admitted to the icu. sepsis is also a well-known risk factor for the development of arf. the combination of arf and severe sepsis was reported to carry a mortality up to % whereas the mortality of arf alone is to %. the aim of the study is to evaluate the role of renal perfusion scanning in detecting the prognosis and outcome of patients with acute renal failure due to sepsis. methods forty patients with acute renal failure due to sepsis, aged between and years, were enrolled in the study. they were monitored for their icu prognosis and outcome after doing renal perfusion scanning. all patients were subjected to routine icu and laboratory investigations including apache ii and sofa score. results thirty patients had normal renal scan and patients had abnormal renal scan. the mortality percentage was higher among abnormal renal scan cases (three out of , %) compared with cases with normal renal scan (seven out of , . %) with nonsignifi cant p value: . . the median length of stay/day in icu was longer among nonsurvivors than survivors . ± , . ± , p value: . (approaching signifi cance). apache ii score was higher in nonsurvivors than survivors . ± . , . ± . , p value: . . the percentage of mortality among cases that needed mechanical ventilation was higher (nine out of , . %) compared with mortality cases that did not need mechanical ventilation (one out of , . % with p value: . ). conclusion arf may exert an independent adverse eff ect on outcome in septic and septic shock patients. it is also a risk factor for mortality. tc- m dmsa scanning is useful for detecting renal dysfunction and help to predict the outcome and prognosis. reference introduction acute kidney injury (aki) complicates over % of icu admissions. episodes of aki are a major risk factor for development or progression of chronic kidney disease (ckd); however, methods of estimated glomerular fi ltration rate (egfr) may be poorly calibrated to survivors of critical illness who may have reduced muscle mass. we hypothesized that egfr may underestimate rates and severity of ckd in icu survivors. methods a retrospective observational study of renal function in all patients admitted to a london teaching hospital icu for ≥ days and surviving to hospital discharge in . we excluded cases with current or new diagnosis of end-stage renal disease or renal transplant. we assessed aki in icu by kdigo criteria and hospital discharge egfr by the ckd-epi equation. for comparison we assumed a normal gfr in a healthy individual as ml/minute/ . m at age decreasing by . per year over age . results we identifi ed patients, of whom had aki. median age was and % were male. median hospital discharge serum creatinine was μmol/l (range to ), median egfr was signifi cantly higher than predicted normal gfr for age at versus predicted (p < . , median diff erence ). in patients who had not had aki discharge the egfr was versus normal predicted (p < . , median diff erence ), suggesting that egfr could be overestimating true gfr in our population by at least a factor of . ( figure ). applying this correction factor to egfrs of patients who had recovered from aki resulted in % more diagnoses of ckd (egfr < ) at hospital discharge ( vs. ). conclusion egfr may overestimate renal function in survivors of critical illness confounding identifi cation of ckd in this at-risk population. prospective studies with measurement of actual gfr are required to assess the burden of ckd in survivors of critical illness. to analyze whether variables related to cardiopulmonary bypass (cpb) infl uence acute kidney injury (aki) occurrence and urinary neutrophil gelatinase-associated lipocalin (ungal) in cardiac surgery patients. methods a total of adult cardiac surgery patients were consecutively included from february to december . exclusion criteria were absence of diuresis due to end-stage renal disease or chronic renal failure and cardiac catheterism with i.v. contrast in the week before surgery. cpb, when performed, was used as standard cpb (scpb) or minicpb. we obtained four serial blood and urine samples, immediately before (pre) and after (post) surgery, and day ( d) and days ( d) after surgery. ungal was measured by architect (abbott diagnostics). akin criteria were used to diagnose aki. the study was approved by the local ethics committee and all patients gave informed consent. results one hundred and eighty-one patients ( . %) were men; mean age was . ± . years. icu and hospital stays were . ± . and . ± . days, respectively. twenty-eight-day mortality was . %. eighty-six patients ( . %) were diagnosed with aki within hours after surgery. in total, patients required cpb ( scpb, minicpb) and did not (no-cpb). seven no-cpb patients ( . %) developed aki and their median ungal post was ( . to . ) μg/l compared with . ( . to . introduction neutrophil gelatinase-associated lipocalin (ngal), measured early after cardiac surgery, has been demonstrated to predict postoperative acute kidney injury (aki). fluid overload potentially masks a subsequent acute renal function loss through dilution of serum creatinine and maintenance of urine output just above akidefi ning criteria. methods we investigated the early postoperative value of ngal versus that of simultaneously measured serum creatinine to predict subsequent fl uid overload. we studied adult cardiac surgery patients in the control arm of a rct (nct ). severe postoperative fl uid overload was defi ned as positive fl uid balance > % of preoperative body weight within hours after surgery. results severe postoperative fl uid overload was present in % of patients with a mean positive fl uid balance of . ± . l. at icu admission, urine ngal predicted severe fl uid overload (auc-roc . ( % ci = . to . )) ( figure ) and mortality (auc . ( . to . )). serum creatinine measured at the same time did not predict severe fl uid overload (auc . ( . to . )) or mortality (auc . ( . to . )). conclusion early ngal-guided adjustments to fl uid management may reduce organ edema after cardiac surgery. findings should be validated in larger cohorts. survivors of acute kidney injury requiring renal replacement therapy rarely receive follow-up: identifi cation of an unmet need cj kirwan, r taylor introduction acute kidney injury (aki) occurs in more than % of icu admissions, requiring renal replacement therapy (rrt) in around % of cases. there is now increasing evidence that aki is a risk factor for the development and progression of chronic kidney disease (ckd); however, when aki occurs as a complication of critical illness appropriate follow-up may be neglected. accordingly, we reviewed the follow-up of renal function in all patients who received rrt on our icu and survived to hospital discharge. methods a retrospective audit of patients who received rrt in a central london adult critical care unit during . results of patients admitted, received rrt with surviving to hospital discharge. we excluded patients who had end-stage renal disease, renal transplant or known glomerular disease. of the remaining aki patients, median age was (range: to ) and ( %) were male. median discharge creatinine was . μmol/l ( to ). forty-two ( %) were off ered follow-up, but in only six cases ( %) was this to nephrology services. twenty-eight attended follow-up (fi ve to nephrology) at a median time of weeks; however, creatinine was measured at in only and in six of these it had risen (by median . μmol/l). in addition, patients had creatinine measured to months post discharge and in eight it had risen (by median . μmol/l). conclusion follow-up of patients who received rrt for aki in the icu was poor and they were rarely referred to nephrologists. where renal function was measured after discharge, there was evidence of progressive renal dysfunction; however, renal function was often not assessed. we propose an algorithm for clinicians to guide follow-up. see figure . introduction hyperglycemia and hypoglycemia have been linked to worse outcomes in critically ill patients. while there is controversy as to the optimal tightness of glucose control in critically ill patients, there is agreement that an upper limit to safe glucose levels exists and that avoiding hypoglycemic episodes should be prioritized. our algorithm can assist clinicians in maintaining blood glucose ([gbl]) within a desired target range while avoiding hypoglycemia. methods our model predictive control (mpc) algorithm uses insulin and glucose as control inputs and a linearized model of glucoseinsulin-fatty acid interactions. to allow the controller model to learn from data, a moving horizon estimation (mhe) technique tailored the tissue sensitivity to insulin to individual responses. patient data ([gbl] measurements, insulin and nutritional infusion rates) were from the hidenic database at the university of pittsburgh medical center. [gbl] measurements, typically hourly, were interpolated to impute a measurement every minutes. the model captured patient [gbl] via nonlinear least squares by adjusting insulin sensitivity (si) and endogenous glucose production (egp ). the resulting virtual patient (vp) is used to evaluate the performance of the mpc-mhe algorithm. results mpc controller performance on one vp is shown in figure . across a population of vps, the average [gbl] under mpc is . mmol/l, the average minimum is . mmol/l, the population individual minimum is . mmol/l and the average absolute average residual error is . mmol/l from a . mmol/l target. with standard intervention, the vps have an average [gbl] of . mmol/l, an average minimum [gbl] of . mmol/l, and a population minimum [gbl] of . mmol/l. algorithm performance deteriorates signifi cantly if the imputed sampling time exceeds minutes, underlining the importance of dynamic variations in insulin sensitivity in this population. conclusion the mpc-mhe algorithm achieves targeted glucose control in response to changing patient dynamics and multiple measured disturbances for a pilot population of vps. furthermore, the mhe scheme updates patient parameters in real time in response to changing patient dynamics. introduction blood glucose (bg) control reduces morbidity and length of stay, and is standard practice in patients undergoing cardiac surgery [ ] . however, maintaining bg in the target range, while avoiding hypoglycemia, is challenging. continuous glucose monitoring (cgm) is a promising technology that may help address these challenges. we investigated the performance and safety of medtronic sentrino®, a newly developed cgm for critically ill adults, in the cardiac icu. methods adult patients with actual or planned cardiac icu admission at a single tertiary center were approached for participation and signed consent. other inclusion criteria were treatment with i.v. insulin (target bg < mg/dl) and life expectancy > hours. after initiation of i.v. insulin, sentrino® subcutaneous glucose sensors were inserted into patients' anterior thighs with planned study participation of to hours. reference bg was collected according to icu protocol, obtained from central venous catheter and analyzed with bedside blood gas analyzer (bga; i-stat®, abbott, usa). sensor glucose (sg) results were displayed, and its predictive alerts and alarms fully enabled. additional reference bgs were obtained during alarms and calibration. all treatment decisions were based on bga data, not on sg values. results a total of patients were enrolled; all successfully completed the study. mean age was years, % were women, % had diabetes. types of surgery were cabg ( %), valve replacement ( %), combined cabg and valve ( %) and cardiac transplant ( %). sg was displayed % of the time during the study, and paired bg-sg points were used for analysis. overall mean absolute relative diff erence (mard) was . %. no diff erences in cgm system accuracy were seen within subgroups of low versus high society of thoracic surgeons (sts) score (mard . % and . % for sts > % vs. ≤ %, respectively) or hemodynamic status (mard . % and . % for compromised vs. stable hemodynamics). consensus grid analysis showed > % of sg values within a/b zones, and % in d/e zones. no device or study-related adverse events were reported. in total, % and % of clinicians found sentrino® easy to use after one and two patients, respectively. conclusion the sentrino® cgm system demonstrated good analytic and clinically relevant accuracy, excellent reliability and safety in critically ill cardiac patients; and was easy to use and integrate in the cardiac icu. future studies are needed to determine whether cgm can improve bg control and reduce hypoglycemia in this patient group. introduction a large rct showed that tight glucose control (tgc), targeting age-adjusted normal fasting blood glucose levels with insulin infusion, decreased morbidity and mortality in critically children [ ] . however, the incidence of hypoglycemia increased substantially in the tgc group. we aimed to assess the eff ect of tgc on the three domains of blood glucose dynamics (hyperglycemia, hypoglycemia and blood glucose variability) and their independent association with mortality in the pediatric icu. methods this is a preplanned substudy of a published rct in one -bed pediatric icu. seven hundred patients (age to years), admitted to the picu between october and december , were randomized to either tgc ( to mg/dl in infants, to mg/dl in children) or to the usual care tolerating hyperglycemia up to mg/ dl (uc). patients with at least two arterial blood glucose measurements were included (uc n = ; tgc n = ). results mean blood glucose levels were lowered from ± mg/dl in the uc group to ± mg/dl (p < . ). the median number of samples per patient did not diff er between uc ( ( to )) and tgc ( ( to )). tgc lowered the hyperglycemic index, a marker of introduction hiv infection is a major public health problem in the world. the use of prophylaxis against opportunist infection and the introduction of haart in increased life expectancies. the therapeutic use of icu resources for hiv patients has been controversial, questioning the admission of these patients especially in advanced stages of the disease, given the poor prognosis. the aim of this study was to determine the experience of the past years in relation to the income of these patients in an icu. methods a retrospective case series consisting of patients with diagnosis of hiv infection (known or unknown) admitted between january and december . we collected demographic and epidemiological data, process of acquisition of the disease, infection status: known or unknown patient infected, whether or not receiving antiretroviral therapy and whether it was eff ective (undetectable viral load at the time of admission), apache ii, cause of admission, need for mechanical ventilation (mv), pathology related or unrelated to hiv infection and icu mortality. results during this period , patients were admitted to the icu, ( . %) hiv-positive. mean apache ii score . , median age years, % men and % spanish nationality. principal risk behavior: addiction drugs injection ( %). seventeen percent of patients did not know who was infected with hiv at the time of admission to the icu. fifty-three percent were not receiving haart. of the patients treated, % were receiving haart (eff ective in % of cases). sixty percent of the patients came from the emergency department of the hospital. main admission diagnoses: acute respiratory failure caused by infection (streptococcus pneumoniae and pneumocystis jirovecii), neurological disorders (coma for illicit drugs and psychotropic) and septic shock. seventy percent required mv. of patients whose hiv infection was not known, . % were admitted for related pathology. in patients of known infection, the pathology associated with hiv was %. average length of stay was days. icu mortality was %. most frequent causes of death: septic shock and multiple organ failure. conclusion depending on the patient and the cause of admission, icu admission may represent an excellent opportunity as a screening method to determine hiv status. given the greater effi cacy of haart at present, most patients with medical or surgical conditions unrelated to hiv infection will be eligible to join the icu. people with hiv can and should benefi t from using reasonable and individualized care in an icu. references conclusion neither immune status-related variables nor comorbidity or infection focus are mortality predictors. poor nutritional status, delayed icu admission, shock or renal failure increase the icu relative mortality risk. tachycardia, hypotension, hypercapnia, acidosis, and oliguria in the fi rst icu hours increase signifi cantly icu mortality. mechanical ventilation is not a mortality predictor. introduction patients with lung cancer commonly require the icu for a variety of acute illnesses related to the underlying malignancy, treatment, or comorbid conditions. icu admission of patients with nonresectable lung cancer has been criticized based on the high mortality rate in this population. however, recent advances in critical care may have changed this scenario. the aim of this study was to identify factors associated with hospital mortality in this group of patients. methods a retrospective study was conducted in consecutive medical and surgical patients with lung cancer admitted to a university hospital icu in são paulo, between and . a univariate analysis was performed to identify associated variables with hospital mortality. selected variables were included in the multivariate model. results from patients included in the study, were medical admissions ( . %) and were surgical admissions ( . %). four hundred and twenty ( %) patients had metastasis, patients ( %) required the icu because of respiratory failure and ( %) because of septic shock. the icu and hospital mortality rates were . % and %, respectively. in the univariate analysis, variables associated with hospital mortality were diagnosis of nonsmall-cell lung cancer, higher charlson morbidity index, medical admission, active neoplasm, vasopressor need at admission to and at hours of icu, acute renal failure at admission, non-invasive ventilation or mechanical ventilation need at admission to and at hours of icu and a higher admission arterial lactate. by multivariate analysis, risk factors of hospital mortality were diagnosis of nonsmall-cell lung cancer (or = . ; % ci, . to . , p < . ), medical admission (or = . ; % ci, . to . , p < . ), acute renal failure at admission (or = . ; % ci, . to . , p < . ), non-invasive ventilation at hours of icu (or = . ; % ci, . to . , p = . ) and mechanical ventilation at hours of icu (or = . ; % ci, . to . , p < . ). conclusion hospital survival in patients with lung cancer requiring icu admission was %. our results provide evidence that icu management may be appropriate in patients with nonresectable lung cancer and appoint risk factors for mortality, helping to better triage cancer patients who will benefi t from icu care. introduction because the prognosis of older patients with cancer may be poor compared with younger patients, it remains controversial whether they benefi t from icu treatment. the objective of this study was to identify factors associated with hospital mortality in older patients with cancer requiring the icu.methods a retrospective study was conducted in consecutive medical and surgical older patients with cancer admitted to a university hospital icu in são paulo, between and . univariate and multivariate analysis were performed to identify associated and independent factors related to hospital mortality. results from , patients with cancer requiring icu at the period, patients were years old or higher. most patients were male ( %), had solid neoplasm ( %), were from medical admission ( %) and % had metastatic disease. the mean age was years (± ). the icu and hospital mortality rates were % and %, respectively. in the univariate analysis, variables associated with hospital mortality were diagnosis of lung cancer, medical admission, active neoplasm, vasopressor need at hours of icu, acute renal failure at admission, mechanical ventilation need at admission to and at hours of icu and a higher admission arterial lactate. by multivariate analysis, risk factors of hospital mortality were diagnosis of lung cancer (or = . ; % ci, . to . , p < . ), medical admission (or = . ; % ci, . to . , p < . ), acute renal failure at admission (or = . ; % ci, . to . , p < . ), mechanical ventilation at hours of icu (or = . ; % ci, . to . , p < . ) and lactate levels at admission (or = . ; % ci, . to . , p < . ). conclusion hospital survival in older patients with cancer requiring icu admission is acceptable. our results provide evidence that icu management may be appropriate in older patients with cancer and appoint risk factors for mortality, helping to better triage cancer patients who will benefi t from icu care. introduction readmission to the icu within hours is an indicator of quality of intensive care and is associated with an increase in mortality. during the last years several groups have published data based on multivariate logistic regression analysis to describe characteristics of patients who needed readmission to the icu. older age, comorbid conditions and severity of illness (apache score) have been among the strongest predictors for readmission. in our icu most patients are in the groups formerly identifi ed as risk groups, which means that stratifi cation and prediction of readmission is diffi cult. because of the unusual high severity of acute and pre-existing illnesses we could not fi nd a data match on comparable patient groups. to investigate whether we could reduce our rate of readmission we therefore decided to perform a qualitative investigation to identify risk factors related to readmission. after identifi cation of the risk factors we will take actions to optimize care and perform ongoing control of the implemented actions to secure that they decreases the rate of readmission. methods retrospective data on patients readmitted to the icu within hours during an -month period (november to june ) were drawn from the critical information system (cis) at icu zit, bispebjerg hospital, denmark. zit is a multidisciplinary unit with beds and to admissions/year and a median saps ii score of . a group of consultants, junior doctors and nurses from the icu and the ward each read the patient fi les with focus on pattern recognition and suggested trigger points to focus on. data on trigger points were then drawn from the cis system and re-evaluated. finally, fi ve key points were identifi ed and serves as basis for future actions. results in a qualitative analysis, readmissions to the icu are related to the following fi ve key points -discharge outside day hours, lack of infection control, stay in icu < days, lung physiotherapy ordinated but not eff ectuated, and several minor organ dysfunctions (atrial fi brillation and acute kidney injury). age, diagnosis, saps ii score or ventilator treatment during intensive care was not diff erent in patients with successful discharge and patients readmitted in this group of patients. conclusion it is possible and suitable to identify key points for future eff orts in a given subgroup of patients using a systematic qualitative approach. conclusion the latest audit follows introduction of a referral system directly to the icu consultant and may account for the reduction in numbers of referrals attended by junior doctors. ed/medicine persist as the main source of referral to the icu. discussion with the referring team consultant may reduce inappropriate referrals. icu staffi ng should not be reduced. [ , ] . this study aims to evaluate the impact of the time elapsed from request until admission to the icu on mortality and icu length of stay (los). methods a retrospective cohort study performed on patients in the icu of hospital regional de samambaia over a period of years, from january to december . the patients were allocated into two groups: patients who waited longer than hours, long waiting period the management of emergency medical admissions has been a subject of recent clinical incidents. there was a high percentage of patients that were referred to the icu by staff in training, and % of referrals were made by junior doctors. consultant physicians had no knowledge of the case in % of referrals. methods a prospective study of cases of referrals and admissions to the icu was conducted at the glasgow victoria infi rmary hospital from to september . a questionnaire was produced relating to the referrals, admissions, seniority involvement, cause of referral, and time of patient review by the icu consultant after icu admission. they were distributed to specialist registrars and the icu consultants. all data were electronically recorded into an excel database. questionnaires that were not completely fi lled were further investigated using patient clinical notes and contact with medical staff . information that may identify a patient or clinician was removed from the questionnaire for confi dentiality purposes. results twenty-one complete questionnaires were collected. fiftyseven percent ( / ) of cases involved admission to the icu. nine percent of the cases involved contacting either a specialist registrar or icu consultant intensivist for assistance in practical procedures. of the patients admitted to the icu, % ( / ) were from medical wards, % were admitted from a&e. consultants were the most common professionals who referred patients to critical care ( %; / ). fourteen percent of cases ( / ) involved the referral of patients into icu by a junior doctor, but only one of the referrals was accepted by the icu intensivist. consultants referred or were aware of the referral in % ( / ) of cases. of admissions, % ( / ) were accepted by the icu consultant and the remaining by the specialist registrars. all accepted were acknowledged by the icu consultant. after admission all of the patients were reviewed by the icu consultant and the time of review after admission was on average hour minutes ( minutes to hours minutes). conclusion there is still an issue with junior doctors referring patients to the icu without the acknowledgement of consultant physicians, resulting in unnecessary admissions and decreased time that icu trainees spend in the icu. there are more appropriate icu admissions when there is involvement with seniority. contact with icu staff to perform practical procedures outside the icu and not about admissions should be explored further. reference introduction the requirements for the intensivist in handling medical technology are constantly growing. it appears necessary to acquire technological competences particularly within the fi elds of medical technology and physics. in the master's degree program 'masteronline physico-technical medicine' , such technical authority is conveyed. to cope with the intensive vocational situation of the physician, this study course follows the blended-learning concept; that is, it is conceived as an online study course with small portions of intermittent presence phases. within the fi rst year, technical basic skills such as 'measurement technique' , 'informatics' , and 'advanced physics' are covered. subsequently, two of various advanced courses in diff erent fi elds of medical technology ('technology in intensive care medicine' , 'technology in surgery' , 'technical cardiology' , 'radiology' , and other) are selected. methods in a survey, we evaluated the study course. therefore, a questionnaire was distributed among all students including the topics course contents, learning materials, time management, supervision, and overall impression. the students were asked to score their agreement to the statements 'content is well structured' , 'content extent is appropriate' and 'content is relevant for medical purposes' on a scale ranging from (fully disagree) to (fully agree). results the students participated actively in this study course with highest motivation and large commitment. the students' workload was in the targeted range of about hours/week. content structure was scored with . ± . , content extent with . ± . and medical relevance with . ± . . conclusion the blended-learning concept fulfi lls the requirements for occupation-accompanying continued medical education, since it off ers the possibility to study self-employed accessing text documents, lecture recordings, and electronic lectures and to convert in concentrated presence phases this knowledge into practical exercises. the fi rst-hour protocol determines the patient-specifi c resources for the start of an icu stay [ ] . staff resources are decided through triage. task charts direct the start of intensive care. our primary goal is to improve patient care. methods a triage method (red, yellow, green) is used to manage icu resources according to the severity of illness. for example, one doctor and one nurse would admit a stable (green) patient coming from the operating room for postoperative icu care. a patient in septic shock with multiple organ disorder (red), on the other hand, would be admitted by a team of two doctors and three nurses. each staff member has a task chart in a checking-list format. also, an admission chart is used to improve data collection. the use of the protocol started as a pilot study in early . simulation education for staff members started in august and has included video recordings and debriefi ng of each simulated icu admission. primary goal-directed therapy goals have been mean arterial pressure (map > mmhg), spo > %, timing of the laboratory tests, start of antibiotics, and blood glucose level to mmol/l. quality indicators have been followed from the data provided by the finnish intensive care consortium. questionnaires for the staff members have been used to evaluate opinions about the fi rsthour protocol. results according to the questionnaire replies, % (n = / ) of our nurses estimate that the fi rst-hour protocol has improved the starting process of our patients' intensive care. twenty percent (n = / ) of the nurses considered that the protocol has no eff ect, and none thought it to be adverse for patient care. corresponding numbers for our icu doctors were % (benefi cial n = / ), % (no eff ect n = / ) and % (adverse). furthermore, . % (n = / ) of the nurses replied that education of new nurse staff members has improved because of the fi rst-hour protocol. a total of . % (n = / ) thought there has been no eff ect, and none considered the protocol harmful for education. for icu doctors the protocol did not bring either clear educational advantages or disadvantages. the variable life-adjusted display curves (the finnish intensive care consortium) have shown improvement in our patient care after the implementation of the fi rst-hour protocol. however, we cannot determine whether it is a signifi cant factor in our intensive care results. conclusion the fi rst-hour protocol has helped us in resource management, start of the patients' intensive care and education of nursing staff . introduction demand for critical care services is increasing yet a comprehensive understanding of how critical care nurses -the largest group of icu direct care providers -impact outcomes remains unclear. the purpose of this study was to determine how critical care nurse education (hospital proportion of bachelor's prepared icu nurses) and icu work environment infl uenced -day mortality of mechanically ventilated older adults. methods a multi-state cross-sectional nurse survey was linked to hospital administrative data and medicare claims ( to ). the fi nal sample included , mechanically ventilated older adults in hospitals. logistic regression modeling was employed to jointly assess the relationship of critical care nurse education, work environment and staffi ng on -day mortality while adjusting for hospital and patient characteristics and accounting for clustering. results a % increase in the proportion of icu nurses with a bachelor's degree or higher was associated with % lower odds of death while controlling for patient and hospital characteristics. patients cared for in better work environments experienced % lower odds of riskadjusted death than those cared for in poorer icu work environments. conclusion patients cared for in hospitals with a greater proportion of bachelor's prepared icu nurses and in better icu work environments experienced signifi cantly lower odds of death. as the demand for critical care services increases, attention to the education level of icu nurses and icu work environment may be warranted to optimize currently available resources and potentially yield better outcomes. introduction information about big hospital geographical transfer is scarce in the medical literature. on february our hospital (in fact, a big university complex) was transferred from their previous location in the north-center of our city towards a new southern peripheral, geographical location. this transfer has been done without any changes in assisted population or nursing/medical staff . the only change was a slight increase in bed number ( to ). our aim is to analyze changes in activity indexes (length of stay, occupancy rate, and so forth) and case mix (origin, previous quality of life and nyha score, main diagnostic groups, severity scores, in-icu and in-hospital mortality). introduction south-east london (sel) presents unique challenges to healthcare providers due to its diverse demographic. the high levels of poverty, immigration and psychiatric illness impact delivery of obstetric care. these were identifi ed as risk factors for poor outcome in the latest cmace report [ ] . the intensive care national audit and research centre (icnarc) produced data on obstetric critical care admissions in [ ] . we reviewed the obstetric critical care admissions in three sel hospitals and compared this with the national average determined in the icnarc and cmace data. methods all critical care admissions in three high-risk obstetric units in sel ( august to july ) were screened for patients who were currently or recently pregnant. we compared local results with national data by icnarc and cmace. there were obstetric critical care admissions in the sel hospitals within the audited time frame. the mean age was . in icnarc data compared with . in sel. average apache ii scores were lower in sel compared with the icnarc data, but length of stay was greater in sel ( . days) compared with icnarc ( . days). haemorrhage was the most common reason for admission in sel, whilst sepsis was the leading cause of death according to the latest cmace report (figure ). conclusion data from national audits may guide protocol, but services must be tailored to local circumstances. sel has unique population characteristics and obstetric critical care admissions diff er signifi cantly from national statistics; in particular, haemorrhage is over-represented in our region. critical care services were generally required for a short period of time; during this period, routine postpartum care may be omitted as treatment priorities diff er. dedicated critical care services on the labour ward may be a way to combine postnatal care with transient high-dependency requirements. this may enhance patient experience and prove cost-eff ective. introduction adverse drug events (ades) are associated with a substantial increase in morbidity and mortality in any setting. because patients in icus were critically ill with complex diseases and varied organ dysfunction, the incidence of ades on such patients is much more crucial than the counterparts. we thus assessed the nature of ades and their infl uence in icus. methods we conducted a prospective cohort study at icus at three large tertiary-care hospitals in japan. trained research nurses reviewed all medical charts, incident reports and reconciliations from the pharmacy to identify suspected ades as well as the background of patients. ades are any injuries that result from the use of a drug. after suspected ades are collected by research nurses, physician reviewers independently evaluated them and classifi ed them as ades or rule violations. we used the validated methodology [ ] . results we included patients with , patient-days. the median age was years and the median length of stay was days. in total, patients ( %) had at least one ade during their stay in the icu. the median icu stay in patients who had ades was days while days in patients who had no ades (p < . ). the median length of the ade onset days since admission was days. regarding the mortality, patients ( %) were dead during their icu stay: deaths ( %) in patients who had ades and three of deaths were caused by an ade, and deaths ( %) in counterparts (p = . ). there were no signifi cant diff erences of patients' characteristics between patients with ades and without ades (table ) . conclusion ades were associated with longer stay and caused a part of death in icu ( %) although they did not increase the mortality. because the characteristics of patients were not associated with ades, early detection and intervention for ades could be important to improve the morbidity and reduce the death caused by ades in icus. introduction in hungary, despite the high level of social support, the number of organ recoveries from deceased donors has not changed signifi cantly. the donation activity shows a positive relationship with the level of education of staff in icus as well as with their attitude towards transplantation. the aim of this cross-sectional study is to estimate the attitude and knowledge of intensive care specialists and nurses as regard donation and transplantation. methods the self-completed questionnaire that consisted of items was completed at the congress of hungarian society of anesthesiology and intensive therapy in . besides the epidemiological data, the intensive care specialists (n = ) and nurses (n = ) were asked about donation activity, participation in an organ donation course, selfreported knowledge of joining eurotransplant, donor management, legislation, and transplantation. the data were analyzed by spss . . results a total of . % of physicians and . % of nurses attended an earlier organ donation course (p < . ). the average age of those who participated in training was signifi cantly higher among doctors (p < . ). fifty-nine percent of doctors and . % of nurses did not even want to participate in such training. donation activity was higher among staff who joined training (p < . ). independently from accepting the presumed consent legislation ( . %), % of physicians agreed with the hospital practice that requests the adult donor's relatives to consent to organ recovery. this standpoint did not depend on donation activity, participation in an organ donation course, opinion about legislation and the nature of staff . a total . % of participants consented to their organ retrieval after death. the staff who participated in an organ donation course had more knowledge regarding the law and ethics of donation (p < . ), donor management (p < . ), living and deceased donor transplantation (p < . ) and joining eurotransplant (p < . ). older professionals had more information about all fi elds (p < . ). nurses had less knowledge concerning donor management (p < . ), law and ethics (p < . ) and deceased donor transplantation (p < . ) than doctors. conclusion education about organ donation needs to be part of specialist training of intensive care staff , and refresher courses every fi fth year as well. the course should include knowledge regarding brain death, donor management and communication with family. this is the fi rst step to improve the number of transplantations. in the uk, three people die each day awaiting trans plantation, due to the unavailability of donor organs. traditionally, donor identifi cation has been restricted to the icu. however, following the uk organ donation taskforce report in [ ] , a number of emergency departments (eds) have been working with specialist nurses for organ donation (sn:od) to identify potential donors and approach their families for consent in the ed. we present our initial experience after the introduction of a sn:od to an irish teaching hospital's ed. methods we conducted a retrospective review of deaths in our ed during a -month period. for those who died in the ed, case notes were reviewed to identify those suitable for organ donation. referral and donation rates were compared in two cohorts, pre and post introduction of a sn:od. fisher's exact test was used to assess diff erences between groups. results ninety-one deaths occurred in the study period. following introduction of the sn:od, referrals increased from zero to eight. of the eight referred, three received consent and were transferred to the icu, two of whom became successful donors. the number of missed potential donors fell from six to one (p = . ). conclusion introduction of a sn:od and a clinical pathway has led to the identifi cation of previously missed potential organ donors in the ed. several patients have subsequently been admitted to critical care solely to facilitate organ donation. reference introduction admission to hospital overnight has been shown to increase mortality and decrease hospital length of stay [ ] . the objective of this study was to determine whether this relationship is valid in patients admitted to our icu, and whether length of stay was aff ected. methods a retrospective data collection identifi ed , patients admitted to a fi ve-bed icu from april to november . data regarding patient age, sex, apache ii score and icu admission date and time were collected along with the length of stay in the unit and hospital. defi nitions of day and night were set to local icu standards of : am to : pm. patients were then separated into two groups and analysed using analyse-it software for excel. results crude icu and hospital mortality rates in patients admitted during the day and overnight were examined. there was no signifi cant diff erence in unit mortality (day . % vs. night . %, or = . , % ci = . to . , p = . ) or hospital mortality (day . % vs. night . %, or = . , % ci = . to . , p = . ). the mean unit length of stay showed no diff erence in patients admitted during daytime compared with those admitted overnight ( . days vs. . days, p = . ). the mean hospital length of stay was decreased in patients admitted during daytime compared with patients admitted overnight ( . days vs. . days, p = . ). the average age of patients was less in those admitted out of hours (night . years vs. day . years, p = <. ). there was no signifi cant diff erence in apache ii scores of patients between the groups (day vs. night , p = . ). conclusion there is no signifi cant diff erence between the mortality of patients admitted overnight and patients admitted during the day to our unit. the hospital length of stay is increased in patients who are admitted overnight to intensive care; however, icu length of stay is not aff ected. adjustment for other confounders such as current bed occupancy and staffi ng ratios during the entire patient stay may help to understand the diff erences seen in the hospital length of stay. introduction interdisciplinary rounds (idrs) in the icu are increasingly recommended to support quality improvement and to reduce confl icts, but uncertainty exists about assessing the quality of idrs. we developed, tested, and applied a scoring instrument to assess the quality of idrs in icus. methods a literature search was performed to identify criteria for instruments about assessing team processes in the icu. then, videotaped patient presentations led by diff erent intensivists were analyzed by delphi rounds. appropriate and inappropriate behaviors were highlighted. the idr-assessment scale was developed and statistically tested. the inter-rater reliability was evaluated by rating nine randomly selected videotaped patient presentations by three raters. finally, the scale was applied to videotaped patient presentations during idrs in three icus for adults in two hospitals in groningen. results the idr-assessment scale had quality indicators, subdivided into two domains: patient plan of care, and process. the domain patient plan of care refl ects the technical performance from the initial identifi cation of a goal to the evaluative phase. the domain process refl ects the team processes that are important to ensure that the appropriate plan of care is agreed, understood, and executed as planned by all care providers. indicators were essential or supportive. the inter-rater reliability of nine videotaped patient presentations among three raters was satisfactory (κ = . ). the overall item score correlations between three raters were excellent (r = . to . ). internal consistency in videotaped patient presentations was acceptable (α = . ). application to idrs led by diff erent intensivists in three icus in two hospitals demonstrated that indicators could be unambiguously rated. the staff and management of all three icus that were rated had considered their idrs to be adequately performed, and they were surprised by these study results. conclusion this study showed that the quality of idrs can be reliably assessed for patient plan of care and process. the idr-assessment scale had satisfactory inter-rater reliability, excellent overall item score correlations, and acceptable internal consistency. our instrument may provide feedback for icu professionals and managers to develop adjustments in quality of care. testing the idr-assessment scale in other icus may be required to establish general applicability. the development of patient-centered care by interdisciplinary teams in the icu has focused attention on leadership behavior. the purpose of this intervention study was to measure the eff ect of leadership training on the quality of performed interdisciplinary rounds (idrs) in the icu.methods in this nonrandomized intervention study, participants included nine intensive care medicine fellow trainees (intervention group) and experienced intensivists (control group). participants in the intervention and control groups previously were untrained in leading idrs in the icus. after each participant led an idr that was videotaped, the fellow trainees participated in a -day leadership training, which was consistent with principles of adult learning and behavioral modeling. after training, each fellow trainee led another idr that was videotaped. quality of the performed idrs was measured by review of videotapes of the idrs lead by intensivists, including patient discussions subdivided into four icus, and assessment with the idr-assessment scale. results comparison of the intervention versus control groups shows that the intervention group has more yes scores on the idr-assessment scale than the control group. this diff erence was signifi cant in of the, in total, quality indicators. conclusion quality of leadership will be reliably trained and measured in the context of idrs in icus. training in a simulation environment, with real-life idr scenarios including confl icting situations, and workplacebased feedback in the preparation and feedback phases, appears to be eff ective to train leadership behaviour. results over a -month period, teleconsultations ( patients) were done. mean age was . years, . % was male and mean apache ii score was . . a total of . % originated from the icu and . % from the ed. main consultation diagnoses were sepsis ( . %); stroke ( . %); survival from cardiac arrest ( . %); trauma ( . %); and acute myocardial infarction ( . %). tm improved diagnosis in . % and infl uenced the clinical management in . % of the consultations. invasive procedures were indicated in . %. life-saving procedures were tm related in seven patients ( . %): stroke thrombolysis (n = ) and limb amputation (n = ). seven patients ( . %) were transferred and submitted to surgical procedures (heart surgery (n = ), neurosurgery (n = ) and liver transplantation (n = )). the majority of the patients remained at hmmd and were discharged. conclusion a tm program is feasible to be implemented in a community hospital. the major benefi t is expertise medical transfer from the tertiary hospital to the community setting, improving diagnosis and management of critical care patients, and avoiding routine transfer to a major urban center. introduction the purpose of our study was to assess the attitudes of slovenian intensivists towards end-of-life (eol) decision-making and to analyze the decision-making process in their clinical practice. methods a cross-sectional survey among slovenian intensivists and intensive care medicine residents from diff erent icus was performed using a questionnaire containing questions about views on eol decision-making. fisher's exact test and the fisher-freeman-halton test were applied to cross-tabulated data; signifi cance level was set at p ≤ . due to the large number of tested hypotheses. the response rate was . % ( questionnaires were returned out of distributed), which represented roughly the same percentage of all slovenian intensivists. termination of futile treatment was assessed as ethically acceptable (p < . ). the statement that there is no ethical distinction between withholding and withdrawing of treatment could not be confi rmed (the answers 'there is a diff erence' and 'undecided' were less frequent, but not statistically signifi cant; p = . ). a do-not-resuscitate order (dnr) was used more often than other withholding treatment limitations (p < . ). a dnr was used most frequently in internal medicine icus (p < . ; compared with paediatric and surgical icus). withdrawal of inotropes or antibiotics was used more often than withdrawal of mechanical ventilation or extubation ( . % vs. . %; p < . ). withdrawal of mechanical ventilation or extubation was more often used in the paediatric icus ( . %) as compared with the internal medicine icus ( . %) and the surgical icus ( %) (p < . ). over two-thirds ( . %) of intensivists were against termination of hydration, which would be more often used in the internal medicine icus (p < . ). thirty-one percent of intensivists used written dnr orders. conclusion termination of futile treatment was found to be ethically acceptable for slovenian intensivists, although they were not convinced that withholding and withdrawing of treatment were ethically equal. a dnr would be used most often. withdrawal of inotropes or antibiotics would be used more often than withdrawal of mechanical ventilation or extubation. termination of artifi cial hydration would be rarely used in practice. of consultant attendees from the uk, completed the survey ( %). for % of consultants there was no formal institutional protocol for withdrawal of futile therapy. when deciding to withdraw therapy, % of consultants routinely seek and document a second opinion. regarding donation after cardiac death (dcd), % of consultants were happy to delay withdrawal to facilitate successful donation, % have already done so in their practice and % routinely withdraw therapy in theatres rather than on the icu. even if it would impact on the care of other patients, % would delay withdrawal of therapy to facilitate dcd. for patients accepted for dcd, % think that some intensivists withdraw more aggressively (in essence, hasten death) in the hope of improving the likelihood of a successful organ donation and % have felt pressurised to withdraw therapy more quickly than their usual practice. furthermore, % experienced pressure to refer a patient for dcd when it they felt it was not appropriate. conclusion this survey confi rms variation in the practice and attitudes to withdrawal of futile therapy amongst uk consultant intensivists. formal protocols were frequently unavailable to guide withdrawal and second opinions were often not sought. nearly one-half of the intensivists delay withdrawal to facilitate donation, even if this may impact on the care of other patients. many intensivists have felt pressure to refer for donation when they feel this is inappropriate and there is a perception that some intensivists may withdraw care more aggressively in those who are accepted for dcd to improve the likelihood of a successful donation. this survey may help inform debate in this ethically challenging area. reference the research shows that the diffi culty of communi cation is a factor that impacts negatively on the grieving process. moreover, it stresses the importance for parents to rediscuss the moment of their child's death with health professionals. references methods a randomised controlled trial was undertaken in adult survivors of icu admission. they were allocated to receive an -week in-hospital supervised aerobic programme consisting of two cycle ergometry and one unsupervised session per week (exercise group) or no exercise (control group). primary outcomes were the anaerobic threshold (in ml o /kg mass/minute), physical function and mental health scores (sf- questionnaire), measured at weeks and . participants were then allocated to focus groups where the interpretation of experiences was compared with outcomes from the pix study. results fifty-nine patients were recruited to the study. the anaerobic threshold increased at week in the exercise group by a clinically and statistically signifi cant amount of ml o /kg mass/minute ( % ci, to ml/kg/minute). there was further improvement in fi tness levels in both groups by week (although no signifi cant diff erence between groups). no signifi cant diff erence in hrqol measures between groups was demonstrated; however, the exercise group did show an improvement in their mental health scores. the focus groups centred on feelings of isolation, abandonment, vulnerability, dependency and reduced physical activity post hospital discharge. many reported a lack of social inclusion as they did not have the energy or confi dence to venture outside. however, those in the exercise group felt that the rehabilitation programme was motivating, built up confi dence, improved fi tness, helped social interaction and gave them a sense of achievement.conclusion the -week exercise intervention resulted in statistically signifi cant improvements in fi tness at weeks while focus group participants highlighted the positive eff ects of the exercise intervention leading to enhanced energy levels, motivation and achievement. psychological benefi ts of the exercise programme are apparent from the focus group, emphasising the important link between physical and mental health. introduction survivors of critical illness often have a prolonged stay on the icu. these patients may suff er from icu-acquired weakness. it has been shown that reduction in muscle mass and muscle strength occurs early after admission to the icu. however, in the very early stage on the icu, patients are often sedated and not able to participate in any active mobilizations. therefore the use of neuromuscular electrical stimulation (nmes) is becoming a treatment of interest in the icu. the aim was to study the feasibility and safety of nmes in a surgical and medical icu of a large, tertiary referral university hospital. methods fifty patients with an expected prolonged stay on the icu of more days (judged on day ) with no trauma or neurological disease were included. they then received daily a nmes session (duo ; gymna, belgium) for minutes on the quadriceps bilaterally during their entire stay on the icu. the main outcome was the ability to produce a contraction of the quadriceps through nmes. the muscle contraction was quantifi ed on a -point scale: (no contraction palpable and visible) up to (contraction very well palpable and visible). patients were classifi ed as responders when an adequate muscle bulk was obtained in ≥ % of the sessions. the potential factors associated with the feasibility were: gender, age, body mass index (bmi), diagnosis of sepsis, barthel index prior to admission to the hospital, apache ii score, glasgow coma scale (gcs), fi ve questions for adequacy, stimulus intensity and leg edema. a multiple regression analysis was performed to identify the factors determining whether or not a contraction could be expected in a patient. safety of nmes was assessed through heart rate, blood pressure, oxygen saturation and respiratory rate. results in % of the patients we were able to achieve adequate muscle contractions in more than % of the sessions. gcs (p = . ), edemaintroduction trauma is the most common cause of morbidity in young people. it has a high social impact both because of the high cost of the acute treatments and because of the physical and psychological consequences that it may cause. a prospective, observational, singlecenter study on quality of life to months after trauma was carried out. the aim of the study is to evaluate life quality after trauma and to identify the most important needs of the patients, in order to improve the level of care after an icu stay and to implement a faster and more eff ective reintegration into the active and productive society. the aim was to analyse the outcomes and patient satisfaction of a recently implemented icu follow-up clinic. these clinics are national institute for clinical excellence recommended [ ] . methods a retrospective analysis of prospective collected data from january to december . the clinic is run monthly by an icu consultant and a critical care outreach sister. criteria to be invited to the clinic are mechanical ventilation ≥ days. patients fi lled an anonymous satisfaction survey after the clinic. results our attendance rate is % ( patients), which is similar to other series reported in the literature. those patients who attended the clinic required a longer length of mechanical ventilation ( . days vs. . ) and a longer length of stay in the icu ( . vs. ) and in hospital ( vs. ). we identifi ed a wide range of physical and nonphysical morbidities on these patients (figure ). we referred them to the appropriate specialities. patients were very satisfi ed with this new service ( figure ). this study aims to quantify the acute exercise response to early passive and active activities in order to inform exercise prescription when designing rehabilitation programmes for the critically ill. critical care survival is often associated with a poor functional outcome [ ] , with recent investigations presenting the case for early rehabilitation in order to optimise functional recovery [ ] . there, remains, however, a scarcity of research investigating the immediate response to exercise and subsequent exercise prescription, in the acute phase following critical illness. methods this study is a prospective randomised controlled trial with a repeated-measures crossover design. eligible participants, requiring mechanical ventilation for or more days, completed two exercise activities routinely used in early critical care rehabilitation, a passive chair transfer (pct) and active sitting on the edge of the bed (soeob). the oxygen consumption and cardiovascular parameters were measured to quantify and compare the exercise response between the two activities. introduction the aim of this study was to investigate the eff ect of a -week exercise programme on outcomes in post-icu patients. with improvements in intensive care medicine, increasing numbers of patients are surviving catastrophic illness [ ] . severe weakness is common in patients with prolonged critical illness and results in considerable morbidity, mortality and healthcare costs [ ] . the nice guidelines rehabilitation in critical care recommend follow-up for post-icu patients and that further research is needed in this fi eld [ ] . methods patients who have been discharged home from hospital following an icu stay of hours or more were recruited to the study. patients were only excluded if they were not considered safe for exercise. baseline measurements were completed prior to stratifi ed (age, gender, apache ii score) random allocation to either the exercise or control group. outcome measures included cardiopulmonary fi tness ( -minute walk test), balance (berg balance scale), grip strength (jamar grip dynamometer) and hospital anxiety and depression (had score). the exercise group completed a -week supervised exercise programme, twice a week for up to hour. in the seventh week, all patients repeated the baseline measurements. an unpaired student's t test was used to compare any diff erences between the control and exercise groups. results at baseline measurements, there were no statistical diff erences in age, gender, length of stays or apache ii scores between the two groups. results indicate that the exercise group (n = ) had signifi cantly greater improvements in cardiopulmonary fi tness (p < . ) and balance (p < . ) compared with the control group (n = ). greater improvements were also evident in anxiety, depression and grip strength in the exercise group, although not statistically signifi cant. conclusion this pilot study highlights that a -week supervised exercise programme can signifi cantly improve cardiopulmonary fi tness and balance in post-icu patients. further recruitment to the study and -month/ -year follow-up is needed. references introduction intensive care patients suff er psychological and physiological distress that may have debilitating and long-lasting eff ects [ ] [ ] [ ] . healthcare professionals are in a position to help avoid or alleviate this stress [ ] . to action this it is important to identify the main stressors from the patient's perspective. a systematic review was performed to provide a list of what patients consider stressors in intensive care. these were then ranked in order to provide an identifi cation tool that can be used to shape appropriate care. methods a systematic review was performed using medline, cinahl, psych info and academic search complete. grey literature was included and searches were not restricted to type of intensive care or country. criteria were used to fi lter those articles that identifi ed the patients' views of their stressor, not the patient experience. eligible articles were critiqued using the critical appraisal skills programme for qualitative studies [ ] and brought together using a narrative synthesis.all of the reviewed studies used a questionnaire as a means to identify what elements on the intensive care patients found stressful. a list of the top- stressors could then be expressed for each study and compared. from this information, a set of guidelines for best practice were devised. introduction this study describes the development and validation of the consumer quality index relatives in icus (cqi 'r-icu'), which aims to measure the satisfaction of relatives and to identify aspect of care that need improvement in the icu in a reliable and valid way.according to the quality standards of the dutch society of intensive care, every icu needs to record the satisfaction of relatives [ ] . at this moment there is insuffi cient insight into the quality of care off ered to relatives on the icu because an evidence-based dutch measurement instrument is missing. methods the cqi 'r-icu' has been developed based on a scientifi c and standardised method [ ] . a mixed design method is used, consisting of qualitative and quantitative survey studies. factor analyses are carried out to determine the underlying structure of the newly developed questionnaire. multiple regression analysis is used to explore the relationship between demographic variables and the perceived quality of care. results in six hospitals the cqi 'r-icu' is sent to relatives after receiving informed consent (n = ), . % of the respondents are the patient's partner. respondents seem to be most satisfi ed with the presence of a professional at fi rst entrance to the icu. the highest need for improvement scores relate to information about meals, parking and other disciplines (for example, social worker, spiritual worker or psychologist). factor analysis shows that quality of care is determined by four clusters of items: support, communication, general information and organisation. the reliability of the cqi 'r-icu' is suffi ciently high, only communication and support are signifi cant predictors of total quality judgement of relatives (adj. r = . ). in addition, there is a signifi cant diff erence in mean total quality judgement between the six hospitals as well as between the four wards within erasmus mc. none we are conducting a cluster randomized trial with two parallel arms to evaluate strategies to improve family satisfaction with the care that themselves and their critically ill relatives receive in the icus of nonacademic brazilian public hospitals. here we report the results of the baseline phase of this trial. methods in this baseline phase, we interviewed the family member most closely involved with the care of critically ill patients who stayed in the icu for at least hours. we applied a form with questions divided into four domains: overall icu experience, communication, decision-making, and questions related to end-of-life care for patients who died in the icu. each question scored from (very poor) to (excellent). the form was adapted from the family satisfaction with care in the icu (fs-icu ). as many questions assessed the quality of intensivist care or communication, the interview was applied by a psychologist or a nurse. results families of patients were interviewed. a total / ( . %) died in the icu. most respondents were satisfi ed with overall icu experience (mean ± sd score . ± . ). however, family satisfaction with communication ( . ± . ) and decision-making ( . ± . ) resulted in somewhat lower scores. most families of patients who died in the icu ( / ( . %)) considered that their relative's life was neither extended nor shortened unnecessarily. also, most of the families believed that their relative did not suff er or suff ered little in the icu ( / ( . %)) and felt supported by the healthcare team ( / ( . %)). conclusion most families were satisfi ed with the care themselves and their critically ill relatives received in the icu. also, most relatives of patients who died in the icu felt that end-of-life care was adequate. although we believe there is much room for improvement in communication, decision-making and support critically ill patients and their families, as their baseline satisfaction with patient care is quite high, it may be hard to demonstrate substantial improvement after interventions. key: cord- -nvzfpntu authors: nan title: research communications of the th ecvim‐ca congress date: - - journal: j vet intern med doi: . /jvim. sha: doc_id: cord_uid: nvzfpntu nan cobalamin concentrations were previously investigated in cats, but little information is available concerning the follow up of hypocobalaminemic cats. we aimed to assess the frequency of hypocobalaminemia within a large cohort of cats with gastrointestinal signs and describe the epidemiological, clinical, biological and follow-up characteristics of hypocobalaminemic cats. cats with gastrointestinal signs and for which a cobalamin assay (simultrac-snb radioassay kit vitaminb Ò , mpbiomedical) was performed between and at the ldhvet laboratory were retrospectively included in the study. ( . %) cats presented for gastrointestinal signs had an hypocobalaminemia: the majority were domestic short hair, % were males ( % castrated) and % females ( % castrated), aged from months to years. the main clinical signs included chronic diarrhea ( %), weight loss ( %), polyuropolydypsia ( %), vomiting ( %), polyphagia ( %), fatigability ( %) and dysorexia ( %) with a median duration of months before diagnosis. cobalamin values ranged from to ng/l (median: ng/l). % of the hypocobalaminemic cats had also a hyperfolatemia (folate > ng/l) at diagnosis. ft was measured in the older cats (> years) and revealed an hyperthyroidism (ft > pmol/l) in % of the cases. / hypocobalaminemic cats had a known clinical and biological follow-up (median time follow-up = days): cobalamin significantly improved month after treatment ( lg/kg im cyanocobalamin in a single dose) for % of the cats, even if % remained hypocobalaminemic. % of the followed cats were clinically improved, of which % with an associated higher cobalamin value. clinical and biological improvement after cobalamin supplementation was significantly associated with an increase in folate concentration (p-value = . ). however, % of the cats with an improved cobalamin value did not show any clinical improvement. hypocobalaminemia is frequently observed in cats as a consequence of gastrointestinal signs. cobalamin concentrations could be used as an indicator of the severity of various gut diseases more than a primary cause, because one third of the cats did not show any clinical improvement despite an improved cobalamin value. a hyperfolatemia appearing after treatment of hypocobalaminemia seems to be a good indicator of a clinical improvement associated with a return to a normal intestinal integrity. disclosures: no disclosures to report. cobalamin malabsorption is common in old cats with weight loss, macronutrient malabsorption and enteric protein loss due to idiopathic chronic enteropathy, ice (patil ap and cupp cj. proc. nestle-purina compan anim nutr summit, - , , williams and czarnecki-maulden, proc rd ecvim-ca congress, ) . high dose oral cobalamin supplementation reverses subnormal serum concentration within week but serum cobalamin can become undetectable within as little as month following cessation of supplementation (williams and czarnecki-maulden, proc rd ecvim-ca congress, ). the objectives of this study were to determine if serum cobalamin concentrations in cats with ice and the response to oral supplementation and withdrawal are associated with differences in the intestinal microbiome. the study evaluated cats older than years of age that were being fed nutritionally complete and balanced diets that included a fortification of vitamin b . thirty-one of these cats had ice demonstrated by increased fecal fat (> %), subnormal fat digestibility (< %), subnormal serum cobalamin or increased serum methylmalonic acid, but without exocrine pancreatic insufficiency as assessed by assay of serum trypsin-like immunoreactivity. serum cobalamin was determined by competitive binding assay and the fecal microbiome by roche sequencing and analysis by qiime (quantitative insights into microbial ecology), pca (principal component analysis) and opls (orthogonal projections to latent structures). of these ice cats were supplemented with oral cobalamin for months. serum cobalamin concentrations were determined monthly during supplementation and for months after cessation of supplementation. in the cats there was a significant (p ≤ . ) association between serum cobalamin and the fecal microbiome, with species being positively correlated with serum cobalamin concentration and species being negatively correlated. serum cobalamin was subnormal (< ng/l) in of the ice cats at the start of the supplementation study and subsequently became normal or supranormal. within to months after cessation of supplementation serum cobalamin was subnormal in the original cats and additional cat. it is concluded that serum cobalamin concentration and the responses to oral supplementation and subsequent cessation of supplementation are significantly associated with the composition of the intestinal microflora as reflected in the fecal microbiome. disclosures: the study described in the abstract was performed at nestle-purina facilities and funded entirely by nestle-purina. david williams is a consultant and adviser for nestle-purina, idexx laboratories, and the gastrointestinal laboratory at texas a&m university. he receives royalties from idexx laboratories and has given continuing education lectures sponsored by nestle-purina. inflammatory bowel disease (ibd) is a common cause of chronic gastrointestinal signs in cats. typically, lymphoplasmacytic inflammation is found in biopsies, but a subset of cats with ibd has neutrophilic inflammation. the clinical significance of neutrophilic infiltration is unclear. the aim of this retrospective study was to use fluorescence in situ hybridisation (fish) to look for the presence of any microorganisms within the intestinal epithelium of cats diagnosed with ibd and then to identity those micro-organisms. our hypothesis was that neutrophilic enteritis in cats would be associated with intestinal mucosal invasion by microorganisms, and specifically by campylobacter spp. the study included cats presented to the small animal hospital, langford veterinary services for investigation of gastrointestinal disease which had duodenal biopsies collected endoscopically. thirteen cats were diagnosed with neutrophilic inflammation (study group) and cats with lymphoplasmacytic inflammation (control group). fluorescence in situ hybridisation (fish) targeting either all eubacteria or campylobacter jejuni, coli and upsaliensis was used to identify and count intra-mural bacteria in the intestinal biopsy samples. neutrophils were detected simultaneously using a fish probe to neutrophil elastase. the pixel distance between different bacterial species and neutrophils was measured. all animals in both groups showed the presence of intra-epithelial bacteria and the number of bacteria present did not differ between the control and study groups. similarly, campylobacter jejuni and upsaliensis were present in some animals in each group but numbers did not differ between the groups. in contrast, campylobacter coli was present in significantly more study cats than control cats (p = . ; chi-squared test) and the study group showed significantly higher numbers of c. coli in the tissue than the control group (p = . ; mann-whitney u test). co-localisation of neutrophils and c. coli was demonstrated with c. coli closer than any of the other bacteria to the neutrophils. this association was statistically significant (p < . ; mann-whitney u test). the role of the intestinal virome in health and disease is gaining increased attention in human medicine. the use of next generation sequencing (ngs) technologies has allowed identification of diversity and distribution of the virome. these approaches can equally be applied to dogs.this study aimed to identify and characterise the virome present in faeces of dogs with chronic enteropathy (ce) compared to the virome of healthy dogs (hd). faecal samples were evaluated from hd and dogs with ce ( food, antibiotic and steroid responsive) using a ngs approach. a viral enrichment protocol, using a series of centrifugation, endonuclease treatments and bacterial filtration were performed. the enriched viral dna and rna were extracted and amplified using sequence-independent single-primer amplification (sispa) protocol, and subsequently sequenced by ngs using the illumina miseq platform at the agrf. two bioinformatic pipelines were used to analyse the viral population. after selecting high quality reads and removing dog and bacterial sequences, sequence information was compared against reference databases. we identified a total of , viral contigs, with , dna viral sequences and , rna sequences across all dog samples. the majority of viral hits from both groups of faecal samples were bacteriophage ( . % hd and . % ce), from several families mainly from the caudovirales order. after all analyses, only viral eukaryotic families were identified across all samples. two groups of sequences similar to known virus families, reoviridae and papillomaviridae, were identified in both groups (hd / and / and ce / and / , respectively). sequences similar to picornaviridae were identified only in one dog with ce and sequences similar to adenoviridae, parvoviridae and coronaviridae were identified only in healthy dogs ( / each).further genomic characterisation and phylogenetic analysis was undertaken on viruses. the genome segments of a rotavirus (reoviridae) isolate were determined. similarly, the sequence of the entire coding region of a kobuvirus (picornaviridae) isolate was determined. preliminary analyses indicated that all rotavirus gene segments exhibited between % - % nt homology to previously reported canine rotaviruses. the kobuvirus sequence exhibited moderate nt homology ( %) to previously described genomes and clustered with other canine kobuvirus sequences available in genbank. in conclusion, viral sequences from a range of different virus families, including both rna and dna families, and known pathogens were identified and characterised, and the largest proportion of viral contigs identified belonged to bacteriophages. disclosures: no disclosures to report. endoscopy is widely used to perform targeted and minimally invasive biopsies for histopathology of the gastrointestinal tract of dogs and cats. only a few studies have focused on the diagnostic contribution of cytological samples of the alimentary tract. the aims of this study were to compare 'imprint' and 'squash' techniques to obtain valuable cytological samples from endoscopic biopsies, and to evaluate the potential interest of cytology compared to histology in reaching the definitive diagnosis. eighteen dogs and cats presenting gastrointestinal symptoms that underwent an endoscopy of their alimentary tract were prospectively included. five biopsies of each area of interest were collected for regular histopathological analysis. an additional biopsy from each area was used to obtain cytological specimens by imprint and squash techniques. cytology samples were all reviewed blindly by the same pathologist. cytology samples of insufficient quality were considered as 'non diagnostic' and were excluded from further analysis. diagnostic conclusions of both cytological and histological analyses were classified into defined categories (inflammation or neoplasia with subcategories, fibrosis, epithelial hyperplasia, and normal) to allow comparison between the techniques. agreement between cytology and histology was determined by cohen's kappa coefficient. from the cases, biopsy specimens were collected from different localizations for histology and cytology slides were obtained. final diagnosis was neoplasia in cases and inflammatory disease in . considering imprint technique, / were considered 'non diagnostic'. for squash technique, only / of cytological samples were considered as 'non diagnostic'. squash cytology and histology gave the same results in . % of the cases (n = ) and agreement between the techniques was considered 'moderate' (k = . ( % confidence interval [ci] . ; . )). agreement was 'fair' between imprint cytology and histology (n = ) (k = . [ % ci . ; . ]). gastric spiral organisms (gso) were observed in cases. in cases they were identified only on cytology. amongst these cases, mast cells were identified on cytology in cases, and not on histology in any cases. mast cells were not found in any other cases. this prospective pilot study demonstrated that cytological examination of gastrointestinal biopsy squash samples obtained during endoscopy of the alimentary tract may give relevant information, which can help the clinician to initiate treatment while histopathological analysis is pending. furthermore, it can give additional information (presence of potential pathogens, mast cells) that may not be identified on histopathology. disclosures: no disclosures to report. intramucosal escherichia coli are implicated in the pathogenesis of granulomatous colitis of boxer dogs. clinical remission hinges upon its eradication, most commonly achieved with fluoroquinolones. antimicrobial resistance is not uncommon among e. coli isolated from dogs with gc and impairs successful treatment. published data is lacking on efficacious therapies for gc dogs with fluoroquinolone-resistant e. coli. the aim of this study was to characterize the antimicrobial resistance patterns and molecular characteristics of e. coli isolated from dogs with gc. additionally, to evaluate the clinical outcome of dogs treated with antimicrobials guided by culture and susceptibility results. the study population was ( boxers and french bulldogs) client-owned dogs with gc. gc biopsies with fish-confirmed intramucosal e. coli were submitted for bacterial culture. antimicrobial susceptibility was determined by broth microdilution. most strains were further characterized by phylogroup and overall genotype using triplex and random amplified polymorphic dna polymerase chain reaction, respectively. treatment and clinical outcomes data were obtained. culture yielded e. coli strains ( - per dog, med ) from / dogs. resistance to fluoroquinolones was identified in / dogs; this was correlated with resistance to other macrophage-penetrating antimicrobials (p < . ). phylogroup a was over-represented among enrofloxacin-resistant strains. in dogs with e. coli isolated at multiple time points, phylogroup changed over time. clinical remission was achieved in / dogs with fluoroquinolone-sensitive e. coli. dogs with fluoroquinolone-resistance had a more variable response; treatment with meropenem (median mg/kg sq q hours for weeks) resolved clinical signs in / . we conclude that antimicrobial resistance is a growing concern. gc-associated e. coli appear genetically diverse. clinical remission can be achieved in the face of fluoroquinolone-resistance though in vitro antimicrobial susceptibility does not consistently predict a positive response. disclosures: no disclosures to report. canine s a has potential as a biomarker of inflammation in dogs. fecal s a concentrations were increased in dogs with chronic gastroenteropathy (ce), and correlated with the severity of clinical and endoscopic disease. a negative outcome was associated with higher fecal s a concentrations in ce dogs, but the response to different forms of treatment and fecal s a has not been reported, and this information will be important to further evaluate the utility of fecal s a as a biomarker for gastrointestinal disease. aim of this study was to evaluate the association between responses to various treatments (i.e., elimination diet, antimicrobial drugs, or corticosteroids/other immunosuppressants) and fecal s a in dogs with ce. fecal samples were collected from dogs diagnosed with ce, and fecal s a was measured in all specimens using an established in-house elisa. based on the response to treatment, dogs were classified as having antibiotic-responsive diarrhea (ard), food-responsive diarrhea (frd), or steroid-responsive/therapy-resistant idiopathic inflammatory bowel disease (ibd). statistical analysis was performed using non-parametric -or multiple-group comparisons, the likelihood ratio to evaluate the association between groups of dogs and response to treatment, and a receiver operating characteristic curve to calculate sensitivity and specificity at the optimum cut-off concentration. a total of dogs with ce (median age: . years; males/ females) were included in the study, the final diagnosis of which were ard (n = ), frd (n = ), or ibd (n = ). response to treatment was complete remission (n = ), partial response (n = ), or no response (n = ). fecal s a concentrations ranged from to , ng/g, and higher s a levels were seen in dogs with ibd than in dogs with frd (p = . ) or ard (p = . ). dogs that did not respond to treatment had significantly higher s a levels than dogs with partial (p = . ) or complete (p = . ) remission, but response to treatment was associated with disease classification (p = . ). despite a small number of patients, fecal s a levels of > , ng/g at the time of diagnosis distinguished dogs that failed responding to treatment from those with at least partial remission with a sensitivity of % and specificity of %. we conclude that, in line with our previous finding that fecal s a may be a useful biomarker of disease severity in dogs with ibd, fecal s a may also have utility in predicting the lack of response to treatment in dogs with ce. the utility of serial fecal s a concentrations to monitor treatment response in dogs with ce warrants further research. disclosures: dr. heilmann and dr. steiner have filed a patent application that includes the s a elisa used for this study. constipation is a common presenting complaint in dogs and cats. differential diagnosis for this clinical sign is well-known but strictures resulting from gastro-intestinal inflammation are not commonly included and have been rarely reported in the literature. acute diarrhea and bone ingestion can lead to anal or rectal stricture which is responsible for the constipation. the aim of this retrospective study was to describe the prevalence of inflammatory rectal and anal stricture in small animals and to describe a simple and effective treatment. medical records of dogs and cats presented for constipation, dyschezia or tenesmus and diagnosed with an inflammatory stricture were obtained from the database of the gastro-intestinal diseases consultation of referral centers in gastroenterology between and ; and were reviewed. signalment, presenting complaint, clinical findings, treatment protocol and outcome were recorded. five dogs and cats were included in the study. of the cats, were purebred kitten between . and months, and among them were persians. the fifth cat was a -year-old female domestic shorthair. three out of cats had history of acute diarrhea and cats had constipation since adoption with unknown history. digital rectal examination under anesthesia revealed stricture in all cats which was treated by bougienage every days and high-fiber diet. of the dogs, age ranged from . to years; dogs had history of acute diarrhea and had ingested bones in prior days. colonoscopy and biopsies were performed in all dogs and showed a lymphoplasmocytic infiltration in all of them. dogs were treated with digital bougienage every other day until disappearance of the stricture, metronidazole, lubricant laxatives, corticosteroids and highfiber diet. the prevalence of inflammatory stricture in dogs was . % based on dogs presented with the same complaints between and . for all dogs and cats, clinical signs related to the stricture resolved for the duration of their follow-up. benign strictures secondary to gastro-intestinal inflammation should be systematically included in the differential diagnosis of constipation. strictures are easily palpated on digital rectal examination, which should always be performed during clinical examination. histology should be a routine part of the diagnosis workup to exclude neoplasia. endoscopy-assisted balloon dilatation with concurrent intralesional injection of triamcinolone has been used in dogs and reported in the human literature. the treatment described here is simpler and effective. in dogs, it can be done at home by the owner. disclosures: no disclosures to report. acute pancreatitis is a diagnostic challenge because of anatomic inaccessibility of the pancreas, vague clinical signs and physical examination findings, and inconsistent laboratory results. common, yet non-specific, clinical signs include abdominal pain, anorexia, vomiting, and diarrhea. ultrasonography is the imaging modality of choice to evaluate the pancreas. the purpose of this study was to compare clinical signs with ultrasonographic findings in dogs with acute pancreatitis to account for differences in clinical presentation depending on the region of the pancreas affected as determined by ultrasonography. the hypothesis was that there would be differences in clinical presentation depending on the pancreatic region involved. records of client-owned dogs diagnosed with acute pancreatitis based on history, clinical signs, laboratory testing, and abdominal ultrasonography were retrospectively evaluated. based on ultrasonography, dogs were divided into groups: group - dogs with changes within the left limb of the pancreas exclusively; group - dogs with changes within the right limb of the pancreas exclusively; and group - dogs with diffuse pancreatic involvement. presence of abdominal pain, anorexia, vomiting, and diarrhea was correlated between groups using chi-square and fischer's exact test. no significant differences regarding age, breed and sex were noted between groups. in group pain was noted in %, anorexia in %, vomiting in %, and diarrhea in % of dogs. in group pain was present in %, anorexia in %, vomiting in %, and diarrhea in % of dogs. in group pain was noted in %, anorexia in %, vomiting in %, and diarrhea in % of dogs. pain was noted with a significantly higher frequency in diffuse pancreatic disease as compared to disease restricted to the left or right limb of the pancreas. anorexia was significantly more common with right limb involvement. both vomiting and diarrhea were significantly more common with disease restricted to the left limb as compared to diffuse parenchymal or right limb involvement. despite overlap between groups, these findings indicate that pain response is expected to occur with a higher frequency in diffuse pancreatitis but overall is not a very common clinical sign. anorexia is more prevalent in dogs with pancreatitis of the right limb whereas vomiting and diarrhea both are more evident in dogs left limb pancreatitis. differences between the groups can possibly be ascribed to gastric involvement when the left side of the pancreas is affected. disclosures: no disclosures to report. increased physical exercise has been reported to improve the clinical symptoms of chronic enteropathies, such as inflammatory bowel disease, in human patients. the aim of this investigation was to evaluate the impact of an intervention to increase physical exercise in dogs with chronic enteropathies. twenty-two dogs ( each in the exercise and control groups) with chronic enteropathies and no response to an elimination diet were included. routine diagnostic work-up (haematology, plasma biochemistry profile, urinalysis, faecal parasitology, abdominal radiographs, and ultrasound) was conducted in all dogs to eliminate underlying causes. all dogs were given oral prednisolone ( mg/kg/day) for days, followed by a tapering dosage over weeks. after weeks of prednisolone treatment, a certified canine rehabilitation therapist instructed the owners of dogs in the exercise group on how to increase their dogs' physical exercise. the exercise protocol combined aerobic and resistance exercises in low-to moderate-intensity interval training. owners of dogs in the control group were asked to maintain the dogs' routine lifestyles. modified canine inflammatory bowel disease activity scores (cib-dais), based on the parameters of activity level, appetite, vomiting, stool consistency, stool frequency, bloating, and weight loss, were calculated pre-treatment and and weeks post-treatment for all dogs. cibdai scores were compared among timepoints (pre-treatment and post-treatment assessments) and between groups (exercise and control) using multivariate repeated-measures models for multiple comparisons. all dogs showed improvement after weeks of prednisolone treatment. modified cibdais decreased in the exercise (from . ae . to . ae . ) and control (from . ae . to . ae . ) groups. after weeks of the increased physical exercise intervention, the modified cibdai in the exercise group decreased significantly ( . ae . ) relative to the first post-treatment assessment (p = . ), whereas this index remained similar ( . ae . ) in the control group. modified cibdais differed significantly between groups after weeks of treatment (p = . ). all parameters of the modified cibdai were significantly affected by the intervention of increased physical exercise; the largest difference was found for body weight (p < . , adjusted r = . ) and faecal frequency (p < . , adjusted r = . ) and activity level (p < . , adjusted r = . ). an increased physical activity intervention had positive effects on clinical symptoms in dogs with chronic enteropathies. disclosures: no disclosures to report. corticosteroid therapy is commonly required in veterinary patients for treatment of inflammatory, immune-mediated, neurological and neoplastic diseases. some of these patients also require assisted enteral nutrition via percutaneous endoscopic gastrostomy (peg) tubes. this retrospective case-control study evaluated the complications associated with peg tube use in veterinary patients receiving corticosteroids in a referral teaching hospital. medical records of dogs and cats in which a peg tube was placed in the qmha between january and march were reviewed. patients were included if the peg tube was in use for at least hours and if complete medical records, including clinical notes from referring veterinarians, kennel sheets, communication records with patients' owners and notes from tube removal, were available. to be included in the steroid group, patients must have received corticosteroid therapy (> mg/kg/day) for at least % of the length of time the peg tube was in use. control patients were not treated with corticosteroids. forty-two cases were included ( dogs and cats). fourteen patients ( dogs and cats) were included in the steroid group and patients ( dogs and cats) were included in the control group. complications were scored in terms of severity as minor ( ), moderate ( ) and major ( ) and compared between groups using the mann-whitney u-test. values of p < . were considered significant. complications included: serous discharge (n = ), sanguineous discharge ( ), purulent discharge ( ), stoma site inflammation ( ), peg tube dislodgement ( ) , pain around the stoma ( ), peg tube blockage ( ) and peg tube chewed by the patient on its tip ( ) or at the stoma ( ). median (interquartile range) of maximum complication scores for control and steroid groups were respectively ( ) and ( ). the maximum complication scores were not significantly different between groups (u = . , p = . ), though patients receiving corticosteroids showed a trend towards higher maximum complications scores than those in the control group. in conclusion, owners of dogs and cats receiving corticosteroids in which a peg tube is planned should be appraised of the possibility of complications beyond those normally associated with tube placement alone. disclosures: no disclosures to report. canine obesity is usually treated with dietary energy restriction, but data are limited regarding nutritional adequacy. the aim of the current study was to compare intake of essential nutrients with national research council recommendations in obese dogs during weight management with a purpose-formulated diet. twenty-seven dogs were included in this non-randomized retrospective observational cohort study. all were determined to be systemically well, and without significant abnormalities based upon physical examination and clinicopathological assessments. the dogs underwent a controlled weight loss protocol of at least weeks, to achieve ideal condition and using a high protein high fiber weight loss diet. median, maximum, and minimum daily intakes of all essential nutrients were compared against nrc recommended allowances (ra) for adult dogs. median weight loss was % ( - %), median daily energy intake was kcal/kg . ( - kcal/kg . ), and no signs of nutrient deficiency were observed in any dog. based upon the average nutrient content of the diet, daily intake of the majority of essential nutrients was greater than their nrc ra (per kg body weight . ), except for selenium, choline, choline ( / dogs) and methionine+cysteine ( / dogs), all essential nutrients remained above nrc minimum requirements (mr) throughout the trial. daily intakes of most essential nutrients meet both their nrc ra and mr in obese dogs throughout a period of weight loss. in light of absence of signs of nutrient deficiency, the significance of the borderline intakes for some nutrients (especially selenium and choline) is not known, and further studies are recommended. disclosures: the following conflicts of interest apply: ajg's readership is funded by royal canin; ajg has also received financial remuneration and gifts for providing educational mate-rial, speaking at conferences, and consultancy work; slh's post at the university of liverpool is also funded by royal canin; the diet used in this study is manufactured by royal canin; ss and vb are employed by royal canin. esvcn-o- endocrine profile of obese dogs. d. j. rochel, c. amato, p. nguyen, l. jaillardon, b. siliart. oniris, nantes atlantic college of veterinary medicine, food science, engineering, nantes cedex , france obesity is a frequent condition of the dog, associated with many endocrine and metabolic disturbances leading to major organ dysfunctions. we therefore aimed to assess biochemical and hormonal profiles of a large cohort of obese dogs. obese dogs were retrospectively included in the study, based on an overweight over % the ideal body weight (ibw). endocrine profiles consisted in assessing prolactin, leptin, insulin like growth factor type (igf ), cortisol after an acth stimulation test, insulin, free thyroxine (ft ) and ctsh serum concentrations. obese dogs ( % females of which % spayed and % males of which % castrated) were from different breeds and ranged from to years [median years, . % between and years]. % of the dogs suffered from generalized (versus abdominal) obesity and long-term obesity (> year) was described in % of the cases. the main observed clinical signs were abdominal distension ( %), fatigability ( %), polyphagia ( %), decline of interest for usual activities, ( %) and polyuropolydipsia ( %). biochemical profile was unremarkable except that % of the dogs had hypercholesterolemia (cholesterol > mmol/l). a high prolactin value (> ng/ml) was observed in % of the dogs, a high leptin value (> lg/l) in %, a high igf value [igf > lg/l (ibw < kg), > ( < ibw < kg) and > (ibw> kg)] in % and a high insulin value in % (> lui/ ml), without significant correlation with glucose concentration in % of the cases. % of the dogs had a high cortisol value (> nmole/l after acth stimulation) and % had alow ft (ft < pmol/l) with % having a high tsh value (> , ng/ml). canine obesity is associated with many endocrine disorders including hyperprolactinemia, hyperleptinemia, high igf value, hypercortisolemia and/or a hypothyroxinemia associated with a high ctsh value. the endocrine profile could be very interesting for the diagnosis and prognosis of canine obesity and could allow the veterinarian to choose a better treatment, particularly when the diet is unsuccessful. further investigations could be done to assess the prognostic value of the endocrine profile at the diagnosis of canine obesity to control the treatment efficiency. disclosures: no disclosures to report. a better understanding of how dogs undergo healthy ageing would benefit owners and veterinarians alike. in july a longitudinal study began to evaluate health and longevity in labrador retrievers ( males and females, all neutered, mean age . years), continuously fed a fixed plane of nutrition with identical housing, standardised husbandry and veterinary care. body condition score was maintained between and on a -point scale. standard veterinary protocols were used for any medical conditions; cancer and severe or life threatening conditions were managed individually based on quality of life assessments. the 'average' lifespan of labrador retrievers was estimated to be years. dogs were classified according to lifespan as 'typical' if they died between and ≤ . years of age, 'long' ≥ to . years and 'exceptional' ≥ . years (corresponding to % longer than the average lifespan). data were analysed using linear mixed models with random effects for slopes and intercepts and a fixed effect for lifespan grouping variable. on st july , dogs ( %) were classified as exceptional with still alive, typical (n = ) and long (n = ). gender and age at neutering were not associated with survival time or risk of death (p≥ . ). body weight change showed a quadratic trend: up to age , body weights increased for all lifespan groups but the changes were not significantly different. there was a significant change in body weight from to years as exceptional dogs increased body weight while the long-lifespan dogs lost weight (+ . versus À . kg/dog/year, p = . ). after age the exceptional and long groups both had similar losses. dual-energy x-ray absorptiometry scans revealed that wholebody fat (g) increased in all lifespan groups to age but the change was significantly slower for the long lifespan dogs when compared with typical dogs which accumulated fat at > times the rate. all groups lost a similar amount of whole-body lean tissue (g) through age (p > . ). up to age the mean % gain in whole body fat, and % loss of whole-body lean tissue, was slower and the mean change in fat to lean ratio was lower in the exceptional and long-lived dogs compared to the typical dogs (p £ . ). typically aged labradors showed a greater gain of fat tissue, and greater loss of lean tissue, up to years of age than exceptional dogs. disclosures: the eukanuba diet used in this study is manufactured by spectrum brands whilst dmm is employed by spectrum brands. vja is an independent epidemiologist who helped analyze the data and was financially supported by spectrum brands for this work. pjw has participated in veterinary seminars organised by spectrum brands and has received an honorarium for this work. introduction: in healthy animals, the phosphate (p) in combination with calcium homeostasis is regulated in comparatively narrow limits: excessively ingested p is excreted via urine. common knowledge is, however, that p is a progressive factor in chronic renal failure (crf) wherefore typically a p restricted diet is prescribed for affected patients. in , pastoor demonstrated that a p excess (significantly at~ mg p/mj me; ca/p . / for days) impairs renal function even in healthy cats, diagnosed mainly by reduced endogenous creatinine clearance. dietary p originates from meat and other protein sources, bones and cartilages, mineral supplements and technical additives (water binding, palatability a/o texture enhancer etc.). the daily amount ingested with complete diets from the european market often exceeds the recommended daily allowance (rda; nrc , fediaf considerably (up to times, anonymus ). our own studies were done with the aim ( ) to survey the reproducibility of the results of pastoor ( ) and ( ) to test effects of different ca/p ratios and p sources on parameters of renal function in healthy adult cats. animals, materials and methods: up to adult, healthy cats were appointed to groups in every trial period. firstly, a balanced diet was fed for days including a days balance trial. one group was then switched to a high p diet whereas the other remained on the balanced diet, again completed by a balance trial. after days of wash-out (balanced diet) both groups were switched in a cross-over design repeating the days trial period. this design was carried out repeatedly with high p diets differently composed concerning ca/p ratios and p sources. endogenous creatinine clearance, glucosuria, microalbuminuria, water and mineral balance were determined at each period. the study was approved by the proper authority for animal welfare. results and discussion: the studies confirmed the results of pastoor ( ): a p content of approximately mg/mj me in a diet consumed by healthy cats at maintenance may lead to a decrease of the creatinine clearance. markers of acute tubular damage, i.e. glucose and microproteins in the urine, showed positive results in several trials. the p concentration of a diet alone is no sufficient marker of its tolerance since ca/p ratio and p origin influence the effects. therefore, high p diets cannot be considered safe and should be avoided also in healthy cats. literature the study aim was to investigate serum global proteomes in dogs with overt dilated cardiomyopathy (dcm) and to correlate protein expression in serum with that in ascitic fluid. eight dogs diagnosed with dcm based on echocardiographic evidence including increased left ventricular dimension at diastole and systole, increased e point to septal separation, and decreased fractional shortening were included in the study. serum and ascitic fluid samples were analyzed for proteomes using a label-free lc-ms/ms method. eight dogs from different breed, sex and age served as controls. proteome analyses revealed significantly different expressions of eight proteins in all samples. expressions in serum of apolipoprotein a , ig heavy chain v, superoxide dismutase and plasminogen were higher (p < . ), while expressions of clusterin, hemoglobin subunit ß, apolipoprotein c ii, b glycoprotein i (ß gpi) were lower (p < . ) in dogs with dcm than in control dogs. in addition, apolipoprotein a , clusterin, hemoglobin subunit ß, ig heavy chain v, plasminogen and ß gpi were down-regulated whereas apolipoprotein c ii and superoxide dismutase were upregulated in ascitic fluid compared with serum in dogs with dcm. data obtained in the present study suggest that serum and/or ascitic fluid proteomes may help explain some of the pathophysiological mechanisms involved in the progression of dcm. tick paralysis is an important disease of dogs and cats in australia, induced by toxins of the paralysis tick ixodes holocyclus, very commonly occurring from spring to autumn on the eastern seaboard. respiratory failure is one of the major clinical derangements occurring in severe cases of tick paralysis, although its pathogenesis is poorly characterised. there is some suggestion that the respiratory failure is secondary to toxin-induced myocardial dysfunction with the subsequent development of cardiogenic pulmonary oedema. the purpose of this study was to determine cardiac involvement in dogs infested with ixodes holocyclus, through measurement of cardiac biomarkers. a cross-sectional study of client-owned dogs was undertaken. dogs enrolled in the study belonged to one of groups: dogs with tick paralysis and no-mild respiratory compromise (group a), dogs with tick paralysis and moderate-severe respiratory compromise (group b) and a control group of dogs with neither tick paralysis nor respiratory compromise. respiratory compromise was scored using a commonly employed grading system. each animal had the following parameters determined: serum cardiac troponin i (ctni) concentration, plasma n-terminal pro-btype natriuretic peptide (nt-probnp) concentration and serum creatinine concentration. for most dogs, but not all, spo was also determined. mean nt-probnp concentrations were significantly lower in dogs with tick paralysis than those in the control group, with no statistical difference detected between dogs with and without respiratory compromise. there was no significant difference in mean ctni concentrations between groups, however there were some high outliers of ctni concentration. creatinine concentrations differed significantly between each group, with the control group having the highest mean creatinine and those in group b having the lowest mean creatinine. there was no significant difference in spo between groups. this study showed no compelling evidence of cardiac insult as measured through cardiac biomarkers in our cohort of dogs with tick paralysis; however there was evidence supporting reduced preload in these dogs. in addition, the results of this study suggested that a small subset of patients with systemic hypoxaemia might have some loss of cardiomyocyte integrity. disclosures: employee/salary: gp nicolson, r malik and nj beijerink are employees of sydney university; alh mcgrath is a student at sydney university; ra webster is an employee of the animal emergency service; carrara; s kaye is an employee of queensland veterinary specialists, stafford heights; j li is an employee of northside emergency veterinary service, forestville. grants/research: this study was funded by bequest grants provided by the faculty of veterinary science at the university of sydney. idexx laboratories provided some funding for the laboratory tests. no other disclosures. speaking & consultancies: none related to this presentation. investments/commercial interests: none related to this presentation. gifts, hospitality, travel support: none related to this presentation. other: none related to this presentation. the use of ntprobnp, troponin i (high-sensitivity, ctni) and pdk pre-screening for occult dilated cardiomyopathy(odcm) in the doberman pinscher(dp) has been previously reported. the aim of this prospective collaborative study was to identify robust pre-screening recommendations for dp utilizing the current generation of commercially available diagnostic tests. a cohort of asymptomatic dp were evaluated at the american doberman national specialty show in , , and (n = , median age years, range - ). evaluations consisted of auscultation, echocardiography (echo), -minute ecg (ecg), ntprobnp (cardiopet plus r ), ctni, and pdk . dp were classified as affected (odcm) if their lvids was > the protect entry criteria with or without vpcs (n = ). dp were classified as normal (nl) if their lvidd and lvids < protect entry criteria and they had no vpcs (ntprobnp:n = , ctni:n = , pdk ;n = ). roc analysis comparing odcm and nl was done for ntprobnp, ctni, and pdk . overall accuracy (percent correctly classified) was considered for individual tests as well as a variety of combinations. the goal of combining tests was to eliminate false negatives while minimizing false positives. the auc for ntprobnp, ctni and pdk was . , . and . respectively with the percentage correctly classified equal to . , . and . (including false negatives for pdk ) when a cut-off of pmol/l, . ng/ml or a positive pdk (hetero-or homozygous) were used respectively. when the cutoffs for ntprobnp and ctni are used in combination the auc was . and . % were correctly classified ( false negatives, false positives). disclosures: research and programatic support from idexx the lab that runs ntprobnp. the study was sponsored by boehringer ingelheim, idexx and the doberman pinscher society of america. with renal disease. r. langhorn , a.s. kloster , l.r. jessen , a. jensen , j. koch . university of copenhagen, frederiksberg c, denmark, copenhagen small animal hospital, valby, denmark cardiac troponins are sensitive and specific markers of myocardial injury. however, their reliability in renal disease has been questioned due to possible renal involvement in troponin elimination. the purpose of this study was to examine whether cardiac troponin i (ctni) is elevated in cats with renal disease and no concurrent cardiac disease, and whether ctni is measurable in urine of cats with normal and compromised renal function. cats presenting with renal disease or primary structural cardiac disease were enrolled in a renal and a cardiac group, respectively. a healthy control group was similarly included. clinical and echocardiographical examination was performed and blood and urine samples obtained for each cat. the mann-whitney u test was applied to evaluate differences between groups. seven cats with renal disease, cats with cardiac disease, and healthy cats were included. serum ctni concentrations were (median [range]) . [ . - . ] ng/ml for the renal group, . [ . - . ] ng/ml for the cardiac group, and . [ . - . ] ng/ml for the control group. the renal group had significantly higher serum ctni concentrations than the control group (p = . ), but was not significantly different from the cardiac group (p = . ). urine ctni was measurable in . % ( / ) of cats in the renal group ( . [ . - . ] ng/ml), % in the cardiac group, and . % ( / ) of controls ( . ng/ml). it was concluded that elevated serum ctni in cats with renal disease may occur without concurrent cardiac disease. moreover, compromised renal function was associated with presence of ctni in urine. disclosures: no disclosures to report. sudden death (sd) commonly occurs in dog breeds with a high predisposition to vpds and vt, occuring in about % of asymptomatic doberman pinschers (dp) and % of dp with chf, and reported in % of boxers with arvc. in human patients with atrial fibrillation (af) on anticoagulant therapy for stroke prevention (n = ), cardiac death (sd and progressive heart failure) has been reported to account for . % of all deaths. the objective of this study was to evaluate the incidence of sd in irish wolfhounds (iw) with dcm and/or af. iw from western europe (n = ) were examined by physical examination, standard echocardiography and electrocardiography between / - / (av). dogs were longitudinally followed, and owners instructed to report date and circumstances of death. dcm and/or af were diagnosed in %. long-term follow-up until death was possible in ( m, f) dogs with dcm and ( m, f) dogs with lone af. based on the initial diagnosis, disease groups were established. results: sd occurred in to % of all groups with dcm or af: ( ) out of dogs with dcm +af, sd occurred in % after median ( - ) days, median age . ae . years. ( ) out of dogs with dcm +sinus rhythm, . % died from sd after median ( - ) days, median age . ae . years. ( ) out of iw with dcm, af +chf, . % died from sd after median ( - ) days, median age . ae . years. ( ) out of iw with lone af, sd occurred in . % after median ( - ) days, median age . ae . years, of these, dogs had developed dcm prior to death. sudden cardiac death (sd) from cardiac arrest is the most common cause of death in people worldwide, accounting for > % of all deaths from cardiovascular disease. ventricular tachycardia (vt)/ fibrillation (vf) is the most common cause of sd, other causes include pulseless electrical activity. the fatal arrhythmia has not recorded in iw. in this study, vpds were recorded at one or more occasions in / iw with af, and in / with dcm, while in iws without heart disease vpds were seen in . % of males and in . % of females. in conclusion, sd occurs in . % of iw with lone af before or after development of dcm and chf, and in . % of dogs with dcm. disclosures: no disclosures to report. tachycardia may induce dilated cardiomyopathy (dcm). irish wolfhounds (iw) are commonly affected with dcm and atrial fibrillation (af). the objective of this study was to compare heart rates (hr) of iw with lone af with hr of an age and gender matched control iw cohort that had neither af nor dcm until death and to iw with dcm with either congestive heart failure (chf), af or sinus rhythm (sr). all disease groups had hr recorded before and after - months of medical therapy. out of iw with cardiovascular examinations including standard echocardiography and electrocardiography long-term follow-up until death was possible in ( m, f) dogs with dcm and ( m, f) dogs with lone af. based on the initial diagnosis, disease groups were established. dogs received single or combination treatment of metildigoxine, aceis, pimobendan, diltiazem, furosemide, spironolactone, atenolol and sotalol. mean hr during minutes ecg monitor recordings with print-outs were evaluated. the differences in hr in the disease groups before and after treatment versus controls were examined by analysis of variance with post hoc multiple comparisons (dunnett t ). mean hr in ( m, f) control dogs was . ae . bpm. mean hr in iw with lone af was . ae . bpm before, and . ae . bpm with therapy. mean hr of dogs with dcm +af was . ae . bpm before, and . ae . bpm with therapy. mean hr of dogs with dcm +sinus rhythm (sr), was . ae bpm before, and . ae sd bpm with therapy. mean hr of iw with dcm, af +chf, was . ae . bpm before, and median . ae . bpm with therapy. in conclusion, compared to control dogs, untreated iw with chf, with dcm+af, and iw with lone af had statistically significant (p = . ) increased hr, but not dogs with dcm and sr, while under medical therapy elevation of hr was only significant (p = . ) in iw with chf and dcm. disclosures: no disclosures to report. echocardiography, as a noninvasive method, is being increasingly used as a complementary means of diagnosis in small animal clinical practice. the need for standardization of techniques by ultrasound operators in the measurement of the different echocardiographic parameters is essential for a proper examination. the aim of this work was to check a potential correlation between the values obtained in right parasternal long-axis and short-axis views in -dimensional mode and m-mode. twenty persian cats were submitted to a complete physical examination, clinicopathologic tests (hematocrit, total solids and t hormone), systolic blood pressure measurement using doppler and echocardiography. seventeen cats fulfilled the criteria inclusion and were included in the study. two-dimensional mode and m-mode echocardiograms were recorded, in systole and diastole, from both short-axis and long-axis views for evaluation of left ventricular internal diameter (lvd), interventricular septum thickness (ivs), left ventricular free wall thickness (lvpw), aorta diameter, left atrium diameter (la), pulmonary artery diameter, shortening fraction (fs) and ejection fraction (fe). statistical analysis included paired t-test (wilcoxon test) and a linear regression analysis with graphical analysis to assess agreement between the methods of data acquisition. there was a highly significant correlation (p < . ) between the values obtained in short-axis and long-axis views for the parameter la diameter (longitudinal: . ae . cm; transversal: . ae . cm), a very significant correlation (p < . ) for the parameter lvds (longitudinal: . ae . cm; transversal: . ae . cm), and significant correlation (p < . ) for the parameters ivss (longitudinal: . ae . cm; transversal: . ae . cm), lvpws (longitudinal: . ae . cm; transversal: . ae . cm) and fs (longitudinal: . ae . %; transversal: . ae . %), with no significant correlation (p > . ) between the methods for the remaining parameters. in conclusion, the data obtained from right parasternal short-axis and long-axis recordings cannot be used interchangeably in the evaluation of diastolic parameters in normal adult cats. disclosures: no disclosures to report. real time three-dimensional transesophageal echocardiography (rt dtee) is an established imaging modality for interventional cardiac procedures in humans. it has been shown to yield comprehensive views of the cardiac valves and congenital heart defects. it potentially provides a more accurate echocardiographic means of evaluating cardiac chamber volumes and a more precise pre and postoperative tool. rt dtee was used in combination with conventional -dimensional transesophageal ( -d tee) and transthoracic echocardiography (tte) standard imaging protocols. the pulmonic valve anatomy and function was evaluated in client-owned dogs with severe valvular pulmonic stenosis prior to and post-balloon valvuloplasty. the -d images were obtained with the phillips ie and cx cardiac ultrasound systems using a -d transesophageal - mhz xmatrix probe. standard cardiac - mhz, - mhz and - mhz sector array probes were used to acquire d tte images. diagnostic images were obtained in all examined patients. rt dtee did not change the balloon size decision when compared with -d tee, but provided additional views, detailed anatomy of the pulmonic valve cusps and commissures, as well as thickness and mobility of the pulmonic valve cusps, when compared to those obtained with -d tee or tte. successful balloon valvuloplasty was achieved in of the patients. repeatable artifacts occurred with respiratory excursions and insufficient probe contact. no complications related to rt dtee were observed. rt dtee provided enhanced views of the pulmonic valve while aiding in the procedure guidance and evaluation of the results post-balloon valvuloplasty. a better understanding of the anatomy of the pulmonic valve may improve procedure success. immediate visualization of the results post-balloon valvuloplasty may reduce patient risk and fluoroscopy time. a larger sample and further research will be needed to establish guidelines and predict success based on particular valve anatomy. we can conclude that rt dtee provided additional anatomical and intraprocedural information and was well tolerated in this group of dogs. disclosures: no disclosures to report. pimobendan is an inodilator utilised extensively in the treatment of canine congestive heart failure. several retrospective studies evaluating clinical records have suggested that it is well tolerated in cats; however its efficacy in this species remains ill-defined. moreover, a recent pharmacokinetic study found peak plasma concentrations of the drug to be around ten times greater than those reported in the dog, thus highlighting inter-species differences in the pharmacokinetics and, potentially, pharmacodynamics of this drug. this study was conducted to evaluate the cardiovascular effects following oral doses of pimobendan in healthy cats. a placebo-controlled, randomised, operator-blinded crossover study was conducted in healthy cats (weight range . - . kg) to evaluate the effect of doses of pimobendan (high dose [hd]: . mg vetmedin chewable tablet po; low dose [ld]: . mg vetmedin chewable tablet po) and placebo ([pl]: water po) on cardiovascular parameters over time. standard echocardiography ( d, m-mode, and spectral doppler) and oscillometric blood pressure measurements (vethdo) were performed repeatedly for hours following dosing. each measured parameter was evaluated for between-and within-treatment effects over time using linear mixed modeling with reml estimation to account for intercat variability. heart rate was used as a proxy for the level of anxiety experienced by the cats, and adjustment for this was performed through inclusion of heart rate as a fixed effect in the final model. the effect of treatment with pimobendan was most evident in the left ventricular internal diameter in systole (lvids). maximal effects occurred hours following treatment with hd and ld. the predicted mean reduction from baseline following heart rate adjustment at this time for lvids was . mm ( % reduction) and . mm ( % reduction) for hd and ld, respectively. although there were no significant differences between hd and ld in the magnitude of effect at any given time point, lvids remained significantly reduced from baseline and the pl group for longer in the hd ( minutes to hours following dosing) than in the ld group ( to hours following dosing). significant treatment effects on aortic velocity and fractional shortening were also present, but to a lesser degree. these results demonstrate that treatment with pimobendan results in measurable changes to systolic indices in cats. a dose-dependent increase in duration of effect was also observed. further studies are required to characterise the optimal dose of pimobendan in cats and to evaluate its efficacy in clinical patients. disclosures: this study was funded by grants provided by the faculty of veterinary science at the university of sydney. m. yata received financial support from luoda pharma, the australian postgraduate awards scholarship, and the eric horatio maclean scholarship whilst undertaking this project. none of the authors involved in this study have current affiliations with the drug company that manufactured the product used in this study (boehringer ingelheim pimobendan has positive inotropic, positive lusitropic and vasodilator effects and is licensed for use in dogs with cardiac disease in many countries. numerous studies have shown benefit with the use of pimobendan in canine dilated cardiomyopathy and chronic degenerative mitral valve disease, and whilst not licensed for use in cats, recent studies have reported benefits with the use of oral pimobendan in a variety of cardiac diseases including dilated and hypertrophic cardiomyopathies. an intravenous formulation has been available in the uk since january . the use of intravenous pimobendan in cats in the clinical setting has not previously been described. the aim of this study was to describe the use of intravenous pimobendan in cats with naturally occurring heart failure and report tolerability and side effects/adverse reactions. the hospital data base was searched for the use of intravenous pimobendan in feline patients. signalment, presenting signs, investigations, diagnosis, dose and time of pimobendan administration, concurrent medications, short-term outcome and adverse reactions were recorded. a boarded-certified cardiologist retrospectively reviewed all the cases in order to confirm the diagnosis. all owners had signed consent forms to permit use of off licensed drugs. eight cats were included in the study. median age was . years (range, . - . ) . six ( %) were male and ( %) were domestic short-haired. weight ranged from . to . kg. all presented with dyspnoea. three out of cats ( %) had a heart murmur and out of ( %) had a gallop rhythm. different heart conditions were diagnosed including / cats with cardiomyopathy and / with suspected endocarditis. median dose of intravenous pimobendan was . mg/kg (range, . - . ). concurrent drugs administered included frusemide, dalteparin, terbutaline, dexamethasone, amoxicillin-clavulanate, maropitant, midazolam, butorphanol, methadone, glyceryl trinitrate, clopidogrel, aspirin and potassium gluconate. no immediate adverse reactions/side effects were observed in any of the cats. five of the cats were discharged from the hospital between and hours post pimobendan administration. one cat was euthanatized, one died during thoracocentesis and one had a thromboembolic episode between and hours post pimobendan administration. intravenous pimobendan was well tolerated by this clinical population of cats with heart failure. no immediate adverse reactions/ side effects were observed. the intravenous route may be considered as an alternative method of administration of pimobendan in cats with heart failure. disclosures: no disclosures to report. spironolactone (sp) is an aldosterone receptor antagonist, registered in europe for the treatment of congestive heart failure (chf) caused by valvular regurgitation in dogs, in combination with standard therapy. in cats, cardiomyopathy (cm) is the predominant cause of heart failure. to evaluate the safety and efficacy of sp in cats with cm, a double blind, randomized placebocontrolled study has been conducted with cats receiving either sp ( . to . mg/kg po once daily) or placebo for up to months in addition to benazepril and furosemide (dose at clinician's discretion). cats ( dsh, ragdoll, siamese and burmese) with cm of various types ( hypertrophic, dilated, unclassified and arrhythmogenic right ventricular) were enrolled. the cats were randomized to either group a or b according to the presence of hcm or not and whether the cat required hospitalization due to clinical need or not. cats were recruited to group a (sp) and cats recruited to group b (placebo). the only significant difference between the groups at baseline were aortic diameter (p = . ) larger in the sp group, and la:ao ratio (p = . ) larger in the placebo group. the survival analysis showed a survival rate at months respectively of % and % in the intention to treat (itt) and per protocol (pp) populations in the sp group and % and % in the placebo group. the difference between the groups was significant (log rank test: itt population p = . ; pp population p = . ). the hazard ratio indicates an % (itt) and % (pp) reduction in risk of an event occurrence in the sp group. the effect of covariates (age, weight, bcs, systolic blood pressure, ratio la/ao) was not significant. although this is a pilot study with small numbers of cats, this data would suggest that spironolactone is likely to be beneficial in the treatment of cats with congestive heart failure secondary to a cardiomyopathy. disclosures: the study was joint funded by ceva and the university of nottingham. the authors have the right to publish the results. of the study irrespective of outcome. the objectives of this study were to describe pulmonary transit time and myocardial perfusion normalized to heart rate (nptt and nmp, respectively), evaluated by means of contrast echocardiography, in dogs with stable stage c acvim myxomatous mitral valve disease (mmvd), and to assess short-term effects of pimobendan on these parameters. we hypothesized that nptt and nmp are increased in dogs with mmvd compared to normal dogs. additionally, we hypothesized that treatment with pimobendan will decrease both variables in dogs with mmvd. we prospectively enrolled normal dogs and dogs with stable stage c acvim mmvd. all dogs had a standard and contrast echocardiographic examination at the beginning of the study. at this time, mmvd dogs were randomly assigned to receive either pimobendan ( . - . mg/kg) or not. all dogs with mmvd were re-evaluated by means of standard and contrast echocardiography after week (t ), by operators blinded to the dog's treatment. our results show that nptt was significantly increased in dogs with mmvd (p = . ), compared to normal dogs. nptt was significantly decreased at t in dogs receiving pimobendan (p = . ). nmp was not significantly different in dogs with mmvd, compared to healthy dogs (p = . ), and it was not significantly different at t in the treatment group (p = . ). in conclusion, contrast echocardiography is a valid, complementary tool for echocardiographic analysis of dogs with mmvd. pimobendan decreases nptt in dogs affected by mmvd. myocardial perfusion is not different in dogs with mmvd and is not changed by pimobendan treatment. disclosures: michele borgarelli has received research funding by boheringher inghelheim for this study. in human beings, assessment of atrial function using -dimensional speckle tracking echocardiography (ste) is useful in several cardiovascular diseases. to date information on the use of ste for the evaluation of canine atrial function is lacking. we assessed the feasibility and reproducibility of ste in the assessment of left atrial (la) function in healthy dogs and dogs with myxomatous mitral valve disease (mmvd) and we compared ste derived indices with other parameters of left atrial and ventricular function and morphology. privately owned dogs including clinically healthy dogs (control, h) and dogs with mmvd subdivided according to heart failure class (b , b , c+d) were enrolled. standard echocardiographic examination was carried out in all dogs. furthermore, video clips were acquired from a -chamber apical view and ste analysis was done using dedicated software. for the ste analysis a region of interest was drawn including the entire left atrial wall. the software provided a strain/time curve that represents the degree of deformation of the la wall over the entire cardiac cycle. similarly, la areas are provided. the following variables were evaluated: peak atrial longitudinal strain (pals, %), as the point of maximal systolic strain; peak atrial contraction strain (pacs, %) just before atrial contracting phase; contraction strain index (csi, %) calculated from these variables. la areas were recorded during ventricular systole (la maximum area, laamax, cm ) and atrial contraction (la minimum area, laamin, cm ), and the la fractional area change (fac, %) was then calculated. the intra-and inter-observer variability was assessed using the coefficient of variation (cv, %). variability was low for all variables (cvs < left atrial measurements are commonly obtained by cardiologists to assess severity of left heart disease. traditionally, measurements were obtained from m-mode images, however several studies have examined measurements of left atrial dimensions and areas from -dimensional ( d) images. studies have demonstrated the interobserver variability of aortic valve measurements, and the effects of timing of the measurements throughout the cardiac cycle. however, few studies have examined interobserver variability of left atrial measurements from d images, factors affecting variability, or the consequences of this variability on ascribing degree of disease severity to a patient. images of the right parasternal short-axis view of the left atrium and aorta were provided to cardiologists or cardiology residents. the images depicted left atria of varying size, from both dogs and cats, ranging from normal to markedly enlarged. each participant placed arrows on each image to denote the start and finish points of their left atrial measurements without prior instructions -the first being near the interface with the aorta and the second being along the caudolateral border of the left atrium. thus, sets of images were analyzed. d distributions were mapped and analyzed to determine dispersion of the start and finish points. these were compared between images to look for association with severity (estimated as the median la:ao for each image) and image complexity. results: variability of measurements around the origin of the la measurement (interface with aorta) was small, and scaled with increasing heart size. variability at the distal measurement point was complex. in only / images was interobserver variability < . la:ao, and ranged up to la:ao ( % to % variability). a systematic observer effect was noted. variability did not appear to scale with severity of disease or image complexity, although the cases with the greatest variability had severe enlargement and indistinct margins. conclusion: this study demonstrates that highly trained individuals vary considerably in their measurement of left atria from the right parasternal short-axis view. the variability did not increase with increasing disease severity or image complexity. in some instances, the same patient could be classified differently by different observers if relying on la:ao thresholds. the study suggests that standardized methods of measurement should be developed to minimize this variability. disclosures: the study was supported by veterinary information network (salary, imaging software). there is growing evidence that fibrosis plays an important role in the development of remodeling and heart failure during cardiac diseases. at cellular level, fibrotic processes are prior to clinical manifestation of symptoms. fibrosis and extracellular matrix remodeling influences cardiac function in a negative manner. to our knowledge there is no biomarker, which is able to properly detect heart-specific fibrotic processes and remodeling in the peripheral blood. such a biomarker would be of great importance in cardiac diagnostics, risk stratification and therapy monitoring. in a preliminary study, using microarray method and pathway analysis in pooled samples, we were able to identify heart specific gene-expression profile representing fibrotic and inflammatory processes in the peripheral blood of tachypacing-induced cardiomyopathy model dogs. our results were validated by histopathology and quantitative real time rt-pcr (qrt-pcr). based on our microarray results, in this current study we aimed to select and investigate a panel of possible cardiac fibrosis and remodeling specific genes in blood. whole blood and left ventricular samples of tachypaced dogs (n = ), healthy controls (n = ) and blood samples of canine clinical patients (n = ) with different cardiomyopathies were collected in rna-stabilizing solution. rna integrity was confirmed by capillary electrophoresis (rin> ). exon-spanning primers were designed. expression of selected genes were measured by sybr-green based qrt-pcr and normalized to different housekeeping genes (hprt , rps ) by ddct method. quality controls were made by melting curve analysis and size determination of the pcr products by agarosegel electrophoresis. for data evaluation descriptive statistics, student's t-test and mann whitney u-test were used. the selected gene-expression panel consisted of different mrnas which represent main biological processes related to fibrosis, remodeling and impaired contractility. col a , mmp , timp , vcan, spp are directly related to collagen turnover and remodeling. il , ccl are inflammatory markers. stc , hsp , s a are early stress response genes. tgfb has central role in fibrosis while myh and myh ensure cardiac specificity. we found significant up regulation (p < . ) of col a , timp , vcan, spp , il , ccl , stc , hsp , s a , tgfb and down regulation of myh , myh genes in the heart tissue samples. all targets also showed similar changes in the blood samples except mmp , however not all alterations were significant. based on this selected panel clinical cases could be clearly differentiated from healthy dogs using their gene-expression pattern in blood samples. our findings suggest that the peripheral blood may have a potential to reveal cardiac specific fibrosis in dogs. disclosures: no disclosures to report. within the distal nephron, the enzyme -beta hydroxysteroid dehydrogenase ( bhsd ) protects the mineralocorticoid receptor (mr) from activation by cortisol, allowing it to interact with aldosterone. in humans, mutations of bhsd cause apparent mineralocorticoid excess, characterised by sodium and water retention with resultant hypertension. sodium and water retention is also a hallmark of canine congestive heart failure (chf). this could partly be explained by dysregulation of renal bhsd activity, exposing mr to activation by cortisol. the aim of this study was to investigate the activity of renal bhsd in canine chf by measuring the concentration of cortisol and its metabolites in the urine from affected dogs. owners collected urine in a home environment from healthy adult dogs (n = ), and from dogs prior to presentation with non-cardiac chronic disease (n = ), and dogs with cardiac disease (isachc ib, n = ; isachcii or iii, n = ). levels of cortisol (f) and cortisone (e) excreted in urine were measured by mass spectrometry. urinary cortisol was normalised to creatinine to account for variations in glomerular filtration rate. cortisol was also measured in plasma obtained from all unhealthy dogs. plasma cortisol levels (p = . )and urinary cortisol:creatinine ratio (p = . ) did not differ between groups. however, the f/e ratio, was increased in dogs with class ii-iii heart failure (p = . ). an increased f/e ratio, in the presence of unchanged plasma cortisol, implies decreased renal bhsd activity and enhanced mr activation by cortisol in canine chf. this data suggests that changes in renal cortisol metabolism in canine chf cannot be explained by chronicity of disease, that the urinary f/e ratio has potential as a biomarker for canine chf and that renal bhsd could offer a therapeutic target in its management. further studies investigating bhsd expression and bioactivity in canine chf are ongoing. disclosures: supported by the fiona and ian russell seed corn grant through the university of edinburgh. in humans endomyocardial biopsy (emb) is highly recommended in case of unexplained left ventricular dysfunction associated to ventricular arrhythmias (va) or high-grade atrioventricular block (avb). despite the frequency of these conditions in dogs, histopathology data are lacking. the aims of this study were to describe the feasibility of emb in dogs and to investigate a possible role of viral myocarditis in case of unexplained dilated cardiomyopathy (dcm) phenotypes, high-grade avbs, supraventricular arrhythmias (sva) and va. twenty-five dogs of different breeds, m/f , , mean age . + . years, mean body weight . + . kg, presented for third degree avb / , dcm / , va / , sva / , and va+sva / , underwent percutaneous right emb under general anesthesia throughout the jugular vein. for each dog clinical records were analyzed. in all dogs at least one right ventricular sample (range - ) was collected for histopathology and immunohistochemistry; in / dogs at least one sample (range - ) for viral pcr was collected. all histopathologic samples were stained with haematoxylin and eosin, masson's trichrome and red elastic picrocirius. in selected cases stains with monoclonal anti-cd and anti-cd were performed. nucleic acids were obtained after sample storage in rna later solution, disruption with tissue lyser and extraction with trizol; and tested for canine viruses (enteric and respiratory coronavirus, herpes virus, distemper virus, adenovirus and , and parvovirus) and for west nile virus and bartonella spp. seven out of dogs had aspecific signs of cardiomyopathy and / suggestive of arrhythmogenic right ventricular cardiomyopathy (arvc). emb gave normal samples in / dogs and not diagnostic in / dog. nine out of samples were suggestive of myocarditis at different stages ( third degree avb, dcm and sva). two of these dogs resulted positive for virus ( enteric coronavirus, herpes virus). none of the dogs had positive immunoistochemical stains. two dogs with cardiomyopathy were positive for herpes virus and for herpes virus and parvovirus, respectively. both of these dogs came from a kennel. no complication was noted in / dogs, one dog had self-limiting pericardial effusion. this study showed, similarly to human cardiology, that emb is a safe and useful technique that allows recognition and classification of unexplained myocardial and rhythm disorders, % of which possibly associated with viral myocarditis. further studies are needed to prove the relationship between viruses and myocarditis in a larger cohort of dogs. disclosures: no disclosures to report. echocardiographic evaluation of the right ventricle (rv) is challenging. studies lack quantitative assessment of the rv in dogs. the goal of this study therefore was to evaluate rv morphology and systolic function using different transthoracic echocardiographic (te) views and to compare the results with magnetic resonance imaging (mri) measurements in adult healthy anesthetized beagles. te variables were rv wall thickness (wt) in short axis and from a subcostal view, fractional shortening (fs), rv fractional area change (fac) from different apical views (an optimized view for the rv and a standard chambers view), tricuspid annular plane systolic excursion (tapse) from different apical views, right ventricular outflow tract diameter at proximal (rvot ) and valvular (rvot ) levels both obtained in long and short axis, tissue doppler imaging (tdi) derived tricuspid annulus systolic wave (s¢), isovolumic contraction velocity (ivcvel), and isovolumic contraction acceleration time (ivcat).mri variables were rv wt, rvot in short and long axis and rvot , ejection fraction (ef), and stroke volume (sv) based on flow quantification. there was no difference between rv wt measured with te in both short axis ( . ae . mm) and subcostal views ( . ae . mm) and mri ( . ae . mm). no difference was found between rvot or rvot when measured in long ( . ae . mm for the former, . ae . mm for the latter) and short axis ( . ae . mm for the former, . ae . mm for the latter) with te; however rvot in both short and long axis was overestimated by te compared to mri ( . ae . mm in long axis, and . ae . mm in short axis). both rvot in short and long axis obtained by te were lower than mri values ( . ae . mm). te fs was . ae %. values of tapse varied significantly when using different apical views, optimized ( . ae . mm) and standard chambers ( ae . mm); the same was true for fac (optimized view, . ae . %; standard chambers, . ae . mm). tdi s¢ was . ae . m/s, ivcvel was . ae . m/s, and ivcat was . ae . msec. the only te correlations found were tapse with fac and s¢. the only echocardiographic variables correlating with the mri based sv ( . ae . ml) were fac and s¢. mri based ef ( . ae . %) did not correlate with any echocardiographic variable. this new approach to assess rv function revealed problems similar to earlier attempts. without a reliable standard for comparison of quantitative results, the value of any te parameter is questionable. furthermore, te parameters obtained from different views produced different results, indicating that standardization maybe difficult, respectively increasing the risk of variability. disclosures: no disclosures to report. spontaneous echo contrast (sec) or 'smoke' is caused by low blood velocity and appears on ultrasound as a swirling blood flow pattern. it is associated with increased risk of thromboembolism in small animals. detection of sec is entirely subjective and there is limited consensus in veterinary medicine regarding the echocardiographic technique that is best for detection of sec. the main hypothesis of this study was that dimensional ( d) colour tissue doppler imaging (tdi) would significantly outperform d colour and grey scale as the best echocardiographic technique to view sec. a further hypothesis was that colour blindness would have no influence on results. echocardiographic data was obtained retrospectively from small animal cases that presented to the university of glasgow small animal hospital. all cases had evidence of sec. using a ge vivid echocardiography machine each of the cases had one video loop recorded with d colour tdi. colour tdi was then replaced by different d colours (gold, sepia and aqua) and different grey scale colours (machine presets and ) and video loops recorded. for each case the order of the recorded video loops was randomised. the video loops from the cases were viewed in standardised conditions by observers (veterinary cardiologists, residents, interns and students); observers had full colour spectrum vision (fcsv) and were red-green colour blind (deuteranopia). each observer ranked their ability to see sec with each colour, with being the least able to visualise sec and being the best able to visualise sec. binary logistic regression using minitab (version . ) was used to identify factors associated with whether tdi was ranked best or not. potential explanatory variables that were examined were view and colour blindness. observer and case were also fitted as fixed and random effects to account for clustering within these variables. tdi was chosen by the observers / ( %) occasions as the best technique to diagnose sec, which was significantly more frequently than all other d colour views together (p < . ). there was no significant difference between colour blind observers and those with fcsv (p = . ) and there was no influence of observer or case on the final model. in conclusion, d colour tdi may assist in easier diagnosis of spontaneous echo contrast in veterinary medicine regardless of colour visual spectrum of the observer. easier detection of sec would allow earlier implementation of preventative measures. disclosures: no disclosures to report. the foramen ovale (fo) is a slit-like passageway between septum secundum and primum that typically closes after birth by fusion of these septa. in - % of humans, a patent foramen ovale (pfo) persists into adulthood. the prevalence of pfo in small animals is unknown. this interatrial channel may serve as a bypass to the pulmonary circulation and is an important cause of paradoxical embolism (pe) and stroke in people. the primary aim of the study was to evaluate the prevalence of pfo in a large population of dogs and cats. secondary aims were to gather data on the prevalence of atrial septal defects (asd) and on the potential association between pfo and a) clinical/pathological signs of stroke or thromboembolism and b) the presence of right-sided heart disease. hearts of all dogs and cats that underwent a full diagnostic post mortem examination were prospectively evaluated for a pfo in a blinded fashion (to clinical history and cause of death). in selected cases with patent and closed fo respectively, a histological examination of the interatrial septum was undertaken. clinical information and the results of the post mortem examination were only evaluated after all hearts had been examined. a total of hearts ( cats, dogs) were examined, of which cats ( %) and dogs ( %) with a median age of [ day- years] and years [ day- years] respectively, exhibited a probe-patent pfo. in adult animals with presumed normal right atrial pressure the prevalence of pfo was % (cats) and % (dogs). none of the animals had an asd. one dog with a pfo also exhibited an aortic thrombus; otherwise there was no evidence of pe in this population. in % (dogs) and % (cats) with closed fo the left side of the interatrial septum (septum primum) was still partially probe-patent through a channel extending from the left atrial crescentic ridge (ostium secundum) to the limbus, but closed at this level by a thin, easily rupturable membrane. in conclusion, pfos are common in dogs and cats, but less prevalent than in humans. in contrast, asds appear to be rare in either. despite the high prevalence of pfo, clinical complications seem to be very rare. the majority of dogs with a closed fo have a fossa ovalis that is weakly fused to the limbus, which may facilitate blunt trans-septal atrial catheterisation and provide an easier access to the left atrium. disclosures: jose novo matos and tony glaus have performed consultancy work for boehringer ingelheim and vetoquinol. in human medicine diabetes mellitus (dm) is known to lead to cardiovascular dysfunction and heart failure, characterized by early diastolic and late systolic dysfunction. diabetic cardiomyopathy has been defined as the existence of left ventricular dysfunction in diabetics without coronary artery disease, hypertension or other potential etiological conditions. the prevalence of a diabetic cardiomyopathy in cats has not been previously studied. we sought to prospectively identify if cardiac diastolic dysfunction was present or would develop in a population of cats with newly diagnosed dm. cats were recruited based on a diagnosis of primary dm. patients received physical examination, biochemical and hematologic profiles including thyroxin and insulin-like growth factor , urinalysis, blood pressure measurement, thoracic and abdominal radiographs and abdominal ultrasound. echocardiography was performed at both diagnosis and months post diagnosis. echocardiographic assessment included conventional d, m-mode, spectral and tissue doppler measurements. patients with relevant concomitant systemic illness or secondary dm were excluded from the study. healthy age matched control cats were retrospectively enrolled. thirty-two diabetics (d ) were enrolled in the study. eighteen were females and were males. mean age was . years. on march , cats had received a month echocardiographic control (d ). ten control cats were enrolled (c). eight were males and females. mean age was . years. results ( fluoroscopically guided pacemaker implantation imparts a risk of radiation exposure. ideally exposure risk should be minimized or avoided. we previously reported using transthoracic (tte) and transesophageal echocardiography to guide pda occlusion and balloon valvuloplasty. therefore, we hypothesized that tte could be used to minimize fluoroscopy time during pacemaker implantation in dogs. we implanted single bipolar lead pacemakers (vvir) in dogs, using either active or passive fixation, as determined by tte assessment of the right ventricular apical myocardium thickness: in dogs with an apical rv thickness < . mm we implanted passive fixation leads. dogs were anesthetized, positioned in right lateral recumbency on a standard echocardiography table and a left jugular vein exteriorization and venotomy were performed. in all dogs, a permanent pacing lead was advanced through the left jugular venotomy and was directed from cranial vena cava through the right atrium into the rv with tte guidance. echocardiographic right parasternal views optimized to visualize the pacing lead were used, starting with a short axis image of the right atrium and ending with a long axis view of the rv optimized to image the ventricular apex. after placing the pacing lead in the rv apex with tte guidance, and after acceptable measures of the capture threshold and impedance had been obtained, fluoroscopy was used to confirm lead placement. the pulse generator was connected to the pacing lead and secured within a right dorsal cervical pocket. incisions were closed routinely and post-implantation thoracic radiographs were performed. the pacing lead appeared hyperechoic on tte images and tte guidance provided images of a quality sufficient to clearly monitor implantation in real-time. real-time monitoring allowed for immediate corrections to pacing lead malpositioning or excessive looping. with active-fixation leads, tte allowed visualization of the fixation helix being implanted into the myocardium in some cases. the right parasternal echocardiographic window allowed imaging of the different positions of the lead in the cardiac chambers during the entire procedure. the implantations were successful in all dogs but in the first cases we required fluoroscopic guidance to follow the intraventricular progression of the lead. in the last dogs we only used the fluoroscope as an intraoperative x-ray machine (no cine mode). we have demonstrated that tte monitoring can guide pacemaker lead implantation and that fluoroscopy is only required to confirm the correct placement of the lead just before the end of the procedure. disclosures: no disclosures to report. deciding whether a cardiac murmur is innocent or the result of a congenital cardiac anomaly could be challenging. the gold standard method to differentiate innocent murmurs from congenital cardiac anomalies is echocardiogram, performed by a skilled operator. the present study investigated whether objective auscultation-criteria can differentiate innocent from pathologic murmurs in asymptomatic puppies between . - months of age. the null-hypothesis was that a systolic murmur with an intensity of - out of with a musical character is innocent. a total of puppies were included between july and january . these puppies originated either from breeders who brought their puppies to the clinic for screening for congenital porto-systemic shunts, or were referred to the cardiology service for evaluation of a murmur. of the puppies that were brought for shunt-screening puppies (age - days) had a murmur that was audible on every beat. all these dogs were small terrier breeds. dogs with intermittently audible murmurs were excluded. the remaining puppies (age - days) were referrals to the cardiology service. based on the above described auscultation criteria the murmur was classified as innocent in dogs and pathologic in dogs. on each of the dogs an echocardiogram was performed. no abnormalities were seen in of the dogs whose murmur was classified as innocent. echocardiography revealed one or more congenital cardiac anomaly in of the dogs whose murmur was classified as pathologic. the congenital anomalies were patent ductus arteriosus, pulmonic stenosis ( severe, moderate and mild; in combination with a small ventricular septal defect), aortic stenosis ( severe and moderate), ventricular septal defects, mild mitral valve dysplasia and double-chambered right ventricle (both moderate, isolated and combined with a mild aortic stenosis, small ventricular septal defect and mild mitral valve dysplasia). the puppy with the isolated mild mitral dysplasia had a soft systolic murmur with a musical character. on every puppy with a murmur of the shunt-screening group also a phonocardiogram was performed. phonocardiograms of the innocent murmurs revealed early systolic murmurs with low amplitude. auscultation turned out to be a sensitive and specific method to differentiate innocent murmurs from pathologic ones. phonocardiogram did not have an additional value. limitation: the above described findings may not be used in breeds predisposed to aortic stenosis, such as boxer. disclosures: no disclosures to report. since the first description of feline hyperthyroidism (feht ) several epidemiological studies have suggested diet as a causal factor of feht . the aim was to critically assess the evidence presented in epidemiological studies suggesting food-associated factors in etiology of feht . scientific literature was screened for peer reviewed publications investigating food-associated factors in feht since it was first described in . study designs were checked against classical epidemiology biases. food-associated factors showing an increased risk for feht were assessed for compatibility with the bradford-hill (b-h) criteria, which are used to evaluate whether an association involves a causal component. evidence for a causal component is higher when more b-h criteria are met. a total of publications investigating food-associated factors in feht were identified, all retrospective. three publications investigated qualitative factors only (e.g. preferred food flavors) but not quantitative. feeding canned food was not found to be a significant risk factor for feht in one study, while it was found to be a significant and quantitative risk factor in publications. however there were important limitations in their design: controls included sick cats ( studies), cases outnumbered controls ( studies), cases and controls differed in age ( studies), or diet information did not reflect diet fed at time feht developed ( studies). three out of b-h criteria were met when considering canned diet feeding as an increased risk for feht development. from the available literature there is insufficient evidence to conclude that canned diet is a food-associated factor in the etiology of feht . retrospective studies only describe an association and not a cause to effect relationship, are sensitive to bias from host and environment, and are less likely to identify etiologic factors when prevalence is below % as is the case in feht . hypotheses linking food-associated factors to feht (such as bpa, pbdes, flavonoids and iodine content) have never been proven to date, and lifelong prospective studies are required to investigate food-associated factors in etiology of feht . an iodine-restricted food has been recently introduced as a potential therapeutic option for feline hyperthyroidism. no controlled studies have been published on this treatment. the aim of this non-randomised controlled trial was to evaluate the effects of the iodine-restricted food on serum tt concentrations, clinical and clinicopathological parameters in client-owned cats with hyperthyroidism. indoor cats with newly diagnosed hyperthyroidism (consistent clinical signs and serum tt concentration > nmol/l), with or without mild to moderate azotemia (iris stage≤ ), were included. cats with severe concurrent disorders (i.e. lymphoma, neoplasia, malabsorption or severe azotemia [iris> ]) were excluded. cats were allocated on owner preference into groups: group a received an iodine-restricted food as a single therapy; the control group (group b) received transdermal methimazole in pluronic Ò lecithin organogel (plo, mg/ml) at the starting dose of . mg/cat q h. in both groups clinical parameters, biochemistry and serum tt were evaluated at baseline (t ), (t ), (t ), (t ), and (t ) days after treatment began. twenty-five cats were enrolled in the study, were included in group a, and in group b. no statistical differences were present between group at t for signalment, clinical and laboratory findings, including tt concentrations. in group a, only / cats ( . %) completed the study. the causes of interruption were: food refusal in / ( . %), loss to follow-up in / ( . %), death of unrelated cause in / ( . %), and poor owner compliance in / ( . %). in group b, / cats ( . %) completed the study. the causes of interruption were: suspected methimazole induced hepatotoxicity in / ( . %) and loss to follow-up in / ( . %). median serum tt concentration at t was nmol/l (range - nmol/l) in group a, and nmol/l (range - nmol/l) in group b. no significant differences were found in serum tt concentrations between group a and group b in any of the evaluated timing. bodyweight and serum creatinine significantly increased only in group b between t and t (p = . and p = . , respectively); nevertheless, urea did not significantly change in both groups. ast, alt, and alp significantly decreased only in group b between t and t (p = . , p = . and p = . , respectively). these results suggest that iodine-restricted food is effective in reducing serum tt concentration in hyperthyroid cats. compared to transdermal methimazole, food does not produce an increase in serum creatinine, but apparently is less effective in improving bodyweight and liver parameters. disclosures: no disclosures to report. the objective of this study was to identify whether pre-treatment plasma ionized calcium (ica) concentrations are predictive of hypocalcemia following parathyroid removal or heat ablation in dogs with primary hyperparathyroidism. fifty-five dogs seen between january , and february , met the inclusion criteria of having persistent hypercalcemia (defined as ica > . mmol/l) due to primary hyperparathyroidism, absence of pre-emptive calcitriol therapy, and ica monitoring post-operatively. each dog was treated with surgery (n = ) or ultrasound-guided percutaneous heat ablation (n = ). hypercalcemia resolved for all dogs within hours of the procedure. dogs were split into pretreatment ica groups of . - . mmol/l, . - . mmol/l and > . mmol/l. there was a significant association between higher pretreatment hypercalcemia and lower post treatment hypocalcemia. in addition, there was a significant dose-response relationship between pretreatment calcium concentration and the absolute decline in calcium following treatment. sixteen dogs became notably hypocalcemic (ica < . mmol/l). four out of dogs with pretreatment ica ≤ . mmol/l, out of dogs with ica between . - . mmol/l and out of dogs with pretreatment ica ≥ . mmol/l became hypocalcemic (ica < . mmol/l). adverse effects of hypocalcemia were observed in dogs, of which had pretreatment ica > . mmol/l. given the risk of significant hypocalcemia following parathyroid removal in dogs with pretreatment ica > . mmol/l, these patients should be treated to prevent rapid decline and development of clinical hypocalcemia. disclosures: no disclosures to report. diabetes mellitus is estimated to affect . % of pet dogs in the uk. most cases are thought to result from insulin deficiency resulting from loss of pancreatic beta cells, similar to human type diabetes. juvenile-onset diabetes is rare (catchpole, et al., ) . seven labrador retriever puppies were diagnosed with diabetes mellitus at between and weeks of age on the basis of the presence of hyperglycaemia, glucosuria and compatible clinical signs including polyuria, polydipsia and polyphagia. two of the dogs were known to be related (full siblings); of the remaining cases, other family members (full or half siblings or one sire) were also reported to be affected, though clinical details were not available. pancreatic histopathology at post mortem in cases showed islet hypoplasia. in the only puppy tested, hypoinsulinaemia was identified. two puppies were euthanased soon after diagnosis, were lost to follow up and survived to > years of age with well controlled diabetes. due to the early age of onset and occurrence within a single breed, it was hypothesised that diabetes in these cases might be due to mutation(s) in a single gene. three candidate genes were selected on the basis that they are the more common genetic causes of monogenic diabetes in human neonates or young children (kcnj , hnf a, hnf a). the coding regions of the canine orthologues of those genes (q bmm _canfa, hnf a, hnf a, respectively) were amplified and sequenced from genomic dna from all affected puppies and unaffected siblings and control labradors. no variants were identified in the coding sequences of hnf a or hnf a. in q bmm _canfa, novel, synonymous coding, single nucleotide base substitution variants were identified in of the affected dogs. however, these variants were considered unlikely to be the cause of the clinical syndrome, as their presence did not co-segregate with disease within families or across the cohort and did not change the protein coding sequence. in conclusion, we report a case series of labrador puppies suspected to be affected with monogenic diabetes mellitus, and results of candidate gene screening which did not identify a causa-tive mutation. further investigation of a possible genetic cause would be required to elucidate the cause of early onset diabetes in this breed. disclosures: er's salary and laboratory costs were paid using a grant from the wellcome trust. samples were submitted to the canine diabetes register at the rvc which has received funding from masterfoods, kennel club charitable trust, msd animal health and eu grant fp 'lupa'. meh is a trustee of the kennel club charitable trust. he was not part of discussions to award funding to the canine diabetes register. some samples were submitted as part of ljd's phd which was funded by the rvc (clinical research fellowship) with additional funding from intervet pharma r&d (currently msd animal health). diabetes mellitus (dm) is a common feline endocrinopathy and pathophysiologically similar to human type diabetes (t dm). t dm occurs due to a combination of insulin resistance and b-cell dysfunction. several studies have identified environmental and genetic susceptibility factors for t dm. in cats, environmental factors such as obesity and physical inactivity have been linked with dm; however, identification of genetic factors has been challenging. to date, mc r is the only gene shown to be associated with increased susceptibility to dm in overweight domestic short hair (dsh) cats. the aim of the present study was to perform a genome-wide association study (gwas) to identify loci associated with dm in lean dsh cats. illumina infinium k iselect dna arrays were used to interrogate genomic dna samples from lean diabetic dsh cats from the royal veterinary college feline dm archive and control dsh cats. the data was analysed using plink whole genome data analysis toolset. significance was established at p < À . snps with a minor allele frequency below . and a call rate below % and individuals with a genotyping rate < % were excluded from analysis. a total of , snps were available for analysis. after excluding cats with low genotypic rate, control dsh and lean diabetic dsh cats were evaluated. diabetic cats had a mean (sd) age of . ( . ) years; ( %) were male, ( %) female. non-diabetic cats had a mean (sd) age of . ( . ) years; ( %) were female, ( %) male. control cats were significantly older than diabetic cats (p < . ; t-test). five significant snps were identified: chra . (p = . À ); chrun . (p = À ); chrun . (p = À ); chrun . (p = À ) and chrun . (p = À ). the first snp is located within chromosome a ; the others are located within a . mb region towards the end of chromosome a . the snp in chromosome a is located kb upstream of dipeptidyl-peptidase- (dpp ), a peptidase similar to dpp- , involved in incretin inactivation. within the identified region of chromosome a , genes of interest include tmem and acp ; both have been associated with t dm in humans, most likely causing insulin resistance. this is the first gwas of dm in cats. a number of significant snps have been identified; some of which are located in proximity to genes that have been associated with t dm in humans others could be involved in pathophysiology related to dm. further investigation of these candidate genes is warranted. disclosures: snp chips for the gwas were provided by the morris animal foundation. diabetes mellitus (dm) and its treatment have been documented to exert a negative psychosocial impact on cats and their owners. common owner concerns include hypoglycaemia worry, socialand work-life impact and a desire for more control over their cat's treatment. home blood glucose monitoring (hbgm) has been suggested to enable superior glycaemic control and could address some of the above-mentioned quality-of-life (qol) issues. conversely, hbgm could also exert negative psychosocial effects such as disturbance of the cat-owner bond. this prospective -month trial aimed to document the acceptance rate of hbgm among owners of diabetic cats, reasons for declining hbgm, possible impact on glycaemic control and whether acceptance altered pet and owner qol measured through the use of a validated psychometric diabetic pet qol-tool (diaqol-pet). at baseline (m ) all owners of recently diagnosed cats received a veterinary glucometer (alphatrak Ò , zoetis) and a standardised demonstration of its use on their cat. diabetic management was standardised and included a low carbohydrate diet, twice-daily insulin following a standardised dose-adjustment-protocol according to, initially, weekly blood glucose curves (bgcs) carried out through hbgm (if adopted; hbgm-group) or in-hospital (if not adopted; non-hbgm-group). mann-whitney u-tests assessed for significant differences in fructosamine, average bgc-value, insulin dose and diaqol-pet-scores at m and month (m ) between the hbgmand the non-hbgm-group. fisher's exact test was used to compare remission rates; average values are given as median (range). hbgm was introduced to owners and was successfully adopted by ( . %). reasons for failure were patient aggression (n = ), owner concerns about patient distress (n = ) and lack of available assistance (n = ). at m , there was no significant difference in fructosamine (hbgm: ( - )lmol/l, non-hbgm: ( - )lmol/l; p = . ), insulin dose (hbgm: . ( - . )u/kg/dose, non-hbgm: . ( . - . )u/ kg/dose; p = . ), average bgc-value (hbgm: . ( . - . ) mmol/l, non-hbgm: . ( . - . )mmol/l; p = . ) or overall diaqol-pet-score (hbgm: À . ( . to À . ), non-hbgm: À . (À . to À . ). on examination of individual diaqolpet-categories hbgm-cat owners reported no significant difference in the bond they felt with their cat (p = . ), degree of worry about hypoglycaemia (p = . ) or restriction to their work-(p = . ) or social-life (p = . ) compared to the non-hbgmgroup. four hbgm-cats ( . %) achieved diabetic remission; none of the non-hbgm-group did (p = . ). hbgm can be successfully adopted in a majority of cat-owner combinations without a demonstrable extra burden on cat and owner's qol. hbgm also did not appear to compromise owners' relationships with their cat. a larger sample size is likely needed to assess whether hbgm promotes superior glycaemic control and remission. disclosures: the research presented in this abstract was supported by zoetis. the clinic at which this research was conducted is also supported by boehringer ingelheim and nestle purina pet-care. ruth gostelow and christopher scudder both receive phd funding from the evetts-luff animal welfare trust. stijn neissen acts as a consultant for the veterinary information network (vin). a major difficulty in the management of diabetes mellitus (dm) is our inability to predict blood glucose values in response to an insulin dose. this is linked to the existence of numerous factors impacting on blood glucose in the diabetic patient (e.g. caloric intake, type of food, exercise, insulin type and dose, stress). artificial neural networks (anns), which are statistical learning algorithms, have shown potential to aid in this prediction process in human dm. their development has been hugely aided by the introduction of continuous glucose monitoring systems (cgms), enabling generation of sufficient data-points. the goal of the current study was to develop an ann for feline dm. algorithms were developed with matlab Ò (mathworks, uk) using data on exogenous insulin dose, serial blood glucoses (obtained through traditional blood glucose curves and cgms) and caloric intake over hours of diabetic cats. all cats were maintained in an environment that enabled normal activities, limiting stress. the neural network toolbox tm (mathworks, uk) was used to construct and test types of anns: multi-layer perceptron (mlp) and radial basis function (rbf). both anns were trained using the diabetic cat data, followed by so-called detrending, elimination of outliers and configuration of external delays. in order to increase accuracy, neural architecture was set as a single hidden layer with a maximum of neurons; inclusion of saturated neurons was forbidden. the accuracy of the resulting mlp and rbf models was assessed by calculating the mean squared normalised error (threshold: . ), generated through comparison of predicted data with actually registered data in recruited diabetic cats. in total, diabetic cats were recruited for this study ( males, females, . ae . [sd]kg, age . ae . ; burmese, dsh, other breeds). all had a -hour blood glucose curve performed (n = with cgms) and response to insulin was predicted by mlp and rbf. calculation of the mean squared normalized error revealed that in / diabetic cats ( %; mlp) and / ( %; rbf), the dynamics of the blood glucose curve were correctly predicted by the ann. in conclusion, our study is the first to describe the successful development of an ann to predict blood glucose dynamics in insulin-treated diabetic cats. further evaluation is indicated, though ann-model-based prediction of glucose concentration may allow clinicians in future to optimise insulin management protocols or may allow the development of an artificial pancreas for the diabetic cat. disclosures: no disclosures to report. glucagon-like peptide (glp) - analogues induce significant weight loss in humans; presumably by slowing gastric emptying and increasing satiety. in lean purpose-bred cats, short-term glp- analogue treatment also induced weight loss. we evaluated the effect of weeks exenatide, a glp- analogue approved for treatment of human type diabetes, or placebo treatment on body composition and adipokines in obese, client-owned cats. cats were randomized to subcutaneous saline (n = ) or exenatide (n = ) injections; . lg/kg q h during the initial weeks and . lg/ kg q h during the following weeks. body weight, body composition using dual-energy x-ray absorptiometry and adipokine levels were measured before and after treatment. all cats were obese (body condition score ≥ out of ). mean body weight was . kg (range . - . kg) and mean % body fat was . % ( . - . %). median percent loss of baseline body weight was . % (range . - . %) for exenatide and . % (range À . to . %) for placebo. only the exenatide group had a significant absolute weight loss; however the difference in median percent loss between groups was not significant. change in total amount or % body fat were not different between groups. correspondingly, plasma leptin and total adiponectin were unaltered by treatment. complications were limited to a single, mild hypoglycemic episode and cases of self-limiting gastrointestinal signs. we conclude that the appointed dose of exenatide was well tolerated and safe in obese healthy cats. a larger study population may be required to fully elucidate the effect of exenatide in obese cats. disclosures: no disclosures to report. feline diabetes mellitus (dm) is recommended to be treated through addressing underlying diseases, bid insulin injections and low carbohydrate diets. good glycaemic control is suggested to promote diabetic remission. a recent systematic review of feline dm literature identified studies on glargine and lente insulin to be proportionately overrepresented compared to other insulin types. additionally, most insulin studies suffered from lack of screening for concurrent disease, homogeneity in management and assessment of quality of life (qol). until recently, only porcine lente insulin was available as a veterinary-licensed product. this prospective trial evaluated the impact of newly veterinary-licensed human-recombinant protamine zinc insulin (prozinc tm , boehringer ingelheim) on clinical signs, glycaemic control and qol in diabetic cats. recently (< months) diagnosed diabetic cats, treated with caninsulin Ò (msd) bid for at least weeks and receiving a specific low carbohydrate diet were recruited. a full history, physical examination, diabetic clinical score (dcs; range [no diabetic signs] - [many diabetic signs]), fructosamine concentration, hour blood-glucose-curve (bgc) and qol-assessment (diaqolpet-score) were performed before and months after transition to prozinc tm (start dose: . - . unit/kg bid), following a set protocol of weekly bgcs and dose adjustments ( . - unit change/injection/week guided by nadir). cats were excluded if screening (biochemistry, urinalysis, fpli, tt , igf- , abdominal ultrasound) identified: ketoacidosis, clinical pancreatitis, glucocorticoid/ progestogen administration, hyperthyroidism, acromegaly, other conditions impairing treatment response. data were assessed for normality and reported as meanae-standard deviation; changes were assessed using paired t-tests (p < . ; without multiple comparisons correction following latest statistical guidelines). sixteen cats were recruited ( male neutered, female neutered; age ae months); all completed the trial. at time of entry cats received . ae . unit/kg caninsulin bid, had a dcs of . ae . ; diaqol-pet-score of - . ae . ; bgc-value of . ae . mmol/l; and fructosamine of ae lmol/l. three months after transitioning to prozinc tm , cats were receiving . ae . unit/kg bid; had a significantly lower mean dcs ( . ae . , p = . ) and diaqol-pet-score (À . ae . , p = . ); bgc-value ( . ae . mmol/l) and fructosamine ( ae lmol/l) were also lower, though not significantly (p = . and p = . , respectively). three cats entered diabetic remission ( %). these results show that transitioning cats from caninsulin to prozinc tm produced a significant improvement in clinical signs and qol. more cases are likely needed to document any additional significant glycaemic impact after transition. finally, in veterinary dm research, this represents the first clinical trial to include validated quantitative qol-assessment as an outcome parameter. disclosures: the study described in this abstract received financial support from boehringer ingelheim. the clinic in which this research was produced also receives support from nestle purina petcare and zoetis. ruth gostelow and christopher scudder both receive phd funding from the evetts-luff animal welfare trust. stijn niessen is a consultant for the veterinary information network (vin). a. hope, s. spence, i.k. ramsey. university of glasgow small animal hospital, bearsden, uk serial blood glucose measurements are currently used as an accepted method to assess diabetic control, however extended curves are expensive and can be technically challenging. a new day continuous glucose monitoring system (cgms) called the dexcom g platinum Ò that incorporates a glucose oxidase-based sensor to measure interstitial blood glucose was evaluated by comparing the results to the blood glucose measured contemporaneously on a glucometer (alphatrak Ò ). these measurements were made at least twice daily at the time of calibration of the cgms, which was a variable period (but not more than hours) after the previous calibration. a total of measurements from eight dogs' glucose curves (blood glucose range - . mmol/l, with a median of . mmol/l) were compared to a paired measurement of interstitial glucose by calculation of the pearson correlation coefficient (r). a minimum of measurements were obtained from each dog. the device only provides a specific measurement of interstitial glucose in the range . to . mmol/l. values above and below this range were not included in the study. subjectively, the device was easy to use with an intuitive user interface that provided wireless real time measurements and was much smaller than older cgms systems. overall, there was excellent correlation between the glucometer and the cgms readings (r = . ), which was statistically significant (p = < . ). the range of differences between the blood and interstitial glucose concentrations was - . mmol/l with a median of . mmol/l. problems encountered with the system included detachment of the system from the dog's skin, as well as variably correlated glucometer and cgms readings in individual dogs (r range . - . , median . ). in conclusion, the dexcom Ò g cgms can be used to assess interstitial glucose concentrations in dogs, and these are generally well correlated with blood glucose concentrations. more work is needed (with larger numbers of patients) to determine the relationship of the correlation to the timing of calibration, and to determine why some dogs seem to have poorer correlation than others. disclosures: no disclosures to report. several continuous glucose monitoring systems that measure interstitial glucose (ig) are currently available. however, they require multiple calibrations and therefore multiple blood sampling; moreover, the sensors are quite expensive and can be used only for a few days. a new human flash glucose monitoring system (fgm) (freestyle libre, abbott, uk) measures ig, does not require calibration, is rather inexpensive and the sensor can be used as many as days. it is composed by a small sensor applied subcutaneously that has to be "scanned"with a reader to obtain real time glucose values. the aim of this study was to assess the accuracy of this fgm in diabetic dogs. in all dogs the sensor was placed on the neck area and fixed with an adhesive patch. during the st - nd, th - th, th - th days from the application, the ig measurements were compared with the peripheral blood (edta plasma) glucose (pg) concentrations analysed by a reference hexochinase based method (olympus/beckman coulter au ). linear regression, bland altman plots and the clarke error grid analysis were used to assess the accuracy. ten client-owned diabetic dogs on insulin treatment were included. median age was . years (range - ), were female (spayed), were male ( neu-tered). median body weight was . kg (range . - . ). four hundred and sixty four simultaneous measurements were taken with fgm (ig) and with the reference method (pg): samples were in the hypoglycemic range (< mg/dl), in the euglycemic range ( - mg/dl) and in the hyperglycemic range (> mg/dl). considering all the measurements together a positive significant correlation between ig and pg concentrations (r = . ) was found. meanaestandard deviation difference from the reference method was À . ae mg/dl in the hypoglycemic range, À . ae mg/dl in the euglycemic range, À . ae mg/dl in the hyperglycemic range. ig values differed > mg/dl from the reference method in %, % and % and > mg/dl in %, % and % in the hypoglycemic, euglycemic and hyperglycemic range, respectively. underestimation-overestimation of ig compared to pg was observed in - %, - % and - % of hypoglycemic, euglycemic and hyperglycemic measurements, respectively; . % and . % of glucose values measured by fgm fall in zone a and zones a+b of the error grid analysis, respectively. the application of the sensor was easy and apparently painless; a mild local erythema after sensor removal was found in / dogs. fgm is a simple and promising glucose monitoring system that seems accurate for the clinical use in diabetic dogs. disclosures: no disclosures to report. the cornerstone of treatment in diabetic cats is insulin. among other issues, insufficient duration of insulin action may lead to poor metabolic control and persistence of clinical signs. with the aim to improve current therapeutic options, the present study evaluated pharmacodynamics parameters, such as onset of action, time to glucose nadir and duration of action, of protamine zinc insulin (prozinc Ò , boehringer ingelheim) and insulin degludec (tresiba Ò , novo nordisk) in healthy cats. additionally, the accuracy of different sensors, sof-and enlite-sensor, of the continuous glucose monitoring system (cgms) ipro Ò (medtronic) was determined with particular attention to the low glycemic range, since reliability of cgms in case of hypoglycemia is crucial. three different doses ( . , . and . iu/kg) of each insulin and both ipro Ò sensors were tested in healthy purpose bred cats in a randomized crossover trial. the sensors were placed in the neck area for days. paired glucose measurements were obtained every - hours with a validated portable blood glucose meter (alphatrak Ò , abbot) set as standard and accuracy was assessed by using iso criteria. additionally, to determine onset of insulin action, time to glucose nadir and duration of action, glucose concentrations were measured and minutes before and , , , , , , and minutes after each insulin administration, then every hours for hours. median (range) onset of action was . ( . - ) hours for pro-zinc Ò and . ( . - ) hours for tresiba Ò . median (range) time to glucose nadir and duration of action were ( . - ) hours and ( - ) hours for prozinc Ò and . ( ) ( ) ( ) ( ) ( ) ( ) hours and ( -> ) hours for tresiba Ò , respectively. with regard to ipro Ò , % of paired glucose measurements with both sensor types were in zone a and b of the consensus error grid. at glucose concentrations < . mmol/l % ( / ) of sof-sensor measurements and % ( / ) of enlite-sensor measurements were within ae . mmol/l of the standard; at glucose concentrations > . mmol/l % ( / ) of sof-sensor measurements and % ( / ) of enlite-sensor measurements were within ae % of the standard. in conclusion, healthy cats injected with prozinc Ò and tresiba Ò showed similar onset of action. later glucose nadir and longer duration of action was seen in cats treated with tresiba Ò compared to those treated with prozinc Ò . both ipro Ò sensors revealed good clinical accuracy and performed similarly in the low glycemic range. disclosures: no disclosures to report. the canine adrenal cortex consists of concentric zones: the zona glomerulosa (zg), the zona fasciculata (zf) and the zona reticularis (zr), which produce mineralocorticoids, glucocorticoids and androgens, respectively. in humans, critical step for the production of either aldosterone or cortisol are the zg-specific aldosterone synthase (cyp b ) and the zf-specific b-hydroxylase cytochrome p (cyp b ). the fact that humans and dogs have the same adrenocortical end products, i.e. aldosterone and cortisol, has led to the assumption that canine steroidogenesis is identical to that of humans. however, in dogs, the zonal expression of steroidogenic enzymes has not been studied previously. moreover, in dogs the expression of cyp b / is unclear, as only one coding gene sequence (cyp b ) has been published in the ncbi database and, adjacent to this, a large non-sequenced gap is present. we hypothesized that canine adrenals possess only one cyp b gene, similar to sheep and pigs. zg and zf tissue was isolated separately by use of laser-guided microdissection of adrenals of healthy dogs. the zone-specificity of the tissues was confirmed by specific markers, with mrna relative expression of wnt , angiotensin ii receptor and disabled- being significantly higher (p = . , p = . , p = . , respectively) in the zg compared to the zf. rt-qpcr analysis of mrna relative expression of steroidogenic enzymes demonstrated a significantly higher fold change of steroidogenic acute regulatory protein (star), cytochrome p side chain cleavage (cyp a ) and a-hydroxylase/ , -lyase (cyp ) (p = . , p = . , p = . , respectively) in the zf compared to the zg. the zfspecific presence of cyp was also demonstrated by immunohistochemistry. no significant difference (p = . ) in the mrna relative expression of cyp b mentioned in the database was found, and southern blot analysis showed that the non-sequenced gap does not contain another cyp b gene. we conclude that there is only one functional cyp b enzyme in canine adrenals. the zone-specific production of aldosterone and cortisol is probably due to zone-specific cyp expression. its presence in the zf is crucial for cortisol synthesis, while lack of cyp in the zg conducts steroidogenesis to mineralocorticoid production. this is the first report providing insights in one of the most important physiological mechanisms of the canine adrenal cortex, its zone-dependent steroidogenesis. disclosures: no disclosures to report. the pathogenesis of cortisol-secreting adrenocortical tumors (ats) has become more clear recently. mutations of the gnas gene provide an explanation for acth-independent hormonal activity of ats, but the autonomous growth remains greatly undisclosed. an approach to elucidate the proliferative capacity of ats is to learn from the current understanding of adrenal growth biology. the sonic hedgehog (shh) signaling pathway plays an essential role in the development of the adrenal gland and in regulating adrenocortical cell proliferation. the members of the shh signaling pathway are present in progenitors of the steroidogenic cells of the normal adrenal gland and dysregulation of shh signaling has been implicated in adrenal cancer in humans. we hypothesized that shh signaling is also enhanced in canine ats, predominantly in carcinomas. we examined the relative expression of shh pathway components (shh, ptch , smo, gli , gli and gli ) by rt-qpcr analysis in cortisol-secreting adenomas (n = ) and carcinomas (n = ) and normal canine adrenals (n = ). the relative expression of members of the shh pathway was detected in both ats and normal adrenal tissue. a significant (p < . ) lower mrna expression of gli was detected in carci-nomas when compared to normal tissue. amongst the other genes, no significant differences were found. since gli is mainly a repressor of genes activated by the shh pathway, a down regulation of gli in carcinomas could point to enhanced shh signaling in adrenocortical carcinomas and could theoretically be responsible for their expansive growth. in conclusion, dysregulation of shh pathway might be involved in the pathogenesis of canine cortisol-secreting carcinomas. modulating shh expression might provide a new target therapy for adrenocortical carcinomas and will need to be explored in the future. disclosures: no disclosures to report. feline hypersomatotropism (acromegaly) has been suggested to be an underdiagnosed endocrinopathy among diabetic cats. treatment options include management of the secondary diabetes mellitus alone, medical pituitary inhibition, radiotherapy (rt) and hypophysectomy (hpx). tools to diagnose the disease and monitor treatment effect are limited, with insulin-like growth factor- (igf- ) currently being the only easily accessible blood test. serum igf- has previously been shown to be insensitive when assessing rt effect. development of additional serological diagnostic tools that can be measured alongside serum igf- is therefore desirable. a pilot study previously validated an n-terminal type iii pro-collagen propeptide (piiinp) elisa for use in cats and found this peripheral biomarker of collagen turnover to be significantly elevated in a small number of hypersomatotropic diabetic (hsdm) cats. this study therefore aimed to: . further evaluate the use of serum piiinp to differentiate hsdm from dm; and . to evaluate piiinp as a marker for treatment success. piiinp concentrations were measured in cats with uncomplicated diabetes mellitus (dm) (igf- < ng/ml [radioimmunoassay], < . iu/kg/injection exogenous insulin requirement) and with confirmed hsdm (igf- > ng/ml, pituitary mass on computed tomography) using the previously validated elisa. additionally, piiinp and igf- were measured in preand post-treatment ( - months) samples of hsdm cats that responded favourably (decreased insulin requirement) to radiotherapy (rt; n = ) or hypophysectomy (hp; n = , of which had achieved diabetic remission at time of sampling). serum piiinp concentrations were significantly higher in hsdm cats (median . ng/ml; range: . - . ) compared to dm cats (median . ng/ml; . - . ; p < . , mann whitney u-test). receiver-operator-curve-analysis revealed a . ng/ml cut-off to differentiate between dm and hsdm cats with % sensitivity and % specificity (auc: . ; % confidence interval: . - . ). after rt, piiinp increased significantly (median pre-rt . ng/ml, . - . ; post-rt . ng/ml, . - . ; p = . , wilcoxon signed rank-test) despite absence of significant change in igf- concentrations (median pre-rt ng/ml, - ; post-rt ng/ml, - ; p = . , wilcoxon signed rank-test). following hpx, serum piiinp concentrations did not change significantly (median pre-hpx . ng/ml, . - . ; post-hpx . ng/ml, . - . ; p = . , wilcoxon signed rank-test) despite significant serum igf- decreases (median pre-hpx ng/ml, - ; post-hpx ng/ml, - ; p = . , wilcoxon signed rank-test). in conclusion, serum piiinp concentration was confirmed to be a useful additional parameter when differentiating hsdm from dm in cats. however, the current data do not suggest piiinp to be a reliable marker of treatment success following rt or hpx. disclosures: no disclosures to report. decreased frequency and function of peripheral regulatory t cells (tregs) have been documented in people with immune-mediated haemolytic anaemia (imha), suggesting that defects in peripheral tolerance may play a role in the pathogenesis of this disease. the aim of the current study was to test the hypothesis that the frequency of peripheral tregs is decreased in dogs with primary imha, accompanied by increases in t helper (th) cells, cytotoxic t (tc) cells and b cells. residual edta-anticoagulated blood samples were obtained from dogs with primary imha (n = ), dogs with inflammatory diseases (n = ) and healthy dogs (n = ). primary imha was diagnosed in dogs with regenerative anaemia (packed cell volume [pcv] < %) and either persistent agglutination of erythrocytes after saline dilution or detection of spherocytosis on a fresh blood smear. the study was approved by an institutional ethics and welfare committee. after erythrocyte lysis, peripheral blood mononuclear cells were stained with fluorophore-conjugated antibodies specific for extracellular (cd , cd , cd ) and intracellular (cd b, foxp ) antigens. multicolour flow cytometry was undertaken to determine the proportion of lymphocytes that were b cells (cd b hi ), th cells (cd hi cd + ), tc cells (cd hi cd + ) and tregs (cd hi cd +-foxp + ); the kruskal-wallis test was used to compare proportions between groups. correlations between the proportions of tregs and pcv and serum total bilirubin concentration (tbil) in dogs with imha at presentation were assessed using spearman's rho coefficients. the median proportion of cd + t cells that expressed foxp was . % (inter-quartile range [iqr]: . - . ) in dogs with imha, . % (iqr: . - . ) in dogs with inflammatory diseases and . % (iqr: . - . ) in healthy dogs, with no difference between groups (p = . ). there was no difference in proportions of t cells that were cd + (p = . ) or cd + (p = . ) between groups, nor in the proportion of b cells (p = . ). the proportion of cd hi cd + foxp + tregs was positively correlated with tbil in dogs with imha (spearman's rho . , p = . ), but not pcv (rho À . , p = . ). though limited by its size, the results of this pilot study suggest that the frequency of tregs is not decreased in dogs with imha; proportions of th, tc and b cells were also comparable to those in control dogs. further work is required to determine whether the function of tregs is altered, or whether other defects in peripheral tolerance contribute to development of this disease. disclosures: no disclosures to report. xenotransfusion of canine blood to cats may be a life-saving procedure when treating an acute anaemic syndrome and compatible feline blood cannot be obtained. published evidence in a limited number of cases dating from the s indicates that cats do not appear to have naturally-occurring antibodies against canine red blood cell antigens. in fact compatibility tests before the first transfusion did not demonstrate evidence of agglutination or haemolysis of canine erythrocytes in feline serum and no severe acute adverse reactions have been reported in cats receiving a single transfusion with canine blood. severe acute reactions not reported so far cannot however be excluded and we decided to perform a pilot study to evaluate the presence of naturally occurring antibodies against canine red blood cell antigens in cats and viceversa. surplus material from diagnostic samples (blood edta and blood serum samples) of cats and dogs was used to perform test-tube major and minor cross-match tests (at °c, °c and room temperature (rt)) and blood typing, after obtaining the informed consent from owners. hemolysis, macro-and micro-ag-glutination were investigated in each test tube and were considered markers of a positive matching. blood from each cat was tested with blood from to different dogs for a total of major and minor cross-matchings each one performed at the different temperatures of incubation. thirty-eight overall major cross-matchings proved positive at °c, at rt and at °c respectively. the minor cross-matching was positive in all but tests performed at °c. no cat tested totally negative ( °c, °c, rt) at both major and minor cross-matching procedures performed towards any single dog. ten cats experienced positive major and minor cross-matching at °c, rt and °c towards - different dogs. five cats were positive in the major cross-match, at least at °c, towards - different different dogs. seven cats obtained a positive major cross-match at rt and/or at °c towards - dogs. only cats tested completely negative at °c, rt and °c, in one out of the different major cross-matchings performed. in conclusion, naturally occurring antibodies against canine red blood cell antigens appear to be frequently detected in cats as well as those against feline red blood cell antigens in dogs. xenotrasfusion of canine blood to cats should only be performed after the selection of a compatible donor by means of at least a negative major cross-match test result. disclosures: no disclosures to report. anti-thymocyte serum (ats), a potent immunosuppressive agent, is commonly used perioperatively in human patients to increase graft survivaland decrease rejection of transplanted tissue. ats has been reported as part of an immunosuppressive protocol to treat immune-mediated diseases including aplastic anemiaand myelodysplastic syndromes (mds). rabbit anti-dog thymocyte serum (radts) has been used in veterinary medicine for perioperative immunosuppression in canine renal transplants. however, there are no reports regarding the use of radts in the treatment of dogs with immune-mediated disorders. the medical records of dogs diagnosed with imha, dogs with itp and dog with mds were reviewed. median age was . years ( . months to years). all dogs failed to respond to traditional immunosuppressive therapy and received radts. none of the dogs experienced any adverse reaction. lymphocyte counts were used to monitor the response to therapy. all dogs, except , had a significant decrease in their lymphocyte count; / had a decrease to < % of the initial lymphocyte count, which was the aim in previous studies on radts. all dogs were discharged, however, the same dog with no changes in his lymphocyte count experienced a relapse of his imha after week and was euthanized. all other cases achieved clinical remission with immunosuppressants being tapered or discontinued. radts appeared to be a safe immunosuppressant agent of interest in refractory immune mediated diseases. disclosures: no disclosures to report. in cats with upper respiratory tract aspergillosis (urta), invasive disease is common. in other species, invasive mycoses are associated with immunodeficiency. characterisation of the humoral immune response in feline urta serves to identify whether selective immunodeficiency underlies susceptibility and to determine the utility of class-specific antibody detection for early diagnosis. we have shown that serum anti-aspergillus igg has high sensitivity and specificity for diagnosis. the aims of the study were to ( ) determine whether serum anti-aspergillus iga can be detected in cats with urta, and ( ) evaluate the sensitivity and specificity of iga detection for diagnosis. sera were collected from groups of cats; group -confirmed urta (n = ), group -upper respiratory disease without aspergillosis (n = ), group -healthy cats (n = ) and cats with non-fungal, non-respiratory illness (n = ). an indirect elisa to detect anti-aspergillus iga was developed. inter-assay and intraassay coefficients of variation were . % and . %, respectively. serum iga was detected in . %, % and % of group , , and cats, respectively. using an optimal elisa cut-off value for diagnosis ( . elisa units/ml), determined by receiver-operating curve analysis, assay sensitivity for group cats was . %. specificity was highest ( . %) when group was used as the control, compared to group ( . %) or group and combined ( . %). we found no evidence of a role for primary iga deficiency in the pathogenesis of feline urta. serum anti-aspergillus iga detection has moderate sensitivity and moderate specificity for diagnosis of urta. disclosures: there is no conflict of interest. the study was partially funded by a australian companion animal health foundation grant . non-invasive topical infusion therapies are widely used in canine sinonasal aspergillosis (sna) but are time-consuming and associated with prolonged recovery and increased costs. therefore, the main goal of the present study was to compare the efficacy of a simplified infusion protocol (d e) with a -hour infusion protocol (d eb). d eb consisted in endoscopic debridement followed by minutes % enilconazole infusion and % bifonazole cream depot into the affected frontal sinus through endoscopically placed catheter. for d e protocol, after debridement, enilconazole infusion was shortened to minutes, with the dog remaining in dorsal recumbency, head flexed at °, during the whole procedure. adjunctive oral itraconazole therapy was prescribed in both protocols. effective debridement of fungal plaques is considered as an essential therapeutic step. unfortunately, it is not always possible to achieve perfect debridement of the sinonasal cavities, due to incomplete accessibility of the whole sinusal area with the endoscope; however, its effect has never been assessed as such. therefore, the second aim of this study was to evaluate the effectiveness of debridement on success rate after the first treatment. fisher's exact test was used to assess the difference in success rate between both protocols and in function of full debridement. twenty-eight dogs with sna were treated with d e and dogs with d eb. the median (range) duration of d e was only minutes ( - ) compared to minutes ( - ) for d eb. first treatment success rate did not differ between both protocols and were % for d e and % for d eb. both protocols had an overall success rate of % after procedures. in contrast to the majority of dogs with d eb, all dogs receiving d e recovered quickly and were discharged the same day. completeness of debridement was assessed endoscopically in dogs ( treated with d e and with d eb). debridement was judged complete in / dogs and had a significant effect on first treatment success rate (p = . ). when debridement was complete, % of the dogs (d e: / dogs; d eb: / dogs) were cured after the first procedure, compared to % (d e: / dogs; d eb: / dogs) of the dogs with incomplete debridement. we concluded that ( ) the simplified infusion protocol is quick, safe, easy and effective, and offers a favourable alternative to hour infusion protocols for treatment of canine sna; ( ) completeness of the debridement undoubtfully is an important step for treatment success of infusion protocols. disclosures: no disclosures to report. gastroesophageal (ge) symptoms are commonly reported in dogs with brachycephalic upper airway obstructive syndrome (bs). since ge symptoms frequently occur during situations of increased inspiratory effort (excitement, respiratory distress), dynamic disorders of the ge junction (gej) are probably involved, due to transient increased negative intrathoracic pressure. however, according to a previous study, only few dynamic abnormalities of the gej are observed during gastroscopy. we hypothesized that both anaesthesia and endotracheal intubation during gastroscopy lead to underestimation of gej abnormalities. the aim of this study was to improve detection of dynamic gej abnormalities during gastroscopy using obstructive manoeuvers mimicking and reproducing upper airway obstruction of variable severity. twenty-six dogs presented with bs were prospectively included. respiratory and digestive symptoms as well as endoscopic abnormalities were scored at initial diagnosis and at control month after surgery. during each endoscopy, gej was assessed and scored (based on esophagitis, gej atony, ge reflux, cranial displacement of the gej) in the consecutive situations: ( ) absence of obstruction with the dog intubated (ob- ), ( ) presence of natural obstruction with the dog extubated (ob-nat) and ( ) during complete manual obstruction of the endotracheal tube during up to spontaneous breathings (ob-compl). spearman's rank test was used to assess correlations between the different clinical and endoscopic scores. taking all endoscopic procedures together, the severity of respiratory symptoms correlated significantly with the severity of respiratory endoscopic abnormalities (p < . , r = . ) and the severity of digestive symptoms (p = . , r = . ). at diagnosis, dogs ( %) presented digestive symptoms while endoscopic gej abnormalities were observed in ( %), ( %) and ( %) dogs during ob- , ob-nat and ob-compl respectively. gej atony, ge reflux, cranial displacement of the gej and sliding hiatal hernia were present in ( . %), ( . %), ( . %) and dogs during ob- , in ( . %), ( . %), ( . %) and ( . %) dogs during ob-nat and in ( . %), ( . %), ( %) and ( . %) dogs during ob-compl, respectively. a significant correlation was found between digestive and endoscopic gej scores during ob-compl (r = . , p = . ) as well as during ob-nat (r = . , p = . ) but not during ob- . it can be concluded that in dogs with bs ( ) gej abnormalities are dynamic and related to the degree of upper airway obstruction; ( ) the use of obstructive manoeuvres during gastroscopy improves the detection of gej abnormalities. disclosures: no disclosures to report. tracheobronchial foreign bodies are common causes of respiratory disease in children but they are rare in veterinary medicine. particularly in cats, reports of tracheobronchial foreign bodies are scarce. this study aimed to describe clinical presentation, diagnostic findings and treatment modalities in confirmed cases of tracheobronchial foreign bodies in cats. we hypothesize that bronchoscopy is highly effective in their extraction in cats. cases of confirmed tracheobronchial foreign bodies in cats admitted to referral centers in france, from may to november , were included. files were retrospectively analyzed for age, sex, breed, clinical signs, delay between onset of signs and presentation, diagnostic procedure, method of extraction, location and nature of foreign bodies. twelve cats were included ( males, females). mean age at presentation was years old ( . years ae . ). cough was the main chief-complaint, being present in / ( %) cats. while / ( %) cats presented to consultation in the first week after the beginning of respiratory signs, / ( %) cats exhibited clinical signs for more than week. chest radiographs were done in / cats. bronchoscopy was performed in / cats, confirming the presence of foreign body material and allowing their extraction in / animals ( %). in / cats ( %), bronchoscopic extraction was unsuccessful and a pulmonary lobectomy was required. the foreign body was located in the trachea in / cats ( %) and in the bronchial tree in the remaining cats ( / in the right caudal bronchus, / in the left caudal bronchus and / in the main left bronchus). / ( %) were vegetal foreign bodies (grain seeds and foxtail awns), / ( %) were mineral (a bone fragment, a teeth and a small stone) and / ( %) of undetermined origin. all the mineral foreign bodies were extracted from the trachea, whilst the majority of the vegetal ones ( / - %) were removed from the bronchial tree. in this case series, bronchial foreign bodies were as frequent as tracheal foreign bodies in cats. this finding differs from previous data reporting that trachea is the preferential location for feline respiratory foreign bodies. vegetal foreign bodies are more common. due to their nature and shape, they may be more prone to lodge in the bronchial tree, while mineral foreign bodies remain in the trachea. according to our results, bronchoscopy is highly effective for identification and extraction of tracheobronchial foreign bodies in cats. disclosures: no disclosures to report. mycophenolate mofetil is the prodrug of mycophenolic acid (mpa). it is a selective non-competitive inhibitor of inosine- monophosphate dehydrogenase, which is expressed in many cell types. mpa's ability to induce lymphocyte cytotoxicity, reduce monocyte recruitment, and suppress dendritic cell maturation, are useful targets in treating immune mediated and inflammatory diseases. it has been used extensively in human medicine for transplant recipients and more recently in veterinary medicine in dogs with various immune mediated diseases. however, its use in cats is limited in part because mpa is primarily metabolized by glucuronidation and cats inherently have a decreased ability to glucuronidate many drugs. we proposed that cats may glucuronidate mpa more slowly than humans and dogs and conducted a series of in vitro studies to explore this hypothesis. we used liver microsomes from cats ( individual and pooled), dogs (pooled), and humans (pooled). these liver samples were incubated at °c in a water bath with mpa and udp-glucuronic acid or udp-glucose. udp-glucose was studied since mpa glucoside is a minor metabolite in humans but may be a major metabolite in other species. hplc-ms was used to determine concentrations of mpa-glucuronide (phenol and acyl) and mpa-glucoside (phenol) formed by incubation. cats formed much less mpa phenol glucuronide ( . nmoles/ min/mg) than dogs ( . nmoles/min/mg), or humans ( . nmoles/ min/mg). cats formed similar amounts of mpa acyl glucuronide ( . nmoles/min/mg) than humans ( . nmoles/min/mg), but less than dogs ( . nmoles/min/mg). in contrast, cats ( . nmoles/min/ mg) formed more mpa phenol glucoside than humans ( . nmoles/min/mg) but less than dogs ( . nmoles/min/mg). when the pathways of metabolism were summed for each species, cats ( nmoles/min/mg) metabolized mpa much less efficiently than dogs ( nmoles/min/mg) or humans ( nmoles/min/mg). variability in metabolite formation between the individual cats was high ranging from fold for mpa glucoside, to fold for mpa phenol glucuronide, to fold for mpa acyl glucuronide. our preliminary results confirm that cats glucuronidate mpa less rapidly than dogs and humans, however cats and dogs were found to glucosidate mpa more efficiently than humans. in addition, individual cats are variable in their ability to glucuronidate and glucosidate mpa. this preliminary in vitro data will be compared to in vivo studies of mpa pharmacokinetics to elucidate proper dosing of mpa in cats. disclosures: no disclosures to report. cystocentesis is the gold standard sampling method for urine microbiology in dogs, as voided samples are associated with a higher risk of contamination. however, the accuracy of the veterinary cut-off values currently recommended for detection of clinically significant bacteriuria in voided urine has been poorly investigated. the aim of this study was to evaluate the accuracy of veterinary and human criteria for diagnosis of urinary tract infection (uti) in dogs using voided urine samples. dogs with suspected uti were prospectively enrolled. paired urine samples collected by cystocentesis and voiding, respectively, were stored at • c and cultured within hours. bacterial counts in voided urine were interpreted using both the veterinary (≥ . colony forming units (cfu) per ml) and the human (≥ . cfu/ml plus presence of clinical signs) criteria for diagnosing uti, and compared to those obtained in urine collected by cystocentesis (gold standard). significant bacteriuria in cystocentesis samples was defined as ≥ . cfu/ml. sixty-five dogs were included in the study. when applying the veterinary criteria for diagnosing uti in voided samples, the diagnostic accuracy was % (sensitivity %, specificity %, positive predictive value (ppv) % and negative predictive value (npv) %). when applying the human criteria the accuracy fell to % (sensitivity %, specificity %, ppv % and npv %). the results indicate that, in most dogs with suspected uti, an accurate diagnosis can be obtained using voided urine, if applying the current veterinary cut-off values to samples stored at refrigeration temperature and cultured shortly after collection. disclosures: the study was supported financially by the uc-care research centre, university of copenhagen, and minor external foundations. antimicrobial resistance (amr) is a major public health concern and will likely be the first cause of mortality in human medicine in . canine bacterial urinary infection is a frequent condition and might be implicated in interspecies transmission of resistance mechanisms. this study aimed to retrospectively describe the evolution of the amr of uropathogens over a -year period in a veterinary teaching hospital. positive urinary cultures obtained by cystocentesis (> cfu/ ml) from dogs treated at the national veterinary school of toulouse (envt) between and , were reviewed. annual prevalence of amr for several enterobacteriaceae, staphylococcus spp, enterococcus spp and streptococcus spp were recorded for various veterinary and human antimicrobials. frequency of extended spectrum beta-lactamase-producing enterobacteriaceae (esbl) and multidrug resistant (mdr) bacteria were noted. logistic regression was performed to analyze the evolution of amrs. a p-value < . was considered significant. over the study period, isolates with stable annual distribution were identified. considering enterobacteriaceae, amr for several antimicrobials significantly evolved over time: despite a possible increase in for some antimicrobials, a general decrease of amr was observed. prevalence of esbl and mdr bacteria remained stable with mean prevalence of % and %, respectively. trends of amr of enterobacteriaceae over the study period in envt are not in accordance with the worrisome general tendency and could be consistent with a rationalized antimicrobials use. however, the persistently elevated prevalence of esbl and mdr bacteria, and the possible increase of amr during the last studied year warrant further investigation and surveillance. disclosures: no disclosures to report. klebsiella pneumoniae are important pathogens that cause urinary tract infections (uti). antibiotic-resistant and virulent bacterial clones with high interhost transmission may play an important role in the spread of antimicrobial resistance. this study aimed to characterize the antimicrobial resistance and virulence of clinical klebsiella isolated from animals and humans with uti and to determine the lineages of companion animal klebsiella pneumoniae resistant to third-generation cephalosporins ( gc). thirty-five companion animal clinical klebsiella spp., obtained between and january , and human clinical strains isolated in were included. antimicrobial susceptibility testing was performed using disk diffusion and clsi breakpoints were applied. extended-spectrum b-lactamases (esbl) and plasmid-mediated ampc genes were detected by pcr whenever resistance to gc was detected. furthermore, gc-resistant klebsiella were characterized by multi-locus sequence typing. regarding virulence, pcr for detection of fimh (adhesin type- fimbriae), mrkd (adhesin type- fimbriae), entb (enterobactin), ybts (yersiniabactin) and rpma (regulator of mucoid phenotype-a) genes was conducted on and companion animal and human strains, respectively. k. pneumoniae was the main species isolated in companion animals ( . % n = / ) and in humans ( . %, n = / ) but klebsiella oxytoca was also identified. resistance to gc (cefotaxime or ceftazidime) was present in . % (n = / ) and . % (n = / ) of companion animal and human strains, respectively. overall, cg-resistant k. pneumoniae were found to be ctx-m group- ( . %, n = / ), cmy ( . %, n = / ) and dha ( . %, n = / ) producers. both companion animal k. oxytoca were dha producers. companion animal cg resistant klebsiella were frequently ( . %, n = / ) co-resistant to fluoroquinoles and trimethoprim/sulphamethoxazole rendering them as multidrug resistant. moreover most companion animal cg resistant strains were also resistant/intermediate to amoxicillin/clavulanate ( . %, n = / ). overall, companion animal klebsiella resistance to amoxicillin/clavulanate ( . %, n = / ), fluoroquinolones ( . %, n = / ) and trimethoprim/sulphamethoxazole ( . %, n = / ) was high. companion animal k. pneumoniae resistant to gc belonged to st (n = ), st (n = ), st (n = ) and st (n = ) lineages. concerning virulence, all k. pneumoniae were positive for fimh, mrkd and entb. yersiniabactin was present in . % (n = / ) and . % (n = / ) of companion animal and human k. pneumoniae, respectively. k. oxytoca (n = ) were positive for entb and ybts. all tested strains were negative for rpma. the detection of k. pneumoniae lineages highly important for humans in companion animals with uti raises great concerns regarding their role as reservoirs. moreover, the fact they were also found to share gc resistance genes and common virulence factors with humans further extends the risk of transfer. disclosures: conflicts of interest: the first author currently receives a phd grant funded by the portuguese foundation for science and technology. feline lower urinary tract disease (flutd) refers to a heterogeneous group of disorders with similar clinical signs. some diets are designed to manage flutd by promoting struvite stone dissolution and addressing key risk factors (overweight, low water intake, stress. . .). the goal of this study is to compare the struvite dissolution potential of diets marketed for flutd, in standardized in vitro conditions. six adult healthy cats were fed successively dry diets (a = royal canin s/o-biopeptide; b = hill's c/d-urinary-stress) for days, with urine collection on the last days. urines collected for each diet were pooled and distributed in bottles containing the mean urine volume produced daily per cat. urine ph and struvite relative supersaturation (rss) were measured for each pool. two feline struvite uroliths homogenous in shape and weight were immersed separately in a urine bottle of each diet, and put in a stove at °c. twenty-four hours later, the urine was filtered to collect the stones, which were dried and weighed. every day, the stones were placed in new bottles of the corresponding urine until the first complete stone dissolution. diet effect on urine ph, volume and rss was analysed non parametrically (wilcoxon paired rank test). diet effect was combined with a period effect (period = days dissolution), in a complete factorial design to analyse struvite stones weight evolution at each period for each diet (mixed model with diet, period, diet x period as fixed effects). fdr method was applied to compare diets at each period. diet a induced a higher mean urine volume ( . versus . ml/kg/day), and a lower rss than diet b ( . versus . ) (p < . ). the urine ph of the diets were not significantly different ( . and . ) (p > . ). after days, the struvite stone immersed in urine from diet a was totally dissolved, versus % dissolution for the stone in urine from diet b. when considering periods of days, the struvite weight diminution was significantly higher when struvite stone was immersed in urine from diet a than from diet b (diet effect: p < . ). the interaction between diet and period effect revealed that the difference in dissolution rate between the diets was significant as soon as the first day period (p < . ), and increased over the other periods (p < . ). a diet inducing a lower struvite rss and a greater urine dilution allows faster struvite stone dissolution. disclosures: the author and co-authors work for royal canin, the company commercializing one of the diets evaluated. serum cystatin c (scysc) and urinary cystatin c (ucysc) are potential markers for detection of feline chronic kidney disease (ckd). our aims were twofold. firstly, we evaluated cysc as marker for ckd. we compared scysc and ucysc between ckd and healthy cats, correlated scysc and scr with glomerular filtration rate (gfr) and calculated sensitivity, specificity for detecting decreased gfr. secondly, we compared assay performance of the turbidimetric assay (petia) with the previously validated nephelometric assay (penia). forty-nine ckd (iris stage - ) and healthy cats were included. gfr was measured with plasma exogenous creatinine (pect), endo-(penict) and exo-iohexol (pexict) clearance test in ckd and healthy cats. based on pexict, scysc was evaluated to distinguish normal, borderline and low gfr. sensi-tivity and specificity to detect pexict< . ml/min/kg were calculated. validation of petia was performed and scysc results of penia and petia were correlated with gfr. statistical analysis was performed using general linear modelling. serum cysc and ucysc were significantly higher (p < . ) in ckd cats. however, ucysc was detected only in / ckd cats. r values between gfr and scr or scysc were . and . respectively. sensitivity and specificity were % and % for scysc and % and % for scr. serum cysc could not distinguish healthy from ckd cats, nor normal from borderline or low gfr, in contrast to scr. penia appeared superior to petia. in conclusion, scysc is not a reliable marker for gfr in cats and ucysc could not be detected in all ckd cats. disclosures: for this work support was received from the institute for the promotion of innovation by science and technology in flanders (iwt) through a bursary to l.f.e. ghys. soblechero, f.j. duque, p. ruiz, r. barrera. university of extremadura, c aceres, spain serum cystatin c (scys c) is a marker of glomerular filtration rate with advantages over serum creatinine. in human medicine, some authors observed that scys c is influenced by methylprednisolone or prednisone administration. with the aim to follow the course of this maker of renal function in acutely diseased patients with a receiving glucocorticoid medication, we followed at dog's whit steroid responsive meningitis. the study was carried out on patients that where divided in groups: control group ( clinical healthy dogs), group b, dogs treated with prednisone due to steroid responsive meningitis (treated with mg/kg prednisone during days, followed to mg/kg prednisone for another days). dogs had no known preexisting renal disease, and have no previous glucocorticoid medication. group c was established to test the effects of endogenous steroids: dogs with hyperadrenocorticism were evaluated. serum cys -c was measured by turbidimetric latex and creatinine by jaffe reaction (spinreac Ò ) and were determined at time of diagnosis for group b, and on days , and in the meningitis dogs. a statistically significant increase of scys-c was observed in group b, with doses of mg/kg of prednisone ( . ae . mg/l; p < . ), and doses of mg/kg of prednisone ( . ae . mg/l; p < . ) respect to these same dogs before treatment ( . ae . mg/l) and compared to the control group ( . ae . mg/l). however, the serum concentration observed in hyperadrenocorticism ( . ae . mg/l) was similar to the one find in the healthy animals group. the creatinine concentration was not increased either, during the prednisone treatment, or in the case of hiperadrenocorticism. in conclusion, the present study agrees with that is described in human medicine, and confirms the effects of glucocorticoids on scys c concentrations in dogs. the administration of high doses of prednisone is associated with a scys c increase. on the other hand endogenous cortisol increase (hyperadrenocorticism) in dogs is not seen to modificate the scys c. disclosures: no disclosures to report. chronic kidney disease (ckd) produces progressive reduction in the number of functional nephrons and directly affects the homeostasis of the solutes excreted in the urine, including phosphorus. hyperphosphatemia is considered a factor directly related to the increased mortality in humans, cats and dogs. in order to provide data from controlled clinical studies to examine the effects of hyperphosphatemia on the progression and survival of naturally occurring canine ckd, the following study was conducted. for the present study dogs, which were followed up by the veterinary teaching hospital of the university of extremadura (spain), were used for the study. distributed in the following groups: group i ( healthy adult dogs) and group ii ( adult dogs with ckd). this second group had a subclasification attending to different factors: phosphatemia: iia ( dogs with phosphatemia < . mg/dl) and iib ( dogs with phosphatemia > . mg/dl). leishmaniasis: iic ( dogs with ckd due to leishmaniasis) and iid ( dogs with ckd not due to leishmaniasis). iris classification: iris ( dogs), iris ( dogs), iris ( dogs) and iris ( dogs). the results of survival were as followed: statistically lower survival was found between the groups iia and iib (p < . ) also between the iris grades , and and the iris grade (p < . ), iris and with iris (p < . ) and iris with iris (p < . ). no significant differences between positive and negative leishmaniasis. in conclusion, plasma phosphate concentration in dogs increases as chronic kidney disease develops. and an inverse relationship to survival in dogs with phosphorus concentrations above mg/dl, and as it progresses the iris scale was observed. disclosures: no disclosures to report. studies analyzing to which extent upc in dogs is influenced by pyuria have yielded conflicting results. moreover, there is no data on the effect of proteinuria on plasma acute phase proteins in dogs. in dogs upc was prospectively measured. upc and if available, results of plasma biochemistry including measurement of c-reactive protein (crp) from the same day were analyzed using the mann-whitney-u-test. samples without sediment analysis (n = ) were excluded resulting in urine samples for analysis. hematuria (> erythrocytes/hpf), pyuria (> leucocytes/hpf), and bacteriuria were present in , and samples, respectively. upc in samples with hematuria was significantly (p = . ) higher (median . ; th - th percentile . - . ) compared to samples without hematuria ( . ; . - . ). in dogs with pyuria upc was significantly (p < . ) higher ( . ; . - . ) compared to samples without pyuria ( . ; . - . ). % of the samples with pyuria had an upc > . this is in contrast to data reported previously where only % of pyuric urine samples had an upc > (vet clin path ; : ). bacteriuria did not influence upc (p = . ). samples of dogs with negative protein dipstick results had an upc > . ( . , . , and . , respectively). all samples had low urine specific gravity ( . - . ) and alkaline ph. for a total of samples corresponding plasma data on albumin (reference interval ri: . - . g/dl) and crp (ri: - . mg/l) were available. crp was significantly (p = . ) higher in dogs with upc > . ( . mg/l; . - . ) compared to dogs with upc ≤ . ( . mg/l; . - . ). albumin was significantly (p < . ) lower ( . g/dl; . - . ) in dogs with upc > . compared to dogs with upc ≤ . ( . g/dl; . - . ). naturally occurring pyuria has a more profound effect on upc results than previously reported. proteinuria is associated with changes of acute phase proteins such as hypoalbuminemia and increased crp. whether this is consequence or cause of the proteinuria needs further investigation. furthermore, animals with low urine specific gravity may have clinically relevant proteinuria even in the light of a negative dipstick result. therefore measurement of upc is recommended to exclude renal protein loss in hypo-and isosthenuric dogs. disclosures: no disclosures to report. high blood pressure causes an increase in vascular endothelial growth factor (vegf) secretion. feline hypertension is commonly associated with chronic kidney disease (ckd) amlodipine is the first choice antihypertensive treatment in cats but could have a negative effect on the kidney by increasing glomerular pressure through afferent arteriolar dilatation. the aims of this study were to: ( ) validate a method for the quantification of vegf in feline serum samples; ( ) assess the association between urinary vegf, serum vegf (svegf) and biochemical and clinical variables in hypertensive cats and ( ) investigate changes in urinary vegf with amlodipine treatment. a randomised, double blinded, placebo controlled parallel group study (n = ) was conducted in phases to determine the efficacy and safety of amlodipine in cats with naturally occurring hypertension. the placebo group was crossed-over to amlodipine after day . a canine vegf elisa (previously validated for feline urine) was used to measure urine and serum vegf. urine vegf concentration was normalised to urinary creatinine (urinary vegf to creatinine ratio [uvc]). univariable linear regression models, followed by a backwards multivariable linear regression model, were performed to identify independent predictors of svegf and uvc. a linear mixed measures model was used to compare the effect of placebo and amlodipine on uvc ( days) and to investigate potential changes in uvc with long-term amlodipine treatment ( days). intra-assay and inter-assay cv of svegf measurements were . - . (n = ) and . - . (n = ) respectively. dilutional parallelism indicated a mean recovery of . % ae . % (n = ). urea and urine protein:creatinine (upc) were independent negative and positive predictors of svegf respectively. plasma creatinine was an independent negative predictor of uvc, upc and sodium were independent positive predictors. no association was found between svegf and uvc. no significant changes in uvc or differences between groups were found with days of amlodipine or placebo treatment. mean uvc at screening was . and . lg/g after days of amlodipine treatment (p = . ), both within the healthy cat reference range ( . to . lg/g). the lack of correlation between urinary and serum vegf suggests that uvc reflects renal vegf production, and is possibly a biomarker of renal stress. uvc does not significantly change with amlodipine treatment suggesting that amlodipine may not cause renal stress when used in cats with hypertension and concurrent ckd. disclosures: this study was sponsored by orion inc. and ceva animal health and used residual samples collected from animals involved in a clinical trial run by orion inc. jonathan elliott provides consultancy advice to the following companies: bayer animal health, ceva animal health, orion inc., elanco animal health, zoetis ltd, boehringer ingelheim, vetoquinol ltd., waltham centre for pet nutrition, idexx ltd. the group is in receipt of research funding from the following companies: novartis animal health, royal canin ltd, zoetis, ceva animal health / orion inc. jonathan elliott serves on the following advisory boards: international renal interest society, european emesis council. diffuse large b-cell lymphoma (dlbcl) is the most frequent subtype of non-hodgkin lymphomas in dogs. in humans, common morphological variants have been recognized by the world health organization (who) classification: centroblastic, immunoblastic and anaplastic. the who classification was recently adapted to canine lymphomas. however, no study clearly correlated prognosis to each morphological variant of canine dlbcl. the objective of this retrospective study was to correlate morphological variants of dlbcl to prognosis, in dogs treated with a standardized chemotherapy protocol. medical records from dogs with a cytological diagnosis of dlbcl between and were retrospectively reviewed by a single boarded clinical pathologist. the centroblastic (dlbcl-cp) and immunoblastic morphotypes (dlbcl-ib) were defined as previously described. anaplastic variant is very rare in dogs, and no case meeting all inclusion criteria were diagnosed during the study period. a fourth borderlines morphological variant was identified and distinguished in this study for clinical considerations (immunoblasts rich centroblastics (dlbcl-irc)). it was characterized by the presence of a higher number of immunoblasts compared to dlbcl-cp. complete initial and follow-up clinical information and application of a standardized chemotherapy protocol were part of the main inclusion criteria. statistical analysis was performed using kaplan-meier analysis. fourty-nine dogs were included. thirty-four ( . %) were dlbcl-cp, ( . %) were dlbcl-ib and ( . %) were dlbcl-irc. median first remission duration for dlbcl-cp, dlbcl-ib, dlbcl-irc were respectively and . and days (p < . ). median overall survival time for dlbcl-cp, dlbcl-ib, dlbcl-irc were respectively , and . days (p = . ). a significant shorter time to obtain complete remission (p = . ) and a significant longer duration of first remission (p < . ) in dogs with dlbcl-cp in comparison to dlbcl-ib were observed when dlbcl-irc were included in the dlbcl-ib group. interestingly for cases, dlbcl-irc variant was observed in peripheral lymph nodes whereas dlbcl-ib variant was observed in the spleen. moreover, / recurrent dlbcl-cp and / of dlbcl-irc displayed progression towards dlbcl-ib variant. in conclusion, this study showed, for the first time, significant prognostic differences between the morphological variants of canine dlbcl, suggesting the prognostic impact of immunoblastic features as it is discussed in humans. disclosures: the residency program of david sayag is supported in part by zoetis. canine lymphoma is a heterogenous group of diseases and evidence exists to describe different behaviours between b-cell and tcell phenotypes of disease. this study aims to describe the response to treatment and survival of canine b-cell multicentric lymphoma (cbcml) cases treated at the royal veterinary college. signalment, clinical findings, staging, treatment, response and survival times were recorded retrospectively. sixty-three cases of cbcml were identified. forty-nine percent presented as stage , % stage , and % stage . sixty-two percent were substage b and % were substage a. forty-four percent received "chop" induction protocols, % "cop," % "coap," and the rest received various induction protocols. ninety-five percent of dogs responded to induction treatment. median first remission duration (frd) was . days. thirty-seven dogs ( %) received rescue protocols with a response rate of %. median overall survival time (os) was days. follow-up was days. this study showed that cop protocols followed by doxorubicin rescue therapy gave no significant difference in os compared with both chop induction alone and chop followed by a rescue protocol (p = . ). os was significantly increased by increased frd (p = . ), absence of an aberrant immunophenotype (p = . ), complete response to therapy (p = . ), and use of rescue protocol (p = . ). frd was significantly increased by use of a chop induction protocol compared with a cop protocol (p = . ), and complete response to therapy (p = . ). age, bodyweight, sex/neuter status, stage, substage, and cell size had no effect on frd or os. seven ( %) of the dogs had a prolonged os in excess of years, and of these dogs remain alive. dogs in the prolonged os group were more likely to be anaemic on presentation (pcv< %, p = . ), experienced a greater frd (p = . ) and were more likely to be treated with a rescue protocol (p = . ) than other dogs. no other significant differences in signalment, clinical presentation, stage, substage, or treatments received were found between this group of dogs and others. in this group of dogs, chop induction therapy gave no survival benefit over the cheaper, less intense cop protocol, providing doxorubicin rescue therapy was later employed. the proportion of dogs receiving chop induction versus cop did not significantly differ between dogs with prolonged survival and those without. the use of rescue protocol, complete response to treatment, aberrant immunophenotype and first remission duration were shown to have prognostic relevance. disclosures: no disclosures to report. lymphoma is the most common malignant haemopoietic tumour in the dog. gene expression profiling (gep) of canine lymphoma has highlighted the important signalling pathways including b-cell activation, b-cell receptor and nf-kb signalling. next-generation sequencing offers benefits over microarray technology for gep in identification of novel transcripts and sequence variants. the aim of this study was to examine gene expression and variant calling in canine lymphoma using rna-seq. lymph node samples were collected from canine multicentric lymphoma patients as part of their clinical investigations. diagnosis was confirmed cytologically or histologically and cell lineage established by pcr for antigen receptor rearrangements (parr) and flow cytometry. cdna was prepared from extracted rna and sequencing performed on an illumina nextseq sequencer generating bp paired-end reads. samples were from b-cell tumours ( stage v, stage iv, stage iii and stage ii) and t cell tumours ( stage iii, each stage ii, iv, v). million reads (mean) per sample were obtained with % mapping to the canine genome. b-and t-cell samples clustered separately on principal component analysis indicating distinct gene expression patterns. genes were upregulated (log fc > , q value < . ) in b-cell lymphomas, many involved in bcr signalling, primary immunodeficiency and haematopoietic cell lineage pathways, innate immune and inflammatory responses. genes were upregulated (log fc > , q value < . ) in t cell lymphomas, most affecting tcr signalling, but also natural killer mediated cytotoxicity, jak-stat signalling, haemopoietic cell lineage and cancer pathways. compared to the reference genome, . million sequence variants were detected across the samples; % not previously described. using the sift (sorting intolerant from tolerant) algorithm, % were predicted to be deleterious for protein function. functional analysis of the affected genes indicated many were involved in bcr signalling and cancer-related pathways. some such as bcl and map k were affected in almost all cases, although proportionally more frequent in b cell lymphoma. others such as traf were exclusive to b cell cases. genes affecting a large number of cases such as bcl tended to have a common variant present in or more cases whereas other genes had variants unique to each single case. although it remains to be confirmed if the detected variants represent true mutations rather than polymorphisms, rna-seq of canine lymphoma samples has generated interesting pilot data that need to be expanded with more samples to validate the results. disclosures: manikhandan mudaliar works for glasgow polyomics which is a commercial company within glasgow university and carries out genomic and polyomic assays. the next gen sequencing was done at glasgow polyomics, partly using an ecvim grant. feline large granular lymphocyte (lgl) lymphoma is uncommonly described in the literature and it is caused mainly by t-cell lymphocyte. to date a standard protocol has not yet been established and long term prognosis is poor. a recent study (krick et al. ) described a median survival time of days (range: - ) in cats with lgl lymphoma receiving mainly a cop-based protocol and in few cases adjuvant surgery or orthovoltage radiation therapy. surprisingly, in that study the longest survival time was achieved from a cat in the non treated group (median survival time days; range: - ) that received only prednisone and single agent cyclophosphamide. considering these data, and the advantages in treating with more than one alchylating agents t-cell lymphoma in dogs (brodsky et al ), the aim of this study was to assess if the sequential use of different alchylating agents was of any benefit in cats with lgl lymphoma. to all owners of cats with a cytological or hystopatological diagnosis of lgl lymphoma that presented to the san marco veterinary clinic from july till december were offered a treatment with sequential alchylating agents and prednisone (saa&p) protocol or palliative care with only prednisone. the saa&p protocol consisted of prednisone at mg/kg q h and chlorambucil at mg/cat (for cats > kg) to q h (for cats < kg). when despite treatment progressive disease or stable disease plus clinical signs referable to the lgl lymphoma were present chlorambucil was substituted with cyclophosphamide at mg/cat q days. finally, when cats stop responding to cyclophosphamide, this drug was substituted with lomustine at - mg/m q - week. during the study period cats were diagnosed with a lgl lymphoma. on owner request cats were euthanased at the time of diagnosis, cats were sent home with no treatment and lost to follow-up, cats received prednisone alone, and cats received the saa&p protocol. median survival time for cats treated with prednisone alone was days (range: - days, % ci - days) and for cats treated with the saa&p protocol was days (range: - days, % ci - ). survival kaplan-meier curves of the treatment group were significantly different (log rank test = . ; p = . ). survival time in cats with lgl lymphoma treated with the saa&p protocol is significantly longer than in cats receiving only prednisone and seems to be longer than historical reported data of cats receiving cop-based protocol. disclosures: no disclosures to report. mast cell tumors are often accompanied by eosinophilic inflammation as they are known to produce eosinophil chemotactic factors. however, little is known about frequency or eventual prognostic significance of blood eosinophilia in mct bearing dogs. thus, the aim of this study was to determine frequency of absolute and relative peripheral blood eosinophilia as well as eosinopenia and to evaluate potential influence on progression free interval (pfi), overall survival time (ost) and tumor specific survival (tss). dogs with mast cell tumors diagnosed between and were included into this retrospective study. data were collected from medical records and follow up phone conversations with patient owners or referring veterinarians. medical records were reviewed to rule out underlying clinical conditions other than mct that could cause eosinophilia. tumor diagnosis was made either by fine needle aspirate and/or tumor biopsy. a patient was allocated to the eosinophilic group, when the eosinophil concentration was > . * /ll or the relative percentage was > %, respectively. when the eosinophil concentration was < . * /ll patients were categorized as eosinopenic. groups were compared by the pearson chi-square test. the pfi, ost and tss curves were generated by the kaplan-meier product limit method. a log rank test was used to compare the curves. one-hundred dogs were included into this study. absolute eosinophilia was detected in / patients and in / a relative eosinophilia was present. median concentration of eosinophils was . * /ll (range, - ) and median relative percentage was . % (range, - %). eosinopenia was found in % of all dogs. a positive association between relative eosinophilia and low grade tumors was detected with both patnaik (p = . ) and kiupel (p = . ) grading system. a positive linear correlation was further noticed between absolute eosinophilia and ost (p = . ). positive correlation was confirmed between relative eosinophilia and pfs (p = . ), ost (p = . ), and tss (p = . ). accordingly a negative linear fit was found between eosinopenia and pfi (p = . ), ost (p = . ) and tss (p = . ). data indicate that peripheral blood eosinophilia might serve as an easily available additional prognostic tool for mast cell tumor bearing dogs. disclosures: no disclosures to report. limited literature is available about prognostic factors for canine renal carcinomas. in humans, histologic differentiation and tumor type are strongly associated with outcome. in dogs only one publication so far has reported this association. cox- expression is documented in several canine neoplasias with prognostic value in canine mammary carcinomas. in renal carcinomas cox- expression has been demonstrated but its significance is not known. the aim of this study was to evaluate clinical and histopathological features of canine renal carcinomas, including cox- expression, and to correlate them with outcome. our hypothesis was that advanced disease, higher histological grade and increased cox- expression would be associated with shorter survivals. this retrospective multi-institutional study within veterinary institutions, included histologically confirmed cases of canine renal carcinoma undergoing nephrectomy between - , with available follow up. histologic features and cox- immunostaining scoring were reviewed by independent pathologists where available. signalment, clinical presentation, stage, adjuvant therapy and survival times were recorded and statistical analysis performed. sixty-two cases were included. male to female ratio was : , median age was . years. cross-breed dogs (n = ) and labrador retrievers (n = ) were over-represented. on presentation dogs had metastasis. overall median survival time (mst) was days ( - days) . dogs without metastasis lived longer (mst versus days, p = . ). twenty-seven dogs received adjuvant therapy post-nephrectomy, without impact in mst (treatment days, no treatment days, p = . ). fifty samples were available for histopathological review, and for cox- immunostaining. shorter survival times were seen in solid histological type compared to others (solid days, papillary days, tubular days, p = . ). histologic degree of differentiation was associated with mst (well days, moderate days, undifferentiated days; p = . ). vascular invasion was associated with shorter survival (mst days versus days if absent; p = . ). marked invasiveness was associated with shorter mst ( days versus mild = days, moderate days; p = . ). patients with low cox- expression had longer mst ( days) than those with high ( days, p = . ). mitotic index, clear cell type, nuclear morphology, fuhrman nuclear grading, presence of pseudocapsule, necrosis, haemorrhage and type of inflammation were not significantly associated with mst. histopathological findings (degree of differentiation, invasiveness, vascular invasion, solid histologic type), cox- expression and metastasis present at diagnosis are strongly associated with survival in canine renal carcinomas and can be used as prognostic factors. disclosures: no disclosures to report. the detection of leishmania infantum-specific antibodies has been extensively exploited for specific diagnosis and monitoring of treatment in canine leishmaniosis. high levels of l. infantum-specific antibodies are commonly observed in dogs with moderate to severe disease. controversial results have been described regarding the use of kinetics of l. infantum specific antibodies during treatment monitoring. the majority of the studies reported that antibodies often decreased slowly but remained detectable over a long period of time while older studies considered that serology was not useful for treatment monitoring. a consensus statement is that measurement of antibody levels is meaningless before months of treatment. the aim of this study was to evaluate l. infantumspecific antibodies at the time of diagnosis and during treatment follow-up visits and to correlate these with the dog's clinical status. nineteen dogs were diagnosed (day ) and followed-up during treatment (days , and ). the treatment protocol was a combination of meglumine antimoniate ( mg/kg/ h sc for month) and allopurinol ( mg/kg/ h po for year). physical examination and baseline laboratory tests (cbc, biochemistry profile, serum electrophoresis, urinalysis and urinary protein/creatinine ratio) were performed during all visits. leishmania infantumspecific antibodies were assessed by an end point sera dilution elisa method. the majority of dogs (n = ) were classified as leishvet stage ii (moderate disease) at the time of diagnosis. three dogs were classified as leishvet stage iii (severe disease, n = ) or iv (very severe disease, n = ). results showed high and variable levels of specific antibodies at the time of diagnosis (meanaesd: ae elisa units (eu)). interestingly, a rapid significant reduction (p < . ) was observed at day during treatment (mean aesd: ae eu). a continuing significant decrease of specific antibodies was also determined at days (mean ae sd: ae eu) and (mean aesd: ae eu). all dogs improved clinically with treatment with the exception of one dog that clinically relapsed at months post-treatment and its specific antibodies level slightly increased. in conclusion, this study reports, for the first time, a rapid reduction of l. infantum specific antibodies after days of treatment by an end point sera dilution elisa method associated with clinical improvement. it is important also to highlight that a marked decrease of antibody levels was also noted after months and year of treatment. disclosures: no disclosures to report. a broad range of clinical manifestations and immune responses have been described in canine leishmaniosis. canine l. infantum infection can manifest as a chronic subclinical infection, self-limiting disease, or non-self-limiting illness. a protective cd + t-cellmediated immune response characterized by production of inter-feron-gamma, il- and tnf-alpha is believed to be present in resistant subclinical dogs while this response seems to be diminished or absent in sick dogs. however, there are few and poorly standardized assays to evaluate this response in the dog. in addition, cellular mediated immunity has been mainly investigated in subclinical or vaccinated dogs but limited information is available in sick dogs with different degrees of disease severity. the aim of this study was to investigate l. infantum-specific cellular immunity in dogs with clinical leishmaniosis at the time of diagnosis. twenty-six dogs were diagnosed based on physical examination, routine laboratory tests (cbc, biochemistry profile, serum electrophoresis, urinalysis and urinary protein/creatinine ratio) and l. infantum-specific antibody levels measured by quantitative elisa. heparin whole blood was stimulated with l. infantum soluble antigen (lsa) and the mitogen concavalin a (cona) and incubated during days. unstimulated whole blood from each dog was used as control. supernatants were collected and ifngamma concentration was measured with a commercial sandwich elisa. the majority of dogs (n = ) were classified as leishvet stage ii (moderate disease). the rest of dogs were classified as stage i (n = ), stage iii (n = ) and stage iv (n = ). twelve dogs (stage i, n = ; stage iia: n = , stage iii: n = ) produced ifngamma after stimulation with lsa (mean ae sd: ae pg/ ml) and cona (meanaesd: ae pg/ml). in contrast, dogs (stage iia: n = ; stage iib: n = ; stage iii = n = ; stage iv, n = ) did not produce detectable ifn-gamma after stimulation with lsa but dogs produced ifn-gamma after stimulation with cona (mean ae sd: ae pg/ml) while one dog was unresponsiveness to cona. no differences in ifn-gamma concentration were found between ifn-gamma producer and nonproducer dogs when blood was stimulated with cona (p = . ). interestingly, ifn-gamma producer sick dogs presented with a lower antibody levels (meanaesd: ae elisa units (eu)) when compared with ifn-gamma non-producer sick dogs (mean ae sd: ae eu) but differences were not statistically significant (p = . ). the results of this study suggest that sick dogs with a more exaggerated humoral response and a more severe disease lack l. infantum specific ifn-gamma production in stimulated blood. disclosures: no disclosures to report. canine anaplasma platys infection (capi) results in thrombocytopenia, but is considered as a subclinical disease in the united states where the disease was first identified. in europe, where the disease seems to be more severe, it has been suggested that circulating strains are more pathogenic, although co-infection with other vector-borne pathogens (vbp) may also contribute to the expression of clinical signs. however, the availability of pcrbased investigation of the impact of co-infection in naturally infected dogs is limited, compromising the assessment of their clinical significance under field conditions. the aim of the present study was to describe epidemiological and clinical features of capi under field conditions in areas endemic for several canine vbp. a study was conducted in veterinary clinics across italy, spain and portugal. sick animals were included when fitting at least clinical and/or biological criteria compatible with ehrlichial disease. serological tests (snap Ò dx, snap Ò leish tests) and diagnostic pcr for ehrlichia canis, anaplasma platys, anaplasma phagocytophilum, babesia/theileria spp, hepatozoon canis and leishmania infantum detection were performed to identify the etiological agents. capi was considered on the basis of suggestive signs associated with positive pcr-based assay for anaplasma platys. among the dogs included, were pcr positive for a. platys. the annual incidence risk of capi was . % and the probability to diagnose capi when facing clinical and/or biological signs suggestive of ehrlichial disease was evaluated at . %. nine dogs were mono-infected, and dogs were co-infected with e.canis ( ), l.infantum ( ), babesia sp. ( ) and h.canis ( ). for dogs, all tests were not performed. anorexia ( %) and weight loss ( %) were common reasons for visit. lymphadenomegaly ( %), hyperthermia and cutaneous signs ( %) were frequent findings whereas musculoskeletal disorders ( %), petechiae/ecchymosis ( %), splenomegaly ( %), dehydration and ocular lesions ( %) then epistaxis ( %) were less common. haematological abnormalities included thrombocytopenia and anaemia ( %), leucopoenia ( %) and leucocytosis ( %). a risk-analysis conducted between mono-and co-infected dogs didn't highlight significant differences except for anorexia that was significantly more frequent in mono-infected dogs. this study illustrates the magnitude of capi in the mediterranean basin and supports the existence of virulent strains in this area. co-infections were common but had a weak impact on clinical expression. these results emphasize also the importance of testing dogs for multiple vbp due to the difficulty in assigning a specific symptom or haematological abnormality to a specific vector-borne infection in endemic areas. disclosures: no disclosures to report. leptospirosis is a worldwide zoonotic disease with high mortality rate in humans and dogs. clinicopathologic changes may reflect renal disease, hepatic disease, or both causing often vomiting, polyuria/polydipsia and diarrhea. therefore, severe electrolytes and anion gap (ag) abnormalities could be expected. the aim of this cohort study was to investigate serum electrolytes and ag in dogs with natural occurring leptospirosis and to assess their prognostic values. the electronic data-base of the san marco veterinary clinic p.o.a system-plus . Ò was searched between october- and april- for dogs with diagnosis of leptospirosis (group ; n = ). inclusion criteria for group were consistent clinicopathologic signs and a positive microscopic agglutination test (titer≥ : in vaccinated dogs, titer≥ : in nonvaccinated dogs or≥ -fold increase in convalescent titer) and/or a positive pcr (urine and/or blood) for leptospirosis. parameters studied were: serum electolytes (sodium, chloride, potassium), ag, and ag albumin-adjusted (ag alb-adjusted = ag + . x ( . -[alb] ).two control populations of randomly healthy dogs (group ; n = ) and sick dogs without leptospirosis (group ; n = ) dogs were created and matched to group for age (ae months), sex (including sexual status) and breed. statistical differences between groups were evaluated by kruskal-wallis test and post-test analysis were performed by wilcoxon-mann-whitney. mortality relative risk (mrr) at days post-admission between group and group was evaluated. roc curves were used to identify the best prognostic analyte. significance level for all statistical test was set at p < . . serum sodium and chloride concentrations were significantly decreased in group compared to group and (p < . for both comparisons). serum potassium concentration was significantly decrease in group compared to group (p = . ), while no difference was present between group and (p = . ). serum ag and ag alb-adjusted were significantly increased in group compared to group and (p < . for all comparisons). there was a significantly increased in mortality rate in group (n = , . %) compared to group (n = , . %) (mrr = . ; % ci = . - . ). between the variables studied serum potassium (auc = %; p = . ) and chloride (auc = %; p = . ), ag (auc = %; p = . ) and ag alb-adjusted (auc = %; p < . ) were prognostic. serum electrolytes, ag, and ag alb-adjusted were significantly different in dogs with leptospirosis compared to healthy and sick dogs without leptospirosis with the exception of serum potassium that was similar between sick dogs with and without leptospirosis. between the variables studied the ag alb-adjusted resulted the best parameter in predicting death in dogs with leptospirosis. disclosures: no disclosures to report. enterococci causes urinary tract infection (uti) in companion animals and may carry important resistance genes such as for the bifunctional enzyme. furthermore, their virulence factors are seldomly reported in veterinary medicine. thus, this study aims to characterize the uropathogenic enterococci antimicrobial resistance, virulence genes and the clonallity of high-level gentamicin resistance (hlgr) enterococcus faecalis. antimicrobial susceptibility testing of clinical uropathogenic enterococci isolated from dogs and cats with uti, isolated between - , was performed by the disc diffusion method. clsi clinical breakpoints were applied. strains showing hlgr were screened for aac( )-ieaph( ')-ia and aph( ')- d genes by pcr. e. faecalis harbouring hlgr genes were typed by multi-locus-sequencing. fifty-nine strains were further characterized by pcr for the presence of gel e (gelatinase), ace (collagen binding antigen), asa- (aggregation substance), and efa a (endocarditis) virulence genes. e. faecalis was the most frequently isolated ( . %, n = / ) followed by enterococcus faecium ( . %, n = / ). overall, antimicrobial susceptibility results were: . % (n = / ) resistance to penicillin/ampicillin; . % (n = / ) resistance to fluoroquinolones (enrofloxacin or ciprofloxacin); . % (n = / ) resistance to nitrofurantoin; . % (n = / ) resistance to chloramphenicol and . % (n = / ) resistance to tetracycline. hlgr was detected in . % (n = / ) enterococci, namely e. faecalis and two e. faecium. all hlgr e. faecalis were aac ( )-ieaph( ')-ia carriers. one e. faecium was positive for aac ( )-ieaph( ')-ia whereas the other was positive for aph( ')- d. interestingly, ampicillin-resistance was only detected in e. faecium ( out of isolates). furthermore, all hlgr e. faecium were also ampicillin-resistant. hlgr e. faecalis were found to belong to st , st , st , and st major lineages circulating in both hospital and community settings in portugal. considering all enterococci, . % (n = / ), . % (n = / ), . % (n = / ) and . % (n = / ) were positive for gel e, ace, asa- and efa a virulence genes, respectively. uropathogenic e. faecium were only positive for ace gene ( out of ), thus e. faecalis had higher virulence genes frequencies. in this study we detected important human hlgr e. faecalis belonging to the clonal complex , such as e. faecalis st , among uropathogens in companion animals. the presence of major clonal lineages in companion animals highlights their role as communityassociated hosts and possible reservoirs of putative human pathogenic enterococci. disclosures: conflicts of interest: c atia marques currently receives a phd grant funded by the portuguese foundation for science and technology. haemotropic mycoplasmas (haemoplasmas) can cause haemolytic anaemias in many species, including people. three feline haemoplasmas have been identified: mycoplasma haemofelis (mhf), 'candidatus mycoplasma haemominutum' (cmhm), 'candidatus mycoplasma turicensis' (cmt). mhf is considered the most pathogenic, whilst cmhm and cmt usually only cause anaemia in cats with concurrent disease or immunosuppression. the aim of this study was to estimate the prevalence of feline haemoplasmas in serbia and identify potential risk factors for infection. surplus edta blood samples from cats in the belgrade region were used. for each cat, the following variables were recorded: age, health status, gender, outdoor access, presence of ectoparasites and haematological results. samples were stored at À °c and transported to the university of bristol for haemoplasma quantitative pcr testing. serology (petchek, idexx) was performed for felv (n = ) and fiv (n = ) infection. statistical analysis was performed using spss; univariable associations between variables and haemoplasma status were first evaluated (v for categorical variables, t-test/mann-whitney u test for continuous variables) followed by multivariable analysis. two samples were negative for internal control s rdna and excluded from the study. of the remaining cats, ( . %) were infected with one or more haemoplasma species; were singly infected ( mhf, cmhm, cmt) , dually infected ( mhf/cmhm, mhf/cmt, cmhm/cmt) and triple infected. the overall prevalences of mhf, cmhm and cmt were . %, . % and . %, respectively. / ( . %) cats were felv infected whilst / ( . %) were fiv infected. multivariable analysis identified significant associations between haemoplasma infection and anaemia (anaemic/non-anaemic, odds ratio (or) . , ci . - . , p = . ), male gender (male/female, or . , ci . - . , p < . ), outdoor access (yes/no, or . , ci . - . , p < . ), non-pedigree breed (non-pedigree/pedigree, or . , ci . - . , p = . ) and fiv positive status (positive/ negative, or . , ci . - . , p = . ). the overall prevalence of feline haemoplasmas in serbia ( . %) is similar to that reported in other european countries ( . - . %). cmhm was the most prevalent haemoplasma species ( . %) in the current study, similar to other european studies (range: . - . %). most previous studies reported that cmt infection is the least prevalent feline haemoplasma species, but in the current study the prevalence of cmt was greater than that of mhf. similarly to previous studies, the presence of anaemia, male gender, outdoor access, non-pedigree status and fiv infection were significantly associated with haemoplasma infection. disclosures: no disclosures to report. canine parvovirus type (cpv- ) is a frequent digestive pathogen in dogs, responsible for high mortality rates in puppies. the control of the infection by disinfection and isolation of patients is of limited efficiency, raising questions about the contagion sources. the aim of our study was to evaluate the epidemiological role of dams in viral circulation during the reproductive period. a total of bitches (mean ae standard deviation: . ae . years old) from one kennel were enrolled in the study. all were annually vaccinated (nobivac dhppi-lepto vaccine; msd, beaucouz e, france). dams were followed from mating to whelping and dams were followed from whelping until weaning. all puppies from the lactating dams (n = ) were followed since until weeks of age. cpv- fecal excretion was evaluated by real time pcr on rectal swabs [ ] every days during gestation (dams) and every days during lactation (dams and puppies). data were analyzed through logistic regression and mixed linear models. a total of samples were collected. during pregnancy, % of the bitches excreted cpv at least once, but only one sample was above the quantification threshold ( . copies/g feces). dur-ing lactation, all bitches were found positive at least once (and times in mean) and % went above the quantification threshold at least once. during lactation, excreted viral loads were significantly higher at d ( . /g feces; p = . ), d ( . /g feces; p < . ) and d ( /g feces; p < . ) compared to the early lactation (< copies/g feces; d to d ). despite threshold for a clinical parvovirosis is . /g feces, none of the bitches expressed any symptom. in % of the cases, the dam excreted before her puppies. viral loads excreted by puppies were not correlated with those excreted by dams. the proportion of puppies excreting viral loads above the clinical threshold increased from d to d (from to % per litter), with overall mortality of only % ( / ). this study demonstrates that appropriately vaccinated adult female dogs may excrete cpv during gestation and lactation. due to the high quantity of cpv- excreted, females probably represent a major source of contamination for their puppies. viral excretion by bitches after lactation until the next breeding period and by males would be interesting to follow to better understand the role of adults in cpv circulation. [ feline panleukopenia virus (fpv) is responsible for one of the most severe infectious diseases in cats, but only few studies have addressed factors of prognostic importance. in an earlier investigation spanning over years, leukopenia, thrombocytopenia, hypoalbuminemia and hypokalemia were found associated with poor outcome. here, we aimed at identifying outcome predictors during shelter outbreaks of panleukopenia between and ; we limited our analysis to fresh cases treated and followed until recovery or death at the same institution. clinical records of the affected cats were reviewed and information was collected at diagnosis and during hospitalization. the data included anamnestic history, physical examination, complete blood count, biochemical profile, blood gas analysis and treatments, including types of antibiotic, antiviral, antiemetic, analgesic, crystalloid, colloid and hemoderivative administered. outcome predictors were analyzed using logistic regression and mixed-design analysis of variance. the study included cats diagnosed with panleukopenia based on clinical findings and positive fecal elisa, of which . % were < months old, and . % females. clinical signs at diagnosis included lethargy ( . %), vomiting ( . %) and diarrhea ( . %). at admission, median (range) leukocyte counts were , /ll ( - , ) and platelets , /ll ( - , ); . % had hypoalbuminemia and . % hypokalemia. treatments included administrations of amoxicillin-clavulanate ( . %), interferon-x ( . %) and intravenous glucose solution ( %). overall, . % of the cats did not survive. lethargic cats were more likely to die (or: . , ci %: . - . , p < . ). leukocyte counts at diagnosis were not associated with outcome, but were after days of hospitalization; in particular, cats alive at days, which succumbed later, had leukocyte counts of /ll ( - , ) whereas survivors had , /ll ( - , ) (p < . ). survivors were more likely to have received amoxicillin-clavulanate (or: . , ci %: . - . , p < . ) and less likely intravenous glucose solutions (or: . , ci %: . - . , p < . ). thrombocytopenia, hypoalbuminemia, hypokalemia and administration of interferon-x were not associated with the outcome. our results suggest that infected cats with lower leukocyte counts later during hospitalization are more likely to die despite treatment. in this study, and different from previous data, lower leukocyte counts at admission did not predict outcome, possibly due to inclusion of cats with early fpv diagnosis. administration of intravenous glucose was associated with poor outcome, perhaps because of an increased risk of sepsis; also, cats in critical conditions were more likely to receive intravenous glucose. the beneficial role of amoxicillin-clavulanate in sick cats might be due to its broad-spectrum bactericidal activity; interferon-x did not show any conspicuous effect. disclosures: no disclosures to report. according to prior studies up to % of cats in southern germany do not have protective antibodies against feline panleukopenia virus and thus, are likely susceptible for feline panleukopenia infection. until now, it is unknown how healthy adult cats with different antibody titers react to feline panleukopenia vaccination in the field. therefore, the aim of the study was to measure antibody titers in healthy adult cats within days after feline panleukopenia vaccination. one hundred and twelve healthy adult cats were vaccinated with a rcp vaccine. before vaccination (day ) and on days and antibodies against panleukopenia virus were determined by hemagglutination inhibition. in . % ( / ) of the cats, no antibodies prior to vaccination were detected; of these cats were vaccinated regularly. nearly one third of the cats ( . %; / ) showed no antibody increase after vaccination and in . % ( / ) of the cats, antibody titer decreased despite vaccination within the days. however, all of these cats were likely protected by their preexisting antibody titer. in cats no antibodies were detected neither prior to nor after vaccination. a large number of adult cats has no protective antibodies and is therefore at risk for feline panleukopenia virus infection. on the other hand, many other cats show high antibody titers and do not develop antibodies due to vaccination. therefore, evaluation of individual antibody status in cats and vaccination only in those cats, that have no antibodies or low titers, should be recommended. disclosures: independent study financed by merial. there was no influence on the results of the study by merial and there is no co-authorship planned with merial. the feline coronaviruses (fcov) occur as pathotypes with an enigmatic, even controversial, relationship: the low virulence or nonvirulent feline enteric coronavirus (fecv) and the highly lethal feline infectious peritonitis virus (fipv). recently, sequence differences within the spike gene region encoding the putative fusion peptide were described and proposed to correlate with the mutated form of fecv (i.e. fipv) leading to the clinical presentation of feline infectious peritonitis (fip). in this presentation, the development and validation of an allelic discrimination real-time pcr typing test which can identify each mutation separately will be described. the diagnostic sensitivity and specificity will be reported from a set of european clinical samples acquired from either fip confirmed cats or from healthy cats that previously tested fcov positive. of these archived samples, fcov positive samples were included into the validation. from these, samples did not pass quality control and had virus levels that were below the limit of detection of the pcr assay. of the remaining samples, were typed correctly with an accuracy of . %. one fip characterized sample was typed fecv (diagnostic sensitivity . %) while all of the healthy cats were typed fecv ( % diagnostic specificity). to confirm that these spike gene mutations are not unique to european cats with fip, additional validation studies from us and japanese samples were conducted. the us clinical study included cases, from fip suspicious cases and with non-fip compatible disease. the fipv realpcr biotyping assay was able to accurately differentiate between the fip or non-fip (fecv) etiologies (p < . ) and did not biotype cats with confirmed non-fip disease as fipv, confirming the high diagnostic specificity of the molecular test. disclosures the aim of this study was to compare the diagnostic accuracy for fip of conventional clinico-pathological tests (routine hematology, serum protein electrophoresis, a -acid glycoprotein -agpmeasurement and analysis of the effusions) with that of molecular tests such as routine pcr and pcr followed by the sequencing of the spike (s) gene. blood, effusion and tissues specimens were collected from cats with symptoms imputable to fip. the in vivo examination consisted of clinico-pathological tests such as complete blood count, serum protein electrophoresis, agp measurement, cytological and biochemical examination as well as the evaluation of the sysmex dtnc of effusions, when present, and of molecular tests such as a screening pcr (directed towards the utr region) and the pcr directed towards the s gene followed by sequencing of the amplification products in order to detect the aminoacidic substitution considered diagnostic for fip. the same molecular techniques were applied to the tissues samples collected during necropsy, which also allowed to divide the cats in a fip group ( cats) and in a non fip group ( cats) based on histology and immunohistochemistry. the diagnostic accuracy (sensitivity, specificity, negative and positive predictive values) of each test was calculated. the best test on tissues was immunohistochemistry (sens: . %; spec: %), while the screening pcr suffered of low sensitivity and very low specificity (sens: . %; spec: . %). the s gene sequencing, positive when revealing the mutated nucleotide, showed very low sensitivity (sens: . ; spec: %). on effusions, the best tests resulted the screening pcr and cytology (sens and spec: %) in comparison with the dtnc measurement (sens: . %; spec: %) and the s gene sequencing (sens: . %; spec: %). in blood samples, agp measurement demonstrated the best diagnostic accuracy (sens: . %; spec: %), while serum protein electrophoresis showed a surprisingly low sensitivity (sens: . %; spec: %). screening pcr (sens: . %; spec: %) and s gene sequencing (sens: . %; spec: %) proved again low accuracy, demonstrating that a negative result with these molecular tests does not allow to exclude fip. . chang hw, egberink hf, halpin r, spiro dj, rottier pjm "spike protein fusion peptide and feline coronavirus virulence"emerg infect dis ( ) diagnosis in feline infectious peritonitis (fip) is still challenging, especially in cats without body cavity effusion. uveitis in cats with fip commonly presents without effusion, which makes a definitive confirmation of fip difficult. the aim of this study was to evaluate the diagnostic utility of an immunocytochemical (icc) assay using aqueous humor in cats suspected of having fip. samples of cats with immunohistochemically confirmed fip and cats that were suspected of having fip due to similar clinical or laboratory changes, but that were definitively diagnosed with another disease were examined. aqueous humor was collected post-mortem after the cats were euthanized due to their diagnosed diseases. icc analysis was carried out using an anti-feline coronavirus mouse monoclonal igg a and an avidin-biotin complex method. sensitivity, specificity, negative and positive predictive values were determined and % confidence intervals ( % ci) calculated. of the aqueous humor samples, ( with fip, controls) revealed positive icc results. false positive icc results were obtained in cats suffering from lymphoma and pulmonary adenocarcinoma. diagnostic sensitivity of the icc assay in aqueous humor was . % ( % ci . - . ); diagnostic specificity was . % ( % ci . - . ); the negative predictive value was . % ( % ci . - . ); the positive predictive value was . % ( % ci . - . ) . unfortunately, false positive results occurred, and specificity, which is considered the most important parameter in a fatal disease like fip, was only . %. positive icc results in aqueous humor should be interpreted cautiously and cannot confirm a suspicion of fip. disclosures: no disclosures to report. alanine aminotransferase (alt) level in plasma is the most commonly used indicator for hepatocellular injury in dogs. however, dogs with advanced liver disease can present with alt levels within reference range. recent studies have shown the potential of circulating micrornas as a biomarker for liver injury. hepatocyte-derived microrna- (mir- ) was identified to be liver specific with superior sensitivity over alt levels in mice and humans. the aim of the present study was to investigate the potential for circulating mir- to serve as a diagnostic serum biomarker of hepatocellular injury in dogs. hereto, liver biopsies of labrador retrievers were collected. liver histology, including grade of hepatitis and stage of fibrosis, was reviewed by a boardcertified veterinary pathologist (tsgamvdi). concurrently, serum samples were collected and analyzed for alt levels and mir- levels. dogs were included into one of the following groups: normal liver and normal alt levels (control group), liver pathology and normal alt levels, or liver pathology and high alt levels. comparative statistics between groups were performed using the mann-whitney u test and associations between mir- and alt levels, grade, stage and hepatic copper concentrations were analyzed using the spearman's rank correlation coefficient. logistic regression models were used to assess the accuracy of mir- and alt to detect the presence of hepatocellular injury. in total, dogs had normal liver histology and normal alt levels. thirtyeight dogs had liver pathology whereof only dogs had increased alt levels. in the high alt group the median level of mir- was (range, - ) times higher compared to the control group (p < . ). even in dogs with liver pathology and normal alt levels, the median mir- level was (range, . - ) times higher compared to the control group (p < . ). univariate logistic regression showed that only mir- and not alt level was a significant predictor for abnormal liver histology (p < . ). serum levels of mir- were positively correlated with alt levels, histological grade and stage of fibrosis (r = . , r = . , r = . , respectively, p < . for all). this study highlights the potential of mir- as an early and sensitive biomarker for liver injury in dogs and is more sensitive than alt levels. early diagnosis of hepatocellular injury opens the opportunity to institute treatment in a subclinical stage of disease with a possibly more favorable outcome. disclosures: this study was financially supported by the ecvim clinical studies fund. the authors declare no further conflict of interest. the evaluation of liver fibrosis is of major importance for the management of chronic liver disease and the prediction of prognosis. although liver biopsy is the gold standard for evaluation of fibrosis, non-invasive tests enable the clinician to stage and monitor a variety of liver diseases in human medicine. as such transforming growth factor b (tgf-b) and hyaluronic acid (ha) are biomarkers of hepatic fibrogenesis, that reflect the activity of the fibrogenic and fibrinolytic process, their use has not been validated in dogs. the aim of this study was to evaluate the measurement of tgfb and ha and assess their sensibility and specificity for the monitoring of dogs with different level of hepatic fibrosis. eighty three adult dogs were prospectively enrolled based on a persistent elevation of alt, with the exclusion of those with focal hepatic lesions on ultrasound examination. all dogs underwent liver biopsy and serum blood collection. lf was staged according to histopathological wsava criteria and the amount of collagen was measured through morphometric analysis. quantitative variables were expressed as meanaesd. bean plots described the relationships between variables. bivariate analysis between ha, alt and pal with lf were performed by spearman correlations. a parametric test (student test) was carried out to assess the relationship between tgfb and lf. diagnostic cut-offs were determined according to the maximum youden index [sensitivity (se) + specifity (spe) - ]. preliminary results in dogs showed that . % of the individuals with ha below ng/ml had a density of < . % collagen. the serum concentration of ha was significantly (p-value = . ) higher in the group whose fibrosis density was ≥ . %. tgf-b was the most sensitive marker but its specificity to diagnose dogs with more than . % of collagen was quite low. the preliminary results show a potential interest of ha as a biomarker to detect liver fibrosis in dogs but the interest of the tgfb could not be demonstrated. ha combines a good sensitivity with a fair specificity. the complete results of the study will help to refine the cut-off value and to improve the diagnostic performance of ah and to evaluate the interest of tgfb. a combination of several markers would be helpful to elaborate a sensitive and specific diagnostic test for liver fibrosis. disclosures: the speaker declares a potential conflict of interest with the company echosens . echosens covers a part of the biological measurements expenses in the clinical trial associated to this abstract. primary hepatitis is a common disorder in dogs. treatments for primary hepatitis are typically symptomatic and importantly, predicting prognosis at point of diagnosis remains challenging. in contrast to human medicine, where the type of hepatitis is defined by the inciting cause, few causes of chronic hepatitis have been identified in the dog, and the majority of cases are idiopathic. systemic inflammation is well recognised in humans with liver disease. systemic inflammatory response syndrome (sirs) is the clinical expression of the action of complex intrinsic mediators of the acute phase reaction. the presence of sirs has been linked to a poor outcome in various liver diseases. the prevalence and predictive value of a sirs in dogs with primary hepatitis has not been examined in dogs with liver disease. this is surprising given the accumulating evidence that sirs is linked to the development of hepatic encephalopathy (he) in dogs with liver disease. although the pathogenesis of he is not completely understood, it has been indicated that ammonia and inflammatory cytokines play a crucial role in the development of he. he is an important cause of morbidity and mortality in patients with liver disease. the hypothesis of this study was to examine the prevalence and severity of sirs n dogs with histological confirmed primary hepatopathies. eighty dogs with primary hepatopathies (confirmed with histopathology) were included in this study. a sirs score was calculated for each (respiration rate > breaths per minute; heart rate > beats per minute; total white blood cell count < or > ^ /l and rectal temperature < . or < . °c). sirs scores presented as a value from to . patient's date of arrival in hospital and date of death were all recorded; therefore survival time (days) could be determined. sirs scoring was applied and survival time was recorded. the median survival for sirs ( - ) was days, while sirs ( - ) had a median survival of days (p value < . , log rank test). this study demonstrates that sirs is a common feature of dogs with primary hepatitis and is valuable in predicting clinical outcome. disclosures: no disclosures to report. the aim of this study was to determine the prevalence of congenital portosystemic shunts (cpss) in deerhounds, focussing on the uk and the usa, and to determine how many deerhound breeders routinely test their puppies for cpss. congenital portosystemic shunts (cpss) are over-represented in certain breeds such as irish wolfhounds, maltese and yorkshire terriers. anecdotal evidence suggests that there is also an increased prevalence in deerhounds. this has not been confirmed, however. the study was questionnaire-based, distributed online to deerhound breeders worldwide (particularly the usa and uk). in addition it was distributed by post in the uk. the questionnaire passed ethical review at the department of veterinary medicine, university of cambridge. fifty-six breeders worldwide returned questionnaires (uk , usa , other countries ). the uk response rate was . % (including postal and online responses). the prevalence of shunts was found to be . % of puppies with prevalences in the uk and the usa of . % and . %, respectively. worldwide, % of breeders were found to test routinely for cpss in their puppies, while the proportions in the uk and the usa were % and %, respectively. the prevalence of cpss in uk and usa deerhounds found in this study was higher than was found for mixed-breed dogs ( . %) in a separate study. this suggests a genetic component to the disease in deerhounds. a lower proportion of breeders rou-tinely tested for cpss in the usa compared with the uk. the prevalence of cpss was also lower in the usa. these findings may be related. it would be advisable for all breeders to routinely test their puppies for cpss before sale, and to avoid breeding from affected animals. disclosures: st catharine's college, cambridge, contributed to the cost of this study. the deerhound club (uk) and the scottish deerhound club of america gave their support, helping to distribute and advertise the study. measurement of neuroendocrine markers can offer diagnostic, prognostic, and therapeutic information that cannot be obtained by clinical examination. nt-probnp is a potential biomarker for hypertensive target organ damage (tod). circulating concentrations of this biomarker are increased in human hypertensive patients with tod and with poor response to antihypertensive treatment. cats with hypertension and tod have significantly higher nt-probnp concentrations than non-hypertensive cats. the aim of this study was to investigate the utility of nt-probnp as a biomarker of hypertension, tod and efficacy of antihypertensive treatment. plasma samples from hypertensive cats seen at first opinion practices were retrospectively identified. hypertension was diagnosed based on systolic blood pressure (sbp) ≥ mmhg with evidence of hypertensive retinopathy (tod-group; n = ) or sbp≥ mmhg on consecutive visits - weeks apart without evidence of retinal pathology (notod-group; n = ). all cats achieved sbp control (defined as < mmhg) on . - . mg amlodipine once daily and had samples available on both a hypertensive visit and the first visit target sbp was achieved. additionally, healthy cats ≥ years old (n = ) and normotensive cats diagnosed with ckd (plasma creatinine ≥ lmol/l in conjunction with usg< . ; n = ) were identified. nt-probnp concentration was measured at an external laboratory. if necessary, variables were log-transformed to meet normality of distribution. binary logistic regression was used to investigate nt-probnp as a predictor of hypertension (using the healthy and ckd cats as comparator group) and tod (using notod as comparator group). comparisons between groups and of response to treatment were performed using mann-whitney u and wilcoxon rank sum tests respectively. higher nt-probnp concentration significantly increased the probability for a cat to be hypertensive (odds ratio log(nt-probnp) = . , [ % confidence interval . , . ], p < . ), but could not reliably predict tod (p = . ). nt-probnp concentration was however significantly higher in cats with tod than in cats with no tod ( . [ . , . ] these data suggest that increased plasma nt-probnp concentration predicts hypertensive status in cats. cats without tod have significantly lower nt-probnp concentrations at diagnosis of hypertension than cats with tod. nt-probnp concentration decreases with effective antihypertensive treatment. further studies are required to determine whether nt-probnp remains elevated in cats with poorly controlled blood pressure. disclosures: esther bijsmans's phd is funded by zoetis. hypovitaminosis d has previously been shown to be prevalent amongst dogs with protein losing enteropathy (ple). outcome is generally poor in canine ple, and there is a lack of studies identifying underlying risk factors. the hypothesis of this study was that low vitamin d serum concentrations could be a risk factor for bad outcome in such patients. medical records for dogs seen at the royal veterinary college between and were reviewed to identify dogs with a diagnosis of ple confirmed by histopathology. dogs were included in the study if they had serum samples frozen within minutes after sampling, had been kept at - degrees c until analysis, and if clinical activity scoring (cce-cai) had been recorded at the time of diagnosis. forty-three dogs were included in the study. follow-up with referring veterinarians was made to determine outcome of patients. patients were divided into groups: patients deceased due to ple (poor outcome group, n = ) and patients alive or deceased due to another disease (good outcome group, n = ). treatments for patients were allocated to groups: one group consisted of patients who were prescribed diet only and the other group received diet and immunosuppressive agents. samples were sent on dry ice to michigan state university's diagnostic center for population and animal health. ionised calcium (ica) was measured using an ion specific electrode and (oh)d was measured using a commercially available radio-immunoassay that has been validated for use in veterinary medicine. comparisons of outcome groups for age, ccecai, treatment, serum (oh)d and ica were performed using a mann-whitney u test or chi . logistic regression analysis was performed to determine possible risk factors for poor outcome. results: ccecai scores, age, and ica concentrations between the groups were not significantly different. there was a significantly greater number of dogs treated with food alone in the group with good outcome ( / ) than in the poor outcome group ( / , p = . ). furthermore, median serum (oh)d concentration was significantly lower in patients with poor outcomes ( . nmol/l, range - nmol/l) compared to patients with good outcomes ( nmol/l, range - nmol/l, p = . ). using logistical regression, (oh)d serum concentration was a statistically significant factor for poor outcome (p = . ), with an increase of (oh)d serum concentration reducing the odds of having a poor outcome (odds ratio = . , % ci: . - . ). further studies are required to investigate vitamin d as a potential adjuvant therapeutic agent in ple patients. disclosures: no disclosures to report. campylobacter jejuni (cj), c. upsaliensis (cu) and c. helveticus (ch) are commonly isolated from dog and cat faeces but association with clinical signs is discordant or lacking. cj is a recognized human pathogen, cu is considered an 'emerging' pathogen and ch is not considered pathogenic despite a high level of genetic similarity. recently, the greater wax moth, galleria mellonella, was described as an animal model of disease; these invertebrates have a high degree of functional and structural homology with the mammalian innate immune system. this study aimed to evaluate the pathogenic potential of cj, cu and ch using the galleria mellonella larvae model. twelve isolates of cj, of cu and of ch from dogs and cats were used for the inoculation of larvae. inocula were prepared by suspending isolates in phosphate-buffered saline (pbs) from which -fold dilutions were made. each dilution was tested in duplicate sets of larvae. each larva was injected with - ll into the haemocoel via the last left pro-leg using g insulin syringes. controls consisted of pbs inoculated larvae and un-inoculated larvae. survival of larvae at °c in a h enriched microaerobic atmosphere was monitored for days postinjection. one subset of isolates was grown in mueller-hinton broth and used for the preparation of secretory products, and another grown on blood-agar and suspended in pbs for heat inactivation of minutes at °c for testing of whole-cell lysates and heat-stable insoluble and soluble components. the overall median survival of larvae was % with cj [iqr - ], % with cu [iqr - ], % with ch [iqr - ], % with pbs [iqr - ] and % for un-inoculated larvae [iqr - ]. a dose-dependent association was evident for each species with larval survival being similar between a low bacterial dose and pbs. larval survival presented a consistent pattern between species for medium and high bacterial loads; cj had a higher and faster larval death rate than cu and ch (p < . ), but no difference was observed between cu and ch (p = . ). there were no significant differences between species in any of the assays with secretory products, inactivated cells and soluble/insoluble cellular components. the observations within this invertebrate disease model support a varying pathogenic potential between the species studied that appears related to the (patho)biology of the species rather than their cellular components or metabolic products. the invertebrate animal model is promising in comparative pathogenicity studies. disclosures: no disclosures to report. acute stress from medium or high duration high-intensity exercise has been reported to be associated with an increase in serum c-reactive protein (crp) concentrations, an important acute-phase reactant in dogs. however, the effect of exercise on fecal s a concentration, a biomarker of intestinal inflammation has not previously been evaluated in dogs. the goal of this study was to determine if moderate intensity short duration exercise causes an increase in crp and/or s a concentrations in dogs, potentially leading to misinterpretation of their results. adult military working dogs (german and belgian shepherd dogs; males; mean age = years [ . - . ]) were included in the study. fecal quality, fecal s a , and serum crp concentrations were evaluated just before and after standardized exercise ( minutes of bikejoring at a speed of km/h). fecal quality was evaluated based on a -point scale (from : liquid to : dry and hard feces). fecal s a and crp concentrations were assayed with previously validated elisa tests. data were analyzed with an anova test for repeated measurements (sas software). results are presented as medians and ranges. serum crp concentrations increased significantly after exercise (median before and after excercise mg/l [ - ] and mg/l [ - ] (p = . ). also, fecal s a concentrations were significantly higher after exercise compared with baseline concentrations ( ng/g [ - ] versus ng/g [ - ], p = . ). no significant effect of exercise on fecal score was observed ( [ . - . ] before and after the exercise; p = . ). our study demonstrates that a moderate-intensity, short-duration effort performed by healthy army dogs causes significant increases in fecal s a and serum crp concentrations, as compared with baseline values, but within the respective reference intervals. therefore, a moderate exercise does not present a confounding variable in the interpretation of fecal s a or serum crp concentrations in healthy dogs. disclosures: this study was performed thanks the financial support of royal canin. imaging is an integral part of the work-up of canine gastrointestinal (gi) disease. radiography and ultrasonography are noninvasive modalities that can evaluate the bowel, but many findings lack desirable sensitivity or specificity. endoscopy directly visualizes gi mucosa, but is limited by the length of the endoscope and the need for general anesthesia, advanced training and expensive equipment. ambulatory light-based imaging (ali) is a new imaging modality that utilizes high-resolution cameras, a microprocessor, and led illumination to non-invasively visualize the gastrointestinal mucosa. ali is performed by oral administration of a fully automated device the size of a pill that is propelled by peristalsis. the aim of this study was to analyze image quality and gi transit times in a series of client owned dogs undergoing ali. dogs were food-restricted for hours before and hours after capsule administration. capsules were retrieved and images were downloaded and analyzed. video clips of frames duration were obtained from the stomach; proximal, middle and distal small intestine; and proximal colon for assessment of image quality. internists rated the images on a scale of - ( = poor, = excellent) based on clarity and resolution of images, and obscuration of the mucosa by fluid, bubbles or debris. scores for each region were compared using general estimating equation analysis. gastric and small intestine transit time were calculated based on visualization of passage of the capsule from the stomach to duodenum, and ileum to colon. clinical analysis of the entire video was performed by one of the authors. ali was successfully performed in / patients, with no adverse effects. average study duration was . ae . hours and mean image acquisition count was , ae , . gastric and small intestinal transit times were . ae . minutes and . ae . minutes, respectively. median (range) image quality scores were ( - ), ( - ) and ( - ), for the stomach, si and colon, respectively. image quality scores were significantly higher in the stomach and si than in the colon (p < . ). visualized lesions were consistent with gi ulcers ( dogs), inflammatory bowel disease ( dog), and bilious vomiting syndrome ( dog). one dog receiving chronic nsaids had a normal study. ambulatory light-based imaging resulted in good to excellent image quality throughout most of the gi tract. bowel preparation should be considered to enhance visualization of the colon. ali was safe and easy to perform in ambulatory dogs, and should therefore be considered in the work-up of canine gi disease. disclosures canine pancreatitis is the most common exocrine pancreatic disorder. the prognosis of canine pancreatitis is variably and no logistic regression constructed severity scoring systems are available. four hundred and thirty nine dogs diagnosed as pancreatitis with acute onset of compatible clinical signs, a positive snap Ò cpl tm test, and/or associated abdominal ultrasonographic abnormalities between january and december were presented at national taiwan university veterinary hospital (ntuvh). one hundred and three dogs hospitalized with complete medical therapy and outcomes were selected for further analysis. the dogs were divided into survival (n = ) and non-survival (n = ) groups. forty-seven parameters including signalment, clinical signs, physical examinations, clinicopathological examination, complications and concurrent diseases were analyzed and compared between the groups. logistic regression analyses were performed in this study. variables with p ≤ . were considered for further analyses. the mortality in this study was . %. age, heart rate, respiratory rate, white blood cell count, albumin, bun, creatinine, potassium, presence of systemic inflammatory response syndrome (sirs) and presence of oliguria or anuria were selected for constructing the scores. continuous variables outside the reference interval were separated into quartiles to yield quartile-specific odds ratios (ors) for survival. based on the integer value of the or, the scoring system was then developed by incorporating weighting factors assigned to each quartile. a predictive total score was calculated for each dog by summing all weighting factors. the total scores of each dog ranged from to . the severity scores in this study achieved an area under the receiver operating characteristic (auroc) of . . the optimal cut-off point for discriminating outcome was . with a sensitivity of . % and specificity of . %, respectively. the mortality was . % with a score ≥ , whereas . % with a score ≤ . there was a significant difference (p < . ) between the groups seperated by the cut-off point. the severity scoring system of this study provides a reliable and clinical applicable method to predict clinical outcome in dogs with pancreatitis. disclosures: no disclosures to report. glucocorticoids (gcs) are known for their anti-inflammatory and immunmodulatory properties and are therefore often used in the therapy of canine inflammatory bowel disease (ibd). it was recently shown that endogenous gcs are also produced in the intestinal epithelium of men and mice and influence the gastrointestinal immune system in case of inflammatory or neoplastic conditions. thus, the aim of this project was to prove that gcs can be produced or metabolized in the canine intestinal epithelium. five healthy beagle dogs were included into this prospective study. all dogs were clinically examined, given a clinical score using the canine ibd activity index (cibdai) scoring system, also gastrointestinal endoscopy was performed. mucosal biopsy specimens from duodenum were examined histologically from a board certified pathologist using the wsava grading. biopsy incubation of - endoscopical mucosal biopsies in tissue culture medium with h-labeled progesterone in the absence of any stimulation was performed. the mean age of the included dogs was . + . years, the mean weight was . + . kg. all beagle dogs had a mean clinical score of + . the mean wsava scoring was + . . after hours, supernatant was harvested and radioactive progesterone metabolites formed were detected using high performance liquid chromatography plus liquid scintillation counting. in all dogs the h-progesterone was metabolized into various steroid species, nevertheless a local production of cortisol could not be proven. in summary, it could be shown that precursors of gcs can be metabolized by healthy canine intestinal mucosal tissue. disclosures: no disclosures to report. we studied the relationship between pancreatitis and cardiac injury in dogs and cats. previously, we validated a cardiac troponin i (ctni; vet j : - , ) assay for sensitive and specific detection of cardiac injury in domestic animals. we found various non-cardiac diseases of dogs and cats were associated with cardiac injury detected by serum cardiac troponin i, including some cases of pancreatitis. also, we validated the dggr-lipase assay for cost-effective, sensitive and specific detection of pancreatitis in dogs and cats (vet clin path : e - , ; :e - , ). herein, we tested the hypothesis that pancreatitis was associated with cardiac injury. ctni was measured by advia centaur tni-ultra assay; dggr-lipase by the randox colourimetric assay. we retrospectively analysed data from dogs and cats admitted to ucd veterinary hospital in which both ctn and lipase had been measured. upper limit of reference range for lipase in dogs is u/l; we consider - indicative of mild pancreatitis, - moderate, and > as marked. upper limit of reference range for lipase in cats is . reference range for ctni is < . ug/l for dogs and cats. we consider . - . indicative of mild cardiac injury, . - as moderate, and > . as marked. dogs and cats had both lipase and ctni measured. dogs had normal troponin; had normal lipase and had normal lipase and normal ctni. dogs ( %) had pancreatitis as indicated by increased lipase. in ( %), pancreatitis was mild, in ( %) it was moderate, and in ( %) it was marked. of dogs had increased ctni: mild in ( %), moderate in ( %), and marked in ( %). cardiac injury in dogs with pancreatitis was absent in %, mild in %, moderate in %, and marked in %. of cats had normal ctn; had normal lipase. of cats had pancreatitis, severely in . lipase and ctni was correlated (r = . ) for dogs and cats. we conclude that both pancreatitis and cardiac injury, as indicated by high-sensitivity and high-specificity assays randox-dggr-lipase and centaur-ctni, respectively, are not uncommon in veterinary hospital cases. we confirm and extend our previous work. pancreatitis in dogs and cats is typically associated with cardiac injury. severities of pancreatitis and cardiac injury are correlated. for~ % of dogs and cats with pancreatitis, cardiac injury is moderate to marked. disclosures: no disclosures to report. intracellular colonization may serve as a protected niche where helicobacter spporganisms evade effective treatment, contributing to recolonization. confocal endomicroscopy (cem) is an endoscopic modality allowing in vivo gastrointestinal imaging at high resolution; and has aided real-time identification of helicobacter pylori and intracellular and mucosally associated bacterial. in dogs, non-helicobacter pylori-helicobacter (nhph) are described intracellularly. the objective of this study was to determine the utility of cem to identify nhph in dogs compared with other diagnostic modalities; and to assess its ability to identify intracellular organisms. fourteen clinically healthy dogs underwent standard gastroduodenoscopy followed by cem using topical acriflavine. images were obtained using cem at a minimum of sites within the stomach. endoscopic pinch biopsies were obtained for histopathology, polymerase chain reaction (pcr) and fluorescence in situ hybridisation (fish). methodologies were compared for their sensitivity in detecting the presence and distribution of nhph and their ability to identify intracellular organisms. cem provided high quality images allowing in vivo identification ofnhph in dogs, as did fish post-procedure analysis. standard histopathology identified nhph in only . nhph were identified within the superficial gastric mucus, and gastric pits. distribution throughout the stomach was diffuse and multi-focal. cem findings correlated with fish and pcr, however only fish enabled identification of intracellular nhph which were present in of dogs. cem provides in vivo histology images and is capable of identifying nhph during gastroscopy, but is unable to identify intracellular organisms using the current fluorophore protocol. nhph in the canine stomach are commonly identified intracellularly. disclosures: dr sharman has shares in optiscan imaging pty ltd. chronic enteropathies (ce) and exocrine pancreatic insufficiency (epi) can both cause hypocobalaminemia in cats. current supplementation protocols for cobalamin in cats call for repeated parenteral injections. in humans, several studies have reported equal efficacy of oral administration of cobalamin. there is also evidence that oral supplementation is effective in dogs with hypocobalaminemia. recently, it has also been reported that oral cobalamin substitution restores normocobalaminemia in healthy elderly cats. the purpose of this retrospective case series was to evaluate whether oral cobalamin supplementation can restore normocobalaminemia in hypocobalaminemic cats with chronic enteropathies. a computerized database search for cats treated at evidensia specialist animal hospital, helsingborg, sweden during - was performed. inclusion criteria were cats with symptoms of ce, an initial serum cobalamin concentration below pmol/l (reference interval: - pmol/l) and daily oral treatment with cyanocobalamin ( mg/tablet; ⅛-¼ tablet/cat daily). follow-up serum cobalamin concentration was measured to days after initiation of daily oral cobalamin supplementation. thirteen cats aged - years (median ) of different breeds met the inclusion criteria. presenting complaints included vomiting ( / ), anorexia ( / ), diarrhea ( / ), weight loss ( / ), and lethargy ( / ). increased pancreas specific lipase (spec fpl Ò ) serum concentrations were reported in / cats and / had increased serum alanine transaminase activity. feline serum trypsin like immunoreactivity (ftli) was determined in / cats revealing results within the reference interval. all cats had an abdominal ultrasound, / had changes related to the gastrointestinal tract such as mild-moderate thickening of the small intestinal wall, thickening of the muscularis layer, poor definition of intestinal wall layers, and/or enlargement of the mesenterial lymph nodes, histopathology was performed in / cats, revealing small intestinal inflammation in cats and small intestinal lymphoma in one. serum cobalamin increased in all cats with treatment. the concentration difference ranged from to pmol/l (mean: pmol/l). mean (ae standard deviation) serum cobalamin concentrations were (ae ) pmol/l before and (ae ) pmol/l after supplementation. this difference was statistically significant (p < . , paired t-test). our results suggest that oral cobalamin supplementation is effective in normalizing serum cobalamin concentrations in cats with various enteropathies. prospective studies are warranted comparing cellular cobalamin status in cats being treated with parenteral or oral cobalamin supplementation. disclosures: no disclosures to report. pulmonary thromboembolism (pte) is observed in dogs with idiopathic-inflammatory-bowel disease (ibd) and particularly with protein-losing enteropathy (ple). hypercoagulability has been attributed to antithrombin (at) loss although the pathogenesis is likely to be more complex. in humans, where venous thromboembolism (te) is a wellrecognised complication of crohn's disease and ulcerative colitis, the pathogenesis of te is still not completely understood. derangements in procoagulant and anticoagulant factors have been demonstrated, including increased circulating procoagulant microparticles (mps). the aim of this pilot study was to evaluate mp-procoagulant activity in the plasma of dogs with ibd and ple using a functional elisa assay (zymuphen-mp-activity, aniara). we hypothesised that all dogs with ple and a subset of dogs with ibd but without ple would have increased levels of circulating mps. the study group consisted of dogs with ibd, including with ple. diagnosis was based on compatible clinical and histopathology and exclusion of other causes of chronic gastrointestinal disease. ple was defined as ibd plus hypoproteinaemia (serum total protein < g/l) and hypoalbuminaemia (serum albumin < g/l). pte was diagnosed in one dog with ple, and suspected in a second. a control group comprised healthy dogs undergoing blood sampling for reasons unrelated to the study including blood donor screening (n = ) and health assessment (n = ). dogs were considered healthy based on owner evaluation, physical examination, haematology and serum biochemistry median mp procoagulant activity in dogs with ibd was . nm (range . - . ) compared with . nm (range . - . ) in the control group. median mp activity in ple dogs was . nm (range . - . ) compared with . nm (range . - . ) in non-ple ibd dogs. using kruskal-wallis test for nonparametric data and dunn's multiple comparisons test the groups were not statistically different. interestingly, mp-procoagulant activity value in the dog with documented pte was . nm; in the dog with high clinical suspicion for pte, mp-procoagulant activity was . nm. the highest mp-procoagulant activity was detected in a healthy control dog, raising concerns for pre-analytical or sampling error. removing this measurement had no impact on statistical analysis, which remained nonsignificant. mp-procoagulant activity > nm is considered clinically relevant in humans. employing a similar cut-off, / of controls, / of ibd and / of ple group would be defined as having increased levels of circulating mps. further studies are required to fully evaluate the clinical relevance and diagnostic potential of mp evaluation. disclosures: no disclosures to report. the intestinal microbiota is increasingly linked to the pathogenesis of chronic enteropathies (ce) in dogs. while imbalances in duodenal and fecal microbial communities have been associated with mucosal inflammation, relatively little is known about alterations in mucosal bacteria seen with ce involving the ileum and colon. the aim of the present study was to use fluorescence in situ hybridization (fish) techniques to investigate the composition and spatial organization of mucosal microbiota in endoscopic biopsies obtained from dogs with ce and controls. tissue sections from the ileum and colon from dogs with inflammatory bowel disease (ibd), dogs with granulomatous colitis (gc), dogs with intestinal neoplasia, and controls were studied by fish targeting the s rrna genes of total bacteria, group-specific organisms, and individual bacterial species shown to be relevant in human ibd. the numbers of mucosal bacteria were analyzed using generalized linear models for each of the colon and ileum tissues, with spearman's rank correlation coefficients used to test the correlation between mucosal microbiota and inflammatory (cib-dai score, histopathology) indices. the ileal and colonic mucosa of healthy dogs and dogs with ce was predominantly colonized by bacteria localized to free and adherent mucus compartments. dogs with ce harbored more (p < . ) mucosal bacteria belonging to the clostridium-coccoides/eubacterium rectale group, bacteroides, enterobacteriaceae, and escherichia coli versus controls. within the ce group, ibd dogs had increased (p < . ) enterobacteriaceae and e. coli bacteria attached onto surface epithelia or invading within the intestinal mucosa. bacterial invasion with e. coli was present in the ileal and colonic mucosa of dogs with gc (p < . ). dogs with intestinal neoplasia had increased (p < . ) adherent (total bacteria, enterobacteriaceae, e. coli) and invasive (enterobacteriaceae, e. coli, and bacteroides) bacteria in biopsy specimens versus all other groups. increased numbers of total bacteria adherent to the colonic mucosa were associated with clinical disease severity (cibdai score) in ibd dogs (p < . ). these results indicate that histopathologic lesions of canine ce are associated with different populations in ileal and colonic mucosal microbiota. these spatial, segment-specific structure and differential response of select bacterial groups to intestinal inflammation may be pivotal regarding the functional consequences of these alterations in the pathogenesis of canine ce. disclosures: no disclosures to report. abdominal girth is used as an indicator of human adiposity, with such measurements being made by tape measure. given concerns in precision and accuracy of repeat measurements, some tape measure designs have inbuilt mechanisms to improve consistency. although body condition scoring is the most common method of assessing adiposity in dogs, zoometric systems have also been developed requiring the use of a tape measure. however, the precision and accuracy of such zoometric measurements are not known. the aim of this study was to determine the precision and accuracy of different types of tape measure for a variety of dimensional measurements. a variety of length (head, forelimb, hindlimb) and circumferential (neck, thorax, and abdomen) were made using different tape measures, of which were designed to improve precision (standard tape; myotape tm and gulick ii tm ). to assess intra-operator variability, measurements were taken for consecutive days from healthy dogs; to assess inter-operator variability, operators independently took measurements from a group of dogs of various breeds and sizes. for intra-operator comparisons, precision was good overall (coefficient of variation [cv] ≤ % for all measurements). for inter-operator comparisons, precision was more variable and, although reasonable on average (mean cv - %), it varied depending upon tape measure type (p = . ; greatest for standard tape measure, least for gulich ii tm ), and could be highly variable for some measurements in individuals dogs (maximum cv % for head measurements with standard tape measure). significant differences also existed in the absolute results of circumferential measurements taken by the different tape measure types (neck p = . ; thorax p < . ; abdomen p < . ). finally, significant operator differences were also evident for some measurements (head p = . ; hindlimb p = . ), but not for others (forelimb p = . ; neck p = . ; thorax p = . ; abdomen p = . ). in summary, although precision for individual operators making zoometric measurements is good, significant inter-operator and tape type differences exist. these results have implications for systems using a range of zoometric measures to assess adiposity. in order to ensure precision and accuracy, it is recommended that the same operator take all measurements with the same type of tape. disclosures: the study conducted was not supported by a research grant. ajg's readership is funded by royal canin; ajg has also received financial remuneration and gifts for providing educational material, speaking at conferences, and consultancy work; slh's post at the university of liverpool is also funded by royal canin. body condition score (bcs) is a method that is commonly used in the diagnosis of nutritional status in small animals. however, this method is subjective due to its sensory evaluation. therefore, the improvement of the precision of the bcs diagnosis is expected. our previous study has shown that the bcs model that we created improved the precision of the bcs diagnosis ( ). however, a palpation site was not identified. a palpation site must be the site where thickness of subcutaneous fat is able to capture for measuring animal's obesity status. therefore the objective of this study was to find a remarkable body site of the changes with obesity status using ultrasonic diagnostic equipment. nine dogs which varied in the percent of body fat were used in this study. the percent of body fat was measured by a body fat analyzer for dog (kao). the image analysis of a palpation site was evaluated using echo, xario ssa- a (toshiba) which attached to a linear probe. the measurement points were , and o'clock positions on the ribs of t , t and t . the distance (d) from skin surface to the rib was measured in the echogram. the distance (l) from scapula to ilium was measured to offset the difference in physique by dog breeds. the d/l was used to compare relative value of the quantity of fat at each measurement point. bcs of dogs which used in this study were from bcs of to bcs of . there were no dogs in bcs of and bcs of . a statistically significant correlation was found between bcs and d/l value. the d/l value increased in order of t , t and t in bcs of and . this suggests that the thickness of subcutaneous fat in the chest is thicker at the head side than the tail side. also, as for the d/ l value from back to abdomen, the highest value was found at the position of : and : . this tendency was the most remarkable in bcs of but no difference in the d/l value was recognized in the dogs in bcs of . in conclusion, the position of : or : on the t is the suitable palpation point at the chest. ( body condition score (bcs) is a method that is commonly used in the diagnosis of nutritional status in small animals. bcs has been recognized as one of the screen method of nutrition diagnosis by american animal hospital association in . however, this method is subjective due to its sensory evaluation. therefore we made a bcs model to increase the precision of the bcs diagnosis and have shown the efficacy of the bcs model ( ). however, the prototype model which we have reported before tended to have higher bcs than a target bcs. therefore, we improved the bcs model in this study. sixty seven dogs which varied in the bcs were used in this study. body fat percentage was measured by using a body fat analyzer for dogs (kao healthlab bif- ). the bcs model was improved by using several rubber sheets. relative hardness of stacking rubber sheets in each bcs was measured by durometer mj-dua-c (satotec tokyo, japan). bcs diagnosis of dogs was performed by pet owner by using the bcs model. bcs of represents the most hard in the bcs model and the hardness decreased linearly and it was the lowest in of bcs. these values were as expected. high correlation was recognized between bcs and body fat percentage. these results suggested the efficacy of bcs model. however, the body fat percentage in the dogs diagnosed as bcs of was higher than body fat percentage which has been reported in the previous paper. there were no dogs with the body fat percentage < % which were diagnosed as bcs of . we need more study in future to make clear the difference of body fat percentage between our data and date of the previous research. the completion of this bcs model will help provide the precision of nutritional diagnosis in dogs. ( in humans the metabolic syndrome (ms) is a well-recognised and extensively studied entity that comprises obesity, hypertension, dyslipidaemia, and glucose intolerance. it is associated with an increased risk of cardiovascular diseases and diabetes. recently, human ms criteria were adapted for dogs to define the condition of obesity-related metabolic dysfunction (ormd). it was observed that ormd was associated with increased circulating insulin and decreased adiponectin concentrations, suggesting that in dogs, as in humans, there are links between obesity, ormd, and associated diseases, although pathogenetic mechanisms and health significance for dogs remain unknown. the main aim of the present study was to compare plasma proteomes of obese dogs with and without ormd, so as to investigate the mechanisms associated with canine ormd and their possible significance in the health status. eight obese dogs referred for weight management at the royal canin weight management clinic, university of liverpool participated in the study. clinical assessments included physical examination, body condition scoring, blood pressure measurement and routine clinicopathological analysis. surplus plasma was used in proteomic analysis. samples were first treated with proteominer for thedepletion of high-abundance proteins and subsequently analysed by using -de dige methodology. of the dogs in the study, dogs had ormd and dogs did not. image analysis and further statistical analysis allowed identification of spots with differential expression concentration between dogs with and without ormd. among the spots, were over-expressed and were down-expressed in dogs with ormd than in dogs that did not presented ormd. although the results of the present study are preliminary and still the identification of the spots is up to be performed, the observed datareveal that dogs with ormd present alterations in their plasma proteomes that could be responsible for the development of ormd-related pathologies. disclosures: the study was funded by waltham. ajg's readership is funded by royal canin; ajg has also received financial remuneration and gifts for providing educational material, speaking at conferences, and consultancy work; slh's post at the university of liverpool is also funded by royal canin. vb is an employee of royal canin and pjm is an employee of wal-tham. the aim of the study was to assess the diagnostic value and the discrimination potential between the normal heart size and microcardia or cardiomegaly of a method which calculates the cardiothoracic ratio (ctr) using area measurement, compared to the vertebral heart scale method (vhs) used as reference for the cardiac size, in dogs. one hundred-nine dog x-rays were accepted into study. the patients belonged to small and medium size breeds, were males and females with age between and years. the analogic xrays were scanned and transferred to a computer where the vhs and ctr was calculated for each patient with a commercial software and the data was collected and processed in a statystical analysis software. the patients were distributed into groups by respiratory phase and heart size. there was a low correlation between the vhs and ctr (r = . ), but statistically significant (p? . ). a good correlation was obtained between vhs and ctr in microcardia, normal heart size and cardiomegaly groups (p < . ). furthermore, between the ctr in dogs with microcardia and those with normal cardiac size, as well as between ctr in dogs with normal cardiac size and those with cardiomegaly, a significantly statistic difference (p < . ), respectively (p < . ), was obtained. among the groups distributed by respiratory phase and vhs, a statistically significant difference was obtained only between normal cardiac size and cardiomegaly during inspiratory phase groups (p > . ). for the x-rays taken in inspiratory phase, a cutoff of . had a sensitivity of % and a specificity of % for diagnosing cardiomegaly. the ctr can be considered a valid method being able to discriminate between the patients with microcardia and cardiomegaly from those with normal heart size. moreover, it was found that a ctr over the cutoff of . , mesured during inspiratory phase is a good predictor for cardiomegaly. key words: cardiac, cardio-thoracic ratio, dog, x-ray. the canine cardiac conduction system is modified by anatomical and functional adaptations of the maternal heart during gestation. however, it is not clear if these changes persist or are modified after parturition. therefore, the aim of this study was to describe canine electrocardiographic features during the course of normal puerperium. twenty healthy pure-bred, - ( . ae . ) year-old, weighing . - kg ( . ae . ) bitches were included in this study. all the animals whelped healthy puppies at term which were weaned on day after parturition (day ). all the dogs were electrochardiographically evaluated on days À , , , , , , and . mean electrical axis (mea; degrees), p wave amplitude (pa; mv) and duration (pd; ms), p-r interval (pr; ms), qrs complex amplitude (qrsa; mv) and duration (qrsd; ms), q-t interval (qt; ms), and s-t segment (st; mv) were calculated at mm/s of velocity. the rr interval immediately preceding each complex was recorded and qt interval was corrected (qtc) by van de water formula [qtc = qt- . (rr- )]. later, lead ii was recorded at mm/sec to analyze heart rate (hr; bpm) and cardiac rhythm (cr; normal sinus rhythm or sinus arrythmia). values of hr, mea, pa, pd, pr, qrsa, qrsd, qt, rr and qtc were analyzed by anova for repeated measures followed by tukey test. cardiac rhythm was analyzed by chi square test (spss . , spss inc. chicago, il, usa). p < . was considered significant. during the study period, hr (p < . ) and qtc (p < . ) progressively decreased, while rr (p < . ) and pa increased (p < . ). qrs complex amplitude diminished in the second week after parturition and then increased during the following weeks (p < . ). mean electrical axis shifted to the right during this period (p < . ). on day À , most of the bitches presented normal sinus rhythm in contrast with day , in which most of the bitches presented sinus arrhythmia (p < . ). from day onward, all the bitches showed sinus arrhythmia. p wave duration, pr, qrsd, qt and st remained unchanged during puerperium. it is concluded that most electrophysiological adaptive changes of canine gestation reverted during normal puerperium. the pre-sent study contributes to the understanding of canine cardiac physiology during this reproductive stage. disclosures: no disclosures to report. esvc-p- echocardiographic assessment of pregnant queens. p.g. blanco, r. rodr ıguez, a. carranza, a. rube, r. vercellini, p.r. batista, m. t ortora, c. gobello. national university of la plata, la plata, argentina cardiovascular adaptation during gestation guarantees an appropriate development of the fetuses and maternal cardiovascular maladaptation is highly correlated with adverse pregnancy outcome. while, the hemodynamic changes occurring during canine pregnancy have been described there is scarce information concerning maternal cardiac variations during feline gestation. thus, the aim of this study was to describe cardiac morphology and systolic function variations during normal feline pregnancy. eighteen pregnant queens were echocardiographically evaluated (toshiba nemio xg, japan, mhz transducer) every days from day (defined as day of mating) to parturition. left ventricular dimensions were measured in the short axis view, during mmode tracing. shortening fraction was calculated as (lvdd -lvds)/lvdd x to assess systolic function. stroke volume (ml) was calculated as the product of the velocity time integral (measured by pulsed-wave doppler) and the cross-sectional area of the aorta. cardiac output (l/min) was calculated as the product of stroke volume and heart rate (bpm) derived from electrocardiographic monitoring. uterine artery resistance index (ri) was obtained by doppler ultrasound. all the parameters were analyzed by repeated measures anova. all the queens delivered healthy kittens at term. throughout the study period, interventricular septum in diastole (p < . ) and systole (p < . ) and left ventricular diameter in diastole (p < . ) augmented during gestation. shortening fraction (p < . ), cardiac output (p < . ) and maternal heart rate (p < . ) also increased up to parturition. conversely, uterine artery resistance index decreased in the same period (p < . ). it is concluded that cardiac structure and function varied during normal pregnancy in these queens. cardiac eccentric hypertrophy, systolic function and cardiac output increases appear to be the consequences of the hemodynamic modifications occurring during pregnancy. the assessment of maternal cardiovascular function may prove a useful screening tool to detect pregnancy complications in feline reproduction. disclosures: no disclosures to report. tricuspid annular plane systolic excursion (tapse) is an echocardiographic measure that allows to assess right ventricular systolic function. it has been described reference values for tapse in normal adult dogs, but there is no reference to influence of age in tapse in dogs. this influence has been reported in humans. thus, the goal of this study is to determine the reproducibility of the measure tapse in normal dogs and to determine the relationship between tapse and age in healthy beagle dogs. tapse was measured from an m-mode recording of the lateral aspect of the tricuspid valve annulus obtained through a left parasternal apical -chamber view. tapse values were averaged from measurements on consecutive beats during sinus rhythm. the measurements were recorded by different persons (c-v, a.; m-m f.) with different grade of experience in canine echocardiography studies.. all patients had a complete -dimensional and doppler study using an envisor chd (philips Ò ) ultrasound system. twenty-three healthy beagles were used. the study was approved by the ethical committee of veterinary medicine service of las palmas de gran canaria university (spain) and it was carried out in accordance with the current european legislation on animal protection. these dogs were divided in different groups according to age: group included dogs under years, group included dogs between and years, group included eight dogs older than years. we analyzed differences between groups using non-parametric (kruskal wallis and wilcoxon scores (rank sums)) test. there were no differences with respect to sex. dogs in group presented higher tapse values than group or ( . ae . cm versus . ae . cm versus . ae . cm; p < . ). statistic intra-observer and inter-observer agreement using the intraclass correlation coefficient was . (p < . ). this study showed that tapse measurement is easily obtainable with a standard echocardiography system, and has adequate interobserver agreement. this study showed higher values of tapse in normal young dogs with respect to older dogs. these results are similar to the results obtained in humans, and could reflect a less effective right ventricle with age. the values presented should be taken with caution due to the relatively small number of patients included. it may also be necessary to validate results in future studies with a second independent sample of dogs of other races. disclosures: no disclosures to report. tetralogy of fallot (tof) is a congenital heart disease characterized by abnormalities, i.e., pulmonic stenosis, ventricular septal defect (vsd), aortic overriding and secondary right ventricular hypertrophy, caused by anterior deviation and abnormal septation of the conal septum during the embryonic period. few studies have reported the hemodynamic consequences and clinical outcome of tof in small animals. the objective of this retrospective study was therefore to document the epidemiological, clinical, echo-doppler findings, and survival, in a canine and feline population with tof. the case records of animals diagnosed with tof by combined use of echocardiography and doppler examination were reviewed ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . tetralogy of fallot was identified in animals ( dogs, cats). the most commonly represented breeds were terriers for dogs ( / , . %), and domestic shorthair for cats ( / , . %). most included animals ( / , . %) were clinically affected at the time of diagnosis. pulmonic stenosis was characterized by a variable systolic doppler-derived pressure gradient both in dogs (median [range] mmhg ) and cats ( mmhg ), and associated with hypoplasia of the pulmonary trunk in one third of the cases ( . %). most vsd were large, with a median vsd:aorta ratio of . [ . - . ] in dogs and . [ . - . ] in cats. median age at death from cardiac cause was . months [ . - . ] without significant difference between dogs and cats (p = . ). these results suggest that in both cats and dogs tof-related death occurs predominantly in young adult animals with major hemodynamic consequences at the time of diagnosis. disclosures: no disclosures to report. the aim of this study was to assess whether and how radiographic and echocardiographic cardiovascular variables differ across age bands of healthy cats. a cohort of clinically healthy cats were categorized into groups: adolescent-adult ( . - years; n = ), middle-aged ( - years; n = ), and geriatric ( - years; n = ). all cats underwent a full physical examination, a complete blood count, routine biochemical profile, a baseline serum total thyroxine concentration, auscultation, non-invasive blood pressure measurements, thoracic radiography, electrocardiography, and echocardiography. cats with hypertension, hyperthyroidism, cardiac, or renal disease were excluded from the study. body weight, body condition score, systolic blood pressure, heart rate, and all echocardiographic indices were similar across the groups. the mean (ae standard deviation [sd]) vertebral heart scale (vhs) value obtained for the geriatric group ( . ae . ) was significantly greater than that obtained for the adolescent-adult group ( . ae . ; p = . ). the mean ratio of the distance between the cardiac base and dorsal sternum to thoracic cavity height at the point of the cardiac base was significantly less in the middle-aged ( . ae . ) and geriatric ( . ae . ) groups than in the adolescent-adult group ( . ae . ; both p < . ). the mean angle between the cardiac long axis and the body axis was significantly smaller in middle-aged ( . ae . °) and geriatric cats ( . ae . °) than in adolescent-adult cats ( . ae . °; both p < . ). the mean angle between the cardiac long axis and the sternum of middle-aged ( . ae . °) and geriatric cats ( . ae . °) was significantly smaller than that in adolescentadult cats ( . ae . °; p = . and p = . , respectively). additionally, the degree of undulation of the thoracic aorta correlated positively with age (r = . , p = . ). these findings suggest that differences in the horizontal alignment of the heart, thoracic-aorta undulation, and vhs in healthy geriatric cats, relative to observations in younger cats, can be considered to be agerelated. disclosures: no disclosures to report. the aim of this study was to investigate the presence of pulmonary hypertension (ph) in young cats affected by single or mixed lungworm infections. twenty-three cats infected with lungworms were examined at the veterinary teaching hospital of teramo, italy, in - . animals underwent to a complete physical examination and to -or -views radiographic analysis of the thorax. a minimum database (i.e. cbc, serum biochemistry, serology for fiv antibody and felv antigen) was obtained for each patient. nine cats were excluded for concomitant diseases, while cats were included in the study. microscopic identification of parasites was confirmed by molecular tests and all cats received an anthelmintic treatment. a single infection by aelurostrongylus abstrusus was diagnosed in cats, while cats had a troglostrongylus brevior infection either alone or in combination with a. abstrusus. transthoracic echocardiography was performed using an ultrasound unit with a mhz phased array transducer. no structural abnormalities of the tricuspid valve and sign of pulmonary stenosis were detected. the -dimensional and m-mode echocardiography showed a cardiac involvement in cats. one cat, infected by a. abstrusus and t. brevior showed a mild systolic tricuspid regurgitant jet with color doppler of . m/sec, while another a. abstrusus-infected cat, had mild tr of . m/sec with a mean paps of mmhg which resolved within weeks after therapy. one cat diagnosed with troglostrongylosis, showed a marked right-sided cardiac enlargement of mm, and a large systolic tricuspid regurgitant jet with a tr peak velocity of . m/s recorded at continuous-wave doppler via a color doppler echocardiography. the minimum pressure difference between the right ventricle and the right atrium was estimated mmhg and the paps was at least mmhg. the echocardiographic and doppler evidence of mild ph persisted at further examination performed until months after diagnosis. ph is rare in cats, despite cases of reversible ph are known in cat aelurostrongylosis. in this study the first case of irreversible ph infection in a cat affected by t. brevior is presented and this finding further supports the high pathogenicity of troglostrongylosis, especially in young patients. in cats with lungworm infection, possible cardiovascular complications must be taken into account and these infections should be always considered in the differential diagnosis in cats with cardiorespiratory signs. disclosures: no disclosures to report. although uncommonly assessed in veterinary cardiology, a right ventricular (rv) function has been shown to be an important prognostic determinant of many congenital and acquired heart diseases in human patients. our group has already demonstrated that -dimensional ( d) color tissue doppler imaging provides a noninvasive evaluation of systolic and diastolic rv function in the awake dog with adequate repeatability and reproducibility. b however, other noninvasive ultrasound imaging variables reflecting rv function need to be further investigated, particularly in correlation with pulmonary arterial pressure (pap) values and left ventricular (lv) function. the aim of this prospective study was therefore to assess several indices of systolic and diastolic rv function using conventional echocardiography and speckle tracking echocardiography (ste) in healthy awake dogs of different breeds with documented systolic pap (spap) and lv function (lv ejection fraction and global lv systolic strain assessed using the simpson's derived method of disks and ste, respectively). imaging rv tested variables included tricuspid annular plane systolic excursion (tapse), right fractional area change (rfac, %), ste longitudinal systolic strain of the rv free wall (rvfw, %) and of the whole rv (i.e., global rv strain, %), ste longitudinal systolic strain rate (sr, s À ) and diastolic early:late sr ratio. additionally, d-guided m-mode ventricular measurements included the end-diastolic rv:lv diameter ratio (rvdd: lvdd) and the end-systolic rvfw:lvfw ratio. correlations between imaging variables were calculated by using spearman's correlation coefficients. means of age and body weight (ae sd; range) of the study population were . years (ae . ; . - . ) and . kg (ae . ; . - . ), respectively. no correlations were found between rv morphological variables (i.e., rvdd:lvdd and rvfw:lvfw ratios) and all indices of systolic and diastolic rv function. global rv strain (meanaesd = . ae . %) and rvfw strain ( . ae . %) were positively correlated (p < . ) with rfac ( . ae . %, r = . and r = . , respectively), and negatively correlated (p < . ) with spap ( . ae . mmhg [ . - . ], r = À . and r = À . , respectively). spap was also negatively correlated with the tapse:body weight ratio and systolic sr (r = À . and À . respectively, p < . ). there was no correlation between indices of lv function and ste indices of rv function, and no correlation either between ste rv indices of systolic function and the diastolic early:late sr ratio. in conclusion, ste provides a rapid and non-invasive evaluation of rv function that may be used for clinical investigations in canine cardiology. doppler-derived +dp/dt and -dp/dt from mitral regurgitation are considered indexes for assessment of systolic and diastolicfunction respectively, that have less load dependence than the ejection phase indexes. this study aimed to determine correlation between doppler-deriveddp/dt and other systolic and diastolic echocardiographic indexes, and if they can be used to identify dogs with and without remodeling, with or without congestive heart failure (chf) and for evaluation of chronic mitral valve disease (cmvd) severity. fifty-seven dogs with cmvd (stages b , b , c+d) were included prospectively in an observational cross-sectional clinical study and distributed in groups regarding the presence of remodeling and chf, to evaluate+dp/dt and -dp/dt, and distributed according to tdi-diastolic pattern tocompare -dp/dt. group c+d ( mmhg/s, p -p = - )had +dp/dt significantly lower compared to b ( mmhg/s, p -p = - )and b ( mmhg/s, p -p = - ) (p = . ). groupc+d also had lower -dp/dt, compared to b ( . mmhg/sae . and mmhg/sae . ; p = . ). dogs with chf compared to those without chf, presented lower +dp/dt( mmhg/s, p -p = - ; mmhg/s, p -p = - ; p = . ) and -dp/dt ( . mmhg/sae . ; mmhg/sae . ; p = . ). regardingdiastolic function, -dp/dt was lower for the restrictive pattern group ( . mmhg/sae . )compared to those without diastolic dysfunction, ( mmhgae . ), delayedrelaxation ( mmhgae . ) and pseudonormal patterns ( mmhgae . ) (p < . ).when +dp/dt< mmhg/s, the post-test chance for the dog with cmvd to havechf is twice the chance than not having it. for -dp/dt< mmhg/s theposttest chance of having chf is times higher than not having it. in conclusion, doppler-derived +dp/dt and-dp/dt may contribute respectively, for systolic and diastolic assessment ofdogs with cmvd. disclosures: no disclosures to report. pulmonic stenosis (ps) is one of the most common congenital heart defects seen in veterinarycardiology practice. pulmonary balloon valvuloplasty (pbv) is considered to be the treatment of choice for dogs withsevere stenosis. whether dogs with moderate stenosis benefit from pbv remains unclear, and variables such as degree of hypertrophy, valve morphology, amount of tricuspid insufficiency and presence or absence of clinical signs aregenerally used when recommendations are made to pet owners. in this study we report the effect of valve type on pbv outcome in dogs treated at different academic speciality cardiology practices. baseline echocardiographic images were evaluated at each institution and valve morphology was classified as either type a (n = , . mmhg, range - ) or type b (n = , . mmhg, range - ) and 'no' (n = , mmhg, range - ) or 'yes' (n = , mmhg, range - ) for presence of pulmonary annular hypoplasia when diameter was compared to aortic annulus. twenty four hours following pbv both type a ( mmhg, range - ) and type b ( mmhg, range - ) valves had significant reduction in gradient compared to baseline (p < . ). this reduction remained significant at days (a: mmhg, range - ; b: mmhg, range - ; p < . for both). dogs with annular hypoplasia ( mmhg, range - ) and without annular hypoplasia ( mmhg range - ) had a significant reduction in gradient hours post pbv. it remained significant at days (with annular hypoplasia: mmhg, range - ; without annular hypoplasia: mmhg, range - ; p < . for both). when comparing to baseline, considering valve type, there was no significant difference in percent reduction in gradient for type a versus type b valves at both the -hour (a: %, range - ; b: %, range - ; p = . ) and -day (a: %, range - ; b: %, range - ; p = . ) recheck evaluation time points. additionally, there was no significant difference in gradient reduction when looking only at whether or not there was annular hypoplasia at hours (yes: %, range - ; no: %, range - ; p = . ) and days (yes: %, range - ; no: %, range - ; p = . ). in conclusion, classification of dogs with ps according to valve type and annulus morphology did not help predict the -day response to pbv. disclosures: no disclosures to report. hypertrophic cardiomyopathy (hcm) is the most common feline inherited cardiac disease and it is a major cause of morbidity and mortality. the osservatorio italiano hcm felina was formed in by a network of clinicians, geneticists and breeders, to monitor and study hcm in italian cats. since april , adult cats, belonging to various breeds, including maine coon, siberian, norwegian forest cats, ragdoll, sphynx, british sh, birmans and others have been prospectively enrolled. recheck evaluations were performed in cats. each cat underwent a clinical examination, echocardiography, and blood collection for genetic testing (when appropriate) and storage in the italian feline bio-bank. the disease status was defined by echocardiography according to established guidelines (left ventricular diastolic wall thickness < . mm = hcm negative, = . but < mm = hcm equivocal; = mm = hcm positive). the prevalence of hcm in the population was % ( cats); equivocal diagnoses were conferred on % ( cats). these prevalences did not differ between breeds. the prevalence of hcm in the italian feline population was lower compared to those reported by other investigators. evaluation of data from the entire population demonstrated that left ventricular end-diastolic wall thicknesses and aortic diameter showed a weak positive correlation with body weight (p < . , r < . for all variables), suggesting that weight-dependent limits on wall thickness should be considered in cats as is currently practiced in dogs. the lower prevalence of hcm in italian cat breeds compared with those examined elsewhere might be explained by different criteria for determining presence or absence of disease, differences in ages at which the subjects were examined, or a selection bias by breeders in presenting cats they consider 'normal'. disclosures: no disclosures to report. chronic mitral valve disease is by far the most common cardiovascular disease in dogs. the disease is caused by myxomatous degeneration of the mitral valve leaflets and, in approximately % of cases, it's accompanied by degeneration of the tricuspid valve. it is also described in previous studies that approximately % of affected dogs also have evidence of associated pulmonary arterial hypertension. the prevalence of the disease is higher in small breed dogs (under kg), although large breeds can also be affected and it occurs more frequently in males than in females. the present study aims to characterize the disease in a population of dogs in portugal. we retrospectively reviewed the medical records of dogs presented to hospital veterin ario do porto, with an echocardiographic diagnosis of canine chronic mitral valve disease, during a period of years. from this records, cases were identified, from which ( . %) were males and ( . %) were females. most of the dogs were mixed breed ( ) and different breeds of dogs were represented. the poodle was by far the most represented breed (n = ; . %), followed by english cocker spaniel ( . %), yorkshire terrier ( . %), boxer ( . %), epagneul breton ( . %), dalmatian ( . %), pekingese ( . %), labrador retriever ( %) and portuguese podengo ( . %). all other breeds represented . % of the population. regarding weight, . % of the dogs (n = ) weighted < kg, with a mean body weight of . kg (range . - kg). the mean age at diagnosis was . years old. we also observed that . % of the dogs (n = ) had concomitant degeneration of the tricuspid valve and . % (n = ) pulmonary arterial hypertension (ph). we categorized these dogs according to the severity of ph, in mild ph if they had a doppler echocardiography derived systolic pulmonary arterial pressure (spap) of - mm/hg, moderate ph (spap - mm/hg) and severe ph (spap > mm/hg). we found that . % (n = ) of dogs had mild ph; . % (n = ) moderate ph and . % (n = ) severe ph. as described in previous studies, the disease affects mainly males and small breed dogs, with a breed distribution that reflects the canine population in the country, including very including very popular large breed dogs in portugal, as the boxer and labrador. both the presence of concomitant tricuspid valve disease and ph had a higher prevalence in our study than previously described. disclosures: no disclosures to report. in people anemia is frequent in patients with heart failure (hf) and it is associated with poor outcomes. the most likely pathogenic factors include iron deficiency, chronic kidney disease (ckd), and cytokine production, although other factors may contribute. little is known about the prevalence of anemia in dog with cardiovascular disease. the aim of this retrospective study was to define the prevalence of anemia (hct ≤ %) in dogs with mitral valve disease (mvd) and to investigate associated risk factors (age, weight, azotemia, hf, iris/acvim class). medical records of dogs presented at the cardiology service, divet, university of milan (january -march ) were retrospectively evaluated. dogs with mvd with complete physical, thoracic and echocardiographic examinations, and serum biochemical panel, including serum creatinine (scr), were included in the study. dogs with other heart or systemic diseases, except ckd, or neoplasm were excluded. statistical analysis was performed using jmp . (sas institute). a p value < . was considered significant. two hundred and ninety dogs ( males/ females), . ae . years of age, . ae . kg of body weight fulfilled the inclusion criteria. the % of males and the % of females were neutered. the most represented breeds were mongrel ( %), miniature poodle ( %), york shire terrier ( %), and cavalier king charles ( %). dogs were % b , % b , % c and % d acvim class. while the % of the dogs were normoazotemic (scr < . mg/dl), . % were staged in iris , % in iris and . % in iris . the prevalence of anemia in dogs with mvd was % ( / ): showed mild ( ≤ hct ≤ %) and moderate ( ≤ hct ≤ %) anemia. sixteen dogs were in b , in b , in c and in d acvim class; were normoazotemic ( %). anemic dogs showed a significant higher scr. normoazotemic dog showed significant higher hb, hct and rbc both in the overall population and in the anemic group. in the overall population dogs in different iris class showed statistically different hb, hct and rbc and hb was significantly lower in decompensated hf dogs. in conclusion although a relationship between anemia and azotemia/ckd was documented in our study, it is important to emphasize that most of the anemic dog were normoazotemic: anemia is not an exclusive finding of cardiorenal syndrome and should be considered as possible complication in dogs with mvd alone. disclosures: no disclosures to report. the objective of this study was to evaluate left atrial (la) function by left atrial total fractional area change (la-factotal) and left atrial ejection fraction (laef) in dogs affected with chronic mitral valve disease (cmvd) naturally acquired with and without congestive heart failure (chf). our hypothesis was that la-factotal and laef decrease with severity of cmvd. eighty dogs were included in a prospective observational cross-section clinical study, grouped according to cmvd severity based on echocardiographic evaluation and clinical signs. the dogs were equally distributed in each group: a, b , b and c, according to american college of veterinary internal medicine staging system. indicators of la function were calculated with the following equations: la-factotal = (lamaximum area -laminimum area)/lamaximum area, measured by apical view; and laef = x (lamaximum volume -laminimum volume)/lamaximum volume, by biplane area-length method from the left apical and chamber views. la-factotal showed lower values (p < . ) in group c ( . %, p - % = . - . ) compared with groups a ( . %, p - % = . - . ), b ( . %, p - % = . - . ) and b ( . %, p - % = . - ). group c had lower laef ( . %, p - % = . - . ) than groups a ( . %, p - % = . - . ), b ( . %, p - % = . - . ) and b ( . %, p - % = . - ) (p < . ). left atrial function, assessed by la-factotal and laef, was reduced in dogs with cmvd and chf compared with healthy and asymptomatic cmvd groups. disclosures: no disclosures to report. recurrent episodes of heart and/or kidney failure are considered one of the causes leading to worsening heart/renal functions in human patients. the aim of this prospective study was to assess the influence of heart/kidney worsening on elected parameters of heart/kidney function in dogs affected by mitral valve disease (mvd). between july and may , dogs affected by mvd in acvim class b and without comorbidities were included in the study group. the control group was constituted by healthy dogs, matched with the cases for age (older than years) and gender. all the dogs underwent physical examination, thorax radiography, ecg, echocardiography, systemic blood pressure assessment, a complete blood count, serum biochemical analysis, including assessment of serum creatinine (scr), serum urea nitrogen (urea) and glycaemia (gly) and urine analysis with urine protein/creatinine ratio (upc). dogs were re-evaluated every -month until october . statistical analysis was performed using ibm spss statistics (p value significant if < . ). twenty-one dogs affected by mvd (cases) were included and healthy dogs (controls) were randomly selected among the eligible population. the % of cases experienced at least one episode of congestive heart failure (chf), but none of these patients developed chronic kidney disease (ckd). the % of cases developed ckd while remaining in acvim class b . no dogs in the control group developed ckd or mvd. correlations between worsening renal function (wrf -scr elevation ≥ . mg/dl or % from baseline), furosemide administration, upc levels, radiographic parameters of heart enlargement and echocardiographic parameter were investigated. only a statistically significant difference in iris class between the groups according to wrf and in the echocardiographic parameter left atrium to aortic root (la/ao) according to furosemide amount were observed. both these results were expected. none of the cases included experienced renal damage (wrf or iris class change or upc change) concomitant to episodes of chf. the persistence of normal renal condition regardless of chf events and therapy administration was unexpected. in conclusion, experiencing chf seems not to directly affect renal function. to authors' opinion, the use of wrf, better than single scr and urea levels, may be useful in the long term management of aged patients affected by mvd. however, the small number of cases included in this study represents a great limit. we consider this work a pilot study. disclosures: no disclosures to report. hypertrophic cardiomyopathy (hcm) is a primary myocardial disease characterized by inappropriate thickening of the myocardium in absence of other causes of hypertrophy including hypertension, hyperthyroidism, aortic stenosis and acromegaly. it is also the most common heart disease in cats. hcm presents a wide variety of clinical sings depending on the severity and location of the hypertrophy. cats affected with hcm have a mean age of . - . years old at the time of the diagnosis however this disease can affect cats as young as months although this later age is unusual hcm is a heterogeneous disease both in terms of phenotypic degree of hypertrophy and clinical outcome. hallmark histopathological hallmarks lesions of hcm are myocyte disarray, small coronary arteriosclerosis and interstitial fibrosis replacement in order to confirm hcm echocardiography has to be made. primary hypertrophy diagnosis is made based on the presence of ventricular hypertrophy, symmetric or asymmetric, in the absence of systemic disorders. the purpose of this study was to assess the prevalence of hcm in a feline population. in order to achieve this goal echocardiograms were made in all cats older of years clinically asymptomatic with or without cardiac murmur. all echocardiograms were made according to the guidelines of the acvim published in . diagnosis of ventricular hypertrophy was made from the right parasternal window using the b mode to measure the diameter of the lvfw and the ivs in diastole. cats with more than mm of wall thickness measured t , bun, crea, blood pressure. only cats within the normal limits of the later parameters were considered hcm positive. total number of cats in this study was cats male and female. from this population had no defined breed, were persian, maine coon, norwegian woods, siamese, chartreaux. no murmour was detected in ( . %) cats, s or s was detected in ( %) cats and differente degree of murmour was detected in ( . %) cats. hypertrophy was detected in cats. from this cats ( . %) were diagnosed as hcm, ( . %) cats were excluded either because of lack of values of t and or because they had high values of blood pressure, t levels or crea. in this study . % of the population had hcm. the epidemiological and phenotype distribution is highly variable. the average age at diagnosis of hcm in this study was . years. disclosures: no disclosures to report. mildly increased concentrations of crp are associated with cardiovascular disease in humans and dogs. it is not known whether increased concentrations of crp are associated with myxomatous mitral valve disease (mmvd) in dogs, or rather its sequel, congestive heart failure (chf). the aim of this study was to investigate whether serum concentrations of crp, determined using a novel automated canine-specific high-sensitivity crp assay (gentian hscrp), were associated with severity of mmvd and certain clinical variables in dogs. the study included client-owned dogs with different severities of mmvd. disease severity was determined by medical history, physical examination, echocardiography and response to diuretic therapy. dogs were allocated into groups based on acvim consensus statement guidelines (group a (n = ), group b (n = ), group b (n = ) and group c (n = )). data were analysed using descriptive statistics and multiple regression analysis. dogs with chf (group c) had significantly higher serum crp concentrations ( . mg/l, [ . ; . ]) (median, [quartile ; quartile ]) compared to dogs in groups a ( . mg/l, [< . ; . ]) (p = . ), b ( . mg/l, [< . ; . ]) (p < . ) and b ( . mg/l, [< . ; . ]) (p < . ). other measures of disease severity including left atrial to aortic root ratio and left ventricular end-diastolic diameter normalized for body weight were positively correlated with serum crp concentration. in conclusion, slightly higher serum crp concentrations were found in dogs with chf whereas the severity of asymptomatic mmvd showed limited association with serum crp concentrations. disclosures: no disclosures to report. medetomidine is a a -agonist widely employed for sedation in dogs but its use is discouraged in cardiac patients even those suffering from myxomatous mitral valve disease (mmvd). however, only one investigation was previously conducted in a wide rangeregarding the class of the disease -of mmvd patients, reporting a general safety of that protocol. the present study was focused just on class b of mmvd, with the aim to provide more detailed information on the cardiovascular effects of medetomidine in such patients, by the analysis of clinical and instrumental parameters suggestive of disease severity or congestive heart failure. dogs weighing < kg, needing a soft clinical procedure and showing a systolic apical heart murmur were screened and selected for the study if la/ao < . . the sedative protocol consisted in an iv injection of lg/kg medetomidine antagonized, after the clinical procedure, by an im injection of the recommended dose of atipamezole. clinical parameters, echocardiographic variables, thoracic radiographs and oscillometric blood pressure measurements were collected at baseline (t ), minutes after medetomidine administration (t ) and hours after atipamezole injection (t ). of dogs screened, were definitively enrolled. at t a significative decrease in the right parasternal regurgitant jet area (rp-arj/laa), peak velocity of mitral regurgitation and shortening fraction was observed along with an increase in lvids (p < . ). left parasternal arj/laa decreased without reaching statistical significance but showing a high correlation with rp-arj/laa (r = . ). interestingly, la/ao changed only mildly and never reached a value > . . the other echocardiographic variables did not show a particular trend. systolic blood pressure showed values at the upper physiologic limit at t , lower values than t at t , and an increase above the initial value at t but without significance. thoracic radiographs were evocative of heart enlargement without pulmonary venous congestion or pulmonary oedema both at t and t . respiratory rate did not change between t and t . the degree of sedation was optimal during the clinical procedure in all cases. sedation with lg/kg medetomidine is safe in dogs suffering from mmvd in stage b (la/ao < . ). the decrease observed in peak velocity and color-doppler appearance of mitral regurgitation at t could be due to a reduction of both myocardial contractility and systolic blood pressure, by a lowering of sympathetic activity via baroreceptors stimulation. disclosures: no disclosures to report. in this retrospective study were included a total of clientowned dogs, undergoing transarterial occlusion of pda with mreye Ò flipper detachable embolization coil (n = ), amplatz â canine duct occluder (acdo; n = ) and amplatzer â vascular plug (n = ). device size selection was based on pda dimensions assessed by transesophageal echocardiography (tee) in cases and transthoracic echocardiography (tte) in cases. angiography was performed during the procedure to assess the success of the occlusion, and it confirmed complete occlusion in dogs and a trivial residual flow in dogs. the following day, transthoracic color-doppler echocardiography revealed that complete ductal closure was achieved in all dogs. the procedure was hemodynamically successful, as evidenced, by a reduction in indexed left ventricular internal diameter in diastole (lvidd; p < . ), fractional shortening (fs; p < . ) and left atrial to aortic ratio (la: ao; p < . ) within hours after procedure. four months after surgery, indexed lvidd was significantly reduced (p = . ) and la:ao remained constant. secondary complications included pulmonary arterial embolization of an acdo and a late rotation of an amplatzer â vascular plug resulting in an increased flow through the pda. the dog with the rotated device required subsequent surgical ligation of the pda. at this time, dogs were reported to be alive and the other dogs were lost to follow up. only one dog remained on congestive heart failure therapy after the pda occlusion. we can conclude that pda occlusion using an acdo for dogs with more than kg and a transarterial coil embolization for dogs with < kg had a high rate of immediate complete occlusion. pda occlusion using those devices proved to be a safe and effective therapeutic method for pda in dogs. disclosures: no disclosures to report. echocardiographic evaluation of the right pulmonary artery distensibility index (rpad index) was recently described as a valuable method for early detection and severity evaluation of pulmonary arterial hypertension in dogs. rpad index is calculated as the percentage change in diameter of the right pulmonary artery (rpa) between systole and diastole, obtained by m-mode echocardiography from the right parasternal long axis view. the aim of this study was to compare the rpad index obtained by different echocardiographic views in dogs. the study design was a prospective, multicenter, observational study. forty-five clientowned dogs from different breeds were included: dogs with heart disease and healthy dogs. two different right parasternal views, long axis (rpla) and short axis (rpsa), were used to measure the rpad index. from the rpla view (method ) and rpsa view (method ) a short axis and a long axis image were respectively optimized for the right pulmonary artery. the rpad index was calculated by m-mode as the percentage change in diameter of the right pulmonary artery: [(systolic diameter -diastolic diameter)/ systolic diameter]* . measurements were done off-line as an average of consecutive cardiac cycles by a single investigator blinded to the dogs' diagnosis. a pearson and a bland-altman test were used to assess correlation and agreement between the methods, respectively. intra-and inter-observer measurement variability was quantified by average coefficient of variation (cv). level of significance was set at p < . . m-mode evaluation of the rpad index was satisfactorily obtained by both methods in all dogs. pearson test showed a strong positive linear correlation between the values of rpad index obtained from both methods (r = . , p < . ). bland-altman test showed a good agreement between the methods in estimating rpad index (bias = . %, sd = . %, % limits of agreement = À . , . %). the mean difference between the methods was . % ( % confidence interval = À . ; . ). intra-and inter-observer measurement variability was clinically acceptable (cv< %).the study showed a good agreement between short axis and long axis m-mode evaluation of rpa. both methods can be used interchangeably to evaluate rpad index. further studies are needed to evaluate the rpad index in a larger population of healthy dogs and the diagnostic and prognostic role of this echocardiographic parameter in dogs with different types of pulmonary hypertension. disclosures: no disclosures to report. this retrospective study (march to october ) includes client-owned great pyrenees diagnosed with hypoadrenocorticism. the medical records of dogs with a diagnosis of naturally occurring hypoadrenocorticism were reviewed, with an emphasis on great pyrenees' record. the prevalence of hypoadrenocorticism in the studied population, as well as the prevalence per breed, was calculated. data collected included breed, clinical signs, laboratory findings, age at diagnosis, treatment, and cause of the death. one hundred dogs were diagnosed with naturally occurring hypoadrenocorticism, representing . % of the overall canine population studied. thirty-five breeds were represented, with a prevalence per breed varying between . % and . %. a high prevalence was observed in west highland white terriers ( . %), great danes ( . %), standard poodles ( . %), saint-bernards ( . %) and jack russell terriers ( . %). out of gp presented during that period of time, . % (n = ) were diagnosed with hypoadrenocorticism. median age at diagnosis was . years (range: . to . ) in dogs with hypoadrenocorticism, and . years ( . to . ) in gp. the main reason for presentation of the addisonian gp was lethargy (n = ) and anorexia (n = ). clinical findings included hypotension (n = ), poor body condition (n = ), and heart murmur (n = ). the majority (n = ) had serum electrolytes abnormalities, with a na:k ratio ranging from . to . . other major laboratory findings included azotemia (n = ), anemia (n = ) and the absence of a stress leukogram (n = ). the majority (n = ) received fludrocortisone, with prednisone as needed. one gp was euthanized at time of diagnosis. great pyrenees diagnosed with hypoadrenocortism were overrepresented in the studied population, with a prevalence of hypoadrenocorticism in our gp population of . %. therefore, an inherited susceptibility can be suspected. reason for presentation and clinical signs were nonspecific, and similar to what is reported in other breed. in human medicine, haemoglobin a c (hba c), a form of glycosylated haemoglobin, is used as the standard measure of average glycaemic control over to months. the measurement of hba c in dogs has been previously demonstrated however high pressure liquid chromatography techniques are too technically difficult for routine use and other methods are no longer available. the objective of this study was to assess the use of latex immunoagglutination inhibition using a monoclonal antibody for the measurement of hba c in dogs, using the siemens dca vantage Ò . repeatability was assessed by measuring samples times within minutes. the effect of storage on edta anticoagulated samples was examined by measuring samples stored at °c every day for up to days. storage was further assessed by freezing samples and measuring them at , and weeks. the machine was then used to compare the hba c values in groups of dogs with diabetes mellitus (group , n = ), hyperadrenocorticism (group , n = ) or non-diabetic/cushingoid hospitalised patients (group , n = ). differences in the groups were examined for significance using a kruskal-wallis analysis of variance. the reference range of hba c has been previously calculated to be . - . % ( - mmol/mol) and values of . -> % ( -> mmol/mol) are seen in diabetic animals using high pressure liquid chromatography. the median coefficient of variation for the repeatability study was found to be % (range % to %). it was possible to store samples at °c for up to days (median cv% = %, range % to %) and at À °c for at least weeks (median cv% = %, range % to %). the median hba c concentrations were group ; . % ( mmol/mol), group ; . % ( . mmol/mol) and group ; . % ( mmol/mol). group was significantly different from the other groups using kruskal-wallis analysis of variance. in conclusion, the latex immunoagglutination method was repeatable for the measurement of hba c in dogs. in addition, hba c in canine edta anticoagulated samples were stable at °c for up to days and, if frozen, could be stored for at least weeks without significant sample deterioration. the assay provides the expected results in dogs with and without abnormalities of glycaemic control. disclosures: the siemens dca vantage was provided on loan from siemens, as well as the cartridges used on this machine to run all samples in the study. a. wehner , r. anderson , s. reese , k. hartmann . clinic of small animal medicine, munich, germany, institute of veterinary anatomy, histology and embryology, munich, germany measurement of total thyroxine (t ) is often the first diagnostic step in the work up of thyroid disease in dogs and cats. blood samples are routinely sent to a reference laboratory causing a delay in testing which might impact the results. the aim of this study was to validate an enzyme fluorescence assay (elfa) as an inhouse method to measure t in dogs and cats. t was measured in sera of dogs and cats by methods, an enzyme immunoassay (eia) and an enzyme fluorescence assay (elfa). the eia served as the standard method to which the elfa results were compared. the elfa was performed with the minividas automated analyser (biom erieux, craponne, france) according to the manufactors instructions. coefficient of variation (cv) of the elfa in dogs sera was . % and of the eia - . %, respectively. cv of the elfa in cats sera was . - . % and of the eia . - . %, respectively. overall bias of the elfa in dogs was . %; however up to À . % in lower t ranges. maximal bias of the elfa in cats was . %. correlation of both methods was linear only in cats. using bland altman plots limits of agreement were - - % in dogs and - - % in cats. cohen s kappa revealed only slight agreement between both methods in dogs, but a good to very good agreement in cats. the elfa is a fast method with a high precision and can be recommended to measure t in cats, but cannot be recommended for dogs. disclosures: no disclosures to report. dysfunctions of the central nervous system (cns) are the most frequent causes of neurological disorders in dogs. our study aimed to find ( ) if some cns diseases could be associated with a selected group of common microbial or viral pathogens in dogs and ( ) if cns diseases have any characteristic profile with regard to parameters, c-reactive protein (crp) and iga, that are reported to be potentially useful but unspecific markers of cns diseases. we analysed cerebrospinal fluid samples obtained from dogs with varying neurological signs between june and november . real-time pcr was employed with probes for toxoplasma gondii, neospora caninum, anaplasma phagocytophilum and canine distemper virus. igg-antibodies to tickborne encephalitis virus (tbe) were assayed and iga titres were measured using elisa, while crp concentrations were determined by immunoturbidimetric assay. the dogs had a median age of years (range: . - ) and comprised breeds most frequently involving chihuahuas, labrador retrievers, bernese mountain dogs and boxers. gender distribution was . % female, . % spayed bitches, . % male, . % neutered male, and . % non-identified. none of the cases were pcr-positive for toxoplasma gondii or canine distemper virus. one dog was positive for anaplasma phagocytophilum and another for neospora caninum. antibodies to tbe virus were within the borderline range in / dogs. the dogs could be divided into age groups: (= . %) for young dogs (< years, median year) and (= . %) for older dogs (≥ years, median years). igahigh (> . mg/dl) cases represented % and % for young and older dogs, respectively. crp-high (> . mg/l) cases were almost half and equal: . % and . % in young and older dogs, respectively. compared with older dogs, young dogs had higher levels of crp (p = . ) and iga (p = . ). within the iga-high cohorts, crp-high and crp-low cases distributed almost equally ( . % versus . %) in young dogs but disproportionate ( . % versus . %) in older dogs. there were no [iga-low/crp-low] cases in young dogs but . % in older dogs. our present data suggest that ( ) canine cns disorders were largely characterized by high iga and particularly in young dogs ( ) inflammatory types (crp-high) were almost equal in both groups and ( ) although the significance remains yet to be determined, pathogens like anaplasma phagocytophilum and neospora caninum could be detected in a few cases of canine cns disorders. disclosures: the authors breu d and guthardt j are employed at laboklin gmbh & co kg, germany. m€ uller, e is owner/manager of the laboklin gmbh & co kg. internet is a potential source of medical information for pet owners. therefore, it could play an indirect but important role in the veterinary practice. this survey assesses the online search behaviour of french pet owners for their pets' health and its influence on a veterinary consultation. in april , french pet owners coming in a veterinary teaching hospital for a medical or a surgical consultation were surveyed. ( . %) owners fulfilled the questionnaire on a voluntary basis. the survey contained questions dealing with topics: the online search behaviour of owners for their pets' health, their perception of the information found online and the internet's influence on a consultation and on the veterinarian/client relationship. . % of owners use the internet to obtain information on their pets' health. among them, . % use it rarely and . % occasionally. they mainly look for information on a disease ( . %), a symptom ( . %), a breed ( %) or a nutritional advice ( . %). . % of owners try to verify the accuracy of the information found, most often by questioning their veterinarian ( . %). few owners ( . %) think that online information is always trustworthy. most of the research ( . %) is randomly made, websites being found through search engines. the majority of pet owners ( . %) aren't aware of any health certification label for websites. internet enables certain pet owners to feel more at ease with their pets' health care: they ask more questions to their veterinarian ( . %) and feel more involved in medical choices ( . %). . % of owners consider that the internet can positively impact their relationship with the veterinarian. relief is the most common ( . %) emotional response to online research for medical information. however, . % of owners feel overwhelmed by the amount of information found, % are confused and . % frightened by the serious or graphic nature of the information found online. this study emphasizes the frequent but measured use of the internet by french pet owners for their pets' health. they seem to consider information found on the net with a critical mind. unexpectedly, it appears that the internet could be an ally for veterinarians by promoting exchanges between the clients and the veterinarian and by improving compliance with the care project. disclosures: no disclosures to report. sinonasal aspergillosis is a well-known and described fungal infection of the sinonasal cavities in dogs. topical treatment either with enilconazole or itraconazole infusion administered surgically or endoscopically are effective. the use of % clotrimazole cream have been described in a surgical setting after itraconazole infusion by sissener et al. in . the aim of the work was to report the effectiveness of the use of topical % clotrimazole cream as the only treatment for sinonasal aspergillosis in dogs. inclusion criteria were a full medical record with radiological and endoscopical imaging, record of clotrimazole discharge after instillation and endoscopic control between and days after procedure. the % clotrimazole cream was applied through catheters placed under direct endoscopic vision after fungal plaques removal. nine dogs were included. three dogs were mixed breed dogs, dogs golden retriever, one dog a german shepherd and one old english sheepdog, one bull terrier and one cane corso. six dogs were male (one neutered) and female (one intact). mean age was . years. main clinical signs were muco-purulent discharge ( ), pain at sinonasal palpation ( ), nasal planum alterations ( ), epistaxis ( ) . nasal discharge was bilateral in dogs. mean duration of clinical signs was . months. main radiological findings were turbinates lysis ( ), frontal sinus empyema ( ), frontal bone thickening ( ) and frontal bone lysis ( ). rhinoscopy disclosed lysis and remodelling of the nasal turbinates ( ), easy access to the frontal sinus ( ), septum lysis ( ), bilateral sinonasal aspergillosis ( ), monolateral nasal aspergillosis ( ), monolateral sinonasal aspergillosis and contralateral nasal aspergillosis ( ), monolateral frontal aspergillosis ( ) . main duration of nasal cream discharge was . days. all dogs underwent endoscopic control between and days after the procedure. seven dogs were disease free; dogs had persistent fungal plaques and underwent a second treatment. success rate was . %. success rate of this study is comparable to other studies with larger and smaller case series. endoscopic removal of the fungal plaques can be time consuming and topical administration of either enilconazole or itraconazole require an additional hour. the catheter placement and the % clotrimazole cream application lasted minutes for each cavity in the dogs here reported. the use of % clotrimazole cream as the only treatment for sinonasal aspergillosis needs further evaluation on a larger case series. disclosures: no disclosures to report. few studies exist on euthanasia in small animal practice. however, such an act belongs to veterinary procedures, more or less frequently depending of the kind of practice, and may deeply impact both owners and veterinarians. we intended to study practical, ethical and psychological aspects of euthanasia of dogs and cats among french veterinary practitioners. from october to february , an on-line -item questionnaire on small animals' euthanasia, addressing practical aspects of euthanasia, communication with the owners, ethical problems, owners' and veterinarians' perceptions, was emailed via professional associations and networks. results were analyzed using commercial software (sphinx iq Ò and excel Ò ). french veterinarians practicing small animal medicine completed the questionnaire, representing > % of this population. euthanasia occurs rarely at home. over % of veterinarians propose the owners some time alone with their pet, and to stay during euthanasia, performed most commonly by intravenous injection ( . %) mainly after sedation/anesthesia ( . %). ninety nine percent of veterinarians consider communication, including description of events' sequence, and disposal of the body, as important. estimated minimum communication time required varies from - to - minutes. following euthanasia, . % are often thanked by the owners. most veterinarians (> %) have refused a euthanasia, considered unjustified, or had their own suggestion of euthanasia rejected. reasons for such a suggestion include intractable pain ( . %), non-acceptable complications ( . %), financial considerations ( . %) or animal considered dangerous ( . %). veterinarians think most owners ( . %) experience some sense of guilt during euthanasia. themselves perceive euthanasia most commonly as relief of animal's suffering ( . %) and part of veterinary practice ( %), less frequently as a defeat ( . %). almost all veterinarians have experienced emotionally challenging euthanasia, and . % estimate that practicing euthanasia influences their perception of death. practical ( %) and psychological ( . %) aspects of euthanasia have been discussed in most teams. veterinarians' gender influences euthanasia management, mostly concerning some communicational and practical aspects. euthanasia is definitely not an ordinary veterinary act, neither for the owner nor for the veterinarian. therefore, this act must be performed with as much care and communication as possible. disclosures: no disclosures to report. canine pancytopenia is associated with a range of intra-marrow or extra-marrow causes, including though not limited to, infectious agents, drugs, toxins and neoplasms. there is currently limited information regarding the clinicopathological features of the underlying causes or the prognosis in pancytopenic dogs. the objective of this retrospective study was to better define the spectrum of diseases associated with canine pancytopenia, to establish possible clinicopathological discriminators for the common causes and to investigate if the severity of pancytopenia or the underlying disease were associated with the clinical outcome (death or survival). medical records of dogs with a comprehensive diagnostic investigation admitted in a veterinary teaching hospital were retrospectively reviewed. pancytopenia was defined by a hematocrit (hct) < % (< % for dogs < months of age), white blood cell counts (wbc) < , /ll and platelet counts (plt) < , /ll. a control group of dogs without any evidence of blood cytopenia(s) was also established. in total, pancytopenic dogs were studied. bone marrow aspiration cytology was examined in cases and aplasia of all hematopoietic lineages was observed in ( . %) dogs. the most common diagnoses included monocytic ehrlichiosis (cme) (n = ), leishmaniosis (canl) (n = ), parvoviral enteritis (pe) (n = ), and concurrent cme and canl (n = ). mixed breed dogs were more likely to develop pancytopenia as compared to purebreds and pancytopenic dogs tended to be younger than the controls (conditional dependent logistic regression model, p = . and p = . , respectively). among the most common diseases associated with pancytopenia, the mean wbc counts were significantly lower in dogs with cme and pe compared to dogs with canl (one way anova with bonferroni test for multiple comparisons, p = . and p = . , respectively), while plt counts were significantly lower in cme compared to canl (p< . ) or pe (p < . ). total protein concentrations were significantly lower in dogs with pe compared to cme (p < . ) and canl (p < . ). using a univariable logistic regression analysis model, no association was established between the underlying disease and the final outcome. however, higher hct (by at least one percentage unit), wbc (by at least , /ll) and plt (by at least , /ll) values tended to significantly increase the odds of survival (p = . , p < . and p = . , respectively). in the present study, cme, canl and pe were the major causes of canine pancytopenia. potentially useful diagnostic indicators included severe leucopenia (cme, pe), thrombocytopenia (cme) and hypoproteinemia (pe). disclosures: no disclosures to report. laryngeal masses (lm) usually produce air flow limitation during inspiration, expiration or transiently during subsegments of both breathing phases. feline bronchial diseases (fbd) have predominantly expiratory flow restrictions. barometric whole-body plethysmography (bwbp) is a non-invasive pulmonary function test (pft) that allows a dynamic study of breathing patterns widely used to evaluate lower airway responsiveness. the objective of this preliminary study was to evaluate if there were significant differences in respiratory rate [rr ( bwbp detects both upper and lower airways diseases because any site of airway obstruction will result in increased pressure changes associated with breathing. nevertheless our results suggest that there are significant differences in tv(p = . ), ti (p = . ), pef(p = . ), eep(p = . ), penh(p = . ) and pau(p = . ) between lm and fbd cats. no other significant difference in bwbp parameters was found. upper airway obstructions have been previously evaluated in cats by using pft (mckieman, , lin, but in authors' knowledgement this is the first study designed to compare upper and lower airway obstructions by using bwbp. attending our results, there is the evidence that bwbp can help characterize mechanical dysfunction of the airways in cats with lm obstruction. however we must keep in mind some limits of this study as the low number of animals, individual variability in breathing pattern and to have the chance of doing bronchoreactivity tests. disclosures: no disclosures to report. the median lifespan of domestic dogs has been estimated to - years, but little is known about risk factors for mortality in aged dogs: most mortality studies in dogs have been carried out among diseased dogs (renal or heart diseases, cancers, post-operative death). to determine which characteristics are associated with mortality in a priori healthy aged dogs, a prospective cohort study has been conducted in guide dogs, followed from a systematic geriatric examination (ge) to either (all-cause) death or cut-off date (july th , ) . survival analyses (kaplan-meier estimators, log-rank tests, and multivariate cox proportional hazards models) were used to assess the associations with time to death. median age at ge was . years, all dogs were neutered, and % were female. the majority of dogs were golden retriever (n = ) and labrador retriever (n = ). among these dogs, % were obese, % presented skin nodules and % used bus as transportation. a total of dogs died during follow-up, leading to a median survival time from ge of . years. after adjustment for demographic and biochemical variables (age, sex, total proteins, cholesterol and alp), an increased alanine amionotransferase level (≥ ui/l; adjusted hazard ratio [ahr], . ), presenting skin nodules (ahr, . ), and not being a labrador (ahr, . ) were independently associated with a shorter time to death (p < . ). public transportation tended to be associated with mortality (ahr, . ; p = . ), highlighting the importance of environment in mortality. neither sex nor other biochemical parameters were significantly associated with mortality. the alanine amionotransferase level and the presence of skin nodules seem predictors of mortality in senior guide dogs, mostly labrador, golden, or mixed breed of labrador/golden. the impact of environment, in particular urban environment, on mortality needs further investigation. studies in other breeds and pets are also necessary to generalize these results. disclosures: sara hoummady received a grant from mp labo for his phd work about dog aging and marc blondot work at the paris guide dog school. laryngeal dysfunction is most commonly associated with aspiration pneumonia, however its role in other lower airway diseases has not been investigated. laryngoscopic and bronchoscopic findings in dogs examined by the author between and were evaluated for the presence or absence of laryngeal abnormalities. dogs that presented for evaluation of inspiratory difficulty or panting were excluded from analysis. clinical diagnoses of inflammatory airway disease, airway collapse, airway infection, eosinophilic bronchopneumopathy or a combination of these disorders were obtained through bronchoscopy and bronchoalveolar lavage fluid analysis. detection rates for laryngeal abnormalities were compared among disease groups using chi square analysis and fisher's exact test, with significance set at p < . . a total of dogs were evaluated and varied in age between months to . years (median years). weight ranged from . - . kg (median kg), with dogs < kg, dogs from . - . kg, dogs from - kg, dogs from . - kg, and dogs > kg. laryngeal hyperemia or swelling was found in / dogs ( %), and detection rate did not differ among disease processes. laryngeal function was considered suspect in / cases, prompting administration of doxapram, which normalized function in / dogs. laryngeal paresis or paralysis was reported in a total of / dogs ( %). a substantial number of dogs with chronic cough displayed evidence of abnormal laryngeal structure or function, suggesting that a complete laryngoscopic examination should be performed in all dogs evaluated for cough. disclosures: member of the feline advisory board, speaker honoraria for international, national, and regional continuing education meetings. bronchiectasis is a poorly characterized disease in dogs identified by airway dilatation on radiographs, computed tomography, bronchoscopy, or histopathology. little is known about underlying disease processes associated with bronchiectasis in dogs. medical records from dogs presented to uc davis were searched for identification of bronchiectasis. underlying disease processes and clinical diagnoses were obtained through review of the history, physical examination, respiratory endoscopy and bronchoalveolar lavage fluid analysis and microbiology. historical reports, results of imaging, bronchoscopy and fluid analysis, and scrutiny of pathologic and clinical diagnoses were comprehensively evaluated to identify the most likely underlying disease process associated with bronchiectasis. between and , bronchiectasis was diagnosed in / dogs ( %) that had bronchoscopy performed. dogs ranged in age from . to years (median years) with / dogs < months, / dogs ( %) - years, / dogs ( %) . - years of age and / dogs ( %) over years of age. dog breeds affected more than once included labrador retrievers, cocker spaniels, golden retrievers and standard poodles. duration of cough ranged from days to years (median months). underlying disease processes included pneumonia in / ( %) dogs, inflammatory airway disease in / ( %) dogs, and eosinophilic bronchopneumopathy in / ( %) dogs. twenty-three of dogs ( %) had positive bacterial cultures, with isolation of streptococcus (n = ) and enteric species (n = ) most commonly. this study found that bronchiectasis often occurs in older, large breed dogs with infectious or inflammatory pneumonia. disclosures: johnson: feline advisory board, speaker honoraria. chronic respiratory disease, often characterized by a chronic cough, is common in dogs. the purpose of this study was to determine the etiology of chronic respiratory disease in dogs that were presented with persistent and chronic coughing. a retrospective study of client-owned dogs with signs of persistent and chronic lower respiratory disease, that underwent bronchoscopy together with either an endotracheal wash (etw) or broncho-alveolar lavage (bal), was performed. all dogs were evaluated by means of full clinical examination, hematology and serum biochemistry analyses, survey thoracic radiographs, echocardiography and ecg (if indicated), and bronchoscopy with cytological analysis and aerobic culture of etw or bal fluid. an etw was performed in / ( %) dogs while a bal was performed in / ( %) dogs. a positive aerobic bacterial culture was identified in / ( %) of submitted etw/bal fluid samples. most commonly isolated bacteria included mycoplasma sp. ( %), bordetella bronchiseptica ( %) and pseudomonas aeruginosa ( %). a definitive diagnosis was made in / cases ( . %). chronic bronchitis was the most common diagnosis ( . %), median age years; followed by airway tracheal collapse or bronchomalacia ( %), median age years,; and primary bacterial infections ( . %), median age years. less common etiologies identified included neoplasia ( . %), median age years; parasitic infections ( . %), median age years; and eosinophilic bronchopneumopathy ( . %), median age years. rare etiologies identified included primary pulmonary hypertension, primary ciliary dyskinesia, excitement-induced cough, and obesity. myxodematous mitral valve disease was found concurrently in / ( . %) dogs. this study concluded that by using a structured combination of survey thoracic radiography, bronchoscopy and etw or bal with cytology and culture, a diagnosis could be made in the majority of dogs with chronic respiratory disease. disclosures: no disclosures to report. canine sterile steroid-responsive lymphadenitis (cssrl) is an uncommon cause of lymphadenomegaly. diagnosis is one of exclusion after extensive investigations exclude infectious, inflammatory or neoplastic aetiologies. resolution of clinical signs occurs with corticosteroids. this retrospective study aimed to further define characteristics, progression and treatment regimens. cases were recruited from uk referral centres between - . diagnostic investigations in each case excluded other potential causes of lymphadenomegaly. thirty-six dogs were diagnosed with cssrl from lymph node cytology and/or histopathology. eighteen breeds were represented, of which were spaniels. english springer spaniels (ess) accounted for cases along with cocker spaniels ( ), cavalier king charles spaniels ( ) and border collies ( ) clinical presentation varied between dogs. clinical signs of pyrexia ( %), lethargy ( %) and anorexia ( . %) were the most common. other signs included cough, tachypnoea, dyspnoea, dysphagia, vomiting, diarrhoea, neck or spinal pain, abdominal pain, joint effusion or dermatologic signs. median referral time was days (ess , cockers and border collies days). twenty-two animals were pyrexic at presentation (mean . °c, range . - . °c). thirty-one animals presented with peripheral lymphadenomegaly, but animals displayed only internal lymph node enlargement. cytology was performed in / cases; neutrophilic lymphadenitis ( ), followed by granulomatous ( ), pyogranulomatous ( ) and reactive hyperplasia ( ). histopathology was performed in / cases documenting neutrophilic ( ), pyogranulomatous ( ) or granulomatous ( ) lymphadenitis. lymph node culture or staining (gram, pas, zn) was performed in and animals respectively, all of which were negative. prednisolone was administered in all cases (dose range . - mg/kg daily). animals were initiated therapy at mg/kg q hours. mean treatment length was weeks. dogs relapsed throughout the study period ( ess, cockers, ckcs, border collie, lurcher and beagle). ess relapsed within months of diagnosis. median relapse time was weeks. this study documents dogs with cssrl in the uk suggesting an over-representation in spaniel breeds (particularly ess), with females and young dogs typically affected. cytologic and histopathologic examination confirmed sterile lymphadenitis with animals showing marked and rapid clinical improvement with corticosteroids. disclosures: no disclosures to report. brachycephalic dogs have unique upper respiratory anatomy with abnormal breathing patterns similar to those in humans with obstructive sleep apnea syndrome (osas). oxidative stress in the body represents the imbalance between the production of reactive oxidative species and the ability of antioxidant defense mechanisms to detoxify the reactive intermediates. oxidative stress is involved in the pathogenesis of many diseases, including hemolytic anemia, atherosclerosis, tissue reperfusion injury and has also carcinogenic potential. several studies have clearly shown an association between obstructive sleep apnea syndrome in humans and oxidative stress, but detailed underlying pathomechanism remains unclear. due to the consideration of brachycephalic dogs as an animal model of human osas, this study was designed to evaluate oxidative stress (paraoxonase type- activity; pon and total antioxidant status; tac) in brachycephalic dogs with brachycephalic airways obstructive syndrome (baos) before and after surgery compared to control dogs. this study was conducted on dogs with baos and control dogs. twenty out of baos dogs were evaluated - months after surgical correction. mean values of tac and pon in different studied groups were as follows: control dogs (tac: . ; pon : . ), baos dogs (tac: . ; pon : . ), baos dogs post-surgery (tac: . ; pon : . ) a statistically significant difference on tac levels is observed between dogs with baos and control dogs (p < . ). no statistically significant differences were observed in pon and tac levels before and after surgery. on the other hand, no differences have been observed between pon and tac levels in baos dogs according type of brachycephalic breed, grade of respiratory and digestive signs or presence of everted ventricular laryngeals. the results of our study showed a statistically significant difference in tac values between control and dogs with baos, confirming the oxidative stress previously described in humans. even that human patients with osas can partially reverse their increase in oxidative stress by using a nasal continuous positive airway pressure treatment, in dogs with baos no differences were observed before and month after surgical treatment. baos surgical treatment is not useful to reduce pon- or tac levels, probably because baos does not induce such an evident inflammatory process in dogs as in human patients with osas. disclosures: no disclosures to report. canine idiopathic pulmonary fibrosis (cipf) is a progressive interstitial lung disease mainly affecting west highland white terriers (whwts). the cipf course varies greatly among dogs from rapid deterioration to slowly progressive forms and the survival time from onset of clinical signs ranges from a few months to several years. in human ipf, increased chemokine (cc-motif) ligand (ccl ) concentrations in bronchoalveolar lavage fluid (balf) are indicative of a poor outcome and serum concentrations are correlated with clinical parameters of lung function. in dogs, serum and balf ccl concentrations were shown to be elevated in whwts with cipf compared with healthy whwts. the aim of the present study was to investigate whether serum ccl concentrations measured in whwts with cipf at diagnosis ( ) can be used as an indicator of prognosis and ( ) correlate with lung function parameters. ccl concentrations were determined by elisa (canine ccl quantikine elisa kit, r&d systems) in the serum of whwts suspected of cipf (median age . years, range . - . ), for which a follow-up was available (median follow-up time . months, range - . ). serum sampling extended from may to january . cipf diagnosis was confirmed by thoracic high resolution computed tomography, lung histopathology, or both examinations in , and whwts respectively. kaplan-meier analysis was conducted to investigate differences in survival times according to serum ccl concentrations at diagnosis. spearman analysis was used to assess correlations between serum ccl concentrations and lung function parameters, namely the distance walked in the -minute walking test ( mwd) and the arterial partial pressure of oxygen (po ). among the cipf whwts included, died or were euthanized for cipf-related reason, died or were euthanized for non-cipf-related reason and were still alive at the end of the study. the median survival of whwts with cipf-related death or euthanasia was . (range . - . ) months from diagnosis. serum ccl concentrations above pg/ml were significantly associated with a shorter survival time in whwts affected with cipf (p = . ). a weak negative correlation was found between serum ccl concentrations and the mwd (r = À . , p = . , n = ), while no correlation was observed with arterial po values (n = ). in conclusion, serum ccl concentration provides prognostic information in whwts suffering from cipf, while this marker is weakly correlated with the clinically lung function parameters available in the present study. disclosures: no disclosures to report. canine idiopathic pulmonary fibrosis (cipf) is a progressive interstitial lung disease mainly affecting west highland white terriers (whwts). this study was intended to ( ) describe thoracic high-resolution computed tomography (t-hrct) findings obtained in cipf dogs under general anesthesia (ga) using the glossary of the fleischner society and ( ) compare images obtained under ga (t-hrct ga ) with those obtained under sedation (t-hrct s ). t-hrct images from whwts with cipf and control whwts were retrospectively reviewed by observers in consensus. specific t-hrct features were assessed and graded for each lung lobe ( = absence, = mild, = moderate and = severe). a global score was then calculated. the khi² test with the threshold % was used for the statistical analysis. ground glass opacity (ggo) was observed in all cipf whwts and in / of controls (p = . ). in controls, ggo was mild and localised mainly in cranial lobes. in cipf whwts, ggo was mild, moderate or severe in , and dogs respectively, without lobe predilection. consolidation was observed in / cipf whwts but not in controls (p = . ) and was mild ( / ) to moderate ( / ). a mosaic pattern, suggestive of air trapping, was noticed in / cipf whwts but not in controls (p = . ) and was mild, moderate or severe in , and whwts respectively, without lobe predilection. nodules were present in / cipf whwts but not in controls. reticulation, subpleural bands and parenchymal bands were noticed in , , and / cipf whwts respectively. honeycombing, emphysema, pleural effusion and pleural thickening were never observed. bronchial wall thickening and mild bronchiectasis were present in / and / cipf whwts respectively but not in controls (p = . and p = . ). the overall t-hrct s quality was good in / examinations compared with / for t-hrct ga (p = . ). the presence of motion artefacts was higher for t-hrct s (p < . ), but were most frequently graded as mild (p < . ). t-hrct s allowed identification of a mosaic pattern in additional cipf whwts, while consolidation could not be identified in others. there was no difference in identification or gradation for the other features between t-hrct ga and t-hrct s . in conclusion, ggo, consolidation, mosaic pattern and bronchial wall thickening are the main t-hrct features of cipf in whwts. honeycombing, the major feature of ipf in humans, was never observed, which suggests a different pathophysiology between the entities. t-hrct s images are in accordance with t-hrct ga and can be used for cipf diagnosis. disclosures: no disclosures to report. literature on mesenterial lymphadenitis (lad) or mesenterial lymph node abscesses (lab) in small animals is scarce. case files from to were searched for dogs with the diagnosis of mesenterial lad/lab based on cytology and/or histopathology. of cases identified, had to be excluded due to incomplete data. the remaining dogs were of mixed breed (n = ), small munsterlander (n = ) and one each of other breeds. nine dogs were male and female. median age was months (range . diagnosis was based on fine needle aspiration (fna; n = ), histopathology (n = ) or both (n = ). significant findings in the dogs' history included gastrointestinal signs (n = ), puppy whose mother had mastitis, bite wounds/abscesses of the skin (n = ), pulmonic stenosis (n = ) and orthopaedic diseases (n = ). most common presenting complaints were lethargy (n = ), hyperthermia (n = ), diarrhoea (n = ), vomiting/nausea (n = ), inappetence/anorexia (n = ), back/abdominal pain (n = ) and lameness (n = ). diagnostic tests performed included haematology/serum biochemistry (n = ), thoracic (n = ) and abdominal (n = ) radiographs, abdominal ultrasound (n = ), ct/mri (n = ), fnas of other organs (n = ), urinalysis (n = ) with culture (n = ), coagulation profiles (n = ), orthopaedic radiographs (n = ), cpl (n = ), blood cultures (n = ), and csf/joint taps (n = ). dogs were retrospectively divided into group a (n = ): dogs with no other disease than lad/lab ("idiopathic") and group b (n = ): dogs with other diseases diagnosed simultaneously. these included neoplasia (carcinoma n = , lymphoma n = , leiomysarcoma n = , histiocytic neoplasia n = , prostate carcinoma n = ), gastroenteritis (n = ), presumed pancreatitis (n = ), purulent monoarthritis (n = ), purulent hepatitis/ splenitis (n = ), fungal infection at a distant site (n = ), and mycobacteriosis (n = ). eleven dogs received surgical treatment and antibiotics, and dogs conservative medical management consisting of supportive treatment and antibiotics. all dogs were discharged alive. dogs in group a were hospitalized longer (mean days, sd . ) than dogs in group b (mean days, sd . ) (p = . ). the median follow-up time was days ( - days). there was no difference in pretreatment with antibiotics or anti-inflammatories between groups. t-tests or kruskall-wallis tests showed that dogs in group a were borderline significantly younger (p = . ), had significantly higher respiratory rate (p = . ), rectal temperature (p = . ), monocyte count (p = . ) and crp concentration (p = . ) than dogs in group b. the small munsterlander had an odds ratio of over other breeds to suffer from lad/lab. in conclusion, idiopathic mesenterial lad/lab was seen in young dogs with hyperthermia and gastrointestinal signs. diagnosis of purulent lad/lab on fna does not exclude the presence of another underlying pathogenesis. disclosures: no disclosures to report. dogs were included, if they showed respiratory signs (< days) consistent with cird and if non-infectious respiratory conditions could be excluded. nasal and pharyngeal swabs were taken from dogs with cird and tested for respiratory pathogens, including canine parainfluenza virus (cpiv), canine adenovirus (cav), canines distemper virus (cdv), canine herpes virus (chv), canine respiratory coronavirus (crcov), canines influenza virus (civ), and bordetella bronchiseptica (b. bronchiseptica) by polymerase chain reaction. results of clinical and laboratory data were correlated with the underlying pathogen using fisher's exact test and chi-square test (p≤ . ). cpiv was detected in , crcov in , and b. bronchiseptica in dogs; patients showed infections with more than one pathogen. there was no significant difference for age and gender distribution between the groups; however, dogs infected with cpiv more likely originated from a shelter (p = . ). when clinical data were compared, there was no significant difference for the parameters depression, fever, cough, nasal discharge, dyspnoea, and abnormal lung sounds. furthermore, there was no significant difference regarding abnormalities of erythrocytes, platelets, leukocytes, and differential count between groups. the study shows that in dogs with cird clinical and laboratory parameters cannot indicate the underlying pathogen. furthermore, diseases severity does not seem to depend on the infectious organism involved. disclosures: no disclosures to report. breed related predisposition to bacterial bronchopneumonia (bp) has been reported in irish wolfhounds (iwhs). underlying factors are unknown, however immune deficit, ciliary dysfunction and aspiration have been suggested as predisposing factors. the purpose of this prospective study was to evaluate lymphocyte subpopulations in iwhs with one or more previous bp and compare results to elderly iwhs without any previous bacterial respiratory infections. additionally, healthy dogs of other breeds were included as controls. previous bp was confirmed in iwhs (median age . years, interquartile range . - . years). healthy iwhs (n = , . , . - . years) or dogs of other breeds (n = , . , . - . years) had no history or findings suggestive of previous bp. edta blood samples, collected from all dogs when they were healthy, were stained with fluorescent mouse anti dog cd , cd , cd , cd and mhc class ii antibodies (abd serotec Ò ) and flow cytometry analysis was performed with bd facsaria Ò ii cell sorter and facsdiva Ò software. statistical comparison between groups and the effect of age was studied using analysis of covariance (ancova) models. the number of leucocytes did not differ significantly between groups. the total numbers of lymphocytes and numbers of major lymphocyte subpopulations (b-cells, cd + and cd + t-cells) were significantly lower in healthy iwhs and iwhs with previous bp compared to dogs of other breeds (lymphocytes p < . and p < . ; b-cells p = . and p = . ; cd + t-cells p = . and p = . ; cd + t-cells p < . and p = . respectively). percentage and number of mhc class ii+ non-b lymphocytes was significantly higher in both iwh groups than in dogs of other breeds (p < . in all comparisons). lymphocyte numbers and subpopulations did not differ significantly in healthy iwhs compared to iwhs with previous bp. an age-related decline in the total number of lymphocytes (p = . ), t-cells (p = . ), cd + t-cells (p = . ) and mhc class ii+ non bcells (p < . ) was noticed only in the group of iwhs with previous bp. these preliminary results indicate that iwhs may have significantly lower numbers of lymphocytes, b-cells as well as cd + and cd + t-cells than dogs of other breeds. further studies are needed to determine whether these alterations represent a breed related phenomenon or are connected to the predisposition to bp. an age-related decline in lymphocyte, total t-cell and cd + t-cell numbers was detected in iwhs with previous bp. in humans, age related changes in cd + t-cells have been associated with increased susceptibility to infections. disclosures: no disclosures to report. feline chronic kidney disease (ckd) is a common feature of ageing cats. angiotensin-converting enzyme inhibitors (acei) are recommended to treat hypertension associated with ckd to limit target-organ damage and especially glomerular hypertension. in addition, the international renal interest society (iris) guidelines recommends the prescription of an acei in patients with ckd and proteinuria. to our knowledge no study has demonstrated the effects of long term administration of acei in a client owned population of cats suffering from ckd on glomerular filtration rate (gfr). the aim of the study was to evaluate the effect of an acei (imidapril, prilium Ò , v etoquinol sa) on the gfr of cats suffering from naturally occurring chronic kidney disease (ckd) over months. sixty-six cats presenting with clinical and biological signs of ckd were enrolled by european investigators and followed up till months in this randomized blinded study. thirty-two cats provided suitable data for gfr analysis; animals received imidapril at the dosage of . mg/kg/day and received placebo. animals with no available gfr value on day or with no data after day were excluded as well as animals for which the iohexol clearance could not be determined. follow up was censored after months due to small sample sizes for statistical comparisons. on day , month , month and month , cats were sampled , and minutes after intravenous administration of mg of iohexol. gfr was based on determination of the iohexol clearance which was calculated with the phoenix Ò winnonlin . software. statistical analyses were performed with sas/stat . software. as gfr were not available on each time point for a given animal, the treatment groups were compared on each gfr determination point using an ancova (analysis of covariance) with the gfr determined on day as the covariate. on d , gfr were . ae . and . ae . ml/kg/min in the imidapril and placebo group, respectively. a significant statistical difference ( . ae . versus . ae . ml/kg/min in the imidapril and placebo group respectively, p = . ) was observed in favor of a higher gfr in the imidapril treated animals on month . higher gfr were also observed in the imidapril group on mon-th and month but not significantly different from the placebo group. daily long term imidapril treatment compared to placebo, may be an effective treatment to slow the progression of renal failure in cats with naturally occurring chronic kidney disease. disclosures: authors are employees of vetoquinol. there is a concern over the potential of cytotoxic drugs which could harm exposed workers. the speciality of oncology of the ecvim-ca published guidelines in order to prevent that risk. however few data exist for evaluation of the real risk of occupationnal exposure. this concern was the aim of our study. biomarkers used were vincristine and cyclophosphamide. surface samples were collected in the consultation room and ward dedicated for chemotherapy. samples were collected with wet filter paper on cm surfaces, or objects (computers for instance). samples were analysed by liquid chromatography and mass spectrometric method.the limit of quantification was . ng/ cm (or . g/object) for vincristine and . ng/ cm (or . g/object) for cyclophosphamide. samples in consultation room were collected after treating dogs with vincristine and after cleaning. samples in dedicated ward were collected after cleaning and after -days stay of treated dogs. aeras/objects were tested in consultation room; in dedicated ward for vincristine; in ward for cyclophosphamide. after treatment of dogs in consultation room, traces of vincristine were detected on the floor and the laboratory bench top ( . to . ng/ cm ). moreover, the surface of auscultation table and extern side of gloves were contaminated after preparation and administration of vincristine (respectively . , and ng/objet). after cleaning, % of samples in consultation room were positive. traces of vincristine were detected on the floor or objects (wall otoscope. . .: . to . ng/ cm ). after cleaning, % of samples in ward were positive. traces of vincristine were detected on the floor and objects (boxes, wastebin, bowls. . .: . to . ng/objet) after cleaning and animals treatment. cyclophosphamide were detected on all areas tested ( . a . ng/objet). despite protective guidelines to avoid spread of cytotoxic drug, environemental exposure was demonstrated. however contaminations were limited and show that handling procedures of cytotoxic drugs are well controlled. most-elevated contamination level for vincristin were noticed on extern side of gloves depsite of using appropriate material. workers should pay a particular attention for gloves withdrawal to limit exposure. small amounts of vincristine were found in inapropriate places: computeur mouse,. . . even if there is few of those residues, we thought about people working on a regular basis in this room for other activities than chemotherapy., and we decided to adapt our clinical practices. evaluation of occupational exposure to cytotoxic drugs is an important step to prevent incidents and heigt awarness of nursing staff to apply those good clinical practices. disclosures: no disclosures to report. the tumor-associated inflammatory response had the effect of enhancing mammary tumorigenesis, helping incipient neoplasias to acquire hallmark capabilities, both in human and dogs. t-cells migration to the tumor site and the following activation may be the essential requirement for their promoting effect on tumors. in human breast cancer the signaling pathways of c-kit have been described as possibly being involved in differentiation, migration, survival, and maturation of t-cells and other inflammatory cells into tumor sites. in order to clarify this subject in canine mammary tumors (cmt), malignant neoplasms were studied by using immunohistochemistry comparing the intratumoral cd + tlymphocytes and c-kit expression together with vegf, microvessel density (mvd) and clinicopathological characteristics of tumor aggressiveness. cd + t cells and high c-kit immunoexpression revealed a positive and statistically significant correlation with vegf (r = . , p < . ; r = . , p = . for cd and c-kit respectively) and cd (r = . , p < . ; r = . , p = . for cd and c-kit respectively). a statistically significant association (p = . ) and a positive correlation (r = . , p = . ) between cd + t-lymphocytes and c-kit was also observed. tumors with high c-kit expression showed higher counts of cd + t-cells. the mvd of high cd /vegf tumors was significantly more elevated (p < . ). a similar association was observed for high c-kit/vegf tumors (p < . ). in this study high cd /vegf, high c-kit/vegf and high cd /c-kit tumors were statistically significantly associated with elevated grade of malignancy (p < . for cd /vegf, c-kit/vegf and cd /ckit), presence of neoplastic intravascular emboli (p < . for cd /vegf and cd /c-kit; p = . for c-kit/vegf) and presence of lymph node metastasis (p < . for cd /vegf, c-kit/ vegf and cd /c-kit). tumors with high cd /vegf (p = . ), high c-kit/vegf (p < . ) and high cd /c-kit (p = . ) expression were associated with shorter os time. inter-estingly the group of tumors with high c-kit/vegf retained their significance by multivariate analysis arising as independent predictor of os. results of this study suggest that t-lymphocytes may share common signaling pathways with c-kit and vegf in cmt progression and may contribute to increased angiogenesis, aggression and shorter os in these tumors. disclosures: no disclosures to report. lgl lymphoma, but no comparisons were made with cats with other diseases or other forms of feline lymphoma. therefore, the objective of this study was to assess differences in prevalence, signalment (breed, sex, and age), physical exam findings (body weight, body condition score, body temperature, heart rate, respiratory rate, and systolic blood pressure), and felv/ fiv status between cats with lgl lymphoma (group ) and all other type of feline lymphoma (group ). the electronic data-base of the san marco veterinary clinic was searched between january- and december- for cats with a cytological or histopathological diagnosis of lymphoma. differences between groups were assessed by t-test, mann whitney, pearson-chi square, pearson chi square yates corrected, and fisher's exact test. during the study period out of sick cats seen at the clinic were diagnosed with lymphoma (group : n = ; group : n = ). the prevalence of all type of feline lymphoma between and compared to sick cats did not change over time ranging from . % to . % per year (p = . ; overall prevalence . %, % ci . - . ). the lymphoma lgl prevalence between and compared to all types of lymphoma did not change over time ranging from . % to . % per year (p = . ; overall prevalence . %, % ci . - . ). among the variables studied, only sex (group : [ . %] females, [ . %] males; group : [ . %] females, [ . %] males; p = . ) and age (group : ae months; group : ae months; p = . ) were significantly different between groups. sixteen out of cats with lgl lymphoma were tested for their felv/fiv status resulting all felv-and one ( . %) fiv+. seventy-four out of cats with all other types of lymphoma were tested for their felv/fiv status resulting ( . %) felv+ and ( . %) fiv+. five cats ( . %) were both felv+/fiv+. prevalence of felv infection was significantly lower (p = . ) in group compared to group . there was no difference in prevalence of fiv infection between groups. lymphoma lgl affects more females and older cats compared to all other type of feline lymphoma. opposite to all other type of lymphoma, and in accordance to previous litterature information, felv+ status does not play a role in the pathogenesis of feline lgl lymphoma. disclosures: no disclosures to report. the activity of t regulatory cells (tregs) is known to be closely associated with the expression of foxp transcription factor. foxp regulatory t cells (foxp treg) are a distinct group of t lymphocytes that have immunosuppressive properties. normally this cells work for prevention of harmful autoimmune responses, however can also interfere with beneficial immune responses such as anti-tumor immunity. in human breast cancer these cells play a crucial role in tumor progression. in canine mammary tumors (cmt) there are only a few studies and this topic are not welldocumented. in this study we included malignant cmt and studied, by immunohistochemistry, the intratumoral foxp expression together with vascular endothelial growth factor (vegf), microvessel density (mvd, by cd antibody) and several clinicopathological characteristics. abundant foxp treg cells was statistically associated with presence of tumor necrosis (p = . ), nuclear grade (p = . ), poor differentiation of tumors (p < . ), high mitotic grade (p < . ), high histological grade of malignancy (p < . ), presence of neoplastic intravascular emboli (p < . ) and presence of lymph node metastasis (p < . ). intratumoral foxp levels were correlated with the levels of vegf (r = . ; p < . ) and intratumoral mvd (r = . ; p < . ). additionally tumors with abundant foxp treg cells were associated with shorter overall survival (os) time (p = . ). results suggest that treg cells play a role in cmt progression and may contribute to increased angiogenesis and aggression in these tumors. the association of intratumoral foxp expression with shorter os of animals suggests a utility of treg cells activity as a prognostic marker. disclosures: no disclosures to report. cyprus is an island state in the eastern mediterranean basin. no epidemiological studies have yet been performed on infectious agents in cats from cyprus. the aim of this study was to determine the prevalence of several infectious agents, including some vector-borne infections, in cats from cyprus. surplus edta-blood and serum samples were recruited from cypriot cats, from which signalment and lifestyle characteristics were recorded. dna was extracted and real-time quantitative polymerase chain reaction (qpcr) assays were used to detect haemplasmas(mycoplasma haemofelis, 'candidatus mycoplasma haemominutum' and 'candidatus mycoplasma turicensis'), leishmania spp.and bartonella henselae. conventional pcr assays were used to detect ehrlichia/anaplasma spp. samples yielding positive results for leishmania spp. or ehrlichia/anaplasma spp. underwent further characterisation (sequencing). elisas were performed for the detection of l. infantum antibodies, feline leukaemia virus (felv) antigen and feline immunodeficiency virus (fiv) antibodies. statistical analysis was performed using spss for the assessment of any associations between variables and infectious agents. of the samples extracted, were excluded due to failure of ≥ one internal control pcr. of the remaining samples, ( . %) were positive by pcr for haemoplasma including ( . %) for m. haemofelis, ( . %) for 'ca. m. haemominutum' and ( . %) for 'ca. m. turicensis'. nineteen ( . %) were positive for b. henselae. one cat ( . %) was pcr positive for ehrlichia/anaplasma spp. and sequencing revealed identity with anaplasma platys. leishmania spp. dna was detected in of the ( . %) cats; sequencing revealed l. infantum in of these cases. l. infantum serology was positive in of the cats tested ( . %). only one cat was positive for both leishmania pcr and serology. of the cats that underwent retroviral serology, ( . %) were felv and ( . %) were fiv positive. statistical analysis identified several significant associations (p < . ) including the following; haemoplasma infection and both outdoor access and feral-shelter cat origin, felv or fiv infection and both anaemia and feral-shelter cat origin. this study documents, for the first time, the presence of haemoplasmas, l. infantum, b. henselae, a. platys, felv and fiv in the feline population of cyprus. the prevalence of haemoplasma, fiv and b. henselae infections were among the highest reported in cats from mediterranean countries, while that of leishmania spp. was similar. this is the second report of a. platys infection in a cat from a mediterranean country. disclosures: no disclosures to report. bartonella species (spp.) are zoonotic pathogens, and infections in cats are common. prevalence in cats from southern germany is still unknown. the aim of this study was to determine the prevalence of bartonella spp. dna in blood of cats in southern germany and to evaluate associations between bartonella bacteremia, housing conditions, feline immunodeficiency virus (fiv), and feline leukemia virus (felv) status, including progressive, regressive, and abortive felv infection. blood samples of cats that were presented to different veterinary clinics in southern germany for various reasons were tested for bartonella spp. dna using a previously published conventional polymerase chain reaction (pcr) targeting a fragment of the s- s rrna intergenic spacer region. for statistical analysis, fisher's exact test was used. prevalence rate of bartonella spp. bacteremia was . % ( / ; ci: . % - . %). b. henselae was amplified in of these cats. one cat was positive for b. clarridgeiae dna. most of the infected cats were clinically healthy, but half of the cats had thrombocytopenia, potentially caused by their bartonella spp. infection. there was no significantly higher risk to be infected with bartonella spp. when living mainly outdoors or being fiv-or felv-infected. prevalence of bartonella spp. bacteremia is low in southern german cats, but there is still a risk of human bartonella infection associated with cat ownership. most clinical changes of the bartonella spp.-infected cats were related to other diseases. however, thrombocytopenia was common and further studies are required to define its potential clinical relevance. disclosures: no disclosures to report. ante-mortem diagnosis of feline infectious peritonitis (fip) is still challenging. the aim of this study was to evaluate sensitivity and specificity of a 'combined reverse transcription nested polymerase chain reaction (rt-npcr) and sequencing approach', detecting mutations at different nucleotide positions within the spike gene, that previously were shown to correlate with the fip phenotype. the study population consisted of cats with confirmed fip and a defined control group of cats for which fip was considered an important differential diagnosis, but that were definitively diagnosed with other diseases. blood and/or effusion samples were examined for feline coronavirus (fcov) rna by rt-npcr and, if positive, nucleotide positions and were sequenced for nucleotide transitions. sensitivity, specificity, negative and posi-tive predictive values were determined and % confidence intervals ( % ci) calculated. rt-npcr detected fcov in cats in blood (n = ) and/or effusion (n = ); all of them had fip. one of the mutations of interest was found in / of the pcr-positive blood samples and in / of the pcr-positive effusion samples. diagnostic specificity of the 'combined rt-npcr and sequencing approach' was % in blood ( % ci . - . ) and effusion ( % ci . - . ). diagnostic sensitivity was . % ( % ci . - . ) in blood and . % ( % ci . - . ) in effusion. a positive test result therefore confirms a suspicion of fip. a negative result, however, cannot be used to rule out fip, especially if only blood is available. therefore, if no effusion is present, diagnosis of fip still remains challenging. disclosures: dr. elisabeth mueller is the managing director of laboklin gmbh & co.kg. dr. karola weider is employed at laboklin gmbh & co.kg. this laboratory offered the 'combined rt-npcr and sequencing approach' on a commercial basis and performed the testing in this study. feline infectious peritonitis (fip) is a viral disease caused by the virulent strain of feline coronavirus (fipv). the disease can appear under clinical forms, dry or effusive, both leading to a fatal outcome. diagnosis was based on histopathologic lesions on necropsy until the recent discovery of mutations associated with the fipv strain in the c and spike (s) genes. our main goal was to detail the distribution of c or s gene mutations in different biological samples of cats suffering from fip. this was a retrospective, observational study of cats showing clinical signs compatible with fip. ten out of cats were of pure breed. . % were males and . % females. median age was . months at presentation. the clinical presentation, pathologic findings and virologic data were reviewed. according to clinical signs, cats were classified with a dry form and with a wet form of fip. the main clinical signs included dehydration, hyperthermia, icterus, abnormal abdominal palpation, neurological and ocular disorders. when possible blood, fecal material, effusion, fine needle aspiration (fna) from relevant organs or a combination of these, was recovered from each cat. feline coronavirus (fcov) was first researched by rt-pcr, then the c and part of the s genes were sequenced to determine the eventual presence of mutations. among the dry cases, fcov was detected in / blood samples, / fecal samples and fna ( / ). among the wet cases, / blood samples, / fecal samples and all effusion samples ( / ) were positive for the presence of fcov. c mutations were never found in fecal samples but were found in / effusion samples and in / fna. s mutations were detected in / fecal samples, / fna and / effusion samples. for cats, no mutation, neither in c or s genes was identified despite the confirmation of fip by necropsy. s gene mutation is more frequently observed than c gene despite in cases where only c mutations were identified. moreover the presence of strains harbouring s mutation in feces has never been described before and could suggest the possible diffusion of fipv among feline population. in conclusion, viral diagnosis of fip based on rt-pcr sequencing in effusion and fna samples is essential. rt-pcr resulting from blood samples should be carefully interpreted because of high risk of missing fipv. finally, searching for mutations in both s and c genes is recommended. disclosures: no disclosures to report. methicillin resistant staphylococcus aureus (mrsa) has recently become a great concern for pet animals' disease and zoonotic infection. mrsa strains transfer between pet animals and humans could occur. the aim of the present study was to determine the occurrence of mrsa in household dogs. from january to june , clinical samples were collected from dogs, patients of the veterinary teaching hospital of the department of veterinary sciences of messina (italy), affected by several diseases of various origins. all samples were processed by bacteriological conventional methods for isolation and identification. all strains were tested for phenotypic susceptibility to oxacillin and were subjected to a pcr protocol for the detection of meca gene. strains carrying the gene were considered methicillin resistant (mrs). lastly, on both mrs and methicillin sensitive (mss) strains, kirby-bauer disk diffusion susceptibility testing were performed to highlight resistance profiles using molecules belonging to the main classes of antimicrobials used in veterinary practice. strains resistant to at least one molecule of or more classes of antibiotics were considered multidrug-resistant (mdr). the statistical analysis of the results was made using the z-test by a primer Ò software. forty staphylococcus spp. strains were isolated, belonging to species. the most frequently isolated microorganisms were staphylococcus aureus with isolations ( %) and staphylococcus pseudintermedius with isolations ( . %), followed by staphylococcus epidermidis with isolations ( %) and staphylococcus cohnii and staphylococcus warneri, both with isolations ( %). a single isolation ( . %) was obtained for each of the species staphylococcus chromogenes, staphylococcus haemolyticus, staphylococcus lentus, staphylococcus lugdunensis, staphylococcus saprophyticus, staphylococcus simulans and staphylococcus sciuri. thirteen ( . %) strains of staphylococcus spp. were phenotypically resistant to oxacillin and staphylococcus aureus ( . %; n. from pyoderma, n. from exudative pleural effusion) were positive for the meca gene. all strains of staphylococcus spp. were mdr. our results showed the presence of mrsa and multidrug-resistant staphylococcal strains in household dogs. a lack of correspondence between antimicrobial susceptibility tests and molecular methods was found in the present study. disclosures: no disclosures to report. a fourth haemoplasma called 'candidatus m. haematoparvun-like' (cmhp) was latter identified in cats. the only published study in chile was carried out in cats, with prevalences by pcr of . % to mhf, and % to cmhm.the aim of this study was to perform molecular detection of haemoplasmas in cats from valdivia, southern chile. blood samples were taken from cats and used for haemoplasmas dna detection by quantitative real time pcr (qpcr) at universidad austral de chile. qpcr protocol was based on detection of feline dna targeting s housekeeping gene and mycoplasma spp. s rrna gene (universal primers, my sf forward, my sr y my sr , both reverse) by sybr green method. the melting temperature (tm) analysis allowed identifying the infecting mycoplasma species (mhf, cmhm, cmt). it was not posible to identify haemoplasmas species on co infected cats, so a second qpcr specie specific protocol was applied on these samples. second qpcr protocol was based on s rrna gene, with specific primers to detect mhf, cmhm, cmt and cmhp. all samples ( / ) were positive to s gene, proving presence of cat dna. from the cats, . % ( / ) were positive to haemoplasmas, where . % ( / ) corresponded to cmhm (tm . - . °c), . % ( / ) to mhf (tm . - . °c), % ( / ) to cmt (tm . - . °c) and . % ( / ) to co infections. associations between cmhm+mhf, cmhm+cmt, cmhm+cmhp and cmhm+mhf+ cmhp were detected on co infected animals. these results agree with those found in previous reports from chile, europe, eua and brazil, where cmhm is the most prevalent species and co infections are less frequent. valdivia cats are infected by different haemoplasma species and cmt and cmhp are reported for the first time in chile.founding: did uach, project s- - disclosures: no disclosures to report. clinical manifestations of canine visceral leishmaniasis (canl) are non-specific and include progressive weight loss, anemia, lymphadenomegaly, hepatosplenomegaly, dermatological, renal and ocular alterations. cardiac lesions resulting in clinical signs has been scarcely described in dogs with vl, and the presence of the parasite in the cardiac tissue has been involved in few reports. accordingly, the present study aimed to evaluate histopathological abnormalities in cardiac tissue from dogs naturally infected by leishmania infantum chagasi. a total of dogs were evaluated. all dogs were symptomatic but no one presented clinical signs of cardiac involvement. in compliance with a federal law and under the owners' signed consent, all dogs were submitted to euthanasia and comprehensive post-mortem evaluation. samples from right atrium free wall (ra), right ventricle free wall (rv), interventricular septum (ivs) and left ventricle free wall (lv) were collected and evaluated. tissue samples were fixed in formalin, embedded in paraffin, sectioned at mm, and stained with hematoxylin and eosin (he) and anti-leishmania immunohistochemistry was also performed. the study was approved by the ethics committee in animal experimentation and animal welfare (protocol number / ). histopathological changes were observed in at least one of the evaluated cardiac regions in % ( / ) of the dogs. the most frequent cardiac injury was an inflammatory reaction, characterized by the presence of mononuclear cell infiltrate in different degrees. of the evaluated regions, ra was the one with the highest incidence of histopathological changes, observed in % ( / ) of the animals, followed by rv, lv and siv, affected in . % ( / ), . % ( / ) and . % ( / ) of the dogs, respectively. immunohistochemistry revealed amastigotes in the cardiac tissue in % ( / ) of the dogs. a positive correlation was found between cardiac lesions and the presence of amastigotes in the myocardium (p < . ). disclosures: no disclosures to report. canine leishmaniosis is a life threatening zoonotic disease. the combination of meglumine antimoniate and allopurinol is consid-ered the most effective therapy for canine leishmaniosis and constitutes the first line protocol against this disease. allopurinol is a parasitostatic drug used in long-term to maintain low parasite loads and to avoid clinical relapses. traditionally, allopurinol is considered a very safe drug in the dog. however, some reports indicate that xanthinuria and xanthine urolithiasis is produced after prolonged therapy with allopurinol in the dog. the aim of this prospective study was to evaluate the prevalence of urinary adverse effects of allopurinol treatment ( mg/kg/bid/po) in dogs with leishmaniosis. diagnosis was made by compatible clinicopathological abnormalitites with leishmaniosis and high leishmania infantum-specific antibody levels assessed by quantitative elisa. once leishmaniosis was diagnosed, a close follow-up (day , , , and during treatment) including physical examination, baseline laboratory tests (cbc, biochemistry profile, serum electrophoresis, urinalysis, urinary protein/creatinine ratio) and abdominal ultrasound was performed. in our preliminary results, dogs were included. dogs did not present any urinary abnormalities based on biochemistry profile, urinalysis and abdominal ultrasound at the time of diagnosis. four out of presented xanthinuria (day- (n = ), day- (n = ), and day- (n = )). two out of dogs presented renal mineralization at day- of treatment. two out of dogs presented bladder urolithiasis since day- of treatment. xanthinuria was presented initially in all dogs that developed renal mineralization or bladder urolithiasis. dogs with renal mineralization and urolithiasis were treated with a restricted protein diet and, so far, they did not develop renal disease. the present study describes early xanthinuria, renal mineralization and urolithiasis as adverse effects due to chronic allopurinol treatment in dogs with leishmaniosis. neither mineral analysis nor renal biopsy was performed to confirm the origin of these lesions, but no urinary abnormality was present before allopurinol treatment was instituted. a thorough monitoring of dogs treated against leishmaniosis combined with urinalysis and abdominal ultrasound should be performed to evaluate urinary adverse effects and to help in the clinical management of these adverse effects. disclosures: no disclosures to report. giardia duodenalis is one of the most important gastrointestinal parasites in dogs and cats with a zoonotic potential. in germany the prevalence in dogs and cats reaches up to % and %, respectively. genotypes of genetic assemblages of the parasites infect humans (assemblages a and b) and other mammals including small animals. in contrast, parasites of the assemblages c and d are specific for dogs, assemblage f for cats. objectives of the study were to analyse the prevalence, potential epidemiological risk factors and symptoms of g. duodenalis infections in dogs and cats. to detect g. duodenalis, feces from dogs and cats was analysed with an elisa technique. after dna extraction real time pcr as well as multi-locus sequence typing was performed for the following gene loci: triosephosphate isomerase-, glutamate dehydrogenase-, beta-giardin-gene, ssu rrna. with a questionnaire possible epidemiological risk factors were evaluated. statistical analyses were performed using spss (odds ratio, kolmogorow-smirnow test, spearman correlation). fecal samples of dogs and cats were collected over a time period of months. the elisa test was positive in / dogs and / cats. of giardia positive dogs and of positive cats had gastrointestinal signs. genotyping was successful in of dog samples and were assigned to assemblages as follows: assemblage a (n = ), a/c (n = ), a/d (n = ), b (n = ), b/d (n = ), c (n = ), c/d (n = ), d (n = ). only one of positive cat samples could be genotyped and was atypically identified as assemblage d. significant correlations between giardia infection and age, clinical signs, deworming status and staying abroad were found. in this monocenter study a prevalence rate of . % in dogs and . % in cats was detected, which is in good accordance with previous studies. the study further highlights a high rate ( %) of asymptomatically g. duodenalis infected animals. as potential zoonotic assemblages were detected, transmission of giardia from small animals to humans (and vice versa) cannot be excluded. especially young and not dewormed animals had a higher prevalence. disclosures: no disclosures to report. canine parvoviral enteritis remains a common cause of morbidity and mortality in young dogs. the goal of this study was to document a large cohort of affected dogs and analyze several factors as possible predictors of fatal outcome. medical records were retrospectively searched for dogs with parvoviral enteritis diagnosed with a positive fecal antigenic test or a fecal pcr. dogs were included only if the medical records were complete. the population was compared to the reference population of the hospital on the same time period with chi square tests and several factors were analyzed as possible predictors of death with a logistic regression. one hundred and fourty seven cases were included. seventy percent of the dogs were non vaccinated puppies under the age of months. intact females and rottweiler, american staffordshire terrier and french beauce shepherd dogs were over-represented. clinical signs such as vomiting, diarrhea and dehydration were present in . %, . % and . % of the dogs respectively. hyperthermia, anemia and leucopenia were observed in . %, . % and . % of dogs respectively. the majority of the affected dogs were hospitalized for to days and the mortality rate was . % ( / dogs). hypoglycemia at admission was observed in / ( . %) dogs in which blood glucose was measured and was the only risk factor associated with death (p < . ). in this study, a predisposition of rottweiler, american staffordshire terrier and french beauce shepherd dogs was observed and hypoglycemia at admission was the only predictor of fatal outcome. disclosures: no disclosures to report. canine parvovirus (cpv) infections in dogs remain widespread around the world and still represent a major health threat in puppies. all vaccine manufacturers include this component in their core vaccination package, recommending injections at - weeks interval from to weeks of age. despite broad vaccination coverage, number of reports suggesting lack of efficacy in vaccinated dogs have been reported, which implicate vaccines belonging to all major manufacturers. these cases are usually considered as being linked to the interference with maternal antibodies (matab), able to persist beyond weeks of age, which has led most expert groups to recommend a third vaccination around weeks of age. persistence of matab actually represents a major issue when immunizing puppies against parvovirosis. indeed, matab titres higher than / in the haemaglutination inhibition (hi) test can still inhibit vaccine uptake whereas such titres do not prevent field virus infection. in contrast, hi titres higher than / to / are usually considered as protective against disease and virus excretion. this "immunity gap"is therefore a critical period for the puppy and the outcome of the vaccination. in order to evaluate the impact of residual mda on the efficacy of a standard primary vaccination protocol, we performed a vaccination field trial with serological follow-up. puppies from to weeks of age presented at veterinary practice received injections at weeks interval. serology was performed by elisa before (at d /v ), during (at d /v ) and after (d ) vaccination. average maternal antibodies titres were strongly correlated with the age of the puppy at primary vaccination, remaining at vaccine inhibiting level until~ week of age. average titres increased significantly after st injection of primary vaccination in most groups and in all groups after the nd injection of primary vaccination. individual variability remained significant: vaccine uptake was inversely and strongly correlated to the pre-vaccinal matab titre at vaccination. out of puppies ( %) didn't seroconvert, despite vaccination complying to the recommended schedule. vaccination was started in such dogs between . and . weeks and completed between . and . weeks and average initial matab titre was . log compared to . for the general population. in conclusion, this trial supports the recommendation of an additional injection of primary vaccination at weeks, especially in areas of high parvovirus prevalence / pressure, where high levels of matab are likely to be transferred to puppies. disclosures: all authors are employees of merial. ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . . % of the dogs were pcr positive. the aim of our study was to evaluate the usefulness of determining serum level of c-reactive protein (crp) in dogs naturally infected with bacterium a. phagocytophilum as a possible indicator of the clinical phase of the disease. pcr and/or ifa positive dogs with clinical presentation and/or thrombocytopenia were included in the study. based on the results, the dogs were divided into groups: pcr positive dogs; ifa positive (subdivided according to titer level from : -> : ) and pcr negative dogs; positive control group -pcr and ifa negative dogs with clinical signs and/or thrombocytopenia; negative control group -clinically healthy, pcr and ifa negative dogs. serum level of crp was determined using lifeassays Ò canine crp (lifeassays, lund, sveden) . an elevated concentration of crp (> mg/l) was determined in pcr positive and ifa positive dogs with an ifa titer ≥ : and coincides with the presence of clinical signs (most commonly general clinical signs, elevated body temperature, gastrointestinal problems) and/or mild ( . %) or severe ( %) thrombocytopenia. the assessment of crp concentration, in correlation with certain clinical alterations and thrombocytopenia, suggests that crp concentration is elevated in the acute phase of the disease and is in correlation with the aforementioned changes therefore can serve as an additional diagnostic parameter. the crp concentration in ifa positive dogs, regardless of ifa titer levels, and with present clinical signs and thrombocytopenia is higher (above detectable level, > mg/l) than in dogs without clinical signs or laboratory alterations, which may speak in favor of reinfection or reactivation of a persistent infection at least in cases when no other cause of inflammation can be found. specific treatment would therefore be reasonable in such cases, especially in cases of rising crp concentration. disclosures: no disclosures to report. gallbladder agenesis is a very rare cause of elevated liver enzymes in dogs. in this study, we evaluated the features of dogs [ males ( castrated) and females ( spayed)] with suspected gallbladder agenesis on ultrasonography. five different breeds were included: chihuahua (n = ), toy poodle ( ), german shepherd ( ), jack russell terrier ( ), and shiba dog ( ). the median age was . ( . - . ) years. ten dogs were asymptomatic, while the other dogs showed decreased appetite ( ), vomiting ( ), ascites ( ), seizure ( ), and diarrhea ( ). all dogs showed elevated liver enzymes, with high alanine aminotransferase levels (median, u/l; - u/l) in dogs and high gamma-glutamyl transpeptidase levels (median, u/l; - u/l) in . gallbladder agenesis was confirmed using laparoscopy in dogs and laparotomy in . liver biopsy samples were obtained from all dogs. additional computed tomography cholangiography was performed for dogs using a -slice multidetector computed tomography (mdct) scanner following the intravenous administration of contrast medium (meglumine iotroxate). the obtained images were analyzed on a workstation, and they revealed an absent gallbladder in dogs and a vestigial gallbladder in . the common bile duct was dilated in dogs. for all dogs, laparotomy or laparoscopy was used to visualize the gallbladder and liver abnormalities, including malformed lobes and surface irregularities. acquired portal systemic collaterals were visually confirmed in dogs, who also exhibited hypoplasia of the portal vein on histological examination. in conclusion, most animals with gallbladder agenesis were asymptomatic in our study, indicating a good long-term prognosis. however, symptoms associated with portal hypertension must be monitored in animals with primary portal vein hypoplasia. disclosures: no disclosures to report. assessment of systolic arterial blood pressure (sap) is an important tool in small animal internal medicine practice, especially with diseases or clinical conditions that can cause hypertension or hypotension. the doppler method is noninvasive and has several advantages compared to oscillometric method. there are few studies about the effect of body position on sap in conscious dogs. the hypothesis was that animal positioning during measurement alters sap values. the study design was prospective and randomized regarding order of positioning measurements. one hundred and twenty client-owned, conscious, healthy or sick adult dogs, weighing up to kg were included. sap was recorded by doppler ultrasonography following american college of veterinary internal medicine consensus statement with animals positioned in sternal recumbency, right lateral recumbency and with the dog laying down on owner s lap. the order of body position was raffled at the time of measurement. five consecutive measurements on each body position were performed always on left forelimb and the average was calculated. sap values were higher in sternal recumbency ( mmhg, p %- % = - . ; p < . ) compared to those obtained on the owner s lap ( mmhg, p %- % = . - . ), and both were similar to right lateral recumbency ( mmhg, p %- % = - ). these results suggest that sap measurement obtained on owner s lap or right lateral recumbency can be used on clinic routine, but sap measurement obtained on sternal recumbency should be avoided, because such measures may be overestimated. disclosures: no disclosures to report. canine patients may be presented for blood pressure (bp) assessment when clinical diseases associated with systemic hypertension (ht) are suspected but not confirmed; this population may encompass patients that have normal bp, true ht or situational ht. the clinician's aim is to identify animals with ht reliably, while minimizing false positives. this prospective study investigated the repeatability of duplicate within-visit systolic bp assessments (sbp and sbp ) in consecutive canine patients presented for bp assessment in the small animal clinic ( duplicate sbp recorded from dogs) and in a control group of healthy dogs ( duplicate sbp obtained from control dogs), resulting in duplicate measurements for analysis. doppler methods were used for duplicate assessments and oscillometric methods were used for duplicate assessments; cuff size/location were consistent within any dog. sbp ≤ mmhg was considered normal (nml); sbp > mmhg was considered abnormal (abn). median (range) elapsed time between duplicate readings was ( - ) minutes; % of sbp were obtained within minutes of sbp . there was no correlation between elapsed time and change in sbp (p = . ). % of sbp were equal to or lower than sbp ; median decrease was ( - no dog with sbp > mmhg (n = ) had nml sbp . more dogs with abn sbp were panting ( / scored, %) compared to the group with dogs with nml sbp ( / scored, %, p = . ). sbp of dogs that stopped panting ( / , %) tended to decrease (p = . ). within-visit repeatability of bp diagnosis was good in dogs with nml sbp , but apparent false positive diagnoses of ht occurred in % of dogs with abn sbp . sbp > mmhg was repeatable in all dogs. panting may be associated with increased measured sbp by these methods. duplicate within-day measurements may help identify false positive ht diagnoses in dogs with initial sbp measurements > mmhg. disclosures: no disclosures to report. hypovitaminosis d has previously been shown to be prevalent amongst dogs with protein losing enteropathy (ple). outcome is generally poor in canine ple, and there is a lack of studies identifying underlying risk factors. the hypothesis of this study was that low vitamin d serum concentrations could be a risk factor for bad outcome in such patients. medical records for dogs seen at the royal veterinary college between and were reviewed to identify dogs with a diagnosis of ple confirmed by histopathology. dogs were included in the study if they had serum samples frozen within minute after sampling, had been kept at À degrees c until analysis, and if clinical activity scoring (cce-cai) had been recorded at the time of diagnosis. forty-three dogs were included in the study. follow-up with referring veterinarians was made to determine outcome of patients. patients were divided into two groups: patients deceased due to ple (poor outcome group, n = ) and patients alive or deceased due to another disease (good outcome group, n = ). treatments for patients were allocated to two groups: one group consisted of patients who were prescribed diet only and the other group received diet and immunosuppressive agents. samples were sent on dry ice to michigan state university's diagnostic center for population and animal health. ionised calcium (ica) was measured using an ion specific electrode and (oh)d was measured using a commercially available radio-immunoassay that has been validated for use in veterinary medicine. comparisons of outcome groups for age, ccecai, treatment, serum (oh)d and ica were performed using a mann-whitney u test or chi . logistic regression analysis was performed to determine possible risk factors for poor outcome. results: ccecai scores, age, and ica concentrations between the two groups were not significantly different. there was a significantly greater number of dogs treated with food alone in the group with good outcome ( / ) than in the poor outcome group ( / , p = . ). furthermore, median serum (oh)d concentration was significantly lower in patients with poor outcomes ( . nmol/l, range - nmol/l) compared to patients with good outcomes ( nmol/l, range - nmol/l, p = . ). using logistical regression, (oh)d serum concentration was a statistically significant factor for poor outcome (p = . ), with an increase of (oh)d serum concentration reducing the odds of having a poor outcome (odds ratio = . , % ci: . - . ). further studies are required to investigate vitamin d as a potential adjuvant therapeutic agent in ple patients. disclosures: no disclosures to report. campylobacter jejuni (cj), c. upsaliensis (cu) and c. helveticus (ch) are commonly isolated from dog and cat faeces but association with clinical signs is discordant or lacking. cj is a recognized human pathogen, cu is considered an "emerging" pathogen and ch is not considered pathogenic despite a high level of genetic similarity. recently, the greater wax moth, galleria mellonella, was described as an animal model of disease; these invertebrates have a high degree of functional and structural homology with the mammalian innate immune system. this study aimed to evaluate the pathogenic potential of cj, cu and ch using the galleria mellonella larvae model. twelve isolates of cj, of cu and of ch from dogs and cats were used for the inoculation of larvae. inocula were prepared by suspending isolates in phosphate-buffered saline (pbs) from which three -fold dilutions were made. each dilution was tested in duplicate sets of larvae. each larva was injected with - ll into the haemocoel via the last left pro-leg using g insulin syringes. controls consisted of pbs inoculated larvae and un-inoculated larvae. survival of larvae at °c in a h enriched microaerobic atmosphere was monitored for days postinjection. one subset of isolates was grown in mueller-hinton broth and used for the preparation of secretory products, and another grown on blood-agar and suspended in pbs for heat inactivation of minutes at °c for testing of whole-cell lysates and heat-stable insoluble and soluble components. the overall median survival of larvae was % with cj [iqr - ], % with cu [iqr - ], % with ch [iqr - ], % with pbs [iqr - ] and % for un-inoculated larvae [iqr - ]. a dose-dependent association was evident for each species with larval survival being similar between a low bacterial dose and pbs. larval survival presented a consistent pattern between species for medium and high bacterial loads; cj had a higher and faster larval death rate than cu and ch (p < . ), but no difference was observed between cu and ch (p = . ). there were no significant differences between species in any of the assays with secretory products, inactivated cells and soluble/insoluble cellular components. the observations within this invertebrate disease model support a varying pathogenic potential between the species studied that appears related to the (patho)biology of the species rather than their cellular components or metabolic products. the invertebrate animal model is promising in comparative pathogenicity studies. disclosures: no disclosures to report. a. grellet , s. dubois , a. feugier , c. girardet , s. magnan , v. andr eo , g. trombini , c.a. boehringer , j. suchodolski , j. steiner . royal canin, aimargues, france, veterinary department of the french army health service, suippes, france, gastrointestinal laboratory, texas a&m university, college station, tx, usa acute stress from medium or high duration high-intensity exercise has been reported to be associated with an increase in serum c-reactive protein (crp) concentrations, an important acute-phase reactant in dogs. however, the effect of exercise on fecal s a concentration, a biomarker of intestinal inflammation has not previously been evaluated in dogs. the goal of this study was to determine if moderate intensity short duration exercise causes an increase in crp and/or s a concentrations in dogs, potentially leading to misinterpretation of their results. thirty-seven adult military working dogs (german and belgian shepherd dogs; males; mean age = years [ . - . ]) were included in the study. fecal quality, fecal s a , and serum crp concentrations were evaluated just before and after standardized exercise ( minutes of bikejoring at a speed of km/h). fecal quality was evaluated based on a -point scale (from : liquid to : dry and hard feces). fecal s a and crp concentrations were assayed with previously validated elisa tests. data were analyzed with an anova test for repeated measurements (sas software). results are presented as medians and ranges. serum crp concentrations increased significantly after exercise (median before and after excercise mg/l [ - ] and mg/l [ - ] (p = . ). also, fecal s a concentrations were significantly higher after exercise compared with baseline concentrations ( ng/g [ - ] vs. ng/g [ - ], p = . ). no significant effect of exercise on fecal score was observed ( [ . - . ] before and after the exercise; p = . ). our study demonstrates that a moderate-intensity, short-duration effort performed by healthy army dogs causes significant increases in fecal s a and serum crp concentrations, as compared with baseline values, but within the respective reference intervals. therefore, a moderate exercise does not present a confounding variable in the interpretation of fecal s a or serum crp concentrations in healthy dogs. disclosures: this study was performed thanks the financial support of royal canin. imaging is an integral part of the work-up of canine gastrointestinal (gi) disease. radiography and ultrasonography are noninvasive modalities that can evaluate the bowel, but many findings lack desirable sensitivity or specificity. endoscopy directly visualizes gi mucosa, but is limited by the length of the endoscope and the need for general anesthesia, advanced training and expensive equipment. ambulatory light-based imaging (ali) is a new imaging modality that utilizes high-resolution cameras, a microprocessor, and led illumination to non-invasively visualize the gastrointestinal mucosa. ali is performed by oral administration of a fully automated device the size of a pill that is propelled by peristalsis. the aim of this study was to analyze image quality and gi transit times in a series of five client owned dogs undergoing ali. dogs were food-restricted for hour before and hour after capsule administration. capsules were retrieved and images were downloaded and analyzed. video clips of frames duration were obtained from the stomach; proximal, middle and distal small intestine; and proximal colon for assessment of image quality. internists rated the images on a scale of - ( = poor, = ex-cellent) based on clarity and resolution of images, and obscuration of the mucosa by fluid, bubbles or debris. scores for each region were compared using general estimating equation analysis. gastric and small intestine transit time were calculated based on visualization of passage of the capsule from the stomach to duodenum, and ileum to colon. clinical analysis of the entire video was performed by one of the authors. ali was successfully performed in / patients, with no adverse effects. average study duration was . ae . hour and mean image acquisition count was . ae . . gastric and small intestinal transit times were . ae . minute and . ae . minute, respectively. median (range) image quality scores were ( - ), ( - ) and ( - ), for the stomach, si and colon, respectively. image quality scores were significantly higher in the stomach and si than in the colon (p < . ). visualized lesions were consistent with gi ulcers ( dogs), inflammatory bowel disease ( dog), and bilious vomiting syndrome ( dog). one dog receiving chronic nsaids had a normal study. ambulatory light-based imaging resulted in good to excellent image quality throughout most of the gi tract. bowel preparation should be considered to enhance visualization of the colon. ali was safe and easy to perform in ambulatory dogs, and should therefore be considered in the work-up of canine gi disease. disclosures: drs. hardy and solomon are employed by infiniti medical. escg-p- establishment of a severity scoring system for outcome prediction in dogs with pancre-atitis. p.c. liu , f.r. wu , y.j. lee , b.l. su . graduate institute of veterinary medicine, national taiwan university, taipei, taiwan, national taiwan university veterinary hospital, national taiwan university, taipei, taiwan, institute of veterinary clinical sciences, national taiwan university, taipei, taiwan canine pancreatitis is the most common exocrine pancreatic disorder. the prognosis of canine pancreatitis is variably and no logistic regression constructed severity scoring systems are available. four hundred and thirty nine dogs diagnosed as pancreatitis with acute onset of compatible clinical signs, a positive snap Ò cpl[trademark] test, and/or associated abdominal ultrasonographic abnormalities between january and december were presented at national taiwan university veterinary hospital (ntuvh). one hundred and three dogs hospitalized with complete medical therapy and outcomes were selected for further analysis. the dogs were divided into survival (n = ) and non-survival (n = ) groups. forty-seven parameters including signalment, clinical signs, physical examinations, clinicopathological examination, complications and concurrent diseases were analyzed and compared between the two groups. logistic regression analyses were performed in this study. variables with p ≤ . were considered for further analyses. the mortality in this study was . %. age, heart rate, respiratory rate, white blood cell count, albumin, bun, creatinine, potassium, presence of systemic inflammatory response syndrome (sirs) and presence of oliguria or anuria were selected for constructing the scores. continuous variables outside the reference interval were separated into quartiles to yield quartile-specific odds ratios (ors) for survival. based on the integer value of the or, the scoring system was then developed by incorporating weighting factors assigned to each quartile. a predictive total score was calculated for each dog by summing all weighting factors. the total scores of each dog ranged from to . the severity scores in this study achieved an area under the receiver operating characteristic (auroc) of . . the optimal cut-off point for discriminating outcome was . with a sensitivity of . % and specificity of . %, respectively. the mortality was . % with a score ≥ , whereas . % with a score ≤ . there was a significant difference (p < . ) between the two groups seperated by the cut-off point. the severity scoring system of this study provides a reliable and clinical applicable method to predict clinical outcome in dogs with pancreatitis. disclosures: no disclosures to report. glucocorticoids (gcs) are known for their anti-inflammatory and immunmodulatory properties and are therefore often used in the therapy of canine inflammatory bowel disease (ibd). it was recently shown that endogenous gcs are also produced in the intestinal epithelium of men and mice and influence the gastrointestinal immune system in case of inflammatory or neoplastic conditions. thus, the aim of this project was to prove that gcs can be produced or metabolized in the canine intestinal epithelium. five healthy beagle dogs were included into this prospective study. all dogs were clinically examined, given a clinical score using the canine ibd activity index (cibdai) scoring system, also gastrointestinal endoscopy was performed. mucosal biopsy specimens from duodenum were examined histologically from a board certified pathologist using the wsava grading. biopsy incubation of - endoscopical mucosal biopsies in tissue culture medium with h-labeled progesterone in the absence of any stimulation was performed. the mean age of the included dogs was . + . years, the mean weight was . + . kg. all beagle dogs had a mean clinical score of + . the mean wsava scoring was + . . after hours, supernatant was harvested and radioactive progesterone metabolites formed were detected using high performance liquid chromatography plus liquid scintillation counting. in all dogs the h-progesterone was metabolized into various steroid species, nevertheless a local production of cortisol could not be proven. in summary, it could be shown that precursors of gcs can be metabolized by healthy canine intestinal mucosal tissue. disclosures: no disclosures to report. we studied the relationship between pancreatitis and cardiac injury in dogs and cats. previously, we validated a cardiac troponin i (ctni; vet j : - , ) assay for sensitive and specific detection of cardiac injury in domestic animals. we found various non-cardiac diseases of dogs and cats were associated with cardiac injury detected by serum cardiac troponin i, including some cases of pancreatitis. also, we validated the dggr-lipase assay for cost-effective, sensitive and specific detection of pancreatitis in dogs and cats (vet clin path :e - , ; :e - , ). herein, we tested the hypothesis that pancreatitis was associated with cardiac injury. ctni was measured by advia centaur tni-ultra assay; dggr-lipase by the randox colourimetric assay. we retrospectively analysed data from dogs and cats admitted to ucd veterinary hospital in which both ctn and lipase had been measured. upper limit of reference range for lipase in dogs is u/l; we consider - indicative of mild pancreatitis, - moderate, and > as marked. upper limit of reference range for lipase in cats is . reference range for ctni is < . ug/l for dogs and cats. we consider . - . indicative of mild cardiac injury, . - as moderate, and > . as marked. dogs and cats had both lipase and ctni measured. seventy-eight dogs had normal troponin; had normal lipase and had normal lipase and normal ctni. dogs ( %) had pancreatitis as indicated by increased lipase. in ( %), pancreatitis was mild, in ( %) it was moderate, and in ( %) it was marked. sixty-seven of dogs had increased ctni: mild in ( %), moderate in ( %), and marked in ( %). cardiac injury in dogs with pancreatitis was absent in %, mild in %, moderate in %, and marked in %. of cats had normal ctn; had normal lipase. of cats had pancreatitis, severely in . lipase and ctni was correlated (r = . ) for dogs and cats. we conclude that both pancreatitis and cardiac injury, as indicated by high-sensitivity and high-specificity assays randox-dggr-lipase and centaur-ctni, respectively, are not uncommon in veterinary hospital cases. we confirm and extend our previous work. pancreatitis in dogs and cats is typically associated with cardiac injury. severities of pancreatitis and cardiac injury are correlated. for~ % of dogs and cats with pancreatitis, cardiac injury is moderate to marked. disclosures: no disclosures to report. intracellular colonization may serve as a protected niche where helicobacter spporganisms evade effective treatment, contributing to recolonization. confocal endomicroscopy (cem) is an endoscopic modality allowing in vivo gastrointestinal imaging at high resolution; and has aided real-time identification of helicobacter pylori and intracellular and mucosally associated bacterial. in dogs, non-helicobacter pylori-helicobacter (nhph) are described intracellularly. the objective of this study was to determine the utility of cem to identify nhph in dogs compared with other diagnostic modalities; and to assess its ability to identify intracellular organisms. fourteen clinically healthy dogs underwent standard gastroduodenoscopy followed by cem using topical acriflavine. images were obtained using cem at a minimum of five sites within the stomach. endoscopic pinch biopsies were obtained for histopathology, polymerase chain reaction (pcr) and fluorescence in situ hybridisation (fish). methodologies were compared for their sensitivity in detecting the presence and distribution of nhph and their ability to identify intracellular organisms. cem provided high quality images allowing in vivo identification ofnhph in dogs, as did fish post-procedure analysis. standard histopathology identified nhph in only . nhph were identified within the superficial gastric mucus, and gastric pits. distribution throughout the stomach was diffuse and multi-focal. cem findings correlated with fish and pcr, however only fish enabled identification of intracellular nhph which were present in of dogs. cem provides in vivo histology images and is capable of identifying nhph during gastroscopy, but is unable to identify intracellular organisms using the current fluorophore protocol. nhph in the canine stomach are commonly identified intracellularly. disclosures: dr sharman has shares in optiscan imaging pty ltd. chronic enteropathies (ce) and exocrine pancreatic insufficiency (epi) can both cause hypocobalaminemia in cats. current supplementation protocols for cobalamin in cats call for repeated parenteral injections. in humans, several studies have reported equal efficacy of oral administration of cobalamin. there is also evidence that oral supplementation is effective in dogs with hypocobalaminemia. recently, it has also been reported that oral cobalamin substitution restores normocobalaminemia in healthy elderly cats. the purpose of this retrospective case series was to evaluate whether oral cobalamin supplementation can restore normocobalaminemia in hypocobalaminemic cats with chronic enteropathies. a computerized database search for cats treated at evidensia specialist animal hospital, helsingborg, sweden during - was performed. inclusion criteria were cats with symptoms of ce, an initial serum cobalamin concentration below pmol/l (reference interval: - pmol/l) and daily oral treatment with cyanocobalamin ( mg/tablet; ⅛-¼ tablet/cat daily). follow-up serum cobalamin concentration was measured - days after initiation of daily oral cobalamin supplementation. thirteen cats aged - years (median ) of different breeds met the inclusion criteria. presenting complaints included vomiting ( / ), anorexia ( / ), diarrhea ( / ), weight loss ( / ), and lethargy ( / ). increased pancreas specific lipase (spec fpl Ò ) serum concentrations were reported in / cats and / had increased serum alanine transaminase activity. feline serum trypsin like immunoreactivity (ftli) was determined in / cats revealing results within the reference interval. all cats had an abdominal ultrasound, / had changes related to the gastrointestinal tract such as mild-moderate thickening of the small intestinal wall, thickening of the muscularis layer, poor definition of intestinal wall layers, and/or enlargement of the mesenterial lymph nodes, histopathology was performed in / cats, revealing small intestinal inflammation in five cats and small intestinal lymphoma in one. serum cobalamin increased in all cats with treatment. the concentration difference ranged from to pmol/l (mean: pmol/l). mean (aestandard deviation) serum cobalamin concentrations were (ae ) pmol/l before and (ae ) pmol/l after supplementation. this difference was statistically significant (p < . , paired t-test). our results suggest that oral cobalamin supplementation is effective in normalizing serum cobalamin concentrations in cats with various enteropathies. prospective studies are warranted comparing cellular cobalamin status in cats being treated with parenteral or oral cobalamin supplementation. disclosures: no disclosures to report. pulmonary thromboembolism (pte) is observed in dogs with idiopathic-inflammatory-bowel disease (ibd) and particularly with protein-losing enteropathy (ple). hypercoagulability has been attributed to antithrombin (at) loss although the pathogenesis is likely to be more complex. in humans, where venous thromboembolism (te) is a wellrecognised complication of crohn's disease and ulcerative colitis, the pathogenesis of te is still not completely understood. derangements in procoagulant and anticoagulant factors have been demonstrated, including increased circulating procoagulant microparticles (mps). the aim of this pilot study was to evaluate mp-procoagulant activity in the plasma of dogs with ibd and ple using a functional elisa assay (zymuphen-mp-activity, aniara). we hypothesised that all dogs with ple and a subset of dogs with ibd but without ple would have increased levels of circulating mps. the study group consisted of dogs with ibd, including with ple. diagnosis was based on compatible clinical and histopathology and exclusion of other causes of chronic gastrointestinal disease. ple was defined as ibd plus hypoproteinaemia (serum total protein < g/l) and hypoalbuminaemia (serum albumin < g/l). pte was diagnosed in one dog with ple, and suspected in a second. a control group comprised healthy dogs undergoing blood sampling for reasons unrelated to the study including blood donor screening (n = ) and health assessment (n = ). dogs were considered healthy based on owner evaluation, physical examination, haematology and serum biochemistry. median mp procoagulant activity in dogs with ibd was . nm (range . - . ) compared with . nm (range . - . ) in the control group. median mp activity in ple dogs was . nm (range . - . ) compared with . nm (range . - . ) in non-ple ibd dogs. using kruskal-wallis test for nonparametric data and dunn's multiple comparisons test the groups were not statistically different. interestingly, mp-procoagulant activity value in the dog with documented pte was . nm; in the dog with high clinical suspicion for pte, mp-procoagulant activity was . nm. the highest mp-procoagulant activity was detected in a healthy control dog, raising concerns for pre-analytical or sampling error. removing this measurement had no impact on statistical analysis, which remained nonsignificant. mp-procoagulant activity > nm is considered clinically relevant in humans. employing a similar cut-off, / of controls, / of ibd and / of ple group would be defined as having increased levels of circulating mps. further studies are required to fully evaluate the clinical relevance and diagnostic potential of mp evaluation. disclosures: no disclosures to report. the intestinal microbiota is increasingly linked to the pathogenesis of chronic enteropathies (ce) in dogs. while imbalances in duodenal and fecal microbial communities have been associated with mucosal inflammation, relatively little is known about alterations in mucosal bacteria seen with ce involving the ileum and colon. the aim of the present study was to use fluorescence in situ hybridization (fish) techniques to investigate the composition and spatial organization of mucosal microbiota in endoscopic biopsies obtained from dogs with ce and controls. tissue sections from the ileum and colon from dogs with inflammatory bowel disease (ibd), dogs with granulomatous colitis (gc), dogs with intestinal neoplasia, and controls were studied by fish targeting the s rrna genes of total bacteria, group-specific organisms, and individual bacterial species shown to be relevant in human ibd. the numbers of mucosal bacteria were analyzed using generalized linear models for each of the colon and ileum tissues, with spearman's rank correlation coefficients used to test the correlation between mucosal microbiota and inflammatory (cib-dai score, histopathology) indices. the ileal and colonic mucosa of healthy dogs and dogs with ce was predominantly colonized by bacteria localized to free and adherent mucus compartments. dogs with ce harbored more (p < . ) mucosal bacteria belonging to the clostridium-coccoides/eubacterium rectale group, bacteroides, enterobacteriaceae, and escherichia coli versus controls. within the ce group, ibd dogs had increased (p < . ) enterobacteriaceae and e. coli bacteria attached onto surface epithelia or invading within the intestinal mucosa. bacterial invasion with e. coli was present in the ileal and colonic mucosa of dogs with gc (p < . ). dogs with intestinal neoplasia had increased (p < . ) adherent (total bacteria, enterobacteriaceae, e. coli) and invasive (enterobacteriaceae, e. coli, and bacteroides) bacteria in biopsy specimens versus all other groups. increased numbers of total bacteria adherent to the colonic mucosa were associated with clinical disease severity (cibdai score) in ibd dogs (p < . ). these results indicate that histopathologic lesions of canine ce are associated with different populations in ileal and colonic mucosal microbiota. these spatial, segment-specific structure and differential response of select bacterial groups to intestinal inflammation may be pivotal regarding the functional consequences of these alterations in the pathogenesis of canine ce. disclosures: no disclosures to report. abdominal girth is used as an indicator of human adiposity, with such measurements being made by tape measure. given concerns in precision and accuracy of repeat measurements, some tape measure designs have inbuilt mechanisms to improve consistency. although body condition scoring is the most common method of assessing adiposity in dogs, zoometric systems have also been developed requiring the use of a tape measure. however, the precision and accuracy of such zoometric measurements are not known. the aim of this study was to determine the precision and accuracy of different types of tape measure for a variety of dimensional measurements. a variety of length (head, forelimb, hindlimb) and circumferential (neck, thorax, and abdomen) were made using three different tape measures, two of which were designed to improve precision (standard tape; myotape tm and gulick ii tm ). to assess intra-operator variability, measurements were taken for consecutive days from healthy dogs; to assess inter-operator variability, operators independently took measurements from a group of dogs of various breeds and sizes. for intra-operator comparisons, precision was good overall (coefficient of variation [cv] ≤ % for all measurements). for interoperator comparisons, precision was more variable and, although reasonable on average (mean cv - %), it varied depending upon tape measure type (p = . ; greatest for standard tape measure, least for gulich ii tm ), and could be highly variable for some measurements in individuals dogs (maximum cv % for head measurements with standard tape measure). significant differences also existed in the absolute results of circumferential measurements taken by the different tape measure types (neck p = . ; thorax p < . ; abdomen p < . ). finally, significant operator differences were also evident for some measurements (head p = . ; hindlimb p = . ), but not for others (forelimb p = . ; neck p = . ; thorax p = . ; abdomen p = . ). in summary, although precision for individual operators making zoometric measurements is good, significant inter-operator and tape type differences exist. these results have implications for systems using a range of zoometric measures to assess adiposity. in order to ensure precision and accuracy, it is recommended that the same operator take all measurements with the same type of tape. disclosures: the study conducted was not supported by a research grant. ajg's readership is funded by royal canin; ajg has also received financial remuneration and gifts for providing educational material, speaking at conferences, and consultancy work; slh's post at the university of liverpool is also funded by royal canin. koizumi , m. noda , c. shimokawa , a. kusumi , t. kobayashi , t. watari , k. otsuji . teikyo university of science, tokyo, japan, grace animal hospital, tokyo, japan, nihon university, fujisawa, japan body condition score (bcs) is a method that is commonly used in the diagnosis of nutritional status in small animals. however, this method is subjective due to its sensory evaluation. therefore, the improvement of the precision of the bcs diagnosis is expected. our previous study has shown that the bcs model that we created improved the precision of the bcs diagnosis ( ). however, a palpation site was not identified. a palpation site must be the site where thickness of subcutaneous fat is able to capture for measuring animal's obesity status. therefore the objective of this study was to find a remarkable body site of the changes with obesity status using ultrasonic diagnostic equipment. nine dogs which varied in the percent of body fat were used in this study. the percent of body fat was measured by a body fat analyzer for dog (kao). the image analysis of a palpation site was evaluated using echo, xario ssa- a (toshiba) which attached to a linear probe. the measurement points were , and o'clock positions on the ribs of t , t and t . the distance (d) from skin surface to the rib was measured in the echogram. the distance (l) from scapula to ilium was measured to offset the difference in physique by dog breeds. the d/l was used to compare relative value of the quantity of fat at each measurement point. bcs of dogs which used in this study were from bcs of to bcs of . there were no dogs in bcs of and bcs of . a statistically significant correlation was found between bcs and d/l value. the d/l value increased in order of t , t and t in bcs of and . this suggests that the thickness of subcutaneous fat in the chest is thicker at the head side than the tail side. also, as for the d/ l value from back to abdomen, the highest value was found at the position of : and : . this tendency was the most remarkable in bcs of but no difference in the d/l value was recognized in the dogs in bcs of . in conclusion, the position of : or : on the t is the suitable palpation point at the chest. ( ) k. otsuji, m. suzuki, n. furukawa, n. kobayashi, a. koizumi, a. kusumi, t. kobayashi efficacy of the body condition score (bcs) model in the bcs diagnosis wsava proceeding p , disclosures: no disclosures to report. body condition score (bcs) is a method that is commonly used in the diagnosis of nutritional status in small animals. bcs has been recognized as one of the screen method of nutrition diagnosis by american animal hospital association in . however, this method is subjective due to its sensory evaluation. therefore we made a bcs model to increase the precision of the bcs diagnosis and have shown the efficacy of the bcs model ( ). however, the prototype model which we have reported before tended to have higher bcs than a target bcs. therefore, we improved the bcs model in this study. sixty seven dogs which varied in the bcs were used in this study. body fat percentage was measured by using a body fat analyzer for dogs (kao healthlab bif- ). the bcs model was improved by using several rubber sheets. relative hardness of stacking rubber sheets in each bcs was measured by durometer mj-dua-c (satotec tokyo, japan). bcs diagnosis of dogs was performed by pet owner by using the bcs model. bcs of represents the most hard in the bcs model and the hardness decreased linearly and it was the lowest in of bcs. these values were as expected. high correlation was recognized between bcs and body fat percentage. these results suggested the efficacy of bcs model. however, the body fat percentage in the dogs diagnosed as bcs of was higher than body fat percentage which has been reported in the previous paper. there were no dogs with the body fat percentage < % which were diagnosed as bcs of . we need more study in future to make clear the difference of body fat percentage between our data and date of the previous research. the completion of this bcs model will help provide the precision of nutritional diagnosis in dogs. ( in humans the metabolic syndrome (ms) is a well-recognised and extensively studied entity that comprises obesity, hypertension, dyslipidaemia, and glucose intolerance. it is associated with an increased risk of cardiovascular diseases and diabetes. recently, human ms criteria were adapted for dogs to define the condition of obesity-related metabolic dysfunction (ormd). it was observed that ormd was associated with increased circulating insulin and decreased adiponectin concentrations, suggesting that in dogs, as in humans, there are links between obesity, ormd, and associated diseases, although pathogenetic mechanisms and health significance for dogs remain unknown. the main aim of the present study was to compare plasma proteomes of obese dogs with and without ormd, so as to investigate the mechanisms associated with canine ormd and their possible significance in the health status. eight obese dogs referred for weight management at the royal canin weight management clinic, university of liverpool participated in the study. clinical assessments included physical examination, body condition scoring, blood pressure measurement and routine clinicopathological analysis. surplus plasma was used in proteomic analysis. samples were first treated with proteominer for thedepletion of high-abundance proteins and subsequently analysed by using -de dige methodology. of the eight dogs in the study, dogs had ormd and dogs did not. image analysis and further statistical analysis allowed identification of spots with differential expression concentration between dogs with and without ormd. among the spots, were over-expressed and were down-expressed in dogs with ormd than in dogs that did not presented ormd. although the results of the present study are preliminary and still the identification of the spots is up to be performed, the observed datareveal that dogs with ormd present alterations in their plasma proteomes that could be responsible for the development of ormd-related pathologies. disclosures: the study was funded by waltham. ajg's readership is funded by royal canin; ajg has also received financial remuneration and gifts for providing educational material, speaking at conferences, and consultancy work; slh's post at the university of liverpool is also funded by royal canin. vb is an employee of royal canin and pjm is an employee of wal-tham. the aim of the study was to assess the diagnostic value and the discrimination potential between the normal heart size and microcardia or cardiomegaly of a method which calculates the cardiothoracic ratio (ctr) using area measurement, compared to the vertebral heart scale method (vhs) used as reference for the cardiac size, in dogs. one hundred-nine dog x-rays were accepted into study. the patients belonged to small and medium size breeds, fourty-seven were males and sixty-two females with age between and years. the analogic x-rays were scanned and transferred to a computer where the vhs and ctr was calculated for each patient with a commercial software and the data was collected and processed in a statystical analysis software. the patients were distributed into groups by respiratory phase and heart size. there was a low correlation between the vhs and ctr (r = . ), but statistically significant (p? . ). a good correlation was obtained between vhs and ctr in microcardia, normal heart size and cardiomegaly groups (p < . ). furthermore, between the ctr in dogs with microcardia and those with normal cardiac size, as well as between ctr in dogs with normal cardiac size and those with cardiomegaly, a significantly statistic difference (p < . ), respectively (p < . ), was obtained. among the groups distributed by respiratory phase and vhs, a statistically significant difference was obtained only between normal cardiac size and cardiomegaly during inspiratory phase groups (p > . ). for the x-rays taken in inspiratory phase, a cutoff of . had a sensitivity of % and a specificity of % for diagnosing cardiomegaly. the ctr can be considered a valid method being able to discriminate between the patients with microcardia and cardiomegaly from those with normal heart size. moreover, it was found that a ctr over the cutoff of . , mesured during inspiratory phase is a good predictor for cardiomegaly. key words: cardiac, cardio-thoracic ratio, dog, x-ray. disclosures: no disclosures to report. the canine cardiac conduction system is modified by anatomical and functional adaptations of the maternal heart during gestation. however, it is not clear if these changes persist or are modified after parturition. therefore, the aim of this study was to describe canine electrocardiographic features during the course of normal puerperium. twenty healthy pure-bred, - ( . ae . ) year-old, weighing . - kg ( . ae . ) bitches were included in this study. all the animals whelped healthy puppies at term which were weaned on day after parturition (day ). all the dogs were electrochardiographically evaluated on days À , , , , , , and . mean electrical axis (mea; degrees), p wave amplitude (pa; mv) and duration (pd; ms), p-r interval (pr; ms), qrs complex amplitude (qrsa; mv) and duration (qrsd; ms), q-t interval (qt; ms), and s-t segment (st; mv) were calculated at mm/s of velocity. the rr interval immediately preceding each complex was recorded and qt interval was corrected (qtc) by van de water formula [qtc = qt- . (rr- )]. later, lead ii was recorded at mm/s to analyze heart rate (hr; bpm) and cardiac rhythm (cr; normal sinus rhythm or sinus arrythmia). values of hr, mea, pa, pd, pr, qrsa, qrsd, qt, rr and qtc were analyzed by anova for repeated measures followed by tukey test. cardiac rhythm was analyzed by chi square test (spss . , spss inc. chicago, il, usa). p < . was considered significant. during the study period, hr (p < . ) and qtc (p < . ) progressively decreased, while rr (p < . ) and pa increased (p < . ). qrs complex amplitude diminished in the second week after parturition and then increased during the following weeks (p < . ). mean electrical axis shifted to the right during this period (p < . ). on day À , most of the bitches presented normal sinus rhythm in contrast with day , in which most of the bitches presented sinus arrhythmia (p < . ). from day onward, all the bitches showed sinus arrhythmia. p wave duration, pr, qrsd, qt and st remained unchanged during puerperium. it is concluded that most electrophysiological adaptive changes of canine gestation reverted during normal puerperium. the present study contributes to the understanding of canine cardiac physiology during this reproductive stage. disclosures: no disclosures to report. esvc-p- echocardiographic assessment of pregnant queens. p.g. blanco, r. rodr ıguez, a. carranza, a. rube, r. vercellini, p.r. batista, m. t ortora, c. gobello. national university of la plata, la plata, argentina cardiovascular adaptation during gestation guarantees an appropriate development of the fetuses and maternal cardiovascular maladaptation is highly correlated with adverse pregnancy outcome. while, the hemodynamic changes occurring during canine pregnancy have been described there is scarce information concerning maternal cardiac variations during feline gestation. thus, the aim of this study was to describe cardiac morphology and systolic function variations during normal feline pregnancy. eighteen pregnant queens were echocardiographically evaluated (toshiba nemio xg, japan, mhz transducer) every days from day (defined as day of mating) to parturition. left ventricular dimensions were measured in the short axis view, during mmode tracing. shortening fraction was calculated as (lvdd À lvds)/lvdd to assess systolic function. stroke volume (ml) was calculated as the product of the velocity time integral (measured by pulsed-wave doppler) and the cross-sectional area of the aorta. cardiac output (l/minute) was calculated as the product of stroke volume and heart rate (bpm) derived from electrocardiographic monitoring. uterine artery resistance index (ri) was obtained by doppler ultrasound. all the parameters were analyzed by repeated measures anova. all the queens delivered healthy kittens at term. throughout the study period, interventricular septum in diastole (p < . ) and systole (p < . ) and left ventricular diameter in diastole (p < . ) augmented during gestation. shortening fraction (p < . ), cardiac output (p < . ) and maternal heart rate (p < . ) also increased up to parturition. conversely, uterine artery resistance index decreased in the same period (p < . ). it is concluded that cardiac structure and function varied during normal pregnancy in these queens. cardiac eccentric hypertrophy, systolic function and cardiac output increases appear to be the consequences of the hemodynamic modifications occurring during pregnancy. the assessment of maternal cardiovascular function may prove a useful screening tool to detect pregnancy complications in feline reproduction. disclosures: no disclosures to report. tricuspid annular plane systolic excursion (tapse) is an echocardiographic measure that allows to assess right ventricular systolic function. it has been described reference values for tapse in normal adult dogs, but there is no reference to influence of age in tapse in dogs. this influence has been reported in humans. thus, the goal of this study is to determine the reproducibility of the measure tapse in normal dogs and to determine the relationship between tapse and age in healthy beagle dogs. tapse was measured from an m-mode recording of the lateral aspect of the tricuspid valve annulus obtained through a left parasternal apical -chamber view. tapse values were averaged from measurements on consecutive beats during sinus rhythm. the measurements were recorded by two different persons (c-v, a.; m-m f.) with different grade of experience in canine echocardiography studies. all patients had a complete two-dimensional and doppler study using an envisor chd (philips Ò ) ultrasound system. twenty-three healthy beagles were used. the study was approved by the ethical committee of veterinary medicine service of las palmas de gran canaria university (spain) and it was carried out in accordance with the current european legislation on animal protection. these dogs were divided in three different groups according to age: group included twelve dogs under years, group included three dogs between and years, group included eight dogs older than years. we analyzed differences between groups using non-parametric (kruskal wallis and wilcoxon scores [rank sums]) test. there were no differences with respect to sex. dogs in group presented higher tapse values than group or ( . ae . cm vs . ae . cm vs . ae . cm; p < . ). statistic intra-observer and inter-observer agreement using the intraclass correlation coefficient was . (p < . ). this study showed that tapse measurement is easily obtainable with a standard echocardiography system, and has adequate interobserver agreement. this study showed higher values of tapse in normal young dogs with respect to older dogs. these results are similar to the results obtained in humans, and could reflect a less effective right ventricle with age. the values presented should be taken with caution due to the relatively small number of patients included. it may also be necessary to validate results in future studies with a second independent sample of dogs of other races. disclosures: no disclosures to report. tetralogy of fallot (tof) is a congenital heart disease characterized by abnormalities, i.e., pulmonic stenosis, ventricular septal defect (vsd), aortic overriding and secondary right ventricular hypertrophy, caused by anterior deviation and abnormal septation of the conal septum during the embryonic period. few studies have reported the hemodynamic consequences and clinical outcome of tof in small animals. the objective of this retrospective study was therefore to document the epidemiological, clinical, echo-doppler findings, and survival, in a canine and feline population with tof. the case records of animals diagnosed with tof by combined use of echocardiography and doppler examination were reviewed ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . tetralogy of fallot was identified in animals ( dogs, cats). the most commonly represented breeds were terriers for dogs ( / , . %), and domestic shorthair for cats ( / , . %). most included animals ( / , . %) were clinically affected at the time of diagnosis. pulmonic stenosis was characterized by a variable systolic doppler-derived pressure gradient both in dogs (median [range] mmhg ) and cats ( mmhg ), and associated with hypoplasia of the pulmonary trunk in one third of the cases ( . %). most vsd were large, with a median vsd: aorta ratio of . [ . - . ] in dogs and . [ . - . ] in cats. median age at death from cardiac cause was . months [ . - . ] without significant difference between dogs and cats (p = . ). these results suggest that in both cats and dogs tof-related death occurs predominantly in young adult animals with major hemodynamic consequences at the time of diagnosis. disclosures: no disclosures to report. the aim of this study was to assess whether and how radiographic and echocardiographic cardiovascular variables differ across age bands of healthy cats. a cohort of clinically healthy cats were categorized into three groups: adolescent-adult ( . - years; n = ), middle-aged ( - years; n = ), and geriatric ( - years; n = ). all cats underwent a full physical examination, a complete blood count, routine biochemical profile, a baseline serum total thyroxine concentration, auscultation, noninvasive blood pressure measurements, thoracic radiography, electrocardiography, and echocardiography. cats with hypertension, hyperthyroidism, cardiac, or renal disease were excluded from the study. body weight, body condition score, systolic blood pressure, heart rate, and all echocardiographic indices were similar across the three groups. the mean (aestandard deviation [sd] ) vertebral heart scale (vhs) value obtained for the geriatric group ( . ae . ) was significantly greater than that obtained for the adolescent-adult group ( . ae . ; p = . ). the mean ratio of the distance between the cardiac base and dorsal sternum to thoracic cavity height at the point of the cardiac base was significantly less in the middle-aged ( . ae . ) and geriatric ( . ae . ) groups than in the adolescent-adult group ( . ae . ; both p < . ). the mean angle between the cardiac long axis and the body axis was significantly smaller in middle-aged ( . ae . °) and geriatric cats ( . ae . °) than in adolescent-adult cats ( . ae . °; both p < . ). the mean angle between the cardiac long axis and the sternum of middle-aged ( . ae . °) and geriatric cats ( . ae . °) was significantly smaller than that in adolescent-adult cats ( . ae . °; p = . and p = . , respectively). additionally, the degree of undulation of the thoracic aorta correlated positively with age (r = . , p = . ). these findings suggest that differences in the horizontal alignment of the heart, thoracic-aorta undulation, and vhs in healthy geriatric cats, relative to observations in younger cats, can be considered to be age-related. disclosures: no disclosures to report. the aim of this study was to investigate the presence of pulmonary hypertension (ph) in young cats affected by single or mixed lungworm infections. twenty-three cats infected with lungworms were examined at the veterinary teaching hospital of teramo, italy, in - . animals underwent to a complete physical examination and to two-or three-views radiographic analysis of the thorax. a minimum database (i.e. cbc, serum biochemistry, serology for fiv antibody and felv antigen) was obtained for each patient. nine cats were excluded for concomitant diseases, while cats were included in the study. microscopic identification of parasites was confirmed by molecular tests and all cats received an anthelmintic treatment. a single infection by aelurostrongylus abstrusus was diagnosed in eleven cats, while three cats had a troglostrongylus brevior infection either alone or in combination with a. abstrusus. transthoracic echocardiography was performed using an ultrasound unit with a mhz phased array transducer. no structural abnormalities of the tricuspid valve and sign of pulmonary stenosis were detected. the two-dimensional and m-mode echocardiography showed a cardiac involvement in three cats. one cat, infected by a. abstrusus and t. brevior showed a mild systolic tricuspid regurgitant jet with color doppler of . m/s, while another a. abstrusus-infected cat, had mild tr of . m/s with a mean paps of mmhg which resolved within weeks after therapy. one cat diagnosed with troglostrongylosis, showed a marked right-sided cardiac enlargement of mm, and a large systolic tricuspid regurgitant jet with a tr peak velocity of . m/s recorded at continuous-wave doppler via a color doppler echocardiography. the minimum pressure difference between the right ventricle and the right atrium was estimated mmhg and the paps was at least mmhg. the echocardiographic and doppler evidence of mild ph persisted at further examination performed until months after diagnosis. ph is rare in cats, despite cases of reversible ph are known in cat aelurostrongylosis. in this study the first case of irreversible ph infection in a cat affected by t. brevior is presented and this finding further supports the high pathogenicity of troglostrongylosis, especially in young patients. in cats with lungworm infection, possible cardiovascular complications must be taken into account and these infections should be always considered in the differential diagnosis in cats with cardiorespiratory signs. disclosures: no disclosures to report. ventricular function by conventional echocardiography and speckle tracking imag-ing although uncommonly assessed in veterinary cardiology, a right ventricular (rv) function has been shown to be an important prognostic determinant of many congenital and acquired heart diseases in human patients. our group has already demonstrated that two-dimensional ( d) color tissue doppler imaging provides a non-invasive evaluation of systolic and diastolic rv function in the awake dog with adequate repeatability and reproducibility. b however, other noninvasive ultrasound imaging variables reflecting rv function need to be further investigated, particularly in correlation with pulmonary arterial pressure (pap) values and left ventricular (lv) function. the aim of this prospective study was therefore to assess several indices of systolic and diastolic rv function using conventional echocardiography and speckle tracking echocardiography (ste) in healthy awake dogs of different breeds with documented systolic pap (spap) and lv function (lv ejection fraction and global lv systolic strain assessed using the simpson's derived method of disks and ste, respectively). imaging rv tested variables included tricuspid annular plane systolic excursion (tapse), right fractional area change (rfac, %), ste longitudinal systolic strain of the rv free wall (rvfw, %) and of the whole rv (i.e., global rv strain, %), ste longitudinal systolic strain rate (sr, s À ) and diastolic early:late sr ratio. additionally, d-guided m-mode ventricular measurements included the end-diastolic rv:lv diameter ratio (rvdd: lvdd) and the end-systolic rvfw:lvfw ratio. correlations between imaging variables were calculated by using spearman's correlation coefficients. means of age and body weight (aesd; range) of the study population were . years (ae . ; . - . ) and . kg (ae . ; . - . ), respectively. no correlations were found between rv morphological variables (i.e., rvdd:lvdd and rvfw:lvfw ratios) and all indices of systolic and diastolic rv function. global rv strain (mean ae sd = . ae . %) and rvfw strain ( . ae . %) were positively correlated (p < . ) with rfac ( . ae . %, r = . and r = . , respectively), and negatively correlated (p < . ) with spap ( . ae . mmhg [ . - . ], r = À . and r = À . , respectively). spap was also negatively correlated with the tapse:body weight ratio and systolic sr (r = À . and À . respectively, p < . ). there was no correlation between indices of lv function and ste indices of rv function, and no correlation either between ste rv indices of systolic function and the diastolic early:late sr ratio. in conclusion, ste provides a rapid and non-invasive evaluation of rv function that may be used for clinical investigations in canine cardiology. doppler-derived +dp/dt and -dp/dt from mitralregurgitation are considered indexes for assessment of systolic and diastolicfunction respectively, that have less load dependence than the ejection phaseindexes. this study aimed to determine correlation between doppler-deriveddp/dt and other systolic and diastolic echocardiographic indexes, and if theycan be used to identify dogs with and without remodeling, with or withoutcongestive heart failure (chf) and for evaluation of chronic mitral valvedisease (cmvd) severity. fifty-seven dogs with cmvd (stages b , b , c+d) wereincluded prospectively in an observational cross-sectional clinical study anddistributed in groups regarding the presence of remodeling and chf, to evaluate+dp/dt and -dp/dt, and distributed according to tdi-diastolic pattern tocompare Àdp/dt. group c+d ( mmhg/s, p -p = - ) had +dp/dt significantly lower compared to b ( mmhg/s, p -p = - ) and b ( mmhg/s, p -p = - ) (p = . ). groupc+d also had lower Àdp/dt, compared to b ( . mmhg/s ae . and mmhg/s ae . ; p = . ). dogs with chf compared to those without chf, presented lower +dp/dt ( mmhg/s, p -p = - ; mmhg/s, p -p = - ; p = . ) and Àdp/dt ( . mmhg/ s ae . ; mmhg/s ae . ; p = . ). regardingdiastolic function, Àdp/dt was lower for the restrictive pattern group ( . mmhg/s ae . ) compared to those without diastolic dysfunction, ( mmhg ae . ), delayedrelaxation ( mmhg ae . ) and pseudonormal patterns ( mmhg ae . ) (p < . ).when +dp/dt< mmhg/s, the post-test chance for the dog with cmvd to havechf is twice the chance than not having it. for Àdp/dt< mmhg/s theposttest chance of having chf is eight times higher than not having it. in conclusion, doppler-derived +dp/dt and Àdp/dt may contribute respectively, for systolic and diastolic assessment ofdogs with cmvd. disclosures: no disclosures to report. pulmonic stenosis (ps) is one of the most common congenital heart defects seen in veterinarycardiology practice. pulmonary balloon valvuloplasty (pbv) is considered to be the treatment of choice for dogs withsevere stenosis. whether dogs with moderate stenosis benefit from pbv remains unclear, and variables such as degree of hypertrophy, valve morphology, amount of tricuspid insufficiency and presence or absence of clinical signs aregenerally used when recommendations are made to pet owners. in this study we report the effect of valve type on pbv outcome in dogs treated at three different academic speciality cardiology practices. baseline echocardiographic images were evaluated at each institution and valve morphology was classified as either type a (n = , . mmhg, range - ) or type b (n = , . mmhg, range - ) and "no" (n = , mmhg, range - ) or "yes" (n = , mmhg, range - ) for presence of pulmonary annular hypoplasia when diameter was compared to aortic annulus. twenty-four hours following pbv both type a ( mmhg, range - ) and type b ( mmhg, range - ) valves had significant reduction in gradient compared to baseline (p < . ). this reduction remained significant at days (a: mmhg, range - ; b: mmhg, range - ; p < . for both). dogs with annular hypoplasia ( mmhg, and without annular hypoplasia ( mmhg range - ) had a significant reduction in gradient hours post pbv. it remained significant at days (with annular hypoplasia: mmhg, range - ; without annular hypoplasia: mmhg, range - ; p < . for both). when comparing to baseline, considering valve type, there was no significant difference in percent reduction in gradient for type a versus type b valves at both the -hour (a: %, range - ; b: %, range - ; p = . ) and -day (a: %, range - ; b: %, range - ; p = . ) recheck evaluation time points. additionally, there was no significant difference in gradient reduction when looking only at whether or not there was annular hypoplasia at hours (yes: %, range - ; no: %, range - ; p = . ) and days (yes: %, range - ; no: %, range - ; p = . ). in conclusion, classification of dogs with ps according to valve type and annulus morphology did not help predict the -day response to pbv. disclosures: no disclosures to report. hypertrophic cardiomyopathy (hcm) is the most common feline inherited cardiac disease and it is a major cause of morbidity and mortality. the osservatorio italiano hcm felina was formed in by a network of clinicians, geneticists and breeders, to monitor and study hcm in italian cats. since april , adult cats, belonging to various breeds, including maine coon, siberian, norwegian forest cats, ragdoll, sphynx, british sh, birmans and others have been prospectively enrolled. recheck evaluations were performed in cats. each cat underwent a clinical examination, echocardiography, and blood collection for genetic testing (when appropriate) and storage in the italian feline bio-bank. the disease status was defined by echocardiography according to established guidelines (left ventricular diastolic wall thickness < . mm = hcm negative, = . but < mm = hcm equivocal; = mm = hcm positive). the prevalence of hcm in the population was % ( cats); equivocal diagnoses were conferred on % ( cats). these prevalences did not differ between breeds. the prevalence of hcm in the italian feline population was lower compared to those reported by other investigators. evaluation of data from the entire population demonstrated that left ventricular end-diastolic wall thicknesses and aortic diameter showed a weak positive correlation with body weight (p < . , r < . for all variables), suggesting that weight-dependent limits on wall thickness should be considered in cats as is currently practiced in dogs. the lower prevalence of hcm in italian cat breeds compared with those examined elsewhere might be explained by different criteria for determining presence or absence of disease, differences in ages at which the subjects were examined, or a selection bias by breeders in presenting cats they consider "normal". disclosures: no disclosures to report. chronic mitral valve disease is by far the most common cardiovascular disease in dogs. the disease is caused by myxomatous degeneration of the mitral valve leaflets and, in approximately % of cases, it's accompanied by degeneration of the tricuspid valve. it is also described in previous studies that approximately % of affected dogs also have evidence of associated pulmonary arterial hypertension. the prevalence of the disease is higher in small breed dogs (under kg), although large breeds can also be affected and it occurs more frequently in males than in females. the present study aims to characterize the disease in a population of dogs in portugal. we retrospectively reviewed the medical records of dogs presented to hospital veterin ario do porto, with an echocardiographic diagnosis of canine chronic mitral valve disease, during a period of years. from this records, cases were identified, from which ( . %) were males and ( . %) were females. most of the dogs were mixed breed ( ) and different breeds of dogs were represented. the poodle was by far the most represented breed (n = ; . %), followed by english cocker spaniel ( . %), yorkshire terrier ( . %), boxer ( . %), epagneul breton ( . %), dalmatian ( . %), pekingese ( . %), labrador retriever ( %) and portuguese podengo ( . %). all other breeds represented . % of the population. regarding weight, . % of the dogs (n = ) weighted < kg, with a mean body weight of . kg (range . - kg). the mean age at diagnosis was . years old. we also observed that . % of the dogs (n = ) had concomitant degeneration of the tricuspid valve and . % (n = ) pulmonary arterial hypertension (ph). we categorized these dogs according to the severity of ph, in mild ph if they had a doppler echocardiography derived systolic pulmonary arterial pressure (spap) of - mm/hg, moderate ph (spap - mm/hg) and severe ph (spap > mm/hg). we found that . % (n = ) of dogs had mild ph; . % (n = ) moderate ph and . % (n = ) severe ph. as described in previous studies, the disease affects mainly males and small breed dogs, with a breed distribution that reflects the canine population in the country, including very including very popular large breed dogs in portugal, as the boxer and labrador. both the presence of concomitant tricuspid valve disease and ph had a higher prevalence in our study than previously described. disclosures: no disclosures to report. in people anemia is frequent in patients with heart failure (hf) and it is associated with poor outcomes. the most likely pathogenic factors include iron deficiency, chronic kidney disease (ckd), and cytokine production, although other factors may contribute. little is known about the prevalence of anemia in dog with cardiovascular disease. the aim of this retrospective study was to define the prevalence of anemia (hct ≤ %) in dogs with mitral valve disease (mvd) and to investigate associated risk factors (age, weight, azotemia, hf, iris/acvim class). medical records of dogs presented at the cardiology service, divet, university of milan (january -march ) were retrospectively evaluated. dogs with mvd with complete physical, thoracic and echocardiographic examinations, and serum biochemical panel, including serum creatinine (scr), were included in the study. dogs with other heart or systemic diseases, except ckd, or neoplasm were excluded. statistical analysis was performed using jmp . (sas institute). a p value < . was considered significant. two hundred and ninety dogs ( males/ females), . ae . years of age, . ae . kg of body weight fulfilled the inclusion criteria. the % of males and the % of females were neutered. the most represented breeds were mongrel ( %), miniature poodle ( %), york shire terrier ( %), and cavalier king charles ( %). dogs were % b , % b , % c and % d acvim class. while the % of the dogs were normoazotemic (scr < . mg/dl), . % were staged in iris , % in iris and . % in iris . the prevalence of anemia in dogs with mvd was % ( / ): showed mild ( ≤ hct ≤ %) and moderate ( ≤ hct ≤ %) anemia. sixteen dogs were in b , in b , in c and in d acvim class; thirty-four were normoazotemic ( %). anemic dogs showed a significant higher scr. normoazotemic dog showed significant higher hb, hct and rbc both in the overall population and in the anemic group. in the overall population dogs in different iris class showed statistically different hb, hct and rbc and hb was significantly lower in decompensated hf dogs. in conclusion although a relationship between anemia and azotemia/ckd was documented in our study, it is important to emphasize that most of the anemic dog were normoazotemic: anemia is not an exclusive finding of cardiorenal syndrome and should be considered as possible complication in dogs with mvd alone. disclosures: no disclosures to report. the objective of this study was to evaluate left atrial (la) function by left atrial total fractional area change (la-factotal) and left atrial ejection fraction (laef) in dogs affected with chronic mitral valve disease (cmvd) naturally acquired with and without congestive heart failure (chf). our hypothesis was that la-factotal and laef decrease with severity of cmvd. eighty dogs were included in a prospective observational cross-section clinical study, grouped according to cmvd severity based on echocardiographic evaluation and clinical signs. the dogs were equally distributed in each group: a, b , b and c, according to american college of veterinary internal medicine staging system. indicators of la function were calculated with the following equations: la-factotal = (lamaximum area Àlaminimum area)/lamaximum area, measured by apical four view; and laef = (lamaximum volume À laminimum volume)/ lamaximum volume, by biplane area-length method from the left apical four and two-chamber views. la-factotal showed lower values (p < . ) in group c ( . %, p %- % = . - . ) compared with groups a ( . %, p %- % = . - . ), b ( . %, p %- % = . - . ) and b ( . %, p %- % = . - ). group c had lower laef ( . %, p %- % = . - . ) than groups a ( . %, p %- % = . - . ), b ( . %, p %- % = . - . ) and b ( . %, p %- % = . - ) (p < . ). left atrial function, assessed by la-factotal and laef, was reduced in dogs with cmvd and chf compared with healthy and asymptomatic cmvd groups. disclosures: no disclosures to report. recurrent episodes of heart and/or kidney failure are considered one of the causes leading to worsening heart/renal functions in human patients. the aim of this prospective study was to assess the influence of heart/kidney worsening on elected parameters of heart/kidney function in dogs affected by mitral valve disease (mvd). between july and may , dogs affected by mvd in acvim class b and without comorbidities were included in the study group. the control group was constituted by healthy dogs, matched with the cases for age (older than years) and gender. all the dogs underwent physical examination, thorax radiography, ecg, echocardiography, systemic blood pressure assessment, a complete blood count, serum biochemical analysis, including assessment of serum creatinine (scr), serum urea nitrogen (urea) and glycaemia (gly) and urine analysis with urine protein/creatinine ratio (upc). dogs were re-evaluated every -month until october . statistical analysis was performed using ibm spss statistics (p value significant if < . ). twenty-one dogs affected by mvd (cases) were included and healthy dogs (controls) were randomly selected among the eligible population. the % of cases experienced at least one episode of congestive heart failure (chf), but none of these patients developed chronic kidney disease (ckd). the % of cases developed ckd while remaining in acvim class b . no dogs in the control group developed ckd or mvd. correlations between worsening renal function (wrf -scr elevation ≥ . mg/dl or % from baseline), furosemide administration, upc levels, radiographic parameters of heart enlargement and echocardiographic parameter were investigated. only a statistically significant difference in iris class between the groups according to wrf and in the echocardiographic parameter left atrium to aortic root (la/ao) according to furosemide amount were observed. both these results were expected. none of the cases included experienced renal damage (wrf or iris class change or upc change) concomitant to episodes of chf. the persistence of normal renal condition regardless of chf events and therapy administration was unexpected. in conclusion, experiencing chf seems not to directly affect renal function. to authors' opinion, the use of wrf, better than single scr and urea levels, may be useful in the long term management of aged patients affected by mvd. however, the small number of cases included in this study represents a great limit. we consider this work a pilot study. disclosures: no disclosures to report. hypertrophic cardiomyopathy (hcm) is a primary myocardial disease characterized by inappropriate thickening of the myocardium in absence of other causes of hypertrophy including hypertension, hyperthyroidism, aortic stenosis and acromegaly. it is also the most common heart disease in cats. hcm presents a wide variety of clinical sings depending on the severity and location of the hypertrophy. cats affected with hcm have a mean age of . - . years old at the time of the diagnosis however this disease can affect cats as young as months although this later age is unusual hcm is a heterogeneous disease both in terms of phenotypic degree of hypertrophy and clinical outcome. hallmark histopathological hallmarks lesions of hcm are myocyte disarray, small coronary arteriosclerosis and interstitial fibrosis replacement in order to confirm hcm echocardiography has to be made. primary hypertrophy diagnosis is made based on the presence of ventricular hypertrophy, symmetric or asymmetric, in the absence of systemic disorders. the purpose of this study was to assess the prevalence of hcm in a feline population. in order to achieve this goal echocardiograms were made in all cats older of years clinically asymptomatic with or without cardiac murmur. all echocardiograms were made according to the guidelines of the acvim published in . diagnosis of ventricular hypertrophy was made from the right parasternal window using the b mode to measure the diameter of the lvfw and the ivs in diastole. cats with more than mm of wall thickness measured t , bun, crea, blood pressure. only cats within the normal limits of the later parameters were considered hcm positive. total number of cats in this study was cats male and female. from this population had no defined breed, were persian, maine coon, norwegian woods, siamese, chartreaux. no murmour was detected in ( . %) cats, s or s was detected in ( %) cats and differente degree of murmour was detected in ( . %) cats. hypertrophy was detected in cats. from this cats ( . %) were diagnosed as hcm, ( . %) cats were excluded either because of lack of values of t and or because they had high values of blood pressure, t levels or crea. in this study . % of the population had hcm. the epidemiological and phenotype distribution is highly variable. the average age at diagnosis of hcm in this study was . years. disclosures: no disclosures to report. mildly increased concentrations of crp are associated with cardiovascular disease in humans and dogs. it is not known whether increased concentrations of crp are associated with myxomatous mitral valve disease (mmvd) in dogs, or rather its sequel, congestive heart failure (chf). the aim of this study was to investigate whether serum concentrations of crp, determined using a novel automated canine-specific high-sensitivity crp assay (gentian hscrp), were associated with severity of mmvd and certain clinical variables in dogs. the study included client-owned dogs with different severities of mmvd. disease severity was determined by medical history, physical examination, echocardiography and response to diuretic therapy. dogs were allocated into groups based on acvim consensus statement guidelines ( in conclusion, slightly higher serum crp concentrations were found in dogs with chf whereas the severity of asymptomatic mmvd showed limited association with serum crp concentrations. disclosures: no disclosures to report. medetomidine is a a -agonist widely employed for sedation in dogs but its use is discouraged in cardiac patients even those suffering from myxomatous mitral valve disease (mmvd). however, only one investigation was previously conducted in a wide rangeregarding the class of the diseaseof mmvd patients, reporting a general safety of that protocol. the present study was focused just on class b of mmvd, with the aim to provide more detailed information on the cardiovascular effects of medetomidine in such patients, by the analysis of clinical and instrumental parameters suggestive of disease severity or congestive heart failure. dogs weighing < kg, needing a soft clinical procedure and showing a systolic apical heart murmur were screened and selected for the study if la/ao < . . the sedative protocol consisted in an iv injection of lg/kg medetomidine antagonized, after the clinical procedure, by an im injection of the recommended dose of atipamezole. clinical parameters, echocardiographic variables, thoracic radiographs and oscillometric blood pressure measurements were collected at baseline (t ), minutes after medeto-midine administration (t ) and hours after atipamezole injection (t ). of dogs screened, were definitively enrolled. at t a significative decrease in the right parasternal regurgitant jet area (rp-arj/laa), peak velocity of mitral regurgitation and shortening fraction was observed along with an increase in lvids (p < . ). left parasternal arj/laa decreased without reaching statistical significance but showing a high correlation with rp-arj/laa (r = . ). interestingly, la/ao changed only mildly and never reached a value > . . the other echocardiographic variables did not show a particular trend. systolic blood pressure showed values at the upper physiologic limit at t , lower values than t at t , and an increase above the initial value at t but without significance. thoracic radiographs were evocative of heart enlargement without pulmonary venous congestion or pulmonary oedema both at t and t . respiratory rate did not change between t and t . the degree of sedation was optimal during the clinical procedure in all cases. sedation with lg/kg medetomidine is safe in dogs suffering from mmvd in stage b (la/ao < . ). the decrease observed in peak velocity and color-doppler appearance of mitral regurgitation at t could be due to a reduction of both myocardial contractility and systolic blood pressure, by a lowering of sympathetic activity via baroreceptors stimulation. disclosures: no disclosures to report. in this retrospective study were included a total of clientowned dogs, undergoing transarterial occlusion of pda with mreye Ò flipper detachable embolization coil (n = ), amplatz â canine duct occluder (acdo; n = ) and amplatzer â vascular plug (n = ). device size selection was based on pda dimensions assessed by transesophageal echocardiography (tee) in cases and transthoracic echocardiography (tte) in cases. angiography was performed during the procedure to assess the success of the occlusion, and it confirmed complete occlusion in dogs and a trivial residual flow in dogs. the following day, transthoracic color-doppler echocardiography revealed that complete ductal closure was achieved in all dogs. the procedure was hemodynamically successful, as evidenced, by a reduction in indexed left ventricular internal diameter in diastole (lvidd; p < . ), fractional shortening (fs; p < . ) and left atrial to aortic ratio (la: ao; p < . ) within hours after procedure. four months after surgery, indexed lvidd was significantly reduced (p = . ) and la:ao remained constant. secondary complications included pulmonary arterial embolization of an acdo and a late rotation of an amplatzer â vascular plug resulting in an increased flow through the pda. the dog with the rotated device required subsequent surgical ligation of the pda. at this time, dogs were reported to be alive and the other dogs were lost to follow up. only one dog remained on congestive heart failure therapy after the pda occlusion. we can conclude that pda occlusion using an acdo for dogs with more than kg and a transarterial coil embolization for dogs with < kg had a high rate of immediate complete occlusion. pda occlusion using those devices proved to be a safe and effective therapeutic method for pda in dogs. disclosures: no disclosures to report. echocardiographic evaluation of the right pulmonary artery distensibility index (rpad index) was recently described as a valuable method for early detection and severity evaluation of pulmonary arterial hypertension in dogs. rpad index is calculated as the percentage change in diameter of the right pulmonary artery (rpa) between systole and diastole, obtained by m-mode echocardiography from the right parasternal long axis view. the aim of this study was to compare the rpad index obtained by two different echocardiographic views in dogs. the study design was a prospective, multicenter, observational study. forty-five client-owned dogs from different breeds were included: dogs with heart disease and healthy dogs. two different right parasternal views, long axis (rpla) and short axis (rpsa), were used to measure the rpad index. from the rpla view (method ) and rpsa view (method ) a short axis and a long axis image were respectively optimized for the right pulmonary artery. the rpad index was calculated by m-mode as the percentage change in diameter of the right pulmonary artery: [(systolic diameter À diastolic diameter)/systolic diameter]* . measurements were done off-line as an average of consecutive cardiac cycles by a single investigator blinded to the dogs' diagnosis. a pearson and a bland-altman test were used to assess correlation and agreement between the methods, respectively. intra-and inter-observer measurement variability was quantified by average coefficient of variation (cv). level of significance was set at p < . . m-mode evaluation of the rpad index was satisfactorily obtained by both methods in all dogs. pearson test showed a strong positive linear correlation between the values of rpad index obtained from both methods (r = . , p < . ). bland-altman test showed a good agreement between the methods in estimating rpad index (bias = . %, sd = . %, % limits of agreement = À . , . %). the mean difference between the two methods was . % ( % confidence interval = À . ; . ). intra-and inter-observer measurement variability was clinically acceptable (cv< %).the study showed a good agreement between short axis and long axis m-mode evaluation of rpa. both methods can be used interchangeably to evaluate rpad index. further studies are needed to evaluate the rpad index in a larger population of healthy dogs and the diagnostic and prognostic role of this echocardiographic parameter in dogs with different types of pulmonary hypertension. disclosures: no disclosures to report. naturally occurring hypoadrenocorticism (addison's disease) is an uncommon illness. its prevalence in the general canine population is estimated between . and . %. certain breeds appear to have an increased risk for developing hypoadrenocorticism, including bearded collie, standard poodle, portuguese water dog and nova scotia duck tolling retriever, with reported prevalence of . , . , . and . %, respectively. the objective is to evaluate the prevalence and clinical features of naturally occurring hypoadrenocorticism in great pyrenees (gp) presented at the centre hospitalier universitaire v et erinaire (chuv) of the university of montreal. this retrospective study (march to october ) includes client-owned great pyrenees diagnosed with hypoadrenocorticism. the medical records of dogs with a diagnosis of naturally occurring hypoadrenocorticism were reviewed, with an emphasis on great pyrenees' record. the prevalence of hypoad-renocorticism in the studied population, as well as the prevalence per breed, was calculated. data collected included breed, clinical signs, laboratory findings, age at diagnosis, treatment, and cause of the death. one hundred dogs were diagnosed with naturally occurring hypoadrenocorticism, representing . % of the overall canine population studied. thirty-five breeds were represented, with a prevalence per breed varying between . % and . %. a high prevalence was observed in west highland white terriers ( . %), great danes ( . %), standard poodles ( . %), saint-bernards ( . %) and jack russell terriers ( . %). out of gp presented during that period of time, . % (n = ) were diagnosed with hypoadrenocorticism. median age at diagnosis was . years (range: . to . ) in dogs with hypoadrenocorticism, and . years ( . - . ) in gp. the main reason for presentation of the addisonian gp was lethargy (n = ) and anorexia (n = ). clinical findings included hypotension (n = ), poor body condition (n = ), and heart murmur (n = ). the majority (n = ) had serum electrolytes abnormalities, with a na:k ratio ranging from . to . . other major laboratory findings included azotemia (n = ), anemia (n = ) and the absence of a stress leukogram (n = ). the majority (n = ) received fludrocortisone, with prednisone as needed. one gp was euthanized at time of diagnosis. great pyrenees diagnosed with hypoadrenocortism were overrepresented in the studied population, with a prevalence of hypoadrenocorticism in our gp population of . %. therefore, an inherited susceptibility can be suspected. reason for presentation and clinical signs were nonspecific, and similar to what is reported in other breed. in human medicine, haemoglobin a c (hba c), a form of glycosylated haemoglobin, is used as the standard measure of average glycaemic control over - months. the measurement of hba c in dogs has been previously demonstrated however high pressure liquid chromatography techniques are too technically difficult for routine use and other methods are no longer available. the objective of this study was to assess the use of latex immunoagglutination inhibition using a monoclonal antibody for the measurement of hba c in dogs, using the siemens dca vantage Ò . repeatability was assessed by measuring samples times within minutes. the effect of storage on edta anticoagulated samples was examined by measuring samples stored at °c every day for up to days. storage was further assessed by freezing samples and measuring them at , and weeks. the machine was then used to compare the hba c values in groups of dogs with diabetes mellitus (group , n = ), hyperadrenocorticism (group , n = ) or non-diabetic/cushingoid hospitalised patients (group , n = ). differences in the groups were examined for significance using a kruskal-wallis analysis of variance. the reference range of hba c has been previously calculated to be . - . % ( - mmol/mol) and values of . to > % ( to > mmol/mol) are seen in diabetic animals using high pressure liquid chromatography. the median coefficient of variation for the repeatability study was found to be % (range - %). it was possible to store samples at °c for up to days (median cv% = %, range - %) and at À °c for at least weeks (median cv% = %, range - %). the median hba c concentrations were group ; . % ( mmol/mol), group ; . % ( . mmol/mol) and group ; . % ( mmol/mol). group was significantly different from the other two groups using kruskal-wallis analysis of variance. in conclusion, the latex immunoagglutination method was repeatable for the measurement of hba c in dogs. in addition, hba c in canine edta anticoagulated samples were stable at °c for up to days and, if frozen, could be stored for at least weeks without significant sample deterioration. the assay provides the expected results in dogs with and without abnormalities of glycaemic control. disclosures: the siemens dca vantage was provided on loan from siemens, as well as the cartridges used on this machine to run all samples in the study. a. wehner , r. anderson , s. reese , k. hartmann . clinic of small animal medicine, munich, germany, institute of veterinary anatomy, histology and embryology, munich, germany measurement of total thyroxine (t ) is often the first diagnostic step in the work up of thyroid disease in dogs and cats. blood samples are routinely sent to a reference laboratory causing a delay in testing which might impact the results. the aim of this study was to validate an enzyme fluorescence assay (elfa) as an inhouse method to measure t in dogs and cats. t was measured in sera of dogs and cats by two methods, an enzyme immunoassay (eia) and an enzyme fluorescence assay (elfa). the eia served as the standard method to which the elfa results were compared. the elfa was performed with the minividas automated analyser (biom erieux, craponne, france) according to the manufactors instructions. coefficient of variation (cv) of the elfa in dogs sera was . % and of the eia - . %, respectively. cv of the elfa in cats sera was . - . % and of the eia . - . %, respectively. overall bias of the elfa in dogs was . %; however up to À . % in lower t ranges. maximal bias of the elfa in cats was . %. correlation of both methods was linear only in cats. using bland altman plots limits of agreement were À to % in dogs and À to % in cats. cohen s kappa revealed only slight agreement between both methods in dogs, but a good to very good agreement in cats. the elfa is a fast method with a high precision and can be recommended to measure t in cats, but cannot be recommended for dogs. disclosures: no disclosures to report. dysfunctions of the central nervous system (cns) are the most frequent causes of neurological disorders in dogs. our study aimed to find ( ) if some cns diseases could be associated with a selected group of common microbial or viral pathogens in dogs and ( ) if cns diseases have any characteristic profile with regard to two parameters, c-reactive protein (crp) and iga, that are reported to be potentially useful but unspecific markers of cns diseases. we analysed cerebrospinal fluid samples obtained from dogs with varying neurological signs between june and november . real-time pcr was employed with probes for toxoplasma gondii, neospora caninum, anaplasma phagocytophilum and canine distemper virus. igg-antibodies to tickborne encephalitis virus (tbe) were assayed and iga titres were measured using elisa, while crp concentrations were determined by immunoturbidimetric assay. the dogs had a median age of years (range: . - ) and comprised breeds most frequently involving chihuahuas, labrador retrievers, bernese mountain dogs and boxers. gender distribution was . % female, . % spayed bitches, . % male, . % neutered male, and . % non-identified. none of the cases were pcr-positive for toxoplasma gondii or canine distemper virus. one dog was positive for anaplasma phagocytophilum and another for neospora caninum. antibodies to tbe virus were within the borderline range in / dogs. the dogs could be divided into two age groups: (= . %) for young dogs (< years, median year) and (= . %) for older dogs (≥ years, median years). igahigh (> . mg/dl) cases represented % and % for young and older dogs, respectively. crp-high (> . mg/l) cases were almost half and equal: . % and . % in young and older dogs, respectively. compared with older dogs, young dogs had higher levels of crp (p = . ) and iga (p = . ). within the iga-high cohorts, crp-high and crp-low cases distributed almost equally ( . % versus . %) in young dogs but disproportionate ( . % versus . %) in older dogs. there were no [iga-low/crp-low] cases in young dogs but . % in older dogs. our present data sug-gest that ( ) canine cns disorders were largely characterized by high iga and particularly in young dogs ( ) inflammatory types (crp-high) were almost equal in both groups and ( ) internet is a potential source of medical information for pet owners. therefore, it could play an indirect but important role in the veterinary practice. this survey assesses the online search behaviour of french pet owners for their pets' health and its influence on a veterinary consultation. in april , french pet owners coming in a veterinary teaching hospital for a medical or a surgical consultation were surveyed. ( . %) owners fulfilled the questionnaire on a voluntary basis. the survey contained questions dealing with three topics: the online search behaviour of owners for their pets' health, their perception of the information found online and the internet's influence on a consultation and on the veterinarian/client relationship. . % of owners use the internet to obtain information on their pets' health. among them, . % use it rarely and . % occasionally. they mainly look for information on a disease ( . %), a symptom ( . %), a breed ( %) or a nutritional advice ( . %). . % of owners try to verify the accuracy of the information found, most often by questioning their veterinarian ( . %). few owners ( . %) think that online information is always trustworthy. most of the research ( . %) is randomly made, websites being found through search engines. the majority of pet owners ( . %) aren't aware of any health certification label for websites. internet enables certain pet owners to feel more at ease with their pets' health care: they ask more questions to their veterinarian ( . %) and feel more involved in medical choices ( . %). . % of owners consider that the internet can positively impact their relationship with the veterinarian. relief is the most common ( . %) emotional response to online research for medical information. however, . % of owners feel overwhelmed by the amount of information found, % are confused and . % frightened by the serious or graphic nature of the information found online. this study emphasizes the frequent but measured use of the internet by french pet owners for their pets' health. they seem to consider information found on the net with a critical mind. unexpectedly, it appears that the internet could be an ally for veterinarians by promoting exchanges between the clients and the veterinarian and by improving compliance with the care project. disclosures: no disclosures to report. sinonasal aspergillosis is a well-known and described fungal infection of the sinonasal cavities in dogs. topical treatment either with enilconazole or itraconazole infusion administered surgically or endoscopically are effective. the use of % clotrimazole cream have been described in a surgical setting after itraconazole infusion by sissener et al. in . the aim of the work was to report the effectiveness of the use of topical % clotrimazole cream as the only treatment for sinonasal aspergillosis in dogs. inclusion criteria were a full medical record with radiological and endoscopical imaging, record of clotrimazole discharge after instil-lation and endoscopic control between and days after procedure. the % clotrimazole cream was applied through catheters placed under direct endoscopic vision after fungal plaques removal. nine dogs were included. three dogs were mixed breed dogs, two dogs golden retriever, one dog a german shepherd and one old english sheepdog, one bull terrier and one cane corso. six dogs were male (one neutered) and three female (one intact). mean age was . years. main clinical signs were muco-purulent discharge ( ), pain at sinonasal palpation ( ), nasal planum alterations ( ), epistaxis ( ) . nasal discharge was bilateral in dogs. mean duration of clinical signs was . months. main radiological findings were turbinates lysis ( ), frontal sinus empyema ( ), frontal bone thickening ( ) and frontal bone lysis ( ). rhinoscopy disclosed lysis and remodelling of the nasal turbinates ( ), easy access to the frontal sinus ( ), septum lysis ( ), bilateral sinonasal aspergillosis ( ), monolateral nasal aspergillosis ( ), monolateral sinonasal aspergillosis and contralateral nasal aspergillosis ( ), monolateral frontal aspergillosis ( ). main duration of nasal cream discharge was . days. all dogs underwent endoscopic control between and days after the procedure. seven dogs were disease free; two dogs had persistent fungal plaques and underwent a second treatment. success rate was . %. success rate of this study is comparable to other studies with larger and smaller case series. endoscopic removal of the fungal plaques can be time consuming and topical administration of either enilconazole or itraconazole require an additional hour. the catheter placement and the % clotrimazole cream application lasted minutes for each cavity in the dogs here reported. the use of % clotrimazole cream as the only treatment for sinonasal aspergillosis needs further evaluation on a larger case series. disclosures: no disclosures to report. few studies exist on euthanasia in small animal practice. however, such an act belongs to veterinary procedures, more or less frequently depending of the kind of practice, and may deeply impact both owners and veterinarians. we intended to study practical, ethical and psychological aspects of euthanasia of dogs and cats among french veterinary practitioners. from october to february , an on-line -item questionnaire on small animals' euthanasia, addressing practical aspects of euthanasia, communication with the owners, ethical problems, owners' and veterinarians' perceptions, was emailed via professional associations and networks. results were analyzed using commercial software (sphinx iq Ò and excel Ò ). french veterinarians practicing small animal medicine completed the questionnaire, representing > % of this population. euthanasia occurs rarely at home. over % of veterinarians propose the owners some time alone with their pet, and to stay during euthanasia, performed most commonly by intravenous injection ( . %) mainly after sedation/anesthesia ( . %). ninety nine percent of veterinarians consider communication, including description of events' sequence, and disposal of the body, as important. estimated minimum communication time required varies from - to - minute. following euthanasia, . % are often thanked by the owners. most veterinarians (> %) have refused a euthanasia, considered unjustified, or had their own suggestion of euthanasia rejected. reasons for such a suggestion include intractable pain ( . %), non-acceptable complications ( . %), financial considerations ( . %) or animal considered dangerous ( . %). veterinarians think most owners ( . %) experience some sense of guilt during euthanasia. themselves perceive euthanasia most commonly as relief of animal's suffering ( . %) and part of veterinary practice ( %), less frequently as a defeat ( . %). almost all veterinarians have experienced emotionally challenging euthanasia, and . % estimate that practicing euthanasia influences their perception of death. practical ( %) and psychological ( . %) aspects of euthanasia have been discussed in most teams. veterinarians' gender influences euthanasia management, mostly concerning some communicational and practical aspects. euthanasia is definitely not an ordinary veterinary act, neither for the owner nor for the veterinarian. therefore, this act must be performed with as much care and communication as possible. disclosures: no disclosures to report. canine pancytopenia is associated with a range of intra-marrow or extra-marrow causes, including though not limited to, infectious agents, drugs, toxins and neoplasms. there is currently limited information regarding the clinicopathological features of the underlying causes or the prognosis in pancytopenic dogs. the objective of this retrospective study was to better define the spectrum of diseases associated with canine pancytopenia, to establish possible clinicopathological discriminators for the common causes and to investigate if the severity of pancytopenia or the underlying disease were associated with the clinical outcome (death or survival). medical records of dogs with a comprehensive diagnostic investigation admitted in a veterinary teaching hospital were retrospectively reviewed. pancytopenia was defined by a hematocrit (hct) < % (< % for dogs < months of age), white blood cell counts (wbc) < . /ll and platelet counts (plt) < , /ll. a control group of dogs without any evidence of blood cytopenia(s) was also established. in total, pancytopenic dogs were studied. bone marrow aspiration cytology was examined in cases and aplasia of all hematopoietic lineages was observed in ( . %) dogs. the most common diagnoses included monocytic ehrlichiosis (cme) (n = ), leishmaniosis (canl) (n = ), parvoviral enteritis (pe) (n = ), and concurrent cme and canl (n = ). mixed breed dogs were more likely to develop pancytopenia as compared to purebreds and pancytopenic dogs tended to be younger than the controls (conditional dependent logistic regression model, p = . and p = . , respectively). among the most common diseases associated with pancytopenia, the mean wbc counts were significantly lower in dogs with cme and pe compared to dogs with canl (one way anova with bonferroni test for multiple comparisons, p = . and p = . , respectively), while plt counts were significantly lower in cme compared to canl (p < . ) or pe (p < . ). total protein concentrations were significantly lower in dogs with pe compared to cme (p < . ) and canl (p < . ). using a univariable logistic regression analysis model, no association was established between the underlying disease and the final outcome. however, higher hct (by at least one percentage unit), wbc (by at least /ll) and plt (by at least , /ll) values tended to significantly increase the odds of survival (p = . , p < . and p = . , respectively). in the present study, cme, canl and pe were the major causes of canine pancytopenia. potentially useful diagnostic indicators included severe leucopenia (cme, pe), thrombocytopenia (cme) and hypoproteinemia (pe). disclosures: no disclosures to report. bwbp detects both upper and lower airways diseases because any site of airway obstruction will result in increased pressure changes associated with breathing. nevertheless our results suggest that there are significant differences in tv (p = . ), ti (p = . ), pef (p = . ), eep (p = . ), penh (p = . ) and pau (p = . ) between lm and fbd cats. no other significant difference in bwbp parameters was found. upper airway obstructions have been previously evaluated in cats by using pft (mckieman, , lin, but in authors' knowledgement this is the first study designed to compare upper and lower airway obstructions by using bwbp. attending our results, there is the evidence that bwbp can help characterize mechanical dysfunction of the airways in cats with lm obstruction. however we must keep in mind some limits of this study as the low number of animals, individual variability in breathing pattern and to have the chance of doing bronchoreactivity tests. disclosures: no disclosures to report. the median lifespan of domestic dogs has been estimated to - years, but little is known about risk factors for mortality in aged dogs: most mortality studies in dogs have been carried out among diseased dogs (renal or heart diseases, cancers, post-operative death). to determine which characteristics are associated with mortality in a priori healthy aged dogs, a prospective cohort study has been conducted in guide dogs, followed from a systematic geriatric examination (ge) to either (all-cause) death or cut-off date (july th, ). survival analyses (kaplan-meier estimators, log-rank tests, and multivariate cox proportional hazards models) were used to assess the associations with time to death. median age at ge was . years, all dogs were neutered, and % were female. the majority of dogs were golden retriever (n = ) and labrador retriever (n = ). among these dogs, % were obese, % presented skin nodules and % used bus as transportation. a total of dogs died during follow-up, leading to a median survival time from ge of . years. after adjustment for demographic and biochemical variables (age, sex, total proteins, cholesterol and alp), an increased alanine amionotransferase level (≥ ui/l; adjusted hazard ratio [ahr], . ), presenting skin nodules (ahr, . ), and not being a labrador (ahr, . ) were independently associated with a shorter time to death (p < . ). public transportation tended to be associated with mortality (ahr, . ; p = . ), highlighting the importance of environment in mortality. neither sex nor other biochemical parameters were significantly associated with mortality. the alanine amionotransferase level and the presence of skin nodules seem predictors of mortality in senior guide dogs, mostly labrador, golden, or mixed breed of labrador/golden. the impact of environment, in particular urban environment, on mortality needs further investigation. studies in other breeds and pets are also necessary to generalize these results. disclosures: sara hoummady received a grant from mp labo for his phd work about dog aging and marc blondot work at the paris guide dog school. laryngeal dysfunction is most commonly associated with aspiration pneumonia, however its role in other lower airway diseases has not been investigated. laryngoscopic and bronchoscopic findings in dogs examined by the author between and were evaluated for the presence or absence of laryngeal abnormalities. dogs that presented for evaluation of inspiratory difficulty or panting were excluded from analysis. clinical diagnoses of inflammatory airway disease, airway collapse, airway infection, eosinophilic bronchopneumopathy or a combination of these disorders were obtained through bronchoscopy and bronchoalveolar lavage fluid analysis. detection rates for laryngeal abnormalities were compared among disease groups using chi square analysis and fisher's exact test, with significance set at p < . . a total of dogs were evaluated and varied in age between months to . years (median years). weight ranged from . to . kg (median kg), with dogs < kg, dogs from . - . kg, dogs from - kg, dogs from . - kg, and dogs > kg. laryngeal hyperemia or swelling was found in / dogs ( %), and detection rate did not differ among disease processes. laryngeal function was considered suspect in / cases, prompting administration of doxapram, which normalized function in / dogs. laryngeal paresis or paralysis was reported in a total of / dogs ( %). a substantial number of dogs with chronic cough displayed evidence of abnormal laryngeal structure or function, suggesting that a complete laryngoscopic examination should be performed in all dogs evaluated for cough. disclosures: member of the feline advisory board, speaker honoraria for international, national, and regional continuing education meetings. bronchiectasis is a poorly characterized disease in dogs identified by airway dilatation on radiographs, computed tomography, bronchoscopy, or histopathology. little is known about underlying disease processes associated with bronchiectasis in dogs. medical records from dogs presented to uc davis were searched for identification of bronchiectasis. underlying disease processes and clinical diagnoses were obtained through review of the history, physical examination, respiratory endoscopy and bronchoalveolar lavage fluid analysis and microbiology. historical reports, results of imaging, bronchoscopy and fluid analysis, and scrutiny of pathologic and clinical diagnoses were comprehensively evaluated to identify the most likely underlying disease process associated with bronchiectasis. between and , bronchiectasis was diagnosed in / dogs ( %) that had bronchoscopy performed. dogs ranged in age from . to years (median years) with / dogs < months, / dogs ( %) - years, / dogs ( %) . - years of age and / dogs ( %) over years of age. dog breeds affected more than once included labrador retrievers, cocker spaniels, golden retrievers and standard poodles. duration of cough ranged from days to years (median months). underlying disease processes included pneumonia in / ( %) dogs, inflammatory airway disease in / ( %) dogs, and eosinophilic bronchopneumopathy in / ( %) dogs. twenty-three of dogs ( %) had positive bacterial cultures, with isolation of streptococcus (n = ) and enteric species (n = ) most commonly. this study found that bronchiectasis often occurs in older, large breed dogs with infectious or inflammatory pneumonia. disclosures: johnson: feline advisory board, speaker honoraria. chronic respiratory disease, often characterized by a chronic cough, is common in dogs. the purpose of this study was to determine the etiology of chronic respiratory disease in dogs that were presented with persistent and chronic coughing. a retrospective study of client-owned dogs with signs of persistent and chronic lower respiratory disease, that underwent bronchoscopy together with either an endotracheal wash (etw) or broncho-alveolar lavage (bal), was performed. all dogs were evaluated by means of full clinical examination, hematology and serum biochemistry analyses, survey thoracic radiographs, echocardiography and ecg (if indicated), and bronchoscopy with cytological analysis and aerobic culture of etw or bal fluid. an etw was performed in / ( %) dogs while a bal was performed in / ( %) dogs. a positive aerobic bacterial culture was identified in / ( %) of submitted etw/bal fluid samples. most commonly isolated bacteria included mycoplasma sp. ( %), bordetella bronchiseptica ( %) and pseudomonas aeruginosa ( %). a definitive diagnosis was made in / cases ( . %). chronic bronchitis was the most common diagnosis ( . %), median age years; followed by airway tracheal collapse or bronchomalacia ( %), median age years,; and primary bacterial infections ( . %), median age years. less common etiologies identified included neoplasia ( . %), median age years; parasitic infections ( . %), median age years; and eosinophilic bronchopneumopathy ( . %), median age years. rare etiologies identified included primary pulmonary hypertension, primary ciliary dyskinesia, excitement-induced cough, and obesity. myxodematous mitral valve disease was found concurrently in / ( . %) dogs. this study concluded that by using a structured combination of survey thoracic radiography, bronchoscopy and etw or bal with cytology and culture, a diagnosis could be made in the majority of dogs with chronic respiratory disease. disclosures: no disclosures to report. canine sterile steroid-responsive lymphadenitis (cssrl) is an uncommon cause of lymphadenomegaly. diagnosis is one of exclu-brachycephalic dogs have unique upper respiratory anatomy with abnormal breathing patterns similar to those in humans with obstructive sleep apnea syndrome (osas). oxidative stress in the body represents the imbalance between the production of reactive oxidative species and the ability of antioxidant defense mechanisms to detoxify the reactive intermediates. oxidative stress is involved in the pathogenesis of many diseases, including hemolytic anemia, atherosclerosis, tissue reperfusion injury and has also carcinogenic potential. several studies have clearly shown an association between obstructive sleep apnea syndrome in humans and oxidative stress, but detailed underlying pathomechanism remains unclear. due to the consideration of brachycephalic dogs as an animal model of human osas, this study was designed to evaluate oxidative stress (paraoxonase type- activity; pon and total antioxidant status; tac) in brachycephalic dogs with brachycephalic airways obstructive syndrome (baos) before and after surgery compared to control dogs. this study was conducted on dogs with baos and control dogs. twenty out of baos dogs were evaluated - months after surgical correction. mean values of tac and pon in different studied groups were as follows: control dogs (tac: . ; pon : . ), baos dogs (tac: . ; pon : . ), baos dogs post-surgery (tac: . ; pon : . ) a statistically significant difference on tac levels is observed between dogs with baos and control dogs (p < . ). no statistically significant differences were observed in pon and tac levels before and after surgery. on the other hand, no differences have been observed between pon and tac levels in baos dogs according type of brachycephalic breed, grade of respiratory and digestive signs or presence of everted ventricular laryngeals. the results of our study showed a statistically significant difference in tac values between control and dogs with baos, confirming the oxidative stress previously described in humans. even that human patients with osas can partially reverse their increase in oxidative stress by using a nasal continuous positive airway pressure treatment, in dogs with baos no differences were observed before and month after surgical treatment. baos surgical treatment is not useful to reduce pon- or tac levels, probably because baos does not induce such an evident inflammatory process in dogs as in human patients with osas. disclosures: no disclosures to report. canine idiopathic pulmonary fibrosis (cipf) is a progressive interstitial lung disease mainly affecting west highland white terriers (whwts). the cipf course varies greatly among dogs from rapid deterioration to slowly progressive forms and the survival time from onset of clinical signs ranges from a few months to several years. in human ipf, increased chemokine (cc-motif) ligand (ccl ) concentrations in bronchoalveolar lavage fluid (balf) are indicative of a poor outcome and serum concentrations are correlated with clinical parameters of lung function. in dogs, serum and balf ccl concentrations were shown to be elevated in whwts with cipf compared with healthy whwts. the aim of the present study was to investigate whether serum ccl concentrations measured in whwts with cipf at diagnosis ( ) can be used as an indicator of prognosis and ( ) correlate with lung function parameters. ccl concentrations were determined by elisa (canine ccl quantikine elisa kit, r&d systems) in the serum of whwts suspected of cipf (median age . years, range . - . ), for which a follow-up was available (median follow-up time . months, range - . ). serum sampling extended from may to january . cipf diagnosis was confirmed by thoracic high resolution computed tomography, lung histopathology, or both examinations in , and whwts respectively. kaplan-meier analysis was conducted to investigate differences in survival times according to serum ccl concentrations at diagnosis. spearman analysis was used to assess correlations between serum ccl concentrations and lung function parameters, namely the distance walked in the -minute walking test ( mwd) and the arterial partial pressure of oxygen (po ). among the cipf whwts included, died or were euthanized for cipf-related reason, died or were euthanized for non-cipf-related reason and were still alive at the end of the study. the median survival of whwts with cipf-related death or euthanasia was . (range . - . ) months from diagnosis. serum ccl concentrations above pg/ml were significantly associated with a shorter survival time in whwts affected with cipf (p = . ). a weak negative correlation was found between serum ccl concentrations and the mwd (r = À . , p = . , n = ), while no correlation was observed with arterial po values (n = ). in conclusion, serum ccl concentration provides prognostic information in whwts suffering from cipf, while this marker is weakly correlated with the clinically lung function parameters available in the present study. disclosures: no disclosures to report. canine idiopathic pulmonary fibrosis (cipf) is a progressive interstitial lung disease mainly affecting west highland white terriers (whwts). this study was intended to ( ) describe thoracic high-resolution computed tomography (t-hrct) findings obtained in cipf dogs under general anesthesia (ga) using the glossary of the fleischner society and ( ) compare images obtained under ga (t-hrct ga ) with those obtained under sedation (t-hrct s ). t-hrct images from whwts with cipf and control whwts were retrospectively reviewed by three observers in consensus. specific t-hrct features were assessed and graded for each lung lobe ( = absence, = mild, = moderate and = severe). a global score was then calculated. the khi² test with the threshold % was used for the statistical analysis. ground glass opacity (ggo) was observed in all cipf whwts and in / of controls (p = . ). in controls, ggo was mild and localised mainly in cranial lobes. in cipf whwts, ggo was mild, moderate or severe in , and dogs respectively, without lobe predilection. consolidation was observed in / cipf whwts but not in controls (p = . ) and was mild ( / ) to moderate ( / ). a mosaic pattern, suggestive of air trapping, was noticed in / cipf whwts but not in controls (p = . ) and was mild, moderate or severe in , and whwts respectively, without lobe predilection. nodules were present in / cipf whwts but not in controls. reticulation, subpleural bands and parenchymal bands were noticed in , , and / cipf whwts respectively. honeycombing, emphysema, pleural effusion and pleural thickening were never observed. bronchial wall thickening and mild bronchiectasis were present in / and / cipf whwts respectively but not in controls (p = . and p = . ). the overall t-hrct s quality was good in / examinations compared with / for t-hrct ga (p = . ). the presence of motion artefacts was higher for t-hrct s (p < . ), but were most frequently graded as mild (p < . ). t-hrct s allowed identification of a mosaic pattern in additional cipf whwts, while consolidation could not be identified in others. there was no difference in identification or gradation for the other features between t-hrct ga and t-hrct s . in conclusion, ggo, consolidation, mosaic pattern and bronchial wall thickening are the main t-hrct features of cipf in whwts. honeycombing, the major feature of ipf in humans, was never observed, which suggests a different pathophysiology between the two entities. t-hrct s images are in accordance with t-hrct ga and can be used for cipf diagnosis. disclosures: no disclosures to report. literature on mesenterial lymphadenitis (lad) or mesenterial lymph node abscesses (lab) in small animals is scarce. case files from to were searched for dogs with the diagnosis of mesenterial lad/lab based on cytology and/or histopathology. of cases identified, had to be excluded due to incomplete data. the remaining dogs were of mixed breed (n = ), small munsterlander (n = ) and one each of other breeds. nine dogs were male and female. median age was months (range . diagnosis was based on fine needle aspiration (fna; n = ), histopathology (n = ) or both (n = ). significant findings in the dogs' history included gastrointestinal signs (n = ), puppy whose mother had mastitis, bite wounds/abscesses of the skin (n = ), pulmonic stenosis (n = ) and orthopaedic diseases (n = ). most common presenting complaints were lethargy (n = ), hyperthermia (n = ), diarrhoea (n = ), vomiting/nausea (n = ), inappetence/anorexia (n = ), back/abdominal pain (n = ) and lameness (n = ). diagnostic tests performed included haematology/serum biochemistry (n = ), thoracic (n = ) and abdominal (n = ) radiographs, abdominal ultrasound (n = ), ct/mri (n = ), fnas of other organs (n = ), urinalysis (n = ) with culture (n = ), coagulation profiles (n = ), orthopaedic radiographs (n = ), cpl (n = ), blood cultures (n = ), and csf/joint taps (n = ). dogs were retrospectively divided into group a (n = ): dogs with no other disease than lad/lab ("idiopathic") and group b (n = ): dogs with other diseases diagnosed simultaneously. these included neoplasia (carcinoma n = , lymphoma n = , leiomysarcoma n = , histiocytic neoplasia n = , prostate carcinoma n = ), gastroenteritis (n = ), presumed pancreatitis (n = ), purulent monoarthritis (n = ), purulent hepatitis/ splenitis (n = ), fungal infection at a distant site (n = ), and mycobacteriosis (n = ). eleven dogs received surgical treatment and antibiotics, and dogs conservative medical management consisting of supportive treatment and antibiotics. all dogs were discharged alive. dogs in group a were hospitalized longer (mean days, sd . ) than dogs in group b (mean days, sd . ) (p = . ). the median follow-up time was days ( - days). there was no difference in pretreatment with antibiotics or anti-inflammatories between groups. t-tests or kruskall-wallis tests showed that dogs in group a were borderline significantly younger (p = . ), had significantly higher respiratory rate (p = . ), rectal temperature (p = . ), monocyte count (p = . ) and crp concentration (p = . ) than dogs in group b. the small munsterlander had an odds ratio of over other breeds to suffer from lad/lab. in conclusion, idiopathic mesenterial lad/lab was seen in young dogs with hyperthermia and gastrointestinal signs. diagnosis of purulent lad/lab on fna does not exclude the presence of another underlying pathogenesis. disclosures: no disclosures to report. canine infectious respiratory disease (cird) is a disease complex caused by different viral and bacterial pathogens. aim of the study was to evaluate clinical and laboratory factors associated with different infectious agents. dogs were included, if they showed respiratory signs (< days) consistent with cird and if non-infectious respiratory conditions could be excluded. nasal and pharyngeal swabs were taken from dogs with cird and tested for respiratory pathogens, including canine parainfluenza virus (cpiv), canine adenovirus (cav), canines distemper virus (cdv), canine herpes virus (chv), canine respiratory coronavirus (crcov), canines influenza virus (civ), and bordetella bronchiseptica (b. bronchiseptica) by polymerase chain reaction. results of clinical and laboratory data were correlated with the underlying pathogen using fisher's exact test and chi-square test (p ≤ . ). cpiv was detected in , crcov in six, and b. bronchiseptica in dogs; patients showed infections with more than one pathogen. there was no significant difference for age and gender distribution between the three groups; however, dogs infected with cpiv more likely originated from a shelter (p = . ). when clinical data were compared, there was no significant difference for the parameters depression, fever, cough, nasal discharge, dyspnoea, and abnormal lung sounds. furthermore, there was no sig-nificant difference regarding abnormalities of erythrocytes, platelets, leukocytes, and differential count between groups. the study shows that in dogs with cird clinical and laboratory parameters cannot indicate the underlying pathogen. furthermore, diseases severity does not seem to depend on the infectious organism involved. disclosures: no disclosures to report. breed related predisposition to bacterial bronchopneumonia (bp) has been reported in irish wolfhounds (iwhs). underlying factors are unknown, however immune deficit, ciliary dysfunction and aspiration have been suggested as predisposing factors. the purpose of this prospective study was to evaluate lymphocyte subpopulations in iwhs with one or more previous bp and compare results to elderly iwhs without any previous bacterial respiratory infections. additionally, healthy dogs of other breeds were included as controls. previous bp was confirmed in iwhs (median age . years, interquartile range . - . years). healthy iwhs (n = , . , . - . years) or dogs of other breeds (n = , . , . - . years) had no history or findings suggestive of previous bp. edta blood samples, collected from all dogs when they were healthy, were stained with fluorescent mouse anti dog cd , cd , cd , cd and mhc class ii antibodies (abd serotec Ò ) and flow cytometry analysis was performed with bd facsaria Ò ii cell sorter and facsdiva Ò software. statistical comparison between groups and the effect of age was studied using analysis of covariance (ancova) models. the number of leucocytes did not differ significantly between groups. the total numbers of lymphocytes and numbers of major lymphocyte subpopulations (b-cells, cd + and cd + t-cells) were significantly lower in healthy iwhs and iwhs with previous bp compared to dogs of other breeds (lymphocytes p < . and p < . ; b-cells p = . and p = . ; cd + t-cells p = . and p = . ; cd + t-cells p < . and p = . respectively). percentage and number of mhc class ii+ non-b lymphocytes was significantly higher in both iwh groups than in dogs of other breeds (p < . in all comparisons). lymphocyte numbers and subpopulations did not differ significantly in healthy iwhs compared to iwhs with previous bp. an age-related decline in the total number of lymphocytes (p = . ), t-cells (p = . ), cd + t-cells (p = . ) and mhc class ii+ non bcells (p < . ) was noticed only in the group of iwhs with previous bp. these preliminary results indicate that iwhs may have significantly lower numbers of lymphocytes, b-cells as well as cd + and cd + t-cells than dogs of other breeds. further studies are needed to determine whether these alterations represent a breed related phenomenon or are connected to the predisposition to bp. an age-related decline in lymphocyte, total t-cell and cd + t-cell numbers was detected in iwhs with previous bp. in humans, age related changes in cd + t-cells have been associated with increased susceptibility to infections. disclosures: no disclosures to report. feline chronic kidney disease (ckd) is a common feature of ageing cats. angiotensin-converting enzyme inhibitors (acei) are recommended to treat hypertension associated with ckd to limit target-organ damage and especially glomerular hypertension. in addition, the international renal interest society (iris) guidelines recommends the prescription of an acei in patients with ckd and proteinuria. to our knowledge no study has demonstrated the effects of long term administration of acei in a client owned population of cats suffering from ckd on glomerular filtration rate (gfr). the aim of the study was to evaluate the effect of an acei (imidapril, prilium Ò , v etoquinol sa) on the gfr of cats suffering from naturally occurring chronic kidney disease (ckd) over months. sixty-six cats presenting with clinical and biological signs of ckd were enrolled by european investigators and followed up till months in this randomized blinded study. thirty-two cats provided suitable data for gfr analysis; animals received imidapril at the dosage of . mg/kg/d and received placebo. animals with no available gfr value on day or with no data after day were excluded as well as animals for which the iohexol clearance could not be determined. follow up was censored after months due to small sample sizes for statistical comparisons. on day , month , month and month , cats were sampled , and minutes after intravenous administration of mg of iohexol. gfr was based on determination of the iohexol clearance which was calculated with the phoenix Ò winnonlin . software. statistical analyses were performed with sas/stat . software. as gfr were not available on each time point for a given animal, the two treatment groups were compared on each gfr determination point using an ancova (analysis of covariance) with the gfr determined on day as the covariate. on d , gfr were . ae . and . ae . ml/kg/min in the imidapril and placebo group, respectively. a significant statistical difference ( . ae . versus . ae . ml/kg/min in the imidapril and placebo group respectively, p = . ) was observed in favor of a higher gfr in the imidapril treated animals on month . higher gfr were also observed in the imidapril group on month and month but not significantly different from the placebo group. daily long term imidapril treatment compared to placebo, may be an effective treatment to slow the progression of renal failure in cats with naturally occurring chronic kidney disease. disclosures: authors are employees of vetoquinol. there is a concern over the potential of cytotoxic drugs which could harm exposed workers. the speciality of oncology of the ecvim-ca published guidelines in order to prevent that risk. however few data exist for evaluation of the real risk of occupationnal exposure. this concern was the aim of our study. biomarkers used were vincristine and cyclophosphamide. surface samples were collected in the consultation room and ward dedicated for chemotherapy. samples were collected with wet filter paper on cm surfaces, or objects (computers for instance). samples were analysed by liquid chromatography and mass spectrometric method.the limit of quantification was . ng/ cm (or . g/object) for vincristine and . ng/ cm (or . g/object) for cyclophosphamide. samples in consultation room were collected after treating dogs with vincristine and after cleaning. samples in dedicated ward were collected after cleaning and after -days stay of treated dogs. aeras/objects were tested in consultation room; in dedicated ward for vincristine; in ward for cyclophosphamide. after treatment of dogs in consultation room, traces of vincristine were detected on the floor and the laboratory bench top ( . - . ng/ cm ). moreover, the surface of auscultation table and extern side of gloves were contaminated after preparation and administration of vincristine (respectively . , and ng/objet). after cleaning, % of samples in consultation room were positive. traces of vincristine were detected on the floor or objects (wall otoscope: . - . ng/ cm ). after cleaning, % of samples in ward were positive. traces of vincristine were detected on the floor and objects (boxes, wastebin, bowls: . - . ng/objet) after cleaning and animals treatment. cyclophosphamide were detected on all areas tested ( . a . ng/objet). despite protective guidelines to avoid spread of cytotoxic drug, environemental exposure was demonstrated. however contaminations were limited and show that handling procedures of cytotoxic drugs are well controlled. most-elevated contamination level for vincristin were noticed on extern side of gloves depsite of using appropriate material. workers should pay a particular attention for gloves withdrawal to limit exposure. small amounts of vincristine were found in inapropriate places: computeur mouse. even if there is few of those residues, we thought about people working on a regular basis in this room for other activities than chemotherapy, and we decided to adapt our clinical practices. evaluation of occupational exposure to cytotoxic drugs is an important step to prevent incidents and heigt awarness of nursing staff to apply those good clinical practices. disclosures: no disclosures to report. the tumor-associated inflammatory response had the effect of enhancing mammary tumorigenesis, helping incipient neoplasias to acquire hallmark capabilities, both in human and dogs. t-cells migration to the tumor site and the following activation may be the essential requirement for their promoting effect on tumors. in human breast cancer the signaling pathways of c-kit have been described as possibly being involved in differentiation, migration, survival, and maturation of t-cells and other inflammatory cells into tumor sites. in order to clarify this subject in canine mammary tumors (cmt), malignant neoplasms were studied by using immunohistochemistry comparing the intratumoral cd + tlymphocytes and c-kit expression together with vegf, microvessel density (mvd) and clinicopathological characteristics of tumor aggressiveness. cd + t cells and high c-kit immunoexpression revealed a positive and statistically significant correlation with vegf (r = . , p < . ; r = . , p = . for cd and c-kit respectively) and cd (r = . , p < . ; r = . , p = . for cd and c-kit respectively). a statistically significant association (p = . ) and a positive correlation (r = . , p = . ) between cd + t-lymphocytes and c-kit was also observed. tumors with high c-kit expression showed higher counts of cd + t-cells. the mvd of high cd /vegf tumors was significantly more elevated (p < . ). a similar association was observed for high c-kit/vegf tumors (p < . ). in this study high cd /vegf, high c-kit/vegf and high cd /c-kit tumors were statistically significantly associated with elevated grade of malignancy (p < . for cd /vegf, c-kit/vegf and cd /ckit), presence of neoplastic intravascular emboli (p < . for cd /vegf and cd /c-kit; p = . for c-kit/vegf) and presence of lymph node metastasis (p < . for cd /vegf, c-kit/ vegf and cd /c-kit). tumors with high cd /vegf (p = . ), high c-kit/vegf (p < . ) and high cd /c-kit (p = . ) expression were associated with shorter os time. interestingly the group of tumors with high c-kit/vegf retained their significance by multivariate analysis arising as independent predictor of os. results of this study suggest that t-lymphocytes may share common signaling pathways with c-kit and vegf in cmt progression and may contribute to increased angiogenesis, aggression and shorter os in these tumors. disclosures: no disclosures to report. few epidemiological data have been published on feline large granular lymphocyte (lgl) lymphoma. a recent study (krick et al. ) described clinicopathologic features in cats with lgl lymphoma, but no comparisons were made with cats with other diseases or other forms of feline lymphoma. therefore, the objective of this study was to assess differences in prevalence, signalment (breed, sex, and age), physical exam findings (body weight, body condition score, body temperature, heart rate, respiratory rate, and systolic blood pressure), and felv/ fiv status between cats with lgl lymphoma (group ) and all other type of feline lymphoma (group ). the electronic data-base of the san marco veterinary clinic was searched between january- and december- for cats with a cytological or histopathological diagnosis of lymphoma. differences between groups were assessed by t-test, mann whitney, pearson-chi square, pearson chi square yates corrected, and fisher's exact test. during the study period out of sick cats seen at the clinic were diagnosed with lymphoma (group : n = ; group : n = ). the prevalence of all type of feline lymphoma between and compared to sick cats did not change over time ranging from . % to . % per year (p = . ; overall prevalence . %, % ci . - . ). the lymphoma lgl prevalence between and compared to all types of lymphoma did not change over time ranging from . % to . % per year (p = . ; overall prevalence . %, % ci . - . ). among the variables studied, only sex (group : [ . %] females, [ . %] males; group : [ . %] females, [ . %] males; p = . ) and age (group : ae months; group : ae months; p = . ) were significantly different between groups. sixteen out of cats with lgl lymphoma were tested for their felv/fiv status resulting all felv-and one ( . %) fiv+. seventy-four out of cats with all other types of lymphoma were tested for their felv/fiv status resulting ( . %) felv+ and ( . %) fiv+. five cats ( . %) were both felv+/fiv+. prevalence of felv infection was significantly lower (p = . ) in group compared to group . there was no difference in prevalence of fiv infection between groups. lymphoma lgl affects more females and older cats compared to all other type of feline lymphoma. opposite to all other type of lymphoma, and in accordance to previous litterature information, felv+ status does not play a role in the pathogenesis of feline lgl lymphoma. disclosures: no disclosures to report. the activity of t regulatory cells (tregs) is known to be closely associated with the expression of foxp transcription factor. foxp regulatory t cells (foxp treg) are a distinct group of t lymphocytes that have immunosuppressive properties. normally this cells work for prevention of harmful autoimmune responses, however can also interfere with beneficial immune responses such as anti-tumor immunity. in human breast cancer these cells play a crucial role in tumor progression. in canine mammary tumors (cmt) there are only a few studies and this topic are not welldocumented. in this study we included malignant cmt and studied, by immunohistochemistry, the intratumoral foxp expression together with vascular endothelial growth factor (vegf), microvessel density (mvd, by cd antibody) and several clinicopathological characteristics. abundant foxp treg cells was statistically associated with presence of tumor necrosis (p = . ), nuclear grade (p = . ), poor differentiation of tumors (p < . ), high mitotic grade (p < . ), high histological grade of malignancy (p < . ), presence of neoplastic intravascular emboli (p < . ) and presence of lymph node metastasis (p < . ). intratumoral foxp levels were correlated with the levels of vegf (r = . ; p < . ) and intratumoral mvd (r = . ; p < . ). additionally tumors with abundant foxp treg cells were associated with shorter overall survival (os) time (p = . ). results suggest that treg cells play a role in cmt progression and may contribute to increased angiogenesis and aggression in these tumors. the association of intratumoral foxp expression with shorter os of animals suggests a utility of treg cells activity as a prognostic marker. disclosures: no disclosures to report. clinical manifestations of canine visceral leishmaniasis (canl) are non-specific and include progressive weight loss, anemia, lymphadenomegaly, hepatosplenomegaly, dermatological, renal and ocular alterations. cardiac lesions resulting in clinical signs has been scarcely described in dogs with vl, and the presence of the parasite in the cardiac tissue has been involved in few reports. accordingly, the present study aimed to evaluate histopathological abnormalities in cardiac tissue from dogs naturally infected by leishmania infantum chagasi. a total of dogs were evaluated. all dogs were symptomatic but no one presented clinical signs of cardiac involvement. in compliance with a federal law and under the owners' signed consent, all dogs were submitted to euthanasia and comprehensive post-mortem evaluation. samples from right atrium free wall (ra), right ventricle free wall (rv), interventricular septum (ivs) and left ventricle free wall (lv) were collected and evaluated. tissue samples were fixed in formalin, embedded in paraffin, sectioned at mm, and stained with hematoxylin and eosin (he) and anti-leishmania immunohistochemistry was also performed. the study was approved by the ethics committee in animal experimentation and animal welfare (protocol number / ). histopathological changes were observed in at least one of the four evaluated cardiac regions in % ( / ) of the dogs. the most frequent cardiac injury was an inflammatory reaction, characterized by the presence of mononuclear cell infiltrate in different degrees. of the evaluated regions, ra was the one with the highest incidence of histopathological changes, observed in % ( / ) of the animals, followed by rv, lv and siv, affected in . % ( / ), . % ( / ) and . % ( / ) of the dogs, respectively. immunohistochemistry revealed amastigotes in the cardiac tissue in % ( / ) of the dogs. a positive correlation was found between cardiac lesions and the presence of amastigotes in the myocardium (p < . ). disclosures: no disclosures to report. canine leishmaniosis is a life threatening zoonotic disease. the combination of meglumine antimoniate and allopurinol is considered the most effective therapy for canine leishmaniosis and constitutes the first line protocol against this disease. allopurinol is a parasitostatic drug used in long-term to maintain low parasite loads and to avoid clinical relapses. traditionally, allopurinol is considered a very safe drug in the dog. however, some reports indicate that xanthinuria and xanthine urolithiasis is produced after prolonged therapy with allopurinol in the dog. the aim of this prospective study was to evaluate the prevalence of urinary adverse effects of allopurinol treatment ( mg/kg/bid/po) in dogs with leishmaniosis. diagnosis was made by compatible clini-copathological abnormalitites with leishmaniosis and high leishmania infantum-specific antibody levels assessed by quantitative elisa. once leishmaniosis was diagnosed, a close follow-up (day , , , and during treatment) including physical examination, baseline laboratory tests (cbc, biochemistry profile, serum electrophoresis, urinalysis, urinary protein/creatinine ratio) and abdominal ultrasound was performed. in our preliminary results, dogs were included. dogs did not present any urinary abnormalities based on biochemistry profile, urinalysis and abdominal ultrasound at the time of diagnosis. four out of presented xanthinuria (day- [n = ], day- [n = ], and day- [n = ]). two out of dogs presented renal mineralization at day- of treatment. two out of dogs presented bladder urolithiasis since day- of treatment. xanthinuria was presented initially in all dogs that developed renal mineralization or bladder urolithiasis. dogs with renal mineralization and urolithiasis were treated with a restricted protein diet and, so far, they did not develop renal disease. the present study describes early xanthinuria, renal mineralization and urolithiasis as adverse effects due to chronic allopurinol treatment in dogs with leishmaniosis. neither mineral analysis nor renal biopsy was performed to confirm the origin of these lesions, but no urinary abnormality was present before allopurinol treatment was instituted. a thorough monitoring of dogs treated against leishmaniosis combined with urinalysis and abdominal ultrasound should be performed to evaluate urinary adverse effects and to help in the clinical management of these adverse effects. disclosures: no disclosures to report. giardia duodenalis is one of the most important gastrointestinal parasites in dogs and cats with a zoonotic potential. in germany the prevalence in dogs and cats reaches up to % and %, respectively. genotypes of two genetic assemblages of the parasites infect humans (assemblages a and b) and other mammals including small animals. in contrast, parasites of the assemblages c and d are specific for dogs, assemblage f for cats. objectives of the study were to analyse the prevalence, potential epidemiological risk factors and symptoms of g. duodenalis infections in dogs and cats. to detect g. duodenalis, feces from dogs and cats was analysed with an elisa technique. after dna extraction real time pcr as well as multi-locus sequence typing was performed for the following gene loci: triosephosphate isomerase-, glutamate dehydrogenase-, beta-giardin-gene, ssu rrna. with a questionnaire possible epidemiological risk factors were evaluated. statistical analyses were performed using spss (odds ratio, kolmogorow-smirnow test, spearman correlation). fecal samples of dogs and cats were collected over a time period of months. the elisa test was positive in / dogs and / cats. sixty-seven of giardia positive dogs and of positive cats had gastrointestinal signs. genotyping was successful in of dog samples and were assigned to assemblages as follows: assemblage a (n = ), a/c (n = ), a/d (n = ), b (n = ), b/d (n = ), c (n = ), c/d (n = ), d (n = ). only one of positive cat samples could be genotyped and was atypically identified as assemblage d. significant correlations between giardia infection and age, clinical signs, deworming status and staying abroad were found. in this monocenter study a prevalence rate of . % in dogs and . % in cats was detected, which is in good accordance with previous studies. the study further highlights a high rate ( %) of asymptomatically g. duodenalis infected animals. as potential zoonotic assemblages were detected, transmission of giardia from small animals to humans (and vice versa) cannot be excluded. especially young and not dewormed animals had a higher prevalence. disclosures: no disclosures to report. canine parvoviral enteritis remains a common cause of morbidity and mortality in young dogs. the goal of this study was to document a large cohort of affected dogs and analyze several factors as possible predictors of fatal outcome. medical records were retrospectively searched for dogs with parvoviral enteritis diagnosed with a positive fecal antigenic test or a fecal pcr. dogs were included only if the medical records were complete. the population was compared to the reference population of the hospital on the same time period with chi square tests and several factors were analyzed as possible predictors of death with a logistic regression. one hundred and forty seven cases were included. seventy percent of the dogs were non vaccinated puppies under the age of months. intact females and rottweiler, american staffordshire terrier and french beauce shepherd dogs were over-represented. clinical signs such as vomiting, diarrhea and dehydration were present in . %, . % and . % of the dogs respectively. hyperthermia, anemia and leucopenia were observed in . %, . % and . % of dogs respectively. the majority of the affected dogs were hospitalized for - days and the mortality rate was . % ( / dogs). hypoglycemia at admission was observed in / ( . %) dogs in which blood glucose was measured and was the only risk factor associated with death (p < . ). in this study, a predisposition of rottweiler, american staffordshire terrier and french beauce shepherd dogs was observed and hypoglycemia at admission was the only predictor of fatal outcome. disclosures: no disclosures to report. canine parvovirus (cpv) infections in dogs remain widespread around the world and still represent a major health threat in puppies. all vaccine manufacturers include this component in their core vaccination package, recommending two injections at - weeks interval from to weeks of age. despite broad vaccination coverage, number of reports suggesting lack of efficacy in vaccinated dogs have been reported, which implicate vaccines belonging to all major manufacturers. these cases are usually considered as being linked to the interference with maternal antibodies (matab), able to persist beyond weeks of age, which has led most expert groups to recommend a third vaccination around weeks of age. persistence of matab actually represents a major issue when immunizing puppies against parvovirosis. indeed, matab titres higher than / in the haemaglutination inhibition (hi) test can still inhibit vaccine uptake whereas such titres do not prevent field virus infection. in contrast, hi titres higher than / to / are usually considered as protective against disease and virus excretion. this "immunity gap"is therefore a critical period for the puppy and the outcome of the vaccination. in order to evaluate the impact of residual mda on the efficacy of a standard primary vaccination protocol, we performed a vaccination field trial with serological follow-up. eighty-eight puppies from to weeks of age presented at veterinary practice received injections at weeks interval. serology was performed by elisa before (at d /v ), during (at d /v ) and after (d ) vaccination. average maternal antibodies titres were strongly correlated with the age of the puppy at primary vaccination, remaining at vaccine inhibiting level until~ week of age. average titres increased significantly after st injection of primary vaccination in most groups and in all groups after the nd injection of primary vaccination. individual variability remained significant: vaccine uptake was inversely and strongly correlated to the pre-vaccinal matab titre at vaccination. seven out of puppies ( %) didn't seroconvert, despite vaccination complying to the recommended schedule. vaccination was started in such dogs between . and . weeks and completed between . and . weeks and average initial matab titre was . log compared to . for the general population. in conclusion, this trial supports the recommendation of an additional injection of primary vaccination at weeks, especially in areas of high parvovirus prevalence / pressure, where high levels of matab are likely to be transferred to puppies. disclosures: all authors are employees of merial. ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . . % of the dogs were pcr positive. the aim of our study was to evaluate the usefulness of determining serum level of c-reactive protein (crp) in dogs naturally infected with bacterium a. phagocytophilum as a possible indicator of the clinical phase of the disease. pcr and/or ifa positive dogs with clinical presentation and/or thrombocytopenia were included in the study. based on the results, the dogs were divided into groups: pcr positive dogs; ifa positive (subdivided according to titer level from : to > : ) and pcr negative dogs; positive control group -pcr and ifa negative dogs with clinical signs and/or thrombocytopenia; negative control groupclinically healthy, pcr and ifa negative dogs. serum level of crp was determined using lifeassays Ò canine crp (lifeassays, lund, sweden). an elevated concentration of crp (> mg/l) was determined in pcr positive and ifa positive dogs with an ifa titer ≥ : and coincides with the presence of clinical signs (most commonly general clinical signs, elevated body temperature, gastrointestinal problems) and/or mild ( . %) or severe ( %) thrombocytopenia. the assessment of crp concentration, in correlation with certain clinical alterations and thrombocytopenia, suggests that crp concentration is elevated in the acute phase of the disease and is in correlation with the aforementioned changes therefore can serve as an additional diagnostic parameter. the crp concentration in ifa positive dogs, regardless of ifa titer levels, and with present clinical signs and thrombocytopenia is higher (above detectable level, > mg/l) than in dogs without clinical signs or laboratory alterations, which may speak in favor of reinfection or reactivation of a persistent infection at least in cases when no other cause of inflammation can be found. specific treatment would therefore be reasonable in such cases, especially in cases of rising crp concentration. disclosures: no disclosures to report. gallbladder agenesis is a very rare cause of elevated liver enzymes in dogs. in this study, we evaluated the features of dogs [six males (three castrated) and nine females (two spayed)] with suspected gallbladder agenesis on ultrasonography. five different breeds were included: chihuahua (n = ), toy poodle ( ), german shepherd ( ), jack russell terrier ( ), and shiba dog ( ). the median age was . ( . - . ) years. ten dogs were asymptomatic, while the other five dogs showed decreased appetite ( ), vomiting ( ), ascites ( ), seizure ( ), and diarrhea ( ). all dogs showed elevated liver enzymes, with high alanine aminotransferase levels (median, u/l; - u/l) in dogs and high gamma-glutamyl transpeptidase levels (median, u/l; - u/l) in . gallbladder agenesis was confirmed using laparoscopy in dogs and laparotomy in three. liver biopsy samples were obtained from all dogs. additional computed tomography cholangiography was performed for dogs using a -slice multidetector computed tomography (mdct) scanner following the intravenous administration of contrast medium (meglumine iotroxate). the obtained images were analyzed on a workstation, and they revealed an absent gallbladder in nine dogs and a vestigial gallbladder in three. the common bile duct was dilated in five dogs. for all dogs, laparotomy or laparoscopy was used to visualize the gallbladder and liver abnormalities, including malformed lobes and surface irregularities. acquired portal systemic collaterals were visually confirmed in five dogs, who also exhibited hypoplasia of the portal vein on histological examination. in conclusion, most animals with gallbladder agenesis were asymptomatic in our study, indicating a good long-term prognosis. however, symptoms associated with portal hypertension must be monitored in animals with primary portal vein hypoplasia. disclosures: no disclosures to report. assessment of systolic arterial blood pressure (sap) is an important tool in small animal internal medicine practice, especially with diseases or clinical conditions that can cause hypertension or hypotension. the doppler method is noninvasive and has several advantages compared to oscillometric method. there are few studies about the effect of body position on sap in conscious dogs. the hypothesis was that animal positioning during measurement alters sap values. the study design was prospective and randomized regarding order of positioning measurements. one hundred and twenty client-owned, conscious, healthy or sick adult dogs, weighing up to kg were included. sap was recorded by doppler ultrasonography following american college of veterinary internal medicine consensus statement with animals positioned in sternal recumbency, right lateral recumbency and with the dog laying down on owner s lap. the order of body position was raffled at the time of measurement. five consecutive measurements on each body position were performed always on left forelimb and the average was calculated. sap values were higher in sternal recumbency ( mmhg, p %- % = - . ; p < . ) compared to those obtained on the owner s lap ( mmhg, p %- % = . - . ), and both were similar to right lateral recumbency ( mmhg, p %- % = - ). these results suggest that sap measurement obtained on owner s lap or right lateral recumbency can be used on clinic routine, but sap measurement obtained on sternal recumbency should be avoided, because such measures may be overestimated. disclosures: no disclosures to report. canine patients may be presented for blood pressure (bp) assessment when clinical diseases associated with systemic hypertension (ht) are suspected but not confirmed; this population may encompass patients that have normal bp, true ht or situational ht. the clinician's aim is to identify animals with ht reliably, while minimizing false positives. this prospective study investigated the repeatability of duplicate within-visit systolic bp assessments (sbp and sbp ) in consecutive canine patients presented for bp assessment in the small animal clinic ( duplicate sbp recorded from dogs) and in a control group of healthy dogs ( duplicate sbp obtained from control dogs), resulting in duplicate measurements for analysis. doppler methods were used for duplicate assessments and oscillometric methods were used for duplicate assessments; cuff size/location were consistent within any dog. sbp ≤ mmhg was considered normal (nml); sbp > mmhg was considered abnormal (abn). median (range) elapsed time between duplicate readings was ( - ) minutes; % of sbp were obtained within minutes of sbp . there was no correlation between elapsed time and change in sbp (p = . ). % of sbp were equal to or lower than sbp ; median decrease was ( - no dog with sbp > mmhg (n = ) had nml sbp . more dogs with abn sbp were panting ( / scored, %) compared to the group with dogs with nml sbp ( / scored, %, p = . ). sbp of dogs that stopped panting ( / , %) tended to decrease (p = . ). within-visit repeatability of bp diagnosis was good in dogs with nml sbp , but apparent false positive diagnoses of ht occurred in % of dogs with abn sbp . sbp > mmhg was repeatable in all dogs. panting may be associated with increased measured sbp by these methods. duplicate within-day measurements may help identify false positive ht diagnoses in dogs with initial sbp measurements > mmhg. disclosures: no disclosures to report. median age at presentation was years. ess, cocker spaniels, ckcs and border collies presented at . , . , . and . years respectively. females were over-represented with / females ( / fn and / fe) and males ( / mn and / me). % of the ess cases presented were fn dogs. clinical presentation varied between dogs. clinical signs of pyrexia ( %), lethargy ( %) and anorexia ( . %) were the most common. other signs included cough, tachypnoea, dyspnoea, dysphagia, vomiting, diarrhoea, neck or spinal pain, abdominal pain, joint effusion or dermatologic signs thirty-one animals presented with peripheral lymphadenomegaly, but five animals displayed only internal lymph node enlargement. cytology was performed in / cases pyogranulomatous ( ) or granulomatous ( ) lymphadenitis. lymph node culture or staining (gram, pas, zn) was performed in and animals respectively, all of which were negative twenty-four animals were initiated therapy at mg/kg q hours. mean treatment length was weeks median relapse time was weeks. this study documents dogs with cssrl in the uk suggesting an over-representation in spaniel breeds (particularly ess), with females and young dogs typically affected. cytologic and histopathologic examination confirmed sterile lymphadenitis with animals showing marked and rapid clinical improvement pastor . hospital clinic veterinari animal medicine and surgery department, faculty of veterinary medicine of murcia, murcia, spain if only blood is available. therefore, if no effusion is present, diagnosis of fip still remains challenging. disclosures: dr. elisabeth mueller is the managing director of laboklin gmbh & co.kg. dr. karola weider is employed at laboklin gmbh & co.kg. this laboratory offered the "combined rt-npcr and sequencing approach which samples are the most relevant for analysis? a retrospective study of cases from maisons alfort, france, umr virologie inra-enva-anses cyprus is an island state in the eastern mediterranean basin. no epidemiological studies have yet been performed on infectious agents in cats from cyprus. the aim of this study was to determine the prevalence of several infectious agents, including some vector-borne infections, in cats from cyprus.surplus edta-blood and serum samples were recruited from cypriot cats, from which signalment and lifestyle characteristics were recorded. dna was extracted and real-time quantitative polymerase chain reaction (qpcr) assays were used to detect haemplasmas (mycoplasma haemofelis, "candidatus mycoplasma haemominutum" and "candidatus mycoplasma turicensis"), leishmania spp.and bartonella henselae. conventional pcr assays were used to detect ehrlichia/anaplasma spp. samples yielding positive results for leishmania spp. or ehrlichia/anaplasma spp. underwent further characterisation (sequencing). elisas were performed for the detection of l. infantum antibodies, feline leukaemia virus (felv) antigen and feline immunodeficiency virus (fiv) antibodies. statistical analysis was performed using spss for the assessment of any associations between variables and infectious agents.of the samples extracted, were excluded due to failure of ≥one internal control pcr. of the remaining samples, ( . %) were positive by pcr for haemoplasma including ( . %) for m. haemofelis, ( . %) for "ca. m. haemominutum" and ( . %) for "ca. m. turicensis". nineteen ( . %) were positive for b. henselae. one cat ( . %) was pcr positive for ehrlichia/anaplasma spp. and sequencing revealed identity with anaplasma platys. leishmania spp. dna was detected in of the ( . %) cats; sequencing revealed l. infantum in of these cases. l. infantum serology was positive in of the cats tested ( . %). only one cat was positive for both leishmania pcr and serology. of the cats that underwent retroviral serology, ( . %) were felv and ( . %) were fiv positive.statistical analysis identified several significant associations (p < . ) including the following; haemoplasma infection and both outdoor access and feral-shelter cat origin, felv or fiv infection and both anaemia and feral-shelter cat origin.this study documents, for the first time, the presence of haemoplasmas, l. infantum, b. henselae, a. platys, felv and fiv in the feline population of cyprus. the prevalence of haemoplasma, fiv and b. henselae infections were among the highest reported in cats from mediterranean countries, while that of leishmania spp. was similar. this is the second report of a. platys infection in a cat from a mediterranean country.disclosures: no disclosures to report. bartonella species (spp.) are zoonotic pathogens, and infections in cats are common. prevalence in cats from southern germany is still unknown. the aim of this study was to determine the prevalence of bartonella spp. dna in blood of cats in southern germany and to evaluate associations between bartonella bacteremia, housing conditions, feline immunodeficiency virus (fiv), and feline leukemia virus (felv) status, including progressive, regressive, and abortive felv infection.blood samples of cats that were presented to different veterinary clinics in southern germany for various reasons were tested for bartonella spp. dna using a previously published conventional polymerase chain reaction (pcr) targeting a fragment of the s- s rrna intergenic spacer region. for statistical analysis, fisher's exact test was used.prevalence rate of bartonella spp. bacteremia was . % ( / ; ci: . %- . %). b. henselae was amplified in eleven of these cats. one cat was positive for b. clarridgeiae dna. most of the infected cats were clinically healthy, but half of the cats had thrombocytopenia, potentially caused by their bartonella spp. infection. there was no significantly higher risk to be infected with bartonella spp. when living mainly outdoors or being fiv-or felv-infected.prevalence of bartonella spp. bacteremia is low in southern german cats, but there is still a risk of human bartonella infection associated with cat ownership. most clinical changes of the bartonella spp.-infected cats were related to other diseases. however, thrombocytopenia was common and further studies are required to define its potential clinical relevance.disclosures: no disclosures to report. ante-mortem diagnosis of feline infectious peritonitis (fip) is still challenging. the aim of this study was to evaluate sensitivity and specificity of a "combined reverse transcription nested polymerase chain reaction (rt-npcr) and sequencing approach", detecting mutations at two different nucleotide positions within the spike gene, that previously were shown to correlate with the fip phenotype. the study population consisted of cats with confirmed fip and a defined control group of cats for which fip was considered an important differential diagnosis, but that were definitively diagnosed with other diseases. blood and/or effusion samples were examined for feline coronavirus (fcov) rna by rt-npcr and, if positive, nucleotide positions and were sequenced for nucleotide transitions. sensitivity, specificity, negative and positive predictive values were determined and % confidence intervals ( % ci) calculated.rt-npcr detected fcov in cats in blood (n = ) and/or effusion (n = ); all of them had fip. one of the mutations of interest was found in / of the pcr-positive blood samples and in / of the pcr-positive effusion samples. diagnostic specificity of the "combined rt-npcr and sequencing approach" was % in blood ( % ci . - . ) and effusion ( % ci . - . ). diagnostic sensitivity was . % ( % ci . - . ) in blood and . % ( % ci . - . ) in effusion.a positive test result therefore confirms a suspicion of fip. a negative result, however, cannot be used to rule out fip, especially feline infectious peritonitis (fip) is a viral disease caused by the virulent strain of feline coronavirus (fipv). the disease can appear under two clinical forms, dry or effusive, both leading to a fatal outcome. diagnosis was based on histopathologic lesions on necropsy until the recent discovery of mutations associated with the fipv strain in the c and spike (s) genes. our main goal was to detail the distribution of c or s gene mutations in different biological samples of cats suffering from fip.this was a retrospective, observational study of cats showing clinical signs compatible with fip. ten out of cats were of pure breed. . % were males and . % females. median age was . months at presentation. the clinical presentation, pathologic findings and virologic data were reviewed. according to clinical signs, cats were classified with a dry form and with a wet form of fip. the main clinical signs included dehydration, hyperthermia, icterus, abnormal abdominal palpation, neurological and ocular disorders.when possible blood, fecal material, effusion, fine needle aspiration (fna) from relevant organs or a combination of these, was recovered from each cat. feline coronavirus (fcov) was first researched by rt-pcr, then the c and part of the s genes were sequenced to determine the eventual presence of mutations.among the dry cases, fcov was detected in / blood samples, / fecal samples and fna ( / ). among the wet cases, / blood samples, / fecal samples and all effusion samples ( / ) were positive for the presence of fcov. c mutations were never found in fecal samples but were found in / effusion samples and in / fna. s mutations were detected in / fecal samples, / fna and / effusion samples. for three cats, no mutation, neither in c or s genes was identified despite the confirmation of fip by necropsy.s gene mutation is more frequently observed than c gene despite in two cases where only c mutations were identified. moreover the presence of strains harbouring s mutation in feces has never been described before and could suggest the possible diffusion of fipv among feline population.in conclusion, viral diagnosis of fip based on rt-pcr sequencing in effusion and fna samples is essential. rt-pcr resulting from blood samples should be carefully interpreted because of high risk of missing fipv.finally, searching for mutations in both s and c genes is recommended.disclosures: no disclosures to report. methicillin resistant staphylococcus aureus (mrsa) has recently become a great concern for pet animals' disease and zoonotic infection. mrsa strains transfer between pet animals and humans could occur. the aim of the present study was to determine the occurrence of mrsa in household dogs.from january to june , clinical samples were collected from dogs, patients of the veterinary teaching hospital of the department of veterinary sciences of messina (italy), affected by several diseases of various origins. all samples were processed by bacteriological conventional methods for isolation and identification. all strains were tested for phenotypic susceptibility to oxacillin and were subjected to a pcr protocol for the detection of meca gene. strains carrying the gene were considered methicillin resistant (mrs). lastly, on both mrs and methicillin sensitive (mss) strains, kirby-bauer disk diffusion susceptibility testing were performed to highlight resistance profiles using molecules belonging to the main classes of antimicrobials used in veterinary practice. strains resistant to at least one molecule of three or more classes of antibiotics were considered multidrug-resistant (mdr). the statistical analysis of the results was made using the z-test by a primer Ò software.forty staphylococcus spp. strains were isolated, belonging to species. the most frequently isolated microorganisms were staphylococcus aureus with isolations ( %) and staphylococcus pseudintermedius with isolations ( . %), followed by staphylococcus epidermidis with isolations ( %) and staphylococcus cohnii and staphylococcus warneri, both with isolations ( %). a single isolation ( . %) was obtained for each of the species staphylococcus chromogenes, staphylococcus haemolyticus, staphylococcus lentus, staphylococcus lugdunensis, staphylococcus saprophyticus, staphylococcus simulans and staphylococcus sciuri. thirteen ( . %) strains of staphylococcus spp. were phenotypically resistant to oxacillin and three staphylococcus aureus ( . %; n. from pyoderma, n. from exudative pleural effusion) were positive for the meca gene. all strains of staphylococcus spp. were mdr. our results showed the presence of mrsa and multidrug-resistant staphylococcal strains in household dogs. a lack of correspondence between antimicrobial susceptibility tests and molecular methods was found in the present study.disclosures: no disclosures to report. haemotropic mycoplasmas (haemoplasmas) are bacteria that infect domestic cats. approximately % of ill cats have haemoplasma infection. three main feline haemoplasma species have been detected worldwide; mycoplasma haemofelis (mhf), "candidatus m. haemominutum" (cmhm) and "candidatus m. turicensis" (cmt). a fourth haemoplasma called "candidatus m. haematoparvun-like" (cmhp) was latter identified in cats. the only published study in chile was carried out in cats, with prevalences by pcr of . % to mhf, and % to cmhm.the aim of this study was to perform molecular detection of haemoplasmas in cats from valdivia, southern chile. blood samples were taken from cats and used for haemoplasmas dna detection by quantitative real time pcr (qpcr) at universidad austral de chile. qpcr protocol was based on detection of feline dna targeting s housekeeping gene and mycoplasma spp. s rrna gene (universal primers, my sf forward, my sr y my sr , both reverse) by sybr green method. the melting temperature (tm) analysis allowed identifying the infecting mycoplasma species (mhf, cmhm, cmt). it was not posible to identify haemoplasmas species on co infected cats, so a second qpcr specie specific protocol was applied on these samples. second qpcr protocol was based on s rrna gene, with specific primers to detect mhf, cmhm, cmt and cmhp. all samples ( / ) were positive to s gene, proving presence of cat dna. from the cats, . % ( / ) were positive to haemoplasmas, where . % ( / ) corresponded to cmhm (tm . - . °c), . % ( / ) to mhf (tm . - . °c), % ( / ) to cmt (tm . - . °c) and . % ( / ) to co infections. associations between cmhm+mhf, cmhm+cmt, cmhm+cmhp and cmhm+mhf+cmhp were detected on co infected animals. these results agree with those found in previous key: cord- - j muh authors: chance, gail d.; bacon, john d. title: systematic implications of seed coat morphology in nama (hydrophyllaceae) date: - - journal: am j bot doi: . /j. - . .tb .x sha: doc_id: cord_uid: j muh seeds from species of nama (hydrophyllaceae) were examined by scanning electron microscopy in order to assess systematic implications of seed coat structure. generally, seed coat morphology is species specific. nevertheless, similarities among species in seed coat organization, particularly, outer testa anatomy and wall thickening‐pitting patterns allow the recognition of six groups among examined taxa; furthermore, seed coat features often suggest both intra‐group and inter‐group relationships. recognized groupings do not correspond well with the more classicial treatments of nama; rather, they suggest that a restructuring of the infrageneric and even the generic taxonomy of nama is in order. the second largest genus in the hydrophyllaceae, nama is a predominantly north american taxon common to more xeric regions of northern mexico and southwestern united states. however, a few species extend into south america and, curiously enough, one is endemic to the hawaiian islands. while the genus, on the whole, is widespread, most species are limited in distribution often by edaphic factors (e.g., gypsum, johnston, ; bacon, ) . the excellent classical treatment of nama provided by c. l. hitchcock ( hitchcock ( , continues as the major source of information regarding the genus. hitchcock recognized species, ranging from delicate annuals to robust, woody perennials. these were distributed among five sections: arachnoidea ( sp.), nerascentia ( sp.), zonolacus ( sp.), conanthus ( spp.), and nama (as eunama, spp.). subsequently, additional species have been recognized, one in sect. conanthus and the remainder in sect. nama, so thattheir number now totals about . each of hitchcock's smaller sections is well defined and segregated from others by singularly notable characters. indeed, sects. arachnoidea and cinerascentia are so well defined that their placement in nama has been questioned (bacon, ; raven and axelrod, ) . in contrast, sect. nama houses a diverse assemblage of species, as noted by hitchcock ( ) , and relationships among constituent taxa, as well as intersectional relationships, have yet to be fully explored. hitchcock's ( ) observation that seeds of different species exhibit variously patterned surfaces offers a promising point of departure for studies aimed at elucidating relationships in nama. indeed, seed coats may retain ingenuous indications of phyletic commonality (martin, ; davis and heywood, ; esau, ) , and many recent studies in various, unrelated groups have confirmed the general utility of seed coat characters for assessing systematic relationships (e.g., chuang and heckard, ; whiffin and tomb, ; hill, ; clark and jernstedt, ; canne, canne, , elisens and tomb, ) . we have examined the seed coats of species of nama utilizing scanning electron microscopy (sem) and report implications of seed coat structure towards systematics of nama. materials and methods -mature seeds removed from herbarium specimens were mounted on brass or aluminum specimen stubs with double-stick scotch tape. specimens were then coated with gold or gold-palladium in either a technics hummer jr. or a polaron e- vacuum sputter coater. sputter coaters were calibrated so that coating for . minutes yielded a metal layer of about ain thickness. in order to examine the fine features of the testa and its component cells, seeds were sectioned free-hand with razor blades. sections were extracted in acetone for - sec to remove lipid material present in the endosperm layer which, on sectioning, covered the testa layer and obscured structural detail (amott and webb, ) . sections were mounted and coated as described for whole seed mounts. [vol. additionally, some seeds were soaked for - min, or longer ifnecessary, in distilled water or a % solution of aerosol ot to facilitate removal of seed coat pieces, peels, from the whole seed. peels were mounted on specimen stubs and sputter coated as previously described. results and discussion-seeds of nama species are morphologically diverse. ranging from . mm to . mm in length, seeds are black, brown, yellow or white in color and are spherical, oval, fusiform, ovate or irregularly multi-sided in shape. however, as noted in other plant groups (chuang and heckard, ; tomb, ; clark and jernstedt, ; canne, ) , the shape and size of mature seeds may vary in some nama species. variation appears to be primarily related to the number and position of ovules developing within the ovary (amott, ; tomb, ) . nevertheless, for each species of nama there is a typical shape and size ( fig. - ) . viewed in section, mature seeds possess an outer testa that is either solid, thus appearing as a dense, melded, acellular layer, or else chambered (appearing as a layer clearly cellular in composition). in surface patterning, seeds with a solid coat generally appear foveolate, papillose or exhibit gentle depressions. seeds with a chambered coat are moderately to strongly reticulate with the degree of reticulation being dependent upon the relative wall height of cells forming the reticulum. moreover, the reticulum provides the most discriminating features of the chambered seed coat, namely thickenings or pits-perforations in the walls of reticulum chambers. utilizing seed coat features, seeds of examined taxa may be divided into six distinct groups. within each group seed size, shape and coat particulars may further characterize each species. we choose not to describe each species; rather, micrographs are included to convey the essence of species individuality. descriptions are restricted to the minimum necessary to facilitate our discussion and systematic appraisal of each group. seed group (fig. - )-the two included species, n. rothrockii (fig. , ) and n. lobbii (fig. , ) , produce seeds with a thick solid coat - ~m in thickness. moreover, the seeds of both species average . mm in length and are the largest of those examined. for both species we infer that the outer testa begins as a cellular layer and develops into a solid layer after intracellular deposition ofwall material. the porous, honeycombed appear-ance of the upper ih~h of the outer testa in n. rothrockii (fig. ) as well as the small gaps associated with papillose extensions (suggestive of cell junctions) in n. lobbii (fig. ) support this contention. we attribute surface patterning of the two to collapse of the upper tangential wall to the level of deposited material. radial walls in n. rothrockii are essentially the same height; collapse of the upper wall results in a foveolate surface. certain areas of the radial walls in n. lobbii are elongated and higher than the remaining wall; collapse of the upper tangential wall produces a papillose surface with each papillus being a wall extension. hitchcock ( ) segregated n. lobbii and n. rothrockii into the monotypic sections arachnoidea and cinerascentia, respectively; the former species produces capsules which are loculicidally and septicidally dehiscent while other namas exhibit only loculicidal dehiscence. nama rothrockii is the sole nama with capitate inflorescences. moreover, chromosome numbers have been determined for well over f ofthe species ofnama (cave and constance, , , constance, ; bacon, ) , and establish the genus as a strikingly diploid group with a base number of x = . n. lobbii is known only as tetraploid, n = , while n. rothrockii is even more radically divergent with n = . seeds ofthe two species also diverge from the bulk of nama. they are unique in terms ofsurface patterning and thickness of the outer testa layer among examined species. indeed, features ofsize and coat thickness would argue that the two are more closely related one to another than either is to yet other namas. we perceive the former relationship as distant. clearly, seed features support our opinion that inclusion of these two species in nama is less than tenable. seed group (fig. - )-this seed group comprises five species characterized by a thin, solid seed coat - ~m in thickness. surface patterning is generally foveolate. the foveae are not formed because of unequal thickening of the seed coat, since the coat is essentially uniform in thickness. rather, the coat conforms to the underlying endosperm topology resulting in shallow surface depressions (fig. , ) . seeds of four included species, n. hispidum (fig. ) , n. turneri, n. stevensii, and n. undulatum (fig. ), reveal surface striations as well as ridges believed to reflect cell boundaries (fig. ) . the fifth species, n. sandwicense, exhibits a bullate surface (fig. ) . additionally, seeds of the former four species are yellow in color and fusiform in outline, while those of the latter taxon are generally gray-white in color and ellipsoid. similarities among the seeds ofn hispidum, n. turneri, n stevensii, and n. undulatum suggest the four are closely related; indeed, a relationship between n hispidum and n turneri has been proposed (bacon, ) . while seed features ofthe anomalous n sandwicense suggest this hawaiian endemic is distantly related, similarities previously enumerated argue that it is allied to this group. seeds of species in group are easily distinguished from those in group , but the fact that both groups possess solid coats hints at a common origin. however, despite external appearances, we have observed no indications suggestive of a cellular structure in seed coat sections among species of group . it is possible, therefore, that the surface ridges arise due to compression of the ovule during development and that the coat may be formed partly from an extracellular exudate rather than wholly from an intracellular deposit as we infer for the species of group . in any event, it seems more plausible to view the solid seed coats of group and group not as characters based in a common origin, but as characters independently acquired in only remotely related groups. seed group (fig. - )-thesixincluded species are characterized by a reticulate seed coat in which pits-perforations (fig. , ) are found in radial walls of the reticulum cells. additionally, the apical rim of each chamber is "knobby" in appearance (fig. , ), although on individual seeds the knobs may be obscured by the adherent tangential wall. generally, seeds ofthis group are ovoid and brown in color. seeds ofnjamaicense (fig. ) are identical with those of n bart/ettii. in both, reticulum cells are arranged into definite rows; each cell is elongated at right angles to the long axis of the seed and the longer radial walls are conspicuously concave (fig. ). this clearly contradicts the suggestion of standley ( ) that n. bartlettii is most closely related to n. undulatum, for the latter resides in seed group . seeds ofn. marshii and n. propinquum ( fig. ) also are identical. in contrast to n jamaicense and n bartlettii, reticulum cells of these are more irregular in shape, size and arrangement; some radial walls may be weakly concave (fig. ) . seed features ofthe two confirm the relationship perceived by johnston ( ) . much variation in seed features occurs in n palmeri. extreme seed forms include a larger fig. - [vol. morph (fig. ) in which reticulum cells are irregularly ellipsoid and exhibit prominent rim knobs (fig. ) and a smaller morph (fig. ) with more rounded, somewhat angulate chambers and less prominent knobs (fig. ) . connecting the two extremes is a continuum of seed forms. variation in seed features is in keeping with variation in other morphological features as noted by hitchcock ( ) , who treated the species as consisting of two poorly defined, intergrading varieties. emphasizing its half-inferior ovary, hitchcock ( ) segregated n. stenocarpum (fig. ) into the monotypic sect. zonolacus. seed features suggest, however, that the species is to be more closely allied with the taxa ofgroup than its present placement would indicate. indeed, seed features argue that the half-inferior ovary is more ofa "technical" than a "phyletic" character. it is noteworthy, too, that at maturity both n. palmeri and n. jamaicense exhibit hardened calyx lobes which tightly invest the capsule; and, while the calyx lobes are never adnate to the capsule, mature calyx-capsule units are reminiscent of the fruits of n. stenocarpum. seed group (fig. - )-each ofthe nine species in this group produces a chambered coat ranging from weakly to deeply reticulate; and all possess localized thickenings in the radial walls of reticulum cells (fig. , , - , , ) . moreover, each species produces characteristic, easily distinguishable seeds; yet, reticulum organization suggests even more intimate relationships among certain species. seeds of n. stenophyllum (fig. , ) and n. canescens (fig. , ) exhibit a deep reticulum with elaborate thickenings which are typically reticulate in the former and reticulate-sca ariform in the latter. these features clearly support the relationship proposed by hitchcock ( ) . certain cells in the reticulum ofn. johnstonii undergo asymmetrical wall development so that one portion of their wall is greatly elongated and projects outward along the largest circumference of the seed (fig. ) ; remaining cells have walls of equal height and are moderately reticulate. less pronounced asymmetrical wall development is also exhibited by seeds of n. hitchcockii (fig. ) . thickenings in all cells of the latter species and symmetrical cells of the former are generally columnar and rarely branched (fig. ) ; in asymmetrical wall extensions of n. johnstonii thickenings are sealariform-reticulate (fig. ) . furthermore, seeds of n. jlavescens (fig. ) , while lacking asymmetrical walls, exhibit reticulum cells similar to the symmetrical cells ofthe previous species. wall thickenings in this species are also columnar and unbranched. seeds of n. havardii (fig. ) are similar in shape and sizeto those of n. jlavescens and are characterized by columnar wall thickenings (fig. ) . however, thickenings in n. havardii are more stout and evenly spaced than in any of the previous species. both n. carnosum (fig. ) and n. constancei (fig. ) produce seeds characterized by columnar wall thickenings. in contrast to other group species, however, thickenings in these species are not apically interconnected; that is, they lack a continuous thickening circumscribing the upper cell margin (fig. , ) . as a result, the reticulum in these species is characteristically knobby, each knob representing the apex of a thickening. nama prostratum (fig. ) produces one of the more striking seed coats in the genus. reticulum cells exhibit asymmetrical wall development and the taller wall portion is elaborately patterned with scalariform-reticulate thickenings (fig. ) . in contrast to other species ofits group, unbranched thickenings often traverse the floor of reticulum cells (fig. ) and are reminiscent of those found in seed group . of the nine species included in this group, hitchcock ( hitchcock ( , was aware of seven and considered five (n. stenophyllum, n. canescens, n. jlavescens, n. johnstonii, and n. carnosum) as closely related (hitchcock, ) . the two unknown to him, n. hitchcockii and n. constancei, are recently described (bacon, ) . all seven are woody-based perennials with sessile, revolute, essentially linear leaves. all are chihuahuan desert endemics, with the exception of n. hitchcockii, found on drier, western slopes of the mountains forming the southeastern margin of the desert. reticulum organization further attests to the unity of this "linear-leaved" grouping and is even more instructive as to relationships among them. the suggested alliance of n. havardii to aforementioned species is not surprising since it, too, is a chihuahuan desert endemic. seed features indicate that n. havardii is a more distant relative which is consistent with its herbaceous, robust habit and its petiolate, broader, generally revolute leaves. nama prostratum departs markedly from other members of group since it is a weakstemmed perennial found in the mesic highlands of west-central, central and southern mexico. its distinctive seed coat and habit suggests early divergence from ancestral stock out of which arose the desert species to the north. indeed, this taxon may prove to be representative of a stock out of which seed groups , and all arose since, in many ways, seeds of n. prostratum are archetypical of seeds in all three groups. significantly, branched thickenings are limited to the more vertically elongated portions of reticulum walls in n. prostratum as they are in n. johnstonii (they are found elsewhere only in the deeply reticulate coats of n. canescens and n. stenophyllum), while unbranched thickenings are found in the shorter wall portion, as they are found in the less deeply reticulate, symmetrical chambers of other group species. moreover, unbranched thickenings commonly present on chamber floors of n. prostratum seeds often continue into the shorter wall of the chamber, much as those thickenings characterizing group species; all group species exhibit a shallower reticulum. additionally, we suggest that concave reticulum walls in group species are merely an alternative manifestation of asymmetrical wall development. and, since thickenings may differ from pits only in degree, widening ofreticulate thickenings in n. prostratum could yield pits, as found in species of group . however, we believe that n. prostratum is correctly housed, although well removed from other group species. seed group (fig. - )-seeds ofthe six species in this group are moderately reticulate and exhibit many "u-shaped" thickenings in each reticulum chamber (fig. ) . each thickening is continuous, from one wall across the chamber floor and into the adjacent wall; apices of thickenings, on collapse of the upper tangential wall, produce the characteristic knobs along the upper margin of each cell. each of the included species is quite distinct morphologically and differs from the others in habit, leaf shape and size, pubescence and corolla shape, size and color. hitchcock ( ) noted the similarities between the seeds of n. torynophyllum (fig. ) and n. parvifolium (fig. ) . it was his opinion, however, that n. parvifolium was most closely related to n. prostratum and, to a lesser degree, apparently, to if. rotundifolium. we have pointed out the 'potential relationshp of n. prostratum to seed group , including n. parvifolium. we view it as remote. seed features confirm a kinship between n. parvifolium and n. rotundifolium and, as hitchcock implied, suggest it is not direct. for, were it not for its wider reticulum cells, seeds ofn. rotundifolium (fig. ) would be essentially identical to those of n. torynophyllum (fig. ) . and, although producing well developed thickenings and a prominently knobbed reticulum as do the former species, seeds of n. parvifolium (fig. ) are much like those of n. serpylloides (fig. ) and n. rzedowskii (fig. , ). in these three species, reticulum cells are less elongated, broader and more irregularly arranged than in n. rotundifolium and n. torynophyllum. seed features argue that n. serpylloides,n. rzedowskii and n. parvifolium are a related trio. nama hirsutum (fig. ) is difficult to relate directly to other members ofgroup . it occurs in the mesic, but seasonally dry, highlands of southern mexico and guatemala; whereas, other group members are inhabitants of the drier desert regions to the north. its reticulum cells exhibit clearly asymmetrical walls and in shape resemble those in group . but, thickenings characteristic of group species are present in its reticulum cells (fig. ) and countenance its placement. nevertheless, similarity of the seeds of n. hirsutum to those of group strengthen even more our previous postulations of a common stock from which group , and arose; for its seeds recall, too, in their reticulum asymmetry, those of n. prostratum. in short, we view the more mesic southern distribution ofthese two taxa as more than fortuitous and suggest that n. hirsutum likely represents yet another early offshoot of that stock. seed group ( fig. -- )-chamberedseeds with undulate chamber walls characterize the species of this group. however, seed features are more diverse in the group than in the others established and we shoulder some misgivings in our structuring of this group. our major concern relates to our placement of n. origanifolium (fig. ) and n. sericeum (fig. ) . in many respects, seeds of n. origanifolium are reminiscent of those of group . indeed, in surface view wall undulations often suggest the "u-shaped" thickenings characteristic of the former group. however, in neither sections nor peels have we observed such thickenings and we attribute the resemblance to folds in the collapsed upper tangential wad where the wall encounters more prominent undulations. in fact, sections and peels reveal chamber walls to be characterized by pores in this taxon (fig. ) as well as in n. sericeum. with its irregular reticulum organization, n. sericeum (fig. ) also is reminiscent of seeds of certain species in groups , and . we are aware that the pores must be related to thickening-pitting alternatives. further study may well prove these two species to have closer relatives elsewhere, but they are included herein due to their undulate walls and [vol. because four of the other seven species in this group exhibit similar pores in their chamber walls. in contrast to the woody-based, perennial habit ofn. sericeum and n. origanifolium, other members of group are annual and strikingly similar in their dichotomously branched growth habit. while reticulum cells in seeds of n. demissum (fig. ) and n. dichotomum (fig. ) tend to resemble more those of n. origanifolium, seeds ofthe former two species exhibit the weak depressions characteristic of seeds of yet other species suggesting that their placement is correct. in contrast to other examined species, seeds of n. aretioides (fig. , ) , n. densum (fig. , ) , n. parviflorum (fig. , ) and n. depressum (fig. , ) exhibit dimorphic testa patterns. one morph exhibits a weakly chambered testa (fig. , , , ), while the alternate form lacks distinct chambers and is characterized by minute pits-pores on the seed surface ( fig. , , ). internal walls of the chambered morph of these species are characterized by pores (fig. ) as are the nonchambered form of n. densum and n. parvijlorum (fig. ) . in contrast, sections of the non-chambered forms of n. aretioides and n. depressum reveal uniformly dense areas, presumably lateral walls, enclosing a porous-granular material, presumably occupying the cell lumen, and pores have yet to be seen in these forms. in n. aretioides the two morphs are clearly distinct in surface patterning (fig. , ) ; whereas, in n. densum (fig. , ) , n. parviflorum (fig. , ) and n. depressum (fig. , ) differences between the two morphs are more subtle. indeed, the non-chambered morphs of the latter three species exhibit surface ridges which are strongly reminiscent of lateral walls. the resemblance is accentuated particularly in some seeds of n. densum and n. parviflorum by restriction of surface pits to such ridges (fig. ) . in contrast, non-chambered seeds of n. aretioides lack surface ridges and pits are more randomly distributed. individual reticulum cells in the chambered form ofn. aretioides differ in shape and organization as compared with the chambered morph ofthe other three species; and, contiguous cell walls are discernablein n. aretioides (fig. ) while they are not apparent in the others. the seed morphs exhibited by n. densum, n. depressum and n. parviflorum are similar enough to suggest that the non-chambered morph might be merely immature. moreover, the chambered morphs ofthe three species are very similar among themselves and one might expect a similar pattern of development for their seed coats. such a similarity could lead to similar immature seed forms. while the seed morphs produced by n. aretioides are easily distinguished from each other and from seeds of the previous species, its non-chambered morph could also be an immature form. it seems unusual, however, that both chambered and non-chambered morphs were never encountered in the same collection ofany species. if developmental age were responsible for the dimorphism, one might expect to encounter occasionally seeds in various stages of development. on the other hand, the dimorphism might reflect genetic differences since examined collections of each species were geographically separated. hitchcock ( ) notes that n. aretioides from washington, idaho and southwestern california has smaller corollas and wider leaves than cohorts from nevada and central california. furthermore, differences in ploidy level have been shown to correlate with different seed coat morphology in portulaca oleracea (danin, baker and baker, ) chenopodium album (wilson, ) , and castilleja (heckard, morris and chuang, ) ; n. parviflorum has been reported as both diploid (n = ) and tetraploid (n = ) (constance, ) . the remaining species have been reported only as diploid, but reports are few in number. we are unable to explain the dimorphisms at present. the final species comprised in group , n. pusillum, exhibits a somewhat atypical reticulum, compared to other members, for the walls are only weakly, and not uniformly, undulate (fig. ) . nevertheless, in section its internal walls exhibit the pores found in other species ofthis group; and, its weak surface depressions are in keeping with those exhibited by seeds of other members. in spite of our misgivings as to the ultimate placement of n. origanifolium and n. sericeum, we are convinced that seed group is essentially a natural alliance. minimally, seed features would argue that n. aretioides, n. densum, n. parviflorum, n. depressum, and n. pusilium must be positioned closely one to another; the latter two species are housed in sect. nama while the former three, because oftheir connate styles, constitute sect. conanthus (hitchcock, ) . clearly, seed features suggest a more direct relationship of those species possessed of connate styles to yet other species with free styles than is presently implied. it is doubtful that the sect. conanthus can be maintained. conclusions-our sem examination of nama seeds confirms the general value of seed coat features as systematic indicators. testa features clearly partition examined species into distinctive groups. moreover, they often offer even further suggestions of intra-as well as inter-group associations. we view the species so grouped as phyletically based lineages. therefore, a rearrangement ofthe infrageneric groupings within nama is indicated. nevertheless, we suggest no formal restructuring at present, preferring to await further confirmation of our views in the seed coats of as yet unexamined species. the seed, germination, and seedling of yucca scanning electron microscopy and histochemistry of oilseeds new species of nama (hydrophyllaceae) from the chihuahuan desert region of mexico a light and scanning electron microscope study of seed morphology in agalinis (scrophulariaceae) and its taxonomic significance chromosome numbers in the hydrophyllaceae seed coat morphology in cordylanthus (scrophulariaceae) and its taxonomic significance systematic studies of eschscholzia (papaveraceae). ii. seed coat microsculpturing chromosome number and classification in hydrophyllaceae cytogeography and taxonomy ofthe portulaca oleracea l. polyploid complex principles of angiosperm taxonomy seed morphology in new world antirrhineae (scrophulariaceae): systematic and phylogenetic implications plant anatomy origin and taxonomy of castilleja montigena (scrophulariaceae) taxonomic and phylogenetic significance ofseed coat microsculpturing in mentzelia (loasaceae) in wyoming and adjacent states a taxonomic study of the genus nama gypsophily among mexican desert plants the comparative internal morphology ofseeds origin and relationships ofthe california flora studies of american plants. xi. field mus sem studies of small seeds the systematic significance of seed morphology in the neotropical capsular-fruited melastomataceae artificial hybridization among species of chenopodium sect appendix: source of seed samples collections indicated with an asterisk are the source of included photographs. collections without herbarium designation will be deposited at tex. nama sect hartman (tex) lemmon & wife ni flavescens brandeg n havardii a. gray: chihuahua, bacon conzatti (gh). n hispidum a. gray: chihuahua, bacon , , palmer (gh). n palmeri a. gray ex hemsl bacon *, johnston etal. (fex) n serpylloides a. gray ex hemsl. coahuila, bacon * hartman and funk (tex). n. torynophyllum greenm chance et al. . n turneri bacon key: cord- -soaz b authors: trivellini, guido; polidori, carlo; pasquaretta, cristian; orsenigo, simone; bogliani, giuseppe title: nestedness of habitat specialists within habitat generalists in a butterfly assemblage date: - - journal: insect conserv divers doi: . /icad. sha: doc_id: cord_uid: soaz b . the habitat requirements of a species are the resources, conditions and space required for survival and reproduction. the habitat requirements of butterflies have been well studied, but the extent to which individuals within a species and between species utilise and share the habitat is poorly known. . in a butterfly assemblage in northern italy, we found that adults from species avoid deciduous high‐density forests and their ecotones, and they were positively related to open areas and their ecotones. besides these common features, five groups of species can be discriminated in relation to a gradient from open area to forest, and species within groups were not equally specialised, as observed from a bipartite network analysis. in particular, some species appeared to be specialised and others appeared to be generalist, suggesting a nested pattern of resource use, rather than a clustered pattern in which each species uses a different subset of habitat types. . the degree of variation in specialisation among species varied with the number of species falling in each group. thus, an increased number of species, and thus possibly competition, is more likely to promote the co‐occurrence of generalist and specialised species (nested patterns) rather than an increased niche segregation among species. . ascertaining how species overlap their habitat use at a local scale can be relevant for conservation purposes, because specialised populations are potentially more susceptible to network distortions. butterflies (lepidoptera) are a well-studied insect group both taxonomically and ecologically (e.g. gilbert, ; kocher & williams, ; ghazoul, ; stefanescu et al., stefanescu et al., , , particularly because they interact with plants both as larval herbivores and adult pollinators (borges et al., ; hardy et al., ) and have different habitat requirements even at each life stage (new et al., ; samways & lu, ; dennis, ) . in turn, because these interactions are important mechanisms of biological diversification (leather, ; basset, a,b; slansky, ) , the abundance and distribution of butterflies within a particular area can give insights into the environment's quality (kocher & williams, ) . correspondence : giuseppe bogliani, department of earth and environmental sciences, university of pavia, via adolfo ferrata , pavia, italy. e-mail: giuseppe.bogliani@unipv.it these largely specialised butterfly-habitat associations are influenced by many physical and biological factors (leps & spitzer, ; spitzer et al., ) , including temperature, humidity, light levels, rainfall patterns, local microclimate conditions, grassland type and host-plant species richness and distribution (hill et al., ; meyer & sisk, ; collinge et al., ; men endez et al., ) . all these variables define the resource-based habitat or habitat requirements of each butterfly species, i.e., the habitat characterised by resources and conditions required by organisms and their access to them (dennis, ) . furthermore, competition among species, presence of invasive species and avoidance strategies to escape from natural enemies (enemy-free space) also affect species occurrence in a given area (murphy, ; dennis, ; wagner & van driesche, ; hanula & horn, ) . while habitat requirements have been assessed for many butterfly species in detail, the degree to which species within an assemblage segregate their habitat use (i.e. how they are specialised in a subset of habitat types) has been less well studied. the concepts of habitat requirements and habitat specialisation are strongly linked to the classical differences between the pure ecological niche based on the physiological optimum (austin, (austin, , (niche requirements) and the true and realised ecological niche (hutchinson, ; pulliam, ) (niche specialisation). thus, while habitat requirements can be seen as a property of a species, habitat specialisation is a variable property that can vary with many interacting factors such as the presence of inter-specific competitors, the population density and thus the intra-specific competition and the body size of the individuals, among others (chase & leibold, ; dennis et al., dennis et al., , rosenfeld, ) . consider, for example, two butterfly species occurring in the same area that use similar habitat types, e.g., open grass areas and ecotones, and thus require the same habitat conditions. the two species may either use both habitat types equally (generalism) or segregate the use of the two habitat types (specialisation). species may in fact overlap to different degrees the relative use of each type of habitat (julliard et al., ; poisot et al., ) , a pattern that may occur either because of an evolutionary trade-off between the ability of species to exploit a range of resources and their capability of using each one (futuyma & moreno, ) , or because of factors such as inter-specific competition (schroder & rosenzweig, ) . it is thus important to analyse the two concepts (habitat requirements and habitat specialisation) simultaneously in a given species assemblage. here, we analysed the relationship between habitat requirements and habitat specialisation in an assemblage of butterflies in a riverine natural park in northern italy. the aim was to test whether butterfly species with similar habitat requirements overlap their habitat use or, alternatively, they segregate their habitat use despite having similar habitat requirements. to do this, we first defined the requirements, i.e., which habitat types positively or negatively correlate with species abundances, and then used a network-based approach (bl€ uthgen et al., ) to analyse the degree of habitat use overlap within groups of species with similar habitat requirements. the study was conducted in the ticino regional park (lombardy, northern italy, approximately from ° ″ n to ° ″n and from ° ″e to ° ″e, with an elevation of - m a.s.l.) in summer - . the study area is characterised by a continental climate with cold winters and hot summers and covers about hectares. the park represents one of the most important green hot spots of the po river plain, which is otherwise very anthropised. within the park, four sites were chosen for the sampling programme. the two southern sites (coded as and ) ( fig. ) were generally characterised by a thick riparian oak forest with some agricultural areas (poplar plantations, transects and ). site in particular showed a high degree of habitat diversity, including a flooded forest with alnus glutinosa, salix alba and populus alba. the two northern sites (coded as and ) ( fig. ) include areas that have previously been intensively used as military areas, and they can be considered partially anthropised areas. although some natural parts still persist, the presence of alien and invasive plant species is relevant. these two sites were mainly characterised by open areas with shrubs (calluna vulgaris, crataegus monogyna, rubus caesius, cytisus scoparius) and by a low density of trees of exotic species, such as robinia pseudoacacia, ailanthus altissima and prunus serotina. sampling was carried out from the end of june to the first days of september for weeks/year. sites and were sampled in , while sites and were sampled in . surveys were conducted between : and : h. every site contained three m line transects (n = plots), in which we followed established guidelines for butterfly monitoring to minimise observer bias (pollard & yates, ) . observations were carried out during systematic walking surveys ( min per plot visitstandardised search time) only in favourable temperature conditions (temperature > °c) and in calm to light winds. every transect walk was repeated twice a week, for a total of transects and walked kilometres. in contrast to previous research on butterflies, this study was based on a precise georeference of every sampled individual leading to a database of butterfly positions characterised by a large sample (n = ) and a good level of accuracy (breed & severns, ) . all the points were recorded by a gps (garmin csx) whose standard error is considered to be between and m in good weather conditions. we considered the average gps error to be two to seven times lower than the minimum detectable linear dimension of the available land cover, which is more accurate (minimum cartographic unit: . ha, scale : ) than land cover data used in other studies of butterfly species distributions (minimum cartographic unit: . ha, scale : , guti errez et al., ) . all the recorded points were imported and overlaid under a gis environment (esri arc view . a) with the database of land cover classes (hereafter: habitat classes) describing the whole lombardy region, thereby including the plots (dusaf, destinazione uso dei suoli agricoli e forestali, ersaf ). in the sampled areas, eight habitats were recognised together with a further seven ecotones between these habitats for a total of habitat classes (see table ). the detail level is equal to an information scale of : . for each land use feature with a polygonal configuration and a measurable surface, the minimum dimensional threshold of representability corresponds to . ha, and the smallest detectable linear dimension of the polygon is m (http://www.ersaf.lombardia.it/upload/ersaf/gestionedocumentale/web_libro_-suolo_en_ _ .pdf). all twelve m transects were first divided into sectors (n = in each transect), each characterised by a length of m and a width of m, in order to consider the influence of habitat classes contiguous to the point of the supposed selection operated by every individual (fig. ) . a double gis spatial join application associated the field-sampled points with the sectors previously associated with habitat classes (fig. ) . when more than one habitat class fell into the same sector, we considered it as a separate habitat class composed and identified by the two source-habitat classes. we then counted the abundance of sampled individuals of each species in each sector and clustered the sectors according to the habitat class they showed, thereby calculating abundances for each habitat type. data were prepared for analysis with the r package 'vegan' (version . - , the r development core team ) to associate the different habitat preferences with each species and assess habitat requirements. the matrix had species as rows and line transects as columns. we calculated morisita dissimilarity indices among species using the 'vegdist' function. morisita is an index of patchiness, and it is used to calculate overlap among samples (morisita, ) . the dissimilarity matrix obtained was clustered specifying the 'complete linkage' method in the 'hclust' function in the 'vegan' package. we applied the 'cascadekm' function to the standardised square root indices and applied the calinski-harabasz criterion (milligan & cooper, ) to select the best partition inside the dendrogram obtained by the cluster, thereby dividing the whole species group into subgroups with a similar use of habitat types. in order to understand whether environmental characteristics influenced the abundance of individuals, we applied a generalised linear mixed effects model (glmm) for count data (atkins et al., ) for each of the previously selected groups. we ran zero-inflated glmms due to the huge amount of zeros in our data set. glmms were run by applying the ad model builder procedure using the 'glmmadmb' package in r (skaug et al., ) , specifying the poisson distribution inside the model (bolker et al., ) . before starting the analysis, we applied a conservative method to calculate significance for each factor included in the model based on the evaluation of the standard deviation calculated for each estimate multiplied by . consequently, estimates were significant only if the interval enclosed by two times their standard deviations did not cross . according to breslow ( ) , generalised linear mixed models may yield biased estimates of the variance component when the mean number of counts per treatment combination is less than five, so we removed from the analysis all the species whose number of counted individuals was below this value. land cover class classification and the year of the sample were inserted in the model as fixed effects and the plot as a random effect. even though network analysis has been previously applied to feeding interactions (bosch et al., ; poulin, ; junker et al., ; polidori et al., ) , it is also adequate for species-habitat webs within given areas when habitats are well characterised and thus represent discrete nodes of the webs. ecologists continuously produce detailed classifications of habitat types based on sophisticated analyses of their components (e.g. soil, vegetation structure, climate), so that these classifications can be used as a basis for species-habitat webs. network indices based on information theory (shannon entropy) were used to characterise our species-habitat webs in each area ( and ) and site (two in and two in ) (dormann et al., ) . the nodes of each network are composed of butterfly species versus their habitat types, and link weights are the number of individuals collected in each habitat type. because we were interested in the degree of habitat segregation between species, we considered the degree of complementarity (or exclusiveness) of interactions, defined as the standardised index h (bl€ uthgen et al., ) . this index characterises the specialisation and habitat partitioning (niche overlap) in the butterfly assemblage. we first calculated the two-dimensional shannon index as: where i is a butterfly species, i is the total number of individuals collected, j is one of j total habitat types, a ij represents the number of records of the habitat type j frequented by the butterfly species i and m is the total number of habitat records associated with all butterfly species in a network. we then standardised h against its minimum (h min ) and maximum (h max ) possible value for the given habitat type frequencies (i.e. marginal totals in the i j matrix fixed), as follows: consequently, h ranges from for the most generalised to for the most specialised case. each value of h was tested against a null model of random associations (h ran ). a number of random permutations of the matrix were performed using patefield's r c randomisation algorithm (bl€ uthgen et al., ) for which probability is derived (fonseca & ganade, ; manly, ) . as a species-level measure of partner diversity, we used the kullback-leibler distance (bl€ uthgen et al., ) , which not only considers the diversity of partners but also their respective availability, thereby comparing the distribution of the interactions with each butterfly species (p j) to the overall habitat type availability (qj); the index is defined as: and then normalised as: the mean values of d i between groups of species were compared using anova. linear relationships between indices and other parameters were tested with spearman's rank correlation test. overall, species of butterflies were collected. the calinski-harabasz partition applied to the dissimilarity matrix ( fig. s ) suggested five subgroups of species based on their habitat requirements (table , fig. ). following the glmm results (fig. ) , in the first group, we found a positive influence on the abundance of open areas ( , ) and a negative influence of natural dense deciduous forests ( ) and poplar plantations ( ) on the abundance. ecotones between open and forest areas were also positively associated with abundance ( _ , _ ). similarly, in the second group, we found a positive influence on the abundance of open heath land ( ) and a negative influence on the abundance of poplar plantations and dense deciduous forests ( ). many types of ecotones ( _ , _ , _ ) and riparian vegetation ( ) were also positively associated with the abundances of these species. negative relationships between the abundance and open heath land ( ) and its ecotone and natural dense deciduous forests ( _ ) were found in the third group, while the abundances of the species belonging to the fourth group were negatively associated with open anthropised heath areas ( ) and positively associated with the ecotone between open green areas and sparse deciduous forests ( _ ). in the fifth group, positive influences on the abundance of sparse deciduous forests ( ), open green areas ( ) and poplar plantations ( ) were found. in addition, species of this group were positively associated with some ecotones, particularly those including riparian vegetation ( _ , _ ) . the year of sampling also affected the abundance of the species of groups , and (fig. ) . overall, the relationships between species and habitats were not random in the studied butterfly assemblage (h = . , p < . ). among species, habitat specialisation (d i ) varied from . (denoting a generalist species) to . (denoting a highly specialised species) with an average of . ae . , showing important variability. the mean d i calculated for each of the five groups identified by the calinski criterion differed marginally (f = . , df = , p = . ), and was highest in group (species strongly positively associated with open habitats) and more similar among the other four groups (fig. ) . the weakness of this difference was clearly due to the large variance within groups, i.e., species with similar habitat requirements were not all equally specialised (table , fig. ). in particular, within all groups but one (group ), it seemed that one or two species were much more specialised than the others. in group , this subdivision was more difficult but the difference between the highest d i (species and ) and the lowest d i (species and ) was still large. the within-group variability in d i , when expressed with its coefficient of variation (cv), increased with the number of species included in the group (spearman's correlation test, q = . , n = , p = . ). we showed for the first time that high precision of handheld gps georeferenced data can give detailed insights into how butterflies occupy possible suitable habitats based on their ecological needs, as previously shown for other animal groups (lindeque & lindeque, ; kissling et al., ; breed & severns, ) . we found a coherent picture and a general rule by which butterfly species seemed to occupy suitable habitats based on their species-specific ecological needs. in particular, species grouping seemed to be based on a continuum index of lightness, ranging from group generally being influenced by open areas to group being strongly related to closed-canopy forests. if we look at the estimates associated with forest habitats and open habitats in our model ( fig. ) , we can see that they changed sign while proceeding from group to group . in particular, forests are negatively related to the abundance of the sampled individuals in the first group, but they increase their positive influence while moving to group ; the opposite occurs for the above-mentioned general open dry areas. furthermore, all the species, regardless of the group identity, seemed to avoid natural dense deciduous forests and associated ecotones. these are closed and shaded habitats, and luminosity was shown to be very important for butterflies, determining minimum and maximum flight conditions (douwes, ) as well as flight duration (shreeve, ) . for example, in a restoration experiment of ponderosa pine forests in north america, butterfly species richness and abundance were up to three times greater in restoration treatment units where host plant and nectar plant species richness were similar to control units, but insolation (light intensity) was significantly greater (waltz & covington, ) . this differential importance of habitat light intensity in structuring our studied butterfly assemblage is confirmed by a comparison of our results with previous information on the habitat characteristics for the studied species, which revealed a general congruence. all the three species of the first group are reported to inhabit bushy places, and dry and hot areas, and are usually associated with forest ecotones and clearing margins (table s ). species of the second group showed a negative relationship with the presence of forest areas, and a positive association with open natural heath areas. furthermore, species of group seemed to be more influenced by ecotones than species of group , with grassland representing the key habitat type. we also found a positive influence of riparian vegetation on individual abundance, probably because most of the individuals belonging to group were sampled in a site characterised by a single line of riparian vegetation and large open areas, thereby representing once again a sort of structural ecotone inside an open area. according to literature, many species of group are defined as ecotone species (table s ) . groups and , on the other hand, which were negatively associated with open heath land and its ecotones, confirmed the decreasing importance of open areas while moving from group to group . indeed, species of group were clearly associated with poplar plantations and sparse deciduous forests. many species in group were previously reported as being somehow linked to a forest environment (table s ) , but some species are reported to be associated with very different habitats (from open grassland to forests) (table s ). additionally, the significant effect of the year in some groups showed a temporal shift in species abundance, suggesting population fluctuations depending on change in abiotic or biotic conditions. the degree of specialisation was not similar among species within groups in our studied assemblage. for example, hipparchia statilinus was much more specialised than the other species of group , while minois dryas frequented many more coppice deciduous forests and their ecotones than the other species of group . two species of group (everes argiades and aglais io), which in literature are reported as generalist species in many habitats including flowery bushy places, grassy banks, forest clearings, flowering meadows, forest edges and sheltered rocky gullies (table s ), were very specialised in our study. even the two closely related species (both from the genus pieris) comprising group differed greatly in specialisation. because the index of specialisation d i increases with the level of specialisation, the positive correlation between the variance of d and the number of species across groups means that an increased number of species are more likely to promote the co-occurrence of generalist and specialised species (nested patterns) rather than an increased niche segregation among species (a clustered pattern). thus, possible increased competition (i.e. a higher number of species sharing the same habitat requirements) would not increase habitat segregation, while a few highly specialised species would use a subset of habitats exploited by more generalist species. this consideration is consistent with previous network-based studies, which showed nestedness common in both mutualistic (e.g. plant-pollinator) networks (bascompte et al., ) and agonistic (e.g. hostparasite) networks (joppa et al., ) (although compartmentalisation is also observed in agonistic webs, e.g. prado & lewinsohn, ) . bastolla et al. ( ) showed that the process by which a new species enters a community will likely lead to a nested pattern of interactions, because the new species tries to minimise its competitive table for species names). note that for a few species (e.g. eight), the sample size was too small to perform the network analysis (see text for details). load, an action that forces it to interact with the most generalist species. this could also be applied to habitats: when a new species arrives in a given area, it will first select sites with certain characteristics (requirements) and then reduce the overlap with competing species, largely using only a subset of the habitats used by generalist species. our results stress the importance of considering both the habitat requirements of species and the specialisation in habitat use by each species when analysing butterfly assemblages. indeed, many species studied here, previously known as generalists, were found to be locally specialised in our analysis. this is particularly important in the light of butterfly conservation, because the more specialised species may also be those with higher susceptibility to network distortions and thus with higher fragility to co-extinction (bl€ uthgen, ) . this would provide elements for deciding protection priorities for the species at local scales. fig. . estimated parameters derived from glmm. significant influences of the parameters on the species abundance are shown by grey highlighting. the estimates (round black points) and their standard deviations multiplied by (bold black lines enclosed by vertical segments) are provided. standard deviation segments were cut when their values crossed À or + in each graph. continuous bold lines without vertical segments are used when the model was not able to estimate reliable parameters. significant influences of the parameters on the species abundance are shown by grey highlighting. digits refer to habitat and ecotone codes as in table . although none of the sampled species are listed as threatened in the european red list of lepidoptera (with the exception of hipparchia statilinus, which is listed as near threatened, van swaay et al., ) , five species (coenonympha pamphilus, lycaena phlaeas, maniola jurtina, ochlodes sylvanus and polyommatus icarus) are reported as being declined in europe since (van swaay et al., ) . these species may become locally vulnerable through persistent increased habitat specialisation associated with habitat disturbance; therefore, their ecology should be finely monitored in order to adopt adequate conservation plans. this work could not have been carried out without the help of stefano basso and ester manzini, students who helped greatly with the fieldwork. thanks are also due to marina trentin for the support she provided during and after the fieldwork. this work was made possible by funding provided by ticino regional park. cp was funded by a postdoctoral contract funded by the universidad de castilla-la mancha and the european social fund (esf). kelsey horvath kindly revised the english editing. additional supporting information may be found in the online version of this article under the doi reference: doi: . / icad. : fig. s . calinski criterion applied to the dissimilarity matrix. the number of possible group partitions is shown on the y-axis and the values obtained by the calinski-harabasz algorithm are shown on the x-axis. table s . previous published information on the habitat requirements of the studied butterfly species. tutorial on count regression and zero-altered count models for longitudinal substance use data searching for a model for use in vegetation analysis. vegetation continuum concept, ordination methods and niche theory the nested assembly of plant-animal mutualistic networks the seasonality of arboreal arthropods foraging within an australian rainforest tree leaf production of an over storey rainforest tree and its effects on the temporal distribution of associated insect herbivores the architecture of mutualistic networks minimizes competition and increases biodiversity why network analysis is often disconnected from community ecology: a critique and an ecologist's guide measuring specialization in species interaction networks getting started with the glmmadmb package butterfly pollination and high contrast visual signals in a low-density distylous plant plant-pollinator networks: adding the pollinator's perspective low relative error in consumer-grade gps units make them ideal for measuring smallscale animal movement patterns whither pql? proceedings of the second seattle symposium in biostatistics: analysis of correlated data ecological niches: linking classical and contemporary approaches effects of local habitat characteristics and landscape context on grassland butterfly diversity a resource-based habitat view for conservation. butterflies in the british landscape the generalism-specialism debate: the role of generalists in the life and death of species towards a functional resource-based concept for habitat: a butterfly biology viewpoint indices, graphs and null models: analysing bipartite ecological networks lycaenidae) in relation to air temperature, solar radiation, and time of day destinazione d'uso dei suoli agricoli e forestali. ente regionale per i servizi all'agricoltura e alle foreste della lombardia asymmetries, compartments and null interactions in an amazonian ant-plant community the evolution of ecological specialisation impact of logging on the richness and diversity of forest butterflies in a tropical dry forest in thailand the contributions of topoclimate and land cover to species distributions and abundance: fine-resolution tests for a mountain butterfly fauna removing an exotic shrub from riparian forest increases butterfly abundance and diversity. forest ecology and management specialism for larval and adult consumer resources among british butterflies: implications for conservation. biological conservation ecology of tropical butterflies in rainforest gaps concluding remarks. cold spring harbor symposia on quantitative biology on nestedness in ecological networks spatial segregation of specialists and generalists in bird communities specialization on traits as basis for the niche-breadth of flower visitors and as structuring mechanism of ecological networks challenges and prospects in the telemetry of insects the diversity and abundance of north american butterflies, vary with habitat disturbance and geography the analysis of species-area relationships, with particular reference to macrolepidoptera on rosaceae: how important is insect data-set quality? entomologist ecological determinants of butterfly communities (lepidoptera, papilionoidea) in the tam dao mountains satellite tracking of elephants in north-western namibia randomization bootstrap and monte carlo methods in biology direct and indirect effects of climate and habitat factors on butterfly diversity butterfly response to microclimatic conditions following ponderosa pine restoration an examination of procedures for determining the number of clusters in a data set measuring interspecific association and similarity between communities enemy-free space maintains swallowtail butterfly host shift butterfly conservation management trophic network structure emerges through antagonistic coevolution in temporally varying environments does prey mobility affect niche width and individual specialization in hunting wasps? a network-based analysis monitoring butterflies for ecology and conservation network analysis shining light on parasite ecology and diversity compartments in insectplant associations and their consequences for community structure on the relationship between niche and distribution a language and environment for statistical computing. r foundation for statistical computing assessing the habitat requirements of stream fishes: an overview and evaluation of different approaches. transaction of key traits in a threatened butterfly and its common sibling: implications for conservation perturbation analysis of competition and overlap in habitat utilization between dipodomys ordii and dipodomys merriami habitat selection, mate location, and microclimatic constraints on the activity of the speckled wood butterfly pararge aegeria glmmadmb: generalized linear mixed models using ad model builder. r package version nutritional ecology: the fundamental quests for nutrients. caterpillars -ecological and evolutionary constraints on foraging habitat preferences, distribution and seasonality of the butterflies (lepidoptera, papilionoidea) in a mountain tropical rain forest determinants of species richness in generalist and specialist mediterranean butterflies: the negative synergistic forces of climate and habitat change butterfly species richness in the north-west mediterranean basin: the role of natural and human-induced factors european red list of butterflies. publications office of the european union threats posed to rare or endangered insects by invasion of nonnative species ecological restoration treatments increase butterfly richness and abundance: mechanisms of response key: cord- -vgjz ts authors: nan title: th international congress of the european association for endoscopic surgery (eaes) sevilla, spain, – june date: - - journal: surg endosc doi: . /s - - -x sha: doc_id: cord_uid: vgjz ts nan laparoscopic cholecystectomy is one of the most commonly performed operations worldwide. bile duct injury (bdi) is a rare but very serious complication of the procedure, with a significant impact on quality of life and overall survival. the high frequency of bdi with laparoscopic cholecystectomy was first considered to be a consequence of the initial learning curve of the surgeon, but it later became clear that the primary cause of bdi is misinterpretation of biliary anatomy. intraoperative cholangiography (ioc) has been advised by many authors as the technique reduces the risk of bdi. however, the procedure has inherent limitations and is therefore reserved for select cases. fluorescent cholangiography using indocyanine green(icg) is a novel approach, which offers real-time intraoperative imaging of the biliary anatomy. a comparative study was contacted by administering icg intravenously or intrabiliary during the operation. forty patients scheduled to undergo an elective lap. cholecystectomy were randomly divided in two groups: in group a icg was administered in a dose . mg in ml solution intravenously hour before surgery. in group b icg was injected intrabiliary in a . mg/ml solution mixed with the patient's bile. also, we observed and analysed the following parameters, liver function, b.m.i, asa score and possible complications, before and after operation. results: group a. intravenous icg was administered in patients. there was no any reaction and the extrahepatic biliary anatomy was identified well. there was no bdi or any complication related to the procedure. group b. icg was injected intrabiliary in patients during the laparoscopic procedure. in all but one patient the extrahepatic biliary tree was delineated very well. in one patient part of icg solution was injected into the gallbladder wall and this resulted in a partially confusing image. there was no bdi and no postoperative complication conclusions: fluorescence cholangiography can be used during laparoscopic cholecystectomy to obtain fluorescence images of the bile ducts following intrabiliary injection during the operation orintravenous injection h before the procedure. the later technique is more easy to perform and does not require catheterization of the biliary tree. endoscopia digestiva chirurgica, policlinico universitario ''a. gemelli'', rome, italy; ihu, strasbourg, france; camma group, icube, university of strasbourg, cnrs, ihu strasbourg, strasbourg, france; ircad, strasbourg, france; digestive and endocrine surgery, nouvel hopital civil, university of strasbourg, strasbourg, france; digestive and endocrine surgery, ihu-strasbourg, strasbourg, france aim: surgical societies are united in promoting the critical view of safety(cvs) during laparoscopic cholecystectomy(lc). nonetheless, reports have shown a discrepancy between the operative reports and the correct application of cvs, which may explain the stability of bile duct injury rates. therefore, surgeons and computer scientists at our institution are developing a machine-learning algorithm to automatize cvs assessment. however, the lack of a consistent cvs video assessment framework limits the ability to generate data to train the artificial intelligence. here we describe and test a method for cvs evaluation in videos. method: between march and july , consecutive videos of lc performed at nouvel hospital civil(strasbourg, france) were recorded. two independent reviewers assessed the achievement of cvs in the s video sequences preceding clipping of cystic duct and artery. in addition to the 'doublet view' method, a 'binary' video evaluation method was tested: each of the criteria composing the cvs( structures entering the gallbladder, clearance of the hepatocystic triangle and lower part of the cystic plate) was classified as achieved or not. if the criteria were met, then the cvs was considered achieved. inter-rater agreement for cvs and for each of the criteria was evaluated. results: twenty-two videos( fundus first and partial lc, and broken videos) were excluded from the cvs analysis. cvs elements were assessable in all but one s videos sequences( . %). after mediation, cvs was achieved in / ( . %) of lc. the cystic plate was identified in only . % of videos. inter-rater agreement using the doublet view vs. the binary method was as follows: . %(? = . ) vs. . %(? = . ) for cvs achievement, . %(? = . ) vs. . %(? = . ) for the structures, . %(? = . ) vs. . %(? = . ) for the hepatocystic triangle and . %(? = . ) vs. . %(? = . ) for the cystic plate ( fig. ) . conclusions: reliable cvs assessment is crucial to generate consistent data for machine-learning algorithms aiming at decreasing bile duct injury after cholecystectomy. our binary cvs video assessment method showed higher inter-rater reliability than the doublet view, originally described for assessment of photos. further studies are on going to validate the cvs assessment in videos and support our initial results. surg endosc ( ) the vital role of surgeries in healthcare requires a constant attention for improvement. surgical process modeling is an innovative and rather recently introduced approach for tackling the issues in nowadays complex surgeries, involving complex logistics, much technology, and large teams. surgical process modeling allows for evaluating the introduction of new technologies and tools prior to the actual development and is beneficial in optimization of the treatment planning and treatment performance in operating room. in this study, we first discuss the concepts associated with surgical process modeling, aiming to clarify them and to promote their use in future studies. next, we apply these concepts to analyze the procedure of challenging interventions, minimally invasive liver treatment (milt) methods, with the ultimate goal of improving and optimizing the treatment procedure. the procedure model of current treatment activities and planning of various milt methods and the associated techniques, are analyzed and combined into a generic procedure model of milt, which provides a firm foundation for qualitative and quantitative analysis of different milt procedures. the generic procedure model is validated by data from erasmus medical center (rotterdam, the netherlands) and oslo university hospital (oslo, norway) . the proposed procedure model is designed to be a basis for improvement of the procedure and to determine how and where the new technologies can be best, effectively and efficiently, employed in the clinical practices prior to and/or during actual development of the new technologies for milt. as a conclusion, the current work illuminates the importance of surgical process modeling for improving different aspects of treatment procedures and provides an overview of various modeling strategies that can be used to establish surgical process models. the generic procedure model of various milt methods, including laparoscopic liver resection, laparoscopic liver ablation and percutaneous ablation, is introduced and validated which is a basis for introduction of the optimized procedure model of milt objective: to determine the most appropriate time to start total laparoscopic living donor right hepatectomy (tldrh) based on the experience with laparoscopic liver resection (llr). summary background data accumulation of experience in llr is essential before starting tldrh to ensure donor safety. methods: we retrospectively reviewed data of and consecutive patients who underwent llr and donor hepatectomy, respectively, between and . operative outcomes of laparoscopic major hepatectomy (lmh) were compared between two periods based on tldrh introduction (phase i - vs phase ii . learning curve of llr was evaluated using the cumulative sum (cusum) method to determine the optimal time of tldrh introduction. conclusion: accumulating an experience of at least lmh cases is needed in low-volume lt centers before starting tldrh to ensure donor safety. introduction: the number of surgical adverse events is still too high. an important number of these adverse events occur within the operating room (or) and are in fact preventable. in order to reduce adverse events in the or, we simply need to know what went well and what can be done better. the aim of this study was to analyze and debrief a predefined selection of surgical procedures, with the use of an operating room 'black box', to identify commonly observed safety threats and resilience support events. methods: in the period - , predefined gastro-intestinal laparoscopic cases were recorded by the or black box'. the postoperative surgical team assessment record (star) questionnaire was used. the recordings were analyzed by specifically trained raters, using the systems engineering initiative for patient safety (seips) model of work system and patient safety to identify relevant safety threat and resilience support events. qualitative data analysis was used to identify the most commonly discussed events during the team debriefings. results: in only . % (n = ) of times or team members, when asked direct following surgery, indicated that they had noticed aberrations (n = ) during the case. a mean number of . (sd . ) relevant positive and negative events (e.i. aberrations) per surgical procedure were identified using the black box performance report. on average, . (sd . ) of events identified by the black box were rated as safety threats. most events discussed during the team debriefings were related to communication. conclusion: these results once again highlighting the importance of clear and closed-loop communication in the operating room. theatre staff underestimated the number of aberrations occurring in the or, when asked to retrieve from memory. postoperative structured team debriefing may be important for resolving incorrect assumptions between operating team members to avoid future unnecessary miscommunication. background: the eaes has recently published an intraoperative adverse event classification to assist the direct measurement and routine reporting of minimal access surgery interventions. we aimed to explore the clinically validity and reliability of the classification. methods: a prospective evaluation utilising case videos and clinical data from a completed multi-centre laparoscopic total mesorectal excision surgery randomised controlled trial was performed (isrctn ). enacted adverse events identified with the observational clinical human reliability analysis technique were graded with the eaes classification by two blinded, independent assessors. test-retest reliability was explored using grades previously applied during the development of the classification with intraclass correlation co-efficients calculated. clinical validity was assessed using -day morbidity events, the clavien-dindo classification and the highest eaes grade per case. results: laparoscopic cases ( h of surgery) contained error events which were all successfully categorised. excellent inter-rater and test-retest reliability was seen (icc . , % ci . - . , p \ . and icc . , % ci . - . , p \ . respectively. % of patients experienced post-operative morbidity (median event, range [ ] [ ] [ ] [ ] [ ] [ ] . labelling analysed cases by their highest eaes classification grade gave % grade , % grade and % grade procedures. % of grade cases developed a morbidity event, but this significantly increased in grade and operations ( % and %, p = . ). the number of complications and highest recorded clavien-dindo grade increased with each additional grade ( . ± . vs. . ± . vs. . ± . , p = . and median vs. vs. , p = . respectively). anastomotic leak and re-operation were correctly captured by the allocated eaes grade ( . % vs. . % vs. %, p \ . and % vs. % vs. %, p \ . respectively). there was a significant rise in length of stay observed with increasing eaes grade (median vs. vs. days, p \ . ). conclusion: in the context of major laparoscopic surgery, the eaes intraoperative adverse classification is seen to be a clinically valid and reliable assessment method. psychological medicine, nuhs, singapore, singapore aims: neurobiological feedback in surgical training could translate to better educational outcomes such as measures of learning curve. the variation in brain activation of medical students when performing laparoscopic tasks before and after a training workshop is not properly studied before and we planned to do this using functional near infrared spectroscopy (fnirs) which is a non-invasive optical brain imaging tool that measures cortical oxygenation change which is used as a marker of pre-frontal cortex activity (pfca). methods: this randomised controlled trial examined the pfc activity differences in two groups of novice medical students during the acquisition of basic laparoscopic tasks. 'trained-group' had standerdised oneto-one training on the tasks, while the 'untrained-group' had no prior trainining and was just shown a video of the tasks. the pfca was measured pre and post intervention using a portable fnirs device. primary outcome was the difference in the pfca pre and post intervention. secondary outcomes were the differences in pfca between the tasks and between the sexes. results: trained and untrained medical students with an equal sex distribution and a comparable age distribution were invovlved in the study. all students were right handed. trained group had a significantly attenuated pfca in the 'precision-cutting' (p = . ) and 'suture-insertion' (p = . ) tasks compared to the untrained group. subgroup analysis based on sex revealed significant attenuation in pfca in trained females compared to untrained females across of the laparoscopic tasks: 'pegstransfer' (p = . ), 'precision-cutting' (p = . ), 'suture-insertion' (p = . ). no significant pfca attenuation was found in male students who underwent training compared to untrained males. conclusion: a standardised laparoscopic training workshop promoted greater pfca attenuation in female medical students compared to males. this suggests that female and male students respond differently to the same instructional approach. these results may have implications for surgical training and education such as a greater focus on one to one surgical training for female students and use of pfca attenuation as a form of neurobiological feedback as a measure of learning curve in surgical training. robot assisted versus laparoscopic advanced suturing learning curve e. leijte , i. de blaauw , c. rosman , s.m.b.i. botden surgery, radboudumc, nijmegen, the netherlands; pediatric surgery, radboudumc, nijmegen, the netherlands aims: compared to conventional laparoscopy, robot assisted surgery is expected to have most potential in difficult areas and demanding technical skills as minimally invasive suturing. this study was performed to identify the differences in the learning curves of laparoscopic versus robot assisted advanced suturing method: novice participants, with the knowledge of basic surgical procedures, were recruited and performed three suturing tasks on the eosim laparoscopic augmented reality simulator or the robotix robot assisted virtual reality simulator. each participant performed an intracorporeal suturing, tilted plane needle transfer and anastomosis needle transfer task. to complete the learning curve, all tasks were repeated for maximal twenty repetitions or until a plateau was reached three consecutive times. clinical relevant and comparable parameters regarding time (seconds), movements and safety were recorded. intracorporeal suturing was used to visualize and compare the learning curves between the groups. results: forty-six participants completed the learning curve, of which laparoscopically and robot assisted. when comparing the suture time, the plateau was reached much faster in the robot assisted group ( - repetitions) than the laparoscopic group ( ) ( ) ( ) repetitions) as shown in figure . there was a significant difference in 'time per suture', during the whole learning curve with median values of versus (first knot), versus (fifth) and and (eighteenth), all with a p \ . . however, the parameter 'adequate surgical knot' was reached earlier in the laparoscopic group than in the robot assisted group. first: % versus %, fifth: % versus %, and eighteenth: % versus %. when assessing the 'needle out of view' parameter, the robot assisted group scored a median of . and . s during the first, respectively eighteenth knot, and the laparoscopic participants had their instruments out of view for and s during the first respectively eighteenth knot. conclusion: the learning curve of minimally invasive suturing can be reduced with the use of robot assisted surgery, with a specific reduction in operation time. the rate of adequate knots seemed to remain lower in robot assisted surgery, although this could be due to the virtual reality aspect of the simulator. introduction: endoscopic sleeve gastroplasty (esg) is a novel promising bariatric endoscopy treatment. gastric volume reduction and delayed gastric emptying are the mechanisms driving weight loss. however, little is known about the factors influencing the effectiveness of weight loss overtime. the present study aims at evaluating the correlation between endoscopic suture appearance and excess weight loss (ewl%) at and months follow up. patients and methods: all patients who underwent follow-up endoscopy at and months after esg were included. esgs were classified in groups according to endoscopic appearance of the gastric sutures: optimal (group ) when all stitches were in place and tights; suboptimal (group ) when one or more stiches were displaced; loose (group ) when all the sutures were completely disrupted. bmi at enrollment and ewl% at and months were recorded and compared to the endoscopic appearance. results: a total of patients were included in the analysis. at months, ( . %) patients had an optimal esg, ( . %) had a suboptimal sleeve and ( . %) had complete sutures failure. bmi at enrollment and ewl% were respectively . ± . and . ± . % for group , . ± . and . ± . % for group and . ± . and . % ± . % for group . twenty five patients had months egds: ( %) presented an intact esg and were classified in group , ( %) in group and ( %) in group . twelve months ewl% was respectively . ± . %, . ± . and ± . %. initial bmi significantly correlated with suture status at both (rho - . ; p \ . ) and months (rho - . ; p = . ) follow-up. furthermore, the sutures' appearance itself correlated with ewl% at both time points (rho ? . ; p = . and rho . ; p = . respectively). conclusion: our preliminary results show that the aspect of the endoscopic suture has a significantly impact on ewl% at and months after esg. furthermore, bmi at enrollment seems to predict endoscopic suture duration overtime. larger studies and longer follow-up are needed to further validate our preliminary findings. background and aim: endoscopic sleeve gastroplasty(esg) is a relatively novel endoscopic procedure that reduces the gastric lumen with proven less complications and less months weight loss compared to laparoscopic sleeve gastroplasty (lsg) . at present there are no studies investigating the role of multidisciplinary approach in esg. the aims of the present study were to evaluate the role of multidisciplinary assessment(ma) prior esg, weight loss outcomes, quality of live improvements and adverse events. material and methods: from may to may all patients that underwent esg were retrospectively evaluated from a prospective database. until september before esg only psychiatric evaluation was requested, while after this date we adopted the guidelines of the italian society for obesity surgery and all patients were evaluated on a multidisciplinary fashion prior esg. the multidisciplinary team was composed by:gastroenterologist, surgeon, psychiatrist, endocrinologist and dietitian. patients were divided in two groups:group were patients with esg before ma and group were patients with esg after ma. we compared this two groups in terms of weight loss outcomes, quality of live improvements and adverse events. quality of live was measured with the bariatric analysis and reporting outcome system(baros).all procedures were done with the apollo overstitch suturing system(apollo endosurgery) and a double channel gastroscope olympus tgif- (olympus japan).all procedures were done in general anesthesia and with insufflation of co . all patients had ambulatory visit t , and months after esg and weight loss outcomes were measured in terms of excess weight loss (%ewl),the total body weight loss (%tbwl) and baros scale were assessed. statistical analysis was done with chi-square test and \ . value was considered significant. results: patients were identified ( female; mean age . , range - ) . mean bmi at inclusion was . (range . - . ). mean %ewl and %tbwl at months was . and . respectively (table ) .non procedure related complications were observed. comparing the two groups there was significant(p \ . ) difference in terms of %ewl and %tbwl (table ) ,with better results in group . there was also a significant improvement in the baros scale in the patients in group . conclusions: ma before esg has a fundamental role in terms of better procedure outcomes for both weight loss and quality of live in obese patients. gastroenterology, hadassah medical center, jerusalem, israel, israel aims: the over-the-scope clip (ovesco) is a novel endoscopic tool that enables non-surgical management of gastrointestinal defects. the aim of this study was to report our experience with ovesco for patients with staple line leaks following laparoscopic sleeve gastrectomy (lsg). methods: a prospectively maintained irb-approved institutional database was queried for all patients treated with ovesco for staple line leaks following lsg from to . primary outcome was complete resolution of leak following ovesco as defined by return to complete oral nutrition and no evidence of leak on imaging. secondary outcome was the number of additional endoscopic or surgical procedures needed following ovesco. results: twenty-five patients ( males, females) were treated with ovesco for staple line leaks following lsg. the median age was years (range - ), and mean body mass index was kg/m . nine patients ( %) were referred from an outside hospital. the median time from index operation to leak diagnosis and from leak diagnosis to ovesco was days (range - ), and days (range - ), respectively. all patients had upper staple-line leaks near the gastroesophageal junction. initial treatment included antibiotics- patients; computed tomography guided drainage and antibiotics- patients; and laparoscopic drainage- patients. ovesco led to final resolution of leak in patients ( %) within days of clip deployment (range - ). leaks which persisted following ovesco were eventually resolved with a combination of ovesco and stent- patients ( %), total gastrectomy and esophago-jejunostomy- patients ( %), and endoscopic suturing- patient ( %). one mortality was noted in a patient who suffered multiorgan failure. the number of additional endoscopic sessions ranged from to (median ). no procedure related complications were noted. all patients were treated with total parenteral nutrition and the total length of stay was days (range - ). conclusions: despite its low success rate, ovesco should be part of the bariatric surgeon's non-surgical armamentarium in treating staple line leaks following lsg. r. bademci , r. vilallonga , p. alberti , r. renato , c. yuhamy , s.s. cordero , l. posadas general surgery, istanbul medipol üniversitesi, istanbul, turkey; bariatric surgery, vall d'hebron, barcelona, spain background: in cases of morbid obesity, treatment is generally applied as either a surgical or endoscopic approach. the number of primary obesity surgery endolumenal (pose) procedures is increasing but the reliability and effectiveness is unclear as yet. the aim of this study was to present a series of cases that required revision surgery due to pose failure and to reveal possible alternative surgeries. materials and methods: a retrospective comparison was made of the data of obese patients with pose failure and conversion to surgical procedures between and in respect of operation, medical illness and bmi results. results: the patients comprised % females, % males with a mean age of . ± . years and mean follow-up period of . ± . months. on average, patients lost . ± . kg, with an average excess weight loss of . %. conclusion: no firm conclusions can be drawn from such a small group. although sg seems to be a safe procedure and should be considered as the first technique to be applied following pose failure, it is possible to perform gastric bypass on patients with this endoscopic precursor. introduction: the population of post bariatric surgery patients is rapidly increasing worldwide. due to the altered anatomy post roux-en-y gastric bypass (rygb), conventional endoscopic management for choledocholithiasis is challenging. these patients are now commonly managed by means of a laparoscopic assisted ercp. although effective, this requires significant resource utilization and potential morbidity related to the need for surgical intervention. we present our preliminary experience with a purely percutaneous management of choledocholithiasis in bariatric patients post-rygb. methods: a retrospective single center review identified five patients with choledocholithiasis after bariatric rygb who underwent percutaneous cbd access and treatment by interventional radiology. four patients underwent percutaneous transhepatic cbd access while one patient underwent percutaneous trans-cholecystic cbd access. in three of the five patients conscious sedation alone was sufficient to perform the procedure. results: all patients had radiologically confirmed choledocholithiasis and were clinically symptomatic prior to intervention. the biliary tree was successfully accessed percutaneously and cleared in all five patients. in the four patients where a percutaneous transhepatic access was utilized, three patients required only fluoroscopic balloon sphincterplasty and sweep of the cbd to clear the ductal stones, while the fourth required percutaneous cholangioscopy assisted lithotripsy for clearance. in the fifth patient with non-dilated intrahepatic bile ducts a trans-cholecystistic approach into the cbd was utilized with percutaneous cholangioscopic assistance to clear the ductal stones. all procedures were completed successfully with no post procedure complications. conclusion: percutaneous clearance of cbd stones in bariatric patients presents a minimally invasive alternative to current surgical practice. the use of conscious sedation and the purely percutaneous approach may potentially reduce morbidity and resource utilization for this increasingly common clinical scenario. laparoscopic narbona-arnau procedure to control the gerd after lsg- years results of a prospective study i.c. hutopila, c. copaescu background: after the laparoscopic sleeve gastrectomy (lsg) alone or associated with calibration of the esophageal hiatus, for some patients the reflux symptoms worsen postoperatively due to development of a hiatal hernia (hh) or due to the recurrence of the hh previously repaired. for these situations, when the conservative treatment fails, are proposed some surgical solutions, one of them cardiopexy with teres ligament-narbona arnau. objective: is to establish a standardized laparoscopic technique for cardiopexy using the teres ligament (narbona arnau technique) and to analyze the procedure's outcomes. methods: the study was performed in a bariatric and metabolic center of excellence-ponderas academic hospital. all the patients undergoing narbona arnau procedure to control gerd after lsg since were included and prospectively analyzed. the selection criteria included lsg patients, presenting hh and symptomatic gerd. preoperative investigations were upper gastrointestinal endoscopy, radiological contrast study, ph-metry, computed tomography with oral contrast. results: patients were included into the study. gerd and hh were preoperatively documented in all the cases. one patient was excluded after years of follow up after being converted to a laparoscopic roux-en-y gastric bypass, for intense relux symptoms. no incidents during surgery. for cases laparoscopic narbona arnau technique was performed concurrent with re-sleeve gastrectomy and gastric curvature plication. without postoperative complications. postoperative follow-up at months, , and years, the percentage of patients without gerd symptoms and free of treatment with ppis was , %, , %, , %, respectively . %. at years postoperatively the upper gi endoscopy showed remission/ improvement of the degree of esophagitis for patients. for the same period of follow-up, the ph-metry highlighted a normal value of demeester score for . % o patients (all the patients had preoperatively high de meester scores). no objective signs of hiatal hernia recurrence at imagistic investigations and upper gastrointestinal endoscopy were encountered. conclusions: complete preoperative evaluation is mandatory for choosing the optimal intervention. laparoscopic narbona arnau technique after lsg is proved to be a good option for the treatment of symptomic gerd, but further studies with high-volume patients are necessary. introduction: the aim of this study was to investigate the influence of baseline glycated hemoglobin level (hba c) level in bariatric patients on postoperative outcomes. we found scarce of clinical data regarding influence of baseline hba c on bariatric surgeries postoperative morbidity and readmission what was inspiration to conduct this multicenter retrospective study. methods and procedures: retrospective cohort study analyzed patients who underwent laparoscopic: sleeve gastrectomy (sg), roux-en-y gastric bypass (rygb) or mini-gastric bypass (mgb) for morbid obesity in seven referral bariatric centers. patients were divided into groups depending on preoperative hba c : hba c \ . %; . - . % and c . %. primary endpoints: influence of hba c level on perioperative ( -days) and postoperative ( -months) morbidity rates, operation time, length of hospital stay (los) and readmission rate. results: study group included , % females and % males. median age was ( - ) years. median hba c was . ( . - . ). hba c \ . % was present in % patients, hba c . - . % in %, and hba c c . % in %. percentage of male patients increased in groups from % in hba c \ . % to % in hba c c . % significantly. same tendency through groups we observed in case of bmi and age. uncontrolled diabetes (hba c c . %) was present in . % patients, while . % patients were not on antidiabetic medications despite having hba c c . %. median operative time in patients was significantly longer than in hba c \ . % and hba c . - . %. -days morbidity rate was . % and did not differ groups significantly, as -months morbidity rate (excl. -days) of . % . los did not differ groups significantly. patients having hba c in range of . - . % and with hba c c . % did not have significantly increased odds for perioperative morbidity, -months postoperative morbidity as compared with those with hba c \ . %. patients with hba c c . % had increased or for prolonged los as compared to those with hba c \ . % (or . ; % ci . - . ). hba c did not influence or for readmissions. patients with baseline hba c c % had significantly increased chances for hospital readmission (or . , % ci . - . ). conclusion: baseline level of hba c did not influence chance for perioperative morbidity, -months postoperative morbidity and prolonged los. patients with hba c c % have increased chance for hospital readmissions. surg endosc ( ) :s -s introduction: surgical resection is crucial for curative treatment of rectal cancer. through improvements in treatment and minimally invasive techniques, -year survival improved to over % of patients. the most recently introduced surgical technique is robotic-assisted surgery (ras). ras and conventional laparoscopy (cl) seem equally effective in terms oncological control. however, ras possibly provides further advantages e.g. d vision or the endowrist function, which have the potential to maximize the precision of surgery and thus has benefits for functional outcomes such as sexual function as well continence. therefore, the aim of this systematic review and meta-analysis was to compare functional outcomes of cl and ras for rectal cancer. materials and methods: this review was done according to the prisma and amstar guidelines andregistered with prosper-o(crd ). the search was planned with the pico criteria and conducted on medline (via pubmed), web of science and central. two independent reviewers first screened titles and abstracts and then eligible full-texts. inclusion criteria were original studies, comparative studies for cl vs. ras for rectal cancer as well as reporting of functional outcomes. quality assessment was done with the newcastle-ottawa-scale for non-randomized studies and the cochrane tool to assess risk of bias for randomized trials. results: the search retrieved hits, of which studies with patients met inclusion criteria. preliminary results yielded a lower rate of urinary retention for ras (odds ratio (or)[ %-confidence interval (ci)] . [ . , . ] ) while there were no differences for ileus (or[ci]: . [ . , . ] ). erectile function (iief) showed no differences after (mean difference (md)[ci] . [- . , . ] , (md[ci] . [- . , . ] ) and months (md[ci] . [- . , . ] ). in terms of urinary problems (ipss) there were no differences postoperative (md[ci] - . [- . , . ]) and month postoperative md[ci] - . [- . , . ] ), but advantages for the cl group after months md[ci] - . [- . , - . ] ). discussion: ras and cl seem to provide similar functional outcomes after rectal cancer surgery. however, the results need to be interpreted carefully as none of the studies had any functional outcome defined as primary endpoint. future studies should evaluate both surgical approaches in terms of functional outcomes and should be appropriately powered. methods: from april to november , laparoscopic right colectomy with intracorporeal anastomosis were performed in our surgical department. all patients in both groups were perioperatively managed using an eras pathway. seventy-two patients had the enterotomy closed with a single layer running suture of filbloc tm (assut europe). these patients were matched with patients who underwent intracorporeal right colectomy with enterotomy closed with a 'hybrid' double layer technique (first layer interrupted stitches in maxon tm - (covidien), second layer using a running suture in pds tm .intraoperative variables, anastomotic leak rate, morbidity and mortality rates were analyzed. results: the two groups were homogeneous with respect to demographics, body mass index (bmi), american surgical association score (asa) as well as for tumor stage. in the barbed group, median operating time was . min vs . min in the hybrid group (p = . ). anastomotic leak occurred in ( . %) patients in the hybrid vs ( . %) patients in the barbed group (p = . ) all patients required a reoperation. intraoperative findings at shows in ( . %) cases in the hybrid group a leak at the enterotomy closure, while an intact staler access was observed in both patients in the barbed group. no difference was observed with respect to non-infectious complications between the two groups (p = . ). patients in the hybrid group experienced a longer hospital stay when compared to the barbed group (p = . ). a re-admission occurred in the hybrid due an intraabdominal collection, while no re-admission was observed in the barbed group. no patient died in the postoperative period. conclusion: our results shows that the use of knotless barbed suture for enterotomy closure after laparoscopic intracorporeal right colectomy is safe, reproducible and associated with shorter operative time. aims: the accurate measurement and staging of rectal cancer, in particular the distal margin of low rectal tumours, is of paramount importance to optimise oncological surgical resection whilst preserving function. it is well recognised that the lower the tumour, the greater the technical challenges, operative time and the possibility of a temporary or permanent stoma. accurate localisation of the tumour is also essential to assist the multi-disciplinary team when considering neo-adjuvant chemoradiotherapy (crtx). the objective was to compare tumour height as reported on magnetic resonance imaging (mri) with endoscopic measurement. methods: a retrospective analysis of rectal tumour heights on pre-operative endoscopy and mri in patients undergoing radical colorectal surgery with curative intent over years from january . rectal tumours were identified as within cm of the anal verge (av). all mri measurements were reported by one of two specialist gastrointestinal radiologists. measurements were taken from the lowermost point of the tumour to the av. endoscopic measurements were as recorded by endoscopists including rectal surgeons, general surgeons, gastroenterologists and a clinical nurse specialist endoscopist. results: records of eighty one patients with histologically confirmed rectal adenocarcinoma were reviewed. median age was years ( to ). twenty three patients had or more endoscopies. on mri the median tumour height from the av was . cm ( . - cm) . on endoscopy the median tumour height was cm ( - cm) . on comparing endoscopy with mri, the median difference was cm ( - cm) . for over a third of patients ( %) tumours were lower on mri than endoscopy, median difference . cm ( . - cm) . only rectal surgeons documented tumour height in relation to the rectal folds. the majority of the repeat endoscopies were performed by surgeons to locate tumours more accurately pre-surgery. on no occasion was it documented whether the tumour had been measured during insertion or withdrawal of the endoscope. conclusions: precise localisation of rectal tumours is imperative to plan complex surgery and give informed counsel to patients. this study demonstrates the urgent need for a standardised protocol for all endoscopists to use while recording the distal extent of rectal tumours. objectives: the aim of the present rct was to compare the incidence of genitourinary (gu) dysfunction after elective laparoscopic low anterior rectal resection and total mesorectal excision (lar ? tme) with high or low ligation (ll) of the inferior mesenteric artery (ima). secondary aims included the incidence of anastomotic leakage and oncological outcomes. background: the criterion standard surgical approach for rectal cancer is lar ? tme. the level of artery ligation remains an issue related to functional outcome, anastomotic leak rate, and oncological adequacy. retrospective studies failed to provide strong evidence in favor of one particular vascular approach and the specific impact on gu function is poorly understood. methods: between june and december , patients who underwent elective laparoscopic lar ? tme in italian nonacademic hospitals were randomized to high ligation (hl) or ll of ima after meeting the inclusion criteria. gu function was evaluated using a standardized survey and uroflowmetric examination. the trial was registered under the clinicaltrials.gov identifier nct . results: a total of patients were randomized to hl (n ) or ll (n ). gu function was impaired in both groups after surgery. ll group reported better continence and less obstructive urinary symptoms and improved quality of life at months postoperative. sexual function was better in the ll group compared to hl group at months. urinated volume, maximum urinary flow, and flow time were significantly (p \ . ) in favour of the ll group at and months from surgery. ultrasound measured post void residual volume and average urinary flow were significantly (p \ . ) better in the ll group at months postoperatively. time of flow worsened in both groups at months compared to baseline. there was no difference in anastomotic leak rate ( . % hl vs . % ll). there were no differences in terms of blood loss, surgica l times, postoperative complications, and initial oncological outcomes between groups. conclusions: ll of the ima in lar ? tme results in better gu function preservation without affecting initial oncological outcomes. hl does not seem to increase the anastomotic leak rate. introduction: robotic single-site cholecystectomy (rssc) has been known to have some advantages such as reducing stress of the surgeon compared to single incision laparoscopic cholecystectomy (silc). however, there are few studies comparing the perioperative outcomes of these two operative methods. patient and methods: between march and february , rssc and silc were performed for benign gallbladder disease in our center. propensity score matching was performed to control variables including sex, age, body mass indes (bmi), diagnosis, american society of anesthesiologist (asa) score and cohorts were selected among the silc group through : matching. the perioperative data of these patients were analyzed retrospectively. the diagnosis was classified into acute cholecystitis, chronic cholecystitis, and gallbladder polyp. results: patient demographics between the two groups were evenly matched. total operation time including docking time was slightly longer in rssc group ( . min vs. . min, p \ . ), but real working time except the docking or set-up was shorter in rssc group ( . min vs. . min, p \ . ). conversion to additional robotic arm or additional port was frequent in silc group ( vs. cases, p = . ). intraoperative bile spillage rate ( . % vs. . %, p = . ) and postoperative hospital stay ( . days vs. . days, p = . ) were comparable in both group. conclusion: both surgical procedures performed safely. but the rssc demonstrated the better performance of the operation with shorter working time and the advantage of overcoming unexpected difficulties during the surgery with low conversion rate compared to silc. even though laparoscopic cholecystectomy(lc) is the gold standard procedure for cholelithiasis, patients are still suffering from various causes of pain. one of main causes is high pressure by pneumoperitoneum which makes peritoneal stretching and diaphragmatic irritation. however, there are few well-designed studies for evaluating pneumoperitoneum. therefore, we conducted a study to compare the postoperative pain after lc at serial different pressure methods. a prospective randomised double blind study was done in patients with benign gallbladder disease. they were divided into groups. each patients underwent lc with different pneumoperitoneum method; group a: far-low ( - mmhg), goup b: low ( - mmhg) and group c: standard pressure ( - mmhg). three groups were compared for pain intensity, duration, analgesic requirement and complications. post-operative pain score was significantly least in far-low pressure group as compared to low or standard pressure group during late periods ( , h). but, there were no pain score difference between far-low and low groups during early period ( , , , h) even though scores of standard group were significant higher than those of low group. number of patients requiring rescue analgesic doses and intraoperative complications were not significantly different among groups. this study demonstrates reducing the pressure of pneumoperitoneum results in reduction in intensity of post-operative pain. this study also shows that low pressure technique is safe with comparable rate of intraoperative complications. however, in immediate postoperative period, there is limitaton of pain relief after low pressure surgery. therefore, there may need new alternatives for pain. background and aim: anatomical hepatectomy with the glissonian approach is widely accepted as an important technique to ensure surgical safety and curability of the carcinoma. however, the histomorphological structure of the hepatic connective tissue is not sufficiently understood by surgeons. this study aimed to clarify the hepatic connective tissue structure using modern tissue imaging and analytical techniques. materials and methods: in total stained thin slices were loaded onto the computer and were reconstructed as dimages and analyzed. results: when the liver capsule enters the liver at the hepatic hilum, it becomes a sheath which envelops the portal pedicle. the hepatocytes in a row that constitute the periportal limiting plate at the edge of the hepatic lobule are firmly supported by the framework of the reticular fiber. the hepatic lobule and the portal area are in contact via the periportal space of mall. the framework of the limiting plate plays a role of a capsule of hepatic lobule (proper hepatic capsule) on the side in contact with the portal area. the binding site between the hepatic capsule and proper hepatic capsule (ppbs) is loose binding and is a layer that is easy to apply to surgical procedures. in order to enter between the liver capsule which became the sheath of the portal pedicle and the proper hepatic capsule at the hepatic hilum, the liver capsule must be dissected to reach the surface of the proper hepatic capsule. then, on the one hand, the portal pedicle is firmly gripped and pulled, on the other hand, the hepatic parenchyma covered by the proper hepatic capsule is pushed to expand between the portal pedicle and the liver parenchyma. at this time, the portal area (glisson's sheath) branched from the sheath of the portal pedicle into the gap of the hepatic lobule breaks like a string. with this dissecting plane, dissecting layer can reach to the next branch of the portal pedicle without entering into the portal pedicle or liver parenchyma. conclusion: understanding the connective tissue constituting the liver and conducting surgery turns the laparoscopic systematic hepatectomy into a standardized procedure. background: postoperative pancreatic fistula (popf) is the primary contributor to morbidity after distal pancreatectomy (dp). to date, no techniques used for the transection and closure of the pancreatic stump showed a clear superiority over the others. this study aimed to compare the rate of popf after pancreatic transection conducted with the reinforced stapler (rs) and ultrasonic dissector (ud) following dp. method: consecutive patients underwent dp from to were retrospectively reviewed. we included dps where pancreatic transection was performed by rs or ud and excluded dps extended to the pancreas head. to overcome the absence of randomization, we conducted a propensity matching analysis according to risk factors for popf. results: overall, patients met the inclusion criteria. the rs was employed in patients and ud in cases. after the one-to-one propensity matching, patients were selected from each group. the matched rs and ud cohort have no differences in baselines characteristics except for the mini-invasive approach, that was more common in the ud group ( % vs. %, p = . ). overall, patients ( %) developed a popf, a grade b ( %) and ( %) a grade c. in the rs group the rate of popf was % (n = ) and the ud group % (n = ) with a p \ . . conclusion: the results of this study suggest that the use of rs for pancreatic transection, reduces the risk of postoperative pancreatic fistula. a randomized trial is needed to confirm these preliminary data. aim: this study compares clinical and cost outcomes of robot-assisted single port and open longitudinal pancreaticojejunostomy (rlpj and olpj) for chronic pancreatitis. single incision mis needs more manual skills than conventional multiport operation. the advantage of better operation course is d vision and dedicate instrument. this paper aims to evaluate the feasibility and safety of the robot-assisted single incision with single port platform for chronic pancreatitis. materials and methods: clinical and cost data were retrospectively compared between open and ralpj. we collected patients since july, to september, . the patient was supinely placed in reverse trendelenburg position. the assistant surgeon was located between patient's legs. under general anesthesia a trans-umbilical . cm skin incision was made. a single incision advanced access platform with lagis port, glove portÒ (nelis, s. korea) and gelpoint combined with the da vinci si and xi surgical system (intuitive surgical, sunnyvale, ca, usa) pure or plus one was performed. the three arms, no. , no. , and da vinci scope, were in dwelled through the glove portÒ. pneumoperitoneum of mmhg was established through the port. a rigid -degree up scope was used during operation. results: twenty-one patients underwent lpj: open and ralpj. no robot-assisted cases converted to open were noted. patients undergoing ralpj had less intraoperative blood loss, a shorter surgical length of stay, less postoperative pain and lower medication costs. operation supply cost was higher in the ralpj group. no obvious difference in hospitalization cost was found. conclusions: versus the open approach, ralpj performed for chronic pancreatitis shortens hospitalization, less postoperative pain and reduces medication costs; hospitalization costs are equivalent. a higher operative cost for ralpj is mitigated by a shorter hospitalization and less pain control. robotassisted puestow procedure using single port platform is feasible and safe method. the total procedures by da vinci robotic system are safe and easily performed in highly selected patients. general surgery, hospital universitario infanta sofia, madrid, spain; general surgery, hospìtal quirón la luz, madrid, spain aims: the concomitant presence of abdominal wall midline hernias and diastasis recti is frequent. diastasis recti might be a risk factor not only for having but for recurrence of midline hernias. most open surgical procedures not consider the treatment of both pathologies, nor laparoscopic most spread out approaches. the author presents a novel endoscopic, extraperitoneal and retromuscular hernioplasty technique and its preliminary results. methods: a serie of patients is presented. a ct abdominal wall study is performed preoperatively. they all presented abdominal wall midline hernias in presence of a [ . cm concomitant diastasis recti. there were females and males. a totally endoscopic, extraperitoneal and retromuscular repair was performed, that included a midline anatomic restoration, tension-free hernia gap closure, omphaloplasty and skin treatment, if needed in every case. the tension-free massive-meshed hernioplasty included a bilateral totally endoscopic posterior components separation when needed. no drainages were used. all procedures included a bladder catheterization. results: all patient were dispatched within a period under h. no reoperations were needed in postoperative period. postoperative pain was measured by an eva scale. % of the patients have no pain medication after - h dispatching from hospital. % of the patients have a skin suffusion or hematoma. a male patient presented a temporary abdominal asymmetry due to a unilateral posterior component added to his technique. the mean following-up is to months ( - months) . no recurrence was observed. conclusions: preliminary results demonstrate this new approach to be a safe, feasible and a reproductible procedure. the 'terra' novel technique could provide of a new minimally invasive approach to abdominal wall midline hernias repair in the presence of a diastasis recti. only time and new results can predict the spreading out of this 'third way'. results: this study comprised males and females. mean age was years (range - years) and mean body mass index was . gh and mh were found intraoperatively in and cases respectively. mean operative time for all hernias (gh/mh) was min (range - min); min for gh (range - min); and min for mh (range - min). in . % of cases, hernia operative measurement was larger than preoperative size, especially in cases of incisional hernias ( . %). in . % of cases, laparoscopy found additional abdominal wall defects previously undetected by physical examination and by us-and/or ct-scan. a composite mesh and a non-composite mesh (up to cm in size) were used in . % and . % of cases respectively. the ethicon securestrap?? absorbable fixation device straps for sm fixation were employed in . % of cases. mean length of hospital stay was . days. mean follow-up time was months (range - months). in our study, there was one early (\ days) postoperative seroma ( . %), plus one late, small ( cm) symptomless recurrence, but neither needed reoperation. conclusion: the sutureless sm technique facilitates intra-abdominal introduction, as well as the handling and fixation of large/very large meshes. this new approach is safe and fast, even in cases of gh/mh repair. aims: any ventral hernia (vh) combined with rectus muscle separation (rms) must be repaired along with repairing the rms, otherwise there is a high risk for hernia recurrence. open rms repair is vast and traumatic surgery and laparoscopy is not effective. at a new era of repairing abdominal wall hernia by assisted endoscopy started with wolfgang reinhold's milos procedure. these procedures are somewhat complexed and real reconstruction of the linea alba (la) was limited, which done better by ferdinand koeckerling's elar technique. we perfected the elar technique to be fully endoscopic with wide mesh fusing to the muscles immediately by fibrin glue: extended endoscopic hernia & linea alba reconstruction glue (eehlarglue), achieving a low traumatic mis for vh and rms with excellent surgical and cosmetic results. methods: our eehlarglue is a totally endoscopic based technique used since . penetrating with optiview trocar and co pressure to the anterior rectus sheet (ars) level is followed by an extensive endoscopic dissection of the sub-cutaneous fat tissue from the ars. three trocars are inserted at the supra-pubic line enabling the dissection up to the xiphoid and costal margins laterally. any hernia sac is dissected, and the content reduced back to the abdominal cavity. relaxing incisions of the ars are performed longitudinally in the lateral aspect. the la is reconstructed by running two layers of non-absorbable sutures from xiphoid to pubis. a light mesh x cm is applied over the repair and the mesh is fused immediately to the muscles by fibrin glue. results: patients underwent the eehlarglue with follow up of months. all had significant rms of - - cm combined with primary or recurrent vh. recovery was smooth with - days of simple analgesics and return to regular activity within - days. no one had recurrent vh, but two males had limited rms and two early cases seroma formation. conclusions: our eehlarglue enables endoscopic vh repair and la reconstruction with extrastrength received by immediate mesh fusion to muscles with fibrin glue. thus, achieving low traumatic mis, easy recovering and very effective results-a perfect solution for patients with vh combined with rms. results: twelve blinded prospective rcts were used. when compared to tep repair, tapp repair has comparable seroma formation rates (chi = . ; (p = . ); ci - . , . ; i = %) and post-op pain at h (chi = . ; (p = . ); ci - . , . ; i = %). however, tep repair is associated with a significantly shorter operative time (chi = . ; (p = . );ci . , . ; i = %), post-op pain at hour (chi = . ; (p = . ); . , . ; i = %) and shorter hospital stay (chi = . ; (p = . ); ci . , . ; i = %). conclusion: tep is significantly better than tapp repair with regards to operative time, post-op pain at h and hospital stay. there is no significant difference with regards to post-op pain at h and seroma formation. background: primary hyperhidrosis (ph) is a neurological condition characterized by excessive sweating most often of the face, palms or axillae . palmar hyperhidrosis is treated through sympathetic chain clipping or transection .we aiming to compare the efficacy and results obtained with both techniques. patients and methods: sixty four patients underwent of sympathetic procedures from march to february . the patients were categorized into two groups: right sided transection sympathectomy and left sided clipping . patients were evaluated to compare the rates of success, satisfaction, compensatory sweating and recurrence either with transection or clipping of the t andt ganglion .mean follow up was ? _ months. results: sixty four patients males and females undergoing electro-coagulation sympathectomy on the right side and clipping on the left side. with mean age was years (range to years). all patients had balanced demographic data . no statistical difference between the two groups according rate of success. compensatory sweating was observed in patients ( . %) overall with cases of severe unsatisfied compensatory sweating. recurrence was reported in one case with transection and cases in clipping. satisfaction was occurred in cases in transection group and cases in clipping group .pnumothorax was occurred in cases in transection group compared to one case in clipping. no gustatory sweating and over dryness were reported in both groups. conclusion: both thoracoscopic sympathetic transection and clipping of t t ganglion are safe and effective procedure in palmar hyperhidosis treatment. with no differences regarding recurrence rate,satisfaction and incidence compensatory sweating. keywords: thoracoscopic sympathectomy,palmar hyperhidrosis, clipping, compensatory hyperhidrosis. introduction: primary ventral hernias and ventral incisional hernias pose a challenge for surgeons throughout the ages. even though minimally invasive surgery and hernia repair have evolved rapidly, there is no standardized method that adequately decreases postoperative complications. hybrid hernia repair is a surgical repair, which has not been adopted widely. it combines both a laparoscopic and open component allowing sac excision, primary defect repair as well as laparoscopic mesh insertion. aims: to evaluate the short-term and long-term outcomes of hernia recurrence for patients undergoing hybrid ventral repair (hvr) for the treatment of primary and incisional ventral hernias. methods: between october- and june- , hybrid vhr was performed in -patients at st mary's hospital, imperial college london. the medical records of these patients were reviewed retrospectively for demographics, comorbidities, prior surgeries, body mass index (bmi), hernial defects, hybrid technique used; mesh selection, operative time, complications and recurrences over a -year follow-up. results: twenty-four patients who underwent hybrid vhr were included with surgery performed by two surgeons. the mean age is -years with a mean bmi of . kg/m . % had incisional hernias and % had primary hernias. the number of hernia defects ranged from to , with the average mesh size used was x cm. extensive adhesionolysis was performed in % of patients. -day postoperative complications; patients developed post-operative seroma, paralytic ileus in , pain control in and urinary retention in patient. there were no conversions to open procedures. the mean length of hospital stay was -days. none of the patients developed chronic pain and only one recurrence over the -year follow-up period. conclusions: the hybrid technique for vhr is safe and feasible, and has important benefits over an open or purely laparoscopic approach, including a low rate of seroma formation, chronic pain and fiveyear hernia recurrence. future investigation may include randomized controlled trials, to fully evaluate the benefits of hybrid vhr, with careful assessment of patient-centred end-points including quality of life and postoperative pain. surgery, medical faculty-university of tetove, tetove, macedonia; general medicine, medical faculty-university of tetove, tetove, macedonia; anestesiology, medical faculty-university of tetove, tetove, macedonia; surgery, clinical hospital-tetove, tetove, macedonia laparoscopic cholecystectomy is widely used operative technique and it's characterized with less postoperative hospitalization and side effects. duration of the hospitalization after laparoscopic surgery depends on several factors of which pain and physical weakness are the most important. dexamethasone is well known; not only for its anti inflammatory effects but at the same time for analgesic and antiemetic effects, although the mechanism of this effects are not clarified yet. objectives: the aim of our study is the evaluation of analgesic effect of dexamethasone on reducing postoperative pain after laparoscopic surgery. patients and methods: in this study, patients aged - years old undergoing laparoscopic surgery, were classified into two groups, patients in each group. the first group were treated with a intravenous injection of mg dexamethasone preoperatively and another dose the next day after operation. the second group received a intravenous injection of normal saline. we evaluated the dose of consumed analgesics and antiemetic's drug during the first h in both groups. results: according to our experience results the total dose of tramadol in a postoperative period in dexamethasone receiving group was smaller than in normal saline group. measure of postoperative pain was assessed using the paper-based vas scale. our result shows that the intensity of post operative pain in a period during first h, after surgery in a group of patients treated with dexamethasone was lower compared with the group of patients treated with normal saline. nausea and vomiting during the first h was significantly lower in the dexamethasone group than in the normal saline group. surgery, hospital quiron sagrado corazon, sevilla, spain; surgery, hospital virgen macarena, sevilla, spain; surgery, hospital virgen del rocio sevilla, sevilla, spain aims: closing the defect (cd) during laparoscopic ventral hernia repair (lvhr) could be related to a reduction of seroma formation or bulging (hernia mesh) compared to conventional lvhr. but tension of the midline may contribute for some authors to a higher incidence of pain, recurrence in medium size defects and suggest to perform a component separation (cs) for restoring the midline in medium-large defects.we have developed a new technique for restoring the midline in medium ventral hernias (lira technique) and weanalyzed our results in terms of pain and recurrence compared to our conventional cd series (ccd). methods: we conducted a prospective controlled study of lvhr with ccd from january to december and a prospective controlled study performing lira technique from january to january . we analyzed and compared both techniques in medium size defects ( - cms) in terms of postoperative pain ( , days, , months and year) using a visual analogue scale (vas), bulging (return to prior distance among rectus muscles with the mesh in the sac in ct that didn't need surgical treatment)and recurrence (by physical examination and tomography). results: ccd was performed in patients (mean age was . ± . years old and mean bmi was . ± . kg/m ) and lira technique in patients (mean age was . ± . years old and mean bmi was . ± . kg/m ). the mean average follow-up in both series was year. mean average vas in ccd was . ± . ( day), . ± . ( days) . ± . ( month) . ± . ( months ) and at year. in lira series vas was . ± ( h) . ± . ( days), . ± . ( month), ( months) and ( year) . there are cases of bulging in ccd series and recurrence. bulging and recurrence were absent in lira series. conclusions: lira technique might be a safe procedure in medium size defects for restoring the midline in lvhr, and could be related to a lower pain rate compared to ccd with no recurrence or bulging. surg endosc ( ) :s -s background: the desire of pediatric surgeon to reduce incision related morbidity and pain while achieving good cosmetic results has recently led to the introduction of single incision pediatric endo-surgery [sipes] and needlescopic surgery. intracorporeal suturing and knot tying during sipes remains challenging. the aim of this study is to introduce a novel and simple technique for intracorporeal suturing of the pediatric inguinal hernia after needlescopic disconnection of hernia sac using just needles rather than laparoscopic instruments. it is an imitation of the principles of sewing machine. methods: the first author discussed the idea of the technique with the co-authors and a demonstration was done on a silicon pad before application of the technique on children with congenital inguinal hernia [cih] for peritoneum closure after needlescopic disconnection of the hernia sac. the main outcome measurements were; feasibility of the technique, knot quality, suture placement accuracy, performance and suturing time and recurrence rate. results: the sutures were snugly applied to the ridges of silicon pad with good approximation and the knot was firmly tightened in all experiments. after applying and mastering the technique on a silicon pad, we shifted to use it on children with hernia defect. all operations were completed by the needlescopic technique without the need for insertion of any laparoscopic instruments. the time required for suturing of the peritoneum around internal inguinal ring [iir] and knot tying, decreased considerably from min s in the first operation to less than min after the fifth operation and stabilized at approximately minute s. no major intraoperative complication and no recurrence. the primary end-point was to compare clinical outcome as well as cost effectiveness study between both groups. results: a total of patients were enrolled ( of them underwent tapp and olr). drop out occurred in cases ( of tapp and of olr group). patient characteristics were statistically similar between the groups. tapp procedure had less early post-operative pain (p = . ), a shorter length of stay (p = . ) and less postoperative complications (p = . ) when compared with the olr approach. a slightly higher recurrence rate in the tapp group was found. additionally, there is a trend towards a higher postoperative quality of life and less chronic pain in the tapp group. conclusions: tapp procedure for bilateral inguinal hernia effectively reduces early postoperative pain, hospital stay and postoperative complications. cannizzaro hospital, catania, italy aim: the purpose of this study was to evaluate the long-term results in terms of safety and efficacy of a new technique to repair incisional ventral hernias with a self-gripping mesh, after a mean follow-up period of months. methods: a retrospective, single-centre study was performed from june to june . all patients undergoing elective incisional ventral hernia repair were included. hernias were diagnosed based on clinical examination at the outpatient clinic. in case of doubtful diagnosis, ct-scan was used to confirm the diagnosis. the component separation technique and, when needed, tar were performed. the self-gripping mesh was placed in sublay position (overlap cm) with the self-gripping surface face down. in all cases drainage tubes were placed in retromuscular and supraaponeurotic position. the following characteristics were collected: age, sex, body mass index (bmi), smoking, comorbidities, number of previous surgical operations, defect size (ehs classification), mesh size, postoperative complications, duration of follow-up. all patients were interviewed by telephone every six months. when patients complained recurrence or other symptoms, visits were organized and when there was the doubt of recurrence a ct-scan was performed. results: a total of patients were included in this study, males, mean age was years. % of patients had bmi [ , smokers and diabetics were respectively % and %. the mean defect size was cm . component separation technique was associated with tar in patients. in cases the size of mesh was cm, while in patients the size of mesh was cm and in cases this was cm. in the other patients the mesh sizes were tailored to defect dimensions. subcutaneous seromas occurred in patients, they were treated conservatively in cases and with percutaneous punction in cases. long-term follow-up demonstrated recurrences in one case, while in another one ct-scan revealed a bulging. no cases of mesh infection, pain or sensation of mesh. conclusions: this study with a mean follow-up period of months demonstrated that the use of self-gripping mesh in sublay position is safe and effective to treat incisional ventral hernias. aim: morgagni hernias present technical challenges. the laparoscopic approach was described at first in , however, as they are uncommon in adult life and, little data exist on the optimal method of surgical management. this study purpose was to analyse a method for laparoscopic repair of morgagni giant hernias using laparoscopic primary closure. methods: this case series describes a method of laparoscopic morgagni hernia repair using primary closure. in all patients a laparoscopic transabdominal approach was used. the content of the hernia was reduced into the abdomen and the diaphragmatic defect was closed with a running laparoscopic suture using a self-fixating suture. clips were placed at the edges of the suture to secure the pledged sutures to both the anterior and posterior fascia. demographic data as age, gender and bmi were collected. operative data (operative time, rate of conversion, blood loss) and post-operative data (short and long term complications, length of hospital stay, need of readmission and reoperation) were recorded. results: retrospectively collected data about patients were analysed. there were ( . %) male and ( . %) females. the median bmi was . ± . kg/m . median operative time was ± min. there were no intraoperative complications nor conversion to open surgery. patients began a fluid diet on the first post-operative day and were discharged after a median hospital stay of ± . days. in a median follow up of months we did not observe any recurrences. conclusions: transabdominal laparoscopic approach with primary closure of the diaphragmatic defect is a viable approach for repair of morgagni hernia. in our experience, the use of laparoscopic transabdominal suture fixed to the fascia allowed the closure of the defect laparoscopically with minimal tension on the repairs. can we predict the success of the laparoscopic approach in the adhesive small bowel obstruction? c. tellez marques, e. sebastian valverde, e. membrilla fernandez, l. grande posa, i. poves prim general surgery, parc de salut mar-hospital del mar, barcelona, spain aims: the laparoscopic approach in the acute adhesive small bowel obstruction and internal hernias (asbo) has shown superior to laparotomy in terms of morbidity and hospital stay. especially, in patients who present simple adhesions or internal hernias. according to this, the aim of the study is to determine those preoperative factors associated with simple adhesions and internal hernias, and consequently, improve the success of the laparoscopic approach in asbo methods: a retrospective study of patients who underwent urgent surgery for asbo was conducted from january to may . we compare preoperative variables between single adhesions and internal hernias vs complex adhesions. a p value \ . was considered statistically significant. results: we analysed patients who underwent surgery for asbo, ( %) by laparoscopy and ( %) by laparotomy. conversion rate in laparoscopy was . %. . % of patients presented a single adhesion or internal hernia; and . % were considered complex adhesions. sex and age did not correlate with the type of adhesions. previous surgery (p \ . ), number of previous surgeries (p \ . ), asa (p \ . ) and previous abdominal wall mesh (p = . ) were significantly associated with complex adhesions. laparoscopy as the only surgical history was significantly associated with simple adhesions (p = . ). only appendectomy (p = . ) or supramesocolic (p = . ) previous surgeries tended to present single adhesions but it did not reach statistical significance. the need for intestinal resection was not related to the type of adhesions (p = . ). there was a significant correlation between the findings in the ct (computed tomography) and the type of adhesion found (p = . ). signs of ischaemia on ct were related to the need for intestinal resection (p \ . ). in the multivariate analysis, the number of previous surgeries, asa and ct scan findings were identified as independent factors related to the type of adhesion. conclusions: according to our study, a lower number of previous surgeries, asa i-ii and internal hernia in the ct scan are associated with single adhesions and internal hernias. patient selection is a key factor for the success of laparoscopic approach in asbo. aims: there aims of this study were: (i) to compare england with the united states in the utilisation of minimal access surgery (mas) and in-hospital mortality from four common abdominal surgical emergencies (appendicitis, incarcerated or strangulated abdominal hernia, small or large bowel perforation and peptic ulcer perforation). (ii) within england to evaluate the influence of mas upon in-hospital and long-term mortality. methods: between and , the rate of mas and in-hospital mortality for four abdominal surgical emergencies were compared between the united states and england. univariate and multivariate analyses were performed to adjust for underlying differences in baseline patient demographics. results: , admissions in england for four abdominal surgical emergencies were compared to an estimated , , admissions in the united states. after adjustment for patient demographics, mas was used less commonly england for three conditions; appendicitis (odds ratio (or) . , % ci . - . ), abdominal hernia (or . , ) and small or large bowel perforation (or . , ). in-hospital mortality in multivariate analysis, was increased in england compared to the united states for three conditions; abdominal hernia (or . , % ci . - . ), small or large bowel perforation (or . , ) and peptic ulcer perforation (or . , % ci . - . ). in england, after adjustment for patient demographics, open surgery was associated with increased in-hospital mortality for three conditions; abdominal hernia (or . , % ci . - . ), small or large bowel perforation (or . , % ci . - . ) and peptic ulcer perforation (or . , . similarly open surgery was associated with increased long-term mortality for three conditions; abdominal hernia (hr . , % ci . - . ) , small or large bowel perforation (hr . , % ci . - . ) and peptic ulcer perforation (hr . , % ci . - . ). conclusions: minimal access surgery was used less commonly and inhospital mortality was increased in england compared to the united states for common abdominal surgical conditions. given the benefits of mas shown in this large study, strategies to enhance adoption of mas in emergency conditions in england need to be optimised and include appropriate patient selection and improved surgeon mas training and experience. surg endosc ( ) :s -s background: in the treatment of inguinal hernias, there is little hard evidence concerning the economic reimbursement in the diagnosis-related-group (drg) era. factors that affect whether a hospital may earn or lose financially depending on open or laparoscopic approach is still underexplored. the aim of this study is to provide a reliable analysis of in-hospital costs and reimbursements in inguinal hernia surgery. methods: this retrospective study analysed the -year experience in inguinal hernia repair in patients undergoing open lichtenstein (ol), laparoscopic totally extraperitoneal unilateral (utep) or bilateral (btep) hernia repair. demographics, results, costs and drg-based reimbursements were recorded and analysed. results: during the study period, patients underwent ol, patients utep and patients btep. the average total cost amounted to eur in ol, eur in utep and eur in btep groups (p \ . *). the hospital reimbursement amounted to eur, eur and eur in the ol, utep and btep groups respectively (p \ . *). finally, the mean hospital earnings were eur, eur and - eur for each patient in ol, utep and btep respectively (p \ . *). conclusions: in-hospital costs were higher in utep and btep as compared to ol. the drg-based reimbursement provided adequate compensation for patients with unilateral inguinal hernia, whereas hospital earnings were profitable in ol group only, and led an overall financial loss in the btep group. surgeons should be conscious that clinical advantages of the laparoscopic approach are not adequately compensated for, from an economic point of view. aims: umbilical hernias are common anatomical defects in swine which become a suitable model for surgical training and research in the field of surgical meshes. the aim of this study was to develop a surgical protocol for a successful laparoscopic implantation of stem cell-coated surgical meshes. methods: large white pigs, weighing - kg and with congenital abdominal hernia were anesthetized for the surgical procedures. non absorbable polypropylene surgical meshes were coated with fibrin glue (fg) (control group) or with fg admixed with porcine bone marrowderived mesenchymal stem cells (fg/bm-mscs). approximation of hernia's borders was performed by intracorporeal suture. the meshes were carefully rolled inside the trocar for laparoscopic implantation. the surgical implantation was performed by laparoscopy using helicoidal staples. laparoscopic inspections and biopsies of the tissue surrounding the mesh were performed at , and days post-implantation. at day , the animals were euthanized and macroscopically evaluated. ultrasonography was used at day , , and to evaluate the size of the hernia. the biopsies were then processed for the histological analysis. results: ultrasonography demonstrated that the mean size of umbilical hernias before mesh implantation was . ± . cm. a decrease in hernia mean size was observed at day and . the laparoscopic procedures allowed a successful mesh implantation in all animals. in most of cases, the implantation site did not show excessive inflammation or tissue adhesions. but one animal showed hernia maintenance. one animal had peritoneal and implant-site infection. foreign body reaction was noted in the histological analysis, although no significant difference was found between the control, and bm-msc group. conclusions: the anatomical similarities between humans and pigs in umbilical hernias make this animal model useful to: i) improve minimally invasive surgical procedures for hernia treatment; ii) evaluate new surgical meshes, and iii) introducing stem cell therapy to hernia surgical repair. the laparoscopic approach is efficient and safe for the implantation of stem cellcoated meshes. gene and protein expression analysis are required to evaluate the molecular changes between the conventional and the stem cell surgical approach. aims: fluorescence angiography with indocyanine green (icg) is used as a marker in the assessment of tissue perfusion, being more frequently used in colorectal procedures. this technology has shown to be a good technique to reduce complications related to vascular supply to the anastomosis. in esophagogastric procedures blood supply to the gastric pouch, jejunum and esophagus could be evaluated by icg fluorescence imaging. it could be also used in bariatric surgery to evaluated the anastomoses, during gastric bypass, and blood supply to the gastroesophageal junction and the angle of his during sleeve gastrectomy. methods: we have collected data during gastric resection due to adenocarcinoma and bariatric procedures that were performed by the same surgeon, using icg fluorescence to evaluate blood supply. the icg was infused before performing the anastomosis in order to evaluate the need to change the transaction line (tl). we analyzed those cases in which the tl was changed and the number of leaks in those cases that we changed this line. results: all the cases were performed by laparoscopic approach: subtotal gastrectomy (sg), total gastrectomy (tg), gastric sleeve (gs) and gastric bypass. there were no changes regarding the tl before performing the anastomosis in any of the four types of procedures (sg, tg, gs, gb). in the analyzed data there is anastomotic leak in one sg procedure ( . %). conclusions: icg fluorescence angiography could be helpful in assessing blood supply during gastrointestinal anastomosis, although we have not find an influence in the results during bariatric and gastric procedures. however, we do not have the sufficient evidence to determine the value of this technology in this entities, being needed more volume and data to improve the significance of the results. aims: hyperspectral imaging (hsi) combines a spectrometer with a camera to analyze the tissues' optical properties in a broad wavelength range, without the need for a contrast agent. it provides extensive real-time information about tissue physiology, including oxygen saturation (sto ). fluorescence-based enhanced reality (fler) is a software solution providing a dynamic, quantitative analysis of the signal evolution of a systemically administered fluorophore, during fluorescence angiography (fa) . the aim of this study was to compare the performance of hsi and fler to assess bowel perfusion, in a porcine, non-survival model of bowel ischemia. methods: in pigs, an ischemic small bowel segment was created and imaged after hour of ischemia. the imaging modalities were applied sequentially to the same area.hsi was performed first, to acquire the sto spectra, by means of the tivita tm system (diaspective vision, pepelow, germany), which provides a spectral range of - nm and a nm resolution. subsequently, fa was performed using a nir-capable laparoscopic camera (d-light p, karl storz, germany), after intravenous injection of . mg/kg of indocyanine green (icg; infracyanine, serb, paris, france). the fluorescence flow was recorded during s, then the slope of the fluorescence flow was analyzed using a proprietary software to obtain a virtual perfusion cartography. the virtual cartography was overlaid onto real-time images to obtain the enhanced reality effect. ten adjacent regions of interest (rois) were selected from hsi datasets and were superimposed to fler-generated cartographies using a custom plug-in software function, allowing for a quantitative comparison of both imaging modalities. hsi was repeated after icg injection. results: the r correlation coefficient between hsi-sto and the fler slope was . . at control hsi after icg injection, the correlation coefficient dropped significantly (r . ). the interference of icg on hsi imaging was clearly identified in the spectral curves. conclusion: sto given by hsi provided results comparable to those obtained with fler in our bowel ischemia model, without the need to inject a contrast agent. icg interferes with hsi datasets, disrupting sto values. surgical treatment is one of the most effective options for treatment of giant hiatal hernia. laparoscopic approach became is a 'gold standard' over the time demonstrating all advantages of minimally invasive techniques over the open procedures. however the utility of robotic operations still remains controversial. aim of the study: evaluate the initial experience of robotic fundoplication in compare to laparoscopic procedures. materials and methods: since the january till the december of thirty operations were operated on. mean age was . ( - ), among them ( %) were female and ( %) were males. mean bmi was . ( . - . ) . laparoscopic procedures were performed in patients ( st group), robotic procedures with davinci system were performed in patients of the second group. nissen fundoplication modified was performed in patients, toupet fundoplication was used for patients. results: the median operative time in laparoscopic group was min, in robotic group- , min. there were no statistical differences between two groups (p = . ). blood loss was minimal in both groups. mean postoperative hospital stay was . days ( - days) in the st group and , days ( - days) in the second. there were no statistical differences between two groups (p = . ). postoperative course was uneventful in all patients of both groups. surgical stress response is associated with systemic inflammatory syndrome, sepsis, multiorgan dysfunction syndrome. robotic assisted surgery has been introduced to overcome the limitations of conventional laparoscopy. this technique has potential advantages over laparoscopy, such as increased dexterity, three-dimensional view, and a magnified view of the operative field. these advantages could result in limited intra-abdominal trauma and hence in attenuated surgical stress response over conventional laparoscopy. aims: this study aimed to synthesize data on the effect of robot assisted surgery on surgical stress response. methods: electronic databases were searched with the search terms 'surgical stress', 'stress response', 'oxidative stress', 'robotic assisted surgery', 'c-reactive protein', 'interleukin ', 'interleukin ','cortisol',;'oxidative stress markers', 'antioxidants', 'antioxidant status', 'mda', 'glutathione', 'cortisol', 'acute phase response' up to and including march . results: one hundred forty studies were identified and their title and abstract were reviewed. one randomized controlled trial, six non randomized comparative studies, one experimental study and one case report met inclusion criteria. data were discordant. one prospective trial concluded that cortisol and il- were lower in laparoscopic assisted distal gastrectomy compared with robot assisted distal gastrectomy in another study comparing robotic assisted laparoscopic radical prostatectomy with open radical prostatectomy based on plasma measurements of il- , il- a and c-reactive protein, it was demonstrated that robotic assisted laparoscopic radical prostatectomy induces lower tissue trauma than open radical prostatectomy. in another study, it was reported reduced expression of genes associated with surgical stress response in patients treated with robotically assisted radical prostatectomy compared with patients treated with open prostatectomy. the case report concerned a case of polymyalgia rheumatic after robotic assisted laparoscopic prostatectomy. the experimental trial demonstrated that cortisol and substance p were significantly higher with open thoracic approach versus robot assisted thoracoscopic oesophageal surgery. conclusion: further research is needed to elucidate the effect of robotic surgery on surgical stress, based on a well standardized protocol for the measurement of surgical stress response. purpose: tissue compression is essential to prepare the tissue for proper staple formation. this study evaluates the risk factors of compression injury on the circular stapling line in vitro. methods: to reproduce the artificial bowel wall, a collagen plate was prepared by mixing collagen extracted from porcine with glycerin. artificial collagen plates with mm and mm in the thickness were made for dry and healthy condition and immersed plates in the tap water for min to make wet and edematous condition. circular stapler (cdh a, ethicon, usa) was applied in the collagen plates (dry and wet condition) and optimal compressions. compression line was evaluated for compression injury score. risk factors for excessive compressions and unacceptable injury were analyzed. results: in the dry condition, optimal compression didn't cause unacceptable injury. in the wet condition, excessive compressions were occurred in . % with optimal approximation. unacceptable injury was significantly different in proper and excessive compression cases as . % and . %, respectively. on the univariate analysis, thickness ( mm), wet condition, proximal side, maximal compression, and excessive compression were associated with unacceptable injury. on the multivariate analysis using logistic regression model, excessive compression was significant independent factor to cause tissue injury (p \ . ) and this significance was also proved in the optimal compression group (p = . ). background: minimal invasive appendectomy gained much popularity due to its better cosmoses, early recovery and less wound site infections. single incision laparoscopic appendectomy (sila) has many disadvantages such as, long operative time, bad ergonomics, surgical site infections, high conversion rate and port site hernia. needlescopic appendectomy (na) using mediflexÒ facial closure needle expected to be more superior over sila. here in we compare our results of needlescopic appendectomy with single-incision one. material and methods: one hundred and twenty patients with acute non complicated appendicitis were randomly assigned to na and sila children for each group during the period between january to october . the main outcome measurements included, demographics, operative time, intraoperative complication, conversion rate, post-operative hospital stay, surgical site infection, port site hernia and cosmetic results. results: a total of children underwent appendectomy. there were children who underwent na and children who underwent sila. there were no difference in age ( . vs . years, p = . ), weight ( . vs . kg, p = . ) and hospital stay ( . vs . days, p = . ) between the two groups. there were no intraoperative complication during the two surgical approaches. operative time for na group is significantly shorter than single incision group ( . vs . min, p = . ). no single case of conversion in na group and cases needed conversion in sila group. seven cases of sila showed surgical site infection. cases of sila group presented with port site hernia. the na group was superior as regard ergonomics. the two groups showed equal excellent cosmetic results. conclusion: needles scopic appendectomy and sila are comparable as regard cosmetic results and hospital stay. na proved to be safe, applicable, repetitive and superior over sila as regard better ergonomics, less operative time, absence of surgical site infection and port site hernia. aims: to objectively analyze the surgical performance and surgeon's ergonomics in the use of a novel flexible laparoscopic instrument during intracorporeal suture, and compare it with the use of a conventional laparoscopic needle holder. methods: three experienced laparoscopic surgeons performed five laparoscopic sutures on an organic tissue using the novel flexible instrument (flexdexÒ) and five sutures using a conventional needle holder with axial handle. the new device is based on a mechanical design with no electrical components, which transfers the surgeon's hand, wrist, and arm movements to the instrument tip in an intuitive manner. the use of the instruments was organized in a random fashion. prior to the study, participants conducted a -minute training session with the new flexible instrument. execution time and quality of the suture were assessed for each repetition. besides, flexion and radioulnar deviation of the wrist were recorded using an electrogoniometer (biopac systems, inc.) attached to the surgeon's hand and forearm. the intensity of the forearm's muscle activation was also analyzed by means of a myo armband (thalmic labs). results: surgeons required more time to perform the intracorporeal suture using the novel laparoscopic instrument ( . ± . s vs. . ± . s; p \ . ), but the quality of the suture was similar with both instruments. the wrist flexion ( . ± . °vs . ± . °; p \ . ) and wrist ulnar deviation ( . ± . °vs . ± . °; p \ . ) were significantly lower when using the flexible instrument. during the suturing tasks, the use of flexdexÒ instrument led to a higher muscular activation of the flexor ( . ± . vs . ± . rms; p \ . ) and extensor ( . ± . vs . ± . rms; p \ . ) muscle groups of the forearm. conclusions: the presented novel instrument allows surgeons to perform robotic-like laparoscopic suturing. we believe that with a longer training period surgeons could potentially reduce surgical times with this device. the preliminary results of this study suggest that the use of this new instrument provides a quality of the suture similar to that obtained with a conventional laparoscopic needle holder and an ergonomically more adequate wrist posture. aims: the intraoperative real-time evaluation of tissue perfusion is one key element for successful visceral surgery. traditionally, tissue evaluation is performed visually by surgeons. newer devices for objective quantification have in majority been based on the application of the fluorescent dye indocyanin green (icg). a novel method derived from geographic research is hyperspectral imaging (hsi). the aim of this study was the evaluation of hsi as a promising method for the evaluation of tissue perfusion and its implementation in the evaluation of the gastric conduit during esophagectomy in a porcine model. methods: the hsi camera records a dimensional data cube from a dimensional surgical situs obtaining wavelengths between and nm. the absorption at different wavelengths is tissue-specific and influenced by the amount of oxygenated haemoglobin and other pigments. a software calculates different indices in real-time including oxygen saturation. a porcine model (n = ) is used for esophagectomy with gastric conduit formation. ischemia is induced artificially by magnets simulating staplers. different shapes of the gastric conduit and anastomosis formation are evaluated for perfusion metrics in order to obtain recommendations for the optimal formation of esophagogastrostomy. conclusion: hsi is a promising method for intraoperative evaluation of tissue perfusion that does not require application or injection of any agents. the preliminary results in this study showed that the gastric conduit receives its main blood supply from the gastroepiploic arteries and not via the mucosa. further results from the current evaluations enable formation of an optimized gastric tube and esophagogastrostomy in esophagectomy. surg endosc ( ) pediatric surgery, al azhar university, giza, egypt; pediatric surgery, beni suef university, beni suef, egypt background: varicocele is one of the most common causes of infertility. many surgical interventions are used for varicocele ligation including open and conventional laparoscopic multiport or single incision techniques. the aim of the study is to present a new needlescopic lymphatic sparing varicocele ligation using mediflexÒ facial closure needle and gauge vascular access cannula. material and methods: twenty-two male children with bilateral varicocele of grade ii-iii. all children were counseled by clinical examination, doppler ultrasonography, abdominal ultrasonography, and routine laboratory investigations. testicular lymphatics were delineated by subcutaneous injection of / cm methylene blue in anterior wall of the scrotum min prior to surgery. the testicular vessels (both vein and artery) were ligated one cm above the deep inguinal ring using two mediflex needles with preservation of lympatics. the main outcome measurements included; operative time, hospitalization, testicular atrophy, hydrocele formation, recurrence of varicocele and intra or postoperative complication. results: a total of twenty-two male children with grade ii-iii varicocele subjected to needlescopic lymphatic sparing technique. twenty one were bilateral. background and aims: even if the clinical outcomes of robotic rectal resections are under investigation, the related robotic costs have not yet been well addressed, and the differences between the robotic rectal resection costs and the laparoscopic approach are still not well known. we have therefore performed a prospective comparative study of robotic rectal resections (rrr) and laparoscopic rectal resections (lrr) performed at our centre with the aim to evaluate the cost-effective outcomes of robotic versus laparoscopic surgery. study design: this is an observational, comparative prospective non-randomized study which includes patients that underwent laparoscopic and robotic rectal resection reaching a minimum of months of follow up from february to march , at the sanchinarro university hospital, madrid. an independent company performed the financial analysis and fixed costs were excluded. outcome parameters included surgical and post-operative costs, quality adjusted life years (qaly), and incremental cost per qaly gained or the incremental cost effectiveness ratio (icer). the primary end-point was to compare clinical outcome as well as cost effectiveness study between both groups. results: a total of rrr and lrr were included. the mean operative time was significantly lower in the lrr approach ( versus min; p = . ). the main pre-operative data, overall morbidity, hospital stay and oncological outcomes were similar in both groups, except for the readmission rate (rrr: . %, lrr: . %;p = . ).the mean operative costs were higher for rrr ( . versus . €; p = . ); however, the mean overall costs were similar ( . € for rrr and . € for the llr; p = . ). mean qalys at year for rrr group ( . ) was higher than that associated with lrr ( . ) (p = . ). at a willingness-to-pay threshold of , € and , €, there was a . % and . % probability that rrr group was cost-effective relative to lrr approach. conclusion: this study provides data of cost-effectiveness differences between rrr and lrr approach showing a benefit for the rrr aim: the efforts were aimed to the introduction of novel surgical technologies to overcome the intrinsic anatomical and technical constraints of rectal surgery. this was the case of the introduction into the clinical practice of laparoscopy and later on of robotic surgery for rectal surgery. however, whether robotic surgery is actually superior to laparoscopy is still debated. the aim of this study was to compare d laparoscopy and robotic surgery for rectal cancer on technical and oncological outcomes. methods: this was a single-center, prospective, randomized controlled trial. all patients more than years of age undergoing elective surgery for rectal cancer situated from to cm from the anal verge were included. patients undergoing abdominal perineal amputation and/or with t and/or m tumours were excluded. patients were randomized before surgery into two arms: arms a ( d laparoscopy) and arm b (robotic), and gave their consensus to the study. demographic data, data regarding the tumour, operative and post-operative data were collected. patients with a follow up shorter than months were excluded as well. results: twenty patients were enrolled in arm a and in arm b in the period time of one year. patients' population of the arms was homogeneous as concerns demographic characteristics and stage of the disease. robot-assisted rectal resection results in comparable operative time ( . vs min; p = . ). the conversion rate was significantly lower for arm b ( vs p = . ). postoperative morbidity was comparable between groups. hospital stay was comparable but time required to resolve post-operative ileus was shorter in arm b ( . vs . days, p = . ). overall survival and disease-free survival were comparable between arms ( . % vs . %, p = . , and . % vs . %, p = . , respectively) conclusions: d laparoscopy and robotic surgery are two viable options for rectal surgery. robotic surgery can add some in terms of post-operative outcomes and ergonomics. aim: currently, robotic surgery for rectal cancer is a surgical operation that is being performed worldwide. we also introduced robotic surgery in . however, after robotic surgery, we observed a rise in creatinine kinase (ck), which is unlikely to happen in other surgeries. we studied the postoperative complications of rectal cancer patients who underwent either robotic surgery or laparoscopy during the same period of time. methods: from january to november , patients underwent surgery using robotassisted rectal resection (da vinci si cases and xi cases) and patients underwent laparoscopic rectal resection. in this study, abdominoperineal resection, intersphincteric resection, and lateral lymph node dissection were excluded. result: the operation time for the robotic surgery group was significantly longer than that for the laparoscopic group ( min vs. min; p \ . ). the ck value of the robotic surgery group on pod was significantly higher than that of the laparoscopic group ( iu/l vs. iu/l; p \ . ). in addition, one case of compartment syndrome was observed in the laparoscopic group. there were no significant differences in age, body mass index, intraoperative bleeding, tumor invasion depth, urination disorder, or postoperative hospital stay. in robotic surgery, it is considered that the increase in ck value is caused by the extended operation time, contact of the patient's cart with the left thigh of the patient, and the extra force applied to the abdominal wall caused by the displacement of the remote center. conclusion: in robotic surgery, it is suggested that the measurement of postoperative ck value is important. therefore, an attempt to shorten the operation time and paying attention to the surgical field are necessary to improve the outcomes. aims: anastomotic leak remains as one of the most important and life threatening post-operative complications in colorectal surgery. this complication has important consequences, both acute and long term, longer hospital stay, re-intervention, and increased morbidity and mortality. among all different circumstances that have been related to this entity, blood supply is an important factor that might have influence. fluorescence with indocyanine-green (icg) is used as a marker in the assessment of tissue perfusion in colorectal surgery which might reduce the numbers of leaks. methods: a multicenter analysis of the experience of centers in spain is collected in order to assess the value of icg in colorectal anastomosis. colorectal procedures were performed using icg to evaluate vascular supply in the anastomosis. icg was infused before performing the anastomosis analyzing the number of cases in which the transection line (tl) was changed. we also analyzed the number of leaks in those cases that we changed this line. results: out of the cases performed, cases were performed by open surgery, by laparoscopy, by single-port and with transanal total mesorectal excision(tatme). the following procedures were performed: right colonic resection(rc), splenic flexure partial resection(sf), left colonic resection(lc), subtotal colectomy(sc), total colectomy(tc), hartman reversal surgery(hr), low anterior resection with partial mesorectal-escision(lar) and ultra low anterior resection with total mesorectal-escision(ular). leak rate(lr) was . % ( . %rc, . %lc, . %sc, . %lar, . %ular). overall lr was . % in colonic surgery and . % in rectal surgery. the tl was changed due to icg in . % of the cases ( . %rc, . %sf, . %lc, % tc, . % lar, . % ular), being . % in colonic resection and . % in rectal resection. the relation between leaks and the cases in which the tl was changed, were % ( . %rc, %lc, . %ular). conclusion: icg fluorescence may play a role in anastomotic tissue perfusion assessment. the lr after colorectal surgery might decrease using icg to detect the proper tl before to perform the anastomosis. however, we do not have the sufficient evidence to determine that the changing transaction line can lead to avoid leaks. surg endosc ( ) aims: to analyse the value of postoperative day crp as an early predictor of safe discharge in robotic rectal cancer surgery. methods: a retrospective analysis was performed, including patients who had undergone robotic total mesorectal excision (tme) in a single centre over a -year period (may -september . patients who had a permanent stoma (abdominperineal resections or hartmann's procedure) were exluded from the study, leaving patients for further analysis. as the los is currently used as a performance tool in assessing outcomes in colorectal surgery (with a cut-off established at days), we compared the crp values in these groups. results: fourty one percent of patients were discharged home within days. they had an earlier peak of crp on postoperative day (pod) (median . , ) . the group of patients that were discharge home after days ( %) had a crp peak on pod (median , ). on pod , the group of patients that went home within days had a lower crp ( - -vs. - -) compared to the group of patients that were discharge after days, p = . ). conclusions: a crp peak on pod in robotic tme can predict an early and safe discharge (los within days). background: purposelateral pelvic lymph node dissection (lpnd) is suggested to treat suspected lymph node metastasis in pelvic side-wall in patients with rectal cancer who underwent preoperative chemoradiotherapy (crt). however, technical difficulties make it possible that lateral pelvic lymph nodes (lpns) are not dissected completely and, thus, remained in the narrow pelvis. near-infrared fluorescence imaging (fi)-guided surgery is expected to help visualization and complete excision of nonvisible lymph nodes during cancer surgery. this study aimed to evaluate the efficacy of fi using indocyamine green (icg) to identify lpns during robotic lpnd. methods: rectal cancer patients who were suspected lpn metastasis and had received preoperative crt were prospectively enrolled. icg in a dose of . mg was injected around tumor preoperatively. all procedures were performed with a totally robotic approach. after completing lpnd, fi was checked again for identifying remained lpns and resecting them completely. results: the lpns were successfully detected in ( . %) of the patients. however, after accounting for eight cases, having finished adjusting icg injection, the lpns were successfully detected in ( . %) of patients. the fi-guided lpnd group (n = ) showed similar mean operative time for unilateral pelvic dissection and complication rate, compared to patients who underwent conventional robotic lpnd (n = ). however, the mean number of unilateral harvested lpns was . in the fi-guided lpnd group, which was greater than the mean of . in the conventional group. lpn metastasis was identified in % of the fi-guided lpnd group, which was higher than that of the conventional group, . %. conclusion: fi-guided lpnd identifies lymph nodes in pelvic side-wall with great reliability. this contributes to increased number of lpns yield compared to conventional robotic lpnd. this technique should be considered to dissect them completely by preventing subsequent missing of nonvisible lpns. aims: to compare the medium-term oncological outcomes of laparoscopic total mesorectal excision (l-tme) vs. robotic total mesorectal excision (r-tme) for rectal cancer. methods: a retrospective analysis was performed including patients who underwent l-tme or r-tme resection between - . patients with disease stage iv at diagnosis or r resection were excluded. patients were initially included, and cases of r-tme were matched based on age, gender, stage and time of follow-up with an equal number of patientswho underwent l-tme. we compared -year disease free survival (dfs) and overall survival (os). in adittion, a multivariate analysis was performed in order to idenfity independent prognostic factors for -year dfs and os. results: pathological outcomes were similar between groups. however, major complications were lower in the robotic group ( . % vs. . %, p = . ), highlighting the anastomotic leakage rate, which was . % in the r-tme vs. . % in the l-tme group (p = . ). overall, the -year dfs rate was % in the laparoscopic group and % in the robotic group (p = . ). the -year os rate was % in the l-tme groups and % in the r-tme group (p = . ). for disease stage iii, -year dfs was significantly higher in the r-tme group. os was also significantly superior in the robotic group for every stage, reaching % in the stage iii. in the multivariate analysis, r-tme was a significant positive prognostic factor for distant metastasis (or . %ci . , . , p = . ) and os (or . %ci . , . , p = . ). conclusions: r-tme for rectal cancer can achieve better oncological outcomes compared to l-tme, especially in stage iii rectal cancers. the robotic approach has demonstrated to be a significant positive prognostic factor for local recurrence and overall survival, due to the better postoperative outcomes. however, a longer follow-up period is needed to confirm the oncologic findings. university hospital for visceral surgery, university of oldenburg, oldenburg, germany; bremen spatial cognition center, university of bremen, bremen, germany aims: in clinical settings, realistic assessment of one's own abilities can enhance performance and promote patient safety, especially in surgical residents, who inevitably have to acquire skills during real surgery. this study thus implemented the global assessment of laparoscopic skills (goals) questionnaire with the aim to explore divergences between resident self-evaluation and specialist's evaluation on laparoscopic performance, as a first step to implement the goals questionnaire as a tool for constructive and objective feedback. methods: between july and october , seven residents from the university hospital for visceral surgery at the pius-hospital oldenburg participated in this study. at the end of every laparoscopic operation where the resident acted as the primary surgeon, the resident and the supervising surgeon independently evaluated the resident's operative performance using the goals questionnaire. the five dimensions evaluated were depth perception, bimanual dexterity, efficiency, tissue handling and autonomy. a cumulative goals-score (with being the highest possible score) was calculated for n = laparoscopic operations. resident's year of training, the level of case difficulty and the type of laparoscopic procedure performed was also analysed. results: residents overestimated their laparoscopic abilities in . % of the operations (goals-scores: residents: median = , mean = . ; specialists: median = , mean = . ; p \ . ). residents in the first three years of surgical training were more likely to overestimate their performance (residents: median = . , mean = . ; specialists: median = , mean = . ; p \ . ) than those with more than three years of surgical experience (residents: median = , mean = . ; specialists: median = , mean = . ; p = . ). goals score differences did not depend on case difficulty and laparoscopic procedure. conclusions: surgical residents tend to overestimate their intraoperative laparoscopic performance when compared to specialist evaluation. overestimation was found to depend on one's own laparoscopic experience and seem to disappear with gained expertise. these results signify the importance of individually adapted training and the greater need for objective feedback for surgical residents. this approach could in return increase the skill acquisition rate of the resident and in return contribute towards enhancing patient safety. introduction: the delivery of safe surgical care is dependent of various, complex and interrelated factors. substantial data exist regarding the impact of training in human factor skills on surgical outcomes. however, except for the standardized time-out process, the best way to go about improving these skills remains unclear. the aim of this study was to gain more insights in the theatre staff's perception of human factors and their importance on surgical outcome in the operating theatre. methods: the surgical team assessment record (star) questionnaire was used to study the role of human factors, such as communication, situational awareness and organization, contributing to surgical team performance. the self-assessment questionnaire was filled out by the theatre staff, directly after the surgical procedure. conditional logistic regression was used to identify the impact of the role in the operating theatre on the yes versus no answers. results: some questionnaires were completed. the theatre staff rated their team's performance with a median of (iqr . , -point likert scale). the surgical fellows (n = ) rated their personal factors significantly lower compared to the rest of the operating team (median versus , p-value \ . ). the staff surgeon (n = ) indicated significantly more often that there were many distractions ( . %, yes n = ) and noticed aberrations ( . %, yes n = ) during the surgical procedure (pvalue \ . ) when compared to the rest of the operating team. most aberrations reported by the surgeons were related to technical performance. conclusions: human factors play an important role in the surgical environment. situational awareness may be less developed in members of operating teams, compared to the surgeon of that team. further work is needed to elucidate the impact of human factor skills on team performance. a team-based approach to safety interventions is recommended. future studies should determine what type of aberrations and distractions are most relevant and valuable to embark on with team training. dept. of digestive surgery, school of medicine, tokushima university, tokushima, japan; dept. of digestive surgery, tokushima university, tokushima, japan background: the qualitative evaluation for laparoscopic training of medical students was performed using rubric evaluation, and weak points in conjunction with the lack of anatomical knowledge were derived. to conquer these weak points, virtual reality (vr) ? augmented reality (ar) training for understanding of regional anatomy was investigated. materials and methods: one hundred and six students in th grade of tokushima univ. participated basic laparoscopic task training (gummy band ligation, beads transfer, delivery of beads, gauze excision) with training box and sham laparoscopic cholecystectomy with virtual simulator. rubric evaluation, as qualitative evaluation, which includes the evaluation standards for each maneuver were performed before and after basic task training and sham operation. the group which self-evaluation was higher in a rubric evaluation was investigated. the d image of vessels and bile duct obtained from mdct of real patient was projected in reality space with microsoft hololens. training of ar image using hololens was performed for understanding of regional anatomy. after training of regional anatomy with hololens, sham laparoscopic cholecystectomy was performed again, and quality of procedure was evaluated by rubric. anatomical questions were. results: rubric evaluation in basic task training showed no difference between self-evaluation and evaluation by tutor before and after practice. in sham laparoscopic cholecystectomy, several students showed higher score than tutor, especially in part of extension of operation field by elevation of the gall bladder, exposure of triangle of calot, and exposure of cystic duct. after ar training, all students showed high score in questions related regional anatomy during operation. especially, rubric evaluation of students who showed high self-evaluation in sham operation showed same score with tutor. conclusions: as rubric evaluation showed weak points of detailed parts of maneuver, and vr ? ar was useful for understanding details of regional anatomy for laparoscopic training. background: the eaes has recently published an intraoperative adverse event classification to aid reporting of minimally access surgery events. this includes capture of non-consequential errors. we aimed to investigate the clinical impact of these apparent 'near miss' events. methods: case videos and clinical data from a completed multi-centre laparoscopic total mesorectal excision randomised controlled trial was utilised (isrctn ). the eaes classification was applied by two blinded assessors to all enacted adverse events identified on video analysis using the observational clinical human reliability analysis technique. the total number of grade (non-consequential) errors were compared with the number and nature of day morbidity events (graded with the clavien-dindo system) and length of stay. results: cases ( h of surgery) contained error events of which ( . %) were classified as eaes grade (median per case, interquartile range - , range - ). there were significantly more inconsequential errors recorded in patients that developed any early morbidity event than those who had an uneventful post-operative recovery (median . (iqr - ) vs. ( - ), p = . ). a stepwise increase in the sum of eaes grade errors is seen for each additional day morbidity event reported ( . vs. vs. vs. , p = . ) and the highest clavien-dindo grade experienced ( vs. vs. vs. . p = . ). positive correlation is observed between the sum of eaes grade a errors and length of post-operative stay (r s = . , p = . ). conclusion: in the context of major laparoscopic surgery, near misses are commonplace and correlate with surgical outcomes. this may represent a novel surrogate assessment method for intraoperative performance. aims: diagnostic laparoscopy (dl) is an under-utilised procedure that can replace non-therapeutic exploratory laparotomies in many contexts. to date, no validated education programme for dl exists. this study seeks to evaluate the feasibility, acceptability and face, content, construct validity of the laplat curriculum (laparoscopic learning for abdominal trauma; a simulationbased curriculum for trauma dl). this is in addition to the development of a novel d-printed bench-top model for abdominal inspection. methods: this prospective and observational pilot study involved novice medical students and junior doctors. surgeons from the uk and international (n = ) were involved in a two stage delphi-process to determine the components of the training course which were used to formulate a final curriculum. in the absence of an adequate model for abdominal inspection, a novel dprinted abdominal inspection model was designed and produced. after an introductory familiarisation session as well as pre-course cognitive lectures, the novices performed tasks on a virtual reality and bench-top simulator with repetitions of each in a half-day session. outcome measures for construct validity were total time to complete task, accuracy, percentage of horizon maintained and economy of movement. face and content validity as well as acceptability was evaluated by a qualitative and quantitative survey. results: face, content and construct validity as well as acceptability was established. face validity was demonstrated in all components of the course (including pre-course cognitive content and technical tasks) in addition to content validity. all also met an acceptability threshold of / on a -point likert scale. one-way anova tests demonstrated construct validity in all tasks (p \ . ) with learning curves in reducing time observed. using a performance improvement metric, one-way anova tests showed similar rates of improvement per participant between most tasks (p [ . ). the course was rated overall mean . / (± . ). conclusion: this pilot study has demonstrated the feasibility, acceptability and face, content and construct validity of the laplat curriculum as well of the novel d-printed abdominal inspection model. randomised controlled trials are needed to establish higher-quality evidence, as part of a wider curriculum with transfer needed to the clinical environment. surgery, regional institute of gastroenterology and hepatology, cluj-napoca, romania; anesthesiology-surgical propedeutics, university of agricultural sciences and veterinary medicine, cluj-napoca, romania; radiology, regional institute of gastroenterology and hepatology, cluj-napoca, romania; urology, training and research center, prof. dr. sergiu duca, cluj-napoca, romania; general surgery, training and research center, prof. dr. sergiu duca, cluj-napoca, romania aims: to evaluate the benefits of systematical use of ex vivoliver model and ct imaging in the planning process for swine laparoscopic liver resections done by residents during training programs. methods: twenty four general surgery residents were equally divided into two groups: first one which performed laparoscopic liver resections without planning stage and the second one which systematically used anatomical data from a swine liver model and interactive ct scans d reconstructions. the planning stage included an interactive tutorial for establishing the strategy for the next resection followed by performing open liver dissection and the same resection on an ex vivoswine model. a total of twelve models were used during this step. afterwards, laparoscopic procedures were performed on sixteen anesthetized domestic pigs, two swine for every team, composed of three residents. both groups were part of a dedicated and continuous training program and used the same 'step by step' protocol for resections. results: the average time for imagistic planning was . min and for open dissection and resection was . min. all teams successfully completed the interventions and followed the standardized protocol without trainers' interventions and with no conversions. the second group obtained better results regarding the time needed for completion and blood loss. also, when the planning stage was applied the resection was more accurate and less functional parenchyma was removed. the 'warming up' by adding the imagistic and anatomical data to the core protocol offer more clarity before laparoscopic liver resections. this also makes an upgrade for our 'step by step' protocol and provides sufficient data to admit this planning stage as mandatory for laparoscopic liver resection on swine during a training program. introduction: submucosal tunnel endoscopic resections (ster) had been increasingly performed for treatment of gastric subepithelial tumors. one of the limitations for ster is the risk of incomplete tumor resection due to close dissection and bridging of tumor capsule. endoscopic full thickness resection (eftr) allowed complete resection of the tumor with margins to prevent recurrence. this study aimed to review the techniques and outcomes of eftr for treatment of gastric subepithelial tumors. method: patients who received endoscopic resection for gastric subepithelial tumors were recruited. the gastric subepithelial tumors were considered eligible for endoscopic resection with size \ mm. all patients received preoperative assessments including eus and ct scan to define the extend of tumors and the proportion of extra and intralumenal components. all the procedures were performed under general anesthesia with co insufflation. eftr started after injection with mucosal incision up to % of tumor circumference, followed by submucosal dissection to identify tumor margin. further dissection was performed using esd devices. after adequate exposure of lateral margins, incision into muscularis propria was performed to achieve full thickness resection. luminal defects were closed by either clips, clip-loop crown method or overstitch suturing. results: from to , patients received eftr for gastric subepithelial tumors. the mean age was . years, and were male. the gist were located at greater curvature ( ), cardia ( ) , lesser curve ( ) and antrum ( ) . the mean size was . mm ( - mm) . most of the eftr were performed in operation theatre while two were done at endoscopy. the mean hospital stay was . days, and mean operative time was min ( - mins). there was no conversion to laparoscopy. closure of luminal defect were performed mostly with clips ( ), followed by overstitch ( ) and clip and loop crown closure ( ) . most patients resumed full diet on day , and all the pathologies confirmed gist tumors with clear resection margins. conclusion: endoscopic full thickness resection is technically feasible and safe procedure for treatment of gastric gist. future research should focus on refining the techniques of eftr and closure of the defect. next generation endoscopic intervention (project engine), osaka university, suita, japan; gastroenterological surgery, osaka university, suita, japan; research & development, -d matrix, ltd., chiyoda-ku, tokyo, japan; research & development, fuso pharmaceutical industries, ltd., cyuou-ku, osaka, japan background: hemostatic peptides have received increased attention. self-assembling peptides (tdms) comprise synthetic amphipathic peptides that immediately react to changes in ph and/or inorganic salts to transform into a gelatinous state. since tdms do not carry a risk of infection, their clinical application as new hemostatic agent is expected to increase. the first generation of these peptides (tdm- ) is currently used as a hemostatic agent in europe. however, tdm- exhibits slow gel-formation and low retention capabilities on tissue surfaces. the second generation (tdm- ) was therefore developed to encourage faster gel-formation and better tissuesealing capabilities, and we subsequently verified its usefulness and increased performance relative to tdm- in preclinical open surgery. aim: the aim of this study was to verify the efficacy of tdm- in terms of its hemostatic effect in endoscopic surgery. materials and methods: evaluation of the hemostatic effect in endoscopic surgery (animal study) was performed using eight female ( kg) pigs in spine position. following systemic heparinization, we established a bleeding model by utilizing flexible endoscopic grasping forceps on the anterior wall of the stomach and duodenum. in the hemostasis method, an endoscope with a distal hood was brought into contact with the bleeding point, and ml tdm- was applied to the wound. after tdm- gelation, the endoscope was removed, and the acute hemostatic effect (after min) was confirmed. histologic evaluation was subsequently performed on resected specimens. results: in the endoscopic bleeding model, of the cases ( . %) showed complete hemostatic effects on the anterior wall of the stomach, whereas on the anterior wall of the duodenum, of cases ( %) showed complete hemostatic effects. moreover, none of the gels were displaced from the anterior walls of the stomach and duodenum, and histologic evaluation confirmed no infiltration of inflammatory cells. the new self-assembling peptide (tdm- ) displayed improved hemostatic effects relative to the previous generation (tdm- ) in endoscopic surgery. tdm- had potential usefulness for upper gastrointestinal bleeding. our future work will assess its usefulness for laparoscopic surgery. objective: indocyanine green (icg) is a dye used in medicine since the mid- s for different applications in ophthalmology, cardiology and hepatobiliary surgery; thanks to its selective hepatic uptake and biliary excretion, it can be used to evaluate hepatic function in patients scheduled for hepatic resection surgery. the aim of this study is to evaluate the efficacy and the feasibility of icg guided surgery in the intra-operative localization of liver tumors, comparing the pre-operative radiological aspect, the intra-operative visualization and the post-operative histopathological features of the tumors. materials and methods: icg was intravenously injected for a routine liver function test (limonÒ) in patients who underwent hepatic resection surgery for primitive and secondary liver tumors in the period between november and september . for each patient was performed an intraoperative visualization of the stain both in vivo and ex vivo, using a nearinfrared imaging system. all the images were recorded. results: a correct differentiation between liver parenchyma and tumor area was obtained in . % of cases. five patients were not evaluable due to widespread uptake or complete absence of uptake; it was probably the first cases enrolled in the study for which we were not able to set doses and timing of administration of icg. in patients in which the method had been feasible, we observed a prevalence of nodular pattern in patients with hepatocellular carcinoma ( %) and a predominance of rim pattern in both cholangiocarcinoma ( %) and metastasis ( %). furthermore, in patients with hccs well-intermediate differentiated (g -g ) was found predominantly a nodular pattern ( . %), whereas in poorly differentiated ones was prevalent a rim appearance ( %). regarding radiological correlations, the only one patient who presented an atypical radiological feature in pre-operative evaluation, showed a lesion with no icg captation in intra-operative visualization. conclusions: icg fluorescence imaging is a safe, minimally invasive and quite inexpensive method, that can be easily administered for routine evaluation of pre-operative liver function. it can be a useful support tool in the intra-operative detection of liver tumors, especially in laparoscopic surgery where it is not possible to directly touch the tissue. surgery, bundang cha medical center, seongnam-si, korea; surgery, severance hospital, seoul, korea; surgery, nhimc ilsan hospital, ilsan, korea; surgery, seoul national university bundang hospital, seongnam, korea; surgery, asan medical center, seoul, korea backgrounds & aims: robotic surgical system had been widely accepted in various surgical field with the expectations of overcoming the limitation of laparoscopic surgery. however, robotic liver resection had not generalized, so far. thus, this study aimed to evaluate the feasibility and safety of robotic major liver resection by prospective multicenter study. methods: from july to december , five surgeons who were novice in robotic liver resection but experienced a lot in open and laparoscopic liver resection in five tertiary hospitals performed cases of robotic major anatomical liver resection. perioperative patient's clinical data and surgical data were prospectively collected. results: cases of left hemihepatectomy, case of extended left hemihepatectomy, cases of right hemihepatectomy, cases of right anterior sectionectomy, cases of right posterior sectionectomy, and one cases of central bisectionectomy were performed. the most common indications were hepatocellular carcinoma for cases following intrahepatic cholangiocellular carcinomas for cases, liver metastases for cases, sarcoma for case, intraductal papillary neoplasms for cases, mucinous cystic neoplasm for case, hemangioma for case, and intrahepatic duct stones for cases. surgical resection margins for all tumor cases were negative. total average operation time was . ± . min and estimated intraoperative blood loss was . ± . ml (minimal to ml). in terms of severe surgical complication, there were cases of postoperative fluid collection treated with drainage and one case of bile leakage treated with percutaneous trans-hepatic biliary drainage. only one case out of cases was converted to the conventional open left hemihepatectomy because of bleeding. conclusions: in this study, robotic anatomic major liver resection might be safely performed even by robotic beginners but advanced open and laparoscopic liver surgeons. surgical technique: with the patient at °on right lateral decubitus, access is gained through the path of the percutaneous drainage catheter after opening of the aponeuroses of the oblique and transverse muscles of the abdomen. a mm laparoscopic trocar is inserted and a cavity is created with pneumoretroperitoneum at mmhg. it is accessed with an optic of °and mm, and the work space is extended with aspiration and hydrodissection. with mm grippers, the necrotic material is removed, washed and drained. a two light silicone probe is left, one light for drainage and another one for washing. results: the mean age was . background: minimally invasive surgery has achieved worldwide acceptance in various fields, however, pancreatic surgery remains one of the most challenging abdominal procedures. in fact, the indication for robotic surgery in pancreatic disease has been controversial. the present study aimed to assess the safety and feasibility of robotic pancreatic resection. methods: we retrospectively reviewed our experience of robotic pancreatic resection done in sanchinarro university hospital. clinicopathologic characteristics, and perioperative and postoperative outcomes were recorded and analyzed. aim: this work aims to study the contact pressure between the moving capsule and a synthetic small intestine in order to provide design guidance for prototyping the self-propelled capsule robot for small-bowel endoscopy. method: since small-bowel peristalsis consists of peristaltic contraction and wave distension, the contacts between the capsule and the small intestine are multimodal. we consider three contact cases for the capsule robot. case : the capsule moves on a flat small intestinal surface; case : the capsule moves in a collapsed intestine with a flat surface support; and case : the capsule moves in a surrounded small intestine. by considering these three contact cases, experimental testing and finite element analysis (fea) were conducted by measuring the contact pressure between the small intestine and the capsule. introduction: traditional laparoscopic instruments have limited degrees of freedom and are not ergonomic. this results in severe limitations in performing complex, and even simple tasks in surgery, limiting many surgeons from performing a variety of minimally invasive procedures. handx tm is a hand-held, electromechanical smart instrument with robot-like features. the instrument is composed of a sophisticated user interface that enables unrestricted hand movement, and a novel, motor driven articulating tool that is controlled by the interface. the instrument is . mm in diameter, lightweight, and can be easily moved between laparoscopic trocars and perform complex motions in the surgical field. after the regulatory process was completed we have tested the device clinically through a structured, approved, clinical trial. materials and methods: after irb approval patients were recruited to the trial. we have included a variety of procedures that require suturing and complex tissue manipulation. two experiences surgeons performed all procedures. after completing each procedure the surgeons completed a detailed standard usability (sus) questionnaire. results: procedures were completed successfully without complications or device malfunction. there were female and male patients with an average bmi of . procedures performed were right hemicolectomis with intra-corporeal anastomosis, paraesophageal hernia repairs and fundoplication, diagnostic laparoscopies, tapp procedures, ventral hernias with fascial suturing, and laparoscopic cholecystectomies. the average performance score was . / . the results suggest that the handx device is safe and easy to use and may offer a simple solution for enhancing minimal invasive surgery capabilities and possibly reduce conversion rates while maintaining current standard surgery flow.the handx could potentially extend the surgeon's abilities to access hard to reach anatomy and perform complex maneuvers and present a cost-effective alternative to large console-based robotic systems. objective: endoscopic submucosal dissection (esd) has become widely accepted treatment for rectum neuroendocrine neoplasm. the aim of this study is to evaluate the safety and efficacy of esd with dental floss-assisted suspension traction for rectal neuroendocrine neoplasm. methods: we retrospectively reviewed the medical records of the patients, who underwent esd for rectum neuroendocrine neoplasm at endoscopy center of zhongshan hospital, fudan university. the data of operation time, r resection and adverse events were collected analyzed.in dfs-esd group: after the mucosa was partly incised along the marker dots, the next step was to construct traction device, similar to others in esd, with dental floss and hemoclip. the dental floss was tied to any arm of the metallic clip. the hemoclip was attached onto the incised mucosa, another hemoclip was attached onto normal mucosa opposite to the lesion in the same way. the submucosa was clearly exposed with the traction of dental floss and the resection could proceed. results: patients were enrolled in the study. there were patients treated by esd with dental floss-assisted suspension traction and patients treated by conventional esd. the average tumor size was ( . ± . )cm in both group. the operation time was . ± . min in conventional esd group and ( . ± . ) min in dfs-esd group (t = . , p = . ). according to pathological grading about rectal neuroendocrine neoplasm, there were grade (g ) and grade (g ) in conventional esd group while grade (g ) and grade (g ) in dfs-esd group (? = . , p = . ). among cases in this study, all the basal resection margins were negative, the en blot resection rate was % and the curative resection rate was %. however, pathological results showed tumor tissue close to the burning margin in cases of conventional esd group and in cases of dfs-esd group (? = . , p = . ). conclusions: esd with dental floss-assisted suspension traction for rectum neuroendocrine neoplasm can assist exposing tumor borders, provide good vision during the procedure and offer clearer anatomic structure, so as to simplify operation, reduce operation time and ensure the negative basal margin. it is especially suitable to be promoted in primary hospitals. surg endosc ( ) aims: force feedback and assessment provides detailed insight into tissue manipulation skills. the aim of this study is to evaluate learning curves for basic laparoscopic skills based of force and motion learning curve patterns. morevover, we aimed to detect the favourable time span for this curriculum for each individual trainee. methods: in this prospective cohort study, first year surgical residents participated in a three week at home training course. a mobile box training was equipped with forcesense system for objective force, motion and time based assessment. the system provides seventeen unique metrics. the training goal was set by the mean score of proficient laparoscopic surgeons. each repetition was captured and made available for analyses. continuous force feedback was provided during training. curve fitting was used to estimate the learning curve plateau and the number of repetitions needed to approach the plateau phase and to reach proficiency level. finally, a comparisson between novices and experts was executed. results: a total of attempts, executed by residents were captured and analyzed. significant improvement of motion analysis parameters (e.g. path length and time) was observed for all training tasks, except for the fifth tasks. tissue manipulation skills (i.e. maximum and mean applied force) significantly improved by training tasks , and . learning curve analysis revealed various shapes and lengths of the individual learning curves. a large range in learning curve plateaus was found between trainees and between tasks. each trainee managed to accomplish the preset goals within three weeks. conclusion: force-and motion based assessment provides insight into both tissue manipulation and instrument handling skills. when combined in learning curve analysis, these parameters effectively show progression towards proficiency for each individual trainee over time. we emphasize the variation in learning curves between trainees. therefore, we recommend individually tailored courses provided with objective force-and motion-based learning curve tracking. aims: the posterior retroperitoneoscopic adrenal access represents a challenge in orientation and working space creation.the aim of this experimental acute study was to evaluate the impact of computer-assisted quantitative fluorescence imaging on adrenal gland identification and perfusion assessment in the posterior retroperitoneoscopic approach. methods: six pigs underwent synchronous (n = ) or sequential (n = ) bilateral posterior retroperitoneoscopic adrenalectomy (pra, n = ). fluorescence imaging was obtained via intravenous administration of ml of indocyanine green (icg) using two near-infrared camera systems. fluorescence-based visualization of adrenal glands before vascular division (n = ), after main vascular pedicle ligation (negative control, n = ) or after adrenal division (n = ) was followed by completion adrenalectomy. one of the animals had undergone icg injection h previously, during another study. the dynamic evolution of fluorescence signal intensity over time was recorded and analyzed using a proprietary software. the computed color-coded perfusion cartography was superimposed onto real-time images obtained by corresponding left (l) and right (r) camera systems. the slope of fluorescence signal intensity evolution over time in the regions of interest (roi) served to assess adrenal perfusion by means of quantitative fluorescence signal analysis. results: in the retroperitoneum, the adrenal glands were promptly highlighted after primary intravenous icg administration or showed an increase in fluorescence signal intensity upon reinjection (both glands in a recovery pig and one gland in the sequential approach). after left adrenal main vascular pedicle ligation, the gland displayed low perfusion (blue; rois a -a in figure ), while a weak fluorescence signal after completion adrenalectomy suggests perfusion via collateral vessels. with intact vascular supply, the caudal segment of the right adrenal (a ) gland showed a significantly higher perfusion rate (red) than the ischemic cranial segment (a ). quantitative analysis of logarithmic fluorescence intensity showed a statistically significant difference between perfused and ischemic zones (p = . ) allowing to assess gland vascularity. kidneys (k) and adrenal glands showed distinct perfusion curves ( figure ). conclusions: prior to dissection, fluorescence imaging allows to easily discriminate the adrenal gland from surrounding retroperitoneal structures. during adrenal gland surgery, icg injection complemented by a computer-assisted quantitative analysis helps to distinguish between wellperfused and low-perfused segments. giant adrenal tumors:technical considerations and surgical outcome a. giordano, g. alemanno, c. bergamini, p. prosperi, v. iacopini, a. dibella, a. valeri sod chirurgia d'urgenza, aou careggi, firenze, italy objectives: giant adrenal tumors are tumors with size more than cm. these are rare cancer associated with malignancy in % of cases. the size of these tumors is an important topic in literature because of their higher probability of malignancy and possible technical limitations of laparoscopic approach. we report our center's experience on laparoscopic adrenalectomy. materials and methods: in the last ten years we performed about adrenalectomies for benign and malignant adrenal tumors. of these were giant tumors. the medium size was . cm ( - cm). tumors were on the left adrenal gland and on the right. there were women and men, the average age was ( - years). of these cancers were laparoscopically removed and with open approach. cases of open conversion. results: betweenn the tumors laparoscopically removed we recorded cases of carcinoma, endothelial cysts, adenomas ( with aldosterone and with cortisol hypersecretion), myelolipomas, pheochromocytomas and metastases from lung carcinoma. the surgical outcomes in these patients were optimal in terms of good pain control and hospital stay (median days). the average time of the intervention was min with very low blood less ( ml). no postoperative complications were recorded. the removal of the adrenal gland necessitated or trocars. in the dissection and resection phases we always used radiofrequency scalpel. the follow up after and months didn't show local recurrences. conclusions: laparoscopic adrenalectomy offers significant advantages over the open approach. the size of these tumors is still at the center of debate for the choice of the technique. the tumor size is only a predictive parameter of possible malignancy. the laparoscopic approach is a safe and feasible method in terms of surgical and oncological outcomes also for the giant adrenal tumors, only if performed by expert surgeons and in high-volume centers. vascular or adjacent organs infiltration is a contraindication to the laparoscopic approach. aims: adrenal gland size greater than cm is considered a contraindication to laparoscopic adrenalectomy (la). aim of the present case-control study is to compare the surgical outcomes in patients undergoing la for adrenal gland measuring = cm versus = . cm in diameter. methods: from january to august , las were performed in the two authors' centers which follow an identical treatment protocol. eighty-one patients with an adrenal gland size = cm (intervention group) were included in the study. based on body mass index (bmi) class [ kg/m ) , lesion side (right or left), surgical technique (anterior transperitoneal for right and left-sided lesions, anterior transperitoneal submesocolic for left-sided lesions) and lesion type (conn-cushing, pheocromocytoma, primary adrenal cancer or metastases, other type of lesion), patients with an adrenal gland lesion measuring = . cm in diameter were included (control group) and paired to the intervention group. results: comparing the intervention and control groups, statistically significant differences were observed in mean lesion size ( conclusions: the only significant difference between the two groups was the operative time which was longer in the intervention group. conversion and complication rates were also higher in the intervention group but the difference was not statistically significant. based on the present data, adrenal gland size measuring more than cm in diameter is not a contraindication to a laparoscopic approach. ; and orthopaedics and urologists for the remaining . %.the costs from these claims, differed from to % of the total damage burden per year. the review of medical charts of claims related to laparoscopic gynaecologic surgery showed that % of claims were filed for visceral and/or vascular injuries ( % bowel injuries, % ureter). % of the injuries were entry-related. a delay in diagnosing injuries was the primary reason for financial compensation. conclusion: evaluating and learning from complications and claims will improve medical health care. in contrast to overall trends and developments considering medical claims, claims concerning laparoscopic surgery decreased, possible due to a rising learning curve. considering laparoscopic surgery, extra caution is required at moment of entry and the early recognising complications and at pre-operative counselling from patients. the aim of the study was to determine indications and contraindications for laparoscopic splenectomy in abdominal trauma patients and to analyze results of the operations. patients and methods: the study involved patients with spleen injury grade iii who were admitted in our institute in the years of - . the patients were divided on two groups. laparoscopic splenectomy was performed in patients (group i) and 'traditional' splenectomy was carried out in patients (group ii). there was no difference in the demographic data and trauma severity between the two groups.non-invasive investigations, such as laboratory investigations, serial abdominal ultrasound examinations (us), x-ray in multiple views and computed tomography (ct) had been performed before the decision about necessity of an operation was made. results: patients after laparoscopic operations had better recovering conditions compare to patients with the same injury after 'traditional' splenectomy. neither surgery related complications no mortalities were registered in both groups. laparoscopic splenectomy was more timeconsuming operation than 'traditional' splenectomy. we suggest that as experience of laparoscopic splenectomy is gained the operation time will be reduced. conclusion: laparoscopic splenectomy is a safe feasible operation in patients with spleen injury. the operation is indicated in patients with spleen laceration more than cm of parenchymal depth with moderate continuing bleeding or expanding hematoma and contraindicated in patients with hemodynamic instability and high bleeding rate (more than ml/h on serial us examinations). the isolated hydatid disease of the spleen is a quite rare condition, liver and lungs being the most common locations. the treatment requires usually splenectomy, open or laparoscopic. there are few reports in the literature describing a spleen-preserving type of surgery. we present a case of a female patient, y.o., with a large cystic lesion of the spleen, cm in diameter. lab tests and ct scan confirmed that is a hydatid cyst. after albendazole treatment and vaccination the patient was referred to us for surgical treatment. the procedure was performed under general anesthesia and laparoscopic approach was performed with the intention to preserve the spleen. after the cyst was identified and adhesiolysis was done, the area was isolated from the rest of the abdominal cavity with sponges with a betadine solution in order to prevent contamination. a needle aspiration of the cyst allowed the evacuation of ml of purulent content, an indicator of a dead cyst. betadine solution was injected into the lesion. laparoscopic excision of the cyst was performed using advanced electrocoagulation devices and the spleen removal was not deemed necessary. two drainage tubes were placed in the remnant cavity. an abdominal ultrasound was performed in the third postoperative day and no collections were identified. the postoperative outcome was uneventful; the patient was discharged in the th postoperative day. the conclusion is that in selected cases, with the cyst located in the anterior part of the spleen, with proper equipment and experienced laparoscopic teams, the cyst can be successfully treated without splenectomy. deep neuromuscular block was induced with rocuronium . mg/kg. in group , forty patients were enrolled for reversal of profound neuromuscular block during thyroid surgery (sugammadex mg/kg, after identification of vagus nerve). in group , thirty-five patients were enrolled profound neuromuscular block during thyroid surgery(without reversal of nmbd). tof-watch acceleromyograph was recorded in response to adductor pollicis muscle for ulnar nerve stimulation in patients with both groups; recovery was defined as a train-of-four (tof) ratio = . .to prevent laryngeal nerve injury during the surgical procedures, all patients were neurophysiologically detected using ionm. results: the total duration of surgery was higher in group than group ( . ± . , . ± . ;p \ . ). the mean time to recovery of the tof ratio to . was higher in group than group ( . ± . , . ± . ; p \ . ). the mean duration of vagus reverse (v : , milisecond) was higher in group than in group ( . ± . , . ± . ; p \ . ). no significant difference was found between left and right v -v and r -r values in group following nerve monitoring, whereas in group , a significant difference was found between left v -v , left r -r and right v -v values ( introduction: oeosphagogastric oncology trials have often lacked robust methods of monitoring and surgical quality assurance (sqa), leading to difficulty in interpretation of trial results. this study aims to assess expert opinion regarding challenges to sqa in oncology trials and potential mitigating strategies. method: a purposive international cohort of expert stakeholders with experience in oncology trials were recruited including: surgeons; oncologists; trial methodologists, and; trial managers. semi-structured interviews were thematically analysed using grounded theory. spss was utilised to assess differences between trial stakeholders' opinions. results: emergent themes were identified and consensus themes emerged on qualitative analysis of stakeholder responses. key consensus challenges to implementation of sqa in oncology trials included: insufficient resources; limitations of surgical volume in centre selection; differing oncological beliefs and resistance to change adoption; overly prescriptive protocols and standardisation contributing to difficulty in surgeon recruitment; and cultural factors leading to difficulties in providing and receiving feedback. seminal consensus mitigating strategies to overcome challenges to sqa in oncology trials included: trial centre selection according to case volume (n = , %); requirement for specific centre attributes for inclusion in trials including specialist centre designation and participation in national audit (n = , %); consideration for surgeons learning curve in surgeon selection (n = , %); flexible standardisation of trial operating (n = , %); operation manual utilisation to aid standardisation of surgical interventions (n = , %); case monitoring using video (n = , %) or photographs (n = , %); direct intraoperative observation by an expert (n = , %), and; histopathological assessment of resected specimens (n = , %). other methods of monitoring surgical quality advocated included: recording post-operative outcomes; lymph node yield; case report forms; and real time data monitoring (n = , %). oncologists were significantly more likely to state the importance of standardisation of surgery in oncology trials (p \ . ), and trial methodologists significantly more likely to advocate consideration of surgeons' learning curve in surgeon selection (p \ . ). conclusion: surveying international expert stakeholder opinion revealed a wide variety of perceived challenges across all domains of surgical quality assurance. proposed mitigating solutions require consensus opinion to formulate a framework to aid design of sqa measures within future oncology trials. research group did not register a single case of ega leakage while patients in control group (? \ , ). had the leakage which was stopped by means of 'endovac' system. there were cases of esophagus postoperative strictures which developed months after the surgery in the research group which was less than in the control group which saw cases of strictures of ega (? \ , ). months after surgery, the number of post-operative strictures increased in both groups, but was lower in the research group and amounted to cases in the research group and cases in the control group (? \ , ). there were cases of esophagus postoperative strictures which developed months after the surgery in the research group which was less than in the control group which saw cases of strictures of ega (? \ , ). neither of the groups had any cases of post-operative mortality. purpose: to investigate the prognostic effects and risk factors of the omission and delay of postoperative chemotherapy of ii/iii gastric cancer (gc), with the goal of providing a reference for interventions of related departments. methods: the clinicopathological data of patients undergoing radical gastrectomy for ii/iii gc were collected and retrospectively analyzed. we defined the chemotherapy delayed until more than days after radical gastrectomy and the complete omission of chemotherapy as unacceptable chemotherapy initiation (uac group), while the chemotherapy conducted within days of radical gastrectomy was defined as acceptable chemotherapy initiation (ac group). the survival between the two groups was compared, and the trends and risk factors of uac were analyzed. results: the total number of patients who underwent totally laparoscopic distal gastrectomy with uncut roux-en-y and delta shaped billroth-i anastomosis was and , respectively. the mean reconstruction time was longer in uncut roux-en-y than in delta shaped billroth-i, ( . ± . vs. . ± . min, p \ . ). the uncut roux-en-y was used more cartridge than delta shaped billroth-i anastomosis ( . ± . vs. . ± . , p \ . ). however there was no significant differences in operation time, estimate blood loss, number of retrieved lymph node and postoperative course between reconstruction methods. postoperative complications more than clavien-dindo grade iiia occurred in cases ( . %) of postoperative early complications and cases ( . %) of late complications. the endoscopic findings showed excellent short and long-term outcomes in terms of very low incidence of bile reflux and reflux-induced remnant gastritis in uncut roux-en-y compared with delta shaped billroth-i anastomosis. conclusions: uncut roux-en-y gastrojejunostomy was a useful reconstruction method with totally laparoscopic distal gastrectomy for cancer, especially for diverting enteral contents from the remnant stomach and preventing remnant gastritis. therefore, it is recommended for young patients with early stage disease who have a long time to live after distal gastrectomy for cancer. operative technique: the seromuscular layer above the tumor is dissected, while the mucosa is kept unbroken. when seromuscular layer is dissected all around the tumor, the full layer is lifted, and the mucosa is stretched. the mucosa is then transected with a stapling device to execute fullthickness resection of the specimen. finally, the seromuscular defect is repaired by hand-sewn suture. results: since december , clean-net has been performed in patients with gastric smts. all tumors were resected en-blocwithout rupture. the average operation time ranged from to min with an average of . min. the postoperative course was uneventful. microscopically the surgical margin was tumor-negative (r resection) in all cases. the margin width was small with an average of . mm ± . . conclusions: clean-net is a useful option in the laparoscopic surgical treatment of gastric smt, when excessive sacrifice of the healthy gastric wall surrounding the endophytic tumor should be avoided. background: the type of fundoplication-complete or partial is still controversial for the surgical treatment of gerd. laparoscopic toupet ( wrap) fundoplication has less post op dysphagia and gas bloating compared to nissen fundoplication ( wrap) and is advised to be the procedure of choice when esophageal manometry findings are abnormal, however it is considered by some less effective and more difficult to perform. the aim of this research was to determine in the functionality and efficacy of the different types of fundoplication. methods: explanted pigs stomachs weighing - kg were studied. two different studies of the les were performed: distensibility and failure point (occurrence of reflux according to volume added to the stomach). for both studies we first disrupted the lower esophageal sphincter using a rigiflex tm dilating balloon. we then performed three different fundoplications-nissen, toupet, dor and measured the distensibility of the egj after each fundoplication. the failure point was determined following each fundoplication type. results: we used pig stomachs for the distensibility study and pig stomachs for the failure point study. there was no statistically significant difference between the nissen and toupet fundoplications when distensibility was measured, however the egj was more distensible following dor fundoplication (p = . for nissen, . for toupet). when the failure point was measured, nissen fundoplication was significantly more effective than toupet, and toupet was significantly more effective than dor (p = . ,p = . respectively) conclusions: we studied the differences between the mechanical effects on the egj following three different fundoplications, encompassing , , and of the esophagus. we demonstrated that there is a significant difference between dor fundoplication and nissen/toupet when distensibility was measured. there was no difference in the distensibility of the egj following a or wrap. there was, however a significant difference of effectiveness between all three fundoplications. these findings suggest that the and fundoplications have similar functionality while the wrap mechanically prevents possible reflux and support proponents of toupet fundoplication rather than nissen due to the similar functional results while decreasing the post op dysphagia and gas bloating complications. surg endosc ( ) aim: to describe patients undergoing surgical treatment of incident gastro-oesophageal reflux disease and the use of anti-reflux treatment in a danish population-based cohort. methods: all adult danes - undergoing upper endoscopy and receiving a diagnosis of gerd within days were identified. patients with previously diagnosed gerd, peptic ulcer-disease, barrett's oesophagus or cancer of the gastrointestinal tract were excluded. in this study, only patients undergoing anti-reflux surgery within two years of gerd-diagnosis were subsequently included. age, sex, charlson comorbidity index (cci), anti-reflux surgery (primary and re-operative) and endoscopic dilatation were identified using the danish national patient registry. mortality was identified using the national civil registry. pharmacological treatment of gerd (proton pump inhibitors, h \ su \/su-blockers and other prescription anti-reflux drugs) as well as use of nonsteroid anti-inflammatory drugs (nsaid) and anti-thrombotic treatment were identified using thethe danish national prescription registry. all data was linked on an individual level using the unique identification number that all danish citizen are assigned to at birth or first immigration. results: a total of first-time fundoplications were performed, hereof . % performed laparoscopically (n = ) and . % performed using open technique (n = ). at one-year followup, . % (n = ) had undergone endoscopic dilatation and . % (n = ) had undergone reoperation. the -day mortality was \ . %. patients had a median age of years ( - years) and were predominately male ( . %-n = ). a total of . % had cci (n = ). diagnoses were gerd with esophagitis ( . %-n = ), gerd without esophagitis ( . %, n = ) and gerd without specification ( . %, n = ). before initial endoscopy, , % (n = ) used at least one type of anti-reflux drug, dropping to . % (n = ) in the year after anti-reflux surgery. however, even when censoring patients with barrett's esophagus or peptic ulcer disease after initial endoscopy and patients undergoing concomitant treatment with nsaids or antithrombotic drugs, . % still used at least one type of anti-reflux drug after surgery. conclusion: in this population-based study, anti-reflux surgery was safe and lowered the use of pharmacological treatment. however, even when adjusting for competing reasons for use of antireflux drugs, . % used at least one type of anti-reflux drug one year after surgery. the new approach to perform nissen fundiplication m. paranyak, v. grubnyk surgery, odessa national medical university, odessa, ukraine nearly % of patients who undergo laparoscopic anti-reflux surgery at long-term follow-up need for surgical reintervention mostly because of hiatal hernia (hh) recurrence, wrap migration or disruption. purpose: the aim of our prospective study was to evaluate and compare several technics of wrap fixation and determine whether modified nissen fundoplication(mnf) reduce failure rate in the long term follow up. materials and methods: this was a prospective, randomized, controlled trial. from november to october one hundred and thirty-eight gerd patients who underwent anti-reflux surgery were divided into two groups. excluded criteria for our study ware diagnosed hiatal hernia (hh) type iii. in the i group which include patients we performed the following manipulations: nf was supplemented with suturing wrap to the diaphragmatic crura ( patients) on each side using two non-absorbable stitches. such technique permit us to create more symmetrical wrap. in case of weak conditions of crura or short esophagus ( patients) fundoplication wrap was sutured to the body of stomach using two non-absorbable stitches on each side. control group ( patients) underwent classic nissen fundoplication (nf) without wrap fixation. all patients were assessed before and after surgery using validated symptoms and quality of life (gerd-hrql) questionnaires, -h impedance-ph monitoring and barium-swallow. results: baseline characteristics were similar between groups. there were no conversion to open procedure or mortality. mean hospitalization was . days ± . days. at , months (range -- ) of followup, the overall rate of complications after mnf was , % ( hh reccurence) and nf , % ( hh reccurence, slipped wrap). patient in mnf group show significant improvement in gerd-hrql score, from . ± . (preoperatively) to . ± . (postoperatively) (p? \ ? . ). complete ppi independence was achieved in %. in the ii group of patients mean gerd-hrql score decline from . ± . (preoperatively) to . ± . (postoperatively), postoperative ppi treatment was necessary in %. conclusions: according to our study mnf minimized risk of slipped wrap and intrathoracic migration of the wrap and can make positive impact on reducing the failure rate of laparoscopic anti-reflux surgery. aims: comparative evidence across laparoscopic antireflux procedures does not exist. aim of this project was to identify direct comparative evidence between laparoscopic antireflux procedures and synthesize evidence using network meta-analytical methods. methods: the databases of medline, amed, central, opengrey were interrogated. pairwise meta-analyses for each pair of interventions using a random-effects model and network metaanalysis in stata was performed using the mvmetacommand and self-programmed stata routines. differences between direct and indirect evidence were explored by comparing direct and indirect estimates though computing the inconsistency factor within each closed loop of evidence. the ranking probabilities for all treatments of being at each possible rank for each intervention were computed using the mvmetacommand in stata. a hierarchy of the competing interventions was obtained using rankograms. quality of evidence was assessed using grade-nma and the cinema application. results: forty-three publications reporting on randomized trials and some patients were identified. the network of treatments formed a closed loop between °, °and anterior °; and star network between °and other treatments; and between anterior °and other treatments. laparoscopic °, °, anterior °and anterior °were equally effective in the control of heartburn and this was supported by low quality of evidence according to grade-nma. the odds for dysphagia were lower for anterior °(high quality evidence), anterior °( moderate quality evidence), °(moderate quality evidence) and proton-pump inhibitors (moderate quality evidence) compared to °. the odds for gas-bloat were lower for °and anterior °compared to °(low quality evidence). the odds for regurgitation, morbidity and reoperation were similar across treatments, albeit these were associated with very low quality evidence. anterior °had a % probability of being the best treatment in terms of dysphagia. conclusion: under consideration of treatment effect estimates, evidence quality as assessed with grade-nma and other parameters, anterior °, anterior °and °should be preferred over °. further research needs to focus on the comparison between °and °/ °. aims: we have recently demonstrated that the tension of crural closure can be reliably measured intraoperatively (alsgbi conference december ). the aims of this study were to further characterise tension at the diaphragmatic hiatus from our prospective pilot study of patients. methods: a prospective analysis was performed of patients undergoing laparoscopic hiatal hernia repair between april and december . patients underwent crural tension measurement intra-operatively. patients had a pre-operative ct scan of the abdomen within one-year of surgery. hiatal surface area (hsa) was measured intraoperatively and a sauter-fh universal digital force gauge was used to measure the tension of crural closure during cruroplasty. outcome measures included the mean tension of the crural closure and the presence of muscle splitting during the cruroplasty. results: for all patients, the mean crural tension measurement was . n and the mean hsa was mm . pre-operative ct was positively correlated with post-dissection intra-operative hsa (r = . , p = . ), however, strength of association was weak (r = . ) and ct consistently overestimated the size of hiatal defect intra-operatively (mean of differences mm , p = . ). crural tension was positively correlated with age (r = . , p = . ), hiatal height (r = . , p \ . ), hiatal width (r = . , p \ . ) and hsa (r = . , p \ . ). crural tension was correlated to the hiatal width to height ratio to assess the shape of defect and there was positive correlation (r = . , p = . ). tension was calculated for the posterior and anterior halves of the suture cruroplasty. anterior tension was significantly higher when compared to posterior tension ( . n vs . n, p \ . ) . patients had evidence of muscle splitting during the cruroplasty. the group with muscle splitting were significantly older ( vs , p = . ), had larger hsa ( mm vs mm , p \ . ) and higher crural tension ( . n vs . n, p \ . ). the lowest observed mean crural closure tension causing muscle splitting was . n. conclusion: there is now a possibility to optimise this operation with objective measures years after it was first described. initial findings suggest that crural closure up to * n could be the permissible tension threshold for suture cruroplasty and higher tension may benefit from the use of mesh reinforcement. background: endoscopic submucosal dissection (esd) and endoscopic full thickness resection (eftr) are advanced endoscopic techniques which can be time consuming using traditional endoscopic instruments. a new endosurgery platform, designed by fortimedix surgical, was developed featuring flexible articulating instruments to use in combination with a standard flexible endoscope. the platform is intended to perform endoscopic cutting, dissecting, and hemostasis. aim: evaluate feasibility of the platform in the upper gi-tract. project description: the platform was tested in a dry esophageal model as well as a second series with a porcine esophagus and stomach. the system has an external docking station affixed to the operative table to stabilize both flexible instruments for the right and left hand of the surgeon. at the tip of the endoscope, a cap containing instrument lumens is attached to allow advancing and removing the flexible instruments. the endoscope with the cap and instrument lumens attached is advanced via an overtube with outer diameter . mm. in the first series, flexibility and range of motion of the endeffectors was assessed. additionally, the ability to advance the instruments to the intraluminal target area from the docking station and along the scope was evaluated. in the second series, the functional capabilities of the system and instruments were evaluated in a porcine model. preliminary results: : in the dry model, the platform was adequately deployed to the target then range of motion was tested as well as cutting and grasping gastric wall with instrumetn triangulation achieved. the grasping forceps provided enough force to pull the mucosal wall and expose the dissection plane. in the pig model, the distal esophagus and stomach could successfully be accessed and platform deployed. esd was performed using newly designed flexible articulating scissors, dissection-hook, and graspers with good triangulation and sufficient grasping force with traction/counter-traction. the new fortimedix surgical endo-surgery platform applied to a standard flexible endoscope is feasible to perform esd. future studies are planned to determine learning curve and compare it to traditional endoscopic instruments. background: in laparoscopic surgery, we usually observe the organs in the same direction to avoid a mirror-image situation. therefore, we are unable to recognize how far the dissection has proceeded on the other side of the target organs or lesions, especially when the plane of dissection is under the mesentery or organs. this becomes a problem not to understand how far the dissection has progressed and how much more dissection is needed. aim: to solve this problem, we developed a laparoscopic device with tip illumination. project description: the device is configured by the long and narrow part made of polycarbonate resin and a battery-powered light-emitting diode to illuminate the tip by shining light through the polycarbonate resin. during the surgery, the tip of the device is inserted into the deepest part of the dissection area, and the transmitted light indicates how far the dissection has progressed. the tip of the device has a prism structure and light is emitted in a direction perpendicular to its axis. tip position can thus be more clearly identified even with insertion in the same direction as the laparoscopic view. to verify the utility of this instrument, laparoscopic surgeries were performed in a porcine model and cadavers. preliminary results: we performed some laparoscopic surgery such as the medial-to-lateral approach to the white line of the left side of the descending colon for sigmoidectomy, dissection of the posterior surface of the pancreas to the upper edge of the pancreatic body or splenic artery for distal pancreatectomy, and the separation of the anterior surface of the inferior vena cava from the liver to the area between the right and middle hepatic vein for right hepatectomy. we quickly and easily identified the deepest part of the dissection area even if identification had been difficult using other techniques such as placing gauze in the deepest position, inserting forceps into the dissection area or simply depending on the experience of the operator. background: recent advancements within surgery have seen artificial intelligence transform traditional approaches. robotic assistive devices have demonstrated particular success, as safe and cost effective, and are widely supported via industry and local government as a step closer to the future standard of practice. an example of seamless and touchless robotic assistive technology is based on touchless and interactive eye tracker glasses worn by the surgical team thereby enabling the team to perform wider surgical tasks, more efficiently and reduced human error. we introduce a perceptually-enabled, smart operating room (smart-or) based on a novel real-time framework for theatre-wide d gaze localisation in a mobile fashion. this framework enables dynamic gaze based user interaction with a robotic scrub nurse to facilitate meaningful practical integration of human and technology intra-opertively. aims: we tested participant acceptability of a novel robotic scrub nurse during simulated surgery. project description: surgeons performed segmental resection of pig colon and handsewn end-to-end anastomosis while wearing eye-tracking glasses to select surgical instruments on a screen. the robotic scrub nurse(rn) picked up and transferred the instrument to the surgeon. the study compared human nurse(hn) vs rn. gaze-screen interaction was based on a d gaze framework we developed with synergy of conventional wearable eye-tracking, motion capture system and fixed in space rgb-d cameras for real-time d reconstruction of the environment. nasa-tlx and van der laan's technology acceptance questionnaires were collected and analysed using anova. preliminary results: overall, teams of surgeons(st) and scrub nurses(sn) participated. nasa tlx feedback for st and sn revealed no significant difference between in mental, physical or temporal demand. importantly, st and sn reported no significant difference in task overall performance. st reported more significant frustration with rn vs hn. van der laan's scores showed positive usefulness and satisfaction scores in using the rn platform. overall, all outcomes were more positive by sn vs rn. conclusions: this is the first platform of its kind. overall, quantitative and qualitative feedback was positive. the source of frustration has been understood and we believe it can be improved by appropriately modifying robot behaviour. importantly,there was no difference on perception of performance. background: endoscopic tumor resections in the gi tract may be facilitated by more advanced instruments for dissecting and suturing. we have focused on developing an endoscopic suturing technique using a standard flexible pediatric endoscope with new, flexible instruments allowing for complex end-effector movements. aim: perform flexible endoscopic suturing using a standard flexible scope in the gi tract project description: a standard flexible pediatric endoscope and a standard gastroscope were used for testing the new technique. via an overtube, the endoscope and newly designed fortimedix surgical flexible instruments (needle holder; grasper) with a diameter of mm were inserted into the esophagus. suture training was performed in an experimental setting in a box in the dry lab and porcine model . the flexible needle holder was advanced into the esophagus next to the scope, and a suture of the esophageal wall was performed, followed by extracorporeal knot-tying with knots. the test series consisted of training with both resident trainees and surgeons to evaluate the learning curve. each participant performed sutures on the box model and in the pig-esophagus. feasibility, duration of the different steps, and handling problems were documented. preliminary results: test series (box training on esophago-gastric explant) with prototype showed good feasibility. suturing was possible in out of attempts. median duration for single bite: min ( - ); knot-tying: min ( ) ( ) ( ) ( ) ( ) ( ) ( ) . test series (training in pig-model) with prototype showed improved feasibility with better flexibility of instrument shaft: median duration of double bite: min ( - ); knottying: min ( ) ( ) ( ) ( ) ( ) , overall duration intraluminal esophageal double bite suture and closing with knots: median duration: min ( - ). the new flexible endosuture instruments seem feasible to use and perform dependable intraluminal sutures. the training period and learning curve is short and the objective is to apply this system clinically for closure of perforations and fistulas. school of mechanical and aerospace engineering, nanyang technological university, singapore, singapore; general surgery, national university hospital, singapore, singapore; gastroenterology, national university hospital, singapore, singapore; surgery, chinese university of hong kong, hong kong, hong kong background: ideally, endoscopic suturing should mimic surgical closure as the latter is stronger than most endoscopic closure devices. however, endoscopic suturing is challenging due to the confined endoluminal space and lack of dexterity of current endoscopic instruments. we have developed a novel robotic suturing device to overcome these problems. aim: this animal study aims to demonstrate the feasibility of this device in closing perforations. method: the trial was conducted on an anaesthetized live pig. a double-channel colonoscope was first inserted into the rectum. following saline lift, a mm submucosal incision was created in the rectum to simulate a perforation. the robotic suturing device and grasper were inserted into the two colonoscope channels, allowing the endoscope to remain in position for tool exchanges or needle reloading. both the effectors were intuitively tele-operated by the user via a robotic master console. this robotic suturing device manipulated a curved, double-point needle (with a cm - vicryl suture) to penetrate tissues at desired orientations. the needle could be switched between both jaws of the device through a locking mechanism. this facilitated passing the needle through tissues to form stitches or through suture loops to form surgical knots. the articulated joints and five degrees of freedom allowed dexterous steering to reach targets and triangulation with other tools in a confined space. the robotic grasper facilitated handling of tissue and suture. result: a total of four running stitches were performed and secured with a surgical knot by passing the needle through suture loops. the suture was cut and the needle was removed by the robotic grasper through the channel. min and min were required to stitch and tie the knot respectively. there was no complication. conclusion: our novel endoscopic robotic device can suture perforations resulting from complex endoscopic procedures. as our suturing method is similar to laparoscopic and robotic suturing, closure using our device is expected to be as strong as a surgical through-and-through closure. when developed further, this device can be used to close full-thickness resection sites and orifices in transluminal endoscopic surgery. modelling a collaborative robot with the ieee sdc standard for combined focused ultrasound and radiation therapy j. berger, m. unger, l. landgraf, a. melzer medical faculty, university hospital leipzig, innovation center computer assisted surgery, leipzig, germany background: surgical robotics require a smooth integration into the operating room (or) . for this propose the ieee sdc(service-oriented device connectivity) standard has been developed in the or.net project. in preparation for a combined focused ultrasound and radiation therapy (fus-rt) we have shown concepts and evaluations to position ultrasound and interventional devices with collaborative kuka arms. however, the safe and intraoperative cooperation with multiple different or-devices (e.g. an irradiation unit) requires a more sophisticated exchange of the robot's information and functionality. aim: to realize a safe clinical integration, the aim of this work is to implement and evaluate a dynamic connection between the kuka robots and other devices using the vendor-independent sdc communication standard. project description: a kuka lbr iiwa r robot (kuka ag, germany) was modeled inside the sdc standard for medical device communication. the interconnection with other devices was implemented and evaluated on a mobile platform to position a clarius l wireless ultrasound transducer (clarius mobile health corp, canada). all necessary information of the robot was represented in the medical device description of the sdc standard to be shared via network. for each joint of the robot arm the position, torque, stiffness, damping, velocity and functional-states were represented, resulting in a total of parameters. the software was implemented in c ?? on a standard pc accessing the kuka controller cabinet with ros (robot operating system) via ethernet. the accessibility of each parameter, as well as activation commands for planning and movement were tested with an sdc-consumer application. preliminary results: the sdc-provider functionality of the robot was successfully implemented, allowing for dynamic changes of the robot state during interventions. all appliances (sdc standard compatible) in the robots network can react to state changes and send movement and planning commands to the robot via activations. after testing, % of the defined parameters are safely accessible. implementing the medical device communication for the kuka robot enables its integration into any networked operation room that supports the sdc standard. it is, therefore, ready to be set up and evaluated for the application of fus-rt in a clinical environment. background: assessment of perfusion of the left colon with fluorescence during anterior resections for cancer changes surgical decisions in up to % of cases. use of fluorescence has been shown to be associated with lower leak rates, and improved short-and long-term outcomes with reduced costs. given the high incidence of colorectal cancer, fluorescence-guided perfusion assessment could be of great importance in contemporary surgical practice. however, there is currently no standardisation of this technique which represents a significant limitation to widespread adoption. aim: to standardise fluorescence-guided perfusion assessment in rectal anterior resection through a computer vision algorithm. project description: videos were collected by a single surgeon in a referral centre for colorectal cancer treatment. perfusion assessment was used before proximal colon division to identify the best location for transection. a bolus of indocyanine green was injected intravenously and a near-infrared camera used to assess perfusion through fluorescence. photographs of fluorescent imaging of the colon were analysed using a non-supervised learning algorithm called 'k-means clustering'. the first step was to digitally subtract all background pixels, leaving only the area of interest of the colon. this area was then subsegmented into 'clusters' corresponding to perfused and nonperfused areas. a mathematical model was applied based on the sub-clusters centres to select the area for transection with optimal perfusion of the proximal colon. preliminary results: representative images of proximal colon under perfusion assessment were presented to expert surgeons. the optimal point for transection was selected based on their clinical judgement on previously delimited areas indicated by random letters. this was compared with the results from the automated segmentation using the algorithm ( fig. ). the area identified for section by the algorithm included the area selected by the expert surgeons in . - % of test cases. these results need to be further validated due to high risk of overfitting. next steps include the collection of multicentre data with a standardised fluorescence perfusion assessment. after robust training, the algorithm will be validated on real-time clinical data to ensure improved outcomes for patients, which is our ultimate goal. background: endoscopic submucosal dissection (esd) is a flexible endoscopic technique that allows for an en bloc removal of lesions of the gastrointestinal (gi) tract. these procedures are typically time consuming due to the difficult control of the tools, and they often require around min for removing lesions, that can reach - cm in diameter. the probability of intestinal perforation exceeds % and the hemorrhage risk ranges from . % to . %. a flexible robotic endoscope may offer a solution to overcome these limitations, by improving the degrees of freedom (dof) and operational efficiency. aim: within this clinical panorama, the aim of this project is presenting the development of a novel miniaturized robotic device to be coupled to the tip of a traditional endoscope for the surgical dissection of gi neoplasms. project description: the robotic platform consists of the miniaturized robot, the actuator housing (hereafter called external platform), the control unit and the master console (i.e.,two geomagic touch phantom) to allow the user driving and control (figure a ). during the operation, one surgeon stands close to the patient to maneuver the endoscope for exploring the gi tract and reaching the target area. another surgeon operates the miniaturized robot through the master console, carrying out the surgical procedure. the robot has been designed to be coupled to the tip of traditional flexible endoscopes of . mm in diameter. it exploits the flexibility of the endoscope for navigation through the intestine and integrates two-active robotic arms (i.e.,cautery and gripper) extending the dofs, and thus enhancing the efficiency during complex tasks such as manipulation and surgical tissue dissection. furthermore, the endoscope provides the optical system for visual feedback and one working channels for conventional instruments. preliminary results: firstly, a mock-up that faithfully reproduces the miniaturized robot has been realized using a d printer machine (projet mjp , d system, inc.) to verify the feasibility of the design solution. after verifying the potentiality of the d printed prototype, a final device, with the same features (i.e.,dof and geometry) of the d printed prototype, has been designed, fabricated and assembled ( figure b ). background: virtual and augmented reality has been widely used in many fields mainly for entertainment purposes. we think that it could be beneficial to use augmented reality in medical practice. aim: the aim of this study was to evaluate usefulness of d holographic images of patients anatomy displayed using augmented reality goggles during endovascular aortic repair (evar). project description: one of the major challenges during endovascular procedures is working on two dimentional x-ray images of three dimentional vascular anatomy. using d holograms of patients anatomy could be beneficial during the evar procedure and could make the orientation in vascular anatomy easier for surgeon. we performed two endovascular aortic repairs with the assists of microsoft hololens -smart glasses using augmented reality. we used carna life application created by polish company medapp. it was one of the first use of holograms during vascular procedures in the world (second and third stent-graft implantation using holographic imaging in the world). results: two patients with abdominal aortic aneurysms, -years old male and -years old female, were operated on. holograms of patient's anatomy made from preoperative angio ct scans by polish company medapp were displayed during the procedures using microsoft hololens. holograms could be displayed in any place and configuration using augmented reality, which means that the images did not interfere with the surgeon's field of vision. microsoft hololens use voice commends which permits the surgeon staying sterile. stent-graft implantations were successful. both patients were discharged three days after the procedure and the hospitalization was uneventful. seeing precise patient's vascular anatomy reconstructions in three dimention certainly helped us to navigate in a vascular tree. we believe that in the future this technology would enable to reduce the operation time and need for radiation. background: interaction with electronically controlled operating room (or) systems embedded in modern surgical environments is everyday practice for surgeons performing minimally invasive surgery (mis). while there is a non-sterile operating nurse available in the or, capable of interacting with these systems upon request by the surgeon, this indirect control is mostly slow, prone for error and disrupting surgical workflow. facing an unanticipated and unwanted outcome may cause distress emotions. distress emotions are undesirable when performing surgery, since they may impact available cognitive workload. furthermore, they may result in negative communication, hampering or-team empowerment and effective leadership. both factors are known to negatively influence quality and safety in the or. aim: the aim of the tedtrial is to investigate what setup best enables surgeons to interact with the endoscopic operating room setup during surgical procedures. as a result, disruptions of workflow, delays and errors may be reduced. outcome parameters will be objectified using medical data recorder (mdr) derived output and biometric analysis using hexoskinÓ. subjective evaluation of outcome parameters is done using questionnaires. project description: the tedcubeÓ system is a plug-and-play device enabling wearable sensors to act as a wireless alternative for a regular computer mouse, therefore enabling direct hands-free and sterile control of the or. the study is an observational trial with three different arms: intervention group ) direct interaction by surgeon with or environment using tedcubeÓ and myo tm armband, intervention group ) direct interaction of surgeon with or environment using tedcubeÓ and plantronicsÓ wireless microphone headset. the third arm is the control group using indirect interaction of surgeon with or environment using third-person computer interaction. main endpoint of study is the number of workflow disruptions due to the operation of laparoscopic or equipment. secondary endpoints are error rate, delay, team communication, subjectively reported frustration and satisfaction with the system and objectively measured stress as symptom of frustration and anger as distress emotions. preliminary results: primary and secondary endpoints of study are compared among groups. it is anticipated that reduction of miscommunication, error and delay may result in a reduction of distress emotions. trial start is expected q . anticipating the automated intraoperative tissue recognition: intraoperative tissue classification using hyperspectral imaging and machine background: iatrogenic injuries may occur despite a sound expertise in surgical anatomy. hyperspectral imaging (hsi) is an emerging optical method, combining the use of a camera system with a spectrometer. hsi analyzes optical properties of tissues and acquires d data sets with two spatial dimensions (x, y) and one spectral dimension (?). the data sets contain information about tissue physiology, composition, and perfusion. those spectral features coupled with machine learning algorithms might allow for automatic tissue recognition. aim: assessing the ability of an hsi-based machine learning to discriminate the hyperspectral features of different tissues during neck and abdominal surgical procedures. methods and procedures: fourteen pigs underwent laparotomy (n = ) or neck dissection (n = ). twenty data sets were acquired in vivo from abdominal organs and from neck structures by means of a customized hyperspectral camera (diaspective vision, germany). different anatomical structures were manually outlined by a surgeon using an image manipulation software (gimp). each pixel contained a hyperspectral curve and each curve was composed of bands (from to nm with a nm resolution). the curves were normalized using the standard normal variate method. a logistic regression machine learning (ml) algorithm was used to train the model to discriminate tissues, based on the hsi spectral features. the efficacy of the prediction model was tested using the k-fold (k = ) cross-validation. results: a large number of tissue-related hyperspectral curves could be extracted ( thyroid, vagal nerve, fatty tissue, cartilage, carotid artery, muscle, carotid vein, portal vein, biliary tract, gallbladder, hepatic artery, pancreas, duodenum, abdominal adipose tissue). the algorithm used min to 'learn' all data sets, and prediction was provided as an immediate output. overall, prediction accuracy was and % for neck and abdominal structures respectively. in particular, biliary ducts could be identified with a % accuracy and the vagal nerve with an % accuracy (see figure for details). background: a gaze-controlled robotic endoscope is innovative technology with myriad potential applications in the rapidly advancing field of flexible endoscopy. improvements to the current flexible device to allow examination of the gastrointestinal tract whilst minimising procedural discomfort and complications are desirable. aim: to use a gaze contingent framework to manipulate a flexible endoscope through a simulated upper gastrointestinal tract (ugit) model. description: a flexible gastroscope (karl storz pks) was attached to a ur axis robotic arm (universal robots), mounted onto a rail and placed on top of a surgical table. two cogwheel shaped dials were d printed and placed onto the up/down and left/right wheels on the head of the gastroscope ( figure ). robotization of these controls was achieved by using two motors (dynamixel rx- f) to steer the distal tip. this system allows users to operate a robotised flexible endoscope using gaze control. gaze interaction with the screen was based on a d gaze framework we developed with the synergy of conventional wearable eye-tracking, motion capture system and fixed in space rgb-d cameras for d reconstruction of the environment. users are able to control endoscope movements without handling the device. the distal tip of the gastroscope was controlled using eye gaze technology. the ur robot was used to enable shaft rotation (initiated by fixed head movements) and linear movements were triggered using a joystick handle (up for forward movement, down for endoscope withdrawal). pause and retroflexion of the endoscope are achieved by moving the joystick left and right respectively. users were asked to navigate an endoscope through an ugit model (chamberlain group) simulating a diagnostic gastroscopy using gaze control and targeting ten points scattered through the stomach. results: four expert endoscopists and one novice used gaze control to successfully navigate a gastroscope through a simulated ugit. all were able to intubate the oesophagus and accurately locate ten targets placed in the fundus, body, antrum and pylorus of the stomach. conclusion: gaze control endoscopy is a feasible concept. it allows ergonomic, user-friendly and intuitive control whilst maintaining the benefits of a flexible endoscope. background: image-guided needle biopsies and histopathological evaluation are the gold standard for the diagnosis of liver neoplasms. most often, however, these are reserved for suspicious, but not diagnostic, situations. radiomic may help to characterize tumor biology by correlating imaging features with relevant tumor-biology information. features derived from radiomic analysis may provide complementary information to support clinical decisions, especially in situations where tissue analysis cannot be performed or is inconclusive. aim: the goal of our technology is to exploit computational capabilities for image analysis in order to identify radiomic features useful for characterizing liver lesions and to identify relevant information related to patient prognosis. project description: patients derived from an internal database and patients randomly extracted from the cancer archive liver dataset were included in this study. lesions were extracted from those volumes using expert annotations ( secondary vs primary; well differentiated vs non-well differentiated). lesions were then split into training and testing sets. first order statistical features were computed and a lasso regression step was performed to reduce the number of features. both logistic regression and random forest models were built using cross-validation to predict the target classes on the test set. preliminary results: only features namely the energy and the volume of the lesion were sufficient, when combined in either model, to predict the differentiation grade on the test set with an f -score of . (± . ). we are currently working on the addition of higher order statistical features to the analysis in order to differentiate primary from metastatic tumors and identify complementary features that may assist clinical decisions in patients with inconclusive hepatic lesions. objective of the technology or deviceideally, the use of medical simulators could provide trainees with initial background information about indications for procedures, endoscopic technique, and early hands-on training experience that could shorten the initial critical learning curve. rationale for using ex vivo models is that in the beginning of the learning curve, the most important issue is having an initial exposure to the basic movements and maneuvers. our objective of is to create a stomach model from renewable polymer, which would closely simulate normal human stomach with gastric pathology for endoscopic diagnostic or interventional skill acquisition/evaluation. description of the technology and method of its use or application stomach model is based in several steps; the first one is in the in-silicodesign of the overall shape, after that we d print the positive two halves of it. the interior detail is obtained shaping the d printer parts with ceramic putty. once concluded, this elaborated part will serve as a template in order to build injection bleeding moulds. in the injection bleeding moulding a mesh is placed between layers in order to provide structural attachment points as stiches or several pathological models that will be incorporated after the casting process. we have developed for these instance polyp moulds, fistulae structures in order to attach endoscopic clamps. the two halves are closed once the pathological models are placed inside via a thermic-fusing and stitching creating a leak proof stomach model. preliminary results if available: our models were evaluated by international experts in ircar/ihu france in interventional endoscopy course and were favorable accepting for next trails in these prestigious institutions. conclusions: future directionsa new endoscopic training model of stomach was made and will be evaluated and validated for feasibility in mastering diagnostic and interventional endoscopic skills. clinical trials will be necessary to compare the ability of the simulator to perform training compared with traditional methods of training in endoscopic procedures. background: endoscopes are the eye of surgeons in minimally invasive surgery (mis). conventional endoscopes are mostly chopstick-like and are steered by the assistant. this limits the field of view and results in issues such as endoscope-instrument fencing, surgeon-assistant coordination. existing robotic endoscope holder enables solo-surgery, however endoscope remains blocking the instrument movement and impairs the operational safety. flexible endoscope such as the endoeye provides angulation at the tip and could enlarge the field of view. however, its steering the view is much more complex compared to the rigid endoscope. aim: to provide an intuitive robotic flexible endoscope with enhanced safety. project description: in this work, we present a robotic flexible endoscope for mis with enhanced safety. in the proof-of-concept system, it contains a flexible endoscope module and a robot manipulator. the endoscope contains a proximal rigid shaft and a distal flexible bending section. it is installed onto the patient side manipulator (psm) of the da vinci research kit (dvrk). visual servoing is adopted to achieve autonomous instruments tracking. during the tracking process, movements of the manipulator as well as the endoscope are minimized to save space for the operation and avoid instrument-endoscope fencing. the endoscope could also be controlled by the surgeon. a foot pedal is used to switch between the tracking-mode and control-mode. preliminary results: a prototype was developed and tested experimentally. in tracking a volume of * * mm , the spaces required by the flexible endoscope are . % (inside the trocar) and . % (outside the trocar) of that occupied by the rigid endoscope. evaluation with the fls tasks involved subjects. all of the participants completed the tasks under the tracking-mode without failure. in the ex-vivo test with porcine stomach, the endoscope successfully guided the detection, dissection and knotting autonomously. background: fluorescence imaging allows to visualize deep-seated anatomical structures, using a deeper tissue penetration of near-infrared (nir) compared to visible light. the most commonly used fluorescent substance, indocyanine green (icg), is not naturally excreted by the urinary system and requires retrograde stent placement and injection. lighted catheters have been proposed to help visualise the ureter. fluorescent dye-coated ureteral catheters could well represent a more effective and less expensive solution. icg is unsuitable for coating materials. aim: to develop a stable fluorescent coating for catheters to be used intraoperatively, working in the same nir window as icg, to facilitate its use with clinically available systems. project description: the coating was developed based on poly(methyl methacrylate) (pmma), a biocompatible polymer, and on specifically designed fluorescent dyes exhibiting icg-like optical properties. three nir dyes (substances a, b, and c) were tested in order to find the optimal one, in terms of fluorescence signal intensity, and were compared to icg in a polymer form and to an icg-based reference card (green balance tm ). the fluorescent coating was applied onto common ureteral stent materials: hydrophilic-coated ultrathaneÒ, silicone-coated latex, and pvc. the coating process involved cycles of immersion into the respective dyes blended in pmma polymer (icg, substances a, b, and c), followed by a drying phase. the various tubes were partly inserted into a porcine ureter, next to the icg-based reference card. images were taken in white light and nir modes using the d-light p camera system (karl storz), at a fixed camera-to-target distance. the fluorescence signal intensity was measured for the different regions of interest (each material/coating combination inside and outside of the ureter, reference card) using proprietary software and normalised against the reference card. preliminary results: the signal intensity was significantly higher for all new substances as compared to icg. substance a showed the strongest fluorescence signal intensity among the tested coatings in all tested conditions and materials and was identified as the ideal candidate to undergo further evaluation and in vivo testing. background: endoscopic resection(er) of early gastric cancers provides tremendous patient advantages. however, post-resection findings of deeper sub-mucosal(sm) and/or lympho-vascular invasion can necessitate a second, surgical intervention. we propose that pre-resection evaluation of the submucosal architecture under the tumour can provide critical information for staging and operative planning. we evaluate three techniques to assess the submucosal architecture underlying the gastric mucosa in a pig model. aim: to evaluate three needle-based methods of evaluating the sm before er. project description: acute pigs were used. a simulation of sub-mucosal tumours (endoscopically and eus visible bleb) by injecting the sm with cc of undyed nac. a linear eus was use for all procedures. the tumours were marked and labelled according to geography. methodology: after creating the tumours, anterior lesions were evaluated using the following g needle-based modalities: confocal microscopy(cm) using the through-the-needle cellvizio (mauna-kea) system; mini-biopsy(mb) using the micro-biopsy forceps moray (us endoscopy) and fine-needle biopsy(fnb). results: cm examinations were video recorded in all a positions. submucosal vascular visualisation was possible in all cases, excellent in / . mb was performed in lesions with a total of biopsies obtained from each lesion (total = ). fnb was performed once in the anterior lesions and twice in the posterior lesions with different needle brands. therefore, there was a total of biopsies collected. passes were performed in each biopsy (total = ). each pass constituted - insertion/withdrawal movements combined with fanning, slow pull technique, no suction and suction ( - cc air negative pressure) to collect the material. all material were sent to an animal anatomo-pathologist blinded to the acquisition method. mean time of confocal examination was min sec ( ' ' '- ' '') . mbtook a mean time of min and fnb was a mean of min for each biopsy. cm identified different patterns of vessels in relation to the probe position (superficial/reticular, middle cross-roads or deep/longitudinal). conclusion: eus-fnb, cm and mb are three potential methods to assess the sub-mucosal space underlying the gastric mucosa. cm offered the most architectural information but required more time to perform. these method's may have a role in better staging patients for appropriate er. background: the overall and disease-free survival of patients with rectal cancer is dependant on its staging, and adequate selection of the treatment strategy. mri has a proven efficacy in rectal cancer local staging and recognition of the adverse prognostic features. however, it can be difficult to utilise it as a navigation tool for surgeons, as it represents a complex three-dimensional pelvic space with a series of individual two-dimensional images. d image reconstruction has been successfully adopted in other surgical fields to overcome these limitations. aim: our primary aim is to develop a bespoke automated generation of patient-specific d pelvic models, which will improve surgical planning and navigation, patient interaction and surgical education. true-size, rotatable d models will offer a more realistic three-dimensional representation of the surgical space and its complex relationships, allowing for a more confident surgical rehearsal and potentially better utilisation of minimally invasive techniques in rectal cancer management. our secondary aim is to develop a large multipurpose database of the d models of male and female pelvis in health and in the disease. project description: our multidisciplinary team consists of colorectal surgeons, radiologists specialising in pelvic mri imaging and computer scientists. virtual d pelvic models are generated based on standard d dicom mri images routinely used for rectal cancer staging, which guarantees the high fidelity of cancer delineation. segmentation of the pelvic anatomy is performed with the use of itk-snap, an open-access, multi-platform software. machine learning technology is then employed to automate the d model generation, making it time-efficient, allowing for its clinical application. preliminary results: in the initial stage, using the manual segmentation, we have created ten models of normal male and female pelvic anatomy. a good inter-rater agreement level was found, which proves reproducibility of the approach applied. various machine learning algorithms are being explored to fully automate the process of d model generation, which will allow for their use in clinical practice and in development of the d colorectal database. the technology will be further implemented in creation of dynamic models of functional pelvic floor disorders. surgery, toho university omori medical center, tokyo, japan; surgery, neuchâtel hospital, neuch tel, switzerland background: laparoscopic gastrojejunostomies are time-consuming and require a specific training. alternatively, sutureless anastomosis can be achieved by means of endoscopically delivered magnetic rings. objective of the study: assessing the feasibility and reproducibility of an endo-laparoscopic gastrojejunostomy technique, using magnets coated with a fluorescent biocompatible polymer. methods and procedures: four pigs ( acute, survival models) and one cadaver were included in this study. the anastomotic device was composed of two magnetic rings ( x x mm; attraction force newton), each one attached to a cm long thread. the distal ring was inserted endoscopically into the first duodenum, and the extremity of the thread was clipped to the gastric mucosa. twenty-four hours later, a two-port laparoscopy ( mm, mm) was performed, using a near-infrared (nir) laparoscope (d-light-p; karl storz). the magnet's position in the jejunum was detected thanks to the transluminal fluorescence of the dye. magnetic interaction with the metallic tip of the laparoscopic grasper allowed to catch the ring and bring the bowel loop to the future anastomotic site on the gastric wall. simultaneously, the proximal magnet was delivered to the gastroesophageal junction using a flexible endoscope. the magnet was carefully advanced into the stomach allowing precise connection with the distal ring. in one cadaver the procedure was repeated. the sole variation was that, in order to reach the second jejunal loop, the distal magnet was placed using a gastroscope inserted through a transgastric port. in two acute animals, the distal magnetic ring was introduced into the jejunum via an enterotomy. the anastomotic procedure (from the distal magnet detection via fluorescence to the magnetic connection using a hybrid approach) was reiterated times. survival animals were followedup for days and underwent control endoscopies and ct-scans. results: the procedure was easy to standardize and reproducible, with a mean anastomotic procedure time of . ± . min. there were no technical problems and magnetic connection could be precisely directed in all cases, at both the anterior and posterior gastric wall. no complications occurred during the survival period and the anastomoses were patent by day . transluminal fluorescence allowed for a rapid detection of the magnet. colorectal cancer is the fourth most common cancer in high-income countries counting [ . deaths worldwide. survival rate reaches % in case of early diagnosis, falling down to % in case of advanced stage. conventional colonoscopy screening is limited by invasiveness, pain and often need of sedation. wireless capsule endoscopy enables inspection without discomfort, but passive locomotion often leads to incomplete and/or false negative results. the european endoo project (grant agreement ) aims to develop a novel system that overcomes most of the drawbacks of conventional colonoscopy, maintaining accurate and reliable diagnosis and therapy. the system is composed of an active robotic platform that magnetically drives a soft-tethered capsule; magnetic guidance is achieved through the magnetic localization of the capsule in combination with a closed-loop control that maintains an optimal and safe link between the capsule and the magnetic end-effector. a stereoscopic camera is integrated in the capsule for enhanced diagnosis though d reconstruction and automated detection of lesions/pathologies. the different modules of the endoo medical platform are illustrated in the figures. the robotic guidance systemconsists of an anthropomorphic manipulator that controls the capsule through an external permanent magnet. the robot, positioned on a dedicated trolley, is equipped with sensors for performing safe human-robot collaboration. the medical workstationincorporates: screens, buttons and pedals for visualization and command initiation, a joystick for system teleoperation and a back-end for fluidic control and data communication. the soft-tethered capsuleembeds an internal permanent magnet, magnetic sensors, an accelerometer, white and infrared illumination and an hd stereoscopic vision system with two wide-angle customized optics. a controller serves as the main control unitfor performing real-time communication and closed-loop control of the robot, localization system, capsule and physician commands. the synergistic cooperation of academic, industrial and clinical partners within the project allowed to develop and validate the system in in-vitro \/i [ , exvivoand preliminary cadaver sessions, performing comparisons with state-ofthe-art commercial colonoscopes. in conclusion, the endoo medical platform provides: reduced procedural pressures, user-friendly procedures, similar functionalities and performances of commercial devices, comparable procedural times and considerably lower costs with a new painless approach. background: this study is aimed at the comparison of the process of manual and robotic-assisted positioning of the electrode performing radiofrequency ablation with the usage of multifunctional robot-assisted surgical platform. under the control of the surgical navigation system. the main hypothesis of this experiment was that the use of a collaborative manipulator will allow to position the active part of the electrode relative to the center of the tumor more accurately and from the first attempt. we also check the stability of the electrode's velocity during insertion and consider some advantages in ergonomics using the robotic manipulator. methods: sphere-shaped tumor phantoms measuring mm in diameter were filled with contrast and inserted in cow livers. livers were used for the robotic experiment and an equal quantity for manual. the livers were encased in silicone phantoms. analysis of ct data gave the opportunity to find the entry and the target point for each tumor phantom. this data was loaded into the surgical navigation system that was used to track and record the position of the rf-electrode during the operation for further analysis. results: standard deviation of points from the programmed linear trajectory totaled in the average . mm for the robotic experiment and . mm for the manual operation with a maximum deviation of . mm and . mm respectively. standard deviation from the target point was . mm for the collaborative method and . mm for manual method. the average velocity was . mm/s for the manipulator and . mm/s for the manual method, but the standard deviation of the velocity relative to the value of the average velocity was . mm/s and . mm/s respectively.thus, in two criteria out of three, the manipulator is superior to the surgeon, and equality is established in one. surgeons also noticed advantages in ergonomics performing the procedure using the manipulator. conclusions: this experiment was produced as part of the work on the developing of the robotic multifunctional surgical complex. we can confirm the potential advantages of using robotic manipulators for minimally invasive surgery in case of collaborative practice for cancer treatment. surg endosc ( ) background and aims: laparoscopy has reduced tactile feedback compared to open surgery. in neuropsychological literature there is increasing evidence that visual and haptic information converge to form a mental representation of an object. through the combination of these inputs, this representation is believed to be more refined and robust. we investigated whether tactile exploration of a lifelike anatomical object before executing a laparoscopic action on this object in a laparoscopic box trainer improves performance of this action. description: a randomized prospective cohort study with two groups (a ? b) of ten laparoscopically naïve medical students was conducted. we compared the groups for baseline characteristics and performance, using a basic laparoscopic task (post and sleeve). to investigate the effect of haptic exploration, students performed ten repetitions of a laparoscopic needle action on a lifelike silicone caecum model (applied medical, rancho santa margerita, usa). group a did a pre-test visual exploration of the model. in group b manual exploration of the anatomical model was added to the visual exploration before executing the task. the box trainer was equipped with the forcesense tm (medishield, delft, the netherlands) system for skill assessment using objective force, motion and time parameters. results: baseline characteristics and-laparoscopic performance were comparable (p [ , ) . performances of trials on the anatomical model were captured and parameter outcomes were compared between groups. significantly less force (maximal force, maximal impulse, mean force and force volume) was exerted by the 'touch' group (p \ . ) (fig. ). this group also completed the task with less distance travelled by the instruments (p \ , ). there was no significant difference in time needed to complete the task (p = , ). conclusion: this study showed that, when performing a laparoscopic task on an anatomical model, pre-task haptic exploration of the model results in the use of significantly less force and less movement. adding haptic exploration to a laparoscopic training curriculum could therefore result in more efficient and more refined learning of laparoscopic actions. this, in turn, could lead to better, quicker and safer performance of laparoscopic operations. . esophagogastroscopy was performed before gabe and -week post-procedure assessing gastric abnormalities. weight and fasting plasma ghrelin were obtained at baseline, -, -, -and -months post-index procedure. after months, the sham group was unblinded and received gabe. both gabe and sham crossover to gabe groups were followed for months and received lifestyle therapy (behavioral-diet education). preliminary results: gabe was successful in all patients with no serious complications. significant, progressive weight loss was observed at and maintained at months. ghrelin in gabe group decreased by % ( . pg/ml) compared to baseline and months levels. weight-loss was approximately . % greater in the gabe group versus sham at months ( table ) . itt = intent-to-treat, pp = per-protocol analysis preformed using independent-sample t-test and à paired-sample t-test conclusions: gabe using eles is safe, accompanied by significant and so far maintainable weight loss. gabe using the eles demonstrated a reduction in ghrelin levels. aims: transanal total mesorectal excision (tatme) is the latest colorectal approach that continues to be in the spotlight. this study aims to describe the technique in depth by identifying and understanding technical advantages, errors and adverse events. methods: detailed video analysis using observational clinical human reliability analysis (ochra) was completed on clinical tatme cases performed by international surgeons. error frequency and error pathways leading to adverse events were described. tatme expert surgeons were interviewed and engaged in a workshop to elicit error-reducing mechanisms. results: overall technical errors and adverse events per procedure on average occurred ± . (range -- ) and ± . (range - ) times respectively. inadequate insufflation and poor camera optics were the most frequent set-up problems. instrument handling errors consisted most commonly of excessive grasper movement during the pursestring phase ( times total), inappropriate force applied ( times) with the energy device during the rectotomy, inappropriate force with the grasper ( times) and excessive movement with the energy device ( times) during tme dissection. incorrect dissection planes were created during tme dissection mostly due to insufficient retraction ( times) which didn't allow adequate exposure of the tissue planes. the most frequently occurring consequence was bleeding (mean: times per procedure). rectal perforation ( cases), vaginal wall injury ( cases), and prostatic injury ( cases) were also recorded. adverse events regularly occurred as a result of poor set-up/exposure, inappropriate retraction and/or instrument movement and incorrect plane surgery. error-reducing mechanisms and 'technical tips' describe specific steps and actions, both set-up/equipmentrelated and technique-related, that aim to prevent errors from occurring and avoid adverse consequences. ochra and individual feedback with error-reducing mechanisms developed by this study have been implemented into the national training programme for tatme. conclusion: tatme is an advanced complex procedure during which technical errors and their consequences are not infrequent. tatme requires knowledge of anatomy 'bottom-up', familiarity with its specialised equipment and technical skill working in a narrow space. appropriate structured training and mentorship are therefore recommended. surg endosc ( ) objective: insufficient vascular supply is one of the main causes of anastomotic leak in colorectal surgery. icg has been shown to provide information on tissue perfusion, identifying a well-perfused location for colonic and rectal transections and thus possibly reducing the leak rate. objective of this study is to evaluate the usefulness of intraoperative assessment of anastomotic perfusion using intraoperative indocyanine-green dye (icg) angiography in patients undergoing left-sided colon or rectal resection with colorectal anastomosis. methods: this randomized trial involved patients undergoing laparoscopic left-sided colon and rectal resection randomized : to intraoperative icg or to subjective visual evaluation of the bowel perfusion without icg (clinicaltrials.gov nct ). the primary aim was to assess whether icg angiography could lead to a reduction in anastomotic leak rate. secondary outcomes were possible changes in the surgical strategy and postoperative morbidity. results: after randomization, patients were excluded. accordingly, patients were included in the analysis; in the study group, and in the control group. icg angiography showed insufficient perfusion of the colic stump, which led to extended bowel resection, in cases ( %). an anastomotic leak developed in patients ( %) in the control group and in patients ( %) in the study group (p = n.s.). conclusion: intraoperative icg fluorescent angiography can effectively assess vascularization of the colic stump and anastomosis in patients undergoing colorectal resection. this method led to further proximal bowel resection in cases, however its role in reducing anastomotic leak rate should be studied in further research. endoscopic sleeve gastroplasty (esg) is a promising endoscopic bariatric procedure carried out with the application of transmural sutures resulting in a gastric reduction and gastric shortening. sutures are placed in u shape fashion, from the incisura to the fundus, which is preserved, using an over the endoscope suturing platform (overstitch, apollo endosurgery, austin, texas, usa). the choice of right lankmarks for suturing the gastric wall is extremely important for the efficacy and safety of the procedure. flexible endoscopy suffers from little anatomical reference points. correct spatial relation to precisely target the insertion of the helix device used for retraction and correct orientation of the full thickhness tissue bite require a good undrestanding of the anatomy of the stomach and sourrounding organs including vascular structures that could be inadvertently injured (left lobe of the liver, gallbladder, spleen, short gastric vessels, pancreas, transverse colon). surgeons by training can 'see' the anatomy beyond the gastric wall and undrestand whether they work in a safe layer or whether an underlying structure should be spared. this video illustrates all the potential risks realted with a wrong chioce of endoscopic landmarks when performing esg with respect to gastric and abdominal anatomy. introduction: central bisectionectomy, anterior sectionectomy, and posterior sectionectomy are technically demanding procedures in minimally invasive approach because of difficult expoure and extensive parenchymal transection planes. with limited robotic instruments including absence of cusa, these procedures have been rarely perfomed by robotic approach. method: consecutive robotic central bisectionectomy, anterior sectionectomy, and posterior sectionectomy were performed. patients were all males and were , , and -years-old, respectively. pathologic diagnoses were all hepatocellular carcinomas of each . , . , and . cm diameter. operative settings were identical for the three kinds of procedure. the patients were placed in supine with a reverse trendelenburg and right side elevation. umbilical -mm camera port, three -mm ports and additional -mm assistant port were used. glissonian approach and icg fluorescence image clearly demarcated the resection planes. parenchymal transection was performed using the maryland bipolar dissector and harmonic scalpel. the rubber band self-retraction method and third arm of robot system helped for stable and excellent exposure of surgical planes result: there were no conversions to laparoscopic or open surgery. the operative time was , , and min and estimated intraoperative blood loss was , , and ml. the pathologic surgical margin was . , . , and . cm. the length of stay after surgery was , , and days and there were no postoperative complications. conclusion: robotic central bisectionectomy, anterior sectionectomy, and posterior sectionectomy are still demanding procedures with long operative time. however, these procedures could be performed safely in regard to short-term perioperative outcomes. robot surgical system provided several benefits for anatomical hepatectomies including a stable and excellent operative field and clear surgical planes. suprapubic hernias (less than cm above the pubic arch in the midline) require important anatomical knowledge because of complexity of their repair and low incidence, by approximately % of all hernias. the problem to repair this type of hernias is that inferior margin of the defect is very close to pubic symphysis, consequently, mesh overlap is often inadequate. treatment of suprapubic hernias is controversial because of limited evidence in the literatura. this video shows the case of a -year-old female patient with suprapubic hernia with a defect of x cm. we performed a laparoscopic repair with a bilateral peritoneal flap of the groin region (as it is perfromed during tapp) for proper view of the pubic symphysis, cooper's ligaments, epigastric and major vessels, nerves and meticulous dissection the space of retzius. the defect was repaired by reconstructing the middle line with a running sutures. subsequently, titanium helical tacks were used to fix the mesh to the pubis and cooper and following the double-crown technique having special attention when fixing the mesh near to inguinal chanal, due to the possibility of causing chronic pain. the peritoneal flap was fixed over the mesh with abdsorbable fixation devices and seal with fibrin glue. laparoscopic repair of suprapubic hernias can be considered as the first option in treatment, because it endeavors to join the advantages of a minimally invasive approach and it is associated to low recurrence. the main advantages are that allows a proper visualization the anatomy and a proper fixation of the mesh. background and aim: thoracoscopic esophagectomy has been performed for two decades and becomes widely spread. we evaluate our cases who undergone the thoracoscopic esophagectomy and consider the future prospective of this operation.transient recurrent laryngeal nerve palsy after lymphadenectomy in this surgery is not rare and induces not only hoarseness but also aspiration or pneumoniae. new method to avoid this complication is desired. patients and methods: patients who received thoracoscopic esophagectomy in our institute from march to october were enrolled and studied retrospectively. operative indication is an all of the clinically resectable cases including with a neoadjuvant treatment or definitive chemoradiotherapy before surgery. overall survival rate of the patients with thoracoscopic approach and with thoracotomy until was analyzed. long term outcome of the patients with thoracoscopic esophagectomy was compared to the result from comprehensive registry of esophageal cancer in japan. short term results of the perioperative parameters were analyzed between left lateral decubitus position and prone position.we had introduced intraoperative nerve monitoring system for prone esophagectomy from . results: there was no significant differences of the survival rate between thoracoscopic group and thoracotomy group based on pathological stage. year survival without neoadjuvant treatment was . % (pstagei), . %(pstageiia), . %(pstageiib), . %(pstageiii), respectively. year survival rate of cstageii and iii with neoadjuvant chemotherapy was . % and year survival rate of the salvage esophagectomy after failure of definitive chemoradiotherapy was . %. every outcomes are as good as any reported results in esophagectomy. in the comparison of the lateral position with the prone position, total blood loss was significantly lower in prone position. inflammatory response after surgery was improved more rapidly in prone group, therefore, prone position is recommended as a minimally invasive procedure for thoracoscopic esophagectomy. transient recurrent laryngeal nerve palsy was observed % of patients. conclusion: thoracoscopic esophagectomy will develop further as a standard operation for esophageal cancer. nerve monitoring is useful for detecting recurrent nerve and avoiding nerve injury. background: laparoscopic total mesorectal excision (tme), in a wide female pelvis is usually technically easier than in a narrow male pelvis. however, this is not always the case, as the uterus and adnexae may obscure the views and hinder safe dissection, especially in obese patients. techniques such as graspers through additional ports or suspension with sutures through the broad ligament may potentially cause injury or need additional ports/assistants. aim: we present a novel technique using a self-retaining gynaecological uterine manipulator to improve access during deep pelvic laparoscopic surgery in female patients. technical tip: the operation is commenced in the standard manner for a laparoscopic rectal excision. once pelvic dissection is commenced, whenever it is felt that uterine retraction would be advantageous (depending on the level of the rectal tumour, size of the uterus and ovaries, obesity etc.) a self-retaining uterine manipulator (as shown in the video) is used. the tip of this disposable device is introduced into the uterus after dilatation of the uterine cervix. once the balloon at the tip has been inflated, the instrument is secure and hence there is no need for active manipulation by an assistant. the shaft can be rotated to allow anteversion/retroversion of the uterus to varying degrees as required to aid dissection. as the video depicts clearly, it acts as a self-retaining retractor for the uterus and is removed at the end of the operation. though the procedure is being demonstrated by a gynaecologist in the video, the instrument is quite easy to insert and some of our colorectal team have been trained as well. conclusion: the self-retaining uterine manipulator is an efficient tool for uterine retraction in laparoscopic rectal surgery and we have been using it routinely in tme in females for the past years, with no complications. this was previously published as a technical tip in the journal of minimal access surgerybut has never been submitted for peer review as a video. the authors present a video of two clinical cases treated by trans-axillary endoscopic approach. methods: a years-old male and a -year-old male presented with intermittent dysphagia and frequent reflux (class ii of lahey). one had a history of recurrent respiratory infections. the disease was characterized by oesophagogastroscopy (egd) and oesophagogram. trans-axillary approach with areolar port. step-by-step as follows: (i) dissection anteriorly to the pectoralis major muscle (ii) isolation of the anterior border of sternocleidomastoid muscle (iii) omohyoid muscle's isolation (iv) identification of the thyroid's upper pole (v) zd isolation (vi) myotomy of the cricopharyngeal muscle (vii) zd's resection with stapler and its withdrawn with sac. results: both cases progressed without complications. complete local recovery was verified in both cases one month after the procedure. conclusion: this technique seems feasible and reproducible, allowing zd diverticulectomy with a better cosmetic result and perhaps lower surgical site infections (ssi). in the authors' knowledge, this approach to dz has never been published. background: gastric leak occurs in - % of patients who undergo roux-en y gastric bypass (rygb) for morbid obesity. the pathophysiology may be related to gastric ischemia, fistula, or ulcer.gastric leak is a severe complication of gastric bypass (gbp) that is associated with significant morbidity and mortality. fistula may have several clinical impacts, depending on patientrelated factors, fistula characteristics, onset time, and therapy proposal. abdominal drainage, gastrostomy, and revisional surgery constitute the traditional approaches to dehiscence and fistula closure, with variable results. methods: we present a video of a clinical case of -year-old lady with body mass index of kg/m who underwent roux-en-y gastric bypass and h later presentedtaquicardia and right cuadrantum pain. the ctscan inform a apical leak at the gastric pouch level. the video shows the relevant aspects of a revisional surgery and the key points to drain the fistula and close de defect laparoscopically. results: after monts, the patient achieved succesful results, defined as a stabel clinical situation with image evidence of gastric fistula remision. conclusions: gastric bypass (gbp) is one of the most efficient bariatric interventions in morbidly obese patients. the most severe risk of this procedure seems to be the staple line leak, and the management of this complication can be very arduous. without any guidelines it is very difficult to determine the right procedure addressing the staple line leak after gbp. laparoscopic sleeve gastrectomy (lsg) has become the most commonly performed operation worldwide as a primary bariatric/metabolic procedure. however, conversion to other surgical procedures such as roux-en-y gastric bypass (rygb) or one anastomosis gastric bypass (oagb) have been described as treatment options for inadequate weight loss after lsg and unresolved co-morbidities or complications such as leak, stricture, and severe gastroesophageal reflux disease (gerd). we present two clinical cases of weight regain and severe gerd and dysphagia, which account for the main indications to reversal of lsg to either oagb or rygb. aims: we show in the video the surgical technique that we perform by laparoscopic aproach, in order to construct a roux-en-y polipropilene banded gastric bypass lrygb-b. methods: we are performing this procedures within a prospective randomized trial that is design to compare the long term results of lrygb-b versus the standard laparoscopic roux-en-y gastric bypass.the video shows our technique in a case of a years old female with a bmi of kg/m . first we create a vertical gastric pouch of about - ml, and a polypropylene mesh ( x mm) is placed - mm proximal to the anastomosis around the gastric pouch, with the help of a laparoscopic band retractor. after that a cm roux-en-y limb is constructed in an antegastric antecolic fashion, been the lenght of the biliary limb cm. a mm gastroyeyunal anastomosis is performed with a linear stapler, and the enterotomy and gastrostomy are closed with a / barbed running sutures. jejunojejunostomy anastomosis is constructed in similar fashion, but with a lenght of - mm. the petersen space and the mesenteric defect are closed with polipropilene / sutures. results: patients has been operated following this technique, and there has been no complications related to the polipropilene band. (the ramdomized prospective trial is still ongoing). conclusions:the video shows a reproductible easy way to perform a lrygb-b using a polipropilene mesh. introduction: a -year old female patient presented at our clinic two years after initial rouxen-y gastric bypass. she had had a preoperative bmi of , and had a significant weight loss which resulted in a bmi of , at two years postoperatively. she currently suffered from severe dumping with glycaemia levels dropping to mg/dl. pharmacological treatment with metformine, sandostatine and acarbose did not yield any results. on top of these problems she felt less restriction, could eat large portions and had gained kg in the last three months. objective: the usual approach for severe dumping-related hypoglycemia would be to undo the gastric bypass. this patient however was extremely anxious to regain weight, so we sought other options. we assumed that by adding more restriction and slowing down the emptying of the gastric pouch we could alleviate some-if not all-of the dumping related symptoms and prevent further weight regain. methods: in this video we present the banding of a gastric pouch for severe dumping after rouxen-y gastric bypass. results: although unconventional, the banding of the pouch yielded excellent results. the slower pouch emptying and reduced portions resulted in a near complete remission of all symptoms. as an additional benefit we found a slight weight loss of four kilograms six weeks postoperatively. conclusion: the usual treatment of severe dumping-related hypoglycemia would be an undo of the gastric bypass. in this case however the patient was extremely anxious to regain weight, being very pleased with the results her gastric bypass had yielded. in agreement with both the patient and treating endocrinologist we attempted a different approach. the slower pouch emptying and increased restriction offered another way to alleviate the dumping and deep hypoglycemia while concomitantly resulting in weight maintenance. aim: the aim of this video is to present a novel surgical technique to avoid stent migration after endoscopic placement in patients with leakage subsequent to laparoscopic sleeve gastrectomy (lsg) . methods: this video shows the case of a patient (bmi , kg/m ) who developed an upper gastric leakage days after lsg. a ct scan showed a small leakage at the eg junction complicated by intra-abdominal abscess. a ct guided percutaneous drainage of the abscess was performed. a stent placement was attempted endoscopically three times and failed for migration. we decided to place laparoscopically a non adjustable gastric ring (nagr) around the stomach, in order to avoid stent migration.first of all the stent is replaced endoscopically in order to cover the fistula tract. the patient is placed in a half sitting position and the pneumoperitoneum was obtained using a veress needle in left subcostal space. a port technique is used as in standard laparoscopic sleeve gastrectomy.the procedure starts with the mobilization of adhesions, the fistula is identified in the upper part of the tubule.the gastric tubule is isolated and the lesser omentum is opened. the blunt needle at the tip of the ring is passed retrogastrically, a tourniquet can be useful is the positioning turn out to be difficult. the nagr is then closed over the gastric tubule containing the stent. a drain is finally placed. results: the stent was removed after weeks. a gastrointestinal ct scan with oral contrast showed a complete resolution of leakage. after months the patient was in a good condition with bmi , kg/m . the stent was endoscopically removed after weeks. a gastrointestinal ct scan with oral contrast showed a complete resolution of the leakage. after months the patient was in a good condition with bmi , kg/m . conclusions: this new technique is feasible and effective, as shown in this video; however the nagr can lead to complications, so a strict follow up is needed and if any complication appears, should be considered to remove laparoscopically the ring. introduction: in this case, we will discuss the case of a year old male patient who underwent a laparoscopic cruraplasty and gastric plication resulting in a weight loss of kg. other medical history reported insulin-dependent diabetes, reflux esophagitis and sleeping apnea with cpap. two years after gastric plication the patient presented with passage problems, gastro-esophageal reflux and epigastric pain. to this end a swallow test was performed revealing a large fundus with a restricted passage of contrast. due to the persistent complaints and the abnormal findings on barium swallow a surgical re-intervention was needed. objectives: despite the current bmi of and the age of the patient, conversion from a gastric plication to a roux-en-y gastric bypass was performed. several other surgical options were considered, including an undo of the gastric plication or a dilatation with a resizing of the fundus. methods: in the video we describe the laparoscopic approach for a conversion of a gastric plication to a roux-en-y gastric bypass. results: at months follow-up the patient showed a weight loss of kg and the resolution of his earlier symptoms. the patient had a normal oral intake without any gastro-esophageal reflux or epigastric pain. conclusion: after a gastric plication, partial loosening of the sutures and stenosis are both wellknown complications. as presented in the video, it is apparent that a laparoscopic undoing of gastric plication is not as straightforward as it seems. firm adhesions between folds can compromise the procedure and inhibit a complete separation of the tissues. we believe that in these cases the best surgical approach is to convert to a roux-en-y gastric bypass. laparoscopic sleeve gastrectomy (lsg) is a relatively new surgical approach in the weight loss surgeon's armamentarium. in literature there is a consensus about the importance of mobilizing completely the gastric fundus before transection. the resg (revised sleeve gastrectomyresleeve) may be a valid option for failure of primary lsg. we focused the attention on the consequences that can have an incomplete resection of gastric fundus during an operation of sleeve gastrectomy and how they can be solved by the repetition of this procedure. a sleeve gastrectomy was performed in an obese -year-old woman (bmi = ). three days after the operation, an upper gi x-ray with gastrografin did not show any abnormalities. three months after the surgical procedure, the woman referred frequent episodes of vomiting and a significant weight loss ( kilos). an upper gi x-ray with gastrografin demonstrated the presence of multiple communicating cavities of the gastric fundus. the esophagogastroduodenoscopy (egd) showed that the gastric tube close to the esophagogastric junction was separated from a recess ( - cm in diameter) by an incomplete septum. a severe hypokalemia and consequent ecg abnormalities were treated with intravenous infusion of potassium. then, we performed a laparoscopic operation. the gastric tube was completely released along the suture line of the previous operation and, especially, the posterior surface of the upper part until the left crus of diaphragm became evident. under the guide of the bougie, the recess was removed. results: the clinical course was regular, and the patient was discharged on third post-operative day after an upper gi x-ray with gastrografin which demonstrated the absence of leakage and a normal gastric tube. after year, the patient was very satisfied with the operation. conclusions: the complete mobilization of the gastric fundus allows to see clearly which part should be resected to obtain an adequate gastric tube and facilitate a correct placement of the stapler. in our experience, in patients with a residual fundus, an upper gi x-ray with gastrografin and an egd are needed to exclude the presence of stenosis. then, a resleeve gastrectomy is an efficient and safe procedure to treat this post-lsg complication. weight regain is one of the main problems in bariatric surgery. we have many surgical option but when we evaluate patients with long follow up and bmi of superobese patient before the first surgery, the weight recidivism can arrive up to - % at years.in most cases the first surgery is a restrictive procedure, and in many cases sleeve gastrectomy.here we present a case of weight regain after laparotomic super-magenstrasse (that we consider like a sleeve gastrectomy except for remnant removal) with a big incisional hernia. after a complete multidisciplinary re-evaluation we decided to perform an oagb (one anastomosis gastric bypass) but in this case we decided to create a functional exclusion to the duodenal transit by positioning a minimizer ring. this solution is effective in food diversion and guarantee gastric and duodenal endoscopic exploration in case of need. we think that this technique can represent an option to take in account for selected cases. at the end of bariatric procedure we perform a laparoscopic repair of incisional hernia with mesh in the hope to avoid future surgery and post operative small intestine herniation. patient rejected additional bariatric procedures and in fact she has gained kg two years later (bmi . ). conclusions: lagb gastric erosion is uncommon ( . - %) . intraoperative (such as perigastric approach) and patient related factors (smoking, alcohol…) have been described as risk factors. the most frequent clinical presentation is weight loss failure; band and port issues (such as infection) are also frequent. erosion is infrequent to present as an acute event (\ %: peritonitis, abscess…) or asymptomatically (\ %). diagnosis is mostly performed under upper endoscopy. the most common therapeutic technique is removal of the band (by endoscopy or surgery), repair of the stomach, if needed, and band replacement (at least three months later). some authors have performed immediate replacement but the incidence of recurrent erosion seems to be higher. other options are lagb removal alone or conversion to different bariatric procedure. for endoscopic removal, it has been advised to wait until the band buckle is in the stomach and is sometimes very difficult. replacement of the band is not associated with weight regain. she reports years of evolution presenting moderate intensity heartburn that was exacerbated during the night as well as submit occasional rejurgutation. the intensity of the symptoms is attenuated by maintaining a diet without irritants and improving feeding times. denies hematochezia, unintentional reduction of weight, dysphagia or early satiety. the patient has suffered from obesity since childhood, after pregnancy she had progressive weight gain and difficulty in controlling blood sugar, so she is scheduled a gastric bypass roux-en-y . preoperative endoscopy was performed, evidencing submucosal tumor in the gastroesophageal junction at of the dentary arch, approximately cm in diameter. an endoscopic ultrasound was performed, demonstrating subepithelial lesion of the gastroesophageal junction, hypoechoic, with well-defined borders, pseudobilobulated, . cm x . cm, and dependent on the external muscular layer. a fine needle aspiration is performed in which spindle cells are identified, leiomyoma is likely diagnosed. it is programmed for laparoscopic resection of submucosal gastric tumor, gastric bypass and laparoscopic cholecystectomy. a tumor at the level of the gastro esophageal junction of approximately . cm is identified in the surgery, which can be resected by laparoscopy without complications. the patient is discharged after days of postoperative stay. the final histopathological result: leiomyoma of . cm with free edges. cd (-) gog (-) caldesmon (?)s (?). background: fifty percent of patients who have undergone gastric bypass, posterior reversal and sleeve gastrectomy and finally complete hiatoplasty presents symptomatic gastroesophageal reflux disease. surgical reinforcement of the lower esophageal sphincter is necessary to prevent acid reflux. here, we describe ligamentum teres cardiopexy, a surgical technique that reinforces the lower esophageal sphincter and restores its competence with a new valve, in patients with previous conversion of sleeve gastrectomy to gastric bypass and hiatal hernia repair. methods: we present the surgical techhnique performed to a patient with initial gastric bypass who underwent sleeve gasterctomy for hipoglycemias and hiatoplastia for severe gerd. persistent gerd requested to undergo ligamentum teres cardiopexy. in this procedure, the ligamentum teres is released from its umbilical connection and the hernia reduced by manual traction, freeing the last - cm of esophagus in the abdomen. the distal ligamentum teres is fixed with one stitch to the apex of the angle of his, one at the gastroesophageal junction, and one joining the gastric fundus to the esophagus. the remainder of the ligamentum teres is fixed over itself with four to six stitches, forming a necktie cardiopexy. the procedure concludes with diaphragmatic crus closure. results: after months, the patient achieved successful results, defined as resolution of gerd, no protonpump inhibitor (ppi) use, and manometry measurement over mmhg after surgery. conclusions: ligamentum teres cardiopexy combined with closure of the gastric crus is a late alternative treatment for gastroesophageal reflux disease in patients with previous sleeve gastrectomy and hiatal hernia. general surgery, ponderas academic hospital, bucharest, romania introduction: as metabolic surgery techniques evolve during the years, we have to face more and more patients with complications ands uboptimal results after the older/initial procedures. vertical banded gastroplasty(vbg) is one of those procedures that gain momentum during the initial experience in bariatric surgery, but has proven to have dissapointing results and a lot of complications, nowadays surgeons having to deal with difficult revisional operations. aim in this video: we want to present from our experience the difficulties encountered during the revisional surgery, rouxen y gastric bypass (rygbp)aftervbg, and the tips and tricks that will make this a safer and easier procedure. objective: after thorough preoperative assessment and a review of the literature multiple treatment options were considered. the procedure of choice ended up being a laparoscopic adjustable gastric banding, with the objective to achieve optimal weight loss with the lowest risk for complications. methods: in this video we present the placement of an adjustable gastric banding in a patient with a cirrhotic liver and portal hypertension and the possible pitfalls. results: postoperatively there were no complications and patient had a satisfying weight loss both months and year postoperatively. in a short review of the literature we've found that bariatric surgery is feasible in patients with portal hypertension as long as the patient is not decompensated or has bleeding varices. conclusion: cirrhosis and portal hypertension are no absolute contraindication for banding, sleeve or rny gastric bypass as long as the patient is not decompensated or has bleeding varices. the type of surgery is dependent on patient and surgeon-related factors. the aim should be to achieve optimal weight loss with the lowest possible surgical risk in this type of patients. surg endosc ( ) :s -s introduction: in this case, we will discuss on a year old female patient who had undergone a laparoscopic nissen fundoplication years ago due to gerd grade b. because of morbid obesity a n-sleeve gastrectomy was performed year ago resulting in a weight loss of kg. at presentation she had regained all the lost weight, resulting in a bmi of , . the patient history also reported insulin-dependent diabetes and obstructive sleep apnea with cpap. gastroscopy was performed showing a large residual fundus but no esophagitis. on the subsequent upper gi series a relatively wide sleeve with an intact nissen-collar was detected. objectives: a laparoscopic conversion to a roux-en-y gastric bypass was performed. other potential surgical treatment options are a sadi procedure or a sleeve gastrectomy with transit bipartition (santoro procedure). methods: in the video we describe the laparoscopic approach for a conversion of a n-sleeve to a roux-en-y gastric bypass. results: at month follow-up the patient presented with a weight loss of kg. the patient had good restriction on oral intake and did not have any reflux-related symptoms or complaints. conclusion: conversion from a n-sleeve to a roux-en-y gastric bypass is a challenging procedure. the largest pitfall during the creation of the gastric pouch is to staple a double fold of the nissen fundoplication. we believe that in these rare cases of weight regain after n-sleeve, the best surgical approach is to convert to a roux-en-y gastric bypass. four years later, in , a laparoscopic conversion to roux-en-y gastric bypass was performed because of weight regain. she now presents with satisfactory and stable weight loss over the last few years. she was recently diagnosed with a brca- mutation for which she underwent a bilateral ovarectomy and mastectomy. the patient's brother was also diagnosed with this mutation and died of pancreatic cancer at the age of . genetic counseling advised a twoyearly follow-up because of an increased risk up to % of developing pancreatic cancer. control gastroscopy showed a normal esophagus and gastric pouch. control ct scan revealed hypertrophic stomach creases in the excluded stomach. these results prompted a laparoscopy-assisted gastroscopy of the excluded stomach which uncovered hypertrophic stomach glands and intestinal metaplasia on biopsy. methods: in this video we demonstrate the laparoscopic approach for complex revisional bariatric surgery. conversion from rny gastric bypass to a sleeve gastrectomy in a patient who already underwent a vbg. the focus of the video is on a manual gastro-gastrostomy with partial gastrectomy of the fundus and part of the stomach where the old vbg-band was placed. results: after , months follow-up the patient had no complaints and a stable weight. upper gi series shows a normal passage of contrast through the sleeve gastrectomy. conclusion: endoscopic surveillance of the remnant stomach and echo-endoscopy of the pancreas is no longer possible after rny gastric bypass. in cases where the need for such a surveillance arises after a rny bypass a patient-tailored approach is necessary. in our patient a laparoscopic conversion from a rny gastric bypass to a sleeve gastrectomy was performed. this approach keeps the patient's wish for weight loss intact while enabling further surveillance through natural-orifice endoscopy. a -year-old morbidly obese japanese woman with a body mass index of kg/m suddenly complained of swallowing difficulty months after laparoscopic roux en y gastric bypass surgery with retro-colic roux limb route. an internal hernia of the defect of the transverse mesocolon was suspected by computed tomography, and emergency intervention was performed. the surgery revealed no internal hernia. however, strong inflammation and adhesion were observed between the transverse mesocolon and the retrocolicroux limb. in addition, the roux limb on the oral side of the adhesion site was dilated and bent.the adhesion between the transverse mesocolon and the flexed roux limb was dissected, linearized and re-fixedby suturing to the transverse mesocolon. however, since the difficulty of oral intake persisted re-do surgery was performed again. after resecting the roux limb involved in the severe inflammation, a 'new' roux limb was lifted to the cephalad via the ante-colic route. finally, the gastric pouch and roux limb were re-anastomosed with - absorbable sutures in an interrupted full thickness single layer manner. in the present case, we experienced difficulty with both adhesiolysis and determining the accurate target line to resect at the 'old' gastrojejunostomy. however, blocking the blood flow of the 'old' roux limb facilitated the accurate recognition of the target line. esofagogástrica, cirugía general y ap digestivo, hospital regional universitario de málaga, malaga, spain; hepatobiliopancreática, hospital regional universitario de málaga, malaga, spain introduction: marginal ulcer is one a serious complications after a bariatric gastric bypass. tobacco, non-steroidal anti-inflammatory drugs (nsaids) and helicobacter pylori (hp) infection are known risk factors. methods: we present a -year-old women operated years before of bariatric surgery with a gastrojejunal (gy) bypass technique due to intraoperative dehiscence of the staple line after attempting a vertical gastrectomy (sleeve). she has persistent vomiting and epigastralgia from months after the intervention, affecting his quality of life. upper gastrointestinal endoscopy (uge) was performed, describing an ulcer in the gy anastomosis. she started hp eradication treatment, treatment with proton pump inhibitors (ppis), tobacco and nsaids were discontinued, but she had slight improvement. after months the uge was made again, which show peptic esophagitis and marginal ulcers. the plasma gastrin level was normal. due to the persistence of symptoms despite conservative treatment, we decided reoperation by laparoscopy. we found herniated bowel in petersen space, which were reduced and the space was closed. we proceeded to truncal vagotomy. the gy anastomosis was resected ( fig. ) and performed again. finally, we perform antrectomy. the pathological anatomy showed ulceration. she was diacharged home on the th postoperative day without any complications. results: a marginal ulcer after bariatric surgery appears in the jejunal mucosa of the g-y anastomosis. the symptoms are epigastric pain, nausea and vomiting. acid, tobacco, nsaids and hp infection has an important role in their development \ sup [ . \/sup [ the first treatment is medical, discarding out the risk factors, but if it is not effective, it will be surgical, resecting the previous anastomosis. the usefulness of vagotomy is debatable, but the percentage of success increases. in our case, we perform antrectomy to avoid retained antrum syndrome. the hernia through petersen space is a cause of intestinal obstruction and abdominal pain as the case presents. although we believe that the symptoms were mainly caused by the marginal ulcer, the internal hernia was probably a symptomatic cause. conclusion: the treatment of a marginal ulcer is medical, eliminating the risk factors, but if it is not effective, the surgery is indicated. results: bowel's measurements and confection of the gastric pouch are identical in both cases. in the first case, intestinal anastomosis is performed in the inframesocolic compartment once small bowel has been divided. in the second case, such union is made next to the gastrojejunal anastomosis with the bowel uncut, making the section once no leakage has been found conclusions: laparoscopic roux-en-y gastric bypass is currently considered one of the technique of choice in the surgical treatment of morbid obesity. there are variations and alternatives for its realization. to know them can allow to individualize the technique to each type of patient. we present a clinical case of a year old female. she had a vertical banded gastroplasty procedure (in another clinic) years ago with an initial weight loss of kg in a period of months. she was seen at our clinic because she was suffering from dysphagia to solids and general diffuse abdominal pain for the last month. at physical exam we found a bmi of and nothing else called our attention. we did an upper gi endoscopy and egd transit; we concluded that a gastric bypass would offer her the best results. therefore, we converted her vertical banded gastroplasty into a gastric bypass laparoscopically. she had an uneventful postoperative period and was discharged home without complications. aims: sadis emerged as a modification of biliopancreatic diversion with duodeno-ileal switch (bpdds) in which after sleeve gastrectomy (sg), the duodenum is anastomosed to an ileal loop in a billroth-ii fashion. sadis has promising outcomes for weight loss and comorbidity resolution in morbidly obese patients avoiding the high morbidity of biliopancreatic diversion with duodenal switch. clinical case: -year-old patient, subjected to bariatric surgery two years ago, including a sleeve gastrectomy (sg). despite this operation and dietary and hygienic modifications, the patient gained weight in recent months, reaching a bmi of kg/m and an overweight of kg. an endoscopy was carried out on her, which provided evidence of a gastric remnant of moderate size with flexible tissue, normal peristalsis, and fast disposal speed. the case was discussed in a joint session, leading to the decision to apply revision surgery. the decision was taken to apply sadis, a novel technique that had never been used before in andalucia. the rate of weight re-gain after the use of classical techniques such as sleeve gastrectomy (sg) or the roux-en-y gastric bypass (rybg) is considerable high. revision surgery due to weight re-gain is necessary in many of these cases. sadis emerged as a simplified alternative to the use of bpdds as revision surgery following a gv due to weight re-gain with good short-term results, in terms of both weight control and comorbidity control. since only one anastomosis needs to be applied, chirurgical time diminishes, as well as the rate of surgery-related complications. moreover, it could be used, through laparoscopy, for patients who have undergone previous, complex abdominal surgery. conclusion: sadis showed a promising short-term weight loss outcome and comorbidity resolution rate but long-term data are missing and there is currently a high level of technical variability. on the other hand, further studies are required to measure its cost-effectiveness compared to the currently popular bariatric procedures, sg and rygb. aims: the lps sleeve gastrectomy is the most common bariatric surgery technique because it has a low surgical complexity and acceptable weight loss results. however, - % of patients present with an insufficient weight loss, weight regnances, reflux or dysphagia. in these cases, it is recommended to perform a second bariatric surgery to combine a component of malabsorption such as gastric bypass or duodenal switch. the video describes the technique of a laparoscopic biliopancreatic diversion with duodenal switch with a previous laparoscopic sleeve. the objective is to describe the safety of the technique and the subsequent success of it. methods: a -year-old female patient presented morbid obesity with a bmi of after performing a laparoscopic sleeve gastrectomy in . initially, she presented a percentage of excess weight loss of %, reaching a bmi of after two years of follow-up. after this, she suffered a reganancia of all the weight lost despite diet and exercise, presenting a bmi . a study was made with tegd where no complications of the previous surgery or symptoms of gastroesophagical reflux or dysphagia were observed. the lps duodenal switch is proposed in the obesity unit committee in , without immediate postsurgical complications. the patient presented a favorable postoperative period and was discharged three days postoperatively. results: at the present time, the patient has achieved a % excess weight loss and has a bmi of . . presents good oral tolerance with stools a day without urgency. it doesn't present protein deficioncies. vitamin deficiencies are orally supplemented. the lps duodenal switch is a technique that can be performed after a sleeve gastrectomy safely in cases of insufficient weight loss or weight reganancia. the patients presented a greater weight loss after the duodenal switch than after the gastric bypass, observing a lost of excess weight of % compared to %. the differences being statistically significant. weight regain after gastric bypass is a challenging problem. a number of revisional surgical options have been reported. this is a case of a year-old woman years after lrygb. her initial bmi was , lowest after surgery- , at presentation- . the video shows a robotassisted laparoscopic conversion of rygb to loop duodenal switch. the roux limb is transected and dissected to the gastrojejunostomy. the gastrojejunostomy is resected and the gastric pouch is recreated over a bougie. the gastric blood suply is confirmed with icg. a gastro-gastrostomy is created to restore gastric continuity and a sleeve gastrectomy is performed. the duodenum is devided and a duodeno-ileostomy is created cm from the ileocecal valve. the remaining roux limb is resected. the patient recovered uneventfully. conversion of rygb to loop duodenal switch requires creation of as little as two anastomoses, in comparison to standard ds, which requires four. it is a safe option for patients with weight regain after lrygb. methods: irb approval and informed consent have been obtained. a dissection is conducted to separate the descending mesocolon of the gerota's plan from the medial aspect to the peritoneal lining to the left parietal gutter. the peritoneal layer is incised parallel to the vessel and close to the colonic wall. the dissection is continued anteriorly up to reach the resected parietal gutter. a passage into the mesentery of the upper rectum is created for the allocation of the stapler and the dissection of the rectum. these maneuvers permit to straighten the mesentery simplifying the identification and cutting of the sigmoid arteries. a caudal-to-cranial dissection of the mesentery is performed from the sectioned rectum to the proximal descending colon by a sealed envelope device. it can be very useful to mobilize the colon in any direction: laterally, medially, or upward. the dissection is performed along the course of the vessel up to the proximal colon, with progressive sectioning of the sigmoid arterial branches. the specimen is extracted by a pfannenstiel incision. the anastomosis is performed transanally with a circular stapler according to knight-griffin technique. results: we performed a laparoscopic segmental colectomy using this approach for patients with benign sigmoid lesions: diverticulitis, flat polypoid lesions (no lift-up sign), and bowel endometriosis. the mean operative time and blood loss were . ± . min and ± ml, respectively. there were not a single conversion to open surgery and no any leakage or stricture. only cases of intraluminal bleeding and case of wound infection (treated conservatively) were observed. conclusion: we consider this approach to be safe and useful for segmental colectomy to be performed sectioning the sigmoid artery close to the colonic wall. aims: to show a clinical case with a video of a patient was operated for colon cancer in hepatic angle by a single suprapubic incision (ssilrh). methods: a -year-old male assessed for abdominal pain and weight loss. on physical examination: a painful mass was detected in the upper right quadrant. the colonoscopy revealed an ulcerated lesion in the hepatic angle and the biopsy revealed a moderately differentiated adenocarcinoma. in the abdominal ct a mass of x cm was observed (figure). the patient was operated with ssilrh technique, as shown in the attached video. results: the patient was placed in the supine position and with the legs separated. the surgeon is placed between the patient's legs. a transverse incision of the skin was made in the middle line of . cm to cm above the pubis. the underlying fascia was divided transversely, the rectus abdominal muscle was exposed, a purse-string suture placed in the fascia. an mm reusable trocar was inserted for the chamber, a mm reusable flexible trocar was placed at the o'clock position and another trocar was placed at the o'clock position. the ileocecal valve was released from the peritoneal parietal foil, as well as the mesocolon right by a lateral to medial approach to the second portion of the duodenum. the hepatic angle was also dissected from lateral to medial. for the anastomosis, the mm trocar was replaced with a mm trocar and a stapler was placed. a mm °chamber was inserted through the mm flexible trocar. the small intestine was divided as well as the proximal transverse colon with endogia. an intracorporeal ileocolic anastomosis was performed. the piece was removed through the suprapubic incision. he was discharged after days without complications. the histological studies confirmed a differentiated adenocarcinoma of x x cm. the surgical margins were free, without infiltrated lymph nodes ( / ) with stage pt n . the ssilrh technique allows a complete resection of the mesocolon and complies with the oncological principles. they can present with abdominal pain, nausea, acute abdomen, symptoms of intestinal obstruction or asymptomatic with incidental diagnosis. their diagnosis can be difficult. the objective is to demonstrate the safety and efficacy of the laparoscopic approach in this infrequent pathology. material and methods: we present a video of the surgical intervention of a -year-old patient, with functional dyspepsia, with a casual diagnosis of a pseudocystic mass of the right colon after performing a ct scan: giant diverticulum of the hepatic colon angle with fecaloid content inside it under tension the patient goes to the emergency room for acute abdominal pain, pending colonoscopy, antibiotic treatment is established, and a laparoscopic approach is decided upon after the patient's evolution. results: intervention: complete laparoscopic approach, trocars. large size tumor in the right colon, diverticular in appearance, with stony content inside, with locoregional adenopathies, oncological radical right hemicolectomy, manual intracorporeal anastomosis, correct postoperative, hospital discharge. on the th day. definitive pathological anatomy: giant diverticula on areas of intense mucosal ulceration, free edges. conclusion: the laparoscopic approach of the symptomatic diverticula of the right colon is safe and effective. introduction: minimally invasive transanal surgery (tamis) is a surgical technique whose established indications are the complete exeresis of rectal polyps that are not resectable endoscopically or early rectal neoplasms with good prognosis criteria. transanal devices with gel platform facilitate dissection in this field. however, one of the drawbacks of this approach is the oscillation of the right nerve, which hinders dissection and prolongs the surgical time. material and methods: we present the case of a patient with a central depression neoformation, located cm from the anal margin in the posterior aspect of the rectum in a male patient. the lesion occupies % of the circumference and was considered unresectable endoscopically. the endoscopic biopsies showed a tubulovillous adenoma with moderate dysplasia. results: an exeresis of full thickness of the rectal wall is performed, with subsequent suture of the defect. we show in the video the use of a glove interposed in the pneumoperitoneum gum to maintain the stability of the neumorectum and the technique of dissection and suture, as well as the stability of the neumorectum with this technique throughout the procedure. the use of a glove as a reservoir to stabilize the nemorectum is an economical and easy-to-use method that can safely replace extra devices. aims: endometriosis is a gynecologic disorder defined by the presence of endometrial glands and stroma outside the uterine cavity. deep infiltrating endometriosis (die) invades mm to the retroperitoneum of the pelvic sidewalls, the rectovaginal septum, or the muscularis of the bowel, bladder or ureters. the rectum is being the most common bowel site of involvement. for symptomatic die, medical therapy should always be the first-line treatment. therefore, a minimally invasive approach using laparoscopy is considered the gold standard option and challenging aiming at complete disease excision. also, there are several advantages of natural orifice specimen extraction when compared with abdominal incision that may directly impact the postoperative results of these young patients. methods: we report a case of a -year-old female with a -month history of chronic pelvic pain, dyschezia and rectal bleeding. these symptoms were refractory to hormonal, antispasmodic and opioid therapy. magnetic resonance imaging reported a nodule x cm invading the rectal wall cm to the dentate lane. we performed a laparoscopy and we found the nodule at the uterine posterior wall invading the rectal anterior wall. the nodule was invading into the rectum in a large area so we proceeded with segmental resection and added hysterectomy and salpinguectomy because it was the preference of the patient. the anastomosis was created intracorporeally and the specimen was removed through the vagina performing in this way a totally laparoscopic procedure with natural orifice specimen extraction. results: the total operative time was h, the postoperative stay was uneventful and the patient was discharged on day four. the pathological report showed an endometrioma cm length predominantly involving colonic muscularis propria. conclusion: laparoscopic surgery is a safe and feasible approach for the surgical management of deep infiltrating endometriosis of the rectum and the gold standard for female young patients that often need multiple surgeries. in addition natural orifice specimen extraction avoids potential complications of abdominal incisions. week-day surgery, university, sapienza, ospedale sant'andrea, rome, italy; urology, clinica mater dei, rome, italy aims: we describe a case of a patient affected by a mass in the left kidney and a diverticular stenosis of the sigma. methods: a years old woman complained abdominal pain in the left flank of the abdomen and in the left iliac fossa radiated to the hypogastrium, with fever and no passing flatus. contrast enhanced computer tomography scan (ct-scan) showed a cm mass of the superior pole in the left kidney and a colonic diverticulitis with thickness of the wall and a microperforation of the sigma. she underwent to medical therapy with resolution of the diverticulitis. after weeks a laparoscopic nefrectomy and sigmoidectomy was planned. patient was positioned on the right flank. this position was kept for both the procedures. we performed four trocar accesses along the left subcostal region and a periombelical incision for the specimen extraction. results: post-operative course was uneventful. patient was discharged in post-operative day. istopathological exam showed a renal cell carcinoma confined to kidney with no positive lymph nodes and a diverticular stenosis of the sigma. laparoscopy allowed to perform two fine procedures in a critical situation using few trocar incisions and obtaining good results. background: hartmann procedure consists in a sigmoidectomy followed by a terminal colostomy. stoma is associated with complications and suboptimal quality of life, so the restoration of colonic continuity should be at least considered in any case. open restoration has been associated with significant morbidity and mortality. many authors have described the advantages of laparoscopic hartmann reversal. we want to go a step further showing our experience using a combined laparoscopic and transanal approach in an attempt to improve the surgical technique in a patient with previous abdominal surgeries and a rectovaginal fistulae. methods: the transanal and laparoscopic team work simultaneously. by the abdominal approach a pericolostomic incision is made, the distal affected colon is resected and a purse string suture is performed around the anvil of the eea mm single-use stapler with . mm staples (autosuture, covidien). a mm umbilical trocar is located for a °camera and a gelport laparoscopic system (applied medical) with two mm trocars is introduced through the colostomy wound. hard pelvic adhesiolysis was performed and splenic flexure was also mobilized.the gelpoint path transanal access platform (applied medical) is introduced through the anal canal with three trocars in a triangle position. the proximal rectum and mesorectum are dissected until the peritoneal reflexion. the previous stapler line with the resected tissue is then exteriorized throught the anus. the distal rectum is prepared with a circumferential purse string suture. the vaginal defect was sutured transanally. the proximal colon and the anvil are extracted through the rectal stump and connected to the circular stapler, performing an end-to-end anastomosis. results: the total operative time was h. the postoperative stay was uneventful and the patient was discharged on day . conclusions: as in patients with rectal cancer, dissection of the stump in hartmann reversal procedure may be better and associated with shorter operative time. as with any new surgical procedure, it is probably too early to draw conclusions but nowadays transanal combined with laparoscopic approach seems to be a safe and feasible technique to perform a hartmann reversal, especially in challenging cases. intravenous and endoluminal contrast enhanced ct revealed the presence of a large retroperitoneal fluid and gas collection, due to diverticular perforation, extended from pelvis to iliac bifurcation, involving the left urether. no hydrosoluble contrast media leakage or massive pnuemoperitoneum were present. after an initial conservative treatment without significant improvement an emergency laparoscopic left colectomy with primary anastomosis and laparoscopic retroperitoneal collection drainage was performed. the laparoscopic approach was very challenging due to the obesity of the patient and the presence of the abscess. the patient was discharged on pod after requiring re-intervention for dehiscence of the left iliac mini-laparotomy on pod . conclusion: diverticular perforation in obese patients adds a further challenge to its laparoscopic treatment and deserves an aggressive surgical approach since its outbreak. although intracorporeal anastomosis has been demonstrated to be safe and effective after right colectomy, limited data are available about its efficacy after left colectomy for colon cancer located in splenic flexure. there are few studies comparing patients who underwent laparoscopic left colectomy with intracorporeal anastomosis or with extracorporeal anastomosis. anyway literature shows that there is no significant difference between intracorporeal anastomosis and extracorporeal anastomosis about oncological result. as for right hemicolectomy, intracorporeal anastomosis seems to show a trend towards a faster recovery after surgery due to the shorter time to flatus and lower post-operative pain expressed in the mean vas scale. laparoscopic left colectomy with intracorporeal anastomosis is associated with a lower rate of post-operative complications as for right colectomy. literature results could suggest that a complete laparoscopic approach could be considered a safe method to perform laparoscopic left colectomy with the advantage of a guaranteed faster recovery after surgery. as usual further randomized clinical trials are needed to obtain a more definitive conclusion. we show a video of a years old patient with a pure splenic flexure colon cancer who underwent to a laparoscopic left hemicolectomy with intracorporeal anastomosis. case presentation: here we describe a case of a year old asthmatic and hypertensive lady with an asa score of iii who presented to emergency after a right knee replacement with a four day history of lower abdominal pain. she was septic upon arrival to the resuscitation roomimmediately prompting the hospital's local septic management protocol. a ct scan of her abdomen showed a rectosigmoid perforation with free intra-abdominal air and fluid. the patient underwent laparoscopic hartmann's procedure within h of admission. after an uneventful postoperative recovery the patient was discharged home after a total of days of hospitalisation. she was followed up at surgical outpatients with no adverse events over the course of the subsequent months. conclusion: this case exhibits the feasibility of laparoscopic hartmann's procedure as a surgical modality for hinchey stage iv diverticulitis. the positive outcome supports the claim that for experienced surgeons laparoscopic hartmann's procedure remains a safe and viable option for elderly comorbid patients in the emergency setting. introduction: mesenteric cysts are a very infrequent pathology, they usually present an anodyne clinic, and their diagnosis is reached casually. objectives: to demonstrate the safety and efficacy of the laparoscopic approach, in cases with intra-abdominal cysts of benign etiology, using material with mini-instruments, reducing surgical aggression, maintaining its safety and efficacy.material and method: clinical case: a -year-old man with no personal history of interest. in the last two months he presented episodes of pain in the right hypochondrium, exploration without findings, us-ct scan: a cystic tumor of cm. in hepatic colon angle compatible with uncomplicated benign mesenteric cyst, tumor markers and normal colonoscopy. evidence of interest is exposed. given the evolution it is decided tto. elective surgical. result: intervention: laparoscopic approach, trocars, two of . mm, optics of mm °, benign cystic tumor, with colloid content of more than cm. of diameter in antimesenteric border of colon, which is not possible to separate, mobilization and resection is carried out by endo-gia, including a portion of the colonic wall, appendectomy, extraction in a pocket. good postoperative course, alt to nd day. definitive ap: mesenteric cyst, absence of malignancy. the laparoscopic approach is a valid and effective alternative in cases of benign intra-abdominal cystic pathology, the use of mini instruments reduces surgical aggression, favoring the recovery of the patient. male, yr, wuth doblue post-operative coloanal stenosi and women, with ultralow rectal neoplatis stenosis ( cm from anla verge). both patients were discharge ater days from prosthesis positionins without pain and complications. the first patient, with protection ileostomy, showed fecal incontinence before the operation and was performed prosthesis positioning because rectal losses of infected material and fever. fecal incontinence was showed also after procedure but he had not fever. second patient, yr, with ultralow rectal tumor, after prosthesis positioning was submitted to radiotherapy and she decided for not to be operated and she survives after months in ful well-being. conclusion: endoscopic prosthesis positioning is a consolidated procedure for treatment of bowel obstruction. this study demonstrated that this procedure is safe and this kind of prosthesis is suitable for correct positioning. results: we present a case of a years old man with faecal occult blood test positivity that was diagnosed by colonoscopy of a villous lesion at cm of anal verge. biopsies were taken showing a tubulovillous adenoma with high grade dysplasia. a rectal mri was done showing the lesion fixed to the postero-lateral left side of the lumen at cm of anal verge. no pathological lymph nodes were reported. extension study was negative. the case was presented in multidisciplinary committee agreeing in local excision. in october the procedure was done without incidents. the patient was placed in lithotomic position finding a lesion occupying of the lumen. resection was done without incidents and posterior suture with continuous barbed sutures. he presented an uneventful recovery being the patient discharged in rd postoperative day. definitive pathological findings showed a ptis with negative margins. after three months of followup the patient remains with good functional results and waiting for the first endoscopic revision. conclusions: tamis is a safe and feasible technique with low morbidity that gives us an alternative for early rectal cancer or big rectal lesions much less invasive than techniques used until now. complete mesocolon excision and d lymphadenectomy are two fundamental points in the oncological surgery of right colon cancer. most of the adenopathic recurrences of colon neoplasia in tumors located in the hepatic angle and the ascending colon are located near the head of the pancreas and the vascular axis of the superior mesenteric vein due to an alleged incomplete dissection. we present a case of right colon neoplasia where we performed a laparoscopic right hemicolectomy associated with a d lymphadenectomy. we use medial to lateral dissection of the mesocolon focused on the dissection of the superior mesenteric vein with the identification of ileocolic vascularization, right colic vessels and henle's trunk. this approach is safe and facilitates a correct resection of the mesocolon, which is approached following the embryological plans and a vascular ligature near the bifurcation. the performance of an extended lymphadenectomy allows a wider resection of the mesocolon and the excision of a greater number of lymph nodes, all of which can contribute to a greater survival. the efficacy of pc treatment is related with a properly preoperative imaging diagnosis of the disease, but the poor sensitivity for identifying small peritoneal metastasis are the major obstacle to achieve a complete resection and that leads to peritoneal recurrence. imageguided surgery using icg, could represent an advance in the detection of small peritoneal nodules. there are only a few clinical studies that have analyzed the role of icg for the staging of pc, specially from ccr, and nearly in all of them the selected approach were exploratory laparotomy. this study presents a laparoscopy case, as a non-invasive way of cs in selected patients with limited pc. a new category, tis, was created for low-grade appendiceal mucinous neoplasms (lamns) that invade or push into the muscularis propia by ajcc cancer staging th ed. management of these tumors depends on stage and histology. traditionally, laparotomy was the most recommended approach, however, if laparoscopy is safe, it could be used. the laparoscopic appendectomy should be done with 'not touch' technique and a radical approach has been recently proposed for its treatment. the laparoscopic radical appendectomy should start by exploring complete abdominal cavity. grasping of appendix should not be done. complete resection of mesoappendix is obligated. cequectomy with stapled endogia is necessary. the specimen must be extracted in an endobag. methods: we report a case of a year-old female patient with a personal history of three caesarean sections. this patient was studied due to chronic abdominal pain. a computerized axial tomography was performed, showing an appendix increased in size and a thick wall. the colonoscopy evidence a lesion that protrudes from appendiceal base which is biopsied. results: a laparoscopic way was used and large and width appendiceal was viewed ( x cm). furthermore, a rounded right anexial tumor was also found. a radical not touch laparoscopic appendectomy with stapled cequectomy was done. the intraoperative study was mucinous appendiceal tumor without serose affection. the final result was ptisnx (lamn) without resection margins affected. after h of admission, the patient is discharged without incidents. conclusion(s): minimally invasive surgery in lamns is possible if it is performed with enough experience, following specific rules and tips to manage this tumors. a correct follow-up should be carried out using tumor markers and computer tomography (ct). introduction: resection of both benign and malignant colovesical fistulae can be particularly challenging and carry with it specific surgical considerations. often there is a large inflammatory mass sat within a narrow pelvis, limiting specimen mobility and consequently access to dissection plains. additionally, with the underlying inflammatory process, the ureters may be displaced anatomically and be at risk of injury. aim: to demonstrate a streamlined and reproducible approach to the laparoscopic management of both benign and malignant colovesical fistula, with specific emphasis on the different modalities for bladder repair. method: the following method portrays an overall technique which is adapted dependant on the clinical scenario and specific intra-operative findings: approach to abdominal cavity in standard fashion.identification of right ureter.poster-medial mobilisation of the mass to facilitate delivery out of the pelvis followed by visualisation of the left ureter on the medial and lateral sides before division of the fistula.division of the fistula in benign disease or resection of the bladder dome in malignant disease.transverse laparoscopically sympathetic suprapubic skin incision.vertical incision through linea alba to deliver bulky specimen.intra/extracorporeal repair of bladder dome. results: all of the considered cases were successfully completed with a laparoscopic approach, irrespective of the malignant status of the disease in question. conclusion: both benign and malignant colovesical fistula disease can make the laparoscopic approach to resection challenging, especially when encountering a bulky mass in a narrow male pelvis. the stepwise and streamlined approach considered here can help facilitate successful and safe laparoscopic completion without the necessity to convert to open. background: primary neoplasms of the retrorectal space are very rare. they are located in anatomically difficult area to be addressed, hence a complete evaluation of the lesion is required to determine the extent of resection and the appropriate surgical approach, which include posterior, abdominal and combined abdominoperineal, depending on the characteristics of the lesion. objective: to show a combined laparoscopic abdominoperineal approach of retrorectal tumor. method: we present a video of a combined laparoscopic abdominoperineal resection of a lowlying retrorectal tumor in a -year-old female without prior abdominal surgery. conclusion: retrorectal tumors are infrequent. their anatomical location can make difficult the surgical approach. preoperative imaging can provide useful information for surgical planning. in the recent years, minimally invasive surgical approach has been proposed. laparoscopic approach is feasible and safe, but it is important to select adequately the patients. background: adult intussusception is a rare clinical event representing only - % of all bowel obstruction cases and % of all intussusceptions and the occurrence of adult intussusception due to colonic cancer is even more rare. aim: we present this case of malignant colo-colic intussusception and literature review to increase the awareness of the incidence of colocolic intussusception due to colonic cancer. case report and literature review: our patient is a years old female was admitted to our hospital due to central abdominal pain, cea level of , she was further investigated with ct scan of the abdomen and pelvis which raised the suspicion of mid transverse colon intussusception due to large polypoid lesion. she was further assessed with urgent colonoscopy which confirmed mid transverse colon tumour with biopsies confirmed adenocarcinoma. laparoscopic extended right hemicolectomy with lymph node dissection was performed. upon laparoscopic exploration it was found that the colocolic intussusception was evident as described on the ct scan and as clearly shown on the video. histologically, the transverse colon carcinoma was a moderately differentiated adenocarcinoma, with no lymph node involvement ' out lymph nodes', tnm staging of pt pn pm and r resection. intussusceptions of the colon in adult are frequently found in the ileocecal portion or sigmoidal colon but rarely in the transverse colon. only two cases of adult intussusception of the transverse colon caused by colonic cancer have been reported. overall cases on literature review reported showing colo-colic intussusception due to colonic malignancy. conclusion: colo-colic intussusception due to colorectal cancer is a rare clinical event, however it should be included in the differential diagnosis of colonic obstruction. laparoscopic surgery is safe in malignant colocolic intussusception. aims: single-incision laparoscopic colectomy (silc) aims to achieve better cosmetic outcomes, less pain, and faster recovery compared to multi-port laparoscopic colectomy, but it also has several limitations, especially the technical difficulties. we report our experience with singleincision robotic right hemicolectomy via video presentation. methods: we arranged robotic-assisted single-incision right hemicolectomy for a -year-old female patient with ascending colon tumor. the operation was performed with gloveport singleport device and a three-arm da vinci robotic surgical system through a small midline umbilical incision. colectomy was proceeded by a medial-to-lateral approach along with one or two accessory instruments for maintaining sufficient bowel traction or surgical field exposure. after vessel ligation, complete colon mobilization and right side omentum division, the robotic arms were undocked to perform anastomosis extracorporeally. results: the operation was performed successfully without drainage tube placement. the total operative time was min. the bowel movement returned on post-operative day ,and the patient tolerated normal soft diet on post-operative day . she was hospitalized for days after operation. the pathology report revealed colon adenocarcinoma (t n m , tumor size . cm), and lymph nodes were harvested. conclusions: single-incision robotic colectomy (sirc) approach seems feasible and safe in treatment of ascending colon cancer. this surgical option provides less pain and wound scar for the patient. moreover, it also achieves further benefits for the surgical procedures compared to silc. reasons being, first, it has better instruments flexibility and precision with endo-wrist, as well as less instruments clashing. second, the improved camera stability achieved through the use of the robotic arm is unattainable through manual hand-controlled methods. third, roboticassisted approach gives us an ergonomic environment, which enables the operator to control the arms while sitting by the console, and also to reassign them whenever they cross each other or block the surgical view. in spite of the advantages above, we still need to sincerely consider each patient's situation for proper management. recently, indocyanine green (icg) fluorescence has been introduced in laparoscopic colorectal surgery to provide detailed anatomical information.the aim of our study is the application of icg imaging during laparoscopic colorectal resections: to identify sentinel lymph node, for studying its prognostic value on nodal status, to facilitate vascular dissection when vascular anatomy of the tumor site is unclear and to assess anastomotic perfusion to reduce the risk of anastomotic leak. after tumor identification ml of icg solution ( . mg/kg) is subserosal peritumoral injected. a full hd image s camera, switching to nir mode, in about min displays fluorescence: the sln is identified and the sln biopsy (slnb) is performed.when tumor is in difficult site, as hepatic or splenic flexure, ml of icg solution ( , mg/kg) is intravenous injected. in about - s a real-time angiography of tumor area is obtained; on this guide, vascular dissection and pedicle ligation is performed.after anastomosis, another ml of icg solution is injected to confirm anastomotic perfusion. if there is an ischemic area, a new anastomosis is performed. from november , patients were enrolled: left colectomy, right colectomy, transverse resections, and resections of splenic flexure. in ten cases, intraoperative angiography led to the identification of vascular anatomy. in two cases the anastomotic perfusion wasn't good and the surgical strategy was changed. four postoperative complications occurred, of which one anastomotic leak, due to a mechanical problem. from november , patients were enrolled to perform the slnb: right colectomy, left colectomy, transverse resection and splenic flexure resections. the sln was identified in cases. cases were found to be n to the conventional examination and were subjected to ultrastaging. icg-enhanced fluorescence imaging is a safe, cheap and effective tool to increase visualization during surgery. it's recommended to reduce the incidence of anastomotic leak, to facilitate the assessment of vascularization in order to perform oncological resections, and to perform the slnb to study its clinical role on nodal status and for the sln ultrastaging in order to identify the micrometastases. background: surgical emptying of lateral pelvic lymph nodes (llnd) is a strategy used differently when compared the approaches to rectal cancer in the west and eastern countries. there is evidence that = mm lymph nodes in lateral compartment should be removed, even in the setting of neoadjuvant chemoradiation. minimally invasive surgery with nerve-sparing technique and sharp dissection with minimal bleeding may help overcome the significant complexity of the procedure that may have been a technical obstacle to implementation in the past. the standardization of the technique may help implementation with shorter learning curves and excellent surgical outcomes. methods: a -year-old male with distal rectal cancer underwent neoadjuvant crt for a mrt cn m mremvi ? mrcrm ? disease. there was one left obturator node of mm prior to crt. following weeks of crt completion, the patient underwent tatme for the primary disease followed by left lateral node dissection by laparoscopy. results: the present video illustrates the most relevant surgical steps to perform lateral node dissection. the procedure has been didactically divided into steps. the left ureter is identified and retracted using a vessel loop (step ). identification of the common iliac vein and dissection with subsequent identification of psoas and internal obturator muscles (step ). identification and dissection of accessory vessels. ( step ) identification of obturator nerve and obturator vessels (step ). blunt dissection of obturator nerve (step ). identification and ligation of obturatory vessels. (step ) umbilical artery is skeletonized to allow identification and clearance of fatty tissue along superior vesical arteries, internal iiliac artery/vein, inferior vesical artery and internal pudendal artery (step ). postoperative course was uneventful. conclusion: standardization of lateral-node dissection for rectal cancer has paramount importance. laparoscopic lateral-node dissection for rectal cancer provides optimal anatomical view and allows safe dissection of the nodes of interest. aims: the aim of this video is to describe our technique using fluorescence to assess the lymph flow to ensure a complete mesocolic excision and central vascular ligation in order to provide expertise to contribute to the standardization of this new tool. methods: laparoscopic right colectomy with total excision of the mesocolon was proposed in all cases. for the detection of lymph flow, we injected indocyanine green dye ( milliliter of milligrams dye dilution in milliliter of distilled water) into the subserosal to submucosal layer around the tumor at point with a -gauge injection laparoscopically after trocar insertion, and observed the lymph flow using a near-infrared system (visera elite ii, olympus) after injection. we also performed a total mesocolic excision with central vascular ligation in the region where the lymph flow was fluorescently observed. results: ( %) patients were included. no intraoperative or postoperative complications presented. no adverse effects were reported due to the infusion of indocyanine green. the lymph flow was visualized intraoperatively in a satisfactory way helping the surgeon in decision making to determine an appropriate separation line of the mesentery. the section line of the mesocolon was modified in ( %) case based on the findings obtained by fluorescence. the mean operative time was ( ) min. the morphometric laboratory data of the specimens to audit the correct complete mesocolic excision were satisfactory according to the oncological standards. conclusion: fluorescence lymphography during colorectal surgery was feasible and reproducible with a minimum of added complexity. fluorescence-guided surgery may be a helpful technique for determining an appropriate total mesocolic excision in colon neoplasms. aims: this video shows our technique for complete mesocolic excision (cme) during right colectomy for cancer. methods: in this video, a years old patient underwent a laparoscopic right colectomy with cme for a cancer of the ascending colon diagnosed with a colonoscopy performed after positivity to fecal occult blood test (fobt). after ct scan staging we obtained d printed models to clarify patient's vascular anatomy. patient was placed in supine position, trocars were inserted in left quadrants as for standard right colectomy. cme is performed by sharp dissection between the visceral fascia that covers the posterior lay of the mesocolon and the parietal fascia that covers the retroperitoneum (toldt's fascia). the ileo-colic vessels are used as landmark to identify the right anterior surface of the superior mesenteric vessels. with a caudo-cranial approach, the mesocolon is sharply dissected and the root of tributaries venous is ligated, up to the inferior margin of the pancreas. the gastro-colic trunk is dissected out with ligation of the right colic vein, while the gastroepiploic vein is preserved (harvesting the sixth group lymph node). the pancreas-duodenum fascial plane is entered and all the lymphoid tissue around the vessel surface is harvested. procedure is completed with ileo-transverse intracorporeal stapled anastomosis. results: in our experience, between april and december , laparoscopic right hemicolectomies with cme were performed. we had no major intraoperative vascular lesions. no patients needed intraoperative blood transfusion. compared to our series of standard right colectomies we did not notice any significant difference in post-operative complications. the follow-up is too short to demonstrate if the cme approach has a better oncological outcome compared to standard right colectomy. conclusions: laparoscopic cme is feasible, although it requires a higher expertise level of surgical know-how. the quality of evidence is limited and does not consistently support the superiority of cme as compared to standard right colectomy. better data are needed before cme can be recommended as the standard of care for colon cancer resections. h. bando gastroenterological surgery, ishikawa prefectural central hospital, kanazawa, japan aim: in case of right-sided transverse colon cancers, it is necessary to dissect the lymph nodes around the root o f the middle colic vessels. but in this area there are dangerous organs, for example : pancreatic head, duodenum, and gastrocolic trunk. it is the point of our technique that we resect the accessory right colic vein and middle colic vein, and then dissect pancreas head and duodenum at early step of the operation. method: we perform the operation by five trocars. the first step is to transect the great omentum, and confirm the lower edge of pancreas.there are much adhesion between mesocolon of transverse colon and stomach, great omentum. it is very important to dissect the adhesion accurately. secondly, the mesocolon is incised at lower edge of pancreas. it is possible to detect the lower edge of pancreas in obese people. the anterior surface of superior mesenteric vein is exposed. the accessory right colic and middle colic vein are resected. and then front face of surgical trunk, pancreas, and duodenum is dissected caudally as possible. the superior mesentery artery is resected below the mesocolon after flip up of transverse colon. this approach is safe and feasible, because the dangerous organs are handled by direct vision. by that, extraction of intestine is easy from small incision. afer flip up of transverse colon, the mesenteric of ileum is incised. the root of ileocecal vessels is exposed and these are resected. the peritoneum of the front of superior mesenteric artery is incised, and the lymph nodes around the surgical trunk are dissected. this dissected area is easily connected with the one done beforehand. uniquely we resect the mesocolon and major omentum from the root of dissected vessels to resected side of transverse colon. and then right-side colon is dissected medial approach. conclusion: we dissect the dangerous organs in advance. that prevent major injury of them. background: good visualisation of the operative field is a fundamental requirement for safe laparoscopic colorectal surgery. over the past years of the senior author's experience, camera systems have evolved from single to three chip, high definition (hd) and most recently, the k system. in parallel, the rest of the infrastructure such as cables, processors, monitors etc. have also undergone improvements, resulting in improved image quality. aim/methods: we present a video of a case of laparoscopic total mesorectal excision (tme), performed with strict adherence to our previously published 'stepwise approach to laparoscopic colorectal surgery' which places particular emphasis on safety aspects. tme was performed in a year old male patient with history of previous abdominal as well as robotic prostatic surgery. the procedure was filmed with all components including the camera head, cables, processing unit, screens as well as the recording/mixing decks being k. multiple external k cameras were also used. live transmission to a remote audience as part of our masterclass was achieved using appropriate bandwidth and projection on to k screens. results: feedback from the operating team as well as from the live audience was that the image quality was far superior to hd systems. the k system accorded a degree of clarity well beyond usual expectations. the depth of field also appeared to be different initially, but within a few minutes of starting the procedure and acclimatisation, the effects were appreciable. the clarity of the image which showed the fine details of the dissection planes and anatomical landmarks as well as the vibrancy of the vasculature gave a distinct three-dimensional effect to the picture. this excellent visualisation added one more layer of safety and complemented our stepwise approach for a successful procedure. conclusion: the laparoscopic k system, in our practice, proved to bea beneficial visualisation tool to enhance the accuracy of dissection. vital structures appeared to be more vivid and clearer with dissection planes being more easily apparent. in our opinion the laparoscopic k system when combined with a systematic approach enhances safety, especially in complex laparoscopic colorectal surgery. accumulating evidence suggests that laparoscopic surgery for colon cancer has feasibility and efficacy equal to or over conventional laparotomy. for cases with pasthistory of laparotomy, especially history of colon resection, however, there is almost no evidence for laparoscopic recolectomy for metachronous colon cancer. since , we have been used submucosal local injection of indocyanine green (icg) around primary colorectal cancer by using intraoperative endoscopy, and complete mescolic excision (cme) have been convincingly carried out, which was clarified by completely resected icg positive area. although evidence on the oncological efficacy of icg guided surgery has not yet been clarified, since it can be easily judged whether cme is performed clearly, it is considered that icg guided surgery for primary colon cancer is useful for education. recently, we are applying this to ensure convincing cme for patients with colorectal cancer who had a history of colic resection. the representative case is as follows. a -year-old female was diagnosed as advanced sigmoid colon cancer, and laparoscopic sigmoidectomy with high tie of the inferior mesenteric artery was performed years ago. then she was diagnosed as the metachronous descending colon cancer. the feeding artery of the new tumor should be the left colic artery, however, the left colic artery was already resected and genuine feeding artery was not identified by preoperative examination. by injecting icg into submucosa endoscopically during operation, it was clearly observed that the lymphatic flow from the tumor was directed to the inlet portion of the inferior mesenteric vein (imv). re-cme was performed by ligating the inlet of imv. intraoperative icg was also useful for clarifying the borderline for adhesion detachment of pastoperation between the mesentery and retroperitoneum (figure) . interestingly, icg flow in the mesentery direct to of the anus side was disrupted clearly at the past anastomotic site. we believe that laparoscopic surgery under icg guidance is potential useful tool that can confirm evidence to date more intuitively in real time. further studies, ideally randomized controlled trials, are required for define the oncological usefulness of icg guided surgery for re-do colectomy. the operation movie will be presented at the meeting. background: laparoscopic lateral pelvic node dissection (llpnd) is a minimally invasive alternative to open surgical therapy for advanced low rectal cancer patients. in this video, we demonstrate the technique of llpnd for rectal cancer patients with suspicion of lln metastases after neoadjuvant chemo-radiation. methods: the principle of this approach is en bloc resection with bilateral peritoneum. the peritoneum is incised lateral to the ureter following the line between external and internal iliac vessels. in the next step, llpnd dissection of the regional lymph node and high ligation of inferior mesenteric vessels were performed. a contralateral llpnd was performed in the same manner as a mirrored technique. after extracting the specimen, an end-to-end double-stapled circular anastomosis was performed. results: the procedure was done safely without any complications.the surgical duration was mins, and the blood loss was ml. the number of harvested lateral pelvic lymph nodes was . the tnm stage was ypt an m . conclusion: this approach enables extended resection during lymph node dissection, allowing autonomic nerve preservation. it is maybe a helpful approach in the treatment of locally advanced rectal cancer with a lateral lymph node metastasis. aims: the aim is to present an inspection method where the anastomosis vascularity is testing simultaneously using the indocyanine green fluorescent angiography intraluminal and intraperitoneal. methods: sixty-five year old female patient underwent standard laparoscopic-assisted low anterior rectal resection for rectal carcinoma. the proximal end of the bowel and the stump of the distal rectum were checked using near-infrared fluorescence imaging with d-light camera. after making sure of adequate perfusion of the bowel, the end-to-end stapled anastomosis was performed under the laparoscopic visualisation. the d-port proctoscope was inserted into the anus. the second icg injection was administered. the perfusion of the anastomosis in transabdominal way and viability of the mucosa in transanal way was evaluated with two d-light cameras simultaneously. the anastomosis was determined cm from the anal verge. an air-water leak and tension of the bowel tests were performed. after evaluation of anastomosis viability with fluorescence imaging, after negative air-water leak and tensions testing, the decision was made by surgeon not to perform preventive ileostomy. results: the patient had no complains for the first three days postoperatively. nevertheless, crp level was growing and was . mg/l on the second postoperative day, and . mg/l on the th postoperative day. the patient complained of the pain in the right iliac area and below symphysis on the th postoperative day. the abdominal and pelvis computed tomography scan with oral contrast was performed which denied our thoughts about the anastomotic leakage. intravenous cefuroxime and metronidazole antibiotics were prescribed. the crp level was . mg/l on the th postoperative day. the patient was discharged on the th postoperative day without preventive ileostomy. conclusion: using the original, standardized colorectal anastomosis inspection method we can determine which patient doesn't need the preventive ileostomy after low colorectal anastomosis. the important causes of anastomotic leak are local ischemia and staple line defect. the purpose of this study was to investigate the combination of methods aimed to reduce the risk of anastomotic leak after anterior resections for rectal cancer. methods: we retrospectively analyzed perioperative outcomes of the first patients, who underwent modified laparoscopic anterior resection with partial mesorectal excision for rectal cancer without preventive stomy. operative technique was modified and included routine preservation of the left colic artery (fig )(aimed to improve anastomotic blood supply), manual suture invagination of the 'dog ears' (fig ) (aimed to reduce the risk of staple line defects), transperineal pelvic drainage and pelvic peritoneum reconstruction (aimed to reduce the risk of reoperation in case of leakage). anastomotic leak rate, reoperation rate, left colic artery preservation rate, additional operative time (time required for left colic artery preservation, 'dog ears' invagination and pelvic peritoneum reconstruction), blood loss, morbidity and mortality were analyzed. results: ( . %) patient developed an asymptomatic leakage, which was managed conservatively. there was no postoperative mortality and no reoperations. median additional operative time was min for the first procedures and min for the last procedures. left colic artery preservation was successful in ( . %) patients. median blood loss was ml. conclusions: additional techniques used in our modification of laparoscopic anterior resection are safe and may lead to improved perioperative outcomes. however, they are associated with increased operative time, which may be reduced with a better learning curve. introduction: parastomal hernias are a significant cause of post abdominal ostomy morbidity with an overall life-time incidence exceeding %. the complications can range from a bulge resulting in stoma bag leakage, to life threatening bowel obstruction. the prevent-trial sought to determine if prophylactic utilisation of polypropylene mesh would decrease the incidence of parastomal hernias, with initial results demonstrating that it was safe to use in permanent end stomas. aim: to demonstrate a reproducible and streamlined technique for laparoscopic parastomal hernia repair with intraperitoneal funnel mesh, and assess the outcomes with the clavien-dindo (cd) classification tool. method: parastomal hernia repairs ( colostomy, ileostomy) were considered, with the following approach adopted for each: swab sutured in stoma orifice to prevent wound contamination.sharp dissection of the stoma using parachute technique.stoma end refreshed followed by change of gloves and instruments.lateral stay sutures placed to tighten sheath later on.pneumoperitoneum temporarily created to assess/divide adhesions.funnel mesh placed in-situ, orientated in the optimal intraabdominal position, and sutured to the peri-colic fat to prevent slip.medial suture placed to narrow the sheath further.pneumoperitoneum re-created and mesh fixed in place with double crown laparoscopic tacks.redundant portion of end stoma excised and stoma formed. results: at median follow up of months: no recurrence.no reported symptoms of pain or decreased stoma functionality.one superficial wound infection treated with drainage at bedside (cd = grade ) conclusion: laparoscopic parastomal hernia repair with intraperitoneal funnel mesh for permanent end stomas yielded good outcomes in our patient cohort. a streamlined and reproducible approach ensures that the technique can be adopted for both prophylactic, primary and recurrent repair. parastomal hernias are common and can be associated with significant morbidity. when taking this into account, in conjunction with the recommendations of the initial results of the prevent-trial, one may consider prophylactic utilisation of a mesh in patients receiving a permanent end stoma. general surgery, rambam medical center, haifa, israel year old, female patient referred to our institution with common bile duct stricture, caused by iatrogenic injury during laparoscopic cholecystectomy. during last year, patient suffered from recurrent episodes of ascending cholangitis. recently, she underwent ercp and severe stricture of middle cbd was diagnosed. plastic stent was inserted through the cbd. mrcp also showed severe stricture of cbd with dilatation of biliary tree, proximal to the stricture. due to severe and resistant (did not resolved by recurrent dilatation) structure of middle cbd, she was referred to operation. patient underwent da vinci robot-assisted excision of the cbd stricture, hepaticojejunostomy and extracorporeal jejunojejunostomy of roux-an-y limb. total operating time was min. day three after operation patient started regular diet and was discharged home on day four. final pathology has shoved part of cbd with severe inflammation. aims: extrahepatic biliary duct resection for the treatment of bismuth i and ii stage klatskin tumor is the standard surgical technique [ ] . methods: a years old patient present at emergency room (er) with right upper abdominal pain with an elevation of the inflammatory markers at the blood exams and fever. the patient was submitted to a computer tomography (ct) that shows a tumor involving the lower tract of the principal bile duct. an endoscopic retrograde cholangio pancreatography (ercp) with biopsy (intraductal papillary neoplasm of the bile duct,ipnb with high-grade dysplasia) and stent placement was performed. considering the good general conditions of the patient and an absence of vascular and nodal invasion at the preoperative imaging, a minimally invasive surgical resection of the biliary tract with cholecystectomy was performed. results: a four port laparoscopic biliary tract resection with cholecystectomy was performed with lymphadenectomy of the hepatic hilum. no vascular or liver infiltration was found. the hepatic hilum was completely skeletonized. the resection of the biliary duct was performed with adequate free margin. a biliary reconstruction with roux-en-y technique was performed and a fully laparoscopic hepatico-jejunal anastomosis was done. and abdominal retro anastomotic drain was placed. the operative time was min. the postoperative course was complicated by a low rate biliary leakage that was treated conservatively. the patient was discharged at post operative day in good general conditions. the histological examination revealed a moderately differentiated in situ cholangiocarcinoma of the principal bile duct with the involving of the cystic duct with free resection margin (pt bn r ). conclusions: laparoscopic resection of the biliary tract is a challenging procedure that allows, in expert hands, to achieve in selected cases negative pathological margin, complete linfonode retrieval and entero-biliary bypass. injury to the extrahepatic bile duct during bile duct or hepatic surgery can be reduced by better real-time visualization. recently, indocyanine green (icg) fluorescence imaging has been used in laparoscopic hepatobiliary surgery. we applied icg fluorescence imaging in patient with huge hepatic cyst which severely deviated extrahepatic bile duct. the patient had received laparoscopic cholecystectomy and huge hepatic cyst stuck firmly with peri-hepatic structures including bile duct. icg fluorescence imaging correctly identified the common hepatic duct and remnant cystic duct and allowed for more meticulous and easier dissection. therefore, icg fluorescence imaging may guide a safe and accurate dissection and excision in hepatobiliary surgery. results: total patients who underwent ercp were , and . percent ( cases) had a first failed ercp and of then were unsuccesfull in the second intent of ercp. intrahospitalary stay was more than days in the percent, in the . percent was to days, with and average of days. conclusions: before, during or after lcbde, ercp remains the gold standard for manegement of choledocolitiasis confirmed by clinics, laboratory and imagenology. lcbde is a very good option that requires experience and specific skills, and especialized equipment. in years the rate of sucess in our hospital was . % and there were no posoperatory complications such as: biliar peritonitis, pancreatitis or liver abscess. aims: easier intraoperative recognition of the biliary anatomy may be accomplished by using near-infrared (nir) fluorescence imaging after an injection of indocyanine green (icg). neither radiological support nor additional intervention such as opening the cystic or common bile duct is required, making it an easy and real-time technique to use during surgery. the aim of this video is to describe our experience in fluorescence-guided cholangiography in different clinical situations. methods: intravenous injection of icg is used to illuminate extrahepatic biliary anatomy. however, the simultaneous enhacement of liver parenchyma can disturb the visualization of clinical details. the key is in the used dose of icg, the route of administration and the time since its infusion. in the first case, a scheduled cholecystectomy is shown in which a dose ( ml of mg dye dilution in ml of distilled water) administered intravenously h before the intervention was used. the second case shows an urgent cholecystectomy in which the dose ( ml of mg dye dilution in ml of distilled water) was administered intragallbladder during surgery. all patients underwent laparoscopic cholecystectomy with traditional four-port technique. all procedures were performed using a -degree mm laparoscope with nir imaging capability (visera elite ii, olympus). results: there were no intraoperative or postoperative complications. there was no increase in operative time due to the use of icg. in the first case, a clear identification of the cystic duct and the main bile duct was obtained thanks to the biliary excretion of the icg and the intravenous clearance. in the second case, the identification of the cystic duct, the main bile duct and the cystic artery occurred due to the intravesicular absorption of icg. conclusion: fluorescence-guided cholecystectomy clarifies the dissection plane. it can be considered to increase the safety of laparoscopic cholecystectomy. being aware of the doses, times and possible routes of administration is basic to universalize the technique and give it utility in different scenarios. introduction: mirizzi syndrome type is an uncommon cause of obstructive jaundice caused by an inflammatory response to an impacted gallstone in hartmann's pouch or the cystic duct with a resultant cholecystocholedochal fistula. the obstructive biochemical changes can be caused by direct extrinsic compression from the impacted gall stone or from the fibrosis caused by advanced chronic cholecystitis, or for the established fistula. objective: we present a case of a mirizzi type syndrome with choledocholithiasis which was solved by laparoscopy approach. material and methods: a -year-old female patient with no past medical history. the history of present illness begans with the presence of icteric dye since the last days; she received symptomatic treatment with poor improvement. a liver and biliary tract ultrasound was performed with report of a mm coledochus, mm wall gallbladder. then an endoscopic retrograde clolangiopancreatography was performed with successful endoscopic sphincterotomy and removal of gallstones. but the patient jaundice persisted after the procedure. the patient underwent cholecystectomy and laparoscopic common bile duct exploration, where the findings were a mirizzi type according to the csendez classification, chronic cholecistitis and choledocholithiasis. results: in this laparoscopic approach we performed a partial cholecystectomy, bile duct exploration with removal of residual gallstones. the closure of the choledocotomy was performed with simple knots using vycril . . a subhepatic drainage was left. the patient showed adequate clinical evolution. after days the patient was discharged. conclusions: it is important to properly identify the anatomy at the time of surgery to avoid injury of the common bile duct. operative treatment of mirizzi syndrome type includes either laparoscopic or open subtotal cholecystectomy or placement of a t-tube or choledocoplasty. near-infrared fluorescent cholangiography (nirf-c) is an innovative intra-operative imaging technique that allows a real-time enhanced visualization of the extrahepatic biliary tree by fluorescence. thanks to the development of laparoscopes/endoscopes with light sources emitting infrared frequencies, it is possible to visualize anatomical structures (vessels, ureters, bile ducts, etc.) through the luminous intensity of substances (fluorescein, blue of methylene, indocyanine green) which are injected into the patient. this technology may be considered as an important teaching tool for laparoscopic surgery, especially for young surgeons in their surgical learning curve and it could lead to reduce the risk of iatrogenic bile duct injuries during laparoscopic cholecystectomy. the following video is characterized by a series of intra-operative images of biliary anatomy by fluorescence, having an important educational interest, while also detecting anatomical variations of the cystic duct. a. umezawa, minimally invasive surgery center, yotsuya medical cube, tokyo, japan aims: laparoscopic cholecystectomy(lap-c) for cholecystolithiasis has become standard. however, serious bile duct injury has been reported as a complication. repeated colic and chronic inflammation in cholecystolithiasis lead to the so-called difficult gallbladder conditions, such as dense fibrosis and scarring of the tissue. dissection of calot's triangle includes the risk of bile duct injury. critical view of safety (cvs) is the most well-known land mark for safe cholecystectomy. in the revised tokyo guidelines (tg ), important land marks and bailout procedures had been proposed. those are for the difficult gallbladder which are not able to achieve cvs. methods land marks: baseline of segment of the liver and sulcus rouvier should be confirmed. the gallbladder wall itself is also useful landmark. bailout procedure: when the dissection of calot's triangle is considered impossible, bailout procedures should be considered. subtotal cholecystectomy which leave the neck is one of option. the fundus first technique is another approach. however, because fundus first technique has a possibility of leading to serious bile duct injury, it should stop by the neck. in this video, first case shows the importance of landmarks from near miss cases of misidentified injuries. second case shows bailout procedure, subtotal cholecystectomy with fundus first technique. result: in the atrophic gallbladder (case , near miss), it is liable to misidentify the junction of common bile duct as the gallbladder neck. the neck and common hepatic duct were lifted together easily. with confirming the landmark, misidentification was corrected and bile duct injury was avoided.in the case , since the calot's triangle was obscured due to repeated cholecystitis, dissection of gallbladder was performed from the bottom to the neck, and was excised with the cervical portion remained. the remaining neck was reconstituted.in each case, intraoperative cholangiography was performed, and it was confirmed that there was no bile duct injury. without postoperative complications, those patients were discharged pod as usual lap-c. conclusion: during lap-c for difficult gallbladder, the most annoying part is bile duct injury. confirming landmarks and switching bailout procedures can be contributory to avoid bile duct injury and to achieve safe lap-c. aims: choledocholithiasis is an important cause of morbidity and is present in about % of patients submitted a cholecystectomy. his treatment should be done in the same operative time, avoiding the morbidity and hospitalization time and costs of multiple procedures.the transcystic approach is preferable to prevent morbidity associated to choledochotomy.large stones can preclude this procedure. the use of laser lithotripsy to stone fragmentation is an option to provide transcystic extraction. methods: we present a video of laparoscopic transcystic common bile duct (cbd) exploration for choledocholithiasis. results: female patient, years old with a previous hospitalization for acute cholangitis with choledocholitiasis.submitted to laparoscopic cholecystectomy with intraoperative cholangiography that showed the presence of stone in distal cbd with cm size. the use of holmium laser lithotripsy made the stone fragmentation and provided his extraction by transcystic route using a basket.the patient was discharged at th postoperative day, with no complications. conclusion: the use of laser lithotripsy for large cbd stones is safe and effective, making possible the transcystic approach and preventing the choledochotomy morbidity. surg endosc ( ) :s -s gallbladder adenocarcinoma is rare and extremely aggressive. its' incidence is higher in elder females and its progression is rapid and silent with a dismal prognosis if diagnosed at advanced stages. we present the case of a years-old female with dyspeptic complaints. the abdominal ultrasound revealed a cm solid lesion of the gallbladder suspect for malignancy. the ct confirmed the presence of a vegetant mass on the free border of the gallbladder fundus with x mm. we performed a radical cholecystectomy with lymphadenectomy and liver bed excision. the post-operative period was complicated with a urinary tract infection, with full recovery after antimicrobial treatment. the histological sample revealed an adenocarcinoma of the gallbladder (t bn m ) and the patient remains asymptomatic and tumour free months after the surgery. gallbladder cancer treatment depends of the stage and clinical presentation of the disease. complete surgical excision is the only curative treatment and should include a limited hepatectomy and portal pedicle lymphadenectomy. laparoscopic surgery might be an option in early stages, although it is challenging and requires both expertise in hepato-biliary and laparoscopic surgery. seen at the emergency room for a two month history of abdominal pain associated with jaundice. she is evaluated by the surgical team and diagnosed with acute cholecystitis and moderate risk for choledocholithiasis. the initial surgical plan was cholecystectomy with intraoperative cholangiogram. during surgery, firm adhesions are found from the gallbladder to omentum. friable tissue with edema and easy bleeding. difficulty is encountered during the dissection of calots'triangle. an intraoperative cholangiogram is done through hartmans'pouch without identifying correctly the biliary tract. therefore, an endoscopic retrograde cholangiopancreatography (ercp) is done to visualize the correct anatomy. during the ercp, a stenotic common hepatic duct is found and no stones are visualized. a biliary endoprosthesis is placed. she is discharged asymptomatic. a month later, the patient is back in the emergency room with abdominal pain. after an abdominal ct scan, we found that the endoprosthesis had migrated to the th portion of the duodenum. a second ercp is done and this time we found a big stone ( . - cm) aims: when training in the residency you watch your teacher perform laparoscopic cholecystectomy with ease, and even yourself perform several steps. but as a young surgeon, when confronted with a patient with acute cholecystitis, you're filled with emotions, and you do not know where to start the gallbladder dissection. the aim of this presentation is to show to young surgeons that you can, and must achieve, critical view of safety when performing laparoscopic cholecystectomy for acute cholecystitis. methods: we present the case of a years old female patient, bmi of . , who presented with a grade ii (moderate) acute cholecystitis. following tokyo guidelines, we initiated antibiotics and general supportive care, but without clinical improvement. the patient was proposed for laparoscopic cholecystectomy. results: at initial exploration we identified a cm long gallbladder, with a thick wall, difficult to manipulate. we opted for an anterograde cholecystectomy, in our opinion the best option in acute cholecystitis. the dissection was started with hook electrocautery and then continued with a combination of blunt dissection with the aspirator and with the hook. when reaching the pedicle, blunt dissection was used in order to appreciate the anatomy of the cystic duct and cystic artery. after correct identification of these structures they ware clipped and cut. a drainage tub was then placed, and the abdomen deflated. conclusion(s): as a young surgeon, when dealing with acute you must maintain your calm, and try to achieve critical view of safety before transecting the cystic duct and cystic artery. this can be achieved with a combination of blunt and sharp dissection, keeping your camera clean and with a good collaboration with the assisting surgeon. conclusions: here, an easy and reproducible method is described for future macroscopic analysis by the surgeon following a cholecystectomy. in addition, we depict several frequent macroscopic abnormalities in order to provide surgical colleagues with some cases of abnormal macroscopic gallbladders. the left hepatectomy is a demanding and difficult procedure, still limited to reference centers. the caudal approach and exposure of the middle hepatic vein is a reliable way to achieve a safely and reproductible left hepatectomy. with this technique, exposing the middle hepatic vein, we believe that we can perform a safe and feasible laparoscopic left hepatectomy increasing the quality of this hepatectomy. we present a -year-old woman with an intrahepatic and common bile ductlithiasiswhich was previously submitted to an ercp. with an unsolved intrahepatic lithiasis the patient was proposed to alaparoscopic left hepatectomy. the minimally invasive approach for alpps in a patient with a large hepatocellular carcinoma in a liver with severe steatosis is shown. during the first stage a partial alpps is performed. pve is performed in postoperative day one. after days from the first stage both liver volume and function (by hida scan) are re-assessed. right hepatectomy (second stage of alpps) is then conducted by laparoscopic aproach. hepato-bilio-pancreatic, centro hospitalar são joão, porto, portugal a year old woman with a previous history of anxiety and catheter ablation to treat heart arrhythmias, was studied for for multiple pancreatic cysts incidentally discovered on a routine ultrasound. an mri was performed showing multiple cystic tumors throughout the pancreas, the largest of which was mm. this led to a suspicion of multi-focal, side-branch intraductal papillary mucinous neoplasm (ipmn), with minimal dilatation of the main pancreatic duct. an echo endoscopy was subsequently performed indicating probable multifocal ipmn. a fna was carried out during this procedure, with aspiration of cystic content which was sent for cea analysis and cytology. cytology was compatible with mucinous neoplasm with mild atypia and cea u/ml. a splenic preserving total laparoscopic pancreatoduodenectomy was proposed. the procedure was uneventful and the patient was discharged on the th post-operative day. pathology revealeded a mm ipmn, with severe dysplasia and foci of microinvasive ductal adenocarcinoma of mm-pt n r . indocyanine green immunofluorescence guided laparoscopic partial hepatectomy y. tai obtaining negative tumor margin during laparoscopic hepatectomy has always been a very challenging topic for surgeons in that the surgeons are not able to palpate the tumor during laparoscopic surgery. although intraabdominal echo is available, but it demands great experiences and skills. with the guidance of icg immunofluorescence, surgeons can avoid failure of not obtaining enough negative margins nor resect too much healthy liver. icg is often used to estimate the liver function prior to hepatectomy traditionally. it binds to plasma protein and has a peak absorbance at nm and emits fluorescence with a wavelength of approximately nm. icg is preferentially retained in or around biliary malignancies due to impaired biliary excretion of hepatocytes in the affected area. we performed icg immunofluorescence guided laparoscopic partial hepatectomy on a years old male who suffers from hcc located at segment and . icg was injected days prior to the operation day. while evaluation of liver is performed, it also allowed us to use a high-end laparoscopic camera system equipped with integrated filters for detection of near-infrared fluorescence. during the surgery, we were able to clearly locate the borders of malignancies through the use of integrated filters combine with icg injection. the pathology study also confirmed that the adequate tumor free margin ([ . cm) were obtained in both tumors and the patient's condition was stable as well. icg immunofluorescence guidance enables surgeons to obtain optimum result in tumor resection through laparoscopic surgery. it also has the ability to detect bile leakage. with the use of icg immuofluorescence, surgeons will have higher chances to achieve adequate negative margins. background: parenchymal sparing hepatic resection has the advantage of preserving valuable tissue in chemotherapy-treated livers, assuring an adequate future remnant volume without compromising long-term survival. moreover, the laparoscopic approach offers the decreased postoperative morbidity of minimally invasive surgery. whenever technically feasible, this kind of procedure should be considered a suitable alternative to the classic major hepatectomy for the treatment of multiple colorectal liver metastases. methods: -year old male with a previous history of laparoscopic sigmoidectomy in november for a pt n m sigmoid adenocarcinoma. a control scanner three years later showed liver metastases in segments v, viii, ii and caudate lobe. after chemotherapy (xelox), control mri and pet scans showed a good response. he was proposed for a laparoscopic parenchymal-sparing liver resection. results: total operative time was h and min with no intraoperative complications. patient presented a right atelectasis as the only postoperative complication and was resolved with respiratory therapy. he was discharged in days. pathology report showed that lesions on segment v and viii had no viable tumor ( % fibrosis) and lesions on segment ii and caudate lobe had moderately differentiated adenocarcinoma. margins were free in all the lesions. after a month follow up, the patient has no recurrence and normal liver function tests. conclusion: minimally invasive liver resection is possible in patients with multiple bilobar liver metastases and allows to perform parenchymalsparing surgery safely. difficult localization of lesions such as the caudate lobe are not a contraindication for this type of surgery. laparoscopic approach for perihilar cholangiocarcinoma is still poorly reported in the literature due to technical challenges secondary to the combination of major hepatectomy, lymphadenectomy and biliary confluence resection. despite this, in selected cases it can be a good option to provide a short term benefit to patients. the video reports the case of a perihilar cholangiocarcinoma with involvement of left bile duct and therefore requiring left hepatectomy. komagome hospital, bunkyo-ku,tokyo, japan aims: segmentectomy is an anatomic liver resection, in which the tertiary branches of the glissonean pedicles are selectively transected. however, the branching pattern of the tertiary branches varies depending on the case, particularly in segment (s ) and segment (s ). the extrahepatic approach to the glissonean pedicle from the hepatic hilum is very difficult depending on the branching pattern. furthermore, the distance of exposing the secondary branches that are to be preserved becomes longer, and there is an increased risk of biliary leakage and delayed biliary stricture due to excessive traction in laparoscopic surgery. therefore, laparoscopic s and s segmentectomy are considered technically difficult. we standardized the intrahepatic glissonean pedicle approach for laparoscopic s and s segmentectomy. methods: we standardized the intrahepatic glissonean pedicle approach for laparoscopic s and s segmentectomy. we identify the targeted glissonean pedicle intrahepatically after the parenchymal transection along the major hepatic vein or its branch running on the intersegmental plane, referring to the preoperative simulation by d imaging. (a)s segmentectomy; after the mobilization of the right lobe, the glissonean pedicles of s (g ) can be approached from the dorsal side by transecting the parenchyma between the ivc and the right hepatic vein. after the division of the g , the parenchyma is transected along the demarcation line and the rhv from the root side to the peripheral side. (b)s segmentectomy; first, the parenchyma is transected along the middle hepatic vein (mhv) from the root side to the peripheral. g is typically detected on the right dorsal side of the mhv. after the division of the g , the liver parenchyma is transected along the demarcation line and the rhv from the root side to the peripheral side. results: we have experienced cases of laparoscopic s segmentectomy and cases of laparoscopic s segmentectomy. conclusion: our approach to the g and the g is safe and very useful. laparoscopic anatomical segmentectomy of right anterior section is technically demanding because it is difficult to dissect the deep tertiary branches of right anterior portal pedicle (rapp). we present three cases of laparoscopic anatomical segmentectomy using the extrafascial and transfissural approach: ) anatomical resection of segment , ) anatomical resection of the ventral area ) anatomical resection of segment dorsal area. the extrafascial and transfissural approach means that the liver parenchyma along the fissure lines is opened, then the surgeon can confirm the glissonean pedicles and territory directly. the extrafascial and transfissural approach in laparoscopic anatomical segmentectomy of right anterior section is feasible and effective because this technique can easily be approached to the deep tertiary branches of rapp. repeated liver resection has significant role in patients with recurrent hepatocellular carcinoma (hcc) in several situations. laparoscopic redo surgery is becoming safer along with advance in surgical technique. we have performed laparoscopic re-resection for limited intrahepatic hcc recurrence. the aim of the present study was to investigate its significance comparing with first laparoscopic liver resections. subjects: patients with limited intrahepatic hcc recurrence after open hepatectomy underwent laparoscopic liver re-resection (n = ). methods: adhesion between abdominal wall and visceral organs was carefully divided, after the first laparoscopic port was safely inserted. adhesion between diaphragm and liver surface or between previous liver cut surface and colon or duodenum was also minimally dissected. approach to the glisson's pedicles at the hepatic hilum was often difficult due to previous surgical procedure, thus pringle's maneuver was generally applied. dissection of hepatic parenchyma approaching to the target glisson's branch was often preceded under the ultrasound-guidance. liver resection was performed using lcs, biclamp, and cusa using intermittent block of the hepatic inflow. operation time, intraoperative bleeding, morbidity, mortality, and postoperative hospital stay were compared with those in patients who underwent first laparoscopic liver resection during the same period (n = ). results: operation time was significantly longer in the re-resection group, possibly due to the adhesiolysis. meanwhile, no significant difference was detected in intraoperative bleeding, morbidity, mortality and postoperative hospital stay between the first and the redo surgeries. methods: the donor was a -year-old gentleman who decided to donate part of his liver to his wife suffering from viral liver cirrhosis and hepatocellular carcinoma. his bmi was . kg/m and the preoperatively estimated donor's right liver volume was ml, representing . % of his entire liver. with the recipient's weight of kg, the graft to recipient weight ratio (grwr) was . %. the liver had classic hilar anatomy except that the right posterior intrahepatic duct seperately joined to the left main hepatic duct. after isolation and clamping of right hepatic artery and portal vein, indocyanine green of . mg was injected intravenously. results: the total operation time was min and the estimated blood loss was ml without transfusion. indocyanine green fluorescence image clearly demonstrated the anatomical demarcation between the lobes and visualized the running of the biliary tree. his postoperative course was uneventful and discharged postoperative day . conclusion: real-time indocyanine green fluorescence image may be particularly helpful to delineate anatomical surgical plane and to determine the appropriate division point of hepatic duct during laparoscopic living donor hepatectomy. surg endosc ( ) the correct management of intraoperative volemic status is essential in laparoscopic liver resection in order to control bleeding and to perform even complex procedures with a good profile of safety. central venous pressure is not really reliable in laparoscopy, due to presence of the pneumoperitoneum and patient position. monitoring of haemodynamic parameters via vigileo system is a minimally invasive method to control stroke volume variation, cardiac output, cardiac index and oxygen delivery in order to optimize the anaesthesiological management by controlling venous bleeding and avoiding tissutal ischemia. introduction: non-hydatid liver cysts represent a heterogeneous group of disorders that differ in their etiology, prevalence and clinical manifestations.within them, the simple hepatic cyst is the most frequent.the majority of simple cysts are an incidental finding during the performance of an imaging test for another unrelated cause and few of them are symptomatic or are associated with complications, and surgery is not necessary in most of them. described various therapeutic approaches so far there is no consensus about the optimal treatment of simple symptomatic, complicated or growth-showing liver cysts during its follow-up. currently the laparoscopic approach is widely used for the management of cysts hepatic, with results similar to open surgery but with the advantages of laparoscopy. objectives: to demonstrate the safety and efficacy of the laparoscopic approach in the approximation of complicated simple hepatic cysts.material and method: clinical case: a -year-old female patient with a history of: giant hiatus hernia intervention with laparoscopic nissen, fibromyalgia, previous ischemic colitis. hospital admission due to pneumonia and right pleural effusion with us: simple cyst x x mm in segment v hepatic, with dilatation of biliary radicals adjacent to the cyst, distended gallbladder with irregular walls in the hepatic side. ct: cystic lesion in segment iv-v of the liver, which has increased in size, with small microabcesses adjacencies to the lesion, thickening of the gallbladder wall, to assess cholecystitis. antibiotic treatment is established with good evolution, deciding surgery. results: intervention: complete laparoscopic approach, trocars, edematous cholecystitis, large retroyuxta vesicular cyst,with thickened walls with serous content. cholecystectomy maintaining the cyst wall, puncturing and taking samples for cytology and biochemistry of the contents, resection of the cyst wall, partial flare of its internal surface, negative intraoperative biopsy, epipoplasty, with drainage placement.correct postoperative course.pathological anatomy: simple biliary cyst with negative cytology, ck ?, ck -, calretina-. conclusion: the treatment of choice of complicated simple hepatic cysts is laparoscopic.we recommend performing an intraoperative biopsy of all resected liver cysts to confirm its nature,we propose cyst enucleation as the best surgical treatment. objective: the objective of the following case is to present a patient with symptomatic polycystic liver disease, which was solved by laparoscopy approach and the management of its complications. material and methods: the case reported is about a years old female patient with abdominal pain in upper right quadrant associated to asthenia, adynamia and hyporexia. ct scan reported heterogeneous liver with multiple ovoid images with regular edges defined which the biggest one measure x x mm with volume of cc on segment and , which comprises stomach, and the other one in segment with a volume of cc and others small sized located in segment , and b. results: in this laparoscopic approach, we performed a cyst unroofing of the two biggest cysts as well as cholecystectomy because of firm and lax adhesions. the patient evolved with fever in the th day postsurgical day and biliary leaking in a volume of cc in hrs. an ercp (endoscopic retrograde cholangiopancreatography) was asked for that was carried out by finding leak at the intrahepatic biliary duct therefore; esphinterotomy with placement of plastic endoprotesis was performed. the patient evolved without complication and was discharged at the th day. conclusions: only symptomatic polycystic liver disease needs to be treated. the choice of treatment is not yet standardized, for voluminous cysts the unroofing ideally by laparoscopy is the gold standard and the ercp is the elected treatment when the biliary leak appears as a complication. introduction: laparoscopic liver resection (llr) for tumors located in the posterosuperior segments of the liver (segments (s) or ) is a challenging procedure. especially, llr for s is difficult because the access of instruments is limited, bleeding control is not feasible, major llr is sometimes required, and obtaining sufficient resection margin is not easy. to overcome this obstacles, we performed llr in s with a lateral approach using intercostal trocars. to obtain competent resection margin, llr through right hepatic vein (rhv) first approach was performed for . cm mass located near the rhv in a year old female. case: after full mobilization of right liver including all short hepatic veins and caudate lobe, rotate the whole liver completely to the left side to approach to the root of rhv. one intercostal trocar was inserted to access the lesion. parenchymal transection started from the confluence of hepatic vein and then, followed along rhv with ligating several small branches from rhv. resection margin was demarcated after localization using laparoscopic ultrasonography. after completion of parenchymal dissection using cusa and ultrasonic shears, hemostatic agents were applied and drain was inserted. operation time and estimated blood loss were mins and ml. the patient was discharged without any complication on postoperative day . final pathological assessment confirmed clear resection margin (safety margin : . cm). conclusion: laparoscopic s segmentectomy with hepatic vein first approach technique is safe and recommended to obtain better resection margin. aims: simple liver cysts are the most common cystic lesions of the liver. most are diagnosed casually in image tests such as ultrasound or computerized tomography, most of which are asymptomatic and do not require treatment. in symptomatic patients (abdominal distension with palpable mass, abdominal pain, dyspnea, jaundice, etc.) the clinical manifestations are usually due to the growth of the cysts or the compression of neighboring structures. liver function tests are usually not altered. intracystic complications occur in less than % of cases and malignancy is exceptional. in this video, we present the case of a symptomatic patient with polycystic liver disease including a large size hepatic cyst. material and methods: -year-old woman with a personal history of arterial hypertension, saos, partial hysterectomy due to endometrial cancer, who was referred to our department complaining of supraumbilical pain and abdominal distension with palpable mases. abdominal ultrasound showed cholelithiasis and multiple simple hepatic cysts. in ct scan, multiple hepatic cysts were found, the largest one of about cm of larger diameter. echinococcus granulosus serology test was negative. there was also no evidence of cancer disease in pet scan. results: a laparoscopic approach was performed with four trocars, three of mm and a hasson trocar inserted thought a umbilical small incisional hernia. aspiration and wide unroofing of the large size cyst and smaller accessible ones was done. the patient also underwent cholecystectomy with intraoperative cholangiography and umbilical eventroplasty. the patient recovered uneventfully and is asymptomatic one year after surgery. conclusion: simple liver cysts rarely require treatment. in some cases, especially in large, complicated and symptomatic simple liver cysts, surgery is indicated. laparoscopic fenestration treatment is the best choice. aims: liver resection is the preferable initial treatment option for solitary or limited multifocal hepatocellular carcinomas. surgical indications for laparoscopic liver resection (llr) are the most important consideration, like liver function, tumor size (diameter less than cm) and location (easy technical access like in the left lateral section or on the surface of the inferior region). partial liver resection or left lateral sectionectomy are the typical procedures for such tumors and are considered the best way to begin llr. with accumulating experience and technical advancement, llr has been performed for tumors larger than cm and for others locations. some requirements to perform llr are to have experience in liver surgery and laparoscopic also, adequate technology and intraoperative ultrasound. methods: a -year-old male smoker, ex-parenteral drug users with chronic hcv liver disease child-a stage. he is diagnosed with a single lesion of cm in segment iii of the liver, biopsied twice without conclusive diagnosis and with a three-phase ct suggestive of hepatocarcinoma li-rads with data of portal hypertension (pht) and mild ascites. after the study is commented on tumor committee deciding surgical intervention. results: a laparoscopic resection of segment iii was performed with trocars. liver is explored by intraoperative laparoscopic ultrasound. vascular control was performed using the pringle technique. liver transection was done with sonostar until identification of intraparenchymal segment iii vascularization, which is sectioned with endogia ( mm) with seamguard. after the resection, we perform hemostasis control with electrocoagulation and hemostatic material. intraoperative bleeding of ml. favorable postoperative evolution, high on the th postoperative day. ap: cm trabecular hepatocarcinoma moderately differentiated pt b, r resection. conclusions: llr allows major liver resections with low morbidity and mortality and the advantages of laparoscopic surgery. an efficient learning curve can be achieved by a parallel evolution of procedures and indications (according to modified bclc staging system and treatment strategy). studies suggest that llr results in less blood loss, shorter postoperative hospital stays, lower abdominal wall trauma and lower incidences of ascites accumulation and postoperative liver failure. with respect to oncological considerations, tumor margins are adequately maintained during llr. v. drakopoulos, s. voulgaris, i. iliadis, k. botsakis, p. trakosari, v. vougas st department of surgery and transplantation unit, district general hospital of athens « evangelismos » , athens, greece introduction: laparoscopic surgery is gaining acceptance in the treatment of liver metastasis. laparoscopic treatment of liver metastasis often presents technical difficulties and requires an extensive learning curve. material-method: we present the case of a year old woman presented with a liver metastasis in section of the liver. the patient had been submitted to a laparoscopic low posterior resection in february . patient underwent laparoscopic left lateral hepatectomy, with the use of three trocars (umbilical mm, and two in the midclavicular line bilaterally.) left lateral hepatectomy was conducted with the use of a linear stapler. the postoperative period was uncomplicated and the patient remains in good condition three months after surgery. conclusion: laparoscopic approach seems to be safe for treatment of liver metastasis, offering better surgical field view and less postoperative complications. year survival rate after laparoscopic hepatectomy is compared to the open approach. general surgery, chang gung memorial hospital kaohsiung division, kaohsiung, taiwan purpose: laparoscopic hepatectomy is a quickly growing method for liver tumor because of modern technology. but for the ihd thrombosis, it is still technique dependent. the video was tried to share our experience for special case. material and method: one y/o female patient suffered from fever episode and image show s cm hcc with right anterior ihd obstruction r/o tumor thrombosis, hilum ln enlargement, double right portal vein, hilum adhesion with duodenum, no ascites . lab data : no-b, no-c child a, afp , icg clearance rate . %, plt . heart, lung function exam normal. the laparoscopic right total hepatectomy and hilum ln dissection was conducted. results: laparoscopic approached was performed. the hilum ln dissection was done with vessel and bile duct isolation. hilum ln frozen show negative malignancy. hemi-vessel control was done with resecting the vessel. right hepatectomy was done with preserving middle hepatic vein. the right anterior and posterior ihd was opened and tumor thrombosis was removed from right anterior ihd carefully. the stump of ihd was closed by suture separately. the total op time was min with cc blood loss. post op minimsl bile leakage was found in the drain at day . the patient discharged at day with drain. conclusions: laparoscopic hepatectomy may be a feasible method for hcc even with ihd tumor thrombosis. surg endosc ( ) introduction: the progressive laparoscopic learning in gastric surgery and the great development of instruments and laparoscopic material that facilitates the realization of advanced procedures, has led to an increase in the use of laparoscopy in the treatment of gastric cancer. material and methods: we present the case of a -year-old man without amc with a history of ischemic heart disease who enters our surgery department for cholangitis secondary to choledocholithiasis. ercp is requested during his admission that describes a gastric lesion from which a biopsy is taken, making it impossible to access vater papilla to perform sphincterotomy and lithiasis extraction due to the existence of duodenal diverticula. the result of pathological anatomy of the gastric lesion was compatible with adenocarcinoma. negative extension study. the clinical case is presented in a committee of multidisciplinary tumors and it is decided to perform surgical intervention of both pathologies. a subtotal gastrectomy was performed with a roux-en-y reconstruction. surgical time of min. choledochotomy was performed with lithiasis extraction, as well as intraoperative exploration of the bile duct and main conduits by means of a choledochoscope. results: income of days, with a clavien ii. the definitive pathological anatomy was an ai stage with a total of isolated nodes without evidence of neoplasia in any of them, therefore it does not require adjuvant treatment. the patient is asymptomatic, with nutritional supplementation with follow-up in ccee of surgery. conclusions: in our case, there were no serious postoperative complications when performing gastric resection and bile duct exploration with drainage of the same. from the oncological point of view, the number of lymph nodes extracted and the surgical margins are similar to those obtained in patients in whom we perform open surgery; therefore, although it is a single clinical case, laparoscopy in expert surgeons is a safe and effective technique. the puestow procedure was initially proposed to alleviate the pain in patients with chronic pancreatitis and dilated wirsung duct. its objective is to provide an efficient drainage of the pancreatic fluids and, in the meantime, to preserve the pancreatic tissue and minimize the risk of endocrine and exocrine pancreatic insufficiency. aims: to describe the particular technical aspects and the efficacy of totally laparoscopic puestow procedure in patients with cystic duodenal dystrophy. methods: a years old patient presenting diffuse epigastric pain, vomiting and weight loss was diagnosed at endoscopic ultrasound and biopsy with cystic duodenal dystrophy. a conservative treatment was decided with octreotide and opioids. however, due to the persistence of symptoms surgery was performed. results: due to the association of a dilated wirsung duct, the patient was submitted to a puestow procedure. the surgical procedure was completed in a minimally invasive manner; after dissecting the anterior surface of the pancreas an intraoperative ultrasound was performed in order to identify the wirsung duct. therefore, the pancreatic parenchyma was transected along the wirsung duct, a totally laparoscopic pancreato-jejunostomy on roux en y limb being performed. the early postoperative outcome was uneventful, the patient being discharged in the sixth postoperative day. at one month and six months follow up the need for opioid treatment significantly diminished. a kinking of the enteral anastomosis required a laparoscopic intervention one year after with a very good evolution after. conclusions: totally laparoscopic puestow procedure seems to be a safe and efficient method in order to treat symptomatic patients with cystic duodenal dystrophy in whom a dilated wirsung duct is present. aims: the approach to the intraductal papillary mucinous neoplasm (ipmn) is various, from a radiological follow-up with magnetic resonance (rm) to the surgical treatment with a pancreatic resection [ ] . the surgical approach is various and depends on the localization of the lesion and on the surgical skills [ ] . methods: a years old patient was admitted at the chi possy-saint germain-en-laye with an acute pancreatitis. at the ecoendoscopy was found a pancreatic cystic at the junction of the pancreatic body and tail with a wirusng diameter of mm. a second episode of acute pancreatitis occurred a few months later. after that episode the patient was submitted to a computer tomography (ct) that found a cystic lesion of cm with an increasing dilatation of the wirsung duct. the serum ca - was ui/ml. a laparoscopic sils distal pancreatectomy with spleen conservation was performed. results: a trans-umbilical incision was performed with the positioning of the gelpoint sils platform with the placement of trocars. a distal pancreatectomy with a spleen preservation and without a standard linfadenectomy was performed. the pancreatic stump was closed with an endo-gia mm with seamguard device. any drain was placed. the post-operative course was uneventfull. a ct scan was performed in …. post-operative day which didn't show collections. the patient was discharged in -…… post'operative day. the histological examination shows an ipmn with low grade dysplasia. no invasive carcinomatoses cells were found. the distal pancreatic sils resection with spleen conservation is a feasible and safe technique that combine all the advantages of the minimally invasive laparoscopic approach with the esthetic advantages of the sils approach. pancreato-duodenectomy is a complex surgery, requiring several anastomoses to reconstruct the digestive tract. due to its technical complexity, the laparoscopic approach is not yet the goldstandard and there remains some controversy about its oncological safety. worldwide experience is limited, and its safety and effectiveness are yet under evaluation.we present the clinical case of a years-old woman with a prior history of epilepsy. she was studied due to painless obstructive jaundice and a cm pancreatic head tumour was diagnosed on imaging, causing cbd and wirsung channels' dilatation. the tumour was considered locally resectable and she was proposed for a radical pancreato-duodenectomy.we present the main steps of the surgery including the oncological resection with lymphatic basin clearance and totally laparoscopic reconstruction.the post-operative was uneventful, and the histologic sample revealed a ductal adenocarcinoma (t ) with an r resection and / lymph nodes invaded. although technically demanding, laparoscopic pancreato-duodenectomy is safe and effective requiring teams with experience both in pancreato-biliary and laparoscopic surgery. chronic pancreatitis is characterized by a progressive pancreatic fibrosis with loss of endocrine and exocrine function. one of its main symptoms is debilitating pain. surgical drainage of a dilated pancreatic duct is an option to consider in cases of refractory pain. longitudinal pancreato-jejunostomy allows an effective decompression of the pancreatic channel and a significant improvement in the quality of life. we present the clinical case of a years-old lady with a prior history of gallstones. she was treated for an acute pancreatitis in may , followed by recurrent relapses of pain and enzymatic elevation. she required opioid use for partial pain control and a significant kg decrease on body weight due to 'fear of eating'. the endo-ultrasonography and the mri revealed a chronic pancreatitis with an mm wirsung duct with ductal stones and an atrophic body and tail. we proposed a laparoscopic longitudinal pancreato-jejunostomy. the surgery was performed with trocars, with the surgeon on the right side of the patient. we performed a trans-mesocolic cm pancreato-jejunostomy. the post-operative was uneventful, and the patient was discharged on the th post-operative day, asymptomatic. laparoscopic longitudinal pancreato-jejunostomy, although effective is a technically demanding surgery but brings the benefits of a minimally invasive approach. background: preservation of spleen in distal pancreatectomy is also useful from the maintenance of platelets and the prevention of overwhelming post splenectomy infection. we have performed laparoscopic spleen preservation distal pancreatectomy: lspdp to benign and low-grade tumors of the pancreatic body tail. the aim of this study was to report our surgical experience with the method of svp: splenic vessel preservation and wt: warshaw technique of lspdp, describe our techniques with videos. method: there are three points of our surgical technique. , precede pancreatic dissection, improve the mobility of the pancreas. , confirming the courses of splenic artery and classified them into two major types. , preserving the left gastro-epiploic vessels and short gastric vessels.the postoperative cases of lspdp which performed from april to september was retrospectively studied. result: of consecutive patients were performed lspdp at our institute, were svp and were wt. ages, gender and bmi were similar for two groups. there were no significant differences in operative time, blood loss and length of stay after surgery. comparing pathological finings, wt was associated with a slightly large tumor lesion (median mm vs. . , p = . ). among the median observation period of months, splenic infarction was observed in case in svp and cases in wt. however, they were focal splenic infarctions, they did not need surgery or drainage. there were no cases in which late onset of splenic artery occlusion or esophageal / gastric varices. conculusion: after performing lspd, the function of the spleen was good in all cases. both svp and wt were safe and feasible procedures. this is the case of a -years-old lady presenting with recurrent abdominal intractable pain she has been suffering from for the last years. msct revealed pancreatic calcifications from mm to - mm and dilatation of the main pancreatic duct in the body of the pancreas up to mm. the patient underwent laparoscopic local resection of the head of the pancreas combined with longitudinal roux-en-y pancreaticojejunostomy-a technique known as frey's procedure. it is recognized as an effective therapeutic option for the surgical treatment of patients with persistent pain caused by chronic pancreatitis.after performing the posterior wall of the pancreaticojejunal anastomosis we've faced an intraoperative complication such as volvulus of the roux limb causing serious ischemia of the limb. we were forced to remove all previous sutures in order to untwist the roux limb, thereafter the pancreaticojejunostomy was started anew.the purpose of this video is to demonstrate that frey's procedure can be performed in a minimally invasive fashion, which provides all the well-known advantages of this approach. we demonstrate that even such serious intraoperative complication as volvulus of the roux limb can be managed without conversion. our center has an experience of over laparoscopic frey's procedures, however this is the first case where we encountered with such complication and we believe this is an experience worth sharing.yet we would like to underline that this approach should be used by highly skilled minimally invasive surgeons experienced in intracorporeal suturing which is the most challenging stage in frey's procedure. v. tomulescu, i. hutopila, c. copaescu spleen preserving distal pancreatectomy (spdp) is commonly applied in patients with benign or low-grade malignant tumors in the body and tail of the pancreas. two surgical techniques for spdp have been described. the first technique was described by kimura (spleen preserving distal pancreatectomy with splenic vessel preservation-spdp-svp) and preserves the main splenic artery and vein and excises the tail of the pancreas and those small, short vascular connections to the body;the second technique was described by warshaw and involves resection of the splenic vein and artery before distal pancreatectomy, and conservation of theshort spleno-colic and gastric vessels to keep normal blood flow for the spleen (spleen-preserving distal pancreatectomy with splenic vessel resection-spdp-svr). we present the case of a years old female with / mm tumor of the pancreatic tail on ultrasonography. ct scan confirmed the tumor and endoscopic ultrasonography with fna have shown a solid pseudopapillary tumor. due to the low grade malignancy we have decided to perform a laparoscopic spleen preserving distal pancreatectomy with splenic vessels preservation (lspdp-svp). for lspdp-svp the difficulty is related with the splenic vessels dissection and manipulation. primary dissection and control of main trunk of splenic artery and vein will help to quickly control bleeding during vascular rupture in small vessels dissection. optimal stapling of any tissue requires an adequate tissue compression time to allow elongation of the tissue being compressed, smooth firing of the instrument, consistent staple line formation balanced against the risk of increased tissue tearing and excessive tensile strength. this is why, for pancreatic division, we prefer choosing a cartridge loaded with higher staplers. the pancreatic stump transection line is evaluated for bleeding and when it is needed, hemostatic clips are applied. histology report confirmed a solid pseudopapillary tumor t nomxl v r at this moment with month good follow up. in conclusion lspdp-svp is safe, reproductible and demonstrated very good outcomes when certain indications are respected. surg endosc ( ) aim: advances in minimally invasive surgery has permitted to perform complex techniques by this approach, being the laparoscopic duodenopancreatectomy (lpd) one of these. the aim of this communication is to present a surgical technique video for a complete laparoscopic pd, showing the most important steps of the resective and reconstructive phase, with the anastomosis realized completely by laparoscopy. methods: a surgical technique video is presented showing the main steps for the lpd and a complete laparoscopic reconstruction with an hepaticojejunostomy, duct-to-mucosa pancreatic-jejunostomy and a gastrojejunostomy. results: an years old woman with past medial history of arteria hypertension, dyslipidemia, type ii diabetes mellitus and a breast cancer treated in with lumpectomy and axillary lymphadenectomy plus radiotherapy, recently diagnosed of and adenocarcinoma of the head of the pancreas. the ct scan showed a neoplasia localized in the head of the pancreas without extension to other organs. a laparoscopic pd was indicated after a multidisciplinary committee evaluation. a supraumibical hasson trocar was used for the pneumoperitoneum, three mm trocars and two mm trocars were used. lpd was performed. the resective phase was done following the conventional steps of the open whipple procedure and for the reconstructive phase, a child limb was used for a termino-lateral hepatico-jejunostomy with an absorbable / monofilament; a duct-to-mucosa pancreatic-jejunostomy with an absorbable / monofilament and finally a latero-lateral mechanical gastro-jejunostomy was performed. surgical time was min. postoperative course without complications and the patient was discharged on the th postoperative day. definitive anatomopathological exam: intraductal tubulopapilar neoplasia, x x mm, with wide high grade epithelial dysplasia. free margins. ptisn ( / ). conclusion: laparoscopic pd is a feasible procedure with a high technical requirement which should be performed in specialized centres with high experience in hepatobiliary surgery and in advanced laparoscopic procedures, because of its high morbidity and mortality. conclusions: robotic assistance in whipple may overcome limitations of laparoscopy and offer a minimaly invasive approach to this procedure potentially resulting in lower blood loss and less morbidity. we need further prospective randomized trials in order to determine the exact role of robotics in pancreatic surgery. aims: distal pancreatectomy is the standard curative treatment for symptomatic benign, premalignant, and malignant disease of the pancreatic body and tail. the most obvious benefits of a laparoscopic approach to distal pancreatectomy include earlier recovery and shorter hospital stay. spleen-preserving distal pancreatectomy should be attempted in case of benign disease. laparoscopic spleen-preserving distal pancreatectomy (lspdp) is expected to be less invasive than laparoscopic distal pancreatectomy with splenectomy. however, there are few reports regarding the details of the procedure for lspdp, and its safety remains unclear. this study aimed to evaluate the feasibility and safety of lspdp. methods: retrospective analysis of surgery treatment of patients was made. lspdp was conducted in the period from to in the department of laparoscopy surgery of state institution o.shalimov national institute of surgery and transplantology. the average age was : . years, the body mass index (bmi) was . ± . results: laparoscopic distal pancreatectomys was performed in % of cases, were attempted in female and male patients. postoperative pathological examinations revealed cases of serous cystadenoma in the body and tail of the pancreas, case of serous oligocystic adenoma, case of mucinous cystadenoma, case of neuroendocrine tumor (insulinoma), and case of solidpseudopapillary neoplasm. complications related to the surgery were like acute pancreatitis with -fold increase normal plasma amylase confirmed by ct- cases, fluid collection- cases, pancreatic fistula (grade a)- cases. the operation time was . min, (range - min) blood loss of . g (range - g), mean hospital stay was . days (range - days). conversion to laparotomy was in case. mortality was . conclusion: laparoscopic spleen-preserving distal pancreatectomy is minimally invasive, safe, and feasible for the management of benign pancreatic tail tumors, with the advantages of earlier recovery and less morbidity from complications. aims: a pancreatic pseudocyst is an encapsulated, mature fluid collection occurring withing the pancreas that have a well-defined wall minimal or no necrosis secondary to pancreatic injury and mediated by the enzimatic and inflammatory disruption of pancreatic tissue. it is a common complication of acute and chronic pancreatitis. we present the case of a pancreatic pseudocyst located within the body of the pancreas due to recurrent necrotic pancreatitis. the objective of this video is to show the minimally invasive surgical approach of this entity. methods: a -year-old man without medical history was admitted to hospital in the digestive service on times for acute necrotizing pancreatitis. after study in which is evidenced cholelithiasis and pseudocyst in pancreatic body of cm maximum diameter and formation of two peripancreatic collections without signs of superinfection, cholecystectomy is indicated. magnetic control cholangiography was performed after surgery and it showed an increase in the size of the pancreatic pseudocyst, suspecting wirsung's duct disruption. therefore, endoscopic retrograde cholangiopancreatography (ercp) was performed by placing a plastic pancreatic prosthesis and performing a sphincterotomy. after hospital discharge, the patient is re-admitted due to recurrent abdominal pain without analytical alteration. tc abdominal observed an increase in the pseudocyst from to cm. this case was discussed in a multidisciplinary committee and surgical intervention was decided. results: laparoscopic approach is decided and four trocars were placed. initially, a gastrostomy was performed with liquid outlet. an aspiration of the liquid and quistogastrostomy with mm endogia was made. the patient progresses favorably, being high on the tenth postoperative day, without complications. conclusions: almost every pancreatic pseudocyst improves spontaneously and needs no specific treatment. draining is indicated when secondary symptoms to compression, complications or rapidly enlarging are found. depending on the complexity of the pseudocyst, its communication with wirsung's duct and the existence of ductal injury, it may perform a percutaneous, endoscopic or surgical drainage. the goal of pancreatic debridement is to excise all dead and devitalized pancreatic and peripancreatic tissue while preserving viable functioning pancreas, controlling resultant pancreatic fistulas, and limiting extraneous organ damage. only the surgical procedure is definitive. case: a y old male presents with intermittent low retrosternal pain and progressive dyspnea with exercise since a couple of months. cardiac investigation was negative and gastroscopy showed a grade b esophagitis. he was treated medically but with only partial response. on a thoraco-abdominal cat-scan the diagnosis of a left sided bochdaleks' hernia was made. the hernia includes the left kidney (with blood vessels and ureter), transverse colon and small intestine which are positioned in the left lower thoracic cavity with the left lung considerably compressed. method: given the clear correlation between the patients' complaints and these anatomical findings, he was referred to our service of abdominal surgery. we performed a laparoscopy with the patient in lithotomy position and the surgeon between the legs. the patient was tilted to his right side. mobilization of the spleen was necessary to gain maximal access to the hernia. we were able to reduce all the herniated content, freed the margins of the defect, reduced the hernia sac and repositioned the kidney intra-abdominally. the defect was manually closed with non-resolvable stitches and covered with a mesh which was secured with tackers. result: postoperatively the patient recovered well with adequate pain relief and pulmonary support. he could leave the hospital after days. control cat-scan on day postoperatively shows an intact lining of the diaphragm with normal positioning of the intra-abdominal organs. on follow-up weeks after surgery the patient had regained normal activities and was symptom free. conclusion: a symptomatic left sided bochdaleks' hernia in adults with an ectopic intrathoracic kidney is extremely rare. we hereby state that, during a laparoscopic repair, the kidney can also be safely reduced, which has almost never been described in literature yet, enhancing pulmonary recovery, improving access for mesh placement and thus diminishing recurrence rate. aims: large incisional hernias repair involves an actual problem for surgeons to face. anterior component separation has been an important method allowing to close the fascia defects without tension while also having underlay mesh reinforcement.therefore, we present a case of incisional hernia reparation performing endoscopic anterior component separation with advantages compared with open approach. method: we present the case of a -year-old woman, bmi kg/m , with previous laparoscopic gastric sleeve and posterior reintervention using open approach. the patient presented a cm size incisional hernia m w . a ct scan was performed, confirming a midline incisional hernia containing colon, with an herniary defect of cm. full minimal invasive abdominal wall repair was proposed. a cm size incision was made in left iliac region to reach the aponeurosis of external oblique muscle. we placed a balloon trocar and subcutaneous pneumo-dissection with mmhg pressure was performed; then, we placed a mm trocar in left lumbar space. the aponeurosis of external oblique muscle was incised and anterior component separation from inguinal to subcostal area was achieved. an extensive intermuscular dissection was performed to achieve complete midline closure. we performed the same procedure on the right side. then, with laparoscopic approach using v-loc n° suture, we completely closed the midline. eventually, we placed a x cm ptfe-c mesh fixed with a double crown of tackers and fibrin glue. results: postoperatory course was uneventful and the patient was discharged h after surgery without any remarkable event during his postoperative stay. the patient has been followed up for months without any complication or recurrence in ct scan, confirming the correct minimally invasive reconstruction of the abdominal wall. conclusions: trends in abdominal wall reconstruction and complex-hernia repairs have advanced rapidly in recent years. the goal is to perform a complete abdominal wall repair with no tension in midline incisional hernias. endoscopic anterior component separation and laparoscopic eventroplasty with closure of the defect, leads to a complete wall reconstruction without tension and avoids drawbacks due to primary close defect in those patients with herniary defects wider than cm. aims: endoscopic technique is a valid and safe approach for the treatment of abdominal wall defects. to combine the advantages of complete endoscopic extraperitoneal surgery with those of sublay mesh repair we propose totally endoscopic sublay anterior repair (tesar), a safe and feasible approach for the treatment of ventral and incisional midline hernias. methods: from may to september patients were referred to our unit for clinical and radiological diagnosis of midline ventral or incisional hernia and selected for tesar. exclusion criteria were: complicated ventral or incisional hernia (i.e. incarcerated hernia), maximum defect width [ cm, contraindications to general anesthesia. the procedure consisted of suprapubic access with trocars, complete endoscopic pre-aponeurotic dissection, isolation and reduction of the hernial sac, bilateral incision of the medial rims of recti aponeurosis and dissection of retromuscular plane to create the retromuscular space, sublay non-absorbable mesh positioning and anterior aponeurosis reconstruction. one drain was always placed in the retromuscular space and one drain in the subcutaneous space. results: all procedures were completed with endoscopic approach, with no conversion to laparoscopy or open surgery. no intraoperative complications were registered. total mean operative time was ± . min. no post-operative major complications were registered. only one subcutaneous seroma was registered ( . %), and treated conservatively. the mean postoperative stay was . ± . days. at post-discharge clinical checkups drains were checked and removed when indicated. no wound complications nor recurrence were registered to date. cosmetic and functional results were successful in all patients. conclusions: tesar is a safe and feasible technique for the extra-peritoneal sublay repair of ventral hernias with totally endoscopic approach. it provides accurate hernia repair with good outcomes in terms of resolution of symptoms and post-operative complications. r. mizuno, m. kondo backgrounds: abdominal incisional hernia is found in more than % after abdominal surgery, and risk factors such as wound infection, obesity, elderly, high abdominal pressure are pointed out. laparoscopic hernia repair using intraperitoneal onlay mesh (standard ipom) is becoming widespread in japan since the insurance release in , and our hospital is actively working on it. recently, ipom plus procedure which also carries out fascia suture in addition to laparoscopic mesh placement has been introduced. aims: we report the clinical results of laparoscopic abdominal incisional hernia repair in our hospital. methods: we performed hernia repairs using a mesh for cases from january to september . of these, cases were standard ipom and cases were ipom plus. there was no significant difference in the patient background such as gender, age, bmi, etc, and in the intraoperative findings such as hernia orifice diameters and adhesions. surgical time, postoperative hospital stay, and the rate of complications such as seroma, mesh bulging, postoperative pain, hernia recurrence were compared and examined between the two groups. results: as a result, in ipom plus group, the operation time was longer and the incidence rate of postoperative pain was higher, but the incidence of mesh bulging was significantly lower. also, in some cases since , the ' u reverse stitch method ' is used as an ingenuity of fascia suture in ipom plus. conclusions: laparoscopic abdominal incisional hernia repair has the advantage of being able to reliably confirm the hernia orifice from the intraperitoneal side?it is excellent in the identification of the fragile part of the abdominal wall and in the visibility of the restoration range. with regard to the ipom plus procedure which has been introduced in the last few years, although the operation time is extended, it has usefulness such as reduction of mesh bulging. from the viewpoint of cosmetic surgery, usage of ipom plus will increase in the future. introduction: incisional hernia is one of the most common complications after abdominal surgery. several methods have been introduced, and yet, there is no consensus on the best method of repair. we present a novel method for hernia repair which uses the retromuscular sublay mesh repair through a single incision at the pubic area to improve cosmesis. methods: medical records of patients who underwent single-port retrorectal incisional hernia repair from may to december were reviewed. patients were placed in supine position and a cm incision was made in the pubic area below the panty line. a flap is made upwards until the defect is found and bilateral rectus sheathes are dissected. a mesh is then placed between the posterior rectus sheath and the muscle. results: a total of patients with midline incisional hernia underwent single-port retro-rectal incisional hernia repair. mean age was . ± . years with an average bmi of . ± . . all the patients had midline hernia defect with an average of . ± . cm. mean operation time was . ± . min and estimate blood loss was . ± . ml. there was no postoperative complication, and ( %) patients were discharged on the day of surgery. conclusion: the single-port retrorectal incisional hernia repair is safe and effective while providing good cosmesis to selected patients with incisional hernia. aims: closing hernia defect during laparoscopic hernia repair is a vast extended technique nowadays. however, this technique is associated with mesh placemnt intraabdominally in contact by the abdominal content. nowadays there is a trend to recontruct the midline and to avoid a mesh intraabdominally in those cases suitable for it, as a new step forward of minimally invasive abdominal wall reconstruction. laparoscopic sublay approach with retromuscular placement of a mesh without mechanical fixation after reconstruction the linea alba migth be considered an option in primary hernias of the midline. methods: we present a case of a year old male with an umbilcal hernia of centimeter in diameter associated with rectus diastasis. a laparoscopic approach was performed, using one and two millimeter trocars placed on the left flank. the first step was to open the lateral side of the posterior fascia of the left rectus muscles, dissecting the retromuscular plane until we reach the linea alba getting into the preperitoneal space where the sac was diseected preserving the integrity of the peritoneum. the contralateral posterior fascia was also dissected all the way to the semilunaris line. the midline was closed, including th hernia defect, using a running double loop suture (maxon-loopÒ). a self gripping mesh (progripÒ) is placed in the retromuscular space in a sublay position ( cm long, cm wide). last, we close the fascia of the left rectus muscle using a barbed suture (v-locÒ). results: surgical time was min, being discharged of the hospital on postoperative day . pain was controlled with conventional analgesia and no postoperative complications, nor seroma was detected. conclusions: sublay approach for ventral hernia can provide a midline reconstruction, reestablishing abdominal function and avoiding the use of intraabdominal meshes and traumatic fixation, decreasing postoperative complications and pain. aims: lumbar hernia is one of the rare cases that most surgeons are not exposed to. hence the diagnosis can be easily missed. this is often related to previous surgery as lumbotomies or primary in the superior lumbar triangle. this leads to delay in the treatment causing increased morbidity. we report a case of adquired lumbar hernia in a middle-aged woman repaired by laparoscopic approach. methods: a years old woman with surgical history of a myelomeningocele surgery by posterior approach over years ago, a laparoscopic left nephrectomy years ago with a left colostomy due to a left colon injury during this procedure. a hartmann reversal by laparoscopic approach months later. patient showed a large lumbar mass over cms in the left lumbar region and a large scar near to spinal cord. it was soft in consistency, reducible and expansible on coughing and straining with defined borders. computerized tomography showed a large defect in the superior lumbar fascia over cms in the grynfeltt-lesshaft triangle with the left colon inside. results: patient was placed in a full lateral decubitus position. in order to optimize exposure, a lumbar roll was placed under the lumbar region. a capnoperitoneum ( - mmhg) was built up. one mm and two mm trocars were used and positioned in the left mid axillary line. a optic was used. adhesions were removed and toldt fascia was opened in order to expose the hernia defect bounded by quadrates lumborum, erector spinae muscles, rib and serratus. hernia content was carefully extracted from the sac using a ligasure maryland (covidien medtronic-usa). hernia defect was measured and an intraperitoneal mesh (dinamesh-ipom feg textiltechnik mbh, aachen, germany) was positioned and sutured by tackers to the margins included the bone. patient was discharged in h with a low pain rate and without complications. there is not recurrence in months follow-up. conclusion: laparoscopy might be a safe and feasible approach for repairing lumbar hernias, either primary or adquired, with a low rate of pain and complications s surg endosc ( ) after pneumoperitoneum is done, three mm trocars are placed on the left flank. the defect is delimited by drawing it over the skin of the patient with aid of an intramuscular needle and intraabdominal vision. posterior fascia is opened longitudinally at its medial edge and the retromuscular space is dissected. the arcuate line of douglas and the epigastric vessels are identified. from this point, transversus abdominis fascia is sectioned cranially cm medial to the semilunar line, preserving the neuro-vascular pedicles that reach the rectus abdominis laterally. at supraumbilical level, transversus abdominis fibers advance behind rectus abdominis, so they need to be sectioned to access to the space below the ribs. lateral dissection of this space enables a tensionfree closure at midline. once the procedure is repeated on the contralateral side using two mm and one mm trocars on the right flank, a continuous suture of the posterior fascia is performed with a barbed suture. the anterior fascia is closed with a slowly-absorbable monofilament loop-type suture. finally, a double-layer polypropylene mesh is placed at retromuscular level without any suture and fibrin glue is applied. results: the patient was discharged hous after surgery. no recurrence has been presented to the moment. conclusions: the section of the aponeurotic plane from the arcuate line of douglas enables a more accurate dissection of the retrotransversus plane without sectioning its fibers except for its cranial end, preserving the innervation and vascularization of the abdominal wall. this technical modification aims to simplify a complex laparoscopic procedure allowing its estandarization. aims: the authors present a video with their standardized laparoscopic ventral hernia intraperitoneal mesh (ipom) hernioplasty procedure but introducing a novel laparoscopic technique for tension releasing while hernia gap closure and midline anatomical restoration. methods: a years old male patient with a bmi presents a symptomatic ventral hernia recurrence after a sigma colic cancer open surgery. a ct scan study showed a cm transverse diameter midline ventral hernia. a laparoscopic ipom hernia repair procedure is performed using mm instruments and a mm camera. when checking tension while midline restoration suturing, we decide to add a tension-releasing maneuver: a totally laparoscopic transverse abdomini muscle release (taltar). this maneuver allow right rectus posterior sheath to advance some distance to the midline, in order to provide a tension-free midline closure. a double-faced ready-to visceral contact mesh is now placed and fixed. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of h with a rate in a eva acute pain visual scale. in a year follow-up, there has no been an anatomical or clinical recurrence. no chronic pain, anatomical recurrence, lateral asymmetry, umbilical or abdominal wall complications have been reported with this technique. conclusions: depending on the patient characteristics, anatomical hernia factors and surgeon mini invasive experience, a taltar maneuver could be a safe and feasible option for releasing tension when midline anatomical laparoscopic closure. more studies are needed in order to standardized this approach. aims: when primary ventral hernia and simultaneous diastasis recti are diagnosed, there is no consensus among the international surgical community on the surgical treatment regarding indications or surgical technique. however, if diastasis recti is symptomatic of or is associated with midline hernias, the corrective surgery of both pathologies at the same time could be the most recommended option. when we only correct the herniary defect, we risk performing a reparation on an anatomically weak tissue, so the rate of hernia recurrence may increase. we propose a minimally invasive access using totally endoscopic retromuscular hernioplasty. by developing this technique, several advantages are provided, such as no peritoneal opening without intraabdominal access, no mesh fixation needed and simultaneous solving of both pathologies. method: we present the case of a -year-old man, with bmi kg/m and no previous medical history complaining of ventral hernia with associated recti diastasis. a cm size umbilical hernia was diagnosed with a cm size supraumbilical diastasis recti associated. full endoscopy retromuscular hernioplasty was proposed. a cm size incision was made in left hypocondrium, openned the anterior rectus sheath and retracted the rectus muscle. we placed a balloon trocar and open the homolateral retromuscular space after placing two mm trocars in left lumbar space and epigastric position. we crossed-over the linea alba and achieve contralateral retromuscular space. after this step, the hernia sac was reduced and we extended the dissection cm caudal to the hernia ring. both medial posterior rectus sheaths were sutured with running barbed suture n° and a x cm size light-weight, big pore, polipropilene mesh was placed in retromuscular space and unrolled properly with enough overlap. a drain was placed and the anterior rectus sheath incision was closed. results: the patient was discharged h after surgery without remarkable events during his postoperative stay. he has been followed up for months remaining asymptomatic. conclusions: totally endoscopic retromuscular ventral hernia repair in men with umbilical hernia and diastasis recti associated, is feasible and reproducible procedure with several advantages compared to traditional laparoscopic ipom in terms of pain and mesh position. aims: parastomal hernia (ph) is one of the most frequent long-term complications of stoma formation, occurring in %- % of patients. surgical treatment for parastomal hernia is the only cure but a fairly difficult field with a recurrence rate ranging from % to % of cases. due to its advantages, the number of laparoscopic mesh repairs for parastomal hernia has gradually increased over the past decade. according to this common complication, we report a case of laparoscopic reparation of ph using the sugarbaker technique. method: we present the case of a -year-old patient with surgical antecedent of laparoscopic low anterior resection due to rectal cancer, presenting in postoperative period an anastomosis leakage with severe peritonitis was identified and a laparotomy with end colostomy was performed. the postoperative course was uneventful. during the follow-up the patient showed a centimetres size paraestomal hernia, being a m w incisional hernia confirmed with ct scan.the patient underwent full laparoscopic hernia repair, performing a sugarbaker technique, exposing parastomal hernia completely to measure the hernia ring size ( centimetres) and the midline associated defect ( centimetres). a x cm size ptfe-c was selected to allow a -cm overlap over two defects. results: using this approach, the bowel loop was pushed into the abdominal wall and appropriate place between the mesh edge and the abdominal wall is left to allow the bowel loop to pass through. postoperatory course was uneventful and the patient was discharged h after surgery without any remarkable event during his postoperative stay. he has been followed up for months without realizing any clinical signs or alterations in ct scan. compared with traditional open surgical repairs, laparoscopic repair has certain advantages including its safe operation, postoperative rapid recovery, fewer complications, and lower recurrence rate. however, it still faces challenges regarding parastomal hernia treatment, and there is a need to improve existing surgical techniques. aims: nowadays, the principal disadvantages of laparoscopic approach in hernia repair are the use of intraabdominal meshes and traumatic fixation. first, intraabdominal meshes involve the contact of the prosthesis with the intestinal loops with the consequent risk of adhesion and fistula. also, using helicoidal sutures in prosthetic fixation produces adhesions to the tackers and a non-negligible incidence of chronic pain. when it comes to lead to better results, placing the mesh in retromuscular space avoids the drawback of contact with the loops, and using self-fixation meshes may decrease the rate of acute and chronic pain. accordind to this facts, we present a case of laparoscopic ventral hernia repair with transabdominal retromuscular mesh placement without traumatic fixation. methods: we present a -year-old patient with a cm diameter hernia showed in preoperative ct scan, m w , with diastasis recti associated. the patient underwent laparoscopic surgery using transabdominal retromuscular route. one mm and two mm trocar were placed in left flank. the posterior rectus sheath on the left side is opened starting cms far from the left egde of the defect. once the retromuscular space is dissected, the hernia ring is dissected and the hernia sac reduced, we continue with the dissection in retromuscular space on the side. craniocaudal dissection is achieved cm distal to the defect margins. the hernia defect with the anterior rectus sheath and the diastasis recti were closed using v-loc running suture. self-adhesive mesh was subsequently placed. the mesh should be overlap cm from the margins of the defect, covering the defect widely, with grips facing upwards. finally, we closed the posterior rectus sheath with peritoneum on the left side with v-loc running suture. results: the postoperative course was uneventful and the patient was discharged h after the surgery. after months of follow-up no clinical or radiological recurrence was showed. conclusions: the combination of laparoscopic approach, retromuscular mesh placement and the use of self-fixation meshes, seems to be an actual useful solution, combining the advantages of each item and avoiding the use of intraabdominal meshes and helicoidal sutures. aims: laparoscopic ventral hernia repair has clear advantages over open repair, including less post-operative pain and earlier return to normal activity. however, a prolonged surgeon learning curve is necessary to perform this technique effectively. robot assistance may improve outcomes of minimally invasive ventral hernia repair with improved three-dimensional visualization and enhanced dexterity with articulating instrumentation. we report a case of robotic rives-stoppa epigastric hernia repair in order to demonstrate the feasibility of the robotic approach. methods & results: a -year-old man came to our attention for the presence of a palpable mass in the epigastric region. the abdominal ct scan showed the presence of an epigastric hernia with herniation of omental content, and the presence of diastasis recti. the patient was then submitted to a rives-stoppa robotic hernia repair under general anesthesia. the da vinci-si surgical system (intuitive surgical inc., sunnyvale, ca, usa) was brought into position over the head of the patient and docked after placement of the ports. three trocars were placed in the hypogastric region along the transtubercular line. a fourth trocar was placed in the left iliac fossa and used by the assistant. the operation started with an extended adhesiolysis and hernia reduction. then, the retromuscolar dissection began by incising the posterior sheath starting from cm above the pubic symphysis. an extended dissection of the rives space was performed to create a correct housing for the mesh. the hernia defect and the diastasis recti were closed using a - absorbable barbed suture. a phasix st tm mesh (bard inc./davol inc., warwick, ri) was positioned in the retromuscular plane, and was anchored with absorbable sutures and glue. the midline incision was closed using a - absorbable barbed suture. the operative time was minute. the postoperative period was uneventful, and the patient was discharged home on the second post-operative day. conclusions: robotic rives-stoppa ventral hernia repair is feasible, safe, and effective when a standardized approach is performed. whether robotics may improve the outcomes of minimally invasive ventral hernia repairs, including lower recurrence rates, decreased post-operative pain, or shorter surgeons' learning curve, will require careful prospective investigation. aims: the authors present a video with a left chronic bochdaleck hernia classical hernioplasty repair but performing a mini invasive thoracoscopic approach and mm instruments. methods: a years old female patient come to hospital due to chronic left dorsolumbar pain. a ct scan study showed a chronic left diaphragmatic bochdaleck hernia. a lateral right decubitus thoracoscopic repair is performed using mm instruments and a mm camera. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of h with no pain and a clean chest x-ray. in a year time follow-up, not an anatomical or clinical recurrence has been reported. neither chronic pain or respiratory complications happened, with in this period of time. conclusions: depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, left bochdaleck hernia mini invasive thoracoscopic hernioplasty repair using mm instruments could be a safe and feasible option. more studies are needed in order to standardized this approach. surg endosc ( ) abdominal wall surgery has expanded exponentially in the last decade. many techniques have been developed, mainly in minimally invasive surgery. laparoscopic ventral and incisional hernia repair (lvihr) has become a common procedure because of its feasibility and safety but unfortunately, it is not free of complications. chronic postoperative pain and bleeding are frequent complications, prolonging hospital stay and altering quality of life of the patients. absorbable or non-absorbable tacks are the usual method of mesh fixation and sometimes combined with transfascial sutures to secure the mesh. these mechanical fixations pierce the abdominal wall causing nerve or vessel injuries. some studies showed no differences between absorbable tacks, non-absorbable tacks or transfascial sutures concerning postoperative remarkably high pain. some authors consider that a non-penetrating fixation of the mesh getting an effective mesh-abdominal wall interface will reduce significantly the postoperative pain after a laparoscopic ventral hernia repair. tissue glues are used in different medical treatments and also have been used successfully for extra peritoneal mesh fixation in laparoscopic inguinal hernia repair, open ventral hernia repair but not so in laparoscopic ventral hernia repair in spite of good results published in the literature. cyanoacrylate and its derivatives are 'synthetic glues' and classified as medical devices with stronger adherent properties than fibrin glues. experimental studies have reported good results compared with suture fixationand also tissue toxicity doesn't lead to an increased foreign body reaction. some authors have studied the use of cyanoacrylate in laparoscopic inguinal hernia repair but unfortunately, clinical trial reports in ventral and incisional hernia repair were not found in the literature because the lacking of experimental studies that guarantee the safety of intra-abdominal mesh fixation and the interaction of the glue with the intra-abdominal tissue. our group developed an experimental study demonstrating the feasibility, safety and effectiveness of the cyanoacrylate using for intraperitoneal mesh fixation and after this conclusion, started a clinical study. this video shows the methodology for laparoscopic mesh fixation with only glue in our first cases. aims: small epigastric hernias, associated or not with the rectus abdominis diastasis, and small umbilical hernias are common in middle-aged women, particularly with past history of pregnancy. the aim of this video is to illustrate a new extraperitoneal approach to these clinical situations. methods: patients between the ages of and years old, with epigastric hernia orifice up to cm, with or without associated umbilical hernia (up to cm), were chosen for this procedure. the surgery begins with a vertical umbilical incision for the umbilical hernia's correction, and dissection of the pre-aponeurotic plane. two mm trocars (mini-laparoscopy instruments) are introduced at both flanks to enlarge the pre-aponeurotic plane towards the xiphoid appendix. in this way epigastric hernial defects are isolated. the surgery proceeds with defect suturing with braded suture, midline invagination and mesh placement if necessary. results: all patients had an eventful post-operative period and were discharged home at postoperative day . the aesthetic and functional results are optimal conclusion: for selected cases with high aesthetic motivation this technique seems to be feasible and with optimal cosmetic results. this technique allows the mesh placement both in-lay and onlay, protecting it from surgical site infections often present at the classical approac bochdalek hernia is a rare entity in adults. fewer than have been reported in medical literature, the majority of which were incidentally diagnosed. as such, the optimal repair of a symptomatic hernia is unknown. we present a case of adult bochdalek hernia repair. methods: a -year-old obese male patient with a years of chronic dry cough and left lung opacity in chest x-ray. a large posterior and lateral bochdalek hernia with herniation of intestinal loops and fat to the left hemithorax was seen in chest and upper abdominal ct scan. the hernia extended to mid-thorax, caused significant atelectasis of left lung. eighteen months later, due to appearance of chest and abdominal pain following a recent motor vehicle accident, a repeat chest ct was done and a slight enlargement of the hernia was shown. results: the patient was operated laparoscopically, positioned in a semi-right lateral decubitus with double lung intubation. a large left posterior and lateral diaphragmatic hernia which contained transverse and descending colon with omental fat was seen. they were pulled in to the intraperitoneal space carefully. the defect was measured to be * cm. it was reduced to * cm by suturing with a non-absorbable v-loc suture . advancing the camera to the thoracic cavity showed the left lung to be severely atelectatic. after selective recruitment lung was well expanded. a symbotex composite cm mesh was fixed to the defect area by suturs and laparoscopic tacker. the operation and post-operative course were uneventful. chest x-ray demonstrated the bowel below the diaphragm. the patient was discharged on pod . at -month follow-up, chest x-ray was normal. objective: to demonstrate the safety and efficacy of the standardized laparoscopic approach in the treatment of large parastomal hernia. currently, this approach is recognized as the one of choice in parastomal hernia pathology, being controversial which is the best technique of choice: keyhole vs sugarbaker. material and method: clinical case: a -year-old woman with a history of laparoscopic abdominoperineal amputation due to rectal neoplasia (pt n ), a year ago, with symptomatic parastomal hernia with incarceration episodes and inflamation changes in the stomal orifice.tac: large hernia parastomal with intestinal content inside. surgical treatment is decided. result intervention: complete laparoscopic approach, right lateral partial decubitus, trocars, dissection of the hernia defect and reduction of the content, partial mobilization of the pre-stomal colon, with bleeding at the level of the vascular origin, requiring careful hemostasis to avoid ischemia of the colostomy, herniorrhaphy with stitches with extracorporeal knotting, placement of polypropylene/pvdf mesh,fixed with irreabsorbable tackers with administration of biological glue at the edges of the mesh. correct postoperative, discharge at the rd day. asymptomatic and without hernia recurrence at one year of follow-up. conclusions: the technique of sugarbaker using a laparoscopic approach is a safe and effective alternative in the treatment of parstomal hernias. objetives: laparoscopic ventral hernia repair provides advantages in term of low infection rates and postoperatory stay when is compared with open repair. trends in laparoscopic abdominal wall surgery is to complete defect closure without tension in midline. closing the defect in ventral hernias wider than - cms creates high tension in midline and postoperatory pain. it's proposed different techniques to solve this drawback. laparoscopic posterior component separation makes the defects closure easier with no tension and placing the mesh extraperitoneally. methods: years old woman with previous total hysterectomy, a m m w midline incisional hernia was clinically diagnosed and confirmed with ct scan. full laparoscopic abdominal wall repair with defect closure was proposed. trocars in left side were placed and posterior rectus sheath right side in the defect margin is freed. once the lateral edge of the rectus sheath is reached, the posterior rectus sheath is incised, dividing the posterior aponeurotic sheath of the internal oblique muscle. this allows access to the plane between the internal oblique and the transversus abdominis muscles. it's is made the same steps in the left side with trocar on the right flank. the posterior rectus sheath both side is reapproximated in the midline and cms polipropilene mesh is placed and unfolded properly. it's fixed using cyanocrilate glue. one drain is left in retromuscular position and mm trocar wounds are sutured. results: postoperatory course was uneventful. hospital stay h. the drain was removed in day after surgery. after months follow-up no complication or recurrence were identified. methods: this video will show the evidence of gangrenous jejunal segment due to superior mesenteric vein thrombosis in a patient with history of breast ca on hormonal treatment.in this video, the gangrenous segment was resected and primary anastomosis was done using endogia mm. results: a second look after h revealed to be negative for any further ischemic bowel. conclusion: therefore, laparoscopy in acute abdomen is diagnostic and for treatment. introduction: gastric pseudo-volvulation is a rare entity of paraesophageal hernia that is characterized by migration of the stomach into the posterior mediastinum. this clinical-radiological picture has severe complications so in certain cases should be operated urgently. another small group of patients are asymptomatic, although the current literature recommends their regulated surgical intervention. we present a gastric pseudo-volvulation in the mediastinum, with a laparoscopic approach, showing that by systematizing the surgery, it is possible to perform this type of intervention with relative ease and safety material and methods: we present a video of an urgent laparoscopic approach in a female patient of years with a personal history of hypertension, smoking and dyslipidemia. with a hiatus hernia diagnosed more than ten years ago. he went to the emergency department due to significant symptoms of heartburn and reflux, as well as incoerctable vomiting and difficulty feeding one week of evolution. a simple abdomen and postero-anterior chest radiograph was performed, showing a paraesophageal hiatus hernia with almost the entire stomach included in the mediastinum. a thoraco-abdominal axial tomography corroborated giant hiatus hernia with pseudovolvulation and incarceration data. urgent intervention was decided by laparoscopic approach in which hiatus hernia reduction and esophageal abdominalization were performed. closure of pillars and reinforcement with bioabsorbable mesh. gastric and gastropexy toupet of anterior face to anterior peritoneum of abdominal wall. results: the patient had a post-operative h without incident, discharged with a crushed diet. the follow-up and evolution has been acceptable without notable complications. conclusion: the laparoscopic approach, in extreme cases of paraesophageal hiatus hernia with incarceration of the stomach and pseudovolvulation of it, is a correct, safe and effective alternative in experienced groups. surg endosc ( ) case report of incarcerated hiatal hernia. years old female was admited to the hospital due to severe chest pain and vomiting for about six h. physical examination and lab test showed no abberations. chest xray revaled incarcerated stomach above the diaphragm. she was rushed to the or. laporoscopic approach was used, the stomach was removed from the chest and nissen fundoplication was performed. day after surgery patient was asymptomatic, got full oral diet. she was discharged on postoperative day two, without a need of any analgetics. gastroduodenoscopy was performed weeks after surgery and showed proper image of oesophagus, stomach and duodenum, neither signs of hiatal hernia nor inflamation were present. laparoscopic approach is good way to treat incarcerated hiatal hernias and is related with shorter lenght of stay, lesser postoperative pain and better patient comfort. and it should be procedure of choice in this kind of cases. she was operated open technique using a cm long incision in right iliac fossa and the appendix was phlegmonous. the patient began feeling bad from the second day postoperative having temperature over °c, pain and increasing crp. the general condition worsened the next day when the temperature went up till . °c, extreme generalized pain and crp: . the ct abdomen control indicates signs for generalized peritonitis and rises the suspicion for a forgotten large gauze. the patient is operated using laparoscopy technique: identifying and taking out the foreign body, doing adhesiolises, extensive lavage and in the end inserting one drain in douglas. the video is presenting what king of special graspers can be used but also tips and tricks when speaking about identifying the anatomy but also dissection in acute and inflamed environment. postoperatively the patient began to feel better and in the th day was released home. conclusion: this case illustrates that even after open surgery, laparoscopy is a viable solution with the condition that there is available experience in minimally invasive surgery. introduction: foreign bodies can enter inside the human body by different mechanisms such as ingestion, aspiration, trauma or in some cases due to medical procedures. they are potentially life-threatening events, the diagnosis could be challenging and its management depends on their location. case report: a -year-old male was referred to our hospital due to chronic abdominal pain. he had cholelithiasis, medical history of acute pericarditis and past surgical history of left adrenalectomy, left nephrectomy, distal pancreatectomy and colon resection due to an adrenal adenocarcinoma (stage t n m ).abdominal radiograph showed a foreign body in the left lower quadrant of the abdomen, as an incidental finding. this was not detected in ct scans during ten years of oncology follow-up. ct scan revealed an extraintestinal metallic curved object in the right lower quadrant. this finding was not related to any surgical intervention or trauma. diagnostic laparoscopy was performed: the foreign body seemed to be a guidewire, it was included into the omentum and almost stuck to the abdominal wall. the guidewire was reached and carefully extracted through a mm trocar without any evidence of intra-abdominal organ injury. then an elective cholecystectomy was also performed due to his medical history of symptomatic cholelithiasis.the procedure lasted min. the hospital discharge was on the third postoperative day and no complication was registered. conclusion: is extremely rare to discover a guidewire that had migrated into the peritoneal space without abdominal injuries.this case report demonstrates the technical feasibility, safety and minimal postoperative morbidity associated with minimal invasive laparoscopic removal. aims: the authors present a video with their standardized laparoscopic groin hernia transabdominal preperitoneal hernioplasty (tap) procedure but using mm instruments and mm camera approach. methods: a years old male patient with a bmi presents a symptomatic bilateral groin hernia for months. us study showed an indirect bilateral inguinal hernia. a laparoscopic tap hernia repair procedure is performed using mm instruments and a mm camera. a selfgripping mesh preperitoneal hernioplasty and peritoneal flap barbed-sutured hermetic closure was performed. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of h with a rate in a eva acute pain visual scale. in a year follow-up, there has no been an anatomical or clinical recurrence. no chronic pain, anatomical recurrence, umbilical or abdominal wall complications have been reported with in this period of time. conclusions: depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, a laparoscopic bilateral hernia repair using mm instruments, could be a safe and feasible option. more studies are needed in order to standardized this approach. results: during tapp approach a direct hernia relapse was identified, the previous mesh was included on preperitoneal space and some non-absorbable sutures to inguinal ligament were identified. stitches and nearly total mesh removal (only the part surrounding cord elements was left in place) were performed. x heavyweight polypropylene mesh was employed fixed with gubran Ò and the flap was closed with running sutures. patient was discharged uneventfully the same day. seven months later he did not need analgesics and had no physical impairment. conclusions: post inguinal hernia repair chronic pain can be severe and disabling, and is becoming more prevalent. the origin is complex and meshes and sutures could play a role. the management is multimodal and demanding. for refractory patients, surgery may be an option. laparoscopic, open and mixed approaches have been employed. they usually combine mesh removal and substitution (often in different planes) and groin nerve therapies. nowadays, triple neurectomy seems to be the most effective treatment (more than % pain relief). generally, removal of mesh alone does not lead to lasting pain relief or has worse outcomes compared with associated neurectomy. introduction: mesh repair of inguinal hernia is sometimes followed by adverse effects such as mesh migration, chronic groin pain or recurrence. removal of the mesh is necessary in selected cases. we affront this cases by tapp intervention. methods: we present a video with two intreventions of inguinal recurrent hernia by laparoscopy (tapp). we remar the points to decide explant the mesh or not to explant. the conditions to decide the explant were the proximity to the main vessels in inguinal area (espigastric and femoral vessels) and the plication of the mesh. results: and conclusion as we show in the video, the explant of the mesh is only conditioned by the plicature of the mesh for its migration and recurrence, accompanied usually with pain. we don't remove any time the mesh or the plug if it is in the triangle of doom with firm adhesions to the main vessels. we cover the previous mesh with a new ligthweigth d mesh and closing at the end the preitoneum over the new reparation. introduction: tep technique isn't a controversial area in surgical practice for inguinal hernias anymore, but a fully accepted method. the use of general anesthesia has been the mainstay of laparoscopic hernia repair, but epidural anesthesia is not a contradiction to properly selected patients. material-method: the approach of the extraperitoneal area achieved without use of a dilation balloon, but via the indroduction of the camera and the dissection of the regional structures. trocars ports were used: a mm trocar through the umbilicus for the camera, exactly as in sils (single incision laparoscopic surgery), another one mm is placed in the midline between the umbilicus and pubis, the last mm trocar is placed in the midclavicular line ipsilateral with the hernia. the key for every operation was the tension free technique with placement and fixation of a mesh x cm. in / cases the mesh was placed with tacks on the inside of the inferior epigastric artery-vein complex. all patients were dismissed from the hospital in h, no drain was placed and no major postoperative complications took place. conclusion: tep is a demanding technique with serious learning curve. the use of a dilation balloon for insertion in the extraperitoneal area is not prerequisite. tep is an appropriate method both for first appearing and recurrent inguinal hernias. epiduralanesthesia instead of general anesthesia is no a contradiction for properly selected patients. aims: the aim of this study was to investigate the effects of preperitoneal carbon-dioxide (co ) insufflation during tapp (transabdominal preperitoneal) repair. materials and methods: male patients with inguinal hernia were include in our study. we obtain laparoscopic access at the umbilicus and introduce mm port. two mm working ports are placed lateral. diagnostic laparoscopy of the entire abdomen is necessary to rule out other pathology or contraindications for surgery. using aspiration needle we insuflate carbon-dioxide ( mmhg) preperitoneal at the level of anterior superior iliac spine while decrease abdominal gas pressure to mmhg. same procedure is made lateral to the umbilical artery. results: we found that preperitoneal carbon-dioxide (co ) insufflation during tapp facilitate the future parietalisation and even can reduce operating time in future improvements of the technique. there were no intraoperative complications related to this procedure. we did not found any potential risk of the technique when is use by trained surgeons. aims: laparoscopic inguinal hernia repairs (lihr) are performed more and more frequently because they offer some advantages; however, we cannot forget their specific complications. lihr are associated sometimes with peritoneal tears that can lead to bowel obstruction. we present two cases of bowel obstruction related to peritoneal defects post tapp procedure and review peritoneal closure, bowel obstruction and options to repair defects. a year-old male was scheduled for tapp due to bilateral relapse. two x tio mesh tm fixed with securestrapÒ, employed also for peritoneal flap closure, were employed. three days later he was readmitted with bowel obstruction with ct suggesting 'adhesions'. a year-old male had bilateral tapp in another centre. seven days later he presented with bowel obstruction. ct showed metallic tackers and suggested 'adhesions' results: first case: after four days of conservative treatment failure, a revisional laparoscopy showed ileum herniation through a peritoneal defect and firm adhesions to the mesh. bowel was labouriously separated and the peritoneal defect closed with two running sutures. he was discharged on the \ sup [ th \/sup [ postoperative day and three years later he is asymptomatic. second: after two days of conservative treatment failure, on laparoscopy, ileum was filmy adhered to polipropilene mesh through a big defect on flap closure. defect was closed with interrupted sutures. as tears persisted, an omental flap was created to cover the area. patient was discharged on the th day and continues asymptomatic three years later. conclusions: lihr bowel obstructions can be divided in adhesive disease and herniation. herniation can be early (through peritoneal defects) or late (trocar site). international guidelines recommends a thorough closure of peritoneal incision or bigger tears (grade b). the closure can be achieved with staples, tacks, running suture, or glue. these last two methods are more time-consuming but less painful. running suture seems to be the best, due to its low costs, tightness and low pain but sometimes can be technically difficult. low intra-abdominal pressures (= mmhg) facilitate suturing. when a herniation appears, careful bowel management is needed and running sutures are recommended. if tears persist, an omental flap can be useful. aims: application of a single port robotic platform to perform an entirely transanal tatme/ tata. methods: the following video demonstrates how a totally transanal proctosigmoidectomy is performed using a novel, single port (sp) robotic platform was used to carry out a totally transanal proctosigmoidectomy, single port robotic tatme/tata. a -year-old female patient with a clinical t n b rectal cancer at the cm level, status post neoadjuvant chemoradiotherapy ( cgy, xeloda) is presented. shown here is the open transanal dissection followed by docking of the sp robot, implementation of the single port instruments (fenestrated bipolar forceps, cadier, scissors, camera, clip applier) through a gelpoint path to complete a totally transanal proctosigmoidectomy including transanal tatme, ima/imv transection, splenic flexure release, and left colonic mobilization, loop ileostomy, and handsewn coloanal anastomosis. results: blood loss was cc. pathology demonstrated a moderately differentiated, rectal adenocarcinoma. the total mesorectal excision was complete (grade ), margins were negative, and all lymph nodes were negative for metastatic carcinoma. the patient was discharged on postoperative day after an uncomplicated hospital course. there was no postoperative morbidity or mortality. conclusions: application of the single port robot to transanal tatme/tata (sprtatme) is presented here. while much work remains to be done to validate the sp robot's safety, this first demonstration of a totally transanal tatme/tata establishes its feasibility and utility. this single port platform stands to greatly expand the application of natural orifice transluminal endoscopic surgery (notes). as shown, the sp robot offers more than sufficient visualization, technical control, and adequate reach to perform such an operation. we present an exciting new avenue by which to complete operations in an entirely transanal fashion, which are classically performed via a combined transanal and transabdominal approach. methods: this video shows the utilization of a new robotic platform to perform transanal endoluminal microsurgery, rtem. presented here is a year old woman with a recurrent rectal adenoma at the cm level, status post a previous tem resection in october . demonstrated is the utilization of the sp robot through a gelpoint path in order to perform a partial fullthickness and full-thickness resection. the robot is introduced through a mm in diameter cannula via a four-channel face-plate. the instruments' two-jointed mobility at the elbows and wrists as well as the novel navigation system are well demonstrated. the docking of the sp robot, utilization of the dissecting devices, and closure of the defect is shown. results: sprtem was performed with a blood loss of cc, and the patient was discharged on postoperative day . there was no postoperative morbidity, mortality, or moderate/severe pain. pathology showed tubular adenoma with low-grade dysplasia in a non-fragmented specimen with negative margins circumferentially. conclusion: initial experience using the sp robot for rtem is demonstrated here. the robot provides wonderful visualization and operative control to the surgeon. articulation of the robot's wrists and arms have the potential to facilitate technical aspects of the procedure. rtem stands as an exciting development in the field of transanal endoluminal surgery. introduction: the application of robotic approach in the esophageal surgical field is in its first phase. the microsuturing and microdissection capabilites of the robotic system can potentially overcome the traditional limitation of the laparoscopic surgery thus enhancing the indications of minimally invasive surgery. methods: we have performed a retrospective analysis of our prospectively maintained database that included patients who underwent robotic-assisted esophagectomy for malignant disease between and . results: ten out of sixteen patients had squamous cell carcinoma meanwhile six had adenocarcinoma. ten mckeown's and six ivor lewis were performed. the mean operative time was min ( - ) and the median blood loss was ml ( - ). no patients required conversion nor intraoperative transfusion. the morbidity rate was / ( . %) : a transitory laryngeal nerve paresis, a pneumotorax and pneumonia. the mean hospital stay was (range - ) days. an r resection rate of . % was achieved with a mean lymph node yield of ( - ). the -year disease free survival was . %, wheres the the -year overall survival was . %. conclusions: robotic assisted minimally invasive esophagectomy (ramie) is safe and feasible, it offers promising results while preserving a good oncology adequacy. this video shows our technique for the treatment of an esophageal diverticolum using a robotic left sided transthoracic approach, followed by a heller myotomy and dor fundoplication using a transabdominal approach. our case is a year old male, who suffered from severe dysphagia, halitosis and gastric reflux who on endoscopic and radiological investigations was found to have low grade and a cm wide esophageal diverticulum, cm from the lower esophageal sphincter. initially conservative management was attempted, however following poor compliance and the persistance of symptoms after year of therapy, surgical intervention was indicated. the operation was performed using the minimally invasive robotic system of the davinci siÒ, starting with the thorax time. the patient is positioned in left side decubitus. the camera-trocar is insert in the thorax via the fifth intercostal space the, two mm and one mm robotic trocars are added. the lung is liberated from pleural adhesions and the esophagus is then prepared exposing the diverticulum which is successfully removed with an endo-giaÒ. the esophageal muscle fibers, near the suture line is reinforced with separated vicryl stitches and the resected piece is extracted via endo-bag. a fr thoracic drainage tube is then placed and the trocar accesses repaired. the patient is the put in supine position with a °anti-trendelemburg angle. three robotic trocars (two mm and one mm) are placed and the robot docking is made from the patient left shoulder. the lesser omentum is divided to visualize and prepare the gastric-esophageal junction (gej) sparing the vagus nerve. the heller myotomy is then performed for cm over the gej and cm under it. the mucosal integrity is assured via laparoscopic and contemporary gastroscopic view. the gastric fundus is attached to the distal esophagus completing the dor fundoplication. post-operative care comprehends the removal of the thoracic drainage during the first post-operative day, the pain management and the progressive realimentation. the hospitalized period lasts day and the patient was dismissed without complications occurred. the uniportal video assisted lung lobectomies gained popularity all over the world during the last years. the technique is safely applied for peripheral pulmonary lesions, under cm, but more and more complex cases are being approached while the indications continue to evolve. our aim is to present the particular aspects of this technique in an -year-old female patient with a giant bullous lesion located in the lower lobe of the right lung. the preoperative work-up for this case is presented and commented. a multidisciplinary surgical team consisting of thoracic and pediatric surgeons was involved. a single . cm length incision in the fourth intercostal space was used for the access. due to the fact that the lesion involved almost the entire lobe and the margins were very close to the hilum, we have decided and performed a right lower lobectomy. dissection and stapling were quite difficult. all the anatomical structures had small dimensions, forcing us to perform an 'artery first approach' in a very narrow space. no complications during or after surgery were encountered. the patient was discharged after four days and she went to school on the sixth day. histopathological examination showed that the lesion was a type ccam (congenital cystic adenomatoid malformation). conclussion: the uniportal video assisted lung lobectomy was safety applied for a giant bullous lesion of the right lung. aim: dunbar syndrome, celiac trunk (ct) compression syndrome, caused by median arcuateligament is a rarely diagnosed disease because of its nonspecific symptoms, which cause adelay in the correct diagnosis. the aim of the study was to demonstrate the usefulness andadvantages of laparoscopic approach in the treatment of dunbar syndrome. methods: we performed laparoscopic release of ct in the department of general, minimallyinvasive and elderly surgery in olsztyn in . all of three patients suffered from severepain of abdominal cavity before the surgery. results: in two cases, there were a complete remission of the symptoms. in one case, there was animprovement. all patients reported relief of symptoms in the first days after the operation.there were no postoperative complications. conclusions: the laparoscopic treatment of dunbar seems to be safe and feasible procedure. thelaparoscopic surgery alone can often eliminate discomfort, while angioplasty and stentimplantation are no longer necessary. introduction: the advances in robotic surgery have permitted the application of such technology to various surgical fields, one of the last of these being hernia surgery. we present a case video of the treatment of a dual-hernia using a robotic retromuscular ventral hernia repair(rrvhr) using the davinci siÒ robotic system. the case report demonstrates the evolution of the trans-abdominal robotic umbilical prosthetic (tarup) in that it utilises a 'double docking' technique to allow the positioning of a large retromuscular mesh. methodology: our patient is a -year-old male who presented with chronic epigastric pain. the abdominal ct confirmed two abdominal wall hernias; an epigastric and supra-umbilical hernia with visceral contents and wall defect diameter of cm and . cm, respectively. using the minimally invasive robotic system of the davinci siÒ we adapted the well known retromuscular mesh technique. the operation was initially intraperitoneal with access to the retromuscular preperitoneale space using a right sided longitudinal incision.(as per standard tarup technique). we proceed with the dissection of the retro-muscular space until the left lateral edges of the rectus sheath, creating a preperitoneal space for the placement of a specifically modified ultrapro polypro-leneÒ x cm mesh. following this we repositioned the davinci siÒ in a symmetrical manner, with ports placed in the retromuscular space. the mesh is positioned and the peritneum subsequently closed with a v-lock sutureÒ. finally we opted for a negative pressure jackson-pratt drain, inserted preperitoneally. results: the patient was discharged on the nd post-operative day without complication follow up continued until months post operatively during which the patient remained asymptomatic, without signs for hernia recurrance . conclusion: the technique highlighted in our video demonstrates the utility of the robotic system in hernia repair. specifically the approach proved a success as it facilites the placement of the mesh totally extra-peritoneally with closure of the posteriore sheath without tension. the added advantages are that the port-sites are distant from the mesh thus reducing infective risk. additionally this technique allows the treatment of large peritoneal defects. surg endosc ( ) aim: to analyse the performance of a robotic fellow during a robotic total mesorectal excision (tme) at the end of the fellowship, and subsequently compare it with their mentor. methods: the fellow is exposed to robotic colorectal lists per week. during the fellowship, assessment of performance is recorded in a structured proforma covering aspects of autonomy, tissue handling and dissection. at the end of the fellowship, areview of cases performed by the fellow and the mentor was carried out in a blindly manner (video footage). results: robotic tme training was divided into modules in order of complexity and the trainee had to achieve sequential proficiency in each module, before progression. docking of davinci robotic system. inferior mesenteric artery exposure and ligation, development of medial to lateral plane and inferior mesenteric vein division. left colonic and splenic flexure mobilization. pancreas identification. rectal dissection (tme). qualitative assessments were recorded by the mentor; the fellow was 'able to perform with verbal help' most of the steps from early on. by the end of the fellowship, all steps were performed in a similar manner in terms of quality and oncological integrity when compared with the mentor. conclusions: at completion ofan advanced robotic colorectal fellowship, high quality trainees can perform every step of the tme dissection in a similar manner with the trainer, when assessed blindly, without compromising oncological integrity. aims: to find safe and simple method in robotic rectal low anterior resection with low tie arterial ligation and lymph node dissection around the root of inferior mesenteric artery. methods: we performed robotic rectal low anterior resection (rlar) by davinci si system in eight patients with rectal cancer. we applied low tie arterial ligation, just caudally to the origin of the left colic artery in all cases. during the procedure, we used tilepro function of davinci si system which enabled to display two other visual informations through external inputs under the normal -dimensional surgeon console view. preoperative d-ct vessel branching simulation video and intra-operative real time ultra sound navigation view were displayed simultaneously under normal operative camera view in the surgeon console. results: left colic artery preservation was completely done in all cases. the mean time to find and expose the left colic artery from the first incision in sigmoid mesentery was min, which was drastically shorter than conventional method. this method needed lesser mobilization of inferior mesenteric artery (ima), and may be less invasive to autonomic nerve around the root of ima which is very important for ejaculation function. conclusion: robotic rectal low anterior resection with low tie arterial ligation was performed safely and in short time, using tilepro intra-operative navigation method. preoperative d-ct vessel branching simulation video and intra-operative real time ultra sound navigation view were very useful in the procedure. we present the method in video. nerve sparing tme and pelvic neuroanatomy for colorectal surgeons p. tejedor, f. sagias, j.s. khan aim: to describe the critical points in which the pelvic nerves can be damaged during a total mesorectal excision (tme) for rectal cancer and the benefits of robotic surgery for identifying these points. methods: there are critical points regarding pelvic neuroanatomy: superior hypogastric plexus (shp): located in front of l -s . the ganglionic sympathetic fibres form the right and left sympathetic trunk, travel along the anterior surface of the aorta and coalesce in the shp at the level of the inferior mesenteric artery (ima). superior hypogastric nerves: they take an anterolateral course into the pelvis. there is an avascular 'holy plane' around the rectum between these two nerves. inferior hypogastric plexus (ihp): lies over the posterolateral pelvis, almost parallel to the internal iliac arteries. this can be identified at the lower end of the rectum. neurovascular bundles(of walsh): in front of the denonvillier's fascia, at and o'clock position. they are responsible for erectile function. results: lack of knowledge or identification of key structures at these points can lead to increased risk of nerve damage and translate into poor functional outcomes. the ima is dissected up to the origin from aorta and here the shp can be seen. care is taken to avoid any damage to these structures. the tme plane is found at the back of ima as the inner most dissectible layer between mesorectum pelvic fascia. right and left superior hypogastric nerves are identified. dissection is carried out posteriorly, laterally and anteriorly. ihp is identified at the lower third of the rectum, when the dissection is about to reach the pelvic floor. care should be taken in not to go too far lateral and damage this plexus. in the anterior dissection, plane is carried in front of the denonvilliers' fascia. the neurovascular bundles can be seen at and o'clock position and the surgeon has to be careful to stay inside that plane in order to avoid damage. conclusions: the precise dissection in robotic surgery results in minimal tissue damage and better visualization and preservation of the pelvic nerves. aims: to describe and evaluate new contributions and eventual advantages of icg fluorescence to perform an icg guided bilateral pelvic lymph node dissection in a patient who underwent low-anterior-resection for rectal carcinoma. we also present the basic steps to avoid ileostomy during rectal surgery in which icg and ghost ileostomy play an important role. methods: a -year-old male patient was referred to our hospital due to abdominal pain and significant changes in usual bowel habits.colonoscopy showed a no obstructing cm middle rectal mass, which was reported as an adenocarcinoma.ct scan and mri revealed a mm polyp in the anterior rectal wall which was located cm from the anal verge. it was involving mucosa and sub-mucosa with muscularis propia invasion. no pathological lymphadenopathies or hepatic metastatic disease were found (stage t n ).a laparoscopic ultra-low-anterior resection plus icg lateral lymphadenectomy with total mesorectal excision was performed. a complete splenic flexure mobilization was performed to achieve a safe tension-free anastomosis. transection line of the proximal rectum was checked after icg intravenous injection. icg was injected around the tumor by inserting an anoscope, just before the surgery. after the dissection of the rectum, lateral lymphadenectomy was performed assisted by icg. an end-to-side anastomosis was made. and a vascular loop was passed around the terminal ileum to create a ghost ileostomy.the procedure lasted min. reactive protein c was monitored to identify an initial leak. the patient was discharge in postoperative day and no complication was detected. results: pathological exam reported a rectal adenocarcinoma. pelvic lymphadenectomy results were: negative nodes, negative nodes and negative nodes from right lymph node dissection, left lymph node dissection and rectosigmoid resection specimen respectively. no metastatic disease was found (stage t n m ). conclusions: in our experience, icg fluorescence imaging system offers important contributions to rectal surgery furthermore than evaluating vascular supply to the anastomosis. lymphatic mapping of the lateral lymph nodes and avoiding ileostomy could be a potential important use in the future. larger studies and more specific evaluations are needed to confirm its role in colorectal surgery and to find its limitations. background: robotic surgery for colorectal cancer is an emerging technique. potential benefits as compared to conventional laparoscopic surgery have been demonstrated. innovative robotic technologies have helped surgeons overcome many technical difficulties of conventional laparoscopic surgery such as hand-eye coordination, a two-dimensional view, and a restricted range of motion. robotic-assisted surgery was established as a new approach to minimally invasive surgery, overcoming these limitations. the following video shows a total robotic sigmoidectomy step by step on the basis of ourexperience. intervention: a -year-old male patient with no previous medical historyand a colon adenocarcinoma, cm from the anal verge, no distant metastases. it was decided to perform a robotic sigmoidectomy. target anatomywas located andwe proceededto the exposure of the mesenteric vessels from medial to lateral. a cautery wasused to open the peritoneum,up to the origin of the inferior mesenteric artery, and caudally past the sacral promontory.the vessels weretransected by ligasuretm. we performedthe complete release of the colon taking care to avoid injury to retroperitoneal structures. we usedligasuretm to section the mesocolon in order to prepare the transection of the proximal colon. indocyanine green was used to check the correct vascularization. an endogia tristapletm was used to divide the colon. subsequently, we sectioned the rectumand extracted the specimen through itwith no need to make any auxiliary incisions. we introduced the anvil of the suture device to perform the anastomosis. we sectionedand close the rectum with an endogia tristapletm. finally we opened the proximal colon to introduce the anvil,making a pursestring to fix it and create a side to end anastomosis. outcome: the surgery took min. the patient started oral intake h after surgery and left the hospital on the rd postoperative day. pathological examination ruled out a colon adenocarcinoma pt n . conclusion: total robotic sigmoidectomy is safe and feasible and can be a procedure of choice to achieve a good surgical qualityand avoid assistance incisions in patients with colon cancer. surg endosc ( ) with more and more data now advocating wait and watch policy for these patients which require close radiological and endoscopic follow-up but unfortunately around % of them have regrowth of tumour which will require surgical intervention. the use of robot for cancer resections is becoming more frequent especially in narrow spaces like in an obese male pelvis. the reason being better -dimensional views, more angulation of the instruments and exclusion of tremors, which in turn leads to better dissection and preservation of hypogastric nerves. in this video, we present a robotic low anterior resection for rectal re-growth in an obese -years old male patient. he was offered neoadjuvant chemoradiotherapy after discussion in mdt. he had an complete response with chemoradiotherapy and was decided to offer him watch and wait regime. unfortunately, he developed rectal re-growth in the first year of his follow up. imaging showed t lesion with no distant metastasis and was later confirmed on histology as well. after mdt discussion he was offered robotic low anterior resection. the video starts by showing the clinicopathological features of patient including his radiological and endoscopic images. robotic port sites are shown. the edited video starts with rectal dissection after ligation of inferior mesenteric artery and vein with emphasis on narrow pelvis and preservation of hypogastric nerves, seminal vesicles and intact presacral fascia. postoperative histology was ypt no and patient was discharged home after days with no postoperative complications. background: minimally invasive surgery for colon resection has improved patient outcome, however a minilaparotomy still is necessary to extract the specimen. this report describes a new approach that combine laparoscopic parellel overlap stapling left colectomy with natural orifice specimen extraction surgery, with the aim to minimize abdominal wall trauma. method: laparoscopic left colectomy for malignant diesease was performed using a standard five-port technique. after releasing the left colon via laparoscopy, divide the proximal and distal of specimen with -echelon, and put distal sigmoid colon and proximal transverse colon together. open sigmoid colon cm apart from distal margin, and incise transverse colon at proximal margin. take transverse colon and sigmoid colon side-to-side anastomosis via -echelon. incise posterior vaginal fornix to get into the abdominal cavity and extract specimen through vaginal. outcome parameters such as complications, conversions, operative time, postoperative recovery, and postoperative pain were prospectively recorded in a database. results: surgery was performed for patients with left-colonic carcinoma. no perioperative complications or conversions occurred. the median operating time was min. the median visual analogue scale score of postoperative pain was , and of patients needed analgesia on postoperative day . the median postoperative hospital stay was days. for malignancies, tissue margins were oncologically adequate, the averge number of harvested lymph nodes were . . the -week follow-up period was uneventful. conclusion: the described technique, a combination of laparoscopic parellel overlap stapling and natural orifice surgery, has the potential to avoid incision-related morbidity of the minilaparotomy in laparoscopic left colon resections. background: open surgical skills training has been well established over centuries, however, there are some significant differences in laparoscopic surgical skills training. it is an obvious advantage that the trainee and the trainer have the same view; however, some of the hurdles include the differences in tactile feedback, hand eye co-ordination, spatial awareness, depth perception and maximizing assistance. aim: we present a video highlighting some of the key challenges faced in laparoscopic colorectal surgical training, show-casing our systematic, structured approach. our approach: we have developed a structured approach starting with junior surgical trainees and progressing through to consultant level as per the levels below: level : attend courses/ workshops level : master camera work level : contra-lateral assisting level : intermediate level trainee-start operating with trainer scrubbed. the trainer is an additional member of the scrub team and stands on the same side as the trainee (does not replace any assistant) level : advanced level trainee-gradual progression from level . trainer un-scrubbed but standing next to the monitor throughout the procedure. level : trainer in theatre but out of sight of the trainee, with little interference level : progression to trainer-once proficiency is achieved at level / , the trainee is trained to become a trainer, for the junior and intermediate level trainees. within each level the complexity of the procedure increases as the trainee progresses through the level. junior trainees (years - of surgical training) are taken through levels - , intermediate (middle years of training) level or and advanced (last - years) up to levels . this way of training allows multiple members of the team to be trained simultaneously in every case. each operating list is preceded by team briefings where the role of every member of the team is clearly identified and followed by individual and collective feedback. conclusion: this training ladder proved very successful through the years. the feedback from trainees at all stages has been consistently positive. several trainees who have progressed to independent consultant practice, in the uk and abroad, are adopting this approach in their practice. introduction: despite the potential microsuturing capabilities of the robotic surgery, most of the esofago-jejunostomy after robotic total gastrectomy are still performed extracorporeal or through mechanical staplers. this can increase the cost of the procedure, the risk related to a improper functioning of the stapler. methods: we reviewed our prospectively maintained database analyzing patients from april to september , who underwent robotic total gastrectomy with hand-sewn esophagojejunostomy for gastric cancer. results: a total of patients were included in the study. the mean estimated blood loss was ml ( - ). the overall operative time was min ( - ). length of hospital stay was days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . no conversion was necessary nor anastomotic leakage occurred. the morbidity rate was / ( . %) and included a subhepatic abscess and wound infection trough pfannenstiel incision. a r resection rate was achieved in all cases. the mean of lymph node yield was ( - ). the -year disease free survival was %, the -year overall survival . %. the robotic-assisted hand-sewn esophago-jejunostomy is a safe and no time-consuming technique. it avoids the complication related to the stapler firing and it offers cosmetic benefit to the patient in terms of extraction site. introduction: colorectal endoscopic submucosal dissection (esd) is increasingly practiced for treatment of early colorectal neoplasia. however, colorectal esd is difficult to perform due to lack of retraction as well as instability especially over hepatic flexure. dilumen eip is an external flexible sheath introduced during colonoscopy to stabilize environment for esd. this video demonstrated the use of dilumen eip for performance of colonic esd at the ascending colon method and results: this is a years old lady who received screening colonoscopy and found a mm lateral spreading tumor (lst) type iia lesion at ascending colon distal to ileocecal valve. under general anesthesia, patient received colonic esd using dilumen eip. due to significant looping, the dilumen device was introduced with the techniques of double balloon enteroscopy. after identification of the lst, the balloon in the front would be deployed to the proximal to the lesion while both balloons would be insufflated and created a stable environment. the esd procedure started after submucosal injection with normal saline in mix with indigocarmine, epinephrine and hyaluronate. mucosal incision was performed over the anal side of the lesion, and after adequate submucosal dissection, clips were applied to attach the mucosal flap to the sleeve of proximal balloon and achieved retraction. the submucosa was adequately exposed for dissection using dual knife jet. this enhanced submucosal dissection especially at one area with significant fibrosis. after the procedure, complete closure of the mucosal defect was performed by clips and assisted by the front balloon. the pathology confirmed intramucosal adenocarcinoma with clear resection margins. discussion: the dilumen eip device stabilized the environment within the colon with the double balloon and provide adequate retraction for performance of colorectal esd. surgery, kobe city medical center general hospital, kobe, japan background: robotic surgery has been widely spread all over the world, but robotic gastrectomy is not common and difficult because of complex anatomy and wide-ranging operation fields. in addition, it had been performed only under a few high-volume centers for reasons of the limitation of national health insurance in japan, which means medical expenses not covered by insurance. the situation was changed from this april, so we started robotic gastrectomy to reduce complications more rather than laparoscopic gastrectomy. we report results and aim to present the methods in detail using da vinci si surgical system. methods: we place five trocars, one is umbilical endoscopy port, and other four ports are placed at the reverse trapezoid, almost fan-shaped. using the arm number , the organ can be lifted up so that sharp lymphadenectomy is able to be done by almost a scissor as the arm number while applying the countertraction by the arm number . in order to achieve a clear and bloodless lymphnode dissection while maintaining the oncological safety, we think not only the ultrasonic coagulating scissor but also the electrocautery of the scissor is very essential in robotic surgery. less postoperative complication such as pancreatic fistula or pancreatitis might be derived from robotic surgery because we can avoid pressing the pancreas during the suprapancreatic dissection of lymph nodes. the billroth i reconstruction can be performed using da vinci endowrist stapler under stable and inflexible surgical fields without needing help of surgical assistant. results: from october to december , patients with gastric cancer were operated robotic gastrectomy, included total gastrectomy. there was no conversion to open surgery and no conversion to other procedures derived from intraoperative complications, and the overall operation time is gradually decreasing from the th case. we are now on the way of learning curve shortening operation time, but robotic gastrectomy is no less safer and adequate than laparoscopic surgery. we will show our robotic procedures including lymphadenectomy around subpyloric and suprapancreatic area, and reconstruction with several important points in our video purpose: this report describes the benefits and drawbacks in the use of a novel articulating device (artisential), which has a multi-degree wrist freedom like the davinci endowrist, in performing complete single-port d lymph node dissection (lnd) in single-incision distal gastrectomy (sidg). methods: the artisential was used in performing sidg with d lnd for patients with advanced gastric cancer. all operations were performed by a single surgeon using a threedimensional camera and a passive scope holder in place of a scopist. the artisential was used mainly in the sb and suprapancreatic lnd, an area that is relatively far from the single port. in certain cases when the pancreas needed to be pushed down, such as obese male patients, the intraabdominal organ retractor was used to lift the tissue and the artisential to push the pancreas. operative results and short-term outcome were analyzed. results: twelve patients underwent the procedure without any intraoperative events, conversion to conventional laparoscopy, or surgery-related complications including postoperative pancreatic fistula. all patients underwent single port d lnd by complete exposure of the portal and splenic vein. mean operation time was . ± . mins. and mean number of retrieved lymph nodes was . ± . . the artisential was found to be useful in grasping the tissues behind the pancreas and the major arteries throughout most of the lnd. the articulating motion also allowed the narrow single-port field of view to be clearly seen without the instrument body obstructing the camera. conclusion: the use of artisential in sidg appears feasible and reproducible, and is mandatory in performing a complete d lnd in sidg. the video shows a case of laterally spreading tumour of the rectum with preoperative benign histology, paris classification -is g (granular type), ut n eus stage, kudo type iv, nice type . the neoplasm measured x cm, and extended from to cm from the anal verge, mainly located on the posterior wall. according to our local policy the indication was a transanal full-thickness excision. this was performed with the medrobotics flexÒ robotic system, used here for the first time outside the united states.the system technology utilizes an articulated multi-linked scope that can be steered along non-linear, circuitous paths in a way that is not possible with traditional, straight scopes. the maneuverability of the scope is derived from its numerous mechanical linkages with concentric mechanisms. this enables surgeons to perform minimally-invasive procedures in places that were previously difficult, or impossible, to reach. with the flexÒ robotic system, surgeons can operate through a single access site and direct the scope to the surgical target. once positioned, the scope can become rigid, forming a stable surgical platform from which the surgeon can pass flexible surgical instruments. the system includes on-board d hd visualization. the flexÒ robotic system contains two working channels to accept a number of different surgical and interventional instruments including monopolar and bipolar electrodes, scissors and graspers for tissue manipulation.the video shows the introduction of the dedicated rectoscope, the connection of the flexible robot, and the way to operate the device performing a full-thickness excision, including suturing of the rectal defect by means of two running sutures by a v-lock / thread. while illustrating the technique the authors will comment pros and cons of the use of the device. background: hepatobiliary procedures using a minimally invasive approachare demanding, especially in major hepatectomies. the use of da vinci surgical system allows to overcome some of the kinematics limitations of the direct manual laparoscopy maintaining the potential advantages of a minimally invasive approach . we herein present a case of left hepatectomy and local lymphadenectomy for hepatocellular carcinoma, carried out with the use of the da vinci xi. methodology: a -years old man with a long-lasting hbv chronic infection and ct scan and mri finding of a -cm solid neoplasia of the left hepatic lobe and gallbladder stones, was operated with the da vinci xi platform. the patient was placed in a supine position, with °anti-trendelenburg inclination. the trocars were positioned according with the intuitive indication for the upper quadrants surgery. results: the procedure was successfully completed in min.at first, an intraoperative us scan with the use of tile-pro technology was done to determinate the tumor extension. the hepatic parenchyma transaction and the local lymphadenectomy were performed with monopolar scissors and bipolar grasps. the left hepatic vein section was performed with an endoscopic vascular stapler. there were no surgical complications or need for conversion to laparoscopy or laparotomy. the post-operative course was uneventful and the patient was discharged days after surgery. conclusion: the da vinci xi can facilitate some technically demanding procedures and ultimately widen the range of application of minimally invasive surgery such as hepatic surgery. besides the well-known advantages provided by robotic surgery on d imaging, increased range of motion and augmented surgical dexterity, one of the most interesting and innovative features of robotic technology is the digitalization of the operative view; furthermore the tile-pro multiinput display allows the surgeon a d view of the operative field along with the ultrasound exam for a precise understanding of anatomy and vascularity and of tumor location. during the last few years, robotic surgery as well, as the latest innovation of minimally invasive procedures, takes its position in this particular field with the benefits of overcoming the limitations of conventional laparoscopy. our aim is to demonstrate the advantages of robotic surgery in procedures of hepatectomies, on occasion of a robotic hepatectomy performed by our team. methods: we present video fragments of a robotic left lateral hepatectomy procedure in an elderly female patient with a symptomatic gigantic haemangioma of the left hepatic lobe. we emphasize on the technical aspects and the advantages that the surgeon gains applying the robotic techniques in such procedures. results: the procedure was completed with minimal blood loss and the patient presented an uncomplicated post-operative course, with discharge on the third postoperative day, minimal need of analgesics and full recovery. conclusions: the excellent three-dimensional and high quality visualization that the robotic system offers, combined with the flexibility and the accuracy of the robotic instruments (especially on suturing), provide to the surgeon an important aid, in order to avoid serious complications, such as intraoperative bleeding and post-operative bile leaks. the restriction of the limitations of conventional laparoscopy is far more beneficial and promising for the evolution and the future of minimal invasive liver surgery. aims: the new da vinci xi surgical cart allows multi-quadrant and complex surgical interventions in a minimally invasive fashion. we present a case of robotic appleby left pancreatectomy using this platform and its specific operating bed. methods: a -years old woman with ct scan finding of a -mm hypo-vascular neoplasm of the pancreas body underwent surgery with the use of the new da vinci xi with four arms upper quadrants trocar' disposition. results: the procedure was successfully completed in min. the pancreatic body was mobilized in order to expose the portal-mesenteric axis. the gland was transected using a robotic endo-stapler as well as the splenic vein. after evaluating the patency of collateral circles with intra-operative ultrasound, the common hepatic artery and the celiac artery were transected. then we increased the right tilted position and the neoplasia was detached from the gastric body by a tangential gastric resection using the robotic endo-stapler. finally, the operation was accomplished with the transection of the posterior attachment of the spleen and the pancreatic tail. no conversion or intra-operative complications were recorded. the post-operative course was uneventful and the patient was discharged days after surgery. the da vinci xi with its specific tools helps in performing challenging procedures such as appleby operation for locally advanced pancreatic cancer. in our experience, the robotic endo-stapler permits the operating surgeon to directly control the transaction phase whereas the specific operating bed allows to perform minimally invasive multi-quadrant surgery and to obtain a better exposition of the operating field. results: the whipple procedure was successfully completed in min. thanks to the dvtm the patient's position changed during the intervention to improve the exposure, with the instruments left inside the abdomen and without undocking the robot. the dissection of the pancreatic head from the portal vein and the section of the retroportal lamina were performed with the use of the endowrist vessel sealer device. a personal modified end-to-side pancreatojejunostomy was carried out, with / prolene and gore-tex double layer suture. no intra-operative complications occurred and no conversions to laparoscopy or laparotomy were required. the postoperative course was uneventful. conclusions: the use of the new fully wristed vessel sealer extend makes easier difficult maneuvers such as the fine dissection of the pancreatic head from the portal vein and the section of the retroportal lamina, enabling an optimized approach for vessels sealing and cutting and tissue bundles. moreover, the dvtm allows patient's movements without undocking the system or removing instruments from the abdomen, enhancing the surgical workflow. background: necrotizing pancreatitis is a devastating illness which can develop in up to % of patients who suffer from pancreatitis. it carries great morbidity with an associated mortality rate between to %. many of these patients require drainage of fluid collections to treat sequela related to pain, per-os tolerance, and source control of sepsis if infected. the step-up approach to treatment of this disease has trended towards minimally invasive techniques, considering the morbidity of open debridement. as such, many centers have implemented the use of transgastric debridement via endoscopic cystogastrostomy. this technique, while effective in draining fluid and particulate necrotic tissue, has difficulty in resection of large necrotic tissue, due to instrument and anatomic limitations. current endoscopic accessories designed for polypectomy or foreign body extraction, for example, are not optimal for performing necrosectomy. to overcome this obstacle, additional access sites can be utilized to assist debridement. we describe the first laparoscopic assisted transgastric endoscopic necrosectomy through a percutaneous gastrostomy in a year old male with infected pancreatic necrosis secondary to biliary pancreatitis. aim: to investigate the feasibility of utilizing gastrostomy access to assist in debridement during endoscopic necrosectomy. methods: the patient previously underwent an open necrosectomy and gastrostomy tube placement for acute emphysematous pancreatitis. post-operatively, there was a persistent and enlarging cm infected walled-off necrosis (won). therefore, endoscopic cystogastrostomy was performed using a lumen-apposing metal stent. results: frank pus was evacuated. initial endoscopic necrosectomy was technically challenging due to the large volume of solid necrotic tissue. repeat endoscopic debridement utilized a surgical laparoscopic grasper via the gastrostomy site to aide solid debris extraction (video). this allowed for complete necrosectomy and resolution of the won. the patient did well and was discharged subsequently. conclusion: this is another emerging minimally invasive technique in the step-up approach for debridement and drainage of won. the use of the gastrostomy as a utility port for accessory instruments not only enhanced the technical aspects of the procedure but increased its efficacy as well. further experience is needed to validate the utility and reproducibility of this technique. objective: the presentation of the minimally invasive surgical approach for pancreatic necrosectomy guided by videoretroperitoneoscopy or var (video assisted retroperitoneoscopic), established in our center, as one of the option of the step-up approach treatment for acute necrotizing pancreatitis (anp) methods: the placement of the patient on the operating table should be in decubitus, with right lateral inclination, at - °on the horizontal surface. the pancreatic cell is approached using the drainage catheter previously placed by radiological control (ultrasound or ct) as a guide, which will allow access to the cavity with safety. an incision of - cm is made around the previously placed catheter, crossing the subcutaneous cellular tissue and muscular fascias, dissolving the musculature. it continues in a blunt dissection, until a loss of resistance is appreciated which generally coincides with the outflow of necrotic or purulent material. once the retroperitoneal cell is accessed, a mm trocar is placed and a pneumoretroperitoneum is performed. the -mm trocar allows the joint use of a mm and °optic and the surgical material that allows debridement and cleaning. the aspiration and hydrodissection of the necrotic material, and the extraction of the solid component of the necrosis are proceeded. once the collection is drained and the necrotic material removed, a wash and drain system is placed, like a -way foley type probe. conclusions: in conclusion, the var is an alternative surgical technique, valid and reproducible in the treatment of anp, which offers comparable results and even superior, in some series, to those of open surgery, with satisfactory results in terms of morbidity and postoperative mortality. aim: lung subsegmentectomy is suitable for small and deep, non-palpable lung nodules. since it is difficult to intraoperatively detect the arteries, veins and bronchi of the subsegment, as well as the intersubsegmental borders, complete video-assisted thoracic surgery (vats) for lung subsegmentectomy is challenging. we use preoperative three dimensional ct to detect the arteries, veins and bronchi of the subsegment before conducting complete vats subsegmentectomy, and perform intraoperative bronchoscopy to detect the bronchi and intersubsegmental borders. i would like to describe our experience of complete vats combined subsegmentectomy for a non-palpable lung nodule. methods and results: the patient was a -year-old woman. during health screening, a small groundglass opacity was observed in her right lung on chest ct. the nodule was mm in diameter and was located in s b (horizontal subsegment of the posterior segment) near s (the anterior segment). we preoperatively diagnosed the lesion as well-differentiated adenocarcinoma, and planned combined subsegmentectomy for s b and s a (lateral subsegment of the anterior segment) of the right upper pulmonary lobe. before the operation, the locations of vessels were confirmed by three-dimensional ct angiography. video-assisted thoracoscopic surgery was performed using four ports: two cm ports in the th intercostal space in the post-axillary line and in the angulus inferior scapulae line for the operator, a cm port in the th intercostal space in the mid-axillary line for the assistant, and a cm port for the camera in the th intercostal space in the mid-axillary line. the cm port was also used for removal of the resected specimen. intraoperative bronchoscopy was used for detecting the subsegmental bronchi. she was diagnosed with primary lung cancer (adenocarcinoma in situ, nonmucinous) postoperatively. the tumor was pathologically graded as tisn m . no tumor recurrence has been noted in follow-up of twenty two months. conclusions: the combination of preoperative three-dimensional ct angiography, intraoperative bronchoscopy and complete video-assisted thoracoscopic surgery can be used for performing lung combined subsegmentectomy. aims: minimally invasive surgery is increasingly widespread for the diagnosis and treatment of abdominal pathology. laparoscopy is a diagnostic resource for those cases in which mass biopsy is not approachable through image-guided puncture, and is often therapeutic in the same act. it avoids the morbidity and mortality associated with laparotomy, favoring the early treatment of malignant processes. methods: we present a case of a year old male who was incidentally diagnosed with an oval-shaped pelvic mass in the right lateral wall of the pelvis, adjacent to the vascular bundle of the right external iliac at its origin( centimeter), without sign of infiltration of surrounding structures. no other pathological findings on the abdominal computerized tomography and magnetic resonance imaging were found. due to its localization, it was not accessible to percutaneous biopsy. the first diagnostic impression was a benign tumor of the nerve sheath (schwannoma), without being able to rule out other diagnostic possibilities. to provide a definitive diagnosis the patient was subjected to an elective laparoscopic resection of the tumor. surgical procedure was performed using a millimiter and two millimeter, umbilicus for the optical system and operative on hypogastrium and left iliac fossa respectively. acleavage plan between the tumorand rightiliac vesselswas found. the exeresis of the masswas achieved, and it was extracted using an endo-bagÒ through the umbilical port site. a drain was put in the surgical bed. results: the patient had a short, uneventful post-operative course, being discharged on postoperative day . pathological examination revealed a lymphatic node with metastasis of poorly differentiated carcinoma, with suspected urothelial lineage. cystoscopy was performed with the finding of a centimeter lesion on the right ureteral orifice with calcifications on the surface. biopsies were taken, confirming the bladder origin of the tumor. conclusions: both diagnostic and therapeutic laparoscopy is useful on pelvic masses because of the direct vision into this narrow anatomical space, especially in obese patients, providinga detailed view that makes easier to isolate and spear the anatomical structures surrounding the tumor, minimizing the risk of tumor rupture and bleeding. surg endosc ( ) aim: indocyanine green (icg)-enhanced fluorescence has been introduced initially in laparoscopic surgery to provide detailed anatomical information during laparoscopic cholecystectomy and to evaluate vascular supply to garantee correct anastomotic perfussion in order to reduce the risk of anastomotic leak. the uses of icg are increasing, specially in hepatic and oncological surgery in order to identify centinel lymph node and lymphatic mapping.we propose the use of icg imaging during complex laparoscopic colorectal resection in cases presenting ureter obstruction, to prevent iatrogenic ureteral injury. methods: we present a case of a year old female previously diagnosed of pelvic endometriosis with severe pain and symptoms related with episodes of pseudo-occlusion .a colonoscopy was performed finding sigmoid cancer in an area of endometriosis in a narrow colon with difficulties to perform a complete colonoscopy that could be related to the process of pseudo-occlusion. the biopsy was informed as an adenocarcinoma.the ct-scan showed a dilatated left ureter in an area next to the sigmoid colon.we propose a preoperative strategy with a bilateral double j stent insertion, finding a ureter obstruction caused by the endometriosis.icg was injected through the ureteral catheter, guiding us during the surgery to avoid a iatrogenic ureteral injury. results: a laparoscopic left colectomy was performed. the icg allows us to follow the ureter during the surgery, disecting the colon properly from the area attached to the ureter. the prestenotic area of the ureter was marked dilatated up to two centimeters allowing the icg to identify it from the anatomic structures of the areas and guarateeing that there was not spill of icg out of the ureter avoiding a postoperative leak of urine. conclussions: when tumors, or another entities like endometriosis, produce a ureteral occlusion, icg could be injected through a j stent, allowing us to identify and to avoid an injury.icg fluorescence imaging is a safe, cheap, and effective tool to increase visualization during surgery, offering additional information of the anatomy in colorectal surgery. in this video we are going to show three cases of the robotic treatment of splenic artery aneurism and the evolution of the technology that we relied on for the preoperative planning and intraoperative navigation. our preoperative evaluation evolved from a tridimensional virtual reconstruction with augmented reality to patient specific anatomical d printed models, initially made of rigid materials and afterwards made of malleable materials, in order to reproduce hollow anatomical structures such as vessels, feasible to simulate the planned surgical plan. the choice of a robotic approach, in selected cases, allowed to restore the continuity of the splenic artery after the exclusion or excision of the aneurism, in order to preserve the spleen. aims: tumor-induced osteomalacia (tio) is a rare paraneoplastic syndrome in which patients presents bone pain, fractures and muscle weakness caused by the fibroblast growth factor (fgf- ), a phosphate and vitamin d-regulating hormone. in tio, fgf- is secreted by mesenchymal tumors that are usually benign but small and difficult to locate. when medical treatment is unsuccessful, surgical treatment is indicated and conclusive.this video shows our technique for tio surgical treatment guided by indocyanine green (icg) fluorescent angiography. methods: the patient is an -years-old woman with tio confirmed by blood sampling of fgf- , gallium- pet/ct scan and abdominal ct scan which identified a highly vascularized mm nodule in the mesentery along the ileo-colic vascular axis.the patient was scheduled for a diagnostic laparoscopy with tio removal.the patient was placed in supine position. three trocars were introduced in the left quadrants. identified the last ileal loop, following ileo-colic vessels, a small mesenteric bulge was found. the icg fluorescent angiography confirmed the localization of the ipervascularised nodule and helped to define its edges. the nodule was removed through monopolar energy and the hemostasis was optimized through bipolar energy. the specimen was extracted through an endobag using one of the trocar access. results: the postoperative course was uneventful and the patient was discharged on postoperative day . histopathological examination showed an extrasurrenalic paraganglioma. conclusion: tio are often difficult to locate for surgical removal. icg fluorescent angiography allows to facilitate tio localization and removal. the minimally invasive technique decreases perioperative morbidity and mortality. laparoscopic removal guided by icg angiography should be considered when tio needs to be removed and is difficult to locate. aim: this video shows our technique to perform laparoscopic resection of a voluminous left paraaortic paraganglioma. methods: the patient is a -years-old man with a recent medical history offever, lumbar pain and haematuria.abdomen ct scan, performed during admission at emergency department, revealed a x cm left paraaortic retroperitoneal mass with pseudo-aneurysm. after procedure of angiographic embolization (with spermatic artery sparing), the patient was scheduled for a laparoscopic resection of paraaortic tumor. the patient was placed in the right flank position. three trocars ( mm) in the abdominal midline and one trocar in left hypocondrium were placed. at initial examination of the abdominal cavity, voluminous left paraaortic mass arising in the contest of left mesocolon was found, dislocating posteriorly kidney vessels. the parietal peritoneum was divided and the paraaortic lesion was dissected on the aortic plane from medial to lateral and from down to up, preserving the inferior mesenteric vessels; the mobilization was carried on to splenic vein. the vessels, supplying the mass and arising directly from aorta, was isolated and taped with vascular clips. on the inferior margin of the lesion a large vessel, probably connected with previously embolized pseudoaneurysm, was dissected with vascular linear stapler. the mobilization was completed through difficult dissection from aortic plane and mesocolic posterior surface. the colonic perfusion was verified with fluorescence angiography. specimen was extracted through an endobag.a drain was left in pelvis. postoperative day .histopathological examination showed a morphological and immunoistochemical pattern for benign paraganglioma. conclusion: laparoscopic resection of paraaortic paragangliomas is feasible by skilled surgeon. the minimally invasive technique decreases perioperative morbidity and mortality. careful preoperative planning and surgeon's experience with vascular dissection and visceral mobilization are mandatory for a good outcome. aims: posterior retroperitoneal endoscopic approach has been considered for many years as a very complex and unsafe surgical technique. often attributed to a difficult location and visualization of retroperitoneal structures. in addition, surgeons were forced to work in a small and easily altered space due to discontinuous flow with constant changes of the retroperitoneal vision. lately this approach is emerging thanks to technological advances, mainly better visualization laparoscopic cameras and high definition screens, as well as continuous flow insufflators of co , maintaining stable and smoke-free cavity uninterruptedly. methods: it shows a management of a potentially serious complication and the reproducibility of the technique through the retroperitoneal approach. results: to operate with high pressure of neumoretroperitoneum allows to contain the hemorrhage and to value with relative serenity and security, the best surgical option to repair said injury being laborious due to the reduced workspace. conclusions: the posterior or retroperitoneal approach is feasible, safe and fast. although the possibility of injuring the vena cava in right adrenalectomy remains one of the most serious and feared complications. as shown in the video, posterior retroperitoneal endoscopic approach allows repair of vascular injury correctly and safely. methods: four patients undergoing adrenalectomy, two of them with right adrenal pathology and two left. minimally invasive access, endoscopic approach, is exposed in all of them. results: in the first two surgeries, right gland is shown. initially, transabdominal approach, which requires mobilization and separation of the liver to access the retroperitoneal space and subsequent proceed to adrenal extirpation. later, right retroperitoneal approach is observed, with a meticulous sealing of the adrenal vein prior to complete the dissection of the gland, despite the small cavity created by co . in the second part, both left adrenal approaches are exposed. transabdominal pathway is necessary to mobilize left colon and spleen to access a narrow space above the upper edge of the pancreas to locate adrenal gland. this is very different in posterior adrenal approach. conclusions: posterior or retroperitoneal approach is feasible and safe, allowing access to adrenal glands, located in retroperitoneal space, without across peritoneal cavity and its disadvantages. colon and small intestine mobilization is not necessary, with a lower rate of intestinal lesions and postoperative ileus. in the same way, liver or spleen mobilization is avoided. aims: when performing a laparoscopic adrenalectomy, especially in the setting of pheochromocytoma, one of the most important steps is to gain control of the adrenal vein early on in the procedure before great manipulation of the adrenal gland. we present the case of a year old female with episodic headaches and tachycardia and severe uncontrolled hypertension, found to have elevated plasma and urine metanephrines with ct scan localizing a . cm right sided adrenal nodule. the patient was prepared preoperatively with phenoxybenzamine until mildly orthostatic with dry mucous membranes and was taken for laparoscopic right adrenalectomy. methods: after positioning our patient in left lateral decubitus, ports were placed inferior to the costal margin. the right lobe of the liver was mobilized and retracted cephalad and the ivc was exposed. careful and meticulous dissection was carried up the ivc, however no main adrenal vein was encountered. the adrenal gland was then dissected circumferentially and was removed in an endoscopic retrieval bag. there was no difficulty in hemostasis and the patient was deemed to be hemostatic prior to withdrawal of the ports and extubation. results: our patient had no issues with hemodynamic stability and her blood pressure was within normal ranges during and following the case. her hemoglobin was stable postoperatively with . immediately post op and . on discharge. her pre-op hemoglobin was . . conclusions: our video demonstrates a right adrenal gland that was congenitally missing a main adrenal vein. it is very possible that small venous branches were taken with dissection however we believe this report to be important to note in the literature for surgeons performing adrenalectomy. surg endosc ( ) aims: adrenal cysts are the most frequently identified adrenal cysts, although they are a rare entity. typically they are presented by abdominal pain or palpable mass, but nowadays, cystic lesions of the adrenal gland are more often discovered incidentally by radiologic studies. adrenal cysts have an extensive differential diagnoses, which makes a difficult definitive diagnosis and a difficulty in later management. the management of an adrenal cyst can be summarized in three fundamental pillars: discard the functional status of the cyst, evaluation of eventual malignancy by images, and avoid possible complications (hemorrhage, infection), especially in large cysts . methods: clinical case: a -year-old male patient, with no history, studied for nonspecific pain in the right hypochondrium, without other accompanying symptoms. an abdominal ultrasound was performed, a cystic lesion in hcd without being able to identify the origin was seen. complementary explorations of interest are shown (ct), the biochemical study discards functionality of the lesion, negative serology for hydatidosis. the minimally invasive approach is the gold standard in the surgical treatment of adrenal pathology, so a laparoscopic approach is proposed for this patient. aims: endometriosis is a high incidence disease (approximately % of women) with a large impact on women's quality of life and fertility. endometriosis nodules surgical treatment is necessary every time there is evidence of active disease. the aim of this video is to present a minimally invasive technique for the resection of an endometriosis nodule from the abdominal wall. methods: a -years-old woman, with past history of endometriosis and a c-section, presents at the office with a palpable nodule at the rectus abdominis left lateral border, close to the umbilical scar. she had complaints of exuberant catamenial pain and magnetic resonance imaging (mri) showed a mm nodule compatible with endometriosis depot. this technique uses trocars ( ? mm) placed at the pfannenstiel scar. stepby-step as follows: (i) dissection of the pre-aponeurotic plane and isolation of the lesion (ii) lesion excision and its removal with sac (iii) closure of the aponeurotic defect braded suture. results: the post-operative period was uneventful and the patient was discharged home at post-operative day one. the aesthetic result was excellent and the patient was asymptomatic one month after the procedure. conclusion: endometriosis of the abdominal wall is related to previous c-section, is a rare event (incidence . - . %) and usually located in the subcutaneous fat underlying the scar. the presence of nodules in the depth of the muscle is much uncommon and particularly in this clinical case, the nodule was located cm cephalad from the previous pfannenstiel scar. this technique seems easy and reproducible in the authors' opinio. aims: general surgeons often face gynecological pathological findings, either along with other abdominal pathology, or as primitive cases that need laparoscopic expertise. with this particular presentation, our goal is to demonstrate the essential laparoscopic skills and the basic operative strategy that a general surgeon should be familiar with, in order to manage such cases. the presentation is made on occasion of a woman with multiple uterine fibromatosis of the pelvis, who was treated by our team. methods: we present video fragments of the laparoscopic excisional procedure for multiple uterine fibromyomatosis of the pelvis, highlighting the proper strategy in order to conclude the operation effectively and uneventfully, in a minimally invasive fashion. results: patients with multiple, large or other complex forms of uterine or pelvic fibromas can effectively be treated with a minimally invasive approach, with minimal blood loss, very fast recovery and minimal postoperative pain and complications. % of pregnancies require emergency surgery for a non obstetric indication, including acute appendicitis, cholecystitis, adnexal torsion, choledoco-lytiasis, hernias, intestinal obstructions, oncologic pathology or other less frequent indications. laparoscopic approach is the preffered surgical option for the patologies presented above. aims: to present the technical particularities and to analyze the outcomes of the emergency operations in pregnant women operated in hospital. method: a retrospective study including all the pregnant women operated in our hospital between - was performed. the preoperative workup and the surgical indication was discussed by a multidisciplinary medical team. the anesthesic and the obstetrical risk and their management was evaluated and specifically planned for each patient. the intraoperative and post-operative outcomes were recorded. results: patients with gestational age between weeks and weeks who underwent emergency laparoscopic procedures were included in the study. out of the cases we have performed appedectomies, cholecystectomies, adnexal torsions. with a min mean operating time, we had no major intraoperative complications; the technical challenges are presented and discussed. the hospital stay was , days ( - days). no major complications were associated with the laparoscopic approach in these cohort. one pre-term labour in a weeks gestational patient was post-operatively encountered. conclusion: laparoscopic surgery can be the first option for pregnant woman with non obstetrical surgical emergencies; challenges in diagnostic, management and surgical techniques of the multidisciplinary team are expected. the objective of this presentation is to demonstrate step by step the technique to the oncologic surgeon and gynaecologist in training, including some tips and pitfalls. this is a laparoscopic transperitoneal approach in a woman with advanced cervical cancer (figo ib ) that will be treated with exclusive radio-chemotherapy. the purpose of the laparoscopic lumbo-aortic lymph node staging is to define the irradiation field. in this indication false negative in pet ct ranges from to % (depending of the existence of pelvic fixation or not). the limits of this lymphadenectomy are: both ureters as the lateral limit of the dissection, iliac bifurcation as the caudal limit and renal veins as the cranial one. since the tumour is cervical and not ovarian, both ovarian veins are not resected. in the pathologic report, lymph nodes were examined free of cancer spread. the patient have had a radio-chemotherapy with restriction of the irradiation field on the pelvis. lymphocele is a frequent complication that only sometimes needs treatment ranging from dietary changing to percutaneous drainage. if conversion to laparotomy for bleeding this technique loose its benefice but this is a rare complication. this technique is feasible and safe but requires advanced laparoscopic skills. objectives: although extremely rare, isolated splenic metastases are being increasingly diagnosed due to the improvement of imaging, survival times, and surveillance of oncologic patients. this video alerts to the growing diagnostic dilemma with primary lesions of the spleen, particularly in patients with history of cancer, and reviews the laparoscopic splenectomy 'step-by-step'. case-report: -year-old male patient diagnosed with rectal cancer (g adenocarcinoma at cm of the anal verge) after a colonoscopy for rectal bleeding. thoracic and abdominal ctscan and pelvicmri, showed a ct n lesion, without distant metastases, except for a mm suspicious splenic lesion. cea- . ng/ml. after neoadjuvant therapy, a complete response was verified at the th week post-crt with a stable splenic lesion, and a 'watch-and-wait' program was initiated with no evidence of disease at the rd month. pet-ctscan did not show active metabolic features, despite an increase in the splenic lesion. in mdt, elective laparoscopic splenectomy was proposed and afterwards performed uneventfully. with the patient in semi-right lateral tilt, we approached the spleen inferiorly by dividing the splenocolic ligament. then we continued upwards, dividing the gastrosplenic ligament and exposing the splenic hilum, which was then carefully dissected, clipped and divided. finally the splenorenal ligament was divided and the spleen was extracted within an endobag, through a small pfannenstiel incision. pathologic report revealed a splenic lymphangioma. the patient is currently under a 'watch and wait' protocol surveillance with no signs of regrowth or relapse disease after year and months of follow-up. conclusion: one out of five colorectal carcinomas are metastatic at their presentation. isolated metastases to sites other than liver, lung or axial skeleton, are extremely rare, but can be found in the spleen. although the rare splenic secondary involvement is usually associated with breast, lung, melanoma, and gynecologic malignancies, if we consider solitary splenic metastases, colorectal and ovarian carcinomas are important sources. also, imaging including percutaneous biopsy, is frequently insufficient to clarify the nature of splenic lesions. for all these reasons, the decision-making process about this issue can be a true challenge, and will probably end up with laparoscopic splenectomy. therefore, surgeons must be familiarized with a standardized technique. sarcoidosis is a multisystem disease of unknown etiology characterized by the formation of noncaseating granulomas. sarcoidosis should be considered in the differential diagnosis of lymphoid disease. indications for diagnostic splenectomy includes a suspicion of a neoplasic process. the less invasive laparoscopic approach is the gold standard. case report: a -year-old female was referred to a general surgery department to complete a study to rule out lymphoid neoplasia. followed by hematology for cytopenias. biopsy of bone marrow and adenopathies were negative for lymphoid process. patient presented ct with multiple solid ( - mm) lesions in spleen, in thorax showed no pathological changes. laparoscopic splenectomy was performed. access with optical trocar, in mammary line. triangle -mm trocars after pneumo under vision. section with ligasure of gastroesplenic ligament with short vessels and phrenic-splenic ligament. identification and preservation of pancreatic tail. section of splenic vessels at hilar level (branches) with ligasure. lower pole release. release of posterior part with gerota and diaphragm. incision by aid helps in bag without fragmenting. review of hemostasis, extraction of trocars under direct vision. intraoperative findings: spleen with normal external appearance, not megalic. postoperative evolution: satisfactory. first hours without incidents and with analytical control without anemization. tolerance and mobilization starts without incidents. the histopathology report shows granulomas formed by epithelioid histiocytes with the presence of multinucleated giant cells of the foreign body type, in some perisinusoidal granulomas the giant cells with the presence of asteroid bodies in their interior. the material has been revised with the extension of special studies. conclusion epithelioid granulomatosis, non-necrotizing, which suggests sarcoidosis. the procedure lasted min. the hospital discharge was on the next postoperative day and no complication was registered. conclusion: splenectomy can be performed in a classic way, but at present the less invasive laparoscopic approach is the gold standard. indications for splenectomy include splenic tumours of unknown origin, suspicion of a neoplastic process, and splenomegaly. sarcoidosis should be considered in the differential diagnosis for lymphoid disease. postoperative pathological examination confirms the diagnosis. week-day surgery, university, sapienza, ospedale sant'andrea, rome, italy aims: we describe an interesting case of a female patient affected by a suspected echinococcus granulosus large cyst of the spleen. methods: a years old woman complained abdominal pain and a sense of gravity in the upper left abdominal quadrant. computed tomography scan(ct-scan) showed a centimetre (cm) cyst of the spleen with thickness of the wall and contrast enhancement uptake referred to an echinococcus granulosus cyst. the sierological blood test assessment, antigens and antybody markes, for echinococcus granulosus infection was negative. a laparoscopic procedure was planned. the patient was positioned on the right flank, four trocars were inserted along the left subcostal region of the abdomen: one millimetre (mm) trocar for camera, one mm for the assistant, and two of mm for instruments. a periombelical minilaparotomy was performed for the specimen extraction. results: post-operative course was uneventful. patient was discharged in third post-operative day. istopathological exam showed a simple epithelial cyst of the spleen. conclusions: laparoscopy is safe and feaseable in case of large cyst of spleen in condition of unclear nature of the cyst. laparoscopy permits to explore the abdominal cavity and to assess the cyst characteristics in a lack overlap between the radiological exam and blood test examination. surg endosc ( ) we describe laparoscopic splenectomy for recurrent splenic cyst after laparoscopic marsupialization and partial resection of splenic cyst. the patient was a -year-old woman with abdominal discomfort and with a -cm palpable mass in the left upper and inferior quadrant. she undergone years ago in another country a laparoscopic operation for splenic cyst. abdominal computer tomography revealed a cystic lesion of the spleen with concomitant huge splenomegaly. serology and oncological marker were negative. we performed laparoscopic splenectomy for the recurrent splenic cyst. the operation took min. histologic examination of the resected spleen revealed a chronic hematoma. the patient had no abdominal symptoms during months of follow-up. postoperative long term follow-up and examination by ultrasound or computed tomography is required after surgical treatment for splenic cyst to exclude the possibility of recurrence after spleen-preserving surgery. hand-assisted surgery is a recognized technique that combines the advantages of laparoscopic approach with the tactile feedback of the laparotomic one. it proved beneficial especially for the treatment of megaspleens due to lymphoma localization, thanks to safer handling of splenic vessels, major bleeding control and more effective detachment of superior splenic pole from the diaphragmatic dome. here we show an hand-assisted splenectomy for megaspleen reaching the omolateral anterosuperior iliac spine due to lymphoproliferative disease, in which the hand, inserted through a right subcostal minilaparotomy, was very useful during the dissecting manoeuvres, the splenic artery recognition and ligation and the isolation of the superior pole of the spleen from the gastric fundus and diaphragm. in any case of huge spleens, the specimen bagging is very difficult to perform in a pure laparoscopic way, not to mention the inexistence of capable endobag; besides, a minilaparotomy would be necessary for the spleen extraction. hand-assisted approach allow to overcome this not underestimable technical difficulty, reducing operative time with similar aesthetic and functional results to that of laparoscopic approach. aim: the evolution of technology and its application to the minimally invasive surgery of the thyroid gland offers new surgical techniques, like the transaxillary approach. this new procedure is still being implemented in our environment and has recently begun to be incorporated into our surgical practice. the objective of this case is to explain step by step how to carry out a right transaxillary endoscopic thyroidectomy and emphasize in the most relevant tips to take into account. also, current indications and limitations of this technique will be addressed. methods: a -year-old woman is referred for evaluation of a right thyroid nodule without any associated symptomatology. the blood test shows normal thyroid profile. cervical ultrasound is performed identifying a . cm single right nodule with well-defined edges and presence of peripheral vascularization. no other nodules are identified. fine needle aspiracion (fna) of the nodule describes a bethesda iii. after evaluation, a right transaxillary endoscopic thyroidectomy was performed. results: dissection begins in the subcutaneous plane above the pectoralis major muscle until identification of the sternocleidomastoid muscle. dissection continues towards the prethyroid muscles in order to perform a lateral approach of the thyroid gland. section of the upper pole allows better exposure of the recurrent laryngeal nerve (rln) which is being monitored intermittenly. identification and preservation of the parathyroid glands is the next step. surgery is completed with the section of the inferior pole of the thyroid along with the istmus. the postoperative period was uneventful and patient was discharged at h after surgery. final pathology revealed a cm nodule without malignancy. conclusion: surgical treatment of the thyroid gland by transaxillary approach may be indicated in previously selected patients with benign pathology, offering the advantages from minimally invasive techniques (shorter recovery time, shorter incision length, etc.). further research is required to make a better assessment of the minimally invasive approaches in thyroid surgery. we present the video of a thoracoscopic esophageal leiomyomaenucleation. it has been widely demonstratedthe advantages of theminimally invasive approach in surgery. esophageal thoracoscopic surgery has been suggested as an alternative to open procedures, presenting less surgical trauma, lower risk of bleeding, less postoperative pain, lower wound infection and lower pulmonary morbidity, showing similar oncologic outcomes. although leiomyomas are the most commonof benign tumors of the esophagus, they are relatively rare, presenting an incidence of - per . autopsy series. in our case, the patient was diagnosed of leiomyoma located at the medium third of the esophagus. he referred a history of months of dysphagia for solid and liquids and retrosternal pain. the complementary studies were esophagoscopy, esophagography, ct and endoscopic ultrasonography. the patient was operated by a thoracoscopy approach using ports. it was completed the enucleation of the tumor following the closure of the muscular layer. methylene blue test confirmed no leaks. the patient was discharged on third day postoperative developing no incidences. pathology report: leiomyoma cm size, actin and desmin positive; s- , cd and cd negative. we want to demonstrate the advantages of a minimally invasive approach in this kind of pathology. aims: this video shows our technique to perform thoracoscopic enucleation of large esophageal leiomyoma. methods: the patient is a -years-old woman with a six months history of progressively worsening dysphagia. chest ct scan revealed a cm lesion of middle esophagus with extrinsic compression of mucosa and no increased fdg uptake on fdg-pet scan. barium swallow study showed a lateral deviation of thoracic esophagus due to extrinsic compression. endoscopic ultrasound confirmed the suspicion of esophageal leiomyoma. patient was scheduled for a thoracoscopic enucleation of esophageal tumor. she was placed in prone position and one-lung ventilation was employed. three trocars were placed in intercostals spaces on right hemithorax. azygos vein was identified and transected between vascular clips. esophagus was circumpherentially isolated from mediastinal structures. after myotomy, the lesion was dissected from submucosal-mucosal layer. since air leak test excluded injury of internal layer, muscular layer was closed with a continuous suture. the specimen was extracted through an endobag. a drain was left in place. results: the postoperative course was uneventful and the patient was discharged on postoperative day . final pathological examination confirmed esophageal leiomyoma. conclusion: thoracoscopic surgery in prone position allows removal of large esophageal tumor with several advantages. the minimally invasive technique decreases perioperative morbidity and mortality. introduction: spontaneous esophageal perforation is life threatening disease and requires emergent surgical treatment. recently, the efficacy of minimally-invasive surgery such as laparoscopic and thoracoscopic surgery for esophageal perforation has been reported. we report a novel technique of minimallyinvasive abdominal and left thoracic approach (malta) for spontaneous esophageal perforation. case presentation: -year-old male, who had been under hemodialysis due to iga nephropathy, complained of chest pain after vomiting several times. since the ct scan showed left hydropneumothorax and pneumomediastinum, and the gastrografin study demonstrated extravasation from left side of esophagus, we diagnosed him with the spontaneous esophageal perforation and planed emergent surgery. the patient was placed in the reverse trendelenburg position, and the legs were split, with the left side of the upper body lifted in order to perform thoracoscopy and laparoscopy simultaneously. first, we explored the thoracic cavity through a mm port in the left th intercostal space and added other ports. we identified the rupture site mm in size on the left wall of the lower esophagus and sutured the mucosa and the muscle layer with a running suture respectively. we covered the perforation section with pericardium fat and irrigated the cavity with physiological saline. then transferred to the abdominal cavity, no contamination was found in the abdominal cavity. a feeding tube was inserted into stomach through the round ligament of the liver and the operation was completed. the total operative time was min and the amount of intraoperative bleeding was ml including pleural effusion. postoperatively, the patient experienced left empyema pleurae but no other severe complications and was discharged on postoperative day . conclusion: we experienced a rare case of spontaneous esophageal perforation of a patient under hemodialysis. malta is an effective procedure for emergent esophageal operation because of great visual field of the chest and abdominal cavity without expanding contamination. introduction: digestive caustic injury is associated with high morbidity and mortality with stenosis in the long term. surgical treatment involves resection of the esophagus and reconstruction with the stomach, colon or jejunum. coloplasty provides several advantages but its vascularization is complex and involves anastomosis. classically, vascular assessment was achieved by palpation through laparotomy and color evaluation. indocyanine green (icg) allows a minimally invasive intraoperative angiography in real time. methods: a -year-old female with medical history of caustic ingestion and subsequent esophagogastric stenosis, carrier of feeding jejunostomy. . thoracoscopy (prone position): dissection of the esophagus from the hiatus to the upper thoracic inlet. . laparoscopy: patient in the supine position, placement of five trocars. total non-oncological gastrectomy, post-pyloric section of the duodenum and omentectomy were completed. mobilization of the righ, transverse and descending colon. measurement of the transverse colon with a tape (distance from the neck and the esophageal hiatus). individualization of the righ, middle (with its branches) and left colic arteries and placement of clamps at the right colic, right branch of the middle colic and left colic arteries. cc of icg were injected allowing for an assessment of the colon vascularization. section of the right branch of the middle colic artery. proximal section of the ascending and distal colon near the splenic angle, preserving the marginal arch. silk point to join the staple line of the descending colon and the pylorys. side-to-side mechanical antiperistaltic anastomosis between the distal endo of the coloplasty and the jejunum. finally an anastomosis between the ascending and descending side-to-side mechanical anastomosis using an assistance incision in the left flank was performed. . cervical dissection: extraction of the surgical especimen under laparoscopic control. vascular assessment with icg is performed before and after the side-to-side anastomosis is performed. results: there were no intraoperative complications. the patient was discharged on postoperative day . discussion: we describe the first case of total minimally invasive colonic interposition with icg assessment of the vascularization. this technique, although technically demanding, avoids the drawbacks of the open surgery and allows for a precise assessment of the vascularization of the graft. surg endosc ( ) introduction: large pedunculated fibrovascular polyps are uncommon, mostly benign, intraluminal massess, usually located in the upper esophageal tract. most frequent reported clinical manifestation is dysphagia, followed by regurgitation, chest pain and intestinal bleeding. ct scan, and mri are the key in the diagnostic work-up revealing a sausage-shaped intraluminal mass. endoscopy with ultrasonography and biopsy add important information for the diagnosis and pedicle location. surgical excision is deemed due to potentially life-threating complication related to airway obstruction. the most frequent polyp resection is performed through cervical esophagotomy or by direct esophagectomy. however, this approach is related to a high morbidity and mortality rate. in the last years, few excisions have been reported by a endoscopical approach with a lower post operative complication. material and methods: this video shows the surgical steps of a trans-oral endoscopic surgical resection of a giant ( cm) pedunculated polyp in a year old man. the procedure was performed under general anesthesia. a flexible endoscope probe was used and the distal end of the polyp was extracted through the oral cavity with a loop. the endo-gia stapler was used to cut the base of polyp and finally removed. the anatomo-pathological study confirmed the diagnostic of a fibrovascular polyp with no evidence of malignancy. results and conclusions: the patient had an uneventful recovery with no recurrency at years of follow up. this minimally invasive approach is a safe and feasible procedure to treat large esophageal fibrovascular polyps avoiding the complications related to more aggresive procedure. introduction: leiomyomas are the most common mesenchymal tumors affecting the esophagus and they usually grow in the mid to distal third of it. they tend to be asymptomatic, but sometimes they can grow to enormous size and produce dysphagia. case report: -year-old male asymptomatic patient was referred to our hospital due to an incidental finding. ct scan revealed a x mm rounded submucosal tumor on the dorsal side of the lower third of the esophagus. upper gastrointestinal endoscopy revealed a cystic lesion in the lower esophagus cm from the incisor teeth, with normal overlying mucosa. an endoscopic-ultrasound-guided fine-needle-aspiration of the mass was performed, which was reported as a likely leiomyoma.conservative treatment was performed, no growth was detected during eleven years of follow-up. but it became symptomatic, the patient complained of progressive dysphagia caused by compression so surgical resection was decided.laparoscopic enucleation of esophageal leiomyoma was performed. the tumor was reached by transhiatal dissection. a careful dissection of the mass was performed, preserving the vagal branches. an intraoperative endoscopy was performed to verify the integrity of esophageal mucosa and that the tumor was completely resected. the muscular layer was sutured after enucleation using absorbable suture material and the hiatus was closed with non-absorbable suture material. a dor fundoplication was also performed. a swallow test with a water-soluble contrast was obtained on postoperative day one. no pathological findings were found so the patient was asked to drink.histopathological exam revealed a tumor measuring mm mm mm consistent with leiomyoma.the procedure lasted min. the hospital discharge was on the third postoperative day and no complication was registered. conclusion: surgical excision is the mainstay of treatment and is recommended for symptomatic leiomyomas and those greater than cm. this case report demonstrates the technical feasibility, safety and minimal postoperative morbidity associated with minimal invasive esophageal surgery. introduction: total esophagectomy by means of minimally invasive surgery has proven to be a valid and effective alternative for performing this procedure. however, this procedure is not implemented in most centers. objective: demonstrate the technique of a total esophagectomy by endoscopic surgery for a benign esophageal stenosis. material and methods: clinical case: a -year-old female patient diagnosed with double esophageal peptic stenosis, treated on several occasions with endoscopic dilation by digestive, showing in the last endoscopy: severe esophagitis with stenosis impassable to cms. additional tests of interest are exposed. resolved: intervention: right thoracoscopy in prone position, dissection and complete mobilization of the thoracic esophagus, section of the azygos vein, pleural drainage. laparoscopic time, trocars, gastrolysis respecting the right gastroepiploic vessels, broad kocher until the cava is identified, vascular section of the vessels left gastric, full mobilization of the stomach, subxiphoid minilaparotomy, beginning of the cervical time with dissection of the cervical esophagus, section and fixation of this to a tube, externalization of the piece by abdominal route, creation of the gastric tubular with successive loads of gia, ascending posterior mediastinal plasty with manual esophago-tubular anastomosis, with placement of drainages and feeding jejunostomy. right operative with radiological control with gastrografin on the th day, discharge from hospital on the th day. asymptomatic one year after surgery, with radiological control without alterations. conclusions: the approach of esophageal peptic stenosis with minimally invasive surgery is safe and effective, adding the advantages inherent to this type of technique. (figs. , ) , showing a cystic lesion in the gastric submucosa with a well defined, medial and superior to the lesser curvature of the stomach with exophytic growth. it causes extrinsic compression of the cardia in the gastric body. within the differential diagnosis are gastric duplication cysts or gastrointestinal stromal tumor. a biopsy was taken, discarding the presence of neoplastic cells. finally, a study of digestive transit showed extrinsic compression at the cardial level, which causes difficulty in passing contrast. a laparoscopic approach was performed beginning with the dissection of the abdominal esophagus. the presence of a cystic lesion on the anterior face of the abdominal esophagus was identified (figs. , ) . we proceeded to the complete resection of cyst. the surgery was completed with °f undoplication anterior dor. the patient went home on the rd day without incident. results: duplication cysts are congenital malformations of the gastrointestinal tract contiguous with the esophagus, which can communicate with the esophageal lumen. most are diagnosed in childhood, but when it is diagnosed in adults, they used to be symptomatics. it is more frequent in men. although the pathogenic mechanism is unknown, it is caused by an anomaly during embryonic development. they are located in the thoracic esophagus, at the level of the lower and posterior mediastinum and, less frequently, in the abdominal esophagus, as in our case. they can give digestive symptoms(epigastralgia, vomiting) or respiratory symptoms. the diagnosis is made with eda, ct, and ecoendoscopy of choice, although it may be incidental. the treatment of choice in symptomatic patients is complete resection or cystic enucleation. in asymptomatic surgical is not defined, because it can cause complications, and, malignization due to degeneration is very infrequent. conclusion: the most of duplication cysts are diagnosed in childhood, although it's more frequent in adults to be symptomatic. surgical treatment can cure this disease. however, the choice between these becomes difficult in young patients, where the low incidence does not allow get series of long patients and decisions must be based on results achieved in adults. objetivos: to demonstrate the safety and efficacy of the laparoscopic approach in this infrequent pathology, pointing out the importance of having standardized the procedure to achieve better results. material and methods: case report: a -year-old man with progressive dysphagia until almost complete afagia, with clinical, endoscopic, radiological and manometric diagnosis,compatible with typical primary achalasia. chagas negative serology,we show the complementary studies of interest.dilatation is not performed, preoperative symptomatic treatment with calcium channel inhibitors. intervention: laparoscopic approach, trocars, aberrant left hepatic artery with signs of severe esophagitis,opening of the gastroesplenic-hepatic ligament, no retroesophageal window, dissection of the hiatus and inferior mediastinal, preservation and mobilization of the left hepatic artery and the anterior vagus,meticulous disection of the cardia,standardized myotomy: first proximal cms. with adequate simultaneous traction of both edges of the myotomy, then distal myotomy including - cm, including selectively the distal oblique fibers of les, tutorization with fouché and methylene blue to confirm good step and absence of leakage, dor-type funduplication, pts on each side, fixed to both pillars, hiatalmediastinal drainage. egd on the st day of normal po, dischargeat rd day, asymptomatic and with normal radiological control at year of age. conclusions: laparoscopic mh should be the first therapeutic option, in patients with primary achalasia, even in young patients. the length of myotomy, especially distal to ueg is one of the most important aspects of surgery, most authors (pellegrini) recommend that the myotomy extend - cm in the stomach, even up to cm below the ueg to achieve an effective disruption of the eei.the standardization of the procedure is fundamental to increase safety and effectiveness in these more complex cases. aims: the surgical treatment of giant hiatal hernias is a complex and demanding procedure, not only in terms of performing the operation in a minimally invasive abdominal fashion by avoiding thoracic approaches, but also concerning the management of large hiatal defects which contribute to high recurrence rates. our aim is to present our surgical technique for the reconstruction of such hiatal hernias, exploiting the benefits of the robotic approach and also to highlight the technical aspects of non-absorbable mesh placement in order to bridge effectively the hiatal defects. methods: we present video fragments from a procedures selected from a series of cases of robotic reconstruction of giant hiatal hernias performed by our team, in which a non-absorbable meshes were utilized to restore the hiatal gap. we emphasize on the clear benefits of robotic surgery in these cases and on the strategy of how to avoid high recurrence rates. results: all of our patients, who underwent reconstruction of giant hiatal hernias with this particular technique, experienced very good early post-operative results, very short hospital stay and no recurrence in a -month follow-up. conclusions: the robotic approach for the treatment of large hiatal hernias offers great advantages to both surgeons and patients, by eliminating the restrictions of conventional laparoscopic surgery, minimizing intra-operative incidents and post-operative complications. large hiatal defects are very effectively closed with the use of advanced suturing techniques and non-absorbable meshes in a tension-free bridging fashion. aims: mckeown esophagectomy is commonly used for invasive esophageal carcinoma. as the morbidity and mortality rates for esophagectomy are persistently high, minimally invasive esophagectomy in prone position is expected to reduce respiratory postoperative complications. there is still limited experience for the use of minimally invasive approaches in patients undergoing surgery after neoadjuvant chemoradiation and many concerns about the feasibility, safety, and oncological outcomes of these procedures are still present. methods: we present the case of a -year-old female with a middle third esophageal squamous cell carcinoma, who received neoadjuvant chemoradiation. she underwent laparoscopic and thoracoscopic (prone position) mckeown esophagectomy with hand-sewn esophagogastric anastomosis through a left lateral cervical incision. results: the operation was completed successfully, with no conversion to open surgery. the operative time was h with minimal blood loss and the patient was fed on day and discharged on day post-op. r resection was achieved and the number of total harvested lymph nodes was ( positive nodes, n ). conclusions: minimally invasive mckeown esophagectomy in patients with esophageal cancer and prior chemoradiation is feasible and safe procedure with acceptable oncological outcomes. results: preliminary results demonstrated that minimally invasive ivor-lewis esophagectomy procedure, provided of a better postoperative pain control and less respiratory complications. in order to standarise our procedure, the video shows how three different types of esophagogastric anastomosis are performed, depending on the patient characteristics, anatomical factors and safety and comfort for the surgeon: manual termino-terminal, mechanical termino-terminal and mechanical latero-lateral. conclusions: in our way to standardization, we are still looking for the best type of anastomosis, even though, we find out that, manually performed anastomosis are easier to performed, when the section in esophagus is lower, involving medium and inferior third. in the other hand, mechanical termino-terminal anastomosis seemed to be an ideal option for upper sections. more studies are needed in order to standardized one anastomosis, for all cases. because esophagectomy with radical lymphadenectomy is highly invasive, thoracoscopic esophagectomy (te) is attracting attention as a less invasive procedure. we first performed te with the left decubitus position in . in we developed a hybrid of the prone and left lateral decubitus positions for te, and a total of patients underwent te with a hybrid position . we introduced te with a hybrid position for the following three reasons: ( ) mobilization and lymphadenectomy around the middle and lower esophagus are easier in the prone position. thanks to artificial pneumothorax and the gravity, the middle and lower mediastinum are opened, and which give us good surgical field. ( ) lymphadenectomy along the left recurrent laryngeal nerve (rln) is more reliable and precise when performed in the left lateral decubitus position. we can dissect lymph node around the rln higher position in the upper mediastinum. ( ) unexpected events requiring conversion to thoracotomy (e.g., massive bleeding, injury of other organs, dense intrathoracic adhesion, resection of adjacent organs) are easier to deal with in the left lateral decubitus position. the patient is fixed on the operating table with the semi-prone position and we can easily change patient positions from the left lateral decubitus position to the prone position and vice versa using rotation system of the operation table. the upper mediastinal procedure including lymphadenectomy along the right and left rln is performed with the patient in the left lateral decubitus position, while the middle and lower mediastinal procedures are performed with the patient in the prone position with artificial pneumothorax ( mmhg). theabdominal procedures wereperformed by hand-assisted laparoscopic surgery (hals) and gastric tube reconstruction through aposterior mediastinal route was performed as a standard surgical procedure in our institution. the magnifying effect of thoracoscope enables us to perform more precise surgery and preserve nerve and vessels, and a hybrid position is thought to be feasible and effective methods. ivor lewis esophago-gastrectomy is a standard procedure for the treatment of distal esophageal cancer. among the years, the surgical community standardized the mininvasive abdominal phase. the thoracic phase is much more complex because usually all surgeons get in trouble in the phase of esophago-gastric anastomosis. in fact, is still very difficult and tricky to perform a mechanical circular anastomosis due to problems with the correct handling of the circular stapler through the minitoracotomy and is also difficult to place the anvyl in the proximal esophagus. the linear anastomosis (side-to-side) is a little bit easier but not so effective as the circular anastomosis in terms of leak rate. we think that robotic approach with its endowrist can allow us to overcome these limits and that a tailored double layer hand sewn esophago-gastric anastomosis could be the right choice. we treated patients with this approach and they were all uneventful in the post operative period except for a case of chylothorax we treated successfully with lipiodol injection in inguinal lymphnodes. we need more cases to analyze the technique in terms of leak rate and major complications but we think this is a promising and cost-effective procedure for robotic approach. aim: anastomotic leakage is one of the most dreaded complication after esophagectomy. indocyanine-green near-infrared angiography (nir-icga) intraoperative use has been recently introduced for visceral perfusion evaluation. in this video we present our technique for gastric conduit fashioning according to the nir-icga blood supply evaluation in a total minimallyinvasive ivor-lewis esophagectomy. methods: a years-old man affected by a siewert adenocarcinoma (ct , n , m ) underwent a preoperative neoadjuvant treatment according to cross protocol. at restaging ct-scan no more pathologic nodes were evident (ct , n , m ). the patient was submitted to a total minimally-invasive ivor-lewis esophagectomy. surgical procedure: after pneumoperitoneum induction and trocars insertion, the lesser omentum was opened and a lymphadenectomy at stations a, , , and performed. the esophagus was dissected at diaphragmatic hiatus with lymphadenectomy at station , and . the larger omentum was opened along the right gastroepiploic arcade, that was preserved, the short gastric vessels divided and gastric fundus mobilized. by evaluating the presence of an intense fluorescence at nir-icga, a tailored partial tubulization of the stomach was performed with multiple linear stapler firing. a right thoracoscopy was performed through trocars. the azygos vein ligated and divided. the mediastinal pleura was opened and the esophagus was dissected entirely with an en-bloc excision of nodes at stations , and . nodes at stations , , and were removed separately. the esophagus was sectioned above the azygos vein level and a purse-string fashioned. the cardia and the gastric tube were pulled up and a minithoracotomy performed. a new nir-icga was repeated to verify the good blood supply and tailor the site of anastomosis on a well perfused area. the stomach was opened and a circular stapler inserted. after the end-to-side esophago-gastric anastomosis fashioning, the tubulization was completed by linear stapler firing and the specimen removed. results: the post-operative course was uneventful and the pathologic examination revealed a cardial adenocarcinoma (ypt ,n , r ). conclusions: nir-icga is an interesting and easy-to use tool for surgeons. nevertheless in literature is still not clear which is the best parameter to measure the blood supply. large studied are needed. aim: uses and application of indocyanine green (icg) fluorescence in the field of surgery are growing exponentially. the safety and feasibility of its usage has been proven in several areas and various pathologies of surgery and surgeons are starting to incorporate it into their common practice. however, there are still several aspects to define regarding this technology. we present different uses of icg in the specific area of esophageal cancer. methods: we used icg fluorescence at different moments of a two-field minimally invasive esophagectomy. first of all, peritumoral injection of icg may offer a lymphatic mapping, both in the abdominal phase of the surgery and the thoracic one, improving lymph node dissection by allowing a more targeted and less morbid approach that includes all relevant nodal stations. at the moment of the gastric section, intravenous injection provides assessment of gastric conduit perfusion, therefore optimizing the construction of the graft to avoid the inclusion of poorly perfused areas that may increase the risk of leak of the anastomosis. besides that, the esophagogastric anastomosis can be tested in the thoracic phase of the operation in order to check an adequate perfusion and prevent further complications. results: we consider that icg fluorescence is a promising technology that could be easily introduced in the surgical routine of the esophageal surgeon as an instrument to assess the anastomosis perfusion. icg is also feasible in detecting lymph node drainage from the esophagus, although its technique of application needs to be defined. conclusions: icg fluorescence has opened a new world of possibilities in all the different surgical specialties. its use in the esophagectomy is safe, simple and feasible. in a near future, its application to esophageal cancer surgery could improve survival by predicting and preventing anastomotic leak and guiding in a tailored lymphadenectomy. further research is needed to demonstrate these promising applications. introduction: the oesophagectomy is currently still mandatory in the curative treatment of the malignant oesphagic pathology. this procedure is defined by important morbidity and mortality. the minimally invasive approach aims to reduce the complications without repercussion on the oncological outcomes, however it's not exempt from them being a demanding surgical technique like it is. aim: we present the video of three complications after a three-stage oesophagectomy (mckeown-like) with the thoracic stage via thoracoscopy and the minimally invasive surgical solution for both of them. methods: all three cases represent a three-stage oesophagectomy for malignant esophageal pathology. the first one was a -year-old male who suffered an intraoperative left main bronchus injury. the second case was a -year-old male with no intraoperative complications whatsoever. nonetheless, on the second postoperative day, milky drainage started to appear through the thoracic tube. the third and final case represents an intraoperative hemorrhage, which is the most common complication of this kind of surgery. results: the first case was diagnosed and treated intraoperatively with the use of an adhesive matrix. during the postoperative period the patient showed no further complications. the second case was a chylothorax, diagnosed on the second postoperative day. it was treated initially with conservative measures. due to bad evolution, he underwent surgery on the tenth postoperative day. we can see how we ligated the stump of the thoracic duct in the original surgery and then how we repaired the unexpected leak. after the second surgery, the patient was discharged on the sixth day. the last patient was also diagnosed and treated intraoperatively successfully, with no repercussion whatsoever in the postoperative time. conclusions: the minimally invasive surgery has many advantages in the upper gastrointestinal field. it is a demanding technique, so it is important to be able to treat the complications that may arise with this approach. surg endosc ( ) aims: the use of icg fluorescence is incrising in surgery, mainly as a test of vascular supply in colonic anastomoses. during the last years, other potential uses have been described, such as the identification of the sentinel lymph node and lymphatic mapping in oncological surgery. these advances could allow a better staging in order to decide the most appropriate treatment to each patient. gastric cancer is one of the fields where this could play a key role in the near future. we present a case of a patient who underwent a laparoscopic total gastrectomy with icg-guided d lymphadenectomy, where a personalized lymphatic mapping was performed. methods: a -year-old male patient underwent gastroscopy for gastric discomfort, and a gastric carcinoma was detected at the greater curvature of gastric body. endoscopic biopsy was informed as diffuse type gastric adenocarcinoma. the preoperative staging was completed with echoendoscopy and ct-scan (t bn m ). we decided to perform a laparoscopic total gastrectomy with icg-guided lymphadenectomy. the preoperative day, a gastroscopy was performed to inject . mg of icg in four submucosal areas around the tumor. results: intraoperatively, the lymphatic mapping marked by icg was checked, allowing the identification of the territory of drainage of the tumor to lymph nodes at the lesser curvature, the greater curvature and the splenic artery. a d lymphadenectomy and a total laparoscopic gastrectomy with roux-en-y reconstruction was performed. during the lymphadenectomy, we were able to observe marked lymph nodes in territory , and also observed that the paraaortic lymph node behind the celiac trunk did not become green and the lymphadenectomy at this area was not continued. the patient presented no postoperative complications, and was discharged on the seventh postoperative day. the histological results showed a diffuse type gastric adenocarcinoma pt n and isolated lymph nodes, being one of them possitive (corresponding to the adenopathy marked at the greater curvature). conclusions: lymphatic icg-mapping in gastric cancer is a potential revolutionary advance that could ensure a correct lymphadenectomy, avoiding lymph node understaging. it is necessary to continue carrying out studies that will allow developing protocols to define appropriate lymphadenectomy based on icg-mapping. introduction: petersen's hernia is one of severe postoperative complication after gastrectomy, which may result in massive resection of small intestine. it is considered an essential proscedure to close the petersen's defect for all cases after such reconstruction after gastrectomy as roux-en y method. we report a case of petersen's hernia after radical gastrectomy, which was repaired laparoscopically. patient: the patient was -year-old male, who underwent laparoscopic distal gastrectomy for gastric cancer (d lymph node dissection followed by roux-en-y reconstruction) two years ago. the closure of petersen's defect was not performed in the initial operation. he was aware of abdominal pain and visited emergency unit in our hospital. abdominal ct scan showed internal hernia of petersen's hernia. surgical procedure: in laparoscopic examination, dilation of small intestinal and mastoid ascites was observed. massive small intestine including y-limb entered into petersen's defect from left to right side. we carefully pulled through the small intestine and confirmed absence of ischemic change in the whole small intestine. then the petersen's defect was closed by continuous suturing with - non-absorbable barbed suture. results: the operation time was min and the estimated blood loss was ml. oral intake was started from the next day of the operation. there was no postoperative complication. the patient was discharged on the th postoperative day. conclusion: we could safely perform laparoscopic repair for petersen's hernia. regarding technical points in the procedure, it is important to judge the direction of the small intestine into the petersen's defect, to manage the dilated small intestine gently, and to close the petersen's defect by laparoscopic suturing. introduction: in this case we present a -year old male with a history of morbid obesity, sleep apnea and psychiatric affliction including alcohol and nicotine abuse. in he underwent a laparoscopic roux-en-y gastric bypass. the results were satisfactory, with no complications post-surgery, and a steady weight loss over time (pre: kg, post: kg). in november , he presented with complaints of dysphagia and weight loss ( kg in months). laryngoscopic examination by the otorhinolaryngologist was negative. he was referred to gastro-enterology for gastroscopy. biopsies showed a mildly differentiated adenocarcinoma of the gastro-esophageal junction with submucosal invasion. objective: after negative staging assessment, multiple treatment options were considered. the route of choice ended up being a laparoscopic radical gastrectomy with esophago-jejunostomy, with the objective to achieve optimal oncological results. methods: the procedure is demonstrated in this video. the gastric pouch as well as the remnant stomach, greater and lesser omentum were resected laparoscopically. due to the invasion of the carcinoma into the distal esophagus, a segment of the esophagus was resected as well. following anatomopathological examination on frozen section, the resection margins were reported malignancy free. results: postoperatively, there were no complications. ct scan with contrast showed no signs of leakage. anatomopathological examination confirmed the tumor to be a mildly invasive and poorly differentiated adenocarcinoma with local signet-ring cell differentiation (pt bn ). there was no need for adjuvant therapy. oral intake was sound. conclusion: adenocarcinomas of the gastric pouch are rarely seen following gastric bypass. this patient presented with complaints of dysphagia, and an adenocarcinoma was diagnosed. consequently, the patient had a total gastrectomy at our hospital. the surgery was performed laparoscopically, and was executed with success. to conclude, it is feasible to treat adenocarcinomas after gastric bypass laparoscopically via total gastrectomy and omentectomy. year old, female patient presented with upper abdominal discomfort and microcitic anemia. an ulcerative lesion was found on gastroscopy examination in body of the stomach (near the grate curvature). biopsy was done and pathology result showed poorly differentiated adenocarcinoma. chest computed tomography (ct) was without any significant findings. abdominal ct showed the lesion in stomach without enlargement of regional lymph nodes. her blood laboratory examinations were within normal limits, including serum cea. patient underwent laparoscopic total gastrectomy with modified d lymphadenectomy and roux-en-y esophagojejunostomy. total operating time (ort) was min. three days after operation, patient has developed none st elevated mi and respiratory failure. she was intubated. on day after operation she was extubated, on day patient started regular diet and was discharged home on day . final pathology result confirmed poorly differentiated adenocarcinoma of the stomach. this video shows our favourite technique for laparoscopic d subtotal gastrectomy. we usually perform the procedure with or trocars; after the coloepiploic detachment we perform the gastric transection first! this manoeuvre provides a perfect view for the lymphadenectomy. at the end of our dissection we transect the duodenum with seamguard reinforcement. before going on with the reconstructive phase, we prepare the roux en 'y' with double loop technique, usually without dividing the mesentery. then we remove the specimen through a periumbilical - cm minilaparotomy; we think it's important anyway to check margins and distance from the tumor before going on with the reconstructive phase. from the same minilaparotomy we retrieve the prepared limb for roux en y and we perform a side to side mechanical linear anastomosis outside.then we proceed with performing the anastomosis between the gastric pouch and the alimentary limb by laparoscopy. we like very much this technique for the increased exposition of tissues during lymphadenectomy. laparoscopic roux en 'y' d surg endosc ( ) a body-tc was performed in which axillary, mediastinal adenopathies and images suggestive of hepatic metastases were identified. the biopsy confirms a gastrointestinal stromal tumor. the case discussed in a multidisciplinary committee and the pet-ct study was completed, subcardial gist t n m was diagnosed. neoadyuvance was decided with imatinib for one month and surgery was performed using a laparoscopic approach. the approach was performed with trocars ( mm supraumbilical, two mm subcostal left and right, mm subxifoid and mm left flank). gastrectomy was performed with d lymphadenectomy following the oncological principles of subcardial tumors. the piece was removed in a bag by extending the mm port to mini-laparotomy. esophagogastric anastomosis was performed by hand assisted circular mechanical suture. methylene blue test was carried out. no nasogastric tube left, but drainage tutoring the esophagogastric anastomosis was left. results: the postoperative evolution was favorable. oral tolerance without incidents at fourth postoperative day. the patient was discharged without incidences on the seventh postoperative day. the pathological study of the piece was reported as subcardial gastrointestinal stromal tumor cm with respected surgical margins and lymph nodes free of malignancy, postoperative diagnosis of t n m . one month after surgery, the patient has adequate oral tolerance. she does not report gastroesophageal reflux and at months remains asymptomatic and with good evolution. conclusions: laparoscopic proximal gastrectomy is a technique that is not currently used but can be performed through a laparoscopic approach. it is a safe technique with good clinical and oncological results, especially in the early gastric cancer and gastrointestinal stromal tumors. however, long-term studies are necessary. laparoscopic gastrectomy is a perfectly safe option nowadays for the treatment of gastric cancer. every year the percentage of the laparoscopic approach is rising not only in the east but also in the west. we present a case of a year old female patient with a gastric tumor of the antrum-g adenocarcinoma with a ct n m staging. we perform a subtotal laparoscopic gastrectomy with a d lymphadenectomy and roux-en-y anastomosis. the patient begin clear liquids on the first post operative day and was discharged on the th. the final anatomopathological result of the specimen was a adenocarcinoma (g )-pt n . there were nodes resected all negative. the case was discussed in multidisciplinary team and was decided for clinical follow up with no further treatments. the patient was evaluated one month after surgery with no complaints and will continue the follow up. upper gi surgery, university of verona, verona, italy laparoscopic endoscopic cooperative surgery is an option in medium size submucosal cancers invading the muscular layer, mainly in border area were wedge resections are nor feasible.in this video we report a case of prepiloric gist treated with news technique (nonexposed endoscopic wall-inversion surgery).we think that this technique is feasible and safe and should be considered a valid option with a view to preserving the organ. aim: laparoscopic wedge resection or partial resection is a safe and feasible stomach preserving approach to gastric submucosal tumors (smt) such as gastrointestinal tumors (gist), and it has been widely performed recently. however, it should not be applied to the tumors at cardia in order to avoid stenosis or disruption of anti-reflux mechanism. we have introduced percutaneous endoscopic intragastric surgery (peigs) for smt at cardia since to preserve function of cardia. we will report the tips, techniques, and clinical result of our peigs. methods: from september to august , seven patients with smt at cardia underwent peigs in our hospital. we insert the mm port at umbilicus and investigate the abdominal cavity at first. then the incision is extended to . cm and lap-protector tm is equipped with the site to perform mini-laparotomy. using peroralendoscopy, a stomach was insufflatedand incision is made at an anterior wall of gastric body under direct vision. additional lap-protector tm is placed into the stomach so that the stomach is fixed on the abdominal wall. it enables us to keep direct access to gastric lumen and stable operative field. ez access tm is attatched on lap-protector tm , and intragastric operation is started. subsequently, two trocars are inserted using funada's gastropexy instrument. tumor is dissected by using energy devices, avoiding injury of capsule of the tumor. the defect of the gastric wall is closed by intragastric suturing. we should take particular care not to damage egj during the suturing, inserting peroral endoscopy in and out. results: the mean operation time was ( - ) min and the amount of intraoperative bleeding was . ( . - . ) ml. the maximum diameter of tumors was ( - ) mm. one case was low risk gist and otherwise were leiomyoma. the postoperative course was uneventful in all cases, without leakage or stenosis. total hospital stay was ( . - ) days. no patient had symptoms of esophagitis. conclusions: peigs for smt at gastric cardia is a feasible and safe approach, preserving function of cardia. our procedure achieves great stability and excellent visualization during the operation, which may have led to the fine surgical results. laparoscopic lymphadenectomyin gastric cancer is considered a feasible and safe procedure. data on the compliance of lymphadenectomy in the various lymph node stations is not yet well understood; moreover it is not clear if there are particular conditions relate to the patients impairing the oncological results. this video reports the use of the icg for the lymph node dissection of station number in a case of obese patient and a case of a cirrhotic patient. fist patient, m.a., was a year old man with distal cancer ct n and a bmi. second patient, t.d., was a year old man with distal cancer ct n and a alcoholic cirrhosis child b . in both cases, intraoperative endoscopy was performed to min before the onset of lymph node dissection. . mg of icg was injected into the submucosal layer in quadrants of the primary tumor. a laparoscopic subtotal gastrectomy was conduced with d lymphadenectomy. lymph note navigation were analyzed by novadaqÒ detector. using navigation system we removed the n basin. in both cases dissection were effective and pancreatic surface were easily detectable. number of lymph nodes retrieved was in the case of obese patient and in the case of cirrhotic patient. pathological tnm were pt n ( / n ?) in the first case and pt n ( / n ?) in the second. no n ? metastases were detected in n station for both cases. no pancreatic fistula was recorded. icg lymph node navigation system should be considered a valid support for the surgeon for completion of a correct lymphadenectomy in surgical challenging cases. aims: morgagni hernia is the rarest of congenital diaphragmatic hernias ( - %). its presentation is rare in adults and its finding is usually incidental. it was first described by giovanni b. morgagni in . it is located in the anterior region of the diaphragm. it is caused by a congenital defect in the fusion of the transverse septum of the diaphragm and the costal arches. the need for surgery depends on the presentation, it is recommended early repair before the development of complications. classically, the surgical approach was thoracotomy or laparotomy. currently, the tendency is to use a minimally invasive approach, which has shown good results, lower morbidity and faster recovery. the need to repair the defect with a mesh is controversial, recommended when it is not possible to close the defect without tension. the objective of this video is to demonstrate the safety and efficacy of the laparoscopic approach for the repair of this type of hernia, as well as the different types of mesh that can be used. aims: the treatment of the non-metastatic gastro intestinal stromal tumour (gist) is the surgical resection [ ] . the duodenal gastro-intestinal stromal tumour (gist) is a relatively rare clinical entity. from all the resected gist, only % are duodenal [ ] . the clinical presentation could vary from the most common acute gastro intestinal (gi) bleeding, chronic anaemia, but also acute abdomen caused by tumour rupture and intestinal obstruction. methods: a years old patient present at the emergency department of the chi poissy-st germain-en-laye (paris, france) with acute gastrointestinal bleeding. at the laboratory exams the haemoglobin was . g/ dl. the patient perform a computer tomography (ct) which shows two hyper vascularised lesion at the th duodenum; this lesions has an intra and extraluminare growing. the ct scan didn't show any other abdominal lesions. the patient were submitted to a minimally invasive surgical operation with the multiport laparoscopic technique. results: the resection of the th and th duodenum and of the first centimetre of jejunum was performed with a four trocar laparoscopic technique. a latero-lateral duodeno-jejunal mechanical anastomosis was performed. the operative time was min. the patient start with oral alimentation on the third post-operative day after a ct scan with oral contrast that was negative for anastomotic dehiscence and collections. the post-operative course was globally uneventful and the patient was discharged at fifth post-operative day without complications. the histological examination shows a low risk gist, cd positive and with a ki- inferior of % (classification tnm th edition pt aims: gastric volvulus are a rare condition that sometimes represent a diagnostic challenge for surgeons. here we present the video of a recent case of a gastric volvulus in our area that was treated with a minimal invasive approach. methods: we report the case of a -year-old woman who was admitted in the emergency room (er) with epigastric transfixing pain and impossibility to vomit that had started h prior to the admission. the physical exam showed good vital signs, and her abdomen was soft, with a tendency to tenderness with palpation in the epigastrium without guarding or rigidity. her lab tests were normal and the conventional radiology showed a double gastric bubble. we run an urgent computed tomography scan (ct scan) and a upper gastrointestinal (gi) endoscopy that showed a big type ii hiatal hernia that was complicated with a gastric volvulus. results: first, a nasogastric (ng) tube was placed for decompression of the stomach at the time when the endoscopy was made. the patient experienced a great improvement of the pain with that initial measure and remained stable. after almost a day of appropriate resuscitation, she underwent urgent surgery: we performed a hernia reduction, resection of the hernia sac, hiatal closure and a gastropexy and nissen fundoplication. the patient suffered no complications in the immediate postoperative time and was discharged after six days. conclusion: gastric volvulus are an uncommon emergency that we need to keep in mind. a simple abdomen x-ray can be very helpful, given that the double gastric bubble sign is a typical sign of this condition. it's always mandatory to perform an upper gi endoscopy in order to get to the diagnose and place a ng tube promptly. the surgery can be safely delayed in stable patients with no signs of ischemia, and a laparoscopic approach is associated with a shorter hospital stay and good long-term outcomes in this kind of patients. aims: during laparoscopic treatment of hiatal hernias the dissection can be complicated, but even more so the closure of the pillars, especially in giant hiatus hernias with a large defect. the use of prosthesis is controversial due to the lack of long-term studies and the possibility of secondary complications. the aim of this video is to demonstrate the safety of mesh hiatoplasty in hiatus hernia surgery. methods: we present the case of a -year-old woman with hypertension, hypothyroidism and right hemicolectomy for neoplasia years ago. the patient presented with malnutrition, with a weight loss of kg in the last months. a gastroscopy was performed in which a large hiatus hernia, that caused gastric volvulation, was shown. the upper gastrointestinal oral contrast study revealed esophageal tertiary waves and good passage to the gastric chamber, with an organoaxial volvulation of the stomach that was completely included in the thoracic cavity. results: through a five trocar laparoscopic approach, a large paraesophageal type iv hiatal hernia ( cm hiatal orifice) with complete herniation of the stomach and greater omentum to the mediastinum was observed. after reduction of the hernia content, complete dissection with partial resection of the sac was performed. an extended mediastinal dissection of the esophagus, with descent of the esophagogastric junction until achieving an abdominal esophagus of - cm, was carried out. after posterior and anterior phrenorrhaphy with nonabsorbable sutures, dislacement of the right pillar without diagragmatic opening was evidenced. it was decided to reinforce the hiatorraphy using a c shape composite mesh fixed with nonabsorbable sutures. the procedure was completed with a nissen-type fundoplication. postoperative course was uneventful and the patient remains without hernia recurrence months after the intervention. conclusion: prosthetic reinforcement in hiatal hernia repair can be a very useful resource in large hiatal defects in which a stress-free hiatus closure cannot be achieved. however, its use must be individualized according to the characteristics of the patient, the quality of the tissues involved and the result of simple hiatorraphy. aims: heller myotomy is an advanced laparoscopic surgical technique for the treatment of achalasia, a rare disease in which long time is needed to achieve the learning curve. surgical simulation, using animal models with an anatomy similar to humans, could help improving surgeon performance in a shorter time. the aim of our video is to show an ex-vivo and in-vivo animal model for heller myotomy training. methods: a cadaveric porcine model was developed using a tissue block including the esophagus and the stomach, without the diaphragm, mounted in a physical laparoscopic simulator. training procedures were also performed in an in vivo porcine model. experiments were carried out in the ' jesús usón' minimally invasive surgery centre in cáceres. results: the surgical technique is described step by step, first in the esophagus-stomach ex-vivo model and later in the live animal model. conclusion: surgical simulation using cadaveric an live animals offers a realistic representation, allows training in a safe environment, and can be very useful for advanced laparoscopic training in low incidence pathologies. introduction: esophagic perforation is one of the least frequent complications after laparoscopic nissen fundoplication, but it remains one of the most dreaded because of its morbidity and mortality rates and its technically difficult reparation. aims: to present how the authors dealt with an iatrogenic esophagus perforation post laparoscopic nissen fundoplication. methods: the authors report the clinical case of a -year-old woman who underwent a laparoscopic nissen fundoplication because of a symptomatic large hiatus hernia in a different hospital. the second postoperative day and after resuming oral intake, she presented respiratory and hemodynamic instability. she needed a chest tube that drained purulent content. the patient was referred to our hospital for clinical management. an urgent ct scan with oral contrast was performed without showing any leakage. results: in spite of the results, as the patient was unstable, she underwent an emergent diagnostic laparoscopy. it was found a small anterior esophagus perforation with right mediastinic collection. a running suture of the perforation was carried out and the nissen fundoplication was converted to a dör fundoplication. the operative time was min. she went to the intensive care unit for ten days. five days after the surgery, she was given methylene blue with no exteriorization through the drainages. as postoperative morbidity, she suffered from a right pneumonia and a thoracic collection that was treated by thoracic surgeons. the patient was finally discharged on the th postoperative day. she did well at home. she attended follow-ups without clinical reflux or any other particular condition. conclusions: esophagic perforation is a life-threatening complication that can be managed laparoscopically if it is detected soon after surgery and an expertise is available. surgical treatment of achalasia fails in - % of patients. the most frequent responsible cause is a previous incomplete myotomy, followed by fibrosis and aspects related with antireflux procedure. revisional surgery can represent a greater difficulty and a challenge. in this video we show revisional surgeries after heller's myotomy with dor fundoplication for achalasia. all cases presented a recurrence of the symptomatology and a revisional surgery was proposed. surgeries were characterized by the presence of a herniation of the previous fundoplication, fibrosis around the prior myotomy and/or the formation of a pseudodiverticulum. we show the steps followed and the aspects to consider during the dissection. these cases demonstrate that laparoscopic reoperation for achalasia is feasible, even after open surgery. aims: upside-down stomach (uds) is a rare type of large paraoesophageal hernia, characterized by migration of the entire or large parts of the stomach into the posterior mediastinum. uds is associated with severe complications like strangulation or volvulus development, possibly leading to acute gastric outlet obstruction and incarceration. surgical repair is the only curative treatment option and therefore recommended for these patients. standard procedure includes a hiatoplasty followed by an anti-reflux procedure. in a variety of studies, the use of mesh proved to be superior with respect to reduction of anatomical recurrences. methods: a -year old woman presented to us with reflux symptoms, dysphagia, dyspnea and tachyarrhythmias. she reported a weight loss of kg in the last months. ct scan and esophagogastroscopy showed a large paraoesophageal hernia, measuring approximately cm, with intrathoracic uds. results: we performed a laparoscopic hernia repair with dissection of the hernia sac from the posterior mediastinum, tension-free intrabdominal reposition of stomach and distal esophagus and hiatoplasty with biologic mesh (tutomesh tm ) augmentation. finally, a toupet fundoplication was performed to recreate the antireflux valve. in consequence of pronounced adhesions, a lesion of the muscularis of the distal esophagus occurred during surgery. the esophageal mucosa was unaffected. we treated the lesion laparoscopically with a simple interrupted suture (vicryl tm - ). an intraoperative patent blue v leak test did not identify any leaks. the recovery was uneventful. the patient was discharged on day after surgery and was free of symptoms in her follow-ups. conclusions: patients with large hiatal hernias and uds can be treated successfully and effectively with laparoscopic mesh repair. intraoperative complications can be handled laparoscopically in a safe manner. iatoplasty followed by nissen fundoplication represent the gold standard treatment of hiatal hernia; however it has been reported high hernia recurrence rate, especially in case of giant hiatal defects. in order to reduce recurrence rate, various techniques of hiatoplasty reinforcement have been implemented, such as prosthetic materials apposition. however, in literature have been reported various mesh complications such as esophageal and proximal stomach erosion and late esophageal perforation after ischemia, especially in case of synthetic non absorbable materials.in this video we are going to show the repair of a huge hiatal hernia by hiatoplasty and positioning of an absorbable biosynthetic 'bio a' mesh which is replaced by connective soft tissue over six months, therefore decresing complications and recurrence rate.as usual, we start with the mobilization of gastric fundus and isolation of diaphragmatic pillars by sectioning the aderences between them and herniated viscera. we proceed then with intrabdominal esophagus mobilization and higher mediastinal dissection in order to obtain an adequate esophageal lenght. after the exposition of the hiatus, we approximate the pillars with some non absorbable stitches and we reinforce the hiatus positioning a 'u' shaped bio a mesh over the esophagus, simply fixed to crura with single stitches. then we go on performing nissen fundoplication.the use of this prosthetic material appears to be cost-effective; first series in literature show very low complication rate and less recurrences of hiatal hernia than hiatoplasty without reinforcement. this video demonstrates the technique of laparoscopic identification and complete dissection of the sac of a totally intrathoracic stomach. identification of the sac is performed centrally by scoring the peritoneum overlying the arch of the diaphragmatic hiatus. the inferior edge is retracted and series of blunt dissection is undertaken. once the areolar tissue of the avascular plan is visualized; a raytec sponge is placed and advanced cephalad to expose the extra-saccular space. this raytec is kept in place to allow carbon dioxide to infiltrate and further delineate the anatomy. we then proceed with dissection at the left crus and right crus. complete reduction of the stomach can be achieved without grasping it. this can be performed by applying caudal retraction on the sac. this maneuver exposes the plane outside the sac. this space is divided into two compartments (right and left) separated by a septum which indicates the proximal extent of the sac. this plane is avascular and blunt dissection can easily free the hernia sac from the mediastinal structures and the pleura. this was followed by excision of the sac and hiatal repair which is reinforced with bioabsorbable mesh. the proximal short gastric vessels were then divided and a standard toupet fundoplication was performed. v -upper gi-reflux-achalasia introduction-objectives: the mixed giant hiatus hernias with paraesophageal component are hernias of difficult surgical correction, the laparoscopic approach of these implies a greater experience of the surgical team, given the complexity involved in its management, being the recurrence a complication that neither the use of meshes in this surgery has been able to avoid. in very high-risk patients, the gastric anterior pexy (boerema) may be an alternative to treat or alleviate the symptoms of these large hiatal hernias, although the frequency of recurrence with this technique is very high. material and methods. objective: the objective of the following case is to present a patient with type- hiatal hernia, barrett's esophagus without dysplasia and situs inversus. method: a laparoscopic partial fundoplication was performed on a -year-old male patient with a history of situs inversus totalis, who was seen in our general surgery service presenting a clinical history of retrosternal pain, heartburn and regurgitation. an endoscopy was performed, which reported hiatal hernia type and incompetence of lower esophageal sphincter, with squamocolumnar junction biopsies with report of barrett's esophagus without dysplasia. results: surgical time was programmed, for toupet type fundoplication; there were lax adhesions from omentum to wall, the lax hiatus and already known situs inversus. partial funcuplication was performed, with the usual technique adapted for structural anatomical abnormality, postoperative course without complications, oral initiation at the next day, drainage penrose type was set draining just a little serohematic liquid, diet was progressed and patient was discharged on the third postoperative day without complications. conclusion: situs inversus is the mirror image of situs solitus, which presents subdivision in situs inversus totalis, which is the most usual form, characterized by the mirror location of the intraabdominal and thoracic organs including the heart; in the case presented, the patient was referred with situs inversus and barrett's esophagus, performing laparoscopic fundoplication. the gold standard of surgical management is laparoscopic in benign esophageal pathology. gastroesophageal reflux disease (gerd) is a condition that reduces the quality of life and can causedisorders associated with acid reflux, such as bronchial asthma, barrett's esophagus and esophagealadenocarcinoma. gerd is often caused by existing of hiatal hernia. in rare instances gerd is associatedwith type iv hiatal hernias in which the part of stomach and other organs migrate into mediastinum.nowadays this condition can cause problems for some surgeons.patient was a -year-old man. he was diagnosed with hiatal hernia in . the condition had beenhaving asymptomatic course until . patient takes omeprazole mg for years. he startedexperiencing chest pains when inhaled and dyspnoea in june . co-morbidities were: arterialhypertension, chronic obstructive pulmonary disease (copd) and obesity (body mass index was . kg/m ). the posterior mediastinum contained the part of stomach, large bowel and small bowelaccording to chest roentgenography. sizes of esophageal hiatus were mm. in our clinical centerwas performed laparoscopic removal of hernia, cruroraphy, mesh repair of the esophageal hiatus andnissen fundoplication in july. during the surgery stomach, the part of small intestine, greatomentum and transverse colon were relocated into abdominal cavity. after cruroraphy, repair of theesophageal hiatus with prolene mesh was performed. the patient was in intensive care during h.total enteral feeding was initiated on second day. patients had been discharged within days aftersurgery. patient was re-examined by a surgeon in september , there were no signs of a reccurence.this case report shows an efficiency and feasibility of the laparoscopic approach to the treatment gerdassotiated with a large defect in the phrenoesophageal membrane, allowing other organs, such as colon,great omentum and small intestine to enter the hernia sac. aims: the authors present a video with their standardized laparoscopic hiatal hernia repair and anti-reflux nissen procedure but using mm instruments and mm camera approach. methods: a years old female patient with a bmi presents a symptomatic gastro esophageal reflux disease (gerd) for years. manometry and ph-metry showed a lack of esophageal motor disorders and a severe acid pattern with a . demeester score. panendoscopy study showed a cm hiatal hernia and a los angeles-grade esophagitis. she decided not to go with ppi treatment anymore. a laparoscopic hiatal hernia repair and standardized nissen procedure is performed using mm instruments and a mm camera. case and technical details are shown in the video. results: the patient was discharged from hospital within a period of h with a rate in a eva acute pain visual scale. in a year follow-up, there has no been an anatomical or clinical recurrence. no chronic dysphagia, anatomical recurrence or abdominal wall complications have been reported with in this period of time. conclusions: depending on the patient characteristics, anatomical factors and surgeon mini invasive experience, hiatal hernia and anti-reflux mini invasive standardized repair using mm instruments, could be a safe and feasible option. more studies are needed in order to standardized this approach. background and aims: parastomal herniation a very frequent complication in stoma patients. in isolated parastomal hernias (type i or iii)* a laparoscopic sugarbaker repair with intraperitoneal mesh is our preferred technique. if a concomitant incisional hernia is present (type ii or iii)* we currently opt for a retromuscular mesh repair as described by pauli. we adopted a minimal invasive approach using the robotic platform. methods: we performed a robot-assisted laparoscopic pauli repair for a wide incisional henria needing component separation and a small parastomal hernia (type ii)*. a non-slit retromuscular mesh was placed after a bilateral tar (transversus abdominus release) and lateralization of the colon. results: the operation was performed robot-assisted laparoscopically with x trocars without the need to convert to an open procedure. the procedure lasted min. the patient was discharged from the hospital on post-operative day three. one month after the repair our patient presented with a parastomal skin infection for which she received surgical cleaning and wound dressing. ct scan three months postoperative shows good positioning of the mesh with a reinforced abdominal wall. conclusions: the modified sugarbaker repair in parastomal herniation is feasible following a pauli approach (retromuscular mesh positioning) completely laparoscopic, albeit robotically assisted. short-term follow up is promising. long-term postoperative follow-up in these patients is needed. methods: case presentation results: a -year-old caucasian female patient was admitted on emergency due to a progressive alteration of her physical condition and weigh loss, caused by intermitent and intense epigastric pain and vomisments. symptomes occurred several years prior to admittance, but used to be mild and rare. during the last months, the described episodes became more intense, lasted longer and occurred more frequently. percutaneous ultrasound raised the suspicion, while thoraco-abdominal ct revealed an enormous intrathoracic morgagni hernia and gastric volvulus inside the hernial sack. after a careful preoperative preparation (restoring of the nutritional and hydric inballances, amelioration of respiratory parameters), laproscopy confirmed the diagnosis; we gently reintegrated the herniated organs from the thoracic hernia into the abdominal cavity (small bowel, large omentum, transverse-doloco-colon, and thisted stomach); a laparoscopic exploration of the hernial cavity was followed by a thorough hemostasis. do to patient's frailty, we decided to leave the hernial sack in situ. surgical direct repair of the defect technique was done by using extracorporeally tied separate sutures through separate skin incisions. the postoperative outcome was completelly uneventful; patient was discharged on postoperative day . barium contrast at mounths followup showed a slight esophageal diskynesia, but normal gastroduodenal passage; due to aerocolia, the normal position of the transverse colon could be confirmed aswell; no signs of reccurrence where detected. conclusions: although very rare, a morgagni hernia should be suspected and included in the differential diagnosis of patinets with dispeptic syndrome and epigastric/thoracic symptomes. thoraco-abdominal ctscanning is the imagistic technique of choice. laparoscopic approach became the gold standard, being far mora addvantageous as compared to laparotomy or thoracoscopy. direct suture with extracorporeally separate sutures through separate skin incisions was chosen for being less time consuming; for the same resons, the hernial sack was left in situ, with no consequences so far. aims: the giant fibrovascular polyp is one of the rarest benign lesions of the oesophagus. the most common locations of origin are the upper oesophagus or crico-pharyngeal region. the lesion is more common in elderly population, particularly men. symptoms include dysphagia, odynophagia. management options include surgical resection or endoscopic removal with endoloop. we aim to demonstrate the optimal management of these rare lesions using an endoscopic approach. method: we demonstrated the management of -year old patient with a giant oesophageal polyp, excised by minimally invasive endoscopic resection. the patient was placed in supine position and tracheal intubation was performed under general anaesthetic before an endoscopic approach was taken. the oesophago-duodenoscopy visualised a cresenteric shaped lumen due to an intraluminal mass occupying two thirds of the oesophageal diameter. the procedure was a multidisciplinary approach with the upper gi surgical and gastroenterology consultants. the polyp stalk was located in the oesophagus at the level of t and an endoloop was manipulated to surround the polyp. the polyp was then separated from the stalk by cauterisation and resected from the patient. the stalk was then injected with adrenaline to prevent haemorrhage. results: the excised specimen was a cm polyp with stalk originating from the t -t level. histology confirmed diagnostic suspicions of a benign pedunculated fibrovascular polyp. the polyp was covered by non-keratinising squamous epithelium with a discoloured tip demonstrating ulceration. there was no evidence of dysplasia or neoplastic process. the video shows a case of laterally spreading tumour of the rectum with preoperative benign histology, paris classification -is g (granular type), ut n eus stage, kudo type iv, nice type . the neoplasm measured x cm, and extended from to cm from the anal verge, mainly located on the posterior wall. according to our local policy the indication was a transanal full-thickness excision. this was performed with the medrobotics flexÒ robotic system, used here for the first time outside the united states. the system technology utilizes an articulated multi-linked scope that can be steered along nonlinear, circuitous paths in a way that is not possible with traditional, straight scopes. the maneuverability of the scope is derived from its numerous mechanical linkages with concentric mechanisms. this enables surgeons to perform minimally-invasive procedures in places that were previously difficult, or impossible, to reach. with the flexÒ robotic system, surgeons can operate through a single access site and direct the scope to the surgical target. once positioned, the scope can become rigid, forming a stable surgical platform from which the surgeon can pass flexible surgical instruments. the system includes on-board d hd visualization. the flexÒ robotic system contains two working channels to accept a number of different surgical and interventional instruments including monopolar and bipolar electrodes, scissors and graspers for tissue manipulation. the video shows the introduction of the dedicated rectoscope, the connection of the flexible robot, and the way to operate the device performing a full-thickness excision, including suturing of the rectal defect by means of two running sutures by a v-lock / thread. while illustrating the technique the authors will comment pros and cons of the use of the device. surg endosc ( ) the video shows the use of a barbed suture of novel concept. this first prototype thread developed together with assut europe (roma, italy) is characterised by a bidirectional / barbed suture, of cm length overall, with two needles mm in diameter, and circumference. in order to fix the thread to the tissue, on the exact midline of the thread a small ( mm) ball of the same material of the thread is fused with heat. this button as the entire thread is made of polydioxanone, a monofilament material for long-term absorption, self-retaining. this small advancement offera a consistent advancement in endorectal surgery helping in making transverse wound closures as easy as never before. the first stitch is placed on the transverse midline of the rectal wall defect, this way approximating proximal and distal edges. the button keeps the thread under tension allowing the completion of a running suture towards one of the two lateral ends of the would. when the first end is reached the needle is cut and the other needle is grabbed in order to perform the other half of the running suture keeping the right tension on the thread, with no risk of lumen stenosis. the two lateral ends of the suture are self-blocked passing them through the last stitch. no need for clips, knotting or buttonholes to pass through. while illustrating the technique the authors will comment pros and cons of the use of the device. background: the usefulness of robotic surgery has been largely reported; however, there are not enough reports on gist's treatment. the aim of this study is to report a single center experience on gastric gist's robotic resection. gastrointestinal stromal tumor (gists) are the most common mesenchymal tumors (overall incidence - % of all gastrointestinal malignant tumor). they are most frequently located into the stomach. complete surgical resection still remains crucial for patients with gists. in cases of difficult localization of tumor (e.g. posterior wall, his angle) and bigger tumor (more than cm in diameter), there still exist apparent difficulty and limitation to conduct laparoscopic resection. robotic assistance provides wide movements of its arms and was recognized particularly useful in case of difficult tumor localization, especially for those positioned at the posterior side of the stomach wall or around the lesser curvature. methods: six consecutive patients were analyzed focusing on safety (conversion/complications rate; hospital stay), oncological (margin resection, recurrence rate) and feasibility (operative time, technical tip and tricks) profile of robotic approach. results: the mean operative time was ± min, the mean hospital stay ± days. conversion rate was nihil. no intra and post-operative (mean follow-up months) complications were registered. in all cases, the resections were classified as r . conclusions: our experience supports the usefulness of robotic system in case of gist located at anatomically difficult gastric portion, such as lesser curvature or fundus close to gej, confirming the excellent oncological outcomes ( % r ) and the encouraging safety profile ( %). regarding the operative time our data are similar or better as compared to those reported by the previous literatures and didn't differ by the most recent published data for laparoscopic gastric resection. the anatomical hand-sewn reconstruction performed by precise hand-sewn suture instead of the usage of mechanical staplers represents a real great advantages of robotic resection. in our series, no patients suffered from stenosis or leakage after operation. background: we describe the use of a different suture from those historically used in the elaboration of a widely spread surgical technique such as the nissen fundoplication, for the treatment of pathological gastroesophageal reflux or symptomatic hiatal hernias. in our unit we have implemented the use of / irreabsorbable barbed suture to close the diaphragmatic pillars and the °fundoplication with the same continues suture. aim: the objetive of the use of the irreabsorbable barbed suture in the nissen fundoplication is to shorten the surgical times, which would achieve benefits for the patient and the institution, increasing the number of ambulant patients and the number of patients to be operated the same surgical session. objective: the goal of the present study was to demonstrate that intraoperative icg fluorescent imaging is a safe technique that can be used in laparoscopy establishing the exact location of the lymphocele and reducing intraoperative risks. method: fifty milligrams of icg dissolved in ml of saline solution was injected via percutaneous drainage placed into the lymphocele to decompress transplanted kidneys weeks before a laparoscopic lymphocele marsupialization procedure. results: during the first exploratory laparoscopy, in the flank and right iliac fossa, near the renal grafts, fluorescence was identified in raised areas that were the internal side of the lymphocele lobes. the lymphocele wall was dissected and ml of serous fluid was aspirated after puncturing. a cm breach was then made in the cyst wall using the ultracision harmonic scalpel (ethicon us). afterwards, a pedicle of the omentum in the lymphocele core was interfered with and fixed by stitches. conclusions: laparoscopic surgery seems to be the preferred surgical option for the treatment of primary symptomatic lymphocele after kidney transplantation. intraoperative icg fluorescent imaging is a safe technique to establish the exact location of the lymphocele and reduces the risk of damaging urinary structures during surgery. conclusions: this method proved safe and risk-free, easily reproducible and without the need for a different toolkit than the one of a modern operating theatre. the preliminary analysis shows a strong correlation between the perfusional data so far obtained and the early outcome of the graft. thus opening the way to further analysis aimed to a future better management of post-operative immunosuppressant and support therapy. these results are quite encouraging, even if our study is at an initial stage. conclusions: results show a persistent dread across specialities regarding ai. rather than be seen as threat, ai should be embraced by clinicians as it will ease the ever-increasing daily workload faced. this will enable clinicians to focus their skills on patient centred activities, interventional procedures and development. despite current regulatory hurdles, ai implementation in medicine is unavoidable. this coming revolution presents a unique opportunity for endoscopist and radiologist to refocus their expertise in novel areas. project description: from february to july a three-armed proof of concept study was conducted at three hospitals, in three groups of patients; recurrent ventral hernia, aortic aneurysm, and healthy controls. patients were measured once at the outpatient clinic using an electronic nose based on three metal oxide sensors. measurement data were compressed to low-dimensional vectors using a tucker like algorithm, and used to train an artificial neural network (ann) to provide a classification between patients (? ) and healthy controls (- ). preliminary resultsa total of patients (hernia n = , aneurysm n = ) and controls were included in the study. based on receiver operating curve (roc) analysis, the ann could differentiate between recurrent hernia patients and controls with the following details: area under the curve (auc) . , sensitivity . , specificity . . aortic aneurysm patients and healthy controls could be differentiated with an auc of . , sensitivity of . , and specificity of . . the aeonoseÒ enose can reliably distinguish patients with weak collagen (recurrent hernia and aortic aneurysm patients) from healthy controls. validation of these results in a prospective cohort study is required before clinical application of the device. background: laparoscopic and endoscopic cooperative surgery (lecs) has been performed gastric submucosal tumor (smt) or duodenal tumor. although minimally invasive surgery using thoracoscopy has been the usual approach for esophageal smt, the treatment method combined thoracoscopy and endoscopy has not been established. in addition, submucosal endoscopic tumor resection (set) for esophageal smt was reported using the technique of submucosal tunnel. aim and project description: we planned to resect large esophageal smt located in the upper or middle thoracic esophagus by a combined endoscopic and thoracoscopic approach. because set is only recommended for tumors up to mm in size owing to the limited submucosal space available and the left thoracic approach is restricted by the aortic arch and the trachea. preliminary results (case presentation): a -year-old woman was diagnosed with a benign schwannoma of length mm originated from either the submucosal or the muscular layer of the middle thoracic esophagus by endoscopic ultrasonography, enhanced computed tomography, and ultrasound-guided fine-needle aspiration biopsy. since the tumor had increased in the years and she had a symptom of dysphagia, we planned to resect it by a combined endoscopic and thoracoscopic approach. on endoscopy in the supine position, a submucosal tunnel was created mm proximal to the cranial edge of the tumor, and its only oral end was dissected from the mucosal and muscular layers. this was followed by the resection of the entire tumor by left-sided thoracoscopic procedure in the prone position. endoscopic mucosal closure was achieved by using clips. no postoperative complications were observed. large benign esophageal tumors can be safely excised with minimally invasive surgery by using a combination of endoscopy and thoracoscopy. background: haemorrhage remains a major cause of morbidity and death in all surgical specialties. in laparoscopic surgery. relatively small amounts of blood can obscure the view of the operative field and increase the risk of injury to surrounding structures. excessive bleeding often leads to longer hospital stays, increased healthcare service utilisation, and higher healthcare costs, among other negative consequences. aim: the aim of this study was to analyse the feasibility of purastatÒ, a new synthetic haemostatic device, made of self-assembling peptides in laparoscopic colorectal surgery. project description: this was a prospective observational non-randomised study. consecutive patients undergoing laparoscopic colorectal surgery were enrolled. informed consent was obtained from all patients inclusion criteria was the need employ a secondary method of haemostasis when traditional methods such as conventional pressure or utilization of energy devices to control the bleeding were either insufficient or not recommended/ appropriate due to proximity to ureter, pelvic/sacral veins and other important structure. preliminary results: twenty patients were enrolled ( males ( %) and ( %) females). mean age was years (± , years). all patients were undergoing elective laparoscopic colorectal cancer surgery ( right hemicolectomy, sigmoid colectomy, anterior resection). we utilised mls of purastatÒ in all patients. the mean area of application was , cm (± . cm ) with the amount of purastatÒ needed per centimetre being . mls. the mean time to apply the product was secs (± s), whereas the mean time to achieve haemostasis was , secs (± . s). there were no post operative complications in this cohort of patients. mean operative time overall was min (± . min). none of the patients experienced delayed post-operative bleeding and the mean hospital stay was days (± . ). in conclusion, according to the purpose of this preliminary study, we have demonstrated that purastatÒ can be easily used in laparoscopic surgery and it is a safe, effective haemostatic agent. this is a feasibility study and additional controlled studies would be useful in the future. during last three years the laparoscopic method of surgery in the presence of common bile duct stones was carried out. after performance of intraoperative cholangiography and visualization of stones in the common bile duct laparoscopic, choledochotomy and bile duct stones extraction was undertaken in patients, using flexible choledochoscopy control. in all patients with gallbladder stones was then performed laparoscopic cholecystectomy. results: laparoendoscopic intervention on common bile duct was successfully performed in patients ( . %) and the operation was completed by common bile duct drainage by kehr. in patients due to technical difficulties conversion to open surgery was carried out. postoperative morbidity in the form of bile leakage were diagnosed in patients ( . %). in three cases they stopped spontaneously in - days after the operation. patients were operated on repeatedly and additional suturing on choledocholithiasis was carried out. postoperative mortality was . %. the death of the patient of years was caused by acute cardiovascular failure. institute for image guided surgery, ihu-strasbourg, strasbourg, france; hepato-digestif, nouvel hôpital civil, strasbourg, france; image guided surgery, nouvel hôpital civil, strasbourg, france; gastroenterology, chu-besancon, besancon, france; gastroenterology, chu-lyon, lyon, france; gastroenterology, clinic de trocadero, paris, france background: eus is difficult to learn and has a steep learning curve. therapeutic eus (teus) is even more so. simulators, ex-vivo models and phantoms are the most common current teaching modalities but are felt by many to be unsatisfactory for high-level training. aim: we designed a training curriculum for teus that uses high-fidelity animal models and present a validation study performed by teus experts. project description: different simulated pathologies were created in each of acute pigs. teus experts performed therapeutic procedures in two or more animals over two days. each intervention was evaluated simultaneously using a structured survey by an non-expert observer. data included demographics and procedure details as well as likert-scale evaluation of the quality, realism and education utility of the simulations. global evaluation of the experience was captured from the experts as written comments. all data was consurrently registered and subsequently analysed by two blinded surgical educators. methodology: three types of models were created using surgical access: -tumors (injection of types of hydrogel), -retro-gastric collections ( - cm long intestinal loops filled with oatmeal, oil-water and gel), -obstructions (bile duct and ureteral ligations days prior to experience). gastric, pancreatic and liver tumor models were used for fna and fnb practice. retrogastric fluid collections and choledochal/ureteral obstructions were used for cyst gastrostomy, hepaticogastrostomy, gallbladder drainage and kidney drainage. results: experts age: - , median intervention time min , total of interventions evaluated, overall quality of experience: ( %) ranked - (excellent), ( %) from - (good), ( %) from - (poor), / procedures were successfully completed. models were rated good to excellent quality ( - ) in ( %), poor quality in ( %). for % ( ) of the interventions the model was considered not good enough to be repeated (solid retrogastric tumor and peripheral hepatic lesion). conclusion: high-fidelity live animal models with simulated pathologies are considered to be excellent training tools by experts and may provide a better learning experience for teus. surg endosc ( ) in our short videos, we present scenarios in which this technology helped: to distinguish a significantly dilated cystic duct from the cbd, to identify an anterior cystic artery in the contest of acute inflammation, to identify a luksha duct, to exclude a leak after endoloops positioning on cystic duct. intra-operative augmented visualisation of biliary anatomy with indocyanine green cholangiography is an essential technology tool with the potential to extend the hour window of safety for emergency cholecystectomies, with significant logistics benefits. introduction: endoscopic resection of subcardial polyps has its limitations; especially when it is necessary to dry out the entire gastric wall. uniportal intragastric surgery is a good alternative for the exeresis of subcardial premalignant lesions with gastric preservation. patient and method: we present a video with two cases. technique: we perform a laparoscopy to explore the entire abdominal cavity, then we open a . cm hole in the great curvature; a cm incision is made in left hypochondrium and the uniportal device is placed inside de stomach. we inject serum in the submucosa with a endoscopic needle. when submucosa is completely separated from muscular lay; a submucosal exeresis can be made; but when there is not a complete separation after injection, then we perform a entire wall resection with a cm circular margin. if a complete wall resection is made, then we close the defect with a barbed suture. results: case : years old male with a , cm subcardial polyp, preoperative biopsy was informed as severe dysplasia. in the laparoscopy we saw an unknown lesion in the great curvature that looked like a gist. we placed the uniportal device intragastric and proceed to the submucosal serum injection. as the submucosal lay was completely separated from muscular, then we performed a submucosal exeresis. we close the gastrotomy and made the resection of the great curvature lesion with endostapler. the pathological analysis confirmed the severe dysplasia in subcardial lesion and gist in the great curvature lesion. patient was discharged with no complications after days. case : years old male with a cm subcardial polyp. preoperative ecoendoscopy suggested a muscular layer infiltration but only severe dysplasia was found in the previous biospsy. laparoscopy did not found more lesions, and uniportal intragastric device was placed. a complete wall resection was made, and the defect was closed with manual barbed suture. pathologyst confirmed severe dysplasia and unaffected margin. patient was discharged with no complications after days. conclusion: uniportal intragastric surgery is feasible and safe and may be useful for subcardial premalignant lesions when endoscopic resection is very difficult or not feasible. introduction: the role of icg in bariatric surgery is still unclear. knowing the lack of perfusion in the gastric pouch could be of great interest in revisional surgeries; but the question remains: is the current icg technology reliable enough to make intraoperative decisions in bariatric surgery? methods: we have carried out a check of tissue perfusion with icg fluorescence in several cases of primary and revisional bariatric surgery. a solution of , mg/kg was injected intravenously and icg fluorescence was performed. we looked for the correct staining of the entire gastric pouch and the intestinal loop trying to rule out areas of tissue ischemia. results: the cases in which the test was performed showed a minimal delay of - s between the intestinal loop stain and the pouch. a correct staining was observed in all but one case shown in the video. is the case of a years-old male patient who was operated years earlier in another center; at that time he underwent a sleeve gastrectomy. we evaluated the patient for persistent gastroesofhageal reflux of years of evolution with esophagitis. we offered revisional surgery to perform gastric bypass and hiatal closure. fundus was dilated so a funduplasty was performed instead of using endostappler in the vertical side of the pouch. manual anastomosis gastric bypass was performed. when the icg test was performed, a corner of the pouch does not stain green (an area of , cm) . so the decision was to resect that part and redo the anastomosis or wait and see. it was decided not to resect and the patient was discharged two days later with no complications and good outcome with a months follow up. conclusion: icg fluorescence may be useful in bariatric surgery in the future but more evidence is needed of its usefulness in making intraoperative decisions. background: lymph node status is one of the key prognostic factors in patients with colorectal cancer, and remains the most important selection criteria for adjuvant chemotherapy. it is believed that at least % of node negative patients will suffer disease recurrence within the first years after surgery. this may be due to understaging of lymph node status. sentinel lymph node mapping is widely used for staging of breast cancer and melanoma, with injection of colloid tc and isosulfan blue (ib). however, indocyanine green (icg) fluorescence guidance is a new technical approach to this issue, with promising results for detection of aberrant lymphatic drainage outside of the planned resection. the icg lymphography has the advantage of offering a good visualization of the lymphatic channels but there are problems in order to identify the lymphatic nodes. aim: the objective of the experimental study is to investigate the possibility to detect the sentinel lymph nodes after the injection of different solutions with indocyanine green in the subserosal colonic layer in the pig. project description: twelve female large white pigs were operated with laparosocpic approach and spies optic filter (karl storz, germany). indocyanine green was injected in the subserosa of the colonic wall ( ml at points). lymphatic flow was observed at - - - - and min, searching for the migration of the icg by the lymphatic channels and its introduction in the sentinel nodes. preliminary results. the identification of the sentinel nodes is very difficult with the solution of icg-sterile water. with this technique we can see the lympjatic channels but not the lymphatic nodes. the adition of % human albumin as a transporter of the icg is very helpful for the correct identifiaction of the lymphatic channels at - - min and the correct visualization of the lymphatic nodes at min after the bowel injection. addition of other transporters like dextran solutions may be helpful too but the time to the correct visualization is longer. there was significant difference among the three groups as regards postoperative les and postoperative ph metery.the incidence of persistent dysphagia was significantly higher in the group i. postoperative gerd symptoms were significantly higher in group iii ( . %. p \ . ). recurrent achalasia was significantly higher in group i ( patients . %, patients in group ii ( . %) and nil in group iii (p \ . ). in conclusion: longer myotomy on the gastric side ([ . cm) ensures complete division of the les with better outcomes in term of resolution of dysphagia but may be associated with higher postoperative gerd. therefore, a myotomy length of . to . cm on the gastric side provides a balance between relieve of dysphagia and development of postoperative gerd. c/t scan of his abdomen revealed a large groin hernia with signs of small bowel obstruction and collapsed distal bowel. emergency theatre was organised for this patient with anaesthetic assessment prior to his surgery. initial plan of local exploration with possibility of small resection was changed once he was under full anaesthetic with muscle relaxation. his abdominal girth provided an opportunity to utilise laparoscopic intervention as an initial approach. laparoscopy with degree lens revealed moderately distended loops of small bowel and a large omental mass along with a loop of small bowel incarcerated in right direct inguinal hernia site. background: robotically assisted surgery is a rapidly developing modality of minimally invasive surgery with proven advantages in the management of cancer. despite its increasing prevalence, there is still an ongoing debate regarding its future role in colorectal surgery. while the prospective randomised multi-centre studies provide research evidence for its potential efficacy, an assessment of its effectiveness and realistic outcomes in everyday clinical practice can add an important perspective to this discussion. the international robotic colorectal registry will allow to compile and pool the international robotic colorectal experience. aims: the aim of the international robotic colorectal registry is to monitor the safety and outcomes, as well as the quality of specimen of robotically assisted colorectal surgery for malignant and benign diseases of the colon and rectum. the primary endpoint is a composite oncological failure. the secondary endpoints include anastomotic leak, resection margin involvement, conversion rate, operative time, post-operative -day morbidity and mortality, long term oncological outcomes, quality of life, functional outcomes and cost-effectiveness. project description: the international robotic colorectal registry is a multicentre web-based, online secure database. the registry has been awarded an ethical approval by a relevant national committee. all surgeons performing robotic or robotically-assisted surgery are invited to participate. the data collected includes patient demographics, cancer characteristics, operative details, histology of the specimen, wound healing, post-operative therapy, readmission, quality of life and functional (bowel, urinary and sexual) outcomes. all the sensitive patient information is encrypted before its introduction into the database. preliminary results: so far, twenty robotic colorectal centres have joined the international robotic colorectal registry. the preliminary results will be published once patients have been enrolled. univariate and multivariate analyses will be performed to identify possible risk factors for poor outcome.the possibility to record open, laparoscopic or other minimally invasive colorectal procedures will facilitate comparison of the outcomes of the robotically assisted surgery and other modalities. the registry will also allow each surgeon enrolled to monitor their skill progression and outcomes over the time. results will be published in surgical literature and presented internationally. background: gastric outlet obstruction (goo) due to benign strictures is an uncommon surgical entity today. this paucity relates to the decrease in its aetiological factors in the modern era as well as to advances in both prevention and medical as well as endoscopic treatments of such condition. the most common of causes relating to peptic ulcer disease, has been subdued for decades with quality acid control medications. on the other hand advances in gastroscopic dilatations skimmed even more the frequency of these cases from arriving to surgical intervention. aim: this presentation gives an update on the standing of this pathology and its surgical management today. it will also shed a light on our early experience in this condition at the royal hospital of muscat in oman. project description: a case series of all patients with goo, who were surgically managed between and results: there were a total of patients, males and females. the cause of obstruction was peptic ulcer disease in , corrosive injury in , iatrogenic perforation in and idiopathic hypertrophic stenosis in . emergency presentation was seen in . management included jaboulay pylorpolasty in , resection in (distal gastrectomy in , total gastrectomy in ) or a bypass (gastrojejunostomy) in . in of the above, the procedure was done by laparoscopy. post operatively, temporary gastric paresis delayed recovery in , however all symptoms resolved in . there were no recurrences at minimum of years of follow up. in spite of advances in medications and gastroscopy interventions, we still seem to identify this condition within our population. although infrequent, they demand awareness from surgeons since they could be managed successfully, especially laparoscopically, with minimal morbidities and early recovery. the introduction of advanced laparoscopy to the unit's setup in recent years, made such option feasible with satisfactory and durable outcomes. background: gists of the upper gi are found mainly in the stomach ( - % of cases) and small intestine ( %). duodenal gists however, comprise a smaller subset with a frequency of to %. the optimal surgical procedure for duodenal gist is still evolving. since wide margins and extensive lymphadenectomy are not required, restrain from more radical resections in this area would be a valid option. aim: this is a video case report of a patient with a gist involving the third part of the duodenum treated by laparoscopic lateral duodenectomy and end-side roux-en-y duodenojejunostomy case report: years lady presented with recurrent mid abdominal postprandial pain with anorexia, nausea and occasional vomiting an ultrasound showed well defined hypoechoic mass of . . cm at the right para-aortic region . ct scan defined the mass as retroperitoneal, intimately related to the pancreas uncinate process and the third part of duodenum with no clear cleavage line between them. an mri endorsed the diagnosis of gist of the duodenum. she was operated upon through a laparoscopic lateral duodenectomy including the gist at the third part of the duodenum. a frozen section confirmed the clear margins . reconstruction was done by a roux-en-y duodenojejunostomy with the alimentary limb taken cm from the dj flexure. she had an uneventful post operative recovery and was discharged well. the histology confirmed a low grade gist tumour hence no further treatment was needed. at follow up six months later, she was doing well and gaining weight. conclusion: complex anatomy of the pancreatico-duodenal area makes conserving the duodenum for tumours rather than a major resection a challenging option. in our case however, with the disease in the third part being of a moderate size, a lateral duodenal wall resection including the mass was possible rather than a segmental resection. this procedure could be an ideal choice for benign, moderate sized tumours in the third and fourth part of the duodenum. background: during laparoscopic colectomy, laparoscopic lymph node dissection and extracorporeal intestinal anastomosis is commonly performed. an umbilical incision of - cm and wide-range mobilization of the intestinal tract is required for extracorporeal anastomosis. previously, we introduced intracorporeal overlap anastomosis in june as a minimally invasive treatment. here, we report its short-term outcomes. aim: we retrospectively compared the surgical outcomes of cases of extracorporeal anastomosis and cases of intracorporeal anastomosis, all of which were performed between june to may . procedures: after lymph node dissection and sufficient mobilization of the intestinal tract, the proximal and distal intestines were resected perpendicularly to the intestinal tract with a -mm linear stapler. the anastomosis was performed after the specimen was extracted from an umbilical incision. the opposite sides of the mesenteric margin cm from the staple line of the one intestinal tract, and cm from the staple line of the other intestinal tract, were marked, and then the respective intestinal tract was positioned to join the opposite mesenteric sides together. an insertion hole was made in the intestinal tract at the marked site. side-to-side anastomosis with a linear stapler was performed, and then the insertion hole was closed with a linear stapler after several temporary sutures. preliminary results: in the extracorporeal anastomosis group, the mean operation time, blood loss, and post-operative days were min, ml, and . days, respectively. furthermore, there were three intraoperative cases of bleeding ( . %), and two postoperative cases of lymphorrhea ( . %) that occurred. however, in the intracorporeal overlap anastomosis group, the mean operation time, blood loss, and post-operative days were min, ml, and . days, respectively. additionally, there were no cases of intraoperative complications, and only one postoperative case of lymphorrhea ( . %). conclusion: intracorporeal overlap anastomosis in laparoscopic colectomy is safe and feasible, and can be used as a minimally invasive treatment. nowadays d-printing it's not a new technology any more but with an exponential developing. there are beliefs that in % of everything that will be produced will be d-printed. in medical field this technology knows the same exponential developing. first used in orthopedics and maxilo-facial surgery now d-printind is used in many other fields for different reasons, like preoperative training models, surgical special instruments, in medical education, etc.. liver surgery is in continuous developing and this is the reason why we need experimental liver model for training and testing. a best liver experimental model should heave liver consistency, to be flexible, to heave the same ultrasound feedback, to be cheap and easy to be reproduced. this is why we developed a liver experimental model made of gelatin by a simple recipe, using a dprinted mold, created after a human liver ct-scan. first was made the segmentation of the liver. after segmentation we create the d virtual liver model and the negative image of the liver, which was used for creation of the pieces of the liver mold, with connections between them and a hole on the top to pour the gelatin solution. ( ) ethical concerns on learning and training with real patients and substitutives such as animals, and ( ) reconciling time devoted to learning with clinical practice, considering the european work time directives. simulation in medical education is and has been the preferred route to address both pedagogical needs. virtual simulation has proven to be a valid tool for training; however, current systems restrict usage to tasks and modules offered, without possibility of personalization. we present the minimally invasive surgery simulator scenario editor (mis-sim) an environment where users can create, edit and run virtual reality tasks designed for medical training. the environment features an editor allowing users to develop learning tasks, defining its learning objectives and task goals in an easy way. a first proof of concept has been implemented for surgical training and training activities (demostrators and short courses) have been carried out in three european sites: spain, the netherlands and hungary. during training activities, different exercises have been created and uploaded to the contents' database. trained technical skills include handeye and bimanual coordination, instrument handling and pulling. preliminary results with users have shown mis-sim training potential, although some functionalities should be made easier. personalization has been highlighted as the key added value of mis-sim with respect to the current competitions in the market: the ability for target users to use virtual reality based learning tools while remaining in complete control of the learning process. mis-sim aspires to break the barrier between vr and medical education by empowering users to create their own tasks. with mis-sim teachers/course creators and learners (healthcare professionals & future healthcare professionals) will benefit from an innovative tool to ( ) create personalised medical learning contents tailored to preferred learning styles, allowing the creation of individualize learning paths; ( ) improve the efficiency of training by focusing on the training needs of the learners and ( ) share and sell vr-based didactic contents. c. tiu , p. sánchez-gonzález , m. chmarra , d. gutiérrez , c. guzmán-garcía , l. sánchez-peralta , g. wéber , f. sánchez-margallo , b. pagador , j. dankelman aims: currently surgical training is largely based on the improvement of technology enhanced learning solutions. the progress of engineering and the diversification of training facilities outside the operating theater results in an even greater contribution of technology in the future. the main reasons to encourage these changes are increased efficiency of simulators and directly increased patient's safety. the goal assumed by the easier project is to develop multi-skill, online platforms for minimally invasive surgical (mis) procedures-based on common pedagogical principles with reference value in a multinational space. the platform will allow the connection of external assets (such as simulators) to centralize all training data from residents. this work presents the milestones of the project during its first year of life. methods: the consortium's activity started with a knowledge elicitation process organizing brainstorms and workshops including experts in mis and interventional techniques, from spain, romania and hungary. this experience led to the formulation of a questionnaire that was implemented online and sent via email to surgeons and residents from the participating countries. results: accumulated experience was used to define the pedagogical needs of the platform. the pedagogical needs form the starting point for defining the technical requirements and specifications. based on them, the design of the platform has been achieved, including its architecture and communication protocol between external assets design, facilitated by the use of state of art educational standards. discussions and conclusions: next steps include the implementation of the easier platform, as well as the definition of cases studies selected by the clinical partners in spain, romania and hungary to solve applications of the platform dedicated to cholecystectomy, lumbar puncture and arthroscopy. a pedagogical model, built by the experience of the consortium, is being used to guide instructional design of the course. finally, results will be validated in a multi-center validation study.the easier project will create a training platform with reference value for european surgery. the structure of the consortium, based on the confluence between collectives with clinical, technological and pedagogical experience, will generate a complex learning tool in surgery embodying technology-based training systems with clinical experience. background: the treatment of groin hernia is an important part of our daily surgical activity. aim: we proposed to evaluate outcomes of the laparoscopic trans abdominal pre peritoneal treatment (tapp) of the groin hernia. project description : one hundred and fifty patients who underwent a tapp for a groin hernia were included in a retrospective study between january and november . results: the gender ratio was . the average age was , years. twenty percent of patients had a history of abdominal surgery. the operative indication was a unilateral hernia in % of cases, associated with an umbilical hernia in % of cases, a recurrent groin hernia in % of cases and a bilateral inguinal hernia in % of cases. the conversion rate was . %. the hernias were classified according to the ehs classification in l type in % of cases, l in % of cases, l in % of cases, m %, l r in % of cases and f r in % of cases. a contralateral inguinal hernia was discovered in % of patients. a polypropylene mesh x cm was fixed by a stapling in % of cases and by a suture in % of the cases. the average operation time was min. the hospital stay average was , day. an antalgic treatment was prescribed in % of patients. the average time to return to normal physical activity was days. a postoperative seroma was noted in % of patients. no cases of mesh suppuration were noted. chronic pain was noted in two patients. no recurrence was noted with an average follow-up of months. conclusion: laparoscopic treatment of the groin hernia by tapp had good results concerning the postoperative pain, early recovery of physical activity and aesthetic damage. a larger setback is needed in our study to evaluate the recidivism rate. background: surgeon's training in ultrasound is viewed and understood differently in different parts of the world. if in united states the need for surgeons' training was accepted and taken over by the american college of surgeons, in europe the practice is completely different from one country to another, from one city to another, from one department to another within the same premises hospital. in some european countries, surgeons currently use ultrasound for diagnosis-especially in urgency, for follow-up, intraoperative, or as guidance for many surgical gestures. during this time, access to ultrasound of other surgical specialties-gynecology, urology, ophthalmology-is considered natural. material and method: once the decision to initiate an ultrasound course for surgeons was taken, a team of experts with technical or clinical expertise in ultrasound was organized. at the initiative of the technology commission, the courses were to be organized at the eaes congresses or others communication events endorsed by eaes. starting from the importance of each ultrasound application in surgery, it was decided to develop different modules to solve different training needs. at this time, the course offered at seville covers the capitols like abdominal ultrasound, guided punctures and trauma. a module dedicated to intraoperative ultrasound is under construction and will be available in november . the course has a skill abilities dominant character, two thirds of it being thought of as a hands-on application on stationary, classical ultrasounds with large screens and also on small size wireless actual devices. results: after his debut in frankfurt in , the course was resumed in london and in bucharest, twice. in this process, new modules and better teamwork skills have been developed. the participants' satisfaction quizzes, coming from all continents, were really encouraging. for the intraoperative ultrasound module the team approach is unique. students will have the opportunity to practice on live animals both laparoscopic and open abdominal procedures conclusions: the ultrasound for surgeons course initiated by eaeas was received with interest. the team will seek to inspect the real needs of training surgeons in this field and will complement and diversify the current platform surg endosc ( ) preliminary results: a total of procedures ( - , ± . ) were carried out in patients. the indications included acute ( leaks following esophageal resection, rupture of the strictured anastomosis following pneumatic dilatation) and chronic conditions (esophagopleurobronchial and gastropleurobronchial fistulas following the resection of esophageal diverticulum and sleeve gastrectomy). the initiation of the therapy was in , and day in case of acute conditions, and after years of the duration of the unsuccessful therapy in chronic cases. the successful closure was observed in patients, patient passed from mods and ards. in case, the initiation of evac was provided as a combined surgical and endoscopic intervention (ct proven distant intraabdominal abscesses). in chronic cases, was discontinued due to the haemophagocytic syndrome of unknown etiology, in the second one, success in reduction of the lesion and symptomatology with long term duration was observed following just applications of evac, despite minimal remanent leakage. the success is to our experience linked to early initiation of the therapy and presumes complex intensive care. the future investigation should specify the timing including preemptive use of evac and the combination of evac with other endoscopic, interventional and surgical therapeutic modalities. the aim of this feasible study is to investigate complete robotic esophagectomy with total mediastinal lymph node dissection (retm) only by the robotic arms. methods: the patient is placed hemi-prone position with one lung ventilation by blocking balloon tube under general anesthesia. the robotic trocar for st arm of da vinci xi surgical system is placed in the th intercostal space (ics) on the scapular line, the trocar of nd arm is placed in the th ics on the posterior axillary line, rd arm trocar is placed in the th ics on the middle axillary line, th robotic arm trocar is placed rd ics on the middle axillary line, and assistant trocar only for taking in and out of gauze is placed in the th ics on the middle axillary line. on the upper mediastinal lymph node dissection, robotic camera exchanges from nd to rd robotic arm to close and identify anatomical structures. esophagectomy with lymph node dissection starts from middle and lower mediastinum to upper mediastinum including along bilateral recurrent laryngeal nerves. all procedure perform under close-up view along the robotic enhanced anatomy to preserve organ functions. background: complete stenosis of the duodenal lumen secondary to a surgical suture in the treatment of a duodenal ulcer is a rare complication. the usual surgical resolution corresponds to a gastrojejunostomy associated or not, to an antrectomy with vagotomy, as a treatment for the peptic disease. the endoscopic resolution of this complication requires the use of complex maneuvers and specific therapeutic instruments. aim: to describe the endoscopic resolution of iatrogenic occlusion after raffia of perforated duodenal ulcer. description: a -year-old man was admitted to the emergency service for four days of pain and abdominal distension associated with abundant retention vomiting. performed ten days ago of a perforated duodenal ulcer, in which manual raffia was performed in two planes and drainage. abdomen and pelvis ct showed great distension and diffuse thickening of the gastric wall. the endoscopy showed abundant gastric retention content, pylorus, and bulb edema, and complete closure of the duodenal lumen, secondary to suture material; it was possible to count three suture threads. with a tipped papillotome and electrocautery, all the suture threads were sectioned, identifying a filiform opening through which a hydrophilic guide is inserted under fluoroscopy until it is sure to overcome the stenosis; we dilated the trajectory with a dilator of mm in diameter and cm in length. with a contrast medium, we observed an adequate trajectory and installed a partially covered duodenal metal stent (hanaro stent) of cm in length by mm in diameter in order to sustain the dilation. he was sent to home with inhibitors of the proton pump. after two weeks, the stent was removed, without complications. he was controlled two weeks after withdrawal, and, with pharmacotherapy, the patient was asymptomatic, making a normal life. conclusion: in this case, the result was positive. satisfactory results can prevent major surgery, which reduces the risk and possible complications. a new range of non-invasive medical tools with a remarkable improvement on the existing market. a manual laparoscopy, with the important novelty of having a bending head with a high degree of movement. this head can get multiple spatial positions to work in surgery and is very easy to use, with the same scissors thimble who controls it, so its performance and learning is very simple and intuitive. the tools can be easily reusable and they can be cleaned and sterilized by ordinary methods, very ergonomic and lightweight . the generic type models we initially have developed are focused in general surgery, but gradually we will develop new applications and different heads for specific medical conditions such as arthroscopy, laryngoscopy, otolaryngology, ophthalmology, orthopedics . its operation is simple and functional, simply moving the scissors thimbles, where they have a dual role, combining the head tilt and the action of opening and closing of this is achieved.the design of this tool allows us to work with some degrees of unparalleled freedom from the existing tools. our instruments replicate the movements of the robot with a simple handheld mechanical instrument, our philosophy is to position our instruments in between a long empty field between the surgeon and the robot. the tip of our instruments are providing the surgeons with angulations impossible to reach with the traditional instruments unless applying huge movements from the hands of the surgeon. we consider that this devices will have a very fast acceptance from the market as this robotic type movements can be managed by the surgeon through the traditional mm trocars, without the need to change to a new surgical technique, just with the traditional method and a very brief training. background: diverticula of the middle thoracic esophagus are infrequent, its etiology may be secondary to traction or pulsion mechanisms. when the etiology is a mechanism of pulsion, they are associated with esophageal motor disorders and its prevalence is estimated between . % and . % of the population . they are rarely symptomatic and the diagnostic is usually incidental. the most common symptoms are episodes of food impaction, chest pain or bronchoaspiration.diverticulectomy and esophageal myomectomy by minimally invasive approach is the treatment of choice in those with large size or associated symptoms. aim: to describe a clinical case of esophageal diverticulum solved by minimally invasive surgery approach. clinical case description: a -year-old patient with a history of epilepsy and hypothyroidism consulted for atypical chest pain and dysphagia to liquids and solids. a study with esophagogastroduodenoscopy was performed: cm from the dental arch, a large wide-mouth diverticulum was identified. we complete the study with an esophagram with barium: voluminous diverticulum in the right lateral face of the middle esophageal and a thoracic ct scan showing esophageal diverticulum located in the carina, from . x . cm to cm from the esophagogastric junction. due to the suspicion of associated motor disorder, high resolution manometry was performed showing a significant motor disorder with alteration of peristalsis and exit obstruction with incomplete relaxation of the inferior sphincter and superior hypertonic sphincter. preliminary results: the patient underwent surgery: diverticulectomy and complete esophageal myotomy by thoracoscopy minimall invasive approach. the patient evolved favorably and was discharged after days with a previus control esophagram without pathological findings. currently, it remains asymptomatic months after surgery. , rectus muscles are re-approximated from xiphoid to pubis using laparoscopic running self-locking, pds sutures to restore anatomy and physiologic function of the abdominal wall. unlike the standard access to the abdominal cavity executed with lateral access, the lap-t technique is performed through sopra-pubic aesthetic approaches, using one mm and one mm bariatric ( cm) instruments laterally, and one mm camera in the middle.the entire procedure is performed in gas-less laparoscopy, with laryngeal mask and intra-peritoneal liquid anesthesia. the repair is consolidated placing an intra-peritoneal semi-absorbable mesh. preliminary results: in all cases abdominal functioning was successfully restored; no higher pain related to the continuous laparoscopic suturing has been reported compared to bridge ipom laparoscopic repair, while allowing for a more physiologic outcome and a stronger repair. the use of miniaturized instruments allowed for minimal tissue trauma and accurate surgical gestures; the tiny trocar sites did not require skin suturing and might reduce the risk of trocar hernias. no intra operative bleeding, no seroma formation, chronic pain, nor mesh infection have been recorded. % follow up at months, % at months with no recurrences observed. the lap-t technique allowed for a sound and anatomic reconstruction, reduced trauma, faster recovery and more satisfactory aesthetic results. surg endosc ( ) background: anastomotic leakage is a serious complication, associated with significant morbidity and mortality. one possible cause of anastomotic leakage is insufficient vascular supply. markers of sufficient perfusion include pink color of the bowel wall, visible peristalsis, palpable pulsations and bleeding from the marginal arteries. these signs are subjective and may be misinterpreted even by experienced surgeons. aim: the assessment of bowel perfusion with the use of indocyanine-green fluorescence angiography might be helpful in decreasing the number of anastomotic leaks. project description: we report a case report of a middle-aged patient without significant medical history who was treated by transanal total mesorectal excision (tatme) for rectal carcinoma. the patient underwent neoadjuvant treatment with radiochemotherapy. during the surgical procedure, indocyanine-green fluorescence angiography showed adequate perfusion of the bowel. the postoperative phase was uneventful and the patient was discharged home on the th postoperative day. preliminary results: indocyanine-green fluorescence angiography is a safe, cost-effective and feasible tool for assessment of tissue perfusion during colorectal resections. background: to properly learn how to perform a laparoscopic suture, along with safe tissue handling, applying an appropriate magnitude of the force on the tissue is essential. for this reason, it is fundamental to investigate and validate if training with real-time visual force feedback improves the suturing performance of laparoscopic novice surgeons. capturing all of the forces applied in laparoscopic in surgery in an unobtrusive way has been difficult in the past. sensor has supplied a novel force-sensing film (forcefilm) that can detect all of the forces applied with laparoscopic instruments without changing the surgical workflow or operation of the instruments. aim: to evaluate the effect of visual force feedback on surgical performance, applied force and surgeon's ergonomics during training of laparoscopic suturing using the sensor technology (sensor medical laboratories ltd.). methods: twenty novice laparoscopic surgeons participate in this study. they perform a laparoscopic suture on an ex vivo stomach tissue from a pig. participants are assigned, in a random fashion, to either group that receives visual force feedback (a) or the control group (b) without visual force feedback. five training trials (t -t ) are carried out in order to assess the learning curve. in addition, an evaluation pretest (t ) and posttest (t ), without visual force feedback but recording the force applied, will be performed after the training trials. the applied force on the tissue and visual force feedback of each instrument are provided by means of the sensor technology. it accurately measures the forces exerted on the tissue from the instrument tip and wirelessly communicates the force information to the surgeon via visual force-feedback. during each trial, several parameters are evaluated such as execution time, applied force, surgical performance, and mental and physical workload. preliminary results: laparoscopic training using visual force feedback leads to an improvement of suturing skills with a reduction of the applied force and therefore providing a potentially positive effect on patient outcomes and surgeon's ergonomics. background: hiatal hernia is a frequent disorder, characterized by a protrusion of any abdominal structure other than the esophagus into the thoracic cavity through a widening of the diaphragmatic hiatus. current anatomic classification is mainly based on the location of the gastroesophageal junction and the presence of a true hernial sac, differentiating sliding from paraesophageal hernias. there is no solid evidence to support an association between gastric carcinogenesis and peh. however, chronic reflux is considered as one of the strongest risk factors of developing adenocarcinoma of the esophagus and proximal stomach. aim: herein, we report a case of an -year-old caucasian female with dysphagia, regurgitation and heartburn accompanied by an iron deficiency anemia, a remarkable total body weight loss and recurrent lower respiratory tract infections due to microaspirations. subsequent work-up with ct, upper endoscopy and barium esophagram confirmed the presence of synchronous distal gastric adenocarcinoma and a giant paraesophageal hernia with complete intrathoracic stomach. after mdt discussion and keeping in mind the patient's age and comorbidity, a d laparoscopic distal gastrectomy with a synchronous hernia reduction with posterior cruropexy was scheduled. project description: the patient was placed in a supine position, five thoracoscopic ports were introduced, and a diagnostic laparoscopy of the abdominal cavity was performed. the stomach was identified through the dilated hiatus into the left thorax. the hernia sac was dissected away from mediastinal structures, then excised to untwist the stomach. after reduction of the stomach to abdominal cavity, a total d ? gastrectomy with a roux-en-y reconstruction was performed. maintenance of optimal vision during minimally invasive surgery is crucial to maintaining operative awareness, efficiency and safety. hampered vision is commonly caused by laparoscopic lens fogging (llf) and lens condensation which has prompted the development of various antifogging fluids and warming devices. numerous tricks have been proposed to overcome this issue, such as heating the scope into a sterile thermos flask filled with hot water, or using one of the commercially available antifogging solutions. however, whether one method is superior to another remains elusive. as most surgeons know, none of these tips are totally efficient, as they don't treat the cause: the temperature difference. taking into account this need, we have developed ehs (endoscopy heater system), a thermoadjustable system by microcontroller, which is implemented in the manufacturing process of the rigid endoscope focused on laparoscopy. the technology enables the self-modulation of the temperature of the endoscope within the different conditions during the surgery, avoiding the % of laparoscopic fogging. with the adoption of ehs surgeons get a clear field of vision avoiding continues repetitions of extraction and insertion of the endoscope in the body during the intervention. in this way the risks of the patients are reduced with a more efficient and shorter duration procedure. ehs also represents an alternative that meets sustainability criteria by reducing energy costs and eliminating much of the waste currently generated by this procedure. therefore, this innovation will disrupt the laparoscopic device market by enhancing safety and effectiveness without introducing new components that could complicate surgical procedures. case report: we presented the case of a year old women with chronic coloenteric fistula. conservative treatment was unsuccessful. the orifice was then closed with two subsequent clips, and the patient recovered well. to our knowledge, this is the first successful case of coloenteric fistula treatment with ovesco discussion: ovesco system is a technique that enables the closure of gastrointestinal defects (perforation sites, leaks, fistulas) . after the system application, the patient can be treated at home as was the case with our patient. a successful closure of the leak or fistula is possible when no extraluminal abscess is present. in our case, we had a cavity (previous sinus or abscess) that drained into the small bowel, thereby forming the coloenteric fistula. this allowed us to succeed with a fistula closure, as the cavity could drain into the small bowel conclusions: looking through the reports, one notes that the success rate of the otsc system procedure for insufficiency of anastomosis or colorectal fistula was - %, but only nine successful reports of chronic colorectal fistula were found). a % success rate is reported if the clip is placed within a week of occurrence of the leak . on considering the financial side, clips could reduce costs and time of hospitalization and avoid patients having to undergo a surgical repair . the major advantage of ovesco clips seems to be their ability to grasp more tissue compared to the standard clips and their strong grip on the wound margins because of their sharpened teeth. the drawback of the clips in fistula sealing is their incomplete grasp when the tissue is fibrotic. most authors agree that ovesco is not very appropriate for fistulas larger than - mm. inguinal hernia repair is one of the most performed interventions in minimally invasive surgery. in this opportunity we report a new technique through the use of innovative devices such as the robotic clamp and magnetic deviceswith this technique and thanks to the magnetized devices and the robotic clamp we have demonstrated to reduce the surgical time between - min as well as to optimize the ergonomics of the surgeon.we explain the technique with a demostrative video and exposition of the devices that are necessary for make it.with this new technique we get a greater capacity of mabiobra for dissection of the peritoneum and later a greater facility for the suture of the same in the repair of the inguinal hernia. a motorized and computerized laparoscopic tool that can be customized to the specific surgeon and procedure a. szold aim: surgeons have different levels of skill and use instruments for different tasks, but laparoscopic instrument are commonly simple mechanical instruments that allow limited degrees of motion, and the same instruments are used regardless of the surgeon or the task. robotized articulating instruments so far have added degrees of freedom, but perform in a standard way for all users and procedures. technology: human xtensions has developed a \ u[hand-held \/u [ motorized smart laparoscopic instrument, that was recently introduced in human procedures. the device has several features that enable to customize it to the user and procedure. the degrees of freedom can be reduced from to , the scale of rotation motion has options that can control both speed and range of rotation, a feature especially useful for the variable types of suturing tasks. results: the variable features were tested in different procedures requiring suturing and grasping. the combination of all optional settings made the instrument customizable to the different skill levels of the surgeons. as such, it enabled to control the complexity of the device and take the surgeon through the learning curve until full control of all features was achieved. in addition, the combination of different controls was used for performing specific tasks requiring different levels of maneuverability. in september , the results of a bomss survey regarding the routine use of pre-operative bariatric surgery were published. they found that % of units surveyed considered routine preoperative ogd completely unnecessary. as part of newly launching bariatric services in a single isolated centre we protocoled that all bariatric patients had to undergo pre-operative ogd, including a clo test, and reviewed if the ogd findings had influenced our surgical choice of operation and any necessary treatment before surgery. all patients embarking on the bariatric programme since its launch in jan to sept were included and had an ogd. the results of these ogds and all the clo tests were reviewed. these ogds were all performed by a single consultant to minimise any potential subjective differences. of the patients, ( %) tested clo positive of which had normal findings on ogd. patients had a hiatus hernia, gastritis, oesophagitis, gastritis and oesophagitis, had other findings e.g. ulcers, polyps' or nodules. the positive clo patients underwent eradication of h pylori. studies have shown that this is a treatable and preventable cause of gastritis/ gastric cancers and potential surgical complications causing prolonged hospital stay in % of patients. knowing about the presence of a hiatus hernia prior to surgery also contributed to the surgical planning, including allowing time for the concurrent correction of the hiatus hernia in the operation. all patients with demonstrable oesophagitis ( %) had their operative choice changed to roux en y gastric bypass thus aiming to prevent post-operative reflux which would have been exacerbated had they undergone a sleeve gastrectomy instead. carrying out a pre-operative ogd had a significant impact in operative choice and additional treatment before surgery and therefore should be advised in all patients. general surgery department, ahievran university, kirsehir, turkey the majority of fatalities worldwide in people under the age of years are caused by trauma . blunt mechanisms account for . to . %of injuries [ ] [ ] [ ] [ ] ,with the abdomen being affected in . to . % of all traumatic injuries. this case contribute to the literature: a patient with sleeve gastrectomy has distorted anatomy at duodenogastric junction, if has bat,her/his small bowel perforation(sbp) will occur on more distal segment. this a unique case before unpublished. years old female who had sleeve gastrectomy years ago presented to emergency department sustained blunt abdominal trauma (bat). when she arrived pyschical exam (pe) revealed an abdominal guarding, tenderness, normal vital signs but those increased h later. wbc values also increased h later. hb was normal.fast showed in cm thickness fluid early in douglas pauch (dp), mm in supravesical, mm diameter in dp h later. abdominal ct: mm diameter fluid in interloop, dp free air at th h from the accident. a diagnostic laparoscopy(dl) was done with diagnossed acute abdomen.there were a sbr-located cm from treitz, intraperioneal fibrin deposits and fluid-repaired with a primary suture.the patient discharged on days without any event. repeat ct scans are recommended for patients with initial suspected bowel injury. we could not do this; cause ct exam could taken in rush hours only but we did repeatly pe that peritoneal iritation signs increased,resulted a dl,surgical therapy. according to the literature; dl may be a good treatment option in these patients, to reduce morbidity or mortality, time to surgery has been emphasized. long interval between presentation and surgery was found to be associated with complications. very few reports of isolated jejunal transection following blunt abdominal trauma have been published in literature. the literature mentioned; the patients with sbp are hemodinamically stable on arrival to the hospital like our case are, a rupture of the jejunum was seen just distal to the duodenal-jejunal flexure but there were a perforation cm below treitz ligament and caused me to think the patient had sleeve gastrectomy and some brid around gastric and duodenal proximal jejunal part of intestines and also caused a new descended treitz ligament. normally external forces across to spine produce a blast effect on small bowel between treitz and ileocolic ligament. introduction: sasi bypass is a novel metabolic/bariatric surgery operation based on minigastric bypass and santoro's operation.it can be offered for patients with weight regain after sleeve gastrectomy. sleeve gastrectomy (sg)is a commonly performed bariatric procedure.weight regain following sg is a significant issue.yet,the understanding of this phenomenon is still unclear.rates of regain ranged from . % at years to . % at years.sasi bypass was an option for some candidates having sg done years back and failed to achieve the required weight loss or having weight regain.in sasi bypass, resleeve gastrectomy of the dilated gastric pouch is done followed by a side to side gastro-ileal anastomosis. the aim of this study is to report the clinical results and the outcomes of sasi bypass as a therapeutic option for patients with weight regain after sg methods: we conducted a retrospective study for morbidly obese patients having history of sg done more than years back and failed to achieve and/or to maintain the required bmi. exclusion criteria:patients with recent history of laparotomy(less than months). procedure was done at sidra hospital in kuwait from november to november . using ports, resleeve gastrectomy was performed over fr bougie tube starting cm above the pylorus then gastro-ileal anastomosis (side to side)was performed cm above the pyloric ring to an ileal loop counted cm from the ileocaecal valve. data was collected from the patients including:weight loss progress,laboratory full results. discussion and results: during the study period: morbidly obese patients with a mean bmi of ± kg/m were evaluated. -%ewl(excess weight loss)reached % at one year. -diabetes was cured in the known diabetic patients (type )within months,and the one known type diabetic patient had better control and less insulin daily doses(results were guided by glycated haemoglobin results every months). follow up laboratory results were normal in % of patients (all were kept on regular vitamins and proteins supplementation)-one patient had postoperative leak(day )from the anastomotic line that was treated conservatively. conclusion: sasi bypass is a promising operation that offers a good weight loss for morbidly obese patients having weight regain after sg conclusions: our study demonstrates a good agreement between the degree of liver steatosis and monocytes fat accumulation as well as between plin levels in liver and circulating monocytes. this suggests that ectopic fat deposition is a generalized feature of insulin resistance in obesity. sg reverses monocyte fat accumulation and restores insulin signalling, which correlates well with insulin sensitivity. moreover, circulating mmp levels significantly dropped after sg suggesting that the state of generalized inflammation characterizing obesity normalizes. her stomach stapled,a foreign tube like body was seen on cut surface of the stomach.the foreign body seen in dissected stomach wall is the tube is in placed a gastric banding insuflation tube.a laparatomy was made and the tube is extracted her stomach sutured primarily,nasogastric decompression,peritoneal drainage was made.her peritoneum was drained.she has a septic condition, leave in icu for a long period.her general status being well and discharged from hospital in days.we learn after the operation not before;she had a gastric adjustable banding and extraction the gastric band, but the tube of gastric band is not removed. alkhaffaf et al present a case of fistulation of the lagb tubing into the jejunum a review of the published data to identify the salient learning points with this and similar rare complications fistulation from lagb tubing is a rare complication that tends to follow removal of an infected port. the clinical presentation is nonspecific, rendering the preoperative diagnosis difficult. the tube and band can be removed laparoscopically, with closure of the small bowel fistula site. securing the tubing to the abdominal wall fascia after intentional detachment from the port might reduce the incidence of this complication.katherine j et al report a late and rare complication of a small bowel obstruction in a -year-old woman from an lagb placed for years. although not a common complication, one that could easily see the safety record of lagb patients tarnished if this small subgroup of patients is not acted upon promptly by emergency departments' unfamiliar lagb surgery. in our case we already made esophagogastroduodenoscopy before operation, ofcourse take past medical history from the patient.the patient hide past operation (gastric banding and removing band and port but leaving insuflation tube). ). there was no difference in the two groups regarding follow-up rate. basic demographics were the same, and other long-term results were similar between the groups. regression models for both post-op complications and failure as defined by baros score did not show that gender is a risk factor. discussion and conclusions: in our study, revisional sleeve surgery were similar. we did not see any significant difference in post-op complications, success of the operation as defined by baros, or subjective feeling of the patients. we do believe that gender-specific outcomes should be taken into consideration in optimizing patient selection and preoperative patient counseling, and that in the case of a sleeve post a band gender is not a risk factor for complication or failure of the procedure. objective: the internal hernia is a rare but a potentially fatal complication of laparoscopic roux-en-y gastric bypass (lrygb). the aims of this study are: ( ) to determine the impact of mesenteric defects closure on the incidence of internal hernia after lrygb; ( ) to determine the symptoms, characteristics and management of internal hernias after lrygb. the median interval between lrygb and reoperation was months in group a and months in group b. the median percentage of excess weight loss (%ewl) was % vs %, respectively (p = . ). the median percentage of total weight loss (%twl) was % vs %, respectively (p = ns). patients, % ( in group a), were admitted to the emergency room with acute abdomen pain. a ct scan was performed in patients, %, and showed signs of occlusion in all cases. the most common symptoms were abdominal pain and vomiting. the surgery was performed using laparoscopy in patients, %, and using laparotomy or conversion in patients, %. conclusions: the closure of mesenteric defects during lrygb is recommended because it is associated with a significant reduction in the incidence of internal hernia. our study intends to analyze the long term results of sleeve gastrectomies performed by d laparoscopic approach. materials and methods: a prospective cohort study was conducted to perform gastric sleeve for morbid abesity. all surgeries were performed by the same surgeon over a period of two years. the operating surgeon is a senior most laparoscopic surgeon with vast experience in laparoscopic surgery. during two years period, cases were operated using d laparoscopy system. scientific calculation was done using spss release . windows software. results: patients, female ( %) and male ( %), with median age of . ± . ( - ) the excess weight lost (ewl) was % in the first year, % in the second, % in the third, % in the fourth, % for the fith year, % for the sixth and % for the seventh. postoperative complications were stenosis of the sleeve always located in the incisura and treated with endoscopic dilatation except one that required conversion to oagb. three leakages, all of them reoperated with drainage and introducing prosthesis by endoscopy in the same act. we have never had a postoperative bleeding of the sleeve. conclusions: d gastric sleeve laparoscopy is a safe and feasible technique for morbid obesity and related pathologies. the ewl is correct in long time. complications are rare but is necessary to have a good level of suspicious in order to a rapid solution. the worst complication is the leak of the sleeve. the oversewn of the gastric section is a good technique to avoid this complication. surg endosc ( ) aims: leak is one of the common complications of laparoscopic sleeve gastrectomy that result prolongation of hospital stay, morbidity and even mortality. methods: i report new approach for the treatment of leaks presented to me post laparoscopic sleeve gastrectomy with laparoscopic roux en y bypass to the leak site at the level of gastroesophageal area. this new approach is possible and feasible, and avoids stenting due to high failure rate, prolonged hospitalization and saves life of patients. results: all leaks healed days from surgery due to well vascularized small intestinal patch, except for leaks that healed after weeks of conservative treatment. aims: analyse the effect of one anastomosis (mini) gastric bypass (mgb/oagb) in the treatment of gastro-esophageal reflux in patients previously submitted to laparoscopic sleeve gastrectomy (sg). methods: a retrospective analysis was performed on the data of patients who underwent mgb/ oagb after a previous sg at policlinico san marco, italy, from january to june . a total of patients, female and males ( % f/ % m) underwent mgb/oagb after sg, due to the development of significant gastro-esophageal reflux disease (gerd), refractory to proton pump inhibitors (ppi), detected with the gerd questionnaire (gerd-q) and esophagogastroduodenoscopy (egds). in three patients ( %) a weight regain was also observed (mean bmi . kg/m , range . kg/m - . kg/m ). mean patients age was . ( - years old). before sg none of the patients had declared symptoms of gerd or was subjected to a therapy with ppi, preoperative egds did not show signs of esophagitis. mean bmi of the patients who developed gerd without weight regain was . kg/m ( kg/m - . kg/m ) at the time of surgery, with a medium ewl% of % ( . - . %). patients were treated unsuccessfully with ppi for at least six months before programming revisional surgery. mean gerd-q score was . results: after mgb/oagb, with a mean follow up of months ( - months), mean bmi was . kg/m and gerd-q score was . however, five patients out of ( %) developed an anastomotic ulcer or a grade c esophagitis. we did not observe any post-operative immediate complication nor any death. conclusion: mgb/oagb is a simple, effective and safe surgical procedure for patients who underwent a previous sg and who developed gerd, with satisfactory results in the short and medium post-operative time, even if there is still concern regarding the complications linked to biliary reflux. v.s. kyosev aims: laparoscopic adjustable gastric band (lagb) was one of the common techniques in bariatric surgery worldwide. the advantages included the possibility of regulation, ease of placement, acceptable weight loss and low rate of perioperative complications. a late complication of lagb is penetration of the gatric band through the gastric wall and migration into the lumen of the stomach. hereby, we present three cases of gastric band migration following lagb. methods: from to we observed cases of gastric band migration in between and years after lagb placement. the patients were hospitalized in surgical department complaining of sudden sharp epigastric pain, nausea and vomiting, with symptoms onset in the last few days. all patients underwent abdominal ultrasound examination, x-ray investigation of the abdomen with oral contrast administration, fibrogastroscopy. in cases the imaging studies revealed gastric band migration into the stomach's lumen and in case-obstruction of the jejunum by the gastric band. all patients underwent laparoscopic surgery. results: two of the patients underwent gastrotomy, extraction of the gastric band and roux-and y-gatric bypass. the patient with jejunal obstruction underwent laparoscopic enterotomy, extraction of the gastric band and cholecystectomy due to concomitant cholecystitis. two of the patients had no additional perioperative complications and were discharged at the th postoperative day. one patient developed fever, left pleural effusion and partial insufficiency of the gastrointestinal anastomosis in the early postoperative period without the need of surgical treatment. the patient was discharged on th postoperative day. all patients were prescribed a diet and monthly blood test of ion balance. conclusions: lagb was one of the most common treatment methods due to the epidemic spread of morbid obesity in western countries. detailed knowledge on possible lagb complications is essential for the treatment of these patients. the diagnosis of lagb complications is often delayed due to its relative rarity and nonspecific clinical manifestations, but in most of the cases it requires emergency surgery for management of life-threatening conditions. results: there was conversion in patients (short mesentery of the small intestine). such postoperative complication like anastomotic leak in patient ( . %) and staple line bleeding in patient ( . %), which was managed laparoscopically. compensation for type diabetes was achieved in ( %) patients, improvement was recorded in ( . %), dyslipidemia in ( . %) and ( . %) patients, arterial hypertension in ( . %) and ( %) patients respectively, what led to metabolic syndrome resolution in ( %) patients. the liquid is allowed to take after day. average postoperative hospitalization- . ± . days. %ewl for months %. conclusions: laparoscopic mini gastric bypass is an effective method of surgical correction of body weight and metabolic disorders in patients with morbid obesity and allows to receive an adequate and stable correction of arterial hypertension, lipid and carbohydrate metabolism, which are components of a metabolic syndrome. introduction: over time laparoscopic sleeve gastrectomy lsg has become the most popular bariatric operation worldwide. a critical step during lsg is ensuring sleeve-size consistency. gastrisail device (gastric positioning system) is a three in one surgical device replacing the standard bougie used in lsg for the application of suction, decompression and to serve as a sizing guide for gastric sleeve creation. the aim of this study is to evaluate the possible merits of gastrisail device in lsg over the standard laparoscopic sleeve gastrectomy. methods: a prospective study of patients randomly divided into two groups: group a composed of twenty patients who undergo lsg with the use of gastrisail and group b composed of twenty patients who undergo lsg with the standard bougie without the use of gastrisail comparing both according to operative time, consistent sleeve formation, delineation and visualization, intraoperative and post-operative complication rates, the lenght of hospital stay,gastric pouch design and percentage of excess weight loss (%ewl). results: regarding intraoperative time, the mean time was . ± . and . ± . for group a and b respectively,while no patients in group b had consistent sleeve formation, patients ( %) had consistent sleeve formation. delineation and visualization were accomplished in % of group a patients, was not accomplished at all in group b patients. the alignment of the stomach was reached in patients in group a but no patients at all in group b, the mean of hospital stay was . ± . and . ± . for group a and b respectively, the smaller tube design illustrated by gastrograffin x-ray at rd post-operative day was accomplished in patients ( %) and patients ( %) in group a and b respectively. there was no significant difference in %ewl in both groups. conclusion: the use of gastrisail device is superior to the standard lsg in consistent sleeve formation, visualization, delineation and good alignment and accomplishment of a small tube design while no significant difference in %ewl. bariatric surgery has spread all over the world. since japan has few patients with morbid obesity compared with western countries, it has been implemented only in limited facilities. however, bariatric surgery in japan is rapidly spreading recently, and many facilities are about to install bariatric surgery. effects of bariatric surgery are known to last for a long time, but some cases require reoperation which is called revision surgery due to late complications or rebound. because of thick subcutaneous and visceral fat, open surgeries are not even always a good solution to make surgery easier in morbid obese patients and all procedures must be completed laparoscopically. therefore, especially in revision surgery, the incidence of complications tends to be increased. as the number of bariatric cases to be increased in japan, cases requiring revision surgery is likely to increase. in revision surgery, it is necessary to select the procedure according to patient condition, and it is necessary to familiar well with those procedures. we will present cases that underwent revision surgery in our department and show the clinical outcome. we have done four revision surgeries after sleeve gastrectomy so far. operative indications are mid-gastric stenosis and rebounding disease. for stenosis cases, we performed roux-en y gastric bypass with distal stomach resection, and for rebounding cases, we performed re-sleeve gastrectomy with duodenal-jejunal bypass. average interval from initial operation to revision surgery is months in rebounding cases, and months in stenosis cases. duration of operation was min in average, and mean estimated blood loss was ml. no postoperative mortality was observed. in rebounding cases, excess bmi loss at year after surgery was . % in average, and both cases achieve diabetes remission at year. one cases of mid-gastric stenosis required a nutritional support with formula diet temporally. in particular after sleeve gastrectomy, revising to roux-en y gastric bypass, re-sleeve gastrectomy, and adding the duodenal-jejunal bypass will be the main techniques. along with an increase of bariatric surgery in japan, it is necessary to acquire sufficient knowledge and skills to carry out revision surgery. methods: we present the case of a year old woman who underwent lsg after lagb removal and lgcp. the patient underwent preoperative endoscopy and barium swallow, with no sign of stomach perforation or erosion. we emphasize that the patient, had undergone three operations of gastric band placement, gastric band removal and gastric plication before sleeve gastrectomy. however, a successful lsg was achieved. results: no severe postoperative complications were mentioned. conclusion: weight loss in the first year was % of the excess weight.sleeve gastrectomy after gastric band removal and gastric plication, for morbid obesity seems to be safe and efficient, especially in casesof absence of gastric erosion. surg endosc ( ) department of surgery, patients were observed with serious septic complications many years after gastric banding operation. we detected a female dominance ( female, male) in patients with a mean age of . years. the leading symptoms were: dysphagia, upper abdominal tenderness and pain, spontaneous fistula formation, fever, masked septic signs, bowel and urinary obstruction. patients underwent video-endoscopy, chest and abdominal ct (computed tomography), fistulography and cystoscopy. results: in still morbid obese patients, laparoscopic procedures were performed with a conversion rate of %: atypic gastric and cardia resection in cases, gastric suture in cases, small bowel resection and suture in - cases. in one case, fistulectomy, abscess evacuation and combined urinary bladder suture and drainage were carried out. the duration of the surgeries were over h with minimal blood loss (\ ml). the foreign bodies were completely removed in every case. intraoperative complication was not occurred. early physiotherapy were promoted, oral feeding were gradually built up from the th postoperativ day depending on the type of the operation. early postoperative complications included recurrent fistula formation (n = ) and wound infection (n = ). all the fistulas were closed after conservative treatment. average hospital stay was days, regular check-ups were held on the rd, th and th months of follow up. conclusion: gastric banding is the most common, routine and safe technique for the treatment of morbid obesity. the development of late, severe septic complications draws attention to the crucial importance of follow up. the surgical management of these patients is recommended in specialized centers in regard to difficult operative conditions and atypic treatment options. aims: single anastomosis duodeno-ileal bypass with sleeve gastrectomy (sadi-s) has been proposed as an alternative to biliopancreatic diversion with duodenal switch (bpd-ds) in order to maintain the outcome of the original procedure simplifying the technical complexity and to avoid potential complications. moreover, it potentially represents the more natural second step bariatric procedure after sleeve gastrectomy (sg). we aimed to report the initial experience with sadi-s of our high volume bariatric center. methods: retrospective analysis of patients who underwent bariatric procedure between july and november was conducted. the primary aim was the evaluation of the safety of sadi-s, defined as the rate of postoperative complications. the secondary endpoint was the bariatric efficacy of the procedure, defined as percentage excess weight loss (%ewl). results: among patients who underwent bariatric procedures at our institution ( . %) patients were scheduled for sadi-s. all patients had multiple comorbidities. initial indication for sadi-s was failed sg in patients (median pre-sg bmi . kg/m \ sup [ \/sup [ ; median months after initial operation respectively) and primary procedure in patients (median pre-operative bmi . kg/m ). the surgical procedure was accomplished with robotic-assisted approach in cases (median operative time min) and with laparoscopic trocars standard approach in the remaining cases (median operative time min). the duodeno-ileal anastomosis was fashioned using a double layer hand-sewn running sutures. no patients showed early post-operative complications, the median postoperative stay was days. at a mean follow up of months the median %ewl was . . to date no patients experienced surgical. one patient develop wernicke encephalopathy months after surgery, but he was non-compliant to multivitamin supplementation. conclusions: at least in a high volume bariatric center sadi-s, both as second step after sg and as primary surgical option, seems to be a safe and effective bariatric metabolic procedure based on solid physiopathologic principles. on the other hand, longer follow-up is necessary to support the use of this procedure as a better alternative to bpd-ds. m.r. elkeleny , a. abo khozima git and bariatric surgery, faculty of medicine, alexandria university, alexandria, egypt; git surgery department, faculty of medicine,alexandria university, alexandria, egypt four bariatric cases . female patient with intragastric balloon, minor leak from the balloon leading to ballon migration to the jejunum;hance, small bowel obstruction occured. emergency diagnostic laparoscopy was done, enterotomy and extraction of the balloon, direct repair of enterotomy and balloon extraction through mm port site. . male patient presented after days of lsg with small bowel obstruction due to entrapment of small bowel loop through one of the port sites;therefor, emergency laparoscopy was done with reduction of the herniated segment and closure of the port site. . female patient presented with stricture of the ogj after re-sleeve gastrectomy managed by balloon dilatation which recur after weeks .she was managed by expandable metallic stent for weeks with good response and the stent was removed. . -year-old male patient presented with sever peripheral neuropathy following months after sleeve gastrectomy, and the patient was getting worse; thus, he used wheel chair. he has been making good progress on vitamin b complex injections. the aim of our study was to compare histopathological findings of gastric specimens to preoperative clinical symptoms and to conclude about the need for ugi endoscopy as a routine prior to surgery. methods: the last two years, morbid obese patients were selected to undergo laparoscopic sleeve gastrectomy (lsg) in our institution. for the needs of our study, all of them had ugi endoscopy and were reviewed for upper gi symptoms. histopathological reports obtained according to our protocol, after surgery. results: gastric histology from specimens revealed: no findings in / patients ( . %), gastritis in / patients ( . %) and focuses of incomplete intestinal metaplasia without dysplasia in / patients( . %). finally, two minor leiomyomas with low cellular proliferation rate were fully excised in a patient's specimen. there was no inconsistency between preoperative symptoms and gastric histology, while leiomyomas found were no reported to ugi endoscopy due to size. conclusions: some of the patients with clinical features of food intolerance, gastroesophageal reflux disease, and peptic ulcer disease had finally findings in histopathology of their stomachs. history of helicobacter pylori infection implements a raised incidence of mucosa pathology as well. because only one case revealed carrying significant pathology (leiomyomas), we consider that is safe to proceed with surgery in an otherwise asymptomatic patient based on his previous medical records and blood tests. aims: splenic abscess following laparoscopic sleeve gastrectomy (lsg) is a rarely seen complication. the aim of our study was to present a case of splenic abscess in a morbid obese patient who underwent lsg. as the main concern in these cases is leakage from the staple line, we present our diagnostic and treatment approach. methods: a -year-old, female morbid obese patient (bmi . kg/m ), without any predisposing risk factors, underwent elective lsg in our department. following an uneventful course, she was discharged at the nd postoperative day. however, at the th postoperative day, she readmitted to our unit with high temperature of . o c, left upper quadrant tenderness and leukocytosis. contrast computed tomography (ct) revealed an abscess at the upper pole of the spleen , cm in maximum diameter, without leakage from the staple line. results: the patient was treated with broad-spectrum antibiotics and radiological percutaneous drainage of the abscess. although there was a partial clinical improvement, a week later, a new ct scan revealed the continuous presence of the abscess. despite the stable general condition of the patient a laparoscopic splenectomy was performed and a gradual recovery was followed. the presence of splenic abscess without splenic trauma or leakage from the gastric staple line, is an extremely rare complication and only a few cases have been previously reported. the cause has not yet clarified, but the proposed mechanism involves infarction of the spleen, due to vascular compromise and subsequent infection. most of the reported splenic abscesses were diagnosed during the late postoperative period. in our report we present a case of early onset, hence highlighting the need of clinical awareness for early diagnosis and treatment. introduction: obese surgical patients with obstructive sleep apnea (osa) have a higher risk of peri-and postoperative desaturations and subsequent morbidity and mortality. currently, the best perioperative management of patients without known osa remains unclear. although routine osa screening has been advocated, sleep studies are costly and time consuming. we hypothesized that bariatric patients can be safely monitored on a surgical ward by continuous postoperative pulse oximetry without preoperative screening for osa. objectives: to evaluate outcomes of continuous postoperative pulse oximetry without preoperative osa-screening, and to compare the results to outcomes of patients with osa and continuous positive airway pressure (cpap) treatment. methods: all patients who underwent bariatric surgery between and were included in this single-center retrospective cohort study. all patients were postoperatively monitored with continuous pulse oximetry on the surgical ward. patients with less than two documented saturation measurements were excluded. patient files were reviewed for osa diagnosis, cpap usage and perioperative details. primary outcomes were -day complication rates, intensive care unit admissions due to cardiopulmonary causes and postoperative desaturations of spo \ %. secondary outcomes were icu admissions following all causes, length of stay and rates of reoperation and readmission. results: in total, patients were included. patients ( %) were preoperatively diagnosed with osa, ( . %) were cpap users. complications occurred in . % of patients without osa and in . % with osa(p = . ). desaturations were documented in . % and % (p \ . ), respectively. in both groups, patient was admitted postoperatively to the icu for cardiopulmonary causes that could be related to osa (p = . ). both recovered without further complications. icu admissions, regardless of cause, occurred in . % of patients without osa and in . % with osa(p \ . ). no significant difference between groups was observed in complications based on clavien dindo classification, length of stay, reoperation-and readmissions-rates. conclusions: these findings suggest that continuous postoperative pulse oximetry without preoperative osa-screening is a safe perioperative management strategy for bariatric surgical patients. future studies are needed to assess cost-effectiveness of pulse oximetry vs. routine preoperative osa-screening in a prospective clinical setting. background: the pathology of colon is one of the most pressing and socially significant problems of modern health care, because it leads to reduction of the working population employed in manufacturing, in some cases to disability and reduced quality of life. mini invasive surgery of the colon has a great advantage: speed recovery, shorter hospital stay and better cosmetic results, the quickest return of patients to work. as a result, mini invasive endovideosurgery is firmly established in clinical practice of coloproctology. objective: the choice of optimal surgical method for treatment of colostasis, achievement of favorable outcomes of treatment. introduction: laparoscopic roux-en-y gastric bypass (rygb) is one of the most important bariatric surgical procedures performed worldwide and it can produce an important loss of weight with reversal of metabolic disorders like diabetes and dyslipidemia. even though it has good results, some complications occur after gastric bypass. a rare but serious complication of rygb is the so-called postprandial hyperinsulinemic hypoglycemia. its prevalence has been estimated less than % of cases and its pathophysiology remains unclear. methods: the aim is to present a case series of reversal surgery in patients with severe hiperinsulinemic hypoglycemia after rygbp in the hospital general universitari de la vall d'hebron. unit of endocrine-metabolic and bariatric surgery (eac-bs center of excellence for bariatric and metabolic surgery by ifso). it is a retrospective analysis of a prospective database same surgical team. we present in this study, the main features of those patients. results: between and , patients underwent a laparoscopic reversal procedure to normal anatomy and age mean was year ( years to years). mean preoperative body mass index (bmi) was . kg/m (range - . kg/m ) and were women. all patients presented hypoglycemia symptoms years after and the longest was years after the procedure. the first step of the standard approach was a laparoscopic reversal to normal anatomy with resection of the alimentary rygb limb in cases. a concomitant sleeve-like gastrectomy (sg) was added. four patients presented postoperative complications: gastrogastric anastomosis leak ( ) introduction: laparoscopic sleeve gastrectomy is the most performed bariatric procedure, but complications might interfere with patient's long-term evolution based on its compliance and tolerance, surgical attitude and unpredictable evolution. materials: we present the case of a female obese patient, with type ii diabetes mellitus and blood hypertension, with multiple, sequential bariatric minimally-invasive interventions: sleeve gastrectomy in complicated by postoperative acute gastric dilation and mediogastric stenosis, reoperated for viscerolysis and cholecystectomy, with endoscopic gastric dilations, initially converted to functional one anastomosis gastric bypass ( cm limb), with a non-adjustable gastric ring positioned instead of stapled division. the last operation was complicated months after by persistent biliary gastro-esophageal reflux, chronic abdominal pain, and gas bloat syndrome. in the patient underwent conversion to laparoscopic r-en-y gastric bypass, with gastro-enteral anastomosis resection, band removal and viscerolysis. results: conversion to r-en-y was complicated by biliary leakage post-viscerolysis, treated with laparoscopic approach in the \ sup [ th \/sup [ po day. after multiple surgical and endoscopic interventions, the patient presents short-term favorable outcomes, with no reflux or abdominal pain, with further weight loss and diabetes improvement. conclusion: bariatric surgery has unpredictable evolution in same cases, and conversion to r-en-y seems to be the best solution. lgcp is widely used in developing countries due to its lower cost and good results. material and methods: we performed in our department lgcp for morbid obesity. excess weight loss (%ewl) was % at month after surgery and % at one year. in cases revision surgery was needed for different complications and in cases for inadequate weight loss or weight regain after month follow up. in cases we performed sleeve gastrectomy (in cases after taking down the plication) and in cases we performed a re-plication in one row. results: the rate of revision surgery was % overall and % for inadequate weight loss (excess weight loss \ %) or weight regain. major complications occurred only in one patient (leak with abscess) but it was solved by laparoscopy. minor complications as vomiting and nausea appeared in patients ( %) and were solved with medication. after one year follow up %ewl in these cases was %. conclusions: revision surgery after lgcp is possible. a new plication or sg was the option in our series with good results. further studies are needed to evaluate the use of lgcp in the armamentarium of bariatric surgery. background: roux-en-y gastric bypass (rygb) is one of the most commonly performed bariatric procedures around the world.however, rygb it sometimes carries the risk of rarebut serious long-term complications such as malnutrition and liver failure. we report a case of laparoscopic reversal of rygb. methods: in march , a laparoscopic rygb was performed for a -year-old female without comorbidities and with a bmi of kg/m . all laboratory test results at the preoperative evaluation were within the normal range. abdominal ultrasound revealed moderate hepatic steatosis and oral endoscopy a hiatal hernia with grade b esophagitis. one year later, patient experienced an important weight loss of kg (from to kg) with a bmi of kg/m . however, patient presented general weakness, abdominal pain, ascitis lower extremitiy edema, anemia, progressive caloric and protein malnutrition, vitamin (a, d), mineral (copper) and folic acid deficiencies, nonalcoholic steatohepatitis (nash) and liver function was progressive worsening. results: a laparoscopic reversal of gastric bypass was performed. the operation was successfully performed via laparoscopy. operating time was min. postoperative was uneventful and patient discharge home at day . hepatic biopsy revealed nash with steatohepatitis of % (fibrosis f - / ). eight months after reversal of gastric bypass, patient has improved her clinical situation (no asthenia), maintains of weight ( kg) and has improved her nutritional status and liver function parameters. conclusion: laparoscopic reversal of rygb is technically feasible and might be performed safely after thorough preoperative evaluation in carefully selected patients with malnutrition and liver failure. conclusion: laparoscopic sleeve gastrectomy it's a safety obesity procedure before major abdominal hernia repair. it's a minimally invasively technique with an absence of anastomoses. these factors prevent fewer complications, without using the small bowel, and skin problems and allow resolution of obesity-associated co-morbidities. body weight loss after surgery may be an opportunity to repair the severe loss of domain incisional hernia. bibliography borbély, y., zerkowski, j., altmeier, j., eschenburg, a., kröll, d. and nett, p. general surgery, benhazi medical center, benghazi, libia, general surgery, royal bahrain hospital, manama, bahrain obesity is a worldwide epidemic with an increasing incidence trends and as a consequence obesity related health problems become priority to healthcare authorities in all the countries. laparoscopic gastric plication is an emergent restrictive procedure which claimed to be low cost because they do not need staplers and carries less complications as compared to laparoscopic sleeve gastrectomy. we present here a years female who was operated for morbid obesity four months back where she underwent laparoscopic gastric plication with no immediate post operative complication and her wight loss was adequate. two days before presentation to our emergency department she started to complains of sever attacks or upper abdominal pain and vomiting.clinical examination was unremarkable apart of abdominal tenderness in left upper abdomen. all blood routine were normal and all inflammatory markers were within normal range.ct abdomen showed large cystic lesion around the greater gastric curvature containing fluid and raised possibility of collection. patient was admitted to hospital, in despite of medical treatment her pain persists and necessitate immediate laparoscopic exploration. gastro-gastric hernia at the greater curvature through loosen ethibond suture that was used to plicate the stomach in the previous surgery. we released the suture to liberate the strangulated stomach which is not gangrenous. re-plication was not possible because of the extensive gastric wall edema and as preoperative discussion with the patient she refused conversion to sleeve gastrectomy no intervention was done. post surgery patient was free of symptoms and tolerating oral diet and discharged home on third post operative day with no complications. gastro-gastric herniation could progress to gastric wall gangrene which will result in high morbidity and even mortality. high index of suspicion is required to diagnose the condition . preoperative patient counseling is important to explore the surgical options if deemed necessary to convert to another bariatric procedure. k. chouillard, a. d'alessandro, l. chahine background: bariatric surgery is the best available, long-term treatment for morbid obesity. currently, laparoscopic sleeve gastrectomy (sg) is the most commonly performed bariatric procedure in france. despite its safety and efficacy, long-term complications of sg are not rare including gastro-esophageal reflux disease (gerfd), twisting, stenosis, insufficient weight loss, and weight regain. the goal of this study was to analyze the pattern and short-term results of surgical revision in patients with sg. methods: revisional bariatric surgery, regardless of its motivation, was always a multidisciplinary decision after clinical, biological, endoscopic, and radiological assessment. patients who had revisional surgery after sg were retrospectively identified and subsequently divided in subgroups according to preoperative body mass index ( we aim to present the management and the particular aspects of the surgical technique in a gastrobronchial fistula after gastric sleeve . the mean time between intervention and diagnosis is . - . months. methods: between and , laparoscopic gastric sleeve resections were performed in our bariatric center. we had one case of gastrobronchial fistula associated with an inferior lobe abscess of the left lung, diagnosed months after the gastric sleeve. the patient was subject for medical treatment for h, than a laparoscopic intervention was performed in order to drain the lung abscess and the gastric fistula and to place a feeding jejunostomy. . months after this intervention ( . months after gastric sleeve) a laparoscopic roux-en-y fistulojejunostomy was performed. the evolution was monitorized with blood tests, upper gi contrast series and ct scans. results: the surgical drainage of the lung abscess, along with the antibiotherapy, controlled the infection and allowed the lung cavity to reduce in size, and thus the drainage tubes introduced in the thorax through the diaphragmatic orifice were retracted progressively. also, the feeding jejunostomy allowed a proper nutrition for the patient with a good recovery. however, . months after the drainage intervention, the gastric fistula was not healed, and a decision to interrupt the communication with the lung cavity was made, by creating a laparoscopic fistulojejunostomy. after this, the evolution was favorable, with the healing of the lung cavity, oral feeding was permitted and the jejunostomy was suppressed. conclusions: the treatment of the gastrobronchial fistula is complex (medical, endoscopic or surgical), phased and long lasting until healing. surgery was our initial choice for treatment due to the existence of the lung abscess, which needed to be drained. key words: gastrobronchial fistula, lung abscess, laparoscopy, fistulojejunostomy s.i. filip, i. hutopila, c. copaescu introduction: leakage remains one of the most dreadful complications in metabolic surgery. the main cause of leakage is poor tissue oxygenation due to inadequate vascular perfusion. the study of intraoperative tissue perfusion in real time due to icg enhanced fluorescence could provide valuable information for the surgeon in order to prevent postoperative fistula. aim: to present our experience in using icg enhanced fluorescence in laparoscopic bariatric surgery material and method: in cases of gastric sleeve, cases of gastric bypass and in cases of revisional surgery or redo cases we used intraoperative icg mediated fluorescence to assure the optimal vascularization of the involved tissues. in our video we present intraoperative aspects before and after using icg in different cases. results: in all cases of primary gastric sleeve and gastric bypass with intraoperative use of icg we did not encounter inadequate perfusion. in one case of redo gastric bypass after failed vertical banded gastroplasty for morbid obesity despite intraoperative laparoscopic normal aspect of the gastro-jejunal anastomosis, icg mediated fluorescence allowed to identify an unexpected ischemic anastomosis and we could prevent consecutive postoperative leakage. discussion: presented cases are discussed and result with referral to literature is made. conclusion: intraoperative use of icg is a valuable tool in assessing the perfusion of the tissues and provide essential information for the surgeon in order to avoid postoperative leakage. , including patients, hemostasis with clips has been performed in all cases. however, among these cases nine patients required reoperation for early postoperative bleeding. in five cases a bleeding source from the stapled line was identified while in cases no identifiable source was found. during the second period ( to present) patients were submitted to bariatric surgery and hemostasis was performed by over sewing with a running suture. among these cases reoperation for postoperative bleeding was needed in cases ( . %), but no bleeding from the staple line being encountered ( %). the difference has statistical significance. no significant complications related to the use of this type of reinforcement were encountered. conclusions: over sewing the gastric stapled line in bariatric surgery is superior to hemostatic clip application in preventing the postoperative bleeding from the stapled line postoperative bleeding. a protocol of active search of the bleeders during the bariatric procedure should be implemented and respected in all the cases. gastroenterological surgery, saitama medical university international medical center, hidaka-shi, saitama, japan intestinal endometriosis is a rare disease which is associated with about to % of patients with endometriosis, and it is favorable to the rectum and sigmoid colon. here we report cases (shown in the table) underwent laparoscopic resection for intestinal endometriosis. there were no postoperative complications in all cases, and all patient was discharged on - \ sup [ th \/sup [ postoperative day. before the operation, of patients were diagnosing intestinal endometriosis, and it was difficult to preoperatively diagnose. among them, the symptoms at the time of menstruation were clear was one case. in case of submucosal tumor, preoperative diagnosis seems difficult. additional image examination at menstruation may be useful for diagnosis. d dissection was performed for case , , because malignant disease could not be denied as a preoperative diagnosis. of them were strongly doubted endometriosis in surgical findings. in intestinal endometriosis surgery, pelvic adhesions and fibrosis are often advanced. in the sigmoidectomy, the average operation time was min and the blood loss was ml. in the rectal resection, the average operation time was min and the blood loss was ml. in case and , pelvic adhesion was severe, residual rectum could not be straightened, and side to side anastomosis was performed. in intestinal endometriosis surgery, intestinal anastomosis method should be considered flexibly. conclusion: laparoscopic surgery for intestinal endometriosis was safe, but technically difficult because of fibrosis and adhesion. it is important to accurately diagnose from clinical symptoms and image also intraoperative findings. anastomotic method should be decided according to the case. aim: the aim of the study was to identify and highlight some of the complications one can encounter in bariatric surgery-specific-sleeve gastrectomy and discuss the therapeutic options one has at his disposal. methods: the study was retrospective. we identified a number of patients which had a sleeve gastrectomy done in our clinic for a year period. of these had important surgical complications encountered during the surgery or in postoperative care. results: the group included patients, with an average bmi of [ kg / m . average hospital stay was days, with an average of . days which increased to days when fistulas were encountered. the most frequent surgical complications were bleeding from the gastric suture ( ) and gastric fistula ( cases). other complications encountered were wound hematoma. surgery was required in of the cases of bleeding and of the fistula cases required reintervention. one case was resolved with endoscopic stenting. conclusions: laparoscopic gastrectomy is considered a safe procedure with good results for the patient. although complications are rare they pose a series of technical difficulties for the surgeon due to the weight of the patient and frequent comorbidities which come with obesity. a thorough understanding of the symptoms and good follow-up ensures the best results. aims: to achieve additional weight loss or to resolve band-related problems, a laparoscopic adjustable gastric banding (lagb) can be converted to a laparoscopic roux-en-y gastric bypass (rygb). there is limited data on the feasibility and safety of routinely performing a single-step conversion. we assessed the efficacy of this revisional approach in a large cohort of patients operated in a high-volume bariatric institution. to the best of our knowledge this series represents the largest single-center study on conversion from lagb to rygb methods: between october and december , a total of patients who underwent lagb removal with rygb were identified from a prospectively collected database. in all cases, a single-stage conversion procedure was planned. the feasibility of this approach and peri-operative outcomes of these patients were evaluated and analyzed. results: a single-step approach was successfully achieved in ( . %) of the patients. during the study period, there was a significant increase in performing the conversion from lagb to rygb single-staged. no mortality or anastomotic leakage was observed in both groups. only patients ( . %) had a -d complication: most commonly hemorrhage (n? = ? / ), with no significant difference between the groups. conclusion: converting a lagb to rygb can be performed with a very low morbidity and zero-mortality in a high-volume revisional bariatric center. with increasing experience and full standardization of the conversion, the vast majority of operations can be performed as a single-stage procedure. only a migrated band remains a formal contraindication for a one-step approach. surg endosc ( ) . six months after surgery the mean hrql score, was ( - ) in patients underwent to lsg and . ( - ) in patients underwent lgb. twelve months after surgery the mean postoperative questionnaire score was ( - ) in patients who underwent lsg. at ph-manometry the mean percentage time of acid reflux in orthostatism was . (range - . ) and in clinostatism . (range . - . ). the mean demeester score at the distal electrode was . ( . - . ). conclusions: in asymptomatic patients, complete gerd evaluation before bariatric surgery allows better selection of surgical procedure, to reduce the postoperative occurrence of severe or de novo gerd. postoperative gerd evaluation provides useful data regarding the impact of lsg on gastroesophageal reflux. a larger patient sample size is required. aims: vertical calibrated gastrectomy (usually know as gastric sleeve) as unique technique gives better results than the roux y bypass in terms of improvement of anthropometric measures, reduces comorbidities and has a lower rate of postsurgical complications, with an improvement of quality of life. material and methods: an observational, longitudinal, retrospective and comparative study with patients, aged - years,during a period of years. everyone must comply with the protocol of the unit. demographics of the population and the anthropometric data will be measured in the presurgical consultation, the month and the year after the surgery: weight, height, bmi, weight loss percentage,bmi percentage and percentage of excess weight lost. we took data on the cardiovascular risk by the framingham score. the quality of life is measured by baros scale. mayor comorbidities are hypertension, diabetes, dyslipidemia. complications will be measured in absolute frequencies. for de statistical study, we apply type t student or chi square being statistically significant p equal to or less than . . results: there was not statistically significant difference between the techniques of surgery month (p = , ), but they were evident to the year of the same (p . ). not gender or age differences were apparent. mayor complications did not appear in gastrectomy (no leaks), highlighting the number of bleeds with this surgical technique. the bypass there were two leaks. there was no statistically significant difference in cardiovascular risk (p = , ) between the two techniques. there was a more significant decrease in number of comorbidities in gastrectomy against the bypass, with a total disappearance of patients with dyslipidemia. there were no statistically significant differences in baros score, although it was higher in gastrectomy. conclusions:-the vertical gastrectomy as unique technique can be considered superior in the short term, as well as safe, according to the aec quality parameter. we think it will be necessary to continue their studies into the medium-long term. aims: analyze the impact of different bariatric surgeries technics in carbohydrate metabolism and pancreatic beta cell population of none obese adult wistar rats. methods: we used twenty healthy not obese adult wistar rats divided in five groups randomly assigned. each with n = . the control groups were divided into fasting control (f) and sham (surgical control). the surgical groups were separated into vertical gastrectomy (gs), % resection of the middle small bowel (ri ) and gastric bypass (gb). in each group was assessment: beta cell mass modifications, pancreatic islets histomorphometry, proliferation, apoptosis and neogenesis in beta-cell pancreatic population; intraperitoneal glucose test tolerance, body weight and food intake. statistical analysis as evaluated using mann whitney test. results: the malabsorptive and restrictive group have a significantly smaller increase weight than the control groups. the intraperitoneal tolerance glucose test reports incremental glucose area under curve (auc) was significantly higher in the malabsorptive group and lower in the restrictive group compare to the control groups during the second (p \ . ) and third (p \ . ) month of the study. the beta-cell mass was significantly higher in the ri group compared with control groups respectively. there was a significantly increased number of beta-cell per pancreatic insulin positive area in gs and gb. proliferation was significantly increased in ri and gb group, and significantly decreased in sg compared. there was no significantly difference during apoptosis assessment among surgical and control groups. in neogenesis differences between groups were assessed qualitatively by the presence pdx - expression, being higher in rygb. the endocrine pancreas in our model is altered by the anatomical and functional conditions arising from surgical techniques. carbohydrate metabolism conditions are affected by temporary adaptive processes due to surgical alternatives. there is a hyperplasia and hypertrophy of the beta cells in surgeries with a malabsorptive component, as well as greater neogenesis. these results could explain part of the existing relationship between the enteropancreatic axis and the existing incretins. m. buza, c. copaescu introduction: nowadays, we have high volumes of obese patients for whom surgery is the answer, but unfortunately the psychological evaluation has no standard recomandation in preoperative evaluation of bariatric patients. it is argued that surgery success, in addition to the operation itself, relies on behavioral changes and that one of the goals of the preoperative assessment is to prepare the patient for the postoperative period, aiming to optimize surgical results. aim: although no formal standard exists in the literature, there is growing recognition of the important elements to be addressed and the appropriate means for collecting the necessary data to determine psychological readiness for these procedures. methods: information regarding the components of the clinical interview and the specific measures used for psychological testing are discussed. given the limited data on predicting success after surgery, determining psychological contraindications for surgery is addressed. additionally, the multiple functions served by the psychologist during this assessment procedure are highlighted along with the value of this procedure in the patients' preparation for surgery as well as the postoperative follow-up. in our center of excelence for bariatric and metabolic surgery (coe) we introduced since a mandatory pre-and postoperative psychological evaluation for all patients addressing the metabolic program. results: psychological evaluation of patients before bariatric surgery is a critical step, not only to identify contraindications for surgery, but also-and more so-to better understand their motivation, readiness, behavioral challenges, and emotional factors that may impact their coping and adjustment through surgery and the associated lifestyle changes. postoperative follow-up is necessary. the psychological evaluation of the patient undergoing bariatric surgery is an invaluable piece of the larger pre-and post-surgical assessment, aiming better results in the short and long term after bariatric surgery. introduction: a mesenteric cyst is defined as a benign abdominal tumors that is located in the mesentery of the gastrointestinal tract, identified in * of , hospital admissions. mesenteric chylous cysts are rare pathologic entities that often present with unspecific symptoms. the preoperative diagnosis requires all the common abdominal imaging techniques. usually the correct diagnosis may be made only at the operation stage or during the histological examination. all mesenteric cyst should be resected in order to avoid their complications, complete surgical resection is recommended and curative in the majority of cases with a low risk of local recurrence. the laparoscopic approach is the gold standard in the treatment of intraabdominal mesenteric chylous cyst. laparoscopic resection provides less pain, shorter hospital stay, and early recovery for the patient. case report: we report a case of -year-old saudi woman who presented to our clinic complaining of upper abdominal pain and mass in the epigastrium for one week, no history of nausea, vomiting, or recent changes in bowel habits. her medical and family histories were clear and she had never had any abdominal interventions. abdominal palpation revealed a smooth-surfaced mass palpable in the left upper quadrant, ultrasonography and with computed tomography of the abdomen revealed an approximately mm unilocular cyst closely related to the mesentery in the left side of upper abdomen not related to the pancreas .the cyst was excised by laparoscopy complete surgical excision to avoid recurrence within healthy borders, it is contained milky white fluid. the histopathological findings were chronic inflamed mesenteric cyst. a review of the literature considering this rare entity was also performed to evaluate our treatment strategy. conclusion: mesenteric chylous cysts represent a diagnostic challenge and they should be considered when a physician encounters an intraabdominal mass. usually the correct diagnosis may be made only at the operation stage or during the histological examination. the treatment of choice is the complete surgical excision that can be safely performed by laparoscopy. surg endosc ( ) background: diverticulum of appendix is relatively rare, and appendiceal diverticulitis was reported to have a higher risk of perforation than appendicitis. in the us and europe, because of the high risk of perforation, preventive appendectomy is recommended to appendiceal diverticulosis, even if the patient has no abdominal pain. methods: we retrospectively reviewed the records of post-operative patients, who were diagnosed appendicitis or appendiceal diverticulitis on the pathological findings in our institution from january to october . all patients were performed computed tomography (ct) before operation. patients underwent laparoscopic surgery, including appendectomy, cecal resection, ileocecal resection and right hemicolectomy, while patients underwent open surgery. total of cases of appendiceal diverticulitis were analyzed in our study. result: patients had abdominal pain before surgery. patients were diagnosed appendiceal diverticulitis by preoperative ct. all patients underwent laparoscopic surgery ( appendectomy, cecal resection, and ileocecal resection). on the pathological findings, perforation of appendix was found in patients and the pseudo type of diverticula with no muscle layer was found in all patients. patients with appendicitis were treated surgically during the same period. among them, a perforation of appendix was found in cases. the perforation rate was . %. on the other hand, the perforation rate of appendiceal diverticulitis was . % in our study. conclusion: the perforation rate of appendiceal diverticulitis was higher than of appendicitis in our study. for the examination of the treatment strategy, including preventive appendectomy, the accumulation of more cases will be expected. case presentation: a -year-old man was referred to our hospital with right lower quadrant abdominal pain for days. his fever was . °c. his white blood cell count was , / ll, and c-reactive protein level was . mg/dl. ct revealed multiple diverticula of cecum and appendix. micro-abscess and free air were found around appendix. we diagnosed this case as appendiceal diverticulitis and laparoscopic appendectomy was performed. a perforation was found in resected appendix. microscopic study revealed a pseudo-diverticulum. the inflammation of appendix was stronger in serous membrane side than in mucosa side. this finding accorded with appendiceal diverticulitis. introduction: in order to reduce the abdominal trauma and the length of scar incisions (also during laparoscopic surgery) many approaches during the last decade has been proposed, such as single access laparoscopic surgery (sals). the aim of our paper was to update the data of our previous paper with a greater cohort of patients and a longer follow-up, also showing the single access laparoscopic left colectomy (salc) technique in particular with inferior mesenteric artery preservation imap (valdoni's technique). materials and methods: we made a retrospective analysis from october and october of all patients who underwent a sals approach for colorectal disease in the department of general and mininvasive surgery of san camillo hospital of trento. statistical analysis was performed using ibm spss statistics . continuous data were expressed as mean ± standard deviation (sd). categorical data were expressed as absolute number and percentage. the results are presented as -tailed values with statistical significance if p values \ . results: from october until october , salc for colorectal surgery were performed in our unit. of this , were for left colectomy. in cases we performed an imap. the salc with imap were performed only in case of benign disease. the mean operative time was . ± . . only one intraoperative complication were recorded, that was a splenic capsule tear, resolved with apposition of fibrillar haemostats. according to clavien dindo classification there were in particular grade ii complications, a bleeding solved with blood transfusion and one pancreatitis solved with medical therapy; grade iiia complications that was anastomotic bleeding solved endoscopically (the two complications raised in patients with imap) and iiib complications due to anastomotic leakage which needed reoperation. the mean length of incision was . ± . cm. logistic regression did not show any correlation between imap and any complications. conclusion: in conclusion, salc is a safe but very challenging technique which need a longer learning curve than the conventional laparoscopic one. in laparoscopic colectomy, also, imap seems to be safe and effective without correlation with post-operative complications also if performed in single access laparoscopic approach. aims: to describe an infrequent anatomical variation that can give rise to diagnostic and therapeutic difficulties. methods: patient with ivermark syndrome (situs ambiguus and polysplenia) with acute appendicitis and bibliographic review results: a -year-old male who consulted for flank and right hypochondrium pain of h of evolution, associated with nausea without vomiting, no fever noir other symptoms. to the physical examination good general condition. painful to palpation selectively on the flank and right hypochondrium, with involuntary defense and positive decompression at this level. the signs of rovsing and psoas were negatives. in the analytical performed leukocytes of , with neutrophils in % and rpc (reactive protein c) in mg/l. abdominal ct (computed tomograph): cecum and the ilio-cecal valve were visualized at the subhepatic level with tubular structure on the side and seemed to correspond to the cecal appendix which is increased in size ( mm), with findings suggestive of acute appendicitis. sigma and descending colon located in right hemiabdomen. second per duodenal portion located anterior to the superior mesenteric artery. superior mesenteric vein located to the left of the superior mesenteric artery, rotating around it, (radiological signs compatible with intestinal malrotation). no free fluid collections nor pneumoperitoneum. laparoscopic appendectomy on phlegmonous acute appendicitis without incidents. correct post-operative course, being discharged at h; the pathological anatomy was reported as acute appendicitis in phlegmonous. conclusions: ivermark syndrome is a genetic alteration with a multifactorial inheritance pattern, characterized by an alteration in the situation of the mesenteric vessels, which leads to abnormal rotation of the intestine during the embryonic period and alteration of the situation of different intra-abdominal organs, without a specific pattern that is pathognomonic, is associated with congenital heart anomalies between and %. reaching adulthood only between and % of them. a case of acute appendicitis is presented in a patient with this anomaly, which can lead to diagnostic and therapeutic difficulties due to the anatomical variations involved. abdominal tomography is the image method that provides the best performance for the diagnosis of acute pathologies in this type of patients. background: the clinical manifestations which occur in relation to decompression during scuba diving are variable. mild symptoms have often been reported in gastrointestinal tract. this is one of the severe cases with gastrointestinal barotrauma. ischemic colitis caused by air embolism very rare, therefore it is to be reported and discussed. case presentation: a -year-old man visited our emergency room with diffuse abdominal pain and bloody diarrhea days ago. the patient was a skilled diver who took seafood through diving for years. two days before presenting, the patient had severe abdominal pain just after diving for h at a depth of meters. he was immediately transferred to a local hospital for hyperbaric oxygen therapy, but there was no improvement with the symptom. abdomen ct angiography showed terminal ileal, ascending, sigmoid colonic and rectal decreased enhancement with wall thickening. sigmoidoscopy showed diffuse huge ulcerative lesions and ischemic changes on mid rectum and sigmoid colon. emergent subtotal colectomy and temporary loop ileostomy were done, and pathologic findings revealed diffuse mural infarct with serosal abscess formation in whole colon and transmural infarct in terminal ileum. conclusion: surgical approach could be one of the treatment options, though it depends on severity of the symptoms and the patients' conditions. colonic lipomas are extremely uncommon benign tumours, with an incidence ranging between . % and . %. although they are most frequently asymptomatic, when colonic lipomas are [ ?cm, they may present symptoms such as constipation, abdominal pain or rectal bleeding. most colonic lipomas typically occur in middle aged women and are located in the ascending colon and the caecum, while occurrence in other parts of the colon and rectum is rare. in this case report, we describe a lipoma that caused descendent bowel intussusception. a -year-old male presented with longstanding history of constipation. personal history of interest included active smoker, hypertension, hypercholesterolemia, psoriasis with joint affectation and reiter syndrome. he had had no previous surgery. he attended the emergency services on th july with a two-day bowel obstruction, without fever or nausea, being attended by our surgical emergency unit. he had been assessed during the previous months by gastroenterology, with a colonoscopy that showed a cm submucosal lesion that partially occluded descendent bowel, with inconclusive biopsy. an abdominal contrast-enhanced computed tomography (ct) was performed, confirming a welldefined mass located in splenic flexure of descendent bowel, conditioning a large bowel intussusception, nevertheless with no obstructive acute signs. the surgery was scheduled a few weeks later, performing a laparoscopic segmental resection with primary anastomosis including oncologic margins. the patient evolved satisfactorily in the postoperative period and was discharged six days after the surgery without any complications. likewise, he was monitored on a regular basis at our outpatient department and was free of symptoms at the -month follow-up visit. the histological analysis revealed a cm ulcerated lipoma affecting % of bowel circumference. the molecular study, using fluorescent in situ hybridation (fish) showed no mdm gene amplification. laparoscopic segmental resection of the large bowel is a safe and feasible technique for the treatment of large bowel intussusception caused by a colonic lipoma. the complete removal of the lipoma will condition the prognosis. furthermore, in the future, endoscopic surgery using colonoscopy could be employed when having a certain preoperative diagnosis of lipoma. surg endosc ( ) introduction: acute appendicitis is one of the most common abdominal surgical emergency, the diagnosis of which mostly relies on conventional methods such as physical examination and blood tests. the use of ultrasonography and ct abdomen aids in more precise diagnosis especially in patients with atypical presentation or in elderly. aim: this study aims to evaluate the ability of the neutrophil/lymphocyte ratio (nlr), platelet/lymphocyte ratio (plr) and mean platelet volume (mpv) in predicting the diagnosis of acute appendicitis. methods: retrospective analysis of prospectivly maintained data of all patients ( ) admitted with acute appendicitis to the emergency department at a tertiary hospital in the middle east between january till september . medical records and database of patients,who had appendicectomy for clinically and radiologically proven appendicitis, were reviewed. the retrieved data included patient's demographic and laboratory values of white blood cells (wbc), neutrophil (n), lymphocyte (l), and platelet (p) along with their ratios for comparison. results: spss version was used for tabulating the data. the recommended cutoff value of the nlr, plr and mpv in predicting the diagnosis of acute appendicitis was decided by using receiver operating characteristic (roc) curve analyses. at least for nlr, the confidence interval (ci) was . which is percentage of the positive values, since the confidence limit was between to %. our results showed that the laboratory parameters were fairly significant since the confidence interval was . in predicting the diagnosis in our population. conclusion: although appendicitis is a clinical diagnosis but laboratory parameters specially nlr, plr and mpv can be used as an adjunct in the diagnosis of acute appendicitis. literature is scarce concerning the validity of such parameters in our part of the world and prospective randomized controlled trials are needed to prove the efficacy of such rationale. objective: tumors of the cecal appendix represent a subset of colonic neoplasms whose early diagnosis is a real clinical challenge. correspond to . % of all gastrointestinal tumors and their prognosis depends on the type of injury, being the most frequent variety the carcinoid type. appendix involvement in endometriosis is rare, accounting for % of all endometriosis cases, and sometimes mimicking cecal tumors. methods: a -year-old woman with a history of hypothyroidism due to autoimmune thyroiditis and atrophic gastritis with gastric neuroendocrine tumors resected by endoscopy that in the digestive unit reviews, tac with double contrast was requested, showing a lobulated lesion in the cecum adjacent to the ileocecal valve, with contrast enhancement of approximately mm, suggestive of tumor. the colonoscopy evidenced a protruding appendicular osteum with inflammatory aspect that was biopsied. the pathological anatomy of the biopsy reports chronic congestive colitis with edema of the own blade and minimal acute activity, with moderate local eosinophilia.the case was presented in the multidisciplinary oncology committee and it is decided, due to the patient's background, to perform surgery on the lesion. laparoscopic right hemicolectomy was performed, with extracorporeal latero-lateral mechanical anastomosis with endogia signiaÒ mm. results: the patient evolves favorably, with good oral tolerance and depositional habit. she is sent home at the sixth postoperative day. the pathological anatomy reports tumor injury in the appendicular ostium compatible with endometriosis at the base of the cecal appendix implantation, ruling out malignant tumor pathology. conclusions: gastrointestinal tract endometriosis represents - % of cases, being most frequently located in the rectal-sigmoid region. appendix involvement in endometriosis is rare, accounting - % of all endometriosis cases and presents a preoperative diagnostic challenge, because sometimes mimicking a carcinoid cecal tumor. in our case, due to the patient's history, we assumed that the cecal lesion was a carcinoid tumor, so we performed a laparoscopic right colectomy, but if we had known that it was an endometriosis, we could have performed an appendectomy, although in both cases the laparoscopic approach gives us some benefits compared to the open approach aims: the natural history and predictive factors associated with chronic anastomotic complications have not been clearly studied. the aim of this study was to evaluated the predictive factors related to chronic anastomotic complications methods: from january to december , a total of patients who underwent anastomotic leakage were enrolled in this study. all patients underwent anterior resection with or without defunctioning stoma due to colorectal cancer. the patients received follow-up by clinical examination and abdominopelvic computed tomography (ct). they underwent a follow-up ct every months for the first year and then every months for the next years after that. complicated group (cg) underwent chronic anastomotic complications. normal group (ng) didn't underwent chronic anastomotic complications like stricture, fistula, chronic sinus, etc. results: there were no significant differences in gender, age, preoperative chemoradiotherapy and operation type between two groups. low rectum lesion and defunctioning stoma at the time of primary surgery were more frequent in cg (p = . , . ). there were no significant differences in type of anastomotic leakage, international leakage grade and ct findings at the time of diagnosis of anastomotic leakage. however, abnormal ct findings at the time of month were more frequent in cg group (p \ . ). in multivariate analysis, abnormal ct finding at the th months was only significant factor related to chronic anastomotic complications. conclusions: abnormal ct findings at the th month associated with prediction of chronic anastomotic complications. aims: acute appendicitis is the most common cause of acute abdomen requiring surgical intervention in the world. nowadays, standard treatment of acute appendicitis involves a surgical approach, eitherlaparoscopic or open.the purpose of the present study is to evaluate the safety of a discharge within less than h after performing appendectomy as a result of an uncomplicated acute appendicitis. conclusions: patients who undergo appendectomy (open or laparoscopic) for acute uncomplicated appendicitis, without surgical incidents and an adequate social/family network, can be discharged in less than h without a higher risk of post-operative complications or readmissions than patients with longer postoperative stays. it will be necessary to conduct more prospective studies with higher level of evidence that could corroborate our results. aims: median arcuate ligament syndrome (mals), also known as the celiac axis compression syndrome, is a rare condition caused by to the compression of the celiac trunk and the nerves located in this area (celiac plexus) by the median arcuate ligament. it is believed that mals is caused by the median arcuate ligament compression of the celiac plexus nerves over the celiac trunk, but another probably cause may be the lack of blood flow to the organs supplied by the celiac artery, however, this theory is controversial. the first clinical sign of mals is the apparition of postprandial abdominal pain in the upper abdomen. this typical pain forces patients to avoid eating, which can lead to loss weight (often more than pounds). other associated symptoms may include nausea, diarrhea, vomiting and delayed gastric emptying (a delay in food moving from the stomach into the small intestine). in relation to this uncommon condition, we present a clinical case of laparoscopic management of mals. methods: we present a -year-old patient with complaints of recurrent epigastric pain, postprandial vomiting and loss weight. blood tests and gastroscopy were performed to help ruling out more common causes of his symptoms, such as gastroesophageal reflux disease (gerd), gastritis or gastroparesis. as a part of the differential diagnosis, mals was suspected and a mesenteric doppler ultrasound was ordered to check blood flow through the celiac trunk and evaluate a possible compression of the celiac plexus. also, an angio-ct scan was also performed to confirm the diagnosis. once the mals was diagnosed, we decided to perform a laparoscopic approach as definitive surgical procedure. results: the patient was discharged h after surgery with no remarkable events during his postoperative stay. he has been followed up during months, remaining asymptomatic. conclusions: laparoscopic approach in mals offers a superior visualization during the surgery and involves lower morbidity in compare to open approach, which makes it an optimal treatment for this condition. aim: pilonidal sinus is a common disease with annoying and often painful symptoms. traditional surgical techniques for its treatment are characterized by either intense postoperative pain and prolonged wound-healing periods (wide resection, marsupialization) or unsatisfying aesthetic results (advancement or rhomboid flaps). 'endoscopic pilonidal sinus treatment' (epsit) is a new minimally invasive technique which utilises the meinero scope, primarily designed for the endoscopic treatment of complex perianal fistulas in a technique known as vaaft. we present our experience and outcomes in three treatment centers in northern greece. methods: between july and november we treated patients with pilonidal sinus using the epsit technique. the mean age of patients was , and % of them were male. patients were treated in the acute phase with the presence of pilonidal abscess. all operations were performed by two laparoendoscopic surgeons specifically trained in the technique. most patients were treated on a day-case basis. postoperative wound care included daily tract irrigation with ml of saline for a total of days. results: there were no immediate postoperative complications. medium postoperative pain was . on a vas scale. % of patients were discharged on the same day, patients remained in hospital for one day mainly due to social reasons. return to daily activities was immediate. in a maximum follow-up of months we observed recurrences. conclusions: epsit is a promising minimally invasive technique for the treatment of pilonidal sinus. what makes it mostly attractive is the minimal amount of postoperative pain, the excellent cosmetic result and the fast recovery with return to daily activities. introduction: isolated acute chylous peritonitis is a rare event. when presented as an acute abdomen warranting surgical intervention, it is often difficult to determine the cause pre-operatively. here, we report a case of acute chylous peritonitis due to meckel's diverticulitis presented with the clinical features suggestive of acute appendicitis. presentation of the case: a -year-old female presented with abdominal pain and clinical features consistent with acute appendicitis underwent diagnostic laparoscopy. she was found to have four-quadrant chylous peritonitis and ileus caused by an inflamed meckel's diverticulum adhered underneath a loop of small bowel and mesentery leaking chyle. after uneventful postoperative recovery, she was discharged at post-operative day two with oral antibiotics and was advised to take a low-fat diet. aims: perforated diverticulitis with purulent peritonitis (hinchey iii) has traditionally been treated with surgery including colon resection and stoma (hartmann procedure) with considerable postoperative morbidity and mortality. laparoscopic lavage has been suggested as a less invasive surgical treatment. methods: a -year-old woman with a -day history of abdominal discomfort exacerbed during the last h. ct scan showed neumoperitoneum accompanied by free fluid and a cm collection adjacent to descending colon showing diverticula suggestive of covert perforation. after h of non-response to medical treatment, associated with the impossibility of percutaneous drainage through interposition of intestinal loops, colon and lumbar vessels, urgent surgical intervention is decided. results: laparoscopic lavage of all quadrants was performed with saline, l or more, of body temperature, until clear fluid was returned. two non-suction j-pratt drains were placed. intravenous antibiotics were continued for a minimum of h, then oral antibiotics were continued for week. oral fluids were commenced on the first postoperative day and solids were subsequently introduced, depending on clinical progress. conclusion: laparoscopic management is reasonable alternative to the traditional open resection for hinchey grade ii-iii perforated diverticulitis with generalized peritonitis. this approach has a low mortality rate despite patient co-morbidity and disease severity. benefits include stoma avoidance and minimal wound infection. subsequent elective resection is probably unnecessary and readmission in the medium term is uncommon. background: constipation and fecal incontinence are common annoying complications after pull through procedures for hirschsprung disease (hsd). many causes could be the etiology of these problems. perineal descent syndrome could be the major hidden cause of these complications. the aim of this study is to evaluate the role of perineal descent syndrome in the development of post pull through constipation and fecal incontinence in addition to evaluate the role of laparoscopic rectopexy for treatment of these problems. \ b[patient and methods: \/b [ patients treated with pull through for hsd over the period of five years. out of the patients presented with constipation and fecal incontinence. patients with constipation and patients with fecal incontinence. rectal exam, anorectal manomety, defecography, contrast enema, rectal biopsy, emg, proctoscopy and endorectal ultrasound were performed to all patients. patients with stricture, missed aganglionic segment, injured internal anal sphincter, and loss of the sensory mucosa above the dentate line were excluded from the study. anterior wall rectopexy was performed for anterior wall rectocele. posterior wall rectocele was treated by retro rectal mesh rectopexy. emg is repeated weeks and months after surgery. outcome measurements included constipation, fecal incontinence and pudendal nerve latency. results: cases of post pull through constipation and fecal incontinence. patients with constipation and patients with fecal incontinence. patients with stricture, patients with missed aganglionic segment, patients with loss of anal sensory sensation and patients with injured anal sphincter were excluded from the study. defecography showed patients with anterior rectocele ( males and females) and patients with posterior rectocele ( males and females). the patients mean age . ± . years . emg showed prolonged pudendal nerve conduction in all cases. anterior wall and retro rectal rectopexy were performed laparoscopically without complications. constipation was resolved in all patients after surgery. all patients showed fully control in defecation. pudendal nerve latency decreased in all patients. conclusion: perineal descent syndrome proved to be a major hidden cause of post pull-through constipation and fecal incontinence. laparoscopic rectopexy showed a good solution of these complications. cystic lymphangioma is a rare entity. the surgical indication is determined by the size and symptomatology, and consists of the complete exeresis of the tumor. the laparoscopic approach is feasible in these cases, allowing a broad visualization of the anatomy, accessibility to the retroperitoneum in the context of a minimally invasive approach and a better recovery of the patient, without providing an increase in morbidity compared to the conventional. in this way we defend as a technique of choice laparoscopic surgery against these rare tumors for the general surgeon in the abdominal cavity, betting on a minimally invasive surgery. aims: laparoscopicposterior sutured rectopexy is one of the accepted treatment options for fullthickness rectal prolapse. recently, reduced port surgery(rps) has beenan emerging concept that, compared with conventional multiple port surgery (mps), yields reduced postoperative pain and improved cosmesis. the aim of the study is to evaluate the feasibility and safety of rps for fullthickness rectal prolapse. methods: rps was performed by single-incision plus one puncture, using internal organ retractor(ior) to secure operative field. straining one ior by - strings in - directions makes it possible to retract the internal organs three-dimensionally. this multi-directional flexible retraction could secure good operative field. from to , patients (rps: cases, mrs: cases) underwent laparoscopicposterior suture rectopexyfor total rectal prolapse. shortterm outcomes were compared between the two procedures. results: there was no significant difference between rps and mps in median operative time ( vs . min, respectively, p [ . ). the median blood loss volume was not significantly different between rps and mps groups ( . vs . ml, p \ . ). the duration of median hospital stay after surgery was not significantly different between two groups ( . vs days, respectively, p [ . ). the frequency of complications after surgery were not different between them. conclusions: reduced port lap-rectopexy can be a good therapeutic option for total rectal prolapse. a prospective, randomized, controlled trial should be conducted to confirm the superiority of this procedure over mps. the piccolo project proposes a new compact, hybrid and multimodal photonics endoscope based on optical coherence tomography (oct) and multi-photon tomography (mpt) combined with novel red-flag fluorescence technology for in vivo diagnosis and clinical decision support. for its development it includes different phases of validation. within this framework, the present study has as main objective: to characterize a model of rat colonic hyperplasia, which will be used for the development and validation of the previously mentioned endoscopic technology. secondary objectives: procure the reproducibility of the model chosen and determine the optimal time, after induction of the model. material and methods: animals (rattus norvegicus), wistar, males and females \ -yearold, randomly distributed. group (n = ): by laparotomy, a non-resorbable suture (silk / ), not stenosing, is placed through the wall of the colon. group (n = ): by endoscopy, a . mm long segment of a polymeric catheter is inserted, which is fixed to the wall of the colon by means of a suture. group (n = ): by means of endoscopy, a self-expanding and uncoated metallic stent are placed in the colon. group (n = ): a superficial laser resection of the colonic mucosa is performed by endoscopy. group (n = ): as an extension of the most optimal model. weekly, the animals were anesthetized again to perform a colonoscopy, which determined the degree of mucosal growth in descending colon and colonic biopsies were extracted weekly ( weeks). results: group . growth around the sutures after the second follow-up, diagnosed as hyperplastic polyps after a histopathological analysis. aim: the role of laparoscopy in the management of generalized appendicular peritonitis is controversial. this is due mainly to the lack of scientific data. through this study and a laborious bibliography research, we proposed to report our experience in terms of postoperative results, in the laparoscopic treatment of generalized appendicular peritonitis and to try to identify the risk factors associated with the occurrence of global morbidity and conclude on the feasibility of this technique in its treatment. methods: we conducted a retrospective study including all cases of generalized appendicular peritonitis managed laparoscopically, in the general surgery department of charles nicolle hospital between january and december . results: we identified patients. the mean age was . years. one fifth of the cases required a midline conversion ( . %). the mean operative time was . ± , min. the overall morbidity rate was % including surgical complications. there were no deaths. in uni-variate analysis, comorbidity, crp [ mg /l, operative time exceeding min and midline conversion were significantly associated with postoperative morbidity. co-morbidity, diabetes, asa score [ , delay of consultation [ days, intra-abdominal abscess and operative time exceeding min were significantly associated with medical complications. the univariate analysis also revealed that crp [ mg /l and midline conversion were predictive of surgical complications.the multivariate analysis identified the midline conversion as the only independent factor significantly associated with post operative morbidity (odds ratio = . , % confidence interval [ . - . ] ). conclusion: based on our results, it appears reasonable to continue the laparoscopic management of diffuse appendicular peritonitis. however, enhance this technique is basic in order to reduce midline conversion rate and to shorten operative time, which can lead to post operative complications. aims: currently, acute appendicitis is the most common surgical emergency. laparoscopic appendectomy is the usual procedure to treat acute appendicitis. the aim of this study is to evaluate the safety of electrocoagulation in the treatment of mesoappendix in laparoscopic appendectomy. methods: we have retrospectively studied a prospective database of operated patients of appendecectomy in emergency surgery unit. we have reviewed laparoscopic appendectomies from june st, to december st, . the mesoappendix was electrocoagulated in every laparoscopic appendectomy. the statistical analyses has been done with spss . version. results: our group consists of patients of which . % were male and . % were female. the average age was . years with a standard deviation of . % and p was . years. the most common total stay was day ( patients). the usual post-operative stay was one day ( ). we classified the diagnosis in complicated apendicitis ( patients) and no complicated apendicitis ( patients). the conversion rate was . % ( ). the main surgical complications were: surgical wound infection ( . %); intraabdominal abscess ( . %); and bleeding ( %). only one of the patients that suffered bleeding had complicated appendicitis. the medical complications were catheter sepsis ( . %); respiratory infection ( . %); cardiologicals ( , %); and paralytic ileus ( . %). the treatment of mesoappendix with electrocoagulation is safe and effective since the complications rate is very low. even so, it would be necessary to conduct more prospectives randomized studies in order to get enough evidence about the treatment of mesoappendix with monopolar electrocoagulation. introduction: the difficulty of resection of the rectum is determined by its anatomical relationships, intimately in contact with the bladder, seminal vesicles, prostate and urethra in the case of the male, vagina in the woman and nerve structures that will give defecatory, genital and urinary functionality. this structure creates a big impediment due to problems of visualization and difficult dissection, in such a way that conventional surgical techniques instigates a series of complications derived from this difficulty. we propose a new approach in rectal surgery in patients with inflammatory bowel disease. material and methods: a -year-old man with a history of ulcerative colitis developed a severe acute outbreak refractory to treatment. a total laparoscopic colectomy with a terminal ileostomy was performed in . in he was notified for reconstruction. we evidenced a rectal stump of about cm with signs of inflammatory disease at the mucosal level. a transanal proctectomy was performed with confection of 'j-pouch' and ileoanal anastomosis about cm from the anal margin by laparoscopy. the postoperative courses favorably, being discharged on the sixth day. currently in follow-up in digestive and general surgery, he is asymptomatic and he has an optimum level of quality of life valued by the sf- weeks after the intervention. conclusions: our service introduces the transanal approach to the performance of proctectomy in cases of inflammatory disease, a technique that provides clear advantages by improving visualization and the identification of anatomical structures. in this way, a safe dissection of the pelvis is achieved, adjusted to the serosa of the rectum, with preservation of the mesorectum and the hypogastric plexus, and with the consequent improvement of the genital and urinary function. the result is an equally safe surgery, which implies little increase in operative time and with better and shorter postoperative recovery.the conservation of the pelvic innervation avoids disorders of ejaculation, vaginal lubrication and bladder and rectal motility. the transanal approach for the performance of proctectomy provides benefits in terms of the preservation of the hypogastric plexus, minimizing the anatomical difficulties involved in rectal surgery and maintaining urinary and sexual function. aims: to evaluate the feasibility and outcomes of laparoscopic appendicectomies in both simple and complicated appendicitis, given the increasing trend towards a laparoscopic approach in the last four decades for the treatment of acute appendicitis. we present data from a district general hospital over a -year period. methods: we retrospectively analysed a single consultant's continually updated database of laparoscopic appendicectomies between / / and / / ( months). patient demographics, investigations, intraoperative findings and postoperative outcomes were recorded and analysed. complicated appendicitis was defined as the formation of appendiceal mass or abscess with or without perforation and peritonitis. results: cases of laparoscopic appendicectomies were identified during the specified period. the median patient age was (range - years). true positive rates for uss and ct were % and %, respectively. the rate of negative appendicectomies was %. transanal minimally invasive surgery (tamis) has been used for the treatment of rectal neoplasms such us benign polyps and early rectal cancer. when the tumour is located in the upper rectum or close to the rectosigmoid junction, this approach may be technically dificcult.we present a video of a tamis resection of a large polyp located cm from the anal verge. after properative examination and ct and mri were performed, the patient was prepared for surgery, and a trasnanal minimally invasive surgery was proposed.resection of the polyp was performed with the aim of an endogia and conventional laparoscopic materials. total resection of the polyp with free margin was possible. the postoperative pathology report confirmed a high grade displasia villo-tubular adenoma with a lesion free margin. tamis resection of tumours located above the rectosigmoid junction may be a safe and feasible technique in selected patients. aims: pelvic organ prolapse (pop) is a very relevant problem for women's quality of life and has a prevalence of about % defined by symptoms and up to % when established by physical examination. nowadays, sacrorectopexy for posterior pop and sacrocolpopexy for apical pop are considered the gold standard techniques. recently, we have seen that laparoscopic lateral suspension is a feasible procedure for apical pop, obtaining a success rate higher than % at one year. these results are similar to what we can achieve with sacrocolpopexy. methods: we herein present the case of a -year-old woman with apical and posterior pop, this was provoking an important impact on her quality of life, with obstructive defecation (needing digitations) and urinary incontinence. we proposed sacrorectopexy for her posterior pop and laparoscopic lateral suspension for her apical pop. in the video we can see how we perform a ventral mesh sacrorectopexy, following d'hoore technique; and a laparoscopic lateral suspension with preperitoneal dissection, following the technique described by the team headed by dubuisson and veit-rubin. we used laparoscopic ports ( , , . and . mm). results: patient was discharged home on the second postoperative day and has not had any sign of recurrence or extrusion after more than two years of follow-up. in addition, she has not suffered lower urinary tract symptoms, constipation or pain. conclusions: we present a case in which we have carried out a laparoscopic lateral suspension instead of a sacrocolpopexy for an apical pop, obtaining good short-term and long-term results. we consider it is very soon to assess this technique's efficacy and it has to be validated in studies with larger source of patients. nevertheless, we think this procedure might become an excellent alternative to sacrocolpopexy for apical pop. aims: laparoscopy is a minimally invasive approach with low morbidity. the aim is to show the usefulness of the laparoscopic approach for massive intra-abdominal abscesses, which it is controversial. we report three patients who underwent emergency laparoscopy for peritonitis or massive intra-abdominal abscesses not amenable to percutaneous approach that were suspected to be caused by acute diverticulitis. methods: all patients had diagnosis of acute diverticulitis (hinchey ii-iii grade) with pelvic abscesses situated between sigma and bladder or diffuse peritonitis. the patients with hinchey ii grade had failed conservative management with antibiotics. they underwent emergency laparoscopy under general anaesthesia, with three abdominal ports. intra-abdominal abscess cavities were exposed and the purulent exudate was sampled and aspirated. copious irrigation was performed under direct vision and thorough examination without other findings. the procedure was completed laparoscopically in all cases. results: all patients had favourable evolution. one of them had a properly drained faecal fistula which changed to a purulent fistula on the twentieth postoperative day. this patient underwent laparoscopic left colectomy three months later because he had have a new episode of acute diverticulitis. other two cases showed very good clinical evolution, without evidence of fistula in postoperative period and they were complete asymptomatic one month later. conclusion: in our experience laparoscopic drainage is a feasible, safe, and effective for the treatment of pelvic abscesses and diffuse peritonitis secondary to acute diverticulitis. n. pinheiro, a. ziegler introduction: solitary rectal ulcer syndrome (susr) is characterized as a rare disease whose pathophysiology remains uncertain. it was first described in by cruveilhier and his clinicopathological feature was reported in by mandigan and morson, where he is associated with defective disorders, internal rectal prolapse, and psychological changes. according to works about % of the patients are asymptomatic. when symptomatic the diagnosis can be made through physical examination, clinical history and, often, confirmed by endoscopy with biopsies. treatment depends on the severity of the symptoms and the existence of associated rectal prolapse. according to the literature, conventional surgical options include local excision, rectal mucosectomy, retopexy, and segmental colonic resection. rolato: a -year-old male complaining of anal bleeding at bowel movements years ago. he performed, several times, conservative treatment, but without improvement. he sought proctological care and underwent colonoscopy, in which he showed an ulcerated lesion on the anterior wall of the distal rectum. new investigation with videodefecogram revealed colorectal intussusception with associated mucosal prolapse, being considered the factor causing the ulcer. elected by the sacropromontofixação. evoluiu with improvement of anal bleeding, mucorrhea and anal discomfort. after a proctological examination, which was normal, a control colonoscopy performed after months of surgery revealed rectal mucosa, with residual scarring and disappearance of the submucosal nodule present in the initial examination. reassessed after months, the patient is asymptomatic. conclusion: rectal solitary ulcer whose causal factor was a colorectal prolapse (intussusception) with mucosal exteriorization through the anal canal, which was individually treated with sacropromontofixation. j.p. mali, p.j. mentula, a.k. leppäniemi, v.j. sallinen approximately - % of patients diagnosed with colonic diverticulitis have an intra-abdominal abscess as a complication. abscess diameter of - cm is generally accepted as a cut-off determining the choice of treatment between antibiotics alone and percutaneous drainage. the aim of this study was to analyze the treatment choices and outcomes of patients with diverticular abscesses. this was a retrospective cohort study which was conducted in helsinki university hospital, an academic teaching hospital functioning as secondary and tertiary referral center. patients with computer tomography-verified acute left-side colonic diverticulitis with intra-abdominal abscess were collected from a database containing all patients treated for colonic diverticulitis in our institution during - . altogether, suitable patients were included in analyses. those treated primarily with percutaneous drainage or antibiotics alone ( and patients, respectively) were further compared in regards to treatment results. the main measured outcomes were need of emergency surgery and -day mortality. abscesses under mm were mostly treated with antibiotics alone with high success rate ( out of , %). in abscesses over mm, the use of emergency surgery increased and use of antibiotics alone decreased with increasing abscess size, but the proportion of successful drainage remained at - % regardless of abscess size (figure ). there were no differences in failure rate, -day mortality, need of emergency surgery, permanent stoma, recurrence, or length of stay in patients treated with percutaneous drainage versus antibiotics alone, even when groups were adjusted for potential confounders. white blood cell count = . * /l, abscess diameter = mm, and corticosteroid medication were independent risk factors for failure of treatment with antibiotics alone. patients without these risk factor had % and patients with one risk factor had % success with antibiotics alone. percutaneous drainage as treatment for large abscess does not seem to be superior to treatment with only antibiotics. majority of patients with abscesses over mm in diameter undergo surgery as primary intervention. introduction: even today, 'chronic appendicitis' is a clinical term that is not widely accepted nor well documented amongst the medical community. its etiology is the presence of a mass (e.g. fecal mass, hyperplasia of lymphatic tissue, etc.) that continuously and partially obstructs appendix lumen. it is presented as a low intensity, intermittent, with exacerbations and remissions, abdominal pain that is located at the right iliac region. the pain lasts up to several months and it is usually underestimated by the patient. its diagnosis is based on imaging examination. appendectomy is the treatment of choice for chronic appendicitis. the operation is challenging for the surgeon who has to cope with an intensively inflamed area around the appendix without the ease of access to that area. purpose: to present our laparoscopic approach to a chronic appendicitis case and to review the literature. case report: a -year-old woman is hospitalized due to chronic appendicitis. the patient was treated conservatively with the use of intravenous antibiotics in two separate hospital admissions dated and months back respectively. eight weeks after the last exacerbation, she underwent a laparoscopic appendectomy. results: even though the procedure was planned six months after the first episode, the laparoscopy revealed a severe inflammation of the appendix, which was extended to the caecum and the surrounding preperitoneal tissues. although the difficultness of the operation it was completed successfully laparoscopically. the histological examination confirmed without any doubt the existence of 'chronic appendicitis'. the patient was discharged uneventfully the third postoperative day. conclusions: chronic appendicitis is an existing clinical entity that the surgeon may come through during his career. in the hands of experienced laparoscopic surgeon, the laparoscopic approach is feasible and safe. introduction: ventriculo-peritoneal shunting (vps) used in the treatment for hydrocephalus is associated with several complications.the exact cause of such extrusion is not known. visceral perforation is an unusual but serious complication with consequeces such as peritonitis, meningitis or encephalitis. management involves prompt removal of shunt, intravenous antibiotics, an adequate recovery gap so that cerebrospinal fluid culture is sterile and then followed by shunt replacement on opposite side. aim: multidisciplinary approach of extrusion of vps through anus by laparoscopic and external ventricular drainage. case exposure: a -year-old woman had a vps inserted year ago after excision of gangliocytoma due to lhermitte-duclos disease. she was admitted in the emergency department without symptos after trans-anal protrusion of vps catheter. the neurological and abdominal evaluation was normal. laboratory tests did not reveal disorders and abdominal ct-scan suggested perforation, itshowed the insertion of the end of the catheter in sigma, without pneumoperitoneum or intraabdominal free fluid. cranial ct-scan did no describe sings of hydrocephalus. the patient underwent an emergencysurgical intervention. first of all, antibiotic therapy was initiated and neurosurgery's team was performed an external ventricular drain and they disconnected the proximal catheter side. after that, an exploratory laparoscopy was performed. it revealed a microperforation and collection beside to an appendix' base due to the proximity with the catheter. additionally, the catheter was freed from adhesions at the point of entry into the colon and after careful dissectionwe release the vps from colon with a . cm transmural trajectory at the sigmoid level. no free fluid was seen and rest of the bowel appeared normal. the distal end was removed through the anus and the proximal end through a laparoscopic port. we performed a laparoscopic segmental cecum resection and an extracorporeal colo-colonic anastomosis was performed for a mini-pfannestiel laparotomy of assistance. there were no complications in the postoperative period, being discharge on the th day. conclusion: the multidisciplinary approach and the laparoscopic support in the diagnosis and treatment of patients with colon perforation caused bay vps catheter is a feasible and safe option in third level centers. background: acute appendicitis continues to be the most common source of complicated intraabdominal infection worldwide. the high incidence of postoperative complications and dissatisfaction with the results of treatment in cases of complicated appendicitis and peritonitis gave the reason for conducting this study. aim: to evaluate the effect of different laparoscopic trocars position in case of laparoscopic appendectomy for diffuse appendicular peritonitis for the incidence of postoperative complications methods: the results of laparoscopic treatment of patients with acute appendicitis complicated by diffuse peritonitis were analyzed. the first group consisted of ( %) patients operated by triangulation access (type trocar placement according sages guidelines for laparoscopic appendectomy (sages qla). the second group consisted of ( %) patients operated by sectorisation access (type sages qla). postoperative complications were classified by clavien-dindo classification. results: the duration of the operation for the analyzed groups was . ± . vs . ± . min. there were no deaths among this group of patients. the incidence of postoperative complications for both group was . %. postoperative complications in the triangulation and sectorisation group were % and . % respectively (p . ). clavien-dindo iiib complications were noted in . % (n- ) patients and presented with intra-abdominal abscesses (iaa). all patients with iaa were operated in sectorisation group. conclusion: sectorisation trocar placement increases the incidence of intra-abdominal complications for laparoscopic appendectomy for diffuse appendicular peritonitis. introduction: the diverticular disease of the colon is a chronic entity with a variety of abdominal symptoms that can present with recurrent episodes of acute diverticulitis (ad). the prevalence of diverticulosis is not influenced by gender and increases with age, which, according to the increase in life expectancy, explains the accumulation of cases in western countries. the classic diagnostic-therapeutic algorithm of the disease is it has been based on the hinchey classification, the use of antibiotics and the intervention of hartmann (ih) at the acute time and elective colectomy in the multirecurrent cases. the use of laparoscopy with washing and drainage is actualymore extended in cases with peritonitis. objectives: to demonstrate the safety and efficacy of the laparoscopic approach, in cases with diverticular disease complicated by severe inflammatory plastron with 'covered' perforation, with several recurrent episodes. material and method: case report: a -year-old man with ap-diverticulitis years ago with complete resolution and normal control colonoscopy. he presents in the last two months three compatible episodes of acute diverticulitis, exploration with plastron-mass in hypogastrium without defense, tac-marked thickening of a segment of cms. of medium sigma, collection not drainable in mesosigma, of cm, which loses the plane of cleavage with loops of thin neighbors with a linear tract that suggests fistulization. evidence of interest is exposed. given the evolution, it is decided surgical elective treatment. result intervention: preoperative ureteral double catheterization, laparoscopic approach, is exposed by video, rectosigmoid resection by diverticular plastron, with negative io biopsy, mechanical colorectal anastomosis. good postoperative course, discaharge at th day. defini-tive ap: perforated diverticulitis, absence of malignancy. the laparoscopic approach is a valid and effective alternative in cases of complex and severe diverticular disease. aim: tamis resection has been described for the treatment of rectal neoplasms, wether benign or early malignant tumours. since tamis appearance, many different indications have been reported.we aim to show an special indication as seen in this video of a tamis resolution of a rectal stenosis non treatable by endoscopy. method: we present a video of a female patient, previously treated for a large rectal adenoma treated by trasnanal apporach, with a postoperative sepsis which required lateral colostomy and trasanal drainage. after surgery, the patient suffered from a rectal stenosis which couldn' t be solved by endoscopy, so the patient was sent back for a surgical treatment.we decided to performed a trasnanal apporach by tamis and a long and circunferiential stenosis around cm from the anal verge was seen.we performed a rectotomy by electrocautery in the posterior rectal wall until the perirectal fat was seen and the stenosis was passed. a dilatation with a foley catether was also performed. results: postoperative course was uneventful and after months she was prepared for colostomy closure with no complications and remains asymptomatic nowadays. conclusion: tamis approach of rectal stenosis may be a safe and feasible technique in selected cases if conservative treatments fail. iatrogenic endoscopic colon perforation it is a severe, but rare complication of colonoscopy. the incidence of this complication is estimated to be . - . % for diagnostic colonoscopies and . - % for therapeutic colonoscopies. the management of these complications depends on the size of the lesion,the time elapsed between the lesions were produced and diagnostic of the lesions and associated pathology. the treatment can be consevative,endoscopic or surgical(clasic/ laparoscopic) in our sevice in last years we treated cases with iatrogenic colon perforation after diagnostic colonoscopies. all lesions were at sigma level. one case was admission in our service at days after a diagnostic colonoscopy.the pacient was operated clasic,in emergency,we found a fecaloid peritonitis,a perforation at sigma level.we made a colostomy, lavage, drainage but the pacient died after days. in cases we made the operation at maximum h after the lesion was diagnosticated by the endoscopist(directly visualisation).we didn't made radiologic investigation.the pacients were operated laparoscopic,we made suture,lavage,drainage. evolutions of the pacients were good. conclusion: iatrogenic colonic perfortion are rare,but severe complication. laparoscopic surgery can be a choice in treatment of this complication introduction: complicated diverticulitis with fistula is responsible for about % of surgical procedures in diverticular disease and is commonly found in patients with diverticulitis of the sigmoid colon. colovesical fistulas are the most frequent ( %), with highest incidence in males. only a third of these patients have a history of diverticulitis. in most cases, treatment is surgical, and colectomy is performed, whether or not in association with vesical recession. case report: year old male with pneumaturia and fecaluria for the preceding months. the colonoscopy identified a diverticulitis of the sigmoid colon and the subsequent pelvic mri suggested a colovesical fistula. the cystoscopy was not able to identify any fistulous opening, but a double j catheter was placed in the left ureter, as surgical treatment had been proposed. a subsequently abdominal pain motivated a preoperative ctscan which revealed a pneumoretroperitoneum and a fluid collection near the left ureteral tract. the multidisciplinary team on the case decided to perform a percutaneous nephrostomy, followed by an exploratory laparoscopy. the fistula tract was identified and a laparoscopic sigmoidectomy with partial cystectomy was performed, as well as a ureterorenoscopy (with double j replacement). there were no intra or postoperative complications, and the patologic repport had no signs of malignancy. video of the surgical procedure is presented. conclusion: a laparoscopic approach to complicated diverticulitis with colovesical fistula is safe and effective when performed by experienced colorectal surgeons. introduction: diverticular disease is characterized by its high prevalence, being one of the most frequent causes for hospital admission when it comes to gastrointestinal pathology. even though it is more frequent in older patients, there has been an increase in incidence amongst lower age groups. the approach to the disease has also suffered changes in the last few years, showcasing a tendency for less invasive options, deferring elective surgery to later in the course of the disease. this study examines the therapeutic approach to diverticular disease in our hospital. methods: retrospective analysis of demographic data, therapeutic options and surgical outcomes in patients admitted for diverticular disease between january and june . results: patients(n = )were included in the study: ( %)were male and ( %) were female, with an average age of years. patients( %) underwent medical treatment, with surgery reserved for the remaining patients, of which were emergencies, with the other being elective( %).about % of patients were only admitted once, %were admitted twice and % had or more episodes. for the single-admission group, the most common treatment was medical( %of cases), as was the case for the group with or more episodes(in which %of cases were subjected to medical treatment). in the patient group with episodes, %were submitted for surgery, most of which elective.as far as the surgically operated group is concerned, no statistically significant differences were found with regards to patient sex. age, however, was significantly greater for the group that underwent emergency surgery vs that submitted to elective ( . years vs . years,p \ . ).the most common procedure overall was colic recession, with hartmann's operation standing out as the most frequent for the emergency surgery group. length of hospital stay was again higher for the emergency group (vs elective; vs ,p \ . ),as well as the morbidity rate. no statistically significant differences were found with regards to mortality rate. conclusion: knowledge of the natural history of diverticular disease led to changes in the approach to treatment, with a tendency to adopt a less aggressive therapeutic. despite controversy around aspects such as selection of patients for elective surgery, among others, it is key to the approach to diverticular disease that existing recommendations are taken into account, treatment is individualized and outcomes are closely monitored. surg endosc ( ) aims: the objective of this analysis is to establish if there is differences after the procedure of laparoscopy appendicectomy comparing the use of endoloop (el) vs. endostapler (es) in complicated and non-complicated acute appendicitis. methods: we performed a retrospective analysis of a prospective database of patients from february to june . we divided the patients in two groups: depending on that the procedure of the appendicectomy was with endoloop or endostapler. the groups were created selecting patients in order to be homogeneous as to perforation appendix rate, thus a propensity score was performed for sex, age and perforation rate. an univariant analysis was carried out in regard to the differences in the use of el vs es in the apparition of abdominal complication, as well as hemorrhage, ileo, surgical wound infection, collection, reintervention or hospital readmission.qualitative variables were expressed in terms of absolute frequencies and percentages and mean values and standard deviation were used to express quantitative variables. introduction: intramural haematomas can develop anywhere within any the gastrointestinal tract . these are most frequently associated with blunt trauma above the level of the sigmoid colon and very rarely occur in the rectum . spontaneous, non-traumatic haematomas are a rare clinical condition usually secondary to haematological blood disorders or anticoagulant therapy . case summary: a -year old gentleman presented to the emergency department with a day history of worsening lower abdominal pain and bloody stool. he presented twice within the previous week with worsening, generalised abdominal pain. the patient had been taking regular aspirin and clopidogrel following insertion of coronary artery stents. on clinical examination, he was guarding with a distended, generally tender lower abdomen but all observations were stable, afebrile. an initial computer tomography of the abdomen reported pneumoperitoneum with haemorrhagic ascites; a differential diagnosis being perforated sigmoid colon with a large localised haematoma. the patient underwent an emergency laparotomy and hartmann's procedure (appendicectomy, sigmoid colostomy and rectal stump). he recovered well with no significant post-operative complications. histology reported the rectal perforation macroscopically associated with an opened haematoma and no evidence of malignancy. the appendix shows reactive appendicitis with serousal inflammation background: ulcerative colitis (uc) is one of the risk factor of developing sporadic colorectal cancer. approximately % of uc patients develop an acute attack of severe colitis, and % of these patients require colectomy. one third of the patients will not respond to steroid therapy. thus, a long-term follow-up has been recommended. case report: we reported a single case of completed years follow of colorectal cancer related ulcerative colitis on years old female patient undergoing emergency operation ( staged total colectomy and j-pouch ileo-rectal anastomosis) after year no responsed of medical treatment before, presenting with bloody diarrhea and anemia. there was no post operative complication reported. pathologic finding was early adeno carcinoma, closed follow up was done each year and for another five years later, no progression of the disease was found in this period and the patients has good quality of life after this procedures. is becoming a standard and feasible surgical method worldwide. % of patients with crohn's disease (cd) and % patients with ulcerative colitis (uc) will require an operation during their life. over the last decade, there have been many studies documenting the safety and feasibility of the laparoscopic approach for ibd in well-selected patients. methods: patients with a cd with the tight stenosis in the distal ileum and/or ileo-colon or various colon and rectum stenosis, patients with uc with ineffective medical therapy, steroid dependence or dysplasia underwent the lcs. from to , ileocolic resections, hemicolectomies, subtotal colectomies and restorative proctocolectomies with ileopouchanal anastomosis were performed either totally laparoscopically or laparoscopically assisted (n = ).the average time of the procedure was min ( - min), average blood loss ml ( - ml) and the conversion to laparotomy was in . %. average return time of the bowel function was . days ( - days) and the average hospital stay was . days ( - days). complications occurred in patients ( . %). cases of the early ileus due to adhesions, cases of the anastomotic bleeding threated conservatively, case of the instrumental perforation of the small bowel, cases of the incisional hernia in minilaparotomy and wound infections occurred. conclusion: in well-selected patients with ibd, thanks to superior short-and long-term outcomes, the laparoscopic approach should be considered a safe and effective method when performed by experienced surgeons. supported by mo . aim: over % of patients with crohn's disease (cd) will require a surgical resection within years of their diagnosis and one quarter will have another resection for disease recurrence. laparoscopy should by preferred approach in surgery in cd due to reduced morbidity, faster recovery time, shorter hospital stay and reduction in adhesions and hernial formation. methods: patients with cd with the tight stenosis in the distal ileum and/or ileo-colon or various colon stenosis were indicated for the laparoscopy. from january to november we performed ileocolic resections, hemicolectomies and subtotal colectomies either totally laparoscopically or laparoscopically assisted. the average time of the procedure was min ( - min). the average return time of the bowel function was . days ( - days) and the hospital stay was from to days. complications occurred in patients ( . %) . in cases early ileus developed due to adhesions, in case was anastomotic bleeding threated conservatively, the incisional hernia in minilaparotomy occurred in cases and wound infections occurred. conclusion: minimally invasive surgery is becoming a gold standard in cd. it is safe and feasible in well-selected patients thanks to short-and long-term outcomes. laparoscopic approach for recurrent disease is still in debate. supported by mo . aim: the aim of the study was to observe when laparoscopy is avoided when treating surgical complications of crohn disease. methods: we did a retrospective study which included all of the patients diagnosed and operated in our clinic for complications of crohn disease during a period of years. results: we identified a number of patients operated for complications of crohn disease. of these were operated by minimally invasive procedures. we observed that laparoscopy was avoided in the case of intestinal fistulas (p = , ). also when sepsis associated the surgical complication-laparoscopy was avoided (p = , ). age under years represented another factor to avoid laparoscopy (p = , ). conclusions: although laparoscopy offers numerous advantages careful selection of the patients is of utmost importance so the safety of the procedure can be ensured. retroperitoneal sarcoma represents approximately - % of all sarcomas and less than . % of all neoplasia. radiotherapy and chemotherapy still do not represent valid therapeutic alternatives; therefore radical surgery remains the only valid option. complete surgical resection is the only potential curative treatment modality for retroperitoneal sarcomas. the ability of complete resection of a retroperitoneal sarcoma with tumor grading remains the most important predictor of local recurrence and disease-specific survival. hypoglycemia is a rare but potentially lifethreatening presentation of soft tissue tumors the etiology of hypoglycemia may be difficult to diagnose, assays for insulin-like activity (ila) were found to be high in the extract of tumor tissue, while insulin was not detected in significant concentration neither in the same extract nor in his serum. the most likely mechanism of hypoglycemia appears to be production of insulin like substance and increased utilization of glucose by the tumor. laparoscopic surgery represents an alternative technique for radical resection of such tumors rather than traditional surgery. only few cases of retroperitoneal tumors resected laparoscopically were reported in the literature. we report a rare case of years old male presented to ed unconscious due to hypoglycemia.he was resuscitated and admitted for further investigations. hypoglycemic attack recurred again during the same evening of admission. initial investigations were within normal except for serum glucose mg/dl ( . mmol/l). his tsh, glucagon & cortisol levels were within normal, insulin and c-peptide levels were undetectable. only hypokalemia ( . meq/l). he tested negative for the anti-insulin antibodies. his abdominal ultrasound as well as his ct scans showed the presence of a large retroperitoneal tumor ( cm cm cm) with a heterogeneous contrast effect. a glucose supplement was required to maintain the plasma glucose level within normal limits during which complete resection of the tumor which was performed laparoscopically. diagnosis of such hypoglycemia inducing retroperitoneal fibrosarcoma represents great challenge especially when patients presents only with hypoglycemia and no other abdominal symptoms, management using minimal invasive technique to resect and remove such tumors from the retroperitoneal region shows superiority in recovery and limitation of complications when done by experienced surgeons. solitary fibrous tumor (sft) is a rare fibroblastic mesenchymal neoplasm, tipically arising from the pleura, less frequently from other anatomic sites. sft is an indolent neoplasm, but it have been described cases of greater aggressiveness in terms of local recurrences and more rarelly of distant metastases. among the various extrapleural sites, intrabdominal, retroperitoneal localization is the most common site, followed by the pelvis soft tissues and parenchymatous organs. the most common clinical finding of intraabdominal localization is a palpable mass, and the pain is the most frequently associated symptom. the diagnosis is performed by imaging, but the histological as well as immunohistochemistry characterization of the lesion is the latest goal. furthermore, histological features are used to attempt to identify the patient with a hight risk of malignant evolution of the tumor. the gold standard treatment is surgical approach, meanwhile there are no evidences about the efficacy of any adjuvant treatment. we present the case of a -year-old man affected by symptomatic tfs arising from mesosigma treated by surgical radical excision. finally, we propose a review of the literature of last decade. background: laparoscopic right hemicolectomy involves making an additional incision to remove the specimen and perform the anastomosis. recently, natural orifice specimen extraction surgery (noses) has been reported as an alternative approach without any additional incisions or extensions, may lead to better outcomes compared to conventional laparoscopic right hemicolectomy. in this video, we aimed to evaluate the safety and feasibility of noses for laparoscopic right hemicolectomy. methods: we describe the technique with transvaginal specimen extraction and d lymph node dissection in laparoscopic right hemicolectomy by this video. we performed intracorporeal anastomosis combined with a transvaginal route of specimen extraction after medial-to-lateral mobilization. transverse transvaginal posterior colpotomy was performed under aid with visualization. the specimen was pulled into the sterilized plastic bag, passed transvaginally. the vaginal incision was then closed with a running suture. results: the operation time was min and the hospital stay was days. an excellent postoperative recovery was demonstrated and has shown future potential for less incision. the pathologic tnm stage is t n m . conclusions: this video has shown that laparoscopic right hemicolectomy with the noses technique is feasible and safe for selected cases. the long-term benefits of this procedure need to be more evaluated. recently, indocyanine green (icg) fluorescence has been introduced in laparoscopic colorectal surgery to provide detailed anatomical information.the aim of our study is the application of icg imaging during laparoscopic colorectal resections: to identify the sentinel lymph node (sln) to search micrometastases that can be missed with the conventional pathological exam, and to assess anastomotic perfusion to reduce the risk of anastomotic leak. after tumor identification ml of icg solution ( . mg/kg) is subserosal peritumoral injected. a full hd image s camera, switching to nir mode, in about min displays fluorescence: the sln is identified and the sln biopsy (slnb) is performed.after the transection ml of icg solution is injected to confirm the stumps perfusion. if there is an ischemic area, a new resection is performed.after the anastomosis is performed, another bolus of icg is intravenous injected to confirm the anastomotic perfusion.when the sentinel node is negative for cancer metastases by conventional histological examination, ultrastaging is performed by serial sections. when no micrometastases are identified on these sections, immunohistochemical techniques are applied. from november , patients were enrolled: left colectomy, right colectomy, transverse resections, and splenic flexure resections. in two cases, one left colectomy and one right colectomy, the anastomotic perfusion wasn't good and the surgical strategy was changed. four postoperative complications occurred, of which one anastomotic leak, due to a mechanical problem. from november , patients were enrolled to perform the slnb: right colectomy, left colectomy, transverse resection and splenic flexure resections. the sln was identified in cases. cases were found to be n to the conventional examination and were subjected to ultrastaging. the serial sections showed micrometastases in two cases. in the other cases the immunohistochemistry was performed but the exam is still in progress. icg-enhanced fluorescence imaging is a safe, cheap and effective tool to increase visualization during surgery. it's recommended to assess the anastomotic perfusion in order to reduce the incidence of anastomotic leak, and to perform the slnb for the sln ultrastaging in order to identify micrometastases. methods: for the last years, tem was performed on patients' with early rectal cancer. there were women and nine men, age to . localization of tumors was - cm from anus. mean size of tumors was . cm. full thickness excision was performed in all patient with suturing of mucosa. during follow-up in three patients' metastasis in lymph nodes of mesorectum were detected. all of these patients were re-operated: laparoscopic colectomy with total mesorectal excision (tme) was done. for the last year in patients with early stage rectal cancer we used indocyanine green (icg) with fluorescent imaging for mapping sentinel lymph node. icg was injected in four quadrants to submucosa around the tumor. during the laparoscopy, sln was detected and removed with morphological examination. results: among nine patients in patients, sln was negative. tem was performed in these patients with good results. after - months no recurrence or metastasis were detected in these patients. in two patients with positive sn laparoscopic tme was performed with low colorectal anastomosis. anastomotic complication was occurred in one patient. conclusion: tem procedure is highly effective in selected group of patients with early rectal cancer. mapping and examination of sln can clarify indication for the tem in the patients with early rectal cancer. purpose: laparoscopic surgery for colorectal cancer provides better short-term benefits and similar long-term outcomes compared with conventional open surgery. unlike minimally invasive surgery, natural orifice specimen extraction (nose) can provide additional advantages by reducing morbidity and postoperative pain related to the surgical extraction site. this study aimed to evaluate the efficacy and safety of a nose procedure using needlescopic instruments for colon cancer surgery. methods: between november and february , patients underwent laparoscopic nose using needlescopic instruments. the first port for the camera was placed at the umbilicus. a -mm or -mm port was inserted in the right lower quadrant. a -mm or -mm port was inserted in the right upper quadrant. individual needlescopic forceps for the assistant were inserted into left upper and lower quadrant ports. thus, a total of ports were placed. the superior rectal artery and inferior mesenteric vein were ligated with clips, and colonic mobilization was performed using a medial to lateral approach. after rectal stump irrigation, the distal rectum was transected using an endoscopic linear stapler. the proximal colon and associated mesentery were transected. after the rectal stump was opened, a wound retractor was pulled through the anus and inserted in the rectal lumen. the resected specimen was transanally extracted through this route. an anvil was intracorporeally attached to the proximal colon, and the open rectal stump was reclosed using an endoscopic linear stapler; colorectal anastomosis was then performed using a double-stapling technique. results: of the patients, were male and were female, with a median age of years ( - years). median body mass index was . . the tumor site was in the sigmoid colon in patients and rectosigmoid colon in patients. median operative time was min and blood loss was ml. there was no conversion to open surgery. no postoperative complication was observed. median postoperative hospital stay was days ( - days). conclusions: nose surgery using needlescopic forceps is an easily performed type of reducedport surgery with a conventional port arrangement. this procedure is feasible for the selected patients. introduction: splenic flexure colon cancer accompanying obstruction is usually managed stent insertion as a bridge to surgery and left hemicolectomy, or subtotal colectomy. however, stent insertion can fail more often than in sigmoid colon because it requires longer colonoscopic approach in the circumstance of impossible bowel preperation. although subtotal colectomy has advantage in the aspect that it is -stage treatment, it needs open surgery in most cases, right colon has to be sacrificed without oncologic neccesity, and preoperative staging and evaluation can be insufficient. despite colostomy is reluctant procedure when considering quality of life, in splenic flexure colon cancer obstruction, we can obtain prompt stabilization of patient state, suffient time to preoperative staging and evaluation, and also we can achieve minimally invasive surgery by using colostomy site as mini-laparotomy and close colostomy before discharge. colostomy site, tumor location, and minilaparotomy site for next radical surgery have to be considered comprehensively before making colostomy incision. colostomy site has to be appropriate as mini-laparitomy site for feasibility of laparoscopic left hemicolectomy and the colostomy has to be included in the specimen with caution to prevent unneccessary lengthening of the specimen. we experienced cases which were treated succefully in this strategy and report them. result: temperary loop transverse colostomy and laparoscopic left hemicolectomy via colostomy site in splenic flexure colon cancer obstruction has advantage of quick stabilization of patient's status, suffient preoperative staging and evaluation, achieving minimally invasive surgery, and also rapid colostomy closure before discharge. our tatme procedure for locally advanced low rectal cancer following chemoradiotherapy y. nakamoto , r. okamoto , f. kimura , h. yanagi , t. nakajima , h. yoshie , n. yamanaka surgery, meiwa hospital, nishinomiya, japan, surgery, yoshie clinic, itami, japan background: short-course chemoradiotherapy using hyper-fractionation method (scrt; gy/ fraction/ days ? s- or xeloda) is performed to secure circumferential resection margin (crm) due to tumor shrinkage, reduction of cancer cells with viability, reduction of radiation hazard for resectable locally advanced lower rectal cancer (more t or n ). the patient underwent radical surgery after one month of scrt. for more locally advanced lower rectal cancer (t or n ), induction chemotherapy is performed before scrt. for patients with poor efficacy of chemotherapy, we also do normal fraction gy radiotherapy. methods: we introduced tatme from last august, and cases were performed so far. in all cases temporary stoma has been constructed, and intersphincter resection (isr) is based on partial isr avoiding total isr considering postoperative anal function. if possible, colonic j-pouch is added, and pelvic floor repair may be added for esr cases and older people. at first one team preceded with the anal operation and shifted to the abdominal procedure, now it is done with two teams with the advantage of getting good visual field from both sides when there is difficulty identifying the right dissecting layer. tatme is very useful in cases such as large tumor, obesity, and narrow pelvis. furthermore, when it is difficult to identify the dissecting layer by scarring after crt, it is more possible to control the crm/drm of cancer. results: cases of isr, case of apr, case of tpe were performed, and in of these cases lateral lymph node dissection was also performed (one side , both sides ). postoperative complications were anastomotic leakage, pelvic floor infection, perineum infection, and bowel obstruction. conclusions: tatme for locally advanced lower rectal cancer is useful even after chemotherapy and scrt. background: although many studies have demonstrated similar perioperative outcomes for single-incision laparoscopic surgery (sils) and conventional laparoscopic surgery (cls) for colon cancer, few have directly compared the costs of them. we aimed to compare costs between sils and cls for colon cancer. methods: we analyzed the clinical outcomes and overall hospital costs of patients who underwent laparoscopic surgery for colon cancer from july to september at severance hospital; were used for analysis after propensity score matching. the total hospital charge, including fees for the operation, anesthesia, preoperative diagnosis, and postoperative management was analyzed. results: the total hospital charges were similar in both groups ($ . vs. $ . , p = . ). however, the patients' total hospital bill was higher in the sils group than in the cls group ($ . vs. $ . , p \ . ) mainly due to the difference of the cost of access devices. there was no difference in the additional costs associated with readmission due to late complications between the two groups ($ . vs. $ . , p = . ). conclusions: sils for colon cancer yielded similar costs as well as perioperative and long-term outcomes compared with cls. therefore, sils can be considered a reasonable treatment option for colon cancer for selective patients. aims: technology improvements in medicine allow the development of new minimally invasive approaches. despite every single advantage of these new devices they also can cause technical problems and difficulties for the surgical team. well known from last few years-laparoscopic assisted transanal total mesorectal excision for distal rectal cancer is perfect example for a quite new procedure, based on the combination of forgotten old surgical principles and technology advances. the aim of the study is to analyze the rate of technical problems during the procedure and to measure the impact of them on the operative time. methods: we conducted prospective observational study related to technical problems during the procedure. for the period between september and november in the department of endoscopic endocrine surgery and coloproctolgy at military medical academy-sofia have been performed laparoscopic assisted transanal total mesorectal excisions. we used standard local preoperative work up and postoperative care protocols. we defined technical problem as intraoperative event different from complication leading to delay in operative time. every technical problem during the procedure was recorded and time for resolving the problem was measured in seconds. results: overall technical problems occurred in of the cases. most of them were related to the insufficient smoke evacuation during the cases. the second most common technical problem were the excessive rectal stump spasms during the procedure-this complication occurred in of the patients. mean delay of the procedure related to technical problems is min. in our series we experienced only one intraoperative complication which was specimen perforation during the dissection. three complications occurred in postoperative period-two urinary retentions and one perianastomotic abscess, without need of reoperation. conclusion: technical problems during the procedure can be source of delay in operative time. correct use of devices in operating room is the key to reduce technical issues. technical problems can increase the rate of intraoperative near miss events and complications during the transanal total mesorectal excision. surg endosc ( ) aims: anastomotic leak after rectal cancer surgery constitutes a severe complication associated with poorer oncologic outcome and quality of life. preoperative assessment of the risk for anastomotic leak is a key component of surgical planning, including the opportunity of creating a defunctioning stoma. methods: studies on rectal cancer surgery published between and were systematically reviewed according to the preferred reporting items for systematic reviews and meta-analyses of individual participant data (prisma-ipd) guidelines. with the aim to generate a score for anastomotic leak, all available per-operative covariates were used as independent factors in a logistic regression model with anastomotic leak as dependent variable. a receiver operating characteristic curve (roc) analysis was generated. we selected as threshold the value that allowed a missing rate of anastomotic leak \ %. the predictive power of the previously selected cut-off was validated in an independent set of patients. results: twenty-six centers provided individual data on patients. with a threshold value of the roc corresponding to . in the training set, the area under the roc curve (auc) was . (p \ . ). sensitivity and specificity of the model's probability [ . to identify anastomotic leak were . % and . %, respectively. accuracy of the threshold value was confirmed in the validation set with . % of sensitivity and . % specificity. conclusions: we trust that, with further refinement using prospective data, this nomogram based on preoperative risk factors may assist surgeons in decision making. the score is now available online (http://www.real-score.org). in ( . %) cases laparoscopic interventions were performed in patients with diverticular colon disease. in the group of patients with colorectal cancer localization of the tumor in the right parts was observed in ( %) patients, in the left-in ( %), in the rectum- ( %). results: in the adenocarcinoma of the sigmoid colon, performed a left laparoscopic hemicolectomy ( cases) and resection of the sigmoid colon ( ). was executed high clipping and intersection of the lower mesenteric vessels, aorto-iliac lymphatic dissection. in the standard scope, lymph node dissection was performed with removal and testing of not less than epi-, para-and mesocolical lymph nodes (max ). the average length of the laparoscopic stage is ± min. laparoscopic right hemicolectomy ( cases) was performed in accordance with the principles of cvl (central vascular ligation) and cme (complete mesocolic excision). intracorporal ileotransversoanastomosis was formed by a semimanual method with endogia universal and v-lock suture material. the average length of the laparoscopic stage was ± min, the open phase was ± . in the tumor of the lower and middle ampullary parts of the rectum ( cases) after neoadjuvant chemoradiotherapy, was executed a laparoscopic total mesorectumectomy. conclusions: the use of minimally invasive technologies in colorectal surgery provides a complete revising of the abdominal organs, adequate scope of resection and lymph nodes dissection in surgical interventions. background: it is thought that complete mesocolic excision (cme) improves the oncologic outcomes for colon cancer. but, precise mesenteric mobilization from retroperitoneum and safe ligations at the origins of central vessels are considered to be technically difficult in single port surgery(sps). to resolve this problem, we utilize retro-mesenteric medial approach for right side colon cancer. herein, we introduce this technique and assess its outcomes. operative procedure: the multi-trocar platform is placed in the umbilical site. d laparosopy is inserted from one of this channels. the surgeon manipulates instruments via the other channels. st step: right colonic mesentery is mobilized medial to lateral from the head of the pancreas and retroperitoneum along the embryonic plane. nd step: the origins of ileocolic and right colic vessels are divided and central lymph node dissection is achieved. rd step: hepatic flexure is taken down from cranial. and right lateral attachment is dissected away and cme is achieved. th step: specimen is extracted and anastomosis is performed using a functional end to end anastomosis extracorporealy. results: from april to december , consecutive patients underwent sps-cme with right side colon cancer. there were in stage i, in stage ii, in stage iii and in stage iv. the mean operative time was min. the mean estimated blood loss was ml. there was no conversion to open surgery. additional port was placed in patients ( . %). intraoperative bleeding was occurred in patient. anastomotic leakage was observed in patient ( . %), intestinal obstruction ( . %) and wound infection in ( . %). conclusion: these results suggest that retro-mesenteric medial approach in single port surgery with right side colon cancer is useful and safe technique. aims: this multicenter, randomized controlled trial (simple trial) aimed to investigate the quality of life (qol) and patient satisfaction of single port laparoscopic surgery (spls) for colon cancer, compared with multiport laparoscopic surgery (mpls). methods: patients with histologically diagnosed adenocarcinoma in cecum, ascending and sigmoid colon were eligible for this trial. eligible patients were randomly assigned to the spls or mpls group at a ratio of : . qol was measured with the eortc qlq-c third edition (korean version) preoperatively and postoperatively at month , , and . in addition, patient satisfaction was surveyed with a five-point questionnaire at postoperative month. to exclude the impact of adjuvant chemotherapy on qol, subgroup analysis for patients with or without adjuvant chemotherapy were carried out. (clincaltrials.gov identifier: nct ) results: total patients were randomly allocated into the spls group (n = ) and mpls group (n = ). in total patients, global health status and five functional scale steadily increased and nine symptom scales also gradually improved over time. but, nausea/ vomiting and appetite loss temporally deteriorated at postoperative month. pain score was significantly worse in the mpls group ( . in the spls group vs. . in the mpls, p = . ) at postoperative month and appetite loss score was significantly worse in the spls group ( . vs . , p = . ) at postoperative month. except for that domains, all the other items of qol between groups were not different until postoperative months. patient satisfaction was significantly higher regarding the operation (p = . ) and the abdominal wound (p = . ) in the spls group. in patients without adjuvant chemotherapy, some items of qol (global health status, physical functioning, role functioning, emotional functioning, fatigue and pain) were significantly better in the spls group at postoperative month. since postoperative month, all of qol domains (except pain score) were similar between groups. conclusion: although postoperative pain was temporarily better in the spls, most of qol domain were similar between the spls and the mpls group until postoperative month. in patients without adjuvant chemotherapy, spls showed better outcomes in some of functional scales and symptom scores at postoperative month. coloproctological surgery, juntendo university, tokyo, japan; gastroenterological surgery, juntendo university, tokyo, japan introduction: laparoscopic surgery causes less postoperative pain compared with pain after laparotomic surgery, and its low invasiveness should be considered for pain control. we have previously controlled postoperative pain by epidural anesthesia. in this study we compared postoperative multimodal analgesia centering on acetaminophen in patients who underwent laparoscopic colorectal cancer surgery with the conventional method. subjects: the subjects were patients who underwent laparoscopic colorectal cancer surgery between january and june . surgery was performed under epidural anesthesia in patients and multimodal analgesia in : periodic acetaminophen administration ? transverse abdominis plane (tap) block in , periodic acetaminophen administration ? local anesthesia of the wound in , and periodic acetaminophen administration ? intravenous patient-controlled analgesia (ivpca) in . the operating roomoccupying time, postoperative pain (nrs), frequency of taking analgesics as needed, and postoperative nausea were investigated for days after surgery and the duration of urethral catheter placement and postoperative intestinal movement were investigated in the epidural anesthesia and multimodal analgesia groups. results: while the time from entering the operating room to initiation of surgery was significantly shorter, the time from completion of surgery to leaving the room was significantly longer in the multimodal analgesia group. there was no difference in the operating room-occupying time. the frequency of postoperative pain was significantly lower in the multimodal analgesia group on postoperative day (pod) . the frequency of taking analgesics as needed was significantly lower in the multimodal analgesia group on pod , , and . no significant difference was noted in the duration (number of days) of urethral catheter placement or postoperative nausea between the groups. regarding postoperative intestinal movement, discharge of gas occurred significantly earlier in the epidural anesthesia group. the total number of incidents of complications in the epidural anesthesia group was . discussion: in laparoscopic colorectal cancer surgery, the effect of multimodal analgesia centering on periodic administration of acetaminophen without epidural anesthesia for postoperative analgesia was sufficient compared with the effectiveness of epidural anesthesia. this approach to analgesia may be useful because none of the potential complications of epidural anesthesia occur. surg endosc ( ) in the last years the application of new technologies like d vision or virtual reality have provided to surgeons the possibility of establish a preoperative surgical plan of each surgery and of each patient. these advances are specially useful in minimally invasive colorectal surgery due to the variability in location, anatomical relationship with other organs and vascular variants of these type of surgeries. the aim of our work is to built a digital -dimensional virtual model of the colorectal ct scan imagen of patients with colorectal cancer. the virtual models are obtained from the preoperative ct scan. the ct scans that we use to this work are general electric healthcare revolution gsiÒ and siemens somatom perspective Ò and the size of each image is mm. a medical software let us build a reconstruction of colorectal digital images where a radiologist has marked the exact image of the tumor so we obtain a d reconstruction which can provide an enhanced understanding of crucial anatomical details like the exact location of the tumor and the relationship with other organs and structures of the patient which can be selectively displayed or hidden. this information has an important applicability into clinical practice since it lets surgeons estimate the colorectal anatomy, tumor size and relationships, providing key landmarks to choose the most appropiate surgery, the best trocar location and a safer dissection specially in some cases whose location can change the kind of surgery radically. we present some cases where virtual models were crucial for the preoperative and intraoperative surgical plan, showing the potential interest of these d reconstructions in colorectal surgery. in conclusion the ct scan colorrectal image reconstruction can provide an enhanced understanding of crucial anatomical details of the colon and tumor location and relations which could contribute to choose the best surgical option and to improve safety in colorectal surgery. background: anastomotic leakage (al) after colorectal procedures are a common surgical experience and represents a significant burden both for patients and surgeons. the incidence of al has been reported to vary between . % to up to %, with rates for the colon and rectum of - % and - %, respectively. they, not only add to potential postoperative patient morbidities and to overall costs of postoperative patient care, but also are considered a quality indicator in colorectal surgery. aim: we aimed to evaluate the clinical burden associated with anastomotic leaks following colorectal surgery. methods: we conducted a retrospective analysis of colorectal patients who underwent conventional or laparoscopic colorectal surgery for colorectal cancer (crc), from january st, to december st, in a single colorectal centre (centro hospitalar de leiria). patient demographics, intraoperative and postoperative aspects were collected and analysed. all statistical analysis will be conducted using stata software (statacorp lp). results: in our cohort of pts, developed a clinical al ( . %), mostly males ( %), with an average age of ± . . male gender and conversion were independent risk factors. the group with al had a higher lohs ( . days vs, . -p \ . ). out of al have been detected after the discharge. the mean diagnostic day was the eighth, and mode estimated at day . when compared with a control group, wcc, eosinophils and crp were statistically significant different in al group, at day and . conclusion: in the present study, no statistically significant risk factors for al in crc surgery were detected, except for male gender and conversion. clinical methods and biomarkers were useful for early diagnosis. technology combined with experience and common sense may be the embodiment of the clinical method. conclusions: our regional screening program has significantly improved early diagnosis and quickened surgical treatment of crc. thanks to this, we obtained an earlier stage at diagnosis, a less invasive surgical approach, and a lower rate of complications and emergency surgery need were obtained also with an improvement in both os and dfs. introduction: surgeons are increasingly being faced with the problem of treating elderly colon cancer patients. we evaluated the outcome of silc in patients of over years with colon cancer with a propensity score matched comparison to assess its perioperative and long-term oncological outcomes. methods: this retrospective cohort study analyzed our experience with silc for colon cancer over years. eighty-seven patients of over years with colon cancer who electively underwent silc were included in this study (elderly group). eighty-seven patients were then chosen out of a collective of patients less than years old in a propensity score matched design (younger group). short-term clinical outcomes in both groups were compared and verified its long-term oncological outcome. results: american society of anesthesiologists score and post-operative complication rate were significantly higher in elderly group. however, the other short-term clinical outcomes including post-operative hospital stay were equivalent in two groups. the rates of -year cancer specific survival were . % in elderly group and . % in younger group, respectively, and the -year overall survival rates were . % and . %, respectively. no significant differences were seen between two groups. conclusions: our initial experiences suggested the oncological and clinical safety of silc in patients of over years with colon cancer. however, further studies are needed to demonstrate the advantages of this procedure compared to conventional laparoscopic colectomy. aim: some clinical trials have reported the safety and efficacy of laparoscopic colectomy for colon cancer. on the other hand, transverse colon cancer was excluded in these trials because of the difficulty of laparoscopic colectomy for transverse colon cancer. in this presentation, we report the tips for laparoscopic colectomy for transverse colon cancer. tips: in our department, transverse colon cancers has been resected by laparoscopically so far. to complete cvl and cme, lymph nodes around middle colic artery should be resected, however many important structure, duodenum, pancreas, superior mesenteric vein (smv) and so on, may be obstacles. this is most difficult point for this surgery. our surgery is as follows. mobilization of ileum and ascending mesocolon from caudal sideconfirm duodenum and pancreasexpose smv and ligation root of ileocecal artery and veindissect lymph nodes around smv and ligation of middle colic artery and accessary right colic veinconfirm pancreas from caudate side of transverse mesocolon and incise the peritoneum along the caudal side of the pancreasdissect lymph nodes sufficiently by dissection from both side of transverse mesocolonmost important point. to dissect lymph nodes safely, confirmation from both side of transverse mesocolon is necessary and dissection should be performed along important structure, smv, pancreas and so on. introduction: we have developed and previously reported single-incision plus one port laparoscopic anterior resection of the rectum (sils ? -ar) as a reduced port surgery in which we can utilize the incision for drainage as an additional access route for laparoscopic procedures including the transection the lower rectum. a consecutive experience from its introduction of sils ? -ar for rectal cancer is reviewed, and its -year oncological outcomes are evaluated retrospectively. methods: one hundred and forty-one patients ( female) with a mean age of . years adopted the sils ? procedure for rectal cancer. a lap protector (lp) was inserted through a . cm transumbilical incision; an ez-access was mounted to the lp and three -mm ports were placed. a -mm port was inserted in the right lower quadrant. results: one hundred and thirty-six patients ( . %) completed with sila ? -ar. the tumor locations in the rectosigmoid, rectum above the peritoneal reflection (ra), and rectum below (rb) were , and , respectively. the median follow-up interval was months. aims: colovesical fistulae came from inflammatory disease or cancer and do have a significant morbidity. the most common location is the sigmoid colon and the most common aetiology is diverticulitis. the treatment of choice is a surgical procedure. the aim was studying compare laparoscopic approach in patients diagnosed by benign (diverticulitis) and malignant (colon adenocarcinoma) colovesical fistulae. methods: from january to march all characteristics of surgical patients with diverticular and colon adenocarcinoma colovesical fistulae were reviewed. patient details (sex, age, symptoms, diagnosis, medical history and anaesthetic risk), surgical approach, hospital stay and complications were recorded. both groups were compared with significance level set at p \ . . results: nine laparoscopic ( %) and open approaches ( %) in diverticular colovesical fistulae were performed, with a conversion rate of %. the procedure done was sigmoidectomy. there were also performed laparoscopic ( %) and open approaches ( %) in colon adenocarcinoma colovesical fistulae. the procedures done were sigmoidectomy, pelvic exenteration, left colectomy, low anterior resection and loop colostomy. comparison between the two groups didn't show significant differences in characteristics but did show significant differences regarding the approach, with more cases performed by open approach in colon adenocarcinoma colovesical fistulae (p = . ). conversion rate didn't show significant differences. patients diagnosed for malignant colovesical fistulae had more complications, cases ( %), ( %) i-ii and ( %) iii-iv-v according to clavien dindo classification, manifesting significant differences (p = . ). laparoscopic approach didn't show significant differences regarding complications. conclusions: generally, surgical approach with colonic resection and partial or total cystectomy is the treatment of choice in colovesical fistulae, although vesical resection can be avoided if it is suspected benign aetiology. whenever laparoscopic approach is performed by experienced surgeons, is feasible in colovesical fistulae and the morbidity and mortality numbers are acceptable. laparoscopic approach allows the advantages of a minimally invasive treatment but implies clinical trials to stablish stronger evidence. aims: laparoscopic right hemicolectomy became the standard of care for treating cecum, ascending and proximal transverse colon cancer in many center. most centers use multiport laparoscopic colectomy with extracorporeal resection and anastomosis (mce). single-incision laparoscopic colectomy with intracorporeal resection and extracorporeal (sci) remains controversial. the aim of the present study is to compare these two techniques using propensity matching analysis. methods: this study analyzed patients who underwent laparoscopic right hemicolectomy including mce surgeries and sci surgeries from december to december . short-term outcomes were recorded. postoperative pain was evaluated using a visual analogue scale (vas) and postoperative analgesic use as outcome measure. results: the length of skin incision in the sci group was significantly shorter than in the mce group: median (range) ( - ) cm verses ( - ) cm (p \ . ). the vas score after surgery was significantly less in srhi than in mrhe. significantly fewer patients required analgesia after srhi after surgery. there were no significant differences in operative time, intraoperative blood loss, the number of lymph nodes removed and postoperative courses between the groups. the cost effectiveness was significantly cheaper in srhi than in mrhe. conclusions: sci for right colon cancer is safe and technically feasible. sci reduces the length of skin incision and postoperative pain compared with conventional mce. aim: this study was designed to clarify the utility of laparoscopic surgery for advanced lower rectal cancer after neoadjuvant chemoradiotherapy (ncrt). patients and methods: we investigated -year disease-free survival rate, operative outcomes and recurrence risk factor in patients with lower rectal cancer (ct - , n - ) who underwent laparoscopic surgery after ncrt from to december in kitasato university hospital. results: of patients, patients underwent low anterior resection (lar), patients underwent intersphincteric resection (isr) and abdominoperineal resection (apr). there were anastomotic leakage, and urinary disorder and sexual dysfunction. ypcr rate was . %, but patients ( . %) had recurrence ( liver, lung and lymph node and local recurrence; there is some overlapping). ypt and lymph node metastasis were detected as a recurrent risk factor. the -year relapse-free survival rate (rfs) was . % and the -year overall survival rate (os) was %. conclusion: in this examination, ypt and lymph node metastasis were risk factor for recurrence. the operative outcomes, -year rfs and the -year os are relatively good results. we will conduct further follow-up, and it is necessary to investigate a long term prognosis. laparoscopic surgery is warranted for rectal cancer after ncrt. surg endosc ( ) introduction: synchronous colorectal neoplasia presents an incidence ranges from % and %. classically its surgical treatment consisted in the realisation of a subtotal colectomy (stc), however, several authors have proposed that in certain occasions the realisation of two segmental resections with two anastomoses was not accompanied by an increased risk of anastomotic failure. the objective of this study was to compare the feasibility and safety of the laparoscopic approach of synchronous colorectal neoplasia using two different techniques: stc versus two segmental resections with two anastomoses. methods: we retrospectively reviewed the clinical data of patients over years of age who underwent colorectal surgery between and at a single center. we included patients with a synchronous colorectal neoplasia who underwent laparoscopic surgery, either stc or double resection (dr). results: a total of patients met the inclusion criteria. mainly males ( %) with an average age of years, with a scale of the american association of anesthesiologists superior to ii in % and with an average body mass index of kg / m . the mean operative time was min in the dr and min in the stc, the stc resulted in a higher conversion rate ( % vs %) and intraoperative bleeding ( % vs %), in addition to a postoperative period with more complications, only % of the patients undergoing stc didn't present any complication while % of the patients with a dr didn't present any complication. % of the stc presented anastomotic failure and only % of the dr. the mean hospital stay was days in the dr and . in the stc. in the dr, an average of cm of colon was resected with an average of . lymph nodes, while in the stc, cm of colon was resected with an average of . resected nodes. conclusions: the double resection with two anastomosis is a less aggressive surgery, with fewer complications and a shorter hospital stay, providing similar oncological results. there were no differences in morbidity, re-operations or hospital stay. regarding tumor stage there were no differences between the three groups. as for the resected nodes, we found a mean of in stc, in lc and sr with no statistical difference. there were no differences in the affected nodes among groups. in our patients we didn't find differences in the recurrences rate or in the distant metastases rate.the average follow-up was months (range: - ), with no differences in overall survival. conclusion: segmental resection of splenic flexure neoplasias is safe and feasible, with no differences in morbidity or in the oncological outcomes compared with more aggressive surgeries. introduction: the evaluation of perfusion in colorectal anastomosis is still a field of study and progress for the development of new modalities that allow reducing the ratio of dehiscence or anastomotic leakage (al) in said surgery. our objective with this work is to highlight the utility of indocyanine green (icg) in the said evaluation after colo-rectal surgery. methods: we present a series of cases of colorectal surgery (benign and malignant disease) intervened in the period between and . the population sample has been homogenized according to age criteria, risk factors and comorbidity. a retrospective database has been developed with the spss v. software for the evaluation of the results obtained. the primary outcome measure was al rate with at least month of follow-up. results: a significant reduction in the incidence of al was observed in patients who underwent colo-rectal surgery (p = . ). low al rates were shown in rectal cancer surgery (p = . ). there was no significant decrease in the al rate when colorectal procedures for benign and malignant disease were combined. conclusions: the use of the image by fluorescence with indocyanine green is a safe, reproducible and relatively simple method with which to evaluate the perfusion of the colorectal anastomosis as well as reduce the rate of anastomotic leak in the postoperative period. large well-designed randomized control trials are needed to provide evidence for its routine use in colorectal surgery. introduction: currently colonoscopy is the gold standard investigation for colonic evaluation. although caecal intubation is one of its quality indicators, it is not attained in up to % of cases. this remains a significant concern. limited data are available on the follow-up of patients with incomplete colonoscopy. aims: to assess colonoscopy completion rate, the reasons for incomplete colonoscopy, and the methods used to complete colonic evaluations after incomplete colonoscopy. methods: we performed a retrospective study of incomplete colonoscopies in our unit over a one year period ( ) these results compare favorably with published data. few statistically significant differences between groups suggest varying modalities of treatment broadly result in similar qol. this data highlights a need for well-delivered support programmes for specific issues, for example stoma care and sexual dysfunction. future studies will need to include a baseline questionnaire to truly measure the impact of surgery and measure quality in an increasingly elderly and comorbid population. splenic flexure cancer (sfc), comprising the tumours raised in the distal transverse colon and proximal descendingcolon, accountfor to %of all surgically treated colorectal cancers.in cme forsfc, dissection of both the transverse and descending mesocolon must be considered. however, the use of laparoscopic surgery as a curative treatment for sfc, has never been investigated in adequate controlled trials, because of difficulty in deciding on the appropriate operative procedure, as well as technical difficulties with laparoscopic lymph node dissection. the aim of this multicenter study is to evaluate the oncologic effectiveness of laparoscopic segmental resection with cme with for cancer located at the splenic flexure. we performed a retrospective analysis of all cases of sfc treated with a laparoscopic segmental resection with cme in five different institution. intra and post operative were evaluated. patientes were evaluated, the mean operative time was . ± . min. a total of ( . %) conversions occurred, due to splenic artery lesion, one for difficult adesyolisis and three due to locally advanced tumour. recurrence was observed in ( . %) patients. there was a significant association between disease stage and recurrence (p \ . ) with a higher proportion of stage iv patients in the recurrence group ( . % vs . %). at days follow-up no mortalitywere recorded.during a median follow-up of months (range - ), deaths occurred (all of them for disease progression). keplan mayer curves showed a compareble suvival with other colo-rectal cancer. in conclusion, laparoscopic segmental resection with cme and cvl seems to be an oncologically safe and effective procedure for treatment of sfc. it may be regarded as the standard surgical method for elective management of this disease. in the future, more tailored patient-and tumor-specific segmental resection might be achieved with the use of routine lymph node road mapping. it is very important to establish a minimum number of lymph nodes to analyse for a correct staging. it has been established as . the treatment of colorectal cancer is essentially surgical. the review of the medical literature indicates that laparoscopic colorectal surgery is a safe procedure that has not found significant differences in the survival rate from open surgery. aim: the aim of our study is to compare the outcomes of laparoscopic and open resection for colorectal cancer surgery evaluating lymph node assessment. methods: the patients were collected in our hospital during the period from / / to / / and the number of lymph nodes obtained in lymphadenectomy has been studied comparing the laparoscopic and laparotomy approaches. results: interventions were performed. were laparotomic, were laparoscopic and converted laparoscopic (fig ) . the average number of nodes found in these interventions was , . nowadays, the recommendations to obtain a proper lymphadenectomy is to find more than lymph nodes. analysing our procedures, surgeries had obtained a good lymphadenectomy. according to the approach, , % of the interventions ( ) are laparotomy, , % ( ) are laparoscopic procedures and , % ( ) are by reconverted laparotomy (figure ). the average number of lymph nodes isolated was similar. laparotomy approach found , nodes while , nodes were found in laparoscopy. converted laparoscopy found , ( figure ). conclusion: the treatment of colorectal cancer is essentially surgical. today, there are a lot of studies that support that laparoscopic surgery has a survival rate similar to laparotomy surgery. according to our study, the data collected indicates that the number of isolated lymph nodes in both approaches is very similar. to sump up, laparoscopic colorectal surgery is safe and has demonstrated oncological adequacy comparable to open approach and better short-term outcomes due to a less invasive approach. background: laparoscopic low anterior resection highlights the advantages of laparoscopic surgery (better surgical field, less bloodloss, less postoperativepain, better cosmeticresult). defunctioning ileostomy prevents anastomotic leakage in low rectal cancers, butincreases morbidity, degrades thequality of life and requires a second surgery for its closure. method: in the last months we performed laparoscopic low anterior resections for rectal cancer, whithout performing any protectiveileostomy, afterchecking the anastomosis intraoperatively( men, women. average age: years). the typical placement of trocars included one supraumbilical mm trocar, two right sided mm trocars in the midclavicular line, one mm in the left midclavicular line and one mm trocar in the suprapubic midline which is also used for specimen removal, after a cm transverse extension of the incision. we present themain stages of the procedure (dissection andmesorectal excision, division of the rectum with linear stapler using the 'chinese hat-parnex' technique, creation of an end-to-end intracorporeal anastomosisusing circular stapler under direct laparoscopic vision). results: no major postoperative complication was observed. the mean operative time was min ( - ) and free surgical margins were achieved. in one case a conversion to open surgery occured. the average length of hospital stay was days ( - ). conclusions: the laparoscopic approach facilitates access to the middle and lower rectum, total mesorectal excision and avoidance of ileostomy if possible. it is a demanding operation with extended learning curve, and requires adequate experience in laparoscopic surgery and colorectal surgical oncology. background: in colorectal cancer, local excision is an attractive treatment option, but additional resection is considered when lymph node metastasis(lnm) is expected at high rate. in lower rectal cancer, advanced surgery techniques are required, so it is often difficult to make judgments. the aim of the current study is to assess the reliability of laparoscopic surgery for submucosally invasive rectal adenocarcinoma (pt ) analyzing short-term outcomes and long-term survival. method: this cohort study analyzed patients who underwent laparoscopic rectal resection for submucosally invasive rectal adenocarcinoma (pt ). conversion rate and functional and oncologic outcomes were analyzed. data on long-term results and survival were evaluated. result: surgical procedure was low anterior resection / intersphincteric resection / abdominoperineal resection: / / , and conversion to open surgery was needed for ( . %) patients. sphincter-preserving procedures were performed in ( . %) patients. there were no perioperative mortalities and positive resection margin. the mean length of hospital stay was . days. complications beyond clavien-dindo grade iii occurred in ( . %) patients,the anastomotic leakage rate was . % ( / ). the positive lymph node metastasis rate was . % ( / ). high tumor budding (p = . ), lymphatic invasion (p \ . ), and mucinous /poor histological differentiation (p = . ) were significantly associated with lymph node metastasis on univariate analysis. on multivariate analysis, only lymphatic invasion was associated with lymph node metastasis (p \ . ).the median follow-up time was months (range, - months), recurrence free survival rates was . % ( / ). conculusion: the outcomes of this study suggest that laparoscopic surgery can be used for safe and radical resection of submucosally invasive rectal adenocarcinoma (pt )?and the absence of lymphatic invasion, budding, and mucinous /poor histological differentiation are each associated with low risk of lnm. risk stratification models integrating these factors need to be investigated further. conclusions: this study highlights the complex nature of sarcopenia, as well as its common incidence. minimally invasive surgery had a higher incidence of sarcopenia than that of open surgery when both were performed within an enhanced recovery setting. despite colorectal patients being a typically well-nourished cohort at low risk of complications, there may well be benefit from interventional strategies such as perioperative immunonutrition or pre-habilitation to reduce the incidence of this poor prognostic indicator. backgrounds: urinary dysfunction is frequently observed after rectal resection and justifies urinary drainage. the concept of enhanced recovery after surgery (eras) has been widely spread from the early s. however, the optimal duration of postoperative urinary drainage is unknown. aims: the aim of this study was to comprehend short-term outcome of early removal of urinary catheter after robotic rectal surgery (rrs). patients and methods: (patients) the data of consecutive patients who underwent rrs at two hospitals between april and november were retrospectively reviewed. the main indication of rrs was the patients who need rectal mobilization with autonomic nerve preservation regardless of benign or malignant disease. perioperative management: none of the patients received epidural anesthesia for postoperative analgesia. our basic principle was to remove urinary catheter on postoperative day (pod) . after removal of urinary catheter, trans-urethral catheterization (tuc) was performed in the following situations: ) no autonomous urination over h after removal ) the decrease in urine volume (\ ml/ hr) ) the appearance of subjective symptoms like abdominal distension. when tuc was required even once, residual urine volume was measured with ultrasonic examination device since then. results: twenty seven male and female were included. the median age of patients and bmi were years old and . kg/m , respectively. the surgical procedures included anterior resection (n = ), intersphincteric resection (n = ), abdominoperineal resection (n = ), hartmann's procedure (n = ), and total coloproctectomy (n = ). only one patient received lateral pelvic lymph node dissection. urinary catheter was removed on pod in cases ( . %), on pod in cases ( . %). although tuc was needed in three cases ( . %) immediately after removal, tuc was no longer needed within three days in all three patients. late dysuria was observed in two cases ( . %), and bladder overdistension was suspected in these two cases. conclusions: our study showed that urinary catheter could be safely removed on pod after rrs. however, careful follow-up observation to avoid bladder overdistension is essential after removal. introduction: intersphincterian low rectal resection is a valid alternative to lower rectal cancers located at about - cm from the anus. methods: we present cases from our personal experience for tumors localized - cm from the anus. of them required preoperative radiochemotherapy. in cases, abdominal surgery was performed laparoscopic, having the surgical specimen extracted transanal. lone star device was used for the perineal procedure in all cases. cases required a manually, separate wires anastomosis; the others cases benefited from mechanical anastomosis performed endoanal with - mm circular stapler. we performed complete mesorectum excision in all cases, ligation at the origin of inferior mesenteric artery, complete mobilization of left splenic flexure and lateral protective ileostomy. all pacients underwent inspection rectoscopy before transit reintegration, and cases were reintegrated over a period of - weeks, except for cases which developed a colo-anal fistula, that closed under conservative treatment over a period of - months. results: there were no postoperative anal incontinence. in one case, a relative anal stenosis occured, which required endoscopic dilation. there was case of tumor recurrence and required abdominoperineal resection. conclusion: literature data sustain a - / ratio for very low rectal resection versus rectum amputation. the limit resection under the tumor is accepted as . cm. very good functional results by considering oncological principles, is a sustainable argument for choosing this kind of procedure as an alternative of rectum amputation. in the few studies conducted on crcs, the reported rate of sln micro-metastases is up to - %. the aim of this ongoing prospective study is to assess the predictability of the ex-vivo nirf sln mapping and of the research of micrometastases in nnd crc patients to propose adjuvant chemotherapy. materials and methods: fifty-eight patients undergoing standard oncological crc laparoscopic resection have been prospectively enrolled in two centre. as previously described by the authors, the intact surgical specimen was extracted and opened longitudinally and ml of indocyanine green (icg; mg/ml) was injected submucosally at four corners around the tumor in order to identify the lymphatic pathway and the slns. each sln presenting as negative at conventional histological analysis, was further investigated with ultrastaging techniques including serial sectioning and additional immunohistochemistry, in order to detect the presence of micrometastases. results: thirty patients were n ? , and were nnd. overall, a total of lymph nodes were retrieved. a total of sln were identified (mean . per case) and of those were nnd. after ultrastaging investigations, micrometastatic cases were found in nnd patients. the patients were so upstaged to n . sln located deeper in the mesenteric and mesorectal fat could easily be identified by nirf (even after nchrt). conclusions: in our preliminary series, the ex-vivo nirf sln mapping rightly predicts the status of loco-regional nodes, as confirmed by the histological investigations. the micrometastases' identification let selected patients to undergo the adjuvant treatment with the aim to reduce the risk of recurrence. ( / ) in lateral node positive group and . % ( / ) in lateral node negative group. four of local recurrence were lateral lymph node recurrence. two patients recurred the other lateral side of previous lpl, then they were laparoscopically resected and no recurrence ( , months). two patients recurred the same side after lpl were not curable because of liver metastasis and extensive invasion to the common iliac vessels. conclusion: selective lpl for rectal cancer was safe and good local control for lateral lymph node positive patients. also curable local recurrence resection was possible for non-treated lateral lymph node recurrence. intestinal malrotation is an embriologic anomaly generally discovered in the first months of life due to bowel obstruction. adult presentation is rare and its association with colon cancer is far more rare. we report a case of a years old man affected by asymptomatic intestinal malrotation incidentally found during an abdominal computed tomography (ct) performed for retroperitoneal colonic perforation in a patient with an endoscopically diagnosed aenocarcinoma of the caecum and a large polyp of the descending colon. preoperative vascular anatomic study allowed us to plan a laparoscopic approach safely also with adequate lymphoadenectomy. the abdominal cavity was entered throught a right flank mm optical trocar on the transverse umbilical line. three additional mm trocars were placed in right iliac fossa, right and left hypocondrium respectively. exploratory laparoscopy confirmed midgut malrotation and a fresh flogistic area at the descending colon perforation site. caecum and ascending colon were on midline and attached due to adhesions to sacral promontory. ileocolic artery (ica), middle colic artery (mca) and ima were selectively ligated but not at their origins due to aberrant anatomy. laparoscopic subtotal colectomy with intracorporeal stapled ileosigmoid anastomosis were carried out (endogia mm, double layer / polyglicolic acid suturing of the breech). the anisoperistaltic nature of the anastomosis is due to the disposition of the mesenterium which did not allow an isoperistalting orientation of the two resected stumps. the specimen was extracted throught a pfannestiel incision. the postoperative course was complicated by intestinal obstruction conservatively treated with slow bowel function's restoration. the patient was discharged from the hospital in th postoperative day. unexpectedly specimen histology revealed two villous adenomas with high grade dysplasia. lymphnodes were retrieved from the specimen (ptisn ). to date our case is the only fully laparoscopic colonic resection reported in literature in malrotation as well as the first intracorporeal stapled ileo-sigmoid anastomosis for such disease. the median hospital stay was days. in-hospital mortality was nil. the overall morbidity was %. the median length of follow-up was months. conclusions: our preliminary results suggest that robotic-assisted surgery for colorectal cancer can be carried out safely and according to oncological principles. robotic surgery is advantageous for both surgeons (in that it facilitates dissection in a narrow pelvis) and patients (in that it affords a very good quality of life via the preservation of sexual and urinary function in the vast majority of patients and it has low morbidity and good midterm oncological outcomes). in rectal cancer surgery, the robotic approach is a promising alternative and is expected to overcome the low penetration rate of laparoscopy in this field. aims: postoperative inflammation have been reported as one of the independent prognostic factors in several types of malignancies.the aim of this study is to clarify the impact of laparoscopic approach on postoperative inflammatory status after surgery for colorectal cancer, and to analyze the association between postoperative inflammation and prognosis in patients with colorectal cancer. methods: a total of patients with stage l-lll colorectal cancer (crc) who underwent curative surgery were retrospectively analyzed. the maximum crp value measured between the times of surgical resection and discharge was defined as 'max crp'. the optimal cut-off value of max crp that best predicts rfs was determined to be mg/dl by the minimum p-value approach. methods: trainees working in this firm were responsible for data collection. patients who underwent emergency surgery during the calendar year of had the following details collected-the presence or absence of a complication in the -day post-operative period, the type of complication and description of complication along with the grade of the complication (see fig. .) . patients who underwent intermediate to major surgery were followed up at outpatients and were specifically asked for the occurrence of complications from the point of discharge up until the outpatient appointment. with one centralised national hospital-the people who were discharged and subsequently experienced considerable or major complications invariably represented back to hospital via the a&e department. results: a total of emergency surgeries were performed by this surgical firm in , % of these being done laparoscopically. of these cases- patients experienced post-operative complications within the first days after their procedure. this equated to a complication rate of . %. the most common complications were abdominal pain, nausea & vomiting, and wound infection. there were complications for each of these categories. post-operative bleeding occurred in cases with fistulas or leak of an anastomosis occurring in cases. death of a patient occurred in instances once as a result of post-operative bleeding from the site of anastomosis after a whipple's procedure, the nd occurred subsequent to post-operative bleeding from a peptic ulcer and in the rd case occurred in an instance of faecal peritonitis as a result of anastomotic failure after a roux-en-y bypass for a patient with pancreatic malignancy. conclusion: the davien-clindo classification proved to be simple, efficient and useful in analysing post-operative outcomes. the results indicate that despite the emergency setting & elderly cohort of patients-minimally invasive surgery proved to be a safe and viable option. conclusions: in this prospective study, we observed greater rates of detection of adenomas among endoscopists. screening colonoscopy on symptomatic and/or high risk group for crc is valuable in early detection and the prevention of crc. large sample size and long period of screening colonoscopy was needed. limitation of our study was the small sample size and no use of high detention endoscopy. results: the mean intraoperative blood loss volume was significantly less in the lap group than in the open group ( vs. ml, respectively, p \ . ). the mean operative time was not significantly different between the lap group and the open group ( vs min, respectively, p = . ). the incidence of severe postoperative complication (grade or higher in the clavien-dindo classification) was lower in the lap group ( / ( %) vs / ( %), respectively). the mean postoperative hospital stay was significantly shorter in the lap group than that in the open group ( vs. days, respectively, p = . ). conclusions: lap-tpe can be a safe and feasible procedure. background: amyloid light chain (al) amyloidosis is a rare protein deposition disorder with an incidence ranging between - cases per million people. it can present insidiously with localized or multisystem symptoms and usually occurs later in life. prognosis is poor as al typically presents at an advanced stage. intestinal pseudo-obstruction is a rarely reported complication of al amyloidosis. here we report a case of al amyloidosis which was identified during surgery for intestinal pseudo-obstruction. case presentation: a year old male presented to the emergency department with a month history of abdominal pain and distension, as well as marked swelling of his lower limbs. this had worsened in the previous weeks and he had developed intermittent diarrhoea. ct showed ileitis with marked dilation of the proximal small bowel. laparatomy revealed small bowel that was grossly distended that rapidly developed multiple petechiae and subsequent haematomas upon handling. two days later a repeat laparotomy was performed and . m of ishaemic small bowel was resected. histology showed amyloid deposition with positive congo red staining. subsequent cardiac events led to an echo being performed that showed concentric left ventricular hypertrophy attributed to amyloid deposition within the myocardium. free serum light chain ratio was sent and confirmed the diagnosis of al amyloidosis. he has recently been started on a treatment regimen consisting of cyclophosphamide and dexamethasone. discussion: systemic al amyloidosis frequently involves the gastrointestinal tract, typically presenting with chronic diarrhoea and associated malabsorption. only case presenting with pseudo-obstruction has been reported in the literature. al amyloidosis presents insidiously with non-specific symptoms depending on which organs are affected. treatment aims to prevent further deposition of protein within the organs. prognosis is determined by the organs that are affected and the extent of protein deposition within them. cardiac involvement holds the worst prognosis ultimately causing sudden cardiac death. the mainstays of management are early identification and treatment implementation to prevent protein build up and subsequent organ failure. conclusion: a diagnosis of amyloidosis should be considered in patients with intestinal pseudo-obstruction to expedite the diagnosis of al amyloidosis and improve survival. aim: in the management of locally advanced rectal cancer (larc), the achievement of a complete total mesorectal excision (tme) with clear resection margins was demonstrated to be the main predictor of overall and disease-free survival. predicting surgical difficulty in larc patients may be of particular importance to choose the best surgical approach. this study proposes a mri-based score to identify preoperatively larc patients with a high risk of having a difficult surgery. methods: this is a retrospective study based on the european mri and rectal cancer surgery (eumarcs) database, including patients with mid-low larc who were treated with neoadjuvant chemoradiation therapy and laparoscopic tme with primary anastomosis. data on pre-treatment and restaging through magnetic resonance imaging were available for all patients. surgical difficulty was defined as high or low grade taking in to account operative (e.g. duration of surgery), and postoperative factors (e.g. hospital stay). score accuracy was evaluated by estimating sensitivity, specificity and area under the receiver operating characteristics curve (aroc). results: seventeen ( . %) of larc patients were graded as high surgical difficulty. the eumarcs score was developed using the following significant predictors of surgical difficulty: bmi [ , interspinous distance \ . mm, ymrtstage = t b, and male sex. the score ranged from to . the cut-off score to best differentiate patients with a high probability of difficult surgery was = points. this cut-off value showed the best balance in sensitivity and specificity. the eumarcs score demonstrated high accuracy (aroc: . ) conclusions: the eumarcs score was found to be sensitive and specific in predicting surgical difficulty in larc patients who were candidate for laparoscopic tme. the score has the advantage of considering patient and cancer related characteristics that can be all assessed preoperatively and it can be useful in the decision making process. this score has not yet been externally validated. background: recently published two non-inferiority randomised control trials has raised questions on laparoscopic surgery for rectal cancer, showing lower quality pathological specimens to those achieved using an open technique. locally advanced rectal cancers add to the level of difficulty for laparoscopy approach. our study was aimed to assess feasibility of laparoscopic rectal surgery, comparing short term outcomes, quality of surgical specimen, morbidity and mortality, between propensity score match groups of locally advanced and early rectal cancers. methods: prospectively acquired data from consecutive patients undergoing laparoscopic surgery for rectal cancer at the minimally invasive colorectal unit in united kingdom between and . locally advanced rectal tumours were identified as t b or t with pre-operative mri scans. all the patients were operated by the same team and the procedures were performed laparoscopically. : propensity score matching was performed to create a perfect match in terms of tumour height. results: total of laparoscopic rectal resections were performed during the study period, out of which patients had locally advanced (la) disease and were propensity-score matched for tumour height with non-locally advanced (nla) patients. median operative time was higher for the la surgery group ( min vs min p = . ). however, conversion to open surgery (p = . ), readmission (p = . ), re-operation (p = . ), clinical anastomotic leak (p = . ) and -day mortality rates (p = . ) were all equivalent between the two groups. r resection was achieved in % of la group as compare to % of nla group (p = . ). conclusion: this study demonstrate that standardised approach to laparoscopy is safe and feasible in locally advanced rectal cancers. comparable post-operative short-term clinical and pathological outcomes were seen between la and nla groups. aims: the application of colorectal cancer screening programs, has showed a decrease in recurrence and mortality. for this reason, these programs are being implemented at a national level in the different spanish regions, as has happened in our community.to present the initial short-term results on the morbidity of the immediate postoperative period to days of colon cancer, mortality and hospital stay after the implementation of a screening program in our center. methods: a retrospective study was performed. patients aged between and years were included in the study, diagnosed with colon cancer. they underwent minimally invasive surgery, in most cases, with any type of colonic resection, from january to december . all patients were diagnosed, conventionally or through a screening program, the latter according to the plan implemented in our community. the sample was divided into two groups of patients according to the way of being diagnosed (group si screening = patients, group no screening = patients) and they were compared according different variables: dependent factors of the patient, factor of type colon cancer, factors of colon cancer resection and follow-up. results: both groups were comparable in all study variables. regarding the variables included in the follow-up, no statistically significant differences were found in terms of postoperative mortality-clavien-dindo v. however we found differences statistically significant in postoperative morbidity (p = . ) and in its classification according to clavien dindo i-iv (p = . ). the complications analyzed independently, such as anastomotic dehiscence (p = . ) or postoperative ileus (p = . ), have also presented significant differences, unlike surgical wound infection (p = . ). conclusion: at our center, the application of the screening program has not influenced in the initial stage of colon cancer or its surgical approach. however, we have found a lower overall morbidity rate and minor complications, justified by a lower incidence of anastomotic dehiscence and postoperative ileus. background: colorectal carcinoma is one of the most common malignancies. surgery is the only definitive method to achieve cure for this illness and can be performed via an open or a laparoscopic approach. the pros and cons of each approach have been discussed extensively, with the oncologic efficiency of the laparoscopic approach being one of the leading topics. objective: the aim of this study was to establish oncological non-inferiority of the laparoscopic approach to colorectal cancer. primary outcome measure was defined as number of harvested lymph nodes. secondary outcome measures were medium-term disease free and overall survival as well as length of hospital stay, time to oral feeding and short-and long-term complication rate. methods: this was a single center retrospective chart review. all consecutive patients who underwent colon or rectal resection due to colorectal carcinoma at hadassah medical center between the years - were included. patients who were operated on for recurrent disease or who had metastatic disease at the time of surgery were excluded. patients were divided into three groups according to the surgical approach: laparoscopic, open or converted. medium-term oncological outcomes were the same for all groups. time to oral feeding, length of hospital stay, short-and long-term complication rate were all significantly improved in the laparoscopic group. conclusions: we were unable to prove non-inferiority of the laparoscopic approach regarding the number of harvested lymph nodes. however, all surgical approaches yielded a high number of harvested lymph nodes which is most probably oncologically sufficient, as reflected by the non-existent difference in medium-term oncological follow up. this study supports previous studies showing the superiority of the laparoscopic approach regarding short term recovery and overall complications rates. aims: two non-inferiority randomised control trials have questioned the utility of laparoscopic surgery for rectal cancer by failing to prove that pathological markers of high quality surgery are equivalent to those achieved by open technique. we intend to present short and long-term postoperative outcomes from the largest single surgeon series of consecutive patients undergoing laparoscopic tme for rectal cancer. we describe the standardised laparoscopic technique developed by the principal surgeon, and the short-term outcomes from three surgeons who were trained in and subsequently adopted the same approach. methods: prospectively acquired data from consecutive patients undergoing surgery for rectal cancer by the principal surgeon (ap) at the minimally invasive colorectal unit in portsmouth between and were analysed along with data acquired between and from surgeons (tq,nf,ah) at three further international centres. end-points were overall and diseasefree survival at years, and early post-operative clinical and pathological outcomes. results: consecutive patients underwent laparoscopic tme surgery by the principal surgeon (ap). at years overall survival was . % (dukes' a = . %; b = . %; c = . %); disease-free survival was . % (dukes' a = . %; b = . %; c = . %). post-operative length of stay, lymph node harvest, mean operating time, rate of conversion, incomplete resection, major morbidity and day mortality were not significantly different between the principal surgeon and those he had trained when subsequently in independent practices. conclusion: laparoscopic tme produces excellent long-term survival outcomes for patients with rectal cancer. a standardised approach has the potential to improve outcomes by setting bench-marks for surgical quality, and providing a step-by-step method for surgical training. results: analysis of association of tumor location (sigmoid, right or left colon), operation time, blood loss, extraction site, type of surgical sutures used for wound closure with postoperative complications or specimen quality either did not show significant correlation or could not be conducted due to data nature. unexpectedly, a significant difference was demonstrated between two surgical teams in terms of hernias. majority of cases- ( . %) were performed by surgeon (s ), surgeon (s ) operated on ( . %) patients, nevertheless minilaparotomy closure was usually performed by junior members of the team. conversion rate was . % for s and . % for s (p = . ). operation time and blood loss were smaller in s group compared to s ( . ± . min vs . ± . min, p = . and . ± . ml vs . ± . ml, p = . respectively). specimen quality and early postoperative complications did not differ. postoperative hernia rate was . % for s and . % for s (p = , ). both surgeons used the same specimen extraction sites and materials for wound closure. hernias were more frequent after vertical minilaparotomy- % ( of patients), and in converted patients , % ( of patients), compared to , % ( of ) in transverse minilaparotomy group. there was no association of hernias and wound infections. conclusions: our study demonstrates, that besides consultant dependent surgical surrogates, steps which are often performed by other members of surgical team (such as wound closure) may contribute to complication rate as well. more thorough supervision of wound closure may be needed. aims: laparoscopic complete mesocolic excision (cme) right hemicolectomy is considered a demanding procedure and it is actually adopted in few centers from the west. the aim of the present study is to analyze the safety of laparoscopic cme right hemicolectomy and to compare its short-term results with standard right hemicolectomy in a single western center. methods: prospectively collected data from patients who underwent laparoscopic cme right hemicolectomy between june and november were retrospectively analyzed (cme group) and compared with data from patients submitted to standard laparoscopic right hemicolectomy between april and november (s group). results: no differences were observed between the cme and the standard right hemicolectomy groups in terms of clinical characteristics. in the cme group, . % of patients were = years old, . % of patients were asa class , . % of patients had = comorbidities, . % of patients had bmi [ and . % of patients had = previous abdominal surgeries. no differences were observed in terms of duration of surgery ( ± min vs. ± min; p = . ) and intraoperative complications ( . % vs. . %; p = . ) between cme and s groups; mean blood loss was lower in the cme group ( . ± . ml vs . ± . ml, p = . ). the percentage of overall ( . % vs. . %; p = . ) and severe (clavien-dindo = ) complications ( . % vs. . %; p = . ), redo surgery ( . % vs. . %; p = . ) and readmission ( . % vs. . %; p = . ) was comparable between cme group and s group. a significant difference was observed in the length of specimen ( ± mm vs. ± mm; p \ . ) as well as in the length of proximal ( ± mm vs. ± mm; p = . ) and distal margins ( ± mm vs. ± mm; p = . ) in favor of the cme group. the number of lymph nodes harvested was slightly higher in the cme group ( . ± . vs. . ± . ; p = . ) as it was for the percentage of cases with less than retrieved lymph nodes ( . % vs. . %; p = . ), although these differences did not reach statistical significance. conclusions: this study represents one of the few western experiences demonstrating the safety of laparoscopic cme right hemicolectomy. cme technique showed good short-term results and better quality specimens when compared with the standard procedure. aim and background: peritoneal dissemination of colorectal cancer (pc) makes the complete resection of cancer lesions impossible. in such cases, multidisciplinary therapy is essential with mainly chemotherapy. preoperative diagnosis of pc is usually uncertain by ct or mri image. for diagnosis of pc needs surgical materials with laparotomy. but the laparotomy and resection of pc with general anesthesia tends to make impossible for immediate chemotherapy. less invasive diagnosis of pc is necessary and expected.endocytoscopy (ec) makes the histological diagnosis with precise images gained by high magnification (x ). as a preliminary examination, ec diagnosis for resected specimens of pc were evaluated. methods: two cases of pc diagnosed in operation were evaluated. under general anesthesia, laparotomy was conducted. peritoneal dissemination lesions obviously diagnosed as pc were resected. immediately the lesions were stained by methylene blue solution for to s. ec observation was done according ec classification ) and ecv classification ). results: in two cases, ec observation was successfully done. images of dilated surface microvessels of a nonhomogeneous caliber or arrangement were observed in nbi ec corresponding to ec-v . histopathological diagnosis of resected specimens was metastatic colorectal carcinoma in peritoneum in both cases. conclusions: histological diagnosis for pc is gained by ec with resected specimen. as the result of this investigation, ec examination via camera port in laparoscopic operation might be possible for diagnosis for pc of colorectal cancer in vivo. aims: the aim of this presentation is to demonstrate and analyze surgical complications, arising during laparoscopic colorectal resections for cancer and to analyze the reasons of adverse events. methods: we demonstrate videos from our surgeries, where different types of complications occurred and share our classification of types of mistakes, that may lead to intraoperative complications and ways to prevent them. results: we divide mistakes in laparoscopic colorectal resections into two large groups-'false strategy' and 'dangerous techniques'. the first includes poor diagnosis, too extensive or insufficient extent of surgery and improper enthusiasm in using platforms. prevention of first type mistakes is in thorough training and peer-review of each consultant practice. second type of mistakes includes two subtypes : 'faulty habits'-use of unsafe techniques (blind port insertion, poor vascular exposure prior to clipping, not obtaining 'critical views', unsafe use of energy and stapling devices etc.) and 'failure in a certain case'-when despite correct general approach a complication occurred (misinterpretation of fascial layers or vessels). prevention of 'faulty habits' lies in supervised training in high volume colorectal departments including dedicated surgical devices training. to avoid 'failure in a certain case' standardization of surgical procedure is essential, as the most efficient way to prevent this type of mistake is 'pattern recognition'ability of a surgeon to compare the picture he sees during a procedure with a 'standard' view, he used to have during previously performed standard surgeries-this is apparentely impossible when every procedure is done differently. regular reviews of own surgeries recording and other surgeons' procedures may also fascilitate pattern formation. in case a complication occurres we use the four step course of action: preservation of the view, temporary control, decision on conversion, permanent control. conclusion: as popularity of laparoscopic colorectal resections is growing rapidly the number of intraoperative compliactions is increasing as well. we demonstrate videos of complications and our approach to classification of possible mistakes. systematic aproach to reasons, underlying certain mistakes helps to produce a strategy to reduce intraoperative complication rate. introduction: the drains placement inside the abdominal cavity has traditionally been carried out to evacuate hematic remains or postoperative collections. there is no scientific evidence of the prophylactic use of drainage in elective colorectal cancer (ccr) surgery to avoid anastomotic complications or other complications. however, it is traditionally used. when the anastomotic leak is produced, it is generally agreed that drainage system should be used for therapeutic purposes. aims: the aim of this study is to evaluate the effectiveness of the use of prophylactic drainage in elective surgery of ccr. we would check if they avoided the appearance of complications, and if they are useful when the anastomotic leak appears. methods and results: we analyzed the data collected in our hospital from / / to / / . we studied the number and type of interventions in which prophylactic drainages were placed, the appearance of anastomotic complications and if these drains were effective. interventions were performed during this period of time. % of these procedures had used prophylactic drainage ( interventions). this percentage was up to % in patients who have performed a left colon surgery as a sigmoidectomy or rectal procedure. during this period, there were cases of anastomotic leakage. in all of them had been placed drainage but only of them were effective. conclusions: we have seen that prophylactic drainage is a common practice independently of the location of the anastomosis. the last multimodal rehabilitation guidelines recommended the nonuse of drains systematically above the peritoneal reflection with a high level of scientific evidence. they cause discomfort to the patient and delay early mobilization. however, it may be useful to use drains in the first h of a pelvic floor procedure. there is not enough evidence to show sistematic drainage after colorectal anastomosis prevents complications of the anastomosis or other complications. aims: colonic cancers of the splenic flexure is uncommon and associated with poor prognosis. several studies were published aimed to identify the optimal surgical option for the best oncological outcomes. however, whether an extended colectomy or a segmental resection is required is still controversial. the aim of this study is to analyse the outcome of the two different approaches through the experience of a single centre. materials and methods: retrospective data of consecutive patients with diagnosis of colonic cancer situated at the splenic flexure of our department between and were analysed. based on type of surgical procedure, patients were enrolled in arm a (segmental resection) and arm b (extended resection). arm a patients were treated with segmental resections with a wide mobilisation of the transverse and descending colon and ligation of the left colic artery, sparing the middle colic artery and the inferior mesenteric artery. functional lateral to lateral anastomosis was performed extracorporeally. arm b patients were treated with more extended colectomies, both associated with central vascular ligation. results: out of patients included, were allocated in arm a and in arm b. patients' population of the arms was homogeneous as concerns demographic characteristics and stage of the disease. operative time was comparable ( , min vs min, p = , ). the length of the specimen was significantly shorter in arms a ( , vs , , p = , ) . the number of harvested lymphnodes did not differ between the two groups ( , vs p = , )postoperative short term complications was comparable in both arms ( vs , p = , ). no postoperative mortality was observed. overall -year survival and disease free survival rates were similar in arm a and b ( . % vs . %, p = , and , % vs , %, p = , ). hospital stay was similar in the two groups (p = , ). conclusions: despite a shorter length of surgical specimen after limited resections, postoperative complications, lymph node harvest, and survival were comparable in both.in our opinion the extracorporeal anastomosis is functional to both the achievement of a cleaner operative field and a better control of the resection margins. incidence of neuroendocrine tumours in the rectal area has increased in recent years.before the onset of minimally invasive colorectal surgery, these lesion had to be treated by a more radical technique when not suitable for endoscopic resection.selection of the cases is mandatory in order to achieve good results not only surgical, but also oncological. we present our series of neuroendocrine tumoirs treated by tamis approach, including technical aspects, deffect closure techniques and data regarding pathological findings.all cases were low grade carcinoid tumours. resection with free margin was obtained in all cases. defect closure was performed in all cases. the tumours were settled , and cm form the anal verge. postoperative course was uneventful, ann no adyuvant therapy was needed.tamis apporach for rectal neuroendocrine tumours is a safe and feasible technique. proper selection of the cases is mandatory in order to achieve good results. surg endosc ( ) aim: to assess the safety and efficacy of single layer of barbed vs double layer 'hybrid' (interrupted and running) suture for the closure of anastomotic stapler access enterotomy after laparoscopic right colectomy with intracorporeal anastomosis. methods: from april to november , laparoscopic right colectomy with intracorporeal anastomosis were performed in our surgical department. all patients in both groups were perioperatively managed using an eras pathway. seventy-two patients had the enterotomy closed with a single layer running suture of filbloc tm (assut europe). these patients were matched with patients who underwent intracorporeal right colectomy with enterotomy closed with a 'hybrid' double layer technique (first layer interrupted stitches in maxon tm - (covidien), second layer using a running suture in pds tm - (ethicon). intraoperative variables, anastomotic leak rate, morbidity and mortality rates were analyzed. results: the two groups were homogeneous with respect to demographics, body mass index (bmi), american surgical association score (asa) as well as for tumor stage. in the barbed group, median operating time was . min vs . min in the hybrid group (p = . ). anastomotic leak occurred in ( . %) patients in the hybrid vs ( . %) patients in the barbed group (p = . ). all patients required a reoperation. intraoperative findings show in ( . %) cases in the hybrid group a leak at the enterotomy closure, while an intact staler access was observed in both patients in the barbed group. no difference was observed with respect to noninfectious complications between the two groups (p = . ). patients in the hybrid group experienced a longer hospital stay when compared to the barbed group (p = . ). a re-admission occurred in the hybrid due an intraabdominal collection, while no re-admission was observed in the barbed group. no patient died in the postoperative period. aims: lymph node status is one of the key prognostic factors in patients with colorectal cancer, and remains the most important selection criteria for adjuvant chemotherapy. it is believed that at least % of node negative patients will suffer disease recurrence within the first years after surgery. this may be due to understaging lymph node status. sentinel lymph node mapping is widely used for staging of breast cancer and melanoma, with injection of colloid tc and isosulfan blue (ib). however, indocyanine green (icg) fluorescence guidance is a new technical approach to this issue, with promising results as it is not influenced by body mass index or lymphatic invasion. intraoperative fluorescence icg navigation also aims for detection of aberrant lymphatic drainage outside the planned resection. the icg lymphography has the advantage of offering a good visualization of the lymphatic channels but there are problems to identify the lymphatic nodes. our objective with this study is to rate the use of the intraoperative lymphogram in cases of elective colorectal surgery to evaluate if there were changes in the surgical attitude regarding the performance of lymphadenectomy. methods: indocyanine green was injected into the submucosal layer around the tumor at points with?a -gauge localized injection before lymph node dissection and the lymph flow was observed at , and min after injection, using a near-infrared camera system. in addition, a complete mesocolic excision with central vascular ligation guided the region where the lymph flow was observed to be fluorescent. the following table summarizes the procedures carried out as well as the lymphadenectomy performed before and after the use of icg. in brief, after the application of intraoperative icg it was observed that in % of patients additional lymph nodes were obtained after the expansion of the surgical plan, moreover % affected lymph nodes were spotted after the expansion of the surgical plan. conclusions: intraoperative real-time visualization of the lymph flow using indocyanine green fluorescence imaging during laparoscopic colon cancer surgery is feasible and a helpful technique for lymph node mapping which may lead to intraoperative changes in lymphadenectomy. tamis resection of rectal tumours has proven to be a sefe and feasible technique, specially for lesion located in the mid and low rectum.when the tumour is located in the upper rectum, and specially near the colorectal junction, tamis resection may be more difficult, not only due to technical aspects, but also due to the risk of a free perforation, specially when a full thickness resection is performed.we present our results of tamis resections of lesions located around the colorectal junction. four resections where performed with the aim of an endostpaler in order to achieve full resection without the risk of a free colonic perforation.in cases, an abdominal combined laparoscopic exploration was made, in order to help and assure proper resection of the lesion as well as avoiding intraoperative complications.distance from the anal verge ranged from to cm.postoperative course was uneventful in all cases, and a complete specimen resection was obtained in all cases.tamis resection of tumours located in the rectosigmoid junction may be a safe and feasible technique in selected patients. methods: between january to april , patients with diagnosis of right colon adenocarcinomas underwent right hemicolectomies. the data was analysed for patients demographic, histology, type of surgical approach, intraoperative details (length of surgical procedure, blood loss, blood transfusion, conversion rate) and short-term post-operative outcomes including complications. introduction: postoperative ischemic colitis is a life-threatening vascular gastrointestinal condition, that mainly occurs after cardiovascular surgery. we present a surprising case following a laparoscopic rectum resection. case report: a -year-old diabetic patient with upper rectal adenocarcinoma undergoing laparoscopic anterior rectal resection (partial mesorectum excision) and mechanical anastomosis following chemotherapy / radiotherapy. after h postsurgery he presented abdominal pain, distension and fever. on adominal computed tomography (ct) scan (contrast enema) no anastomotic leakage (al) finfings were revealed. neither digital palpation nor proctosigmoidoscopy ( th day) showed al signs. the patient clinical situation improve with conservative treatment (antibiotics, digestive rest …), c-reactive protein levels decreased and the blood cultures were negative. on the th day he was discharged presenting semiliquid stools. eight days later he needed hospital readmission: air and feculent/purulent discharge from the previos abdominal drainage orifice. ct scan: no evidence of dehiscense found although rectum and sigmoid colon distention and an image of a 'large fecaloma' were observable. on the th day of hospitalization he expulsed a large malodorous segment of tissue with necrotic asppearance (image) through the anus with surprising histologic features: 'complete-thickness necrotic colonic wall'. further rectosigmoidoscopy: complete anastomosis, signs of ischemic colitis proximate to the anastomosis and a fistulous orifice. surprisingly, the patient progressed favorably, being discharged the th day for ambulatory control with a low debit enterocutaneous fistula. histopathological diagnosis: ypt n m . follow up: the fistula discharge quantity increased maintaining diarrheal stools through anus along with persistent anemia and malnutrition. a exploratory laparotomy was schedule. fistulous tract towards a small stenotic segment of colon inmediately proximal to the colorectal anastomosis was identify and resected. finally a terminal colostomy was performed. subsequent postoperative without incidents. currently the patient is asymptomatic. comments: it seems indisputable that a colon segment, proximal to the anastomosis, was necrosed and expelled through a colorectal anastomosis. the mechanism seems inexplicable to us. it is even more disconcerting that there was no disruption of the anastomosis. objectives: fluorescence-guided surgery has emerged as a new imaging modality to improve the detection of liver and lymph node metastasis in colorectal cancer. in right-sided colon cancer, the standard lymphadenectomy should reach the ileocolic vessels and the right branch of the middle colic vessels. the purpose of this study is to perform an objective estimation of lymphatic drainage and metastatic lymphonodes in right-sided colon carcinoma through indocyanine green (icg) lymphography. methods: patients with right-sided colon adenocarcinoma were included, excluding those in stage iv, t and those who underwent urgent surgery. cc of icg peritumoral were injected using a peripheral intravenous catheter at the beginning of the intervention. the lymphatic drainage mapping of the tumor was identified. lymphadenectomy of the ileocolic vessels and right branch of the middle colic vessels was performed extending it to the left branch and origin of middle colic vessels if it was shown in the mapping. results: patients were included. the average age was . in patients the tumor was located in the ascending colon and in patients in the hepatic angle. in patients, the mapping showed lymphatic drainage to ileocolic vessels and right branch of the middle colic vessels. in patients ( %) it showed drainage to the left branch and origin of the middle colic artery, therefore extended lymphadenectomy was performed at that level. in patients, the postoperative period was uneventful. patient presented infection of the surgical wound and another patient developed a cm perianastomotic collection treated with percutaneous drainage. the anatomopathological report showed nodal metastasis in of the patients ( %) in whom lymphatic drainage was observed in the territory of the middle colic vessels with icg. these patients presented the tumor in the hepatic angle. therefore, of the patients with right-sided colon carcinoma ( %) presented nodal metastasis in the territory of the middle colic vessels. conclusions: fluorescent lymphography may improve the results of lymphadenectomy in colon cancer. in patients with tumors of the hepatic angle, lymphadenectomy extended to the left branch and origin of middle colic vessels, could be an adequate alternative. introduction: over the last decade, the common principles of surgical treatment in colon surgery are central vascular ligation (cvl) and complete mesocolic excision (cme). however, the superior mesenteric vessels anatomy, while performing the right colectomy is characterized by wide variability, which can lead to complications, especially during minimally invasive surgical intervention. objective. the purpose of this study is describing vascular variations around the superior mesenteric artery and vein-middle colic, right colic and ileocolic vessels, henle trunk in the laparoscopic right colectomy. materials and methods: the study was held in the 'dobrobut' clinic and o. o. bohomolets national medical university, department of general surgery (kyiv, ukraine) during the - period. patients were included to the study, females ( . %), males ( . %) in the average age of , ± , years. all the patients underwent the laparoscopic right colectomy (cme ? cvl) with d lymph node dissection. recorded video materials from each laparoscopic right colectomy were analyzed during the study. results: ileocolic vessels were the most stable. there were typical anatomical position in all cases. . % of cases, ileocolic vein was identified anteriorly to the ileocolic artery, while . % being posteriorly. right colic vein was absent in . % of cases. right colic vein drainage was to henle trunk and inferior mesenteric vein in . % and . % respectively. the right colic artery was present in % of patients, it's origin was superior mesenteric artery in . % and . % the middle colic artery. the middle colic vein was present and drained to superior mesenteric vein in % of cases. same as the middle colic artery with the superior mesenteric artery origin. henle trunk was present in . %, gastro-pancreato-colic trunk in . % of cases gastro-pancreatic trunk in . %, gastro-colic in . %. conclusions: knowing the options of surgical vessels anatomy, while performing the right colectomy, altogether with surgeons preparation, using the ct-scan data can reduce the risk of iatrogenic damage and complications risks. introduction: the enhanced recovery after surgery (eras) protocol was designed to accelerate convalescence, reduce morbidity and shorten the length of hospital stay (los). one of its major interventions is balanced perioperative fluid therapy. the impact of this single intervention on short-term outcomes is widely discuss. aim: the aim of this study was to assess the impact of perioperative fluid therapy on short-term outcomes. material and methods: the analysis included consecutive prospectively registered patients operated laparoscopically for colorectal cancer between november and january . patients were divided into two groups: balanced (= ml) or unbalanced ([ ml) perioperative fluid therapy. all patients were treated according to eras protocol. study outcomes were: recovery parameters, morbidity rate, los, -day readmission rate. results: group consisted of and group of patients. there were no statistically significant differences between the groups in terms of demographic and operative parameters. morbidity was lower in group ( . % vs . %, p = . ). patients in group were discharged home earlier than in group ( vs days, p \ . ). moreover, we observed differences in recovery parameters between the groups: tolerance of an oral diet on the st postoperative day ( % vs. %, p = . ) and patient mobilization on the day of surgery ( % vs. %, p = . ). -day readmission rate was lower in group ( . % vs. %, p = . ). conclusion: a balanced perioperative fluid therapy on the day of surgery may be associated with faster convalescence, lower morbidity rate, shorter los and lower -day readmission rate. methods: a retrospective analysis was performed including patients who underwent lcs or ocs for cancer treated as emergency in a single centre between and . patients who underwent palliative surgery were excluded. lcs were : propensity score-matched based on pposum and stage of disease with ocs. short-term outcomes included oncological quality, length of hospital stay (los) and postoperative mortality. for long-term outcomes, -year overall and disease free survival (os and dfs) rates were analyzed. results: during the study period, a total of emergency colorectal resections were performed. of them, % (n = ) were coloniccancers. lcs were matched to an equal number of ocs.median age was ( ) years and % were females. median follow-up was ( ) months. the majority of resections were right hemicolectomies ( %), followed by sigmoid resections ( %) and subtotal colectomies ( %). operative time ( ( ) background: total mesorectal excision (tme) offers the best reported rates for local recurrence and survival in patients with rectal cancer. our series from a single high-volume center, assessed the feasibility, safety and long-term oncologic adequacy of laparoscopic total mesorectal excision methods: we reviewed the prospective database of consecutive unselected patients undergoing laparoscopic tme for rectal cancer between and at the department of general surgery, onze-lieve-vrouwziekenhuis hospital (olv), campus aalst, belgium. the objective of the present study was to evaluate the effectiveness of laparoscopic tme, with an emphasis on perioperative variables and long-term oncological outcomes. results: pts with mid and distal rectal cancer up to cm from the anal verge had laparoscopic tme resection. patients ( . %) underwent a sphincter-preserving surgery and the remaining patients ( . %) had an abdominoperineal resection. end-to-end anastomoses: pts ( %), j-colonic pouch: pts ( % introduction: the rica clinical pathway (intensified recovery in abdominal surgery), also called surgical multimodal rehabilitation, is the application of a series of perioperative measures and strategies in those patients who are going to undergo a surgical procedure with the objective of reducing secondary stress to the surgical intervention. in this way, we achieve a better recovery of the patient and significantly reduce complications and morbidity. objective: s to analyze, through our database of patients undergoing crc, the percentage of postoperative ileuses and the following quality indicators: the postsurgical hospital stay, the anastomotic leak, and the infection of the surgical site. to check if the implantation of the rica pathway has meant an improvement in our postoperative hospital stay and with that, a lower sanitary cost. methods and results: we analyzed the data collected from those patients who underwent ccr in our hospital between / / and / / , during which time we implemented the rica clinical pathway. the average hospital stay was days. of the patients, . % presented anastomotic leak, . % infection of the surgical wound and . % paralytic ileus. we have verified how the average hospital stay increases with the appearance of anastomotic leak ( . days), infection of the surgical wound ( . days) and paralytic ileus ( . days). when we divided this -month period into two halves to see the impact of the implantation of the clinical pathway, we obtained the following results: the post-surgical hospital stay in the period from / / to / / was . . the stay from / / to / / was . . the implantation of the rica clinical pathway is providing us with important advantages in our clinical practice, with greater postoperative comfort and an improvement in our quality indicators, such as the decrease in the average hospital stay of our patients. on the other hand, after starting its implementation we have encountered the resistance to change clinical habits and the one that requires a multidisciplinary participation, so adherence to this is being progressive, and requires periodic audits to reinforce and consolidate our achievements, and identify our points of improvement. however, tem has not yet achieved widespread use. recently, transanal minimally invasive surgery (tamis) using single-port surgery devices has been reported. initially facilitated by existing single-port surgery devices, two platforms for transanal access, the gelpoint Ò path (applied medical, rancho santa margarita, ca, usa) and the sils tm port. the gelpoint Ò path is the only platform to be specifically designed for tamis y tatme. objetive: in the present study, usesa gelpoint Ò path was performed in patients with lower rectal neplasms. results: complete full-thickness excision was performed in all cases of tamis and free margins over rectal cancer. on two cases no neoplasm was visualizad. the patient characteristics, operative techniques and operative outcomes were evaluated. the mean age of the patients was . years (range - ). the mean operating time were min (range - ). patients was selsted for tatme, for tamis and two patients for evaluation and biopsy if was necesary. additional transabdominal rectal resection was not performed, and adjuvant chemoradiotherapy was performed in all cases. tamis using a gelpoint Ò path was revealed to be easy and safe to perform. although only a small number of cases were treated, and the operation was demonstrated to be sufficiently feasible. conclusion: gelpoint path is a good tool for colorectal surgery in tatme, tamis and evalluation of anastomoses or de novo lesions introduction: several improvements in rectal cancer treatment, in the last decades, resulted in a markedly increased survival. nevertheless, surgery remains the prevalent treatment and to % of operated patients experience some kind of functional abnormalities. as nowadays we acknowledge the importance to focus not only on survival rates but also on quality of life, we craved for a precise, reproducible, simple, clear and user-friendly tool for evaluating bowel function in rectal cancer patients after sphincter saving operation. therefore, we performed a thorough translation with cultural adaptation of the patient reported outcome tool, low anterior resection syndrome (lars) score, to the portuguese language (lars-pt) and population. methods: according to the current international recommendations, we designed this study encompassing three main phases: (i) cultural and linguistic validation to european portuguese; (ii) feasibility and reliability tests of the version obtained in the previous phase; and (iii) validity tests to produce a final version. the questionnaire was completed by patients from six portuguese colorectal cancer units, and completed it twice. results: the portuguese version of lars score showed high construct validity. regarding the test-retest, the global intraclass correlation showed very strong test-retest reliability. looking at all five items, only items and presented a moderate correlation. lars score was able to discriminate symptoms showing worse quality of life in patients submitted to preoperative radio and chemotherapy. conclusion: lars questionnaire has been properly translated into european portuguese, demonstrating high construct validity and reliability. this is a precise, reproducible, simple, clear and user-friendly tool for evaluating bowel function in rectal cancer patients after sphincter saving operation. therefore, his sistematic use should be implemented. oesophagectomy is the mainstay of curative treatment for oesophageal cancer and post-oesophagectomy diaphragmatic hernia (podh) represents a potentially life-threatening surgical complication characterized by an underestimated occurrence rate and unknown related risk factors. this study analyses the experience of two tertiary designated centers in order to evaluate key elements concerning development and treatment of podh. a cohort of consecutive patients affected by a clinically resectable oesophageal cancer (any t, any n and m ) underwent ivor-lewis oesophagectomy between march and april according to three different approaches: totally open incision procedure (oilo), hybrid (hilo) and totally mininvasive to esophagectomy (milo). all population was retrospectively observed in the context of a postoperative calendarised follow-up in order to record the incidence and postrepair results of podh. patients underwent ivor-lewis oesophagectomy for cancer and ( . %) developed podh within a median follow-up period of months ( - ). surgical repair was generally applied by the mean of laparoscopic cruroplasty ( %) with a conversion rate of %. postoperative morbidity did not include early recurrences but exclusively cardio-pulmonary complications ( patients) with one case of respiratory failure leading to death. the discharge was reached after a median hospital stay of days ( - ) while recurrences ( %) occurred over a median followup period of . months. a wide univariate analysis identified statistically significant associations between podh occurrence and the administration of preoperative chemoradiotherapy, the complete pathological response (cpr) and a lymph node harvest (lnh) larger than stations (p-value of . , . and . respectively). the strong influence of an extended lnh was confirmed by the multivariable analyses ( . ) along with cpr which should however be considered as longer survival-related bias. the minimally invasive surgery and the neoadjuvant chemoradiotherapy represent a considerable part of multimodal treatment for oesophageal cancer presenting a not statistically significant association with podh development while a lnh including more than nodes resulted to be an independent risk factor mirroring the extent of surgical demolition in oesophagectomy. l. barbulescu aim: to asses the safety and effectiveness of robotic total meso-rectal excision vs laparoscopic total meso-rectal excision and to analyse the primary outcomes. methods: the operative, post-operative and oncological outcomes were evaluated to assess the effectiveness of both techniques of tme. in our center were performed robotic rectal resections and laparoscopic resections from january to present. results: the rtme was associated with longer operation time, early bowel movements, lower risk of conversion and shorter hospitalization. the statistical equivalence was seen between rtme and ltme for non-oncological variables like blood loss, morbidity and reintervention risk. the oncological variables such as number of harvested nodes and positive circumferential resection margin risk were also comparable in both groups. the length of distal resection margins was similar in both groups. conclusion: rtme in patients with rectal cancer was associated with a lower rate of conversion and less incidence of urinary retention. the operative time in rtme was significantly longer than in ltme. the initial oncological and function outcomes of rtme seem to be equivalent with ltme. c. athanasiou aims: two randomized controlled trials failed to show non-inferiority of the laparoscopic total mesorectal excision (ltme) compared to open. ltme becomes particularly challenging in low rectal cancers and in narrow pelves. many surgeons report that robotic tme (rtme) may be beneficial in that setting. our aim was to systematically review the literature and compare the pathologic outcomes of open, laparoscopic and robotic tme for rectal cancer methods: medline, embase, scopus, cochrane library and web of knowledge databases were searched for randomized controlled trials (rct) reporting patholologic outcomes of open, laparoscopic or robotic tme with no language restriction. our primary outcome was quality of tme on macroscopic assessment of the specimen. secondary outcomes included positive circumferential resection margin, distance to radial margin, number of lymph nodes and positive radial margin. the included studies were quality assessed and the jadad score was reported. the grade approach was used to rate the certainty of each network estimate. results: fourteen rcts were included in our study. seven rcts compared the otme to the ltme, six compared the ltme and rtme and one study the otme to the rtme. no statistical significant difference was found in quality of tme when the the ltme was compared to the otme or = . ( . , , ) or the rtme or = . ( . , . ) . no difference was found in pcrm for the laparoscopic or = . ( . , . ) or the robotic approach or = . ( . , . ) when compared to open. distance to radial margin and number or lymph nodes didn't differ between the groups. conclusions: no significant advantage on pathologic specimen quality has been found with the robotic approach. the ltme doesn't seem to compromise the quality of the specimen. h. samura , j. arakaki , k. sugata , y. hori , y. nagamine , f. kohagura , h. motonari , s. kameyama , t. ishimine division of digestive and general surgery, urasoe general hospital, okinawa, japan; department of surgery, urasoe general hospital, okinawa, japan colorectal cancer often invade adjacent organs and it is known that prognosis improves with resection of the involved organ. we report our experience of invaded adjacent organ resection, which include seminal vesicle, uterine and bilateral appendages, posterior wall of the vagina and bladder wall. method: although the range of resection is predicted by image study preoperatively, at the time of operation, it was decided by palpation with a forceps. each operation is evaluated by operation time, blood loss, blood transfusion volume, postoperative complication, postoperative hospital stay, and short term prognosis. result: resection cases of seminal vesicle, posterior vaginal wall, uterine and bilateral appendages and bladder wall were , , and , respectively. the results are shown in the order of seminal vesicle / vaginal posterior wall / uterine / bladder. median age was , , and years old. the median operation time was , , , min, the median blood loss was , , , ml, and only one case of uterine and bilateral appendages resection required the blood transfusion. the average postoperative hospital stay was , , , days. nine cases have postoperative complication, that include delayed wound healing, anastomotic leakage and rectovesical fistula, postoperative ileus, chyle ascites and neurogenic blodder. all of those were improved with conservative treatment. the mean hospital stay in complication cases was days ( - ) and ( - ) days without complications. the median observation period was days ( - ), and there was no local recurrence. all of the case of stage iv were dead. there was no local recurrence and all patient without stage iv are alive, it seems that the resection range was sufficient. conclusion: even with adjacent organ invasion colorectal cancer, it was possible to determine the resection line by palpation with laparoscopic forceps manipulation, and possible to resect margin free of cancer. laparoscopic low rectal resection with/without diverting ileostomy p. ihnát, m. tesar, p. ostruszka, p. gunková, p. vávra background: the construction of diverting ileostomy (di) is recommended to avoid septic complications of anastomotic leakage. the aim of our study was to assess the benefits and risks of di constructed during laparoscopic low anterior resection (lar). methods: retrospective clinical cohort study was conducted in university hospital ostrava, czech republic. all patients undergoing laparoscopic lar with tme because of rectal cancer within a -year study period were assessed for study eligibility. results: a total of patients ( patients without di, patients with di) after laparoscopic lar were enrolled into the study and underwent analysis. both study subgroups were comparable in terms of demographic and clinical features. postoperative -day morbidity was significantly lower in patients without di ( . % vs. . %, p = . ). anastomotic leakage frequency was higher in patients without di ( . % vs. . %, p = . ); surgical intervention was necessary in . % of patients without di. stoma-related complications were noted in . % of patients with di; some patients had more than one complication. surgical intervention because of stoma-related complications was needed in patients ( . %). distinctive complications of di laparoscopic construction (small bowel obstruction due to di semi-rotation around its longitudinal axis) was noted in patients ( . %). mean stoma period (interval between lar and di reversal) was more than months in our study; only . % of patients were reversed without delay (= months). postoperative morbidity after di reversal was . %; re-laparotomy was needed in . % of patients. conclusions: despite benefits of di in protecting low rectal anastomosis, ileostomy construction remains fraught with many stoma-related complications and long stoma periods associated with significantly decreased quality of life. aims: single port laparoscopic is a minimally invasive surgical technique that joint the cosmetic advantages with the well recognized benefits of the standard laparoscopic approach [ ] . we describe a laparoscopic single port hartmann reversal in a patient by the use of the umbilical colostomy site for surgical access [ ] . methods: a years old patient was submitted to a laparoscopic single port hartmann procedure with an trans-umbilical colostomy for a recurrent sigmoid volvulus that was treated at the beginning by endoscopic de-rotation. after three months the patient was reevaluated for a hartmann reversal with a laparoscopic single port technique. after routine skin preparation and laparoscopic setup, the colostomy is mobilized from its mucocutaneous border, and the anvil of a circular stapler is secured to the distal lumen. by the use of a gelpoint system with trocars, the intra-abdominal adhesiolisis in performed. the splenic flexure is mobilized to achieve a sufficient mobilization of the left colon that allows the fashion of a tension free anastomosis. the rectal stump is mobilized to the mid rectum, starting from the posterior mesorectal fascia around to the anterior rectal wall. a tension-free colorectal anastomosis is secured with a standard circular mm stapling device inserted transanally. the colostomy wound is closed. the operative time was min. results: the postoperative course was uneventful, the patient was discharged at forth postoperative day, oral intake started on postoperative day three. conclusions: single port laparoscopic hartmann reversal thought the umbilical stoma site is a minimally invasive surgical option that is safe in selected patients and offer the best cosmetic results. [ the progressive evolution of surgical techniques and oncologic protocols on rectal cancer disease facilitates surgeons to challenge the skills for anus preservation in low rectal cancer surgery. the laparoscopic surgery is already one of the best ways to reach the pelvic floor and to try procedures, which were previously difficult to apply through open surgery. the anastomotic leakage has particularly high occurrence if the anastomosis is performed in the anal or distal rectum area. it is evident that although the fecal diversion does not decrease post operatory mortality, it significantly reduce the risk of anastomotic leak and the risk of a second major surgery when the leak occur. diverting stomas are low-risk procedures from a technical point of view, but they potentially expose the patients to postoperative morbidity, impacting the patients' quality of life. it is not easy to decide whether the fecal diversion is needed or not. this decision must be made on a case to case basis, trying to apply the stomas only when they are really needed. we report our initial experience by living a transmesenterial cotton loop around the pre terminal ileum which extremities are turned out usually through the lateral trocar wound in laparoscopy or by applying a dedicated mini incision in open surgery. the purpose is to perform (in case of suspected fistula), a mini invasive diverting procedure, by widening the loop wound and by pulling up the ileum in a lateral loop ileostomy. we applied this procedure to consecutive patients with low colorectal anastomosis and in two of them we performed a lateral loop ileostomy with good results. we believe this can be an alternative that needs to be standardized. purpose: sarcoidosis is a chronic, multisystem inflammatory disorder with unknown aetiology characterised by noncaseating granulomas within involved organs. gallbladder involvement in sarcoidosis is extremely rare and literature review revealed only reported cases to date. in this paper, we present a case of gallbladder associated sarcoidosis. method: a -year-old lady was known to the clinic for regular surveillance of liver steatosis and incidental gallbladder polyps. the largest polyp was mm at presentation in and has grown to mm in . in view of worsening symptoms of biliary colic and growing polyps, a laparoscopic cholecystectomy was performed. results: laparoscopic cholecystectomy was unremarkable and specimens of the gallbladder and lymph nodes were sent for histology. histological examination revealed chronic cholecystitis with polypoid cholesterolosis of the gallbladder and noncaseating granulomata within a lymph node, which strongly suggest sarcoidosis. conclusion: in conclusion, we report a case of incidental finding of gallbladder sarcoidosis over the course of treatment of biliary colic and symptomatic gallbladder polyps. therefore, the definitive treatment for patients with symptomatic gallbladder sarcoidosis is a cholecystectomy. the surgical management of cholelithiasis can be associated with significant morbidities. despite the relatively low incidence of bile duct injuries during laparoscopic cholecystectomy, the total number is large due to the high frequency of the operation. the subtotal cholecystectomy with its variants is a well known bailout strategy to the surgical community. however, there is no agreement on when and how to perform these procedures. indeed, the majority of surgeons will adopt these solutions when there is a struggle to identify the critical view of safety. this struggle results increases the risk of injuries. we hypothesize that a primary intent gall bladder lithotomy and disconnection (glad) when the dissection of the gb pedicle is anticipated difficult dissection is a safe and feasible strategic option. methods: out patients elevtively admitted to aberdeen univesity hospital with gall stone disease between march and november , consecutive patients were operated with glad procedure based on intraoperative criteria. the primary outcome was the operative time. secondary outcomes were length of hospital stay, the criteria to do this procedure will be explained, the outcomes will be listed. indocyanine green is a molecule that becomes fluorescent when excited struck with light of a specific wavelength in the infrared spectrum (nir-infrared), allowing the visualization of anatomical structures in which it has accumulated. the aim of the study is the application of icg enhanced fluorescence in laparoscopic cholecystectomy in order to identify the anatomy of the biliary tract, to reduce the risk of iatrogenic lesions and the conversion rate. the study involves laparoscopic cholecystectomy for cholecystitis and gallstones of main biliary tract. the evening before the surgery, a vial of icg ( mg) diluted in ml of saline solution was intravenous injected. during the procedure, after opening the calot triangle, switching to the nir mode on the camera, the anatomy of the biliary tract and in particular of the main biliary tract is visualized. the cystic duct and cystic artery are isolated, their section between clips is cut and the cholecystectomy is performed. from january patients were enrolled: cases of acute cholecystitis, cases of gallstones of main biliary tract, undergoing preoperative ercp. in cases of cholecystitis, the angiography allowed the visualization of the main biliary tract. in one case, an abnormal course of the cystic duct was identified. in two cases of gallstones of common bile duct, it favoured the visualization of the biliary tract anatomy. all cases were completed with laparoscopic technique. there were no intra-and post-operative complications. icg-enhanced fluorescence is a safe, effective, cheap and rapid tool that can also be applied in small hospitals with no need for training. its use does not extend the time of surgery and allows the visualization of the anatomy of the biliary tract, especially in situations where it can be altered by reducing the conversion rate and potentially the risk of iatrogenic lesions of the main biliary tract. case presentation: patient is a year old female with no significant past medical or surgical history presented to the emergency department with a day history of worsening sharp right upper quadrant pain with associated nausea, vomiting, and po intolerance. the pain started a few months prior, however it was self-limited with diet modifications. an ultrasound demonstrated a contracted gallbladder with a mm gallbladder wall. white blood cell count was within normal limits and total bilirubin was slightly elevated to . mg/dl. no palpable mass was noted on physical exam. an mr cholangiopancreatography was performed which demonstrated a dilated gallbladder measuring . x . cm, a severely thickened gallbladder with a small intramural collection and multiple gallstones. the patient proceeded with a laparoscopic cholecystectomy. intraoperatively, the omentum was densely adhered to the gallbladder and needle decompression of the gallbladder was unsuccessful due to the wall thickness. the gallbladder was subsequently removed without any complications. patient's remaining hospital course was uncomplicated. surgical pathology returned demonstrating acute on chronic cholecystitis. discussion: cholecystomegaly or 'giant gallbladder' disease is a rare pathology encountered in the surgical world. there have been few reported cases, most of which occurred in the elderly ([ years). kuznetsov et al. defined an enlarged gallbladder to have a volume of - cc and a giant gallbladder as exceeding cc (the average weight of the liver). the etiology remains unknown, however certain factors exist to allow the gallbladder to reach this size without life-threatening sequela. preoperative imaging, such as mr cholangiopancreatography, is important to differentiate biliary pathology and delineate anatomy. removal of the gallbladder is recommended to prevent the development of complications like cholangitis or bowel obstruction. the cause of cholecystomegaly still remains uncertain and warrants further research. the management and treatment remains similar to acute cholecystitis. aims: mini-laparoscopic cholecysectomy (mlc) is considered to be the best variant of minimizing surgical trauma and improving cosmesis in laparoscopic cholecystectomy. the most challenging techniqual step of mlc is clipping the cystic duct. it may be impossible or unsafe when diameter of cystic duct exceeds mm, which is common in severe chronic colecystitis or acure cholecystits. there is very limited data in the literature about the use of mlc in acute cholecystits. the aim of study was to access the first results of new technique of mlc. methods: five women with the mean age of years ( - ) underwent mlc. the st -mm troacar was inserted in the umbilicus and used for the camera and removal of the gallbladder. the nd -mm troacar was inserted in subxyphoidal area and used for the main working instruments, including medium-large polymer clip-applier (hem-o-lok type). the rd and th -mm troacars were placed in right subcostal area and used for mini-graspers (karl storz). in initial procedures we used conventional -mm clip-applier with adopted medium-large titanium clips. to improve safety, we aplied -mm hem-o-lok type clip-applier for the last patient with acute cholecystitis. in this case the diameter of cystic duct was , mm. the clipping was performed successfully. the -mm drain was placed via subcostal troacar incision. also, in this case we applied original technique of removal of the bladder using wound retraction instrument (karl storz). results: in all the cases there were no intra-or postoperative complications. the mean duration of procedures was min ( - min). the postoperative stay was days in every patient. the patients estimated their pain on postop day as 'almost absent' and cosmethic results mo postop as 'exellent'. conclusions: . new technique of mlc alowed to perform the clipping of cystic duct safely, which is essential in acute calculous cholecystitis. was conducted in department of surgery lumhs jamshoro. all the patients having age = year of age, either gender presented with history of abdominal pain, nausea and vomiting and were diagnosed as cholelithiasis included in the study and were planned either for mini-laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy were explored for outcome while the patients with empyema gallbladder, gangrene, mucocele gallbladder and adhesions were excluded from the study. results: during one year study period, total five hundred patients were diagnosed as cholelithiasis with means age . ± . (sd). of five hundred, ( . %) were underwent for mini-laparoscopic cholecystectomy with ( . %) were males and ( . %) were females. the outcome were measured as postoperative pain (vas) . ± . , size of wound (umbilical mm, epigastrium mm and subcostal mm), excellent cosmetic results, mean ± sd for hospital stay (hrs) and operative time (minutes) was . ± . and . ± . , early return to work ( . %), minor oozing ( . %), port size hernia ( . %). remaining ( . %) were underwent for conventional laparoscopic cholecystectomy with ( . %) were males and ( . %) were females. the outcome were measured as postoperative pain (vas) . ± . , size of wound (umbilical mm, epigastrium mm and subcostal mm), mean ± sd for hospital stay (hrs) and operative time (minutes) was . ± . and . ± . , early return to work ( . %), port size hernia ( . %) along with zero ( %) mortality. conclusion: it has been concluded that mini-laparoscopic cholecystectomy is superior and feasible than conventional laparoscopic cholecystectomy and has decreased early postoperative incisional pain, avoided late incisional discomfort and safe procedure with nearly scarless wounds with superior cosmetic effect especially for young female patients. objective: to determine the outcome of immediate versus late laparoscopic cholecystectomy in acute cholecystitis at tertiary care hospital hyderabad / jamshoro sindh pakistan patients and methods: the descriptive case series study of one year ( - ) was conducted in department of surgery lumhs jamshoro. all the patients having age = year of age, either gender presented with history of abdominal pain, nausea and vomiting and were diagnosed as acute cholecystitis (cholillthiasis) included in the study and were planned for laparoscopic cholecystectomy and were explored for outcome as immediate (within h) and late components ([ weeks). the frequency and percentage was calculated for categorical variables and mean ± sd was calculated for numerical variables. as this was descriptive case series so there was no any statistical test of significance was applied. results: during one year study period, total one hundred patients were diagnosed as acute cholecystitis with means age . ± . (sd). of one hundred, % were females and % were males. the immediate outcome reported as tissue fragile %, pancreatitis %, slipage of ligature of cystic duct %, empyema gallbladder %, mucocele % and gangrenous gallbladder % while the late outcome reported as adhesions %, cholecystoduodenal fistula and mirizzi syndrome % and %, gallstone ileus %, perforated gallbladder % and cholidochiolithiasis % while the mean ± sd for hospital stay (days) in immediate as . ± . while in late outcome (days) during acute cholecystitis . ± . and after surgery ( weeks later) as . ± . respectively. conclusion: it has been concluded that early lc for acute cholecystitis with cholelithiasis is safe, low cost and feasible intervention and offering the additional benefit of shorter hospital stay and reduce the economical burden. surg endosc ( ) :s -s general surgery, chang gung memorial hospital kaohsiung division, kaohsiung, taiwan background: the treatment of common bile duct (cbd) stones is challenging while unclear hepatic hilum anatomy especial experience of previous laparotomy. a minimally-invasive approach choledocholithotomy is feasible, but can be difficult and converted for the unclear anatomy of the biliary tree. near-infrared (nir) cholangiography by systemic administration of indocyanine green (icg) can enhance the visualization of the biliary tree anatomy but is limited by the high intensity of background fluorescence signal coming from the liver. nir fluorescence cholecysto-cholangiography by direct biliary tree administration of the icg can enhance the biliary tree without background noise signal. we created the nir cholangiography via different route according to patient situation : systemic circulation or biliary tree injection to see the feasibility of those application. material and method: ten patients who suffered from obstructive jaundice due to cbd stone and patients received percutaneous biliary tree drainage as first treatment and patients received endoscopic biliary tree drainage. those patients received laparoscopic choledocholithotomy as definite treatment after acute infection phase. patients received biliary tree icg injection via drain tube and patients by systemic injection. visualization and fluorescence patterns around cbd was recorded. results: in our series, one patient received previous gastrectomy and patients had previous biliary tree surgery. background: laparoscopic cholecystectomy (lc) has become the gold standard for the treatment of gallstone disease. multiple studies have confirmed its safety, lc at index admission is still not widely practiced in ireland. we present our experience in performing index cholecystectomy at cuh after the start of acute care surgery program in may . aim: the aim of this study is to determine the safety of laparoscopic cholecystectomy at index admission, complications,re-admissions, and los. methods: electronic records, theatre records and imaging reports were searched to enroll all patients who underwent lc for gallstone disease at index admission from may to october . patient demographics, indication for surgery, postoperative complications, readmission and conversion rate were recorded.in addition timings of mrcp and ercp, imaging findings, and los were also noted. results: a total of patients underwent lc during the study period. median age was years ( - ). male to female ratio was : . . ( %) patients had acute cholecystitis, ( %)had acute biliary pancreatitis, ( . %)biliary colic and ( . %) had cholecystitis with signs of cbd obstruction. ( . %)patients had obstructive jaundice and one with adenomyomatosis. patients ( %) had preop mrcp while ( %) underwent pre-op ercp. all except patients undergoing ercp had preprocedure mrcp. patients had pre-op cholangiograms. in terms of complications, ( . %) patients had bile leak and one( . %) had re-operation. one patient had the post-op hematoma which was drained percutaneously, one patient had procedure abandoned because of bradycardia upon induction of anesthesia. there was no common bile duct injury, no conversion to open and no days mortality was reported. the average length of hospital stay has been days. ( to days). conclusions: laparoscopic cholecystectomy at index admission for cholecystitis, choledocholithiasis, and biliary pancreatitis, has been a safe and feasible treatment option in our hospital. a safe practice can be ensured by adherence to a care pathway and a multidisciplinary, consultant-led service. index cholecystectomy service can be provided safely across the country to prevent diseaserelated morbidity and multiple re-admissions in patients awaiting interval surgery. when to use the two-stage surgery to treat choledocholithiasis: the size aims: the treatment of choledocholithiasis has been provided by various of studies worldwide. the most common accepted minimal invasive treatment was two-stage treatment using endoscopic retrograde cholangiopancreatography before or after laparoscopic cholecystectomy(ercp ? lc), and one-stage treatment with laparoscopic exploration of the common bile duct(lcbde). in fact, despite several large studies have been published in recent years, the debate for the ideal treatment of choledocholithiasis is way from being concluded. we aim to find the proper treatment option for the patients with variable sizes of choledocholithiasis. methods: we retrospectively analyzed patients who underwent treatments for cholidocholithiasis in our institute between january , and july , . the patients who received either ercp and lc in the same admission, and the patient who received lcbde, irrespective of trans-cystic(ltcbde), or choledochotomy(lcd), were included. the data was analyzed with chi-square test and mann-whitney u test. results: the stone size of the ercp ? lc group is significantly smaller than the lcbde group. we further analyzed the ercp failure case, and the group of stone size [= . mm has a significantly higher rate of procedure failure. the failure rate is increasing with the stone size. conclusions: both the treatment of lcbde and ercp ? lc have similar safety and success rate, and the rate of residual stone was also similar in both group. however, the failure rate for ercp is significantly increased when stone size is larger than . mm in this study. aims: the xanthogranulomatous cholecystitis (xc) is a rare entity that can cause doubt in the choice of surgical treatment, because of differential diagnosis with gallbladder carcinoma (gc). methods: a -year-old patient presented acute abdominal pain in the right upper quadrant, nausea and low-grade fever with signs of peritonitis. he had elevated pcr, leukocytosis with neutrophilia. abdominal ultrasound showed an acute xanthogranulomatous cholecystitis. a laparoscopic cholecystectomy was decided but it was converted to open surgery due to the difficulty in the dissection, with fundus embedded in the hepatic bed and intraoperative finding of hilar adenopathic conglomerate .the postoperative period was torpid, with abdominal pain, jaundice, elevated bilirubin and enzymes of cholestasis. postoperative abdominal tomography showed injury in the iv segment of the liver suggestive of neoplasia. metastatic adenopathic conglomerate at the hepatic hilum caused extrinsic biliary obstruction with hepatic failure later so an internal-external drain was placed in the bile duct. the patient was died a week later. the pathological anatomy reported a stage four of gc. results: xc is a rare, non-neoplastic, inflammatory and destructive entity of the gallbladder wall, considered a variant of chronic lithiasic cholecystitis. it may be due to extravasation of bile or ulceration of the mucosa, causing an inflammatory reaction and fibrosis, with xanthomatous cells. the prevalence is to % in the resected gallbladders. it is more frequent in - years oldfemales. its clinical presentation does not have specific characteristics that differ from cholelithiasis, except for the weight loss. radiologically it is characterized by nodular thickening and increased attenuation of the vesicular wall with signs of cholecystitis, indistinguishable from a vc. the xanthogranulomatous inflammatory foci infiltrate the hepatic parenchyma, having an invasive behavior; hence, it mimics a neoplastic disease. the confusion in diagnostic and the risk of gc (up to %) makes treatment contentious. conclusions: the xc can simulate an advanced gc that sometimes makes us wonder if we should perform a radical surgical treatment; when presented in an emergency situation, our therapeutic decision can focus on solving the acute problem and be conditioned by the patient's general condition. single port transumbilical laparoscopic surgery (sptls) is a techinque that has been around for about years. although the enthusiasm for this type of surgery seems to have diminished in recent years it is expected to rise considering the recent development of sophisticated devices for its execution . we report retrospectively our year experience with procedures performed by sptls technique. in a private practice setting in mexico city. procedures include cholecystectomy ( ), appendectomy ( ), inguinal hernia tapp and tep ( ), hiatus and esophageal ( ) , sleeve gastrectomy ( ), colon ( ), gyn ( ) . different access platforms were employed. we explain our selection criteria for the application of the technique and describe the evolution of the instruments employed during the past years, from laparoscopic conventional to curved and bendable; regular scopes to extra long telescopes with different angles. or time, top bleeding, conversion rate, the need to employ an extra trocar, complications, pathology reports, scheduled or urgent kind of surgery and length of hospital stay were recorded from the beggining; patients variables such as bmi, asa status, tep risk, satisfaction with the procedure and other were recorded . we describe the evolution of our technique, and our learning curve with cholecystectomies. we compare our group of sptls transvaginal assisted laparoscopic hysterectomy (tvalh) patients vs tvalh multiport patients. we explain the feasibilty, and efficiency of the procedure in our hands compared to other series. background: in japan, the severity of acute cholecystitis(ac) is assessed by the severity classification of the tokyo guidelines (tg ). the value of c-reactive protein (crp) is not included in the severity classification criteria. the first line treatment, according to tg , for mild (grade i) to moderate (grade ) ac is laparoscopic cholecystectomy, but laparoscopic surgery may not be feasible in some cases due to adhesion or local inflammation of the gall bladder. aim: the aim of this study is to assess the effect of crp on the open conversion rate in laparoscopic cholecystectomy for acute cholecystitis.method: we conducted a retrospective study. patients who were diagnosed with ac and treated with emergent laparoscopic cholecystectomy between june and may in our institution are included. we set the cutoff value for crp at mg/dl and compared the open conversion rate. secondary endpoints are amount of bleeding, operation time, post-operative course (peak in body temperature and inflammatory markers) and the frequency of complications according to the clavien-dindo classification. results: out of patients had a crp value greater than or equal to mg/dl. the median crp values for the crp \ group and crp = group were . and . , respectively. the open conversion rate of the crp = group was significantly higher than that of the crp \ group ( / , / , p = . ). the most common reason for these conversions was local adhesion ( / ) . there were no differences in the amount of bleeding, operation time, post-operative course, and frequency of complications with clavien-dindo grade ii or higher. background: reports about clinical value of fluorescent cholangiography using indocyanine green (icg) during single-incision laparoscopic cholecystectomy (silc) were increasing. we report clinical value and pitfalls of fluorescent cholangiography during silc for the patients with the infraportal type of the right posterior bile duct. methods: our silc procedure utilized the sils-port with an additional -mm forceps through the umbilical incision. before silc, ml of icg ( . mg) was administrated by intravenous injection. for fluorescent cholangiography, icg fluorescent laparoscope system was used. results: we performed fluorescent cholangiography during silc in patients with the infraportal type of the right posterior bile duct. all procedures were completed successfully. the interval from the injection of icg to the first obtained fluorescent cholangiography before the dissection of calot's triangle ranged from to min. detectability of infraportal type of the right posterior bile duct before dissection in claot's triangle was . % (n = ) and that during dissection in calot's triangle was . % (n = ). the infraportal type of the right posterior bile duct could be identified under fluorescent cholangiography only when it joined into the common hepatic duct. conclusions: utilization of fluorescent cholangiography can lead silc to safe even for the patients with the infraportal type of the right posterior bile duct. its benefit is emphasized when the infraportal type of the right posterior bile duct joins into the common hepatic duct. aims: due to the development of laparoscopic surgery and the progress made in surgical treatment ofhydrocephalus, surgeons may come across patients with ventriculoperitoneal (vp) shunt, as candidates for laparoscopic procedures. according to this fact, we report a case of an unusual complication of laparoscopy surgery that can appear in this kind of patients. methods: we present a case of a -year-old man with medical history of normotensive hydrocephalus with vp shunt, that came to the emergency room complaining of abdominal pain and fever since two days. blood test showed an elevation of infection parameters and inflammatory markers, and the ultrasound study revealed an emphysematous cholecystitis. therefore, we decide to carry out an emergency laparoscopic cholecistectomy. the patient did not present any adverse event during the surgery or the immediate postoperative period, being discharged the third postoperative day and evaluated ambulatory one month after the surgery with no complications. two months after surgery, the patient returned to the emergency room presenting alteration in consciousness and fever. results: during the study of the pacient, an abdominal ct was performed, showing a complete section of the vp shunt in the subcutaneus space of the upper abdominal wall and intraperitoneal migration of the remaining catheter. the patient was transferred to neurosurgery to carry out an emergent replacement of the ventriculoperitoneal shunt. after surgery and intravenous antibiotic treatment, the patient evolved favourably and was discharged a few days later. conclusions: the rate of serious complications associated with a laparoscopic approach is overall low and up to % of them occur during the abdominal access for camera or port placement and may not be recognized until postoperative period. vp shunts should not be a contraindication for laparoscopic surgery. however, laparoscopy approach must be carry out with good anesthetic and monitoring facilities and taking several previous considerations, such as verifying the proper functioning of the vp shunt, identifying the path of the catheter within the abdominal wall to avoid inadvertent damage to the catheter during trocar placement and ensuring that the intraperitoneal portion of the catheter is not twisted or obstructed prior to decompression of the abdomen. surg endosc ( ) introduction: since advantages of robotic surgery is being more emphasized, robotic cholecystectomy (rc) cases are increasing. ajou group had introduced a method called which technique places the trocars transversally on the bikini line and it makes cosmesis and pain beneficial. however, rc with low incision port has several limitations. therefore, we changed port placement which may be a one of safe tehniques for rc. method: this study retrospectively reviewed data for patients who received rc with port changing method (rcpc, n = ) and rc with low incision port (rcli, n = ) from february -february and surgical variables were analyzed. results: patients in both groups had similar demographic features and indications for surgery. the rcpc group required no conversions to conventional robotic surgery and no additional operation, whereas the rcli group had one incisional hernia ( . %) and two bowel perforation ( . %) cases. length of stay ( . ± . vs. . ± . days, respectively; p = . ) did not significantly differ between the rcpc and scli groups. however, the rcpc group had shorter operative time ( . ± . vs. . ± . min; p = . ) than the rcli group, although the parameters mentioned above were not statistically significant. conclusion: robotic cholecystectomy with bikini line incision has some limitations even though it has cosmetic benefits. whereas robotic surgery with changing port method is one of safe and feasible procedures for performing robotic cholecystectomy. also nothing more to say that it gains cosmesis effect and escapes complications. mini surgery, odessa medical university, odessa, ukraine the aim of the study was to optimize the diagnostic and therapeutic tactics for yatrogenic injuries of the extrahepatic bile ducts. methods: patients were examined. typical manifestations were jaundice, cholangitis, biliary peritonitis, external biliary fistula, subhepatic abscess.cholecystectomy main cause of damage.a visual, manual and x-ray examination of the hepato-choledochus and cholangioscopy were performed. ultrasound, endoscopic retrograde cholangiopancreatography, fistuloholangiography or percutaneous transhepatic cholangiography play a leading role in diagnosing. the results: high damage to the bile duct was detected in . % of patients, low-in . %.percutaneous transhepatic drainage under ultrasound control was performed in . % of patients.emergency laparotomy, sanation of the abdominal cavity and external drainage of the bile ducts were performed with bile peritonitis. recovery operations produced . % of patients. reconstructive interventions were performed in . % of patients after - weeks after the first stage. the covery operations were successful in . % of patients. . % of the sick had complications in the form of biloma. a scar stricture formed in . % of patients after - months. patient underwent recanalization of the stricture zone with a dilatation balloon through interchangeable transhepatic drainage. balloon dilatation was performed retrogradely through the large duodenal papilla in patients. deaths in the postoperative period was not observed. conclusions: the surgical team should be strengthened by an experienced surgeon when intraoperative diagnosis of yatrogenic damage to the bile ducts.the operation should be completed by external drainage of the bile duct and the abdominal cavity in the absence of an experienced specialist.recovery operations are shown only with lateral injury of the ducts.the patient must be sent to a specialized institution for radical surgical treatment after stabilization of his general condition. aim of the study sub-hepatic bile collections, biloma and hematoma are rare complications and we present our experience in treatment this complications. material and methods: from laparoscopic cholecystectomy performed in our clinic, three patients (two women and one men) to whom it was performed laparoscopic cholecystectomy, came back two weeks later after they were released from the hospital because of epigastric discomfort, fever and nausea. results: clinical examination after rehospitalization showed tenderness in the epigastrium and right subcostal region. in all patients were measured high levels of leukocytosis and crp . an ultrasound examination of the abdomen revealed a large hypoechoic collection in the sub hepatic space, after the abdominal ct scan was performed, the density of the collection did not indicate the presence of blood in two patients. percutaneous drainage of the collection in both patients was realized under us guidance and - fr catheter was inserted in the sub hepatic region. in the first patient cc of bile-stained liquid, and in the second patient cc of biliary liquid was drained. in a third patient h after surgery signs of significant hypotension and limited tenderness at the right subcostal region occurred. a complete blood count (cbc) showed a decrease in the level of haemoglobin to . g%. ultrasound examination revealed a fluid collection in the sub hepatic space, which is also confirmed by computed tomography. laparotomy was performed and the large sub hepatic hematoma was evacuated. after that the fr abdominal drain was inserted into the sub hepatic space. the postoperative course of all three patients was not complicated. conclusion: sub hepatic biloma and hematoma are rare complications of laparoscopic cholecystectomy, while early diagnosis followed by percutaneous drainage or open laparotomy is the only way to resolve these complications. ( ), hemoperitoneum . % ( ) . the average number of days of hospitalization was . days. there was no mortality at days. conclusion: in the emergency setting the rendezvous technique has an adequate success rate of cannulation and clearence of the bile duct, an acceptable surgical time, few complications, these being more frequent in those patients with inflammation of the gallbladder and without associated mortality at days. there is a need for controlled randomized studies with a greater number of patients recruited and follow-up to determine the usefulness of this technique. intraoperative cholangiography could serve as a fundamental solution to avoid the bile duct injury during laparoscopic cholecystectomy. however, it is difficult to identify the cystic duct to which the contrast catheter should be inserted in cases with high degrees of adhesion around the calot's triangle. in these cases, it is not possible to conduct cholangiography from the cystic duct. for these types of cases, intraoperative cholecystography may serve as an option. however, since the bladder is a bag-like organ that expands when liquids are entered, directly inserting a contrast dye into the bladder would make the bladder itself expand, which makes it impossible for to maintain enough pressure in the contrast dye to flow into the cystic duct, extrahepatic bile duct, and intrahepatic bile duct. also, since it is difficult to control leakage of the contrast dye from the catheter insertion site, it is not possible to obtain enough images to sufficiently understand the anatomical characteristics of the bile duct in many cases. therefore, cholecystography is not generally recognized as a method to be used during surgery. in our facility, we insert the contrast catheter through the bladder after stretching the gallbladder neck as much as possible, hold the gallbladder neck with a removable intestinal clamp, and then apply the contrast dye to the bile duct. through this method, it is possible to insert enough contrast dye into the cystic duct, extrahepatic bile duct, and intrahepatic bile duct to understand the anatomical characteristics of the bile duct, allowing us to obtain appropriate images of the biliary tract. because this method uses equipment that is highly versatile, we believe that it is inexpensive and convenient. during this presentation, we will also conduct a case presentation of the methods of bladder contrasting that we utilize in our facility during laparoscopic cholecystectomy. introduction: retrieval of a thick walled gallbladder during a difficult laparoscopic cholecystectomy (lc) for an acute or chronic calculous cholecystitis can be exasperating. it increases operative time and often necessitates enlargement of mm port to deliver the specimen. the 'in-situ cholecystotomy', which we wish to call the 'delhi maneuver' is very helpful in improving the ergonomics of specimen retrieval, saves time and conserves cosmesis. patients & methods: one hundred and ten patients of acute or chronic calculous cholecystitis were placed randomly in groups. a disposable transparent plastic bag was used in all cases to retrieve the gallbladder specimen through the - mm port using a rampley's sponge holding forceps. retrieval was done using conventional technique in patients (group b). the delhi maneuver was used in the remaining patients (group a). it involved cutting the gall bladder inside the plastic bag in a certain fashion, delivering the gallstones in the bag, and removal of gallbladder preceding the stones. the retrieval time, number of insertions of sponge holder, any rupture of plastic bag as well as the number of cases needing port enlargement were noted. results: the average time taken by delhi maneuver (group a) was min as compared to was min by conventional method (group b). the number of insertions of sponge holder ranged from - in group a (mean ) and - in group b (mean ). four patients needed port enlargement in group a ( %) while patients needed enlargement in group b ( . %). there were incidences of bag rupture in group a ( %) and in group b ( %). the delhi maneuver improved the ease and speed of specimen extraction at laparoscopic cholecystectomy for thick walled gallbladders. it also decreased the need for port enlargement for specimen retrieval. the bile duct injuries are a very complex desease to confront, the inciian managment is to clasificate the injury and to identifie the mechamism of the injury. it's important for the optimal heal of the patient to have a multidisciplinary approach including internal medicine, surgery, endoscopy and interventional radiology specialists. the laparoscopic cholecystectomy responsible for %- % of them.this is a retrospective study on the incidence, classification and management of bile duct injuries in a private sector hospital in monterrey nl. mexico. in this study, bile duct injuries were identified in years of experience in a single center. were categorized using the strasberg classification. variables were evaluated such as type of injury, mechanism of injury, hospital stay, if the surgery was scheduled or of emergency, the moment in which the surgeon evidenced the injury, the way in which the surgeon became aware of the injury performed. the type of management that was given to this lesion was also studied and the days of intrahospital stay and the number of reinterventions or procedures performed were compared.the average age of the patients was years, patients belonged to the female sex, although there were lesions of all kinds in this work, there was a greater incidence in strasberg type a lesions, which represented % of the lesions. the most common diagnosis presented was cholecystolithiasis. in surgeries the evidence and repair of the bile duct was in the same intervention aims: bile leak is a rare but recognised complication after laparoscopic cholecystectomy. this usually occurs after a difficult procedure complicated by adhesions, unusual anatomy or if the surgeon is inexperienced or unfamiliar with the anatomy. this video aims to demonstrate the laparoscopic diagnosis and treatment of this complication particularly for surgical trainees. methods: we report a case of significant bile leak occurring soon after a straightforward laparoscopic cholecystectomy due to very short cystic duct (cd). the procedure was carried out uneventfully but the cd was clipped flush with the bile duct. the patient was discharged on the day of surgery feeling well but readmitted with abdominal pain h later. results: after readmission the patient underwent a ct demonstrating only a small amount of fluid suggestive of a small collection. she was treated conservatively but suddenly deteriorated and a repeat ct confirmed significant intraperitoneal fluid. a diagnostic laparoscopy was carried out urgently confirming a cd stump bile leak where the clips had sloughed off causing the leak. two litres of bile was aspirated with copious irrigation and a latex t-tube inserted into the cbd. patient made a full and rapid recovery. conclusions: this is a rare complication and learning opportunities for trainees are therefore infrequent. this video demonstrates a successful laparoscopic approach to management of postoperative bile leak showing t-tube insertion technique and highlighting the need for careful cd closure techniques during laparoscopic cholecystectomy when the duct is very short. about - % of bile duct stones could not be extracted using conventional endoscopic techniques (baloon, sphincterotomy). there is lower success rate in elderly patients; among the biggest challenges are intrahepatic stones, size of stone is large, etc. aims: to present the case of a recurrent intrahepatic lithiasis and its management using spyglass choledochoscopy.to expose, other cases and the main outcome and complications of other difficult cases of bile duct stones that solvedusing this choledochoscope vs. the traditional one and the beneffits. we present a case of years old male who presented with cholangitis caused by an intrahepatic stone that required multiple sessions of endoscopic retrograde cholangiopancreatography with spyglass for clearance. one year later, he presented again with cholangitis, that required another session of spyglass lithotripsy and cholecistectomy. conclusions: besides ercp, there are different approaches to treat difficult bile duct stones, as transhepatic percutaneous drainage, surgical techniques, or other endoscopic techniques (doubleballoon, enteroscopy). ercp and sphincterotomy are the first step of endoscopic treatment with more than % of success rate, and a low mortality and morbility rate; other steps include some lithotripsy techniques, or the use of biliary stent as a bridge before definite treatment. spyglass is a visualization & intervention system used when common ercp has been unsuccessful, and it is first line for better and direct image of biliary ducts, with °range of motion, with multiple advantages like the concomitant use of lithotripsy devices. aims: the number of elderly people has increased, because of the strong association between age and gallstone disease, both prevalence and incidence of this disease are increasing. this presentation aims to review our current management options of octogenerian patients with acute cholecystitis. methods: we retrospectively analyzed octogenerian patients who were admitted to the our hospital with the diagnosis of acute cholecystitis between january and october . the patients were initially allocated to four different treatment groups as follows: immediate surgery, delayed surgery, medical treatment and cholecystostomy. differences in the outcomes between the treatment groups were evaluated. results: there were males ( . %) and females ( . %) with a mean age of . years (range - years). the patients had different co-morbid diseases, especially hypertension ( , . %) cardiovascular disease ( , . %) and diabetes mellitus ( methods: a retrospective observational study where were analyzed patients older than years who underwent urgent surgery for ac who fulfilled an indication for surgery according to tokyo guidelines . the type of cholecystitis, stay and postoperative complications, the type of intervention, the conversion rate, the need for reoperation and re-admissions in patients older than years were analyzed and compared with those of patients operated on for cholecystitis younger than years. outcomes: a total of patients were registered, older than years ( %) and younger ( %). in cases, cholecystitis were complicated ( . %), cases older than years ( . %) and in cases younger than years ( . %). the approach was laparoscopic in % of the cases older than years, with a conversion rate of . %, not finding statistically significant differences with younger than years ( % laparoscopies with . % of conversions). % of patients older than years had some type of postoperative complication, not finding statistically significant differences in patient younger than years ( %); being the most frequent complication the intrabdomintal abscess ( . % of patients [ years, and . % of those \ years = '' span = '' [ being not statistically significant with % ci. any patient older than years required re-entry after discharge, compared to patients younger than years who were re-entered, not being statistically significant; and any patient older than years required reintervention, while it was necessary to reoperate patients younger than years ( %), being not statistically significant. mortality was very low, finding case in older than years ( . %) and case in younger ( . %), not obtaining statistically significant differences. the postoperative stay in patients younger than years of age has a median of days and in older than years a median of days, not finding statistically significant differences with % ci conclusions: laparoscopic cholecystectomy is safe and effective in the treatment of elderly patients with (ac), there being no differences with younger patients. introduction: significant bile leak is an uncommon but serious complication of laparoscopic cholecystectomy. our study aims to evaluate the efficacy of relaparoscopy in treating symptomatic bile leak and biloma formation. material and methods: patients presenting with postoperative bile leak after different operations on extrahepatic biliary tree from january to december were reviewed retrospectively (in total, , laparoscopic surgical interventions were performed for the period under study). the sites of bile leaks were the cystic duct stump in thirty seven patients, the bile ducts of luschka in fifty two, liver beds in cases after hepatectomy, in had small injury of cbd, and seven patients with tubular stenosis of the common bile duct. results: three main approaches of mini-invasive treatment of bile leakage was used: ( ) percutaneous puncture with or without drain under ct-scan or ultrasound guidance in patients; ( ) endoscopic management in patients (in patients ( . %) were managed with ercp alone and fifteen ( . %) were treated with a percutaneous intervention followed by ercp. endobiliary stent placement was performed after es in patients and without es in twenty seven patients ( ) relaparoscopy has been performed in patients, in cases of biliary peritonitis. conclusions: relaparoscopy was the ultimate method of treating postoperative complications of laparoscopic surgery in . % of patients. in general, this method, as well as laparoscopic intervention, is highly effective in the diagnosis and correction of postoperative complications, with minimal surgical trauma for the patient, with great therapeutic effect and subsequent rapid social rehabilitation of patients. introduction: laparoscopic operations have already become routine, even for pancreatoduodenectomy for periampular cancer. for unresectable cases, endoscopic bibliary stenting or hepaticojejunostomy are usually used. these methods are quite expensive and may be accompanied by complications. materials and methods: laparoscopic cholecystogastroanastomosis was performed in patients with unresectable periampullary cancer. there were females and men and average age was , . the indications for surgery in all patients was unresectable periampullary cancer and biliary hypertension with preserved patency of the cystic duct. the level of bilirubinemia ranged from to lmol/l (the average level was , lmol/l). we used -port technique. optical trocar was placed in the right iliac region, one mm above the navel and one mm in the right hypochondrium after punction gallblaber and aspiration of bile, we cut the apex of the gallbladder and gastric antrum up to . cm and performed cholecystogastroanastomosis with barbed-suture v-loc. results: we had not conversion to open surgery. the average operation time was min. postoperative stay was average days and on median follow-up of month. post-operatively, there were no major morbidity and nil mortality. we had cases of leakage of bile through drainage for up to - days, which spontaneously stopped. all patients showed a decrease in the level of bilirubinemia. patients were later radical operated (pancreatoduodenectomy), while they did not have such phenomena as cholangitis, pancreatitis, inflammation of the hepatoduodenal ligament elements, which we often observe after endoscopic biliary stenting. conclusions: laparoscopic cholecystogastroanastomosis is safe, effective and feasible for patients with periampular cancer and obstructive jaundice. aims: surgeons with the expertise and resources to perform laparoscopic common bile duct exploration often prefer the 'one stage approach' over endoscopic retrograde cholangio-pancreatography (ercp) for the management of common bile duct (cbd) stones. this case series aims to evaluate the effectiveness of lcbde in a single benign upper gastrointestinal (gi) unit. methods: all patients with suspected and confirmed pre-operatively cbd stones who underwent a lcbde between january and october were included. lcbde was performed on the basis of pre-operative suspicion of cbd stone confirmed by intra-operative imaging. results: patients with confirmed choledocolithiasis had lcbde during this time period. the indications for lcbde were deranged liver function tests, dilated cbd or confirmed stones on preoperative imaging. median age was (range - ), % of whom were female. % of patients had confirmed cbd stones pre-op. % of cases were performed as emergencies and conversion rate to open was . %. choledocotomy was performed in % of cases. in % of these t-tube was left in situ. transcystic approach was used in the remaining %. despite positive intraoperative imaging no stones were found on cbd exploration in cases ( %). in patients stones were unable to be cleared with lcbde. the overall morbidity was %. % of patients had gallstone related complications. overall mortality was % (due to bile leak). / patients required re-intervention with re-look laparoscopy (n = ) or ercp (n = ). patients re-presented within months with cbd stones. overall median length of stay was days. conclusions: our case series demonstrates that lcbde is an effective and safe treatment for choledocolithiasis in both the elective and emergency settings. complication rates are comparable with therapeutic ercp ( % specific complications) followed by laparascopic cholecystectomy ( % day morbidity). the variability in anatomic location of subvesical bile ducts puts them in danger during hepato-biliary operations. its prevalence varies between % and %. the origin and drainage of these ducts were limited mainly to the right lobe of the liver, but great variation could be seen. some authors think of them as small bile ducts that drain directly into the body of the gallbladder; others consider them to be networks of miniscule bile ducts between the liver capsule and the gallbladder. recent studies suggest that clinically relevant bile leaks complicate approximately . - . % of cholecystectomies. injury to a subvesical duct is one of the most common causes of cholecystectomy associated bile leak and occurs as often as major bile duct injuries and leaks from the cystic duct stump. indeed, recent studies suggest that about % of clinically relevant bile leaks are caused by inadvertent injury to a subvesical bile duct. there are four types of subvesical bile ducts, including ( ) superficial variations of segmental and sectorial bile ducts, ( ) superficial or intercommunicating accessory bile ducts, ( ) hepaticocholecystic ducts, and ( ) aberrant bile ducts.we present a case of year old patient who developed a coleperitoneum after a routine daycase colecystectomy due to the inadvertent injury of a hepatocholecystic duct. a superior comprehension of ductal anatomy is essential in preventing and managing operative injury to the subvesical ducts, although some times is unavoidable. nowadays, the diagnosis of liver cancer is primarily radiological, as recommended by the principal international societies. in doubtful cases or due to the clinician needs, diagnostic evaluations can eventually be completed with a liver biopsy. the goal is to perform the examination, or the examinations, that guarantee the most elevated sensibility and specificity levels being as little invasive as possible. nevertheless, even using the best radiological tools, the diagnosis is not certain, due both to device limitations and radiology experience. recently, various diagnostic algorithms have been proposed, relating with contrast enhancement characteristics, different radiological techniques, blood examinations and cross evaluations from different radiologists. one of the most recent algorithm purposed is liver imaging reporting and data system (li-rads), that evaluates ct and mri imaging to classify hepatic lesions in different diagnostic categories, in order to perform a better and more precise diagnosis of hcc or other liver benign or malignant lesion. through a retrospective study, we evaluated and compared preoperative imaging and post-operative histological reports. results reveal that li-rads routine use increases hcc diagnosis up to %. background: we previously developed a modified difficulty scoring system (dss-ihd) of laparoscopic liver resection (llr) for patients with intrahepatic duct (ihd) stone. we validated dss-ihd in patients who underwent llr for hepatolithiasis. methods: dss-ihd was based on the extent of liver resection ( to ), stone location ( to ),atrophy of liver parenchyma ( to ), ductal stricture \ cm from the bifurcation ( to ), and combined choledochoscopic examination for remnant ihd ( to ). results: the dss-ihd ranged from to and divided to -level groups of low group (score * ; n = ), intermediate group ( objective: improving the surgical treatment of patients with cholangiogenic abscesses of the liver through the application of minimally invasive technologies. material and method: in the presented study presented results of treatment of patients with biliary liver abscesses. surgical interventions for hepatic abscesses were performed simultaneously with the elimination of the primary pathological process of the biliary system, which caused the occurrence of cholangitis, or in the near future (up to days) after biliary drainage drainage. among patients with biliary liver abscesses, treated with minimally invasive methods, revealed abscesses of the right hepatic lobe, -abscesses of the left hepatic lobe, -abscesses and right and left hepatic lobes. single abscesses were detected in patients, and in -two or more abscesses. in terms of liver abscesses, more than cm were detected in patients, more than cm in patients. drainage of the biliary tract was carried out endoscopically transpapillary and (if the endoscopic approach was unsuccessful) with transcutaneous transhepatic approach. results: drainage under ultrasound guidance was performed on patients with solitary and patients with two or more cholangiogenic abscesses of the liver. laparoscopic interventions were performed on patients. among the patients operated on using minimally invasive technologies, occurred complications ( . %). patient died due to the development of biliary sepsis ( . %). conclusion: percutaneous drainage of liver abscesses under ultrasound control is appropriate not only for single abscesses, but also for their larger number, which has many advantages over other interventions. it was proved possibility of simultaneous drainage of liver abscess and bile duct. percutaneous drainage of the liver abscess, drainage of the biliary tract and laparoscopic surgical intervention are complementary aspects in the treatment of liver abscesses of biliary origin. after laparoscopy residual calculus can be removed endoscopically in more favorable conditions after stabilization of the patient's condition is achieved and the infection-associated disorders are eliminated. in case of localization of abscesses in the marginal segments of the liver, laparoscopic atypical resection of the liver with an abscess is most desirable. general surgery, rambam medical center, haifa, israel background: recently robotic surgery has emerged as one of the most promising surgical advances. despite its worldwide acceptance in many different surgical specialties, the use of robotic assistance in the field of hepatobiliary (hbp) surgery remains relatively unexplored. our study presents single institution's initial experience of robotic assisted surgery for treatment of benign hepatobiliary pathologies. methods: a retrospective analysis of a prospectively maintained database on clinical outcomes was performed for consecutive patients that underwent robotic assisted surgery for benign hbp disease at rambam medical center during - . results: there were robotic assisted surgical procedures performed for benign hbp pathologies during the study period. there were anatomical robotic liver resections for symptomatic hemangiomas, cases of giant liver cyst, robotic assisted surgery for type i choledochal cyst, case of benign (iatrogenic) common bile duct (cbd) stricture, cases of robotic (cbd) exploration due to large intra choledochal stones and cases of cholecystectomy for cholelithiasis. the median postoperative hospital stays for all procedures were . days (range - days). general morbidity (minor) was %. there was no mortality in our series. conclusion: robotic surgery is feasible and can be safely performed in patients with different benign hbp pathologies. further evaluation with clinical trials is required to validate it's real benefits. most liver cysts are asymptomatic and tend to have a benign clinical course. however, symptomatic or complicated liver cysts sometimes require surgical intervention. needle aspiration is safe and can be the lease invasive procedure, this procedure is however associated with a high failure rate and rapid recurrence. surgical approach is the crucial and provides definitive treatment for such cysts. thirteen cases were nominated from shonan kamakura general hospital between january and december . mean age and body mass index (bmi) were . and . , respectively. all patients have had any complaint such as upper abdominal pain, dyspnea, and fever. two cases were clinically diagnosed as the infectious cyst and serum crp was elevated before surgery. additional cholecystectomy was planned for one case of chronic cholecystitis with gallbladder stones. all cases were prompted the reduced port surgery (rps) and cases were performed rps with trans-vaginal approach (hybrid notes) and case was chosen in single port surgery. cyst unroofing was performed for all cases. mean operation time and blood loss of all cases were . min. and . ml, respectively. no surgical complication has been occurred in all cases, an infectious cyst case was however required additional drainage for infectious control after surgery. although statistic difference was not shown, fewer blood loss and shorter hospital stay was seen in non-infectious cases, compared to laparotomy cases. mean hospital stay after surgery of whole cases, non-infectious cases, infectious cases was . , . , . days, respectively . no recurrence of any symptom was shown in any cases in observation period ( - days) . laparoscopic unroofing is the definitive treatment for the complicated or symptomatic liver cyst. however, for the infectious cyst, infection control such as intensive drainage and/or administration of antibiotic before surgery may be needed to avoid additional treatment, leading to longer hospital stay. laparoscopic unroofing of liver cyst can be the first choice for symptomatic or complicated liver cyst. also, reduced port surgery can be nominated to achieve less invasiveness. introducction: laparoscopic liver resection (llr) has been increasing since it was first reported in . three international expert consensus conferences on llr surgery were held in louisville, ky, usa, in , morioka, japan in and southampton, uk, in . while most initial minimally invasive liver resections were typically done for benign lesions in anterior o left segments, llr is currently being applied for major anatomic resections, malignancy, cirrhosis and liver donor hepatectomy. clinical case report: this is a -year-old male patient with a history of hta and liver cirrhosis due to hepatitis b virus. hepatocarcinoma is diagnosed in liver segment vi with a size of cm . in the digestive study the patient presents a child a stage, meld \ , without signs of portal hypertension. complete analytical with normal afp and cea . markers. after presentation of the patient in a multidisciplinary committee and being a stadium according to the early bclc classification, laparoscopic surgery with segment vi resection was decided. discussion: laparoscopic liver resection is becoming widely accepted for the treatment of hepatocellular carcinoma. liver resection is a first-line option in very early and early-stage disease. many meta-analysis have shown that llr is better than open liver resection in terms of short-term outcomes for patients with child-pugh a cirrhosis, solitary tumors, and minor resections. in the long-term setting, the results demonstrate that a minimally invasive approach is comparable to an open approach in terms of overall. in conclusion, the current evidence conclude than llrs for hcc are safe and may be considered a standard practice in specific settings. results: there were women ( %) and men ( %). the age of patients ranged from to years. the patients underwent complex examination including abdominal ultrasound, esophagogastroduodenoscopy, and some of them underwent ct (computed tomography). all patients in the first stage were performed antegrade external drainage of biliary tracts with x-rays of the biliary tracts, and specifying the level and extent of the block.total miniinvasive interventions were hold. two patients in connection with the uncoupling of equity ducts were performed antegrade bilobar stenting with preliminary split external bile release.there were complications after carried out interventions in cases, which were associated with dislocation of holangiostomic drainage in patients ( . %); with acute cholecystitis in patient ( . %); with hydrothorax in patients ( . %); perihepatic biloma in case ( . %). patient ( . %) had a recurrence of obstructive jaundice due to germination of endobiliary stent in the late period after stenting. lethal outcome appeared in patient. conclusions: ultrasound examination allows us to determine the level of obstruction of the biliary tract, to substantiate the tactical position in the application of mini-invasive technologies. antegrade miniinvasive technologies in the treatment of tumor lesions of the proximal bile ducts allow timely and effectively stop biliary hypertension and to determine further treatment strategy. acknowledgements this study was supported by the russian science foundation under project ? - - . background: repeat hepatectomy is an effective treatment, with long-term surgical outcomes for recurrent hcc and colorectal liver metastasis(crlm). however, the efficacy of a minimally invasive surgical approach for recurrent liver tumor is not yet confirmed. the purpose of this study is to examine the efficacy of laparoscopic repeat hepatectomy(lrh) compared with open repeat hepatectomy(orh) for recurrent liver tumor. we retrospectively analyzed the clinicopathological features and short-term surgical outcomes between lrh and orh. methods: from to , patients with liver cancer underwent repeat hepatectomy. of those patients, patients underwent partial hepatectomy, patients were undergone laparoscopically, and patients underwent open hepatectomy. we compared the clinicopathological and surgical parameters in the lrh group with those in the orh group. results: there were no significant differences in patients' gender, age, viral infection status, child-pugh classification, tumor size, tumor number, and tumor location in the two groups. the operative times were similar, but blood loss was significantly lower in lrh group ( vs. ml, p \ . ). the postoperative hospital stay was significantly shorter in the lrh group ( . vs. . days, p = . ). postoperative complications(cd = a) were observed only in the orh group, with a complication rate of . %. conclusions: we demonstrate that lrh reduces blood loss and postoperative complications compared with orh. lrh might be a feasible and effective procedure for the selected patients. background: the liver is the most common site of metastatic disease with up - % of all cancers having the potentiality for sending liver metastasis during the disease. consequently, increasing value for surgical resection of hepatic deposits of different types of cancers, the need for accurate evaluation of the extent of hepatic metastasis was established for choosing the most suitable patients for surgery and in planning the extent of hepatic resection. the aim of this work is to evaluate the role of intra-operative ultrasound in the detection of hepatic deposits in intra-abdominal malignancies with special emphasis on its accuracy, sensitivity, specificity. patients and method: this study was carried out on thirty patients who were admitted to the gastrointestinal surgery unit, main alexandria university hospital with intra-abdominal malignancies for whom elective open surgical intervention was recommended in the period from st of september till the th of march . results: in the present study consisted of males ( . %) and females ( . %). their mean age at admission was . ± . years. six of the included patients ( %) were found to have hepatic lesions by using ious including the four cases ( . %) already detected by preoperative imaging. two cases ( . %) were newly discovered in the operative room by using ious. conclusion: the current study has proved that ious demonstrates superior lesion detection over the various non-invasive preoperative imaging modalities causing significant impact on change of the planned surgical strategy laparoscopic approach to the liver has become an integral part of surgery. two consecutive international consensus meeting recommends major hepatectomy has been on the expert hands. tumors located in the right posterior section are considered to be difficult for laparoscopic resection. patients and methods: since , until , cnuhh has been performing laparoscopic hepatectomies including major hepatectomies. among major ones, there are rh, lh, rps, ch, and as. we analyze data on patient demographics, tumor characteristics, operative date, and posterior outcome retrospectively. results: during - , laparoscopic rps were performed. the diagnosis were hcc in and crlm in patients. median operative time was min, and median blood loss was ml. no blood transfusion was occurred. median tumor size was mm, and median resection margin was . mm. six of the patients ( %) were cirrhotic on pathology. there was no conversion and was no postoperative mortality. median hospital stay was . days. conclusion: laparoscopic rps is known challenging procecedure. strict preoperative planning and operative procedure is mandatory. even though it should be performed by the experienced hands both on hepatic surgery and laparoscopic skill, it can be an good option for treatment of the tumor locating over right posterior section. purpose: previously we developed a new sponge (named endoractor) as an organ retraction device in laparoscopic surgery in and have reported that it is useful in various surgical procedures including rectal surgery we confirmed that it is also useful in laparoscopic radiofrequency ablation of the liver in terms of pulling and protecting organ, so we report it materials and methods: a case is an -year-old female with liver cirrhosis. she had primary hepatocellular carcinoma in s lesion with a diameter of . cm very close to the inferior vena cava and middle hepatic vein root and in s lesion with a diameter of . cm we thought she could not put up with hepatic resection because of her poor hepatic reserve capacity. and we could not expect treatment effect by embolization therapy since contrast effect was poor. so we decided to select ablation therapy in the puncture and ablation of the s tumor, since there was concern about the thermal damage of the middle hepatic vein and the cooling effect by the inferior vena cava, we would dissect the right coronary mesentery sufficiently and pull the liver apart from the inferior vena cava and the middle hepatic vein as much as possible using our endoractor also, in the puncture and ablation of the s tumor, it was feared that the stomach would be thermally damaged, so we would place endoclactor between the liver and the stomach to protect the stomach results: when ablating the s tumor, we could pull the liver securely without slipping, so we did not cause thermal damage to the middle hepatic vein. and there was no cooling effect by the inferior vena cava, so we could obtain sufficient cautery margin. in ablation of s tumor, we were able to puncture by stabilizing the lateral segment of the liver on our endoractor, and avoid thermal damage of the stomach conclusion: it seems possible to perform safe and reliable puncture and ablation by using our endoractor as well in laparoscopic radiofrequency ablation surg endosc ( ) surgical reinterventions in patients with complicated hepatic hydatid cysts usually occur as a result of diagnostic or technical failures during the initial procedure. according to recent studies, the most common complication after liver hydatid cyst surgery is local sepsis at the residual cavity and long-term biliary leak. we report the case of a -year-old male with a history of liver hydatid disease four years before the current episode, admitted in our surgical department for intense upper right quadrant pain. abdominal ultrasonography, ct and mri scans revealed three cysts in the gastrosplenic ligament, in liver segments vii-viii, and ii-iii respectively, sized between and cm. the intraoperative aspect during laparoscopy was strongly suggestive for liver hydatid disease. laparoscopic fenestration with tunneling for the hepatic cyst in segment viii, partial cystectomy in the left liver lobe and ideal cystectomy in the gastrosplenic ligament were performed. postoperatively, the patient displayed a constant biliary drainage output of - ml from the cavity remnant in the segment viii. conservative therapy for external biliary fistula and concomitant treatment with albendazole for months were initiated. evolution was slowly favorable with decreased biliary drainage to ml two months after surgery and complete symptom resolution five months after hospital discharge. aims: this study aimed to evaluate the effectiveness of fluorescence imaging with indocyanine green (icg) during laparoscopic deroofing of hepatic cysts. methods: this was a single-center, case-control study. we included patients who underwent laparoscopic deroofing between november and october . imaging with and without icg fluorescence was performed in (icg group) and (non-icg group) patients, respectively. icg was intravenously administered between min and . h before surgery. we performed a standard laparoscopic procedure. we detected a thin bile duct on the hepatic cyst on using intraoperative icg fluorescence imaging. we adjusted the resection line of the cyst wall and ligated the bile duct at the point at which it crossed the resection line. data on age, sex, cyst size, resected cyst size, operative time, estimated blood loss, post-operative hospital stay, complications, and recurrence were compared between the groups. results: the mean cyst size was ± . and ± . mm, the mean resected cyst size was ± . and ± . mm, and the mean operative time was . ± . and ± . min in the icg and non-icg groups, respectively. using icg fluorescence imaging, the bile duct was detected on the cyst wall in patients ( %). all surgeries were completed laparoscopically, and no post-operative complications occurred in either group. recurrence of the hepatic cyst occurred in one patient ( %) of the non-icg group. conclusions: fluorescence imaging with icg is used widely in hepatobiliary surgery for intraoperative identification of biliary and vascular anatomies. this method does not require complicated techniques or instruments. icg fluorescence imaging may facilitate the prevention of intra-or post-operative complications, such as biliary leakage, in laparoscopic surgery. in this study, icg fluorescence imaging was found to be effective in detecting the bile duct on the cyst wall intraoperatively, allowing for wider resection of the cyst and avoiding inadvertent injury. our study suggests that wider resection of the cyst wall might prevent recurrence of hepatic and that icg fluorescence imaging could ensure procedural safety. abdominal ct showed: large hepatic cyst ( x , x cm size), with no malignity signs, that occupies practically the whole right liver, causing subsegmentary atelectasis of the middle lobe, superior and inferior cava vein compression, and displacement of right kidney, pancreas and right atrial. due to breath involvement, a percutaneous drainage is performed achieving clinical improvement and reduction of the size of the injury. the patient was released but a cyst superinfection occurred; once this problem was solved, the drainage was removed. results: in light of the complication, surgical treatment was decided, which confirmed the large cyst located in right posterior hepatic segments with tight diaphragmatic adhesions. we carried out the cyst evacuation and a wide laparoscopic resection of the cyst walls, until the posterior area of the cava vein, combining supra and infrahepatic access. the patient was released on the sixth postoperative day and continues asymptomatic. conclusions: simple cysts can be approached in a no surgical way (punction-aspiration with/ without sclerosing products injections) or in a surgical way (cyst wall fenestrations, cystectomy or liver resections). a conservative treatment will obtain symptomatic relief but with a high risk of recurring. recurrence is the main drawback of unroofing. cystectomy is the better option but may be too complicated depending on the cyst's location. to our patient, we carried out a wide laparoscopic unroofing (even though its posterior localization) to minimize recurrence possibilities. in conclusion, laparoscopic resection of the cyst wall is a simple and effective approach in symptomatic or complicated cases. background: single-incision laparoscopic surgery or laparoendoscopic single-site surgery is emerging as an alternative to conventional multiple-incision laparoscopic surgery. it has a potential benefit of less postoperative pain and faster recovery compared with conventional multiple-incision laparoscopic surgery. single-incision laparoscopic hepatectomy (silh) has been reported in only a few small series and the majority were minor resections. case report: a y/o male patient is a case of chronic viral hepatitis b and early cirrhosis of liver. two atypical hepatocellular carcinomas (up to . cm in diameter) located at the junctions of segments & and segments & were impressed by liver magnetic resonance imaging (mri). we performed single-incision laparoscopic anatomical hepatic resection of the right posterior section via a -cm transverse incision on the right middle abdominal wall. inflow control was carried out with an extra-glissonian approach before parenchymal transection. the glissonean pedicles of segments and were divided by linear staplers respectively as well as a major branch of the right hepatic vein in segment . the operative time was min and the estimated blood loss was ml. the pathologic examination revealed two foci of hepatocyte dysplasia with a safe margin of cm. the patient was discharged eight days after the surgery uneventfully. conclusion: single-incision laparoscopic anatomical right posterior sectionectomy is feasible and safe by experienced laparoscopic surgeons. it provides a fast recovery but needs a long operative time. the mortality in the patient with liver cirrhosis is very high. the aim of this work was to decrease mortality and morbidity by using endoscopic local heamostasis and laparoscopic operations, in the patients with bleeding from cirrhosis by variceal bleeding. methods and material: we observed patients with cirrhosis complicated by variceal bleeding during years. there were patients with child phue a, ones with child phue b, ones with child phue c. all the patients were performed prolonged endoscopic heamostasis with conservative therapy. the main methods that we used were the ligation in cases, sealing in cases, sclerotherapy in cases. in cases we couldn't stop the bleeding with band ligation method and introduce the danis stents into esophagus and stopped the bleeding successfully. to prevent the re-bleeding we performed the laparoscopic dissection the abdominal part of esophagus with suturing the venous vessels, coagulations and dissection of short gastric vessels between stomach and spleen, clipping the left gastric artery and vein in the patients. in patients we performed laparoscopical suturing the variceal veins by introducing the laparoscopic trocars into the stomach. in cases with varices vien of stomach, with non-effective local endoscopic heamostasis we performed laparoscopic resection the fundal part of stomach. results: endoscopic local heamostasis were successful (in %) in cases. the relapse of bleeding were in patients. patients died. there was no mortality after laparoscopic operations. there were cases for trocar wounds infection, cases of subphrenic abscess. goals: the advance of laparoscopic surgery also includes the more complex procedures of abdominal surgery such as those affecting the liver and pancreas. there are multiple indications that laparoscopy has in hepatobiliopancreatic surgery, both in benign and malignant pathologies. material and methods: we present the video of a -year-old male patient with a history of right hemicolectomy due to disease-free intestinal lymphoma who, in the control analysis by his attending physician, detects the elevation of tumor markers. an extension study was started showing a hepatic lesion in the caudate lobe with a pathological anatomy suggestive of hepatocarcinoma and an adenopathy suspicious for malignancy adjacent to the right renal vein. the clinical case is presented in a multidisciplinary tumor committee and it is decided to perform surgery. a laparoscopic caudate lobe resection was performed, previously performing intraoperative ultrasound and a lymphadenectomy of the portal territory, vena cava and exeresis of adenopathy of the right renal vein. introduction: major vascular complications during laparoscopic surgery occur approximately in one in cases, but mortality rate can reach - %. most major vascular injuries lead to conversion to laparotomy but successful laparoscopic repair is also possible. simulation training improves laparoscopic performance and possibly reduces surgeons mental strain. materials & methods: during two editions of advanced laparoscopic training course participants had a task to control a major vessel damage (damage). before the task an educational video explaining the methods of obtaining haemostasis was shown. the algorithm of the 'damage' task was as follows: without previous preparation a cm injury of a major vessel was done with l-hook electrocautery. after the injury participants were free to control the damage the way they wanted. heart rate of the participants was measured with an ear electrode. measurements were carried out times-before the injury, immediately after, and afterwards obtaining vessel control. after participants were interviewed for their feelings after the 'damage' task. results: there were vessel injuries in animals. one animal died during the 'damage' task min after desuflation due to relapse of bleeding. there was no conversion to open procedure. temporary vessel control was obtained with different methods. all participants used vicryl . or pds ii . suture for final hemostatic purposes. heart rate of the participants before injury were - ± . bpm, immediately after the injury it rose to - ± . bpm, and after obtaining vessel control were in the range - ± . bpm. a statistically significant difference was found between the ratio of the first and second hr measurement (p = . , t = - . ), and second compared to the third (p = . , t = . ) measurement. participants judged their experience on a -point scale ( - was not helpful at all; -was extremely educative). the educational value of the task received points in cases and points in one case. conclusion: participants feel stress during major vessel bleeding even in animal model, and this stress can result in a serious intraoperative mental strain and significantly increase heart rate. participants found the 'damage' task very useful for their daily practice. the aim of study was to improve the results of treatment of patients with hepatic echinococcal cysts by using of argon plasma coagulation. methods: the analysis of treatment results of patients was put into the basis of this study. it was ( . %) men and ( . %) women in total. an average age of them was . ± . years. the main difference between groups was a way of liver parenchyma coagulation in order to make reliable hemostasis. in main group the final stage of surgical intervention on liver was argon plasma coagulation. it was performed to ( . %) patients. alternatively, monopolar coagulation was performed to ( . %) patients (comparison group). results: in main group in the . % cases pericystectomy was conducted. the resecting surgeries was performed to . % cases. in comparison group was conducted in . % cases. in early postoperative period in main group the complications were observed in . % of cases. the same parameter was . % in comparison group. it led to relaparomies. the forming of external biliary fistulas was observed in ( . %) patients in main group and in ( . %) patients in comparison group. however, all the fistulas have closed spontaneously on th- th day in both groups. hernias of abdominal wall and peritoneal adhesions that manifested by intestinal obstruction of different degree were considered as complications of late postoperative period. these values were % and . % in main group versus % and . % in comparison group, respectively. the resection of hepatic echinococcal cysts with further application of argon plasma coagulation on the cyst bed was accompanied by complications quantity decrease in patients that underwent surgery in early as well as in late postoperative period. in this case more positive dynamics of functional liver values improvements was observed. aims: indocyanine green (icg) fluorescence imaging has been reported as a reliable and safe navigation tool in laparoscopic hepatectomy. however, the factors affecting the sensitivity of tumor detection with icg fluorescence imaging is relatively unclear. the aim of the present study is to analyze the factors of successful icg fluorescence in laparoscopic hepatectomy. methods: this is a retrospective single-center study. this study population consisted of laparoscopic hepatectomies from january to november undertaken at kurashiki central hospital. we excluded patients whose tumors were located more than mm from the liver surface, those who did not receive icg fluorescence imaging, and those who were not injected with icg dye ( . mg/kg) intravenously within days of surgery. the pinpoint endoscopic fluorescence imaging system was used to detect the tumor location. we evaluated the relationship between successful fluorescence and the timing of injecting icg before operation, tumor size, icg r , liver damage and bmi. results: following exclusion, patients were eligible for analysis. among the tumors resected, icg fluorescence imaging detected tumors ( . %), including hepatocellular carcinomas and liver metastases. icg fluorescence imaging detected all tumors in the patients injected with icg to days before hepatectomies . icg fluorescence imaging detected all tumors which were more than mm in diameter. there was no relationship between indocyanine green fluorescence with icg r , liver damage and bmi. conclusions: the injection of icg to days before operation and a tumor size of more than mm can be factors in successful fluorescence in laparoscopic hepatectomy. introduction: cysts in the liver have a wide variety of aetiologies. it is important to characterize the cystic lesion before treating it. the simple cyst has a low prevalence and is more frequent in women. fenestration is a useful option for the treatment of simple cysts in selected patients. case presentation: a -year-old woman was referred to our hospital with a one-year history of intermittent, right upper quadrant pain, with no other associated symptoms. computed tomography and magnetic resonance imaging showed a large cyst ( , x , cm) in the right of the liver. the cyst presented lobulated morphology, smooth edges and well delimited. there were other smaller cysts in the left lobe. hepatic function in blood analysis was normal. biomarkers, tumor markers and hepatitis virus markers were negative. outpatient follow-up and symptomatic treatment of pain was decided. after six months of follow-up, the pain persisted, so surgical treatment was proposed. a laparoscopic fenestration was performed, widely resecting the free wall of the cyst. there was no evidence of a connection to the bile duct. there were no complications. on days she was discharged. discussion: some giant hepatics cysts become symptomatic due to mass effect. persistence of pain is an indication of surgical treatment. laparoscopic fenestration is an alternative for the management of simple hepatic cysts. aim: laparoscopic liver resection for malignant pathology such as colorectal cancer metastases has been a matter of discussion for several groups in the last years. it has been proposed as a safe and feasible treatment but subjects like short and long term outcomes and oncologic results have not been adequately assessed. methods: we performed an observacional retrospective study of patients undergoing laparoscopic liver resection for colorectal metastases in our center. from november to november a total of patients underwent laparoscopic liver resection. data for resection margin, hepatic and extrahepatic recurrence and both disease free survival and overal survival were collected. patients were discussed in a multidisciplinary group with oncologist, radioterapic oncologist and surgeons. the surgical procedures were perfomed by the same team in all the cases to minimize bias. results: a total of patients ( . %) were non resectable at the time of surgery.the mean overall survival was months with a maximum of months. we got a mean of disease free survival in our patients of . months. the hepatic recurrence was %, most of them in high risk patients, and from this group . % underwent a new liver resection. major complications took place in patients ( . %) two biliar leaks, one bowel perforation, two hepatic failure, one evisceration and three respiratory insufficiency needing urgent surgery in three of the cases. mean hospital stay was . days. a mean of days of this stay were in an intensive care unit. conclusions: laparoscopic liver resection for colorectal liver metastases could be a feasible technique when perfomed by trained surgeons. it improves the postoperatory recovery with a reduction of hospital stay and less postoperatory pain without increasing the development of major complications or mortality in the first days after surgery. we got good oncological results that have been improving with the experience acquisition of the surgical team. aged to underwent surgery for cirrhosis with massive refractory ascites child c ( - ), without obvious signs of hepatic encephalopathy. major etiological factors were: viral hepatitis c ( patients ( . %)), b ( patients ( . %)), b ? d ( patients ( . %)), toxicity ( patients ( , %) ). to prevent possible bleeding at the first stage, endoscopic filling of esophageal varices with fibrin glue was performed in patients ( . %). after testing the effectiveness of varices filling, in the following - days decompression surgery of thoracic lymphatic duct was performed under local anesthesia to improve lymphatic drainage from liver and abdominal organs. simultaneously, laparoscopic sanitation of abdominal cavity was performed, with complete evacuation of ascites fluid, rinsing and drainage. fractional post-surgery rinsing was repeated daily for - days towards removing peritoneum edema and improving its absorptive properties. results evaluation was performed , and months after surgery, based on criteria of liver reserves and ascites volume. results: post-surgery mortality from liver failure was . % ( patients) . other patients died of the same cause the following - months. annual survival rate was . %. complete ascites regression over - months after surgery was noted in patients ( . %), significant regression and stabilization in ( . %), moderate regression with need for periodic decompressive laparocentesis in cases. in all patients, functional liver reserves and life quality significantly improved. conclusions: the use of the given technique of refractory ascites correction, in patients with depleted liver cirrhosis, by laparoscopic sanitation with post-surgery fractional rinsing of abdominal cavity, with simultaneous decompression of thoracic lymphatic duct showed very high efficiency and deserves establishment as a clinical practice. t. urade, hepato-biliary-pancreatic surgery, kobe university, kobe, japan aim: anatomical liver resections guided by a demarcation line after portal staining or inflow clamping of the target territory were established as essential methods for the curative treatment of hepatocellular carcinoma (hcc) and then subsequently applied to other malignancies. however, laparoscopic anatomical liver resection (lalr) is much more difficult to reproduce these procedures and to confirm demarcation of the hepatic segment visually on the monitor. recently, laparoscopic fluorescence imaging system has been used as a tool for real-time intraoperative navigation in llr. the aim of this study is to demonstrate how to perform lalr using indocyanine green (icg) fluorescence imaging. methods: three patients underwent pure lalr using icg fluorescence imaging. the following operative procedures were performed: partial liver resection for hcc, segmentectomy for liver metastasis and right anterior sectionectomy for hcc. in all patients, preoperative d simulation images from dynamic ct were reconstructed using a d workstation to decide on cutting points of the glissonean branches. after mobilization of the liver, intraoperative ultrasonography was performed to identify the location of the tumor and glissonean pedicles corresponding to the tumor-bearing hepatic region. we dissected or transected the hepatic parenchyma to encircle the glissonean pedicles. after clamping or closure of them, . mg of icg was injected intravenously to identify the boundaries of the hepatic segments under near-infrared light. parenchymal transection was started according to the demarcation on the liver surface. the lateral aspect of the parenchymal transection was carried out based on the demarcation between non-fluorescing and fluorescing liver parenchyma as far as possible. results: in all the cases, demarcation lines on the liver surface could be visualized clearly after injection of icg. in addition, boundaries of cone units, segments and sections could be recognized to some extent because the tumor-bearing hepatic region became non-fluorescing parenchyma during parenchymal transection. these procedures were completed successfully, and the postoperative courses were almost uneventful. aim: sintrahepatic cholangiocarcinoma is the second most common primary liver cancer after hepatocellular carcinoma (hcc). although the laparoscopic approach of these tumours is not frequent due to its complexity, it is performed increasingly by hepatic surgeons.traditionally, the abdominal surgery in cirrhotic patients has been reserved to selected cases secondary to the high rate of complications. the advance on the treatment of the hcc on liver cirrhosis and the higher safety when performed by laparoscopic approach has encourage some surgeons to extend surgery to child b-c or portal hypertension patients. methods: we present a male of years old, diagnosed in of liver cirrhosis accompanied with portal hypertension. on mri in was found a solid lesion of mm located on segment ii hepatic. biopsy confirmed the diagnostic of intrahepatic cholangiocarcinoma. after a liver function evaluation (child c, meld ), an hepatic chemoembolization was performed. sequentially ct scans indicated a complete radiologic response. after years of follow up, mri showed a recurrence of mm between segment ii and iii of the liver.on multidisciplinary committee liver resection was decided due to suitable liver function and low aggressiveness of the tumour. a laparoscopic left lobe liver resection was performed. sonastarÒ and ligasure tm were used to perform the liver transection and endo gia tm for portal and hepatic veins sections. the surgery develop was complicated due to trend to bleeding that finally was achieve through cauterization. results: early after the surgery, the patient presented a haematic debt through the drain of cc accompanied of hypotension, therefore an emergent surgery was indicated. an exploratory laparoscopy was performed finding hemoperitoneum and diffuse bleeding of the liver surface that was controlled. the patient had a proper recovery and was discharged on the th day post-surgery. the analysis of the specimen showed a . cm cholangiocarcinoma with a . cm margin of resection. conclusion: there is an augmented risk of complications on liver resection of cirrhotic patients with portal hypertension. the laparoscopic approach allows to reduce potential complications, despite bleeding continuous to jeopardize this surgery, this option could be proposed on selected patients. introduction: accessory spleen itself is found in approximately % to % of the population. most ( %) are located near the splenic hilum but intrapancreatic accessory spleens (ipas) are the second most frequent location ( . %) of accessory spleens. in adults, ipas are clinically silent. they may become clinically important because of their radiographic similar appearence of cancer. intrapancreatic accessory spleen is a rare cause of pancreatic pseudotumors and is located in the pancreatic tail in approximately % to %. ipas can be difficult to differentiate radiologically from hypervascular pancreatic tumors such as pancreatic endocrine neoplasms because theycan share a similar enhancement pattern. as a result, most of the reported cases of ipas have been diagnosedonly after distal pancreatectomy was completed. material and methods: we present the case of a -year-old male patient with a history of large vessel vasculitis followed-up for rheumatology, which showed a pancreatic nodule in a control ct so he was referred to digestive for study. an echoendoscopy was performed. it showed, at the level of the tail, in the third distal, a lesion of x mm, hypoechoic, with rounded morphology and well-defined edges that can not be biopsied given the absence of adequate window for the realization of fine needle aspiration biopsy (fnab). based on these radiographic findings, the differential diagnosis included a pancreatic endocrine tumor. due to the high suspicion of malignancy and the absence of biopsy, he was referred to general surgery for scheduled surgery. a laparoscopic corporocaudal pancreatectomy was performed without incidents and the definitive histology showed an intrapancreatic accessory spleen in the pancreatic tail that excluded the presence of cancer. conclusion: intrapanceratic accesory spleen is a challenging diagnosis to make and it should be included in the differential diagnosis of pancreatic neoplasm. its early identification precludes surgical resection. however, the preoperative diagnosis of ipasmay be difficult, and distal pancreatectomy is a safe and relatively simple operation, most of the reported cases of ipas being diagnosed correctly only after surgery there are various options for treating pps. this paper describes our tailored and methodological approach to laparoscopic drainage of pancreatic pseudocysts based on an anatomical classification. methods: we adopted the laparoscopic approach in patients who had pps requiring surgical drainage. the laparoscopic method had been decided according to preoperative computed tomography (ct) and intraoperative findings. the results shown represent median (range). the aim of this work was to decrease mortality and morbidity in patients with combined trauma. methods and material: for years patients were brought to our clinic with combined trauma. everybody was performed ct and ultrasound examination. patients were performed open laparatomic operation due to massive liver rupture, spleen rupture and massive trauma of bowels, pancreas and kidney with massive bleeding. in circumstances we didn't found the trauma of the abdominal organs and the massive abdominal bleeding after ct observation. those patients were cured conservatively. in circumstances with combined trauma after ct examination we performed laparoscopic operation. in circumstances from the patients, who we started laparoscopic operation in, we conversed to laparotomy, due to massive liver rupture, and trauma spleen and hollow organs. in those circumstances we performed urgent laparotomies with suture ligation of bleeding points, suturing of liver and hollow organs and drainage of abdomen cavity. results: we performed laparoscopic operation in patients. in circumstances with trauma of liver we performed laparoscopic electro coagulation and argon-plasma coagulation. in circumstances with trauma of liver we performed electro coagulation with packing the omenture to its surface. in circumstances with trauma of spleen we performed argon plasma coagulation and used fibrin glue. after laparotomic operations mortality were in circumstances, morbidity were in patients. after laparoscopic operation mortality were in circumstances of severe combined trauma with multiple abdominal trauma and morbidity in patients. conclusion: laparoscopic operations in patients with combined trauma decrease mortality and morbility. aims: in laparoscopic distal pancreatectomy, getting away liver and stomach from the surface of the pancreas is sometimes difficult. when we separate the pancreatic body from the retroperitoneum, we must not injure the pancreas to prevent breaking a tumor. when we cut the dorsal side of the spleen from the retroperitoneum, we rarely cut into the spleen accidentally. based on our experiences, we gradually explored a set of procedural operation steps to resolve these problems. our three-step maneuver simplifies the procedure and improves the efficiency and safety of laparoscopic distal pancreatectomy. methods: as the first step, to get away the liver we sutured the round ligament of liver and crus of the diaphragm using - pds and the both ends were tugged form the outside of the body through both side of the xiphoid process. and the stomach was hung from the outside using two nylon thread like a bridge, so we could see the surface of the pancreas body with a good view. the second step was a rolling up maneuver of the pancreas. when we separate the pancreatic body and tail from the retroperitoneum, we rolled the pancreas with gauze for use in laparoscopic surgery and lifted the gauze up in only one assistant's forceps. then we could find the correct line for dissection clearly. the last step was a hanging maneuver of the spleen. when we cut the dorsal side of the spleen from the retroperitoneum, we hanged the hilum of spleen with cotton tape. with this technique we could find easily the correct line to dissect. results: the operation time was h and min and the estimated blood loss was a little. we did not injure the tumor or spleen in this operation. the patient recovered uneventfully after short hospitalization. conclusion: our three-step maneuver can be effective to perform laparoscopic distal pancreatectomy. about - % of patients with pancreatic collections will develop walled off necrosis, with an associated - % mortality. there are multiple options for intervention and drainage, usually the outcomes after endoscopic drainage are related with the nature of the collections. aims: to evaluate and present the rol of endoscopy in pseudocyst and walled off necrosis treatment, and favorable outcomes. methods and results: we present a case of a years old male, who presented biliary pancreatitis treated with cholecystectomy and transoperative cholangiogram weeks ago. he continued with persistent abdominal pain; his ct scan showed a big walled off necrosis; he was taken to surgery for an endoscopy-assisted laparoscopic cystogastrostomy with necrosectomy, he was discharged days po. conclusions: the step-up management of walled off necrosis has proven to be a better option than conventional surgical or endoscopical techniques alone; by reducing complications and mortality vs conventional necrosectomy. the use of endoscopic treatments reduce the pro-inflamatory response. drainage of walled off necrosis can be done by a transpapilar or transmural endoscopic apporach each one with its own advantages. some authors avoid the use of endoscopy in walled off necrosis because of a higher rate of complications, re-interventions and a greater lenght hospital stay. in our experience, we have achieved excellent results with this combined technique. nearest and long- patients underwent chemotherapy after electroporation procedure. day mortality was . % (n = ) in electroporation group. it was found that erreversible electroporation improved local recurrence-free survival ( and months, respectively, p = . ) and distant recurrence free survival ( and months, respectively, p = . ) . overall survival was and months, respectively (p = . ). conclusion: irreversible electroporation of locally advanced pancreatic cancer is safe. four month chemotherapy followed by surgical procedure is associated with good local response and better overall survival compared with chemotherapy alone. these data will be validated in further multicenter study. introduction: pancreatic pseudocysts are the most frequent complication of acute or chronic pancreatitis. usually asymptomatic, they can be managed conservative or, in case of complications, by several methods, endoscopic, percutaneous or by surgery. material and method: we present the case of a years old patient known with an episode of acute pancreatitis five years ago, who was hospitalised now for an upper gastrointestinal bleeding with hematemesis. the upper endoscopy showed a subcardial bulking with an erosion of the posterior gastric wall, with signs of recent bleeding, managed by clipping. patient work-up showed a cm pancreatic pseudocyst at endoscopic ultrasound. taking into consideration the history of the patient, the size and the complication of the cyst, the patient was proposed for a drainage intervention. results: a minimally invasive approach was decided. using ultrasonography guidance, a posterior gastrotomy was performed with the cystotome, establishing the comunication with the pancreatic pseudocyst. dilatation of the path with mm cre baloon, with partial evacuation of turbid liquid. the drainage consisted in pigtail fr plastic stents. the patient was discharged the following day in a good health condition.the endoscopic ultrasound control at weeks showed complete resolution of the pancreatic cyst and was followed by stent removal. the endoscopic drainage of the pancreatic pseudocyst represents the first treatment option as an alternative to the surgical intervention, being minimally invasive, with low risk and fast recovery. clinical case report: a -year-old man was admitted to the hospital with a diagnosis of severe acute pancreatitis and multi-organ failure. during the first month patient has in uci and non invasive procedures were attempted: enteral feeding by a nasoduodenal tube was started and antibiotics were administered to control sepsis. on day , percutaneous drainage was performed for large retroperitoneal abscess. on days, endoscopic transgastric necrosectomy was performed and the left collection was resolved. due to the multi-organ failure persistence and the evidence of size increase of the right retroperitoneal collection, a vard was decided.the right collection was accessed following the previously pigtail catheter. a mm trocar was placed to create retro-pneumoperitoneum with a pressure between - mmhg. a trocar of mmhg was placed, purulent content was aspirated and a debridement was performed. irrigation and aspirate was performed with normal saline and povidone-iodine solution. drainage was used to perform washes with physiological saline and urokinase.on days, the ct confirmed collection resolution. on days he was discharged. after months, the patient is in good clinical condition. discussion: drainage of the retroperitoneal abscesses via laparotomy is highly invasive and risky. vard enables radical necrosectomy and drainage less invasively. in this patient, the complete resolution of the right collection is obtained with retroperitoneal debridement without complications. we conclude that careful retroperitoneal necrosectomy is a valid alternative for the management of right collections. aims: in this study we analyze laparoscopic approach for hepatocellular carcinoma in order to clarify iwe can take advantage in some outcomes as complications, postoperative recovery or long-term survival outcomes. methods: a retrospective case consecutive study has been taken analyzing: age, sex, body max index, comorbidity, surgical extension and tumor size. the outcomes analyzed were: operation time, intraoperative blood loss, blood transfusion, postoperative morbidity and mortality, intensive care stay, hospital stay, tumor size, r resection, conversion rate, early reintervention, disease-free survival rate, overall survival rate results: in this study patients were analyzed males and females with ages between and years (mean age ) and diverse comorbidities: arterial high pressure ( / ; %), diabetes ( / ; , %) ; dislipemy ( / ; , %) , hepatophaty measured as liver cirrhosis ( / ; , %). all of them underwent laparoscopic liver surgery, in cases non-anatomical resection was performed while in the other a segmentectomy was performed. in cases the laparoscopic was strict, in and assistance incision was needed. operative time was - min (mean: min). blood loss mean was , g/dl and only intraoperative transfusion were needed. massive blood loss was reported in case. postoperative medical complications were observed: hepatic failure and renal insufficiency and in case we observed a postoperative hemorrhage that needed an urgent reintervention. the mean of intensive care stay was day and hospital stay was . days. about oncological outcomes r resection was achieve in / ( %), r in / ( %). at years / cases were free disease, dead by progression of disease and dead by other causes. aim: the purpose of this study is to analyze our initial experience with laparoscopic duodenopancreatic resection. introduction: laparoscopic procedures have advanced to represent the new gold standard in many surgical fields. laparoscopic pancreatoduodenectomy and laparoscopic distal pancreatectomy(ldp) are advocated to improved perioperative outcomes, including decreased blood loss, shorter length of stay, reduced postoperative pain and expedited time to functional recovery. however, the indication to minimally invasive approach for pancreatic surgery is often benign or low grade malignances. material and method. the steps of ldp procedures are similar to the open procedure. we perform destructive part of procedure totally laparoscopically and we prefer to do reconstructive part of procedure using hand-assisted techniques. for the period - , we have been perform pd, ( %) we have done with laparoscopic approach. ( %) of patients were operated totally laparoscopic and ( %) of patients were operated by handassisted techniques. results: a significantly higher conversion rate was encountered when lc was done - weeks after es, as compared to week after ercp. it is estimated that pancreatitis after ercp affects roughly three to percent of patients and many endoscopists quote a post-ercp pancreatitis rate of - %. however, - % is probably a more realistic answer for the majority of ercp endoscopists. wise endoscopists inform their patients that there is a spectrum of post ercp pancreatitis severity, from mild ([ % of cases) to severe ( - % of cases). in mild forms, pancreatitis after ercp may resolve itself. conclusion: endoscopic retrograde cholangiopancreatography is a procedure used to diagnose and treat disorders involving the pancreatic and bile ducts. acute pancreatitis is the most common and feared complication of endoscopic retrograde cholangiopancreatography. the assumption is that the duration of the laparoscopic method is longer, but on the other hand the patient have better wound healing and fewer possibility of developing postoperative hernia . the postoperative period is much more simple due to the significantly shorter hospitalization and the faster recovery, and according to patients the level of pain is much smaller as well. however the oncology results are the same. introduction: spiegel hernias are a rare, representing only between . % and % of all abdominal wall hernias. due to its location, below the spiegel line, its diagnosis requires a high index of suspicion. the physical examination only detects % of the spiegel hernias and, in many occasions, imaging tests are necessary for the diagnosis. goals: our objective is to describe the case of an urgent laparoscopic repair of a case of high grade bowel obstruction secondary to a spiegel hernia. material and methods: we present the case of a -year-old male patient with no medical history that comes to the emergency department of our center due to an eight hour evolution of abdominal discomfort associated with nausea without vomiting or other symptoms. the patient was afebrile and hemodynamically stable at all time. on physical examination, the abdomen is soft and depressible, painful on the left flank where a tumor compatible with spiegel's hernia is palpable. in the blood count there is no leukocytosis nor alteration of inflammatory parameters. an abdominal computed tomography (ct) scan was requested from the emergency department which demonstrated a high-grade small bowel obstruction caused by an entrapped loop of distal jejunum conditioned by a left-sided spiegel hernia. given the situation, an informed consent was obtained, and the patient was taken to the operating room for emergency laparoscopic repair. we performed a laparoscopic hernioplasty with ventralpatch mesh between oblique major and transverse and primary closure of defect in continuous suture. after this, the evolution of the patient is favorable, with good oral tolerance and re-establishment of intestinal transit, being able to be discharged h after surgery. the spiegel hernia is a rare entity that requires a high index of suspicion for its diagnosis. despite the limited evidence published in the literature on the laparoscopic repair of incarcerated spiegel hernias, the studies published so far suggest that the laparoscopic repair is a valid alternative to the classic approach when it is performed by a well-trained laparoscopic surgeon. introduction: repair of lateral abdominal wall hernias (both primary and incisional) can be challenging due to the complexity of anatomy, issues with fixation and the low incidence of such cases. a good understanding of abdominal wall and retroperitoneal anatomy, coupled with proficient laparoscopic technique is essential for successful repair via the minimally invasive approach. methods: a retrospective review of a prospectively maintained database was performed to identify patients with lateral abdominal wall hernias who underwent laparoscopic repair from january to july . results: patients with hernias were identified ( primary, incisional). mean patient age was (range - ) and mean bmi was . kg/m (range . - . ). according to ehs classification, the incisional hernia defects were located at subcostal (l , n = ), flank (l , n = ), iliac (l , n = ) and lumbar (l , n = ) regions. background: it is commonly admitted that laparoscopic surgery has the advantage of abdominal wall preservation. however, the increased use of laparoscopy has resulted in certain complications specifically associated with the laparoscopic approach, such as trocar-site incisional hernia. until today, it is not finally clarified 'patient-dependent' factors contributing to the occurrence of postoperative hernia after laparoscopic abdominal surgery. methods: between and , patients were operated due to trocar-site incisional hernia in one surgical centre. 'the patient-depending' factors which caused postoperative trocar site incisional hernia data was collected and retrospectivily analysed. results: port site incisional hernia occurred in % ( patients) after the use of trocars with mm or larger diameter. the presence of metabolic syndrome was the decisive factor in the development of postoperative incisional hernia in % ( patients). in % ( patients) the postoperative hernia occurred on the background of a long cough symptoms caused by chronic obstructive pulmonary diseases. the cause of postoperative hernia in % ( patients) of patients was the condition of lifting a one-time severity or heavy physical work. in % ( patients) of postoperative patients hernia developed due to prolonged constipation of chronic inflammatory colon diseases. conclusions: thus, when the aponeurosis of the trocars is adequately closed, the reason of the occurrence of postoperative hernias was caused by patient-dependent factors which increase intra-abdominal pressure. for this method, small midline incision cm in length - cm away from hernia orifice was carried out initially. dissection of intraperitoneal adhesion was carried out by sils with sils device. subsequently after closure of initial laparotomy unilateral anterior rectus sheath was incised from the same incision and dissection of retro-rectus space up to preperitoneal space was done under laparoscopic vision. dissecting the other side was carried out by same fashion. initial dissection of linea alba could be done by open surgery from initial incision. further dissection of linea alba, retro-rectus space, and hernia orifice was carried out by sils. defect closure of anterior and posterior rectus sheath using barbed suture was also done by sils and self-grip mesh was inserted. additional trocar to assist retro-rectus dissection, defect closure, and decompression of intraperitoneal cavity was inserted as required. aims: the laparo-endocsopic approach of inguinal hernia contiue to bring many clarifications concerning inter-parieto-peritoneal space of this region through in vivo exploration, obtained by magnification by means of specific optic intrumentation. our study aimed to revalue the in vivo fascias, to establish their embryological correspondences and to reunite the variable nomenclature existing in the classical anatomy of this region. these observations find their applicability in tapp and tep hernia procedures, as the old anatomical descriptions are no longer operative. methods: we have tried to identify the structures that delimit the anatomical regions of retzius and bogros in recording of tapp procedures performed on men, on the right side, for small indirect hernias on patintes with clear view of the structures. additional, a review of literature on this subject has been performed through a search in the detabases according to the following keywords: bogros space, retzius space, preperitoneal approach, urogenital fascia. results: retzius and bogros are the medial and lateral compartments of the inter-parietalperitoneal space, located between the transversal fascia and the parietal peritoneum. these narrow, virtual spaces are best highlighted today with the help of insufflation techniques during laparo-endoscopic procedures. a competent and careful dissection confirms a 'deep and superficial' stratification, highlighting embryonic relics derived from the uro-genital fascia: urinaryprevesical fascia and spermatic fascia. in addition, the real retzius space is located previously and the real bogros space is located behind this strcuture. the confluence area of the two spaces is a critical point of laparo-endoscopic dissection, its non-recognition may 'wander' the dissection. conclusions: literature data in this topic reflects a certain terminological confusion using general terms such as 'preperitoneal tissue' or 'arreolar tissue' to denote what we consider to be the urogenital fascia or its prologations. the data obtained were synthesized in several drawings and diagrams very useful in training surgeons to use tapp / tep techniques. aim: spigelian hernia containing epiploic appendage is really rare entity. in this paper, we present a very rare case of spigelian hernia involving epiploic appendage performed laparoscopic hernia repair. case report: a -year-old woman presented to the emergency department with sudden onset abdominal pain in the left lower quadrant. on physical examination, she had a small, palpable tender mass in the left lower abdominal quadrant. temperature and white blood cell count were normal. an inflamed epiploic appendage with an oval shape, a fatty core, and a central thin hyperdense line in the hernia sac was detected on abdominal computed tomography. its intraabdominal relationship with the normal wall of the sigmoid colon was well appreciated (figure a, b) . diagnostic laparoscopy was performed. (figure ) adhesions between the sac and epiploic appendage are released using sharp dissection. a peritoneal flap is then created (figure ). laparoscopic tapp repair was used without closing the defect (figure ) . the patient was discharged on th days uneventfully. aims: morgagni's hernia is an in infrequent, congenital, anterior or retrosternal diaphragmatic defect. the right side is the most frequently affected, up to % of cases. it represents between and % of congenital diaphragmatic hernias. in childhood, they usually attend asymptomatically or with respiratory symptoms. up to % are diagnosed in adulthood, incidentally or after gastrointestinal obstruction debut. the treatment is surgery, which can be by laparoscopic or open approach.we present a case of laparoscopic approach with intra-abdominal mesh placement of giant morgagni's hernia diagnosed in senile age. methods: -year-old woman with a history of advanced alzheimer's dementia, partially dependent in daily life activities and institutionalized who consulted for intermittent episodes of oral diet intolerance associated with vomits of one month of evolution. abdominal examination was anodine. chest radiograph revealed a right lower lung field mass with fluid collected. thoracoabdominal scan showed small bilateral pleural effusion and large, right anterolateral morgagni's hernia, which contains dilated segment of transverse colon and greater omentum . results: laparoscopic approach was performed. hernia was reduced and hernia sac was removed. the defect was repaired with a dual-component (absorbable and non absorbable) mesh anchored with intracorporeal suture. patient recovered and was discharged days after surgery. conclusion: laparoscopic approach for morgagni's hernia reapir is secure and offers the advantages of less post-opertive pain, faster recovery and short postopatory stay. introduction: recently, laparoscopic operations for ileus are increasing. we have undergone laparoscopic operation to adhesive ileus with umbilicar incision at the beginning. the umbilicar incision at the beginning makes it possible to secure the laparoscopic field by peeling the adhesion under direct view, and makes it easy to repair damage to the intestinal tract. surgical procedure: at first, the umbilicus - cm incision was made and peeled the adhesion as much as possible under direct vision. secondly, ez access was set and inserted one mm port, therefore laparoscopic operation was performed with or pieces of mm ports. when the repair or resection of small intestinal due to damage is necessary, it is pulled out through the ez access. objective: to investigate the possibility of problems of laparoscopic ileus operation to adhesion ileus by umbilicar incision at the beginning. introduction: small bowel obstruction (sbo) during pregnancy is a rare condition with an incidence of . - . % and in around % of cases it is most caused by adhesions from previous abdominal surgery. other diagnosis, such as, hernias, malignancy, volvulus or intussusception are extremely rare. when sbo occurs in pregnancy, it carries a significant risk to mother and fetus. its diagnosis of can be difficult to make as symptoms are often attributed mistakenly to the pregnancy. goals: a case report of congenital bowel obstruction during the second trimester of pregnancy handled by laparoscopy. material and methods: we report the case of a year old woman with a history of chronic lung disease, pregnant because in vitro fertilization ( ? weeks) who attended the emergency department with abdominal pain and bloating accompanied by nausea and vomiting for two days. on physical examination she showed a distended, soft, depressible and painful abdomen without peritonism. laboratory tests were normal. a nasogastric tube was placed with generous output fecaloid intestinal contents. abdominal ultrasound by expert radiologists in abdomen showed a moderate amount of free abdominal fluid with normal uterus moderate and sbo to the ileum because of intestinal adhesion. this results were confirmed with an magnetic resonance imaging (mri). results: the patient was operated by laparoscopic approach with three trocars. the main problem was discovered. we founded a congenital adhesion which conditionated the obstructive syndrome. postoperative recovery was uneventful and the patient was discharged h after surgery. conclusion: the non-obstetrical acute abdomen in pregnant patient is a reality that occurs in one of every pregnancies. its diagnosis in more difficult than in nonpregnant patients requiring or high index of suspicion. the laparoscopic approach of acute abdomen during pregnancy is a valid and safe option, even in the early hours after diagnosis of bowel obstruction when it is performed by a well-trained laparoscopic surgeon. aim: intestinal malrotation (im) without midgut volvulus in adults is a rare clinical entity, which is the result of an incomplete rotation of the small bowel during embryogenesis, due to the nonlysis of the ladd bands. these ligaments spread between the duodenum and caecum and do not allow the gastrointestinal tract to take its normal position into the peritoneal cavity. im appears in to - newborns and is usually asymptomatic. diagnosis is usually made in the first month, and presents with findings of an acute abdomen, small bowel ileus and volvulus. im in adults is a rare entity. most of the times it is asymptomatic, but it can cause chronic abdominal discomfort and constipation. we present the laparoscopic management of an adult patient with intestinal malrotation. methods: our patient, a year old female, presented to the emergency room with a -month history of abdominal pain and nausea. all blood tests were normal. an abdominal mri showed intestinal malrotation without volvulus. due to persisting symptoms, she underwent a diagnostic laparoscopy with complete lysis of the ladd bands. the only unusual finding was a slight oedema of the duodenum. results: her symptoms settled postoperatively and she was discharged on the nd postoperative day. since her discharge, she has not developed any similar abdominal pains or complaints. conclusions: symptomatic intestinal malrotation in adults is an unusual clinical entity, but it is definitely one of the differential diagnoses we need to consider in case of chronic abdominal symptoms. the management consists of the division of the ladd bands, and this procedure can be performed safely with laparoscopy. many small intestinal obstructions are due to adhesions after laparotomy, but small bowel obstructions without history of open surgery is relatively few. in diagnostic imaging such as preoperative ct examination, the cause is diagnosed to some extent, but details are sometimes unknown unless operative observation is actually made. in many institutions, laparoscopic surgery is also actively introduced into the operation to relieve bowel obstruction, and its effectiveness is beginning to be recognized. we examined the usefulness of laparoscopic surgery for patients with small bowel obstruction without history of laparotomy from experience in our hospital. aim: from december to october , we searched cases of laparoscopic surgery for a small bowel obstruction without previous laparotomy at our hospital, and clinical findings, surgical results, and postoperative course were examined. results: there were ten cases. eight men and two women. the median age was years ( - yrs.) . reasons for intestinal obstruction were adhesions cases, internal hernia cases, persimmon stones case, small intestine tumor case. four cases of adhesions were emergency surgery. there were cases of emergency surgery and waiting surgery. five laparoscopic operations were completed and five cases during laparotomy transition. the median surgical operation time was min ( - min), and the median bleeding amount was g ( - g). there was no fatal case after operation, only one complications of ileus. the median length of hospital stay was days ( - days) . conclusion: laparoscopic surgery for intestinal obstruction with no history of laparotomy was thought to be a safe and effective procedure. although the transition to laparotomy would be higher in case of emergency, but there was no case of large incisional laparotomy. conclusions: laparoscopic surgery for sbo reduces postoperative complications and contributes to shortening the postoperative hospital stay and to decreasing the rate of recurrences, although it is a retrospective study, which is a safe and a useful approach. furthermore, first episode of sbo without previous operation seems to be an appropriate indication for laparoscopic surgery. background: postoperative adhesion after abdominal surgery may cause intestinal obstruction, chronic pain, or female infertility, which constitutes the major problems after surgery. adhesion formation are reported to be reduced by laparoscopic surgery and the use of anti-adhesion barriers. seprafilm composed of sodium hyaluronate carboxymethylcellulose bioresorbable membrane has been widely used to date, especially in open surgery. the characteristics of seprafilm, which is easily stick when wet, conversely brittle when dry cause it difficult to deliver into the abdominal cavity via the small incision in laparoscopic surgery. therefore, seprafilm is not much used in laparoscopic surgery. although various methods of insertion of seprafilm have been reported, some need special devices, or some acquire skill. methods: we adopted the pre-moistening technique for the replacement of seprafilm in consecutive cases of laparoscopic gastrointestinal surgery. a sheet of seprafilm was cut into equal pieces. to soften the sheets, one of the pieces was placed on a folded wet gauze until it became naturally curled then it was reversed, and the same procedure was repeated. softened sheet is easily to deliver into the abdominal cavity via a small incision by pushing with digital finger. moistened sheet expands naturally in the abdominal cavity. one or two pieces were needed to cover the incision. this process took only a few minutes. results: in all cases, the sheets were successfully introduced into the abdomen and spread widely enough to cover the incision. there have been no adverse effects, no postoperative complications, or gastrointestinal obstruction due to adhesion in the observation period of median two years. conclusions: short term outcomes were good after applying this technique. however, to record the incidents of intestinal obstruction and chronic pain, over years observation is indispensable. long term follow-up studies are required to clarify the usefulness of the anti-adhesive barrier in gastrointestinal surgery. b. east, rd department of surgery, motol faculty hospital, prague, czech republic aim: since when the ipom acronym was used for the first time our views at intraperitoneal mesh positioning has changed several times. despite growing evidence on its possible long term consequences it is still preferred method at some centres for large number of patients. the aim of this study is to point out the pitfalls of this method but also show that ipom is a good technique but only for highly selected cohort of patients. methods: this is a review of the literature focusing on the indications and complications of ipom pointing out controversies among the published articles over last two decades. some mesh material characteristics are being discussed as they are basic for understanding this complex and highly sensitive issue. results: a wide range on indications of ipom from little umbilical to large incisional hernias is advocated by many. however, some opinion leaders promoting this technique as universal and ideal for everyone just few years ago are advising to avoid it if possible lately. a necessary overlap has also been questioned recently. despite improving anti-adhesion barriers and methods of fixation in may a surgical mesh has become classified as risk class iii by the eu parliament and council on medical devices hoping to prevent physiomesh like incidents in the future. the need for post market registries and long term follow up is obvious. conclusion: us as surgeons implant a mesh in our patients and therefore we should be aware of its possible long term effects. no mesh on the market has a long term safety evidence especially in the intraperitoneal space. ipom is a good technique but possess a significant risk of long life complications and therefore should be spared only for those unfit for other methods of repair, patients with too high mesh infection risk, obese or older patients. introduction: acute appendicitis in elderly patients is relatively uncommon and could represent an underlying neoplasm. hence patients over the age of are often referred for a follow-up colonoscopy after management of acute appendicitis. the current routine use of computed tomography (ct) scans in the evaluation of suspected acute appendicitis in elderly patients prior to surgery coupled with intra-operative findings at laparoscopy question the role of follow-up colonoscopy for these patients. aims: to determine the role and optimal timing of colonoscopy in early detection of colorectal neoplasia after treatment of acute appendicitis in elderly patients. methods: all patients aged years and above with confirmed appendicitis admitted to our hospital during the period / / to / / were included. follow-up colonoscopy, diagnosis of colorectal neoplasia and its location in this patient cohort was evaluated. results: number of people aged and above in olol who had appendectomies from the dates / / to / / = . out of them / ( %) had full colonoscopy within years of the appendectomy.of them of the colonoscopies done were maleand were females. / ( %) of these colonoscopies were completely normal. colonoscopy identified colorectal carcinoma in ascending colon ( . %). other pathologies identified included: benign polyp ( %), polyp with low grade dysplasia ( %) and others ( . %) (lymphocytic colitis, ulcerative colitis, medication related ulceration, diverticulosis, melanosis coli, haemorrhoids). conclusions: in elderly patients above years of age: there may be an increased risk of colorectal cancer after acute appendicitis. only % of this patient cohort underwent colonoscopy after appendectomy. the current recommendations suggest the need for follow-up colonoscopy in elderly patients post acute appendicitis. further studies are needed to decide whether routine colonoscopy is indicated after acute appendicitis patients over years. introduction: it is generally accepted that the main aetiology of appendicitis is obstruction due to appendicoliths in adults and lymphoid hyperplasia in children. in contrast, incidental appendicoliths have been reported to occur in up to % of the asymptomatic population. controversy still exists regarding the association of appendicolith and appendicitis. is the appendicolith a causative factor or merely an incidental finding? aims: to determine the association between the presence of appendicolith and acute appendicitis (perforated or non-perforated) vs healthy appendix. methods: we collected the data retrospectively from the electronic records of all appendicectomies performed between january and december in our institution. data collected included: age, sex, appendix histology and the presence of appendicolith. interval or incidental appendicectomies were excluded from this study. we analysed the data using spss software version . results: during the study period appendectomies were performed (males: , females: , age range: - years). cases were histologically confirmed cases of acute appendicitis and of these, were perforated. a normal appendix was identified in cases. the remaining cases were due to chronic appendicitis, sub-acute appendicitis, lymphoid hyperplasia, parasitic infestation, and neoplasm. appendicolith was found in cases, of which were found in a normal appendix and were found in an inflamed appendix. out of the cases of appendicolith with normal appendix: cases were aged between and years old, cases were aged between and years old and case was aged between and years old. out of cases of appendicolith with acute appendicitis, cases were aged between and years old, cases were aged between and years old and case was aged over . conclusions: appendicolith may merely be an incidental finding and is not the primary cause of appendicitis. no significant correlation between gangrenous/perforated appendicitis and the presence of appendicolith. contrary to popular belief appendicoliths are more common in paediatric appendicitis than in adult cases. further research is recommended. over the last years, patient satisfaction surveys have gained increased popularity. nowadays, respect for patients' needs is central to our health care system. hospitals use patient satisfaction surveys to assess quality of care. many hospitals routinely survey patient satisfaction but relatively little data has been published. our acute surgical assessment unit operates from am to pm monday to friday and in its first year saw surgical patients, of whom were discharged and were admitted to the hospital for further management. aims: to assess the levels of satisfaction of patients attending asau at our lady of lourdes hospital. methods: a random sample of patients seen in the asau was surveyed to determine their level of satisfaction and the experience they had whilst attending asau. a novel self-reported patient satisfaction questionnaire was developed and used to assess patients' opinion regarding the treatment they received, the doctor's explanation of their condition, the waiting time and the service in asau. also the questionnaire encouraged patients to suggest improvements to the service. aim: sintestinal obstruction is a very common cause of presentation to an emergency department. the most common cause in patients with prior abdominal surgery are adhesions, but the list of differential diagnosis is large. internal hernia is a very rare cause of obstruction, with a reported incidence of between . and . %. the herniation related with broad ligament defects is even more uncommon. methods: we report the case of a -years-old woman with antecedents of liver transplant, tubal ligation and appendectomy. the patient was admitted refering abdominal pain in the epigastrium of h duration, accompanied by nausea and vomiting. on physical examination, abdomen was depressible, tender in the right low quadrant, without evidence of peritoneal irritation. laboratory studies were normal except for an elevated leukocyte count with a left shift. computed tomography (ct) revealed dilated small bowel loops with a transition point in right lower quadrant. radiological diagnosis was intestinal obstruction, with fibrous adhesion as the most probably aetiology. management was conservative at the beginning, with intravenous hydration, nasogastric tube and administration of gastrografin (diatrizoate) without a good response. results: at h, an exploratory laparoscopy was perform, finding dilatation of small bowel loops and a cm defect in the right broad ligament in which a segment of ileum was herniated. ileal segment was liberated without evidence of ischemia. the hernial defect was closed by laparoscopy with simple silk stitches. the postoperative course was excellent, tolerating oral feeding next morning. the patient was discharged h after surgery. conclusions: internal hernias of the broad ligament are an extremely rare cause of intestinal obstruction, but must be added to the differential diagnosis for female patients due to the risk of intestinal strangulation and perforation. even if clinical and radiological diagnose is difficult, ct is the best tool to delineate the cause and location of the obstruction. laparoscopy allows reduction of the hernia and closure of the defect with minimal invasiveness. because of that, the laparoscopic approach of bowel obstruction should be considered as the first choice if there is the suspicion of an internal hernia, without signs of necrosis or perforation. the laparoscopic approach is a safe and effective tool in the management of postoperative complications. it is well tolerated in critically ill patients and avoids respiratory and wound related morbidity associated with laparotomy. it also reduces diagnostic delay and a considerable number of unnecessary laparotomies, with a high resolution rate and minimal morbidity. it thus represents a valid and necessary alternative in surgeon's armamentarium. in the management algorithm of our institution we always choose the laparoscopic technique as the fisrt tool in case a reoperation is necessary. , small bowel obstruction ( . % vs . %), and colorectal cancer obstruction ( . % vs . %) was found higher for acs unit group, and also progressively higher during the last years. conclusion: according to our study, laparoscopic approach in abdominal emergencies shows an upward trend, and surgeons from acs units seem to have higher rates of laparoscopy than general surgeons in emergency procedures. background: incarcerated and strangulated hernias present a major problem in emergency medicine. there is scarce data about the role of laparoscopy in the management of these patients. laparoscopic repair offers the benefits of the ability to survey the incarcerated organ and to evaluate its viability, apart from the obvious advantages of laparoscopic surgery. the use of mesh repair in these emergent operations is also a major concern, due to the un-sterile conditions in which they are performed. objective: to evaluate the safety and short-term efficacy of laparoscopic emergent repair of incarcerated hernias. methods: retrospective review of prospectively collected data of all the patients who underwent emergent laparoscopy due to an incarcerated hernia between november and october . results: during the study period, patients underwent emergent laparoscopy due to incarcerated hernias ( females, males). had incarcerated inguinal hernias, and had incarcerated umbilical hernias. mean age was . . all inguinal hernias were repaired in the tapp approach, and using an absorbable mesh. all umbilical hernias were repaired using the ipom approach. patients had bowel obstruction, had incarcerated omentum, and one patient had incarcerated urinary bladder. patients underwent resection of an ischemic organ ( bowel, urinary bladder, omentum). mean hospital los was . days. during the follow up period there were no mortalities, and no recurrences. one patient had a wound infection that resolved with antibiotics. conclusion: laparoscopic emergent repair of incarcerated hernias is a safe and feasible approach. further studies with longer follow up time need to be conducted, in order to evaluate the added benefit of the laparoscopic approach. gibraltar is a small overseas british territory with a residential population of approximately , inhabitants, that increases up to , daily due to incoming tourists and cross-frontier workers. as a geographically isolated center we have to provide a varied service including emergency surgery, and elective operating such as colectomies, gastrectomy's etc. one of the challenges faced is the limited stock of red blood cell (rbc) units within gibraltar and reliance on platelets (plt) from across the border from spain. given the immanent brexit we need to prepare for the challenges we will face in these times of political and distribution uncertainty. a prospective audit of all blood use within gibraltar was carried out over months. the number and type of units requested, the number of units given, the speciality, location and indication for requests was recorded. introduction: the use of laparoscopic surgery in abdominal emergencies, such as in trauma, has had a slow acceptance. the advantages with this approach include less postoperative pain, faster recovery, quicker return to everyday activities, and fewer complications. we have collected the cases and indications of laparoscopy in abdominal trauma in the main hospitals in the andalusian capitals and compared with the national registry material and methods: a total of patients who underwent laparoscopic surgery in the main hospitals of seville, cordoba, malaga, cadiz, huelva, jaen, granada and almeria were analyzed. they have been compared with the traumas archived nationally by the spanish association of surgeons taking into account age, sex, score of the american society of anesthesiologists, hemodynamic stability and mechanism of injury. the intra and postoperative variables were compared between groups. results: at the national level, the main cause of abdominal trauma were traffic accidents, therefore, it was the patients who had a greater number of laparoscopies ( . %), followed by stab wounds ( , %) and run over ( . %). in our series, the average age of the patients is years and % are male. only eco-fast was performed in % of the patients, being positive in . % of the cases. as they were stable patients, in % of the cases a tac was possible. in our data, % of the laparoscopies were performed for therapeutic purposes as well as being diagnostic, thus avoiding a posterior laparotomy. conclusion: slaparoscopic surgery for abdominal trauma, either blunt or penetrating, is safe and technically feasible in hemodynamically stable patients. we found that laparoscopic surgery was associated with shorter operative time, lower estimated blood loss and faster return to normal diet. based on our findings we establish the indications of laparoscopy in these patients aims: submucosal aneurysm of small intestine is extremely rare, but its rapture can be lifethreatening. due to the unstable hemodynamics and unknown site of bleeding, emergency laparotomy has been widely performed for the rupture. we will present case reports and show the strategy for minimally invasive treatment for ruptured aneurysm. methods: we experienced two cases of ruptured submucosal aneurysm resected by laparoscopic surgery. case is a -year-old male who was taken to our er with massive hematochezia. ct showed arterial bleeding in the small intestine and angiography revealed bleeding from the ilial artery. selective embolization using gelatin sponge and micro coil was performed and hemostasis was obtained. video capsule endoscopy found the hemispheric elevated lesion with protrusion at the top in the ileum. using balloon assisted enteroscopy, the site of aneurysm was marked with injecting india ink, which allows surgeons to accurately and easily identify the part of small intestine with aneurysm. subsequently, a single incisional laparoscopic assisted partial ileectomy was performed for the purpose of definitive diagnosis and preventing re-bleeding. the ileum with aneurysm was easily identified in laparoscopic exploration owing to the marking, and it was taken out from the incision to perform resection. case is a -year-old female who was transferred to our emergency department with sudden onset of massive melena. ct and angiography were perfomed, and bleeding from the rd jejunal artery were confirmed. subsequently, therapeutic embolization was performed in the same way as case . enteroscopy revealed submucosal elevation similar to case in the jejunum. we carried out endoscopic tattooing, followed by single incisional laparoscopic assisted partial jejunectomy. results: the operative time in case and case were min and min, respectively, and the amount of blood loss was both ml. the postoperative course was uneventful in both cases. case was discharged on the postoperative day , and case was on postoperative day . conclusions: our experience indicates that ruptured submucosal aneurysm of the small intestine can be effectively managed by a laparoscopic surgery with combination of therapeutic embolization and enteroscopic evaluation, which is safe and minimally invasive. background: laparoscopic bilateral inguinal hernia repair may be completed with one large selffixating mesh crossing the midline in front of the bladder. no studies have investigated in detail whether preperitoneal mesh placement induces temporary or more lasting urinary symptoms. methods: urinary and hernia related symptoms were evaluated preoperatively and postoperatively at , and months in patients using the iciq-mluts questionnaire and eurahs-qol score. results: voiding symptoms and bother scores were unchanged at or months, but there was significant improvement at months compared with preoperative findings (symptoms p \ . ; bother score p \ . ). incontinence symptoms improved at month (p \ . ) but not at or months, with a bother score significantly improved at month (p \ . ) and months (p \ . ). diurnal and nocturnal frequency did not change significantly postoperatively, but months nocturnal bother score was decreased (p \ . ). eurahs-qol scores showed significant improvement in all domains for all measurements compared to previous measurements. postoperative symptoms were improved at months, compared with preoperative pain scores (- . ), restriction of activity (- . ) and cosmetic scores (- . ) these findings were statistically significantly (p \ . ). at months, there were no patients with severe discomfort (score = ) for any of domains. no recurrences were diagnosed with % clinical follow-up at months. conclusion: placing a large preperitoneal self-fixating mesh for bilateral groin hernia repair did not cause new urinary symptoms and demonstrated significant improvement in voiding symptoms at months. incontinence and nocturnal bother score were significantly improved. introduction: tep/tapp hernia repair is an increasingly widely used surgical methods for minimally invasive treatment of inguinal hernia. tep advantages to tapp are noincision of the parietal peritoneal sheet, therefore no need for its recovery-sewing or sticking at the end of the procedure, and no need for attachment of the prosthetic mesh to the structures of the anterior abdominal wall, which results in a reduction in the financial cost of operation.various types of meshes with different characteristics are used, depending on the surgeon's preferences.the aim of this study is to highlight mesh-related postoperative complications, which can be serious and life-threatening. material and methods: a retrospective cohort study of cases of unilateral or bilateral tep and tapp hernia repair performed at the university hospital for the period - with a study of early and late postoperative complications potentially causally related to the implanted prosthetic mesh and methods of their treatment. results: for a -year period tapp ( bilateral) and tep ( bilateral) have been performed. three complications (clavien-dindo iva, ivb and v) were found, of which were early postoperative (up to pod)-one in tapp- pod small bowel adhesive ileus due to suture dehyscense of the peritoneal sheet and adhesion of a bowel loop to the surface of polypropylene mesh.one in tep- pod-a large preperitoneal hematoma with haemorrhagic shock at years old female in anticoagulant therapy-an open revision of the preperitoneal space and definitive haemostasis; followed in pod established bladder lesion from erosion from the edge of self-locking polypropylene mesh. suture and drainage performed, but the patient died of decompensation of concomitant diseases. a late complication- months after bilateral tep-erosion of soft polypropylene mesh of sigma (probable undetectable lesion of the peritoneum) with faecal peritonitis-hartmann procedure with laparostoma followed by restitution but persistent chroniosepsis with established abscess in retzii. months after-revision with abscess incision and extraction of infected meshes. discussion: use of biologic meshes is quite expensive, however synthetic non-resorbable meshes implanted in preperitoneal layout is a prerequisite for specific severe postoperative complications. inguinal hernia repair is one of the most performed procedure all over the world, with more than million procedures performed each year, it represents one of the top three most performed procedures. the lichtenstein procedure is one of the first procedures that a young trainee in general surgery learn, not only for its reproducibility and for the great numbers of procedures that could be done in each department, but also because during inguinal hernia repair the trainee learn a lot of skills which are the basis of major surgical interventions. the surgeon's performance for any procedure could be evaluated by way of established learning curves that can predict the minimum number of procedures required to reach the same intra and post-operative outcomes as an experienced surgeon performing the same technique. the aim of our multicentre study was to analyse how many cases are required to stabilize operating time (ot) and intra and post-operative complication rates over the course of the learning curve period for a lichtenstein procedure. from january to december all lichtenstein procedures from four different institutions were recorded in a prospective maintained computer database. the results of the first consecutive procedures performed by three different trainees (group a; group b; group c) were compared with the same numbers of procedures by two senior surgeons of the same institutions (group e, group f). cusum analysis was performed to evaluate the achieving of learning curve. no differences in terms of biometric and hernia type were recorded between the five groups. cusum analysis showed that the trainees achieve the learning curve between the - procedures. no intra or post-opertive complications were recorded during the training period.in conclusion after our analysis we found that at least procedures are needed for the trainees to achieve the learning curve for lichtenstein procedures. background: since its first description in the s, the total extraperitoneal (tep) technique has established itself as a popular endoscopic method for the repair of inguinal hernias. the tep repair is generally viewed as a technically-demanding procedure requiring adequate experience to minimize and handle complications. in this case report, we describe an uncommon complication of urethral injury, which was successfully repaired laparoscopically. case report: mr r is a year old gentleman with no significant past medical history who presents to the department of general surgery, tan tock seng hospital, with a two-month history of a reducible right inguinal hernia, associated with some tenderness. an ultrasonography confirmed the diagnosis of a fat-containing indirect right inguinal hernia. in view of persistent pain, mr r was counseled for a laparoscopic repair of his right inguinal hernia. as mr r was able to empty his bladder just prior to surgery, no urinary indwelling catheter (idc) was inserted. an infra-umbilical incision was made to access the posterior rectus sheath and a balloon was used to bluntly dissect the pre-peritoneal plane. on inspection of the operating field, persistent pooling of blood was noted in the retropubic space. careful inspection revealed a defect in a tubular structure just inferior to the bladder neck. an idc was inserted, which confirmed a . cm defect in the pre-prostatic urethra. decision was made for primary repair using absorbable sutures in two layers. the bladder was subsequently filled via the idc, which did not reveal any leak. we then completed the right inguinal hernia repair using a mesh. mr r made an uneventful recovery and was discharged on post-operative day with instructions to keep the idc in-situ for two weeks. the idc was removed after two weeks and a micturating cystourethrogram was performed, which showed no filling defects along the urethra and no contrast leaks. discussion: though uncommon, urethral injuries can be a complication of laparoscopic tep repair. the key to managing these complications is in the early identification of such injuries intra-operatively. with early recognition and careful assessment, such complications can be managed laparoscopically with minimal post-operative morbidity. aim: the purpose of this study is to report surgical technique and outcome of hybrid tapp procedure (a combination of tapp and ipom) for inguinal hernia patients complicated with preperitoneal space adhesion. methods: hybrid tapp procedure is applied if peritoneal dissection or closure of the peritoneum is difficult due to severe adhesion. the peritoneum should be dissected as much as possible. for the site where adequate dissection was achieved, the collagen mesh is placed outside the peritoneum. in the part where dissection was difficult it is placed inside the peritoneal cavity. in order to prevent mesh migration, the mesh should be directly fixed to the cooper's ligament with a tacker. for this purpose, the peritoneum around the cooper's ligament must be well-dissected, even if it is strongly adhered, so that the ligament can be exposed. the crucial points in the hybrid tapp procedure are fixation of the mesh and prevention of the bowel herniation into the preperitoneal space. at the site where peritoneal dissection is possible, the mesh is directly fixed on the fascia using a tacker. if it is difficult, the mesh is placed in the peritoneal cavity and fixed over the peritoneum. if there is a risk of migration along with peritoneum, transcutaneous full-thickness fixation can be performed using non-absorbable sutures. the preperitoneal space should be closed tightly as soon as possible in order to prevent the bowel herniation into the preperitoneal space. at closure of the preperitoneal space, the peritoneum is fixed on the collagen mesh using non-absorbable sutures. objective: show a tapp approach using a self-fixating mesh( x cm. progrip tm laparoscopic self-fixating mesh, medtronic) with bipolar peritoneal defect sealing, avoiding the use of tackers and performing an easy and sutureless peritoneal closure. material and methods: years old male, asa ii, medical history of beta-latacm allergy, high blood pressure, dyslipidemia and bilateral knee surgery. diagnosed of bilateral inguinal hernia at consultation due to inguinal disconfort. surgical site infection prophylaxis with iv vancomycin. balanced general anesthesia. supine decubitus position with shoulder supporting to allow a forced trendelemburg. degree optical device with trocars disposition: one mm umbilical trocar and mm trocar in both flanks, same distance and height to umbilical trocar. peritoneal opening and flap creation with monopolar energy, blunt maneuvers and pneumoperitoneum dissection. anatomical landmarks identification(cooper's ligament, epigastric and iliac vessels, hernia defect and spermatic cord elements). reduction of hernia sac content(pseudosac in this case, direct hernia) and complete peritoneal dissection to achive a correct mesh placing. mesh is folded in parts(one inferior part, two superior parts) in vertical axis outside the abdomen to facilitate the posterior intraabdominal maneuvers. introduction: into abdominal cavity with grasping forceps and correct unfolding mesh assesment: medially(pubic bone), caudal(cooper's ligament) cranial(more than cm of hernia defect/ deep inguinal ring) and lateral(anterior superior iliac spine). finally, we use a bipolar forceps to close de peritoneal defect. in order to facilitate this step, its necessary to decrease pneumoperitoneum pressure and to use the grasping forceps to bring together both peritoneal flap edges prior to bipolar energy sealing. results: min. surgical procedure. h hospital discharge, no complications. routine outpatient follow up(week, month, months and month later) with an epididymitis episode months after surgery(treated with oral ciprofloxacin). conclusions:-this procedure is an easy implementation technique once the intraabdominal mesh unfolding procedure control is reached.-the use of a self-fixating mesh avoid the use of tackers and its potential disadvantages(e.g. increasing postoperative pain).-bipolar peritoneal sealing offers a quick, easy, cheap and safe peritoneal closure, avoiding the contact of the mesh with the viscera in the same manner. results: we performed procedures within patients. the average age was years. twenty six percent of hernias were bilateral, , % were inguinoscrotal and % in the right side. the median asa score was . the conversion rate was , %. the average duration of the procedure was , min min. overall morbidity was %. there were seromas ( , %) . on -year follow-up, one recurrence ( , %) was found and chronic postoperative pain in one case . we had no mortality. in the univariate analysis, male sex, inguinoscrotal hernias, hernias classified as nyhus a were significantly associated with overall postoperative morbidity. a chronic obstructive pulmonary disease was the only variable significantly associated with the occurrence of medical complications. conclusion: given these results, the tapp technique is a good alternative in the treatment of groin hernias. however, enhancing this approach is essential to reduce the operating time and the postoperative outcomes. introduction: studies have emphasized the impact of a strong safety culture on patient outcomes. consequently, many interventions focus on improving the safety culture, of which teamwork and safety climate are important ingredients. it is known that differences in culture and safety attitudes may also impact teamwork. implementations of safety interventions, such as a ' black box', are dependent upon these differences. the aim of this study was to assess the safety culture at the operating theatre complex, along with the theatre staff's attitude towards a specific quality improvement intervention, a black box in the operating room as a tool for structured team debriefing. methods: the validated dutch version of the hospital survey on patient safety culture was administered to all healthcare professionals working in the operating room complex at one academic medical centre. this survey was supplemented with questions regarding the use of a 'black box', a medical data recorder in the operating room, to measure the staff's attitude towards this quality improvement tool and its potential contribution to patient safety. aims: the aim of the study was to compare two methods of treatment of dunbar syndrome: thelaparoscopic release of median arcuate ligament alone and the hybrid method consisting ofsurgery and percutaneous stent implantation to celiac trunk. methods: we performed laparoscopic release of ct in the department of general, mini-mallyinvasive and elderly surgery in olsztyn in - . all of patients suffered from severepain of abdominal cavity before the surgery. three patients underwent doppler percutaneousangioplasty of the ct with stent implantation one month after the laparoscopy. results: all patients reported relief of symptoms in the first days after the operation. in two cases fromboth groups, there were a complete remission of the symptoms. in one case respectively,there was an improvement. there were no postoperative complications. the results of both methods do not show the differences therefore the surgery alone seems tobe a safe and feasible procedure. it increases the comfort of the patient and brings theopportunity for normal functioning. the method of wedge resection of lungs in patients with limited forms of chemo-resistant pulmonary tuberculosis is developed. in order to evaluate the efficacy, patients underwent surgery (the main group). for comparison, the data on similar operations in patients, made according to the traditional method (with the help of a cardboard weaving machine yo- ) were selected. compared the duration of the stage of resection itself, the frequency of need for additional hemostasis of the parenchyma sutures, the degree of deformation of the pulmonary tissue in the seam area, the frequency of postoperative complications and reoperations, the duration of postoperative inpatient treatment. the developed method, in comparison with the traditional one, has the following advantages: simultaneously leak proofness and hemostasis with minimal electrothermal damage to tissues are provided and there is no need for additional hemostasis, there are no negative effects of manual stitching of parenchyma of lung with abandonment of foreign material, a significant reduction in the duration of wedge resection of the lung from . to . min, a decrease in the number of postoperative pulmonary-pleural complications is achieved by . % and caused by them reoperations-by . %, shortening the duration of postoperative inpatient period of treatment from . to . days. introduction/aims: laparoscopy is a diagnostic and therapeutic resource that is largely used in elective gastrointestinal surgery due to its well-known advantages over the classic open approach. nevertheless, there is still some discussion about its application in emergency surgery. our aim is to analize the use of the laparoscopic approach by the members of the surgical emergency unit from our medical center. methods: a descriptive research based on the data of patients who required emergency surgery, that was performed by the members of the surgical emergency unit of a spanish hospital between november and may , was conducted. these data were analyzed according the pathology that motivated the surgical procedure and the chosen form of surgical approach (open versus laparoscopic). results: out of the patients in whom emergency surgery was performed, suffered from a pathology that actually allowed the laparoscopic treatment. laparoscopy was used in . % of these patients. according to pathology, the most common were acute appendicitis and cholecystitis, in which the laparoscopic approach was used, respectively, in % and % of the cases. regarding other less frequent pathologies, such as gastroduodenal perforation, bowel obstruction, diverticulitis and pancreatitis, laparoscopy had a less significant role. according to the year, a general tendency to increase the use of the laparoscopic approach was found, most notably in the cases of acute appendicitis and cholecystitis (with rates above % in ). conclusions: despite our positive results in the terms of the implementation of the laparoscopic approach in emergency surgery, there is still room for improvement, especially in regards of the less common pathologies. furtheremore, additional studies are needed in order to identify the factors that have had an effect, in favour or detriment, in the development of emergency laparoscopy in our center. aims: laparoscopic surgery, which produces small scars, has become widespread. when performing surgery through small laparoscopic incisions, a surgeon manipulates tools inserted into the abdomen through ports. for minimally invasive accurate procedure, the port as the pivot point should be stabilized on the abdominal wall. however, these laparoscopic incisions are loaded while manipulation because it is difficult for the port to be fixed on. thus, it is necessary for the patient friendly manipulation to be fixed the port mechanically. we developed a new pivot restraint device (prd) attached to a trocar for guiding the tool. the purpose of this study is to evaluate both of reducing the operating time and the load of the port with the prd experimentally. methods: the prd uses gimbal mechanism for two rotating axes and a linear guide mechanism for the insertion axis though into the forceps. in the experiment, the left hand forceps with or without the prd and the right hand forceps without the prd were set on the training box. the box had a measuring system created with a pressure sensitive sensor for the continuous force (resolution . n, fps) applied to abdominal wall fulcrum. the experiment task was performed as following three steps. ( ) the surgeon lifted the g weight for s at the initial position using the right hand forceps. ( ) the weight was transferred from the right hand forceps to the left hand forceps, and held for s. ( ) the weight was moved to the predetermined position, held for s, and returned to the initial position. the surgeons were five endoscopic specialists and five non-specialists. the operating time and the time ratio exceeded n for the left hand forceps were measured. two grouped datasets with or without the prd were compared using two-sided t-test. results: the prd was associated with both of reducing the operating time ( . s vs. . s; p \ . ), and the load of the port ( . % vs. . %; p \ . ) at the statistical analysis. conclusion: the prd could be used for reducing the operating time and the load of the port in minimally invasive accurate procedure. background: pathophysiological changes during laparoscopic surgery and positive pressure pneumoperitoneum (pp) may include (beside cardiovascular changes) elevated intra-thoracic as well as intracranial pressures. however, the possibility of physiological and functional cerebral impairment under pp is still debated. aim: to study the effects of pp on brain activity during different modes of anesthesia and ventilation during laparoscopic cholecystectomy (lc). patients and methods: thirty patients undergoing elective lc were divided to those who were ventilated by intermittent positive pressure ventilation (ippv, pt.) and by high frequency jet ventilation (hfjv, pt.). in those under hfjv we used total intravenous anesthesia (tiva). in those under ippv we either used inhalational anesthesia or tiva. intra-ocular pressures were detected in both eyes, trans-cranial doppler was used to measure the changes in flow of the middle cerebral artery, and cerebral oxygenation (o saturation) was measured too. each parameter was detected during anesthesia before surgery, several times during surgery under pp and after co evacuation. a novel computerized signal analysis by a continuous recording through a single electrode was done to explore cerebral cognitive activity during surgery. results: all surgeries went uneventful and without complications, pp was set to mmhg, and each patient was positioned in a degree anti-trendelenburg posture. cerebral perfusion and oxygenation were not changed significantly during pp. intra-ocular pressures decreased during anesthesia and increased during pp, but to a lesser extent under tiva. however, pressures during pp did not exceed pre-surgical values. we did not observe changes in cognitive brain activity during pp, although enhanced cerebral activity was seen under hfjv. conclusions: increased intra-abdominal pressure during laparoscopic surgery was not accompanied by decreased cerebral functions, maybe due to cerebral circulatory auto-regulation. changes in cerebral cognitive functions under hfjv might be explained either by the different cerebral effects of tiva in comparison to inhalational anesthesia, or due to dissimilar hemodynamic changes during hfjv. aims: gallstone ileus (gi) is a rare complication of cholelithiasis and accounts for . - % of small bowel obstructions. intermittent and non-specific presentation often results in late diagnosis. the triad of rigler is pathognomonic (pneumobilia, small bowel obstruction and ectopic gallstones), so an image test is usually mandatory in order to assure the diagnose. our aim is to expose our experience regarding this topic to show that a minimally invasive approach is feasible in selected cases. methods: since january we treated cases of gi, of whom ( %) underwent laparoscopic surgery. in all cases a ct was made to reach diagnosis. enterolithotomy alone is our preferred procedure for the resolution of this pathology. here we present a descriptive analysis of our data in those cases where a laparoscopic treatment was attempted. epidemiological variables, surgical technique, postoperative complications, days until hospital discharge, recurrence, etc. has been collected. results: % of patients were female( ) and % male ( ). mean age was . size of gallstones varied from to mm and ct located them all in the ileum. two conversions to open surgery were made ( %), in one case because the gallstone could not be found and in the other case due to the need of an intestinal resection. in two cases ( %) la aparoscopic-assisted surgery was performed using a pfannestiel incision for the gallstone extraction and enterorrhaphy. only one case was total laparoscopic approach ( %). two cases needed an intestinal resection and anastomosis, one of them was complicated with a leak that needed reintervention. there were two cases of recurrence during the follow-up time. hospital stay varied from to days, mean of days. conclusion: the widespread use of ct facilitates early diagnosis with high sensitivity detecting rigler's triad. a totally laparoscopic procedure might be ideal for patients specially with solitary stones even though a laparoscopic-assisted approach is an easier technique for surgeons with less experience in laparoscopic surgery. although experience in minimally invasive surgical treatment of gi is still developing, it may be recommended in selected cases and experienced hands. introduction: most of surgical interventions in hospitals in the world, where laparoscope is used, it is common that the vision inside the human body is constantly interrupted by fogging in laparoscope tip. the laparoscope fogging is caused by the difference of temperatures between the optic tip and the abdominal cavity. material and method: we replaces the traditional laparoscope for the ehs (endoscope heater system) with resistance between the internal and external tube that maintains the temperature of laparoscope at ( - °celsius) without modifying the external architecture of traditional laparoscope. results: ehs does not generates any waste like other anti-fog systems, like liquids, plastics covers or electric heater. reduces intervention time, can keep same instruments or accessories for the intervention. all of the above means a saving of resources with have a positive environmental impact. conclusions: the discomfort transmitted by surgeons about the fogging in laparoscopy tip make success of the product and it will replace the current laparoscope which is fogged. aim: synchronous locally-advanced low rectal cancer and prostate adenocarcinoma represent a rare condition and a challenging situation for colorectal surgeons and urologists. the simultaneous resection of both adenocarcinomas after long-course chemoradiation therapy combines two major surgical procedures associated with a potentially increased postoperative morbidity. in the other hand, simultaneous resections minimize the risk of difficult dissections, which are expected if the two procedures are scheduled sequentially. in the past decade, robotic-assisted minimally-invasive surgical techniques have been increasingly used to treat both rectal and prostatic malignancies. especially in case of prostatic malignancy, the robotic approach is considered the treatment of choice because it is associated with significantly lower blood loss and transfusion rate, and much greater functional outcomes compared to laparoscopy. methods: we present the case of a -year-old male patient (bmi: . ) diagnosed with a histologically proven locally-advanced rectal adenocarcinoma (ct an ) located at cm from the anal verge and concurrent histologically proven prostatic adenocarcinoma [gleason score of ( ? )] located in the postero-basal right lobe. the preoperative total-body computed tomography (ct) scan showed no evidence of metastatic disease. after discussion in a multidisciplinary meeting, the patient received a long-course neoadjuvant chemoradiation therapy (ncrt). at the restaging positron emission tomography / magnetic resonance imaging (pet-mri), the rectal lesion was classified as ymrt n . preoperatively, the surgical difficulty was assessed as high, based on the calculation of the eumarcs score (equal to / ). moreover, due to the high-risk status of the prostate cancer (gleason ), it was decided not to preserve the neuro-vescular bundles during the radical prostatectomy. results: the patient was operated on after weeks from completion of ncrt by using the da vinci robot system si with a single docking approach, as previously described, in order to address both cancers. conclusions: this video shows the main surgical steps of the simultaneous robotic resection of the low rectal adenocarcinoma first, of the prostatic carcinoma then, and the mechanical colo-anal anastomosis followed by drain positioning and ileostomy. this video demonstrates the perioperative safety and feasibility of the minimally invasive robotic approach in case of extended and challenging oncologic resections. general surgery, rambam medical center, haifa, israel year old, male patient presented with melena, without abdominal pain, nausea or vomiting. patient underwent colonoscopy and tumor was found in ascending colon (near the hepatic flexure). biopsy from the tumor has showed moderately differentiated adenocarcinoma. his blood laboratory examinations were within normal limits except of hgb level- . . cea and cea - were normal. abdominal computed tomography was normal . patient underwent da vinci robot-assisted right hemicolectomy with extracorporeal anastomosis. total operating time was min. three days after operation patient started regular diet and was discharged home on day four. final pathology result confirmed diagnosis of moderately differentiated adenocarcinoma. introduction: one of the goals of colorectal surgery is to decrease the number of leaks once an anastomosis has been performed. this life-threating entity after elective surgery has been related to the clinical history of the patients, the location of the tumor and to technical reasons, specially due to tension in the anastomosis or to lack of vascularization. tension could be identified during surgery, while vascular supply is evaluated by the surgeons based on a subjective analysis of the color of the colon/ileum. fluorescence tries to make these subjective parameter more objective in order to avoid an anastomosis with lack of vascularization, decreasing the numbers of leaks related to this factor. patients and method: the study presents a quasi-experimental analysis made from january to october in two hundred and eighty-five patients who underwent elective colerectal surgery, performing either a colo-rectal, ileo-rectal or intracorporeal ileo-colic anastomosis. vascular supply was eveluated using indocianyne green (icg) in one hundred and forty-five patients, while one hundred and forty subjects were operated in a previous period without using this technology, being considered the control group. the number of time that the attitude changed and the number of leaks were collected. results: out of the cases performed, were right colectomies (rc), left colectomies (lc) and rectal excision (re). in % the transection line was changed ( , % in rc, , % in lc and , % in rr) . in comparison with the control group, the icg group had a significantly less indicence of anastomotic leak compared to the control group ( , % vs. , %, p = , ), lower rate of terminal stoma after reoperation ( , % vs. , %, p = , ), a shorter length of hospital stay ( days vs. days, p = , respectively), and a low morbidity and mortality. conclusions: the rate of leaks after colorectal surgery decrease using icg to detect the proper transsection line before to perform the anastomosis in comparison with control group. these findings might influence in the final results although it is necessary in the future to find a system that provides greater objectivity by quantifying icg. aims: anastomotic leaks continue being one of the most important complications when a colorectal surgery is performed. this complication is usually related to the level and type of resection, the patient clinical history and surgical technique, where tension and vascular supply are the most important. indocyanine green (icg) fluorescence angiography seems to be helpful in order to evaluate the vascularization at the resection margins. methods: we have collected data on colorectal procedures that were performed by the same surgeon using icg fluorescence angiography to evaluate vascular supply to the anastomosis. in order to asses in which of the different type of colorectal procedure has more value to be used, we analyzed the type of surgical procedure, the percentage change in the resection margin and the number of anastomotic leaks (al). results: all of the cases were performed by laparoscopic approach: left colonic resection (lc), right colonic resection (rc), splenic flexure partial resection (sf), low anterior resection with partial mesorectal escision (lar), ultra low anterior resection with total mesorectal escision (ular) and total colectomy (tc). there was a change of transection line (ctl) in lc ( , %), rc ( %), sf ( , %) and ( , %) in rectal anastomosis (lar, ular and tc). as far as al we found: lc ( , %), rc ( %) and , % in rectal procedures. lc, sf and rectal procedure showed more ctl and less al, while rc showed less ctl and more al. conclusion: icg fluorescence angiography as an additional tool to try to reduce the anastomtic leak rate seems to have more value in the procedures that involve the left colon and the rectum, since that is where we have observed the greatest number of ctl, this could be explained by the riolan's arcade and the variability of the vascular anatomy. however, it seems that this is a line of research should continue developing with longer and larger studies, so in that way we can have more significant results. retrorectal tumors ara rare and often found incidentally. the majority of retrorectal tumours are benign, but they have potential for malignant transformation and therefore should be resected when found. a case of a -year-old female patient with a retrorectal tumor is showed. the tumor was found incidentally on ct scan of the abdomen for evaluation of non specific right side abdominal pain. a mri was also performed and imaging was informed as a probably congenital retrorectal tumor (tailgut cyst) there was no evidence of involvement or invasion of other structures the tumor was palpable at rectal examination. a transanal minimally invasive surgery (tamis) approach was proposed. preoperative preparation was done with a full mechanical and oral antibiotic bowel preparation. preoperative parenteral antibiotics werw administred. under general anesthesia, lithotomy position. the contour of the tumor is not visible due to the small size. palpation of tumor and placement of clips to lolocate was done. placement of gel point path and rectal insufflation. a longitudinal incision was made to the posterior left side of rectal wall. the insufflation of the perirectal extraperitoneal space allowe for excellent exposure of the tumor. the tumor was disected with ligasure. then the tumor was extracted transanally.the proctotomy was closed in a single layer with reabsorbible monofilament continuous suture (pds). no complications after the procedure. the patient was discharged at days. discusion: traditionally, the retrorectal tumors have been resected using a posterior parasacrococcygeal approach, an abdominal approach or a combined abdominal and posterior approach. with the advent of minimally invasive surgery, laparoscopyc approach has been described too. however, tamis approach is feasible, with low pain, morbidity, fester recovery and excellent cosmetic (no scare) results. it can be accomplished using standard laparoscopic equipment, with transanal access. we think that perhaps it could be the gold standar approach for this tumors. aimes: robotic-assisted laparoscopic surgery (rals) is a promising advanced technology that can overcome the inherent limitations of conventional laparoscopic surgery (cls). its advantage includes free-moving multijoint forceps, a motion scaling function, high-quality three-dimensional imaging, and stable camera work by an operator. this study aimed to clarify the short-term outcomes of rals for rectal tumors. methods: this study group comprised patients who underwent rals for rectal tumors (cancer in patients and gastrointestinal stromal tumor in patient), excluding ones with distant metastasis from november through december . the clinicopathological findings and short-term outcomes in rectal tumors were analyzed. results: the median operative time was min ( - ). the median console time was min with a median blood loss was ml ( - ). conversion rate was . % ( / ). the median postoperative hospital stay was days ( - ). patients ( . %) had postoperative complications. patients ( . %) had lymph nodes metastases. the mean harvested lymph node was . . the r resection rate was % ( / ). conclusions: these results suggest that rals for rectal tumors is safe and feasible, and the perioperative outcomes are acceptable. introduction: anastomotic healing defects are a feared complication which might have a fatal impact on the patient. fundamental conditions for proper anastomotic healing include sufficient blood supply. fluorescent angiography using indocyanine green in the spectrum of near infrared light facilitates the monitoring of tissue perfusion during a surgery. aim: a presentation of the results of our non-randomized study in which we assessed prospectively obtained data from a perioperative assessment of anastomosis perfusion by fluorescent angiography using indocyanine green during robotic rectal cancer surgery. method: thirty patients with rectal cancer, who underwent a robotic resection with primary anastomosis, were consecutively included in the study between april , and june , . the study included patients facing a least invasive surgery with a guaranteed payment by a health insurance company. during the surgery, we monitored and assessed the quality of the perfusion of the resection line of the sigmoid colon and subsequent anastomosis by means of fluorescent angiography using indocyanine green in the spectrum of near infrared light. the data were obtained prospectively and subsequently analyzed. results: between april , and june , , we consecutively included rectal cancer patients in the project: men and women. monitoring of the perfusion of the resection line and anastomosis was successful in all cases and perfusion quality was satisfactory across the sample. perfusion insufficiency requiring a change in the resection line level or anastomosis adjustments was not detected with any patient. in two cases ( . %) of tme, we gave up the planned protective ileostomy owing to quality perfusion of the anastomosis. one patient ( . %) suffered from defective anastomosis healing without clinical symptomatology (type a). we found no technical complications related to fluorescent angiography or undesirable effects due to the application of indocyanine green. conclusion: even though we did not register insufficient perfusion in our sample and hence we did not have to change the resection line level or adjust the anastomosis, we may state that fluorescent angiography performed by an experienced colorectal surgeon may potentially reduce the frequency of complications linked to defective anastomosis healing.supported by mo aims: the aim of our study is to demonstrate whether robotic surgery has any influence on the reduction of complications in the aged population undergoing rectal cancer. methods: we performed a retrospective analysis of a prospective database of patients who underwent robotic surgery for rectal cancer. we divided our population in groups: under year old, between and year old and above year old. we recorded complications in each group intra and post procedure. qualitative variables were expressed in terms of absolute frequencies and percentages and mean values and standard deviation were used to express quantitative variables. the analysis of data was applying fisher's exact test or chi-squared test for qualitative variables and variance analysis or student'-t test for quantitative variables. statistically significant values of p \ . underwent multivariate logistic regression analysis. results: the present study included patients ( males).seventy seven patients were under year old, patients were between and year old and patients were above year old. the analysis showed conversion rates of . %, . %, . %, and complication rate of . %, . %, and . % in each group. univariate analysis showed no differences between the three groups. nevertheless, there were statistical differences from bmi, asa and neoadjuvant therapy. in multivariant analysis only neoadjuvant therapy was significant. conclusions: robotic approach do not decrease complications in elderly population. introduction: it has been described the advantages of total transanal mesorectal excision (tatme), with better visualization and access to the lower rectum. we use this access whith the gel point path device, to repair a rectovaginal fistula with stenosis of low rectal anastomosis in two patients, that would be difficult by conventional abdominal approach method: we show our surgical technique for repair a rectovaginal fistula with stenosis of low rectal anastomosis in two female patients operated due to rectal neoplasia. one of the patients underwent prior chemo-radiotheratpy. rectoscopy and image test was performed at the patients prior the intervention. no recurrence signs are recorded at mri.we describe the operation technique: a new anterior rectal resection was performed with a combined transanal (gel point path) and abdominal minimally invasive approach. redo anastomosis whith eea stappler was performed, vaginal repair and epiploplasty. the intervention was especially laborious due to the fibrous tissue. pathology: fistulous path without tumor infiltration in the two patients. at two months, a opaque enema show permeability and absence of leaks in the two patients. the ileostomy was closed at three months. discusion: we believe that transanal access through the gel point path can be a good option for rectovaginal fistula and stenosis of low rectal anastomosis, allowing a better visualization and acces, and making more easy a very difficult intervention. introduction: tamis or transanal minimally invasive surgery for polyp resection has increased fame for several situations in which adenomas with or without dysplasia cannot be removed with conventional colonoscopy. in this video we show the step by step technique performed with the da vinci xi system. material and methods: in this video we show the setting and the location of the patient-side cart and the arms to perform the resection of polyps in different patients and how to develope the procedure. results: after placing the patient-side cart the arms are connected to ports and the camera, double fenestrated grasper and scissors are connected to the arms through a transanal gel-port device. a line is described around the polyp with monopolar energy to determine the place of the dissection. the scissor is exchanged by a robotic harmonic wrist instrument and the complete dissection is performed. the wound is closed using a robotic needle holder and a suture. results: transanal robotic surgery could be safely performed after a standardized technique is stablished. aims: robotic rectal cancer surgery has demonstrated to obtain at least the same results than laparoscopic surgery. however, robotic surgery is associated with high rates of costs, specially when conversion to opened surgery occurs. the goal of this study is to create a predictor nomogram of conversions for robotic rectal cancer surgery. methods: we performed a retrospective analysis of a prospective database of patients who underwent robotic surgery for rectal cancer from october to november . we performed a bivariant analysis and detected the variables which were related with the conversion: body mass index (bmi) and the t. we divided the patients of the population in two groups depends on obesity (bmi of kg/m ) and on t (t - /t - ). we registered conversions in each group calculating the pretest risk. we performed likelihood index (lr ?/-) for under and above kg/m of bmi, adding in a second step the lr of t; obtaining the prediction index for four groups by using a standardize nomogram. results: the present study included patients ( males). were under bmi of kg/m and above. regarding t, were with a tumor of t - and with t - . the analysis showed a conversion rate of the statistical sample of %. univariant analysis showed significative differences in the bmi (p = . ) and t (p = . ). a nomogram was performed; as regards the bmi, the positive likelihood index in the group of bmi [ a prediction index of conversion of % (lr ? , ) and in bmi \ the prediction index of conversion is % (lr- , ). adding the t group data, for bmi [ and t - the conversion prediction rate is . % (lr- , ); for bmi [ and t - the conversion prediction is % (lr ? , ). bmi \ and t - the conversion prediction is % (lr- , ); imc \ and t - , the conversion prediction is %. conclusion: a standardize nomogram with the variable bmi and t facilitates the selection of patients for robotic surgery in rectal cancer avoiding conversion to open surgery. background: d-laparoscopy is proven to improve performance in dry laboratory settings, especially for novice surgeons due to better depth perception. however, the benefits for experienced laparoscopic surgeons are still discussed. aim: the aim of this study is to compare the results of right hemicolectomy (rc) using a conventional ( d hd) laparoscopic system with rc performed using a d laparoscopic system in terms of duration, complications and results. material and methods: from all laparoscopic right hemicolectomies performed in our clinic we selected all procedures performed by the same team of consultant surgeons using the same technique and divided them in groups. the study group comprised of all patients operated using our d einstein vision . system; all other patients which were operated using our standard wolf hd laparoscopy system comprised the control group. all patients were retrospectively analyzed in terms of patients characteristic, or time, duration of operation, intra-and postoperative complications, length of hospitalization, pain score, necessity of analgesics and number of lymph nodes retrived. risk factors for complications (bmi, smoker, diabetes, copd, bph) were also registered. results: there were patients included in the study group, while the control group comprised of patients. mean operation time in the study group was . min in the study group, while mean or time was . min. mean operation time in the control group was . min, while mean or time . min. one reintervention was noted in the control group and two in the the study group; no conversion to open surgery was noted. there were no significant differences regarding patient characteristics, pain score, wound complications, hernia rate, length of hospitalization or number of lymph nodes removed. conclusions: there were no significant differences regarding the outcome of rc using d laparoscopy; total or time was significantly higher in the study group due to the time needed to set up the d-laparoscopy unit. this is biased by the fact that the d system needs to be set up manually while the conventional hd system is integrated in the or. also, there was no significant difference in complication rate. background/purpose: robotic approach can be a treatment option for patients with pelvic recurrence after primary resection for rectal cancer. however, data regarding patient selection, complication rates, and oncologic outcomes are rarely reported. we aimed to present initial experience and to evaluate feasibility, safety, and oncologic outcomes of robotic salvage surgery for recurrent rectal cancer. methods: ten patients who underwent robotic salvage surgery for local recurrence at the anastomotic site, lateral pelvic side-wall, or lateral pelvic lymph nodes (lpns) were retrospectively evaluated from a prospectively maintained database. results: two patients underwent pelvic mass excision with en bloc resection of anastomosis and redo-anastomosis, and eight patients underwent lateral pelvic lymph node dissection (lpnd) for lpn metastasis; one of these eight patient underwent additional en bloc resection of anastomosis. all patients achieved r resection. the median operation time was min and the median estimated blood loss was ml. there were no conversions. as for intraoperative complications, one patient experienced ureter injury during lpnd because the metastatic lpn was closely abutting to the ureter. the median hospital stay was days. in six patients who underwent lpnd, the median number of harvested lymph nodes was (range - ) and the median number of metastatic lymph nodes was (range - ). with median follow-up months, one patient developed lung and pelvic recurrence at months after salvage operation and seven patients remained in disease-free state at the last follow-up. conclusion: initial experience of robotic salvage surgery for pelvic recurrence in rectal cancer indicated that it is safe and feasible. therefore, the robotic approach can be considered as a treatment option for the treatment of local recurrence in selected patients. introduction: there is uncertainty regarding the effects of simulated patient death. several reports showed increased cognitive load and poorer learning outcomes, and others increased performance without causing stress to learners. we have not found any report studying the impact of animal death in the simulation lab. methods: this was an observational cohort study to assess the emotional and cognitive load of surgeons who experienced animal death in the simulation lab. seventy-four faculty and residents from different surgical specialties training minimally invasive surgery participated in the study. one cohort consisted of surgeons whose animal died during surgery, and the other by those whose animal survived. emotions were assessed using the scale for mood assessment and cognitive load with nasa task load index. results: twenty percent of participants experienced mortality while training anti-reflux surgery ( cases) and other procedures ( cases). causes of death included intraoperative pneumothorax (n = ), hemorrhage (n = ), and cardiac dysrhythmias (n = ). participants exposed to animal death had higher levels of sadness and anxiety, and lower levels of happiness (p [ . ). cognitive load was slightly higher in the exposed cohort (p [ . ). conclusions: these findings suggest that mortality in the animal lab do not have a significant effect on cognitive workload and emotions of surgeons training complex laparoscopic procedures. introduction: the visuospatial profiles of expert laparoscopic surgeons remain unaccounted in the current literature for as the influence of visuospatial ability on laparoscopic learning has mainly been investigated in medical students or novice surgeons and using simulators as means of performance measurement. such knowledge is critical, as without understanding how clinical experience may impact visuospatial processes in surgeons, we hinder our efforts to utilize the available knowledge to support surgical education for the future. this study is aiming to explore the development and influence of visuospatial processes on intraoperative laparoscopic learning. method: the study reports the interim baseline results from the ongoing longitudinal study throughout a -year period of training on laparoscopic surgery. data from surgeons including residents undergoing training were captured and compared to specialists who are working in departments of general and visceral surgery at two large hospitals. the mean experience of the surgical residents was years. the mean laparoscopic experience among the senior surgeons is years, with each surgeon performing an average of laparoscopic procedures per week. visuospatial ability was tested using mental rotation test (mrt), guay visualization of views tests (gvvt), spatial perspective taking and spatial orientation test (ptost) and pictorial surface orientation (picsor). spearman correlation coefficient was used in this study with a p-value of significance at \ . . results: senior surgeons have an overall good visuospatial profile, in the sense that they performed close to optimum on all measurement scales. the spearman rho revealed a significant correlation between scores on gvvt and picsor (r = . , p = . ) and between ptost and picsor (r = -. , p = . ). a significant correlation between years of laparoscopic experience and ptost score was also observed (r = . , p = . ). when comparing residents and senior surgeons, no significant difference on the mrt was observed (m = . , sd = . ), nor between baseline scores of senior surgeons and resident surgeons on all tests. conclusion: the results of this study carry important clinical and theoretical implications, as the results hint towards the idea that intraoperative laparoscopic experience lends little to no influence over the development of visuospatial ability. learning models and laparoscopic technical skills, how to adapt each case to improve objectives: according to da. kolb learning is the result of how people perceive and then process what they have perceived. the aim of this study is to identify the personal characteristics of learning in of the participants in a course of laparoscopic technical skills according to the styles described by kolb. methods: between june and november , participants performed a h course distributed over five consecutive days performing laparoscopic manual intestinal anastomosis in endotrainer. they all filled in kolb's learning style test adapted to spanish. the anastomoses were performed in 'ex-vivo' swine intestines. in each anastomosis we evaluated the quality at the end and execution time. the test and quality variables were analyzed through statistical studies. results: in our study, % of the participants were women and % wew men. %were staff surgeons and % were resident. the median age among residents was years and among the staff years. the most frequent learning model in the sample studied was converging ( %). the predominant model among women was assimilating ( %), which, however, represented only % in men. in men, converging model was predominant ( %). among the staff, the most frequent model was diverging ( %). adaptation style prevailed among residents ( %), being rare among the staff ( %). the mean time of the anastomosis was min for both the adapter model and the assimilator, min, for the convergent and divergent models. the quality of the anastomosis performed by each participant was % for the adapter model, % for the assimilator model, % for the convergent model and % for the divergent model. the predominant style in our study was convergent. among women, the most frequent model was assimilator wheras in men it was the least frequent. in the residents, the most frequent model was adapter however, it was very rare in adjuncts. among residents we do not find divergent styles. the highest quality of the anastomosis was achieved by those who worked with an assimilating style. knowing previously the training style we can individualize the teaching methodology in order to improve competences. aims: assess whether laparoscopic appendicectomies (la) are a superior option to open appendicectomies (oa). specifically, comparing the time taken, complication rates and whether it is more appropriate to perform an la overnight, as opposed to oa. finally, to find out how a range of outcomes differs between different grades of surgeon. methods: an information request was sent to the clinical coding department to derive patient identification numbers for all appendicectomies over a ten-month period ( total surgeries). these numbers were then inputted into the hospital information system where the electronic operation note is present, and specific outcomes were derived and analysed. results: % of operations were oa and % were la. mean la times for consultants, sas and spr were . , and min respectively and oa , and min respectively. their respective conversion rates were %, % and %. oa had a complication rate of . %, la was . %. conclusion: oa are performed more than la. spr doctors had the slowest completion times for la but the lowest conversion rates. sas doctors had the fastest completion times for la and oa but higher conversion. la takes longer than oa but has lower complication rates; key factors when performing at night. key statement: laparoscopic appendicectomies require more surgeon-hours and have the potential to be converted to open, however the rates of complications and serious complications are significantly lower. background: paper based resources have been the standard sources for information for centuries. however, more and more people (patients and staff alike) are looking online for information. while the internet often provides excellent resources, there is often conflicting and confusing material of doubtful veracity. trainee staff and patients/carers should be able to access reliable resources whenever and wherever they are. the aim of this project was to create a high-quality resource fulfilling these needs. aim: we present a video demonstrating our integrated colorectal education website ( http://www.colorectaleducation.com/). our approach: high quality health care provision requires highly trained staff as well as wellinformed patients. information resources for these two groups are usually accessible from different repositories. our integrated website provides a common platform for all those involved in colorectal surgery, to use, learn and reflect on. users are directed to separate sections for patients and colorectal professionals. multiple disclaimers prevent patients accidentally stumbling across clinical/ operative information, whilst providing access to those who wish to do so. trainees struggle with balancing their educational needs with their service commitments. this website gives them the opportunity to view detailed operative training videos on the go. many of videos are chapter based allowing them to stop and re-start with ease. modules are also available for nurses providing them access to relevant educational material. the modular design of the website allows us to build upon it with more topics planned to be added over the next eighteen months. the resource also has detailed chapterised videos for patients due to undergo various colorectal procedures. all have been approved by a multi-professional panel including patients and are designed to provide information, offer support and to allay any anxiety. videos with the care pathway and previous patients' experiences are accessible on demand. conclusion: on demand information has now become the norm with the use of smart phones/ tablets. this website provides patients, surgical trainees and other healthcare professionals access to information and education in a clear and reliable format anywhere in the world. colorectal education, on demand and just a click away! objective: in the last decade the growing interest in robotic surgery is evident as shown by several published articles. the aim of the present study is to evaluate the main outcome of a single center experience and to describe the organizational system we have progressively established in our center in order to improve the development of robotic program in all surgical area. materials and methods: we report a case series of patients who underwent robot-assisted surgery at sanchinarro university hospital since the beginning of the program (october ) until november main patient demographic characteristics, type of surgery, peri and postoperative data and follow-up were evaluated. results: a total of robotic procedures were performed for a total of patients. the prevalence of malignant disease was %. a total of pancreatic surgery were performes; liver resections (mean operating time: min); gastrectomy (mean operating time min); esophagectomy (mean operating time: min); colorectal resections ( rectal resections, sigmoidectomy hemicolectomies right, left colectomy) (mean operating time: min); nissen procedures (mean operating time: min), esofagheous myomectomy for achalasia (operating time: min); adrenalectomy (mean operating time: min); three biliary surgery for benign desease, splenectomy. eight partial resection of the duodenum, one yeyunal resection, one mesenteric cyst resection and retroperitoneal tumor have been performed. conversion rate was %, total morbidity have been %. there has been no peri and postoperative mortality up to days after surgery. the average hospital stay and intensive care were respectively days (range - days) and . days (range - days). conclusions: the organizational model defined in our center is facilitating the constant and progressive development of the robotic program. a broad and flexible availability of the robotic system, a progressive increase of young surgeons joining this technology as well as the institutional and departmental economical effort are the points with which the robotic system may increase its development in a surgical department. aims: endoscopic surgery has been widespread in the field of general surgery. however, in japan, there is no standard program for endoscopic surgery training, and its competency has not been considered for the acquisition of board certified surgeon. the purpose of this survey was to investigate the current situation of endoscopic surgery training and autonomy of young surgeons for endoscopic surgery in japan. methods: the survey was planned to target general surgery members of the japan society for endoscopic surgery (jses) who was post graduate year or less. after approval by the ethics committee of jses, the request for the participating in survey was mailed to object members. questionnaire responses were available in print or online media. the contents of the questionnaire consisted of items, about the conditions of endoscopic surgical training, experienced case number, and the self-assessment of autonomy from to point by zwisch scale in specific procedures of endoscopic surgery. results: the total response rate was . % ( / ). sixty five answers were excluded due to inadequate response and answers were analyzed. of the questionnaire respondents, % were male and % were female. the ratio of board certified surgeon was %. although % of the teaching hospitals had simulators for basic training of endoscopic surgery and % of the respondents practiced basic skill of endoscopic surgery, only % teaching hospitals had specific training programs for endoscopic surgery. the surgeons who operated cases of laparoscopic appendectomy and inguinal hernia repair and cases of laparoscopic cholecystectomy, right hemicolectomy and sigmoidectomy, felt confident to perform each procedure independently. regarding with laparoscopic rectal resection and gastrectomy, even though the surgeons who had cases of experience, they didn't had confidence to perform those procedures independently. conclusions: this study is the first national survey to investigate the status of endoscopic surgery training in japan and the autonomy of young surgeons for endoscopic surgery. in order to develop a training system for not only basic skills but also advanced procedures of endoscopic surgery, cooperation of each teaching hospital, academic surgical society, medical specialty board is necessary. currently there is a debate about what is the most optimal work schedule for residents of general surgery, it is important to respect the free time of residents to avoid burnout, however it is also important have enough exposition to clinical cases that allow a satisfactory development in the clinical practice. this becomes even more important when we talk about the learning of surgical skills. this is where the laparoscopic simulation industry opens a large area of opportunity, for a reasonable price it is possible to practice basic laparoscopic skills without compromising patient safety. this is a pilot study that was carried out during the period from january to june , in a public hospital in monterrey, nl, mexico, the composition between the execution of the standardized exercises of the fls (fundamental laparoscopic surgery) in an endoscopic simulator was performed to residents of general surgery (from first to fifth year) hrs before being on call vs these same residents post call. a series of questions was asked to each resident in each measurement, so in this way they answered the same questions twice, then a comparison of the results of both questionnaires was made. the results of the exercises were assessed and rated by the same person using the criteria established in the fls for the scores of each exercise and for the final grade. an average age of years was obtained, measurements were taken of residents of which are male and female. on average, the residents before be on call performed the exercises with h of having slept while the post call performed the exercises with . h of having slept, the residents before be on call had on average . h without sleep while the post call had h without sleep. the average number of hours worked per week is h, measured by the time in and out of the hospital. in this study, conclusive results were obtained regarding the null relationship of sleep deprivation with the performance of laparoscopic skills in surgical residents. aim: 'precision cutting' is one of skills tasks of the fundamentals of laparoscopic surgery (fls) program, which is cutting a circle on a piece of gauze under laparoscope and assessed by completing time (maximum time limit: s). there is no definition of quality of the final product. the aim of this study is to develop an assessment tool of laparoscopic precision cutting and test its reliability. method: an assessment tool of laparoscopic precision cutting was developed with four items based on completion, degree of deformation, degree of being pulled, and overall appearance of the final product of laparoscopic precision cutting by experts' meetings. the scale of each item was points likert scale. a descriptive sheet with a legend and a text description for each scale (fig) was attached for assessors' reference. for our high school entry medical students, they gained hands-on experiences of laparoscopic skills first time by attending a -hour course at minimally invasive surgery training center, national taiwan university hospital (ntuh). we invited students to participate this study after this training. we collected participants' final products of ' precision cutting' station and assessed them by using this assessment tool. this study was proved by institutional review board, ntuh (irb no: rinb). results: students were enrolled between february to june . two non-medical assessors and a senior surgeon were invited to assess the products. the mean score and cronbach' s alpha value of each item were as followed: completion . ± . , . ; degree of deformation . ± . , . ; degree of being pulled . ± . , . ; and overall appearance . ± . , . . conclusions: in summary, we successfully developed an assessment tool for laparoscopic 'precision cutting' and showed its reliability. the tool could provide qualitative descriptions for objective feedbacks. validating this tool in a large scale is undergoing. purpose: to evaluate whether the participants who experienced this scenario could recall an interventional scenario for testing trainees' situational awareness and intra-operative decision making when they participated this training again. methods: we designed an iodm training course for junior surgical trainees and nurses by using live pigs since sep . in the first simulation, we created an interventional scenario and then provided an educational session. a researcher disconnected the ekg monitor on purpose for creating a scenario that the pig would lose vital signs when the team nearly finished a diagnostic laparoscopy. if the team did not aware the situation after . min, a researcher would remind the team (fig). we used a new developed assessment tool of iodm and an assessment tool for nontechnical skills for surgeons (notss) for self-evaluations and objective assessments. we also discussed with them about their reactions while encountering this interventional scenario. results: between sep to june , teams participated this training and experienced this interventional scenario. fourteen nd year surgical trainees have experienced it before. only one participant ( %) recalled it and made a quick decision while encountering this interventional scenario again. the results of iodm assessment and notss did not show statistical difference comparing their self-assessments in the first and second year. based on the analysis of the discussions, most of them remembered this this interventional scenario and reminded themselves to react it properly before the simulation. however, when they were the primary surgeon of diagnostic laparoscopy, they focused on performing this procedure and tutoring their junior trainee. they had no capacity in their brain to notice the change of vital signs. in addition, although they increased their situation awareness in clinical settings after the st time iodm training, they did not show this ability in the simulation. conclusions: recalling of an interventional scenario for testing situational awareness of surgical trainees was very poor ( / , %) among the nd year surgical trainees. qualitative analysis of discussions showed their brain capacities were occupied by performing new procedures and tutoring others. how to enhance trainees' situational awareness should be addressed. aims: a well-designed learning curve is essential to measure the progress of surgical abilities. learning curves are very important to test the skills of trainees. however, there are still no welldefined criteria for developing good learning curves. as a result, many authors use subjective evaluation criteria. the purpose of this review is to analyse this field of surgical education and to identify the key criteria for good learning curves. methods: learning curves were investigated in the field of laparoscopic and robotic minimally invasive surgery. surgery of appendectomy, cholecystectomy, cholectomy, inguinal hernia repair and gastrectomy were considered. the type of surgery, the year of publication, the design of the study, the surgeon's experience (resident, young or senior), the surgical technique, the number of patients involved in the study and the suggested learning curve by the different studies were taken into account. in the selection of articles, more importance was given to those based on the activity of young surgeons or residents. results: the literature analysis showed conflicting results. the different learning curves for the same surgery may be due to the different evaluation criteria considered. only a few studies investigate the learning curves of young surgeons and residents. conclusions: the data available in the literature on learning curves are contradictory. several factors need to be evaluated in order to create more accurate learning curves. we suggest the introduction of checklists with a score for each parameter to be examined, in order to develop more objective and standardized learning curves. aim: the uk training programme for transanal total mesorectal excision (tatme) has completed its first round of training. the study aim was to design a reporting platform that provided trainees with video-assisted feedback in a clear, concise and useful manner to support their training. methods: an established method of video analysis called observational clinical human reliability analysis (ochra) was used to assess the surgical performance of the trainees during their clinical tatme cases. a reporting form for the ochra results was designed identifying areas of difficulties in each procedure and providing error reduction mechanisms. this was piloted during the national training programme for tatme in the uk. results: the ochra reporting form underwent three modifications before the content and format was agreed upon. the final version is divided into three sections: a. case details, b. ochra findings, and c. suggested error-reducing mechanisms. for part b the tatme procedure was divided into four phases of the operation: . pursestring, . rectotomy, . tme dissection, and . connected phase when the abdominal and transanal teams work together synchronously. for each phase, ochra findings described the most frequently occurring technical inaccuracies/errors, number of consequential errors/adverse events and the most frequent and serious consequences encountered. suggested error-reducing mechanisms in part c were developed and established by an expert workshop and individual interviews with international surgeons experienced in tatme.trainee and mentor feedback stated that the reporting form had a clear format, easy to follow and understand. the error-reducing mechanisms were particularly useful and allowed the trainee to focus on improving specific technical aspects in their subsequent cases. conclusion: video analysis using ochra can provide a wealth of information on surgical performance, especially for trainees at the start of their learning curve. as an exploratory study, validation of the reporting platform is required; however, its potential to offer detailed, individualised feedback to enhance training is promising. laparoscopic pelvic surgery training program-using a new concept d-printed versatile pelvi-trainer r.c. elisei , f. graur , c. popa , e. mois , l. furcea , n. al hajjar general surgery, bistrita emergency county hospital, bistrita, romania; general surgery, regional institute of gastroenterology and hepathology ,,prof. o. fodor,,, cluj-napoca, romania pelvic laparoscopic surgery (rectal, urological, or gynecological laparoscopic surgery) is an advanced surgery which require advanced skills, not easy to acquire. there are a lot of training programs for advanced laparoscopic skills but many of them are not affordable for most of surgery residents in eastern europe, where the training programs are far behind from those in western europe. because of that those training programs need to be improved and optimized. in the european union we want equal and high skilled surgeons. this is why we designed a new concept of pelvi-trainer, a versatile one in order to offer the residents the possibility to achieve advanced laparoscopic skills like perfect coordination, precise movements, ability to cut and suture after a well defined route, all of them in the pelvis tight space. we d-printed this pelvitrainer which has multiple characteristics: cheap and easy to produce, easy to be used, versatile because offer the possibility to achieve the skills named above, and many others, but also to train on real ex vivo animal rectum (suine model). we also believe that with a proper training a medical student and a young surgery resident are able to achieve the same skills like experienced surgery residents or specialists. in order to demonstrate that we need a study to compare the time to perform or more exercises in this new concept pelvi-trainer by the medical students, young and experienced residents and surgery specialists. what we want to achieve with this training program project is to have more and more skilled surgeons in advanced laparoscopy and an equal laparoscopic surgery training all over the country, close to the level of training in the western europe. also we want this training program to make a standardization of the pelvic laparoscopic surgery training first in our country and then in other countries if possible. aims: the objective of this systematic review is to provide an evidence-based overview of the different components of laparoscopic training curricula, emphasizing the value of objective forcebased assessment and how this in implemented in modern laparoscopic training. methods: bibliographic databases of pubmed and embase were searched till april to identify studies reporting on evidence-based laparoscopic skills training. abstracts of retrieved studies were reviewed by two authors independently and those meeting the inclusion criteria were selected for full-text review. results: the search yielded a total of individual records. a total of articles were included. the articles were divided into nine different categories, which include 'metrics', 'benchmark criteria', 'measurement systems', 'timetable', 'training modalities', 'camera settings', 'training tasks', 'serious gaming', and 'competition'. a descriptive analysis of the data is provided. motion analysis parameters, such and path length and time are frequently validated and used for assessment. the results of validation studies on tissue manipulation parameters, such as maximum force and mean force show proved their discriminating power between different levels of proficiency. however, implementation of these metrics remain restrained. conclusions: numerous studies on laparoscopic skills training have been conducted over the years. nevertheless, no consensus is reached towards the use of objective assessment tools. although the value of validated metrics is described well, implementation of objective metrics is limited. we recommend to consider objective force-and motion metrics for feedback and assessment during laparoscopic skills training. surgery, regional institute of gastroenterology and hepatology, cluj-napoca, romania; anesthesiology, university of agricultural sciences and veterinary medicine, cluj-napoca, romania; radiology, regional institute of gastroenterology and hepatology, cluj-napoca, romania aims: the aim of the study was to create a new easy learning method of swine liver anatomy for residents in training. based on human liver surgical anatomy we put 'face to face' the similar structures and also the differences using ex vivo porcine models and ct reconstructions from live pigs. methods: having in mind the human liver anatomy, in the first stage we used data obtained from dissection of twelve porcine liver models to create an anatomical pattern, which summarized the most important surgical information. in the second stage, anatomical data obtained from ct scans of twelve living anesthetized pigs were analyzed. the ct reconstructions and volumetry data were added to the gross anatomy pattern to create a more complex learning module. results: the residents established the most frequent description of swine liver anatomy by putting together the information from ex vivo model dissection. the liver parenchyma is divided into four main anatomic lobes: left lateral, left medial, right medial and right lateral. all those lobes are connected only in the posterior part, which allows a very good separation between them by deep fissures. just as in humans, we found eight distinct segments with independent vascularization and biliary drainage. portal vein has a specific 's' shape; in most cases hepatic artery was found like a trifurcation and extrahepatic biliary tree has a very thin wall. in the right hemi-liver, the inferior vena cava passes through the liver parenchyma. most frequent, we found five hepatic veins which are running completely intraparenchymal. the imagistic data offered a very useful d reconstruction with anatomical positions of the vascular-biliary tree and liver segmentation and gave us the possibility to create practical scenarios for resections. perhaps the most important information was to discover and see the section plan and to calculate the volume of the remaining liver after resection. conclusions: the anatomical-imagistic pattern based on \ i[ex vivo \/i [ model disections combined with imagistic data offers a unique mindset before intervention. the concept 'human \ i[vs \/i [ swine' to create an easy method of learning for residents in training can be applied to swine liver anatomy. the learning of surgery is traditionally based on the behaviourist model . goals are set, standards of care fixed, with regular assessments of the level achieved. the teacher exercises control over the student, imposing rules and models, supported by 'reinforcing' actions (reward or punishment). the theory of skinner's program of education, from , is reflected in surgical learning. it foresees a gradual progression by level of difficulty, following a transmission-imitation model . these theories seem currently outdated to face the new challenges of medicine and surgery and to keep up with technological developments. bruner, one of the theorists of the constructivist model, proposed in a method of collaborative learning between those who teach and those who learn. the goal of the method was to improve strategic problem solving. the comparison between various perspectives (between teacher and student), allowed the learner to better absorb knowledge and improve critical thinking. in kapur published on the theory of 'productive failure'. this model makes the error of a single person useful for all his colleagues, privileges the practice of theoretical knowledge, contextualised learning as opposed to abstract learning, and 'guided' practice compared to a 'guided' theory. bruner and kapur's systems favour creativity, critical analysis of a problems origin, and the practical use of knowledge. they represent a hypothesis of learning, based on constructive discussion and a continuos 'give-take' feedback system. in order to put these new models into practice in the clinical context, one may hypothesise and propose the adoption of a formal discussion of clinical cases that are complicated or difficult. thereby making the theoretical lessons more collaborative, intuitive and inclusive. in the surgical field, one could adapt such a concept to surgery simulation, virtual reality and anatomical models. aim: large hiatal hernias have a surgical indication when the patients suffering disabling symptoms such as anaemia, dyspnea, chest pain, gastric reflux. several studies showed that in the case of large hernias the placement of a prosthesis was safe and could protect against recurrence. mini-invasive surgery is the preferred approach for hiatal hernia repair and anti-reflux procedure and the toupet fundoplication has been shown to be the best surgical technique for the hiatal hernias repair.the laparoscopic approach is currently the surgical gold standard but is burdened by technical difficulties especially in the case of large hiatal hernias. the robotic system is designed to overcome some technical difficulties of laparoscopy and the studies available in literature report the safety and effectiveness of the robotic approach in complex hiatal hernias repair. methods: we present the case of a grade iv hiatal hernia treated with a robotic approach in a years old woman (bmi: kg/m ). the medical history consisted of a road accident with a probable mechanism of deceleration, three years before. the patient had been suffering from dyspnea for three years. due to the recent discovery of an anaemia, the patient was subjected to an endoscopic examination with the identification of a voluminous grade iv hiatal hernia. a subsequent computed tomography (ct) scan showed also the partial herniation of the transverse colon. results: the patient underwent to surgery by using the da vinci robot system siÒ (intuitive surgical, sunnyvale, usa) with a single docking approach. the surgery consisted in the liberation of the hernial sac, the placement of a goretex prosthesis and the packaging of a toupet fundoplicatio. the surgery was performed without complication. conclusions: the robotic approach in the hiatal hernia surgery seems to be a valid alternative to laparoscopy, especially in complex cases. the surgical ability in robotic surgery is of paramount importance. general thoracic surgery, kawasaki municipal hospital, tokyo, japan aim: video-assisted thoracoscopic surgery (vats) with carbon dioxide (co ) for mediastinal surgery is known to improve the visualization of medaistinal space. we report our experiences with two cases that underwent vats thymectomy using co insufflation under the one-lung ventilation general anesthesia by double lumen tube. methods: the instruments that were used for vats thymectomy were only the -mm -degree rigid thoracoscope, maryland jaw energy device, cotton made-dissectors, and straight endoscopic grasping forceps. they were used through sealed ports designed for laparoscopic surgery. lowpressure co insufflation set at mmhg were used for compression of surround tissue of mediastinal tumor during the releasing procedure. results: the patients were an -year-old male and a -year-old female. thoracoscope with the mmhg co insufflation provides excellent visualization of the medaistinal space and operation could be done smoothly without any hemodynamic compromise. their pathological diagnoses were thymic cancer and thymoma, type b . the operative times were min and min. the postoperative courses were uneventful and the patients were discharged on day th and rd . conclusion: we have just begun to routinely use co insufflation for mediastinal tomorectomy and present our early experiences of successful vats thymectomy by utilizing co \ su \/su insufflation. aims: this retrospective study aims to evaluate the feasibility of single-incision thoracoscopic surgery (sits) for primary spontaneous pneumothorax (psp), using a novel multichannel port (x gateÒ). methods: between october and november , ten patients who underwent sits using x gateÒ. nine patients were male and was female, with mean age of . ± . years old. a . cm incision is placed in the middle axillary line on the th or th intercostal space, depending on the lesions. postoperative outcomes of these patients were compared with those of patients with psp who underwent conventional three-port video-assisted thoracic surgery (vats). results: there were no conversions from sits to vats. mean operative time of sits group was significantly shorter than that of three-port vats group ( . ± . min vs . ± . min, p = . ). mean number of staplers used in surgery was . ( ) ( ) ( ) ( ) in sits group and ( ) ( ) ( ) ( ) ( ) in vats group (p = . ). mean duration of postoperative drainage was also shorter in sits group ( . ± days vs . ± . days, p = . ). no recurrence and wound infection were observed in sits group. conclusion: sits using x gateÒ is feasible when performed for selected patients with psp. x gateÒ provides good visualization of intrapleural space and esthetic outcomes, as well as a superb maneuverability by decreasing mutual interference of surgical instruments. although conventional three-port vats for psp is well established, sits using x gateÒ can be a permissible alternative. further examinations are required to evaluate efficacy of sits using x gateÒ. aims: haemorrhage remains a leading cause of potentially preventable death in trauma. in particular non-compressible torso haemorrhage is approximated to cause - % of mortality in civilian trauma patients with otherwise survivable injuries and % in war setting. we performed a literature review to assess the potential for using endovascular stenting in traumatic venous injuries and explore the evidence of their efficacy and safety with different venous injury patterns. methods: systematic online search of pubmed performed using key words'endovascular stent', 'venous injury', trauma, penetrating, blunt, abdominal and pelvic. inclusion criteria included all studies that explored the use of endovascular stents following traumatic abdominopelvic venous injuries. english language studies were used. results were presented according to prisma guidelines. results: of the studies generated by the search,there were only four case reports in the literature documenting the use of endovascular stents in traumatic venous injuries dating back to and most recently . the four cases included three retrohepatic ivc injuries, two secondary to blunt trauma and one penetrating; whilst the final case a blunt injury at the ilio-caval bifurcation. all four cases reported successful deployment of stents via the femoral or internal jugular veins, with subsequent resolution of haemorrhage. length of time taken for stent insertion ranged from to min. three of four patients made full recoveries and discharged from hospital, with one patient subsequently dying of a brain injury independent of the successful venous stent insertion. no complications were reported at up to months follow up in remaining cases including stent leak, stenosis or migration. conclusion: endovascular venous stents have been used successfully in managing complex abdominopelvic traumatic venous injuries. in particular retrohepatic venous injuries refractory to hepatic packing and vessel embolization, which are not amenable to direct surgical repair due to anatomical location. however before endovascular stenting can be added to the arsenal of interventional radiologists for abdomino-pelvic trauma, further development of stents custom made for venous injuries as well as prospective studies examining their long term safety and outcomes is needed. tracheal papilloma is a rare neoplasm growing from the tracheal or bronchial epithelium and has no specific clinical presentations. this is a -year-old female who complained of progressive dyspnea for about months. physical examination was unremarkable and the there was no abnormal finding by the chest plain film. chest computed tomography was arranged and revealed a mass lesion located at the tracheal lumen with more than % luminal obstruction. we used fiberoptic bronchoscopy to evaluate the airway and found a mass lesion with pedicle originated from the posterior tracheal wall. cryotherapy was considered for the tumor mass removing to establish a patent airway. the pathologic report revealed tracheal papillomatosis without any malignant component. dyspnea was immediately improved and the patient chose closely observation after the bronchoscopic cryotherapy. aims: recent advances in laparoscopic surgery, both in techniques and instrumentation material, have led to the emergence of innovative technological fields, among which robotic surgery stands out.one of the handicaps of this surgery is its high cost as well as the long learning curve. in this stage a new tool arises, the flexdex semi robotic arm, which combines the precision and the range of movements of robotic surgery with the greater availability, simplicity of use and learning of conventional laparoscopic surgery.the objective of this study is to evaluate the efficacy and safety of the flexdex device in different laparoscopic procedures. methods: flexdex's is a three-axis gimbal technological device integrated in a conventional laparoscopic instrument that translates the surgeon's hand, wrist, and arm movements from outside the patient into corresponding movements of an end-effector inside the patient's body.the greater accessibility provided by the flexdex allows the surgeon to perform sutures in areas of difficult access where mobility with conventional laparoscopic instruments is not optimal. the comfort of the surgeon remains fundamental in any type of surgery, even more when we are in anatomical locations with complex access, especially for the realization of sutures. here is where surgical innovation instruments such as flexdex provides ergonomic comfort for the surgeon and improves the patient's safety, especially in high-risk situations, such as when performing anastomosis. results: we present a prospective series of laparoscopic procedures carried out by the same surgical team being the initial experience in our environment in the use of the flexdex semi robotic arm for the realization of complex anatomical sutures.this is a case series of patients to whom different surgical techniques requiring manual suture have been performed. these being tapp procedures, nissen-type fundoplicature and reinforcements of colorectal anastomosis. it is important to note that in none of the cases complications were recorded conclusions: flexdex can provide an excellent alternative to the robotic systems in complex surgical procedures, offering surgeons the precision and control they desire while maintaining the balance of cost, outcome and patient benefit. background: a new single-port device (fsis-flexible-single-incision-surgery) is presented. this new platform has three working channels, two for rigid instruments and one for the flexible endoscope. the channel for flexible instruments offers a pneumatic sealing to avoid the air's leak of the cavity (abdomen, rectum, vagina) . in this study the preclinical data are shown testing the feasibility and safety for laparo-endoscopic instruments. methods: experimental evaluation of feasibility and safety in two stages. in the first stage a working channel with pneumatic sealing was tested in simulators to use a flexible endoscope. in the second stage (animal model) the single incision device that makes possible to use laparoscopic instruments and flexible endoscopes was tested. the measured variables were: time of the procedure, co employed, adverse intraoperative events, grip's losing, losing of pneumatic sealing, feasibility and safety of the procedure for the surgeon. results: the hysterectomy and double adnexectomy was done with a median time of . min. the median of the co consumption was . litres. only in one case ( . %) the surgeon had problems with the abdominal navigation of the endoscope that was easily solved. the grip's lose wasn't a major problem. the median size of the skin incision was . cm. the median surgeon' score for the feasibility was and for the safety was . . conclusions: the surgeons considered that the use of the device was very feasible and safe. the fsis-device is a universal platform for single-incision-surgery for surgeons and gastroenterologists and for abdominal, rectal and vaginal access. aim: despite the near-infrared fluorescence (nirf) via the intravenous administration of indocyanine green (icg) improves the visualisation of the cystic duct (cd) and the extrahepatic biliary tract (ebt), the back fluorescence of the liver reduces the signal-to-noise ratio.we have modified the technique of nirf cholecystocholangiography with intragallbladder icg injection by using the arrow-karlan tm balloon cholangiography catheter instead of the purse string at the gallbladder's fundus. this procedure allows a high rate of visualisation of the ebt, with few cases of icg leakage.aim: of this study is to confirm the feasibility of this different technique and to analyse the icg spillage from the gallbladder and to identify the ebt. methods: we enrolled nine patients undergoing laparoscopic cholecystectomy for cholelithiasis. the gallbladder was perforated with the cholangiogram catheter, the balloon inflated with . ml of saline and tightened. the bile was drained and the icg bolus injected. a titanium clip was the placed on the catheter strict closely to the gallbladder in order to prevent the catheter dislocation. results: the cd and the ebt were visible before dissection in / and / patients respectively. after dissection the cd was visible in all the patients and the ebt again in / patients. there was only one icg spillage due to a tardive positioning of the clip. in a case of inflamed gallbladder this technique helped in the identification of the dissection plane. conclusions: our preliminary results of this ongoing study confirm the feasibility of this different approach as a possible alternative to the purse string and a good visualisation of ebt. introduction: robotic-assisted surgery is a promising technique for overcoming the limitations of laparoscopic surgery, especially with regards to complex and advanced surgical procedures. here, we describe the establishment and implementation of our robotic upper gastrointestinal (gi) and hepato-pancreato-biliary (hpb) surgery program within our center of excellence for minimally invasive surgery as well as the first-year results. method: robotic-assisted surgery was performed using the davinci xi surgical system tm and performed by two surgeons specialized in minimally invasive surgery (db and tk). our robotic surgery program of upper gi and hpb surgery was established in three steps: ( ) first, surgical procedures with easier degree of difficulty were performed robotically, including cholecystectomy, minor gastric resections and fundoplications. ( ) then, pancreatic distal resections, enucleations, adrenalectomies and atypical liver resections were robotically performed, as procedures with moderate degree of difficulty. ( ) finally, advanced and highly complex procedures were performed, including right hemihepatectomy, complex pancreatic head resections (including portal vein resections), total gastrectomy and esophagectomy. data collected from july till july were retrospectively analyzed with regard to conversion rate, morbidity (clavien dindo grade £ ) and mortality. results: within the first year, a total of robotic assisted upper gi and hpb resections were performed. the first step of establishing our robotic surgical program included eight procedures. here, conversion rate, morbidity and mortality were %. within the second step of establishment procedures were performed. conversion rate, morbidity and mortality were %, % and %. the last step included of advanced and highly complex procedures. these procedures resulted in a conversion rate of %, % morbidity and % mortality. conclusion: our stepwise approach enables a safe implementation of a robotic surgical program for upper gi and hpb surgery with low morbidity and no mortality even for highly complex procedures. however, highly complex procedures required a high conversion rate, which might be caused by the early stage of experience. the standard surgical procedure of choledochal cyst is a complete excision of the cyst with rouxen-y hepaticojejunostomy and laparoscopic surgery had been increasingly used. this is still a challenging way to perform anastomosis due to the small diameter of bile duct and the possibility of bile leak or stricture. robotic system can overcome the shortcomings of laparoscopy with providing three-dimensional view, magnification, and articulated instruments. from jan to dec , patients underwent robotic cyst excision and hepaticojejunostomy by single surgeon. we reviewed the clinical data and compared with laparoscopic outcomes of early (from to ) and late (from to ) group, retrospectively. patients of robotic series were all female with mean age . years and bmi . . the mean size of cyst was . . cm, and todani type ia , ic and iva , respectively. total trocars were used with robotic working arm and assist and camera. the mean operative time . ± . min, and it was similar with late laparoscopic group ( ± . min) and significantly shorter than early group ( ± . min).there were no open conversion in robotic and late laparoscopic group, however, the early laparoscopic group involved % of conversion rates. the hospital length was ± . days in robotic group, and it was similar with late group ( ± . ) and more shorter than early group ( . ± . ). in robotic series, postoperative complications occurred patients. one case included cholangitis which was resolved after conservative treatment. bile leakage was developed in patient, and treated with drain that inserted intraoperatively. last cases showed incisional hernia at postoperative months, and was corrected by laparoscopic herniorrahphy. complications (n = ) in late laparoscopic group included hepaticojejunostomy stricture and stone, bleeding of jejunal branch, portal vein thromobosis, acute pancreatitis, and adhesive ileus. there were no mortaility case in any groups.robotic surgery of choledochal cyst is a safe and feasible option with short-term results that are comparable to laparoscopic approach. general surgery, sanchinarro university hospital, madrid, spain background: the incidental detection of benign to low-grade malignant small pancreatic neoplasms increased in the last decades. the surgical management of these patients is still under debate. the aim of this paper is to evaluate the safety and feasibility of robotic enucleations. methods: we retrospectively reviewed our prospectively databases from november . demographics, pathological characteristics, perioperative outcome, and medium-term follow-up of patients who underwent robotic pancreatic enucleations were collected. results: patients were included. the mean age of the patients was years ( - ). the median body mass index was ( - ). ten lesions were located in the pancreatic head, in the pancreatic body, in the pancreatic tail. operative time was min (range - ), no intraoperative transfusion were needed and in one patient conversion to open approach was needed. in three patients grade b pancreatic fistula occurred. the mean postoperative stay was , days. conclusions: robotic enucleation is a feasible and safe approach, with low incidence of morbidity. the results of surgical treatment of patients with pulmonary tuberculosis were evaluated depending on the prevalence of the tuberculosis process and the type of surgical intervention used. according to the results of the questionnaire, people operated on pulmonary tuberculosis in the period from to years ago, the frequency of cases of tuberculosis reactivation, the complicated course of the remote postoperative period, as well as the mortality and causes of lethal outcomes were assessed. it was found that after sublobular resection and lobectomy, treatment failure was noted at . %, relapse of tuberculosis- . %, pleural empyema- . %, bronchial fistula- . %, cardiovascular insufficiency-in . % operated. the mortality rate was . % with a total clinical efficacy of . %. after combined resection and bylobectomy, treatment failure was noted at . %, relapse of tuberculosis- . %, pleural empyema- . %, bronchial fistulae- . %, cardiovascular failure- . % operated. the mortality rate was . % with a total clinical efficacy of . %. after pneumonectomy, treatment failure was noted at . %, relapse of tuberculosis- . %, pleural empyema- . %, bronchial fistulae- . %, cardiovascular failure- . % operated. the mortality rate was . % with a total clinical efficacy of . %. robotic reduced-port splenectomy using single-site platform j.h. lee background: in the era of minimal invasive surgery, single incision laparoscopic splenectomy can offer some advantages compared to conventional laparoscopic splenectomy. but it requires expertise in minimally invasive techniques due to technical difficulties. the da vinci robotic reduced-port splenectomy using single-site platform permits greater freedom of movement and higher levels of accuracy than previous laparoscopic surgery through two small incisions. methods: we performed a retrospective review of all patients who underwent robotic reduced-port splenectomy using single-site platform at our institution between january, and november, . one cm periumbilical incision was made for glove port insertion and the other incision was made at left side of abdomen for additional mm port insertion.the surgical technique is much same as open procedure. short gastric artery was ligated, firstly. splenic artery and vein were ligated individually. during the surgery, any stapling device was not used. vessel sealer was used for hemostasis and mobilization of spleen. a specimen was removed through umbilical port site within lap-bag. result: eight patients ( female and male) with median age of . years underwent robotic reducedport splenectomy using single-site platform (one case with combined robotic cholecystectomy for gall bladder stones without additional trocar). the indications were; hematological disease (n = ), splenic mass (benign n = , malignant n = ). preoperatively measured spleen size was ranged . cm to cm (mean cm). there were no intraoperative complications and open conversion. mean operative time was min. (range - min) including docking (mean min) and console time (mean min) mean blood loss was under ml. mean hospital stay was . days after surgery. one patient underwent oral anticoagulation therapy only for portal vein thromobisis without any symptoms, and thromobisis was resolved at month follow-up ct scan. there were no clavien-dindo class iii or above postoperative complication. conclusions: robotic reduced-port splenectomy using single-site platform seems to be feasible and effective. it seems to overcome certain limits of previous robotic or conventional single-site laparoscopic splenectomy and single-site only robotic splenectomy. we think mm additional port allows to use endo-wrist da vinci instruments such as vessel sealer which enhances dissection efficiency andsafety of procedures. aims: inguinal lymph node dissection carries an important risk of post-operative complications, mainly related with wound complications and long term lymphedema. the minimally invasive approach aims to reduce the morbidity of this procedure, avoiding the traditional groin incision but still allowing a full access to the lymph node basin. the authors aimed to describe their videoassisted inguinal lymph node dissection (vilnd) cases, comparing the surgical outcomes with a sample of open inguinal lymph node dissection (oilnd) cases. methods: we performed a retrospective descriptive study that compared the data from patients submitted to vilnd since (the year in which this technique was first performed in our institution) with the patients submitted to oilnd in and . gynaecologic and urologic malignancies were excluded. the statistical analysis was performed using spssv Ó, with a p value \ . indicating statistical significance. results: a total of cases of inguinal lymph node dissection were analysed, . % of which vilnd (none of them requiring conversion to the open approach). melanoma was the primary tumour in % of patients. the vilnd and oilnd groups had no statistically significant difference between them regarding age, body mass index, smoking status or the reason for lymph node dissection-clinically detected lymph node vs. positive sentinel node biopsy. the mean of isolated lymph nodes in the vilnd ( . ) and oilnd ( . ) groups was also not statistically different (p = . ). there was no difference in the rate of post-operative seroma, wound dehiscence or lymphedema. the rate of surgical site infections was higher in the oilnd group- % vs. . % during post-operative hospital admission (p = . ); . % vs. . % after discharge (p = . ). conclusions: in our population of patients we conclude that the main advantage of the videoassisted approach regarding surgical morbidity lies in the reduction of the infection rate, as the published literature also confirms. the equivalent number of lymph nodes retrieved in both groups points toward the oncological safety of the minimally invasive procedure, that we hope to study further in the future after a longer follow up period. objectives: to evaluate the clinical feasibility of tumor localization technique with radio-frequency identification (rfid) clip marker methods: we developed the proto-type rfid integrated endoscopic clip (rfid-clip) and probe to detect it on serosa surface during the laparoscopic surgery. a pig weighing kg was used as the specimen for the in-vivo test. endoscopist performed the application of the rfid-clip on porcine gastric mucosa. after then, the surgeon tried to find the location of rfid-clip using the detection probe and marked with the electrocautery. after the gastrectomy with cm margin (each to proximal and distal), we confirmed the prediction of rfid-clip location and accuracy of resection. results: rfid-clip location was detected and recorded on the exact site of clip application. detection range was very short and we confirmed there are almost no differences between actual clip location and our prediction. this result might arise from using the low-frequency rfid tag to increase the accuracy through reduction of the range. however, some rfid-clip were not detected because of the issue of clipping trouble, not rfid tag. conclusions: this is a basic study to evaluate the clinical usefulness and feasibility of the new localizing technique. we confirmed the possibilities of this system and it could be the helpful option to provide the information of exact location for the minimally invasive surgery or early gastrointestinal tumors. background: the advantages of laparoscopic posterior retroperitoneal adrenalectomy (lpra) have been described in the literature. the aim of this study was to compare the clinical outcomes of lpra and robotic posterior retroperitoneal adrenalectomy (rpra) and determine the differences that could affect the outcomes. methods: we retrospectively analyzed adrenalectomy cases at asan medical center from to . there were lpra and rpra cases, and their clinicopathological features and surgical outcomes were compared. results: in lpra, there was a positive relationship between operation time and male gender, early period of experience, adrenal tumor size, and pheochromocytoma. in rpra, adrenal tumor size and pheochromocytoma were the only factors affecting the operation time. when the adrenal tumor size was = . cm, the operation time of lpra was shorter than that of rpra (p = . ). when the tumor size was [ . cm, there was no significant difference in the operation time of lpra and rpra (p = . ). conclusions: rpra is a feasible and technically safe approach for benign adrenal diseases. the use of rpra could benefit patients with large tumors and provide comfort by overcoming the factors contributing to a longer operation time in the laparoscopic technique. methods: twenty years experience at the american university of beirut medical center for laparoscopic adrenalectomy. a total of cases were done laparoscopically with no conversion and minimal complication. the average operative time is mins.the video will show the various steps used for lap redo (lt) adrenalectomy for a cm pheochromocytoma using the lateral position and through trocars. attempt to remove the pheochromocytoma in iraque was complicated by cardiac arrest treated successfully and patient referred to the american university of beirut medical center. results: patient had smooth postoperative course following laparoscopic adrenalectomy and patient discharged days later with no complications. conclusions: even large adrenal masses can be completed laparoscopically in advanced experienced centers in laparoscopy. surg endosc ( ) aims: the adrenocortical of uncertain malignancy neoplasm is a spectrum of classification for adrenal tumors whose histopathological diagnosis is uncertain. clinical case: we present a year old patient with constitutional syndrome and severe hypercortisolism and hypokalemia reason why she was admitted to icu for episodes of ventricular fibrillation. no other medical history of interest except refractory hypertension to treatment. the tc showed a left adrenal mass of . . cm with microcalcifications, areas of necrosis and hemorrhage, no infiltrating, without disease to distance. the surgery was a laparoscopic left adrenalectomy with no evidence of infiltration and no lymph nodes. the histopathology lesion presented a dense proliferation cellular of cortical type, with incomplete fibrous, without vascular or capsular invasion, with a % ki ; positivity vimentin and cd . all epithelial markers, were negative. all this leads to the diagnosis of a neoplasm of uncertain malignancy potential adrenocortical. during the postoperative period, the patient presents a crisis of adrenal insufficiency that was treated with intravenous replenishment corticoidea and later orally with good clinical response. discussion: the adrenal carcinoma has a low incidence ( . %), incidence peak around the years, the most frequent is the mixed secretory. they are - % of the adrenal incidentalomas. it is usually presented to the diagnosis as a locally advanced tumor with metastases (to liver, lung, retroperitoneal ganglia and bone). may present clinically due to hormonal hyperproduction; or be non-functioning tumors. the adrenal carcinoma poses a great difficulty at the time of the diagnosis pathological, and includes as differential diagnosis to other abdominal tumors. the distinction between corticoadrenal adenoma and adrenal carcinoma is sometimes difficult, so it has been defined a spectrum of intermediate category called adrenocortical neoplasm of intermediate or uncertain malignancy. it is obtained with the weiss criteria, being necessary at least of them for confirm the diagnosis of adrenal carcinoma. this category has a low risk of local recurrence or metastasis, but it needs a narrow follow-up. conclusion: adrenal carcinoma of uncertain malignancy implies a new category in those tumors of difficult classification. aims: multiple endocrine neoplasia type (men ) is an autosomal dominant disorder with an estimated prevalence of per , in the general population. among patients suspected to have a pheochromocytoma, the diagnosis is rarely confirmed and only % is presented bilaterally. we present bilateral laparoscopic adrenalectomy in patients with men . method: a -year-old woman with a family history of medullary thyroid cancer and breast cancer. personal history: hypertension, medullary thyroid cancer, breast cancer, laparoscopic cholecystectomy. appendectomy. after a study by endocrinology and suspicion of bilateral pheochromocytoma, discussing the case in a multidisciplinary committee, bilateral adrenalectomy was decided by laparoscopic approach. selective alpha- -adrenergic blocking agent (doxazosin) were utilized before surgery. under general anesthesia left adrenalectomy was performed first in right lateral decubitus position. mmhg pneumoperitoneum was started with the verres needle and trocars ( mm umbilical, mm subxifoid and mm left subcostal).once dissection was completed the gland was placed in a plastic bag and extracted through one of the trocars incisions, then the position of the patient was changed to left lateral decubitus for the right adrenal approach. another right subcostal mm trocar was used. adhesiolysis of previous cholecystectomy was performed to right adrenal approach. adrenal veins were divided between metallic clips.no drainage was employed. results: the procedures were successfully performed without conversion. surgical time was min and hospital stay was days. had a clinical reversion with control of blood pressure monitored by endocrinology conclusions: currently, the laparoscopic approach is the technique of choice for the management of adrenal pathology.lateral decubitus transperitoneal approach is the procedure of choice in most cases. bilateral laparoscopic synchronous adrenalectomy is feasible and safe with good results as in our patient. traditionally the treatment of hyperparathyroidism for patients with familial hyperparathyroidism was subtotal parathyroidectomy or total parathyroidectomy and auto transplantation. in the era of minimally invasive parathyroidectomy, the removal of only abnormal glands guided by preoperative localizing studies has been suggested. aims: this systematic review aimed to investigate the role of focused minimally invasive parathyroidectomy in the treatment of patients with familial hyperparathyroidism. methods: electronic databases were searched with the search terms 'men i', 'familial hyperparathyroidism', 'men a','hyperparathyroidism-jaw tumor syndrome', 'parathyroidectomy', 'minimally invasive ', for the time period up to and including december . full publications, including clinical trials randomized or not, retrospective studies, case series, case reports that provided relevant data met inclusion criteria. results: thirty five possibly relevant studies were identified. abstracts were reviewed and fifteen articles were excluded. twenty studies, that met inclusion criteria were retrieved in full text and included in the systematic review, including three retrospective cohort studies i.e. two presenting data on meni associated hyperparathyroidism and the third study on familial hyperparathyroidism and seventeen small case series or case reports. the two retrospective studies on meni hyperparathyroidism included patients treated either with focused minimally invasive parathyroidectomy or with the conventional approach. these studies presented conflicting data with one supporting and the other negating the focused minimally invasive parathyroidectomy due to the failure of localization studies to identify enlarged parathyroid glands in a great number of patients. conclusion: undoubtedly, the idea of minimally invasive parathyroidectomy in patients with hereditary and familial hyperparathyroidism is interesting. this idea is especially challenging in the case of meni. existing data suggest that focused mimimally invasive parathyroidectomy is feasible under the condition of exact preoperative localization studies. the main advantage of this approach is the minimization of the risk of postoperative hypoparathyroidism. however, data are limited and further research is needed before valid conclusions can be drawn on the suitability of this approach. objective: resection of pheochromocytomas is a challenging procedure due to hemodynamic lability, tumor vascularity and malignant potential.given the technical challenges for resection of large pheochromocytomas, there were hesitations about using the laparoscopic approach for these tumors during the first decade of laparoscopic surgery. however, improvement in imaging modalities,better pharmacological preparation,advances in anaesthesia and laparoscopic surgery rendered laparoscopic surgery for pheochromocytomas safe and efficient. our aim was to evaluate surgical outcomes in patients with pheochromocytoma and to validate the role of laparoscopic surgery in the treatment of these tumors. design: a total of procedures for pheochromocytoma were performed between january -september . the preoperative diagnosis, operative details, complications, length of hospital stay, morbidity and follow up were retrieved from the hospital records of patients who underwent adrenalectomies for benign and malignant adrenal tumors in the same period. preoperative localization was established in all patients with computerized tomography (ct) or magnetic resonance imaging (mri), while iodine - -metaiodobenzyguanidine(mibg) scan was reserved for ambiguous cases where paraganglioma or metastatic disease was suspected. endocrinological evaluation and complete adrenal dynamic testing were performed to determine whether the tumor was functional or not. results: eighty-seven tumors were removed from patients. one patient with meniia underwent bilateral resection of pheochromocytomas in two stages. tumor size in laparoscopic procedures ranged from . cm to . cm (mean . cm). forty-three patients had benign disease, potentially malignant (based on pass), malignant with metastasis. eight were in the context of a familial syndrome. sixty -eight patients underwent laparoscopic adrenalectomy, patients had open approach from the start for recurrent pheochromocytoma or large benign tumor, patient had open approach due to inoperable malignant pheochromocytoma and patients had conversions from laparoscopic to open procedure. nine patients received sodium nitroprusside intraoperatively to treat hypertension. one patient developed pulmonary embolism, and succumbed month later. there were no recurrences for the benign tumors during the follow-up period. conclusions: laparoscopic resection of pheochromocytomas despite its increased level of difficulty compared to that of other adrenal tumors, is a safe and effective procedure. aim: the concept 'large' in transperitoneal lateral laparosopic adrenalectomy (tlla) has been evolving along time, ranging from to - cm depending on different authors. on the other hand, some authors discourage laparoscopic surgery in larger tumors due to the increased risk of malignancy in those larger than - cm, referring to malignancy in out of or cases. paragangliomas are rare tumors originated in extra-adrenal chromaffin cells, with an incidence of - cases per million inhabitants. they can appear in any location between neck and pelvis. sympathetic paragangliomas are usually functional and catecholamines producers. we present a movie of surgical intervention of a -year-old patient who, in study for refractory hypertension, presented paraganglioma producing norepinephrine, whose approach was performed laparoscopically. -year-old woman studied by nephrology for refractory hypertension. on physical examination, only obesity standed out. in blood exams, levels of normetanephrine were observed in plasma of pg/ml and aldosterone pg/ml. abdominal scintigraphy was performed in which there was no evidence of increased activity at adrenal level. abdominal ct shows retroperitoneal extra-adrenal tumor of inter-aortocava location immediately below renal vessels with dimensions of . . cm. after preparation, she was operated. laparoscopic access was performed under exhaustive monitoring. an heterogeneous, polylobulated tumor of cm, located interaortocava, intimately adhered to left renal vascular pedicle, was observed. a cattell-braash and kocher maneuver was performed, with exposure of inferior cava and aorta to iliac bifurcation. complete tumor excision was performed after clipping arterial and venous tributary branches. after the operation, the pacient presented favorable evolution being discharge on the second postoperative day with good control of blood pressure levels. laparoscopic approach of retroperitoneal paragangliomas is a safe technique, which allows minimally invasive access, with consequent improvement in postoperative results. the exact location of lesions and their relationships with surrounding structures, as well as their functional behavior, are very important when considering the best therapeutic strategy for these patients. we present the case of a -year-old obese male patient referred for adrenalectomy after being diagnosed with left adrenal incidentaloma. abdominal mri showed a . / . / . left adrenal mass with normal hormonal levels. after preoperative workup, the patient underwent standard laparoscopic adrenalectomy. the lateral to medial dissection and mobilization of the spleen and pancreatic tail was difficult due to the abundance of peritoneal and pararenal fat. the anatomy was peculiar: the bulky pancreatic tail was located well inferior to the splenic hilum and was visible throughout the intervention and the spleen was quite elongated-long axis = cm. the exposure of the adrenal gland was therefore cumbersome. the operating time was min and blood loss ml. the abdominal drainage was maintained for h. before discharge the patient underwent a control abdominal us examination that only showed a thin line of left pleural fluid. the patient was readmitted days after discharge for chest pain, fever ( . °c) and malaise with no abdominal signs. the emergency ct scan diagnosed left basal pneumonia with minimal pleural effusion and a / cm fluid collection between the spleen and diaphragm while the blood test showed leukocytosis. the patient was treated for pneumonia with an apparent clinical benefit for three days and lowered white cell count but his condition worsened during the forth day. repeat abdominal us demonstrated that the abdominal collection increased in size therefore the patient underwent emergency surgery. during laparoscopic exploration, the collection was unveiled as being pancreatic juice (more than times the normal serum levels of lipase and amylase). after thorough lavage, two drainage tubes were positioned in the left subphrenic space. the postoperative course was uneventful under antibiotic treatment for pneumonia and pancreatic antisecretory medication. the patient was discharged after days with minimal pancreatic drainage and the drainage tube was extracted after more days. the aim of the study was to develop the algorithm and the choice of the method of endoscopic treatment of a combined pathology of uterine leiomyoma and adenomyosis depending on the reproductive plans. methods: the study involved patients with a combined pathology of uterine leiomyoma and adenomyosis. indications for conservative myomectomy were: the size of the uterus is more than weeks. pregnancy; multiple leuomatous nodes and adenomyotic foci up to cm in size; hemorrhagic and pain syndromes, anemia, compression of the adjacent organs; suspected node malfunction; submucous leiomyoma deforming the uterine cavity with foci of adenomyosis; subserous, cervical isthus nodes and foci of adenomyosis; the presence of endometrial hyperplasia, tumors of uterine appendages; growth rate of uterine leiomyoma more than weeks pregnancy for the year; the growth of uterine leiomyoma on the background of drug treatment; infertility associated with leiomyoma and uterine adenomyosis.the laparoscopic myomectomy of the subserous node on the 'leg' with a size of more than cm and nodes of more than cm of intramural location is shown with an interest in preserving the organ.the hysterectomy is indicated for women after years of age who insist on hysterectomy, with a combination of uterine leiomyoma with atypical endometrial hyperplasia. results: the conservative myomectomy and removal of adenomyotic foci were performed in ( . %) patients: from hysteroscopic access- , vaginal access- , laparoscopic access- , abdominal access- in the presence of reproductive plans.the hysteroscopic myomectomy was performed in ( . %) patients, hysterectomy in ( . %) patients: from laparoscopic access- , from vaginal access- , from abdominal access- in the absence of reproductive plans. conclusions: the choice of surgical treatment of uterine leiomyoma and adenomyosis depends on the reproductive plans of the woman and the severity of the lesion.the laparoscopic method of treating a combined pathology of uterine leiomyoma and adenomyosis in the presence and absence of reproductive plans is a priority for women. surgery, policlinico ,,paolo giaccone,,, palermo, italy background: breast cancer in females represents the most frequent neoplasm in all age groups. the risk of getting breast cancer (mc) increases with age. the brca and the brca genes (tumor-suppressor genes, autosomal dominant transmission at high penetrance) alone justify from % to % of cases of hereditary breast cancer. methods: from january to june we have analyzed patients with brca mutation. all patients had in common a genetic mutation of brca or brca tumor suppressor genes. results: the frequency of germline mutation on brca ( patients: %) was identical to brca gene ( patients: %). of the analyzed patients were women ( . % of patients) brca and brca , and men ( . %) all with brca mutation. conclusions: prophylactic surgery must be seen as a way to put the patient in the condition to implement the most appropriate treatment. further studies will be necessary to support the validity of prophylactic surgery in patients with mutations in brca and brca genes. introduction: laparoscopic hysterectomy is a safe surgical technique for removing the uterus with or without including the ovaries and fallopian tubes. laparoscopic surgery of endometrial cancer is a safe method, with the mean time of recovery being two days only. material-method: the case of a yr old woman with metrorrhagia and anaemia (ht , %) due to adenocarcinoma of the endometrius is presented. the patient underwent a laparoscopic hysterectomy and oophorectomy. trocar ports were used during the procedure (a mm transumbilical port, similar to the port used in single incision laparoscopic operations, two mm ports at the level of the anterior superior iliac spines, and a mm port in the middle of the imaginary line between the pubic symphisis and the umbilicus). the uterine vessels and the uterine ligaments were ligated and dissected by using a thermal energy source. the patient's postoperavite course was uneventful. the patient continues to be in good condition, months post-surgery. conclusion: laparoscopic hysterectomy seems to be a safe method for addressing endometrial cancer, as it offers the surgeon a better surgical field, is tissue friendly and causes fewer postoperative complications. it is considered to be a less traumatic operative method, as due to zooming in the picture there is greater accuracy in handling the tissue, and blood loss is minimal. m. shahin background: hysterectomy is one of the most frequently performed surgical procedure. though there are three approaches in hysterectomy (open, vaginal and laparoscopic), still there are controversies regarding the optimal route for performing it. methods: this prospective comparative study included obese patients subjected for panhysterectomy as a treatment. the forty-two patients were allocated into two groups: group (a) subjected to laparoscopic pan-hysterectomy, group (b) subjected to open pan-hysterectomy. results: there was significant difference between the two groups regarding mean operative time, blood loss, analgesic requirements and hospital stay, while no significant difference regarding intra-operative complications. conclusions: laparoscopic hysterectomy in obese patients has emerged as a viable, safe and better alternative to open hysterectomy amongst appropriately trained surgeons. general: endometriosis in the inguinal region is rare. the usual presentation is that of a woman in the reproductive age group. it accounts for . - . % of patients affected by endometriosis. the groin swelling is usually slow growing, painful with exacerbations during menses. the incidence of inguinal endometriosis on the right side is - % as compared to the left. aim: to present our laparoscopic approach for the treatment of the diagnostic dilemma. case presentation: a -year-old woman presented with a palpable mass in the right groin. the swelling was associated with a dull aching pain. the patient was suffering from increasing pain over the swelling during menstruation. she had undergone cesarean section some years ago and the scar had healed by primary intention. mri scan revealed a nodular hypoechoic lesion at the level of the internal inguinal ring with the absence of vascular flow around the lesion. results: since inguinal endometriosis was in the differential diagnosis and it may be associated with pelvic or intraperitoneal endometriosis, a laparoscopic approach was decided. the procedure was successfully completed laparoscopically following the transabdominal preperitoneal approach. the endometriosis was found, after dissecting the internal inguinal ring, firmly adhered to the round ligament. it was excised en bloc with the round ligament. a preperitoneal polypropylene mesh was inserted to protect for future inguinal hernias due to extensive dissection at the level of the internal inguinal ring. no intraperitoneal endometriosis was appreciated. histopathology revealed endometriosis of the round ligament. the patient was uneventfully discharged the next day. on follow up the patient was asymptomatic. conclusions: round ligament endometriosis is a rare entity. it is a disease of specific interest to the physician. it can be confused with an inguinal hernia and thereby pose a diagnostic dilemma. we recommend considering endometriosis in the differential diagnosis of groin swellings in women. the transabdominal preperitoneal approach is feasible and safe in the hands of an advanced laparoscopic surgeon. introduction: sentinel node biopsy is the newest accepted method for surgical staging of early stage endometrial and cervical cancer. aim: to evaluate the role of the technique of indocyanine green (icg) identification of the sentinel lymph nodes in cases of early endometrial cancer. material and method: five patients with early endometrial and cervical cancer were introduced in a prospective study. icg was locally injected during the laparoscopic exploration. novadac pinpoint near to red technology was used. guided biopsies were performed into the marked sentinel nodes and histological results were evaluated. results: sentinel lymph nodes were easily identified by using icg and near-infrared technology. technical details are described. no associated complication was encountered. conclusion: sln mapping using icg in uterine cancers is demonstrated as an effective and safe procedure. laparascopic extraction of an intraperitoneal gossypiboma following c/s and a retroperitoneal gossypiboma following pyeloplasty n. ozlem general surgery department, ahievran university, kirsehir, turkey gossypibomas are forgatten foreign bodies,iatrogenic.their symptoms are different where they are. they extracted with laparotomy in the past but now we can some article mentioned their extraction was made with laparoscopy. case : y o female has abdominal pain after c/s for . years. a gossypiboma was extracted with laparoscopy above umblicus.a superficial surgical site infection existed,drained,subsided. case : yo m had a pyleoplasty operation years ago.a gossypiboma was extracted with retroperitonescopy,no postoperative event. basibuyuk et al reported retroperionescopic extraction of a gossypiboma from single port in first time.althoug every effort taken the incidence of foreign body detected in the body is about . - . %.they are most frequently localized in the intraabdominal cavity followed by tracheobronchial area,pleural cavity,pararenal area,vagina,spinal chord, neck, femur,breast,bladder,pancreas,and they may cause local irritation,and infection.tactile sense is absent in laparoscopy. all radiologic examinations(usg ct pet mri etc) be used to detect.we used usg ct.in the end laparoscopy make the diagnosis and remove gossypibomas in our cases with less postoperative pain and cosmosis. justo et al the computerized tomography (ct) scan is the most useful method for diagnosis; however, sometimes the preoperative diagnosis remains uncertain even after the imaging exam. in that case, laparoscopy arises as a valuable diagnostic tool, as well as a prompt treatment option. concerning gossypiboma, prevention is preferred rather than treatment. notwithstanding, there is no highly reliable prevention system. counting sponges is a method based on staff communication during the surgery with only % sensibility. routine surgical postoperative x-ray (spox) constitutes an early detection system, but the need to incorporate a radiopaque marker and to expose the whole surgical field to maximize its efficacy limits its use. more recently, electronic dispositives based on barcode detection and other technological adjuncts for counting sponges are being developed. none of these prevention systems are reliable when used alone. our education and research clinic was a state hospital before. no surgeon followed above instruction.but now we use all. multiple procedures and surgical teams, long operations and non-elective operations are the evidenced risk factors.c/s operation was learned full opened of ostium of cervix of the patient. urology, japan, nagoya, japan aims: some scoring systems have been suggested to standardize the renal tumor characteristics. among them, renal score is widely used in partial nephrectomy. whereas diameter-axis-polar (dap) score was developed to be more significantly related with postoperative renal function. our study compared dap score with renal score in robotic partial nephrectomy (rpn) outcomes. methods: records of patients who underwent rpn at nagoya daini red cross hospital between april to october were analyzed retrospectively. those include three oncocytomas. accordingly, we calculated the estimated glomerular filtration rate (egfr) just before rpn and month postoperatively in patients. we compared two nephrometry scores with warm ischemic time and change in egfr. results: in our institution, four surgeons performed rpn. according to dap score, patients were high, were middle and were low. according to renal score, were high, were middle and were low. the median warm ischemic time was min ( - ). the median egfr decreased from . ( . - . ) to . ( . - . ) ml/min/ . m . there were no significant differences in warm ischemic time and percentage change in egfr between renal score groups (p = . and . ) but significant differences between dap score groups (p \ . and p \ . ). univariate and multivariate analyses were used to identify factors influencing postoperative renal function. that confirmed that dap score was independent poor predictors of change in egfr after rpn. conclusions: dap score is simpler estimate system than renal score. our study suggested that dap score is a useful scoring system for preoperative evaluation of renal tumor for rpn. further investigation is needed to better understand preoperative dap score. aims: retroperitoneal primary tumors comprise a great variety of neoplasm with different histological typologies, with insidious clinical symptoms and little specificity in most cases. its diagnosis is established through imaging tests and anatomopathological study is needed so complete surgical resection is the treatment of choice. the aim of the video is to demonstrate the safety and efficacy of the minimally invasive approach in patients with retroperitoneal lesions. methods: a -year-old female patient who, in the course of an abdominal pain at the right iliac fossa suspected of possible acute appendicitis, is diagnosed with a right retroperitoneal tumor, compatible with primary neurogenic tumor on a ct. radiographic imaging is a key component of the evaluation of a patient with a retroperitoneal mass, a ct scan is necessary to evaluate the primary site as well as to rule out metastatic disease. after complete biochemical study, nonfunctioning tumor is determined. the study is completed with mri where the lesion is located below the right kidney, in front of the right psoas muscle and lateral to the inferior vena cava, and without contact with these structures. ??it is in intimate contact with the ovarian vein. the complementary tests and iconography of interest of the case are exposed. surgical intervention is proposed with a laparoscopic approach. results: full minimally invasive approach in left lateral decubitus position: trocars-lateral laparoscopic transabdominal approach. laparoscopic liberation of the right colon, kocher maneuver until the inferior vena cava is visualized, identification of a tumor of approximately cm in the right infrarenal region, lateral to the right ureter, which includes the gonadal vessels. resection of the tumor in block with margins previous dissection and clipping of the proximal and distal gonadal vessels with ligasureÒ. the patient presented a successful postoperative recovery, being discharged h after the intervention. definitive result of the specimen: leiomyosarcoma, grade of the fnclcc with negative margin. the laparoscopic approach is a safe and effective technique in the approximation of retroperitoneal tumors, a radical oncological criterion is always needed with correct margins of resection especially in those of uncertain etiology. we started endoscopic thyroidectomy using the lifting method in and have developed single incision endoscopic thyroidectomy (siet) via chest (c-) or axillary incision (a-) by our original retractor since . we created a new approach in . recently, we have applied this method to parathyroid surgery. in this study, we present our method and results in parathyroid surgery with regard to surgical outcome and patients' complaints. method: endoscopic parathyroidectomy of c-siet was performed in patients with hyperparathyroidism (primary , secondary ) in new approach (mean age , male female ). single parathyroid adenoma was diagnosed using ultrasonic device, preoperatively. the patient is placed in a supine position with the neck extended. mm vertical incision is made in anterior chest. flexible endoscope (olympus co. japan) is used through mm trocar detached the retractor. in new approach, the parathyroid and thyroid are exposed through the avascular space between sternal head and clavicular head of sternocleidomastoid muscle. both of the skin and sternal head are lifted up by our original retractor (takasago medical co. japan). parathyroid adenoma behind the thyroid is resected using an ultrasonic scalpel. i would like to present our c-siet procedure. results: no scars in the neck were left in all cases. benign and hemi lateral parathyroid adenoma sized from mm to mm (mean: . mm) were operated. mean operation time is min. in new approach. there was no complication. parathyroid hormone levels decreased in all patients immediately after operation. conclusion: it is a little possible to make recurrent nerve palsy in this approach. new approach is useful to operate and make the working space wider without stress to find out of parathyroid adenoma. our original retractor can be introduced easily in most hospital, because it is not so expensive. most of women satisfied cosmetic results because of hidden scars. objectives: radiofrequency ablation (rfa) is a novel and developing technique for the treatment of parathyroid hyperplasia/adenoma in the context of secondary hyperparathyroidism (hpt) to chronic kidney disease (ckd) and there is little literature on the subject. the purpose of this study is to determine its usefulness by contributing a case carried out in our hospital. methods: we selected a case of secondary htp in a patient of years old with ckd who presented a parathyroid adenoma detected clearly by ultrasound scanning. the patient was dismissed for surgery due to high surgical risk due to his comorbidities. rfa of a right inferior parathiroid adenoma was performed. intact parathyroid hormone (ipth) was measured before arf and min after de procedure, calcium and phosphorus were measured the day after. the treatment was considered effective if ipth levels decreased at least % min after rfa and calcium levels decreased the day after. results: ipth level before rfa was pg/ml. ipth level after min of rfa was pg/ ml, this meant a % reduction (normal values - pg/ml). calcium levels were from . at the baseline to . the day after (normal values . - . mg/dl) and phosphorus from . to . mg/dl (normal values . - . mg/dl). the patient presented dysphonia as a complication that improved with corticosteroid therapy. we are currently waiting for the next analytical controls at , and months after the proceidure. conclusions: rfa of parathiroid adenomas for treating secondary hpt in patients with ckd is feasible in selected patients. this treatment may reduce the morbidity that surgery supposes, it is developed in an outpatient regime avoiding hospital admission and this contributes to a reduction of health costs. however, a longer follow-up is necessary to verify the good results in our case. splenectomy is one of the treatment strategy for advanced portal hypertension due to liver cirrhosis. after splenectomy, thrombocytopenia is dramatically ameliorated, and liver function parameters have also been improved in several clinical settings. however, the mechanism underlying such a phenomenon remains unclear. the aims of the present study was to analyze histological changes of the liver after splenectomy in human, and to speculate the underlying mechanism. subjects and methods: cirrhotic patients with hepatocellular carcinoma (hcc) who had undergone laparoscopic splenectomy prior ( weeks- months) to hepatic resection were analyzed (n = ). non-tumorous liver specimens obtained at hepatectomy were histologically investigated. liver tissues from cirrhotic hcc patients who underwent only hepatectomy were used as controls (n = ). results: after splenectomy, significant leukocytosis, especially increase in monocytes, was observed in addition to thrombocytosis. in the non-cancerous liver tissues, many round-shaped cd -positive macrophages accumulated after splenectomy, while this phenomenon was merely observed in patients without splenectomy. the macrophages were cd ? (m marker) and cd -cd ? , suggesting their anti-fibrotic population. the accumulated macrophages existed around fibrous scar as well as ck ? epcam ? cells spreading out from the ductular reactions (dr). as a result, the number of ki -positive hepatocytes significantly increased after splenectomy. the amount of platelets detected in the liver did not change even after splenectomy. finally, remarked attenuation of the established liver fibrosis was detected after relatively long duration. the accumulated macrophages expressed metalloproteinase (mmp)- and fibroblast growth factor (fgf)- , suggesting these molecules may possibly participate in resolution of established fibrosis and hepatocyte proliferation. conclusion: splenectomy in cirrhotic patients with portal hypertension ameliorate liver fibrosis, and stimulate liver regeneration. the mechanism possibly include hepatic accumulation of anti-fibrotic cd -positive macrophages and stimulation of dr-derived ck ? epcam ? progenitor-like cells. in patients with advanced splenic fibrosis, splenectomy could be a feasible therapeutic modality. the paper tries to establish the role and the opportunity of using laparoscopy in regard with abdominal contusions, as well as its indications or contraindications, combined in a therapeutic algorithm. we analyzed two groups of patients with abdominal contusions divided over two -year periods, - ( patients) and - ( patients) respectively. we have separated the two periods because starting from we have established a strategy for dealing with cases of abdominal contusions where we included diagnostic and / or therapeutic laparoscopy and nonoperative management. the investigation was done by fast echography, ct scan, simple abdominal radiography, peritoneal lavage puncture, and sometimes arteriography. in the second period we determined the diagnostic and therapeutic laparoscopy indications: suspicion of hollow or parenchymal organ injury, or mesentery injury, the presence of hemoperitoneum or fluid in the peritoneal cavity in a stable patient without major hemorrhage, apparent with unique injuries, without immediate vital risk and without other associated severe trauma. we have associated in this last period the nonoperative management for patients with grade and lesions of parenchymal organs that do not have fluid in the peritoneum, or only a very discreet quantity. in the first period, all patients were treated by classic surgery, resulting in unnecessary laparotomies where no visceral lesions were revealed. in the second period, we applied non-operative management to patients out of , patients with grade and splenic injuries, and patients with grade and hepatic lesions. diagnostic laparoscopy was performed in cases, in of them without evidence of lesions, and in other cases of grade lesions no therapeutic action was required. therapeutic laparoscopy was required for one case of splenectomy and one of hepatorrhaphy. diagnostic laparoscopy is useful in abdominal contusions, if certain indications are followed and in selected patients. in our study, with the introduction of modern therapeutic strategies, unnecessary laparotomies were completely avoided, some lesions being even treated by laparoscopy. the new algorithm introduced allowed % of patients to avoid laparotomy. aims: about cases of splenic hamartoma have been described in the literature since it was first described by rokitansky in , it is a rare benign tumor. it is usually a casual finding in laparotomies or autopsies. they are usually asymptomatic, but there are few symptomatic splenic hamartomas and they can be associated with haematological alterations, being in some cases associated with spontaneous splenic rupture and acute abdomen, two thirds of them have multiple tumors. there are no specific data that allow the preoperative diagnosis of this entity, which is performed after the anatomopathological study of the surgical specimen, which must be extracted entirely, this together with the size of the spleen makes the laparoscopic approach difficult. the aim of this video is to demonstrate the surgical technique of a complete laparoscopic approach for this type of lesions, without the need for assistance laparotomies (handport). methods: clinical case: a -year-old man admitted to internal medicine due to fever and left lumbar pain. additional explorations of interest are discussed, including: thrombopenia of probable peripheral origin secondary hypersplenism (fna of bone marrow), ct: splenomegaly with splenic masses, which deform the splenic contour, compatible with atypical hemangiomas, without being able to discard other vascular splenic tumors. results: complete semi-laparoscopic approach, trocars, multilobulated splenomegaly ( x cm.), mechanical vascular section, complete bag extraction after minilaparotomy on the left flank. the patient presented a successful postoperative recovery, being discharged on the th po day. abdominal ultrasound at st week with portal vein thrombosis, which resolves after treatment with heparin. definitive result of the specimen: multiple splenic hamartoma. asymptomatic one year after surgery. the laparoscopic approach is a valid and effective alternative to splenic benign tumor lesions. the size does not contraindicate this type of approach, although the complete extraction of the spleen is recommended for its pathologic study. we recommend eco-doppler control per week, given the risk of portal thrombosis with an existing laparoscopic post-splenectomy. objectives: splenic cysts are a rare entity, currently described between - cases in literature. a female patient's case is hereby presented, giant splenic cyst treated by conservative laparoscopic surgery obtaining good results. method: years old female, without any relevant medical history, examined after abdominal pain on the left hypochondriac region, nausea, postprandial swelling and mass sensation. after exploration the presence of such mass was ratified, the rest of exploration found no relevant findings, no record of previous traumatism nor any other relevant incidence. diagnosis was made through ultrasound and computerized tomography, the existence of a big splenic cyst is confirmed, cm by cm, on the superior section of the spleen, negative results after parasitism test, normal haemogram, coagulation and biochemistry levels. patient was intervened using laparoscopic surgery, performing the deroofing technique on the cyst (two liters of orangey amber serous liquid that was sent for analysis) as well as extirpation of superior wall of the cyst, which was sent to pathological anatomy, a saline solution was used to cleanse the cavity, omentum and drainage were then set in place. results: patient evolved satisfactorily, hospital discharge and drainage withdrawal after h. regular check-ups, after and months, patient presents no symptoms nor recurrence. pathological anatomy confirmed primary splenic cyst and the extracted liquid as cystic. conclusion: splenic cysts are primary ( %) or secondary ( %). diagnosis is performed through imagery tests, cat scan the being standard test used. regarding her treatment there is no clear consensus, due to the fact that up to a few years ago, complete splenectomy was the recommended treatment, techniques with preservation of the spleen are currently being widely recommended through laparoscopy in literature. among the conservative techniques percutaneous aspiration, with or without the injection of a sclerosing agent, partial splenectomy, marsupialisation, cystectomy, decapsulation, unroofing or fenestration can be found. the main issue is recurrence rates. few cases of primary giant splenic cysts treated by laparoscopic decapsulation can be found in literature, this treatment being simple and quick to perform, resenting a recurrence rate lower than other techniques such as aspiration and marsupialization. introduction: technology's progress and its application in the minimally invasive surgery of the thyroid gland offers us new surgical approache's like the transaxillary approach. this new technic still unusual in our environment and has recently begun to be incorporated into our surgical practice. the objective of this case is to explain step by step how to carry out a right transaxillary thyroidectomy and emphasize in the most relevant tips to take into account. also we going to review the main limitations we observed so far. statement of the case: we present the case of a -year-old woman referred for evaluation of a left thyroid nodule without associated symptomatology. the blood test shows normal thyroid profile. cervical ultrasound is performed identifying a . cm single right nodule with welldefined edges and presence of peripheral vascularization . no other nodules are identified. fna of the nodule describes a bethesda iii. after evaluation we decide to perform a left transaxillary thyroidectomy. discussion: surgical treatment of the thyroid gland by transaxillary approach may be indicated in previously selected patients, offering the advantages from minimally invasive techniques (shorter recovery time, shorter incision length, etc.). surely, more evidence and experiencie is required to make a better assessment of minimally invasive approaches in thyroid surgery. surgery, taipi city hospital, yan-ming branch., taipei, taiwan; surgery, taipei city hospital, taipei, taiwan the first endoscopic thyroidectomy was performed in using a cervical approach. since then, various remote-access method, have been developed for thyroid surgery to avoid scarring of the neck. trans axillary approach(taa),bilateral axillo-breast approach(baba),and retroauricular approach(raa) are common in use. the main benefit of these procedure is that there are no visible scar that is one of the drawbacks of conventional kocher's incision. however,these methods require more dissection and longer operation time than conventional thyroidectomy transoral thyroidectomy(tovet) is a new approach and has become popular in recent years, however,most surgeons peformed a single procedure because of the limited patients and the learning periods sine ,more than cases were performed,patients received endoscopic thyroidectomy(et) procedure at our hospital. we compare the surgical procedure of bilateral axillo-breast approach(baba) with transoral vestiblar approach(tovet) in our hospital both performed by one single surgeon .the surgen has expended eaqual amounts of time with these two procedures. the patient seletion process,operation time, operation procedure and approach,learnig experience, consmetic effect,onaologic consideration and surgical outcome were discussed yhroughly. presenting a case of a thyroid metastasis from an ovarian carcinoma, we conducted a review of the literature without finding similar reported cases. case: a -year-old woman consults for progressive asthenia, weight loss and ascites. abdominal ct finds a conglomerate in the pelvis involving the ovaries and peritoneal implants, the largest up to cm. an omental epigastric lesion biopsy and paracentesis is performed resulting in adenocarcinoma and omental metastasis from ovarian neoplasm, associated with ca of . patient starts neoadjuvant therapy with carboplatin-paclitaxel. in image controls there is a favorable response. three months later, intervention was carried out; laparotomy hysterectomy ? double anexectomy ? omentectomy ? appendectomy ? pelvic and paraaortic lymphadenectomy.the anatomopathological study shows a low-differentiated endometrioid carcinoma, omentum infiltration and absence of metastatic lymphatic involvement. while getting the maintenance treatment with bevacizumab the patient presented symptoms of arthritis and hypercalcemia was detected ( . ) with pth . a gammagraphy was performed and an increased uptake area was detected in the lower pole of rtl, suggestive of a parathyroid adenoma. we initially proposed the possibility of performing radiofrequency ablation but in a previous thyroid ultrasound we visualize nodular lesions in rtl compatible with adenoma and a mass in the superior mediastinum that seems to correspond the area of greatest uptake in the gammagraphy so finally the procedure is dismissed and surgery is proposed. during the intervention we found a hard consistency nodule in the inferior pole rtl and lymphadenopathies of hard consistency in right vi area that are sent for intraoperative anatomopathological study with the result of adenocarcinoma metastasis without identifying origin. a total thyroidectomy, parathyroidectomy and central ganglion drainage is performed with the result of a parathyroid adenoma, lymphatic invasion of ovarian-grade latent carcinoma and extensive vascular permeation by carcinoma of the thyroid. the patient maintains oncological treatment with carboplatin-caelix. in the last follow-up, the pth and calcemia remains normal. conclussion: although some cases of neoplasic thyroid involvement associated with struma ovarii have been published, no cases similar to the one described are found, neither in our experience, which is why it is an exceptional case. the aim of the study was to evaluate the effectiveness of the use of embolization of the splenic artery in order to prevent portal bleeding. methods: the study included patients, who had esophageal varices bleeding, which developed as a result of decompensated cirrhosis of the liver of various etiologies of classes b and c according to child-pugh. patients were divided into groups. the main group included ( . %) patients who underwent endoscopic ligating of bleeding varix and in order to prevent recurrence of bleedingembolization of the splenic artery with gianturco coils. the comparison group consisted of ( . %) patients who received only drug therapy. to assess the effectiveness of the treatment, the patient's condition was monitored for months. results: the average age of patients in the comparison group was . ± . years. using only drug therapy, we stopped bleeding in ( . %) patients. in all cases, at the end of treatment, we received an improvement in clinical and laboratory parameters. ( . %) patients died. the duration of treatment was . ± . days. the average age of patients in main group was . ± . years. performing endoscopic ligation of bleeding varices, we stopped bleeding in ( . %) patients. in all cases, at the end of treatment, we received an improvement in clinical and laboratory parameters. ( . %) patients died. the duration of treatment was . ± . days. a statistical analysis of mortality and duration of treatment revealed a significant difference (p \ . ) between the groups in both indicators. after splenic artery embolization in all cases managed to achieve a reduction in blood flow of - %. after months among patients in the comparison group, bleeding relapse occurred in ( . %) cases. in the main group, this indicator was . % ( patients). the indicator in the main group was significantly (p \ . ) different from the same indicator in the comparison group. conclusion: performing embolization of the splenic artery in patients after endoscopic hemostasis of variceal bleeding allows to reduce the pressure in the portal system, which in turn leads to a decrease in the frequency of bleeding recurrences. thoracoscopic esophagectomy for aortoesophageal fistula y. ebihara, t. shichinohe, y. kurashima, s. murakami, surgery ii, hokkaido university, sapporo, japan background: aortoesophageal fistula (aef) is an uncommon but one of highly fatal conditions. there are surgical, endoscopic and interventional radiological treatment options, however, definitive treatment is the surgical intervention. video-assisted thoracoscopic surgery (vats) has been gradually accepted as a substitution for thoracotomy to reduce the invasiveness of the surgery as radical surgery for esophageal cancer. we aimed to evaluate a feasibility of vatsesophagectomy (vats-e) for aef in this study. introduction: achalasia is the most common motility disorder of the esophagus. heller's cardiomyotomy associated with a antireflux technique is the treatment of choice in patients with this disease; however, a small group of patients could present a recurrence of the symptoms being necesary a new surgery, what is an important challenge for most of the surgeons. we report the case of recurrence after a laparoscopic miotomy and dor fundoplication as a paradigm for the appropiate management in this kind of patients. methods: a years old female, who underwent a previous miotomy and a dor fundoplication in due to an achalasia.six years after surgery, the patient showed epigastric pain and dysphagia. the study of the patient was performed with: barium swalow, phmetry, manometry, ct-scan and mri showing a recurrence of her disease.the patient was transfered to our center where she underwent a new surgery.the key points of the new surgery includes the next steps: dissection of the previous adhesions, dissection of the dor's partial fundoplication, avoid dissection of the anterior esophageal wall at the leve lof the hiatus (the area of previous myotomy) in order to avoid perforation of the esophagus, lateral and posterior dissection of the distal esophagus, lateral myotomy at the rigth wall of the esophagus and a toupet's funduplicatury. all of thisis procedures are done under intraoperative endoscopy in order to confirm a good passage to the estmach and to identify a perforationic supervision. results: following theseis steps several patients have been operated in our center with excellent results. in all of these cases, including the patiente presented previously, the symptoms have dissapeared. conclusions: achalasia is a rare motility disorder of the esophagus, being recurrences an important challenge for surgeons. a great proper therapeutic strategy using the different diagnostic exams and the supervison by a group of experts in this kind of entity are the basis in order to obtain good results in these situations. aims: re-do fundoplication is usually performed for recurrent reflux symptoms due to wrap failure or recurrent hiatus hernia. conversely, persistent dysphagia may occur early due to tight wrap/crural repair which should be avoided by good surgical technique. a small group of patients however may suffer progressive dysphagia due to weakening motility (especially in older patients), fibrosis of the wrap or a combination of the two. this video demonstrates the successful treatment of this problem with a laparoscopic conversion from nissen to posterior toupet fundoplication. a year old man underwent an uncomplicated laparoscopic nissen fundoplication in with complete resolution of reflux symptoms. he re-presented years later, still free of reflux but suffering progressive dysphagia and troublesome regurgitation. investigations demonstrated intact wrap and no mechanical obstruction, but confirmed low-amplitude peristalsis. a trial endoscopic dilatation improved symptoms for days before recurrence, suggesting likely wrap fibrosis (which would reduce elasticity and impede passage of food bolus), justifying consideration for a conversion from nissen to toupet. results: this video demonstrates the expected adhesions between fundoplication and inferior surface of left lobe liver, mobilisation and division of the nissen fundoplication, and reconstitution of a posterior toupet fundoplication. the patient made a good recovery and was discharged the following day. three-and six-month follow-up confirmed complete resolution of symptoms with no recurrence of reflux. conclusion: laparoscopic re-do surgery for late-onset progressive dysphagia is a safe and viable option. patients must be thoroughly investigated and carefully selected for an appropriately tailored procedure. they should also be advised of the increased risks associated with re-do surgery. the anatomy can be unpredictably distorted by variable adhesions and this operation should therefore only be performed by laparoscopic surgeons experienced in both primary and re-do fundoplication. methods: i report unusual iatrogenic injury of cervical esophagus that resulted with complete resection post total thyroidectomy for papillary ca of thyroid patient presented days post surgery to our center. the video will show the steps used to treat this unusual complication by neck exploration, laparoscopic trans hiatal esophagectomy with creation of gastric tube with preservation of the right gastroepiploic artery and the neck anastomosis between the cervical esophagus and stomach. were open and minimally invasive esophagectomies. of the patients, were for squamous cell carcinoma, were adenocarcinoma and were of other histological diagnosis such as gastrointestinal stromal tumor and schwannoma. the median length of stay for patients who underwent minimally invasive esophagectomies was days ( to days) while the median length of stay for patients who underwent open esophagectomies was days ( to days). the minimally invasive group had a shorter icu stay of day. for day morbidity, the minimally invasive esophagectomy group had patients who encountered anastomotic leaks, with post operative pneumonia while the open esophagectomy group had patient with anastomotic leak, patient with post operative stricture and patient with delayed gastric emptying. there were mortalities in the minimally invasive group while there were no mortalities in the open group. conclusion: our data show that patients who underwent minimally invasive esophagectomies had a shorter duration of hospitalization with similar perioperative morbidity rates. minimally invasive esophagectomy is a viable surgical option for a select group of patients. aims: there has been an increasing tendency towards minimally invasive surgery for esophageal cancer. our aim was to evaluate the results of the thoracoscopic approach (ta) and compare them with the ones of open approach (oa) at our institution. methods: retrospective review of all patients who underwent esophagectomy due to esophageal cancer (adenocarcinoma or squamous cell) between and were included. patients with siewert iii tumors and those who didn't need a thoracic approach were excluded. results: during the study period were performed esophagectomies, through ta. in . % of these, the abdominal stage was done by laparoscopy. when comparing ta versus oa, there were no statistically significant differences in the baseline characteristics of the two groups (mean age, median body mass index, ecog performance status, asa score, smoking status, diabetes mellitus, pulmonary disease, histologic type, clinical staging and neoadjuvant chemo and radiotherapy). regarding outcomes, there were no significant differences in need of intraoperative transfusion, median intraoperative blood loss, operative time and length of stay. although not significant, in ta group there was a tendency for higher overall morbidity ( . % versus . %, p = . ); major morbidity-ctcae - ( . % versus . %, p = . ); anastomotic leak ( . % versus . %, p = . ) and re-intervention rate ( . % versus %, p = . ). on the other hand, in ta group there was a tendency (although not significant) towards lower rate of respiratory complications ( . % versus . %, p = . ), lower rate of r margins ( . % versus . %, p = . ) and higher median of lymph nodes removed ( versus , p = . ). conclusions: in our series, outcomes of ta were similar to oa, with a tendency towards lower respiratory complications, lower rate of r margins and higher number of lymph nodes removed in ta group. the impact of these findings in survival remains to be seen. the tendency towards higher morbidity may be related to the learning curve, since this were the first cases performed at our center. background: esophagectomy is a surgical procedureburdened by a high morbidity rate. the effect of minimally invasive (mi) approach on elderly patients is still not clear. aim: of this study was to analyze the impact of mi approach on post-operative course according to the patient age. methods: a consecutive series of patients underwent to elective oncological esophagectomy between and . all data were entered into a prospective database. patients submitted to -flield or trans-hiatal esophagectomywere excluded andonly ivor-lewisopen, hybrid or totally minimally invasive esophagectomywere. patients were stratified according to age in groups:group a(= years) patients, group b ([ and \ years) and group c (were = years) .clinical and pathological factors influencing surgical outcome were evaluated. complications were classified according to clavien-dindo (cd). results: as expected outcomes worsened with patients age(cd = b: . % group a, % group b and % group c. p = . ), mortality ( % group a, % group b and . % group c. p = . ) and length of stay ( days group a, days group b and days group c. p = . ).a statistically significant higher incidence of anastomosticleaks was observed among patients submitted to totally mi esophagectomy in group c vs a and b that were respectively , %, % and %. major respiratory complications were not statistically different among these three sub-group. conclusions: old age has a significant impact on outcomes afteresophagectomy. in this subset of patients a mi approachcould also increasepostoperative morbidity. elderly patients should be carefully selected before to be submitted to mi esophagectomy. introduction: esophagectomy is a major surgical procedure with morbidity and mortality related to the patient's condition, stage of the disease, complementary treatments, and surgical experience. minimally invasive esophagectomy (mie) may lead to a reduction in perioperative morbidity and mortality with very good quality of life. material and method: we present the experience of the center of excellence in esophageal surgery regarding totally mie through thoracolaparoscopic modified mckeown three-stage approach followed by esophageal reconstruction by gastric intrathoracic pull-up and cervical esophagogastric anastomosis used for the treatment of thoracic esophageal cancer. results: in the last years, mie was performed initial, in our clinic with extracorporeal preparation of the gastric conduit with reduced lung complications and hospital stay. we introduced the totally minimally invasive esophagectomy with laparoscopic-assisted feeding jejunostomy using a d high definition camera. operative times were: thoracic- min, abdominal- min and cervical- min with a total of min. the augmented d high definition image provided an excellent visual field, that allowed an accurate identification of dissection plans and extensive periesophageal and perigastric lymphadenectomy. the short-term outcomes of the totally minimally invasive esophagectomy procedure were very encouraging with early feeding on jejunostomy and the control of cervical anastomosis was usually performed in the th day postoperative and the patients were discharged in the th day postoperative without any symptomatology. at the first and third-month follow-up was not reported any major complications. the long-term oncological results are being evaluated. conclusions: the totally minimally invasive approach using advanced technology of endoscopic surgery allowed for these patients a simple postoperative evolution, no major complications, and a good recovery after an extensive surgery. the solid experience in open esophageal surgery of the upper gastrointestinal surgeons provides a fast learning curve of complex minimally invasive surgical procedures with reduced perioperative morbidity. long-term follow-up should confirm the results from the literature regarding the survival, which is expected to be for these patients at least equivalent with outcomes after open esophagectomy. introduction: esophageal fistulas, benign or malignant, represent a real challenge for the surgeons and gastroenterologists, regarding the treatment and the outcome. in these cases, endoscopic treatment is the first line approach, being less invasive and sometimes avoiding the need for surgery. this includes clips, stents, glue and even suture. material and method: we have analyzed esophageal fistulas in patients with benign or malignant pathology, diagnosed and treated in the first months of . the management of this complication included a self-expandable esophageal metallic stent. we have evaluated the diagnosis, the surgical intervention, the timing until the development of the leak, the localization and management of the fistula. results: were postoperative leaks and spontaneous esophageal fistulas. the localization was cervical in one case, thoracic in cases and abdominal in cases. for the postoperative fistulas, in patients the treatment included at least one surgical reintervention with lavage and drainage, beside the insertion of an esophageal metallic stent. in the other cases, endoscopic treatment and antibiotic therapy was enough. in cases, the stent migrated needing repositioning. days mortality was %, both patients from postoperative group. conclusions: esophageal fistulas represent a severe complication, usually in patients already immunocompromised. endoscopic management, including self expandable esophageal metallic stent, can be the main approach, by stopping the contamination and by permitting the early per oral feeding. disadvantages include the possibility of migration and the need of removal after - weeks. methods: five hundreds and one patients with esophageal cancer who underwent mie from to at our department were eligible. we considered the risk factors of complications of pneumonia, anastomotic leakage, and hoarseness after surgery, and the risk factors of difficulty of surgery. results: the risk factors of postoperative complications in univariate analysis were more than years old (odds ratio: . , p = . ), more than ii in asa-ps (odds: . , p \ . ), more than g of bleeding (odds: . , p = . ), more than min. of operation time (odds: . , p \ . ), and colon reconstruction (odds: . , p = . ). the one in multivatiate analysis was more than ii in asa-ps (odds: . , p = . ). the risk factors of much bleeding were colon reconstruction (odds: . , p \ . ), and more than of lymph node dissection (odds: . , p = . ). the risk factors of long operation time without cervical lymph node dissection were neo-adjuvant therapy (odds: . , p \ . ), more than of lymph node dissection (odds: . , p = . ), and colon reconstruction (odds: . , p \ . ). the ones with cervical lymph node dissection were more than pstage iii (odds: . , p \ . ) and more than of lymph node dissection (odds: . , p = . ). conclusions: considering those risk factors, we should perform perioperative management more carefully. method: sa -year-old man with a tobacco and alcoholic habit was suspended for years, under treatment for arterial hypertension, who consults for a logical dysphagia of months of evolution. he is diagnosed of stenosing esophageal distal third epidermoid carcinoma txn m . it is decided to place a prosthesis that is effective and subsequent neoadjuvant qt-rt, after weeks of its completion the surgery is performed. results: the surgery is performed in times, initially by laparoscopy. the esophageal hiatus and the greater curvature are dissected preserving the right gastroepiploic, and lymphadenectomy of the celiac trunk with pedicle section of the left gastric. gastric plasty is performed with a section of lesser curvature towards fundus. it is continued by thoracoscopy. a section of the azygos vein is performed, dissection of the esophageal middle and lower third and lymphadenectomy. gastric plasty is promoted, proximal esophagus section and latero-lateral intrathoracic gastro-oesophageal anastomosis. the anatomopathological study reports ypt and pn with / adenopathies, and disease-free surgical margins. he was discharged without complications on the th day and did not require re-entry. conclusions: ivor-lewis endoscopic surgery is safe and meets oncological criteria in selected patients with distal esophageal neoplasia and performed by an experienced esophagogastric unit. background: the rates of thoracoscopic esophagectomy performed in the prone and left lateral decubitus positions are similar in japan. we retrospectively reviewed short term outcomes of thoracoscopic esophagectomy for esophageal cancer performed in the left lateral decubitus position under artificial pneumothorax by co insufflation in a single institution. this study aimed to evaluate the feasibility of applying this procedure. methods: between july and december , patients with esophageal cancer underwent thoracoscopic esophagectomy in the left lateral decubitus position under artificial pneumothorax by co insufflation. the thoracic procedure is performed as follows:the lymph nodes around the right recurrent laryngeal nerve are dissected. on the cranial side, the lymph node dissection is advanced to the level of the inferior thyroid artery. then, the assistant rotates the trachea toward the ventral side, and the lymph nodes around the left recurrent laryngeal nerve are dissected. the middle and inferior mediastinal lymph nodes are dissected including supradiaphragmatic lymph nodes and the dorsal lymph nodes around the thoracic descending aorta. then, the esophagus is transected using an automatic suture device. finally, the tracheal bifurcation area lymph nodes are dissected. we retrospectively analyzed these patients. results: the completion rate of thoracoscopic esophagectomy was . %, and the procedure was converted to thoracotomy in five patients, due to hemorrhage,severe adhesion. the mean intrathoracic operative time, intrathoracic blood loss, and number of dissected mediastinal lymph nodes were . min, . ml, and . , respectively. postoperative complications included pneumonia ( . %), anastomotic leakage ( . %), and recurrent nerve paralysis ( . %). postoperative ( d) mortality was / ( . %) due to ards and nomi, respectively. conclusions: standardization of the procedure for thoracoscopic esophagectomy in the left lateral decubitus position under artificial pneumothorax by co insufflation, with a standardized clinical pathway for perioperative care led to favorable surgical outcomes. introduction: recently thoracoscopic surgery has become widespread even in chest procedure in thoracic esophageal cancer surgery. as an advantage of minimally invasive esophagectomy, it is possible to perform sophisticated procedures due to its magnified visual effects. on the other hand, short-term perioperative safety and oncological safety are still unclear. in cases where abnormal anatomy or comorbidity in the thoracic cavity is observed, it is thought that it is necessary to carry out thoracic surgery which ensures safety while keeping in mind the transition to transthoracic surgery. here, we report on esophageal resection of the thoracic esophageal cancer accompanied by a mm saccular aneurysm inside the aortic arch. patient: a -year-old man visited a nearby doctor with a chief complaint of discomfort during swallowing. upper gastrointestinal endoscopy examined middle cervical esophageal cancer and received referral to our hospital. ct revealed a mm saccular aneurysm inside the descending aorta in contact with the thoracic esophagus. preoperative diagnosis was middle thoracic esophageal cancer; -iic ct bn m stageia (uicc th). we performed thoracoscopic esophagectomy and lymph node dissection as curative surgery. the anterior surface of the aorta was exposed from the lower mediastinum and descended ascendingly, reaching the lower end of the saccular anus at the head level of the lower pulmonary vein. peeling off the esophagus dorsal side along the margin of the saccular sac and performing esophageal resection. conclusion: we reported thoracoscopic esophageal resection for thoracic esophageal cancer with chest descending aortic saccular aneurysm. thoracoscopic surgery, which can fully exploit close magnification effect, seemed to be useful for anatomically disqualified cases. introduction: anastomotic leakage from oesophagojejunal (oj) anastomosis after total gastrectomy is associated with a high morbidity and mortality rate. leakage rates reported vary between ?% and ?% but lack of consensus in management. in the past, it often required surgical intervention or radiologically abscess drainage that will keep patients fasted with external drain for a long duration. recently, variable endoscopic options-oesophageal stents, clips, fibrin glue and endoluminal vacuum therapy had been introduced with variable outcomes. here, we presented a case of oj anastomotic leak management with combination innovative endoluminal and radiologically technique to insert double pig-tailed catheter. aim: to introduce the feasibility of double pig-tailed catheter for drainage and management of oj anastomosis leak. a year old man presented with two months history of dysphagia. upper endoscopy (ogd) showed suspicious cardio-oesophageal lesion. histology biopsy confirmed with adenocarcinoma. ct-scan of thorax, abdomen and pelvic showed irregular thickening at cardiooesophageal junction with regional lymphadenopathy. no distant metastases. he underwent uneventful d total gastrectomy. on th post-operative day, patient had spike fever and newly developed atrial fibrillation. urgent ct-thorax, abdomen and pelvis with oral omnipaque. it showed lower mediastinal gas-containing fluid adjacent to oj anastomosis within the left retrocrural space suspicious for leak. ogd evaluation showed pin-hole oj leak. guidewire inserted via endoscopy into left retrocural space under radiologically guidance. double pig-tail fr cm subsequently inserted via seldinger approach over guide wire. the proximal end of pig-tail pushed into left retrocural space and distal end positioned into efferent jejunal limb with crocodile jaw through endoscope. diluted contrast injected and passed down to efferent limb with minimal leak. outcome: after double pig-tail insertion, patient started on clear feed on st day post-insertion. one week later, he was started on full feed. repeat upper endoscopy and stent removal done two weeks later. contrast injection showed small blind ended sinus tract from anastomosis toward left pleural space without obvious leak. conclusion: radio-endoscopic is a novel minimally invasive technique that allows insertion of double pig-tailed internal drainage to control oj anastomosis leak. it allows early enteral nutritional feeding and avoid external drainage. background: the number of gastric cancer (gc) survivors, especially long-term survivors, is increasing. how best to evaluate the diseasespecific survival (dss) of gc survivors over time is unclear. we aimed to assess changes in the conditional survival of patients with gc after curative intend gastrectomy and the evolution of the impact of well-known risk factors. methods: clinicopathological data from , patients who underwent curative intend resection for gc at four specialized centres (three in china and one in italy) and from the surveillance, epidemiology, and end results (seer) database were retrospectively analysed. changes in the patients' -year conditional disease-specific survival (cs ) were analysed. we used time-dependent cox regression to analyse which variables had long-term effects on dss and devised an accurate, dynamic dss predictive model based on the length of survival. results: the median follow-up time was months, and disease-specific death occurred in , cases ( . %). the dss of the patients after surgery was dynamic, and most of the disease-specific deaths occurred within the first years after surgery. based on -, -, -, -and -year survivorships, the cs of the population increased gradually from % to . %, . %, . %, . %, and . %, respectively. subgroup analysis showed that the cs of patients who had poor prognostic factors initially demonstrated the greatest increase in postoperative survival time (e.g., n b: . %- . %, ? . % vs. n : . %- . %, ? . %). time-dependent cox regression analysis showed the following predictor variables constantly affecting dss: age, the number of examined lymph nodes, t stage, n stage and site (p all \ . , years after gastrectomy). the influence of prognostic factors on dss and cs changed dramatically over time. based on data from several large global centres, we developed an effective model for predicting the dss of gc patients based on the length of survival time. this model can provide personalized long-term follow-up strategies for patients. methods: we retrospectively analyzed clinicopathological data for rgc patients who underwent radical gastrectomy from centers. the prognosis prediction performances of the ajcc th and ajcc th tnm staging systems and the trm staging system for rgc patients were evaluated. web-based prediction models based on independent prognostic factors were developed to predict the survival of the rgc patients. external validation was performed using a cohort of chinese patients. result: the mean number of retrieved lymph nodes was . , and in . % of patients, the number was = . the predictive abilities of the ajcc th and trm staging systems were no better than those of the ajcc th staging system (c-index: ajcc th vs. ajcc th vs. trm, . vs. . vs. . ; p [ . ). within each staging system, the survival of the two adjacent stages was not well discriminated (p [ . ). multivariate analysis showed that age, tumor size, t stage and n stage were independent prognostic factors for overall survival (os), disease-specific survival (dss) and disease-specific survival (dfs). based on the above variables, we developed web-based prediction models, the huang os model, the huang dss model and the huang dfs model, which were superior to the ajcc th staging system in their discriminatory ability (cindex), predictive homogeneity (likelihood ratio chi-square), predictive accuracy (aic, bic), and model stability (time-dependent roc curves). the stratified analysis showed that regardless of whether more or fewer than lymph nodes were retrieved, the predictive performances of the web-based prediction models were still better than those of the other three staging systems. a decision curve analysis showed that the huang model provided better net benefits than the other three staging systems. external validation showed predictable accuracies of . , . and . , respectively, in predicting os, dss and dfs. conclusion: the ajcc tnm staging system and the trm staging system did not enable good distinction among the rgc patients. we have developed and validated visual web-based prediction models that are superior to these staging systems. objective: to perform competing risk analysis and evaluate cancer-and noncancer-specific mortality in patients with gastric cancer after radical surgery. methods: a total of patients from our department (as training set) and a total of patients from the surveillance, epidemiology, and end results (seer) database (as validation set) were enrolled in the study. the cumulative incidence of cancer and noncancer-specific mortality was determined by univariate and multivariate competing risk analysis. results: the five-year cancer-and noncancer-specific cumulative incidence of death (cid) in the training set were . % and . %, respectively, which were significantly lower than that in the validation set ( . % and . %, respectively). multivariable analysis showed that age, tumor site, tumor size and ptnm stage were independent predictors of gastric cancer-specific mortality and overall survival, whereas age was an independent predictor of gastric noncancer-specific mortality. noncancer-specific cid surpassed cancer-specific cid for ptnm stage i patients after approximately years of surgery, but never for stage ii and iii patients. moreover, for stage i patients, the time point when noncancer-specific cid surpassed cancer-specific cid become earlier as age increasing, with only . years after surgery for patients more than years of age. conclusions: age is an independent predictor of gastric cancer-and noncancer specific mortality and overall survival for patients after radical surgery. for patients with stage i gastric cancer, noncancer-specific mortality is a significant competing event, with an increasing impact as age increases. aim: of the study was to analyse the possibility of function preserving gastrectomy based on the sentinel lymph node (sln) concept. methods: during last years in two clinics odessa national medical university we used mapping procedures in the patients with early gastric cancer. there were men and women, age to years, mean age . ± . years. blue dye was injected into quadrants of the submucosal layer surrounding the primary lesion using an endoscopic puncture needle in patients. blue lymphatic vessels and blue-stained lymph nodes can be identified by laparoscopy within min. of the blue dye injection. we used . % indocyanine green in patients, which we injected by intraoperative endoscopy. new technology indocyanine green (icg) fluorescent imaging was used for sln mapping in this patients. results: amany patients, in which we used blue dye for mapping sln, positive sln was in patients, negative-in patients. in all patients distal gastrectomy (dg) was performed with d lymphdissection. from patients with negative sln in patients metastasis in other lymph nodes were detected.among patients in whom we used icg fluorescent mapping positive sln were detected in patients. laparoscopic-assisted distal gastrectomy with d lymph node dissection was performed in these patients. in patients with negative sln partial wedge resection was performed in patients, segmental pylorus preserving gastrectomy was performed in patients. during follow-up period from to months no recurrences or metastasis were detected in these group of patients. qol in this group of patients was much better, than in patients with conventional distal gastrectomy. conclusions: icg fluorescent method is highly effective for detection of sln. in the patients with early gastric cancer function preserving gastrectomy based on sln navigation may be promising strategy to achieve better results. laparoscopic procedure taking advantage of robotic gastrectomy for gastric cancer to prevent pancreatic fistula gastrointestinal surgery and surgical oncology, ehime university, toon-city, japan backgrounds and aims: analysis of japanese national clinical database (ncd) showed that laparoscopic gastrectomy(lg) had rather increased pancreatic fistula (pf) compared with open gastrectomy. on the other hand, last year, multicenter collaborative research result of robotic gastric cancer surgery(rg)was shown that the complications including pf were significantly decreased as compared with lg. in this study, we have employed a new easy to use device in lg to minimize pf during suprapancreatic lymph nodes dissection requiring pancreatic retraction and compared with conventional lg and rg. materials and methods: internal organ retractor (aesculapÒ) to grasp the gastropancreatic fold and the suprapancreatic peritoneum to imitate davinci's forceps was guided with a thread outside the body. patients(jan. * nov. ) were divided into three groups as follows, group lg- (n = ), lg using the standard devices, group lg- (n = ), lg using organ retractor, group rg (n = ). amylase value in drain(d-amylase) and the volume in drainage, intraoperative bleeding, postoperative hospital stay, incidence of cd (] grade iii) were compared among three groups. results: data are indicated as lg- /lg- /rg(mean ± sd), respectively. on the day and third day after surgery, d-amylase were ± / ± / ± and ± / ± , ± (iu/l). d-amylase was significantly lower in lg- and rg group than in lg- the day after surgery. the operation time was significantly longer in rg, ± / ± / ± (min). bleeding volume and hospital stay did not differ among groups. pancreatic fistula (cd ] grade iii)was observed only in lg- group at (%) . discussion: pf(grade]cdiii), which may lead to mortality, occurred in lg- group. a significant elevation of d-amylase on the st postoperative day was prevented in lg- just like rg, which seemed to lead to prevent pf afterwards. the multijoint forceps is known to be an advantage of rg but it cannot be reproduced by lg using a linear forceps. however, another advantage such as vertical grasping and lifting of the gastropancreatic fold at rest could be mimicked by lg using this device, which seemed to enable a safe lymph node dissection and lead to reduce the pancreatic damage. conclusion: this inexpensive and easy to use method taking the advantage of rg seems to reduce surgeon's fatigue and tissue damage(pf). the study presents comparison of perioperative outcome between different surgical approaches for gastric adenocarcinoma (ac). methods: retrospective cohort of patients that underwent gastrectomy for (ac) at rambam hospital during - . patients data was collected based on demographic characteristics, bmi, operating room time (ort), number of lymph nodes (ln), length of hospitalization (loh), and perioperative complications. results: study population included patients after total gastrectomies, of them robotic and partial gastrectomies, of them robotic. age, gender and bmi were similar between patients who underwent any type of procedures. median length of hospitalization (loh) for robotic total gastrectomy was . days and it was significantly shorter than both laparoscopic total gastrectomy (ltg) . days (p = . ) and open total gastrectomy (otg) . days (p \ . ). similar significant differences in (loh) between the groups were observed among patients who underwent partial gastrectomy, but the comparison between robotic and laparoscopic procedures was limited due to small numbers of (lpg). median(ort) was significantly longer among robotic gastrectomies compared to open, the difference was min in total gastrectomy group and min in partial gastrectomy group (p \ . for both differences), but the difference in(ort) between laparoscopic and robotic procedures were smaller and non-significant. the number of dissected (ln) was similar between the procedures in total gasrectomies. in partial gastrectomies, the number of dissected (ln) was even higher among both laparoscopic and robotic gastrectomies compared to open (p \ . ).) conclusions: robotic total and partial gastrectomies for gastric (ac) are associated with oncologically adequate lymphadenectomy and faster patient recovery, but longer ort. objectives: during esophagojejunostomy using a circular stapler after latg, placement of the anvil head via the transabdominal approach proved difficult. the authors report on a method modified for laparoscopy-assisted, esophagojejunostomy performed by placing the pretilted anvil head(orvil) via the transoral approach. methods: between january and november , esophagojejunostomy was performed using orvil in patients after latg. the anesthesiologist introduced the anvil while observing its passage through the pharynx. during the anastomosis, we kept the jejunum fixed in position with a silicone band lig-a-loops, thereby preventing the intestine from slipping off the shaft of the stapler. results: esophagojejunostomy using the orvil was achieved successfully in all patients. no other complications, such as hypopharyngeal perforation and/or esophageal mucosal injury, occurred during passage. the postoperative complications of anastomosis were leakage in two patients and stenosis in patients, in whom mild relief was achieved using a bougie. conclusions: esophagojejunostomy using the orvil is a simple and safe technique. gastrointestinal tract surgery, fukushima medical university, fukushima-shi, japan; surgery, ohara general hospital, fukushima-shi, japan background: juvenile polyposis of the stomach is a very rare disease, and its malignant potential has been reported previously and total gastrectomy has been recommended as a standard treatment. recently, the usefulness of laparoscopic surgery for this case has been reported, however this type of surgery is thought that maintaining the surgical space is difficult because of distended and thickening stomach. case presentation: eight years ago, a -year-old woman who had no family history of gastrointestinal polyposis had been diagnosed with gastric polyposis and polyp-related anemia and received twice endoscopic submucosal dissection to early gastric cancer in another hospital. she had received an annual upper gastrointestinal endoscopy and she had taken iron supplements for anemia caused from the occasional bleeding from the polyps. however, the number of the polyps had increased over time. because she had a loss of appetite, she admitted to our hospital. enhanced computed tomography showed gastric wall thickening and multiple gastric polyps without lymphadenopathy or distant metastasis. colonoscopy showed no specific findings. she was diagnosed as the juvenile polyposis of the stomach, and she received laparoscopic total gastrectomy with roux-en y esophagojejunostomy. in operative findings, although there were the excessive distention and congestion of the stomach, standard laparoscopic surgery could be performed. the resected specimen revealed multiple variously sized polyps throughout the stomach except for lesser curvature and fundus and the histopathological examination revealed that all polyps were hyperplastic polyps without containing cancer. she was discharged on postoperative day . we successfully performed laparoscopic surgery to treat a rare case of juvenile gastric polyposis. introduction: we report a novel technique for combined use of laparo and thoracoscopy for faradvanced adenocarcinoma of esophagogastric junction (aeg). case presentation: a 's years old man presented with far-advanced aeg. an esophagogastroduodenoscopy revealed a type lesion with the entire circumference around esophagogastric junction (egj). contrast radiography revealed a severe stenosis in the egj and wall irregularity from egj to cardia. computed tomography revealed a stenosis of egj, suspected invasion into the left side diaphragm and some lymph nodes metastases at the abdomen. we diagnosed siewert type ii aeg (ct an m , cstage iiia : japanese classification of gastric carcinoma ver. ). surgical technique :the patient was placed in the reverse-trendelenburg position with the left upper body lifted and legs spread, under general anesthesia. the tumor was huge, exposed from the serous membrane and invaded the left crus. first we performed from laparoscopic proximal gastrectomy using five ports. then, three ports were added in the th, th, and th intercostal spaces with the patient in the same body position, and performed thoracoscopic lower esophagectomy under artificial pneumothorax with intrathoracic pressure of - mmhg, which allows the ventilation of both lungs. the lower esophagus was resected under the thoracoscopic view to ensure an adequate margin. following this resection, intrathoracic esophagojejunostomy was performed by using the laparo-and thoracoscopic techniques. the operative time was min, and the blood loss was g. he was discharged on the th day after the operation without any postoperative morbidity. the histopathological diagnosis was pt bn am , p , pstage iv. after adjuvant chemotherapy with capecitabine and oxaliplatin, ramcilumab monotherapy is undertaken now. ct revealed solitary lung metastasis in months after the operation. conclusion: malta for locally advanced aeg invading the surroundings could be performed safely. introduction: despite being the pioneer in laparoscopic surgery, europe did not have similar surgical experience compared to east asia due to decreased exposure to gastric cancer. several studies on minimally invasive gastrectomy for gastric cancer have been conducted in europe. however, some of them did not analyse total gastrectomy as a distinct entity combining both distal and total gastrectomies; moreover, most of them do not provide data on full five-year follow up for each patient. baltic countries stand in between east and west in terms of gastric cancer incidence: incidence rate per , is . in united kingdom, . in lithuania and . in japan. this exposure to gastric cancer provides unique opportunity to investigate the role of laparoscopic gastrectomy. therefore, a case-control study was designed to evaluate laparoscopic (ltg) versus open total gastrectomy (otg), comparing short-term surgical and long-term oncologic outcomes. surgery, jeju national university, school of medicine, jeju, korea; surgery, chosun university, school of medicine, gwangju, korea objective: although mcv (mean corpuscular volume) levels are known to be associated with the prognosis of various diseases, few study investigated mcv as prognostic factor after gastric cancer surgery. the aim of this study is to address the prognostic value of mcv in gastric cancer who underwent curative gastric cancer surgery. methods: patients (june -december ) with stage i, ii, and iii cancer were consecutively included in this study. all patients underwent curative gastric cancer surgery including subtotal gastrectomy or total gastrectomy. overall survival (os), disease-free survival (dfs) and postoperative complications rate were compared between mcv [ group and = group. results: of all patients, the mean mcv was fl (normal range, to fl). the dfs was significantly higher in the high-mcv ([ ) than low-mcv group(= ) (p \ . ) group. there was no significant difference in postoperative complications when compared with clavien-dindo scale. the survival rate of the high mcv group was higher but there was no significant difference. conclusions: mcv may be a predictive factor after gastric cancer surgery. unlike previous studies, patients with low mcv group showed lower dfs. more research is needed on the significance of mcv in variety of disease. methods: and materials. for years we observed cases with gist of stomach and duodenum. seven patients were brought to clinic with the bleeding and two patients were brought to clinic with vomiting and compensate stenosis. in all circumstances we done the ct, mrt and endoscopic examinations of stomach and duodenum with biopsy . in two circumstances we performed endoscopic operation. in one circumstance we successfully take off the gist from the duodenum endoscopically. during the operation we use the endoscopic instruments. in another circumstances,after endoscopic excision the tumor appear the bleeding which was stopped by endoscopic local heamostasis, by putting clipps on the vessels. in circumstances the tumors were in stomach. in circumstances we performed laparoscopic wedge resection the tumors by staplers. in circumstances when the tumor was very big and situated in the fundus of stomach, we performed laparoscopic resection of the fundal part of stomach by using laparoscopic staplers and 'liga sure' sealing. in circumstance we took off the tumor by putting laparoscopic trocars inside the stomach for instruments and for visualization tumor. after excision the tumor and took it of the stomach we sutured the holes in the stomach. we have no mortality after laparoscopic operation. there were no malignisation in all circumstances. we have cases morbidity. in circumstance the bleeding from the stomach that was stopped endoscopically. in circumstance there was wound infection. the aim of the study to decrease the morbidity in the patients with perforated ulcers of the stomach and duodenum. we observed patients with perforated ulcers of stomach and duodenum. women were , men were . average age about years. patients had perforation ulcer of stomach and duodenum. patients had perforations with bleeding. all patients were divided in two groups. the first groups patient operated laporocopically, in the second group patients operated traditionally. results: there were no mortality in the group that operated laparoscopically. in the group that were operated traditionally one patient died after rebleeding. the average stay in hospital in the group that were operated laporoscopically about days. in the groups with traditional operations, were about days. the morbidity in the first group were in cases. pneumonia in cases, suppuration of the troacar points were in cases. in the second group pneumonia were in cases, suppuration of the operation wound were in cases, subdiaphragmatic abscess was in cases. conclusion: laporoscopic operation in during treatment decrease the mortality, morbidity and hospital staying in the patients the perforated ulcer of stomach and duodenum . of the patients of the third group ( . %) were operated about ulcer rebleeding in the hospital, and ( . %)-about the profuse bleeding ulcer. noonr patient had recurrent bleeding. the average treatment time for patients in group was . ± . days. conclusions: the development of hemorrhagic shock in patients with peptic ulcer bleeding significantly increases the risk of rebleeding and mortality. the application of endoscopic hemostasis allows to reduce the risk of rebleeding and mortality compared with conservative antiulcer therapy. surgical treatment can achieve reliable hemostasis, but accompanied by higher mortality and longer duration of hospital treatment. tan tock seng hospital is second largest hospital in singapore. it is affiliated to two medical schools in singapore and it is a training hospital for both undergraduates and postgraduates. minimally invasive surgery for both benign and malignant diseases of upper gastrointestinal tract becomes more and more popular nowadays. in our department, all the residents have to view the step by step instructional videos of mininally invasive surgeries before they can assist in the cases or perform on their own under the supervision of consultant surgeons. the viewing of the instructional videos help them with better understanding of the procedures. the viewing of videos help them with the importance of steps, standardization of steps. with the help of instructional video, they can not only assist better in the surgery but also reduce the learning curve when they start doing the procedure themselves after the graduation from the residency programme. this is the step by step instructional video of laparoscopic repair of perforated duodena ulcer for surgeons-in-training rotated to our department. in general duplication cysts are rare developmental congenital disorders of the gi tract. three morphological criteria should be met in order to confirm the pathological diagnosis: . they should be attached to the stomach's wall and should be the continuation of it, . at least one of the muscle layers of the stomach's wall should be included and .it should have normal gastric mucosa. the treatment is either enucleation or partial gastrectomy. aim: present our minimally invasive approach to a rare prepyloric submucosal cystic lesion causing gastric outlet obstruction. case report: a -year-old female with vomiting, weight loss and in bad general condition was diagnosed after a full work-up (blood tests, endoscopies, eus, ct and mri) with a submucosal cystic tumor. this cyst first was thought to be a duplication cyst. since the patient was young, our intention was to offer the least invasive surgical technique in order to spare gastrectomy and billroth anastomosis. results: the procedure was completed laparoscopically with enucleation of the cyst through a gastrotomy on the anterior wall of the stomach. after the enucleation of the cyst the gastric mucosa was sutured back and then the gastrotomy was closed with continuous sutures. the result of the pathological report confirmed a rare case of a heterotopic pancreatic cystic lesion. the postoperative course of the patient was uneventful and was discharged with instruction for her diet the th postoperative day. the patient months post-operative has no symptoms. conclusion: in such benign conditions and especially in young patients, gastrectomies could be avoided if possible and give their place to less invasive approaches in order to reduce lifelong risks and morbidity. trangastric enucleation of the cyst although a demanding approach is safe and could be considered as a 'gentler' technique with reduced morbidity. background: pancreatoduodenectomy is considered to be very invasive for early superficial duodenal tumors (sdts), which have a lower risk of lymph node metastasis. partial duodenal resection with endoscopic submucosal dissection for sdts is an attractive technique but it is associated with a high risk of complications. the full-thickness resection of the duodenum wall including laparoscopic and endoscopic cooperative surgery has risk of spreading tumor cells and digestive juices into the abdominal cavity. we have developed novel technique for sdts to decrease the risk of exposure to abdominal cavity of tumor cells and digestive juices, called nonexposed duodenum laparoscopic and endoscopic cooperative surgery (neo-dlecs). aim: the aim of this study is to evaluate the feasibility and safety of neo-dlecs for sdts. surgical procedure: the attachment of the transverse mesocolon was freed from the head of the pancreas and retroperitoneal tissues under laparoscopy. the duodenum and the head of the pancreas were mobilized from the retroperitoneum using the kocher maneuver. a standard esd was performed for the sdt using endoscope. the serosa of the esd ulcer bed was reinforced using the laparoscopic hand-sewn suturing technique in the seromuscular layer around the resected area. after completing the procedure, the endoscope was inserted and passed over the resected area to confirm that there was no stenosis or leakage. methods: ten consecutive patients with sdt underwent neo-dlecs in our institute between march and march . the clinicopathological features of the patients and surgical outcomes were prospectively collected and retrospectively analyzed. results: pathological diagnosis was adenocarcinoma for six patients, adenoma for three patients, and neuroendocrine tumor grade for one patient. the median tumor size was ( - ) mm. the median operative time was . ( - ) min. the median blood loss was ( - ) g. there were no conversions to open surgery in this series. intraoperative perforation was found in two cases during the esd procedure. however, all perforations were closed and reinforced using hand-sewn sutures. no postoperative complications were above grade in the clavien-dindo classification system. conclusions: neo-dlecs is safe and feasible and can be an option for surgical sdt resection. aims: wilkie's syndrome is caused by the entrapment of the rd part of the duodenum between the aorta and the superior mesenteric artery (sma). surgery is indicated for chronic cases and failure of conservative management, being reported a laparoscopic duodenojejunostomy as a minimally invasive option. methods: all cases treated by laparoscopic duodenojejunostomy in our centre because of chronic wilkie's syndrome were recorded. results: females and male underwent a laparoscopic duodenojejunostomy, with a mean age of years (range - ). all patients presented abdominal pain, and weight loss was identified in most of them. a reduced aortomesenteric angle measured by ct scan was the key for the diagnosis (mean angle . degrees, range - ). conventional laparoscopic approach was performed in two patients, the other two patients underwent a sils port approach. mean time of surgery was . min (range - ) and length of stay was days (range - ). after a mean follow-up of . months (range - ), patients improved their symptoms. conclusions: surgery is the mainstay in complicated or refractory cases of sma. laparoscopic duodenojejunostomy has the advantages of the laparoscopic approach (including rapid recovery time, reduced post-operative pain and shorter hospital stay) and it is feasible, safe and effective. in mexico in , gastric cancer represented the rd cause of death; it may manifest in a variety of histologic, anatomic, and genetic patterns, which influences the surgical approach. until now gastrectomy with curative intent is the only treatment that offers potential cure in gastric cancer. in recent years, laparoscopy has emerged as an important modality in the surgical management. in multiple trials no significant difference in recurrence, long-term survival and disease-free survival was observed when compared to the standard open gastrectomy. we present the case of a year old man. with a smoking history of pack years, suspended years earlier. he presented unspecific upper gastrointestinal symptoms; an upper endoscopy was made observing a suspicious depressed lesion of cm located in the greater curvature between the body and the antrum, the biopsy resulted in a poorly diferentiated signet-ring cell carcinoma of the stomach. an endoscopic ultrasound and a thoracoabdominal ct scan showed no evidence of enlarged adenopaties or metastatic disease. initially a diagnostic laparoscopy was made, there was no evidence of carcinomatosis, nor free intraperitoneal fluid; so the greater omentum was dissected towards the splenic and hepatic flexure; a d lymph node dissection was performed, and a subtotal gastrectomy with reconstruction of roux en y was done; intraoperative endoscopy was done to identify the lesion, so adequate margins could be obtained. the patient had a good post operative evolution and was discharged home at th day tolerating oral intake. minimally invasive techniques have proved equivalency of oncologic results when compared to the conventional approach; these techniques are becoming the preferred approach in the treatment of well-selected patients with gastric cancer and have a role in definitive staging, curative resection, and lymphadenectomy. appropriate selection of patients and optimal technical approach are paramount for good outcomes. most data of laparoscopic gastrectomy come from eastern countries, where the prevalence is higher; however western experience is growing along with evolution and development in surgical instruments and new technology. wilkie syndrome is a rare cause of high intestinal obstruction, resulting from the compression of the duodenum between the abdominal aorta and the superior mesenteric artery. the main symptoms are nausea and vomiting, weight loss, early satiety, abdominal distension and epigastric pain. historically, the barium study and arteriography were the diagnostic tests used; more recently the angiotac has shown greater sensitivity. the diagnostic criteria are: dilated duodenum, duodenal compression by the superior mesenteric artery and aortomesenteric angle less than degrees. patients with an acute condition usually respond to conservative treatment (decompression, correction of hydroelectrolyte alterations, nutritional support…). however, those with chronic symptoms usually require surgery preferably with laparoscopic approaches of duodenojejunostomy or the strong's procedure. the strong procedure mobilizes the duodenum by dividing the ligament of treitz. once the duodenal-jejunal junction is mobilized, the duodenum is positioned to the right of the superior mesenteric artery and it is preferred because it provides less morbidity due of the maintaining of the integrity of the gastrointestinal tract, but it has a failure rate of %. gastrojejunostomy allows gastric decompression, but does not relieve duodenal compression, so digestive symptoms may persist, leading to the appearance of a blind loop syndrome or recurrent peptic ulcers. on the other hand, the duodenojejunostomy, which according to some series may be the procedure of choice, may obtain a success rate higher than %. we advocate to initiate the surgical approach with the strong procedure and if it fails to perform to a duodenojejunostomy. during this procedure, gastro-esophageal reflux was evaluated and assigned to severe, moderate and slight category. if the reflux was observed slightly up to cervical esophagus, the case was assigned to moderate category. if the reflux was observed intensely up to cervical esophagus, the position was returned to head high position for the safety and the case was assigned to severe category. the anti-reflux surgery was considered in the moderate and severe categories. results: we have performed laparoscopic nissen procedure in cases. the outcome was assessed by reflux test performed on - postoperative day, and the results showed the reflux was disappeared in every cases. median follow-up period of this study was months ( - months) . in cases ( . %) ppi was restarted before months after the anti-reflux surgery. in cases ( . %) ppi was restarted after the anti-reflux surgery during the whole follow-up period of this study. the bmi of the patients had no relationship to the needed restart of ppi. to evaluate the degree of esophagitis objectively before and after the anti-reflux surgery we designed 'the esophagitis score'. in this scoring method, a number from - was assigned according to the degree of esophagitis along with the la classification. the results of the study have shown that the reflux esophagitis was improved obviously after the anti-reflux surgery even in the ppi restarted group (p \ . ). discussion: to extract the gerd patients who really need anti-reflux surgery is important. reflux test is feasible because of its convenience and visual effects for the patients. the results of the laparoscopic nissen fundoplication were good. background: laparoscopic paraesophageal hernia repair with fundoplication has become more and more popular nowadays due to less morbdity and mortality with shorter length of hospital stay. discussion: tan tock seng hospital is the second largest hospital in singapore. it is affiliated to two medical schools in singapore and it is a training hospital for both undergraduates and postgraduates. in our department, all the residents have to view the step by step instructional videos of mininally invasive surgeries before they can assist in the cases or perform on their own under the supervision of consultant surgeons. the viewing of the instructional videos help them understand the procedures better. the videos can also help them recognize the important steps and standardized safe approach. with the help of instructional video, they can not only assist better in the surgery but also reduce the learning curve when they start performing the procedure themselves during their training period. this is the step by step instructional video of laparoscopic paraesophageal hernia repair with fundoplication for surgeons-in-training who are posted to our department. conclusion: the step by step instructional video on laparoscopic paraesophageal hernia repair with fundoplication can help the surgeons in training reduce their learning curve and improve their surgical skills so that they can perform the procedure safely. the human immunodeficiency virus (hiv) is a neurotropic virus. there have been reports of patients with hiv who have esophageal motility problems, sometimes associated with opportunistic infections. the absence of contractility is defined as a major motility disorder according to the chicago v . classification, which is characterized by normal esophagogastric union relaxation and % peristalsis failure. we present the case of a -year-old male patient with a history of acquired immunodeficiency on treatment with efavirenz, emtricitabine and tenofovir. he presented progressive dysphagia, gastroesophageal reflux and pyrosis of months of evolution. physical examination showed no alterations. upper endoscopy is done reporting a normal esophagus and diffuse chronic gastritis. the esophagogram reported inadequate esophageal motility with contrast stasis and a delayed emptying. the esophageal manometry reported an upper esophageal sphincter with high resting pressure. the middle and distal esophagus showed absence of peristalsis with a pan-esophageal pressurization pattern. the lower esophageal sphincter presented normal resting pressure and borderline relaxation ( %). the integrated relaxation pressure was less than mmhg. the diagnostic impression was absence of contractility (chicago classification v . ).medical management was initiated with inhibitors of the proton pump, isosorbide dinitrate and injections of botulinum toxin without success. it was decided to program the patient for a heller myotomy with toupet fundoplication. a trans-surgical endoscopy revealed a complete myotomy with no leakage or obstruction. the patient went home on the second postoperative day tolerating a solid diet.heller myotomy by laparoscopy with partial fundoplication is safe in the treatment of patients with hiv and esophageal motility disorders, reporting a mortality of . %. the effect of endoscopic treatments prior to surgery is controversy aims: epiphrenic diverticulum represents an infrequent entity and it is usually associated with esophageal motility disorders, such as achalasia, distal esophageal spasm, nutcracker esophagus or hypertensive lower esophageal sphincter. nowadays, epiphrenic diverticulectomy, esophageal myotomy and partial fundoplication is the gold standard technique; although it supposes a challenging procedure and it may provoke lots of complications. approach for diverticulectomy usually depends on the distance from the upper border of the diverticulum's neck to gastroesophageal junction, considering that thoracoscopy should be carried out when this distance is more than cm. methods: we presentthecase of a -year-old male patient, with a bodymass index of anda medical history of diabetes, smoking and alcoholism. his symptoms were mainly regurgitation and dysphagia. upper endoscopy showed esophageal dilatation and the presence of a diverticulum with its neck cm over the gastroesophageal junction. ct scan confirmed these findings and manometry showed achalasia. in the video we can see how we perform a laparoscopic diverticulectomy with esophageal myotomy and dor fundoplication. results: patient was discharged home on the second postoperative day with no complication. after more than two years of follow-up, he has not suffered regurgitation, heartburn, dysphagia or chest pain. conclusions: we present a case with an epiphrenic diverticulum secondary to achalasia in which we performed a laparoscopic diverticulectomy, esophageal myotomy and dor fundoplication. some authors suggest that the correction of the underlying motility disorder is the key in the management of these patients and they do not recommend concomitant diverticulectomy for all cases. however, we consider that the complete procedure, adding diverticulectomy, supposes the gold standard and it is feasible to perform for teams which are skilled in esophageal and gastric laparoscopic surgery, despite its high morbidity rates. purpose: a laparoscopic wedge resection for a gastric submucosal tumor closed to gastroesophageal junction or involved to gastroesophageal junction is technically challenging and more aggressive compared with tumors in other sites of the stomach. a gastroesophageal reflux disease would be more prevalent after laparoscopic wedge resection of a gastric submucosal tumor in gastroesophageal junction because of the destruction to low esophageal sphincter. we hypothesized that a prophylactic anti-reflux surgery after this surgery would be less prevalent the gastroesophageal reflux disease (gerd) and more improve the quality of life of the patients. the aim of this study is to analyze our experience with prophylactic anti-reflux surgery after laparoscopic wedge resection for a gastric submucosal tumor of gastroesophageal junction materials and methods: we retrospectively collected data from patients who diagnosed with submucosal tumor of near the gastroesophageal junction underwent laparoscopic wedge resection between january and december . the patients were divided into groups according to operation with prophylactic anti-reflux surgery (group a) and without one (group b). results: there were no difference in the frequency of the preoperative gerd symptoms between the groups, whereas postoperative gerd symptoms and postoperative use of acid suppressive medications were more frequent in the group b (p = . , p = . ). however, there were no differences in the follow-up endoscopic findings in terms of reflux esophagitis and hill's grade between the groups. in group a, postoperative mean low esophageal sphincter (les) pressure was . ± . . the les pressure was dropped until mmhg in the only one patient. however, there was no reflux symptom in this patient. conclusions: the prophylactic anti-reflux surgery after laparoscopic gastric wedge resection of gastroesophageal junction is an effective method of prevent gastroesophageal reflux symptoms. background: the most critical obstacle is a pancreatic leakage(pl). the most cause of pl might be an activation of pancreatic juice by the mixing of pancreatic juice and intestinal fluid because of the anastomosis technique, the difference of anastomosis between pancreatic duct and caliber of jejunum, and the topple of jejunal mucosa. aim: in this study, we devised the new anastomotic method of pancreato-jejunostomy, so called ' pancreatic stent sliding guide' (pssg) method using a pancreatic duct stent. we would like to demonstrate its method and results. (operative procedure) the cases of hybrid laparoscopic pancreatico-duodenectomies (pd) were done by shuriken-shaped umbilicoplasty with pssg. the pancreatic duct stent, which is fit for a diameter of pancreatic duct, is used for the direct puncture without any incineration. the aims of direct puncture are both the avoidance of the enlargement of anastomotic opening and disturbance of blood flow. the contralateral of anastomotic opening is also punctured and the stent is pulled out of the jejunum. the - pds with the needles at both ends is used for anastomotic thread. firstly, the eversion anastomosis of posterior wall is done by sliding the needle on the stent. and then the anastomosis of anterior wall is done by the same way. the stent of contralateral side is cut and the hole is closed. materials and methods: the cased of pancreato-jejunostomy by pssg method were done by february . the average of patient's age was y.o. the disease of patients were pancreatic cancer (n = ), bile duct cancer (n = ), and papilla vater cancer(n = ). the pancreatic leakage by the isgpf were grade : ,a: ,b: ,c: respectively. in the same periods, we underwent the more ten cases of open pd by pssg method. the pl were only one case of grade a and there were none of clinical pl. conclusion: our new device of pancreato-jejunostomy by pssg might be very effective for the decrease of pl from the view point of machanisms of pl even for laparoscopic pd. year old, male patient presented with upper abdominal discomfort and pain, without nausea, vomiting or weight loss. an sub mucosal lesion was found on endoscopy examination in first part of the duodenum. endoscopic ultrasound has showed . cm sub mucosal lesion in first part of duodenum (anterior wall and close to pylorus). cytology examination from the lesion has showed neuroendocrine tumor. computed tomography of abdomen and chest were normal. his blood laboratory examinations were within normal limits. patient underwent da vinci robotic partial gastrectomy with intra corporeal billroth ii gastrojejunostomy. total operating time (ort) was min. three day after operation patient started regular diet and was discharged home on day fife. final pathology report confirmed diagnosis of carcinoid tumor with ki less than %. surg endosc ( ) :s -s p -robotics & new techniques-education integrated education for colorectal disease-a digital solution for a digital age united kingdom aims: surgical plume has problem in poor visibility of the operative field, inclusion of harmful chemical substances, and biological risk. it is desirable that plume should be removed appropriately to minimize these risks. we assessed whether these problems can be solved by using commercialized evacuator semi-quantification of residual chemicals in the abdominal cavity: was performed using industrial smoke tester by aspirating the intra-abdominal plume onto filter papers and digitizing the stains. ( ) detection of dna in the exhausted gas from the evacuator: the hepa filter, which was interposed at the inlet or outlet of the evacuator, was analyzed using pcr method to detect any dna derived from porcine tissues. results: ( ) laparoscopic visualization: judgement score were . vs. . for ec and . vs. . for us (evacuator: on vs. off, both p \ . ), indicating the visualization was significantly better in the use of the evacuator on both devices general surgery, royo villanova hospital general surgery minimally invasive surgery centre, jesús usón minimally invasive surgery centre methods: i report my experience at the american university of beirut medical center for laparoscopic adrenalectomy cases, left adrenalectomy and cases for right adrenalectomy. three out of the series are large adrenal of cm, and all of these were completed laparoscopically.the video will show the steps of this procedure.a large rt. adrenal mass measuring cm, wt. gm was removed laparoscopically using trocar techniques. the lateral position facilitated the exposure and ease of dissection. the mass was removed by extending one of the trocar site with muscle splitting using endocatch mm. results: patient was discharged home days after surgery. the operative time was hour. pathology revealed carcinoma with no involvement of the capsule or vascular invasion patients (male: n = ; female: n = ) underwent minimally invasive adrenalectomy (tp: n = ; rp: n = ) at our institute. mean patient age was . years ( - years). besides comparing operative (intraoperative blood loss, previous abdominal surgeries, conversion rate, operative time, tumor size) and perioperative factors (time of hospitalization, time to oral intake, histology, postoperative complications) in each group, perioperative outcomes of a learning curve (lc)-the first procedures in both groups-was also analyzed in terms of tumor size, significantly larger lesions were removed with tp (tp: . ± . mm vs rp: . ± . mm; p = . ). the number of asa (american society of anesthesiologists) ii patients were significantly higher in the tp group while there were significantly more asa iii patients in the rp group conversions ) showed no significant difference. the analysis of lc showed a significant difference in previous abdominal surgeries min vs rp: . ± . min; p = . ] all favoring the tp approach. conclusion: both methods proved to be feasible and safe in terms of minimally invasive adrenalectomy. based on our own experience the tp approach resulted in improved operative time and conversion rates to demonstrate the safety and efficacy of the laparoscopic approach in the treatment of large splenomegaly. currently, this approach is recognized as the one of choice in benign splenic pathology, being controversial in the face of a massive splenomegaly or neoplastic pathology. material and method: clinical case: a -year-old man followed in the dept. of internal medicine for a hepatosplenomegaly of probable lymphoproliferative origin. additional explorations of interest are provided. result: intervention: complete laparoscopic approach, right lateral partial decubitus, massive splenomegaly, ? cm, splenuncle of - cm that is resected, section of short vessels, dissection of the splenic hilum, vascular section with endogias, splenectomy with full extraction in a pocket through reduced laparotomy in the left flank for anatomopathological study the aim of this video is to demonstrate the safety and efficacy of the laparoscopic approach in the treatment of large splenomegaly. currently, this approach is recognized as the one of choice in benign splenic pathology, being controversial in the case of a massive splenomegaly or neoplastic pathology it can transform into adenocarcinoma. patients and methods: between and we performed laparoscopic nissen fundoplication (lars) in cases of gerd. in cases of gerd patients be was proved by endoscopy and histological examination. the demeester score was higher ( . versus . , p \ . ), and bile re?ux was measured more frequently among the be patients on the other hand during the . years long endoscopic follow up early barrett carcinoma developed in patients, . months after the lars. both patients underwent a limited surgical resection of the distal esophagus and esophagogastric junction, regional lymphadenectomy, and reconstruction by interposition of an isoperistaltic jejunal segment. there were no complication. histological examination was shown pt n stage disease in both cases. oncological follow up was months long ( . y) and both patients are still disease free. conclusions: although lars can affect regression in a part of be patients, progression to adenenocarcinoma can also occur. endoscopic surveillance is important in the case of be to recognize early cancer, to perform limited surgical resection with low morbidity and long overall-and disease free survival gastric cancer development a nomogram for predicting the conditional probability of survival after d lymphadenectomy for gastric cancer this study aimed to devise a nomogram to predict the conditional probability of cancer-specific survival (cpcs) in gastric cancer (gc) patients after gastrectomy with d lymphadenectomy. methods: clinicopathological data for , gc patients who underwent d lymphadenectomy in a large-volume eastern institution (the training cohort) were analysed. cancer-specific survival (css) was predicted using cox regression models. a conditional survival nomogram was constructed to predict cpcs at and years post-gastrectomy. two external validations were performed using a cohort of , chinese patients and a cohort of italian patients. results: in the training cohort, the -year cpcs was . % immediately post-gastrectomy and increased to . %, . %, . % and . % at , , and years post-gastrectomy, respectively. multivariate cox regression analyses showed that age; tumour site, size and invasion depth; numbers of examined and metastatic lymph nodes; and surgical margins were independent prognostic factors of cancer-specific survival (all p \ . ) and formed the nomogram predictor variables. internal validation showed that the conditional nomogram exhibited good discrimination ability at and years post-gastrectomy (concordance index, . and . , respectively) gastric cancer does non-compliance in lymph node dissection affect oncological efficacy in gastric cancer patients undergoing radical gastrectomy? univariate and multivariate analyses revealed that non-compliance was an independent risk factor for os. logistic regression analysis demonstrated that the extent of gastrectomy, primary tumour site, history of intraperitoneal surgery, bmi and open gastrectomy were independent preoperative predictive factors for non-compliance. cox analysis demonstrated that age, pt, pn, and the extent of gastrectomy independently affected os in patients with noncomplaint lymphadenectomy. however, os was significantly better in the compliant group than in the non-compliant group regardless of the recommendation for chemotherapy. stratified analysis demonstrated that os was significantly better in chemotherapy patients than in patients without chemotherapy and stage ii patients (pt n /n m and pt n m ) in whom chemotherapy was not recommended. conclusion: non-compliance is an independent risk factor after radical gastrectomy for gc we prospectively collected and retrospectively analysed the medical records of patients with proximal gc who underwent lspsd. the data were split / , with one group used for model development and the other for validation testing. results: of the patients enrolled in this study, ( . %) required laparoscopic haemostasis treatment. a multivariate analysis determined the following preoperative adverse risk factors for the model group: gender, preoperative n stage, and terminal branches of the splenic artery (spa), and we developed a scoring system based on these findings. each of these factors contributed point to the risk score. the intraoperative laparoscopy hemostasis rates were . , . , . , and . % for the low-, intermediate-, high-, and extremely high-risk categories, respectively. there were statistically significant differences among groups (p \ . ). with the increase in risk, both blood loss volume (blv) and operative time (min) of lspsd increased significantly (p \ . ).the area under the receiver operating characteristic curve for the score of intraoperative laparoscopic haemostasis was . . the observed and predicted incidence rates for intraoperative laparoscopic haemostasis were parallel in the validation set. conclusions: this simple we compared the survival of src patients with that of tubular adenocarcinoma patients according to bmi. results: the -year survival of src was significantly worse than that of wmd (p \ . ) but superior to that of pd (p \ . ). bmi-stratified analysis showed that in the high-bmi group, the prognosis of src was similar to that of wmd (p [ . ) and better than that of pd (p \ . ). in normal-bmi patients, src had a worse prognosis than wmd (p \ . ) but a more favorable prognosis than pd (p \ . ). src among low-bmi patients displayed much poorer survival than did both wmd (p \ . ) and pd (p = . ). multivariate analysis indicated that the risk of death was lowest for src patients with a high bmi and highest for src patients with a low bmi baseline characteristics were compared in a -patient rspshl cohort and a -patient lspshl cohort. one-to-four propensity score matching was performed to determine between-group differences. result: in total, patients were matched, including patients who underwent rspshl and who underwent lspshl. no significant differences in baseline characteristics were observed between these groups after matching. significant differences in total operative time, estimated blood loss (ebl), splenic hilar blood loss (shbl), splenic hilar dissection time (shdt), and splenic trunk dissection time were detected between these groups (all p \ . ). furthermore, no significant differences were evident between rspshl and lspshl in the overall noncompliance rate of lymph node (ln) dissection ( the highest body temperature within week after operation was used to establish diagnostic thresholds for high body temperature and low body temperature, which was obtained by x-tile software. the study used cox regression to analyze the influence of high body temperature on -year dfs. results: a total of patients were included in the analysis. the diagnostic threshold for high body temperature was defined as °c; patients with a high postoperative body temperature were allocated to the high temperature group (htg), while another patients were allocated to the low temperature group (ltg) cao department of gastric surgery, fujian medical university union hospital, fuzhou, china background: laparoscopic surgery for remnant gastric cancer third step: baring of the right side of the esophagus. fourth step: exposure of left gastroepiploic vessels and lns dissection in the splenic hilar area. fifth step: baring of the left side of the esophagus. the above procedure was performed for rgc patients with stage ct - an /? disease. results: there was no conversion to open surgery. mean operation time was . ± . min, mean blood loss was . ± . ml, and mean times to first flatus p -upper gi-gastric cancer a novel prognosis prediction model after gastrectomy for remnant gastric cancer: development and validation using international multicenter databases fuzhou, china; department of gastrointestinal surgery the model calibration was accurate in predicting -year survival. dca showed that the model has a greater benefit. the results were also confirmed by bootstrap internal validation. in external validation, c-statistics and dca showed good prognostic performance in patient datasets from participating institutions. moreover, we verified reliability of the model in an analysis of patients with different eln counts p -upper gi-gastric cancer a novel abdominal negative pressure lavage-drainage system for anastomotic leakage after r resection for gastric cancer while risk of gastric cancer for ppi users was higher than non-ppi users when duration between - year, = year, = year and = year. the risk of gastric cancer when duration = year(rr = . )and duration = year(rr = . )are higher than risk of gastric cancer when duration between - year (rr = . ). according to location subgroups meta-analysis,risk of non-cardiac gastric cancer for ppi users higher than non-ppi users conclusion: based on a systematic review with meta-analysis, we found the correlation between long-term use of ppi and the risk of gastric cancer and long-term use of ppi may increase the risk of non-cardiac gastric cancer when duration = year p -upper gi-gastric cancer age-adjusted charlson comorbidity index (acci) is a significant factor for predicting survival results: there were patients included in the analysis. the high-acci and low-acci groups had significant differences in preoperative abdominal surgery history, asa grade, tumor size, tumor stage, histologic type, age and comorbidity (all p \ . ). the incidence of postoperative complications was . % in the high-acci group and was significantly higher than that in the low-acci group (p = . ). the overall survival rate (os) and cancer-specific survival (css) rate in the low-acci group were both higher than those in the high-acci group (p \ . ). univariate and multivariate analyses showed that the acci was an independent risk factor for os and css (p \ . ). furthermore, a combination of the tnm staging system and acci showed a trend toward higher prognostic value and higher auc for os and css than the tnm staging system alone (p \ . ). conclusions: the acci was an we aimed to investigate the clinicopathological features and prognosis of patients with mgc and the impact of postoperative adjuvant chemotherapy on long-term survival. methods: the clinical and pathological data of patients diagnosed with gastric adenocarcinoma and undergoing radical gastrectomy from stratified analysis showed that, in advanced gastric cancer (agc), the -year os rates of mgc without adjuvant chemotherapy and sgc without adjuvant chemotherapy were . % and . %, respectively, with a statistically significant difference (p = . ). the -year os rates of advanced mgc after adjuvant chemotherapy and of advanced sgc after adjuvant chemotherapy were . % and . %, respectively, and the difference was not statistically significant (p = . ). the -year os rate of advanced mgc after adjuvant chemotherapy was significantly higher than that of patients without adjuvant chemotherapy ( . % vs. . %, p = . ). conclusions: mgc is a poor prognostic factor after radical gastrectomy for gastric cancer background: whether the tumor-node-metastasis (tnm) staging system is suitable for patients with node-negative gc is still controversial. the modified staging system established by rpa showed good prognostic performance in a variety of cancers. the application of rpa has not been reported in the prognostic prediction of gc. methods: node-negative gc patients who underwent radical resection at fujian medical university union hospital (n = ) and sun yat-sen university cancer center (n = ) with an at least -year follow-up information were selected as the training set. rpa was used to develop a modified staging system. patients from the surveillance, epidemiology, and end results databases (n = ) were selected as the external validation set. results: the -year overall survival (os) rates of patients with th ajcc-tnm stage ia-iiia in the training set were ia %, ib %, iia %, iib % and iiia %. multivariate analysis (mva) showed that larger tumor size, older age, and deeper depth of invasion were independent risk factors for os in patients with node-negative gc (all p \ . ). patients were reclassified into rpa i, rpa ii, rpa iii, and rpa iv stage based on rpa, the -year os rates were %, %, %, and %, respectively, with significantly difference (p \ . ). two-step mva showed that the rpa staging system was an independent predictor for os (p \ . ) were retrospectively collected. patients were classified into two groups according to bmi of \ kg/m ( patients; high bmi group) and = kg/ m ( patients; low bmi group). for these patients, clinicopathological variables were analyzed using propensity score matching to mitigate the selection bias: sex, age, asa physical states, clinical stage, laparoscopy-assisted total gastrectomy (latg) or totally laparoscopic total gastrectomy (tltg), d lymph node dissection, combined resection of other organs, method of anastomosis, jejunal pouch reconstruction. the surgical results and postoperative outcomes were compared and examined between the two groups. results: a total of patients were matched for the analysis. contrary to our expectations, there were no differences in the surgical results about operative time and estimated blood loss (low bmi . ± . min, high bmi . ± . min; p = . , low bmi . ± . g, high bmi . ± . g; p = . , respectively). furthermore, there was no significant difference in postoperative outcome of complication (clavian-dindo [ iiia) and the length of postoperative hospital stays (low bmi cases, high bmi cases baiocchi general surgery, university of brescia-spedali civili, brescia, italy background and aim: recently indocyanine green (icg) was introduced in clinical practice as a fluorescent tracer. the use of icg for sentinel lymph node (ln) mapping was investigated in lots of fields such as breast methods: we conduced a single center prospective trial. we included patients with gastric cancer candidate to surgery. icg was injected intraoperative or the day before surgery, via submucosal or subserosal. total or subtotal gastrectomy was performed open, laparoscopic or video-assisted access. during gastric cancer standard lymphadenectomy we studied lymphatic flow and ln bright in vivo and ex vivo japan introduction: in japan, the number of elderly patients with gastric cancer has been increasing in correlation with the increase in average age of the population. the aim of this study is to assess the safety and efficacy of laparoscopic gastrectomy for cancer in elderly patients compared with the short-term outcome in the nonelderly. method: we reviewed patients who underwent laparoscopic gastrectomy (dital gastrectomy,proximal gastrectomy,total gastrectomy)between ).the incidence of advanced cancer(stageiior more)was higher in elderly patients there were no significant differences in the operating time,blood loss and postoperative hospital stay. there were no significant differences in the incidence of postoperative morbidity. conclusion: in elderly patients, there was a tendency of reduction surgery being selected according to individual condition, but there was no significant difference in the short-term outcome.hence,we conclude that laparoscopic gastrectomy is indicated even in elderly patients. p -upper gi-gastric cancer improved technique of vacuum therapy and carried out ltg . a patient factor (the gender, the age and bmi), an operation factor (operation time, the bleeding amount, lymph node dissection and conjurer), a coincidence related complication (clavien dindo classification, sutural insufficiency of grade more than , anastomotic stricture, anastomotic region bleeding and reflux esophagitis) and the post-operatively length of stay were considered . result: cs crowd met cases ( . %) and ls cluster ( . %) cases. years old of age medians ( - ), men and women were examples ( . %), examples ( . %) and bmi median . ( . - . ) by a patient factor, and a significant difference didn't admit by two groups for days, the post-operatively average length of stay was days by ls group by cs group. conclusion: operation time was short for a coincidence by linear stapler more than a coincidence by circular stapler in comparison of an esophagoenterostomy way in ltg on the day before the operation, we endoscopically clipped several points located cm proximal to the tumor edge to cover about half of the tumor. after lymph node dissection, we incised the stomach with an endoscopic linear stapling device,including the previously placed clips. reconstruction was performed in all patients who underwent billroth i or roux-en-y procedures. result: no complications were observed during pre-operative endoscopic clipping or intraoperatively p -upper gi-gastric cancer small intestinal tumors after laparoscopic surgery in our hospital small intestinal tumors are rarely observed, accounting for about - % (malignant cases: - %) of all gastrointestinal tumors. therefore, occasionally, their diagnoses can be difficult. however, recently, capsule and balloon endoscopes have been widely employed were examined regarding patient backgrounds, diagnostic methods, pathological findings, postoperative courses, and prognoses. results: the subjects consisted of males and females, with a mean age of years. their chief complaints were black stools the median distance from the treitz ligament or bauhin valve was cm ( - ) postoperative complications were abdominal abscess ( cases; . %) and surgical site infection (ssi), hemorrhage, and paralytic ileus ( case each; . %). pathological diagnoses were lymphoma metastatic small intestinal tumor ( cases; . %), and granuloma, lipoma, peutz-jeghers polyp, clear cell sarcoma, malignant mesothelioma, and ectopic pancreas most patients were diagnosed in bleeding, complicated by anemia and black stools. however, as most tumors were relatively close to the treitz ligament and bauhin valve, almost a half could be diagnosed with a small intestine endoscope before surgery patients were classified as popf and no-popf according to their grade b or c popf status. popf was diagnosed according to international study group of pancreatic fistula (isgpf) criteria or clinical findings. patient characteristics, intraoperative parameters, electrosurgical device type, pathological findings, and early postoperative outcomes were compared. electrosurgical devices were classified asthunderbeat (tb) or laparosonic coagulating shears (lcs) based on energy sources. results: eighteen patients developed grade b or c popf. among them, ( . %) and ( . %) were diagnosed with popf according to isgpf criteria and clinical findings ), operation time (p = . ) and electrosurgical device type (p = . ) were significant risk factors for popf following lag ) and tb device (or, . ; % ci ) were independent risk factors for popf following lag. conclusions: operation time and tb use significantly affect the risk of popf and should be considered in future clinical studies. p -upper gi-gastric cancer feasibility and nutritional benefits of double flap with no-knife stapler reconstruction after laparoscopic proximal gastrectomy for gastric cancer were analyzed. receiver operating characteristic curves were generated, and by calculating the areas under the curve(auc) and the c-index, the discriminative ability of crps during different periods were compared, including pre-crp, postoperative days , , and postoperative maximum crp (post-crp max ). a decision curve analysis was performed to evaluate the clinical utility. result: ultimately, patients were included this study and the median follow-up time was ( - ) months. for postoperative recurrence, the auc and c-index of pre-crp were . and . , respectively, significantly higher than the other crps, all p \ . . among = ''''''the = '''' post-crps = '''' post-crp = '''' sub = similar findings were observed for overall survival. conclusion: both pre-crp and post-crp max , cheap and easily obtained, are independent predictors of recurrence for gc. act significantly prolonged the rfs for stage ii/iii gc patients with high-prep p -upper gi-gastric cancer robot-assisted gastroduodenal surgery: a single center experience robot-assisted gastroduodenal surgery (ras) was introduced to overcome the technical limitations of conventional laparoscopy. it provides a d-amplified view to the surgeons and an increased ability to control the operative field by manipulating optics, as well as enhanced mobility and precision of instruments. the aim of the present study is to evaluate the main outcome of a single center experience in gastroduodenal robotic surgery. materials and methods: we report a case series of patients who underwent robot-assisted gastroduodenal surgery at sanchinarro university hospital between conclusions: robot-assisted gastroduodenal surgery is a safe and feasible technique in experienced centers with advanced robotic skills. in the literature, there are only few reports of robotic assisted gastroduodenal resection. further studies are necessary to better confirme our results. p -upper gi-gastric cancer atypical methods: retrospective review of ogd reports before and after the introduction of the new guidelines. inclusion criteria: all elective ogds. exclusion criteria: emergency ogds and elective therapeutic ogds. data recorded: patient demographics, endoscopist, indication, number of photos, anatomical site photographed, pathology identified and whether pathology photographed or not. results: ogds reviewed, before the guidelines (group ) and afterwards (group ). the most common indication was reflux ( %) in group and anaemia ( %) in group clinical utility of systematic pre treatment staging laparoscopic exploration methods: all locally advanced gastric adenocarcinoma managed in surgical oncological unit between st january and th november were prospectively enrolled in the study. in the absence of emergency surgery or preoperative contraindications, all patients with curative intent underwent either preoperative chemotherapy followed by surgical exploration in the intent of curative gastrectomy (g)or systematic pretreatment laparoscopic exploration (l) benkabbou surgical department the patient background (age, gender, bmi) and c-stage of the preoperative factor were matched using propensity score matching method, and the surgical results were compared and examined. results: thirty rg groups matched rag cases. the operation time (rag / lg) was significantly longer in the rag group as . ± . min / . ± . min (p \ . ). amount of blood loss was not significantly different each other; ml / ml (p = . ). pathologically t a case was involved in cases in rag and cases in lg. the extent of lymph node dissection (d ? / d ) was / cases in both groups conclusions: rag in our clinical experiences can be safely introduced and short-term results are comparable to those of lg. verification of superiority of robotic surgery including long-term results seems to influence the future of robotic surgery conclusions: totally laparoscopic gastrectomy is feasible method in terms of surgical outcomes. furthermore, totally laparoscopic total gastrectomy is not technically difficult in advanced gastric cancer such as early gastric cancer and safety method. key words: gastrectomy, reconstruction, laparoscopic surgery, stomach neoplasm aims: meckel's diverticulum (md) is one of the most common congenital anomalies of the small intestine caused by an obliteration defect of omphalomesenteric duct. the objective of this study was to review surgical treatment and clinical outcomes of md, and evaluate the safety and feasibility of minimal invasive surgery (mis) in md. methods: we performed a retrospective analysis of medical record for patients who underwent meckel's diverticulectomy at six hallym-university-affiliated hospitals between d), as well as the average of drainage stay. patients who underwent laparoscopic repair required significantly less parenteral analgesics than the open group.the mean postoperative stay was significantly shorter for laparoscopic group (mean, . d) than the open one.morbidity of medical and surgical complication was higher in open groups ( vs ). the most common complication in both groups was medical complication.more case of pneumonia was occurred in open groups compared to laparoscopic groups methods: a retrospective study using our prospective database was designed to analyse all the resected md in our centre. epidemiological data, clinical setting, diagnostic test and histological results were reported. results: md was resected in patients, males and females, with a mean age of . years ( . - . ). in cases, a laparoscopic approach was chosen. eighty-seven percent of the patients had a presurgical imaging test (ultrasounds, ct-scan or meckel's scan) background: perforated peptic ulcer (ppu) is a substantial health problem with significant postoperative morbidity up to % and mortality up to % worldwide. aims: this study aimed to estimate the sensitivity scoring systems for prognosis morbidity of patients operated for ppu with diffuse peritonitis. methods: a total of patients were underwent emergency repair for ppu with diffuse peritonitis in pirogov russian national research medical university's surgical clinics during - years. different scoring systems used to predict outcome in ppu patients were identified: boey score, peptic ulcer perforation (pulp) score, asa, mannheim peritonitis index (mpi), world society of emergency surgery sepsis severity score (wses score). to quantify the strength of the concatenation of prognostic score and morbidity we use odds ratio (or) with % ci ), respectively. pulp score and asa score have good prognostic value in relation to morbidity, but less than boey, mpi and wses sss. patients with pulp [ had or with % ci of p -upper gi-gastroduodenal diseases gastrostomy tube placed by laparoscopy as a new therapeutic option for continuous intestinal infusion treatment with levodopa/ carbidopa we present year outcomes of our initial consecutive patient cohort. methods: patients were identified in a prospectively maintained irb-approved database ( - ). post-operative eckardt scores and a -point validated system questionnaires were obtained via telephone interviews one patient required reoperation for failed myotomy. the mean eckardt score at years was . (± . ), with all fourteen patients having an eckardt score \ . all patients reported significant improvement in their quality of life. classic gerd symptoms (heartburn and regurgitation) were present in ( . %) patients. proton-pump inhibitors are being used by % of with patients with excellent symptom control. seven patients returned for a repeat egd (median . yrs) with patients having normal anatomy and having la grade a esophagitis ( patient on ppi). barrett's esophagus was not detected. conclusion: long-term results from our early experience with lhm are excellent and durable with only one patient requiring re-intervention in years until recently the esophagectomy was the only choice in treatment of patients with end-stage achalasia. developing of minimally invasive techniques such as a laparoscopic heller miotomy and peroral endoscopic myotomy (poem) allowed to use them as a treatment options. aim: to present an experience of treatment of patents with end-stage cardiac achalasia. materials and methods: since . till the laparoscopic heller myotomy was performed in , and esophagectomies were performed in patients with failed previously myotomy made in other clinics. gastric tube was used to replace the esophagus in patients underwent esophagectomy after skeletization of crura posteriorly to esophagus, two separated rectangular patches of parietene progrip mesh (covidien) measuring x . - cm were attached to the posterior surfaces of the crura. the patches were fixated themselves due to special hooks. than continious twodirections suture was placed through both crura along with the patches using self-gripping v-loc - suture (covidien). the same suture was used for construction of nissen fundoplication wrap . cm long. aditional anchoring stich through the wrap and esophageal wall was placed using ti-cron - suture (covidien). d laparoscopy was used while suturing using richard wolf epic system. results: all the procedures were performed successfully. there were no cases of bleeding from the suturing points either from the crura and the fundus wall. there were no crural dehiscence while suturing, even if the distance between crura was more than cm. the mean duration of suturing facilitated by d laparoscopy was min (range, - min) for crural repair, and min (range, - min) for fundoplication. there were no excessive postoperative pain in all the patients. there were no disphagia month postop in every patient. conclusions: . the new technique of posterior buttress of crural repair using small patches of parietene progrip mesh and v-loc suture showed feasibility and safety. . the use of d in such case most commonly manifested symptoms are cough, sore throat, hoarseness, dysphonia, globus and only % patients with lpr have typical gerd symptoms. also ppi therapy are less effective in patients with lpr in comparison with patients which have typical features of gerd. purpose: to compare the outcomes between surgical treatment and conservative therapy in patients with laryngopharyngeal reflux. materials and methods: for the period chesarev faculty surgery # , federal state autonomous educational institution of higher education i.m. sechen, moscow, russia p -upper gi-reflux-achalasia a case of a primary parahiatal hernia associated with a type i hiatal hernia emergency county hospital parahiatal hernia is a rare disease that occurs when an abdominal organ protrudes through an opening adjacent to an anatomically intact esophageal hiatus. the herniated organ is usually the stomach, although cases of omental and colonic herniation exist we report the case of a -year-old woman which accused epigastric pain, starting years prior, pseudo-angina, heartburn and bloating. based on imagistic findings the patient was diagnosed with a parahiatal hernia and an associated type i hiatal hernia. patient underwent surgery and a cm diameter defect in the diaphragm lateral to the left crus was discovered, through which - % of the stomach had herniated. the hiatal orifice was slightly enlarged but anatomically intact, with an associated small sliding hiatal hernia. we performed closure of the defect, hiatoplasty and a floppy-nissen fundoplication pneumatic dilation with mm balloon was performed under general anesthesia. radiological contrast control and endoscopy reevaluation revealed a perforation just above the squamo-columnar junction. a minimally invasive approach was decided. an fully covered esophageal stent was inserted. radiological control after days reveals left pleurisy and migration of the stent. the same day was performed an endoscopic repositioning of the stent with clip fixation. left pleural puncture was performed and clear fluid was extracted. the condition of the patient got worse and she was transferred on icu ( . ). we performed left pleurostomy and initial exploratory laparoscopy-no intraperitoneal lesions. due to difficult transhiatal access to the inferior mediastinum the surgery was converted to open-perisophageal mediastinal abscess was found, evacuated and drainage and jejunostomy were performed. after a week, the patient presented progressive altered condition, febrile syndrome. thoraco-abdominal ct-scan showed left pleural effusions. left pleurostomy was performed, with extraction of fetid fluid. continuous lavage was instituted. on st of august, the pleurostomy tube drained gastric content, and the clinical examination revealed signs of generalized peritonitis. laparotomy was performed with lavage, drainage and posterior decompression gastrostomy. results: postoperative evolution was favorable, with the suppression of pleural drainage in . and discharge in . with alimentation exclusive on jejunostomy. one month later, she had normal clinical and radiological examination evaluation of efficacy was performed with reflux symptom index (rsi) specific for extraesophageal symptoms, subjective satisfaction and occurrence of dysphagia and gas-bloat syndrome. a rsi score [ was considered as pathological. results: rsi significantly decreased after surgery ( and msa as compared with total fundoplication; , % of patients were satisfied with surgery: a comparison between techniques showed superiority of msa objective: to demonstrate the efficacy of hiatorraphy without the use of meshes in thegiant paraesophageal hiatus hernia, as well as the standardization of our technique, with thetechnical steps that we make successively. material and method: clinical cases: -year-old man,with symptomatic hiatal hernia with progressive intolerance and dysnea. egd: the stomach rotated in a giant hiatal hernia.gastroscopy not completed due to endoscope loop formation within giant hiatal hernia with gastric volvulation. ct: large hiatal hernia,combined volvulation (axial axial mesenteric organ), the stomach in a right subpulmonary situation. results: intervention: laparoscopic approach.hh of large paraesophageal size,double organoaxial-and-mesenteric volvular component,gastric walls very thickened and adhered to the mediastinum.reduction of all content and the sac,is adhered to the pleura, extended med-iastinal esophageal disection, up to vein pulmonary and get enough abdominal esophagus and rule out the presence of an short esophagus,posterior-anterior and left tutorized modified hiatorraphy with stitches in ''u'' with non-absorbable suture on teflon reinforcement patches.nissen fixed to both pillars, intramediastinal drainage.egd at the st day with esophageal stenosis due to inflamation of the nissen, resolved with medical treatment. dischage at th day.asymptomatic and without radiological recurrence after months of follow-up. conclusions: in giant and paraesophageal hiatus hernias, modified primary hiatorraphy together with mediastinal esophageal dissection extended can be an effective and safe alternative, and can be advised as a technical gesture prior to a collis nissen and-or placement of a hiatal-hiatoplasty mesh united states of america aim/background: prescribed opioids for pain control have been implicated as major contributors to addiction through their illicit use. efforts to reduce opioid prescriptions and measure their impact on outcomes are novel. we analyzed how patient outcomes are affected with reduced opioid prescriptions following laparoscopic foregut surgery narcr: %), length of hospital stay (narcs: . days vs. narcr: . days), -day readmission rates (narcs: % vs. narcr: %) and perioperative complication rates. additionally, no significant qol outcome differences between the groups were reported at one month postoperatively. conclusion: our study supports reducing opioid prescriptions as a strategy to counter illicit drug use and addiction patients who underwent paraesophageal hernia repair at a tertiary referral center were analyzed retrospectively. demographic data, asa classification, characteristics of peh, onset of symptom, dysphagia severity score, characteristics of fundoplication (partial vs. total; laparotomy vs. laparoscopy; emergency vs. elective) and surgical outcome (length of stay, complication and -day mortality) were recorded and reviewed. results: patients were included; % were female (mean age of . years old and mean body mass index of . ). mean onset of symptom was . weeks after peh repair, dysphagia severity scores were changed . from . . conclusion: in our series, the dysphagia severity scores reduced after surgery upper gi surgery, the catholic university of korea mary's hospital, incheon city, korea p -upper gi-gastric cancer general surgery biopsy from the mass has showed poorly differentiated signet ring cell adenocarcinoma. chest computed tomography revealed mm thoracic aortic aneurism. abdominal computed tomography showed mm infra renal aortic aneurism and no evidence of metastatic disease general surgery year old, female patient presented with upper abdominal pain, weight loss ( kg during last three month), without nausea or vomiting biopsy was done and pathology result showed intestinal type, her -negative adenocarcinoma of the stomach. chest and abdominal computed tomography (ct) were normal. endoscopic ultrasound (eus) revealed cm lesion with invasion to the muscularis propria (mp) she was treated by neo adjuvant chemotherapy ( cycles carboplatine ? fu). patient underwent laparoscopic partial gastrectomy with modified d lymphadenectomy and billroth ii gastrojejunostomy. total operating time (ort) was min. three day after operation patient started regular diet and was discharged home on day fife. final pathology result confirmed intestinal type, modified differentiated adenocarcinoma of the stomach economou st surgical department general, visceral and transplant surgery, section minimally invasive surgery, heidelberg university hospital, heidelberg, germany; department of surgery, iuliu hatieganu university, cluj-napoca, romania; general and visceral surgery, klinikum mittelbaden, baden-baden, germany surgery, toyonaka municipal hospital, toyonaka city, osaka, japan; gastroenterological surgery, osaka university, osaka, japan; next generation endoscopic intervention, osaka university, osaka, japan aims: uncomplicated healing of anastomoses in colorectal surgery is the basis for early adjuvant oncology therapy. the basis for proper healing is good blood flow. we use by robotic surgery foor control the firefly by intuitive. since january , icg has used for blood flow in laparoscopic bowel surgery for the d-light system of storz. method: use of icg wants to accurately determine the resection line for free colon operations based on good blood circulation. we use icg pulse in two batches and color detection using d light from storz to verify blood flow. the first dose is given after the skeletalisation of the intestines intraabdominally and the second after the colic anastomosis to verify its vitality. results: in the period under review we performed laparoscopic operations on the free colon, % of the operations were elective. we had . % leakage across the set, however, in the subset of elective operations, we had only a leak of . %. conclusion: in an unselected set of colorectal operations, leakage was . %, but only . for elective operations. in our group there was a clear effect of using icg in elective laparoscopic resections with an intracorporal anastomosis, the effect was not shown in others, probably due to leakage were factors other than blood flow. objective: right hemicoloctomy (rhce) is the first choice in treating the right colon cancer. complete mesocolic excision with extended lymph node dissection at the roots of superior mesenteric artery (sma) branches enables removal of all lymphatic tissue and prevents local recurrence. previously variability of sma branches was demonstrated. the aim of presented study was to compare the distribution of sma branches in two ethnically different cohorts methods: preoperativect scans with vascular d reconstruction were assessed in patients ( - years) from russia and patients ( - years) from turkey with right colon cancer operated in - . the distribution of ileocolic artery (ica), right colic artery (rca) and middle colic artery (mca) was investigated. results: ica and mca could be found on ct scans in all patients, whereas rca had significantly different distribution between patient cohorts: it was visible in ( %) of turkish patients and only in ( %) of russian patients (p = . ). conclusion: these results suggest that there might be ethnical differences in sma branches distribution. in turkish patients all named sma branches ate visible on ct scans in %, whereas in russian patients only in %. the majority of patients from russia don't have rca. ica and mca could be found in all patients regardless ethnicity. knowing the variant of sma branching before the operation can help plan extended lymph node dissection. the national training programme in laparoscopic colorectal surgery (s-micras-lapserb) in serbia was set up to introduce standardized and structured training in laparoscopic colorectal surgery. method: an assessment based structured training programme (lapserb) started in . series of hands on supervised workshops were conducted for four different hospitals using the structured training by single trainer. this study aims at retrospective analysis of prospectively collected data for patients undergoing colorectal resections. we look at short-term clinical and pathological outcome of patients within laparoscopic colorectal resections performed in national training program. results: during the period november until november , laparoscopic colorectal resection was performed in ( male and female) patients. mean age of patients was . ( - ). the most common indication was colorectal cancer ( patients, . %), ( . %) patients were operated due to the colorectal polyps not suitable for endoscopic resection and ( . %) was operated due to ibd. there were ( . %) right colonic, ( . %) left colonic /tme and ( . %) other resections. average number of lymph node harvested in patients with colorectal carcinoma was . . there were / ( . %) r resections mean duration of hospital stay was . days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . postoperative complications were encountered in / patients ( . %). overall, mortality rate was . % ( / ). conclusions: this study demonstrates successful and safe adoption of laparoscopic technique for colorectal resections. short term clinical and pathological outcomes are compared to published data and shows wider adoption at the national level. standardization of operative technique and structured training remains the key in success. introduction: femal adnexal tumor of probable wolffian origin (fatwo) was first described in . it is a tumor of mesonephiris wolffian duct origin. fatwo is rare tumor which is usualle benign. in the literature has been reported cases and only cases of recurrent disease. next rare tumor in pelvic localisation is sex cord-gonadal stromal tumor of sertoli cells. methods: we present case report of women who presented metastatic fatwo with duplicity of sertoli tumor. results: -year old women underwent years ago exstirpation of tumor in the left broad ligament. histologically there was rare benign fatwo. this year was indicated adnexectomy at gynecology department. during the operation was done bilateral adnexectomy and discovered tumor of anterior wall on upper rectum. microscopic examination showed sertoli tumor on the left ovary. afterward we completed next examinations. colonoscopy without any abnormality. on ct scan was tumor cm without contact to rectum wall, without distant metastasis. the same was described on rectal ultrasonography-normal wall of rectum, tumor probably from uterus. at diagnostic laparoscopy was tumor mass cm, with necrosis arising from anterior wall of the rectum. next small metastasis on pelvic peritoneum. we performed debulking of this big tumor and metastasectomy, there was no infiltration to muscularis propria of the rectum. patient did not have any postoperativ complications. microscopic examination of the rectal tumor and small peritoneal metastasis showed metastatic fatwo. after weeks she underwent laparoscopic second look operation. there were small metastasis on pelvis peritoneum. we removed two biggest metastasis and the rest was destroyed wit j plazma. microscopic examination showed in this metastasis sertoli tumor. conclusion: our patient has metastatic fatwo and sertoli tumor. fatwo is so rare, that in the literaure is not enough information for observation or adjuvant therapy. in one case was described imatinib mesylae (gleevec) therapy with good results. surgeons must be ready to meet new diagnosis. bochdalek hernia is a type of congenital diaphragmatic hernia. in most cases, it is diagnosed during the neonatal period. we present a case of laparoscopically treated congenital bochdalek hernia that led to jejunal strangulation in an adult . case: an fifty eight year old obese(bmi = . ) female admitted for gradually worsening right flank pain, vomiting and respiratory distress for one day. there was no trauma history to chest or abdomen. the past medical history were old cva, well controlled hypertension and dm. she was hemodynamically stable. her right flank was very tender. there was no abdominal distension. initial cbc tests showed leukocytosis ( , /ul) , but electrolytes were normal. chest pa revealed right side diaphragmatic hernia. there was poorly enhanced, herniated small bowel in the right hemithorax on chest ct scan. the patient was taken for emergency operation. on laparoscopy, the normal liver was displaced leftward because of herniated bowel. there was incarcerated jejunum and omentum which could not be reduced. so we widened a cm sized posterolateral diaphragmatic defect first, and then we could reduce the strangulated jejunum( cm in length) and omentum. there was no hernial sac. the defect was closed with -o prolene. finally, the strangulated jejunum was resected and anastomosed extracorporeally. the hospital progress of the patient was not eventful. on post-operative day , the patient was allowed soft diet. the patient was discharged on post-operative day without any complication. conclusion: congenital diaphragmatic hernia is an uncommon condition in adults, but you should keep in mind the diaphragmatic hernia as a cause of intestinal obstruction and respiratory distress in an adult. prompt surgical intervention is required to a favorable outcome. laparoscopic repair of bochdalek hernia is a good management option. aims: intestinal obstruction is one of the most frequent abdominal conditions in the emergency department (ed). up to % of patients having undergone a laparotomy will have an episode throughout their lives, of which % up to % will respond to conservative management. the laparoscopic approach is widely accepted and supported by the studies published up todate. it is recommended in patients with suspected single band, who have less than one previous laparotomy and less than h of clinical evolution. our objective is to validate in our experience that these premises are the appropriate ones in the election of candidates for a minimally invasive approach. methods: we present a series of cases admitted with symptoms compatible with adhesive intestinal obstruction in the ed of a third level hospital during months. all patients underwent abdominal ct to rule out the possible causes of obstruction. emergency surgery was indicated because of failure of a conservative medical treatment or for the findings of the complementary tests. results: a initial laparoscopic approach was performed in the patients, with a conversion rate of % of the cases (resection and anastomosis was required in patients, due to loop suffering or intestinal tumor not seen in the ct). among the patients who required laparotomy, % had more han h of clinical evolution before de surgery and % had free fluid in the tc. as surgical complications: intestinal perforations were produced secondary to the manipulation. there was recurrences of obstruction in the following months. conclusion: the laparoscopic approach is feasible in selected cases and experienced hands. acording to our results it is recommended to perform it in only in patients with less than h evolution and with a single band image in the ct without free fluid. the intestine should be explored avoiding the manipulation of the most extensive loops to prevent complications and keep in mind the possible conversion to laparotomy in case of complications. aim: the aim of the study was to evaluate whether physiologic and operative severity score for the enumeration of mortality and morbidity (possum) is useful to predict the risk of complications in patients older than years. methods: we performed a retrospective study of patients older than years old diagnosed with acute abdomen who were admitted to the department of general, minimally invasive and elderly surgery in olsztyn between may and october . results: the most common disagnosis was ileus. the mortality rate in surgery department was %.after relocation to the intensive care unit, the overall mortality rate was . %. the patients who died a short time after surgery had mortality rates greater than % and morbidity rates greater than % according to possum. conclusions: this study shows that possum seems to be a valuable scale to predict the risk of death after surgery in older patients. patients with higher mortality and morbidity scores should be very carefully selected for surgery. aims: diaphragmatic hernia in adulthood is rare. the most common causes are blunt and penetrating trauma. we present an intraoperative video of the laparoscopic repair of an adult onset, non-traumatic, diaphragmatic hernia in a patient with splenomegaly. method: a year old woman was referred to upper gastrointestinal surgery with epigastric burning and pain in the left side of her chest, radiating to the left shoulder, for one year. there was no recent or distant history of trauma. she has a past medical history of treated hepatitis c, cirrhotic liver disease, splenomegaly, thrombocytopenia and iron deficiency anaemia. gastroscopy was interpreted as a fundal diverticulum. ct abdomen/pelvis with intravenous (iv) contrast showed this to be a left diaphragmatic defect with herniated stomach causing a volvulus, which lay immediately above an enlarged spleen. a ct three years prior to this showed no diaphragmatic hernia. the patient had some symptomatic relief with a proton pump inhibitor and oral antacids, however due to her persistent symptoms surgery was undertaken. the patient had laparoscopic repair of the diaphragmatic hernia. ports were as follows: mm umbilical, mm left upper quadrant, mm right upper quadrant, mm left iliac fossa. a left posterior diaphragmatic defect was found, just above the enlarged spleen, containing the incarcerated fundus of the stomach. the hernia was reduced by gradual dissection of the sac. a cm nonabsorbable polypropylene mesh (proceed) was used to cover the defect a cm margin. this was tacked in place with protack. a single french robinson drain was left in situ. results: the procedure was uncomplicated. oral diet was introduced on post-operative day and the drain was removed and patient discharged on day . there were no post-operative complications. conclusions: the video shows an effective dissection of a left sided diaphragmatic hernia and mesh repair, overcoming multiple technical challenges secondary to splenomegaly and portal hypertension. aims: creating laparoscopic anastomosis is a challenging surgical skill with high clinical relevance. to assure efficient training and enhanced learning curves, constructive and objective feedback is essential. currently there is no appropriate instrument to assess the surgical performance while creating laparoscopic anastomosis. the aim of this study is to develop and validate the anastomosis-objective structured assessment of technical skill (a-osats) score. methods: to obtain an international expert consensus for a procedure specific checklist (psc) for laparoscopic anastomosis, a modified delphi survey with an integrated analytic hierarchy process is currently being performed. each a-osats sub step is assigned a specific weight to determine its importance to the final outcome of the anastomosis. to validate the a-osats score, a laparoscopic side-to-side small bowl anastomosis with a linear stapler and hand-sewn closure of the enterotomy was chosen and is performed by surgeons with varying degrees of laparoscopic experience on a live porcine model. all performances are recorded and rated twice using the a-osats by two blinded experts. results: the final a-osats score includes a weighted psc developed by the modified delphi survey and the already validated global rating scale of previously published osats scores. four key steps (bowel placement, creation of enterotomies, stapling, closure of enterotomy) and sub steps, as well as their definitions, were established during the delphi survey. to validate the a-osats, surgeons ( experts, intermediates, novices) have participated in the study so far. preliminary results showed significant differences between all three levels of laparoscopic experience (novices: . ± . ; intermediates: . ± . , experts: . ± . ; p \ . ) for the overall a-osats score as well as the psc itself (novices: . ± . , intermediates: . ± . , experts: . ± . ; p = . ). conclusions: the a-osats is a weighted score that objectively assesses surgical skill during the creation of laparoscopic anastomosis. preliminary results confirm construct validity of the proposed score. furthermore, by offering the possibility to differentiate single aspects during the procedure, the a-osats allows focused feedback to enhance one's performance. minor changes in weights are expected after the last round of the delphi survey. interand intrarater reliability will be assessed after final inclusion of all participants.aims: to apply augmented reality technology from three-dimensional colon models as preoperative planning method in colorectal surgery. method: from three-dimensional anatomical models of the colon we have developed holograms of augmented reality. the models were obtained from ct images (siemens somatom perspective Ò) with abdominal image cuts with mm thick. the recovery of the images was in dicom format and the processing to achieve the three-dimensional reconstruction was performed with the programs osirixÒ and horosÒ, which made a complete segmentation of the colon surface, and a modification of the image density. in this way models d were obtained of the isolated colon, and in relationship with the bone structure. the application colon d ar was designed (increased hyper experience-visualizer with slam technology) creating a hologram of augmented reality to scale : from each three dimensional model to make a projection of it on the abdomen of the patient by modifying the position in height of the reconstruction, using the bone pelvis as anatomic reference point to calibrate the placement of the hologram. results: in the preliminary phase (from october to december ) holograms of augmented reality were developed in patients with colorectal cancer (right colon, left colon, transverse colon and rectum) to complement the radiological reconstruction with the virtual model. in the application phase (from january ) the holograms developed are going to be applied as a method to improve preoperative study. conclusions: three dimensional reconstruction of the tumor in the preoperative plan of colorrectal surgery combined with hyperreality technology allows to develop models of augmented reality in order to improve colon anatomy knowledge and to plan the surgical technique.aims: laparoscopic adrenalectomy has become the standard of care for most adrenal masses. we report a case of laparoscopic adrenalectomy for left adrenal adenoma. methods: we present the case of a -year-old caucasian female patient with an asymptomatic, left-sided adenoma, that was incidentally detected during abdominal ultrasound. no headaches, palpitations, tachycardia, tremor, dizziness or vomiting were reported. pre-operative blood tests confirmed that the tumor was a non-secreting one and a ct-scan revealed a . . cm left adrenal mass. laparoscopic surgical excision was proposed. the patient was placed in semilateral right-sided decubitus position. four trocars ( epigastric- mm & subcostals- mm & mm) were used, without the use of a liver retractor. the adrenal vessels were clipped not only with the standard laparoscopic clips, but also with the hem-o-lok ligation system. results: the operation lasted for h with minimal blood loss. the patient's post-operative course was uneventful and she was finally discharged four days post-operatively. histology report ensured that it was adenoma of the adrenal cortex. aims: since the first laparoscopic adrenalectomy in (gagner), the laparoscopic lateral transabdominal approach has proved to be the one of choice. it provides an easy anatomical orientation, overall the technique is similar to other traditional laparoscopic procedures. on the other hand, the posterior retroperitoneoscopic adrenalectomy (pra), described in (waltz), has proven to be a safe technique and effective for the surgical management of several adrenal pathologies. the advantages include direct access to the adrenal gland, without the need for visceral mobilization or lysis of adhesions from previous abdominal operations and the ability to perform a bilateral adrenalectomy without repositioning the patient. currently there is controversy about which is the approach of choice, having to take into account the learning curve necessary for the retroperitoneal approach and the reduced number of patients with adrenal pathology subsidiary of surgical management. the objetive is to demonstrate the safety and efficacy of the standardized laparoscopic approach of the left adrenal gland with trocars for selected cases. methods: clinical case: -year-old man, resistant hypertension despite concurrent use of three antihypertensive agents, with biochemical and radiological diagnosis of left adrenal adenoma with primary hyperaldosteronism. demonstrative video of the technical steps in a standardized way that we propose for laparoscopic left adrenalectomy only using trocars. results: full laparoscopic surgical approach in right lateral decubitus position: trocars-lateral transabdominal approach. steps: . laparoscopic liberation of the splenic flexure of the colon for the colo-spleen-pancreato-gastric en block mobilization until identification of the left pillar, . dissection of the medial border of the gland, identification of left renal and diaphragmatic vein, as well as the adrenal vein which is dissected and clipped, . dissection of the lateral edge of the adrenal gland, . lower pole dissection of the gland completing the resection with ligasureÒ. the patient presented a successful postoperative recovery, being discharged h after the intervention. asymptomatic, the patient does not need antihypertensive drugs at year follow-up. conclusion(s): the standardization of the procedure allows reducing the number of trocars, maintaining the safety and effectiveness of the minimally invasive approach. aims: cortical-sparing adrenalectomy is a suitable treatment for hereditary and sporadic bilateral pheochromocytoma, in cases of low risk of malignancy, to reduce the possibility of adrenal insufficiency assuming the chance of local recurrence. the aim of the study is to analyze the functional results of partial adrenalectomy by retroperitoneal endoscopic approach in singleadrenal patients or patients requiring bilateral adrenalectomy. methods: prospective study between january and october including pheochromocytoma patients diagnosed with low risk of malignant mutations. all patients agreed to be included in the study. experienced endocrine surgeons who have been trained in minimally invasive endocrine surgery performed the procedure using the same surgical technique. demographic variables and clinical characteristics were collected, subsequently carrying out the descriptive analysis of the data. results: a total of eight patients were registered, five associated with men type syndrome and three in the context of vhl syndrome. retroperitoneoscopic resection was performed without laparoscopic or open conversion and no postoperative complications; the average hospital stay was . days. preservation of the functional cortex without corticosteroids was achieved in ( . %) of out cases with a follow-up of . ± months. today, these seven patients have a preserved adrenal function without hormone replacement. conclusions: cortical-sparing adrenalectomy by the retroperitoneal endoscopic approach, in expert hands, is safe and feasible for the treatment of hereditary and sporadic pheochromocytoma in a context of low malignancy, making it possible to avoid the need for corticoid replacement in most cases. biomedical sciences, university of west attica, athens, greece partial adrenalectomy has been suggested for patients benign adrenal tumors especially in the case of hereditary syndromes, like multiple endocrine neoplasia type , von hippel-lindau disease and neurofibromatosis type i. aims: this systematic review aimed to investigate the role of partial adrenalectomy in the treatment of hereditary pheochromocytoma. methods: electronic databases were searched with the search terms 'men ii', 'von hippel lindau', 'neurofibromatosis', 'laparoscopic partial adrenalectomy', 'robotic assisted partial adrenalectomy' for the time period up to and including december . full publications, including clinical trials randomized or not, retrospective studies, case series, case reports that provided relevant data met inclusion criteria results: thirty five possibly relevant studies were identified. abstracts were reviewed and fourteen articles were excluded as they were review articles or articles presenting data on open partial adrenalectomy. twenty one studies, that met inclusion criteria were retrieved in full text and included in the systematic review. eight studies presented data on partial adrenalectomy in patients with von hippel lindau including two case series with median follow up ranging from to . years and six case reports. thirteen studies presented data on partial adrenalectomy in patients with men ii, including two case series and eleven case reports. recurrence rate was estimated at about % for pheochromocytoma. overall steroid dependence rate was estimated at %. conclusion: minimally invasive partial adrenalectomy is a therapeutic option especially in patients with heritable pheochromocytoma, given that tumors are often bilateral, tumors are commonly benign and severe morbidity and mortality may be associated with life-long steroid replacement therapy such as the possibly lethal addisonian crisis . however, data are limited, follow up is not standardized and not appropriately reported and rcts are difficult to be done due to the rarity of the disease. a multinational registry on the short term and long term outcomes of partial adrenalectomy in hereditary pheochromocytoma would be a significant source of knowledge. results: patients were operated on after an average of months with complaints. in both groups, the leading symptoms were severe dysphagia and severe regurgitation. no intraoperative complication was detected. in the transoral group, one patient had to be reoperated on for bleeding, another patient developed pneumonia in the transcervical group. the average duration of the surgeries ( . vs. min, p \ , ), the time to oral feeding ( . vs. . days, p \ , ) and the mean hospital stay ( . vs. . days, p \ , ) were significantly shorter in the transoral group than the transcervical group. patients were completely symptomless postoperatively. after transcervical treatment, complaints were developed in cases (moderate dysphagia and hoarseness). after transoral surgery, recurrent symptoms were observed in patients, had to be reoperated transcervically due to severe regurgitation. conclusion: transoral stapler diverticulostomy is a fast procedure and offers short hospital stay especially in comorbid, aged patients and intermedium diverticulum size. in the long term, some of the patients may require reintervention due to persistent regurgitation. the transcervical approach has higher perioperative morbidity, which can be performed in patients with less than cm or large diverticulum size. aims: complex hiatal hernias, either implicating large hiatal defects or concerning cases of recurrence, often need apart from the primary closure of the hiatal gap, the re-enforcement of the crura with the use of meshes. our aim is to demonstrate the surgical technique for the on-lay placement of the absorbable mesh (phasix tm st mesh /bard) in challenging cases, presenting both the laparoscopic and the robotic approach. methods: we present video fragments from procedures of laparoscopic and robotic reconstruction of complex hiatal hernias, performed by our team, in which an absorbable mesh was utilized in an on-lay fashion. results: patients having undergone a minimally invasive surgical approach (laparoscopic or robotic) for the treatment of complex hiatal hernias with the use of an absorbable mesh, had an uneventful post-operative course and very short hospital stay and recovery time. the -month follow up revealed no recurrences or late complications. conclusions: treating complex cases of hiatal hernias with a minimally invasive approach can be proven quite challenging, with high recurrences and possible complications rate. a proper surgical technique, either laparoscopic or better (based in our primary experience) robotic, by experienced surgical teams and the use of meshes with the right strategy, minimizes the complications, offers all the benefits of minimally invasive surgery and reduces the recurrence rates. aims: several flexible endoscopic techniques for symptomatic zenker's diverticulum have been developed during the last decade. thulium laser has limited tissue penetration and may decrease the risk of perforation. this study reports the first use of thulium laser through flexible endoscopy for cricopharyngeal (cp) myotomy. aims were safety and efficacy of flexible endoscopic thulium laser myotomy and quality of life (qol) changes after treatment. methods: a retrospective review of a prospectively collected database of patients who underwent thulium laser septum division for symptomatic zenker's diverticulum was done. demographic data, presenting symptoms, diverticulum characteristics, and intraoperative data were analyzed. functional outcome swallowing scale (foss) and m.d. anderson dysphagia inventory (mdadi) questionnaires were administered to determine severity of dysphagia and its effect on qol, both preoperatively and during follow-up visits. all the operations were carried out under general anesthesia. a continuous laser configuration and an emissionpower of w was used in non-contact mode. once the mucosa was opened, the fibers of the cricopharyngeal muscle were divided until the buccopharyngeal fascia was visibile. results: between march and september , patients ( males) underwent flexible endoscopic cp myotomy with thulium laser. mean age was ± . , mostly males ( . %). seven patients ( . %) presented with recurrent diverticulum after previous transoral or open treatment. mean diverticulum size was . ± . cm. preoperative main symptoms were dysphagia ( . %), regurgitation ( . %), and cough ( . %). foss score was = in patients ( . %). mean mdadi global and composite score were . ± . and . ± . . complete division of the septum was achieved in all patients. mean hospital stay was . ± . days. there was only one perforation treated conservatively. no -days mortality was observed. at median follow-up of months, foss was = in ( . %) patient and mdadi global and composite score were . ± . and . ± . . all main symptoms were significantly reduced and qol significantly increased. conclusions: flexible endoscopic approach with thulium laser is a safe and effective treatment option for zenker's diverticulum either as a primary treatment or as a rescue therapy. objective: this study sought to explore prognostic factors for patients with borrmann type iv gastric cancer and to establish a predictive model for survival benefit of postoperative adjuvant chemotherapy in such patients. method: this study reviewed the clinical data of patients who underwent curative surgery at fujian medical university union hospital from to for borrmann type iv gastric cancer using a prospective database. cox regression analyses were performed to identify prognostic factors that formed the basis for a nomogram and risk groups. establishment of risk groups to identify patients with borrmann type iv gastric cancer who would benefit from adjuvant chemotherapy. results: patients who underwent r resection were included in this study.multivariate analysis showed that bmi, tumour differentiation, pt stage, pn stage, and asa score were independent prognostic factors. patients in the act-group had longer os than patients in the sagroup, although the p-value for this difference was marginally above the threshold for statistical significance ( . % vs. . %, p = . ). stratified analysis showed that there was no significant difference in os between the act-group and the sa-group for each ajcc stage (stage ii: . % vs. . %, p = . ; stage iii: . % vs. . %, p = . ).a nomogram was established based on these independent risk factors, and nomogram scores were used to divide all patients into a high-risk group (score [ ), an intermediate-risk group ( \ score = ) and a low-risk group (score = ).further stratified analysis based on ajcc stage showed that the -year survival rate was higher in the adjuvant chemotherapy group than in the surgery alone group for low-and intermediate-risk patients in each ajcc stage, while high-risk patients in stage iii did not significantly differ. objective: this study sought to explore the prognostic factors for smoking patients with gastric cancer and to establish a predictive model for the survival benefit of postoperative adjuvant chemotherapy in such patients. methods: we studied patients who were diagnosed from september to september at union hospital of fujian medical university. cox regression analyses were performed to identify prognostic factors. the kaplan-meier method was used to assess the effect of smoking history on the benefit of adjuvant chemotherapy after gastric cancer surgery. a decision tree algorithm was used to identify smoking patients who benefited from postoperative adjuvant chemotherapy. results: the median follow-up time for the whole group was . months, and the average age of all the included patients was . years.multivariate analysis showed that age (p \ . ), bmi (p \ . ), degree of tumor cell differentiation (p \ . ), and ajcc stage (p \ . ) were independent risk factors for the prognosis of smoking patients. based on these independent risk factors, a decision tree model for the benefit of adjuvant chemotherapy for smokers with gastric cancer was established, and the smoking patients were divided into the low-risk patients . %), medium-risk patients ( - year os, . %) and high-risk patients ( - year os, . %) (p \ . ). conclusion: cigarette smoking may reduce the efficacy of adjuvant chemotherapy after gastric cancer surgery. our decision tree model is simple and effective for identifying smokers who would benefit from adjuvant chemotherapy. objective: our study investigated the effect of lymph node (ln) noncompliance on the longterm prognosis of patients after laparoscopic total gastrectomy (ltg) and explored the risk factors of ln noncompliance. methods: the clinicopathological data of gastric cancer (gc) patients who underwent ltg with d lymphadenectomy from june to december were prospectively collected and retrospectively analyzed. the effects of ln noncompliance on the long-term prognosis of patients with gc after ltg were explored. results: the overall ln noncompliance rate was . %. ln noncompliance was significantly correlated with age, bmi, asa score, tumor size, macroscopic tumor type and tnm staging (p values \ . ). the survival rate of patients after ltg with ln compliance was significantly superior to that of patients with ln noncompliance (p = . ). the stratified analysis of tnm stage indicated that there was no difference between the os of stage i patients with ln compliance and those with ln noncompliance; os of stage ii/iii patients with ln compliance was significantly better than that of those with ln noncompliance. cox regression analyses showed that ln noncompliance was an independent risk factor for os. logistic regression analysis showed that high bmi ([ kg/m ) was an independent risk factor for preoperative prediction of ln noncompliance in cstage ii/iii patients. compared with patients with a low bmi (bmi \ kg/m ), those with a high bmi were more likely to show ln noncompliance during surgery, especially during the dissections of # , # a and # a ln stations. conclusion: ln noncompliance was an independent risk factor for poor prognosis in patients with advanced gastric cancer (agc) after ltg. patients with high bmi were more likely to have ln noncompliance, especially during the dissections of # , # a and # a ln stations. ln tracing was recommended for these patients to reduce the rate of ln noncompliance. aim: to study the differences in pathology, survival, and recurrence between special remnant gastric cancer (srgc) and nonspecial rgc (nrgc). method: a total of rgc patients were analyzed in hospitals in china from january to july .we compared the -year overall survival (os) disease-free survival (dfs) rates and used two-step regression explore the influence of the rgc categories on patient outcomes. results: all of the patients divided into srgc group (group s) (n = ) and nrgc group (group n) (n = ). the r resection rate and lymph node (ln) dissection number of group s were significantly higher than group n (p \ . ). the difference in -year os was not significant (p = . ), but the -year dfs of group s was worse than group n (p = . ). twostep multivariate analyses showed nrgc was an independent risk factor for poor dfs. of the patients who had undergone r resection, patients ( . %),suffered recurrence, and the recurrence rate of group s was significantly higher than group n (p = . ), moreover, the ln recurrence rate of group s was significantly higher than group n (p = . ). cox regression analysis showed that age, ca level, n stage and category of rgc were independent risk factors for rgc recurrence. conclusion: srgc has a higher r resection rate and ln dissection number than nrgc, but among patients who had undergone radical gastrectomy, srgc patients had worse dfs and a higher tendency for ln recurrence; thus, they should be treated differently in the clinic. objective: the aim of this study was to report our institution's experience with a novel abdominal negative pressure lavage-drainage system (anplds) for anastomotic leakage (al) after radical gastrectomy (rg) for gastric cancer (gc). background: al is a severe complication associated with high morbidity and mortality after rg for gc. the optimal creation of drainage in al patients after rg remains controversial. methods: the study enrolled patients who underwent r resection for gc at our institution between and . anplds was routinely used for patients with al after january . al rates and postoperative outcome were compared before and after the anplds therapy. we used multivariate analyses to evaluate clinicopathological and perioperative factors for associations with al and failure-to-rescue (ftr) after al. results: al occurred in patients ( / , %), leading to deaths. the al rate was similar before ( - , period ) and after ( - , period ) the implementation of anplds ( . % vs . %, p = . ). age and malnourished were independently associated with al. the ftr rate and abdominal bleeding rate after al occurred were respectively . % and . % for the entire period, but compared with period , it significantly decreased at period ( . % vs . %, p = . ; . % vs . %, p = . , respectively). what's more, only anplds therapy was an independent protective factor for ftr after al. conclusion: our experience demonstrates that anplds is feasible and cost-effective for the management of al after rg for gc. objective: to apply the principles of the 'metro-ticket' paradigm to develop a novel tnm staging system (ntnm) for gastric cancer (gc). background: the 'metro-ticket' prognostic tool for hepatocellular carcinoma has been proven to predict outcome, but a similar concept has not been investigated for gc. methods: the ntnm considered the distance from the origin on a cartesian plane incorporating the pn (x-axis) and pt (y-axis) stages. gc patients undergoing radical resection at fujian medical university union hospital (fmuuh) (n = ) were included. the ntnm was validated using external cohorts from the sun yat-sen university cancer center (sysucc) (n = ) and surveillance, epidemiology, and end results (seer) (n = ) databases. results: ntnm classes with the same distance from the origin have same stage; the stage increases with this distance. among all patients, . % (n = ) were restaged in the ntnm compared with the th edition of the ajcc-tnm classification; . % (n = ) were downstaged in the ntnm compared with the th edition. the ntnm provides significant survival differences between stages (all p \ . ). the survival difference between stages ib and iia was especially large for the ntnm (p \ . ) compared to the th and th editions (p = . ). the concordance index and hazard ratio increased successively with the ntnm stage. similar findings were observed in both external cohorts. conclusion: compared with the ajcc-tnm classification, the 'metro-ticket' ntnm for gc is easier to remember and provides some improvements; therefore, the ntnm may be considered for adoption in future editions of the ajcc-tnm classification. objective: to investigate the prognostic value of complete blood count (cbc)-based biomarkers for patients with resectable gastric cancer (gc). methods: patients with gc who underwent curative resection between december to december were included. estimated area under the curve (auc) and multivariate cox regression models were used to identify the best cbc-based biomarker. time-dependent receiver operating characteristics (t-roc) analysis was used to compare the prognostic impact. results: based on multivariate analysis, the lymphocyte-monocyte ratio (lmr) and hemoglobin (hb) level were the independent prognostic factors (both p \ . ). based on the lmr and hb level, we established the cbc-based inflammatory score (cbcs). higher cbcs was associated with older age, female sex, higher american society of anesthesiologists (asa) score, proximal tumor location, larger tumor size, later stage and vascular involvement (all p \ . ). univariate analyses showed that higher cbcs was also associated with poorer overall survival (os), which was consistent in each stage (all p \ . ). multivariate analysis revealed that the cbcs was a significant independent biomarker (p \ . ). furthermore, t-roc curve of the cbcs was superior to that of the prognostic nutritional index (pni), systemic immune-inflammation index (sii), modified glasgow prognostic score (mgps) and c-reactive protein/albumin ratio (crp/ alb) throughout the observation period. conclusion: preoperative lmr and hb were optimal cbc-based biomarkers for predicting os in gc patients after curative resection. based on the lmr and hb, we developed a novel and easily obtainable prognostic score called the cbcs, which may improve the prediction of clinical outcomes. purpose: the aim of this study was to evaluate the prognostic value of the eighth ajcc tnm staging classification for patients with gastric cancer who had already survived for years. patients and methods: patients who underwent radical gastrectomy at a large eastern center were considered. the prognostic value of staging systems were assessed and compared. additional external validation was performed using a dataset from the surveillance, epidemiology, and end result (seer) database. results: the -year overall survival (os) rate for patients in the training set was . %. with the prolongation of the survival time after surgery, the -year os improved significantly (p \ . ). however, there were no significant differences in survival curves among patients who have survived years after surgery. the auc and c of the eighth ajcc classification for predicting of -year os decreased gradually after surgery and appeared stable after years. for patients who survived years after surgery, we constructed a new tnm staging system (ntnm) according to the survival curves of t stage and n stage. a -step multivariate analysis showed that ntnm, age and sex were independent prognostic factors. the ntnm demonstrated superior prognostic stratification, with higher c-statistic and likelihood ratio chi-square scores and lower aic values than those of the ajcc classification. similar results were observed in the external validation set. conclusion: the ntnm predicted an additional survival more accurately than did the ajcc classification for patients who have survived years after surgery; this may guide decisions regarding surveillance. objective: to investigate the relationship between preoperative sarcopenia and systemic inflammation and evaluate the prognostic impact of these factors on patients with resectable gastric cancer (gc). methods: patients with gc who underwent radical gastrectomy between december and december were included. a multivariate cox regression analysis was performed to identify the prognostic factors. a novel prognostic score (slmr) was developed based on preoperative sarcopenia and the lymphocyte-monocyte ratio (lmr), and its prognostic value was evaluated. results: in total, patients with resectable gc were included in the study. on multivariate analysis, preoperative sarcopenia and the lmr were shown to be independent prognostic factors (both p \ . ). a low lmr was an independent predictor from sarcopenia (p \ . ). based on preoperative sarcopenia and the lmr, we established the slmr. an elevated slmr was associated with older age, higher asa scores, larger tumor size, advanced stages and vascular invasion (all p \ . ). multivariate analysis revealed that the slmr was a significant independent predictor (p \ . ). we incorporated the slmr into a prognostic model that included tumor size and tnm stage and generated a nomogram, which accurately predicted -and -year survival for gc patients. objective: to explore whether adjuvant chemotherapy is still needed in patients aged less than years with pt n - and pt / n gastric cancer. methods: multi-center cohort data of patients with gastric cancer who underwent radical gastrectomy were analyzed. kaplan-meier curves and cox regression were used to analyze the relationships between chemotherapy and prognosis. additionally, nomograms to predict the benefit of chemotherapy were established. results: in total, , patients with pt n - and pt / n gastric cancer were included. patients ( . %) were aged \ years. the -year overall survival (os) was not significantly different between the \ years of age group and = years of age group ( . % vs. . %, respectively; p = . ). lymph node (ln) metastases (hr . ; p = . ) and ln dissection number \ (hr . ; p \ . ) were independent risk factors for the os of patients aged \ years. adjuvant chemotherapy did not improve the -year os for patients aged \ years with pt n - and pt / n gastric cancer (p = . ). however, chemotherapy showed a significant benefit (p = . ) when there were ln metastases and/or ln dissection number was \ . two nomograms were constructed, and the calculated difference was the potential benefit of adjuvant chemotherapy for the patients aged \ years. conclusions: ln metastases and ln dissection number \ were independent prognostic risk factors of patients aged \ years with pt n - and pt / n gastric cancer. patients with these risk factors may benefit from the addition of adjuvant chemotherapy. objective: the choice of reconstruction after distal gastrectomy remains controversial. we have performed roux-en-y (r-y) method after laparoscopic distal gastrectomy(ldg) as a standard since , but we have performed billroth ii (b-ii) method in an increasing number of cases, depending on the patient. we retrospectively investigated the outcomes of patients with b-ii method after laparoscopic distal gastrectomy in our hospital. methods: patients who underwent b-ii and r-y reconstruction after ldg from january to december were included. the patient characteristics, surgical outcomes, and postoperative outcomes between the procedures were retrospectively analyzed. we also compared extend of gastritis on endoscopy and loss of body weight after surgery at year. results: b-ii / r-y : / . b-ii was selected in the elderly patients with poor asa-ps (p \ . ). in surgical outcomes, operative time was shorter for b-ii than r-y (p \ . ), and blood loss was also smaller (p = . ). in postoperative outcomes, there were significant differences in complications (?grade ) (b-ii vs. r-y: . vs. . %, p = . ) and length of stay (b-ii vs. r-y: median . vs. -day, p \ . ). there was significant difference in presence of gastritis between b-ii ( . %) and r-y ( . %) (p \ . ), but no significant difference in loss of body weight (p = . ). conclusion: b-ii reconstruction may be an adequate procedure for high-risk cases because of its shorter operative time and the absence of severe complications. background: numerous studies have shown that the short-term efficacy of three-dimensional ( d) laparoscopic radical gastrectomy (lg) is comparable to that of two-dimensional ( d)-lg. whether d-lg affects the recurrence pattern after surgery has not been investigated. using data from a prospective clinical trial, the present study compares the recurrence patterns between d-lg and d-lg. methods: from january to april , a total of patients were recruited for the clinical trial (nct ). the recurrence types, the first recurrence time and recurrence-free survival (rfs) were compared between the two groups. multivariate analyses of factors associated with rfs were performed to identify whether d-lg affects the recurrence patterns. results: ultimately, patients were analyzed ( in the d-lg group and in the d-lg group), and there were no differences in the clinicopathological data between the two groups. distant metastasis was the most common type of recurrence. there were no significant differences between the two groups in the recurrence types, the first recurrence time or rfs (all p [ . ). according to the th american joint committee on cancer tumor-node-metastasis (tnm) staging system, both groups were stratified into pathological (p) i, ii, and iii stages. the stratified analysis showed that there were no statistically significant differences in rfs between the d group and the d group among patients in each subgroup (all p [ . ). the multivariate analysis of rfs showed that pathological tnm (ptnm) stage and lymphovascular invasion were independent risk factors (all p \ . ). the multivariate analysis of post-recurrence survival (prs) showed that adjuvant chemotherapy was an independent protective factor (p = . ). conclusions: distant metastasis was the most common type of recurrence after lg. the postoperative recurrence patterns, rfs and prs after d-lg were similar to those after d-lg. purpose: the aim of this study is to evaluate the efficacy of delta-shaped anastomosis compared to circular stapler anastomosis in laparoscopic distal gastrectomy with billroth i reconstruction (ladg-bi). method: this is a single-center randomized controlled study. eligibility criteria included histologically proven gastric adenocarcinoma in the lower third of the stomach, clinical stage i tumor. patients were preoperatively randomized to circular stapler anastomosis or delta-shaped anastomosis. the primary endpoint is the number of analgesics use during days after surgery. we compared the surgical outcomes of the two groups. postoperative qol was evaluated using the postgastrectomy syndrome assessment scale- . this trial was registered at the umin clinical trials registry as umin . results: between december and september , patients (delta-shaped anastomosis , circular stapler anastomosis ) were enrolled. there was no difference in the number of analgesics use during day after surgery (median : delta-shaped anastomosis vs. : circular stapler anastomosis, p = . ). there was no difference in the overall proportion with in-hospital grade ii-iiib surgical complications ( %: delta-shaped anastomosis, %: circular stapler anastomosis). there was no operation-related death in either arm. regarding postoperative qol evaluated month after surgery, diarrhea subscale was significantly worse in delta-shaped anastomosis than in circular stapler anastomosis. conclusion: we did not demonstrate the advantage of delta-shaped anastomosis in terms of postoperative pain. since delta-shaped anastomosis tended to cause postoperative abdominal symptoms related to diarrhea, we should carefully apply the delta-shaped anastomosis to ladg. introduction: the use of a three-dimensional( d) camera for laparoscopic surgery has been reported in literature. however, there are only few comparative studies demonstrating its benefits, and no reports on the application of d vision to single-incision laparoscopic surgery. this study aims to compare d vision to the previous two-dimensional( d) system in solo single-incision laparoscopic distal gastrectomy(sidg). methods: medical charts of gastric cancer patients who underwent solo sidg from february to december were retrospectively reviewed. patients were grouped into either d group or d group depending on the type of camera used. all the operations were performed by a single surgeon using a flexible camera(olympus, japan), fixed onto a passive scope holder without the use of a scopist or an assistant. operative data, postoperative outcome, and early complication were analyzed. results: ninety had their operations under d vision and used the d scope. in both groups, there was no difference in age, body mass index, staging, and other demographic or histopathologic criteria. operative time was significantly faster in the d group( . ± . vs. . ± . mins., p = . ) and ebl was also less( . ± . vs. . ± . ml, p = . ). patients in the d group started small fluid diet faster( . ± . vs. . ± . postoperative days, p = . ), and were discharged faster( . ± . vs. . ± . postoperative days, p = . ). early complication was also less in the d group( . % vs. . %) but there was no statistical significance(p = . ). conclusion: the use of the d camera improves operative outcome and hospital stay in patients undergoing solo sidg. the frequency of anastomotic leakage after gastrectomyreaches - %. at the same time, mortality in this group of patients reaches %, and the use of aggressive methods of surgical treatment for the treatment of anastomotic leakage increases the mortality rate from to %. since , vacuum-assisted closure has been used to treat anastomotic leakage of various localizations. the essence of this method is based on the creating a local negative pressure, which is transmitted to the drip cavity through a special porous spongy system. the negative pressure created in the closed cavity, allows you to remove exudate, helps to reduce tissue swelling, improvesmicrocirculation, which in turn contributes to the development of granulations and wound healing with separation of the fistulous course. failures in using the method of vacuum therapy in anastomotic leakage are associated with the great difficulty of delivering a polyurethane sponge with a drainage tube to the leakage zone. in this regard, we have developed an improved method of endoscopic local vacuum therapy, in which the delivery of a polyurethane sponge was carried out with the help of a thread through a pharyngeal ring, a leakage zone and brought out through a drainage tube. this technique has been successfully used in the treatment of four patients with anastomotic leakage after operations on the upper part of the digestive tract. for complete healing of the cavity of the leakage and defect of the organ wall, it took , , and sessions of replacing the vac system, respectively (average . ± . ). there were no complications during the endoscopic local vacuum therapy. when the control endoscopic studies after months after the completion of the treatment at the site of defects of the seams of the anastomoses formed tender scar tissue without signs of narrowing of the organ. aims: enhanced recovery after surgery pathways are safe and effective for patients undergoing gastrectomy. this study aimed to identify perioperative factors influencing the adherence to the protocol, the postoperative course, and the consequent length of stay. methods: between and , patients were referred to our institution for gastric cancer. among these, patients underwent atypical gastric resection and were excluded from this analysis. were assigned to either total or distal gastrectomy and represent the study population. all patients were managed with a standardised perioperative pathway according to eras principles. according to data from the literature and based on our clinical experience, patients with optimal adherence to eras protocol may fit the criteria for discharge within ninth postoperative day, that was considered our ideal threshold for hospital discharge. data were retrospectively collected and analysed from a prospectively maintained database. statistical analyses were performed using spss version for macintosh. the v test, with a significance level of . , was used to investigate the association between the outcome and perioperative categorical variables. when parametric assumptions were met, student's two-tailed t-test was used to compare the means of continuous variables; otherwise, the mann-whitney test was performed. a significance level of . was chosen. logistic binary regression with a backward selection procedure and selection criteria of p-value \ . were exploited to determine significant predictors. results: preoperative, intraoperative and early postoperative variables were considered. among all, multivariate regression analysis revealed that incomplete preoperative immunonutrition, failure to extubate the patient at the end of surgery, intraoperative crystalloids infusions [ ml and blood transfusion [ ml, surgery duration [ min, and failure to mobilise patients within h from surgery were associated with delayed discharge. the logistic regression model was statistically significant (p \ . ) and correctly classified . % of cases. sensitivity and specificity were . % and . %, respectively. conclusions: results seem to be clinically rational and focus the attention on the importance of some perioperative clinical issues for the management of postoperative course. these variables could be considered as clinical goals to be reached in order to get an early discharge. objectives: the purpose of this study is to confirm the safety of laparoscopic gastrectomy with intraperitoneal cisplatin administration as a treatment for advanced gastric cancer with potential for peritoneal seeding. methods: from july to august , patients with advanced gastric cancer who underwent ip chemotherapy after diagnostic laparoscopy were retrospectively studied. all patients underwent laparoscopic gastrectomy with ip chemotherapy or ip chemotherapy alone after a diagnostic laparoscopy. gastrectomy was performed for palliative purposes even with seeding. results: the average age of the patients was years. eight patients ( . %) had preop chemotherapy. curative resection (r ) was performed in patients ( . %). in diagnostic laparoscopy, cytology was performed in patients ( . %) and cy was ( . %). peritoneal metastasis was detected in patients ( . %). of the total cohort, the year os rate was . % and the median survival time was months. in the case of stage iiib and below, the -year os rate was %, but it was % in stage iiic-iv group. when the r resection group and the r - resection group were compared, the -year os rates were . % and . %, respectively. hematological toxicity such as neutropenia was not seen in all patients. the mean hospital stay was . days and adjuvant chemotherapy was performed in patients ( . %). background: radical proximal gastrectomy (pg) and lymph nodes dissection are indicated for selected gastric cancers at the upper third of the stomach. with the advent of laparoscopic surgeries, more and more pg were performed by laparoscopic apporaches. in the past years, our team has accomplished and reported the oncological outcome of laparoscopic distal gastrectomies in cases of clinical stage i gastric cancer in taiwan. through the evolution of surgical trechniques and team work, we have cruised the learning curve of laparoscopic gastrectomy and reconstruction. materials and methods: in this report,we would like to present our surgical experience of laparoscopic proximal gastrectomy for gastric cancer patients. from to , pateints with gastric cancer underwent laparoscopic gastrectomies by the same surgical team at the national taiwan university. among them,six consecutive pateints (male:female = : ) with gastric adenocarcinoma of the upper stomach underwent laparoscopic pg in . the demographics, dissection, reconstruction methods and peri-operative outcome are presented. all six patients tolerated the procedure well, onepatient had mild anastomotic stenosis and improved with one session of endoscopic dilatation. one patient needed temporary proton pump inhibitor for controlloing acid reflux. four of the patients were pathological stage i, and the rest two pateint were stage iia and iiia disease. there was no tumor recurrence until now. summary: laparoscopic proximal gastrectomy is technically safe for treating upper third gastric cancers. the long term oncological outcome deserve further observation. introduction: open gastrectomy (og) has long been the preferred surgical approach worldwide for treatment of gastric cancer (gc). nowadays, several randomized, prospective trials have confirmed improvements in postoperative outcomes for laparoscopic gastrectomy (lg) compared to open procedures, with similar oncologic outcomes. however, most part of these studies comes from the eastern countries. material and methods: a prospective non randomized study was conducted with all patients operated of gc at ramón y cajal university hospital from january to december . over patients enrolled, patients underwent lg and og. textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. results: a textbook outcome was achieved in . % of patients operated of gc. the outcome parameter 'no severe postoperative complication' had the greatest negative impact on the textbook outcome. a statistically higher number of patients with early cancer ( % vs. . %) and subtotal gastrectomy ( . % vs. . %) were found in the laparoscopic group. no statistically differences were found between open and laparoscopic approach regarding operating time, rate of microscopic margin positivity, hospital stay, number of retrieved lymph nodes, complications, reinterventions, mortality and readmissions. no statistical differences in textbook outcome were found between both groups ( . % vs. %; p = . ). conclusions: laparoscopic gastrectomy for treatment of gastric cancer seems to be safe and feasible with similar textbook outcomes compared to open gastrectomy. introduction: laparoscopic surgery has been increasing for treatment of gastric cancer. however, standardization of this minimally invasive approach has not been reached yet because of its technical difficulties and the concern about oncological safety. the aim of the study was to analyze the outcomes of our learning curve in this complex surgical technique. material and methods: the first consecutive cases of laparoscopic gastrectomy (lg) performed at our hospital from november to february were enrolled. patients were divided into two groups based on the period they were operated. training phase (tp) was considered between and ( cases) and more-developed phase (mdp) between and ( cases). conversion, lymphadenectomy and retrieved lymph nodes (ln), hospital length of stay, mean operative time, complications, reintervention and mortality rates were compared between the two phases of learning curve. results: the number of retrieved ln was higher in the mdp ( ± , vs. , ± , ; p = , ). furthermore, we have also found less complications ( , % vs. , %; p = , ), a decreased reintervention rate ( , % vs. , %; p = , ) and overall mortality ( , % vs. %; p = , ) in the mdp. there were no significant differences in conversion rate, mean operative time, and hospital length of stay between phases. conclusion: although we consider that our learning curve is not completed yet because the average of monitored parameters have not reached a steady state, the improvement on surgical parameters and postoperative course in the last two years have showed our results are near to the best results published in the literature. aims: lymph node (ln) dissection proves to be essential for oncological gastrectomy, given that the presence of ln metastases is very high, even for early gastric cancer ( . % for t a and . % for t b). this way, d dissection for advanced gastric cancer and d ? for early gastric cancer are the gold standard procedures. some teams are using indocyanine green (icg) lymphography to improve their ln dissections, claiming that this technique facilitates the harvesting of small fluorescent ln that, otherwise, would be difficult to identify by conventional laparoscopic methods. methods: we herein present the case of a -year-old man with a t b distal gastric cancer. endoscopic ultrasound discarded the presence of metastatic ln and ct scan showed no distant metastases. icg was administrated endoscopically the day before the surgery, an amount of mg was injected along the submucosal layer around the tumour. in the video we can see how we perform a laparoscopic distal gastrectomy with d ? ln dissection and roux-en-y reconstruction. icg lymphography helped us to complete our expected ln harvesting, especially for groups (infrapyloric) and (left gastric artery). thanks to this technique, we could resect ln that we might have obviate during a usual laparoscopic procedure. results: patient was discharged home on the sixth postoperative day without complications and with adequate oral tolerance. conclusions: we present a case in which we have performed a laparoscopic distal gastrectomy with d ? dissection and roux-en-y reconstruction. we used icg lymphography to help us to improve our ln harvesting. although it is soon to assess if this technique may increase the number of retrieved ln and in which stations might be more useful, we consider this is a harmless method that may help gastric teams to complete their expected ln dissections. introduction: gastrointestinal stromal tumor (gist) represents around . % to % of gastrointestinal neoplasms, with the mesenchymal tumor being more frequent than the digestive one.the gist can be produced from the esophagus to the anus, at any point, being the stomach of ( to %) and the small intestine ( to %) more frequent sites.it is characterized by the expression of the tyrosine kinase growth factor receptor,cd ,differentiating it from other mesenchymal tumors,which do not express it.it is accepted that its origin corresponds to the interstitial cells of ramón y cajal,which act as a pacemaker for intestinal motility.they are very heterogeneous tumors, which vary in size,morphology and biological behavior,being neoplasms with uncertain malignant potential.the incidence is between the fourth and sixth decades,being the distribution by gender similar. clinical case: female patient of years,who goes to the general surgery service,as interconsultation,after a veda,by dyspepsia.it is reported stomach:ceiling mucosa without alterations,at the level of the greater curvature is seen a tumor of cm,hard to the touch with the biopsy forceps,slightly irregular covered with mucosa of normal appearance. computed tomography: stomach body:rounded image of nodular aspect which does not present heterogeneous enhancement after administration intravenous iodine contrast extending to peritoneal region, measures x x mm liver:hypodense image without heterogeneous enhancement adjacent to this,a mm rounded image that is suggested to be studied with nmr. gadolinium nmr liver hypodense image with well-defined limits without heterogeneous enhancement of cystic aspect. gastric roof,heterogeneous formation,which enhances with gadolinium mmx m-mx mm,having to discard a gist. surgical technique laparoscopic partial gastrectomy. pathological anatomy and immunohistochemistry . cm injury with net edges.uncertain malignant fusocellular nodule, cd ??? actin-dog ??? s -no mitosis or invasion of the mucosa is observed. conclusion: a case of stomach gist is presented,which,the main symptom was dyspepsia,being the clinical presentation very variable,in relation to the place in which it is located. there is fletcher criteria for the risk of malignancy,this being less than . cm,very low risk,less than cm, the patient evolved favorably,without surgical complications.aims: to present the surgical procedure of resection of the lesser gastric curvature and its pedicle with laparoscopic surgery, fulfilling oncological criteria, carried out in the general surgery service of the hospital of torrecárdenas. methods: an -year-old man with prostate cancer treated with complete hormonal block and epoc, who consults for rectal bleeding of week of evolution. it is diagnosed of gist in gastric lesser curvature, x x cm, very vascularized and infiltrates the wall producing marked imprint on the fundus. it is tributary of left gastric artery. precise blood transfusion and presents hemodynamic stability, is decided surgical resection scheduled. results: the surgery is performed by laparoscopy, with a tumor of approximately cm, which is dependent on the lesser curvature. the esophageal hiatus and the lesser curvature are dissected with section of the left gastric pedicle. atypical gastrectomy of the lesser curvature including gist, making a gastric sleeve dependent on the greater curvature. the anatomopathological study reports pt pn with lymph nodes without adenopathies, and disease-free surgical margins. he was discharged without complications on the th day and did not require re-entry. conclusions: the laparoscopy surgery for atypical gastrectomy of lesser curvature is safe and meets oncological criteria in selected patients and performed by an experienced esophagogastric unit. aims: to present the surgical procedure of total gastrectomy with d lymphadenectomy with laparoscopic surgery, fulfilling oncological criteria, carried out in the general surgery service of the hospital of torrecárdenas. methods: a -year-old male with a tobacco habit who consults due to epigastric pain and constitutional syndrome of months of evolution. it is diagnosed of gastric adenocarcinoma t n m . neoadjuvant qt is decided, after weeks of its completion, scheduled surgery is performed. results: the surgery is performed by laparoscopy, showing a stenosing tumor in at gastric antrum of approximately cm. dissection of the greater curvature with section of the right gastroepiploic at its birth and duodenal section is performed. dissection of the lesser curvature with d lymphadenectomy, section of the pedicle of the left gastric and the distal esophagus. the transit is restored with latero-lateral esophageal-jejunal anastomosis and jejunojejunostomy. the anatomopathological study reports ypt a and pn with / adenopathies, and disease-free surgical margins. he was discharged without complications on the th day and did not require reentry. conclusions: the laparoscopy surgery for total gastrectomy with complete d lymphadenectomy is safe and meets oncological criteria in selected patients and performed by an experienced esophagogastric unit. background: in gastric cancer surgery, to secure surgical margin, it is necessary to accurately judge the position of the tumor. however, with conventional marking clips, it is difficult to identify the exact location of the tumor during laparoscopic surgery. purpose: we investigate whether icg (indocyanine green) fluorescence navigation method is effective and safe for determination of cutting line in laparoscopic gastrectomy. patients and methods: subjects underwent laparoscopic gastrectomy (including robot-assisted surgery) based on the icg method for gastric cancer in the period from april to december . the day before surgery, icg diluted times ( . ml of reagent ? . ml of distilled water) was injected at cm from the tumor edge and . ml at the four submucosal layers around. then clip to the same part. gastrectomy based on standard surgery is performed, and the position of the tumor and spread of icg are confirmed by icg fluorescence navigation during operation, and a cutting line is determined. the extent of icg from the tumor is again measured with the excised specimen and compared with the pathological margin. results: among the patients who underwent intraoperative pathological examination, they were negative in all cases except one. the spread of icg was . cm on average, and considering the marking position ( cm) from the tumor edge, securing of . cm or more was possible. the operation time was . ± . min and the estimated bleeding loss was . ± . ml. conclusion: laparoscopic gastrectomy with icg method can evaluate tumor position and spread easily and in real time during operation and it was effective for determining the cutting line in laparoscopic gastrectomy. epstein-barr virus (ebv) has been known as one of causal virus of gastric cancer. ebv-related gastric cancer considered to be about % of the entire gastric cancer, and it is rare that ebvrelated gastric cancer has multiple lesions. the patient was years old female. she was diagnosed with upper gastrointestinal endoscopy with lesion in the lower major stomach body, lower anterior wall of the stomach body, rear wall in the middle part of the stomach, rear wall in the middle part of the stomach, and lesser curvature of the stomach angle, as a result of biopsy, adenocarcinoma was observed from the former four. the patient underwent a robot-assisted total gastrectomy. adding a newly found lesion, the histopathological diagnosis was pt b in the lower major stomach body, pt b in the lower anterior wall of the stomach body, pt b on rear wall in the middle part of the stomach, pt b on rear wall in the middle part of the stomach, and pt a in lesser stomach body, pn , pstageia. pathological examination results showed that the four lesions were positive for tumor cells in eber in situ hybridization and were considered to be ebv-related gastric cancers. she was discharged on the th day after the operation without any postoperative morbidities.there has been no sign of recurrence without postoperative therapy for months. results: a -year-old female with no medical history of interest or allergies to medications, who consulted for palpable mass at mesogastric level to the left of the midline associated with abdominal pain of - months of evolution, without concomitants or relationship with the intake, valsalva or physical efforts, without change in the depositional habit or toxic syndrome. the abdominal ct (computed tomography) revealed a cystic mass in jejunum mesentery, defined edges, about cm in diameter and that does not capture contrast; likewise, there is no ascites, retroperitoneal adenopathies or other intra-abdominal or pelvic masses, radiology recommends completing the study with abdominal mri (magnetic resonance imaging) that informs of possible lymphangioma at the level of the jejune mesentery. surgical exeresis was decided, which was carried out by laparoscopic approach, with emptying of the lesion and enucleation of the lesion without incidents, the postoperative evolution was favorable being discharged at h. the pathological anatomy reported fibro-adipose tissue with presence of lymphatic dilatations associated with a cystic lesion without epithelial lining, with serous fluid and abundant macrophagic reaction compatible with mesenteric lymphangioma. conclusions: the mesenteric cyst is a rare pathology with an incidence ranging from / , to / , , predominating in the fourth decade of life. it is defined as any cystic lesion in the mesentery, and is subdivided according to its origin into lymphatic, mesothelial, urogenital, dermoid, and enteric and pseudocysts. most of the time they are asymptomatic although they can (as in our case) present with abdominal pain and even produce complications such as intestinal obstruction, volvulus, intracystic hemorrhage, infection, rupture, and even malignant transformation. for the diagnosis, the palpation can be of great help, showing mass of well-defined limits and partially mobile. the imaging test of choice is abdominal ultrasound / abdominal ct, supplemented by magnetic resonance imaging. the recommended treatment is surgical exeresis, considering laparoscopy as the first option; if it is complete, it can be considered as a curative treatment. purpose: gastrostomy(og) is an alternative method for nutrition support, especial for the patients with oral-esophagus route obstruction or dysfunction. the most operation were conducted by young surgeon or residents. laparoscopic gastrostomy(lg) was a new coming procedure and the skillful suture techniques were needed. the most the residents can't be qualified for this operation. we designed the method for laparoscopic gastrostomy to provide the traning opportunity of suture skill training and guarantee the patient's safety. material and method: laparoscopic gastrostomy procedure was done with two mm trocar. the lower body of stomach was chose. four point around gastrostomy wound were chose for subcutaneous fixation. the straight needle with - prolene was inserted into peritoneal cavity from upper point, then punctured the sero-muscular layer of stomach. the needle was retrieved out from the same point by guidance of gauge needle. the same way was used for other three points. one purse string around gastrostomy was created by one hand suture method and fastened by köckerling knot tier after insertion of fr foley tube. finally, the peritonization was finished by hand tie externally and knot were keep in subcutaneous layer material-method: we present the case of a year old woman who presented with melena, hematemesis, anemia (ht . %) and being haemodynamically unstable. after the stabilization of the patient, a gastroscopic examination followed, where it revealed a tumor of the fundus (adenocarcinoma). the patient was submitted to laparoscopic total gastrectomy and oesophagojejunal anastomosis, omega type (o), and intestinal anastomosis braun, with the usage of trocars (umbilical mm as inserted in laparoscopic surgery of a single incision, and two mm in the midclavicular line bilaterally). the oesophagojejunal anastomosis was conducted with the use of a linear stapler for the posterior wall and the convergence of the anterior wall with laparoscopic sutures in two layers. patient remains in well condition, months after the operation. conclusion: laparoscopic approach seems to be safe for treatment of gastric cancer of the fundus and of the gastroesophangeal junction, as it offers better surgical field view and less postoperative complications. the restoration of the continuity of the gastrointestinal tube with anastomosis of w type is considered safe alternative to the classic roux-en-y anastomosis. git and bariatric surgery, faculty of medicine, alexandria university, alexandria, egypt; git surgery, faculty of medicine, alexandria, egypt background: superior mesenteric artery syndrome is best described as compression of the third part of duodenum by the superior mesenteric artery, resulting in obstruction. the study of this rare medical condition was carried out since decades yet remain obscure. this study aimed to analyze different clinical presentations, diagnostic modalities, treatment approaches and outcomes, as well as to emphasize the importance of long term follow up. methods: thirty-five superior mesenteric artery syndrome cases were collected retrospectively from a facebook group called 'superior mesenteric artery syndrome awareness & support'. a questionnaire was designed using google form to obtain the demographics, presenting symptoms, risk factors and co-morbidities, investigations, means of treatment and the outcomes. data was entered into microsoft office excel for statistical analysis. results: the median age at diagnosis was years. the median body mass index was . kg/ m ;. the median time interval from symptom onset to initial diagnosis was months. the major presenting symptoms were abdominal pain ( . %), nausea ( . %), and vomiting ( . %). abdominal computed tomography scan with contrast ( . %) was commonly used for confirmation of diagnosis. thirteen cases ( . %) were congenital. thirty patients ( . %) had received treatment. the overall management success was only . %. surgical management ( . %) was the most used regimen. conclusion: diagnosis of superior mesenteric artery syndrome is established after a thorough assessment of the clinical presentations and confirmation with suitable imaging modalities. the choice of treatment should be dependent on the causes and severity as different patients respond differently to therapy. recurrence is possible in all patients thus a long-term follow up is required. aims: in the last hundred years much has been written on peptic ulcer disease and the treatment options for one of its most common complications: perforation. laparoscopic repair of perforated peptic ulcer has been gaining popularity in recent years. treatment for perforated ulcer can be performed laparoscopically in % of cases, making it possible to avoid a median laparotomy which can lead to wound infection and late eventration. methods: a -year-old male presented to emergency room with a three-hour history of progressively worsening epigastric pain and nausea. physical examination revealed rebound tenderness compatible with an acute abdomen. a ct scan showed: important pneumoperitoneum unable to define the drilling point; distended stomach with plenty of fluid inside and dense content fundus / body suggestive of active arterial bleeding . results: the patient was emergently taken to the operating room for diagnostic laparoscopy . perforation shown in greater gastric curvature associated blood remnants. gastrotomy for clot removal is done without observing active bleeding. the gastrotomy was repaired using standard stitches. all exudate was aspirated and the peritoneal cavity was irrigated with warm saline solution the patient had an uncomplicated post-operative course. jp drain was removed and he was discharged one week after surgery. conclusion: the role of laparoscopic surgery in emergencies is well documented. laparoscopic approach is indicated in any case of suspected gastroduodenal perforation and seems to offer the same advantages as for the vast majority of laparoscopic procedures. laparoscopic surgery may therefore have a real place in the treatment of perforated peptic ulcer. the aim: of our study was to evaluate of effectiveness of local injection of platelet-rich plasma for treatment of peptic ulcer bleeding with hemorrhagic shock in experiment. methods: the study was performed on wistar rats according to local and international rules for working with experimental animals. the average weight of animals was ± grams. in all animals our modification of type acetic acid ulcer (susumu okabe, ) was modeled. we randomly divide all animals in groups. rats with only modeled ulcer were included in group . rats with modeled ulcer and hemorrhagic shock after - . ml blood sampling were included in group . in group we included rats with modeled ulcer and hemorrhagic shock and performed local injection of platelet-rich plasma (local periulcelar injection of . ml of autologous platelet-rich plasma). on st, th and th day measurement of the ulcers square and morphological study were performed. results: the data we have received demonstrate a tendency of decrease of ulcers' square in all groups with time flow. we also compared sizes of ulcerative defects in all groups at every point of the study. on the st day of investigation there were no differences (p [ . ) between ulcers' square in all groups. on the th day we found out more rapid decrease of size in group (p [ . ). however, this tendency had no statistical significance. on the th day difference was larger and it was statistically significant this time (p \ . ). also the better ability to stimulate the activity of fibroblasts and revascularization in the young connective tissue with improving oxygenation in the ulcers and enhancing of cell proliferation, differentiation and accelerating of maturation of connective tissue and healing of ulcers was demonstrated in group . conclusion: platelet rich plasma reduces inflammatory response and stimulates proliferation of gastric epithelial cells on th day with the restoration of secretory activity and epithelialization of ulcers in . % of experimental animals on th day, the activation of the fibroblastic reaction during the all experiment and decreasing of ulcers' square. h. fujii, depat. of surgery, japanese red cross fukui hospital, fukui, japan introduction: in conjunction with charmant, a local eyeglass frame manufacturer, we developed novel devices called the fj (free jaw) clip to grasp organs in the abdominal cavity and the f (free) loop plus to pull thread extracorporeally from within the abdominal cavity. product summary: the fj clip is used to grasp organs in the abdominal cavity, a stainless steel, removable forceps for use in laparoscopic surgery. it provides a strong grip but rarely crushes organ tissue. the clip comes in two sizes, one for use in a -mm port and the other for use in a -mm port, and in two lengths, . mm and . mm, respectively. to pull out thread tied to the fj clip, we developed the f loop plus, which is a g by -mm-long special stainless needle with f . -mm niti alloy thread which is used pull suture threads from inside the abdominal cavity to outside the body. case: we performed cases of reduced port laparoscopic and endoscopic cooperative surgery (lecs). we performed reduced port surgery (rps) by making a . -cm incision at the umbilicus, inserting trocars ( mm and mm), and inserting another trocar ( mm) at the left side of the abdomen. we expanded the left hepatic lobe with a -mm fj clip for penrose drain placement, grasped the front wall of the gastric body with a -mm fj clip, applying traction toward the legs to pull up the tissues around the tumor, and resected all layers of the tumor via oral endoscopic submucosal dissection technique. the resected area was closed with a suturing device or interrupted sutures in the abdominal cavity. a year-old female was admitted to the emergency department with complaints of abdominal cramping pain, back pain and diarrhea for one day. she also had fever, ever up to °. in these two weeks, she felt occasionally epigastric pain. her past medical history included hypertension. on physical examination, she was conscious and alert. abdominal examination revealed diffuse tenderness and knocking pain over right flank. laboratory tests indicated an degraded white cell count of /cumm with % band forms, c-reactive protein of mg/dl and abdominal liver function tests (alanine aminotransferase: u/l, alkaline phosphatase: u/l, gammaglutamyl transferase: u/l) without hyperbilirubinemia. abdominal x-ray showed paralytic ileus. our presumptive diagnosis was acute peritonitis, based on the patient's symptoms. empirical antibiotics were administered immediately, and a computed tomography (ct) imaging study was performed. the ct scan showed a stick like foreign body noted between ventral side of pylorus and smv lumen, about . cm in length and associated with perifocal infiltration and segmental smv thrombus formation. (fig. ) however, there is no obvious pneumoperitoneum and no evident ascites is associated. an emergency exploratory laparotomy was performed, revealing stomach perforation at posterior wall with a cm fish bone thourgh pancreas into smv. localized inflammation and fibrosis were identified without obvious fluid accumulation( fig. - ) . removal of fish bone and simple closure of stomach perforation were performed. blood cultures revealed bacteroides thetaiotaomicron. three weeks later, she received a follow-up ct scan which showed smv obliteration with chronic pylephlebitis. aim: here we present a case report about the endoscopic treatment for iatrogenic gastric perforation secondary to a chest tube insertion. methods: a case report of a -year-old male with history of a road traffic accident. described injuries were severe brain injury with gcs \ at pre-hospital care arrival, thoracic injury with several rib fractures on the left hemithorax and hypoventilation on the left side. prior to hospital transfer a chest drain was inserted on the left side, and the patient was intubated. results: at hospital admission, the patient was hemodynamically stable and connected to a mechanical ventilator. thoracic exam showed persistent hypoventilation on the left chest. no other abdominal or pelvic injuries were found in the physical exam. a frontal chest x-ray revealed pneumothorax and the chest tube was not viewable. a further ct scan showed the chest drain placed in the abdominal cavity, into the stomach, besides a subdural hematoma, comminuted pelvic fracture of the pubic rami and a left sacroiliac fracture. during the first h in the icu, neurological worsening was observed, and a new cranial ct revealed enlargement of the subdural hematoma, for what the patient underwent decompressive craniectomy, with improvement thereafter. following a five-day period of stabilization after surgery, the patient was evolving satisfactorily, and the removal of the intragastric chest drain was considered. endoscopy was performed to confirm the placement of the drain, and it was removed under direct vision. approximately twenty five centimeters of the catheter were visualized in the gastric lumen, and then successfully removed. the patient recovered well and was discharged from icu to medical hospital ward after fourteen days, and a week later he was discharged home. conclusion: endoscopic management for gastric perforation after a chest drain insertion may result effective and can prevent open surgery morbidity. aims: intestinal infusion treatment with levodopa/carbidopa (duodopa) is a therapeutic option concerning the advanced parkinson disease cases with no response to the conventional treatment. the drug requires carrying out a gastrostomy either by percutaneous endoscopy way, or by laparoscopy -if the first one is not possible-. later, a duodenum-yeyunum tube is placed in order to infuse the duodopa gel continuously by a portable bomb. in this report, we explain the laparoscopic gastrostomy technique. method: sin this report, we include two patients with advanced parkinson disease: the first one is a year-old female patient suffering from an important gait disorder; and the second one is a year-old male patient with uncontrolled motor fluctuations. in both cases, a percutaneous endoscopic gastrostomy was proposed, but neither was feasible because of the non-traslumination between the gastric and the abdominal wall. under general anesthesia, neumoperitoneum by veress needle was performed. three main trocars and one accessory were placed. at the level of the gastric antrum, a cm incision was conducted to insert a gastrostomy tube, to be the guide for the drug infusion catheter. next, the gastrostomy is fixed to the abdominal wall by the stamm technique, externalizing the catheter through the accessory trocar in the medial line. results: on the first post-operative day, a duodenum-yeyunum tube is placed by endoscopic control through the gastric device. both patients got well satisfactorily, and no complications were described; and they develop a total normal life within the limitations of their underlying disease. conclusions: the duodopa intestinal infusion shows a significative improvement for the advanced parkinson disease symptoms, compared with oral medication; appreciating positive results referring to life quality. when the catheter placement by endoscopy way does not seem posible, gastrostomy by laparoscopy constitutes a valuable surgical option for the treatment of this kind of patients. peptic perforated ulcus (ppu) is a common surgical emergency and laparoscopic repair has been introduced as an alternative to open repair. it has shown good results and allows closure and peritoneal lavage, just like the open repair does but with the advantages of a minimally invasive surgery. the objective is to report the outcome of laparoscopic ppu in our hospital. methods: from january to october , patients with a clinical diagnosis of ppu were assigned to undergo laparoscopic repair. this retrospective study included all husm patients who underwent laparoscopic ppu repair by emergency surgeons. minimum follow-up of months is carried out. results: of the patients in this series, % were men and % were women, between and years of age at the time of surgery, average of years. the time between the manifestation of symptoms and surgery was [ to h in % of patients. in patients there was a history of previous ulcer or non-steroidal anti-inflammatories intake and up to % were smokers. a ct scan was performed in all cases to reach the diagnosis primary closure with simple suture plus omental patch was the elected technic ( %). the approach was performed with trocars in %, trocars in % and in case. cases ( %) were gastric ulcer, duodenal cases ( %) and in one case no perforation was found. the conversion rate was %, in two cases due to technical difficulty and in the other case because the level of the perforation was not found. the median postoperative stay was days although there were cases with intrabdominal complications. there was an exitus due to a metastasic pulmonary neoplasia diagnosed in the immediate postoperative period. there were no cases of recurrence in the follow-up time. conclusion: in most centers, including ours, the rate of laparoscopic management has gradually increased along with the improvement of technical skills. improvements in the outcome of laparoscopic ppu repair are to be expected with more experience surgeon and a good selection of the cases. general surgery, jzu hospital ,,sveti vracevi,, bijeljina, bosnia-herzegovina introduction: diverticulum is an outpouching of a hollow organ. gastric diverticulum is rare form od this disease. incidence of detection varies depending on investigation method. it has been reported in . % cases of autopsies, . % cases of gastroduodenal roentgenographies with contrast, and . - . % cases of upper endoscopies.small diverticula are usually asimptomatic, but bigger diverticula can cause variable symptoms such as abdominal pain, feeling of epigastric fullness right after meal, feeling of discomfort in upper parts of abdomen, and severe 'foetor ex ore' .diagnosis is usually established in procedures such as gastroduodenal roentgenographies with contrast, upper endoscopies and abdominal ct scan. case report: a -year-old woman came to our hospital because of feeling of discomfort and mild pain in upper abdomen that lasted for last year. diagnosis is established after ct scan of abdomen and upper endoscopy procedure. initially she has been prescribed conservative therapy (proton pump inhibitors). since the symptoms persisted, laparoscopic resection of the gastric divertuculum was performed using endogia stapler. considering the feeling of discomfort and abdominal pain dissapeared, the patient was discharged from hospital on the fourth postoperative day. conclusion: asymptomatic gastric diverticula doesn't require treatment. since gastric diverticulum can have complications such as bleeding, perforation and neoplasia, patient without symptoms should be monitored. initial therapy for symptomatic diverticula is conservative therapy (proton pump inhibitors). if conserative therapy doesn't procude expected results, laparoscopic resection of the diverticulum should be considered. introduction: the acute perforation of a gastric ulcer is a serious entity that requires urgent surgical treatment in most of the occasions, it is increasingly accepted that the approach of choice is laparoscopic, depending, above all, on the time of evolution of the process. objectives: to demonstrate the safety and efficacy of the laparoscopic approach in the perforation of a pyloric peptic ulcer, even in cases of severe peritonitis, by means of a standardized procedure, insisting on the sequential thorough washing of the cavity.material and methods: we present a video of the surgical intervention of a patient with acute abdomen, with a history of nsaid ingestion, exploration and ct-analysis compatible with perforation of hollow viscus, probably of gastric origin. results: intervention: complete laparoscopic approach, trocars. severe biliopurunitic peritonitis, by pyloric perforation 'acute', liquid culture, suture of the perforation, epipoplasty, sequential thorough washing of the cavity with physiological saline and placement of drainages.correct postoperative period, discharge from the hospital on the th day after completing antibiotic treatment. endoscopy and helycobacter test are performed on an outpatient basis with normal results. conclusion: the laparoscopic approach is safe and effective in acute and complicated gastric ulcer disease, even in cases of severe peritonitis. surgical procedure: the clean-net procedure involves the selective dissection of both the serosa and muscle layer using a laparoscopic monopolar endoscopic scissor. the preserved mucosal layer provides a mechanical barrier between the gastric lumen and peritoneal cavity that aids in the prevention of peritoneal cavity contamination with gastric contents. tumors are observed with an upper gastrointestinal endoscope with the injection of indocyanine green (icg) into peri-tumoral submucosal layers at points. selective seromuscular dissection is performed using a laparoscopic electrocautery monopolar scissor. the mucosa surrounding the gist is then resected using a endoscopic mechanical stapler to prevent exposure of the gastric lumen to the peritoneal cavity and peritoneal tumor cell seeding. results: there were males and female, and the average age was years. the operation time was min, the average bleeding volume was . ml, the postoperative hospital stay was . days. the mean tumor diameter was . mm, the final histopathological diagnosis was gist, schwannoma. there were no postoperative complications of clavien-dindo classification or more. conclusion: clean-net was found to be safe and useful for the treatment of gastric smt with ulceration. year outcomes: laparoscopic heller myotomy stands the test of time aims: laparoscopic cardiomyotomy leads to excellent relief of dysphagia in % of patients and avoids thoracotomy or laparotomy. methods: we present a video illustration of the procedure that was modified at the american university of beirut medical center. so far, patients underwent laparoscopic cardiomyotomy, age range of to years, with males and females. most of them have had previous balloon dilatation. results: all cases were successfully completed laparoscopically without complications. followup of months to years revealed excellent results with complete resolution of symptoms and no need for further medications. this will result in minimal post-operative pain and very short recovery period and is associated with low complication rate. conclusion: cardiomyotomy for achalasia is ideal for laparoscopic approach. magnification allows for precise division of muscle fibers. the new technique of hydro dissection and enseal for division of esophageal muscle allows for completion of the procedure without injury of the mucosa. therefore, adequate release of the obstructing segment followed by anti reflux procedure toupet will lead to excellent results with minimal morbidity and no mortality. aims: laparoscopic repair of huge hiatus hernia methods: twenty two cases of huge hiatus hernia presented to the american university of beirut medical center. patients underwent through trocars in the upper abdomen reduction of the hernial sac from the chest. special care was taken in the dissection of the mediastinum to keep the thoracic fascia and pleura intact. the defect was sutured primarily by -ethibond sutures reinforced by onlay prolene mesh u-shaped was fixed at the rt. and lt. crus and a floppy nissen fundoplication performed . results: the video presentation includes the technical aspects and the method of reducing and repair of huge hiatus hernia.aim: nowadays, there is little experience in the world of applying robotic surgical system (rss) in treatment of patients with hiatal hernia (hh) and reflux-esophagitis (re). the aim of study was to determine the possibility and feasibility of using rss in treatment of patients with hh. materials and methods: a total of patients underwent robot-assisted hh repair without mesh, followed by fundoplication with our original method ( °full symmetric wrap). the clinical and technical analysis did not reveal any advantages over similar laparoscopic procedures, so we abandoned the use of rss for hh type i, and these patients were excluded. there were ( %) patients with hh type iii and ( %) type iv. the surgeries were performed by experienced robotic upper gastrointestinal surgeon and conducted with the davinci si surgical system (intuitive surgical, sunnyvale, ca). results: average operation time was ± ( - ) min. the respondents' mean age was . ± . years (range - ) and bmi was . ± . (range . - . ) cm/kg . average blood loss was ± ( - ) ml. average hospital stay was ± . ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) days. the average follow-up time was ± . ( - ) months. postoperative x-ray imaging and upper gi endoscopy was conducted in all ( %) patients. there was no hh recurrence diagnosed. we did not observe a relapse of hh or clinical manifestations of re in the early (less than days) and long-term (more than months) postoperative periods. conclusion: we can conclude that robot-assisted surgery is safe, appropriate and justified in patients with hh type iii and iv. all procedures performed to the patients with giant hh revealed clear technical advantages of rss over similar laparoscopic operations: an enlarged d hd image, bendable instruments with endowrist technology allowed for precise dissection of tissues (hernial sac, cicatricial adhesions) in a narrow anatomical space-posterior mediastinum without damage to pleura, pericardium and vagus nerves. we believe that use of rss in treatment of patients with reflux esophagitis and/or hh type i is unjustified, due to the lack of proven advantages over laparoscopy. introduction: the presence of major anatomical obstacles -such as massive caudate lobe-in the confined operative field of laparoscopic hiatal hernia repair (lhhr) poses significant challenge to the foregut surgeon. aim: to provide a safe alternative for lhhr using a laparoendoscopic approach. method: this patient is a year old female, with bmi of . . her past medical history includes diabetes, hypertension and hyperlipidemia. she had gerd for years. her egd showed x cm hiatal hernia and class b esophagitis. manometry showed ineffective esophageal motility. we used the classic five ports approach for lhhr. we found a massive caudate lobe which was comparable to the size of an already enlarged left lobe of the liver. the operative strategies: terminating the procedure proceeding with the standard approach and taking the risk of bleeding from the caudate lobe itself or the inferior vena cava (ivc) with possible catastrophic outcome. using the laparoendoscopic approach. the following three steps facilitated the performance of safe and effective surgery. additional liver retractor this improved exposure and minimized manipulation of the caudate lobe. extracorporeal sliding arthroscopic knots (esak) esak are similar to the knots used in endoloop. they are tied extracorporeally and require a single insertion of the knot pusher as they do not unravel. transoral incisionless fundoplication (tif) we performed tif to avoid a limited operative field and to prevent excessive tissue manipulations associated with laparoscopic fundoplication. tif also preserves the angle of his and produces partial fundoplication which has less side effects of dysphagia and gas bloat syndrome. results: the operative time was min (lhhr min and tif min). there were no complications. patient discontinued omeprazole which she used daily for years. at months follow up, her gerd related quality of life (hrql) and gerd symptom (gerss) scores were ( vs ) and ( vs ). conclusion: the laparoendoscopic repair of hiatal hernia in the presence of anatomical obstacles is safe and effective. longer follow up is needed to assess the durability of this repair. gastroesophageal reflux disease (gerd) is a condition that reduces the quality of life and can causedisorders associated with acid reflux, such as bronchial asthma, barrett's esophagus and esophagealadenocarcinoma. gerd is often caused by existing of hiatal hernia. nowadays, some surgeons haddifficulties with the laparoscopic approach to treatment of recurrent hiatal hernias.patient was a -year-old man. he requested medical assistance with dysphagia, nausea after eatingand heartburn getting worse in a horizontal position. conservative treatment was not effective.transthoracic nissen fundoplication was performed in . the main complaints of the patientpersisted during the postoperative period. the upper half of stomach and s-like curved esophagus werelocated in the mediastinum according to multislice computed tomography of the thorax in august.in our clinical center was performed laparoscopic cruroraphy, cardiomyotomy and nissen fundoplicationin november. during the surgery the normal anatomical position of stomach has been restored, s-like curve of esophagus has been removed; a gastric cuff (collis-nissen) has been created and anteriorand posterior cruroraphy has been performed. the patient was in intensive care during h. anasogastric tube feeding was continued during the first h. passage of the contrast through theesophagogastric junction was free within h after surgery. patients had been discharged within days after surgery.this case report shows that at the current stage of surgery laparoscopic approach can be useful not onlyfor treatment of primary hiatal hernias-but also for treatment of recurrent ones. aims: laparoscopic heller myotomy procedure, completed with an anti-reflux procedure is technically demanding. we report a case of laparoscopic heller myotomy followed by a dor anterior fundoplication. methods: this is the case of a -year-old caucasian woman with gradual dysphagia for solids and liquids, accompanied by severe regurgitation and chest pain. an initial diagnosis of achalasia was made in , with the use of manometry and barium swallow. endoscopic dilatations were attempted pre-operatively with no clinical improvement. decision was made to perform a laparoscopic heller myotomy, combined with a standard dor anterior fundoplication. a -ports operation took place (one intra-umbilical mm trocar-single incision laparoscopic surgery (sils) technique, two -mm subcostal trocars, and one another mm subcostal trocar for the use of liver retractor). the operation lasted h and min. results: no post-operative complications were noted. the post-operative swallow test showed improvement of the esophageal patency. the patient started a liquid diet three days later and was discharged six days post-operatively. two months later the patient presented no complications. conclusions: heller's myotomy has demonstrated good long-term results in the treatment of esophageal achalasia and the laparoscopic approach has been well established in the last two decades. it is a very demanding operation to perform and the disease is relatively rare, making the learning curve difficult to achieve. aims: achalasia is a type of motor disorder of the esophagus due to degeneration of ganglion cells in the myenteric plexus, leading to failure of relaxation of the lower esophageal sphincter, accompanied by a loss of peristalsis in the distal esophagus. the association of a long-term achalasia and a large size hiatus hernia is an infrequent entity. among the therapeutic options is medical treatment, endoscopic treatment and surgical treatment associated with an antireflux procedure. the laparoscopic approach being the more indicated due to its better results in terms of morbidity, mortality and recurrences. the aim of the video is to show the effectiveness and safety of the laparoscopic approach in this infrequent pathology, pointing out the importance of performing a standardized procedure. methods: -year-old male patient, with personal history of chronic ischemic heart disease and obesity, diagnosed with long-term achalasia with moderate dilatation of the esophagus associated with giant hiatus hernia. the complementary explorations and iconography of interest are exposed. results: intervention: complete endoscopic approach, trocars. reduction of hernial content into the abdominal cavity, dissection of the hernial sac and esophageal lipoma. extended mediastinal esophageal dissection. complete resection of both the sac and lipoma, respecting the posterior vagus. heller's myotomy of cm, including cm distal to the ueg, perforation of mm of the mucosa at the ueg level, suture and blue methylene verification of the sealing. hiatorraphy and dor-type anterior fundoplication as antireflux technique. correct postoperative, with egd control on the rd po day and discharge on the th. asymptomatic at months after surgery. conclusion(s): for achalasia laparoscopic heller myotomy with a partial fundoplication should be the treatment of choice in patients who are at low surgical risk. the length of the myotomy, especially distal to ueg is one of the most important aspects of the surgery, to achieve an effective disruption of the les. the presence of a giant hiatus hernia makes the procedure difficult, increasing the risk of complications, such as perforation. standardization is essential to increase safety and efficacy in these complex cases. purpose: there is evidence that the application of mesh-reinforced hiatal repair has resulted in a significant reduction in recurrence rates in comparison with primary suture repair, at least in short-term follow-up. however, and instead of this, the standard of care for repairing large paraesophageal hiatal hernias (lphh) remains controversial because no clear guidelines are given regarding indications, mesh type, shape and position. the aim of this study is to evaluate our short-term outcomes in management of lphh with a biosynthetic monofilament polypropylene mesh surrounded by a high-purity and adherent titanium dioxide surface coating to enhance the biocompatibility (tio mesh tm ). methods: a retrospective study was conducted on our institution between december and october . data were collected on patients with lphh greater than cm in which a laparoscopic repair was carried on by primary suture and additional reinforcement with a tio mesh tm . clinical and radiological recurrences, dysphagia and mesh-related complications were investigated. results: there were females and males with a mean age of years (range, - years). all operations were completed laparoscopically. median postoperative stay was days. after a mean follow-up of months, patients developed clinical recurrence of reflux symptoms ( . %) and radiological recurrences ( . %). there were no mesh-related complications. conclusions: the use of tio mesh tm for laparoscopic repair of lphh is suited and with a reasonably low recurrence rate in this short-term study. additional long-term studies with enormous numbers carried out for years will be necessary to affirm whether this mesh is convenient in the prevention of recurrences and mesh related complications. background: surgery for refractory gastroesophageal reflux disease (gerd) has a satisfactory outcome, however sometimes fundoplication fails and redo surgery is required. several publications have investigated the feasibility of performing reoperative fundoplications using laparoscopic techniques. the aim of this study was to describe our experience in laparoscopic redo fundoplications in the last years. material and methods: we retrospectively reviewed consecutive patients who required laparoscopic redo fundoplication from january to august .the indications were recurrent symptoms of gastroesophageal reflux disease (gerd) ( . %), recurrent symptomatic paraesophageal hernia ( . %), dysphagia ( . %) and acute volvulus ( . %). results: all redo fundoplications (basically toupet . % and nissen . %) were completed laparoscopically. the mean operative time was min (range, - . min). a mesh was placed in % of cases. intraoperative and postoperative complication rates were . % and . % respectively. the mean hospital stay was days (range, - days). one patient ( . %) from the laparoscopic group required a third operation-one for acute recurrent paraesophageal herniation of the redo wrap one month after surgery, which was repair laparoscopically again. symptomatic outcome was successful in . % without any kind of proton bomb inhibitors therapy. conclusion: laparoscopic redo fundoplication is technically feasible and clinically effective with a reasonable low rate of postoperative complications p -upper gi-reflux-achalasia objectives: in recent years, balloon dilatation (bd) for diseases requiring correction of the impaired patency of the sphincter zones of the esophagogastroduodenal region has become widespread. purpose: to assess the effectiveness of the use of the balloon dilatation in patients with impaired sphincter zones of the esophagogastroduodenal region. materials and methods: in the institute department of surgery for the period from to , bd was performed in patients. of them diagnosed with achalasia of cardia (ac): - stage, - stage, - stage, - stage. patients diagnosed with pylorospasm, patients had compensated stenosis and patients had subcompensated ulcerative pyloroduodenal stenosis. there were males, females, average age ( . ± . ). bd was performed under endoscopic and / or x-ray control by 'boston scientific' balloons with a diameter of - mm, mm and mm, a course of - sessions with an interval of - days and a cylinder exposure of - min. evaluation of bd was performed using esophagogastroscopy, balloon manometry and x-ray passage of barium. results: in the course of the study, the existing indications were refined and new indications were developed for performing an endoscopic bd in pyloroduodenal stenosis and in ac. in patients with stage - ac, a positive result was noted in . % of cases already after the first session of bd. recurrences of ac after bd for up to years were established in ( . %) patients: at stage -in . %, at stage -in . %, at stage -in . % and at stage -in . %. repeated bd courses in case of ac recurrence in ( . %) cases turned out to be ineffective. recurrence of pyloroduodenal subcompensated stenosis was diagnosed in . % of cases in the period of months after performing bd. conclusions: bd is an effective method for correcting the permeability of the sphincter zones caused by the pathology of the esophagogastroduodenal region. keywords: balloon dilatation, achalasia of cardia, pylorospasm, ulcerative pyloroduodenal stenosis, recurrences. introduction: the reoperation in antireflux surgery significantly increases morbidity and mortality up to - %, reaching rates of % in patients undergoing or more surgeries. the advantages of laparoscopic surgery used in this surgical technique have amplified its acceptance and use, resembling its results in terms of feasibility, safety and efficacy of laparoscopic surgery to open surgery.objective: :evaluate the currently literature about antireflux surgery reintervention, focusing on the main indications of re-intervention, type of approach and morbidity and mortality of laparoscopic antireflux surgery. material and methods: a literature search was conducted in two electronic databases, med-line and embase. the search was limited to the period to . terms were used in relation to the procedure or intervention and the underlying disease. we chose observational studies (cohort, cases and controls and series of cases), where the main indication for antireflux surgery would have been gastroesophageal reflux disease. results: a total of studies were selected, most of them were case series ( . %), cohort studies ( %) and case-control studies ( . %). a total of patients. the main indications were anatomical faults, of these failures, recurrent hiatus hernia and sliding occupy the highest percentage, while physiological failures, failure in esophageal and gastric motility occur more frequently. the main type of approach was laparoscopic in %, the conversion rate was . % and the open approach was reserved for complex cases with more than one re-intervention . %, for abdomen . % and chest . %, this last for cases with high esophageal lesions that can not be repaired via trans-abdominal.the main complications were injuries to hollow viscera, such as: esophagus and stomach among others. these complications are related to the complexity of the procedure. mortality has remained low up to . %, however, the cause of death was due to medical complications and not related to the procedure. conclusions: this systematic review on reoperation in reflux surgery has confirmed that morbidity after reoperation surgery is higher than after primary surgery and reoperation indications increase with the use of new technologies (manometry) and the laparoscopic approach continues on the rise, with great adaptation to its use and improvement in results. aims: eras protocol is not commonly used in acute emergency procedures. elective lc is commonly performed as one day surgery, while in an emergency setting of acute cholecystitis, the in hospital stay averages , days. the aim of this trial is the application of eras protocol in patients with acute cholecystitis, undergoing laparoscopic cholecystectomy. methods: a randomized prospective trial was conducted in first surgical department of sismanogleion g.h.a. the study included patients, who were admitted with acute cholecystitis and underwent lc into h from their admission. preoperatively, they all received crystalloid isotonic solutions and antibiotics. . % were submitted to ercp, preoperatively, due to choledocholithiasis. the postoperative care included early mobilization into h after surgery, early fluid intake (into h) and early liquid food intake (into h). they all received systematically antibiotics, analgesics and antiemetic on demand. asa score was not an exclusion criterion. results: conversion to open procedure was necessary in . % of patients, whom were excluded from the study. all the rest were discharged into h from the surgery with the guidance to receive oral antibiotics for more days. readmission was necessary for patients, one week after the operation. the first one presented with bile leak and submitted to ercp with stent placement and percutaneous drainage of the intrabdominal collection. the second one presented with choledocholithiasis and underwent ercp with balloon catheterization. conclusion: it is commonly accepted that eras protocol in elective procedure enhances the postoperative recovery while reduces the in hospital stay and cost. in emergency condition eras cannot be applicated preoperatively. however, a modified post surgery application seems to have advantages equal to those observed in elective procedures. aim: laparoscopic cholecystectomy is the gold standard for the treatment of symptomatic cholelithiasis. administration of one single dose of chemoprophylaxis before an elective laparoscopic cholecystectomy is a broadly accepted practice. however, its value is currently questioned, especially in low risk patients. method: this study was conducted in a high volume surgical department. one hundred and twelve patients submitted to elective laparoscopic cholecystectomy were included in this research. a written consent was acquired after thorough patient briefing. half the patients that underwent surgical operation received one dose of antibiotics min prior to the incision and the other half did not receive any chemoprophylaxis. results: the age ranges from to years old. commonest concomitant diseases were arterial hypertension, type ll diabetes, hypothyroidism and respiratory deficiency. approximately % of patients were smokers and % were obese (bmi [ ). the duration of the operations was between and min. intra-operative gallbladder rupture was observed in patients (rate %). all the patients were discharged the first post-operative day and their monitoring continued for more days. in the chemoprophylaxis group, no surgical site infection or other major complication was observed. from the group that did not receive any antibiotics, one patient developed surgical site infection and specifically infection of the surgical port in the epigastrium, which was treated with drainage of the abscess and oral antibiotics administration. no other complications were recorded. conclusion: our study concluded no statistically significant difference between the two patient groups, which depicts that chemoprophylaxis may not be necessary in elective cholecystectomy operations. on the contrary, antibiotics increase the cost of hospital stay and are often accompanied by multiple mild or severe side effects. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- - p yr n authors: nan title: poster exhibition date: - - journal: hepatol int doi: . /s - - - sha: doc_id: cord_uid: p yr n nan background: biliary atresia (ba) is one of the most common causes of neonatal cholestasis and the most frequent hepatic cause of death in early childhood. the incidence rate of ba is higher in asian countries, occurring in approximately of , (asian countries ) to of , (european countries) live births. early identification and prompt intervention is very important. to im prove the early diagnosis, we used proteomic technology to screen serum biomarker for ba. methods: two-dimensional electrophoresis ( -de) and matrix-assisted laser desorption /ionization time-of-flight mass spectrometry (maldi-tof-ms) were employed to screen serum biomarkers specific to ba sera from idiopathic neonatal hepatitis. after pretreatment including albumin and immunoglobulin (igg ) depletion, sera were subjected to -de and there after image analysis. the differentially expressed protein spots were identified by maldi-tof-ms. result: from optimized -de gel images, thirty-four spots were differentially expressed and identified by maldi-tof-ms to be eight proteins. overall, kininogen variant was under expressed and alpha- -b-glycoprotein, leucine-rich alpha- -glycoprotein , 'sp , ', a bg protein, vitamin d-binding protein/group specific component , apolipoproteina-, aqgv were over expressed in ba group com pared to idiopathic neonatal hepatitis. conclusion: -de based serum proteome analysis can be useful in detecting protein expression alteration and new discovered biomarkers might be an aid in the diagnosis of ba, though further validation is needed. s. somani , a. somani , a. jain , v. dixit suvidha, navjeevan hospital, ims, bhu, varanasi, india background: a variety of autoreactive antibodies are detected in patients with chronic liver disease. this prospective, nonrandomized study was undertaken to evaluate the nature & prevalence of various autoantibodies in patients with chronic liver disease of diverse etiologies. methods: study population included patients ( % males), who met defined criteria for chronic liver disease. detailed clinical, laboratory and sonographic evaluation was done. sera were tested for asma, anti-lkm type , ama, apa, ana, by standard methods. p< . was considered significant. results: among various etiologies for chronic liver disease, hepatitis b was most common ( %), followed by alcohol ( %), autoimmune hepatitis in %, hepatitis c ( %) and miscellaneous ( %). % of patients were labeled as cryptogenic after detailed investigations. ana (> / ) was positive in % of definite aih, % of hcv related cld but at titer of > / , . % of hcv related cld & % of probable aih were found positive. asma (> / ) was positive in % of hbv related cld, % of alcohol related cld, % of definite aih, % of probable aih, % of hcv related cld but asma in titer of > / was positive only in % oh definite aih. apa was detected in . % of cryptogenic cld, . % of hbv related cld & % of alcohol & probable aih related cld each. ama was detected in % of cryptogenic, hbv, aih (definite) & hcv related cld each, and % of alcohol related cld & % of pbc. conclusions: apart from aih there is high prevalence of ana & sma in hcv related cld while other antibodies has low prevalence in non-aih related clds. this study also suggests that prevalence of various autoantibodies should be borne in mind while considering the diagnosis of cld especially of mixed etiology. conclusions: oa infusion did not lower ammonia levels or improve survival. results: the mortality ( . %) of patients in lamivudine group with meld score from to was lower than that ( . %) of control group ( = . , p= . ). univariate analysis showed that mortality was significantly related to age (p= . ), meld score (p= . ), treatment method (p= . ), pretreatment hbv dna load (p= . ), the decline of hbv dna load during therapy (p= . ) and encephalopathy (p= . ). in multivariate analysis, in patients with meld scores - , treatment method (p= . ), pretreatment hbv dna load (p= . ), decline of hbv dna load during therapy (p= . ) and encephalopathy (p= . ) were independent predictors of mortality; for meld scores above , only meld score (p= . ) was independent predictive. conclusions: lamivudine treatment significantly decreases the month's mortality of patients with meld score - , and a low viral load pre-treatment and quick decline of hbv dna load are good predictors for the survival of lamivudine treatment. background/aims: early identification of patients with fulminant hepatic failure (fhf) who need a liver transplantation is very important. to construct a prediction model for early diagnosis and prognosis of fhf, we studied dynamics of metabolic profiles using a d-galactosamine/lipopolysaccharide (galn/lps)-treated mouse model. methods: balb/c mice were used to construct fhf model and sacrificed for blood collection at , , and hour after treatment, respectively. levels of plasma metabolites were quantified using gas chromatography/time-of-flight mass spectrometry and data were processed using partial least squares discriminant analysis (pls-da). results: distinct clustering differences were observed and h after treatment between survival and dead groups. at h, plasma levels of some metabolites differed significantly between survival, dead and control groups. ketogenesis and the tca cycle were inhibited in both survival and dead groups, but in dead group, the urea cycle was also inhibited and glycolysis was elevated. pls-da indicated that principal component weighting was greatest for plasma levels of phosphate, -hydroxybutyrate, urea, glucose and lactate. the y-predicted scatter plot in pls model assigned samples to survival or dead groups using an apriori cutoff of . with % sensitivity and specificity. similar results were observed in fhf patients with different outcomes. pe association between polymorphisms in the interleukin- gene promoter and hepatitis b-related acute liver failure conclusions: the pls model based on metabonomics analysis can be used to predict outcomes well, and plasma levels of phosphate, -hydroxybutyrate, urea, glucose and lactate may constitute a set of markers for early diagnosis and prognosis of fhf. il- promoter are associated with the susceptibility to hepatitis b-related alf in the chinese population. il- a- c may be a regulatory polymorphism that affects gene regulation. hepatocyte cell death in aclf: mechanism and significance -an immunohistochemical study. p. sakhuja , a. rastogi , s. s hissar , a. singh , a. kumar , r. gondal , s.k. sarin gb pant hospital, institute of liver and biliary sciences, new delhi, india background: acute on chronic liver failure (aclf) is defined as acute hepatic insult complicated within weeks by ascites and/or encephalopathy in a patient with previously diagnosed or undiagnosed chronic liver disease. caspases play an essential role in apoptosis. cox- is an inducible immediate early gene responsible for the release of prostaglandins during inflammatory response. we studied the immunohistochemical expression of cox- and caspase- in liver tissue to assess their role in pathophysiology and in predicting outcome of aclf. method: a retrospective analysis of liver biopsies with clinical diagnosis of aclf was undertaken. patients were divided into two groups a and d based on clinical outcome (alive/died respectively). immunohistochemical analysis for cox- and caspase was performed on and cases respectively and scored from - as per intensity and distribution. score - indicated high intensity with focal to diffuse distribution, and was considered significant. results: etiology of acute liver failure was viral or alcoholic. increased expression of caspase was observed in / cases in group d and none of the cases in group a(n= ) (p= . ). increased expression of cox- was observed in / cases in group d and none of the cases in group a (n= ) (p= . ). conclusion: increased immunoreactivity of caspase in liver biopsies of patients of aclf may indicate worse prognosis and its important role in the pathophysiology of aclf. immunostaining for caspase is useful for assessment of prognosis and possibility of anti-apoptotic and anti-fibrotic therapies in future. conclusion: hhgf expression vector (pcmv-hhgf) has been successfully constructed and repeated hydrodynamic injections can promote sustained and high expression of hhgf in vivo. j.h. kim , k.w. kim asan medical center, seoul, korea background: splenic artery embolization (sae) is performed to increase hepatic arterial flow or to decrease portal venous flow in recipients of liver transplantation (lt). thus, the purpose of this study was to estimate sae effect on the basis of changes in caliber of related vessels and splenic volume on pre-sae and serial post-sae ct scans in lt recipients. methods: between and , among lt recipients who underwent sae and serial follow-up ct, with no compounding factor that may obscure sae effect were included in this study. they underwent ct before and after ( week, month, and year) sae. a radiologist retrospectively measured diameters of ca, cha, sa, sv and splenic volume on serial ct scans. their diameters and splenic volume on each ct were compared with those on the prior and pre-sae ct. the difference was compared using repeated-measures anova tests. results: cas decreased between week and month after sae (p<. ), but were stable before week and after month. chas increased within week (p<. ) but decreased between week and month (p<. ) and remained stable after month. compared with pre-sae ct, chas were larger for month after sae. sas continuously decreased for year (p<. ). svs decreased for month (p<. ) and remained stable after month. compared with pre-sae ct, sas and svs were smaller from week after sae and on. splenic volume continuously decreased for year except a period between week and month. conclusion: the increase of hepatic arterial flow persists for month after sae, but returns to baseline thereafter. the decrease of portal flow may lasts for at least year after sae. poster exhibition -cholangioca and other liver neoplasm poster session, hall b background: now, rfa has becoming an important practice of hcc therapy. in this study, we evaluated whether rfa therapy for metastatic liver tumor has a beneficial effect on patients' survival. methods: forty six patients were treated by rfa for metastatic liver tumor from july through february in our hospital, of the , patients were metastasis either form colon or stomach cancer. these patients were analyzed in this investigation. cumulative survival rate from initial rfa therapy was calculated by kaplan-meier method. predictive factors for survival were identified using cox proportional hazard regression model. results: the mean age of the patients were . (range, - ) . the mean size of the tumor is mm (range, - mm) and the numbers of tumor foci are . nodules range, . the survival rates of patients treated by rfa were . % at years and . % at years in colon cancer, . % at years and . % at years in gastric cancer. in this series of patients, primary cancer: colon (p= . odds ratio . %ci . - . ), younger patients ( ) (p= . odds ratio . %ci . - . ) and multiagent chemotherapy (p= . odds ratio . % ci . - . ) were significantly correlated with better survival. conclusion: the survival of patients treated by rfa for metastatic colon cancers had better survival than those of gastric cancers. in addition, good indication of rfa is for metastatic colon cancers, younger patients and has to be treated by multiagent chemotherapies. utility of contrast enhanced ultrasonography with sonazoid in radiofrequency ablation (rfa) for liver metastasis e. goto , s. shiina , r. tateishi , r. masuzaki , k. enooku , t. sato , j. imamura , t. goto , y. sugioka , h. ikeda , , h. yoshida , m. omata department of gastroenterology, university of tokyo, department of clinical laboratory, tokyo, japan background & aims: contrast enhanced ultrasonography (ceus) with sonazoid is effective for liver metastasis because enhance defect in kupffer imaging is well delineated. the aim of this study is to investigate the detection ability of ceus and the utility of sonazoid in rfa for metastasis liver tumors. material & methods: from january to december , a total of liver metastatic nodules in patients ( colon cancer, breast cancer, gastric cancer, islet cell tumor, and others) admitted to receive rfa were studied. the detection ability of liver metastasis was compared between ceus and conventional us using enhanced ct as reference standard. the mean numbers of treatment session of rfa were compared between patient treated with ceus assistance and historical controls matched for size and number of tumors. results: the detection rate was . % with conventional us and . % with ceus (p= . ). nodules in patients were not detected by conventional us and detected after injection of sonazoid. in addition, nodules in patients were detected not by ct but only by ceus. the mean number of session was . ± . as compared to . ± . in the historical controls (p< . ). conclusions: ceus with sonazoid is useful for detection of liver metastasis. sonazoid is an excellent supportive agent in rfa of liver metastasis. background/aims: carcinogenesis of intrahepatic cholangiocarcinoma (icc)-associated liver fluke infection accumulated genetic and epigenetic alterations. cholangiocarcinoma cell line (kku-m ) is adenosquamous carcinoma which rare variants and not commonly found in icc. however, interactions of liver fluke-associated icc proceed to genetic alterations in adenosquamous carcinoma that have been not elucidated. objectives: to analyze the whole genome-wide genetic alterations in kku-m using microarray comparative genomic hybridization. methods: dna of kku-m and matched-sex reference were differentially labeled with fluorescence dries (cy and cy ) and mixed together with cot- dna. the mixture was hybridized on array with spotting , human bacterial artificial chromosomal (bac) clones in triplicate and mapped these directly onto human genome sequence. the genetic alterations were classified the dna copy-number variations according to the intensities of log ratio (cy /cy ) as dna copy-number loss/gain and deletion/amplification. results: the whole genomic alterations in kku-m , which revealed a variety of chromosomal aberrations with a part and/or entire chromosomal gain and loss. chromosomal amplifications were detected on q . , q . , q . , p tel, and p . , whereas homozygous deletions were detected on q , q , q , q - , q . , q , q , q - q , p - p , p , q . , q . - q . , q . , q . and q . . conclusions: the whole genome-wide genetic alterations were characterized which previously not defined in adenosquamous carcinoma. this recent advance tool is usefulness for discovering novel cancer-related gene (oncogene/tumor suppressor gene) and substitutes in in vivo experiment for functional testing of candidate gene involving liver fluke-associated icc carcinogenesis. artificial chromosomal (bac) clones in triplicate and mapped these directly onto human genome sequence. the genetic alterations were classified the dna copy-number variations according to the intensities of log ratio (cy /cy ) as dna copy-number loss/gain and deletion/amplification. results: the whole genomic alterations in kku-m , which revealed a variety of chromosomal aberrations with a part and/or entire chromosomal gain and loss. chromosomal amplifications were detected on q . , q . , q . , p tel, and p . , whereas homozygous deletions were detected on q , q , q , q - , q . , q , q , q - q , p - p , p , q . , q . - q . , q . , q . and q . . conclusions: the whole genome-wide genetic alterations were characterized which previously not defined in adenosquamous carcinoma. this recent advance tool is usefulness for discovering novel cancer-related gene (oncogene/tumor suppressor gene) and substitutes in in vivo experiment for functional testing of candidate gene involving liver fluke-associated icc carcinogenesis. acknowledgements: this work was supported by faculty of medicine, kku, thailand (grant no. i background/aims: we studied the clinical efficacy of arterial chemoinfusion therapy through an implanted port system for patients with intrahepatic cholangiocarcinoma (icc). thirty patients with unresectable icc or intrahepatic recurrence of icc after surgery were studied. comparison was made between patients who received arterial chemoinfusion therapy through an implanted port system with adriacin and lecithin-added lipiodol emulsion in patients and -fluorouracil ( -fu) in patients. eighteen patients were treated without port system. results: disease was stable in patients with adriacin and lecithin-added lipiodol emulsion and in patients with -fu. disease was progressed in patients with -fu. the mean survival period was . months in patients with adriacin and lecithin-added lipiodol emulsion, . months in patients with -fu, and . months in patients without port system (p= . , p= . ). conclusion: arterial chemoinfusion therapy through an implanted port system is useful for patients with intrahepatic recurrence of icc after surgery. pe s. kaur , t. kaur department of biophysics, panjab university, chandigarh. india background: a number of dietary factors have been involved in the pathogenesis of cholelithiasis. cholesterol overfeeding is the primary means of inducing supersaturated bile and cholesterol gallstones in animal models.aim of the study was to investigate the rate of epithelial cell death and proliferation in gallbladder during gallstones formation. methods: balb/c mice was divided into two groups control in this group animals were fed normal chow diet, high fat diet group in this group ( % cholesterol, . % sodium cholate, % butter fat and % coconut oil) mixed with chow diet was fed to the mice for weeks. cell apoptosis and proliferation was assayed in gallbladder epithelial cells. histological analysis of gallbladder sections were done with hematoxylin and eosin staning. results: mice fed high fat diet had apoptotic as well as necrotic epithelial cells. rate of proliferation was enhanced after and hrs in mice fed high fat diet group as compared to the control group. the histopathological section of control gallbladder has normal morphology whereas gallbladder wall thickness was markedly increased; epithelial cells appeared more elongated in mice fed high fat diet. conclusion: results obtain show that high fat diet markedly induced biliary epithelial cell proliferation and biliary epithelial cell apoptosis. it has been determined that when there is an injurious stimulus that leads to apoptosis, it is later followed by reparative proliferation and when there is no injurious stimulus, apoptosis occurs late in the course as part of remodeling. background: obstructive jaundice can be caused by malignancy. the treatment can be drainage by biliary stenting. in advanced malignant jaundice, the stent placement is often difficult. objective: to evaluate the success rate of malignant obstructive jaundice evaluation of ercp and success rate of stent placement. methods: retrospective study based on data of ercp from october until july . results: we evaluated patients who has done ercp examination, ( , %) patients have clinical diagnosis of obstructive jaundice. there were ( , %) male and ( , %) female, age range - (median age was ). there were no malignancy in ( , %) patients; malignancy in ( , %) patients and ( %) patients need further evaluation.. from patients, ( %) patients attempted to have stent placement, ( , %) patients do not and ( , %) patients have no data. we done descriptive study on patients attempted to have stent placement, ( , %) patients succeed in stent placement whereas ( , %) failed. malignancy was showed to be a factor of stent failure (malignancy: fail and success ( , %) vs non malignancy: fail and success ( , %)). conclusion: ercp can identify the cause of obstructive jaundice in % patients. the success rate of stent placement was , %. the success rate of biliary stenting in malignant obstructive jaundice was , % whereas in non-malignant cases was , %. papillary carcinoma was the most frequent cause of malignant obstructive jaundice. background: in hydatid disease of the liver cystobiliary fisula (cbf) constitutes an entity characterized by the occurrence of a life-threatening cholangitis with increased morbidity. aim: to study the different diagnostic and therapeutic aspects of cystobiliary fistula in hydatid disease of the liver. patients and methods: fourteen patients with complicated cysts were divided into groups; group a: nine patients presented with cholangitis, and group b: five patients had history of jaundice. in all patients, the diagnosis of cbf was confirmed by erc (endoscopic retrograde cholangiography). preoperative endoscopic sphincterotomy (es) was done in group a with retrieval of hydatid daughter cysts. seven patients (subgroup a ) were subsequently submitted to surgery entailing endocystectomy in and hepatic resection in two. the remaining patients in group a (subgroup a ), were managed by endoscopic therapy only. patients of group b (n= ), were not submitted to preoperative es and were subsequently managed by hepatic resection in one patient and endocystectomy in four. results: there was no mortality in the studied group. postoperative bile leak occurred in four cases in group b. in contrast, none of the patients who were submitted to preoperative es (subgroup a ) had bile leak. all patients received albendazole treatment. conclusion: erc is important in confirming the diagnosis of cbf. also, therapeutic erc has a place in the treatment algorithm of cbf as it was found to be a safe and a reliable therapeutic alternative especially in high risk patients for surgery. v. singh , g. singh , g.r. verma , v. gupta , s. ghosh , r. gupta , r. kapoor , n. sharma , a. bhalla , s.k. mahi background: endoscopic palliation in malignant hilar biliary obstruction requires ercp. however, contrast injection leads to cholangitis. recently, contrast-free metal stenting with or without mrcp has shown encouraging results. however, mrcp and metal stents are costly. there have been no reports on the use of air cholangiography in these patients. methods: we prospectively studied the role of air cholangiogaphy assisted unilateral plastic stenting in these patients. results: ten patients with unresectable malignant hilar biliary obstruction were studied. air cholangiography detected type ii obstruction in and type i in patients which is similar to mrcp. all patients underwent unilateral plastic stenting. a successful endoscopic drainange was achieved in % patients. cholanngitis occurred in none and there was no -day mortality. no major complications were observed. conclusion: air cohlangiography assisted plastic stenting in these patients is a safe and effective method of palliation. however, it requires a larger study. introduction: a description of igg -related sclerosing cholangitis (igg -sc) without pancreatic lesion has recently been reported. in addition to imaging, diagnosis relies on findings of elevated serum igg and immunodetection of invading igg -positive cells. here we report a case of igg -sc with only slight common bile duct abnormalities and normal pancreatic findings. case study: a -year-old man suffering from cephalalgia, general malaise and muscle ache was admitted to our hospital. his blood examinations on admission revealed eosinophilia, mild anemia, liver dysfunction and an igg level of mg/dl (igg mg/dl). although ercp did not reveal typical stenosis or irregularities of the bile duct wall, visualization of peripheral bile ducts was slightly impaired. echography revealed thickening of the intrahepatic bile duct and gallbladder walls as well as adenopathy. due to a gradual increase in pleural effusion and a progression of anemia, oxygenation was begun on the seventh day of illness. based on the combination of eosinophilia, elevated serum igg levels, image findings and a negative result for helminth, igg -sc was suspected. liver biopsy was performed on the ninth day of illness and steroid therapy was initiated, after which symptoms and laboratory findings improved. the igg -positive plasmocytic infiltrate present around the portal region at the time of biopsy disappeared within eight months of treatment. summary: this case displayed two unusual features that are not generally observed with igg -sc: complications due to hemolytic anemia, and destruction of the peripheral bile duct with little damage to the common bile duct. introduction: various systemic diseases have been reported to be associated with igg . although steroids are effective in the treatment of igg -related diseases, there are some reports on relapses with their treatment, and cases are often difficult to differentiate from malignant diseases. we encountered a case of autoimmune pancreatitis with sclerosing cholangitis (aip-sc), in whom ca - was elevated with episodes of exacerbation and an elevated serum igg concentration. igg staining was also useful for the diagnosis. case study: an -year-old woman noticed tumors beneath the bilateral jaw and was found to have an elevated level of ca - ( ) seven years previously. her left submandibular gland was removed and diagnosed as sclerosing sialadenitis. four years previously, she was diagnosed as having diabetes mellitus complicated by a recurrence of ca - ( ) elevation and liver dysfunction. cholangiocarcinoma was suspected based on ercp, but was not confirmed by histologic findings of bile duct biopsy. elevated igg and other test results established the diagnosis of aip-sc, so steroid therapy was initiated, after which symptoms and laboratory findings improved. this recurrence of ca - elevation ( ) was diagnosed as a relapse of aip-sc based on an increased igg level and histologic findings. summary: some papers have reported that igg -positive cells are found in liver tissue in this disease, but such cells were not detected in the liver specimens in our case. this might be because intra-liver sites may have differed in the degree of morbidity, and long-term steroid therapy might have suppressed inflammation in the liver tissue. s. kaur , t. kaur department of biophysics, panjab university, chandigarh, india background: cholelithiasis, a gallstone disease is major cause of morbidity affecting millions of people throughout the world. aim of the present study was to investigate the predisposing factors that lead to the formation of gallstones. methods: the study was carried out on gallstones, bile and serum of patients. gallstones and bile were divided into three groups' cholesterol, pigmented and mixed gallstones. blood of the patients was divided into two groups with gallstones and without gallstones patients. trace elements and various biochemical estimations were carried out. clinical history of the gallstones patients was recorded from the hospital records. results: trace elements analysis in bile and gallstones showed that calcium is the main element in all the three types of stones. iron was the main element in mixed gallstones. in pigmented gallstones magnesium and zinc were the major trace elements. liver function tests and lipid peroxidation levels in sera were significantly increase whereas, antioxidant enzymes concentrations in sera were significantly decreased in patients with gallstones. clinical history of the gallstones revealed the cases had jaundice, diabetes mellitus and estrogen replacement therapy respectively. conclusion: results suggest that trace elements in gallstones and bile as well as clinical history of patients with chronic cholelithiasis could be the underlying factor in the pathogenesis of gallstones. the concentration of products derived from the free radicals reactions increases with degree of inflammation. such a condition increases risk of bile saturation which would further contribute to the progress of gallstones formation. background and aims: diseases of the biliary tree and gallbladder are being described with increasing frequency among patients with the acquired immunodeficiency syndrome (aids).therefore there is a need to do a research about the risk factors of gallbladder diseases in hiv/aids patients. so it can be useful to clinicians to predict the possibility of a patient having gallbladder disease and consider the options of further plans. the aim of this study was to find the prevalence and varieties of gallbladder diseases in hiv/aids patients. methods: a cross sectional study was performed in patients with hiv/aids who visited ciptomangunkusumo hospital, jakarta. the risk factors (route of transmision,cd ,arv,hepatitis) and clinical presentations were studied.ultrasonography examinations were performed to detect gallbladder annormalities. results: patients with hiv/aids match the study criteria. there were gallbladder abnormalities in ( . %) subjects, which ( . %) had acalculous cholecystitis and ( . %) had cholecystitis with cholelithiasis. on bivariate analysis, there was a significant association between abdominal pain, jaundice and the use of arv to gallbladder abnormalities (p = . ; . ; . ; . ). however, there was no association between age, sex, transmision route of hiv, hepatitis and cd to gallbladder abnormalities. conclusion: hiv/aids patients are susceptible to opportunistic gallbladder infection. acalculous cholecystitis is the most frequently encountered gallbladder abnormalities of hiv/aids patients in this study. poster exhibition -hbv poster session, hall b long-term stopping therapy t.b. trung , p.h. phiet university medical center, hochiminh city, vietnam background: among the approved nucleos(t)ide analogues therapies for chronic hepatitis b, lamivudine was used widely, sometime inappropriate in practice due to high safe and low price but lamivudine is associated with the highest rate of drug resistance. objectives: the aim of the study was to determine the ymdd variants after long-term stopping treatment in lamivudine-resistant patients using more sensitive technique. methods: blood samples from lamivudine resistant patients were collected after long-term stopping therapy. the ymdd variants are detected using technique pcr restriction fragment length polymorphism (pcr-rflp) at hcmc university medical center results: after stopping lamivudine treatment months ( - months) ymdd mutants were detected in ( , %) of patients. among them ( . %) had the most important m v/i mutant, ( %) had accompanying l m mutant. it means that once drug resistant mutants have been selected, they are archived for the long time even if treatment is stopped. many of patients have the features characterized for the patients in immune tolerance phase (young age, hbeag positive, normal alt). the treatment of this group is not strongly recommended due to low efficacy and high risk of drug resistance. conclusion: the most important m v/i mutant was still detected with significant portion of the virus population after long-term stopping therapy in lamivudine resistant patients. the options of retreatment for this patients when necessary are limited due to cross-resistance. the management of chronic hepatitis b should be followed strickly the recommendations of specialized association to avoid this problem. background/aim: whether liver stiffness measurement (lsm) using transient elastography is reliable to assess liver fibrosis in the settings of severe acute exacerbation of chronic hepatitis b (chb) is uncertain. methods: we prospectively recruited consecutive patients with severe acute exacerbation of chb (alanine aminotransferase or alt > x upper limit of normal). the relationship of alt levels and lsm were serially assessed and liver biopsy was performed after alt normalization. results: eleven patients ( male, median age years) were followed up for weeks; patients received anti-viral therapy. overall, lsm was positively correlated with alt levels (r= . , p< . ). at initial presentation, the median serum alt and lsm was ( - ) iu/l and . ( . - . ) kpa. a progressive reduction in lsm was observed during subsequent visits in parallel with the reduction of alt levels. even after the normalization of alt at week , lsm of patients continued to drop at week . at the last visit, the median alt was ( - ) iu/l and lsm was . ( . - . ) kpa. among the patients who had liver biopsy performed at week , patients had f fibrosis (lsm . - . kpa) and patient had f fibrosis (lsm . kpa). conclusions: lsm using transient elastography may misdiagnose liver cirrhosis in patients suffering from severe acute exacerbation of chronic hepatitis b. lsm should be assessed after normalization of alt levels in order to accurately assess the degree of fibrosis. h.c. lai , s.w. lai , k.f. liao , c.s. liu , t. lin , c.c. lin china medical university hospital, taichung, taiwan background: in , chronic liver disease was the seventh leading cause of death in taiwan. hepatitis b and hepatitis c are two major causes of chronic liver disease in taiwan. the purpose was to investigate the seroepidemiology of hepatitis b surface antigen (hbsag) and hepatitis c virus (hcv) antibody in taiwan. method: this was a hospital-based cross-sectional study. we analyzed viral hepatitis data from subjects who received health checkups at one medical center in taichung from to . all subjects were divided into three age groups, including - , - and . this study emphasized the prevalence of hbsag and hcv antibody by gender and age. the statistical analysis was performed by t test and . result: there were men ( . %) and women ( . %). the mean age was . (standard deviation . , range - ). the overall prevalence of hbsag was . %, with statistically significant difference(ssd) between gender ( . % for men vs . % for women, p < . ). the prevalence of hbsag was decreased with age in men, with ssd (p < . ), and also decreased in women, without ssd (p = . ). the overall prevalence of hcv antibody was . %, without ssd between gender ( . % for men vs . % for women, p = . ). the prevalence of hcv antibody was increased with age both in men and in women, with ssd (p < . ). conclusion: we hope this study can provide the epidemiological data for further studies of hepatitis b and hepatitis c virus infection in taiwan. s.m. wu , x. zhou wuhan medical treatment center, center for gene diagnosis, zhongnan hospital, wuhan university, china e-selectin is revealed to facilitate leukocyte adhension to the endothelium and migration into inflamed tissue in inflammatory diseases. chronic hepatitis b virus infection is regarded as a chronic inflammatory process. to examine the possible involvement of e-selectin in the etiology of chronic hbv infection, we analyzed two polymorphisms of e-selectin and determined the plasma souble e-selectin levels in patients with chronic hbv infection and controls. the frequency of c allele of the a c polymorphism was significantly increased in patients with lc campared with controls. no significant positive association was observed between the g t polymorphism and chronic hbv infection. but in patients with lc, divided according to the child-pugh classification, the frequency of t allele was of significant difference between child'class a and class b plus c. plasma levels of soluble e-selectin were significantly increased in patients with chronic hepatitis and liver cirrhosiscompared with controls. in the liver cirrhosis group, levels of se-selectin were significantly decreased from child' class a to class c. in each group, patients with c allele of the a c polymorphism showed higher soluble e-selectin levels than those with a allele. this is the first report describing the association between e-selectin polymorphisms and hbv-related hepatic fibrosis. our data showed the a c polymorphism of e-selectin gene is associated with disease progression in patients with hbv infection and controls the expression of plasma soluble levels, the g t polymorphism may be related to fibrotic severity in patients with liver cirhosis. background: chronic hepatitis b (chb) patients with high serum hbv-dna and normal serum alanine aminotransferase (alt) levels might be considered for treatment if histopathological findings show fibrosis stage or more. however, to our knowledge there is no recommendation with regard to the therapeutic agents for this group of patients. objective: this study was aimed to evaluate the efficacy of nucleoside analogues (entecavir or telbivudine) in treating chronic hepatitis b patients with high serum hbv-dna and normal serum alt levels. patients and method: this was an open-label study in chb patients with high level serum hbv-dna levels between january and october . patients were included if they showed normal serum alanine aminotransferase (alt) level at two measurements within a -month interval and had fibrosis stage > on liver biopsy specimens. patients were treated with entecavir . mg/day or telbivudine mg/day. the primary endpoint was the reduction or undetectable of serum hbv-dna at week and week of treatment, while the secondary endpoint was hepatitis b e antigen (hbeag) seroconversion. results: during a -year period, chb patients with high level serum hbv-dna with normal alt two times with months interval underwent a liver biopsy. twenty-eight ( . %) of pts showed fibrosis stage on histological findings (metavir score). twelve of these patients received nucleoside analogues, ( . %) of them were men. patients' median age was (range: - ) years. there were patients with stage- , patients with stage- and patient with stage- fibrosis. eleven ( . %) patients had genotype b virus. at baseline, the mean serum alt level was + . u/l and mean hbv-dna level was . x iu/ml, ranging from . x to . x iu/ml. six patients received entecavir and the other six received telbivudine therapy. undetectable hbv-dna was achieved by ( . %) patients at week- and ( . %) patients at week- of treatment. one patient who had the highest hbv-dna level had viral load reduction to . x iu/ml at week- of treatment. two out of patients with positive hbeag achieved hbeag seroconversion at week- of treatment. conclusion: this preliminary study has shown that nucleoside analogues might be considered in the treatment for chronic hepatitis b patients with high serum hbv-dna and normal serum aminotransferases levels. j. chen , x.j.. wu , y. wang , g.q. wang department of infectious diseases, peking university first hospital, beijing, china background: the dysfunction of t cells may represent a mechanism of hepatitis b virus (hbv) persistence. programmed death- (pd- ) and its ligands, pd-l /pd-l , are new members of cd /b family, as co-stimulatory molecules expressing on t cells and antigen present cells (apcs). their engaging can downregulate the t cells function, including proliferation, cytokines secretion and cytotoxicity. in periphery blood, pd- was upreguated on virus specific-t cells, leading to the impairment of t cells. blocking the pd- /pd-l can improve the function of t cells. methods and patients: patients with chronic hepatitis b (chb) were treated by pegylated ifn - b (pegintron from schering-plough, once a week, . or g/kg/weight). the periphery blood were taken at weeks, weeks, weeks, and weeks. periphery blood mononuclear cells (pbmc) were isolated from fresh heparinized blood by ficoll-hypaque (density: . g/l) density gradient centrifugation. then the cells were incubated with apc-conjugated anti-pd- antibodies. the pd- expression on lymphocytes was detected by flow cytometry (fcm). results: the pd- expression on lymphocytes at weeks was . ± . %, at weeks was . ± . %, at weeks was . ± . %, at weeks was . ± . % (p< . ). conclusion: treatment with ifn - b can downregulate the pd- expression on lymphocytes and may partially restore the function of t cells. to investigate the effects of nucleoside analogs therapy in hepatitis b related acute-on-chronic liver failure, we treated hbv related acute-on-chronic liver failure patients with entecavir. as control, the remaining were not treated with nucleoside analogues. results show the survival rate of entecavir therapy group has no significantly difference with none-treated group (p> . ). although entecavir greatly reduced hbv replication during different therapy times (p< . ), the meld score and liver function (alt, albumin, bilirubin, prothrombin time) had no significant changes (p> . ). further more, we analyzed the meld score and liver function in different hbv-dna level patients .no significantly difference was observed (p> . ). there is no significant correlation between hbv-dna level and meld score in different therapy times (p> . ).the hbv-dna level between patients with over months and less than months survival patients showed no significant difference either (p> . ). however, meld score and some parameters of liver function (albumin, bilirubin, prothrombin time) showed significant difference (p< . ). these results suggest hbv-dna loading may not be a direct factor to increased liver injury and suppression of hbv replication may not reduce the severity of liver failure in hbv related acute-on-chronic hepatitis. s. firdoos , u. adeeb , a. mehmood , m. gill islamabad specialists clinic, islamabd, pakistan background: before the availability of etv, it was common to use adv for treatment of chronic hepatitis b patients. primary nonresponse and suboptimal response is a common problem with adv treatment. methods: we wanted to study the outcomes of entacavir therapy in this subset of patients. study was conducted between april to april . we enrolled chb patients who had non response to - weeks of mg adv therapy. non response and suboptimal response was defined as non dimunition of at least one log of hbvdna from baseline after weeks of therapy and persistence of log after weeks of therapy respectively.they were switched to mg entacavir before breakfast daily for at least months.they had serial alt cbc and hbvdna measured every weeks. results: out of patients male and were female. only patients were hbeag(+).mean hbvdna level prior to adv exposure was . log copies/ml.mean duration of exposure to adv was weeks. patients lost to f/u.we did intention to treat analysis. out ( %) patient has, undetectable level of hbvdna after weeks of therapy labelled as group . out of ( %) had hbvdna level reduced by a mean of log copies/ml labelled as group .on week treatment analysis all patients from group was hbvdna undetectable, additional patients from group had undetectable hbvdna. conclusion: entacavir therapy results in rapid suppression of hbvdna levels in majority of patients with primary nonresponse or partial non response to adv therapy. background: except for serum alt level, baseline factors predictive of therapeutic response to lamivudine in patients with hbeag-positive chronic hepatitis b remain largely unknown. we thus studied the influence of pre-therapy viral factors on end-of-treatment responses to lamivudine therapy. methods: a total of treatment-naïve hbeag carriers who had pre-therapy serum alt level> xuln and received lamivudine for months reimbursed by the national health insurance were prospectively enrolled. hbeag seroclearance and combined hbeag seroclearance, alt normalization as well as undetectable hbv dna at the end of therapy were defined as primary and secondary endpoint, respectively. the pre-therapy viral factors including viral load, genotype, precore stop codon (pc)/ basal core promoter (bcp) status, and pre-s deletion were determined to correlate with therapeutic endpoints. results: the frequency of patients with detectable pc mutation (g a), bcp mutation (a t/g a), and pre-s deletion at baseline was . %, . %, and . %, respectively. after completing -month lamivudine therapy, overall hbeag seroclearance rate was . %. patients with hbeag seroclearance had a higher prevalence of baseline pc mutation than those without ( . % vs, . %, p= . ). by multivariate analysis, the odds ratio of patients with pc mutation to develop hbeag seroclearance was . (p= . ). in addition, the presence of pc mutation also correlated with the combined response. conclusions: for hbeag-positive chronic hepatitis b patients with serum alt> xuln, pc mutation could predict a higher hbeag seroclearance rate at the end of -month lamivudine therapy. the efficacy of adefovir dipivoxil against all patterns of lamivudine resistant hepatitis b d.j. kim , y.d. park , y.g. kwon , h.g seo daegu fatima hospital, kunngpook national university hospital, daegu, korea background: our aim was to evaluate the efficacy of adefovir dipivoxil (adv) and determine patient-dependent or laboratoroy variables that are predictive of hbeag loss and ivr for hepatitis b patients resistant to lamiduvine. also we evaluated the activity of adv against all patterns of lamivudine-resistant hbv. method: hbv-infected patients with lamivudine resitance received adv for months. quantitative hbv dna, hbeag/anti hbeag, alt was checked every - months. the hbv polymerase of patients were sequenced for baseline samples to determine the presence of lamivudine resistance mutations. result: there is no significant difference in all patterens of hbv mutation about hbv dna reduction at w, w, w. there is no significant difference in all patterens of hbv mutation about alt normalization at w, w, w. conclusion: adefovir dipivoxil demonstrated similar potent anti-hbv efficacy regardless of the different patterns of lamivudine-resistant hbv mutations. g. novelli , m. rossi , v. morabito , f. pugliese , p. berloco la sapienza university, rome, italy background: hepatitis b (hbv)-related end-stage liver disease is one of the most common indication for liver transplantation (lt). a number of patients dying while on the waiting list or removed because of being too ill is progressively increasing. we valued the possibility to improve the model end-stage liver disease (meld) of patients awaiting liver transplantation using a albumin dialysis: molecular adsorbent recirculating system (mars). methods: we treated patients ( male and female) with a mean age . . inclusion criteria: serum bilirubine > mg/dl, meld , inr > . , encephalopathy grade ii. all patients were treated with mars mean ± . hr cycles and mean treatments (range - ). all patients received standard medical treatment in addition to mars dialysis. the patient survival was valued at six months. results: we obtained a significant change of cytokines levels as interlukine (p< . ) and tumor necrosis factor alfa (p< . ) in association with an improvement of kidney, hepatic and hemodynamic parameters. at the end of mars treatments we observed a significant reduction of meld score (p< . ). the results of meld show a rebound effect between the end of treatment and the follow up at six months without returning at starting values (p< . ). twenty patients lived and dead for clinical complications. conclusion: the improved meld score with mars gave patients on lt waiting list more time of survival, thus allowing them more opportunity for liver transplantation. entecavir for treatment of lamivudine-refractory patients chronic hepatitis b h.t. dat , p.t.t. thuy medic medical centre, ho chi minh, vietnam lamivudine treatment is associated with frequent development of resistant hepatitis b virus. this incidence especially is higher in longer time of treatment and loss of treatment benefit. entercavir is a new antiviral agent shown its high efficacy even in cases of mutations with lamivudine resistance. in this study, we evaluate the efficacy, the safety of entercavir in treatment of lamivudine-refractory patients chronic hepatitis b. sixty chronic hepatitis b patients with evidence of lamivudine resistance were randomly divided into two groups in proportion of : . group i (n= ) used entecavir mg/day, group ii (n= ) used lamivudine mg/day. treatment time was weeks. histology, alt, hbvdna were evaluated in the end of the treatment. age, sex, alt, hbvdna, genotype, hbeag were analyzed to evaluate their influences to the treatment. the results have showed hbvdna< copies/ml in entecavir group . % vs. % lamivudine group (p< . ). hbvdna negative in entecavir group was . % and incidence of seroconversion of hbeag was . %. alt was normal in entecavir group . % vs. . % in lamivudine group (p< . ).histologic improvement in entecavir group was . % vs. . % in lamivudine group (p< . ). patients with hbeag negative, genotype b, low viral load were shown better results. entecavir was shown to be efficacious in treatment for chronic hepatitis b patients experienced with lamivudine resistance. entercavir is safe, with almost no side effects. factors such as hbeag negative, genotype b, low viral load seems to be better in response to treatment. recurrence or mutation of entecavir resistance should be studied further in future. j.m. kim , s.k. hwang , b.h. choe department of pediatrics, kyungpook national university hospital, daegu, korea backgrounds: by analyzing the characteristics of children with chronic hepatitis b who have lost hbsag by long-term lamivudine treatment, the selection of target patients could be relevantly predictable in the treatment of chronic hepatitis b in children. methods: a total of hbeag positive children (< y-o) were recruited who have visited kyungpook national university hospital from mar. , to may , . they were treated with lamivudine for at least months. hbeag seroconversion occurred during lamivudine treatment in out of children. they were divided into hbsag clearance and non-clearance group. parameters influencing treatment results were analyzed according to hbsag loss. result: thirteen out of the ( . %) patients with hbeag seroconversion were classified as hbsag clearance group, while ( . %) as non-clearance group after lamivudine treatment. twenty five of patients with hbeag seroconversion were under years old, in ( / , %) of whom hbsag loss occurred as well. twenty four of patients were over years old, in ( / , . %) hbsag loss occurred, that showed significantly difference (p-value= . , or: . , ci: . - . ) compared to younger group. age was significantly lower in hbsag clearance group ( . ± . years) than non-clearance group ( . ± . years) (p= . ), but no difference was observed in other parameters. anti-hbs appeared in patients. conclusion: in the treatment of hbeag positive chronic hepatitis b with lamivudine, age was significantly lower in hbsag clearance group than non-clearance group. background: dysfunction of t cells may represent a mechanism of hepatitis b virus (hbv) persistence. programmed death- (pd- ) and its ligands, pd-l /pd-l , are members of cd /b family, was reported to transfer inhibitory signal, leading to the dysfunction of t cell. background: hepatitis b viral mutants can emerge in patients as a result of selection pressure from either immune response or treatment options. mutations of hbsag allow mutant virus to propagate in the presence of a neutralizing immune response, while wild-type virus in reduced to undetectable levels. methods: immunohistochemical analysis of tissue samples from patients with chronic hepatitis b (chb), acute hepatitis b (ahb) patients and health controls was performed. results: pd- was positively expressed on lymphocytes infiltrating the portal area.pd-l expression was the same as pd- ,also expressed in interlobular.pd-l expressed on kupffer cells and dendritic cells.pd- -,pd-l -,and pd-l -positive cells express index of chb patients were much more than that of health controls and ahb patients(p . ).between groups in chb,the expression rate increase with the disease progression (p . ). methods: chronic hepatitis b patients with both positive for hbsag and hbsab were studied.serological markers of hbv were detected by elisa and microparticle enzyme immunoassay. hbv dna levels were determined by fluorescent quantitative pcr, s gene fragments were directly sequenced, liver function was analyzed by automatic biochemistry analyzer au . correlation test was conducted to evaluate their dependablity. conclusion: overexpression of pd- and pd-l within liver might be involved in inhibiting the immune response and be a mechanism of chronicity in hbv infection. results: the level of hbsag and hbsab was . ± . s/n and . ± . miu, respectively. hbv dna was detectable in patients. fifty-one mutations of s gene were detected in patients, and the relating amino acid substitution was at the sites of , , , , , , , , , , and . eight ( . %) out of mutations were located at the "a" determinant region in patients, while no mutation was found at the sites of , and . however, the mutation did not affect hbv replication. hbv dna was positive correlated with hbeag. conclusions: change in hbsag antigenicity due to s gene resulted in concurrent hbsag and hbsab. the existence of hbsab did not affect hbv replication. the damage of liver failure in those patients was slight. background: hbv infection is common in bangladesh. we often encounter young patients incidentally detected with hbeag negative chronic hepatitis b (chb) in our clinical practice. however the characteristics of these patients is yet to be studied in this country. the aim of this study was to study the characteristics of young bangladeshis incidentally detected with hbeag negative chb. methods: we did percutaneous liver biopsies of chb patients aged between to years. they were all hbeag negative with persistently normal or raised serum alt values. we did pre-core mutation (pcm) study in patients who were randomly selected. results: % patients had significant necro-inflammation (hai-ni > ), while significant fibrosis (hai-f > ) was seen in . %. serum alt (cut off u/l) was raised in . %, while high hbv dna load (> copies/ml) was observed only in . %. pcm was negative in all . conclusion: although chb patients between - years of age are supposed to be in immune clearance phase, which is characterized by low hbv dna and hbeag positivity, the study shows that hbeag negative chb is an entity that can also be seen in this age group and a significant percentage of such patients may have considerable hepatic involvement. this challenges our current concept about immune clearance state of hbv infection, although much larger study is needed to draw any specific conclusion. background: hbv infection is common in bangladesh, but characteristics of young patients incidentally detected with chronic hepatitis b is yet to be studied in this country. methods: we did percutaneous liver biopsies of chb patients aged between to years. results: significant necro-inflammation (hai-ni > ) was seen in . % patients with hbeag positive and % patients with hbeag negative chb, while significant fibrosis (hai-f > ) was seen in . % and . % patients in these two groups respectively. serum alt (cut off u/l) was raised in % hbeag positive and . % hbeag negative patients, while in these two groups % and . % patients respectively had high hbv dna load (> copies/ml). conclusion: hbeag negative chb is an entity that can also be seen in young population. a significant percentage of both hbeag positive and negative patients may have considerable hepatic involvement. profile of hbeag +ve chronic hbv infection in bangladesh m. mahtab , s. rahman , f. akbar , f. karim , a. shrestha , m. khan , m. kamal bangabandhu sheikh mujib medical university, toshiba general hospital, dhaka, bangladesh background: inactive hbv carriers constitute the major reservoir of hbv. present management guidelines provide inadequate treatment modalities. they are recommended for regular check-up; treatment is only recommended when patients exhibit evidence of liver damage. this is due to lack of information about their extent of liver damage. aim of this study was to assess extent of liver damage in hbeag +ve patients, unaware of their infection. methods: in this retrospective study, records of hbeag +ve chb patients from our pool of chb patients were reviewed. they were tested for hbsag, hbeag, hbv dna, anti-hcv and serum alt. all underwent per-cutaneous liver biopsy. results: . % ( / ) patients were males and . % ( / ) females. they were between - years of age. alt was raised > times unl in % ( / ). . % ( / ) patients had high hbv dna (> copies/ml), while low hbv dna (< copies/ml) was seen in . % ( / ) . in high hbv dna group, significant necro-inflemmation (hai-ni > ) was seen in . % ( / ) and significant fibrosis (hai-ni > ) in . % ( / ) . figures were . % ( / ) and . % ( / ) respectively in low viral load group. none tested positive for hcv infection. conclusion: study indicates that machinery should be developed to characterize undetected hbv carriers in developing countries by conducting multi-center clinical studies. we have shown that considerable number of patients, unaware of their hbv infection, suffer from progressive liver damage. the overall strategy of management of chronic hbv infection should also be revisited. high viral load does not necessarily represent significant liver damage in patients with chronic hbv infection in bangladesh m. mahtab , s. rahman , f. akbar , f. karim , a. shrestha , m. khan , m. kamal bangabandhu sheikh mujib medical university, toshiba general hospital, dhaka, bangladesh background: in general, it is assumed that patients with chronic hepatitis b virus (hbv) infection with high viral load exhibit increased liver damages. treatment guidelines also emphasize on reducing viral load. these observations were mainly accumulated from developed countries. > % chronic hbv carriers live in the developing nations, but little is known about relationship between hbv viral load and extent of liver damage in these countries. in this study, we addressed this issue. methods: in this retrospective study we reviewed records of chb patients from our pool of patients. all had high hbv dna (> copies/ml). . % ( / ) were hbeag +ve and . % ( / ) hbeag -ve. they were alsotested for anti-hcv and serum alt. all underwent per-cutaneous liver biopsy. results: . % ( / ) hbeag +ve patients with high hbv dna had non-significant hepatic necro-inflammation (hai-ni < ); this figure was . % ( / ) in hbeag -ve patients. non-significant hepatic fibrosis (hai-f < ) was observed in . % ( / ) and . % ( / ) in hbeag +ve and -ve patients respectively. none tested positive for hcv. conclusion: correlation doew not exist between viral load and liver damage in chb in bangladesh. many with both hbeag +ve and -ve chb with high hbv dna do not have significant hepatic necro-inflammation and fibrosis. further study may be needed to find out influence of other factors on liver damages in chb in bangladesh. most of these patients have not been characterized and treatment modalities have not been defined for them. background/aims: expression of intrahepatic hepatitis b core antigen (hbcag) is related to the immunopathogenesis of hepatitis b virus (hbv) infection. the role of hbv genotype and basal core promoter (bcp) mutation in expression of hbcag was investigated. methods: seventy hbeag-positive chronic hepatitis patients (genotype b in and c in ; bcp t /a mutation in ) were enrolled. clinical, virologic and histologic features were compared with regard to localization and expression of intrahepatic hbcag. the effects of hbv genotype and bcp t /a mutation on the expression of hbcag were further evaluated by in vitro assays. results: cytoplasmic, mixed cytoplasmic/nuclear, and nuclear localization of intrahepatic hbcag were found in ( . %), ( . %) and ( . %), respectively. fifty-eight ( . %) of these patients expressed a high level of hbcag. in multivariate analysis, cytoplasmic localization of hbcag correlated only with low serum viral load (p= . ) and bcp mutation (p= . ). high expression level of hbcag also correlated with high serum viral load (p= . ) and bcp wild-type sequence (p= . ). in vitro assays supported that hbv bcp mutant had lower subcellular expression of hbcag compared with bcp wild-type strain. conclusions: hbv bcp mutation and viral load but not genotype contributes to the expression of intrahepatic hbcag. hepatitis b virus (hbv) genotypes show distinct geographical distributions and virological and clinical differences. in some of genotypes, specific substitutions and mutations have been described in association with hepatitis b e (hbe) protein expression and viral replication. in this study, genetic characteristics of hbv genotype e (hbv/e) were investigated using clinical samples obtained from hepatitis b e antigen (hbeag)-positive, and anti-hbe-positive asymptomatic carriers (ascs) in west-africa. full-genome analysis of isolated hbv strains revealed strong association between precore (pc) mutation and hbeag to anti-hbe seroconversion. furthermore, using partial genome sequences, correlation among hbeag/anti-hbe status, viral load and key mutations were analyzed. the data showed that pc mutation is associated with hbeag seroconversion and enhanced viral replication efficiency. comparison between hbv/e and hbv/d strains reveals these two genotypes to have an identical sequence in their core-promoter-upstream and basic core promoter (curs/bcp) regions. it has been known from the previous phylogenetic studies, that hbv/d and hbv/e cluster together in trees reconstructed on x and precore/core orfs. in addition, this study, demonstrates that in spite of the high sequence similarity of curs/bcp region, the seroconversion-related mutation patterns are different between hbv/e and hbv/d in asc. further studies are needed to clarify the clinical significance of the regulatory sequence similarity between hbv/e and hbv/d. necro-inflammation and fibrosis p. siddappa , p. kar , b. das , r. gondal , m. asim maulana azad medical college, icpo, new delhi, india background: chronic hepatitis b(chb) is an important cause of morbidity and mortality. methods: pilot study involving patients of chb, were equally randomized to receive either adefovir or lamivudine for months. quantification of serum and hepatic hbv dna levels by real time pcr and liver biopsy done at start and end of months. results: after months there was significant and comparable reduction in serum and hepatic hbv dna viral load and liver biopsy showed significant reductions in hai scores in both the groups. serum alt which was elevated to or more times normalized in both the groups. in the adefovir group patients became hbeag negative and patients who were hbeag negative at the start of therapy remained so. in the lamivudine group one patient became hbeac negative and patients who were negative at the start of therapy remained so. in the adefovir group patients became hbv dna (qualitative test) and in the lamivudine group patients became hbv dna negative. there was strong correlation between serum and hepatic hbv dna levels both before and after the completion of therapy. conclusion: both the drugs bring about biochemical, histological and serological improvement with significant reduction in viral load in serum liver after months without complete clearance of virus. there was not enough evidence to show therapeutic advantage of one drug over the other. the serum and hepatic hbv dna levels correlate well with eachother before and after treatment. aim: assessing efficacy and safety of treatment of chronic hepatitis b in children with pegylated ifn. materials and methods: children ( boys and girls) aged - years with chb treated with peg-ifn alfa- a, g/m /week during weeks, hbeag-positive and hbeag-negative children, previously treated with recombinant interferon. no child had liver disease greater than grade , stage . serum hbv dna was quantified at baseline, tw , ("rvr") tw , tw (etr) and w (svr) with rt pcr method (roche taqman). alt activity, haematology and adverse events were monitored. results: after weeks treatment median hbv dna level decreased from . x iu/ml at baseline to . x iu/ml (p< . ). "rvr" -undetectable hbv dna at tw was observed in / children and associated with lower pretreatment alt levels < iu and pretreatment viral load < iu/ml. all children with "rvr" were hbeag-negative pretreatment. at tw and tw seven children including all with "rvr" had undetectable hbv dna. children achieved svr (undetectable serum hbv dna in w ), among them with "rvr". in / children with "rvr" hbsag disappearance was observed since tw . leukopenia was reported in children, thrombocytopenia in . no adverse events were observed following dose modifications. conclusions: . peg-ifnalfa- a is a good therapeutic option for children with chb, in particular with hbeag-negative chb . low pretreatment viral load and "rvr" seem to be predictive factors of efficient therapy. control by investigating the sanitizing modes among appliances used in the public service places (psp) and hbsag among appliances and practitioners worked in those places. methods: beauty parlors, barber shops and bathing centers selected by stratified randomization sampling, workers were investigated in questionnaire. the hbsag in appliances of psp and employee was detected by ria. results: the rate of hbsag among appliances of psp was . %. the rate of hbsag in large-, medium-and small-sized appliances was . %, . % and . %. the rate of hbsag has different( = . p . ). the rate of hbsag among appliances of beauty parlors, barbering shops and footbath inns was . %, . % and . %. different appliances had different rate of hbsag, such as the rate of acne needle and the forceps was . % and . %. the positive of hbsag amongworkers in psp was . %. the rate of hbsag among workers in large-, medium-and small-sized psp was . %, . % and . %. the rate of hbsag among workers in beauty parlors, barbering shops, footbath inns and bathing centers was . %, . %, . % and . %. the hbsag rate among workers was different in different works, the rate was higher in tattoo workers ( . %), pedicures workers ( . %), massagists ( . %). conclusions: it is important to enhance the sanitizing management in psp and improve workers kap) of hepb. and we should promote health education to enhance the knowledge of hepatitis b control and build up supervision consciousness. background: integration of hepatitis b virus (hbv) dna into host chromosomes is often found in chronic liver disease and hepatocellular carcinoma, which is likely an early event of hbv-related carcinogenesis. however, the molecular mechanism of integration remains unclear. here we describe a potential mechanism of hbv integration and identify that ku and ku , the gatekeepers of non-homologous end-joining (nhej) repair pathway, can serve as targets for anti-hepatitis virus integration. methods: using i-sce endonuclease-based system, we induced a dna double-strand break (dsb) in human hepatoma cell line huh- . the cells were then incubated with serum from patients with chronic hbv infection. pcr amplification and direct sequencing were used to detect the inserted sequence in the site of dsb. finally, we employed taqman-based real-time pcr assay to quantify the integrated hbv dna and evaluate the effects of shrna on hbv integration. result: when huh- were exposed to viral serum and incubated for several days, hbv dna was detected in integrated form at the exact site of dna damage. furthermore, small interference rna (sirna) targeted against gatekeeper genes for nhej can down-regulate nhej repair and even the frequency of hbv integration. conclusion: thus, this project provided us with the first direct evidence that dna double-strand breaks are potential targets for hbv integration. the study has also shown that shrnas targeted against gatekeeper genes for nhej can regulate the frequency of hbv integration. objective: to screen proteins of human pancreas cdna library interacting with hbsag protein. methods: the library was amplifed, purified and evaluated, and then the puried library plasmids were transformed into yeast strain y . the reconstructed plasmid pgbkt -hbsag was transformed into yeast strain ah and screened on the nutrient deficiency medium sd/-trp. the transformed ah mated with y containing the library plasmid. the diploid yeast cells were plated on nutrient deficiency medium sd/-trp/-leu/-his/-ade and sd/-trp/-leu/-his/-ade containing x--gal for selecting. the plasmids in diploid yeast cells were extracted and electrotransformed into e.coli dh . the plasmids in dh were extracted, sequenced and analyzed by bioinformatic methods. results: sixteen proteins interacting with hbsag were founded. conclusions: these results show that hbsag protein may be related with metabolism of glucose and lipid. comparison of the sensitivity and specificity of the elecsys ® hbsag ii assay with other available assays in china for detection of hbsag j.d. jia , l. wei , x.x. zhang , y.l. mao , l.l. wang , z.l. gao , j.l. hou , j. zhang , w. melchior , w. van der helm , beijing friendship hospital, beijing, china, beijing people hospital, beijing, china, ruijin hospital, shanghai, china, beijing hospital, beijing, china, west china hospital, chengdu, china, guangzhou, china, guangzhou nanfang hospital, guangzhou, china, shanghai public health clinical centre, china, roche diagnostics ltd, rotkreuz, switzerland, conclusions: in this patient population the prevalence of hbsag positive and anti-hcv were much higher than reported in community studies. genotypes and accounted for most of hcv. these very high rates of viral hepatitis in a hospital setting challenge to healthcare providers in terms of patient management as well as caregiver's prevention. hepatitis b is one of the major diseases of mankind that kills about one million persons each year in the world. accoring to primary study about % of iranian population is chronic hbv carriers. among iranian cirrhotics, - % has evidence of exposure to hbv and - % is carriers. because increase demand of blood transfusion, high blood dependent patients and long term window period of hbv infection, any controlling hbv infection program in blood donors can enhance the blood safety and public health. pe in this descriptive study included all the blood donors that referred to dezful blood transfusion center during - . all the blood donors screened for hbs ag by using enzyme immuno assay and repeatedly reactive (r.r) samples confirmed by hbc-ab or confirmatory (neutralization) tests. the data analyzed by using spss . . we found that in the first year . % were repeatedly reactive and . % confirmed. the results for other years as the followed: . %(r.r) and . % confirmed and in the last . % (r.r) and . % confirmed. the repeated blood donors increase in this period ( . %, . % and . % respectively). aim: we aimed to evaluate the cost-effectiveness of telbivudine versus entecavir with reference to lamivudine by roadmap model. methods: decision analysis model was used to study the incremental cost-effectiveness ratios (icer), i.e. the additional cost (in usd) required to achieve undetectable hbv dna or hbeag seroconversion for a patient at years in america and hong kong. entecavir was used as a continuous monotherapy. lamivudine and telbivudine would be shifted to entecavir if hbv dna was detectable at month and continued otherwise with drug resistance treated by add-on adefovir. weighted event rates based on previous reports were estimated for analysis. according our study, although the prevalence was higher than other region in our province, the hbv prevalence showed good decrease after stablishment strategies such as of repeated blood donor recruitment , improvement the donor selection and other educational programs . good following up those strategies to enhance the blood safety recommended. results: telbivudine was generally cheaper than entecavir to achieve an incremental case of undetectable hbv dna from lamivudine at years. entecavir was least effective and most costly for hbeag seroconversion. conclusions: telbivudine is a cost-effective alternative to entecavir particularly when its cost is low in hong kong. h. tang , g.l. zhang , y.x. li , r.q. tian , m. liu , x. li tianjin life science research center, tianjin medical university, tianjin , china micrornas (mirnas) are single-stranded noncoding rnas of to nucleotides that play critical roles in a wide spectrum of biological processes. we investigated whether the mirnas-silencing machinery influences hbv replication or antigen expression. on the basis of elisa and mtt, the effect of mirnas on the hbsag expression and cell proliferation was examined. three micrornas efficiently inhibited hbsag expression without significant effect on the proliferation of hepg . . cells compared to lacz control. subsequently, bioinformatics analysis were used to predict targets for the three mirnas, and the prediction results were conformed by cdna microarray analysis. the target region in hbv genome and the 'utr region of one cellular gene were identified by fluorescent reporter assay, semi-quantitative rt-pcr and western blot. the results demontrated that mirna may play an important role in replication and gene expression of hbv. hepatitis b virus (hbv) infection is a global public health problem, which plays a crucial role in the pathogenesis of chronic hepatitis, cirrhosis and hepatocellular carcinoma. although considerable progress has been made, the pathogenesis of hbv infection is still elusive. there's an urgent need to elucidate the mechanisms of hbv-host interactions, to discover novel biomarkers for diagnosis and prognosis and to develop therapeutic targets for anti-hbv treatment. herein, we applied a two-dimensional gel electrophoresis and maldi-tof/ms based comparative proteomics approach to globally analyze the host response to hbv by using an inducible hbv-producing cell line hepad . of the differentially expressed proteins identified, glucose regulated protein (grp ) was one of the most striking proteins elevated by hbv replication, which was confirmed by real-time pcr and western blotting. knockdown of grp expression by rna interference resulted in a significant increase of both intracellular and extracellular hbv virions in hbv-transfected hepg cells. reversely, grp overexpression led to hbv suppression. the expression levels of hepatitis b surface antigen (hbsag) and hepatitis b e antigen (hbeag) were determined by enzyme linked immunosorbent assay (elisa). immunofluoresce further revealed a positive correlation between the expression levels of grp and hbsag in both hbv-transfected hepg cells and hbv-infected human liver tissues. altogether, these data demonstrate for the first time that grp is an endogenous anti-viral factor in hbv-transfected hepg cells and may serve as a potential prognostic indicator of viral status in anti-hbv therapies. background/aims: to evaluate the predictors of response to long-term treatment of adefovir dipivoxil (adv) in patients with emerging lamivudine (lam)-resistant hepatitis b e antigen (hbeag)-positive chronic hepatitis b (chb) patients. methods: one-hundred-thirty-four lam-resistant hbeag-positive chb patients were treated with adv for a median of . months (range, - months), following lam therapy for a median of . months (range, - months). patients ( . %) were switched from lam to adv monotherapy, ( . %) were switched to adv with month of lam overlap therapy, and ( . %) were switched to adv with months of lam overlap therapy. the influence of baseline parameters on treatment response to adv in patients with lam-resistant hbeag positive chb was analyzed. result: during the follow-up period, ( . %) of patients achieved complete response, defined as normalization of alt level, negative hbv dna by a digene hybrid capture assay and achievement of hbeag loss. sixteen ( . %) patients achieved hbeag seroconversion. twenty-eight ( . %) patients developed adv-related mutations during adv treatment. in multivariate analysis, virological response at months (or= . , % ci: . - . , p= . ), defined as serum hbv dna levels less than log copies/ml or a reduction in serum hbv dna levels greater than log copies/ml after months of adv therapy, independently predicted complete response. conclusions: virological response at months was the strongest predictor of adv response in lam-resistant hbeag-positive chb patients. background/aims: to explore the effects of hbv dna level hbv genotype/subgenotype on the pathogenesis of severe liver diseases in chongqing. methods hbv dna level was analyzed in patients with severe liver diseases in retrospect,and hbv genotype/subgenotype hbv dna level and hbeag were determined in patients with hepatocellular carcinoma (hcc,n= ), liver cirrhosis(lc, n= ),chronic hepatitis b(chb, n= ) and acute on chronic liver failure(aclf, n= ). results hbv level from high to low with chb were lc, aclf and hcc in turn(p . ). hbv genotype was mainly genotype b.the rate of genotype b and c were . % and . respectively in hcc patients, . % and . in lc patients, % and in chb patients, % and in aclf patients. the percentage of genotype b/c in aclf patients was higher in compared with other groups. but the distribution of hbv genotype among groups was not statistically different(p . ).subgenotypes of genotype b were almost ba but one. subgenotypes of genotype c were mainly ce in chongqing area, and there was no statistical difference among the groups (p . ). conclusion: hbv dna level seems not to be a determining factor at end point of severe liver disease. both genotype b and c of hbv can lead to severe liver diseases, and there are more mixed infections by different genotypes in aclf. the efficacy of switching to entecavir (etv) monotherapy in japanese lamivudine (lvd)-experienced patients. background: this study aims to determine the efficacy of switching to . mg etv daily in chronic hepatitis b (chb) patients previously treated with lvd. method: retrospective analysis of chb patients (n= ) previously on mg lvd daily and switched to . mg etv daily. results: lvd-experienced patients were divided into three groups based on hbv viral load at time of switching to etv (< . log copies/ml; . - . log copies/ml and > . log copies/ml). detection of lvd-resistant virus at the time of switching was higher in the group with hbv dna . log copies/ml ( % in both . - . and > . log copies/ml groups versus % in < . log copies/ml group) and was higher in patients treated with lvd for years ( % versus % for patients on < year of lvd). a year after switching to . mg etv daily, hbv dna undetectable rates were % ( / ), % ( / ) and % ( / ) for < . , . - . and > . log copies/ml groups, respectively. alt normalization occurred in more than % patients at the end of the first year of switching to etv for all three patient groups. only one patient in the . - . log copies/ml group, who had lvd-resistant mutants at the time of switching, developed etv resistance during follow-up. conclusion: switching from lvd to etv maintains or improves viral suppression and alt normalization, especially in patients with viral load < . log copies/ml. background/aims: we investigated the association between on-treatment hbsag decline and sustained response in patients treated with pegasys±lamivudine. methods: hbsag levels were measured retrospectively pre-treatment and at weeks , , and using the abbott architect hbsag assay in sera from patients ( % asian) treated with pegasys alone ( g qw; n= ) or combined with lamivudine ( mg qd; n= ) alone for weeks as part of a large multinational trial. response was measured months post treatment. results: more patients treated with combination therapy had > log decline in hbsag from baseline to week ( figure) . hbsag level < iu/ml at week was associated with higher rates of response to pegasys±lamivudine months post treatment ( figure) . data comparing hbsag and hbv dna as on-treatment predictors of response will be presented. conclusion: on-treatment hbsag monitoring may be useful for predicting response in patients treated with pegasys. y. wakui , j. inoue , y. ueno , t. shimosegawa division of gastroenterology, tohoku university graduate school of medicine, sendai, japan background/aim: chronic hepatitis b patients are clinically treated with nucleot(s)ide analogues and ifn-. nucleot(s)ide analogues have problems including drug resistance in continuous treatment, and ifn-has disadvantages of limited effectiveness and side effects. therefore, novel antiviral drugs are still needed. in this study, the suppressive effect to the replication of hbv was examined in vitro by using bezafibrate and rosiglitazone, which are ligands of peroxisome proliferator activated receptor (ppar) and , respectively. methods: the cytotoxicity of bezafibrate and rosiglitazone to hepg cells was examined with mts assay, and the concentration of % cytotoxicity (cc ) was calculated. hepg cells were transiently transfected with the plasmid containing . -fold hbv genome of a genotype b strain. after hours of transfection, rosiglitazone and bezafibrate was added to the cells. using the medium at day after the addition of drugs, hbv dna was quantified with real-time pcr. results: the cc of bezafibrate and rosiglitazone in hepg cells were m and m, respectively. the amount of hbv-dna in the medium was decreased when the density of bezafibrate was over m, but the density demonstrated considerable cytotoxicity. in contrast, rosiglitazone of m, which showed no cytotoxicit, decreased the amount of hbv dna. the % effective concentration (ec ) was calculated to be . m. conclusions: in this study, it was suggested that the replication of hbv was inhibited by rosiglitazone of the density without cytotoxicity. the mechanism is uncertain and being investigated now. q. zheng center for liver diseases, the first affiliated hospital, fujian medical university, fuzhou, p. r. china background: the objective of this study was to evaluate the early virologic response for prediction of achievement of hbeag seroconversion and hepatitis b virus (hbv) dna negativity after two years of lamivudine treatment in chronic hepatitis b (chb) patients. methods: in this retrospective study, adult patients with chronic hepatitis b ( hbeag-positive and hbeag-negative) were treated with lamivudine ( mg/day), and followed-up up to months. response and resistance to the treatment were assessed during the treatments with lamivudine. results: it was found that gender, age, baseline levels of alt and hbv dna, serum hbv dna at week (p = . , or = . ) were closely related to the achievement of hbeag seroconversion, undetectable hbv dna level and emergence of drug resistance after years of lamivudine treatment. hbeag positive patients with baseline serum hbv dna in - copies/ml and serum hbv dna copies/ml at week showed high response rate of alt normalization rate ( . %), undetectable hbv dna rate ( . %), hbeag seroconversion rate ( . %), as well as low drug resistance rate ( . %) after years of treatment. similarly, hbeag negative patients with serum hbv dna copies/ml at week could achieve high -year response rate of alt normalization rate ( . %), undetectable hbv dna rate ( . %), and low drug resistance rate ( . %). conclusion: serum hbv dna copies/ml at -week provide the best prediction of -year lamivudine treatment response. background/aims: unlike oral antivirals, a finite course of (peg)interferon can induce sustained post-treatment response in patients with chronic hepatitis b (chb), with increasing rates of hbsag clearance observed in patients who respond during post-treatment follow-up. hbsag clearance is considered to be the closest outcome to a cure, being associated with improved histological outcome, reduced incidence of hcc and increased survival. methods: in a randomised multinational study, patients (hbeag-negative) received µg pegasys+placebo (n= ); µg pegasys+ mg lamivudine (n= ); or mg lamivudine (n= ) for weeks, and were assessed months post-treatment. from this initial study, of those who had received pegasys±lamivudine and patients who had received lamivudine monotherapy participated in a long-term observational study to investigate post-treatment response. hbsag clearance at yearly post-treatment follow-up visits up to years post-treatment was analysed. results: hbsag clearance in patients treated with pegasys±lamivudine increased post-treatment ( % at year to %, %, % and . % at years , , and ). at year , pegasys-treated patients ( . %) had cleared hbsag compared with ( . %) of lamivudine-treated patients (p= . ). / pegasys-treated patients had anti-hbsag (hbsag seroconversion). detailed analysis of the -year follow-up data will be presented. conclusion: the ability of a finite course of pegasys to induce sustained response with increasing hbsag clearance rates in responders during post-treatment follow-up supports its use as first-line therapy in hbeag-negative patients with chb. background/aims: recent studies suggest that quantification of hbsag levels early during treatment can be used to predict post-treatment response to pegasys. elecsys ® hbsag ii (roche) is a sensitive assay for the detection of hbsag. this assay can be used for the quantification of hbsag levels using a simple dilution algorithm. we compared results obtained using the elecsys ® hbsag ii method with those of a commonly used quantification assay. methods: hbsag levels obtained using the elecsys ® hbsag ii assay were compared with those obtained using the abbott architect ® hbsag assay for a total of samples from patients infected with hbv genotypes a (n= ), c (n= ), d (n= ) and f (n= ). samples were diluted : in diluent provided by the manufacturer. samples with hbsag levels > iu/ml were retested at a final dilution of : . samples with hbsag levels < . iu/ml were retested undiluted. results: overall, hbsag levels measured with the two assays correlated well (r = . ) over a wide range ( - x iu/ml). discrepancies in hbsag levels >± % were reported for a minority of the samples (n= ), mainly distributed evenly above and below the ideal line (n= ). in the four low titre (range - x iu/ml) samples with greatest discrepancy elecsys ® underestimated values (in two cases by > %). conclusion: the elecsys ® hbsag ii assay provides a simple and reliable means for determining hbsag levels. this simple assay format could be used to provide useful information during on-treatment monitoring of hbsag levels in patients with chronic hepatitis b undergoing therapy. conclusions: hbv/a has been increasing in chb patients in japan as the consequence of ahb, spreading in the younger generation through promiscuous sexual contacts, thrust by an inclination of hbv/a to induce chronic hepatitis. the spread of hbv/a infection in japan should be prevented by universal vaccination programs. introduction: chronic viral hepatitis is common in end-stage renal disease (esrd), from endemic hepatitis b (chb) and nosocomial hepatitis c (chc). reduced outcomes post-renal transplant were reported thus chb and chc cirrhosis became contraindications to listing. however, these predated effective anti-viral therapies. we reviewed outcomes of patients with chronic viral hepatitis following assessment for renal transplantation. methods: prospective database of esrd patients with viral hepatitis referred for renal transplantation was reviewed. results: patients were assessed. patients underwent kidney transplantation. two were cirrhotic and had liver/kidney transplantation; both died within months. were non-cirrhotics, of whom are alive. / have functioning allografts; predictors were normal alt and low viral load. of the non-transplanted, had cirrhosis; / received anti-virals. mortality was % - liver-related ( hepatoma, bacterial peritonitis, sepsis - inactive cirrhosis); non-liver related ( cerebral, haemorrhage, renal - inactive cirrhosis). / surviving cirrhotics received anti-virals. in non-transplanted non-cirrhotics, mortality was %; % of survivors had inactive disease. chb patients received lamivudine; adefovir (lamivudine resistance). chc patients received ifn-based therapy. conclusion: excellent outcomes are achieved in esrd patients with chb/chc post-renal transplant, in absence of cirrhosis. normal alt/non-detectable viral load can predict graft function. however, cirrhosis is associated with high mortality on dialysis whereas non-cirrhotics with inactive disease do well. the role of kidney transplantation in cirrhotics with suppressed viral replication needs to be reassessed. the truncated hbc interferes with replication of hepatitis b virus j.c. han , , x.b. pan , , l. wei , , k. deng , institute of hepatology, peking university people's hospital, china hepatitis b virus (hbv) capsids play an important role in production of progeny virus and other elements of the virus life cycle. misdirection of capsid assembly and formation of aberrant particles may be an effective approach to interfere with virus replication. hbv capsids can be assembled in vivo and vitro from the dimeric hbv core protein (hbcag). the interaction of single and dimeric hbcag with some truncated hbcag is verified in vitro. the truncated hbcag consists of the first amino acids and lacks the c-terminal, -residue rna-binding domain. method: we transiently transfected hepg . . with pcdna . hbc by fugene .after and h, hbvdna, hbeag and hbsag in culture supernatant were detected and cell subjected to southern blot and immunofluorescence analysis. result: the level of hbsag and hbeag had gentle change, we found that hbvdna decreased at h after transfection( copies/ml p< . ) ,but replication intermediates obviously decreased from h. some positive signal of hbcag located around the nuclear and conglomerated in cytoplasm compared to the control. conclusion: the truncated hbc can inhibit replication of hepatitis b virus. misdirection of capsid assembly and formation of aberrant particles could be an important cause. y.p. li , r.c. li objective: to assess the long-term efficacy of recombinant yeast derived hepatitis b vaccine in infant s born to hbsag and hbeag carrier mother. methods: a total of neonates born to hbsag, hbeag both positive mothers were vaccinated with , , g doses of recombinant yeast derived hepatitis b vaccine by , , and months schedule. they were all followed for years after the primary vaccination. results: twelve infant s ( . %) become hbsag positively conversed in year after primary vaccination ,and the positive rate of hbsag in - year was . %- . % , . % of child in no/ lowly respond become hbsag positively. at the ninth year, the positive rates of anti-hbs were % above. anti-hbs positive rates and immunity level were higher at - year old by repetition immunity than others. conclusion: the recombinant yeast derived hepatitis b vaccine have good immunogenecity and long-term protective efficacy to hbv interruption of perinatal transmission , a booster dose seems necessary in aged - years to the mother with hbsag and hbeag.it is high risk tobecome hbsag positively in the baby of norespones to hepatitis b vaccine. chb patient group-initiated programme to improve awareness, adherence and treatment outcomes in asia pacific n. leung founding chairperson of asiahep background: worldwide, over million people live with chronic hepatitis b (chb); million in asia pacific. regional survey data from , patients in countries showed a lack of knowledge and understanding of chb, its severity and impact on quality of life. this initiative aims to coordinate patient groups in the region and devise programmes to improve knowledge and healthcare outcomes. methods: the patient groups met in hong kong in may and identified common needs to: ( ) improve educational resources; ( ) raise awareness; ( ) increase diagnostic yield; and ( ) enhance treatment compliance through education about the need for sustained viral suppression to reduce long-term complications. results: a patient engagement programme was developed for people with newly diagnosed or known chb. the programme comprises: -detailed information about chb -a health-tracking tool for self-monitoring of blood tests and treatment progress -detailed information for carers/family -a patient-physician communications video (including role-play) -mobile phone text messages providing advice and compliance/appointment reminders conclusion: this programme was developed to address the needs of patients and clinicians. improved knowledge and long-term support, particularly for patients on antiviral medication, is expected to improve quality of life. the programme encourages clinicians and patients to develop enduring therapeutic partnerships to promote optimal outcomes. acknowledgement: the chb patient group meetings and the patient engagement programme are supported by an unrestricted educational grant from glaxosmithkline. serum hbv rna level reflects the potency of nucleos(t)ide analogue y.w. huang , , k. chayama , , m. tsuge , , s. takahashi , , t. hatakeyama , , m.y. lai , , h.l. you , j.t. hu , c.j. liu , , p.j. chen , , d.s. chen , , s.s. yang , j.h. kao , liver unit, cathay general hospital medical center, background and aims: serum hbv rna is detectable in patients treated with lamivudine (lmv) or entecavir (etv) (hatakeyama, and huang, ) . the aim of this study was to determine the clinical significance of serum hbv rna levels in patients treated with nucleos(t)ide analogues of different potency. methods: serum hbv rna was serially determined in patients treated with nucleos(t)ide analogues for to weeks ( with adefovir (adv), with lmv, and with etv). serum hbv rna was quantified by reverse transcription of hbv nucleic acid extract with subsequent real-time pcr. results: hbv rna was detectable in patients as follows: of in adv ( %), of in lmv ( %), and of in etv ( %) (p = . ). mean log serum hbvdna levels at baseline were . ± . for adv, . ± . for lmv, and . ± . for etv, which were comparable between less potent adv and most potent etv (p = . ). during antiviral therapy, peak log hbv rna level of patients with etv was significantly higher than that of those with adv or lmv ( . ± . vs. background: in the phase iii clinical trials, clevudine mg for months showed potent antiviral activity along with a marked post-treatment antiviral effect. the objective of this study is to compare the anti-hbv activity of combination of clevudine and vaccine over clevudine alone in chronic hepatitis b (chb) patients in a randomised way. methods: the patients are received clevudine for weeks and then combination of clevudine and vaccine for another weeks or clevudine alone for weeks. eligible patients were treatment-naïve hbeag(+) chb patients with hbv dna levels , copies/ml. the primary endpoint is the proportion of patients with hbeag loss. preliminary results are presented here. results: thirty-one patients have completed week visits and from them, patients ( in clevudine alone and in combination group) have completed week visits. at week , % of patients had hbeag loss. at week , % in clevudine alone and % in combination group ( months on combination after clevudine monotherapy) had hbeag loss. at week , % of patients had negative hbv dna by amplicor pcr (< copies/ml). at week , all of patients in both groups had negative hbv dna by pcr and % in clevudine alone and % in combination group had normal alt. conclusion: clevudine demonstrated good serologic response as well as significant viral suppression and alt normalization. with this data, we conclude that combination therapy of clevudine and vaccine for short period does not show the superiority over clevudine alone. background/aims: to determine the reasonable number of clones for hbv quasispecies analysis. methods: chronic hepatitis b patients were enrolled with hbvdna levels range from ~ log copies/ml. hbvdna was extracted. hbv reverse transcriptase (rt) gene encompassing the overlapping surface s gene was amplified by polymerase chain reaction, then cloned and sequenced. ten positive clones for each sample were sequenced in the first group, and then additional ten positive clones were sequenced in other groups until up to thirty clones. the characteristics of hbv quasispecies including shannon entropy and genetic distance were calculated. results: the shannon entropy and genetic distance of clones group was higher than those of and clones group, either in rt gene or in s gene (p< . ). while the shannon entropy and genetic distance of clones group showed on difference with those of clones group, neither in rt gene nor in s gene (p> . ). the number of different quasispecies detected in clones group was higher than that of and clones group (p< . ). the shannon entropy and genetic distance in three different clones group had no correlation with hbv dna levels (p> . ). conclusion: although the number of different quasispecies detected was increased with the augmentation of clone number, the quasispecies characteristic didn't changed significantly when the clone number more than . the information contained in clones per sample could well represent the quasispecies characteristics. the clone number was not necessary modulated according to different hbv dna levels. background: recent studies reported that basal core promoter mutation (a t and g a) was associated with more aggressive progression of liver disease from inactive carrier to active hepatitis, and eventually to liver cirrhosis and hcc. but the effect of the double mutations on the activity of enhancer ii/basal core promoter is still uncertain. objectives: to evaluate the influence of nt a/t and nt g/a mutations on hbv enhancer ii/basal core promoter activity. methods: the pcr fragments of hbv enhancer ii/basal core promoter (nt to nt ) from the serum-derived genotype b hbv dnas of one hbv carrier aged and one hbv related hepatocellular carcinoma patient aged were introduced into the pgl -basic-vector from promega via restriction sites of xho i and hind iii. the nt a to t and t to a, the nt g to a and a to g mutations were carried out by genetailor site-directed mutagenesis system from invitrogen. the promoter activity was evaluated by comparing firefly luciferase measurement with renilla luciferase as the internal control using the dual-luciferase reporter assay system from promega. results: the luciferase reporter assay results indicated that the t to a combined with a to g mutations increase (p< . ) while the a to t combined with g to a mutations decrease (p< . ) the hbv enhancer ii/basal core promoter activity significantly. conclusions: associated with increased risk of hepatocellular carcinoma, a t and g a double mutations of hepatitis b virus reduce the enhancer ii/basal core promoter activity. background/aims: a substantial proportion of chronic hepatitis b (chb) patients with mildly elevated alanine aminotransferase (alt) have significant fibrosis. we evaluated the factors associated with significant fibrosis and clinical outcomes in these patients. methods: one hundred five chb patients with alt less than two times the upper limit of normal underwent liver biopsy. multiple clinical, biochemical and virologic variables were evaluated to determine the predictors of significant fibrosis and progressive liver disease. results: there were patients in the low normal alt group, in the high normal alt group, in the low elevated alt group, and in the high elevated alt group. fifty eight patients ( . %) had significant fibrosis ( stage ) and ( . %) had significant inflammation ( grade ). the age, platelet count and grade of inflammation were factors associated with significant fibrosis. progressive liver disease was observed in ( . %) of the followed-up patients. the stage of fibrosis, alt group and antiviral therapy were significant predictive factors for progressive liver disease. conclusion: liver biopsies should be recommended in patients over years with mildly elevated alt levels, and antiviral therapy should be considered in patients with significant fibrosis to prevent progressive liver disease. background: four nucleos(t)ide analogues (nas) are currently approved for the treatment of hbv infection in china. however, long-term benefits are limited by the emergence of drug-resistant viruses. methods: patients accepted the examination based on physician's instruction. hbv reverse transcriptase gene was amplified from serum via nested pcr and sequenced directly. results: well-recognized drug-resistant mutations were detected in of , patients. in patients receiving na monotherapy, corresponding drug-resistant mutations were detected in / for lamivudine (lam), / receiving adefovir (adv), / for entecavir (etv), and / for telbivudine (l-dt). the mutations were detected in / patients receiving kinds of sequential/combined usages of the nas. m i ( %), m v+l m v l ( %), and m i+l m ( %) were identified as major mutant patterns of lam monotherapy. n t a substitution was the dominant adv-resistant mutation. t substitution was the dominant etv-resistant mutation always accompanied with lam-resistant mutation. l-dt-resistant mutation was m i l m exclusively. adv-resistant mutation was frequently seen in lam-resistant patients receiving adv sequential therapy rather than those receiving adv add-on therapy. controversial lam/adv-resistant mutations including a t, v a, q s and i v were detected in some patients singly or with the well-recognized drug-resistant mutations. interestingly, the drug-resistant mutations were also observed in a few of patients naïve to nas. conclusions: the exploration of hbv drug-resistant mutation profile in large clinical samples furthers our understanding of hbv drug-resistant status in china with implications for administrating anti-hbv therapy more reasonably. toll-like receptor (tlr) , tlr and cd +cd +cd low/-regulatory t cells correlate with hepatitis b virus infection y. zhang , j.q. lian , c.x. huang , x. wei , j.p. wang , p.z. wang , x.f. bai center of infectious diseases, tangdu hospital, the th military medical university, xi'an, china background: tlrs play a crucial role in sensing and initiating innate antiviral response and tregs actively suppress immune response, contributing to viral persistence and chronic tissue damage. in this study, we determined tlr and expression and treg frequency, as well as their function in the effect of hbv infection. methods: tlr and tlr expression on monocytes and circulating cd + cd + cd low/-tregs were determined by flow cytometry in ahb, chb, asc and nc. spearman correlation was performed to investigate associated variables on treg or tlrs. pbmcs were stimulated with hbeag or hbcag and the tlrs profile was examined. result: tlr expressions were up-regulated in chb and asc, while tlr were increasingly expressed in ahb and asc. treg frequency in chb was significantly higher than that in nc. in chb, the increased tlr negatively correlated with hbv dna loads and treg frequency negatively correlated with tlr expressions. tlr was up-regulated after hbeag stimulation in both nc and chb. conclusion: increased tregs may be associated with chb and there might be possible interactions between hbeag, tlr signaling and the innate immune response, which may partially explain the mechanism of hbv infection induced immuno-tolerance. ( . ± . ) . hbv-dna was quantitatively determined by polymerase chain reaction (pcr) technique, and hbv genotype was determined by pcr microwave gene chip technique. antiviral efficacy was assessed using measuring the following scales: the alt normalization rate, hbv-dna negative conversion rate and the hbeag/anti-hbe seroconversion rate. results: among serum specimen, hbv genotype distribution was genotype c, genotype b, and genotype non-b or c respectively. in genotype b, alt normalization rate was . %( cases), hbv-dna negative conversion rate was . %( cases) and the hbeag/anti-hbe seroconversion rate was . %( cases). in genotype c, alt normalization rate was . % ( cases), hbv-dna negative conversion rate was . %( cases) and the hbeag/anti-hbe seroconversion rate was . %( cases). the efficacy of adefovir dipiroxil showed no significant differences between genotype b and c in the treatment of chronic hepatitis b p> . . conclusion: adefovir dipiroxil is an effective antiviral drug. hbv genotype is irrelevant to the antiviral efficacy of adefovir dipiroxil in treatment of patients with chronic hepatitis b. the effect of anti-hbv drugs on albumin and bilirubin levels, and platelet count h. yoshida , h. taniguchi , r. nagano , k. sakitani , e. seki , t. serizawa , y. ito , h. mizuno , y. mitsuno , r. nakata , m. omata japanese red cross medical center, university of tokyo, japan background/aim: we assessed the efficacy of anti-hbv drugs on the liver function. methods: patients with hbv-related disease followed at our center between and were enrolled. lamivudine ( mg), lamivudine ( mg) +adefovir ( mg), or entecavir ( . mg) was administered to the patients with detectable hbv dna and elevated alt. liver function (alt, alb, and t.bil) and platelet count were observed. alt, alb, t.bil, and platelet count of treated group at pretreatment, year , and year were compared with untreated group. results: eighty six patients with positive hbsag were enrolled between jan and dec . seven patients ( acute infection, overlap infection with hcv, lost of follow up) were excluded. in total patients were followed up for a median follow up of (range - ) months. of patients, received anti-viral treatment. twenty one patients were treated with lamivudine, with lamivudine+adefovir, and with entecavir. the mean of levels of pre-treatment-year -year were alt: - - (u/l), alb: . - . - . (g/dl), t.bil: . - . - . (mg/dl), and plt: . - . - . (x mcl) respectively. markers of untreated group (n= ) (at baseline-year -year ) were alt: - - (u/l), , t. bil: . - . - . (mg/dl), and plt: . - . - . (x mcl) respectively. although all of four markers in treated group were significantly worse than untreated group at baseline, all of four markers did not showed significant difference from untreated group at year . conclusion: treatment with anti-hbv drugs showed the efficacy not only transaminase levels, but also on albumin, bilirubin, and platelet count improvement-improvement of "hepatic reserve" which is valuable for prevention of cirrhosis. background: currently, hbeag-negative chronic hepatitis b(chb) is increasing. but there are still controversial on the treatment of hbeag-negative chb with alt ×uln. we have investigated the clinical efficacy of nucleotide analogues(nas) in the treatment of hbeag-negative chb with alt ×uln. methods: the data of patients who were treated by nas for more than years and with alt ×uln (n= ) , alt ×uln(n= ) and alt ×uln(n= ) were collected, and w and w virologic response, w and w complete response, virologic breakthrough and clinical resistance were analyzed. results: compared with the base line, hbv dna level in all three groups were significantly decreased (p . ), and there was no significant difference between alt ×uln group and alt ×uln group. the viral load was significant decreased in alt ×uln group at w, w and w (p< . ). virologic response at w and w complete response at w and w was . %, . % , . % and . % respectively in alt ×uln group and was . %, . %, . % and . % respectively in alt ×uln group. there was no significant difference between alt ×uln group and alt ×uln group. virologic response at w and w and complete response at w were significant decreased (p< . ) in alt ×uln group. there was no significant difference among the three groups in virologic breakthrough and clinical resistance. conclusion: hbv replication can be satisfactory inhibited by nas in hbeag-negative chb patients with alt ×uln, which suggests that in these patients the indication of alt is different from hbeag-positive patients. quantitative hbeag assay as a predictive factor of hbeag seroconversion induced by peg-ifn - a therapy to hbeag-positive chronic hepatitis b y.y. zhu , j. dong , y.t. chen , j. chen , j.j. jiang liver diseases research center, the first affiliated hospital of fujian medical university, fuzhou, fujian, china rp, background: to find predictive factor for hbeag seroconversion in the treatment of hbeag-positive chronic hepatitis b (chb) by peg-ifn - a. methods: hbeag-positive chb patients were given peg-ifn - a treatment for weeks. clinical data were collected every months. receiver operator characteristic (roc) curve was employed to calculate positive predictive value (ppv), negative predictive value (npv), sensitivity and specificity. results: sixty-five patients completed peg-ifn - a therapy. among them, ( . %) were found hbeag seroconversion and ( . %) were found hbeag loss at cessation of therapy. none of age, gender, alt level and hbv dna load at baseline had relationship with hbeag seroconversion. hbeag level of baseline was correlated to hbeag seroconversion, with p value as . (table ) . according to roc curve, supposed auc as . and p value as . , the ppv, npv, sensitivity and specificity of hbeag level as at week were . , . , . and . , respectively. supposed auc as . and p value as . , the ppv, npv, sensitivity and specificity of hbeag level as at week were . , . , . and . , respectively. the hbeag level (s/co) and decreased degree (percentage) at week and week were significant related to hbeag seroconversion (table ) . conclusion hbeag level at baseline and at th and th week and its decreased degree (percentage) during the treatment course could be used as predictive factor for hbeag seroconversion. background: it is well documented that perinatal transmission is the major cause of chronic hbv infection in china. the aim of this study was to evaluate the efficacy of interruption of hbv intrauterine infection with hepatitis b immunoglobulin (hbig) in pregnant women with hbeag positive. methods:: a prospective randomized controlled trial was adopted. each subject in the trial group ( cases) was given iu hbig intramuscularly every weeks from -week of gestation, while each subject in the control group ( cases) received placebo in the same way. the cord blood of newborns were collected for detecting hbsag, hbeag and hbv-dna. results: for newborns, hbeag positive rate in trial group was . %( / ).hbeag positive rate in control group was . %( / ). there was significant difference in hbeag positive rate of newborns between the two groups( p < . , rr = . ). hbv-dna positive rate in trial group was %( / ). hbv-dna positive rate in control group was . %( / ). there was significant difference in hbv-dna positive rate of newborns between the two groups( p < . , rr = . ). hbv-dna load of cases of newborns in trial group was lower than that of their mothers(t = ,p = . ). there was no significant difference in hbv-dna load between women and their newborns after delivery in control group (t = . ,p > . ). conclusion: it is effective and safe to prevent hbv intrauterine infection with hbig from the (th) wk in pregnant women with hbeag positive. ), especially, the cirrhosis and hcc cases obviously more in both hbeag and anti-hbe patients are negative than hbeag-negative but anti-hbe positive patients (. . % vs . %; . %vs . %, p ) .the prevale nce of pre-core g a mutate have no significant difference regardless of hbv serum marker status or the state of illness. conclusion: recent years the hbeag-nagative chronic hepatitis b patients are gradually increasing in yunnan province. while the hbeag disappear but no anti-hbe serum transfer, and the virus still active replication -it may be a crucial phase determined the diseases outcome, which should be pay more attention by physicians. the clinical significant of pre-core g a mutate remain unknow. efficacy of interferon for chronic hepatitis b patients with normal or paranormal alt z. liu , j.z. guo , y.j. lin , y.j. zhang , z.w. lang beijing ditan hospital, beijing, china background: we reported interferon treatment for cases with normal or paranormal alt but in which liver histologic exam showed g - and/or s - . methods: patients were male with an average age of years.mean alt was . iu/l and hbv dna level was ~ log copies/ml. two patients were hbeag positive; one patient was both negative for hbeag and anti-hbe and one patient was anti-hbe positive. liver biopsy showed g ~g and s ~s respectively. patients were treated with ifn-alpha, liver biopsy was repeated after year.only one patient had received combination therapy with ifn and adefovir after months treated ifn monotherapy and liver biopsy was taken after . years. results: all patients got normal alt after year treatment. hbv dna was undetectable in patients. patients with initial positive hbeag cleared. but patients still were anti-hbeag negative.liver biopsy showed change fromg s - to g s - in patient; fromg s to g s in patient and no change in the other patients. conclusions: though alt and hbv dna improved after year treatment, histological improvement is not satisfying. patient's improvement in liver histology may be due to seroconversion before treatment and adding adefovir after months of interferon therapy. after months of combination therapy we did liver biopsy again. the other patients were hbeag negative, but hbeab were also negative, liver biopsy was taken year later without combination of nucleoside analogs. evaluation of long term efficacy of hepatitis b vaccination r.c. li , j. gong , j.y. yang objective: to evaluate the long term effectiveness of preventive hbv infection and to monitor the incidence of hepatitis b in children to see possible impact on the program of long an that was launched in . methods: ( ) set up a surveillance systemof hepatitis ,to evaluate the possible impact on incidence of hepatitis b. ( ) to serologically evaluate the effect of the program, a stratified random sampling of subjects in birth cohorts was recruited for long term follow up at the age - years. ( ) cross-sectional seroepidemiolgical survey was carried out in the county in before the program and years later. hbsag , anti-hbs and anti-hbc were tested by ria. results: the average coverage of hepatitis b vaccine was . %. at years after vaccination, the seropositivity for hbsag in population of - years has decreased from . % to . %, the annual effectiveness was . %. hbv accumulated infection rate was . %, protective rate was . %. the incidence of acute hepatitis b was . per , in population aged - years , it decreased by . % as compared with the incidence of . per , in same age group in - . conclusion: mass hepatitis b vaccination program in long an county has proved to be effective in control of hbv chronic infection and incidence of acute hepatitis b. background and aims: although the evolution of viral quasispecies may be related to the pathological condition of disease, little is known about this in hepatitis b virus (hbv), especially during hbeag seroconversion. methods: nucleotide sequences of hbv precore/core genes from time points were analyzed in four cohorts of chronic hepatitis b, interferon-induced seroconverters (is, n= ), interferon non-responders (in, n= ), spontaneous seroconverters (ss, n= ) and non-seroconverters (sn, n= ), followed during months on average. only patients with genotype c were used. viral diversity was then estimated after nucleotide genetic distance was assessed and phylogenetic trees were constructed. results: analysis of nucleotide sequences showed that the nucleotide genetic distance of seroconverters (is and ss; x - substitutions/site and . x - subsititutions/site, respectively) was similar to that of non-seroconverters (in and sn; both x - substitutions/site) before seroconversion. compared to that of nonseroconverters (in and sn; substitutions/site and . x - substitutions/site, respectively) the viral diversity of seroconverters (is and ss; x - substitutions/site and x - substitutions/site, respectively) was significantly higher after seroconversion (p< . ) and it was higher after seroconversion in seroconverters compared with that berore seroconversion (p< . ) while it almost didn't change in non-seroconverters irrespective seroconversion. phylogenetic trees also showed that complex trees appeared in secoconverters and relatively simple in nonseroconverters. conclusions: the distinctly higher viral diversity after seroconversion in hbeag seroconverters could be related to increased hbv-specific t-cell responses and escape mutant which arise from stronger selective pressure caused by host immune activity. adefovir dipivoxil mg (adv) resistance at yrs in chinese hbeag+ve chronic hepatitis b (chb) j.l. hou , y.z. wang , x.q. zhou , j.q. niu , y.m. wang , h. wang , y.m. mao , k.f. barker nanfang hospital, guangzhou, prc, jinan infectious disease hospital, jinan, prc, ruijin hospital, shanghai, prc, st hospital of jilin university, changchun, prc, xinan hospital, chongqing, prc, people's hospital, beijing, prc, renji hospital, shanghai, prc, glaxosmithkine r&d, london, uk background: long term adv provides clinical and histological improvement in chb, but may lead to emergence of treatment associated resistant mutations. we report on adv resistance data from chinese hbeag positive subjects treated for years. methods: hbeag positive chb subjects were randomized in an initial weeks controlled adv study (with a weeks placebo period in half of patients) and then offered open label adv treatment for a further weeks. a total of , , , and subjects completed the st , nd , rd , th and th yr, respectively. at the end of each year samples were analysed from those subjects with protocol-defined hbv dna breakthrough for the rtn t or rta v adv mutations associated with resistance. sera from subjects with breakthrough were analysed at all subsequent yearly timepoints whenever possible. results: at the end of the st yr, none of the subjects with hbv dna breakthrough had either mutation. sera were available for analysis from , , and subjects with viral breakthrough at the end of the nd , rd , th and th yr, respectively, with new mutations identified in , , and subjects at the same timepoints. of the cumulative subjects at the th yr analysis had rtn t, had rta v, and had both mutations. conclusion: treatment with adv in chinese hbeag positive chb subjects for up to yrs resulted in a cumulative rate of . % ( / ) adv resistance-associated mutations with hbv dna breakthrough. background and aims: to evaluate the predictive significance of rapid virologic response (rvr) for achieving an end-of-treatment virologic response (er) or hbeag seroconvertion and the predicting indicator of nonresponse (nr). methods: patients with chronic hepatitis b were treated with adv and prospectively observed to weeks. we assessed the values of virus load reduction at weeks , , and weeks to predict the er and hbeag seroconversion. the association between less reduction of viral load at and weeks and nonresponse was also analyzed. results: of etv-treated patients enrolled in etv- , met criteria for inclusion into year etv treatment analyses. the proportion of patients achieving efficacy endpoints through years of etv therapy is presented the table. results: after weeks of therapy, serum hbv dna levels decreased with a median . ± . log copies/ml. twenty-three( . %) of patients had er. twenty-six ( . %) patients achieved hbeag seroconversion. hbv dna < log copies/ml at week predict both er and hbeag seroconversion. hbv dna> log copies/ml at weeks but decline to < log copies/ml at weeks or weeks both can predict er and hbeag seroconversion. less than log hbv dna reductions at weeks might predict nr. conclusions: the majority of patients experienced durable serum hbv dna suppression ( %) and alt normalization ( %) after years etv therapy. conclusions: the virologic response within weeks could be useful for prediction of er and hbeag seroconversion of adefovir therapy. failing to evr might not predict nr. objectives: to determine the accuracy of hbcigm in diagnosing ahb and the correlation between hbcigm and liver inflammation (alt), bilirubin & biosynthetic functions (albumin,pt). result: a total of patients were included: in patients, adv was added on lam (add-on therapy), and in patients, lam was switched to adv (switch therapy). during . months of follow-up, patients developed adv resistance (rta v and/or rtn t) and all had undergone switch therapy. the cumulative probability of adv resistance at the th month was . %. although add-on therapy induced no adv resistance, it failed to show significant superiority over switch therapy (p= . ). in multivariable analysis, female (odds ratio [or], . ; % confidence interval [ci], . - . ; p= . ), liver cirrhosis (or, . ; % ci, . - . ; p= . ), and age > yr (or, . ; % ci, . - . ; p= . ) were independent risk factors of adv resistance. methods: a retrospective cross-sectional study involving patients with hbcigm positivity between june -december , satisfying the definition for ahb and chbf,and fulfilling the exclusion criteria was performed. hbcigm test were done by using microparticle enzyme immunoassay (meia) and results were expressed as an index value.hbcigm positivity was defined as index value of > . results: patients were positive for hbcigm and fulfilled the criteria( ahb, chbf).hbcigm was significantly higher in ahb compared with chbf(median . vs . ;p < . ).the hbcigm arbitary index value of . was highly sensitive( %) and specific( %) in diagnosing ahb with high accuracy(auroc . ; % ci: . - . ;p< . ).among patients in both groups, there was a weak, but significant negative correlation between hbcigm and pt above control(r = - . ,p = . ).however, among patients with chbf,the negative correlation between hbcigm and pt above control was moderately strong(r = - . ,p = . ).there was also a weak, but significant positive correlation between hbcigm and albumin in with chbf(r = + . ,p = . ). conclusion: adv add-on therapy developed no adv resistance during the observation period. therefore, add-on therapy is recommended to lam-resistant chb patients with genotype c who have any risk factors for development of adv resistance: female, liver cirrhosis, and age > yr. hbcigm-hepatitis b core igm antibody ahb-acute hepatitis b,chbf-chronic hepatitis b flare alt-alanine transaminase,pt-prothrombin time pe detection of emerging drug resistance mutations associated with major approved hbv antivirals using a novel line probe assay (lipa). j. doutreloigne , f. shapiro , r. maertens , e. van assche , e. sablon hepatitis diagnostics unit, innogenetics nv, belgium background: in study etv- , etv demonstrated superior virologic, histologic and biochemical benefit compared to lamivudine (lvd). this study (etv- /- ) presents efficacy and safety results for patients who received years continuous etv treatment. background/aims: an increasing number of antiviral drugs are being used to treat chronic hepatitis b virus (hbv)-infected patients. however, induced viral escape mutants -some potentially cross-resistant -lead to viral non-responsiveness and treatment failure. effective treatment strategies must therefore take possible drug resistance (dr) into account with respect to monitoring and selection of alternative drugs. we evaluated the use of an updated inno-lipa hbv dr v +v reverse hybridization assay versus sequence analysis to detect resistance mutations. methods: the study evaluates etv-treated nucleoside-naïve hbeag (+) patients who completed etv- and enrolled into etv- with a treatment gap days. the proportion of patients with hbv dna < copies/ml, alt normalization, hbeag loss or hbeag seroconversion was evaluated at week . background: etv resulted in improved liver histology compared to lvd at year. histologic data for patients on etv for a median of years is evaluated. methods: clinical samples (from untreated hbv patients or treated with different antivirals; hbv genotypes a-h) were tested for mutations with the lipa assay and sequencing. for lipa, samples were extracted with the qiaamp® dna blood mini kit (qiagen), and then tested on the lipa strips. sequencing-derived reference data were subjected to phylogenetic analysis (kodon version . applied maths, neighbour joining, with kimura- parameter). sequential samples from patients were evaluated as well. methods: etv-treated patients completing etv- or etv- received etv ( . mg daily) in etv- . primary endpoints included -point decrease in knodell necroinflammatory score, no worsening of knodell fibrosis score and improvement in ishak fibrosis score (ifs) ( -point decrease) vs. baseline. secondary endpoints included proportions with hbv dna< copies/ml, alt normalization, and ifs normalization in patients with advanced fibrosis/cirrhosis. results: quasi-perfect concordance (> . %) was obtained between the two assays for the samples tested. no indeterminate results were observed. for one sample, lipa provided additional information (wild-type/mutant mix), whereas sequencing showed only wild type. for sequential samples, lipa was clearly able to detect emerging treatment-resistance mutations associated with viral breakthrough. results: etv treatment led to significant histological improvements and improved ifs in % ( / ) and % ( / ) of patients respectively. of patients with baseline fibrosis/cirrhosis (ifs ), all demonstrated -point improvement in ifs (median change of - ). conclusions: lipa accurately detects the complex quasispecies nature of hbv and can help unravel the dynamics of emerging hbv resistance during treatment with different antiviral drugs. like its predecessor, it is useful for the monitoring and early detection of drug resistance. conclusions: long-term etv therapy in nucleoside-naïve chb patients results in durable virologic suppression, continued histologic improvement and regression of fibrosis/cirrhosis. precore (pc, g a) and basal core promoter (bcp, a t and g a) mutations of hbv are important for predicting the risk of hepatocellular carcinoma (hcc). we developed a new mass spectrometry-based assay using restriction fragment mass polymorphism (rfmp) to detect a and t /a mutations, and applied it to analyze their clinical significance in type b liver diseases (n= ), including hccs, liver cirrhosis (lc), chronic hepatitis b (chb), and hbsag-positive with low level viremia (inactive hbsag carrer, ihc). we devided patients into major groups according to the presence of wild (w) or mutant (m) genes in bcp/pc regions; w/w, w/m, m/w and m/m gene types. each proportion was . %, . %, . % and . %, respectively. mixed infection (x) was also found as minority; w/x, m/x, x/w, x/m and x/x. disease distributions (hcc, lc, chb and ihc) in each group were as follows; [w/w (n= )] . %- . %- . %- ; [w/m (n= )] - . %- . %- %; [m/w (n= )] . %- . %- %- . %; [m/m (n= )] . %- . %- . %- . %. these results suggest that, in korea where only genotype c has been identified, bcp dual mutation is predominant (> . %), while bcp wild alone is only . %. especially, a mutation alone without bcp mutation (w/m type) is uncommon, while bcp mutation alone without a mutation (m/w type) is most common. it might be suggested that prognosis of wild type in bcp and pc region (w/w type) is much better than that of m/w or m/m types. background/aims: entecavir is a potent inhibitor of hbv dna polymerase, which has been shown to be safe and effective for the treatment of chronic hepatitis b (chb) patients. the aim of this study was to evaluate the virologic, biochemical, and serologic responses of entecavir through year in chb patients. methods: from may to october, we reviewed patients (mean age ± years, male:female= : ) who were diagnosed as chb patients (hbeag (+) ). forty-seven patients ( . %) had been treated with . mg of entecavir and ( . %) with mg of entecavir, respectively. mean follow-up period was ± weeks. hbv dna was quantified by bdna assay with a lower limit of detection of , copies/ml. results: median hbv dna levels before therapy was . log copies/ml and the median decreases from baseline in hbv dna were - . , - . , - . , - . , and - . log copies/ml at (n= , p< . ), (n= , p< . ), (n= , p< . ), (n= , p< . ), and (n= , p = . ) weeks of follow-up, respectively. at baseline, overall median alt was iu/l and the proportions of patients with normal alt were %, %, %, %, %, and % at baseline (n= ), (n= ), (n= ), (n= ), (n= ), and weeks (n= ) after entecavir therapy, respectively. thirteen cases ( . %) of hbeag seroconversion were noted. background: hepatitis b virus (hbv) infection is a major risk factor for the progression of liver diseases. because its clinical course varies, it is difficult to detect the predictive factor for the prognosis of patients with hbv infection. the aim of the present study was to determine the risk factors for the occurrence of hcc. methods: a total of patients who tested positive for hepatitis b surface antigen and were referred to chiba university hospital between february and march were included in the study, and their following characteristics were analyzed: age, gender, the status of hbeag, alt, hbv-dna level, and plt. result: hcc was detected in cases during the follow-up period ( . ± . years). multivariate analysis revealed that age [compared with young patients: odds ratio (or) = . , % confidence interval (ci) = . - . ] and plt level (compared with patients with low plt level: or = . , % ci = . - . ) were the predictive factors for hcc occurrence. in patients with age more than years, the hbv-dna level (compared with < . log copies/ml: or = . , % ci = . - . ) and plt level (or = . , % ci = . - . ) were the predictive factors for hcc occurrence. conclusion: advanced age and low plt level were the risk factors for hcc occurrence in patients with hbv infection irrespective of the plt level at baseline. in patients with age more than years, viral load was also a risk factor for hcc. results: before treated by lps, the total mapk p level of pbmcs have no significant difference among the healthy control group, different stage groups with hbv infection, however, after treated with lps, the phosphorylated mapk p (ptpy / ) in healthy control group are significant elevate than hbv infected groups( . ± vs . ± . , p< . ). in the two groups which hbsag, hbv dna are positive, alanine aminotransferase elevate than normal and hbsag positive, but hbv dna lower under the detect limited level, after treated by lps the ptpy / although lower than healthy control yet, but significant elevated than themselves before treated by lps( . ± . vs . ± . , . ± . vs . ± . ; p< . ).otherwise, in the group of both hbsag and hbv dna are positive, but alt is normal, before and after treated by lps, the level of ptpy / have no significant difference. conclusion: mapk p is a important signal transduction pathway which involving in inflammation and immune response, especially, mapk p activated up-regulate the ifn-gamma mrna. according to the result shown, we propose a hypothesis, hbv infection and virus active replication inhibit the mapk p activated, consequent on host immunotolerance and hbv persistence, thus, mapk p may be as a potential therapeutic target to break immnotolerance and establish host anti-viral states. van der helm siriraj hospital, bangkok, thailand, ramathibodi hospital, bangkok, thailand, phyathai hospital, bangkok, thailand, singapore general hospital, singapore, national university hospital, singapore, changi general hospital, singapore, cheil general hospital, korea, hwasun jeonnam university hospital, korea, st mary hospital, korea, roche diagnostics ltd, rotkreuz, switzerland background/aims: hepatitis b virus (hbv) surface antigen (hbsag) is one of the most important markers for diagnosis of acute and hbv infection. high sensitivity of hbsag assays can reduce the diagnostic window during course of disease. in addition, the presence of hbv mutants may be affected by the performance of the hbsag kit. therefore, the technical performance of the elecsys ® hbsag ii assay was explored, using samples (including recombinant mutants), at multiple sites in three countries. methods: nine hbsag screening centers in thailand, korea and singapore compared the sensitivity of elecsys ® hbsag ii assay with that of their routine testing procedure -abbott architect ® ( centers), abbott axsym ® ( center) and bayer advia ® centaur hbsag assays ( center) using preselected seroconversion panels (n= ), recombinant hbv mutant panels (n= ) and routine clinical practice samples (n= , ). results: the sensitivity of elecsys ® in seroconversion samples was equivalent to the architect ® assay, but more sensitive than the axsym ® and advia ® centaur assays ( vs and vs positive bleeds, respectively). there was concordance between the elecsys ® and architect assay results with respect to potentially cross-reactive samples ( . %). the elecsys ® and architect ® assays detected all recombinant mutant samples, whilst axsym ® and advia ® centaur failed to detect three and nine samples, respectively. conclusion: elecsys ® hbsag ii assay was not only highly sensitive and specific when compared with established hbsag screening assays, but also reliably detected hbsag mutants. therefore, this attractive assay is suitable for hbv diagnosis and assessing safety of blood products. background: recent studies have shown a higher rate of adefovir-resistant mutation in lamivudine-resistant chronic hepatitis b (chb) patients treated with switch-to therapy than those treated with add-on therapy. we compared the clinical efficacy of adefovir monothrapy and lamivudine-adefovir combination therapy in lamivudine-resistant chb. methods: a prospective cohort study was performed in patients with lamivudine-adefovir combination therapy and patients with adefovir monotherapy for lamivudine-resistant chb over months. result: biochemical response was achieved in patients ( . %) treated with combination therapy and in patients ( . %) treated with monotherapy (p= . ). virologic response was observed in patients ( . %) in combination therapy and in patients ( . %) in monotherapy (p= . ) and treatment periods for virologic response was significantly shorter in patients with combination therapy than in monotherapy ( . ± . months vs. . ± . month, p= . ). cumulative rate of virologic response was significant higher in patients with combination therapy than monotherapy (p= . ). hbeag loss was found in patients ( . %) in combination therapy and patients ( . %) in monotherapy (p= . ). biochemical breakthrough was found in patients ( . %) with monotherapy significantly more frequent than patients ( . %) with combination therapy (p= . ). genotypic resistance to adefovir was developed in patient ( . %) in combination therapy and patients ( . %) in monotherapy conclusion: to achieve a complete virological response and reduce the risk of adefovir-resistant mutants in lamivudine-resistant chb patients, adefovir in combination with lamivudine is preferable. background/aims: adefovir dipivoxil (adv) effectively inhibits both wild-type and lamivudine (lam)-resistat chonic hepatitis b virus (chb) replication. the aims of this study were to determine the factorts associated with antiviral effect of adv in lam-resistant chb. methods: one hundred-eighteen lam-resistant chb patient ( . % hbeag-positive) were treated with adv plus lam (n= ) or adv monotherapy (n= ) for a mean of . months. restriction-fragment mass polymorphism analysis was used for detection ymdd and adv mutants. results: fifty-eight patients ( . %) achieved complete response(cr) defined as hbv-dna levels < copies/ml and alt normalization. twenty-eight patients ( . %) achieved initial vilologic response(ivr) defined as hbv-dna levels < copies/ml within the first month of treatment. ( . %) of hbeag-positive patients exhibited hbeag loss and % seroconverted to anti-hbe ab. five ( . %) patients developed adv-related mutations. factors associated with ivr were pretreatment level of alt (p= . ), ast (p= . ), pretreatment hbv dna level (p= . ), hbeag negativity (p= . ) and hbeab positivity (p= . ). factors associated with cr were ivr (p= . ), hbeab positivity (p= . ), pretreatment level of alt (p= . ), ast (p= . ) and y-glutamyl transferase (p= . ). age, sex, presence of liver cirrhosis, pretreatment hbv dna level and the type of ymdd mutants were not related to an cr during adv treatment. conclusions: adv therapy achieved cr in more than % of lam-resistant chb. factors associated with cr were ivr, hbeab positive status, high base line alt, ast, ggt levels. q.j. sheng , y. ding , x.g. dou department of infectious disease, shengjing hospital affiliated to china medical university, shenyang, , china objectives: to study a kinetics of hepatitis b virus during -week and -week of treatment with enticavir (ent); to compare the detecting results of hbvdna levels from different detection reagents. methods: thirty-seven cases of chronic hbv infections were selected randomly, treated with daily dose of ent . - . mg ( . mg for nucleoside-naïve patients, . mg for lamivuding-refractory patients). evaluation indexes: serum hbvdna, hbv serological markers, and liver function tests. hbvdna levels were measured by pcr assay, using both domestic reagents and roche cobas amplicor,. the lower limits of measure level of hbvdna were copies/ml and copies/ml, respectively. results: mean baseline of hbvdna was . log copies/ml for detection using domestic reagents and . log copies/ml for that using roche cobas amplicor, (p> . ). the ratios of cases with undetectable (< copies/ml) hbvdna at week- and week- were . % and . %, respectively. the ratios of cases with undetectable (< copies/ml) hbvdna at week- were . %. among the cases whose hbvdna were lower than copies/ml(using domestic reagents), the ratio of hbvdna lower than copies/ml(using roche cobas amplicor) was . %. conclusions: ent can suppress hbv dna rapidly no matter the patients with alt elevation or not. there is a concordance on hbvdna levels detection between domestic reagents and roche cobas amplicor. background the study on the effect of nucleoside analogue therapy on the quantity of hepatocellular cccdna and tdna and sera hbv dna, hbsag to probe reliable marks for evaluation of therapy endpoint. methods the quantity of hepatocellular cccdna and tdna and sera hbvdna were assayed by fq-pcr, and sera hbsag by elisa in chb patients over years nucleoside analogue therapy satisfied the china criteria of therapy endpoint (therapy group)and chb patients without antiviral therapy and sera hbvdna< copies/ml(control group). results: the quantity of hepatocellular cccdna, tdna and sera hbvdna, hbsag in therapy group were lower than that of control group,but low level hepatocellular cccdna in therapy group could be detected. conclusion: long term nucleoside analogue therapy may consume hepatocellular cccdna with decreasing of hepatocellular tdna and sera hbvdna, hbsag; although the patients have satisfied the china criteria of therapy endpoint, low level of hepatocellular hbvcccdna were detected, cessation of therapy may cause relapse. peptides that lead nuclear entry of nucleocapsid of hepatitis b virus in hepg . . cells x.b. pan , , l. wei , , j.c. han , , k. deng , peking university hepatology institute, peking university people's hospital background: the nuclear entry of nucleocapsid is a key step for the hbv life cycle and the formation of covalently closed circled dna (cccdna). it has been supposed that the carboxyl-terminal arginine-rich domain of the core protein contains a signal for nuclear localization (nls). whereas hbcag was primarily distributed in cytoplasm and no marked cccdna was detected in hepg . . cells. methods: we designed peptides containing a cell-penetrating sequence (rrrrrrr) and a nucleocapsid binding sequence (gsllgrmkga) with/without a classic nuclear localization sequence (pkkkrkv) and these sequences were linked by a soft linker acp. hepg . . cells were treated with the peptides at levels of m, m and m for days. results: compared with that of control cells, the results showed hbv dna levels in culture medium decreased at least log both in m of peptide rrrrrrracpgsllgrmkga treatment group and rrrrrrracpgsllgrmkgaacppkkkrkv treatment group; whereas hbsag and hbeag increased at . + . folds and . + . folds respectively. the signal strength of cytoplasmic hbcag increased at about . -fold in both groups. in rrrrrrracpgsllgrmkgaacppkkkrkv treatment group, nuclear hbcag increased about . -fold and obvious cccdna signal was detected by southern blot. conclusion: our results implied that the nls of core protein likely does not expose to surface of nucleocapsid in hepg . . cells, the artificial peptide containning nls binds to the nucleocapsid and leads nuclear entry of nucleocapsids and then facilitates the formation of cccdna. our study presents a tool for study on cccdna formation and nuclear entry of nucleocapsid. b. tang , j. xia , y.m. wang , h.f. wang liver failure treatment and research center, rd military hospital, the dept. aims: to establish a reliable real-time fluorescence quantitative (rfq) pcr method to quantify hbv cccdna, basing on lightcycler system and taqman probe. methods: hbv genotypes a-g were aligned to obtain a conserved sequence, crossing rcdna gap, which was used to design cccdna primers and taqman-mgb probe. also another pair of primers for quantify hbv total dna (tdna) was designed, utilizing the same probe. to increasing specificity, we added plasmid-safe atp-dependent dnase (psad) digestion step just before cccdna pcr amplification. a standard curve from standard plasmid samples, from . × to . × copies, was created to examine our system. hbv cccdna samples with known-amount were quantified by creating standard curve from standard samples. results: the standard curve had clear log-phase and excellent parallelism, which means nice and equal amplification efficiency in all reaction capillarys. the slope (regression coefficient) of standard curve was - . , mean square error was . and regression coefficient was - . . all of these key indexes measured up. in tests, we got right results if the starting templates of cccdna copies were between ~ copies. the range was superior to commercial hbv kits. by quantifying samples containing different amounts of cccdna and rcdna, digested or undigested, psad digestion would eliminate rcdna molecules, leaving cccdna molecules untouched. the test specificity was maintained up to : , ratio of cccdna:rcdna. conclusions: the rfq-pcr based on lightcycler system for hbv cccdna quantification is reliable, sensitive, with high specificity and low cost. background: to study the changes of toll-like receptor (tlr) on dendritic cells derived from peripheral blood mononuclear cells(modc) and its role in the pathogenesis of chronic hepatitis b(chb) and chronic severe hepatitis b(cshb). methods: the expressions of tlr on modc were stimulated by poly i:c, and then were determined by flow cytometry in healthy controls, patients with chb and patients with cshb.the level of interferon ifn-was determined by elisa. the differences of expression of tlr on modc and serum ifn-among the three groups of study subjects were determined by student-t test.the correlation between tlr and ifn-were determined by linear correalation test. results: the values of mean fluorescence intensity(mfi) of tlr on modc of the healthy controls, patients with chb and cshb were . ± . , . ± . ,and . ± . .the serum ifn-(pg/l) of respective groups was . ± . , . ± . and . ± . . there was a gradual decrease of these values from the group of healthy controls to the group of patients with chb and cshb .significant positive correlations between tlr and serum ifn-were found. conclusion: tlr may have a role in the pathogenesis of chb and cshb. background/aim: to evaluate the efficacy and safety of entecavir treatment in patients with hbeag-positive chronic hepatitis b who had not previously received a nucleoside analogue. methods: fifty-five patients received -week entecavir . mg/d therapy. serum hbv dna load was measured with quantitative real-time-pcr. alanine aminotransferase (alt) activity, hbeag, anti-hbe-antibodies, hbv dna level in serum were evaluated at baseline, week , , and during therapy. evaluation of safety and tolerance was based on clinical adverse events and laboratory analyses. results: hbv dna levels declined sharply by around log copies/ml during the first two weeks, with a highly significant reduction (p< . ) at week and thereafter, as compared to those at baseline; %, % and % of the patients had undetectable serum hbv dna levels at week , and respectively. highly significantly decreasing serum alt (p< . ) occurred during the first weeks of the study. at week , alt levels were normalized in % of the patients. hbeag seroconversion (hbeag negative, hbeab positive) was achieved in . % and . % of patients by and week. at the end of th and th weeks, complete response (alt normalization and hbv dna and hbeag loss) was observed in % and %, respectively. there was no evidence of drug resistance or adverse effect in chb patients treated for up to weeks. conclusion: entecavir treatment through weeks was well tolerated and resulted in continued benefit for patients with hbeag-positive chronic hepatitis b. aim: to assess the associations of single nucleotide polymorphisms of the mxa gene promoter and sustained treatment response of chronic hepatitis b or c patients with interferon treatment by meta-analysis of individual dataset from all studies published till date. methods: to clarify the impact of mxa gene promoter polymorphisms on sustained treatment response of chronic hepatitis b or c patients with interferon treatment, we performed a meta-analysis of the published data from eight studies comparing the frequencies of mxa gene promoter polymorphisms at nt - g/g, - g/t, - t/t and nt - c/c, - c/a , - a/a alleles in individuals with interferon treatment. as we identified the heterogeneity between studies, summary statistical data were calculated based on a random-effect model. results: the sustained treatment response rate was higher in patients with the nt - g/t and nt - c/aalleles in the mxa promoter snp . the meta-analyses yielded summary estimatesodds ratio (or) were . [ %ci ( . , . ), p < . ] and . [ %ci ( . , . ), p = . ] of the nt - g/t and nt - c/a alleles, respectively. conclusion: mxa gene promoter polymorphisms at nt - g/t and nt - c/a may be useful as a marker to predict the sustained treatment response of chronic hepatitis b or c patients with interferon treatment, and further investigation regarding their real significance is warranted in a large series of patients. background: to determine whether hbv with the same characteristics causes dissimilar mutations in different hosts. methods: full-length hbv genome was amplified and linked with pmd t vector. positive clones were selected by double-restriction endonuclease digestion (ecori and hindiii) and pcr. twenty seven clones were randomly selected from an asymptomatic mother [at two time points: ( d) and ( mo)] and her son [ (s)]. bioeditor, clustal x and mega software were used to perform phylogenetic and mutational analysis. potential immune epitopes were determined by the stabilized matrix method (smm), smm-align method and emini surface accessibility prediction. result: all of the sequences were genotype c, the inner-divergence for the mother and son was %- . %. specific nucleotides differed from the other pubished genotype c isolates were co-exist in the mother and her son. aa - deletion in pres was the dominant mutation in the mother ( / ). the t/ a double mutation existed in all clones of the mother, of them were also coupled with g a mutation, but none were found in the son. bp deletion starting at nucleotide was the major mutation ( / ) in the son, which caused seven potential hla class i epitopes and one b cell epitope deletion, and produced a presumptive new start codon, downstream from the original one of the p gene. conclusion: the son was infected hbv from his mother, and discrepant mutation occurred in the mother and her son during infection. background/aims: nucleos(t)ide analogues have been recognized as an effective treatment for chronic hepatitis b. this randomized, double-blind trial compared the efficacy and safety of telbivudine and lamivudine after -week therapy in patients with compensated chronic hepatitis b in taiwan. methods: we analyzed taiwanese patients from globe trial receiving telbivudine mg (n= ) or lamivudine mg (n= ) once daily for weeks. the primary efficacy endpoint was therapeutic response with serum hbv dna < log copies/ml and either hepatitis b e antigen (hbeag) loss or alanine aminotransferase (alt) normalization. results: the therapeutic response at week was . % in telbivudine group versus % in lamivudine group (p= . ). more patients with telbivudine achieved nondetectable serum hbv dna (< copies/ml) (p= . ) and alt normalization (p= . ) at the end of treatment. the cumulative resistant rate was significantly lower in those with telbivudine treatment (p= . ). the rate of hbeag seroconversion was comparable in both groups (p= . ). although a lower percentage of patients in lamivudine group ( . %) reported adverse events than those in telbivudine group ( . %), the difference was not significant. conclusions: telbivudine demonstrates a significantly greater efficacy and a lower resistant rate than lamivudine in treatment of chronic hepatitis b in taiwan. background: tumor necrosis factor-(tnf-) plays a pivotal role in the viral clearance and host immune response to hbv, and the capacity for tnf-production in individuals is influenced by a major genetic component. the studies of tnf-- gene promoter polymorphism in chronic hbv infection have reported apparently conflicting results. objective: to derive a more precise estimation of the relationship between the polymorphism of tnf-- gene promoter and chronic hbv infection. method: meta-analysis was done of case-control studies in relation to tnf-- gene promoter, involving a total of chronic hbv infection cases and controls. the pooled odds ratios (ors) for the risk associated with the genotypes of ga, aa, and ga+aa (a-allele carriers) compared with the gg genotype were calculated. results: overall meta-analysis indicated that - a heterozygotes (ga) had % decreased risk of developing chb with a borderline significance (or = . ; % ci: . - . ; p = . ). for the - a allele homozygotes (aa) and carriers (ga+aa), the pooled ors both indicated a significantly decreased risk of chb (or = . ; % ci: . - . ; p = . ; and or = . ; % ci: . - . ; p = . , respectively) ( table ). in the subgroup analyses by ethnicity, significantly decreased risks were associated with - variant genotypes (ga and aa) in mongoloid populations in all genetic models. however, no significant associations were found in caucasoid. conclusion: the meta-analysis suggests that the tnf-- a allele is a low-penetrant protective factor for chronic hbv infection, especially in mongoloid. aim: to define the potential role of pd- /pd-lpathway in different hbv infection status; we examined the expression of pd- on cd + t cells in pbmc of patients with chb and aehb infection. methods: the pd- level on cd + t lymphocytes and the number of hbv specific cd + t lymphocytes in patients and healthy controls were analyzed by flow cytometry. pcr was used to measure the serum hbvdna levels. results: the level of pd- expression on cd + t cells in chb patients was higher than that in aehb patients and healthy individuals. compared to aehb patients, lower frequency of hbv-specific cd + t cells was detected in chb patients. there was an inverse correlation between the strength of hbv-specific cd + t-cell response and the level of pd- expression. besides, there was a significant positive correlation between hbv viral load and the percentage of pd- expression on cd + t cells in chb and aehb subjects. however, pd- expression was not associated with alt levels. conclusion: our results confirm previous reports that hbv specific cd + t-cell response in the peripheral blood is more intense in patients with aehb than in chb with persistent viral infection. moreover, there is a negative correlation between the level of pd- and the intensity of virus specific cd + t cell response. observed in . % of patients with a mean age of . ± . . the ethnic composition was . % chinese; . % malay; % indigenous sabahans; . % indigenous sarawakians; . % indians and . % others. chinese patients were on average, older (mean . ± . years), indians patients had higher mean alanine transaminase and indigenous sarawakian patients had the highest rate of cirrhosis (p< . ). during the study period, . % of patients were on treatment and they were significantly older than those who were not on treatment (mean age . ± . vs . ± . ). lamivudine was the first agent used in . % of cases. conclusions: in malaysia, chb remains a public health issue and significantly afflicts males in the productive age groups and of chinese ethnicity. the observed differences among ethnic groups could point to different disease severity which needs to be addressed in the local treatment guideline and policy. background/aims: liver stiffness measurement (lsm) has been validated for predicting fibrosis stage in patients with chronic hepatitis c. however, studies on lsm for chronic hepatitis b (chb) are few, and the relationship between histologic findings and liver stiffness needs to be further elucidated. this study was conducted to assess the association of histologic activity on liver stiffness in addition to fibrosis in patients with chb methods: thirty three patients who had taken liver biopsy and lsm at korea university ansan hospital between march and october were enrolled. necroinflammatory activity and fibrosis stage were assessed by metavir system. activity, fibrosis, and the sum of both score were included for the correlation analysis with lsm results: among patients, ( . %) were male, and median values were as follows: age, ( ~ ); ast, iu/l ( ~ ); alt, iu/l ( ~ ); total bilirubin, . mg/dl ( . ~ . ); lsm, . kpa ( . ~ . ). fibrosis stages were f in ( . %), f in ( . %), f in ( . %), and f in ( . %) patients. spearman correlation coefficient with lsm were . (p= . ) for activity, . (p< . ) for fibrosis stage, and . (p< . ) for the sum of activity and fibrosis. in linear regression analysis, only the sum of activity and fibrosis remained to be significant. conclusions: not only fibrosis but also activity was an important factor for determining lsm for chb. it would be more appropriate to consider both activity and fibrosis for interpretation of lsm in patients with chb background: hbeag seroconversion is a key goal of chb therapy. hbeag kinetics may predict hbeag seroconversion during treatment. we aim to develop a robust hbeag quantitative method as the value of hbeag quantitation is undefined and data is limited. methods: we evaluated two commercially available qualitative hbeag assays (abbott architect, siemens centaur) for their linear range and validated them against paul-ehrlich institute (pei) standards. hbeag levels were determined from samples of untreated and telbivudine-treated chb patients. results: as a pre-requisite for quantitative use, the linear range for the architect ( . - peiu/ml) and centaur ( . > peiu/ml) assays were defined. architect was selected for further investigation. hbeag levels of untreated patients (mean hbv-dna . log copies/ml, mean alt . iu/ml) varied from . to . peiu/ml (median . peiu/ml). in patients (mean hbv-dna . log copies/ml, alt iu/ml) treated with telbivudine for weeks, baseline hbeag levels varied from . to peiu/ml (median . peiu/ml). after weeks of telbivudine treatment, median hbeag level was . peiu/ml, with % decline from baseline (median decline . peiu/ml, range . - . peiu/ml). individual hbeag decline from baseline varied but occurred in all patients and was not correlated to baseline or decline from baseline hbvdna. conclusion: hbeag quantitation is feasible and robust with architect hbeag assay. hbeag decline occurred in all telbivudine-treated patients, and was not correlated to hbvdna. whether the magnitude of hbeag decline is predictive of future hbeag seroconversion merits further investigation. experience from the combined globe (nv- b- /cldt a ) and (nv- b- ) study clinical safety database. c. avila , r. laeufle , w.b. bao novartis pharma ag, fabrikstrasse , basel, switzerland, novartis pharma ag, basel, switzerland, novartis pharma, east hanover, us background: creatine phosphokinase (ck) is a commonly used marker of muscle damage and is elevated by many factors (e.g. exercise, injury, drugs). normal ck levels are affected by muscle mass and elevated levels are described during the natural course of chb. % of patients in the globe study had pretreatment grade - ck elevations. methods: we reviewed data from this combined study clinical safety database, and describe the experience of ck elevation and its relationship to adverse event reports of muscle related symptoms. results: the frequency of new onset of grade - ck elevations in telbivudine-treated patients (combined database itt population) was . % ( / ), . % ( / ), . % ( / ) and . % ( / ) from weeks - , - , - and - respectively. the frequency of grade - ck elevations for all patients from week - was . % ( / ). the majority of grade - ck elevations were asymptomatic, rarely resulted in discontinuation or interruption, spontaneously declined within or visits and were not associated with more frequent muscle-related adverse events. cumulative data from this combined database showed no relationship of the degree of increased ck to acute or persistent muscle disease. conclusion: ck elevations are associated with hbv disease and were also common during the globe and trials and were not predictive of the development of muscle related symptoms. onset of muscle-related symptoms should prompt clinical and treatment review, including concomitant medications. backgrounds: leptin plays a crucial role in the regulation of energy balance and body weight control by activating the long form of the leptin receptor (ob-rl). epidemiologic studies showed that obesity is one of the factors associated with hbv related hepatocellular carcinoma. methods: huh cells were transiently transfected with . copies of hbv-replicon plasmid. after h, cells were harvested and total rna of the cells were extracted and reverse-transcribed into cdna. long form and short form leptin receptor (ob-rl, ob-rs) mrna transcription levels were assayed by real-time pcr respectively. and mrna transcription levels and protein expression of ob-rl and ob-rs in hepg . . cells were also detected. results: after transfected by . copies hbv-replicon plasmid, the mrna transcription level of ob-rl was inhibited significantly (**p< . ), but the mrna transcription level of ob-rs did not change, and the ob-rl protein expression was reduced. in hepg . . cells, the mrna transcription level of ob-rl was also significantly lower than the mrna transcription level of ob-rl in hepg cells, while the mrna transcription of ob-rs in hepg . . and hepg cells didn't show significant difference. besides, the protein expression level of ob-rl in hepg . . was also lower than it in hepg cells. conclusion: hbv replication down-regulated the expression of long form leptin receptor in cell cultures, which could in part explain the clinical observation of obesity in association with development of serious sequelae in hbv infections. the results of entevavir treatment in patients with chronic hepatitis b s. kose , g. akkoclu , m. turkeri , a. gozaydin the ministery of health tepecik training and research hospital, izmir purpose: we evaluated the short and long term effectiveness of entecavir. patients and methods: those patients had received diagnosis of chronic hepatitis b. their pretreatment transaminases, hbsag, anti-hbs, hbeag, anti-hbe, hbv-dna were checked and a liver biopsy and a resistance test for lamivudine (lam) and adefovir (adv) were performed. a total of patients who were taking entecavir for at least weeks were included in the study. findings: the biochemical and virologic response were observed in . % at and months and in % at months. in hbeag positive patients who had received therapy previously, the biochemical response was observed in . % at and months and in % at months. the virologic response in . % at , in . % at , and % at months. posttreatment hbeag seroconversion did not develop. in hbeag negative patients the biochemical and the virologic responses were observed in . % at months and % and months, respectively. in hbeag negative patients had received therapy previously, the biochemical response was observed in . % at , in % at and months. the virologic response in . % at , in % at and at months. conclusion: in our study, a higher therapy-response rate was achieved, especially in hbeag negative patients. in hbeag positive patients biochemical and virologic response rates were high. background/summary: patients with liver disease are known to have a higher prevalence of glucose intolerance. preliminary studies suggest that viruses can be an additional risk factor for the development of diabetes mellitus. individuals with type ii diabetes have an increased prevalence of cirrhosis, and a proportion of patients with acute and chronic liver disease develop diabetes mellitus. there is now emerging epidemiological data to suggest that hepatitis c virus (hcv) infection may also contribute to the development of diabetes reported to be higher than expected compared with the general population. while these investigations suggest an epidemiological association between hcv infection and diabetes, large controlled studies are required to observe association between hbv infection and diabetes. the present study was designed to study the relative proportion of diabetes mellitus in patients suffering from hepatitis b virus (hbv) infection. background: in easl , we reported significant liver disease among hbeag negative patients with serum hbv-dna level < log copies/ml (i.e. . x log iu/ml) and alanine aminotransferase (alt) < iu/l. this reflects fluctuating nature of these levels. the aim of this retrospective study is to demonstrate the frequency of fluctuation among this group of chb patients. methods: clinical records of hbeag negative treatment naïve chb patients with at least one serum hbv-dna < log copies/ml were reviewed. results: there were ( . % male, median age . years) chb patients with negative hbeag and hbv-dna < log copies/ml (roche cobas amplicor pcr assay, lod< copies/ml). had serial hbv-dna measurements within years; of them ( . %) had increase serum hbv-dna level by > log copies/ml; patients had associated serum alt elevation from normal (normal range < iu/l), had persistent normal alt, and one had persistently raised alt. ( . %) had serum hbv-dna level decrease by > log copies/ml. another patients had hbv-dna levels fluctuating within log copies/ml. hbeag negative patients with single hbv-dna measurement showing < log copies/ml had serial serum alt measurements within years. ( . %) patients had intermittent / persistently raised alt; while ( . %) patients had persistently normal alt. conclusions: hbeag negative chb is common among chinese. serial serum hbv-dna and alt measurements are necessary to detect fluctuating levels and progressive liver disease that may require antiviral therapy. background: to determine the best vaccination strategy, a model that reflects the country-specific infection profile is needed. methods: a model was built in order to obtain the age-specific infection frequency q(t) for neonates(n), infants(i), children(c), and adults(a). the infected group can either become hbsag(+) or anti-hbs(+)* based on f(t). q(t) can be found from p(t) = [q(t) x ( -f(t)) x crs + q(t) x f(t) x ( -cras)], where p(t) represents the proportion of the late anti-hbs(+)** group and crs/cras denote natural conversion of hbsag/anti-hbs. to test the model, cross-sectional serologic marker data in korea were used. because f(t), crs, and cras were known(f(n)= . , f(i)= . , f(c)= . , f(a)= . , crs= . , cras= . ), in order to determine q(t), only p(t) values were needed, which were evaluated from logistic modeling using the glm() function of s-plus. results: the infection frequencies during neonate, infant, children, and adult periods in non-vaccinees were . %, . %, . %, and . %, respectively. each group's likelihood of infection compared to adults was then: neonates . times more likely, infants . times, and children . times, making a strong case for neonatal and infantile vaccination for the studied region. conclusions: the hbv infection model can be used for determining the most cost-effective strategy for hb vaccination in nations where longitudinal data are not available. and where longitudinal data are available, it can be used to determine the appropriate time of transition of vaccination strategy to maintain cost-effectiveness. the effect of telbivudine on peripheral blood regulatory t cells and its significance in patients with chronic hepatitis b x.c. pan , f. yang , m. chen objective: to investigate the effect of telbivudine on peripheral blood regulatory t cells and its significance in patients with chronic hepatitis b. methods: patients with hbeag positive chronic hepatitis b were recruited and receiving telbivudine treatment for months. before and during months of treatment , flow cytometry was used to detect the proportion of peripheral blood tregs; real-time pcr was used to detect the levels of hbv dna in surum, markers of hepatitis b virus infection were detected by elisa assay and levels of alanine aminotransferase in serum were measured. results: the proportion of peripheral blood tregs in patients with chb was significantly higher than that in healthy controls and decreased over or months of treatment to a level comparable to that of healthy controls. after months of treatment, the rate of alt normalization in patients which the proportion of peripheral blood tregs was unreduced was significantly lower than that in patients which the proportion of peripheral blood tregs was reduced (p< . ). , or months of telbivudine treatment resulted in negative hbeag in ( %) patients, ( %) patients or ( %) patients respectively. within months of treatment, ( %) patients seroconverted from hbeag to anti-hbe , in which the proportion of peripheral blood tregs had decreased to a level comparable to that of healthy controls over or months of treatment. conclusion: during antiviral treatment with subsequent reduction of the viral load or alt levels, the proportion of tregs decreased to a level similar to that of normal healthy controls. in addition, seroconversion from hbeag to anti-hbe was prone to be established in patients which the proportion of tregs decreased quickly at the early phase of antiviral treatment with telbivudine. background: in china a part of patients with alt < . ×uln and hbv dna > copies/ml will advance into hepatic cirrhosis even hepatoma. so these patients should not only be monitored but also be treated. this study was made to determine the safety and efficacy of combining therapy of pegylated interferon alpha a (peg-ifn - a) and entecavir in treating naive patients with alt < . ×uln and hbv dna> copies/ml. methods: nine patients with hbsag positive over months and alt< . ×uln hbv dna > copies/ml were taken as research subjects. before treatment,liver biopsy was used to assess histological damage. patients were treated with peg-ifn - a g /week for weeks, and in the first weeks entecavir . mg/day was applied, then it was stopped. results: liver biopsy showed that patients had mild inflammation. after weeks' treatment , hbv dna level in all patients decreased to less than copies/ml, and after weeks' treatment( weeks after entecavir was stopped)hbv dna in all patients was less than copies/ml. normal alt was seen in all patients after weeks' treatment and weeks' treatment. none of the patients had peripheral neuropathy with combining treatment. conclusions: . bulk of patients with alt < . ×uln and hbv dna> copies/ml had mild inflammation and need treatment. combing treatment of peg-ifn and entecavir was safe and effective to this group. it proved that it was safe for patients to stop treatment with entecavir after short time use. background & aims: quantification of serum hbv dna levels is important to monitor viral replication in chronic hepatitis b (chb) patients. both abbott realtime hbv and roche cobas amplicor hbv monitor are updated fully automatic commercial assays for hbv dna quantification. the aim of this study is to compare the performance of these two assays on the hbv dna quantification in chb patients. methods: serial serum samples from chb patients were collected at the baseline and at days , , and and weeks , , and after the commencement of therapy. genotype was determined by sequence alignment. abbott and roche assays were employed for hbv dna extraction and quantification according to the instructions of manufactories. results: hbv dna quantification results of abbott assay was significantly correlated with those of roche assay (r= . , p< . ). for genotype c, the difference in hbv dna levels [median (range): . (- . - . ) log units] measured by these two assays was significantly higher than that for genotype b [ . (- . - . ) log units, p< . ]. moreover, the difference in serum hbv dna levels after weeks antiviral treatment [ . (- . - . ) log units] measured by these two assays was significantly higher than that in baseline serum hbv dna levels [ . (- . - . ) log units, p< . ]. conclusion: the quantification results of abbott realtime hbv showed a good correlation with those of roche cobas amplicor hbv. but the performances of these two assays have significant difference in the quantifications of serum hbv dna levels in genotype c patients and in patients after weeks antiviral therapy. background: guidelines suggest hepatitis b virus (hbv) vaccination to all hepatitis c virus (hcv) infected patients and healthcare workers. we attempted to find out hbv vaccination status in our hcv infected population, and healthcare workers. methods: prospective survey of consecutive hcv infected patients and also doctors and paramedical staff in our hospital. results: major sources of viral infection in study patients ( males; average age years -range to yrs) were reused syringes ( pts). twenty had a household member infected with hcv. twenty were co-infected with hbv. eighty five of hcv infected patients were not vaccinated.against hbv. twenty five of them ( %) had financial reasons and patietns ( %) had lack of awareness. out of doctors, and did not know about their hbv and hcv status respectively, but none was known to have either of these infections. four ( %) were not vaccinated against hbv. out of paramedical staff, was hcv positive, each were unaware of their hbv and hcv status, and remaining were negative for these markers. thirteen of them ( %) were not vaccinated against hbv. conclusion: thirty eight percent hcv infected patients were infected by reuse of syringes. eighty five percent were not vaccinated against hbv, out of which % had no awareness about it, whereas % could not financially afford it. a significant number of paramedical staff and some doctors were also not vaccinated background: early prediction of efficacy could decrease unnecessary interferon exposure of patients with chronic hepatitis b. methods: a multi-center clinical study. patients were injected interferon alpha b million iu subcutaneously every other day for weeks and -week follow-up was followed. results: patients ( male) were enrolled, . ± . years old. hours after administration, hepatitis b virus (hbv) load decreased significantly ( . ± . log copies/ml, p< . ) from baseline ( . ± . log copies/ml). hbv load was . ± . and . ± . log copies/ml at week and , respectively. at the two points upwards, complete response rate was . %( / ) and . %( / ), partial response rate was . %( / ) and . %( / ), respectively. at week and , hbv dna levels of complete responder and partial responder were lower than those of non-responder (p< . ) at week . at baseline, on hour , day , , week , and , hbv dna levels of complete responder were lower than those of non-responder at week (p< . ). multiple linear regression showed that baseline hbv dna was the independent variables to predict the response at week and . conclusions: interferon alpha b was effective in treating patients with hbeag positive chronic hepatitis b. it could decrease the hbv dna level rapidly. early hbv dna levels were predictive to response at the end of treatment and follow-up. baseline hbv dna level was the independent predictor of the response at the end of treatment and follow-up. aim: to investigate features of pd- expression on peripheral tcells and pd-l expression in liver in chronic hepatitis b (chb) patients in immune clearance phase. methods: pd- expression on total peripheral t cells were evaluated by using flow cytometry. immunostaining was performed according to the envision chemmate methods. the degree of pd-l expression was scored and assessed according to the percentage and staining intensity of positive cells. results: compared to health control, the percentage of total peripheral t cells expressed pd- was elevated in chb with repeatedly increasing alt level. no specific association between the percentage of pd- positive and the mean fluorescence intensity mfi of pd- expression on total t cells with serum viral load were found. but alt level was correlated with the mfi of pd- expression on total cd +t cells significantly. pd-l is up-regulated on hepatocytes by viral infection, and high expressed in fibrosis section. conclusion: the mfi of pd- on cd +t cells plays important role in regulating the immune-host interaction in chb in immune clearance phase. and pd- expression on t cells is correlated with high immune inflammatory refection. aim: to study the quantity, characteristic of hbv-specific t-cell and the extent of liver damage in chronic hepatitis b (chb) patients with different hbeag status. methods: chb patients were enrolled and divided into two groups according to the hbeag status, and the liver damage index were analyzed. the frequency and foxp expression of cd + cd + regulatory t cells (treg) were measured, as well as the frequency and phenotypic molecules expression of hbv-pentamer+ t-cell. hbv specific t-cell responses including cellular proliferation and ifn-production, with or without anti-pd-l and/or anti-ctla- blocking, were also observed. results: the demographic characters, serum alt, ast levels, the frequency and foxp expression of cd + cd + treg were similar, while the serum hbv dna levels were higher in hbeag+ patients (p < . ). the liver necroinflammation was comparatively more severe in hbeag-patients (p = . ), but the median percentage of liver cirrhosis was much higher in hbeag+ patients (p < . ). the difference of hbv-specific t-cell frequency was not significant between two groups, while the expression levels of pd- and ctla- on hbv-specific cd t cells were significantly higher in hbeag+ patients (p both < . ). combined using of anti-pd-l and anti-ctla- mab significantly increased the cellular proliferation in either hbeag+ or hbeag-patients, but only markedly enhanced the ifnproduction in hbeag+ patients. conclusion: hbeag persistency could probably induce higher expression of pd- and ctla- on the hbv-specific t cells and result in t-cell impairment, high hbv dna load and high percentage of liver cirrhosis in hbeag+ chb patients. hepatocyte apoptosis in patients with chronic hepatitis b y. liu , k. wang background: to investigate the relationship between hepatocyte apoptosis and the level of inducible nitric oxide synthase (inos) in hepatic tissue in the patients with chronic hepatitis b chb . methods: we observed cases with chb and normal controls. transferase-mediated-utp-biotin nick-end labling ( tunel) technique was used to detect apoptosis cells and immunohistochemical staining were also performed to investigate the expression of inducible nitric oxide synthase (inos) in biopsy samples .the serum level of alt hbv-dna grading of necroinflammatory activity and staging of fibrosis were also assessed. results: hepatocytes in all chb liver tissues were positively stained by tunel in various degree. in contrast, control tissues did not show dna fragmentation. a significant correlation was seen between apoptosis index (ai) and necroinflammatory grading ((r= . , p= . ) and serum inos level r= . , p= . . it did not correlate with fibrosis stage and serum alanine aminotransferase level. conclusion: the oxidative stress.in patients with chb may reflected the apoptosis of hepatocyte. apoptosis involves in liver injury of chb,but with no significant correlation to serum level of alt. objectives: to investigate the genotype-dependent development of lamivudine resistance in hepatitis b virus (hbv). methods: patients with chronic hepatitis b who had been treated with lamviudine for more than year, and become lamviudine resistance were analysed for the hbv genotypes and cumulative rate of rt region mutant with standard dna sequencing technology. results: among the patients, patients were infected with hbv genotype b (hbv/b)( . %), and with genotype c (hbv/c)( . %). in the hbv/b patients, / ( . %) were of subtype ba, and / ( . %) were of of subtype bj. the cumulative type and ymdd mutation rates in patients with genotype c were showed as l m+m v ( / , . %) > l m+m i ( / , . %) > m i ( / , . %), while in patients with genotype b as l m+m v / ( . %) > m i( / , . %), none of l m+m i. conclusions: our results indicated that in patients with lamivudine resistance, hbv genotype c (hbv/c) were higher than genotype b (hbv/b). in both genotypes the combined mutations ( + sites) were found more than the single site, showed some significance for monitoring lamivudine resistance. background & aims: il- , a novel identified inhibitory cytokine specifically produced by regulatory t cells (tregs), is an ebi -il- heterodimer encoded by epstein-barr-virus-induced gene (ebi ) and interleukin- alpha (il ). the aim of the study is to determine the expression levels of il- in peripheral blood mononuclear cells (pbmcs) of chronic hepatitis b (chb) patients in different phases. methods: a total of treatment naïve chb patients, including in immune-tolerant phase [group , alt: ( - ) u/l, serum hbv dna: . x ( . x - . x ) copies/ml] and in immune-clearance phase [group , alt: ( - ) u/l, serum hbv dna: . x ( . x - . x ) copies/ml] were enrolled in the study. the relative mrna expression levels of ebi , il and foxp were determined by semi-quantitative pcr. results: the significant correlations were observed between the expression of ebi and il (r= . , p< . ), ebi and foxp (r= . , p< . ), il and foxp (r= . , p< . ). the relative expression levels of ebi and il in pbmcs were significantly higher in group when compared with those in group ( . ± . vs . ± . and . ± . vs . ± . , p< . , respectively). furthermore, the relative expression levels of ebi and il in group were significantly correlated with alt levels (r= . , r= . , p< . , respectively), but not with serum hbv dna levels. conclusions: the expression levels of il- in pbmcs were significantly higher in chb patients in immune-clearance phase than that in immune-tolerant phase. increased il- expression levels were associated with liver injury. background: there are a number of oral antivirals approved for chronic hepatitis b. lamivudine, the first oral nucleoside analog, is associated with increased rates of drug resistance with prolonged use--from % at one year to % at three years. therefore, an alternative or add-on treatment is necessary. adefovir, an oral nucleotide analog, is used either in combination with lamuvudine or as monotherapy in lamivudine-resistant chronic hepatitis b. we did a meta-analysis to compare the efficacy of adefovir in combination with lamivudine versus adefovir alone in the treatment of lamivudine-resistant chronic hepatitis b infection. methods: a comprehensive literature search was performed using the following databases: medline, cochrane, and embase. a total of randomized controlled trials were retrieved and analyzed. outcomes measured were virologic response, biochemical response and resistance rates. results: meta-analysis on virologic response showed that combination treatment with adefovir and lamivudine is as effective as adefovir monotherapy (or . , % ci . - . , p= . ). likewise, in terms of biochemical response, both regimens were equally effective (or . , % ci . - . , p= . ). one study showed statistically significant increase in adefovir resistance rate in the monotherapy arm compared to combination arm (p= . ) after the first year of therapy. conclusion: in patients with lamivudine-resistant chronic hepatitis b infection and compensated liver disease, adding adefovir to lamivudine is as effective as switching to adefovir alone in terms of virologic and biochemical response. r. safadi , q. xie , y.g. chen , y.k. yin , l. wei , s.g. hwang south korea, bnai zion medical center, haifa, israel, beijing friendship hospital, beijing, china, novartis pharma ag, basel , switzerland background: ldt produces greater viral suppression than lam. we investigated whether patients receiving lam can benefit from switching to ldt. methods: hbeag positive and negative persistently viraemic patients (median hbv dna . (ldt), . (lam) log copies/ml) and lam treated for - months, were randomized to either switch to ldt or continue lam. we report the benefit of ldt switch assessed by primary treatment failure (tf, < log hbv dna decline) and viral breakthrough (vb, > log above nadir). results: % ( / ) of the ldt switch and % ( / ) continuing lam patients had pre-existing m mutations at screening. tf was % (ldt) versus % (lam, p< . ). in patients with > weeks prior lam treatment, tf was % (ldt) versus % (lam). % ldt tf ( / ) was associated with resistance at screening versus % lam tf. in ldt switch with < weeks prior lam, no ldt tf occurred versus % lam. in hbeag positive, tf occurred in % (ldt) versus % (lam). among hbeag positive with > weeks prior lam treatemtn, vb was % (ldt) versus % (lam, p< . ). differences were not significant for hbeag positive with > weeks lam or for hbeag negative regardless of duration of prior lam treatment. conclusions: early switch to ldt is associated with better virological outcomes in these patients. persistent viraemia for > months on lam treatment is associated with a high risk of tf and vb. for these patients, genotypic analysis is recommended prior to screening. objective: the aim of this study is to evaluate the proper endpoint in the treatment of chronic hepatitis b with antivirals by investigating the viral rebound ratio after one year's nucleosides or (three months) sustained treatment with lamivudine, adefovir, entecavir, or interferon when viral response and seroconversion response have been finished . methods: eag positive chronic hepatitis b naïve patients with alanine aminotransferase (alt) more than uln were assigned to receive mg of lamivudine, mg of adeforvir, or . mg of entecavir once daily, respectively. patients in the interferon group were administrated with , , iu of a interferon on every other day, and the therapeutic duration lasted for another three months after eag-ab seroconversion appeared. hbv dna and eag-ab in the serum were tested during the off-treatment period of months. results: thirty four patients in lamivudine group of cases got eag-ab seroconversion after treatment with ± months of average duration, and the viral rebound ratios in the off -treatment an months follow up period were . / and . / , respectively. in adeforvir group were / and . / . in enticavir group were / and . / . in interferon group was . / in the off-treatment months follow up period. conclusions: we conclude that eag-ab seroconversion in the treatment of eag positive chronic hepatitis b patients is the goal but not an endpoint of therapy physicians should aim at. to gain everlasting effect, longer duration of treatment may be needed. background: universal hepatitis b(hb) vaccination of hbsag negative people (especially infants) is widely recommended and practised. objective: to assess whether there is robust evidence of protective efficacy to back such practice. methods: this cochrane review included randomised trials identified from six databases through detailed electronic searches. trials comparing hb vaccine versus placebo/another vaccine, in hbsag negative persons were included without any restrictions. the primary outcome was hb infection (developing hbsag or anti-hbc). robustness of evidence was assessed through comparison of available-case analysis versus intention-to-treat(itt) analysis using four different models: (i)assuming unfavourable event for all missing data, (ii)assuming favourable outcome for all missing data, (iii)best-case-scenario and (iv)worst-case-scenario results: twelve trials were eligible among citations; all were methodologically poor (high risk of bias). data from four trials could be included in meta-analysis. efficacy of vaccination varied with the type of data analysis. available-case analysis suggested efficacy in reducing risk of developing hbsag (rr= . ; %ci= . - . ;n= ) and anti-hbc (rr= . ; %ci= . - . ;n= ). itt analysis results varied depending on the model chosen (table) , but liberal approaches suggested high efficacy, whereas conservative approaches did not. the available evidence on efficacy of hb vaccination in hbsag negative people is not robust; there are serious limitations in quality and quantity. background: open-label rollover study (etv- ) assessed histologic improvement in chb patients on at least years etv therapy. methods: % nucleoside-naïve patients and % lamivudine (lvd)-refractory patients from etv- and etv- studies, respectively, entered etv- study and received etv at . / mg for greater than weeks. improvement in knodell necroinflammatory (ni) score and knodell fibrosis score at weeks and were studied. results: at week , % of nucleoside-na ve patients and % of lvd-refractory patients achieved hbv dna < copies/ml. furthermore, % of nucleoside-na ve patients and % of lvd-refractory patients had normalized alt levels. mean platelet counts in both naïve and lvd-refractory patients were improved at weeks and compared with baseline. conclusions: naïve and lvd-refractory chb patients showed significant improvement in liver histology after year etv therapy, and improved dna and serum alt levels. results: . percent of patients were younger than years old, . percent were older than in this study. . % patients' mothers were hbsag positive. high levels of serum hbv dna were founded in all patients, > copies/ml were . %. only cases ( . %) whose liver inflammation grade were g , the rest patients were mild inflammation, in which g were cases ( . %), g were ( . %); there were patients ( . %) had no signifecant liver fibrosis, the rest cases ( . %) had different fibrosis, among those s were cases ( . % , s were . % , s were . % , none of patients had cirrhosis. the fibrosis stages of higher alt level were markedly severer than lower alt in patients with normal alt p < . . conclusions: most of patients with chronic hepatitis b virus in immune tolerant phase present mild inflammation in liver, part of them have already appeared fibrosis, so some patients determinated by clinics are actually not in immune tolerant phase. although alt testing are in the normal range, but the possibility of liver fibrosis is increased in patients with relative higher alt level, so liver pathology should be recommended to judge illness correctly. background/aims: hepatitis b virus infection (hbv) is a global health problem. in bangladesh, - % of people are hbsag positive. this study was carried out to evaluate the efficacy and safety of peginterferon alfa- a in chronic hepatitis b patients. methods: a total of patients with chronic hepatitis b, ( . %) were hbeag positive (group a) while ( . %) were hbeag negative (group b) were included in this study after meeting the following criteria: age to years, hbsag positive for more than months, serum hbv-dna was > log( ) copies/ml and alt more than two times the upper normal limit. they were given peginterferon alfa- a ( microgram once weekly) for weeks and followed for an additional weeks. results: after weeks of follow-up, the percentage of patients with normalization of alanine aminotransferase levels or hbvdna levels below , copies per milliliter was significantly higher in hbeag positive patients ( percent and percent, respectively) than among hbeag negative patients ( percent and percent). loss of hepatitis b surface antigen occurred in patients in group a, as compared with patients in the group b (p< . ). adverse events including pyrexia, fatigue, myalgia, headache and haematologic abnormalities were similar in both groups. conclusions: patients with hbeag positive chronic hepatitis b had significantly higher rates of response, sustained for weeks after the cessation of therapy, with peginterferon alfa- a. background: the effect of hepatitis b vaccination on individuals with isolated anti-hbc in endemic areas is not clear. we investigated the prevalence of individuals positive for anti-hbc only and their antibody response after hepatitis b vaccination in a single healthcare center. methods: the study included , healthcare workers. after screening for hbsag and anti-hbs, the individuals negative for both hbsag and anti-hbs were examined for anti-hbc and were vaccinated with a recombinant hepatitis b vaccine at , , and months. the serum anti-hbs level was measured after the vaccination. results: of the subjects, ( females) were negative for both hbsag and anti-hbs. forty ( . %) subjects had isolated anti-hbc, including more males ( . % vs. . %) and older people ( . ± . vs. . ± . years), compared with individuals negative for all of the viral markers. the anti-hbs seroconversion rate and anamnestic response in the individuals with isolated anti-hbc after the first vaccine injection were % and . %, respectively. in the persons who were negative for all hepatitis b viral markers, the seroconversion rate after the first vaccination was . %. the anti-hbs seroconversion rate did not differ between the isolated anti-hbc positive individuals and those negative for all hepatitis b markers ( . % vs. . %) after the full course of vaccination. conclusions: serum hbsag and anti-hbs tests are sufficient for screening before hepatitis b vaccination, especially in healthcare workers. objective: to understand the quantity and distribution of cd + mature dendritic cells in patients with hepatitis b virus in immune tolerant phase. methods: there were immune tolerant phase patients with hepatitis b virus infection (fibrosis stages were s ), immune clerance phase patients, non-active status patients and healthy controls involved in our research. the quantity and distribution of cd + mature dendritic cells in liver were determined by immunohistochemical staining. result: the liver inflammation grades were between g -g in patients who in inmmune tolerant phase and non-active status, moreover, patients in immune clerance phase were between g -g . there were a small amount of cd + dendritic cells in healthy liver tissue, scattered in portal areas and hepatic lobules. the quantity and distribution of cd + dendritic cells in patients who in inmmune tolerant phase and non-active status were similar to the healthy, and the quantity were no difference among them p . .the number of cd + cells in patients of immune clerance phase was significant increased compared with other groups, there were differences among them p . , the cd + cells mainly distributed in portal areas infiltrated with inflammatory cells and hepatic lobules with inflammatory necrosis. conclusion: cd + mature dendritic cells are involved in liver immune response in patients of inmmune clerance phase, is likely to related to hepatitis b virus clearance. lack sufficient mature dendritic cells may be one of the mechanisms of immune tolerance. background: local hospitals provide obstetric services including antenatal care to women normally living in the mainland china, whose prevalence of hepatitis b carrier is unknown. objectives: compare prevalence of hbv carrier of pregnant women from the mainland china with local counterparts and discuss the implications of results. materials and methods: antenatal serological results were retrieved from corporate laboratory information system databases. pregnant women from the mainland china were identified by a specific set of temporary-allocated identity number during january -october . results: pregnant local residents and pregnant women from the mainland china underwent antenatal serological tests for hepatitis b surface antigen. positive hepatitis b surface antigen results were more frequent in pregnant women from the mainland china ( . %) than in local pregnant women ( . %) (p< . ). discussion: because infected pregnant women can transmit the hepatitis b virus to the infant at delivery, specific management could entail maternal medication, injection of hepatitis b immune globulin to the infant at birth and immunization later on. however, early repatriation to the mainland china, which is common, will make completion of immunization program difficult. these babies will be at a higher risk to be infected by hbv, particularly when breast-fed by hbv carriers. their return to hong kong later will dilute the effects of local immunization program. the volume of work derived from the provision of obstetric services to women from the mainland chinese is larger with regard to medication, counseling and immunization for babies born to hbv carriers. immunosuppressive or anticancer therapy k. hirano , t. kodani , s. sato , y. narita , t. kikuchi , t. genda , k. iijima , k. ogawa , t. ichida background/aim: we compared the prevention of hbv reactivation in (hbsag)-positive patients with hbsag-negative patients who were positive for antibody to (anti-hbc) and/or (anti-hbs) undergoing immunosuppressive, anticancer or molecular target therapy. methods: from sep to nov hbsag-positive patients and anti-hbc and/or anti-hbs-positive patients were enrolled in this study. we compared with groups about background disease, age, blood examination, and nucleoside analogues. results: in hbsag-positive patients mean age were . ± . years old, median ast levels were ( - ) iu/l, and median alt levels were ( - ) iu/l for ( %) haematological disease and ( %) collagenosis disease. in anti-hbc and/or anti-hbs-positive patients mean age were . ± . years old, median ast levels were ( - ) iu/l, median alt levels were . ( - ) iu/l for ( %) haematological disease and ( %) collagenosis disease. serum hbv-dna levels > . log copies/ml were ( %), . ~ . were ( %), < . were ( %) in hbsag-positive patients, and serum hbv-dna levels < . were all cases in anti-hbc and/or anti-hbs-positive patients. ( %) of hbsag-positive patints received nucleoside analogues ( lam and etv), and ( %) of anti-hbc and/or anti-hbs-positive patients received nucleoside analogues ( lam and etv). mean duration of treatment for . months in hbsag-positive patients, and for . months in anti-hbc and/or anti-hbs-positive patients, the resistance virus occurred to ( %) of hbsag-positive patients treated with lam for collagenosis disease more than two years. conclusion: when hb carriers of collagenaous disease undergoing immunosuppressive therapy required the nucleoside analogues more than two years, we recommended treatment to prevent hbv reactivation with etv. background: adefovir dipivoxil is used for the initial treatment of chronic hepatitis b or rescue treatment of lamivudine-resistant chronic hepatitis b, and exhibits excellent antiviral activity. however, the presence of resistance to adefovir dipivoxil was more frequently in lamivudine-resistant chronic hepatitis b patients than in lamivudine-naïve patients during adefovir dipivoxil monotherapy. but the rate of adefovir resistance related mutations is little known in lamivudine-resistant patients before adefovir dipivoxil treatment. the aim of this study was to investigate the rate of adefovir resistance-related mutations in polymerase gene of hepatitis b virus in lamivudine-resistant patients not treated with adefovir dipivoxil. methods: the existence of adefovir resistance-related mutations was examined in lamivudine-resistant chronic hepatitis b patients with breakthrough hepatitis and antiviral-naïve chronic hepatitis b patients. both polymerase chain reaction restriction fragment length polymorphism (pcr-rflp) and directly sequencing of pcr product were used to detect resistant viruses. results: rta t mutants were detected in only two sera of lamivudine-resistant patients, while none in the antiviral-naïve chronic hepatitis b patients. there was no rtn t detected in the two groups. conclusion: our results suggest that the rta mutant virus were present in a few lamivudine-resistant chronic hepatitis b patients before they have been treated with adefovir dipivoxil, but the rtn t mutant was not detected in any of the two groups. the rate of adefovir resistance-related mutations in polymerase gene of hepatitis b virus was low in such lamivudine-resistant patients before adefovir dipivoxil treatment. objective: in this study, we tried to detect and identify the special protein of hbv related chronic hepatitis, liver cirrhosis and hepatocellular carcinoma. to find new opinion on the developing of chronic liver disease. methods: the sera of health adult, hbv related chronic hepatitis, liver cirrhosis and hepatocellular carcinoma were respectively detected by surface enhanced laser desorption/ionization time-of-flight mass spectrometry (seldi-tof-ms). the arrays of every group were analysised by clustering analysis and to establish disease predictive model. then the sample was eluted with different ph tris, trypsinization on-chip, mass determination and peptide database comparison. results: according cm chip we find protein with obviously deviation (p< . ) among hbv related chronic hepatitis, liver cirrhosis and hepatocellular carcinoma. clustering analysis for the data from seldi-tof-ms confirmed differentially expressed proteins. then we developed disease predictive mathematic models ( decision tree model, dt model ) with average validity up to . . the da protein peak was identified to be chondroitin sulfate synthase (chss ), which is a potential molecule involved in the pathologic process and a potential serum marker for the hbv related hepatic diseases as well. conclusions: our results suggest that seldi-tof-ms is a usefull technique for differential expressed proteins screening and analysis in hbv related chronic liver disease. chss may be useful during the developing of hbv related chronic liver disease. backgound: clevudine is a new nucleoside analogue with potent antiviral activity in chronic hepatitis b patients. however, the efficacy and safety of clevudine in cirrhotic patients are not well recognized. this study was conducted to evaluate the early virologic and biochemical response rate as well as safety of clevudine in cirrhotic patients with chronic hbv infection. methods: patients with chronic hbv infection who visited korea university ansan hospital and guro hospital between may and may were included. patients had chronic hepatitis b (group a) and had liver cirrhosis (group b). early virologic response was defined as hbv dna less than iu/ml at week . early biochemical response was defined to be normalization of alt (< iu/l) at week . result: pretreatment hbv dna levels were higher in group a compared with group b ( . log iu/ml vs . log iu/ml, p= . ). pretreatment alt levels were not significantly different between the two groups ( iu/l vs iu/l, p= . ). the rate of early virologic response was significantly higher in group b compared with groups a ( . % vs %, p= . ). the rate of early biochemical response were not significantly different in both groups ( % vs . %, p= . ). conclusion: clevudine is considered to be safe and effective in cirrhotic patients with chronic hbv infection as well as chronic hepatitis b patients. long term safety and efficacy need to be evaluated in the future. objective: the aim of this study was to evaluate the role of nucleos(t)ide analogues against hbv reactivation in immunosuppression. methods: non-active hbsag carriers suffering from cancer, autoimmune diseases and needing the treatment of immunosuppressants or cytotoxic chemotherapy were enrolled in the study. the outpatients or in-patients from april to july were enrolled. the nucleos(t)ide analogues were used in cancer patients - weeks before chemotherapy, and the duration lasted - months according to patients' compliance after completion of chemotherapy. patients with other diseases used nucleos(t)ide analogues in - months before using glucocorticoids or other immunosuppressive agents, and continued to use for - months after accomplishing the course of immunosuppressant treatment. the characheristics and clinical manifestations about hbv reactivation were investigated. results: of the thirty two patients in prospective group, twenty two patients suffered from cancer, eight patients suffered from idiopathic thrombocytopenic purpura, two patients suffered from chronic nephritis. the amount of hbv dna was detected in the first, third, sixth and th month after the use of nucleos(t)ide analogues. after chemotherapy or immunosuppressant treatment, only . % ( / ) of them suffered from hbv reactivation, which presented with hbv dna positive and abnormal liver function. conclusion: non-active hbsag carriers would appear potential incidence of hbv reactivation during use of chemotherapy or immunosuppressant. nucleos(t)ide analogues could be used in early phase as prophylaxis for reactivation of hepatitis b in immunosuppression and to improve clinical prognosis. background: hbv therapies are evolving toward combination antivirals. this study evaluated the combination of clevudine (clv), a potent nucleoside analog, with tenofovir dipivoxil (tdf). methods: a phase i, single-arm, multi-dose study in healthy adult volunteers to evaluate pharmacokinetic and safety interactions between clv and tdf. subjects received days of clv mg followed by days of clv mg +tdf mg. pk profiles were obtained on days , and . clv auc and cmax were compared on days and . day tenofovir pk was compared to historical data. safety assessments were conducted throughout. results: subjects were enrolled ( m/ f); completed the study. the mean (range) age was y ( - ) and body mass index (kg/m ) was . ( . - . ). aes were reported by subjects, with aes reported during clv-only dosing and aes reported during clv+tdf dosing. aes included nausea ( ) and pharyngolaryngeal pain ( ). the majority of the aes were mild. there were no clinically significant changes in ecgs or laboratory parameters. comparisons of clv auc and cmax on day and revealed no significant impact of tdf upon the plasma clv exposure (d /d auc ratio= . , d /d cmax ratio= . ). there is no significant effect of clv on tenofovir when comparing auc and cmax of tdf to historical values. conclusion: safety and pharmacokinetic results demonstrate that clv and tdf may be safely co-administered, supporting the further study of this drug combination for the treatment of chronic hbv infection. s. kuznecovs , , i. kuznecovs , k. jegina , g. kuznecova background: dolichyl (dol), the main lipid intermediator of dolichyl phosphate cycle (dpc) has been reported to be elevated in urine of patients with multidrug resistance in cancer. drug resistance poses a major threat to nucleoside analogue-based therapies for chronic hbv infection. methods: with focus on a risk predictor for susceptibility to the development of hbv drug resistance the present study was carried out to estimate urinary levels of dol in chronic hbv infection. the samples obtained every week before and during the course of treatment from patients with hbv. the occurrence of exacerbations of chronic hbv were registered for years. dol in urine was assayed by hplc method. results: the normal amounts of dol in healthy persons urine (n= ) are , + , mkg/mmol creatine. during the period of observation ( %) of patients treated with nucleoside analogue-based therapies were diagnosed with exacerbations due to resistance of hepatitis b virus to antiviral drugs. from this group of hbv patients ( %) have had elevated urinal dol excreation ( , ± , g/ml vs . , ± , g/ml, p< . ) in more than months of observation. conclusion: there is a reason to suggest that elevated urinal dol detected in patients with exacerbations during hbv treatment may evidence of possible defect of host mechanism of drug resistance development to nucleoside analogue-based therapies. the interest drawn to the employment of dol as a predictor for exacerbation of chronic hbv is explained by the role of dpc in p-glycoprotein regulation in human hepatocytes. background: a significant proportion chb patients treated with adv have a suboptimal response, increasing the risk of disease progression and development of resistance. we report clinical results from patients who either failed or relapsed following adv therapy and were subsequently switched to etv. methods: study etv- was a randomized, open-label study comparing antiviral efficacy of etv ( . mg/day) vs adv ( mg/day) in nucleoside-naïve hbeag-positive patients. after up to weeks of treatment in etv- , patients treated with adv ( suboptimal responders) rolled over into study etv- ( . mg/day). hbv dna viral suppression and safety was evaluated during weeks of etv treatment. results: at entry to etv- , the median hbv dna was . log copies/ml. median exposure to etv ( . mg) in etv- was weeks and patients currently remain on study therapy. at week , the mean reduction in hbv dna was . log copies/ml and / ( %) reached hbv dna levels < copies/ml. nine patients have achieved week and all have achieved hbv dna < copies/ml and / ( %) had hbv dna levels < copies/ml. no patients experienced virologic breakthrough on etv. the safety profile of etv in adv-treated patients remained consistent with the previously reported experience. conclusions: the majority of patients who were suboptimal responders or virologic rebounders following adv treatment in study etv- , experienced rapid reductions in hbv dna levels when switched to etv. hbv dna levels continued to decline to undetectable levels with weeks of etv treatment. y. li , , t. han tianjin third central hospital, aim:to quantify hepatitis b virus (hbv) total dna and covalently closed circular dna (cccdna) in liver biopsies and sera which from chronic hepatitis b(chb) liver cirrhosis of hepatitis b(lc) and hepatitis b relevance hepatocellular carcinoma(hcc) patients, and analysis hbv replication under the circumstances of different diseases. methods:total hbv dna and cccdna in serum and liver biopsy samples were measured in chb lc and hcc patients by the real-time pcr assay. results: the levels of total hbv dna in serum,intrahepatic total hbv dna, intrahepatic cccdna, as well as the proportion of intrahepatic cccdna in total hbv dna decreased progressively in chb,lc and hcc ,moreover chb had significantly higher levels of total hbv dna in serum and liver biopsy samples than lc (log [total serum hbv dna] p = . ;log [total intrahepatic hbv dna] p = . ); chb and lc had significantly higher levels of intrahepatic cccdna and the proportion of intrahepatic cccdna in total hbv dna than hcc(p < . ); cccdna couldn't be detect in all patients'serum. in chb ,the levels of serum's total hbv dna,intrahepatic total hbv dna and cccdna in hbeag-positive group had significantly higher than the hbeag-negative group(p < . ) ,but in lc only intrahepatic total hbv dna had statistical difference between hbeag-positive and negative group (p= . ) , no statistical difference between hbeag-positive and negative group in hcc. conclusions: the replication activity of hepatitis b virus in chb,lc were higher than hcc, hbv reproduction reduced significantly in hcc. duplication of hbv in lc was lower than chb but had no statistical difference. the levels of hbv reproduce in hbeag-positive group was higher than hbeag-negative group of all three desease. background: clevudine is a pyrimidine analogue with potent and sustained antiviral activity against hbv in the week therapy. the present study assessed the efficacy and viral resistance of week clevudine therapy in patients with chronic hepatitis b. method: a total of patients ( hbeag positive and hbeag negative) who were received clevudine mg once daily for weeks were included in this analysis. serum hbv dna was quantified by real time pcr assay. result: at week , median reductions of serum hbv dna from baseline were . log iu/ml ( . log iu/ml for hbeag positive and . log iu/ml for hbeag negative) and . % of patients showed undetectable serum hbv dna (< iu/ml) ( . % for hbeag positive and . % for hbeag negative). the normalization of alt levels (< iu/l) was achieved in . % ( . % for hbeag positive and . % for hbeag negative). . % of hbeag positive patients showed hbeag loss or seroconversion. hbv dna negativity at week was associated with hbeag negativity (p = . ), hbv dna < , iu/ml at weeks and (p = . and . , respectively). two hbeag positive patients showed viral breakthrough with m i mutation during week. conclusion: clevudine therapy in patients with chronic hepatitis b showed potent virologic responses at week , especially in those with hbeag negativity and complete early virologic response (hbv dna < , iu/ml at weeks and ). but clevudine resistance can occur in hbeag positive patients. background: serum alanine aminotransferase (alt) activity, the variable most commonly measured to assess hepatic disease, fails to identify many patients with hepatic injury. current standards for "normal" alt level were defined by using populations that included persons with subclinical liver disease. there is no study regarding normal level of alt and its modulating factors in healthy thai people. objective: to definitions of normal ranges for serum alt level in thai people. design: prospective observational study setting: phramongkutklao hospital and army institute of pathology pramongkutklao medical center(a.i.p.), bangkok, thailand participants: persons who were first-time blood donors from august through december were negative for anti-hepatitis c virus(hcv), negative hbsag(hbv), and had no contraindications to donation. measurements: univariate and multivariate analyses examined associations between clinical and laboratory factors and alt levels. normal ranges for alt were computed from the population at lowest risk for liver disease. results: serum alt activity was independently related to body mass index, age, alcoholic consumption and to laboratory indicators of abnormal lipid or carbohydrate metabolism. normal ranges for serum alt level in thai people upper limits for men u/l and for women . u/l. conclusion: in men serum alt is strongly associated with body mass index, age, alcoholic consumption and to laboratory indicators of abnormal lipid or carbohydrate metabolism. the normal range of alt should be defined for male and female separately. background: the open-label rollover study etv- was conducted after etv phase ii clinical study etv- for nucleoside-na ve adult chb patients in japan. in this analysis, we report etv long-term efficacy and safety in patients who were switched from -week lvd treatment to etv therapy. methods: ninety-seven percent ( / ) of lvd-treated patients from etv- were rolled over into etv- treated with . mg of etv. thirty patients completed weeks of etv therapy and were evaluated for hbv dna level, alt normalization, hbeag seroconversion, resistance and safety. results: comparing to baseline before switching to etv, after week of etv treatment, the proportion of patients achieving undetectable hbv dna (< copies/ml) increased from % to %. increases were also observed for alt normalization ( % to %) and hbeag seroconversion ( % to %). three patients had detectable hbv dna at week after etv treatment and samples from two were tested for resistance. neither demonstrated substitutions associated with etv or lvd resistance. five patients had grade - laboratory abnormalities, including increased ast/alt and increased lipase levels. conclusions: switching patients from lvd therapy to etv resulted in increased proportions of patients achieving hbv dna suppression, alt normalization and hbeag seroconversion, with no evidence of etv resistance. etv was well tolerated during treatment. backgrounds/aims: hepatitis b virus (hbv) reactivation in patients undergoing chemotherapy hampers an adequate administration of cytotoxic agents and even causes an treatment failure. prophylaxis failure occasionally results from viral breakthrough or withdrawal flare. the aims of this study were to identify predictors of anti-viral prophylaxis failure and to determine the optimal strategy for anti-viral prophylaxis. methods: cancer patients with positive hbsag who underwent cytotoxic chemotherapy in a tertiary medical center from january to june were included. prophylactic lamivudine was started with initiation of chemotherapy, continued during the chemotherapy, and discontinued within months after the completion of chemotherapy. all patients were followed up even after withdrawal of lamivudine. results: patients were enrolled. twenty-nine patients ( . %) had hematologic malignancies and eighty-six ( . %) had solid tumors. median follow-up duration was . months and twenty-six patients ( . %) experienced the prophylaxis failure: viral breakthrough ( patients, . %), withdrawal flare ( patients, . %). ymdd mutation developed in four patients. withdrawal flare occurred at a median . months after discontinuation of lamivudine. using log-rank test and cox multi-variate analysis, our results showed that the type of underlying malignancies (hr . , % ci, . - . ; p= . ) and baseline hbv dna titer (hr . , % ci, . - . ; p= . ) were significant independent risk factors for antiviral prophylaxis failure. conclusion: cancer patients with high viral load of hbv and hematologic malignancies may need more prolonged and potent anti-viral prophylaxis to avoid interruption or delay of chemotherapy. back ground: the usefulness of hepatitis b virus (hbv) dna and hbv core-related antigen (hbcrag) was evaluated for timing hepatitis flare after viral breakthrough or withdrawal of antiviral treatment in chronic hepatitis b. method: a total of events of hbv reactivation due to withdrawal of lamivudine (lam) or emergence of mutants resistant to lam or adefovir dipivoxil (adv) virus were analyzed in patients with chronic hepatitis b ( men, median age years [range: - ]). they were followed monthly for serum alt, hbv dna and hbcrag before, during and after the treatment. result: high alt flare (alt > iu/ml) after viral breakthrough or withdrawal was related with baseline hbeag positivity (p= . ), hbcrag level at hbv dna elevation (p= . ) and duration from hbcrag elevation to salvage therapy (p= . ). in multivariate analysis, hbcrag > . log u/ml (or . , %c.i. . - . , p= . ) and salvage therapy after weeks from hbcrag elevation (or . , %c.i. . - . , p= . ) were selected as related factor with high alt flare. after appearance of resistant-virus or withdrawal of lam or adv therapy, hbv dna re-elevated without increase of hbcrag, then hbcrag elevated with hbv dna. re-elevations of alt occurred in of the ( %) events. in of the ( %) events, alt re-elevated within weeks from the start of hbcrag increase. conclusion: hbcrag was useful for timing the re-elevation of alt after hbv dna re-elevation induced by drug-resistant virus or withdrawal of lam or adv therapy. background and objectives: the aim of the study was to observe the efficacy of a patient's therapy for switching lamivudine + placebo to adefovir dipivoxil (adv), and modeling the viral dynamics. methods: the studied object was a chinese chb patient with lamivudine mutation. used the lvd + placebo for weeks' therapy. then switched adv for another weeks. after that stopping the treatment and following up for weeks. based on our modified basic virus infection model, we introduce a personalized model consisting of four variables: x, y, v, e , representing uninfected cells, infected cells, free virus, and ctl cells, respectively. results: selected the model parameters, the simulation data of hbv dnas of our model are good in agreement with the clinical ones. observe that after weeks' treatment cessation, the benefit (hbv dna < copies/ml) for suppressing hbv replication can still be kept. numerical simulation show that if the patient's immune functions can be kept after therapy stops, it needs years to replace all infected cells by normal ones. conclusion: for lvd mutation patients, lvd+ placebo to avd therapy scheme may help patients to suppressing hbv replication. further researches are promising. acknowledgments: this work is jointly supported by the nnsf of china background: g-a- pre-core mutants (p-c-mt) cause hbeag-negative chronic hepatitis (chb) in genotype d infected mediterranean adults. we studied their emergence during chronic hbv infection in children. methods: eighty consecutive hbsag carriers ( / males/females, age y, range . - y) with vertical ( %) or intra-familial ( %) transmissions were followed-up for . y (range - y). hbv genotype and hbeag status were determined at the admission, hbeag/anti-hbe every years thereafter. during the follow-up, hbv-dna was measured in sera ( - sera/patient) (cobas-amplicor, roche); p-c populations were characterized by direct sequencing (ds), by oligo-hybridization (oha) and allele-specific-pcr (as-pcr) with %, % and . % sensitivities, respectively. results: seven children were genotype a and d; ( . %) were hbeag-positive. fifty-five ( . %) underwent hbeag/anti-hbe seroconversion (median age y, range . - y). baseline hbv-dna (cp/ml) was lower in seroconverters ( . + . vs , + , , anova p= . ). ds/oha p-c-mt were . % at the admission and . % after follow-up; as-pcr p-c-mt . % and % respectively. after seroconversion ( . %) became inactive carriers, ( . %) lost hbsag ( genotype d/p-c-wt); p-c-mt had chb. hbv-dna (cp/ml) was lower in p-c-wt than in p-c-mt inactive carriers ( . + . vs . + . ; anova p= . ). conclusions: in genotype-d infected children p-c-mt is selected progressively after hbeag/anti-hbe seroconversion to become predominant in hbeag-negative chb. early and efficacious immune control of hbv replication avoids p-c-mt selection and leads to hbsag loss. , a, , d, k, u, m, n , k ,k and k . here k , k , and k are the rate of ctl production and dead, killing virus, respectively. results: the patients with hbv dna levels less than copies/ml were reported in . % ( / ). a patient whose hbv dna levels were higher than copies/ml can keep treatment benefits even stopping the therapy for over ten weeks. the simulation data of our model are in agreement with the patient's hbv dna data. our simulation also shows that it needs to spend about years for clearing all infected cells. conclusion: the simulation result implies that some chinese patients may need long term's therapy to clear all infected cells. patients' ctls assays are needed to confirm the effectiveness of the personalized modeling, and help doctors to decide whether stop the drug treatment even patients' hbv dnas are higher than undetectable levels. background/aim: recent reports have shown that programmed death (pd- ) expression is associated with t cell exhaustion and persistent viral infection. we studied longitudinally chronic hepatitis b(chb) patients undergoing treatment with nucleos(t)ide analogues or pegylated interferon-(peg-ifn-) in - weeks to determine the relationship between pd- expression levels on t cells and early reduction of viral load induced by treatment. methods: our investigations were focused on three points: baseline (time point , t ), treatment weeks - (time point , t ) and treatment weeks - (time point , t ). pd- expression on total cd and cd t cells in chb patients during antiviral therapy was detected by flow cytometry. serum hepatitis b virus (hbv)-dna load was measured by real time polymerase chain reaction. results: between t and t , pd- expression on total cd (p< . ) and cd t cells (p< . ) dropped concurrently with treatment-induced hbv-dna decline(p< . ). between t and t , however, only the hbv-dna levels reduced significantly (p< . ). conclusion: early suppression of hbv replication induced by antiviral treatment results in a significant decrease in pd- expression on total cd and cd t cells in chb patients. c. zhao , , w. zhang , , x.c. tian , c.y. fang , , h.j. lu , , p.y. yang , , y.m. wen , background/aims: hepatitis b virus (hbv) is still regarded as one of the major causes of chronic hepatitis, cirrhosis and hepatocellular carcinoma worldwide. the interactions between hepatitis b surface antigen (hbsag) and host cells still remain largely unknown and need to be explored in detail. methods: differential protein expression profiles of hepg -s-g ( stably expressing hbsag cell line) and hepg -neo-f ( control cell line) were compared using two dimensional gel based differential proteomic approach. cell proliferation assay and survival assay were used for further studies on the candidate protein. results: compared with the control down regulation of proteins and up regulation of proteins were found in hepg -s-g cell. all these regulated proteins were identified by ms/ms and could be fell into several categories including metabolism-associated, immune-response-related, protein modification, signal transduction and others. among them, a group of proteins in putative pathways associated with apoptosis were found out and discussed, including glucose-regulated protein kd (grp /bip), heterogeneous nuclear ribonucleoprotein (hnrnp), far upstream element-binding protein (fusebp), rho gdp dissociation inhibitor (gdi), cystatin b and some scaffold proteins. grp , an important chaperone protein involved in multiple functions in host cells, was consistently decreased in hepg -s-g and in huh cell transiently transfected with hbsag expression plasmid. decreased crp inducing by hbsag or blockage of rnai consistently led to the less resistance to staurosporine-induced cell death. conclusions: these results revealed a possible pathogenesis induced by hbsag via grp . background/aim: to evaluate the efficacy of adefovir dipivoxil alone and in combination with lamivudine in treating patients with lamivudine-refractory hbeag-positive chronic hepatitis b. methods: eighty-five hbeag-positive patients who had received lamivudine treatment for various periods and had a lamivudine-resistant liver function abnormality, documented ymdd mutations and persistent viremia were randomized to adefovir dipivoxil mg, lamivudine mg, or addition of adefovir dipivoxil to ongoing lamivudine daily. the primary efficacy measure was virological response. the secondary efficacy measure was serological response (hbeag loss rate and hbeag seroconversion rate) and alt normalization rate. results: after weeks of therapy, mean reduction of hbv-dna level, the percentage of patients with hbv-dna lower than log copies/ml and the percentage of patients with hbv-dna level decrease of more than log copies/ml in patients of adefovir dipivoxil/lamivudine and adefovir dipivoxil monotherapy groups were significantly higher than those in patients of lamivudine group ( . , . log copies/ml vs. . log copies/ml, . %, . % vs. . %, . %, . % vs. . %; p < . , respectively). at the end of weeks, mean reduction from baseline in serum hbv-dna level at was . , . , and . log copies/ml in the lamivudine, adefovir dipivoxil/lamivudine, and adefovir dipivoxil groups, respectively. alt normalization rates were significant hihger in adefovir dipivoxil/lamivudine and adefovir dipivoxil recipients than those in lamivudine recipients ( %, % vs. %, p < . , respectively). a similar pattern was observed in hbeag loss among three groups. conclusions: adefovir dipivoxil is an effective treatment option for patients with lamivudine-refractory hbeag-positive chronic hepatitis b. aim: to find the prevalence of hbv virologic flare as defined by hbv dna viral load of > , iu/ml in inactive chronic hepatitis b (hbv dna less than , iu/ml), hbeag-negative patients who have not received any treatment and to identify if there are any predictors that can predict virologic flare. methods: we retrospectively analyzed medical records of the patients who have attended hepatitis clinic, siriraj hospital from january , to february , . the patients were eligible if they were naïve to any treatment and hbv dna less than iu/ml at entry. co-infection with hiv and/or hepatitis c virus were excluded. hbv dna measurement determine by roche amplicor ® (detection limit of iu/ml). hbv virologic flare was defined as hbv dna more than iu/ml during follow up period. result: there were patients with mean follow up time was days with annual prevalence of hbv virologic flare of . , . , and . % for the first, second and third year of follow up, respectively. initial hbv dna level was the only predictor that can predict reactivation. no patients with hbv dna at entry below detection limit developed flare and the patients with hbv dna above iu/ml had times higher chance to develop flare during follow up. conclusion: hbv dna flare is not uncommon in inactive chronic hepatitis b patients. most of the virologic flares occur in the first year. the most important predictor or virologic flare is higher hbv dna at beginning. background: multi-drug resistant hbv developed with multiple antiviral agents. there existed difficulty in dealing with multi-drug resistant hbv. methods: retrospective analysis of consecutive patients who exhibited chronic hepatitis b associated with multiple drug-resistant mutations to lamivudine and adefovir during antiviral treatment. multiple drug-resistant mutations were detected in those patients by dna direct sequencing. result: before multiple drug-resistant hbv emerged, patients accept sequential antiviral therapy, patients accept na monotherapies. there were cases of rta t/v rtm v/i mutation, cases of m v/i +n t mutation, cases of a t/v+m v/i +n t mutation, case of l m+a t/v mutation. cases received rescue therapy of interfronand hbv dna level of cases decreased; other cases received combination treatment and hbv dna level of cases decreased. conclusion: the main reason of multiple drug-resistant mutations was sequential antiviral therapy. another reason may be pre-exist drug-resistant mutation before nucleoside or nucleotide analogue treatment. de novo combination of antiviral agents should be recommended. combination therapy directed against mutants resistant to each treatment may not be adequate in suppressing multi-drug resistant hbv. interfron may be one choice for hbv of multiple drug-resistant mutations. background: to furnish basis for an accurate evaluation of hbeag negative chronic hepatitis b (e chb), the present study studies the clinical features and hepatic pathology, and analyzes the relation between the data and the grade and stage of hepatic pathology in e chb. methods: a study is performed in chinese e chb patients ( men and women; mean age sd, . . years). the relationship between the clinical features and the grade and stage of hepatic pathology was analyzed by spearman's rank correlation test or kruskal-wallis test by applying stata . software. result: negative correlation is shown between the grade and leucocyte count methods: patients with hbeag-positive compensated chb with hbv dna > log copies/ml, serum alt x uln were divided two groups:one treated with telbivudine and the other treated with entecavir. results: baseline characteristics were well balanced between treatment groups. at wk of the treatment the hbv dna undetectable rates of hbeag-poitive patients in the telbivudine group and the entecavir were respectively . (p . ), the rates of hbeag negative were respectively, the rates of hbeag seroconversion were respectively; at wk of the treatment the hbv dna undetectable rates of hbeag-poitive patients in the telbivudine group and the entecavir were respectively (p . ), the total rates of hbeag negative were respectively, the total rates of hbeag seroconversion were . . respectively(p . ).no adverse reactions were found in both groups conclusion: there was no significant difference in hbv dna undetectable rates between two nucleotide analogs in short-term ( weeks).the telbivudine group has better effect in hbeag seroconversion rate than the entecavir group in early stage,but no statistical significance. j.w. song , , z. xin , j.x. tang , l. yao , b. wu sun yat-sen university, zhuhai sinochips biosci. co.,ltd., china background: to develop a equipment free, and can be widely used in clinical practice biosensor-based microarray for hepatitis b virus pre-c/bcp mutation assay. methods: a thin film optical biosensor were applied for amplification the microarray signal in situ. and hbv sites , , , and were selected as the targets and the microarray were be fabricated. the mutated plasmids contained , , , and sites and hbv sera were be tested in our study and all the plasmids and sera pcr products were be assayed by really time pcr and sequencing. results: the biosensor based microarray signal can be easily record by digital camera or even by the naked eyes and the detection signal for positive discriminated from negative were sharply contrasted as whole yes or no and it looks be significantly superior to classical microarray technique; . the sensitivity of the detection limitation of sera hbv load is x e copies/ml with % reproducibility. the concordance index of times negative and mutated plasmids were %(kappa= . ). . sera samples of hbv> e load and sera of hbv negative tested by pcr fragment sequencing were showing very good agreement between sequencing with our biosensor based microarray and the concordance index kappa was . . conclusion: our biosensor-based microarray for pre-c/bcp mutation assay were a both sensitive and accurate method. and its advantages of equipment free, sharply contracted signal of positive vs negative and easily be perform in testing were make it be a promised assay for clinical application. objective: to investigate the frequencies of cd + cd + regulatory t cells in the cord blood of fetuses whose mothers are patients with chronic hepatitis b, we assayed the differences among hbsag-positive and healthy subjects by flow cytometry. the results might offer some experimental evidence to explain the high rates of hbv persistent infection in vertical transmission of hbv from hbv-infected mothers. methods: newborns born from hbsag positive mothers were recruited , healthy subjects being used as a control group. the cord blood and peripheral blood of mothers were collected respectively .frequencies of cd + cd + regulatory t cells in the cord blood of fetuses whose mothers are patients with chronic hepatitis b were analyzed by flow cytometric analysis. result: the number of cd + cd + regulatory t cells/pbmcs in the cord blood of newborns born from hbsag positive mothers . ± . significantly exceeded that in normal controls . ± . ,p . ;and newborns born from hbsag positive mothers presented a much higher fraction of cord blood cd + cd + /cd + . ± . than those in normal controls . ± . ,p p= . p . . conclusions: the results indicate that the proportion of cd + cd + regulatory t cells in hbsag positive mother cord blood was higher than those of healthy cord blood. objective: to study the clinical features of chronic severe hepatitis b with negative hepatitis b e-antigen (hbeag) and positive hepatitis b e-antigen (hbeag) methods: a total of in-patients with chronic severe hepatitis b were recruited into the study and divided into two groups according to the hbeag status. the serological chemistry data, hepatitis b virus (hbv) dna quantification data were detected, and morbility of cirrhosis, its complications and prognosis were also studied. results: of the in-patients, ( . %) patients were hbeag-negative. ( . %) patients were hbeag-positive. the ratio of hbeag-positive patients was significantly higher than that of hbeag-positive patients (p< . ).the average age of hbeag-negative patients was older than that of hbeag-positive patients (p= . ). the serum hbv dna level of hbeag-negative patients was significantly lower than that of hbeag-positive patients ( . ± . ) vs( . ± . ) log copies/ml (p< . ).the ratio of patients who had a serum hbv dna level less than log copies/ml in hbeag-negative patients was significantly higher than that in hbeag-positive patients ( . % vs . % ,p= . ). there was no significant difference in serological chemistry data, morbility of cirrhosis and its complications on infections, ascites, hepatoencephalopathy, gastrointestinal hemorrhage, as well as prognosis of the patients between those two groups. conclusions: the study suggested that serological chemistry data, morbility of complications and prognosis of the disease of hbeag-negative patients mimics that of hbeag-positive patients. the hbeag-negative patients had a higher level of age, while a lower level of serum hbv dna. to reduce the incidence of liver failure, more frequent monitoring and earlier antiviral therapy prone to be reasonable for chronic hepatitis b patients with negative hepatitis b e-antigen. background: the emergence of lam-resistant virus greatly limits the efficacy of therapy and induces the liver injury. the aims of this study were to assess the related factors of lam-resistant mutation in hbeag positive chb patients. methods: thirty-five patients carrying lam-resistant with hbeag positive were enrolled in this study. all of them underwent percutaneous liver biopsy, histological findings and had detectable viral load. age, viral load, levels of alt, types of mutation and hbv genotype was monitored. result: the median year of mutation found was months. . % were genotype c and . % were genotype b. the mutation of l i, l v, g l, l m, m v and m i were detected. the emergence rates were . %( / ), . %( / ), . %( / ), %( / ), . %( / ), . %( / ) respectively. the rate of patients with two or three mutation were much more than one or four mutation. . % patients were found to have significant histological findings, even had established cirrhosis. two had no histological finding. one had rtl i and rtm i. the other had rtl v, rtl m and rtm v. the number of resistant mutation has no significant finding with histological finding, basic alt level and basic viral load. conclusions: the emergence rate of l m, m v and m i were higher than that of l i, l v, g l in hbeag positive chb patients with lam-resistance. most of them have two or three lam-resistant mutation regardless of histological finding severity, level of basic alt and viral load. we must select the efficacious method to treat the patients with lam-resistant. objective: to investigate the therapeutic efficacy of foscarnet sodium in the treatment of patients with severe chronic hepatitis b. methods: forty four patients were randomly divided into foscarnet sodium treatment and placebo groups.each group consisted of patients, patients in foscarnet sodium group were treated with foscarnet sodium twice daily . g given by intravenous infusions ,in addition to general therapy for days.the other cases were treated without any form of antiviral therapy as control.all patients were followed up for months.the hbv markers, quantification of hbv-dna, serological chemistry data were measured at baseline , during therapy period and the end of follow-up period . results: clinical symptoms were improved in two groups patients, meanwhile alanine aminotransferase (alt) and total serum bilirubin (tbil) decreased. compare alt and tbil at the end of trentment, there were no significant differences between the two groups (p> . ). in foscarnet sodium treatment group, the level of serum hbv-dna descreased from ( . ± . ) log copies/ml to( . ± . ) log copies/ml (p< . ), the rate of hbv-dna descrease of more than two log was . % / . in the control group, the level of serum hbv-dna descreased from( . ± . ) log copies/ml to ( . ± . )log copies/ml, the rate of hbv-dna descrease of more than two log was . % / .a comparison of serum hbv-dna showed significant differences between the two groups(p< . ) conclusion: foscarnet sodium administered can inhibit hbv replication in treating severe chronic hepatitis b.it can rapid lower the level of serum hbv-dna obviously.but the relapse rate was . % in foscarnet sodium treated at the end of follow up period objective: evaluation of efficacy and safety of five years trail of entecavir for chronic hepatitis bpatients failed with lamivudine therapy in the chongqing area. methods: thirty-two eligible patients were enrolled who had documented lvd failure.in the double-blind phase,patients were randomized( : )to etv . mg/d (n= )and placebo (n= ) for weeks.in the open-lable phase ,patients received etv . mg/d for weeks.hbv-dna level,liver function tests,hbv serology and safety assessments were conducted. results: the mean reduction in hbv dna levels at week was logl copies ml in etv group compared to . logl copies ml in placebo group(p< ). the mean of hbv dna levels after weeks of etv treatment decreased to . logl copies m the proportion of hbv dna< log copy/ml raised from at baseline to . % at week ,to . % at week ,to % at week ,and raised to . % at week .there were two patients with hbsag seroconversion and four patients with hbeag seroconversion at the end of study. the mean of alt became normal at week and remained normal throughout week .there was one patient who had a severe adverse event during the trail. conclusion: the findings from this study demonstrated the antiviral activity and safety of etv in adults with chb who have failed lvd pe showing delayed response on t cells as increased on day .the mrna expression of il- and il- showed no response to hbv vaccine but highly regulated in tt after day (p= . , . ).myd andtraf (p= . )upregulated in hbv vaccine group followed by of ifn-( . )no change of ifn found in tt conclusions: i) hbv vaccine stimulates innate response by day which potentiates further cascade,peripheral dendritic cells plays significant role in generating immune flare follows myd pathway and releases ifn-.ii) whereas t cells marjory involved in tt showed delayed immune response.iii) identification of key factors at different time points may prove to be a novel model to study the initial events after vaccination. objective: to compare th /th cytokines' dynamic change and its clinical significance in hepatitis b e antigen-positive patients treated with telbivudine. methods: twelve hepatitis b e antigen-positive patients treated with telbivudine.the blood sample was collected at baseline, week , week , week , week and week and stored at - c; serum il- , il- , il- , il- , tnf-and ifn-were tested at each time point by cytometric bead array (cba), compare th /th cytokines' dynamic change at different time point in each group and compare th /th cytokines' dynamic change cross four different groups: complete response, partial response, non-response and break through . results:the level of th type cytokines in complete response group are obviously higher than the group of partial response non-response and breakthrough,but the level of th type cytokines are lower than the group of partial response, non-response and breakthrough. conclusions: th /th cytokines is essential for the regulation of the immune function of the body. after treated with telbivudine, the level of th -type cytokines in the complete response group increased significantly, while the level of th cytokines declined trend. a. soamni , s. somani , a. jain , v. dixit navjeevan hospital, suvidha, background: chronic infection with hepatitis b virus causes spectrum of manifestations ranging from asymptomatic carrier state (often inactive with low replication) to the development of cirrhosis-related complications.the characterization of asymptomatic state has not been done in this part of the country, which forms important objective of present study. methods: incidentally detected asymptomatic hepatitis b surface antigen positive (idahs) subjects having hbsag positivity for > month presenting to our liver clinic were enrolled after appropriate consent. detailed clinical, laboratory and sonographic evaluation was done. they were divided into two groups according to presence or absence of e antigen. group a -hbeag + (n= ) group b -hbeag -(n= ) results: most of our patients ( %) were young adults ( - years) with male to female ratio of . : . approximately half of our patients were detected during routine medical checkup, followed by family screening of contacts. most of our patients were asymptomatic, and fatigue was most common symptom found in %. all demographic and biochemical parameters other than ast & alt were comparable in both groups. among hbeag negative ( %) subjects, hbv dna level > copies/ml was found in %. subjects with positive hbeag as compared to non-replicative infection (antihbe positive and hbv dna negative) had more frequent elevation of transaminase levels ( % versus %, p< . ). antihbe antibody was positive in all hbeag negative subjects. mean age of seroconverted (antihbe positive) individuals was a decade older than hbeag positive. conclusion: from our study we can suggest that ongoing liver disease is present in approximately one-thirds of incidentally detected asymptomatic hepatitis surface antigen positive subjects previously referred to as carrier state. hbsag testing should be mandatory in all routine medical checkup and family and sexual contacts of index case should be screened. background and objectives: this research was carried out to determine the prevalence of hbcab among the hbsag negative first-time blood donors who had referred to khorramabad and borujerd centers for blood donation. materials and methods: this study was established on a descriptive cross-sectional basis in which hbsag test (elisa) was primarily performed on all of the donors having referred to khorramabad and borujerd blood centers; then, out of all those referred subjects, who were first-time and hbsag negative, were selected for furthur investigation. the information concerning age, gender, job, blood transfusion, and hbv vaccine injection was included in the questionnaire of the study. hbcab (total & igm) and hbsab tests were performed on the selected donors. data were collected and finally the prevalence rate of hbcab was determined. results: the results of the study showed that out of hbsag-negative first-time blood donors, only were hbcab+, from which were hbcab (total)+, and were hbcab (igm)+. were both hbsab+ and hbcab+, and were seropositive only for hbsab. conclusions: it was demonstrated that the first-time blood donors who are seronegative for hbsag marker will be easily identified through hbcab test if they are in the so-called core window period of the virus. meanwhile, this group of donors have been implicated as high-risk for transfusiontransmitted hbv infection. so, detecting this marker will remarkably reduce the chance of latent cases of hbv infection and help promote blood safety. background: tumor necrosis factor-(tnf-) plays a pivotal role in the viral clearance and host immune response to hbv, and the capacity for tnf-production in individuals is influenced by a major genetic component. the studies of tnf-- gene promoter polymorphism in chronic hbv infection have reported apparently conflicting results. objective: to derive a more precise estimation of the relationship between the polymorphism of tnf-- gene promoter and chronic hbv infection. method: meta-analysis was done of case-control studies in relation to tnf-- gene promoter, involving a total of chronic hbv infection cases and controls. the pooled odds ratios (ors) for the risk associated with the genotypes of ga, aa, and ga+aa (a-allele carriers) compared with the gg genotype were calculated. results: overall meta-analysis indicated that - a heterozygotes (ga) had % decreased risk of developing chb with a borderline significance (or = . ; % ci: . - . ; p = . ). for the - a allele homozygotes (aa) and carriers (ga+aa), the pooled ors both indicated a significantly decreased risk of chb (or = . ; % ci: . - . ; p = . ; and or = . ; % ci: . - . ; p = . , respectively) ( table ). in the subgroup analyses by ethnicity, significantly decreased risks were associated with - variant genotypes (ga and aa) in mongoloid populations in all genetic models. however, no significant associations were found in caucasoid. conclusion: the meta-analysis suggests that the tnf-- a allele is a low-penetrant protective factor for chronic hbv infection, especially in mongoloid. method: hbv transgenic mice were randomly divided into physiologic saline group and matrine injection group. another normal mice at the same species and age with hbv transgenic mice were regarded as the normal group. the mice in matrine injection group were administrated at dosage of . mgkg - d - by intraperitoneal for days. the mice in physiologic saline control group and normal group were administrated normal saline with the same volume at same time. the contents of hbv dna in serum and liver were quantitated by pcr. and the spleens were separated for cultivating dendritic cells. the surface molecules of dendritic cells were tested by flow cytometry. ifn-mrna and tnf-mrna in liver were tested by rt-pcr. result: there was no significant difference of the serum hbv-dna level between physiologic saline and matrine injection groups. the content of serum hbv-dna after treatment showed a significant decrease in two groups. the content of serum hbv-dna in matrine injection dropped significantly as compared with that in the physiologic saline group. but there was no significant difference in the content of hbv-dna in liver between physiologic saline and matrine injection groups. the expression level of mhc-ii on dendritic and hepatic ifn-r mrna and tnf-a mrna showed a significant decrease in hbv transgenic mice than normal mice. in comparison with physiologic saline group the expression level of them in matrine injection group showed a significant increase. conclusion: matrine injection was effective on depressing hbv-dna in hbv transgenic mice. its antiviral action may be achieved through regulating mhc-ii on dcs surface and promoting the production of antiviral factor such as ifn-and tnf-. purpose: to stimulate non-specific immune response capacity as the main content of the study to explore the hbv-dna and non-specific immune responses in the relationship between the low response capability, methods: cases of asymptomatic carriers, double-blind, randomized into mycobacterium fu , lamivudine and traditional chinese medicine for the treatment group, mycobacterium fu with traditional chinese and lamivudine with traditional chinese medicine were in the control group, a total of weeks of treatment, follow-up six months after the termination of treatment. results: different treatment of hbv -dna effect of the existence of significant differences; p> . , the performance of different types of asymptomatic carriers negative rate of hbv-dna there is a significant difference; p> . , as well as the performance of the different types of asymptomatic carriers continued application a treatment plan presented hbv-dna rebound rate there is a significant difference; p> . , conclusion: hbv-dna and non-specific immune responses in response to the lower capacity, anti-hbv therapy is not associated with non-specific immune response capacity or improve is the anti-hbv drugs alone can not solve the asymptomatic carriers in anti-hbv therapy where the cause of the problem, solve the asymptomatic carriers in the anti-hbv treatment although the need for anti-hbv drugs with non-specific immune activation synchronous drugs on the basis of the joint application , but the simultaneous combination of two drugs rather than as a result of hbeag and hbv-dna can hbeag-positive asymptomatic carriers receive hbv-dna negative effect of the results. background: adefovir dipivoxil (adefovir) effectively inhibits both wild-type and lamivudine (lam)-resistant hepatitis b virus (hbv) replication and resistance to this drug is infrequent compared with lam. in this study, we tried to identify factors affecting the emergence of resistant mutants after adefovir monotherapy in lam-resistant chronic hepatitis b (chb) patients. methods: the subjects were chb patients with lam-resistance who had received adefovir for more than months (range - months). the initial viral response (ivr) was defined as hbv dna < . log copies/ml. the adefovir resistant mutant was assayed at baseline and every months during adefovir administration. results: ivr was observed in % of patients. the cumulative emergence rates of adefovir resistance were . % at months, . % at year, . % at years and % at years. in univariate analysis, factors contributing to the emergence of adefovir resistant virus were baseline hbv dna > log copies/ml (p= . ) and ivr (p< . ). the presence of precore mutation and type of ymdd mutants were not related. in multivariate analysis, only ivr was an independent factors affecting the emergence of adefovir resistant virus (p< . ). conclusion: ivr is a useful predictor for emergence of adefovir resistant mutants after adefovir monotherapy in lam-resistant chb patients. for ivr-negative patients, the change of therapeutic options such as add-on lam or switch to other drugs should be considered because of the high incidence of the emergence of adefovir resistant mutants. background: elevated hbv dna is strongly associated with the risk of disease progression. this study investigated the early viral suppression effects of etv and lvd in nucleoside-naïve chinese patients with active hbeag (+) chb. methods: this open-label study was conducted in major hospitals in china. at study entry all patients had hbv dna levels copies/ml, elevated alt ( . - xuln) and compensated liver function. patients received either . mg etv or mg lvd daily. hbv dna measurements were taken at baseline and at weeks , , and during treatment, using roche cobas amplicor assay (llod copies/ml). results: a total of patients were enrolled; / etv patients and / lvd patients completed weeks of treatment. at baseline, mean hbv dna levels were . . in etv group and . . log copies/ml in lvd group (p< . ). the mean change in hbv dna from baseline (log copies/ml) was - . ± ngo's/funding-agencies representative at apasl -conference need to address-this-issue. we ngo-representatives from developing-nations need exposure to research treatments used by european/american experts. do we all failed in addressing socio-economic issues of cancer-sufferers? we need to address these socio-economic issues of affected population in resource-poor-nations. background: a garlic derivative s-allylcysteine (sac) has anti-cancer effect in human prostate and colon cancers. we aimed to investigate the effect of sac and combination of chemo-drug on tumorigenesis and metastasis of liver cancer. methods: the orthotopic liver tumor model using a metastatic liver cancer cell line mhcc l labeled with luciferase gene was applied. sac was given at day after tumor implantation at mg/g/day, or mg/g/day combined with low dose cisplatin for weeks. tumor growth and metastasis were monitored by xenogen in vivo imaging system. hepatic stellate cell (hsc) activation and tumor-associated macrophage (tam) in the tumor tissue were detected by -sma and ed /ed staining. tumor micro-vessel density (mvd) and apoptosis were also analyzed. in vitro functional tests including proliferation assay, cell cycle analysis and apoptosis analysis were performed. results: tumor growth was inhibited by sac combined with cisplatin treatment at different time points accompanied by lower incidence of lung metastasis compared with other groups. the observation of xenogen ivis was confirmed by histopathological examination. the hsc activation by -sma staining in the liver tumors was suppressed by sac and cisplatin treatment accompanied with less tam infiltration. consistent with in vivo study, in vitro functional study also demonstrated that sac not only induced cell cycle arrest, apoptosis, and inhibited tumor cell proliferation, but also sensitized the anti-cancer effect of cisplatin. conclusion: sac treatment inhibited liver tumor growth and metastasis by inhibiting tumor cell proliferation, inducing apoptosis and sensitization of chemotherapy. background: anti-angiogenic therapy would be a promising approach against hepatocellular carcinoma (hcc). although a sorafenib has survival benefits in patients at advances stages of hcc, there seem to be several serious concerns to employ this agent for chemoprevention against hcc. branched-chain amino acid (bcaa) reportedly inhibits the incidence of hcc in patients with insulin resistance (ir). however, the possible mechanism is still obscure. the aim of the current study was to examine the effect of bcaa on hepatocarcinogenesis under the condition of ir, especially in conjunction with angiogenesis. methods: the effect of bcaa on the development of liver enzyme-altered pre-neoplastic lesions and angiogenesis in the obese diabetic otsuka long-evans tokushima fatty rats was examined. we also performed an in-vitro study to elucidate the possible mechanisms involved. result: treatment with bcaa markedly inhibited the glutathione-s-transferase placental form (gst-p)-positive pre-neoplastic lesions along with suppression of neovascularization in the liver. the hepatic expression of the vascular endothelial growth factor (vegf), a potent angiogenic factor, was also attenuated. bcaa treatment significantly suppressed the glucose-and insulin-induced in-vitro angiogenesis in the presence of vegf. these results indicate that bcaa exerted a chemopreventive effect under the condition of ir via suppression of vegf-mediated angiogenesis. conclusion: since bcaa is widely used in the clinical practice for patients with chronic liver diseases, this agent may represent a new strategy for chemoprevention against ir-based hcc in the future. background: krüppel-like factor (klf ) is a member of transcription factors. whether and how klf signaling pathways contribute to hepatocellular carcinoma (hcc) development and progression is unknown. this study investigated role of klf in hepatocellular carcinoma cell line hcclm proliferation, invasiveness and epithelial to mesenchymal transition (emt). methods: the expression of klf in different liver cell lines was detected by quantitative real-time pcr and immunocytochemistry. we used small interfering rna (sirna) to down-regulate klf expression in hcclm . the change of proliferation and invasive ability of klf down-regulated hcclm was investigated by mtt reduction assay and trans-well invasive assay respectively. the change of proliferation, invasiveness and emt related gene in klf down-regulated hcclm was evaluated by quantitative real-time pcr. result: klf protein expressed predominantly in the nuclei of cancer cells and its expression is positively correlated with metastatic potential of these cell lines. hcclm has the highest klf level. decreased klf expression can notably inhibit the proliferation (p< . , n= ), mobility and invasiveness of hcclm (p< . , n= ). we found that the mrna level of n-cadherin, fibronectin and vimentin is much higher than that of e-cadherin in hcclm . the expression of cyclin d , focal adhesion kinase (fak) and fibroblast markers including n-cadherin and fibronectin was obviously suppressed in klf down-regulated hcclm . conclusion: klf plays an important role in the process of hcclm proliferation, invasiveness and emt. background: insulin resistance (ir) has shown to play an important role in the progression of chronic liver diseases, including liver fibrosis development and hepatocellular carcinoma. the aim of this study was to elucidate the possible mechanisms of ir on the liver fibrosis development and hepatocarcinogenesis using obese diabetic otsuka long-evans tokushima fatty (oletf) rats. methods: to induce liver fibrosis, . ml/kg of pig serum was injected twice a week for weeks in the oletf and leto rats. in the hepatocarcinogenesis model, glutathione-s-transferase placental form (gst-p)-positive pre-neoplastic lesions were induced by a single injection of mg/kg of diethyl nitrosamine (den). we also performed in-vitro studies to examine the mechanistic insights. results: the liver fibrosis development and gst-p-positive pre-neoplastic lesions were both markedly accelerated in oletf. in the fibrosis experiment, -smooth muscle actin-positive activated hepatic stellate cells (hsc) also increased in oletf along with augmentation of the hepatic collagen content and transforming growth factor-b . in the den model, the neovascularization was up-regulated in oletf almost in parallel with the pre-neoplastic lesions development and a potent angiogenic factor, the vascular endothelial growth factor. our in-vitro study showed that both glucose and insulin stimulated the proliferation of the activated hsc and augmented the neovascularization. conclusion: these results indicated that the ir status directly accelerated the liver fibrosis development and hepatocarcinogenesis at least partly through the stimulation of activated hsc proliferation and hepatic neovascularization, respectively, in the rat. n. wakui , t. ikehara , r. takayama , m. takahashi , k. shiozawa , h. nagai , m. watanabe , k. ishii , k. iida , y. igarashi , y. sumino case: a years old man diagnosed with chronic hepatitis c regularly visited our hospital. in april of , ultrasonography revealed a tumor mm in diameter in s of the liver and another tumor mm in diameter in s / of the liver. the patient was hospitalized for further examination. computer tomography (ct) revealed that the tumor localized in s / presented a pattern of hypervascular hepatocellular carcinoma (hcc). for the tumor localized in s , the following were revealed. ) contrast-enhanced ultrasound findings: a tumor vessel passed from outside the tumor to the center of the tumor in the early vascular phase, then radiated in a wheel-like shape at the center of the tumor; parenchymal phase perfused imaging in the area produced a similar imaging obtained from the area surrounding the liver. ) ct: no tumor was detected. ) spio-mri (t weighted imaging): iso-low intensity images were obtained. although these imaging findings indicated fnh, the patient was hcv positive. in order to disprove the possibility of hcc, a biopsy was performed on the tumor at s in the liver. the resulting diagnosis was well-differentiated hcc. discussion: until now, a characteristic finding of fnh has been spoke-like vasculariation, which is considered diagnostically quite important. however, some recent cases of hcc have been reported to present fnh-like vascularization. from now on, when evaluating a tumor that presents spoke-like vascularization underlining chronic hepatitis, the possibility of hcc should be considered and a close examination may be needed. chronic infection with hcv is problem .clinical management of chronic hcv depend on extent liver fibrosis .liver biopsy gold stander an invasive procedure responsible for severe complications and sample variability interpretation. serum biomarkers for inflammation/fibrosis investigated to wave liver biopsy. diagnostic accuracy panel of non-invasive serum biomarkers for hepatic fibrosis (fibrosure , apri score, forn's score) versus liver biopsy. hcv patients subjected for: apri, forn's , fibrosure scores pcr quantitative hcv-rnaliver functions .lipid profile cbc . ultrasound guided liver biopsy. forns score; auroc ( . ) with % ci( . - . ) for(fof ) vs. (f f f ) while( . )with % ci( . - . )for(fof f ) vs.(f f ). cutoff(> . )sensitivity for significant fibrosis(f f f )and extensive fibrosis (f f )were ( %) and with low specificity ,with accuracy( %) and ( %)respectively.-apri score; auroc( . )with % ci( . - . )comparing(f f ) vs.(f f f )while was( . )with % ci( . - . )for( f f f )vs.(f f ).cutoff(< . ) had low sensitivity and specificity( %)with accuracy( %)for significant fibrosis and( %)for extensive fibrosis.-fibrosure(fibro-acti test); showed best auroc( . )in different fibrotic stages with % ci ( . - . ).cutoff(> . ) sensitivity( %)for significant fibrosis and( %)for extensive fibrosis while specificity( %)in all fibrotic stages. the ppv ( %)for significant and extensive fibrosis .npv and accuracy( %, %)respectively for significant fibroses,while it was ( %) for extensive fibrosis respectively.significant correlation between liver biopsy and fibro-test(p . )and acti-test(p . ).significant correlation between liver biopsy hepatitis activity score and apri (p . )and forns score (p . ). conclusion: forns score wasn't considered since does not discriminate between significant and extensive fibrosis. low sensitivity of apri prohibtes detection of minmal fibrosis and allow undetermined results. fibrosure classified all cases of chronic hcv sufficient to wave liver biopsy pe introduction: hcc is the th common cancer. global increase of hepatitis b and c infection, the incidence of hcc steadily increasing. egypt seroprevalence of hcv in nile delta - %. afp had limited sensitivity % and specificity % for small hcc. gpc- oncofetal protein over expressed in hcc. evaluating validity of glypican- as early detector of hcc.: healthy controls and hcv positive patients: patients chronic hepatitis c virus infection. patients compensated cirrhosis [child-pugh class a and b]. patients decompensated cirrhosis [child-pugh class c]. patients hcc. liver functions: alt, ast, bilirubin(t), albumin, gt.tumor markers: afp and gpc- .viral markers: hcv antibodies, hbs ag and hbc ab. the median value of gpc- in hcc, dc, cc significantly higher than chronic hepatitis and control groups. no significant correlation between afp and gpc- . auroc of afp . & auroc of gpc- . . the diagnostic sensitivity of afp ( ng/ml) % with ppv . %. the specificity % with npv . %. while the diagnostic sensitivity of gpc- ( ng/ml) % with ppv %. the specificity . % with npv %. combined serial approach of afp and gpc- improved specificity to . %. conclusion:gpc- although a serological test for early detection of hcc, showed limited specificity, where detected in different stages of chronic liver disease,it is oncofetal protein produced by regenerating liver cells. the diagnostic signature approach for simultaneous determination of afp and gpc- improve prediction accuracy of hcc patients in those showing seronegativity to afp. results: patients with hcv infection (n= ) were significantly older (mean age, years) than patients with dual virus (n= , years) and hbv infection (n= ; years) (p< . ). the male-to-female ratio for hbv, dual virus and hcv group was . , . and . , respectively (p< . ). patients in the hbv group more often had higher total tumor volume (mean, cm ) than the dual virus group ( cm ) and hcv ( cm ) group (p< . ). no significant differences of the severity of liver cirrhosis, performance status, cancer staging and tumor cell differentiation were noted among the three groups. patients in the hcv group had a significantly poor survival in comparison to the hbv group only in the subset of patients with small tumor volume (< cm ) in the cox proportional hazards model (relative risk: . , p= . ). conclusions: dual hbv and hcv virus infection does not accelerate the speed of hcc formation in patients with chronic hepatitis b, and appears to have a modified course of carcinogenesis pathway diverted away from the biological behavior of hbv and hcv infection. background: patients presenting with hcc is not infrequent in our clinical practice. the aetiology vary ranging from hbv, hcv, nash and alcohol. the aim of this study was to see the aetiology of hcc in bangladeshi patients. methods: in this retrospective study, records of patients who attended our opd between july to august were reviewed. patients having hepatic sol and/or heterogeneous echotexture of liver on usg and/or ct scan were included. diagnosis of hcc was confirmed at usg guided fine needle aspiration cytology with or without elevated serum afp (> ng/ml). results: of the patients, % ( / ) had hbv infection. hcv infection was diagnosed in % ( / ). nash was responsible for % ( / ) cases, alcohol in % ( / ), while in the rest % ( / ) cases no specific aetiology could be established. conclusion: the study shows that hbv is the commonest cause for hcc in bangladesh followed by hcv. background: the aim of this study was to determine whether the hepatitis b virus (hbv) dna viral load and antiviral therapy is associated with hepatocellular carcinoma (hcc) recurrence. methods: this retrospective study involved patients who underwent hepatic resection or radiofrequency ablation for initial hcc curative treatment. the patients were divided into four groups. fifteen patients with low serum hbv dna levels ( log copies/ml) at the time of initial hcc treatment received antiviral therapy (lamivudine, adefovir, dipivoxil, entecavir) before hcc appeared (pre antiviral therapy group; pre-tg). thirty-four had low serum hbv dna levels without antiviral therapy (low virus group; lvg). fourteen had high serum hbv dna levels and received antiviral therapy after hcc appeared (post antiviral therapy group; post-tg). thirty patients had high serum hbv dna levels without antiviral therapy (high virus group; hvg). results: the cumulative hcc recurrence rates at years in the hvg, lvg, pre-tg, and post-tg groups were . %, . %, . %, and . %, respectively. there were significant differences in the hcc recurrence rates between the hvg and lvg groups (p = . ), and between the hvg and pre-tg groups (p = . ). the recurrence rate was lower, though not significantly, in the post-tg group than in the hvg group (p = . ). conclusions: not only hbv dna viral load but also antiviral therapy is associated with hcc recurrence. antiviral therapy before hcc appears is important for patients with high serum hbv dna levels to prevent hcc recurrence. background/aims: few reports have described methods for predicting prognosis in unresectable hepatocellular carcinoma (hcc) patients, especially those treated by repeated transcatheter arterial chemoembolization (tae). to determine risk factors for death and determine prognosis in patients treated with repeated-tae, we evaluated clinical data. methodology: we retrospectively analyzed clinical parameters of unresectable hcc patients treated with repeated-tae from january to december . tae was repeated when recurrence was diagnosed by tumor marker elevation and/or dynamic computed tomography findings. factors affecting survival were evaluated using multivariate analysis after univariate analysis. next, we combined the score for each significant factor into a single prognostic score, after which the results were compared with jis and clip score methods. results: multivariate analysis revealed that bilobular hcc, alpha-fetoprotein ( ng/ml), tumor invasion of the portal vein, tumor size ( cm), and albumin (< . g/dl) were related to poor prognosis, using those factors, we developed a new prognostic scoring system. the % survival period was . months for all subjects, while it was . , . , . , . , and . months for those with scores of , , , , and or over, respectively (p< . ), using our new system. clip score was not useful to predict prognosis, while jis score was better. however, subjects with jis scores of and were difficult to differentiate. conclusion: our scoring system was easy to perform and the results showed that repeated-tae was effective for unresectable hcc with a score of or less. local ablative therapies and intrahepatic pressure c. kawamoto , a. yamauchi , k. kaneko , n. miyagi , k. kani , t. aoyama , k. yakabi saitama medical center, saitama medical university, japan background: some of the unexpected recurrence observed after radiofrequency ablation (rfa) might be caused by increased intratumoral pressure. the present study examined the relationship between local ablative therapies and intrahepatic pressure. methods: a. basic study: under general anesthesia, laparotomy was performed on pigs. a leveen needle and a percutaneous ethanol injection (pei) needle were inserted into the liver and intrahepatic pressure was monitored using an invasive blood pressure monitor. ablation was performed as follows: . rfa. ) single-step method: after fully deploying the electrode, the power was initially applied at w, then increased in increments of w/min until power roll-off. ) multi-step method: the array was deployed in steps. at each step, the power was fixed at w until power roll-off. . pei. injection of ethanol ( ml). b. clinical study: we examined the multi-step rfa and pei for hcc. under local anesthesia, intratumoral pressure was monitored. . rfa. patients with a mean tumor size of . ± . mm were studied. . pei. in patients with a mean tumor size of . ± . mm, to ml of ethanol was injected per session. results : a. basic study: the intrahepatic pressures were: single-step method, . ± . mmhg; multi-step method, . ± . mmhg; and pei, . ± . mmhg. b. clinical study: intratumoral pressure was . ± . mmhg for rfa and . ± . mmhg for pei. conclusion: these results suggest that consideration of intrahepatic pressure is crucial in local ablative therapies. background: a late evening snack (les) is recommended for liver cirrhosis. however, no clinical study has evaluated the nutrition status and the effect of les in cirrhotic patients with hepatocellular carcinoma (hcc). we investigated the effect of les undergoing hepatic arterial infusion chemotherapy (haic) in patients with hcc. method: nineteen patients with hcc were enrolled. ten patients were les group, and nine were control group. in the les group, the patients received les supplementation with a branched-chain amino acid (bcaa)-enriched nutrient mixture. in the control group, the patients received ordinary food. there were no significant differences in relation to age, gender, etiology, child-pugh scores, tumor stage, clinical responses to haic between two groups. blood biochemical data, nutrition status using an indirect calorimeter were evaluated at before and at the end of chemotherapy. results: the non-protein respiratory quotient (nprq) and molar ratio of branched-chain amino acid to tyrosine (btr) were significantly improved in the les group but not in the control group. there were no significant differences in the area under the concentration curve for glucose between before and the end of chemotherapy in two groups. background & aims: hepatocellular carcinomas (hccs) often show hypoor mixed vascularity, and the prognosis of these relatively hypovascular hccs is not fully elucidated. cytokeratin (ck) expression profiles may also be useful prognostic indicators, and specifically ck may reflect metastastic potency in hccs. this study was to assess the prognostic implication of tumor vascularity and its relation to ck expression in hcc patients. methods: a total of patients who underwent surgical resection for hcc were enrolled. tumor vascularity was evaluated according to arterial enhancement pattern on ct scans and ck expression was evaluated using tissue microarray methods. clinicopathologic data were analyzed using kaplan-meier and cox proportional hazard model. results: during follow-up period, ( . %) patients experienced tumor recurrence. forty-five patients ( %) had hypovascluar tumor at the time of diagnosis, and they showed significantly higher positivity for ck expression (p= . ) and shorter disease-free survival (p= . ) than patients with hypervascular hccs. in addition, recurred tumors in these patients showed more frequently hypovascular pattern than in patients with hypervascular hccs (p= . ). hypovascularity at initial diagnosis and microvascualr invasion were independent poor prognostic factors predicting survival. following treatment of recurred hccs, hypovascular tumors showed poor response to transarterial chemoembolization (tace), which resulted in shorter overall survival than hypervascular tumors (p= . ). conclusions: these results demonstrate that tumor hypovascularity in hccs is associated with positive ck expression, early tumor recurrence, poor tace response and poor survival. therefore, tumor vascularity may also be a prognostic indicator in hcc patients. background: hepatic stellate cells (hscs) transdifferentiate to become extracellular matrix-producing myofibroblasts during liver injury. myofibroblasts can also promote invasion and metastasis of hepatocellular carcinoma(hcc). in this study, we determine gene expression changes in two different models of hscs activation and investigate whether induction-activated hscs(ihscs) gene expression changes are different from culture-activated hscs(ahscs). methods: hscs were isolated by density centrifugation and exposed to conditioned medium from rat hcc cell lines c f. twenty-seven thousands and one hundred gene expression between quiescent hscs(qhscs), ahscs and ihscs was analyzed by microarray and confirmed by real-time rt-pcr and western blot. results: sixteen hundreds and seventy-one probe sets were differentially expressed in ahscs, including genes that encode proinflammatory factors, adhesion molecules, cell surface receptors, signaling transduction and immune factors. seven hundreds and eleven probe sets were differentially expressed in ihscs. induction-activated hscs showed specific gene expression patterns including raf , rac , adam , wnt , mmp- and tnf, suggesting that hcc cells can specifically induce hscs activation. induction-activated hscs might play a important role in invasion and metastasis of hcc. conclusions: induction-activated hscs gene expression patterns are different from ahscs. culture-activated hscs does not properly regulate gene expression in hscs, suggesting that ihscs may be considered the model for the study of hscs biology in hcc. background: hepatocellular carcinoma (hcc) is a hypervascular tumor, and angiogenesis is important for tumor growth. ephrin receptors are related with vascular system development and the polymorphism of ephb in the carcinogenesis of digestive tract has been reported. our aim was to examine the polymorphsims of ephb with the occurrence of hepatocelluar carcinoma in korean population. methods: genomic dna was extracted from patients with hepatocellular carcinoma (hcc), healthy subjects. ephb polymorphism was determined by polymerase-chain reaction-based assays, and the association with hcc was investigated. results: with regard to ephb polymorphism, a/a genotype at rs , t/t genotype at rs , a/a genotype at rs , t/t genotype at rs and g/g genotype at rs were significantly associated with hcc but these were not associated with clinical characteristics of hcc. conclusions: five out of seven polymorphisms on ephb gene were statistically associated with hcc, in the korean population. therefore, more studies of ephb gene polymorphisms including various risk factors should be performed to use as genetic markers of hcc occurrence. background: we aimed to compare the results of hepatectomy for hcc in patients older than years old with those for younger patients. methods: clinicopathological data and outcomes for elderly patients and younger patients with hcc who underwent hepatectomy between and were retrospectively compared. results: although postoperative delirium was more common in the elderly group, there were no significant differences between the groups with regard to operative morbidity, hospital death, disease-free survival, and overall survival. the overall recurrence rate was significantly higher in the elderly patients with alcohol abuse than in younger patients with alcohol abuse. multivariate analysis revealed that preoperative alcohol abuse was a prognostic factor for elderly patients. conclusions: elderly patients with preoperative alcohol abuse should be followed closely, even after r surgery, because alcohol abuse is strongly correlated with postoperative recurrence and worse survival. background: little is known about the effect of transfusing fresh frozen plasma on the outcome after hepatectomy for hepatocellular carcinoma. methods: among patients who underwent curative resection between and , patients had perioperative transfusion with whole blood or packed red blood cells and fresh frozen plasma (group a), while patients were only transfused with packed red cells (group b), patients were only transfused with fresh frozen plasma (group c), and patients had no transfusion (group d). results: group c had significantly fewer postoperative complications and a shorter hospital stay than group a. preoperative coagulation was significantly worse in group c. survival was significantly better in groups c and d than in group a. conclusions: perioperative transfusion of fresh frozen plasma improves clotting factors without an adverse influence on the survival of patients with liver dysfunction undergoing resection of hepatocellular carcinoma. background: this study investigated risk factors for postoperative liver failure after resection of hepatocellular carcinoma to detect markers that could identify candidates for hepatectomy. methods: perioperative risk factors for liver failure after hepatectomy were analyzed in patients with hepatocellular carcinoma. results: liver failure occurred postoperatively in patients, of whom died. the hyaluronate/gsa-rmax ratio was a risk factor for postoperative liver failure by univariate analysis and was the only risk factor according to multivariate analysis. all patients who died had a hyaluronic acid/gsa-rmax ratio mg min/dl. conclusions: to reduce postoperative liver failure, preoperative planning should employ various measures of the hepatic functional reserve, including tests of both parenchymal and nonparenchymal liver function. the hyaluronate/gsa-rmax ratio can predict liver failure after hepatectomy, and a ratio greater than mg min/dl is a relative contraindication to liver resection. the patient was a -year old japanese man with chronic hepatitis c(ch-c) who achieved a sustained virological response(svr) to interferon(ifn) therapy. as a result the liver functions were normalized and the histological findings of the liver also improved. however, years after svr, mild liver dysfunction was noticed along with a marked increase of tumor markers. several modalities revealed huge liver tumors about cm in greatest diameter in the left lobe invading the bile ducts and another tumor about cm diameter in segment v. we performed liver biopsy and confirmed that this tumor was well-differentiated hepatocellular carcinoma (hcc). only mild fibrosis development could be observed in the adjacent non-cancerous lesions. we successfully treated these tumors with transcatheter arterial chemoembolization and stereotactic radiosurgery. recent studies revealed that the risk of developing hcc still exists even after svr. since most of hcc that develop in patients with svr are usually detected within years, several investigators speculate that hcc is already present but too small to be detected at the time of completion of ifn therapy. this speculation is not the case in our patient, since svr was achieved years ago and no hcv-rna could be detected when hcc appeared. therefore, another possible mechanism should be considered. an annual follow-up with strict surveillance program for hcc should be performed for more than years after the completion of ifn therapy. background/aims: in order to investigate the role and importance of oxidative stress as to carcinogenecity of hepatocellular carcinoma (hcc) we analyze the expression of -hydroxydeoxyguanosine ( -ohdg) in the liver tissue of the hcc patients with and without hepatitis viral marker. methods: patients undergoing hepatic resection for the first hcc from to were enrolled into the study. only the cases that took no alcohol or small amount of alcohol were enrolled. cases were negative for hepatitis b surface antigen (hbsag) and antibody to hepatitis c virus (hcvab) (nbnc group). were positive for hbsag and negative for hcvab (b group). were positive for hcvab and negative for hbsag and antibody to hepatitis b core antigen (c group). staining with hematoxylin and eosin (h&e) and berlin-blue, and immunohistochemical staining for -ohdg were performed using the non cancerous liver regions. the degree of -ohdg immunostaining was expressed as the labeling index, which means the percentage of positive hepatocytes per hepatocytes. results: the labeling index of -ohdg for nbnc group is . (± . ), significantly lower (p= . ) than that for b group . (± . ), and also lower (p= . ) than that for viral group (b group and c group)( . ± . ). the labeling index of -ohdg had no correlation with grading, staging, fatty and iron deposit among all cases. conclusions: there is possibility that oxidative stress might not associate with the carcinogenesis of hcc in some cases without hepatitis viral infection. background: no effective chemopreventive agent has been approved against hepatocellular carcinoma (hcc) yet. since neovascularization plays a pivotal role in hcc, an angiostatic agent is considered as one of the promising approaches. recently, it has reported that vitamin k (vk) and angiotensin-converting enzyme inhibitor (ace-i) exert anti-angiogenic activity. the aim of the current study was to elucidate the combination effect of the clinically used vk and ace-i on cumulative recurrence after curative treatment, especially in consideration of neovascularization. methods: vk (menatetrenone; mg/day) and/or ace-i (perindopril; mg/day) were administered for to months after the curative therapy for hcc. the cumulative recurrence and several indices were analyzed. results: a -month follow-up revealed that the combination treatment with vk and ace-i markedly inhibited the cumulative recurrence of hcc in association with suppression of the serum level of vascular endothelial growth factor (vegf); a central angiogenic factor. the serum level of lectin-reactive a-fetoprotein was also suppressed almost in parallel with vegf. these beneficial effects were not observed with single treatment of vk or ace-i for months. conclusions: the combination treatment of vk and ace-i may suppress the cumulative recurrence of hcc after the curative therapy, at least partly through suppression of the vegf-mediated neovascularization. aim: the aim of this study was to clarify the cilnicopathologic features and management of hepatocellular carcinoma (hcc) patients surviving more than years after hepatectomy. materials & methods: retrospective study was carried out on hcc patients who underwent curative hepatectomy between and . clinicopathologic factors in -year survivors and patients who died within years were compared. the prognostic factors affecting survival were examined among the -year survivors. results: there were patients who survived for more than years after initial hepatectomy, and of those patients survived for more than years after hcc recurrence. the overall -, -, -and -year survival rates were . %, . %, . %, and . % respectively. in multivariate analysis, absence of underlying cirrhosis, solitary tumor, alfa-fetoprotein less than ng/ml, and absence of microscopic vascular invasion were favorable independent factors associated with -year survival. negative hepatitis c virus antibody status was favorable independent factor associated with longer disease-free interval and survival after tumor recurrence. multimodal treatments such as repeat hepatectomy or percutaneous ablation led to improved survival after recurrence, compared with the survival after transarterial chemoembolization (p<. ). conclusions: the results suggest that patients without underlying cirrhosis who have a solitary hcc that does not demonstrate vascular invasion or high afp levels might survive for longer than years after the initial hepatectomy. close follow-up and multimodal treatment could contribute to prolongation of survival in such patients, even if cancer recurrence occurs. the history of the use of carbon ion radiotherapy (cirt) for treating hepatocellular carcinoma (hcc) goes back to , when clinical trials were initiated at the national institute of radiological sciences. we have already reported that cirt used for the treatment of hcc is safe and effective, and that it causes only minor liver damage. in a phase ii clinical trial, the local control and cumulative overall survival rates were % and % at years, respectively. however, the patients with tumor adjacent to the gastrointestinal tract are thought to be ineligible for cirt because of the high risk of radiation injury of the digestive organs. in order to extend the indication of cirt, we have challenged the cirt for such patients under the use of spacers. a case was a -year-old female with cm tumor in segment . in radiological findings, the tumor revealed typical enhancement pattern for hcc, and was near the ec junction. she had been judged ineligible for hepatectomy because of the high retention rate of indocyanine green. she could undergo the . gye/ -fraction cirt after the placement of gore-tex soft tissue patch under the laparoscopic procedure. up to the present date, no adverse effect due to the spacer has been occurred, and an apparent anti-tumor effect has been observed. this method seems to have a promising efficacy for extension of the indication of cirt to the patients with tumors adjacent to the gastrointestinal tract. background: previously we reported that high ubiquitination was marker of human hepatocellular carcinoma. on the basis of these finding, we firstly analyzed the effect of bortezomib(proteasome inhibitor) on human hcc cell line. we also reported that hhm/dip /gcip was early marker for human hepatocarcinogenesis. hhm was suggested to be a new tumor suppression gene, but the mechanism was not well confirmed. we analyzed change of hhm signal by bortemib. method and result: we used hcc cell line (huh , hlf, hepg ) . the inhibitory effect of bortezomib was evaluated using mtt assay. nm bortezomib significantly inhibited proliferation of hcc cell line. the inhibitory effect by nm bortezomib was similar with m cisplatin. on the other hand, bortezomib has no inhibit effect in isolated hepatocyte from rat. in this condition, we analyzed the expression of cyclin d , phospho-rb and hhm in hcc cell line by western blot analysis. expression of cyclin d , phospho-rb decreased, but hhm was increased with time. next we analyzed cell cycle by facs. bortezomib induced hcc cell line into cell cycle arrest in g /m. the transcriptional activity of hhm was also activated by bortezomib administration using ptimer-promoter-hhm plasmid. conclusion: bortezomib has specific anti-proliferative effect on hepatocellular carcinoma. the induction of hhm by bortezomib might be related with cell cycle arrest. bortezomib will be a useful drug for hcc. neovascularization is required for carcinogenesis of non-alcoholic steatohepatitis: experimental and clinical study m. kitade , h. yoshiji , r. noguchi , k. kaji , t. namisaki , y. aihara , h. background/aim: non-alcoholic steatohepatitis (nash) may progress to liver cirrhosis, and finally hepatocellular carcinoma. recent study suggested that development of hepatic angiogenesis correlates the risk for hepatocarcinogenesis in liver cirrhosis patient. we therefore examined the role of angiogenesis in the hepatocarcinogenesis of nash in both experimental and human study. methods: as an experimental nash model, zucker (z) rats, which naturally develop leptin receptor mutations, and their lean littermate (l) rats were fed a choline-deficient, amino acid-defined (cdaa) diet. in human study, patients with nash-related cirrhosis or pre-cirrhosis, regarded as high risk group of hepatocarcinogenesis, and with simple fatty liver (fl) were enrolled and underwent clinico-pathological examinations. immunohistochemical analysis of -hydroxy- -noneal ( -hne) and cd were employed for detection of reacrive oxidative stress (ros) and angiogenesis in the liver tissues, respectively. results: in experimental nash model, both groups showed marked steatohepatitis by feeding cdaa diet. in sharp contrast, the development of glutathione-s-transferase placental form (gst-p)-positive pre-neoplastic lesions and hcc could be observed only in the l-rats. the hepatic neovascularization was also significantly increased only in the l-rats. in human study, both nash and fl exerted a marked elevation of ros. in sharp contrast, significant development of hepatic neovascularization was observed only in nash, whereas almost no neovascularization could be observed in fl. conclusion: in conclusion, these results suggested that neovascularization might play a important role in hepatocarcinogenesis in nash. background: paternally expressed gene (peg ), which was an imprinted gene with an active paternal allele but silent maternal allele, was highly expressed in a great majority of hepatocellular carcinoma(hcc). the aim of this study was to generate transgene mice expressing peg in the liver under the control of mouse albumin (alb) promoter and study the integration, transcription, expression of peg gene in the transgenic mice methods: the linearized bp transgene fragments, which contained alb promoter and structural gene of peg , were microinjected into fertilized eggs of mice. then manipulated embryos were transferred into the oviducts of pseudo-pregnant female mice. all the newborn mice were screened and identified by pcr detecting genomic dna in tail tissue. as the transgene was driven by the alb promoter, we examined its expression in the liver of transgenic mice by rt-pcr and western blotting. results: the transgene fragment was microinjected into the male pronucleus of fertilized oocytes. the injected eggs were implanted into oviducts of pseudo-pregnant foster mothers, of which mice became pregnant and give birth to offspring. of them died from unknown reason. among the offspring, were identified to carry peg cdna as demonstrated by pcr, and peg transgene could be expressed successfully in the liver of the established transgenic mice. the ratio of transgene integration were . % ( / ) by pcr. conclusions: the peg transgenic mouse model should be valuable for studying the in viro function of this imprinted gene in hcc. background/aims: brivanib alaninate is the l-alanine ester prodrug of bms- , an oral selective dual inhibitor of vascular endothelial growth and fibroblast growth pathway receptors. it is being developed in treating hepatocellular carcinoma (hcc), a disease highly prevalent in asia-pacific region. this analysis investigated whether bms- exposure was different between asian and non-asian subjects. methods: a population pharmacokinetic (ppk) model was developed with data collected in subjects ( non-asian, asian) with advanced and metastatic solid tumors (including hcc) from clinical studies. potential effects of the following covariates on model parameters were examined: age, gender, race, and baseline body weight. model-based simulation was performed to examine bms- exposure in asian and non-asian patients following brivanib doses of mg qd (phase iii dose). results: the ppk of bms- was characterized by a -compartment model with first-order absorption and elimination. clearance was found to slightly increase with body weight (p< . ). however, effects of age, gender and race on clearance were not statistically significant. the median of apparent clearance in asian was . % lower than that of non-asians, which was adequately explained by % lower body weight in asians. there was substantial overlap in steady-state bms- auc of asian and non-asian patients, simulated based on their observed body weight distributions in these patient groups. conclusions: bms- pk can be adequately described by a linear -compartment model; exposures in asian and non-asian subjects are similar following brivanib doses of mg qd. background/aims: hepatic resection is the standard treatment for hepatocellular carcinoma. in some patients with multiple hcc, one-block resection can not be feasible due to either the tumor location or the reserved liver function. in this study, we attempted to analyze the outcome of multiple-site resection or combined resection and rfa in patients with multiple hcc. the prognostic factors for postoperative survival were also investigated. methods: among patients who received resection from january to august , patients had a radiologically detected multiple hcc. patients with multiple hcc were divided into: group a, patients treated with one-block resection (n= ) and group b, patients with multiple-site resection or combined resection and rfa (n= ). results: in group b, received multiple-site resection and underwent combined resection and rfa. the clinicopathological variables and postoperative complication rate were not significantly different between the two groups. the -year disease-free survival rates for group a and b were . % and . %, respectively (p= . ). the overall survival rates were also not significantly different ( . % vs. . %, p= . ). the multivariate analysis revealed that radiological tumor number , edmondsons-steiner grade (iii-iv) and indocyanine green retention rate at minutes> % were adverse prognostic factors for overall survival. conclusions: active treatments including multiple-site resection and combined resection and rfa showed similar treatment outcomes compared with one-block resection in patients with multiple hcc. the prognosis after treatment was associated with tumor number, tumor grade and icg r . background: nasopharyngeal carcinoma (npc) is endemic to southern china. mortalities are mostly associated with secondary metastases. novel treatments for npc metastases are thus urgently needed. we aim to test the efficacy of a physiologically stable gold compound, gold (iii) meso-tetraarylporphyrin a (gold- a), in treating intrahepatic npc metastasis in athymic mice. methods: twenty million of c - human npc cells were injected into the livers of athymic mice to induce primary tumors. gold- a was administrated by intraperitoneal injection. survival times, tumor volumes and degrees of metastasis of the animals were evaluated. intratumoral microvessel density was determined by immunohistochemical staining for cd . tube formation by ms mouse endothelial cells were conducted with an in vitro angiogenesis assay kit. gene expression level was determined by semi-quantitative reverse transcription-polymerase chain reaction. cell proliferation was performed by methylthiazolyldiphenyl-tetrazolium bromide assay. result: gold- a prolonged the survival and inhibited intrahepatic and lung metastasis of the tumor-bearing animals. the compound induced tumor tissue necrosis and reduced tumor microvessel formation. in in vitro studies, gold- a inhibited tube formation and proliferation of ms cells, and downregulated the expression of stanniocalcin (stc ), which plays roles in angiogenesis. furthermore, our preliminary data showed that overexpression of stc in ms cells rescued cells from gold- a-induced death. conclusion: gold- a is a novel anticancer agent that prolongs survival of the npc metastases-bearing mice. it inhibits intrahepatic and lung metastasis in vivo and inhibits angiogenesis in vitro, in part via downregulation of stc . tbx is a transcriptional repressor that is important for embryonic development. overexpression of tbx was found in a large variety of cancers, including breast cancer, ovary cancer, cervical cancer, lung cancer, bladder cancer and liver cancer. tbx promote carcinogenesis by bypass cellular senescence via suppression of p arf . our resent studies revealed that two key motifs composed of + residues are essential for its transcriptional repression. based on this finding, we designed a set of peptides to block its transcriptional repression activity and tested their antiviral effects. we found that tat-tagged peptides (taps) effectively transduced hepatoma hepg and bel cells at almost % efficiency and inhibited cell growth in a dose dependent manner. further studies revealed that the tap treated cells underwent up-regulate apoptosis via suppression of p arf both at mrna and protein levels, demonstrating the potential of novel taps for anti-hcc treatment in the future. safety and long-term outcomes of radiofrequency ablation therapy in elderly and cirrhotic patients with hepatocellular carcinoma k. kakisaka , h. kuroda , k. kasai , y. takikawa , k. suzuki iwate medical university background and purpose: a tendency of the aging in patients with hepatocellular carcinoma (hcc) is predominantly seen in japan. in fact, the mean age of patients with hcc in our institute in was . years old, while that in was . years old. it is not still remained whether the percutaneous radiofrequency ablation (rfa) therapy in elder patients with hcc is safety and equal in therapeutic usefulness compared to the non-elder patients with hcc. subjects and methods: two hundred six cirrhotic patients with hcc ( tumor nodules) received rfa therapy curative intent since august, were enrolled. we divided all patients into two groups: over years (elder group: n= ) and under years (non-elder group: n= ), and compared the patient's characteristics, tumor factors and survival rate and causes of death in two groups. results: the characteristics of patients, tumor factors, cumulative survival rate and recurrence rate were not revealed in two groups. although in elder group two patients complicated aspiration pneumonia and respiratory depression due to sedation under rfa respectively, total occurrence rate of complications did not differ between two groups. conclusion: rfa therapy is safety and effective even in elder patients with hcc, although their care is necessary to prevent any complications which are often occurred during the rfa therapy. background and purpose: the aim of this study is to evaluate whether administration of the branched-chain amino acid (bcaa) enriched nutrient (namely, aminoleban en, ostuka pharmaceutical company, japan) might improve protein-energy malnutrition (pem) status and quality of life (qol) in cirrhotic patients with hcc receiving rfa therapy. subjects and methods: thirty-five cirrhotic patients with hcc who had received rfa therapy from october to october in our institute were randomized into two groups: diet with supplementation of aminoleban en (en group: patients, kcal/day) and diet only (control group; patients). the total intakes of calories ( - kcal/kg) and protein ( . - . g/kg) were equal between tow groups. the primary end point was event-free survival rate (development of liver cancer, rupture of esophageal varices, or progression of hepatic failure) and second end points were serum albumin levels and the health-related qol by shortform- questionnaire (sf- ). results: total intakes of calories and protein were similar during the one year after rfa. no significant differences in event-free survival rate were seen between two groups. however, decreased serum albumin levels and one (general health perception) of domains in sf- were significantly improved in en group compared to the control group. conclusion: supplementation of bcaa-enriched nutrient may improve the impaired liver function and qol after rfa therapy. large scale prospective study should conduct to confirm these results near the future. backgrounds and aims to investigate the effects of selective cox- and cox- inhibitor on proliferation and apoptosis of hcc cell. methods hep b and snu cells were treated with ns- and sc- . mtt assay, caspase / activity assay and tunel assay were performed. cox protein and mrna expression were measured by western blot and real time rt-pcr. results in hep b cell line, cox- , cox- ( , , um) and combination ( + , + , + um) treatment after hr showed a significant dose dependent inhibitory effect on cell growth (p< . ). cox- , cox- ( um) and combination ( + , + um) treatment after hr significantly increased caspase / activity (p< . ) and induced apoptosis (p < . ). however, the combination treatment could not showed a additive effect to cox- or cox- inhibitor (p> . ). in snu cell line, cox- inhibitor and combination treatment showed a inhibitory effect on cell growth (p < . ) similar to hep b cell line but any of treatment could not induce apoptosis significantly (p > . ). in cox protein and mrna expression, snu cell line showed significant cox- predominency (p= . ) but hep b cell line showed cox- predominency (p= . ). conclusions in hcc cells, no additive effect of the combination treatment of cox- and cox- inhibitors could be anticipated. the apoptosis inducing effect of cox inhibitor could be different between hcc cell lines. more studies for the mechanism of different response to cox inhibitor between cell lines is needed. background: the aim of this study was to determine the maximum tolerated dose and recommended dose of combination chemotherapy with mitoxantrone and uracil/tegafur (uft) (phase i part), and to clarify its efficacy (tumor response, overall survival, and progression free survival) and safety in patients with advanced hepatocellular carcinoma (hcc) at the recommended dose (phase ii part). methods: patients eligible for study had histologically confirmed, chemo-naïve advanced hcc, who were unsuitable for resection, local ablation therapy or transcatheter arterial chemoembolization. the therapy consisted of mitoxantrone dosages ( , and mg/m /day) intravenously on day and oral administration of uft mg/m on day through day . the treatment was repeated every four weeks if there was no evidence of tumor progression or unacceptable toxicity. results: a total of patients were entered into the study. all had a good ecog performance status score of - . in phase i part, dose limiting toxicities occurred in all three patients (two patients: grade neutropenia, one patient: grade creatinine elevation) given mitoxantrone at dosage of mg/m /day, and the recommended mitoxantrone dosage was mg/m /day. among patients administered at the recommended dosage, one patient ( . %) achieved a partial response, patients ( . %) had stable disease and patients ( . %) had progressive disease. one-year survival proportion, median survival and median progression free survival were . %, . months and . months, respectively. the most common toxicities were grade - leucopenia ( . %) and neutropenia( . %). conclusion: mitoxantrone mg/m with uft mg/m /day is recommended dose. this regimen is generally well tolerated, but appears to have little activity for advanced hcc. these findings do not support its use in practice, and further trials with this regimen in patients with advanced hcc are not recommended. the study assessed the benefits of -d reconstruction of spiral ct scans for the diagnosis of and surgical guidance to large liver tumors or tumors at the hepatic hilum. we retrospectively analyzed cases of children with such tumors treated in past years.the patients were examined by -d reconstruction using slice spiral ct. in cases, the volume of tissue removed exceeded / the entire volume of the liver. in cases, the excised tissue represented less than / of the total liver volume, but the location of the tumor was adjacent to major hepatic vessels. pathological diagnoses included hepatoblastoma (n = ), hepatocellular carcinoma (n = ), mesenchymal hamartoma (n = ), teratoma (n = ) and adenoma (n = ). all children had curative resections with tumor-free microscopic margins. -d ct imaging can provide high quality images and accurate location of the tumors. it could help the surgeon identify the tumor borders accurately and devise a safe surgical strategy. with its help the surgeon could identify vital hepatic blood vessels before operation, and can avoid massive hemorrhaging during operation. background: to investigate the association between c- t polymorphism of transforming growth factor (tgf)- gene and hbv-related hepatocellular carcinoma (hcc). methods: patients with hbv infection ( cases were hbv carriers, cases were hcc) and healthy volunteers were enrolled. the polymorphism of tgf- gene c- t was identified by polymerase chain reaction-restriction fragment length polymorphism method. the concentrations of plasma tgf- were measured by enzyme linked immunosorbent assay (elisa). tgf- mrna expression was quantified by real-time pcr. a recombinant construct containing - c>t variant as promoter and cat as reported gene was transfected into hepg cells. the reporter gene cat was detected with elisa. results: the ct genotype at position - of tgf- gene prevailed in all three groups, the frequency of genotype cc and allele c at - in hcc were significantly higher than those of the hbv carriers and controls. the plasma tgf- concentration among the three genotypes did not show any significant difference in three groups. however, both the tgf- concentration and liver mrna levels were statistically higher in patients with cc genotype than in those with tt genotype in the hcc group. reporter gene cat was elevated when hepg were transfected with - c-cat recombinant construct compared to that with - t-cat one (p< . ) conclusion: the presence of c allele at position - may play an important role in the development of hbv-related hcc through influencing tgf- expression both at mrna level and protein level. background: to assess diagnostic value of n-glycan markers in identifying hepatocelluar carcinoma (hcc) from liver fibrosis after hbv infection. methods: a total of cases of hbv related liver fibrosis (n= ) and hcc (n= ) patients as well as matched healthy controls (n= ) were recruited. routine liver function and tumor markers were detected by automatic biochemistry or immunological analyzer. n-glycome of serum protein was profiled by dna sequencer-assisted fluorophore-assisted carbohydrate electrophoresis with a capillary electrophoresis-based abi sequencer. results: the abuncance of a single agalacto biantennary glycan (ng a f, peak ) was increased in liver fibrosis and decreased in hcc, while that of a branching triantennary glycan (na fb, peak ) was decreased in fibrosis and increased in hcc. the efficacy of the log ratio of above two n-glycan abundance [log (p / )] was similar to afp in differentiation hcc from fibrotic patients. with logistic regression analysis, the accuracy and sensitivity of the diagnostic model combining afp with n-glycan analysis(cscore b) were increased - % compared to afp. log(p / ) was even more powerful in monitoring the progresison of hcc with the specificity improved % and accuracy improved % compared to that of afp. besides, log(peak / ) was correlated well with other tumor markers and tnm stages. conclusions: the log ration of the abundance of a branching triantennary glycan (na fb, peak ) to a single agalacto biantennary glycan (ng a f, peak ) and the model combining afp with n-glycome markers are promising in hcc diagnosis and progression monitoring. the low incidence of tumor seeding and post-procedure bleeding after radiofrequency ablation (rfa) of hepatic tumors has been attributed to the use of thermocoagulation of the tract, which results in necrosis, upon electrode withdrawal. however, different investigators use different techniques with no experimental evidence of the effectiveness of a particular technique. objective: we aimed to compare the necrotic zone produced using different electrode withdrawal techniques. methods: eighteen tract ablation zones were created in ex vivo porcine livers by withdrawing an internally-cooled rfa electrode (cool-tip radiofrequency system, valleylab) - mm/second using energy-dependent ( vs. vs. vs. watts) and temperature-dependent ( vs. c) techniques. horizontal mathematical modeling suggests an impractical number of radiofrequency ablation (rfa) zones needed in order to ablate a medium-large hepatic tumor. however, overlapping rfa zones may increase the necrotic diameter disproportionately to that deduced from single ablation alone. objectives: to compare the necrotic diameter in single (group ), dual overlapping (group ) and dual non-overlapping (group ) ablation. methods: single (n= ) and dual (overlapping n= ; non-overlapping n= ) ablation zones were created in ex vivo porcine livers using cool-tip rfa electrodes. necrotic diameter was measured at the midpoint (maxd) of the single and the two distinct rfa zones of the dual ablation groups and compared with the necrotic diameter at the tip of the second ablation (maxd-o), corresponding to the point of overlap in group . the rfa electrode was withdrawn . and . cm before re-ablating for group and group , respectively. results: despite no difference in end-rfa temperature between groups (group = . + . cvs.group = . + . cvs.group = . + . c; p= . ), maxd was significantly greater (p= . ) in group ( . + . cm) as compared to group ( . + . cm) and group ( . + . cm), with no difference between group and group (p= . ). further proof of synergism between two overlapping ablations is that the maxd-o in group ( . + . cm) was larger than maxd of group (p= . ) and group (p= . ), and was similar to maxd of group (p= . ). conclusions: overlapping two rfa zones results in incremental increase in necrotic diameter compared to single and dual non-overlapping ablation. this may explain the discrepancy in the number of ablation zones needed between clinical and mathematical modeling studies. background: hepatocellular carcinoma (hcc) is the fourth most common cancer worldwide, main etiological factors being chronic infections with hepatitis b and c viruses. the present study was undertaken to evaluate the association of glutathione-s-transferase (gst) t and m null genotypes and microsomal epoxide hydrolas e(mephx) polymorphisms with hepatitis virus related hcc risk in indian population. subjects and methods: three groups of subjects were considered viz. control (n= ), chronic viral hepatitis (n= ) and hcc (n= ). pcr-rflp was used for this polymorphic study. genotype distributions between categories were compared using the test; odds ratios (ors) and % ci were calculated to express the relative risk. results: presence of gstm null genotype significantly (p< . ) decreased the risk for hcc development among chronic viral hepatitis subjects. however, gstt null genotype was associated with an increased risk for hcc by . and . times among control and hepatitis subjects respectively. in case of mephx, tyr his and his his genotypes significantly (p< . ) reduced the risk of hcc development in both viral hepatitis and control subjects. in case of mephx exon genotypes, arg arg imposed an approximate fold risk for hcc development in the two groups. combination of heterozygous mutant genotypes at mephx exons & also imposed around fold risk (non-significant) for hcc. conclusions: polymorphic forms of gst and mephx share an association with viral related hcc risk in indian population and should be further evaluated as the candidate genes to determine individual susceptibility for viral related hcc. background : the association between type diabetes mellitus (dm ) and hepatocarcinoma (hcc) has been identified in the last ten years. methods: to clarify the temporal relationship between dm and hcc and the possible effects of antidiabetic therapy on hcc risk, we recruited patients with hcc compared with control subjects without liver diseases and cirrhotic patients. results: prevalence of dm was . % in hcc, . % in cirrhotic and . % in control group. in univariate and multivariate analysis, the odds ratio (or) for hcc in diabetic patients were respectively . (ci . - . ; p < . ) and . (ci . - . ; p= . ). or in univariate analysis were higher in male than in female patients. in . % of the patients dm pre-exists the diagnosis of hcc from a mean time of . months. moreover, the insulin treatment was more frequent in diabetic hcc patients than controls and we report an or for hcc of . (ci . - . ; p= . ) in patients treated with insulin or sulfonylureas, and an or of . (ci . - . ; p= . ) in patients treated with metformin. conclusion: our study confirms that male patients with type diabetes mellitus have a significantly increased risk of hcc independently of other cofactor such as hbv, hcv and alcoholic abuse. dm is a pre-existing disease in most hcc patients and suggests that insulin and sulphonylurea treatments in dm are associated with an increased risk of hcc development, while metformin may have a protective effect. background & aims: over the last few years, techniques that allow systematic analysis of chromosome aberrations at a genome-wide level were applied to hcc. the purpose of this study is to apply gene loss expression profiling in the attempt to discover new related genomic regions not revealed by loh or cgh, and search the new tumor suppression genes for hcc. methods: primary hcc and corresponding non-tumor liver tissues were obtained from surgery. serologically, cases were with hepatitis b virus infection and cases were with hepatitis c virus infection. four non-viral infected tissues from four patients receiving surgical resection for hepatic adenoma or focal nodular hyperplasia.affymetrix genechip, u a, was used to compare the loss and gained gene expression in liver needle biopsy samples (n= ). results: after adjusting by chromosome arm length, p, p, p, q and q showed higher gene loss-expression ratio (>= loss / cm) in the comparison between normal samples and tumor samples; q, p and q showed higher gene loss-expression ratio in the comparison between tumor and non-tumor tissues. more than genes showed different loss expression level in this study. for example, cd was loss expression in all non-tumor samples comparing to four normal samples. ficolin and ficolin were loss expression in hcc samples with hbv infection and with hcv infection, respectively. conclusion: our results revealed the potential tumor suppression genes and the genomic region they harbored. further study is needed to validate the observation. background/aims: hepatocellular carcinoma is common malignancy in human, accounting for million deaths in the world annually. caspase , as an initiator caspase, is involved in the induction of apoptosis. survivin, a novel inhibitor of apoptosis is related to the ability to inhibit caspases and involved in critical steps of onset and progression of hcc with unfavorable prognosis. methods: to explore the possibility that the epigenetic alteration of caspase and survivin genes is implicated in the development and progression of hcc, promoter methylation of two genes was analyzed in cases of primary hcc by methylation specific pcr. the relationship between immunohistochemical expression of gene products and proliferative/apoptotic indices, and clinicopathologic parameters was also investigated. results: the methylation of caspase ( . %, / ) and survivin ( . %, / ) demonstrated a negative correlation with immunohistochemical expression of capsase ( . %, / ) and survivin ( . %, / ) (p= . and p= . respectively). methylation of caspase and immunohistochemical expression of its gene product was significantly correlated with apoptosis (p= . and p= . ). survivin nuclear immunoreativity revealed significantly correlated with proliferative activity of tumor cells (p= . ). by survivial analysis, the negative caspase expression and positive survivin expression showed worse prognosis in hcc, that was statistically insignificant (p> . ). conclusion: in conclusion, caspase and survivin may contribute an important regulatory mechanism for tumor cell proliferation and apoptosis, and may be prognostic predictors in hcc. injection was recently reported to be effective against hcc with pvi, though the therapy is not always applicable for the patients with arterial abnormality. therefore we tried combination therapy of transcatheter arterial cisplatin embolization and radiation, and will report the effectiveness and toxicity of the therapy. methods: the combined therapy was conducted in hcc patients with pvi. transcatheter arterial embolization with mg/kg cisplatin powder (ia call) was performed against intralobar lesions, followed by external radiation targeted for pvi ( gy in gy fractions). the following variables were evaluated with the survival rate: gender, age, viral etiology, child's class, performance status, and location of pvi. results: one ( %) patient showed complete response and another two ( %) partial response. two ( %) showed no change, and one ( %) showed progress of disease. the survival rates at six months among overall patients were . %. adverse events were limited to nausea and appetite loss. one of the patients with partial response underwent curative resection, and is still alive without any recurrence for days. conclusions: the combination therapy of cisplatin embolization and radiation is safe, effective and also feasible to the patients with arterial abnormality. this therapy is suggested to be a useful alternative therapy for the patients with extensive pvi. recently, the injection port has been used for hepatic arterial infusion chemotherapy (hai) in japan. hai is usually used for the treatment of multifocal bilobar tumors of the liver or hccs combined with portal vein tumor thrombosis (pvtt), not amenable to tace. this study examined the efficacy and toxicity of repeated hepatic hai using lipiodol suspension mixed with cisplatin powder. methods: from april to september , patients with inoperable advanced hcc were enrolled in this study. all received cisplatin powder ( mg) and lipiodol ( ml) suspension, with an intervening weeks interval. the drugs were delivered from an injection port. patients had hcc with pvtt, and had hcc without pvtt. patients with liver function of child grade a, of grade b, and of grade c were enrolled. result: the mean number of hai given during the follow-up period was . times. we found complete response in case, partial responses in , no change in , and progressive disease in . the overall response rate was . %. the -year survival rate was . % and the -year survival rate was . %. although patients had cisplatin-induced anaphylaxis, no severe adverse events (hepatic failure and renal failure) were observed. conclusion: chemo-lipiodolization using cisplatin powder delivered via an injection port provides some clinical benefits without severe adverse events in patients with far advanced hcc. background: recently, the antitumor efficacy of angiogenesis inhibitors is expected in the treatment to hepatocellular carcinoma. the gene expression relevant to the vascularization, which is a target of these inhibitors, has a difference according to each case and it is thought that it influences the therapeutic effect of them. however, there are still few reports of mrna expression of vascular endothelial growth factor (vegf) receptors in hcc. methods: the relative mrna level of vegf and its receptors (kdr and flt- ) was analyzed using quantitative rt-pcr in patients with hcc. matched samples of hcc (t) and non-tumor liver tissue (nt) were obtained by fine needle ( gauge) biopsy. results: gene expression level of vegf and flt- was significantly higher in hcc than nt (vegf; p< . , flt- ; p< . ). according to the clinicopathological findings, gene expression level of vegf and kdr in hcc was significantly high in hypervascular hcc compared to hypovascular hcc (vegf; p= . , kdr; p= . ). additionally, flt- tended to be expressed higher in hypervascular hcc than hypovascular hcc (p= . ). moreover, gene expression level of vegf, kdr and flt- tended to be higher in advanced-stage hcc than early-stage hcc. conclusion: not only vegf but kdr and flt- were highly expressed in hypervascular and advanced hcc. aims: fibrinogen-like protein /fibroleukin (fgl ) has been reported to play a vital role in the pathogenesis in mhv- (mouse hepatitis virus) induced fulminant and severe hepatitis, spontaneous abortion, allo-and xeno-graft rejection by mediating "immune coagulation". fgl functions as an immune coagulant with the ability to cleave prothrombin to thrombin directly. therefore, this study was designed to examine the role of fgl in tumor development. methods: tumor tissues from patients with six types of distinct cancers and the animal tumor tissues from human hepatocellular carcinoma (hcc) model on nude mice (established from high metastasis hcc cell line mhcc lm ) were obtained. results: hfgl was detected in tumor tissues from out of patients as well as tumor tissues collected from human hcc nude mice. hfgl was highly expressed both in cancer cells and interstitial inflammatory cells including macrophages, nk cells, and cd + t lymphocytes and vascular endothelial cells. hfgl mrna was localized in cells that expressed hfgl protein. fibrin (nogen) co-localization with hfgl expression was determined by dual immunohistochemical staining. in vitro, il- and ifn-increased hfgl mrna by - folds and protein expression in both thp- and huvec cell lines. one-stage clotting assays demonstrated thp- and huvec cells expressing hfgl had increased procoagulant activity following cytokines stimulation. conclusion: the hfg contributes to the hypercoagulability in cancer and may induce tumor angiogenesis and metastasis via cytokine induction. . the therapy was either terminated at the end of the first cycle in cases with progressive disease, or continued for at least cycles, when responses to treatment were evaluated by eastern cooperative oncology group criteria. results: of patients treated (male, %; median age, years), % had child-pugh a, and % had b. % had either metastasis or vascular invasion. % had metastasis and % had vascular invasion. on the basis of independent assessment, three ( . %) patients achieved a complete response, thirteen ( . %) had a partial response, and ( . %) had stable disease. there was no grade / drug related toxicities. median overall survival was . months. conclusion: combination therapy of ifn + -fu has modest efficacy in hcc. background: amt is a mixture of approved pharmaceuticals in low therapeutic doses (human insulin and chlorpheniramine) and herbal components (aqueous camomile extract). preclinical and phase i data in healthy volunteers showed a favourable safety profile for amt. this pilot study should examine efficacy and safety of amt in the patients with advanced hepatocellular carcinoma (hcc). methods: thirteen patients with advanced hcc (tnm stage iii-iv), who did not respond to existing therapy, were treated with i.m. amt at . ml/kg up to a maximum volume of ml twice daily for - months. primary study objectives: clinical benefit response (cbr). secondary objectives: safety of amt, tumor response according to who-recist criteria, quality of life (qol) and iimmunomodulatory effects. the effects were evaluated by cytokine production of pbmcs before and after the treatment. results: there were no significant safety issues. four and patients showed positive and stable responses for cbr, respectively. tumor response was pr, sd and pd. even in the patients with pd, and patients showed positive and stable responses for cbr. qol data showed clear improvement. immune monitoring demonstrated effects of amt on the functional immune parameters in about half of patients. in the patients with pr, histological examination showed tumor necrosis and many lymphocytes including plasmacytes infiltrating in the tumor. conclusion: these results suggest that a promising rate of patients with advanced hcc respond clinically to the amt treatment without significant safety issue and amt has some immuno modulatory capacities. background/aims: dysplastic nodules are important due to premalignant potential. the aim of this study was to evaluate the electron microscopic findings of liver dysplastic nodule in patients with liver cirrhosis. methods: a total of patients (mean age: ± years old, male ) with dysplastic nodules which suspected as malignant nodule (mean size . ± . cm) was enrolled from cases of liver cirrhosis undergone ultrasonography-guided biopsy from december to january . the etiologies of liver cirrhosis were as follows; alcohol ( patient), hepatitis b virus ( ), and hepatitis c virus ( ). results: hepatocytes showed rosette formation of regenerative hepatocyte or degeneration. the nucleus was round or oval shaped and the nucleus membrane was irregular. the nucleolus was prominent and clear, the mitochondria were crowded to one side in the cytoplasm with megamitochondria. glycogen granules and lipofuscin pigments were abundant. sinusoid formation was poorly developed and collagen fiber bundles were increased. the hepatocytes of rosette formation and bile ductules cell made of canal of hering, which was dilated and microvilli was decreased. the number of canal of hering was , which was composed of . ± . with hepatocyte and . ± . with bile ductule cell, respectively. there was no oval cell in the canal of hering, which was relatively well developed. schwann cells were clustered together in nerve plexus. therefore, these electron microscopic findings showed that dysplastic nodule was similar to early hepatocellular carcinoma. conclusions: this study showed that dysplastic nodule in liver cirrhosis is nearly identified to early hepatocellular carcinoma. dcp is an important risk factor for recurrence after radiofrequency ablation of single hepatocellular carcinoma -< cm in diameter r. kuromatsu , a. takata , n. fukushima , s. sumie , m. nakano division of gastroenterology, department of medicine, kurume university school of medicine background and aims: the aim is to analyze the risk factors for local recurrence + intrahepatic metastasis after radiofrequency ablation (rfa) and hepatic resection (hr) for single hepatocellular carcinoma (hcc) < cm in diameter. methods: between and , patients with single nodule < cm in diameter and child-pugh grade a were treated by hr and rfa, and recurrence rate and survival rate using kaplan-meier method, and important risk factors for recurrence using cox's proportional-hazards regression model were analyzed. factors used for multivariate analyses were age, gender, viral marker, tumor diameter, afp, afp-l , dcp, and platelet count. results: mean age was years old, m/f ratio was / , hr/rfa was / , and mean observation period was days. five-year survival rates, and -year local recurrence-free + intrahepatic metastasis-free rates were not significant between hr group and rfa group ( / %, / %). in rfa group, the only independent risk factor for local recurrence-free + intrahepatic metastasis-free survival was dcp (p= . ). tumor diameter was not significant for recurrence. in hr group, there was no risk factor for recurrence. in pathological analyses of hr group, dcp had a tendency to associate with microvascular invasion (p= . ). conclusions: rfa was effective for hcc < cm in diameter and dcp < mau/ml. hepatic resection should be selected for single hcc with dcp > mau/ml even though hcc < cm in diameter. background: radiofrequency ablation (rfa) is now a common treatment for small hepatocellular carcinoma (hcc). however, critical complications after rfa such as rapid intrahepatic dissemination have been reported. in this study, we investigated the method how to estimate the malignant potential of small hcc by dynamic ct before rfa. methods and results: firstly, hccs less than cm in diameter were analyzed. those tissues were classified into groups as followed, small nodular type with indistinct margin (type e), simple nodular type (type ), simple nodular type with extranodular growth (type ), confluent multinodular type (type ). in the type and groups, portal invasion over vp were observed more frequently than those in the type and e groups. at the next step, these hccs were classified into above-mentioned types by two radiologists according to the shape of early stain or defect of delay phase of dynamic ct before operation. the accorded rate was % between those classifications. next, patients, which had solitary hcc less than cm in diameter and treated with rfa, were classified into those types by dynamic ct before rfa. the recurrence rate and prognosis of those patients were examined. in the type and groups, the recurrence rate was higher and significant worse prognosis was showed than those in type and e group . conclusion: it was suggested that hcc with type and might process higher malignant potential and rfa should be carefully performed on those types of hcc. background/aims: hypoxia-inducible factor- (hif- ) is the central transcriptional factor in the cellular response related to various aspects of cancer biology, including proliferation, survival, angiogenesis, and extracellular matrix metabolism to hypoxia. il- became known to replace hif- functions in the other cancer cell lines. the aim of this study was to evaluate whether il- may induce angiogenic factors without hif- by inflammation signal of hypoxic condition. methods: hif- knockdown cell lines of hcc (huh and hepg ) were constructed by rna interference tools, and cultured under normoxia ( %o , hours) and hypoxia ( %o , hours) conditions. following transfection, the amounts of hif- , il- , angiogenic factors and matrix metalloproteinase (mmp) were examined using rt-pcr and western blotting, respectively. results: the expression of hif- , angiogenic factors, mmp, il- was markedly enhanced in wild types that were cultured under hypoxia, and the hypoxic induction of angiogenic factors and mmp was partially blocked in hif- knockdown hcc cell lines. nf-b inhibitor suppressed angiogenic effects by blocking il- activity. conclusion: these data suggest that il- induced tumor angiogenic factors in hif- knockdown hcc cell lines. background there were some reports that liver caner related to the levele of sera hbvdna our research focused on the relationship between the quantity of hepatocellular hbv cccdna , tdna and liver cancer. methods the samples included the liver tissue of chb patients (chb group) and the para-liver cancer tissue of primary liver cancer patients (phc group) the quantity of hepatocellular hbvcccdna, tdna were assayed by fq-pcr in both groups. result: the quantity of hepatocellular hbv cccdna in chb group was . ± . copys/cell higher than phc group( . ± . copys/cell), p= . ; the quantity of hepatocellular hbv tdna in chb group was . ± . copys/cell higher than that of phc group( . ± . copys/cell),p= . .; conclusion: the quantity of hepatocellular hbvcccdna, tdna can not be used as predictors of liver cancer for hepatitis b patients. hepatic cancer predominantly occurs in males. this is almost a commonsense to most of us. but the detailed mechanisms underlying such phenomenon are still not well-known. the average age of liver cancer patients are about - years old. so most female patients have udergone pregnancy at least one time. pregnancy is a very important event before or during the development of liver cancer in females. in this special period, not only sex hormones secrete in a strange manner, but also immune system functions in a special module which is very different from normal. so it is urgent to investigate the impact of process of pregancy on the development of hepatic cancer. in this study, female sd rats are randomly divided into two groups: pregance group and controll group. rats in both groups are injected iv diethylnitrosomine(a chemical carcinogen). in pregnance group, rats are raised together with male rats in : ratio( female, male) to make every rats undergo pregnancy. while in controll group, rats are coupled with spermaduct-ligated male rats. the size and amount of hepatic cancers in pregancy group are smaller and less than those in controll group. the survial rate is also significantly higer than that in controll group. we conclude that the process of pregnancy exerts an inhibitory role in the development of chemical induced hepatic cancer in rats. acknowledgement: this project was sponsed by the national natural science foundation of china. the number of the grant is : the use of alpha-fetoprotein measurement in detection of recurrent hepatocellular carcinoma after living donor liver transplantation n. yamashiki , , y. sugawara , , s. tamura , r. tateishi , h. yoshida , j. kaneko , y. matsui , n. kokudo , , m. omata organ transplantation service, department of gastroenterology, university of tokyo, department of surgery, university of tokyo background: the recurrent hepatocellular carcinoma (rhcc) after liver transplantation (lt) can occur in to % of transplant recipients despite with a careful patient selection. for the surveillance of rhcc, frequent measurement of alpha-fetoprotein (afp) and annual ct scan is commonly used. however, the usefulness of afp is not clear. we report the update of our experience using our surveillance protocol. methods: between and march , adult living donor lt were performed at the university of tokyo. among them, recipients with hcc in their explanted liver were subjected to analysis. we used monthly measurement of afp and des-gamma carboxy prothrombin (dcp) with annual dynamic ct scan. results: met milan criteria pre-operatively and did not. were incidental hcc. rhcc was experienced in patients at ( - ) months after lt. recurrence sites were graft ( ), lung ( ), bone ( ), and multiple organs ( ). rhcc was first suspected from elevation of tumor markers in ; afp in , dcp in , and both afp and dcp in . rhcc was confirmed with ct scan ( ) or mri ( ) in ( - ) months after the first sign of rhcc. when the cutoff level of afp> ng/ml was used, the sensitivity and specificity for rhcc were % and %. six cases were treated surgically of which two achieving prolonged survival. conclusions: although the confirmation of the rhcc sites required multiple imaging studies, afp measurement was useful as for the first sign of rhcc. purpose: to evaluate the therapeutic effect of heated ( c) lipiodol via hepatic artery administration in vx rabbit liver cancer model. materials and methods: thirty male new zealand white rabbits were randomly divided into groups with rabbits for each group. vx carcinoma cells were surgically implanted into the left liver lobe. the tumors were allowed to grow for weeks, and studies were performed until the diameter of tumors detected by ultrasonograph reaching to cm. under the anaesthesia, transcatheter hepatic arterial embolization was performed and doxorubicin-lipiodol ( ºc) ( ml), lipiodol ( ºc) ( ml) and control (physiological saline ( ºc) ( ml)) were injected into hepatic artery of the different groups. one week later, the volume of tumor was measured by ultrasonograph again. the serum of all rabbits was collected before injection and at and days after injection and the level of aspartate aminotransferase (ast) was checked. the survival period of groups of rabbits after treatment was also recorded. during the last course of their disease, the rabbits were given some analgetics to relieve suffering. results: the tumors' growth rate in lipiodol ( ºc) background/aims: hepatocellular carcinoma (hcc) is one of the male-dominant cancers, and hepatitis c virus (hcv) is one of the causes of hcc. it was reported that androgen receptor (ar) is expressed in hcc and its surrounding tissues. androgen signaling and ar may be involved in hepatocarcinogenesis. in this study, we investigated whether hcv interacts with androgen signaling in human hepatocytes. methods: hcv protein expression vectors were co-transfected with ar-expression vectors and ar-responsive element-driven reporter vector into immortalized human hepatocytes (ihhs) and human hepatoma cell lines. kinase inhibitors were used to examine the activation of the akt, mapk, and jak/stat pathways. real-time pcr and western blotting were performed. cell culture grown hcv (hcvcc) were also used, and angiogenesis was evaluated by tubule formation assays in human coronary microvascular endothelial cells in the presence of -androgen- -ol- -one. results: hcv enhances ar-responsive gene expression in the presence of androgen. hcv core protein has the strongest effects and induced ar activation associated with jak/stat signaling. hcvcc enhances vegf mrna expression and angiogenesis. conclusions: hcv core protein is an enhancer in androgen signaling and can be expected to play an important role in hcv-related hepatocarcinogenesis. background: to evaluate the therapeutic outcomes and the toxicity of the combination of arsenic trioxide and the chinese traditional jianpiliqi (jplq) formula in the treatment of advanced hepatocellular carcinoma (hcc). methods: patients with advanced hcc, not suitable for resection but with normal major organ functions, were enrolled to receive a therapeutic regimen consisting of intravenous arsenic trioxide ( mg / m ) administration from days - , and an oral administration of jplq formula twice daily from days - . each cycle was composed of days and treatment could expand up to cycles before evidences of intolerable toxicity or disease progression. result: one patient had partial response, one had minor response, showed stable disease and ( . %) had disease progression. total disease control rate was . %, median survival time was . months ( - . ms), and time to progression was . months ( - . months). the incidences of grade - abdominal distention and nausea/vomiting were . % and . %, respectively. increases in ggt occurred in patients ( grade , grade , and grade ) and increases in serum creatinine in patients ( grade and grade ), respectively. conclusion: compared with the single arsenic trioxide treatment reported in past literature, treatment by arsenic trioxide combined with jplq showed modestly higher anti-tumor activity and tolerable toxicity in patients with advanced hcc; its manageable toxicity and increased tumor response rate may offer a better treatment regimen, and deserve further investigation. aim: to investigate the effect of osteopontin (opn) expressions down-regulated by rna interference (rnai) on the invasion and metastasis of human hepatocelluar carcinoma (hcc). methods: hcc cell line (hcc-lm ) was transfected with the chemically synthesized small interfering rna (sirna) in study arm and with non-specific sirna in control arm. real-time pcr and western blotting were used to quantify the mrna and opn protein levels. the malignant phenotypes including cellular growth rates, colony formation and matrigel invasion activities of the hcc cell line were analyzed. results: in study arm opn mrna expressions decreased % and opn protein decreased % compared to those of blank arm. the number of formed colonies and migrating numbers of the cells in vitro decreased significantly ( . % and . % respectively) in study arm compared to these of blank controls (p< . ). the parameters in the control arm did not differ from those of the blank arm (p> . ). conclusion: the specific sirna was able to reduce opn expressions at both the mrna and protein levels and significantly diminished the invasiveness of hcc cells. methods: the expressions of mif and vegf in hcc and adjacent tissues were detected from patients. specific sirna targeting mif gene was synthesized, and transfected into the hcc cell lines (plc and hepg ) in study group and non-specific sirna was used in controls. the mrna and protein expressions of mif and vegf were examined by pcr and western blot. results: mif and vegf mrnas were overexpressed in the hcc tissues compared with adjacent tissues (rq= . ± . and . ± . , p . ). the mrna and protein expressions of mif and vegf of hcc cell lines significantly decreased in study group compared with controls (p . ). vegf mrna levels decreased . %± . %; . %± . % in plc, and . %± . %; . %± . % in hepg cells when disposed with sirna nm and nm. vegf protein levels also significantly reduced in study group p . . conclusions mif and vegf mrnas were overexpressed in the hcc tissues in vivo, and mif sirna was able to knock down the expressions of mif and vegf in hcc cell lines in vitro. y.y. li, y.c. zhang, y.j. zhou, y.m. wei aim: to identify tumor-associated genes by constructing transcription profiles of pure hepatocellular carcinoma (hcc) tissues and normal liver tissues with the combination of laser capture microdissection and microarray. methods: hcc cells and normal liver cells from resection samples of patients were laser capture microdissected. micro-rna was isolated from them for linear amplification then crna was tested with whole genome microarray. differentially expressed genes were screened. results: the quality control of this technique was satisfactory with rna integrity number> , a /a ratio for crna measurement= . ~ . and good pictures for microarray. compared with normal liver tissues, hcc had differentially expressed genes, with being up-regulated and being down-regulated genes respectively. among the top ten ranked up-and down-regulated genes (total ), genes were known as hcc differentially expressed genes, , known as other tumors expressed genes previously. four unknown tumor related genes (depdc b, aspm, fcn and bbox ) were detected in this study. conclusion: the combination with laser capture microdissection and microarray was effective in screening the differentially expressed genes of hcc. background/objective: young patients present with large hcc on initial presentation are not uncommon. our aim is to study the computed tomography(ct) imaging of hcc and the clinical features of this special group of patients. methods: hcc patients had ct imaging of liver peformed in a three year period, patients had ct imaging peformed at the time of initial hcc diagnosis in our centre and were selected. they were divided into three age groups: young patients with age </= year-old(group ), age to (group ), age > (group ) to study imaging and clinical factors. univariate and multivariate analysis by cox regression model done to look for prognostic predictive factors. results: infiltrative tumour in ct scans, symptomatic presentation, child's and tm staging are prognostic factors in hcc. conclusion: young hcc patients have larger infiltrative tumour in initial ct scans and more being symptomatic. age is not an independent prognostic factor. aim: to investigate the expression change of nk cells receptor nkg d from human peripheral blood in patients with primary carcinoma of liver and study the relationship between nkg d expression and cytotoxicity of nk cells. background/aims: lens culinaris agglutinin-reactive alpha-fetoprotein (afp-l ) is a specific protein produced by hepatocellular carcinoma(hcc), which is more valuable than afp in the diagnosis of hcc. aptamers are oligonucleotide ligands binding to target molecules sensitively and specifically, which are screened from a great capacity of synthetically oligonucleotide library by systematic evolution of ligands by exponential enrichment (selex). our aims were to select the aptamers against afp-l from a self-designed ssdna library for potential application in diagnosis of hcc. methods: a random ssdna library and its corresponding primers were designed and synthesized. aptamers against afp-l were selected by selex. individual aptamers were separated by polymerase chain reaction-single strand conformation polymorphism (pcr-sscp) analysis and characterized. results: a ssdna library of nucleotides with random nucleotides in middle were designed and used for the selection. the binding rate of library against afp-l was increased from . % to . % after round selection. seven aptamers (s to s ) were isolated, and their sequences in random region and secondary structures were different from each other. all aptamers could bind afp-l in a different extent, and the dissociation constants of s and s are nmol/l and nmol/l. conclusions: aptamers for afp-l are successfully screened out and could bind afp-l specifically. methods: flow cytometry was used to determine the number of nk cells and the expression of nk cells receptor nkg d from human peripheral blood in patients with case primary carcinoma of liver case hepatitis b cirrhosis case hepatitis b and healthy cases and enzyme mark instrument was used to detect cytotoxicity of nk cells in all cases. results: killing rate of nk cell for k cell,nkg d expression level of nk cells, and the number of nk cells in the patients with primary carcinoma of liver decreased significantly p< . compared with those in the healthy subjects and hepatitis b group ,and decreased a little compared with those in the hepatitis b cirrhosis (p> . ).the activity of nk cells showed a obvious positive-correlation with the number of nk cell and expression level of nk cell receptor nkg d. conclusion: the cytotoxicity of nk and the nkg d expression of nk cells decreased significantly from human peripheral blood in patients with primary carcinoma of liver .the activity of nk cells is closely related to the nkg d expression level of nk cells. enhancing the nkg d expression level of nk cell may provide a new idea for adoptive immunotherapy of primary carcinoma of liver. and alpha-fetoprotein afp in serum and tissues for primary hepatic cancer(phc). methods: sixty-six phc and cirrhotic patients were enrolled. in phc patients,male /female was : , age was . ± . .of them, patients were defined as stage a-a. in cirrhotic patients, male /female was : , age was . ± . . serumgpc was detected using elisa. serum afp was detected using electrochemiluminescence. the hepatic expressions of gpc and afp were measured using immunohistochemistry in phc and cirrhotic patients. results: the cutoff value of afp diagnosis for phc was g / l or more, afp positive in phc patients was . % ( / ); the cutoff value of gpc diagnosis for phc was ng / l or more, gpc positive was in . % ( / ), p = . . in a-a stage phc patients,the positive of gpc and afp was . % ( / ), ( / ), respectively,p = . . in serum afp negative or positive patients, the positive of gpc was . % ( / ) , . % ( / ), respectively,p = . . the relationship between gpc with age, sex, child-pugh grade, hbv infection, tumor size and metastasis were not observed.the positive expression of gpc and afp in hepatocellular carcinoma tissue was . % ( / ), . % ( / ), respectively, p = . . neither gpc ,nor afp in the paracarcinomatous and cirrhotic tissue, was expressed. conclusions: diagnosis of glypican- protein for primary hepatic cancer is superior to afp.gpc can be regared as a early marker to diagnosis phc. objective: to investigate the effects and the possible mechanism of curcumin on the proliferation and the invasion of human hepatocellular carcinoma in vitro and in vivo. methods: hcclm -rfp cell lines were maintained in dmem medium supplemented with % fetal bovine serum. the fluorescent areas of hcclm -rfp were photographed daily and repeated in consecutive days after curcumin treatment for obtaining cell growth curves. the cell morphologic changes were also observed. cell invasion experiment was performed with boyden chamber array. the rfp-expressing human hcc xenograft model in nude mice was established to study the anti-tumor effects of curcumin. the ctc was detected by facs. the expression of cyclind and mmp- was detected by sybr green real-time pcr. results: after incubation with m, m and m curcumin respectively for , and hours, the growth of hcclm -rfp was significantly inhibited and some morphologic changes were observed. the mean tumor size in nude mice treated with curcumin since day were significantly less than those of the control group(p . ). the mean metastasis area of lung and the number of ctc in curcumin group on day were remarkably less than in the control group(p . ). the mrna levels of cyclin d p . and mmp- p . in curcumin group on day were significantly lower than in the control group. conclusion: curcumin can inhibit the proliferation and invasion of hcclm cell line not only in vitro but also in vivo mainly by down-regulating the expression of cyclin d and mmp- in mrna levels. phosphorylated erk is a potential predictor of sensitivity to therapy with sorafenib in hepatocellular carcinoma -evidence from in vitro study z. zhang , y.h. wang background: sorafenib is the first agent that has demonstrated an improved overall survival benefit in advanced hepatocellular carcinoma (hcc) and thus sets the new standard for the first-line treatment of advanced hcc. however, it remains unresolved to predict the drug sensitivity in treating hcc with sorafenib. pretreatment perk level has been shown to be associated with favorable response to such therapy in a phase preclinical study, indicating that perk may be a potential biomarker for treatment of hcc with sorafenib. methods: the effects of sorafenib and -fluorouracil on cell proliferation were evaluated by cell viability assay in four types of hcc cell line (smmc- , mhcc -l, mhcc -h and hcclm ), with different metastatic potential and basal perk expression. levels of perk expression were determined by immunocytochemical analysis and quantification, along with western blot analysis. correlation analysis was carried out between the ic values of drugs and mean optical density values of perk. results: the basal perk levels increased stepwise in cell lines in accordance with their metastatic potential. sorafenib inhibited erk phosphorylation at a concentration between and m dose-dependently, while no changes were observed after -fu treatment. correlation analysis between the ic values and mod values of perk revealed that the effects of sorafenib were significantly correlated with basal perk levels (spearman r=- . , p= . ). on the other hand, the resistance to -fu were significantly associated with basal perk expression in these hcc cell lines (spearman r= . , p= . ). conclusions: in this vitro study, perk was confirmed to be a useful biomarker predictive of sensitivity in treating hcc with sorafenib. the raf/mek/erk pathway may be involved in invasion, metastasis and drug resistance to traditional chemotherapy in hcc. background: to investigate the dynamic expression of igf-ii and igfbp- and its alteration of bcl- in hcc. methods: hcc models were induced with -faa on male sd rats. morphological changes of livers were observed and the dynamic changes of liver or serum igf-ii, igfbp- , and bcl- were quantitatively analyzed by elisa. the expression and distribution of liver igf-ii were observed by immunohistochemistry. result: hepatocytes from granule-like degeneration to a typical hyperplasia to hcc and the progressing increasing of the levels of hepatic igf-ii after rats induced by -faa. the levels of igf-ii in hepatoma and sera were significantly higher than any of other groups. the positive relationship of igf-ii was found between liver and sera (p< . ). the igfbp- levels in hepatoma were significantly lower than that in other groups (p< . ) and the progressing increasing of the levels of hepatic bcl- expression during the course. the levels of bcl- in hepatoma tissues were significantly higher than those in normal and degeneration ones. the immunohistochemistry evidences indicated the positive expression and hepatocyte distribution of bcl- in rat hepatoma. conclusion: hepatic igf-ii, igfbp- and bcl- may participate in hepatocyte canceration and accelerate the occurrence and development of hcc. the expression of igf-ii and igfbp- could be useful molecular markers for early diagnosis and prognosis of hcc. background: this study was done to assess the etiological role of hepatitis b virus (hbv), hepatitis c virus (hcv) and aflatoxin b (afb ) in development of hepatocellular carcinoma (hcc) in bangladesh. it was also investigated whether alpha-feto protein (afp) and protein induced by vitamin k absence or antagonist ii (pivka-ii) has any diagnostic advantage over each other methods: fifty five histologically proven hcc patients were tested for serological markers of hepatitis b and hepatitis c, and afb -dna adduct. during the diagnosis, they were also investigated for liver function tests, afp pivka-ii. results: out of fifty five hcc patients, ( . %) were found positive for serological markers of hbv, ( %) for hcv and ( %) for both. eight cases ( . %) were negative for the markers of hbv and hcv. however, none had afb -dna adduct above normal range. both pivka-ii and afp is strong marker for hcc with satisfactory level of sensitivity and specificity; but pivka-ii is more sensitive ( . %) and afp is more specific ( %). conclusions: hbv and hcv is the major etiological agent responsible for the development of hcc in bangladesh. background: to investigate the influences on the malignant transformation of hepatocytes through the intervention of nf-b activation pathway. method: hcc models were induced with -faa on sd rats, thalidomide was administered intragastrically and rats were sacrificed fortnightly interval to the twelfth week. morphological changes were observed by he staining. nf-b expressions were detected by ihc. the relationship between nf-b expression and pathological characteristics in hcc and non-hcc were analyzed. results: rat hepatocytes showed vacuole-like denaturations at the early stages, then dysplastic nodules appeared at middle stage, and finally progressed to tubercles of cancerous nest, all of which were highly differentiated hcc. thalidomine can repress the morphologic change of liver cells. there were only punctiform denaturations at the early and middle stage; nodosity hyperplasy and minority atypical hyperplasia were found at the finally stage. the ihc results demonstrated that nf-b level was significantly higher than those in normal ones, and the nf-b level of livers in hcc was higher than those in thalidomide group. an increasing tendency of nf-b was found from normal to hcc. nf-b in hcc were significantly higher than those in nc. the nf-b levels with thalidomide intervence raised first and decreased later. nf-b expressions in hcc were higher than that in their non-cancerous tissues. no positive relationship presented between nf-b expression and histological differentiation grade or the number of tumor, and size of tumor. conclusion: decrease nf-b expression can inhibit hcc development and nf-b is expected to be a new molecular target of hcc therapy. method: the cellular distributions of vegf expression in hcc tissues were investigated by immunohistochemistry. the levels of total rna and vegf were quantitatively detected in hcc, their paracancerous, and distal cancerous tissues, respectively. simultaneitily, serum vegf were analyzed in patients with chronic liver diseases for clinical values. results: the positive expression showed palm-yellow or palm-brown granules and distributed in hepatocyte plasma of hccs. the incidence of vegf was . % in hcc tissues, . % in non-encapsulated hccs, and . % in hccs with extrahepatic metastasis, respectively. no significant difference was found between hepatic vegf and hcc diameter or differentiation degree. the specific concentration (pg/mg liver) of vegf expression was significantly higher (p< . ) in hcc than their paracancerous or distal cancerous tissues, respectively. the circulating vegf was abnormally elevated in hcc. if the cut off values was more than pg/ml, the incidence of serum vegf was . % in hcc, . % in chronic hepatitis, and % in liver cirrhosis, respectively. the combined vegf and afp can increase positive rate up to . % for hcc. conclusion: the vegf overexpression is a useful marker for vascular invasion and metastasis of liver tumors. background: hepatocellular carcinoma (hcc) represents a major health problem world wide. it accounts for % of all primary liver cancers and is the fifth most common malignancy ( ). objectives: evaluation of radiofrequency thermal ablation versus transarterial hepatic chemoembolization with the effect of viscum (fraxini ) on tumour recurrence. methods: patients with hcc were enrolled in the study. group include patients and were treated with radiofrequency thermal ablation ( patients of them received viscum by subcutaneous route for years). group included patients with hcc and were treated by tace ( patients of them received viscum subcutaneously for years). results: group patients showed total ablation in % with persistant inactivity during years follow up. group did not show significant difference from group as regards relapse rate nor the performance status. complications as nausea, vomiting, fever, jaundice, and elevation of transaminases were significantly more encountered with tace. viscum did not significantly arrest tumour recurrence. conclusion: non surgical patients with hcc can achieve curative treatment with radiofrequency with minmal side effects. tace is a palliative treatment option for large hcc. a new technique had been attempted to increase the field of radiofrequency ablation of expandable electrode needles in the treatment of hepatic neoplasms much larger than the routinely covered size of - cm according to the needle size overcoming the technical difficulties usually met with in the overlapping balls technique due to the hyperechoic focus that develops at the needle tip making reinsertion difficult and inaccurate. in this technique, two or three needles were inserted from the start into the mass with accurate estimation of the exact field of ablation of each needle trying to cover the whole extent of the mass before application of radiofrequency waves. patients were included in the study, all presented with hepatic neoplastic mass lesion that range in size between and cm in its maximum diameter. all had a pretreatment helical (triphasic) ct study for accurate delineation of the whole extent and vascularity of the mass. two needles were sufficient to cover the whole extent of the mass in patients ( %) while in the remaining patients ( %) three needles were necessary. the procedure was done under general anathesia and ultra sound guidance, patients tolerated procedure well with smooth recovery. no major complications. follow up spiral (triphasic) ct was done weeks after ablation revealed percentage of tumour necrosis of % or more in patients ( %), - % in patients ( %) while in the remaining four patients ( %) the percentage was - % necrosis. in conclusion this technique should be considered in the treatment of hepatic masses larger than the usual field of the needle. results: the median value of gpc- in hcc, dc, cc was significantly higher than chronic hepatitis and control groups. no significant correlation found between afp and gpc- . auroc of afp was . & auroc of gpc- was . . the diagnostic sensitivity of afp ( ng/ml) was % with ppv . %. the specificity was % with npv . %. while the diagnostic sensitivity of gpc- ( ng/ml) was % with ppv %. the specificity was . % with npv %. combined serial approach of afp and gpc- improved the specificity to . %. conclusion:gpc- although it is a serological test for early detection of hcc, it showed limited specificity, where it is detected in different stages of chronic liver disease, as it is an oncofetal protein produced by regenerating liver cells. the diagnostic signature approach for simultaneous determination of afp and gpc- may improve the prediction accuracy of hcc patients in those showing seronegativity to afp. outcome of inoperable hepatocellular carcinoma patients receiving transarterial chemoembolization: retrospective analysis in an asian regional hospital w.m. yip , k.f. li , k.k. li , m.l. szeto background: hepatocellular carcinoma (hcc) is a common cancer worldwide causing substantial mortality. although surgical resection is a form of curative treatment in hcc, only a minority of patients is suitable for this treatment and the postoperative recurrence remains high. transarterial chemoembolization (tace) is a treatment option for inoperable hcc and it was proven by randomized control trials that tace can prolong survival in selected patients. the aim of this study is to evaluate the survival and the prognostic factors in patients with advanced hcc treated by tace. methods: seventy four patients with inoperable hcc diagnosed from january to december were analyzed retrospectively in this study. only patients with unresectable hcc or who refused operation were included. patients with advanced cirrhosis, extrahepatic metastasis or previously treated hcc were excluded. multiple host, tumor and treatment variables were analyzed in order to evaluate the predictive factors of favorable response to treatment and better survival. results: the median survival of the study patients was . days. the cumulative survival rates at year, year and year were . %, . % and . % respectively. by multivariate analysis, superselective cannulation performed in tace (hazard ratio: . , % ci: . - . , p= . ), embolization with gelfoam (hazard ratio: . , % ci: . - . , p= . ), treatment interval more than days (hazard ratio: . , % ci: . - . , p= . ), child-pugh grade b (hazard ratio: . , % ci: . - . , p= . ), and pre-treatment serum fp level (hazard ratio: . , % ci: . - . , p= . ) were independent predictors of survival. conclusions: survival of patients with inoperable hcc is still grave despite treatment. this study provided information in predicting the survival of patients with inoperable hepatocellular carcinoma treated by transarterial chemoembolization. result: age < , total bilirubin (tb) < . mg/dl, albumin (alb) . g/dl, prothrombin time (pt) %, platelet counts (plt) . /mm , single nodule, and type of treatment (surgery or local ablation therapy) were linked to increased survival at univariate analysis of clip - hcc patients. of clip - hcc patients, tb < . mg/dl, alb . g/dl, des-gamma-carboxy prothrombin (dcp) < mau/ml, absence of vascular invasion, and type of treatment were correlated with survival. the following factors were related to survival by multivariate analysis: clip - hcc patients; age, alb, single nodule, and absence of vascular invasion, clip - hcc patients; age, tb, alb, alpha-fetoprotein (afp) < ng/ml, dcp, absence of vascular invasion, and type of treatment. conclusion: age, albumin, vascular invasion were significant predictors of survival both clip - and clip - hcc patients. clip - hcc patients: single nodule; clip - hcc patients: lower levels of tumor markers and patients receiving promising treatment had a better chance of prolonged survival. the role of gross classification as the predictor of microvascular invasion in hepatocellular carcinoma. s. sumie , r. kuromatsu , k. okuda , e. ando , a. takata , n. fukushima , m. sata background; the presence of microvascular invasion (mvi) as the risk factor in hepatocellular carcinoma (hcc) is controversial. the aim of this study was to determine the outcomes and predictive factors after hepatic resection for hcc with mvi. methods; one hundred and ten patients who underwent curative resection for hcc were included in this retrospective study. the risk factors of these patients for recurrence-free and disease-specific survival were investigated, and the clinicopathological factors predicting the presence of mvi were also evaluated. result; multivariate analysis showed that cirrhosis and mvi were identified as independent risk factors for recurrence-free survival. the -year recurrence-free survival rates for patients with and without mvi were . % and . %, respectively. multivariate analysis showed that the number of tumors, presence of mvi, and im were identified as independent predictors of disease-specific survival. the -year disease-specific survival rates for patients with and without mvi were . % and . %, respectively. by univariate analysis, mvi was significantly associated with greater tumor size, gross classification, histological grade, and intrahepatic micrometastasis (im). gross classification proved to be the only independent predictive factor for mvi by multiple logistic regression analysis. the gross classification could be evaluated by preoperative imaging diagnosis. conclusion; mvi is strongly associated with recurrence and survival in hcc patients after curative resection. furthermore, gross classification of hcc can be helpful in predicting the presence of mvi. background: hcc is a common cause of cancer morbidity and mortality. pxd is a novel, low molecular weight, histone deacetylase inhibitor. this phase i study aims to determine dose limiting toxicity (dlt) and maximum tolerated dose (mtd). methods: patient eligibilities include unresectable disease, ecog , adequate organ functions. pxd was given intravenously on day - every weeks; dose levels were: (level ), (level ), (level ) and mg/m /day (level ). dlts are defined as grade hematological toxicity or grade / non-haematological toxicity during cycle (according to nci ctc v ), or treatment delay > weeks. the mtd is defined as the dose below which > of or > of patients experiencing dlt. results: patients were entered; level ( ), level ( ), level ( ) and level ( ). grade / / toxicities in cycle included: raised alt / / , diarrhea / / , abdominal distension / / , anaemia / / . a total of cycles were administered; overall grade / / toxicities: raised alt / / , bilirubinaemia / / ; cardiac ischaemia / / ; diarrhoea / / , abdominal distension / / , anaemia / / ; variceal haemorrhage / / ; hypercalcaemia / / ; hyperkalaemia / / ; hyponatraemia / / ; infection / / ; liver dysfunction / / ; muscle weakness / / ; abdominal pain / / ; prolonged qtc / / ; syncope / / ; seizure / / . there were sd and pd. conclusion: at the maximum dose of mg/m /day, mtd has not been reached. pxd is very well tolerated. sponsor: the division of cancer treatment and diagnosis, national cancer institute, usa. tumor thrombus (pvtt) is prone to be produced in the portal vein near the main tumor nodule for hepatocellular carcinoma (hcc) patients and its molecular mechanism is still unclear. in this study, we first established a hcc cell line named csqt- from resected tumor thrombus in portal vein in a patient with histopathologically proved to be a moderately differentiated hepatocellular carcinoma . this cell line was composed of polygonal shaped cells and its peaks of the chromosome number was and . study on stem cell biology in this cell line suggests that cd cells represent about one fourth of the tumor cell population and cd (+) cells possess a greater colony-forming efficiency, higher proliferative output, and greater ability to form tumor in vivo. with this cell line model and resected tumor thrombi specimen, we also studied the different expression of proteins in primary tumor and tumor thrombus and found proteins expressed differentially between primary tumor and the pvtt. from these proteins, annexinv, prx , cycb were selected for further analysis to find potential biomarkers of pvtt in hepatocarcinogenesis. for clinical study, we recommended a new tumor thrombus type system ( type i iv) according to anatomic features of portal vein and tumor thrombus of hcc developing modes, then evaluate this type system to predict prognosis of hcc patients. the retrospective data of hcc patients with pvtt underwent resection shows that the y, y, y overall survival rates were . , . and . for type i, . , . and . for type ii, . , . and . for type iii, . , and for type iv, respectively, suggests tumor thrombus type system may be helpful to determine treatments and prognosis of hcc patients with pvtt. polyprenol could decrease the risk of hepatocarcinogenesis in hbv g. kuznecova , , s. kuznecovs , , i. kuznecovs , background: over-expression of p-glycoprotein (pgp) is associated with liver cancer development from hbv . glycoprotein synthesis in malignant tissues is limited by dolichyl phosphate (dolp). the aim of the present study was to investigate the effect of polyprenol (pp) which provides a dolp substitute in regulation of n-glycosylation on pgp over-expression in the development of liver cancer in hbv infection. methods human hepatocytes, infected with hbv and human hepatocarcinoma hep b cell line were used. pgp was assessed by an immunohistochemical technique. dolp fractions were analysed by hplc methods. results it is confirmed that plasmatic membrans of hepatocytes cells contain , - , % of pgp (the total protein amount) as a resistance marker. hbv infected cells differ from normal hepatocytes in pgp content by - times and hep b cells differ by - times the study showed -fold dolp decrease in hbv infected cells and -fold dolp decrease in hep b cells. the investigations demonstrate that the situation can be changed by treatment with dolp and pp. the dolp concentration in hbv infected hepatocytes was returned to the normal level. it is established that dolp in the concentration - m aid - -fold reducing pgp in membranes of hbv infected cells. background: metastasis is one of the most complicated and major pathological processes responsible for poor prognosis of hepatocellular carcinoma. snail was recently highlighted as a critical transcriptional factor for tumor metastasis. method & result: real time rt/pcr and western blot analysis demonstrated that snail mrna and protein, respectively, were induced by -otetradecanoylphorbol- -acetate (tpa) in hepatoma cell hepg . blockade of gene expression of snail by antisense oligodeoxynucleotide and/or sirna technique can prevent not only the tpa-triggered emt/cell migration and growth inhibition of hepg but also tpa-induced down-regulation of e-cadherin and up-regulation of p ink b. moreover, the tpa-triggered promoter activation of p ink b was also prevented. on the other hand, two of the hepg clone overexpressing snail, namely s and s , had a scattered fibroblastic morphology and acquired higher motility than parental hepg . also, the proportion of g /g phase of s and s was higher than that of parental hepg , consistent with the longer doubling time of both cells. semiquantitative rt/pcr analysis demonstrated a greatly elevated gene expression of snail accompanied with decreased e-cadherin and increased p ink b in both snail-overexpressing cells. on the transcriptional level, p ink b promoter activity was . -fold higher in s as compared with parental hepg . furthermore, electrophoretic mobility of dna fragments encompassing proximal p ink b promoter can be retarded by incubation of nuclear extract of s . conclusion: our results demonstrated that snail play diverse trans-regulatory roles in hepg . notably, we suggested that snail may upregulate p ink b gene expression by directly activating its promoter. a. schmitt-graeff , r. fischer , m. grosse-perdekamp , o. skalli universityhospital freiburg , louisiana state university health sciences center, shreveport background/aims: synemin is an intermediate filaments (if) protein which affects the motility of several cell types by modulating the dynamic properties of alpha-actinin and f-actin. we have previously shown that synemin is expressed in resident hepatic stellate cells (hsc) and myofibroblasts (mf) in hepatic inflammation and fibrosis. in the present study we evaluated systematically the expression of synemin in a large cohort of western european hepatocellular carcinoma (hcc). methods: single and double immunolabelin for alpha-smooth muscle actin (sma), vimentin, cd , cd , cd , cea, cd , cellular retinol-binding protein (crbp- ) and synemin were performed on paraffin-embedded hccs and controls. results: synemin-positive hscs/ mfs were a hallmark of non-neoplastic fibrotic liver tissue at the border to the neoplastic lesion but were absent from normal controls. tumour cell plates of the trabecular and pseudoglandular types of hcc were covered by scattered synemin-positive cells outlining sinusoidal structures. a subpopulation of these cells showed features of pericytes while others resembled endothelium. this pattern correlated with the degree of differentiation and was not observed in poorly differentiated hccs which generally contained rare intratumoral mfs. conclusion: the presence of synemin-positive hscs/mfs in the vicinity of hccs suggests a possible contribution of mesenchymal cells to the promotion of liver carcinogenesis. since synemin expression is linked to motility, a migration of this cell type into the tumour and a differentiation in vascular mural cells may be implicated in sinusoidal remodeling and the expansion of the neoplastic population. a.s. butt , a. ahmed , s. hamid , w. jafri , h. ali shah aim: to estimate the prevalence of viral marker negative hcc and to compare the clinical, biochemical, histological, radiological characteristics and initial treatment response among patients with viral marker negative and viral marker positive hcc. methods: medical records of patients diagnosed to have hcc visiting aga khan university hospital, karachi during january to december were reviewed. patients were divided in to nbnc-hcc(those who have negative hbsag and anti-hcv antibody)and viral hcc(those who have positive hbsag and anti-hcv antibody)group. results: out of patients ( . %) had nbnc-hcc. over all mean age was . ± . years and . % were males. the proportion of hcc detected under surveillance was significantly smaller in nbnc-hcc group(p . ). there was no difference in distribution of age, gender, bmi, child score, bilirubin, serum albumin, prothrombin time and alfa feto protein in both groups. however, patients with viral-hcc were found to be more thrombocytopenic( . ± . vs. . ± . ,p< . ) and had hepatopulmonary syndrome. on liver biopsy greater proportion of moderate to poorly differentiated hcc was observed in nbnc group( . %vs. . %,p< . ). hcc measuring cm in diameter( . %vs. . %, p . ), non -solitary hcc(p . ) and portal thromboses(p . ) were strongly demonstrated in nbnc-hcc group. involvement of right hepatic lobe and extra hepatic tumor spread was greater in nbnc-hcc group but that difference was not statistically significant. out of patients who underwent for liver transplantation( . %),tace( . %),resection( %),ethanol ablation( %) and chemotherapy( %), poorer responses were observed in nbnc-hcc group (p . ). conclusion: hcc secondary to nbnc-cirrhosis is not uncommon. patients with nbnc-hcc tended not to be under surveillance that leads to diagnoses at more advanced stage and poor prognosis. background: hepatocellular carcinoma is a common malignancy in asia and is related to the high prevalence of chronic viral hepatitis. we examined the clinical features, treatments and survival rates in asian americans with hcc. methods: retrospective cohort study of hcc patients who presented to the ucla liver cancer center in los angeles, california, usa from september to december . results: two hundred and seventeen of ( %) hcc patients were male, % and % had hbv and hcv infection respectively, and % had cirrhosis. hcc patients detected by surveillance had smaller tumor sizes, more within the milan and ucsf criteria, lower hcc tokyo system scores and had improved , , year overall patient and disease free survival rates compared to hcc patients who presented with symptoms (p< . to p< . ). by multivariate analysis, independent predictors of patient survival were tumor volumes greater than cm (hr . , p= . ), afp per unit log increase (hr . , p= . ), hcc tokyo score per unit increase (hr . , p< . ), liver transplantation (hr . , p< . ), hepatic resection (hr . , p< . ), rfa (hr . , p< . ), tace (hr . , p= . ), and hepatitis b infection (hr . , p= . ). factors associated with disease free survival were age per year increase (hr . , p= . ), meld per unit increase (hr . , p= . ), liver transplantation (hr . , p< . ), and hepatic resection (hr . , p< . ). conclusion: hbv and hcv infection accounts for the majority of hcc in asian americans. hcc detected by surveillance resulted in treatments which improved overall patient and disease free survival. treatment of small ( cm) hcc tumours can be achieved by surgical resection and complete eradication always correlates with good patient's outcome, with low local recurrence and high survival rates. indeed, surveillance program for the early detection of small hcc tumour is imperative to facilitate curative treatment, and hence better survival. discovery of new blood-based biomarkers is obligatory and vimentin is a distinct novel small hcc tumour marker herein identified using proteomics. experimental design: a total of liver tissues were evaluated by -de analysis. differentially expressed proteins were unequivocally identified by maldi-tof/tof and validation of the best candidate from protein to gene levels. indirect elisa assay was developed to detect soluble vimentin from serum samples. results: vimentin was significantly over-expressed in small hcc tumours compared to non-malignant controls and maintained expression in > cm tumours using -de analysis. blind verification displayed over-expression of vimentin in both transcripts and proteins levels. soluble vimentin was significantly detected at high level in small hcc as well as in overt hcc tumours. receiver operating characteristic analysis showed vimentin exhibited . % sensitivity and . % specificity in detecting small hcc at a cutoff of ng/ml. combined diagnostic performance of soluble vimentin and serum afp increases the detection sensitivity and specificity to . % and . %, respectively. conclusion: in this context, over-expression of vimentin is associated with the favourable cm sub-class of hcc thus may potentially be used as an effective serum-based diagnostic marker for cancer surveillance in high-risk cirrhotic patients. purpose: our recent comparative oncogenomic analysis in mouse model has identified yap (yes associated protein) as a novel oncogene in hcc. however, its clinical significance is unknown. in this study, we aimed to investigate the clinical values of yap as an independent prognostic marker in hcc. experimental design: a total of hcc cases with retrospective clinicopathologic and follow-up data were recruited in this study. both tumor and adjacent non-tumor tissues were examined for immunoreactivity of yap expression by immunohistochemistry. clinicopathologic features and yap expression were investigated with pearson test. hcc-specific disease free survival and overall survival with yap expression were analyzed by kaplan-meier curves and log-rank test. cox regression was used to test the independence and magnitude of the effects. results: yap was found over-expressed in hcc ( . %) with nuclear expression pattern. positive yap immunoreactivity was significantly correlated with worse tumor differentiation grade (p= . ) and high serum alpha-fetoprotein (afp) level > ng/ml (p< . ). kaplan-meier plot and cox regression showed that yap was an independent predictor for hcc-specific disease free survival (hazard ratio, . ; % ci, . - . ; p= . ) and overall survival (hazard ratio, . ; % ci, . - . ; p= . ). conclusions: yap expression in hcc is correlated with tumor differentiation and serum afp level. it served as an independent prognostic marker for hcc. background: integrative analysis of global protein and mrna expression patterns could help researchers to understand cancer cell physiology without the need of any prior hypothesis. methods: we used a d-page approach to profile and compared the global protein expression profiles of hepatitis b virus-related hcc tissues, adjacent non-tumor liver tissues, normal liver tissues and hcc cell lines. subsequently, we established the bioinformatic tools for integrative analysis of gene expression and protein expression data. we compared the dysregulated protein list and the dysregulated gene lists obtained by meta-analysis of microarray gene expression data from research centers in different countries. results: we identified proteins dysregulated in hcc. hierarchical clustering analysis revealed that there was a progressive change of protein expression patterns from normal liver, adjacent non-tumor liver tissues, hcc tissue, then to hcc cell lines. according to the biological functions, the differential proteins could be classified into various groups, including heat shock protein, chaperone, kinase substrate, cell signaling, apoptosis regulation, transcription regulation, free-radical scavenger and metabolic enzyme. ontology analysis of the genes with consistent dysregulations at both mrna and protein levels identified specific pathways down-regulated during the progression of hcc. the inhibition of those pathways provides new insights in the hepatcarcinogensis and treatment strategies. results: in pre-s/surface regions, hcc patients had higher frequencies of pre-s deletions, amino acid substitutions at codon , , and in pre-s genes, at the start codon in pre-s genes, and at codon in surface genes. but they had a lower frequency of amino acid substitution at codon in pre-s genes than those without hcc. in bcp/precore regions, hcc patients had higher frequencies of c or g , a /t , t , and a than those without hcc. multivariate analysis showed that pre-s deletions, i t in surface gene, t /a , and a were independent factors for hcc. the hbv with a complex mutation pattern (pre-s deletion, t /a , and a ) rather than a single mutation was associated with hcc. patients with combined mutations of t /a and pre-s deletion, t /a and a , pre-s deletions and a , and t /a , pre-s deletions and a had a . , . , . , and . fold increased risk of hcc, respectively, compared to patients with wild-type at both or three genomic regions. conclusions: pre-s deletions, i t in surface gene, t /a , and a were independent factors for hcc. combination of these viral mutations appeared increasing hcc risks. high peritumoral expression of placental growth factor in hepatocellular carcinoma is a poor factor for survival after curative resection h.x. xu , x.d. zhu , p.y. zhuang , w.zhang , h.chuan sun background/aims: angiogenesis plays a significant role in the metastasis and recurrence of hepatocellular carcinoma (hcc). placental growth factor (plgf), which is one member of the vascular endothelial growth factor family, may have prognostic values in patients after curative resection of hcc. methods: expression of plgf was assessed by immunohistochemistry in tissue microarray containing paired peritumoral liver tissue and tumor from patients underwent hepatectomy for histologically proved hcc. prognostic values of plgf and clinicopathological factors were evaluated. result: plgf staining was mainly on the cytoplasm of tumor cells or hepatocytes. the mean integrated optical densities of peritumoral and intratumoral density of plgf were . ± . and . ± . respectively. peritumoral plgf density was significantly higher than that in tumor (p< . ), and this result was also validated in another cohort of patients by quantitative real-time reverse transcription-pcr (p= . ). intratumoral density of plgf was not correlated with common clinicopathological factors (eg, tnm stage, tumor size, microvascular invasion, intra-hepatic metastasis) or overall survival (os) (p= . ) and time to recurrence (ttr) (p= . ). however, peritumoral density of plgf, which was correlated with tumor size (p= . ) and intrahepatic metastasis (p= . ), was a prognostic factor for both os (p= . ) and ttr (p= . ). in multivariate analysis, peritumoral expression of plgf was also an independent prognostic factor for os (p= . , rr: . % ci: . - . ) and ttr (p= . , rr: . % ci: . - . ). conclusion: peritumoral expression of plgf in hcc patients is an independent risk factor for survival and recurrence, and may be a target of anti-angiogenic therapy in preventing post-operative recurrence. purpose: to further research rfa in combination with hepatic artery-portal vein chemotherapy and ethanol injection for treatment of advanced hepatocelluar carcinoma (hcc). methods: cases were treated with transhepatic artery chemoembolization (tace) + radiofrequency ablation (rfa) + introportal vein chemotherapy (pvc) + percutaneous ethanol injection (pei) (four combined group) and this method was compared with cases that were performed tace + pei (two combined group) . the serum level of afp was measured respectively after and months, ct scan and color doppler ultrasound were measured after treatment for six months. results: the serum level of afp declined in two groups after months. for treatment after six months, afp in four combined groups was rose lower than two combined group (x = . , p< . ). ct and doppler ultrasound examination, four combined groups was superior than two combined groups to the control in tumor shrinkage (x = . , p< . ) and blood supply x = . , p< . ), relapse and mortality are also less. conclusions: rfa in combination with hepatic artery-portal vein chemotherapy and ethanol injection is a safe, effective combined method and has less complication in treatment of advanced hcc. poster exhibition -hcv poster session, hall b on the average, hepatitis c virus infects . % of the population worldwide. in egypt, the prevalence rates reach % in some areas. ability of the virus to persist in about - % of infected individuals is related to the virus higher mutation rate. six major hcv genotypes have been identified. genotype seems to be confined to the middle east and central africa. extra hepatic syndromes have been reported in up to / of hcv patients. we aim in this study to determine the relationship between viral genotypes and specific extra hepatic haematological disease in patients with chronic hepatitis c. the study group included selected patients with chronic hepatitis c having various haematological problems. we studied hepatitis c virus genotypes using rt-pcr. we found among patients , genotype ( %) and patients genotype a ( %). patients ( . %) were diagnosed as chronic hepatitis c with associated thrombocytopenia, patients ( . %) were diagnosed mixed essential cryoglobulinemia(mec), patients ( . %) were diagnosed non-hodgkin's lymphoma, and patients ( %) were aplastic anemia. positive serum cryoglobulins level was found in patients ( . %).no significant correlation was found between the level of viraemia and specific haematologic disease, biochemical liver markers or liver enzymes (p> . ). we did not find correlation between hcv genotype and specific extrahepatic haemological disorder in hcv infected patients. several environmental, genetic and immunological factors may contribute in disease progression. results: in the targeted area shops of barbers were successfully interviewed and total questionnaires were filled by both groups. the mean age were found in both groups of barbers (n= ) and clients (n= ), . years. the both groups showed that there are no any drugs which can protect us from diseases. both of the groups were not vaccinated for hepatitis b diseases. regarding the care providers the barbers replied that they prefer registered medical practitioners and the clients generally prefer the hakeems. those who knew hepatitis as liver disease, were ( . %), out of barbers only ( . %) were knowing about hepatitis-b&c, when we enquired about routes of hbv& hcv transmission only ( %) replied correct routes of transmission in both groups. about hbv vaccination ( . %) were aware, only ( . %) were vaccinated against hbv. % barbers claimed for disinfection of instruments before shaving ( . %) claimed for use of new blades. in the sero-surveillance the hbv found was very low and hcv became epidemic ( . % - . %) respectively. conclusion: the both groups need awareness for transmission. the use of new blade for the clients reduces the burden of hbv and hcv. the study highlights the roles of male sex, older age, and genotype b in the progression from chc infection to hcc. patients with higher hcv viral load potentially tend to develop hcc; however, hcc occurrence could be prevented using antiviral treatment. these two points need to be clarified further by a larger study population with longer follow-up period. an approach have recently been described that retroviral vectors encoding t cell receptor (tcr) genes are used to redirect the specificity of normal peripheral blood lymphocyte (pbl)-derived t cells to recognize the tumor antigens. the therapy in which t cells have been genetically modified with tcr genes to recognize hcv would represent a novel approach for the treatment of hcv infections and hcv-related malignancies. we have previously shown that hcv+ liver transplant patients that have received hla disparate liver allografts have hcv reactive t cells of host origin in their peripheral blood that are restricted by the donor hla molecules. initial studies indicate that the tcrs expressed by hcv reactive t cell clones from these patients have relatively high affinity for their ligands. we have cloned and expressed two tcrs which mediate recognition of the - and - epitopes from the hcv ns protein. the results indicate that these tcr transduced t cells can recognize the wild type epitopes, as well naturally occurring mutant variants of these epitopes. most importantly, the tcr transduced t cells could also recognize hcv+ hepatocellular carcinoma cells. these data suggest this high affinity hcv-specific tcr might have potential new immunotherapeutic implications. background: factors associated with svr in patients without an rvr remains unclear. methods: hcv- ( for and weeks, separately) and hcv- ( for weeks, for weeks) patients were randomized to peginterferon-alpha- a and ribavirin for analysis. results: multivariate analysis showed that treatment duration and a complete evr were the strongest independent factors associated with an svr. a higher svr rate and a lower relapse rate were observed in the standard regimen group than in the abbreviated group in patients who had a cevr (table ). the best levels of viral loads in predicting cevr at week were < iu/ml (table ) . conclusion: it was crucial to achieve a cevr with adequate treatment duration in patients who failed to achieve an rvr. our aim was to evaluate the impact of some biochemical, histological and viral factors on both evr and svr in patients with genotype chronic hepatitis c (chc) treated with peginterferon plus ribavirin. patients and methods: we evaluated retrospectively naïve patients with chc treated with peginterferon plus ribavirin at standard weight-based doses for weeks. biopsies were assessed for inflammatory activity and fibrosis. steatosis was categorized by the proportion of hepatocytes per low-power field with fatty changes: > %, > - %, - %, > %. biopsies were also assessed for stainable iron using the brissot scoring system. all patients were evaluated for metabolic syndrome (ms) using the ncep-atp iii criteria. results: evr was achieved in / pts ( . %) while svr occurred in / ( . %). after adjusting for sex and age, independent factors that negatively interfered with both evr and svr were: fibrosis score, steatosis, iron score, homa-ir index and viral load. after excluding the patients with ms criteria (n= ), evr was observed in / ( . %) and svr in / ( . %). factors that independently influenced both evr and svr were: fibrosis score, steatosis, iron score and viral load. conclusion: fibrosis, steatosis and iron scores, as well as viral load are independent parameters that can affect both evr and svr in genotype chc patients, regardless the presence of ms. if ms is present, high homa-ir index can also additionally impair viral response. issue/argument: asia has rising cases of hepatitisb/c. alcohol/food-habits cause high prevalence in rural/tribal areas. lack of monitoring/follow-up complicates management. vaccines emerge as hope. clinical-trials of vaccines debated-issue. design of hepatitis-vaccine-trials in developing-countries complex ethical-issue. we focus on controversies identified in international/regional/local cme/pharma programs as vulnerability of volunteers to exploitation by foreign/local research-groups/funding-agencies. critical task is protect interests of vaccine-subjects in face of substantial-risks. determine if hepatitis-vaccine-volunteers will have access to treatment during trial. access to vaccine-trial-outcome. interaction with seniors th apasl-congress from developed-countries will give voice to such burning-issues. methodology: researchers/pharmaceuticals/govt-policy planners need to develop forum to solve these problems. ngo's can play pivotal role. obligation on part of researchers to create mechanisms to offset anticipated risks of participation in controversial, risky vaccine-development. conclusion: counselling/right to withdraw from trial be made basic guideline. apart from monetary aspects unsuspected adverse reactions/deaths be properly evaluated/monitored. researchers need to evolve policy-guidelines to overcome barriers as variation in interpretation of essential ethical ideas, legal-system-differences, educational/economic-status. need to develop common consensus between research-community/pharma sector to reduce suffering of hepatitis-affected patients community. recommendations: researchers/ngos should come together at th apasl-congress platform to form workgroup to settle these issues. we shall raise our this burning issue & present hepatitis-prevention-advocacy plan of our ngo graphically to apasl- participants. results: % patients expressed that alternative-medicines-rx most important factor to cope with hepatitis. higher scores of qol (anova p < . ) correlated with alternative-medicines-rx. our ngo-initiative suggests that over % patients will need well trained specialist for home-based-care unit. conclusions: life-span/qol of hepatitis-sufferers depends on appropriate-palliative-care. ngo-personals should be trained in palliative-care-services. our data is being used for palliative care advocacy. field of spiritual/psycho-social/community support is fertile ground for further investigations. such use of complimentary indian medicinal plant extracts needs further evaluation in a large group in multicentre trial. treatment with adacolumn in patients with hepatitis c related who have undergone kidney transplantation: preliminary study g. novelli la sapienza university introduction: patients who have undergone kidney transplant and suffer from hepatic c related (hcv) cannot be treated with standard therapy (peg-ifn combined with ribavirine) due to acute rejection risk. furthermore, immuno-suppressive therapy facilitates progression and infection and chronic hepatopathesis. monocytes and macrophages are known to produce extra-hepatic breeding sites and spread disease. our aim was to lower macrophages, granulocytes,monocytes, pro-inflammatory cells and viremia levels using an extra-corporeal device:adacolumn®(otzuka). methods: the adalcolumn filter is filled with mm. cellulose acetate beads immersed in sterile saline solution. these carriers absorb granulocytes and monocytes/macrophanges through fcr receptors. six patients were treated in our department. all patients were affected by virale genotype b. patients underwent five hour treatments for five consecutive days according to protocol. results: during treatment cycles and successive follow ups we observed a stabilization of kidney parameters and a non significant decrease in transaminase levels. at rd month follow up we observed a significant decrease in plasma hcv-rna in patients (p< . ) associated with attenuation of inflammatory phase (p< . ) and variations in immunomodulation. only one patient presented altered cd + and cd + where positive was observed at rd month. in another patient, even though immunomodulation improved, there was no reduction in viremia. conclusions: considering the results this method should be used on a greater number of patients evaluating successive treatment times in case of viremia increase. background: patients who have undergone kidney transplant and suffer from hepatic c related (hcv) cannot be treated with standard therapy (peg-ifn combined with ribavirine) due to acute rejection risk. furthermore, immuno-suppressive therapy facilitates progression and infection and chronic hepatopathesis. monocytes and macrophages are known to produce extra-hepatic breeding sites and spread disease. our aim was to lower macrophages, granulocytes,monocytes, pro-inflammatory cells and viremia levels using an extra-corporeal device:adacolumn®(otzuka). methods: the adalcolumn filter is filled with mm. cellulose acetate beads immersed in sterile saline solution. these carriers absorb granulocytes and monocytes/macrophanges through fcr receptors. six patients were treated in our department. all patients were affected by virale genotype b. patients underwent five hour treatments for five consecutive days according to protocol. results: during treatment cycles and successive follow ups we observed a stabilization of kidney parameters and a non significant decrease in transaminase levels. at rd month follow up we observed a significant decrease in plasma hcv-rna in patients (p< . ) associated with attenuation of inflammatory phase (p< . ) and variations in immunomodulation. only one patient presented altered cd + and cd + where positive was observed at rd month. in another patient, even though immunomodulation improved, there was no reduction in viremia. conclusions: the treatment was found to be safe without hemodynamic or infective complications. considering the results this method should be used on a greater number of patients evaluating successive treatment times in case of viremia increase. m. sharaf-eldin , h. el batae , n. abd el-ghaffar , w. rasheed tanta faculty of medicine , egypt., national research centre, cairo, egypt aim: we aimed to characterize serum cytokine levels of interleukin- beta (il- ) and interleukin - (il- ) in hcv infected patients & in patients with hepatocellular carcinoma (hcc) in comparison to control group and their possible use as markers of disease progression. patients and methods: sixty patients were divided into three groups: group i: twenty hcv infected patients without cirrhotic changes. group ii: twenty hcv infected patients with liver cirrhosis (lc). group iii: twenty hcv infected patients with hcc and healthy subjects as control group. all patients and control group were subjected to biochemical and serological tests, anti hcv, hcv (rt-pcr) and cytokines measurements of serum il- & serum il- levels. results: showed a high statistically significant elevated serum il- and il- levels in patients with chronic hcv infection in comparison to control group. highly statistically elevated levels of il- and il- in liver cirrhosis and higher levels were found in hcc group in comparison to control group. the levels of il- and il- increased significantly in hcv infected patients as the disease progress. conclusion: serum il- , and il- levels are elevated in patients with hepatitis c-related liver diseases, especially in lc and hcc patients. their levels reflect hepatic dysfunction better than liver inflammation parameters; accordingly, we may use serum il- and il- as markers for liver disease progression in hcv-infected patients instead of invasive techniques. atsushi tanaka , naoko hanawa , mitsuhiko aiso , yoriyuki takamori , hajime takikawa teikyo university school of medicine background and aim: pegylated interferon (peg-ifn) therapy is not indicated for many cases with hcv-related cirrhosis due to various adverse effects. however, patients with hcv cirrhosis are at high risk for development of hepatocellular carcinoma (hcc). thus we have introduced low-dose peg-ifn treatment for patients for compensated hcv cirrhosis. patients and methods: selection criteria for low dose peg-ifn is ) compensated hcv-related cirrhosis, and ) either the elderly (> ) or presence of thrombocytopenia (< . x / l). we have treated patients who met these criteria with low-dose peg-ifn, consisting of either peg- a g/ - w or peg- b . g/kg/w+ribavirin mg/d. [results] twenty patients with compensated hcv cirrhosis (all patients genotype b) have been treated with low-dose peg-ifn (peg- a: , peg - b+rib: . the age, platelet counts (x / l), and alt (iu/l) of patients at baseline were . ± . , . ± . , and . ± . respectively. all patients were well tolerated. low-dose peg-ifn has been continued . ± . weeks on average. although viral response was not detected, biological response (br), defined as maintenance of alt within normal range, was obtained in patients ( / = %). of note, neither development of hcc nor decompensated cirrhosis was observed in these br cases. by contrast, hcc and decompensation developed in and patients respectively among patients who failed to achieve br. conclusion: low-dose peg-ifn treatment was safe and well tolerable, and could potentially prevent hcc or decompensation in patients with liver cirrhosis when br was obtained. aims: to study the efficacy of peginterferon and ribavirin in treating chronic hepatitis c (chc) with genotype a in hong kong chinese. methods: to assess sustained virological response (svr) (serum hcvrna< iu/ml) at -months follow-up. results: nine patients with genotype a chc (included from jan to dec ) received peginterferon and ribavirin. mean age: (range - ). mean alt before treatment: iu/l (range - iu/l). seven patients had liver biopsy performed, only one showed stage - fibrosis and others showed active hepatitis without advanced fibrosis. mean serum hcv-rna: . x iu/ml(range . x - . x iu/ml). six patients had received peginterferon alfa- b ( . mcg/kg/week), other received peginterferon alfa- a ( mcg/week). ribavirin dosage ranged from mg- mg/day depending on body weight and baseline haemoglobin. treatment durations were - weeks in patients, - weeks in patients as one showed rapid virologic response at week and the other was intolerant to side effect of peginterferon. eight patients had early virologic response at week and one had > log drop of hcvrna. eight patients had end-of-treatment response. eight patients ( . %) achieved svr at end of follow-up. two patients who received only - weeks of combination therapy also achieved svr. the one who failed to achieve svr was at older age of and had advanced fibrosis. conclusions: the efficacy of pegylated interferon and ribavirin in treating chinese patients with chronic hepatitis c genotype a can achieve high sustained virologic response rate of . %. t. bharati , , p. kar , a. mohammad , k. mariappan , j. annamalai , r. introduction: hcv is a recognized cause of hcc. information on hcv genotypes in hcc are scanty in india. methods: a total of hcc cases from delhi, hcc cases from madurai and cases of chronic hepatitis without hcc were controls in the study. rt-pcr for hcv rna and genotyping were carried out in all the cases results: in group-i, hcv rna was positive in . % hcc cases in which genotype was found in . % genotype was observed in . % hcc cases. whereas . % cases remained nontypable. in group-ii, hcv rna was positive in . % hcc cases, with genotype in . % cases, genotype in . % cases and genotype in . % cases. however, . % cases remained nontypable. out of the control cases, were ch and were cirrhosis. in ch group, hcv rna was positive in . % cases in which, genotype was detected in . % cases whereas genotype was observed in . % cases . however . % cases remained nontypable. in cirrhosis group, hcv rna was positive in . %cases. genotype was found in . % cases. while genotype was present in . % cases and . % cases remained nontypable. conclusion: genotype in delhi and genotype in madurai were predominant. in hcc cases. our study demonstrates that no particular hcv genotypes were associated with hcc and genotype did not appear to influence the development of hcv-associated hcc. background/aims: the standard treatment for chronic hepatitis c infected with hcv genotype- is a combination of pegylated interferon alfa and ribavirin for a weeks. it is unclear if weeks treatment is possible for patients showing a rapid virologic response (rvr) without compromising the sustained virologic response (svr) in korea. method: between june and july , among patients chronically infected with the hcv genotype- (hcv- ) who were treated with pegylated interferon alfa subcutaneously once weekly plus ribavirin (weight-based), consecutive paients who had low pretreatment viral load ( . x copies/ml) and rvr were treated for weeks and then followed up for weeks. the hcv rna was quantitatively assessed pretreatment, at weeks of treatment and was qualitatively assessed at weeks of treatment, the end of treatment ( weeks), weeks after end of treatment. rvr was defined as undetectable hcv rna at the weeks. results: baseline characteristics of patients was as followed; age ( - years:mean years), bmi ( - kg/m²:mean . kg/m²), hcv rna titer ( . - . × copies/ml:mean . × copies/ml), alt ( - iu/l:median iu/l). among the patients, all patients ( %) had sustained virologic response (svr). conclusions: hcv- infected patients with a low baseline hcv rna concentration ( . × copies/ml) who had hcv rna negative at week of treatment may be treatment for weeks without compromising sustained virlolgic response. however, an additional trial will be needed to optimize the treatment duration. background/aims: acute hepatitis c (ahc) has a high chronicity rate of up to ~ % if it is not treated. although the good treatment response to pegylated interferon (peg-interferon) therapy has reported, there is not definite guideline to treat of ahc in korea yet. the aim of our study was to investigate the clinical course and treatment outcome of ahc in single center of korea. methods: we performed a retrospective analysis of patients who were diagnosed with ahc during the period from may to december . the diagnosis of ahc was based on seroconversion to anti-hcv antibody or the clinical and biochemical diagnostic criteria satisfactory to ahc and on the presence of hcv rna in first serum sample. the spontaneous resolution was defined as loss of hcv rna in serum for -month in untreated group, and in treatment group, the sustained virological response (svr) was defined as a index of treatment success. results : thirteen of thirty-five patients were treated, six of thirty-five were untreated and observed clinical course, and sixteen patients were not followed up after diagnosis. in treatment group, nine of thirteen ( %) acquired svr, and two of six ( %) showed spontaneous resolution in untreated group. ten of thirteen treatment patients used conventional interferon, and another three patients used peg-interferon. conclusion : compared with untreated group, there was higher svr rate in treatment group ( % vs. %). so early interferon treatment in acute hepatitis c should be considered. background: this study was conducted to identify predictors of thyroid dysfunction and to determine whether virologic factors or treatment response affect thyroid dysfunction development during peginterferon (pegifn) therapy in chronic hepatitis c patients. methods: sixty chronic hepatitis c patients treated with pegifn - a or - b in combination with ribavirin from st july to th july were included in this study. treatment responses were evaluated and thyroid functions were assessed every weeks. results: seventeen patients ( . %) experienced thyroid dysfunction during treatment, and that occurred more frequently in women and in patients with a lower body mass index (bmi). the proportion of patients with a high viral load (a serum hcv rna titer > , iu/ml) was significantly higher in the thyroid dysfunction group rather than in the euthyroid group( . % vs. . %, p= . ). among patients with hcv genotype , the rate of sustained virologic response was lower, and relapse occurred more frequently in the thyroid dysfunction group than in the euthyroid function group during pegifn-based therapy(svr, p= . ; relapse, p= . ). the female gender and the high viral load were independent predictors of thyroid dysfunction in multivariable analyses (female, or . , p= . ; high hcv rna titer, or . , p= . ) . conclusion: the risk of thyroid dysfunction during pegifn therapy for chronic hepatitis c was found to be higher for women and for those with a low bmi and a high viral load. background: in peginterferon alpha b (peg-ifn b) and ribavirin (rbv) combination therapy for weeks for patients with chronic hepatitis c, it is still difficult to predict which patients will achieve sustained viral response (svr) at the completion of this therapy. aim: to predict svr and non-svr (relapse) at the end of this combination therapy by determining changes of serum hyaluronic acid (ha) levels. methods: eighteen patients were enrolled and their serum ha levels were measured before therapy, and after the st, nd, rd, and last trimesters during therapy. results: eleven patients achieved svr and became relapsers. all patients showed higher ha levels in the st trimester than the pretreatment levels. in the svr group, of ( . %) patients in the nd, of ( . %) in the rd, and of ( . %) in the last trimester showed lower ha levels than the pretreatment levels. by contrast, in the relapser group, none in the nd, of ( . %) in the rd, and of ( . %) (p< . ) in the last trimester showed lower ha levels than the pretreatment levels. this study revealed that as the -week therapy went on, ha levels were more likely to fall below the pretreatment levels by the last trimester in patients achieving svr. however, ha levels of relapsers tended to continuously be above the pretreatment levels. conclusion: determination of changes of serum ha levels during peg-ifn b and rbv therapy predicts svr and non-svr at the completion of this therapy. results: the most frequent lymphomas were with high malignancy ( %), intermediate ( . %) and low degree ( . %). cryopathy was negative ( . %). the presence of viral markers was performed soon as possible after the nhl diagnosis, at the same time ( . %) or during the first year of evolution ( . %). the prevalence of the hcv infection was %, comparable to the one in the control patients group ( . %), admitted in a gastroenterological clinic. on the other hand, this prevalence is significantly increased compared to the one in the general romanian population ( . %). the patients with nhl and hcv infection belonged especially to the low and intermediate malignancy degrees; the survival was influenced by the malignancy degree and not by the presence of hcv infection. the prevalence of hbv infection in the tested patients was . %, being lower than that of hcv infection ( . % vs. %, p = . ) but comparable to the one in the general population ( . % vs. . %, p = . ). conclusions: the prevalence of hcv infection in the patients having nhl was %, comparable to the one in the control group, but significantly increased compared to the one in the general population, leaving open the issue of a causal relationship between hcv infection and nhl. iron hepatic overload and hepatitis c d. damian , m. grigorescu , m.d. grigorescu , t. zaharie third medical clinic, cluj napoca, romania aim: evaluation of the prevalence and the degree of iron loading and the relationships with the clinical, biological and morphological changes. method: patients with chronic hepatitis c were included, to whom we tested the blood iron level. in order to evaluate the hepatic iron accumulation we performed the perls staining, using a qualitative analysis and a semiquantitative scoring system (deugnier). results: from a total of patients, . % presented increased blood iron level (p = . ). the evaluation of the liver iron loading was performed in patients, some having normal blood iron level (n = ) and others (n= ) increased (p = . ). the stainable iron was observed in patients. the iron loading was usually low, the deposits were observed mostly at the sinusoid cells and the hepatocyte and less in the portal spaces, usually as a pale staining or of small, nonmerging granules. the total iron score deugnier was low. the increased blood iron correlated with the alt and ggt levels, the necroinflamatory activity and fibrosis. no correlationships between stainable iron and increased blood iron. the presence of liver iron accumulation only correlated with the fibrosis degree. conclusions: of the patients to whom we tested the blood iron, . % had increased levels. the perls staining was positive in % of the patients. the iron loading was mainly low, with a more frequent distribution in the sinusoid cells and in the hepatocytes and correlated only with the stage of fibrosis. response patients whose hcv rna became negative at - weeks t. ide , t. arinaga , k. ogata , i. miyajima , k. kuhara , r. kuwahara , m. background/aim: chronic hepatitis patients whose hcv rna became negative at weeks of peg-interferon/ribavirin treatment achieved excellent svr(sustained viral response) rate of almost %. however, in patients whose rna became negative after weeks, the svr rate is very low. since many patients became rna negative at - weeks, it is important to clarify the characteristics of the patients. material and method: among patients, became rna negative at - weeks and the therapy completed (total - weeks). the characteristics were analyzed by using sex, age, weight, bmi, alt, gtp, hemoglobin, platelet counts, ccr, hyaluronic acid, the mutation of hcv core region (aa , ) and interferon sensitivity determining region, adiponectine, home-ir, rna dynamics, dose and the treatment period. result: the svr rate was . %( / ). because all patients of non svr were female, we compared these patients and female svr. the platelets counts were low in non svr (non svr . ± . (x /mm ) vs svr . ± . (p< . )). the mean dose of ribavirin was lower ( ± mg/day) in non svr (p< . ) than in svr ( ± ). conclusion: as for the characteristics of the patients whose hcv rna became negative at - weeks but became non svr, female, low platelet count and low dose of ribavirin were important factors. in the patients who received reduced ribavirin doses, the idea to increase the ribavirin dose and to maintain it are necessary. (ex, use mg and mg alternately) pe background: chronic hepatitis c virus (hcv) infection poses a challenge for a growing number of infected patients who exhibit disease complications, including cirrhosis, hepatocellular carcinoma, and liver failure in china. the combination treatment of peginterferon alpha (peg-ifn alpha) plus ribavirin (rbv) is recommended as a standard care for hcv infections, which can improves hepatic markers and eradicates the virus in about % of patients. however, a significant number of patients do not respond to therapy or relapse following treatment discontinuation. several viral, hepatic, and patient-related factors influence response to therapy. methods: in our clinical practice, a total of interferon-naïve patients ( % male; median age years) with chronic hepatitis c include cirrhotic patients (no genotyping) received peg-ifn alpha- a mcg/week plus rbv - mg/day for weeks and follow up weeks. results: show that the patients have more rvr and evr rate ( % and . % respectively). while the svr (undetectable hcv-rna weeks after treatment completion) rate is only . % in conclusion: comparing with the data of clinical trail, the rvr, evr and eotr were higher, while svr was the same in chinese patient with chronic hepatitis c patients received the combination therapy of peg-ifn plus rbv. the reason of high relapse was still unknow. although optimal duration of retreatment and benefits and safety of maintenance therapy have not been determined, an extended duration is likely needed, even for the patients who achieved evr. s. nakamoto , f. imazeki , k. background/aims: recently amino acid (aa) substitutions in hepatitis c virus (hcv) core region (double wild (dw); arginine at aa , leucine at aa ) were reported to be associated with sustained virological response (svr) in a combination therapy of peginterferon and ribavirin. we evaluated the viral factors influencing treatment response. methods: nucleotide sequences of core region were determined directly in patients with genotype and high viral load ( kiu/ml) treated with peginterferon-alpha b and ribavirin for weeks. rapid virologcal response (rvr) was defined as more than log decrease of hcv-rna during the first four weeks of therapy and early virological response (evr) as that during the first weeks. svr was defined as negative hcv-rna months after the end of treatment and non-virological response (nvr) as less than log decrease of hcv-rna during the treatment. results: dw at aa and was shown in / ( %) patients with rvr and in / ( %) with non-rvr (p= . ), in / ( %) with evr and in / ( . %) with non-evr (p= . ), in / ( %) with svr and in / ( %) with non-svr (p= . ), and in / ( %) with nvr and in / ( %) with non-nvr (p= . ). in multiple logistic regression analysis, dw was significantly associated with rvr, evr, svr and nvr. conclusions: dw at aa and in hcv core region was closely associated with virological response in a combination therapy of peginterferon and ribavirin. medicine and hepatology, henry dunant hospital, athens, greece, biometrics, ist gmbh, mannheim, germany, background: among patients with chronic hcv treated with pegylated interferon and ribavirin, the highest sustained virologic response (svr) rates are achieved in patients with a rapid virological response (rvr). here we investigate how the time taken to become hcv rna undetectable influences the probability of relapse during untreated follow-up. methods: data from patients treated for weeks with peginterferon alfa- a ( kd) µg/week plus ribavirin / mg/day were included in the intent-to-treat analysis. response was classified as rvr, complete early virological response (cevr) slow responder and non-evr. results: there was a correlation between the time required to become hcv rna undetectable and the relapse rate after stopping treatment. patients with an rvr had the lowest relapse rate ( %); this increased among patients with slower responses. conclusion: there was an inverse correlation between the time taken to achieve a virologic response and the probability of relapse. background: rapid virologic response (rvr; hcv rna < iu/ml) at week of treatment with pegylated interferon plus ribavirin can be used to predict the probability of achieving an svr. patients with detectable hcv rna at week have a lower probability of achieving an svr than those with an rvr; further subdivision of these patients may be useful in predicting outcomes. methods: we conducted a retrospective analysis including genotype patients treated for weeks with peginterferon alfa- a ( kd) g/week and ribavirin / mg/day. patients were categorized as rvr and non-rvr. those without an rvr were further subdivided into detectable but unquantifiable, , , or < log drop in hcv rna. the proportion of patients with undetectable hcv-rna at week and achieving an svr was calculated within each category. results: rvr and non-rvr patients had an % and % rate of svr respectively. among non-rvr patients, rates of svr depended on the categorical response at week : detectable but unquantifiable hcv rna, %; log drop in hcv rna, %; log drop, %; log drop, %; and < log drop, %. independent of week response, undetectable hcv rna at week was also highly predictive of svr. conclusions: patients achieving an rvr have high rates of svr. among patients who do not achieve an rvr a more precise prediction of svr can be achieved by considering the extent of viral load reduction at week and week . retrospective japanese validation study of fibrotest and actitest in patients with chronic hepatitis c. n. nagata , t. mine background: fibrotest (ft) and actitest (at) are biochemical markers of fibrosis and activity for use as a non-invasive alternative to liver biopsy in patients with chronic hepatitis c virus. the aim of this study was to perform a validation study the discordances between ft and at(ft/at) and liver biopsy in patients with chronic hepatitis c in japan. methods: serum samples of chronic hepatitis c patients sended at - °c at the biochemistry department of pitié salpetrière hospital were analysed between july and august . ft/at components were assessed on thawed sera for patients. from patients had liver biopsy at the moment of serum analysis. liver biopsy fibrosis and activity scores were assessed by a pathologist in japan according to metavir scoring system. for each individual test-ft/at the following statistical analysis were performed result: ft observed auroc for the diagnosis of advanced fibrosis was . and after adjustment according to the prevalence of different stages of fibrosis the auroc was . . this difference could be explained by the non-homogenous distribution of different stages of fibrosis (low prevalence of extremes stages of fibrosis -f and f -and high prevalence of adjacent intermediate stages -f and f ). the observed auroc of ft for the diagnosis of precirrhosis and cirrhosis was . and the observed auroc of at for the diagnosis of moderate to severe activity was . . conclusion: these results are similar to those observed in all independent validations worldwide. background: accurate monitoring of hcv-rna level throughout anti-hcv therapy is key factor for predicting sustained virological response (svr). real-time detection polymerase chain reaction (rtd-pcr) based methods are sensitive, have wide dynamic range of quantification and carryover contamination caused by classical pcr. aim: to compare rtd-pcr based assays; cobas ampliprep/cobas taqman (cap/ctm) and recently developed abbott realtime hcv for hcv rna quantification and measurements differences by assays in different genotypes. methods: in total, serum samples were used including, , , , , and with genotypes b, a, b, a and respectively were tested quantatively for hcv-rna by cap/ctm and abott realtime. results: good correlation between two assays as overall (r= . ) with correlation coefficient (r) in genotypes b, a, b, a ranged between . to . and least in genotype (r= . ). mean differences between cap/ctm and abott realtime was significnat in genotypes b and . significantly hcv-rna genotype underestimation by cap/ctm ( . + . log iu/ml) than abbott realtime ( . + . log iu/ml; p= . ). in genotype b, significantly higher hcv-rna measurement by cap/ctm ( . + . log iu/ml) than abbott realtime ( . + . log iu/ml, p= . ). two hcv genotype samples showed measurement differences (cap/ctm minus abbott realtime) of - . and - . log iu/ml. studying genotype sequences within utr , target for cap/ctm rt-pcr amplification, revealed nucleotide polymorphisms at positions a , a , t , a , and a . conclusion: different measurement efficiency by commonly used cap/ctm in different genotypes compared to abbott realtime. new york, new york, usa, vertex pharmaceuticals, cambridge, ma, usa, duke clinical research institute , duke university, durham, nc, usa background: prove is a placebo-controlled study of subjects with genotype chronic hepatitis c randomized to weeks of peginterferon-alfa- a ug/week (p) plus ribavirin - mg/d (r) (pr , n= ), or regimens of mg q h telaprevir (tvr) with pr: tvr/pr for wks followed by pr for wks (t /pr , n= ), wks (t /pr , n= ) or wks (t /pr , n= ). the impact of african american race (aa) and bridging fibrosis on sustained virologic response (svr) was examined. methods: subjects with cirrhosis were excluded from study. fibrosis was categorized as mild/minimal, portal, or bridging from biopsy within years. itt analysis was performed. results: overall, svr was achieved by % of subjects in the pr group, % in t /pr group, % in t /pr group, and % in t /pr group. subgroup analyses indicated svr was improved with tvr/pr (tvr/pr arms pooled) vs pr alone in aa subjects ( % ( / ) vs % ( / )), and in subjects with bridging fibrosis ( % ( / ) vs. % ( / )). adverse events leading to discontinuations were more frequent in the tvr/pr groups ( % vs. %). rashes, gastrointestinal events and anemia were more common in the t/pr arms, and rashes were more frequently severe ( % vs %). conclusions: tvr-based treatment for or weeks was associated with an increase in svr rates compared to pr . subgroups with impaired response to standard peg-ifn/rbv therapy appeared to benefit from the addition of telaprevir. adverse events leading to discontinuation were more frequent in tvr-based regimens. background and aims: induction of type i ifns is a core issue in antiviral responses and must be tightly controlled. the protein kinase tbk is critically involved in virus-triggered type i ifn signaling. in previous studies, an alternatively spliced isoform of tbk , termed tbk s, was identified to be induced in both human and mouse cells. bound to rig- , it is able to disrupt the interaction between rig-i and visa. this study was designed to observe the expression of tbk s in hcv-infected patients. methods: total rna was extracted from samples of peripheral blood mononuclear cells obtained from hcv patients, hcv patients treated with ifn-/ribavirin and healthy controls, and subjected to real -time pcr using the primer-probe sets for human tbk s, tbk and ifn-genes. results: the tbk s expression was significantly elevated in hcv-infected patients, while treatment of hcv-infected patients with ifn-/ribavirin resulted in down-regulation of tbk s to the normal level. conclusions: the study strongly supports the idea that expression of tbk s is correlated with hcv infection, and indicates that tbk s may play an important role in the regulation of hcv infection.this work was supported by nsfc( , , background: infringement of iron metabolism is one of fibrosis progressing factors during diffuse liver diseases. the interrelation between the syndrome of iron overload (sio) and svr achievement is studied during chronic hcv infection treatment. methods: patients with chronic hcv infection (genotyping: - ; + - ; - ; - ; - ) are investigated. sio criteria: iron increase-more than mkmol/l, ferritin -more than mkmol/l, percent of transferriny saturation with iron (%tf) -more than %. results: sio revealed in patients ( . %): patients - genotype ( assotiative with a diabetes) and patients-genotype ( -in combination with liver steatosis and obesity). venipuncture series were done up to getting ferritin referential parameter values before therapy beginning. rvr: sio - patients, normal metabolism - ; evr: and , svr: and relatively. nonresponding patients (sio) had steatosis and diabetes, hereditary hemochromatosis (c y/h d) is verified in case. increase of ferritini values and %tf during therapy and positive hla-a and hla-b is registered in nonresponding patients. conclusions: sio in hla-a , hla-b and c y/h d positive patients is independent predictor of nonresponse during peginterferon alpha- a ( kd)" ribavirin treatment. a.p. srivastava , g. dogra , s. sachdeva , n. nigam , a. chakravarty dr. rml hospital, new delhi (india)- , maulana azad medical college & associated hospitals, new delhi, india background: hepatitis c virus (hcv) has emerged as a leading cause of chronic hepatitis, liver cirrhosis and hepatocellular carcinoma worldwide. genotyping and assessment of viral load in hcv patients are vital for designing therapeutic strategies. we aimed to determine the pattern of hcv genotypes and its association with viral load and biochemical profile. methods: hcv rna positive patients were included in the present study attending the medical-opd and wards of dr rml hospital, a tertiary care hospital in new delhi during - . hcv genotyping was carried out by restriction fragment length polymorphism (buoro et al ) followed by the type specific primers from the core region (ohno et al ) . viral load estimation was carried out by taqman real time pcr system using previously described method (martell et al ) . result: . % of cases were having genotype ( a, b, f & i) followed by genotyping ( a & b) in . % and genotype in . %. there was no statistical significant difference seen in the biochemical profile between the three groups of genotypes. genotype one was associated with a significantly higher viral load as compared to the genotypes three and two. parentral mode of transmission was accounted for the % of all the infected cases. conclusion: hcv genotypes and accounted for % of our cases. the genotype is associated with higher degree of disease severity as assessed by viral load. also two unusual subtypes i and f were identified from this geographical region. a.p. srivastava , g. dogra , s sachdeva , n. nigam background: the development and resolution of an inflammatory process is regulated by a complex interplay among cytokines that have pro and anti-inflammatory effects. regulatory mechanisms that control the production of cytokines include genetic polymorphism in particular promoter/leader region. polymorphisms may directly or indirectly affect the binding of transcriptional factors, consequently increasing or decreasing the production of mrna, thus regulating cytokine production. we aimed to determine the polymorphism of tumor necrosis factor-alpha (tnf-alpha) and interleukin- (il- ) genes in chronic hepatitis c patients. methods: hcv rna positive patients were included in the present study conducted during - . healthy controls were also included. genomic dna was extracted by using q a amp dna blood kit protocol according to manufacture's instruction and desired fragment was amplified by using the primer's of vidigal et al . result: genotyping of - -promoter variant of tnf-alpha was performed by pcr. polymorphism in the tnf-alpha (g/g, g/a and a/a allele) was different between hcv patients and healthy controls. il- variants (c/t, c/c) were more frequent among hcv patients as compared to healthy controls. conclusion: genetic polymorphism analysis on il- promoter have indicated that distribution pattern of il- polymorphism was significantly different between controls and hcv patients. furthermore, polymorphism in promoter region of tnf-alpha (- ) was found, though the difference was not significant. since this is a preliminary study, we believe that our findings may stimulate further research on larger number of patients. introduction: the assessment of liver fibrosis provides useful information not only for diagnosis but also for therapeutic decision. although liver biopsy is the gold standard for fibrosis assessment, it is invasive and may have some risks, this has led to the development of non-invasive biochemical markers of liver fibrosis. fibro-test which have five parameters used for the quantitative assessment of liver fibrosis. our aim is to validate the performance of fibro-test in an independent cohort of patients with chronic hepatitis c genotype . methods: subjects were patients with chronic hepatitis c genotype . all biopsies were scored using metavir system by two independent pathologists. fibro-test was done with (biopredictive, houilles, france) for the assessment of liver fibrosis. sensitivity, specificity, ppv and npv were measured for distinguishing between different degrees of severity of fibrosis. results: patients ( male and female) age ranged - years, liver biopsy showed % (f ), % (f ), % (f ), % (f ), % (f ). the efficacy of fibrotest is . %, sensitivity . %, specificity %, positive predictive value % and negative predictive value %. conclusion: fibrofast has a low performance in assessment in fibrosis in chronic hepatitis c genotype . introduction: liver biopsy is the reference method for assessing liver fibrosis. however, it is invasive, costly and has some limitations. european liver fibrosis (elf) markers have shown to be accurate in assessing liver fibrosis in a range of chronic liver disorders. our aim is to test the performance of elf markers in an independent cohort of patients with chronic hepatitis c genotype . methods: subjects were patients with chronic hepatitis c genotype . all biopsies were staged for fibrosis using metavir system by two independent pathologist. elf markers were done by (diagnostic & operations, england) and fibrosis scores were derived using the published elf algorithm. the area under the curve (auc) for receiver operator characteristic curves was measured along with sensitivity and specificity, positive (ppv) and negative (npv) predictive values for distinguishing between different stages. results: patients ( male and female), age was ranged - years, liver biopsy showed % (f ), % (f ), % (f ), % (f ) and % (f ). elf markers had no correlation with fibrosis score where r = - . , p = . , aucs: . , specificity . %, sensitivity only . %, ppv: only . %, npv: . % and efficacy . %. conclusion: the performance of elf marker is low and can not be used for assessment of fibrosis in chronic hepatitis c genotype . background: the prove trial is a randomized, placebo-controlled study that assessed the safety and efficacy of mg q h telaprevir (tvr) combined with g/week peg -ifn alfa- a (p) ± - mg/day ribavirin (r) in chronic hcv genotype -infected treatment-naïve patients without cirrhosis. methods: overall, patients received tvr + pr for weeks (t /pr ; n= ), tvr + pr for weeks then pr for weeks (t /pr ; n= ), tvr + p for weeks (t /p ; n= ), or to pr for weeks (pr ; n= ). primary endpoint: sustained virologic response (svr, undetectable hcv-rna weeks post-treatment). results: baseline characteristics were well balanced across groups. numerically higher svr rates were observed in patients receiving t /pr ( %; p= . for difference vs. pr ) than t /pr ( %), t /p ( %) or pr ( %). relapse rates were lower in the t /pr group ( %) than the t /pr ( %), t /p ( %) and pr ( %) groups. the relapse rate in patients receiving t /pr with -week and -week undetectable hcv-rna was % ( / ). the aes occurring more frequently with the t/pr regimen were pruritus, rash, asthenia, nausea and anemia. in the t/pr arms, patients discontinued due to rash, discontinued due to pruritus, and patients due to anemia. conclusion: these results showed that a telaprevir-based regimen led to significantly higher svr rates than pr, and indicate that this regimen could shorten the overall treatment duration from weeks to weeks for most patients infected with hcv genotype . a.c. cardoso , c. stern , r. moucari , n. giuily , p. bedossa , p. marcellin hopital beaujon background/aim: this study evaluated the effect of the response (svr) to therapy on fibrosis stage, as assessed by ls, in patients with advanced fibrosis (f ) or cirrhosis (f ). methods: hcv patients with f or f who received interferon-based treatment were studded. ls was assessed after treatment (median delay of months, - ) in patients with or without svr. correlations between ls and clinical and treatment characteristics were analyzed. results: patients were included: male gender ( %), mean age ( ± years), diabetes ( %), mean bmi ( ± kg/m ), genotype ( %). % had svr. ls was performed - , - , > years following treatment. by linear regression, the median of the ls was independently associated with svr (p= . ) and diabetes (p= . ). svr patients had lower ls ( . kpa; range . - ) than non svr patients ( . kpa; range . - ) (p< . ). among the svr patients the median ls was lower when the delay between ls and the end of treatment was longer ( . , . , . ) (p= . ). on the opposite, among the non-svr patients the median ls was not significantly different (p= . ). the median of liver stiffness was higher in patients with diabetes (p= . ). bmi and dyslipidemia did not influence the median of the ls. conclusion: in patients with advanced fibrosis or cirrhosis, ls was lower in patients with svr and decreased with time while it was higher and did not decrease in non-svr patients. ls could be important for assessment of fibrosis stage during the post-treatment follow-up. to study peripheral blood and intrahepatic natural killer (nk) cells in patients with chronic hepatitis c in relation to disease activity and severity of hepatic fibrosis. patients & methods: fifteen untreated patients with histologically-proven chronic hepatitis c, and matched healthy subjects. the nk cells and natural killer t (nkt) cells were identified in fresh whole blood samples using two-color flow cytometric assay as cd -cd + and cd + cd + positive cells. immunohistochemical staining of liver biopsies taken from all patients was done using monoclonal antibody against cd for detection of nk cells and rabbit polyclonal antibody against smooth muscle actin (sma) for identification of activated hepatic stellate cells (hscs). results: patients with chronic hepatitis c showed significant decreases in the percentages of nk cells and nkt cells in peripheral blood. a negative correlation was found between serum hcv rna levels and the percentages of peripheral blood nk cells and the intensity of intrahepatic nk cells. the percentages of circulating nk cells and nkt cells and the intensity of intrahepatic nk cells were inversely correlated with the metavir fibrosis stage and the steatosis grade, and also with the intensity of intrahepatic activated hscs. conclusion: patients with chronic hepatitis c had significant deficiency in circulating nk and nkt cells as well as in intrahepatic nk cells. this may provide a possible mechanism for the suppression of innate immunity against hcv. background: hcv infection is the major cause of chronic hepatitis, cirrhosis and hepatocellular carcinoma. the virus is classified in six genotypes and more subtypes, which are related distinct with antiviral therapies reply. in brazilian amazon, epidemiologist's studies in blood donors had pointed high frequency of genotype ( %) followed by genotypes ( %) and ( %). however, epidemiological research in populations of risk to the infection still is scarce. aim: to determine hcv genotypic frequency in blood donors, patients with blood transfusions multiples, patients in hemodialysis and drugs users in the state of pará, brazilian amazon. methods: using real time pcr and nucleotide sequencing followed phylogenetic analysis had been gotten viral diagnosis and genotyping. results: in blood donors, hcv distribution was constituted by genotypes ( . %) and ( . %). in multitransfunded patients occurs maximum prevalence of genotype ( %), probably reflect of genotype specific transmission of blood donors population. on the other hand, in hemodialysis patients had been detected genotypes ( . %), ( . %) and ( . %), result of a bigger diversity of transmission routes (transfusional, interfamilial, nosocomial, etc) . in drug users occurs the biggest frequency of genotype ( . %) with prevalence of genotype ( . %), suggesting that the sharing of abuse machinery is allowing strains diffusion of genotype . conclusions: the genotype possesses the biggest frequency in different population. moreover, through hcv genotypic frequency if it detached the contribution of transmission distinct routes indicated by previous epidemiologists researches. virol. ). we established real-time polymerase chain reaction (pcr) assays for the easy detection of these hcv mutations. methods: plasmids p-core-w, including wild type hcv core coding region ( r and l), and p-core-m, including mutant type hcv core ( q/h and m), were constructed by cloning and pcr-based mutagenesis for control vector of wild type core and that of mutant core, respectively. using serially diluted forms of these vectors, sybr green-based real-time pcr detections with mutation-specific primers were performed. results: analysis of known scalar concentrations of references indicated that the detection limits of these methods were at least copies, copies, copies, and copies of -wild, -mutant, -wild, and -mutant, respectively. each primer could clearly distinguish the difference between p-core-w and p-core-m at the same copy numbers. concerning substitution , the ratios : , : , : , : , and : of p-core-w versus p-core-m could be distinguished. on the other hand, for substitution , the ratios : , : , : , : , : , and : could be distinguished, confirming the sensitivity and specificity of the assay. conclusions: this method could represent a useful alternative for the detection of genotype b hcv core amino acid substitutions and and be reliably applied for rapid screening. efficacy and tolerability of hcv treatment in asian patients according to age and genotype at a tertiary centre in western australia n. saroj , n. kontorinis , t. lorenzo , m. marion , s.l. chen , w. cheng , royal perth hospital, centre for international health, curtin introduction: race and ethnicity can influence efficacy and tolerability to treatment in hcv. the higher response rate in asians is thought to be associated with better adherence and tolerability. objectives: ( ) to evaluate the adherence according to age and genotype ( ) to assess the effect of age on treatment efficacy ( ) background: hepatitis c virus (hcv) infection is a major health problem. there is huge regional variation in its prevalence and genotypic distribution. voluntary blood donors are thought to have somewhat lesser prevalence than the rest of the community. reliable statistics are not available for the entire country, particularly for the rural areas. it is important to know local situation and rationalize use of limited resources. methods: retrospective study of the records of patients attending the free liver clinic (flc) of our hospital located in a rural area of pakistan, and those screened for hcv infection prior to voluntary blood donation. results: patients at flc ( out of [ %; males %] were found to have higher chances of being reactive for hcv antibodies as compared to voluntary blood donors ( / [ %]; p = . ; or . - % ci = . - . ). out of a total of hcv reactive patients, ( %) were found to be positive on hcv rna testing. out of a total of typeable genotypes, ( %; % ci = . - . , estimated odds = . ) were infected with a single genotype, and only patients ( %) were infected with genotype , either alone (n= ) or in combination with a. conclusions: one out of every people tested in our flc is seropositive for hcv, and % of "healthy" voluntary blood donors have the same results. genotype is very rare in our region. s.a. batool , s.z. abbas department of gastroenterology, muhammad hospital, mirpurkhas, pakistan background: hepatitis c viraus (hcv) infection is common in our region. data is not available on success rates of conventional interferon (inf) based products here. we attempted to find out the dominant genotype, and to determine the success rate of conventional inf-based treatment in eradicating hcv. methods: retrospective case series study of hcv infected patients' records treated with different brands of inf. results: / ( %) of all patients tested were positive for hcv antibodies. hcv-rna was tested by pcr for patients, of which ( %) turned out to be positive. genotype type was the dominant genotype -found in / ( %) patients. men and women were treated with various brands of inf with the same manufacturer's brand of ribavirin. the overall etr achieved was / ( %) - / ( %) men and / ( %) women. / ( %) of genotype achieved etr. there was no significant difference in average ages for those who achieved good etr and those who did not ( years each). the etr achieved by different brands ranged from % to %. svr was achieved by / patients. conclusions: % of all people tested positive for hcv antibodies, of which about % had evidence of active hcv infection. etr achieved by different brands averaged %. this was % in female sex, although age did not appear to be a factor in determining a favourable etr. patients & methods: a total of consecutive diabetic patients of either sex were evaluated for hcv and hbv infection by using enzyme linked immunosorbant assay (eliza- ) along with serum alt levels. on the basis of this test, the patients were divided into two groups, sero +ve and sero -ve. different variables were: age, sex, bmi, area of residence (rural or urban), type and duration of dm, smoking, literacy and alt. results: males . % and females . %. age ranged from to . majority were married ( . %), from rural area ( . %), had type- dm ( . %), normal weight ( . %), normal alt( . %) and non-smokers ( . %). seroprevalence for hcv, hbv and both were . %, . % and . %. two groups were made, sero +ve and sero -ve. raised alt ( . %) was significant (p< . ) factor while all others variables were insignificant (p> . ). conclusion: hbv and hcv infections are more prevalent in dm with increased alt levels. while hcv infection is more common than hbv in patients with dm. hepatitis c virus (hcv) envelope proteins (e and e ) mediate the entry of virus into host cells by binding to its cellular receptors and resulting in the fusion of the viral membrane with host cell membrane. the expression and secretion of biologically active envelope proteins in vitro have proven to be a difficult task due to the high degree of glycosylation and the existence of hydrophobic domains within these sequences. in order to obtain glycosylated, correctly-folded hcv envelop proteins in large quantities, we optimized the dna sequences of hcv envelop proteins by substituting the encoded sequence with human preferable codons and expressed them in human embryonic kidney (hek) cells. both proteins were detected intracellularly, with a small portion secreted into supernatant. in order to enhance secretion, truncated forms of envelop proteins including e tm, e - , e - were also expressed. both full-length and truncated forms of envelop proteins were glycosylated and expressed at high level. in addition, we also expressed the codon-optimized hcv receptors cd and claudin- in cells. by comparing the expression level of codon-optimized sequences and the sequences that were obtained from cdna library by pcr, we found that codon-optimization enhance protein expression significantly in cells. these results not only lay solid foundation for further research concerning the mechanism of hcv entry, including the optimal ph and right protein conformation for fusion, cell types that permit viral entry; but also potentiate a useful cell model for testing antiviral agents. background: prolactin (prl) is an immunoregulatory hormone secreted from lymphocytes, however, prl induction in relation to hepatitis c virus (hcv) infection has not been elucidated. methods: serum prl levels were measured in both subjects of our hcv cohort study and male patients of the hospital, who were chronically infected with hcv. furthermore, serum prl levels were compared in male patients before and after interferon therapy. we measured expression of prl mrna level in pbmcs in male patients, and also investigated prl mrna of pbmcs collected from healthy men that stimulated by hcv produced by huh . cells in vitro. result: serum prl levels were significantly higher in the hcv-infected subjects than in the controls (p< . ). they were significantly higher in hcv-infected male subjects than in the controls (p< . ). serum prl levels were significantly higher in male patients than in the controls (p< . ). serum prl levels decreased significantly after interferon therapy in patients with sustained virological response to therapy (p< . ). the levels of prl mrna in pbmcs derived from hcv-infected patients were significantly higher in male patients than in the controls (p< . ). conclusion: the high levels of prl expression are associated with hcv infection in carriers. background and objectives: hepatitis c virus (hcv) is a major cause of chronic liver hepatitis, cirrhosis, and hepatocellular carcinoma.current clinic standard therapy is interferon alpha (ifn-) combination with ribavirin, but this treatment is associated with adverse effects and often fails to induce a sustained response. until recently, development of a hcv cell culture system (hcvcc) provides a suitable tissue culture system to study the complete hcv life cycle. in this study, we tested the effect of ifn omega (ifn-)-a member of type interferon on hcv compared with ifnbased on hcv b replicon and hcvcc. methods: we compared ifn-and ifn- a effects on hcv rna replication and protein expression, as measured by ribozyme protection assay and western blot. we also compared the intracellular protein level of phosphorylated signal transducer and activator of transcription (p-stat ) treated with different interferon type and concentration with western blot analysis. results: hcv rna and protein level were inversely related with ifnconcentration and compared with ifn- a, at the same concentration, the hcv rna and protein levels treated with ifn-were lower than that treated with ifn- a p . .also based on the hcv rna analysis, ec of ifn-was folds lower than ifn- a. ifns increased intracellular p-stat level at a dose dependent manner and compared the same concentration of ifn-and ifn- a, p-stat protein level was higher in ifn-treated group p . . conclusions: these results demonstrate distinct antiviral effect of ifncompared with ifn- a and this difference maybe partly caused by the stronger stimulation of ifn receptor . outstanding antiviral activity of ifnmay be useful for developing new hcv treatment strategies. background & aim: hepatitis b virus (hbv) infection with undetectable levels of hepatitis b surface antigen (hbsag) is called an occult infection, which although has been described among subjects with chronic hepatitis c liver disease in the western world, it's prevalence and clinical significance are still ambiguous in the indian subcontinent. materials and methods: we investigated hbv-dna pcr in serum samples of hbsag negative subjects with chronic hcv-related liver disease, and apparently healthy volunteers negative for hbsag and anti-hcv as control. results: serum samples found positive by at least two independent pcr assays were considered hbv dna positive. hbv-dna was detected among hcv-related chronic liver disease (cld) patients ( . %), which was higher (p = . ) as compared with the control volunteers ( . %). it was more frequent ( . %) in anti-hbs negative/anti-hbc positive patients than in anti-hbs/anti-hbc positive ( %, p < . ). hcv rna by qualitative pcr was significantly (p < . ) higher in occult hbv compare to non-occult. hcv genotype b was predominantly associated with occult hbv ( %), especially among subjects with hepatocellular carcinoma (hcc) (p< . ) as compared to non-occult hbv cases. though not significant, frequency of occult hbv infection was higher than healthy controls and hcv b genotype was significantly associated in patients with hcc. conclusion: this study suggests that in all hbv-endemic areas, the possibility of occult hbv in patients with hcv should be considered and hbv-dna should be performed. j. zhao , , w.d. cai , l. chen , y.x. gan , m.l. he , x.r. wang background: besides hiv and syphilis, hepatitis c virus (hcv) is also rapidly spread among men who have sex with men (msm). this study was designed to identify the prevalence of these sexual transmitted diseases in msms in shenzhen, china. methods: a cross sectional study was conducted by using time location sampling method from april to july, . msm participants (including male sex workers) were recruited and finished guided self-administered questionnaires (or interviews if they have difficulty in reading or understanding) in venue-date-time randomly selected from active venues. results: results were analyzed using spss. blood samples were collected for hiv, syphilis and hcv test. participated msms were between the age of to years ( . ± . ) with a majority of - years ( . %). most of them finished junior high school education ( . %). . % had high level of knowledge on modes of transmission and prevention. likewise, . % msms have ever sold sex to men, . % of them were self identified as gay, . % as bisexual. . % msms had multiple male sexual partners and . % msms always used condom. . % of them had sex with women in the past month, and the condom use rate decline to . % during both male and female sex. hiv positive rate is of . % and syphilis for . %, hcv is only found in cases ( . %). conclusions: a greater number of the participants have both male and female sex partners. this survey shows that hcv infection rate is still low among msms in shenzhen, although the hiv and syphilis rate is high and continuing increased in the past few years. the change of insulin sensitivity in hepatitis c patients with normal insulin sensitivity s.g. park , y.k. cho , j.w. lee , j.w. yun , h.j. kim , w.k. jeon , b.i. background: hepatitis c virus (hcv) infection is associated with a high prevalence of diabetes mellitus (dm). insulin resistance (ir) is known to play a crucial role in the development of dm in chronic hepatitis c (chc) patients. we prospectively investigated the change of insulin sensitivity in chc patients during -year period, and analyzed factors significantly associated with ir. methods: subjects consisted of non-cirrhotic chc patients with normal alanine aminotransferase (alt) and normal insulin sensitivity (chc group), and healthy control group of subjects matched by age, sex, body mass index and life styles. we compared initial baseline insulin sensitivity, metabolic parameters and incidence rate of ir at the end of follow up period in both groups. the change of insulin sensitivity and metabolic parameters and development of ir was analyzed, and factors associated with development of ir were evaluated. results: ir developed in . % of chc patients and . % of normal individuals (p< . ). hcv infection per se and genotype were independent risk factors of ir. initial fasting glucose - mg/dl, fasting insulin uiu/ml, homa-ir . - . were significantly associated with development of ir in chc group. conclusions: hcv infection is independent risk factor of ir. even if chc patients with normal insulin sensitivity, careful monitoring for ir is necessary. prevalence of viral hepatitis c in latvia i. tolmane , , b. rozentale , , j. keiss , f. arsa sa infectology center of latvia, riga stradin's university background and aim: viral hepatitis c (vhc) because of its prevalence and clinical course has become one of the most actual infectious diseases in the world. to date chronic hepatitis c affects over million individuals worldwide. chronic vhc is a leading cause of cirrhosis and hepatocellular carcinoma. the aim of this study was to investigate how many residents of latvia, that are over years of age have been exposed to vhc (anti-hcv prevalence) and how many are infected at the moment (hcv-rna prevalence). until now such research has not been performed in latvia. methods: from the register of general practitioners there were randomly selected gp's from different regions of latvia, persons over years of age were selected out of each gp register and tested for anti-hcv with screening test (elisa). in case of positive result antibodies were confirmed with western-blot reaction and person was tested for hcv-rna (pcr). results: in total person was invited by general practitioners for the test and persons responded (response rate . %). confirming test (western-blot) was positive in participants and out of which hcv rna test was positive in patients. conclusions: there are . % of people exposed to hepatitis c virus in latvia and . % are infected with hepatitis c virus, respectively, infected persons per thousand individuals. genetic variation in the ikk/nf-b pathway and the live fibrosis progression in chronic hepatitis c r. sho , k. ishii , r. ishii , h. watanabe , k. sugahara , y. nishise , k. okumoto , t. saito , s. kawata , a. fukao department of public health, department of gastroenterology, yamagata university faculty of medicine background/aims: i b kinase/nf-b (ikk/nf-b) signaling pathway is thought to play critical roles in liver inflammation and fibrogenesis. we carried out a haplotype-based association study to examine the contribution of common genetic variations in the genes encoding nf b inhibitor kinase alpha and beta (ikbka and ikbkb; the major components of ikk/nf-b pathway) to the progression of live fibrosis in chronic hepatitis c. methods: based upon the common single nucleotide polymorphisms (snps; minor allele frequency(maf) . ) and linkage disequilibrium (ld) information derived from the hapmap, we selected and tag snps from ikbka, and ikbkb, respectively, for genotyping. by using melting curve analysis, snps were genotyped in chronic hepatitis c patients, including patients with hepatocellular carcinoma. association between common genetic variations in ikbka/ikbka and platelet count (plt) was tested by both genotype-and haplotype-based approaches. results: we succeeded in genotyping a total of tag snps that efficiently capture common variation across the kb-block of ikbka and the kb-block of ikbkb. for each of genes tested, haplotypes were found in population studied. all snps were in hardy-weinberg equilibrium, but no significant association was observed between any single tag snp or haplotype and decreased plt in patients analyzed. conclusions: our data suggest that it is unlikely that polymorphisms within the ikbka and ikbkb genes are involved in the progression of live fibrosis in chronic hepatitis c. further studies on genetic variations in other nf-b-related genes in chronic hepatitis c are needed. background: hepatitis c virus infection is a major burden after liver transplantation. the effective treatment for patients who underwent liver transplantation has not been well established. management of these patients is the most challenging task. cyclophilins are essential host factors for hcv replication. we report here the efficacy of divided administration of ifn plus cyclosporine a in the treatment of chronic hepatitis c patients who failed peg-ifn or ifn combined ribavirin. patients and method: we prospectively included patients (median age, ) with genotype b and, failures to combination ifn plus ribavirin or combination pegylated ifn plus ribavirin. the present treatments consisted of an induction therapy, an intensified therapy and a maintenance therapy. the induction therapy comprised intravenous mu ifn every hours for the first days, . mu ifn every hours for the next days and mu ifn every hours for the following weeks, totaling mu of ifn . the intensified therapy was induction therapy shortened to weeks. the maintenance therapy comprised of pegylated ifn b and ribavirin. csa was given times daily during the induction and the intensified therapies. ribavirin was given twice daily during the maintenance therapy. results: the end treatment response and sustained virological response rate of the present study were % ( / ) and % ( / ), respectively. the relapse rate was %( / ). non-responders was % ( / ). all adverse effects were completely reversible. the treatment protocol was well tolerable. conclusion: we concluded that our protocol should be effective in failures to the previous combination therapies. host factor targeting treatment will become a promising treatment option. cyclophilin targeting treatment is a promising new anti-hcv treatment k. inoue , t. watanabe , s. yoshiba background: hepatitis c virus (hcv) is the most common cause of chronic liver disease. however, the efficacy of currently available treatments is limited. we recently reported the effects of combined interferon-/cyclosporin a treatment. cyclophilins are associated with hcv replication and bind cyclosporin a. which cyclophilins are closely associated with hcv replication remains controversial. in this study, several cyclophilins were found to be essential host factors for hcv replication and hcv replication was rescued by overexpression of cyclophilin a in the presence of cyclosporin a. methods: we evaluated the effect of cyclosporin a and its analogues on the replication of hcv in vitro using several types of hcv replicon. the gene expression of representative cyclophilins and pin- was knocked down using small interfering rna (sirna) to identify cyclophilins associated with hcv replication. the specificity of the effect of sirna was confirmed by western blot analysis. the effect of overexpression of cyclophilins on hcv replication in the presence of cycloporin a was also studied. results: cyclosporin a and its analogues suppressed hcv replication in a dose dependent manner. cyclophilin f, cyclophilin lc and cyclophilin lc as host factors which are closely associated with hcv replication, in addition to the previously reported cyclophilin a. knockdown of chclophilin b showed little effect on hcv rna replication. cyclophiln-dependent hcv replication varied among the three hcv replicon cell-lines used. overexpression of cyclophilin a rescued hcv replication in the presence of cyclosporin a. conclusions: these findings suggest several cyclophilins are essential host factors for hcv rna replication. thus potent cyclophilin inhibitors have the potential to be anti-hcv drugs. background/aims: hepatitis c virus (hcv) genotypes - have a worldwide distribution. types a and b are predominant in northern europe and north america, and in southern and eastern europe and japan, respectively. type is endemic in south asia and is variably distributed in different countries. genotype in egypt, genotype in central and south america and genotype is common in china, japan and south east asia. in pakistan a is the commonest genotype, which is associated with the most favorable outcome regarding end treatment response and sustained virological response after weeks of therapy. the aim of this study is to find out hcv genotypes in newly diagnosed chronic hepatitis c patients. methods: this observational study was conducted in chronic hepatitis c patients. all patients had raised alt levels for last months, had positive polymerase chain reaction (pcr) for hcv rna by real time method and liver biopsy was done in all patients under national program for prevention and control of hepatitis during year - . genotyping was done on roche genotyping kit. data was analyzed by spss . results: out of patients, . % (n= ) were genotype a. . % (n= ) were genotype b. . % (n= ) were genotype a. n= had genotype b. . % (n= ) had mixed genotype ( a, b/ a, b, a, b). conclusion: majority ( . %) of chronic hepatitis c patients were genotype a which is associated with favorable outcome after weeks of interferon and ribavirin therapy and only . % had genotype a in this cohort. s.t. zhou , y. zhao , f.j. zhang background/aims: as human immunodeficiency virus (hiv) infected children who are receiving antiretroviral therapy (art) are living longer in china, comorbidities of hepatitis b virus (hbv) and hepatitis c virus (hcv) coinfection should be carefully considered when making management decisions. however, the coinfection rate of either hbv or hcv is unknown in hiv-infected children in china. we evaluated the seroprevalence of hbv and hcv in the china national pediatric art cohort of hiv-infected patients. methods: patients were selected from hiv infected children medically eligible for art who were enrolled into the china national pediatric art cohort since . interviews, medical assessment, serology for hbsag, anti-hcv antibody, transaminase levels, and hiv serostatus and cd counts at baseline of patients were obtained. results: of hiv-infected children were hbsag seropositive ( . %; %ci: . %- . %), and of children were anti-hcv antibody seropositive ( . %; %ci: . %- . %). only age was associated with hbv coinfection. multivariate analysis revealed that children infected with hiv through contaminated blood or transfusion of blood products were . times more likely to be anti-hcv antibody positive than those infected with hiv through other routes. and children from central china provinces, henan, anhui, shanxi, and hubei were . times more likely to be hcv seropositive. conclusion: the high seroprevalence of hbv and hcv coinfection in hiv-infected children attending china national pediatric art cohort calls for routine screening for hepatitis viral coinfection and modification of the management of hiv-infected children in china. background: bms- is a first-in class and highly selective hepatitis c virus (hcv) ns a inhibitor with picomolar in vitro potency against genotypes a and b. in a sad study with healthy subjects, bms- was safe, well-tolerated, and had a pharmacokinetic profile suggestive of once-daily dosing. methods: the objectives of this randomized, double blind, placebo-controlled, sad study were to evaluate the safety, tolerability, antiviral effect and pharmacokinetics of bms- in patients with genotype chronic hepatitis c (chc). treatment naïve or experienced patients were randomized to receive , , or mg of bms- or placebo. results: all bms- single doses were well tolerated and had a safety profile similar to that of placebo. following oral administration, bms- was readily absorbed with dose proportional exposures over the studied dose range. the mean terminal half-life of bms- was approximately hours. mean decline in hcv rna hours after a single , and mg dose of bms- was . log (range . to . log ), . log (range . to . log ) and . log (range . to . log ), respectively. the mg dose resulted in a mean decline of . log (range . to . log ) hours after dosing, which was maintained at hours. conclusions: single doses of up to mg of bms- were safe and well tolerated in patients chronically infected with hcv genotype . bms- produced a robust decline in hcv rna and has a pharmacokinetic profile that potentially supports once-daily dosing. background: the global infection rate of hcv is approximately %, and nearly . % in china. only %- % of patients with genotype b can achieve sustained virological response (svr) after antivirus therapy, nearly half of them experienced treatment failure. the study aimed to determine hcv- b sequence evolution in patients experienced treatment failure during and after therapy, and further analyze relations between the mutations and treatment outcome. methods: patients with genotype b accepted antiviral treatment of ifn plus ribavirin for weeks, and long-term follow-up after therapy. patients experienced treatment failure were further analyzed (one for relapser, another for nonresponder). sera were reserved at baseline, w, w and -year after therapy. hcv-rna was extracted. hcv full-length orf was amplified by rt-nested-pcr and sequencing. result: of the patients achieved svr ( . %). from sequence alignments of relapser at baseline and w, we find that p , ns a and ns a have higher mutation rate both in nucleotide and amino acid level ( . % and . %, . % and . %, . % and . %, respectively). but there is no significant difference in the alignments of w and -year after therapy, the mutation rate is lower. mutation rates of the non-responder among baseline, w, w and -year after therapy are very low. conclusion: antivirus effect is correlated with specific hcv sequences in chronic hepatitis c, mutations in hcv non-structure protein p , ns a and ns a have important impacts on treatment outcome in ifn-based therapy. background: the results of antiviral therapy for hepatitis c (hcv) have improved recently with the use of peg-interferon (peg-ifn)/ribavirin therapy. however, age of patients are concerned because of side effects and safety. as we known, a few studies have targeted therapy in elder with chronic hcv. aim: we reviewed the results of interferon based antiviral therapy in the elderly with chronic hcv at our institution. methods: patients were defined as elderly if they were years and elder who received therapy for hcv. the prescribed treatment duration, end of treatment response were mention. the data recorded included laboratory tests, adverse events (ae), dose modification, and withdrawal rate of therapy. results: of chronic hcv patients treated with peg-ifn/ribavirin between nov and feb . patients were older than years old. the mean age of the elder patients was . ± . years old. were male and were female. histological studies showed with cirrhosis. almost all patients had experienced ae/side effects. the most common abnormalities were anemia and neutropenia. therapy was discontinued in % ( / ). the rate of dose modification was % ( / ) patients who received weeks therapy. transaminases were normalized in % ( / ) after weeks treatment and sustained in % ( / ) one year later. conclusion: the elder patients are more at risk of developing ae while on treatment. most patients should be discontinued or decreased dosage of medication. however, the elder patients with chronic hcv can be treated successfully. background: in the general population the incidence of interstitial lung disease is estimated to be . % and has also been reported with the use of interferons. the higher reporting rate of ip in japan has created interest and warrants further investigation. methods: using both data from randomized clinical trials (ex-japan) and the roche world-wide safety database (advent), the frequency of ip was estimated in patients treated with peginterferon alfa- a ± ribavirin. ip was defined as: interstitial lung disease, alveolitis, pulmonary fibrosis, pneumonitis and pulmonary toxicity. results: one case of ip was reported among the patients included in the clinical trials ( . %). in the advent database considering the estimated , patients with cumulative exposure to peginterferon alfa- a ( , in japan and , us/row) the reported cases of ip represent a rate of . % with a proportional reporting ratio (prr) of . (p< . ). of these cases, were reported in japan (prr . ; p< . ), in the usa (prr . ; p= . ) and row (prr . ; p= . ) representing reporting rates of . % in japan and . % in the usa and row. japanese patients with reported ip were older ( versus - years) and were more likely to have been treated with peginterferon alfa- a monotherapy ( % versus - %). furthermore, the yearly incidence rate has remained unchanged. conclusions: the apparently higher rate of ip reported in japan may result from differences in patient demography, diagnostic criteria and treatment patterns. the overall incidence of ip remains low. background: hepatitis c virus (hcv) infection carries a significant risk for development of insulin resistance (ir) and/or diabetes (dm). recently, retinol-binding protein (rbp ) has been reported as a protein contributing to ir. this study aimed to assess the different expression of serum rbp between chronic hcv infection (chc) patients and non-chc controls. methods: serum rbp was measured in treatment-naïve chc patients and its correlation with the homeostasis model assessment of insulin resistance index (homa-ir), liver histology, virology and metabolic factors was investigated. patients were stratified into different stages of glucose tolerance by oral glucose tolerance test. another sex-and age-matched non-chc adults served as the controls. results: the mean rbp level of controls tended to be higher than that of chc patients ( . ± . vs . ± . g/ml, p= . ). the mean rbp level of igt control-group subjects was . ± . g/ml, which was significantly higher than that of ngt ( . ± . g/ml, p< . ) and dm controls ( . ± . g/ml, p< . ). in contrast, the mean rbp level ( . ± . g/ml) of dm/chc patients was not significantly different from that of ngt/chc ( . ± . g/ml, n= ) and igt /chc ( . ± . g/ml, n= ) patients. amongst chc patients, there was a significant decreasing linear trend of rbp dependent of both histological grading and staging progression, whilst a significant increment of homa-ir was found. conclusion: serum rbp is dysregulated in chc patients. introduction: sustained viral response (svr) in hepatitis c treatment with interferon alfa and ribavirin is affected by adherence and compliance due to severe myalgia, fatigue-anxiety and disturbed sleep. pregabalin, an orally effective gabasergic drug is not metabolized via cytochrome p and is used in fibromyalgia and fatigue-anxiety syndromes without hepatic toxicity.this study evaluates the addition of pregablin to standard agents in achieving svr by reducing side events. methods: thirty patients with chronic hepatitis c {mean age - years, male: female - : ,genotype(g) (n= ), g (n= ), fibrotic score f - (n= ) and f (n= ), mean bmi > kg/m , initial viral load > , iu/ml} were randomized to pregablin mg (n= ) or duloxetine mg (n= ) both orally daily with interferon alfa a mcg sq once a week and ribavirin mg daily for weeks. myalgia anxiety scale, modified quality of life score -evaluated at entry and tri-monthly. all were tested for rapid viral response, early viral response and end treatment viral response and svr. results: at the end of weeks, in the pregablin arm, ( . %) completed the therapy without interruption, one stopped due to excessive somnolence. duloxetine arm - ( . %) completed with interruptions, ( . %) withdrew from the trial due to side events, one left the country. ( . %) achieved svr in pregablin arm and ( . %) with duloxetine. conclusions: pregablin may be considered with ifn and rbv for better adherence and compliance in achieving svr in treatment of chronic hepatitis c. larger randomized studies are needed to confirm the findings. in this study we extended this treatment approach to on treatment nonresponders (defined as having detectable hcv-rna after at least weeks of soc). methods: so far, pts. hcv-rna pos. after weeks of soc ( male, female, genotype : ; genotype a: , with cirrhosis) participated in this protocol; were treatment naïve pts, relapser to two previous therapies ( and weeks). mg/kg/d sil was given for days, soc was continued. hcv-rna was quantified by taqman (roche diagnostics, usa) at monthly intervals on standard treatment and weekly after starting sil. results: all patients received at least weeks of soc, at week had a log drop < , two patients had detectable but unquantifiable hcv-rna (< iu/ml). after days of sil all had undetectable hcv-rna, in one hcv-rna increased to iu/ml and recived after a second course of sil. .all patients are still on soc and are hcv-rna negative. conclusion: sil iv. is an effective "rescue treatment" for on treatment nonresponders to full dose of peginterferon/ribavirin combination therapy. poster exhibition -imaging modalities poster session, hall b background: levovist-enhanced ultrasonography using subtractions makes it possible to depict the perfusion of hyperechogenic nodules. our institution performs sonazoid-enhanced ultrasonography using a toshiba aplio that is set to a ps low images, as generally recommended. the resulting images, however, are difficult to evaluate the kind of staining image that is obtained from a hyperechogenic nodule. these staining images were then compared to advanced dynamic flow (adf) images of a hyperechogenic nodule recorded using levovist-enhanced ultrasonography. methods: the subjects were five nodules who had undergone sonazoid-enhanced ultrasonography. two patients had experienced a recurrence of hcc after tace, while three patients had a hyperechogenic nodule of hcc that had never been treated. one patient with hcc after tace was imaged at a ps low. the second patient with hcc after tace and the three patients with hcc showing a high echoic nodule, were imaged using adf. results: in the patients with hcc after tace, the remaining tumor was difficult to observe in both the vascular phase and the kupffer phase taken at a ps low. in the other patients, however, images taken using adf clearly showed the residual tumor. also, with regard to the findings from the perfused images obtained from the three patients with hyperechogenic nodules of hcc, the hcc was more easily detectable in the adf images than in those taken at a ps low. conclusion: hyperechogenic perfused nodules are easier to identify in images taken using adf than in images taken using ps low. y. komorizono , t. shibatou , k. sako nanpuh hospital background: this study aimed to evaluate the usefulness of sonazoid enhanced radiofrequency ablation under real-time virtual sonography (rvs) guidance in a series of patients with hepatocellular carcinoma (hcc). method: twenty-five patients with a solitary hcc tumor measuring < = . cm in greatest dimension were enrolled in this study. eight patients received an initial treatment, seven also received an additional treatment for local recurrent tumors, and the remaining ten had distant recurrent tumors. all patients were easy to scan by multiple detector ct (mdct), but not by conventional ultrasound ( conclusions: the combination of the rvs system with sonazoid-enhanced us appears to have a high potential for use on patients that are difficult-to-scan by us examinations for percutaneous radiofrequency ablation. background & aims: contrast enhanced ultrasonography (ceus) with sonazoid can be expected to be useful not only for detection of tumor but also for us guided ablation therapy because kupffer imaging lasts for long time. the aim of this study is to investigate the usefulness of sonazoid in rfa for hcc. material & methods: a total of hcc nodules in patients admitted to receive rfa were studied. the detection ability of hcc was compared between ceus and conventional us using dynamic ct as reference standard. the effectiveness in the treatment was assessed by comparing the mean numbers of treatment session of rfa in patient treated with ceus assistance and that in historical controls matched for tumor and background conditions. results: the detection rate was . % in conventional us and . % in ceus (p= . ). sixty-nine nodules in patients were not detected by conventional us and detected after injection of sonazoid. the mean increase in detected tumor number with contrast enhanced us were well correlated with serum albumin level (p= . ). ceus was not superior to conventional us in patients with low albumin level. the mean number of session was . ± . as compared to . ± . in the historical controls (p= . ). conclusions: ceus with sonazoid is useful for detection of tumor in patients with well-conserved hepatic reservoir. the decrease in the mean number of sessions compared to historical controls suggested that sonazoid is an excellent supportive agent in rfa treatment of hcc. direct measurement of peri-operative change in portal blood flow and pressure is difficult in human. in the present study, computational simulation of pre-and post-operative portal blood flow and pressure was performed using computational flow dynamic (cfd) software in patients with primary liver cancers. methods: patients with fibrotic or non-fibrotic livers were analyzed. according to preoperative md-ct, mesh models of portal branches were constructed. cfd software (fluent . , fluent inc.) was employed for flow simulation. on the fluent . , changes in flow dynamics in the remnant portal branches were simulated by virtual cutting of an interested portal branch. the simulation was also performed days after the operation using dicom data obtained at that time. results: relative increase in blood flow in each remnant portal branch was not uniform throughout the liver in each patient. the sudden increase in portal pressure just after the virtual cutting of interested portal branch was almost normalized by day in non-fibrotic liver according to the flow simulation, while the increase in fibrotic liver did not return to the pre-operative values by day . these results suggest that responsive dilatation of remnant portal branches and subsequent regional regeneration could normalize the sudden increase in portal pressure after surgery in non-fibrotic livers, while the mechanism is impaired in fibrotic livers. discussion: computational flow dynamic simulation is useful to analyze the differences in the peri-operative portal flow dynamics and liver regeneration between non-fibrotic and fibrotic livers. aim: to determine if roi analysis can characterize washout in hepatocellular carcinoma (hcc) better than visual analysis. methods: surgically proven hccs from a single institution were studied. the patients' gender, age, date of scan, date of surgery were recorded. patients with pre-operative triphasic (n= ) and quadriphasic ct scans (n= ) were included. a representative section containing the lesion was selected for each case. the hu change between the precontrast and arterial (huabsolute hypervascularity) and the hu change between the peak attenuation and late portovenous phases (huabsolute washout) were recorded. cases were deemed positive if the hu change was more than the standard deviation ( hu). this was compared against visual analysis to determine if our method would increase sensitivity of ct for hcc. results: the mean patient age was . years (range to years); there were males and females. the mean duration between surgery and the scan was . days (range to days). peak enhancement was seen in the early portal venous phase in . % cases. the mean huabsolute washout was . hu (range - - ). roi analysis detected / cases ( . %). this was . % more than visual assessment, which detected / cases. this was statistically significant (p= . ). conclusion: visual assessment of lesion density is subjective. quantitative measurement of lesion attenuation changes between scan phases is a simple and objective method that is more sensitive than visual assessment in determining lesion washout. background: abdominal ultrasonogram(usg) is a common available diagnostic tool to screen and follow up for hepatocellular carcinoma(hcc). but it has been reported that the specificity of ultrasonogram is high but the sensitivity of it is insufficient. we investigated the characteristics of hccs that was missed in the usg but was detected in the ct. methods: total patients who were diagnosed with hcc between december, and february, , were enrolled and analysed retrospectively. all patients were performed with a usg prior to a spiral ct. the period between usg and spiral ct was limited within month. we investigated age, gender, cause(hbv, hcv, alcohol), the size of hcc(the length of long diameter), stage(modified uicc), child-pugh grade, cirrhosis, tumor number, portal vein thrombosis, diffuse type of hcc, regenerative nodules(rns), and the tumor location at segement as the possible related factors. results: the mean period between usg and spiral ct was . ± . days. the diagnostic accuracy rate to hcc was . %( / ). there was no interobserver variation. in analysis of associated factors, there was no statistical significance in age, gender, cause(hbv, hcv, alcohol), stage(modified uicc), child-pugh grade, cirrhosis, portal vein thrombosis, diffuse type of hcc, regenerative nodules(rns) (p > . ). there was statistical correlation in the tumor size less than cm, the solitary tumor and location at segement . (p > . ). conclusion: tumor size less than cm, solitary lesion and location at segment are significant factors to miss hccs in usg diagnosis. s. somani , a. somani , a. jain , v. dixit suvidha, navjeevan hospital, background: histopathological examination is required in the evaluation of various liver diseases for both diagnosis and prognosis. earlier blinded percutaneous liver biopsy was done commonly but now there are various studies suggesting that sonographic guided percutaneous liver biopsy could be more precise and safer. our aim was to compare the safety and diagnostic utility of sonographic guided versus blind percutaneous liver biopsy. methods: it was a retrospective single center study done between june and may . trucut liver biopsy needle was used in all patients. demographic, clinical and histological characteristics between the two groups were evaluated. insufficient biopsy was defined as a sample with less than portal spaces. we reviewed the type of complications and if hospitalization was required, or any mortality related to the procedure. results: out of liver biopsies done in this period after excluding patients we included patients, in group a( %, blind approach) and in group b ( %, sonographic guided approach). mean age was ± . years and male: female ratio was . : . biopsy was sufficient in % in group a and % in group b (p < . ). minor complications occurred in % in group a and % in group b which was not significant. major complications occurred in . % in group a and . % in group b which was statistically significant. mortality was . % in group a and . % in group b which was statistically significant. conclusion: our study suggest that sonographic guided percutaneous liver biopsy is superior in the diagnosis of liver diseases in all aspects when compared to blind approach as it is more safe, has more diagnostic utility with significantly less complications and mortality. poster exhibition -liver fibrosis poster session, hall b background/aims: hmg-coa reductase inhibitors have been shown to reduce hepatic stellate cell proliferation and collagen production and decrease oxidative stress and hepatic vascular tone in cirrhotic patients. therfore, the aim of the present study was to examine whether the lipid lowering agents atorvastatin (ato) or rosuvastatin (ros) would prevent experimentally-induced acute or chronic hepatic damage in rats. methods: liver cirrhosis was induced by thioacetamide (taa, mg/kg, i.p.) twice a week, for weeks. acute damage was induced by two consecutive taa injections ( mg/kg in a h interval). rats were treated concurrently with taa only or taa and either ato or ros daily by nasogastric gavage. another group was treated with taa+pentoxifyline (ptx), an agent with known antifibrotic effect through a different mechanism and served as positive control. results: presented in the conclusions: the lipid lowering agents used in our study had no effect on the development of acute or chronic hepatic damage in rats or on oxidative stress induced by taa. purpose: the development of hepatic fibrosis in patients with chronic liver disease increases the risk of liver cancer. the present study was conducted to determine whether an easily performed myocardial examination technique can be applied to the assessment of hepatic fibrosis. strain rate imaging is a new method based on tissue doppler imaging (tdi). the usefulness of strain rate imaging in assessing the degree of hepatic fibrosis was evaluated. this time, it mede comparative study with fibroscan in cases. methods: strain rate imaging was performed using a diagnostic ultrasound system (aplio tm , toshiba medical systems corporation, tochigi, japan) in a total of subjects: in the chronic hepatitis group, in the cirrhosis group, and in the normal control group. tdi-q, the tissue doppler analysis software installed in the aplio system, was used for analysis. measurement was performed five times from the epigastrium, with the roi size set to mm and the derivative pitch to mm. results: (i): both scores were largely reproducible among the different laboratories. however, compared to the histological findings, the error ratio was % for all results calculated by fibrotest and actitest. (ii): calculated scores varied among f ( %), f ( %), f -f ( %), and f ( %) (fibrotest), as well as a /a ( %), a ( %), a -a ( %), and a ( %) (actitest). results: the mean strain value was . in the chronic hepatitis group, . in the cirrhosis group, and . in the normal control group.the correlation was not thought to be fibroscan. conclusion: the results of the present study suggest that this noninvasive method permits quantitative assessment of the degree of hepatic fibrosis to be performed easily and in a short time. it is expected that the accuracy of the strain rate imaging method in determining the degree of hepatic fibrosis will be improved when it is used in combination with histological examination. conclusion: despite reproducibility of fibro-and actitest results among the six laboratories, large scale investigation (n= ) displayed increasing variability of the results depending on interlaboratory differences that were still in a quality controlled, analytically acceptable range. furthermore, calculated scores coincided with histological findings only in less than % of all cases. thus, the diagnostic accuracy of these tests seems low, if histology is accepted as gold standard. background: current knowledge attributes connective tissue growth factor (ctgf/ccn ) a crucial role in enhancing tgf-actions during hepatic fibrogenesis. recently, we demonstrated that caffeine leads to an upregulation of ppar in hepatocytes, thus sensitizing these cells to the well known inhibitory effect of -deoxy- , -prostaglandin j ( -d-pgj ) on ctgf expression. however, upregulation of the receptor alone is not sufficient per se, its physiological ligand -d-pgj is required for exerting its inhibitory effect on ctgf synthesis. aim and methods: this study compares serum concentrations of -d-pgj in caucasian patients with fibrotic liver diseases (n= ), caucasian controls (n= ) and caucasian non-liver disease sick (n= ), as well as of chinese patients with hepatocellular carcinoma (n= ) and chinese healthy controls (n= ) in order to characterize their suitability for therapeutic approaches with ppar inducing (i.e. ctgf inhibitory) drugs such as caffeine. results: presented data show that caucasian patients with ongoing hepatic fibrogenesis (mean . ± . µg/l) display impressingly higher serum concentrations of -d-pgj than healthy probands (mean . ± . ) and caucasian patients with non-liver disease (mean . ± . µg/l). similar results are found in chinese patients with fully developed hcc (mean . ± . µg/l) compared to chinese healthy controls (mean . ± . µg/l). we identified the predictors of tumor recurrence using cox-regression model. introduction: non-invasive, i.e. serum-based multiparametric panels of biomarkers have been proposed for the diagnostic assessment of liver fibrosis. aims/methods: (i) haptoglobin, alt, ggt, alpha -macroglobulin, apolipoprotein a and bilirubin in sera of patients with histological proven fibrosis (f -f , a -a ) were determined in different quality-controlled laboratories. interlaboratory variations of the calculated fibrotest score for staging and actitest score for grading (both biopredictive tm ), and their error ratios compared to biopsy results were calculated. (ii) the variability of obtained fibrotest/actitest scores depending on differential combinations of the allowed analyt-specific maximum/minimum permissible values as determined by the external quality control of the german association of laboratory medicine was determined and the frequency distribution of the results calculated. results: a total of patients (mean age, . ± . years; male, . %) were included. median follow-up duration was . months (range, . - . ) and patients ( . %) experienced local tumor recurrence during the observational period. multivariable analyses showed that low p /ms level (relative risk, . ; % confidence interval [ci], . - . ; p= . ) and serum alpha-fetoprotein level > ng/ml (relative risk, . ; % ci, . - . ; p= . ) were independent risk factors for tumor recurrence. patients with p /ms level < . revealed . -fold ( % ci, . - . ; p= . ) increase in the risk of recurrence after adjustment for serum alpha-fetoprotein level, as compared to those with p /ms level > . . however, tumor size, child-pugh score, and hepatitis b virus dna level failed to significantly affect the time-to-recurrence. conclusion: our study suggests that lower p /ms value, which means more severe liver fibrosis, is an independent predictor for hcc recurrence after rfa. background/aims: despite of its high prevalence, osteoporosis is an underestimated complication of liver cirrhosis. the aims of this study is to prove the prevalence of osteoporosis and osteopenia in patients with liver cirrhosis and to identify the principal risk factors associated. methods: the prevalence of osteoporosis and osteopenia was studied in patients with alcoholic or viral liver cirrhosis who were admitted to the institute of gastroenterology and hepatology, cnuh between march and september . osteoporosis and osteopenia was evaluated by measuring their bone density using dual energy x-ray absorptiometry (dexa) at lumbar spine and femoral head. the variables taken into consideration were: sex, body mass index (bmi), presence of cholestasis, severity and duration of liver disease. results: total patients (male and female , respectively) were estimated for association of liver disease and osteoporosis. of these, patients were estimated for bone density of lumbar spine and neck of femur by dual x-ray absorptiometry (dexa). morning blood samples were taken for hormonal and biochemical analysis from all patients. among patients, patients ( %) were found to have osteopenia or osteoporosis. there was no statistically significant correlation between age, bmi, severity and duration of liver disease, pth, vitamin d, alp and igf- . conclusion: there is high prevalence rate of osteopenia or osteoporosis in liver cirrhosis. although the causes of osteopathy are heterogeneous, the early diagnosis and treatment of osteopathy in patients with liver cirrhosis is important. background: to build and to evaluate mathematical models for predicting liver fibrosis progression by using conventional laboratory indicators in chronic hepatitis b. methods: liver biopsy and routine laboratory tests were performed in patients with chronic hepatitis b. using multiple logistic regression to analyze evidently relevant indicators, then the predicting models were built and analyzed by roc curve. results: after spearman analysis, factors such as age, platelet count(plt), international rate(inr), total bilirubin(tbil), albumin(alb), aspartate aminotransferase (ast), gamma glutamyltranspeptidase (ggt), total bile acid(tba) and cholinesterase(che) were found to be correlated with liver fibrosis p . . three models (s , s , s= , respectively) were built by plt, inr, alb, ggt and che, which were independent predictors after multiple logistic regression analysis.finally, fibrosis score (fs) was calculated to predict different liver fibrosis stages. roc curve analysis revealed that the auc of fs was . in model (s ), . in model (s ) and . in model (s= ) fig .the cut-off fs in model was at . with . % sensitive, . % specificity and the accuracy was . %. the cut-off fs in model was at . with . % sensitive, . % specificity and the accuracy was . %. the cut-off fs in model was at . with . % sensitive, . % specificity and the accuracy was . %. conclusions: the predicting models, built by using conventional laboratory indicators, have fairly well value for diagnosing hepatic fibrosis or hepatocirrhosis in chronic hepatitis b. background: to investigate the effect of liver cirrhosis on the development of atherosclerosis in the rabbits chronically fed with high fat diet. methods: normal male new zealand white rabbits were randomly divided into four groups: a control group, a high fat diet group, a carbon tetrachloride (ccl ) group and a complex group. pathologic changes in ascending aortas and livers were observed. the levels of serum alanine aminotransferase alt , lipid, c-reactive protein (crp) were also determined. results: significant hepatic steatosis, inflammation and fibrosis could be observed in the three treatment groups; while atherosclerosis and typical arteriosclerotic plaques in ascending aortas could only be observed in the two high fat diet groups. compared with the control group, serum alt and lipid levels in ccl group were increased significantly (p< . ), but no difference of arterial intima-media thickness (imt) and i/m ratio between these two groups. the levels of serum alt, lipid, crp and imt in two high fat diet groups were significantly increased compared with the control group (p< . ). the level of serum alt in the complex group was significant higer than that in the high fat diet group, but the i/m ratio was just opposite (all p< . ), and there was no difference of imt between the two groups. conclusions rabbits treated with ccl can elevate serum lipid levels, but can not induce atherosclerosis. though the activity of liver inflammation was aggravated in the complex model group, it has no effect on atherosclerosis possibly partly because of malnutrition. higher values of liver stiffness in males with mild chronic hepatitis c c. stern , a.c. cardoso , r. moucari , a.d. pumpo , n. giuily , p. bedossa , p. marcellin hopital beaujon background/aim: liver stiffness (ls) measured by fibroscan (echosens) is a noninvasive method to assess liver fibrosis in patients with chronic liver diseases. we evaluated the impact of factors on ls results in mild chronic hepatitis c (chc). methods: chc patients with metavir fibrosis stage at liver biopsy and a reliable ls exam were eligible. all patients had no prior antiviral treatment. the ls values were compared to clinical and biochemical data. results: patients were included with the following characteristics: mean age , male gender ( %), mean bmi . , median ls . kpa ( . - . ), diabetes ( %), genotype ( %), metavir activity a ( %), a ( %), steatosis at biopsy % ( %), mean glucose . , abnormal alt ( %), abnormal ggt ( %), homa ( . ). the ls values were associated wtih male gender (median . in males vs . in females) (p= . ), bmi (p= . ), alt (p= . ), ggt (p= . ) and glucose levels (p= . ). no association was found between ls and activity stage (p= . ) or steatosis (p= . ). in the linear regression, the only factor independently associated with higher ls was gender (p= . ). in men, higher ls was related to levels of alt (p= . ), but not to necro-inflammation grade (p= . ). in women, ls was not associated with alt levels, but with bmi (p= . ) and ggt levels (p= . ). conclusion: in patients with mild chc, liver stiffness values are higher in males. these results suggest that different cut-off for fibrosis stage should be proposed according to gender. aims: to investigate the effects of shuanghu qinggan granule(sqg) on prevention and treatment of hepatic fibrosis induced by carbon tetrachloride in rats. methods: sd rats were divided into groups, normal control groupamodel groupb, sqg largec , middlec small dose groupsc and silymarin positive contrast groupd. the rats of bc c c d were injected with carbon tetrachloride for weeks. the rats of c c c were then administered with sqg for weeks. the rats of d were then administered with silymarin for weeks. results the liver structure of rats of b was severely damagedlarge amount of liver cells became obviously degeneratedand hepatic veins were clearly congested. the hepatic cells fatty degeneration and infiltration of inflammatory cells in rats of c c c d reduced significantly. there was no fiber hyperplasia in liver tissues of rats of c c c d. blood serum ha cp p levels in rats of b were significantly higher than those in ac c c d. conclusion: sqg has remarkable therapeutic effects on rats with hepatic fibrosis induced by carbon tetrachloride, the higher the dosage of sqg was, the more effective the results would be. conclusions: none of sophisticated biomarkers had value in addition to readily available laboratory data for the prediction of significant fibrosis in hbeag positive patients. two markers out of sophisticated biomarkers provide additional diagnostic information in hbeag negative patients. before new biomarkers are accepted, their superiority to routine laboratory data should be meticulously appraised. objective: to evaluate the efficiency and safety of "tinmax" hb- herbal compound (cpd) in treatment of hepatofibrosis and cirrhosis post chronic hepatitis b. methods: a double-blind randomized method was employed. patients of hepatofibrosis or cirrhosis post hepatitis b were separated into study group ("tinmax" hb- group) and control group (natural vitamin group) by randomized method. the course was weeks. patients visited once every weeks and the last visit at weeks after the cessation of treatment. part of patients had liver biopsy before and after treatment. before, during the course and at the end of therapy, clinical symptoms and physical signs were evaluated, hepatic function, and serum markers of hepatofibrosis (such as hyaluronate acid, laminin, serum type iii procollagen and collagen iv) were tested, and ultrasound evaluation was performed. results: patients enrolled in the evaluation. patients completed the evaluation according to the protocol. patients had liver biopsy twice, from the study group and from the other one. at the end of therapy, the total effective rate of hepatofibrosis in histopathology is . % in the study group, much higher than that of . % in the control group (p< . ). the total effective rate of serum markers of hepatofibrosis at the end of therapy in the study group was . %, much higher than that of . % in the control group (p< . ). the total effective rate of non-invasion markers of hepatofibrosis at the end of therapy in the study group was . %, much higher than that of . % in the control group (p< . ). the drugs of adverse event had not happened in both groups. conclusion: "tinmax" hb- herbal compound (cpd) is effective and safe in treatment of hepatofibrosis and cirrhosis post chronic hepatitis b. w.h. sha , xiaohui zeng , yuyuan li gi department, first municipal hospital of guangzhou, guangzhou aim: to investigate the clinical value of serum indices for hepatic fibrosis in chronic liver diseases. methods: competitive radioimmunoassay was used to determine the serum level of collagen type ( c), laminin (ln) and hyaluronic acid(ha) in patients with different severity degree of chronic liver diseases, and in healthy subjects. results: the serum levels of c, ln, and ha in the patients with liver diseases increased to different extent, compared with those in the healthy subjects. of which the highest of c, ln, and ha were found in the patients with primary carcinoma of liver or hepatocirrhosis and the serum level of ha is highlight. the combination detection of serum c, ln, and ha is more valuable than single index. conclusion: joint detection of serum c , ln, and ha is of higher significance in clinical diagnosis and prognosis of hepatocirrhosis, and is also available for successive observation on the development of liver diseases. aims: to investigate the mechanism of fuzheng huayu decoction (fzhy) on hepatic stellate cells (hscs) activation relating to tgf- signal transduction pathway. methods: hscs were isolated from normal rats by in situ pronase/collagenase perfusion followed by density gradient centrifugation. at day after isolation, cells were stimulated with pm tgf- for h, then incubated with % fzhy pharmacological serum or m t r -i inhibitor (sb- ) for h. protein expression of -sma, smad was assayed by immunofluorescent stain; total protein expression of -sma, t r -i, smad / and nuclear expression of smad was analyzed by western blotting. results: fzhy pharmacological serum significantly decreased expression of -sma, t r -i, and inhibited smad nuclear expression and translocation in tgf- stimulated hscs. conclusions: fuzheng huayu decoction can prevent hscs activation through tgf- signaling transduction pathway in hscs, which may be the important molecular pharmacological mechanism of fuzheng huayu decoction action against liver fibrosis. background: fatty liver disease has become a health problem related to metabolic syndrome worldwide although its molecular pathogenesis has remained further studied and it is unclear whether advanced fibrosis induced by steatohepatitis will regress when diet is controlled. aim of this study is ) to study the involvement of endoplasmic reticulum stress (er stress) in the occurrence of seatohepatitis and ) to obtain the evidence of resolution of fibrosis by changing the diet. methods: non-alcoholic steatohepatitis with advanced fibrosis was produced in rats by giving methionine-choline-deficient diet (mcdd) for weeks. methionine-choline-control diet (mccd) instead of mcdd was given for the last weeks in an experimental group. fibrosis and inflammation was determined by several tissue stainings. gene expression related to fibrosis and inflammation was determined by immunoblotting and real-time pcr. expression of caspase- , caspase- , and glucose-regulated protein was evaluated to clarify the presence of er stress aim against liver fibrosis relating to hypoxia and angiogenesis regulation. methods: the rats were divided into normal, model, sa-b and perin control group. rats in sa-b and perindopril group were administrated with sa-b and perindopril respectively. liver fibrosis was induced by ip dimethylnitrosamine (dmn) for w. fibrosis degree was observed by sirius red staining. col-i protein expression was analyzed by western blot; col-i , vcam- , icam- , hif- and vwf expression in liver tissue was checked by immunohistochemistry; gelatinase activities in liver tissue were detected by gelatin zymography and in situ flourescent zymography. result: compared to normal group, col-i, hif- , icam- , results: ) changing the diet from mcdd to mccd triggered the reduction in fat in hepatocytes, the decrease of inflammatory gene expression and oxidative stress, and the regression of fibrosis accompanied by the disappearance of activated stellate cells and macrophages. ) immunohistochemistry, immunoblotting, and rt-pcr analysis all indicated the occurrence of er stress in steatohepatitis while it recovered immediately after changing the diet from mccd to mcdd. vwf protein expression and gelatinase activity in liver tissue were increased obviously in model group, while sa-b and perindopril treatment significantly decreased these protein expressions and gelatinase activity. conclusions: this simple experiment clearly shows that the changing diet from steatohepatitis-causing mcdd to mccd triggers the resolution of inflammatory and fibrotic reaction in the liver, suggesting that food intake is a very important factor for controlling the state of fat and pathology of the liver. er stress is involved in the process. background: liver fibrosis results from chronic damage to the liver in conjunction with the accumulation of extracellular matrix proteins, which is a characteristic of most types of chronic liver disease. under injury conditions, hepatic stellate cells (hscs) are activated to transdifferentiate into myofibroblasts, which are capable of secretion of many connective tissue elements, especially collagens i, iii, and iv. gynostemma pentaphyllum is a popular folk medicine that has been used for treatment of hepatitis in asia. gypenosides are the major saponins derived from g. pentaphyllum. in previous study, gypenosides have hepatoprotective and anti-fibrotic activities in rat chronic liver injury induced by ccl , and anti-proliferative effect in rat isolated hscs. methods: in cultured hscs model, we detected type procollagen protein and mrna by western blot and rt-pcr. result: we found that g. pentaphyllum inhibited type procollagen protein expression in % at hours. furthermore, g. pentaphyllum also inhibited type procollagen and mrna expression in % and % respectively. in addition to transcriptional inhibition, we found that g. pentaphyllum also enhanced the degradation rate of type procollagen protein. base on the effect of enhancing protein degradation, we used some protease inhibitors like ca- me, z-fa-fmk, aebsf, tpck and tlck to identify the potential target of g. pentaphyllum. on the other hand, in the ubiquitin-proteasome system analysis, we quantified the change of some target proteins of proteasome in the presence or absence of g. pentaphyllum. conclusion: g. pentaphyllum reduced type procollagen protein by inhibiting transcription and enhancing protein degradation. aim: excessive oxidative stress in diabetic patients has been implicated in the pathology and complication of liver. the present study was designed to examine whether ginger has a direct hepatoprotective effect in diabetic cases. methods: wistar strain albino rats were selected for this study. the rats were divided into groups: (i) control, (ii) ginger treated ( mg/kg b.w. orally, days) (iii) diabetic ( mg/kg b.w., i.p.) and (iv) diabetic + ginger treatment. the lipid metabolic profiles such as total cholesterol, triglycerides, phospholipids and lipid peroxidation as stress markers and histopathological studies were carried out to assess the damage in hepatic tissue. results: ginger treated diabetic rats demonstrated significant reduction in glucose levels as compared to the nontreated diabetic animals. diabetic rats have shown increased total cholesterol, triglycerides, phospholipids and lipid peroxidation content in hepatic tissue compared to control, indicate prevailing of oxidative stress and alterations in fatty acid metabolism in these rats. further, degenerative changes of hepatic cells in diabetic group are minimized to nearness in structure by administration of ginger as evinced by histopathological examination. conclusion: we summarize that the hypolipidemic and antioxidant compounds present in ginger may be useful in delaying the complicated effects of diabetes. this results also reveal that ginger possess hepatoprotective properties in diabetic cases. anti-fibrotic action m. naime , s. ali hamdard university rhizomes of valeriana jatamansi (family, valerianaceae) have long been used in indian subcontinent by the traditional healers for the treatment of various diseases. this study provides experimental evidence suggesting the therapeutic effect of the crude extract of rhizomes on rat liver fibrosis, and demonstrates its antiproliferative role. crude extract ( % ethanolic) at a dose level of mg/kg body weight was administered to rats to study the effect on biochemical and other markers of liver fibrosis. administration of the extract for weeks could bring down elevated the levels of biochemical markers of liver injury, and modulate several other biochemical responses. morphology and hisopathological examination cooroborated with the biochemical changes, and indicated partial reversal of fibrosis. dpph assay confirmed the antioxidant property of the extract, which is suggested to be due to -ionone, -sitosterol and other chemical constituents. further, treatment could restore depleted glutathione level, inhibit lipid peroxidation, and inhibited elevated xanthine oxidase activity in fibrosis. the study also reports anti-tumour promotion activity of the extract as evident by a significant decrease in [ h]-thymidine incorporation by hepatic dna in extract treated rats. results suggest that v. jatamansi extract has curative effect and can partially reverse biochemical and histological changes associated with liver fibrosis. with chronic hepatitis c c. wongjitrat , s. chainuvati , a. manuyakorn , s. aroonparkmongkol , t. tanwandee mahidol university, background: leptin is a peptide hormone that mainly regulates food intake, energy expenditure and reproductive function. leptin also releases from activated hepatic stellate cells and may have a role in regulation of fibrogenesis and inflammation. in human chronically infected by hcv, the role of leptin-associated fibrosis of the liver is still unclear. there is no data in thai patients chronically infected by hcv regarding leptin level and its correlation with hepatic histology and fibrosis.the purpose of this study was to evaluate the relationship between leptin level and severity of liver fibrosis in thai patients chronically infected by hcv. methods: sixty-six patients ( men, women) with chronic hcv infection and liver biopsy was done within months were enrolled. fasting blood samples were obtained and serum leptin levels were measured by elisa. bmi, blood sugar, liver function test, lipid profile, hcv rna viral load and hcv genotype were also measured and related to histological findings. results: mean serum leptin levels were significantly higher in women than in male. there was a significantly correlation between serum leptin and bmi (r = . , p < . ). leptin levels were not associated with hepatic fibrosis (r = . , p = . ) and necroinflammation (r = . , p = . ). steatosis was significantly associated with severe necroinflammation (r = . , p = . ), but not fibrosis (r = . , p = . ). conclusions: these findings failed to demonstrate correlation of serum leptin and hepatic fibrosis in thai patients chronically infected with hcv. background and aim: liver cirrhosis is one of the leading causes of mortality in our country as well as in our region. even though deterioration of glucose metabolism and existence of insulin resistance in liver cirrhhosis has been well documented in many studies, it is still unclear how insulin resistance mechanism develops. the aim of the present study is to assess insulin resistance, cytokines and crp levels in patients with liver cirrhosis and control subjects. in additon, we aimed to investigate the relation of insulin resistance in liver cirrhosis with such parameters as age, sex, etiology, child-pugh classification, spleen size, tnf-?, il- ?, il- res, il- , il- , il- , crp and hs-crp. material and method: a total of patients with cirrhosis of different etilogy ( male, female) were included into the study. as controls, ( male and female) subjects were taken. the two groups were compared with each other in terms of glucose, insulin, c-peptid, homa-ir, tnf-?, il- ?, il- res, il- , il- , il- , crp and hs-crp levels. in the second part of our study, the liver cirrhosis group was divided into two subgroups: patients with homa-ir value > . as insulin resistance positive, and those with homa-ir value > . as insulin resistance negative. these two groups, i.e. , homa-ir positive and homa-ir negative, were compared in terms of age, sex, etiology, child-pugh classification, spleen size, tnf-?, il- ?, il- res, il- , il- , il- , crp and hs-crp levels. results: in liver cirrhosis group, glucose, insulin, c-peptid, homa-ir, tnf-?, il- res, il- , crp and hs-crp levels were determined to be significantly higher than controls. between patients with homa-ir positive and negative, however, statistically no significant difference was found in terms of age, sex, etiology, child-pugh classification, spleen size, tnf-?, il- ?, il- res, il- , il- , crp and hs-crp levels, but il- level was seen to be significantly low in patient homa-ir positive. conclusion: in patients with liver cirrhosis, the levels of glucose, insulin, c-peptid, homa-ir, tnf-?, il- res, il- , crp and hs-crp increase with respect to normal population. determination of increased homa-ir level in liver cirrhosis supports the view that insulin resistance develops in liver cirrhosis as reported in related studies. in the study, it was also determined that the mechanism of insulin resistance development occurs independent of age, sex, etiology, child-pugh classification, spleen size, tnf-?, il- ?, il- res, il- , il- , crp and hs-crp levels. the determination of statistically lower level of il- in patients with homa-ir positive with respect to those with homa-ir negative does not indicate similarity with the studies carried out earlier. ) in patients ( . %) than in controls( %)in group i hla-b significantly increased in patients ( %)as compared to controls ( %) . in group ii hla -b significantly higher in patients ( . %)than controls ( %) also hla-aw significantly higher ( . %) in patients than controls ( . %).in group iii hla-aw significantly increased in patients ( . %) compared to controls.no significant association between hla antigens and cases with hbv or hcv infection. conclusion: the significantly high association of hla-aw and hla-b in patients with hepatic schistosomiasis as compared to normal controlstogether with the lack of any association with active intestinal schisto . antigens predispose to liver affection.individuals possessing hla-aw appear to be more prone to severeform of liver disease background: atp b mutation is one of the factors that result in cholestasis and progress to chronic liver disease, but has never been reported in the mainland china before. the aim of this study was to elucidate the role of atp b mutation in mainland chinese patients with progressive intrahepatic cholostasis and low ggt. methods: children who presented with progressive intrahepatic cholostasis and low ggt were admitted in a tertiary pediatric hospital in eastern china. abcb gene was analyzed firstly to exclude bsep deficiency. afterwards, all the encoding exons and their flanking areas of atp b gene were sequenced in the remaining patients in whom only one or no mutations of abcb were found. results: mutations of atp b gene were found in patients. i n had been reported in taiwanese patients with pfic , and the others were novel. p t and ivs + t g were linkage and found in of patients, including homozygote and heterozygote. liver biopsy had been performed in patients with atp b mutations and with abcb pe mutations. variety portal fibrosis was showed in patients with atp b mutations and patients with abcb mutations. giant cell transformation was detected in one patient with atp b mutations and patients with abcb mutations. laboratory of exercise biochemistry, taipei physical education college, jhongcheng rd., no. , sec. , taipei city- , taiwan, roc background/aim: generation of reactive oxygen metabolites are depends on the consumption of oxygen and their cumulative effects may be different from lean to obese population. this study was designed to investigate the deleterious effects of oxidants on hepatic antioxidant defence system in lean and obese rats under hypoxic condition. methods: zucker rats lean ( ± gms) and obese ( ± gms) were divided into control and acute hypoxia groups. the acute hypoxia treatment was performed in a hypoxic chamber at % oxygen consumption. objectives: to compare the diagnostic value of morning urine copper to zinc (copper/zinc) ratio and hour urinary copper excretion in wilson's disease (wd) children. results: in the results, acute hypoxia caused a significant (p< . ) decrease in major antioxidant enzymes including superoxide dismutase (sod), catalase (cat), glutathione peroxidase (gsh-px), glutathione reductase (gr) and glutathione (gsh) content in lean groups when compare to their controls. the decrease in the activities of all antioxidant enzymes was also noticed in obese group with hypoxia treatment. however, this decrease was not significant in case of cat, gsh-px activities and gsh content. the mda levels (lipid peroxidation marker) were higher in obese rats compare to lean rats. methods: morning urine and hour urine were collected from patients over three years age who were hospitalized in a tertiary pediatric liver service. each patient was re-evaluated according to wd scoring system, and was assigned to one of the three groups: wd, suspecting wd, and non-wd. , , and cases were assigned to wd, suspecting wd, and non-wd respectively. urine copper and zinc concentration was determined simultaneously by using inductively coupled plasma mass spectrometry. conclusions: the higher hepatic mda values observed in obese rats indicate that accumulation of free radicals may be more in obese rats thus leads to promote the lipids oxidation. from this study it is concluded that decrease of antioxidant enzymes (except gr) with acute hypoxia treatment were more in lean group compared to with that of obese group. results: the morning urine copper/zinc ratio and hr urinary copper excretion correlated well (r= . , p < . ). the median of morning urine copper/zinc ratio, hr urine copper/zinc ratio, h copper excretion, and h zinc urinary excretion were . , . , . and . in wd group, and . , . , . and . in the non-wd group respectively. the differences of morning urine copper/zinc ratio, hr urine copper/zinc ratio, and h copper excretion were significant (z-value - . , - . and - . respectively, all p values < . chd l is a recently discovered oncogene localized at q , one of the most frequently amplified chromosomal regions in hcc. herein, by yeast-two hybrid assay, we demonstrate that the anti-apoptotic ability of chd l is associated with its interaction with nur , a critical member of a p -independent apoptotic pathway. as the first cellular protein identified to bind nur , chd l inhibits the nucleus-to-mitochondria translocation of nur , and subsequently hinders the release of cytochrome c and the initiation of apoptosis ( figure ). further study found that c-terminal macro domain of chd l is responsible for the interaction with nur , and a chd l mutant lacking residues - failed to interact with nur and prevent nur -mediated apoptosis. we also find that chd l confers cellular chemoresistance to drugs that induce apoptosis via the nur -mediated pathway, which may lead to the identification of new therapeutic targets for hcc treatment. background/aim: accumulation of oxidative damage to proteins, lipids and mitochondria could increase with advancing of age. the current study was aimed to test the hypothesis that swimming exercise training could revert the age dependent oxidative damages in liver. methods: sprague-dawley rats of young ( months) and old ( months) were divided into four groups; young control (n= ), young exercise (n= ), old control (n= ) and old exercise (n= ). minutes of swimming exercise was given to the exercise group for a period of two weeks. results: the estimated antioxidant enzyme activities including, superoxide dismutase (sod), catalase (cat), glutathione peroxidase (gsh-px) and glutathione reductase (gr) were decreased with age and significantly (p< . ) increased with exercise training. however, elevated protein carbonyls and mda levels were noticed in old animals, which indicate that old liver had greater accumulated oxidative damages. the significant drop in protein carbonyl content and increase in mitochondrial succinate dehydrogenase (sdh) activity was observed with response to swim training in old rats. conclusions: this data implied that swim exercise training could revert the oxidative damages in liver. this was also proven by enhanced antioxidant enzyme status with response to exercise training in old rats. to sum-up these results it is cleared that age induced detrimental effects to the liver might be reversed by regular swimming exercise training in old rats. results: peg was expressed in l /peg (fig. ) . peg accelerated the growth of l . after treatment with mm h o for h, the inhibitory rate of l /peg cells was . %; the chromosomal condensation and ladder-like dna fragmentation were not observed (fig. ) . methods: hepg or hepg . . were co-cultured with jurkat cells, with blocking test by adding anti-pd- antibody. the pd- expression was detected by flow cytometry (fcm); cytokines in culture supernatant in blocking groups and controls were measured by enzyme-labeled immunosorbent assay (elisa); cytotoxic test of t cells were measured by methyl thiazolyl tetrazolium (mtt). conclusions: over-expression of peg can significantly promot l proliferation and ameliorate apoptosis-inducing effects of h o on l . results: the pd- expression on jurkat cells was induced by hepatoma cells, the expression rate were . ± . % (by hepg ) and . ± . % (by hepg . . ), respectively. the cytokines il- level ( . ± . pg/ml), inf-level ( . ± . pg/ml) and il- level ( . ± . pg/ml) in culture supernatant of blocking groups were significant higher than that of controls (il- , . ± pg/ml, inf-, . ± . pg/ml and il- , . ± . pg/ml, respectively. p < . ). the cytotoxic test (od value) was markedly higher in blocking group ( . ± . ) than that of control group ( ± . p< . ) . conclusion: the pd- expression on lymphocytes can be induced by hepatoma cells, and cytokines expression and cytotoxic test were recovered by blocking pd- /pd-l interaction. background: hedgehog (hh) pathway is well known as a positive regulator for tissue construction( during development) and reconstruction (in adults). our aim to observe the expression change of hh pathway on rat hepatic regeneration . materials and methods: adult male sprague-dawley rats underwent approximately % partial hepatectomy (ph) or sham operation (so). liver specimens were collected at , , , , , , , and h after ph or so. hedgehog expression was determined in mrna level by rt-qpcr as well as in protein levels via immunohistochemical staining and western-blotting. results: so treatment did not induce remarkable changes in hedgehog expression; however, the level of transcript for hedgehog was significantly upregulated after ph. we found sonic hedgehog(shh )and glioblastoma (gli - ) mrna expression in the regenerating liver arrive at its peak at as early as h and returned to its physiologyical level h later. it is similar to the change of proteins (shh and gli ) .as seen from immunohistochemistry experiments; shh protein was expressed uniquely in regenerating hepatocytes. similarly, ph induced over expression for shh protein occurred from h with a peak level at h after surgery. but gli protein mainly located in nucleus and no significantly changes in the phrase of liver regeneration. conclusion: hedgehog pathway may play a role in the activation of hepatic proliferation during liver regeneration induced by physiological stress or pathological states, such as ph. background: to investigate whether peg , an imprinted gene with an active paternal but silent maternal allele, was involved in hydrogen peroxide (h o ) induced cellular apoptosis. methods: peg gene was stable transfected into l . cellular gene expression was determined by rt-pcr, western blot and immunocytochemistry. cell proliferation was analyzed by mtt. after treatment with different concentrations ( - mm) of h o , cell proliferation inhibition rate was measured by mtt. morphological changes of apoptotic cells were determined by hoechst staining, dna fragmentation was observed by agarose gel electrophoresis. hua tang , xiao-yan tang , min liu , xin li tianjin life science research center, tianjin medical university, tianjin , china we determined how afp modulates the proliferation of hepatoma cells. a recombinant adenovirus expressing sirna against afp (adv-afpsirna) was created and found that it reduced expression of afp specifically in hepatoma cells, and markedly inhibited the proliferation of hepatoma cells in vitro. local treatment using adv-afpsirna caused significant repression of the growth of hepatoma derived hepg cells in xenograft in nude mice. knockdown of afp resulted in an obvious delay in the g /s transition of cell cycle, but did not affect apoptosis in hepg cells, as analyzed by flow cytometry and tunel assay. also, differential expressions of some genes related to the cell cycle, including skp , cyclin d , csk and ebag were identified by microarray and rt-pcr in hepg cells and hepg cells with knocked down afp. these results suggest that endogenous afp is a critical determinant of the growth of hepatoma cells. hematopoietic stem cell (cd +) therapy can improve liver function in patients with cirrhosis. these cells can be mobilized into peripheral blood using granulocyte colony stimulating factor (gcsf). this study was undertaken to assess feasibility and safety and of gcsf induced cd + cell mobilization and its impact on liver function in patients with cirrhosis. patients with liver cirrhosis (cryptogenic or alcoholic with m abstinence) with cpt > and < , and splenic diameter < cm were included. gcsf injection was given for days ( mcg/kg/dose). baseline & day- cd + counts in peripheral blood were done by flow cytometry. follow up was weekly for weeks and then monthly. cpt was compared at baseline and months. patients (median age y, range - y, males; etiology: alcohol, cryptogenic; median cpt , range - ) were included. cd + cell counts at baseline and day were ( - ) and ( - ) respectively (median, range). side effects were fever in , allergic reaction in and increase in splenic size in (excluded). in follow up, patients died ( , & m after therapy, after olt), lost to follow-up. patients showed improvement in - ) at -month follow-up. gcsf treatment is safe and yields adequate cd + cells in peripheral blood. in short term it results in improvement in liver function in patients with cirrhosis pe molecular cloning and transcriptional analysis of kctd gene promoter b. pi , j.s. wang , m.f. han , y.y. zhou , x.j. liu , x.p. luo , q. ning department of infectious disease, tongji hospital, tongji medical college, huazhong university of science and technology, department of pediatrics, tongji hospital, tongji medical college, huazhong university of science and technology aim: our previous work has shown that high expression of kctd , a potassium channel associated gene, correlated with the disease severity of patients with severe chronic hepatitis b(schb). to further understand the gene transcription and regulation, kctd promoter was cloned and gene transcription was studied. methods: a full length of isolated promoter and series of ' truncated promoter of kctd gene was subcloned into the luciferase report vector pgl -basic to form the promoter-report constructs. the kctd promoter-report construct upstream of the luciferase report gene was cotransfected with constructs expressing hbv x,c and s protein respectively or stimulated with cytokines (il- , ifn and tnf ) in t cells to investigate kctd gene regulation upon both viral factors and host cytokines. result: a bp kctd segment upstream of atg translation start site was evidenced to contain potential regulative domains. an important regulation site located between - bp and - bp upstream of atg translation start site. based upon the luciferase activity assay, il- was able to upregulate the transcription of kctd whereas there was no effect from neither hbv viral proteins nor ifn and tnf . conclusion: here we first successfully cloned the full length promoter of kctd . il- significantly enhanced the transcription of kctd , a gene which has been shown to be involved in t cell activation and disease severity of schb from our group. this work was supported by nsfc( , , ) istanbul university, cerrahpasa medical school, marmara university, okmeydani teaching hospital, background: the treatment in chronic hepatitis c virus (hcv) is not highly effective, and cost, duration, and side effects are challenging. predicting favorable factors of response to treatment would make it possible to give it only responsive patients. recent studies report more conclusive results about the role of apoptosis in inflammation and fibrosis seen in chronic viral hepatitis. hepatocyte damage in hcv is mediated by cytotoxic t-cells. apoptosis primarily developed by the interaction between fas antigen on hepatocyte and fas ligand on t-cell corresponds to a main mechanism for hepatocyte damage. methods: in this study, we aimed to detect any relationship between apoptotic markers (fas, fas ligand, fas-associated death domain, caspases , , and , insitu apoptosis) in liver biopsy taken before the treatment and response to the treatment of interferon+ribavirin. additionally, any relationship between these parameters and the other ones predicting the response to therapy including alt level, viral load, genotype, and gender were studied. results: the study includes the patients in centers managing chronic hcv infection. all parameters were studied in patients. study results revealed that histological activity index is correlated with cd staining density, caspase intensiveness, and portal and parenchymal fas ligand scores. fibrosis is also seen to be correlated with the same parameters. apoptotic parameters of the responsive cases were not significantly different from unresponsive ones. conclusion: apoptotic parameters studied in the liver tissue is associated with inflammation and fibrosis, however these parameters may not predict the response to the treatment. s. gao , d. xi , j.w. guo , c.l. zhu , x.p. luo , q. ning department of infectious disease, tongji hospital, tongji medical college, huazhong university of science and technology, department of pediatrics, tongji hospital, tongji medical college, huazhong university of science objective: this study was designed to explore the opportunity of microrna interference technique in the inhibitory application of human fgl , human fas and tnfr expression. methods: the eukaryotic expression plasmids of human fgl , fas and tnfri genes were constructed and have successfully expressed hfgl , hfas and htnfri protein. mirna expression plasmids of hfgl , hfas and htnfri complimentary to the sequence responsible for hfgl , hfas and htnfri respectively were also constructed, meanwhile an irrelevant mirna plasmid was used as control. by respective cotransfection of p-hfgl mirna and pcdna . -hfgl , p-hfasmirna and pcdna . -hfas, p-htnfri mirna and pcdna . -htnfri expression construct into t cells, the inhibition of hfgl , hfas and htnfri expression were analyzed by quatitative real time pcr and western blot. results: the experiments showed the significantly inhibitory effect of p-hfgl mirna on hfgl , p-hfasmirna on hfas and p-htnfri mirna on htnfri expression at h post-transfection both at rna level and at protein level, as well in t cell lines the inhibitory efficiency reached as high as . % for hfgl , . % for hfas and % for htnfri, respectively. conclusions: the study demonstrated the constructs of p-hfgl mirna, p-hfasmirna and p-htnfri mirna successfully interfered their target genes expression in vitro, which provides the foundation for further investigation of these constructs' application in vivo and further more as a therapeutic strategy for a targeting intervention in the diseases which the gene fgl , fas and tnfri contribute to. this work was supported by nsfc , , ; cb , cb pe influence of the id on the anti-tumor activity of histone deacetylase inhibitor in hepatocellular carcinoma cells r. tsunedomi , , s. harada , n. iizuka , m. oka dept. of digestive surgery and surgical oncol., yamaguchi univ. , research fellow of the japan society for the promotion of science for young scientists background: our recent study revealed that levels of the inhibitor of dna binding/differentiation (id ) were associated with the progression of hcv-related hepatocellular carcinoma (hcc) and can affect susceptibility of hcc cells to histone deacetylase (hdac) inhibitors. we here aimed to investigate how and whether id expression affected on the anti-tumor activity of sodium butyrate (nab), one of hdac inhibitors. methods: two hcc cell lines, hle and huh- , were used for gene targeting experiments. the id over-expressing and knockdown cells were subjected to mts assay to evaluate the susceptibility to nab. time-course of the expressional change of bcl- and bcl-xl genes after nab administration was measured by real-time rt-pcr. result: upregulation and downregulation of id levels in hcc cells resulted in decreased and increased susceptibility to nab, respectively. we observed that after nab administration, the id expression was induced gently, the bcl- expression was greatly increased immediately, and the bcl-xl expression was decreased to less than half once and then recovered. these increase and recovery of the expression of anti-apoptotic genes were inhibited in the id knockdown cells. in the id overexpressing cells, the bcl- expression was more upregulated than mock-transfected cells. conclusion: in hcc cells, id influences the susceptibility to the hdac inhibitor by regulating the expression of anti-apoptotic genes caused by the hdac inhibitor stimulus. we suggest that id could serve as a fascinating marker predictive of response to hdac inhibitors. the role of zinc finger protein in liver cancer m.m.y. waye , , t.l. yeung , , j.l. zhu , the chinese university of hong kong, croucher laboratory for human genomics background/aims: the aim of this research project is the characterization of a krüppel zinc finger protein, zinc finger protein (znf ) using hepatocellular carcinoma as a disease model. zinc finger protein (znf ), also named as only zinc fingers protein (ozf), is a kda nuclear zinc finger protein consisting solely of ten c h zinc finger motifs of the krüppel type. like most of krüppel proteins, it is assumed to be the transcription factor and involved in the regulation of gene expression. the znf gene is amplified in - % of pancreatic carcinomas and overexpressed in more than half of the tumors including liver cancer. it is thus proposed that overexpression of the znf may contribute to the development or progression of hepatocellular carcinoma. methods: we used flow cytometry, microarray, green fluorescent recombinant protein, rt-pcr site-directed mutagenesis, and transfection to study the effect of expression of znf . results: our results shown that znf was over-expressed in two human hcc cell lines hepg and hep b. expression profiles of znf over-expressing shown that genes related to the p tumor suppressor activity or dna damage, repair response and control were deregulated upon overexpression of znf . conclusions: znf is possibly involved in liver carcinogenesis by affecting dna repair and cell cycle control upon induced dna damage. background: in the present study, we reported the establishment of a real-time monitor system for directly observing the catalytic, kinetic characteristics of dnazyme - in vitro cleavage on the target rna molecules as well as for rapid, accurate, high-throughout evaluation of varied dnazymes on their counterpart rna molecules. methods: dnazyme named dz-hcv- specific to hepatitis c virus (hcv) orf aug were designed and synthesized. dz-hcv-mis- with mismatched substrate-recognition domains, dz-hcv-mut- with mutant catalytic domains, antisense oligonucleotide ason and nonsense oligonucleotide nson were synthesized respectively as controls. a chimeric oligonucleotide of nt containing both rna and dna bases was designed and synthesized as the substrate: ' fam-gt agaccgugcaccaugagcacgaaucct-bhq ', corresponding to the - nt (underline) of hcv genome(gi: ) the reporter fam/bhq was incorporated at the ' and ' end, respectively. under simulated physiological conditions ( ), kinetic characterization of rna-cleaving dnazyme was analyzed in a real-time way. factors that influencing dnazyme cleavage were analyzed. results: dz-hcv- specific to hcv orf aug could cleave target rna at a•u site, a continuous change of fluorescence intensity was monitored. while the control oligonucleotides couldn't cleave rna, there were no change of fluorescence intensity. factors that influencing dnazyme cleavage concluded different substrate-recognition domain, mg + concentration and ph. conclusion: a real-time monitoring system for kinetic characterization of rna-cleaving dnazyme was successfully established in the first time. the study on the apoptosis of hepatoma cells synergeticly induced by plasmid-mediated anti-angiogenesis and immunopotentiation therapy p.y. li , q. zhang , y. chang , j.s. lin , d.a. tian background: angiogenesis is improtant to hepatoma and decreasing of host immunity promotes the development of tumor. we want to study the effect and mechanism of apoptosis of mice implanted hepatoma cells induced by eukaryotic plasmid-mediated anti-angiogenesis and immmunopotentiation therapy. methods: mouse endostatin eukaryotic plasmid (pseces) and mouse il- (interleukin ) eukaryotic plasmid (pmil- ) were extracted and purified from e. coli. h hepatoma cells were inoculated into the leg muscle of mice, which was divided into four groups and injected with pseces, pmil- , pseces+pmil- or pcdna . naked plasmid dna respectively into implantation sites repeatedly. tumor formation and its weight was evaluated. tumor microvessel density, tumor infiltrating lymphocytes and apoptosis of tumor cells were assayed by cd staining, he staining and tunel assay respectively. results: inoculated mice received pseces, pmil- injection formed tumor slowly with less microvessel density, more tumor infiltrating lymphocytes in the latter and more tumor apoptosis cells in both groups compared with pcdna . injection. there were much more tumor apoptosis cells in pseces+pmil- group ( . ± . per × microscope field p< . ) than any other single plasmid injection group ( × microscope field: pseces . ± . , pmil- . ± . , pcdna . . ± . ). conclusion: tumor cells of implanted hepatoma in mice could be synergeticly induced to apoptosis by eukaryotic plasmid-mediated anti-angiogenesis and immunotherapy through inhibiting tumor angiogenesis and promoting tumor lymphocytes to infiltrate, by which mice implanted hepatoma was inhibited. ( , , , , ng/ml) in a serum-free medium for h. cell proliferation was measured by brdu incorporation analysis, untreated wb-f cells were taken as controls. after treatment with wnt a ( ng/ml) for h, subcellular localization and protein expression of -catenin in wb-f cells treated and untreated with wnt a were examined by immunofluorescence staining and western-blot analysis. cyclind mrna expression was determined by semi-quantitative reverse-transcript polymerase chain reaction (rt-pcr). mrna levels of some phenotypic markers (afp, ck- , alb) and two hepatic nuclear factors were measured by rt-pcr. expressions of ck- and afp protein were detected by western-blot analysis. results: wnt a promoted proliferation of wb-f cells. stimulation of wb-f cells with recombinant wnt a resulted in accumulation of the transcriptional activator -catenin, together with its translocation into the nuclei, and up-regulated typical wnt target gene cyclind . after d of wnt a treatment in the absence of serum, wb-f cells retained their bipotential to express several specific phenotypic markers of hepatocytes and cholangiocytes, such as afp, ck- following activation of the canonical wnt signaling pathway. conclusion: the canonical wnt signaling pathway promotes proliferation and self-renewal of rat hepatic oval cells. the expression level of bid and other pro-and anti-apoptotic proteins were detected by immunoblotting. results: hbx/ showed the most sensitive towards dox treatment, and truncated bid (tbid) was also only detected in this cell line. the level of bax was also increased in hbx/ cells. conclusions: the carboxy-terminal of hbx may enhance the processing of bid into tbid, which may contribute to increased sensitivity of the cell towards the dox treatment. cell homeostasis were performed with concentrations of oxysterol ( x - - - m) faraway from the physiological and/or pathological one ( . and x - m). in our study, we asked the effects of oxysterols ( k and ' s) on hepatoma cell lines homeostasis. to this purpose we used concentrations similar to those described in physiological or pathological conditions. sub-physiological ( - m) to pathological ( - m) oxysterol ( k and ' s) concentrations were used to stimulate hepg cells. a surprising pro-proliferative effect of ' s at sub-physiological ( - m) concentration was observed. this behaviour was confirmed by the synergic increase of erk / levels. facs analysis revealed an early progression of cells in s phase at the lowest concentration of ' s, while all the remaining concentrations of the two studied oxysterols induced a weakly accumulation of cells in g /m phase. apoptosis was absent at all concentration used, except for the highest one ( - m). at this point we asked if cells didn't undergo apoptosis but acquired a senescent profile. effectively, both k and ' s, at all concentration used (except for - m), induced cell senescence (revealed by sa-ß-gal staining and sirt and p over-expression). in conclusion the two oxysterols analyzed have different and in same case opposite effects on hepatocellular line. the main effect is surely the senescence induction, but it is important to highlight the proproliferative effects of ' secosterol at low concentration. mortalin, a member of hsp family protein, has been shown to play an important role in hepatocellular carcinoma (hcc). it has been reported that mortalin is binding to the c-terminal of p , which acts as a safety guard and is a commonly mutated gene in hcc. in this study mortalin was silenced by specific shrna in plc/prf/ , a hcc cell line constitutively expressing p ser , and normal liver cells miha, and we found that suppression of mortalin can selectively trigger the mitochondria mediated apoptosis pathway by p dependent way in plc cells. tunel staining positive cells were only found in the plc cells mortalin knockdown group, and apoptosis associated protein, such as p , bax, bcl-xl, cleaved-caspase , have been screened by western blot after transfection. quantitative-pcr data also showed that p mrna level are upregulated about folds in mortalin knockdown group compared with the control groups in liver tumor cells. two p inhibitors, pft-and pft-, which can reverse this apoptosis was applied to demonstrate p dependent way. in summary, knockdown mortalin can selectively kill liver cancer cells through reactive apoptosis by sensitizing mutant p in plc cells, but had no effect on normal cells. the clinical application of this study suggested that motalin specific shrna might be a potential anti-cancer drug for hcc. background: nafld can proceed to nash and are at risk of cirrhosis and hcc. aim was to study profile of bangladeshi nafld patients. methods: patients with nafld were included. of them . % were males and . % females. patients were between - years of age. they presented with dull right upper abdominal ache and/or incidental detection of raised alt/ast and/or fatty liver on ultrasonography. all tested negative for hepatitis b and c. none had history of alcohol. all underwent per-cutaneous liver biopsy for histopathology. they were also tested for dm, dyslipidaemia, insulin resistance, hypothyroidism and hepatitis c. their bmi and bp were recorded. results: . % had nash. . % of them were males and rest . % females. . % had nafl. of them % each were males and females. majority had nash. . % were obese and . % had dyslipidaemia. . % had hypertension, . % insulin resistance and % were diabetics. . % had hypothyroidism. none had hepatitis c. alt was raised in % and ast in %. although all patients with nash did not have elevated alt, it was raised in majority, contrary to ast, which was normal in most. conclusion: majority nash patients in bangladesh are obese. other leading causes of nash include dyslipidaemia, hypertension and insulin resistance. some nash also had diabetes and hypothyroidism. this study also reveals that elevated alt in patients with nafld is suggestive of fibrosis, although normal serum alt does not exclude nash. the study further suggests that alt is superior to ast in predicting nash. background: non-alcoholic fatty liver disease is prevalent in obese patients. liver biopsy remains the best diagnostic tool for confirmation. we tried to find out the correlations of laparoscopic parameters with histology and laboratory data. besides, we also evaluated the effectiveness of laparoscopy in liver disease diagnosis. methods: in the period of one year and five months, morbidly obese patients submitted to laparoscopic bariatric surgeries at our institutions were prospectively studied. results: laparoscopic parameters of significant correlations with histologic steatosis, inflammation and fibrosis were summarized in table . besides, important parameters with relationships to laboratory data were summarized in table department of internal medicine, seoul national university hospital gangnam healthcare center, seoul, south korea, department of internal medicine and liver research institute, seoul national university college of medicine, seoul, south korea background/aims: hepatic fibrosis is associated with poor prognosis in non-alcoholic fatty liver disease (nafld). recently, many non-invasive fibrosis markers have been studied to overcome the limitations of liver biopsy. among them, bard score and guha's simple panel are easy to use in clinical practice. in this study, we evaluated the efficacy of bard score and guha's simple panel as a noninvasive fibrosis marker in korean nafld patients. methods: data from patients with biopsy-proven nafld in seoul national university hospital from to were used. bard score and guha's simple panel were calculated by using clinical and biochemical data and were compared with the histological fibrosis stages. results: stage fibrosis were found in patients, stage in , stage in , stage in and stage in . the relationship between fibrosis stage and bard score ( = . , p < . ) was statistically significant. all patients with advanced fibrosis (stage - ) had bard score greater than . mean values from original guha's simple panel for no fibrosis were not different between the patients with and without fibrosis. however, after adjusting coefficients by logistic regression analysis, the differences in mean values became statistical significant (p < . ). conclusions: our data suggest that bard score may be effective for detecting high risk patients for advanced fibrosis, and modification of coefficients within the guha's simple panel may be needed to use as a fibrosis marker in asian nafld patients. s.k. mohan , s. subramaniam , s. subramaniam assistant professor, department of biochemistry, saveetha medical college & hospital, saveetha university, t.n, india., consultant, department of biochemistry, apollo hospitals, chennai, t.n, india. , department of biochemistry, apollo first med hospitals, chennai, t.n, india. background: non-alcoholic fatty liver disease (nafld) covers a spectrum of liver diseases from simple fatty infiltration to progressive fibrosis. non-alcoholic steato hepatitis (nash) is a severe form of nafld and progresses to the end stage of liver disease. it is becoming the leading cause for referral to liver clinics in most areas. the prevalence of nafld in indian population is estimated around - %. the nafld has the potential to progress to hepatocellular carcinoma or liver failure, both events that ultimately lead to early death. aim: to evaluate the combination of inter cellular adhesion molecule - (icam - ), adiponectin and type-iv collagen, a new biomarker profile for nash in patients with nafld. methods: patients with nafld and age & sex matched normal healthy individuals as controls were selected for this study. levels of serum icam - , adiponectin, type-iv collagen, lipid profile and liver function test parameters were estimated in patients and compared with controls. results: serum icam - & type -iv collagen levels were significantly increased in patients with nash among the nafld patients compared to controls. the serum adiponectin levels were significantly reduced in patients with nash among the nafld patients compared to controls. compared to liver function test parameters and lipid profile levels, nash profile has got positive negative predictive value among the nafld patients. conclusion: in patients with nafld, nash profile test -a simple, noninvasive and reliable to predict the presence or absence of nash. background/aim: oxidative stress and cytokines plays an important role in the pathogenesis of nonalcoholic fatty liver disease (nafld). aim of study was to assess lipid peroxidation, serum levels of transforming growth factor-( tgf-) and tumor necrosis factor-( tnf-) in patients with nafld and compare it with patients of chronic viral hepatitis (cvh) and healthy controls (hc). methods: lipid peroxidation was studied by estimating plasma malondialdehyde (mda) levels as per the methodology described by buege and aust and tgf-& tnf-levels were measured by elisa kits (ray biotech, usa, & diaclone, uk) in the stored sera in biopsy proven patients with nafld (m: , f: , mean age: . ± . yrs), patients with cvh ( m: , f: , mean age: . ± . yrs) and hc (m: , mean age: . ± . yrs). results: there was no difference in mean plasma mda levels amongst patients with nafld ( . ± . mol/l), cvh ( . ± . mol/l) and hc ( . ± . mol/l). serum tgf-levels between nafld ( . ± . ng/ml) and cvh ( . ± . ng/ml) patients and hc ( . ± . ng/ml) were also comparable. though patients with cvh ( . ± . pg/ml) and nafld ( . ± . pg/ml) had higher levels of tnf-than hc ( . ± . pg/ml), the difference was not significant statistically. conclusion: lipid peroxidation, tgf-and tnf-need to be studied in a larger number of patients with nafld. background/aim: burnt out nonalcoholic fatty liver disease (nafld) may be responsible for cirrhosis and hepatocellular carcinoma (hcc) in the absence of other causes. aim of this study was to evaluate the surrogate markers of nafld in patients with cryptogenic cirrhosis (cc) and cryptogenic hcc (chcc). methods: sixty five patients with cc and patients with chcc were analyzed for the presence of abnormal body mass index (bmi) and type diabetes mellitus (dm aim: to investigate the relation of phosphatidylethanolamine n-methyltransferase pemt gene g a single nucleotide polymorphism (snp) with the susceptibility to nonalcoholic fatty liver disease nafld . methods the genotypes and allele frequencies of pemt exon snp g a were analyzed by using pcr-rflp in nafld patients and controls. results: the g to a variation of the pemt gene g a snp was significantly higher in nafld group compared with controls. the frequencies of gg ga and aa genotypes were . . and . in nafld and . . and . % in controls (p= . . the a allele of the pemt gene was significantly more frequent in nafld group ( . %) than that ( . %) in controls p= . .there were significant differences in serum levels of cholesterol, triglyceride, hdl-c and ldl-c between gg and ga/aa genotypes p < . . n. assy , , g. lipez , s. korem , m. grozovski sieff hospital, safed, israel, technion institute, faculty of medicine, haifa, israel, ort braude college, karmiel, israel background: previous studies reported increase in serum protein c and decrease in serum paraoxonase levels in patients with non alcoholic fatty liver diseases (nafld). conclusion people with pemt gene g a snp were more susceptible to develop nafld aim: ) determine whether there is a relationship between nafld, protein c and paraoxonase levels in quiescent and in regenerating rats fatty liver ) determine the effect of isa on hepatic "protein c" and paraoxonase mrna. pe methods: forty-eight sd rats were treated with fructose enriched diet (fed), or fed with metformin ( mg/kg/d), fed with rosiglitazone ( mg/kg/d), or the combination of both drugs for wks. % phx was performed at wk . protein c, paraoxonase mrna expressions, lipids, mda were measured before and hours after phx. results: hepatic "protein c" mrna was higher in rats with fatty liver than control rats (+ %, p< . ) whereas hepatic paraoxonase mrna was lower in rats with fatty liver than control rats (- %, p< . ). hepatic protein c and paraoxonase mrna increased in rats with fatty liver in regeneration (+ %, p< . , and + %, p< . respectively). the combination of metformin and rosiglitazone decreased hepatic protein c expression at hours after phx by - % (p< . ) and increase paraoxonase mrna by + % (p< . ). serum paraoxonase correlates with serum protein c (r=- . ), mda (r= . ), background: non-alcoholic steatohepatitis (nash) is a type of non-alcoholic fatty liver disease (nafld), and may progress to hepatic fibrosis and cirrhosis. the pathogenesis of nash remains unclear. the aim of this study was to explore the arginase change in the progress of steatohepatitis in rats. methods: male sd rats weighing - g were obtained. twenty animals were randomly divided into two groups. in the model group, five animals were fed with high lipid forage that includes % cholesterol and % lard for weeks, five were fed for weeks, while the control group ate normal foods. the animals were sacrificed after weeks. the animals were sacrificed after weeks and weeks. liver and blood serum were collected while the serum levels of alt, ast, tg and tc were measured. the pathology of liver was observed by he staining. western blot was used to investigate the expression of arginase in control and model group. tg (r=- . ). conclusion: hepatic "protein c" mrna levels are high at baseline, up regulated during liver regeneration and decrease after treatment with (isa) whereas hepatic paraoxonase mrna levels are low at baseline, up regulated during liver regeneration and increase after treatment with isa. results: vacuolization were observed extensively in hepatic cells in the model group after weeks and weeks of high-fat diet. it is demonstrated that rats fed with high-cholesterol food are indeed fatty liver models. western blot showed that the level of arginase ii increase in the liver of model group rats as compared to the control group. furthermore, the level of arginase was higher in liver samples obtained from model rats that were weeks on a fat diet as compared to rats that were only weeks on the same diets. conclusion: the level of arginase ii was altered in the progress of non-alcoholic steatohepatitis in rats suggesting that arginase ii is putative biomarkers and may represent new targets in the development of therapeutic strategies against fatty liver disease hepatic fibrosis and cirrhosis. methods: c bl /j mice were fed with mcd diet to induce hepatic fibrosis and rosiglitazone was given in treated group. effect of rosiglitazone was assessed by comparison of the severity of hepatic fibrosis in liver sections, expression of mmp- / , timp- / mrna and protein detected by rt-pcr and western blot respectively. the ethanolic extract of fructus schisandrae chinensis decreased hepatic triglyceride level in mice fed with a high fat/cholesterol diet results at week , fibrosing nash models showed severe hepatic steatosis, infiltration of inflammation and fibrosis, which is associated with down-regulated mmp- / mrna and protein, up-regulated timp- / mrna and protein. rosiglitazone significantly reduced mcd-induced fibrosis by induced mmp- / expression and reduced timp- / expression by activating ppar . s.y. pan , z.l. yu beijing university of chinese medicine, hong kong baptist university effects of the ethanolic extract of fructus schisandrae chinensis (etfsc) on serum and liver lipid contents were investigated in mice fed with normal diet or high fat/cholesterol diet for or days. single dose of etfsc ( or g/kg/day, i.g.) increased the serum triglyceride (tg) level ( and %, respectively), but decreased hepatic total cholesterol (tc) level ( and %, respectively) in normal mice. the hypertriglyceridemia produced by etfsc was suppressed by the co-administration of fenofibrate. the induction of hypercholesterolemia by high fat/cholesterol diet caused significant increases in serum and hepatic tc levels (up to %) and hepatic tg levels (up to %) in mice. etfsc treatment ( or g/kg/day for days, i.g.) significantly decreased the mouse hepatic tg level (by %) and slightly increased the hepatic index (by %). whereas fenofibrate treatment ( . g/kg/day for days, i.g.) significantly lowered the hepatic tg level (by %), it significantly elevated the hepatic index (by %) in hypercholesterolemic mice. the results indicate that etfsc treatment can invariably decrease hepatic tg in hypercholesterolemic mice, suggesting its potential use for fatty liver treatment. aim: to investigate the influence of multiple gene polymorphisms in the susceptibility of nafld. methods: the data of single nucleotide polymorphisms (snps) in nafld patients who had at least one of the genetic variations at the sites of tnf-- , adiponectin - and leptin- were analyzed. the genotypes were determined by using pcr-rflp. our previous studies showed that the variations of these sites increased the susceptibility of nafld. results: the prevalence of nafld in adiponectin variation alone group (n= ) was . %; in tnf-alone group (n= ) . %; in leptin alone group (n= ) . % (p> . ). in comparison with the above groups with single snp, the prevalence of the groups with two gene variations of tnf-plus adiponectin ( . %, n= ) increased significantly (p< . ). however the prevalence of other two groups i.e. adiponectin plus leptin ( . %, n= ) and tnf-plus leptin ( . %, n= ) did not differed significantly from those of groups with single snp (p> . ). the prevalence in the group with three gene variations ( . %) differed significantly from all (p< . ) except that of tnf-plus adiponectin group (p> . ). the metabolic features of the nafld patients in the groups mentioned above were not different significantly (p> . ). conclusion: nafld is a polygenic disease. multiple gene polymorphisms may, but not always, increase the susceptibility of nafld. chronic hepatitis b patients with nonalcoholic fatty liver disease r.d. zheng , c.r. xu , j. chen , b.f. chen southeast hospital background: to investigate clinical pathological characteristic in hbeag negative chronic hepatitis b (chb) patients with nonalcoholic fatty liver disease (nafld). methods: we measured fasting blood glucose, insulin, triglyceride, cholesterol, alanine aminotransferase (alt), aspartate aminotransferase (ast) in hbeag negative chronic hepatitis b (chb) patients with nonalcoholic fatty liver disease (nafld). and we detected hepatitis b virus marker, hbv-dna, counted body mass index, insulin resistance index and observed pathological characteristic. all these patients with diagnosis were confirmed by clinical and pathological evidence. result : the body mass index, homeostatic model assessment (homa) of insulin resistance, fasting blood glucose, insulin, triglycerides, cholesterol, were significantly higher in hbeag negative chronic hepatitis b (chb) patients with nonalcoholic fatty liver disease (nafld) than hbeag negative chronic hepatitis b patients. but the alanine aminotransferase (alt), aspartate aminotransferase (ast), hbv dna levels were significantly lower in hbeag negative chb patients with nafld than in hbeag negative chronic hepatitis b patients. histologic features in hbeag negative chronic hepatitis b(chb) patients with nonalcoholic fatty liver disease (nafld) are in zone predominate macrovesicular steatosis and mild inflammatory infiltrate in portal region. conclusion: the hbeag negative chronic hepatitis b (chb) patients with nonalcoholic fatty liver disease, whose hepatic steatosis changes are mainly caused by the metabolic factors. to carry out liver biopsy selectively for the patients with hbeag negative chronic hepatitis b having metabolic factors, which is helpful for early diagnosis in hbeag negative chronic hepatitis b (chb) patients with nonalcoholic fatty liver disease (nafld). aims: to investigate the preventive effect of cordyceps sinensis and its possible mechanism on apoptosis of nafld. methods: rats were randomly divided into basic diet group (b group), pathologic group (nash group) and cordyceps sinensis group(cs group).the latter two groups were administered with high-fat diet to establish nafld animal models. cs group were treated with cs at the th week after high fat diet. rats were sacrificed at the end of the th week. biochemical examination were used to detect superoxide dismutase (sod) of liver tissue. hepatocyte apoptosis was assessed in each group using the tunel assay and immunohistochemistry for activated bax bcl- caspase- and nf-kb p . results: ( ) compated with the b group, severe hepatosteatosis, inflammative necrosis and local fibrigenisis were showed in liver of nfsh group. sod lever was significantly decreased (p< . ) and tunel-positive cells were significantly increased (p< . ). immuunohistochemistry test demonstrated active bax caspase- was increased (p< . ) while no apparent change was observed in bcl- . ( ) in cs group, only diffusive steatosis but not inflammation or fibrosis was found. sod lever was increased than that of nash group (p< . ). tunel-positive cells and active bax caspase- were significantly decreased (p< . p< . ) that those of nash group. bcl- and nf-kb p were increased (p< . ) than those of nash group. conclusions: hepatocyte apoptosis is a prominent feature of nafld. cordyceps sinensis may be useful as an antiapoptosis theraphy in this syndrome through increasing activity of sod, decreasing express of bax and increasing express of bcl- and nf-kb p . background: non-alcoholic steatohepatitis (nash) is a leading cause of chronic liver disease. insulin-sensitizing , anti-inflammatory and anti-fibrotic effect of thiazolidinediones support their use in the treatment of nash. we aimed to evaluate the efficacy of thiazolidinediones in the treatment of nash. methods: we have identified randomised clinical trials, evaluating the efficacy of thiazolidinediones versus placebo in nash, through medline, embase, ami, cochrane central register of controlled trials. data were abstracted from each study and disagreements were resolved by consensus. dichotomous outcomes were reported as relative risk with % confidence interval based on fixed-effects model. results: we included three trials, two evaluating pioglitazone and another rosiglitazone. a total of patients were involved in the analysis. thiazolidinediones was noted to improve liver function tests. it was effective in the reduction of steatosis among patients with nash (rr . , % ci . - . ). it was found to be beneficial in improving ballooning necrosis (rr . , % ci . - . ). it was also found to improve lobular inflammation (rr . , background: it is well known that the weight reduction is effective for alt normalization in patients with non-alcoholic fatty liver disease (nafld). the necessary condition for alt normalization is still unclear. to clarify the necessary and sufficient condition for alt normalization, we investigated the effects of body fat decrease in nafld patients by body composition analyzer. methods: forty-six nafld patients ( male, female, mean age . ± . years old) with abnormal alt levels were evaluated. the volume of skeletal muscle, body fat and bmr were examined by using the body composition analyzer (in body ; biospace co. ltd., tokyo japan). all patients were received an individualized diet consultation by dietician every weeks for months. daily energy was bmr (basal metabolic rate) x . kcal and protein was . - . g per ideal body weight. result: twenty-eight of patients ( . %) were achieved normal alt level. in alt normalized group, the body weight and fat loss were . ± . kg, . ± . kg ( . ± . %body fat) respectively. on the other hand, in cases with alt remained abnormal level, the body weight and fat loss were . ± . kg, . ± . kg ( . ± . %body fat). conclusion: our results demonstrate that the fat loss of kilograms or more was necessary to normalize alt level in nafld patients. a. somani , s. somani , a. jain , v. dixit navjeevan hospital, suvidha, background : nafld is often clustered within families and the causes include both genetic and environmental factors. family studies done thus far have been limited by small sample size. to examine the familial patterns , we performed a prospective study to see (a) whether nafld is more common in first degree relatives (b) genetically determined risk factors associated for clustering. methods: first degree relatives of histologically confirmed nafld patients and spouses (controls) were included after excluding other causes of fatty liver. those having raised transaminases > months or sonographic examination consistent with fatty liver, had undergone liver biopsy for histological confirmation. they were divided into three groups. group i patients group ii first degree relatives group iii spouses results: nafld was more prevalent among first degree relatives then spouses ( % and %, p< . ). anthropometric measurements, systolic and diastolic blood pressure, lipid profile and liver function tests were comparable in three groups. homa-r was similar in group i and ii (p= . ), but was significantly different in group i and iii (p= . ) and group ii and iii (p= . ) respectively. metabolic syndrome was present in > % of patients and were comparable in three groups except for fasting glucose > , which was present in %, % and % of patients in group i, ii and iii respectively. majority (> %) of our patients among groups i, ii and iii were having only steatosis while nash was present in %, % and % of patients. a. somani , v. dixit , a. jain , s. somani navjeevan hospital, ims, bhu, varanasi, suvidha background: normal levels of alanine aminotransaminase (alt) have been demonstrated in nafld patients. alt levels are also modulated by age, gender, bmi, fasting glucose, and serum triglyceride levels. we performed a prospective study of patients with histologically confirmed nafld and having alt < . times and compared them with those having raised alt to determine (a) clinico-pathologic features of nafld patients with normal alt (b) to observe any differences between them. methods: patients with fatty liver on sonography had under gone biopsy for histological confirmation after excluding other causes of fatty liver. participants were divided into two groups (a) those having alt > . times normal (n= ) (b) those having normal alt (n= ) results: mean age was comparable with slight male predominance. there were significant differences in anthropometric measurements like bmi (p= . ) and whr ( . ± . and . ± . , p= . ). mean bp, lipid profile, fasting glucose, insulin, and homa r were comparable. there were significant differences in both mean ast ( . ± and . ± . , p= . ) and alt ( ± . and . ± . , p= . ) levels. metabolic syndrome was present in > % of patients and individual components were comparable except for increased waist circumference which was significantly more in those with raised alt ( . % and . %, p< . ). majority of our patients were having only steatosis, while nash was present in ( . % and . %, p< . ) of patients. conclusion: nafld can exist in patients with normal alt values. although more work is needed to determine who should be screened for nafld and how such individuals should be evaluated, this study is a step toward the identification and characterization of nafld patients with normal alt. we can suggest that patients having metabolic syndrome or insulin resistance, despite having normal alt, should be screened for nafld. also alt values should be adjusted for variables like bmi to appropriately screen nafld patients. background: scientific evidence has demonstrated that traditional chinese medical (tcm) approaches and products can be beneficial for managing non-alcoholic fatty disease (nafld), but few rigorous criteria of patterns of tcm therapy are available to guide practitioners in deciding the cam interventions. objectives: to evaluate criteria of patterns of tcm therapy for the management of nafld identified by biomedicine. methods: literature research, clinical epidemiological investigation and mathematical statistics were employed to make information collecting tables and to establish database. descriptive analysis, factor analysis, and cluster analysis were involved. results: ( ) background/aim: serum uric acid level has been suggested to be associated with factors that contribute to the metabolic syndrome. the aim of this study was to investigate the association of serum uric acid level with nonalcoholic fatty liver disease (nafld). methods: a cross-sectional study was performed among the employees of zhenhai refining & chemical company ltd., ningbo, china. results: the study included subjects ( men) with a mean age of years. the prevalence rate of nafld and hyperuricemia was . % and . %, respectively. nafld patients had significantly higher level of serum uric acid than controls ( . ± . vs. . ± . mol/l; p < . ). the prevalence rate of nafld was significantly higher in the subjects with hyperuricemia than those without hyperuricemia ( . % vs. . %; p < . ), and the prevalence rate increased along with serum uric acid levels (p value for trend < . ). multiple regression analysis showed that hyperuricemia was associated with increased risk for nafld (odds ratio [or]: . , % confidence interval [ci]: . - . ; p < . ). conclusion: serum uric acid level is significantly associated with nafld, and increased serum uric acid level is an independent risk factor for nafld. background: development of fatty liver is believed to be an early and reversible consequence of excessive alcohol consumption. however, the cellular and molecular events in the early development of alcoholic liver diseases (ald) and the contributory effects of a high fat diet are not fully understood. methods: this study was designed to quantify specific enzymatic and cytokinetic activity as well as the development of hepatic steatosis in a rat model of alchohol-induced liver injury without high fat diet. results: ethanol-fed rats exhibited high blood ethanol levels ( . + . %) and significant increases in serum alt ( . + . unit/l), ast ( . + . unit/l), and alp ( + . unit/l) when compared with control rats (p< . , respectively). histopathological examination found unevenly raised knodell scores ( . + . in the ethanol-fed livers vs. . + . in control), which were characterized by scattered hepatocyte ballooning, portal inflammation and collagen fiber deposition. however, typical steatosis lesions were absent. qpcr demonstrated up-regulation of genes in the ethanol-fed livers, including hepatocyte metabolism enzymes/receptor (adh , p< . ; cytochrome p e , cyp e , p< . ; gsta , p< . ; ppar , p< . ), and genes coding for pro-inflammatory cytokines (il- , p< . vs. control livers; tnf-p< . ; tgf -, p< . ; rantes p< . ), ecm components and proteinases (collagen- , p< . ; sma, p< . ; mmp - , p< . and timp- , p< . ). conclusion: chronic administration of ethanol to rats without high fat diet productively induces alcohol hepatitis in the absence of fatty liver, suggesting that alcohol hepatitis may precede steatosis in the development of ald. the aim of the present study was to evaluate the changes of several cytokines associated with inflammatory liver disease and liver regeneration by molecular adsorbent recirculating system (mars) in aclf patients versus patients treated with medical standard therapy (smt) that presented alcoholic liver disease etiology and similar model end-stage liver disease (meld). methods: mars group: fifteen ( male and female) patients were treated with mars® (gambro). five patients were excluded by study.the number of mars applications was about , the length of applications was about h. smt group: fifteen patients ( male and female) were treated medical standard therapy such as prophylaxis against bacterial infections, albumin and fresh plamsa and judicious use of diuretics. three patients were excluded by the study. the patients were valued during days from inclusion with a survival follow up a three months. results: mars group: we observed a significant changes in levels of il- (p< . ), il- (p< . ), il- (p< . ) and tnf-alfa (p< . ) in association with improvement of hepatic growth factor (p< . ). the patient's survival at three months was %. smt group: we observed only a significant changes in il- (p< . ) and tnf-alfa (p< . ). the patient's survival at three months was %. conclusion: the mars liver support device has corrective effects on disturbed pathophysiology of aclf and may be used to enhance spontaneous recovery or as bridge to transplant. a study of protective effect of centella asiatica in -methyl- phenyl- , , , -tetrahydropyridine (mptp)-induced liver injury n. haleagrahara , s. chakravarthi , p. kumar international medical university, malaysia background: centella asiatica has been used for centuries as a medicinal herb for wound healing, memory enhancement, cancer, vitality, respiratory ailments, psoriasis and eczema, revitalizing connective tissue, burn and scar treatment, skin infections, arthritis, rheumatism, periodontal disease, varicose veins, hypertension, sedative, anti-stress, anti-anxiety, aphrodisiac, and as immune booster. results: ppc significantly reduced hepatocyte damage, hepatitis, and hepatic fibrosis, but did not affect steatosis. phosphorylation of apoptosis signal-regulating kinase , p mitogen-activated protein kinase, and protein kinase c, as well as activation of nuclear factor-kappa b, were markedly suppressed by ppc. these effects were likely a consequence of decreased oxidative stress through down-regulation of reactive oxygen species (ros)-generating enzymes, including cytochrome p e , acyl-coa oxidase, and nadph oxidases, in addition to restoration of ethanol-induced increases in toll-like receptor and cd . ppc also decreased the pro-apoptotic proteins bax and truncated bid, thus inactivating mitochondrial permeability transition. furthermore, ppc suppressed overexpression of transforming growth factor- and hepatic stellate cell activation, which retarded hepatic fibrogenesis. conclusion: ppc exhibited anti-inflammatory, anti-apoptotic, and anti-fibrotic effects on ald as a result of inhibition of alcohol-induced ros production. background: dysctamnus dasycarpus has used for the promotion of health in south korea. but, there were rare a report concerning the hepatotoxicity. we report cilinical features of liver injury by dysctamnus dasycarpus. method: eighteen patients diagnosed as acute toxic hepatitis by dysctamnus dasycarpus in chungnam national university hospital between january and arpil was enrolled. toxic hepatitis was diagnosed by rucam score ( ). the medical records were reviewed, retrospectively. result: eleven patients ( %) were female and the mean age was . . most common symptom was jaundice. initial laboratory findings were as follows(mean value): wbc /ul, hemoglobin . g/dl, platelet × /l,alt iu/l, total bilirubin . mg/dl, alkaline phosphatase u/l, ggt u/l, prothrombin time(inr) . . the mean hospitalization was . days. peak laboratory findings were as follows: alt iu/l, total bilirubin mg/dl. recovery time of each biochemical finding was as follows: alt days, total bilirubin . days. recovery rates of alt and total bilirubin were . % and . %, . % and . % at weeks, weeks, respectively. the main biochemical pattern of hepatotoxicity was hepatocellar ( . %) type. prednisolone was prescribed in six patients. progressive anemia and thrombocytopenia were detected in one patient diagnosed as pure red cell aplasia. other one patient had prolonged jaundice ( days). but, all patients had recovered without sequelae. conclusion: in south korea, liver injury by dysctamnus dasycarpus was more frequent in women. the main pattern of hepatotoxicity was hepatocelluar type. most patients had prolonged icteric phase and hospitalization. patients were recovered by supportive management after drug cessation or prednisolone therapy. in korea, traditional medicine that is based on the use of herbal medicine developed from a long time ago. however, clinical study of the herbal medicine is not conducted in a structured manner. we report three cases of toxic hepatitis caused by the intake of dictamnus albus. the first patient, a year old woman was admitted due to nausea after ingestion of liquor containing dictamnus albus for months. total bilirubin was . mg/dl ast/alt / , iu/l on admission. liver biopsy observed hepatocyte necrosis and cholestasis. the elevated bilirubin and transaminase returned to normal weeks later after cessation of dictamnus albus. the second patient, a year old man was admitted due to jaundice after ingestion of boiling dictamnus albus for months. total bilirubin was . mg/dl ast/alt , / , iu/l on admission. liver biopsy observed pericellular fibrosis and necrosis. the bilirubin decreased slowly compared to the transaminase and normalized months later after cessation of dictamnus albus. the third patient, a year old man was admitted due to jaundice after ingestion of liquor containing dictamnus ablus for month. total bilirubin was . mg/dl ast/alt , / , iu/l the hepatocyte necrosis was observed by liver biopsy. the elevated bilirubin and transaminase levels normalized month later after cessation of dictamnus albus. all patients had negative viral markers and non-specific ultrasonographic findings. the above mentioned three cases demonstrate that liver may have been damaged by dictamnus albus, which indicated clinical characteristics. background/aims: cmili poses a diagnostic challenge as no tests are available to confirm the causality. the aims of this study were ) to evaluate clinical features and patterns of cmili and ) to assess the likelihood of causality among patients with liver impairment and exposure to chinese medicine (cm) by a multidisciplinary approach. method: between / and / , patients who had liver derangement and cm or proprietary cm exposure within six months managed in the united christian hospital were studied. clinical features and the cm were reviewed by a multidisciplinary team involving a hepatologist, a toxicologist and cm experts. literature search of relevant herbs in chinese and western journals were performed. cm samples or residue were sent to toxicology laboratory for analysis to look for any toxic constituents, adulterant or contaminant. the likelihood of causality was ranked by various experts independently and disagreements were settled by a consensus meeting. results: there were forty-six cases of suspected cmili, nineteen cases with alternative causes of liver diseases were excluded. twenty-seven cases of cmili proceeded to detailed analysis. median age of patients was ( - ) with female predominance. the median duration of cm exposure to presentation was ( - ) days. majority of them ( %) had hepatocellular liver injury pattern. one case of adulteration with nsaid and erroneous substitution of herb was identified respectively causality were classified as unlikely, possible, probable and highly probable in , , and patients respectively. conclusion: a multidisciplinary approach allows systemic evaluation of suspected cmili. mouse model i. nassar , t. pasupati , i. segarra , j.p. judson international medical university, kuala lumpur, malaysia background: imatinib, a selective tyrosine kinase inhibitor, exhibits drug interactions with other drugs that are metabolised via the cytochrome p pathway. acetaminophen, a widely used analgesic and anti-pyretic drug is also metabolised via p pathway. this study aimed to evaluate the nature of hepatotoxicity after co-administration of imatinib and acetaminophen in a preclinical mouse model. methods: four groups of male icr mice ( - g) were used. the mice were administered either saline solution orally, imatinib mg/kg orally (control), acetaminophen mg/kg intraperitoneally (positive control) or co-administered imatinib mg/kg and ip acetaminophen mg/kg (study group). the mice (n= per group) were fasted overnight, dosed respectively and sacrificed at pre-determined time intervals of , minutes, , , , and hours and liver samples obtained by dissection. h&e stained liver sections ( µm thick) were histopathologically analysed. results: the liver samples showed reversible cell damage like feathery degeneration, microvesicular fatty change, sinusoidal congestion and pyknosis, with both imatinib and acetaminophen, administered separately. the damage increased gradually with time, peaked at hours and then resolved completely by hours. liver samples showed irreversible damage (cytolysis, karyolysis and karyorrhexis) when both drugs were administered concurrently, the damage increased with time and had not resolved after hours duration. conclusion: co-administration of acetaminophen and imatinib increased the hepatoxicity caused by acetaminophen and imatinib to become irreversible. this may be due to the fact that both drugs are metabolised by the cytochrome p pathway in the liver. background: a higher risk of antituberculosis drug (att) induced hepatotoxicity has been reported in indian subcontinent compared to the western counterparts. slow acetylator genotype of n-acetyltransferase (nat ) and ci genotype of cytochrome p e (cyp e ) gene are two known risk factors associated with this disease. cyp e gene encodes a rifampicin inducible enzyme which increases hepatotoxicity. therefore slow acetylation of isoniazid and simultaneous use of rifampicin may augment the toxicity of isoniazid. objectives: to analyze the allelic distribution of nat and cyp e gene in patients of pulmonary tuberculosis who developed att induced hepatitis materials and methods: the study included cases of pulmonary tuberculosis ( ) and att induced hepatitis ( ). polymorphism of nat and cyp e gene was studied by pcr-rflp method in both these groups. results: occurrence of att hepatotoxicity was . %. there was a higher prevalence of slow acetylator genotype particularly nat * /* and nat * /* in patients with hepatotoxicity compared to patients without hepatotoxicity ( . % vs . %, p value < . ). no association of cyp e rsai polymorphism could be considered with att hepatotoxicity. however, drai c/d genotype of cyp e appears as a risk factor for predicting the occurrence of antituberculosis drug induced hepatitis (or . , p value < . ). conclusion: the study demonstrates that patients with slow acetylator genotype particularly nat * /* and nat * /* and heterozygous mutant c/d genotype of cyp e gene are predisposed to develop antituberculosis drug induced hepatotoxicity. regular monitoring of clinical and biochemical profile may be considered in these patients when they receive antituberculosis treatment. background: drug-induced liver injury is the most common adverse drug reaction. we often use two kinds of diagnostic scales to evaluate suspected patients. however, we still can't diagnose accurately without the direct drugs history and the pathological evidence. methods: twenty-seven drug-induced liver injury cases with liver biopsies from to were reviewed retrospectively by maria and japanese scale. result: there were . % of cases with increasing eosinophils. herbs ( . %) were the most common suspected drug and unknown drugs intake history ( . %) were described in these cases. the high possibility and possibility were . %, . % by maria scale and . %, . % by japanese scale, respectively (p= . ). conclusions: japanese scale seems more sensitive than maria scale in these cases. however, there are still some definite cases ignored as low possibility due to absence of obvious drug using history. early treatment and suspected drugs prohibition interferes the outcomes of the two diagnosis systems and lead to a false result. it is still a clinical challenge without strong drug using history or pathological evidence of liver biopsies to diagnose the drug-induced liver injury quickly and accurately. background: previous study suggested that oxidative stress may be an important mediator of methamphetamine-mediated tissue injury. the study was to examine the mechanism of antioxidant activity and methamphetamine-mediated liver injury. materials and methods: the days old male sprague-dawley rats were subcutaneous injected daily with methamphetamine ( mg/kg body weight) for , , and days. control group received equal volumes of vehicle. the liver tissues were extracted to measure the activities of sod, catalase, glutathion reductase (gr), and glutathione peroxidase (gpx), and the level of glutathione. western blot were used to measure the expression of rho and phosphor-ezrin-radixin-moesin (p-erm). results: compared with vehicle group, treated with methamphetamine for and days, the activities of liver sod, gpx, and catalase were significantly decreased. in and days group, the activities of antioxidant enzymes of methamphetamine-treated liver was not different from that of vehicle group. the levels of glutathione production also had the same trend. the activities of gpx and catalase on vehicle group gradually reduced following the days of treatment. however, administration of methamphetamine resulted to a lower activity of catalase through the treated days. there was no difference on the activity of gr between vehicle and methamphetamine group. the expression of rho and p-erm were also increased by methamphetamine treated for days. conclusion: these results suggested the methamphetamine lead to liver remodeling via decreased antioxidant activity. finally, the situation of mechanism needs taking in advantage discussion. background: to observe intervening effects of preventive and theraptical treatment of radix sophorae tonkinensis's polysaccharides(rstp) on alpha-naphthylisotheganate(anit)-induced cholestasis in mice. methods: kunming mice intoxicated with anit mg/kg orally and treated with rstp mg/kg for days before anit exposure and for days after anit exposure respectively, the general condition,mortality rate and serum alt activity are obeverated. result: it was found that by preventive treatment the general condition and mortality rate were improved, serum alt activity reduced.by therapeutic treatment,the general condition deteriorated,mortality rate and serum alt activity increased. conclusion: the preventive treatment of rstp reduce the liver damage due to increasing the anti-stress ability such as the antioxidant capacity,its therapeutic treatment increase the injuried liver damage due to increasing the non-specific immune response and aggregating the preexisting liver inflammation. background: the product's instruction pointed out that in some patients polyphenolic acids' salt from salvia miltiorrhiza(ppas-sm) may lead to a temporary increase in serum alt activity.so we observe effects of ppas-sm on alpha-naphthylisotheganate(anit)-induced cholestasis in mice. methods: hours after intoxicated with anit mg/kg orally, kunming mice were treated with ppas-sm , , mg/kg/days for days orally, then serum alt activity was measured. result: all doses of ppas-sm led to rise of serum alt activity in mice, most obvious in group of high dose.but the general situation and mortality rate did not increase significantly. conclusion: ppas-sm lead to rise of serum alt activity in mice with damaged liver.the auther suggests as a double-edged sword,the antioxidant ppas-sm may have a prooxidative effect in some condition too. *this project was supported by grants from shanghai municipal education commission under high school high-tech characteristic development programme (no smec finance ( ) ) pe a. somani , a. jain , v. dixit , s. somani navjeevan hospital, ims, bhu, varanasi, suvidha introduction: hepatic encephalopathy, a complex neuropsychiatric syndrome secondary to acute liver failure, chronic parenchymal liver disease or portal-systemic shunting, may possibly develop through mediators of endotoxin and tumor necrosis factor-alpha (tnf-). several studies have shown that serum levels of (tnf-) are significantly elevated in patients with acute and chronic liver diseases, where these elevations are independent of the etiology of the underlying disease. it has been shown that plasma levels of tnf-correlate with the severity of hepatic encephalopathy (he) in fulminant hepatic failure. however, still there is very few published data regarding the relationship between serum levels of tnf-and the presence or severity of he in patients with chronic liver failure. methods: the aim of this study is to determine the relationship between serum levels of tnf-and clinical grades of he in patients with chronic liver failure. this prospective study included consecutive male patients with alcoholic cirrhosis in various clinical grades of he (according to west haven criterion). detailed clinical, biochemical and sonographic examination was done in all patients. circulating levels of tnf-was measured using solid-phase elisa. results: the mean±sem values of serum tnf-at presentation in patients with mhe (n= ), grade (n= ), grade (n= ), grade (n= ), and grade (n= ) were . ± . , . ± . , ± . , . ± . , and ± . pg/ml, respectively. significant positive correlation was found between serum levels of tnf-and severity of he (correlation coefficient = . ). conclusion: from the present study we can suggest that there is significant relationship between tnf-and he in patients with alcoholic cirrhosis and it could be involved in its pathogenesis. background: acute hepatitis a (aha) is one of the most common infectious diseases and usually a self-limiting disease. although extrahepatic manifestations are not common, a few cases associated with acute renal failure (arf) have been reported. methods: we reviewed clinical features of aha patients complicated with arf (group a) and compared with non-complicated aha patients (group b). medical records of patients with aha were reviewed between january and december . we experienced patients ( . %) with arf associated aha. result: there were no differences between group a and group b in sex ratio and age. the peak value of alt (median: iu/l vs iu/l, p< . ), alkaline phosphatase (median: iu/l vs iu/l, p= . ), prothrombin time (inr, median . vs . , p< . ) was significantly higher in group a than b. nine patients ( . %) recovered completely with hemodialysis ( patients, . %) and only conservative management ( patients, . %), while patient underwent liver transplantation and patient died due to fulminant hepatic failure. there were patients who underwent kidney biopsy. two patients were diagnosed as acute tubular necrosis and patient as acute interstitial nephritis and iga nephropathy. conclusion: aha patients with arf had higher alt and more prolonged prothrombin time. the prognoses were poorer than those without arf. however, arf patients with nonfulminant aha had a good prognosis with a proper treatment and should not be confused with hepatorenal syndrome. background/aims: to investigate the hev infection among different animals and people with special profession, and to analyse the genotype of hev isolated in this study. methods: serum and fecal samples were collected from various animals and people with special profession in the south suburbs of beijing. hev antigen and anti-hev antibody were detected by das-elisa. hev rna was extracted from fecal samples and amplified by rt-npcr. the nucleotide sequence homology and phylogenetics of hev strains isolated from swine were analysed. results: the anti-hev antibody positive rate of adult swine, cow, sheep and younger swine were . % ( / ), . % ( / ), . % ( / ) and . % ( / ), respectively. the hev antigen positive rates of adult swine, cow, sheep and younger swine were . % ( / ), . % ( / ), . % ( / ) and . % ( / ), respectively. the hev antigen and anti-hev antibody positive rate of professional group was . % ( / ) and . % ( / ) respectively. the hev rna positive rate of fecal samples from younger swine was . %( / ). of samples were hev rna positive by pcr with primers of hev orf and orf . the sequence analysis of the samples showed that there were groups designated as bj- ( / ) and bj- ( / ). the nucleotide homology of bj- and bj- was %. phylogenetic analysis of hev orf indicated that both of them belonged to genotype d. conclusion: phylogenetic analysis of hev orf indicated that hev isolated in the south suburbs of beijing belonged to genotype d. bracops hospital brussels , st. jan hospital, bruges , chu brugmann, chu sart tilman, liège , gent university hospital , zna middelheim, antwerp hepatitis delta virus is a subviral satellite requiring hepatitis b virus to propagate, usually leading to severe, chronic liver disease. as data on epidemiology and management practice of hdv infection in belgium are lacking, a retrospective and prospective, multi-centric questionnaire-based registry is performed in . results of patients are reported. background/ aims: hepatitis a is an acute infectious disease that is transmitted by fecal-oral root. because the incidence of hepatitis a has been increased in gwangju and chonnam province of korea recently, hepatitis a patients in chonnam national university hospital employees had been increased. so we investigated the seroprevalence of igg anti-hav in hospital empolyees less than years old. methods: we analysed seroprevalence of anti-hav igg from , hospital employees (men: , women: ) . serum alt and bilirubin at admission were , , iu/l and . . mg/dl, respectively. these levels were elevated up to , , iu/l and . . mg/dl, respectively. ana was positive in patients ( . %). age, duration from peak-alt day, duration from peak-bilirubin day, alt level, and peak-bilirubin level were not different between ana(-) patients and ana(+) patients. in the while, sex, duration from symptom-onset day, and bilirubin level, and peak-alt level were significantly different. in ( %) of patients with positive ana, ana was followed after month and ana became negative in patients ( . %). among patients with positive ana after month, titer decreased from the baseline in patients, showed no interval change in , and increased in . conclusions: positive ana result is not rare in patients with acute hepatitis a. it is considered that ana transiently appear during the course of acute hepatitis a and then, disappear with the improvement of acute hepatitis. ( ), ( ). the clinical data such as sex, admission period, ast, alt, total bilirubin, prothrombin time, crp, alt normalization time did not show difference. just wbc and gtp were higher on group. the older age patients were more on group. the patients admitted mainly on april, may, june, july ( %) on while admitted even on past years. conclusion: acute hepatitis a ptients is increasing. it is occurring in older age people and mainly on specific period. the more concern to prevention should be needed. background: we analyzed the ' non-translated region ( 'ntr), non-structural proteins b and c of hepatitis a virus (hav) genome, whose mutations have previously been shown to be important for enhanced replication in cell culture systems, in order to align all of our data and examine whether genomic differences in hav are responsible for the range of clinical severities. methods: our accumulated hav strains of 'ntr (nt and ), entire b and c from japanese patients with sporadic hepatitis a, consisting of patients with fulminant hepatitis (fh), with severe acute hepatitis (ahs), and with self-limited acute hepatitis (ah), in whom the sequences of all regions were available, were subjected to phylogenetic analysis. results: fh patients had fewer nucleotide substitutions in 'ntr, had a tendency to have more amino acid (aa) substitutions in b, and had fewer aa substitutions in c, than ah patients. four fh and ahs with higher viral replication were located in the near parts of the phylogenetic trees, indicating the association between the severity of hepatitis a and genomic variations in 'ntr, b and c of hav. conclusions: our study suggests that genetic variations in some parts of hav might cooperatively influence replication of the virus, and thereby affect virulence. viral factors should be considered and examined when discussing the mechanisms responsible for the severity of hepatitis a. aims: the incidence of acute viral hepatitis a in adults is increasing very much in south korea, . the aim of this study was to the clinical features and course in daejoen and its surrounding area. methods: forty seven patients admitted as acute viral hepatitis a in chungnam national university hospital between january and june were enrolled. the medical records were reviewed, retrospectively. results: the mean age was . . common occupations were company employee and studuents. most common symptom was jaundice. presumptive infection sources were raw fish or shellfish and raw meat. initial laboratory findings were as follows(mean value): wbc /ul, hemoglobin . g/dl, platelet × /l, ast iu/l, alt iu/l, total bilirubin . mg/dl, alkaline phosphatase u/l, ggt u/l, prothrombin time(inr) . . hospitalization was . days. peak laboratory findings were as follows: alt iu/l, total bilirubin . mg/dl. leukopenia (< /ul) and thrombocjtopenia (< × /l) were ocurred in sixteen and six patients, respectively. recovery time of each biochemical finding was as follows: alt . days, total bilirubin days. recovery rates of altand total bilirubin were . % and %, . % and % at weeks, weeks after diagnosis, respectively. prolonged jaundice ( days) was detected in one patient. all patients were recovered by supportive management. conclusions: in south korea, acute viral hepatitis a was more prevalent in young adults, recenlty. presumptive infectious sources were raw fish or guangxi center for disease prevention and control shellfsh and raw meat. if it can not change the food style that many korean enjoy raw seafood, vaccination for adults must be considered to prevent it. objective: to assess the safety and immunogenicity of a new inactivated hepatitis a vaccine (vero cell). pe methods: subjects were selected in gongcheng city of guangxi zhuang autonomous region, and the clinical trail was carried out according to the random, double-blind and parallel principle from january to august, . after vaccination by , schedule, adverse events of the subjects were observed, the seroeonversion rate and geometric mean titer (gmt) were tested by the competitive inhibition elisa. results: after immunization, the systemic and local reaction rates of adults were . % and . %, which was no significantly statistical difference compared with control group, . %and . %; while the rates of children were . and . %%, and no significant statistical difference compared with control group, . %and . %. one month after first dose of vaccination, the seroconversion rates of children and adults were . % and . %, and one month after second dose of vaccination, the rates were all %, the gmts of children and adults were miu/m and miu/ml, which was significant statistical difference in children compared with control group, miu/ml and miu/ml, respectively. methods: igg anti-hav was measured in a total of subjects under the age of , who visited hanyang university seoul and guri hospitals between january and may . results: fig. shows the relatively low positive rates of the antibody in ages of to and the lowest rates of . % and . % in the age group of to , following the ages of to with rates of background: some viruses encode proteins that affect their cap-independent internal ribosomal entry site (ires)-mediated translation and their replication. it was recently reported that hepatitis a virus (hav) proteases interact with intracellular dsrna-induced retinoic acid-inducible gene (rig-i)-mediated signaling, but it remained unknown whether hav proteins have any effects on hav ires-independent translation. in this study, we investigated the effects of hav non-structural proteins on their ires-mediated translation using a reporter assay. pe methods: the bicistronic reporter constructs, termed psv -hm -ires, psv -a -ires, psv -a -ires, psv -f -ires, and psv -f -ires, contain the sv promoter that controls the expression of a bicistronic message coding for renilla and firefly luciferases separated by hav ires, and are derived from strain hm , acute convalescent hepatitis clones a , a , fulminant hepatitis clones f , f , respectively. human hepatoma cell lines were co-transfected with psv -hav-ires and each hav protein-expression vector. luciferase activity was determined h after transfection. were from other countries within asia, africa, middle east, and eastern europe. patients of a wide age range were affected by hepatitis delta (mean age . , median . , range - ). ( %) of were co-infected with hcv. hepatitis b virus (hbv) dna was detectable in ( %) patients and negative in ( %) patients. all hepatitis delta patients were extracted from a prior study conducted by this collaboration. there were , chronic hbv carriers. ( . %) were hbv/ hcv/hdv infected. ( %) of patients carried a diagnosis of cirrhosis compared to ( %) of chronic hbv patients. ( %) hcv co-infected patients had evidence of cirrhosis while ( %) patients did not. conclusion: individuals with hbv/hdv co-infection have higher rates of cirrhosis. individuals with hbv/hcv/hdv infection have rates of cirrhosis significantly higher than individuals with either chronic hbv infection or hbv/hdv co-infection. testing for hdv should be performed in all patients, especially those with advanced liver disease or high risk behavior. clinical characteristics were compared between the patients with significant endoscopic findings (group a) and without such findings (group b). peak ast and alt level were higher in group a (p< . ). there were no statistical differences in age, gender, comorbidity, and etiology of acute hepatitis between group a and group b conclusion: significant endoscopic findings were found in considerable proportion of patients with acute hepatitis. severity of acute liver injury was associated with significant upper gastrointestinal endoscopic findings. in patients with severe acute hepatitis who complain of upper gastrointestinal symptom, esophago-gastro-duoenoscopy should be performed. background: in japan, hepatitis e virus (hev) testing is not allowed as routine one. to study the role of hev testing, we checked sera of the patients diagnosed as etiology-obscure acute liver injury. methods: we have seen cases of acute liver injury from january through december in our hospital and cases of them were etiology-obscure. in cases, were retrospectively tested for hev-igm, hev-iga and hev-rna (rt-pcr) by direct sequence method on stored sera taken at the time of presentation. result: two of cases ( . ) were positive for both hev-igm and hev-iga and one case was positive for hev-rna. in cases of acute liver injury, the cause of virus was cases ( . %) and unknown was cases ( . %). hev was occupied in . % in all cases and . % in the cases caused by virus. one of the two cases had been misdiagnosed as "drug induced hepatitis". hev of genotype was detected in one case and its nucleotide sequences of hev showed quite a high degree of similarity to the reported one at closed city in the same year. conclusion: hev is not rare in japan and the hev testing can reverse the diagnosis of acute liver injury. hev testing sould be used as routine one for acute liver injury. association of progesterone receptor gene with hepatitis e disease severity in pregnancy p.d. bose , b. das , a. kumar , p. kar maulana azad medical college, background/aims: incidence of fulminant hepatic failure (fhf) in hepatitis e is high in pregnancy particularly during rd trimester when there is an altered status of hormone and immunity. progesterone receptor (pr) up regulation provides fetal protection via immunosuppression but lower immune status in pregnancy may add to the disease severity. till now, no data is available whether pr can play any role in hepatitis e disease severity during pregnancy. progins, a haplotype of pr consisting of -bp insertion in intron g together with point mutations in exons and is associated with increased stability and higher transcriptional activity. the aim of the study is to analyze pr mutation (progins) and m rna expression in hepatitis e virus infected pregnant women with avh and fhf. methods: a total of avh and fhf cases were studied. blood and placental tissue were collected from the medicine and gynecology wards of lnjp hospital, new delhi. cases were screened for acute viral markers by commercially available elisa kit. extraction of dna from blood and rna from placental tissue was done by qiagen kit. mutation in pr was detected by pcr-rflp. semiquantitative rt-pcr for pr expression was performed in placental tissue using beta-actin as internal control. results: pr mutation (progins) was significantly more in fhf compared to avh ( . % vs . %, p value< . ). protein expression was found higher in progins carriers. conclusion: progesterone receptor mutation (progins) may have a role in the hepatitis e disease severity in pregnant women. results: the hepatitis e was predominantly sporadic, some patients superinfected with other viral hepatitis, especially hepatitis b. in the old patients, jaundice lasted longer and the length of stay was longer, the incidence of complication was higher than the young men. the incidence of complication in the superinfected group was higher than the simple infection. the transaminase in the simple infection group was obviously raise than superinfected with liver cirrohsis. methods: liver sample were paraform-glutaral fixed, paraffin-embedded, sectioned and immunohistochemical stained, and positive samples were selected for histological analysis and rt-pcr detection. result: positive rate of hev immunohistochemistry ranged from % to % (fig. ) . hepatocyte degeneration, scattered singled karyopyknosis, lymphocytic infiltrate, hyperplasia of bile canaliculus at the portal area and fibrous connective tissue hyperplasia been observed during histological analysis (fig. ) , and two genotype hev which closely related to many strain isolated from patients with sporadic acute hepatitis been detected. conclusion: the patients infected with hepatitis e of young men were frequently. jaundice lasted long in the old patients, the incidence of complication was higher in the superinfected men and the old men. conclusion: additional public-health concerns might be placed on pork safety and the risk of hev infection via the consumption of undercooked pork products. poster session, hall b aim: esophageal varices (ev) recurs frequently after endoscopic variceal ligation (evl) or endoscopic injection sclerotherapy (eis). we retrospectively investigated risk factors for early recurrence of ev after endoscopic treatment. methods: we treated patients with ev, who had no past history of ev, at ehime prefectural central hospital from october to june . of those, ( %) were observed for at least months after treatment and enrolled. we divided them into rupture cases at initial endoscopic treatment [(bleeding group; n= ( %)], and cases with preventive evl or eis performed [preventive group; n= ( %)]. all received periodic upper endoscopy examinations to confirm recurrence or no recurrence of ev. results: recurrence of ev occurred in of all subjects and the average period after treatment was . ± . months. the recurrence rate was significantly higher in the bleeding group ( / ) as compared to the preventive group ( / ) (p= . ). there was a significant relationship between recurrence of ev and hepatic reserve function (child-pugh a+b, c; / , / respectively; p= . ). in logistic multi-variant analysis, ev rupture at initial treatment and child-pugh c were risk factors for recurrence. in contrast, age, sex, hepatocellular carcinoma, portal tumor thrombosis, continuous alcohol consumption, therapeutic modality (evl or eis), number of treatment sessions, and operator experience did not have a significant relationship with recurrence. conclusion: in cases with ev rupture at initial treatment or child-pugh c, the risk for early recurrence must be considered and patients carefully observed in follow-up examinations. endoscopic cyanoacrylate injection: less oil for less ectopic embolism c.z. li , l.f. cheng , z.q. wang , f.c. cai , q.y. huang , e.q. linghu general hospital of chinese pla background and aim: endoscopic injection sclerotherapy with n-butyl- cyanoacrylate (nbca, histoacryl) has been reported to be effective for hemostasis of bleeding gastric varices, but occasionally the gel flows to other organs and causes ectopic embolism. the present study aimed to determine whether less amount of iodized oil preload in nbca injection helps in decreasing ectopic embolism. methods: from january to april , different methods of endoscopic nbca injection, "sandwich method" and "modified sandwich method" (in which iodized oil preload was minimized), were applied on gv cases, to evaluate if decrease of iodized oil preload resulted in less ectopic embolism. results: altogether cases of ectopic embolism occurred in the whole group ( . %), including cases of splenic infarction, case of transient paralysis and case of minor infarction of the lung. the modified sandwich method showed some superiority over original method in decreasing ectopic embolism ( / vs. / , p= . ). less cough during procedure was also found with the modified method ( / vs. / , p= . ). conclusions: less amount of iodized oil preload in endoscopic nbca injection is beneficial to decrease ectopic embolism. background: portal hypertension is closely associated with serious complications of liver cirrhosis which contribute to bad prognosis. hepatocellular carcinoma (hcc) and low serum sodium (sna) are manifestations of end-stage liver disease (esld) and are associated with poor survival in decompensated cirrhosis patients. therefore, we aimed to determine the relationship between hepatic venous pressure gradient (hvpg) and the development of hcc or low sna in decompensated alcoholic cirrhosis patients. methods: child-pugh scores, meld scores, and hvpg at baseline, and the development of low sna (sna < meq/l) or hcc during follow-up were analyzed prospectively in patients with decompensated alcoholic liver cirrhosis. the predictive values of different risk factors for the progression to the esld were investigated by multivariate analysis and the kaplan-meier method results: twenty-four patients developed hcc during the follow-up period. in the multivariate analysis, only baseline hvpg> mmhg was an independent predictive factor for the development of hcc (relative risk (rr)= . , p< . ). those with hvpg > mmhg showed a significantly shorter time for the development of hcc on kaplan-meier analysis. twenty patients developed low sna during follow-up. initial hvpg was also an independent predictive value for the development of low sna in the multivariate analysis (rr= . , p< . ). those with hvpg> mmhg also showed significantly shorter times for the development of low sna on kaplan-meier analysis. conclusions: in decompensated alcoholic cirrhosis, hvpg may be a useful predictive factor for the development of hcc and low sna, both of which are characteristic of esld and poor prognosis. the effectiveness of the treatment of octreotide on chylous ascites after liver cirrhosis d.x. zhou , , h.p. hu , background: octreotide is a crucial drug used for treating patients with chylous ascites; however, there have been few reports related to octreotide that are being used in cirrhotic patients. thus, this thesis is designed to determine the effects of octreotide on patients with chylous ascites after liver cirrhosis. methods: eight patients were diagnosed with chylous ascites, on the basis of laboratory findings on ascites samples, between january and may . octreotide was given to the six patients, while the remaining two were treated as a control. all patients had persistent peritonea drainage with the quantity and quality of the drainage fluid observed once every other day. all the necessary care was individually given to the patients during the therapy results: all patients properly received combined therapy including low fat and sodium diet, and diuretic and peritoneal drainage. the volume of the peritoneal drainage was reduced to zero in one of the six patients who received octreotide therapy, while the other five had the drainage volumes decreased from ml to ml with a clear appearance and negative qualitative analysis of chyle for those two patients who did not receive octreotide therapy, the conditions of peritoneal drainage seldom changed both from the qualitative and quantitative aspects. conclusion: octreotide, along with combined therapy, can rapidly relieve portal hypertension and reduce fat absorption from intestinal mucosa. it appears to be an effective therapy available for the treatment of chylous ascites caused by liver cirrhosis. albumin < g/l were the best predictors of large varices. a model using these predictors in a validation cohort study is planned. background-aim: cirrhosis is associated with raised acute phase proteins (app), irrespective of infection. it is, however, unclear whether their values differ significantly or whether a particular app might be more indicative of infection, and these questions were addressed in our study. methods: we measured serum crp, fibrinogen, ferritin, haptoglobin, -microglobulin, c , c , and c inhibitor in consecutive, cirrhotic patients, on admission. all patients were investigated according to a standard protocol for infection. child-pugh scores (cps) were calculated. results of app were expressed as means sem and compared with the mann-whitney test. results: ( , %) patients, median age years, (cps: a= ; b= ; c= ), were diagnosed with infection (spontaneous bacterial peritonitis= ; pneumonia= ; septic shock= ; extensive cellulitis= ; listeria monocytogenes meningitis= ; viral infection= ), while ( %) patients, median age years, (cps: a= ; b= ; c= ), showed no infection. although most app values were raised, there was no statistically significant difference between patients with or without infection, or among different cps groups, except for crp, which was significantly more raised in patients with infection (p< . ). this difference remained even after cps a cases in the non-infection group were excluded from analysis. interpretation: a significantly raised crp in cirrhosis would seem to be independent of cps staging and should prompt a thorough work up to exclude infection. by contrast, the discriminating power of all other app in the face of possible infection is negligible. the predictive value of crp towards infection is under investigation prospectively. although bleeding from ectopic varices such as duodenal, jejunal, ileal, colonic, and rectal varices is less common, it can also cause life-threatening problem, which is often difficult to diagnose and treat successfully. here we present a novel endoscopic approach for hemorrhagic rectal varices using endoscopic injection sclerotherapy with ligation (eisl). patients and methods: in - , we performed endoscopic treatment in patients with portal hypertensive varices. among those, four cases of hemorrhagic rectal varices were treated with the combined evl and sclerosing technique. the etiology of portal hypertension included oen idiopathic portal hypertension and three hcv cirrhosis. all patients had a history of prior abdominal surgery or endoscopic treatment for gastro-esophageal varices. results: hemostasis was obtained easily by the evl initially. furthermore, to avoid recurrent bleeding, the patients underwent endoscopic varicerography injection sclerotherapy (evis) using % ethanolamine oleate with iopamidol and the feeding vein was sclerosed successfully with no major complication occurred during the entire course of the treatment. conclusions: it is important to recognize the possibility of ectopic varices as a cause of gastro-intestinal haemorrhage especially in patients with a history of variceal therapy or abdominal surgery. the eisl technique is useful to control the initial and recurrent bleeding from rectal varices. t. hirano , t. okada , j. yamanaka , y. iimuro , n. kuroda , k. oh , y. yoshida , j. fujimoto aim: interferon (ifn) therapy is a powerful treatment for hcv-related hepatitis and is known to decrease the incidence of progression of hepatocellular carcinoma (hcc). however, thrombocytopenia is a common side effect of ifn treatment, often leads to discontinuance without insufficient therapeutic effect. in this study, we investigated the efficacy and safety of laparoscopic splenectomy ( ) in reversing thrombocytopenia in patients with hepatitis c cirrhosis and portal hypertension. patients and methods: out of patients who underwent ls in our department during aug and december , patients associated with portal hypertension. among these patients, three patients had hcc, and they were simultaneously underwent partial hepatectomy after splenectomy. platelet count, operative time, blood loss, complications and length of stay were calculated. results: thirteen patients underwent laparoscopic splenectomy; their mean age was years (range to years). six patients were child's class a and seven patients were class b. mean operative time was minutes (range to minutes). blood loss was little, and none required transfusion with packed red cells. a hand-assisted laparoscopic technique was used in four cases ( . %). average length of stay was . days. there have been no major complications during follow-up. platelet counts improved from a preoperative mean of /ul ( to ) to /ul ( to ) postoperatively. six patients are ongoing ifn treatment without remarkable thrombocytopenia. conclusion: laparoscopic splenectomy is safe and in patients with portal hypertension and thrombocytopenia. it may allows these patients by reversing thrombocytopenia. background: hepatic encephalopathy (he) is a significant cause of mortality in advanced cirrhosis patients. l-acyl-carnitine has been suggested as an alternative treatment for patients with he patients. to assess the clinical efficacy of acetyl-l-carnitine in the treatment of hepatic encephalopathy in cirrhotic patient, especially in diminishing the recurrence and reduction serum ammonia level. methods: we performed a randomized placebo-controlled, cross-over study. we administered acetyl-l-carnitine to group during months first then placebo during later months, and administering acetyl-l-carnitine to group alternatively. results: between january and february , thirty two selected cirrhotic patients were enrolled in this study. following randomization, the patients were divided into two groups (group = , group = ). during administering acetyl-l-carnitine period, serum ammonia level was decreased significantly in both groups significantly (p= . , vs. p= . respectively). however, during administering placebo period, serum ammonia level changes were not significant. in group , the first recurrence cases of hepatic encephalopathy were more than group (group = , group = ), and the first recurrences were occurred during first months in all groups. conclusion: our study demonstrates that acetyl-l-carnitine administration reduced serum ammonia level, but not definitely diminishing the recurrence of hepatic encephalopathy. sodium (na + ) and water retention are the most common abnormalities in cirrhotic patients and the magnitude varies from patients to patients. aim: to assess the relationship between the meld score and urinary excretion of na+ in non-azotemic cirrhotic patients. methods: fifty four cirrhotic patients with ascites and normal serum creatinine (< . mg/ml) were admitted and placed on a low sodium diet ( g/day), while all diuretics were withdrawn for days. the electrolytes (na + , k + , na + / k + ) were measured in a random urine and both the volume and na + concentration of urine collected for h after administration of furosemide mg i.v. were determined. results: table. conclusions: the meld score was significantly correlated with the degree of impairment of urinary na+ excretion. the ratio of na + /k + in a random urine specimen and furosemide-induced na+ excretion reflect the degree of impaired natriuresis in non-azotemic cirrhotic patients with ascites. background: portal hypertensive gastropathy (phg) is common finding in patients with liver cirrhosis and portal hypertension. despite portal hypertension remains the crucial trigger for the development of phg, the relationship between portal hypertension and phg has not been widely investigated. methods: fifty-three cirrhotic patients ( males, mean age years) who were performed hepatic vein catheterization between november and august were prospectively included in this study. the degree of phg was assessed according to the third baveno international consensus workshop, and classified three degrees as no, mild and severe. the hepatic venous pressure gradient (hvpg=whvp-fhvp) measurements were performed by triplicate in each case, and results were given as arithmetic means of the three determinations. result: hvpg values did not differ between the patients without phg ( . ± . mmhg) and those with phg ( . ± . , p= . ), nor between those with mild ( . ± . mmhg) or severe phg ( . ± . mmhg, p= . ). the degree of phg and hvpg did not differ regarding the etiology of the cirrhosis(p= . , p= . ) nor regarding the child pugh classification(p= . , p= . ). no correlations were found between the degree of phg and child pugh score, age, with or without ascites, albumin, bilirubin, creatinine, meld score and the degree of gastroesophageal varices. conclusions: our data show that the presence and the severity of phg does not correlate with the degree of hvpg, and that correlate with esophageal varices in patients with liver cirrhosis. introduction: phlebosclerotic colitis is a rare form of ischemic colitis characterized by the thickening of the colonic wall due to fibrous degeneration of the submucosal layer and fibrotic sclerosis of the venous wall. there are a few reports those this entity might be related to portal hypertension with disturbed venous return from the colon and mesentery. case description: a -year old man with alcoholic liver cirrhosis presented with right lower abdominal pain/tenderness and bloody diarrhea. a colonoscopy revealed multiple circumferential ulcerations in the transverse colon and the scope could not get through the ascending colon due to luminal stenosis, showing histologic finding of ulcerative inflammation with inflammed granulation tissue. abdominal computed tomography demonstrated liver cirrhosis with splenomegaly, multiple portosystemic venous collaterals, diffuse vascular engorgement and the wall thickening of right proximal to mid ascending colon with increased density in the surrounding fatty tissue. a follow-up colonoscopy performed one month later showed still remained multiple ulcerations in the transverse colon and could not further advance to ascending colon. superior mesenteric angiography revealed no main branch occlusion but pooling at the venous phase on ascending colon. a right hemicolectomy was performed because of the colonic obstruction. gross findings on operation showed thickening of the cecum and ascending colon. microscopic examination showed fibrous thickening in the submucosa, abundant neurovascular bundles in the mesentery and several intravascular hyaline thrombi of the mesenteric vessels. here we report the first case of early stage of phlebosclerotic colitis in a cirrhotic patient in korea. spontaneous bacterial peritonitis (sbp) is one of the severe complications in advanced cirrhotic patients with a high mortality rate. although a more rapid diagnosis should lead to the better survival, it takes several days to detect the causal bacteria from ascitic fluid cultures. furthermore, despite the use of sensitive methods, ascitic fluid cultures were negative in more than % of patients with suggestive clinical manifestations of sbp. therefore, diagnosis of sbp is based on the polymorphonuclear leucocytes (pmn) cell count in the ascitic fluid. the hybrizep kit (fuso pharmaceutical industries, osaka, japan) detects the dna of bacteria that have been phagocytized in neutrophils and macrophages, using in-situ hybridization method within one day. here we present a case of the patient for whom the hybrizep kit was used to detect the causal pathogen of sbp. a -year-old man had been admitted for the treatment of ascites and esophageal varices. one week after the admission, he complained abdominal pain and fever. because the pmn cell count in ascites fulfilled the criteria of sbp ( /mm ), we started an empirical antibiotic therapy without waiting for a result of the culture, and his symptoms improved within a few days. on the following day of the onset, in situ hybridization showed the positive signals by the ek probe, which detected the genomeic dna of e.coli species. however, the ascitic fluid culture was negative. this case suggested that the hybrizep kit was useful for the rapid diagnosis of sbp with high sensitivity. background: it has not been known that the hemodynamic effect of a portal hypertension for splenomegaly or esophageal and gastric variceal formation. this study was performed to access the parameters of doppler ultrasonography associated with splenomegaly or varices in patients with cirrhosis. patients and methods: from may to may , cirrhotic patients were performed the doppler ultrasonography. of these patients were accessed the severity of varices endoscopically. the three dimensional volume of spleen was measured from a length, width and thickness on sonography. results: the splenic volume ( . ml vs . ml, p= . ) and blood flow of main portal vein ( . cm/s vs . cm/s, p= . ) were statistically significant different in alcoholic ( / ) and non-alcoholic ( / ) cirrhosis groups. the splenic volume ( . ml vs . ml, p= . ), damping index ( . vs . , p= . ), and blood flow of main portal vein( . cm/s vs . cm/s, p= . ) were statistically significant different in esophageal variceal groups ( / ) and non-esophageal variceal groups( / ). the only splenic volume ( . ml vs . ml, p= . ) were statistically significant different in gastric variceal groups ( / ) and non-gastric variceal groups ( / ). the hemodynamic parameters venous ammonia and cff at baseline and after one month of treatment with lactulose. mhe diagnosed by abnormal psychometry and/or p erp.response defined by normalization of abnormal test parameters. results: mhe diagnosed in ( %) patients. of patients ( %) had both abnormal psychometry and p erp whereas ( %) alone had abnormal psychometry, ( %) had abnormal p erp.cff was < hz in ( %) patients. mhe recovered in % with treatment and cff > hz was seen in ( %) of patients. cff sensitivity, specificity, positive predictive value (ppv), negative predictive value (npv) and diagnostic accuracy before and after treatment is shown in table. conclusions: critical flicker frequency is a simple and accurate test without any age or literacy dependence for the diagnosis and recovery of patients with mhe. background/aims: endoscopic injection of n-butyl- -cyanoacrylate (histoacryl) is an effective treatment of varix bleeding. but nontarget embolizations and septicemia are unwanted complications. we evaluate the risk factors for complications. methods: thirty-three patients with esophageal or gastric varix bleeding received endoscopic histoacryl therapies ( procedures). baseline varix size, ctp score were checked. serum leukocyte, blood culture and body temperatures were repeated checked within one week after procedure. average volume of histoacryl per each session was . ml, and dilution volume ratio of histoacryl/lipiodol was / or / . results: average of ctp score was . ± . . three cases of septicemia were correlated with ctp score rather than session frequency or injection volume. two cases of systemic embolizations (pulmonary and splenic arterial embolism) were correlated with high lipiodol dilution ratio ( / ) and lipiodol volume rather than histoacryl volume or ctp score. conclusion: ctp score, lipiodol volume and dilution ratio of histoacryl/lipiodol were significant risk factors for complications. detection of circulating toll-like receptor and and cd +cd + regulatory t cells in patients with hbv-related liver cirrhosis x.q. wang , y. zhang , x.f. bai , j.q. lian background : to detect circulating cd + cd + regulatory t cells and toll-like receptor(tlr) and tlr expression on the peripheral blood mononuclear cells (pbmcs) of patients with hbv-related liver cirrhosis (lc), and to explore the correlation between them. methods: pbmcs isolated from lc patients , chronic hepatitis b (chb) patients and normal controls(nc) were stained with fluorescent labeling anti-tlr -pe, anti--tlr -apc, anti--cd -fitc monoclonal antibodies and anti-cd -percp anti-cd -fitc anti-cd -pe. samples were collected and detected of three-color immunofluo rescence by flow cytometry. results: the expression of tlr and tlr were significantly up-regulated in patients with lc than those in the controls.the expression of tlr was significantly increased in patients with lc than those in patients with chb, but there were no differences of tlr expression between lc and chb.treg/cd + t cells were significantly increased in patients with chb than those in patients with nc and lc, but there were no differences between lc and nc. there were no correlation between the expression of tlr ,tlr and treg in patients with lc . the expression of tlr and tlr on pbmcs in patients with lc were positive correlation.the expression tlr and hbv dna level were negative correlation in patients with lc. conclusion: the expression of tlr and tlr were up-regulated on pbmcs in patients with lc. it seems to be expression of tlr and tlr invovlved in the pathogenesis of lc. evaluation of c-phenylalanine breath test for the measurement of hepatocyte function in patients with chronic liver disease z.j. bao , d.k. qiu , , x. ma , , g.s. zhang , y.q. huang , z.p. fan , , s.m. yin huadong hospital, fudan university, renji hospital, shanghai jiao tong university school of medicine, background: the objective is to investigate whether the c-phenylalanine breath test(pbt) would be useful for the evaluation of hepatic function in patients with chronic hepatitis b, liver cirrhosis and minimal hepatic encephalopathy (mhe). methods: l- [ - c] phenylalanine was administered orally in a dose of mg to patients with liver cirrhosis, with chronic hepatitis b and healthy subjects. the pbt was measured at different time points ( , , , , , , , min) to obtain the values of delta over baseline, percentage co exhalation rate and cumulative excretion (cum). the relationships of the cumulative excretion with the c-%dose/h and blood biochemical parameters were investigated. results: the c dose h - at and min combined with the cumulative excretion at and min showed correlations with the chronic liver diseases, especially child-pugh score and mhe or not. and the data showed correlations with serum albumin hemoglobin platelet and child-pugh score. prothrombin time, total and direct bilirubin were significantly increased, while serum albumin, hemoglobin and platelet, the cumulative excretion at and min values decreased by degrees in healthy controls, child-pugh a, b, and c patients (p< . ). similar results of pbt were in the patients with and without mhe, while only prothrombin time prolonged and total bilirubin increased (p< . ). conclusions: the pbt can be used as a non-invasive assay to evaluate hepatic function in patients with liver cirrhosis and mhe. the % c dose h- at min, % c dose h- at min and cumulative excretion at min may be the key value for determination at a single time-point. branched chain amino acids in improving survival and decreasing risk of liver failure among cirrhotic patients: a meta-analysis h. flores , e.l. ang , n. iv estanislao philippine general hospital background: the state of a patient's nutritional status greatly affects disease outcome. among cirrhotic patients, approximately - % are in a state of protein-energy malnutrition. hence, adequate nutritional support is essential to improve their general medical condition and long term prognosis. several studies have shown than branched chain amino acids (bcaa) may be of benefit for this purpose. it is the aim of this study to evaluate the effectiveness of diet plus bcaa compared to diet alone in improving survival and in decreasing liver failure among cirrhotic patients. methods: pubmed, cochrane, and embase search was done for articles which compared the clinical effects of bcaa supplementation versus diet alone among patients with liver cirrhosis. the following free-text terms and mesh words were used -"branched chain amino acids", "amino acids, branched chain", "bcaa", "liver cirrhosis", "cirrhosis", "randomized controlled trials'" and "meta-analysis". after critical appraisal of the included studies, a random effects model using odds ratio was used to synthesize the results (revman . ). results: rcts were included for analysis with a total study population of . combination of the studies showed a significant decrease in the risk of liver failure (or . , % ci . - . , p= . ) and a trend towards benefit in improving survival (or . , % ci . - . , p= . ). conclusions: the overall trend appears to show benefit in the use of branched chain amino acids for patients with cirrhosis with respect to liver failure and survival. background: the proxisome prolifrator-activated receptor gamma (ppar ) is a member of the nuclear hormone receptor superfamily that is involved in the control of inflammation, carcinogenesis and gastric ulcer. on the other hand, the frequency of gastrointestinal ulceration is higher in cirrhotic patients compared with the normal population. the present study was designed to investigate the effect of specific ppar ligand, pioglitazone, on the mucosal lesions induced by ethanol in cirrhotic rats and the possible involvement of nitric oxide in the pioglitazone effect. methods: cirrhosis was induced by surgical ligation of bile duct and sham-operated rats served as controls. both cirrhotic and sham rats were kept for days after the operation. different groups of sham and cirrhotic animals received saline, or , or mg/kg pioglitazone, daily during last days of the fourth week after the surgery. another groups of bdl or groups of sham rats received l-name, a non selective inhibitor of nitric oxide synthase, alone or along with mg/kg pioglitazone for days. on day , rats were killed hour after ethanol administration and the area of gastric lesions was measured. results: the ethanol-induced gastric mucosal damage was significantly more sever in cirrhotic rats than sham-operated ones (p < . ). pretreatment with pioglitazone dose dependently attenuated gastric lesions induced by ethanol in both sham and cirrhotic rats, but this effect was more significant in cirrhotic ones. concurrent treatment of l-name and pioglitazone decreased the ulcer index in bdl rats more than the groups that received l-name or pioglitazone alone. conclusion: we conclude that chronic treatment with pioglitazone exerts a potent gastroprotective effect on the stomach ulcers of cirrhotic rats probably due to inhibition of nitric oxide synthase. inhibition of phosphodiesterase -a novel therapeutic strategy for portal hypertension l. halverscheid , p. deibert , b. pannen , r. schmidt , m. roessle , w. kreisel university hospital duesseldorf, germany, university hospital freiburg, germany introduction: the no-cyclic gmp system is a key factor in the regulation of splanchnic and hepatic blood flow and may be a target for medical treatment of portal hypertension. clinical data have shown that inhibitors of phosphodiesterase (pde ) lower portal pressure in cirrhotics. methods: we monitored in rats the effects of the pde inhibitors vardenafil and sildenafil on systemic and hepatic hemodynamic parameters up to minutes after the drug. the drugs were administered intravenously into the tail vein at (group a), (group b), and g/kg body weight (group c). . % nacl was the control. n = for each group. results: the most prominent changes were observed in the vardenafil b group: mean arterial and portal venous pressure decreased (- %, - %), as well as portal venous, hepatic arterial, and systemic vascular resistance (- %, - %, - %). portal venous and sinusoidal flow increased (+ %, + %). in the vardenafil c and sildenafil b and c groups there was an increase of portal venous flow by - %, an increase of sinusoidal flow by - %, and a decrease of portal venous resistance by about %. there was a trend for reduction of portal venous pressure. conclusions: vardenafil and sildenafil influence portal hemodynamics in the rat. portal venous flow increases by - %, portal venous resistance decreases by > %. dependent on the dose, portal venous pressure decreases significantly. these data yield further evidence that pde inhibitors may be a novel therapeutic option for portal hypertension. groups of liver cirrhosis e. havrilyuk lviv national medical university introduction: rupture of esophageal varicose resulting in posthemorrhagic anemia is a common life-threatening complication of liver cirrhosis. but it is not clear, why the other patients, having the same degree of sclerosis and histologic activity index, die from hepatocellular failure or other reasons. aims & methods: autopsy cases performed in lviv regional hospital in - were analyzed. screening of slides with liver tissue allow to select cases ( , %) with cirrhosis (complete and incomplete), which are examined in order to evaluate the frequency of lethal portal hypertension complications in the different etiologic groups of liver cirrhosis. results: according to the etiologic factor the following groups of liver cirrhosis were examined: alcoholic disease ( , %), viral hepatitis ( , %), nonalcoholic steatohepatitis ( , %), secondary biliary cirrhosis ( , %), cardiac sclerosis ( , %), combined lesions ( , %) and cryptogenic cirrhosis ( , %). analysis shows that in cases ( , %) patients die from cirrhotic complications (hepatocellular failure, jaundice, portal hypertension) and only in cases ( , %) -from posthemorrhagic anemia caused by rupture of esophageal varicose. in the latter cases correlation between the etiologic types of cirrhosis is almost the same, as in the main group and only alcoholic lesions ( %) and biliary cirrhosis ( , %) are more frequent. conclusion: analysis shows that development of lethal complications of portal hypertension can not be explained only by etiologic factor. probably additional stimuli are more important for morphogenetical variants of cirrhotic transformation. patients with viral cirrhosis k. mumtaz , s. ahmed , h. ali shah , s. hamid , w. jafri background and aims: increased nitric oxide (no) production is incriminated in the pathogenesis of arterial vasodilation and hyperdynamic circulatory state in non cirrhotic models of portal hypertension (pht). we investigated the relative roles of constitutive nos (enos) and inducible nos (inos) isoforms in the development of rabbit models of endotoxemia induced portal hypertension (eipht) methods: eipht was induced by chronic injection of lipopolysaccharide via an indwelling cannula placed in the gastrosplenic vein of rabbit and maintained for months. the concentration of no, expression of nos (enos and inos) mrna and protein was measured in eipht and sham operated control animals. results: rabbits with eipht compared with controls had raised portal pressure (in mmhg- . ± . vs . ± . ;p< . ; mo; . ± . vs . ± . ; p< . , mo; . ± . , vs . ± . ;p< . ), arterial hypotension (in mmhg- . ± . vs . ± . , p< . , mo; . ± . vs . ± . ,p< . , mo; . ± . vs . ± . , p< . , mo), splenomegaly (in g- . ± . vs . ± . , mo; . ± . vs . ± . , mo; . ± . vs . ± . , mo), normal liver functions and preserved hepatic architecture at , and mo. serum levels of no as well as the no were significantly elevated in eipht rabbits as compared to the controls. the expression of enos, at the level of mrna, was significantly increased in eipht rabbits consistent with increased levels of expression of inos as compared to the controls. the enos but not inos protein expression was elevated in eipht than control rabbits. conclusion: vascular dysfunction in the splanchnic circulation during the development of endotoxemia induced portal hypertension is predominantly characterized by enos and partly by inos gene up-regulation. liver cirrhosis contributed to the immunocompromised status by shedding the membranous tnfrii t.n. lin , c.h. chao , i.s. sheen , y.p. ho , w.t. chen , c.j. lin , c.t. yeh , c.y. lin liver research unit, linkou medical center, chang gung memorial hospital, chang gung university, taoyuan, taiwan background & aim: patients with decompensated liver cirrhosis (dlc) were regarded as immunocompromised, reflected by high incidence of bacterial infection. paradoxically, the proinflammatory cytokine like tnfincreased significantly in patients with dlc even in the face of this immunocompromised status. on the other hand, regulatory t cell (treg cell) is believed to play an important role in inhibiting immune responses, including innate immune responses like blockade of tnf-effect through soluble tnfrii. here, we studied the role of treg cells and tnfrii in patients with decompensated liver cirrhosis. patients and methods: healthy volunteers and cirrhotic patients were enrolled. the percentage of treg cells were enumerated by flow and serum levels of il- , tgf-and tnf-by elisa. results: the percentage of treg cells increased significantly in patients with dlc associated with increased serum levels of il- and tgf-. in addition, these treg cells were mainly memory type reflected as high cd ro. furthermore, the tnfrii expression increased significantly on these treg cells of dlc. interestingly, these membranous tnfrii on treg cells could be shed-off. lastly, we found the serum soluble tnfrii concentration increased significantly in patients with dlc when compared with normal volunteers. conclusion: our results demonstrated memory treg cells with high tnfrii expression increased significantly in patients with decompensated liver cirrhosis that could possibly blocked the biological effect of tnf-by shedding membranous tnfrii and contributed to the immunocompromized status of dlc. background: portal pressure measured as hepatic venous pressure gradient (hvpg) correlates with severity of portal hypertension and the development of complications. hvpg measurement is invasive. recently, liver stiffness measurement has been shown to correlate with liver biopsy and helps predict outcome in chronic liver disease patients. this study was conducted with the aim to study the correlation between portal pressure as measured by hvpg and liver stiffness as measured by fibroscan among patients with portal hypertension due to various causes. methods: between august and september , consecutive patients with portal hypertension were included and were subjected to hvpg measurement and fibroscan (echosens, france). results: of the patients with portal hypertension, both hvpg and liver stiffness were measurable in [ ( %) males; mean age . ( . ) years]. the etiological distribution was hbv related cirrhosis in patients, hcv cirrhosis in , cryptogenic cirrhosis in , alcoholic cirrhosis in , hbv and alcoholic cirrhosis in and primary extra-hepatic portal vein obstruction in . the mean hvpg and liver stiffness of this group were . ( . ) mm hg and . ( . ) kpa respectively. there was a strong positive correlation between hvpg and liver stiffness [r = . ; p = . ]. conclusions: non-invasive measurement of liver stiffness correlates well with invasive measurement of portal pressure. liver stiffness measurement could be used as a prognostic indicator to predict the severity of portal hypertension. endpoints were rate of rebleeding and mortality till day after inclusion and to see for any adverse events. results: the bleeding was stopped in all patients ( %). rebleeding till day was observed in ( %) patients ( each in group a and b). total patients ( %) died ( each in both groups) due to rebleeding. transfusion needs were higher in group a ( . ± . versus . ± . , p<. ). serious adverse effects leading to treatment discontinuation were not seen in any patients in both groups. conclusion: prolonging terlipressin treatment did not confer any significant decrease of mortality or bleeding recurrence. however transfusion requirements were significantly decreased in patients receiving prolonged treatment. serious adverse effects leading to treatment discontinuation are rare. poster exhibition -miscellaneous poster session, hall b background: it is important to know the prevalence of atp b gene mutations of different geographical areas to justify the local screening strategies for wilson disease (wd). materials: eleven unrelated lithuanian families, including wd patients were tested. genomic dna was extracted from whole venous blood using a salt precipitation method. firstly, semi-nested pcr technique was used to detect the c. c>a (p.h q) mutation. patients not homozygous for c. c>a (p.h q) mutation were further analyzed. the exons of the wd gene were amplified in a thermal cycler. direct sequencing of the amplified pcr products was performed by cycle sequencing using fluorescent dye terminators in an automatic sequencer. results: total of wd patients (mean age . years; range - ; male/female, / ) presented with hepatic disorders and their first degree relatives were studied. some of wd patients in addition to hepatic symptoms have had extrahepatic disorders (haemolytic anaemia ; fanconi syndrome ; neurophsychiatric and behavioural disorder ). twelve of ( . %) wd patients have had c. c>a (p.h q) mutation, of them in both chromosomes, were presented as compound heterozygotes with additional c. - delggtttaaccat, c. delc or c. g>a (p.r q) mutation. for one patient with liver cirrhosis and psychiatric disorder no mutations were found. out of first degree wd relatives ( . %) were heterozygous for c. c>a (p.h q) mutation. conclusion: c. c>a (p.h q) missense mutation is characteristic for lithuanian wd patients. even . % of wd patients with hepatic presentation of the disease are homozygous or compound heterozygote for this mutation. background: diabetic dyslipidemia is a crucial problem of diabetic patients with inadequate control. we investigated the relationship between glutamic-pyruvic transaminase (gpt) and high-density lipoprotein cholesterol (hdl-c) in diabetic patients. methods: with informed consents, we recruited outpatients with diabetes at a hospital in rural area in taiwan in [ ] [ ] [ ] [ ] . anthropometric measures, blood tests and urine screening were examined in diabetic patients. results: overall, there were diabetic patients aged - years enrolled in this study and ( . %) of them had low hdl-c. diabetic patients with the highest quintile of gpt had higher average of body mass index (p< . ), diastolic blood pressure (p = . ), but lower average of hdl-c (p< . ) compared with diabetic patients with the lowest quintile of gpt. the prevalence of obesity ( . % vs. . %, p< . ) and low hdl-c ( . % vs. . %, p< . ) were higher in diabetic patients with highest quintile of gpt than in diabetic patients with lowest quintile of gpt. in the multivariate logistic regression, diabetic patients with highest quintile of gpt had higher odds ratio (or) of low hdl-c compared with diabetic patients with lowest quintile of gpt (or = . , % confidence interval [ci] = . - . ). the corresponding or of low hdl-c in patients aged years and older was . ( % ci = . - . ). conclusion: high gpt is one of factors associated with low hdl-c in diabetic patients. the effect of desferrioxamine as supplement to cefotaxime in the treatment of spontaneous bacterial peritonitis na. seda , m. el-hamamsy , r. el-wakil , m. al azizi ain shams specialized hospital, faculty of pharmacy,ain shams university, faculty of medicine,ain shams university, faculty of pharmacy ,ain shams university background: oxidative damage lead to cell damage, organ dysfunction and death in sepsis. desferrioxamine (dfx), an antioxidant iron chelators. the aim was to assess the efficacy of desferrioxamine supplemented to cefotaxime in the treatment of spontaneous bacterial peritonitis (sbp) in cirrhotic patients. methods: thirty patients divided into two groups: group i (n= ) with sbp and receiving cefotaxime ( g iv every hours) alone and group ii (n= ) with sbp receiving cefotaxime ( g iv every hours) with desferrioxamine ( mg im twice daily).all patient were monitored for seven days, their vital organs were screened and their ascitic fluid was assessed completely including microbiological investigations. results: the concomitant administration of desferrioxamine with cefotaxime significantly at (p< . )and(p< . ) improved the therapeutic outcome and the cure rate after days of treatment as compared to patients using cefotaxime only. conclusions: desferrioxamine can improve the therapeutic outcome by preventing iron-induced organ damage and inhibiting bacterial growth. oligella ureolytica is a gram-negative, nonfermenting rod that is infrequently recovered from clinical specimens and is most commonly isolated from the urine of patients with chronic indwelling urinary catheters or other urinary drainage systems. bacteremia due to this organism is an extraordinary finding. we describe here a case of oligella ureolytica being detected in the blood of a patient with decompensated cirrhosis. a -year-old male man was admitted to hospital with -month duration of debility, poor appetite and abdominal distension. decompensated cirrhosis was diagnosed based on clinical findings such as hepatic face, ascites, edema of lower limbs and icteric sclera. laboratory results showed positive serum anti-hcv and high serum hcv rna level. the patient received a therapeutic regimen of pegylated interferon alpha a plus ribavirin after being admitted to hospital. during hospital stay, a fever of -day duration with shivering occurred to the patient. three blood cultures were drawn, which all grew oligella ureolytica in pure culture. the organism was identified by the viteck compact (biomerieux, france). additional tests for identification resulted positive for nitrate reduction and urea hydrolysis, strongly positive for phenylalaninedeaminase activity and showed no growth at . c. tests for nitrite reduction and motility resulted negative. the organism was resistant to amikacin, cefoperazone, levofloxacin, piperacillin/tazobactam, trimethoprimsulfamethoxazole, aztreonam, cefotaxime, piperacillin and was susceptible to gentamicin, imipenem, meropenem, and netilmicin. a -day of combined therapeutic regimen with cefminox and isepamicin was administered to the patient. within days, the patient became afebrile. background: endoscopic ultrasound (eus) is often performed in patients with unexplained liver tests to assess the gallbladder, bile ducts and pancreas. an unremarkable eus exam and negative hepatology workup often leads to a liver biopsy. eus may provide histopathologic evaluation of the liver in these cases under direct, real-time visualization. aim: to assess the feasibility and efficacy of eus guided core biopsy of the liver in a porcine model. methods: female pigs were used and live procedures were performed under general anesthesia. a linear echoendoscope was used and the liver identified endosonographically. transgastric core biopsies of the liver were obtained with a gauge quick-core ultrasound biopsy needle (wilson-cook) and sent for histopathologic evaluation. live animals were euthanized at the end of the procedure and necropsy performed. results: core biopsies of the liver biopsy were obtained in animals ( cadaver and live anesthetized). a total of thirteen needle passes were made (mean . ; range - needle passes per animal) and a visible core of tissue obtained. the maximum length of liver tissue obtained was mm and considered adequate for assessment as more than one such specimen could be obtained. microscopic evaluation confirmed liver tissue. no complications were noted. necropsy did not show any evidence of bleeding, perforation or damage to surrounding structures. conclusion: eus-guided liver biopsy is feasible and can be performed at the time of routine echoendoscopic exam in select patients undergoing eus examination for abnormal liver tests. background: as the common indexes, alt, ast and plt play an important role in disease diagnosis, treatment and prognosis. many researchers suggested that there was inflammatory changes and fibrosis in chronic hepatitis b and c patients whose alt level was persistently normal. a large sample investigation showed that the serum level of alt in healthy persons is lower than the normal reference value. this study re-evaluated the normal serum level of alt, ast and plt. methods: people were enrolled in the study between sep. and oct. . the platelet count and serum alt and ast levels were measured. frequencies, one-sample kolmogorov-smirnov test and nonparametric tests were used to analyze the difference between age groups, male and female, glucose groups, cholesterol groups and triglyceride groups. result: in the five groups, there is significant difference in alt and ast levels between male and female. in group , the alt and ast levels showed a significant difference between different age groups, between different glucose groups and triglycide groups. in the three groups the plt level is significantly different between male and female, and the serum level in male is higher than female. there is significant difference between different age groups conclusion: the serum levels of alt, ast and plt are all significantly different between male and femal. there is significant difference between different genders and age groups for plt. the serum level of plt is higher than the reference value. background/aims: myeloproliferative disorders (mpd) (like polycythemia vera, essential thrombocythemia and primary myelofibrosis) are responsible for % cases of hepatic venous thrombosis (hvt) and % of portal venous thrombosis (pvt) in western series. latent form of mpd lacks the characteristic blood picture and may be classified as idiopathic thrombotic disorder. a point mutation at val phe of janus kinase tyrosine kinase gene (jak v f mutation) occurs in high proportion of the patients with mpd. this non-invasive test with high positive predictive value is now considered to be essential for diagnosis of various mpd. this test may be useful in diagnosing latent form of mpd in splanchnic venous thrombosis methods: patients with confirmed pyogenic liver abscesses admitted from to in our institution were included. there were men and women ranging in age from to years. the medical records were reviewed for clinical, laboratory and radiographic characteristics. results: among patients, ( . %) experienced at least one complication. there were pulmonary (pleural effusion, pneumonia, empyema) complications, septic shock, acute renal failure, abscess rupture, pseudomembranous colitis, and pericardial effusion. the predictive factors for its complications were: systemic inflammatory response syndrome (sirs, factors), thrombocytopenia ( , /ml), hypoalbuminemia ( . g/dl), elevated ast or alt (> iu/l), hyperbilirubinemia ( > . mg/dl), k. pneumonia, air within abscess cavity (p< . ). conclusions: the incidence of complications in the pyogenic liver abscess was . %. the various predictive factors of complication should be monitored carefully. further large scaled study should be warranted. background/aims: hepatic iron deposition is a common feature in chronic hepatitis c (ch-c), however, whether it could enhance the progression of fibrosis or not is controversial. the aim of this study was to evaluate the status and significance of hepatic iron deposition in the korean patients with chronic hepatitis c. methods: untreated, ch-c patients who underwent liver biopsy were included. the hepatic iron was assessed by scheuer's scoring system, and activity, fibrosis, and steatosis were scored by a pathologist in a blind manner to the clinical features. clinical and laboratory data including serum iron indices, virological, biochemical results were analyzed to search for significant factors associated with hepatic iron deposition. results: hepatic iron staining was positive in ( %). among patients with hepatic iron deposition, serum levels of ferritin (p= . ) and -fetoprotein (p= . ), and body mass index(bmi) (p= . ) were significantly elevated. there was no significant association between the degree of hepatic iron deposition and fibrosis stage (p= . ), although elevated levels of serum hyaluronic acid (p= . ), -glutamyl transpeptidase (p= . ), and prothrombin time (p= . ) were associated with advanced fibrosis. conclusions: hepatic iron deposition in asian-pacific ch-c patients seemed to be neither frequent nor related to hepatic fibrosis, but related to obesity. therefore, phlebotomy might not commonly applicable to this area. further studies on the pathogenic role of iron in ch-c in asian-pacific countries are warranted. a late stage of progressive hepatic fibrosis characterized by distortion of the hepatic architecture, necrosis of hepatocytes and the formation of regenerative nodules contributes to cirrhosis. limitations like organ donors shortage, high cost, absence of proliferation in cultured hepatocytes, inherent risks of infection, rejection in xenogenic cells and other socio-economical complications emerges advanced regenerative human hepatic stem cells(hhpscs) transplantation. hhpscs are located in the ductal plates in fetal and canals of hering in adult livers [schmelzer et al.( ) ]. hepatoblasts, in turn, give rise to the hepatocytic and biliary lineages, the hepatocytes and cholangiocytes [schmelzere etal( ) ].hhpscs express cd (epcam)marker. scjelzer etal demonstrated that during embryogenesis % of the epcam positive cells had hepatoblast phenotype. in animal study, on transplantation of freshly isolated hhpscs in scid mice results in mature liver tissue expressing human-specific proteins. recently, we(aleem etal )have shown clinical improvement in study in patients with crigler-najjar syndrome, biliary atresia using hhpscs infusion. in the present study we transplanted hepatic progenitors to five subjects of end stage liver cirrhosis with meld score > . hhpscs were sorted using macs with cd antibody microbeads and infused through hepatic artery via femoral artery catheterization, a safe procedure provided portal pressure to monitor cell infusion route in order to prevent vascular thrombosis. all the patients showed improvement clinical and functional biochemical parameters after first month of cell infusion. ascites was decreased and changed encephalopathy grade into normal level was observed. meld score system falling to normal level from > to < after infusion. the aga khan university patients. the apri of . in combination with a cut-off ha of ng/ml can best detect patients with moderate to severe fibrosis (stages - ). it has a ppv of . %. also, for patients without moderate to severe fibrosis, the test is hardly ever positive (specificity of . %). but the apri of . in combination with different ha as cut-off points is not possible to detect patients with no or mild fibrosis. objectives: terlipressin is used in esophageal variceal bleed (evb) along with endoscopic band ligation (ebl) for days (uc). due to its high cost, it was stopped < days (sc) who could not afford & were stable after achieving hemostasis with ebl. we retrospectively assessed the efficacy of sc vs uc of terlipressin for control of evb and length of stay. conclusion: the apri of . in combination with ha ng/ml as cut-off points to predict patients with moderate to severe fibrosis (stages - ) is an easy and accurate method. methods: patients with evb who had achieved hemostatsis with ebl from jan -dec were included. all were managed on standard protocol on hospital variceal bleeding pathway. the course of terlipressin as sc or uc was based on patient's inability to afford the cost of hospitalization and terlipressin. the efficacy of terlipressin in the control of evb was defined based on baveno iii criteria. results: total of patients were admitted during the study period. out of them, received uc & sc of terlipressin. the base line characteristics were comparable except younger age in sc. there were re-bleed ( %) in uc and ( %) in sc terlipressin group. the length of stay was shorter in sc group. ( . ± . vs . ± . days). conclusions: sc seems as effective as uc terlipressin in the control of evb after initial control of hemostatsis with ebl and may reduces the length of hospital stay. rcts are needed to assess this as all stable patients may not need to continue terlipressin for hours. background/aims: to analyze the relationship between conventional laboratory results and death risk in patients with esophageal varices bleeding due to cirrhosis (cevb), and establish a simple model for timely predicting death rsik of the patients. outcome of patients with gastro-oesophageal bleeding in a tertiary center j. wat, w.h. li, m.t. cheung methods: the medical documents of cevb patients were reviewed retrospectively and the data were collected. univariate and multivariate logistic regressions were performed, in which the discharged results (survival or death) as dependent variable and the results of liver function, kidney function, serum electrolytes and blood cell analysis as independent variables. the multivariate regression equation was as the model for the prediction of patient outcome and its predictive performance was evaluated. objectives: to determine the rebleeding rate, mortality and long term survival in cirrhotic patients presented with acute gastro-oesophageal variceal bleeding. method: this is a retrospective review of adult patients who were admitted to our hospital with the diagnosis of acute gastro-oesophageal variceal bleeding for the first time regardless of their underlying causes for cirrhosis. the study period was from january -october . data were collected from our hospital computer system and records. results: in univariate regression, the significant positive variables for death outcome were dbil, akp, k, wbc and plt, and the significant negative variables were tp, ap, a/g, na, cland ca + . the variables entered the multivariate regression are alt, tbil, dbil, gp, a/g, cr, na + , cl -, ca + , wbc, hb, plt. the sensitivity, specificity and accuracy of the regression model for predicting death of cevb patients were . %, . % and . %. results: a total of patients were included in this study, with male and female. their mean age was . . the initial failure rate in endoscopic haemostasis was . %. the -day and -week mortality rates were . % and . %, respectively. poor child's grading, multiple columns of oesophageal varices, high grade of varices, failed initial endoscopic haemostasis, presence of inoperable hcc, low platelet count on admission, and short duration from index bleed to rebleed were factors associating with increased risk of -week mortality (p < . ). mean duration from index bleed to first rebleed was . months. poor child's grading and presence of inoperable hcc were associated with both early or multiple rebleed (p < . ). overall, . % of our patients developed rebleed before their variceal eradication. -year survival in patients with child's a, b and c were %, %, and %, respectively (log rank test p . ). conclusions: the liver function, kidney function, serum electrolytes and blood cell analysis are generally independent factors for cevb patient death risk, especially dbil, a/g and ca + . the established model shows a excellent predictive performance. an imbalance in plasma amino acids of advaced cirrhotic patients impairs the maturation of dendritic cells via mtor/s k signaling pathway e. kakazu , y. ueno , y. kondo , k. fukushima , m. shina , j. inoue , k. tamai , m. ninomiya , t. shimosegawa division of gastroenterology, tohoku university hospital conclusion: although endoscopic haemostasis is an effective treatment modality; rebleeding is still commonly seen among patients with poor child's grading and inoperable hcc. this will result in significant bleeding-related death and poor overall survival. further advancement in treatment strategies for this group of patients are required to improve their outcome and prognosis. background: we have demonstrated that extracellular branched-chain amino acids (bcaas), especially valine, regulate the maturation and function of monocyte-derived dendritic cells (j immunol. : ) . however, it is not clear whether an imbalance in plasma amino acids of advaced cirrhotic patients influence the function of dendritic cells (dcs). methods: we used human pbmcs and cd c+dcs in this study. we made two mediums: a serum free culture medium consistent with the average concentration of the plasma amino acids from a healthy volunteer (n= ) was defined as the healthy control medium (hcm); whereas that from advanced cirrhotic patients (n= ) was defined as the advanced cirrhotic active hepatitis b replication is defined as hbeag + or hbv dna > fibrosis was scored according to the metavir system. alt levels were characterized as being normal, < x normal, and > x normal. conclusions: pe frequency of portal hypertensive gastropathy and its non-invasive predictors in patients with viral methods: medical record of all patients with cirrhosis due to hepatitis b and c who underwent for screening egd for varices in last years was reviewed. phg was defined endoscopically by using mccormack classification. noninvasive markers such as spleen/platelets ratio, meld score and child score of all the patients who underwent for egd were recorded. results: out of patients ( . %) were males. out of ( . %) patients who had phg, ( . %), ( %) and ( . %) had mild, intermediate and severe phg respectively. higher proportion of esophageal varices ( . %) was present among those who have phg (p< . ). ( . %) with phg has child score of . meld score > and were seen in . % and . % of patients with phg, respectively. platelet/spleen ratio was . ± in patients with phg as compared to methods: retrospective analysis of cirrhotics undergoing surveillance endoscopy was undertaken assessing for oesophageal varices. clinical, biochemical and radiological indices were analysed. results: cirrhotics underwent surveillance endoscopy during the study. childs pugh scoring (cps) to assess prognosis of liver disease showed cps a( %), cps b( %) and cps c( %). % were male albumin ( g/l vs g/l significant factors on multivariate analysis were albumin (p= . ) and platelet count (p= . ) conclusion: in our cohort there were significant biechemical and radiological differences in differentiating patients with large varices (grade - ) on surveillance endoscopy aims and objectives: to study the frequency of ev in patients with cirrhosis due to viral etiology and its correlation with different non-invasive markers. methods: medical record of all patients with cirrhosis due to hepatitis b and c who underwent screening egd for varices in last years was reviewed. ev were divided in two grades (small and large) as proposed in consensus development workshop. noninvasive markers such as spleen/platelets ratio, meld and child turcotte pugh (ctp) scores of all patients were recorded. results: out of patients, ( . %) were males on multivariate analysis ctp score of (or . , p< . ), meld score > (or . , p< . ) and platelet/spleen ratio (or . , p= . ) were found as significant predictors of large ev. conclusion: the frequency of ev is high in viral cirrhosis patients on screening egd. meld score> , ctp score and spleen/platelets ratio can be used as non-invasive predictors of large ev. pe treatment outcome and prognostic factors of spontaneous bacterial peritonitis and culture negative neutrocytic ascites in patients with hepatitis b virus-related thirty-seven ( . %) patients had sbp while ( . %) had cnna. except the higher proportion of renal failure at admission in patients with sbp than cnna ( . % vs. . %, p= . ), no significant difference in the clinical and laboratory data related to liver and renal function was observed. overall mortality during hospitalization was higher in patient with sbp than that of cnna evl was repeated every -weeks till varicial eradication.bb dose was titrated to achieve a resting heart-rate of bpm or a maximum dose mg/d or when side-effects began to appear.primary end-points were rebleed and death.secondary end-points were complications as a result of evlor beta-blocker,variceal recurrence afterevl,and decrease in variceal grade inbb limb. results: patients (median age [range - ] yrs, males %) were included (evl arm[n= ]and bb arm[n= ]. median grade of varices was iii(range ii to iv) nitric oxide synthase isoforms play distinct roles in the evolution of hyperdynamic state in endotoxemia induced portal hypertension m.r. rizvi , m. shahid institute of genomics and integrative biology, mall road, delhi , department of physiology a seconderc was performed after two or more years to assess the progression of the disease. results: ehpvo patients(median age [range - ]yr, males %) were studied.history of present or previous jaundice was present in %,ascites % and pain %. on erc, % had portal biliopathy.the type of bile duct involvement was categorized as: type b( %) and type ( %).the pattern of involvement included indentations( %) and dilatation and strictures( %). %of the patients had bile duct stone and % had history of cholangitis.the mdian bilirubin was . (range . - . ) mg/dl and median serum alkaline phosphatase (range - ) iu/l.all patients were treated endoscopically by endoscopic stone extraction, dilations with/without stenting. ( %) patients underwent second erc after a median interval of (range - )months.the type of involvement progressed, % patients developed type- involvement compared to % at the baseline (p=ns).indentations progressed to develop strictures, from % to %.the frequency of new bile duct stones per year was %(p= ns). conclusions: portal biliopathy is very common in ehpvo, often remaining asymptomatic.however,it is slowly progressive leading to development of biliary strictures objective: to investigate the mechanisms of angiotonin ii (angii)-induced ca ( +)-independent pathways mediated by rho kinase in hepatic stellate cells (hscs) various vasoactive drugs that reduce portal pressure are used in treatment of esophageal variceal bleeding alongwith endoscopic treatment. terlipressin use decreases both, recurrent bleeding and mortality. it is given usually for - days, nevertheless there is very little data comparing different time periods. our aim was to compare the efficacy and safety of -days versus days of terlipressin treatment in bleeding esophageal varices. methods: out of patients who presented with variceal bleeding, were randomized to receive terlipressin mg hrly, i.v. daily for first days and placebo for next days (group a) and to receive terlipressin mg hrly, i.v. daily for days (group b). both groups were both age and sex matched. (svt) {consisting of hvt and pvt}. there is no such data from india a comparative study of male vs background: mucosal lesions are frequently observed.gender differences are expected due to food habits, nature of job, mobility related to work, consumption of alcohol, tobacco etc. material and methods: procedure done in m & ( . %) f& duo ( . %) m & %)f.varices ( ) eso varices ( . %) m & ( . %) f & gastric varices (. %) m & (. %) f .growth ( )eso growth (. %) m & (. %) f & stomach growth ( . %)m & (. %) f & laryngeal (. %)m. eso monoliasis ( ) (. %) m & (. %) f.polyp ( ) eso polyp (. %) m & (. %) f & gastric polyp (. %)m & (. %) f & moniliasis and ulcers are more common in female lee department of internal medicine, gyeongsang national university school of medicine background/aims: although the pyogenic liver abscess is a common intraabdominal inflammatory disease, this complications are not rare. however, reports dealing with this complications are not good enough and results are often variable. the aim of this study was to identify the predictive factors of complication in the pyogenic liver abscess. pe effects of saikosaponinsd (ssd) on expression of c-myc and pcna in experimental hepatocarcinoma of all rats were killed in the th week, then general conditions of rats were recorded, the serum alt akp ggt afu was detected and pathological examination was made. the expression of pcna and c-myc were tested by immunohistochemistry. results: he staining showed that rats were induced to hepatocellular carcinoma,the results of liver function in the th week displayed that alt akp ggt and afu of all groups were increased than that of normal control group conclusion: ssd can inhibit development of hepatoma induced by den, possibly by down-regulating the expression of pcna and c-myc protein lethal endotoxic shock was induced by single endotoxin (e.coli) mg/kg injection into abdominal cavity. ppc in % gs was given via tail vein at ml/ g ( . mg/kg) h and h before endotoxin. rats' behavior and h survival were recorded, venous blood taken for ast and alt, liver preserved for he staining and liver/body weight ratio l/b and liver wet/dry weight ratio (w/d) calculated. intercellular adhesion molecule- (icam- ) expression in liver tissue was observed with -step immunohistochemistry assay. results: rats of ns and ppc group demonstrated similar normal activity, histology and other characters (p> . ), while lps group showed sag and less water-intak and severe inflammation in liver including inflammatory cell accumulation, parenchymal cells edema and tissue exudation. p+l group turned tired but could drink water the role of insulin resistance, adipokine and cytokine pro-inflammatory in non-alcoholic fatty liver disease n. ratnasari , , s. anam , p. bayupurnama , , s. maduseno , , s. nurdjanah , dr sardjito general hospital yogyakarta indonesia, background: non-alcoholic fatty liver disease (nafld) is a benign disease during - years period, with %- % survival. nafld can progress to fibrosis, cirrhotic and cancer of the liver. the etiopathogenesis of nafld is still unknown, however genetic and environment factors are predicted. objective: to know the role of insulin resistance, adipokine and cytokine pro-inflammatory on nafld. methods: the cross sectional study was performed on general check-up population at dr. sardjito general hospital yogyakarta, indonesia. the study was begun from january until november at internal medicine outpatient department. inclusion criteria: adult, alcohol consumtion g/day, metabolic syndrome patients, and healthy subjects. exclusion criteria: the diseases with increasing liver enzymes (hbv, hcv, ischemic hepatitis, congestive liver), a "bright liver" on ultrasound examination (malnutrition, rapid weight decreased, post gut surgery on obesity patients, and drug induced). based on liver ultrasound subjects were devided into steatosis group and non-steatosis group. data were analyzed by t-test and non-parametrical test. results: subjects that were enrolled the study steatosis ( . %) and non-steatosis ( . %) and the subjects who completed cytokine and adipokine examination were steatosis and non-steatosis. there were significantly different on homa -ir and adiponectin level in steatosis group (homa-ir . ± . vs. . ± . , p= . ; adiponectin . ± . vs. . ± . , p= . ). there were not significantly different on tnf-, il- , leptin and visfatin level (p> . ). conlusions: there were significantly different on homa-ir and adiponectin level in nafld patients compared non-nafld patients. background: to optimize management of nonalcoholic fatty liver disease (nafld), a simple screening tool is necessary. in this study, we aimed to devise a simple index that reflects the presence of nafld in the korean population. methods: a cross-sectional study was conducted on , health check-up subjects at a healthcare center ( , cases with nafld versus age-and sex-matched controls). study subjects were randomly assigned to a derivation cohort or a validation cohort. an index reflecting the presence of nafld was derived in the derivation cohort and validated in the validation cohort. results: multivariable analysis indicated that body-mass index (bmi), serum alanine aminotransferase (alt) to serum aspartate aminotransferase (ast) ratio, sex, and the presence of diabetes mellitus were independent predictors of nafld. using these variables, a formula was derived using a linear regression model: nafld index (nafldi) = ×alt/ast ratio +bmi (+ , if female; + , if diabetes mellitus).nafldi had an area under receiver-operating curve of . ( % confidence interval, . - . ). at a value < . , nafldi ruled out nafld with a sensitivity of . % and a negative likelihood ratio of . , and at a value > . , nafldi detected nafld with a specificity of . % and a positive likelihood ratio of . . in the validation cohort, the predictive power of nafldi was maintained at similar levels.aim: since nash could progress to liver cirrhosis and hepatocellular carcinoma, it is important to correctly diagnose between nash and simple steatosis (ss). the aim of this study was to determine the prevalence of nash among nafld patients and to clarify differences in clinical features between nash and ss. subjects and methods: thirty-one patients with nafld showing abnormalities in serum transaminase (ast and /or alt > iu/l) were enrolled (sex: male , female ; mean age: . yrs, mean body mass index: . ), after obtaining informed consent. differential diagnosis between nash and ss was performed histologically according to the matteoni classification and clinical features were compared. results: among the patients with nafld, % and % were diagnosed with ss and nash, respectively. no significant differences in the sex, mean age and bmi were seen between nash and ss groups. the levels of ast, alt, homeostasis model assessment-insulin resistance (homa-ir) and hyaluronic acid were significantly elevated in nash patients compared to ss patients. no significant differences in serum levels of adiponectin, as well as the rates of occurrence of diabetes, hypertension and hyperlipidemia were observed between the two groups. conclusion: the prevalence of nash in nafld patients was about %. nash patients showed higher levels of serum transaminase, homa-ir and hyaluronic acid, compared to ss patients. a large-scale biochemical study is required to accurately diagnose nash patients and confirm these results. conclusion: nafldi was a simple, efficient screening tool for nafld that could be utilized for selecting individuals for liver ultrasonography and for determining the need for lifestyle modifications.pe aim: this study was conducted to evaluate the hepatoprotective effects of the centella asiatica extract in -methyl- phenyl- , , , -tetrahydropyridine (mptp)-induced liver injury in rats. methods: sprague dawley rats were treated with alcohol extract of centella asiatica orally in two doses ( and mg/kg/day) for months along with intraperitoneal injection of mptp ( ml/kg). biochemical parameters such as serum total protein, albumin and marker enzymes were estimated. histopathological studies of liver were also carried out to confirm the biochemical changes.results & discussion: mptp -induced hepatotoxic effects were evident by a significant (p < . ) increase in the serum marker enzymes and a decrease in the total serum protein and albumin. administration of extract of centella asiatica effectively inhibited these changes in a dose-dependent manner; maximum effect was with mg/kg. histopathological examination of liver tissue corroborated well with the biochemical changes. hepatic steatosis, hydropic degeneration and necrosis were observed in mptp-treated group, while there was a significant reduction in these changes in the treatment group. conclusion: centella asiatica extract exhibited hepatoprotective action against mptp induced liver injury. further optimization of tuberculosis chemotherapy requires a comprehensive evaluation of the effects of antitubercular drugs on metabolic processes in organism.wistar albino male rats, body weight (b.w.) of - g, were divided into three groups: group i received pyrazinamide per os at a dose of mg/kg b.w./day, whereas group ii received a dose of mg/kg b.w./day, in both groups it was given for days; the control group was composed of intact animals. the contents of free amino acids were determined using an amino acid analyzer - (czech republic). the study of the effects of pyrazinamide administered in different doses on the liver contents of free amino acids showed the largest number of changes at a dose of mg/kg b.w./day. the content of free amino acids at the level of amino acids and total sum of amino acids significantly differed from controls. part of these changes could be regarded as compensatory answer of organism to this drug action. further pyrazinamide dose increasing caused exhaustion of liver adaptive possibilities. the study of the influence of pyrazinamide on liver contents of free amino acids allows to fully estimate the effects of this substance on metabolic processes in this organ. moreover, the effect of pyrazinamide on the majority of free amino acids in the liver is dose-dependent. background: taiwan is an endemic area of hbv and hcv infection, chemotherapy for lymphoma patients who has been hbv infection, may induce serious clinical sequela due to reactivation of hbv. this study want to clarify the difference of the chemotherapy induced hepatitis between hbv and hcv carrier in lymphoma patients. methods: from july, to july , non-hepatocellular carcinoma patients were enrolled, ( . %) cases were lymphoma, in these lymphoma patients, ( . %) cases have been hbv infected, and ( . %) cases have no hbv or hcv infected. ( . %) cases have been infected with hcv. all patients received chemotherapy with the regimen of chop or r-chop. liver function , viral markers, hbv dna, hcv rna were checked before and after chemotherapy. results: hepatitis happened in ( . %) lymphoma patients, ( . %) cases were in hbv infected patients, ( %) cases were in non-hbv infected patients, cases of hcv infected patients suffered from hepatitis. hbv infected hepatitis patients hbv dna elevated more than log as before chemotherapy. non of the hcv infected patient has elevated of hcv rna after chemotherapy. the mortality rate in hbv infected patient is %. no mortality in hcv infected patients after chemotherapy. conclusions: .high rate of hbv reactivation and mortality in chemotherapeutic lymphoma patients who has been hbv infected. screening of hbv viral markers among candidates for cancer chemotherapy is mandatory, especially in lymphoma patients. large number and prospect study for chemotherapy induced hepatitis in hcv carrier are needed. background: excessive drinking leads to social, psychological, physical and other problems. this study investigated the epidemiology of ald and analyses the associated risk factors. methods: from , residents , blood samples were collected. alcohol consumption and the impact of alcohol on liver function, blood lipids, blood pressure and bmi and mcv have been evaluated. results: the drinking rate and average daily alcohol intake was . % and . ± . g respectively. the total alcohol intake was . ± . kg and the average drinking age was . ± . years. the average -gt, ast, alt, mcv, chol, tg, ldl-c, hdl-c and bp increased gradually with increase in alcohol intake. the population ald prevalence was . %. the prevalence of ald among the drinking population and the alcoholic population was . % and . % respectively. conclusion: chol, -gt, ast, alt, and mcv were highly correlated with daily alcohol intake which closely related to the occurrence of ald. n. tanaka , w. okiyama , t. aoyama background: alcoholic liver disease (ald) is one of the leading causes of cirrhosis and yet efficient therapeutic strategies are lacking. polyenephosphatidylcholine (ppc), a major component of essential phospholipids, prevented alcoholic liver fibrosis in baboons. however, its precise mechanism remains uncertain. we examined the effects of ppc on ald using peroxisome proliferator-activated receptor (ppara)-null mice treated with an ethanol-containing diet, which showed pathological features similar to human ald. methods: male ppara-null mice were pair-fed a lieber-decarli control or % ethanol-containing diet with or without ppc at a clinically comparable dose ( mg/kg/day) for months. o. parkash , a. almas , s.h. ali shah , w. jafri , s. hamid , j. akhtar aga khan university hospital karachi .hdv-hbv co-infection presents mostly as moderate to advanced liver disease. background: liver injury due to dengue infection is not uncommon. acute liver injury is a severe complicating factor in dengue, predisposing to life-threatening hemorrhage, dic and encephalopathy. results: there were no significant differences of demographic features and laboratory parameters such as peak serum alt, total bilirubin and creatinine between groups. however, peak ast was higher in superinfected group than control group (median: , iu/l vs iu/l, p= . ,). additionally, the peak serum albumin levels, prothrombin time and platelet counts were lower in superinfected group than control group (median: . mg/dl vs . mg/dl, p= . , . % vs . %, p= . and x /mm vs x /mm , p< . , respectively). of superinfected group, patients were followed over months after resolution of aha. interestingly, serum hbv-dna levels decreased significantly over months following resolution of aha, then rebounded subsequently (median: - . , - . , - . , . and . log copies/ml at , , , and months, respectively).methods: the overlapping fragments of hev isolate swgx were amplified with reverse-transcription nested polymerase chain reaction (rt-npcr) and the ' and ' ends of viral genome were amplified with rapid amplification of cdna ends (race). the pcr products were cloned and sequenced. the phylogenetic analysis of swgx was performed.result: the genome of swgx consisted of , nucleotides, excluding the poly (a) tail of residues. the genome contained three open-reading frames (orfs), orf- encoding amino acids, orf- encoding amino acids and orf- encoding amino acids. the full-length genomic sequencing showed that swgx strain shared similarity with all known hev genotype , and isolates by . % to . %, and with an identity of . % to . % among genotype hev isolates, and a high nucleotide identity as % with chinese guangxi human strain lz- .conclusions: acute hav super-infection may suppress hbv-dna replication in chronic hbv carriers and chronic hepatitis b, although the suppressive effect did not seem to sustain longer than months. conclusion: the swine hev strain swgx was phylogenetically close to the human hev strain lz- , both from the same region in south china. therefore it was concluded that hev sub-genotype b might have existed in south china at least for years and now it was prevalent both in local human and swine, which also strongly supported the zoonosis hypothesis of hepatitis e. associated with splenic volume were damping index (r= . , p= . ) and blood flow of portal vein (r=- . , p= . ). conclusions: the splenomegaly in portal hypertension was more frequent in non-alcoholic groups, and associated with a damping index and a blood flow of portal vein. the measurement of blood flow of portal vein, damping index, and splenic volume by a doppler sonography can be helpful to predict the varices.z.q. zhang , j. cao , w. lu , l.g. shi objective: to appraise the clinical efficacy of simple non-invasive models of ast-to-alt ratio (aar), ast-to-platelet ratio index (apri), spleen-to-platelet ratio index (spri), age-platelet index (api), age-spleen-to-platelet ratio index (aspri) for predicting hepatitis b associated cirrhosis. methods: patients and patients were diagnosed pathologically as non-cirrhosis and cirrhosis, respectively. the simple non-invasive models were calculated as described originally. spss . was used for statistical analyses.background: to reveal the microrna (mirna) expression profile of the hepatic fibrosis inducing cells, rat hepatic stellate cells (hscs), during in vitro activation. results: the areas under roc curve of aar, apri, spri, api, aspri for predicting the cirrhosis were . , . , . , . , . , respectively which were larger than those under the diagnosis reference line (p . , . , . , . , . , respectively).methods: the hscs were isolated from male sd rats by in situ perfusion and density-gradient centrifugation. the quiescent and activated hscs, which were harvested at day and , respectively, were then subjected to immunocytochemical staining (desmin and -sma), oil red o staining and quantitative rt-pcr (desmin, -sma, albumin, cd , cd and cytokeratin- ). after extraction and labeling, the hy -labeled cellular rna samples and hy -labeled reference pool rna samples were mixed pair-wise and hybridized to the lna mercury microarray. differentially expressed mirnas were filtered and randomly verified by stem-loop rt followed by quantitative pcr.conclusion: all of the simple non-invasive models of aar, apri, spri, api, aspri can be used for predicting hepatitis b associated cirrhosis; and aar has the most practical efficacy for predicting hepatitis b associated cirrhosis. results: both the purity and the total activation of hscs were validated. global analysis of the mirna expression profile based on quiescent and activated hscs demonstrated differentially expressed mirnas. among these, mirnas were up-regulated more than -fold in activated hscs as compared to that in quiescent hscs, while mirnas were less than the threshold level ( . -fold) during the hsc activation. furthermore, the expression of mir- , b, , , and had been proved. background/aims: only limited patients with chronic hepatitis b virus (hbv) infection will develop liver cirrhosis, and no effective methods to precisely predict ones who will develop cirrhosis. we try to establish a model to predict the patients with the risk of cirrhosis development basing on a clinical epidemiological factor survey. z.q. zhang , w.y. bao , w. lu , l.g. shi methods: cirrhosis patients with hbv markers (case group) and asymptomatic hbsag carriers (control group) were recruited and inquired by researchers with a specific designed questionnaire including items. a multivariate logistic regression analysis were conducted to establish a predictive model, in which two third patients selected randomly as model sample and another / patients as validating sample, key factors screened out as variables. the predictive performance of the model was evaluated. objective: to explore the practical significance of the peripheral blood corpuscle counts for prediction of hepatitis b associated cirrhosis. methods: and male patients with chronic hepatitis b were pathologically diagnosed as non-cirrhosis and cirrhosis. peripheral blood corpuscle counts were measured by coulter ac•t diff hematology analyzer. results: red blood cell (rbc), platelet (plt), neutrophil (n) counts in cirrhosis were significantly lower than those in non-cirrhosis; and lymphocyte, mid-cell counts were similar to those in non-cirrhosis. the areas under the roc curves of rbc, plt, n counts for prediction of cirrhosis were . , . , . respectively; according the optimal cut-off determined by the roc curves, the sensitivity, specificity, positive predictive value, negative predictive value, accuracy of rbc, plt, n counts for prediction of cirrhosis were . - . method: pbmcs of active chb patients under pyg-interferon treatment were analyzed for their th , treg and pdc by flow cytometry. they were determined by cd /il- for th- , cd /cd /foxp for treg and cd /cd /cd -for pdc. pbmc were collected every weekly during the treatment until end of therapy (week ) and every weekly until the end of follow-up (week ). alt was quantified at every time of the pbmc collection. ifn-gamma release cells were analyzed by elispot to hbv-core and s ag.background: alpha fetoprotein (afp) is a well-recognized tumor marker for hcc; elevated level of afp is found in at least % of hcc. other liver diseases such as cirrhosis and chronic hepatitis are also related with an elevated level of afp. the regulation of afp gene expression has been relatively less studied although the gene has been suggested to play a role in hcc development. in this study, we tried to identify genetic variations in afp gene and analyze its effect on serum afp level and possible hcc progression.results: in parallel with decline in alt for the first weeks, we found decline in both pdc (r= . , p= . ) and elispot (r= . , p= . for hbv-core ag; r= . , p= . for hbv-s ag). although there is trend that th- decline with treg decline, but they are not statistically significant differences in the same period. there is no significant difference between the svp and non-svp patients.methods: direct dna sequencing was carried out to sequence afp promoter and bp upstream and downstream of afp coding regions in dna samples isolated from hcc subjects and controls respectively. for each samples serum afp levels were determined using commercially available elisa kits. conclusions: under pegyintron treatment, pdc, ifn-gamma change in the same trend of alt during weeks of treatment. it implied that pdc take regulatory effects on ifn-gamma releasing cells and be very tightly related to alt. there wasn't a significant difference in both treg and th- , which implies that treg and th might be of important cells in keeping the stability of the immune system.results: a total of snps were detected in the afp genomic region analyzed, including known snps and one novel snp. among the identified snps, the c>g nucleotide change in the position - bp upstream of afp transcriptional start site showed a significant association with hcc (p < . ) and a decrease in afp gene expression level. conclusion: our preliminary results indicated a possible association between serum afp expression and - g allele. the identified snp is located in afp promoter region with possible binding sites for known transcription factors, such as tfiid, coup, apf and nfiii. - °tail-suspension (ts) rats were used as the model to simulate the physiological effects of weightlessness. thirty-two wistar male rats were randomly divided into groups: control for d ( d con), d con, ts for d (ts d) and ts d. histopathological changes of testicle of the rat were observed by he stain. localization and expression of ar and hsp in testicle of rat were observed comparatively by means of immunohistochemistry, and the density of ar and hsp immunoreactivety in four groups were compared. results: signal molecules mrna level are shown in the table (** p< . , * p< . ). tnfa, il , il and il were higher in group , and than those in group . ifna was higher in group than that in other groups. there are no significant difference in infc, il , and il . there was a positive correlation between tnf and myd in group , tnf and nfkb in group and . results: obvious pathological lesions presented in testicle of ts d and ts d rat. germinal epithelium irregularity and malformed spermatozoa were found in seminiferous tubules. degeneration and necrosis of germinal epithelium appeared in testicle of ts d and ts d rat. ar immunoreactive cell density in the ts d and ts d groups were significantly decreased compared with the in-phase normal control groups ( p < . ). while hsp immunoreactive cell density in the ts d and ts d rats were significantly increased than those of control rats( p < . ), and in testicular interstice or extracellular there were very strong ehsp immunoreactive positive staining signals. the results indicate that ground simulated weightlessness induced by d- d tail-suspension in rats can lead to the serious injury , depressed expression of ar and enhanced expression of hsp in testicle. despite the absence of any serologic marker of hbv recurrence, however, it remains unknown whether there is occult reinfection in the liver graft. we aimed to detect and quantify the presence of intrahepatic hbv dna in the liver grafts of patients who remain seronegative for hbsag for more than year after liver transplantation. materials and methods: liver biopsy and blood samples were obtained from patients who had been receiving nucleoside analogue prophylaxis alone and remained persistently seronegative for hbsag for at least year (median . months, range . to . months) after liver transplantation for chronic hepatitis b. quantitative polymerase chain reaction was performed to detect and quantify total and covalently-closed circular (ccc) hbv dna in the liver (lowest detection limit, copies/ml), serum and pbmc. direct sequencing was used for hbv quasispecies screening. results: liver biopsy was performed and intrahepatic hbv dna as measured by quantitative real-time pcr was detectable in of recipients. donors anti-hbc status before liver transplant was significantly related to the presence of intrahepatic hbv dna in the recipient's study biopsy (p= . ). donor intrahepatic hbv cccdna levels correlated with recipient post-liver transplant intrahepatic hbv cccdna levels (p= . ). hepatitis b virus sequencing results and phylogenetic analysis revealed that hbv reinfection in two recipients were of donor origin, four recipients were of recipient origin and four recipients were of both donor and recipient origins. conclusions: our findings demonstrate the presence of occult hbv reinfection with persistence of hbv dna in liver allografts despite long term nucleoside analogue prophylaxis after liver transplantation, suggesting the need to continue indefinite antiviral therapy. the use of liver grafts from anti-hbc-positive donors might increase the risk of occult hbv reinfection. both donor and recipient hbv dna could contribute to occult hbv reinfection in liver transplant recipients. aim: to construct one noninvasive assessment model consisting of routine laboratory data to predict both significant fibrosis and cirrhosis among patients with chronic hepatitis b(chb). methods: we have retrospective analyzed consecutive patients with chronic hepatitis b who underwent percutaneous liver biopsy. we calculated sensitivity, specificity, positive predictive value(ppv), and negative predictive value(npv) of an apri . in combination with different hyaluronic acid(ha) cut-off points medium (acm). we stimulated pbmcs or dcs under hcm and acm, and evaluated the function. results: after adding the stimulants under hcm, the cd and cd expression of dcs from cirrhotic patients (lc) were lower than those from healthy contorols (hc). in both hc and lc, the cd and cd expression of dcs stimulated under acm was lower than that under hcm. the il- production in acm was lower than that in hcm. the expression of cd , which is related to amino acid transport, was not different between hcm and acm. however, dcs cultured in acm expressed lower levels of phospho-p s k than those cultured in hcm. finally, we ascertained that the ifn gamma production by pbmcs was significantly decreased under acm.conclusions: an imbalance in plasma amino acids of advanced cirrhotic patients suppresses the maturation of dcs via mtor/s k signaling pathway. key: cord- - n bm j authors: gillani, syeda shaista; munawar, munawar ali; khan, khalid mohammed; chaudhary, jamil anwar title: synthesis, characterization and applications of poly-aliphatic amine dendrimers and dendrons date: - - journal: j iran chem soc doi: . /s - - - sha: doc_id: cord_uid: n bm j in the current era, the dendrimers have vast potential applications in the area of electronics, healthcare, pharmaceuticals, biotechnology, engineering products, photonics, drug delivery, catalysis, electronic devices, nanotechnologies and environmental issues. this review recaps the synthesis, characterization and applications of poly-aliphatic amine dendrimers. the "dendrimer" term has been derived from the greek word dendron, meaning "tree" or "branch", and meros meaning "part". the terms "arboroles" and "cascade polymers" are also used for dendrimers. in , fritz vögtle first time reported the synthesis of a dendrimer. in , tomalia et al. introduced, a novel class of dendrimers constructed with a blend of amines and amides. these polyamidoamine dendrimers are generally called pamam dendrimers [ ] [ ] [ ] [ ] [ ] [ ] . ever since, more than dendritic structures have been designated to explore the improved properties and innovative applications in fields such as nano-and bio-technologies, catalysis and materials science [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . during the s and s, many dendrimers were designed by different researchers [ ] . figure shows the well-defined structure of a dendrimer composed of various components: a) multiple reactive sites originate from the central core which further grows into branches layer-by-layer in a symmetric fashion to form dendrimer generations. b) terminal groups surfaces increases radially and provide platforms for the covalent add-on of multiple functions. c) after third or fourth generation, internal cavities formed which give the dendrimers a circular shape. the foremost part is the focal core, captures different chemical species which possess incomparable properties because of the distinctive nano-environment enclosed by various dendritic splitting. second part consists of different internal layers of iterating units provides a stretchy interstellar of dendritic constructing blocks, to capture numerous minor guest molecules. third part describing the dendrimer's macroscopic properties is composed of multivalent surface that can attach various functionalities to interact with the external environment [ ] . figure shows the structure of a dendron in which focal point is a distinct chemically addressable group. branches originate only to one direction. a few terms and abbreviations utilized in the dendrimer science have been clarified. a brief structural classification has been depicted. hyperbranched polymers is a term clarifying a particular class of polymers typically get by incoherent polymerization of ab n (n ≥ ) monomers, for the most part by one-pot reaction. dendrimers have a place with an exceptional instance of hyperbranched polymers with an exact structure. to enhance the availability of dendritic assemblies, hyperbranched polymers are for sure reasons used as dendrimer "mimics", due to their more facile synthesis. in any case, being polydisperse, these sorts of polymers are not legitimate to analyze the chemical events taking place which for the most part need a specific constrained engineered topic empowering the master to examine the substance strategies happening. the physicochemical properties of the undefined hyperbranched polymers are at center between linear polymers and dendrimers as shown in fig. [ ] . dendrigrafts constitute a class of dendritic polymers just like dendrimers that can be worked with a well-described molecular structure, for instance being monodisperse. be that as it may, as opposed to dendrimers, dendrigrafts are focused on linear polymer chain, to which branches including copolymer chains are attached. these copolymer chains are also changed with other copolymer chains, and so on, giving a hyperbranched substance created by a fixed number of joined polymers [ ] . while the dendrimer look like a tree in structure, the central bit of a dendrigraft somewhat be like the structure of a palm-tree. dendrons are dendritic wedges with no center. the dendrimer can be synthesized by combining at least two dendrons. dendrons are entirely significant tools in the synthesis of dendrimers by the convergent synthesis. a class of dendrons, monetarily open and has been used with multitudinous achievement in the covalent and non-covalent assembly of dendrimers, is known as the "fréchet-type dendrons" [ ] [ ] [ ] . these are dendritic wedges created by hyperbranched polybenzylether structure, similar to the fréchet-type dendrimers. these dendrons have been used in the advancement of various dendrimers having different structures and capacities. generation is typical for all dendrimer designs and the hyperbranching when moving from the focal point of the dendrimer toward the edges, achieving homo-assistant layers between the focal core points. generation number is the amount of focal centers climbing from the center towards the outside of a dendrimer. for example, a dendrimer having five focal centers when creating from the middle towards the surface is the fifth-generation dendrimer and is abbreviated as g -dendrimer, for instance fifth-generation polyamidoamine and polypropylene imine dendrimers can be compressed as "g -pamam" and "g -ppi" dendrimers independently. the focal point of the dendrimer is intermittently implied as zero generation or as "g ". the core structure having no focal centers, such as hydrogen substituents, cannot be considered as focal core points. thus, in ppi dendrimers, , -diaminobutane addresses the g focus structure and in pamam starburst dendrimers base addresses the g focus structure. intermediates during the dendrimer association are so often implied as half-generation. a perceived model is the carboxylic finished pamam dendrimer which, would has properties attractive over the amino-terminated dendrimers when associated with normal structures. shell: the dendrimer shell is the "generation space" spatially separated between the focal core interests. the outside shell is the space between the end spreading point and the periphery. the inward shells are generally implied as the dendrimer interior. pincer: dendrimer's external shell involves a variable number of pincers molded by the last focal point before moving to the dendrimer surface. in ppi and pamam dendrimers, the number of pincers is half the amount of terminal surface groups as in these dendrimers, the chain disconnects into two chains in each focal point. end-group is normally referred as the "terminal group" or the "surface group" of the dendrimer. the word terminal is not as exact, as in the dendrimer branches can sometimes fold into the interior of the dendrimer. dendrimers having amine terminal are named as "amino-terminated dendrimers". map dendrimer outlook for "multiple antigen peptide", is a dendron-like molecular create reliant on a polylysine skeleton. lysine with its alkylamino side-chain serves as a good monomer for the introduction of numerous branching points. this sort of dendrimer was first reported by tam in [ ] . it has usage in biological applications, for instance, vaccine and diagnostic research. the main point is its exceptional structure, a "tree shaped" dendron without an inside. nonetheless, whole dendrimer has been based upon this motif either by segmental coupling in solution using dendrons or stepwise by solid-phase synthesis. ppi-dendrimers signify "poly(propylene imine)" depicting the propylamine spacer moieties in the dendrimer was developed initially by buhleier et al. [ ] . these dendrimers are typically poly-alkylamines having primary amines as surface groups. the dendrimer inside is made up of various tertiary tris-propylene amines. ppi dendrimers are commercially open up to generation five, and have found wide applications in material science. as an alternative name to ppi, popam is sometimes used to depict this class of dendrimers. popam stands to poly(propylene amine). pei-dendrimers are constitute a less standard sub-class of ppi dendrimers reliant on poly(ethylene imine) dendritic branches. in these dendrimers, diaminoethane or diaminopropane are the core structures. pamam dendrimers stance for polyamido-amine, and refer to one of the sole dendrimer types made up of polyamide branches with tertiary amines as a middle point. after the initial report by tomalia et al. [ , ] in the mid- s, pamam dendrimers have found wide use in science. pamam dendrimers are commercially available, usually as methanol solutions. the pamam dendrimers having end or surface amino groups (full generations) or carboxylic acid groups (half-generation) have been prepared. pamam dendrimers are commercially available up to g [ ] . starburst dendrimers is the trademark name for a subclass of pamam dendrimers reliant on a tris-aminoethylene-imine focus. the structures of such type of dendrimers appear star like when one looks structures of the high-generation dendrimers of this type in two dimension. these dendrimers are ordinarily known under the abbreviation pamam (starburst) or just starburst. fréchet-type dendrimers are the recent type of dendrimers made by hawker and fréchet [ ] [ ] [ ] subject to a poly-benzylether hyperbranched skeleton. these kind of dendrimers can be symmetric or grown unevenly including or bits of segmental parts (dendrons) with, e.g. different generation or surface motif. these dendrimers usually have carboxylic acid groups as surface groups which act as anchoring points for further surface functionalization, and also help to increase the solubility of this hydrophobic dendrimer type in polar solvents or aqueous media. black ball: due to the large molecular structure of a dendrimer, the full picture of reactions taking place on the dendrimer surface or in the outer shell could be difficult to depict. a way to facilitate the depiction of these macromolecules is by showing the inner (and unmodified) part of the dendrimer as a "black ball". depending on whether the reaction takes place at the surface groups or in the outer shell, the appropriate part of the molecular motif, e.g. the outer pincers, may be fully drawn out to give a concise picture of a reaction involving the outer shell. in this way of reactions taking place at the dendrimer surface or in the outer shell is greatly simplified. after the basic reports and improvement of these specific well-described structures, logical specialists have begun to develop excessive number of different designs of dendrimers for wider applications. newkome and his group [ ] have developed the unimolecular micelle consisting of an almost pure hydrocarbon scaffold. majoral and caminade have introduced the multivalent phosphorus to create intriguing new dendrimeric designs and dendrimers having new properties. silicon and sulfur have also been participated in the dendritic structures resulting dendrimers having different properties from the conventional pamam and ppi designs [ ] . the carbohydrates [ ] , amino acids [ ] and nucleotides [ ] [ ] [ ] have been applied as monomers also. utilizing biological relevant monomers as building blocks presents an intriguing opportunity to incorporate biological recognition properties into the dendrimer [ , ] . metals can serve as good focal points and have found extensive use in various functional dendrimer designs as well as in the synthesis of dendrimers by self-assembly [ ] . two significant methodologies like divergent or convergent can be utilized to prepare dendrimers in contrast to the growth of direction. the divergent methodology (fig. ) was familiarized by tomalia and newkome [ , ] . the convergent methodology (fig. ) was presented by hawker and frechet [ , ] . the two methodologies supplement one another. recently, a third methodology is introduced by percec group [ ] double-stage convergent-divergent strategy (fig. ). in the early periods, unique methodology was used which is an inside-outward [ ] [ ] [ ] . it begins to develop from the center of the dendrimer and arms are added by incorporating construction hinders in a complete and turning way. new monomer auxiliary can be introduced to the developing exterior of the circle in every age (fig. ) . the proficiency of synthetic combination is fundamentally improved with the procedure of unique union. unique union is routinely another alternative to direct amalgamation or focalized blend [ ] . the main demerits of this methodology are the incomplete growth and the side reactions which lead to blemished dendrimers. the side reactions and imperfections can be minimized by using reagents in excessive amounts. in the convergent methodology, the growth of dendrimers is from outward-in, wherein dendrons are coordinated regardlessly and are in this manner coupled to a spread center. it starts growing from the outward; begin with the molecular structure which finally transforms into the fringe arm of the end dendrimer (fig. ) . in this procedure, the end generation number is pre-calculated, mixing the parts of a combination of basic dimensions up to this time for each generation [ ] . the two methods have their own advantages and disadvantages. with an extension in the generation number of dendrimers using unique advancement, the amount of open end clusters at the periphery extends exponentially and it ends up being to an incredible degree difficult to motivate % change to get defect free dendrimers at larger generations. the cleansing of dendrimers winds up troublesome, and in like manner, an excess of reagents is required to change over different terminal groups. however, the development can be controlled and stopped at any stage as demonstrated by the need of number of terminal groups and size of dendrimers using special procedures. the concurrent methodology, on the other hand, can create imperfection free dendrimers in view of the proximity of less number of end groups. as the dendrons are smaller in size, the cleansing is almost more straightforward [ ] . in the combined convergent-divergent strategy, the synthesis of aliphatic polyamide dendrimers till g with eda core and g with ppz core have been achieved (fig. ) [ ] . polyamidoamine (pamam) dendrimers [ , ] are one of the huge classes of dendrimers. the different arms in pamam dendrimers promote the availability and utilization of surface functionalities [ ] . it is typically difficult to integrate monodisperse higher generation dendrimers with no cut arms. therefore, as to propel the limit of dendrimer blend, a decrease in opportunity to integrate bigger generation, various techniques to diminish these combinations have been referred. these include two fold exponential development, two fold organize, hyper monomer, combined divergent-convergent synthesis [ ] and symmetrical coupling systems. in this methodology, hyperbranched monomers [ , ] (ab ) can be utilized to make bigger generation items in a less number of steps. symmetrical functionalities utilized for ab type monomers can upgrade a few inadequacies forced by old style dendrimer union. however, a straightforward and reasonable engineered approach to aliphatic polyamide dendrimers utilizing ab hyper monomer has not yet been noted. in the literature, different kinds of dendrimers and dendrons have been reported: tomalia et al. introduced the first family of dendrimers [ and reference therein]. at that time, poly(amidoamine) (pamam) dendrimers with molecular weights ranging to , were prepared on a marketable scale. the dendrimers shown in the (fig. a, b) have been synthesized by the addition of the branches in the first step to methyl acrylate via exhaustive michael addition followed by aminolysis. ethylene diamine is a key core [ ] . literature reveal the synthesis of a number of aliphatic polyamide amine dendrimers shown in pamam dendrons based silica-coated magnetic nanoparticles have been synthesized (fig. ). the dendritic species have been claimed to show selectivity and greater reactivity for hydroformylation reactions [ ] . polyamide dendrimer with ethylene diamine (eda) core has been synthesized to g by divergent method. the synthesis of dendrimers having , ′-diaminopivaloyl moieties involves the successive acylation-hydrogenation reactions. the generations of dendrimer have been grown by amide bond formation [ ] . figure describes the strategy planned for construction of dendrimer containing two iterative steps: one involves the linkage between azide species and whichever the dendrimer center or terminal amino groups of the resultant dendrimer generation, accomplishing amide-connected multi-azides, and second involves the reduction of azide to amino structures. the linkage steps have been carried by straight forward techniques used in the condensation of carboxylic acids and amines. the reduction steps have been ideally accomplished by means of synergist hydrogenation conditions under h environment on pd/c in methanol. divergent synthesis of g dendrimer with an ethylene diamine (eda) core has also been reported using the methodology reported earlier with some modifications (fig. ). the main modification was the use of ch cl / et n solution at - °c in place of water/naoh in amidation steps. this change upgraded the yield of the amidation venture at all generation with a significant increment at g from to %. the other modification attempted was the use of -hydroxybenzotriazole (hobt) derived activated esters in place of acid chlorides. the same methodologies have also been applied to synthesize five-generation dendrimers with a piperazine (ppz) core (fig. ) . as compared to ethylenediamine (eda) core that permitted the blend of just g , the piperazine (ppz) also delivered g dendrimer in good yields ( - %) using the both strategies. the convergent synthesis of three generations, and the divergent synthesis of six generations of aliphatic polyamide dendrons (fig. ) have also been reported by the same group of researchers using the both acid chloride and benzotriazole ester pathways. the nature of the terminal groups determined the chemical reactivity of dendrimers as well as their physical parameters such as chemical reactivity, solubility and glass transition temperature. this is because of the radially increase in number of terminal groups with the increase in generation number of the dendrimers in comparison to linear polymers having only two terminal groups [ , [ ] [ ] [ ] [ ] . the gradual change in the shapes of dendrimer molecules from an extended arrangement for lower generation dendrimers to a globular shape for higher generation dendrimers may cause the deviation in physical behavior of dendrimers from those of linear macromolecules. the solubility of dendrimers is usually increased in connection to their generation numbers. nevertheless, the reactivity and solubility of the dendrimers especially in case of globular shape molecules by the nature of the peripheral groups. [ , , , ] . the volume of a dendrimer increases cubically while the molecular weight increases exponentially with upturn in generation number. this leads to deviation in solution properties of dendrimer molecules from those of linear macromolecules especially at higher molecular weights. the intrinsic viscosity is used to determine the extent of deviation in case of dendrimers in comparison to that of linear macromolecules. usually, dendrimers have low intrinsic viscosity. [ , , [ ] [ ] [ ] . dendrimers have some interesting characteristics in contrast to classical polymers: ) low poly-dispersity. ) precise number of peripheral groups. ) nominal cell take-up. ) the shape and size of dendrimers can be controlled at certain generation number. ) capacity of physical attachment to ligands and drug molecules is more. ) numerous dynamic sites. ) tailor made structure. the number, nature and position of the peripheral groups which play a vital role to tailor the unique properties of a dendrimer. these properties include unparalleled molecular uniformity, multifunctional surface and the presence of internal cavities in addition to other specific properties to be suitable for a variety of high technology uses. the advances in the chemistry of dendrimer and the biomedical application have been carried out by a number of researchers like astruc et al. [ ] , smith and diederich [ ] , emrick and fréchet [ ] , frey and schlenk [ ] , [ ] , vogtle et al. [ ] . more than families of dendrimers, each with unique properties and tailored for different types of application are described in literature. these applications are portrayed in fig. . in recent era, the use of dendrimers in biomedical field has gain much curiosity from the researchers. dendrimers are charming candidates for biomedical applications because of their special characteristics including: hyperbranching, size, shape i.e. globular structures, extending length/thickness, periphery functionalities, consistency, multivalency and high natural comparability. in particular, the threedimensional building of dendrimers can join an arrangement of naturally unique administrators to shape normally powerful conjugates. these dendrimers and related species can be easily functionalized and can behave as synthetic analogous of enzymes, proteins and viruses. dendrimers and other molecules can either be connected to the outskirts or can be exemplified in their inside voids [ ] . in modern medicines, an assortment of such materials are being used, for instance, polyamidoamine (pamam) dendrimers can be utilized as potential blood substitutes [ ] . the advancement of specific frameworks with exact sizes and shapes may lead to remedial applications like drug movement [ ] , quality transfection [ ] , and imaging [ ] [ ] [ ] [ ] [ ] . one of the fundamental concerns of modern medicines is to enhance their pharmacokinetic properties especially for malignancy [ ] . the drugs conjugate with polymeric species have been recognized by extended half-life, high stability, water solubility, reduced immunogenicity, and antigenicity [ ] . the pathophysiological attributes of tumors incorporate broad angiogenesis bringing about hypervascularization, aberrant vascular architecture, enhanced permeability, and restricted lym-phatic drainage and consequently cause the particular gathering of macromolecules in tumor tissue. this phenomenon is known as 'enhanced permeation and retention' [ ] . the dendrimer conjugates indicate high solubility, decreased systemic lethality and particular collection in solid tumors. the structures and tunable surface functionalities of dendrimers allow for the encapsulation/complexation/conjugation of multiple entities, i.e. the drug molecules, and genetic materials, targeting agents and dyes, either in the core or on the surface, rendering them ideal carriers for various drugs. initial investigations on dendrimers as potential drug delivery carrier were focused on their use as unimolecular micelles and 'dendritic boxes' for encapsulation of drug molecules. in initial studies, dna was complexed with pamam dendrimers for gene delivery applications [ ] , and hydrophobic drugs and dye were incorporated into various [ ] dendrimer cores [ , , [ ] [ ] [ ] ]. an advantage of using dendritic unimolecular micelles is their structure maintenance at all concentrations due to covalently connected hydrophobic segments. however, the release of drug molecules from the dendrimer core is difficult to control. in some cases, harsh conditions are needed, whereas in others, the encapsulation is not much effective and the drug molecules are released relatively rapidly [ , ] . another approach to develop dendrimers as drug carriers is to exploit their multivalency for the covalent attachment of drug molecules to the dendrimer periphery. the drug loading and releasing can be controlled by varying the dendrimer [ ] generation number and by incorporating degradable linkages between the drug and dendrimer. for example, embodiment of the anticancer medicine cisplatin inside pamam dendrimers gave conjugates that demonstrated more moderate release, lower lethality, increased water solubility and selective accumulation in solid tumors as compare to free cisplatin [ ] . furthermore, the dendrimer-platinum complex has been found to show increased efficacy relative to cisplatin in the treatment of subcutaneous b f melanoma. in such a way, malik et al. [ ] have developed an anticancer prodrug 'complexed carboxylate-finished pamam dendrimer with cisplatin' that can release cisplatin particles by hydrolysis. malik and duncan [ ] have claimed that the dendritic polymer palatinate can be administered in required amounts intravenously, orally, parentally, subcutaneously or topically to an animal having a malignant tumor. the dendritic polymer palatinates have been claimed to show high drug efficiency, high drug carrying capacity, good water solubility, good stability on storage, reduced toxicity, and improved anti-tumor activity in vivo. in a similar fashion, balogh et al. [ ] have incorporated silver salts inside pamam dendrimers that demonstrated moderate silver release rates with enhanced antimicrobial activity against staphylococcus aureus, pseudomonas aeruginosa and escherichia coli microorganisms. pamam dendrimers as carrier have been widely studied for oral drug delivery [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] because of their water solubility, unique branching architecture and compacts spherical shape in solution [ ] . the large number of arms and peripheral amine groups can be utilized to immobilize drugs, enzymes, antibodies, or other bioactive agents [ , ] . dendrimers also have many applications in trans dermal drug delivery of bioactive drugs possessing hydrophobic moieties in their structures and have low water solubilities [ ] . gene delivery genetic treatments have a significant role in our armamentarium. a specific and proficient delivery sys- fig. the convergent synthesis of three generations, and the divergent synthesis of six generations of aliphatic polyamide dendrons [ ] tem is very important for genetic therapies [ ] . dendrimers are being investigated to be used to introduce genes into cells without harmful effect on the dna. polyamidoamine (pamam) dendrimer-dna complexes encapsulated in biodegradable polymer have been investigated for substrateinterceded gene delivery. fast-degrading functional polymer has been claimed to have unbelievable potential for limited transfection [ , ] . magnetic resonance imaging (mri) is used to provide high-quality three-dimensional images of organs and tissues in the body. the signal intensity in mri mainly stems from the relaxation rate of water protons (in vivo) and can be enhanced by using a contrast agents i.e. gadolinium chelates, super paramagnetic iron oxide particles etc., prior to the scan. the important properties of mri contrast agents include good biocompatibility, low toxicity, and high relaxivity. the low molecular weight mri contrast agents can diffuse rapidly from blood vessels into the interstitial space and can excrete from the body very rapidly [ ] . paramagnetic metal chelates such as gd(iii)-n,n′,n″,n‴-tetracarboxymethyl- , , , -tetraaz acyclododecane (gd(iii)-dota), gd(iii)-diethylenetriaminepentaacetic acid (gd(iii)-dtpa) and their derivatives have been reported to be used as contrast agents for mri. these metal chelates increased the relaxation rate of surrounding water protons [ ] . short circulation times within the body and inefficient discrimination between normal and diseased tissues were the major problems. subsequently, macromolecular gd(iii) complexes were developed by conjugating gd(iii) chelates to biomedical polymers, i.e. polysaccharides, proteins, and poly(amino acids) to improve image quality. these macromolecular agents demonstrated much better contrast enhancement for cancer imaging and blood pool imaging in animal models. unfortunately, their clinical application faced limitations due their slow excretion rate and more accumulation within liver which enhances the risk of potential toxicity by gd(iii) ions released during the metabolic processes of these agents [ , ] . wiener et al. [ ] have developed a new class of mri contrast agents, gd(iii) dtpa-based pamam dendrimers, with much more proton relaxation enhancements and molecular relaxivities. the g pamam dendrimer possessing reactive terminal amines, has been conjugated to -( -isothiocyanatobenzyl)- -methyl-(dtpa) through a thiourea linkage. this dendrimeric contrast agent has been claimed to have relaxivity up to six times higher than that of free gd(iii)-dtpa complex. in vivo studies on rabbits have illustrated the excellent mri images of blood vessels and long blood circulation times (> min). kobayashi et al. [ ] have investigated the relationship between relaxivity and dendrimer generations using gd(iii)-dtpa-pamam contrast agents. the study revealed that relaxivity increased as the dendrimer generation increased, but beyond th generation, the increase was insignificant. the tissue engineering has developed in the last few decades [ ] [ ] [ ] . the regeneration of native tissues by supplementing the natural healing process and the creation of entire organs for transplantation have been main focus. the first is the selection of an appropriate scaffold material upon which cell/tissue can grow [ ] . the scaffold may have porous structure that allow the diffusion of nutrients to and waste products away from the cells. it must be biodegradable at such a rate that after regeneration of native extra cellular matrix (ecm), it eventually replaced altogether. polymeric scaffold compositions can be divided into two main categories: natural and synthetic. natural scaffolds have been constructed from proteins, carbohydrates, or glycoproteins [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the synthetic linear polymers, such as poly(lactic acid) (pla), poly(glycolic acid) (pga), poly(caprolactone) (pcl), and poly(ethylene glycol) (peg) have also been used extensively as scaffold materials [ , ] . the dendrimers have also been utilized either as auxiliaries to an existing scaffold, or as primary scaffold components in tissue engineering. there are many examples where dendritic species including pamam dendrimers have been incorporated into scaffolds for the regeneration of a variety of tissues and cell types [ ] . chan et al. [ ] incorporated g pamam dendrimer into extracellular matrix (cem) derived from the perimuscular subserosal connective tissue of porcine cholecysts developed in their laboratory [ ] in varied feed concentrations of the dendrimer in cem using the edc/nhs cross-linking system which resulted in covalent binding of pamam on cem. they observed varied degrees of cross-linking, better stability of cem to enzymatic degradation, increase in amine functionalities useful for tethering bioactive agents, upholding of tensile strength with enhanced flexibility of scaffold, and maintenance of the ability of cem to support cells in vitro. on the other hand, boduch-lee et al. [ ] have designed and synthesized star polycaprolactone (pcl)hydroxyapatite films for use as a biodegradable matrix for bone tissue engineering. they used a scaffold composed of pcl chains conjugated to a poly(lysine) dendritic core to fabricate an ha composite for in vitro bone regeneration. the cell line mg- was used to evaluate the effect of these scaffolds. they observed that the performance of dendrimer-pcl ha hybrid was much better than linear pcl both in bone cell growth and adhesion over h. vaccination has been an influential tool to control infectious diseases produced by microbial pathogens i.e. bacteria, virus, etc. with the passage of time, the pathogens become resistant to the existing vaccines as well as mutations in the pathogens lead to more harmful varieties. therefore, there is always a growing need for new generations of vaccines with optimal qualities to target these infectious diseases [ ] . dendrimers, due to their optimum physical characteristics, have ability to act as efficient immune stimulating compounds (adjuvants) that can enhance the efficacy of vaccines. in addition, dendrimers can provide well-defined multivalent scaffolds to produce conjugates with immune stimulators and/or antigens [ ] . these conjugates supposed to be superlative exporters of small antigens upon administration without any side effect. in this respect, peptide dendrons build up solely from lysine have gain much interest from the researchers [ , ] . the two amino groups (r and ε) present in lysine molecule can act as branching points for logarithmic development. thus, two-layer and three-layer dendrons may have four and eight free amino groups, respectively. tam coined the term "multiple antigenic peptide" (map) for such a structure. wang et al. [ ] have examined the vaccine function of a map which was obtained by coupling the v loop (third variable region of envelope glycoprotein gp of hiv) sequence to lysine dendrimer by tam and his fellows [ , ] . elicitation of relatively high and sustained levels of hiv- -specific neutralizing antibodies in animals was observed. baigude et al. [ ] have reported the synthesis of first glycopeptide dendrimer-type aids vaccine model consisting of a v loop peptide-succinyl-maltose-proline-poly(lysine) dendrimer scaffold. this vaccine model has been claimed to have enhanced water solubility, low cell toxicity, and antigenicity of dendrimer itself due to the presence of sugar moieties [ ] . up till now, several studies have been performed using dendrimeric species especially pamam dendrimers as adjuvants against various pathogens. enhanced efficacy and reduction in adverse effect on host demonstrate that dendrimers in conjugation with vaccines/antigens can be used successfully [ ] [ ] [ ] [ ] [ ] [ ] [ ] . is a therapeutic method for treating various oncological and related diseases. first, a photosensitizer (ps) is accumulated in specific target cells. then, selective optical irradiation (visible or near ir) of an appropriate wavelength is used to generate highly reactive singlet oxygen species (ros) which induce apoptosis and/or necrosis culminating in cellular death. the continuing efforts to improve pdt focus on strategies to enhance the solubility of the ps, design new ps molecules, and strategies for higher accumulation of ps in the targeted tissue. in pdt, ps-dendrimer conjugates have been tested by three strategies: entrapment of ps in the voids of a dendrimer [ ] , covalent linkage between ps and dendrimer [ ] , and generation of dendrimer using ps as a scaffold [ ] . the ps-dendrimers have been claimed to show significant tumor suppression as compared to free ps in a xenograft animal tumor model. it has been reported that conjugation of a ps with dendrimers especially pamams, and targeting agent has enhanced the photodynamic therapeutic effects of the ps [ , ] . a single molecule of a dendrimer contains large number of terminal functional groups to be useful for covalent association or closeness of a high number of species. balzani et al. have studied the fluorescence of a g poly(propylene amine) dendrimer elaborated with thirty two dansyl units at the periphery [ ] . the amine units allow the rational number of a metal ions to coordinate. it was observed that the strong fluorescence decreased by the incorporation of co + inside the dendrimer. it has been claimed that low concentrations of co + ions ( . × - m) can be identified using dendrimer concentration of . × - m. so the dendrimers containing fluorescent could be use full as a sensors [ ] . the effect of ph on different generations of pamam dendrimers has been investigated (fig. ). the pamam dendrimers (g -g ) were explored in acidic, neutral, and basic ph atmospheres. the change in ph effected the shapes of the dendrimers. the dendrimers usually attained more compact globular shapes at higher ph with more prominent effect in the higher generations (g -g ) at basic ph [ ] . the role of dendritic polymeric species in catalysis have been investigated by many research groups. the high surface area and high solubility in reaction media are among the prominent features of the dendrimers which make them useful as nanoscale catalysts. dendrimers have multifunctional surfaces and the catalytic sites are usually exposed. the bigger dendrimer-based catalysts may have many terminal active sites. these catalysts can be separated efficiently by filtration [ ] . dendrimers have capacity to encapsulate a single catalytic site, i.e. metallic or non metallic whose activities can be enhanced by dendritic superstructure [ ] . insoluble materials, for e.g. metals, can be entrapped in the dendrimers and can transported into the reaction media. there are numerous examples of using dendrimers in organometallics [ , ] such as ferricenic sandwich [ , ] with remarkable redox catalysis properties. since , a lot of work has been developed in the area of catalysis by entrapping the catalyst in the periphery, the scaffolding, or on the core of dendrimers [ , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the main goal always remain to find the ideal catalyst with high catalytic efficiency, selectivity for whatever reaction, versatile (substrate, metal, conditions), easily recoverable/recyclable and longevity (durable and stable). the use of pamam dendrimeric species always remain a point of interest by the researchers in catalysis. one example is the use of pamam dendrons based on silica-coated magnetic nanoparticles for hydroformylation reaction with very high reactivity and selectivity [ ] . the designing of molecules with controlled motion of charges is always remain the main focus for the development of light harvesting materials. the multiple functionality and structural features including in the functional groups moving from the periphery to the core render dendrimers to be used in light harvesting (fig. ) . most of the studies validate the energy funneling from the chromophore at the periphery to a chromophore at the core [ ] . a σ-conjugated dendrimeric family based on truxene and thienylethylene has been asserted to exhibit intrinsic energy gradient from periphery to the core. a broad absorption in the uv-vis range and a proficient energy transfer to the lower energy centre has also been claimed. such type of dendrimeric conjugates may have remarkable potential as light harvesting materials [ ] . dendrimers are being used in toners composition as additives. xerox corporation has incorporated dendrimeric additives in the form of charge enhancing species [ ] . dendrimeric additives ensure uniform adhesion of ink to both polar and non-polar foils. the multifunctionality of a dendrimer facilitate the fixation of pigment constituents and exterior of the foils (fig. ) . dendritic polymers are being used as a part of polyurethane paints which offer superficial hardness, light swiftness and weathering resistance in addition to polish. these characteristics have encourage their use in furniture and car ventures. use of dendrimeric auxiliaries may alter the peripheral portrayal of thermoplastic resin with synergic effects on stiffness, strength, process ability and high softening temperature. the dendrimeric species have also been investigated as separating agents. the ease to form micelle structure provide high functional density at the surface, high surface area and ease of separation for isolation and regeneration of the compound. it has been reported that unmodified commercial dendrimers containing amine and hydroxyl functionalities fig. pamam dendrimers generations (g -g ) at low, neutral, and high ph are generally more effective for boron absorption and could be used for the removal boron like species from sea water. certain polyamidoamine (pamam) dendrimers have been reported to be used as chelating agents for the removal of certain metal ions from waste water and as well as from contaminated soil [ , ] . some other modified chelating pamam and poly(propylene imine) dendrimer have also been claimed to be functional for the removal of hard metal cations [ , ] , polycyclic aromatic hydrocarbons [ ] and other particles [ ] . the good solubility and easiness to prepare a homogeneous film are absolutely necessary for a material to be used in organic electronic devices (e.g., integrated circuits, fets, thin-film transistors, solar cells, field quenching devices, light-emitting transistors, light-emitting electrochemical cells, optical detectors, organic photoreceptors, organic laser diodes, and organic electroluminescent devices). dendrimers incorporating a specify component can serve as holeinjecting, hole-transporting, electron transporting, or holeblocking materials [ , ] . majoral's group has designed dedrimers incorporated with fluorophores at the periphery which can absorb two photons and can be utilized as fluorescent markers for biomedical applications [ ] . dendrimers architecture i.e. high density of functionalities at periphery and interior voids is suitable for entrapping small gas molecules and low molecular weight organic compounds as well as metal cations. this property enables the dendrimers to be used in the field of environmental remediation environmental [ ] [ ] [ ] [ ] . pamam dendrimers with amine, carboxyl, and hydroxyl terminal groups have been used to remove the toxic metal ions from waste water and contaminated soil [ ] [ ] [ ] [ ] . some ultrafiltration membranes supported with dendrimeric architecture have also been designed with potential application in soft water. in this review, we emphasized on some key aspect of dendrimers such as synthesis, characterization and their applications. topic in current chemistry u. boas, dendrimers, dendrons, and dendritic polymers: discovery, applications, and the future advances in catalysis dendrimer used as light harvesting material fig. dendrimers used as printing inks, additive, and paints journal of the iranian chemical society preprints, st spsj polym dendrimers and other dendritic polymers proc. natl. acad. sci. usa topics in current chemistry topics in current chemistry dendrimers ii. topics in current chemistry, f. vögtle ed dendrimers ii. topics in current chemistry, f. vögtle ed dendrimers in cancer treatment & diagnosis functional molecular nanostructures dendriticantineoplastic drug delivery system dendritic-platinate drug delivery system vessella bowlin multiple antigen peptide system proc. natl. acad. sci. usa vaccines pharmaceutical applications of dendrimers dendrimers and dendrons (concepts, synthesis, applications usa a key: cord- -nypnib h authors: olsufyeva, evgenia n.; yankovskaya, valentina s. title: main trends in the design of semi-synthetic antibiotics of a new generation date: - - journal: nan doi: . /rcr sha: doc_id: cord_uid: nypnib h this review summarizes main advances achieved by russian researchers in the synthesis and characterization of semi-synthetic antibiotics of a new generation in the period from to . the following classes of compounds are considered as the basis for modification: polycyclic antibacterial glycopeptides of the vancomycin group, classical macrolides, antifungal polyene macrolides, the antitumour antibiotic olivomycin a, antitumour anthracyclines and broad-spectrum antibiotics, in particular, oligomycin a, heliomycin and some other. main trends in the design of modern anti-infective and antitumour agents over this period are considered in relation to original natural antibiotics, which have been independently discovered by russian researchers. it is shown that a new type of hybrid structures can, in principle, be synthesized based on glycopeptides, macrolides and other antibiotics, including heterodimers containing a new benzoxaborole pharmacophore. the review addresses the influence of the length of the spacer between two antibiotic molecules on the biological activity of hybrid structures. a combination of genetic engineering techniques and methods of organic synthesis is shown to be useful for the design of new potent antifungal antibiotics based on polyenes of the amphotericin b group. many new semi-synthetic analogues exhibit important biological properties, such as a broad spectrum of activity and low toxicity. emphasis is given to certain aspects related to investigation of a broad range of biological activity and mechanisms of action of new derivatives. the bibliography includes references. the review addresses the influence of the length of the spacer between two antibiotic molecules on the biological activity of hybrid structures. a combination of genetic engineering techniques and methods of organic synthesis is shown to be useful for the design of new potent antifungal antibiotics based on polyenes of the amphotericin b group. many new semi-synthetic analogues exhibit important biological properties, such as a broad spectrum of activity and low toxicity. emphasis is given to certain aspects related to investigation of a broad range of biological activity and mechanisms of action of new derivatives. the bibliography includes references. antibiotics are commonly used in the treatment and prevention of various infectious diseases. one of the major problems of modern chemotherapy is the disappointing efficacy when using available drugs against resistant bacterial strains. natural antibiotics, i.e., antibiotics produced by various microorganisms, have been and continue to be an important source of new highly active antimicrobial and antitumour agents. one of the most relevant approaches to the design of new drugs relies on targeted chemical transformations of natural antibiotics. in the world science, considerable efforts are currently underway to combat the problem of resistance of microorganisms to available drugs. however, in comparison with other drugs, the development of new antibiotics is not carried out sufficiently. the design of anti-infective drugs and the creation of marketable products are still a challenge. since the development of medicines for the treatment of chronic diseases is much more profitable and because of high requirements for safety, large cap pharmaceutical companies (big pharma) shut down their antibiotic research projects. currently, small-and medium-sized enterprises are developing a majority of new drugs through investments, venture capital, etc. because of high demands for new anti-infective drugs and extremely high cost of these works, cross-country collaborations are needed for research in this field. only a few new compounds were approved for therapeutic use in human medicine or have completed phase-iii clinical trials. the problems are compounded by the fact that the increasing percentage of the population, particularly in developed countries and russia, suffer from infections that were not earlier dangerous, i.e., from opportunistic infections. this is due to a significant decrease in the immune status of the population caused by natural or man-made factors. the translation of semi-synthetic antitumour antibiotics (e.g., doxorubicin) into clinics resulted in the development of gold standard chemotherapeutic agents. many antibiotics have made a great contribution to understanding of mechanisms of development of resistance in bacterial and tumour cells. due to high innate or acquired drug resistance of cancer cells, chemotherapy of malignant tumours is often ineffective. the international research community has focused its attention on the search for new, more effective and less toxic antitumour agents. one of the most rational approaches to the targeted therapy is based on the search for inhibitors of important tumour cell targets among natural products, primarily antibiotics. even the repurposing of known antitumour antibiotics is considered in order to address the problem of antibiotic resistance of antiinfective agents. researchers of the gause institute of new antibiotics (gina) headed by academician of the ussr academy of medical sciences g.f.gause in the ± s made considerable contribution to the discovery of a series of original antibacterial and antitumour agents (a total of compounds), their characterization and introduction to medical practice. major achievements of the institute during this period are considered in the review. antibiotics comprise an important class of natural products with unique structural diversity. chemical transformations of natural antibiotics imply a change of particular functional groups of the starting molecules with preservation of structural elements responsible for biological activity. the structure determines the possibility of chemical transformation of the antibiotic and reaction conditions. for example, many antibiotics contain nitrogenous and(or) nitrogen-free sugars, which are easily eliminated in acidic or alkaline media. many antibiotics are sensitive to oxidants, are poorly soluble in organic media or, on the contrary, in aqueous solutions, etc. on the other hand, in the case of similar structures of certain moieties [e.g., the presence of nh , co h, oh, c(o), etc. groups)], methods developed for one class of antibiotics can be applied to antibiotics of another class. the goal of synthetic chemists is to transform natural products with preservation of the sites responsible for biological activity. besides, targeted modification can be performed to gain better understanding of the mechanisms of action, in particular in order to investigate the interaction between the antibiotic and the target. in this review, the following classes of compounds are considered as scaffolds for the synthesis of new antibiotics: polycyclic glycopeptides of the vancomycin ± teicoplanin group, classical macrolides, macrolides of the amphotericin b ± oligomycin group, anthracyclines, aureolic acid derivatives, heliomycin, synthetic benzoxaboroles and some other antibiotics. such representatives as eremomycin, carminomycin, olivomycin a, oligomycin a and heliomycin . olivomycin a . . modification of olivomycin a at the aromatic ring of the aglycone . . modification of olivomycin a at the side-chain h -keto group of the aglycone . . modification of the side chain at the c( h ) c ( h the discovery of vancomycin ( ) and teicoplanin ( ) (fig. ) has given impetus to research on polycyclic glycopeptide antibiotics. natural antibiotics and are still used in medical practice and are considered as reserve antibiotics. they are commonly applied for the treatment of infections caused by gram-positive cocci, particularly, methicillinresistant staphylococcus aureus (mrsa) strains. glycopeptide antibiotics bind with high affinity to the terminal d-ala-d-ala group of the growing peptidoglycan chain on the outer bacterial cell wall, thereby inhibiting the enzymes transpeptidase and transglycosylase. the vancomycin resistance in enterococcus strains (vre) (for vana and vanb phenotypes) arises due to replacement of the d-ala-d-ala group by d-ala-d-lactate, which weakly interacts with the antibiotic. semi-synthetic glycopeptide analogues, such as oritavancin, telavancin and dalbavancin, have recently been used worldwide in medicine. these drugs only partially solve the problem of the treatment of infectious diseases caused by vancomycinresistant enterococci. , the search for more effective glycopeptide analogues is an ongoing process. ± eremomycin (see fig. ), the natural antibiotic of this group, was discovered in the gause institute of new antibiotics. this compound differs from vancomycin ( ) by the absence of a chlorine atom and the presence of the additional amino sugar eremosamine in the side group of amino acid (aa ), as well as by the structure of the amino sugar ( h -epivancosamine or eremosamine) at the d-glucopyranose moiety attached to aa . eremomycin ( ) is ± times more active against gram-positive bacteria than antibiotic ; however, drug is also ineffective against vre and vancomycin-intermediate resistant staphylococcus aureus (visa). in recent years, series of new semi-synthetic derivatives of eremomycin, vancomycin and teicoplanin active against resistant vre and visa strains were prepared. ± figure presents main possible directions of modification of the cand n-terminal groups of the peptide core (a and f ), h -amino sugar (b), the amide group of asparagine (asn) (c), sugar elimination (d ) and edman degradation (e) for antibiotics ± . the presence of (benzotriazol- -yl)oxytripyrrolidinophosphonium hexafluorophosphate (pybop) as the peptide coupling reagent afforded a series of new carboxamide derivatives of eremomycin ± (scheme , fig. a ) . ± after the purification, these compounds were isolated in * % ± % yields. eremomycin pyrrolidide ( ) has high in vitro antibacterial activity against sensitive and resistant gram-positive bacterial strains, including mrsa, visa and vre isolates. , besides, compound is much more effective in the treatment of induced sepsis in mice compared to vancomycin ( ) and does not cause a pseudoallergic reaction typical of many antibiotics of this group. compound was successful in preclinical evaluation (in collaboration with the limited liability company`medicine technology') and was recommended for further clinical trials. eremomycin n-adamantan- -ylamide ( ) was synthesized in a similar way as amide (see scheme ). in in vitro assays, compound exhibits activity against mrsa, visa, vre and bacillus anthracis strains. this compound is also effective against ciprofloxacin-resistant strains of bacillus anthracis. model in vivo assays in mice infected with s. aureus or bacillus anthracis showed that compound provides a higher survival rate of animals compared to ciprofloxacin and has pharmacologically relevant properties, exhibiting an excellent distribution in tissues. the synthesis of eremomycin carboxamides containing bulky substituents, such as -aminoadamantane ( -ad) (compound ), in the presence of pybop at ph * . afforded the previously characterized unsubstituted eremomycin amide ( ) as a by-product. compound is produced by the competitive amidation reaction of the antibiotic with ammonia, which is eliminated through transpeptidation of asparagine-containing peptides in an alkaline medium. an original method was developed for the selective introduction of different amino acids containing a hydrophobic substituent into glycopeptide antibiotics or via selective aminoacylation of the h -amino group of the amino sugar moiety of the disaccharide branch. for instance, the reaction of vancomycin with n-fmoc-(n-n-octyl-o- benzyl)-l-alanine n-hydroxysuccinimide (osu) ester gave figure . structures of vancomycin ( ), teicoplanin a - ( ) and eremomycin ( ) and directions of their chemical modifications: amidation (a), acylation (b), alkaline hydrolysis of the c(o)nh group to co h followed by amidation (c), sugar elimination (d ), edman degradation (e) and modification of the n-terminal amino group of the peptide core ( f ). fig. b ) . in this reaction, the n-terminal group of the peptide core of the antibiotic remains intact. the n-fmoc protecting group can easily be removed by the treatment with a % secondary amine solution. compound exhibits high activity against sensitive and resistant clinical strains of gram-positive bacteria, including vre. in order to study in detail the interaction between the antibiotic and the target in the intact bacterial cell by solid-state nmr spectroscopy using the rotational-echo double resonance (redor) technique, nh -or f-labelled substituents were introduced into amino acid residues (aa ) and(or) (aa ) of the peptide chain of the antibiotic eremomycin ( ). the n label was introduced in the vicinity of the binding pocket of the antibiotic. this was accomplished using carboxyeremomycin ( ) , which was synthesized previously by the selective alkaline hydrolysis of compound in a saturated aqueous solution of ba(oh) . under these conditions, vancomycin ( ) decomposes. carboxyeremomycin [ n]-bisamide was synthesized by the reaction of compound with appropriate amines in the presence of pybop (scheme , fig. a ,c ) . eremomycin -fluorophenyl-n-piperazide ( ) was synthesized by the conventional amidation method in the presence of pybop. the redor experiments were performed using intact staphylococcus aureus cells, which were grown in a culture medium containing bioprecursors with isotope-labelled atoms (e.g., c-amino acid). the n-or f-containing antibiotic that was added to the medium inhibits bacterial growth by forming a stable complex with c-labelled peptidoglycan moieties (see fig. , hydrogen bonds are indicated by dashed lines). , the study of the complex with compound provides an estimate of the distance from the distance between the c-terminal [ n]-amide of eremomycin ( ) and l-[ c( )]ala of the peptidoglycan stem is . # a (see fig. , a solid arrow). consequently, higher activity of eremomycin amide (compared to antibiotics or ) against resistant visa staphylococci can be attributed to the fact that this compound interacts with the peptidoglycan not only via a classical model (i.e., with the d-ala-d-ala target) but also with the l-[ c( )]ala group of its stem. besides, there is an additional binding site of derivative to the target, which can also account for its high antibacterial activity against vre and visa. previously, it was shown that the elimination of sugars (see fig. d ) and the introduction of a hydrophobic residue into the aglycone can give rise to aglycone derivatives of antibiotics exhibiting activity against different types of enveloped viruses. the modification of the eremomycin aglycone ( a), its de-d-meleu analogues (hexapeptide, a), which was produced by the cleavage of amino acid (aa ) using the edman method (see fig. e), and the teicoplanin aglycone ( ) gave a series of new hydrophobic derivatives. ( -adamantylmethyl)amide of the eremomycin aglycone ( b) and its hexapeptide analogue ( b) are derived by the reaction of -adamantylmethylamine with a or a in the presence of diphenylphosphoryl azide (dppa) (scheme ). diphenylphosphoryl azide rather than pybop is the reagent of choice for the amidation of aglycones, because the reactions in the presence of pybop often afford by-products containing the pybop moiety in the phenol group of the aglycone at aa . the acylation of compound with di-tert-butyl dicarbonate (boc o) followed by amidation under standard conditions in the presence of pybop gives the disubstituted derivative Ð ( -adamantyl)amide of the n-boc-teicoplanin aglycone ( ) . the acylation of with -adamantylmethyloxy carbonate (adoc o) affords the n-adoc-teicoplanin aglycone ( ) (see fig. f, scheme ). compounds b, b and ± exhibit high in vitro activity against different corona-and flaviviruses, in partic-ular feline infectious peritonitis virus (fipv) and the coronavirus (sars-cov). the most interesting data were obtained when studying antiviral activity of ( -adamantylmethyl)amide of the eremomycin aglycone ( b) and its de-(d-meleu) analogue ( b) against human immunodeficiency viruses (hiv): ic = . and . mmol l for hiv- , . and . mmol l for hiv- , respectively. compounds of type b are promising selective anti-hiv agents because they cannot bind to bacterial targets. apparently, they cannot induce resistance of bacteria during long-term application and can be used in the future for the prevention of hiv infections. the doubly modified teicoplanin derivative Ð n-bocprotected -adamantylamide of the teicoplanin aglycone Ð exhibits high in vitro activity against a series of flaviviruses: hepatitis c virus (hcv), yellow fever virus (yfv), japanese encephalitis virus (jev), tick-borne encephalitis virus tbev) and dengue virus (denv). , compound is unique in that it can inhibit replication of the closely related denv and hcv viruses by different mechanisms: in the former case, the inhibition occurs in the stage of virus entry in the host cell; in the latter case, after virus entry. protein kinases play an essential role in the virus entry in the cell and virus replication. hence, analogues of the eremomycin and teicoplanin aglycones (including compounds a,b, a,b and ± ) were tested on a panel of recombinant human protein kinases (pks) and two rat liver pks (ck and ck ). these compounds were shown to inhibit pk activity by % at a concentration of < mmol l and by % at a concentration of mmol l . teicoplanin aglycone derivatives and exhibit higher activity against many pks compared to eremomycin derivatives b and b, which also correlates with their higher activity against many types of enveloped viruses. the kinetic analysis of the inhibition of protein kinase ck a demonstrated that teicoplanin n-adoc-aglycone does not compete with atp and peptide substrates. on the available data, it was suggested that one of the mechanisms of antiviral activity of glycopeptide derivatives can be based on the inhibition of serine/threonine protein kinases. the synthesis of hybrid analogues containing covalently bonded compounds of different classes (dual-acting antibiotics) with different spectra of antibacterial activity is a promising approach to the search for new antibacterial agents to combat antibiotic resistance of bacteria. , boronic acids and benzoxaboroles are compounds capable of interacting with various biologically important components of the living cell, such as alcohols, amino alcohols, carbohydrates, rna and some peptides. a new class of synthetic antibiotics possessing antifungal, antimicrobial and antiparasitic activity was designed and synthesized based on benzoxaboroles and is currently developed by anacor pharmaceuticals (usa). certain starting benzoxaboroles used in the synthesis also exhibit biological activity (see below). series of hybrid analogues ± linked to the borole or benzoxaborole moiety either directly or through a spacer were synthesized for the first time from glycopeptides and . to introduce a substituent containing a boronic acid moiety into molecule or , it is necessary to employ picolinic acid as a protecting group, which is easily removed in a weakly acidic medium (scheme ). the amidation of the carboxyl group of antibiotics and with -or -aminomethylphenylboronic acid picolinate esters in the presence of pybop gave new carboxamides of these antibiotics ( a ± a). the hydrolysis of the picolinic group under mild conditions in a weakly acidic aqueous medium affords derivatives b ± b containing the unprotected boronic acid moiety. borole-containing derivatives ± were found to be as effective as the starting antibiotics and . eremomycin derivative b exhibits the highest activity against gram-positive bacteria and is more effective against resistant staphylococcus strains (visa) compared to compounds and . a series of vancomycin conjugates containing different types of benzoxaborole substituents were synthesized: amido derivatives a,b, n-acyl derivatives ( ) n-alkyl derivatives ( ) (scheme ). similar schemes were applied to synthesize benzoxaborole derivatives of eremomycin ( ) (see scheme ) and the teicoplanin aglycone (scheme ). carboxamides of eremomycin ( ) (see scheme ), vancomycin ( a) (see scheme ) and the teicoplanin aglycone ( a) (see scheme ) were synthesized by a standard procedure based on the treatment of compounds , and , respectively, with -(aminomethyl)benzo[c] [ , ] oxaborol- ( h)-ol in the presence of pybop. the reaction of compound or with o-amino-n-alkylamines affords the corresponding amides b and b,c (n = , and ) containing a longer spacer. the reactions with osu-activated esters of the same in situ generated compounds were used to synthesize n-[ -( -hydroxy- , -dihydrobenzo[c] [ , ] oxaborol- -yl)propanoyl] derivatives of vancomycin ( ) and the teicoplanin aglycone ( a). the alkylation of vancomycin ( ) with appropriate aldehyde in the presence of nabh cn affords n,n hdi( -hydroxy- , -dihydrobenzo[c] [ , ] oxaborole- -methyl)vancomycin ( ) in quantitative yield (see scheme ) . the amidation of n-acyl-substituted teicoplanin aglycone a with appropriate amine (in a similar way as the synthesis of amides and a) gave disubstituted teicoplanin aglycone derivative b. the five-membered oxaborole ring cleavage is not observed in various reactions of benzoxaboroles (see scheme ) . the presence of peaks at m/z . [m oh], . and lower ( . and . ) in the tandem mass spectrometry (esi-ms/ms-mrm) spectrum of compound indicates that the antibiotic molecule contains a substituent in the n-terminal amino group of the peptide core rather than in the amino sugar n( h ) group of vancosamine (fig. ) . vancomycin derivatives a, and proved to be less effective against gram-positive bacteria than the starting compound , except for amide a, which exhibits activity comparable with that of vancomycin . hybrid derivatives, in which benzoxaborole and the teicoplanin aglycone are linked by a spacer with a particular length, exhibited the highest antibacterial activity against clinical isolates of gram-positive bacteria. -amino-n-( hydroxy- , -dihydro[c] [ , ] oxaborol- -yl)propylamide of the teicoplanin aglycone ( c, n = ) possesses particularly high activity, in particular against vancomycin-resistant strains. besides, this compound exhibits moderate activity against vancomycin-resistant enterococci (vre); the minimum inhibitory concentration (mic) is ± mg ml . an increase or a decrease in the spacer length and the introduction of two benzoxaborole substituents into the n-and c-terminal groups of the peptide were found to decrease antibacterial activity. the broad-spectrum antibacterial drug kanamycin a ( a) is an important antibiotic of the aminoglycoside (aminocyclitol) class, which is still used in medicine for the treatment of many infectious diseases and also in agriculture. aminoglycosides are active against gram-positive and gram-negative bacteria. the mechanism of their action is related to the interaction with the decoding site (a site) of the s subunit of ribosomal ribonucleic acid (rrna), which leads to disturbance of translation, i.e., protein biosynthesis. according to the literature data, a number of semi-synthetic derivatives of a new generation were synthesized based on aminoglycosides. various heterodimeric aminoglycoside conjugates with other antibiotics were reported, and some of them are used in medicine. , the synthesis of hybrid kanamycin a conjugates with glycopeptides and was described for the first time in our publication. kanamycin a ( a) was conjugated with compounds or via an amino group of the antibiotic at the position of -deoxy-d-streptamine. the acylation of this amino group is known to reduce the risk of the development of resistance, because it prevents deactivation of the antibiotic by enzymes. the amino group at the position of -deoxy-dstreptamine and the h -amino group of h -deoxy- h -amino-d-glucopyranose of aminoglycoside a were protected by the benzyloxycarbonyl group (cbz). , h -bis-(cbz)-kanamycin a ( b) was synthesized by the reaction of the zinc complex of compound a with cbzcl in the presence of a base (et n) using a modified method (scheme ). (mic * ± mg ml for compounds , a,b) and vre stains (mic = mg ml for compound a). based on the results of these studies, methods were developed for the selective introduction of functional groups at the amino sugar amino group of vancomycin ( ) or eremomycin ( ), with the terminal methylamino group of the peptide core of the antibiotic remaining intact. the amidation of the terminal carboxyl group of these antibiotics with various amines, including amines with bulky substituents, was studied in detail. , , an unusual byproduct of amidation (previously unknown for these classes of antibiotics) was isolated, and the optimal conditions were found for the amidation providing the target products in high yields. , the introduction of various groups into glycopeptides at certain positions of the molecule can give new derivatives active against bacteria that are resistant to the initial antibiotics Ð glycopeptide-resistant enterococci. , this resulted in the discovery of compounds exhibiting high activity against glycopeptide-resistant enterococci (mic = ± mg ml ) and staphylococcus aureus with intermediate resistance to glycopeptide antibiotics (mic = ± mg ml ). generally, eremomycin derivatives possess higher in vitro antibacterial activity than analogous vancomycin derivatives and show significant advantages over vancomycin in the treatment of animals in a mouse model of staphylococcal sepsis. , conditions were found for the selective introduction of isotopic labels at both the terminal carboxyl group and the asparagine residue (aa ) of the peptide core of eremomycin, with carbohydrate moieties and other labile functional groups remaining intact. the investigation of interactions of these compounds with native cells of gram-positive bacteria by the redor technique confirmed the mechanisms of action of this group of antibiotics proposed in our previous studies. , modifications of glycopeptide aglycones at the carboxyl and(or) amino group were performed in a series of studies. ± this resulted in the discovery and characterization of a new class of polycyclic peptides exhibiting antiviral activity at micromolar concentrations against hiv- and hiv- , as well as against the enveloped viruses hcv, denv and many other. ± the correlation between antiviral and pk inhibitory activities was established for a class of hydrophobic derivatives of glycopeptide aglycones. the first heterodimeric conjugates of glycopeptide antibiotics with boroles, , and with kanamycin a were synthesized. the conjugates exhibit activity against resistant vre and(or) visa strains. the synthesis of chimeric (heterodimeric) macrolide-based antibiotics is a promising area of research to search for new antimicrobial agents. these antibiotics are among the most effective broad-spectrum antibacterial agents. the semi-synthetic antibiotics clarithromycin ( ) and azithromycin ( ) are commonly used in medicine for the treatment of various infectious diseases caused by many gram-positive and gram-negative bacteria (fig. ) . azithromycin ( ) has the best pharmacological profile among macrolide antibiotics. the mechanism of action of macrolides is based on the inhibition of protein synthesis. the target of macrolides is the peptidyl transferase centre on the large s subunit of bacterial ribosome. however, clarithromycinand azithromycin-resistant clinical isolates of bacteria were isolated. researchers at the gause institute of new antibiotics have developed methods for the conjugation of macrolide antibiotics with benzoxaboroles or polycyclic glycopeptide antibiotics and synthesized series of new chimeric antibiotics. conjugates based on clarithromycin ( ), azithromycin ( ) and various substituted benzoxaboroles were synthesized by the targeted modification of macrolides at the c( ), c( h ) and c( hh ) atoms and the c( ) ± c( ) bond (see fig. a ± d ). according to the literature data, the introduction of arylalkyl groups at the hh position of the cladinose moiety may help antibiotics overcome resistance caused by methylation of the macrolide-binding site of s rrna of the large ribosomal subunit. a method was developed for the introduction of aminobenzoxaboroles at the c( hh ) atom of the cladinose moiety of the antibiotic through the carbamoyl group. hybrid structures containing hydroxamic acid-derived benzoxaborole at the c( ) keto group of the aglycone were prepared, because modification of this group does not lead to the loss of antibiotic activity. scheme shows the synthesis of conjugates based on clarithromycin via the introduction of benzoxaborole groups (a and b) into the antibiotic molecule at the c( ) atom of the aglycone or at c( hh ) o-cladinose with acetyl protection of the c( h ) oh group of desosamine. the former approach is based on the treatment of clarithromycin ( ) with aminoacetic acid giving intermediate clarithromycin -syn(anti)-(o-carboxymethyl)oxime ( a). the reaction of a with aminobenzoxaboroles ha figure . structures of the macrolide antibiotics clarithromycin ( ) and azithromycin ( ) . arrows indicate the directions of modification: at the position of the aglycone (a), at the c( h ) oh group of desosamine (b), at the c( hh ) atom of cladinose (c), the formation of c( ),c( )-cyclic carbonate and modification of the c( ) atom (d ). or hb gives the corresponding amides of clarithromycin (e/z)- -carboxymethoxime b,c (see scheme ). another approach was accomplished by a modified procedure involving the following four steps: the protection of the c( h ) oh group of desosamine by the acetyl group giving h -oac-clarithromycin ( ), the transformation of the latter into activated h -oac-clarithromycin hh -o- h-imidazole- -carboxylate ( ) by the treatment with carbonyldiimidazole (cdi), the amidation of with amines ha or hb in the presence of the peptide coupling reagent , -diazobicyclo [ . . ]undec- -ene (dbu) giving h -oac-substituted carbamoyl derivatives of clarithromycin a,b, and the deacetylation of a,b by heating in methanol to form target unprotected carbamoyl derivatives of clarithromycin a,b. compounds b,c and a,b exhibit the inhibitory effect against staphylococci and streptococci comparable with the activity of starting compound . in these assays, derivatives at the c( hh )-cladinose position were found to be more effective than the derivatives at the c( ) position of the aglycone of antibiotics b and c. compound b is the most effective against the strains staphylococcus epidermidis atcc and streptococcus pneumoniae atcc . clarithromycin analogues c and b possess an opposite activity against gram-negative bacteria, such as sensitive strains of e. coli and resistant strains of e. coli (tolc and tolc puc erm ). thus, compound c is more active than b. in the former case, e. coli tolc and tolc puc erm are bacterial strains containing the outer membrane protein tolc, which is responsible for antibiotic efflux from the cell. in the latter cases, the strain contains, apart from tolc, the puc plasmid cloning vector and methylase erm . attempts were made to extend the method developed for the synthesis of c( hh )-substituted clarithromycin ± benzoxaborole conjugates to the synthesis of related azithromycin conjugates (scheme ). it appeared that the success of introducing the aminobenzoxaborole moiety into a macrolide antibiotic depends on the structure of antibiotics and , as well as on the structure of aminobenzoxaborole. the acetylation of azithromycin ( ) giving the h -oac derivative ( ) followed by the treatment of the latter with n,n h -carbonyldiimidazole in the presence of et n produces the desired activated imidazole derivative Ð azithromycin h -oac- hh -o- h-imidazole- -carboxylate ( ) (see scheme ) . however, unlike the synthesis of clarithromycin analogue a, the amidation of compound with -(hydroxy- , -dihydrobenzo[c] [ , ] oxaborole)methylamine in the presence of dbu does not give the desired outcome. the introduction of the latter amine was accomplished using the trisubstituted derivative, the , -cyclic carbonate azithromycin h -oac- hh -o- h-imidazole- -carboxylate as the substrate. compound the same conditions as those used for was not successful (see scheme ) . meanwhile, this reaction with another amine containing an aminoethyl spacer gives the corresponding azithromycin carbamoyl derivative (see scheme ) . however, the elimination of the h -oac group finally results in the decomposition of the deacetyl derivative during its purification on silica gel. an alternative procedure for the introduction of benzoxaboroles into molecule using carboxy derivatives and diaminoalkane spacers (scheme ) proved to be more successful. the treatment of imidazole derivative with stronger bases, such as diaminoethane or , -diaminopropane, in the presence of dbu resulted in the formation of aminoalkylcarbamoyl derivatives (n = ) and (n = ). the subsequent acylation of the latter with various benzoxaborole acids under standard conditions (dcc, hobt) gives a series of acylaminoalkylbenzoxaborole-containing carbamoyl derivatives of , -cyclic carbonate, h -oacazithromycin a ± a (see scheme ) . the deacetylation of these compounds affords the corresponding cyclic carbo-nates b ± b containing the free c( h ) oh group of the desosamine moiety (r = h) in quantitative yields. compound b and its h -oac analogue a were synthesized from azithromycin h -oac- hh -o- h-imidazole- -carboxylate through intermediate h -oac analogues (n = , ) (scheme ). therefore, the synthesis of compound a and its h -oac analogue b showed that the introduction of the acylaminoalkylbenzoxaborole moiety can be accomplished using a scheme described above without protection of the c( ) oh and c( ) oh groups by cyclic carbonate. the evaluation of antibacterial activity of hh -o-substituted derivatives , a ± a (n = ), b ± b (n = , ) and b (n = , ) compared with that of compound showed that the activity of compounds , ± and against gram-negative bacteria ( isolates) is lower than that against gram-positive bacteria ( isolates). for example, the activity of compounds , a (n = ), a (n = ) and b (n = ) against the gram-positive strains streptococcus pyogenes atcc and propionibacterium acnes atcc is comparable with that of the starting com- pound , while conjugates b (n = ), a (n = ), b (n = ) and b (n = ) are more effective than compound against the strains streptococcus pneumoniae atcc or enterococcus faecium. the presence of the h -oac group or , -cyclic carbonate in analogous hybrid antibiotics was found to have almost no effect on antibacterial activity. for compounds a (n = , ), a (n = , ), a (n = ), b ± b (n = ) and b (n = , ), the mechanism of antibacterial activity was studied using the prfpcer-trpl a reporter construct, which responds to inhibitors of translocation of the ribosome along the matrix nucleic acid (mrna). all compounds were found to inhibit the peptide chain growth at the exit from the ribosome tunnel like typical macrolide antibiotics. it is worth noting that one of the starting benzoxaborole acids, -( -hydroxy- , -dihydrobenzo[c] [ , ] oxaborol- -yl)propanoic acid (see schemes and , marked with an asterisk), also exhibited activity in this assay. . . azithromycin ± benzoxaborole conjugates at the -oh group of the aglycone , -cyclic carbonate can be used not only as the protecting group for two hydroxyl groups but also as the activated group to introduce benzoxaborole substituents at the position of antibiotics. the reaction of , -cyclic carbonate azithromycin h -oac derivative , which was generated from azithromycin ( ) in two steps (treatment with ethylene carbonate followed by acylation of the h -o group of the desosamine moiety), with diaminoalkane gave h -oacetylazithromycin -aminoalkylcarbamates (n = , ) (scheme ). the acylation of compound with benzoxaborole acids under standard conditions (dcc, hobt) produced a series of azithromycin h -oac derivatives a ± a. the deacetylation of these compounds afforded target benzoxaborole derivatives b ± b. new hybrid antibiotics b ± b exhibit broader-spectrum antibacterial activity against gram-positive and gram-negative bacteria compared to azithromycin ( ) and tobramycin. compound b proved to be the most effective compound in this series, but its activity is lower than that of compound . the modified antibiotics do not overcome the antibiotic resistance in mrsa strains (strain atcc ). higher activity of these three compounds against the sensitive strain s. pneumonia atcc compared to tobramycin (mic is . ± . versus mg ml ) is a particularly valuable property. , or , or , dcc, hobt; dcc is n,n h -dicyclohexyl carbodiimide, hobt is -hydroxybenzotriazole; in the former case, the reaction of azithromycin -aminoalkylcarbamates (n = , ) with antibiotics , or in the presence of pybop affords the corresponding derivatives of vancomycin ( , ) , eremomycin ( ) or the teicoplanin aglycone ( , ) (scheme ). in the latter case, , -cyclic carbonate azithromycin hh -o-alkylaminocarbamoyl derivatives and are amidated with antibiotics , or in the presence of pybop (scheme ). after the removal of the h -o-acetyl protecting group from compounds a ± a and the column chromatographic separation on silanized silica gel followed by sephadex lh- chromatography, five new conjugates b ± b were isolated in % ± % yields based on the corresponding starting antibiotic. antibacterial activity of derivatives ± modified at the c( ) oh group of the aglycone was evaluated compared to the starting antibiotics vancomycin ( ) and azithromycin ( ) on a panel of gram-positive and gramnegative bacterial strains ( and strains, respectively). none of the conjugates exhibited activity against gramnegative bacteria, which attests to the absence of the effect of the azithromycin moiety active against gram-negative bacteria. generally, compounds ± display similar or somewhat lower activity against gram-positive bacterial strains compared to compounds and(or) , the activity against staphylococci being higher than that against the streptococci s. pneumoniae atcc and s. agalactis - . azithromycin ± teicoplanin aglycone conjugate containing a long spacer (n = ) exhibits higher activity against all tested gram-positive bacterial strains (staphylococci and derivatives at the hh -cladinose position show a similar tendency. thus, they are inactive against gram-negative bacteria. the fact that the hybrid structures are ineffective against e. coli atcc and other gram-negative bacterial strains indicates that they cannot penetrate the outer phospholipid layer of the bacterial cell. in all the tested gram-positive bacterial strains, compounds ± exhibited activity comparable to or higher than that of azithromycin ( ) and vancomycin ( ) . their activity is provided by the presence of the glycopeptide moiety. unlike hybrid vancomycin analogue b, hybrid eremomycin analogue b displays significant activity against the vancomycin-resistant enterococci (vre) strains enterococcus faecium and enterococcus faecalis (mic = . and . mmol l ), which can be attributed to the effect of the azithromycin moiety attached to the c-terminal group of the peptide core of antibiotic . , the mechanism of action against gram-positive bacteria was confirmed by quantum chemical calculations of the energy of interaction dg in relation to hybrid antibiotics b and b with the model d-ala-d-ala ligand typical of glycopeptides. these studies resulted in the development of methods for the synthesis of macrolide-based hybrid antibiotics containing benzoxaborole as a new pharmacophore. , , the behaviour of the macrolide antibiotic aglycone in chemical reactions was found to be affected by its structure, in particular it depends on the presence of an additional methylamino group in azithromycin ( ) . , the position of the benzoxaborole substituent was shown to influence the antibacterial activity of antibiotics and . it was established that the c( )-substituted analogues are less effective inhibitors of gram-positive and gram-negative bacteria compared to hh -substituted analogues. , the presence of , -cyclic carbonate or the h -o-acetyl group in the azithromycin molecule was shown to have no significant effect on the antibacterial activity of the conjugates, while an increase in the spacer length generally leads to an increase in activity of the final compounds. a method was developed for the synthesis of a series of chimeric antibiotics based on glycopeptides and azithromycin ( ) . the activity of almost all the synthesized compounds against the tested gram-positive bacterial strains, including vancomycin-resistant strains, is similar to or higher than that of the starting antibiotic. the range of antibacterial activity of the resulting hybrid derivatives and quantum chemical calculations suggest that the antibacterial activity is determined by the presence of the glycopep- carbohydrate-containing polyene macrolides are commonly used in medicine for the treatment of both superficial and systemic mycoses due to their high activity and a broad spectrum of action. , the mechanism of action of polyene macrolides is related to their ability to interact with sterol-containing cytoplasmic membranes and form pores (channels) in these membaranes, by which ions leave the cell causing its death. the efficacy of polyenes against fungal pathogens is due to their stronger binding to fungal membrane ergosterols compared to cholesterol present in human and animal cell membranes. nystatin ( a), partricin and pimaricin are administered locally, whereas amphotericin b (amb, a) is the only polyene that is applied for the treatment of systemic mycoses. unfortunately, polyenes are rather toxic agents because of their low selectivity for fungal versus mammalian cell. poor solubility of polyenes in water, their high hematotoxicity and nephrotoxicity and a number of other adverse effects have stimulated an extensive search for new, less toxic and more effective agents. previously, it was shown that toxicity of compound a and other polyenes can be reduced by chemical modification, which leads to a decrease in side effects. , the toxic effect of compound a on blood cells (haemolysis) is particularly dangerous. in order to improve antifungal properties, cytotoxic and therapeutic characteristics and to study the mechanisms of action, series of new semi-synthetic derivatives based on amb ( a) and bioengineered analogues s hp ( a), bsg ( a), bsg ( a), bsg ( ), bsg ( a) and bsg ( ) were synthesized (in collaboration with the company biosergen, norway) (scheme ). ± the structural diversity of the above-mentioned polyenes a ± a, , a and was provided by using methods of genetic engineering to alter genes encoding the nystatin-producing strain streptomyces noursei. new analogues compare favourably with nystatin ( a), primarily due to the presence of a double bond (instead of a single one) at c( ) ± c( ) characteristic of a and other polyenes ± . the heptaene group of the aglycone imparts rigidity to the antibiotic structure and improves antifungal activity. new monosubstituted polyene macrolides at the terminal -co h group of the aglycone were synthesized based on compounds a and a; monosubstituted polyene macrolides at the mycosamine h -amino group were prepared based on a, a and a. , the synthesis of doubly modified analogues of antibiotics a and a was reported. the related amido derivatives ( b ± h) substituted in a similar way at the c( )-carboxamide group of s hp were prepared. ± the yields of c( )-amido derivatives were * % ± % depending on the structure of the starting amine and the antibiotic. the antibiotic structure was found to have almost no effect on antifungal activity against the fungal strains candida albicans (atcc ), cryptococcus humicolus (atcc ), aspergillus niger (atcc ) and fusarium oxysporum (vkm f- ). the activity in each pair of the derivatives containing the same substituents is almost the same in magnitude. carboxamides b,d,g and b,e,i were found to be the most effective against the above-mentioned strains (mic & . ± mg ml ). the major directions of chemical modification of s hp ( a) and bsg ( a) at the mycosamine h -amino group in alkylation and aminoacylation reactions, the aminocontaining reagents are protected by the -fluorenylmethoxycarbonyl (fmoc) group. conventional h -n-alkyl derivatives of polyenes, such as the h -n-( -dimethylaminobenzyl)-substituted compounds s hp ( l) and bsg ( c) and the n,n-di(aminopropyl)-substituted compounds s hp ( m) and bsg ( d), were synthesized by reductive alkylation of compounds a and a with appropriate aldehydes in the presence of nacnbh (see scheme , conditions b and c). the yields of compounds m and d with respect to the starting antibiotics are * % ± %. h -n-acyl derivatives n and e were synthesized by the reaction of antibiotics a and a with n a ,n e -(fmoc) -l-lysine in the presence of pybop in * % ± % yields (see scheme , conditions d ). the removal of the fmoc group from intermediate derivatives o,p and f,g with a % piperidine solution in dmso affords the corresponding h -n-aminoacyl derivatives m,n and d,e in * % ± % yields. the evaluation of the influence of substituents in the terminal group at the c( ) atom of the aglycone and the mycosamine amino group on the antifungal activity of polyenes showed that the replacement of the co h group by me has no significant effect on antifungal activity against the tested strains. the activity of s hp ( a) and its analogue k is similar to that of bsg ( c) and its analogue b. thus, the effect of the same modifications on the activity of the initial antibiotics s hp and bsg with very close values of antifungal activity can be multidirectional. the mic values are changed in the following series: a = a, k = b, l > c, m > d, n < e. ( ) . the removal of the fmoc protecting group from compound a gave h -n-(l-lysyl)-s hp n-( -dimethylaminopropyl)amide ( b). an alternative scheme involves the initial synthesis of fmoc-protected h -n-aminoacyl derivatives of s hp followed by their transformation into the corresponding c( )-carboxamides (scheme ). the reaction of compound a with n-fmoc- -aminomethylbenzoic acid in the presence of pybop affords h -n-(n-fmoc- -aminomethylbenzoyl)-s hp ( ) . the amidation of the latter with appropriate amines in the presence of pybop gives h -n-(n-fmoc- -aminomethylbenzoyl)-s hp dmae-amide ( a) and -hydroxypropylamide ( a). known compound p, which was prepared by the reaction of a with n a ,n e -(fmoc) -l-lys in the presence of dcc and hobt, was used to synthesize n-( -dimethylaminoethyl)amide ( a) and -hydroxypropylamide ( a) of n a ,n e -(fmoc) -l-lysyl-s hp. the removal of the fmoc group from compounds a ± a under mild conditions gave target products b ± b containing free amino groups (see scheme ) . the evaluation of antifungal activity of doubly modified s hp derivatives ± against the above-mentioned four fungal strains compared to the corresponding monomodified s hp c( )-carboxamides b,c demonstrated that the additional modification of the mycosamine h -amino group of carboxamide b has no significant effect on antifungal activity against these fungal and yeast strains (mic * . ± mg ml ). meanwhile, the corresponding modifications of s hp -hydroxypropylamide lead to a considerable decrease in antifungal activity. in the series of doubly modified derivatives, s hp -n,n-dimethylethylamides ( and , respectively), prepared via the amadori rearrangement with d-glucose or d-galactose, exhibit the highest activity, similar to that of the starting antibiotics a and a. experiments in animals play a significant role in the selection of lead antifungal agents. since only rather toxic amb ( a) is used for the treatment of systemic fungal infections, compounds exhibiting the highest in vitro activity are currently tested for the haemolysis and(or) acute toxicity. new genetically engineered polyene macrolides a, a, a and a, the semi-synthetic derivatives dmae-s hp ( b), h -n-lys-bsg ( e) and doubly modified h -n-( deoxy-d-fructos- -yl)-s hp dmae ( ) were evaluated for antifungal activity in the treatment of candida albicansinduced sepsis in mice and tested for toxicity. , the largest margin between the therapeutic and toxic doses was observed for compounds b and . compounds, the effective dose was % and % of the maximum tolerated dose (mtd), respectively, whereas amb ( a) is effective only at a dose of % of mtd. the antifungal activity of c( )-methyl-c( )-decarboxypolyenes against four fungal strains changes in the following order: bsg [c( ), c( )] ( a) > bsg [c( )] ( ) > bsg [c( ), c( )] ( ) . this confirms the pattern of changes in the activity against c. albicans observed previously in the series of c( )-carboxy-containing antibiotics with a similar arrangement of hydroxyl groups at c( ) c( ): s hp ( a) > bsg ( ) [c( )] > bsg ( a) [c( ), c( )]. the following amides were synthesized from polyenes a, a and a and -(n,n-dimethylamino)ethylamine according to the conventional amidation method in the presence of pybop: dmae-s hp ( b), dmae-bsg ( b) and dmae-bsg ( b) (see scheme ) . , the activity of these compounds, like that of the starting antibiotics, changes in a similar series: dmae-s hp ( b) > dmae-bsg ( b) > dmpe-bsg ( b). it is worth noting that low antifungal activity of compounds b and b was confirmed also by animal experiments related to the treatment of murine candida sepsis. these studies clearly demonstrated that the c( ) c( ) group of the polyol moiety plays a critical role in antifungal activity, although this group has not previously been considered of importance in the model of antibiotic binding to the target. compounds containing a single hydroxyl group at the position of c( ) c( ) ( a and ) exhibit low activity against the tested fungal strains. polyenes containing two hydroxyl groups at the and positions ( a and ) are inactive. antibiotics and semi-synthetic derivatives containing hydroxyl groups at the and positions (amb, a,b) and at the c( ) and c( ) atoms [s hp ( a,b) and bsg ( a,b)] displayed the best results. the design of hybrid analogues of antibiotics containing pharmacophore moieties, which affect targets different from those used by the starting antibiotics, is a promising line of research. , some benzoxaborole-containing compounds exhibit pronounced antifungal activity. methods were developed for the synthesis of dual-action antibiotics based on amb ( a) and different types of benzoxaboroles. the following five types of conjugates were synthesized depending on the nature of the functional group in benzoxaborole, which can be used to attach the latter to the amb molecule: c ( ) h -n-sulfo derivative and h -n-mono-and h -n,n-dialkyl derivatives a and (scheme ). amide was produced by the standard procedure that was applied to prepare the above-described amides; however, the yield of was low ( %). apparently, the amidation interferes with the formation of the aminoborole complex with amb. as mentioned above, the yields of amb carboxamides in this reaction using other amines are higher than %. h -n-derivatives a ± a were prepared from amb ( a) using in situ generated osu-activated esters. h -n-sulfo derivative was synthesized by the reaction of a with the appropriate sulfochloride in the presence of pyridine (py); h -n-alkyl analogues a and were prepared by the reaction of a with the appropriate aldehyde in the presence of nabh cn. the amidation of derivatives a and a with n,n-dimethylethylenediamine in the presence of pybop gave b and b, respectively (scheme ). an attempt to synthesize disubstituted h -n-alkyl-dmae analogue b according to a similar scheme from h -n-alkylamino derivative a failed (see scheme ) . nevertheless, compound b was prepared using an alternative approach by the alkylation of c( )-amide derivative b with -hydroxy- , -dihydrobenzo[c] [ , ] oxaborole- -carbaldehyde in the presence of nabh cn (see scheme ). tandem mass spectrometry (esi-ms/ms-mrm) studies showed that different fragmentation patterns are possible depending on the modification of the starting polyene (scheme ). in many cases, the introduction of the benzoxaborole substituent leads to a decrease in cytotoxicity and haemolytic activity with retention of high antifungal activity. these facts were confirmed by membrane activity assays. the results are given in table . semi-synthetic amb derivatives b,d,e, a,b, a, b and a,b were shown to have a significant pore-forming ability in artificially formed sterol-containing membranes. compounds with high antifungal activity and low haemolysis have higher selectivity for ergosterol-containing fungal membranes (c chol /c erg ) versus cholesterol-containing human cell membranes compared to compound a. for example, the high selectivity ( . ae . ) of compound b correlates with low haemolysis of human erythrocytes ( %). on the contrary, high haemolysis ( %) is determined by low or even reverse selectivity (c chol /c erg = . ae . ). for amb ( a) and its derivative b, the corresponding parameters have intermediate values (c chol /c erg = . ± . , haemolysis % ± %). amphotericin b ( a) was selectively modified at the mycosamine h -amino group or the c( ) carboxyl group. the developed approaches were extended to the related polyenes s hp ( a), bsg ( ) and other genetically engineered polyenes, which differ from the starting amb by the substituent at the c( ) atom and the positions of hydroxyl groups at c( ) ± c( ) of the aglycone moiety. the structure ± activity relationship analysis of new semisynthetic derivatives of polyene macrocycles revealed several general features of antifungal activity. in particular, antibiotics and, consequently, their semi-synthetic analogues containing two hydroxyl groups in this region at the and positions (amb, a) or the and positions (s hp and bsg ) exhibit high activity. a series of new semi-synthetic derivatives were shown to have pore-forming ability in artificially formed sterol-containing membranes. it is worth noting that they have selective activity against ergosterol-containing fungal membranes and lower haemolysis compared to amphotericin b. the aim of chemical modifications of the antibiotic oligomycin a ( a) (fig. ) acting as the f f -atp synthase inhibitor is to prepare new analogues possessing selective antitumour or anti-infective activity and to elucidate the mechanisms of sensitivity of microorganisms to this agent. oligomycin a ( a) (hereinafter oligomycin) belongs to macrolides Ð -membered a,b-unsubstituted macrolactones. it is a highly specific inhibitor of oxidative phosphorylation in the mitochondria of eukaryotes. oligomycin inhibits adenosine triphosphate (atp) synthesis and causes cell death. note. cerg is the minimum concentration of the compound that causes the pore formation in the dphpc/erg bilayer; cchol/cerg is the ratio of the minimum concentrations of the polyene in the dphpc/chol and dphpc/erg bilayers (dphpc is , -diphytanoyl-sn-glycero- -phosphocholine, chol is cholesterol, erg is ergosterol). the oligomycin molecule ( a) was found to contain a functional group, the chemical modification of which can produce the largest number of semi-synthetic analogues with various biological activities. the docking study of the interaction between the antibiotic and the target of the enzyme f f -atp synthase showed that the c( ) c ( ) side chain is not directly involved in the formation of this complex. a series of -substituted oligomycin derivatives were synthesized using -deoxy-o-mesyl oligomycin ( ) as the key compound, which was prepared by the selective treatment of a with methanesulfonyl chloride in a dmap ± py mixture (scheme ). the nucleophilic substitution of the group r via the s n or s n mechanism using various reagents gave the following -substituted derivatives: -(s)-oligomycin a ( b), -deoxy- -(s)-thiocyanooligomycin ( ), -deoxy- -(r,s)-bromooligomycin ( ) and -deoxy- -(s)-azidooligomycin ( ) (see scheme ) . the racemization is observed only for bromo derivative . the -epimer of this antibiotic, -(s)-oligomycin a ( b), was synthesized by the solvolysis of -(r)-deoxy-omesyl oligomycin ( ) with an aqueous mixture of tiourea and methyl cellosolve on heating. the reaction involves the walden inversion of configuration at the c( ) atom through a plausible mechanism presented in scheme . the biological activity assay of compound b revealed that the inversion of the hydroxyl group decreases activity against the actinobacteria streptomyces fradiae, while the antifungal activity remains at the same level. -(s)-oligomycin a ( b) exhibits somewhat higher activity against tumour cells compared to the starting analogue a. both antibiotics are able to overcome different drug resistance phenotypes and have low toxicity to non-malignant cells. the treatment of oligomycin with % formic acid afforded c( )-o-formyloligomycin ( ) (see scheme ) . formylated derivative retains the ability to inhibit tumour cell growth, whereas the activity against most other test cultures, including non-malignant cells, decreases. due to selectivity against tumour cells, c( )-o-formyloligomycin ( ) holds promise for further investigation. -deoxy-o-mesyl oligomycin ( ) can be quantitatively converted into -dehydrooligomycin ( ) by the kornblum oxidation in a dmso ± et n mixture at c (see scheme ) . attempts to oxidize the oh group at the c( ) atom of oligomycin ( a) to the keto group using different oxidizing agents failed. the cited study is interesting because this structure was previously presented as a new natural compound. however, the structure of this compound was not described in detail and its biological activity was not evaluated. derivative exhibits twice lower activity against s. fradiae atcc- compared to com- pound a; its activity against candida spp. and other filamentous fungi is very similar to that of compound a. docking studies of the binding of derivative to f f -atp synthase also showed that the affinity for the enzyme decreases compared to the starting antibiotic a. a method for the synthesis of , -disubstituted , , triazoles of oligomycin was developed based on -azido- -deoxyoligomycin . the method involves the regioselective [ + ]-dipolar cycloaddition of the -azido group to monosubstituted alkynes (scheme ). the reaction of azide with alkynes (phenylacetylene, propiolic acid and methyl propiolate) in a tert-butanol ± water mixture ( : ) can be performed both in the presence of a catalyst (cu i ) or without catalysts. this approach was applied to synthesize -deoxy- -( -phenyltriazol- -yl)oligomycin ( ), -deoxy- -( -methoxycarbonyltriazol- -yl)oligomycin ( ) and -deoxy- -( -carboxytriazol- -yl)oligomycin ( ) in %, % and % yields, respectively. compound served as the starting compound for the synthesis of water-soluble -deoxy- -[( -dmae-carbonyl)triazol- yl]oligomycin amide ( ) exhibiting selective antitumour activity. oligomycin a undergoes a retro-aldol rearrangement accompanied by dehydration in the presence of bases (scheme ). the structure of alkaline degradation product a was established by the detailed h and c nmr study, including heteronuclear correlation, combined with tandem mass spectrometry (esi-ms/ms-mrm). the structure of the carbon skeleton of the starting antibiotic a undergoes a significant transformation at c( ) c( ) (the cleavage pathways a, b and c) giving open-ring compound a. the mechanism of alkaline degradation of oligomycin a presented in scheme accounts for the formation of derivative a (through intermediates c,d) but not for the formation of b (through intermediates e,f). as opposed to compound a, compound a does not exhibit activity against proteasomal f f -atp synthase at a concentration of mmol l because of the loss of conformational rigidity. the hydrogenation of oligomycin ( a) on a palladium catalyst occurs both at the , -unsaturated bond of lactone and the diene system at c ( ) the hydrogenation of compound a under other conditions leads to the sequential selective reduction of keto groups Ð first at the c( ) atom and then at the c( ) atom. thus, the use of nabh(oac) latter with nabh in ethanol afforded ( s, r)-tetrahydrooligomycin ( ) (see scheme ) . the hydrogenation of double bonds of the macrolactone ring causes a decrease in the activity of compound a both against actinobacteria and fungal and mammalian cells. this may be attributed to the loss of conformational rigidity and the fact that the geometry of the macrocycle favourable for the interaction with the target (f f -atp synthase) is changed because of destruction of the diene system of the starting antibiotic a. the retention of activity of the starting compound against some strains of candida spp. supports the previous suggestion that there are additional targets in yeast cells of this genus, the binding to which is apparently independent of the geometry of the macrocycle. the reaction of compound a with m-chloroperoxybenzoic acid (m-cpba) in dichloromethane on decreasing the reaction temperature to c allows the selective epoxidation of oligomycin at one of c = c bonds to form unstable intermediate epoxide (scheme ). in the presence of formic acid, the latter compound gives a stable disubstituted oligomycin derivative Ð , -dihydro- s, s-dihydroxy- , -diformyloligomycin ( ). previously, -bromo derivative of this antibiotic was synthesized using n-bromosuccinimide as the brominating agent (see scheme ). the addition of hydroxylamine and related compounds to a was studied. the comprehensive study of the resulting compound by h and c nmr spectroscopy, including heteronuclear correlation, made it possible to establish the structure of nitrone a and exclude the possible existence of isomer b. it was found that an additional ring involving the c( ) ± c( ) atoms is formed, the activity of the antibiotic against f f -atp synthase being reduced. the reaction of antibiotic a with aminopyridinium and -dimethylaminopyridinium iodides in pyridine affords cyclic derivatives of pyrazolo [ , -a] pyridine and -methylpyrazolo[ , -a]pyridine a,b, respectively, annulated to the macrocycle (see scheme ) . their structures were established by h and c nmr spectroscopy, including heteronuclear correlation, and structure c was excluded. biological assays of new derivatives of oligomycin ( a) demonstrated that, in most cases, modifications reduce biological activity of the starting antibiotic against s. fradiae. , ± the growth inhibition assay of the strain s. fradiae atcc sensitive to very low concentrations of oligomycin (< . nmol ml or . nmol per disc surface) and hypersensitive to most of the known antibiotics was used to study the mechanism of resistance of microorganisms. mutant strains of this microorganism sensitive to analogues of compounds (ref. ) and a, as opposed to the starting antibiotic a and other derivatives, were produced under experimental conditions. the results of assays demonstrated that antibiotic a has several biotargets. these data confirm the conclusion that both the diene system of the macrocycle and its hydroxypropyl side chain play an important role in biological activity. therefore, the chemical modification of the antibiotic oligomycin ( a), a highly active f f -atp synthase inhibitor, was performed for the first time. more than new semi-synthetic oligomycin derivatives were prepared and the mechanism of their action was studied. analogues with selective antitumour or anti-infective activity were synthesized. the chemical modification of antibiotic a, which enables the efficient modulation of its biological activity due to a decrease in the binding to f f -atp synthase, was found. this provides the possibility to optimize pharmacological properties. olivomycin a ( ) (hereinafter olivomycin) is a highly effective antibiotic with a unique mechanism of antitumour activity discovered in the gause institute of new antibiotics , , (fig. ) . its structure consists of the aglycone olivin and two carbohydrate chains attached to the aglycone at the and positions. the antibiotic is a dna duplex minor groove ligand, which binds to the guanine-cytosine (gc)-rich region. compared to other antibiotics of the aureolic acid group (mithramycin and chromomycin a), olivomycin has better therapeutic efficacy. in recent years, antibiotics of this group have attracted increasing interest. , antibiotics of this group were shown to be able to prevent the development of resistance of tumour cells to other antitumour agents, in particular via a mechanism involving the inhibition of transcription of the mdr gene, overexpression of which is responsible for multidrug resistance of tumour cells. mithramycin is used to treat paget's disease and testicular carcinoma. chromomycin is a drug of limited use in japan for the treatment of gastrointestinal cancer. olivomycin ( ) was applied in the ussr for the treatment of ovarian cancer, reticulosarcoma and some other tumours. however, serious adverse effects limit the therapeutic potential of these drugs. various aspects of antitumour activity of antibiotics of the aureolic acid group were addressed in detail; however, chemical modifications of this class of antibiotics are poorly known. selective modifications of olivomycin ( ) at the c( ) atom (a), the c( ) oh (b) and c( h ) = o groups (c), the c( h ) c( h ) bond (d ) and the residues a and e (e) (see fig. ) were developed in the gause institute of new antibiotics. the selective acylation of compound at the phenolic hydroxyl group at the c( ) atom with a ac o py mixture affords -o-acetylolivomycin ( ) (scheme ). an investigation of the reaction of olivomycin ( ) with aryldiazonium salts showed that the azo coupling gives aryldiazenes monosubstituted at the position of the aglycone accompanied by the elimination of the disaccharide branch at the c( ) atom: -(phenyldiazenyl)olivomycin ( ), -( -sulfamidophenyldiazenyl)olivomycin ( ), -( methoxyphenyldiazenyl)olivomycin ( ), -( , -dichlorophenyldiazenyl)olivomycin ( ) and -( -methylphenyldiazenyl)olivomycin ( ) (see scheme ) . to explain the outcome of this reaction, the frontier electron density in the highest occupied molecular orbital (homo) was calculated by the semiempirical quantum chemical am method (fukui indices f). alternative directions of the nucleophilic attack by the phenyldiazonium cation were chosen by considering possible anionic forms of olivomycin ( a ± c) (scheme a). it was found that the position in anion a is the most favourable for electrophilic attack giving compound (the fukui index f homo is . ). meanwhile, the nucleophilicities of the c( ) and c( ) atoms are lower ( . and . , respectively). the formation of anion a in an alkaline medium is confirmed by the above-mentioned selective acylation of compound giving acetate at the same hydroxyl group at the c( ) atom in high yield (see scheme ) . the calculated energy parameters of alkaline hydrolysis of the disaccharide branch are in agreement with the experimental data. thus, the hydrolysis proceeds very rapidly in the presence of the diazenyl substituent at the position, while the storage of in an alkaline medium (used for the azo coupling) on cooling to ± c for h in the absence of diazonium salt does not lead to hydrolysis. the azo coupling of aryldiazonium salts with the aglycone of olivomycin Ð olivin ( ), which was synthesized by quantitative acid hydrolysis of compound , was investigated. aryldiazenyl derivatives of olivin a ± c containing the same substituents as compounds , and (scheme ) were synthesized. the geometric configurations of the most probable tautomeric structures a ± d of derivative a were determined (scheme ) and the total energies of each tautomeric form were calculated by the density functional theory at the b lyp/ - g(d) level of theory. the h nmr spectroscopic data also indicate that compounds a ± c exist as equilibrium mixtures of isomeric forms a ± d. the reaction of olivomycin ( ) with (o-carboxymethyl)hydroxylamine affords h -(carboxymethoxime)olivomycin (cm) (scheme ). the introduction of the carboxyl group into molecule makes it possible to subject this compound to further modification. the reaction of compound with appro- the introduction of the carboxyl group into molecule , as in the case of long acid , provides a route to its further modification. the reaction of short osa with appropriate amines in the presence of pybop or diphenylphosphoryl azide (dppa) affords osa n-methylamide it is worth noting that the method developed for the synthesis of intermediate osa ( ) can be applied to prepare the related derivative of mithramycin bearing a similar side chain at the c( ) atom of the aglycone. hence, short' mithramycin acid becomes more available compared to the combinatorial biosynthesis and can be used for further chemical modification of mithramycin. olivomycin a ( ) has two carbohydrate chains bearing the acetyl group at the a position of the oliose moiety and the isobutyryl group at the e position of the olivomycose moiety. a series of analogues of compound , which differ in the set of functional groups, were synthesized in order to elucidate the influence of acyl substituents in carbohydrate chains on biological activity. two analogues, de-e -isobutyrylolivomycin a ( ) and de-e -isobutyryl-de-a -acetylolivomycin a (or de-e isobutyrylolivomycin c) ( ), were synthesized by selective alkaline hydrolysis of the e -isobutyryl group of olivomycin a ( ) or c ( ), respectively (scheme ). it is worth noting that the hydrolysis of the e -isobutyryl group in olivomycin ( ) antibiotics (de-e -isobutyrylolivomycin a) and (de-e -isobutyryl-e -acetyl-olivomycin a or olivomycin b) were isolated from the natural olivomycin complex produced by fermentation of the streptoverticillum cinnamoneum strain. after the purification by silica gel column chromatography and semipreparative hplc, compounds and were isolated in % and % yields, respectively. , these compounds are identical to the previously characterized natural olivomycins c and b, respectively. the modification of antibiotic at the c( ) phenol group of the aromatic ring (compound ) was found to have no effect on antiproliferative activity against cancer cell lines and does not alter its ability to inhibit topoisomerase i. the transformation of giving diazenyl derivatives accompanied by elimination of the disaccharide branch from the aglycone (compounds ± ) leads to a sharp decrease in antiproliferative activity. compared to the starting olivomycin , compounds , and acquire considerable selective activity against human immunodeficiency viruses hiv- and hiv- in assays in the human t-lymphocyte cell line (cem). the evaluation of antiproliferative activity of olivomycin ( ) and its analogues modified at the side-chain h -keto group of the aglycone (cm amides ± and ) against the leukaemia cell lines k and l showed that these compounds are more effective than the starting acid but are less active than compound . for derivatives of antibiotic with a shorter aglycone side chain (osa, ) and its amides ± , the evaluation of antiproliferative activity in the human chronic myeloid leukaemia cell line k and the human colon the evaluation of antiproliferative activity of olivomycin analogues ± against hct cells showed that acyl groups in carbohydrate chains of antibiotic play a significant role. the activity decreases with elimination of acyl groups from molecule ; ic is . (for ), . (for ), . (for ) and > mmol l (for compounds , and ). these results correlate with the data on the ability of these compounds to inhibit dna-dependent topoisomerase i. in the absence of antibiotics, the relaxation of supercoiled (sc) dna leads to the disappearance of inhibitory activity and the formation of a set of topoisomers. the inhibition of topoisomerase i is detected from the presence of residual amounts of sc-dna and a decrease in the amount of rapidly migrating topoisomers. a decrease in the inhibitory activity of the enzyme is consistent with a decrease in the antiproliferative activity in the series of compounds > > . the removal of the e -isobutyryl group from the trisaccharide branch has a lower effect than the removal of the a -acetyl group from the disaccharide branch. a similar pattern of activity is observed in another group of olivomycin derivatives. compound displays low antiproliferative activity and is inactive against topoisomerase i. h -(carboxymethoxime)olivomycin n-( -adamantyl)amide ( ) is active in both assays. h -(carboxymethoxime)olivomycin n-(tert-butyl)amide ( ) and h -(carboxymethoxime)olivomycin n-( , -dihydroxy- -methylpropan- -yl)amide ( ) are even more effective inhibitors of the enzyme, capable of inhibiting sc-dna relaxation even at concentrations of . mmol l . the data on antiproliferative activity of some analogues of antibiotic do not correlate with the activity against topoisomerase i. for example, the analogue of olivomycin osa ( ), which exhibits weak antiproliferative activity, displays inhibitory activity against topoisomerase i similar to that of olivomycin a ( ), whereas dmae-osa ( ) possessing high antiproliferative activity is a weaker inhibitor of this enzyme. , recently, it was shown that highly effective analogue can act as a dna duplex minor groove ligand in another assay. it can disrupt the key epigenetic dna methylation process with the dnmt a enzyme on an equal basis with antibiotic . both compounds inhibit the formation of the dna ± enzyme intermediate covalent bond, required for the methylation, at nearly equal micromolar concentrations. olivomycin complexes with model oligonucleotide ± dna duplexes were studied by circular dichroism (cd) and fluorescence titration (ft). according to hartree ± fock - g calculations of the d structure of the dimer [ ] mg + , the presence of the dmae group in compound leads to an increase in the binding constant (k a ) of the mg + complex with the dna duplex by an order of magnitude compared to the acid osa ( ) (k a = . versus . mol l , as evaluated by ft). however, the presence of the bulky adamantyl substituent in compound results in a decrease in the binding constant of the dimer [ ] mg + with the dna duplex by an order of magnitude (k a = . mol l ). the elimination of one acyl substituent also leads to a decrease in the antiproliferative activity compared to that of antibiotic due probably to a decrease in its affinity for dna. the molecular docking of complex of with dna shows that the antibiotic can bind only to gc-rich regions in the minor groove of the dna duplex. carbohydrate chains of olivomycin interact with the sugar ± phosphate backbone of dna, and the aglycone interacts with nucleic acid bases. the sites of responsible for the interaction with dna (an additional hydrogen bond with the nh group of the g base) and the complexation of the antibiotic with dna were identified. the structural fragment, which is not directly involved in the interaction with dna but models the affinity of the antibiotic to the target Ð the minor groove of the dna duplex, was determined. based on these data, a schematic model of the interaction between olivomycin a and dna was proposed (scheme ). two semi-synthetic olivomycin derivatives ( and ) with the modified aglycone side chain were chosen based on the evaluation of antiproliferative activity in animal assays. compound is more effective in the treatment of p murine leukaemia than the starting antibiotic due to a decrease in toxicity and the absence of the cumulative effect. , compound (olivamide) is also more effective in this assay compared to the starting antibiotic . detailed preclinical assays in transplanted syngeneic tumours confirmed the efficacy of the agent based on compound for further clinical trials. ± these studies enabled the development of methods for selective chemical modification of the antibiotic olivomycin a, resulting in the synthesis of a series of semi-synthetic derivatives of this antibiotic; besides, structure ± activity relationship analysis was performed. , many of these compounds exhibited high antiproliferative activity in different tumour cell lines. some aspects of the mechanism of action of olivomycin a and its natural and semi-synthetic analogues were considered. , , , ± it was concluded that high antitumour activity of these compounds is related to their high affinity to the dna duplex. based on the results of in vitro assays, compounds were chosen for the evaluation of antitumour activity in in vivo assays. after the preclinical evaluation of antitumour activity and toxicity in laboratory animals, semi-synthetic olivomycin analogue Ð olivamide Ð was recommended for further clinical trials. ± anthracycline antibiotics are important chemotherapeutic agents commonly used in the treatment of malignant tumours. daunorubicin ( a), which was independently discovered under the name of rubomycin in the gause institute of new antibiotics (gina), is applied mainly for the treatment of leukaemia in children and adults. doxorubicin ( -hydroxydaunorubicin, dox) ( a) is used in combination chemotherapy of breast cancer, smallcell lung cancer, sarcoma, tumours in children and haemoblastosis. an original method for the one-pot preparation of semi-synthetic doxorubicin from rubomycin was developed in the gina. carminomycin ( a), which was also discovered in the gina, has lower cardiotoxicity than other anthracyclines and can inhibit the growth of doxorubicin-resistant tumours ( a). the structures of anthracycline antibiotics a, a and a are shown in fig. . the mechanism of cytotoxic activity of anthracycline antibiotics is related mainly to the inhibition of nucleic acid synthesis via intercalation between nitrogeneous base pairs, dna damage and inhibition of dna topoisomerases. an adverse effect of anthracyclines is the potentially irreversible and cumulative dose-related cardiotoxicity, apparently associated with the free-radical damage of myocardial cell membranes. the chemical modification of anthracycline antibiotics was extensively studied in the gina for a long period of time. in recent years, efforts were focused on the synthesis of new semi-synthetic analogues of drugs with improved anticancer properties. daunorubicim ( a) and carminomycin ( a) were modified at the c( ) atom (b), the c( ) = o bond (c) and the daunosamine h -amino group (d, e) (see fig. ). h -n-alkyl or h -n-aminoacyl derivatives exhibit high antitumour activity, because they retain the amine function at the daunosamine moiety. this function is required for the primary interaction of the antibiotic with the sugar ± phosphate backbone of dna. however, the drawback of reductive alkylation of anthracyclines a and a with aldehydes in the presence of nabh cn is that it is accompanied by the reduction of the c( ) = o group as the side reaction giving n-alkyl- -dihydro derivatives of daunorubicin ( b) and carminomycin ( b), respectively (scheme ). these analogues are less active than the related compounds containing the c( ) = o group. ± -dimethyl ketals of -bromo derivatives of daunorubicin ( c) and carminomycin ( c) were used to avoid this side reaction (see scheme ) . the reductive alkylation of compounds c and c in the presence of nabh cn can be accomplished using d,lglyceraldehyde and aldoses (the monosaccharide arabinose and the disaccharide melibiose) to form the following bromo-substituted -dimethyl ketals in quantitative yields: the antiproliferative activity of compounds e and against leukaemia cells k is virtually as high as that of derivative e, but is lower than that of carminomycin ( a). the activity of -hydroxycarminomycin derivative evaluated in the same assay is an order of magnitude lower than that of the starting anthracycline a, and the activity of doxorubicin e is two orders of magnitude lower than that of compound a. it should be emphasized that -hydroxycarminomycin derivatives and are equally active against the wildtype human breast adenocarcinoma cell lines mcf- and k and resistant pgp-expressing cell lines (mcf- dox, k i/s ). the antitumour activity of compound e evaluated in the murine leukaemia cell line p compares favourably with that of analogue a. thus, an increase in life span (ils) of mice bearing p leukaemia after a single admin-istration of mg kg of compound e is the same as that observed after administration of analogue a at a dose of mg kg (ils %). it was shown that anthracycline antibiotics a, a and a, which are known to inhibit dna topoisomerase ii at micromolar concentrations, can inhibit dna topoisomerase i at the same concentrations. new derivatives e, e, and have higher inhibitory activity against topoisomerase i compared to compounds a and a. the introduction of polyhydroxylated substituents at the h -amino group of the daunosamine moiety of anthracycline antibiotics increases the inhibitory activity of anthracyclines against topoisomerase a method was developed for the preparation of new watersoluble depot forms of doxorubicin ( a) Ð conjugates with high-molecular-mass polysaccharides. , galactomannan davanat ( ) was used as the polysaccharide. the latter was prepared by controlled partial hydrolysis of water-insoluble high-molecular-mass , -b-d-galactomannan isolated from seeds of cyamopsis tetragonoloba or guar gum. the molecular mass of compound , determined by gel chromatography on a sephadex g- column calibrated with pullulans, is * kda. to conjugate compound with a, the former is activated by the oxidation with periodate using a deficient amount of the oxidizing agent ( . ± . equiv. with respect to the total amount of sugar residues). this gives rise to schiff bases between the aldehyde groups of the oxidized polysaccharide ( a ± c) and the h -amino group of the antibiotic (scheme ). different structures of the final products are possible ( a ± c). the content of the starting antibiotic a in conjugate is mass % (determined from the content of the chromophore per unit mass of the dried powder by uv spectroscopy at nm). in order to increase the doxorubicin content in the conjugate with davanat , the antibiotic molecule was attached to the polysaccharide through a spacer giving h -n-l-lysyldoxorubicin ( ) (scheme ). compound contains two amino groups (while doxorubicin contains one amino group), which may facilitate the formation of the schiff base. besides, it is known that a series of n-acyl conjugates of daunorubicin or doxorubicin with amino acids possess high antitumour activity. h -n-l-lysyldoxorubicin ( ) was synthesized by the acylation of the amino group of doxorubicin ( a) with n a ,n e -(fmoc) -l-lysine osu-ester followed by the deprotection of the fmoc-protected intermediate with a morpholine solution. the schiff base in the resulting conjugate can have either a linear ( a) or cyclic structure ( b). scheme presents the possible structures for one of the oxidized subunits of activated davanat . it should be noted that h -n-l-lysyldoxorubicin can be attached to conjugate through either the a-amino-or e-amino group of h -n-l-lysyldoxorubicin (is not shown in scheme ). the introduction of the lysine spacer between compounds a and allows an increase in the antibiotic content in the conjugate to mass % with retention of water solubility. the conjugates were purified by gel chromatography on a sephadex g- column and dialysis against deionized water using a membrane with molecular weight cut-off (mwco) m w > kda. the molecular masses of conjugates and evaluated by gel chromatography on a sephadex g- column calibrated with pullulan standards are * and * kda, respectively. the antiproliferative activity of the doxorubicin conjugates was tested in three tumour cell lines: the murine melanoma cell line b -f , the breast cancer cell line mcf- and the colon cancer cell line ht- (htb- ). the ic values for conjugate (taking into account the percentage of antibiotic a in the conjugate) are . ± . , . ± . and . ± mg ml , respectively; for antibiotic a, . ± . , . ± . and . ± . mg ml . despite the fact that the cytotoxicity of conjugate is * ± orders of magnitude lower (data were not reported) than that of doxorubicin ( a), these results indicate that conjugate is an active depot form of doxorubicin ( a). the antiproliferative activity of the h -n-l-lysyldoxorubicin ± davanat conjugate ( ) (ic > mg ml ) against these tumour cell lines is much lower compared to cytotoxicity of conjugate . this can be due to the fact that the imine bonds in the h -n-l-lysyldoxorubicin ± da-vanat conjugate ( ) are more stable than those in conjugate . it should be noted that h -n-l-lysyldoxorubicin is not released in in vitro assays. therefore, a biological model, which would provide release of , is apparently required to evaluate the therapeutic potential of conjugate . based on these studies, a method was developed for the introduction of polyhydroxylated substituents of different types and different length into anthracycline antibiotics, which was used to synthesize a series of new hydrophilic h -n-alkyl derivatives of doxorubicin and -hydroxycarminomycin, including those containing mono-and disaccharide residues. , this modification was found to enhance the inhibitory activity of anthracyclines against topoisomerase i with retention of antitumour activity of the antibiotics. the new -hydroxycarminomycin derivatives, unlike doxorubicin derivatives, were shown to suppress the tumour cell growth insensitive to doxorubicin. a new water-soluble depot form of doxorubicin Ð a conjugate with the highmolecular-mass polysaccharide galactomannan dava-nat Ð was prepared. , this depot form exhibits antiproliferative activity against the above-mentioned three tumour cell lines. the antibiotic heliomycin (resistomycin, , , , -tetrahydroxy- , , -trimethyl- h-benzo[cd ]pyrene- , -dione) ( ) with a broad spectrum of biological activity (scheme ) was discovered in the gause institute of new antibiotics. first of all, this antibiotic is highly effective against grampositive and some gram-negative microorganisms, including drug-resistant strains. more recently, heliomycin was found to exhibit antifungal and antiviral (anti-hiv) activity. besides, compound can block proliferation of some tumour cells in in vitro assays. in the soviet union, heliomycin ( ) was produced on a commercial scale and was used as a gel for topical treatment of skin infections and healing of burn wounds. the chemical modification of heliomycin is poorly known. hence, structure ± activity relationship studies require the development of method for the synthesis of new semi-synthetic derivatives and evaluation of their biological properties. the main goal is to prepare series of derivatives with improved water solubility in order to expand their practical application. a method was developed for the synthesis of aminomethyl derivatives at the position of compounds (where x is an amine moiety or a nitrogen-containing heterocycle). typical synthetic procedures are presented in relation to compounds a ± c (see scheme ) . , the mannich aminomethylation of compound can be performed using amines and formaldehyde in dmf (see scheme b ). an alternative procedure for the synthesis of derivatives is based on the use of pre-prepared stable iminium salts (see scheme , conditions a). in the case of aminomethylation of compounds with polyfunctional amines, the amino group is protected with boc (see scheme c) and then deprotected with acid (see scheme d ). the reaction of compound with n,n-dimethylamino(methylene)ammonium chloride afforded -[(n,n-dimethylamino)methyl]- , , , -tetrahydroxy- , , -trimethyl- -h-benzo[cd ]pyrene- , -dione hydrochloride ( a). -[(tert-butylamino)methyl]- , , , -tetrahydroxy- , , -trimethyl- h-benzo[cd ]pyrene- , -dione hydrochloride ( b) is produced by the treatment of compound with tertbutylmethylamine in the presence of formaldehyde. the treatment of compound with tert-butylpiperidin- -ylcarbamate in the presence of a formaldehyde solution gives -( -boc-aminopiperidinomethyl)- , , , -tetrahydroxy- , , -trimethyl- h-benzo[cd ]pyrene- , -dione, which is quantitatively converted to the corresponding amine dihydrochloride ( c) upon the treatment with hcl meoh. the antiproliferative activity (ic ) was evaluated by the colorimetric determination of cell metabolic activity (mtt assay) using a standard procedure in eight tumour cell lines, including both drug-sensitive and drug-resistant cell lines. the resulting compounds inhibit tumour cell proliferation in a low submicromolar to micromolar concentration range, similar to that of doxorubicin ( a). however, most of these compounds significantly outperform doxorubicin in terms of the drug-resistance index. these compounds block the growth of the wild-type cell lines k and hct and the following multidrugresistant cell lines: the k / subline isogenic to p-glycoprotein (pgp)-positive multidrug resistance and the hct p ko subline with p gene deletion. the development of multidrug resistance in these tumour cell lines is the crucial factor responsible for a decrease in activity of antitumour drugs. as opposed to compound , derivatives a ± c show a high level of induced apoptosis in the t bladder cancer cell line model. the introduction of the -aminomethyl moiety enhances the dna-binding affinity and the inhibitory activity against dna topoisomerase i. hence, compound c is the most promising candidate for preclinical trials. based on these studies, methods were developed for chemical modification of heliomycin ( ). series of new analogues, water-soluble salts of amino-containing derivatives, were synthesized and they were shown to exhibit high antiproliferative activity against many tumour cell lines and inhibitory activity against various targets. the value of these studies is that the majority of aminomethyl derivatives of heliomycin are active against both wild-type and drugresistant cancer cells at micromolar or submicromolar concentrations. the development of new-generation drugs is a challenging problem because of the increasing risk of the development of drug resistance in microorganisms. different approaches to the search for new compounds were developed in recent years. particular attention is given to semi-synthetic derivatives based on available natural antibiotics, since there are numerous examples of the successful application of this approach. some semi-synthetic derivatives based on macrocyclic glycopeptides have advantages over the gold standard chemotherapeutic agent Ð vancomycin. , , the distinguishing features of new representatives of this class are selectivity against multidrug-resistant pathogenic bacteria and higher bioavailability. the new semi-synthetic vancomycin analogue telavancin (vibativ) (manufactured by theravance and astellas pharma, us) was approved for use in the united states and europe. two semi-synthetic derivatives of glycopeptide antibiotics have completed phase clinical trials and were approved by the united state food and drug administration (fda): chloroeremomycin (discovered by eli lilly, acquired by the medicine co in ) and dalbavancin (discovered by lepetit; acquired by pfizer in ). , the drawbacks of vancomycin are the poor accumulation within tissues, because of which it is not used in the treatment of, for example, pneumonia, and a pronounced pseudoallergic reaction typical of glycopeptides. research in international cooperation showed the promise of chemical transformations of the antibiotic eremomycin belonging to this group of glycopeptide antibiotics. eremomycin is a highly active domestic antibiotic that suppresses the growth of gram-positive organisms; it is ± times more effective than vancomycin but is inactive against drug-resistant strains of staphylococci and enterococci. original approaches and methods were developed under the supervision of professor m.n.preobrazhenskaya in the gause institute of new antibiotics. these methods can be applied to prepare derivatives of antibiotics of this group with desired properties. in , the method for the synthesis of glycopeptide analogues was protected by an international patent. promising analogues, various n h -derivatives and carboxamides of eremomycin, were synthesized. these derivatives compare favourably in efficacy against drug-sensitive and drug-resistant strains of staphylococci and enterococci with the related vancomycin derivatives and they are even more effective in a number of assays. ± some carboxamides show no allergenicity. other derivatives (e.g., the adamantane derivative of eremomycin) are promising as a protection against biological risks because they were found to be active against the bacterium bacillus anthracis, including fluoroquinolone-resistant strains. high activity of the resulting hydrophobic glycopeptide derivatives can be attributed to the dual mechanism of action on gram-positive bacteria. , modifications of aglycones of glycopeptide antibiotics with hydrophobic substituents resulted in the discovery of a new class of polycyclic peptides active against a large group of enveloped viruses, such as hiv or hepatitis c virus. studies on the mechanisms of antiviral activity are currently ongoing. it was suggested that protein kinase is one of possible targets for this agluco analogue, because antiviral activity was shown to correlate with the inhibition of serine/ threonine protein kinases. comprehensive research on the synthesis and characterization of heterodimeric conjugates based on different classes of antibiotics was initiated in the gause institute of new antibiotics under the supervision of professor m.n.preobrazhenskaya. the following hybrid antibiotics were synthesized: glycopeptide ± macrolide, glycopeptide ± aminoglycoside and hybrid compounds containing the benzoxaborole chromophore. the literature data provide evidence that this line of research holds promise. , macrolides modified through the carbamoyl group at the hh position can acquire activity against drug-resistant bacterial cell lines. generally, conjugates containing a long spacer exhibit higher activity than the related compounds with a shorter spacer. , investigations of interactions between different benzoxaboroles and antibiotics made a significant contribution to the chemistry of not only antibiotics with complex structures but also the relatively poorly studied borole compounds. benzoxaboroles were found to be quite stable under different reaction conditions. in particular, the acylation, amidation and reductive alkylation with reactive agents and on heating are virtually not accompanied by oxaborole ring opening. the introduction of the benzoxaborole substituent into the polyene macrolide amphotericin b (amb) also enhances biological activity. the resulting compounds possess valuable properties, such as lower cytotoxic and haemolytic activity compared to amb combined with high antifungal activity. the efficiency of the approach to the design of antibiotics of a new generation was demonstrated in relation to antifungal polyene macrolides. it is based on a combination of genetic engineering techniques and methods of organic synthesis ± and is protected by an international patent. the chemical modification of polyene antibiotics, which were obtained via the genetic engineering of nystatin a biosynthesis at the norwegian university, gave a series of agents exhibiting lower toxicity and higher activity compared to amphotericin b in animal assays. the dependence of antifungal activity on the structure of the polyol region [c( ) ± c( )] of these antibiotics was revealed for the first time by preobrazhenskaya et al. pioneering studies on the development of methods for selective chemical modification of the unique macrolactone oligomycin a, a specific f f -atp synthase inhibitor, and the original antitumour antibiotic olivomycin a of the aureolic acid group were performed. in both cases, examples of chemical modifications of related compounds for these antibiotics are absent in the literature. these results are of great scientific value. investigations of f f -atp synthase inhibitors are of considerable interest because this enzyme is involved in the development of resistance in microorganisms. chemical transformations of oligomycin a using different reagents were studied in detail. alkaline hydrolysis reactions were performed and conditions for the selective reduction of double bonds and keto groups, cyclization, etc. were found. the replacement of the c( )-hydroxyl group by the activated mesyl group has proved to be particularly successful. this modification has no significant effect on biological activity of the antibiotic but provides a possibility to optimize its pharmacological properties. , only transformations via the biosynthesis were described for the aureolic acid group antibiotics mithramycin and chromomycin. , these natural antibiotics, which have a limited use in the treatment of some malignant tumours, have attracted increasing attention of researchers in different fields. , the synthesized compounds were tested for antiproliferative activity. based on the results of in vitro studies of a series of new olivomycin a analogues of different types, compounds were selected for the in vivo evaluation. after preclinical trials in laboratory animals (evaluatrion of antitumour activity and toxicity), one olivomycin a analogue was recommended for further clinical trials. ± a systemic approach applied to series of new semisynthetic analogues of olivomycin a allows a detailed study of the molecular mechanism of antitumour action of this antibiotic. ± in particular, it was shown that olivomycin and its analogues, acting as dna duplex minor groove ligands, can inhibit topoisomerase i and the dnmt a enzyme responsible for the disruption of the key epigenetic dna methylation process. , the structural fragments of olivomycin a critical for antitumour activity were identified. a model of the interaction of the antibiotic and some its analogues with the dna duplex was proposed. new analogues of anthracycline antibiotics with substituents of different types and different length, including those containing mono-and disaccharide residues, were prepared. the evaluation of the effect of polyhydroxylated moieties of doxorubicin and -hydroxycarminomycin on antitumour activity showed that this modification does not lead to the loss of activity of anthracyclines ± and enhances inhibitory activity against topoisomerase i. -hydroxycarminomycin derivatives proved to be particularly valuable because these compounds, as opposed to related doxorubicin derivatives, inhibit the proliferation of both doxorubicin-sensitive and doxorubicin-resistant tumour cell lines. a new water-soluble depot form of doxorubicin with the high-molecular-mass polysaccharide galactomannan davanat was constructed and it was shown that it exhibits antiproliferative activity against three tumour cell lines. , series of new heliomycin analogues Ð water-soluble salts of amino derivatives Ð were synthesized and these compounds were shown to have high antiproliferative activity against many tumour cell lines and inhibitory activity against different targets. the value of these studies is that the majority of aminomethyl derivatives of heliomycin are active against both wild-type and drugresistant cancer cells at micromolar or submicromolar concentrations. the method is protected by a patent. targeted chemical modifications of antibiotics are not only performed in order to prepare new potential drugs of a new generation but are used as an efficient tool for investigation of the mechanisms of action on bacterial or tumour cells. it should be emphasized that many potent antibiotics are indispensable tools for molecular biology research of the living world. such comprehensive studies can lead to the design and synthesis of new-generation drugs, which would be more effective than the starting antibiotics and which are of theoretical interest as new compounds with high biological activity. figures , , and were composed by the authors based on the cited publications (the references are given in the figure captions). new approaches to natural anticancer drugs. springer briefs in pharmaceutical science and drug development antibiotics: challenges, mechanisms, opportunities markovnikov congress on organic chemistry (book of abstracts) handbook of experimental pharmacology doctoral thesis in chemical sciences, m.v.lomonosov institute of fine chemical technology glycobiology and drug design. (acs symp. ser. ) carbohydrates and drug design. (asc symp. ser. ) key: cord- -xn cf a authors: tanz, robert r.; shulman, stanford t. title: sore throat date: - - journal: practical strategies in pediatric diagnosis and therapy doi: . /b - - - - . - sha: doc_id: cord_uid: xn cf a nan sore throat is a common chief complaint. each year approximately million patients in the united states visit physicians because of throat complaints. the majority of these illnesses are nonbacterial and neither necessitate nor are alleviated by antibiotic therapy (tables - to - ). acute streptococcal pharyngitis, however, warrants accurate diagnosis and therapy to prevent serious suppurative and nonsuppurative complications. furthermore, life-threatening infectious complications of streptococcal and nonstreptococcal oropharyngeal infections may manifest with mouth pain, pharyngitis, parapharyngeal space infectious extension, and airway obstruction (tables - and - ). most episodes of pharyngitis are caused by viruses (see tables - and - ). it is difficult to clinically distinguish between viral and bacterial pharyngitis with a very high degree of precision, but certain clues may help the physician. accompanying symptoms of conjunctivitis, rhinitis, croup, or laryngitis are common with viral infection but rare in bacterial pharyngitis. many viral agents can produce pharyngitis (see tables - and - ). some cause distinct clinical syndromes that are readily diagnosed without laboratory testing (see tables - , - , and - ). in pharyngitis caused by parainfluenza and influenza viruses, rhinoviruses, coronaviruses, and respiratory syncytial virus (rsv), the symptoms of coryza and cough often overshadow sore throat, which is generally mild. influenza virus may cause high fever, cough, headache, malaise, myalgias, and cervical adenopathy in addition to pharyngitis. in young children, croup or bronchiolitis may develop. rsv is associated with bronchiolitis, pneumonia, and croup in young children. rsv infection in older children is usually indistinguishable from a simple upper respiratory tract infection. pharyngitis is not a prominent finding of rsv infection in either age group. parainfluenza viruses are associated with croup and bronchiolitis; minor sore throat and signs of pharyngitis are common at the outset but rapidly resolve. infections caused by parainfluenza, influenza, and rsv are often seen in seasonal (winter) epidemics. adenoviruses can cause upper and lower respiratory tract disease, ranging from ordinary colds to severe pneumonia. the incubation period of adenovirus infection is to days. upper respiratory tract infection typically produces fever, erythema of the pharynx, and follicular hyperplasia of the tonsils, together with exudate. enlargement of the cervical lymph nodes occurs frequently. when conjunctivitis occurs in association with adenoviral pharyngitis, the resulting syndrome is called pharyngoconjunctival fever. pharyngitis may last as long as days and does not respond to antibiotics. there are many adenovirus serotypes; adenovirus infections may therefore develop in children more than once. laboratory studies may reveal a leukocytosis and an elevated erythrocyte sedimentation rate. outbreaks have been associated with swimming pools and contamination in health care workers. the enteroviruses (coxsackievirus and echovirus) can cause sore throat, especially in the summer. high fever is common, and the throat is slightly red; tonsillar exudate and cervical adenopathy are unusual. symptoms resolve within a few days. enteroviruses can primary infection caused by herpes simplex virus (hsv) usually produces high fever with acute gingivostomatitis, involving vesicles (which become ulcers) throughout the anterior portion of the mouth, including the lips. there is sparing of the posterior pharynx in herpes gingivostomatitis; the infection usually occurs in young children. high fever is common, pain is intense, and intake of oral fluids is often impaired, which may lead to dehydration. in addition, hsv may manifest in adolescents with pharyngitis. approximately % of new-onset hsv-positive adolescent patients have herpetic lesions; most patients with hsv pharyngitis cannot be distinguished from patients with other causes of pharyngitis. the classic syndrome of herpetic gingivostomatitis in infants and toddlers lasts up to weeks; data on the course of more benign hsv pharyngitis are lacking. the differential diagnosis of vesicular-ulcerating oral lesions is noted in table - . a common cause of a local and large lesion of unknown etiology is aphthous stomatitis ( fig. - ) . some children have a combination of periodic fever (recurrent at predictable fixed times), aphthous stomatitis, pharyngitis, and cervical adenitis (pfapa); this syndrome is idiopathic and may respond to oral prednisone or cimetidine. pfapa usually begins before the age of years and is characterized by high fever lasting to days, occurring every to weeks, and resolving spontaneously. infants and toddlers with measles often have prominent oral findings early in the course of the disease. in addition to high fever, cough, coryza, and conjunctivitis, the pharynx may be intensely and diffusely erythematous, without tonsillar enlargement or exudate. the presence of koplik spots, the pathognomonic white or bluewhite enanthem of measles, on the buccal mucosa near the mandibular molars provides evidence of the correct diagnosis before the rash develops. acute exudative pharyngitis commonly occurs with infectious mononucleosis caused by primary infection with epstein-barr virus (ebv) ( table - ) . mononucleosis is a febrile, systemic, self-limited lymphoproliferative disorder that is usually associated with hepatosplenomegaly and generalized lymphadenopathy. the pharyngitis may be mild or severe, with significant tonsillar hypertrophy (possibly producing airway obstruction), erythema, and impressive tonsillar exudates. regional lymph nodes may be particularly enlarged and slightly tender. infectious mononucleosis usually occurs in adolescents and young adults; ebv infection is generally milder or subclinical in preadolescent children. in united states high school and college students, attack rates are to per , population per year. ebv is transmitted primarily by saliva. after a -to -week incubation period, patients with infectious mononucleosis usually experience an abrupt onset of malaise, fatigue, fever, and headache, followed closely by pharyngitis. the tonsils are enlarged with exudates and cervical adenopathy. more generalized adenopathy with hepatosplenomegaly often follows. fever and pharyngitis typically last to weeks, while lymphadenopathy and hepatosplenomegaly subside over to weeks. malaise and lethargy can persist for several months, possibly leading to impaired school or work performance. laboratory studies of diagnostic value include atypical lymphocytosis; these lymphocytes are primarily ebv-specific, cytotoxic t lymphocytes that represent a reactive response to ebv-infected b lymphocytes. a modest elevation of serum transaminase levels, reflecting ebv hepatitis, is common. tests useful for diagnosis include detection of heterophile antibodies that react with bovine erythrocytes (most often detected by the monospot test) and specific antibody against ebv viral capsid antigen (vca), early antigen (ea), and nuclear antigen (ebna). acute infectious mononucleosis is usually associated with a positive heterophile test result and antibody to vca and ea ( fig. - ) . the findings of acute exudative pharyngitis together with hepatomegaly, splenomegaly, and generalized lymphadenopathy suggest infectious mononucleosis. early in the disease and in cases without liver or spleen enlargement, differentiation from other causes of pharyngitis, including streptococcal pharyngitis, is difficult. indeed, a small number of patients with infectious mononucleosis have a throat culture positive for group a streptococci. serologic evidence of mononucleosis should be sought when splenomegaly or other features are present or if symptoms persist beyond days. patients with infectious mononucleosis require supportive treatment. corticosteroids may be indicated for acute life-threatening conditions, such as airway obstruction caused by enlarged tonsils. in the evaluation of a patient with sore throat, the primary concern is usually accurate diagnosis and treatment of pharyngitis caused by group a streptococci, which accounts for about % of all episodes of pharyngitis. the sequelae of group a streptococcal pharyngitis, especially acute rheumatic fever and acute glomerulonephritis, at one time resulted in considerable morbidity and mortality in the united states and continue to do so in other parts of the world. prevention of acute rheumatic fever in particular depends on timely diagnosis of streptococcal pharyngitis and prompt antibiotic treatment. group a streptococci are characterized by the presence of group a carbohydrate in the cell wall, and they are further distinguished by several kinds of cell wall protein antigens (m, r, t). these protein antigens are useful for studies of epidemiology and pathogenesis. group a streptococcal pharyngitis has been endemic in the united states; epidemics occur sporadically. episodes peak in the late winter and early spring; rates of group a streptococcal pharyngitis are highest among children aged to years old. spread of group a streptococci in classrooms and among family members, especially in crowded living conditions, is common. transmission occurs primarily by inhalation of organisms in large droplets or by direct contact with respiratory secretions. pets do not appear to be a frequent reservoir. untreated streptococcal pharyngitis is particularly contagious early in the acute illness and for the first weeks after the organism has been acquired. antibiotic therapy effectively prevents disease transmission. within hours of institution of therapy with penicillin, it is difficult to isolate group a streptococci from patients with acute streptococcal pharyngitis, and infected children can return to school. molecular epidemiology studies of streptococcal pharyngitis have shown that numerous distinct strains of group a streptococci circulate simultaneously in the community during the peak season. "dna-fingerprinting" techniques further demonstrate that children with streptococcal pharyngitis serve as a community reservoir for strains that cause invasive disease (e.g., sepsis, streptococcal toxic shock syndrome, cellulitis, necrotizing fasciitis) in the same geographic area and season. the classic patient with acute streptococcal pharyngitis has a sudden onset of fever and sore throat. headache, malaise, abdominal pain, nausea, and vomiting occur frequently. cough, rhinorrhea, conjunctivitis, stridor, diarrhea, and hoarseness are distinctly unusual and suggest a viral etiology. examination of the patient reveals marked pharyngeal erythema. petechiae may be noted on the palate, but they can also occur in viral pharyngitis (see table - ). tonsils are enlarged, symmetric, and red, with patchy exudates on their surfaces. the papillae of the tongue may be red and swollen; hence the designation "strawberry tongue." anterior cervical lymph nodes are often tender and enlarged. combinations of these signs can be used to assist in diagnosis; in particular, tonsillar exudates in association with fever, palatal petechiae, and tender anterior cervical adenitis strongly suggest infection with group a streptococci. however, other diseases can produce this constellation of findings. some or all of these classic characteristics may be absent in patients with streptococcal pharyngitis. younger children often have coryza with crusting below the nares, more generalized adenopathy, and a more chronic course, a syndrome called streptococcosis. when rash accompanies the illness, accurate clinical diagnosis is easier. scarlet fever, so-called because of the characteristic fine, diffuse red rash, is essentially pathognomonic for infection with group a streptococci. scarlet fever is rarely seen in children younger than years old or in adults. the rash of scarlet fever is caused by infection with a strain of group a streptococci that contains a bacteriophage encoding for production of an erythrogenic (redness-producing) toxin, usually erythrogenic (or pyrogenic) exotoxin a. scarlet fever is simply group a streptococcal pharyngitis with a rash and should be explained as such to patients and their families. although patients with the streptococcal section one respiratory disorders streptococcal toxic shock syndrome is usually associated with a primary cutaneous rather than a pharyngeal focus of infection. the rash of scarlet fever has a texture like sandpaper and blanches with pressure. it usually begins on the face, but after hours it becomes generalized. the face, especially the cheeks, is red, and the area around the mouth often appears pale in comparison (circumoral pallor). accentuation of erythema occurs in flexor skin creases, especially in the antecubital fossae (pastia's lines). the erythema begins to fade within a few days. desquamation begins within a week of onset on the face and progresses downward, often resembling that seen after a mild sunburn. on occasion, sheetlike desquamation occurs around the free margins of the fingernails and is usually more coarse than the desquamation seen with kawasaki disease. the differential diagnosis of scarlet fever includes kawasaki disease, measles, and staphylococcal toxic shock syndrome (table - ). although signs and symptoms may strongly suggest acute streptococcal pharyngitis, laboratory diagnosis is highly recommended, even for patients with scarlet fever (fig. - ) . scoring systems for diagnosing acute group a streptococcal pharyngitis on clinical grounds have not proved very useful. using clinical criteria alone, physicians overestimate the likelihood that patients have streptococcal infection. the throat culture has traditionally been used to diagnose streptococcal pharyngitis. plating a swab of the posterior pharynx and tonsils on sheep blood agar, identifying β−hemolytic colonies, and testing them for the presence of sensitivity to a bacitracinimpregnated disk is the "gold standard" diagnostic test, but it takes to hours to obtain results. there are a number of rapid diagnostic tests that take less than minutes. these "rapid strep" tests detect the presence of the cell wall group a carbohydrate antigen after acid extraction of organisms obtained by throat swab. rapid strep tests are highly specific (generally > %), with the throat culture used as the standard. unfortunately, the sensitivity of most of these rapid tests can be considerably lower. in comparison to hospital or reference laboratory throat culture results, the sensitivities of these tests are generally % to % and can be lower. however, when both throat cultures and rapid tests performed in physicians' offices are compared with cultures performed in reference laboratories, the sensitivities, specificities, and overall accuracy of the office culture and the office rapid test are quite similar; the latter often performs better than the culture. the low sensitivity of these tests, coupled with their excellent specificity, has led to the recommendation that two swabs be obtained from patients with suspected streptococcal pharyngitis. one swab is used for a rapid test. when the rapid antigen detection test result is positive, it is highly likely that the patient has group a streptococcal infection, and the extra swab can be discarded. when the rapid test result is negative, group a streptococci may nonetheless be present; thus, the extra swab should be processed for culture. physician offices that have demonstrated that their rapid test and throat culture results are comparable may be able to rely on the rapid test result even when it is negative, without performing a backup culture. in general, patients with a negative result of the rapid test do not require treatment before culture verification unless there is a particularly high suspicion group a streptococcal infection (e.g., scarlet fever, peritonsillar abscess, or tonsillar exudates in addition to tender cervical adenopathy, palatal petechiae, fever, and recent exposure to a person with group a streptococcal pharyngitis). testing patients for serologic evidence of an antibody response to extracellular products of group a streptococci is not useful for diagnosing acute pharyngitis. because it generally takes several weeks for antibody levels to rise, streptococcal antibody tests are valid only for determining past infection. specific antibodies include antistreptolysin o (aso), anti-dnase b, and antihyaluronidase (aht). when antibody testing is desired in order to evaluate a possible post-streptococcal illness, more than one of these tests should be performed to improve sensitivity. treatment begun within days of the onset of group a streptococcal pharyngitis is effective in preventing acute rheumatic fever. therapy does not appear to affect the risk of the other nonsuppurative sequela, acute post-streptococcal glomerulonephritis. antibiotic therapy also reduces the incidence of suppurative sequelae of group a streptococcal pharyngitis, such as peritonsillar abscess and cervical adenitis. in addition, treatment produces a more rapid resolution of signs and symptoms and terminates contagiousness within hours. for these reasons, antibiotics should be instituted as soon as the diagnosis is supported by laboratory studies. there are numerous antibiotics available for treating streptococcal pharyngitis (table - ). the drug of choice is penicillin. despite the widespread use of penicillin to treat streptococcal and other infections, penicillin resistance among group a streptococci has not developed. penicillin can be given by mouth for days or intramuscularly as a single injection of benzathine penicillin. intramuscular benzathine penicillin alleviates concern with patient compliance. a less painful alternative is benzathine penicillin in combination with procaine penicillin. intramuscular procaine penicillin alone is inadequate for prevention of acute rheumatic fever because adequate levels of penicillin are not present in blood and tissues for a sufficient time. other β-lactams, including semisynthetic derivatives of penicillin and the cephalosporins, are at least as effective as penicillin for treating group a streptococcal pharyngitis. their broader spectrum, their higher cost, and the lack of formal data concerning prevention of acute rheumatic fever relegate them to second-line status. the decreased frequency of dose administration of some of these agents may improve patient compliance and makes their use attractive in selected circumstances. patients who are allergic to penicillin should receive erythromycin or another non-β-lactam antibiotic, such as clarithromycin, azithromycin, or clindamycin. resistance of group a streptococci to erythromycin has increased dramatically in areas such as japan, france, spain, taiwan, and finland, where erythromycin has been widely used. this has not yet emerged as a major problem in the united states, where the rate of macrolide resistance is about %. sulfa drugs (including sulfamethoxazole combined with trimethoprim), tetracyclines, and chloramphenicol should not be used for treatment of acute streptococcal pharyngitis because they do not eradicate group a streptococci. antibiotic therapy has greatly reduced the likelihood of developing suppurative complications caused by spread of group a streptococci from the pharynx or middle ear to adjacent structures. peritonsillar abscess ("quinsy") manifests with fever, severe throat pain, dysphagia, "hot potato voice," pain referred to the ear, and bulging of the peritonsillar area with asymmetry of the tonsils and sometimes displacement of the uvula (fig. - ; see table - ). on occasion, there is peritonsillar cellulitis without a well-defined abscess cavity. trismus may be present. when an abscess is found clinically or by an imaging study such as a computed tomographic scan, surgical drainage is indicated. peritonsillar abscess occurs most commonly in older children and adolescents. sore throat necrotizing fasciitis diarrhea *case definition of streptococcal toxic shock syndrome requires (i) isolation of group a streptococci from (a) a normally sterile site (blood, synovial or peritoneal fluid) or (b) a nonsterile site (throat, wound). (ii) severity is defined by (a) hypotension and (b) two or more of renal impairment, coagulopathy, liver involvement, adult respiratory distress syndrome, a generalized erythematous macular rash (with or without later desquamation), and soft tissue necrosis (necrotizing fasciitis, myositis, gangrene). the definitive diagnosis requires criteria ia and iia plus b. criteria ib and iia plus b are considered probable if no other identifiable cause is present. alt, alanine aminotransferase; ast, aspartate aminotransferase; bun, blood urea nitrogen. retropharyngeal abscess represents extension of infection from the pharynx or peritonsillar region into the retropharyngeal (prevertebral) space, which is rich in lymphoid structures (figs. - and - ; see table - ). children younger than years old are most often affected. fever, dysphagia, drooling, stridor, extension of the neck, and a mass in the posterior pharyngeal wall may be noted. surgical drainage is often required if frank suppuration has occurred. spread of group a streptococci via pharyngeal lymphatic vessels to regional nodes can cause cervical lymphadenitis. the markedly swollen and tender anterior cervical nodes that result can suppurate. otitis media, mastoiditis, and sinusitis also may occur as complications of group a streptococcal pharyngitis. additional parapharyngeal suppurative infections that may mimic streptococcal disease are noted in table - . furthermore, any pharyngeal infectious process may produce torticollis if there is inflammation that extends to the paraspinal muscles and ligaments, producing pain, spasm, and, on occasion, rotary subluxation of the cervical spine. the differential diagnosis of torticollis is presented in table - . oropharyngeal torticollis lasts less than weeks and is not associated with abnormal neurologic signs or pain over the spinous process. nonsuppurative complications include acute rheumatic fever (see chapters and ), acute post-streptococcal glomerulonephritis (see chapter ), and possibly reactive arthritis/synovitis. in addition, an association between streptococcal infection and neuropsychiatric disorders such as obsessive-compulsive disorder and tourette syndrome has been postulated. this possible association has been called pandas (pediatric autoimmune neuropsychiatric disorders associated with streptococci). therapy with an appropriate antibiotic within days of onset of symptoms is highly effective in preventing rheumatic fever, but acute glomerulonephritis is not prevented by treatment of the antecedent streptococcal infection. pharyngitis caused by one of the nephritogenic strains of group a streptococci precedes the glomerulonephritis by about days. unlike acute rheumatic fever, which occurs only after group a streptococcal pharyngitis, acute glomerulonephritis also can follow group a streptococcal skin infection. treatment with penicillin cures group a streptococcal pharyngitis but is unable to eradicate group a streptococci from the pharynx in approximately % of patients ( fig. - ) . this causes considerable consternation among such patients and their families. penicillin resistance is not the cause of treatment failure. a small proportion of these patients are symptomatic and are thus characterized as having clinical treatment failure. reinfection with the same strain or a different strain is possible, as is intercurrent viral pharyngitis. some of these patients may be chronic pharyngeal carriers of group a streptococci who are suffering from a new superimposed viral infection; others may be noncompliant with regard to therapy. many patients who do not respond to antimicrobial treatment are asymptomatic and are identified when follow-up culture specimens are obtained, a practice that is usually unnecessary. patients who are compliant with regard to therapy are at minimal risk for acute rheumatic fever. one explanation for asymptomatic persistence of group a streptococci after treatment is that these patients were chronic carriers of group a streptococci who were initially symptomatic because of a concurrent viral pharyngitis and who did not truly have acute streptococcal pharyngitis. patients who are chronically colonized with group a streptococci are called chronic carriers. carriers do not appear to be at risk for acute section one respiratory disorders headache pyuria (sterile); gallbladder hydrops rheumatic fever or for development of suppurative complications, and they are rarely sources of spread of group a streptococci in the community. there is no reason to exclude these carriers from school. there is no easy way to identify chronic carriers prospectively among patients with symptoms of acute pharyngitis. the clinician should consider the possibility of chronic group a streptococcal carriage when a patient or a family member has multiple culturepositive episodes of pharyngitis, especially when symptoms are mild or atypical. a culture specimen is usually positive for group a streptococci when the suspected carrier is symptom-free or is receiving treatment with penicillin (intramuscular benzathine penicillin is recommended in order to eliminate concern about compliance). carriers often receive multiple unsuccessful courses of antibiotic therapy in attempts to eliminate group a streptococci. physician and patient anxiety is common and can develop into "streptophobia." unproven and ineffective therapies include tonsillectomy, prolonged administration of antibiotics, use of β-lactamase-resistant antibiotics, and culture or treatment of pets. available treatment options for the physician faced with a chronic streptococcal carrier include the following: . obtaining a rapid test, throat culture, or both each time the patient has pharyngitis with features that suggest streptococcal pharyngitis, and treating with penicillin each time a test is positive. . treating with one of the regimens effective for terminating chronic carriage. the first option is simple, as safe as penicillin, and appropriate for many patients. the second option should be reserved for particularly anxious patients; those with a history of acute rheumatic fever or living with someone who had it; or those living or working in nursing homes, chronic care facilities, hospitals, and perhaps schools. the two antibiotic treatment regimens that have been effective for eradication of the carrier state are: • intramuscular benzathine penicillin plus oral rifampin ( mg/kg/ dose up to mg, given twice daily for days beginning on the day of the penicillin injection) • oral clindamycin, given for days ( mg/kg/day up to mg, divided into three equal doses) clindamycin may be preferred because it is easier to use than intramuscular penicillin plus oral rifampin and may be somewhat more effective. in controlled, comparative trials, no other antibiotic regimens have been demonstrated to reliably terminate the chronic streptococcal carrier state. successful eradication of the carrier state makes evaluation of subsequent episodes of pharyngitis much easier, although chronic carriage can recur upon reexposure to group a streptococci. some patients seem remarkably susceptible to group a streptococci. the reasons for frequent bona fide acute group a streptococcal pharyngitis are obscure, but appropriate antibiotic treatment results in resolution of symptoms and eradication of group a streptococci. the role of tonsillectomy in the management of patients with multiple episodes of streptococcal pharyngitis is controversial. fewer episodes of sore throat have been reported among patients treated with tonsillectomy (in contrast to patients treated without surgery) during the first years after operation. the patients enrolled in that study had experienced numerous episodes of pharyngitis, but it appears that not all episodes were caused by group a streptococci. of particular concern is the reported tonsillectomy complication rate of % and the improvement over time noted among the nontonsillectomy patients. in addition, the presence of tonsils is not necessary for group a streptococci to infect the throat. tonsillectomy cannot be recommended except in unusual circumstances. it seems preferable to treat most patients with penicillin whenever symptomatic group a streptococcal pharyngitis occurs. obtaining follow-up throat specimens for culture helps distinguish recurrent pharyngitis from chronic carriage. certain β−hemolytic streptococci of serogroups other than group a cause acute pharyngitis. well-documented epidemics of food-borne group c and group g streptococcal pharyngitis have been reported in young adults. in these situations, a high percentage of individuals who have ingested the contaminated food promptly developed acute pharyngitis, and throat cultures yielded virtually pure growth of the epidemiologically linked organism. there have been outbreaks of group g streptococcal pharyngitis among children. however, the role of these non-group a streptococcal organisms as etiologic agents of acute pharyngitis in endemic circumstances has been difficult to establish. group c and group g β streptococci may be responsible for acute pharyngitis, particularly in adolescents. however, the exact role of these agents, most of which are carried asymptomatically in the pharynx of some children and young adults, remains to be fully characterized. when they are implicated as agents of acute pharyngitis, groups c and g organisms do not appear to necessitate treatment, inasmuch as they cause self-limited infections. acute rheumatic fever is not a sequela to these infections, although post-streptococcal acute glomerulonephritis has been documented in rare cases after epidemic group c and group g streptococcal pharyngitis. arcanobacterium (formerly corynebacterium) haemolyticum is a gram-positive rod that has been reported to cause a scarlet fever-like illness with acute pharyngitis and scarlatinal rash, particularly in teenagers and young adults. detecting this agent requires special methods for culture, and it has not routinely been sought in patients with scarlet fever or pharyngitis. the clinical features of a. haemolyticum pharyngitis are indistinguishable from group a streptococcal pharyngitis; pharyngeal erythema is present in almost all patients, patchy white to gray exudates in about %, cervical adenitis in about %, and moderate fever in %. palatal petechiae and strawberry tongue may also occur. the scarlatiniform rash usually spares the face, palms, or soles. it is erythematous and blanches; it may be pruritic and demonstrate minimal desquamation. erythromycin appears to be the treatment of choice. section one respiratory disorders ( to ) , and infection has been documented in several travelers from western europe. the pathogenesis of diphtheria involves nasopharyngeal mucosal colonization by c. diphtheriae and toxin elaboration after an incubation period of to days. toxin leads to local tissue inflammation and necrosis (producing an adherent grayish membrane made up of fibrin, blood, inflammatory cells, and epithelial cells) and it is absorbed into the blood stream. fragment b of the polypeptide toxin binds particularly well to cardiac, neural, and renal cells, and the smaller fragment a enters cells and interferes with protein synthesis. toxin fixation by tissues may lead to fatal myocarditis (with arrhythmias) within to days and to peripheral neuritis within to weeks. acute tonsillar and pharyngeal diphtheria is characterized by anorexia, malaise, low-grade fever, and sore throat. the grayish membrane forms within to days over the tonsils and pharyngeal walls and occasionally extends into the larynx and trachea. cervical adenopathy varies but may be associated with development of a "bull neck." in mild cases, the membrane sloughs after to days and the patient recovers. in severe cases, an increasingly toxic appearance can lead to prostration, stupor, coma, and death within to days. distinctive features include palatal paralysis, laryngeal paralysis, ocular palsies, diaphragmatic palsy, and myocarditis. airway obstruction (from membrane formation) may complicate the toxigenic manifestations. accurate diagnosis requires isolation of c. diphtheriae on culture of material from beneath the membrane, with confirmation of toxin production by the organism isolated. laboratories must be forewarned that diphtheria is suspected. other tests are of little value. treatment includes equine antitoxin to neutralize circulating toxin, as well as systemic penicillin or erythromycin. in a teenager, the retropharyngeal space normally does not exceed mm when measured from the anterior aspect of the c vertebral body to the posterior pharynx. in infants, the retropharyngeal space is usually less than one width of the adjacent vertebral body. however, during crying, this distance may be three widths of the vertebral body. also, under normal circumstances, the retrotracheal space does not exceed mm in teenagers when measured from the anterior aspect of c- to the trachea. dotted lines depict the "thumbprint" sign, noted on a lateral neck radiograph, made by a swollen epiglottis. (from reilly bm: sore throat. in practical strategies in outpatient medicine, nd ed. philadelphia: wb saunders, .) acute symptomatic pharyngitis caused by neisseria gonorrhoeae occurs occasionally in sexually active individuals as a consequence of oral-genital contact. in cases involving young children, sexual abuse must be suspected. the infection usually manifests as an ulcerative, exudative tonsillopharyngitis but may be asymptomatic and resolve spontaneously. gonococcal pharyngitis occurs in homosexual men and heterosexual women after fellatio and is less readily acquired after cunnilingus. gonorrhea rarely is transmitted from the pharynx to a sex partner, but pharyngitis can serve as a source for gonococcemia. diagnosis requires culture on appropriate selective media (e.g., thayer-martin medium). recommended therapeutic regimens include a single intramuscular dose of mg of ceftriaxone or a single oral -mg dose of ciprofloxacin. spectinomycin is ineffective performance of a predictive model for streptococcal pharyngitis in children group a streptococcal infections and acute rheumatic fever acute pharyngitis optical immunoassay test for group a ß-hemolytic streptococcal pharyngitis: an office-based, multicenter investigation potential mechanisms for failure to eradicate group a streptococci from the pharynx the changing epidemiology of invasive group a streptococcal infections and the emergence of streptococcal toxic shock-like syndrome: a retrospective populationbased study persistence of group a streptococci in eukaryotic cells-a safe place? what is a throat culture streptococcal pharyngitis: the carrier state, definition and management streptococcus associated toxic shock persistence of acute rheumatic fever in the intermountain area of the united states outbreak of group a streptococcus septicemia in children: clinical, epidemiologic, and microbiological correlates working group on severe streptococcal infections: defining the group a streptococcal toxic shock syndrome: rationale and consensus definition other pathogens community-wide outbreak of group g streptococcal pharyngitis periodic fever, aphthous stomatitis, pharyngitis, adenitis: a clinical review of a new syndrome arcanobacterium haemolyticum in children with presumed streptococcal pharyngotonsillitis or scarlet fever chlamydial pharyngitis mononucleosis caused by epstein-barr virus and cytomegalovirus in children: a comparative study of cases pharyngitis associated with herpes simplex virus in college students pharyngoconjunctival fever caused by adenovirus type epstein-barr virus infections: biology, pathogenesis, and management epstein-barr virus infectious mononucleosis in children: i. clinical and general laboratory findings epstein-barr virus infectious mononucleosis in children: ii. heterophil antibody and viral-specific responses arcanobacterium haemolyticum: biology of the organism and diseases in man life-threatening infections of the head and neck clinical infections and nonsurgical treatment of parapharyngeal space infections complicating throat infection pharyngitis followed by hypoxia and sepsis: lemierre syndrome peritonsillar abscess: clinical and microbiologic aspects and treatment regimens upper respiratory tract infections in young children: duration of and frequency of complications deep neck infections and respiratory distress in children new approaches to the treatment of group a streptococcal pharyngitis treatment of streptococcal pharyngotonsillitis: reports of penicillin's demise are premature penicillin and the marked decrease in morbidity and mortality from rheumatic fever in the united states efficacy of tonsillectomy for recurrent throat infection in severely affected children: results of parallel randomized and nonrandomized clinical trials effect of antibiotic therapy on the clinical course of streptococcal pharyngitis resistance to erythromycin in group a streptococci streptococcal pharyngitis: the case for penicillin therapy duration of positive throat cultures for group a streptococci after initiation of antibiotic therapy clindamycin treatment of chronic pharyngeal carriers of group a streptococci in gonococcal pharyngitis. examination and testing for other sexually transmitted diseases and pregnancy are recommended. chlamydia species and mycoplasma pneumoniae may cause pharyngitis, although the frequency of these infections is disputed. chlamydia trachomatis has been implicated serologically as a cause of pharyngitis in as many as % of adults with pharyngitis, but isolation of the organism from the pharynx has proved more difficult. chlamydia pneumoniae has also been identified as a cause of pharyngitis. because antibodies to this organism show some crossreaction with c. trachomatis, it is possible that infections formerly attributed to c. trachomatis were really caused by c. pneumoniae. diagnosis of chlamydial pharyngitis is difficult, whether by culture or serologically, and neither method is readily available to the clinician.m. pneumoniae most likely causes pharyngitis. serologic (positive mycoplasma immunoglobulin m [igm]) or, less often, culture methods can be used to identify this agent, which was found in % of college students with pharyngitis in one study. polymerase chain reaction (pcr) is diagnostic.there is no need to seek evidence of these organisms routinely in pharyngitis patients in the absence of ongoing research studies of nonstreptococcal pharyngitis. the efficacy of antibiotic treatment for m. pneumoniae and chlamydial pharyngitis is not known, but these illnesses appear to be self-limited. treatment of more complicated m. pneumoniae infections, such as pneumonia (table - ), is indicated with erythromycin, azithromycin, or clarithromycin; doxycycline may be used if the patient is older than years. key: cord- -xo r authors: zhang, yuanzhe; luo, ling; wang, yang; wang, zhiyong title: fcp filter: a dynamic clustering-prediction framework for customer behavior date: - - journal: advances in knowledge discovery and data mining doi: . / - - - - _ sha: doc_id: cord_uid: xo r customer purchase behavior prediction plays an important role in modern retailing, but the performance of this task is often limited by the randomness of individual historic transaction data. in the meanwhile, fragmentation and coagulation process (fcp), a stochastic partition model, has recently been proposed for identifying dynamic customer groups and modeling their purchase behavior. however, fcp is not able to forecast the purchase behavior because such a data-driven method requires transaction observations to conduct clustering. to tackle this challenge, we propose fcp filter, a clustering-prediction framework based on fcp, which can forecast purchase behavior and filter random noise of individual transaction data. in our model, fcp clusters customers into groups by their temporal interests to filter random noise of individual transaction data. then a predictor is built on grouped data. the predicted results are also fed to fcp to adjust the parameter for prior knowledge at the next time step. our model is superior in capturing temporal dynamics and having flexible number of groups. we conduct experiments on both synthetic and real-world datasets, demonstrating that our model is able to discover the latent group of individual customers and provides accurate predictions for dynamic purchase behavior. in modern retailing, accurate prediction on the quantity that customers are going to purchase over items helps retailers to design effective marketing and warehousing strategies. however, the purchase behavior of individual customer is often random, limiting the accuracy of prediction. for example, tom normally purchases bottle of milk in his weekly visit to supermarket, but may buy bottles occasionally. the observation of purchase intensity on transaction data is or but the real purchase intensity could be . , so the observational noise is . and . for those two observations. in the above example, we can see that the purchase behavior of individual customer is not stable. to address this problem, we propose to cluster customers into groups by their historic transaction data because the purchase intensity of customer group is more stable and can represent the real purchase intensity of individuals. the random purchase noise of a customer can be filtered if his latent group could be accurately found. for clustering customers into groups, a dynamic and flexible clustering model, fragmentation and coagulation process (fcp) [ ] , has been recently proposed. fcp is a data-driven clustering model, with scalable number of customer groups, which does not need to be predefined, and can evolve with the data. this property enables fcp to capture the dynamic purchase behavior of customers accurately. however, fcp clustering can only be conducted when customer purchase data is given, which makes it hard to forecast the behavior of customer groups in the future. the significance of fcp in real-world applications is limited by the unavailability of future transaction data. for retailers, forecasting the behavior of customer groups is more important than just grouping customers in the past time. in order to reduce the purchase random noise of individual customers as well as to enable fcp to forecast group purchase intensity, we propose our fcp filter based on fcp to predict purchase intensity at group level instead of individual customer. for example, as shown in fig. , there are groups at t = . we aim to predict the purchase intensity of these groups at t = and use the predicted value of each group as the purchase intensity of its members. the purchase intensity of individual customer changes rapidly and randomly, but the group-based purchase intensity is more stable and easier to discover regular patterns. we can take the group-level purchase intensity as the actual state of its members, while taking the individual customer purchase intensity as the observation of group purchase intensity. by predicting over actual states instead of observations, the individual randomness can be filtered. also, in our model, not only the clustering results influence prediction but also the prediction results influence fcp clustering. in traditional fcp clustering, there is a hyperparameter to represent the prior knowledge of group purchase intensity. since our fcp filter can get the prediction of group purchase intensity, we propose to update this parameter in a time-evolving manner instead of using a predefined value. this parameter can be calculated from prediction results and influence fcp clustering at the next time step. theoretically, an accurate prediction leads to better clustering fitness than fixing the parameter. in summary, we construct a dynamical clustering-prediction framework for modeling customer behavior. the main contributions of our model are ( ) from prediction perspective, this framework helps to filter individual random purchase noise, ( ) from clustering perspective, we enable fcp, a data-driven clustering model, to forecast group purchase intensity. the flexibility and dynamics of our fcp filter are appropriate for modeling customer behavior. it is flexible that the number of groups do not need to be predefined but estimated from customer transaction data. it is dynamic that the customer membership and group number can change with time. the hyperparameter controlling the priori knowledge of group purchase intensity is also updated dynamically so that the group purchase intensity can be estimated more accurately. clustering on customers is also known as customer segmentation, which aims to identify the customers whose purchase behavior is in the same manner [ ] . in order to identify customer groups, the data-driven approaches based on clustering analysis are formal and reliable solution [ ] . decision tree [ ] was used to segment customers using their demographic information. clustering models like k-means [ ] for static clustering and mixture model based on non-homogenous poisson process [ ] for tracking dynamic group interests were also proposed. however, the preferences and interests of customers may also change over time. in order to track the customers' temporal shifting across groups, a novel bayesian non-parametric customer segmentation model fc-csm [ ] based on a random partition process, fragmentation and coagulation process (fcp) [ ] , was proposed. it achieves high accuracy in fitting individual purchase frequency. besides modeling the dynamics of segmentation, another advantage of fc-csm is the flexibility. there is no need to set the number of customer groups manually, which can be learned automatically from data directly. however, the fc-csm relies on the observed transaction data, so that the clustering can only be conducted for the past time. it is more meaningful to forecast the purchase behavior of groups instead of only analyzing past data. in this way, we propose to build prediction on fcp. due to the efficiency of fcp to identify latent groups and model purchase behavior, the prediction could be more accurate than individual prediction. our problem can be formally described as follows. given the transaction data of a product, a matrix x u ×t is generated to record the transaction quantity, for u customers during t time steps. each entry x it in x u ×t refers to the purchase quantity of customer i at time step t. the task is to forecast the purchase quantities of customers at the next time step t + , i.e.Λ u × t + in whichλ i(t + ) means the predicted purchase quantity of customer i at time t + . overall, our model has three main components: ( ) customer segmentation based on fcp; ( ) tracking model to track group purchase intensity trajectory and ( ) predictor to forecast group purchase intensity at next time step. we adopt fragmentation and coagulation process (fcp) [ , ] , a dynamic random partition model, to segment customers and capture dynamic interests of customers. the schematic diagram of fcp from time step t to t + is illustrated in fig. . fcp contains two procedures: fragmentation and coagulation. given the initial customer partition π t , at the fragmentation step, each customer group can remain the same or be split into several subgroups, forming the intermediate partition π t . then, at the following coagulation step, a group can remain the same or be merged with other groups, forming the new partition π t+ . in this way, fcp can capture the evolution of customer segmentation from t to t + . theoretically, fcp is flexible to model any change of segmentation, which means that the new segmentation can be totally different from the previous one. priori probability of customer segmentation. fcp defines the priori transition probability from partition π t to π t+ . formally, at t = , we adopt a random partition process chinese restaurant process (crp) [ ] to model the initial partition of customers, and the probability of customer i in group g is: where the hyperparameter ρ is to control the probability that the customer starts a new group, and m g denotes the set of customer members in group g. π −i t is the partition of customers except for customer i at t, which assumes customer i is the last one who needs to allocate. in crp model, the larger groups of a partition tends to attract more members and becomes larger. given partition and allocation at previous time step, for customer i, the transition probability from group g in the current partition to group g in fragmentation step is defined as: which refers to the groups splitting from m g . equation ( ) shows that a customer is more likely to join large groups splitting from m g . the hyperparameter δ controls the probability that customer i starts a new group not existing in the previous group π t (i), which is also the temporal dependency of partitions between consecutive time steps. similarly, in the coagulation step, the transition probability of customer i joining group l from the intermediate group g is: where c t (m l ) = b|b ∈ π −i t+ , b ⊆ m l , b = φ denotes the set of subgroups merged into m l . the priori knowledge is that a customer is more likely to join the group that merged by more subgroups. the individual purchase quantity is modeled by poisson distribution. given the purchase quantity of customer i at time step t, x it , the likelihood of customer i belonging to group g at t is represented as follows: where the purchase intensity for customer group g is λ g . the purchase intensity has gamma distribution as its prior, due to the conjugacy of poisson and gamma distributions. therefore, we have the maximum a posteriori (map) of λ g as follows: where the purchase intensity of a group can be interpreted as the average purchase quantities of its members, and impacted by the hyperparameters of α t (i.e. shape parameter) and β (i.e. scale parameter) of the gamma prior. for each customer i, we need to determine the purchase intensity trajectory {λ it } t in order to predict for the future. an intuitive idea is to use the purchase intensity of the group that customer i belongs to along the time as the trajectory of purchase intensity, i.e. λ it = λ πt(i) for any t. however, the customer interests are evolving with time that the groups from the past may not fit the customers' current interests, and those λ πt −n(i) may demonstrate misleading trends for prediction. therefore, we propose to predict their purchase intensityλ i(t + ) only considering the current group membership, π t (i) and backtrack the intensities of this group in the past time steps, instead of using the actual groups the customers belonged to. the difficulty for tracking the purchase intensity of group π t (i) is that the group members could be totally different in consecutive time steps i.e. m πt(i) = m πt− (i) . to address this problem, we build a backward tracking model to get the series of purchase intensities for the current group m πt (i) in partition π t . assume the group we are going to track is denoted as g tracking and the members of g tracking as m g tracking . the group g tracking is initialized as π t (i) for current time step t = t . if there exists g ∈ π t− satisfying tracking rules (eq. ( )), we update the group g as the new group to be tracked. in the tracking rules (eq. ( )), we require that the majority of group g has shifted to group g tracking and the majority of group g tracking come from group g. the hyperparameter η and η are generally set as > . , so there could only be at most one or no tracked group. if there is no group g ∈ π t− satisfying the tracking rules, g tracking remains the same: as to the individual purchase intensity, it is defined as follows based on whether there is a group g found: if there is no tracked group g found, we use the average purchase intensity at t − of all members of group g tracking to represent tracked group intensity. by computing backwards from t = t to t = , we can finally get the trajectory of group purchase intensity {λ it } t for customer i. finally, the prediction model can be applied on the tracked purchase intensity in traditional fcp, the priori distribution of group purchase intensity is modeled by gamma distribution with static predefined hyperparameter α t and β in eq. ( ). since our fcp filter can get the prediction of group purchase intensity, we propose to update this prior hyperparameter with the prediction results so that the priori knowledge of group purchase intensity could be more accurate. for gamma distribution, we estimate the parameter α t + by maximum likelihood estimation (mle), taking the predicted group purchase intensityλ g at time step t + as observations, and we have: where |π t | is the total number of groups in the partition. our framework does not restrict the prediction models to use, and we have tested the performance of using the framework with various models including linear regressions and long short term memory (lstm) in our experiments. the generative graphical model of our fcp filter is shown in fig. . the initial partition π is sampled based on crp rules and the partitions in following time steps obey fcp rules as described in sect. . . given customer i belonging to group π t (i) at time t, the individual purchase intensity x it is drawn from poisson distribution with parameter λ πt(i) , which is the purchase intensity of the group he belongs to. the group purchase intensity λ πt(i) at time t is drawn from gamma distribution with hyperparameters α t (i.e. shape parameter) and β (i.e. scale parameter). it is worth noting that α t is dynamic, which means that different α t at different time step t, that is different from original fcp. the parameter α t is computed by using mle of gamma distribution with the predicted group purchase intensityλ t and the scale parameter β as shown in sect. . . the customer partition and allocation are inferred by sampling using the posterior transition probabilities, computed by eqs. ( ) and ( ) based on the priori transition probabilities and the observation likelihood terms. for the customer segmentation component, we use gibbs sampler to infer the group membership of each customer over time π t (i). in more detail, since the fcp is exchangeable and projective [ ] , we assume that customer i is the last customer to be sampled, which means that we can allocate customer i given the allocation of all the other customers. according to bayesian theorem, the sampling posterior transition probabilities for split and merge steps are defined respectively as: where the priori terms in the equations above can be calculated based on eqs. ( ) and ( ) by forward and backward algorithm as used in hidden markov model [ ] , with the likelihood terms given in eq. ( ). in summary, the dynamic customer segmentation is firstly modeled by fcp. then we build tracking model to get intensity trajectory of each latent group. after that, predictor can be used to predict the purchase intensity of tracked groups. finally, the predicted results also influence fcp clustering at the next time step by updating α t . we conducted experiments on synthetic and real-world datasets to illustrate that our model can ( ) identify dynamic customer groups based on purchase behavior, ( ) achieve more accurate prediction results by filtering individual random noise. the hyperparameters are empirically set using validation dataset as follows: ρ = . , δ = . , η = η = . , α = and β = . . the evaluation metrics in our study is the mean absolute error (mae). the mae measures the average error between predicted purchase intensity and the ground truth. we generate a synthetic dataset to demonstrate our model's capability to identify the latent group and customer shifting over groups. there are products in the synthetic dataset. for each product, we generate purchase quantity x × of customers from latent groups with time steps. specifically, we firstly generate the group purchase intensity of those groups at the first time steps randomly Λ × . at each time step, we sort the grouplevel purchase intensities from large to small values, so that those groups can show relevant purchase patterns continuously. to fill in the intensity matrix Λ × of time steps, λ gt from t = to t = is generated by linear regression of orders: λ gt = n= a n * λ g(t−n) + b. then all customers are allocated into those groups randomly at t = . we assume that a customer changes group membership over time with probability of . , which means that the customers have % of chance shifting into another group. finally, we generate customer purchase quantities using poisson distribution with parameter λ = λ πt(i) based on their allocation. we test the predicting performance using fcp filter model and using individual records. as the purchase intensity of each group in our synthetic data evolves according to the rule of linear regression of orders, the same regression predictor is used for both cases. accurate prediction results could demonstrate the capability of our model to identify latent groups for customers. the results are shown in fig. comparing these two models. we can see that our fcp filter achieves lower mae on almost all products. the average mae over products of individual prediction and our fcp filter are . and . , respectively. this means that fcp filter successfully tracked the evolving purchase intensity of latent groups in this dynamic dataset and predicted accurately. to illustrate the flexibility of fcp filter, we also compared the average mae using prediction models built on static k-means clustering with different number our model outperformed static k-means clustering with k = or , even when the ground truth for the number of clusters is . it shows that the importance of dynamics and flexibility of fcp filter in capturing the evolution of the purchase intensities. moreover, there is no need to pre-define the number of clusters in our model. in this section, we use a real-world supermarket dataset to illustrate our model's capability of filtering random purchase noise of individuals to get accurate prediction and usage of various predictors. the dataset contains , , transaction records of , frequent customers on , products in days (about two years). the transaction data is sparse in the first several months, so that we use the transaction data from days to days ( weeks) for experiments. we divide weeks into time steps with weeks in each time step. we select popular products, which had the largest number of records and common in our daily life for experiments such as milk, cereal, eggs and so on. for each product, we discard customers who never bought that product and who ranked at the top % based on purchase quantities as outliers. we randomly sample customers for computational convenience and the purchase frequency is defined as the quantity purchased by a customer at one time step ( weeks). several predictors are applied in our experiments to show fcp filter can generally achieve better prediction accuracy. they are lstm network, -order and -order linear regressions, and a last-step predictor which takes the value at last time step as predicted value λ i(t + ) = λ πt (i) . the average mae is shown in table . similar to the results on the synthetic data, our fcp filter achieves the best prediction accuracy with all the predictors. it is mainly because our dynamic model is suitable for modeling customers' dynamic interests and identifies the latent groups covered by random individual purchase behavior. we notice that the -order regression is not accurate and stable, and the possible reason could be that it is sensitive to the input purchase intensity series data. specially, fig. shows the prediction results of our model and individual model with the simple last-step predictor on all products. our fcp filter gets higher prediction accuracy than individual prediction for every product. since the predictor is quite simple, this result implies that the evolving customer purchase intensity is closer to group purchase intensity than individual one, and our fcp filter is able to find the latent group of customers and filter the noise in the individual records to produce accurate prediction results. we build a dynamic and flexible clustering-prediction framework fcp filter to predict customer purchase intensity regardless of the random noise of individual customer behavior. our model segments customers by fcp and then predict customer purchase intensity on the tracked group purchase intensity. after that, the prediction result adjusts priori knowledge of clustering at next time step. we conduct experiments on both synthetic and real-world datasets, and show that fcp filter model is able to ( ) identify the latent group and track purchase intensity evolving trends of groups; ( ) improve the accuracy of customer purchase intensity prediction. our framework is scalable with the datasets, without the needs of defining the number of clusters and is flexible to work with different predictors. generally, our proposed model is not restricted to the domain of customer behavior modeling. it is also useful for other sequential data containing subjects that shifting among latent groups. in our future work, our model will be built on other domains with sequential data to improve prediction accuracy. random fragmentation and coagulation processes pattern recognition and machine learning customer segmentation based on transactional data using stream clustering data mining for shopping centres-customer knowledge-management framework customer segmentation and strategy development based on customer lifetime value: a case study discovering temporal purchase patterns with different responses to promotions tracking the evolution of customer purchase behavior segmentation via a fragmentation-coagulation process combinatorial stochastic processes modelling genetic variations with fragmentation-coagulation processes a survey of the challenges and pifalls of cluster analysis application in market segmentation key: cord- - egdwe authors: gouda, walaa; yasin, rabab title: covid- disease: ct pneumonia analysis prototype by using artificial intelligence, predicting the disease severity date: - - journal: egypt j radiol nucl med doi: . /s - - - sha: doc_id: cord_uid: egdwe background: since the beginning of , coronavirus disease has spread widely all over the world and this required rapid adequate management; therefore, continuous searching for rapid and sensitive ct chest techniques was needed to give a hand for the clinician. we aimed to assess the validity of computed tomography (ct) quantitative and qualitative analysis in covid- pneumonia and how it can predict the disease severity on admission. results: one hundred and twenty patients were enrolled in our study, ( . %) of them were males, and ( . %) of them were females with a mean age of . ± . years old, ranging from to years. groups b and c showed significantly increased number of involved lung segments and lobes, frequencies of consolidation, crazy-paving pattern, and air bronchogram. the total lung severity score and the total score for crazy-paving and consolidation are used as severity indicators in the qualitative method and could differentiate between groups b and c and group a ( . % sensitivity, . % specificity, and . % sensitivity, . % specificity, respectively), while the quantitative indicators could differentiate these three groups. using the quantitative ct indicators, the validity to differentiate different groups showed . % sensitivity and . % specificity for the opacity score, and . % sensitivity and . % specificity for the percentage of high opacity. conclusion: advances in ct covid- pneumonia assessment provide an accurate and rapid tool for severity assessment, helping for decision-making notably for the critical cases. coronavirus disease (covid- ) was firstly diagnosed in wuhan, china; was announced by the who to be caused by a novel coronavirus (sars-cov- ); and causes a respiratory disease pandemic [ ] [ ] [ ] [ ] . initially, covid- diagnosis was depending upon real-time reverse transcriptase polymerase chain reaction (rt rt-pcr). ct has shown to be a sensitive method for the initial evaluation of the patients [ ] . on ct scan, the disease was commonly presented in the form of peripheral multifocal ground-glass opacities and consolidation [ ] [ ] [ ] [ ] [ ] . with the dramatic increase in the patient's number, it becomes necessary to create methods to help doctors in their war against the virus. that is why the artificial intelligence (ai) starts to share to reduce the burden on clinicians [ , ] . so, the role of ct in the assessment of covid- can be greatly optimized by the help of automated image analysis with artificial intelligence techniques allowing accurate and rapid assessment in a large number of patients, help for the fast clinical decision-making, and improve workflow efficiency. the average time for manual (semi-quantitative) ct assessment is min which can be reduced into s using the ai [ , [ ] [ ] [ ] [ ] [ ] [ ] [ ] . our study was aiming to evaluate the performance of the quantitative and qualitative ct severity scores and their usefulness as rapid and sensitive indicators for the disease severity. one hundred and twenty patients who were tested positive for novel coronavirus by nasopharyngeal swap were enrolled in our retrospective study in the period of may and june . there were males and females with a male to female distribution of . : and with an age range from to years old with mean = . ± . . the study protocol was approved by the local ethics committee. all patients provided a written informed consent. patients were stratified into three clinical groups based the who interim guidance [ , ] : group a, mild cases; group b, severe cases; and group c, critical cases. group a involves patients with mild clinical symptoms in the form of fever, mild respiratory tract manifestations, and positive ct findings of pneumonia. group b involves patients with respiratory rate ≥ times per minute, oxygen saturation ≤ % at rest, arterial oxygen partial pressure (pao )/inspired oxygen (fio ) ≤ mmhg ( mmhg = . kpa), or significant progression of pneumonia ct findings within - h ≥ %. group c involves patients that are admitted to the intensive care unit for mechanical ventilation or had a fio of at least % or more. all ct examination was performed using two multidetector ct scanners (somatom perspective, siemens, germany, and optima ct , ge, america), using the following parameters: tube voltage = kvp, tube current (regulated by automatic dose modulation), - mas, pitch = - . mm, matrix = × , slice thickness = mm, and fov = mm × mm. image reconstruction was done at a slice thickness of - . mm. all were the initial ct scans at the time of patients' admission and are performed as non-contrast studies. two experienced radiologists ( years of experience) independently reviewed all the scans, and they were blinded to the patients' clinical and laboratory data. ct severity score was estimated for each one of the five lung lobes by calculating the dissemination of the chest manifestations (opacity), namely the ground-glass opacities (ggo), consolidation, crazy-paving pattern, septal thickening, and pulmonary fibrosis giving score ( - ) for , , , and ≥ % involvement, respectively, with the sum representing the total severity scores for the whole lung ( - ). previous studies [ , ] reported that the degree of consolidation and crazy-paving pattern was highly suggestive for the disease progression/peak, so we used a total sum extent of crazy-paving and consolidation as an indicator for the disease severity. the severity score for the consolidation and crazy-paving was calculated for each lobe using the same criteria ( - scores), and the total score for the lungs is the sum of individual lobes ( - scores). ct pneumonia analysis algorithm is designed by siemens healthineers to automatically identify and quantify abnormal tomographic patterns in the lungs from chest ct for research purposes. the system takes as input a non-contrasted chest ct, and identifies and d segments the lungs and lobes before segmenting the abnormalities. it outputs two combined measures of the severity of lung/lobe involvement, quantifying both the extent of covid- abnormalities and presence of high opacities. high opacity abnormalities were shown to correlate with severe symptoms. the first disease severity measure is global, while the second is lobe-wise: the computed results could be used to analyze the severity and monitor the progression of abnormalities in patients exhibiting covid- symptoms. the family of ai-powered augmented workflow solutions, running on the teamplay digital health platform, helps to reduce the burden of basic repetitive tasks and increase the diagnostic precision when interpreting medical images. its solutions provide automatic postprocessing of imaging datasets through ai-powered algorithms. the automation of routine workflows with repetitive tasks and high case volumes helps to ease the daily workflow, so that the radiologist can focus on more critical issues. this system is capable of computing the severity scores in approximately s per case versus min for manual annotations. these results could be used to rapidly assess the extent of lung infection and monitor the progression of abnormalities in patients exhibiting covid- symptoms. using an artificial intelligence algorithm, the abnormal tomographic patterns commonly present in lung infections, namely ground-glass opacities (ggo) and consolidations, were automatically detected and quantified. this algorithm estimates the overall lung affection and quantifies the high opacity abnormalities using a d segmentation of lesions, lungs, and lobes. opacity score is calculated for each lobe by estimating the given region percent opacity as follows: score= , ≤ %; score = , - %; score = , - %; score = , > %; and score = and the total score is the sum of these values. variable parameters are also obtained including lung volume (ml), volume of opacity (ml), percentage of opacity within a given lung region (%), volume of high opacities as absolute value (ml), a given lung region percentage of high opacities, total mean hu, given lung region mean hu of opacity, total hu standard deviation, and a given lung region opacity hu standard deviation. all these parameters are calculated for the whole lung, left lung, right lung, and per lung lobe, respectively. anova test was used for the comparison of quantitative variables between more than two groups of normally distributed data with tukey's test as the post hoc test while the kruskal-wallis test was used for the comparison of quantitative variables between more than two groups of not normally distributed data with tamhane's test as the post hoc test. pearson's correlation was used to show correlation between two continuous normally distributed variables while spearman's correlation was used for not normally distributed ones. -chi-square test (χ ) was used to study association between qualitative variables. whenever any of the expected cells were less than five, fisher's exact test was used. z test was used to compare column proportions. -receiver operating characteristic (roc) with respective points of maximal accuracy for sensitivity and specificity was generated to determine radiological variables' performance. area under the roc curve (auroc) measures the accuracy of the test. an area of represents a perfect test; an area of . represents a worthless test. two-sided p value of < . was considered statistically significant. one hundred and twenty proven covid patients were enrolled in this retrospective including ( . %) males and ( . %) females. the patients' age ranged from to years old with a mean age of . ± . . there were patients ( . %) within group a, patients ( . %) in group b, and patients ( . %) in group c. covid- pneumonia ct chest manifestations generally show more common bilateral and peripheral distribution ( patients, . %) with the ggo as the commonest finding ( patients, . %) followed by the consolidation ( patients, . %) and septal thickening ( patients, . %) then the crazy-paving pattern ( patients, . %). air bronchogram was also a common finding ( patients, . %) while pleural fibrosis and effusion were seen only in patients ( . %) and patients ( . %), respectively. table shows the comparison of the chest manifestations among different clinical groups, all chest findings: diffuse lung involvement ( fig. ) was significantly higher in group c than other groups while peripheral and random distribution was significantly lower in group c as compared to the other groups. consolidation, air bronchogram, septal thickening, lung fibrosis, and pleural effusion have a significant difference between group a and other groups (b and c) with p value < . , so it can differentiate between them. but it could not differentiate between groups b and c. crazy-paving pattern (fig. ) was significantly higher in group c than other groups (a and b) and significantly lower in group a than other groups (b and c). it was the only chest finding that could differentiate between all groups with p value < . . ggo showed similar distribution in different groups with no statistically significant difference between them. there was a highly statistical significance between the different groups as regards the calculated total severity score and total score for crazy-paving and consolidation as well as number of involved lung segments with p value < . , while for the number of involved lobes of the lungs, there was a statistical significance between group a and other groups (b and c) with no statistical significance between group b and group c. significantly lower than other groups in the same category *significantly higher than other groups in the same category groups b and c also showed longer time interval between the disease onset and the initial ct scan than group a, yet with no significant difference between the two groups (b and c). as regards the quantitative analysis, most of its parameters were significantly different among different clinical groups. the total opacity score, percentage of opacity, volume of opacity, and mld were significantly higher in groups b and c compared to group a as well as between group b and c (all p value < . ) ( table ). the total lung volume was significantly lower in group c compared to group a (figs. , , , , , and ). lav and hav could not differentiate between group a and group b, but it showed a high statistically significant difference between groups a and c for lav (p value < . ), and high significant difference between groups b and c for hav (p value < . ). all the other quantitative parameters showed significant difference between different groups except the mean hu of the opacity that showed no significant difference between both groups b and c (p value = . ). the cutoff values of statistically significant ct parameters were estimated by applying the curves of the receiver operating characteristic to assess the sensitivity and the specificity of these indicators to differentiate between group a from the other two groups (table ) . we found that the cutoff values to differentiate between group a from other groups were . for total severity score . with . % sensitivity and . % specificity, while . for total opacity score with . % sensitivity and . % specificity. total score for crazy-paving and consolidation > . can differentiate between group a from other groups (b and c) with . % sensitivity and . % specificity. lav and hav had low specificity to differentiate between groups . % and . %, respectively. when more than lung segments are involved, it can differentiate group a from other groups with . % sensitivity and . % specificity. the cutoff value for mld was − . to differentiate between different groups with . % sensitivity and . % specificity. there was a high statistical significance between total severity score, total opacity score, and total score for crazy-paving and consolidation in relation to the clinical grouping with p value < . (table and fig. ) . so, most of the qualitative parameters could not differentiate group c from group b while quantitative parameters provide an easy, rapid, and highly sensitive tool for accurate differentiation between the different clinical groups. covid- disease is a highly contagious illness that showed rapid worldwide spread. early disease diagnosis is very crucial for disease containment strategies and the management of the patients [ , ] . the significant increase of the patients' number creates a great challenge for covid- laboratory testing owing to the limited facilities and inadequate supply of nucleic acid kits. using chest radiographs at the initial disease assessment showed a significant number of false negatives due to its deficiency to detect the early disease abnormalities [ ] . chest ct shows significantly higher sensitivity for detection of mild pulmonary manifestations in early disease stages. that is why, chest ct has become a forefront diagnostic tool during the covid- pandemic [ ] . previous literature has shown similar results [ ] [ ] [ ] [ ] , concerning the predominance pattern of abnormal chest ct manifestations to be bilateral and peripheral with the ggo and consolidation which are the commonest findings; however, they are not indictors for different clinical group stratifications. correlation with pathological findings can give explanation for this, as in early disease stages virus invasion causes alveolar damage with interstitial pulmonary infiltration manifested as alveolar edema with protein exudate and interlobular thickening of the interstitium. through the disease progression, diffuse alveolar damage with cellular fibromyxoid exudate can induce critical disease stage, yet both types of exudate manifest as ggo [ , ] . disease progression (severe/critical stages) is probably induced by more infiltration of the lung parenchyma and interstitium [ , ] which is caused by invasion of the respiratory epithelium by the virus with disseminated damage of the alveoli, necrotizing bronchitis, and total quantitative analysis by ai-rad companion research ct pneumonia analysis was presented (d-g) with the measured parameters seen in table (g). quantitative total opacity score was fig. a -year-old male with positive covid- virus. ct chest shows bilateral consolidation patches with air bronchogram, crazy-paving appearance mainly peripheral and basal, and subpleural lines (arrows) with more involvement of the left upper and both lower lobes (arrows in a-c). total severity score = . quantitative analysis (d-g) by ai-rad companion research ct pneumonia analysis was presented with the measured parameters seen in table (g). quantitative total opacity score was gouda and yasin egyptian journal of radiology and nuclear medicine ( ) : page of alveolar filling by the inflammatory exudate. this explains the increase of consolidation and crazy-paving pattern frequencies in severe/critical cases comparing to the mild ones [ , ] . in our study, qualitative chest findings such as consolidation, air bronchogram, septal thickening, lung fibrosis, and pleural effusion showed a significant difference between group a and other groups (b and c) with p value < . , but it could not differentiate between groups b and c. this agreed with lyu et al. who stated that using qualitative indicators could not differentiate group c from group b, but quantitative indicators could distinguish them [ ] . in our study, crazy-paving pattern could differentiate between all groups with high statistical significance (p value < . ). it was significantly higher in group c than other groups (a and b) and significantly lower in group a than other groups (b and c). the total score for crazy-paving and consolidation > . could differentiate between group a from other groups (b and c) with . % sensitivity and . % specificity. this agreed with lyu et al. who had proposed the use of the total score for crazy-paving and consolidation as indicator for differentiation of different clinical groups and proved its significance; higher total score for crazypaving and consolidation > had % sensitivity and % specificity [ ] . our study showed that the number of involved lung segments and lobes was significantly higher at different disease stages with positive correlation with the disease progression. the whole lung total severity score has been shown as a poor prognostic indicator in patients with covid- . we found that the cutoff values to differentiate between group a from other groups were . for total severity score . with fig. a -year-old male with positive covid- virus. ct chest shows diffuse bilateral confluent consolidation with air bronchogram, crazypaving appearance, subpleural thickening with fibrosis, and organizing pneumonia pattern of covid- (arrows in a-c). total severity score = . quantitative analysis (d-g) by ai-rad companion research ct pneumonia analysis was presented with the measured parameters seen in table (g). quantitative total opacity score was [ ] . also, chung et al. did a study on cases of covid- and found the total lung severity score ranged from (in the three normal ct examinations) to a maximum of , with a mean score of . . the patient with the highest lung severity score was admitted to the intensive care unit [ ] . the time interval between the initial ct scan and the disease onset was significantly longer in severe/critical cases compared to mild ones, and this might be partly due to that some cases were only hospitalized with progression of the disease symptoms. comparing the quantitative parameters among different clinical groups, most of them were significantly different in our study. the total opacity score, percentage of opacity, and volume of opacity were significantly higher in severe cases compared to the non-severe cases, and these were consistent with previous results [ , ] . different from previous studies of the quantitative analysis [ , , ] that assessed the disease extension depending on the quantifying opacification percentage, our study also envaulted the relative volume of normal lung density which was significantly lower in critical cases and this could be very helpful for the management of these patients and add an important value of quantitative analysis in clinical practice. the cutoff value for mld in our study was − . to differentiate between different groups with . % sensitivity and . % specificity. lyu et al. found in their study that critical cases showed higher mld > − hu with sensitivity and specificity of % and % [ ] . table spearman's correlation between total severity score, total opacity score, and total score for crazy-paving and consolidation in relation to clinical grouping we observed in our data that the hav and percentage of high opacity were significantly higher in severe cases denoting high-density lesions, which match with the increased total score for crazy-paving and consolidation in the qualitative method. hav > − . and the percentage of high opacity > . showed . % and . % sensitivity and . % and . % specificity for the detection of critical/severe cases. mld at cutoff value > − . hu showed . % sensitivity and . % specificity for clinical group stratification. this agreed with lyu et al. who stated that hav values increased in more severe cases due to increased high-density lesions. the higher hav values (above than − hu) are seen in the critical cases [ ] . the quantitative pneumonia analysis was standardized depending upon the changes in lung density and volume changes, except for cases with co-existent chest condition where the manual adjustment was performed if necessary, to ensure the accuracy of lung segmentation. the limitations of our study included a specific software that is required for the quantitative ct application which may restrict its clinical application. that is why the qualitative analysis can give a hand for initial disease assessment as it also showed a good sensitivity and specificity for disease stratification allowing early management of the critical cases. our study included only the initial ct study; assessment of the follow-up scans may be recommended in later researches. we concluded that the qualitative parameters including the whole lung total severity score and the total score of crazy-paving and consolidation can be used as a good indicator for disease stratification, while the other parameters could not distinguish moderate and severe disease stages. quantitative parameters have been shown to be helpful in this and provide accurate discrimination of this intermediate stage from severe one. world health organization website the clinical and chest ct features associated with severe and critical covid- pneumonia the performance of chest ct in evaluating the clinical severity of covid- pneumonia: identifying critical cases based on ct characteristics quantitative computed tomography analysis for stratifying the severity of coronavirus disease crazy paving" pattern at thin-section ct of the lungs: radiologic-pathologic overview clinical course and outcomes of critically ill patients with sars-cov- pneumonia in wuhan, china: a single-centered, retrospective, observational study ct image visual quantitative evaluation and clinical classification of coronavirus disease (covid- ) imaging profile of the covid- infection: radiologic findings and literature review initial ct findings and temporal changes in patients with the novel coronavirus pneumonia ( -ncov): a study of patients in wuhan, china chest ct severity score: an imaging tool for assessing severe covid- radiology serial quantitative chest ct assessment of covid- : deep-learning approach clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan fleischner society: glossary of terms for thoracic imaging evaluation of the extent of ground-glass opacity on high-resolution ct in patients with interstitial pneumonia associated with systemic sclerosis: comparison between quantitative and qualitative analysis pulmonary pathology of early phase sars-cov- pneumonia imaging of pulmonary viral pneumonia pathological findings of covid- associated with acute respiratory distress syndrome early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia viral pneumonia requiring differentiation from acute and progressive diffuse interstitial lung diseases novel wuhan ( -ncov) coronavirus mortality of critically ill patients with severe influenza starting four years after the pandemic ct imaging features of novel coronavirus ( -ncov) publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to thank all people who helped us in this work including the clinicians and technicians. equal sharing between authors as regards the writing of the manuscript, the collection and analysis of data, and the revision of the final manuscript. all authors have read and approved the manuscript. self funding. all data and material are available. the study protocol was approved by the local ethics committee. all study procedures were performed in accordance with the ethical standards laid down in the declaration of helsinki and its later amendments. there is no available ethics committee reference number. a written consent was taken from all patients prior to the study to be included in our study. a written consent was taken from all patients prior to the study for publication. no competing interests.received: july accepted: september key: cord- -gqltd u authors: nan title: poster sessions date: - - journal: pediatr pulmonol doi: . /ppul. sha: doc_id: cord_uid: gqltd u nan in this study. the near-fatal group accounted for %. the months to years age group accounted for %. female/male ≈ . / . sixtyone percent of children were from hồ chí minh city. admission to icu increased recently. dyspnea was the chief complaint, accounting for %. cough, wheezing, dyspnea were essential symptoms. fiftly-one percent had a history of asthma. preventer medication ownership was recorded in % of cases. the rate of impaired consciousness was . %. % had a ph < . % and % had a paco > mm hg. chest x-rays showed hyperinflation, infiltrates and atelectasis. time of treatment was days ( , ), days in icu was days ( , ). ten children were intubated, . % received ncpap; . % of children older than year were given mgso , % children were given diaphyllin, % children were given salbutamol and % children were given adrenaline subcutaneously. all intubated patients received pressure control ventilation. inspiratory pressure was to cmh o to achieve tidal volume of approximately ml/kg, mean peep was cmh o, fio was approximately % and i/e was / - / . conclusions: appropriate treatment at first is crucial to lower the number of children to be intubated. mechanical ventilation still remains the last recourse in the treatment of near fatal exacerbations of asthma after mgso , diaphyllin and salbutamol. a- | peanut and brazil nut sensitization profile among asthmatic patients in southern taiwan data on its importance in asian populations. the relevance of cdhr to childhood lung functions is also unknown. this cross-sectional study investigated the associations between cdhr and wheezing illnesses and lung function of preschool children in hong kong. methods: chinese children younger than years of age were recruited from randomly selected nurseries and kindergartens throughout hong kong. the demographic, early-life exposures and allergy phenotypes of these preschool children were recorded by validated and modified isaac questionnaire. these children underwent incentive spirometry to measure their forced expiratory indices. their buccal swabs were collected for dna extraction and tagging single-nucleotide polymorphisms (snps) of cdhr were determined by taqman genotyping assays. genotypic and haplotypic associations between these snps and wheezing and lung function traits were analyzed by multivariable regression and r-package haplo.stats . . , respectively. results: the mean (sd) age of a total of children was . ( . ) years. forty-one percent of them had domestic exposure to cigarette smoking, whereas % and % had wheeze ever and current wheeze respectively. current wheeze was associated with rs and rs of cdhr , with the respective odds ratios (ors) being . and . . these two snps were also associated with frequency of wheezing illnesses over the past months, with ors being . (p = . ) for rs and . (p = . ) for rs . current wheeze was also associated with the -locus gac haplotype of cdhr (or, . and p = . ). two cdhr , snps rs and rs were associated with fev . , fvc and fev . /fvc, and the ggg haplotype was associated with fev . . a- | development and validation of an adherence questionnaire for adolescents with asthma on controller inhaled corticosteroids with asthma on ics at multiple hospitals and clinics in japan. adherence to ics medication was separately evaluated by "confidential" questions to ask frequency of "forgetting to take medicine" by nonmedical study staff. the best model to predict adherence was formed by multivariate logistic analysis. validation of the model was performed using answers to the questions from a separate group of ics-treated asthma patients of the same age. results: responses from adolescents were used as development data set and those from separate adolescents were used as validation data set. a -item logistic model was selected from the development data set. it showed good statistical fit and well discriminated poor adherence with auc at . and . in development and validation datasets, respectively. probability of adherence was calculated as propensity score in the logistic regression model and named as the pediatric asthma adherence questionnaire (paaq) score. the paaq scores for the physicians' ratings of adherence differed significantly in the hypothetical direction. the paaq may be a useful tool to evaluate adherence in adolescents with ics-treated asthma. a- | effect of long-term inhaled corticosteroid therapy on adrenal suppression growth and bone health in children with asthma years diagnosed as having asthma on inhaled corticosteroid therapy for more than months were included as cases. children who were on oral steroids for exacerbations a week before the study, asthma with other chronic illnesses and children over years old to avoid the confounding effects of pubertal growth acceleration seen at this age, were excluded. comparison group consisted of age-matched children with asthma who were not on ics. heights were assessed according to their mid parental heights (mph). serum calcium, alkaline phosphatase and vitamin d levels were assayed in both groups. low dose short synacthen test was performed on cases and serum cortisol at , , minutes of the test was performed to assess hpa axis function. peak cortisol level > nmol/l at minutes was considered to have passed the test and exclude adrenal suppression. the average daily dose of ics was categorized as low, medium and high according to published literature. results: both the associations between long-term ics and growth (chi square value = . , p = . ) and calcium levels (p = . ) were not statistically significant. a significant association was found between long-term inhaled corticosteroid therapy and alp level (p < . ) although the interquartile ranges of serum alp in both groups were within the normal range for the age. there was no statistically significant difference in vitamin d levels in both groups (p = . ), although vitamin d levels were deficient in % of cases and % of controls (< nmol/l). interestingly suppressed cortisol levels were seen in % of cases. cumulative doses of ics in cases were low, medium and high in %, % and % of children respectively. results: total antibiotic use appeared to have decreased year after follow-up in a specialized asthma clinic. both the overall use (p . ) and the use of amoxycillin / clavulanate (p . ) were statistically significant. the use of amoxycillin, cephalosporins and macrolides was also found to be reduced. a statistically significant reduction was also found in the use of antihistamines (p . ). in terms of quality of life, a statistically significant improvement was found in the worry domain of asthma both in children (p . ) and their parents (p . ) as well as in the impact domain for parents (p . ). methods: in this prospective cross sectional study, we enrolled consecutive children between to years of age with poorly controlled asthma (partly controlled and uncontrolled as per gina guidelines) between july to march . we excluded children with cystic fibrosis. the enrolled children were investigated for abpa that included total ige, aspergillus-specific ige, aspergillus-specific igg, skin prick test for aspergillus, serum precipitins, absolute eosinophil count (aec), chest x-ray, and chest ct (in selected patients). abpa was diagnosed as per recent criteria: if both of the following criteria were fulfilled: ( ) total ige > iu/ml and positive skin prick test (spt) to aspergillus or aspergillus-specific ige > . kua/l; ( ) at least of two of following three: presence of precipitating antibody or aspergillus-specific igg > mg/l; chest radiology suggestive of abpa; and total eosinophil count > cells/mm . data were analyzed using stata . . we used the receiver operating characteristic (roc) curve along with area under the curve (auc) to determine the utility of various parameters to differentiate children with abpa from those without. to determine best cut-offs, youden's index was used (sensitivity + specificity - ). results: we included asthmatic children (male: female : ) with mean (sd) age of . ± . years. the prevalence of abpa was / ( . %; % ci, . %, . %). among baseline characteristics including spirometry of included children, only the presence of brownish sputum s | abstracts was greater in abpa children. among diagnostic criteria, all were significantly different between children with abpa and without abpa except aspergillus-specific igg and positive spt. the auc ( % ci) of rocs are shown in figure . the difference between auc of total ige and aspergillus-specific ige vs. aspergillus-specific igg was significant. the sensitivity and specificity of total ige (> iu/ml), aspergillus-specific ige (> . kua/l), aec (> / mm ) and aspergillus-specific igg (> mg/l) cut-offs as defined by diagnostic criteria was % and . %, . % and . %, . % and . %, and . % and . % respectively. the best cut-off values as per youde's index of total ige, aspergillus-specific ige, aec, and aspergillus-specific igg were iu/ml, . kua/l, /mm , and . mg/l, respectively with corresponding sensitivities and specificities of % and . %; . % and . %; . % and . %; and . % and . %, respectively. conclusions: aspergillus-specific ige levels had the best discriminative value followed by total ige, aec, and aspergillus-specific igg for abpa in asthmatic children. the currently proposed cut-off values may not be appropriate for children. reflections and concrete proposals for action: there is need to develop childhood-specific diagnostic criteria for abpa. methods: this is a one-year retrospective study that was conducted in our pediatric intensive care unit (picu) comparing the intervention failure rate of three different noninvasive respiratory support modalities (bi-level positive airway pressure (bipap), continuous positive airway pressure (cpap) and hfnc) for infants and young children between the ages of month and years admitted with the diagnosis of bronchiolitis. a sample size of patients was collected with a median age of months. children who required hfnc were older (mean . months) than children who required bipap ( . months) while the mean age for children who required cpap was ( . months). results: hfnc carried a higher failure rate in comparison with the other two respiratory support modalities ( . % for hfnc n / vs. zero % for cpap n / % and % for bipap n / , p < . ). among the patients who failed hfnc, ( %) were successfully shifted to bipap and weaned off later, while the other were intubated and needed mechanical ventilation. on the other hand, all patients who failed bipap were intubated and mechanically ventilated. no difference was found between the three groups in terms of gender or the causative virus. no respiratory complications or mortality was reported in the three groups. in the bipap group, oxygen requirement was significantly reduced at hours from the start of the intervention and afterward in comparison with the hfnc group (p < . - . ), although not statistically significant with the cpap group. no difference was observed in length of picu stay or hospital stay between the three groups. we did not observe any association between causative virus(es) and the number of er or pulmonology clinic visits for wheezing or recurrent bronchodilator use after discharge from the hospital. in the ba group, we found virus infection only in %, predominantly adenovirus, followed by rv and rsv. in % of the cases, streptococcus pneumoniae was confirmed in the throat swabs vs. only % for isolated moraxella catarrhalis. there were no other bacteria isolated in the ba group. in the cwc group, we found only in % of viral infections mainly hmpv, followed by adenovirus and rv. results: children had been taking antibiotics before hospitalization while the remaining patients were antibiotic naïve. in . % of the cases, we could not prove etiological agent, while bacteria were confirmed in . % and viruses in . % (in . %, we found combined virus and bacteria), and fungi were found in . %. when dividing the cases according to prior antibiotic use, the distribution was: . %, . %, % and . % for antibiotic naïve vs. . %, . %, . % and . % for the others respectively (p = . ). when looking at the bacterial isolates and prior antibiotic use, we did not find any significant difference regarding mycoplasma pneumoniae isolation (p = . ) although there was one for streptococcus pneumoniae (p = . ), mainly due to the standard guidelines to gps to start with penicillin antibiotic for pneumonia. as expected mycoplasma was isolated in older children, while streptococcus was mainly isolated in younger patients. mean age for children with bacterial pneumonia was . years, for those with viral pneumonia . years., for combined (viral+bacterial) . years. and for fungal pneumonia . years (p = . ). the values for crp were lower in cases with mycoplasma and in cases with non-compact infiltrate changes on x-rays (p = . and p = . ). almost / of the children have been immunized with pneumococcal vaccine ( %). the immunized patients had higher numbers of viral and lower numbers of bacterial isolates − . % and . % vs. non-immunized patients − . % and . %, respectively (p = . ). there was no difference in streptococcus pneumoniae isolation and vaccination status, but there was a major drop in mycoplasma isolates in vaccinated patients ( . % vs. . %, p = . ). for the patients with asthma only, we could not identify the microorganism in %, while in . % and . %, we found viruses and bacteria, respectively (co-infection was found in . %). in % of children without asthma, we did not isolate the etiological agent and there was co-infection only in one case, while viral pneumonia and bacterial pneumonia was confirmed in . % and . % respectively (p = . ). all children but were discharged healthy for mean . days in hospital stay. the mentioned patients had severe complications and required surgical intervention. conclusion: in the future, we could expect more viral pneumonia with increasing vaccination coverage and maybe we should reevaluate our treatment guidelines. objective: to compare the need for pediatric critical care in a tertiary children's hospital with a diagnosis of community-acquired pneumonia (cap) or hospital-acquired pneumonia (hap). furthermore, we conducted a pilot study to evaluate the possible medical biomarkers which are associated with longer pediatric intensive care unit stay. methods: an observational, retrospective cohort analysis was conducted in children who were admitted to our tertiary children's hospital with a diagnosis of cap or hap. patient demographics, clinical characteristics, and comorbidity were collected between january and december . the following prospective pilot study was conducted in children who were admitted to our pediatric intensive care unit (picu) due to pneumonia progression. we evaluated the clinical profiles and medical biomarkers. the primary endpoint was the duration of picu stay with associated predicting factors. results: a total of patients with episodes of pneumonia ( males; females) requiring admission to our children's hospital were included. the mean age at admission was . ± . months and the average length of stay was . ± . days. episodes were identified as cap and the other episodes were hap. patients with cap had significantly shorter lengths of hospital stay and duration of icu stay than those with hap ( . ± . vs. . ± . days, p < . ; ± . vs. ± days, p < . ). the most common co-morbidities in cap were neurological diseases and atopy history. among the cap patients, episodes ( %) led to icu admission during treatment course with the most common comorbidities being neurological diseases. however, in hap patients, cardiovascular diseases were the most common co-morbidities as well as those ( . %) who required picu care. the overall mortality rate was . %, with the mortality rate being significantly higher in the hap group (p < . ). the pilot study included children with the diagnosis of pneumonia in picu from jan to dec . neither progressive ards mobility nor mortality occurred. the mean age at diagnosis was . ± . months. the average number of days of picu stay was . ± . days. the median duration of hospital stay was days. patients were divided into two groups: picu stay more than days and less than days. the values of pro-bnp, aado , platelets, crp and ci in patients with picu stay more than days showed a significant difference with those less than days in the initial picu admission (p < . ). however, the values of thoracic fluid content (tfc) or even tfc corrected by cardiac output were not significantly different between the two groups. the levels of sputum -isoprostane and urinary ohdg revealed a trend of decreasing level after disease relief. conclusions: in this study, we found that ( ) hap resulted in significantly longer lengths of hospital stay and picu stay than cap. the possible risk factors for the need of critical care are associated neurological disease in cap and heart disease in hap; ( ) the possible biomarkers of pro-bnp, platelet, crp, ci, -isoprostane and ohdg may predict the duration of picu stay in our pilot study. these results not only help further our understanding of the risk of pneumonia in children who require critical care but also provide chances for better intensive respiratory care. background: pneumonia is a leading cause of respiratory morbidity and mortality in children younger than years of age. the incidence of severe cases of community-acquired pneumonia (cap) in low-and middle-income countries is still high. although severe cap can be diagnosed by clinical features and chest x-ray, it could be useful to measure biomarkers to predict the outcome. the aim of the study was to determine the association between methods: ninety children aged between > days to < years hospitalized with diagnosis of severe cap in the pediatric department of west nusa tenggara province general hospital from january to october were enrolled. data on demographic and clinical characteristics, and laboratory examination were recorded. all subjects were treated in accordance with the hospital cap protocol and prospectively monitored until discharged. results: out of subjects, % were ages < year, % male, % passive smoke exposure, % lived in crowded environment, % came from low family income, % showed infiltrate on chest x-ray % with comorbidity and fe deficiency anemia was the most common ( %). c-reactive protein, esr, lc, and nlr were not significantly associated with hospital length of stay and duration of oxygen consumption (p > . ). after adjustment for crp, lc, nlr, and age, esr was found associated with mortality, with every increase in one log of esr decreasing the log odds of death about . (p = . ). conclusion: higher esr was associated with lower risk of death. however, none of the biomarkers were associated with hospital length of stay or duration of oxygen consumption. keywords: community-acquired pneumonia, outcome, children, biomarker. recurrent episode of bronchial obstruction were enrolled in this study. detailed history, physical examination, blood sample and nasopharyngeal aspirate (npa) collection were performed. the viral etiology of the respiratory tract infections was determined using polymerase chain reaction (pcr) and the concentration of ifn-γ in npa by elisa kits. results: the mean npa levels of ifn-γ in rsv (+) infants - . ( - . ) pg/ml was lower than rsv (-) infants - . ( - ) pg/ml, (p = . ). a gender difference in ifn-γ was detected with significant higher values in girls (or, . ; [ci] . - . ; p = . ). the cytokine ratio did not differ between infants with or without atopic status and family history of asthma. moderate-to-severe bronchiolitis in cases ( %) was associated with lower ifn-γ level (or, . ; [ci] . - . ; p = . ), none of them required mechanical ventilation. decreased ifn-γ production correlated with the recurrent episodes of wheezing (p = . ). objectives: to test the hypothesis that high amplitude bcpap support after acute lung injury may have different effects on gas exchange efficiency and lung injury protection compared to high flow cpap (mimicking hfnc) support in rats with ali. methods: after normal saline lavage lung injury, all rats initially received high tidal volume mechanical ventilation ( ml/kg) for minutes, then were randomly divided into three groups: high amplitude bcpap group using the bubble technique with degrees of expiratory limb (n = ); standard bcpap group using the bubble technique with degree of expiratory limb (n = ); and high flow cpap (mimicking hfnc) group using the high flow technique ( l/min, n = ). all groups were killed . hours after bcpap or high flow cpap (mimicking hfnc) support. arterial blood gases, respiratory rate, peak inspiratory pressure (pip) and mean airway pressure (map) of rat lung during respiratory support, wetto-dry lung weight ratio, lung homogenate and/or bronchoalveolar lavage fluid tumor necrosis factor-α, macrophage inflammatory protein- , interleukin- and total protein levels were measured and compared among groups after study completion. results: the high amplitude bcpap group exhibited a significantly higher pao , lower paco and significantly lower alveolar protein, pip, map, wet-to-dry lung weight ratio and cytokine level compared to high flow cpap (mimicking hfnc) group. high amplitude bcpap group also exhibited a lower cytokine level compared to the standard bcpap group. no difference in gas exchange efficiency was observed between the two bcpap groups. conclusion: high amplitude bcpap support decreases lung inflammation, increases gas exchange efficiency and lung compliance compared to high flow cpap (mimicking hfnc) support in rats with ali, and may have a better lung protective effect than standard bcpap. keywords: bubble continuous positive airway pressure, high-flow nasal cannula, respiratory support, acute lung injury. nontraumatic chylothorax in children is rare and more difficult to treat than traumatic chylothorax. in some cases, they are refractory to conventional treatment, leading to severe morbidity and mortality. thus, the purpose of this study is to analyze the clinical features of chylothorax in pediatric patients in our hospital and seek appropriate therapeutic management. methods: a retrospective review was performed in patients with chylothorax from january to december in the children's hospital of seoul national university. traumatic or postoperative chylothorax was excluded. a total of patients with nontraumatic chylothorax were included in our study. etiology, treatment, and outcome of chylothorax were analyzed. results: nontraumatic chylothorax was diagnosed in patients. male patients ( / = %) were more frequently affected than female ( / = %) patients. eighteen patients were diagnosed before year of age ( %), only two patients were diagnosed after year of age ( years old, years old respectively). the most common cause of spontaneous chylothorax was idiopathic factors, constituting . % ( ), three cases were related to high central venous pressure due to venous thrombosis and recurrent sepsis, cases were related to down syndrome, case was noonan syndrome, and the remaining case was gorham stout syndrome. seventeen patients needed a respiratory support device, of the latter received low flow oxygen supplementation, patients received ventilator support. dietary modification (npo or mct base feeding), conventional medication (somatostatin or octreotide), sirolimus, surgical management were administrated to our patients. in the neonate and infant group, three patients who were related to venous thrombosis died because of recurrent septic shock before chylothorax management was administered. fifteen patients received a dietary modification (npo or mct base feeding) and nine patients improved by conservative management. one patient died due to heart failure before medical treatment. somatostatin or octreotide was used in patients who failed dietary modification, but only one patient improved with octreotide. among the somatostatin or octreotide failure group, patients received surgical management (pleurodesis or thoracic duct ligation). three of these patients improved, although one patient died after thoracic duct ligation operation because of post-op ards. two patients who were diagnosed after -year of age were refractory to nutritional modification and conventional medication such as somatostatin or octreotide. however, lymphatic intervention and surgical treatment were not suitable for these two patients. considering that their underlying disorder consisted of noonan syndrome and gorham stout syndrome, we used sirolimus to treat the refractory chylothorax. after administration of sirolimus, their chylothorax improved compared to before. conclusions: most of the nontraumatic spontaneous chylothorax in pediatric patients occur in newborns and the most common cause of chylothorax in the neonatal and infantile period is idiopathic. on the other hand, nontraumatic chylothorax in childhood is rare and tends more to be accompanied by the underlying syndrome. moreover, the treatment failure rate is higher in the childhood group. in such cases, sirolimus which is an mtor inhibitor, can be beneficial to patients who tend to be refractory and cannot be treated with lymphatic intervention or operation. purpose: specific genetic causes for childhood interstitial lung disease (child) in immunocompetent patients have been identified within the past decade. however, little is known about the pathogenesis of many forms of child, and treatment approach has not been standardized. a national survey was carried out by the japanese society of pediatric pulmonology (jspp) to identify the histopathology and response to current treatment, especially hydroxychloroquine, which is contraindicated for children younger than years old in japan. methods: a questionnaire was sent to pediatricians who registered a child patient to the jspp. we conducted the survey over a period of years, between and . children ( - years) were included in the survey with persistent hypoxemia (pao less than torr or spo less than %) for more than weeks, diffuse infiltrates on ct scanning, and elevated serum markers such as kl- , sp-a, or sp-d. immunodeficiency and other diseases which present with similar symptoms to child were excluded. the questionnaire included information on the patients' clinical symptoms, family history, pathological histology, clinical genetic findings, treatments and clinical outcomes. informed consent was obtained by all patients' guardians before participating in the survey. results: twenty-six cases were identified, including males and females. age of onset was between months and years. fourteen ( %) cases presented in the first year of life. lung biopsy was performed in ( %) cases. five cases showed changes of nonspecific interstitial pneumonia (nsip), case with desquamative interstitial pneumonia (dip), case with cryptogenic organizing pneumonia (cop), case with usual interstitial pneumonia (uip), case with acute lung injury (ali), and cases untagged. genetic testing was performed in ( %) cases. mutation in sp-c gene (sftpc) was detected in cases, atp binding cassette subfamily a member (abca ) in case, nk homeobox (nkx - ) in case, coatomer associated protein subunit alpha (copα) in case, and no mutation was detected in cases. in the first half of the study period, only out of ( %) cases were diagnosed with genetic testing without lung biopsy, which increased to out of ( %) cases in the latter half. prednisolone was used in ( %) cases and hydroxychloroquine in ( %) cases with no onset of retinopathy. conventional treatment with prednisolone or hydroxychloroquine, monotherapy or in combination, resulted in a good response in ( %) cases. three ( %) children died despite all therapies. in addition, it turned out that case was diagnosed as juvenile idiopathic arthritis years after registration. conclusions: this is the first nationwide prospective study regarding child in japan. the histopathology in this study is similar to that reported previously. there is increasing emphasis on genetic studies in the diagnosis of child as it can help avoid unnecessary lung biopsy. corticosteroid and hydroxychloroquine were the main therapeutic agents in our study. hydroxychloroquine therapy was tolerated in many cases, with no significant side effects. methods: twenty three children aged . ± . years with bos after allogeneic hematopoietic cell transplantation were enrolled, and their clinical data were reviewed retrospectively. all subjects repeated the pulmonary function test at an interval of month after occurrence of results: among subjects with bos, ( . %) subjects expired due to respiratory failure, ( . %) subjects underwent lung transplantation, and ( . %) subjects needed o therapy. the mean value of fev % predicted at the diagnosis of bos was . ± . %, and it rose after months ( . ± . %). fev % predicted at diagnosis of bos tended to be lower in subjects with oxygen therapy ( . ± . ) than in subjects without oxygen therapy ( . ± . ), [yj ] although there was no statistical significance. the changes in fev % predicted at months after bos diagnosis were significantly lower in the subjects with oxygen therapy (- . ± . %) than in subjects without oxygen therapy ( . ± . %). however, there was no significant difference in the change over months of fev % predicted values between the two groups at , , and months. in addition, the group with a negative slope of fev % predicted change during the first months had a higher likelihood of o therapy, compared to the group with a positive slope of fev change during the period (hr of . , p = . ). the change in fev during the first months after bos was significantly different between the subjects with and without oxygen therapy. these results suggest active intervention strategy is needed during the first months after bos to improve the prognosis. this study is aimed to assess the effectiveness of hs nebulizations before physiotherapy over conventional physiotherapy in children with non-cf bronchiectasis. objectives: primarily to compare the change in fev from pretreatment phase to posttreatment phase between the two groups. method: we performed a retrospective cohort study of extremely preterm infants born before weeks of gestational age in our nicu. study subjects were divided into two groups: auto group who underwent the automated control of inspired oxygen concentration (auto) with cpap, and manual group who underwent manual control of inspired oxygen concentration (manual) with cpap before introduction of auto in our nicu. we retrospectively investigated the patient characteristics and short-term outcome related to the respiratory system (reintubation rate, duration of cpap, introduction rate of home oxygen therapy) and retinopathy of prematurity (incidence, stage, and therapy rate). the mann-whitney u test and chi-squared test were used for statistical analysis, and logistic regression was used for multivariable analysis. result: a total of infants were eligible for this study. there were and infants in the auto group and manual groups, respectively. in the auto and manual groups, the median (range) of their gestational age in weeks was . ( . - . ) and . ( . - . , p = . ), birth weight in grams was ( - ) and ( - , p = . ), the rate of maternal steroid administration was % and % (p = . ), age at study entry in days was ( - ) and ( - , p = . ). reintubation rate was % and % (p = . ), duration of cpap (day) was ( - ) and ( - , p = . ), and introduction rate of home oxygen therapy was % and % (p = . ). the incidence of total retinopathy of prematurity (rop) was % and % (p = . ), the incidence of rop over stage Ⅱ was % and % (p = . ), and therapy rate for rop was % and % (p = . ) in each group. there was a statistically significant association between the decreasing risk of rop over stage Ⅱ and use of auto by multivariable analysis adjusted for confounding factors (odds ratio: . [ % ci: . - . ], p = . ). discussion: in this study, the incidence of rop over stage Ⅱ was significantly decreased in extremely preterm infants who underwent auto with cpap. it is suggested that exposure to the excessive oxygen levels and the fluctuation of oxygenation are related to the incidence of rop. large studies indicate the strict spo target range. but in fact, the manual control of inspired oxygen concentration during respiratory support is not sufficient for the maintenance of spo within the latter. auto can maintain spo within the target range compared to the manual control of inspired oxygen concentration. auto has the potential to prevent rop by decreasing the exposure to excessive oxygen levels and the fluctuation of oxygenation. several limitations should be considered in our study. this was a retrospective, single-centered, non-randomized study; a further multi-centered prospective study is needed. since their pulmonary function is decreased, lower respiratory tract infections in this population may have a more severe clinical course. in our study, in addition to lung function measurement, we also wanted to see whether there is a connection between mental abilities and pulmonary function. methods: before the examination, a license was obtained from the ethical committee of the university of szeged. conclusions: we could also detect in our smaller population that vlbw patients at the age of to years have lung function test values in the lower normal region of the reference range. this may raise the presumption of the higher susceptibility of these children to respiratory tract diseases also in the later decades of life. bpd patients have lower pulmonary function test results than non-bpd patients. on the other hand, we could not find any connection between low raven test performance and lung function results. background: esophageal atresia (ea) and/or tracheoesophageal fistula (tef) is one of the rare congenital anomalies occurring in out of , - , births. there has been improvement in the survival of these infants during recent decades. the diagnosis of tef with ea is commonly made during the first hours after birth. preoperative flexible endoscopy (fe) is not yet routinely included in the diagnostic and postoperative assessment. this study aimed to evaluate the predictive factors that affected patients' prognosis and the role of flexible endoscopy application in managing infants with ea and/or tef in a tertiary medical center. methods: we enrolled patients who were admitted into our hospital due to suspected ea and/or tef and accepted an fe examination for one or more times between jan. and dec. . all associated medical and surgical records were retrospectively reviewed. the analyzed data included basic characteristics, diagnosis, age of surgical repair, associated anomaly, timing of fe before and after surgical repair, and mortality. factors related to patient's mortality were analyzed. results: a total of patients were enrolled, including ( . %) cases referred from other hospitals. their mean birth weight was ± gm, including ( . %) low-birth-weight infants, ( . %) cases with cardiac anomalies, ( . %) cases aged > days, and ( . %) cases underwent fe before reconstruction. the most common classification of enrolled cases was type c ( . %). additional other airway anomalies were found in ( . %) cases, including tracheomalacia, bronchostenosis, lung hypoplasia, and laryngeal cleft. one case underwent nasaltracheo-fistula-gastric catheter insertion before surgery. the mean age of receiving surgical reconstruction was ± days. the most common postsurgical complication was anastomotic stenosis ( , . %) that required laser therapy ( , . %), balloon dilatation ( , . %), or stent implantation ( , . %). gastroesophageal reflux was also commonly found in ( . %) cases. the overall -year survival rate was . % ( / ). significant factors related to -year mortality were post-reconstruction referral (p = . ), age of reconstruction > days (p < . ), and cardiovascular surgery requirement (p = . ). conclusions: in infants with ea and/or tef, fe is feasible for the early identification of associated airway and esophageal anomaly, as well as postoperative diagnosis and therapeutic interventions. postreconstruction referral, age of reconstruction > days, and cardiovascular surgery requirement were significantly related to -year mortality of infants with ea and/or tef. background: patent ductus arteriosus (pda) is a common cardiovascular complication among premature infants and may be responsible for prematurity-related complications. surgical ligation is considered when medical treatment has either failed or was contraindicated. transcatheter occlusion, which was established in term infants, has recently been applied to premature population. previous reports stated that the complication and success rates were not statistically different between the transcatheter technique and surgical ligation. in this study, our aim was to compare the oxygenation status and oxygen dependence between these two techniques. the basic demographic data, fio change, pulmonary score, intubation days, ventilator-dependent days, oxygen-dependent days and mortality within year were evaluated. results: the birth body weight, gestational age, post-menstrual age on procedure day, body weight on procedure day, pulmonary score and fio before procedure were not different between these two groups. the range of body weight on procedure day was from to gm in group a and from to gm in group b. the overall mortality within year was similar (p = . ). the overall incidence of chronic lung disease was not significantly different ( / vs. / , p = . ). when comparing the fio change before and days after the procedure, the transcatheter closure group had a significant improve- are rare disorders of which the incidence is not precisely known. this malformation might threaten the fetus, but it can also disappear spontaneously, or neonates can be asymptomatic with the malformation. according to previous studies, cpam may increase the risk for lung infections and lung malignancies, which is also the argument used when treating asymptomatic cpam-patients with surgery. purpose of the study: the purpose of the present study was to investigate whether there are differences between the treatment protocols between nordic countries. material and methods: a questionnaire was sent to nordic centers dealing with pre-and postnatal management of patients with congenital lung malformation. this questionnaire was aimed to collect information on pre-and postnatal treatment protocols in the centers involved. results: the treatment protocols of this malformation vary largely in nordic centers. prenatal ultrasound was the primary examination in all centers. magnetic resonance imaging (mri) was used routinely as next prenatal examination in four centers for every cpam-patient with persistent finding in ultrasound during whole pregnancy ( of ). five centers ( of ) used mri if needed for differential diagnosis. various prenatal interventions were used in cases of fetal hydrops caused by cpam. shunting macrocystic lesion was used in out of centers, maternal cortisone in out of . over half of the centers ( / ) consulted and co-operated with centers that performed fetal surgery and out of did consider ex utero intrapartum (exit) surgery. postnatally surgery was performed in every center ( %) for symptomatic cpam-patients. one center ( %) did not remove cpam but instead performed follow-up on asymptomatic patients. four infants used precision flow: three used single prong cannula (tip od . mm), and the remaining infant used double prong, infant cannula (tip od . mm). pharyngeal pressure tended to rise to flow rate dependence with any type of cannula. in patients managed with the optiflow junior, the mean pharyngeal pressure at the flow rates of , , , and l/kg/min for premature size cannula were . , . , . , and . cmh o, respectively, and for neonatal size cannula were . , . , . , and . cmh o, respectively. in patients managed with precision flow, the mean pharyngeal pressure for each cannula at flow rates of , , , and l/kg/min for single prong cannula were . , . , . , and . cmh o, respectively, and for double prong, infant size cannula were . , . , . , and . cmh o, respectively. background: even though it is considered as a screening test, sweat conductivity (sc) analysis seems to be an alternative diagnostic method to the coulometric quantitative test (cqt) for the diagnosis of cystic fibrosis (cf). it is widely accepted that coulometry requires specialized technicians, in addition to being performed only in referral centers. on the other hand, sc sweat analysis is a semiautomated procedure, simpler and faster than the conventional cqt. specially in poor-resource settings, it allows the decentralization of the diagnostic network and, consequently, a wider accessibility to cf diagnosis. to date, there are no studies comparing two concomitant conductivity tests performed in the same patient. objective: to assess the agreement between two sweat conductivity results performed concomitantly in young infants. methods: this was a prospective, cross-sectional study in which two sweat samples were obtained from the two arms among consecutive patients, using the wescor macroduct collection system conclusion: since the strength of agreement was perfect, it reveals a high reliability of sc. apart from its role as a screening test, it seems that it has a place as a diagnostic tool in cf. background: because of frequent exacerbations and pulmonary deterioration in cystic fibrosis (cf), the radiological exposure to chest x-ray and ct scan is frequent in patients with cf, with subsequent potential secondary effect, although also required. lung ultrasound is, abstracts | s currently, a useful method of evaluation in multiples diseases such as: pneumonia, pleural effusion, interstitial syndrome or pulmonary fibrosis; therefore, the use of lus in cf would be of interest aim of the study: evaluation of thoracic ultrasound utility in cf exacerbations. methods: fifty cf patients were included in the study and monitored for years of age. lung ultrasound was performed every months, at clinical and biological evaluation. ct scan was performed during exacerbations and for stable patients, every years timetable (aged over years). ultrasound was performed using a linear high frequency to mhz probe, using a score based on specific artifacts which quantified the presence of consolidation, interstitial syndrome, saccular bronchiectasis and pleural effusion. ct was interpreted using the bhalla scoring system, independently of the lus score. pearson's correlation was used for the evaluation of the relationship between lus score and ct. results: median ct bhalla score was . + - . , and the average lus score = . + - , consistent for moderate morphological lung injury. a good correlation was found in patients with increased lus (> ) and ct score, r= . , p < . . there was no reliable correlation between the lung ultrasound score and ct, therefore, validation of the lus-cf score (r= . , p = . ) was impossible with the currently identified artifacts. for patients in acute exacerbations, alveolarinterstitial syndrome described by multiple b-line artifacts and the presence of lake signs quantifying cystic bronchiectasis were accurately identified by lus and confirmed by ct. methods: we conducted a retrospective descriptive study at the university hospital of montpellier between / / and / / . we collected the various respiratory disorders presented during the follow-up of these children. results: one hundred and two files were examined and patients were included in our study. asthma concerned patients in our cohort ( %) which is more frequent than in our general population ( % in occitania region, france). it was significantly related with atopy (p < . ). respiratory tract disorders were identified in patients ( %). the most common were: tracheomalacia and laryngomalacia. lower respiratory infections were found in patients ( %) and were significantly related to lymphopenia (p < . ) and swallowing disorders (p < . ). infants were tested for hiv using pcr and antibody testing. the association between hiv and arv exposure and lung function during years was assessed using linear regression, adjusted for bmi for age z-score, sex, ethnicity, socioeconomic status (ses) abstracts | s quartile at enrolment and pre-and postnatal smoke exposure (based on urine cotinine). results: a total of infants had at least one lung function measurement and were followed over years, ( %) were heu; ( %) male, ( %) black african ancestry, ( %) mothers smoked during pregnancy, ( %) household tobacco smoke exposure. nine hundred and ten ( %) infants had lung function tested at weeks and ( %) children at years. the majority of heu infants were black african ( % vs. % hu, p < . ), heu infants had less household smoke exposure ( % vs. %, p = . ), lower ses (p = . ) and had higher bmi zscore at years (p = . ) compared to hu; other demographics were similar. at weeks, heu infants had higher tidal volume compared to hu ( . ml, ci, . ; . , p = . ). amongst the heu infants, those whose mothers had triple therapy arvs had lower expiratory flow ratios, tptef/te, compared to those whose mothers had zidovudine (azt) only (- . , ci - . ; - . , p < . ). at years, tidal volume differences were no longer seen, but heu infants had a higher lung clearance index compared to hu ( . , ci, . ; . , p = . ). low antenatal maternal cd count was associated with an average . ml lower tidal volume at years compared to infants whose mothers had cd counts> cells/ mm (ci, . , . ; p = . ). background: chronic wet cough, which is prevalent in indigenous children, is the most common symptom of bronchiectasis and its precursors. early recognition of chronic wet cough leading to prompt and appropriate treatment may potentially prevent progression to bronchiectasis. therefore, timely health seeking for chronic wet cough by families, and its effective management by health practitioners is potentially important to prevent development of bronchiectasis. purpose: to identify the barriers to and enablers for timely health seeking for chronic wet cough by families, and optimal management by health practitioners, for chronic wet cough in aboriginal children. method: a qualitative study was conducted in two communities (one remote town and one very remote community) in the kimberley region of northern, western australia, of which % of the population is aboriginal. data were gathered through individual semi-structured in-depth interviews and focus groups to ascertain: the key enabler described was the provision of culturally appropriate health literacy information. all participants reported that they would seek help for chronic wet cough once they were informed that it could signify underlying disease. furthermore, families suggested that improved health practitioner knowledge of chronic wet cough database. complete monitoring data for the air pollutants (so , no , o , co, pm . and pm ) and meteorological factors (relative humidity, rainfall, and daily average temperature) were collected from environmental protection agency monitoring stations of the taiwanese government. in the present study, each er visit for asthma ae was defined as case day. in bidirectional control samplings, the same weekdays , or weeks before and after er visit for asthma were defined as the control days. multiple correlation coefficients (r) (multiple regression analysis) were used to explain how much of the variance in the ed visits could be explained by a given set of air pollutants. result: as the study cases were divided as male and female, a ug/m increase in the -h averages of pm . and a ℃ increase in temperature were associated with asthma er visit [or= conclusion: in taiwan, asthma ae is closely related to low temperature and indicated air pollution. there is an obvious bias if only a single air pollutant is being considered and neglects the influence of meteorological factors in studying the effects of the environment on asthma. with the result of this study, we can predict asthma exacerbation precisely according to individual age, gender and local air pollution/ meteorological conditions. in days with high risk for asthma exacerbation, patients with asthma should avoid/decrease outdoor activity, dress warmly and maintain inhaled corticosteroid therapy. however, while the path length of the right dorsum manus was not statistically significant, there was a significant difference in completion time between the two groups. the reason considered was that their left hand was their nondominant hand, while their dominant hand needed to be kept clean to touch an asepstic suction catheter. therefore, novice participants were unfamiliar with manipulating suctioning equipment with their left hand, which appeared as a difference in their proficiency. benefits of d cg were reported that the function of a virtual camera improved the accessibility to aois by screen transition, whereas operation was difficult, so they could not realize the effect of learning. advantages of d video was described that it is easy to concentrate because the device was familiar, while there was a negative impression that it was hard to observe aois compared to d cg. there was no significant difference between the groups who watched d video or d cg animation in the frequency distribution of fixation point movement speed analysis. however, considering the unignorable potential of d cg animation as a training tool, we concluded that defining visual criteria for assessing learning outcome of digital contents requires more research in the future. graduate school of nursing, the jikei university school of medicine -tokyo, japan the aim of this study is to compare the level of endotracheal suctioning proficiency between experts and novices, using an eyemark recorder. a head-mounted eye-tracking device (pupil, pupil lab, usa) was used to capture eye movement of the participants. twelve experienced nurses from three healthcare facilities who had more than years of experiences of suctioning, and twelve nursing students from a university who had no experience of providing suctioning for real patients, participated in a simulation scenario of a patient with endotracheal intubation. we utilized cephalothorax realia with a simulated upper respiratory tract from mouth, nose, to a tracheal bifurcation, which did not represent any biological/patholo- showed that . % of students are exposed to environmental tobacco smoke, which causes inflammation of respiratory tracts and a decrease in lung function. urinary cotinine can be used as a biomarker for cigarette smoke exposure. objectives: to examine the effects of environmental tobacco smoke exposure on urinary cotinine level and lung function test in children. methods: subjects were students aged to years-old in jakarta. data were obtained from questionnaire, spirometry and urinary cotinine test using elisa method. results: there were subjects, consisting of in the case group and in the control group. urinary cotinine level > ng/ml was found in . % of the case group and . % of the control group; p = . ; or= . (ci, % . - . ). there were significant differences between urinary cotinine level with number of smokers (p = . ) and number of cigarettes per day (p = . ). no association was found between cigarette smoke exposure and lung function test. there was a significant difference in school absenteeism between the case group and control group; p = . ; or= . (ci, % . - . ). conclusions: children exposed to environmental tobacco smoke there are relatively little data in healthy children and no data that compared these techniques. in children without respiratory disease, we described (i) the bal differential cellular count and its correlation with age, and (ii) compared the differential cytology versus b-bal ( %, iqr - %)). however, when adjusted for age using regression statistics, these differences were not significant. there was no significant difference in the total cell count (nb-bal . x /ml, iqr . - . x /ml versus b-bal . x /ml, iqr - . x /ml) and neutrophil percentage (nb-bal . %, iqr . %- % versus b-bal . %, iqr . - %) between the two groups. there was no significant difference in the differential cytology with age in both b-bal and nb-bal. conclusion: nb-bal provides comparable information on the cellularity components of bal when compared to b-bal and should be considered an alternative. as age influences cellular differential count, age-matched data are required for comparative studies on bal in children. j- | spirometry assessment in children with congenital heart disease after open heart surgery in these spirometry assessments, obstructive type was more common than restrictive type ( . % vs. . %). however, in tof patients, restrictive type was slightly more common than obstructive type. j- | to squeeze or not to squeeze? can the raised -volume passive expiration flow-volume curve be used to estimate pulmonary functions in infants? background: spirometry is an essential tool for assessing patients with lung disease. however, it necessitates cooperation and thus, it cannot be performed in infants. one of the established alternative techniques in infants is the raised-volume rapid thoraco-abdominal compression technique (rvtct) which uses a compression vest to squeeze the chest forcedly after inflating the lungs to near total lung capacity (tlc). although it is an acceptable method, it is far from being perfect since it is not easy to perform. obtaining the raisedvolume passive expiration curve (rvpe) from passive deflation of the lungs from tlc is an easier technique (figure ) . however, to our knowledge, data obtained from the rvpe curve were not assessed for their ability to estimate expiratory airway function in infants. tst was considered positive if induration > mm and qft-git however, anesthetic choice as a risk factor for fever has not yet been reported. objectives: the aim of our study was to explore the role of sedative agents as a risk factor for fever during the hours after the procedure. additional risk factors were investigated as well. multivariate analysis of the data (comorbidities, sedation choice, age, indication for performing the procedure, bal performed and its findings, post-prematurity, ftt, and medications) suggested that only sevoflurane and young age were statistically significant risk factors for fever. chronic treatment with montelukast was found to be a protective factor against fever. we conclude that post-bronchoscopy fever is probably an inflammatory noninfectious process. sevoflurane is a significant risk factor for developing post-bronchoscopy fever by generating such inflammation. the same mechanism may also explain why montelukst has a protective role. conditions were mostly present in young children less than years old while obesity was more common in adolescents. of the treated patients, . % had allergic rhinitis. comparing symptoms before and within months after pap trial, there were significantly less patients with complaints of habitual snoring ( . % vs. . %, p < . ) and excessive daytime sleepiness ( . % vs. . %, p < . ). there was significant improvement in psg parameters with mean oahi decreasing from . ± . /hour tst to . ± . /hour tst (p < . ) and mean spo (oxygen saturation) nadir increasing from . % ± . % to . %± . % (p < . ) after pap therapy. within months of follow up, . % of the patients adhered to pap satisfactorily while the adherence dropped to . % at the time of the latest follow-up. satisfactory usage established before months was associated with favorable long-term outcomes of satisfactory usage or cessation of therapy due to improvement at the latest follow-up (chi square test p = . ). the commonest reported reason for non-adherence was due to nasal obstruction. results: forty-three bemss were placed in infants. the mean bw and mean age were . ± . kg and . ± . months, respectively. there were , and stents located in trachea, carina and mainstem bronchi, respectively. seven infants with stents died without obvious stent-related mortality. among them, stents in children were successfully retrieved by rigid endoscopy. at placement, the diameters of tracheal and bronchial stents were . ± . ( - ) and . ± . ( - ) mm, respectively. these implanted bemss could be gradually and significantly (p < . ) expanded. at the end of this study, all the remaining stents in infants could be kept functional. the diameters of the remaining tracheal and remaining bronchial stents were . ± . ( - ) and . ± . ( - ) mm, respectively. results: eithty -three children were included. males represented . %, average age was . ± months. the rate of ards was . %. the mortality rate in children with this syndrome was . %. septic shock with ards had a higher mortality rate than septic shock without this syndrome ( %). most children with this syndrome were in the moderate and severity range ( . %); . % were ventilated. the tidal volume was . ± . ml/kg and average peep was . ± . cmh o, the medium fio was . ± . %; . % of cases had a tidal volume of to ml/kg. there were no differences in tidal volume, peep and fio between survivor and non-survivor cases. conclusions: ards had a high prevalence in pediatric septic shock and the mortality rate among septic shock cases with this syndrome is still very high. according to the unit policy to transfer to icu which is based on idsa guidelines, % of the patients needed intensive care. hdu care was given for % of patients who required supplemental oxygen to maintain pulse oximetry above %. analysis of length of hospital stay indicated that % of the patients were discharged by the th day and % were hospitalized for to days. there was no mortality among the patients evaluated. conclusions: this retrospective analysis revealed that childhood community-acquired pneumonia is associated with significant morbidity and is an economic burden. the majority ( %) needed therapy beyond first line antibiotics which may indicate significant antibiotic resistance. central sleep apnea (csa) and periodic breathing are unusual findings described in pediatric patients with congestive heart failure. however, csa has not been reported in children with pulmonary hypertension. we hereby report on a -year-old girl with idiopathic pulmonary arterial hypertension (ipah) who had frequent central events in a periodic breathing fashion seen in her polysomnography, which was normalized following medical treatment leading to improvement of the pulmonary pressures. this case supports the importance of psg in pediatric patients with ipah, not only to exclude osa as a potential cause but also to assess for the presence of pb. we also show that the presence of pb might be a sign of disease severity and can be a marker of response to we present two children from a tb endemic region, with microbiologically confirmed tb presenting with parapneumonic effusion containing chyle, that were misdiagnosed initially as pleural empyema. tuberculous pleural effusion occurring with chylothorax is uncommon. the first case is a -year-old girl who presented with localized left-sided chest pain and parapneumonic effusion and a previous liver transplant and long-term intravenous catheter, who was on chronic immunosuppressive therapy. the second case was a -year-old boy who was hiv-exposed but uninfected and presented reports, to our knowledge, on using gastric lavage pcr to diagnose pjp. we report two cases in which p. jirovecii was identified by gastric lavage pcr and was treated appropriately. case was a -year-old preterm, low-birth-weight male infant with down syndrome who had undergone operation for necrotizing enterocolitis and was being administered central venous nutrition. he was started on prednisolone for pericardial effusion because of postpericardiotomy syndrome when he was months old and had been in an nicu for a year. on the day of onset of pjp, he required increased oxygen levels, and infiltrative shadows were observed in both lung fields on chest radiography. further, his ( → )-d glucan (bdg) levels were elevated. p. jirovecii was detected on gastric lavage polymerase chain reaction (pcr), and trimethoprim-sulfamethoxazole was administered for weeks, following which his condition improved. case was an -month-old preterm, very-low-birth-weight male infant who was under central venous nutrition because of digestive tract disease. he was under treatment with hydrocortisone for months because of refractory hypoglycemia and had been in an nicu. on the day of pjp onset, he showed increased oxygen demand, and chest radiography showed infiltration in both lung fields. further, his bdg level was elevated. p. jirovecii was detected on gastric lavage pcr, and trimethoprim-sulfamethoxazole was administered for weeks, following which his condition improved. discussion: about %- % of immunocompetent children carry p. jirovecii in their respiratory tract, and this percentage, depending on the underlying disease, is %- % in immunosuppressed patients. therefore, when p. jirovecii is detected, it is important to distinguish infection from colonization. in these two cases, we suspected pjp on the basis of the clinical symptoms, backgrounds, bdg levels, and observations from image examination, and p. jirovecii was detected on gastric lavage pcr analysis. the patients' condition improved after definitive therapy. to our knowledge, there has been no report of pjp diagnosis by gastric lavage pcr to date, and this diagnostic technique may be useful if it is difficult to collect lower respiratory tract specimens. both patients had cellular immunodeficiency because of long-term steroid administration, although prophylactic treatment with trimethoprim-sulfamethoxazole for pjp had not been administered. this suggests the necessity of prophylaxis. we are reporting a -month-old boy, who was previously hospitalized with recurrent monthly pneumonia since birth until presentation to a regional tertiary center with pediatric respira- tracheal agenesis (ta) is extremely rare and usually fatal. complete or partial absence of the trachea below the larynx can be found, and a tracheoesophageal fistula may exist. there is usually no prenatal symptom, but other congenital anomalies are commonly found. we present a low-birth-weight male infant (gestational age weeks; birth weight g) born with respiratory distress. physical and radiological examination disclosed single umbilical artery, bilateral malalignment of thumbs, sacral dimple, and hemi vertebra. difficult intubation was noted soon after birth. after being transferred to our center with an intubated endotracheal tube, flexible bronchoscopy was performed and found it was an esophageal intubation. a blind pouch at the subglottic level of the trachea without a fistula was observed. diagnosis by computed tomography (ct) with d-reconstruction revealed ta (floyd type ii) with a small esophago-bronchial (eb) fistula at the lower esophagus and linked to the right upper bronchus. at the age of days, esophageal ligation and gastrostomy were performed. at the age of days, with the assistance of dprinting simulation and veno-venous extracorporeal membrane oxygenation (ecmo) support, cervical esophagostomy and tracheoplasty were executed. the cervical esophagus was end-to-end anastomosed to the larynx. after dividing and excision of the eb fistula, the proximal end of the lower thoracic esophagus just above the fistula was end-to-side anastomosed to the right main bronchus. the distal end of the lower thoracic esophagus was ligated. however, pneumothorax, anastomosis dehiscence and repair, narrowing of anastomosis, collapse of esophageal-consisted airway, and bilateral pulmonary atelectasis developed in the following weeks. flexible bronchoscopy aid balloon dilatation and stent implantation were planned. however, massive air-leak to mediastinum and peritoneum, shock and disseminated intravascular coagulation (dic) occurred. initially, nasal cpap (continuous positive airway pressure) was provided for respiratory support; however, intubation was finally performed with high-frequency oscillation use due to fluctuating respiratory condition. series of chest plain film showed progressive diffused infiltration, while high-resolution computed tomography showed bilateral ground glass appearance. in combination of her clinical features and image presentation, lung biopsy was performed due to the high suspicion of diffuse lung disease. oral steroid and azithromycin was administered but her improvement was poor. we did not administer hydroxychloroquine because of her g pd (glucose- -phosphate dehydrogenase) deficiency. recurrent ventilator-associated pneumonia was noted which needed several types of antibiotics. at months of age, a tracheostomy was performed. lung transplantation was offered to the family but they decided to proceed with mechanical ventilation use. due to worsening of clinical condition and resistance to medication treatment, she received palliative extubation after full discussion with her family at the th month. a blood sample was collected for genetic testing before the patient passed away. revolutionized imaging of the "forgotten third circulation", improving our understanding of lymphatic diseases and paving the way for a new treatment modality, lymphatic embolization. we present a -year-old girl with kla whose pleural effusion stabilized following two lymphatic embolization procedures. case report: our patient presented at years with recurrent severe non pulmonary infections. chest radiographs showed prominent diffuse reticular opacities despite the absence of respiratory symptoms or signs. comprehensive immunology and rheumatology investigations were normal, as were exhaled and nasal nitric oxide, ciliary biopsy, bronchoscopy and lavage, echocardiography and oxygen saturation at rest, on exertion and overnight. a chest ct showed thickening of interlobular septae with preservation of parenchymal architecture. a bone scan showed reduced uptake at l , as well as t and the left clavicle in keeping with "vanishing bone disease". at has no effect on osa caused by ca, although rapid maxillary expansion (rme) is reported to be useful for it. objectives: herein, we report the case of a patient with osa likely due to ca that was successfully treated with rme. nights. respiratory event index (rei) were . /h and . /h on nights and , respectively; nadir spo were % and %. as a result, severe osa was diagnosed. since his family did not wish for at, rme was performed. snoring and retractive breathing during sleep disappeared weeks after the start of rme, and months later, ocst was performed again on two consecutive nights. rei had improved to . /h and . /h on nights and , respectively, and nadir spo had improved to % and %. no evidence on the usefulness of rme for osa in children has been established. however, rme was useful for osa likely due to moderate ath and ca in this patient, suggesting that tongue space expansion by rme can be a useful therapeutic method for osa. gorham-stout disease is also known as vanishing bone disease. it is a rare disease of unknown etiology characterized by progressive osteolysis and proliferation of lymphatic vessels. we report cases of gorham-stout disease presenting with recurrent chylothorax and lytic bone lesion. we present a -month-old female infant with fever, cough, and vomit for days. she was transferred to our medical center due to rapid progression to pards within day, and her throat swab cmv pcr test revealed positive. her chest radiograph showed bilateral white-out, and very high ventilator settings were required to maintain oxygenation. cardiac disease was excluded by ultrasonography. intravenous ganciclovir, broad-spectrum antibiotics, and methylprednisolone were given, but the gas exchanges were still poor (oxygenation index= at hours after hospitalization). hfov was then applied (fio = . , map= cmh o, amplitude = cmh o, frequency = , i time = %). after using hfov, the lungs were recruited and the settings could be weaned down gradually. intravenous immunoglobulin was given for suspected viral sepsis. case report: patient a was an -month-old girl with down syndrome, congenital hypothyroidism, small patent ductus arteriosus and anorectal malformation who presented with persistent fever and cough for weeks post stoma closure. on examination, she was tachypneic with a respiratory rate of breaths/minute and subcostal recessions. her breath sounds were reduced over the right lower zone with stony dullness. chest x-ray (cxr) showed right lower lobe consolidation with a loculated parapneumonic effusion. minimal thick stale blood-stained fluid was aspirated during an ultrasound guided thoracocentesis and an unusual mass was seen. hence the chest drainage was aborted and a contrast-enhanced ct angiography revealed a pulmonary pseudoaneurysm within the consolidated lung, adjacent to the right pleural collection. blood investigations showed a drop in hemoglobin from g/l to . g/l. chest x-ray showed an extensive right pleural effusion and ultrasound described a right basal consolidation with a pleural effusion of ml. pleural fluid sample obtained by thoracentesis was purulent with exudate characteristics and a chest tube was inserted for drainage. due to these findings, a thoracic ct scan was performed and revealed atelectasis of the right lung and severe loculated pleural effusion with fluid-filled cavities in the right middle and lower lobes. since the patient was stable, a conservative management was preferred and empiric iv antibiotics, cefotaxime and clindamycin, were started. after days of treatment, pleural fluid culture was positive for s. mitis. s. mitis was sensitive to ampicillin, thus treatment was completed with days of ampicillin and days of cefotaxime and clindamycin with a satisfactory outcome. considering that s. mitis is an innocuous commensal organism of the oropharynx, skin, and gastrointestinal and genitourinary tracts, we looked for primary infection sites. the origin of the infection was a cavity in the third lower molar that extended to the root. the patient had a history of a dental procedure weeks before diagnosis. case report: a nine-month-old male preterm bpd infant with maternal premature rupture of membranes delivered by emergency caesarean section at + weeks gestation due to fetal distress. apgar score was at -minute and at -minutes and birth weight was g. because of respiratory distress syndrome, endotracheal intubation was performed and the patient was transferred to the neonatal intensive care unit. after months of mechanical ventilation support, the endotracheal tube was removed and the patient was treated under niv support. after months of mechanical ventilation support since birth, we decided to make an assessment of the neurodevelopment of the patient by brain mri. conclusion: most of the time, preterm bpd infants with vd who are receiving niv support will be considered as high risk and follow-up for mri delayed because of two reasons: ( ) need of oral intubation with endotracheal tube to guarantee the safety of the respiratory system; ( ) the neonatal mri-ventilator which includes niv mode is too expensive and requires a well-trained respiratory therapist to operate the mri-ventilator. we believed that once we well-prepared the mri-ventilator, infants with vd who are receiving niv support could undergo mri more safely. by sharing this case experience, we hope the profession of neonatal respiratory therapy could receive more attention. we present two cases that were diagnosed after multiple consultations: case . a -year-old girl presented with a history of recurrent episodes of cyanosis during her first months of life, worsening respiratory symptoms and poor exercise tolerance. she was assessed on several occasions by a general practitioner (gp) who did not consider that further investigations were necessary. she also had recurrent epistaxis and was being followed by the local ent specialist who considered the episodes as normal. at the age of two, she was admitted to her local hospital with a lrti, cyanosis and persistent low oxygen saturation levels ( %). she was treated with antibiotics, but given her slow improvement she was referred to our center for further workup. on examination, she presented with failure to thrive, general cyanosis, multiple telangiectasia in oral cavity and nostrils, and clubbing fingers. initial chest x-ray showed abstracts | s ct angiography revealed an arteriovenous malformation (avm) in the middle segment of the right lower pulmonary lobe, multiple intraparenchymal small avms in both lungs and an aberrant artery from the descending aorta that irrigated the right upper lobe. embolization of the main pavm was proposed, however, it was not possible due to its large extension since there was no embolic device according to its size. further discussion in several international forums, a thoracotomy and pulmonary segmentectomy of the right lower lobe was suggested and then performed months after presentation. since then, the patient has been asymptomatic, despite the fact that spo levels have not improved as expected. background: children with cystic fibrosis (cf) have frequent respiratory exacerbations, therefore the occurrence of cough and fever in a cf child raises the suspicion of an acute infectious event, while in a non-cf child this fever/cough association would suggest a pneumonia. what about the presence of tachycardia, which would suggest a different diagnosis, from myocarditis or hyperthyroidism. we herein present the case of a -year-old girl with cystic fibrosis with frequent acute cough, persistent fever and tachycardia attacks. a -year-old girl was diagnosed with cystic fibrosis in infancy, because of a pseudo-barterr syndrome. the child's evolution was very good, with good clinical and biological status, normal pulmonary lung function described by a normal lung clearance index and germ-free cough swab and negative induced sputum. she was monitored according to the national romanian guidelines every months in the regional cf center and annually at the national center, by clinical and biological investigation. no ct or bronchoalveolar lavage was performed until age of years. results: in evolution, her mother noticed episodes of tachycardia months before the actual admission, supposed secondary to play or hospital anxiety, without any electrical ecg alteration. four months before admission, she had a mild exacerbation associated with insignificant chest x-ray findings and she received intravenous cephalosporin. after month, she started to productively cough and fever, with a relatively strong persistence despite ains. her first sixteen emergency situations will be presented in detail using the above format. purpose: obstructive sleep apnea (osa) is a common disorder estimated at %- % in school-aged children. with the obesity prevalence reaching staggering rates globally, osa in obese adolescents is estimated to be to fold higher than their lean peers. there is a paucity of data regarding obesity-related osa in children years and less. this is particularly relevant as osa is associated with neurocognitive deficits. the aim of this study is to evaluate the prevalence of osa among obese toddlers and preschool children and further to determine what other factors may be associated with the presence of osa. methods: a retrospective study involving children < years, identified from two canadian pediatric tertiary care centers who had an in-lab polysomnography (psg). obesity was defined by a bmi of > th percentile for age and gender or a z-score of > . osa was diagnosed if the obstructive apnea-hypopnea index (oahi) was greater than events per hour. results: there were participants included; the mean age was . years (standard deviation [sd] + . ), mean bmi z-score was . (sd + . ). of these, / ( . %) had osa. compared with the non-osa group, the osa group had a higher epworth sleepiness score (p = . ) and were more likely to snore (p = . ). the present study "comparative study of nebulized beta agonist, nebulized adrenaline and any added advantage of % hypertonic saline in bronchiolitis" was undertaken to assess the efficacy. a total number of patients ( patients in each group) were examined below months of age. group a was nebulized with salbutamol, group b was nebulized with adrenaline and similarly, group c was nebulized with % hypertonic saline. comparison of mean ± s.d. of rdai score before and after nebulization was performed in all groups. in each patient from all groups (ie a, b and c), rdai scores were recorded at the time of admission (ie at minutes), at minutes and minutes (after nebulization) and on subsequent days. the mean value of rdai score at admission and discharge was . ± . and . ± . respectively in group a. in group b, rdai score at the time of admission and discharge was . ± . and . ± . , respectively. similarly in group c, rdai score at the time of admission and discharge was . ± . and . ± . , respectively. all the parameters before treatment had a p value > . (not significant at minutes.) and at the time of discharge, the p value became < . (extremely significant). mean differences in hr, rr, rdai score and spo were assessed after subsequent nebulization in all groups. the post treatment values for group a (salbutamol), group b (adrenaline) and group c ( % hypertonic saline) were compared. all groups showed an increase in hr, but group b (mean difference of . ) showed a more increasing trend than group a (mean difference of . ) and group c (mean difference of . ) and had a p < . . regarding rr, all groups showed decreased rr, but group b (mean difference of . ) was more significant than group a (mean difference of . ) and group c (mean difference of . ) and had a p < . . regarding rdai score, all groups showed improved score, but group b (mean difference of . ) was more significant than group a (mean difference of . ) and group c (mean difference of . ) and had a p < . . similarly, all groups showed improved spo %, but group b (mean difference of . ) showed more improvement than group a (mean difference of . ) and group c (mean difference of . ) and had a p < . . clinical parameters (heart rate, respiratory rate, rdai score and spo %) in both groups were comparable before nebulization. nebulized salbutamol was given to group a, nebulized adrenaline to group b and nebulized hypertonic saline to group c. different clinical parameters in the groups were compared before and after subsequent nebulization. mean respiratory rates, rdai scores and spo (%) significantly improved in all groups. however, improvement was more significant in the adrenaline group. shorter length of hospitalization was noted in group c (hypertonic saline). no undesirable side effects were noted in all groups. all groups showed a transient increase in heart rate, although more so in the adrenaline group. objectives: endothelial dysfunction (ed) is one of the initial pathological changes ultimately leading to atherosclerosis and consequent cardiovascular disease. children with endothelial dysfunction are at higher risk of developing systemic and pulmonary hypertension, atherosclerosis and cardiac remodeling, with potential long-term adverse outcomes into adulthood. obstructive sleep apnea syndrome (osas) has been found to cause impaired endothelial function in adults. however, the evidence in pediatric osas is limited. the aim of the study is to evaluate endothelial function in a large cohort of children clinically referred for suspected osas, and to identify risk factors contributing to the presence of ed. methods: children aged to years old with habitual snoring (snoring ≥ nights per week) were recruited to this study between june st -march st . all subjects underwent an overnight polysomnography (psg), as well as endothelial function testing using peripheral arterial tonometry (pat) to derive the reactive hyperemic index (rhi). subjects were then divided into osas and primary snorers (ps) groups according to their obstructive apnea-hypopnea index (oahi). results: a total of cases completed the study, with children being diagnosed as osas, and children assigned to the ps group. there were no differences in age, gender and bmi z-score between the two groups (all p > . ). the osa group had lower rhi than that of ps (p < . ). univariate correlation analysis showed that rhi was linearly correlated with age, gender, oahi, oxygen desaturation index, respiratory related arousal index, and oxygen saturation nadir. the relationship between bmi z-sore and rhi was quadratic. rhi and bmi z-sore were positively correlated when bmi z-score< . year follow-up, we regularly performed ekg, cardiac echogram, minute walk testing (smwt) and monitoring of serum bun, bnp and creatinine. also, cardiac catheterization and hemodynamic studies, pet study with uptake of glucose analog -deoxy- -﹝ f﹞fluoroglucose ( f-fdg) and pulmonary perfusion-ventilation scan were performed. we enrolled six patients with es including atrial septal defect type ii ( cases), atrial septal defect type i ( case), right atrial isomerism after total cavopulmonary connection (tcpc) ( case) and ventricular septal defect ( case); the male:female ratio was : . hemodynamic studies revealed that mean pulmonary arterial pressure was ± . mm hg; pulmonary vascular resistance index was . ± . wu*m , except the case receiving tcpc. in addition, three cases of intrapulmonary thrombus in right pulmonary artery, three cases of cerebral stroke and three cases of atrial fibrillation were found. the lung scan revealed that there were nonspecific findings noted in the es patients with or without intrapulmonary thrombus. very interestingly, an increased uptake of f-fdg in the right ventricle was noted in three cases. subsequently, there were two mortalities because of right ventricular failure. and pediatric settings which corresponds to a child of kg weight (tidal volume ml, breaths/min, ratio between inspiratory and expiratory / and peep cm h o). a filter was placed between the endotracheal tube and the test lung model (smartlung adult, imt medical, switzerland) to collect the drug. all components were tested for drug deposition. deposited doses were quantified by spectrophotometry. all measurements were performed five times. results: the percentages of the nominal dose of salbutamol deposited on the filter with the adult model after nebulization and aerosolization, were similar when the device was located before or after the y piece results: flow analysis. during inhalation, the pressure differential (y)/ flow rate (x) relationship was y = . x + . x (r = , ). during exhalation, the pressure differential (y)/flow rate (x) relationship was y = - . x + . x (r = , ). this indicated that the flow rate closely followed the pressure differential (n = ). furthermore, the ap was able to measure flow rate with great stability and reproducibility during all the experiments. results: valve resistance generated at low inspiratory flow rate ( l/min) varied greatly between the different valves ranging from . to . cmh o/l/s; however as the flow rate increased, variations were reduced ( . to . cmh o/l/s at l/min). the ability to close varied strongly from one valve to another: for some valves, expiratory flow did not pass through the inspiratory valve while for others, only partial closing could be achieved ( % of expiratory flow passed through the inspiratory valve). these results were confirmed by measuring the flow through the expiratory valve, maximum ( % of the initial flow rate) when inspiratory valves were completely closed. tilting the chamber did not seem to affect this result. ed measured with pediatric breathing parameters in coordinated and uncoordinated use was similar for four of the custom vhcs while with the other two vhcs, ed was lower. , and a high-speed camera (hxlink ,nac) and two different shapes of membrane models were used in this study. five catheter motions: ) quiescent technique, ) piston technique, ) rolling technique, ) twist technique, and ) dynamic pressure technique, were performed times each and the weight of secretion was measured by a digital scale. the negative pressure was set at kpa, suctioning time was counted seconds. one-way anova and tukey test were used to analyze the obtained data. in experiment , the mean amount of secretion for ) to ) were . , . , . , . , and . , respectively. there were significant differences between ) quiescent technique and ) piston technique (p = . ), ) piston technique and ) rolling technique(p = . ) on a flat membrane model with high viscous sputum. the high-speed camera showed that absorption was started when a catheter tip aperture and two side apertures were sealed with the high viscous sputum. as dynamic pressure technique, sputum was quickly absorbed right after the researcher released her thumb which bent the suctioning catheter. in experiment with high viscous sputum on a tracheal membrane model, mean secretion weight ) to ) were . , . , . , . , and . respectively. there were no significant differences between these five techniques. in experiment with low viscous secretion on a tracheal membrane model, mean amounts of suctioned secretion were . , . , . , . , and . respectively. there were significant differences between ) piston technique and ) twist technique (p = . ), ) piston technique and ) dynamic pressure technique (p = . ). in conclusion, the piston technique could absorb the most amount of secretion when a catheter tip was visible on a flat membrane model, however, the catheter motion which suctioned the most secretion was the dynamic pressure technique in a tracheal model despite the viscosity of the secretion. even though nurses had to carefully apply the level of negative pressure before their procedure, this result indicated that dynamic pressure technique is the most effective catheter motion to remove secretion on a tracheal model. background: respiratory syncytial virus (rsv) infection is the main cause leading to acute bronchiolitis in infants or children less than years of age. children are more susceptible to rsv infection than adults, especially those who have hemodynamic-significant congenital heart disease or heart failure. in this study, we aimed to evaluate the possible risk factors leading to prolonged stay in the pediatric intensive care unit (picu) or hospital stay for chd children with rsv infection. methods: data were retrospectively retrieved of patients who had chd from jan to dec . those patients who had concurrent rsv infections and underwent computed tomography imaging study were included as the study group. clinical presentations were recorded and classified. statistics used descriptive analysis and p < . was taken as significant. results: a total of patients with associated congenital heart disease were included. the mortality rate was about % due to pulmonary edema, dysfunction or cyanosis. the total number of subjects whose age was below year old was similar to those whose abstracts | s age was between and years old. there were chd children with airway problems, including trachea-bronchomalacia, stenosis of the trachea or bronchus. patients aged less than year old had longer hospital stay than those whose age was above year old. the mean picu stay and the intubation period had a similar trend. in the comparison of groups without airway anomalies, the hospital stay in children who had hemodynamic-significant chd or heart failure (without associated airway anomalies) was . days compared to . days in children who did not have hemodynamic-significant chd or heart failure(without airway anomalies) (p < . ). in children with airway anomalies but did not fulfill the criteria of hemodynamic-significant chd or heart failure had longer hospital stay ( . days) than those without airway anomalies but with hemodynamicsignificant chd or heart failure ( . days) (p < . ). conclusions: patients with airway anomalies are not rare in children with chd, although the severity varies. lower airway anomalies were associated with longer hospital stay in chd children who were not hemodynamic-significant or heart failure. we found that airway problem is a risk factor for prolonged hospital or picu stay in chd children with rsv bronchiolitis. to achieve successful and sustainable outcome in chd children with rsv bronchiolitis, it is crucial to have early identification of concomitant airway anomalies in these children. childhood pneumonia and diarrhoea : global burden of childhood pneumonia and diarrhoea key: cord- - quigar authors: nan title: posters date: - - journal: j pept sci doi: . /psc. sha: doc_id: cord_uid: quigar no abstract is available for this article. laboratory of molecular biology and immunology, department of pharmacy, university of patras, patras, greece antimicrobial peptides (amps) are an important component of innate immune system of most living organisms. they have recently gained much attention as new anti-infective drugs with new modes of actions and few or no side effects. their antimicrobial spectrum covers gram-positive and -negative bacteria as well as fungi and certain viruses . fish have proven to be a rich source of antimicrobial peptides. three chrysophsin peptides (chrysophsin- , - , - ) have been identified in the gills of the red sea bream, chrysophrys major, which are all bactericidal to pathogenic bacteria at low concentrations . they are cationic α-helical peptides, rich in histidine residues and all end in an unusual rrrh motif. however, in addition to its high antimicrobial potency, chrysophsins have considerable hemolytic activity. the development of new analogues which would preserve high antimicrobial potency, but would lack the undesired hemolytic activity, could be a useful tool with possible commercial and clinical applications. in the present study, we synthesized a series of analogues of chrysophsin- with different ratios of lys and leu residues, utilizing the fmoc/but solid phase methodology . the synthesized analogues were purified and isolated by rp-hplc. the antimicrobial properties of the above peptide analogues are currently testing in gram positive (s. aureus, s. epidermidis, e. faecium) and gram negative (e. coli, p. aeruginosa) bacteria. the goal is to identify the minimum bacteriostatic and bactericidal concentrations of the analogues, under conditions that simulate the best possible that of the human organism. hemolytic or cytotoxic activity of the peptides will also be determined. the rise of antibiotic resistance demands the development of new antimicrobial agents. these should exhibit a novel mechanism of action so as to overcome the resistance and be invulnerable to 'not yet acquired resistance mechanisms'. such criteria are difficult to meet. however, cationic host defence peptides (hdps) have emerged as promising candidates. hdps target and disrupt bacterial membranes. in order to evade such a threat a bacterium would need to make substantial changes to its membrane composition disfavouring the development of resistance ( ) . however, exact role and mechanism of hpds in the regulation and monitoring of microbial invasions remain to be established. herein we will present new potential mechanisms of antimicrobial regulation by helical hdps using de novo ( ) and native systems ( ) . biophysical and microbiology aspects of the experimental designs will be discussed. the low number of the newly discovered antibiotics, emergence of multiple-drug resistance, and the alarming death rate due to the infection disease led to development the alternative means to combat the infections. the researchers accumulate information about antimicrobial drugs that could be result of the innate immunity mechanisms. armed only with the innate immunity, the insect has developed into the most widespread class in living kingdom. they produce several antimicrobial peptides with complementary and rapid mode of action. so far there are hundreds of antimicrobial peptides isolated from insect and lot of them are waiting to be discovered. the fleshly neobellieria bullata was chosen for isolation of these active compounds. its larvae in the third instar were squeezed to collect the haemolymph, which was gradually centrifuged and precipitated by acidified methanol. supernatant was subsequently separated by chromatographic methods (spe column, rp-hplc) to obtain fractions of short peptides. identification and characterization of these fractions were performed by tricine electrophoresis, mass spectrometry maldi-tof analysis and n-terminal sequencing. several fractions showed antimicrobial activity against institute of chemical kinetics and combustion, novosibirsk, russian federation in this work, we extracted d-structural information on newly synthesized, medium-length, double spin-labeled peptaibiotics using peldor spectroscopy. we investigated the magnetic dipole-dipole interactions between spin labels and the orientation selectivity effects. in particular, the medium-length peptaibiotics tylopeptin b , and heptaibin , double spin-labeled with the nitroxyl probe toac ( -amino- -oxyl- , , , -tetramethylpiperidine- -carboxylic acid), were studied by means of x-band peldor spectroscopy. this study was conducted on tylopeptin labeled at positions and (t ) and heptaibin labeled at positions and (h ) in frozen glassy methanol solutions at Κ. peldor data analysis was carried out using the theory developed for short interspin distances. the distance distribution functions between spin labels for Τ (maximum at . nm, halfwidth of . nm) and Η (maximum at . nm, half-width of . nm) were determined. the intramolecular distances observed between the labels allowed us to assign an essentially α-helical conformation to Τ and a largely prevailing -helical structure to Η under the aforementioned experimental conditions. are amidated at the c-terminus, as a result of a posttranslational enzymatic reaction. temporins are particularly active against gram-positive bacteria and are not toxic to eukaryotic cells. in this study we designed a series of analogues of tb with the aim to improve the peptide antimicrobial activity against both gram negative and gram positive strains and then to structurally elucidate the mechanism of interaction of active peptides with lps. the peptides have been synthesized substituting one or two amino acids with an alanine and lengthening the sequence with positively charged amino acids. among the designed peptides, one of the analogues, tb_kkg a, showed highly increased activity against gram negative bacteria and also a slightly increased activity against gram positive bacteria with a total lack of hemolytic activity. to develop ll- -derived short amps with prokaryotic selectivity and lipolysaccharide (lps)neutralizing activity, a series of amino acid-substituted analogs based on ig- (residues - of ll- ) were synthesized. analog a showed the highest prokaryotic selectivity, but much lower lps-neutralizing activity compared to ll- . the analogs, a , a , a and a with higher hydrophobicity displayed lps-neutralizing activity comparable to that of ll- , but much lesser prokaryotic selectivity. these results indicated that the proper hydrophobicity of the peptides is crucial to exert the amalgamated property of lps-neutralizing activity and prokaryotic selectivity. to increase lps-neutralizing activity of the analog a , we synthesized trp-substituted analogs (a -w and a -w ), in which phe or phe of a is replaced by trp. despite their same prokaryotic selectivity, a -w displayed much higher lps-neutralizing activity compared to a -w . this result suggested that the effective site for trp-substitution when designing novel amps with higher lps-neutralizing activity, without a remarkable reduction in prokaryotic selectivity, is the amphipathic interface between the end of the hydrophilic side and the start of the hydrophobic side rather than the central position of the hydrophobic side in their α-helical wheel projection. furthermore, d-enantiomeric peptides (a -w -e and a -w -e) of a -w and a -w possessed not only more improved prokaryotic selectivity and retained lpsneutralizing activity compared to a -w but also protease stability. taken together, a -w -e and a -w -e can serve as promising templates for the development of therapeutic agents for the treatment of endotoxic shock and bacterial infection. department of zoology, faculty of science, charles university, prague, czech republic antimicrobial peptides (amps) are among the most promising lead compounds for developing medicines in the fight against resistant pathogenic bacteria. we have already shown that the venom of wild bee is a rich source of pharmacologically interesting antimicrobial peptides [ ] [ ] [ ] [ ] . from the venom of solitary bee macropis fulvipes, we isolated and characterized the novel antimicrobial peptide named macropin (mac- ). by edman degradation and mass spectrometry, its primary sequence was established as gfgmalkllkkvl-nh . mac- possesses potent antimicrobial activity against both gram-positive andnegative bacteria and moderate hemolytic activity against human red blood cells. cd spectra confirmed that mac- can form an amphipathic α-helical secondary structure in the presence of membrane-mimicking substances as sodium dodecyl sulfate or organic solvents like trifluoroethanol. we prepared a series of mac- analogs to study the effect of incorporating d-amino acid residues into the sequence in various positions on antimicrobial and hemolytic activity, α-helicity and serum stability. the substitution of l-amino acid residues at n-terminal part of sequence by d-amino acid residues led to the improving hemolytic activity with maintaining or increasing antimicrobial activity. these modifications increased peptide stability in human serum. effect of the incorporation of d-amino acid residues into the mac- sequence on its α-helical structure will be discussed. the neutralization of endotoxins (lipopolysaccharide, lps) by suitable compounds has been shown to be a key step in the treatment of infectious diseases, in particular in the case of gram-negative bacteria. the active endotoxic center of lps is lipid a, its lipophilic part. an effective antimicrobial peptide against gram-negative bacteria is magainin , which was originally found in the skin of an african frog. here, we studied the interaction of hexa-acyl bisphosphoryl lipid a prepared from erwinia carotovora lps with magainin with some minor substitutions in the amino acid pattern. by using fourier-transform infrared spectroscopy, the gel to liquid crystalline phase transition of the acyl chains of lipid a, the conformation of their phosphate groups due to peptide binding, and the profile of the secondary structure of the peptides was investigated. the zeta potential of lipid a aggregates in the presence of the peptides was determined by measuring the electrophoretic mobility. small-angle x-ray scattering was performed for the elucidation of the aggregate structures in the absence and presence of the peptides, and isothermal titration calorimetry was applied for evaluating the thermodynamics of binding between peptides and lipid a. the data show that asp-or glusubstituted peptides improved the binding activity to lipid a correlated with characteristic changes in the physical parameters, which were stronger expressed for the aspsubstituted peptide. the new hydrogen bond connection between glu and asp by carboxylic acids apparently leads to a more pronounced -structure of the peptide. the conformation change of the peptide enhanced the activity of incorporation into the lipid a aggregates, along with changes in biochemical and biophysical parameters. royal college of surgeons, dublin, ireland cationic antimicrobial peptides (caps) have been reported to exhibit anticancer activity . one such peptide, p , has been shown to inhibit the growth of several cancer cell lines, with inhibiting concentration (ic ) in the range of to μm . however the concentration at which p and other caps act is too high to be clinically relevant. the enhancement of their activity can be achieved through the modification of their amino acid composition or the addition of other molecules. conjugation of naturally produced hydroxylated fatty acids to p showed a -fold improvement in its anticancer activity on a variety of human-derived cell lines. in addition to the enhancement of activity we wished to understand the mechanism of action of the peptide and conjugates. we investigated the uptake of conjugated and unconjugated peptides into hela (cervical) and miapaca (pancreatic) human cancer cells and the localisation of the peptide in the cell once taken up. we investigated the effect of altering the carbon number of the hydroxylated fatty acids ranging from hydroxyhexanoic acid (r ) to hydroxydodecanoic acid (r ) conjugated to p peptide and tested on hela and miapaca cell lines. circular dichroism studies were performed to investigate the effect on α-helical content due to amino acid composition alteration and hydroxyalkanoic acid conjugation. the effect of the position of the hydroxyl moiety on enhancement of activity was also investigated. in the current study p and its derivatives also lacked haemolytic activity with concentrations up to fold higher than ic values needed to observe any haemolysis. when current antibiotics become less efficient, there is a promise that some antibiotics can be replaced by other nature's substances, e.g. peptides. halictines are novel antimicrobial peptides isolated from the venom of the eusocial bee halictus sexcinctus. we obtained four analogues of the native peptide hal from iocb av cr. they already characterized structural properties of these peptides and their antimicrobial activity against selected bacteria . the analogues were prepared by point mutations of native peptide, which could increase antimicrobial activity and decrease undesirable hemolytic activity. our aim was to characterized membrane permeation activity of halictines through the use of a basic model of biological cells -large unilamellar phospholipid vesicles luvs. we prepared two basic types of leakage assays based on luvs with free dyes entrapped inside and one assay with laurdan content. we used classical steady state fluorescence spectroscopy and advanced fluorescence methods for study of dyes escape from luvs and we also used laurdan generalized polarization technique gp for better understanding peptide insertion into membrane. in this way we received complementary information and we can conclude that the most active peptides are the native hal and analogue hal / . however hal / requires presence of negatively charged phospholipids in membrane which may explain its higher selectivity against bacteria. furthermore, fcs results have shown that the leakage happens via pore formation. results from gp revealed that peptide insertion in the membrane do not lead directly to formation of pores. against a wide range of microorganisms, mainly by perturbing the permeability of bacterial membranes through the formation of pores. however, amps effects on membrane properties probably extend beyond poreformation. we performed a systematic spectroscopic analysis of the effects on membrane structure and dynamics of two very different amps: the cationic pmap- , which creates pores according to the "carpet" model , and alamethicin, which forms "barrel-stave" channels . by using fluorescence anisotropy measurements on liposomes comprising probes localized at different depths in the bilayer, we measured peptide effects on membrane fluidity and order. laurdan spectral shifts provided indications about water penetration in the bilayer. in the case of pmap- , it was possible to focus specifically on the lipids surrounding the peptide by following the membrane-probe fluorescence due to fret from the peptide trp residues. finally, peptide-induced perturbation of lateral mobility and domain formation were determined by several methods. all experiments were compared with liposome-leakage measurements: while for pmap- all membrane-perturbing effects are correlated with the vesicle leakage process, alamethicin does not significantly influence membrane dynamics at the concentrations in which it forms pores. surprisingly, in all cases the most significant peptide-induced effect is a reduction in membrane fluidity. we have reinvestigated -residue peptaibols named metanicins from an ascomycetous fungus originally described as metarhizium anisopliae strain cbs . (cbs = centraalbureau voor schimmelcultures, utrecht, the netherlands). however, due to unusually shaped conidia and based on rna-sequencing of its internal transcribed spacer (its) region, the identification of cbs . as metarhizium has been withdrawn and this particular strain is currently under taxonomic reinvestigation . sequencing of four isolated peptides by fab-ms, esi-ms and edman degradation of partial hydrolysates revealed structural relationship to -residue peptaibol antibiotics paracelsins from trichoderma reesei (=hypocrea jecorina). sequences determined are: ac-u-a-u-a-u-a(u)-q-u-v-u-g-l-u-p-v-u-u(j)-q-q-fol (exchange positions in parenthesis; ac, acetyl; u, aib, α-aminoisobutyric acid; j, d-isovaline; fol, l-upmc univ paris laboratoire des biomolécules; cnrs umr ; ens lbm; address: laboratoire des biomolécules, ens dpt de chimie, , rue lhomond f- , paris, france current data suggest that the cellular uptake of cellpenetrating peptides (cpps) occur by two processes: direct translocation across the plasma membrane and endocytosis . the large diversity of cpp sequences described in the literature (derived either from fragments of proteins, structurally constrained synthetic peptides, peptide libraries or dendrimers) has hampered the identification of general rules for their efficacy of internalisation. we have used a reductionist approach, restricting the cpp functional groups (amide and guanidinium) and tailoring cpp amphiphilic properties. two families of cpps have been designed: ) primary amphiphilic cpps corresponding to tetra-arginines functionalised with fatty acid chains of different lengths and ) secondary amphiphilic cpps containing arginine and alanine or tryptophan residues . these cpps were linked by a disulfide bridge to a peptide inhibitor of protein kinase c (pkci). the efficiencies of internalisation of the conjugates were quantified by a method based on maldi-tof mass spectrometry previously developed in our group . the mechanism of internalisation was studied by comparing the amounts of cell-surface bound and internalized pkci cargo on cho-k cells and glycosaminoglycan-deficient cho cells at o c and o c. conjugates were found to enter by both direct translocation and glycosaminoglycandependent endocytosis. in addition, the primary amphipathic cpps were found to be more efficient than the secondary amphipathic ones. furthermore, structural or mechanistic novelty does not guarantee immunity from resistance, with strains resistant to linezolid identified prior to fda approval. therefore, modifying existing antibiotics to overcome resistance mechanisms presents an opportunity to rationally develop effective new drugs more rapidly than screening for new structures. vancomycin is a glycopeptide commonly used as a front line treatment for infections caused by methicillinresistant staphylococcus aureus (mrsa). the emergence of vancomycin-resistant enterococci (vre), vancomycinintermediate s. aureus (visa) and vancomycin-resistant s. aureus (vrsa) has prompted the development of semisynthetic glycopeptides . we have generated a variety of glycopeptide derivatives that show superior antibacterial activity against mrsa and vre compared to vancomycin and second generation lipoglycopeptides. this was undertaken by employing a combination of solid phase and solution phase chemistry to attach a membraneassociative element that selectively binds to bacterial membranes in preference to eukaryotic membranes, thus increasing the local concentration at the lipid ii d-ala-d-ala peptidoglycan cell wall precursor target site. three novel antimicrobial peptides, named panurgines (png), were isolated from the venom of wild bee panurgus calcaratus. one of them is dodecapeptide with sequence lnwgailkhiik-nh (png- ). the next two peptides are almost identical. these are cyclic peptides containing amino acid residues and two intramolecular disulfide bridges ldvkkiicvackixpnpackkicpk-oh (x=k png-k and x=r png-r). all peptides exhibited antimicrobial activity against gram-positive bacteria and gram-negative bacteria, antifungal activity and low haemolytic activity against human erythrocytes. we prepared analogues of α-helical amphipathic png- with the aim to improve its biological properties and a linear analogue of png-r to elucidate the importance of disulfide bridges for its activity. in the second part of the study, we followed the effect of panurgines on the degree of membrane disruption by observing the leakage of fluorescence dye (calcein) entrapped in artificial phospholipids vesicles [ ] . specifically, we investigated membrane interactions of pngs with the vesicles made from negatively charged : dopc/dppg and : dopc/dopg vesicles as a general model of bacteria membrane and : : dopc/dopg/cl as a possible model for a membrane of bacillus subtilis. the membrane interaction of pngs was also investigated on uncharged dopc vesicles as potential model membrane for erythrocytes. pngs exhibited weak dye-leakage activity for neutral vesicles, while they effectively induced dye leakage in the presence of negatively charged vesicles. these results indicate that pngs have stronger potency to disrupt bacteria-mimicking anionic membranes than those which mimic eukaryotic cell membrane. department of biochemistry and toxicology, university "lucian blaga", sibiu, romania a common tool to bias the conformation of linear peptides is the insertion of side-chain modified amino acids or sidechain/main-chain conformationally restricted building blocks. an alternative approach is a simple backbone modification. in this connection, backbone amide replacements with (almost) isosteric surrogates were extensively used. these modifications may impart resistance to enzymatic degradation and better bioavailability to the peptides, but also influence the secondary structure. a thioamide (ψ[cs-nh]) is perhaps the closest structural mimic of an amide. however, it possesses different and attractive features: (i) its nh group forms stronger hydrogen bonds, being more acidic than that of the amide. (ii) its c-n bond undergoes cis/trans isomerization by irradiation at nm (π→π* transition). (iii) it may act as a "minimalist" fluorescence quencher. for all these reasons, we started a programme aimed at exploring how the endothioamide bond affects peptide folding and bioactivity. in this communication, we describe the synthesis and conformational results of the three analogs of the membrane-active peptaibiotic trichogin ga iv listed below: n-octanoyl-aib-gly-ψ[cs-nh]-leu-aib-gly-gly-leu-aib-gly-ile-leu-ome ( / ) n-octanoyl-aib-gly-leu-aib-gly-ψ[cs-nh]-gly-leu-aib-gly-ile-leu-ome ( / ) n-octanoyl-aib-gly-leu-aib-gly-gly-leu-aib-gly-ψ[cs-nh]-ile-leu-ome ( / ) the syntheses of the three peptides were accomplished in solution according to a fragment condensation approach. appropriate thioamide-containing tri-or tetrapeptides were prepared by treating the corresponding all-amide precursors with the lawesson reagent. ft-ir absorption, d-nmr and cd conformational investigations on the three analogs were conducted in comparison with the naturally occurring peptaibiotic. all three analogs maintain the capability to interact with the dope/dopg model phospholipid membranes and exhibit a comparable bioactivity against s. aureus. peptide-peptide interaction of lactococcin g class iib two peptide bacteriocin h. etayash, w.soliman and k. kaur* faculty of pharmacy and pharmaceutical sciences, university of alberta, edmonton, alberta, t g e lactococcin g, a class iib two-peptide bacteriocin, consists of two complementary peptides lcng-α and lcng-β that act as one functional unit with optimal antimicrobial activity achieved by the presence of both peptides in approximately equal amounts. in this study we have investigated the mechanism of pairing of the two complementary peptides as well as explored any specific interaction that could take place between the peptides. molecular dynamics (md) simulation was employed to study the interactions at the atomistic level. four different md simulations with the peptides in a lipid bilayer system were conducted. md results from these simulations confirmed and pointed out that (i) the two putative gxxxg motif, g xxxg in lcng-α and g xxxg in lcng-β, were attracted and came closer to each other, showing the role of these motifs in attracting the two peptides to each other. closer views, however, showed no clear interactions between these two motifs. most likely, nonspecific interactions play a role in bringing the two peptides together; (ii) variations and loss in the secondary structure in both the peptide fragments were confirmed among the four simulations. on the contrary, stability of helical regions was identified between residues w -g and d -q in lcng-α and v -e in lcng-β; and (iii) role of tryptophan at the n-terminal regions in positioning and setting the peptide orientations were confirmed which matched the previous reported results. faculty of pharmaceutical sciences, unesp -univ. estadual paulista, araraquara, sa͂ o paulo, brazil antibiotic resistant bacterial strains represent a global health problem. antimicrobial peptides (amps) are promising novel antibiotics because they have displayed little or no resistance effects. it is well known that the charge, amphipathicity, hydrophobicity and helicity of the peptide are fundamental for the biological activity. in addition, covalent dimerization appears as a new parameter to be studied. in this way, several bioactive sequences were dimerized obtaining pharmacotechnics advantages like enhanced antimicrobial activity, solubility and proteases resistant. however, the effect of this modification is unclear since dimeric versions of some amps are toxic . to evaluate the effects of dimerization on the structure and biological activity of the amp aurein . , the monomeric version (au) and the c-and n-terminal dimers, (au) k and e(au) , respectively, were synthesized. circular dichroism results indicated that dimeric versions showed more defined structures in aqueous solution. e(au) showed "coiled coil" structure while (au) k an αhelix structure. in contrast, au displayed typical spectra for disordered structures. in tfe and lpc, all the peptides acquired a high amount of α-helix structure. the antimicrobial activity against bacteria and yeast decreased with dimerization. however, dimeric peptides promoted the aggregation of c. albicans. hemolytic and vesicle permeabilization assays showed that au has a concentration dependence activity, an effect that can be assigned to a "carpet" like mechanism peptide, whereas this effect was less pronounced for dimeric versions, suggesting that dimerization may change the mechanism of action. in conclusion, our studies showed that the effects of amp dimerization are complex and still unclear. , the first antimicrobial peptide generated in vivo and isolated from the gut contents of the cattle tick boophilus microplus . we have shown that these peptides are equally lethal to candida albicans mdm and practically not active on human erythrocytes . to examine the properties and mode of action of hb - a, we synthesized it and its fluorescently labeled analogue (fam-hb - a) by the solid-phase method at o c, purified them by rp-hplc and characterized their purified forms by lc-esims. at low salt concentration, both peptides were found to inhibit the growth of candida albicans atcc , candida parapsilosis atcc and candida krusei atcc , but hb - a was two-fold more active (mics of . ; . and . μm, respectively). at those concentrations, both peptides also kill the fungi. assays with human erythrocytes showed that, likewise hb - a, fam-hb - a present activity lower than % at μm. apparently, hb - a targets the membrane cell because confocal microscopy analysis revealed that, at the half of mic value, fam-hb - accumulates on the fungal cell membrane. in contrast, fluorescence activated cell sorting (facs) analysis revealed that, at the mic, more than % of the fam-hb - a penetrates into the cell. membrane permeability assay using hb - a, c. albicans atcc and the kit live/dead funga light confirmed progressive membrane damage associated with an increase in peptide concentrations. the use dibac ( ) and facs analysis showed that hb - a alters the plasma membrane potential, leading to cell death. supported by fapesp, cnpq and capes. lasso peptides form a growing class of to residue ribosomally-synthesized and post-translationally modified peptides produced by bacteria. they share a rigid and compact interlocked structure consisting of a macrolactam ring at the n-terminus and a c-terminal tail that is looped back and threaded through the ring, forming a typical [ ] rotaxane , . the macrolactam is formed by condensation of an asp or glu side-chain with the free amino group of a gly or cys . the lasso fold is stabilized either by steric hindrance assumed by bulky amino acid side-chains and/or by disulfide bonds between cysteines from the tail and the ring. given this structure, lasso peptides display a high stability against proteolytic and chemical degradation. they are biologically active on various enzymatic targets, which confer them in some cases an interesting antimicrobial activity. given its characteristics, the lasso scaffold thus represents a promising tool for biotechnological application in the development of bioactive peptides. until now, nine peptides had been structurally characterized as lasso peptides. based on a genomics-based approach, we identified a novel lasso peptide from streptomyces sviceus that we termed sviceucin. it was produced in high yield by heterologous expression in s. coelicolor and submitted to structural analysis by mass spectrometry and nmr. sviceucin is residue long and stabilized by two disulphide bonds. their connectivities were identified mainly from the typical noes between the beta-protons of the cysteines. the lasso structure of sviceucin was obtained by nmr-based molecular modelling. sviceucin was shown to exhibit antibacterial activity directed against gram positive bacteria, while gram-negative bacteria and fungi showed resistant. the penicillium chrysogerum antifungal protein (paf) is a cysteine-rich, cationic protein that inhibits the growth of a variety of filamentous fungi without toxic effect on mammalian cells . although paf is used to be produced in p. chrysogerum or a similar microorganism, preparation of analogues of the protein for structural and functional investigations requires an efficient chemical method. the unsuccessful continuous synthesis of the -mer small protein prompted us to use native chemical ligation . the syntheses of the fragments were performed by solid-phase method applying tboc chemistry. using the acid-labile tboc protecting group, the thioester end of the n-terminal fragment remains intact during the course of the synthesis. the first attempt was the synthesis of peptides with pmethylbenzyl groups on the side chains of all of the six cysteine residues. under no circumstances oxidative folding provided the natural disulphide bridge pattern. the failed attempts led us to orthogonal protection of the sulphydryl groups. different sets of protecting groups were tried and evaluated. our experiments showed that basic treatment triggered rearrangement of the previously formed disulphide pattern. thus, base-labile protecting groups (such as -fluorenylmethyl, fm) have to be avoided in the synthesis of paf. the alarming increase and spread of antibiotic resistance among bacterial pathogens has stimulated the development of new antibacterial agents with innovative mode of action. antimicrobial peptides with broad spectrum activity are widely distributed in nature and play an important role in innate immunity in several species, including humans. tigerinins are a unique family of -to -residue antimicrobial peptides found in skin secretion of the indian frog rana tigerina , . characterized by a disulfide-bridged loop composed of nine amino acids, tigerinins do not show primary structural homology to any known antimicrobial peptides from amphibians. tigerinins could provide novel lead compounds for the design of effective antimicrobial peptides with a new mode of action. the peptide murdp has been identified after the screening of phage display libraries against pseudomonas aeruginosa cell wall biosynthesis murd amide ligase enzyme . murdp is a low micromolar range inhibitor of murd enzyme and showed good antimicrobial activity. composed of nine amino acids, it is also characterized by a nine residues disulfide-bridged loop containing two prolines. this great similarity with tigerinins, led us to investigate if murd enzyme could be a potential target for these peptides. in silico analyses using modelling, molecular dynamics and docking with p. aeruginosa murd showed that murdp and tigerinin- and - make similar interactions in the binding site. these results suggest that murd may be an intracellular target for tigerinin- and tigerinin- . synthesis, murd enzymatic inhibition assay, antibacterial activity evaluation and structure-activity relationships of murdp and tigerinins analogs will be presented. h. etayash, l. norman, t. thundat*, k. kaur* faculty of pharmacy and pharmaceutical sciences, department of chemical and materials engineering, university of alberta, edmonton, alberta t g e , canada listeria monocytogenes is a gram positive bacterium that accounts for about % of the deaths resulting from food borne illnesses in north america. moreover, l. monocytogenes is considered one of the most difficult bacteria to detect in contaminated food products. while standard microbiological and biochemical assays currently used are accurate and sensitive, they are time consuming and often require specialized instruments operated by a trained user making on-site testing difficult. to this end, we propose the development of an antimicrobial peptide (amp) or peptide fragment sensor for the on-site detection of l. monocytogenes. leucocin a, which is a naturally occurring amp consisting of a amino acid sequence, is known to exhibit specific activity against l. monocytogenes at pico to nanomolar concentrations. for this reason, we have synthesized a shorter peptide fragment of leucocin a consisting of amino acids using solid phase peptide synthesis. the peptide was purified by reversed phase hplc and maldi-tof mass spectrometry indicates the desired biological entity was achieved. by including an n-terminal cysteine group, the tailored amp was readily immobilized at a gold interface. the resulting thickness and molecular orientation, determined by ellipsometry and grazing angle infrared spectroscopy, respectively, indicate that the helical peptides were adsorbed on the interface with a preferred orientation parallel to the surface. the bacterial specificity of the anchored leucocin a fragment was tested against three gram positive bacteria and results reveal that the adsorbed amp exhibits a limit of detection of approximately one bacterium/μl which is a clinically useful detection range. faculty of science, university of south bohemia, České budějovice, czech republic during the last few years we have identified three novel defensins from arthropods. two of them, lucifensin and lucifensin ii were purified from various tissues of lucilia sericata and l. cuprina larvae, respectively. larvae of these flies are routinely used in the hospitals around the world for the treatment of non-healing infected wounds in the procedure known as maggot therapy. these amino acid residues and three disulfide bridges peptides differ from each other only in one amino acid residue in position (val-ile). linear precursor of lucifensin was prepared by fmoc-spps chemistry which was then subjected to the oxidative folding yielding a peptide with a pattern of disulfide bridges identical to that of native lucifensin and other insect defensins. this was examined by the identification of the fragments resulting from the thermolysin digestion of lucifensin by means of mass spectrometry. however, this cyclization reaction proceeded via an intermediate having incorrect pairing of disulfide bridges. from the hemolymph of blood sucking tick dermacentor marginatus (d.m.) we purified defensin containing amino acids and three disulfide bridges. its sequence determined by edman degradation and mass spectrometry was identical to that previously determined by molecular biology methods . sequence of d.m.defensin shows no homology to insect defensins. by spps prepared linear precursor of d.m.-defensin was subjected to oxidative folding under the open air. the linear peptide was straightforwardly folded into cyclic one which was identical to the native peptide. in antimicrobial assay using a set of different bacteria all three studied defensins show activity preferentially against gram-positive bacteria including staphylococcus aureus but are inactive against gram-negative ones. the importance of disulfide bridges on tertiary structure of defensins and their antimicrobial activity will be presented. recently, the chemical structure and conformation of pseudodesmin a has been determined through x-ray diffraction and nmr spectroscopic analysis . in this way pseudodesmin a was identified as a new member of the viscosin group of antimicrobial peptides (amps). in addition, it was demonstrated that individual molecules self-assembly in apolar environment into a supramolecular pore-like structure, providing structural support for its biological activity , . to further explore the structure-function relationship, a viable synthesis strategy for pseudodesmin a analogues was developed, based on side-chain attachment of the first amino acid to the solid support, followed by stepwise fmoc solid-phase synthesis of the linear peptide precursor and on-resin head-to-tail cyclization. nmr study confirmed the molecular structure and thus the development of an efficient and successful synthesis of this type of amp's. these results and the synthesis route will be presented. trichogin ga iv, isolated from the fungus trichoderma longibrachiatum , is the prototype of lipopeptaibols, a subclass of short-length peptaibiotics exhibiting membranemodifying properties. its primary structure is as follows: n-oct-aib -gly-leu-aib-gly-gly-leu-aib-gly-ile -lol, where n-oct is n-octanoyl, aib is α-aminoisobutyric acid, and lol is the , -amino alcohol leucinol. this peptaibol is predominantly folded in a mixed -/αhelical conformation with a clear, albeit modest, amphiphilic character . in this work, we synthesized by solution and solid-phase methodologies a set of trichogin ga iv analogs in which the four gly residues, lying on the poorly hydrophilic face of the helical structure, are substituted by one (or more) strongly hydrophilic lys residues. moreover, we synthesized another set of analogs where one (or more) aib residues are replaced by leu. the conformational preferences of these analogs were assessed by x-ray diffraction, cd, and d-nmr techniques . we tested the role played by the substitutions on the peptide bioactivity, e.g. protease resistance, cytotoxicity, and hemolysis. cytotoxicity was tested using three in vitro cell-based assays: (i) human red-blood cells lysis; (ii) cell mortality in total human blood leukocytes and in separate subpopulations; (iii) cell mortality in three tumor-derived stable cell lines (hela, a , and a ). our data show that some of our trichogin analogs are active against tumor cells, leaving the leukocytes unaffected. a convenient post-screening ring opening approach for the decoding of one-bead one-compound cyclic peptide libraries a. girard, e. biron* faculty of pharmacy, université laval and chuq research center, quebec, canada combinatorial chemistry has been widely used as an effective method for the generation and screening of synthetic peptide libraries. amongst the different combinatorial methodologies to discover new bioactive peptide-based compounds, we were particularly interested in the one-bead one-compound (oboc) approach . this powerful approach fully exploit the great molecular diversity accessible with peptides and has been used to identify a great number of ligands and modulators for a wide variety of biological targets. however, its use with cyclic peptides is limited by difficulties in sequencing hit compounds by edman degradation or tandem mass spectroscopy due to the lack of free n-terminal amine and complicated fragmentation patterns, respectively. this problem has been overcome by pei and coworkers by using a bead segregation strategy in which the outer layer exposes the cyclic peptides and the inner layer the linear counterpart for sequencing . more recently, lim et al. reported an elegant method to prepare and sequence oboc cyclic peptoid libraries without encoding by using a ring opening approach with triazine-based cyclic derivatives . unfortunately this method is incompatible with amino acids bearing some functionalized side chains. based on this strategy, we have developed an efficient method to prepare oboc cyclic peptide libraries that does not require encoding by using a simultaneous ring opening/cleavage approach. the procedure is compatible with commonly used amino acids and allows rapid and efficient sequencing of selected hits after on-bead screening. the synthesis of an oboc cyclic peptide library, ring opening methodology and sequencing by mass spectrometry will be presented. cyclotides are a very abundant class of plant peptides that display immense sequence variability around a conserved cystine knot motif and a head-to-tail cyclized backbone conferring them with remarkable stability . their intrinsic bioactivities combined with tools of peptide engineering make cyclotides an interesting template for the design of novel agrochemicals and pharmaceuticals . however, laborious isolation and purification prior de novo sequencing limits their discovery and hence their use as scaffolds for peptide-based drug development . here we extend the knowledge about their sequence diversity by analyzing the cyclotide content of a violet species native to western asia and the caucasus region . using an experimental approach, which we named 'sequence fragment assembly' by maldi-tof/tof-based peptidomics, we were able to characterize novel cyclotides from viola ignobilis. amino acid sequencing of various enzymatic digests of cyclotides allowed the accurate assembly and alignment of smaller fragments to elucidate their primary structure, even when analyzing mixtures containing multiple peptides. using in-source decay and high energy collision induced dissociation of digested cyclotides allowed to distinguish isobaric residues ile and leu. overall this work underlines the immense structural diversity and plasticity of the unique cyclotide framework. the presented approach for the sequence analysis of peptide mixtures facilitates and accelerates the discovery of novel plant cyclotides. glycation is a nonenzymatic reaction occurring between reducing sugars and reactive amino groups of biomolecules. the reaction leads to a formation of a heterogeneous mixture of compounds which are classified as early, intermediate or advanced glycation end products (age). these compounds, especially advanced glycation end products, are involved in many pathological processes, mainly diabetic complications, and could be markers of certain diseases. detection of early products of glycation (amadori products) is a relatively easy task and can be performed by various methods including e.g. ms/ms techniques, isotopic labeling and affinity chromatography on immobilized boronic acid , . however, the diverse structures of ages make detection of these compounds more challenging. the aim of the study was testing a new method of ages identification based on isotopic c labeling. a model protein (hen egg lysozyme) was modified with an equimolar mixture of [ c ]glc and [ c ]glc. then the glycated protein was subjected to reduction of the disulfide bridges followed by enzymatic hydrolysis. the obtained digest was analyzed by lc-ms methods. the glycation products were identified on the basis of characteristic isotopic patterns resulting from the use of isotopically labeled glucose. this method allowed for identification of early maillard reaction products and different structures of the glycation end products. isotopic labeling technique combined with lc-ms is a new and very sensitive method for identification of the advanced glycation end products even if their structures are unknown. this method could be also used as an alternative method of detection of amadori products. in the course of a project aimed to assess the significance of antibiotics for the producing organism(s) in the natural habitat, we screened a specimen of the fungicolous fungus hypocrea phellinicola growing on its natural host phellinus ferruginosus . using a peptaibiomics approach , , we detected -and -residue peptide sequences by (u)hplc/hr-esi-qqtof-ms. structures of peptaibiotics found were independently confirmed by analyzing the peptaibiome of an agar plate culture of h. phellinicola cbs (ex-type) grown under laboratory conditions. notably, h. phellinicola could be identified as a potent producer of -, -, (culture) and -residue (specimen) peptaibiotics of the suzukacillin-type . minor components of the -residue peptaibols, herein named suzukacillins c, are assumed to carry a c-terminal residue tentatively assigned as tyrosinol (tyrol). in addition, the previously isolated suzukacillin b was sequenced and shown to be a microheterogeneous mixture of -residue peptaibols. in order to further investigate the significance of antibiotics for the producing organism(s) in the natural habitat, we screened specimens of the fungicolous fungus hypocrea pulvinata growing on its natural hosts piptoporus betulinus and fomitopsis pinicola . using a peptaibiomics approach , we detected -, -, -(major sequences), and -residue peptide sequences in the five specimens analyzed by (u)hplc/hr-esi-qqtof-ms. structures of peptaibiotics found were independently confirmed by analyzing the peptaibiome of pure agar cultures obtained by single-ascospore isolation from the specimens . major, -residue peptaibols were assigned as deletion sequences of the trichosporins b lacking the ala/aib residue in position . our results corroborate that: i) peptaibiotics are, indeed, biosynthesized in the natural habitat, thus, ii) their membrane-perturbing formation of ion channels may support the parasitic life style of a fungicolous fungus. based on methodology that we have developed in our lab , we identified specific and selective substrates for these serine proteases. we used a , membered pnaencoded peptide library to screen , possible peptide substrates in a single experiment. the library was incubated with the protease of interest and then hybridized on a custom designed dna microarray. microarray scanning and data analysis allowed the measurement of the changes in fam/tamra ratios resulting from the protease activity and the determination of the protease specificity. to verify the predicted activity and specificity, fret peptides were synthesized, incubated with the enzymes and the hydrolysis reaction was followed by monitoring fluorescence emission. specificity constants kcat/km were calculated and the cleavage sites of the peptides were identified. dubs were, moreover, found to be associated with several diseases and as such are emerging as potential therapeutic targets . several directions have been pursued in the search for lead anti-dub compounds. however, none of these strategies have delivered inhibitors reaching advanced clinical stages due to several challenges in the discovery process, such as the absence of a highly sensitive and practically available high-throughput screening assay . in this study, we report on the design and preparation of a fret-based assay for dubs based on the application of our recent chemical method for the synthesis of ub bioconjugates . in the assay, the ubiquitinated peptide was specifically labeled with a pair of fret labels and used to screen a library comprising compounds against uch-l . such analysis identified a novel and potent inhibitor able to inhibit this dub in time-dependent manner with kinact = . μm and ki = . μm. our assay, which was also found suitable for the uch-l enzyme, should assist in the ongoing efforts targeting the various components of the ubiquitin system and studying the role of dubs in health and disease. . more recent work based on rna interference experiments on a mouse model suggested that isoform-specific inhibitors against nmt might be effective anti-cancer agents as a knockdown of nmt inhibits the tumour growth, whereas knockdown of nmt has no effect . if residual nmt activity can compensate for loss of nmt function in healthy cells, potential toxicity may also be minimised. we developed a method to identify peptide or protein substrates of nmt and/or nmt . peptides/ proteins are exposed to nmt and/or nmt and an alkyne-tagged analogue of myristoyl coa. subsequent azide-alkyne "click" cycloaddition allows visualisation of the myristoylated substrates in fluorescence or chemiluminescence, using a fluorescent or a biotin moiety on the capture reagent. this labelling technology was applied to peptide libraries prepared on microarrays to investigate nmt / isozyme substrate specificity using recombinant nmt and nmt . peptides made of the first or amino acids at the nterminus of known myristoylated proteins were functionalised with a biotin moiety at the c-terminus and immobilised on an avidin-functionalised glass plate before being screened for activity. selective peptide substrates will be developed as isozyme-specific inhibitors and applied in cancer cell lines. using chemical proteomics and the labelling technology, a selective nmt or nmt inhibitor could also be used to identify protein substrates of one isozyme. for this purpose computer programs are created which can generate fragments of one compared structure and to reveal homology by their scanning along the amino acid sequence of another. our analysis was performed by comparing the primary structures of all possible protein fragments with the amino acid sequences of all presently known natural regulatory oligopeptides. the oligopeptides were extracted from the erop-moscow database which at the time of analysis contained data on the structures and functions of more than , natural oligopeptide regulators. the structure-function analysis was performed using a specialized software package. the input data were the complete amino acid sequences of the proteins used as a source of fragments with a specified length. then the initial sequence was fragmented in a stepwise manner. for example, in the case of dipeptide fragments, this procedure produced fragments with the following numbers of amino acids from the n-terminus - - , - , and so on until the fragment that started at the second residue from the c-terminus. the cases when the amino acid sequence of a fragment coincided with part of the primary structure of a natural oligopeptide were recorded in the total protein chemical synthesis requires a case by case design and optimization which is governed by factors such as the solubility of the individual peptide segments, their primary sequence and in particular the presence of "difficult" amino acid residues at ligation junctions such as proline or the location of cysteines. usually, a subset of chemical tools are selected among a vast array of methodologies to match the specificities of the target protein. in this context, methods enabling the assembly of three peptide segments in the n-to-c and c-to-n direction play a central role and must be considered as complementary as they can be selected for building subdomains of the target protein. to date, most of the proteins were assembled in the c-to-n direction. only few methods are available for the n-to-c sequential assembly of proteins, whose design is highly challenging. we have recently reported that sea ligation, that is the reaction of a bis( -sulfanylethyl)amido group (called sea) with a cysteinyl peptide, allows the formation of a native peptide bond in water and at neutral ph . in this communication we will show that native chemical ligation and the unique chemical properties of sea group , can be combined in order to design a highly efficient one-pot three segments protein assembly procedure, working in the n-to-c direction amylin is one of the most amyloidogenic peptides, its fibrils are responsible for causing type ii diabetes. amyloid formation mechanism is investigated both to find amyloid inhibitors as potential medical drugs, and to use amyloids as potential self-assembling biomaterials [ ] . amyloid formation of amylin - , its reverse and designed analogue beta-sheets and beta-sheet stacks was studied by molecular dynamics (md), amber . , f force field. md revealed that for amylin - and its reverse analogue both the parallel and antiparallel beta-sheet and beta-sheet stack structures are stable suggesting that this could explain the high tendency of amylin to form amyloid fibrils. parallel amylin - beta-sheet stacks are kept together by two hydrophobic cores, while for the antiparallel system the dominating is the backbone hydrogen bonding between neighbor strands. also the bent form of the amylin - beta-sheet is stable. this is in concordance with transmission electron microscopy (tem) experiments stating that all three peptides, amylin - , its reverse and designed analogues, exhibited significant fibrillar polymorphism [ ] university of gdansk, poland molecular dynamics (md) of two peptides dlsfmkge (mk) and dlsfkkge (kk) not related to any known disease was run to investigate the mechanism of the amyloid formation. the parallel and antiparallel [ ] betasheets of mk and kk peptides were simulated by molecular dynamics (md), amber . , f force field, ntp protocol. it was found that antiparallel beta-sheets both of mk-and kk-peptides show much higher stability than the corresponding parallel beta-sheets. this md result was supported by atr-ftir spectroscopy [ ] . the betasheet stacks built from six ten stranded antiparallel beta-sheets of mk-and kk-peptides: x xmk and x xkk, were subjected to md. it was found that the mk-system, x xmk, is strongly kept together due to hydrophobic core built from two metionines, two phenylalanines and two leucines, but the kk-system, x xkk, which differs only by one mutation m k dissolves already at ns of md run, because the separate beta-sheets don't hold togather in the betasheet stack due to lost hydrophobic core. the hydrophobic core of the mk-system consists of hydrophobic units centered on the two phenylalaninetwo metionine hydrophobic interactions, and two leucines from the both sides stabilize the unit. this mechanism could be used in amyloid based biomaterials. urokinase plasminogen activator (upa) is a serine protease involved in the metastasis of several tumor types. upa is therefore an interesting target in cancer therapy. upain- is a new analogue of a highly specific peptidic inhibitor (upain- ) of upa. the peptide contains twelve amino acids and is cyclized through the cysteines at its termini (s -s cyclo-ac-cswrglenhaac-nh ). upain- inhibits upa with a ki of approximately μm. one method to improve binding affinity is multivalent exposure of the inhibitor, where the local concentration at the binding site is increased. fusion of upain- to the trimeric tetranectin showed improved binding affinity compared to the single peptide. here, we report efforts towards novel chemically linked upain- peptides to allow multivalent display. the ki value of an upain- dimer, linked by a short peg chain through the n-termini, was almost halved compared to that of the single peptide ( μm). this motivated us to explore the role of the site (n-or cterminal) and the size of the linking segment on the binding affinity. additionally, the influence of the number of upain- peptides in the molecule (two vs. four) was investigated by synthesizing a carboprotein that displayed four upain- peptides. we present two novel nmr spectroscopic approaches to study reversible self-assemblies in solution. both methods were applied on the self-assembling pseudodesmin a, a pseudomonas produced cyclic lipodepsipeptide that has the capacity to form pores in cellular membranes. , the first method is based on the dependence of the c α relaxation rate constants on the anisotropy of the assembly. when the monomer conformation is known and the multiple ch bonds in the monomer sufficiently sample all orientations, the rotational diffusion coefficients can be assessed, revealing assembly shape information. in addition, the orientation of the monomer within the assembly is obtained. the second method is based on fitting translational diffusion coefficient data as a function of concentration in a model-free way, i.e. without assuming an oligomer shape beforehand. here, it is assumed that the diffusion coefficient's dependence on the oligomer size behaves as a power law, which dramatically simplifies the expression for the average diffusion coefficient (measured by pfg-nmr) as a function of concentration. the fitted value of the exponent of the power law fully embeds all shape information of the assembly, and may be related to the socalled fractal dimension of the oligomer. moreover, this approach reveals mechanistic information concerning the assembly formation. both methods thus allow structural information of the assembly to be obtained, even when there is little or no prior knowledge available on the mechanism of the selfassembly. nucleotides and α-amino acids are crucial building blocks for living organisms. these chiral molecules are the biosynthetically precursors of two of the most important classes of biopolymers, dna and proteins, respectively. the d-structures of biomolecules are currently studied using a variety of techniques, while helical handedness is routinely detected by means of light pulses of opposite circular polarization. the difference in the uv absorption of these two circularly polarized pulses is called electronic circular dichroism (ecd). in nature, biomolecules explore a wide range of conformations with intrinsically strong ecd signals in the - nm region, but these signals are essentially absent in the visible. nanomaterials such as metallic nanoparticles (depending on their sizes) display absorptions in the visible region but are achiral. as a result, when biomolecules are co-assembled with nanomaterials their chirality is transferred to create a plasmon-induced ecd signal in the visible region. in this work, we present our results which underscore the occurrence of moderately strong ecd bands in the range - nm resulting from a series of appropriately thiolfunctionalized peptide oligomers (based on alternating l-ala and aib residues) covalently anchored to - . nm sized gold nanoparticles. we related the (positive or negative) signs of the ecd plasmonic signal with the oligopeptide length, that in turn is strictly associated with their secondary structure. this latter property was simultaneously monitored via ecd in the - nm range. we believe that in our systems a peptide-tometallic surface chirality transfer would take place. light can be controlled with high temporal and spatial precision. if a specific molecule is made light-sensitive, then a precise spatiotemporal control of some of its properties can be achieved. azobenzene is the most widely used photochromic group due to its propensity to pass reversibly from the cis to the trans state under irradiation with light of the appropriate wavelength. the cisand transazobenzene isomers exhibit different spatial arrangement of the aromatic moieties that give rise to significantly distinct physical and chemical properties. the design of novel azobenzene-based molecules with precisely placed photochromic groups able to induce photomodulation of macroscopic properties is currently attracting much interest. in this work, we explored the behaviour of the conjugate formed by linking each of the four hydroxyl groups of pentaerythritol to the carboxylic function of bis[p-(phenylazo)benzyl]glycine. this c α -tetrasubstituted α-amino acid bears two side-chain azobenzene groups. the resulting system exhibits tetragonal symmetry, with a total of eight azobenzene moieties, and can be viewed as a central core surrounded by a shell of azobenzene groups at the periphery. up to eleven (out of the possible fifteen) discrete states produced by sequential trans-to-cis isomerization of the individual azobenzene units have been observed depending on the time of exposure to uv-light. this process is fully reversible (cis-to-trans) under vis-light irradiation for several cycles. in addition, this compound has been shown to exhibit photomodulated physical properties, such as polarity and hydrodynamic volume. moreover, it shows a high propensity to self-assemble in aqueous solution, giving rise to supramolecular vesicles. light-scattering and electron microscopy experiments confirmed that a conformational reorganization of the vesicles can be triggered under exposure to uv or vis light. the total chemical synthesis of native or modified proteins is gaining increase importance in the study of protein function, but also in the development of protein therapeutics. it is usually achieved by assembling in water unprotected peptide blocks using so-called native peptide ligation methods. recently, our group has developed a novel native peptide ligation method based on a peptide featuring a bis( sulfanylethyl)amido (sea) group on its c-terminus in reaction with a cysteinyl peptide in water at ph . we will discuss in this communication the scope and limitations of sea native peptide ligation. for this, model sea peptides featuring all the possible proteinogenic amino acids were synthesized. their rate of sea native peptide ligation with a model cys peptide were determined in the absence of presence of guanidinium hydrochloride or other additives frequently used in ncl. we will present also experiments intended to clarify the mechanism of sea ligation such as the effect of ph on the rate of ligation, or the ability of the transient thioester sea form produced by in situ n,s-acyl shift to participate in thiol-thioester exchange , . overall, the data show that sea ligation is an interesting method for native peptide ligation at various x-cys junctions, and thus an interesting alternative to ncl. plga copolymers were used as the support for inducing controlled biomarkers releasing system. visualization of the penetration in the hippocampus of mice with confocal microscope was carried out by testing both peptide-free and peptide-bearing nanoparticles, previously labeled with the phthalocyanine fluorescent probe. the encapsulation degree of the larger ( - ) segment was less effective than the others thus stressing the importance of the peptide length to this internalization process. the results showed that all peptide-containing nanoparticles were able to cross the blood-brain-barrier thus indicating improved bioavailability and uptake for peptide delivery into the brain. in regard to the radiolabeling approach, the m tc radioisotope was used to label the peptide sequences at his residues, as previously described . stable metal-peptide complexes were obtained in - - - m peptide concentration range. noteworthy, higher metal labeling yield was achieved with peptide segments bearing his residues at peptide c-terminal position, thus pointing to a positiondependent effect for the m tc coupling reaction. in conclusion, the findings indicate potentials for the proposed encapsulation and radiolabeling strategies applicable for in vitro and in vivo diagnostic assays with these peptides for the study of amyloid plaques. we have used bifunctional short peptides (ac-cg n c-nh , n= , , ) to selectively link gold nanorods in an end-to-end manner. additionally, we have manipulated the gap distance between the rods by changing the length of the peptide linker. the presence of the peptide in the gaps was shown by incorporating a propargylglycine residue in the sequence, which was detected with surface-enhanced raman spectroscopy (sers). the acetylene moiety will allow further chemical modification of the linker in the gaps, opening a wealth of interesting molecular systems to be placed and studies inside self-assembled nanogaps. in this work, the fragmentation pathways of alitame, neotame and andvantame in comparison to those of aspartame and aspartame-d , were studied by negative ion electrospray ionization (esi) high resolution mass spectrometry (thermo orbitrap mass analyzer). accurate mass spectra of the dipeptides allowed proposing specific fragment ions. neotame and advantame, which are the n-( , dimethylbutyl) and n-[ -( -hydroxy- -methoxyphenyl)propyl] derivatives of aspartame, presented similar fragmentation to that of aspartame. for neotame and advantame, the "diketopiperazine'' pathway seemed to be the major one, while a pathway resulting to the formation of a pyrrolidine- , -dione derivative, through the involvement of the side chain carboxyl group of aspartate, was also observed. for alitame, the "pyrrolidine- , -dione" pathway was recorded. similarities in the fragmentation using either orbitrap or triple-quadrupole mass spectrometry have been observed. elucidation of the fragmentation is very useful for the trace-level determination of the artificial dipeptide sweeteners in complex matrices. generation of silver nanoparticles in the presence of oligoproline derivatives p. feinäugle, h. wennemers* eth zürich, switzerland in the last years, the generation of silver nanoparticles (agnps) attracts, due to its unusual physical and chemical properties, more and more attention. agnps offer great opportunities for applications in molecular electronics, catalysis, imaging and for antimicrobial coatings. the characteristics depend on their shape and size. many efforts have been made to optimise the generation process by, for example, varying the reducing agents, which usually are used for the synthesis or using manifold additives which should guide the nucleation and also stabilize the resulting particles. nevertheless, the generation of agnps in defined sizes and shapes still remains a challenge. we address this goal by utilizing functionalized oligoprolines that form a conformationally well-defined and rigid helical secondary structure (ppii) as additives. recently, we showed that by decorating this template with aldehydes which allow for in situ reduction of the silver, they act as scaffolds in the generation process and allow the formation of defined nanoparticles. we will report the results of the generation of agnps with various oligoprolines as additives, which differ in the attached functional groups as well as in the length of the peptides. laser desorption/ionization mass spectrometry (ldi-ms) using specific inert surfaces to promote ion formation has been widely investigated the last decade [ ] . in addition to porous silicon through the original dios technique, different materials were tested as potent ldi-promoting agents. we explored a variety of inert silicon-based uvabsorbing materials that were presenting different physico-chemical properties for the analysis of peptides [ ] [ ] [ ] . both material architecture (amorphous powders, structured particles, structured surfaces) and material hydrophilic/hydrophobic character tuned by specific chemical derivatization (oxidation, silanization) were probed as crucial parameters for achieving efficient and robust detection of an home-made array of model peptides covering a wide structural and mass diversity. through this set of experiments, we were able to compare the performances of all investigated silicon-based supports, especially taking into account peptide detection sensitivity (down to femtomolar concentrations) and reproducibility/repeatability (intra-spot/inter-spot signal variations) as well as the method robustness using conventional maldi-tof/tof instrument. having illustrated the capability to achieve both peptide detection and sequencing on these ionizing surfaces in the same run, high-throughput identification of protein tryptic digests by a rapid ms profiling and subsequent ms/ms analyses was achieved. comparison of the ms and ms/ms data with those obtained with sample conditioned in organic matrix [ , ] showed a great behavior for low mass responses demonstrating the capability of ldi on nanostructured silicon supports to be a complementary method to maldi in proteomic workflow. the dipeptides aspartame, alitame, neotame and advantame are low caloric artificial sweeteners. advantame , which is the n-[ -( -hydroxy- -methoxyphenyl)propyl] derivative of aspartame, is the most recent among them. an application for its approval has been applied in usa, australia and new zealand. such sweeteners are used in food products and beverages and they can help in managing body weight and disorders like obesity and diabetes. in this work, the simultaneous determination of aspartame, alitame, neotame and advantame by negative and positive electrospray ionization (esi), under hydrophilic interaction chromatography (hilic), is presented. advantame, neotame and intermediates were synthesized in our laboratories for the present application. the key-step for the synthesis of advantame and neotame was the reductive amination of h-asp(obu t )-phe-ome with -( -hydroxy- methoxyphenyl)propanal and , -dimethylbutanal, respectively. the chromatographic behavior of the artificial sweetener dipeptides was studied on two hilic columns: kinetex hilic (a fused core silica column) and zic-hilic column (a sulfoalkylbetaine column). the separation of dipeptides was achieved on kinetex hilic using mm ammonium formate buffer ph . / methanol / acetonitrile ( / / ), with a flow rate of μl/min at o c column oven temperature. at this ph, silica is neutral and the dipeptides are in positively charged form. the retention mechanism of all analytes seems to be partition to the water layer as well as hydrogen bonding. département de pharmacologie, université de sherbrooke, sherbrooke, qc, canada plasma and in vivo stability are essential requirements for the successful development of potential drug candidates or diagnostic imaging probes. rapid degradation of compounds in plasma may result in insufficient concentration to produce the desired pharmacological activity or to be used as a diagnostic agent. there are several strategies to improve plasma half life of peptides including pegylation, modification of nand cterminal fragments of peptide, replacement of labile amino acids, and cyclization . we have previously reported on probes which specifically detect matrix metalloproteinase- (mmp- ) activity with magnetic resonance and optical imaging , . mmps are zincdependent endopeptidases degrading the extracellular matrix (ecm) and involved in cancer progression. the main goal of this work was to find more stable probes without sacrificing enzyme specificity. we have selected specific mmp- substrates and their stability was evaluated in three different conditions: in plasma, in plasma with a mmp inhibitor and in a mmp- solution. the samples were analyzed by hplc to detect the degradation pattern of our compounds and by lc-ms to determine the molecular mass of peptide fragments. based on these studies, the most stable peptide was selected and incorporated in a solubility switchable probe with radiolabelled ( )ga-dota. its in vivo stability was estimated up to minutes, making it a suitable candidate for further investigations. cancer of thyroid gland is the most common malignancy of the endocrine system. the treatment improvement could be achieved by early diagnosis. the aim of the study was to identify cancer specific markers using the libraries of artificial receptors immobilized on the cellulose. an array of supramolecular structures formed from n-lipidated peptides attached to cellulose via aminophenylamino- , , -triazine was prone to formation of monolayer of "holes" and "pockets" in dynamic equilibrium. this selforganized structures were found capable of binding small guest molecules very efficiently recognizing the shape, size, and polarity of ligands, thus resembling arti cial receptors . recognition and binding properties of guest molecules by artificial receptors depends mainly on the character of peptidic pockets and structure of the fatty acid. proper construction of the binding pocket allows selective binding components of mixtures of compounds from a living organism . the preliminary data indicates that it is possible to construct an array of artificial receptors with diversified structures of peptidic pockets which are able to distinguish between components of homogenates from tumor and normal tissue. century. most of opioid alkaloids and their derivatives have μ-opioid affinity, while endogenous enkephalins are rather δ-than μ-selective. morphine is still the drug of choice for treating severe pain caused by cancer or surgical operation, but its side effects are the reason for the searching and development of new, selective mor agonists. the aim of our study is to choose within recently published crystallographic structures templates for homology modeling of the human μ-opioid receptor. we generated several models using different templates and all of them were evaluated by docking procedure (gold . ) ligands used in this investigation were synthesized and evaluated for their biological activity in our previous studies. they are enekphalin analogues with substitutions in second position. the best model of the human mu-opioid receptor was chosen according to data obtained from docking and in vitro biological activity of analogues and endogenous enkephalins. acknowledgments: this work was supported by nfsr of bulgaria project dvu / and cost action cm project do - / . . . pneumoniae, h. pylori, proteus sp. are considered as important factor contributory to development of rheumatoid arthritis (ra). the aim of this study was to investigate the level and specificity of antibodies binding to the synthetic peptides corresponding to the bacterial ureases "flap" region sequences in the rheumatoid arthritis patient's sera. for these investigations, peptides with amino acid sequences derived from "flap" regions of different ureases were synthesized using -( , -dimethoxy- , , -triazin- -yl)- -methylmorpholinium tetrafluoroborate (dmt/nmm/bf ) as coupling reagent. peptides were immobilized on a cellulose membrane. the level of antibody binding as well as specificity of them was analyzed by quantitative dot blot method using sera sera from rheumatoid arthritis patients (rap) and sera from volunteer blood donors (vbd). the results of studies suggest that "flap" region may be involved in arising antibodies participating in autoimmunological processes but not to fight infection. this effect indicates that the peptides analyzed by us could be useful for investigation of ra pathogenesis. this suggestion was confirmed by the antibodies absorption experiment which indicates that specificity of antibodies present in rap serum is slightly lower in comparison with vbd serum. it has been found that antibodies present in rap serum recognize not only a specific peptide but also peptides containing fragments with different amino acid sequences. it means that immune system of rap is unstable and may produce a wide spectrum of antibodies recognizing not only a specific epitope but also a set of similar structures. autoantigen-specific t-cells also play a crucial role in the initiation and perpetuation of dsg /dsg -specific t-cell responses. t-cells recognize epitopes from dsg protein and produce different cytokines, e.g. interferon-γ (ifnγ). functional t-cell epitopes of dsg protein have outstanding importance in immunopathological research, development and the design of novel diagnostic tools. our previous studies have shown that certain t-cell epitope peptides are able to stimulate the peripheral blood monomorphonuclear cells (pbmc) of pv patients more effectively than those of healthy donors. our aim was to select a set of t-cell epitope peptides as potential synthetic antigens which are reliably able to distinguish between donors based on the in vitro t-cell stimulating activity. we have prepared synthetic dsg oligopeptides by fmoc/tbu solid phase methodology. after cleaving from the resin with tfa the peptides were purified by rp-hplc, and they were characterized by rp-hplc, mass spectrometry and amino acid analysis. pbmc of pv patients and healthy donors were isolated; and the cultures were stimulated by dsg peptides in a concentration of . mm for hours, and the rate of ifnγ production was determined from the supernatants in sandwich elisa. synthetic dsg oligopeptides induced different in vitro ifnγ production rate on pbmc obtained from pv patients and healthy controls determined by elisa. our approach identified a synthetic antigen set as a promising biomarker for pemphigus vulgaris. [ ] . in particular, cap b (pelyafprvamide) has been shown to elicit antidiuretic activity in the green stink bug acrosternum hilare [ ] , an important pest of cotton and soybean in the southern united states. analogs of cap b containing either an (e)-alkene, cispro or a transpro isosteric component [ ] were synthesized and evaluated in an in vitro stink bug diuretic assay, which involved measurement of fluid secretions of malpighian tubules isolated from a. hilare [ ] . at a concentration of μm, the conformationally constrained transpro analog demonstrated significant antidiuretic activity, whereas the cispro analog failed to elicit any activity. the results provide strong evidence for adoption of a trans orientation for the pro in cap b neuropeptides during interaction with the receptor associated with the antidiuretic process in the stink bug. the work further identifies a scaffold with which to design biostable mimetic cap b analogs as potential leads in the development of environmentally favorable pest management agents capable of disrupting cap bregulated diuretic systems. the enkephalins are pentapeptides (tyr-gly-gly-phe-met/leu) with a proven antinociceptive action. it is believed that the interaction between them and the lipids composing the membranes is important for converting the peptides into a "bioactive" conformation , . using langmuir's monolayer technique the interaction of a synthetic methionine-enkephalin (met-enk) and its amidated derivative (met-enk-nh ) with mixed lipid monolayers composed of palmitoleoylphosphatidylcholine (popc), sphingomyelin and cholesterol was studied. the surface pressure-area (π-a) isotherms with regard to πmin, π max and the hysteresis curve shape of the pure lipid monolayers and after the addition of the respective enkephalins were detected. in addition, by using brewster angle microscopy (bam), the surface morphology of the mixed lipids-enkephalins monolayers were determined. our results suggest that there is a strong penetration effect of the enkephalins studied into the mixed monolayers. moreover, our results demonstrate the potential of lipid monolayers formed in langmuir's through in combination with bam to be successfully used as an elegant and simple membrane models to study lipid-peptide interactions at the air/water interface. acknowledgments: this work was supported by bulgarian ministry of education, youth and science, projects n do - / , drg / and my-fs- / . dept pharmacolgy, temple univ, philadelpha, pa , usa bioinformatic algorithms has predicted the existence of several potential hormone-like peptides transcribed from the ecrg gene . previous publications indicated a highly level of gene expression of ecrg products has been found in the pancreas , choroids plexus, epithelial cells, leukocytes, and macrophages . however, the presence in the hypothalamus and the major form of derived peptides in each tissue haves not been clearly identified. knowingledge of the precise peptide generatesd within a given tissue is essential to understanding its functions. we have generated the peptide specific antibodies to against ecrg -derived pprepro-augurin( - ) and developed a specific ria kit for the quantification of the such peptide in question. a method for the purification of endogenous ecrg -derived peptides from bovine hypothalamus also has been established. using ria to monitor the immunoreactive fractions and maldi-tof to identify the endogenous peptides, we foundhave detected the presence of ecrg derived molecular of bovine preproaugurin( - ) from the homogenates of bovine hypothalamus. immunohistochemistrycal staining by antibody aalso confirmed the presence of thee peptide in some of the hypothalamic cells. of hypothalamus. the amount of prepro-augurin( - ) in the hypothalamus although not soas high as pancreas, but is one third of the augurin level of the pituitary. conclusions: the native peptide derived from augurin preproteinecrg has been discovered.identified. we have confirmed the property of purified peptide,s prepro-augurin( - ), along with the synthetic peptide standards. the present study provides the necessary procedures such as the elution from ( ) c column, ( ) p sizing column, and ( ) a further purification conditions for hplc in order to enhance the immunoreactivity from tissue fractions and yield enough amount for identification. this dsip-related peptide (kn-dsip or knd) differs from dsip by only amino acid residues in positions and . we do not consider the homology between dsip and knd as accidental, bearing in mind functional significance of histone demethylases of the jmjc-group. methylation-demethylation of histones is known as an important mechanism of posttranslational modification playing a prominent role in epigenetic regulation of chromatin structure and gene transcription. dsip is also known as an effective "normalizer" and protector from homeostatic disorders induced by stress related disturbances. we suggest that histone demethylase of the jmjc-group containing dsip-related region can be considered as a possible protein precursor of endogenous peptides with dsip-like activity. in order to test our hypothesis we synthesized knd and studied its biological effects. in a preliminary assay cited below [ ] knd showed similar and probably more pronounced effects than dsip as an agent that stimulates endurance and stress-resistance of animals in the forced swimming test. also knd provided a more active detoxifying action after administration of a semi-lethal dose of the cytostatic agent. in the present work we assessed neuroprotective and antioxidative potency of both peptides in vivo and confirmed the higher efficiency of knd. this study is supported by the moscow government. is a tridecapeptide (pglu -leu -tyr -glu -asn -lys -pro -arg -arg -pro -tyr -ile -leu ) highly expressed in the central nervous system. this peptide elicits an analgesic response following peripheral or central administration. importantly, nt exerts a more potent analgesia than morphine at an equimolar dose, without having the associated side effects of opioid drugs. structure-activity studies have identified the c-terminal fragment nt( - ) as the biologically active minimal sequence. however, nor the full or truncated peptides cross the blood-brain barrier (bbb), thus hampering its clinical development. the substitution of pro by an unnatural amino acid silaproline (sip) increased bioavailability and plasma stability. structural properties conferred by the pro were also retained as determined by nmr and ir. aiming at delineating the mode of action of cl, three new cl derivatives bearing suitable labeling moieties, i.e the fluorescent molecule fitc, the streptavidin-counterpart biotinyl-group and the m tc-radiometal chelating unit dimethylgly-ser-cys, were designed, synthesized, purified, and characterized to be applied in in vitro and in vivo evaluation studies. the structure of the cl derivatives in aqueous solutions was studied with nmr, in parallel and in comparison with the parent molecule cl, in order to examine whether the presence of the labeling moieties has induced changes to the structure of the biologically active part of cl. cell survival assays with cl and the cl derivative bearing the fitc moiety were conducted in the pc cell line in order to explore their rescue effect. in parallel, the cl derivative bearing the dimethylgly-ser-cys moiety was successfully radiolabeled with m tc and its stability was assessed over time in its synthesis reaction mixture and in plasma. this m tc-radiolabeled derivative was subsequently administered to swiss albino mice in order to determine the biodistribution of cl in the living organism and its route of excretion, a study that has not been carried out so far for any peptide of the humanin family. furthermore, the potential interaction of cl with β-amyloid peptide, the hallmark of ad pathogenesis, was explored with circular dischroism. the results of this multifaceted approach to the biological action of cl will be presented. institute of biochemistry and biotechnology, martin-luter university, halle-wittenberg, germany kinins, such as the nonapeptide bradykinin, are important mediators of various physiological and pathophysiological responses including inflammatory disease, asthma, rhinitis, cell division, pain, vascular permeability, allergic reactions, pathogenesis of septic and endotoxic shock. there are two types of receptors for kinins, known as b and b . b receptors are constitutively expressed in wide variety of cells and required entire bk sequence for recognition, while b receptors have normally very limited expression and respond to [desarg ]bk. b receptors gene is turned on following either tissue damage or inflammation. accumulated evidence indicates that most of the clinically relevant effects of bk are functions of b receptors this being the reason why research on their antagonists is a topic of great interest. in our previous study we described the synthesis and some pharmacological properties of four new analogues of bradykinin (bk), designed by substitution of position or of the known [d-arg ,hyp ,thi , ,d-phe ]bk antagonist with l-pipecolic acid (l-pip) (both analogues were also prepared in n-acylated form with -adamantaneacetic acid (aaa)). our results showed that presence of l-pip in position slightly increased antagonistic potency in the blood pressure test, but it turned the analogue into an agonist in the rat uterus test. replacement of thi by l-pip in position also enhanced antagonism in the rat pressure test but preserved the antagonism in the rat uterus test. in the present study we continue our previous investigations to find structural requirements which in the case of bk analogues result in high b antagonistic activity. several new bradykinin analogues modified in their cterminus with d-pipecolic acid were synthesized using spps method. the biological properties of the analogues were assessed by their ability to inhibit vasodepressor response of exogenous bk in conscious rats and by their ability to inhibit the contractions of isolated rat uterus evoked by bk. acknowledgements this work was supported by the university of gdansk (ds/ - - - ). peptides with beta-turn structure in peptide/mhc complexes a. stavrakoudis department of economics, university of ioannina, greece major histocombatibility complex (mhc) molecules interact with small peptides and form complexes. in most of the cases, peptide's structure in these complexes is found in extended conformation. however, notable exceptions exist where the peptide forms a beta-turn structure. this happens mainly in the central part of the peptide in class i complexes [ ] , or at the c-terminal of class ii complexes [ ] . several peptide/mhc complexes were, derived with xray studies, were extensively subjected to molecular dynamics simulations [ ] in order to investigate the stability of this turn-like structural feature and to explore the factors that possibly contribute to this stability. it was found that both intra-peptide and peptide/mhc interactions might be responsible for peptide's conformation. the peptides were found to undergo several structural transitions indicating conformational plasticity and not a completely rigid structure inside the mhc groove. the results might be of special importance in designing defective peptide vaccines and beta-turn pharmaceuticals. the heptapeptide met-enkephalin-arg -phe (merf) with the sequence of yggfmrf is a potent endogenous opioid located at the c-terminus of proenkephalin-a (penk), the common polypeptide precursor of met-and leuenkephalin. our systematic bioinformatic survey revealed considerable sequence polymorphism at the heptapeptide region of different penk prepropeptides among vertebrate animals. four orthologous heptapeptides with single or double amino acid replacements were identi ed among animals, such as yggfmgy (zebra sh), yggfmry (newt), yggfmkf (hedgehog tenrek) and yggfmri (mudpuppy). each novel hepta-peptide, together with the mammalian consensus merf and metenkephalin, were chemically synthesized and subjected to functionality studies, using radioligand binding competition and g-protein activation assays in rat brain membranes [ ] . equilibrium binding af nities changed from good to modest as measured by receptor type selective [ h]opioid radioligands. the relative af nities of the heptapeptides reveal slight mu-receptor (mop) preference over the delta-receptors (dop). [ s]gtpγs assay, which measures the agonist-mediated g-protein activation, has demonstrated that all the novel heptapeptides were also potent in stimulating the regulatory g-proteins. all peptides were effective in promoting the agonist induced internalization of the green uorescence protein-tagged human mu-opioid receptor (hmop-egfp) stably expressed in hek cells. thus, the c-terminally processed penk heptapeptide orthologs exhibited satisfactory bioactivities, moreover they represent further members of the so-called "natural combinatorial neuropeptide library" emerged by evolution. corticotropin releasing factor (crf) exerts most of its physiological and pathophysiological actions by interacting with its type receptor (crf ) and activating different intracellular signalling pathways. the crf is a plasmamembrane protein, which belongs to the family b of g-protein coupled receptors (gpcrs) and like the other gpcrs consists of an amino-terminal extracellular region, a carboxyl-terminal intracellular tail and seven, mostly hydrophobic, membrane-spanning segments (tm -tm ), connected by alternating intracellular (il) and extracellular loops (el). binding of crf and its related peptides, such as sauvagine, to the extracellular regions of crf is associated with receptor activation and subsequent activation of different g-proteins and regulation of diverse signalling pathways. using a mutagenesis approach in combination with a radioligand binding study we found that trp and phe in the second extracellular loop of crf interacted with the amino-terminal portion of crf and sauvagine. interestingly only the interaction of sauvagine with trp and phe is important for crf -mediated stimulation of camp accumulation. in marked contrast the interaction between crf and the residues trp and phe was unimportant for the activation of adenylate cyclase. thus it is possible for trp and phe of crf to regulate distinct signalling pathways, or different sets of them, after their interaction with different peptides. we are now performing experiments to fully elucidate the signalling pathways that are regulated by the interaction of crf and sauvagine with trp and phe . these studies will advance the development of crf -selective selective signalling-specific peptides that would be extremely useful for the elucidation of the role of crf in many physiological and pathophysiological situations, and possibly for the treatment of several crf -related diseases. thymus humoral factor gamma- (thf-γ ), an octapeptide, purified from crude thf, retains essentially all the biological properties of thf [ ] [ ] . it regulates clonal expansion, differentiation and maturation of t-cell precursors, stimulates the production of lymphokine, maitains the normalization of impaired ratios between helper(cd +) and suppressor / cytotoxic (cd +) subsets and augments il- production in spleen cells. thf-γ has a calculated molecular weight of and has the following amino acid sequence: leu-glu-asp-gly-pro-lys-phe-leu. its poor stability towards protein enzyme limits its extensive application. with the inte ntion to promote its bioavailability, bioactivity and develop ideal immunoregulatory drug candidat, four series of derivatives of thf were designed and synthesized: . n-and cterminal acylation. .restitution the flexible segment gly-pro by unnatural amino acids -aminohexanoic acid (aca) in order to shorten the synthetic steps and simultaneity improve the bioavailability and biostability of peptide; . reserve protected group of some amino acid residus as spot mutation. . mannich-based cyclization was carried out on resin [ ] , phe was replaced by tyr serving as the active hydrogen component, a proline was introduced at the n terminal as the amine component and formaldehyde was used as the only component in solution. the bioactivity of synthesized products were detected. the leukocytopenia model in mice was induced by cyclophosphamide intraperitioneal injection. white blood cell count, thymus index and spleen index were detected to evaluate the immune function of compounds in mice. the results show that those compounds play a significant role in improving immune function in mice. the activity of compound lhl and lhl are also better than authentic compound tp- and tα . marine organisms have been recognized as a promising source for the development of new pharmaceuticals. in the course of screening for antitumor substances from marine organisms, we found cyclic peptides containing many nonribosomal amino acids such as hydroxyasparagine, hydroxyleucine, or other supporting a hydrophobic side chain that were shown to be a key element for their biological activity. the laxaphycine b, a cyclic lipopeptide isolated from marine cyanobacteria anabaena torulosa harvested in french polynesia constitutes an example of this peptide class. this compound has attracted our attention because of its micromolar cytotoxic activities on different cancer cell lines as well as its antiangiogenic properties which seems to be due to an interaction with the vegf receptor- - . the synthesis of the non-natural amino acids - and of laxaphycine b analogues will be presented along with their preliminary biological activities. immune response suppressors are used in the medical praxis to prevent graft rejection after organ transplantation and in the therapy of some autoimmune diseases including dermatology. cyclolinopeptide a (cla) c(pro -pro -phe -phe -leu -ile -ile -leu -val -), a cyclic, hydrophobic nonapeptide isolated from linseed, possesses strong immunosuppressive and antimalarial activity. it has been suggested that both the pro-pro cis-amide bond and an 'edge-to-face' interaction between the two aromatic rings of adjacent phe residues in tetrapeptide unit are important for biological activity. this edge-to-face interaction can be influenced when phenyl rings are replaced by naphtyl substituent. in this communicate new analogues of cla modified by naphtylalanine ( -nal) in positions or or both and ( - linear analogues, - cyclic analogues) will be presented. the synthetic strategy and biological activity as well as conformational analysis will be evaluated. the onset of type ii diabetes mellitus (t dm) coincides with the deposition of fibrillar material in the islet of langerhans in the pancreas that is a clinical hallmark of more than % of patients suffering this disease. the main component of the pancreatic amyloid deposits is a -residues polypeptide hormone called islet amyloid polypeptide (iapp) or amylin. in this work we have examined, by means of cd spectroscopy and tht-fluorescence, the conformational polymorphism of both full-length - hiapp, and the related fragment hiapp - , and compared the results with the respective rat counterparts. moreover, the cytotoxic activity was determined toward different pancreatic β-cells lines in the attempt to correlate iapp's fibrillogenic properties with the ability to mediate cell death. together the results suggest that β-sheet conformational transition, that generally preludes to fibril formation, is not a prerequisite for eliciting toxicity toward β-cells cultures. interestingly, confocal microscopy indicated that both hiapp - and hiapp - can enter the cell and might exert their toxic action at intracellular level. acknowledgments: this work was supported by miur, firb-merit project rbne hwlz. due to its physiological functions, s proteasome is considered the target molecule in overcoming several diseases [ ] . its core particle s has three types of active sites: chymotrypsin-, trypsin-and caspase-like. many natural and synthetic compounds were tested for their ability to inhibit proteasome. a recent report describing the inhibition of s by the serine proteases inhibitor -bovine pancreatic trypsin inhibitor -was considered by us with great attention [ ] . our scientific interest is focused on peptide inhibitors and their interaction with serine proteases. sunflower trypsin inhibitor (sfti- ) is the smallest and the most potent peptide inhibitor in the bowman-birk family. owing to its size and the rigid structure (disulfide bridge and "head to tail" cyclisation) sfti- is willingly chosen as the lead structure in the search for new inhibitors [ ] . its sequence is shown below (lys the p residue responsible for specificity): & gly-arg-cys(& )-thr-lys -ser-ile -pro -pro-ile-cys(& )-phe-pro-asp& since native sfti- is not able to inhibit s [ ] , we have designed its monocyclic analogues (with disulfide bridge only) with lys or arg in position (p ) and at least one basic amino acid (lys or arg) in positions (p ') and/or (p '). all analogues inhibit chymotrypsin -(ic at the range of ÷ μm) and caspase-like (ic at the range of . ÷ μm) activities in vitro, whereas their activity towards trypsin-like specificity is much weaker. in several rat tissues, our view on ras has changed. metabolism of the ang-( - ) may represent alternative pathway of ang ii formation, importantly, independent on renin and ace activity , . ahmad et al. have described metabolism of ang-( - ) by human atrial tissues and showed that ang ii is formed mainly by chymase. this renin-inependent ang ii production could explain the "resistance" regarding use of ace inhibitors in patients with hypertension or diabetic nephropathy. noteworthy, the role of ang-( - ) in circulation is still unclear and there are no information about possible pharmacological modulation of its metabolism. in our study, we compared the ex vivo metabolism of angiotensinogen (fragment - ) in hypertensive (shr) and normotensive (wky) rats in organ bath of aorta and heart using lc-ms method . surprisingly, we identified ang-( - ) formed via reninindependent pathway to be a main product of angiotensinogen metabolism in rat aortic tissue and heart. in this setting, ang-( - ) appeared to be not only prevalent metabolite of angiotensinogen, but also served as a substrate for generation of ang i and ang ii. as compared to wky rats, formation of ang ii, from ang-( - ), was much higher in shr aortas but not in the heart. the functional consequences of these findings require further investigation. this study was supported by the grant n n polish ministry of science and higher education. the lysosomal cysteine protease cathepsin c (cat c), also known as dipeptidyl peptidase i (dppi), activates a number of granule-associated serine proteases with proinflammatory and immune functions by removal of their inhibitory n-terminal dipeptides. activity of this protease is associated with several pathologies in human body [ ] . in this work the characterization of cat c specificity using combinatorial chemistry methods will be described. the main goal of this work was to determine of substrate specificity of the prime region of this enzyme. the chemical synthesis and deconvolution of two libraries will be described. the hemostatic mechanism has the crucial role to prevent loss of blood from injured blood-vessels. this loss is prevented by the integrity of the vessel walls, by platelets aggregation or by blood coagulation, which in normal conditions is limited onto the local trauma of the vessel wall. in generally, the blood coagulation mechanism is important for maintaining vascular integrity and thus for the precaution of an organism from bleeding, which may also occur by blood coagulation caused by thrombin production. the diversion rate of this production leads to an expansion of thrombin to the general blood circulation. thus, when thrombin generation is not controlled by the mechanisms of inhibition, a widespread undesirable intravascular thrombosis is occurred. the whole process of platelets adhesion requires the presence of clotting factor viii (fviii), a necessary for the blood coagulation cascade glycoprotein, which takes part in the intrinsic pathway and acts as a coenzyme for the activation of factor ix, a serine protease depended on the thrombin production. the target of the present research is the synthesis of biologically active cyclic, head to tail, peptides, analogs of the sequence - of a subunit of fviii, which are potentially capable to block fviiia-fixa complex, reducing the thrombin production and thus the blood coagulation. the synthesized peptides are investigated for their inhibitory activity and tested for clotting deficiency by measuring the chronic delay in the activated partial thromboplastin time (aptt) and the reduction of the % value of the fviiia, which they generate in samples containing recombinant fviiia, in vitro. the blood coagulation is part of an important host defence mechanism, which under pathological conditions results in inappropriate intravascular coagulation when thrombin is produced. clotting sequence is the result of a cascade of two biochemical pathways, intrinsic pathway, so called because all components are present in blood, and extrinsic pathway, in which tissue factor is required in addition to circulating components. the activated form of factor viii (fviiia) is a key component of the fluid phase of the blood coagulation and plays an important role formatting a trimolecular complex with factor ixa, ca + and negatively charged phospholipids of the cells membrane. this complex is called tenase and participates in activation of prothrombin, which acts on fibrinogen to generate fibrin monomer, polymerized rapidly to form fibrin clot. the fviii is comprised of a heavy (a -a -b) and a light (a -c -c ) peptide chain, both cleaved by proteases at three sites, resulting in alteration of its covalent structure and conformation. its deficiency is known as haemophilia a. our research effort is focused on the synthesis, identification and biological evaluation of peptide analogs, expected to inhibit selectively the increasing of thrombin production. their sequence is based on the regions in which the fviii interacts with fix, specifically on the sequence - of the a subunit. the synthesized peptides are examined for their activity and tested for clotting deficiency by measuring the chronic delay in the activated partial thromboplastin time (aptt) and the reduction of the % value of the fviiia, which they generate in samples containing recombinant fviiia, in vitro. inhibitor with the following structure: ac-llllrvkr-nh , which has potent effects on the proliferation of prostate cancer cells. the potency and stability of this compound was subsequently enhanced by substitution of arg residue in position p with its conformationally restricted mimetic - -amidinobenzylamine (amba). nevertheless, the specificity toward pace was significantly reduced by this modification. thus, in order to improve its selectivity without sacrificing inhibitory potency we decided to use positional scanning approach. in this study we present synthesis of two series of peptide libraries, which were designed by substitution of leu in the p , p position of our control peptide (ac-llllrvkr-amba) with each of nineteen amino acid residues in order to verifying its influence on activity and selectivity of the resulting analogues. all peptides were synthesized by a combination of solid phase peptide synthesis and solution synthesis and tested for their inhibitory potency against furin and pace . the p -p fragments were synthesized by fmoc/tbu spps strategy on hydrazinobenzoyl or acid labile chlorotrityl chloride resin. then coupling of the -amidinobenzylamine · hcl was performed. the best modifications were combined to give as several multipoint substituted inhibitors. we believed that our work, will provide new important information about structure-activity relationship of these class of analogs in order to obtain potent and highly specific pace inhibitor. institute for research in biomedicine, parc cientific de barcelona, barcelona -spain a bacterial toxin-antitoxin (ta) system is composed of two genes organized in an operon encoding a toxin and an antitoxin that regulate the growth and death bacterial cell under various stress conditions. the operon parde encode a ta system formed by pare toxin and its antitoxin pard. pare is a kda protein that inhibits dna gyrase activity and thereby blocks dna replication. however the pare-gyrase interactions and the gyrase activity inhibition mechanism have not been explored. as an approach for understanding of this mechanism and to elucidate the pare region responsible for protein-protein interactions we have designed and synthesized a series of linear analogues of pare and investigated the ability of peptides to inhibit dna topoisomerases activity. so, based on structural data inferred from pare three-dimensional model , peptides were synthesized by solid-phase method. four peptides (parelc , parelc , parelc and parelc ), showed complete inhibition of dna gyrase supercoiling activity, by gel electrophoresis assay , with an ic of to μmol.l - . in addition, intrinsic fluorescence and fluorescence anisotropy assays showed that inhibition process must occur by interaction with the gyra subunit. differently of wild type pare, the peptide analogues were able to inhibit the dna relaxation of topoisomerase iv with lower ic values. interesting was that only parelc displayed inhibition of the relaxation activity of human topoisomerase ii. our results suggest a new class of molecules with simultaneous inhibitory activity in dna gyrase and topoisomerase iv. furthermore, we have obtained the first example of a synthetic peptide from a bacterial toxin with inhibitory activity on human topoisomerase ii. institute of experimental endocrinology, slovak academy of sciences, bratislava, slovakia the renin-angiotensin system (ras) has long been recognized as an important regulator of systemic blood pressure and electrolyte homeostasis. our understanding of ras has experienced remarkable change over the past two decades. besides, angiotensin ii, the new biologically active peptides [e.g. ang-( - ), ang-( - ), ang iv, ang-( - )] and pathways [e.g. angiotensin converting enzyme -ace ] have been described ; some of them, like ang-( - ) may oppose many actions of ang ii. importantly, despite all components of classical ras are found in adipose tissue , the data about fat formation of various angiotensins remain scarce. in our study, we compared the ex vivo metabolism of angiotensinogen, ang-( - ) and ang i in hypertensive (shr) and normotensive (wky) rats in organ bath of retroperitoneal and periaortic fat tissue using lc-esi-ms method. additionally, qpcr measurements of mrna expression of main enzymes involved in ang i metabolism were performed. both in the periaortic and epidydymal fat, the formation of ang-( - ) was higher than production of ang ii. fat tissue formation of two main ang i conversion products, ang ii and ang-( - ), differed significantly between shr and wky rats. compared to wky rats, the formation of ang-( - ) in periaortic fat tissue was decreased in shr. in opposite, in epidydymal fat tissue formation of ang-( - ) and ang ii was higher in shr. interestingly, there were no differences in aorta formation of ang ii and ang-( - ) between shr and wky rats. our results suggest that in hypertension visceral fat production of angiotensin peptides is increased, while generation of "beneficial" ang-( - ) in periaortic fat is decreased. however, the functional importance of such finding require further investigation. department of chemistry and biochemistry, university of washington, usa phospholipases a (pla ) are a superfamily of enzymes involved in various inflammatory diseases. in particular, human secreted giia spla is an attractive target for the development of novel medicines. we have shown that oxoamides based on γ-or δ-amino acids are potent inhibitors of cytosolic giva pla . very recently, we have demonstrated that a long chain -oxoamide based on (s)leucine displays inhibition of human and mouse giia spla s (ic nm and nm, respectively). a combined experimental/computational study was undertaken to further understand the role of the α-amino acid of -oxoamides for the inhibitor-enzyme binding. the crystal structure of giia spla s reveals a highly conserved ca + -binding loop and a catalytic dyad consisting of his /asp . -oxoamides based on hydrophobic αamino acids showed better binding score prediction compared to polar α-amino acid derivatives. a number of new -oxoamides based on α-amino acids were synthesised and tested for their inhibitory activity against giia, gv and gx pla . the -oxoamide based on (s)-valine displayed potent inhibition of giia spla (ic nm) in accordance with the predicted docking score. docking results reveal that (s)-valine-based inhibitor forms key interactions with the active site of the enzyme. the carboxylic group participates in a hydrogen bonding with gly and lys , and -carbonyl group with gly . furthermore, both carbonyl groups are in the proximity with ca + . the side chain of (s)-valine adopts a suitable orientation to interact with tyr and lys . the long aliphatic -oxoacyl chain is accommodated in the hydrophobic region of the active site and creates proximal contacts with leu , ile , his and phe . the search for novel classes of pharmaceutical molecules with enhanced therapeutic power has been the subject of numerous research groups all over the world. moreover, systems of immobilization and controlled release which are adapted to these new classes of molecules, has proven to be an area of extreme importance to provide the same therapeutic efficacy. using solid-phase chemistry a series of ccdb toxin analogous peptides were synthesized and were synthesized and tested against the capacity of inhibition of bacterial enzymes dna gyrase and topoisomerase iv (topo iv). subsequently those peptides were detained in drug delivery systems (dds) to be tested against the inhibition of growth of different bacterial species. in this data we could observed that the analogue ccdbsg could inhibit only dna gyrase and not the topoisomerase iv. in the other hand the analogue ccdbsg presents a hard inhibition potential against topo iv specially because of their structural difference. is possible conclude that topoisomerase iv presents the tertiary structure very similar to dna gyrase, but those mechanisms of action must be clearly distinct . in the in vitro studies, as expected, results revealed that the drug delivery systems are the key to the power efficiency of peptide analogues against the bacterial growth inhibition which cannot be observed when the peptides are free in solution. some of the different lipid compositions of the dds are demonstrating to be more efficient in the membrane cell transverse and this data previously assumes that it is possible to apply different types of dds to promote the peptide molecules transport across the cellular membranes according to several specific therapies. with this studies we have obtained more knowledge about the interaction system of enzyme-toxin and hopes which helps in future studies to development a new antimicrobial molecules class. it is urgent to develop less toxic and more efficient treatments for leishmaniases and trypanosomiases. we propose to target an ancestral form of the proteasome, the hslvu protease, which is present in the parasite's single mitochondrion, essential for the growth of these organisms and has no analogue in the human host. originally discovered in eubacteria, this complex is constituted by two central hexameric hslv protease rings sandwiched between two hexameric hslu atp-ase rings. as hslv shares a similar enzymatic mechanism with the host proteasome, we propose to inhibit the assembly of the complex in order to be selective. according to studies on bacterial hslvu, , the c-terminal segment of hslu is essential in hslv activation and in complex assembly, therefore representing a privileged target. we produced recombinant hslv, which is inactive alone, and showed that a synthetic c-terminal hslu peptide was able to induce the digestion by hslv of a fluorogenic substrate that we developed. with this enzymatic test in hands, we started the characterization of the interaction of the c-terminal portion of hslu with hslv. we will present the results obtained with various series of analogues of the original c-terminal hslu peptide, including truncated forms, ala scan, constrained analogues and multivalent constructions. helped by molecular modelling studies, the aim is to establish structural requirements, which could lead to high affinity and stable ligands able to inhibit the interaction between the hslu and hslv rings, obligatory for the degradation of proteins by the hslvu complex. finally, we checked that hslv was inhibited by classical active-site directed proteasome inhibitors like bortezomib. f. babos a,d , e. szarka b , gy. nagy c , z. majer d , g. saŕmay b , a. magyar a , f. hudecz a,d citrullinated filaggrin peptide (ccp) were detected in ra sera and anti-ccp positivity is widely used for diagnostic purposes. identification of new epitopes of filaggrin would be useful in the diagnosis of anti-ccp seronegative patients. in order to achieve optimal immune recognition of biotinylated epitope peptides it is important to analyse the effect of the labelling moiety on antibody binding. for these studies -as well as -mer peptides with nor c-terminal biotin were synthesised manually by spps, using fmoc/ t bu strategy. biotinylation was performed by using biotin, biotinyl- -aminohexanoic acid or , , -trioxa- , -tridecanediamino succinic acid linker modified biotin. labelled peptides were used in an indirect elisa, on neutravidin pre-coated plates and the binding was detected by anti igg-hrp. to examine the role of the presence/position of biotin in the secondary structure of the peptides, electronic circular dichroism (cd) method was used. we found that the ccp + serum samples specifically recognized the c-terminally biotinylated -mer filaggrin peptides, while showed no binding with the n-terminally biotinylated compounds. in case of the -mer epitope peptides there was no difference between the recognition of nand c-terminal biotinylated analogues. data presented suggest that the position of the biotin in case of the short filaggrin epitope peptides markedly influence the serum antibody binding. upon activation process, they are released from the granules and then involved in immunoresponse of the organism. when out of the cell those enzymes remain in free form or become associate with the cell membrane. the physiological role of this proteases is manifestated in several processes such cytokine and chemokine processing, platelet activation, and degradation of extracellular matrix's proteins [ ] . in this work results of the specificity of two members of nsps pr and hne evaluated using the combinatorial chemistry methods will be presented . both enzymes share primary specificity and to obtain the selective substrate that will be recognized only by one enzyme, the prime sites should be investigated. the general formula of the designed library is as follows: where in positions x ', x ' and x ', the set of proteinogenic amino acids (except cys) was introduced. abz is -amino benzoic acid served as donor of fluorescence and -nitro-l-tyrosine as acceptor. eukaryotic proteasome is a highly organized protease complex comprising a catalytic s core particle (cp) and two s regulatory particles (rp), which together form the s structure. the main function of this large intracellular protease is to degraded ubiquitine labeled proteins. the catalytic particle of the proteasome displays three distinct enzymatic activities: trypsin-like, chymotrypsin-like and glutamyl-like. the increase activity of the proteasome is associated with several disease including cancer [ ] . the main aim of this work is to synthesized the cell permeable fret displaying peptides that will selective cleaved by single proteasome activity. additionally each peptide when independently cleaved by the proteasome subunit, should emit the fluorescence energy in a different spectral region. our intention was designing substrates which would allow to monitor simultaneously (in a single experiment) and independently of three proteasome activities in this report, we will describe the chemical synthesis of several peptides modified at on cand n-termini by synthetic fluorescent amino acids the general formula of these peptides is as follows: where x is a non proteinogenic amino acid that serve as a donor of fluorescence, y amino acid that is a acceptor of fluorescence. the obtained fluorescent peptides were examined for their ability to cross the cell membrane. also kinetic parameters (k cat, km, kcat/km) with proteasome will be presented. approximately dubs are encoded in the human genome and are involved in a variety of regulatory processes, such as cell-cycle progression, tissue development, and differentiation. recently, several groups have introduced various methods for linking ubiquitin to different substrates via nonhydrolyzable isopeptide bonds, which resist the action of dubs. using these methods, one could explore the function and the mechanism of dubs and apply them in activity based profiling. here we present a new and convenient strategy for preparing nonhydrolyzable ubiquitinated peptides and proteins by nmethylating the isopeptide bond. using this method we prepared several nonhydrolyzable ubiquitinated peptides with different lengths derived from ubiquitinated h b and examined their affinity to different dubs. f.i. nollmann, c. dauth, d. reimer, h.b. bode* goethe universität, frankfurt, germany bacteria of the genus xenorhabdus and photorhabdus are gram negative gamma proteobacteria that live in symbiosis with nematodes of the genus steinernema. undergoing their partly entomopathogenic life cycle these bacteria not only produce antibiotics , and insecticides but also several different small molecular compounds and peptides. for the most part the biological benefits of these secondary metabolites have not fully been understood yet. with the help of inverse feeding experiments, hr-ms and nmr as well as molecular engineering we were able to characterize and/or isolate some of these peptides. since they are mostly produced in trace amounts, we synthesized them in order to make them accessible to continuative testing. given that not only linear but also highly methylated or cyclic peptides are produced, the synthesis was quite challenging. nevertheless, we were able to establish in our laboratory a general synthesis route for cyclic peptides and depsipeptides , as well as highly methylated hydrophobic linear sequences. testing several of these peptides has revealed activity against insect cells and against the causative organisms of neglected tropical diseases. cyclotides are a large class of plant peptides defined by a head-to-tail cyclized backbone and three conserved disulfide bonds in a knotted arrangement. these unique structural features confer them with remarkable stability and due to a range of bioactivities they are extensively investigated as templates in drug discovery . based on the use of oldenlandia affinis in traditional african medicine for its uterotonic principle we investigated crude plant extracts and semi-pure cyclotide fractions for the ability to induce uterine contractions using a collagen-gel contractility model . pharmacological analysis of the effects led to the identification of the oxytocin receptor, a representative of the g-protein coupled receptor (gpcr) family, as a molecular target for cyclotides. mass spectrometry-based sequence analysis of 'active' fractions revealed cyclotides with high similarity to the human oxytocin (h-ot) peptide that exhibited weak binding to the human oxytocin receptor. we further analyzed synthetic cyclotide-derived small ot-like peptides and grafted the h-ot sequence into the stable cyclotide frame. these peptides showed increased binding and activation as compared to native cyclotides. these findings may open new avenues for the discovery of gpcr ligands from natural peptide sources. gpcrs are promising drug targets and ~ % of currently used drugs act via binding to these receptors. natural combinatorial peptide libraries are likely to play an important role in identifying novel gpcr ligands . particularly plant cyclotides cover a large chemical space based on their high sequence diversity. together with their range of bioactivities and unique stable structure suggests that cyclotides are of current and future interest for drug discovery and development. acknowledgements: this work is funded by the austrian science fund fwf (p ). drosha and dicer are two key endonucleases for biogenesis of micrornas (mirnas) that regulate target mrna. drosha converts pri-mirna to ~ nucleotide (nt) pre-mirna in nucleus and dicer converts pre-mirna to linear ~ nt single-stranded mirnas in cytosol. even though dicer is potentially important to control availability of mature trans-acting rnas in cytosol, the enzyme itself does not seem to be the suitable target controlling mirna processing due to the lack of its substrate specificity. nature, however, might be intelligent enough to differentiate a variety of pre-mirna, so that a certain specific pre-mirna is converted to mature mirna in case it needs. therefore, other component(s) in the enzyme complex could be involved in recognition of auxiliary proteins from out sources to give extra specificity. we have synthesized trp-containing amphiphilic peptides against several pre-mirna. peptide b showed a picomolar binding affinity and a large specificity against pre-let a- . in vitro mirna processing, dicer activity was also selectively enhanced in the presence of this peptide. on treatment with this peptide on hct colon cancer and p ec cell lines, let a- mirna was more processed than reference mirnas. the toxicity of furan is known to rely on its selective oxidation in the liver by cyt p enzymes transforming it into the very reactive butenedial, which quickly reacts with proximate nucleophiles. this principle was used in our laboratory to develop a high yielding dna interstrand crosslinking methodology. in view of the demonstrated site-selectivity, the method further holds promise for sitespecific crosslinking dna to its binding proteins, which is highly relevant in the study of transient protein-dna interactions. furthermore irreversible dna binding can be achieved through such a covalent linkage, which is potentially useful for new generation therapeutics. the reactive furan moiety can in principle be incorporated either in the dna or in the protein. in the former case, a furan modified nucleotide was built into an oligonucleotide positioning the furan moiety at the periphery of the dna, to avoid interstrand crosslinking. for the latter approach, we initially chose to synthetically access a furan modified dna binding protein mimic. next to a previously described non-covalent gcn mimicking dimer, we have also investigated a new type of steroid-based dipodal dna binders. synthesis of the latter constructs has proven challenging in view of the immobilization of two peptide chains with helix forming tendency at close distance on the template. results, showing the power of microwave assistance will be discussed. in an alternative approach, a full length protein was modified with furan by amber suppression based on the structural similarity between a furan modified amino acid and pyrrolysine. pharmaceutical institute, university of bonn, an der immenburg , bonn, germany human matriptase- is a kda protein with trypsin like specificity. this protein exhibits a domain organization similar to family of membrane-bound serine proteinases known as type ii transmembrane serine proteinases. among many ascribed function in human body, this enzyme is a potent negative regulator of hepcidin, the peptide involved in iron homeostasis [ ] . matriptase- has a similar fold as other tmsp members, however their detailed specificity still remain unclear. the aim of this study was to determine the substrate specificity of this physiological important enzyme using combinatorial chemistry approach. in order to characterize the matriptase- specificity, the tetrapeptide library with c-terminal amide of aminocoumarin (acc-nh ) that serve as a fluorophore, was synthesized. its general formula is given below: x -x -x -x -acc-nh , where in position x -x the set of proteinogenic amino acid residues are present, whereas in position x lys or arg was introduced. deconvolution of such library was performed using iterative approach in solution. the results obtained indicate that matriptase- display diverse p -p specificity as compare to matriptase- . the most efficient hydrolyzed amino acid residue in position p appear to be ile, that is followed by arg in p and ser in p . the arg in position p is % faster hydrolyzed then lys. for selected substrates, the kinetic parameters (kcat, k m ) were determined. amyotrophic lateral sclerosis (als) is a chronic progressive disease. it is characterized by degeneration of upper or lower motor neurons, but its pathogenesis is still unknown and no effective treatment currently exists. it is known that antibodies to gangliosides have been found in some als patients, and these antibodies are also well known to be present in the patients affected by a variety of autoimmune diseases including multiple sclerosis. up to now anti-gangliosides antibodies are detected in clinical immunology laboratories using isolated non consistent antigen mixtures. therefore, we are interested in developing reliable and univocally characterized synthetic antigens for efficient antibody detection. csf (glc) is a family of structure-based designed glycopeptides that we previously developed as multiple sclerosis (ms) synthetic probes. these n-glucosylated peptides are able to detect specific autoantibodies in the sera of an antibody-mediated form of ms. autoantibody recognition was favored because of the exposition of the sugar amino acid on the tip of type ' β turn structures. aim of this study is the introduction, in the type ' β turn peptide structure, of the sugar moiety specific for anti-gangliosides antibody recognition by synthesizing specific building blocks. these building blocks are amino acids carrying glycans mimicking the biological activity of complex oligosaccharides. we selected sialic acids (in particular the n-acetylneuraminic acid -neu ac) because they are involved in a significant number of biological events. neuraminic acid and its derivates are widely distributed in animal tissues and in bacteria, especially in glycoproteins and gangliosides. therefore, we synthesized fmoc-l-asn(neu ac)-oh and fmoc-l-ser(neu ac)-oh. these building blocks will be introduced in the type ' β turn structure for the detection of anti-gangliosides antibodies in als. as a distinct pattern of ms could involve an antibodymediated demyelination, identification of autoantibodies as specific biomarkers is a relevant target. even if interesting data focused on the diagnostic and prognostic role of the detection of antibodies to myelin oligodendrocyte glycoprotein (mog) in adults' serum, its value remains dubious due to many other contrasting results. our research group identified csf (glc), an nglucosylated peptide, able to detect disease-specific autoantibodies in the sera of a statistically significant number of ms patients. , since this synthetic antigen may be considered as a mimic of aberrant post-translational modification (i.e. n-glucosylation) of myelin protein(s) triggering autoimmunity in ms, our goal is to obtain the extracellular domain of mog properly glucosylated thanks to a simplified native chemical ligation approach. for this purpose, the n-glucosylation will be introduced in a synthetic peptide fragment following the building-block approach by spps. the other protein fragment bearing an n-terminal cysteine will be expressed in e. coli after introduction of a selective point mutation into mog. finally, our aim is to test the semi-synthetic protein by sp-elisa to study the ability to detect autoantibodies in ms patients' sera and to find a potential cross-reactivity with csf (glc). this peptide is an endogenous ligand of the opioid receptorlike (orl ), previously referred to as "orphan" receptor, structurally and functionally related to the classical opioid receptors. also the hexapeptide ac-ryyrwk-nh is shown to be a selective ligand for the nop receptor with marked analgesic effect. with a view to developing ligands for the nop receptor with more potent analgesic activity, new series of the ac-rfmwmk-nh and ac-ryyrwk-nh , modified at position and respectively with newly synthesized β tryptophan analogues were synthesized . the aim of the present study was to examine the effects of naloxone (nal) and jtc- (nop receptor antagonist) in the analgesic activity of newly synthesized hexapeptide analogues. all peptides ( μg/kg), nal ( mg/kg) and jtc- ( , mg/kg) were injected intraperitoneally (i.p.) in male wistar rats. antinociceptive effects were evaluated by two nociceptive tests -paw-pressure (pp) and hot-plate (hp) and statistically accessed by anova. the results will be discussed compared to the referent compound in both tests used and mechano-and thermo-receptors are involved. [ ] . socs and socs have many similarities as well as some intriguing differences. both can block signalling by direct inhibition of jak enzymatic activity yet apparently require different anchoring points within the receptor complex. while the primary socs interaction is with a critical py residue within the jak catalytic loop [ ] it interacts also with py residues in the ifnαr and ifn r subunits in a jak -independent manner; the socs -sh domain also interact with y in jak , albeit with slightly lower affinity, but subsequent studies demonstrated a high affinity interaction with py residues located within receptor subunits [ ] . mutagenesis studies identified small regions at the n-termini of the socs and socs -sh domains, and at the c-terminus of the socs -sh domain, which were critical for phosphotyrosine binding. in order to gain insights in molecular discriminants for the interaction of both socs and socs toward jak and tyk we designed and synthesized peptides encompassing regions involved in proteins recognition. we set up a spr assay to evaluate the affinities of complexes formation. then through an alascanning approach we have designed new peptide sequences containing un-natural amino acids that are able to better recognize wild sequences and whole proteins. cellular experiments on stat activation signaling suggest their potential application as modulators of disorders involving socss overexpression. targeting proapoptotic death receptors (drs) to trigger apoptosis in cancer cells is a promising anticancer therapeutic approach. trail (tnf-related apoptosis inducing ligand) is a transmembrane homotrimeric protein belonging to the tnf family that triggers selective tumour cell apoptosis upon binding to its cognate receptors dr and dr . several strategies are being developed to exploit the unique cancer selectivity of the trail-dr pathway in therapy, including the use of recombinant trail targeting dr or dr . [ ] recently, a disulfide-bridged macrocyclic -mer peptide (derived from phage display) that binds selectively to dr has been identified. [ ] oligomeric versions of this macrocyclic peptide display increased binding avidity to the receptor and exhibit the capacity to activate the trail apoptotic pathway both in vitro and in vivo. [ ] however, disulfide bonds are susceptible to reduction and scrambling in vivo potentially resulting in the loss of the desired biological activity. among alternative linkages with increased redox stabilities, lanthionine thioethers, in which one of the sulfur atoms of the disulfide bond is removed have previously been introduced into biologically active peptides with some success. [ ] disulfide bridges can undergo a -elimination in alkaline conditions, followed by a michael addition to give a thioether bridge. optimization of this reaction led to the desulfurized analogue of the dr -binding peptide. the native dr -binding peptide and its desulfurized analog have been compared for their structural (nmr conformational analysis) and biological properties (affinity to dr and signaling pathways). the apelin/apj complex has been detected in many tissues and is emerging as a promising target for a number of pathophysiological conditions. in the central nervous system, apelin/apj was detected in brain regions involved in spinal and supraspinal control of pain, such as the amygdala, hypothalamus, dorsal raphe nucleus and spinal cord. we propose the hypothesis that apelinergic agonists represent a potential new approach to pain modulation and that the synthesis of stable analogues would lead to compounds with antinociceptive properties. there is currently little information on the structure/activity relationship (sar) of the apelin hormone. in an effort to better delineate sar, we synthesized analogs of apelin- modified at selected positions with unnatural amino acids, with a particular emphasis on the c-terminal portion. analogs were then tested in binding and functional assays by evaluating gi/o mediated reduction in camp levels and by assessing β-arrestin recruitment to the receptor. the plasma stability of new analogs was also assessed. several were found to possess increased binding and higher stability compared to the parent peptide. there is compelling evidence that the neuropeptide rfa and its cognate receptor gpr , are involved in the control of food intake and bone mineralization. among the gpcrs whose structures have been solved, gpr exhibits the highest sequence homology with the beta adrenergic receptor. the aim of this work was to experimentally characterize predicted ligand-receptor interactions by site-directed mutagenesis of gpr and design of point-substituted rfa analogs. starting from the x-ray structure of the beta -adrenergic receptor, a d molecular model of gpr has been built. the bioactive c-terminal octapeptide rfa( - ), kggfsfrf-nh , was subsequently docked in this gpr model and the ligandreceptor complex was submitted to energy minimization. in the most stable complex, the phe-arg-phe-nh part was oriented inside the receptor cavity whereas the n-terminal lysine remained outside. a strong intermolecular interaction was predicted between the arg residue of rfa and the gln residue located in the third transmembrane helix of gpr . in order to study this interaction, we have investigated the ability of rfa and arg-modified rfa analogs to activate the wild-type (wt) and the q amutant receptors transiently expressed in cho cells. the platelet receptor αiibβ plays a critical role in the process of platelet aggregation and thrombus formation. upon platelet activation its conformation changes leading to an increased affinity for fibrinogen. the αiibβ activation is regulated by "outside-in" and "inside-out" signaling. among the protein-protein interactions, which contribute to «inside-out» signaling, the most important is that of talin with the β cytoplasmic tail. it has been recently suggested that talin-mediated αiibβ activation relies on the cooperative interaction of the membrane proximal (mp) and the membrane distal (md) β regions with talin f domain and that the -n ply -motif of β , which can be phosphorylated at y , plays a critical role in this process. to evaluate the interaction of talin with the β tail of integrin we designed and synthesized three peptides corresponding to the md and mp parts of β in their carboxyfluoresceinlabeled form (md: cf-r akwdtannplyke -nh , cf-n nplykea -nh and mp: cf-k llitihdrke -nh ). emission and anisotropy fluorescence spectroscopy was used to quantitatively assess the affinity of these peptides for talin. furthermore, to challenge the role of the y phosphorylation in talin-α iib β interaction we also studied the binding of talin to the modified analogues of md, cf-r akwdtannpl(ptyr)ke -nh and cf-n npl(ptyr)kea -nh . our experiments revealed that the md and mp parts of β bind tightly to talin and that y phosphorylation has an inhibitory effect on this binding. functionalized oligoprolines as multivalent scaffolds in tumor targeting p. wilhelm, h. wennemers* eth zurich, zurich, switzerland oligoprolines are known to be structurally well-defined molecular scaffolds. in aqueous media, even short chain lengths of six proline residues adopt a polyproline ii helix (ppii). this secondary structure is a highly symmetric helix where every third residue is on top of each other in a distance of about . Å. [ ] the incorporation of azidoproline (azp) allows facile and versatile functionalization either via copper-catalysed azide-alkyne cycloaddition (cuaac) or an acylation that followed a staudinger reduction. [ ] based on the structural integrity of the oligoproline scaffold, targeting vectors can be conjugated via coppercatalysed azide-alkyne cycloaddition in defined distances. recent studies on radiolabeled oligoproline-bombesin conjugates, to target the gastrin-releasing peptide receptor (grp-r), showed in vitro and in vivo superior internalization in prostate cancer cells compared to the established monovalent ligands. [ ] a facile route to synthesize alkynylated ligands has been developed successfully. we are currently expanding this concept to the integrinligand c(rgdyk) as well as to [tyr ]-octreotide, which binds to somatostatin-receptors. the monovalent analogue of the latter, dota-[tyr ]-octreotide (dotatoc), is well established for diagnosis [ ] and therapy [ ] of somatostatinpositive tumors such as neuroendocrine tumors. the cu i -catalyzed azide-alkyne addition (cuaaa), the useful variant of "click chemistry," has emerged as a powerful technique for specific addition. that chemistry is also commonly used for conjugation, and cyclization of peptides. it is known that cyclization can increase the metabolic stability of peptides, as well as enhance potency or selectivity. another useful application of the cuaaa, which we are reporting, is the n-terminal crosslink of two synergic peptides to gain their potency. cuaaa reaction is performed on solid phase (merrifield resin) where one of the peptide components with azido group on the linker ( azido-hexanoic acid) is "clicked" with second peptide component in solution, made by fmoc strategy in partially protected form containing at n-terminal side alkyne group (fmoc-l-propargylglicine). cuaaa coupling is performed in dmf/t-buoh/h o with presence of cui and sodium ascorbate when reacting mixture was degassed. linked peptides are cleaved finally from resin and purified. as an application example we picked two endothelin active peptide analogues: bq derivative (a highly potent and selective eta antagonist) and irl- derivative angiogenesis is a key step in the transition of tumors from a dormant state to a malignant state. the vascular endothelial growth factor (vegf) is a major contributor to tumor angiogenesis. its pro-angiogenic activity is mainly mediated through binding to two tyrosine kinase receptors located predominantly on the surface of endothelial cells: vegfr- and vegfr- . vegf binding to these receptors triggers the activation of different signal transduction pathways responsible for the proliferation, survival and migration of endothelial cells . vegf/vegfr system constitutes a target to stop tumour growth. an attractive approach is the development of peptides, or small-molecules, with a high affinity for the extracellular domain of the receptors to prevent vegf binding. based on the x-ray structure of vegf and the d domain of vegfr- , cyclic peptides had been developed in our group . such peptides, mimicking simultaneously the - loop and helix · of vegf, can bind to d domain of vegfr- and inhibit receptors phosphorylation and thus map kinase pathway . we describe here our strategies to optimize peptidic antagonists of vegfr- . chemical modifications are made in order to better mimic peptide conformations and to increase their receptor binding affinities. we introduce a hydrophobic functional group at the c-terminal of the original cyclic peptide , some of such modified peptides reveal improved vegfr- binding affinity. otherwise, as the helix · presents most of the important residues in vegfr binding according to alanine-scan in the literature , we try to stabilize the helical conformation by insertion of aib residues or by peptide cyclisation. the peptides affinities are evaluated by an elisa test developed previously . institute of chemistry and biochemistry, freie universität berlin, thielallee , d- berlin, germany new polypeptide was isolated from the azemiops feae viper venom by combination of gel filtration and reversephase hplc and called azemiopsin. its amino-acid sequence (dnwwpkpphqgprpprprpkp) was determined by means of edman degradation and mass spectrometry. it consists of residues and does not contain cysteine residues. according to circular dichroism measurements, this peptide adopts a β-structure. peptide synthesis was used to verify the accuracy of the determined sequence and to prepare sufficient peptide amount for biological activity studies. azemiopsin efficiently competed with α-bungarotoxin for binding to torpedo nicotinic acetylcholine receptor (nachr) (ic . ± . m) and with lower efficiency to human α nachr (ic ± μm). ala scanning showed that amino-acid residues at positions - , - and - are essential for binding to torpedo nachr. in biological activity azemiopsin resembles waglerin, a specific blocker of muscle-type nachr from tropidechis wagleri venom. however the sequences of these peptides are markedly different, and azemiopsin is the first natural toxin to block nachrs that does not possess disulfide bridges. laboratory of peptide science, nagahama institute of bio-science and technology, nagahama, shiga - , japan while neutrophils infiltrate into damaged sites immediately after tissue injury, endogenous factors which induce their acute transmigration and activation have not been thoroughly elucidated. for the candidates, we recently identified two novel neutrophil-activating cryptides, mitocryptide- (mct- ) and - (mct- ), which were hidden in mitochondrial cytochrome c oxidase and cytochrome b, respectively [ ] [ ] [ ] . in addition, the presence of many neutrophil-activating peptides other than mct- and - was observed during their purification. these findings suggest that neutrophils are regulated by many unidentified peptides. here, we purified a novel neutrophil-activating octadecapeptide whose primary structure was identical to mitochondrial cytochrome c ( - ) from porcine hearts. we named this functional peptide as mitocryptide-cyc (mct-cyc). the structure-activity relationships of cytochrome c on β-hexosaminidase release from neutrophilic differentiated hl- cells demonstrated that cytochrome c ( - ) was the most potent cryptide among cytochrome c-derived peptides. since cytochrome c is known to be involved in the apoptotic process, our present results suggest that cryptides produced from cytochrome c play an important role in scavenging toxic debris from apoptotic cells by neutrophils. anthracis spores are very resistant and can remain dormant in soil for decades. therefore, an effective detection system for b. anthracis is urgently needed. recently, it was found that one of the components of the b. anthracis exosporuim is a collagen like protein whose carbohydrate portion is composed of the tetrasaccharide with the highly specific monosaccharide upstream terminal, named anthrose. since anthrose was not found on other bacterial spores, including those closely related to b. anthracis, this monosaccharide is an attractive target for the development of new b. anthracis detection and identification methods. peptide cyclization represents particularly interesting approach for the design of artificial receptors for anthrose, because cyclic peptides provide the possibility of having a spherical lipophilic binding site of appropriate size and shape for a particular carbohydrate substrate. the presence of hydrogen donor/acceptor groups within a three-dimensional structure permits carbohydrate substrates to be encapsulated, thereby allowing their binding in water. in order to determine whether the cyclic peptide receptor can selectively detect the anthrose, we have successfully prepared cyclic peptide combinatorial library (total peptides) by the process of divide, couple and recombine ("tea-bag" technology) using standard fmoc solid-phase peptide synthesis. prepared combinatorial library is screened for anthrose binding in fluorescence-based assay, and individual cyclic peptides with enhanced affinity toward anthrose are identified by the positional scanning deconvolution process. cyclization of linear sequences is a well-known approach used to restrict the flexibility of peptides. cyclization often increases selectivity of peptides towards one specific receptor type, increases metabolic stability and generally increases lipophilicity, which often improves the bloodbrain barrier permeability of peptides. in our previous study [ ] we have reported on the synthesis of a cyclic endomorphin- (em- ) analog, tyr-c(d-lys-phe-phe-asp)-nh , which elicited analgesia after peripheral administration. encouraged by the fact that this analog was able to cross the blood-brain barrier we designed and aliskiren is the first orally active, direct renin inhibitor to be approved for the treatment of hypertension. its structure and conformational analysis were explored using molecular dynamics (md) simulations. for the first time, md calculations have also been performed for aliskiren at the receptor site, in order to reveal its molecular basis of action. it is suggested that aliskiren binds in an extended conformation and is involved in several stabilizing hydrogen bonding interactions with binding cavity (asp / , gly ) and other binding-cavity (arg , ser , tyr ) residues. of paramount importance is the finding of a loop consisting of residues around ser that determines the entrapping of aliskiren into the active site of renin. the details of this mechanism will be the subject of a subsequent study. additionally molecular mechanics poisson-boltzmann surface area (mm-pbsa) free energy calculations for the aliskiren-renin complex provided insight into the binding mode of aliskiren by identifying van der waals and nonpolar contribution to solvation as the main components of favorable binding interactions. adamantyltripeptides and phospholipids in liposomal bilayers . now, we were primarily interested to study incorporation profile of mannosylated adamantyltripeptides. we have demonstrated that the adamantyl moiety, due to its liphophilic properties, penetrates into the lipid core of the bilayer while the hydrophilic part with the mannosyl moiety is exposed on the liposome surface. after concanavalin a (con a), a lectin, which specifically binds α-d-mannosyl residues, was added to the liposome preparation, increase in liposome size and appearance of aggregates has been observed. the enlargement of liposomes was ascribed to the specific binding of the con a to the mannose present on the surface of the prepared vesicles. the afm analysis revealed that the adamantyltripeptide molecules grouped into small domains that raise above the bilayer surface. the molecule size and molecular geometry, as well as the hydrophilic and hydrophobic surfaces in the structure of mannosylated adamantyltripeptides, are responsible for arrangement of molecules in the lipid bilayer. this approach might be a useful model for investigation of specific protein interactions with membrane receptors. also, the adamantyl moiety may be considered as a potential membrane anchor for different carbohydrate or other molecules of interest, which could be bound on it and thus exposed on liposome surfaces and as such used in targeted drug delivery. the assay is carried out in a well format p and images are captured throughout the course of the assay, thus we can not only determine a ligand's propensity to induce internalization, but also its efficacy and internalization rate. addition of test compound, followed by the standard agonist at a later interval, enables differentiation between agonist or antagonist activities. in the positional scanning format [ ] , while the possibility of agonists and antagonists working against each other within a mixture exists, the effects are minimized in screening the whole library as there are as many arrangements of the sub-libraries as there are defined positions. therefore while an agonist and antagonist might be present in a particular mixture in one sub-library they will be in different mixtures in all other sub-libraries. we have used this assay format to simultaneously screen for novel agonists and antagonists against the orexin receptor. assay development and library screening will be presented. [ ] . since the pro residue in position of em is very important in the proper conformational alignment of the two aromatic residues tyr and phe in em molecule at the receptor site, it is possible that structural modification around the pro residue yields compounds with unique biological properties and improved metabolic stability. in the present study, we synthesized seven em analogues containing isopro or constrained residues with oxopyrrolidine or oxopiperadine ring, instead of pro residue in position . all peptide analogues were synthesized solid phase method. incorporation of oxopyrrolidine and oxopiperadine rings were carried out on a solid support by the methods of gellerman, et al. [ ] and mohamed, et al. [ ] , respectively. opioid receptor binding activity for μ and δ-receptors using the development of resistance to mainstay cancer therapies has become a major limitation for the treatment of many cancers. there is an urgent need to develop new antineoplasic agents with innovative anticancer approaches. to overcome resistance to cancer therapies, our attention has turned to proteins that regulate multiple signalling pathways essential for tumour survival. among the few known nodal proteins upregulated in cancer cells and involved in many hallmarks of cancer, we are interested in survivin. an essential regulator of cell proliferation and apoptosis, survivin is sharply overexpressed in cancer cells and plays a major role in resistance. being a small protein, its bioactivity is relies mainly on protein-protein interactions (ppi) with different partners. a critical point for its multiple functions in cancer is its association with hsp , which is required for its stability. a nonapeptide from survivin called shepherdin has been shown to modulate the interaction of survivin with hsp by binding to hsp and to induce death of tumour cells. unfortunately, shepherdin is not cell permeable, has low proteolytic stability and shows poor bioavailability, limiting its use as anticancer therapeutic agent. to improve pharmacological properties of shepherdin, cyclic and peptidomimetic analogs of shepherdin have been synthesized followed by structure-activity relationship studies. in hsp binding studies, some cyclic hexa-and heptapeptidic analogs showed increased affinity compared to shepherdin. the synthesis of cyclic and peptidomimetic analogs and the results from the binding assays and the conformational analyses will be presented. the hexapeptides with formula ac-ryyr/kw/ir/k-nh have been identified as shortest peptide sequence with high nop receptor affinity, selectivity and marked analgesic effect. it was found that the following peptides act as partial or full agonists or antagonists of nop receptor in different in vivo and in vitro systems. these hexapeptides were used as chemical templates in sar studies , . the aim of the present study was the synthesis and the biological screening of new analogs of ac-rfmwmk-nh and ac-ryyrwk-nh , modified at position and respectively with newly synthesized β -tryptophan analogues . these non natural amino acids were prepared using reaction of asymmetric friedel-crafts alkylation of various indoles with a chiral nitroacrylate to provide optically active β-tryptophan derivatives. the four newly synthesized ligands for the nociceptin/orphanin fq (n/ofq) receptor (nop) have been prepared by solidphase peptide synthesis-fmoc-strategy. these compounds will be tested for agonistic activity in vitro on electrically stimulated smooth-muscle preparations isolated from vas deferens of wistar rats. bacterial infections are a common problem associated with dermal wounds. these infections can prolong or impair wound healing. hydrogel materials that display inherent activity against bacteria can be used to directly treat accessible wounds to prevent or kill existing infection. in this work, we describe the design and utilization of injectable gels prepared from self-assembling β-hairpin peptides having a high content of arginine. these gels were found to be extremely effective at killing both gram-positive and gramnegative bacteria, including multi-drug resistant p. aeruginosa. importantly, no added antibacterial agents are necessary since the nanostructure of the gel, itself, is the active agent. using self-assembling peptides for material construction allows facile structure-activity relationships to be determined since changes in peptide sequence at the monomer level are directly transposed to the bulk material's antibacterial properties. structure-activity relationships studies show that arginine content largely influences the hydrogel's antibacterial activity, and influences their bulk rheological properties. these studies culminated in an optimized gel, composed of the peptide pep r. pep r gels prepared at . wt % or higher concentration, demonstrate high potency against bacteria, but are cytocompatible towards mammalian mesenchymal stem cells. the general mechanism by which pep r exerts its action was explored and it is suggested that involves membrane disruption that occurs when cells come in contact with the gel's surface. atomic force microscopy (afm) was used to study the effect of the gel on the cell envelope morphology of e. coli. rheological studies indicate that the gel is moderately stiff and displays shear-thin recovery behavior, allowing its delivery via simple syringe. they are intimately involved in the molecular process leading to the delicate nano-patterned silica shells of diatoms. deciphering the mechanisms of silica-biogenesis in diatoms will inspire the development of novel routes for the biomimetic synthesis of silicon-based materials under mild conditions and expand the scope of biotechnological applications, e.g. for immobilization of enzymes in silica matrices. we synthesized silaffin peptides derived from c. fusiformis that carry posttranslational modifications such as phosphorylation or polyamines linked to lysine side chains. a distinct alteration of silica precipitation activity depending on the particular modifications of the silaffins emerged. these modified silaffin peptides were covalently linked to recombinant proteins by expressed protein ligation leading to stable protein-silaffin conjugates. using egfp as model protein, we could show that egfp-silaffin conjugates can induce biomineralization of silica and ensure an efficient and homogeneous immobilization of egfp into silica particles, superior to simple co-biomineralization approaches. moreover, a significant stabilization of immobilized egfp against denaturing agents was observed. we established a method for controlled immobilization of biomolecules based on covalent attachment of silaffin peptides with well-defined silica precipitation properties. currently this method is applied to the immobilization of biotechnological relevant enzymes in order to test their activity and the stabilization effect. herein, we present the covalent functionalization of multiwalled cnts (mwcnts) with organocatalysts based on proline or proline derivatives carrying either a dipeptide or a sulfonamide moiety. two different approaches were followed, namely, covalent grafting of the organocatalysts either at the tips or at the sidewalls of the cnts. for the former approach, mwcnts were oxidized in order to introduce carboxylic units at their tips and make them easily dispersed in aqueous solutions. then, oxidized mwcnts readily reacted with proline-based derivatives carrying a free amino unit yielding the corresponding hybrid materials. for the latter approach, the functionalization methodology based on in-situ generated aryl diazonium salts was followed. in this context, mwcnts were modified with aryl units carrying free amino terminal groups, which were subsequently conjugated with proline-based derivatives carrying a free carboxylic unit. all newly formed hybrid materials were fully characterized with complementary spectroscopic (atr-ir, raman), thermal (tga) and microscopy (tem) techniques. the catalytic evaluation of the activity of the cnt-based organocatalysts in aldol reactions is in progress. financial support from gsrt/ΕΣΠΑ - ΣΥΝΕΡΓΑΣΙΑ through ΣΥΝ- - -ΝΑΝΟΚΑΤΑΛΥΣΗ project is acknowledged. novel organogels based on self assembly of rationally designed pseudopeptides c. pappas, n. sayyad, a.g. tzakos, i. plakatouras section of organic chemistry and biochemistry, department of chemistry, university of ioannina, ioannina, gr- , greece self-assembly is becoming a rather intriguing way to build an array of nano-and micro-structured materials. low molecular weight organogelators can self-assemble into various architectural types in organic solvents through weak intermolecular interactions. such organogelators have potential applications in the generation of novel materials for nanobiotechnology . herein, we report the synthesis of rationally designed pseudopeptides and the conditions to form organogels. the obtained gels are responsive to temperature, and the sol-gel process is thermoreversible. the architecture of the constructed organogels was characterized via tem and spectroscopic techniques. diffusion ordered nmr spectroscopy (dosy) was further utilized to determine differences in the molecular shape of the different pseudopeptides. applications of the resulted compounds in nanotechnology will be reported. since , organocatalysis has met such a great rate of expansion that is nowadays considered the third major branch of modern asymmetric catalysis along with the transition metal catalysis and biocatalysis. after the seminal work of list, lerner and barbas on the enantioselective aldol reaction between acetone and -nitrobenzaldehyde catalyzed by proline, it became clear that amino acids and peptides could serve as an abundant pool full of potential to develop novel organocatalytic motives. following our recent report that the combination of a prolinamide with a thiourea group having as a spacer a chiral diphenylethylenediamine leads to an efficient organocatalyst for the aldol reaction, we recently considered the possibility to couple the prolinamide unit with an urea moiety. one of our main interests was the substitution of the diphenylethylenediamine spacer by a gem diamine derived from an α-amino acid. the gem diamine is easily synthesized via a curtius rearrengement of the corresponding acyl azide. after synthesis and evaluation of a number of potential catalysts, the prolinamide derivative bearing a gem diamine derived from (s)-phenylalanine and an aryl urea moiety proved to provide the best results in the reaction between cyclic ketones and aldehydes. utilizing mol% of our organocatalyst, the aldol products were obtained in high to quantitative yields (up to %), high to excellent diastereoselectivities(up to > : ) and high to excellent enantioselectivities (up to % ee). peptide self-assembled monolayers are of current interest to study physicochemical properties of modified metal (e.g. au) surfaces. rigid peptide scaffolds could enhance the interaction between gold surfaces and labels by reducing and precisely monitoring the distance between the supported monolayers and gold. the c α -tetrasubstituted αamino acid -amino- , -dithiolane- -carboxylic acid (adt) , which contains a cyclic disulfide system, is interesting in this respect because it may allow the parallel binding of the peptide helical chain to the metal surface. adt occurs in nature and has been utilized in medicinal chemistry and in a model compound of [fefe] hydrogenase. we synthesised a series of constrained helical peptides, based on the ala-ala or the ala-aib sequence, containing one or two adt residues. these peptides were functionalised with spectroscopic or opto-electronic labels. among the large number of reactions involving the formation of carbon-carbon bond, the addition of ketones to nitroolefins is a powerful tool for the synthesis of γ-nitrocarbonyl compounds, useful intermediates for pharmaceutical industry. our recently reported primary amine-thioureas based on tert-butyl esters of natural amino acids exhibit excellent performance for the michael reaction of ketones with nitroolefins providing the products quantitatively and almost stereospecifically (> % ee). , using this methodology, enantiopure baclofen and phenibut (analogs of gaba) have been synthesized. polymersupported organocatalysts constitute a great challenge for the michael reaction. in the current study, we report the immobilization of amine-thiourea catalysts containing ( s, s)or ( r, r)-diphenylethylenediamine and tert-butyl aspartate, on various polymer supports, either directly or through spacer units. the solid-supported catalysts evaluated in the reaction between acetone and βnitrostyrene and highlighted the importance of the choice of the polymer as well as the presence of the spacer or not. the direct attachment of the primary amine-thioureaaspartate to a crosslinked polystyrene-divinyl benzene resin containing a uniform distribution of aminomethyl groups provides a supported catalyst that affords the product of the reaction between acetone and β-nitrostyrene quantitatively and in high enantioselectivity ( % ee a. theodorou, g.n. papadopoulos, c.g. kokotos* laboratory of organic chemistry, department of chemistry, university of athens, athens, greece after the pioneering report that proline can catalyze efficiently the intermolecular aldol reaction between acetone and a variety of aromatic aldehydes, it became evident that amino acids and peptides can afford a plethora of different structural scaffolds for novel catalysts. along the first decade of its life, organocatalysis has grown to such an extend that now it is considered the third major branch of asymmetric catalysis. recently, researchers have paid special attention to other amino acids rather than proline. some primary amino acids have already been applied to a number of transformations with success. usually improved catalytic properties are observed when derivatives of primary amino acids are utilised. we have undertaken a study on the application of simple and cheap primary amino acids and amino acid derivatives, either commercially available or easily obtained, as organocatalysts for the asymmetric α-amination of aldehydes. in the present work, we report that the use of simple derivatives of primary amino acids like phenylalanine and aspartic acid can efficiently catalyze this transformation leading to products in high to quantitative yields and enantioselectivities up to % ee. the majority of the organocatalysts developed up to now for asymmetric organic transformations employ more than one functionalities in the catalytic mechanism that act through either covalent or non-covalent interactions. for example, proline employs the pyrrolidine nitrogen and the carboxylic acid group, while chiral thioureas combine the thiourea functionality with a tertiary or a primary amino group. we have recently shown that an amide of proline with a diamine carrying a thiourea group is a very good catalyst for the enantioselective aldol reaction. trying to improve the activity, we have found that a tripeptide-like thiourea having as building blocks (s)-proline, ( s, s)diphenylethylenediamine and (s)-di-tert-butyl aspartate provides the products of the reaction between ketones and aromatic aldehydes in high to quantitative yields and high stereoselectivities (up to : dr and % ee). a number of structural modifications of the catalyst were undertaken in order to understand the role of the hydrogen bond donors of the catalyst, i.e. the prolinamide hydrogen and the two hydrogen atoms of the thiourea group. we have come to the conclusion that the importance of the hydrogen bond donors of the catalyst follows the order: thiourea hydrogen originated from aspartate › amide hydrogen › thiourea hydrogen originated from diphenylethylenediamine. g eldrug s.a., patras , greece a convenient and facile synthesis and in vitro biological evaluation of n-substituted -butylimidazole derivatives as potent angiotensin ii (ang ii) receptor type (at ) antagonists have been reported in the present study. a series of imidazole based compounds bearing the biphenyl moiety at the n- position, a halogen atom at the c- and polar substituents such as hydroxymethyl at the c- position were synthesized. , these compounds were evaluated for binding to human at receptor and for ang ii antagonism in vitro on isolated rat uterus. in particular, butyl- -[[ ΄-( h-tetrazol- -yl)biphenyl- -yl]methyl]imidazole derivatives complexed with the at receptor and showed high binding affinity. these analogues were also found to be active in the rat uterotonic test. importantly, their binding affinities and potencies were comparable to those of losartan. these results indicate that the hydroxymethyl at the c- position of the imidazole ring is favorable for high affinity binding and antihypertensive activity and in line with the activities of the losartan counterparts. experimental findings are in good agreement with docking studies, which were undertaken in order to investigate ligand/at receptor interactions. z-leu-glu-his-asp-aluc, suc-leu-leu-val-tyr-aluc) are good substrates for bioluminescence assays, for example in the detection of caspase activity during apoptosis . these substrates generally offer significant advantages, such as increased sensitivity, ease of use, and high throughput screening capacity. luciferase-based assays are typically -to -fold more sensitive than the comparable fluorescent assays (rhodamine , -amino- -methylcoumarin (amc) and -amino- trifluoromethylcoumarin (afc)). the synthesis of different type peptide-amino-luciferin conjugates and their precursors have been published and some of them are commercially available. however, because of their high price the in vivo application of these conjugates is limited. to solve this problem we successfully worked out a new, easier and more convenient and economical method for the preparing these derivatives starting from -chloro-benzothiazole. moreover this products have excellent purity (> %) and adequate yield ( - %). major health problems arising from bacterial resistance towards existing antibiotics make discovery of antibacterial drugs with new mechanisms of action pertinent. although proof of concept for a novel antimicrobial approach using peptide nucleic acid (pna) antisense targeting of essential bacterial genes was obtained a decade ago, this technology is still limited by the lack of carriers that facilitate effective bacterial delivery and confer optimal pharmacokinetic properties to the prospective drugs. [ , ] in the past two decades, parallel efforts of exploiting naturally occurring antimicrobial peptides (amps) as drugs have been made. the cationic amp subclass appears to be directly involved in the innate immune response towards microbial infections. [ ] so far only few cell-penetrating peptides, with activity on mammalian cells, and other membrane-active peptides, have been investigated as potential vehicles for bacterial delivery. for instance, cationic amps with an internal target appear not to have been investigated for bacterial delivery of antibiotics. the aim of this project is to develop highly potent genetic antibiotics by exploiting naturally occurring antimicrobial peptides as potential delivery vehicles for antisense peptide nucleic acid oligomers. the amps are chosen from amps reported to act via intracellular targets, and thus must possess an inherent ability to permeate bacterial cell membranes without direct killing of the bacteria. faculty of chemistry university of gdansk, gdansk, poland azt ( '-azido- ' '-dideoksythymidine), a modified nucleoside used in antiretroviral therapy and peptide plant hormone -systemin were used as substrates of , -dipolar cycloaddition (click chemistry). systemin is -aa peptide defense hormone released in response to plant (tomato, tobacco) damage or pathogen attack. we examinated whether systemin's fast movement through plant tissues could be used for cargo (azt) transport. the huisgen cycloaddition also known as , -dipolar cycloaddition is a chemical reaction belonging to the larger class of cycloadditions. reaction between organic azide and alkyne appended substrates allows the synthesis of the desired conjugate in high purity and yields irrespective of the sequences and functional groups on either of the two substrates [ , ] . conjugate of azt-systemin has been synthesized by click chemistry, using systemin modified at n-terminus with propiolic group and azt. the conjugation was catalyzed by cu(i). the reaction was fast, efficient and regioselective. its progress was easily monitored by capillary electrophoresis (ce). ce was also applied for characterization of systemin and azt-systemin stability and movement throughout tomato leaf and stem. despite the fact that systemin moves rapidly through tomato tissues, our calorimetric (itc) studies showed that the peptide does not interact with liposomes-cell membrane model. universitätsklinik für nuklearmedizin, inselspital, bern, switzerland regulatory peptides (e.g., somatostatin, bombesin) have been shown to be suitable vectors for the specific delivery of radioactivity to tumors for diagnostic and therapeutic applications in nuclear oncology. a potential drawback of such vectors is their inherent instability in vivo. thus, new strategies are needed for the stabilisation of radiopeptides in order to improve their bioavailability and, consequently, increase their accumulation in the targeted tissue. it has been suggested that , , -triazoles, readily obtained by cuaac, are suitable amide bond surrogates which are resistant to proteases. in the present study, we report the synthesis and pharmacological evaluation of radiolabelled, triazole-containing analogues of the gastrin releasing peptide receptor (grpr) targeting peptide bombesin (bbn). to study the effect of backbone modifications in the minimal grp-binding sequence, we synthesized a series of analogues of [nle ]bbn ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , in which each amide bond is individually replaced by a , -disubstituted , , triazole. after radiolabelling of the peptidomimetics, their binding affinity and internalization kinetics were determined using pc- cells. metabolic stability was evaluated in blood serum. a number of the novel tumor-targeting peptide analogues presented exhibit both a retained high affinity (nm) towards the grpr and an improved serum stability. first preclinical data on the in vivo evaluation of the most promising candidate will be presented. to the best of our knowledge, this is the first report of the systematic replacement of amide bonds with , , triazoles within the binding sequence of linear, high affinity peptides. the methodology can be applied to a variety of peptide vectors and thus, holds great potential for the development of novel, stabilized peptide-based radiopharmaceuticals. dna is the molecular target for many of the drugs that are used in cancer therapeutics, and is viewed as a nonspecific target of cytotoxic agents. although this is true for chemotherapeutics, other agents that were discovered more recently have shown enhanced specificity. the development of new site-specific dna binders, which are associated with the recognition of the dna major groove, are based on the design of transcription factor mimics that bind the dna as a dimer , and prevent specific genes from being transcribed. these could ultimately result in interesting biomedical applications as designed genome interfering agents or diagnostics. in order to approach this biological constructs, we choose the bzip leucine zipper transcription factor as a model to mimic. as the entire structure cannot be synthesized without expensive, complicated and time-consuming biotechnological methods, the substitution of the dimerization domain by a less complex scaffold is the first step in the design. thus, we consider a steroid based scaffold as a candidate. the specific choice of the steroid scaffold as substituent is inspired by its known ability to enhance proteolytic stability of attached peptides, by its conformational properties ensuring correct positioning of the two appended chains and by its potential to increase bioavailability. this transcription factor binds specific dna sequences by dimerization and inserting short α-helices into the dna major groove. in order to attach the peptides to the scaffold, different strategies were studied. firstly, applying the well-known click chemistry, functionalizing the scaffold with an alkyne moiety, the peptide with an azide and viceversa. secondly, via the unknown resin to resin transfer reaction (rrtr), which has not been applied on peptide chemistry so far. this unprecedent methodology consists on the reaction of a peptide, which is attached on a safety-catch resin, with a second resin bearing a nucleophilic amino terminus resulting in amide bond formation. during the process, the peptide on solid support undergoes cleavage. an hexapeptide was synthesized on a preloaded safetycatch resin. deoxycholic acid derived scaffold with orthogonally protected amines was attached to tentagel resin that acts as acceptor resin. rrtr experiments were performed at both c and c positions of the deoxycholic acid derivative. in addition, this convergent strategy can be applied to other different peptide conjugated systems. we recently described a new kind of cyclized peptide in which the cyclization is performed between the side-chains of two diaminoacyl residues via a diversely substituted guanidine bridge. we showed that the degree of bridge substitution could impact on the orientation of the bridge inside the cycle and therefore the peptide conformation. we prepared two series ( and atoms cycle size) of cyclic enkephalin analogues to assess the potential effect of this kind of bridge on the biological activity. the compounds were synthesized on the solid support via the formation of a thiourea bridge and with the variable substituent being introduced at the last step before cleavage. it is noteworthy that the synthesis afforded at least two stable and separable conformers for each analogue of the shortest cycle series. generally, one major and one minor species were recovered. but in the case of di-substituted compounds with a cyclic moiety (pyrrolidine or piperidine substituents), three significant species were obtained. analogues were submitted to various biological assays (binding to μ and δ opioid receptors and functional assays). we observed a significant variation in affinity and selectivity for the receptors as a function of the degree of bridge substitution. a structural analysis by d nmr has been undertaken and correlated the variation in activity with a variation in conformation. the origin of the multiple conformers observed for the analogue with a pyrrolidine susbtituent was also investigated. this kind of cyclization could represent a useful tool to easily modulate the conformation and biological activity of a unique peptide sequence. the t-cell response is triggered by the formation of the trimolecular complex between the major histocompatibility complex (mhc), the immunodominant myelin protein epitopes and the t cell receptor (tcr). herein, we report the design and synthesis of non-peptide analogues with the ability to mimic the immunodominant epitope - of mbp , . the mimetics were designed to block the formation of the trimolecular complex and therefore the t-cell activation , . more specifically, indole analogues were synthesized with substitution at positions and or . these molecules contain a carboxyl or an ethyl ester group in position and a benzylamino or phenylamino group in position or . the synthesis of the indole ring was achieved by fischer reaction followed by catalytic hydrogenation, reductive amination or arylation and ester hydrolysis. the synthesized molecules were purified using liquid chromatography, and they were identified by mass spectrometry and h-nmr. laboratory of peptide science, nagahama institute of bio-science and technology, nagahama, japan amyloid β peptide (aβ), the main component of senile plaques in the brain of alzheimer's disease (ad) patients, is formed by proteolysis of amyloid precursor protein (app). as β-secretase (bace : β-site app cleaving enzyme ) triggers aβ formation by cleavage at the aβ domain nterminus, it is a molecular target for ad therapeutic intervention. previously, we reported potent pentapeptidic and non-peptidic bace inhibitors containing a substrate transition-state mimic. although these inhibitors exhibited potent inhibitory activities, their molecular-sizes appeared a little too big (mw> ) for developing practical drugs. in this study, we designed a series of small molecular peptides, with bace inhibitory activity, lacking the p -p ' region on the basis of the conformational structure bound in bace . design and synthesis of new '-peptidyl-trna analogues, in particular "hydrolysable" analogues, which represent covalent conjugates of peptide-nucleic acid (pna) with "stop-peptides," were carried out. such compounds are of interest as tools to study the ribosome functioning and as inhibitors of protein biosynthesis. ( aminoethyl)glycine pna models '-end trna sequence cca in designed structures. computer simulations showed the formation of watson-crick pairing of the pna cytosine residues with s rrna nucleotides g and g involved in interactions with peptidyl-trna during its specific binding in p site of the ribosomal peptidyl transferase center (ptc). short "stop-peptides" were planned for conjugation with pna. these peptides form stable complexes with the ribosomal tunnel (rt) that leads to ribosome stalling and translational arrest. structures of "hydrolysable" 'peptidyl-trna analogues that could form peptide bond with amino acid residue of aminoacyl-trna in a-site of ptc included '-deoxyriboadenosine instead of the pna adenine containing residue. such conjugates would permit to identify the chemical nature of specific sites localized in rt and responsible for interactions with amino acid residues of the nascent polypeptide chain. pna and "stop-peptide" as well as pna-"stop-peptide" conjugates were prepared by solid phase synthesis on sasrin polymer using fmoc/bhoc(boc) strategy. synthesis of "hydrolysable" conjugates included modification of the 'hydroxyl of '-protected '-deoxyadenosine by n-blocked "stop-peptide", deprotection of the '-hydroxyl, its conjugation with n-protected pna and removal of protecting groups from the resulted conjugate. the binding of the new '-peptidyl-trna analogues with ribosome will be tested by chemical probing and in the cell free translation system. this study was supported by the russian foundation for basic researches (grant - - -a). a close structural similarity of endomorphin- and another atypical opioid peptide, morphiceptin, which both have a phe residue in the third position, encouraged us to study antinociceptive activity of these two peptides and their analogues. in order to improve the affinity and chemical stability of these opioid peptides, we have designed, synthesized, and analyzed novel analogues. the first modification included endomorphin- and morphiceptin analogues, where halogenated phenylalanines in position or were incorporated as surrogates of the native phenylalanine. another important modifying element is non-protein amino acid canavanine (cav) and its analogue (sarg). it is well documented that cav and sarg exhibit strong analgesic activity. two new morphiceptin analogues were synthesized by introducing cav and sarg in position . we further characterized their antinociceptive activities by the paw pressure (pp) test. the experiments were carried out on male wistar rats ( - g), treated with i.p. doses of mg/kg. e eldrug s.a., patras , greece the renin angiotensin system (ras) has been a prime target for the therapy of cardiovascular diseases. angiotensin ii type (at ) receptor mediates vast majority of biologically detrimental actions. non-peptide at receptor blockers are presently the most specific means to block the ras enzymatic cascade. the dupont group was the first to develop losartan (dup ), an orally effective angiotensin ii receptor blocker, which is metabolized in vivo to the more potent antagonist exp . herein, we report on the preparation of e-urocanic acid based analogs, focusing our attention on the introduction and structural modifications of the substituents on the imidazole ring as well as the modifications on the acrylic side chain. in particular, we have designed and synthesized a series of urocanic acid analogs bearing the biphenylmethyl tetrazole moiety at the n- of the imidazole ring. additionally, the rigid acrylic chain was lengthened by esterification resulting in the ethyl ester and on the other hand the latter was readily converted to the corresponding acrylic alcohol or aldehyde which may proved to be effective structural elements for enhancing biological activity. finally, a lipophilic alkyl chain such as the n-butyl group was introduced at the -position of the ring which may possibly enhance the antihypertensive activity. docking studies and biological evaluation of the synthesized analogs are being undertaken. university of athens, department of chemistry, laboratory of organic chemistry, , panepistimiopolis zografou, athens, greece the backbone modification of bioactive peptides with replacement of a scissile peptide bond in enzymatic hydrolysis is a well-established strategy for developing protease inhibitors. in particular, for zinc metalloproteases, which contain a zinc atom in their active site, several successful modifications have been reported over the past years. phosphinic pseudopeptides are among the best candidates when addressing the challenge to potent and selectively inhibit zinc proteases. a thorough search in the literature revealed the absence of any reference regarding thiophosphinic pseudopeptides. we thought that this class of compounds would add a valuable tool in the field of zincbinding groups. in the present study, we describe in detail the first synthesis of a new class of phosphorous compounds, thiophosphinyl dipeptide isosters (tdis). we prepared several fully protected thiophosphinate pseudodipeptides of the general formula pg-phe-Ψ[p(s)(ox)ch ]-gly-pg' starting from the corresponding phosphinate pseudodipeptide using lawesson's reagent. selective deprotection of these compounds was also studied and the results are disclosed. these compounds can be used as building blocks for the synthesis of longer thiophosphinic pseudopeptides after suitable deprotection and elongation as well as transition transition state-mimicking inhibitors for several zinc metalloproteases. in the last decade, trypsin inhibitor sfti- isolated from sunflower seeds [ ] has become one of the most studied peptidic inhibitors of serine proteases. owing to its small size and a strong trypsin inhibitory activity (ka = . × m - ), sfti- is considered to be a very attractive template for designing proteinase inhibitors with the potential use as pharmacological agents [ ] . it could also serve as an affinity probe for the isolation of trypsin like (sfti- ) or chymotrypsin like ([phe ]sfti- ) proteinases. following this idea, we decided to synthesize a set of cell-permeable monocyclic sfti- analogues with a fluorophore moiety attached at their n-termini. the presence of the fluorophore in the molecule enabled us to show that the analogues can cross the cell membrane. the cell penetration assay was performed using multiple cell lines (hela cells and human fibroblasts cell line ( br. n) was obtained from european collection of cell cultures (ecacc)). for all the obtained peptidomimetics, we determined the association constants with cognate proteinases. selected peptides were also used as a probes for the detection of inhibitor -proteinase complex, which was achieved by the means of gel filtration chromatography equipped with fluorescence detector and acrylamide native gel electrophoresis. the functional reconstruction of folded protein surfaces with peptide-based mimics is an enormous scientific challenge. the majority of proteins show activity through a small area of their folded surface: "the binding site". however, linear peptides are too flexible and seldomly adopt the correct d-structure of the binding site spontaneously. therefore, they show limited or no activity at all . crucial for activity is to control the secondary (αhelix, β-sheet and/or β-turn) and tertiary structure (relative orientation of subdomain structures). we present the development of a new type of watersoluble scaffolds that have the potential to control both secondary and tertiary structure of discontinuous (i.e. double-loop) protein mimics. the new scaffolds contain a first pair of reactive functionalities to constrain the linear peptide conformation via a 'clips' reaction , stabilizing the secondary structure. next to this, a second functionality allows for ligation of two dissimilar constrained peptides to form a discontinuous binding site mimic via oxime-ligation or click-reaction. these ligations offer the ability to position different peptide loops in d, thus mimicking the tertiary structure of the native protein. most unique to our approach is the fact that all chemical conversions are performed in aqueous media, using side-chain unprotected peptides . growth hormone-releasing peptide (ghrp- ) is a synthetic hexapeptide (his-d-trp-ala-trp-d-phe-lys-nh ), which interacts with two kinds of receptors: growth hormone secretagogue receptor a (ghs-r a) and cluster of differentiation (cd ). the latter is a membrane glycoprotein member of the class b scavenger family, and decreases the internalization of oxidized lipids into macrophages, as well as causes inhibitory effects on angiogenesis associated with binding to thrombospondin. to increase activity and selectivity for the cd receptor, different analogues of ghrp- were synthesized. in particular, substitution of trp in ghrp- by aza-amino acids has given selective analogs, due likely to induction of a β-turn secondary structure. for aza-peptide synthesis, a submonomer solid-phase approach has proven effective to introduce side chains onto the semicarbazide residue. studying influences of benzylidene, benzhydrylidene and fluorenylidene residues during the alkylation of the semicarbazide, superior conversion was observed with fluorenone derivative, and mild alkylation conditions employing et noh as base have improved yields and minimized racemisation. our presentation will focus on the improved submonomer synthesis method for optimization of selective and potent cd- ligands with antiatherosclorotic and anti-angiogenic effects. for instance, the integrin αvβ , vitronectin receptor, is expressed in a number of cell types and has been shown to mediate adhesion of osteoclasts to bone matrix, vascular smooth muscle cell migration, and angiogenesis. integrin αvβ also play a significant role in tumor growth, invasion and metastasis, and is a receptor for the extracellular matrix proteins with the exposed arginine-glycine-aspartic (rgd) tripeptide sequence. rgd has been shown to be potent antagonist of the integrin αvβ , and has excellent anti-angiogenic properties including its suppression of tumor growth in animal models. in this context, drug design based on the rgd structure may provide new treatments for diseases such as thrombosis, osteoporosis, and cancer. we designed and synthesized series of short rgdmimetics containing the sequence xaa-gd, where xaa is arg-mimetic. as promising candidates we have chosen canavanine (cav) and canaline (can) instead of the basic residue arg. in order to improve antitumor activity of the parent molecule, c-terminal modifications were also applied. their cellular uptake was determined on human breast (mcf ) cancer cell lines. furthermore, the in vitro cytostatic effect was evaluated by mtt assay on human liver hepatocellular carcinoma (hepg ) and human breast (mcf ) cancer cell lines after , and hours of treatment. in the case with the human tumor cell lines (hepg , mcf ) and c-modified analogues, statistically reliable results were achieved for the most of concentrations used. acknowledgements: this work was supported by bulgarian ministry of education and science, project my-fs- / . microwave assisted solid phase synthesis of urea and urea/amide based foldamers k. pulka, c. douat-casassus, g. guichard* european institute of chemistry and biology, university of bordeaux -cnrs umr , pessac, france foldamers are fully arti cial molecules that structurally and functionally mimic variety of biopolymers. among them, aliphatic n,n'-linked oligoureas with proteinaceous side chains can adopt extremely robust helical folds stabilized by intramolecular three-centred h-bonds. owing to their resistance to enzymatic degradation, diversity of side chains and structural predictability urea-based foldamers represent unique scaffolds to elaborate functional mimetics of α-polypeptides. of note, heterogenous oligo(urea/γamides) backbones obtained by substituting nh groups by ch display very similar folding propensities. in our laboratory we are investigating the solid phase synthesis of urea and urea/γ-amide oligomers. urea bonds are incorporated into the growing chain by reaction of active succinimidyl carbamates. previously we have applied two different strategies involving fmoc-or bocchemistry, but both methodologies suffer some limitations. therefore a new strategy (compatible with the use of tfa sensitive linkers and side chain protecting groups) featuring azide as a masked amine group has been developed. the synthesis of new azido protected succinimidyl carbamate building blocks is reported. they were obtained in steps from α-amino acids ( - % overall yield). the staudinger reduction with pme was successfully applied to restore the amine group after urea formation on solid support. in addition, microwave irradiation has been found to dramatically accelerate the synthesis. overall, this azide-strategy combined with microwave irradiation was found to be very effective for the solid phase synthesis of oligoureas and related hybrids, surpassing previously developed approach utilizing fmoc chemistry. these antibiotics should have a mechanism different from currently used antibiotics to circumvent existing resistance mechanisms . previous results have shown that "genetic" antibiotics operating by gene silencing in bacteria via rna interference may be successful new candidates. efficient silencing requires efficient crossing of cell membrane. this step can be alleviated using cell penetrating peptides (cpp) as carrier of drug candidates, such as peptide nucleic acids (pnas) which inherently have poor internalization properties . the aim of this study is to elucidate mechanisms of uptake in bacteria using pna-cpp conjugates, which previously have shown promising antibacterial effects . the fate of the pna and cpp parts of the conjugates, once inside the cell, is investigated regarding localization and possible degradation within the cell. furthermore, a method for toxicity testing of pna-cpps is being developed using histamine release in rbl- h cells as a quantitative measure of allergenicity of pna-cpps. the prospect of this information is to define boundaries within which cpps can be found, thereby rationally designing novel efficient antibacterial biomolecular drug delivery systems. oxytocin and its fragments have the potential to influence behavioral and cognitive functions, including their disturbances in some brain disorders. therefore, there is an interest to synthesize new peptide-steroids chimeras for potential therapeutic use. oxytocin analogue was synthesized in solution by coupling azido-phenylalanyl residue or p-azidopegylated handle to the n-terminal end of oxytocin molecule. its c-terminal fragment pro-leu-gly-nh (mif- ) was elongated at proline residue by the same type of azido handles as well. both peptides were marked for fluorescent detection of their possible binding on brain slices. peptide chimeras with the suitable steroids were prepared via azide click to the triple bond on the modified steroid counterpart like ( α)- -hydroxypregn- -en- -yn- -one, -norchol- -en- -yn- β-ol. steroidyl-peptides were then used in the trials using rat-brain slices. the sites of the peptide-steroids chimeras bound to the brain tissue were identified with the aid of fluorescent microscopy. the suitable chimeras will be tested for their penetration through blood brain barrier for the pharmacological effects. indicating that the orientation of the n-butyl group is of primary importance. docking studies revealed that the highly active analog affords an additional hydrophobic binding feature compared to losartan which fits to an extra hydrophobic cavity. these results may contribute to the discovery of new biologically active molecules by a convenient and cost effective synthetic strategy. the context of pain research, the co-administration of opioid agonists and nk antagonists previously led to an enhanced antinociceptive potency, and recently largent-milnes and co-workers have shown that a hybrid opioid-nk octapeptide was able to attenuate tolerance development, related to sustained opioid treatment. our group has prepared a compact opioid agonist-nk antagonist peptidomimetic chimera dmt-d-arg-aba-gly-nme- ', '-bn(cf ) that served as a lead structure. we report a solid phase method for the synthesis of the amino- , , , -tetrahydro- -benzazepin- -one (aba) structure, which is used as a central unit in the investigated dual ligands. this method allowed the rapid assembly of new bifunctional ligands containing the aba structure. variations of the d-arg , gly and n-benzyl substituents were made. the introduction of d-cit , a gly → β-ala substitution and the removal of the trifluoromethyl substituents in caused considerable shifts in receptor binding. the obtained structure-activity relationships will be presented. hence, a promising approach for the treatment of dmd is the use of drugs to force ptc readthrough. (+)-negamycin is a dipeptidic antibiotic containing a hydrazide structure. although (+)- was not clinically developed due to some toxicity, it was recently reported that (+)- restore dystrophin expression in the muscles of mdx mice, an animal model of dmd. therefore, (+)- is a promising therapeutic candidate for diseases caused by nonsense mutations. based on our own efficient total synthetic method of (+)- , structure-activity relationship (sar) study was perfromed to discover derivatives with a potent readthrough-promoting activity. we found a derivative, ( r)- -hydroxy- -aminohexanoyl-glycine exhibited not antimicrobial activity but a similar readthrough activity to (+)- , suggesting that the ptc readthrough mechanism can be distinguished from the antimicrobial mechanism. moreover, we synthesized -epi-negamycin and found that this analog exhibited a similar activity to (+)- in in vitro readthrough assay. this result hence prompted us to synthesize a -dehydro-derivative, e.g., -dehydro- -epinegamycin , which is a natural product with little antimicrobial activity. surprisingly, we found that showed a higher in vitro readthrough-promoting activity than (+)- . this result suggests that mother nature independently evolved readthrough-promoting products like suppressor trna, in distinction from aminoglycosides, which show both antimicrobial and readthrough-promoting activities. agricultural university of athens, athens, greece high interest has been paid to synthetic structural motifs that promote specific conformations because of their importance for the development of new therapeutic peptidomimetics. in addition, such motifs may show catalytic activity for asymmetric organic transformations. during the last two decades, various synthetic structural motifs that promote reverse turns have been studied. following our interest on chiral prolinamide-thioureas that present interesting organocatalytic activity, we have undertaken a combined experimental/computational study to understand the structural features that may stabilize a reverse turn in short-length peptidomimetics containing a thiourea functionality. compounds with the sequence r-pro-diphenylethylenediamine-thiourea-asp(obut)-obut (r: boc or fmoc, or boc-ala), were synthesized and studied by nmr spectroscopy (tocsy, h- c hsqc, noesy, roesy spectra) for the sequential assignment and the exploration of the dipolar connectivities. sampling of the conformational space was driven by the noe intensities while molecular dynamics simulations were further applied to the consistent with the experimental data conformers in order to monitor the stability of the formed hydrogen bonding interactions in the course of time. energy refined produced conformers were subsequently modified by applying all combinations of d-and l-amino acids at each site in a stepwise manner. the modelled structures were studied in silico aiming to explore the combinations of heterochiral residues which would promote a folded structure and would favour the potential of β and γ turn motif. the most promising combinations were chosen for synthesis and subsequent nmr characterization. in this research project we will deal with chemical strategies to produce suitable surface modifications in order to induce multidirectional cellular migration along gold surfaces. to achieve this objective we want to use and characterize self-assembled monolayers (sams) of thiolated dna chains (dna-sh) adsorbed on gold surfaces through the hybridization with complementary modified single-stranded pnas. pna is a structural dna mimic obtained by polymerization of n-( aminoethyl) glycine monomers that replace the ribose-phosphate backbone characteristic of natural nucleic acids. it is an achiral, uncharged, and relatively rigid biopolymer of high biological and chemical stability, and it can bind complementary dna strands with higher affinity than the corresponding dna sequences.for all these reasons we have chosen pna as a key molecule to promote and assist the movement of cells. by producing a chemical gradient of dna-sh along a gold surface in the presence of a chemotactic molecule it will be possible to obtain and control a directed cellular migration. the norwegian structural biology centre and the centre for theoretical and computational chemistry, department of chemistry, university of tromso, troms , norway renin is a highly selective aspartic protease which catalyzes the hydrolysis angiotensinogen, a protein secreted from the liver, to the decapeptide angiotensin-i. angiotensin-i is further processed by the relatively nonspecific angiotensin converting enzyme (ace) to give the octapeptide angiotensin-ii, a potent vasoconstrictor and the dominant peptide produced by the reninangiotensin system. renin catalyses the rate determining step in the formation of angiotensin-ii, and has for several decades been an established therapeutic target for drug development in relation to hypertension. in the search for renin inhibitors, substituted piperidine derivatives have been identified as promising, - and piperidines have proven to be efficient scaffolds for the development of novel non-peptide aspartic protease inhibitors, particularly towards renin. [ ] [ ] [ ] we herein describe a series of -triazolyl substituted piperidine derivatives that have been synthesized from n-boc protected trans- -ethynyl- -hydroxy piperidine and tested as novel renin inhibitors. piperidine derivatives containing a -substituted , , -triazol- -yl substituent were found to be most active and molecular docking experiments provides a rank order that is in very good agreement with experimental data. the cxcr /sdf- axis is involved in many biological processes such as hematopoiesis, immune cell migration, as well as in cancer metastasis. cxcr also mediates the infection of t-cells with x -tropic hiv functioning as a coreceptor for the viral envelope protein gp . cxcr , as a pharmaceutical target, is of utmost importance but the lack of synthetic agonists has seriously slowed down drug development. it has been recently described by our research group , that grafting the sdf- n-terminus onto a side-chain of the inverse agonist t . generated high affinity synthetic agonists as well as partial agonists for the chemokine receptor cxcr . to remain stable towards proteases and act as useful pharmaceutical tools, the pk-adme properties need to be improved with a gradual transition to peptidomimetic structures. medicinal chemistry witnessed major advances with the discovery of small synthetic molecules that mimic the natural peptidic substrates. these small molecules do not undergo proteolytic degradation, an advantage they hold over natural counterparts. in order to improve stability against proteases, part of the sdf- chain was replaced with variable lengths of polyethylene glycol and unnatural amino acids at differents positions. here, we have produced a series of compounds, most of which showing nanomolar affinities for cxcr and some are displaying partial agonistic properties. tlrs are the innate immunity receptors that recognize the epitopes found on surfaces of various cells and therefore they initiate and sustain the atherogenic inflammatory response [ , ] . we assume that the use of small stat mrna−binding pna−inhibitors to manipulate the activity and expression of stat could prove an attractive therapeutic strategy in treatment of atherosclerosis. to that end we synthesized a specific stat mrna−binding pna inhibitor as well as a non-specific pna to compare their inhibition of gene expression. in our work we developed effective method of synthesis of pna−peptides conjugates by means of "click chemistry". determination of optimal conditions for conjugation (connection of pna with the peptide) will allow for the design of compounds useful in gene therapy. the specificity of pna hybridization to complementary dna fragment was verified by capillary electrophoresis (ce). as an artificially synthesized somatostatin analogue, tyr octreotate (toca) can specifically bind to somatostatin receptor (sstr), which are usually over-expressed on many tumor cells. carbohydration of n-terminus of toca has resulted in improved pharmacokinetics and tumor targeting ( ) . f is an ideal nuclide for positron emission tomography (pet) imaging; there may be significant uses of f labeled glucitol-toca and its analogues as tumor probes for the diagnosis of sstr-positive tumors. in order to explore a novel pet probe for diagnosis of sstrpositive tumors, we designed a synthetic route to synthesize n-gluc-lys(nota)-toca, which uses , , -triazacyclononane- , , -triacetic acid (nota) as the chelating reagent. n-gluc-lys([al f]nota)-toca is radiosynthesized quickly and efficiently using the chelation reaction of al f complex and n-gluc-lys(nota)-toca. the aim of this study is to develop an efficient method for the synthesis of monomers of triazolic nucleic acid (tna), a new class of artificial nucleic acids. but- -yne- , -diol and nucleobases derivatives will be substrates of the monomers synthesis. tna oligomers could be used as specific inhibitor of tar rna hiv- , the regulatory rna structure crucial for hiv replication. "click chemistry" based on , -dipolar cycloaddition will be used to conjugate an alkyne and azide derivatives of monomers subunits. a ru (ii) complex will be used as a catalyst of internal alkyne (but- -yn-based) cycloaddition. the reaction gives exclusively of , , -trisubstituted derivative of triazole ring . the monomers will be characterized using rp hplc, capillary electrophoresis (ce) and h and c nmr. the resulting monomers containing fmoc-protected amino group and a free carboxyl group will be used for the classical spps method to synthesize tna oligomers. tna sequences will be designed against tar's bulge and an external loop. through the recognition that the repertoire of polypeptide conformations can be greatly expanded by the creation of structures incorporating β-amino acids. moreover, the numerous advantages of hybrid (mixed α-and β-) backbone peptidomimetics with respect to homogeneous ones were quite recently outlined. we describe here various β-amino acid-based β-hphe-β-hphe dipeptide derivatives, also conformationally constrained, and their application to the synthesis and biological evaluation of hybrid analogues of the opioid endogenous peptide endomorphin- (em- ). the opioid system mediates a wide variety of pharmacological and physiological processes, including pain perception and modulation. the amidated tetrapeptide em- has been shown to be μ-opioid receptor (mor) agonist exhibiting a very high μ-receptor affinity and selectivity, and it is an important model in the search towards new analgesics. structural investigation of em- reveals the high conformational freedom of the phe side chains and also the inherent flexibility of the peptide backbone, indicating many probable bioactive conformations, ranging from βturns to extended conformations. with the aim of better clarify the relevant role of the proper spatial orientation of the aromatic rings and in particular of the benzyl side chains at position and , h nmr studies, molecular modelling, and molecular docking to a homology mor model of our hybrid analogues are currently under way. the lantibiotics represent a class of antimicrobial peptides, in which the unusual amino acids dehydroalanine and dehydrobutyrine and the intramolecular thioether bridges (lanthionines) are important structural features for bioactivity.the lipid ii -nisin complex is responsible for pore-formation since the c-terminal part of nisin is inserted into the bacterial cell membrane which ultimately results in cell leakage and collapse of vital ion gradients. in order to increase the metabolic stability of nisin, the oxidationsensitive thioether bridges can be replaced by metabolically stable dicarba moieties, as successfully demonstrated by the synthesis of nisin ab(c) analogs containing alkane/alkene bridges [ ] . to obtain more insight into the importance of the cross-bridged de-ring structure (i→i+ , i+ →i+ connectivity) on nisin's bioactivity, we synthesized a series of all four diastereomers of the crossed alkene-bridged de-ring mimic, using ring-closing metathesis. all four diastereoisomers were obtained by hplc and structurally characterized by nmr spectroscopy. an orthogonal protection scheme was used, to enable the independent n-or c-terminal modification of the bicyclic hexapeptides with azide/alkyne functionalities. via cu(i)-catalyzed cycloaddition chemistries, alkyne-functionalized natural abc-fragments of nisin, which were obtained by tryptic digestion of full length nisin followed by hplc purification, have been conjugated to synthetic de-ring mimics to obtain novel nisin derivatives and their affinity toward lipid ii and pore-forming capacity have been studied. herein, we report on the details of the synthesis and characterization of the geometric isomers of the synthetic de-ring mimics, and their use as synthons in cu(i)-catalyzed click chemistry to obtain newly designed nisin hybrids as potential novel peptide antibiotics. università di ferrara, dipartimento di biochimica e biologia molecolare, ferrara, italy mirnas play an important role in regulation of gene expression, being involved in numerous processes such as cell proliferation, cell differentiation, apoptosis and also in the progress of diseases as cancer and cardiovascular disorders. mirnas associated to diseases recently become targets for the development of new drugs based on antisense oligonucleotides or analogues complementary to the chosen mirna, in order inhibit the binding of the mirna to its mrna target. therapeutic silencing of mirna has been also observed in several animal disease model. in this work we propose a new approach to interfere in the mirna function, based on peptide nucleic acid (pna) oligomers designed to be complementary to selected regions of the mirna precursor (pre-mirna). as the pre-mirna bases belonging to the stem are not perfectly complementary, we hypothesized that the mismatched duplex of the pre-mirna could be opened by pnas inhibiting of its maturation into mirna. two pna sequences, targeting respectively the "sense region" and the " ' end region" of the pre-mir were designed. pnas were conjugated to different carrier peptides, hiv-tat, r , k and two nuclear localization signal (nls and binls), in order to increase their cellular uptake. to verify the ability of the designed pnas to give strand invasion on the pre-mirna, we conjugated also pnas to the thiazole orange, a probe which lights-up upon hybridization the development of privileged molecular scaffolds efficiently mimicking reverse turn motifs has attracted remarkable interest when structural constraints are exploited to increase both binding and selectivity of model peptides. one of the successful approaches to restrict peptide conformation is the disubstitution in the α position of an α-amino acid, leading to a conformational constraint and a stereochemically stable quaternary carbon center. in particular, spirocyclic scaffolds are able to provide, upon the attachment of appropriate functional groups, useful high-affinity ligands, relevant to the field of drug discovery. at present, we are interested to spirocyclic tryptophan (trp) analogues, in order to develop new reverse turn nucleating moieties able to be inserted into pharmacologically relevant peptidomimetic compounds. among peptides sharing a tryptophan-containing β-turn motif of which the trp residue is critical for binding, we looked at the hormone peptide somatostatin, acting in various organ systems as a neuromodulator and a neurotransmitter, as well as a potent inhibitor of various secretory processes and cell proliferation. somatostatin and its analogue octreotide (sandostatin® drug, clinically used for the treatment of endocrine tumors and acromegaly) are thought to interact with the sst - receptors mainly by inserting a β-turn substructure, carrying a lysine (lys) and a trp side chain into a pocket of the g protein-coupled somatostatin receptor. we report here the preparation and structural characterization of a new , , , -tetrahydro-β-carboline (thbc)-based spirocyclic lactam as type-ii β-turn model compound and the application of its core structure to the synthesis of a somatostatin mimetic, whose biological evaluation is under way. the analogues of sfti- modified in the p position by, βand γ-amino acids and n-substituted β-alanines r. lukajtis, a m. filipowicz, a a. legowska, a d. debowski, a a. lesner, a k. rolka a a faculty of chemistry, university of gdansk, - gdansk, poland serine proteinases play very important roles in many physiological processes in humans, such as: food digestion, fertilization of the ovum, blood clotting and dissolution of blood clots, immune response. however, their uncontrolled activity can evoke serious pathological conditions. therefore, serine proteinase inhibitors are considered to be a promising class of therapeutic agents. trypsin inhibitor sfti- , on which we focused our attention in the last decade, is an attractive template for the design of such compounds. its primary structure is shown below: & gly-arg-cys(& )-thr-lys -ser -ile-pro-pro-ile-cys(& )-phe-pro-asp& the inherent feature of natural peptides and proteins is their low stability towards proteases, which seriously reduces their bioavailability. there is a growing need for the development of artificial biopolymers with diverse side chains, capable of mimicing peptide function. β-and γpeptides are an interesting class of peptidomimetics with significant chemical and biological properties. the present communication describes the chemical synthesis and inhibitory activity of a series of trypsin inhibitor sfti- monocyclic analogues (with disulfide bridge only) modified in p position by βand γamino acids and n-substituted β-alanine (β-peptoid units). the following mimetics of proteinogenic lys or phe were used: β hlys, β hphe, γ hhlys, γ hhphe, βhnlys, βhnphe. all compounds were synthesized manually on solid support. β-peptoid monomers were introduced into the peptide structure by two steps method [ ] . newly obtained sfti- analogues modified in p position by β-derivatives of lys and phe were able to inhibit bovine β-trypsin and bovine αchymotrypsin, respectively, whereas the remaining ones (except for [βhnphe ]sfti- ) appeared to be inactive. the notion that early soluble aß intermediates are endowed with cytotoxic effects suggests that a major effort should be directed toward the inhibition of amyloid aggregation at very early stages. inhibiting aß self-oligomerization could, therefore, provide a useful approach to treating and controlling the pathogenic pathways underlying alzheimer's disease (ad). likely, agents that target the basic molecular recognition process preceding the formation of early intermediates are the most valuable candidates. we have conjugated a trehalose moiety to the known ß-sheet breakers pentapeptides lpffd. trehalose has received a special interest because it has been found to be effective in the treatment of neurodegenerative diseases associated with peptide or protein aggregation. the glycosidic moiety was covalently linked to different regions of the peptides' primary sequence, including the n-terminus or c-terminus or the aminoacid side chain. this new class of peptides showed an increased resistance to proteases. in this work, the inherent ability of these peptides to recognize and bind the monomeric form of recently reported a d-amino acid-containing hiv protease inhibitor with a sulfonyl group showed an activity enhancement against drug resistant viruses. x-ray crystallographic study of the derivative revealed existence of four bridging water molecules. we suggest that the additional indirect interactions through water molecules induced the inhibitor's flexibility in binding conformation, keeping the affinity with the mutated proteases. oxalyamide, so-called oxamide, has two carbonyl oxygen atoms as hydrogen bonding acceptor similar to sulfonyl group, which is promising to interact with water molecules. to increase the numbers of bridging water molecules, we built-in two oxamide structures to both terminals of pseudo-symmetric compounds with hydroxymethylcarbonyl-hydrazide isostere. the derivatives were tested for inhibitory activity using wildtype hiv protease and a highly mutated protease with lopinavir resistance. we found that the loss of potency against the mutated protease was relatively small in the oxamide derivatives. the molecular dynamic simulations suggested the ability of bridging water formation of the two oxamide groups. optimization of the pna-synthesis using different bases for fmoc-deprotection s. rawer , k. braun , r. pipkorn life technologies, darmstadt, germany dkfz, heidelberg,germany pna (peptide nucleic acids) are considered as highly sensitive and specific tools for antisense strategies especially conjugated with cell penetrating peptides. individual designed shuttle systems can be applied in cancer diagnostics and possible therapy ( ) . it is, however, undisputed that proper pnas' syntheses prove to be a challenge for coupling and fmoc-deprotection. due to the structure-formation the success of the synthesis depends strongly from parameters, like activator's quality and deproctection kinetics correlating to the length of the pna polymer spps product. using the example of the spps pna synthesis' results of the coding sequence of c-myc human exon ii, different bases, acting as fmoc-deprotection reagents, are compared and analyzed aiming at optimizing the pna synthesis strategy ( ) peptidoglycans are central structural components of the cell wall of bacteria. several plant receptors are known to recognize peptidoglycan fragments. it is believed that these receptors form part of the defense mechanism against bacterial infections in several plant species. peptidoglycans consist of long chains of alternating β( - )linked glcnac and murnac moieties that are crosslinked by short, non-ribosomal peptides. these peptides consist of several d-amino acids and the symmetrical (r,s)diaminopimelic acid (meso-dap). in particular, the latter complicates the synthesis of peptidoglycan fragments due to the requirement for individually addressing the two pairs of functional groups. some chemical syntheses of peptidoglycan fragments have been reported [ ] [ ] [ ] [ ] , hhich involved multi-step formation of an orthogonally protected dap moiety, and elaborate oligosaccharide synthesis. here we present a new and simple approach to peptidoglycan synthesis which is based on the use of commercially available building blocks for the dap and oligosaccharide components. this allows easy access to a range of peptidoglycan fragments for structure-activity studies. the introduction of solid-phase peptide synthesis (spps) and the subsequent refinement of resins, linkers, coupling reagents and amino acid protecting groups allowed access to a wide range of peptides. therapeutic peptides, in particular, have benefitted from the maturation of spps, as complex peptides can be synthesized more efficiently in comparison to conventional solution phase synthesis. however, peptides containing multiple disulfide bonds often still remain difficult to make due to a lack of orthogonal cysteine protecting groups that can be used in routine spps. the cysteine protecting group s-tertbutyl mercapto (s-tbu) is commercial and orthogonal to other cysteine protecting groups. removal of the protecting group is facilitated by reducing agents (e.g. thiols or phosphines) and is stable to tfa and piperidine, hence compatible with fmoc/o-tbu peptide synthesis. however, the protecting group cannot be used in routine spps due to long deprotection times ( - h) . in certain cases it has been shown to be impossible to remove due to proximity of bulky protecting groups and sensitivity to certain sequences. additionally, reports of desulfurization of s-tbu protected cysteine to dehydroalanine, by the use of prolonged exposure to reducing agents, show the limitations of this protecting group. the concept of cysteine protecting groups labile to reducing agents is promising due to orthogonality to other cysteine protecting groups and the limitations of s-tbu initiated an investigation into novel reductive cysteine protecting groups. herein, we introduce s-tmp as a novel cysteine protecting group that is very labile to reducing agents. the increased lability, in comparison to s-tbu, allows utilization of reducing agent labile protecting groups in routine peptide synthesis of disulfide containing peptides. as modern automated spps protocols allow the assembly of larger and increasingly complex peptides, a precise control of the coupling reactions is a crucial prerequisite in peptide synthesis. monitoring the progress of synthesis allows the detection of undesirable products caused by side reactions, incomplete couplings or deprotections. although different methods have been developed for monitoring spps, we observed that the use of colorimetric test or continuous-flow uv absorbance of the reaction column effluent was not informative enough to identify difficult steps in the synthesis. in this study we demonstrate the usefulness of the combination of a mw-assisted mini-cleavage protocol and the uplc-esi-ms analysis for monitoring the quality of the reaction steps. as a proof of concept, based on this strategy, we monitored the synthesis of pthrp( - )nh (synthesised by fmoc/tbu rt-spps, liberty™, cem), characterised by a cluster of arginine residues in the - region. by the use of mw irradiation during the mini-cleavage protocol, we optimized time for mini-cleavages particularly in case of multi-arginine containing peptides, protected by pbf group. the results obtained by uplc-esi-ms showed that the complete removal of the pbf groups from the arginine sidechain residues required h at rt. on the other hand, the mw-assisted mini-cleavage monitoring let us to obtain final results just in min, confirming that the use of microwave irradiation in mini-cleavages is an efficient strategy to monitor also difficult peptide couplings, such as multiarginine peptides. identification of some deletion sequences was helpful to recognise critical couplings in order to adopt more efficient coupling strategies and therefore to optimise the final yield and purity of the crude peptide. development of green sustainable chemistry is currently regarded as a challenge in science and technology to reduce the use of organic solvents and utilize less toxic solvents instead. water and aqueous-based solvent systems represent an increasingly significant choice for replacing traditional solvents in synthetic chemistry. until recently, peptide synthesis in aqueous solution has remained largely unexplored. this is because the most common building blocks are sparingly soluble in water and are considered inappropriate for in-water peptide synthesis. we have developed a method for solid-phase peptide synthesis in water, which utilizes water-insoluble fmoc-amino acids that are converted to water-dispersible nanoparticles. in this way, the solubility problem is overcome. our technology, which uses suspended nanoparticle reactants for the coupling reaction, offers many advantages in terms of reaction efficiency over inwater synthesis using water-soluble or non-disperse reactants. however, there are two main problems with this nanoparticle approach; (i) slow reaction rates compared to general peptide synthesis in ordinary organic solvents (ii) poor yields for the synthesis of long peptides because the protected peptide chains on the resin have a tendency to aggregate in water. mw assisted spps is particularly attractive because of the widespread availability of the new technology, including automated peptide synthesizers. a trial of mw assisted inwater solid-phase synthesis using non-disperse boc-amino acids has been reported by albericio previously. currently, fmoc-amino acids are routinely used as building blocks for solid-phase peptide synthesis. with this in mind, we have developed a mw irradiation procedure aimed at reducing reaction time and increasing reaction yield for in-water solidphase synthesis using water-dispersible fmoc-amino acid nanoparticles. and we demonstrated in-water solid-phase synthesis of difficult sequence peptide with mw irradiation. m. lebl, z. flegelova spyder institute praha, czech republic cotton was shown as a convenient solid phase support earlier - , but did not find wide acceptance by the peptide community. we decided to try its application as (i) a support of choice for the synthesis driven by combination of capillary forces and gravity, (ii) support for synthesis utilizing in situ neutralization boc based protocol, (iii) support for combinatorial synthesis based on easy labeling and physical separability of cotton substrate, and (iv) support for multisupport synthesis. -we have built a simple synthesizer in which the cotton carrier (functionalized thread) is placed inside the capillary tubing and the appropriate reagents are introduced by connecting the inlet with appropriate reagents. the speed of "pumping" the reagents is driven by the difference between the elevation of the inlet and outlet of the capillary tubing. -we have shown that boc solid phase synthesis utilizing in situ neutralization is compatible with cotton substrate and provides high quality products. combining with the fact that cotton by itself acts as the self-association breaking agent, makes cotton a suitable carrier for synthesis of "difficult" sequences. -labeling of individual solid support particles can be easily based on the length of the cotton thread pieces, number and positions of knots, or their attachment to a secondary carrier. in addition, it is possible to synthesize peptides differing by the partial structure (alternative linkers, terminal modifications, etc.) in a mixture of classical resin with labeled cotton carriers, which are easily separable at the end of the synthesis. . use of microwave irradiation provides peptides in a fraction of time compared to conventional methods, and the peptides are also often generated in higher yield and purity. while microwave technology is particularly suited for the synthesis of "difficult" to synthesize peptides, this tool can routinely be used for the synthesis of a wide variety of peptides without the need for extensive method optimization. the focus of this study is to demonstrate how a peptide can be synthesized on a small scale (for example μmol) up through larger scales (> mmol) with ease. as a biologically relevant model peptide the last residues of the human platelet factor protein (hpf - ) was selected due to its significant antimicrobial activity. however, the problem of developing a robust fmoc thioester method is that the deprotection of the fmoc group with base at each cycle is not compatible with an active ester at the c-terminus. many ingenious approaches have been developed to generate the required thioester peptide. , , the most popular has been to use an nacylsulfonamide as a base and acid stable (safety-catch) linker for peptide synthesis. alkylation of the sulfonamide after peptide assembly makes the linker labile to cleavage with nucleophiles. whilst popular, it has been plagued by notoriously low yields which originate from the incomplete acylation of the resin-bound sulfonamide with the c-terminal residue, incomplete alkylation of the sulfonamide and the incomplete thiolysis of the resin-bound protected peptide. in this poster we describe the development of a novel dual linker strategy , involving anchoring of the sulfonamide linker to a standard acid-labile resin. this variation overcomes many of the current limitations of the sulfamylbutyryl linker approach and provides a simpler and scalable method for peptide ligation via fmoc spps. m. ziovas, d. tataraki, p. manousou, n. parveri, f. satoglou, d. gatos and k. barlos department of chemistry, university of patras, patras, greece solid phase peptide synthesis is traditionally performed by the attachment of the c-terminal amino acid through its α-carboxyl function on a suitable solid support and elongating peptide chain towards the amino terminal of the peptide by adding sequentially the amino acid residues in the gradually growing peptide chain. several thousands of publications and patents describe this methodology and its application for the production of peptide pharmaceuticals. in contrary to the attachment of the c-terminal carboxyl function, attachment of amino acids and peptides through an amino acid side-chain on suitable resins and their application in spps is described in a small number of publications and patents. most of these publications describe the attachment of the amino acids through a side-chain carboxyl group of asp and glu. in the present work peptides were synthesized very efficiently in high yield and purity by anchoring of side-chain hydroxyl, amino or thiol groups of amino acids, amino acid amides, amino alcohols or small peptides on resins of the trityl or benzhydryl type. several peptides of pharmaceutical interest, such as exenatide, octreotide, pramlintide, calcitonin, bivalirudin, insulin b-chain and others were produced as examples of this technology, either by the step-by-step procedure or by fragment condensation in solution and on solid phase. step given that some of these diseases are caused by a mutation and/or malfunction of an essential protein, a better understanding of the structure and function of such proteins will allow us to prevent, slow down or even cure these diseases. to increase our knowledge, the synthesis of the target protein, a fragment involved in its activity or interacting peptides that modulate the protein activity is often required. in some cases the preparation of a protein analogue that improves its efficacy is envisage. however, conventional solid-phase peptide synthesis methods have some limitations when attempting to achieve these complex sequences of considerable length. using novel technologies, such as a microwave-assisted solid phase synthesis, commonly found in many peptide synthesis labs, here we performed the step-wise solidphase synthesis of a protein holding more than residues (d-vegf). this synthetic achievement indicates the suitability of this approach for synthesis of long proteins or their analogues. the detailed synthesis of the enatiomeric version of vegf and the selenomethionine substituted analogues of huprp ( - ), proteins involved in angiogenesis and prion protein amyloidoses respectively, are described as study cases, where the use of microwaves allow us to obtain them in a fast and efficient manner. therefore, the development of novel peptide analogues with enhanced in vivo stability could potentially provide therapeutic alternatives. the pharmacological evaluation of a bioactive peptide [des-gly ,tyr (ome),d-leu ,aze-nhet ]gnrh, analogue , is presented herein. in vitro (kidney mouse membranes) and in vivo (clinically relevant pharmacokinetic mouse model) bioassays were coupled to liquid chromatographytandem mass spectrometry. analogue , an agonist of the gnrh receptor with a binding affinity in the nanomolar range, caused testosterone release in mice that was acutely dose-dependent, an effect blocked by cetrorelix. repeated dosing studies in mice demonstrated that analogue was well tolerated and had potency similar to that of leuprolide, based on plasma and testis testosterone reduction and histopathological findings. analogue also shared with leuprolide similar significant antiproliferative activity on androgen-dependent prostate cancer (lncap) cells. on the basis of pharmacokinetic advantages, we expect that analogue or analogues based on this new design will be therapeutically advantageous for the treatment of cancer and endocrine disorders. cortexin is a polypeptide drug isolated from cattle and porcine brain cortex. cortexin is effective in monotherapy and in combination with traditional methods of treatment. cortexin produces tissue-specific, regulatory, and reparative effects on the brain cortex and contains active low-molecular-weight neuropeptides (< kda) penetrating through the blood-brain barrier. cortagen is a tetrapeptide h-ala-glu-asp-pro-oh (geropharm) produces nootropic and neuroprotective effects. oleylcortagen is a lipophylic analog of cortagen c h o-ala-glu-asp-pro-oh was created for increased proteolytic stability and increased penetrating through the blood-brain barrier. the main aim of our investigation is the analysis of psychopharmacological profile of peptide preparations in comparison with piracetam. have been shown oleylcortagen ( mg/kg) and piracetam ( mg/kg) possess activating effect on motor and research components of behavior in «open field» test. two of peptides (oleylcortagen, cortexin) decreased period of immobilisation and demonstrated antidepressant effects on rat behavior in the porsolt's test, on other hand cortagen demonstrated depressant action. therefore, the significant psychoactivating properties are typical for oleyl-cortagen, cortexin. the mechanism of the action of these peptides can be explained from the viewpoint of the regulatory cascade. they produce a direct information impact on cell structures of the brain, and then promote release of the regulatory peptides, which in turn, induce the release of the next group of peptides. neurology, queen square, london wc n bg, uk one of the hypotheses of alzheimer's disease neuropathology involves beta-amyloid (βa) binding with proteins on neuronal cell surface which leads to cell lysis and amyloid plaque formation. according to the latest data α -type of the nicotinic acetylcholine receptor (achr) and the prion protein can be the target for betaamyloid toxicity [ , ] . aggregated βa causes many pathological changes in cultures of mixed neurons and astrocytes such as sporadic cytoplasmic intracellular ca + -signal, activation of reactive oxygen species (ros) production and cell death. in the present work we demonstrated the ability of affinity purified antibodies to synthetic fragment - of α -subunit of the achr (achrabs) or to peptide - of the prion protein (prpabs) to protect cells from βa induced cell death. we also showed that both antibodies did not block βa induced ca + -signal in astrocytes. however, preincubation of cortical co-culture of neurons and astrocytes with achrabs or prpabs significantly reduced the rate of caspase activation and the rate of βainduced ros production via modulating nadph-oxidase. more detailed research of involvement of α -type achr revealed that α-bungarotoxin was also very effective in the inhibition of caspase activation and superoxide production. the observed positive effect of antibodies to α -type achr or to the prion protein gives an additional explanation regarding the involvement of these proteins in ad pathology and provides new approach into an anti-ad vaccine design. capturing and macrophage-aided clearance of amyloid beta by surface modified proteineous particles m. richman, s. rahimipour department of chemistry, bar-ilan university, ramat-gan , israel imbalanced homeostasis and oligomerization of amyloidβ (aβ) peptide in the brain are hallmarks of alzheimer's disease (ad). microglia and macrophages play a critical role in ad progression by clearing aβ from the brain or inducing inflammation. recent evidence suggests that the phagocytic pathway of aβ may be defective in ad microglia/macrophages that contributes to the build-up concentration of aβ in the brain. , therefore, efforts have been directed toward developing treatments that trigger these cells to clear aβ through alternative mechanisms. we have recently demonstrated that protein microspheres modified at their surface with multiple copies of an aβrecognition motif can strongly bind aβ, inhibit its aggregation and directly reduce its toxicity by sequestering it from the medium. here, we describe how the aβ-bound microspheres can stimulate microglial cells and be phagocytosed through a mechanism that is distinct from that of aβ. the phagocytosis was mostly effective with microspheres having diameter size of about . - mm and introduction of polyethylene glycol to the surface of the microspheres changed the kinetics of the phagocytosis. moreover, while aggregated aβ induced a significant inflammatory response that was manifested by the release of tnf-α from the microglial cells, the aβ-bound microspheres dramatically reduced the amount of the released cytokine. our data suggest that surface-modified microspheres could be utilized to detoxify other pathogenic or misfolded proteins that their accumulation may lead to genesis of other diseases. vasoactive intestinal peptide (vip) and its derivatives have been thought to be promising drug candidates for airway inflammatory diseases. however, the therapeutic potential of vips is highly limited because of rapid metabolic degradation and systemic side effects following systemic administration. previously, to overcome these drawbacks, our group developed a novel vip derivative, [arg , , , leu ]-vip-grr (ik ), with improved metabolic stability ( ), and respirable powder (rp) formulation of ik (ik -rp) for pulmonary administration ( ) . these attempts successfully led to enhanced pharmacological effects of ik in the airway system and reduced systemic exposure; however, further chemical modification of ik with a focus on metabolic stability might provide better clinical outcome. the present study aimed to design a pegylated vip derivative with improved metabolic stability and to develop its respirable powder (rp) formulation for inhalation therapy. ik was chemically conjugated with peg ( kda, p k), the physicochemical and biochemical properties of which were characterized by cd spectral analysis, binding assay, and metabolic stability. the rp formulation of pegylated ik (ik /p k) was prepared with a jet mill, and in vitro inhalation performance and in vivo pharmacological effects in antigen-sensitized rats were also evaluated. the cd spectral analysis demonstrated that peg conjugation had no impact on the solution structure of ik . although receptor-binding activity of the ik /p k (ic : nm) was estimated at ca. -fold less than that of ik (ic : . nm), metabolic stability for the ik /p k was highly improved. according to the laser diffraction and cascade impactor analyses, ik /p k-rp had fine in vitro inhalation performance. insufflation of ik /p k-rp ( μg of ik /p k) in antigen-sensitized rats resulted in marked attenuation of inflammatory events, as evidenced by significant decrease of inflammatory biomarkers and granulocyte recruitment in pulmonary tissue at h after antigen challenge. from these findings, pegylation of vip derivative, as well as its strategic application to the rp formulation, might be a viable approach to improve its therapeutic potential for treatment of airway inflammatory diseases. the previous studies have shown that trkb (tropomyocin receptor kinase) acts as an oncogenic agent and its binding to bdnf (brain derived neurotrophic factor) activates signaling angiogenesis of tumor proliferation [ ] . for finding the most stable and potentially effective peptides against the trkb, we applied the following protocol. at the first step of this protocol we designed a peptide library by using sequence tolerance method in rosetta . package, then peptide energy optimization performed by backrub protocol for finding the most stable peptides. the five best peptides in energy optimization selected based on backrup scores by using r package [ ] . d-structure prediction of the selected peptides was performed by using molecular dynamic in hyperchem software. docking of peptides with trkb receptor was carried out in haddock software. we used cyclotraxin, a selective trkb inhibitor as positive control for this protocol. cyclotraxin and the peptides were compared by anova or t-test. the peptides are going to be tested against the trkb in an in vitro model. dirucotide (mbp - ) is a synthetic peptide analog of , that consists of amino acids and tested in a phase trial were failed to reach his tolerance level on previous phase ii in rpms patients. one of the major disadvantages of peptide therapy is the activation of proteolytic enzymes, leading to peptide degradation. to address this problem cyclic peptide analogues have been synthesized. thus we synthesise a linear and cyclic analogues of dirucotide. the two analogues were synthesized by changing the amino acid residue at position from to the synthesis of the linear peptide, as well as of the cyclic one, was carried out by the fmoc/tbu methodology, utilizing the -chlorotrityl chloride resin (cltr-cl). the purification was achieved using semi-preparative rp-hplc and the identification was assessed by analytical rp-hplc and by mass spectrometry (esi-ms). the linear and cyclic peptide analogues will be used in human t-cell cultures to test their immunogenicity in patients versus healthy controls. in the first approach a reporter moiety was introduced to diagnose and treat cxcr related diseases. therefore, an anchor point to attach additional molecules to the ligand was elucidated. using sar studies to optimize the linker from the ligand to the detectable moiety the excellent receptor affinity could be retained. in a final step the reporter moiety was introduced to give a ligand for diagnosis via pet imaging and for possible endoradiotherapeutic applications. originating from the dimeric motif present in many active cxcr ligands several dimers were prepared using a monomeric ligand identified in the prior study. comparison of monomers and dimers yielded a possible subsite binding mode explaining why the dimers exhibit enhanced affinity using a model derived from the origins of the monomer. several peptidomimetic modifications were introduced to the ligand to reduce the peptidic structure. in a conformationally guided approach introduction of a peptoid motif could enforce a single active conformer that was enhanced through subsequent modifications. this yielded a compound times better than the original cxcr antagonist which is the most affine cxcr ligand reported so far. our previous studies have demonstrated that pace represents a potential therapeutic target for the treatment of prostate cancer . moreover, we have developed potent and selective pace inhibitor, ( -fold specificity over furin), known as multi-leu or ml peptide, which has a significant inhibitory effect on the proliferation of prostate cancer cell lines. peptide-based drug candidates can be limited by their poor metabolic stability and low bioavailability. thus, we performed structure-activity relationship studies to improve the pharmacokinetic properties of our ml inhibitor. we have designed and synthesized new ml peptide analogs having various chemical modifications. first, based on our previous results, we combined the most effective modifications of position p (d-amino acids) and p the arginine mimetic amidinobenzylamine (amba) to improve overall properties of our leading compound. second, the n-terminus of the resulting analogs was modified with a fatty acid, in order to enhance their cell permeability properties. third, we modified the inhibitors with a peg moiety to increase their stability and bioavailability. we tested the inhibitory activity, stability in plasma, cellular uptake, and cytotoxicity of each inhibitor. the results of this study demonstrate that the presence of the n-terminal extension (c or peg ) does not affect activity of our inhibitors. on the other hand, we show that introduction of the peg moiety does not increase cytotoxicity of ml analogs. it is interesting to note that the pegylated analog ac-peg -d-leu-lllrvkr-amba has better cell-permeability activity than its counterpart without peg unit. this combination of pharmacological properties makes our new ml analogs promising candidates for the development of potential anti-prostate cancer agents. [ ] peripheral coadministration of rf with opioid analgesics led to confirm the involvement of npff receptors as a part of the antiopioid system. indeed, rf was able to reverse the opioid induced hyperalgesia in rat (randall selitto test). then, a complete structure-activity relationships analysis was performed with rf , assessing the involvement of each moiety for affinity and selectivity towards both npff receptors. a first exploration of the n-terminus part of rf (> synthesized derivatives) led to replace the hydrophobic adamantane moiety by a hindered aromatic group, providing a subnanomolar npff ligand with more than two log-units selectivity against npff . then, the removal of the cterminal amide function led to reduce the dipeptide arg-phe-nh into an arginine derivative. in spite of an initial loss of affinity, optimization of the phenethyl moiety at the cterminus part of arginine led to non-selective nanomolar ligands for both npff & receptors. next, we applied efficient methodologies in order to synthesize non-natural analogs of arginine, leading to various compounds exhibiting selectivity for either npff or npff receptors. in particular, compound rf was identified as a selective npff antagonist (npff , ki = nm; npff : ki > μm). lacking of analgesia properties, oral administration of rf ( mg/kg per os) to rats was able to fully reverse fentanylinduced hyperalgesia. rf is the first orally available npff antagonist capable of reversing opioid induced hyperalgesia at low dose. moreover, this result allows identifying for the first time npff receptor as a key-partner of the anti-opioid system. administration of multiple antiplatelet agents has become the mainstay in the treatment of acute coronary syndromes in everyday clinical practice. we have previously reported significant antiplatelet effects of novel synthetic peptides' single administration on experimental carotid artery thrombosis in rabbits . in the present study we sought to investigate the peptides' effects when administered in marginally effective doses (significantly lower than those utilized in the past), in animals that had previously received low doses of aspirin. the peptides when co-administered with aspirin preserved the carotid artery's blood flow, in contrast to the total artery occlusion observed in animals receiving aspirin and placebo. blood flow at min after electrical stimulation was reduced to . ± . % and . ± . % in the ymesradr and psrcdcr-nh groups respectively (p< . vs aspirin and control). thrombus weight was significantly reduced in animals receiving ymesradr and psrcdcr-nh versus aspirin and control ( . ± . mg and . ± . mg, vs . ± . mg and . ± . mg respectively, p< . ). platelet aggregation was significantly inhibited in the ymesradr and psrcdcr-nh groups by . ± . % and . ± . % for adp (p< . vs aspirin and control), and . ± . % and . ± . % for aa (p< . vs aspirin and control), respectively. blood loss did not significantly differ among the various groups. administration of novel synthetic peptides, even at marginally effective doses, in animals previously treated with low doses of aspirin results in enhanced antiplatelet effects in an experimental model of arterial thrombosis. the study of peptide metabolism is particularly important when examining anticancer peptides; it can provide pivotal clues for the evaluation and improvement of stability of a peptide drug leading to enhanced pharmacokinetics and efficacy. gnrh analogues are used for the treatment of prostate cancer. as with other peptides a drawback is their short half-life due to their metabolic degradation. in order to examine the stability of these analogues we have developed several in vitro peptide stability and metabolism assays using specific tissues, isolated membranes, cancer cells that are analyzed subsequently using lc-ms/ms based approaches. such in vitro studies are followed up with pharmacokinetic studies in mice in order to establish the correlation between in vitro and in vivo approaches. the kidney is the main metabolic organ for peptide metabolism and for that reason we employed a peptide stability and metabolism assay previously described by our group using isolated mouse kidney membranes for the evaluation and comparison of different gnrh analogues. we tested gnrh analogues in other tissues such as mouse plasma, which is the "distributing" tissue for these drugs and mouse brain homogenate, a tissue known for its abundance in peptidases and relevance for centrally mediated effects. stability studies were also performed in cancer cells. in all cases lc-ms/ms based assays were developed for measurement of peptide drug and the resulting metabolites. for triptorelin, and a series of gnrh analogues, degradation and metabolite formation was studied by our mouse kidney membranes assay. studies of coadministering the peptide of interest with inhibitors that are presumed to block the metabolism in mice are ongoing. the vulnerability of gnrh analogues was verified after incubation with plasma and brain homogenate and by metabolite identification we obtained clues about the key cleavage sites. the described in vitro/in vivo protocols provide valuable information that could lead to the synthesis of more stable anticancer peptides with improved anticancer efficacy. in this work, we explored the use of a high-throughput synthesis and screening approach with peptide arrays to identify and structurally optimize shortened hiv- fusion inhibitors. the peptide array technology involves miniaturized synthesis of immobilized peptides, followed by affinity testing with a five-helix bundle, as a mimetic of the fusogenic gp protein. this exercise resulted in the identification of a class of truncated peptides which demonstrates a surprisingly high antiviral potency, despite the absence of the pocket-and the lipid-binding domain. the propensity of these peptides to adopt the bioactive α-helical conformation in solution as determined by circular dichroism, could be the key factor for this unexpected potency. these peptides are promising leads for the treatment and prevention of hiv. the pathological role of platelets in cardiovascular disease (cvd) is well established. platelets secrete adp to recruit additional platelets to a thrombotic site. we have previously identified novel cell-permeable peptide modulators of platelet function by using a bioinformatic screen based on patterns of evolutionary conservation in transmembrane proteins . in this study we further explored peptides derived from cadherin cell adhesion molecules. we explored a range of overlapping peptides derived from different cadherins varying from - amino acids long. peptides are synthesized and analyzed in a high-throughput platelet adp secretion assay. peptides ( . - μm) were assessed in the presence and absence of thrombin receptor activating peptide (trap; μm). we identified cadh- and proteins, but not cadh or in human platelets using western blotting and mass spectrometric analysis. peptides derived from paralogous juxta-membrane, cytoplasmic regions of these cadherins are potent modulators of platelet secretion. by systematically deleting amino acids from c or n-terminus of active peptides, we established that the minimal functional sequence for biological activity was a short six-residue motif, which corresponds to the known catenin-binding region of cadherin tails (kepllp) . peptides alone have no biological activity. however, they potentiate the response induced by the platelet agonist trap at low doses. thus we have identified a cadherin-derived peptide that can modulate platelet secretion events. this highlights a previously unknown role of cadherins in the regulation of platelet function. agents that interfere with cadherin signaling in platelets might have a therapeutic role in cvd. ageing of the brain leads to impairments in cognitive and motor skills, and is the main risk factor for several common neurological disorders such as alzheimer's disease (ad) and parkinson's disease (pd). altered protein handling (proteolysis, repair system, chaperones) forms a basis for a large number of protein conformational disorders. extra-and intracellular, as well as intranuclear accumulation of abnormal proteins, in the form of protein inclusions and aggregates, and dysfunction of the quality control mechanisms are common in all these disorders. alterations in protein homeostasis occur with age, causing molecular changes such as protein misfolding and aggregation. many biologically active proteins lack stable secondary and tertiary structure, these are called intrinsically disordered proteins (idps), some of them (e.g. β-amyloid, α-synuclein) are coupled to neurodegenerative disorders. idps exist as assemblies of rapidly fluctuating structures undergoing coupled folding and aggregation process. protein aggregation is characterized by polymorphism, where a mixture of soluble oligomers, amyloid fibrils and amorphous aggregates is the final product. soluble oligomers are inevitable formed during the self-association process and might initiate the neurodegenerative cascades of ad, pd and similar diseases. the emerging consensus that protein misfolding (leading to idps) is the cause of several neurodegenerative disorders now offers the opportunity to develop a general therapy. soluble oligomers with id regions are potential drug targets. recently short peptide fragments and small peptidomimetic molecules have been found also in our laboratory; these molecules bind to the id regions of β-amyloid and are putative drug candidates. precise control of bleeding is ensured by anticoagulant mechanisms, which under normal conditions prevail over coagulants mechanisms. disrupting the balance between procoagulant and anticoagulant systems due to congenital or acquired defects leading to thrombotic disorders. anticoagulants are substances that inhibit blood clot formation. their action consists in inhibiting the synthesis of prothrombin, the substances forming thrombus as well as some coagulation factors. many peptides and proteins with different molecular weight, such as antistasin (ats), ghilantens, hirudin, etc. showing high anticoagulant activity are isolated from salivary glands of ticks and leeches. they inhibit the action of serine proteinases from blood coagulation cascade. this creates an opportunity for targeted synthesis of low molecular weight analogues of some of these proteins, which can be used in the prevention and treatment of thrombotic disorders. ats is competitive, slow-binding inhibitor of factor xa. it is well known that blood coagulation could be blocked at different stages of the coagulation cascade through inhibition of various enzymes. therefore, it is interesting to determine the place of action of newly synthesized antithrombotic agents in the blood coagulation cascade. this can be done by determining the inhibitory constants of newly synthesized peptides on different enzymes of this cascade. herein we report on our kinetic investigation of newly synthesized peptide amides, analogues of isoform of ats . ki, km, vmax and type of inhibition on the factor xa, thrombin and plasmin were determinate. some interesting differences between type of inhibition of ats, free acids and amide analogues of ats were revealed. to evaluate the relative anti-platelet aggregation activities of each peptide, the lebetins were chemically synthesized and fully characterized. here we described the synthesis, the solution structure of lebetin g -g from the venom of vepera lebetina by h bidimensional nmr and the relation structure-activity. this peptide has been demonstrated to be associated with a potent anti-platelet aggregating activity. the g -g three dimensional structure consists in a compact β-bulged hairpain core from which emerges one loop and the cterminus and the n-terminus. we report on an approach whereby ligands are designed to bind and stabilize the - region of aβ in an α-helical conformation. these ligands reduce aβ toxicity to cells in culture and to hippocampal slice preparations. in addition, when these inhibitors are administered to drosophila melanogaster expressing human aβ ( - ) in the central nervous system, a prolonged lifespan, increased locomotor activity, and reduced neurodegeneration is observed . stabilization of the central aβ α-helix appears to counteract polymerization into toxic assemblies and indicates that this approach holds promise for the development of orally available compounds against alzheimer's disease. encouraged by the above results we are currently developing a second generation of designed ligands. this involves synthesis of different new peptoids and unnatural amino acids. additional support for the concept comes from recent molecular dynamics simulations that also uncover details of the mechanism of unfolding of the aβ central helix as well as retardation of the folding in presence of ligands designed to interact with the native helical conformation . synthesis and methodology for new ligands, which includes synthesis of novel amino acids, will also be presented. triostin a is a well-known natural product with antibiotic, antiviral, and antitumor activities. it inhibits rna synthesis by bifunctional intercalation into dna base pairs through its two quinoxaline units showing cpg selectivity. triostin a must adopt an altered conformation upon dna bisintercalation that is substantially different than its preferred native x-ray or solution conformation. this fact suggests that the destabilizing conformational change in the cyclic octadepsipeptide counteracts much of the gains derived from a second intercalation. nonetheless, the wide range of pharmacological activities exhibited by this compound prompted interests in identifying novel and additionally potent lead compounds with improved pharmacokinetic properties for clinical applications. herein, a library of twelve simplified triostin a analogues has been synthesized by solid-phase peptide synthesis. the introduction of the key quinoxaline units was carried out in solution. the analogues' conformation corresponds to the staple form that bisintercalator cyclic (depsi)peptides adopt when binding to dna and, in addition, some of the synthesized compounds showed improved solubility. our library was evaluated for its antiproliferative activity against four human cancer cell lines and one analogue showed greater cytotoxicity than triostin a and even comparable activity to doxorubicin, a very commonly used drug in cancer chemotherapy nowadays. surprisingly, little is known about its mechanism of degradation in solution or the degradation products. a recent study identified monomeric polysulfides and dimeric degradation products, postulated to derive from β-elimination followed by deamidation and dimerization. we recently reported that degradation of oxytocin and its analogues in aqueous solution at ph . produced monomeric polysulfides with up to sulfur atoms as well as dimeric products. unexpectedly, incubation of ot or of various analogues modified in position resulted in identical dimeric degradants. we concluded that β-elimination via breakage of the c-s bond of cys must be a key step of the process, and that the resulting Δala residue would have to undergo further modifications to yield the same dimeric products independently of the substitution of the n-terminal nitrogen. here we further clarify the degradation mechanism and propose a structure for the dimers. we postulate that hydrolysis of the Δala residue yields an n-pyruvoyl linear peptide, which loses one sulfur atom and subsequently forms dimers, which we found are linked by one disulfide bridge and one non-reducible bond. the putative linear n-pyruvoyl oxytocin intermediate was synthesized and found to degrade to the same dimers as the ones in the incubations of ot. a [u- c]cys ot analogue gave degradation products with c-nmr spectra consistent with a non-stereospecific aldol-type condensation. detailed experimental procedures, structures of the degradants and the postulated mechanism of ot degradation in near neutral solutions will be presented. inserm u paris, france αiibβ is the main platelet integrin and is responsible for platelet aggregation. a lipid-modified peptide corresponding to αiib intracellular sequence - (palmitoyl-k-l eeddeege , pal-k- - ), is platelet permeable and inhibits human platelet aggregation induced by thrombin . ymesradr, a peptide corresponding to the extra-cellular sequence - of αiib, is a platelet activation and aggregation inhibitor . the aim of the present study was to investigate the cooperativeness of the intracellular and extra-cellular peptides on platelet aggregation and their effect on the phosphorylation of fak and erk. pal-k- - together with the extracellular ymesradr peptide, at concentrations lower than their ic values, showed cooperative inhibition of platelet aggregation. the peptide combination inhibited also fibrinogen and pac- binding to activated platelets. fak phosphorylation is a postaggregation event related to outside-in activation of the receptor. the combination of peptides inhibited fak phosphorylation. erk phosphorylation is independent from platelet aggregation, and is enhanced by rgd-peptide inhibitors. the combined peptides inhibited erk phosphorylation. ovarian cancer (oc) is considered a rare disease and represents the fifth most common cause of death from cancer in women. the standard first-line treatment consists of a combination of paclitaxel and carboplatin (ddp) or carboplatin alone. in the case of progressive disease or drug resistance to platinum-based agents, either alone or in combination, investigational compounds should be used ( ) . the mechanisms behind acquired resistance to ddp and its derivatives are not clear yet, although it is evident that the process is multifactorial, including enhanced dna repair processes. some peptides designed from the interface subunit of the human thymidylate synthase (ts) have been identified recently ( ), as effective anticancer agents against sensitive and resistant oc cells. one of them was also able to recover the cellular sensitivity towards cisplatin in resistant oc cells in the μm range. to improve its potency and selectivity structural studies have been performed in combination with cellular assays aimed at understanding the mechanism of action. a label-free quantitative proteomic approach has been undertaken to study the effects of the peptide on the proteins involved in the modulated metabolic pathways, in particular those involved in the folate metabolism. structure-activity relationships (sar) have been performed to improve the lead peptide pharmacodynamics. all the compounds have been assayed and a protein profile set was studied to mark and validate their behavior as inhibitor of oc cell growth. hepatitis c is a liver disease provoked by a virus known as hcv. the disease is insidious. hcv causes anorexia, nausea, vomiting, fever, fatigue and jaundice. in about % of sufferers the disease is short, but others become chronic. in the chronic form in about % of cases the final result is cirrhosis of the liver and in the remaining % it leads to liver cancer. hcv is a very serious problem today. about % of people infected with hcv worldwide, i.e. about million are residents of europe. million people carry the disease as a chronic illness with the potential to develop into cancer in their liver. all these people represent a "reservoir" for storage and distribution of hcv. ribavirin, the nucleoside analog -β-d-ribofuranosyl- , , triazole- -carboxamide, known by the trade name virazole (also known as rebetron in combination with interferon-α), exhibits antiviral activity against a variety of rna viruses (paramyxoviruses, flaviviruses, etc.) as well as some dna viruses. in humans ribavirin is currently used in combination with interferon-α to treat hcv infections. this lack of strict specificity and a broad spectrum of activity are due to its multifunctional mechanism of action against viruses. these characteristics have made ribavirin a drug of substantial research interest. unfortunately, ribavirin shows a significant toxicity, causing bleeding in accumulation [ ] . herein, we report a total synthesis of modified in position ' of ribose residue, ribavirin in order to be further linked to cell penetrating peptides (cpps). in addition the synthesis of some cpps as well as bonding between two parts of final hybrid molecules will be reported. in our case the design of new hybrid molecules is done in order to: (a) vectorize ribavirin into liver cells; (b) transport ribavirin molecule trough cell membrane and (c) decrease toxicity of ribavirin. to obtain oligomeric aβ peptide, our laboratory uses a precursor depsipeptide of aβ. this precursor, termed as "iso-aβ" has an ester bond between the side chain of ser and gly . at physiological ph this ester bond becomes an amide bond via an o→n acyl shift. binding partners by which the oligomeric aβ mediates its toxic effect has not been yet investigated in the proteome or subproteome level. we used protein array technology to study the interaction of oligomeric aβ with recombinant human proteins, immobilized on a protein chip. aβ binding proteins were identified with the aid of a monoclonal aβ antibody. altogether proteins were found to interact with our aβ-oligomers. these proteins were grouped according to their function. one of the major groups contained proteins participating in translation. these proteins were found in ribosomes. to prove our proteomic results ribosomes from rat hippocampus were isolated. elisa experiment revealed that aβ binds to ribosomes in a dose-dependent manner. using the sequence of the aβ-binding proteins a homology search was performed to find oligopeptides, that possibly bind to aβ. based on these sequences a peptide chip containing hexapeptides was prepared. aβ interacting peptides were identified with a monoclonal antibody. several peptides were synthesized and tested on mtt assay. two out of four compounds inhibited the toxicity of aβ on rat hippocampal slices. summarizing our results aβ binding proteins and peptides were identified. knowledge about aβ binding proteins can help to understand the pathogenesis of ad, such us the possible involvement of ribosomes. oligopeptides can be lead compounds of future drug development. huge proteolytic complex named proteasome catalyzes protein degradation in every eukaryotic cell. it consists of subunits forming four stacked rings and one or two regulatory caps. two inner rings of the proteolytic part contain three catalytic β-subunits that possess different substrate specificity. higher vertebrates can express γinterferon-inducible immuno-β-subunits. proteasome plays an essential role in continual turnover of intracellular proteins and in antigen processing. autoimmune diseases such as multiple sclerosis and its murine model eae are believed to rise from breakdown of tolerance of the immune system. it assumed that immunoproteasome could play an important role in autoimmune diseases. several classes of chemicals proved to be inhibitors of proteasome and the most active are boronate peptide derivatives. these inhibitors totally inactivate proteasome and result in full stop of intracellular protein turnover and cell death via apoptosis. another class of inhibitors, epoxy ketones, was shown to be more selective for immunoproteasome and could be used not for full stop of proteasome function, but for fine tuning of altered proteasome functioning. we examined properties of several inhibitors of four different classes, namely peptide boronate bortezomib, peptide aldehyde mg , lactam lactacystin, and peptide epoxyketones epoxomicin, mg ek, uk and pr- . for inhibition experiments we used proteasome isolated from eukaryotic cell lines cho, nso and hek, treated and non-treated with γ-interferon, as a model cells contatinig constitutive and immunoproteasome. the upregulation of proteasome immunosubunits was revealed in cho and nso cells treated with γ-interferon. the ic values for all studied inhibitors were obtained, and ki in some cases were calculated. the epoxyketones were shown to selectively inhibit in submicromolar concentrations the proteasome sample which contain high amount of immunosubunits. in order to find an effective antimalarial, this study refers to some angiotensin ii (aii) analogues which were considered the important physicochemical characteristics described by silva et al. to verify the biological activity against plasmodium gallinaceum and to understand the hydrophobic cluster influence, explained by tzakos et al. these analogues were synthesized and characterized as described by silva , as well as the biological assays and comprises, to verify: the hydrophobic cluster activity -a) drvyhipf; b) drvypr; c) ryhipf and d) fphiyvrd; the importance of these residues in aii molecule -e) rypf; the importance of aromatic residues -f) yhpf and the action of these hydrophobic residues, when interacting with the parasite membrane -g) vipf. it was observed that in a ( % of bioactivity), the phenol group of tyr is close to imidazole group of his that could promote a hydrogen bond formation. besides that, could occur van der waals interactions between ile and phe residues due its proximity and non-polar characteristic. these interactions could not be effective in native aii ( %) , because ile residue promote a steric influence on the organization of his and tyr residues that not exist in b ( %). in c ( %) and e ( %) analogues, the influence of the arg residue could promote a cation-π interaction with tyr residue and the cluster may have suffered slight destabilization and its antiplasmodial activity was compromised subtly. in d ( %), the electrostatic change, obtained with the total inversion can have disordered its interaction with parasite membrane, since it is not related to membrane receptors, because d-aii presented % of biological activity. moreover, hydrophobic and aromatic residues importance was confirmed through the results obtained % and % of activity, with g and f, respectively. we conclude that hydrophobic cluster modifications and interactions of amino acid side-chain influences in the biological activity. closed joint-stock company "vertex", st-petersburg, russia creatine (cr), a small molecule synthesized in the kidney, liver and pancreas plays important role in atp synthesis, replenishing its store even in the absence of oxygen. cr is able to protect brain cells against ischemic damage; however it has poor ability to penetrate the blood-brain barrier without specific carrier protein. thus, synthesis of stable hydrophobic derivatives capable of crossing the bbb by alternative pathway is of great importance for the treatment of different neurological diseases including stroke, traumatic brain injury and hereditary crt deficiency. here we describe the synthesis and biological activity of new hybrid compounds -creatinyl amino acids. originally the title compounds were synthesized by guanidinylation of sarcosyl peptides. however, for large scale synthesis better results can be obtained using direct cr conjugation with amino acid or peptide derivatives by isobutyl chloroformate method. addition of equivalent amount of ptoluenesulfonic acid as lipophilic counterion ensures efficient cr dissolution in dmf along with its simultaneous protection towards intramolecular cyclization. it excludes the application of expensive guanidinylating reagents and permits to simplify the synthetic procedure. purification of final product and its conversion into appropriate salt form can be achieved by iec followed by crystallization from organic solvents. synthesized creatinyl amino acids and peptides exhibited significant biological activity in different assays including platelet aggregation test, ischemic stroke and nano -induced hypoxia model. one of the most effective compounds -creatinyl-glycine ethyl ester increases life span of experimental animals more than two times in hypoxia model and has neuroprotective action in brain stroke model when applied both before and after ischemia. these data evidenced that creatinyl amino acids can represent promising candidates for the development of new drugs useful in stroke treatment. the efficient recognition and destruction of tumor cells via specific cellular markers is a major goal in cancer therapy. various growth factor receptors such as egfr, hgfr, vgfr and their downstream signaling networks have been proven to be effective molecular targets, as they are frequently involved in cancer proliferation and metastasis. downregulation of these receptors and/or blocking their signaling pathways have clear anti-tumoral effects. drugs based on monoclonal antibodies (mab) targeting such cell surface receptors have attracted a lot of attention as a new generation of therapeutics. however, their production is costly and identifying new, variable routes to modified molecules with similar properties is currently a major focus. , here we present an approach to chemically synthesize a molecule that combines the mode of action of antibodies with the advantages of smaller, chemically accessible molecules. these "synthetic antibody" (sab) molecules contain a chemoattractant that activates the innate immune response and resembles the fc domain of a typical antibody. specificity is imparted by two binder peptides that assume the function of the variable antibody domains and bind to a cell surface target. the fc and fab domains of the sab molecules are connected via polyethylene glycol linkers. sab molecules are prepared by solid phase synthesis, a flexible technique that allows fast production, full control of their properties and targeting two different cell surface receptors (bispecific tumor targeting). they are currently tested in vitro and in vivo for their effect on the innate immune system, general toxicity and selective binding to cancer cells. the key enzyme in the processing of polyproteins translated by viral rna genome of sars-cov is a kda protease called c-like protease ( cl protease). sars cl protease is a cysteine protease containing a cys-his catalytic dyad, and cleaves precursor poly proteins at as many as conserved site involved a conserved gln at the p position and a small amino acid (ser, ala, or gly) at the p' position. due to its functional importance in the viral life cycle, sars cl protease is considered to be an attractive target for drug design against sars. recently, we found tetrapeptide aldehyde, ac-thr-val-cha-his-h, showed high inhibitory activity with ic value of nm toward cl-r i mutant protease , . to compare the inhibitory activity of small compounds with those containing active functional groups, we synthesized serine-derivatives within the essential functional groups and evaluated its inhibitory activity. the synthetic scheme was started from fmoc-ser(tbu)-oh, following modification of c-terminal carboxyl group with p , n-terminal amine with p and side chain alcohol with p functionalities. steps overall reaction led to obtain novel serine derivatives for the small molecular inhibitors of sars cl protease. the assay with cl r i mutant protease was examined to evaluate the inhibitory activity of the synthetic serine derivatives. then, molecular docking study of complex of cl protease with the ligand was carried out. docking simulation experiment with r i (pdb id: aw ) and the inhibitor, which has the best activity in the serine derivatives, indicated that p fitting s ' pocket. at the result of assay, p , p and p positions of the inhibitor should be modified by benzoyl group, cyclohexyl group and cinnamoyl group, respectively. their bioactivities are underpinned by their distinctive structure with exceptional stability, thus making cyclotides exciting, not only for agricultural and pharmaceutical purposes, but also as a template in drug design. in all of the reported activities, cell membranes seem to be the primary target for cyclotide activity. to unravel the importance of lipid membranes on the reported activities of cyclotides, a set of cyclotides belonging to möbius and bracelet subfamilies were compared in their mode of action. the lipid selectivity and membrane affinity were compared with their efficiency against different target cells (e.g. red blood cells, bacteria, hiv particles). we have found that the bioactivity of cyclotides is dependent on the lipid composition of the target cell membrane and independent of a protein chiral receptor. in particular, all the native cyclotides tested target the cell membrane through specific binding to phospholipids containing phosphatidylethanolamine (pe)headgroups, but the membrane binding affinity is further modulated thorough non-specific peptide-lipid hydrophobic interactions, which are dependent on the specific cyclotide. in addition, the bioefficiency of cyclotides broadly correlate with their ability to target and disrupt the cell membrane. overall, we have shown that even with a common specificity for membranes containing pe-phospholipids, a fine selection was found across the family. in particular, each cyclotide inserts and disturbs the membrane in a distinct way, which explains the diversity of this family but also their distinct activities. the observation that all the tested cyclotides have a preference for a specific lipid makes this family truly intriguing and brings insights to optimize the use of the cyclotide template in drug design. malaria is a disease that affects around million people causing . - million of deaths annually. based on our previous studies, angiotensin ii (aii) presented antiplasmodial activity against plasmodium gallinaceum, but due to pressure activity, it cannot be used as an antimalarial drug. in an attempt to increase antiplasmodial activity and reduce hypertensive activity, we synthesized by solid phase method, cyclic analogues of aii with i-(i+ ) and i-(i+ ) lactam bridge scaffold using asp and lys residues. the bridge was more effective when inserted next to n-terminal extremity , probably this insertion, on another portion of the peptide, provides a change in the conformation of the molecule and its hydrophobic cluster formed by tyr, ile and his , which may have influence in the peptide-membrane interaction. thus, we have focused in the n-terminal extremity, testing new analogues, using glu/asp/orn/lys residues as bridgeheads components in i-(i+ ) lactam bridge scaffolds, which showed that antiplasmodial activity is increased using glu residue and that larger lactam rings are better to biologically active. therefore, new restrict peptides by i-(i+ ) and i-(i+ ) lactam bridge were designed, using glu residue as bridgehead element, but the same effect was not verified, getting a maximum of % of bioactivity. on the other hand, we promoted an increase in the hydrophobic character of the molecule, replacing the asp residue of aii sequence by fmoc-glu and asp(ofm), in order to improve the interaction of these compounds in the sporozoite membrane. the replacement by fmoc-glu provided a decrease of activity, while that asp(ofm) kept the aii activity, because there are changes of charge in the peptide, which may have modified the conformation in physiological medium. this kind of approach may offer the basis for development of new drugs and chemotherapy against malaria. animal venoms are complex chemical cocktails, comprising a wide range of biologically active reticulated peptides that target with high selectivity and efficacy a variety of membrane receptors such as ion channels or g-protein coupled receptors. venoms can therefore be seen as large natural libraries of biologically active molecules that are continuously selected and highly refined by the evolution process. the vision associated with the venomics project is to investigate in depth the enormous structural and pharmacological diversity of venom peptides through the development, integration and implementation of a novel research paradigm combining cutting-edge "omics" technologies in a high-throughput workflow. this new paradigm enclosed in venomics aims at replicating in vitro the diversity of venoms to generate original peptide banks to be used in drug discovery programs. herein, we show the different strategies we adopted for efficient solid phase synthesis and folding with an easy purification of peptides rich in cysteine and containing posttranslational modifications (ptm). angiogenesis depends on the adhesive interactions of vascular cells. the adhesion receptor integrin av b was identified as a marker of angiogenic vascular tissue. the αν β integrin receptor plays an important role in human metastasis and tumor-induced angiogenesis, mainly by interacting with matrix proteins through recognition of an arg-gly-asp (rgd) motif. inhibition of the αν β integrins with a cyclic rgd peptide impairs angiogenesis, growth and metastasis of solid tumours in vivo. the aim of this study was to investigate the effects of replacement of a-amino acids by aza-β -amino acid analogs in cyclic rgd-peptides as αν β -integrin antagonist on angiogenesis, microcirculation, growth and metastasis formation of a solid tumour in vivo. the selectivity profile of these antiadhesive cyclopeptide is rationalized by a special presentation of the pharmacophoric groups. we synthesized cyclic rgd peptidomimetics that include aza-β -amino acid residues. modifications were added to the rgd skeleton in order to optimize the peptide activity. then, we investigated the pharmacokinetics activity of these pseudopeptides in hek (human embryonic kidney ) and endothelails cells huvec (human umbilical vein endothelial cells) cell by analyzing cell viability and protein involved in the angiogneisis processes. since tenascin c is a factor expressed highly in the tumorassociated matrix, targeting it would be a desirable first step for targeting the tumor-specific microenvironment in fact, a high level of tenascin c expression has been reported in most solid tumors, including lung cancer, colon cancer and glioblastoma. therefore, the targeted binding of tenascin c in tumor stroma would inhibit tumor metastasis by modulating cancer cell growth and migration. we isolated a peptide that bound to tenascin c by phage display peptide library selection, and the selected peptide specifically recognized tenascin c protein in xenograft mouse tissue. we also observed exclusive staining of tenascin c by the selected peptide in tumor patient tissues. moreover, the peptide reduced tenascin c-induced cell rounding and migration. we propose that the tenascin c targeting peptide may be useful as a specific anti-cancer diagnostic and therapeutic tool for most human solid tumors. radiolabeled pansomatostatins are expected to enhance hsst - tumor-uptake and to broaden clinical indications as compared to currently established sst -prefering radioligands. previous experience has revealed [ in-dota ,dtrp ]ss- ([ in]at s) as a true pansomatostatin analog, exhibiting however poor in vivo stability. in order to enhance metabolic stability, we introduced a second disulfide bridge to the at s motif by formation of extra / -amino acid (aa) or / -aa ring generating at s and at s, respectively. the orthogonally protected sequences were assembled on the solid support, deprotected and cleaved from the resin with tfa. the first cys -cys (at s) or cys -cys (at s) cyclization was performed in dmso, while the second was completed with iodine oxidation after in situ deprotection of cys (acm) and cys (acm). during hsst - +-autoradiography, at s showed unexpected total loss of sst - affinity, whereas at s showed high affinity (ic in nm) to all hsst - (hsst = . ± . ; hsst = . ± . ; hsst = . ± . ; hsst = . ± . ; and hsst = . ± . ). consistent with this finding, only at s stimulated sst internalization during immunofluorescence-based internalization assays, showing agonistic properties for sst . furthermore, [ in]at s internalized rapidly and specifically in sst + ar - j and hek -hsst +-cells. hplc analysis of min ex-vivo mouse blood samples revealed that > % [ in]at s remained intact. after injection in scid mice bearing ar - j and hek -hsst + tumors [ in]at s specifically localized in the rsst a+ ( . ± . %id/g vs. . ± . %id/g + nmol tate at h postinjection (pi)) and in hsst + implants ( . ± . %id/g vs. . ± . %id/g + nmol ke at h pi). this study has shown that introduction of an extra disulphide bridge in at s confers high metabolic stability. however, in a / member ring combination it leads to total loss of affinity. the reasons for this effect are currently investigated by nmr conformational studies. transporter compounds are useful tools to solubilise and increase the delivery of therapeutic molecules in the human body. one system to improve the cellular uptake of such therapeutic molecules are cell-penetrating peptides (cpps). these short peptide chains are either polycationic (containing several arg and lys) or show a more amphiphatic structure. it is known that the multivalency effect -the presentation of several copies of a cpp motif on a single molecule -can increase the cellular uptake. peptide dendrimers represent a group of tree-like, multivalent macromolecules, which are synthesized for different chemical and biological applications in our group. we now combine linear cpps with peptide dendrimers to get a well defined branched molecule made up of only natural amino acids. in our systematic study of peptide dendrimers decorated with different cpps we found that the potency of the single cpp as a transporter for small molecules can be increased and that these peptides show usually low cytotoxicity. additionally we designed new dendritic cell penetrating peptides with similar activities like linear cpps. all compounds are covalently linked to fluorescein for visualization with flow cytometry and confocal analysis. the results show that the peptides can transport efficiently a hydrophobic cargo into the cells. chemical stability of esters of acyclovir with amino acid and cholic acids k. chuchkov, r. chayov, i. g. stankova* south-west university "neofit rilski", blagoevgrad, bulgaria amino acid esters of antiviral drugs are a very good solution for improving oral bioavailability of the actual medicine. one of the most effective and tolerant prodrugs is valine ester of acyclovir -valaciclovir. taken orally exhibits three to four times higher bioavailability of acyclovir. the chemical stability of amino acids ( -fphenylalanine) (r,s) and bile acids (deoxycholic acid and chenodeoxycholic acid) esters of acyclovir was studied in experimental conditions simulating some relevant biological medias (ph . and . , °c).the chemical stability experiments revealed that the examined amino acid ester of acyclovir were relatively unstable in acidic ph, but bile acid ester is stable in the same ph. the examined amino acid and bile acid esters of acyclovir in neutral ph are relatively stable. in ph , all of tested compounds are more stable than valacyclovir (t / = h) -the first effective prodrug of acyclovir. in acidic ph acyclovirdeoxycholat and acyclovirchenodeoxycholat are more stable than valacyclovir. acyclovirchenodeoxycholat is the most promising anti-ebv prodrug candidate with high activity and satisfying chemical stability. cell-penetrating peptides (cpp) have become efficient tools for the cellular internalization of bioactive molecules due to their ability to cross the plasma membrane of diverse cells and cell lines. [ ] we recently reported that the cpp sc , which consists of the residues - of the c-terminal region of the cationic antimicrobial peptide cathelicidin (cap ), is an effective carrier peptide for small organic molecules like fluorophors and toxic peptide sequences into various cell lines [ ] . however, in general linear peptides are more susceptible to proteolytic degradation than their cyclic analogs [ ] . therefore, we investigated the cyclization of cpp derived from sc by means of cui-mediated azidealkyne cycloaddition (cuaac) [ ] . furthermore, we examined their conformation and proteolytic stability as well as their internalization efficiency and toxicity against various cell lines, in comparison to their linear equivalent and to other cpp. looking for the proper prodrug: a peptidomimetic approach to identify and inactivate bacterial mono-adp-ribosyltransferase toxins m. beich-frandsen, r. jørgensen division of microbiology and diagnostics, statens serum institute, copenhagen, denmark mono-adp-ribosylation is an endogenous posttranslational modification in eukaryotic cells, simultaneously utilized as virulence strategy by deadly secreted bacterial toxins. many bacterial toxins have been found to act as mono-adp-ribosylating enzymes, targeting anything from g-proteins to the actin skeleton. the diphtheria toxin from c. diphtheriae and exotoxin a from p. aeruginosa, both target the diphthamide-group of a unique modified histidine in eef , inhibiting protein synthesis by ribosome mimicry , . we aim to inactivate these nad+-utilizing toxin enzymes by nad-conjugated peptidomimetics, in a target-specific prodrug-approach. the adp-ribosylation reaction follows a random third-order s n mechanism. in the proposed model for the transition state of the reaction, the cleavage of the n c -nn bond of nad + releases strain and generates a oxacarbenium ion intermediate with a positively charged nicotinamide (n)ribose, subject to a nucleophilic attack from the substrate , , . adp-ribosylating toxins are commonly characterized by a artt-motif involved in substrate recognition . studies suggests conformational rearrangement of the residues surrounding the substrate binding site to be required for optimal geometry of the initial glycosidic nc -nn bond cleavage within nad + . subtype specific nad-conjugated peptides, designed based on previous structural analysis of the adpribosylation reaction, act as substrate for the enzymatic adp-ribosyl-transfer, and hereby attach covalently to and inactivate the nad + -utilizing toxin. relying on previous structural studies, and established ligand-binding and kinetic data, an initial peptide library, designed by bioinformatics and evaluated for specificity of common targets in-silico identifies initial leads. lead-scaffolds are implemented in rational peptide-design, based on high-resolution structural-and biophysical studies of multiple peptide-enzyme complexes, to identify possible prodrug-strategies for enzyme inactivation. nanoparticles play a crucial role in medicine for their potential application as in vivo carriers of active principles [ ] . liposome display unique pharmacokinetic properties slowly releasing drugs loaded in the inner aqueous cavity. in the last years we have developed supramolecular aggregates labeled by bioactive peptides able to recognize overexpressed receptors on tumour cells membrane delivering doxorubicin chemiotherapeutic drug [ ] . neurotensin(nt), a amino acid peptide, has dual functions of neurotransmitter or neuromodulator. the cterminus short fragment - preserve the activity but the half life of wild type form in vivo is very short. nt receptor type (nts ) is overexpressed in severe malignancies such as small cell lung cancer and colon, pancreatic, and prostate carcinomas. we have designed new amphiphilic molecules containing in the hydrophobic moiety two aliphatic chains and in the hydrophilic moiety a the bioactive portion able to aggregates with phospholipid molecules achieving liposome. we have synthesized neurotensin wild type sequence, the truncated form and the tetra-branched neurotensin(nt - ) or a truncated form(nt - ) tetrabranched peptides(nt ) adopting an opportune synthetic strategy on solid phase. all liposome were formulated adding the neurotensin amphiphilic monomer in ratio : with dopc in order to evaluate the capability to recognize selectively receptors overexpress on cell membrane surface. the liposomes size was determined by dynamic light scattering measurements, values for the hydrodynamic radius(rh). the selective internalization and cytotoxicity of fully doxorubicin loaded liposomes as compared to pure dopc liposomes, was tested in ht human colon adenocarcinoma and te human rhabdomyosarcoma cells. recently, small interfering rna (sirna), one kind of rna interference (rnai) technology represent the most common and, to date, the most effective method to inhibit target gene expression in human cells. it is also a common recognition that non-toxic delivery of sirna is an urgent problem for the therapeutic application of sirna. for the efficient gene silencing in vivo, prolonged circulation of sirna with take efficient and non-toxic cellular uptake and resistance against enzymatic degradation are indispensably required. ) telomerase activity has been regarded as a critical step in cellular immortalization and carcinogenesis and because of this, regulation of telomerase represents an attractive target for anti-tumor specific therapeutics. in this paper, we present the efficient and non-toxic cellular uptake of sirna using novel amphiphilic peptides and the application to silencing of htert in human cancer cell lines. in the present study, we investigated the intracellular delivery of sirna using some amphiphilic peptides and the silencing effect of sirna targeting htert mrna in human cancer cell lines, jurkat, hela and k . the complex of sirna and a specific amphiphilic peptide or its hybrid with an intracellular transport signal peptide could be effectively taken up into cells. the complex also showed a high silencing effect against htert mrna. moreover, the combination of sirna-nes conjugates and the amphiphilic peptides improved silencing effects up to . %. the amphiphilic peptides and their hybrids showed almost no cyto-toxicity and protected sirna against intracellular nuclease digestion in % fbs (half life time was over h). tumor targeting with the decapeptide gonadotropinreleasing hormone (gnrh) or its analogues is based on the discovery that gnrh receptors are overexpressed in many tumor cells, compared with their expression in normal tissues. using these peptides as carriers/targeting moieties in a conjugate with therapeutic agents can increase the selectivity and the stability of the conjugates, or eliminate the toxic side effects of the drug. gnrh-iii (<ehwshdwkpg-nh ) is especially favoured as a targeting moiety because of its antiproliferative effect and weak endocrine activity in mammals. the aim of our work was to synthesize novel short-chain fatty acid (scfa) acylated daunorubicin-gnrh-iii bioconjugates with enhanced enzymatic stability, cellular uptake, in vitro and in vivo antitumor activity. ser in position of gnrh-iii was replaced by lys and its ε-amino group was acylated with various fatty acids. gnrh-iii( lys(x), in conclusion, glu - /dglu - substitution in gi-derived radiopeptides enhanced stability and reduced renal values by ~ . fold. on the other hand, removal of the (glu) sequence in mg suppressed renal uptake but undermined stability. both modifications, however, compromised tumor targeting, demonstrating that more efficacious structural changes in the gi motif are warranted to improve the in vivo profile of resulting radioligands. synthesis and characterization of a mtc-labeled rhodamine-conjugated angiotensin peptide as a potential cardiac function imaging agent s.m. okarvi king faisal specialist hospital & research centre, cyclotron and radiopharmaceuticals department, riyadh , saudi arabia angiotensin ii (ang ii) is an -amino acid peptide that has been known to play a vital role in cardiovascular system. the actions of ang ii have been implicated in many cardiovascular conditions, such as coronary heart disease and heart failure. in an effort to develop a cardiac imaging agent with enhanced targeting capacity, we attached ang ii to rhodamine (rh), a lipophilic cation that specifically accumulates in the myocardium. the rh conjugated ang ii was evaluated for its potential as a heart imaging agent. rh-lys-gly-cys-asp-arg-val-tyr-ile-his-pro-phe-conh was prepared by solid-phase peptide synthesis according to fmoc/hbtu methodology. nhs-rh was attached to the ang ii peptide via the free amino group of lys residue by manual synthesis. rh-ang ii conjugate was labeled with tc- m by the stannous-tartrate exchange method. in vitro stability was determined in human plasma and in excess of cysteine. in vivo biodistribution and biokinetics were performed in balb/c mice and sprague dawley rats. the rh-ang ii conjugate radiolabeled efficiently with tc- m (> % labeling efficiency) as determined by hplc analysis. tc- m-rh-ang ii exhibited good chemical stability against cysteine transchelation and sufficient metabolic stability in human plasma. in mice, the bioconjugate displayed efficient clearance from the blood and excreted mainly through the renal route with some excretion by the hepatobiliary pathway. the uptake in the heart was . ± . % id/g as early as min post-injection; whereas, the uptake in the lungs, liver, stomach and kidneys varied between - % id/g. in rats, the bioconjugate displayed relatively better pharmacokinetic characteristics, with low uptake in the major organs (< % id/g). the uptake in the heart ( . ± . % id/g) was found to be higher than the uptake in the blood and muscle, resulting in good heart-to-blood and heart-to-muscle uptake ratios. this initial study towards the development of an effective cardiac imaging agent advocates that the use of hybrid conjugates appears to hold a great promise as a new and attractive approach for rapid and efficient imaging of heart. in humans two isoforms of gnrh are exist, gnrh-i (<ehwsyglrpg-nh , where <e is pyroglutamic acid) and gnrh-ii (<ehwshgwypg-nh ). in contrast to gnrh-i, exact function of gnrh-ii is not well identified. however, it was indicated that gnrh-ii derivatives have more potent antiproliferative activity on human endometrial and ovarian cancer cells in vitro than gnrh-i analogs. some kinds of tumor cells (e.g. breast, prostate, colon) produce gnrh-i and gnrh-ii, and express their receptors. however, the presence of functionally active gnrh-ii receptors on cancer cells is still not clear - . on the other hand, gnrh-ii analogs, both agonists and antagonists, induce apoptosis in many different cell types. in contrast to gnrh-i agonists, gnrh-ii agonist [d-lys ]gnrh-ii does not activate nfκb, therefore does not protect the cancer cells from apoptosis [ ] [ ] [ ] . in the regulation of apoptosis, not only the pro-and antiapoptotic proteins play a role , but other molecules also attend (e.g. ck , casein kinase ii enzyme) . our aim was to synthesize new proapoptotic peptide or enzyme inhibitor containing [d-lys ]gnrh-ii based derivatives and investigate their in vitro cytotoxic, cytostatic and apoptotic effects. the sythesis of [d-lys ]gnrh-ii, which is one of the most potent gnrh-ii agonist, was carried out on solid phase using fmoc/tbu strategy. different proapoptotic peptides or enzyme inhibitors were attached directly to the gnrh-ii derivative. in vitro cytostatic and cytotoxic effects of gnrh-ii conjugates were investigated by mtt-assay using different human breast (mcf- and t -d) and colon carcinoma (ht- ) cell cultures. early apoptotic effect of gnrh-ii conjugates was studied by flow cytometry on mcf- , t- d and ht- cell lines. according to our results, these conjugates might be potential candidates for cancer treatment, because the combination of a targeting moiety (gnrh derivative) with proapoptotic peptides or enzyme inhibitors and drug molecules might have synergistic activity resulting in highly potent multifunctional therapeutic agents. department of pharmaceutical and pharmacological sciences, university of padua, padua, italy melanoma is the most deadly skin cancer with an increasing incidence. its therapy continues to be a challenge since, regardless of the treatment used, longterm survival is quite uncommon. melanoma cells are characterized by high levels of glutathione s-transferase p - (gstp - ) isozyme. this enzyme is also highly expressed in solid tumours and drugresistant cells, where a role for this protein in the regulation of cell proliferation has been described. in the past, lyttle et al. synthesised glutathione (gsh)linked anticancer prodrugs activated by physiological concentration of gsts. structure and mechanistic studies showed that in the gst-gsh complex, the gst tyr residue placed near the s atom of the cys in gsh, is in the phenoxide form to facilitate the deprotonation of the sulfhydryl group in gsh, making it able to react with electrophilic species. by taking advantage of this active-site geometry, we synthesised two tyrosinase activated melanoma prodrugs ( -methoxyphenol and n-acetyl- -s-cysteaminylphenol) linked to gsh. in these compounds an ethoxycarbonyl group was placed between the gsh sulphur, oxidate to sulfone, and the tyrosinase-activated prodrugs. in this way the tyr phenoxide (tyr in gstp and tyr in gstm isozyme) would be able to abstract one of the acidic methylene protons linked to the sulfone moiety. such a deprotonation should trigger a beta-elimination, resulting in the release of melanoma prodrugs. the stability of the obtained putative prodrugs has been evaluated in different ph buffers and in rat liver and kidney cytosolic fractions. synthetic peptides represent first choice biomolecules, with respect to proteins and mab, for the monitoring of population variability and receptor functionality associated to a tumor pathology due to their favorable pharmacokinetic profile. it has been demonstrated that the surface molecule integrin alfa-v beta- could be an ideal target for the interaction with melanoma directed radiolabeled peptides. this integrin is indeed overexpressed both in tumor cells and in tumor vessels endothelium, while it is not expressed in the majority of normal tissues. cyclic peptides with the sequence arg-gly-asp (rgd), are known to bind the integrin alpha-v beta- with high affinity and selectivity and could conveniently target a radiotherapeutic to melanoma cells. we previously demonstrated that the cyclic rgdfk peptide interact with high affinity to a human melanoma cells. the aim of this work was to conjugate the mtc to the peptide by using the [ m tc(n)(pnp)] + system (pnp=aminodiphosphines) to obtain a radiolabeled peptide useful in melanoma imaging. , spectrum. a nh(i)→βch(i- ) cross peak more intense than the nh(i)→βch(i) cross peak is observed when the peptide adopts the . -helixl conformation. by contrast, an opposite trend of intensities of the same noe cross peaks indicates the occurrence of a -helical conformation. by using this method, we were also able to determine that polar solvents, such as mecn or meoh, may induce a helical structure in deg homo-peptides which otherwise adopt the . -helix conformation in cdcl . this finding allows us to rapidly switch these peptide series from "short" ( -helix) to "long" ( . -helix) by changing the solvent only, thus making them extremely attractive tools. school of biological sciences, university of auckland, auckland , new zealand naturally occurring anti-freeze proteins (afps) enable organisms like polar fish to survive the freezing temperatures of their natural habitat. as well as being cryoprotective, afps exhibit properties of ice recrystallization inhibition (ri). the ability of afps to influence the size, morphology and aggregation of ice crystals can be used in food technology, where the growth of ice crystals in frozen foods is of primary concern. chemical synthesis of afps enables access to pure material for structural and functional studies. our new research programme in the 'food and health' area, prompted us to develop tailor made anti-freeze peptides for potential applications in the frozen food industry. 'multiple salt-bridge analogues' of the naturally occurring winter flounder afp were synthesized and evaluated for their antifreeze activity in comparison to the natural sequence. details on the molecular modelling, structural characterization and anti-freeze activity analysis on the synthetic afps will be presented. several disorders are now believed to be conformational diseases caused by misfolding in the structure of specific proteins leading to the gradual aggregation and deposition of these abnormal proteins. attempts to develop effective therapies for these proteopathies (such as alzheimer's, parkinson's and huntington's disease) have been directed toward reducing the production of the proteins, inhibiting their aggregation, or promoting their removal. conformation-dependent antibodies that specifically target misfolded proteins are proving to be useful tools to study the pathogenesis and as possible treatments of these diseases. we have previously shown that active immunization with tetrapalmitoylated aβ - peptide embedded in liposomes (aci- ) was capable of eliciting a conformation-specific immune response in mice. the antigenic peptide was shown to mimic the aggregated β-sheet conformation of the pathological a β peptide on the surface of the liposomes by cd, ssnmr and tht assay. we have also reported the modulation of the conformation of aβ - derived sequences by means of different lipidation patterns, lipid chain lengths and liposome surface charge. here we present the characterization of this panel of liposomal peptide constructs by atr-ir and correlate the results with previous studies by cd. in summary, atr-ir secondary structure analysis of a battery of amyloid-derived lipopeptides allowed to study the key parameters responsible for the adopted conformation on the lipid bilayer. the presented strategy to control the conformation of liposomal peptide immunogens could be applied to the rational design of vaccines against a range of protein misfolding diseases, such as alzheimer's disease. cyclic lipodepsipeptides (clps) are secondary metabolites produced by various bacteria, most prominently bacillus and pseudomonas. these often display potential antimicrobial properties, frequently ascribed to the ability to disrupt cellular membranes or form ion-pores. clps are a structurally diverse group of molecules always consisting of an oligopeptide chain cyclized by a lacton bond and a fatty acid moiety. they are divided into several groups based on sequence similarity. one such group is the viscosin group, which contains clps produced by pseudomonas that all feature nine amino acids and a conserved sequence pattern of hydrophobic and hydrophilic residues. recently, we have extensively described the self-assembly properties of one viscosin group member, pseudodesmin a. , we have shown that in non-polar organic solvents this clp forms anisotropic supramolecular structures of unrestricted size, reminiscent of the ability to form ionpores in the non-polar cellular membrane environment. here, we report on how the most prominent structural variations within the viscosin group affect the conformation and self-assembly properties. since the well-defined monomer conformation of pseudodesmin a is key to this self-assembly, the most striking variation within the viscosin group is the variability of the leu stereochemistry. for the first time, a conformational study will be reported for clps featuring an l-leu residue, such as viscosin and viscosinamide. the results of this study contribute to a deeper understanding of the structure-function relationship of clps in general. effective design of peptide mimicking protein helical segments is a great challenge. an intriguing approach to improve the helical content in a peptide sequence is achieved through the "peptide stapling" strategy using a hydrocarbon cross-linker (staple) . in this study we have investigated the effect of the introduction and location of staples on secondary structure of sequences derived from a reported peptide, mimicking cullin binding region to kctd , , to gain an insight into the designing of new molecular entities able to modulate the kctd oncosuppressor activity. indeed, kctd plays a crucial role in the ubiquitination of hdac by acting, in complex with cullin , as an e ubiquitin ligase, thereby affecting hedgehog activity and medulloblastoma growth. in the designed peptides the stapling has been achieved by ring-closing olefin metathesis between two s- -( 'pentenyl) alanine residues incorporated at i and i+ positions and into different sites within the peptide chains. the stapling position has been chosen on the basis of cullin -kctd complex model. circular dichroism studies have highlighted that the stapled peptides exhibit remarkable and different changes in secondary structure contents in comparison with the linear precursors and the unmodified sequence. a nmr conformational analysis will allow the determination of the conformational preferences of the stapled peptides at atomic resolution with also relevant implications for the kctd-cullin recognition. based on our findings from protease-mediated ligation of cleavage-sensitive peptides and proteins using ionic liquids (ils) as additives and from chemical acylation reactions of peptides in ils, we hypothesized direct and unique interactions between biomolecules and ils as the molecular reason for il-mediated structural effects. to verify this, we performed systematic structural investigations of suc-ala-xaa-pro-phe-pna and ala-xaa-pro-phe model peptides dissolved in aqueous imidazolium-based ils using high resolution magic angle spinning (hr-mas) nmr spectroscopy. highly resolved nmr spectra are obtained that allow for complete h resonance assignments of the peptides as solutes and the ils as solvents. the changes in the proton chemical shifts Δδ( Η) of a peptide on dissolution in ils arise from direct interactions between both, including il-induced structural/conformational changes of the peptide molecules. , the strength, position, and type of these interactions are influenced by the nature of the amino acid residues in the peptide sequence as well as the nature and type of the il anions. downfield shifts indicate strong interactions between the ils and the peptide backbone, whereas upfield shifts point to hydrophobic interactions and stacking effects with the il imidazolium ring. the pattern of Δδ( Η) along the peptide chain reveals the sites and the type of interactions. the extent of Δδ( Η) implies a significant effect on the structure of the peptides. different Δδ( Η) were obtained for cis-and trans-configured peptide isomers and point to a conformer-specific il/peptide interaction. calcitonin is a -amino acid polypeptide hormone, which takes part in calcium metabolism in bones. it belongs to a protein family whose members may form amyloid fibrils. these fibrils (or pre-fibrillar aggregates) are related to serious diseases known as amyloidoses, whereas amyloid-like fibrils may have natural functional roles in many organisms. the amyloid form of human calcitonin is related to medullary thyroid carcinoma. using our online consensus prediction tool for 'amyloidogenic propensity' of protein molecules "amylpred", a novel hexapeptide of human calcitonin was predicted as a novel, possible amyloidogenic peptide. we investigated experimentally its ability to form amyloid fibrils, utilizing tem, x-ray fibre diffraction, atr ft-ir spectroscopy and polarized light microscopy. analysis of the results shows that this peptide self-assembles into amyloid-like fibrils and that amyloid fibrillogenesis is mediated via nuclei of liquid crystalline nature, known as spherulites. we thank the university of athens for the financial support. school of pharmacy, university of norwich nr tj ; inserm u , université de rouen, mont saint aignan rfa, a rfamide neuropeptide, is the ligand of gpr and the system rfa/gpr is involved in feeding behaviour [ ] . a structural study by nmr showed that rfa, in a membrane mimetic medium, possesses a helix p -r -linker k -g -turn f -r motif. sar studies on truncated fragments of rfa indicate that, in addition to the turn motif, additional residues are required to maintain a correct biological activity ( rfa ec = , nm; rfa - ec = , nm; rfa - ec = , nm; rfa - ec = nm) [ ] . our aim is to synthesize new gpr ligands using an iterative process combining rational conception, peptide and modified amino acid syntheses, biological and structural analyses. structural and biological results will allow us to find new modifications and conceive more potent analogues. using nmr, we demonstrated that rfa - encompasses a nascent helix and a turn while rfa - possesses only the c-terminal turn structuration. the destabilization of the helical structure on fragments with a shorter n-terminal region could explain the decrease of the biological activity of rfa fragments. we decided to focus on the importance of a stabilized helix on the biological activity. we chose the hydrogen bond surrogate method which stabilizes a helix by replacing the main hydrogen bond with a covalent link without modifying the side-chains [ ] . syntheses, nmr characterization and molecular modelling of analogues will be discussed. acknowledgments: this work is supported by erdf funding through the is:ce-chem project and interreg iv a france-(channel)-programme. firstly, it induces a constraint by restricting the ı o-dihedral angle to values around - °. secondly, the xaa-pro peptide bond is subject to cis-trans isomerization characterized by an increased cis population and an activation energy that is low when compared to the other amino acids. besides, the five-membered ring of the pro residue can adopt two main distinct conformations (up-puckered or downpuckered) that are almost equally abundant in peptides and proteins. a variety of mimics and analogs have been designed in order to control the conformation of the peptide backbone and/or to alter the cis/trans ratios and the rotational barriers for cis-trans isomerization. in this presentation, nmr studies and theoretical calculations have been performed on model peptides ac-ser(Ψpro)-nhme, (s,s)-ac-ser(Ψh, cf pro)-nhme, and (r,s)-ac-ser (Ψ cf ,hpro)-nhme. their thermodynamic and kinetic features have been analyzed in chloroform, dmso, and water, allowing a precise description of their conformational properties. we found that trifluoromethyl c δ -substitutions of oxazolidine-based pseudoprolines can strongly influence the cis-trans rotational barriers with only moderate effects on the cis/trans population ratio. in chcl , the configuration of the cf -c δ entirely controls the ψ-dihedral angle, allowing the stabilization of γ-turn like or ppi/ppii-like backbone conformations. moreover, in water and dmso, this c δ -configuration can be used to efficiently constrain the ring puckering without affecting the cis/trans population ratio. theoretical calculations have ascertained the electronic and geometric properties induced by the trifluoromethyl substituent and provided a rational understanding of the nmr observations. in contrast to formation of the native state, aggregation of misfolded protein molecules into so-called amyloid fibrils is a strongly irreversible, kinetically-controlled process which may lead to structural variants of fibrils composed of chemically-identical protein chains. this poorly understood aspect of polymorphism of amyloid fibrils has important implications in vivo in the course of amyloidassociated neurological disorders -e.g. in the form of prion strains in creutzfeldt-jakob disease. in this paper, we examine cross-seeding behavior of a model amyloidogenic polypeptide -bovine insulin (bov-ins) and recombinant lys b -arg b insulin (kr-ins). fibrils of bov-ins and kr-ins exhibit characteristic "fingerprint" features in the amide i' infrared region. these spectral traits are transferred to daughter generations of fibrils upon cross-seeding of native bov-ins with kr-ins fibrils and vice versa. this study highlights an interesting aspect of a non-anfinsenian behavior of aggregating insulin: the memory effect. our results indicate that fine infrared features in the amide i region of fibrils from closely related proteins may not reflect different amino acid composition but rather the fact that a particular amino acid sequence favors an amyloidogenic pathway that determines a certain and spectrally-distinct stacking mode of β-strands. an encounter with an alien seed on the amyloidgenic pathway would hijack the yetnative monomers and force them to follow the assembly pattern (and resulting ir characteristics) of the preformed fibril. phosphorylation and oglcnacylation are dynamic intracellular protein post-translational modifications that often are alternatively observed on the same protein serine and threonine residues. phosphorylation and oglcnacylation commonly occur on residues in natively disordered regions of proteins, and often have opposing functional effects. in the microtubule-associated protein tau, hyperphosphorylation is associated with protein misfolding and aggregation as the neurofibrillary tangles of alzheimer's disease, whereas oglcnacylation is stabilizing. a series of peptides derived from the prolinerich domain (residues - ) of tau was synthesized, with the free ser/thr hydroxyls, with phosphorylated ser/thr, with oglcnacylated ser/thr, and with the dietylphosphorylated ser/thr. phosphorylation and oglcnacylation were found by cd and nmr to have opposing structural effects, with phosphorylation favoring polyproline helix (ppii) formation, with oglcnacylation opposing ppii, and with the free hydroxyls intermediate. phosphorylation of serine and threonine residues in prolinerich sequences was found to induce ppii in other proline-rich sequences, with significant conformational restriction at phosphoserine and phosphothreonine residues observed by nmr. notably, serine and threonine residues are common in proline-rich domains of proteins, and ppii is a common conformation observed for phosphorylated ligands in protein-protein interactions. the ser/thr diethylphosphate was found to be a practical mimic of oglcnacylation, as an easily synthesized neutral amino acid with similar sterics to oglcnac and strongly opposing ppii. dept. of biology, university of padova, padova , italy we recently established that designed hairpin peptides interfere with the amyloidogenesis of both human pancreatic amylin and α-synuclein ( α-syn), two 'unstructured' polypeptides associated with human diseases. in the case of α-syn, the most potent 'amyloid inhibitors' act by diverting α-syn to non-amyloid aggregates. the binding sites for these agents and nonhairpin peptides of similar sequence have been determined by d-nmr-monitored titration studies using universally n-labeled α-syn. in the case of the hairpins that produce non-amyloid aggregates from α-syn, initial binding occurs in the non-amyloidogenic c-terminal segment of α-syn and the hairpin peptide is incorporated in the resulting aggregates. nmr studies also serve to define binding interactions and conformational changes that may be essential early steps in aggregation and pre-amyloid state processes. mt-ii is a long acting, non-selective super-agonist of melanocortin gpcr receptors, characterized by lactam bridge between residues i and i+ stabilizing a type-ii β turn structure. the recently introduced cui-catalyzed azide-alkyne , -dipolar cycloaddition, presents a promising opportunity to develop a new paradigm for an orthogonal bio-organic and intramolecular side chain-toside chain cyclization. we introduced this [ , , ]triazolyl-mediated cyclization in a pthrp model peptide, and demonstrated that i-to-i+ side chain-to-side chain cyclization offers a powerful approach for generating stable helix mimetic structures. , , in the current study we explored the potential of the i-to-i+ side chain-to-side chain , -disubstituted [ , , ] triazolyl-bridge to stabilize -turn conformations. we designed a series of [ , , ]-triazolyl containing cyclo-heptapeptides, derived from the model peptide lactam mt-ii, differing in the size of the bridge, the location and orientation of the [ , , ]-triazolyl moiety. conformational and biological studies, performed on this series demonstrate that [ , , ] triazolyl-mediated side chain-to-side chain cyclization results in the conformational stabilization of type-i β turn generating heterodetic cyclopeptides with enhanced in vitro potency and improved receptor subtype selectivity. this study confirms the versatile nature of the [ , , ] triazolyl-mediated side chainto-side chain cyclization. moreover the chemical accessibility, functional compatibility, and metabolic stability suggest that the [ , , ] international associated laboratory samuel de champlain, regional platform for cell imaging of haute-normandie (primacen), institute for medical research and innovation (irib), university of rouen, mont-saint-aignan, france scorpion toxins are polypeptidic molecules capable of selectivity binding to ion channels with the highest affinities and represent natural peptide blockers that are good tools to characterize new or particular types of ion channels. astroglial cells appear to express all ion channels species even voltage-gated ion channels previously suspected to be present only in excitable cells; but these channels are poorly studied and their function are not still completely elucidated.thus, the purpose of the present study was to investigate for the first time, the global effect and the potential protective effect of one scorpion toxin acting on kv channels, the pi ,on h o -induced oxidative stress and cell death in rat astrocytes. pi is a -residue toxin crosslinked by disulfide bridges, isolated from the venom of pandinus imperator and is one of the most potent and selective inhibitor of shaker b and kv . channels . in our study, pi was obtained by solid phase peptide chemical synthesis(spps) and named spi . the identity and homogeneity of spi were also verified by hplc, mass spectrometry analysis(maldi-tof) and an enzyme-based cleavage to determine the assignment of spi half-cystine pairings.the synthetic spi was found to be indistinguishable from the natural toxin. incubation of cultured astrocytes with graded concentrations of h o for h provoked a dose-dependent reduction of the number of living cells as evaluated by flow cytometric analysis and lactate dehydrogenase assay. interestingly, pre-treatment of astrocytes with very low concentrations of spi ( - to - m),dose-dependently prevented cell death induced by h o , and the effect of spi was accompanied by a marked attenuation of ros accumulation. also, spi stimulated sod and catalase antioxidant activities in a concentrationdependent manner,and blocked h o -evoked inhibition of sod and catalase activities. in addition, at low concentration ( - to - m) the toxin exhibits no toxic effect on astrocytes.taken together these data indicate that the spi acts as a protective agent on astrocytes from oxidative assault and then might have therapeutic value in the potential treatment of a number of neurodegenerative diseases. [ ] . in order to select small active peptides, the library was kept at the minimum size and was built using only selected d-amino acids to avoid structural redundancies. to further increase the chemical diversity [ ] a set of different carboxylic acids were coupled to the n-terminus. the iterative screening led to the identification of an n-terminally modified tetrapeptide with a very high radical-scavenging activity. by analyzing several peptide variants, we found that antioxidant properties were strongly sequence-and structure dependent, because scrambled or proline-scan variantswhose secondary structures are deeply altered -are much less effective. data on peptide structure-activity relationship will be presented. an investigation of the in vitro effects produced in cellular models of oxidative stress are also in progress. structural analysis of peptide-analogues of zp proteins with amyloidogenic properties: insights into mammalian zona pellucida formation. n.n. louros, v.a. iconomidou, s.j. hamodrakas* department of cell biology and biophysics, faculty of biology, university of athens, athens , greece a filamentous structure surrounding mammalian oocytes, called zona pellucida, is responsible for species-specific sperm binding. this extracellular porous structure is composed of - glycoproteins, termed zp - , which assemble into filamentous polymers that are cross-linked by disulfide bonds. all zp proteins present a unit with high sequence homology at their c-terminal end, designated as the zp domain. this structural module is found in a family of extracellular proteins with various functions and from a wide variety of organisms (zp domain proteins). it is a binary structure of approximately amino acids, divided into two domains, the n-terminal region named zp-n and the c-terminal region known as the zp-c domain. the zp-c block is associated with protein function, whereas the zp-n domain is responsible for protein polymerization. structural analysis revealed a possible polymerization model based on backbone interactions between specific parts of the zp-n units. peptide-analogues of the aforementioned segments were synthesized, since the ''amylpred'' application, an 'amyloidogenic determinant' prediction algorithm developed in our lab, predicted them as being potentially 'aggregation prone'. our experimental data clearly indicate that these peptides do actually fold and self-assemble into amyloid-like fibrils. therefore, all the derived data suggest that mammalian zona pellucida is a novel functional amyloid, similar to its biological equivalent, silkmoth chorion that has been established to be a natural, protective amyloid. we thank the university of athens for the financial support. biostrucutres and bioimmaging institute of national research council, naples, italy the definition of the molecular basis of human diseases is one of the most important goals of structural biology. nucleophosmin (nmp ) is an ubiquitously expressed protein is a nucleolar chaperon and has a key role in several biological processes from ribosome biogenesis, to cell-cycle regulation and is a frequently target of oncogenic mutations in acute myeloid leukaemia (aml) [ ] . these mutations occur predominantly at the c-terminal domain of npm compromising its stability and causing the aberrant translocation of npm to the cytosol. this domain is structurally characterized by the presence of three alpha helices, and the folding of cter-npm proceeds via an extended nucleus and the denatured state retains significant malleable structure at the interface between the second and third helices [ ] . here, we have further investigated the structural determinants in the folding process of the c-term npm domain and on the basis of available structural and composition data, several peptides covering the three helices were designed and synthesized. their conformational properties were investigated by cd and nmr spectroscopy: these studies demonstrated that once removed from the protein architecture helix and helix substantially miss fully ordered conformations while helix retain a high helical content also in mutated variants. our observations may help structure-based drug-design inserm u university of evry-val d'essonne, bâtiment maupertuis, evry, france sl (stop-like protein with mass of kda) is a neuronal protein with a calmodulin-binding and microtubulestabilizing activity. microtubule binding is inhibited by calmodulin , . the lack of the stops gives rise to defects in synaptic plasticity, as observed in schizophrenia . to study the sl protein's structure and its interaction with calmodulin, we have used a residue peptide derived from sl , containing the microtubule binding motif mn. the structure of the peptide has been analyzed using circular dichroism (cd) spectropolarimetry. the cd spectra showed that the peptide's secondary structure consists in a predominantly β-sheets, while the tertiary structure consists in rather folded d-structure. the temperature dependence of cd indicated that the secondary structure of the peptide remained very stable between °c and °c, while the tertiary structure changed at about °c. the interactions between the sl peptide and calmodulin have been studied using the isothermal titration calorimetry (itc). the results showed that calmodulin binds the peptide with the affinity of m- , in a ca + -independent manner, the reaction being driven by entropic contributions. our results might contribute to understanding the microtubule stabilizing activity of the sl protein. peptides , . based on the structure in polar environment a transition from -helical to an α-helical conformation at the water/lipid interface in bilayer membranes is hypothesized the efficient method development for the analysis of proteins, peptides, and synthetic oligonucleotides with a novel hybrid reversed phase column f. becker * , n. shoji * , a. matsui * , c. yokoyama * , t. sato * , t. takai * , and n. kuriyama * * ymc europe gmbh, * ymc co., ltd. the recent development of bio-pharmaceutical industry has been remarkable and an effective analytical method with higher sensitivity, superior selectivity, and increased speed has been required in the characterization of peptides, proteins and oligonucleotides by highperformance liquid chromatography (hplc). the method development of reversed phase hplc requires optimization of several conditions, such as bonded-phase, column efficiency, solvent type, ph and temperature. especially ph and buffer type is a most important parameter to control retention of biomolecules which have multiple ionic functional groups. furthermore, temperature often becomes a key tool to achieve better peak shapes and resolution for larger molecular-weight compounds. although silica based reversed phase columns have been widely used for separation of biomolecules, they have low stability under alkaline conditions and a limited usable ph range. to improve the chemical stability at an expanded ph and temperature range , we have developed a new type of organic/inorganic hybrid reversed phase column, ymc-triart c and ymc-triart c . the novel technologies of manufacturing particles and surface modification provide outstanding chemical stability and excellent peak shape for many types of compounds under a variety of mobile phase conditions. in this poster, we will show characteristics of this new hybrid column, and some example cases of efficient method development in separation of the biomolecules such as peptides, proteins and synthetic oligonucleotides. the fully-extended peptide conformation ( . -helix) is the longest possible for a single α-amino acid as it is characterized by an axial translation per residue of about . Å. therefore, it is extremely attractive for its application as a molecular bridge. however, it is known that the stability of this type of helical structure (relative to the competing, much shorter -helix) appears to be dramatically governed by the choice of the c-terminal functionality (only esters seem to be appropriate). in this work, we examined the series pyrac-(deg)n-o-(pno )bzl [where pyrac is the fluorophore -pyrenylacetyl, deg is cα,α-diethylglycine, n= - , and o-(pno )bzl is para-nitrobenzoxy] with the deg homo-peptides as fully-extended bridges in a static fluorescence study. to perform a very stringent comparison with our ft-ir absorption and nmr results, the solvent used was chcl . the trend observed in the quenching efficiencies for the shortest members of the series, the (deg) - peptides, steadily decreases from . (n= ) to . (n= ), and . (n= ). this finding is compatible with the conclusion that these three peptides are all essentially fully-extended in chcl solution. however, the quenching efficiencies for the longest deg homo-peptides. . for n= and . for n= , are not further reduced. the inevitable conclusion is that the tetra-and pentapeptides populate at least two different conformations (most probably, the . -helix and the helix), in which the probe dyads are located at different distances. notably, these results fit well with those extracted from our ft-ir absorption and nmr studies in the same solvent of low polarity. we conclude that a combination of terminally aromatic groups, as in the deg homo-peptide series investigated in this work, is not eligible for the fabrication of a stable fully-extended conformation. the surfactant protein c (sp-c) is a -residue highly hydrophobic peptide with two covalently linked fatty acyl chains that adopts a mainly helix structure while associated with the membrane. however, it misfolds into a β-rich structure under certain environmental conditions, which suggests that sp-c is in a metastable state . the slow α→β transitions are likely to be caused by the membranedissociation, deacylation and exposure to the neutral ph of the alveolar subphase, leading to the formation of amyloid aggregates associated with pulmonary alveolar proteinosis. we have been studying the ph-dependent conformational behaviour of both the acylated and deacylated isoforms of sp-c in a membrane mimetics chloroform/methanol/water mixture using a constant-ph molecular dynamics method [ ] [ ] [ ] . our simulations identify the increase of ph as a promoter of peptide-peptide interactions, which may contribute to the α→β transitions observed at neutral and alkaline ph conditions in the experimental results . we also observe that the loss of structure is more prone to begin at the c-terminal region and that the β motifs start to form between the n and cterminal disordered regions of the sp-c. in addition, the presence of the acyl groups results in a slightly higher structural stabilization of the sp-c helix and in a decrease of the n-terminal plasticity at acidic and neutral ph. since a comprehensive conformational analysis and the elucidation of the mode of association between sp-c and the membrane are essential to understand the interactions involved in structure stabilization and in some specific functions of the peptide, we are now studying both sp-c isoforms in a membrane environment. these studies will not only be the most relevant for the in vivo situation but will also answer to some questions left open by the previous work. were rather small. vp plays a very important role in controlling resorption of water by the distal tubules of the kidney and in regulating the osmotic pressure of blood in mammals. vt, while exhibiting both oxytocin and vasopressin activities, has not changed over the last million years until appearance of the mammals. currently, it occurs naturally in the non-mammal vertebrates [ ] . here we report on studies of arginine-vasopressin (cyfqncprg-nh , avp) and arginine-vasotocin ([ile ]avp, avt) in a mixed dodecylphosphocholine (dpc) and sodium dodecylsulfate (sds) micelles. dpc micelles are considered good models of eukaryotic cell membrane [ ] , while the sds micelle improves peptide/micelle solubility [ ] . for these studies we use d nuclear magnetic resonance (nmr) supported with molecular modelling methods. conformation-activity considerations relationships and the role of the peptide-micelle interactions on the structure of the analyzed peptides will be described and discussed. vibrational and chiroptical spectroscopic investigation on diamide peptide models k. knapp, a m. hollósi, a e. vass, a zs. majer a a eötvös lor nd university, institute of chemistry, laboratory for chiroptical structure analysis, budapest, hungary understanding of peptide folding has great importance in many fields of chemistry. since amino acid residues are the simplest building blocks of peptides, the investigation of their conformational properties could help us in understanding the structures of peptides or in designing peptides of specific d structure. describing the conformational building blocks of even the simplest peptide models (e.g., amino acid diamides) can serve as a good starting point to decipher higher-level structural properties of their polymers. among the simplest compounds which include the essential structural elements of polypeptide backbone are the n-methylamides of n'acetylamino acids. these compounds have been the subject of extensive spectroscopic analyses (ftir, vcd, ecd, nmr) [ , ] . the conformational landscape of these model compounds were analyzed by solution phase vcd and ecd spectroscopy and density functional theory (dft) computations. this work reports systematic vcd and ecd spectroscopic studies in different solvents on synthesized diamide models (ac-α/βhomo-xxx-nhch , xxx = ala, pro, phe). vcd and ecd data, combined with quantum chemical calculations performed at the b lyp/ - ++g** and - ++g** level of theory was particularly useful for identifying the preferred dipartimento delle scienze biologiche, università di napoli "federico ii", napoli, italy c dipartimento di scienze ambientali, seconda università di napoli, caserta, italy β-hairpin is an important secondary structural element used by many proteins for biomolecular recognition, and thus is an attractive tool for mimetic design . aβ -hairpin motif consists of two antiparallel strands linked by a turn region. in this work we aimed to stabilize a β-hairpin conformation by an interstrand covalent bridge, made through a click chemistry reaction, which yields , -disubstituted , , , triazole, starting from alkyne and azide reactive groups. in particular, we explored the conformational stability of a series of β-hairpin peptides containing a , -disubstituted , , triazole bridge with variable length. we employed the well structurally characterized trpzip peptide as a convenient b-hairpin model system. as alkyne amino acids were introduced propargylglycine (pra), homopropargylglycine (hpg) or bishomopropargylglycine (bpg), while the following azide amino acids were inserted: lβ-azidoalanine (dap (n )), l-γ-azidohomoalanine (dab (n )), and l-δ-azidoornitine (orn (n )). all peptides were synthesized and purified. successively, the linear unprotected peptides were cyclized in solution by the cu(i)-catalyzed azide alkyne cycloaddition (cuaac) reaction and purified prior to the spectroscopic characterization. linear and cyclic peptides were analyzed by a combination of cd and nmr techniques. have been investigated. their behaviour has been compared with that of proline in homochiral and heterochiral dipeptide sequences including l-or dphenylalanine. nmr and ir studies as well as x-ray diffraction analysis provide evidence that the additional β-phenyl substituent does not disrupt the tendency of proline to occupy the i+ position of a β-turn. moreover, the β-turn conformation is stabilised, with reference to l-pro, when l-cis(βph)pro or l-trans(βph)pro are combined with d-phe, that is, in the heterochiral sequences. the pyrrolidine conformation is significantly affected by the presence of the β-phenyl group. the puckering modes that alleviate most the steric hindrance introduced by the bulky phenyl substituent are preferred. the l-cis(βph)pro residue shows a marked propensity for the cγ-endo/cβexo half-chair arrangement whereas the trans derivative exhibits a higher flexibility, with different pyrrolidine shapes being accessible. interactions between the aromatic ring of (βph)pro and that of the contiguous l-or d-phe residue are observed in all the dipeptides crystallised. in solution, they seem to occur only for the heterochiral sequences. this intramolecular aromatic-aromatic interaction may be responsible for the higher β-turn ratio observed for such sequences and also seems to affect the conformational preferences of the pyrrolidine ring. in fmoc chemistry the trt and acm groups are widely accepted as a protecting group for cys. upon incorporation of these cys derivatives onto the growing peptide chain, however, considerable base-catalyzed racemization of cys is known to always occur at the activating and coupling steps with phosphonium or uronium reagents such as pybop or hbtu, respectively. in addition to this, racemization of the c-terminal cys esterified to resins also occurs during the repetitive n α -fmoc deprotection using piperidine. in order to find an s-protected cys derivative applicable for fmoc chemistry that can efficiently suppress racemization of cys both when its incorporation is conducted by phosphonium or uronium reagents and when it is linked to a resin via ester linkage, we introduced the methoxybenzyloxymethyl (mbom) group into the thiol function on cys. the mbom group was found to substantially supress racemization of cys ( . %) during its incorporation mediated by phosphonium or uronium reagents in comparison with the trt and acm groups ( . % and . %, respectively). even after a -h treatment of the peptide resin, in which its c-terminal cys was linked to a trt-type resin, with % piperidine in dmf, the mbom group caused a significant reduction in the level of racemization with the c-terminal cys ( . %) while trt and acm groups led to a considerable extent ( . % and . %, respectively). next, we demonstrated the usefulness of the mbom group on cys by applying it to ncl chemistry involving the coupling of a peptide thioester and a cys-peptide. in the synthesis of the latter peptide, however, a diastereoisomer with racemization of the nterminal cys tends to be difficult to separate from the intact peptide as its chain length increases. thus, this measure using fmoc-cys(mbom) can facilitate the avoidance of ambiguities in the quality of the synthesized peptides. labeled peptides are important tools in chemical biology to obtain information on their biological function in, for example, cellular communication processes as well as to study the molecular basis of diseases. the functionalization of bioactive peptides with biophysical reporter groups like strongly absorbing chromophores, is most often performed via post-synthetic chemoselective biocojugation reactions, involving amino, thiol, or azide specific reactions. an alternative approach for the installation intense chromophoric organic molecules, is the coupling of nonchromophoric precursor molecules to obtain chromophoric properties in the final product. recently, we have shown that the [ + ] cycloaddition-cycloreversion reaction between peptide-functionalized electron-rich alkynes and electrondeficient cyanovinyl derivatives results in the formation of a new class of π-conjugated peptidic donor-acceptor chromophores. , the chromophoric properties of the final product can be tuned by varying the p-electron conjugation pattern. herein, we describe the synthesis of the versatile building blocks, n-a-( -ethynylphenyl)-n-a-(methyl)-glycine and n-a-( -( , , -tricyanovinyl)benzoyl)-glycine, their subsequent application in spps to functionalize peptides with d-p-a chromophore precursor molecules, and their uvvis absorption characteristics. as a typical example, alkyne-functionalized aβ peptides, val-ala-ile and lys-leu-val-phe-phe-ala-glu, have been reacted with a series of cyanoolefins to obtain far-red intense imaging chromophores for amyloid-rich peptide aggregates. a novel method for regioselective disulfide formation in mini-proteins by kinetic oxidation control t. lindner, u. haberkorn, w. mier department of nuclear medicine, university hospital heidelberg, im neuenheimer feld , heidelberg, germany rigid frameworks are essential for the development of peptide-based alternatives to immunoglobulins. [ ] disulfideconstriction covalently stabilizes tertiary structures, which allows further miniaturization of protein-derived drugs by chemical synthesis. while the amino acid assembly steps in solid phase peptide synthesis are highly efficient, regioselective formation of multiple disulfide bonds is still a challenging and time demanding task. even after applying laboriously optimized folding conditions and extensive purification, a successful synthesis of the correctly folded isomer is not guaranteed. [ ] to circumvent these problems, a procedure that takes advantage of the different reactivity of free vs. acmprotected thiols during iodine oxidation was developed. this protocol to sequentially form two disulfide bridges in a one-pot reaction was applied to different peptides, such as (a) min , a mini-protein scaffold for phage-display assisted drug design; [ ] (b) α-conotoxin imi, a neurotoxic peptide isolated from the venom of marine cone snails; [ ] and (c) endothelin- , a peptide involved in blood pressure regulation. [ ] the presented technique tolerates precarious residues within the to-be-folded-peptide, such as fluorescent dyes or metal chelators as used for bioactivityassays. compared to the individually optimized literature procedures, this novel approach offers significant improvements: overall yields > % are obtained in first attempts and stepwise formation of the disulfide bridges is performed within a few hours instead of days. in recent thirty years, c-terminal modified peptides have been proved to have greater potential as apis (active pharmaceutical ingredients) due to their increased chemical and enzymatic stability and improved pharmacodynamic properties - . a prominent example, octreotide - , an octapeptidoalcohol, has witnessed as a potent anti-cancer agent targeted for gastro-entero carcinomas. in view of synthetic methodology, peptidoalcohol can not be directly prepared by standard spps protocol becouse of the c-terminal structure released from resin are not alcohol but always peptidoacid or peptidoamide. to overcome this problem, a novel protocol of shortened n- coupling cycles on merrifield resin and then the ammonolysis of peptedyl resin by an aminoalcohol as the c-terminal residue getting peptido-alcohol as targetting product has been devoloped in our lab. because of the cleavage treatment of peptidyl merrifield resin is not under acidic condition, such as hf or tfmsa, but ammonolysis, some side-chain producting groups(spg) related to boc chemistry like bzl, clz, tos…; must be avoided in sequence assembly. therefore a hybrid orthogonal protection (hop) of boc/fmoc protocol was adopted for the sake of producing naked peptidyl (without any spg) resin before ammonolysis. fifteen peptidoalcohols with different terminal alcohols were conveniently prepared, most of them released form resin with very good yields. due to its cyclic structure, proline is the coded amino acid with a more restricted conformational flexibility. the incorporation of additional groups into the pyrrolidine ring is a useful means to produce new amino acids that combine the conformational properties of proline with sidechain functionality. this is the case of β-phenylproline, (βph)pro, that can be regarded as a proline-phenylalanine hybrid in which the orientation of the aromatic substituent is dictated by the conformation of the five-membered ring and the cis or trans configuration of the phenyl group relative to the carbonyl moiety. accordingly, cis(βph)pro and trans(βph)pro combine the conformational properties of proline with an aromatic side-chain functionality that is rigidly oriented with respect to the peptide backbone, and this may be useful in the design of biologically active peptides and other applications relying on specificallyoriented side-chain moieties. we have developed synthetic procedures for the preparation of the cis(βph)pro and trans(βph)pro stereoisomers in enantiomerically pure form. the methodology is based on the preparation of racemic precursors of each amino acid and their subsequent hplc resolution on chiral columns. multigram quantities of the target amino acids have been isolated in optically pure form and suitably protected for use in peptide synthesis. the importance of peptide cyclization for studying peptide conformation, creating new structures, or for developing peptide therapeutics is well established. in particular, sidechain lactam bridges linking two amino acid residues that are several residues apart in the linear sequence or headto-tail backbone peptide cyclization enable rigidification of the structure and improvement of in vivo stability. native chemical ligation (ncl) is now an established method for producing backbone-cyclized peptides or proteins. the application of ncl to the synthesis of sidechain cyclized peptides is less frequent. head-to-side-chain cyclization by ligating a c-terminal thioester with a cys residue located on a lysine side-chain was used by few authors. the alternative tail-to-side-chain cyclization mode is rare, probably due to the difficulty of installing a thioester group on amino acid side-chains such as aspartic or glutamic acids the reaction of a bis( -sulfanylethyl)amido (sea on ) group with an n-terminal cysteine residue in water and at neutral ph results in the formation of a native peptide bond. [ ] oxidation of sea on results in a cyclic disulfide called sea off having a , , -dithiazepan- -carbonyl structure. [ ] sea off is a self-protected form of sea on . we show here that bis( -sulfanylethyl)amido side-chain acid(dab), ornithine and lysine were selected as building block; a and n,n'-cbz- -amidinopyrazole ( b) were selected as guanidinylating reagents for specific situation. for synthesis of n-terminus local cyclo-guanidine peptide, designated peptides were assembled on acid labile solid support such as rink amide resin by fmoc strategy. then either fmoc-dab(boc)-oh, fmoc-orn(boc)-oh or fmoc-lys(boc)-oh was incorporated respectively at n-terminus. fmoc was removed followed by guanidinylating by b and then peptide was cleaved by acid. by neutralizing with nmm in acetonitrile solution, side chain amino group and a-guanidine would form , or membered local cycloguanidine. the remaining cbz could be removed by hydrogenation. for synthesis of backbone side chain cyclic peptide, bis-fmoc-daa was introduced in the peptide previously on resin followed by removal of fmoc. selective guanidinylate side chain aminogroup by a followed by peptide assembling with an insertion of orthogonal protected daa at - aa apart from first daa. for synthesis of a-nh sidechain cyclic peptide, first daa should be introduced with orthogonal protected form. b was used to guanidinylate a-nh . after cleavage and neutralization of those two kinds of intermediates, guanidine-bridged marco-cyclic peptide was formed. the resin is also a multipurpose tool for the synthesis of carboxylic acids, esters and thioesters. when the synthesis is completed, the fully protected peptide hydrazide resin is oxidized with either n-bromosuccinimide (nbs) or copper(ii) acetate in pyridine. the resulting acyl diazene resin is then cleaved by peptide displacement at the c-terminus with amine. the fully deprotected peptide amide is finally obtained by treatment with trifluoroacetic acid (tfa). in our approach, we used a -fmoc-hydrazinobenzoyl am novagel resin to synthesize a peptide-substituted amide in the c-terminus. first, the oxidative cleavage was carried out with nbs in pyridine and a nucleophile [a protected (aminomethyl) benzimidamide (amba)]. however, the yield of the reaction was very poor. in the next step, we applied copper(ii) acetate in the presence of pyridine and amba. following optimization, the efficiency of the process was significantly improved. herein we discuss the conditions needed to obtain a reasonably high efficiency of the oxidative cleavage in the synthesis of our c-terminal modified peptides using the aryl hydrazine resin linker. blood vessels on tumor tissues, similarly to integrin receptors. this observation suggests cd as a selective target for targeted delivery of drugs and nanoparticles to tumor neovasculature using ngr peptides as homing motif. in our work, new cyclic-ngr peptides containing a thioether linkage were prepared. the influence of their structure on the speed of succinimide ring formation and deamidation was evaluated and compared with the previously published data on cyclic-ngr derivatives containing amide bond or disulfide bridge in the cycle (c[kngre]-nh and c[cngrc]-nh ). to avoid the deamidation under the conditions used for cyclization, the synthetic routes were optimized. the influence of the ph, ionic strength and temperature of the solution on their chemical stability was investigated. the structure of the cyclic peptides was investigated by circular dichroismand nmr-spectroscopy. receptor binding ability and the influence of the cyclic peptides on the cell adhesion and motility were also evaluated. this work was supported by grants from the hungarian national science fund (otka nk and k ) and the national innovation office (bio_surf, om- / ). clickable peptides and their attachment to oligonucleotides m. wenska, m. alvira, r. strömberg department of biosciences and nutrition, karolinska institutet, novum, se- huddinge methodology for the ready conversion of peptides into "clickable" azido-peptides with the possibility of selecting either n-terminus or c-terminus connection is presented. synthesis of peptide-oligonucleotide conjugates (poc's) include conjugates of oligonucleotides with peptides known to be membrane penetrating and nuclear localization signals. a general procedure, based on a new activated alkyne linker, for the preparation of poc's has been developed. with this linker, conjugation is effective at room temperature in mm concentration and submicromolar amounts. this is made possible since the use of a readily attachable activated triple bond linker speeds up the cu(i) catalyzed , -dipolar cycloaddition ("click" reaction). the main scheme for conjugate preparation involves sequential conjugation to oligonucleotides on solid support of i) an h-phosphonate based aminolinker ii) the triple bond donor p-(npropynoylamino)toluic acid (pata) and iii) azido-functionalized peptides. the method gives excellent conversion of oligonucleotide to the poc on solid support, and only involves a single purification step after complete assembly. the procedure which makes use of a low concentration of copper ions leads to a product with very little copper left (similar or less than in drinking water). the synthesis is flexible and can be carried out in non-specialist laboratories without the need for specific automated synthesizers since it has been designed to utilize commercially available oligonucleotide and peptide derivatives on solid support or in solution. comparison of alternative deprotection reagents to piperidine for the synthesis of a poly-alanine peptide on the tribute® peptide synthesizer m.a. onaiyekan,* j.p. cain, c.a. chantell, m. menakuru protein technologies, inc. tucson, az, usa in peptide synthesis, piperidine is a common agent for fmoc removal. however, piperidine is a controlled substance which requires special handling and cannot be used in some countries. therefore, it would be useful to identify alternative deprotection reagents to piperidine for fmoc removal. it is well known that poly-alanine sequences have a high propensity to aggregate after the fifth residue. in this application, (a) k-oh was synthesized using the tribute®'s intellisynth uvmonitoring and feedback system to compare the efficiency of fmoc removal by piperidine vs. three alternative bases (pyrrolidine, cyclohexylamine, and tertbutylamine) in the last cycles of the synthesis. it was found that pyrrolidine produced a higher purity product with fewer deprotection repeats and shorter deprotection times per cycle than piperidine, proving it to be a highly efficient, viable alternative to piperidine for fmoc removal. the endogenous tripeptide gpe also nammed "glypromate" is made up by the three n-terminal residues (glycine-proline-glutamate) of the insulin-like growth factor (igf ). this tripeptide is a partial glutamate antagonist and showed good results in different neuroprotective in vitro and in vivo experiments. , gpe also binds to glial cells regulating neurotransmitter levels in the brain. , however, gpe suffers from poor lipophilicity and a short half-life in vivo. that's why there is a need for more lipophilic and protease resistant analogues of gpe. in this poster we present the synthesis of trifluoromethylated analogues of gpe based on the or -cf -pseudoproline residues. introduction of fluorine atoms on bioactive compounds is known to deeply modify their physico and biochemical properties increasing lipophilicity and resistance to protease. thus, developing a trifluoromethylated analogues, we intend to increase the bioavailability of gpe, keeping the benefit of its neuroprotective properties. our research team is strongly involved in the synthesis of trifluoromethylated alpha-amino acids. recently we published the synthesis of -trifluoromethyl- , oxazolidines derived from fluoral and (l)-serine and we demonstrated that these five membered ring -cf pseudoprolines are hydrolytically stable and can be considered as proline analogues. that's the reasons why we are interested to replace the proline residue of gpe by those trifluoromethylated compounds. the development of original coupling conditions and the detailed synthesis of two pseudoprolines analogues of gpe will be presented in this poster. modifications. in combination with automated spps, unprecedented access to large peptides and small proteins for biological research has been achieved. we demonstrate the application of this methodology to the synthesis of a variety of peptides on the prelude® peptide synthesizer. exploring the space of fluorine-labeled α-amino acids for solid state f-nmr structure analysis of peptides: rational design, synthesis and applications p. solid state f-nmr is a powerful method to study membrane-active peptides, as it can reveal their conformation, orientation and dynamics when embedded in biomembranes. for this purpose the native peptide has to be selectively labeled with a suitable f-containing amino acid at several different positions. the resulting battery of singly f-labeled analogues is then analyzed by solid state f-nmr. the main limitation to this approach currently lies in the poor arsenal of available f-labels. we have therefore rationally designed and synthesized several specific amino acids bearing a cf -reporter group, which fulfil all strict criteria to a "proper" f-label. , to allow a geometry-based structure calculation, the cf group has to be rigidly attached to the peptide backbone. we thus rigidified the side chain using either a [ . . ]bicyclopentane moiety, a cyclobutane ring, or the intrinsic proline framework. this way, suitable cf -labeled analogues were created as substitutes for bulky hydrophobic amino acids (leu/ile/val/met), for aromatic residues (phe), for polar side chains (ser/thr), and for proline (pro). by now we have applied the developed f-labels for a comprehensive structure analysis of more than ten different membrane-active peptides (gramicidin s, pgla, mag , kigaki, sap, temporin a, bp , etc). recently, several new activators have been introduced into the market, and they were evaluated along with some older activators for their ability to synthesize a range of peptides with shorter and longer reaction times on the symphony® peptide synthesizer. it was found that hdmc, pyclock, comu, hctu, and hatu worked well at shorter reaction times ( x min), but pyoxim and tffh only worked well at longer reaction times. the performance of pybop at shorter reaction times was poor only for more difficult sequences. these results are important for selecting an appropriate activator for fast spps applications. the plant cyclotides form the largest family of cyclic peptides . they contain a signature motif referred to as the cyclic cystine knot, which is derived from the cyclic backbone and three inter-knotted disulfide bonds. intriguingly, cyclotides can be boiled, treated with chemicals or enzymes without disrupting their overall fold. thus, they are sometimes labeled as ultra-stable proteins. in addition, cyclotides are tolerant to mutations, and as a scaffold they can successfully accommodate foreign bioactive epitopes of variable sequences . cyclotides share many of these properties with another disulfide containing cyclic plant peptide, the sunflower trypsin inhibitor (sfti- ) . emerging evidence indicates that cyclotides and sfti- are valuable not only as peptide stabilizing scaffolds; in combination with their cell penetrating properties, these disulfide rich cyclic peptides have significance as intracellular drug carriers. although both peptides are genetically encoded, studies to ascertain the exact mechanisms of their biosynthesis are currently on going. thus, the synthesis of cyclotides and sfti- are currently restricted to chemical means. we have recently adapted a fmoc-spps method for cyclic peptide synthesis, via n-acylurea intermediates with the assistance of microwave irradiation. this method is a safe and convenient alternative to boc-spps and has the ability to be automated conveniently. using this method, parent scaffolds as well as several cyclotide and sfti- analogues with potential antimicrobial and matrix metalloprotease activities were synthesized. with the rising interest in the cyclization concept as a tool to impart stability on unstable peptides, the cyclic peptide synthesis method adapted herein is anticipated to have numerous applications. fixed configuration. the nonnatural oligomers have an extended conformational space and are supposed to adopt non-canonical secondary structures . in addition, the backbone modification makes these molecules more stable towards proteolytic degradation. the majority of proteins in nature are post-translationally modified, and the most abundant modification is the protein glycolysation, which introduces wide structural variety to proteins. glycoproteins have an important role in the biological recognition process, such as immunodifferentiation, cell adhesion, cell differenciation and regulation cell growth . new aza-β -amino acids bearing either an azide instead of amine on lys and orn chain or an alkyne group will be described and used in solid phase synthesis to finally performed a click chemistry to cyclize pseudopeptides or to introduced a glycosylated function . true for a series of peptides that display strong corticotropin releasing factor (crf) antagonistic activity. seminal studies by rivier et al. have shown that the incorporation of a lactam bridge in the crf-sequence resulted in an enormous increase in activity and potency, due to stabilization of the bioactive a-helical conformation of the peptide; and the newly designed peptide was called astressin. based on the astressin sequence, we started a truncation and deletion study to arrive at astressin analogs with a reduced size but still remain active as crf antagonists. this study resulted in the smallest active crf antagonist, astressin( - ). this sequence was further optimized by the introduction of novel covalent constraints, other than the well-known lactam bridge. as a first approach, the alkene/alkane bridge, which can be introduced via ring-closing metathesis via alkenesubstituted amino acid side chains, and as a second approach, the triazole bridge ('click' macrocyclization), via either a cu(i)-or a ru(ii)-catalyzed cycloaddition reaction between azide-and alkyne-derivatized amino acid residues were explored. herein, we will present the details of the synthesis of the alkene-, azide-, and alkyne-functionalized amino acids, their use in spps, and the optimized approaches for macrocyclization. furthermore, the peptides have been characterized by hplc, nmr, lcms, and studied by circular dichroism spectroscopy to obtain insight into the helical propensity of the peptides in relation to the cyclic constraint. the synthesis of a nitronyl nitroxide, c α -tetrasubstituted αamino acid (a class of sterically restricted amino acids that promote the formation of peptide β-turns and helical structures) was achieved by derivatisation of racemic amino- -cyano-indan- carboxylic acid [aic(cn)]. racemic boc-aic(nn)-oh was prepared by bis(alkylation) of ethyl isocyanoacetate under phase transfer conditions with , -(bis)bromomethyl benzonitrile as alkylating agent, followed by acidic hydrolysis, n α -boc protection, and saponification of the ester function. resolution was achieved through formation of the diastereomeric amides of (s)-phenylglycinol with chromatographic separation and mild acidic hydrolysis. reduction of the nitrile group to an aldehyde was carried out with raney nickel in the presence of sodium hypophosphite. condensation with , -diamino- , -dimethylbutane gave the corresponding tetramethylimidazolidine, which was oxidised with chloroperbenzoic acid to the desired nitronyl nitroxide. the uv-vis absorption and epr spectra of the amino acid were recorded and its magnetic properties were examined. in order to develop the synthesis of this peptide using the fmoc solid-phase peptide synthetic methodology, orthogonally protected β-hydroxyaspartic acid was needed. more precisely we wish to dispose of ( r, r)-n -fmoc- -tbdm-silyloxy-aspartic acid α -allyl ester instead of the recently reported dmab ester - indeed, in preliminary assay using this protective group we experienced difficulties during the final cyclisation step . the synthesis was developed starting from inexpensive l(+) dimethyltartrate and extended to the others stereoisomers of the β-hydroxyaspartic acid. structure. for that, we chose to replace proline by silaproline to afford polysilaproline. this study shows the comparison of two polyamino acids: polyproline and polysilaproline polymers. homopolypeptides were synthesized by polymerization of corresponding amino acid n-carboxyanhydride . multicomponent reactions (mcrs) represent a chemical process involving at least three reactants for the formation of several covalent bonds in one operation . by definition mcrs are chemo-and regioselective, convergent stepefficient procedures and take place with high atom economy. the copper(i)-catalyzed , -dipolar cycloaddition of organic azides and terminal alkynes (cuaac) reported by meldal and sharpless has been involved in various fields of chemistry and biochemistry research. however only few reports describe the implementation of cuaac and mcrs. , recently our research focused on a novel threecomponent reaction based on a cu(ii)-triggered aminolysis of peptide hydrazide resin and an azide-alkyne cycloaddition sequence. copper(ii)-induced oxidative aminolysis of hydrazides generates cu(i), catalyst of the azide-alkyne cycloaddition. this feature was exploited to design a solid phase detaching three-component reaction. the mcr process requires a peptide hydrazide resin, an amino azide linker and an alkyne, resulting in the formation of peptide modified at the c-terminus through an amino , , -triazole linker. this method can potentially be applied to the synthesis of a large variety of peptide derivatives starting from fmoc-spps assembled peptidyl resins. furthermore, it is not practical to compare hplc spectra from different resin samples (e.g., before and after reaction) directly. a comparison by analyzing the same (mg) amount of resin would involve tedious sample preparation that is extremely error-prone and would be impractical because factors resulting from the increase or decrease of the molecular weight of the resin-bound compounds may have a significant influence on the results. the use of internal reference compounds allows rapid assessment of reactions performed on solid supports. the internal reference compound is bound to the resin together with the substrate and cleaved with the products after completion of the reaction. commercially available compounds can be used for this purpose, or likewise, the reference compound can be generated from the substrate by partial capping of a functionality. the peak integration of the reference compound in the hplc-uv spectra can be correlated directly to those of the rest of the compounds present in the reaction mixture and therefore a quantitative interpretation of the spectra with respect to conversion and yield is possible. here we demonstrate the proof of principle as well as the accuracy of this method. modifier proteins such as ubiquitin are conjugated to protein substrates in cells and thereby mediate various biological processes. of high interest, is the ubiquitin fold modifer (ufm , residues) which has structural similarity to ubiquitin but has no sequence similarity. unlike ubiquitin, ufm has not been extensively studied and little is known about its biological role. to understand ufm 's biological functions, access to pure, homogeneous natural and modified ufm protein is essential. chemoselective ligation techniques are suitable for providing such proteins. recently, a variation of the α-ketoacid-hydroxylamine (kaha) ligation was developed, which utilizes the chemoselective reaction between a c-terminal peptide αketoacid and a n-terminal -oxaproline. this modified form of the kaha ligation furnishes a native peptide bond and a homoserine residue. this ligation is useful for the synthesis of proteins from two unprotected protein segments in aqueous buffers. for the synthesis of larger proteins, a sequential ligation strategy is necessary. using ufm as the model system we have developed a sequential ligation procedure using kaha ligation with -oxaproline. applying the new sequential ligation strategy we have prepared ufm by total chemical synthesis. we have also prepared a cterminal thioester surrogate of ufm protein, which is suitable for conjugation to proteins of interest. the syntheses required the development of a bifunctional peptide segment bearing an α-ketoacid and an orthogonally protected -oxaproline. the preparation of the protein segments, their intermediates, the deprotection, and sequential kaha ligations towards the syntheses of ufm protein and c-terminal modified thioester ufm protein will be discussed. affinity and biological activity, we have designed and synthesized new analogues by multiple n-methylation of hut-ii( - ) backbone amide bonds. all the peptides were performed by a novel synthetic approach, in which the introduction of n-methyl groups occur during regular solidphase peptide synthesis. on these new ligands we evaluated the binding affinity and biological activity at the ut receptor and performed preliminary nmr conformational studies. since that time a number of different machines have been used to automate peptide synthesis. modern machines are following two general setups; the so called "single approach" and the "parallel approach". in the single approach, the machine is developed to synthesize one or few peptides simultaneously. the user is able to optimize the synthesis conditions on each single peptide and each single coupling step. the maximum product quality regarding purity and yield is the major task of this approach. in the parallel approach, the machine is developed to synthesize a huge number of different peptides in the same single setup and time-frame. the user always has to find a synthesis protocol appropriate for the needs of each peptide to reach the maximum quality, knowing that there will be always a number of failed peptides. as a result you will find both types of peptide synthesizers in laboratories all over the world: the single machine, for the complicated peptides, and the parallel machine, allowing generation of multiple peptides with standardized protocols for each. the tetras is the first instrument combining the advantages of both machine types and allows the user to synthesize up to different peptides in parallel. each peptide can have its own individual synthesis protocols, separate of all others. the user can combine different synthesis scales, peptide lengths, and activator reagents in one run. finished peptides can be removed and new peptides can be started while the tetras is still running. the tetras allows the user to establish an uninterrupted production shop using one instrument only. siemion, i. z.; peptide res the peptides: analysis, synthesis and biology monitoring peptide folding in membrane-active peptides: a time-resolved spectroscopic study e. gatto a cordopatis p. st european peptide symposium sar studies of triazolyl-containing cyclopeptides: a defined -turn structure increases potency and selectivity to melanocortin receptor subtypes c. testa, a,b proc. natl. acad. sci proc. natl. acad. sci usa multicomponent reactions microglobulin: a "difficult" protein s. abel, m. beyermann the protein ß -microglobulin constitutes the noncovalently bound light chain of the major histocompatibility complex class i (mhc) and plays an essential role in the dialysisrelated amyloidosis. [ , ] to examine the amyloid fibrils of the ß -microglobulin (ß -m) via infrared spectroscopy we intended to synthesize -c-labeled ß -m. [ ] due to the two cysteine residues in positions and we used the native chemical ligation (ncl) strategy for assembling the -mer protein. this necessitates the synthesis of three segments which was accomplished on solid phase using the fmoc/t-bu chemistry. the preparation of the segments had to be optimized with respect to aggregation, aspartimide and piperidide formation, trifluoracetylation, and s-tert-butylsulfonium formation. additionally, ncl steps had to be optimized, because of "internal" thioester formation, dimerization and the formation of side-products of the activated n-terminal segment peptaderm inc., krakowskie przedmie cie str. , warsaw, poland immunosuppressors, such as cyclosporine a (csa) and tacrolimus®, are routinely used in prevention of graft rejection after organ transplantation and in therapy of some autoimmune diseases, including skin inflammation. a naturally occurring in linseed oil cyclolinopeptide a (cla, c(-pro-pro-phe-phe-leu-ile-ile-leu-val) possesses a strong immuno-suppressive activity, comparable at low doses with that of csa , but is much less toxic. we synthesized new cla analogs, containing instead of one proline residue its six-membered mimics, pipecolic acid (pip): c(-pip-pro-phe-phe-leu-ile-ile-leu-val) ( ) and c(-pro-pip-phe-phe-leu-ile-ile-leu-val) ( ). the incorporation of pipecolic acid residue led to different conformational behavior of the nonapeptide cycle. nmr experiments in cdcl solution showed that cla analogue with the pipecolic acid residue in position was much more flexible than cyclopeptide . the new peptides were devoid of toxicity up to μg/ml with regard to human peripheral blood mononuclear cells (pbmc), did not inhibit tumor necrosis factor alpha production in blood cell culture, but exhibited dosedependent, anti-proliferative actions for phytohemagglutinin a-activated pbmc. since peptide was more potent it was tested for growth inhibition of l- lymphatic leukemia. the peptide was found to strongly inhibit the cell growth even at low concentration ( % inhibition at μg/ml). hiv- has emerged as the largest and the most devastating public pandemic in our days, affecting approximately million people worldwide . development of an effective, safe and preventive hiv vaccine remains an urgently needed priority. epitopes for hiv-specific antibodies in elite controllers, a subgroup of long term non progressors, encompassing segments of mper of gp and for the v loop of gp were identified using the phage display technology . immunization experiments with epitopes conjugated to an artificial sequential oligopeptide carrier (soc ), formed by four repeats of the tripeptide lys-aib-gly in tandem, or to the palmitoyl group are currently in progress. all syntheses were performed on a rink amide resin following the fmoc technology. conjugation of epitopes to the soc carrier was realized via a chemoselective ligation approach, which generates an oxime bond between the h n-o-groups of the modified lysine residues and the aldehyde group of each epitope institute of immunology and experimental therapy, polish academy of sciences, - wrocław, poland peptaderm inc., krakowskie przedmieście , - warszawa, poland nonproteinogenic amino acids have been a tool to modify the structures of natural peptides since a long time . bioactive peptides involved in a physiological and biochemical processes cannot be applied in the therapy because of their instability in physiological conditions. that's why the synthesis of their stable active analogues is a challenge for medicinal chemistry nowadays. -trans-hydroxyproline (hyp) is an important building block of natural collagen. it is responsible for the stabilization of collagen super helix, forcing the trans amide bonds configuration with preceding amino acids . at the same time the impact of trans- -hydroxyproline on the conformation other than the collagen peptide chains of biologically important compounds is little known. it is known that immunosuppressive activity of cla is comparable with cyclosporine a and is associated with the presence of the tetrapeptide fragment pro-pro-phe-phe containing pro-pro cis amide bond. now we present synthesis, conformation and biological activity of new analogues of cyclolinopeptide a (cla), containing -transhydroxyproline instead of proline residues in position or . we expected that the introduction of the hydroxyl group in the pyrrolidine ring might influence the biological activity and conformation of the native peptide due to its hydrophilic character and hydrogen bonding ability. the linear precursors of modified cla analogues were prepared manually by standard solid-phase procedure "step by step" on wang resin using fmoc/tbu strategy and tbtu as coupling reagent. the cyclizations of linear peptides have been made under high dilution conditions by means of edc/hobt coupling reagents. the biological activity of newly synthesized compounds as well as the conformational study will be evaluated. dip. di scienze ambientali, seconda università di napoli, caserta, italy nmr spectroscopy is a powerful method to perform structural studies on peptides. to completely fulfill the potential of nmr, peptides labeled with stable isotopes ( n, c, h) are essential. peptides are easily prepared on solid-phase but chemical synthesis becomes prohibitively expensive when applied to the incorporation of isotopes. an alternative cost-effective strategy is the recombinant expression of peptides in e. coli as fusion constructs with carrier proteins. the main problem of this approach is the need of chemical reagents or proteases to cleave the target peptide from its fusion partner after purification. proteases may determine the heritage of extrasequence amino acids at the peptide n-or c-terminus, while chemical reagents require harsh reaction condition that may modify target peptides. an interesting solution is represented by the use of inteins as fusion partner. inteins are protein elements that can catalyze their self-excision from a flanking sequences in mild conditions, by adding nucleophilic agents such as thiols or simply by shift of ph and temperature, bypassing the use of proteases or chemical reagents. we used the self-cleaving mxegyra mini-intein as fusion partner for the preparation by recombinant means of two isotope labeled peptides, hplw and qk. , the two peptides target vascular endothelial growth factor receptor (vegfr) and have been described to modulate vegf-dependent angiogenesis. our expression and purification scheme allows to obtain homogeneously isotope labeled peptides. the availability of isotope labeled hplw and qk opens the way to nmr studies aimed to characterize the folding dynamics of the two peptides and their structures in complex with vegfr. an nmr method to discriminate between the fullyextended and different helical conformations in a spacer peptide c. peggion*, m. crisma, f. formaggio, c. toniolo icb, padova unit, cnr, department of chemistry, university of padova, padova, italy the ideal fully-extended, α-peptide conformation, also known as . -helix, is characterized by φ = ψ = ω = °t orsion angles. the repeating motif of this foldamer is a pentagonal (pseudo)cyclic structure (called c ), stabilized by an intraresidue h-bond. the n-h and c=o groups in the . -helix are not involved in intermolecular h-bonds. multiple c conformations were observed in homopeptides made up of c α,α -dialkylated glycines with both side chains longer than a methyl. this is the case for c α,αdiethylglycine (deg), the residue studied in this work. it is known that deg homo-peptides can adopt the . -helix or the -helix depending on environmental factors and nand/or c-terminal moieties. , in this communication, we introduce an nmr method to discriminate between the . -helix and the -helix based on the observation of cross-peak intensities in the noesy human serum amyloid a (saa) is a highly conserved apolipoprotein produced by the liver under inflammatory conditions accompanying e.g. atherosclerosis, cancer and amyloidosis [ ] . it is also known that saa α isoform has the amyloidogenic properties [ ] . till now it is little known about structure of human saa, as it hampers structural studies due to its facile aggregation. the analysis of protein sequence and cd data together with theoretical studies revealed a typical globular structure of the protein [ ] . the c-terminal sequence of saa contains three proline residues, which probably are responsible for the unordered structure. recent in vitro studies involving saa and human cystatin c (hcc) revealed direct interactions between the ( - ) fragment of saa and the ( - ) sequence of hcc. the results of elisa test for the ( - ) saa fragment have shown that it binds to hcc very well. the nmr studies for the wild ( - ) sequence found an unordered structure in phosphate buffer. based on these data we decided to check how the point mutations pro→ala in ( - ) saa fragment could influence the peptide's structures. we synthesized four peptides with pro→ala point mutations and we performed cd experiments at different conditions. the results show that two of them contain disordered structure and two α-helical structures. in this project we analyze the solution structures of these peptides at the atomic resolution using d nmr supported with molecular dynamics. design and conformational analysis of stapled peptides mimicking cullin binding region to kctd . i. de paola, a l. pirone, a e. pedone, a s. di gaetano, a l. vitagliano, a r. fattorusso, b g. malgieri, b l. zaccaro*, a acknowledgement: this study was supported by eu within the european regional development fund (poig. . . - - / - ). model of angiotensin ii bound to the at receptor in the lipid bilayer environment m.t. matsoukas, t. tselios* department of chemistry, university of patras, gr- , patras, greece the renin-angiotensin system () plays a major role in blood pressure regulation. a sequence of enzyme reactions leads to the release of angiotensin ii which interacts principally with the type- angiotensin ii receptor (at ), a -residue, which belongs to the g protein-coupled receptor family. in the present study, the human at d model was constructed using modeler for the sequence alignment and loop refinement tools. on this basis, the crystal structure of bovine rhodopsin, (pdb code u ), was used as a d template. the gromacs software and amber sb forcefield were utilized for molecular dynamics calculations [ ] in order to evaluate the binding mode of angiotensin ii. the role of the critical amino acids of the binding site v , n , l , a , k , s , h , n and y is being studied. moreover, newest information on the role of the nd extracellular loop by unal et. al. [ ] have been implemented on the model, therefore we propose the contribution mechanism of the residues f -q for binding of angiotensin ii to the at receptor for activation and signaling. a. stavrakoudis department of economics, university of ioannina, greece one key step in the immune response against infected or tumor cells is the recognition of the t-cell receptor (tcr) by class i major histocompatibility complexes. it has been found [ , ] that such peptide/mhc complexes can interact with antibodies as well. this happens mainly in the central part of the peptide in class i complexes [ ] , or at the cterminal of class ii complexes [ ] . in some cases, the same peptide/mhc complex has been found to interact with both tcr and antibodies [ ] . in these study a series of supermolecular complexes have been studied with stateof-art molecular dynamics simulations [ ] the dipeptide kyotorphin (tyr-arg, kyo) plays a role in pain modulation in the mammalian central nervous system (cns), and is one of the most investigated neuropeptides. the tyr-arg motif exists widely throughout the brain not only as kyotorphin, but also as the n-terminal part of several endogenous analgesic peptides , . also, this peptide is very rapidly degraded by aminopeptidases . one of the successful strategies in the design of neuropeptides with enhanced stability and improved delivery to the cns is that with the use of non-protein amino acids, like canavanive (cav), a structural analogue and antimetabolite of arginine (arg trichogin ga iv (noct-aib-gly-leu-aib-gly-gly-leu-aib-gly-ile-lol, in which noct is n-octanoyl and lol is leucinol) is an antimicrobial lipopeptaibol, a unique group of membraneactive compounds of fungal origin, characterized by a high content of the nonproteinogenic ca,a-disubstituted glycine aib (a-aminoisobutyric acid). owing to the gem-dimethyl substitution on the c a atom, aib exhibits a strong propensity to induce β-turns and /α-helical conformations in peptides. we have previously reported on a fluorescent analog of trichogin ga iv, the primary structure (and acronym) of which are: fmoc-aib-gly-leu-aib-gly-gly-leu-toac-gly-ile-leu-ome (f t ) where fmoc is fluorenyl- -methyloxycarbonyl, toac is , , , -tetramethylpiperidine- -oxyl- -amino- -carboxylic acid, and ome is methoxy. the double substitution of an energy donor (fmoc) at the n-terminus and an acceptor (toac) in the trichogin sequence enabled us to make use of time-resolved optical spectroscopies, spanning from the nanosecond to the microsecond time regime, to investigate the conformational propensity and the dynamical features of f t . experimental and computational results indicated that the d-structural and dynamical properties of f t are characterized by a transition from an elongated helix to a more compact conformation mimicking a helix-turn-helix motif. to further investigate the role of the flexible gly -gly central motif we synthesized a new trichogin analog having the gly residue substituted by aib: fmoc-aib-gly-leu-aib-gly-aib-leu-toac-gly-ile-leu-ome (f a t ) experimental and computational results indicated that also the f a t peptide populate two conformations, the dynamics of which were studied at different temperatures using time-resolved spectroscopic measurements. this replacement was demonstrated to stiffen the peptide backbone by reducing the flexibility around the crucial -gly -gly -dipeptide unit. the antigen α β , a member of the integrin family, is involved in the migration of lymphocytes through endothelium to the site of inflammation. thus, α β antagonists may be useful tools for the treatment of various inflammation disorders such as asthma and inflammatory arthritis. in addition, recent studies indicate that α β integrin promotes angiogenesis by allowing the invasion of myeloid cells into tumors, while α β antagonists prevent monocyte-induced angiogenesis, macrophage colonization of tumors and tumor angiogenesis. aiming to the discovery of novel α β antagonists, a series of new peptide analogues cyclized through cysteine disulphide bonds were synthesized and tested in vivo against angiogenesis in chicken embryo chorioallantoic membrane (cam model) . sar results indicated that: yr-c(cdpc)-conh promoted angiogenesis at the higher studied concentration and showed slight inhibition at the lower one, sal-r-c(cdpc)-oh, sal=salicylic acid, showed important inhibition of angiogenesis at dose-dependent manner, yr-c(cdpc)-oh and sal-yr-c(cdpc)-oh both showed no activity on angiogenesis. nmr spectroscopy was applied for the sequential assignment as well as for the elucidation of specific conformational features. experimental noe data were further imposed as distance constraints to a thorough conformational search by applying molecular dynamics simulations. energy refined produced conformers were used as template for the generation of the pharmacophore model associated with the antagonistic activity. such studies are intended to drive a rationalized design and development of this class of inhibitors. hynes r. o. cell, , , - . scaffold discovery by phylomers: a novel cd l specific scaffold derived from glycyl trna synthetase s.r. stone [ ] , k. hoffmann [ , ] , n. milech [ , ] , p. t. cunningham [ ] , m. kerfoot [ ] , s. winslow [ ] , y-f, tan [ ] , m. anastasas [ ] , c. hall [ ] , m. scobie [ ] , p.watt [ ] , and r. hopkins [ , ] [ ] drug discovery technology unit, telethon institute for child health research, roberts road, subicao, , western australia [ ] phylogica pty ltd, roberts road, subiaco, , western australia biopanning of phylomer phage display libraries against human cd l yielded a cluster of highly specific overlapping peptide fragments, from three bacterial genomes, corresponding to the highly conserved catalytic domain from the tetrameric gα β class of glycyl trna synthetases. structural analysis of the overlapping peptide fragments described a scaffold consisting of a central βsheet, comprising anti-parallel β-strands, flanked by nand c-terminal α-helices. further structural analysis revealed that these key structural features, which also encompass the crucial atp-binding motifs of the catalytic domain, are conformationally conserved across both tetrameric gα β and dimeric gα glycyl trna synthetases, yet importantly, there is only limited sequence conservation across these classes. given the identical function of the described domain and it's structural conservation, we postulated that members of the dimeric gα class would display similar cd l specific binding as the tetrameric gα β class, despite the sequence dissimilarity. to test this hypothesis, structurally equivalent peptide fragments of representative bacterial, archaeal and eukaryotic genomes comprising the dimeric gα class were tested for cd l binding in a process we termed ortholog scanning. the results showed that both archaeal (p. horikoshii) and eukaryotic (h. sapiens) structurally equivalent peptides bound to cd l with reasonable specificity and inhibited the cd :cd l interaction with comparable ic 's to the primary gα β class sequences. similar results were also observed for the representative bacterial gα class peptides. that the sequentially diverse orthologous peptides display cd l specific binding has important implications to the affinity enhancement strategies to develop the scaffold as a therapeutic agent, and in improving its "drug-like" properties. we have initiated an investigation related to the effect of radical species upon structures of some peptide segments. in the proposed experimental protocol, aqueous peptide solution was submitted to gamma ray irradiation in controlled - kgy doses. the generation of peptide analogues, possibly induced by reactive oxygen species were examined by electrospray triplequadrupole tandem mass spectrometry (collision induced dissociation approach) and amino acid analysis of crude and/or purified by-products. noteworthy, the gamma irradiation process induced, regardless of the peptide sequence, a non-linear and progressive degradation of all peptides assayed. furthermore, these peptides could be classified in some different classes according to their halflife dose. for instance, the vasoactives angiotensin ii (aii), ang ( - ), bradykinin (bk) and some related peptides were more stable than the melanocyte-stimulating hormone α-msh, substance p or the bk 's ( - ) b receptor fragment (lvyvivgkrfrkksrevyqai). usually, the most prominent derivatives generated from this experimental protocol revealed that they are likely induced by oxidation process, yielding a variation of + da in their molecular weight. the main source of peptide modifications seems to lie either on the phe (hydroxyl group insertion at o-, m-or p-positions of its aromatic side chain) or met oxydation. in the former case, only phe and not phe is oxidized in the bk structure whereas substance p generates an analogue bearing metsulfoxide without modifying its phe , residues. thus, collectively, these findings clearly stress the complexity of factors involved in peptide structural modifications induced by gamma ray-type strong electromagnetic irradiation experiment. an additional target of this approach lies indeed, in the production of unusual peptides for further structure-function investigations. university of bern, bern, switzerland linear peptides are typically poor drug candidates due to their low bioavailability and rapid proteolysis. these limitations can be overcome by rigidifying their structure through head-to-tail or side chain-involving cyclizations. cyclic constraints may also increase biological activity by stabilizing secondary structures and by reducing the entropic penalty of binding to a protein target. the use of multiple branching amino acids in a peptide sequence, like diamino acids (as used in peptide dendrimers ) or amino diacids, allows to design peptides resembling polycyclic alkanes, a type of topology only rarely found in nature (e.g. amatoxins and lantibiotics). bicyclic homodetic peptides such as "norbornapeptides" (bicyclo[ . . ]heptapeptides) were prepared using an orthogonal protection scheme: the first cyclization is performed on resin after selective deprotection of a glutamic acid residue, whereas the second ring closure is achieved by amide bond formation at high dilutions. these peptides are structurally well-defined and cover an almost pristine area of peptide topological space. their conformational rigidity was investigated by means of d-nmr and x-ray crystallography and may offer a platform to design drugs tackling protein-protein interactions. the interaction of peptide ligands with protein receptors face peculiar challenge in recognizing binding surfaces due to availability of a multitude of conformations. therefore it is essential to constrain the peptide conformations for the recognition of receptors and thus finding the bioactive conformation. the cell surface receptor protein family integrins recognize "rgd" sequence which is present in different proteins. to determine the bioactive conformation required to bind with receptor αiibβ , the peptide sequence "riprgdmp" from kistrin was inserted into cdr loop region of rei protein (rei-rgd ). it helps out in finding the possible bioactive conformation of peptide by restricting the sampling space. the activity of rei-rgd was studied and found that as the temperature increased rei-rgd showed a higher affinity towards the receptor αiibβ . the proposed mechanisms for the increased activity of rei-rgd at higher temperature were justified in either of two ways. the modified complex forces the restricted peptide to adopt a bioactive conformation or it unfolds the peptide in a way that opens its binding surface with high affinity for receptor. in this study we model the conformational preferences of "rgd" sequence in octapeptide "riprgdmp" at two different temperatures ( o c and o c) using multiple md simulations. we found that at higher temperature "rgd" sequence from "riprgdmp" adopt turn conformation, while a bend conformation was observed at low temperature. the analysis of various pharmacophoric parameters hint that the turn conformation of "rgd" sequences adopted at higher temperature could be the potential bio-active conformation, and helps out in designing of antagonists for cell surface receptor αiibβ . the -residue peptaibol antibiotic trichovirin i- a (tv) of the linear, covalent structure ac-aib-asn-leu-aib-pro-ala-val-aib-pro-aib-leu-aib-pro-leuol (ac, acetyl; aib, α-aminoisobutyric acid; leuol, l-leucinol) has been synthesized and very thin (~ μm) hair-like crystals were obtained from a methanolacetonitrile-water mixture. diffraction data were collected at k at the diamond light source england, using the microfocus beamline i and a x-ray beam focused to a size of μm full-width-half-maximum. two independent molecules (a) and (b) were located in the crystal's asymmetric unit . both chains assume complete turns of a curved right-handed helical conformation stabilized by intramolecular hydrogen bonds. up to now tv represents the longest right-handed -helix of a natural peptaibol sequence complementing those of synthetic, protected homooligo-aib- insulin is a protein hormone that plays a key role in regulation of blood glucose levels and, thus, has widespread impact on lipid and protein metabolism.insulin is known to act through binding to the insulin receptor (ir); however, the structure of the insulin-ir complex is not known. the crystal and nmr structures of insulin represent only inactive storage forms. it is widely acknowledged that insulin must undergo structural changes in the c-terminus of the b-chain upon binding to the ir. in addition, the n-terminus of the bchain may adopt two different conformations in hexamer, known as t-and r-states. the r-state of the n-terminus of the b-chain creates a long b -b central a-helix. the t-state of n-terminus is in an extended conformation. however, the biological relevance of the t/r forms remains elusive . in this study, we have focused on the synthesis of new insulin analogues modified at the nterminus of the b-chain and subsequently correlated their biological activities with their d-structures. the invariant residue glyb seems to be critical for the t/r transition. glycine can adopt wide range of dihedral angles (φ/ψ) and it occupies significantly diverse dihedral angles in t-and r-states. a-aminoisobutyric acid (aib) is an amino acid with a high helical propensity, which often folds into right-or left-handed α-helix. we have introduced aib at position b , b and b with the aim to induce the r-state of the hormone. in contrast, as d-pro and nmeala are not able to adopt the φ/ψ angles of the right-handed α-helix we have introduced these amino acids at position b to obtain the t-state of insulin. peptide dendrimers are tree-like molecules formed by alternating functional amino acids with branching diamino acids such as lysine. unfortunately these molecules have not yielded to structural characterization and little is known about their molecular-level structure. computational methods seem to be an adequate tool to address these issues.herein we present a comprehensive structural characterization of peptide dendrimers using molecular simulation methods. multiple long molecular dynamics (md) simulations were used to extensively sample the conformational preferences of several third-generation peptide dendrimers, including some known to bind aquacobalamine. we used several conformational analysis procedures (clustering, energy landscapes and multivariate analysis) to analyze conformational changes that can be correlated with particular structural trends.the results point to a high conformational flexibility of these molecules, with no clear "folded state", although two markedly distinct behaviours were identified. some dendrimers favour mainly loose conformations, while others prefer more compact configurations. through a series of computational mutations we investigated the influence of the presence and placement of charged residues in dendrimer topology, finding that electrostatic interactions among charged residues are a major determinant in structure acquisition by peptide dendrimers. these conclusions bring new insight into the conformational behaviour of these systems and may provide better routes for their functional design. acid-mediated prevention of aspartimide formation in solid phase peptide synthesis t. michels, a r. dölling, b u. haberkorn a , w. mier*, a a department of nuclear medicine, university hospital heidelberg, heidelberg, germany; b biosyntan gmbh, robert-rössle-straße , berlin, germany aspartimide formation is one of the major obstacles that impede the solid phase synthesis of large peptides and proteins. the main reason for aspartimide formation is the piperidine-catalyzed fmoc cleavage of peptides containing aspartic acid. several side chain protecting groups have been developed but the complete prevention of aspartimide formation can only be achieved using n-( hydroxy- -methoxybenzyl) (hmb) as backbone protecting group. however, hmb-protected building blocks are difficult to synthesize and only the dipeptide containing glycine (fmoc-asp(tbu)-(hmb)gly) is commercially available. until now, no cost effective strategy to suppress this side reaction has been developed. formally, aspartimide is the result of an attack of an amidate species at the carbonyl carbon of the otbu protected side chain carboxylate of aspartic acid, which might be prevented by protonation of the amidates with piperidinium ions. in this work the suppression of aspartimide formation by adding small amounts of organic acids to the deprotection agent piperidine was studied. this procedure was shown to efficiently prevent the formation of aspartimide side products in several peptides, i.e. pres - -y, a -mer peptide derived from the hbv surface antigen and a peptide parathyroid hormone (pth) fragment. the testing of a series of different acids covering a broad range of pka values showed that this effect is virtually independent of the acid strength. since aspartic acid is found in most oligopeptides, the authors recommend to generally add % (v/v) formic acid to piperidine based fmoc cleavage mixtures. decomposition of the resin linkers during tfa cleavage of peptides in fmoc-strategy leads to alkylation of sensitive amino acids . this side product formation is a crucial drawback, especially during the synthesis of biologically important cys-containing peptides on wang support. through a battery of approaches ( h-nmr, uv and lc/esi-ms) we detected an unexpected alkylation of the sulfhydryl group of cysteine side-chain residues by the phydroxyl benzyl group from the wang resin linker. herein, we present the feasibility for s-alkylation of cys-containing peptides from wang linker decomposition. this sidereaction occurs during the final tfa cleavage of the peptide from the solid support, while the position of the cysteine residue within the peptide sequence as well as the resin's substitution influence the extent of cys-alkylation. the stephan angeloff institute of microbiology, bulgarian academy of sciences, sofia, bulgaria influenza viruses cause epidemics and pandemics all over the world. therefore, the development of virus resistance to drugs, leads to search for novel derivatives and approaches to chemotherapy for human influenza infection. antioxidant therapy is known to be one potential approach. the application of combination therapy of antioxidants with antiviral drugs could reduce the complications and lethal effects, caused by an influenza virus . in our study, amino group of neuraminidase inhibitor -oseltamivir, which belong to second generation anti-flu drugs, was covalent conjugated with known antioxidantscysteine, histidine. tryptophan and etc. the study of the role of the modified by antioxidants oseltamivir on proliferation of influenza virus is in progress. recently we reported a short synthesis of or -membered cyclic guanidine via intramolecular reaction of alkyl diamine with n,n'-cbz-methylisothiourea( a). here we report a further application of synthesis two types of cyclo-peptide guanidine-bridged cyclopeptides utilizing this mechanism -n-terminus local cyclo-guanidine peptide and backbone guanidine-bridged marco-cyclic peptide. three n,n'protected diaminoacids (daa) including , -diaminobutyric p . antifreeze glycoproteins (afgps) are found in the deep sea teleost fish in arctic and antarctic oceans. these biomolecules are able to inhibit the growth of ice crystals and depress the freezing temperature of the blood serum in fish enough to keep them from freezing in their sub-zero environments while the melting temperature remains unchanged . despite afgps have been consider as a potent cryopreservation, obstacles to develop afgps as medicinal and industrial application are mainly due to the lack of access to pure form from natural sources and the problem of understanding how afgps inhibit ice crystal growth. as a result, a considerable progress toward the design and synthesis of afgp analogues has been made several groups . in the course of the studies on the structure-activity relationships of afgps, we are interested in peptoids as mimics of α-peptides and synthesized monoglycosylated peptoid analogues by substituting the glyco-thr residue as afgps mimics. in this presentation, we will show our studies on how the insertion of peptoid residue into afgp backbone affects the afgp activity by measuring both thermal hysteresis (th) and ice recrystalliztion inhibition (iri). [ ] , both for diagnosis and endoradiotherapy. for this application the peptides can be attached with chelating agents that bind radioactive metals such as ga, ga or in for imaging or therapeutic radiometals such as y and lu. the chelating agent most frequently applied is the macrocyclic ligand , , , -tetraazacyclododecane-n,n',n'',n'''-tetraacetate (dota), it is commonly introduced as the tris(tbu ester). the cleavage of the tbu protecting groups on dota is known to be sluggish [ ] . several attempts have been made to synthesize dota with protecting groups that can be removed under mild conditions. however, these derivatives have not yet found widespread application. our new approach was to prepare a protecting group for dota-based prochelators that is convergently cleaved under the cleavage conditions of the amino acid protecting groups of the peptide. o-phenylisopropyl (opp) esters are more sensitive towards acid than tbu esters. deprotection occurs with % trifluoroacetic acid in dichloromethane [ ] . therefore, a synthesis of the prochelator dota-tris(opp ester) was developed. the copper-catalyzed azide-alkyne cyclization (cuaac), the most commonly recognized variant of "click chemistry," has emerged as a powerful technique for ligation, conjugation, and cyclization reactions of peptides. it is known that cyclization can increase the metabolic stability of peptides, as well as enhancing potency or selectivity by stabilizing an active conformation. one application of the cuaac that has generated interest is the use of this reaction to replace a disulfide bridge with the product triazole, which among other complementary properties may prevent in vivo redox chemistry. in this poster, we synthesize a new analogue of the cyclic cancertargeting peptide cngrc where we replace the disulfide bond with a triazole linkage using click chemistry and a fully automated, on-resin method using the single-shot delivery feature on the prelude® peptide synthesizer. unnatural amino acids including d-amino acids are manufactured mainly by the enzymatic process. however, one enzyme can produce only one amino acid due to its high specificity and it takes a long time and a lot of expenses to develop the appropriate enzyme itself. arca (alanine racemase chiral analogue) is an organic catalyst which can overcome these drawbacks and can produce almost all kinds of amino acids efficiently. the amine functionality of l-threonine is freely reacted with the aldehyde group of arca to form the corresponding imine, which is easily epimerized in the presence of organic base due to the acidity of the alpha proton of imine. the difference in the stability between the imines of the optical epimers rendered them to be shifted to d-allo-threonine derivative dominantly. once the epimerization reaction reached equilibrium, the reaction mixture was hydrolyzed under acidic condition to give d-allo-threonine and arca, which could be recycled repeatedly without significant loss in yield or purity to produce more d-allo-threonine from lthreonine in excellent yields. optimization of the reaction conditions with various bases and solvents is discussed and mass production of optically active d-allo-threonine including optical purification is described. the manufacuring process for the preparation of arca will be shared as well. our group is interested in the development of efficient synthetic routes for the preparation of enantiopure atrifluoromethylated amino acids (a-tfm-aas) starting from chiral cf -oxazolidines or imines and their incorporation into a peptide chain. these non-natural amino acids are very attractive compounds for the design of biologically active molecules, particularly peptides, due to the unique physical, chemical and biological properties impart by the cf group. as conformationally constrained cyclic amino acids have recently gained considerable interest, we are particularly focused on the preparation of pyrrolidine-type a-tfm aas. , incorporation of proline derivatives is known to restrict the amino acyl-proline cis/trans isomerization, to limit the protein folding and consequently to modulate the biological activity of peptides. based on these observations, mutter's group introduced pseudoproline building blocks (ψpro) into a peptide sequence as reversible protecting groups for ser, thr and cys. the ψpro residues proved to be versatile tools for overcoming the aggregation caused by hydrophobic interactions encountered during solid-phase peptide synthesis (spps). they also turned out to be inducers of βturns containing predominantly cis-amide bond and useful tools in peptide cyclization. here, we report the results obtained for the preparation of various hydrolytically stable trifluoromethylated pseudoprolines (cf -ψpro) as well as the methodological studies developed to optimize the synthesis of various c-and n-terminal cf -ψpro containing dipeptides. rennes, france protein strructure and function rely on a still not fully understood interplay of energetic and entropic constraints defined by the permutation of the twenty genetically encoded amino acids. many attempts have been undertaken to design peptide-peptide interaction pairs and synthetic receptors de novo by using special building blocks. a rational approach starting from hydrazine to create new building blocks based on a tailored metalchelating amino acid analogues was envisaged. to create chemical recognition units, which bind oligohistidine tags with high affinity and stability, several supramolecular entities containing one to three nitrilotriacetic acid analogue (ynta) moieties were synthesized. these new building blocks additionally contained an amino group or an acido group, which can be flexibly introduced into peptide in n or c-termini or into the peptidic chain by solid phase chemistry in fmoc/t-bu strategy. these multivalent chelators were characterized and the corresponding metalchelating peptides could act as metal sensors and synthetic receptors for histidine-tagged proteins. the potential of peptides as drug candidates is often limited by their pharmacokinetic properties. structural modification of the peptide backbone via n-methylation is a powerful medicinal chemistry tool that confers oral bioavailability to these molecules. n-methylation exerts a strong effect on the backbone conformation and, as a result, many n-methylated peptides show enhanced biological activity and higher receptor selectivity. another approach to increase the solubility of peptides is by conjugation of peg to a derivatizable functionality. by combining these two approaches we have developed n-oegylation. this novel form of peptide modification consists of the attachment of oligoethylene glycol (oeg) chains to the amide bonds. many bioactive peptides comprise one or more n-me amino acids which are essential for their activity. thus, we consider that replacement of a backbone n-me group by an oeg chain may imply a minimal structural perturbation and may lead to n-oegylated peptides with preserved biological activity. furthermore, our strategy is a promising way to improve the bioavailability of cyclic peptides that do not have any site where a peg could be attached. as a proof of principle, several n-oeg analogs of two bioactive cyclic peptides were synthesized in spps. first, we performed a full n-oeg scan of the sansalvamide a peptide. next, several analogs of cilengitide were prepared by replacing the n-me of valine by oeg chains of different length. depending on its size, the oeg residue was incorporated by using an n-oeg derivative as building block or, alternatively, using an n-substituted amino acid bearing an attachment site where a peg was conjugated post-synthetically.the biological activity of all the n-oegylated peptides was evaluated. some of the sansalvamide a peptide analogs exhibited cytotoxicity within the same range as the original peptide, which suggests that backbone amide groups may be useful oegylation sites in bioactive cyclic peptides. the modification of peptides is an important step in pharmacology to vary the affinity and the stability of peptidic drugs. whereas a wide range of strategies exists for the functionalization of the n-terminus and the side chains, facile variation of the c-terminus remains an important challenge. we consider peptidyl-phosphoranes as a promising platform to enable orthogonal and mild introduction of a great variety of chemical functionalities at the c-terminus. a convenient method for the synthesis of soluble peptidyl-phosphoranes has been presented by our group recently. in this, -bromo-acetyl bromide was coupled to a wang-resin followed by alkylation of triaryl-or trialkyl phosphine moiety. deprotonation to the phosphorus ylide and subsequent acylation with an fmocamino acid created the basis for assembly of the peptide by spps. final acidic cleavage produced a decarboxylated and unprotected, soluble peptidyl-phosphorane. from this point, a variety of orthogonal modification reactions at the peptides c-terminus is possible, e.g. click reaction with azides allow for the incorporation of triazoles as peptide bond mimetics. the wittig reaction opens up another interesting portal for c-terminal modification, as vinyl ketones are formed by reaction with aldehydes. the described chemistry was applied to modify caspase- inhibitors. in order to address the s site of caspase- , the commonly known devd inhibitor was varied at the c-terminus by introduction of different residues. the devd motif was synthesized as peptidyl-phosphorane and modified in wittig reactions. the resulting c-terminal vinyl ketones were obtained by the reaction of aliphatic and aromatic aldehydes. a small library was generated, and novel compounds were tested for their potential to inhibit caspase- . semmelweis university, department of biophysics and radiation biology, budapest, hungary considering the impact of uv irradiation on the structure and function of proteins , it is a matter of utmost importance to resolve the conditions of photolysis more deeply. we think that a protein, as a complex unit, gives multiple responses to all impacts therefore the analysis of these responses is a rather complex problem. the main goal of our research is the deeper understanding the tryptophan-mediated photolysis of disulphide bridges in bio-active proteins upon near-uv irradiation using cyclic peptide models, as small protein units, to define the caused functional damage. cation -pi interaction is increasingly recognised as an important noncovalent binding interaction which plays a role in establishing the final structures of proteins. within a protein, cation -pi interactions can occur between the cationic side-chains of either lys or arg and the aromatic side-chains of phe, tyr or trp . our earlier results with gla indicate that new covalent bonds are also formed between cys and lys during illumination, which is also a reason why the lys residue is planned to be included in the sequence of the models. our aim is to study whether the cation -pi interaction can have an influence on the ss-bridge splitting in small cyclic pentapeptide models. here we report about the conformational analysis, synthesis and spectroscopic investigation of lys-and arg-containing model peptides. the azide functionality is very popular mainly due to azidealkyne click chemistry used in many peptide ligation strategies. azido-peptides are usually prepared by incorporation of azide containing residues or azide functionalization of aldehyde resins affording c-terminal azido-peptides. alternatively, the n-terminus can be converted into an azide via a cu(ii)-catalyzed diazotransfer reaction using triflyl azide. recently, a number of safer, shelf-stable and easily prepared diazotransfer reagents has been developed, of which imidazole- -sulfonyl azide has been used to introduce azide moieties in proteins under copper-free conditions. typically, it has not been reported to be used on the solid phase. we provide a very easy, fast and efficient method for conversion of amines into azides on a solid phase support which in our opinion has major benefits over earlier reported methods making using of less stable reagents that require a metal ion catalyst. we demonstrate how the diazotransfer reaction can be performed on a solid phase support using the imidazole- sulfonyl azide reagent without the need for a metal ion catalyst. using a model peptide we studied the effect of stoichiometry, added base and solvent. in addition we examined the effect of the nature of the n-terminal residue on the efficiency the diazotransfer reaction. finally, we found that the optimal conditions to perform the reaction also depend on the nature of the solid phase support the reaction is performed on. the novo nordisk foundation center for protein research, university of copenhagen, copenhagen, denmark site-selective strategies for post-translational modification of peptides and proteins are essential tools for many areas of research in the life sciences, yet remain a chemical challenge due to the multiplicity of functional groups present. there are powerful chemoselective reactions, however, they aim at introducing only one functionality at each reaction site. here we present a one-pot, threecomponent dual-functionalization of peptides or proteins based on a , -dipolar cycloaddition between a functionalized malemide, an n-hydroxylamine and a peptide or protein with an n-terminal serine residue at the n-terminus, which is selectively oxidized to a -oxoaldehyde. most common moieties for labeling, e.g. fluorophors and peg-chains, are commercially available as maleimides. nitrones were easily obtained by condensation of peptide-aldehydes and primary nhydroxylamines under aqueous conditions. the chemoselective , -dipolar cycloaddition reaction between the peptide-nitrone, and a functionalized maleimide proceeded in aqueous solution at room temperature or with gentle heating, which provided the stable isoxazolidine product. we envision that this 'one site -two functions' method can be used widely to introduce two separate moieties. the method was used to introduce two separate ligands in a range of other peptides. for example, new multimodal molecular imaging techniques depend on facile chemical methods for site-selective dual-functionalization. we used our new methodology to synthesize a cyclic rgd-peptide for combined pet and optical molecular imaging. finally, the small protein ipb was successfully n-terminally modified, including with a peg-chain, using this new, general method. multiple sclerosis (ms) is the most known chronic, inflammatory, demyelinating disease of the central nervous system (cns), characterized by a progressive neurodegeneration, caused by an autoimmune response to self-antigens in genetically susceptible individuals. it is nowadays known that post-translational modifications may affect the immunogenicity of self-protein antigens, triggering an autoimmune response and creating neoantigens; in particular aberrant glycosylations affect various parts of the immune response and have profound effects on immune tolerance. in previous studies we demonstrated the value of the glycopeptide csf (glc) which, by virtue of the particular type i' β-turn structure, optimally exposes the minimal epitope asn(glc) to autoantibody recognizing in elisa in multiple sclerosis patients' sera . elisa assays allowed to conclude that the ability in detecting autoantibodies in multiple sclerosis sera was stricktly linked to saccharidic moieties and to conformation around minimal epitope of the antigenic glycopeptide. herein, taking advantage of such considerations, we focused our attention on the synthesis of a little library of lysine branched multiple antigen peptides (maps), containing the minimal epitope asn(glc), in an attempt to increase the antigenicity of linear peptide sequences . with this aim, we performed the spps of glucosylated maps via the building block approach, studying the role of different long spacers on the dendrimeric core, and the role of different peptide sequences around the sugar moiety, in order to optimize the synthetic process and to evaluate the influence on the affinity and specificity in sp-elisa. environmentally induced co-or post-translational modifications of autoantigens are hypothesized to break immune tolerance leading to self reactivity in pbc. it has been previously reported that the use of synthetic post-translationally modified peptides, introducing fmoc-l-lys(nε-(±)-α-lipoic acid)-oh, as peptidomimetics of natural neoantigens allowed to detect autoantibodies in the sera of patients affected by pbc, and they might be useful diagnostic tools that can be used in earlier stage patients and possibly to monitor disease activity. only the r-(+)-enantiomer of α-lipoic acid exists in nature and is an essential cofactor of four mitochondrial enzyme complexes. but it remains unclear if the tridimensional structure of the lipoic acid is of any importance in the interactions antibody-peptide during the indirect elisa tests. therefore, it is necessary to synthesize each peptide separately with one absolute configuration of the lipoic acid. herein, we describe the synthesis of the two diastereoisomers fmoc-l-lys(nε -(r)-α -lipoic acid)-oh and fmoc-l-lys(nε -(s)-α-lipoic acid)-oh that have to be used in fmoc/tbu spps as building blocks for the synthesis of post-translationally modified peptides. recently it has been reported the introduction of a new generation of cd diagnostics based on a unique antigen approach, consisting on human ttg cross-linked with gliadin peptides coated on the elisa plates . on the basis of experimental data obtained by mass spectrometry and indicating which are the fragments of these two proteins that are supposed to be involved in the antibody recognition, we were able to select the most representative ttg and gliadin fragments , to design and synthesize by fmoc-spps nine cross-linked eoepitopes. aim of our study was the characterization of autoantigenic epitopes by testing, in celiac patients' sera, the reactivity of these nine synthetic peptides. these neoepitopes were tested in elisa to evaluate the iga and igg response against ttg-gliadin adducts in celiac patients' sera in order to develop a new elisa test based on peptides as an even more powerful diagnostic tool in terms of specificity and sensitivity. more than analogs have already been described, wherein the hydroxy acid and the amino acid constituents were replaced by d-amino acids and/or n-methyl amino acids with preserved or altered side chains. for certain types of cancer cells, several of these analogs were found to be more active than the natural product itself. however, it does appear that many of these compounds have limited solubility in water. b here we report the synthesis of novel analogs of the sansalvamide a peptide bearing an n-oligoethyleneglycyl (oeg) chain attached to the different backbone positions. attachment of this chain is aimed to enhance the hydrophilicity of the original peptide. our synthetic strategy to modify the backbone with the n-oeg group relies on the use of n-oeg amino acids, which were synthesized in solution and then used as building blocks in spps. as expected, couplings to the n-oeg residues were found to require special conditions. methods for the coupling to nmethyl amino acids were applied and this enabled to obtain the different linear pentapeptides, which were cyclized in solution. both the synthetic strategies of these demanding peptides as well as the preliminar evaluation of their biological activity will be deeply discussed. glycoconjugates such as glycoproteins and glycolipids have important roles in cell functions, for example, intercellular recognition, cell proliferation control, and information transmission. in order to study the structurefunction relationship, synthesis of these glycoconjugates is essential. glycoproteins and glycopeptides are classified into two categories: n-and o-glycosylated derivatives. the n-acetyl-α-d-galactopyranosylated ser or thr derivatives [ser/thr(α-d-galnac)] are important intermediates for o-glycopeptide synthesis. however, the synthesis of ser/thr(α-d-galnac) derivatives by chemical glycosylation is difficult because of the decreased nucleophilicity of hydroxy function in the glycosyl acceptor due to an unfavorable hydrogen-bonding pattern between the oh and α-nh groups . several approaches to overcome this problem have been reported , . in addition, the o-glycosidic bond is cleaved easily in acidic conditions. in this study, we assumed that the formation of a cyclic structure containing an α-nh group would increase the reactivity of oh function. thus, we focused on the n, n'isopropylidene derivatives of ser/thr containing dipeptides . we found the reaction of mannopyranosyl trichloroacetimidate and the n, n'-isopropylidene dipeptide in the presence of tmsotf in dichloromethane produced the desired glycosylated dipeptide in good yield. however the selective intermolecular disulfide bond formation is a very difficult and complicated synthetic problem. in this work we report on synthetic approaches for the formation of conjugates with intermolecular thioether or disulfide bonds. for the disulfide bond formation, we use two activation approaches: i) activation of the four cys residues of the carrier testing two activating reagents, in both solid and liquid phase respectively and ii) activation of the cys containing bioactive molecule. as bioactive molecule we selected the r ppleed sequence derived from the intracellular part of the αiibplatelet integrin receptor. this region is critically involved in platelet aggregation and is a target of intervention for developing antithrombotic agents . the ac-[lys-aib-cys(ch co-αiib - )] -nh and ac-[lys-aib-cys(cys-αiib - )] -nh conjugates were synthesized and examined for their ability to inhibit platelet aggregation. the biological assays indicated that the synthesized conjugates penetrate the platelet membrane and inhibit human platelet aggregation, in contrast to the corresponding free peptide analogues. the molecules were reported to exhibit broad-spectrum cytotoxicity against the tumor cell lines. although these peptides contained the novel β-methoxytyrosine, lipton et al. reported the synthesis and cytotoxicity of desmethoxycallipeltin b, in which substitution of d-tyrosine for β-methoxytyrosine did not substantially affect the cytotoxicity of callipeltin b , . however, a structure-activity relationship study of the molecules has not been shown to date in detail. in the course of our recent research regarding the synthetic study of cyclic depsipeptides, we conducted studies on the synthesis of callipeltins supposed to be efficient structures for ccr inhibitors as anti-hiv drugs or anti-cancer agents. in the present study, we report the synthesis of cyclic depsipeptides of callipeltin b analogues consisting of l-, d-amino acids and/or n-methyl amino acids, for a structure-activity relationship study of linear-and cyclic depsi-peptides against hela cells . in the assay of synthetic peptides, all of the synthetic callipeltin b analogues exhibited no cytotoxicity. we supposed that dimethylpyroglutamic acid of callipeltin b was essential structure to show the cytotoxicity against hela cells. monash university, melbourne, australia protein-protein interactions represent a significant portion ( - %) of all interactions within the cell; as such these interactions are ideal targets for drug discovery. while difficult to target using small molecules, these interactions can be disrupted using a small section of the protein's binding partner. these short peptides must retain the defined secondary structure associated with the protein binding interface in order to inhibit their protein targets. as the secondary structure adopted by the parent protein is not always exhibited by its derived peptides, constraints are introduced as necessary to help define the structure of the peptide. inducing secondary structure reduces the energy required for organisation, decreasing the energy of binding and has the potential to increase stability with respect to degradation by proteases. solid phase peptide synthesis was used to make several small peptides corresponding to the structured sections of the binding partners for three protein-protein interactions. these peptides were designed to target heart disease, prostate cancer, and liver cancer respectively. secondary structure was introduced using lactam bridge constraints. for the αhelical peptides, a side chain constraint approach was used to nucleate helix formation. as hydrogen bonding between the c=o of the i th residue and the nh of the (i+ ) th residue stabilises native α-helices, constraints were introduced linking the side chains such that the residues were held in close proximity. for β-pleated peptides, an antiparallel β-sheet arrangement was achieved by introducing turn regions into the peptide in such a way that the β-strands were aligned. constraints were again introduced using lactam bridges between lys and arg or glu side chains. these peptides were characterised by nmr and cd spectroscopy to verify the correct secondary structure had been induced. göttingen, germany different properties can be combined in a single molecule by using a scaffold arranging functional groups in a predefined topology. the tasp (template-assembled synthetic proteins) concept describes templates to reinforce and direct the folding of designed molecules into a predetermined topology. [ ] due to their resistance to proteolytic degradation and their rigid basic structure, cyclic β -tripeptides are suitable carrier molecules for bioactive compounds; they are further known to form tubelike structures by stacking of the peptide rings leading to higher organization of functionalized peptides. [ ] with this scaffold different inhibitory systems were synthesized that feature cell penetrating and fluorescent properties. the signal transducer and activator of transcription (stat ) protein, which has been described as an oncogenic protein, was selected as the first target. [ ] a peptide sequence which targets the sh domain of stat was used in two different approaches. it was either directly attached to the cyclic β-tripeptide via a huisgen [ + ]cycloaddition or the peptide was incorporated into the inhibitor loop of the cystine knot microprotein omcoti-ii, which was also attached to the cyclic-β -tripeptide. [ ] further, sodium channels are addressed usingconotoxines. first, an alkyne functionalized conotoxin siiia was synthesized applying different folding methods. the alkyne linker will be used to attach a fluorophore or to functionalize a cyclic-β-tripeptide. using single molecule imaging the spatial distribution, local concentration and organization of the ion channels in neurons will be imaged. further, the cyclic-β -tripeptide templating effect will be used functionalizing with μ-conotoxines. those proteins are folding helper proteins. together with chaperones, they form receptor complexes. they catalyze the isomerization of prolyl bonds in various folding states of target proteins. indeed, their role has been implicated in refolding of denatured proteins, de novo protein synthesis and the biologically active conformation of proteins . among them, the fkbp subclass comprises the small ppi calstabin and . it is of interest to try to understand the way those proteins act, in order to help the overexpression of various types of membrane proteins, aiming at the renaturation, purification and crystallization attempts of receptors. we chose to work on calstabin because this short ( aa) protein has been described as a sub-family comprising isoforms (from ~ to ~ aminoacids), some of them not being fully described to date. the relative shortness of those proteins together with the fact that the two higher molecular weight ones are catalytically active as prolyl isomerases, facilitate the characterization of the synthetic proteins.in order to obtain the full length calstabin , a native chemical ligation (ncl) approach was chosen . an optimized stepwise elongation allowed the obtention of the c-terminal segment up to the cys . moreover, several methods were compared for the synthesis of peptide - opportunely functionalized at its c-terminus for the ncl.the ligation at thr site between peptide - featuring a bis( -sulfanylethyl)amino the chemical diagnostics of paintings is a relevant topic in the field of chemical sciences applied to the conservation and safeguard of cultural heritage. chromatography is a highly sensitive and suitable technique for accurate methods of analysis of the limited amount of sample material typically available from works of art. paint media deriving from proteins traditionally include egg, milk, animal and fish collagen glue. egg yolk (egg tempera), egg albumin (glair) and casein (a blend of related phosphoproteins commonly found in milk) are traditionally used as pigments binders. we propose the uplc-based amino acid analysis as diagnostics technique on non pre-treated or submitted to extraction processes model samples, showing that good results can be achieved with very scarce sample manipulation and great advantage. we applied the amino acids analysis carried out by the accq•tag™ ultra performance liquid chromatography to the standard and model samples. in particular, after protein hydrolysis ( h, °c, m hcl) of the samples, the amino acid derivatization by -aminoquinolyl-n-hydroxysuccinimidyl carbamate allowed a reproducible amino acids analysis characteristic of the protein type. the results obtained confirmed the reliability of the data achieved and demonstrated that the accq•tag™ ultra uplc method could be a powerful technique to be applied to the relevant field of protein binders diagnostics for paintings conservation. moreover a multivariate analysis that offers a wide variety of tools and methods mainly concerned with mathematical models for the representation of multidimensional data has been proposed and the high model efficiency has been established for sample containing mixture of proteins. reactions performed on solid supports, such as resin, are commonly monitored by hplc-uv after cleaving the products from the support. however, uv-absorption coefficients may differ between compounds, and therefore the relation of the area percentage values of the peaks may not directly reflect the molar concentrations of the corresponding compounds. it is for this reason that, for example, in solid-phase peptide synthesis it is difficult to calculate the yield of the coupling of a fmoc-amino acid or the removal of the fmoc-group because of its high absorbance. recently, we reported the identification of minimal phosphopeptides that specifically interact with the pbd of human plk , but not those of the closely related plk and plk . comparative analyses of the crystal structures of the plk pbd in complex with the minimal phosphopeptides revealed that the c-terminal spt dipeptide functions as a high-affinity to the interaction. in an attempt to obtain the adequate cellular permeability and stability in vivo, we have accomplished the peptide-peptoid hybrid or peptomers cyclization using various methods like formation of amide, thioether and triazole and screened the plk inhibition activity on the first cyclic peptomers liibrary using pbd-binding assay. based on our first screening results, we also carried out the detailed investigation to further increase the activity and also to understand the significance of peptoid mimics as plk inhibitors. the mode of interaction between the cyclic peptomers and pbd might provide a template for designing therapeutic agents that target plk . a synthetic amino acid long peptide corresponding to the minimal metacaspase catalytic domain induces cell death in leishmania major c. servis, h. zalila*, i. gonzalez, l. lozano, n. fasel department of biochemistry, university of lausanne, epalinges, switzerland despite a lot of controversy during the last decade, there is increasing experimental evidence that cell death (cd) is genetically programmed in lower eukaryotes.in the cd proteolytic cascade of plants and protozoa, caspases are likely replaced by metacaspases that are cysteine peptidases recognizing arginines or lysines in p position. metacaspases have been found to control cell death in plants. the human protozoan parasite leishmania major expresses a single metacaspase (lmjmca) harboring a central domain with the catalytic dyad histidine and cysteine as found in caspases. metacaspase could therefore be one of the executioners of the death pathway in leishmania.in this work we showed that, in stress conditions, lmjmca precursor forms were extensively processed into soluble forms containing the catalytic domain and this domain was sufficient to enhance sensitivity of parasites to hydrogen peroxide by impairing the mitochondrion function. we tested different lengths of the lmjmca catalytic domain and found that the overexpression of the polypeptide corresponding to amino acids - was sufficient to sensitize l. major mitochondria to oxidative stress.we synthetized an aa long peptide corresponding to the minimal metacaspase catalytic domain (aa - ) and showed that it has specific metacaspase activity in vitro.we are currently investigating its activity on possible target proteins, which have been identified in a yeast two-hybrid screen. identifying proteins involved in the metacaspase signaling pathway will shed light on the understanding of cd in leishmania and open new perspectives in drug target investigation to fight leishmaniasis and other major infectious diseases. s. alasibi, g. ashkenasy department of chemistry, ben-gurion university of the negev, beer-sheva, israel various factors can affect the conformations and folding states of protein molecules and as a consequence their activity. these factors include amino acid mutations, interactions with other macromolecules, binding to regulatory molecules, and also external changes such as ph jump or shining light. in order to control the folding states and to modulate the functions of peptides and proteins by light, photocleavable groups are usually incorporated into specific residues to mask critical interactions. for example, introducing caging groups into coiled-coil proteins recognition interface affects complex formation and template-assisted ligation reactions, in which the coiled-coils serve as templates to catalyze the condensation reactions between two short peptide fragments . our research group has been studying peptides replication networks, which were made of coiledcoil peptides and analyzed the response of such networks to light as external trigger . it was shown that even replicating networks made up of a small number of molecules can possess complex behavior, considering the wealth of catalytic pathways and transformations. hence, boolean logic operations can provide valuable means to analyze and interpret their behavior . herein, we describe the use of chemical inputs and uv light to manipulate peptides folding and functionality within new synthetic networks. these networks perform complex behavior and, as a result, selective product formation is used to implement boolean operations that have not been achieved before. institute of bioorganic chemistry of ras, moscow, russia earlier, we have shown that n-acylated amino acid nitriles and amides react with ethylene derivatives forming the amino-and -hydroxypyridines and pyrroles [ ] . a possible reaction mechanism is the geterodienic condensation of aminooxazole derivatives to dienophiles. the higher yields were observed when used the dicarboxylic acids as dienophiles and -amino or alkoxyoxazole as geterodienes. while the same reactions with the fullerene derivatives, as dienophiles, gave low yields. the nitrile groups of specified pyridines possess ability to react with amino groups of peptides and proteins even at room temperature. in view of high activity of nitrile groups such pyridines can form tetrapyridotetrazoporphyrins and self-condensation products giving appropriate dendrimers (possible due to mobile hydrogen in the th position). high molecular weight dendrimers were identified by massspectrometry, gel electrophoresis and dynamic light-scattering. catalytic oxidizing properties of tetrazaporphyrin derivatives and phtalocyanin were used in synthesis of cyclic peptides and for the s-s bonds formation. the transformation of peptides into heterocycles via an intramolecular reaction of nitrile groups was used to determine the sequence of some peptides, which favored the resistance of transformed compounds to hydrolysis and to the electron impact at mass spectrometry. diazotization of peptides and their derivatives facilitates identification of amino acid sequence by mass spectrometry due to the peculiarities of their fragmentation. in addition, an amino acid analysis of the diazotized peptide makes it easy to determine the n-terminal amino acid. we present here a multi-disciplinary approach combining x-ray crystallography, computational analyses, and immunological tests to identify epitopes of the oligopeptide-binding protein a (oppa bp) from the gramnegative pathogen burkholderia pseudomallei, the etiological agent of melioidosis. computational analysis on oppa crystal structure was used to design potential consensus epitopes, that once synthesized as free peptides (comp - ) were found to be immunoreactive against sera from melioidosis patients. notably, one of the predicted peptides allowed to distinguish between seropositive, seronegative and recovered groups, underlining its potential for diagnostic purposes. parallel experimental epitope mapping, based on proteolysis and mass spectrometry, allowed us to identify linear peptide epitopes (exp - ) localized in similar protein regions as comp - . moreover, the match between theoretical and experimental mapping of epitopes was improved by expanding our computational approach, i.e. including an energy based decomposition procedure to divide oppa bp into separate fragments. overall, our results illustrate the successful development of a novel integrated structurebased approach for the discovery, design and preparation of epitopes. nonetheless, given antigen crystal structures, our method is expected to be broadly applicable in the design and generation of new epitope candidates, as being confirmed by on going experiments on different antigens. the application of peptide thioacids as reactive intermediates and building blocks has received considerable attention recently. the chemical ligation reaction between thioacids and azides has been reported for the synthesis of small to larger peptides as well as for the modification of proteins. fmoc based methods for the preparation of peptide thioacids have to our knowledge not been extensively researched and a facile approach to their synthesis is desirable.we have recently shown that t-butyl thioesters are robuster than previously reported, and can be used for the fmoc based solid-phase preparation of peptide thioesters being also easily cleavable with thiolates. peptides attached via a -mercapto -methylpentanol (mmp) resin can be cleaved using -mercaptopropionitrile to obtain protected thioacid peptides with a ß-elminable cyanoethyl group.the thioacid peptides could then be obtained in situ after treatment with dbu ( . % in dmf) and further reacted with sulfonyl azides in the presence of , -lutidine in a one pot reaction. by treating the cyanoethyl peptide thioesters with (nh ) s in a sodium phosphate buffer (ph = ), various model penta-peptide thioacids could be obtained cleanly at room temperature in up to % overall yield based on initial coupling. these peptides were then further ligated with electron deficient sulfonyl azide functionalized peptides.larger peptide thioacids could also be obtained using this protocol. a mer derivative of penetratin- , a cell-penetrating peptide from the third helix of the homeodomain of the antennapedia protein, was prepared as a peptide thioacid in a % yield (based on coupling of the first amino acid). in this report, a sensitive, selective and rapid uplc-ms method was developed for the determination of the [lys-gly] -mog - peptide in order to control the conjugation of mannan with the [lys-gly] -mog - peptide. the separation was performed on an acquity uplc system with a beh c column packed with . μm particles. the total run time was min. calibration curve based on peak area ratio was linear at the concentration range of - μg/ml, with a detection limit of μg/ml. the method showed satisfactory reproducibility and confirmed the entire conjugation between oxidized mannan and peptide sequence. the development of simple, low-cost and fast methods for protein purification is of increasing importance both for academic and industrial applications. a very promising approach is inverse transition cycling (itc) that exploits the temperature dependent aggregation properties of elps. elastin-like polypeptides (elp) are artificial polypeptides composed of pentameric repeats (val-pro-gly-xaa-gly) derived from mammalian elastin. elps are characterized by a specific transition temperature (t t ) that depends on the amino acid composition of the pentarepeat; they are water-soluble below and aggregate reversibly above this narrow temperature range (t t ). these properties are transferred to target proteins by n-or cterminal fusion with elps. during itc these fusion proteins precipitate, while other components remain in solution. repeated cycles of heating and cooling allow simple recovery of the target protein.we synthesized various elps consisting of to pentameric repeats and including different guest residues. the transition temperature of all synthetic elps was determined using photometric assays and measuring turbidity. in order to test if elp properties can be efficiently transferred, we fused elp to a small recombinant protein (ras-binding domain, rbd) by expressed protein ligation. this approach will allow the incorporation of elps with unnatural amino acids and other chemical modifications into target proteins. currently we are focusing on biotechnologically relevant enzymes that constitute a major cost factor in industrial processes. the authors thank süd-chemie/clariant for their financial support. department of pharmacy, university of patras, rio, greece peptides penetrating the cell membrane, known as cell penetrating peptides (cpps), as well as their mimics, used as delivery agents to cells have been reported , . cpps can be natural sequences or artificial constructs designed to capture the features of natural formations. cpps are particularly important in the delivery of peptides, proteins, nucleic acids, small molecule drugs or imaging agents. incorporation of a heterocyclic motif into a peptide or peptide-like backbone introduces conformational constraints and/or latent reactivity related to the heterocycle's structural profile. heterocycle-based cpp mimics are, thus, promising candidates for therapeutics protected synthetic non-ionic peptides, which are for example synthetic intermediates for the production of api's, are often very hydrophobic and not soluble in most common solvents. they are thus difficult to purify by preparative rp-hplc, classically used for industrial production. it is then challenging to develop alternative purification chromatographic processes using suitable solvents and providing good yields, high purity and sufficient productivity. the technique of support free liquid-liquid chromatography , including both its hydrostatic (centrifugal partition chromatography or cpc) and its hydrodynamic (counter-current chromatography or ccc) declensions, are mainly involved in phytochemical studies but has also been applied to peptide purification . the previously developed biphasic solvent systems are not adapted to the purification of highly hydrophobic protected peptides. to overcome this problem, two new scales of biphasic solvents systems and a ternary biphasic solvent system were developed to overcome solubility problems often encountered with those peptides. the new systems composed of heptane/thf/ch n/dmso/water, heptane/me-thf/nmp/water, and cmpe/dmf/water were efficiently used for the cpc purification of a mer protected exenatide and a mer protected peptide intermediate of bivalirudin synthesis. the developed scales show a wide range of polarity and should be useful for general use in cpc for the separation of hydrophobic synthetic free or protected peptides. the progressive aggregation of β-amyloid peptide (β-ap) into insoluble amyloid fibrils ultimately leading to formation of toxic amyloid plaques is widely considered to be the central pathogenic cause of alzheimer's disease. in the last decade accumulating evidence suggests that soluble oligomeric non-fibrillar forms of β-ap are neurotoxic as well. consequently, inhibiting the aggregation of β-ap is one of the therapeutic strategies against alzheimer's disease and a number of small molecules have been identified as inhibitors of β-ap aggregation and neurotoxicity. among these, curcumin, the phenolic yellow pigment and active ingredient of the turmeric herb, is receiving special attention because of its rich pharmacology that includes in vitro and in vivo inhibitory action against alzheimer's disease insults. in the current work the interaction of β-ap( - ) with curcumin is investigated with fluorescence, cd, and nmr spectroscopies in water and water-methanol mixtures and at various β-ap( - ):curcumin ratios. in nmr studies in % methanol curcumin behaves like a macromolecular species with a change in the sign of its noe signal providing direct indication of its association with β-ap( - ). in % methanol the presence of β-ap( - ) results in great broadening of the h peaks of curcumin, indicative of a complete change in its solution state. additionally, the fluorescence of curcumin in % methanol shows a blue shift with enhanced intensity, observations consistent with a hydrophobic modification of curcumin environment upon interaction with β-ap. finally, in water the induced circular dichroism spectrum of curcumin in the near uv region provides clear evidence for the loss of symmetry of curcumin molecule due to changes in its microenvironment generated by interaction with β-ap( - ). our experimental findings support the direct interaction of β-ap( - ) with curcumin and establish its importance as a potential aggregation inhibitor of β-ap. [ ] . based on its sequence, we synthesized h-tyr-d-trp-nh- -ada ( -adamantane) (yo- ) and h-tyr-d-trp-nh- -ada ( -adamantane) (yo- ) and reported they had potent antiproliferative activity on cancer cells (a- and sw ), which were comparable to tt- and cycloheximide. a structure-activity relationship analysis revealed that lipophylicity of yo- and - could be responsible for their antiproliferative activity. now, we described the substitution of tyr of yo- and - by tyr(bzl), phe, -nal( -naphthylalanine), -nal ( -naphthyalanine) and the anticancer and dna polymerase inhibitory activities in order to explore the effect of hydrophobic substituent. among the compounds, yo- and - had the highest lipophilicity judging from their retention time and lipophilicity index (yo- : . min, . ; yo- : . min, . ). yo- and - exhibited strong dna polymerase inhibitory activity as well as antifroliferative activity on hct cells at m. these activities were greater than those of yo- and - . antiproliferative activity of the compounds containing -ada such as yo- , - , - , - and - , was comparable to that of the compounds containing -ada such as yo- , - , - , - and - . these findings suggest that the lipophilicity well correlates with dna polymerase inhibitory activity and antiproliferative activity on hct cells. further structureactivity relationship study is progressing in our group. multiple sclerosis (ms) is a chronic autoimmune disease of the central nervous system (cns) , . our aim was to immunologically control the attack of the myelin sheath in ms patients without the total suppression of the immune system. anthraquinones (mitoxantrone, ametantrone) are widely used in cancer therapy as immunosuppressants.mitoxantrone is also used to treat several forms of advancing ms, including secondary progressive ms, progressive relapsing ms, and advanced relapsingremitting ms . more specifically, mitoxantrone is an inhibitor of the type ii topoisomerase, which disrupts dna synthesis and dna repair in both healthy cells and cancer cells. herein, we report the synthesis of an anthraquinone type compound conjugated to the immunodominant - myelin oligodendrocyte glycoprotein (mog - ) for the selective immunosuppression of the encephalitogenic t cells in ms patients. the anthraquinone was synthesized by a friedel-crafts acylation of hydroquinone from phthalic anhydride, followed by reduction of the resulted quinizarine to its leuco form, addition of the appropriate diamine and air oxidation . the synthesized molecules were purified using liquid chromatography, and they were identified by mass spectrometry and h-nmr. the synthesis of the mog - was performed under microwave irradiation and its conjugation with the anthraquinone was performed in solution. the final analogue was purified by rp-hplc and identified by esi-ms. benzopyrans, diketopiperazines and , benzodiazepin- , -diones are well-known and widely investigated scaffolds, e.g. the latter showing anxiolytic and antiarrhythmic effects. now, we propose a new potential "privileged structure" containing a triazole moiety mimicking the cis-amide bond within the , -benzodiazepin- , -dione motif .molecules based on this [ , , ]-triazolo [ , -d] benzo- , diazepin- -one scaffold are synthesized and decorated via a modular approach on wang resin using α-amino acids, -ethynylaniline building blocks and n-alkylating agents resulting in five points of diversity. the methodology involves the attachment of α-amino acids onto a solid support, subsequent removal of the fmoc group followed by an optimized diazotransfer reaction of the resulting amine yielding a resin-bound azide. conversion of the latter into a , -disubstituted , , -triazole moiety is achieved quantitatively by addition of a range of -ethynylaniline building blocks using a ru(ii)-catalyst. the desired scaffold can be obtained in high crude purities (> %) in solution via an acid catalyzed one-step cyclisation-release strategy. solution-phase n-alkylation finally affords the fully diversified scaffold. interestingly, n-alkylation induces atropisomeric effects which can be studied via h nmr spectroscopy.taking into account future screening results of the synthesized libraries, a well-thought decoration of this scaffold leading to discovery of new lead molecules is within reach. peptide symposium in the wonderful small seaside town of porto carras. maurice manning and lajos balaśpiri were nominated as captains of the two teams, the rest of the world and europe. similar matches were organized at subsequent european peptide symposia. now, in greece, the two captains would like to hand over their roles to younger scientists [professors gabor mezö(hungary) and laśzlóÖtvös (usa)] to continue this tradition at the coming european and possibly american peptide symposia. it seems best to play in the free time (in the evenings after the excursions). necessary conditions: good weather; a nice large soccer field; a soccer ball, preferably new; and jerseys and shorts (different colours), organized as always by the organizer commettee. the captain of the winning team will receive a trophy at the end of the nd european peptide symposium. the teams will remember two earlier excellent referees: professor lajos kisfaludy in porto carras [ ] and the soccer professor + ferenc puskaś (hungary) in budapest ( ). in the poster session, the results from the past years will be presented in about - pictures. these pictures may possibly be bought free, % can be saved at the poster session. all participants are welcome at the new party in athens. conclusion will be presented by the players and fans in athens. the human lactoferrin-derived peptide, hlf - , was proven to be highly active against antibiotic-resistant bacteria . however, the clinical use of this antimicrobial peptide (amps) is hampered by the peptide low stability due to fast degradation or to peptide aggregation, as the use of higher peptide concentrations results on higher toxicity levels. amp immobilization onto a biomaterial surface could be the pathway to overcome these difficulties . the aim of this work is the development of an antimicrobial surface by covalent immobilization of hlf - onto the surface of chitosan thin films. chitosan ultrathin films were prepared through the spincoating of a . % chitosan solution in gold substrates. hlf - immobilization was performed through an ss bound between hlf - terminal cysteine and an n-acetyl cysteine previously coupled at chitosan films. surfaces were characterized using ellipsometry (thickness), infrared reflection absorption spectroscopy (irras) and x-ray photoelectron spectroscopy (xps). bacterial adhesion studies were performed using methicillin-resistant s. aureus (atcc ). chitosan films were incubated with this bacterial suspension at ºc for h and h. the viability of the attached bacteria was evaluated using live/dead® bacterial viability kit (baclight tm ) and fluorescence microscopy. hlf - peptide was successfully covalently immobilized onto chitosan thin films. both soluble and attached peptide presented a higher antimicrobial activity than the control chitosan. identified as a potent vasoconstrictor that binds with high affinity to ut receptor. the cysteine-linked cyclic region, hut-ii( - ), is responsible for the biological activity and has been widely used to elucidate the structure-activity relationship of hut-ii. with the aim to investigate the role of hydrogen bond and the effects of a peptide backbone constraint on binding key: cord- -g hez authors: hu, yuan; liu, xu; zhang, tianyi; chen, chao; dong, xianzhe; can, yan; liu, ping title: behavioral and biochemical effects of kxs on postmyocardial infarction depression date: - - journal: front pharmacol doi: . /fphar. . sha: doc_id: cord_uid: g hez background: depression and coronary heart disease (chd) often occur together in clinical practice. as a traditional chinese medicine, kai-xin-san (kxs) has been widely used for the treatment of emotion-related disorders. in the present study, we aimed to explore whether kxs had both antidepressive effects and cardioprotective functions in a rat model of myocardial ischemia (mi) with depression. methods: a total of sd rats were randomly assigned into five groups as follows: normal control (control group), celiac injection of isopropyl adrenaline (iso) (mi group), depression (depression group), mi+ depression (model group) and mi+ depression treated with intragastric administration of mg/kg kxs (kxs group). mi was induced by subcutaneous injection of mg/kg iso. depression was developed by a -week chronic mild stress (cms) challenge. behavioral test was conducted before and during the experiment. echocardiography and biochemical analysis were carried out after weeks of cms challenge. results: after weeks of experiment, depression-like behaviors were observed in all the groups except for control and kxs groups, and kxs treatment dramatically increased open-field test scores and sucrose consumption (p < . vs. model group). echocardiography and biochemical analysis showed that kxs treatment could improve levels of ejection fraction (ef) and fractional shortening (fs), which were reduced by depression and iso challenge. meanwhile, kxs treatment significantly decreased the levels of creation kinase mb (ck-mb) and lactate dehydrogenase (ldh), which were increased in the model group. the activities of superoxide dismutase (sod), glutathione peroxidase (gsh-px), catalase (cat) were increased, while the malondialdehyde (mda) activity was significantly decreased in the kxs group. moreover, kxs treatment reduced the levels of c-reactive protein (crp), interleukin- (il- ) and tumor necrosis factor-α (tnf-α) in myocardial tissue compared with the model group. conclusions: kxs had antidepressant-like activity and offered cardioprotective effects against iso-induced myocardial infarction with depression. depression and coronary heart disease (chd) are both common conditions and often occur together. there is a complex interrelationship between depression and chd, where depressive illness results in cardiovascular disease and in turn heart disease causes depression (goldston and baillie, ; seymour and benning, ) . increasing evidence has shown that depression can be linked to an increased risk of chd in an independent manner, and patients with chd and depression exhibit a higher morbidity and mortality compared with those with chd only (nemeroff and goldschmidt-clermont, ; headrick et al., ) . as the classical emergent manifestation of chd, acute myocardial ischemia (mi) is associated with an increased mortality risk (wang et al., ) . depression is an important clinical issue in mi patients due to its extreme commonness, and the comorbidity complicates the depression treatment and worsens the cardiovascular prognosis (shapiro, ) . although many therapeutic strategies have been used to treat chd or mi patients with depression (colquhoun et al., ) , such as psychological therapy (cognitive-behavioral therapy and interpersonal psychotherapy) and pharmacological therapy (fluoxetine, sertraline, citalopram, and mirtazapine), clinical outcomes remain unsatisfied, which can be mainly attributed to the unavoidable adverse effects of these treatments. therefore, a great deal of efforts have been made to develop efficient therapies based on traditional chinese medicine (tcm), which is a crucial part of complementary and alternative medicines (francis et al., ) , and in some parts, its multi-components with the multitarget characteristics may contribute to complex somatopsychic illness (wang et al., ) . the tcm kai-xin-san (kxs) is composed of ginseng (panax ginseng c.a. meyer), hoelen (poria cocos f.a. wolf), polygala (polygala tenuifolia willd), and acorus (acorus calamus var. angustatus besser syn. acorus tatarinowii schott) with a ratio of : : : (hu et al., a; hu et al., b) , which was first recorded in thousand formulae for emergency (bei ji qian jin yao fang) by sun si miao. this formula is widely used in asia, especially in china, and kxs is effective in treating depressionassociated deficits of learning and memory. in our previous studies, we have proved its antidepressive effect using different animal models, such as the chronic mild stress (cms) challenge, tailsuspension test, and forced swim test zhou et al., ; dong et al., ) . kxs is effective in improving behavior disorders by activating trkb/erk/creb/bdnf and trkb/pi k/creb/bdnf pathways and influencing various inflammatory pathways, such as il- and tnf-a . in the present study, we further explored shen-zhi-ling (szl) tablets, which are the proprietary chinese medicines based on kxs decoction, and verified its safety and efficacy in patients with depression (unpublished data). huang yf (huang et al., ) et al. have found the protective effect of kxs on kidney in rats using ischemia-reperfusion injury model. kxs can increase sod and no activities, decrease mda content and improve kidney tissues. these finding suggest that kxs can protect the blood vessels effectively. here, we hypothesized that kxs might balance psychosomatic status and effectively relieve symptoms of chd with depression. in this study, we investigated whether kxs possessed both antidepressive effects and cardioprotective functions. kxs, supplied in the form of a powdered herbal extract, was obtained from beijing tongrentang drug store (beijing, china). all kxs formulations were provided by the chengdu luye medicinal material plantation co., chengdu, china. the voucher specimens of the four plants, identified by professor ping liu and registered under the numbers nu− , nu− , nu− and nu− , respectively, were preserved at the pharmacy of the herbarium of traditional chinese medicinal (tcm), chinese people's liberation army (pla) general hospital (beijing, china). the total extract was prepared as previously reported . averagely, g yielded kxs powder equaled to . g total herbs. the standardization of kxs was ensured by determining its chemical fingerprinting according to our previous study (hu y. et al., ) . thin-layer chromatography (tlc) of the total extract and each herb showed in supplement . male sprague-dawley (sd) rats, weighing - g, were used for the experimental procedures. rats were purchased from beijing vital river laboratory animal technology co., ltd. and given days to acclimate to the housing facility. animals were housed in × × mm cages and given free access to food and water. a total of sd rats were randomly and evenly divided into five groups (n= ) as follows: normal control (control group), isopropyl adrenaline (iso) model (mi group), cms model (depression group), mi+ depression (model group) and mi+ depression treated with intragastric administration of , mg total herbs/kg kxs (about mg/kg kxs, kxs group), and the antidepressive effect of kxs at such dosage has been proved in several previous studies (hu et al., a; dong et al., ) . except for the kxs group, other groups were given the same volume of saline by intragastric administration. rats in all other groups were challenged with the same cms for days, except for the control group. behavioral tests, including openfield and sucrose preference tests, were performed during the experiment. for the kxs group, rats were administered by gavage with kxs dissolved in distilled water once a day for days after days of cms challenge, and meanwhile, the rats were continuously challenged with cms. in order to establish mi and mi+ depression models, rats were fixed in the supine position, and mg/kg iso (sigma-aldrich, st. louis, mo, usa) was subcutaneously injected on the limb roots and back in three consecutive days (cheng et al., ) . the mi model was verified by echocardiography as well as the levels of serum creatine kinase mb (ck-mb) and lactate dehydrogenase (ldh). all animal-related experiments were approved by the animal experimentation ethics committee of chinese pla general hospital (number: -x - ). at the end of the trial, the rats were sacrificed by cervical dislocation. figure illustrates the protocol of the animal experiment. at day , the rats were anesthetized rats ( % chloral hydrate, mg/kg) and sacrificed by cervical dislocation. rats no exhibited signs of peritonitis after the administration of % chloral hydrate. in the present study, the cms model was employed as a validated animal model of depression (wang et al.) . all rats were challenged with the following stressors (hu et al., a) , including repeated confinement to a small ( × × cm) cage, restraint ( h), water deprivation ( h), food deprivation ( h), isolation ( h), flashing light ( h), forced cold-water swimming ( min) or group-housed in a soiled cage overnight. above-mentioned stressors were given every day for days in a random and unpredictable order. the open-field test (yan et al.) and sucrose consumption test (dang et al., ) were employed to assess the behavior and anhedonic-like state of all rats. these tests were performed on day , and during the experiment. for open-field test, the emotional state, including assessment of horizontal movements (the total number of crossing squares) and vertical movements (grooming and rearing), during a period of min was recorded as the behavioral response to a new environment. a special white square consisting of sectors with black stripes on the ground was used ( × × cm) in the test. animals were individually placed in the same central sector, and a video camera was used to record their activity during a period of min. subsequently, the results of video tapes were analyzed by observers (anymaze, stoelting co., usa). sucrose consumption test is a trial reflecting the anhedoniclike state of animals. rats were deprived of food and water for h prior to sucrose consumption test, and then they were fed with two pre-weighted bottles containing either % sucrose solution or water for h. water intake was determined by weighing the bottles before and after each test. all tests were carried out in the home cage, by which the extraneous novelty and disturbance were minimized. the sucrose preference was calculated as sucrose intake/total water intake (sucrose intake +water intake) (chen et al.) . the hairs on the chest of anesthetized rats were removed with depilatory paste (strep co., milan, italy). subsequently, rats were placed on the scanning platform of a high-resolution ultrasound system in the supine position (visualsonics corporation vero , canada). the chest of each rat was covered with a layer of ultrasonic coupling agent. m-mode echocardiography was conducted to determine cardiac parameters, including length of left ventricular internal diameter at end-diastole (lvidd), length of left ventricular internal diameter at end-systole (lvids), ratio of stoke volume at left ventricular end diastolic volume (ejection fraction, ef), and (lvidd-lvids)/lvids (fractional shortening, fs) after the ecg detection, arterial blood samples were collected and centrifuged at , rpm for min, and serum was collected and then stored at − °c. serum samples were thawed at room temperature before analysis. the serum levels of ck-mb and ldh were determined by commercial kits (nanjing jiancheng bioengineering institute, nanjing, china) to evaluate the myocardial damage according to the manufacturer's instructions. activities of sod, mda, cat, and gsh-px in myocardial tissue were determined using commercial kits (nanjing jiancheng bioengineering institute, nanjing, china) according to the manufacturer's instructions. levels of crp, il- and tnf-a in myocardial tissue were determined by elisa kits using specific antibodies (antix biotech china co., ltd., changsha, china) according to the manufacturer's instructions. absorbance at a wavelength of nm was determined on a microtiter plate reader (perkinelmer, inc., waltham, ma, usa), and results were expressed as ng/l. the freshly dissected heart tissues were fixed in % formalin solution. the sectioning and staining of heart tissue were performed according to previously established protocols. sections ( mm, leica rm , germany) from the left ventricle were stained with hematoxylin and eosin (h&e) and examined by light microscopy (nikon, tokyo, japan) at a magnification of ×. results were expressed as means ± sd. statistical analysis was performed using the one-way anova, followed by dunnett's t test. p < . was considered as statistically significant. table displays the fluid intake during the sucrose consumption test and the changes of open-field test scores, which were used to define anhedonia in five experimental groups. there were no differences in sucrose intake test and open-field test scores among various groups at the baseline. however, after days, the sucrose consumption and open-field test scores were significantly reduced in the depression and model groups (data not shown), and such results were consistent with previous study . after days, the sucrose consumption and open-field test scores were significantly reduced in the mi group, depression group, and model group. for these three injured groups, the levels of sucrose consumption and open-field test score were similar between the model and depression groups, while higher levels were observed in the mi group. collectively, kxs administration could significantly improve sucrose consumption and open-field test scores (vs. model, p < . ). figure a shows that the myocardial cells exhibited uniform he staining, and striated filaments of cardiac myocytes were neatly arranged with clear cell boundaries. in the control group, typical normal cardiac myocytes were observed. only minor infiltration of inflammatory cells was detected, and no apparent fibrosis was found. compared with the control group, fibrotic tissues were slightly increased, and the gaps of myocardial fibers became wider in the depression group. in the mi and model groups, myocardial fibers were thicker and disordered, the gaps were wider, and extensive cardiomyocyte injury and necrosis were observed, indicating increased infiltration of inflammatory cells. compared with the model group, less infiltration of inflammatory cells was observed in the kxs group, fibrous tissues were significantly decreased, and only fewer disordered cells were detected. figure b reveals that ef and fs were decreased in the mi group, depression group, and model group compared with the control group (p < . or p < . ). compared with the model group, levels of ef and fs were significantly increased in the kxs group (p < . ). figure c shows that the levels of ck-mb and ldh were higher in the mi group, depression group, and model group compared with the control group (p < . or p< . ). moreover, the levels of ck-mb and ldh were significantly decreased in the kxs group compared with the model group (p < . or p< . ). figure indicates that the mda activity was significantly increased, while the activities of sod, cat, and gsh-px were significantly decreased in other groups compared with the control group (p < . ). moreover, the highest mda activity was found in the model group. compared with the control group, the levels of crp, il- and tnf-a were significantly increased in other groups (p < . ). the activities of antioxidant enzymes and levels of inflammatory factors were similar between the mi and model groups. compared with these two groups, higher levels of sod, cat, and gsh-px but lower levels of crp, il- and tnf-a were observed in the depression group. after kxs treatment, the activity of mda was significantly decreased (p < . ), while the activities of sod, cat, and gsh-px were significantly increased compared with the model group (p < . ). in addition, the levels of crp, il- and tnf-a were significantly decreased in the kxs group compared with the model group (p < . ). generally speaking, comorbid depression occurs in . - % of individuals with one or more chronic physical diseases (moussavi et al., ) . similarly, the prevalence of depressive disorder is %- % in mi patients, which is about five times higher compared with the general population. a meta-analysis indicates that the risk of cardiac mortality and new cardiovascular events is increased by . -fold and -fold under the conditions of post-mi depression, respectively (meijer et al., ) . in the present study, lower levels of ef and fs but higher levels of ck-mb and ldh were observed compared with normal rats, indicating the myocardial injury in depressive rats. moreover, rats in the mi group showed depression-like behaviors. these results verified the relationship between depression and mi. although many therapeutic strategies have been used to treat mi, the outcomes remain unsatisfied. therefore, it is urgently necessary to develop an alternative medicine for mi treatment and to investigate its potential mechanism. our previous study has shown the anti-depressive effect of kxs in several depression models (dang et al., ; yan et al., ) . in this study, in order to investigate whether kxs possessed both antidepressive effects and cardioprotective functions, we first established a rat model of mi with depression. the model was established using cms-challenged rats, followed by iso-triggered induction of mi. iso is a synthetic catecholamine and b-adrenergic agonist, and it triggers necrosis, hypoxia, hyperplasia, and mi at high doses (abbas, ; zhang et al., ) . in our current study, mi model was established in rats by intraperitoneal administration of iso for three successive days with a dose of mg/kg and a -h interval between the applications. then the model was tested by depression-like behavior and myocardial injury. for the determination of depression-like behavior, we found that sucrose intake and open-field test scores were significantly reduced in rats exposed to cms. for myocardial injury, we tested it by echocardiography and cardiac markers. mi leads to significantly decreased contractile and diastolic forces of the heart, especially in the region of the mi. these alterations can be attributed to ischemia in the ventricular walls, limiting the movement. previous studies have reported that lesion severity and left ventricular function determine the prognosis of mi. therefore, left ventricular function plays a crucial role in evaluating treatment effect (wang et al., ) . echocardiography is a useful tool to determine the cardiac function and assess the changes in left ventricular function by ef and fs, which can accurately diagnose mi in animals (xu et al., ) . ck-mb and ldh, related to the cellular damage and loss of functional integrity, are important myocardial enzymes in the evaluation of myocardial injury and congestive heart failure, and these markers have also been used to diagnose mi (dhivya et al., ; lin et al., ) . in this work, the levels of ef and fs were significantly decreased, while the levels of plasma ck-mb and ldh were increased in the mi and model groups compared with the control group. the above-mentioned findings indicated that an mi+ depression model was successfully established. in addition, such model showed similar results to those of the depression group in behavioral test, including open-field test and sucrose consumption. moreover, the mi+ depression model also exhibited similar results to those of the im group in terms of echocardiography (ef and fs), cardiac markers (ck-mb and ldh), antioxidants (sod, gsh-px, and cat) and inflammatory factors (crp, il- , and tnf-a). after kxs treatment, open-field test scores were increased, and the sucrose consumption was also elevated, suggesting the antidepressive effects of kxs, that consisted with our previous studies (hu et al., ; dong et al., ) . kxs could partially increase the levels of ef and fs and decrease the serum levels of ck-mb and ldh, indicating that kxs could not only improve the depression-like behavior of rats in the model group but also improve the cell functional integrity and restrict the leakage of these enzymes into circulation. in addition, he staining is another method frequently used in evaluation of myocardial injury lin et al., ) . in the current study, the cardioprotective effects of kxs were further validated by the significantly improved histological results. the histopathological changes were significantly restored by kxs treatment, and less area of degeneration was found in the heart tissue sections of the kxs group compared with the model group. these findings also provided convincing evidence that kxs exerted cardioprotective effects against iso-induced myocardial injury. according to published many literatures about kxs antidepressant mechanism, such as dong xz (dong et al., ) and wang s (wang et al., ) . therefore, we believed antioxidant enzymes and inflammation index are related with depression. at the same time, antioxidant enzymes and inflammation index are more related with chd, so we hypothesized the antioxidant enzymes and inflammation index might be the co-morbid condition of heart disease and depression. the status of oxidative stress was assessed by determining the mda activity and activities of several endogenous antioxidants. mda [a reactive oxygen species (ros)] as well as sod, gsh, and cat (antioxidants) are important markers of myocardial oxidative damages yang et al., ) . antioxidants can scavenge free radicals under pathologic conditions, and excessive ros disturbs the existing balance of antioxidant system . kxs treatment reduced the mda activity, and the activities of sod, gsh, and cat were restored by kxs treatment compared with the mi rats. the over-production of pro-inflammatory cytokines, including il- , crp, and tnf-a, can be induced by excessive oxidative stress. many studies have linked the elevated levels of inflammatory markers to ischemia (willerson and ridker, ) . kxs treatment decreased the contents of pro-inflammatory cytokines, suggesting that its cardioprotective effects were partially attributed to its anti-inflammatory properties. these findings were consistent with previous data that kxs treatment can modulate the disturbance of cytokines induced by chronic fatigue syndrome . in addition, these results were consistent with the histological evaluation of inflammatory cellular infiltration in myocardial tissues. a randomized, double-blind, positive-drug, parallel-controlled clinical trial has been conducted to evaluate the efficacy and safety of kxs in treatment of mild/moderate depression since . pharmacologically, kxs with its active compounds may exert its effects on mental illness mainly through adjusting the adrenergic activation, hpa axis dysfunction and immuno-inflammation (hu et al., ; cao et al., ; hu et al., a) , which are the comechanisms in psycho-cardiology (headrick et al., ) . in the present study, we demonstrated that kxs had beneficial effects on cardiac function in mi rats. moreover, kxs treatment showed remarkable anti-depression and cardioprotective effects in an mi rat model with depression. the cardioprotective function of kxs might be associated with its ability to attenuate oxidative stress, leading to reduced myocardial damage. taken together, our findings supported that kxs had therapeutic effects on patients with cardiovascular disease. however, such beneficial effects of kxs were only verified by behavior and biochemical tests. therefore, further studies are required to reveal its underlying mechanisms. in the present study, we found that kxs had antidepressive effect and cardioprotective function by a rat model of mi with depression. after kxs treatment, open-field test scores, and sucrose consumption, which are indicators for evaluating depression-like behaviors, were significantly increased compared with the model group. for cardioprotective effects, kxs treatment could improve the ef and fs, down-regulate ck-mb, ldh, and mda, and upregulate sod, gsh-px, and cat. meanwhile, kxs treatment reduced the levels of crp, il- , and tnf-a in myocardial tissue compared with the model group. the raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher. all animal related experiments were approved by the animal experimentation ethics committee of chinese pla general hospital (number: -x - ). all animal handling procedures were carried out in compliance with the 'principles of laboratory animal care' and the chinese legislation for the use and care of laboratory animals. yh, xl, pl, and yc contributed to study design, trial, and writing of this study. tyz, cc, and xzd contributed to the trial. financial support was provided by national natural science foundation of china (no and ) for the study and collection, analysis, interpretation of data and in writing the manuscript, and clinical research support funding of pla general hospital ( fs-tsys- ) for the study and analysis. cardioprotective effect of resveratrol analogue isorhapontigenin versus omega- fatty acids in isoproterenol-induced myocardial infarction in rats effects of a chinese traditional formula kai xin san (kxs) on chronic fatigue syndrome mice induced by forced wheel running anti-depression effect of kai xin san and research of its compatibility the impacts of along-channel acupuncture on the protein expressions of the chloride channel of the rats with myocardial ischemia screening, referral and treatment for depression in patients with coronary heart disease preventive action of kai xin san aqueous extract on depressive-like symptoms and cognition deficit induced by chronic mild stress piperine modulates isoproterenol induced myocardial ischemia through antioxidant and anti-dyslipidemic effect in male wistar rats a representative prescription for emotional disease, ding-zhi-xiao-wan restores -ht system deficit through interfering the synthesis and transshipment in chronic mild stress-induced depressive rats kai-xin-san, a traditional chinese medicine formulation, exerts antidepressive and neuroprotective effects by promoting pcreb upstream pathways antidepressant effects of kai-xin-san in fluoxetine-resistant depression rats. braz disparities in cardiovascular disease among caribbean populations: a systematic literature review depression and coronary heart disease: a review of the epidemiological evidence, explanatory mechanisms and management approaches the heartbreak of depression: 'psycho-cardiac' coupling in myocardial infarction possible mechanism of the antidepressant effect of , '-disinapoyl sucrose from polygala tenuifolia willd behavioral and biochemical effects of a formulation of the traditional chinese medicine, kai-xin-san, in fatigued rats effect of kai xin san on learning and memory in a rat model of paradoxical sleep deprivation anti-inflammatory effect of sodium butyrate preconditioning during myocardial ischemia/reperfusion antidepressant and neuroprotective effect of the chinese herb kaixinsan against lentiviral shrna knockdown brain-derived neurotrophic factorinduced injury in vitro and in vivo synergistic cardioprotective effects of danshensu and hydroxysafflor yellow a against myocardial ischemia-reperfusion injury are mediated through the akt/nrf / ho- pathway protective effect of kaixinsan power on kidney in rats with ishchemia-reperfusion injury protective effects of shexiang tongxin dropping pill on pituitrininduced acute myocardial ischemia in rats adjusted prognostic association of depression following myocardial infarction with mortality and cardiovascular events: individual patient data meta-analysis depression, chronic diseases, and decrements in health: results from the world health surveys heartache and heartbreak-the link between depression and cardiovascular disease depression, cardiac mortality and all cause mortality management of depression after myocardial infarction strategies and techniques for multi-component drug design from medicinal herbs and traditional chinese medicine the effects of escitalopram on myocardial apoptosis and the expression of bax and bcl- during myocardial ischemia/reperfusion in a model of rats with depression effect of acupuncture at neiguan (pc ) on cardiac function using echocardiography in myocardial ischemia rats induced by isoproterenol effect of kaixinsan on monoamine oxidase activity inflammation as a cardiovascular risk factor protective effects of olive leaf extract on acrolein-exacerbated myocardial infarction via an endoplasmic reticulum stress pathway a chinese herbal decoction, reformulated from kai-xin-san, relieves the depression-like symptoms in stressed rats and induces neurogenesis in cultured neurons etanercept attenuates myocardial ischemia/reperfusion injury by decreasing inflammation and oxidative stress protective effects of berberine on isoproterenol-induced acute myocardial ischemia in rats through regulating hmgb -tlr axis cardiaprotective effect of crocetin by attenuating apoptosis in isoproterenol induced myocardial infarction rat model antidepressant-like effect of the extracted of kai xin san, a traditional chinese herbal prescription, is explained by modulation of the central monoaminergic neurotransmitter system in mouse we want to thank all of the members of pharmacology and pharmacy research department for their work. the supplementary material for this article can be found online at: https://www.frontiersin.org/articles/ . /fphar. . /full#supplementary-material supplement figure | thin-layer chromatography (tlc) of the total extract and each herb. key: cord- -a qz tb authors: nan title: th annual meeting of the austrian society of surgery, graz, june – , date: journal: eur surg doi: . /s - - - sha: doc_id: cord_uid: a qz tb nan background. aortic valve replacement (avr) in the elderly with significant co-morbidities is associated with increased operative risk. trans-apical catheter based avr is being evaluated in a phase study. we report the initial results of the first generation equine pericardial cribrier- edwardsvalve. methods. access is through a small antero-lateral thoracotomy with direct puncture of the apex. after initial balloon valvuloplasty the ascendra delivery system is used to position the balloon mounted crimped bioprosthesis under fluoroscopic and transesophageal echo guidance in the native aortic annulus. results. high risk patients (log euroscore . ae , female and male) with a mean age of ae . years were operated. valve positioning was successful in pts (valve size in pts and size in pts) and were converted to full sternotomy and conventional valve replacement performed. deployment time was . ae . min. delivery was achieved without cardiopulmonary bypass in % of patients. however in pts cpb became necessary to treat bleeding complications. there were deaths within days ( valve related, cardiac, abdominal). operative revision was necessary in patients for bleeding and was related to the apical access in , intercostals artery , lung laceration and was diffuse in . hemodynamic evaluation showed satisfactory results in regard to aortic insufficiency (none: , minimal ) and excellent gradients (peak gradient: . ae . mmhg). conclusions. we conclude from our data that trans-apical aortic valve replacement with the cribrier-edwards bioprosthesis can be performed in high risk patients successfully. cardiopulmonary bypass may be avoided. complications may be attributed to the high risk profile of the elderly population treated in the early learning curve. excellent imaging technology in the operating room and excellent collaboration between surgeons and cardiologist as well as anesthetists appears crucial for the successful implementation of this new treatment modality. aortic valve replacement through partial upper sternotomy: a safe alternative to full sternotomy erate to good left ventricular function and without any previous cardiac surgery at our institution. we reviewed retrospectively data on patients ( males, females) who underwent avr through a partial upper sternotomy between and . mean age was . ( - ) years. mean logistic euroscore and mean peak transvalvular gradient were . ( . - . ) and . ( - ) mmhg, respectively. results. mean cross clamp time, mean bypass time and mean operation time were . ( - ) min; . ( - ) min and . ( - ) min, respectively. in patients ( . %) a conversion into full median sternotomy was necessary. patients ( . %) had to be reexplorated due to bleeding. the mean intraoperative and postoperative red blood cell transfusions were . and . , respectively. deep sternum infection occurred in patients ( . %) . mean icu and total hospital stay were . and . days, respectively. there were hospital deaths giving a perioperative mortality of . %. conclusions. avr through a partial upper sternotomy is a safe and effective technique with a similar perioperative morbidity and mortality to conventional aortic valve surgery showing superior cosmetic results. state-of-the-art : mitral valve repairminimally invasive or median sternotomy? background. more than ten years have passed since minimally invasive mitral valve surgery employing different access and different techniques has been introduced. in spite of obvious advantages acceptance by cardiac surgeons is generally low. to define its current position in clinical practice the development of our program, actual indications and results are presented. methods. minimally invasive and conventional mitral valve procedures from to were documented prospectively. indications for the minimally invasive vs. conventional approach through median sternotomy are compared. results. seventy-five patients had minimally invasive mitral valve surgery through a cm minithoracotomy. carpentier type i, ii and iiia lesions involving the posterior, anterior or both mitral leaflets were treted using carpentier repair techniques. combined procedures of the tricuspid valve, asd and modified maze operations were performed in % of cases, patients had prosthetic mitral valve replacement. patient died at home on postoperative day from unknown causes. functional results: residual mi grade : %, grade i: %, grades i-ii: . %, grade ii: . %, grade iii or iv: . reoperations after months: . in in our department % of all mitral valve repairs needing no concomitant cabg or aortic valve operations were performed minimally invasive. conclusions. more than % of mitral valve repairs can be performed minimally invasive with excellent results. as the procedure is superior concerning cosmesis, the procedure is favored by patients and referring cardiologists. at this time disadvantages are neither proven nor suspected, advantages concerning surgical complications and rehabilitation are assumed. insights from cases of remote access perfusion for minimal invasive cardiac surgery n. bonaros , t. schachner , a. Ö hlinger , o. bernecker , g. feuchtner , g. laufer , j. bonatti background. remote access perfusion (rap) is a prerequisite for performance of minimal invasive cardiac surgery on the arrested heart. during implementation several technical challenges may be encountered. in this study we assess the incidence and the influence of these challenges on the perioperative outcome and we describe clinical results in a large patients' series. methods. we retrospectively analyzed patients who underwent minimal invasive cardiac surgery (totally endoscopic coronary artery bypass grafting: , endoscopic atrial septal defect repair: , totally endoscopic mitral valve repair: ) using rap (estech: , heartport: ). intra-and postoperative parameters were analyzed according to the occurrence or not of technical challenges attributed to remote access perfusion. results. we observed no perioperative mortality and no severe complications in this patients' series. technical problems occurred in patients ( %). three patients ( %) underwent conversion to other operative method as severely atherosclerotic peripheral vessels did not allow positioning of the balloon in the ascending aorta. another patients required an additional arterial cannula in the contralateral femoral artery to ensure adequate perfusion. balloon migrations occurred in patients ( %). in cases was a cannula replacement required ( %), in four of which due to balloon rupture. in patients ( %) positioning of the balloon in the ascending aorta required the use of fluoroscopy, as this was not possible under echocardiographical guidance. patients with technical difficulties (group ) had no worse outcome than those in whom no rap-associated problems occured (group ) with the exception of longer total operative time (group : ae min group : ae min, p ¼ . ). ventilation time, intensive care unit stay and hospital stay were all similar in the study groups (p ¼ ns). a comparison between the two cannula types showed only a higher balloon pressure needed for positioning of the estech cannula vs the heartport system ( ae vs. ae , p < . ) although comparable injection volumes were used. conclusions. we conclude that technical difficulties are not rare during rap but in most of the cases can be easily managed at the cost of increased operative time. the postoperative outcome is not compromized provided that major complications are avoided. neoangiogenesis after combined transplantation of skeletal myoblasts and angiopoietic progenitors leads to increased cell engraftment and lower apoptosis rates in ischemic heart failure background. we report on a modified minimally invasive and cosmetic approach of surgical repair of atrial septal defects (asd) i with emphasis on infant patients weighing below kg. methods. from august to july , patients underwent this procedure (mmit-modified minimally invasive technique). the heart was exposed by a limited midline skin incision and partial sternotomy (newly developed sternal spreader, fa. fehling, germany), and the atrial septal defect was closed through a right atriotomy using special new aortic and dual venous cannuals. basic results were matched to those obtained from patients (st-standard technique) . results. atrial morphology was more complex in mmit pts ( overriding svcs, sinus venosus defects), nevertheless op times were accurate and similar to st pts. early extubation was forced and made possible by fast-track methods. totally, asds were directly closed, pts had patch repair. postoperatively we observed mild postpericardectomy syndroms, cholecystitis and pneumothorax requiring drainage in st pts, only pt with mild pericardial effusion was found in mmit group. retention of pericardial effusions was not a risk factor and hospital stay was also not prolonged. conclusions. this approach achieves a cosmetically superior result with newly developed but standard instrumentation and cardiopulmonary bypass techniques, without compromising exposure or using peripheral incisions even in dysmorphic, low weight congenital patients. mmit (pts) . clinical data and follow-up were collected prospectively and analyzed retrospectively. statistical data are shown as mean values and standard deviation. in larger tumors a preoperative interventional embolization was performed. postoperatively pts were seen as outpatients once per year including ultrasound control. results. of the pts with a mean age of . þ . years there were female and male pts. in pts the unilateral tumor was located on the right side, in pts on the left side. at time of diagnosis pts ( = pts ¼ %) presented with bilateral paraganglioma. histological analysis showed benign paraganglioma in pts and malignant paraganglioma in pt. after a follow-up of to months (mean: . þ . months) pts were alive and well whereas pts were lost to follow-up. duplex ultrasound gave no evidence for recurrence of npg in pts. the patient with the malignant tumor is alive and free of recurrence after years and months. the most recent patient with bilateral paraganglioma tested positive for sdh-d mutation. two brothers and sister of this patient were diagnosed with phaeochromocytoma. conclusions. more female patients were affected than male pts. in male patients there was a higher incidence of bilateral paraganglioma of the neck. long-term survival in patients after surgical removal of neck paraganglioma appears not limited. because of the possibility to identify mutations in the sdhgene (sdhd, sdhb, sdhc) further testing of patients with bilateral paraganglioma is mandatory. screening for phaechromocytoma in these pts and evaluation of patients' families is recommended. background. endarterectomy remains the treatment of choice for ica stenosis. one major complication of surgery is cni ( - %) , encouraging transfemoral stent placement for ica stenosis. the aim of this study is to evaluate a possible reduction of this complication by the use of eversion endarterectomy (eea) compared to standard patch endarterectomy. methods. prospective study design in patients treated at a tertiary university based care center. consecutive patients were enrolled into the study. age (median years, range - years), sex (male , female ), medical risk factors (smoking %, hypertension %, diabetes mellitus %) and indication for surgery (asymptomatic stenosis %) were equally distrtributed among both groups ( patients each). all patients were evaluated pre-and postoperatively for cni by an independent neurologist and ent specialist blinded for the operative procedure. results. one patient in the conventional group suffered patch rupture with consecutive stroke days postoperatively. two patients in the conventional group developed cni ( recurrent larygeal and facial nerve deficit, hypoglossal and glossopharygeal nerve deficit). after months of follow up the latter patient showed spontaneous resolution of cranial nerve symptoms. no patient developed cni after eea. conclusions. cni has been detected in % after endarterectomy of the ica in our series. symptoms of cni may be transient, but are disturbing if no clinical improvement is observed. eea requires less operative dissection in the neck compared to standard patch endarterectomy, and therefore seems to be favourable technique with regard to cni development. eea has the potential to curb the current trend toward application of endovascular surgery for ica stenosis. background. total occlusion or stenosis of the common carotid artery is rare and the indications and techniques of surgical treatment are still a matter of controversy. we demonstrate the feasibility of retrograde common carotid endarterectomy. methods. retrospective case report study. participants. in a period of fifteen years thirty-nine patients underwent retrograde endarterectomy of the common carotid artery. twenty-nine patients were males, middle age (min , max ). ten patients were females, middle age (min , max ). symptoms of brain ischemia were present in fifteen patients. retrograde endarterectomy of the common carotid artery and endarterectomy of the internal carotid artery were done together in all patients. indication for retrograde tea was a verified stenosis > % or occlusion of the common carotid artery diagnosed by duplex ultrasound and arteriography. in three patients iatrogenically dissection of the common carotid artery was seen as indication for that procedure. main measurements. postoperative early mortality, stroke rate, medium and long-term endarterectomy patency. results. in all patients who underwent that procedure there was no occurence of major complications or statistically increased mortality. the day mortality was . % ( patients). one of them died in cause of a heart attack and one because of a cerebral bleeding. there was one ipsilateral stroke ( . %) eight month after the procedure. three patients were lost to follow-up. mean follow-up was months ( to ). there were ( . %) late deaths caused by cardiovascular related problems, pneumonia and cancer. in all living patients, controlled by duplex ultrasound, no occlusion or stenosis was found. conclusions. retrograde tea can be done through only one cervical incision for common carotid artery stenosis= occlusion, for tandem lesions of the carotid arteries as well as for iatrogenic dissections of the common carotid artery. compaired to bypass grafting this technique is a faster and easier method. our retrospective study indicates a long-term patency and freedom from neurologic events. stenosis and occlusion of the proximal subclavian artery -surgical or interventional treatment? an analysis of our own patients and international studies m. tomka, a. baumann, p. konstantiniuk, t. ott, t. cohnert division of vascular surgery, department of surgery, medical university of graz, graz, austria background. seventeen percent of all supraaortic occlusions concern subclavian artery, but only % of them fulfil the clinical and angiographic qualification of steal syndrome. methods. since patients with stenosis or occlusion of the proximal subclavian artery were treated on our department. patients underwent end-to-side transposition of the subclavian into the common carotid artery; a carotid-subclavian bypass using synthetic grafts was applied to patients. surgical treatment and evaluation, complications, short and long term patency of our patients were compared to interventional techniques and international literature. results. the primary success rate of both operative techniques achieved %. -days mortality was %, -days morbidity % ( = ) in the transposition group and . % ( = ) in the bypass-group respectively. median follow-up time was months in the transposition-group vs. months in the bypass-group. only in the latter one late occlusion ( . %) was seen. conclusions. our data show a slight (not significant) favour for the transposition, which is consistent with results from other studies. concerning long term patency and infection rates the transposition of the subclavian into the common carotid artery by single incision is to be recommended first choice of treatment. avoiding synthetic grafts leads to optimal compliance. flow in natural direction and less mortality and morbidity rate are ensured. critical, because preoperative ef is predictive for long-term survival. here, we report results from a genomic study in patients with as in compensated and decompensated state and present candidate genes that could be predictive for the progression of heart failure. methods. biopsies from the lv septum of male patients (  a ae yrs) with isolated as undergoing biologic aortic valve replacement (carpentier edwards magna a + ) were harvested either from hearts with normal ef (> %, n ¼ ) or from a group with low ef ( %, n ¼ ) and served as controls. total rna was analyzed on affymetrix hg-u a genechips, which allowed to measure expression levels of more than . human gene transcripts. low level expression analysis was performed using the gc-rma algorithm and statistical significance analysis was done by bayesian t-test. class prediction was performed using the brb arraytools package (nci). results. expression levels clearly distinguished as from cad. annotation of these transcripts revealed a close correlation with the hypertrophic response and progressive fibrosis. these targets completely reflected the current understanding of key processes involved in heart failure. within a list of several ( ) as classifier genes that revealed well-known markers such as the natriuretic peptide precursors a and b and troponin i, we identified: ( ) the connective tissue growth factor ( vs. ; p < . ), known to be triggered by mechanical stress in fibroblasts; ( ) periostin ( vs. , p ¼ . ), an important matricellular component recently shown to be responsible for ventricular dilation. when specifically searching for low ef class predictors, we found potential candidates of unknown function, which were consistently expressed at a higher level only in as with ef < %: ( ) the pom and zp fusion gene ( vs. , p ¼ . ) and ( ) the transcription factor ets variant ( vs. , p ¼ . ). conclusions. in this study we could clearly identify patients with cad from those with as by the help of gene expression profiling. moreover, we were able to identify gene expression signatures that could be predictive for the progression of heart failure. background. despite tremendous advances in immunosuppressive therapy acute rejection still remains a problem following solid organ transplantation. proteome analysis has emerged as a valuable tool for the study of large scale protein expression profiles and biomarker detection. here we applied this novel technology to identify specific biomarkers for acute cardiac allograft rejection. methods. cardiac allografts of c bl= mice were placed into fully mhc-mismatched c h=he recipients. syngeneic transplants served as controls. protein expression analysis was performed using fluorescence two-dimensional difference gel electrophoresis ( d-dige) on day six post transplant. spots of interest were subjected to nanospray ionization tandem mass spectrometry (ms=ms) for protein identification. expression of selected proteins was confirmed by western blot analysis. results. median graft survival of untreated hearts was . ae . days whereas all syngeneic animals showed indefinite graft survival > days. analysis of the d-dige gels revealed a total of protein spots that were significantly regulated by more than . -fold during acute rejection when compared to syngeneic controls. spots with highest altered regulation identified with ms=ms were derived from coronin a, vimentin, protein disulfide isomerase a precursor, skeletal muscle lim-protein , aconitate hydratase, and fumarate hydratase. peroxiredoxin and pyruvate kinase isozyme m were selected for further analyses. western blotting and immunohistochemistry showed significantly higher expression of these proteins during acute rejection compared to syngeneic grafts. conclusions. this study demonstrates that proteomics is a powerful method to detect biomarkers of acute cardiac allograft rejection. identified proteins like peroxiredoxin and pyruvate kinase isozyme m represent novel indicators of acute rejection and may become useful surrogate markers for monitoring the alloimmune response. impact of endothelin-a receptor blockade on myocardial gene expression post mi w. dietl , g. mitterer , m. bauer , k. trescher , w. schmidt , b. k. podesser background. despite promising experimental results of endothelin-a (et-a) receptor blockade in treatment of heart failure (hf), clinical trials failed to confirm these findings. in order to elucidate this discrepancy, we decided to evaluate the impact of et blockade on myocardial gene expression (ge) post myocardial infarction (mi). methods. mi was induced in male sprague-dawley rats using lad ligation. three days post mi, rats were randomized to receive either tbc -na or placebo and to survive either or days. sham-operated rats served as control group. prior scarification, rats underwent echocardiography. following excision, hearts were analyzed morphometrically. rna was extracted from non-infarcted areas of the lv. targets for quantification were identified using affymetrix gene chip + technology and subsequently quantified by real time pcr. results. et-a blockade did not influence morphology or hemodynamics on day , while it significantly improved both parameters on day . in contrast, ge analysis revealed that the majority of mi-induced changes in ge occur early after mi, with the majority of genes returning to baseline after days. five days of et-a blockade resulted in an attenuated expression of mi-induced transcripts (e.g. tnc, spp , sparc, mmp ) involved in post-mi remodeling. conclusions. apparently, endothelin receptor blockade influences early post-mi remodeling. this data adds further evidence that timing is crucial in et therapy post mi: administered to early, myocardial wound healing is disturbed and lv function deteriorates. given in time, excessive ventricular remodeling is attenuated and lv function improves. identification of sex-specific targets in experimental heart failure m. bauer , g. mitterer , w. dietl , k. trescher , w. m. schmidt , b. k. podesser background. sex-specific differences have been reported in ischemic heart failure. the aim of the present study was to screen for diferentially expressed genes in experimental ischemic heart-failure using genechip + technology. methods. mi was induced in male (n ¼ ) and female (n ¼ ) sprague-dawley rats by ligation of the lad. and days post-mi, surviving animals were sacrificed and samples of the non infarcted free wall gained to perform transcription analysis. sham-operated males (n ¼ ) and females (n ¼ ) served as control. extracted rna of animals per group was pooled and affimetrix genechip + technology was used to screen for differentially expressed targets. genechips + were analyzed using the mas . algorithm and the following rules employed comparing mi vs. corresponding sham to identify sex-specific targets: ) increase in expression in one sex and a decrease in the other, ) increase in expression one sex and absent in the other, ) decrease in expression one sex and present in the other. results. our strategy revealed targets differentially expressed. of these targets were expressed differentially on day only, on day , only one target was expressed differentially on both and days post-mi. of this targets were selected for further analysis including: keratins, caspase- , aldehydoxidase- , cdkn- a and triadin and will be evaluated using rt-pcr. conclusions. ) there are sex-specific targets in post-mi gene expression. ) this targets can be identified using gene-chip as screening tool. bilirubin rinse suppresses early mapk activation in cardiac ischemia-reperfusion injury r. Ö llinger , p. kogler , f. bösch , c. koidl , r. sucher , m. thomas , j. troppmair , f. bach , r. margreiter background. heme oxygenase- (ho- ) expression is crucial in preventing ischemia reperfusion injury (iri). bilirubin, a product of heme catabolism by ho- at least in part accounts for the protective effects mediated by ho- , however, the mechanisms by which bilirubin mediates these effects remain to be elucidated and strategies to apply the bile pigment are needed. mitogen activated protein kinases (mapk) are activated upon stress and play an important role in the early phase of iri. we hypothesized that in a mouse model of heart transplantation, a brief rinse with bilirubin of the graft before reperfusion would affect mapk activation. methods. isogenic c bl= hearts (n ¼ =group and time point) were harvested, stored in uw solution at degrees for h and then rinsed with bilirubin at . mm or ringer lactctate as a control before anastomosis. anastomosis time was kept constant at min by using a cuff-technique, subsequently thereafter perfusion was restored. samples were collected at various times. western blot analysis was carried out for total (t) and phosphorylated (p) forms of akt, erk = , jnk = and p mapk. p=t ratio was quantified by imagej and statistically analyzed using anova. results. after anastomosis and before any reperfusion phosphorylation of erk and p mapk was increased when compared to h of ischemia allone. this was not seen when grafts were rinsed with bilirubin. further, at min after reperfusion, phosphorylation of all mapks being investigated was dramatically increased when compared to the non-reperfused isografts. at this time point, bilirubin significantly inhibited phosphorylation of erk and jnk (p < . ) as well as p -mapk and akt (p < . ). conclusions. bilirubin rinse of mouse cardiac isografts causes a dramatic decrease of mapk activation associated with the proinflammatory response to the stress of iri. bilirubin rinse of allografts before implantation might be a potent aproach to avoid early organ dysfunction. improvement of myocardial protection by a selective endothelin-a receptor antagonist added to cardioplegia in failing hearts background. ischemia=reperfusion (i=r) injury due to cardioplegic arrest is a problem in patients with reduced lv function. we investigated the effect of chronic versus acute administration of the selective endothelin-a receptor antagonist tbc- na during i=r in failing hearts. methods. male sprague-dawley rats underwent coronary ligation. three days post infarction group (n ¼ ) was administered tbc- na continuously with their drinking water, groups and received placebo. seven weeks post infarction hearts were evaluated on a blood perfused working heart during ischemia and reperfusion. in group (n ¼ ) tbc- na and in group placebo was added to cardioplegia during ischemia. results. at similar infarct size postischemic recovery of cardiac output (group : ae %, group : ae % vs. placebo: ae %; p < . ) and external heart work (group : ae %, group : ae % vs. placebo: ae %, p < . ) group was significantly enhanced in both tbc- na treated groups while recovery of coronary flow was only improved in group (group : ae % vs. group : ae %, placebo: ae %, p < . ). evaluation of blood gas measurements showed enhanced myocardial oxygen delivery and consumption with acute tbc- na therapy. in addition high energy phos-phates were significantly higher and transmission electron microscopy revealed less ultrastructural damage only under acute tbc- na administration. conclusions. acute endothelin-a receptor blockade is superior to chronic blockade in attenuating i=r injury in failing hearts. ultrastructural and biochemical evaluation indicate an improvement in capillary perfusion by acute tbc- na administration during reperfusion resulting in a better cardiac function post ischemia. therefore acute andothelin-a receptor blockade might be an interesting option for patients with heart failure undergoing cardiac surgery. background. except in inguinal hernia with strong fascia, treatment of these hernias requires a reinforcement of the inguinal wall. different methods have been established based on different approaches and different degree of reinforcement: partially (lichtenstein, rutkow=robbins) or totally (rives, stoppa, wantz, tipp, tep, tapp) . in danish and swedish hernia register a surprisingly high number of female (especially femoral) recurrencies were found emphasizing the problem, as mainly lichtenstein procedure was performed. increasing knowledge of reasons of fascial insufficiency give further hints towards using a total reinforcement of the inguinal region. among these procedures the transinguinal preperitoneal hernioplasty with a memory-ring armed polyprolylene patch (polysoft patch tm ) is new and promising. methods. between . . and . . inguinal hernias in patients have been treated by tipp with polysoft patch tm ( bassum-suhlingen, idstein). operation and patient data were recorded prospective. we operated male and female hernias. after - month patients were interviewed with a standard questionaire. = patients ( . %) answered. results. medial, lateral, combined and femoral hernias were done. = recurrent hernias ( . %), = incarcerated hernias ( . %). intraoperative complications: = ( . %). postoperative complications have been bleedings, infection, wound dissections. haematomas= seromas we have seen preperitoneal in cases, subcutaneous in cases. re-operations and punctions have been performed. a hydrocele has been seen in = cases, an ileoinguinal syndrome we have noted in cases (no resection has been performed). under intention of a preperitoneal repair, patients have got another treatment: lichtenstein, rutkow and shouldice procedures. in = patients ( . %) the positioning of the patch was difficult mainly due to very small or fatty anatomy. longterm results ( year postoperative): . % had some pain or heavy pain, . % had occasional pain and . % had little or some movement problems. there was recurrent femoral hernia ( mm hole with fat; months post op), only one patch has been removed because of strong pain in riding or sitting in low seats. conclusions. tipp is a safe procedure which fulfills the requirement of a total reinforcement of the inguinal wall. the memory-ring armed polypropylene patch covers the inguinal region and makes the procedure easier compared to the predecessors (e.g. wantz). results. there were primary and recurrent hernias. in cases local and in spinal anaesthesia was used. no intraoperative complications occured, all meshes could be placed easily. patient had local pain for weeks. at followup patients were symptom-free, had paresthesia and infra-inguinal swelling. conclusions. parietene mesh is easy and fast to use and gives satisfying early results. since part of the mesh will resorb within year long-term results will have to be awaited. light versus heavy meshes for laparoscopic inguinal hernia repair -a biomechanical study the incidence of recurrence, first of all, has been lowered by a laparoscopic technique. methods. during the last years we have operated on patients for incisional and abdominal wall hernias. results. there were men and women with a mean age of . years. we applied an intraperitoneal onlay meshtechnique (ipom) by a laparoscopic way. twenty-three patients had an abdominal incisional hernia, an umbilical hernia, an epigastric hernia, a trocar-hernia and one patient a spigelian-hernia. the diameter of abdominal wall defects was - cm. in patients a parietex composite-mesh has been used, in a proceed-mesh, in a bard composix-mesh and in one patient two  cm timeshes. mesh-size was  cm to  cm . hernia sacs were left in place, hernia contents, mostly omentum, were replaced into the abdominal cavity. meshes were fixed using endo-clips in patients, tacks in and the salute fixation-system in patients. postoperative follow-up includes a control at week, month and year postoperatively. there were no problems during operation. patients were discharged on the second postoperative day. after a mean follow-up of . months ( - months) two patients have a hernia recurrence, three patients had local pain for one month and one patient had an umbilical infection, which could be managed without the removal of the mesh. conclusions. laparoscopic incisional and abdominal hernia repair has a low incidence of complications and shows a rapid postoperative recovery of patients. long-term follow-up is necessary for evaluation of mesh reactions with regard to infection as well as to adhesion formation with the intestine. background. the fixation of hiatal meshes with perforating devices, such as tacks or sutures, can be associated with potentially life threatening complications [ ] . fibrin sealant (fs, tissucol, baxter biosciences, vienna, austria) is successfully used for atraumatic mesh fixation in inguinal and incisional hernia repair [ , ] . the rationale of this study was to test the potential of fs fixation of hiatal meshes in pigs. methods. in general anaesthesia, domestic pigs were subjected to laparotomy and designated meshes (ti-sure, gfe, nuremberg, germany) were implanted at the hiatus. the titanized polypropylene material was found to be favorable in combination with fs in a previous study [ ] . meshes were sealed with ml of fs, which was applied with a spray system. the observation period was weeks in all animals in order to assess tissue integration after the fs was already degraded. results. all meshes showed excellent integration and no sign of dislocation or perforation into the neighbouring organs. histology was used to confirm. conclusions. fs for hiatal mesh fixation provides a safe and effective alternative to perforating fixation devices in an animal model of repair. background. we aimed to assess the incidence for esophageal, cardiac and gastric cancer. methods. annual incidence data and age adjusted rates for the years to were obtained from statistics austria which operates the nationwide austrian cancer registry. according to icd-o- (international classification of diseases for oncology, third edition), the following categories were considered: esophageal squamous cell carcinoma (c , - ), esophageal adenocarcinoma, (c , - ), cardiac adenocarcinoma (c . , - ) and non cardiac gastric adenocarcinoma (with known and unknown subsite, c . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , esophageal and gastric tumors with ill-defined histology and death certificate only (dco)-cases. results. annual incidence of esophageal squamous cell carcinoma increased from cases in to in , peaked in ( cases) towards ( ) , declined towards and cases in and , respectively. from to adenocarcinoma of the esophagus increased fold ( vs. ). the number of unspecified epithelial neoplasms of the esophagus remained stable ( - cases). dco cases, comprising no histological information, were stable from (n ¼ ) to (n ¼ ), decreased until ( cases) and increased in ( cases). from to adenocarcinoma of the cardia increased . fold ( vs. ) and remained rather stable with about cases per year until ; cases were registered. non cardiac gastric adenocarcinomas and gastric adenocarcinomas with ill-defined location decreased . fold ( vs. ) and . fold ( vs. ), respectively. the numbers of histologically unspecified cases of malignant cardia tumors and dco cases remained rather stable (unspecified: in and in ; dco: cases in and cases in ) . gender distribution shows an increase of esophageal squamous cell carcinoma in females (male:female : ¼ . in to : ¼ . in ) and esophageal adenocarcinoma (male: female ratio vs. ; : vs. : ; ratio . vs. . ) and cardiac adenocarcinoma for males ( : vs. : ; ratio . vs. . ) . age adjusted rates per . population of non-cardiac gastric carcinomas decreases for both sexes (data not shown). we observed an increase of esophageal squamous cell carcinoma in females and esophageal and cardiac adenocarcinoma for males and a decrease of non-cardiac gastric carcinomas for both sexes. endoscopic versus open esophageal resection: a prospective case-control study within the learning curve background. esophageal resection for cancer is followed by remarkable morbidity. endoscopic surgery has been established to reduce the physical burden. in our institution endoscopic and open esophageal resection is performed transthoracally (tse) or transmediastinally (lstme) as appropriate. we aimed to compare outcomes of case matched open and minimal access esophageal resection by a case-control analysis. methods. endoscopic minimal access esophageal resection (mae) has been performed since (mae). a retrospective case control study including patients (prospectively collected data) who underwent mae (tse, , lstme, ) has been undertaken with matched (pairs matched for sex, age, tumour type and type of resection) historical open (oe) cases operated between and (transthoracic esophageal resection tte, , transmediastinal esophageal resection tme, ). groups were comparable regarding age, sex distribution, tumour type (as consequence of matching) as well as regarding tumour stage and comorbidities. results. forty patients (males, ; females, ; mean age ae yrs) were included in the study. there were adenocarcinomas and squamous cell cancers. patients had neoadjuvant chemotherapy (fu=cis). duration of surgery, number of resected lymphnodes, duration of intubation, icu stay and hospital stay was vs. min (p ¼ . ), vs. (p ¼ . ), . vs. . days (p ¼ . ), vs. days (p ¼ . ) and . vs. days (p ¼ . ) in the mae and oe group, respectively. due to preexistent anemia = mae patients received erythrocyte substitution preoperatively, = patients of the oe group needed erythrocyte subsitution perioperatively. = and = patients underwent reoperation for a complication in the mae and oe group. overall surgical morbidity was % ( = ) and % ( = ). postoperative pneumonia was observed in = and = among mae and oe patients. conclusions. during the learning curve duration of mae is significantly longer when compared with oe. morbidity was reduced, icu and hospital stay were significantly shorter after mae, regarding duration of postoperative ventilation there was a trend towards mae. oncological quality was comparable between groups with respect to the number of resected lymph nodes. the need for blood substitution and reoperation was higher in open esophageal resection. even during initial establishment mae seems advantageous for the patient in this case-control study. randomised trials are still missing. does the route of gastric pull-up influence the oxygen supply of the anastomosis? background. microcirculation and oxygen supply at the level of oesophagogastric anastomosis following oesophagectomy are among the crucial factors determining anastomotic healing. methods. twenty-nine patients (mean age . yrs) were evaluated during oesophagectomy and on the intensive care unit by inserting a micro-probe (licox) and continuously recording the interstitial po of the tubulated stomach in the anastomotic region. two different surgical procedures were applied: group ( = ) had gastric pull-up via a retrosternal, group ( = ) via an orthotopic route. the interstitial po values were averaged over specific consecutive periods: intraoperatively after ligation of the short gastric vessels, after ligation of the left gastric artery, after forming the conduit and after gastric pull-up. postoperative measurements were recorded during intubation, while breathing oxygen by mask or by nose delivery, respectively and finally while breathing air. results. before ligating the left gastric artery the interstitial po -levels were significantly higher (mean . mmhg) than after ligation (mean . mmhg; p < . ). comparing the retrosternal ( . mmhg) versus the orthotopic pull-up route ( . mmhg) a significant difference (p < . ) in favour of the orthotopic route could be found after gastric pull-up as well as during each postoperative measurement period. no differences could be detected when comparing the various oxygen supply systems. conclusions. these data suggest that the oxygen supply at the anastomosis of the pedicled gastric conduit reaches higher levels after orthotopic than following retrosternal gastric pull-up. p tailored therapy for esophageal cancerpilot study in reported -year survival rates of % in this group. factors identifying this subgroup of responders and selecting optimal drugs for non responders could dramatically enhance treatment efficacy. several studies suggest that mutations in the p gene may induce drug resistance especially for agents whose effect is based on apoptosis induction, like cisplatin. methods. in order to test the hypothesis that the p genotype is predictive for chemotherapy response, a prospective study was conducted. thirty-eight patients with potentially respectable esophageal cancer were evaluated for the relation between p genotype and response to two different neoadjuvant treatments. p gene mutations were assessed by complete direct sequencing of dna extracted from diagnostic biopsies. response to neoadjuvant chemotherapy was assessed pathohistologically in the surgical specimen. results. twenty squamous cell carcinoma and adenocarcinoma were included. overall the p mutation rate was % ( = ), with % for squamous cell and % for adenocarcinomas, respectively. patients received cis= fu (cisplatin mg=m d -fu mg=m d - , q , cycles), received docetaxel ( mg=m , q , cycles). the overall response rate was % ( = ). patients with p mutation did not respond to cis= -fu ( = ), while all mutant patients responded to docetaxel ( = ). the overall response to p adapted neoadjuvant therapy was %. p adapted treatment was associated with a significant survival advantage (p ¼ . ) after a median follow up of . months. conclusions. a prospective randomized trial was initiated to test the interaction between the predictive marker p and response to respectively. a new method of anti-ischemic graft protection in retrosternal colon esophagoplasty a. albokrinov , a. pereyaslov , r. kovalskiy lviv children's regional clinic hospital, lviv, ukraine; lviv d. halytsky national medical university, lviv, ukraine background. retrosternal colon esophagoplasty is the operation of choice in infants with esophageal atresia with great diastasis. although complications are rare, some cases of graft ischemia are registered. epidural block have beneficial effect on splanchnic blood flow because of drug sympathectomy. methods. we retrospectively analyzed rate of graft ischemia in infants with retrosternal colon esophagoplasty and conventional postoperative course with anticoagulants and antiaggregants (group , n ¼ ). group , n ¼ was investigated prospectively with preoperative catheterization of epidural space (th -th level, lost of resistance test, g size) and . % bupivacaine administration in daily dose of . mg=kg every h. the rest of therapy was equal in all patients. graft status was determined visually. gut motility was considered to restore when stool have been obtained. results. rate of graft ischemia was significantly lower in group then in group ( vs , p < . ). besides this, gut motility restoration in group was significantly earlier ( . ae . vs . ae . days, p < . ). conclusions. epidural block with local anesthetic is an effective method of anti-ischemic protection of neo-esophagus and powerful instrument in gut motility restoration. background. atrial fibrillation (af) is often associated with thromboembolic complications, heart failure and stroke; in addition an increase in mortality, even with adequate anticoagulation, is observed. the maze operation is an effective and accepted method to terminate af, nevertheless the risk for intraoperative bleeding is increased compared to left atrial ablation procedures using variable energy sources. left atrial ablation is an alternative method to convert af into sinus rhythm (sr), as with this procedure linear lesions connecting the four pulmonary veins and the posterior mitral annulus are created with microwave or high frequency technique. methods. a consecutive series of patients ( females, males; age a, range - a) underwent ablation during various cardiac surgical procedures between and . endocardial ablation using either microwave or radiofrequency energy was performed times ( . %) and epicardial with microwave energy in five cases ( . %) . preoperative parameters: ejection fraction . % ae . %; diameter left atrium . ae . mm. forty-one patients underwent mitral valve repair (mvp), patients obtained mitral valve replacement (mvr), patients received aortic valve replacement (avr), patients underwent coronary bypass surgery (cabg) and patients had combined valve surgery (others). results. others combined valve replacement: mvr þ tvp, mvr þ avr; af atrial fibrillation; aflut atrial flutter; pm pace maker no intraoperative or postoperative complications related to the concomitant ablation procedure were observed. one patient died because of multiple organ failure. after a mean follow up period of months ae patients remained in sr ( . %), patients into af ( . %), patients changed rhythm into atrial flutter ( . %) and one patient required a pace maker ( . %). conclusions. in approximately two thirds of patients left atrial ablation is effective in restoration and maintenance of sr in patients with structural heart disease and af. this method represents a valid alternative to the maze technique, reducing myocardial ischemic time and risk of bleeding. midterm results are promising; however for determination of a long term benefit especially regarding thromboembolic events, a higher number of patients and a longer follow up period are desired. background. the study aim was to evaluate the efficacy and outcome of endocardial and epicardial atrial fibrillation (af) ablation in patients undergoing heart surgery. methods. between february and december , patients (mean age years, range - ) underwent left atrial ablation combined with other type of cardiac surgery. in patients endocardial left atrial ablation using a unipolar radiofrequency device (cardioblate tm , medtronic, usa) was performed, mainly in combination with mitral valve (mv) surgery ( mv repair, mv replacements) . in patients epicardial pulmonary vein isolation using microwave energy (flex tm , guidant-boston scientific, usa) was done during aortic valve replacement ( ) and bypass grafting ( ) . indication for atrial ablation was permanent af in all patients. endocardial ablation was performed during extracorporal circulation (ecc) with a mean time of min ( - ), epicardial ablation before ecc with a mean ablation time of min ( ) ( ) ( ) ( ) ( ) ( ) . % of the patients ( ) received amiodarone postoperatively, % ( ) betablocker. patients underwent epicardial cardioversion with synchrus tm (guidant, usa) wires postoperatively. results. the overall mortality was . % ( patients during mv replacement due to posterior bleeding) complications were posterior rupture ( ) , lco with the need of intraaortoc pallon pump ( ), resternotomies for bleeding, and and ( %) pacemaker implantations ( . %). there were no ablation procedure related complications. sinus rhythm (sr) was achieved in % after operation, % at discharge and % at the month follow up. a nodal rhythm was found in % after operation, % at discharge and in % after months. patients developed atrial flutter ( in the group of endocardial and in the group of epicardial ablation). af persisted in % of the patients at month. conclusions. af ablation combined with cardiac surgery is safe and effective. recurrent af is frequent during the first three months after ablation also under therapy with antiarryhthmic drugs. background. patient-prosthesis mismatch is a frequent cause of high postoperative mortality and gradients. the objective of this study was to determine whether mismatch can be predicted at the time of operation. methods. indices used to predict mismatch were valve size, indexed internal geometric area and projected indexed effective orifice area (eoa) calculated at the time of operation, and results were compared with the indexed eoa measured by doppler echocardiography after operation in patients. results. the sensitivity and specificity of these indices to detect mismatch, defined as a postoperative indexed eoa of . cṁ =ṁ or less, were % and % for valve size % and % for indexed internal geometric area, and % an % for projected indexed eoa. conclusions. the projected indexed effective orifice area calculated at the time of operation accurately predicts mismatch, where as valve size and indexed internal geometric area cannot be used for this purpose. excellent long-term results after emergency cardiac surgery d. martin, a. yates, h. mächler, l. salaymeh, d. dacar, b. rigler division of cardiac surgery, department of surgery, medical university of graz, graz, austria background. data from all adult patients undergoing emergency heart surgery between and at the division of cardiac surgery, medical university of graz, austria, were reviewed retrospectively. methods. data were stored in a local cardiac surgery database. the registery included all relevant patients data and euro-score. no patient was lost to follow-up. a series of relevant perioperative data were collected. recorded complications were use of the intra-aortic balloon pump (iabp) and low cardiac output syndrome. hospital and late mortality data were collected from the austrian national populations register. multivariante analysis was performed to determinate predictors for cardiac related death. results. between and patients underwent emergency cardiac surgery at our institution. there were men ( . %) and women ( . %) with an average age of . years. coronary artery bypass was performed in . %, . % combined valve and bypass, . % valve, . % aortic dissection and . % had other procedures. eighty-seven patients ( . %) had a postoperative low cardiac output syndrome. the intra-aortic balloon pump was used in patients ( . %). variables identifying as high risk for perioperative cardiac related death were diagnosis other then coronary artery disease, patients with iabp and high catecho-lamine demand. there were no postoperative wound infections. eighteen patients ( . %) had excessive postoperative bleeding and ( . %) required a late re-intervention. hospital mortality was . % and the late mortality after years was . %. conclusions. the hospital mortality was higher in the emergency group but there was no difference in the long-term results for elective and emergency surgery. early mortality was significant higher in patients operated for other reason than coronary artery disease. background. acute renal failure is a serious adverse event after cardiac surgery, which is associated with high perioperative mortality and prolonged hospitalization. the aim of our study was to evaluate pre-and intraoperative risk factors for the development of acute renal failure requiring hemofiltration (arf) after cardiac surgery. the influence of different methods for evaluation of renal function was investigated. methods. from = through = , patients underwent cardiac surgery at our institution. patients developed arf ( . %), patients suffering from chronic end-stage renal insufficiency were excluded from the study. patient characteristics and operative variables were analyzed. a multivariate logistic regression analysis was performed to determine risk factors for arf. results. patients, who developed arf, were older (p < . , or: . ) as compared to patients who did not develop arf. furthermore, diabetes mellitus (p ¼ . , or: . ), peripheral artery disease (p ¼ . , or . ), cardiogenic shock (p ¼ . , or: . ), congestive heart failure (p ¼ . , or: . ) und emergent surgery (p ¼ . , or: . ) were predictive for development of arf. preoperative serum creatinine was not predictive for arf (p ¼ . , or: . ). classification of preoperative serum creatinine into normal ( . mg=dl), slightly elevated ( . to < mg=dl) and severely elevated (! mg=dl), reveals a correlation with the development of for severely elevated creatinine levels (p ¼ . , or: . ), as well as for slightly elevated levels (p ¼ . , or: . ). calculation of creatinine clearance mwith the cockcroft-gault formula demonstrated a strong correlation with the development of arf (p ¼ . , or: . ). calculation of creatinine clearance with the mdrd formula, however, failed to reveal any correlation with (p ¼ . , or: . ). conclusions. our data indicate, that advanced age, diabetes mellitus, peripheral artery disease, cardiogenic shock and congestive heart failure, as well as emergent surgery independently predict arf after cardiac surgery. even slightly elevated creatinine levels are a risk for the development of arf after cardiac surgery. calculation of creatinine clearance with the cockcroft-gault formula is more suitable for preoperative risk stratifica-tion as compared to calculation of creatinine clearance with the mdrd formula. background. the matricellular protein tenascin-c (tn-c) induces production of matrix metalloproteinases (mmps), inhibits cellular adhesion and mediates cellular deadhesion. these effects are crucial in the dynamic process of cardiac remodeling. it has been reported that tn-c expression is up-regulated in ventricular remodeling following myocardial infarction (mi) in the border zone between scar tissue and non-infarcted area. we analysed the expression of tn-c in the post mi infarcted and non-infarcted area after the treatment with the selective endothelin a (et a )-receptor antagonist tbc -na. blockade of the et a -receptor decreases cell proliferation, lv hypertrophy, and secretion of pro-inflammatory mediators. methods. mi was induced in male sprague dawley rats by lad ligation. three days post mi, rats were randomised to receive either the endothelin antagonist tbc -na (n ¼ ) or placebo (n ¼ ), as control rats were sham-operated without lad ligation (n ¼ ). after days hearts were harvested and tissue samples from scar, peri-infarct and free wall were analysed by western blot using a monoclonal antibody specifically recognizing the egf like domain of tn-c. tissue was homogenized in urea buffer and protein samples were subjected to % polyacrylamide gel sds-page, transferred on to a membrane and immunostained with the anti-tn-c monoclonal antibody and antimouse alkaline phosphatase antibody. additionally on day and echocardiography and morphological analysis were performed to assess the effect of tbc -na therapy on cardiac function. results. infarct size was comparable in all groups (et agroup . ae . %, placebo group . ae . %). during early remodelling on day , in the placebo group, tn-c was upregulated in scar tissue. in contrast, in the et a -group, tn-c was down regulated in scar tissue. on day post mi, no differences were seen in the tn-c levels. echocardiography showed significant improvements in hemodynamics in the et a -group in contrast to controls. conclusions. from these results, we can conclude that ( ) endothelin-a receptor blockade attenuates the development of heart failure post mi, ( ) reduction of tn-c expression seems to have a positive effect on postinfarct remodeling, ( ) tn-c regulation is influenced by et a -blockade and ( ) that tn-c is a marker for lv remodeling after myocardial infarction. background. diabetes is a risk factor for neurocognitive and neurological complications after cardiopulmonary bypass. we sought to determine if temperature management during cardiopulmonary bypass (cpb) affects the incidence of neurocognitive and neurological complications in diabetic patients. methods. in this prospective randomized study, we measured the effects of mild hypothermic ( c, n ¼ ) vs. normothermic ( c, n ¼ ) cpb on neurocognitive function. all patients underwent elective coronary artery bypass grafting (mean age . ae . years, mean es . ae . ) . neurocognitive function was objectively measured by objective p auditory-evoked potentials before surgery, week and months after surgery, respectively. clinical data and outcome were monitored. results. p evoked potentials were comparable between patients operated with mild hypothermic ( ae ms) and normothermic cpb ( ae ms) before the operation (p ¼ . ). patients operated with mild hypothermic cpb, showed marked impairment ( ¼ prolongation) of p evoked potentials week ( ae ms; p< . ) and months ( ae ms; p ¼ . ) after surgery. in contrast, patients operated with normothermic cpb did not show impairment of p evoked potentials week ( ae ms; p ¼ . ) and months ( ae ms; p ¼ . ) after surgery. group comparison revealed prolonged p peak latencies in the patient group operated with mild hypothermic cpb (p ¼ . ) week after surgery. four months postoperatively, no difference between the two groups could be shown (p ¼ . ). operative data and adverse events were comparable between the two groups. conclusions. normothermic cardiopulmonary bypass reduces neurocognitive deficit in diabetic patients undergoing elective coronary artery bypass grafting. ergebnisse. die paclitaxelbehandlung führte zu einer dosisabhängigen reduktion der intimalen hyperplasie im vergleich zur kontrollgruppe (p ¼ . bei mmolar, p ¼ . bei mmolar, p ¼ . bei mmolar und p ¼ . bei mmolar). in der elasticafärbung fanden sich sowohl in der media als auch in der intima meist nur vereinzelte elastische fasern, wohingegen sich in der trichromfärbung in der media insbesondere subintimal reichlich kollagene fasern fanden, die intima selbst jedoch hierfür negativ blieb. immunhistochemisch zeigte sich die media und die intima praktisch vollständig positiv für sma. bei der desmin-färbung fand sich die media ebenfalls fast durchgehend spezifisch positiv für desmin, die intima hingegen färbte sich hierfür jedoch in unterschiedlichen ausmaß ( - %) an. in der proliferationsfärbung mit ki zeigten sich vorwiegend die längsverlaufenden muskelfasern der media stark proliferierend, wohingegen der subintimale mediabereich und die intima nur vereinzelt ki positiv war. schlussfolgerungen. paclitaxelbehandlung reduziert die intimale hyperplasie in der vena saphena im organkulturmodell. elastische fasern, kollagenfasern, sma positive und desminpositive zellen sowie ki positive (proliferierende) zellen weisen unterschiedliche bevorzugte lokalisationen innerhalb der gefässwand auf. heat shock proteins = = = = = = = = = a and s proteasome in on-versus off-pump coronary artery bypass graft patients background. heat shock protein (hsp) , hsp , hsp , hsp and s immune-proteasome are known chaperons. they play a prominent role in housekeeping processes, in the intracellular regulation of the immune system and in apoptosis. serum levels of circulating chaperons are not known in patients undergoing the on-versus off-pump coronary artery bypass graft (cabg) procedure. methods. forty patients were prospectively included in the study (on-vs. off-pump cabg, each n ¼ ). elisa technique was utilized to detect levels of soluble hsp , , , and s immune-proteasome in serum samples. results. on-pump cabg procedure is associated with an increased leakage of heat shock proteins into the vascular bed when compared to off-pump cabg technique. these differences were highly significant for hsp , and min after initiation of cardiopulmonary bypass (cpb) (all, p< . ). concentrations of soluble s immune-proteasome were increased h after operation in on-and off-pump cabg patients (p < . ) and correlated significantly with the serum content of hsps , and at min after initiation of cpb (p < . ). conclusions. our data evidence the spillage of chaperons, normally intracellular restricted proteins, into the systemic circulation. as these proteins are related to immunomodulatory and apoptotic processes, we conclude that the innate immune system is more activated in on-pump as compared with off-pump cabg patients. however, the precise immunological consequence and interpretation requires further investigations. background. in the treatment of ruptured abdominal aortic aneurysm (raaa) the results of open graft replacement (ogr) remained constant but discouraging over the last four decades. provided patients have a suitable vascular anatomy, elective endovascular abdominal aortic aneurysm repair (evar) turned out to be less invasive than ogr and led to improved perioperative mortality especially for patients with severe comorbidities. thus, it is reasonable to assume that endovascular treatment should improve the results of patients with risk factors heavily impaired by rupture of their aaa. the purpose of this study was to test whether the use of both endovascular and open repair for raaa was able to improve results. methods. retrospective analysis of a consecutive series of patients presenting with raaa from october, , until july, . observation period was divided in two periods of months, respectively. during the first period patients were treated by ogr exclusively. period two started with the availability of an evar protocol to treat raaa, according to which patients received open repair while patients underwent evar. kaplan-meier survival estimates were calculated and possible differences were analyzed by log-rank and wilcoxon-test. results. kaplan-meier survival estimates revealed a statistically significant reduction in overall postoperative mortality following the introduction of evar in (p < . ). ninety day overall mortality was reduced from . % during period one to . % during the second period (p < . ). especially survival of patients older than . years was improved ( % vs. . %, p < . ). in parallel there was a significant reduction of the day mortality rate after ogr from . % (i.e. overall mortality) to % (p < . ). conclusions. offering both evar and ogr in the treatment of raaa led to significant improvement of postoperative survival. especially older patients seem to benefit from the less invasive endoluminal technique. fast track concept for infrarenal aortic aneurysm repair c. senekowitsch , r. schwarz , a. assadian , w. hartmann , g. hagmü ller background. the aim and main benefit of the fast track concept in surgery are increased patient comfort and reduced perioperative morbidity and mortality. in abdominal surgery, this concept has proven efficient. we present our experience of fast track aortic surgery. methods. retrospective analysis of prospectively collected data. since initiating this method of perioperative patient management in january , patients underwent infrarenal aortic reconstructions for aortic aneurisms applying the fast track concept. this comprises of modified nutrition and fluid management, anaesthesiological management and a special retroperitoneal access allowing aggressive postoperative mobilisation. results. patients were included in the study, their mean age was years (range - years) none of the patients had surgical complications, no mortality was observed. the icu days were reduced to for all patients. the mean hospital stay was days (range - days). conclusions. hospital stay and icu days could be reduced dramatically compared to standard therapy at our institution. this new concept in aortic surgery is a valid alternative to evar for selected patients. aneurysma der a. lienalis: fallbericht über interventionell-chirurgisches management e. gü nen, j. demmer, c. groß department of cardio-thoracic and visceral surgery, general hospital linz, linz, austria aneurysms of splenic arteries are seldom ( . % of all aneurysms). nevertheless they are disastrous when ruptured since they bleed into the free abdominal cavity without any means of self-tamponade. occurrence of splenic aneurysms is related to female gender, esp. after multiple gravidities. these aneurysms are usually symptomless and tend to rupture during labour pains. this fact explains the reports on ruptured splenic aneurysms in young women from developing countries whereas in western countries most findings are incidental in routine imaging scans. we report on a yo female from chechnya with a huge splenic aneurysm and splenomegaly. she complained about chronic fatigue and nausea. splenomegaly and a pulsating growth in the mid epigastrium were palpable in the physical examination. the wbc blood counts showed severe pancytopenia. ct-scan revealed a calcified aneurysm (Ø cm) of a tortous splenic artery and an enlarged spleen ( cm). we decided to occlude the origin of splenic artery interventionally and and to perform a ''lone splenectomy'' leaving the unperfused aneurysm in situ. the intervention achieved total angiographic occlusion. however during surgery the aneurysm was still under pulsatile pressure. the pulsation ceased on surgical ligation of the proximal splenic artery. subsequently the splenectomy was performed. the patient recovered without surgery related complications. a year after surgery she has normal blood counts. the aneurysm has not shrunk but shifted to left to adopt the space left over by the spleen. background. the transilluminated powered phlebectomy (tipp; trivex + , smith and nephew) was introduced in the year in our hospital. trivex + is a procedure for minimal invasive vein surgery including an illuminator device, a powered vein resector, a light source and a controll unit. the use of tumescent solution allows hydrodissection and facilitates ablation (rotating inner blade of vein resector combined with suction). methods. in an retrospective study we report patients ( males and females; mean age . years; limbs) treated with this technology during the years and . we used a combination stripping the saphenus veins ( ligations of the sapheno-femoral junction, ligations of the popliteo-femoral junction) or ligations of perforantes ( ) if necessary according to sonography. twenty-seven patients underwent single trivex + treatment. . % were done in general anaesthesia. a follow up is proposed to all patients after to months ( patients, . %). results. the average time of surgical treatment was . min, with single trivex . min. the trivex + procedure for one single leg took about min. the average stay was . days. regarding to postoperative complications one patient experienced laceration of the femoral vein ( . %), one profound bleeding caused a revision the same day ( . %). patients developed lokal wound infektion within the first weeks ( . %). during the follow up period complications like swelling ( ), seroma ( ), brown scars ( ), nerve injury=numbness ( ), haematoma ( ) occured. there was no skin perforation, no phlebitis, none of our patients died. conclusions. according to these results the trivex + procedure seems to be a quick and safe treatment for minimal invasive removement of superficial varicosities. background. this randomized, patient and observer blinded trial compared early postoperative outcomes in saphenectomy with either a new bipolar coagulating electric vein stripper (evs) or invagination stripping. methods. the primary outcome was pain at rest and following physical stress (climbing stairs), as assessed by a visual analog scale (vas) h after surgery. secondary outcomes included haematoma formation (diagnosed and measured by ultrasound), duration of postoperative compression, and disability. quality of life was assessed by a disease-specific chronic lower limb venous insufficiency questionnaire (civiq), and the generic short form (sf- ). results. two hundred patients were assigned to three vascular centers, with patients randomized to the evs and to the conventional arm. there were no complications or conversions. pain at rest averaged . in the evs and . in the conventional group (mean difference . , per cent confidence interval (c.i.) . to . , p < . ). following physical stress, mean ratings were . and . (mean difference . , per cent c.i. . to . , p < ). no measurable haematoma was found in the stripping canal of the evs group, while in the conventional arm patients had haematomas within this region (risk difference per cent, per cent c.i. to percent). duration of compression therapy was significantly decreased in the evs group (mean difference days, per cent c.i. to days). in the evs group, patients returned to work after week and after weeks, compared to and patients in group . civiq and sf- ratings favored the evs. conclusions. the evs is a safe instrument. it is effective in avoiding painful haematomas following saphenectomy, reduces recovery time and improves patients' ratings of quality of life. elt in combination with pin stripping in the treatment of epifascial truncal veins a. j. flor background. in the treatment of varicose truncal veins, endolaser treatment has widely been accepted as the method of choice. yet laser treatment -in particular in epifascial veins -may result in a painful contraction. we examine the functional and cosmetic results as well as the patients' comfort, combining elt and pin stripping in patients with epifascial truncal veins. methods. preoperative evaluation is carried out by color duplex sonography. emphasis is laid on patients with a partially epifascial course of the greater saphenous vein (gsv). following extensive evaluation and information of the patient, the decision is made to use endolaser treatment (biolitec, nm) in combination with pin-stripping (retriever-pin by oesch, salzmann medico). a guiding wire is inserted, duplex-controlled or through miniphlebectomy, into the gsv at the point of perforation through the fascia. a laser fiber is then positioned at the sapheno-femoral junction, and laser energy is applied to the intrafascial part of the truncal vein ( - j=cm) depending on the vein diameter. the epifascial part of the vein is then retrieved by the pin stripper. results. until now the combination of endolaser plus pin stripping has been applied in patients. following observation periods of to months, endolaser treatment provides an occlusion rate of %. skin incisions need not be wider than mm. crossectomy can be avoided. patients tend to have more hematomas in the pin-stripped region, yet a hardened, sometimes brown coloured and often painful strand -as often seen in patients treated by endolaser only -can be avoided thereby. conclusions. in about - % of the cases, an epifascial position of the gsv might been detected by duplex sonography. in cases of epifascial course of the truncal vein, decision to use elt treatment alone should be considered critically. in such cases, endolaser treatment combined with pin stripping should result in a higher degree of patient comfort, apparently providing an optimal solution for a minimally-invasive approach. endovenous laser treatment with the nm laser system; years of experience, follow-up of over veins k. freudenthaler background. chronic venous insufficiency is a common desease. the aims are to offer a minimal invasive alternative to traditional surgery such as crossectomia and stripping with less pain for the patient and a short reconvalescence. methods. since years over patients with more than veins have been treated by evlt, by grand saphenous veins a valve repair by venocuff ii was possible. only patients have been treated by traditional crossectomia and stripping. usually the grand and the short saphenous vein as well as the acessoria vein, insufficient perforaters and the giacomini anastomosis are treated by evlt. the treatment is done in general or in local anaesthesia and monitored by permanent ultrasound control. in no case a surgical crossektomia was necessary. after treatment the patient has to wear a compression stocking for two weeks dayover and should not lift heavy duties. results. after treatment the results are verified by ultrasound. the patients are controlled after one week, month and yearly thereafter. the total sucess rate is % in all cases (complete resorption of the treated vein). there were no complications like pulmonal embolia, infects or skin burns. conclusions. the evlt is a very safe treatment of chronic venous insufficiency and offers a minimal invasive alternative to traditional surgery such as crossektomia and stripping. Ö sterreichische gesellschaft fü r chirurgische forschung: die zukunft hat schon begonnen -bedeutung der molekularen biologie fü r diagnostik, prognose und therapie in der gastrointestinalen chirurgie proteomic profiling of the secretome of human liver endothelial cells (hlec) background. liver endothelial cells play significant roles in the physiology and pathology of the liver. they are not simply barrier cells regulating the traffic of blood components to the parenchyma and vice versa, but highly specialized cells with complex roles, including scavenger functions and regulation of inflammation, leukocyte recruitment and host immune responses to pathogens and shaping of the microenvironment by secretion of functionally relevant proteins. thus, investigation of the functional and physiological properties of lec is critical in understanding liver biology and pathophysiology. the aim of this study was to establish techniques to isolate and cultivate human liver endothelial cells and to obtain a protein profile of the secretome of quiescent and vegf-activated hlec. methods. hlec from unaffected tissue of resected liver segments from patients undergoing surgery for liver tumours were isolated using magnetic beads coated with anti-cd -antibodies. cells where cultured in medium ebm- (mv) supplemented with vegf, bfgf, igf, egf, heparin, endothelial cell growth supplement and % fetal calf serum. expression of endothelial cell surface markers cd , cd , cd e, cd and podoplanin as well as fibroblast marker cd was investigated by facs. hlec where starved for h in protein free medium and activated with vegf for further h. supernatants were collected and subjected to shotgun proteomics. human umbilical vein endothelial cells (huvec) served as a control. results. isolated cells where morphologically similar to huvec. % of cells where positive for cd , cd , and cd . % expressed cd . % of cd positive cells where positive for podoplanin. expression of cd was low, but consistent. cd e was induced in % of cells and expression of cd was upregulated fold after h activation with tnf-. shotgun proteomics of the secretome revealed a distinct differ-ence in the secretion pattern of several functionally relevant proteins compared to huvec. conclusions. our results point towards a significant and persistent difference in secretion patterns of functionally relevant proteins between hlec and other endothelial cells both in quiescence and after vegf activation. these findings may lead to a better understanding of physiology of the liver. finally, this study demonstrates the suitability of magnetic bead isolation in combination with in vitro cell culture and proteomics for investigation of hlec functions. hypermethylation of sfrp gene in stool dna test: a future technology in colorectal cancer screening w. zhang, w. hohenberger, k. matzel background. stool dna test is considered as a future technology in screening for colorectal cancer (crc). both genetic and epigenetic changes in shed cells from gastrointestinal tumours into stool could be detected. epigenetic hypermethylation can result in transcriptional silencing of tumour suppressor genes and is considered to be a key event of sporadic colorectal carcinogenesis. sfrp is a tumour suppressor protein that contains a domain similar to one of wnt-receptor proteins and inhibits wnt-receptor binding to its signal transduction molecules. detection of hypermethylation of sfrp gene in human dna isolated from stools might provide a novel strategy for the detection of sporadic crc. our study aims to prove the methylation status of sfrp gene in stool samples, and compare the dna methylation status before and after neoadjuvant radiochemotherapy. methods. to explore the feasibility of stool dna test, fecal samples were obtained from crc patients (crc patients post neoadjuvant radiochemotherapy n ¼ ). twenty fecal samples were obtained from patients without evidence of gastrointestinal disease or neoplasia. isolated genomic dna from stool was modified with sodium bisulfite and analyzed by specific pcr for methylation of sfrp promoter. results. with stool dna test we were able to detect the hypermethylation in the promoter region of sfrp gene in the fecal dna from colorectal cancer patients (p ¼ . ). sensitivity was %, specificity was %. methylation status of sfrp gene was significantly changed after neoadjuvant radiochemotherapy (p ¼ . ). conclusions. the hypermethylation of sfrp gene in the stool dna test has a high sensitivity and specificity for crc and may be valuable for screening purposes, especial for the sporadic crc. compared with current colorectal cancer screening methods, stool dna test is more patient-friendly, non-invasive, more sensitive and specific. the cost-effectiveness of screening may also be improved by using single dna stool test with one sensitive dna marker. the methylation status of sfrp seems to be changed after neoadjuvant radiochemotherapy, which may open new fields for crc research. summarized this new diagnostic tool may yield ben-efits in earlier detection and in the design of better antitumour interventions. background. although the function and interaction partners of the glycoprotein dickkopf- (dkk- ) still remain unclear, gene expression of dkk- has been shown to be upregulated in tumor endothelium of colorectal cancer. for the first time, we analyzed expression of dkk- protein and its potential as a marker of neoangiogenesis in colorectal cancer. methods. we utilized tissue microarrays (tmas) to evaluate dkk- protein expression in microvessels of colorectal cancer samples from patients, in microvessels of adjacent tissue samples from the same patients compared to normal colorectal mucosa tma samples. a second microarray section was stained with cd to quantify neoangiogenesis by defining the microvessel count. results. out of cancer samples with cd positive microvessels, . % were dkk- positive in all microvessels. these samples showed a significantly higher mean microvessel count ( . vessels) than dkk- negative samples ( . vessels; p ¼ . ). dkk- protein expression increased with rising numbers of microvessels per sample (p < . ). out of cd positive adjacent tissue samples, % were dkk- positive. these samples also had a higher mean microvessel count ( . vessles) than dkk- negative samples ( . vessels; p < . ). similar to colorectal cancer tissue, dkk- expression in non-cancerous adjacent tissue increased with rising numbers of microvessels (p < . ). in contrast, all microvessels in normal colorectal mucosa samples demonstrated a negative staining reaction for dkk- . univariate analysis of several clinicopathologic variables in correlation to dkk- expression revealed significant differences in tumor site (colon vs. rectum; p ¼ . ) and mean age (p ¼ . ). survival analysis according to kaplan-meier method showed a statistical trend toward a higher diseasefree survival for patients with dkk- negative samples (p ¼ . ). conclusions. our study demonstrates for the first time that microvessels of colorectal cancer and adjacent non-cancerous tissue are identical concerning dkk- protein expression, but distinct from normal colorectal mucosa. therefore, dkk- can be considered as a putative pro-angiogenic protein in the process of neovascularization, may have the potential to serve as a marker for neoangiogenesis, and may represent a target structure for novel therapeutic approaches. nevertheless, it is mandatory to further confirm these findings using normal tissue sections. background. we have developed the first genetically engineered oncolytic influenza a viruses (ns deletion viruses), which replicate and lyse cancer cells but are apathogenic in normal tissue. infection of influenza a viruses are usually highly dependent on the presence of a serine-like protease (i.e. trypsin), which cleaves the viral entry protein, the hemagglutinin. cancer cells are known to endogenously produce proteases. methods. we here investigate, whether colon cancer associated proteases support lytic growth of the oncolytic influenza viruses in those cells. results. ns deletion viruses grew to high titers in the colon cancer cell lines caco or ht- independent of the addition of trypsin. correspondingly, viral infection rate, cleavage of the hemagglutinin and virus-induced cytopathic was not compromised by the lack of trypsin in these cell lines. zymogram analysis indicated that the caco and ht- associated protease is not trypsin itself but trypsin unrelated. conclusions. the specific activation of the influenza a virus in colon cancer cell lines suggests an effective use of this virus for oncolysis in colon cancer in vivo. background. for decades the bile pigment bilirubin has been considered a toxic waste product of heme catabolism. however, serveral clinical studies show an inverse correlation between elevated plasma bilirubin levels in healthy individuals and the incidence=mortality of colorectal cancer. based on these findings, we hypothesized that bilirubin and its precursor biliverdin may suppress tumor cell growth in vitro and inhibit tumor progression in vivo. methods. in vitro hrt- colon cancer cells were treated with bilirubin at various concentrations or pbs as a control. a casy cell counter was used for proliferation assays. cell cycle progression and apoptosis were analyzed by facs. western blot analysis was carried out using antibodies directed against p , rb, p , parp- and caspase as well as total and phosphorylated forms of erk, mek and akt. further, cells were treated with pharmacological inhibitors of mek and pi -kinase in presence or absence of bilirubin. in vivo, nude mice bearing hrt- tumors were treated with bilirubin i.p. at mg=kg=day or pbs as a control. tumor size was measured using a caliper. statistical analysis was performed using anova. results. bilirubin significantly inhibited proliferation of hrt- colon cancer cells in a dose dependent manner. this mainly was mediated by induction of g =g cell cycle arrest and apoptosis through strong activation of akt, mek and erk resulting in overexpression of the cell cycle regulators p , p , hypophosphorylation of rb as well as an increase of parp- and caspase cleavage. the antiproliferative effects were dependent on akt and erk activation, in that inhibition of upstream pi -kinase and mek reversed the effects observed under bilirubin treatment. in vivo, bilirubin dramatically decreased tumor growth by % (sd ae . ) when compared to the control. conclusions. bilirubin is a potent inhibitor of hrt- colon cancer cell growth in vitro and in vivo, presumably by modulating mitogen activated protein kinase signaling pathways resulting in cell cycle arrest and apoptosis. background. tetrahydrobiopterin (bh ) is an essential cofactor for nitric oxide synthases and thus a critical determinant of no production. recently we have shown that bh depletion contributes to ischemia reperfusion injury (iri) after pancreas transplantation. here we analysed the therapeutic potential of bh supplementation during organ procurement and the early post-transplant period. methods. murine cervical heterotopic pancreas transplantation was performed with a modified no-touch technique. pancreatic grafts were subjected to h prolonged cold ischemia time (cit) and different treatment regiments: untreated (i), bh mm to perfusion solution (ii), bh mg=kg i.m. at reperfusion (iii). nontransplanted animals served as controls (iv). intravital fluorescence microscopy was used for analysis of graft microcirculation by means of functional capillary density (fcd) and capillary diameters (cd) after h of reperfusion. quantitative assessment of inflammatory responses (mononuclear infiltration) and endothelial disintegration (edema formation) was done by histology (h&e) and peroxynitrite formation assessed by nitrotyrosineimmunostaining. results. fcd was significantly reduced after prolonged cit, paralleled by an increased peroxynitrite formation, when compared with controls (all p < . ). microcirculatory changes correlated significantly with intragraft peroxynitrite generation (spearman: r ¼ À . ; p < . ). pancreatic grafts treated with bh either during retrieval (ii) or systemically (iii) displayed markedly higher values of fcd (p < . ) and abrogated nitrotyrosine staining (p < . ). cd were not significant different in any of the investigated groups. histologic evaluation showed increased inflammation, interstitial edema, hemorrhage, acinar vacuolization and focal areas of necrosis after h cit in group i, which could be diminished by both bh treatment regiments (p < . ). conclusions. bh treatment significantly reduces postischemic deterioration of microcirculation as well as histologic damage and might be a promising novel strategy in attenuating iri in clinical pancreas transplantation. methods. forty-seven biopsies obtained from the endoscopic esophagogastric junction in patients ( females, males; age ; range - years) with symptoms of gastroesophageal reflux disease were processed for histopathology and immunohistochemistry. biopsies were stained with routine h&e and immunofluoresence staining using an antibody directed against hydrogen=potassium atpase (h þ =k þ atpase beta) (pot) for detection of parietal cells (pot ¼ monoclonal clonal mouse igg antibody, g clone, dilution : ; product numberma affinity bioreagents d- hamburg, germany). pot detects the beta-subunit of hydrogen= potassium atpase in bovine, human, canine, porcine, rabbit, mouse, ferret, and rat tissues. histopathology in h&e stained sections was conducted according to the paull-chandrasoma classification of columnar lined esophagus (cle) including oxyntocardiac (ocm; mucus and parietal cells) and cardiac mucosa (cm; mucus cells only) with or without intestinal metaplasia (im ¼ barrett esophagus). out of biopsies also contained gastric oxyntic mucosa (mucus, parietal and chief cells) and served as controls (these biopsies contained both cle and om). the detection of parietal cells in h&e and pot-staining was compared. results. h&e staining showed that out of patients had cm with im (barrett esophagus), had cm without im. a total of slices was investigated ( h&e pot). pot stained the cytoplasma of parietal cells indicating the presence of biologic active acid pump. in biopsies parietal cells were only detected in pot stained slices, whereas in the other biopsies parietal cells were detected by both h&e and pot-staining. parietal cells were detected in all biopsies containing gastric om. therefore pot did not significantly increase the parietal cell detection rate in cle compared to h&e staining. conclusions. detection of ocm within biopsies from columnar lined esophagus is not significantly increased by the use of an antibody directed against h þ =k þ atpase. h&e staining is adequate for detection of parietal cells within cle. lymphovascular invasion and lymphangiogenesis in adenocarcinoma of the esophagus: impact on patient survival e. rieder , s. schoppmann , s. kandutsch , f. wrba , f. langer , c. neumayer , p. panhofer , g. prager , j. zacherl background. a special feature of esophageal cancer is its early lymphatic spread in comparison with other cancers of the gastrointestinal tract. due to the discovery of specific markers for lymphatic endothelium, selective staining of lymphatic vessels has become possible. in recent studies the prognostic value of peritumoral lymphangiogenesis and lymphovascular invasion in various human malignancies has been shown. tumor-associated macrophages (tam), expressing the lymphoangiogenic growth factor vegf-c, were shown to be related to tumor-associated lymphangiogenesis, lymphovascular invasion and lymph-node metastasis. aim of this study was to assess tumor-associated lymphangiogenesis as well as the role of tams in a cohort of adenocarcinoma of the esophagus. methods. fourty formalin-fixed, paraffin-embedded surgical specimens of patients (age range: - ) presenting with adenocarcinoma of the esophagus at the university hospital of vienna were included into this study. specimens were stained with antibodies against podoplanin, vegf-c and anti-cd . semiquantitative measurements of lymphatic microvessel density (lmvd) and lymphatic vessel invasion (lvi) were carried out. results. it could be demonstrated that lymphangiogenesis occurs in barrett adenocarcinoma and is correlated with lvi. statistical analysis revealed that lvi is associated with disease-free (p ¼ . ) as well as overal survival (p ¼ . ) of patients with barrett carcinoma. furthermore over-expression of vegf-c was seen in barrett carcinomas and vegf-c expressing tams were detected peritumoral and therfore may play a role in lymphogenic metastasis of esophagus carcinoma. conclusions. these preliminary data demonstrate that lymphovascular invasion as well as tumor-induced lymphangiogenesis is associated with patient survival in barrett adenocarcinoma and anti-lymphangiogenic therapies might be a beneficial approach. background. the role of tissue-inhibitor of metalloproteinases- (timp- ) in cancer progression is still unclear. although timp- is an important inhibitor of metastasis-associated proteases, it is often correlated with a bad prognosis. in an animal model, elevated levels of timp- , achieved by adenoviral-gene-transfer, led to induction of hepatocyte growth factor (hgf)-signaling and expression of several metastasispromoting genes in the liver, representing a host-microenvironment with increased susceptibility to a challenge of tumor cells. we examined the expression of candidate metastasis-promoting factors by qrt-pcr. methods. liver-tissues of consecutive metastatic colorectal cancer patients ( males, females; mean age, . ae . y) were obtained. to determine timp- -associated gene expression signatures in the normal liver tissue, specimen were harvested from zones greater than cm away from visible liver metastases and analyzed by quantitative-real-time-pcr (qrt-pcr, taqman + -low-density-arrays) of metastasis-associated genes. results. human liver tissue with elevated timp- levels was associated with an identical pro-metastatic gene expression signatures as previously identified in the animal model, namely increased expression of hgf, pcna, upa, upar, tpa, matriptase, mmp- , mmp- , adam- , cathepsin g, and neutrophil elastase. conclusions. we reveal here for the first time a ubiquitous (human and mouse=different tumor types) timp- -related gene expression profile. this profile, consisting of metastasis-promoting genes, can explain the correlation between tumor aggressiveness in cancer patients and increased levels of timp- and demonstrates the impact of the host microenvironment on its susceptibility to invading tumor cells. this concept is important for future considerations of cancer therapies. Ö gth -herz: varia rv-lv depolarisation-interval as a predictor of longterm-survival of crt-patients: a criteria for intraoperative quality control t. schwierz , s. winter , h. nesser , r. fü gger surgical department, elisabethinen-hospital, linz, austria; cardiological department, elisabethinen-hospital, linz, austria background. for cardial resynchronisation therapy the left-ventricular lead should stimulate the most delayed myocadial area. we introduce a method, established in or dayly routine, for intraoperative verification of the hemodynamically best lead-position. methods. the electrical distance between rv-and lv-lead we verify by measurement of the time between rv-pacing and lv-sensing (depolarisation-intervall). by a cox regressionmodel we analized the data of patients with regard to possible predictors of patients-survival following crt. results. significant predictors of survival were the age of patients (p ¼ . ), lvef (p ¼ . ), biventricularly stimulated qrs-duration (p ¼ . ), reduction of qrs-duration under biventricular stimulation in relation to rv-pacing in % (p ¼ . ), depolarisation-intervall (p ¼ . ), depolarisation-intervall in relation to qrs-duration under rv-pacing in % (p ¼ . ). conclusions. out of the predictors significant for the patients-survival following crt only the depolarisation-intervall can be influenced activly during the implantation procedure. the rv-and lv-lead should be implanted so that the depolarsation-intervall is as long as possible. ideally, the depolarisation-intervall covers the entire qrs-duration under rv-pacing. in that case the lv-lead stimulates exactly the latest depolarisized myocardial area. the fibrin derived peptide b-beta - ameliorates ischemia-reperfusion injury in a rat heart transplant model background. the purpose of this study was to evaluate the protective effect of the fibrin-derived peptide b-beta - on ischemia=reperfusion injury in a rat cardiac transplant model. methods. lew hearts were flushed with chilled ( - c) custodiol preservation solution and either transplanted immediately or stored for or h in the same solution and then transplanted into syngeneic recipients. b-beta - was given i.v. at a dose of . mg immediately after transplantation or added to the preservation solution prior to harvest. at h and d, graft function was assessed and hearts were retrieved for morphological evaluation. at time of harvest, serum samples were collected for troponin level analysis. results. hearts transplanted immediately or after h of cold ischemia did neither show any morphological damage at h nor at days. in contrast, h of ischemia resulted in severe myocardial ischemia associated with an inflammatory response at h. lesions further progressed at days. administration of b-beta - resulted in a significant amelioration of myocardial necrosis together with a diminished inflammatory response. a protective effect towards myocyte damage was further underlined by reduced troponin levels in groups receiving b-beta - . acute cellular rejection after cardiac transplantation -is there a way to reduce the number of biopsies? background. acute cellular rejection significantly contributes to mortality and morbidity after cardiac transplantation (htx). routine endomyocardial biopsies (embs) are performed to early detect and treat cellular rejection. although emb can be performed with little risk, a number of potentially fatal complications are inherent in the procedure. the aim of our investigation was to evaluate the incidence of acute cellular rejection after heart tranplantation and to evaluate possibilities to reduce the number of embs. methods. patients underwent cardiac transplantation from january through december at our institution. the mean age of the patients was . ae . years. . % were female. indication for htx was icmp in . %, dcmp in . % und others in . % of the cases. according to our institutional standard, patients underwent emb weekly during the first month after htx, biweekly during months and , monthly up to month , once in month , and . a total of embs were investigated over a follow-up period of months after htx. results. the majority of embs showed no signs of rejection ( . % ishlt ). mild signs of rejection without therapeutical consequence (ishlt ia) were found in . % of embs. rejection ishlt ib was found in . % of the evaluated embs. the incidence was . % during the first month after htx, in the second month . %, in rd month . %, in th and th month . %, in th and th month . %, and from the th month . %. a moderate rejection (ishlt ii) was detected in . %. during the first month after htx, the incidence was . %, during nd month . %, during rd month . %, in th und th month . %, in th und th month . % and from the th month . %. more severe rejections were rare ( x ishlt iiia ¼ . %, x ishlt iiib ¼ . %) and occurred in month , , and . conclusions. severe cellular rejection after htx is seldom. mild to moderate rejection episodes, however, occur more frequently. in contrast to the traditional emb schedules, rejection hardly ever occurs during the first weeks after htx. most rejection episodes are observed between the second and seventh month after htx. afterwards, the incidence of rejection lowers again. based on these findings, the number of routine embs can safely be reduced, especially during the first weeks after htx. background. renal dysfunction has consistently been one of the greatest risks for mortality with the use of left ventricular assist devices (lvad). we aimed to determine the impact of renal function on survival and time-dependent changes in renal function after lvad implantation. methods. we retrospectively reviewed patients with advanced heart failure (mean age . ae . yrs, % male, % ischemic cardiomyopathy) who received lvad implantation as a bridge to transplant therapy from to . renal function was assessed using the modification of diet in renal disease (mdrd)-derived glomerular filtration rates (gfr). patients were divided into groups based on renal function pre-lvad implantation; group : normal (gfr ! ml=min= . m , n ¼ ), group : impaired (gfr < ml=min= . m , n ¼ ) renal function. results. patient survival was comparable between the groups. the , and -month kaplan-meier estimate of survival was . %, . % and . % for group and . %, . and % for group (p ¼ . ). gfr paired sample analysis in group showed an early increase in gfr from preimplantation ( . ae . ml=min= . m ) to postoperative day (pod) ( . ae . ml=min= . m ; p ¼ . ). there was no increase in gfr from pre-implantation ( . ae . ml= min= . m ) to heart transplantation ( . ae . ml=min= . m ; p ¼ . ). in contrast, gfr paired sample analysis in group showed an early increase in gfr from pre-implantation ( . ae ml=min= . m ) to pod ( . ae . ml= min= . m ; p< . ), and a further increase in gfr from pod ( . ae ml=min= . m ) to pod ( . ae . ml= min= . m ; p ¼ . ). there was a significant increase in gfr from pre-implantation ( . ae . ml=min= . m ) to heart transplantation ( . ae . ml=min= . m ; p< . ). conclusions. renal function improves rapidly after lvad implantation. renal dysfunction does not adversely affect outcome after lvad implantation. methods. bed interdisciplinary paediatric intensive care unit, university hospital. patients. patients after open heart surgery; prospective controlled study. group a received mg tc=kg bodyweight pre-and post operation and h after operation, whereas group b received mg tc=kg bw in the same period. drug levels and routine laboratory parameters were investigated daily in the picu. the aim of both groups was a tc serum concentration of - mg=l by adapting dosage after h. results. in group a tc concentration were . ae . and . ae . mg=l after and h, in group b . ae . and . ae . mg=l (p < . both), respectively. crp values were in group a ae . mg=l and ae . mg=l and in group b ae . mg=l and ae . mg=l (p < . and p < . ), respectively. there were no differences in physiological scoring. conclusions. to achieve drug levels of tc higher than mg=l during the first h after surgery, the higher dosage of mg=kg bw had to be administered initially. the high tc dosage was well tolerated and was associated with significantly lower crp in the first two days. background. the fontan operation eliminates the systemic hypoxemia and ventricular volume overload in congenital patients with single ventricle physiology. retrospectively, we report on our longtern results of surgical palliation and on different concepts concerning tcpc (total cavo-pulmonary connection). methods. between and , a total of patients (mean age . ae . years) underwent surgical fontan palliation at our institution by tcpc technigue. in % of all patients, a staged concept was carried out, patients had a central fenestration ( mm). all of our latest patients in the operation series were palliated -according to the new ''fontan concept'' -with an extracardiac conduit as second step. in , inhalative no (nitric oxyde) therapy was also introduced in the early postoperative phase. results. kaplan-meier overall survival after a mean followup of years was . % (in patients with staged procedure . %, . % in patients with fenestrated fontan). out of patients survived a periopertive fontan take-down. without any exception, we lost patients in the learning curve phase, of them because of neurologic complications, patients died due to low cardiac output (lco). in those patients who were palliated with an extracardiac fontan, mortality was %; furthermore under no-therapy, perioperative mortality also was %. after ae months of follow-up, % of all patients were in nyha i, % in nyha ii, % of all patients were in sinus rhythm. pleuropericardial effusions were found in % of all patients. conclusions. definitive palliation by means of tcpc in patients with congenital single ventricle physiology leads to more than acceptable clinical results. staged palliation, fenestration procedures, extracardiac fontan and inhalative no-therapy were introduced as ''modern'' surgical therapy concepts and resulted in a significant positive influence on perioperative and longterm clinical results. neue erkenntnisse in der mund-, kiefer-und gesichtschirurgie background. as we are living in an aging society, the number of active patients older than is increasing. the impact of age on trauma related injuries, e.g. femur neck fractures, and their outcome has been well documented in the literature. so far, data on a broad cohort suffering from oraland maxillofacial injuries (omfi) are missing. thus it was the aim of the present retrospective analysis to observe the effect of increasing age on trauma related omfi. methods. the records of patients with omfi were collected at the department of cranio-maxillofacial and oral surgery at the medical university of innsbruck in the period from = = to = = . according to the who definition of elderly people the collected values were divided into persons older than years of age and younger. were younger and were older than years. data were registered regarding: diagnosis, age and gender, cause, type and localization of the injury and concomitant injuries. subsequently the data of both groups were compared and statistically analysed. statistical analysis was performed in spss (version . ) using chi-square-test, fisher s exact test and mann-withney u test. this was followed by a logistic regression analysis in order to investigate trends and to demonstrate significant differences between the groups. a value of p< . was considered significant. results. with increasing age the risk for a domestic accident was raising. the accident mechanism in the elderly people was mainly a fall ( . %) or was not reproducible ( . %). there was a significant difference between both groups regarding concomitant injuries. . % of the older and . % of the younger patients suffered from additional neurological symptoms (p < . ). until the age of the risk for concomitant neurological injury is increasing, beyond there is no significant higher risk. the injuries in the older patients were mainly referred to the soft tissue and the mid face. conclusions. thanks to major progress in general health care the percentage of elderly and most notably active old people in our society has been constantly stepping up in the past three decades. the increased number of concomitant injuries in elderly people requires a detailed investigation of the injured patient. furthermore medication and possible cardiovascular disease of the older generation restricts the indication for surgical treatment of these patients. influence of different surface termination on surface energy and subsequently on connective tissue attachment in vivo background. connective tissue attachment is of major significance for the longevity of transdermal=-mucosal implants. a tight soft tissue sealing around the implant prevents from acute and chronic infections. major focus of former investigations has been the influence of different surface roughness on the connective tissue attachment to the implant surface. the aim of the current investigation was to demonstrate the influence of different surface terminations of nano-crystalline diamond (ncd) on surface energy and subsequently its influence on in vivo connective tissue healing. methods. ncd coated titanium membranes were terminated either by hydrogen or oxygen and were compared to pure titanium membranes. these samples were evaluated by contact angle measurement, scanning electron microscopy, atomic force microscopy and electrostatic force microscopy to evaluate the surface potentials. to assess the in vivo integration, the different substrates were randomly distributed and inserted into the sub-dermal layer of wistar rats. animals were sacrificed after , and weeks to investigate the adjacent connective tissue histologically. cell number, connective tissue=implant contact ratio and scar formation were evaluated. statistical analysis was performed using wilcoxon-rank test and kruskal-wallis h-test. p < . was considered significant. results. the ncd coating of the titanium membranes preserved its microstructure. contact angle measurement confirmed h-termination hydrophobic and o-termination hydrophilic. o-termination resulted in a strong polarity, whereas no electrostatic interactions were observed at the hydrophobic surface. the histological evaluation demonstrated a comparable cell number after week in all groups. after four weeks a significantly increased cell number at the o-terminated ncd with a less tight scar formation was observed. furthermore a markedly higher connective tissue=implant contact was observed after weeks at the hydrophobic surface. conclusions. o-termination of ncd renders the surface electrostatically active. the surface polarity promotes connective tissue healing in vivo. furthermore the surface energy is of higher importance compared to the structure of the surface. the o-termination of surfaces thus is a promising technique for a controlled influence of connective tissue adhesion in vivo. the risk of concomitant injuries and complications in cranio-maxillofacial trauma. das risiko von begleitverletzungen und komplikationen in der kiefer-gesichtschirurgie background. the registration of concomitant injuries on patients with cranio-maxillofacial trauma is an important criteria to optimize the healing process and to minimize the incidence of complications due to unlevied diagnostic findings. interdisciplinary, cranio-maxillofacial trauma management includes exact documentation. therefore a large collective of patients was examined against the background of their maxillo-facial trauma to diagnose the additional injuries. methods. between - at the department of oraland maxillofacial surgery among patients with craniomaxillofacial trauma, patients ( . %) with concomitant injuries were registered. data of patients were recorded including age and gender, cause and type of injury, location and frequency of their additional trauma. statistical analyses performed including descriptive analysis, chi square test, fisher's exact test and mann-whitney s u-test. logistic regression analysis determined the impact of different ages on the type of injury. results. within patients (mean age ¼ . ; #:$ ¼ . ) the most common sort of concomitant injury occured during sports, household and play ( . % each). the most frequent type of additional injury was the commotio cerebri in . % ( patients). fracture of the base of the skull occurred in patients ( . %), patients had a fracture of the skull and patients suffered from contusio cerebri. even one patient had a paresis of the facial nerve. in patients injuries of the eye were denoted, among them . % had a contusio bulbi and patients a retrobulbar hematoma. contusio of the lung appeared in . %, blunt abdominal trauma in . % and a fracture of the cervical spine in . % of patients with concomitant injuries. in patients fractures of the facial bone were recorded. soft tissue injuries of the face were found in patients ( . %). in concomitant injuries male persons aged between to are prone to cervical spine fractures (increase of %=year of age) and thoracal injuries (increase of %=year of age), as well as neurological trauma (increase of %=year of age) mainly found in traffic accidents. conclusions. in the catchment area of our department injuries of the neurocranium and the eye were often associated with trauma of the viscerocranium. interdisciplinary and coordinated management is not only important for the initiation of preventive measurements but also for forensic causes. to minimize the complication rate and to optimize the therapy a neurological-, neurosurgical-, as well as eye-consiliary examination should be preferably accomplished at a preoperative stage on the awakened patient. background. orbital injury may lead to incarceration of periorbital tissue and to ocular motility disturbances and diplopia on a long-term basis. however, orbital surgery is not free of risks. the treatment of periorbital lesions demands a precise planning approach in order to secure high success rates without causing iatrogenic damage. we want to demonstrate computer assisted surgery as part of the surgical routine of posttraumatic orbital reconstruction. methods. four cases of posttraumatic orbital deformities are presented. two patients showed protruding bone fragments after unrecognized fractures of the orbital walls. two patients presented with foreign bodies in the orbital cavity after shotgun injuries. in all four patients preoperative acquired ct-data was reformatted on a commercially available d-navigation system. image guided surgery in the orbital cavity was performed using an intraoperatively calibrated high-resolution endoscope. results. the shotgun pellets and the protruding bone fragments were easily detected and removed via a minimal invasive access. diplopia and bulb motility improved significantly. postoperative rehabilitation was restricted to a few days. conclusions. according to our opinion computerized navigation surgery of the orbit can improve the results of surgery in terms of safety and accuracy. these extended techniques should lead to a more direct and less invasive method for approaching orbital lesions or posttraumatic deformities giving the surgeon a high degree of security in sparing vital anatomic structures. background. surgically assisted rapid maxillary expansion (sarme) has become a widely used and acceptable technique to expand the maxilla in adolescents and adult patients. sarme takes the advantage of bone formation at the maxillary edges of the midline, while they are separated by an external force. sarme is indicated in patients with isolated, considerable (more than mm) transverse maxillary deficiency. while surgically assisted palatal expansion is performed in patients after closure of the sagittal palatal suture, conservative rapid maxillary expansion can be used in younger patients. studies concerning such cases show, that just % of the expanded width is located in the area of the palatal suture, while the rest of the extention ( %) are reached by dentoalveolar movements like tipping. the aim of this study was to evaluate the amount of expansion caused by expansion of the maxillary suture and by the dentoalveolar complex. furthermore changes of the nasal cavity should be discussed. methods. all patients included in the study showed a tranverse maxillary deficiency of at least mm. all patients were older than years ( min, max). in all patients a fractional le fort i osteotomie consisting of sagittal osteotomie and osteotomie of the anterior maxilla and the pterygoid bone was performed. ct scans were performed preoperatively and about weeks postoperatively (after the needed expansion). measuring points were defined to evaluate the skeletal and the dental changes after maxillary expansion. conclusions. the results of the current study will be presented. background. the main indication for microvascular reconstruction of the face is the best possible functional and aesthetic outcome. here every special kind of missing tissue is to be substituted. by using the chimera-flap technique a combination of different transplants for individual defect coverage is possible. methods. in seven patients with extended or penetrating defects of the lower face, reconstruction was performed with a double flap technique. a combination of microvascular iliac crest transplants or microvascular femur transplants for mandibula reconstruction and an anterolateral thigh perforator flap (altpf) or saphenus perforator flap for soft tissue reconstruction was performed after ablative tumour surgery. the pedicle of the altpf or saphenus flap was used for elongation of the microvascular bone flap pedicle. all patients had radiotherapy weeks after surgery. results. all patients had good functional and aesthetic results and have been successfully treated with implant retained prostheses. there were no severe postoperative complications. there was no tumour relapse within - months postoperatively. conclusions. the chimera-technique makes good aesthetic and functional outcome possible. the iliac crest transplant is of a good dimension for reconstruction of non-high atrophic mandibles after complete resection. the microvascular femur is well suited for covering partial defects of the mandible. implant placement is possible in both transplant types. the altpf and the saphenus perforator flap have a low incidence of complications and donor site morbidity and can be shaped adequately to a soft tissue defect of the lower face. parry-romberg-syndrom (hemiatrophia faciei progressiva) -interdisziplinäre zusammenarbeit mehrerer ü bergreifender fächer bei der definitiven diagnosestellung und den daraus resultierenden therapiemöglichkeiten zugt gesichts-und schädelskelett. die hemiatrophia faciei progressiva (v. romberg) ist primär durch einen schwund der betroffenen gesichtsseite, an der die haut, das subcutane fettgewebe und bindegewebe und später auch die muskelatur und die gesichtsschädelknochen beteiligt sind. die ausgeprägte gesichtsasymmetrie ist häufiger als ein funktionsausfall ursache der behandlung. nur eine effiziente diagnostik sichert eine gute therapie und gute resultate bei einem romberg-syndrom-patienten. bei der diagnostik wird nicht nur die mund-, kiefer-und gesichtschirurgie herangezogen, sondern interdisziplinär mit der dermatologie, hno, mund-, kiefer-und zahnheilkunde, augenheilkunde, neurologie, psychiatrie, plastischen chirurgie und radiologie zusammengearbeitet. es werden die jeweiligen disziplinen mit ihrem abklärungsgebiet beim romberg-syndrom präsentiert und dargestellt. in jeder disziplin werden die patienten in der dermatologie auf eine sklerodermie, in der neurologie -anhand eines mrtsdie neuralgiformen symptome und in der augenheilkunde die ophthalmologischen symptome, in der radiologie -anhand von bildgebungsverfahren (ct, szintigraphie) die knochenaktivität in bezug auf die fortschreitende knochenatrophie untersucht und abgeklärt. die therapieform wird nach der diagnosestellung und der daraus resultierenden diagnosebestätigung und anhand der symptomatik beim patienten bestimmt. verschiedene therapieoptionen wie eine autologe lipoinjektion, eine fettgewebstransplantation, eine freie mikrochirurgisch-anastomosierende fettgewebslappenplastik oder injektion allogener materialien werden angewendet. die diagnostik und das chirurgische vorgehen werden an zwei fallbeispielen demonstriert. die grundlegenden behandlungsstrategien stammen aus der zeit der beiden weltkriege. Ä nderungen der konzepte ergaben sich im bereich der sekundären rekonstruktion verlorengegangener strukturen sowohl im weichgewebe als auch im hartgewebsbereich durch etablierung neuer operationstechniken, welche die erzielung besserer ästhetischer und funktioneller ergebnisse ermöglichen. neben der beschreibung des traumamechanismuses erfolgt anhand von klinischen fällen die darstellung der versorgungsprinzipien. responsible for preventing fecal incontinence as well as enabling defecation. methods. works on anorectal vascularization are presented and diagnostic tools for clinical practice are discussed. results. filling and drainage of the internal hemorrhoidal plexus can be visualized by transperineal color doppler ultrasound. the terminal branches of the superior rectal artery exclusively contribute to the arterial blood supply of the internal hemorrhoidal plexus. according to anatomical studies an intramural network of anastomoses exists between the superior and inferior rectal arteries. ultrasound studies of the anorectum clearly highlighted a stage-dependent alteration of the morphology and perfusion of these terminal branches in different grades of hemorrhoids. conclusions. hypervascularization of the anorectum is proposed to contribute to the growth of hemorrhoids rather than being a consequence of hemorrhoids. pre-and postoperative assessment of the anorectal vascularization helps to judge the success of a technique for treatment of different grades of hemorrhoids. the doppler-guided haemorrhoidal artery ligation is a new, minimally invasive technique in the treatment of haemorrhoidal disease. since february patients with symptomatic second and third degree haemorrhoids have been treated this way at our department. postoperative complications occurred in , %. one month after treatment % of the patients were symptom-free and satisfied with the results. since there are very little data regarding the efficiency and the patient comfort on the long term, we questioned consecutive patients which had undergone surgery between february until december st . the questionnaire was done via telephone using standardised questions. patients with persisting or recurring symptoms were invited for a control re-examination. the results of this follow-up will be presented. background. guidelines may be helpful to standardize the management of hepatocellular and cholangiocellular carcinoma as the diagnostic and therapeutic spectrum has been considerably enlarged by recent developments. methods. ''state of the art'' guidelines deducted from the literature and from recent consensus conferences are elaborated; issues that remain controversial or not sufficiently documented by data are discussed. results. some standards have been introduced in hepatic surgery such as preoperative evaluation of liver function (and portal branch embolisation if required) or intraoperative ultrasonography. for other essential items such as techniques used for transsection of liver parenchyma or for hemostasis a variety of possibilities is at choice and the decision often depends on the personal attitude of the surgeon. as success of surgery is influenced by so many factors and imponderabilities, exact clinical evaluation is delicate and statements fulfilling the strict criteria of evidence based medicines are rarely found. only in a minority of patients with hepatocellular carcinoma transplantation or resection is possible. for the remaining patients, a variety of therapeutic procedures are warranted with effects difficult to compare given the bias of patient selection and the great inter-patient and inter-institutional variability. in the treatment of patients with bile duct carcinoma, surgery (liver resections for klatskin tumors stage bismuth i-iii, whipple's procedure for more distally localized tumors), if feasible, plays a key role as well. conclusions. excellent interdisciplinary cooperation is the clue to providing ''state of the art'' management of hepatocellular and cholangiocellular carcinoma. treatment not only has to consider tumor type and stage, but also the individuality and the overall condition of every single patient. background. colorectal carcinoma is one of the most common malignant diseases primarily diagnosed in the industrialized world. thanks to standardized surgical procedures and multimodal treatment concepts, the prognosis has improved considerably in recent decades. methods. state-of-the-art treatment of colorectal carcinoma is presented and discussed on the basis of the current literature, including the current status of minimally invasive techniques in the surgical treatment of malignant colorectal disease. results. carcinomas of the colon and rectum are two separate entities as far as biology, probability of local recurrences, metastasis patterns, surgical strategy and multimodal treatment regimes are concerned. operative treatment of colon carcinoma is generally standardized, but the concept of sentinal node biopsy is a new aspect. a metaanalysis of stage ii colon carcinoma showed a survival advantage of up to % for adjuvant therapies including -fu. the mortality rate for stage iii colon cancer could be reduced by - % with adjuvant chemotherapy. the operative standard for rectal carcinoma is heald's technique of total mesorectal excision. for proximal rectal carcinomas, a partial mesorectal excision with a greater distance (at least cm) to the edge of the tumor is adequate. with rectal carcinoma, neoadjuvant radiochemotherapy is more effective at reducing local recurrences and involves fewer complications than does postoperative treatment. accordingly, neoadjuvant radiochemotherapy is indicated at least for t- tumors of the lower and middle thirds of the rectum. in all, total survival and fewer local recurrences are seen with combined radiochemotherapy for rectal carcinoma. a number of randomized prospective studies published since showed comparable long-term results for laparoscopic and open colon surgery. the results of such studies on rectal carcinoma are not yet available. conclusions. the key factors for improving the prognosis of colon and rectal carcinoma are, besides early diagnosis, standardized surgery and multimodal, individualized treatment concepts. prophylactic operations in palliativ surgerya conflict? background. to date approximately % of the eu-citizens decease on malign tumors. here an increased tendency was noticed in the past. this circumstance is present in the surgical day-to-day life. patients with predictable and linited prognosis often require the decision whether a prophylactic surgical procedure would prevent further complications or may declerate progression of malign tumors. methods. the status and progression of patients with oncological focus were analyzed in the department of surgery of the helios-hospital schwerin. two groups were studied. first surgical procedures due to general symptoms of the tumorous disease. second, surgical therapy of specific symptoms as a consequence of the tumor. results. inter-disciplinary diagnosis and discussion were crucial for the decision whether a palliativ-prophylactic operation was necessary or not. futhermore, prophylaxis in palliative medicin and surgery required a multi-disciplinary therapy regime. for the inter-disciplinary decision, guidelines proposed by the established ''tumorboard organization'' were applied. for general symptomatic treatment, palliativ-prophylactic procedures due to pain therapy, gastro-intestinal symptoms, emesis, ileus, ascites, icterus, cachexia, respiratory and urological complications, and wound management were accomplished. conclusions. prophylactic operations are frequent and represent the reality in palliative surgery. the ''tumorboard organization'' was administrable for a structured ultimate therapy decision. here forensic guidelines regarding self-determination, protection of integrity, autonomy of the patient, and euthanasia have to be considered. the perception of the personally responsibility of the attending physician still possess highest priority. background. within the last decade thyroid surgery has been radicalized. two parties have emerged from the discussion. one group, trying to preserve thyroid as central element of the body -the other one, in light of an easy replacement therapy, does not feel the need for that. methods. we compare patients operated from - at our department. one group underwent dunhilloperation (dh) n , the second thyroidectomy (t) n . complication rate and change of therapy were compared, remaining tissue was sonographed. the patient's opinions were sought using questionnaires. results. monitoring period lasted - months. recurrensrate showed no significant difference (dh: . =t: . ) and bleeding results also didn't show any differences. we did notice a higher hypoparathyroidismus rate with the thyroidectomy group (dh: . =t: . ). % of all sonographies in the dunhill group required further investigation because of remaining nodulare tissue. changes with substitution therapy didn't show any differences. the patient's opinions were identical in both groups. conclusions. both techniques require a simple substitution therapy. they are both safe methods, although the hypoparathyroidism is higher with thyroidectomy. on the other had we observed a progress in learning over the years thus we noticed no significance in . when using dunhill procedure, remaining tissue must be checked regularly. in our opinion, it is no benefit for patients with replaced tissue. evaluation of a new needle for thyroid fine needle aspiration biopsy p. wretschitsch , m. glehr , t. kroneis , a. leithner , r. windhager background. to verify the destinction of thyroid tumors, the volume of harvested cells in fine needle aspiration biopsy is one of the significant parameters for histological criteria and diagnosis. in consequence of the new aeration valve, the new needle is deaerated after the aspiration. thereby no blood or other not thyroid-cell elements are aspirated and more thyroidcells are harvested. methods. under blinded setting punctures, for each needle (standard needle, -needle with air valve and multi needle system with air valve), from fresh pig thyroid gland were made and recorded. the measurement was done according the manufacturers recommendations for casy (casy + technology, reutlingen). the aspirated cell material was evacuated into ml casyton (cell-culture liquid, casy + technology, reutlingen) and calculated with the casy (casy + technology, reutlingen) cell counter. total cell amount and amount of vital cell was counted and recorded. statistical analysis was performed using t-test (p < . was considered significant). results. per needle respectively punctures were made and counted. the mean cellular amount of the standard needle was cells=ml. the mean cellular amount of the -needle system with aeration valve was cells=ml. the average of cell amount for the multi needle system (thyrosampler + kurtaran-frass, vienna) was cells=ml. the mean difference between the standard needle and the -needle system with air valve was significant with total cells (p ¼ . ) and with vital cells (p ¼ . ). the difference between -needle and multineedle system was not significant with total cells (p ¼ . ) and with vital cells (p ¼ . ). tag conclusions. the needle systems with the air-valve lead to a significant higher cell amount in needle aspiration biopsy. according to the requirement of cytological diagnosis more cell volume could be harvested, which is a well-defined benefit. does the lunar phase influence the incidence of postoperative haemorrhage after thyroid surgery? a preliminary report background. it is claimed by non-scientific sources that operations carried out at waxing moon or especially at full moon are associated with a higher incidence of postoperative complications. therefore patients referring to lay press confront surgeons with the lunar phase's influence and claim for special dates for surgery. postoperative haemorrhage is a typical complication after thyroid surgery with an incidence of about . %. thus it is a suitable to assess this assumption by evidence-based data. methods. we retrospectively evaluated patients requiring reoperation after thyroid surgery. the exact time of skin incision was evaluated by anaesthesia's reports and its lunar phase was calculated by an online-calculator. results. in a timeframe of days (in all) around full moon patients had to be reoperated, days around new moon patients needed surgical reintervention. patients were operated during waxing moon, the phase that is believed to be a risk for postoperative complications, and patients during waning moon. no differences were seen between the categories st þ th quarter ( operations), the quarters around new moon, and nd þ rd quarter ( operations), the quarters around full moon. conclusions. our study shows no correlation between postoperative haemorrhage after thyroid surgery and lunar phase at initial surgery. these evidence-based data prove, that lunar phase does not influence the risk of bleeding after surgical interventions. these results should serve as information for those patients, who are convinced, not to be operated during full moon phase. the result should also bring the ''superstition'' to a halt. background. recently gender-specific medicine has become the focus of interest. after thyroid surgery we observed more hypocalcaemia-related symptoms in women than in men. our goal was to find out gender-specific differences in the postoperative calcium-and parathyroid hormone (pth)-kinetics. methods. pth-and calcium-levels as well as postoperative hypocalcaemia-related symptoms were monitored according to a prospective protocol. a total of women and men underwent extensive thyroid surgery. postoperative calcium levels revealed a non-significant difference of . mmol between women and men on the st postoperative day. perioperative pth-kinetics showed no significant differences too, neither in symptomatic patients, nor in the whole study population. the rate of postoperative hypocalcaemia-related symptoms was about higher in women than in men ( - %, respectively). conclusions. despite of similar perioperative pth-and calcium-kinetics women suffer more often from postoperative hypocalcaemia-related symptoms. the mechanism remains unclear and needs further research in gender-specific postoperative calcium-metabolism. background. grave's disease (gd) is thought to be associated with a higher incidence of postoperative hypocalcaemiarelated symptoms. methods. parathyroid hormone (pth)-and calcium-levels as well as postoperative hypocalcaemia-related symptoms were monitored according to a prospective protocol. preliminary data were analysed for patients with an observation period of more than months. results. total or near-total thyroidectomy was carried out in patients with gd and patients with benign euthyroid multinodular goitre. differences between patients with gd and patients with benign euthyroid nodular goitre were found for postoperative hypocalcaemia-related symptoms ( . , . %, respectively). these findings were statistically significant (p < . ). furthermore, no significant differences were found in perioperative pth-and calcium-kinetics between the groups. patients with gd were of a significant (p < . ) lower mean age ( ae ) than patients with benign euthyroid multinodular goitre ( ae ). conclusions. there is a significant higher risk of postoperative hypocalcaemia-related symptoms after surgery for gd compared to benign euthyroid multinodular goitre. there is no significance concerning the risk of permanent hypoparathyroidism in our preliminary data set. background. intraoperative parathyroid hormone [pth] monitoring is an important prerequisite for minimally invasive parathyroid surgery. thus, surgical success essentially depends on the correct intraoperative interpretation of the pth-decay. pth-''spikes'' caused by unintentional ''manipulation'' of the hypersecreting glands during dissection may lead to interpretation problems. it is unclear how often these ''spikes'' occur and how they influence the operative strategy. we evaluated manipulated pth-excretion during surgery in a large number of patients and analyzed its influence on the interpretation of the intraoperative pth-curve. methods. intraoperative pth-values (intact pth, nichols, san jose, california) of patients with primary hyperparathyroidism and single gland disease were analyzed. of these patients, ( . %) were successfully treated with open minimally invasive parathyroidectomy (omip), ( . %) with primary bilateral neck exploration (bne) and ( %) patients had to be converted from omip to bne. to evaluate the occurrence of manipulation, patients were divided into groups: ''moderate'' pth-increase (< pg=ml), ''extensive'' increase (> pg=ml), ''no'' increase (ae pg=ml) and ''decrease'' before excision. changes were referred to the ''baseline''-level which was sampled right after induction of anaesthesia and before incision. intraoperatively, pth was measured before, , and min after removal of the enlarged gland. results. overall ( %) had a moderate increase and ( . %) an extensive increase. no increase occurred in ( . %) and a decrease in ( . %) patients. in patients undergoing omip, ( %) glands were manipulated moderately, another ( %) glands were extensively manipulated, ( . %) had no increase and ( . %) had a decline. in patients undergoing primary bne, ( . %) glands were manipulated moderately, ( . %) extensively and ( %) had no increase. a decrease was observed in ( . %) patients. a conversion from omip to bne was performed in patients because of incorrect preoperative localization by sestamibiscintigraphy and=or sonography. five ( %) of them had moderate manipulation and no patient had extensive manipulation. eighteen ( %) showed no pth alterations and ( %) a decrease, retrospectively. in none of the converted patients a misinterpretation of pth-''spikes'' were the underlying cause. conclusions. the data show that intraoperative manipulation is documented in bne and omip. the ''spikes'' caused by unintentional manipulation were identified by a subsequent prolonged pth-decline but did not lead to a change in the surgical strategy. parathyreoideakarzinome zählen zu den seltenen tumoren und sind für weniger als % aller primären hyperparathyreoi- background. at international meetings, delegates from many countries report an increasing lack of young doctors willing to choose operative specialities. the aim of this study was to evaluate the working conditions for surgeons in austria and to define the most crucial items calling for amelioration. methods. an anonymous survey was prepared and by e-mail all the members of the austrian surgical society were asked to complete a questionnaire which could be reached online by a direct link. it comprised twenty questions and was kept deliberately short in order to require a minimum of time for response. results. just some examples of the essential items can be given here: working conditions (such as working hours and payment) have to be improved. notably the young surgeons require career perspectives that are better and defined more clearly. the time spent for non-medical duties such as organization and documentation must be reduced. more priority is needed for surgical training both in the operating room and in practically oriented courses. conclusions. this evaluation provides the basis for further discussion at a session dedicated to this topic during the austrian surgical congress of . background. surgical training and education is neither standardized nor regulated. there is no validation, no obligatory training goal and no implementary rotation system. recently, the training permission for surgeons in education in the surgical department of kaiserin elisabeth spital has been shortened by the austrian medical association from to years without evidence based data i.e.without the consideration of the underlying number of operations performed in the clinic. methods. the surgical department is a center of thyroid and parathyroid surgery, which also covers the extended oncological cases, minimal invasive surgery, hernia operations and has the largest capacity for acute abdominal diseases in vienna. to analyze the quality of surgical education, the whole number of operations as well as the number of trainees in nd and th training year are tallied for analysis. results. in , a total number of operations ( thyroid and non thyroid operations) have been performed in our surgical department. trainee a ( years of education) performed ( thyroid and non thyroid operations), trainee b ( years of education) operations ( thyroid and non thyroid operations). the non thyroid operations of trainee a included cholecystectomies, herniotomies, appendectomies, operations of colon or small bowel, all other will be listened in detail. trainee a had = , trainee b = gastroscopies=colonoscopies performed. conclusions. the number of operations prove that the goal of training for surgeons in education is easily achievable. the reduction of training permission by the vienna medical chamber was not evidenced by data. however, this procedure has once again raised the insufficient structures in surgical education, the lack of valid training program and standardized approaches for a defined rotation and the obligation for both, senior surgeons and trainees to perform a certain number of teaching operations. a structured reform of rules and regulations for training is necessary. background. the purpose of this study was to review our hospital's experience in a retrospective single-center analysis of all patients undergoing surgery for posttraumatic thoracic pathologies between and . methods. from to october a total of aortic procedures were performed at our institution. eighty eight patients ( . %) underwent an intervention ( surgical procedures, stentgraft implantations) due to a posttraumatic injury of their thoracic aorta. in > % the descending aorta was involved, the injuries consisting of % aortic rupture, . % posttraumatic pseudo-aneurysms and . % aortic dissection. in the surgical cohort . % of the patients had to undergo an emergency procedure, . % an urgent and . % an elective procedure. there were . % female patients and . % male patients with a mean age of . years (range - yrs). results. during the three decades total hospital mortality was . % with a decrease over the years, thus resulting in a hospital mortality of . % ( - ) versus . % ( - ) . hospital mortality in the emergency group dropped from . % ( - ) to . % ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . improved outcome is mainly due to preoperative aggressive control of blood pressure and aortic shear forces using -blockade, intraoperative the use of heparin bounded circuits with cardiopulmonary bypass and most of all, a selectively delayed operative procedure (!). conclusions. although endovascular stent graft techniques continue to evolve, emergent=urgent patients will be anatomically not suitable for stent grafts and long term outcomes have yet to be determined. we therefore still consider selectively delayed surgery in patients with posttraumatic aortic pathology as a cornerstone in the choice of treatment for these patients. combined surgical and endovascular repair of complex aortic pathologies with a new designed hybridprosthesis background. in the present study the use of a new combined surgical and endovascular approach in the treatment of aortic dissection or aneurysm is evaluated. the aim of this technique is to treat extensive aortic diseases in a single stage procedure. the operative and follow up data are summarized in this report. methods. between = and = six patients ( ae years; female) with different aortic pathologies ( dissections, aneurysms) underwent replacement of ascending aorta, aortic arch and stentgraft implantation into the descending aorta using the e-vita open endoluminal stentgraft under circulatory arrest in moderate hypothermia with selective antegrade cerebral perfusion. the stentgraft was deployed under direct vision through the open aortic arch into the true lumen. results. intraoperative antegrade stenting of the descending aorta combined with distal ascending aorta and aortic arch repair was performed successfully in all patients. all patients survived the procedure one patient had neurological deficit, which recovered completely. a complete thrombosed perigraft space was observed in patients after one to eleven days. in two patients a partial thrombosis of the false lumen of descending aorta was observed. one patient underwent thoracoabdominal repair five months later. conclusions. this report shows that a combined surgical and endovascular approach of extended aortic lesions is a feasible option and extends aortic repair in a single stage method without increase of risk. background. to evaluate mid-term results of supraaortic transpositions for extended endovascular repair of aortic arch pathologies. methods. from through , patients (mean age yrs) with aortic arch diseases were treated (arch aneurysms n ¼ , type b dissections n ¼ , perforating ulcers n ¼ ). strategy for distal arch disease was autologous sequential transposition of the left carotid artery and of the left subclavian artery in patients. strategy for entire arch disease was total supraaortic rerouting using a reversed bifurcated prosthesis in patients. endovascular stent-graft placement was performed metachronously thereafter. results. two in-hospital deaths occured (myocardial infarction on the day prior to discharge n ¼ , rupture while waiting for stent-graft placement n ¼ ). at completion angiography, all reconstructions were fully patent. four patients had small type ia endoleaks, two of them resolving spontaneously. mean follow-up is months ( - months) . three late deaths occured (myocardial infarction n ¼ , sudden unknown death n ¼ ). one year survival was % and three year survival was %, respectively. redo stent-graft placement was performed in one patient after months (type iii endoleak). the remaining patients had normal ct scans with regular perfusion of the supraaortic branches without any signs of endoleaks. conclusions. mid-term results of alternative treatment approaches in elderly patients with aortic arch pathologies are satisfying. extended applications provide safe and effective treatment in patients at high risk for conventional repair. background. to determine mid-term durability of endovascular stent-graft placement in patients with perforating atherosclerotic ulcers (pau) involving the thoracic aorta and to identify risk factors for death as well as early and late adverse events. methods. from through , patients (mean age yrs) presented with pau, seven patients had rupture. seventy-eight percent were unsuitable for conventional repair. mean numeric euroscore was and mean logistic euroscore was . median follow-up was ( - ) months, being complete in all patients. outcome variables included death and occurrence of early and late adverse events. results. in-hospital mortality was %. primary success rate was %. actuarial survival rates at , and years were , and % and actuarial event-free survival rates were , and %, respectively. hemodynamic instability as well as logistic euroscore was identified as independent predictos of early and late adverse events. conclusions. endovascular stent-graft placement in patients with pau is an effective palliation for a life-threatening sign of a severe systemic process. hemodynamic instability at referral and a high preoperative risk score predict adverse outcome. during mid-term follow-up, patients are mainly limited by sequelae of their underlying disease. background. the performance of endovascular stent-graft placement in patients suffering from aneurysms involving the descending aorta originating from chronic type b dissections is unclear. methods. within a two-year period, we treated six patients with this pathology. four patients required extension of the proximal landing zone (autologous double transposition n ¼ , subclavian-to-carotid artery transposition n ¼ ) prior to stentgraft placement. results. supraaortic rerouting procedures and endovascular stent-graft placement were performed successfully in all patients. closure of the primary entry tear, full expansion of the stent-graft and consecutively, thrombosis of the false lumen was achieved in five patients. in one patient with a short proximal landing zone, a persisting type ia endoleak had to be observed. in all patients with successful primary entry closure, a reduction in aneurysm diameter could be seen. mean follow-up is months ( - months). conclusions. endovascular stent-graft placement of aneurysms involving the descending aorta originating from chronic type b dissections may serve as a valuable treatment option in a complex pathology. the chronic dissection membrane can be successfully approximated to large parts of the native aortic wall. a sufficient proximal landing zone is mandatory for early and late success. background. the aim of the study was to determine late vascular events in patients after endovascular stent-graft placement of thoracic aortic diseases. methods. between and a total of patients (mean age a; % male ¼ ) underwent endovascular stentgraft placement of thoracic aortic diseases at our institution. indications were aneurysms (n ¼ ), acute and chronic type b dissections (n ¼ ), penetrating ulcers (n ¼ ) and traumatic transsections (n ¼ ). results. during a median follow-up of months ( - months), in % of patients, late vascular events were observed. the highest incidence was observed in patients after stent-graft placement for type b dissections ( %), closely followed by patients after stent-graft placement for penetrating ulcers ( %). the incidence after stent-graft placement for aneurysms was %. no events were observed in patients after traumatic transsections. interestingly, patients undergoing stent-graft placement due to dilatative arteriopathy developed further dilatations in other regions and patients undergoing stent-graft placement due to obliterative arteriopathy were more prone to sustain obliterative diseases in other vascular beds. conclusion. this study clearly outlines the necessity of a close follow-up in these patients, not only to assess long-term outcome of endovascular stent-graft placement, but also to monitor these patients for new vascular pathologies. tenascin-c as a key factor in the remodeling of the ascending aorta leading to chronic dilatation and acute type a dissection background. the extracellular matrix molecule tenascin-c (tn-c) plays an important role in embryonic development, wound-healing, cancer invasive fronts and myocardial remodeling by loosening the linkage between connective tissue and cells lying within. as there is clear evidence for an involvement in vascular remodeling as well, we hypothesized tn-c being a mediator in the pathogenesis of chronic dilatation of the ascending aorta and acute aortic dissection. methods. ascending aortic wall specimens were obtained from patients undergoing aortic reconstruction due to chronic dilatation of the ascending aorta (n ¼ ) and acute aortic dissection stanford type a (n ¼ ). specimens of patients (n ¼ ) undergoing aortic valve replacement with a macroscopically normal aorta served as controls. formalin-fixed paraffin-embedded specimens were morphologically evaluated by hematoxylin-eosin staining and immunostaining for tn-c expression. results. there were no differences in clinical characteristics concerning age and gender between patients with acute dissection, chronic dilatation and control. patients with a known connective tissue disorder or bicuspid aortic valve were excluded from the study. histologic examination showed a clear difference between chronic dilatation and acute dissection. in chronic dilatation tn-c staining was homogenously distributed throughout the media parallel to the orientation of vascular smooth muscle cells. in contrast specimens in acute aortic dissection showed a focal strong positive staining especially surrounding vasa vasorum and sites of intramedial hemorrhage and subsequent dissection throughout the whole vessel wall with tn-c negative areas in between. whereas in control aorta tn-c expression was almost absent. conclusions. these data suggest a role for tn-c in the remodeling of the ascending aorta leading to chronic dilatation and type a dissection. keeping in mind the differences in tn-c expression between chronic dilatation and acute dissection one may speculate that changes of the vascular wall leading to aortic dissection are mediated or at least accompanied by a change in tn-c distribution. a complicated type b-dissection: how (not) to do it j. demmer , m. alavian , p. pichler , c. groß chirurgie , akh linz, linz, austria; radiologie, akh linz, linz, austria complex type b-dissection is still accompanied with high mortality. we report on a years old male with a weeks ongoing history of thoracic pain. he was admitted to another hospital where a left renal artery stenosis in ct scan was suspected and a stent was applied into the false lumen of this artery. then the patient was transferred to our institution. angiogram revealed a type b-dissection with a hugh entry distal to the left subclavian artery, the coeliac trunk arising from the false lumen but the hepatic arteries adequately collateralized by the superior mesenteric artery. though guidewire insertion to the true lumen of the common hepatic artery was feasible, stent application was not possible.the entry in the proximal descending aorta was covered with an endostent, thoracic pain disappeared immediately. though a slight pain in the right upper abdomen and a moderate raise of got, gpt and y-gt was to be seen for a few days, the patient could be discharged weeks after stenting in good condition without having pain or signs of cholecystitis. another days later he was readmitted in bad condition with signs of peritonitis in the right upper abdomen, , wbc and a massive increase of liverenzymes. laparatomy was performed immediately. the gallbladder presented necrotic, the whole liver dark blue without any pulsation in the hepatic arteries. after choecystectomy an autologous venous bypass from the common iliac to the propriet hepatic artery was performed. the postop. course presented uneventful, angio-ct at postop. day showed a well contrasted bypass. the patient could be discharged at postop. day without any signs of infection and only slightly elevated liverenzymes. background. endovascular aneurysm repair (evar) evolved as a treatment option for high risk patients, in whom previously open graft replacement (ogr) could only be carried out with a high, nearly prohibitive risk or open repair even had to be denied. by employing evar the mortality rates (mr) were lowered to - % in specialized centers. unsolved is the problem of how to deal with patients unsuitable for evar. the hypothesis of this study was to test whether thoughtful watching combined with management of present risk factors or ogr were second best to evar in asa class iv patients with abdominal aortic aneurysms (aaa). methods. out of a total of aaa-patients two groups of asa class iv patients were selected and compared. group consisted of patients who underwent ogr from - . group included patients unfit or unwilling to undergo evar in the period from - . kaplan-meier survival estimates were calculated and possible differences were analyzed by the log-rank-test. results. the day survival was . % in group versus % after days following the denial of operation in group (p < . ). the days survival was again significant with p < . , group % versus group . %. after one year survival was not significant anymore, i.e. group . % versus group . % (p < . ). conclusions. ogr has a significantly worse survival than conservative treatment in asa class iv patients in the first months after operation. after one year both treatment options show similar results. background. abdominal aortic aneurysm (aaa) size has been recognized as risk factor of rupture. several reports presented evidence that aaa with diameters exceeding . cm are associated with increased risk of rupture compared to smaller aneurysms. regarding these findings a diameter of more than . cm is generally considered as indication for exclusion. this analysis was undertaken to determine the influence of aneurysm diameter on long term outcome after either type of elective aaa repair. methods. eight hundred and sixty four consecutive patients underwent elective repair of an infrarenal aaa either by open graft replacement (ogr, n ¼ ) or endovascular aneurysm repair (evar, n ¼ ) from january, , through june, . median aaa diameter was chosen as threshold to discriminate between small and large aneurysms. patient characteristics, distribution of preoperative risk factors and postoperative outcome after either type of aaa exclusion were assessed. survival was compared using kaplan-meier estimates at years. results. overall median aaa diameter was . cm as well as in both treatment groups. analysis of risk factors only re-vealed that patients with larger aneurysms were significantly older (ogr . years vs. . years, p < . ; evar . vs. . years, p < . ) but comparison of individual health status expressed by the american society of anesthesiologists (asa) score did not reach statistical significance. at years, overall survival was higher in patients with small aneurysms ( . vs. . %, p < . ). similar results were obtained in patients undergoing ogr ( . vs. . %, p < . ) as well as evar ( . vs. . %, p < . ). conclusions. patients with aneurysms smaller than . cm have improved survival at years after either type of elective aaa repair. large aneurysm diameter is accompanied with increased age, which might negatively influence long term outcome. thus, the provoking issue to exclude small aaa before they reach . cm may rise again. background. about microsurgical techniques without sutures many references in literature databases are found. among facilities like rings, clips, stents, laser and adhesives the vessel coupling system (coupler + ) is mentioned. thereby two coupling rings interlock, which anastomose the vessels. methods. over the last two years in our division the coupler + was used in nine cases of free tissue transfer for breast reconstruction. in six of them the arterial and venous anastomosis were performed with the coupler + , in three cases only the venous anastomosis was done mechanically. in all cases the anastomosis was end-to-end. results. because of insufficient arterial adaptation in two cases we switched to a conventional procedure with sutures. all the other anastomosis showed a normal flow. except of one partial necrosis of a flap, which was not due to the coupler + , all flaps survived. the mean duration of doing the anastomosis was less than five minutes. conclusions. the coupling system (coupler + ) is a useful, secure and time saving tool for the venous anastomosis when performing a free tissue transfer. for the arterial anastomosis the conventional method is preferable, especially in cases of arteries with thick walls. background. non-operative management of splenic injuries is beneficial compared to surgery in hemodynamically stable patients. aim of this study was to assess whether conservative treatment would also translate into better quality of life post injury. methods. all consecutive patients with splenic injuries between january to february were included. splenic injuries were graded according to aast recommendations [ ] . patients were identified from our electronic inpatient index and stratified by non-operative treatment (non-operative group, nog) or primary surgery (splenectomy) (surgical group, sg). postdischarge quality of life was evaluated by a standardized telephone questionnaire. data are reported as total numbers (%) and statistical analysis performed using chi -tests. significance was assumed if p < . . results. of a total of patients enrolled, ( . %, nog) were treated non-operatively, and ( . %, sg) underwent splenectomy. splenic injury grading was comparable between both groups. after trauma, most patients were able to leave their bed three days after trauma ( rd postoperative (po) day: nog ( . %) vs. sg ( . %), p ¼ . ; st week po: nog ( . %) vs. sg ( . %), p ¼ . ; nd week po: nog ( . %) vs. sg ( . %), p ¼ . ), and the majority felt seriously ill during hospitalization (critically ill: nog ( . %) vs. sg ( . %), p ¼ . ; seriously ill: nog ( . %) vs. sg ( . %), p ¼ . ; not very ill: nog ( . %) vs. sg ( . %), p ¼ . ). unlike sg patients, about half of the nog patients could be discharged one week after trauma ( week: nog ( . %) vs. sg ( . %); p ¼ . ). sg patients significantly longer felt severe pain compared to nog patients ( weeks: nog ( . %) vs. sg ( . %), p ¼ . ; > months: nog ( . %) vs. sg ( . %), p ¼ . ). after discharge, nog patients were able to resume daily life activities earlier compared to patients after surgery ( weeks: nog ( . %) vs. sg ( . %), p ¼ . ; < month: nog ( . %) vs. sg ( . %), p ¼ . ; ! months: nog ( . %) vs. sg ( . %), p ¼ . ). conclusions. patients with non-operative management reported less pain and were earlier able to resume daily life after splenic trauma compared to patients undergoing splenectomy. plantation in order to prevent cmv disease. we recently evidenced immunomodulatory properties of pooled human immunoglobulines. the aim of this study was to evaluate influence of cytotect + and cytoglobin + a) on proliferative properties of peripheral blood mononuclear cells (pbmcs), b) on cell viability and c) on natural occurring cell mediated cytotoxicity. methods. pbmcs from healthy donors (n ¼ ) were stimulated with anti-cd ( mg=ml) or in an allogeneic mixed lymphocyte reaction (mlr). proliferation was determined by incorporation of [h]-labeled thymidine. apoptosis was measured by flow cytometric analysis (annexinv, -aad, cd , cd , cd , cd ). transmission electron microscopy (tem) was utilized to support facs data. antibody dependent cell mediated cytotoxicity (adcc) was determined utilizing a standard europium release assay. cmvig (cytotect + biotest, cytoglobin + bayer) was used at therapeutic concentrations in all experiments. results. cytotect + and cytoglobin + evidenced anti-proliferative properties in t-cell specific stimulation and in mlr blastogenesis assays. this effect was dose dependent and ceased at concentrations of . mg=ml (p < . ). facs analysis and tem pictures revealed that the reduced proliferation was associated with induction of apoptosis in stimulated as well as in resting pbmcs (p < . ). furthermore, adcc against panc- and jurkat cell lines was significantly reduced after preincubation of effector cells with cmvig (p < . ). conclusions. our results provide evidence that cmvig containing drugs possess, in addition to their known application as passive cmv immunization, immunological features related to tolerance induction. background. multichannel intraluminal impedance (mii) monitoring is a new diagnostic tool for esophageal bolus transport and reflux assessment. methods. review on mii technology for diagnosis of esophageal disorders. results. impedance is a measure of resistance to the flow of an alternating electrical current. a low voltage current is applied to surface ring electrodes on a nonconductive catheter. impedance is determined by the conductivity of the medium bridging these electrodes. entry of liquid into the esophageal lumen produces a drop of impedance. gas entry results in a sudden rise of impedance. monitoring impedance in several channels detects direction, velocity and extent of the movement of liquid or gas through the esophagus. stationary equipment combining manometry and impedance is used for simultaneous esophageal motility and transit studies. transport studies using impedance only can also be done with probes intended for reflux testing. saline and a viscous gel are used to assess transport through the esophagus. in a recent study with combined impedance and manometry a significantly higher proportion of patients with incomplete transport of both liquid and viscous boluses ( = , %) presented with dysphagia than patients with complete transport of both ( = , %) or incomplete transport of only one ( = , %) of the test substances. equipment joining impedance with high-resolution manometry is currently being developed. a higher sensitivity and specificity for regional motility and transport abnormalities is to be expected from this technical advancement. portable recorders are available for -hour mii-and ph-monitoring. refluxes are detected by retrograde impedance changes: liquid refluxes are characterised by retrograde drops, gas refluxes by rapid increases and mixed liquid=gas refluxes by a sequence of both deviations from the baseline. the main advantage of impedance technology over conventional ph-monitoring is the detection of refluxes independent of ph. off antisecretory medication refluxes with ph > are mainly encountered postprandially, at a time when regurgitation is commonly experienced by reflux patients. the diagnostic yield of symptom to reflux association analysis is significantly increased by the inclusion of refluxes with ph > . distribution of impedance channels along the catheter facilitates the calculation of reflux exposure at different levels above the lower esophageal sphincter. conclusions. mii is a valuable new diagnostic tool for esophageal transport assessment without radiation exposure. combined mii-and ph-monitoring significantly increases the diagnostic yield of reflux testing. both applications of impedance technology have implications on surgical decisionmaking. trans-illuminated powered phlebectomy w. mayerhoffer the trans-illuminated powered phlebectomy was introduced in austria in about by smith and nephew as the ''trivex system''. a . mm shaver, as used by orthopaedists for cartilage, was used in order to mill out subcutaneous veins in a transilluminated technique. due to only a few and small incisions needed, the method seemed very attractive, so many surgical departments started using this orthopaedic equipment. most surgeons had a lot of complications, such as disastrous extensive haematomas, which made them stop using this method. mean while the trans-illuminated powered phlebectomy has been further developed. instead of the orthopaedic tools, a special phlebologic equipment is used now which allows the vein to be ''sucked'' out in a very non-traumatic order, instead of being milled out. the procedure is standardized and can be reproduced easily. it shows to be a non-traumatic and minimal invasive method to extract subcutaneous varicose veins, leaving a minimum of scares. large clusters of varicose veins are the best indication to use this procedure. the veins are made visible by transillumination in order to be accurately removed through a minimal number of small incisions. the new equipment and the technique will be described and explained. examples and results will be shown. background. total endoprosthesis in wrist joint is a rather new procedure compared to hip and knee surgery. biomechanics of the wrist joint is very complex and therefore designing the carpal and radial component of the prosthesis should respectfully consider this. indication for joint replacement and total endoprosthesis are posttraumtic and degenerative arthrosis of wrist joints. generally we tend to perform a partial fusion depending on where the arthrosis is located, but we have stopped to perform total arthrodesis of the wrist joint due to unsatisfying long term results, according to literature. we perform total endoprosthesis in all cases when a partial fusion is impossible for any reason or a total arthrodesis would be indicated. methods. nine males [ - a] four females [ - a]. seven of nine men suffered from a posttraumatic arthrosis ( slac snac). all patients sufferd from serious reduction of range of motion and severe pain. in one case a partial fusion was converted into a total prosthesis. two women had degenerative alterations of their wrists based on rheumatoid desease. the follow up covered months to years. results. in = cases range of motion was improved impressively and pain was relieved almost completely. seven men displayed a rom of s = = ; pro-supination totally unaffected and free. in one case we found rds. x-ray examination revealed a slightly false implant position of the radial component to us. rom in women was at least s = = . conclusions. in the beginning of wrist joint endoprosthesis results were less well and it was shown that this was due to misunderstanding biomechanical basics of the wrist joint. the fixation of the carpal element was a severe problem, like passing through the cmc , and joint line distally into the basis of the metacarpal bones and since cmc and joints have a rather high rom the distal element consequently often loosened immediately. recent implants respectfully avoid passing through these joints and loosening of the distal element has never been seen in all our cases. in our opinion the endoprosthesis of wrist joint is a real alternative to common procedures in the treatment of wrist arthrosis. background. volar fixed-angle plate osteosynthesis of distal radius fractures is a new method of treatment that provides the benefits of stable internal fixation without incurring the disadvantages of the dorsal approach. the aptus + plate is a new fixation implant that was introduced specifically for the purpose of managing dorsal displaced fractures (colles fracture) from the volar aspect. the aptus + system provides stepless multidirectional placement of screws. the range of swivel ae in all directions, can be freely selected by the surgeon. methods. between april and september ( months) we have seen patients with a distal radius fracture. eighty five patients ( women, men; mean age . years) were treated with the medartis + aptus + plate. our therapy regimen: closed reposition in the operating room palmar access along the radial side of the flexor carpi radialis (fcr) muscle plating with subchondral screw placement begin of physiotherapy on the first postoperative day and removeable orfit splint for weeks. results. the clinical and radiological follow up after Ø months showed no secondary loss (relative protrusion of the ulna, dorsal or radial tilting) of correction. compared to the contralateral side the range of motion was decreased for % in extension=flexion, % in ulnar=radialduction, % in pronation=supination. the grip strength was decreased for % compared with the contralateral side. the castaing score shows perfect results, good results, adequate result and no moderate, poor or bad results. conclusions. our data clearly show that secondary correction loss can be avoided with the aptus + system. the system provides a reliable subchondral screw placement and solid support for the joint surface. this new plate makes meaningful early mobilization possible. the palmar approach provides exact fracture reposition and with its good soft-tissue coverage not only reduces the risk of infections but also offers the possibility of not having to remove the plate. a cancellous bone graft is not necessary. background. the arthrosis of the first carpometacarpal joint is one of the most common problems in handsurgery. primarily elderly women are affected by rhizarthrosis. under conservative treatment the continuing progress leads to operation indication, for pronounced pain and insufficiency of conservative therapy options. the huge amount of well-know operation methods shows, that no satisfying option could have been described. next to simple resection procedures, today interposition and suspensionarthroplasties play a key role in the care of arthrosis of the thumb saddle joint. the amount of endoprothetic procedures in the first carpometacarpal joint has been rather small, the results often remained unsatisfying. a rather new concept is the prosthesis elektra, developed by fixano in , that reminds of the classic de la caffiniere prosthesis, first described in . methods. in the years = in our department patients (Ø . years - , male:female ¼ : ) with advanced saddle joint arthrosis were treated with different operation methods: patients received an elektra-prosthesis, patients a resection-suspension arthroplasty martini. thirty seven of these were recorded in the follow-up study. the rest of the patients were deceased, removed or not accomplishable. the follow up examination contained following criteria: dash score, subjective pain scale, range of motion and radiology. results. in the follow-up examination of patients no significant differences in average results of the different operation methods could be investigated. thus, the group of patients with very good results contained significantly more patients with elektra prostheses than patients treated with martini operation. in the opposition a higher complication rate could be seen in patients with elektra prostheses. especially the loosening of the implant cup was a frequent complication in average dash score, subjective pain scale and range of motion showed similar results in both methods. conclusions. our results show that the elektra prosthesis is a good and efficient alternative method to other well-known treatment concepts of rhizarthrosis. the amount satisfying results of the elektra group excel the good results in the martini group. the biggest problem concerning the elektra prosthesis is the high frequency of cup loosening, that is unacceptable high. the treasons for that matter could be complex: . biomechanical problem, because of the converting of a saddle joint to a universal joint, . metallurgic problem that could be solved by the use of different surface material, . vitality problem of the os trapezium because of an unfavourable quotient of metal and bone. unsettled remains, if revision or cementing of the cup could be a possibility to salvage of the implant. a conversion of the procedure to resection methods is possible anytime. so the use of the elektra prosthesis still is a good alternative under the condition of a clear indication and information of the patient about the possibilities of loosing. background. posttraumatic arthrosis as well as loss of function in the pip joint due to rheumatoid disease mean for the patient to be afflicted with pain. in many cases this leads to serious diminution of quality of life and in some cases the patient looses his occupation. it is the goal of implantation of total endoprosthesis to sustain movement and improve the range of motion, but most importantly to exterminate the pain. certainly removement of pain can be obtained by a simple arthrodesis but this of course is less satisfying in comparsion with mobility in the pip joint provided by the prosthesis. since pip joint endoprosthesis is a relativley young and new procedure there are only view experiences found in literature. methods. nine pip-endoprostheses have been implanted without cement so far. in cases posttraumtic arthrosis was the indication for this procedure; in cases rheumatoid destruction of the joint. in all cases the collateral ligmantes were intact. four lpm and sr avantas were used. postoperative the finger was placed on a splint for one week in intrinsic plus position. after days we commenced passive ergotherapiy and after one week we started with active motion. results. mobility was improved impressively in cases. all patients were almost completely free of pain. all pipjoints were stable. there was one patient who suffered from a new trauma after the operation and the proximal component had gotten loose, so we had to convert it to an arthrodeses. in cases we found a significant loss of extensor tendon function. conclusions. development and design of pip endoprosthesis has not found its final goal; this can be told by the variety of pip-joints which are found in the free market. passing throgh the extensor tendon is a sensitive point in the procedure and it should be noted in the preoperative information that there might be a decreased extensor tendon function. nevertheless in our eyes the pip prosthesis represents an intersting alternative to pip-arthrodesis and in cases of failure of the prosthesis it can be easily converted into a classical arthrodesis. osteosynthesis of proximal humeral fractures using a dynamic angular stable plate e. aschauer , l. schmid , c. maier unfallchirurgie, bad ischl, austria; fa. hofer, fürstenfeld, austria background. fractures of the proximal humerus are frequent and represent a therapeutic problem. the proximal humerus plate of the dfd system (double-fix-dynamic) fixes the fragments angular and rotational stable and is implanted minimally invasive. a special instrument allows precise closed reduction. due to the dynamic character of the osteosynthesis bone healing is stimulated. methods. two plates are connected with short screws in linear holes so that they can move against each other. the head fragment is fixed to the main plate with long screws coming steeply from distally. the dynamizing plate fixes this situation to the humeral shaft. for implanting the plate is fixed to a guide instrument, which therefore can be used as a joy-stick. so it is possible to reduct the shaft to the head exactly. to implant the dfd only two small incisions are required. one of cm to slip the plate under the delta muscle and to insert the head screws. and a second of cm proximally to fix the guide instrument and insert the shaft screws. in bad ischl the dfd-php is in use since november . up to now patients were operated. fourty three were female, male. the average age was . years ( - ). in cases it was a dislocated subcapital fracture. nineteen had a threepart-, a fourpart fracture. four fracture dislocations and true headsplits also could be done with closed reduction on this technique. four fractures were located at the anatomical neck. results. our first experiences were very well. currently we cannot report any complications due to the implant. there was no loosening or breakage. we watched no loss of reduction. noticeable was lack of pain immediately after the operation. so the patients came back to their former level of activity very fast. our complications were one infection forcing us to remove the implant -the case came to an end in pseudarthrosis which the patient bears well. another lady suffered a repeated fracture caused by a slight injury. one pseudarthrosis happened due to too early removal. conclusions. with the dfd-php now an implant is available that enables us to expand the indications for head preserving therapy of proximal humeral fractures. especially older people benefit from this method because there is hardly soft tissue damage but nevertheless a reliable stable situation that leads to bone healing in correct position and a good shoulder function. background. treatment of unstable distal metaphyseal tibial fractures with intramedullary nailing remains challenging even in fractures without intra-articular involvement. proximity to the ankle and biomechanical aspects makes the surgical treatment more complicated compared to fractures of the midshaft. intramedullary nailing (imn) is the ''golden standard'' for midshaft fractures but can be challenging in distal metaphyseal fractures. therefore, optimal surgical treatment of these fractures remains controversial. the aim of our study was to evaluate different tibial nails of the newest generation in a biomechanical approach. methods. defined osteotomy was performed in sawbone composite tibial fractures to create an unstable distal tibial fracture model. after nail insertion, distal tibial locking was performed with or locking screws. samples were cyclically loaded with , cycles and increasing load from ae n to and n. defined parameters such as alignment, varus, valgus deformation, antecurvation and recurvation were recorded. samples were then statically loaded until failure. acoustic emission technique was used to detect microfractures of bone, screws and nail. data according to failure of screws and nail were obtained. results. in case of physiological loading ( , cycles; ae n) loss of stability and damage of screws, nails and bone could not observed. failures occurred in loading series. stiffness was significantly higher in tibial nails with distal locking screws. stability of nail-bone construction was significantly higher in nails with distal locking options and in nails with diameter of distal locking screws more than mm. conclusions. intramedullary nailing can be recommened in unstable distal metaphyseal tibial fractures without intra articular involvement. four distal locking screws with . mm diameter should be used. our data suggests that immediate full weight bearing is possible postoperatively in young healthy patients without osteopenia even in this fracture type. because of the rising number of implantation rates of hip and knee arthroplasty as well as the increase number of osteosyntheses of the femur in geriatric patients the periprosthetic fractures are becoming more importance in orthopedic and trauma surgery. osteoporosis and the high rate of comorbidity makes a strong preoperative planning of the operation procedure necessary. prosthesis loosening or defects of the periprostetic bone may indicate a revision arthroplasty. in the new literature ostheosynthesis is usually conducted with locked screw plates as well as with intramedullary locking nail systems. a traditional alternative is the application of a condylar plate. usually used in trochanteric and subtrochanteric fractures of the proximal femur as well as in complex distal femur fractures it is also an effective implant system in periprosthetic fractures. several examples are shown and discussed. we respect to the classification of periprostetic fractures of johanson in our report about patients. six of them underwent a revision arthroplasty and in cases an osteosynthesis was done. five of them include the implantation of a condylar plate. the improved trauma room management by installation of a four-phase watch g. fronhöfer, m. kerl background. since the parameters of the severe traumatised patients of the trauma hospital graz have been collected and analysed at the trauma register of the dgu. according to the recommendation of the dgu a special four-phase watch was installed in to improve the effectiveness of the diagnosis and treatment process optimize in the trauma room. methods. the watchface has the typical colour coded phases and a flipchart shows the prepared standard sequence of trauma room management which has been developed interdisciplinary by surgeons, anesthetists, radiologists and carers. the parameters and the time process are further documented according to the guidelines of the trauma register of the dgu. results. the timelapse to x-ray or ct is reduced, the diagnoses are found quicker and patients can therefore be treated earlier at their adequate therapy. the motivation of the medical team is increased. conclusions. the four-phase trauma room watch has a many advantages and as recommended by the dgu should be installed in each trauma room. background. the treatment of an acute abdomen is without a doubt a domain of the surgical department. there are already specific treatment algorithms in place. due to the ever-present pressure to keep costs to a minimum, as well as the ever-changing technical advancements of diagnostics, it is vital to re-think and possibly modify existing treatment algorithms. therefore, patients in our facility were analyzed. methods. in erlangen, patients with an acute abdomen were treated in the timeframe from january , to december , . the average age was years, and the ratio males:females was : . . all data were collected prospectively through patient histories as well as clinical documentation. consequently, they were retrospectively evaluated. following the case history, labarotory tests and physical examination, sonography of the abdomen was used as the baseline diagnostic modality, as well as conventional radiography of the abdomen. results. of the treated patients, only ( %) required surgery. the average length of stay was days. in patients, a clinical diagnosis of appendicitis was made. in % of these patients, the confirmation of their diagnosis could be made, using the baseline diagnostic modalities. for the rest of the patients, further diagnostic modalities were needed (such as ct). in patients, a primary diagnosis of coprostasis was made. in % of these patients, a conservative treatment could be offered, and the patients left our facility without symptoms. in % of the patients, further diagnostic modalities (radiological and=or endoscopic) showed a finding that required surgical attention. conclusions. in the normal=routine clinical picture of appendicitis, baseline diagnostics are sufficient. however, behind apparently harmless diagnoses such as coprostasis, there are serious illnesses that may be masked. therefore a different course of action must be considered (ct). as a possible side-effect of this course, patients without pathological manifestations could be treated on an out-patient basis, thus reducing total costs. background. the aim of the study was to investigate: i) relevant and combined determinants of the development, management and outcome of a representative patient cohort (n ¼ . ) with acute appendicitis enrolled in a prospective unicenter study through a time period of years (middle europe), and ii) the frequency and impact of specific categories (e.g., characteristics of the medical history, clinical and intraoperative findings, complications), correlation and relative risk factors of the disease and its prognosis. methods. by the mean of a prospective unicenter observational study, numerous characteristics as mentioned in the ''aims'' were documented and influencing variables with significant impact on the outcome were statistically determined. results. ) the wound abscess rate was . %. perforation, surgical intervention on time, acute, gangrenous and chronic appendicitis, age, adverse diseases such as obesity, arterial hypertonus, diabetes mellitus, sex and missing pathological finding intraoperatively showed a significant impact on the postoperative development of a wound abscess. ) the longer the specific appendicitis-related medical history lasted, the i) more frequent a perforated appendicitis occurred (interestingly, this rate significantly increased up to . % through the various time periods), ii) greater the false-positive appendectomy rate was (p < . ), and iii) higher the rate of the required second (subsequent) interventions was ( . %; p < . ), which occurred significantly more often in obesity ( . %) and wound abscess ( . %). ) the mean postoperative hospital stay was days. ) there was a significant decrease of the percentage of patients with no pathological finding of the ''appendix vermiformis" intraoperatively, who underwent appendectomy, in particular, to only . % through the last investigation period from to ( - , . %; - , . %). ) the mortality was . % showing no significant difference between male and female patients (p ¼ . ), between the investigation periods (p ¼ . ) and between the patients with false-positive appendectomy ( . %) and that with acute appendicitis ( . %; p ¼ . ). conclusions. in summary, this study demonstrated a substantial progress of the quality of surgical care within the participating clinics with regard to the rates of false-positive appendectomies, of postoperative wound abscesses and, in particular, to mortality, one of the strongest criteria of quality control. despite this, there is an increasing rate of perforated appendicitis in the investigated cohort. in conclusion, quality control remains an indispensable tool for evaluation and assessment of surgical care even in the most frequent diseases of the daily practice, which can be further improved by a multicenter study setting. acute mesenteric ischaemia -looking at the past, learning for the future e. schröpfer, a. thiede, t. meyer background. acute mesenteric ischaemia (ami) is a rare disease with still -despite all progresses in medicine -a high mortality rate ranging from to % according to literature. the aim of this study was to analyse the outcome of our patients after traditional therapy, in order to be able to conduct new strategies of treatment. methods. in this retrospective study all clinical reports (since = ) containing the diagnosis ami (icd : k . ) were analyzed with regard to initial laboratory findings, pre-operative diagnostics, surgical methods, intra-operative results, etc. results. the diagnosis ami was encoded for patients in the aforementioned period of time. twenty patients had to be excluded from the study, due to other collateral diseases. among the remaining patients (with an average age of . years) died initially (initial mortality . %). the main risk factor ( . %) was arrhythmia absoluta. . % of the patients presented the symptoms of an acute abdomen, . % were suffering from progressive abdominal pain. besides anamnesis, physical examination and laboratory only . % of the patients obtained an abdominal ct and . % obtained a dsa. because of the unambigousness of the anamnestic and clinical findings . % of the patients received an immediate explorative laparotomy without any further diagnostic. conclusions. despite the typical triphasic progression of the ami (intense abdominal pain -apparent recovery -acute spreading peritonitis) and all modern possibilities of diagnostics the mortality rate of ami is still appallingly high. looking at the past, diagnostics as well as therapy should be included in modern findings and open up new possibilities. bckground. data are rare about the impact of infection on postoperative mortality in an unselected surgical population. aim of the study was to analyze whether infection is a significant cause of death in these patients. methods. at a department of general, vascular and thoracic surgery in a secondary to tertiary referral centre, all patients operated from = to = (n ¼ ) were included in a prospective database and analyzed retrospectively. overall mortality rate . % (n ¼ ( abdominal, vascular, thoracic surgery)). . % emergency - . % planned operations. cause of death was defined by clinical chart review and post mortem section. stratification criteria (sex, age group, asa, malignancy, infection prior to surgery, abdominal surgery, emergency operation) were analyzed by multivariate regression analysis. results. cause of death: n ¼ ( . %) infection, n ¼ ( . %) cardiovascular, n ¼ ( . %) progression of malignancy, n ¼ ( . %) pulmonary embolism. subgroup analysis of postoperative death due to infection revealed that . % (n ¼ = ) of patients had infection already prior to surgery and . % (n ¼ = ) developed postoperative lethal infection. mortality caused by infection was . % (n ¼ ) in abdominal, . % (n ¼ ) in vascular and % (n ¼ ) in thoracic surgery. regression analysis identified infection prior to surgery (p ¼ . ) and abdominal surgery (p ¼ . ) as statistically significant independent risk factors for postoperative mortality due to infection. conclusions. postoperative mortality is highly associated with infection. in an unselected cohort of surgical patients those presenting with infection prior to surgery and those undergoing abdominal surgery are at highest risk of death from infection. management of complications in laparoscopic colo-rectal surgery m. hufschmidt, u. obwegeser, a. haid, e. wenzl background. laparoscopic colo-rectal surgery is considered to be a standardized procedure for the two main-indications: diverticular disease of the sigmoid colon and complicated crohn's disease of the ileo-cecal region. moreover these procedures seem to have served as a sort of pacemaker to so-called fast-track-protocols. while the extension of laparoscopic procedures to oncological indications is in a wide-spread controversial discussion, only few publications are considering the impact of complications in the outcome of surgical therapy of benign diseases. methods. a retrospective study of laparoscopic colorectal procedures performed between = and = was undertaken. indications and technical approaches as well as rates of conversion, duration of intervention and hospital-stay are detailed. complications leading to relaparotomy, interventional or conservative therapy are reviewed in detail to analyse their reasons. results. with a conversion-rate of . %, a mortality of . % and an overall morbidity of . % the occuring complications may be categorised in different groups, distinguishing intra-operativly, early or late, major or minor and procedurerelated or intercurrent-ones solicitating either conservative, interventional ( . %) or surgical ( . %) treatment. several causes are being isolated such as learning-curve, body-mass-index, comorbidity, sequelae of previous operations and severity of intraoperative findings. conclusion. as for conversion, complications influence parameters as hospital-stay or feasibility of fast-track-protocols somewhat watering the advantageous results of laparoscopic colo-rectal surgery. a careful analysis is therefore advisable not only to avoid reiterating complications but also to permit the access to oncological colo-rectal laparoscopic surgery as well. background. the value of quality control in general surgery is actually soaring. unplanned reoperation is seen as one of the most important quality measures. however, there is a lack of data regarding the impact of infection as an indication to unplanned reoperation. methods. at our department of general (including kidney transplant), vascular and thoracic surgery in a secondary to tertiary referral centre, all patients undergoing unplanned reoperation from = to = were included in a prospective database. unplanned reoperation was defined as unplanned return to the or within days during hospitalization. targets were unplanned reoperation due to infection, type of infection, type of primary surgery, mortality and a comparison to a former data collection from = - = after starting a monthly review of reoperation data in terms of a morbidity-=mortality conference = . results. one hundred and thirty nine ( . %) of patients were undergoing unplanned reoperation. ( . %) due to infection, ( . %) due to postoperative bleeding and ( . %) due to other indication. subgroup analysis of those reoperated due to infection identified leakage of the anastomosis in % ( = ) and abdominal wall rupture in . % ( = ) as predominant causes to reoperation. other indications to unplanned reoperation were small bowel perforation ( = ), abscess ( = ), leakage of ileostoma ( = ), thoracical phlegmon ( = ), ureter-necrosis ( = ), recurrent infection of lung parenchyma ( = ) and superficial surgical site infection ( = ). mortality in the infection subgroup was . % ( = ) compared to . % ( = ) of all reoperated patients. overall mortality was . % ( = ). furthermore we could achieve a decrease of mortality in infection subgroup from to . % comparing to our former data collection of = - = . an additional analysis of infection germs was not striking. conclusions. postoperative infection is the underlying mechanism leading to reoperation in a significant number of patients. data analysis showed a much higher mortality in these patients. the reported decrease of mortality from to . % maybe attributed to the consequent prospective monitoring and monthly review of reoperation data we had introduced = . gallstone-ileus -nowadays still a remaining important differential-diagnosis to consider at presence of acute abdominal pain r. hammer , p. habertheuer , w. brü nner , c. bauer , n. schreibmayer , f. flü ckiger , p. steindorfer department of surgery, lkh graz-west, graz, austria; department of radiology, lkh graz-west, graz, austria background. - % of all mechanical obstructions in small bowel are represented by gallstone-ileus as a complication of cholelithiasis. as it is frequent in the elderly population (it accounts for almost % of non-strangulated intestinal obstruction in patients > years), there is a high mortality-rate of - % depending on age and co-morbidity. in less than % of patients with gallstones cholecystoenteric fistula occurs (most likely cholecystoduodenal in %, cholecystocolic, cholecystogastric-and cholecystodochoduodenal have also been described). methods. between october -december we performed cholecystectomy on patients and laparatomy on patients due to mechanical obstruction of the small bowel. the frequency of gallstone-ileus can be reported on patients, which underwent surgery due to intestinal obstruction because of gallstones. one recurrence of gallstone-ileus due to the lack of exploration on finding massive postinflammatory adhesions and adherence of the major omentum was seen. in all patients clinical evidence of intestinal obstruction detected pneumobilia as well as ectopic gallstones was confirmed by either plain x-ray or ct-scans. results. at our department a frequency of patients (average age . yrs (range - yrs) males, females) presenting with gallstone-ileus (in a total of patients undergoing cholecystectomy and patients undergoing laparotomy due to small-bowel-obstruction) were treated, that means a rate of gallstone-ileus in . % ( = ) compared to the patients with che, and . % ( = ) in laparotomies due to small-bowel obstructions performed at this period. all patients underwent an one-stage operation, in cases consisting of enterolithotomy and stone-extraction as single procedure only (without dismantlement and exploration of the fistula), in further cases cholecystectomy and suturing of the entero-biliary fistula synchronously were additionally performed. the obstruction occurred  duodenal,  jejunal and  ileal, the location of the fistula situated duodenal in times, once jejunal and  non-explored. the diameter of the obstructing stone varied between and cm (average of . cm), patients recovered well, one expired because of the development of ards. conclusions. gallstone-ileus is a rare diagnosis, nevertheless it should still be kept in mind and considered as important differential-diagnosis in acute abdominal pain as shown on the numerous cases at our department. for reducing perioperative mortality the treatment has to be adapted on patients conditions, if necessary performing enterolithotomy as a single procedure only, and considering to correct the fistula in a second procedure on symptomatic patients. in the program of the austrian surgical convention different working groups and specialised societies are listed up, stating that the specialisation in surgery is increasing. however, the question remains, which fields of specialisation are realistic for a general surgical department with a limited staff? in the last years a main focus of interest has been established for the following fields: endoscopy: gastroscopy, sigmoideoscopy, colonoscopy with interventions is performed by all, ercp by two surgeons of the staff. minimal-invasive surgery: choleystectomy, appendectomy, hernia surgery is performed by all surgeons, colon resections, gastro-oesophageal surgery by three of the staff. endocrine surgery: surgery of the thyroid and parathyreoid gland by three surgeons. specialized breast surgery: such as oncoplastic surgery and breast reconstruction by two surgeons. varicositas surgery: crossectomy and stripping, evlt, trivex, venocuff by two surgeons. the development of specialization in a general surgical unit will be presented. methods. review on cle. results. due to reflux esophageal squamous epithelium is damaged and replaced by cle, which is of esophageal origin and interposed between squamous and gastric oxyntic mucosa (om). the paull-chandrasoma histopathology cle classification includes oxyntocardiac (ocm; mucus and parietal cells) and cardiac mucosa (cm; mucus cells only) without or with intestinal metaplasia (im ¼ barrett esophagus). via low (lgd) and high grade dysplasia (hgd), im may progress towards eso-phageal adenocarcinoma (ac; annual incidence . - . %). presence of cle is associated with pathologic esophageal acid exposure and impaired esophageal motility and dysfunction of the lower esophageal sphincter, as assessed by ph monitoring and esophageal manometry, respectively. cle without and with im is assessed in and - % of symptomatic gerd patients, respectively, irrespective of presence or absence of endoscopic visible cle. surveillance endoscopy and biopsy sampling are recommended after - , - and . years for cm, im and lgd, respectively. treatment of hgd and ac stage ia include endoscopic mucosal resection or esophagectomy. esophagectomy is recommended for ac > stage ia. recent studies indicate that antireflux surgery may reverse im and low grade dysplasia (lgd). seven years after ph-monitoringproven effective (n ¼ ), but not ineffective (n ¼ ) nissen fundoplication, im reversed towards cm without progression towards ac. fourty months after nissen fundoplication and bile diversion (n ¼ ), % regressed from im to cm, % remained at im. . years after gastric bypass (n ¼ ), im-patients regressed (n ¼ ) or had im (n ¼ ), none progressed. a recent study compared the effect of proton pump inhibitor (ppi) (n ¼ ) vs. fundoplication (n ¼ ) in patients with cle containing low grade dysplasia (lgd). eighteen months after ppi treatment and fundoplication, out of ( . %) and all out of patients, respectively, reversed from lgd towards intestinal metaplasia. conclusions. cle is defined by histopathology. evidence justifies to investigate impact of effective fundoplication on cle within prospective studies. background. during endoscopy the stomach is considered to commence at the level of the rise of ''gastric'' rugal folds. anatomy studies suggested that rugal folds may contain columnar lined esophagus (cle), the morphologic consequence of gastroesophageal reflux disease (gerd). we investigated the histopathology of endoscopic ''gastric'' rugal folds in gerd patients. methods. seventy-five consecutive gerd patients ( males), age: ( - ) years, prospectively underwent endoscopy, including biopsy sampling from the endoscopic esophagogastric junction (egj): , . , . cm distal and . and . cm proximal to the rise of the rugal folds. cle was cataloged according to the histopathologic paull-chandrasoma classification. results. normal endoscopic esophagogastric junction, visible cle . and > . cm was assessed in ( %) and ( %) and ( %) patients, respectively. histology: all patients had cle at the level of rise of the ''gastric'' folds. in and % of patients cle extended . and . cm, respectively, distal to the rise of the rugal folds. gastric oxyntic mucosa was not assessed above the level of the rise of rugal folds. intestinal metaplasia (¼ barrett esophagus) was assessed histologically in ( %) patients. conclusions. regarding the diagnosis of cle, the esophagogastric junction (egj) cannot be assessed by endoscopy, but by histopathology (i.e. level of transition from cle towards gastric oxyntic mucosa). presence or absence of barrett esophagus can not be excluded by endoscopy. histopathology of multi level biopsy sampling should be considered for definition of egj and exclusion of barrett esophagus in gerd patients. pre-clinical trial of a modified gastroscope that performs a true anterior fundoplication for the endoluminal treatment of gerd background. laparoscopic fundoplication provides good reflux control but side effects due to the surgical procedure are known. different endoluminal techniques have been introduced but all with disappointing results. evaluation of the feasibility and safety of a new device, that enables a totally endoluminal anterior fundoplication for the treatment of gerd. methods. the device is a modified video gastroscope, which incorporates a surgical stapler (using standard . b shaped surgical staples) and an ultrasonic sight. the cartridge is mounted on the shaft and the anvil is at the tip. this enables accurate stapling of the fundus to the esophagus, using the ultrasonic sight to guide distance and alignment of the anvil and the cartridge. sixteen female swine of mixed breed were used in the study, underwent the endoscopic procedure, and were used a controls to monitor weight gain. the study animals were sacrificed at , , and weeks ( pigs each time) and visually inspected for complications, healing and fundoplication. the study was sponsored by medigus ltd. and monitored for compliance with glp regulations by an external company (econ inc.), which is glp certified by the german federal government. it was conducted at the animal testing facility of the charite virchow clinic in berlin. results. the procedure went smoothly in all pigs, median procedure time was min (range - min). at sacrifice the stapled area had healed well, all animals had a satisfactory anterolateral fundoplication, and there were no procedure related complications. conclusions. creating a satisfactory anterior fundoplication with the new device is feasible, easy, and safe. proof of efficacy must await clinical trials, which are underway. design and instrumentation of new devices for performing appendectomy at colonoscopy g. silberhumer , e. unger , w. mayr , t. birsan , g. prager , j. zacherl , c. gasche background. appendectomy is the most common operation in the gastrointestinal tract. there is increasing interest in interval appendectomy as a treatment for refractory ulcerative colitis. a less-invasive flexible endoscopic method for removing the appendix might offer advantages especially for interval appendectomy in patients undergoing colonoscopy. aim: to design, develop and test new devices for removing the appendix via natural orifice transluminal endoscopic surgery (notes). methods. tests were performed on the bench in colons from adult human cadavers. various prototypes were tested, which could be inserted into the appendiceal orifice to its tip and could invert the appendix at its base in a controlled fashion into the lumen of the cecum. the advantage of using a tubular structure as counter force to aid inversion of the appendix was evaluated. after partial inversion the growing strain was relieved by endoluminal incision of the mesenteric side of the appendix. closure methods with endoloops, clips and thread ties were studied. appendiceal resection was completed by snare diathermy leaving an inverted intraluminal stump. results. the position of the appendix was retrocecal in seven cases, pelvic in two, and pre-ileal or post-ileal in one each. the median length and luminal diameter was mm ( - mm) and . mm ( - mm), respectively. partial obstruction of the lumen was present in = cases. it was possible to advance the guide-wires and retraction devices to the tip of the appendiceal lumen in all cases. partial inversion of the appendix was successful in = tests. the median length of the inverted stump was mm ( - mm) . the tension and volume (due to fat deposit) of the mesoappendix was the main reason for incomplete inversion. complete inversion was achieved by endoluminal incision in = tests. the mean volume of the resected tissue (inverted appendix incl. its mesoappendix) was . ae . ccm. conclusions. despite high individual variability, appendectomy at flexible colonoscopy proved to be feasible and relatively easy. new devices to allow appendix inversion were successfully tested. endoscopic necrosectomy -a feasible and safe alternative treatment option for infected pancreatic necroses in severe acute pancreatitis (case series of patients) u. will , r. gerlach , i. wanzar , f. meyer department of gastroenterology, municipal hospital, gera, germany; department of surgery, university hospital, magdeburg, germany background. endoscopic necrosectomy of infected pancreatic necroses in severe acute pancreatitis is considered an alternative but minimally invasive treatment option instead of the more traumatic open surgery. the aim of the study was to investigate feasibility and outcome of endoscopic necrosectomy in infected organized pancreatic necroses (iopn). methods. through a -year time period, all consecutive patients with symptomatic iopn who underwent this novel endoscopic approach were prospectively documented in a computer-based registry and were retrospectively evaluated (systematic case series). the endoscopic approach comprised: . necrosectomy via the transgastric route under eus guidance; and (optionally). . additional a) transpapillary stenting of the pancreatic duct; or b) percutaneous drainage if indicated. feasibility was characterized by success rate (clearence=downsizing of iopn, hospital stay) and outcome by complication rate (frequency of bleeding or perforation), mortality and shortterm follow-up. results. from = = - = = , patients with symptomatic iopn (maximal diameter, - cm) who underwent endoscopic necrosectomy were enrolled in the study. sixteen of them ( . %) were necrosectomized from all nonviable tissue using - (range) necrosectomies (mean, . ). in = cases ( . %), iopn were incompletely removed. the pancreatic duct was drained through the papilla because of duct disruption or dilatation in = cases ( . %). a percutaneous drainage was placed into fresh, non-organized necroses or because of acute septic problems in = patients ( . %). complications occurred in = subjects (rate, . %): bleeding (n ¼ ) managed endoscopically; cardiac arrhythmia (n ¼ ); no perforation. at the time of discharge (mean hospital stay, . d), i) internal drainage was still in situ (range, - double pigtails) in = individuals ( . %), which was extracted in the post-hospital range of - d; ii) = patients ( . %) were asymptomatic indicated by normal inflammatory laboratory parameters; iii) = subjects ( . %) showed no further iopn whereas in = patients ( . %), there was a -fold (mean) down-sizing of iopn. one patient ( . %) died from cardiac infarction on the th day of hospital stay (intervention-related mortality, %). follow-up investigation (range, - d): = subjects ( . %) developed pancreatic pseudocyst, which was endoscopically approached. conclusions. endoscopic necrosectomy combined with endoscopic placement of a internal (transgastric) drainage or transpapillary stent into the pancreatic duct is a feasible and safe treatment option even in the case of extended iopn with large pieces of necrotic tissue. background. leakage and fistulization of the gastrojejunostomy have been the major drawback of gastric bypass surgery since its first description. most authors agree that operative treatment is the mainstay of therapy in all patients with signs of sepsis. however, intestinal contents causing localized infection may impede healing of sutured leaks in some patients and fistulas develop. as the anastomosis cannot be disconnected or exteriorized for anatomical reasons other forms of treatment have to be applied. results. leakage of the gastro-jejunostomy occurred in three patients after gastric bypass and resulted in formation of a fistula; one fistula developed in a patient days after surgery. coated self-extending stents were implanted endoscopically in all patients. enteral nutrition could be started six days later. stents were removed two months after implantation without problems. weight loss and quality of life after stent removal were excellent in all patients. conclusions. in our experience implantation of coated selfexpanding stents represents a very effective and minimally invasive therapy of gastro-jejunal anastomotic fistulas after gastric bypass when surgical repair is not possible. in these cases application of stents allows septic source control without any other intervention. methods. fetal mri studies were performed on a . t (philips) superconducting unit using a five-element surface phased-array coil, usually after th gestational week. no sedation is necessary. in addition to routine t -weighted (w) sequences, t w sequences (mainly to demonstrate meconium-containing bowel loops), t à w-sequences (in case of hemorrhagic lesions), steady state fast precession (ssfp) sequences (to depict vessel-abnormalities), dynamic ssfp sequences to show swallowing and peristalsis, flair and diffusionweighted sequences (for further tissue characterization) were done. results. one hundred and twenty-six fetuses with extra-cns malformations, prenatally examined with fetal mri, had postpartal or postmortal follow up at the medical university clinic of vienna: among these, congenital diaphragmatic hernias (cdh, ) could be selected for primary repair ( ) because of adequate lung maturity, with extreme lung hypoplasia underwent extra corporal membran oxygenation. cystic adenomatoid malformation ( ) and lung sequestration ( ) were diagnosed, requiring immediate postnatal or later repair. abdominal anomalies ( ): stenosis, obstructions or atresias of small bowel ( ) were treated by adequate therapy from the very beginning. anal atresias ( ) were differentiated into high and low forms, cases which needed colostomy or could be corrected in an one stage repair. nine gastroschisis ( ) and omphaloceles ( ) were delivered pretermly dependent on the amount of eventerated bowels. ovarial cysts ( ) were differentiated from abdominal tumors ( ), the latter requiring immediate surgery, the former only depending on size and content. urologic pathologies ( ) could often be treated conservatively. conclusions. the results of fetal mri do not have an impact on the type of surgical procedure. however, early accurate diagnosis of pathology, including information about vital functions (such as the degree of lung maturity) may influence the decision of the time to perform the operation, to achieve a most successful outcome for the patient. background. common bile duct (cbd) stones represent a diagnostic and therapeutic challenge in pediatric age group. the aim of the study was to evaluate our management of children with suspected cbd stones and to develop an algorithm for the rational use of perioperative ercp, mrcp and intraoperative cholangiography (ioc). methods. between and , children that had undergone laparoscopic cholecystectomy (che) were evaluated for preoperative findings suggestive for cbd stones, preoperative use of ercp or mrcp, use of ioc and findings during surgery. a diagnostic and therapeutic algorithm for cbd stones was developed. results. twelve children ( %) had preoperative findings suggestive for cbd stones. of the children with elevated liver enzymes and abnormal ultrasound findings, ( %) were identified to have cbd stones. five had preoperative ercp which detected and successfully cleared stones in patients. ioc identified cbd stones in children, including one patient with a preoperative negative ercp. of the children with either elevated liver enzymes or abnormal ultrasound, only one stone in the cystic duct was identified by a gall bladder edema in the preoperative mrcp followed by ioc. three children received preoperative mrcp and ioc was performed in . no retained stones were detected postoperatively. conclusions. cases with high suspicion for cbd stones should undergo a preoperative ercp followed by intraoperative cholangiography, if no stones could be found. in case preoperative findings are ambiguous, prevalence of cbd stones is low and we suggest mrcp or ioc as the diagnostic methods of choice. pure esophageal atresia with normal outer appearance -a new subtype? -case report m. sanal , b. häussler , w. tabarelli , k. maurer , c. sergi , j. hager background. isolated esophageal atresia (vogt type ii) is characterized by an agenesia of the midportion of the esophagus. this paper presents a case of such a form of esophageal atresia with a cm long fibrous segment between the two esophageal pouches resembling the subtype ii according the kluth's atlas. methods. thirty-seven week gestation boy born by uneventful vaginal delivery with g birth weight was transferred to our department because of inability to pass a nasogastric catheter. resection of the fibrous segment and primary anastomosis of the esophagus was performed succesfully. results. the postoperative course was uneventful and the patient was discharged on the postoperative day. histological examination of the atretic segment showed an haphazard distribution of not functional lumina and blood vessels. conclusions. kluth has described ten types of esopageal atresia in his atlas; pure esophageal atresia is classified as type ii in which the proximal and distal segments are atretic without a tracheo esophageal fistula. matsumoto described a subtype in which the midportion of the esophagus is atretic and there is a cyst located in the atretic strand. loosbroek also described in a new type of isolated esophageal atresia that included double membranes with a cm gap between them. we describe here a similar case of pure esophageal atresia, showed neither a cyst nor a membrane. extensive review of the literature failed to disclose any similar case showed this kind of histological character. we report our experience with the minimal invasive method of surgical reconstruction of pectus excavatum recurrence. since at our department pectus excavatum patients have been operated on by the modified minimally invasive method of reconstruction (modified nuss technique). seven patients aged . ae . showed a severe recurrence ( patients after ravitch-welsh-rehbein method primarily operated elsewhere, one after explantation of the ''nuss bar'' operated in our department). five patients suffered on reduced physical effort and patients aim for a better cosmetic result. preoperative investigations include blood samples, ecg, heart sonography, chest x-ray, chest mri=ct with -d reconstruction and spirometry. the following intraoperative events deserve mention: . severe retrosternal scarred tissue complicate the retrosternal preparatory mobilisation of the pericardial sac and the sternal portion of the diaphragm n ¼ . . intraoperative thoracoscopy showed pleural adhesions which were divided thoracoscopically n ¼ . . non compliant stiff thorax due to sternal kinking and=or ossification of the regenerated ribs after ravitch procedure made the following procedures necessary: a. additionally osteotomies of the ossificated ribs (n ¼ ). b. implantation of a second bar (n ¼ ). c. an oblique wedge shaped partial sternal osteotomy (n ¼ ). due to preparation we had intraoperative bleeding episodes of the internal mammaric vessels, lesion of the pericardial sac (scar tissue) and superficial lesion of the right visceral pleura (adhesions). vertebral index changed from preoperatively to a normal range of postoperatively. postoperative cosmetic results were perfect in %. in summary cases with pectus excavatum recurrence are manageable with extremely satisfactory results using the described extended modified correction technique. osteotomies do not destabilize the chest and can be sufficiently combined with the nuss technique. background. former surgical approaches to laparoscopic repairs of morgagni hernias in children involved pros-thetic as well as nonprosthetic repairs. we simplified a nonprostethic laparoscopic method to an easily feasible procedure. methods. two boys with retrosternal diaphragmatic hernias (morgagni) underwent primary laparoscopic repair. a nonabsorbable suture was inserted directly through the anterior abdominal wall and the hernia was tightened in a lateral to medial fashion by a continous suture and tied in the subcutaneous tissue of the xiphoid region. results. two boys, months and five-year old, with coincidentally diagnosed bilateral retrosternal diaphragmatic hernias (morgagni), underwent laparoscopic repair of their hernias. they had an uneventful postoperative recovery, apart from a port site hernia in one. conclusions. this technique for primary laparoscopic repair of morgagni hernia is safe and easy to perform. laparoscopic closure of the defect by suturing the posterior rim of the hernia to the anterior abdominal wall with a continous nonabsorbable suture provides a safe and effective therapy for this type of diaphragmatic hernias. our experience of post-natal diaphragm paralysis treatment in newborns a. kuzyk , a. pereyaslov , r. kovalsky , o. leniv background. the paralysis of right cupula of diaphragm in newborns in many cases is the result of birth trauma and is indicated as erb-duchene syndrome. the paralysis declares itself by the high standing of diaphragm and its paradoxical movements during respiration, displacement of mediastinum and lung compression which bring to heavy respiratory distress, cardiovascular insufficiency development and requires artificial pulmonary ventilation in first post-natal hours. methods. in the period of - , children with post-natal paralysis of diaphragm right cupula and child with post-natal paralysis of diaphragm left cupula have been treated in our clinic. the body weight at birth was - g. the basic symptoms were: hard respiratory distress and cardiovascular insufficiency, pulmonary hemorrhage, depression of the central nervous system. two children with low body weight had been on artificial pulmonary ventilation during period from the birth to surgical treatment. conservative therapy was done from to . months without positive clinical effect -respiratory insufficiency had not been reduced, the children had retarded in physical growth and development. all children were operated on diaphragm goffering from thoracotomy on the affected side. results. after surgery all patients needed artificial pulmonary ventilation during - days. with good clinical results all children were discharged from the hospital. conclusions. the newborns with post-natal diaphragm paralysis with not effective treatment during - weeks needed surgical correction -diaphragm goffering on the affected side. long term experience with the paulprocedure in a large animal model background. this study was designed to assess the long term efficacy of the paul-procedure for abdominal wall defect repair in a large animal model (lam). methods. we created  cm full-thickness abdominal wall defects in goettinger miniature piglets (n ¼ ; body weight: . - . kg). the defect was repaired by the paul-procedure, using an extracellular matrix of xenogeneic origin as an interpositional graft. a weekly examination of the animals followed, including measuring of bodyweight and observation the possible development of a hernia. additional the abdominal cavity was evaluated laparoscopically at , , and months after paul-procedure. the adhesions to the intestine were measured and the neo-abdominal wall was taken for histological examination. results. ( ) the paul-procedure could be performed technical easily in lam. ( ) background. gastroschisis is a relatively rare congenital anomaly in which eviscerated fetal abdominal organs are exposed to amniotic fluid in utero through an anterior abdominalwall defect. since the first surgical treatment of gastroschisis by fear in the evolution of therapeutical concepts is steadly proceeding. methods. a retrospective study enclosing all children with gastroschisis treated at vienna general hospital from to was carried out using patient charts. statistics was performed using spss . . the results are compared with the literature. results. fifty-five children with gastroschisis were treated. birth was performed between and week of gestation ( % caesarean section). diagnosis was established between and week of gestation. in % of the patients primary surgical closure was performed. oral feeds were started on . day, mechanical ventilation was stopped after . days. twenty children developed infection=sepsis=pneumonia ( . %) children developed ileus=perforation=vovolus=nec=patch infection ( . %). thirty four children had single gastroschisis related surgery ( . %), secondary surgery up to operations. mortality was . % ( deaths). conclusions. since bianchi's publication of minimal intervention management for gastroschisis in traditional surgical concepts have often been questioned. our results are comparable with international data. although very tantalizing there are no large prospective randomized multicenter studies that show clear superiority of one or another strategy. epidemiologic data show an increasing incidence of gastroschisis which shows the importance of standardized successful procedures for the future. background. colorectal cancer is one of the most common cancers in western countries with incidence rates that are quite stable through the last years. while surgical therapy with high central vessel ligation and adequate lymph node dissection seems well standardised -in laparoscopy as well as conventional surgery -great efforts have been made in new adjuvant treatment strategies and in treatment of colorectal liver metastases. methods. we report about a consecutive series of more than patients treated with colorectal cancer since . . . data about epidemiology, localisation of the primary, surgical methods, tumor classification, complication and mortality rates and survival will be presented in detail. results. the median age was years, % of the patients were more than years old, . % were female. fifteen percentage were treated with an acute onset like ileus or perforation. thirty five percentage had right sided primary, hartmann procedure was performed in %. about % of patients were operated as stage (uicc), the year survival rates of all groups including stage was %. pathohistological assessment showed % r resections (stage included) and a median lymph node count of (pn). perioperative mortality was %, complication rate with the necessity for at least surgical reintervention was . %. conclusions. we demonstrate that surgical therapy of colorectal cancer is safe and effective in terms of oncological outcome and perioperative morbidity and mortality, although colon resections in our department are typical teaching operations. modern anaesthesia and intensive care allows radical oncological surgery even in the elderly. interdisciplinary treatment keeps its way, exact pathohistological processing and cooperation with the pathologist still is the most important factor in quality assessment of oncology surgery of the colorectum. background. although adjuvant -fu-based chemotherapy showed to increase -year survival in stage iii colon cancer, the role of adjuvant chemotherapy in stage ii colon cancer is still unclear. p , a frequently mutated tumour suppressor gene needed for correct induction of apoptosis, is a promising marker to define subgroups of patients who benefit from adjuvant chemotherapy in stage ii colon cancer. methods. in order to evaluate the clinical relevance of p mutations, we investigated stage ii colorectal tumor biopsies from a previous randomised study of adjuvant chemotherapy, who were randomly assigned to adjuvant chemotherapy or surgery alone. for detection of p mutations we used singlestranded conformation polymorphism analysis. results. p mutation was detected in ( %) of informative tumor dnas. when receiving -fluorouracil-based adjuvant chemotherapy, patients with p mutation turned out to have a significant better disease-free -year survival ( . vs. . %, p ¼ . ). in contrast, when assigned to the surgery alone group there was no significant difference in -year disease-free survival between patient with p mutation and patients with wildtyp p . the difference between the patients receiving chemotherapy as compared to those which did not in respect to the presence of p mutations was significant (p ¼ . ). conclusions. in our patient cohort patients whose cancer had a mutation of p had a significantly better benefit from -fluorouracil-based therapy, what is contrary to previous observations. this discrepant result emphasise the need for a standardisation and validation of the methodology, patient selection and interpretation of clinical data before any prognostic marker can be routinely used. is tme an adequate treatment for low rectal cancer? p. lechner, g. humpel background. two patients who had had neo-adjuvant chemotherapy followed by surgery for cancer in the lower rectum presented with metastases in pre-aortic lymph-nodes after and months, respectively. this rose our suspicion that distant spread may in some cases follow the lymphatic vessels along the aorto-iliac axis. methods. after having performed very low anterior or even abdomino-perineal resection for cancer in the lower third of the rectum, biopsies are taken from nodes at the pelvic wall, along the iliac arteries, and the aorta. these are all compartments that remain untouched during routine tme. results. in one out of four patients we find at least one of the above mentioned groups of nodes to be involved. this is most often the case in patients, in whom the mid rectal vascular bundle requires ligation on at least one side. so there are obviously metastases that cannot be detected during the pathological work-up of the tme-specimen. twenty five p.c. of the patients considered to be n-o are already in dukes' stage c, thus requiring additional treatment. these findings -confirmed by the recent literature -suggest, that metastases may arise via lymphatic vessels along the mid rectal arteries and -further onalong the aorto-iliac vessels. conclusions. after standard tme for low rectal cancer lymph node biopsies should be taken in order to avoid understaging of the disease and to allow accurate patient stratification in clinical trials. transanal endoscopic microsurgery for rectal carcinoma: own experiences after cases p. patri, r. schmiederer, a. tuchmann background. transanal endoscopic microsurgery (tem) is an one access technique for local excision of rectal tumours using gas dilatation of the bowel and a stereoscope for unrestricted vision on the operation field. the tem-technique was invented by buess, theiss and hutterer and has been performed at our department since . sessile benign adenomas of the rectum inappropriate for colonoscopic resection represent the vast majority of cases indicated for tem-procedure, using the advantages of sphincter preserving resection in all thirds of the rectum without considerable access trauma. furthermore, tem can be applied to a highly selected group of rectal carcinoma patients in curative objective, including t g or g l v lesions, classified as low risk carcinomas after hermanek's criteria for malignant potential, with recurrence and -yearsurvival-rates equal to radical surgery. under palliative purposes tem can be considered in more advanced carcinomas such as high risk carcinomas (t g ) or in t - carcinomas without stenosis in patients with high risk for general anaesthesia, rejection of stomal construction or present distant metastases. methods. from = until = tem procedures were performed in patients, males, females, mean age was . years ( - ), the median hospital stay was days . following diagnoses were included: rectal adenomas (n ¼ ), rectal carcinomas (n ¼ ), carcinoids (n ¼ ), fistulas (n ¼ ), gist (n ¼ ) and melanoma (n ¼ ). all patients underwent tem-procedure as described by buess et al., the median operation time was min ( - ). highlighting the carcinoma patients regarding to postoperative histopathology tem was performed in n ¼ tis-lesions, n ¼ t low risk carcinomas, n ¼ t high risk carcinoma, n ¼ t and n ¼ t carcinomas. results. in carcinoma patients undergoing tem for curative objective recurrence rate was . %. if tem was performed in primarily palliative intention recurrence rate was %. no conversion to open technique had to be performed, no postoperative surgical complications were observed, one patient died weeks postoperative due to liver failure following esophageal varices bleeding. conclusions. transanal endoscopic microsurgery is a technically highly demanding but excellent procedure for curative therapy of rectal adenomas and low grade early carcinomas. furthermore, tem is feasible in more advanced carcinomas for palliative purposes. besides the technical advantages the procedure can prevent patients of rectal resection or stomal construction. background. anastomotic leak is the most feared early complication in the postoperative period after low anterior resection. the incidence varies between and %. use of tme technique lessens the percentage of local recurrences but increases the incidence of an anastomotic leak. a surgeon has to assess the risk factors and decide whether to create a protective stomy that protects the patient from fatal consequences of an anastomotic leak. methods. one hundred and three patients who had a low anterior resection without a protective ileostomy in the period - were included in the analysis. data of those who developed an anastomotic leak and those without were compared and the connection between specific risk factors and the incidence of an anastomotic leak was assessed. results. eleven patients ( . %) developed a clinically confirmed anastomotic leak. death after low anterior resection occurred in cases ( . %), in two cases in patients who developed a leak, resulting in a . % mortality rate for anastomotic leakage. there was no difference between males and females (p ¼ . ) and age groups (< vs. > years), (p ¼ . ). tumor localization in the lower third of the rectum was roughly showing statistical importance (p ¼ . ). the stage iv. of disease showed obvious connection (p ¼ . ). connection between the anastomotic leak and preoperative radiotherapy or high asa score (> ) was not established (p ¼ . and p ¼ . ). conclusions. the incidence of an anastomotic leak was comparable with results of other studies. localization of a tumor in the lower third in advanced disease represents an important indication for protective ileostomy. background. while adverse events occur in up to ten percent of all patients admitted to hospitals sentinel events do not happen often. however, these events represent great risks for medical institutions and persons involved. a thorough analysis of sentinel events is mandatory and can be achieved by root cause analysis (rca). methods. root cause analysis has been designed in order to assess underlying human, technical, and organizational factors contributing to adverse events. rca has to be performed in a standardized way by a team approach. the main goal of this analytic technique is to establish a relationship between causal factors and events under systemic aspects. after identifying incidental findings causal statements are formulated and actions are developed. conclusions. root cause analysis is a standardized investigative technique which allows to identify causes of severe adverse events and to develop preventive actions for the future. background. thyroid surgery can be followed by typical complications i.e. recurrent laryngeal nerve injury, postoperative hypoparathyreoidism and postoperative haemorraghe. refined surgical technique has improved the outcome and lowered the risk of complication to a minimum. methods. we analyzed global outcome and individual performance in more than , thyroid operations. the complication rates were compared in consecutive periods representing different surgical techniques and individual surgical performances. the data were repeatedly presented to the surgeons. the effect of this quality control procedure was reevaluated. results. exposure of the recurrent nerve and the parathyroid glands significantly reduced the global rate of post-operative=permanent rlni and hypoparathyreoidism. some but not all surgeons improved their results by recurrent nerve dissection (e.g., permanent rlni rates ranged from to . %) and refined dissection of the parathyroid glands (e.g., parathyroid insufficiency ranged from to . %). global outcome and individual performance were compared in periods and presented to the surgeons. the effect of this quality control procedure and the selective improvement of outcome will be shown by data. the extent of resection and the individual refinement of surgical technique was the source of variability. conclusions. refined surgical dissection significantly reduces the risk of complications in thyroid surgery. quality control can improve the global outcome and identify the variability in individual performance. this cannot be eliminated by merely confronting surgeons with comparative data; hence, it is important to search for the underlying causes. recent developments in medical litigation and liability in austria d. schaden , j. pritz krankenhaus der barmherzigen brüder, graz, austria; amt der steiermärkischen landesregierung, graz, austria the recent medical judgements of the highest court (e.g.: wrongful birth ogh ob = h) have been debated very controversially in medical profession and have attracted closer attention to the legal aspects of medical documentation and enlightenment. particularly in the surgical disciplines the patient should be made fully aware and get a detailed information about the risk of treatment failure, possible complications, limits to the procedures and long term outcome. exact information by the doctor is the condition necessary for the patient to give valid consent to the treatment and to avoid medical negligence litigation in these risky specialties. unfortunately these often for the doctors existentially important aspects are not part of the medical or surgical training nor are there any compulsory guidelines of medical enlightenment in the austrian legal practice which creates widespread individualism in all disciplines. we want to give an overview of the latest medico-legal lawsuits and judgements and their consequences for the daily working routine focussing on issues that can result in a doctor or facility being sued. background. every patient has the right to be informed about the consequences of surgery enabling him to give his informed consent. until recently the process of giving this information was not well organized. in the context of improving quality control at the hospital, a uniform process for patient information was established and the training of interns for giving informative talks was standardized and intensified. to measure whether these changes are reflected by an improved patient satisfaction, patients were surveyed before and after the changes. methods. two surveys were performed on patients before and after the improvements were introduced, and the results were compared. results. in each survey and questionnaires were returned. with the improved process the number of patients satisfied with the length of the informative talk rose ( - %, p < À ), less patients wanted a more detailed talk ( - %, p ¼ . ) and more patients considered the sketches on the informed consent protocol helpful ( - %, p <  À ). fewer patients thought the surgery was worse than expected ( - %, p ¼ . ). conclusions. using the new information process, a measurably better patient satisfaction could be observed. thus, by relatively simple means a highly efficient information process can be established even at a large hospital. the discontented patient j. pritz , d. schaden the number of claims after surgical procedures (not only bariatric or cosmetic surgery) is still increasing and patients nowadays are getting better informed about medical malpracti-ce=error in the media and the various possibilities to assert their rights. in austria various kinds of out-of-court settlement are installed to facilitate patient's compensation without the risk of litigation. in many cases misconceptions in the patient-doctor relationship can be solved without motion to court. but how can the terms ''malpractice'' or medical error be defined at all? which conditions must be fulfilled for the motion to court or the medical arbitration committee? we want to give a survey of the activity of the arbitration committee, the members, and the possibilities of compensation. moreover, the different consequences between criminal and civil law should be explained. the role of the expert witness, the course of procedure at the arbitration committee and possible consequences for the doctor or the facility will complete the presentation. background. negative resection margins are significant for prevention of recurrence in liver surgery. preoperative d models of imaging data provide significant improvements for visualization and planning, but intra-operative realisation is still a challenge. possibly navigation technology can improve oncological safety in liver resections. methods. fifty-four of liver resections for liver metastases were selected for intra-operative navigation due to complex anatomical situations. exact surgical plan was documented on virtual d models. planned resection margins were assessed and measured preoperatively. intra-operative d ultrasound data were acquired and localized with an optoelectronic tracking system, thus navigation of surgical instruments was provided in a virtual environment of these registered ultrasound data. surgical resection margins were compared with the surgical plan. results. navigated surgery was realized in of resections. r resection was achieved in of patients. mean histological resection margins were ( - ) mm. maximum deviation from the surgical plan was mm. conclusions. d ultrasound-based optoelectronic navigation is a feasible device for liver surgery, provides optimal anatomic orientation and can realize precise resection margins. background. during liver resection, a low central venous pressure plays a crucial role in reducing blood loss and intra-as well as post-operative morbidity. however, excessive volume restriction could lead to microcirulatory impairment and organ hypoperfusion. in the present study, we evaluated a standardized intra-operative protocol for optimal fluid replacement therapy. methods. in a prospective study, patients for elective liver resection were included. intra-operative fluid replacement was restricted to ml=kg=h in patients with thoracic epidural analgesia or ml=kg=h for patients without thoracic epidural analgesia. following target parameters were defined: central venous oxygen saturation > %, intra-operative lactate levels < mmol=l, urine output > ml=h, central venous pressure < mbar, and norepinephrine dosage < . mg=kg=min. in patients where at least one of the parameter values exceeded the predefined limit, fluid replacement therapy was intensified and dobutamine . mg=kg=h was started. patients were monitored for intra-operative blood loss, intra-and post-operative complications, and length of hospital stay. results. patients that remained within the intra-operative target parameters for central venous oxygen saturation, lactate levels, urine output, central venous pressure, and norepinephrine dosage had lower blood loss, fewer complications, and shorter hospital length of stay. conclusions. the standardized protocol is a good approach for optimal intra-operative fluid replacement and to minimize blood loss, post-operative complications and hospital length of stay. background. bile duct injuries (bdi) are still the most feared complication of laparoscopic cholecystectomy. the patient has to face prolonged postoperative treatment, even life threatening complications; the hospital and the surgeon rising costs and pricely and possibly time-consuming malpractice procedures. the repair of bdi requires special hepatobiliary expertise, but the long-term results even in the best centres are still sobering. there are different types of bdis requiring a tailored approach. we analyzed predisposing factors and types of bile duct injuries treated in our institution. methods. we analyzed our operative and endoscopy database from - for patients treated with bile duct injuries after cholecystectomy. bile duct injuries were classified according to a system proposed in by siewert and colleagues. results. between and a total of cholecystectomies were performed at our institution. there were laparoscopic (lc) and open procedures (oc; inculuding procedures with conversion from lc to oc); during the same period, patients ( females= males, mean age years; range: - ) were treated for bile duct injuries; of these patients were initially operated in an other hospital. there were patients with class i lesions (bile leak of the cystic duct or lesion of luschka ducts), patients with class ii leions (stricture of the cbd). two patients with class iii injuries (incomplete trans-section of the common bile duct) and patients with class iv lesions (transsection of the cbd or chd). thirty four of the initial ( % -all open and converted and laparoscopic) operations were considered difficulty by the surgeon performing the cholecystectomy. of operations were laparoscopic ( - %), converted from lc to laparotomy ( %) and laparotomy from the incision ( - . %). of the original operations, had been performed by an experienced surgeon, by a novice. conclusions. cystic duct leakage is still the most common type of biled duct lesions after cholecystectomy. bile duct injuries occur a s commonly in operations performed by by novices as in procedures done by experienced surgeons. in order to present the current concept for treatment of bpl patients suffering from traumatic brachial plexus lesion (bpl) who underwent microsurgical reconstruction were analysed. within one year in our institution male patients, aging from to years were scheduled for surgery. three suffered from complete, from upper bpl. six patients were diagnosed as supraclavicular lesions and as infraclavicular lesions. patients with diagnosed supraclavicular lesions were scheduled for surgery between and months after trauma. surgical exploration revealed root avulsion and or rupture in all cases. classic intraplexual reneurotisation was performed in patiens, whereas all patients received extraplexual reneurotisation procedures, utilising the spinal accesssory, the ulnar and intercostal nerves. three patients received secondary reconstructive procedures. patients with infraclavicular lesions were treated surgically between and months after injury. in all patients nerve grafts were used to reconstruct the injured fascicles, a nerve transfer was used in case only. one patient required secondary reconstructive surgery. the reconstructive strategy in bpl surgery has been changed dramatically during the last years. the strategy changed from a single surgical intervention one year after the trauma to a prozessual concept consisting of early primary nerve reconstruction and secondary reconstructive procedures. nerve grafting with use of autologuous nerve grafts for ''intraplexual'' reconstruction is still state of the art, additionally nerve transfers were introduced to utilize ''extraplexual'' sources for reeinnervation. regarding this concept most of the patients regain not only some motor function but functionality of their impaired upper extremity. teaching means learning -who benefits from academic teaching duties? p. lechner, g. humpel background. in the department of surgery at the danube clinics intulln, a level i hospital, has been named a teaching institution associated with the vienna medical university. this has certainly led to various organisational changes the results and consequences of which we attempt to identify. methods. all teaching institutions are subject to continuous evaluation by the students. in addition to that, we undertook an extra evaluation aiming at potential organisational and medical improvements from which patients, personnel, and students may benefit. results. ) as the students are available only from . through . o'clock, all organisational routines at the department (staff-rounds, meetings, lectures, etc.) now follow a more rigorous daily schedule. ) bed-side teaching means explaining everything that is undertaken in the presence of the patients. so the patients receive more information on their diseases and treatments. ) students tend to question everything, and so we also call in question many routines ''that have always been performed like that''. this allows us to simplify numerous operating procedures and means continuous organisational learning to the institution. ) for the same reason lecturers -and all those who are involved in teaching (physicians, nurses, and others)have to keep their academic knowledge up-to-date any time. ) teaching during meetings and ward rounds is of course not ''limited'' to university students, but also comprises interns and residents. conclusions. the department's current status as an academic teaching institution turned out beneficial for patients, personnel, and students, concerning professional, technical, and organisational aspects. though the additional workloadespecially in the beginning -must not be under-estimated, the advantages clearly exceed the burdens. background. necrotizing enterocolitis (nec) is the most common gastrointestinal complication of prematurity at the neonatal intensive care unit. the first aim of the study was to investigate the correlation between clinical parameters, extent of disease and mortality, and the second purpose was to analyse the surgical procedures and their outcomes. methods. in a retrospective study we reviewed medical charts of patients who were operated within a five years periode. preoperative blood results and demographic data were collected and evaluated. according to the extent of disease, birth weight and operative procedure different groups were analysed. results. a total number of patients underwent surgical procedures for nec from to , and % (n ¼ ) weighted less than g. in patients focal disease, in patients multifocal disease and in children panintestinal disease were found. preoperative blood tests revealed a median crp level of . mg=dl (normal range . ), median wbcc of . g=l and a median platelet count of g=l. primary laparotomy with defunctioning enterostomy was performed in %. overall mortality was %. conclusions. the extent of disease and the condition of the infants still determines the survival. preoperative blood results are of limited prognostic value. primary laparotomy with defunctioning enterostomy was the preferred technique in our unit, and even in the group of vlbw and elbw neonates surgery was well tolerated. discussion regarding the best operative procedure is still going on and no consensus in the management of nec is agreed on. methodik. während der letzten jahre wurden neugeborene (gestationsalter - wochen, geburtsgewicht - g, alter bei der darmperforation - tage) mit einer oder mehreren dünndarmperforationen beobachtet. die symptome waren jeweils etwa ident: abdominelle distension mit verfärbung der flankenhaut bei initial insgesamt stabilem allgemeinzustand. bei ,,nur'' der kinder zeigte sich im abdomen-leer-röntgen freies gas in der bauchhöhle, bei allen aber war sonographisch intraabdominell freie flockige flüssigkeit festzustellen, ohne nec-typische veränderungen am intestinaltrakt. kinder wurden aufgrund ihres schlechten zustandes nur punktiert=drainiert und antibiotisch behandelt. patienten wurden laparotomiert: bei kindern fand sich die perforation im bereich des jejunum, bei weiteren im unteren jejunum=oberen ileum und bei im terminalen ileum, davon hatte eines und eines perforationen. der betroffene darmabschnitt wurde jeweils reseziert; bei kindern wurde eine end-=end-anastomose durchgeführt, bei den verbleibenden patienten wurde wegen der peritonitis eine doppelläufige enterostomie angelegt. eines dieser kinder verstarb aufgrund einer sepsis-bedingten gerinnungsstörung. eines der beiden drainierten kinder wurde wochen nach der intervention wegen eines ,,verwachsungsbauches'' adhäsiolysiert. ergebnisse. die Ü berlebenschance sehr kleiner frühgeborener nahm während der letzten jahre deutlich zu. parallel dazu mußte bei diesen kindern eine zunahme umschriebener, ätiologisch nach wie vor nicht ganz geklärter darmperforationen zur kenntnis genommen werden. zur behandlung stehen grundsätzlich differente vorgehensweisen zur verfügung: im vordergrund steht eine resektion des lädierten darmabschnittes und, abhängig von den lokalen gegebenheiten (peritonitis ja=nein), entweder eine end-zu-end-anastomose und=oder nur eine doppelläufige enterostomie. als zweite prinzipielle therapieform gibt es die möglichkeit, die bauchhöhle zu punktieren= drainieren, wodurch die affektion auch beherrscht werden kann; im einzelfall kann sie letztlich aber doch nur chirurgisch zu sanieren sein. dieses vorgehen gilt für uns als ultima ratio. schlussfolgerungen. auch wenn eine isolierte darmperforation bei einem kleinen frühgeborenen relativ gut behandelbar ist, sollte durch klärung ihrer Ä tiologie eine prävention dafür möglich werden, da diese kinder wegen ihrer kritischen voraussetzung bereits per se außerordentlich gefährdet sind. the endorectal pull-through procedure (erpt) for hirschsprung's disease g. schimpl background. whereas in the past various operative techniques in patients with hirschsprung's disease (hd) were used, erpt was introduced as a single-stage operation. methods. sixteen patients with hd ( females, males) aged months to years were treated using the erpt procedure and the level of bowel resection was determined by intraoperative biopsies. results. the length of hd was in patients up to the sigmoid colon, in patients up to the transverse colon and one patient had a total colonic hd. two patients required a laparoscopic mobilisation of the left colonic flexure. in the patient with total colonic aganglionosis, the resection of the entire colon and sauer's procedure was performed using a periumbilical laparotomy. oral nutrition was started in all but on the first post operative day and they were discharged after - days. complication occurred in two patients: one had to be reoperated due to misinterpretation of intraoperative biopsies and a second patient with years of age developed a retrorectal abcess which was treated coservatively. in a follow-up, - years postoperatively, all patients are continent and have normal bowel movements. conclusions. erpt is an advance in the treatment of hd and can be performed at any age. it avoids the creation of enterostomies, is a single step procedure with excellent functional results and low complication rates. in long segment hd this procedure can be combined with laparoscopic or open surgical procedures. single-port appendectomy in obese children -a useful alternative? t. petnehazy, h. ainoedhofer, s. beyerlein, j. schalamon background. the rapidly increasing prevalence of obesity among children poses challenging problems in abdominal surgery. there is a growing body of evidence that single-port appendectomy (spa) is a feasible and safe alternative to open appendectomy (oa). very little is known about the clinical outcome of spa in overweight children. we present our experience with the treatment of suspected appendicitis in obese children using spa. methods. from january to december we performed spa in obese children with suspected appendicitis ( females, males, median age of . years). obesity was defined as a bmi > th percentile for age and gender (median weight . kg). in the procedures a -mm instrument was introduced through the umbilicus (combination of a -mm wide angle optic with -mm working channel). after exploration of the abdominal cavity and meckel's search, the appendix was exteriorized through the umbilical trocar and removed by open technique. patients' records were evaluated regarding anaesthetic time, complications, time until reintroduction of solid diet and histopathological findings. results. average operating time was . min (range - min). neither intra-nor postoperative complications occurred. reintroduction of solid diet to all patients was possible on the first postoperative day. the histology is presented in the below table. our results indicate that the advantages of spa such as: excellent evaluation of the peritoneal cavity, minimal rate of intraoperative incidents and superior cosmetic results make this technique a valid alternative for the treatment of appendicitis in obese children. background. ovarian torsion is a surgical emergency. because of unspecific clinical findings, diagnosis can be delayed and therefore may result in oophorectomy. recently preservation of ovarian function by means of laparoscopic detorsion has been proposed even in advanced cases. methods. we retrospectively reviewed patients with diagnosis of ovarian torsion who presented at our institution between and . a total of ovarectomies and detorsion were performed. twenty patients underwent minimal-invasive surgery, in cases laparotomy was performed. in cases a conversion was necessary. the accuracy of preoperative imaging modalities, surgical technique, correlation with postoperative histopathologic findings, complications and outcome were assessed. results. all patients were investigated by means of ultrasound. mri was applied in patients whereas ct-scan was done in patients. histopathological and intraoperative findings revealed simple torsions, twisted cysts and twisted teratomas. sensitivities to detect ovarian torsion were % for ultrasound (us), % for mri, and % for ct. entirely oophorectomies and detorsions in patients were performed. one of these patients presented with asynchronous bilateral ovarian torsion caused by a unilateral benign teratoma. in patients a laparoscopic contralateral oophoropexy was done. mean hospital stay was (laparoscopic) versus days (open approach). the complication-rate was marginal in both groups. conclusions. preoperative imaging is essential to improve the diagnostic accuracy. however, sensitivity only approaches %, emphasizing the importance of surgical exploration when symptoms are compatible with torsion. when a neoplasm is suspected, mri or ct imaging is essential. in order to preserve ovarian function and fertility, laparoscopic detorsion without primary resection should be the procedure of choice. it constitutes an easy, quick and equally safe procedure. the need for contralateral oophoropexy has to be discussed. background. differential diagnosis of lower abdominal pain include beneath common causes such as appendicitis and gastrointestinal infections some not so common diseases as ovarian pathologies in female patients. this may be ovarian cysts but can also be pathologies like ovarian torsions or tumours that have to be operated. however, the differential diagnosis between ovarian cysts and ovarian torsions is often radiologically inclonclusive and therefore makes a surgical intervention mandatory. methods. we analysed retrospectively the data from female patients hospitalised for ovarian pathologies in between and . twenty nine patients underwent surgical intervention for different causes. results. most patients presented with acute abdominal pain demonstrated signs of peritonitis and required pain relief. on the other hand we had patients with only mild clinical signs such as newborns with already prenatally diagnosed ovarian cysts. we found in our patients cases of benign ovarial cysts, cases of benigne teratomas, cases of serous cystadenomas, case of serous cystadenofibroma, case of yolk sac tumor and cases of ovarial torsions. conclusions. diseases of the ovaries are a rather rare but important cause of lower abdominal pain in children and adolescents and requires a mediculous diagnostic procedure and often an urgent surgical intervention. background. adrenal tumors, other than neuroblastoma, are rare in children. the aim of the study was to present the outcome of functioning tumors of the adrenal gland in children. methods. we reviewed medical records of children with adrenal tumors treated in our unit from to . demographic datas, clinical features, operative details, histopathological details and follow up were studied. results. there were children with the mean age . ae . years. two patients had virilizing tumors and presented with an acute abdomen, one patient had conn's syndrome, one patient cushing's syndrome and one patient presented with severe haemorrhagic shock syndrome. all patients were treated surgically. histopathological diagnosis were adrenocortical carcinoma (acc) in two patients, adrenocortical adenoma (aca) in two patient and adrenocortical cyst in one patient. ultrasound sonography, computerized tomography and magnet resonance imaging were used for diagnosis and follow up. patients with acc had advanced-stage disease and died despite total surgical resection and agressive chemotherapy. patients with aca and adrenocortical cyst were cured by surgical resection. conclusions. adrenal tumors constitue less than % of paediatric neoplasm. aca and adrenocortical cyst are cureable by surgical treatment, but the outcome is still poor in cases of acc. endoscopic subureteral injection of bulking agents has become an established alternative to long-term antibiotic prophylaxis and ureteral reimplantation. we evaluated the effectiveness of dextranomer=hyaluronic acid copolymer (deflux + ) and predicting factors for success or failure. a total of ureters= patients with a mean age of . years underwent endoscopic treatment with dextranomer= hyaluronic acid (dx=ha) copolymer. vur in duplex ureters was treated in patients. the presence of voiding dysfunction and renal scars, the volume of deflux injected and the endoscopic appearance of the ureter were recorded. dextranomer-hyaluronic-acid was injected submucosally beneath the intramural part of the ureter at o'clock, but if the appearance was not satisfying or the ureter opens during flow an additional injection at and o'clock was performed. all patients received antibiotic treatment till a voiding cystourethrography (vcug) was performed weeks after injection. ultrasound examination was performed after hours, months, months and one year. success was defined as no reflux on postoperative voiding cystourethrography. a total of ureters underwent to treatments. the overall success rate was %. the cure rate according to reflux grade was % for grade i, % for grade ii, % for grade iii. in vur grade iv and v the endoskopic treatment failed in most cases. there was no case of obstruction at up to month postoperatively. haemorrhage occurred in one patient. in five ureters an increase of vur grade developed. new contralateral vur was seen in six patients. in . % vur was found on postoperative vcug at years after endoscopic treatment. there was no statistic significant difference in volume injected when successes were compared with failures. among children with a small kidney the response rate was %. a positive response was observed in % of children with duplex ureters. the presence of voiding dysfunction had no influence on success. patients in whom endoscopic treatment failed underwent open surgery. the subureteral injection of dextranomer=hyaluronic acid is an effective and well tolerated alternative to open surgery or conservative treatment, also in patients with duplex ureters. in patients, who subsequently require reimplantation, the operative repair does not appear to be compromised. background. almost all patients with symptomatic vur were treated with a cohen procedure and a very high success rat. since we offer the endoscopic procedure with deflux. the outcome of the endoscopic treatment is evaluated. methods. between = and = , patients with refluxing units were treated (i ¼ , ii ¼ , iii ¼ , iv ¼ , v ¼ ). the control after treatment was between and months. additional urological diseases are: solitary kidney ( ), double kidney ( ), neurogenic bladder with mmc ( ), bladder trabeculation w=o neurological disease ( ), cloacal malformation ( ), bladder exstrophy ( ), urethral valve ( ) . age at treatment was between mths and yrs. injection was performed under general anesthesia, bolus was between . and . ml. three patients were additionally treated with botox. results. sixty patients need no further treatment after injection ( resolved and patients have reflux). in of patients, who need a second injection ( overactive bladder), reflux resolved as well as in patients after third injection. in patients with neurogenic bladder and mmc we had no success and further treatment (augmentation) was necessary. in patients reflux worsened and cohen operation was performed. in patients a vcug will performed in the near future and three are lost for control. conclusions. in cases of moderate reflux with no neurogenic bladder it is an excellent method to treat reflux. in cases of neurogenic bladder, we cannot recommend it and cases with bladder trabeculation need an additional medical treatment or operation with a higher success rate. all these patients need a long term follow-up. background. bariatric surgery in austria has a long tradition since , but has always been different to the international trends. in order to obtain an overview of growth and time trends of obesity surgery in austria a nationwide review has been done by the austrian national federation for surgery of obesity every two years since . methods. e-mail requests are sent to every department of surgery in public hospitals and clinics to collect the recent number of operations including revisional procedures. results. the last reviews (including ) showed a steady increase of obesity surgery particularly in the years through the number of operations increased %. since a constant number of interventions of about per year ( : ) had been observed. predominant operation techniques were restrictive procedures: - vbg (vertical banded gastroplasty) and since agb (adjustable gastric banding). since the late nineties austria is a gastric-banding country ( % in ) compared to the worldwide review data ( % in ), but since we observe a steep increase of gastric bypass paralleled by a decrease of agb. by the time of the conference data of the review starting in january will be presented a showing the trend of the last two years. conclusions. bariatric surgery as the only effective treatment against the alarmingly increasing disease of severe obesity is already an important part of the surgical work of some austrian surgical departments. in view of this fact quality control by continuous data collection is of major importance. restrictive bariatric procedures -long term results and complication management k. miller background. vertical banded gastroplasty (vbg) has been in clinical use since and the adjustable gastric band (agb) since . as promising results were achieved with the adjustable gastric bands available in the market, some surgeons came to the conclusion that vbg might be entirely abandoned and replaced by the adjustable gastric band. the aim of this study was to compare the long term outcome of the two different restrictive procedures. methods. within a period of years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , gastric restrictive procedures were performed in the course of a prospective non-randomized comparative trial. we report the outcomes of vbgs and agbs performed by two surgeons. the mean bmi was . ae . for vbg and . ae . for agb. patient selection was performed by admittance to one of the two surgeons. vbg was performed via laparotomy and agb by the laparoscopic procedure. the bariatric analysis and reporting outcome system (baros) was used to evaluate the postoperative health status and quality of life. results. the mean duration of follow-up was months, with a minimum of years (range, - months). the overall follow-up rate was %. in the short-term follow-up of years, no statistically significant difference was registered between agb and vbg in terms of weight loss, reduction of co-morbidity or improvement of quality of life. the -day mortality rate was . % ( patients) for vbg and . % ( patient) for agb. the overall re-intervention rate in the long term was . % for vbg and . % for agb (p < . , or . , % ci . - . ), the re-operation rate . % for vbg and . % for agb (p < . ), respectively. the excess weight loss (ewl) was significantly higher in the vbg group after months ( % for vbg vs. % for agb; p < . ). in the long-term follow-up with a mean value of months, no significant weight loss was registered between the study groups ( % for vbg and % for agb; p ¼ . ). the baros score in the short term ( years) was good to excellent in and % of the vbg and agb groups, respectively. in longterm follow-up the baros score was significantly in favor of the agb group ( . vs. . %; p < . , or . , % ci . - . ). the overall loss of co morbidities was % in both groups. conclusions. this long-term follow-up study shows that vbg and agb are effective restrictive procedures to achieve weight loss, and loss of comorbidities. a statistically significant lower re-intervention and re-operation rate and an improved health status and quality of life were registered for agb. pilot study on the effects of gastric electrical stimulation (tantalus tm ) on glycemic control in morbidly obese patients with type diabetes (t dm) a. bohdjalian , b. ludvik , s. shakeri-manesch , r. weiner , c. rosak , g. prager background. previous work suggests that non-excitatory electrical stimulation, synchronized to the gastric refractory period and applied during meals, can induce weight loss in morbidly obese subjects. the tantalus tm system (metacure n.v.) is a minimally invasive implantable gastric stimulation modality that does not exhibit malabsorptive or restrictive characteristics. aim: to investigate the potential effect of the tantalus tm system on glycemic control and weight in morbidly obese subjects with t dm. methods. in this european multi-center, open label study, t dm obese ( m, f, bmi: . ae . kg=m ) subjects treated either with insulin ( ) or oral anti-diabetic medications ( ) were implanted laparoscopically with the tantalus tm system. the system includes a pulse generator and three bipolar leads and delivers a non-excitatory signal initiated upon automatic detection of food intake. results. twenty subjects have completed one year and exhibit a decrease in hba c from ae . % at baseline to . ae . % (p ¼ . ) and in fasting blood glucose from ae mg=dl to ae mg=dl (p< . ). sixteen subjects on oral anti-diabetic medications showed a decrease in hba c from . ae . % at baseline to . ae . % (p< . ) and an average weight loss of . ae kg (p< . ), self glucose monitoring available at months post-op from subjects shows a significant (p< . ) decrease in hours post-prandial glucose ( ae mg=dl vs. ae mg=dl). in a subset of patients at months of post-operative follow-up we could find an increase in adiponectin ( . ae . vs. . ae . mg=ml, p < . ) and a decrease in fasting ghrelin ( ae vs. ae pg=ml, p < . ). the areas under the curve (auc) measured during meal tolerance test were significantly higher for adiponectin and lower for ghrelin (p < . ) compared to pre-therapy. four insulin subjects have completed one year and showed no significant changes in hba c and weight. conclusions. interim results with the tantalus tm system suggest that this stimulation regime can potentially improve glucose levels and induce weight loss in obese t dm subjects on oral anti-diabetic therapy. further evaluation is required to determine whether this effect is due to induced weight loss and=or due to direct signal dependent mechanisms. background. gastric sleeve resection was initially devised as the first step of the duodenal switch operation in bariatric surgery. later, it was performed as an isolated restrictive procedure, mostly laparoscopically. we present intermediate to long-term results from a large series of laparoscopic sleeve resections (lsg) in three austrian centers. methods. ninety-eight patients ( males, females) who all met the ifso criteria for bariatric surgery were included in this study. the mean bmi was . kg=m (range, - kg=m ). patients with symptoms of gastro-esophageal reflux or large hiatal hernias as well as ''sweet eaters'' were excluded and allocated for a different procedure (usually roux-en-y gastric bypass). ninety-five of the operations were performed laparoscopically: after establishing a pneumoperitoneum of mmhg, four to five working trocars were introduced. beginning opposite the crow's foot, the greater curvature was dissected from the omentum up to the angle of his. the left crus of the diaphragm was always identified to ensure complete resection of the gastric fundus. the stomach was then reduced to a tube over a f gastric bougie with several magazines of an endostapler, the staple line was finally oversewn with a continuous - pds suture. three patients had sleeve resection via an open access. results. after a median follow-up of months, patients had lost . kg=m of their bmi or % of their excessive weight on the average. there were six failures of lsg: three patients had gained weight despite lsg and three patients had lost less than % of their ew within one year. three of these patients underwent gastric bypass operations that were successfully performed laparoscopically. major complications included leaking of the staple line necessitating reoperation (three patients), severe wound infection (two cases, one of them after conventional sg), minor wound infections (three cases), and postoperative gastro-esophegeal reflux (one case), resulting in an overall complication rate of . % for severe and . % for minor complications. there was no operative mortality. conclusions. laparoscopic gastric sleeve resection is an effective and safe procedure with encouraging intermediate results. there is no implantation of foreign material, the procedure is less invasive than malabsorptive techniques. in the case of failure, it can readily be converted to gastric bypass or duodenal switch (with or without biliopancreatic diversion). on the other hand, this method has yet to stand the test of time within the spectrum of bariatric surgical procedures. background. bariatric surgery is indicated in patients with a bmi exceeding and presenting comorbidities or bmi ! . lgb is accepted as one of most successful surgical procedures to treat obesity. aim of study: a prospective analysis of the first patients who had been treated with lgb in our centre. methods. according to our treatment protocol at least dietetic attempts have to be failed to enrol the patient in the surgical program. lgb is performed in patients with a bmi ! with comorbidities or a bmi ! when gastric banding is unlikely to succeed. thirty patients (f:m ¼ : ) with a mean age of ( - ), mean bmi . (sd . %) underwent an antecolic, laparoscopic gastric bypass, performing the gastro-enteric as well as the entero-enteric anastomosis with linear stapler, closure of the enterotomies with manual continuous suture with pds, closure of the mesenteric defect with a non absorbable running suture. the postoperative controls had been performed on month ., ., ., . and . calculating the corresponding bmi. results. perioperative morbidity: two reoperations due to intestinal obstruction, two intraluminal bleeding of the anastomotic suture line, one case treated endosopically, one conservatively, no mortality was observed. the ewl months after performance of lgb was calculated to be % (sd %). conclusions. this series document that acceptable results may be achieved even during the learning curve of laparoscopic gastric bypass. background. in up to twenty five percent of morbidly obese patients restrictive procedures as vertical banded gastroplasty (vbg) or adjustable gastric banding (lagb) do not lead to adequate weight losses. transformation to a gastric bypass represents a therapeutic option in these patients. methods. from to revisional gastric bypass was performed in patients ( after vbg, after lagb, and after sleeve gastrectomy). the main indication for redo surgery was inadequate weight reduction. results. four ( %) surgical complications (incarcerated trocar hernia, intra-abdominal abscess, subphrenic abscess, leakage gastro-jejunostomy) occurred and had to be treated by a reoperation. one patient died of septic shock caused by a subphrenic abscess resulting in gastro-jejunal leakage and peritonitis (mortality rate: %). on follow-up patients after complications lost equal amounts of excess weight compared to uncomplicated cases. conclusions. revisional gastric bypass is a safe and potentially effective option for patients with inadequate weight loss after restrictive surgery. however, postoperative morbidity and mortality rates are higher compared to primary operations. operational cost accounting reflects in an impressive manner the medically already evident advantages for our patients. a laparoscopically performed colon resection with fast tracking costs e . , including pre-and post-surgical hospitalization. the same procedure without fast tracking results in costs of e . , . open colon resection including fast tracking adds up to e . , . conventional procedure without fast tracking even amounts to e . , . furthermore combining the operational results with the economical calculation results in a cost cutting potential of an extra e , per person, who has undergone laparoscopic surgery and was treated with fast tracking. in conclusion it can be stated, that this strategy of treatment means not only a severe post-surgical improvement of quality of life but in addition also shows significant economical advantages. the best method of treatment from both the medical but also the economical point of view is therefore the combination of laparoscopic colon surgery with fast tracking. is the laparoscopic sigmoid resection with a primary anastomosis in acute sigmoid diverticulitis the optimal surgical therapy? background. the late elective laparoscopic sigmoid resection for diverticulitis has become an acceptable therapy for diverticulitis, but the optimal surgical procedure of the acute diverticulitis has not been established. the optimal waiting period after acute symptoms of diverticular disease is still discussed controversial. the resection and primary anastomosis in acute diverticulitis may advance the challenging process for this surgical approach. methods. from may to january a laparoscopic sigmoid resection was performed in patients (male: , female: ) with a sigmoid diverticulitis. the average age was years for the males and years for the females. = patients were operated early elective within days after acute signs of diverticular disease (according to hansen and stock grade iia and iib) by a single surgeon, and = patients late elective by different surgeons. from all patients the clinical course, the operative time, the length of the sigmoid resection, the post-operative hospitalization and the complication rate were evaluated. results. according to the asa-classification = patients were graded as asa i, = as asa ii and = as asa iii. patients were divided in three groups. group i ( = ): early elective operations, group ii ( = ): late elective operations but with intraoperatively signs of an acute diverticulitis and group iii ( = ): late elective operations without manifestations of an acute process. the average operative time in minutes was in group i: (range - ), group ii: (range - ) and group iii: (range - ). the length of the resection specimen was comparable in group i and iii with an average length of mm, in group ii mm. the average extent of hospitalization was in group i: . days, group ii: . days and group iii: . days. none of the patients had conversion to laparotomy. complications were: group i one wound seroma, group ii one ureteral injury, one incision hernia and group iii three wound infections, one anastomotic leak and one incision hernia. since the localization and operative technique of the wound suturing was varied, an incision hernia was not observed. conclusions. the advantage of the early elective sigmoid resection after acute sigmoid diverticulitis is a short one-stage hospitalization with a low complication rate. in experienced centers the laparoscopic early-elective sigmoid colectomy seems to be a feasible and optimal surgical procedure for the acute sigmoid diverticulitis. laparoscopic resections for colorectal diseases: indications, operations, results s. riss, c. bittermann, p. dubsky, f. herbst background. laparoscopic assisted surgery for colorectal diseases has potential advantages over the traditional open technique. several studies reported that the laparoscopic approach offers multiple benefits such as faster recovery, better cosmesis, a lower incidence of adhesion-related complications and incisional hernias. the current study was designed to assess the role and feasibility of laparoscopic procedure in colorectal surgery. methods. from to patients ( females, males) underwent laparoscopic colorectal resections. mean age was (range - years) with a mean body mass index of . kg=m (range . - . kg=m ). indications included benign (inflammatory bowel diseases, diverticulitis, slow transit constipation, colon adenoma, fap) and malignant conditions with curative and palliative intent. all operations were performed or directly supervised by one single surgeon. intraand postoperative parameters were documented and statistically analysed retrospectively. results. over a year period operations in patients were performed, including bowel resections ( malignant) and anastomoses. average duration of operation was min (range - ). the mean time of hospital stay was days (range - ). the total conversion rate was . %. postoperative complications were observed in patients: surgical complications occurred in cases, with patients requiring reoperation (bowel obstruction n ¼ , anastomotic leak n ¼ , trocar hernia n ¼ , anastomotic bleeding n ¼ ). thirteen patients developed medical complications after operation and were treated conservatively. one patient ( . %) died due to cardiorespiratory failure. conclusions. the present study included a wide range of indication criteria. notable, despite a high number of patients with inflammatory bowel diseases, there was a low rate of surgical complications. thus the minimal invasive approach seems to be safe and effective for a broad spectrum of colorectal diseases. rectal carcinoma in the era of ''minimal invasive''-and ''fast track''-surgery p. razek, c. kienbacher, a. tuchmann background. laparoscopic surgery for colon cancer is feasible and effective with good results in regard of postoperative recovery. fast track protocols are changing perioperative treatments to the same aim. at the time there are no randomized studies available to compare the effect of laparoscopy and fast tract strategies to an open and conventional procedure for rectal carcinoma, which is still surgical standard. methods. from to patients were operated laparoscopically for rectal cancer ( males and females; mean age a, a- a). patients staged t were excluded. excessive preoperative surgery (i.e. right hemicolectomy, sigmoid resection, prostate resection), severe cardiac and pulmonary diseases or a high bmi did not effect the indication for laparoscopy. patients, ( %) staged t preoperatively, received chemotherapy and long time radiation. in the first period (-ii= ) patients were treated according to a conservative perioperative management. thereafter ( ) ( ) ( ) a fast track protocol was applied to the following patients. results. abdominoperineal extirpations (n ¼ ), anterior resections in double stapler technique (n ¼ ) and coloanal anstomosis (n ¼ ) were performed. conversion to open surgery was necessary in two cases ( . %), [bulky disease and a narrow male pelvis (n ¼ ), anatomical reasons (n ¼ )]. operation time was long and varied from to minutes (mean minutes). r was achieved in % ( patients with metastatic disease were staged r , one patient with a colonic wall lesion and potential spillage). postoperative stay for the laparoscopic group was days, for the combined laparoscopic þ fast track group was days (in comparison with days for conventional and open surgery). complications, mortality and side effects were reported. conclusions. exceptional view inside a narrow pelvis by the means of laparoscopy creates good conditions for total mesorectal excision and nerve sparing technique. minimal invasive surgery reduces the surgical trauma as a basis for an early postoperative recovery. the combination with a fast track protocol furthermore helps to establish even better results. the importance of laparoscopy in the management of postoperative complications c. kienbacher, p. razek, p. patri, a. tuchmann background. postoperative complications, especially anastomotic leakage after laparoscopic colon surgery are a hazard for all surgeons. most important is to recognize the early signs of complications such as abdominal pain, fever, chill, persisting nausea and vomiting and increasing abdominal swelling. the erlier a reintervention is done the better is the outcome for the patient. requesting a single and sufficient procedure, most surgeons don't even think about a minimal invasive reintervention. from = until = patients underwent laparoscopic colon surgery, patients had to be reoperated. twenty-five patients had a relaparoscopy, only two times we converted to the open procedure. patients had to underwent primarily open abdominal surgery, patients had abdominal wall problems and did not need an intraabdominal procedure. methods. concerning the intraabdomial complications we performed laparoscopic washouts, patients had a laparoscopic incisional hernia repair, patients bleeded from the trocarincisions, a laparoscopic anastomosis resection was performed, patients got a laparoscopic ileostomie, times it was necessary to perform a laparoscopic bowel diversion and times the hartmann procedure was performed minimal invasive. results. the traditional open reinvention was required in patients, all showed a peritonitis and a colon diversion with stomatherapie was done. eighteen patients had a single reintervention. after laparoscopic redos the median postoperative stay was far shorter than after open procedure. patients died. conclusions. laparoscopic reinterventions are feasable in most cases, the advantages are less postoperative pain, shorter hospital stay, quicker return of bowel fuction and improved cosmetic results. compensatory sweating after endoscopic sympathetic block at t background. endoscopic thoracic sympathectomy is the treatment of choice for patients with primary hyperhidrosis (hh). compensatory sweating (cs) is the most frequent unwanted side-effect of this surgical procedure. recently, clip application (endoscopic sympathetic block, esb) has been introduced as it provides reversibility. furthermore, sympathetic block solely at the level of the th thoracic ganglion (t ) was proposed to reduce cs and still effectively cure palmar hh. the aim of the study was to analyze the outcome of patients treated by esb at the level t with special reference to cs. methods. between and patients (mean age . ae . years) prospectively underwent procedures (one unilateral and bilateral operations). satisfaction rates and quality of life scores have been evaluated. mean follow up was . ae . months obtainable from patients ( . %). results. one hundred and three patients ( . %) had palmar, ( . %) axillary and ( . %) combined hh. at follow-up, all patients with palmar and . % with axillary hh were completely or nearly dry. cs was observed in ( . %) patients. most frequently, the back ( . %), the thighs ( . %), the abdomen ( . %), the feet ( . %) and breasts ( . %) were affected. in . % one single body region was affected, in . % two and in . % three regions became humid. cs significantly diminished quality of life (p < . for both questionnaires). consequently, . % were unsatisfied with the final outcome. however, the vast majority of patients were completely or almost completely satisfied. conclusions. esb at t gives excellent results for palmar and good results for axillary hh. however, cs primarily affecting the back and the thighs diminishes patients' quality of life and satisfaction. right donor nephrectomy, a major challenge is adequate renal vein length, due to vascular anatomy. methods. all patients undergoing laparoscopic donor uretero-nephrectomy between and were included. side of nephrectomy was selected based on selective renal function assessment and vascular anatomy. standard laparoscopic access was gained through trockars, the kidney dissected from its capsule, the vessels isolated, and the ureter transsected. following transsection of the renal artery (proximal closure with clips to maximize retrieved vessel length), and the renal vein (proximal closure with vascular stapler), the organ was procured through a mini-laparotomy connecting two trokars. in laparoscopic assisted right nephrectomy, the vein was retrieved with a vena cava patch using a semi-open approach: following isolation of the vascular structures and ureteral transsection, the confluens of the renal vein with the inferior vena cave was excluded using a curved clamp through a mini-laparotomy in the right upper quadrant. the caval patch was created by cutting the vein closely distal to the clamp, with reconstruction of the vena cava by a running blalock suture. patients undergoing laparoscopic assisted right resection (study group sg) were compared to patients with laparoscopic left nephrectomy (control group cg). data are reported as mean ae standard deviation or total numbers (% . total morbidity was ( . %), including ( . %) infections, and ( . %) postoperative lymphatic leaks. two ( . %) major complications (bleeding ( ) and intraabdominal abscess ( )) resulted in reoperation (sg vs. cg ; p ¼ . ). conclusion. the laparoscopic assisted approach to right kidney procurement is feasible, allows for sufficient length of the right renal vein for transplantation, and donor morbidity is comparable to laparoscopic left nephrectomy. clinical implementation of radius surgical system in mis w. feil, i. pona, t. filipitsch, p. jiru, u. satzinger limited mobility of instruments and absence of depth perception are significant issues in advanced laparoscopy. by that procedures including complex suturing and anastomoses in narrow operating fields in difficult angles of visualisation exceptionally challenge experienced surgeons. the radius surgical system (tübingen scientific medical gmbh, tübingen, germany) consists of manipulators for mis (right and left hand) suitable for mm trocars allowing a freedom of movement comparable to robotic devices. the instrument tip can be deflected by by handle deflection and rotated via handle knob. compressing and releasing of the instrument jaws works conventionally. radius system was implemented in the ekh vienna by = . in advance a -day training course was absolved by the surgical team. radius system was used for a series (n ¼ ; = ) of reflux operations to perform hiatal suturing and fundoplication. in practice handling of radius taking advantage of all features turned out so physically mandatory, that a training course is unanimously recommended even for surgeons with experience in all mis suturing techniques. in pratice the needle could be guided with significantly higher precision if compared to convention needle-holders. even suturing in narrow cavities and in difficult angles became feasible (video). after full accomodation to radius the next step of implementation is the creation of handsewn anastomoses, esp. in bariatric surgery. precision, reliability, safety and tightness of sutures and sewn anastomoses are crucial for the outcome quality of advanced mis procedures. for that the radius surgical system has shown to be extremely beneficial. does lifting of the abdominal wall for the set up of the pneumoperitoneum for laparoscopy increase the safetiness? a. shamiyeh , j. zehetner , h. kratochwill , k. hörmandinger , f. fellner , w. u. wayand background. to evaluate the intraabdominal changes while lifting the fascia with regard to the distance between the fascia and the retroperitoneal vessels and the intestine for access in laparoscopy. fifty percent of all complications during laparoscopic procedures occur during the establishment of the pneumoperitoneum. the blind insertion of the veress needle is the most popular way of access. elevation of the abdominal wall or the fascia is recommended, though the benefit has not been proven yet. methods. for patients scheduled for laparoscopic cholecystectomy the operation started in the ct scan. after orotracheal intubation a ct scan was performed of the umbilical region with cm proximal and distal margin. after a supraumbilical incision the fascia was freed and elevated with stay sutures. during maximal elevation, a second ct scan was performed. the distance between the fascia and the intestinal structures (small bowel) and the retroperitoneal vessels (iliac artery, aorta, vena cava) was measured after both scans and the difference was evaluated. results. lifting of the fascia increased the distance between the fascia and the intestinal structures with a mean of . cm (range . - . cm), the distance between the fascia and the retroperitoneal vessels with a mean of . cm (range - cm). conclusions. elevation of the fascia at the umbilical region prior to the first entering into the abdominal cavity for laparoscopy does increase the safeties due to enlargement of the distance between the fascia and the intraabdominal and retroperitoneal structures. background. despite many years of experience in breast reconstruction even as an immediate one stage procedure, there are still rumours about this technique, even among oncologic surgeons. these are concerning the influence on the oncological outcome, radio-and chemotherapy, severity of the operation, possible complications and patient's satisfaction. the presentation offers answers to most of these rumours from our own experience and the recent literature. methods. one hundred and eighty breast reconstructions were performed between and in our department, as immediate and as delayed procedures. eighty-seven were done with microsurgical autologous flaps and with a latissimus dorsi flap, in the rest various techniques like prostheses and expanders were applied. patient data were collected concerning early and late complications, oncological outcome, influence on radio-and chemotherapy and patient's satisfaction. results. reconstructions with prostheses required shorter operating times, but mostly late revisions were more frequently, especially in combination with radiotherapy. among the group of patients, in whom flaps were applied, only one was lost. with increasing experience, the need for blood transfusions, the postoperative morbidity and the length of the hospital stay decreased. in no case radio-or chemotherapy had to be delayed due to immediate breast reconstruction. secondary axillary lymph node dissection due to a positive sentinel node was possible even after a flap which was pedicled in the axillary vessels. our experience is well reflecting the results of the recent literature. conclusions. despite many existing rumours breast reconstruction, even as an immediate single stage procedure, can be regarded as an operation which does not inflict the oncological therapy. to optimise the results, however, indications must be set very carefully. background. positron emission tomography with the glucose analog [ f]-fluorodeoxyglucose (fdg-pet) has been used for response evaluation in patients with esophageal squamous cell carcinoma (escc) during neoadjuvant radiochemotherapy (rtx=ctx). this prospective study was undertaken to compare fdg-pet assessment of tumor response during rtx=ctx with histopathology in patients with escc, and to correlate the findings with survival. methods. sixty-one patients with histologically proven escc (ct , cn =þ, cm ) underwent preoperative, simultaneous rtx=ctx followed by esophagectomy between and . the patients underwent fdg-pet prior to and weeks after the begin of rtx=ctx ( gray). histopathological response was quantified as the percentage of residual tumor cells. the threshold pre-therapy-to-during-therapy decrease in standardized uptake value by fdg-pet used to define metabolic responders (Ásuv r ) was À %. results. receiving-operator-curve analysis (roc) for determination of metabolic response revealed an area-under-curve (auc) of (p ¼ . ) with a sensitivity of %, specificity ( %), a positive predictive value of % and a negative predictive value of % (p < . ). responder by fdg-pet during the neoadjuvant treatment (p ¼ . ) as well as histopathology (p < . ) showed substantially better survival compared to nonresponders. conclusions. changes in tumor metabolic activity by fdg-pet during neoadjuvant rtx=ctx allows an accurate determination of response due to the multimodal approach in patients with escc. this stratification may lead to a change of the neoadjuvant into a definitive therapy concept in nonresponders (individualized tumor therapy). background. totally endoscopic coronary artery bypass grafting (tecab) requires telemanipulation technologies because attempts using conventional thoracoscopic instrumentation have completely failed. these complex operations take individual and team learning curves and a stepwise approach is necessary. methods. from to cabg procedures were performed using the davinci tm system. a low risk patient population (age ( - ) years, euroscore ( - )) was treated. the following procedures were carried out: endoscopic ima takedown in midcab, opcab, and cabg (n ¼ ), robotic suturing of lima to lad anastomoses through sternotomy (n ¼ ), single vessel tecab (n ¼ ), double vessel tecab (n ¼ ). results. the number of totally endoscopic approaches through ports only increased from % in to % in . there was no hospital mortality and cumulative risk adjusted mortality (cram) plots showed that . predicted events did not occur. given event free procedures clopper pearson estimations revealed a % confidence interval between . % and . % for perioperative mortality. cumulative year survival was %, and year freedom from angina was %. conclusions. introduction of robotic totally endoscopic coronary artery bypass grafting seems to meet current cabg safety standards. initial application in low risk patients and a stepwise approach to completely endoscopic versions of the operation seem worthwhile. using this way single and double vessel tecab can be performed. intermediate term survival and revascularization results appear to be very satisfactory. icu stay was a mean of day in both groups and hospital stay lasted on average . ae . days in the bh group and . ae . days in the ah group (p ¼ . ). the advantages of arrested heart tecab are various -more space through the relaxed heart, -superior anastomosis quality through the arrested heart, -no manipulation of the lad with tapes and a clear operating field through the use of crystalloid cardioplegia, -no occlusion of the lad with the risk of ischemia, and result in shorter anastomosis as well as operating times and do not increase icu and hospital stay. methods. initially an experienced gi-surgeon was trained in an experimental centre in the application in both, open and laparoscopic application of the flexible shaft stapling system. after experimental sessions the system was used in clinical open surgery in cases before the laparoscopic approach was used. for laparoscopic procedures a stepwise learning curve was applied (from laparoscopic appendectomy, colon resection to laparoscopic gastric resection and esophageal resection). for intraabdominal application of the linear stapling device a mm trocar and for the circular stapling device a mm trocar was used. technical problems, operation time and operative complications were prospectively documented. results. the flexible stapling device was used in patients ( conventional, laparoscopic surgery). a mean of stapling procedures (range - ) was performed per patient. during the early phase technical problems were observed in patients ( formation of gastric tube for esophageal reconstruction, three formations of colonic anastomoses). all problems were solved by repetition of the anastomoses. nine leakages ( . %) were observed: two after esophageal surgery ( = ; . %), one after gastric surgery ( = ; . %) and six after colon surgery ( = ; . %). conclusions. the flexible shaft stapling device is safe in open and laparoscopic surgery. technical problems in the early phase were not due to malfunction of the device. the problems and complications are within the limits of conventional stapling. since there is a learning curve for handling, proper training in laparoscopic and open surgery is advised. the new flexible stapling device showed beneficial in special indications in laparoscopic surgery. the handling of the device is possible in any location in the abdomen, which makes procedures like collis-plasty feasible to be performed laparoscopically. circular stapled anastomoses of the colon above the rectosigmoid junction can easily be performed in circular stapling technique. background. intra-und extraplexuale nerventransfers kommen routinemäßig in der rekonstruktion posttraumatischer plexus brachialis läsionen zur anwendung. in den letzten jahren wurden einige neue selektive distale nerventransfers beschrieben, welche ein geringes defizit an spendernerven hervorrufen, möglichst nur motorische fasern beinhalten und ein hohes maß an funktioneller synergie besitzen. in der vorliegenden retrospektiven arbeit werden die operativen details, und langzeitergebnisse von patienten bei welchen diese techniken zur anwendung kamen vorgestellt und analysiert. methodik background. long lasting brachial plexus lesions (bpl) require free functional muscle transplantation to restore some distinct motor function. methods. five patients, receiving a total number of free vascularized muscle transplants are presented. all patients were male, aging , , , and years. patients suffered from obstetrical, from traumatic bpl. unstable shoulder (n ¼ ) and lacking biceps function (n ¼ ) were the indications for surgery. the gracilis muscle was used in cases to replace deltoid (n ¼ ) and biceps (n ¼ ). in one case a rectus femoris muscle was transferred into deltoid position. reinnervation of the muscle transplants at the shoulder was perfomed end-to-side to the spinal accessory nerve. in biceps position the motor nerves of the gracilis were coaptated end-to-end with the ulnar nerve (oberlin procedure, n ¼ ) or intercostal nerves (n ¼ ). results. surgery was successful in all cases primarily. all transplants showed reinnnervation starting months after surgery. stabilisation of the shoulder was achieved in all cases, furthermore of these cases regained active shoulder abduction= flexion up to degree. gracilis in biceps position reached m , are reinnervating. conclusions. free vascularized muscle transplantation seems to represent an useful tool for reconstruction of some distinct, essential motor function in paretic limbs due to bpl. background. since viterbo presented his exquisite results from terminolateral coaptation in small animals a new source for neurotisation seemed to be provided. viterbos results and our own good experience with free functional muscle transplantation encouraged us to use the technique in brachial plexus surgery. in a retrospective analysis we wanted to prove whether or not terminolateral neurorrhaphy produces functional results in brachial plexus surgery. methods. in patients, suffering from minimum c , avulsion and=or rupture a total of terminolateral procedures was carried out: times the suprascapular nerve was connected with the spinal accessory nerve and times the biceps motor nerve with the ulnar nerve, after creation of an epineureal window in all cases. results. patients were investigated . (ae ) month after surgery. the modified oberlin procedures (n ¼ ) showed m . the ss to xi procedures ranged from m (n ¼ ) to m (n ¼ ). multichannel emg evaluation did not reveal isolated function of the reinnervated muscles but action in parallel with the ''source muscles''. in out of procedures the terminolateral neurorrhaphy was sufficient to regain useful muscle function, i.e. to stabilise the shoulder and to add some minimal active function. conclusions. with respect to the severity of the lesions one might consider this an acceptable result. actually we did expect better results from the procedures, as we did achieve m and m function with free functional muscle transplantation and terminolateral neurorrhaphy in children. regarding our experience, the technique represents an useful tool for reinnervation, provided an unimpaired function of the donor nerve. current concept for treatment of obstetrical brachial plexus lesions w. girsch background. for a long time the treatment of obstetrical brachial plexus lesions (obpl) consisted of conservative treatment mainly. surgery was indicated only in severe cases suffering from persistant complete flail arm. gilbert introduced a much more aggressive concept with surgical intervention whenever the biceps is not working at three months of life, a strategy which caused discussions permanently. as a result of this discussion and with respect to clarkes work the concept was modified in the last years again. methods. the diagnosis of an obpl has to be followed by monthly clinical examinations. testing for muscle regeneration is not only focussed on biceps muscle but also on time and topographic course of regeneration. lack of shoulder and biceps activity at three months of life or negative ''handkerchief-test'' at six months represent indications for immediate surgical revision of the brachial plexus (primary early nerve surgery). in cases showing ongoing regeneration the conservative treatment is maintained. relevant deficiencies in motor function (less than % of rom or power in correlation with the unaffected side) at twelfe months of life represent an indication for brachial plexus surgery again (primary late nerve surgery). further nerve procedures, usually isolated nerve transfers (secondary late nerve surgery), can be performed in selected cases up to two years of life. after that time musle transfers and osteotomies (secondary procedures) are perfomed to achieve further increase in function. results. in brachial plexus surgery new concepts of ''extraplexual neurotisation'' and ''end-to-side neurorraphy'' have increased the possibilities of reconstruction by increasing the amount of nerve sources. secondary procedures, including free functional muscle transplantation, have become an integrative part of the overall treatment strategy. conclusions. although obstetrical techniques have improved in the industrialized countries, there still exists an incidience of - obpl per newborns, last but not least with regard to an increasing number of babies weighing more than g. it is known that of obpl recover spontaneously. new investigations have revealed relevant deficiencies in out of of these children at an age of years. actually the number of children requiring surgery is small. but for these children it is important to make the right decisions in time to minimise deficiencies and achieve optimal results. external derotation osteotomy of the humerus in patients with erb's palsy -effects on upper extremity kinematics b. gradl, m. mickel, m. schmidt, g. weigel, a. kranzl, w. girsch orthopädisches spital speising, kinderabteilung, wien, austria background. patients with untreated upper brachial plexus lesions frequently develop an internal rotation contracture of the shoulder, deficient active shoulder abduction and especially external rotation. the humeral derotation osteotomy combined with muscle transfers is one of the most common secondary reconstructive procedures to correct this deformity and improve the upper limbs function. the aim of this study was to investigate the patients' benefit of the surgical intervention. in order to objectively assess the functional outcome an optoelectronic motion analysis system was used to capture and analyze the kinematics of the involved limbs pre-and postoperatively. methods. eight children with secondary deformities following an obstetrical erb palsy were investigated before and after humeral derotation and muscle transfers. the patients' movements were captured by tracking the reflective markers which were applied to the upper limb and the trunk. the motion analysis was finished on the pc, resulting in various kinematic parameters, such as joint angles, motion curves, velocity and acceleration. static data was calculated to measure the amount of the shoulder malposition. results. results of the motion analysis document a dynamic as well as a static improvement of the involved limb in all eight patients. the average effective external derotation of the upper arm was , which means a correction to a nearly physiologic rotational positioning. active abduction increased in of patients with enhancement between and . active shoulder rotation improved in all patients ($ ). the maximum active elbow flexion did not increase, but the motion curves describing the movement changed: the velocity increased ( %), the compensatory shoulder abduction, which was observed during elbow flexion preoperatively in all patients, was reduced to a physiologic extent (compared to healthy probands). conclusions. derotation of the humerus as a secondary procedure allows functional improvement in patients with erb's palsy. this can be assessed by using a d motion analysis system. following global or lower brachial plexus lesions with intact biceps function in combination with missing radial nerve and weak median nerve function a supination contracture of the forearm is resulting. the supinated position of the forearm is functionally useless and often causes neglect of the extremity. five patients underwent surgical correction of this deformity, females (aging , and years) and males (aging and years). the biceps tendon was rerouted to the outside of the radius in cases and to the medial side of the ulna in one case. additionally correction osteotomies of radius and ulna had to be performed in the y old patient. reconstruction of extensor function was done in classical manner by tendon transfers. the tendon transfers did not only reanimate the extensors of carpus and hand but also augmented the light pronation of the forearm. all patients regained normal biceps and some simple hand function. regarding this, all patients started to use the extremity during adl for some, mostly bimanual tasks. correction of the supination contracture was highly beneficial for the patients. the procedure changed a useless extremity into a functioning part of the body. background. reconstruction of the distal weight-bearing area of the foot is surgical challenge, especially in diabetic patients. skin grafts do not provide adequate and permanent coverage of a weight-bearing region. local surgical options to cover these distal skin defects include forefoot amputation, a toe fillet flap and a reverse medial plantar island flap. the reverse medial plantar island flap is based on a very thin and possibly damaged intermetacarpal network. conventional angiography often is not a helpful tool for preoperative assessment, because foot vessels often remain occult. methods. the purpose of this study was to evaluate the viability of the distally based medial plantar flap in cadavers. angiographic imaging was possible in only cadavers reflecting the clinical preoperative assessment. distally based medial plantar flap dissection was done in all cadavers, as well as vascular dissection of the superficial and deep plantar arch. results. we found a well developed deep plantar arch in all cases. the deep plantar artery formed the main feeder of the deep plantar arch in %, while the second proximal perforating artery contributed to the deep plantar arch in %. the superficial plantar arch usually appeared slender and incompletely. conclusions. the distally based medial plantar flap could be dissected in all cadavers, whereas the quality of vessels was varying explicitly. the results of dissection always showed a constant vascular supply, but varying quality of supply. no clinical conclusions can be drawn, considering the slender vas-cular supply of the distally based medial plantar flap. optimized diagnostic angiographic procedures like mra or biplane selective dsa are essential for preoperative assessment planning distally based medial plantar flap. limberflap -salvage procedure for the non healing pilonidalis sinus t. kapp, h. marlovits, j. beck, f. hetzer kantonsspital st. gallen, switzerland background. surgical treatment of pilonidal sinus disease has a significant morbidity and recurrence rate. the rhomboid flap of limberg is a transposition flap that has been advocated for treatment of this condition. we present the technique and our experience. methods. in a prospective study starting in january we analysed consecutive patients ( females), median age years (range - years), with recurrent pilonidal sinus disease. we performed a complete rhomboid excision and closed the lesion by an excentric transposition flap designed to obliterate the middle cleft. morbidity was recorded and patient's satisfaction was analysed by a visual analog scale (vas). results. the median hospital stay was . days ( - days). we found in all patients a primary healing. minor complications were found in two patients. there was one flap oedema and one wound dehiscence, which were conservatively treated. no wound infection was observed. during the median followup of months ( - months) no recurrence occurred and high patient satisfaction was noticed. conclusions. although the limberg flap results in a slight asymmetric gluteal region patient's acceptance is high. fast healing, low complication and recurrence rate are the important advantages for this procedure. treatment of human painful neuromas and complex regional pain syndromes (crps) by co laser welding and regional subcutaneous venous sympathectomy (rsvs) -a new surgical approach w. happak, l. kriechbaumer background. since nearly years the treatment of painful neuromas is an unsolved problem. up to techniques are described with a recurrency rate of the pain between and %. the intramuscular transposition, the implantation into a vein and the end-to-side coaptation of the nerve stump are the state of the art operations. besides for years the treatment of complex regional pain syndromes type ii (crps ii) has been an unsolved problem. therapeutic approaches have included conventional pain medication, physical therapy, sympathetic blocks, transcutaneous or spinal cord stimulation, injections or infusion therapies and sympathectomy. alone or in combination these therapies often yielded unfavorable results. the majority of physicians, dealing with crps patients are convinced that surgical treatment only exacerbates the symptoms, and after the third neuroma pain-operation no improvement can be expected. after unsuccessful anaesthesiologic pain therapy over more than months, patients, with chronic neuroma or phantom pain were operated by co laser welding of the nerve stump in the last years. one third of the patients had or more pain operations. subsequently patients developed a crps type ii at the upper or the lower limb. the exact pain area was determined and the most proximal part where the crps commenced was infiltrated with % xylocain. when the sympathetic, deep, burning pain could be blocked, the subcutaneous veins in the previously determined area were removed surgically in a second step. a visual analogue scale (vas), the nottingham health score (nhs) and physical examinations were used to evaluate outcome of the operation. results. ninety-five percent of surgically treated painful neuromas and crps type ii patients showed significant improvement of limb function, the visual analogous scale (vas) and the nottingham health score (nhs). the medical pain therapy could considerably be reduced. conclusions. the presented data show that the superficial epicritical pain of neuromas can be treated successfully with co laser welding. the sympathetic, deep pain of the complex regional pain syndrome type ii can be treated successfully by a regional subcutaneous venous sympathectomy (rsvs). first clinical study of successful erbium-yag laser vaporisation of cutaneous neurofibromas l. kriechbaumer, w. happak background. with a prevalence of in births neurofibromatosis type i is one of the most common genetic defects. the mode of inheritance is autosomal dominant and affects a gene (nf ), which is responsible for the production of the tumor suppressor protein neurofibromin. the consequence is an uninhibited expansion of neural tissue which leads to cosmetic disfigurement of the patients. in comparison to the plexiform neurofibromas the cutaneous tumors do not undergo malignant transformation. excision and co laser vaporisation were established as standard treatment but cause unattractive scars. methods. in operations on two patients more than neurofibromas were removed with an erbium:yag laser. the tumors were dissected by shooting holes into the skin and vaporising the neurofibromas in-between or underneath. from test areas several biopsies were harvested for er:yag-, co and electrosurgical treatment in vitro to evaluate the difference of thermal necrosis histologically. photographs were taken to assess the cosmetic results. results. the fast healing by second intention as well as the minimal discomfort and scar formation following er:yag laser vaporisation was judged as excellent by patients and surgeons. we did not observe any hypertrophic scarring or lasting dyspigmentation. histologic evaluations revealed minor thermal damage to adjacent tissue resulting from this laser. conclusions. scars and changes in pigmentation resulting from excision or co laser-vaporisation often yield unfavourable results and the treatment is time consuming. er:yag laservaporisation of huge numbers of cutaneous neurofibromas is an uncomplicated and rapid procedure that achieves excellent cosmetic effects. background. lichen sclerosus usually presents a precancerous skin lesion of the genital region. skin grafting of penile defects is difficult because of the flexibility of the underlying recipient bed. this leads to disruption of the vascular ingrowth into the skin graft and compromises the results of the reconstruction. methods. we successfully used a circumferential vacuumassisted closure dressing with an incorporated urethral catheter to secure penile skin grafts in place during the early postoperative period. results. we achieved perfect take-rate of the graft and postulate good functional result concerning the stretched penile position during application of the vac-device. conclusions. a vacuum-assisted closure dressing can be used successfully to secure large and circumferential skin grafts, as well as skin grafts on concealed penises. background. there is a trend in reconstructive surgery towards modern techniques of defect coverage. such techniques are expected to combine high levels of safety, low donor-site morbidity, high aesthetic claims, short patient immobilisation and inpatient periods. the speculative applications for free, microvascular tissue transfers are expanded monthly while traditional reconstructive flap designs are no longer accepted as ''state of the art''. we present a case where modern defect coverage was not successful due to multiple comorbidities, localisation and complexity of the defect, and a step back to traditional flap designs was inevitable. methods. a previously healthy -year-old woman found a tumour on her back four years ago. diagnostic imaging and multiple biopsies revealed a cm-diameter chondrosarcoma with partial osteolysis of th = , tumour reaching into the spinal canal. she underwent radical resection and orthopaedic stabilisation from th -l , followed by chemotherapy and radiation of gy. one year after the operation metastatic lesions were found in both lungs. they were resected by video assisted thoracic surgery. due to resection of the erector trunci, the spine stabilisators loosened, two screws broke and the metal parts penetrated the skin. after local necrectomy, vac-therapy was performed for more than one year. severe headache and massive exsudation of the wound started in , suggesting dural leakage. a reversed latissimus dorsi-flap was performed, additional microanastomosis could not be done due to the very small calibre of the intercostal vessels. after one week, the metal-covering part of the flap showed muscle necrosis and had to be resected. a large fasciocutaneous transposition flap was designed and cautiously raised in steps of delay and could finally cover the defect. results. in this rare case of a chronic vertebral defect including spinal instability and liquorrhea reconstructive aims could not be reached by microsurgical techniques but by returning to traditional local flap designs. the patient is mobile and painfree, and there is no recurrence of liquorrhea since discharge. conclusions. technical advances and refinements in defect coverage are the basis for progress in reconstructive surgery. selected indications for traditional flap techniques still remain in modern reconstructive surgery dominated by microsurgical tissue transfer to cover problem defects. the missing link between tradition and innovation: skin tissue engineering l. kamolz, m. frey background. the need to achieve rapid wound closure in patients with massive burns and limited skin donor sites led to the investigation of in vitro cellular expansion of keratinocytes. the use of cultured epithelial grafts was first reported in the treatment of major burns. since , support for the use of keratinocytes has varied. the factors potentially limiting the use of cultured keratinocytes were cultivation time, reliability of 'take', vulnerability of grafts on the newly healed surface and long-term durability. the aim of this review is to evaluate the real impact of the clinical use of keratinocytes. one of the main aspects is to introduce new methods, which found or will find their way into clinical practice. methods. this study is mainly based on our long lasting experience in cultivating and transplanting cultivated keratinocytes (more than patients and sheets). results. the coverage of burn wounds with viable keratinocytes renders constant and reliable results. understanding keratinocyte-matrix interactions has not only allowed us to influence keratinocyte outgrowth, adhesion, and migration, but also has guided us to modify matrices for enhancing keratinocyte take. due to these improvements we have achieved a proper material in the adequate situation. conclusions. as surgeons, our goal is to help burn patients with the best quality of skin in the shortest time possible. as tissue engineers, we have not achieved the goal of a universal skin product yet, but by continually reviewing new options and using them, the anatomy and physiology of engineered skin substitutes will improve and they will become more similar to native skin autografts. thereby tissue-engineered skin may match the quality of split-skin autografts in future. background. the survival of patients with major burns goes hand in hand with early escharectomy and the survival of skin grafts. methods. the application of topical negative pressure has improved increased graft take especially in difficult anatomic regions. results. securing skin grafts in pediatric burn patients enabled a near % graft take. perfect protection from shear forces, early mobilisation, patient comfort, nursing comfort and abandonment of splinting are major advantages concerning conventional dressings. conclusions. we postulate the application of vac for securing skin grafts as a valuable tool in pediatric burns management. wide meshed grafts and including donor sites protected by silicon layers into the dressing in extensive burns should be evaluated carefully because of possible bleeding. background. versajet is a high -pressure hydrosurgery system, which enables a very precise surgical procedure. this single device technique combining lavage, excision, cleansing and aspiration allows a sharp debridement on any surface, or space. there are lot different indications for the use of versajet in plastic and reconstructive surgery. this system is appropriate for a variety of burn and traumatic wounds. because of the precise handling the use of this device is also in cosmetic surgery possible. methods. in this device a high velocity stream of sterile saline jets across the operating window and into an evacuation collector. because of a physical effect, a localised vacuum is created across the operating window. this holds and cuts targeted tissue while aspirating tissue from the site. therefore it enables to precisely target damaged tissue and spare viable tissue. surgical techniques can be enhanced, for instance the device holds targeted tissue during irrigation and excision. in addition, versajet cleans and cools at the same time as debriding, so additional cleaning techniques are not required. the depth of the skin -debridement is absolute predictable. in about cases the versajet has been used. the range of indications included burns, infected wounds (decubitus ulcers, traumatic wounds, fournier gangrene, necrotizing fasciitis). the advantage of this hydrosurgery system compared to sharp debridement using scalpels, dermatome, etc. is a more rapid and precise debridement, therefore the preservation of viable tissue, the precise and easy treatment of concavities and convexities and a reduction of blood loss could be achieved. histological findings proved the feasibility of an exact abrasion into different layers of the dermis. results. by using the versajet device, a reduction of the debridement procedures, an earlier reconstruction and a shorter time of hospitalisation could be achieved. the most important indication is the treatment of b burn-wounds. in burn cases the necrosectomy with some other devices may be quicker and more useful. although there is a learning curve which is very short, this tool is easy to handle. there has been no adverse effects. conclusions. the versajet-handpiece is a disposable product, but because of the advantages it is at least cost-covering. debridement is highly effective since it enables selective tissue targeting. removal of non-viable tissue is more complete as a result. background. in more than children (age < years) were suffering from burns. the gold standard of surgical care is still under discussion. the aim of the study was to evaluate an optimised treatment regime for scalds in children. methods. between and , children underwent surgical intervention due to salds. thirty-six of them were enrolled into the study. twenty-two children with deep dermal scalds (total-body-surface-area burned (tbsa) . %) were treated by early excision and keratinocyte-coverage (keratinocyte-group). fourteen children (tbsa . %) were treated with autologous skin grafts (skin-graft-group). both groups were comparable according to age, burn depth and tbsa. the complete clinical follow-up was at least months. the scar formations were classified (vancouver-scar-scale (vss) and the need of blood transfusions were administered. results. the use of keratinocytes led to complete epithelialisation. no secondary skin grafting was necessary. skin take rate was % in the skin-graft-group. the mean volume of transfused blood was . ml in the keratinocyte-group and thereby significantly lower than the volume of . ml, which was administered in the skin-graft-group (p ¼ . ). the vss observed in the keratinocyte-group was . and thereby significantly lower than the vss of . in the skin-graft-group (p ¼ . ). conclusions. in children the use of keratinocytes renders constantly reliable results in deep dermal scalds. it minimizes the areas of skin harvesting and reduces the amount of blood transfusions. the fact that also less scarring is observed leads to the conclusion that skin grafting should be restricted to full thickness scalds. background. ventriculo-peritoneal (vp) shunting is the treatment of choice for hydrocephalic children. however, serious complications related to infectious and non-infectious reasons may subsequently appear during lifetime of these patients. as we attend nearly all our patients from birth to adulthood we had to face various kinds of abdominal problems over the years. hydrocephalic children underwent vp shunt placement. outcome and follow-up of these patients were discussed. results. our analysis showed that non infectious complications like: shunt dislocation, kinking and obstruction including some rare phenomenon are well described in literature and can hardly be avoided. but being confronted with various infectious complications we had to change our strategy over the years. severe shunt infection appeared after appendicitis in patients. therefore we consequently performed elective appendectomies since . consecutively we had to face problems with following malone procedure. because of abdominal pseudo cysts after recurrent shunt revisions bacterial culturing methods and antibiotic therapy regimen changed. treatment of post haemorrhagic ventricular dilatation in premature very low birth weight infants had changed over the years from intervention with external drainage, early lumbar punctures, repeated ventricular punctures to implantation of the new ''side-inlet integra reservoir''. conclusions. the lesson we learned out of this retrospective analysis is that treatment of these hydrocephalic patients needs to be designed concerning all problems of the disease during life time period. therefore we think that experience and retrospective analysis is a very important point of view for the future. years' experience with lymphangiomas in children j. burtscher, e. horcher background. the management of lymphangioma in children is still challenging. complete resection is difficult to achieve in some cases and recurrences are common. methods. a retrospective study over a period of years was carried out. fifty-one patients were treated. males and female patients. the involved sites were head and neck, trunk and extremities as well as retroperitoneal, intraabdominal or intrathoracic location. prenatal mri was introduced to plan operative strategy especially for cervical location. results. there were recurrences. recurrence rate was highest in intrathoracal location. there was so significant differences, in terms of outcome, between those who had their surgery immediately at the time of diagnosis and those who had delayed surgery. conclusions. prenatal mri is a helpful tool in planning operative strategies like exit-procedure (ex utero intrapartumprocedure). risk factor for recurrence included location, size or complexity of lesion. background. hemangioma is the most frequent tumor in childhood. in more than % of cases hemangiomas are located in the face and the decision about the need for treatment, and the type of treatment may be difficult. complex hemangiomas need emergent systemic drug therapy, which may be combined with other types of interventional therapy, such as surgery or laser treatment. the aim of this study was to evaluate our experience in the treatment of complex hemangiomas. methods. analysis of complete records of patients who were treated in the period between . . and . . . results. out of patients referred to us, patients ( %) needed hospital treatment ( % girls), mainly because of rapid growth, and complications which were present in patients ( %). the most frequent localization of hemangiomas were the head and neck region ( %) and % of patients had multiple hemangiomas. median age at first referral was months, with % of patients referred to us before months of age. more than half of patients received their first treatment before months of age, and within days after referral. treatment consisted in laser therapy ( %), excision ( %), and additional (or exclusive) drug therapy in % of patients (cortisone, interferon). interdisciplinary treatment was necessary in patients ( %), involving mostly plastic surgeon, dermatologist, pediatric oncologist, pediatric radiologist, ophthalmologist, and psychotherapist. the majority of interdisciplinary treated patients ( %) received initial treatment in other centers, patients ( %) presented with complications, and rapid growth was present in % of patients. parotid hemangiomas (n ¼ ) were treated solely by systemic cortisone treatment (n ¼ ). intra-tracheal hemangiomas (n ¼ ) required often a laser treatment (n ¼ ), in addition to administration of systemic cortisone. massive segmental facial hemangiomas (n ¼ ) needed additional treatment with interferon (n ¼ ). in one case a phaces syndrome was diagnosed and the patient needed a complex therapy. conclusions. the need for treatment of hemangioma must be made on the individual basis. most hemangiomas need only observation. however, patients with complications and=or facial localization of hemangioma with rapid growth require often emergent treatment in medical centers with the possibility for an interdisciplinary management. early therapy may be a precondition for a good cosmetic result. background. treatment of appendicular peritonitis is closely connected with prophylaxis and treatment of surgical complications during postoperative period. the abscess of omentum major is one of such a complications, elsewhere discussed in medical literature. the aim of the study was the reduction in frequency of this complication. methods. during - years we treated patients with the abscess of caul. all of the patients were also treated for the appendicular peritonitis in the past. the time since the discharge from outpatient department to re-admission to the hospital varied within - days. the disease manifested with abdominal pain, increase in body temperature to the febrile grade. all the patients presented with tumour-like abdominal mass of various size. two patients presented with umbilical fistula and purulent effusion. abdominal ultrasound elicited masses with fluid content in patients. laboratory work-out revealed significant increase of tests relevant to endotoxicosis. all patients were operated. five patients underwent dissection of infiltrate, and the total resection of caul. two patients passed drainage of abscess through the anterior abdominal wall. results. all the patients recovered. complications of early and late postoperative period were not observed. patients were on the close follow-up for to years without any sequalae. hospitalisation span was . ae . days. conclusions. . abscess of caul can manifest during early as well as late postoperative period. . management of omental abscess: -complete resection within visually intact tissues; -careful washing of abdominal cavity with antiseptic solutions; -vigorous antibacterial therapy in postoperative period. beneficial effects of mixed hyperalimentation in children with septic form of acute hematogenic osteomyelitis a. albokrinov , a. pereyaslov lviv children's regional clinic hospital, lviv, ukraine; lviv d. halytsky national medical university, lviv, ukraine background. septic form of acute hematogenic osteomyelitis (aho) is severe sepsis with multiple organ dysfunction syndrome (mods) according to accp=sccm consensus conference committee, . mortality and morbidity rates from this remain unacceptably high, in spite of achievements in intensive care medicine. nutritional support is the method of intensive care with proven efficacy, but the ''perfect'' regimen of it is unknown. methods. in - in our clinic children with septic form of aho were treated. they received standard therapy of severe sepsis which included surgical treatment (osteoperforation, suppurative focus drainage, pleural drainage in case of pyopneumothorax), antibacterial therapy, hemodynamic support. all of patients were mechanically ventilated (mv) because of acute hypoxemic respiratory failure on the basis of metastatic pneumonia. regarding to nutritional regimen patients were randomized on two groups: control (enteral alimentation with isocaloric isonitrogenic diet fitting basic energy expenditure (bee) multiplied by coefficient . ), and basic (mixed enteral ( . bee) plus parenteral (protein ¼ g=kgÃday, energy ¼ . bee) hyperalimentation). results. there was strong tendency of patients in basic group to have less pulmonary complications, better gas exchange values, less ventilation days and less intensity of hypermetabolic-hypercatabolic syndrome (see table, à p < . ). conclusions. mixed enteral-parenteral hyperalimentation in children with septic form of aho is an effective method of prevention of pulmonary tissue destruction and respiratory function improvement. background. the aim of this study was to gain information about the mechanisms of injuries and injury pattern at primary and secondary schools in austria. methods. at the department of pediatric surgery in graz and six participating hospitals (klagenfurt, salzburg, steyr, krems, schladming and innsbruck) all children from to years presenting with trauma were included within a two year study period. in total, pediatric trauma cases were filed. data were analyzed regarding personal data, site of the accident, circumstances and mechanisms of accident and the related diagnosis. results. at the department of pediatric surgery, medical university of graz, questionnaires were completed, out of which children had suffered from school accidents ( %). questionnaires from outside hospitals included school accidents ( %) with a mean age of . years in the children from graz and . years in children from participating hospitals. the male=female ratio was : . in general, sport injuries lead to a higher rate of severe trauma ( % severe injuries) compared with other activities in and outside of the school building ( % severe injuries) with ball-sports being the most dangerous activity with a % proportion of severe injuries. over all, the upper extremity was most frequently injured ( %), followed by lower extremity ( %), head and neck area ( %) and injuries to thorax and abdomen ( %). conclusions. half of all school related injuries occur in children between and years of age. there are typical gender related mechanisms of accident: boys get frequently injured during soccer, violence, and collisions in and outside of the school building and during handicrafts. girls have the highest risk of injuries at ball sports other than soccer. background. objects and notably coins are frequently swallowed by children - years old. their precise management on asymptomatically passing the gastro-esophageal junction remains controversial. this study was performed to assess dissolution of specific metals from coins immersed in simulated gastric juice. methods. four types of euro and us coins were immersed in simulated gastric juice for , , and hours. six metals were evaluated by inductively coupled plasma-atomic control group (n ¼ ) basic group (n ¼ ) sofa, mean (sd) . ( . ) . conclusions. coins retained in the stomach will release a number of heavy metals well known to cause dose-dependent poisoning. studies to evaluate their toxicity and absorption are needed to optimize treatment. the surgical tactic on the splenic injury in children a. pereyaslov, s. chooklin, i. korinevska, a. troshkov medical university, lviv, ukraine splenectomy in children often leads to various complications. retrospectively, results of the management of children (range from to years), which underwent surgery due to the liens' injury, were examined. the immunological and hormonal investigations were performed. out of operations in the splenectomy, in cases the splenectomy with the tissue autotransplantation of the lien in the greater omentum and in cases the organ-preservation operations were performed. purulentseptic postoperative complications were noted in ( . %) patients, which connected with the inadequate of the immune answer. the obvious t-cellular immunodeficit, low concentration of igm, decrease of phagocytosis were observed in this category of patients. by that, on the background of activation of the renin-aldosteron system and changes of the eicosanoids synthesis, the danger of the sepsis and septic shock development were arisen. the autotransplantation of the lien tissue did not protect the organism from the purulent-septic complications in the nearest postoperative period. as the answer to the transplanted tissue and necrobiotic processes, which had been occurred in it, the autoimmune processes and reactions of the hypersensitivity of the immediate type (the increase of ige and dna antibodies levels) were intensified. with the goal to prevent complications in the postoperative period the thymic hormones, interferon a, aspirin and dipyridamol were applied. in the remote terms, the postsplenectomy syndrome manifested itself in patients, which underwent the splenectomy in childhood. predisposition to the infections and thrombohemorrhagic processes prevailed. the disturbances of hemostasis are linked with the significant increase of the t-helpers that connected with the intensifying of the il- action, which also evokes the proliferation of the preactivated b-lymphocytes, and, as the result, the obvious synthesis of igg. igg in the composition of the immune complexes can stimulate the function of the neutrophyles. all this promotes to transfering the hageman factor in the active condition, activation of the coagulative and kininogen-kinin blood system, intensification of the fibrinolysis, the deposit of fibrin and the development of the hemorrhages. the autotransplantation of the lien tissue could not enhance defence of the organism in full value. thus, at the traumatic injury of the spleen the prevalence must be given to the organpreserving operations. background. mri of the breasts has been described the most sensitive imaging modality for detection of multicentric or multifocal malignant tumor manifestations. in we began with routine preoperative mri-staging in breast cancer patients. the aim of this study is to analyse the benefit of preoperative mr-imaging regarding surgical treatment and follow up in patients with invasive breast cancer. methods. the retrospectice study (n ¼ ) includes all female patients with histologically verified invasive breast carcinoma, which have been operated at our department between and . exclusion criteria were carcinoma in situ, local recurrence, inflammatory carcinoma and neoadjuvant therapy. demographic, radiological, operative and histological data, standardized follow up (dfs, os) and recurrence rate were analysed. results. surgical treatment consisted in bct ( . %) and mrm ( . %). % of tumors showed an invasive ductal differentiation. lymph nodes were positive in %. tumor size showed the following pattern: pt %, pt % and pt = %. grading was . % (g i), % (g ii) and . % (g iii), respectively. mr-imaging revealed multifocal or multicentric tumor manifestations in % of patients, the mri results changed surgical treatment in % of cases. mean follow up was months. the local recurrence rate was . %, . % of patients developed carcinoma in the contralateral breast, incidence of distant metastases was . %. conclusions. the data confirm the importance of routinely performed mr-imaging in preoperative staging of breast cancer patients. mri-identification of multifocal or multicentric tumor manifestations is essential to choose the optimal surgical treatment and reach a minimal recurrence rate. methods. between july and october patients with operable breast cancer were treated at general hospital feldkirch. of subsequent patients with non-palpable lesions intraoperative sonography was used in (group ), wire localisation in cases (group ). the study was conducted as nonrandomised trial with prospective data collection. results. breast-conserving surgery was performed in % in group and % in group . primary r -resection was significantly higher in group ( %) than in group ( %, p < . ) while median clear margins were . and . mm in these groups (p < . ). both wire localisation and intraoperative sonography proved to be feasible with tumor identification rates of %. conclusions. intraoperative sonography proved to be reliable and feasible in breast cancer patients in the hands of the surgeon. clear advantages next to tumor identification and topographic orientation for excision were organisational acceleration and improvement: discomforting, time and labour intensive wire localisation can be avoided and breast lesions can be excised in a tissue-sparing and breast-conserving technique in a very high percentage. background. extensive intraductal disease represents an important clinical problem in the management of patients with invasive or in situ breast cancer. we present a new method for intraoperative ductoscopy with intraductal biopsy of suspicious lesions. methods. intraoperative ductoscopy was performed in women undergoing operation for breast cancer or nipple discharge. a rigid gradient index microendoscope ( . mm) with a special biopsy device for vacuum assisted biopsy was used for all examinations. ductoscopy findings were documented prospectively and correlated with preoperative mammography and histology of the resection specimen. results. ninety-two percent of the patients were examined successfully. ductoscopy identified intraductal lesions (ie, red patches, ductal obstruction, or microcalcifications) in % of the patients. abnormal ductoscopic appearance was found in more than % of the patients with extensive intraductal disease %. patients with an abnormal ductal appearance on ductoscopy, compared with those with a normal ductal appearance, had a greater incidence of extensive intraductal spread of cancer ( % vs. %) and a greater incidence of positive surgical margins ( % vs. %). ductoscopic biopsy of intraductal lesions was technically successful in all but one case. generally, the quality of the biopsy samples was good. diagnostic biopsy samples were obtained in of patients ( %). two samples contained necrosis and were considered to be non-representative. histological analysis of the biopsy specimens showed papilloma, in situ carcinoma and invasive carcinoma. conclusions. high-resolution ductoscopy is able to detect extensive intraductal disease in a considerable number of women with breast cancer. vaccum assisted biopsy allows intraductal tissue sampling of very small lesions. in selected patients, a combination of both preoperative imaging and intraoperative ductoscopy may help to avoid incomplete resections and re-excisions. background. preoperative chemotherapy (pc) for breast cancer was initially focused on locally advanced tumors. later on it has been established to downstage operable tumors primarily not suitable for breast conserving surgery. now pc is often used as an invivo test for chemotherapy regimens. methods. since the austrian breast and colorectal cancer study group (abcsg) conducted trials with pc. abcsg- analysed the effect of pre-and postoperative versus postoperative chemotherapy alone with cyclophohamide= methotrexate=fluorouracil. abcsg- compared versus cycles of epirubicin=docetaxel þ g-csf regarding the rate of pathologic complete response (pcr). abcsg- analysis the rate of pcr between cycles of epirubicin=docetaxel and cycles of epirubicin=docetaxel=capecitabine ae trastuzumab for her- positive patients. results. from to abcsg- enrolled eligible patients. after a follow up of years recurrence-free survival is worse in the pc arm (hr . , . - . ; p ¼ . ), overall survival doesn't differ significantly (hr . ; . - . ; p ¼ . ). patients were accrued to the abcsg- trial between and . the rate of pcr was significantly higher in patients after cycles than in those after cycles ( . % vs. , %; p ¼ . ). also significantly more patients had a negative axillary status after cycles than after only cycles ( . % vs. . % p ¼ . ). recruitment of abcsg- started in and is still ongoing. conclusions. while pc fails to improve prognosis so far, regimens which improve the rate of pcr have been found and we are still hoping to tranpose this effect in better prognosis. sentinel node biopsy performed before preoperative chemotherapy for axillary lymph node staging in breast cancer p. schrenk , c. tausch background. sentinel node (sn) biopsy following preoperative chemotherapy (pct) in breast cancer patients is associated with a lower identification rate (ir) and an increased false negative rate (fnr) compared to sn biopsy in patients with primary breast cancer. methods. sn biospy was performed in breast cancer patients with a clinical negative axilla prior to pct. following chemotherapy sn mapping was repeated and the current lymph node status was assessed with axillary lymph node dissection (alnd). results. sn mapping prior to chemotherapy successfully identified a mean of . sns in all patients (ir %). patients revealed a negative sn, a positive sn (micrometastasis in = ). following pct re-sn mapping was successful in = patients (ir %). ir for re-mapping was % for patients with a primary negative sn or a micrometastatic sn compared to % for patients with primary macrometastatic sns. none of the patients with a negative sn biopsy and none of the patients with micrometastasis prior to chemotherapy revealed positive lymph nodes following pct. contrary to that = patients with a macrometastasis prior to pct revealed positive nodes following chemotherapy, and this was irrespective of the type of tumor remission due to pct. the fnr of remapping was % and false negative sns were only found in patients with macromatastatic sns in the primary sn mapping. conclusions. patients with a negative sn biopsy or with a micrometastatic sn prior to pct may forego complete alnd following pct, whereas this may not be valid for patients with macrometastatic sns. sn biopsy following pct is associated with a low ir and a high fnr. background. standard pancreatoduodenectomy (pd) for the treatment of resectable tumors of the periampullary region or the pancreatic head involves a radical pancreatoduodenectomy with an extensive gastric resection. the modified whipple operation aims to preserve the stomach, pylorus and proximal duodenum so as to decrease postgastrectomy complications and improve the patient's quality of life. however, there were still many postoperative complications after pylorus-preserving pancreatoduodenectomy (ppd). unfortunately, in some retrospective studies tumors of the periampullary region and the ductal carcinoma of the pancreatic head are still not differentiated. this methodological problem and the improved surgical strategy (lymphadenectomy, etc.) in combination with the excellent histopathological diagnosis by experienced pathologists are decisive factors in determining the ultimate outcome as demonstrated. methods. patients (all treated at smz-süd -kaiser franz josef spital department of surgery) with a exocrine malignant tumor of the pancreatic head or periampullary region were retrospectively analyzed by comparing a year period before and after . results. in the last period of observation the complication rate and lethality was reduced (there was one cases of death because of technical reasons). the number of r resections (incl. mesoduodenum) improved from % to %. also the number of the resected lymphatic nodes increased from to ( - ). the actuarial year survival rate in patients after resection of a pancreatic ductal adenocarcinoma at r , n stage increased from % up to %. an increase in long-term survival could also be observed in the n-positive group. conclusions. at an oncologic center with optimal interdiciplinary collaboration of the different departments (internal medicine, surgery and pathology) a respectable actuarial year survival ( %) of the pancreatic ductal adenocarcinoma can be achieved without interfusing different tumorentities. the lethality caused by technical reasons should be almost %. detailed information will be discussed during the presentation. background. complete surgical resection remains the only potentially curative treatment, improving -year survival, for patients diagnosed with pancreatic cancer. preoperative administration of chemotherapy or combined radiochemotherapy may present a way in increasing the number of patients were radical surgical therapy is reasonable and feasible. lower perioperative mortality and morbidity rates are reported in high volume centres. methods. between jan. and dec. patients, diagnosed with locally advanced non metastatic pancreatic cancer, received preoperative chemotherapy with neoadjuvante intent. patients had curative surgery at time of diagnosis and adjuvant chemotherapy depending on their stage of disease. a subset of patients have been diagnosed at an far advanced stage of disease and were treated in palliative ways. results. the observed perioperative mortality rate was . % ( = ). a total of ( . %) patients required reoperation because of complications after curative resection. minor complications, which have been treated in conservative ways, occurred in . % of patients. sixteen patients ( = , . %) demonstrated sufficient tumor response to undergo surgical curative resection after neoadjuvante chemotherapy. in this group the median survival time was month ( . - . % ci). median survival time for patients who underwent curative tumor resection at the time of diagnosis, was month ( . - . % ci). for patients, unable to undergo curative surgery after neoadjuvant therapy (n ¼ ), median survival ( month, . - . % ci) did not differ from life expectance of primary palliative treated patients ( . - . % ci). conclusions. we suggest that in several patients, suffering from nonresectable cancer of the pancreas, preoperative chemotherapy significantly rises overall survival to a level so far reserved to patients with operable carcinoma. in other malignancies neoadjuvante chemotherapy is an accepted standard of cancer treatment. there are many potential advantages of neoadjuvant chemotherapeutic regimes for both resectable and advanced pancreatic carcinoma. novel targeted molecular therapies and their combination with established chemotherapeutic agents may lead to higher conversion rates after neoadjuvante therapy and improved -year survival rates in the near future. background. haemodynamic impairments after pneumonectomy are rare complications and present in two different forms or a combination of both. changes in the anatomical situation of the left atrium and elevated pulmonary artery pressure can lead to a significant right-left shunt via a previously closed foramen ovale (pfo) and diaphragmatic relaxation can lead to a dislocation of the liver into the right hemithorax, compressing the right atrium with subsequent inflow obstruction. methods. we retrospectively analysed our patient cohort from to for occurrence of haemodynamic complications requiring surgical intervention after pneumonectomy. results. five patients ( female, males, age ae years) were identified. all underwent right pneumonectomy due to nsclc (n ¼ ) or atypical carcinoid (n ¼ ). two patients were readmitted months and years postoperatively due to increasing platypnoea and orthodeoxia. after closure of a pfo which was found as the underlying pathological mechanism respiratory symptoms were resolved. one patient required reintubation already hours postoperatively; after surgical closure of a pfo the respiratory situation significantly improved. one patient was readmitted due to right atrial inflow obstruction months after right pneumonectomy. underlying cause was a severe diaphragmatic relaxation with compression of the atrium by the liver. after diaphragmatic plication all symptoms resolved. one patient was readmitted months after pneumonectomy and partial atrial resection due to cyanosis and dyspnoea. diagnostics revealed a pfo and a massive raise of the right diaphragm with compression of the right atrium. after surgical correction of the contorted foramen ovale and diaphragmatic plication symptoms vanished. conclusions. haemodynamic alterations due to a reopened foramen ovale or right atrial inflow obstruction are rare however severe complications after pneumonectomy. they occur at variable points in time after pneumonectomy. closure of the pfo either surgical or interventional and=or plication of the elevated diaphragm are mandatory. in our experience these complication occur only after right pneumonectomy. chronic sequels after thoracoscopic procedures for benign disease -long-term results j. hutter, s. reich-weinberger, h. j. stein background. video-assisted thoracic surgery (vats) is recognized to be as effective as open surgery for a variety of diagnostic and therapeutic conditions, but with significantly less morbidity. chronic postoperative pain (cpp) is defined as persisting more than months after the procedure. cpp and other neurological sensations like disesthesia or numbness are found frequently, but little is known about the outcome of those patients many years after the primary procedure. methods. in we retrospectively investigated a group ( . %) out of patients who were identified with sequels at a mean of months after a vats procedure. now at months post-operation we reinvestigated those patients for ongoing sequels. results. from patients were still alive and could be reached for an interview. ( %) were now free of symptoms while ( %) still suffered from sequels. from the group of patients operated on, sequels were now present in ( . % at months vs. . % at months, p ¼ . ) patients. pain was present in ( . vs. . %, p ¼ . ), in three ( . vs. . %, p< . ) even at rest, and in ( . vs. . %, p ¼ . ) patients only at exercise. ten ( . vs. . %, p ¼ . ) patients suffered from pain occasionally e.g. due to changing weather. painkillers were only taken by one ( . vs. . %, p< . ) patient occasionally, and the sequels impacted the life of one woman ( . vs. . %, p< . ) badly. numbness was present in . vs. . % (p ¼ . ) of patients. conclusions. early postoperative sequels are frequently found in vats procedures, but patients with pain even after years have a nearly % chance to eliminate their problems. in addition, numbness and disesthesia seem to disappear almost completely several years after the procedure. intrapulmonary injection of fibrin glue as a treatment of persistent parenchymal fistulas after pulmonary surgery: a case series s. b. watzka , h. redl , b. el nashef background. persistent parenchymal fistulas are a major problem after pulmonary operations particularly in lung emphysema patients. conventional surgical remedies, like over-suturing or stapling of injured lung surfaces are rarely efficient. here we present our preliminary experience with a novel application of fibrin glue as a sealant of persistent parenchymal fistulas. methods. patients with postoperative parenchymal fistulas persistent for more than six days, and not responding to conservative measures, underwent re-operation. lung surfaces not anymore suitable to reconstruction by suturing were sealed by peripheral intrapulmonary injection of fibrin glue. after discharge, the patients were regularly followed-up. in addition, the macroscopic distribution of injected fibrin within lung tissue has been investigated in a porcine in vitro lung preparation. a total of six patients underwent the above described procedure. the primary operation was upper lobectomy in four cases, laser resection in the upper lobe in one case, and empyema evacuation by vats in one case. the mean volume of injected fibrin was ae . ml. in five out of six patients the fistula was stopped permanently. in one case, however, the parenchymal fistula re-appeared and had to be treated by combined application of fibrin glue and hemostyptic tissues. after a mean follow-up of . ae . days, all patients are well and symptom-free. in the animal tissue preparation, the fibrin was macroscopically distributed exclusively in peripheral lung parenchyma. conclusions. in selected cases of persistent postoperative parenchymal fistulas, peripheral intrapulmonary injection of fibrin glue offers a low-risk and efficient surgical option. background. recent case-matched studies demonstrate that stage i non-small cell lung cancer (nsclc) in functionally inoperable patients can be treated by limited resection approaches without compromising the oncological result. the recently introduced -nm nd-yag laser enables the highly selective and parenchyma-saving excision of pulmonary lesions, and was thus originally designed for the removal of multiple lung metastases and more central lesions. in this prospective study, we are evaluating for the first time the mid-term results after local resection of stage i primary nsclc by laser knife in functionally inoperable patients as defined by predicted postoperative fev (ppofev ) less than %. methods. between and , functionally inoperable patients underwent local resection of stage i nsclc by -nm nd-yag laser. we assessed their postoperative course, tumor recurrence, and survival by statistical means. results. postoperative mortality was zero. three patients ( %) had minor surgical complications in the postoperative period (persistent air leak, delayed wound healing). the postoperative respiratory function was unchanged as compared to the pre-operative value. the median follow-up was . months (range - months). recurrence rates ( . %) and actuarial -year survival ( %) were comparable to standard lobectomy results, as reported in the literature. none of the three deaths observed during the follow-up period was cancer-related. conclusions. the -nm nd-yag laser enables the resection of stage i nsclc in functionally inoperable patients under complete preservation of respiratory function, but without jeopardizing the oncological outcome. zentrumsbildung breast-cancer centers -between european visions and regional feasibility h. hauser background. there have been major improvements in the western world in recent decades in early diagnosis of breast cancer, breast conservation and survival. nonetheless, there are blank spaces on the map of europa and very likely of austria as well, where diagnosis and treatment of breast cancer are not optimal. collecting and treating patients with diseases of the breast in a few defined ''breast centers'' should give every patient with breast cancer the same highest quality treatment. methods. in , a working group was formed in florence, italy, to define the tasks to be met by such a center. in , the results produced by this group were published (eusoma ) . the aim of this guideline was to improve quality and quality control in the treatment of breast cancer. one of the main demands made of a breast center is to treat at least new primary breast cancer cases per year. further, a multidisciplinary nucleus team specialized in the treatment of breast cancer should be in place and should hold regular interdisciplinary tumor conferences. this team should include a surgeon=gynecologist, radiologist, pathologist, medical oncologist, radiotherapist, breast-care nurse, data manager, etc.). results. as early as , roohan et al. (am j public health , ) showed that the probability of survival of breast-cancer patients was directly proportional to the treatment volume of the hospital. regardless of tumor stage, patients treated in a hospital that saw less than cases per year had a % higher mortality risk than those treated in hospitals with more than operated cases per year. an operation performed by a breast cancer specialist reduces the mortality risk by % in comparison to operations performed by non-specialists (gillis cr, hole dj bmj , ) . the results of dubois et al. ( ) and others also indicate a better outcome for breast cancer when patients are operated in a specialized hospital with a large number of cases and a suitable interdisciplinary environment. the minimum number of cases of primary new breast cancer cases per year and center recommended by eusoma (but with an evidence level of and so not scientifically verified) would reduce the number of breast centers in austria to about . an analysis of the austrian situation nonetheless showed that many small surgical units produced excellent results, with interdisciplinary cooperation, in some cases together with external services. conclusions. certified, highly qualified interdisciplinary breast centers are intended to provide breast-cancer patients with highest quality care. the extent to which the eusoma criteria can be adapted to the austrian situation remains to be seen. breast cancer centres -can quality only be achieved in high-volume-institutions? b. zeh, g. humpel, p. lechner background. discussion is ongoing about institutional caseload and technical equipment that both may be required for up-to-date-treatment of breast cancer. we present the network architecture our department of surgery at the danube clinics in tulln is part of, aiming at multi-disciplinary diagnosis and treatment of approx. cancer patients per year. methods. . diagnosis: mammogram, ultrasound and mri can -and shall -be performed in an outpatient setting, considering that a close partnership with an experienced radiologist has been established. this is true also for the imaging techniques for staging. . interventional diagnosis with core needle biopsy, mammotome + , ecc., should be left to the surgeon! this may facilitate localisation of a non-palpable lesion during the subsequent operation. . surgery for breast cancer is not that demanding per se, on condition that the technical equipments for sentinel biopsy, specimen radiography, and frozen section are at hand. the procedures must be left to permanent team if surgeons with an individual experience of more than cases each. . systemic adjuvant treatment requires the availability of a clinical oncologist, at our institution on a consultant basis. patients are treated in clinical trials whenever feasible, preferably in those launched by abcsg. . radiotherapy is typically performed on an outpatient basis, disregarding at which institution the previous operation was performed. . follow-up needs to be co-ordinated by a qualified physician. we have established an oncological outpatient department, but co-ordination could also be left to an office-based oncologist. the mandatory management tools for close follow-up as well as for the prevention of unnecessary examinations are it-support and a patient log-book. conclusions. being embedded in a multi-disciplinary network, our institution's self perception is that of a part in a ''virtual centre of excellence''. we think that we are not only able to provide high medical quality, but that this quality is also subject to external control by our partners. background. the expectancy of life of patients with intraabdominal malignancies and peritoneal dissemination is usually poor. the surgical approach of a combination therapy of complete resection of the primary cancer, the peritonectomy and a perioperative intraperitoneal chemotherapy was developed to improve the prognosis of these patients. this treatment is cost-intensive and associated with special technical expertises. the aim of this study was to determine the modalities and to discuss the feasibility of this approach. methods. since june , a combination-therapy of visceral resections, cytoreduction of the peritoneal cancer and a heated intraoperative intraperitoneal chemotherapy was performed in patients ( female, male, average age . years) with visceral malignancies and peritoneal carcinomatosis as a curative approach. the same procedure was designated for six more patients but was not performed because of inoperable tumor masses. mitomycin c ( mg=m ) was utilized for the intraperitoneal chemotherapy and applied to the abdomen using a heartlung machine to guarantee a steady circulation and to keep the intraperitoneal fluid at c. the handling with the chemotherapeutic substance required special protective clothing for the staff as well as the competent disposal of all used materials. results. a multi-visceral resection was performed in = patients. a complete cytoreduction (cc- ) was obtained in eight patients, in one a cc- and in another one a cc- situation remained. the average operative time was minutes (range - minutes). a peridural catheter was necessary for a sufficient postoperative pain therapy. the average time at the intensive care unit was . days (range - days) and the average hospitalization was . days (range - days). no complications were observed associated with the surgery. morbidity was determined by gastrointestinal symptoms like prolonged postoperative ileus. in the follow-up three patients had a recurrence of the malignancy, = with a cystadenocardinoma of the pancreas after three and five months, respectively, and = patients after months with a metastatic sigmoid carcinoma. one patient died eight months after surgery because of malignancy progress. the average expense of this treatment was . eur. conclusions. specialized centres may provide the logistics and expenses to establish this treatment innovation to the surgical approach of intraabdominal malignancies to extend the long-term survival of patients with otherwise poor outcome. prospective studies are needed for additional adjuvant and neoadjuvant concepts in diseases with peritoneal malignancies. background. rectal carcinoma needs careful preoperative staging. in our department neoadjuvant treatment with long term radiation and chemotherapy is standard in patients with carcinoma of low and middle part of the rectal wall. main prognostic factors for long term survival are r resection, sharp dissection of the mesorectal fascia without coning, distal resection margin of at least mm and complete lymph node dissection along the mesentery vessels. there is no recommendation about the lymph nodes that should minimally be dissected in this group of patients until now. methods. we consecutively evaluated patients after neoadjuvant radiochemotherapy (rct) and surgery in terms of survival, local recurrence, perioperative mortality and morbidity. tumor regression grading (trg) and number of dissected lymph nodes (ypn) were analysed and correlated with survival. results. in our series local recurrence rate was lower than %, the r resection rate reached % and sphincter preserving surgery was possible more than %. the median number of dissected lymph nodes (ypn) reached > , the perioperative morbidity was lower than %. especially leakage and anastomotic stenosis with the need for reoperation or dilatation are typical complications of radiation therapy. the tumor regression grade clearly correlates with outcome. conclusions. multimodality treatment of rectal carcinoma including preoperative radiochemotherapy (rct) is well standardised with good results in outcome and morbidity. we show that high numbers of lymph nodes even after rct can be collected and suggest a minimum account of at least . tumor regression grading is a marker with prognostic significance and should be taken into clinical-pathohistological classification. we suppose that some patients are overtreated with preoperative rct. to proof this hypothesis, a randomised multicenter trial -together with german cancer centers -based on mri diagnostic is currently planned. background. the incidence of (hpv)-associated disease of the anal canal is rising. efficient anal screening by cytology is hampered because of poor specificity. hpv testing is proposed in addition to pap testing for the detection of cervical neoplasia. the purpose of this study was to determine the usefulness of a hpv-dna detection test (hc ) to detect hpv-associated disease and to compare two different methods of sample collection. methods. in patients anal samples were obtained using a cervix brush and a dacron swab to test for hr-and lr-hpv-dna. qualitative (positive=negative) and quantitative (rlu's, relative light units) were obtained. patients positive for hpv dna underwent anoscopy. biopsies were taken from visible lesions. results. lr-hpv-dna was found in of patients ( . %) and hr-hpv-dna in of patients ( . %). dacron swab sampling yielded more positive results than sampling by cytobrush ( . % vs. . % for lr-hpv, p < . ; . % vs. . % for hr-hpv, p < . ). a positive correlation of rlus was found for both sampling methods in the total cohort (p< . ), and patients with positive results (p< . ). sampling with dacron swabs yielded higher rlu values compared to sampling with cervix brush for lr-hpv-dna and hr-hpv-dna. conclusions. anal screening for hpv-dna by hc is a useful method for detection of hpv-associated disease. sample collection using dacron swabs identifies more hpv-positive patients, and yields higher rlu values, than using the cervix brush. background. persistent human papilloma virus-(hpv-) infection, immunedeficiency (hikv, immunosuppression after organ transplantation) are known risk factors for anal intraepithelial neoplasia (ain) and squamous cell cancer (scc) of the anus. the incidence in high rik groups is rising (hivpositive, men who have sex with men (msm)). screening programms employing anal cytology or anal colposcopy have been implemented in these risk groups. however, sensitivity and specificity are low for both screening methods. since persistent hpv-infection seems to be a prerequisite for ain and scc it seems reasonable to use hpv-typing as an adjunct to screening in risk groups. methods. three hundred and eighty-five consecutive patients with hpv-associated anal disease were included. sexual orientation, hiv-status, smoking habits and psychological strain were documented. all patients underwent clinical examination, rigid sigmoidoscopy and anal hpv-testing. biopsies from macroscopically visible lesions were taken and categorized in condyloma or the three grade-scale of ain according to the bethesda terminology for reporting results in cervical histology. hpv-testing for low-risk (lr) and high-risk (hr)-types was performed using hybrid capture (hc ). qualitative (positive=negative) and semiquantitative results (relative loight units, rlu's) as an indirect measure of ''viral load'' were obtained. results. hiv-status was the only significant risk factor for hr-hpv-infection in univariate and multivariate analysis. in univariate analysis positive hiv-status and patients tested positive for hr-hpv-dna or both types of hpv-dna were significant risk factors for presence of any type of ain. smoking habits, presence of psychological stress and detection of lr-hpv-dna did not significantly influence presence of ain. in multivariate analysis only presence of hr-hpv-dna was a significant risk factor for ain. univariate interclass correlation showed a significant correlation between grade of anal dysplasia and presence of hr-hpv-dna, grade of anal dysplasia and smoking, grade of anal dysplasia and positive hiv-status, presence of lr-hpv-dna and hr-hpv-dna and presence of hr-hpv-dna and positive hiv-status mean number of rlus for hr-hpv-dna was . for hiv negative patients and . for hiv positive patients. there was also a significant difference in the number of rlus for hr-hpv-dna for different grades of anal dysplasia. this difference was only seen in hiv-positive patients, but not in hiv-negative patients. conclusions. our results show the strong relation between persistent hr-hpv-infection and grade of dyplasia. this warrants hpv-typing to be introduced as an adjunct to screening for ain in risk groups. human papillomavirus and anogenital lesions: burden of illness and basis for treatment f. aigner, e. gander, f. conrad background. human papillomavirus (hpv) infections in the anogenital region have become an immanent disease pattern in daily clinical routine. still there is ignorance concerning the etiology and course of hpv associated anogenital lesions, thus demanding an interdisciplinary approach to this disease, which affects more frequently younger individuals. high recurrence rates and the propensity of high-risk hpv associated lesions for malignant transformation (cervical=anal cancer) led to the assessment of diagnostic and treatment options within our association. methods. the results of a consensus meeting in the framework of the rd innsbruck coloproctology winter meeting based on this topic are presented. results. the incidence of anogenital hpv associated lesions (anogenital warts, anal and cervical intraepithelial neoplasia, ain and cin, and anal=cervical carcinoma) has dramatically increased over the last years. in our centre the number of patients presenting with anogenital warts has been doubled from to , closely associated with an increase of diagnosed anal cancers. in the last two years new cases of ain iii (mean age years; males, females), cases of ain ii (mean age years; males, females) and cases of ain i (mean age years; males, one female) were treated in our proctologic unit and introduced to the gynaecologists. treatment algorithm includes excision, electrocauterization or laservaporisation of perianal or anal warts or ain i, ii and anal ain iii on the one hand and radical excision of perianal ain iii on the other hand. immunomodulatory treatment with imiquimod (aldara + ) should be preferentially applied for recurrent anogenital warts. histological examination of suspect lesions has to be performed routinely. conclusions. hpv associated anogenital lesions should be treated by a multidisciplinary approach. histological investigation of the excised material should be performed routinely as well as patients' surveillance including standard anoscopy and colposcopy in a specialized unit. gigip: tissue engineering und implantat induzierte immunologische reaktionen th -immunresponse to xenogeneic matrix grafts t. meyer , k. schwarz , b. höcht pediatric surgery unit, department of surgery, würzburg, germany; department of anatomy, saarland university, homburg=saar, germany background. extracellular matrix (ecm) biomaterials of xenogeneic origin, such as lyoplant + , pelvicol + or surgis + are beginning to be used as acellular, resorbable bioscaffolds for tissue repair in pediatric surgery. although a vigorous immune response to ecm is expected, to date there has been evidence for only normal tissue regeneration without any accompanying rejection. the purpose of this study was to determine the reason for a lack of rejection. methods. full-thickness abdominal wall defects were created in wistar-wu rats and reconstructed with either a lyoplant + -matrix (b=braun aesculap, germany) or prolene +matrix (polypropylene-matrix [ppp], prolene + , ethicon germany). animals were checked daily for local and systemic complications in both treatment and control groups. bodyweight was recorded and the possible development of a hernia was monitored. after weeks the abdomen was reopened and adhesions to the intestine were determined. histopathology and immunohistochemistry were performed to evaluate the immunological reaction to the xenograft. results. compared to the untreated animals, all rats had a physiological growth and body weight curve: no wound infection could be observed throughout the experiment. only in one rat, treated with a ppp-matrix, an abdominal hernia developed at the implant site. all other animals showed excellent clinical recovery and cosmetic results. ppp animals showed a pronounced inflammatory response indicated by an increased number of fibroblasts. the lyoplant + -matrix implantation induced an infiltration of cd and cd positive cells. in addition an active neovascularization was found, observing a remodelling process. this inflammatory response was significantly milder than in ppp implanted rats. interestingly some cd positive cells were detected in the lyoplant + -group. conclusions. xenogeneic extracellular matrix, such as lyoplant + , induces an immune response, which is predominately th -like, comparable with a remodeling reaction rather than rejection. background. mesh graft infections after hernia repair are an awkward complication. in more extensive infections many surgeons recommend removal of the mesh, due to the difficulty to treat microbes in th infected artificial material. the vac system now offers a new possibility in the treatment of complicated wounds, including mesh infections. methods. in this study, records of patients with mesh graft infections after incisional abdominal wall hernia repair were retrospectively analysed who have been operated on between january st and february th at the department of surgery, general hospital vienna. results. of patients ( %, female and male) operated in the period of investigation were suffering from mesh graft infections ( vypro ii mesh, composix mesh and surgipro mesh). mean age of patients was years. mean duration of wound therapy was days. % of the patients had an extensive infection. in those, topical negative pressure therapy (vac) was used. this led to a preservation of % of meshes in this group. in patients with a wound smaller than cm, infection could be successfully treated in of cases ( %). the type of mesh had an influence, whether it could be preserved. all of vypro ii-mesh grafts ( %), of composix mesh ( %) and of surgipro mesh ( %) could be preserved by conservative treatment. conclusions. data suggest that vypro ii mesh grafts are superior to composix and surgipro mesh regarding mesh graft preservation in case of postoperative mesh graft infection. vac therapy should be considered for successful treatment of more extensive infection. finally, small wounds (< cm) seem to have a good prognosis for mesh graft preserving healing. background. revisional procedures after restrictive bariatric operations are necessary in increasing numbers of patients. these procedures may be performed laparoscopically but represent demanding and in some cases risky operations. a meticulous technique is mandatory in order to achieve good postoperative results. methods and results. laparoscopic roux-y gastric bypass is performed as revisional procedure after laparoscopic gastric banding, sleeve gastrectomy and vertical gastric banding. the indication for a transformation to gastric bypass is inadequate weight loss or weight regain and technical failures of procedures. formation of the gastric pouch may be difficult because of adhesions and formation of a capsula in case of banding. gastro-jejunostomy may be performed by different techniques. conclusions. revisional gastric bypass is a more complicated procedure than primary bypass. in order to achieve good results a number of technical details have to be respected. background. laparoscopic sleeve gastrectomy has become a standard bariatic procedure in the last five years. this procedure has been performed with a number of different techniques using laparoscopic staplers and mobilizing the greater curvuture as primary step of the operation. methods. sleeve gastrectomy with a modified technique starting with the formation of the gastric sleeve prior to mobilisation of the greater curvuture is demonstrated. stapling is performed with linear straight staplers. conclusions. the advanages of performing laparascopic sleeve gastrectomy by a modified technique are shorter operating times, and a better overview especially near the his angle. the modified technique may therefore become a surgical standard in bariatric surgery. we present a video showing the technique of laparoscopic approach for reoperation on cases with complications due to ''lost gallstones'' after laparoscopic cholecystectomy. case is a years old female patient, operated for symptomatic cholecystolithiasis in august . in august she presented with right upper quadrant pain, the computertomography revealed a liver abscess in the right lobe and a retroperitoneal abscess. case is a years old male patient, operated for symptomatic cholecystolithiasis in november . in july he presented with right upper quadrant abdominal pain, the computertomography showed a small suspected abscess formation between liver segment and the right kidney. laparoscopic reoperation was performed the day after diagnosis. in case after adhesiolysis the liver was elevated and the abscess opened to perform rinsage and drainage of the cavity. the ''lost gallstones'' were taken out with a suction device. in case multiple stones were found in the upper abdomen under the peritoneum and in the abscess cavity. adhesiolysis and rinsage was performed. if abscess formation around the liver is seen even years after laparoscopic cholecystectomy, the diagnosis of a complication from ''lost gallstones'' should be suspected. reoperations for ''lost gallstones'' after laparoscopic cholecystectomy can be performed by laparoscopy if the abscess formation is accessible; results will be superior to ct-guided drainage due to the stone extraction by laparoscopy. grundlagen. die isr ist eine technik, bei der auch tiefsitzende karzinome des rektum sphinktererhaltend reseziert werden können. wir haben kürzlich eine operationstechnik entwickelt, bei der dieser eingriff laparoskopisch ohne großen zusätzlichen zeitaufwand durchgeführt werden kann. methodik. dieser eingriff wird nach genauer präoperativer abklärung durch ) digitalbefund, ) endoskopie und biopsie, ) mrt des rektums und ) sphinktermanometrie geplant. ausschließungsgründe für die operation sind: undifferenzierter tumor, t -stadium und schlechte sphinkterfunktion. der abdominelle teil wird im trokarttechnik (  mm optikport,  mm arbeitsport) durchgeführt. die präparation erfolgt entweder mit dem mm ultracision oder dem mm ligasure-atlas. der eingriff wird synchron von abdominell und peranal von teams durchgeführt. dafür wurde eine eigene lagerungstechnik entwickelt. die operation verläuft in folgenden phasen: ) totale mesorektale exzision, ) peranale intersphinktäre resektion des rektum ) bildung eines axialen kolonpouches, ) durchzug des kolon und koloanale anastomose, ) protektive transversostomie oder ileostomie. die präparatbergung erfolgt von peranal, sodass keine zusätzliche inzision am abdomen notwendig ist. der stomaverschluß erfolgt nach wochen. ergebnisse. von den insgesamt intersphinktären resektionen wurden laparoskopisch durchgeführt. die mittleren operationszeiten betrugen bei der offenen isr min, bei der laparoskopischen min. schlussfolgerungen. die laparoskopische intersphinktäre resektion ist ein praktikables operationsverfahren, dass mit vertretbarem zeitaufwand durchgeführt werden kann. die vorteile der laparoskopischen vorgangsweise können derzeit bis auf das hervorragende kosmetische ergebnis noch nicht abgeschätzt werden. schlussfolgerungen. der konsequente einsatz eines hochthorakalen pdks mit adäquater füllung zur schmerztherapie und sympathikolyse war von unserer anästhesieabteilung nicht regelhaft umsetzbar, so dass wir in der oralen gabe von oxycodon plus oraler stimulation des gastrointestinaltraktes eine hervorragende alternative zur durchführung der fast-track-rehabilitation gefunden haben. unsere ergebnisse decken sich mit den resultaten die derzeit von den chirurgischen zentren publiziert werden. die wiederaufnahme-( . %) und die gesamtkomplikationsrate ( %) ist bei längerer verweildauer etwas niedriger. unsere ergebnisse zeigen, dass das konzept der fast-track-rehabilitation gut in einem nicht ausgewählten patientengut umsetzbar ist. aufgrund der ausbildungssituation ist die zahl der lap. eingriffe relativ gering.in der oralen opiod-analgesie haben wir eine unerwartet gute alternative zum pdk gefunden. fast track surgery without thoracic peridural anaesthesia? background. thoracic pda is considered to be one of the main pillars of fast track surgery (fts). our anaesthetists being reluctant to perform thoracic pda as a routine, we decided to make an attempt to do surgery without thoracic pda yet following all other criteria of fts. methods. between jan. and dec. we have performed elective colonic procedures following our modified criteria. in these patients we have prospectively examined those parameters which could be expected to be influenced the most by pda: -postoperative intestinal paralysis -postoperative pain control -rate of complications results. the postoperative need of antiemetic drugs and the time of the first clinical signs of bowel activity (passing winds or stool) were examined as criteria for postoperative paralysis: - . % of patients never needed an anitemetic drug - . % of patients were having bowel activity not later than on po day standard postoperative pain control regimen contained two doses of mg paracetamol and two doses of mg diclofenac iv. as long as needed followed by the same combination given orally. mg of piritramid sc. was presribed as reserve treatment. - % of patients needed the standard iv-regimen for longer than three days - % of patients never needed a single dose of piritramid - . % of patients needed more than two doses of piritramid in the last months of the study only patients ( . %) needed piritramid for sufficient pain control (learning curve of nurses and doctors!). overall we have seen complications ( . % of procedures): background. multimodal fast track rehabilitation is based on modified perioperative fluid management, avoidance of preoperative fasting, effective analgesic therapy using epidural anesthesia, early postoperative mobilisation and immediate oral nutrition in order to accelerate recovery, reduce general morbidity and decrease length of hospital stay. young people seem to be the most suitable patients for fast track rehabilitation, but majority of the patients requiring colorectal surgery is older than years and often has several comorbidities. in this analysis we compared ''fast track'' feasibility and efficacy in young and old patients to examine, whether an age dependent management is required. methods. during one year all patients scheduled for colorectal surgery for colorectal cancer or sigmadiverticulitis on one ward were treated according to our multimodal ''fast track'' program. demographic and perioperative data, postoperative follow up (e.g. first bowel movement, vomiting, intravenous infusion therapy, fluid balance), local and general complications were prospectively assessed and evaluated on the basis of two groups (group a: age< a, n ¼ ; group b: age> a, n ¼ ). results. median postoperative hospital stay was days (a) and . days (b) with one readmission in both groups. the incidence of local and general complications was . % and %, respectively. a aged patient with stenotic rectal cancer with liver metastases and parkinsons disease died because of multiorgan failure. conclusions. the multimodal ''fast track'' rehabilitation concept is feasible in young and old patients. although older patients have a higher morbidity, our data show, that especially older patients benefit from enhanced recovery programs. background. the restrictive perioperative intravenous (i.v.) fluid management is an important element of multimodal fast track surgery. recent studies have shown a better outcome for patients with moderate or restrictive intravenous i.v. fluid therapy, but adequate interdisciplinary standards are missing and therefore optimal perioperative fluid management still remains controversial. in october we started ''fast track'' treatment in colorectal surgery on one ward, in this study we present our experience with modified perioperative fluid management. methods. during one year consecutive patients underwent elective surgery for colorectal cancer or sigmadiverticulitis ( laparoscopically, conventionally). demographic, pre-, intra-and postoperative data (e.g. fluid supply, urine excretion, creatinine, electrolytes, first bowel movement, vomiting), local and general complications were prospectively assessed and evaluated, median age of patients was years ( - years). results. intraoperative i.v. fluid administration was . ml=h=kg. on the first postoperative day patients oral intake was ml ( - ml) with an urine excretion of ml ( - ml). no hypovolemia associated complications were observed, creatinine and electrolytes showed no significant pre-and postoperative changes. general morbidity was % (urinary tract infection, pneumonia). median postoperative hospital stay was days (no readmissions). conclusions. reduced intraoperative and restrictive postoperative i.v. fluid therapy is feasible and has no negative impact on water and electrolyte balance. early oral fluid administration guarantees a sufficient hydration with adequate urinary output and contributes significantly to fast (track) rehabilitation and improvement of patients comfort. background. malignant pleural mesothelioma is a mainly asbestos-related neoplasm with increasing frequency associated with a poor prognosis. extrapleural pneumonectomy was initially performed as a stand-alone treatment in patients with respectable disease, however is currently almost uniformely applied as part of a multi-modal approach. its value and advantage over other therapeutic strategies remain point of discussion. we therefore analysed our experience with extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma. methods. we retrospectively reviewed our institutional experience with all consecutive patients undergoing extrapleural pneumonectomy for malignant pleural mesothelioma from to . patients were analysed with regard to hospital data and outcome. results. forty-nine patients ( females= males, mean age ae years) underwent extrapleural pneumonectomy during the observation period. median icu stay was day, median postoperative length of hospital stay was days. after a mean follow-up of days median survival was days (mean ae days, range - ). year survival was . %, years survival . % and years survival . %. conclusions. extrapleural pneumonectomy as part of a multi-modal treatment regimen is a good treatment option for selected patients with malignant pleural mesothelioma. the long term results of this limited series compare favourable to non-surgical treatment regimens. larger randomised prospective multi-center trials are warranted to establish clear guidelines. background. the accelerated progress in genomics and data analysis technologies give a new view to customized treatment for stage iii lung cancer. the histopathological diagnosis will be accompanied by molecular classification. present treatment for advanced lung cancer is unsatisfactory and nearly % of newly diagnosed patients will die within two years. methods. from to patients underwent neoadjuvant treatment with platin-based chemotherapy followed by surgical resection. a panel of genes (p , p , mib- , cyclind , cycline, ercc ) were identified in pre-and posttherapeutic specimens. the expression profile was correlated to the histological regression grade and survival. results. the investigated different pathways allow an explanation of platin-based chemotherapy resistance and short duration of response according to the gene expression levels. conclusions. a prediction of a patient's prognosis could be improved by combining standard clinical staging methods with molecular-pathological evaluation. background. in the last years the video assisted approach (vats) has become the standard of care for persistent or recurrent (after tube drainage) spontaneous pneumothorax (sp) . but what is the standard treatment in recurrent pneumothorax after primary operation in the era of vats? moreover, we only have little information about the rate of contra lateral pneumothorax in those patients. to find answers to these questions we investigated the patients operated for sp in recent years. methods. we retrospectively analysed patients with sp treated by vats between = and = . only patients with years of age or younger without any underlying chronic lung disease were included. the treatment of choice was bullectomy or apical lung resection with apical partial pleurectomy (app) by vats. results. we identified patients at a mean age of years ( - ) with the female: male ratio of : . . the interval of the study and the operation was at mean of months. the primary vats for sp was successful in % (n ¼ patients). in three patients with primary failure persisting pneumothorax was reoperated by vats (postoperative day , , ) . none of these three patients had a recurrence. of patients treated successfully for spontaneous pneumothorax . % (n ¼ patients) suffered from recurrence at a mean of ( - ) months with one case of a second recurrence. only minor or no adhesions were found at the apex of the thoracic cavity, a bulla was found in one woman. moreover, in all patients an intact neopleura was found. major morbidity was postoperative hemothorax treated conservatively in % (n ¼ patients). interestingly, % (n ¼ patients) developed primary pneumothorax on the contra lateral side at a mean . ( - ) months. all these patients underwent vats without recurrence. conclusions. . successful treatment of sp can be achieved by vats with low recurrence rate, low morbidity and a high primary success rate. . in sp with bullae the role of app is not defined as yet and in recurrence or primary failure a thoracoscopic pleurodesis e.g. with talcum, should be considered. . in the light of the high rate of almost % of contra lateral sp a primary intervention on both sides should be considered. . a study to identify patients of risk for contra lateral sp with e.g. low dose ct in the first event should be considered. background. surgical treatment of myasthenia gravis and thymoma necessitates the complete resection of the thymus with the whole fatty tissue adherent to the pericardium. the aim was to investigate the efficacy and safety of robotic approach. methods. from = to = patients with myasthenia gravis (n ¼ ) or thymoma (n ¼ ) (mean age ae years, male to female ratio : ) were operated with the intention to perform a totally endoscopic, complete resection with the davinci telemanipulator system. in all but one patient a left sided approach was chosen. results. in out of patients the operation was carried out totally endoscopic. two patients had to be converted because of bleeding (patient ) and thymus carcinoma (patient ) requiring extensive resection. in the remaining patients, operative time was ae minutes, intubation time ae minutes. icu stay was day, in hospital ae . days. in all patients it was possible to identify both phrenic nerves and the complete fatty tissue above the anonymal vein along the supraaortal vessels was resected. histology revealed normal persisting thymus tissue (n ¼ ) and thymoma (n ¼ ) -who stage b and b (in cases each); masaoka stage i (n ¼ ), ii (n ¼ ) and ivb (n ¼ ), respectively. all resection borders were free of tumor. in all myasthenia gravis patients acethylcholinereceptor antibodies decreased during follow up. conclusions. complete endoscopic thymus surgery with the da vinci surgical system, is feasible and safe to implement into clinical practice. due to the minimal trauma, patients can return to full activity in a short time period. self-expandable covered metal tracheal type stent for sealing cervical anastomotic leak after esophagectomy and gastric pull-up: pitfalls and possibilities background. the rate of anastomotic leakage after cervical esophagogastrostomy following esophagectomy and reconstruction with the tabulated stomach ranges between and %. the treatment options comprise redo-surgery, endoscopical stapling, glueing or insertion of plastic stents, or conservative management with drainage procedures. the aim of this study was to evaluate the efficacy of self-expandable covered metal tracheal type stents for sealing the anastomotic leak. methods. from = to = , patients with leakage of the cervical esopahgogastrostomy following esophagectomy and reconstruction underwent endoscopic stenting using the self-expandable covered tracheal type device. the extent of the dehiscences ranged from to % of the anastomotic circumference. mortality, morbidity, healing rate of the anastomosis and hospitalisation time were evaluated. results. in all cases stenting was done without any complication. stent extraction could be performed after an average period of days, ranging from to days. in all cases, healing of the anastomosis was satisfactory. patients developed stenosis after removal which was successfully managed by bouginage. stent migration was observed in patients, treated by repositioning in one and two attempts of re-stenting followed by eventual suturing of a small residual leak in the other. conclusions. endoscopic insertion of a self-expandable covered metal tracheal stent represents a safe approach resulting in immediate closure and subsequent healing of cervical anastomotic leakage. there was no leakage-related morbidity, oral intake of food was resumed one day after successful stenting. however, stent dislocation and stricture after stent removal may occur. background. squamous-lined cyst of the pancreas is a rare entity with only about one hundred reported cases. three types of cysts are differentiated: lymphoepithelial, dermoid and accessory-splenic epidermoid cysts. the literature on this entity is limited to reports of single or small numbers of cases. the two most common cystic tumors of the pancreas are serous cyst adenoma and mucinous cystic neoplasms. we herein report the case of a lymphoepithelial cyst of the pancreas. case report. a -year-old man presented with a month history of upper abdominal pain and bloating. the disorders were related to food ingestion and were not followed by nausea or vomiting. he experienced low weight loss. he was in good general health with a normal physical examination and no tenderness in the upper abdomen. laboratory investigation including ca - , cea and hcg were within the normal range. imaging studies with ct, mrt and eus showed a  cm mass in the uncinate process of pancreas with contact on to the mesenterial vessels. the mass presented in ct=eus as a solid, expansive tumor, whereas mrt showed a cystic mass. fine-needle biopsy revealed squamous epithelial cells with sebaceous material, but without atypia. because of the progressive symptoms with compression of the duodenum and to rule out malignancy we resected the cystic tumor. no encasement, invasion or other aspects of malignancy were found. the resection defect was drained with a jejunal y-roux-loop. histological findings showed a benign lymphoepithelial cyst and the patient had an uneventful postoperative and four-month follow-up period. conclusions. establishing a preoperative diagnosis of a lymphoepithelial cyst is not possible. squamous-lined cysts of the pancreas have a low malignant potential, however, there are reports of mature dermoid cysts developing into malignant forms. to distinguish squamous-lined cysts from other cystic lesions of the pancreas, particularly malignant processes, is rather difficult. therefore we recommend a complete surgical removal of every cystic lesion suspicious to be a squamouslined cyst to avoid or treat malignancy. ten year experience with duodenum preserving pancreatic head resection in chronic pancreatitis r. j. klug, f. kurz, m. aufschnaiter kh barmherzige schwestern linz, chirurgie, linz, austria background. the chronic head accentuated pancreatitis is on the rise in industrialised countries. alcohol is the predominant aetiological factor.the incidence is per . inhabitants. in up to % of patients with chronic pancreatitis the head of the gland will be grossly enlarged by an inflammatory mass, often associated with bile duct stenosis and duodenal hold-up.in our institution the standard whipple operation has been replaced by the duodenum preserving pancreatic head resection (dpphr). methods. we present our meanwhile year experience with dpphr. our patients are analysed retrospectively. results. between november and november we performed dpphr in males and females patients. the average age was . years ( - years). the follow-up was done by the aid of an inventory referring to postoperative pain control, development of diabetes, postoperative weight gain and subjective success assessment. the complications are described and discussed as well. the results are presented. conclusions. the dpphr developed by beger about years ago has become the standard procedure for the operative treatment of.chronic head accentuated pancreatitis in our institution. the intervention is demanding but offers the advantages of maximal organ preservation, satisfactory endocrinological and functional results, a justifiable low complication rate as well as a high degree of satisfaction on the part of the patients. segmental duodenectomy at periampullary lesions -an adequate therapy? j. karner, b. sobhian, m. klimpfinger, g. udvadi, f. sellner smz-süd kaiser franz josef spital, vienna, austria background. the radical surgical procedure for treatment of the resectable periampullary tumors is the partial pancreatoduodenectomy or the pylorus-preserving pancreatectomy. in rare selected cases a segmental duodenectomy with reinsertion of the pancreatic and choledochus duct might be suitable alternative to improve the patient's quality of life. methods. about to patients were hospitalized annually with the diagnosis of a pancreatic or periampullary tumor at the smz-süd -kaiser franz josef spital department of surgery. to ensure radical resection either a partial pancreatoduodenectomy or a pylorus-preserving pancreatectomy was performed. in two patients with low-and=or high-grade dyspla-sia of the papilla and the peripapillar mucosa a segmental duodenectomy with resection of the papilla vateri was performed. after radical excision (proven by an intraoperative frozensection diagnosis) a duodeno-duodenal anastomosis with reinsertion of the splinted pancreatic and choledochus duct was performed. results. the postoperative course was uneventful. three months after the operation, clinical follow-up including gastroscopy revealed a normal mucosa of the duodenum and an excellent quality of life. conclusions. accurate surgical technique and pre-(gastroscopy), intra-and final histopathological diagnosis by an experienced pathologist are decisive factors in determining the ultimate outcome. if the histological findings as to benignity are uncertain, resection of the head of the pancreas with or without preservation of the pylorus by an experienced surgeon is indicated. the segmental duodenectomy might be an adequate therapy of the periampullary lesions in carefully selected cases. background. five randomized trials and an increasing number of phase studies confirm the opinion that the combination of peritonectomy-procedures and intraperitoneal chemotherapy positively influence the outcome in patients suffering from peritoneal carinomatosis (pc) of appendiceal tumors, colon cancer, ovarian cancer and gastric cancer as well as rare tumors of the peritoneum per se. nevertheless, according to the literature postoperative mortality was observed in - %, postoperative minor and major morbidity in - %. methods. in the last years patients (pts) suffering from pc arising from different primary tumors were treated at our institution in cooperation with surgical, gynecological or oncological departments in austria and germany. at the time of writing complete records from patients (mean age: . ae yrs, others ) are evaluated for analysis. primary objectives to assess were overall survival and time to progression of intraperitoneal or general disease. factors influencing these parameters were determined. secondary objectives to assess were postoperative mortality and morbidity. results. completeness of cytoredutive surgery, favourable histology (ovary, appendix, colon) and n -stage - (n ¼ pts) made a -year survival rate of % and a -year survival rate of % possible. (updated extended analysis of the different groups of patients will be presented) postoperative mortality within days was . %, within days . %. conclusions. cytoreductive surgery in combination with intraperitoneal, hyperthermic chemoperfusion ae systemic chemotherapy has a curative potential in selected patients. background. an increasing amount of patients confronted with an incurable or chronic progressive disease demands a special palliative procedure in physical, psychosocial and spiritual treatment. medical and nursing staff members in the hospital are not always prepared to handle with these patients and their relatives in a proper way. reasons behind may be lack of time, skills and experiences. deficits in management and in multiprofessional communication complicate the situation. a palliative liaison service provides, in this context, support in pain management, control of severe symptoms, treatment of terminal patients, coordination of professionals, discharge management, cooperation with mobile hospiz teams and support in ethical conflicts. methods. in we asked medical and nursing staff members for the importance and the need of palliative support in their daily routine. from may to december we documented consultations of patients, which means an effort of , hours. in we asked members of the medical and nursing staff in leading positions about the amount of satisfication with the provided support and the acceptance of the instution pls year after the implementation. results. in % of the staff members asked, confirmed the importance of palliative care and % agreed to the cooperation with a palliative liaison service. from may to december , , % of the demands for support came from surgical wards. the primary reasons for the first contact were pains and other severe symptoms. about % of the patients had cancer in the diagnosis. in the extent of satisfaction with the performances of the palliative support team was between , and , (satisfaction is defined until , within a range of to ). % to % from the provided performances were already requested. conclusions. the service of a palliative support team in the hospital was highly accepted already after a short time. more than the half of the consultations took place on surgical wards. we conclude that a palliative support service provides benefits for staff and patients in a difficult situation. especially in a time of rapid medical progress, limited resources and increasing ethical demands of autonome patients, the public health institutions may request for the right balance between curative and palliative settings. background. the ileus is often the sign of an advanced stage of malicious illnesses that require palliative treatment. medicine and especially palliative medicine has changed medical treatment in the way that it now aims at an improvement of life quality. methods. in our hospital cases with patients were analysed. these patients suffered from ileus in connection with an advanced malicious illness. results. an ileus was localised with patients in the field of the small intestine and with patients in the field of colon. cases were treated in a conservative way, cases required operative treatment. primary tumors were found predominantly in the colon and also in the feminine genitals as well as in the stomach. on average the remaining life time was two months. % of the patients with ileus in the field of the small intestine were treated without operation. conclusions. the life time of patients with ileus and advanced malicious illness is short. operations with high risk should be avoided. patients with ileus in the field of the small intestine should be given conservative treatment which in case of failing may be converted into interventional or operative treatment. operation can hardly be avoided with patients with ileus in the field of colon. if available, interventional therapy for the removal of stomach and intestine contents should be applied. the patient's wish is to be considered. treatment should aim at improving the patient's life quality. penetrating abdomino-thoracic injuriesreport of four impressive cases z. halloul, f. eder, f. meyer, h. lippert department of surgery, university hospital, magdeburg, germany background. penetrating wounds are distinguished in impalement and gun shot or stab wounds (stab=impalement injuries more frequently in europe), which are often very spectacular. the aim of the representative case reports is to analyze the kind of injury þ the adequate surgical, in particular, the complex wound management. methods. the impressive case series includes patients with abdomino-thoracic penetrating traumas ( stab=impalement wounds each) who were treated in a surgical university hospital centre during months. results. ( ) impalement injury by a steel pipe i) entering the body above the right kidney behind the liver, through the mediastinum via the right thorax, passed heart and aortic arch up to the left clavicle, ii) approached with sternotomy=median laparotomy to remove the rod including suture of the left subclavian vein only (postoperatively, residual lesion of the left brachial plexus=temporary pneumonia). ( ) one leg of a chair drilled into the left ''foramen obturatorium'' leaving the body at the right anterior iliac spine: initial removal=excision of the gluteal penetration canal. developing abdominal signs= symptoms indicated explorative laparotomy revealing peritonitis because of perforated ileum: segmental resection= anastomosis (postoperatively, i) right inguinal wound necrosis requiring excision=vacuum-assisted closure sealing; ii) remaining paresthesia in the left leg due to sacral plexus lesion). ( ) due to a violent conflict, stabs entered the right thorax while one injured the right pulmonary lobe=diaphragm=liver dome between segment viii&v þ a big scalp avulsion at the left= right parietooccipital site þ a transection of the right biceps muscle approached with right subcostal incision=anterior thor-acotomy=liver packing ( towels removed after d)=suture of the diaphragm=pleural drainages. ( ) stab injury at the left thorax (pneumothorax=lesions of the diaphragm & left third of the transversal colon) and neck (lesions of the pharynx=internal jugular vein) approached with left thoracic drainage=suture of the colonic & diaphragmatic lesions (postoperatively, i) right thoracotomy because of a right pleural empyema due to bronchopneumonia as a consequence of the blunt right thoracic trauma; ii) relaparotomy because of an abscess within the douglas' space; iii) billroth-ii gastric resection because of recurrent forrest-ia bleeding). conclusions. important aspects of such trauma care are immediate life-saving measures, transferral to a trauma centre, first care, prompt diagnostic=initiation of an adequate surgical treatment provided by trauma=general=abdominal=vascular and=or cardiac surgeons (e.g., surgical interventions at vessels= organs=soft tissue) as well as the postoperative course and rehabilitation. if these measures are provided with high medical standards and an interdisciplinary setting, optimal outcome can be achieved in order to prevent fatal outcome, to ensure maximal organ function, and to minimize permanent damages. background. today infections with clostridium perfringens are rare, but still most of the cases turn out lethal, although receiving timely medical treatment. this report deals with three different patients, who were transferred to our surgical department since june . the first patient (male ), with the suspected diagnosis ''femoral hematoma'', a second patient (male ) because of an ''acute abdomen'' and the third patient with suspicion of gas gangrene after chronic ulcer of the right food. methods. first patient: already at the physical examination of the femoral an impressive crepitation was palpable. besides this the man was suffering from myelodysplasia and showed a marked ulcer on the left side of the scrotum. on suspicion of gas gangrene we performed an exarticulation of the left femoral after intensive-care stabilization. besides all efforts this patient died the same day because of an acute circulatory failure. second patient: because of an acute abdomen the second patient received a ct and in suspicion of appendicitis an explorative laparotomy was indicated. furthermore a known haematoma at the right shoulder began to extend in sizeand shortly after the typical crepitation was palpable as well. even though the arm was exarticulated during an immediate operation the patient died because of the massive progressing infection. third patient: this patient was sent to our hospital because of the suspicion of gas-gangrene. during physical examination the typical crepitation was palpable at the right femoral and lower leg with associated emphysema. during operation the wound seemed unsuspicious. immediate examination of the tissue (department of hygienic and microbiology) showed a negative result concerning an infection with clostridum perfringens, so it could be refrained from an amputation of the femoral. entirely some incisions of the skin and the fascia were done. postoperative we kept watch on the wound in short intervals -showing consistent results the patient was transferred to our general ward to be treated because of his chronic ulcer on the right leg. conclusions. once pandora's box has been opened, still % of all gas-gangrene-infections pass off lethal. the first two cases demonstrate that (besides the low incidence of . events per mio. persons and year) infections of clostridum perfringens should always be kept in mind, especially in high-riskpatients. in contrast to this the third patient shows, that severe consequences because of a precipitate indication can be avoided by experience and careful evaluation. results. altogether patients were treated for rsh at our institution during the study period. seven patients were on oral anticoagulation, patients were taking acetylsalicylic, was on clopidogrel and patient was on anticoagulation with low dose heparin, whereas patients had no anticoagulation. a previous trauma event was apparent in six of the cases, one of this patient was on oral anticoagulation, one on acetylsalicylic, one was taking clopidogrel and three had no anticoagulation. rsh was correctly identified by means of ultrasound in of cases, in which this investigation was performed. a ct scan investigation demonstrated the haematoma in all ( of cases) cases. thirteen patients were managed conservatively, patients underwent surgical treatment. eight patients needed blood transfusion and four patients received vitamin k medication. all patients could be discharged from hospital in good general condition. clinical re-evaluation (median follow up years, range month- years) showed all patients were free of symptoms at this time. conclusions. our data confirm the multifactorial aetiology of rsh and the strong association with different forms of anticoagulation. ct scan is the diagnostic tool of choice, whereas identification with ultrasound is strongly dependent on the experience of the examiner. conservative as well as surgical management have good results, with good restitution to fine health of all patients. surgery seems to be only indicated when complications appear (homodynamic instability, severe pain, which cannot be managed conservatively). background. intestinal metaplasia (im) in specialized columnar lined epithelium in the distal esophagus is a precancerous lesion with a cancer risk of . % or case in patientyears. there are no prospective multicenter-data available for germany regarding the cancer-risk and also no data regarding different therapeutic treatment options. the purpose of this study was to evaluate the progression of dysplasia in barrett's esophagus (be) in patients under antireflux therapy -laparoscopic fundoplication (lf) or treatment with proton pump inhibitors (ppi) -based on the data of the german barrett esophagus registry. methods. in a consensus process a protocol was established by pathologists (n ¼ ), gastroenterologists (n ¼ ) and surgeons (n ¼ ). patient history, findings on endoscopy, histopathology and functional diagnostics were collected in a multicentric database. patients gave their informed consent for a central data registration. barrett's esophagus was defined as specialized, intestinal metaplasia in the endoscopic visible columnar lined epithelium of the esophagus independent of its length. the natural and posttherapeutic course of patients with im was registered prospectively. participating centres were free to decide for their own treatment approach for each patient regarding im as well as the underlying reflux disease. patients were followed with routine endoscopy and biopsy every - months. results. since january , patients with be were prospectively registered and analysed. of fourteen participating centres three were surgical (n ¼ ) and gastroenterological (n ¼ ). symptoms of reflux were present in % of patients daily or weekly, in % they were absent. the mean age of patients was years (range - ). two hundred and ninety six were male and female. three hundred and fifty patients ( %) had short-segment-be and ( %) long-segment-be. intraepithelial neoplasia was initially diagnosed in patients (low grade intraepithelial neoplasia (lgien) in , high grade intraepithelial neoplasia (hgien) in , indefinite in ). in the second histological confirmation hgien, lgien and indefinite ien were confirmed. in the other patients ien was excluded. from all patients ( insufficient and on competent lf) have shown progression from im to lgien and one from im to cancer (ppi) in a total of patient-years. conclusions. the current analysis shows a low rate of progression of im to ien for ppi treatment as well as antireflux surgery. this confirms recent reports on barrett's esophagus, that progression is a rather infrequent problem, which cannot be prevented by antireflux surgery or ppi. background. impaired esophageal motility plays an important role in the pathogenesis of gastroesophageal reflux disease (gerd) and its evaluation is important for the assessment of a therapeutic effect. the comparison of szintigraphic, manometric and symptomatic evaluation has not been shown yet. methods. sixty patients were evaluated with endoscopy, esophageal manometry, radionuclide scanning of esophageal emptying and assessment of symptoms prior to treatment (operation or medical therapy) and months later. in gerd patients with normal esophageal peristalsis the nissen fundoplication was performed, in further patients with impaired esophageal peristalsis a partial posterior fundoplication was chosen and further patients received continous medical treatment with ppi. all groups were comparable regarding age and gender of the patients. esophagitis was most pronounced in those patients who underwent partial posterior fundoplication. results. on endoscopy acute esophagitis resolved in all patients after fundoplication, whereas after months of medical therapy patients still had an acute esophagitis. on manometry there was a significant improvement of the competence of the lower esophageal sphincter postoperatively regardless of the performed technique. however, les relaxation was complete only after the toupet fundoplication but incomplete after the nissen fundoplication. esophageal peristalsis measured manometrically did not improve after medical therapy, was significantly strengthened after partial posterior fundoplication but was worsened by the nissen fundoplication. on szintigraphic evaluation of esophageal emptying for solid meals, there was no improvement after medical therapy but a significant improvement after partial posterior fundoplication. after the nissen fundoplication there was a significant deterioration of esophageal emptying. there was a strong correlation between szintigraphic and manomteric evaluation of peristalsis, preoperatively (rs ¼ À . p < . ) and postoperatively (rs ¼ À . p < . ). evaluation of symptoms showed no change regarding dysphagia after medical therapy and after the nissen fundoplication but a significant improvement after partial posterior fundoplica-tion. globus sensation was significantly improved after partial posterior fundoplication but did not change after medical therapy or the nissen fundoplication. postprandial bloating and inability to belch were significantly more common after the nissen than after partial posterior fundoplication. conclusions. antireflux surgery controls gerd better than medical therapy with ppis. however, partial posterior fundoplication is the more physiologic approach than the nissen fundoplication. background. combined impedance-and ph-monitoring (mii-ph) is a recently introduced diagnostic tool to assess gastro-esophageal reflux. we report our experience with this technology. methods. three hundred and fifty-seven mii-ph studies were performed in patients with clinical signs of gastroesophageal reflux disease (gerd) between may and december . a catheter was introduced into the esophagus via the nose and connected to a portable data logger. ph was monitored cm and impedance , , , , and cm above the manometrically located lower esophageal sphincter. symptoms were entered by the patients by pushing buttons on the data logger. diagnostic criteria for gerd were: pathologic acid exposure: ph < during > . % of total, > . % of upright, or > . % of recumbent recording time. pathologic impedance monitoring: > liquid or mixed liquid=gas refluxes detected by retrograde impedance drops > % from the baseline. positive symptom to reflux correlation: > % of > symptom events within a -minute time window after a reflux episode detected by mii-ph. results. three hundred and nine mii-ph procedures were performed after discontinuation of antisecretory medications for ! days in patients without prior esophageal or gastric surgery (age . ae . years). recording time was . ae . hours. the diagnostic yield of mii-ph is summarized in table . median total acid exposure was significantly higher in males than females ( . vs. . %; p < . ) as was the median number of reflux episodes detected by impedance ( vs. ; p < . ). the median number of symptoms was almost equal ( vs. ; n.s.). positive symptom correlation was significantly more frequent in females than males (p ¼ . ). the overall diagnostic yield of mii-ph was not significantly different between genders. conclusions. mii-ph is a valuable new tool for the diagnosis of gerd with significantly increased diagnostic yield over conventional ph-monitoring. acid exposure and the number of reflux episodes were significantly higher in male than female patients. sensitivity to reflux was significantly higher in females. diagnosis of gerd based on acid exposure alone lacks diagnostic sensitivity, especially in female patients. background. the surgical treatment is the most effective method for weight reduction in morbid obesity laparoscopic adjustable silicone gastric banding (lsgb) for morbid obesity has been reported to provide long term weight loss with a low risk of operative complications. nevertheless, esophageal dilation leading to achalasia-like and reflux symptoms is a feared complication of lasgb. patients undergoing obesity surgery were prospectively included in an observation study. this study evaluates the clinical benefit of routine preoperative esophageal manometry in predicting outcome after lasgb in morbid obese patients. methods. before surgery, each of the patients underwent pulmonary functional test, esophageal manometry and gastroscopy. drug medication and esophageal symptoms were recorded. a review of prospectively collected datas on patients (male , female ), who underwent esophageal manometry routine prior to lasgb for morbid obesity from january -december were performed. aberrant motility and other non specific esophageal motility disorders noted on preoperative esophageal manometry defined patients of the abnormal manometry group. outcome differences in weight loss, emesis, band complications were compared between patients of the abnormal and normal manometry groups after lsagb. results. of the patients tested had abnormal esophageal manometry results, whereas had normal manometry results before lsagb. there was no significant difference in wheight loss between the groups after gastric banding. severe postoperative emesis and achalasia like esophageal dilation occurred more frequently in patients with abnomal manometry results. band related complication were found in both groups. there was no difference in the prevalence of reflux symptoms or esophagitis before and after gb. the lower esophageal sphincter was unaffected by surgery, but contractions in the lower esophagus weakend after lsagb. conclusions. postoperative esophageal dysmotility and gastresophageal reflux are not uncommon after lsagb. preoperative testing should be done routinely. low amplitude of contraction in the lower esophagus and increased esophageal acid exposure should be regarded as contraindication to lsagb. patients with such findings should be offered an alternative procedure, such as laparoscopic sleeve gastrectomy or gastric bypass. background. laparoscopic implantation of an adjustable gastric band (agb) still represents the most frequently performed bariatric operation in austria. however, in recent years a general tendency to gastric bypass procedures can be observed. a mayor cause for this development may be long term problems such as the development of an esophageal dilatation. methods. from january until november , patients ( female, male) were treated with agb for morbid obesity at the krankenanstalt rudolfstiftung in vienna. adjustments of the band were performed under radiologic control weeks after the operation and on demand thereafter. of these patients, patients ( female, male, median age: years, range: - years), an equivalent of %, developed an esophageal dilatation during follow up. the median time from the operation to the occurrence of esophageal dilatation was months (range: - months). at the time of esophageal dilatation the median excess weight loss was % (range: - %), the median filling volume was ml (range: . - . ml). twelve patients had to be reoperated in a median of months (range: month- months) after the dilatation occurred. eleven patients had a gastric bypass operation after band explantation and one was converted into a sleeve gastrectomy. in the other patients a conservative approach has been persued so far, consisting of a deflation of the band and careful refillings after approximately month. eleven patients were already available for follow up a median of months (range: month- months) after the dilatation. ten patients significantly gained weight again. the median excess weight loss was reduced from % (range: - %) at the time of the dilatation to % (range: À - %) at follow up. only one patient managed to lose further weight without radiologic signs of esophageal dilatation after refilling of the band. conclusions. esophageal dilatation is a serious long term complication after agb which occurs approximately years after the operation and leads to a failure of this bariatric procedure in the majority of cases. further studies are needed to identify potential candidates for esophageal dilatation after agb. oversewing of gastric pull up staple line in reconstruction after esophageal resection: counterproductive or helpful procedure? considerable postoperative morbidity and mortality. recent studies have emphasized a notable improvement in morbidity rates at specialized centers. in our analysis we put special considerations on the need for an invaginatig suture of the mechanical staple line used for gastric tubulization. methods. between and , patients were treated for esophageal cancer by resection. perioperative data were collected prospectively. among those patients ( . %) underwent gastric pull-up reconstruction. the gastric tube has been constructed by gias using mm staple cartridges. these patients were included in the presented study. it was put upon the discretion of the treating surgeon, whether the staple line has been oversewn by an interrupted invaginating suture or not in a non-randomized manner. the main endpoint measure of the study is leak rate at the longitudinal staple line of the gastric tube without signs of major gastric ischemia. results. the mean age of the patients was . ae . years, . % of the patients were male. in = ( . %) patients an adenocarcinoma was diagnosed, whereas = ( . %) patients had a squamous cell carcinoma and = ( . %) were classified as others. in = ( . %) patients the gastric staple line was not oversewn (group a). in = ( . %) patients the gastric staple line has been reinforced by an invaginating interrupted suture (group b) . a leak at the staple line has to be reported in = ( . %) patients in group a, whereas no leak was seen in group b (p ¼ . ). two= patients ( . %, a: , b: ) experienced ischemic gastric tip necrosis. other surgical complications were anastomotic leakage ( = patients; . %; a: = , b: = ), temporary recurrent nerve injury ( = patients; . %; a: = , b: = ), anastomotic stenosis ( = patients; . %; a: = , b: = ) and chylus fistula ( = patients; . %; a: = , b: = ). conclusions. no significant difference was found between group a and b. however, all staple line leaks of the gastric tube developed, when the gastric tube staple line has not been oversewn. background. cardia carcinoma (ca) is characterized by different features compared with the remaining gastric ca; its incidence in western countries is increasing. the aim of the study was to investigate diagnostic, therapeutic and outcome measures of cardia ca in daily surgical practice. methods. all consecutive patients with cardia ca out of a pool of patients with histologically confirmed diagnosis of gastric ca who were treated in surgical departments were enrolled in this prospective observational multicenter study through a period of months. detailed patient, diagnostic and treatment characteristics were recorded in a computerbased format for analysis. short-term outcome was characterized by hospital stay, complication rate, morbidity and hospital mortality. results. from = - = = , . patients with gastric ca from surgical departments of each level of care were registered out of them subjects ( . %) with cardia ca. tumor localization was classified in patients according to siewert: typi, n ¼ ( . %); typii, n ¼ ( . %); typeiii, n ¼ ( . %). one hundred and seventy two patients underwent surgical intervention (operation rate, . %) of whom individuals underwent resection (rate, . %). a potentially curative resection could be offered to patients (r resection rate, . vs. . % in all gastric ca). fresh frozen section was only used in resections (rate, . %). of standard resections (distal esophagectomy with proximal or total gastrectomy), systematic d , d and d lymphadenectomy was performed in . , . and . %, respectively. histologic investigation revealed uicc stage i=ii in . % of all operated patients: iii=iv, %; not classified, . %. distant metastases occurred most frequently at the peritoneal site ( . %), liver ( . %) and non-regional lymph nodes ( . %). postoperative morbidity was . %. anastomotic leakage occured in patients ( . vs. . % in total of all gastrectomies in gastric ca) from whom subjects ( . %) underwent surgical reintervention. hospital mortality was . % (n ¼ ) compared to . % in all patients with gastric ca. conclusions. more than % of patients diagnosed with cardia ca show an advanced tumor stage at the time of surgical intervention. not all resections estimated as potentially curative were accompanied by d lymphadenectomy. in particular, to further improve hospital volume and r resection rate, to consequently use intraoperative fresh frozen section for the detection of an adequate tumor-free resection margin and to lower the rate of anastomotic insufficiency, it is suggested to treat patients with cardia ca at surgical centres for optimal outcome ( -year survival rate is being under investigation). deep brain stimulation therapy for psychiatric diseases g. m. friehs brown university, providence, usa background. obsessive-compulsive disorder (ocd) and major depressive disorder (mdd) causes tremendous suffering in those affected and in their families. neurosurgical lesioning procedures have been in existence for several decades and the overall reported success rate is widely quoted in the - % range. over the past years deep brain stimulation (dbs) has become available for a variety of conditions including ocd and mdd and has largely replaced lesoining procedure. methods. we report on our experience with patients with ocd ( ) and mdd ( ) treated with dbs of the anterior limb of the internal capsule (al-ic). patients who did not have multiple medication trials of adequate length and dose and trials of psychotherapy or behavioral therapy were excluded. also, mdd patients were required to have had a full course of electro-shock therapy (ect). patients were evaluated by a panel of independent psychiatrists before being referred for neurosurgery. all patients underwent a routine dbs surgery with implantation of bilateral electrodes into the al-ic. the stereotactic coordinates were - mm anterior to the anterior commissure (ac) and - mm lateral to anatomical midline, the electrode tip reached into the area of the nucleus accumbens. all patients had pre-and postoperative neuropsychology evaluations with testing batteries including the yale-brown-obsessive-compulsive-disorder scale (ybocs), global assessment of functioning scale (gaf) and hamilton-depression scale (ham-d) or the montgommery depression scale (mds). results. patients were followed for - months (average: . years), follow-up was complete for all patients ( %). = patients ( %) with ocd had improvements in their ybocs scores of more than % which was found to be significant (p < . ). also, these patients showed a significant (p < . ) improvement in their overall gaf. it was furthermore noted that the depression scores had a tendency towards improvement. of the five patients with mdd = patients ( %) had a significant improvement in their ham-d scores and gaf scores (p < . ). complications included one postoperative seizure, slight wound healing problems which did not require surgical intervention ( = , %). of note is the fact that the dbs batteries have to be changed very frequently (on average every - months). conclusions. dbs for ocd and mdd is a viable treatment for patients who have failed all other known therapeutic options. it is currently reserved for research centers who have a team of psychiatrists dedicated to the treatment of such patients. controlled studies will be necessary to develop guidelines for electrode placement and programming parameters. background. the number of patients demanding endoscopic neck surgery is rising. the access trauma of the axillary, breast and chest approaches is bigger than in open or video assisted surgery. we tested the feasibility of he sublingual transoral access which is in our opinion the only real minimally-invasive extracollar endoscopic access to the thyroid gland. methods. we performed an experimental investigation in a porcine model. in pigs we made endoscopic transoral thyroidectomys with a modified axilloscope with the help of ultrasonic scissors and a neuro-monitoring system for identification of the recurrent laryngeal nerve. results. the average operation time from the introduction to the removal of the obturator just above the larynx was seconds. the mean operation time was minutes. with the help of the neuro-monitoring system we proved in all cases the function of the recurrent laryngeal nerve on both sides. the pigs were observed for another two hours after operation. during and after the operation no complications appeared. conclusions. we could show that the endoscopic transoral thyroid resection in pigs is possible and save. our results might be useful for using this access for endoscopic thyroid resection in humans. background. actually, the surgical community receives some new impulses from interventionally orientated and skilled gastroenterologist by the so-called ''n.o.t.e.s.'' -natural orifice transluminal endoscopic surgery. this seems to be challenge enough to cooperate and contribute some surgically constructive ideas and critics. the surgical answer -with the intention to develop the arguments for a surgical engagement -to the presently still extra-clinical concept of ''notes'' may be given through an alternative procedure named ''flexible endoscopic minimally invasive transperitoneal'' (f.e.min.in. tra.p.) cholecystectomy. methods. after presentation of ''notes'', it's principles and aims, it's supporting societies and boards and their self-definition, a summary of already existing ''notes''-procedures and description of instrumental developments will be given. in contrast surgical considerations will be focused on more or less established surgical transluminal or even natural-orifice-transluminal techniques. in this context a special attention will be paid to surgical history and the life and times of e.mÜ he and the fact of a nearly-missed change of paradigms. as testimony for surgical endoscopic competence in interventional procedures the hybrid-model of f.e.min.in. tra.p. cholecystectomy will be opposed as surgical pendant to the conceptual idea of ''notes'' throughout a short clip-sequence. results. arguments for a surgical engagement in the development of ''notes'' are based on the following items: conclusions. only a close interdisciplinary cooperation may show weather the idea of ''notes'' will lead to clinical usefulness. it's invasivity as well as it's apparent strangeness to surgical behaviour and thinking should incline to an at least active interest. background. sacral nerve stimulation (sns) proves to be an effective therapy in patients with faecal incontinence. during the past years there were as well some promising results in the therapy of chronic obstipation. this study describes the experience with sns in patients with outlet obstruction. methods. four patients suffering of outlet-obstruction ( women), median age years (range - ) underwent test stimulation with a permanent electrode (tined lead). all patients had multiple previous conservative and operative unsuccessful therapy attempts. when complaints could be reduced by at least % with external stimulation, a permanent stimulator was implanted (two staged procedure). success of treatment was evaluated by: clinical examination, patient satisfaction (visual analogue score;vsa), cleveland-clinic-obstipation-score, and morbidity. evaluations were performed before start of treatment, before implantation and months after implantation. results. three of four patients completed the test stimulation stage successfully and received a permanent implant; median duration of stimulation stage was days (range - ). all these patients had a clear improvement according to their vas and cleveland-clinic obstipations-score. there was no postoperative morbidity. the median follow-up was months ( - ). conclusions. chronic obstipation can be treated successfully with chronic sacral nerve stimulation even after other therapeutic approaches have failed. however, this observation has to be confirmed in larger, controlled trials. background. the stapled transanal rectum resection (starr) is an accepted technique for the treatment of the obstructed defecation syndrome (ods). however, the technique with a circular stapling device (pph- ) is limited in large prolapse and the resection is performed ''blind''. a new device, the contour trans-starr (str g), has been designed with the aim of overcoming pitfalls of the current starr technique. this study describes the new technique and the initial experience in treating outlet obstruction or rectal prolapse. methods. all patients had multiple previous conservative or operative unsuccessful therapy attempts. the procedure was performed in lithotomy position and under spinal or general anaesthesia. the prolapse was sutured at the apex with the goal to obtain a uniform circumferential traction (parachute technique). then the new device was introduced into the rectum and a circumferential resection was performed step by step. success of treatment was evaluated by: clinical examination, ods-score, and morbidity. evaluations were performed before the treatment and months later. results. the study started in january and we estimate to enrol eight patients until the end of may . indications, patient's inclusion and exclusion criteria, morbidity and short term outcome will be discussed. conclusions. with the new device the starr procedure may become easier and more effective in the treatment of ods. however, safety and effectiveness has to be confirmed in larger, controlled trials. leber-gallengang therapeutic options for pyogenic liver abscesses h. cerwenka background. clinical management of pla (pyogenic liver abscess) has changed in the last decades due to constant improvements, for instance, in inventional radiology and antibiotic therapy. in surgical departments, we usually treat a selected group of patients with particularly severe forms. methods. our clinical study comprised a series of patients with pla. antibiotic treatment was modified according to sensitivity testing. additional therapy consisted of percutaneous puncture=drainage, endoscopic papillotomy=stenting and surgical interventions when indicated. results. fifty-eight patients ( %) had single and patients multiple pla. the disease was confined to the right hepatic lobe in % and to the left lobe in %; both lobes were affected in %. etiology was biliary in %, hematogenous in %, posttraumatic in % and cryptogenic or attributable to rare reasons in the remaining patients. microbiological culture was sterile in %, which was at least partly due to antibiotic pre-treatment. staphylococci, streptococci and e. coli were most often identified. anaerobes were found in %. factors associated with the need for surgery included: empyema of the gallbladder, underlying malignancy, perforation, multicentricity, vascular complications (hepatic artery thrombosis) and foreign bodies (e.g., toothpick, infected ventriculo-peritoneal shunt). in patients with biliary fistulae it was crucial to ensure prompt bile flow (for instance, by papillotomy=stenting). conclusions. assessment of underlying diseases is decisive for timely identification of patients requiring more invasive treatment. microbiological testing provides clinically important information for treatment monitoring and modification. special attention must be paid to diagnosis and treatment of concomitant biliary fistulae. therapy methods of hydatid disease from the tradition to the future m. sanal , h. guvenc , j. hager in europe. however there are some regions: upper bavaria, suedwuerttemberg (swabian alb), bathing (black forest), furthermore tirol, kaernten and steiermark, switzerland and north italy involved with this parasite. also people from turkey and the balkans bring the illnesses again and again. this lead to the necessity for physicians to be aware of its clinical features, diagnosis and management. methods. thirty patients with cyst echinococcus (ce) in liver, lung, kidney and spleen were in three different pediatric surgery departments innsbruck, bursa and kocaeli surgically treated. in the patients were cystotomy capitonage, simple cystotomy, unroofing, splenectomy, cyst excision performed. seven patients underwent minimal invasive surgery. results. postoperative bronchopleural fistula resolved spontaneously under negative pressure in five cases. the long-term postoperative results are considered good, with no recurrences observed. conclusions. surgery has remained the mainstay for the treatment of ce. the basic steps of the surgical procedures are eradication of the parasite by mechanical removal, sterilization of the cyst cavity by injection of a scolicidal agent, and protection of the surrounding tissues. pair technique in ce; performed using either ultrasound or ct guidance, involves aspiration of the contents via a special cannula, followed by injection of a scolicidal agent for at least minutes, and then reaspiration of the cystic contents. in the last years video assisted intervention has also been performed successfully. background. group milleri streptococci (gms), a heterogeneous group of streptococci, are associated with purulent infections. methods. retrospective analysis of all consecutive biliary infections due to gms in a four-years period. results. out of gms positive patients the innsbruck medical university within the study period, the biliary tract was affected in ( . %). the mean patient age was . ae . years, with a female:male ratio of : . . polymicrobial infections were present in . %. thirty percent of all patients were immuno-compromised after liver transplantation ( = ). seventy-nine patients ( . %) had clinical signs of infection, which was confined to the gallbladder in ( . %) (group i), while patients ( . %) presented with cholangitis (group ii). underlying diseases in the cholangitis group were biliary complications following liver transplantation in , other causes for mechanic cholestasis in , malignant intrahepatic disease in , ascending infections in and a ductus choledochus cyst in one patient. twenty patients ( . %) had gms positive bile cultures without clinical signs of infection (group iii) obtained during evaluation of cholestasis ( ), status post liver transplantation ( ), bilioma post liver resection ( ), and psc ( ). antibiotics were administered to patients ( . %) in group i, all patients ( . %) in group ii, and one patient ( . %) in group iii. in group i, all patients also underwent cholecystectomy. interventions were required in patients ( . %) in group ii (ercp ( ), external drainage ( ), surgery ( )), and patients ( . %) in group iii (ercp ( ), external drainage ( ), surgery ( )). gms isolates were susceptible to all penicillins, clindamycin and most cyclosporins, but were resistant to aminoglycosides and showed intermediate susceptability to ciprofloxacin. conclusions. the biliary tract was affected in one out of five patients with group milleri streptococci (gms). gms cause infection in % of all cases, and are often associated with mechanical cholestasis. background. peritonitis ossificans is a rare disorder with only few reported cases in literature. metaplastic bone formation in abdominal scars seems to be an own entity with only several descriptions mostly associated with trauma, gun shot wounds and repeated abdominal surgery. we report about a case with development of metaplastic bone formation and peritonitis ossificans after multiple acute surgical interventions. methods. chronological review of our patients medical history, pathohistological features and comparison of published data of ''peritonitis ossificans'' and ''metaplastic bone formation'' via pub med. results. our patient developed multiple nodular lesions with massive calcifications between the small bowel mesentery (heterotopic mesenteric ossification) after primary adhesive ileus and revision surgery because of colonic leakage. the situation developed within days from a prior abdominal situs without calcification. small bowel fistula occurred and we used abdominal vac therapy. ten weeks later partial secondary closure was performed and no sign of calcification could be observed. histological features showed fatty necrosis and scary tissue with metaplastic cartileage and bone tissue. literature is rare, pathophysiology, therapy and prognosis remains unclear. conclusions. male gender, multiple abdominal surgery or trauma with peritonitis, peritoneal dialysis and pancreatitis seem to be predisposing factors. extensive activation of myofibroblasts appears to be the major cause for hyperproliferation. the prognostic impact depends on secondary complications including postoperative fistula and leakage and intestinal obstructions. actually, literature shows no causative therapy. background. the differential diagnosis of dysphagia predominantly includes gerd, neoplasm, diverticula or achalasia. infrequent causes are diffuse esophageal spasm, scleroderma and other systemic diseases. eosinophilic esophagitis as a cause for dysphagia is found increasingly in recent literature and as a headline topic at congresses. methods. case report of a a old adipose male patient with multiple allergies who was suffering from dysphagia and bolus events for about years. they have been independent from pain, stress, temperature or consistency of food. gastroscopic examination showed a narrow esophagus with fragile, slightly corrugated mucosa. barium radiography and mri did not show any pathology. the patient underwent an esophageal manometry which showed a normal les with normal relaxation, but pressure peaks of mmhg on swallowing and % simultaneous waves. iced water or metoclopramide had no effect. ppi and nitro showed no improvement. sample biopsies of the whole upper gi during a second endoscopy revealed massive eosinophilic infiltration of the whole esophagus. results. the diagnosis eosinophilic esophagitis was herewith confirmed. the patient was treated with orally administered topic steroids (pulmicort spray bid orally for three months). his symptoms improved markedly. conclusions. eosinophilic esophagitis is an uncommon disorder. only publications with all over patients are published. male to female ratio is to . in % of the patients, food allergies can be found. peripheral eosinophilia can be detected in % and high ige in %. most of the patients are in the range of normal weight. the main symptoms are dysphagia in %, food impaction in % and heartburn in % of patients. endoscopically mucosal fragility can be detected in almost all patients, furthermore edema %, rings %, strictures %, corrugated esophagus, papules % and small caliber esophagus in %. eosinophilic infiltration ( =hpf) in the upper and lower esophagus without presence of eosinophils in the stomach or duodenum are detected histologically. the recommended therapy is oral administration of fluticasonpropionate or bethametason spray for two months. the initial response is about %, but relapse is common. systemic steroids are also effective. dilatation should not be performed because of a significantly elevated perforation risk and a high relapse rate. sample biopsies of the upper gi should be taken in every patient with unclear dysphagia since eosinophilic infiltration exclusively in the whole esophagus is pathognomonic for eosinophilic esophagitis and consequently dilatation should not be performed. p cholangiocellular carcinoma of the bile duct after resection of a congenital choledochal cysta rare manifestation background. the risk of malignant degeneration of a bile duct cyst is reduced by an early resection, but the risk of malignant change persists, as we show in our case. only few cases are published in the literature. as the prognose of a malignant degenerated choledochal cyst is very poor, the only useful possibility to minimize the risk of carcinoma is the early cystectomy. based on our case we like to discuss the indication for surgery, incidence of malignant change, risk factors, discovery and diagnosis, detection and prevention, the surgical procedures for the treatment of chledochal cysts and especially whether the typ of surgery have an impact on malignant transformation? methods. we report about a female patient who was examinated by ercp because of recurrent cholangitis. in her medical history we found out that on our patient a cholecystectomy has been carried out at the age of years and in addition to that procedure a congenital choledochal cyst typ i was resected, nevertheless the patient developed a massive cholangiocellular carcinoma which leaded to death at the age of years. after examination using multiphase ct we diagnosed a carcinoma to a great extent, which was inoperable. with the intention to obtain an operable condition, our patient was treated with neoadjuvant chemotherapy which remained unsuccessful. results. there are series of theories in the literature which try to explain the genesis of choledochal cysts, the real reason of their development is not clear, many possibilities for their emergence are discussed: i.e. weakness of the bile duct, distal obstruction, pancreatico-choledochal reflux caused by a long common channel, a wrong estuary of the pancreatic duct in the choledochus or also a pathologic distribution of ganglion cells on the wall of the choledochus. reviewing the worldliterature, the risk of degeneration of choledochal cysts is described differently, but the early resection is always recommended. conclusions. choledochal cysts are associated with an increase in the incidence of bile duct carcinoma. as it is shown, excision of a choledochal cyst is not protection by itself against the development of cancer in the future. after resection patients should have long term follow up. any patient, especially any adult, with recurrent symptoms following cyst related surgery must be evaluated for malignancies in the biliary tract. a surgical treatment after diagnosis of a choledochal cyst is necessary to avoid bile duct carcinoma. background. sporadic lymphangioleiomyomatosis (lam) is a nonmalignant proliferation of immature smooth muscle cells, usually in the lung but occasionally in the retroperitoneal lymph nodes as well. there is perilymphatic, perivascular and, with pulmonary manisfestation, peribrochiolar proliferation and invasion. it is an extremely rare disease (prevalence : ) that exclusively afflicts women of childbearing age. the most common presenting symptoms are dyspnea, cough, recurring pneumothorax or chylous ascites. the definitive diagnosis is obtained by biopsy. lam has a typical histological picture featuring diffuse, sometimes nodular proliferations of immature smooth muscle that stain specifically with the marker hmb- . unlike tuberous sclerosis (ts), sporadic lam is triggered by a mosaic mutation of the tsc- gene in the involved tissue. ts in contrast is caused by a somatic mutation of the tsc- gene. this somatic mutation leads above all to neurological symptoms (a trias of epilepsy, cognitive impairment, dermatological manifestations) but, in some cases, to a pulmonary manifestation of lam. at present, there is no curative treatment for lam, though a trial with gestagens is an option. terminal pulmonary failure is an indication for lung transplant. case report. in the course of a routine sonographic examination, a -year-old woman was found to have an expansive cystic process in the retroperitoneum. abdominal ct showed a pre-aortal lesion measuring .   cm with a partially cystic, partially soft-tissue structure suggestive of a cystic lymphoma or a cystic lymphangioma. the cyst was drained and partially resected laparoscopically. the histological diagnosis was lymphangioleiomyomatosis without indication of malignancy. preoperative chest x-ray and spirometry were within normal limits, but high-resolution thorax ct showed the cystic alterations typical for pulmonary lam. at present, the patient is free of complaints but due to the typical chronic course of the disease, close follow-up is indicated. conclusions. although it is a very rare disease, the diagnosis of a cystic retroperitoneal expansive process should suggest lam as a differential diagnosis. a definitive diagnosis can only be obtained with histology. because pulmonary involvement tends to be the rule, a thorax ct is indicated with primary abdominal manifestation. if there are neurological or dermatological manifestations, tuberous sclerosis should also be considered in the differential diagnosis. fetal mri: what is its worth outside the central-nervous system in extra-central-nervous system regions as it is mandatory in pediatric surgery. since fetal mri is performed at our institution, whenever a congenital malformation is suspected in the prenatal ultrasound. methods. fetal mri studies are performed on . t (philips) superconducting unit using a five-element surface phased-array coil, after th gestational week to avoid the possibility of magnetic fields interfering with organogenesis. no sedation is necessary. in addition to routine t -weighted (w) sequences, t -weighted sequences (mainly to demonstrate meconium-containing bowel loops), t -sequences (in case of hemorrhagic lesions), steady state fast precession (ssfp) sequences (to depict vessel-abnormalities), dynamic ssfp sequences to show swallowing and peristalsis, flair and diffusion-weighted sequences (for further tissue characterization) were performed. results. fetal mri is applied the following pediatric surgery cases: suspected lung anomalies ( cases), abdominal anomalies ( ), anal atresias ( ), esophageal atresias ( suspected), congenital diaphragmatic hernias (cdh) ( ), head-and-neck diseases ( ) and for urologic cases ( ). conclusions. detailed morphological description of congenital malformations is possible with fetal mri which may have a bearing on prognosis. it has become mandatory for antenatal counseling. in some findings such as esophageal atresia, gastroschisis or cdh an antenatal transport can be arranged to a perinatal center. background. in inflammation, activation of coagulation and inhibition of fibrinolysis lead to microvascular thrombosis. thus, clot stability might be a critical issue in the development of multiple organ dysfunction syndrome. activated fxiii (fxiiia) forms stable fibrin clots by covalently cross-linking fibrin monomers. in recent studies, multiple polymorphisms have been described in the fxiii-a subunit gene. the val leu polymorphism affects the function of fxiii by increasing the rate of fxiii activation by thrombin, which results in an increased and faster rate of fibrin stabilization. in the present study, we analysed the influence of the common fxiii val leu polymorphism on inflammatory and coagulation parameters in human experimental endotoxemia. methods. healthy volunteers received ng=kg endotoxin (lps, n ¼ ) as a bolus infusion over min. blood samples were collected by venipunctures into edta anticoagulated vacutainer tubes before lps infusion. for determination of the fibrinogen promoter polymorphism, we developed a new mutagenic separated polymerase chain reaction assay. results. fxiii levels were higher for homozygous carriers of the fxiii v l polymorphism in comparison to wild-typ and heterozygous. homozygous carriers had lower levels of tnf and il- in comparison to wild-type. interestingly, subjects homocygous for the fxiii v l polymorphism had lower monocyte and neutrophil levels throughout the timecourse. the fxiii v l genotype was not associated with clinically relevant differences in plasma d-dimer or f þ levels after lps challenge, which is consistent with the lack of effect on early thrombin generation. conclusions. our findings indicate, that the common fxiii v l polymorphism is associated with differences in the selected inflammation parameters and in monocyte and neutrophil cell counts in response to systemic lps infusion in humans. those findings may have an impact on clinical treatment for patients with inflammatory diseases. p stamm-kader gastrostomy or peg w. h. weissenhofer time-honoured or forgotten? the stamm-kader gastrostomy, introducing a nelaton catheter via a stab incision through the upper abdominal wall, guided by direct vision after laparotomy or using a minilaparotomy or even by laparoscopy can be considered an easy alternative to the widely used peg or similar endoscopic procedures. the ''old'' and simple stamm-kader procedure offers not only direct vision, possibilities of local anaesthesia and a minimum of instruments and therefore costeffectiveness, but is also a welcomed addition to the surgical armamentarium -once learned. the actual procedure includes an abdominal accesswhether minimal or already present in case of operations for bowel obstruction, further a double pursestrig suture between large and small curvature of the stomach, stab incision and introduction of a large lumen balloon catheter, the double pursestring sutures are tied in such a way that a short channel in the stomach wall is formed and then covering sutures between abdominal wall and stomach are tied. the catheter can be used immediately for decompression and early feeding. obviously this is a surgical method and has therefore a much smaller following and tends to be forgotten as there are no ''progressive'' endoscopic devices to be advertised and there is minimal economic interest to be generated for medical companies. nonetheless it is in my opinion and experience an useful route in more ways than the peg or button gastrostomies can ever offer. the blood levels of c-reactive protein (crp), interleukin (il) , , and icam- were measured using the elisa technique in all patient before, immediately after operation, at the first and third day after surgery. the pre-operations levels of crp and all mediators had no differences in both group of patients. significant increase of il- , il- and icam- level was noted in the first group vs. insignificant changes of mediators' levels in patients of the laparoscopic group immediately after operation. the gradually increase of all mediators' plasma levels were noted in first group up to the third day after operation. crp was peaked at the third day in both group, but the increase after open adrenalectomy was more pronounced (p < . ). levels of il- and icam- had strong correlation with the hematological changes that observed in the postoperative period. the cytokines play a pivotal role in the orchestration of the immune response. the increased levels of il- and il- pointed on enhance of th response. activation of th cytokines may provoke the immunosuppression and the catabolic stage and may have adverse consequences for patient recovery. thus, there is a clear correlation between the changes in cytokine levels and the degree of surgical trauma. methods. combined retroperitoneal pancreas-kidney transplantation was performed in a -year-old patient with type-idiabetes and diabetic nephropathy. the patient had a bmi of and had undergone renal transplantation in the right iliac fossa years ago. after mobilization of the colon and mesocolon ascendens, the graft was anastomosed end-to-side to the aorta and to the inferior caval vein. the graft was in a retroperitoneal position. for exocrine drainage a side-to-side duodenojejunostomy was performed after bringing a jejunal loop through a window in the colon mesentery. results. the anastomoses could be performed with ease. duration of the pancreas implantation was minutes, minutes for implantation of the kidney in the left iliac fossa. ischemic time was hours. a revision was necessary due to obstruction of the graft ureter. from day after transplantation the patient required no more insulin, and lipase and amylase levels were within the normal range. conclusions. the first experience with retroperitoneal pancreas transplantation with systemic-enteric drainage showed, that the technique was safe, and had technical advantages as compared with the classic method. it should be especially applied in high risk patients (obesity, severe atherosclerosis). background. recell + is a new medical product for yielding a cell suspension of the skin. in this process cells are removed from the basal layer of a thin split skin graft. the removal of the skin graft, the preparation of the cell suspension and the covering of the defect can be done in one treatment session in the operating theatre. recell + could be used for the coverage of superficial defects in burns, scars, skin resurfacing and vitiligo. the advantages of this new technique are a shorter healing period, better scar quality and the ability of repigmentation. methods. for yielding cell suspension, which is quickly available, a thin split skin graft (thickness . - . mm) is taken. depending on the defect, the size of the split skin biopsie is from  cm for coverage of cm to  cm for coverage of cm treatment area. after separation of the different layers of the skin, the special cell suspension could be prepared. then the cell suspension is immediately sprayed or trickled on the prepared wound area. a special laboratory is not required. the first change of the wound dressing is done week postoperatively. conclusions. the result of this new treatment option is a skin of good quality, colour and function -comparable with the original skin. the first experiences show recell + as an interesting amendment to the previous therapeutical options. however, other studies should be done to fathom the spectrum of the indications and to confirm the first results. p early experience with ductoscopy guided minimal invasive surgery for intraductal breast lesions c. tausch, p. schrenk, e. grafinger-witt, t. gitter, s. wölfl, s. bogner, w. wayand background. intraductal breast lesions which have been diagnosed by radiological ductography are sent to breast surgery. by a cirumareolar incision a poorly defined extent of tissue will be removed. it can be supported by presentation of the main duct by injection of blue dye. taking into consideration that papillomas are benign in - %, it is worthful to minimize the extent of the intervention. this fact and the aim to visualize the origin of most types of breast cancer -the terminal ductolobular unit (tdlu) -induced the development of endoscopes for the milk ducts. methods. after canulating the ductus lactiferous it will be distended by a special dilatator. the endoscope (laduskop + , polydiagnost comp.) is inserted through this dilatator and the inspection of the ductal system is possible til over the fourth bifurcation. endosopes are available with device for flushing and working ducts for biopsies. results. this a first report about the experience with ductoscopy in patients presented with unilateral secretory disease. after successful localisation of an intraductal leason a tissue sparing excision of the affected duct follows guided by the in situ lying ductoscope. conclusions. endoscopy of the mammary duct system is a precious diagnostic tool for onesided secretory disease und is able to minimize the extent of the removed tissue. the role of the method in the perioperative visualisation of intraductal diessemination of breast malignancies needs further evaluation. p ruptured aneurysma of arteria lienalis with massive bleeding because of fibromuscular dysplasia background. fibromuscular dysplasia (fmd), a non-ather-osclerotic=non-inflammatory vascular disease, is a rare cause of visceral artery aneurysmas (vaa). in about % of all cases, vaa presents first with rupture and leads to a overall-mortality of . %. about % of fmd are familial, most likely in female and often as multifocal lesions. patient's history. a years old female patient was admitted to our department with nausea and epigastric pain. former history showed an aneurysma of the iliacal artery treated by iliacofemoral bypass (pathohistological examination of the aneurysma showed fmd), and several episodes of spontaneous subcutaneous haematomas. abdominal ultrasound, x-ray and gastroscopy showed no abnormalities. moderate anaemia without any sign of gastrointestinal bleeding made us perform a ct-scan which showed an intraabdominal and peripancreatic haematoma without any sign of a recurrent aneurysma. under icu-monitoring the patient showed another episode of acute epigastric pain and developed signs of haemorrhagic shock. we performed an acute median laparotomy and found no cause of intraabdominal bleeding. exploration of the peripancreatic haematoma showed the cause of bleeding as a ruptured aneurysma of the central splenic artery. resection of the aneurysma and splenectomy had to be performed. the patient was discharged from the hospital on the th postoperative day. conclusions. ruptured vaa caused by fmd as rare reasons for acute abdominal pain need most aggressive treatment to avoid postoperative mortality. background. today, iatrogenic injuries are the most common cause of hemobilia. the hepatobiliary system is at risk for damage as side effect from procedures such as percutaneous bile drains and liver biopsies. complications of open and laparoscopic surgical procedures can also be responsible for hemobilia. methods. we report of a rare case of iatrogenic hemobilia occurring after laparoscopic cholecystectomy. results. a -year-old patient was readmitted to our department, days after laparoscopic cholecystectomy, complaining about upper abdominal pain and presenting with signs of jaundice (bi ¼ . mg=dl but ap ¼ u=l) and anaemia (hb ¼ . g=dl). the patient, who was a jehovah's witness, refused blood transfusions. on readmission ercp demonstrated fresh active bleeding from the papilla of vater. cholangiography demonstrated obstruction of the common bile duct by intraluminal blood clots. blood clots were retrieved by means of an endoscopic ballon-catheter. ct scan and angiography showed a . cm contrast retaining pseudoaneurysm in the hilus of the liver oroginating from the stump of the cystic duct. interventional radiological selective stenting of the hepatic artery could not be performed for technical reasons. the patient was re-operated, the site of bleeding was identified as the cystic artery stump and surgically controlled with sutures. the patient's further postoperative course was uneventful with quick recovery and without the need for blood transfusion. conclusions. hemobilia is a rare complication after cholecystectomy, which may stem from a pseudoaneurysm of damaged vessels, e.g., the stump of the cystic artery. when management by interventional radiology fails, surgical intervention is mandatory. background. we describe on of the rare cases with a perforated barrett-ulcer resulting in an esophagopleural fistula. the importance of recognizing esophageal disorders and catastrophes in the management of acute abdominal emergencies is emphasized. methods. chronological review of our patients medical history, pathohistological features and comparison of published data of ''esophageal perforation'' via pub med. results. a young, male, alcohol-addict patient presented to the emergency department after a fall over staircase with serial rips-fracture and only little discomfort. chest x-ray and blood sample were inconspicuous. on the following day patients general condition got worse, a pneumothorax occurred. so it was necessary to install a bulau drainage which encouraged food out of the left pleuracave -therefore an ''esophageal perforation'' was supposed. the patient was transferred, now with a mediastinial sepsis and multi organ-failure, to our medical surgery unit, where primarily a esophageal stent and a thoracotomy with cleansing and drainage of the mediastinum and the pleural cavity was set. but within a week the stent became insufficient and an esophagectomy and a gastrostomy were necessary. after weeks therapy on the intensive care unit, the patient underwent again a thoracotomy with decortication of a pleura callositiy because of the persistence of a fluidopneumothorax. the patient is now disposed to a colon interposition. conclusions. possible risk factors for perforation in general and in this patient included alcoholism, severe gastroesophageal reflux, noncompliance with antacid and ppi blocker therapy and the presence of acid-secreting parietal cells in the barrett's epithelium. misdiagnosis is the most important contributing factor in the continuing high morbidity and mortality of esophageal-perforation as shown by all reported cases. background. the use of ergotamine, e.g., suppositories for migraine headaches, may have systemic as well as local side effects. systemic poisoning is known as ergotism, historically mostly due to the ingestion of rye infected with claviceps purpura fungi. local complications, like rectal ulcers and rectovaginal fistula may require surgical management. methods. we report about the case of a year old female patient with deep anal necrosis, insufficiency of the anal sphincter, anovaginal cloaca and rectal prolapse, as long-term sequelae of ergotamin suppository application. results. the patient was hospitalized for treatment of the rectal syndrome mentioned above. the anoderm appeared completely destroyed, with extensive scarring and manifestation of an anaovaginal cloaca. anal manometry showed almost no anal pressure. anal sonography demonstrated an anterior semicircular defect of the internal as well as the external anal muscles. the patient had already been seen in our hospital two years previously, when a perineal necrosis had raised suspicion of a locally advanced anal cancer. that time, she had refused to undergo further diagnostic work-up (including re-biopsy, etc.) and treatment, after endosonography had suggested an infiltrative process affecting the anal sphincter and the histopathologic diagnosis spoke of a ''tumor necrosis . . . but without viable tumor cells''. now, after exclusion of a neoplastic process, the patient underwent a complex surgical procedure for management of her incontinence syndrome: a laparoscopic resection of the rectum and rectopexy was performed. furthermore sphincter and perineum were reconstructed using an anterior levator plasty and ventral sphincter-overlapping repair. a temporary protective loop ileostomy was created in addition. conclusions. this case describes the -to our knowledgemost extensive local complication due to ergotamine suppositories, in the world literature. it suggests that ergotamine suppositories should be used with precaution, and a close followup by the prescribing practitioner is mandatory. furthermore, patients with unclear inflammatory destructive alterations of the perineum and unexplained rectal syndrome should be asked for ergotamine suppository (ab)use. p intrapancreatic accessory spleen: a differential diagnosis of pancreatic tumour background. according to autoptic studies, accessory spleens may be found in to % of the population and most of them are usually located at or near the splenic hilum. only in to % they are located in the pancreatic tail. we report a rare case of intrapancreatic accessory spleen which radiologically mimicked a tumor in the tail of the pancreas. methods. a -year-old man was diagnosed with a tumor at the pancreatic tail. in the preoperative computed tomography (ct), there was a lesion ( . cm in diameter) in the pancreatic tail and two locoregional lesions ( . and . cm in diameter), which had intensive contrast enhancement. it was diagnosed as a nonfunctioning endocrine pancreatic tail carcinoma with lymph node metastasis. results. intraoperative examination showed two accessory spleens nearby the pancreatic tail. as pancreatic cancer could not be excluded because of the local findings, an oncological left pancreatectomy was performed. histological examination excluded cancer and revealed an intrapancreatic accessory spleen and two accessory spleens nearby the pancreatic tail. conclusions. intrapancreatic accessory spleen should be included in the differential diagnosis of pancreatic neoplasm. a useful diagnostic tool is scintigraphy with technetium- marked, heat shock denaturated autologous erythrocytes. background. sacral nerve stimulation (sns) is a widely accepted therapeutic options for patients suffering from faecal incontinence based on a neurogenic dysfunction. more recently case reports have been published showing a positive effect of this treatment in patients suffering from faecal incontinence after low anterior rectal resection. the purpose of this study was to perform a nationwide survey for this selected indication for sns in order to gain more information by recruiting a larger number of patients. methods. in the period to three austrian departments reported data of patients who underwent sns for faecal incontinence following rectal resection. data were available of patients ( females, males) with a median age of years (min -max ). six patients had undergone rectal resection as a treatment for low rectal cancer. one patient had undergone rectal resection for crohn's disease, one patient subtotal colectomy and ileorectostomy for slow colon transit constipation. results. in all patients test stimulation was performed in the foramen s unilaterally over a median period of days ( - d) . seven patients reported a marked reduction of incontinence in the observation period. five patients reported a marked improvement compared to the baseline of their continence situation. three patients had no further incontinence episodes following the permanent implant. two patients reported ''rare events'' ( - incontinence episodes= month). one patient who had previously reported an improvement of his continence function during his test stimulation complained about repeated urgency problems as well as incontinence episodes. conclusions. despite our observations and the promising results of others the role of sns in the treatment of faecal incontinence following rectal resection needs further research as well as more clinical data by a larger number of patients. p lymphatic vessel invasion in upper gi cancer: an indication for an additive or adjuvant therapy? and ac had significant lower lvi-rates compared to nonresponders. these data warrant prospective data and might result in the future into an additive or adjuvant multimodal therapy. [up to now = recurrencies ( . %) were seen.] all patient data were collected prospectively. in the present study we compared all patients with an operations time of minutes or more with those with operation times < minutes and compared patient related factors (asa, bmi, type of hernia, recurrent hernia, scrotal hernia, incarcerated hernia and situs-related problems) and operation related factors (surgeon's experience, intraoperative problems, anaesthesiologic problems). results. mean operation time was . ae . minutes. operation time did not increase with asa and bmi (pearson coefficient . resp . ). direct hernia were faster operated than indirect, combined or recurrent hernias in total (average time . ae . ; . ae . ; . ae . ; . ae . ). the proportion of recurrent ( . %) and scrotal hernia ( . %) in operations longer than minutes was significantly higher (n.s. resp. p < . ), in incarcerated hernia ( . %)and hernias with long anamnesis and difficult scarred situs ( . %) or combined with additional operations ( . %) as well. in operation related factors individual designed ring-armed patches demanded - minutes more operation time and thus clearly prolonged the operation (p < . ), unexpected intraoperative problems (e.g. in positioning the patch) or complication (bladder injury) as well. in rare cases anaesthesiological problems (insufficient spa) caused delay as well. most important seems to be surgeon's experience. with increasing experience the average operation time and the proportion of long lasting operations decrease. conclusions. while patient's asa and bmi do not influence the tipp operation significantly, hernia type, recurrency, incarceration and scrotal hernia resp scared situs influence the operation clearly. in operation related factors surgeon's experience seems to be most important, intraoperative problems or complications result in an unexpected delay as well. in preoperative planning knowledge of recurrency (previous operation method), scrotal hernia or incarceration or scar-inducing anamnestic factors give hints to a prolonged hernioplasty. p biomechanical analysis of the ventral abdominal wall for incisional hernias c. hollinsky, c. yiwei, j. ott, s. sandberg, m. hermann background. for the therapy of ventral abdominal wall hernias, different reinforcement techniques with mesh are available. nevertheless the outcome of treatment for ventral abdominal wall hernias is currently unsatisfactory. biomechanical load flow calculations are introduced in this study. methods. we took peritoneum and abdominal wall muscles of recently deceased cadavers to determine the friction coefficient for mesh protheses. therefore we placed the mesh between peritoneum and muscles and loaded them with tension. furthermore we analyzed the different fixation elements for their load resisting capacity. results. the prostheses demonstrated a frictional coefficient of m ¼ . . the elasticity module e of polypropylene is ¼ n=cm . for laparoscopic techniques, leight meshes showed an unproportional high bending and sheared off at low loads. for the reinforcement elements, large differences between different tensile load capacities were detected. conclusions. the overlap of the protheses over the hernia orifice should be selected proportionally to the hernia size. light meshes are unfit for the laparoscopic techniques and should not be used for the therapy of ventral wall hernias. p the axillary access in unilateral thyroid resection k. witzel ; universitätsklinik für chirurgie, salzburg, austria; the new european surgical academy (nesa), berlin, germany background. with this study, we intended to find out if it is possible to avoid the typical scar after thyroid resection by using a mm axillary access and a . mm incision in the jugulum. methods. we present the results of our proof-of-concept study with patients. for this technique, a modified axilloscope and ultrasonic scissors were used, which permit a total resection of the unilateral thyroid. results. the feasibility of this endoscopic technique was shown by the successful operation of these patients with uni-lateral pathological findings. furthermore, we showed that this technique allows to resect tissue up to a whole lobe while at the same time finding and identifying the recurrent laryngeal nerve and subsequently verifying the findings by using the neuromonitoring system. conclusions. this study shows that endoscopic thyroid surgery approximates the norms of endocrine neck surgery. the presented method is useful in thyroid surgery for patients with single nodules and a small thyroid gland. background. ventral incisional hernias have a high incidence after laparotomy closure. laparoscopic hernia repair is a minimal invasive technique with less operative trauma. the aim was to assess the reccurence rate and morbidity after the laparoscopic repair. methods. data of all patients with laparoscopic incisional hernia repair operated in our department between december and november were recorded in a prospective data base. forty two patients (m:f ¼ : ) with a mean age of years ( - ) and a mean bmi of kg=m ( - ) were operated. results. conversion rate was % due to intraoperative lesions to small bowel during adhesiolysis. mean operation time was min ( - ). in patients the dual-mesh, in patients the bard composite ex mesh and in patients the parietex mesh was implanted. mean hospital stay was days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the morbidity-rate was . % ( hematomas) . four patients complained about prolonged pain. in the long term follow up patient had to be reoperated due to mesh related complications. mean follow up time was months, patients presented with a recidive hernia. conclusions. laparoscopic ventral hernia repair can be performed with acceptable recurrence rate ( . %) and low morbidity ( . %) independent of the used mesh. p outcome of clip removal after endoscopic sympathetic block anecdotal reports are available on clinical outcomes after cr. the aim of the study was to investigate whether cr actually resulted in reversal of compensatory sweating (cs), and whether the initially obtained therapeutic effect on hyperhidrosis of the upper limbs (hh) and the face (fh) and facial blushing (fb) diminished with time. methods. between = and = a total of patients ( females, males) with a mean age of ae years underwent cr after esb. three patients underwent unilateral clip removal due to mild ptosis (one patient with esb , patients with esb ). twenty patients had their clips removed due to unbearable cs. levels of hh, fh, fb and cs were graded by a visual analogue scale ranging from (no sweating= blushing) to (most severe sweating=blushing). mean followup after cr was ae months obtainable from patients ( %). results. the patients who suffered from ptosis started to improve weeks after cr, complete relief was observed months thereafter. in each group with esb and esb , . % of patients underwent cr. only one patient after esb had to be reoperated ( . %, p < . compared to esb and esb ). four patients ( %) reported no change in cs after cr, in patients ( %) cs dissolved completely. overall, cs improved from . ae . to . ae . (p < . ). hh, fh and fb recurred to about % of the initial levels, patients ( %) reached preoperative levels. conclusions. clip removal because of unwanted side effects is more common in patients after esb and esb than after esb . cr results in partial reversibility of cs and causes partial recurrence of the initial complaints. although some patients do not benefit from cr, our study provides valid data that esb is a reversible technique. p acute reinterventions following laparoscopic transabdominal preperitoneal inguinal hernia repairs (tapp) b. walzel, p. patri, p. razek, a. tuchmann background. today the tapp method is a frequently used surgical procedure for treating inguinal hernia. although this type of operation has some advantages compared to open procedures, some complications typical for laparascopy might arise. we report about managing such complications as based on our experience. methods. between january and december tapp was applied in our hospital to (n ¼ ) patients. from among those patients (n ¼ ), ( m, aged - ) laparoscopy had to be repeated because of acute complications which occurred between the st and th postoperative day. three patients presented post op a bilateral tapp. reasons for interventions were: obstruction of the small intestine due to incarceration with a dehiscent peritoneal suture (n ¼ ), hematoma in the area of surgery applied (n ¼ ) and one hemorrhage caused by a trocar (n ¼ ). in three patients (n ¼ ) with a mechanical obstruction of the small intestine, repositioning by laparoscopy of the incarcerated ileus was carried out, followed by a peritoneal suture. in two cases with intraabdominal hemorrhage, the bleeding was stopped and the prolene nets were removed via laparoscopy. in only one of the cases replacement of the net was possible, in the other one the procedure was changed to open surgery for inguinal hernia because of an infected net. in one patient (n ¼ ) hemorrhage due to injury by trocar repair was possible by a simple suture. results. in out of cases the complication was successfully repaired by way of laparoscopy. in one case the shouldice repair was applied. in the other a paralysis of the ileus occurred post laparoscopy, requring a smoothing of the ileus by laparotomy. conclusions. among our patients severe complications following tapp needing surgical intervention occurred but rarely ( . %). frequently treatment by way of laparoscopy was successful. p clip displacement does not effect postoperative outcome after endoscopic sympathetic block p. t. panhofer , c. neumayer , s. nemec , r. jakesz , g. bischof , j. zacherl background. endoscopic thoracic sympathectomy is the treatment of choice for patients with severe primary hyperhidrosis (hh). recently, clip application (endoscopic sympathetic block, esb) has been introduced providing potential reversibility. the clips are visible on x-rays allowing postoperative evaluation. at our institution ganglion oriented procedures are performed taking rib levels into account. the aim of the study was to investigate if failures, recurrences and unwanted sideeffects (compensatory sweating, cs) can be explained by clip displacement. methods. between and , patients (mean age . ae . years) prospectively underwent esb procedures. esb was performed in patients ( . %) with facial blushing (fb), esb in patients ( . %) with facial sweating (fs) and esb in patients ( . %) with hh of the upper extremities following the lin-telaranta scheme. a mm titan clip was placed above and below the corresponding ganglion. two quality of life scores have been evaluated. mean follow up was . ae . months obtainable from patients ( . %). results. ninety-eight patients ( . %) had palmar, ( . %) axillary hh, ( . %) fs and patients ( . %) fb. cs was observed in ( . %) patients. a total of clips ( . %) were displaced in patients ( . %). two patients with fs ( . %) and with hh of the upper extremities ( . %) showed up with side differences regarding placement. in each group, one single patient was found with clips one level below the expected destination ( patients, . %). four patients ( . %) were completely and patients ( . %) partly satisfied after esb despite displaced clips. two patients have been lost to follow-up. moderate cs was observed in one patient ( . %) in each of the fb and fs groups. the patient from the latter group suffered from a mild transient ptosis additionally. two recurrences ( . %) were documented. methods. blood samples were collected from patients before major surgery. whole blood was incubated with escherichia coli lipopolysaccharide (lps) and il- production in supernatants was assessed by enzyme-linked immunosorbent assay. the prognostic impact of ability to synthesize il- before surgery was investigated in patient subgroups with respect to sepsis-related mortality using multivariate binary logistic regression analysis. results. il- synthesizing capability in patients who survived sepsis was significantly higher than that in patients who developed fatal sepsis (p ¼ . ). in multivariate analysis only il- was associated with a lethal outcome from postoperative sepsis (p ¼ . ). the prognostic impact of il- was evident in patients with underlying malignancy (p ¼ . ) and in those who had undergone neoadjuvant tumour treatment (p ¼ . ). when patients were analysed according to the type of neoadjuvant therapy, preoperative ability to synthesize il- had a significant prognostic impact in patients who had neoadjuvant radiochemotherapy (p ¼ . ), but not in those who had neoadjuvant chemotherapy. conclusions. il- production after stimulation of whole blood with lps appears to be useful for the preoperative assessment of risk of sepsis-related death after operation in patients who have undergone neoadjuvant radiochemotherapy. p lipocalin- , regulator or byproduct during ischemia and reperfusion? background. the main focus of this work was to analyze the possible implication of lipocalin- (lcn- ) upregulation for the course of ischemia=reperfusion (ir) during heart transplantation and effects on polymorphonuclear cells (pmn) as well as to investigate the nature of the lcn- producing cell. methods. male inbred c bl= and the lcn- À=À mouse were used in our transplantation experiments. pmn from wildtype and lcn- À=À mice as were isolated and promyeloid cell lines ( d) used to demonstrate the effect of lcn- on cell physiology. western blot, rt-pcr, immunohistochemistry and tunel assay were performed to determine lcn- expression and apoptosis in the graft. cell viability and migration assays after various stimuli (e.g. ir) were applied to elucidate cell growth and viability. results. infiltrating pmn were the major contributors to lcn- expression during ir peaking h after reperfusion. the number of infiltrating pmn was significantly reduced in lcn- À=À recipients. no difference was observed in the apoptotic rate between wildtype and lcn- À=À donors and lcn- expression also increased during acute graft rejection. migration of pmn during reperfusion was negatively influenced by the absence of lcn- or lack of lcn- specific cell surface receptors in the lcn- À=À mice. the promyeloid cell lines responded to ir with increased lcn- mrna and protein levels. conclusions. our data suggest a chemoattractant function of increased lcn- expression in the transplanted heart due to infiltrating pmn. lcn- is a novel inflammatory marker upregulated during ir and acute graft rejection. our observations shed light on a possible function of lcn- to the recruitment of pmn to the site of ir and identify possible targets for therapeutic intervention. p preliminary results of a tumour-lysate loaded dendritic cell vaccination therapy in patients with recurrent or metastatic skeletal malignancies p. t. background. vaccination with tumour-lysate loaded dendritic cells (dc) has shown to modulate potent immune response in several animal models and clinical trials. this study presents preliminary data of patients treated with dc-vaccination for recurrent or metastatic skeletal malignancies. methods. in patients suffering recurrent chondrosarcoma ( ), haemangio-endothelioma ( ), ewing's sarcoma ( ), osteosarcoma ( ), or osseous metastatic disease of renal cell carcinoma ( ) dc-vaccination was applied additional to standard therapy such as surgery and=or chemotherapy and=or radiation. dc precursor cells were obtained from peripheral blood mononuclear cells by apheresis and incubated with autologuous tumor cell lysate gained by surgery. in each patient vaccinations of  e cells ( ¼ . ml) were administered intranodally under sonographic guidance in weekly intervals. delayed type hypersensitivity (dth) controls and standard clinical and radiological follow-up was performed before and after treatment. results. no adverse or side effects were observed in any patient throughout treatment. dth reaction was negative in all patients after therapy. six patients died of disease, patients showed progressive state of disease in terms of local recurrence or pulmonary metastasis, revealed stable disease. helper as well as cytotoxic t-lymphocytes of patients showed in vitro reactivity in terms of cd expression against tumour antigens and against the tracer antigen klh by both cd and cd expression. one patient had no increase of cd and cd expression neither against tumour nor tracer antigen, one patient showed positive immunological reaction against klh but not tumour. conclusions. in all patients with recurrent or metastatic skeletal malignancies investigated in this study dc vaccine therapy was primarily administered at very late stage of disease. the best clinical results could be achieved in patients with metastases of renal cell carcinoma, who both revealed stable disease over more than months. all patients with metastatic disease of recurrent sarcoma showed poor clinical response to therapy, though some showed immunological reaction. the absence of adverse reactions and uncomplicated therapeutic regimen, however, together with monitored immunological responses suggest that the effects of dc-vaccination should be investigated in earlier stages of sarcoma to improve clinical outcome in these patients as well as in all stages of metastatic disease of renal cell carcinoma. p analysis of the risk factors helicobacter infection, overweight, sex, and age in gallstone disease and gallbladder carcinoma in germany background. helicobacter infection of the hepatobiliary system has been proposed as a novel risk factor in the pathogenesis of gallstone disease (gsd) and gallbladder carcinoma (gbc). because there seem to be differences in the incidences of helicobacter infection in various populations, we investigated whether helicobacter infection of the biliary tract is present in germany, a region with a high incidence of gsd, but with a low incidence of gbc. methods. gallbladder tissue from patients who had undergone cholecystectomy were investigated: patients with gsd, cases with gbc, and control patients. the presence of helicobacter spp. was investigated by culture, immunohistochemistry, and a group-specific pcr targeting the s rrna and detecting all currently known helicobacteraceae. results. of the cases investigated, only one patient with gsd was pcr-positive for helicobacteraceae. in this subject, sequence analysis of the s rrna showed closest homology to the s rrna sequence of h. ganmani. helicobacteraceae were not detected by culture or immunohistochemistry. there was a higher body mass index in patients with gsd compared to controls (p < . ). mean age of patients with gbc was significant higher than for gsd (p < . ) or control patients (p < . ), whereas there was no difference between gsd and controls. conclusions. these data suggest that helicobacteraceae play no predominant role in the pathogenesis of gsd and gbc in the german population. the low prevalence of helicobacteraceae in the gallbladder mucosa of german patients could be a possible explanation for the relatively low prevalence of gbc although gsd is frequent. background. apoptosis is implemented in colorectal cancer (crc) development and has emerged as a potential target for cancer treatment at various stages of tumor progression. measurement of the apoptosis (m )=necrosis (m ) ratio may have a role in therapy monitoring. to define the value of preoperative assessment of apoptosis and necrosis we measured these parameters in the sera of crc patients and correlated these values with conventional clinical parameters. methods. we used an enzyme linked immunosorbent assay (elisa) to detect an apoptotic product and necrosis (m and m -antigen) in the sera of patients with crc; uicc i: n: ; uicc ii: n: , uicc iii: n: ; uicc iv: n: ; relapse: n: and healthy controls. results. patients with colorectal cancer showed significant higher m antigen levels than healthy controls (p < . ). when stratified to tumor stages the different preoperative m antigen expressions between healthy controls and tumor patients remained throughout all stages. detailed results are depicted in the following table: m results and the clinical applicability of the m =m ratio are under investigation and will be presented at the meeting. conclusions. levels of circulating m -antigen are increased in patients with colorectal cancer. clinical follow up studies will reveal the usefulness of a ratio value of apoptosis and necrosis. methods. expression of fgf in tumor tissue was determined from tissue specimen obtained from patients with colorectal carcinoma by rt-pcr relative to gapdh. furthermore immunostaining in carcinoma, adenoma, normal mucosa and liver metastases was performed. the biological function of the growth factor was analysed using cell lines expressing high (sw ) or low fgf (caco , lt , vaco ) as a model. low expressors received exogenous fgf while expression in sw cells was knocked down by sirna. the effects on tumor cell growth was determined by mtt and colony formation assays. signaling events were investigated by western blotting. in addition paracrine effects on fibroblasts and endothelial (huvec) cells were investigated using scratch assay for migration and tube formation for blood vessel formation. results. addition of the growth factor to the culture medium of slowly growing colorectal tumor cell lines lt , vaco and caco stimulated growth within hours. the stimulatory effect involved increased phosphorylation of erk = - minutes after factor addition and increased phosphorylation of s - minutes after fgf addition. sw cells that produce large amounts of autocrine fgf were not affected within this time frame, but fgf supported tumor cell survival under conditions of serum starvation. in addition down-modulation of fgf production by sirna significantly reduced colony formation after plating at low density in sw cells and restored sensitivity to exogenous fgf . secreted fgf also affected colonic fibroblasts inducing growth and migration and stimulated huvec cells to differentiate. conclusions. fgf is upregulated during tumor progression in the majority of the investigated patients. we showed that fgf can induce both autocrine and paracrine effects on the epithelial as well as the stromal compartment of colorectal tumor cells to further tumor growth, spread and neovascularization. this makes fgf an oncogene. further studies should prove the clinical relevance of fgf as a prognostic marker and as a potential target in antitumor therapy. p immunohistochemical peculiarities of gastric carcinomas in patients younger than years c. w. schildberg , a. dimmler , s. merkel , t. littwin , w. hohenberger , t. horbach background. young patients ( < years) comprise - % of all gastric carcinomas. therefore, immunohistochemical peculiarities were analyzed in our facility. methods. the examined group had patients. the median age of the group was years ( - years), the ratio male= female was . = . tumor tissue, which was embedded in paraffin, was initially marked, so that it could be further examined using the tissue array technique and consequently immunohistochemically stained. following this, the following markers were analyzed: cox , egfr, e-cadherin, p , tff and cdx . after semi-quantitative representation, a link to data of the tumor register was performed. results. in the younger patients, the diffuse type (laurén-classification) was overwhelmingly represented with %. early tumor stages (i and ii) were distributed similarly with % as advanced stage carcinomas with %. the -year survival rate was %. notable was that stage iiia had a distinctly better -year survival rate with % than those patients with stage ii ( %). in our evaluation of the immunohistochemical stains, it showed that younger patients with the diffuse type showed significantly more down-regulation of cox . this is particularly noticeable when one compares tumor stages ii and iiia ( vs. %). with tff , there was a notable over-expression shown (p > . ) in stage ii and iiia ( vs. %). cdx and e-cadherin were significantly more frequently extracted for the diffuse type. conclusions. it is known that younger patients with worse histological results (diffuse vs. intestinal = %) display a better -year survival rate. in particular, there seems to be a difference between stages ii and iiia. this could be contributed to and explained by a down-regulation or an over-expression of cox or tff . p toxic responses and side effects using various antineoplastic drugs in an experimental setting of peritoneal carcinomatosis in rats a. hribaschek , k. ridwelski , f. meyer , d. kuester , w. halangk , h. lippert background. during the last decade, intraperitoneal (i.p.) chemotherapy against peritoneal tumor spread originating from gi-cancers has been increasingly used. the aim of this systematic comparative study was to investigate various toxic responses=side effects of various cytostatic substances, which had been primarily tested for their efficacy to prevent=treat experimentally induced peritoneal carcinomatosis in rats. methods. using a basic experimental trial, established= novel antineoplastic drugs such as mitomycin ( mg=m ), cisplatin ( mg=m ), -fu ( mg=m ), oxaliplatin ( mg=m ) and cpt- ( mg=m ) (limited dosage adapted according to their ld ) were applied i.p. to prevent=treat peritoneal carcinomatosis induced in rats by transfer of , , tumor cells (colon adenocarcinoma cell line cc- ; cell-lines service, heidelberg, germany) via laparotomy (groups of animals per drug; control groups [sham operation ae tumor cells]). animals were sacrificed under general anesthesia on the th postoperative day and autopsied. toxic responses=side effects were characterized by occurrence of i) necrosis assessed as ''þ'' vs. ''À'' (equal to yes=no) at the peritoneal surface, ii) hepatic necrosis, iii) bleeding at the mesenteric tissue, and iv) death. the cytostatic effects were used as control for the therapeutic efficacy of the agents indicated by tumor weight and '' ae '' detectable tumor growth, which were correlated with the nonfavorable adverse phenomenons. results. (table ) : mitomycin and cisplatin were the most toxic substances (e.g., peritoneal necrosis in and animals out of , respectively) comparing the chemotherapeutic drugs but, however, this correlated with the most pronounced cytostatic effect (no detectable tumor growth). though the use of oxaliplatin showed also a high rate of necrosis (n ¼ = ) and death (n ¼ = ), its therapeutic potential was only low (tumor detectable in each animal). it was not surprising that the occurrence of necroses at the peritoneal surface was the most sensitive characteristic of toxic responses=side effects. in addition, the induction of a treatment-related bleeding was associated with earlier death prior to the th day after tumor cell transfer, the end of the experimental observation period, in the majority of cases. interestingly, cpt- provided the best compromise in decreasing i.p. tumor growth on one hand and an acceptable rate of side effects on the other hand. conclusions. the results suggest that, despite some favorable effects of novel=established cytostatic drugs in i.p. chemotherapy, toxic responses=side effects need to be simultaneously tested even in earlier stages of drug development as well as experimental=clinical studies for an appropriate dose escalation=adaptation. further studies should also focus on other parameters=study characteristics, e.g., i) combination of drugs, ii) various application time=mode (e.g., i.p.=i.v.), and iii) effects on wound=anastomosis healing as well as iv) induction of peritonitis. p retrograde reperfusion via inferior vena cava reduces ischemia= = =reperfusion injury after orthotopic liver transplantation in a rat model methods. in a pilotstudy patients with a significant internal carotid stenosis will be investigated prae-and postoperatively for visual field changes. results. at the time of the congress we will present the study design in detail and early results. conclusions. in case of no changes perioperatively, the study will be closed. in case of perioperative changes a larger prospective trial with additional neurological assessment will follow. p occlusion of the common femoral artery after misplacement of an angio-seal tm vascular closure device t. ott, p. konstantiniuk, t. cohnert background. femoral closure systems are becoming increasingly popular. they promise to shorten both the time to hemostasis and to mobilization. the most frequently used systems are angio-seal(tm), perclose + and vasoseal + . case report. a -year-old male patient underwent successful percutaneous transluminal coronary angioplasty, stenting and hemostasis with angio-seal tm , which, however, was followed by acute deterioration of pre-existing stage iib peripheral arterial occlusive disease (paod) with incomplete ischemia of the right lower extremity and development of a dry necrosis of the right great toe. magnetic resonance angiography showed occlusion of both superficial femoral arteries (afs) and of the right common femoral artery (afc). intraoperatively, the right afc was found was found to be completely occluded by a collagen plug from the angio-seal(tm), which was removed without difficulty. the symptoms improved significantly after the operation. due to the patient's critical cardiac situation, no further reconstructive measures were undertaken. conclusions. the literature indicates that femoral closure systems have led to complications in the form of vascular stenoses or occlusions that are unknown with conventional compression. these systems may be contraindicated in patients with known paod. background. ablation of the vein by endovenous laser treatment (evlt) is a new procedure that is less invasive than surgery and has a lower complication rate. evlt works by means of thermal destruction of venous tissues. methods. we retrospectively analysed the results of the endoluminal laser-treatment, which we applied at patients in a time frame of years ( - ) . we compared them with the effect of the traditional surgical approach ligation and division of the saphenous trunk and all proximal tributaries followed by the stripping of the vena saphena magna. results. there was no significant difference in the rezidiverate between endoluminal laser technique and the traditional stripping of the vena saphena magna. the biggest problem of the laser technique appeared to be a lower sensibility in the range of the inner ankle during a year ( %). in % of the cases the vena saphena magna was rechannelled. and also % reported about a still noticeable cord for a year. ninety six percentages demonstrated remarkable improvement. conclusions. the evlt-procedure is simple and effective. it takes less than an hour and get patients back to their everyday activities right away. with a high success rate and minimal side effects evlt is a new standard in varicose vein treatment. although we know that saphenofemoral recurrence occurs even after correct saphenofemoral ligation, it does not imply that this ligation has become obsolete. background. this study presents long-and short-term results after surgery of currently active, chronic venous leg ulcers, focusing on the effects of ulcer healing, recurrence and concomitant risk factors. methods. between january and march , patients ( legs) with a currently active, chronic venous leg ulcer were surgically treated, based on the two main steps of functional phlebologic surgery: the surgical interruption of reflux in the superficial and perforating veins to reduce venous hypertension in the entire leg and=or the affected area and occasionally, the surgical procedure involving the ulcer. a total of patients ( legs) who came to the follow-up were examined. the data collection included a preoperative examination incorporating medical history and clinical diagnoses and various measurements at the follow-up. results. initial ulcer healing occurred in % of the cases ( legs), % ( legs) of the venous ulcers never healed, and recurrent venous ulcers occurred in % ( legs). conclusions. we conclude that surgery is indicated before an ulcer is intractable to treatment. based on the understanding and identification of the causes and symptoms of venous ulceration we recommend standard surgical methods for the therapy of venous leg ulcers at any stage. background. popliteal artery aneurysm (paa) is a rare condition with an incidence of approximately % in men ( - years). it involves the risk of peripheral embolism or progressive thrombosis that may result in acute or chronic ischemia with claudication or loss of the extremity. distal vessels are increas-ingly embolized through a persistent dispersion of mural thrombi, and the possibilities for surgical vascular reconstruction are limited by the absence of open outflow vessels. case report. a -year-old male patient with an acute ischemic left leg was referred for emergency treatment. he presented with a -year history of intermittent claudication in his right leg. no signals were detected by duplex screening above the foot arteries of the left leg, and typical symptoms of acute occlusion were present. imaging tests revealed a paa on each side (diameter left cm; right . cm). the left paa was completely occluded, the right paa was partially open but the distal popliteal artery and the the posterior tibial artery were already completely occluded. a vascular bypass reconstruction to improve circulation was not possible due to occlusion of the outflow vessels. the patient was treated conservatively (systemic heparinization, i.v. prostacyclin administration). circulation in the left leg gradually improved, with remaining claudication, a free walking distance of m, and rest pain. amputation was prevented for the time being. conclusions. elective surgery for asymptomatic paa > cm is recommended to prevent permanent limited mobility or amputation. the procedure of choice is to ligate the aneurysm and to restore blood flow by a concurrent interposition of a vein segment, from the superficial femoral artery to the open infragenual popliteal artery. the male risk population ( þ) should undergo duplex screening of the popliteal artery. while asymptomatic aneurysms > cm should be treated surgically, smaller ones should be observed, since aneurysms < cm in diameter have a distinctly lower occlusion and amputation rate. in symptomatic cases a revascularisation with venous bypass should be attempted, if there are open outflow vessels to connect the venous graft to. if a vascular bypass reconstruction is not promising a conservativ treatment may prevent amputation. background. three dimensional motion analysis is a new evaluation method of upper extremity function. this video based system provides accurate and reproducible d kinematic data by tracking movements. the method is derived from clinical gait analysis which has already reached global acceptance within this field. it should overcome the deficiencies of subjective investigations. in order to demonstrate the use of the system the analysis of patients with brachial plexus lesions before and after surgical treatment is presented. methods. a d optoelectronic camera system with passive markers was used to capture the possible active rom. twenty seven markers coated with retroreflective tape were applied over anatomical landmarks on both upper limbs and recorded simultaneous by cameras. a -dimensional reconstruction of the position of the markers was done by special designed software. joint centres and joint movements were calculated by using the expert vision and orthotrak software (motion analysis corporation). healthy probands and patients suffering from brachial plexus lesions and receiving primary nerve surgery or secondary reconstructive procedures were investigated. results. the motion curves of all, probands and patients with different questions argue for a reproducible motion sequence. we were able to produce and analyse static data, rom and position of segments as well as kinematic data, especially motion curves of distinct movements. moreover compensatory movements could be investigated. obtained pre-and postoperative kinematic data document the enhancement of the involved limbs' function. conclusions. the method enabled objective analysis of patients suffering from brachial plexus lesions. measured angles are reliable and reproducible but generally lower than angles obtained from physical measurements. this is due to several reasons concerning the biomechanical model. because of the more complex nature of upper limb kinematics the transfer of the system from lower to upper extremity still involves unsolved problems. p thoracic outlet syndrome: objective criteria to indicate surgery g. weigel, b. gradl, m. mickel, w. girsch background. reviewing the literature the indication for thoracic outlet syndrome (tos) -surgery is based on clinical findings only in the majority of the cases due to lack of objective findings. in a retrospective study we have analyzed our cases in order to evaluate objective criteria for surgical intervention. methods. seventeen patients ( men, women aging from to ) were diagnosed clinically times for tos (duration of symptoms months, nrs ). additionally objective investigations were performed: x-ray of the cervical spine to detect a cervical rib; a comprehensive electroneurographic investigation to detect signs of nerve compression; mr-angiography of the subclavian artery with elevated and adducted upper extremity to detect a stenosis of the artery as an indirect sign of compression of the brachial plexus. results. concerning the objective assessment a cervical rib was present in % of our cases. the electroneurographic investigation revealed signs of nerve compression in % of our cases. in nearly % of our cases a stenosis of the subclavian artery confirmed the clinical diagnosis. all patients underwent tos-surgery via a small single supraclavicular incision and recovered from their symptoms. conclusions. in our series we did base the indication for tos surgery not only on clinical examination but also on objective findings, either the presence of a cervical rib and=or positive electroneurographic findings and=or a stenosis of the subclavian artery. the mr-angiography was the most significant investigation to objectify the clinical findings. the presented investigation setup seems to be appropriate to objectively diag-nose tos and indicate surgery. the small supraclavicular incision gave adequate access to perform neurolysis of the brachial plexus, scalenotomy and resection of cervical or first rib without major complications in all cases. background. the necessity of antibiotic prophylaxis in the clinic of child surgery is caused by following: -increase invasive method of investigation; -increase cases of postoperative supurative complication; -high economic expenses; -spreading of polyresistent microorganism. methods. the clinic retrospective investigation of the patients, who were treated in the surgical department of lviv regional children's hospital ''ohmatdyt'' from till yr. the antibiotic prophylaxis was performed in surgical operation of ii category (conventional purity) and iii category (contaminational) of purity, which are accompanied by middle or high individual risk of the development of pyo-septic complications. eighty two of the patients took combined medications of clavulane acid with amoxicillin (augmentin, amoxuclav in dose mg per kg, the others patient took cephalosporinus of i-ii generastion (cephazolinum, cephuroximus in dose mg per kg) conclusions. effective abp allows to reduce the amount of the postoperative complications ( group- %, group- %), postoperative fever ( group- . %, group- . %), duration of the hospital treatment in the group- . days, in the group- . days), and treatment expenses. optimal drugs of choice for abp in the clinic of pediatric surgery are combined preparations of clavulane acid with amoxicillin. the goal of this study was to improve the results of management children with bat. one hundred twenty-eight children with the age ranged from weeks to years were enrolled in this study. among these patients the splenic injury was established in ( . %), liver injury -in ( . %), intraperitoneal hematoma -in ( . %), and retroperitoneal hematoma -in ( . %) of patients. according to the moor's classification grade i of the liver damage was established in patients, grade ii -in , grade iii -in , and grade iv -in one patient. according to the classification of american association of trauma surgery the grade i of splenic injury was diagnosed in patients, grade iiin , grade iii -in , grade iv -in , and grade v -in patients. laparoscopic drainage of abdominal cavity was performed in patients with active bleeding, which stopped by the surgicel + (ethicon) and electrocoagulation, from the hematoma of mesocolon and mesojejunum and in patients with grade i liver and splenic injury. the laparoscopic coagulation with applying of surgicel was performed in all patients with grade ii liver and splenic damage and in patients with grade iii. laparotomy was performed in patients with grade iii and in all patients with grade iv-v. resection of the spleen was applied in patients with grade iii and in two patients with grade iv. for the bleeding control, the surgicel nu-knit + (ethicon) was used in one patient with the grade iv of splenic damage. splenectomy was performed in patients with the grade v. parenchymal suture was used in patients with the grade iii of the liver damage and non-anatomical resection -in one patient with grade iv. retroperitoneal endoscopy with coagulation was performed in all patients with retroperitoneal hematoma. one child died with the grade iv of the liver damage. thus, the endoscopic coagulation with applying of surgicel + is effective in the management of patients with bat. the choice of management dependent of the grade of damage. we used malone antegrade continence enemas (mace), administered through a continent cutaneous appendicostomy or a caecal flap to achieve reliable evacuation and faecal continence in seven children with myelomeningocele and after surgery of anorectal malformation. postoperative complications included one subcutaneous pericaeceal abscess requiring exploration and in one case stenosis of the stoma. except well known and already described complications all seven patients are continent of stool at a mean of months follow-up. despite our efforts to develop an effective bowel management program regarding application of the enema regimen this procedure provided some technical problems especially for children who have had prior appendectomy. so we developed a new simple technique to perform a caecal tube stoma. we also want to demonstrate a new device to simplify handling and application of enemas. the basic idea of a simple method of bowel cleansing like mace is followed by significant improvement in quality of life and more social acceptance of patients. but overall success will be achieved by improvement of technical procedure and handling. extended caecum. the appendix could not be detected. a surgical intervention was decided with the intention for an appendectomy. at the operative sight a caecum duplex was revealed. the lumen of the blind caecum was completely filled by a large fecolith. also the appendix vemiformis was inflammated. caecal duplex resection and an appendectomy was performed. the pathology report described ulcerations and segmental ischemia of the resected caecum. an oxyuriasis of the vermiform appendix was also reported. there was no immediate or delayed post-operative complication. conclusions. approximately % of duplications have been reported to be located within the abdominal cavity. small bowel lesions are the most commonly described ( %), while colonic lesions are found in % of cases. a review of the literature has revealed cases of colonic duplications, that occurs mostly in pediatric patients. surgical intervention is indicated in case of complicated colonic duplications such as obstruction of the colon as a result of direct compression, volvulus, hemorrhage, ulcerations, ischemia or perforation. in most instances duplications can be completely excised as described in our case. special care should be taken of the possible abnormal blood supply to the adjacent intestinal segment. background. reports on complications are part of every medical scientific investigation. regarding the definition of a surgical or post-interventional complication there are different views. this is one reason for the variation width in complication reporting concerning the same interventions in the surgical literature. the following work presents the advantages of a prospectively standardised documentation of complications in a surgical department as a part of a hospital quality management. methods. over a period of one year in patients data sheets about post surgical complications were collected and entered in a electronically data base. all abdominal procedures, including the abdominal wall and additionally varices surgeries were enclosed in the following evaluation. patients were excluded from the investigation when treated in the surgical ambulatory or treated as day-surgical patients. the complication system according to clavien was used to classify the complication grades. this system encloses five grades, lower grading indicating lower level of complication whereas grade three is divided in subclasses a and b (dindo et al. ( ) ann surg : - ) . for statistical analysis the mann-whitney u-test and spearman correlation were used (p < . ). results. out of operations there were ( . %) operations according to our inclusion criteria with patient's average age of . ae . years ( . % male patients). the overall complication rate according to clavien averaged . % (differences between different surgical methods and surgeons are given in a table). referring to general used grading the mean complication rate ranged between . and . %. conclusions. using the system of clavien complication rates appear higher than usual. this is caused by the fact that all post surgical events apart from normal stay slip into the system. the system allows a good comparability between single surgeons and between different operations. results from prospectively entered data evaluation can be used to detect weak points in a team, and to find out technical as well as personal problems. as a consequence, for instance education programs could be provided to compensate weaknesses or the team could be restructured. periodical evaluation of a standardized data bank allows fast reactions to occurring problems and guaranties an adequate surgical complication management. lymphatic vessel invasion (lvi) has been rtx=ctx þ esophagectomy). ( -ac): n ¼ : n ¼ (esophagectomy) vs. n ¼ (ctx þ esophagectomy). results. ( -escc): rtx=ctx led to a lvi-reduction detectable lvirate: ( -escc): rtx=ctx led to significant lower lvi-rates compared to primary resected patients tyrolean cancer research institute, innsbruck, austria; department of pathology germany p the role of fgf in colorectal carcinogenesis institut für krebsforschung p , p , p sachsenplatz - , wien, Ö sterreich. -datenkonvertierung und umbruch: manz crossmedia druckerei ferdinand berger & söhne gesellschaft m. b. h., horn, Ö sterreich. -verlagsort: wien. -herstellungsort: horn. printed in austria p. b. b.= = =erscheinungsort: wien= = =verlagspostamt wien background. survival of patients with lung cancer is strongly affected by lymph node metastases. identification of n disease is thus crucial. we compared the diagnostic accuracy of image fusion of positron-emission tomography (pet) and computed tomography (ct) with that of ct only and that of pet only for mediastinal lymph node staging in patients with non-small-cell lung cancer (nsclc).methods. in patients with proven nsclc a preoperative fdg-pet and ct examination of the body trunk were performed. pet, ct and pet-ct image fusion were evaluated separately; nodal stations were identified according to the mapping system of the american thoracic society. a lymph node was considered to be infiltrated by tumor if the minimal diameter was cm or more in ct, or the standard uptake value (suv) was larger than . in pet. all patients underwent mediastinoscopy, biopsies from lymph node regions were taken (ats . %, ats . %, and ats . %). if primary pulmonary resection was achieved, ipsilateral lymph nodes were dissected and the histological findings were considered for statistical analysis. histological findings were compared with results of ct, pet and pet-ct image fusion. sensitivity and specificity were obtained using the confusion matrix.results. histopathological assessment revealed positive mediastinal lymph nodes out of , sensitivity was . % for ct, . % for pet and . % for image fusion, specificity was . % for ct, . % for pet and . % for pet-ct fusion.conclusions. pet-ct image fusion improves sensitivity, specificity and accuracy in mediastinal staging of nsclc patients. the high negative predictive value of pet-ct image fusion ( . ) may abandon mediastinoscopy in nsclc patients with negative mediastinal pet-ct image fusion. however, larger series are mandatory in order to gain statistical significant power. local resection of stage i primary lung cancer by -nm nd-yag laser in functionally inoperable candidates: a prospective study s. b. watzka , w. grossmann , p. n. wurnig , f. lax , m. r. mü ller , p. h. hollaus background. hydatid disease is a parasitic infestation by a tapeworm of the genus echinococcus. it is not endemic background. in a pathway regarding the management of liver trauma was established in our hospital. the aim of the study was to assess the outcome after implementation of the guidelines.methods. data on all patients with liver injuries managed in our institution in the past years was evaluated. liver trauma was classified using moore's trauma score. additionally, coexisting injuries were assessed.results. from to a total of patients with liver trauma (motor vehicle accidents , falls , horse riding accidents ) were admitted to our trauma unit (median age of . years). grade iii traumas ( . %) were the most common injuries, followed by grade iv ( . %), grade i ( . %), grade ii ( . %), grade v ( . %) and grade vi ( . %). the laparotomy rate varied from . % in grade i injuries to % in grade v injuries, resulting in an overall laparotomy rate of . %. two patients required second look laparotomy for removal of liver packing and one patient required puncture of a posttraumatic bilioma. the most common associated concomitant injuries were right or bilateral rib fractures ( ), pelvic fractures ( ), long bone fractures ( ), laceration of the spleen, spine injuries ( ), and head injuries ( ). the mortality rate of patients with liver trauma ranged from % in grade iv injuries to % in grade i injuries with an overall mortality rate of % ( ). all patients with grade v or grade vi traumas survived ( ). if laparotomy was required because of hemodynamic instability or concomitant abdominal injury the mortality rate increased to %.conclusions. the clinical pathway of management of hepatic trauma in our patients showed favourable results. apart from the grade of liver injury the overall laparatomy rates and mortality rates largely depend on concomitant injuries. colitis cystica profunda is a rare benign disorder of the large intestine characterized by submucosal cyst formation. the clinical appearance of the disease can be highly variable; it can be associated with rectal prolapse and chronic inflammatory bowel disorders such as crohn's disease and ulcerative colitis.we describe a case of colitis cystica profunda associated with rectal prolapse. the female patient had a one-year history of constipation and rectal pain. an altemeier procedure was performed to correct the rectal prolapse. histology confirmed the presence of colitis cystica profunda. the operative and postoperative course was uneventful.it should be borne in mind that colitis cystica profunda can be associated with rectal prolapse. conservative management is usually satisfactory, but a mucosal resection (delorme's procedure) or perineal protectomy (altemeier procedure) is recommended when there is rectal prolapse.p peritonitis ossificans -a rare situation after acute major abdominal surgery m. ruzicka , s. thalhammer , s. stättner , m. mostegel , b. sobhian , j. karner background. treatment of the congenital intestinal obstruction of newborns is one of the main problems of the pediatric surgery.methods. patient p. had been hospitalized to the intensive care unit days after birth with symptoms of absence of stool from birth, frequent vomiting, full-blown abdominal distension. the signs of endotoxicosis, the intestinal loops posterized image through the anterior peritoneal wall, dilatation of the venae anterior peritoneal wall, abdomen lower sections and scrotum edema were noted at the time of admission. x-ray of the abdominal cavity reveals the signs of the low intestinal obstruction, bowel perforation -presence of liquid and free air at the abdominal cavity. diagnosed -the intestinal obstruction, peritonitis and after a short-term of the preoperative preparation patient underwent surgery. atresia of the sigmoid colon, necrotic enterocolitis with the affection of the = of the large bowel, perforation of rising section of the large intestine, the meconium peritonitis were established during surgery. the right side hemicolectome, terminal ileostomy and transverse colostomy. the reoperation at the month was done: ileotransversostomy, descendosigmostomy with the preserving of transverse colostomy were performed. the diameter of the descending large bowel exceeded the diameter of the sigmoid colon by - . times, that's why the anastomosis had been raised by the type ''side to side''.results. within the course of weeks after the radical surgery the child started to have stool passage through the rectum. presently the child's condition is satisfactory, the physical development corresponds to the age norms, stool passage takes place only through the rectum. the final stage of the treatment will be the closure of the transverse colostomy with the complete restoring of the passage of the chyme through the bowels.conclusions. the bringing of the intestinal stomas out with the delayed radical surgery in some case of newborns may significantly improve the prognosis of the results of treatment. background. different inguinal hernia operationtechniques must be compared to their recurrency rate, acute and long term complication rate, patients comfort and duration before returning to daily life, return to work and to sports etc. under economical aspects they should be safe, quick, and require limited resources (personal, equipment, implantate). with increasing economical pressure the latter features gain increasing importance. we therefore made a comparative time analysis between tipp and lichtenstein.methods. between . . and . . hernias were operated in tipp technique and hernias in lichtenstein (lich) technique. patients were from an identical district and comparable in epidemiological data, comorbidity, hernia distribution and in-resp outdoor treatment. each series was performed by surgeon in the same operation unit. implantates used were polysoft hernia patch tm (tipp) and ultrapro mesh tm (lich). total operation time was recorded (min). additionally, operation phases were defined:opening phase: from skin split to preparation phase: from opening of the external aponeurosis to introduction of the mesh repair phase: from introduction of the mesh to the end of the suture of the external aponeurosis closing phase: end of repair phase to skin closure.assuming individual differences between the surgeons and management-associated differences as well as intermethodical differences relative phase intervals were deduced from the original recordings and compared. statistical comparison was done by t-test and pearson correlation coefficient.results. average operation time of lich was ae . min (range - min, median min), average operation time of tipp . ae . min (range - min, median min). up to now there was = recurrent hernia in tipp and = in lich (n.s.). the correlation of preparation phase time and operation time was high (pearson coefficient: tipp . ; lich . ) and lower for repair phase (tipp . ; lich . ). there was no difference in the correlation of the preparation phases in tipp and lich (p < . ). on this basis we estimated the expected time of the compared method to each series, i.e. presumable time for lich in tipp series and vice versa. comparison of lich vs. tipp (expected) and lich (expected) vs. tipp revealed that tipp was faster and required . % time of lich (p < . ).conclusions. tipp and lich show a comparable time effort towards preparation, tipp is significant faster in repair phase enabling a quicker total operation time.p transinguinal preperitoneal hernioplasty (tipp) using a memory ring armed polypropylene patch: which factors influence the operation?quality of life improved significantly in all patients with clip displacement.conclusions. esb has a displacement rate of less than % and gives excellent results for quality of life, which are not diminished by inappropriate clip application. grundlagen. post anal repair ist eine methode zur verbesserung der kontinenzfunktion bei diffuser schädigung des schließmuskels. die methode wurde in den letzten jahren kontrovers diskutiert. langzeitergebnisse wurden nur sporadisch publiziert. methodik. die operation wurde in der technik von parks [i] in steinschnittlage und allgemein-, oder spinalanästhesie durchgeführt. eine präoperative darmreinigung und eine perioperative antibiotikaprophylaxe wurden routinemäßig durchgeführt. prä-, und postoperativ wurde eine sphinktermanometrie in der durchzugstechnik mit einem perfundierten dreilumigen katheter vorgenommen. die auswertung erfolgte mit einem programm der firma gastrosoft. bei der klinischen untersuchung wurde der kontinenz-score nach williams verwendet.ergebnisse background. peptic ulcer in the excluded segment of a gastric bypass has been reported in the literature in only cases. we report a -year-old woman with a perforated duodenal ulcer, who underwent laparoscopic roux-en-y gastric bypass surgery for morbid obesity months ago.methods. on physical examination, the patient's abdomen was marginally tender to palpation. laboratory findings were unremarkable except for an elevated leucocyte count of . =ml (normal . - . =ml). abdominal radiography and sonography showed no pathology. because of the persistent abdominal pain we performed an abdominal computed tomography scan, which demonstrated free air.results. she was successfully treated by a laparoscopic repair of the perforated duodenal ulcer. after surgery, a standardized analgesic regimen was administered for pain relief. intravenous piperacillin-tazobactam was continued for at least days, then a helicobacter eradication therapy was performed. feeding was resumed on the first postoperative day and the patient was discharched on day six without any complications.conclusions. peptic ulcer in the excluded segment of a gastric bypass has been reported in the literature in cases. the pathogenesis of ulcer perforations in the excluded sto-mach=duodenum is unclear. of the total cases, free air in the abdominal radiography was only noted in one case. recognizing that free air under the diaphragm will be absent is one of the most important diagnostic considerations when gastric or duodenal ulcer perforation is suspected in the postgastric bypass patient. abdominal ct scan and early surgical exploration remain the treatment of choice.chirurgische forschung p blood interleukin as preoperative predictor of fatal postoperative sepsis after neoadjuvant radiochemotherapy background. a serious impediment in transplantation medicine especially after liver-transplantation is the damage by ischemia and reperfusion. we compared different types of reperfusion within a rat model and investigated the different consecutive ischemia=reperfusion injuries.methods. arterialized orthotopic liver transplantation (olt) was performed in syngenic male lewis rats. the animals were divided into experimental groups: i-and ii-control groups with antegrade reperfusion and group iii with retrograde reperfusion. laboratory parameters as well as histopathological changes of the liver-graft-tissue were evaluated , and hours after olt.results. the got-values showed hours after olt significant differences between group i=ii (antegrade reperfusion) and group iii (retrograde reperfusion) ( . ae . u=l vs. . ae . u=l; p < . ). gpt-as well as got-values were significantly lower in group iii (retrograde reperfusion) hours after olt. evaluation by histopathology revealed significant less areas of necrotic liver tissue within group iii compared to group i=ii (p < . ).conclusions. these results show that the retrograde reperfusion (by order of: infrahepatic inferior vena cava -opening suprahepatic inferior vena cava -hepatic veins -retrograde reperfusion of the liver) has a protective effect on the graft in regard to the ischemia=reperfusion injury. background. clamping of internal carotid artery during carotid endarterectomy (cea) leads to cerebral ischemia in - % of patients. routine carotid shunting has a high morbidity as described in literature. selective carotid shunting under general anaesthesia requires an intraoperative monitoring. the registration of somatosensory evoked potentials (sep) is a well accepted technique.methods. from to we assessed prospectively consecutive cea under general anaesthesia and sep monitoring, without primary shunting. routinely preoperative neurological assessment, duplex sonography and mr-angiography were performed. the onset of a clinical neurological deficit after carotid artery clamping was related to changes in the n =p waveforms in sep-recording. sep was evoked by stimulating median nerve. criteria for shunting was reduction in sep-amplitude > %. routinely postoperative neurological examination and duplex sonography were performed.results. patients underwent cea between and . intraoperativ sep-monitoring was available in patients. in patients ( . %) sep-monitoring was inadequate (primary shunting). in procedures ( . %) sep-monitoring didn't show deviations. significant sep-alterations appeared in of cases ( . %). in cases sep-alterations normalised after shunting without neurological deficits. in cases sep-alterations were reversible after shunting, but were associated with postoperative neurological deficits ( permanent, transient). cases ( . %) had normal sep-findings (false negative), but postoperative neurological deficit occurred ( permanent, transient).conclusions. the selective use of carotid shunting during cea requires an intraoperative monitoring technique. based on our data and literature findings, sep-monitoring is a reliable method to prevent neurological vascular deficits and effectively minimizes shunting frequency.p perioperative changes in internal carotid endarterectomy p. konstantiniuk , t. ott , u. gratzer , i. steinbrugger , a. wedrich , t. cohnert p poland syndrome with partial heart ectopia and dextrocardia r. kovalsky , a. kuzyk , o. leniv , i. avramenko lviv regional children hospital, lviv, ukraine; lviv national medical university, lviv, ukraine; lviv regional children hospital ohmatdyt, lviv, ukrainebackground. poland syndrome is seen in = of the newborns. it can declare itself by its different components and joining of the additional defects in every concrete patient.methods. a girl, born by the cesarean section, with the weight of g and week gestational age was brought to the pediatric surgery clinic on the . . in a couple of hours after birth. when examined the skewness and chest distortion attracted attention, especially on the right side. the oval form defect of the chest wall  cm was seen in the anterior of the chest parasternal on the right in the ii rib level from the costal margin, an also thinning of body of sternum. a part of liver with the size of  . cm covered with peritoneum was projecting form the lower part of the latter. a gastric part of the heart, covered with pericardium and non-epithelized membrane with the upper part directed to the right was projecting over it from the defect. there were no signs of heart and respiratory failure. during the echocardiography the following was discovered: heart rotation in the chest, right ventricular and atrial hypertrophy, good running of the great vessels, not violated valve function and good myocardial contractility. ejection fraction from the left ventricle %. during the intraoperative inspection the diaphragm defect in the right place parasternal triangle with the size of  cm through which the part of liver prolapses. the hepatic lobectomy was done as well as diaphragma defect repair.results. in eight months the plastic operation was done on the defect through the replacement of the front edge of the costal arch and musculocutaneous flap, formed from the greater pectoral muscle. the child was discharged from the hospital in a good shape.plastische, Ä sthetische und rekonstruktive chirurgie background. traditional abdominoplasty aims at elimination of redundant fat tissue and skin as well as tightening of muscular aponeurosis on the abdomen. in the massive weight loss (mwl) patient this procedure often yields only mediocre results. specific areas such as hips, buttocks and the lateral thigh are addressed inadequately.methods. patients after mwl are treated with a central or lower body lifting according to the specific needs at our institu-tion. the central body lift includes a circumvertical dermolipectomy concentrated on the central torso without significant mobilisation of caudal tissues. in the lower body lift, the circumvertical dermolipectomy is located more inferior on the torso with an additional extensive mobilisation of the subcutaneous tissue down to the level of the knee.results. these new innovative techniques led to a much improved contour and results compared to the traditional abdominoplasty procedure. although there is an increase in operative time, postoperative recovery and complications appear comparable according to our initial limited experience. we present in detail representative cases with step-by-step explanation of operative techniques.conclusions. especially after mwl, such as after bariatric surgery, the surgeon has to deal with a tremendous amount of redundant tissue on the lower part of the torso and thighs. traditionally this problem was solved in a staged manner with multiple surgeries, such as abdominoplasty, buttock lift or medial thigh lift. however, in many cases this approach led to unsatisfying results. new innovative techniques allow for an optimal repositioning of the descended tissues und most often to a much improved postoperative result compared to the traditional techniques. a. m. rokitansky, r. j. hahn background. we report our experience using the modified minimal invasive method of pectus excavatum repair in adults. thirty one adults with a mean age of ( - . ) suffering from pectus excavatum have been corrected using by the extended modified minimally invasive repair method. the ravitch= welsh=rehbein technique, performed elsewhere, has corrected patients insufficiently. reduced physical capacity, mild cardiac valve dysfunctions (prolapse, pulmonary valve insufficiency), chest pain in the area of the funnel and reduced ventilatory function were detected. two thirds of the patients emphasized the wish of a better cosmetic result. preoperative investigations include blood samples, ecg, heart sonography, chest x-ray, chest mri=ct with -d reconstruction and spirometry.methods. retrosternal mobilization and intraoperative stretching of the anterior thorax by long lasting sternal elevation modified the original nuss technique. additionally an oblique wedge shaped partial sternal osteotomy and=or osteotomies of the ossificated ribs were performed. in adults usually pectus pars (ps -implant + fa. hofer austria) should be used.results. due to preparation we observed intraoperative bleeding episode from the internal mammaric vessels, superficial lesion of the right visceral pleura (adhesions). postoperatively we saw pleural effusions, subcutaneous hematoma and two prolonged wound-healing episodes (superficial infections with no necessity of bar removal). vertebral index changed from . preoperatively to a normal range of . postoperatively. postoperative cosmetic results were perfect in %. in summary adults with pectus excavatum are manageable with extremely satisfactory results using the described extended modified correction technique. osteotomies do not destabilize the chest and can be sufficiently combined with the nuss technique. background. minimal invasive av-valve surgery is an increasingly popular procedure in cardiac surgery, but -due to the complexity -still reserved to few selected centers. aim of this study was to present learning curve issues for program introduction. methods. a total of minimal invasive av-valve procedures were performed by a single surgeon and were successful in ( . %). seventy one patients ( . %) underwent av-valve repair, ( . %) received mitral valve replacement. in patients ( . %), concomitant asd closure and=or tricuspid valve repair had to be performed. one intraoperative conversion to valve replacement had to be performed due to residual mitral regurgitation. for calculation of learning curves, regression models with logarithmic curve fit for operating time (ot), aortic cross-clamp (axt) and cardio-pulmonary bypass time (cpbt) for all patients and for patients with posterior mitral leaflet prolapse were applied.results. within approximately consecutive minimal invasive procedures, a steady decline of either ot, axt and cpbt could be observed for the overall surgical population even despite the increasing number of concomitant procedures and was similar in patients with posterior mitral leaflet prolapse. after overcoming this steep learning curve, a mean axt of ae min, a cbp time of ae min and a total ot of ae min is required to treat isolated posterior leaflet prolapse.conclusions. minimal invasive av-valve surgery can be safely introduced into a heart surgery program. however, sufficient number of cases per year are required per surgeon to come over this learning curve. case report. a -year-old male patient without clinical symptoms presented an enlarged heart shadow in a routine radiological examination. the following ct revealed a structure in the pericardial sac that was initially classified as a pericardial cyst. in order to confirm the diagnosis, an ecg-triggered multi-slice ct was performed resulting in the diagnosis of a gigantic coronary fistula originating from the left main coronary artery leading to the right atrium. the shunt volume of the coronary fistula was estimated to be %. echocardiography demonstrated dilatation of the right chambers due to volume overload. since operative mortality was deemed extremely low in this patient surgical correction was advised. after median thoracotomy, initiation of heart lung machine and extensive cardioplegia, the coronary fistula was identified to originate from the left main coronary artery meandering around the posterior side of the left heart with a mean diameter of cm and entering the right atrium at the level of the vena cava superior. the fistula was ligated in the right atrium and at its origin at the branching site of the circumflex artery. to secure optimal surgical outcome bypass grafting was performed to lad (left anterior descending) and its diagonal branch as well as the circumflex artery. postoperatively performed ecg-triggered multislice-ct evidenced successful repair of this anatomical malformation. the postoperative course was uneventful. background. to document severity of illness and to evaluate the predictive value of clinical scoring systems in infants and children after cardiac surgery. prospective study with follow up to hospital discharge. a bed multidisciplinary paediatric icu in a university hospital. between = and = infants and children were admitted after open heart surgery.methods. data relevant to the acute physiologic score for children (apsc), pediatric risk of mortality (prism iii), therapeutic intervention scoring system (tiss ) and organ system failure (osf) score were collected in all patients during the first days of postoperative intensive care. eighty one percentages of the patient underwent a total repair, % had a palliative correction.results. the mean age of the patients was . ae . years. there were survivors (s) and non survivors (ns). the mean duration of mechanical ventilation was . ae . days for survivors and . ae . days for non survivors. on the first postoperative day the mean apsc and prism iii scores of survivors and non survivors were . ae . vs. . ae . (p < . ) and . ae . vs. . ae . (p< . ), respectively. the mean tiss and osf scores of survivors and non survivors were . ae . vs. . ae . (p< . ), and . ae . vs. . ae . (p< . ), respectively. the overall hospital mortality rate was . %. patients with an apsc score < and a prism score < had a survival rate of %, whereas patients with an apsc score > and a prism score > had a mortality rate of %. the area under the receiver operating characteristic (roc) curve for apsc, prism, osf and tiss was . , . , . and . , respectively.conclusions. apsc, prism and tiss describe accurately the severity of illness in infants and children after cardiac surgery, and all physiologic scores identify those patients at increased risk for mortality.p non-bacterial pyopericardium leading to lethal sepsis in a patient with severe humoral immunodeficiency k. mészáros , i. knez , b. rigler , g. p. tilz klinische abteilung für herzchirurgie, graz, austria; abteilung für klinische immunologie, graz, austriabackground. pyopericardium is the accumulation of pus in the pericardium mainly caused by bacterial infection. purulent pericarditis most commonly occurs as a direct extension of an infection from an adjacent pneumonia or empyema. alternatively, a distant infection can haematogenously seed the pericardium. primary pericardial infection is rather rare. pyopericardium is an illness requiring acute intervention by the heart surgeon (pericardial drainage) and adequate medication.methods. a -year-old man was admitted with diffuse chest pain, dyspnoea, tachycardia and nausea. laboratory examination revealed massive leukocytosis and elevation of creactive protein. echocardiogram showed circumferential pericardial effusion without valvular vegetations. after a subsequent clinical impairment to a highly septic state, he underwent surgical pericardial drainage. the pericardium was full of pus of creamy aspect. after continuous pericardial lavage and operative revision in several steps, final sternal closure took place ten days later. no infectious agent could be identified to be responsible for the purulent pericarditis.at the term of next surgery, . litres of serous ascites and . litres of serous pericardial effusion were drained. the patient developed a gangrenous cholecystitis, op-site findings revealed a non-purulent ascites, intra-operative cholangiography was without pathological findings.results. detailed immunological analysis showed a severe decompensated immunodeficiency with adentritocytaemia. the therapy with polyvalent immunoglobulin and imutin was ineffective, the patient died one day later from a therapy-refractory septic shock.conclusions. in cases with unclear non infectious purulent pericarditis, it is of high importance to carry out the correct diagnosis as soon as possible to provide an adequate therapy. background. early results of mi treatment of proximal humeral fractures using the ncb + -ph plate showed promising results reaching points ( % of age related normal value) in the constant score months postoperatively and an acceptable complication rate ( . %). the purpose of this study was to analyze the long-term results focusing on functional outcome and complications.methods. so far out of a total number of cases we have gained the data of patients ( women, men; age in the mean) who sustained fractures of the proximal humerus treated mi with the ncb-ph + plate (zimmer company, winterthur, switzerland). in cases ( %) osteoporosis had been diagnosed preoperatively. radiological follow-up in two planes and functional outcome is assessed clinically (rom) and using visual analogue scale (vas) for pain and function, constant score and a modified adl score (activities of daily living).results. average rom (in degree) for anteversion was , glenohumeral abduction , external rotation and internal rotation . average vas for pain was , points ( ¼ worst) and for function , points ( ¼ best). average constant score was points, average adl score was points ( ¼ best). between and months postoperatively one case ( , %) of sintering of the humeral head and one case ( , %) of avascular necrosis was detected. in cases ( %) of reversed impingement we performed total removal of hardware. four younger patients ( %; age in the average) underwent the same procedure demanding it though not suffering of limited rom or pain.conclusions. in the early results ncb-ph + proved to be an effective mi method of treatment of fractures of the humeral head. the year follow up data show further functional improvement (approx. % of constant score). the complication rate remains low ( = ¼ %). especially, no cases of lesions of the axillary nerve or frozen shoulder were seen. the latter we believe is due to the mi procedure and the early functional treatment which is possible since the ncb-ph + plate creates high primary stability. the long-term results prove the ncb-ph + plate to be a safe and effective method of treatment reaching a functional outcome that enables the mostly old patients to regain an acceptable level of activity. removal of hardware is easy to perform and offers especially in the younger patient a possibility to at least improve patients' subjective outcome. background. the gastrointestinal duplication in adults is a rare congenital abnormality and only few cases are described in the literature. although intestinal duplications are considered to be benign lesions, mostly asymptomatic, they may result in significant morbidity and mortality, if left untreated. this study reports of one case of caecal duplication with an overview of the literature.methods. a -year-old female patient was hospitalised with pain in the right lower abdomen. a relocatable and solid tumor ( cm dm) was palpable. blood examination revealed a slight increase of leu and crp. the gynaecologic examination was entirely unremarkable. the sonography showed only an key: cord- -z hthkgy authors: newsom, megan; bashyam, arjun m.; balogh, esther a.; feldman, steven r.; strowd, lindsay c. title: new and emerging systemic treatments for atopic dermatitis date: - - journal: drugs doi: . /s - - - sha: doc_id: cord_uid: z hthkgy atopic dermatitis (ad) is a prevalent inflammatory skin condition that, depending on its severity, can cause enormous morbidity. corticosteroids and systemic immunosuppression, traditionally standard of care for difficult-to-treat disease, have many undesirable side effects. the desire for targeted treatments along with an improved understanding of the pathophysiology of ad has spurred the development of novel treatments. in this article, we review promising new treatments and discuss how their targets—il- , il- , ox (cd ), and the janus kinase family of proteins—participate in the pathogenesis of ad. we review the published phase ii and iii data for dupilumab, tralokinumab, lebrikizumab, nemolizumab, anti-ox antibody, baricitinib, abrocitinib, and upadacitinib. the introduction of new agents may offer new options, but it remains to be seen how narrow-acting agents, like single interleukin inhibitors, will compare in safety and efficacy to broad-acting agents such as jak inhibitors. atopic dermatitis (ad) is a common inflammatory skin disease characterized by pruritus and skin barrier dysfunction [ ] [ ] [ ] . current mainstay treatments include topical moisturizers, topical corticosteroids, topical calcineurin inhibitors, phototherapy, and systemic immunotherapies [ ] . moderateto-severe ad is often refractory to first-line topical treatments; while systemic immunosuppressants are efficacious, they have significant adverse effects [ ] . the shortcomings of mainstay treatments prompted the development of targeted topical and systemic immunotherapies involving pathways directly responsible for ad. the us food and drug administration (fda) approved a topical phosphodiesterase- (pde ) inhibitor, crisaborole, in for mild-to-moderate ad and a monoclonal antibody, dupilumab, in for moderate to severe ad [ ] . while the efficacy of dupilumab is considerable, the clinical success effector immune cells are recruited to sites of skin damage when injured keratinocytes release pro-inflammatory signals. in the acute phase, type helper t cells (t h ), type terizes the chronic phase of the disease [ ] . cytokines, such as thymic stromal lymphopoietin (tslp), interleukin (il)- , and il- promote the maturation of skin resident t h and group innate lymphoid cells (ilc s) [ , ] . ilc s are tissue-resident lymphocytes that do not derive from either the t cell or b cell lineage. along with t h cells, ilc s produce a large amount of the pro-inflammatory cytokine il- [ , ] . when il- or il- binds to either type (i or ii) of the il- receptor complex, an associated janus kinase (jak) protein-jak , jak , jak , or tyrosine kinase (tyk )is phosphorylated and activated ( fig. ) [ ] . activation of jak proteins leads to a phosphorylation cascade, which ultimately activates the transcription factors signal transducer and activator of transcription (stat ) and signal transducer and activator of transcription (stat ) [ ] . many proteins essential for skin-barrier function-including filaggrin, loricrin, involucrin, and ceramides-are downregulated or inhibited in this way through the effect of il- and il- on gene expression [ ] . additionally, activation of stat results in increased gene expression of periostin, a pro-inflammatory extracellular matrix protein, trophic to keratinocytes that stimulates them to produce tslp [ ] . t h cells also express il- , which acts on keratinocytes to potentiate the release il- . this, in turn, leads to decreased flg production and resultant skin barrier breakdown [ , ] . il- is a suitable therapeutic target in the treatment of ad, as increased levels of il- correlate well with disease severity [ , , ] . preventing il- signaling is the basis for three monoclonal antibody treatments for refractory ad-dupilumab, tralokinumab, and lebrikizumab. dupilumab binds to il- rα, a component of both the il- and il- receptors essential for pro-inflammatory signal transduction [ , ] . additionally, by inhibiting activation of the il- rα on sensory nerves, the sensation of pruritus is decreased [ ] . in comparison with systemic immunosuppressants like methotrexate and cyclosporine, dupilumab is dosed more conveniently (two initial injections and then one injection every weeks) and provides more targeted immunomodulation. several clinical trials support dupilumab's clinical success in treating moderate-to-severe ad (table ). in the phase iii solo- randomized controlled trial (rct), an investigator global assessment (iga) score of or plus ≥ -point improvement from baseline was considered success. by week , a larger percentage of patients receiving dupilumab achieved success compared with the group receiving placebo (table ) [ ] . additionally, a higher proportion of patients receiving dupilumab achieved eczema area and severity index (easi)- compared with the group receiving placebo. these results were replicated in the phase iii solo- trial and the phase iii liberty ad cafe trial (table ) [ , ] . in the -week open-label long-term extension study, . % of subjects achieved an easi- compared with the baseline of the parent study and . % of subjects achieved a -point or greater improvement in iga score compared with baseline [ ] . in a phase iii rct in adolescents, by week , a larger percentage of the group receiving dupilumab (either every weeks [ . %] or every weeks [ . %]) achieved an easi- when compared with the group receiving placebo ( . %; p < . for both) [ ] . additionally, by week , a larger percentage of the group receiving dupilumab (either every weeks [ . %] or every weeks [ . %]) achieved an iga of or compared with the group receiving placebo ( . %; p < . for both) [ ] . dupilumab had an acceptable safety profile in clinical trials, which has borne out in clinical practice [ ] . idiopathic and allergic conjunctivitis can occur with dupilumab use, although this side effect is rarely treatment limiting [ , , ] . in the long-term open-label extension study of dupilumab, % of the group receiving mg per kg of dupilumab and % of the group receiving mg per kg of dupilumab reported conjunctivitis [ ] . conjunctivitis is less likely to occur with dupilumab treatment in other t h -driven diseases such as asthma [ ] . additionally, there are several case reports of the development of alopecia areata (aa) after starting dupilumab [ ] [ ] [ ] . however, patients with ad have higher rates of aa, and clinical trials found no increased risk in the groups receiving dupilumab compared with placebo [ ] . mouse models of il- rα deletions indicate increased vulnerability to helminthic infections. this is attributed to the necessity of this subunit in dendritic cell maturation. however, an increase in parasitic infections has not been reported in humans using dupilumab [ ] . understanding the clinical effectiveness of dupilumab will impact the reception of the novel agents discussed in later sections. while the trial data presented here may suggest that dupilumab is only modestly effective in moderateto-severe ad, this underestimates dupilumab's ability to achieve clinically meaningful improvement. the primary outcome measures used in clinical trials (e.g., iga / or easi- ) are investigator-reported measures of disease clearance. however, investigator-reported outcomes do not correlate strongly with patient-reported outcomes, which are key to patients' quality of life-the goal of clinical treatment [ ] . also, while investigator-reported measures of lesion clearance are useful in clinical trials for distinguishing drug from placebo, there is evidence that they underestimate the percentage of patients who have clinically meaningful improvement [ ] . this is supported by the results from studies evaluating dupilumab in the real-world setting [ , , ] . additionally, in clinical practice, when patients have only a partial response to systemic treatment, topical treatment can be added to achieve more complete clearing. tralokinumab is a humanized monoclonal igg antibody (mab) that neutralizes il- [ ] . in a phase iib rct, by week , there was a larger mean decrease from baseline in easi score in the groups receiving tralokinumab ( mg vs mg) compared with placebo (p = . and p = . , respectively) [ ] . additionally, by week , a higher proportion of subjects achieved an easi- in the group receiving mg of tralokinumab ( . %) compared with placebo ( . %; p = . ). however, there was no difference in the percentage of subjects achieving an iga of or at weeks in the pooled group of subjects receiving tralokinumab (p = . ). recently, leo pharma announced positive preliminary results from the three phase iii eczema tralokinumab (ecztra - ) trials, although this data is not yet publicly available [ ] . in a phase i study evaluating the safety of tralokinumab, headache and somnolence occurred in the treatment group but not in the placebo group [ ] . in the phase iib trial, the most common treatmentemergent adverse events (teaes) reported were headache and infection of the upper respiratory tract. only one participant (of ) developed a positive titer for anti-drug antibodies [ ] . lebrikizumab is a mab that binds il- , inhibiting the dimerization of il- rα and il- rα [ ] . one ongoing phase iii clinical trial is evaluating lebrikizumab in adults with ad (table ). in the phase ii treble trial, at weeks, a higher proportion of subjects in the group receiving lebrikizumab mg every weeks achieved an easi- ( . %) compared with the group receiving placebo ( . %; p = . ) [ ] . additionally, at weeks, a higher proportion of subjects in the group receiving lebrikizumab mg every weeks achieved an easi- ( . %) compared with the group receiving placebo ( . %; p = . ). there was no significant difference in the percentage of subjects achieving an iga of or between the group receiving lebrikizumab mg every weeks ( . %) and the group receiving placebo ( . %; p = . ). a second phase iib trial in adults reported similar efficacy results (table ) [ ] . in the treble study, there were no life-threatening adverse events and no adverse events showed a dose-dependent trend [ ] . nemolizumab (cim ) is a mab that binds the il- receptor α component. this prevents il- from acting on neurons, which inhibits the potentiation of the sensation of pruritus [ ] [ ] [ ] . several phase iii clinical trials are ongoing for nemolizumab in ad patients (table ). in a -week phase ii rct with a -week extension, by weeks there [ ] . in the phase i trial, infections were the most commonly reported teae. nasopharyngitis ( of subjects) and herpes simplex ( of subjects) were reported in the treatment group but not the placebo group. there were no dose-dependent adverse events [ ] . in the long-term extension of a -week phase ii trial, no severe adverse events occurred for up to weeks after treatment with nemolizumab. most adverse events were mild and included headache, lower extremity edema, increased creatine phosphokinase levels (cpk), nasopharyngitis, and upper respiratory tract infections [ ] . a phase iib clinical trial reported a dose-dependent increase in mild asthma exacerbations in subjects treated with nemolizumab. two subjects discontinued the study due to elevations in creatine kinase levels [ ] . anti-ox antibody (also called gbr ) is a humanized monoclonal igg antibody targeting the costimulatory molecule ox (cd ) [ ] . ox is expressed on activated antigen presenting cells and endothelium and is essential for t-cell expansion [ ] . a phase iib clinical trial is currently recruiting ( table ). in the published phase iia clinical trial conducted in adults, the primary study endpoints included incidence and characterization of adverse events, change in epidermal hyperplasia compared with baseline, and mrna expression signatures from skin biopsy [ ] . the treatment group had reduced epidermal hyperplasia (compared with their baseline) at days (p < . ) and days (p < . ) while the placebo group did not. il- , ccl , ccl , and thymic stromal lymphopoietin (tslp) levels were all decreased in the treatment group compared with baseline by days (p < . ). il- , il- , il- a, and il- levels were not altered after treatment with gbr . by day , in an intention-to-treat analysis, there was a larger proportion of subjects in the group receiving mg/kg of iv gbr ( . %) that achieved an easi- compared with the group receiving placebo ( . %; p value was not reported). by day , there was a larger proportion of subjects in the group receiving mg/ kg of iv gbr ( . %) that achieved an iga score of or compared with the group receiving placebo ( . %; p value was not reported). the most common teaes were headache ( %), ad ( %), and nasopharyngitis ( %). adverse events of moderate severity included one subject with facial edema in the placebo group, one subject with a dental abscess, and one subject with worsening ad in the treatment group [ ] . several small-molecule jak inhibitors are being actively investigated in the treatment of moderate to severe ad, including baricitinib, abrocitinib, and upadacitinib. the jak proteins are intracellular and, when activated, activate stat proteins to dimerize and translocate to the cell nucleus to increase gene expression of inflammatory mediators [ ] . some of the following agents are selective for particular jak proteins while others inhibit the whole family. baricitinib is an oral, small-molecule, selective inhibitor of jak and jak [ ] . there are ongoing phase iii clinical trials ( table ). in two phase iii clinical trials, breeze-ad and breeze-ad , by weeks, a higher proportion of subjects in the treatment groups ( mg, mg, and mg) achieved an iga of or , a ≥ -point improvement, and easi- compared with the group receiving placebo (table ) [ ] . in a phase ii clinical trial in adults with ad, by week , a higher percentage of subjects receiving baricitinib mg with a topical corticosteroid (tcs) achieved an easi- than subjects given placebo with tcs (p = . ) [ ] . in contrast, by week , there no lifethreatening adverse events were reported in this study. one serious teae was reported (a benign colonic polyp) in one subject receiving baricitinib mg plus tcs. several adverse events present in the treatment groups but not the placebo group include increased cpk levels, decreased neutrophil levels, and increased platelet levels. in the breeze-ad and studies, the frequency of teaes was similar among the placebo and the treatment groups. in breeze-ad , there was an increased rate of herpes simplex infections in the treatment groups compared with the placebo group but this was not seen in breeze-ad . elevations in cpk caused treatment suspension in two subjects receiving baricitinib and discontinuation in one subject. abrocitinib (pf- ) is an oral, small-molecule, selective inhibitor of jak [ ] . the recently released data from the phase iii trial evaluating abrocitinib monotherapy in subjects years and older, jade compare, is promising. by weeks, a significantly higher proportion of subjects in the treatment groups ( mg or mg daily) achieved an iga of or and a ≥ -point improvement than the group receiving placebo. the proportion of subjects achieving an easi- was also significantly higher in the treatment groups than the placebo group at weeks [ ] . in a phase iib trial evaluating abrocitinib in moderate-to-severe ad by week , a higher proportion of subjects receiving mg of drug and mg of drug ( . % and . %) had an iga of or plus a ≥ -point improvement from baseline compared with those receiving placebo ( . %; p < . and p < . , respectively) [ ] . additionally, by week , a higher proportion of subjects receiving mg of drug and mg of drug ( . % and . %) obtained an easi- compared with placebo ( . %; p < . and p = . , respectively) [ ] . four serious teaes were reported in the treatment groups, including one case of pneumonia, one case of eczema herpeticum, and two cases of recurrence of herpes simplex. gastrointestinal upset was also seen with slightly increased frequency in the group(s) receiving abrocitinib. dose-dependent thrombocytopenia was also noted for doses > mg, but this reversed by week of treatment. upadacitinib is an oral small-molecule selective inhibitor of jak [ ] . several phase iii clinical trials evaluating upadacitinib in subjects with ad are ongoing ( table ). in a phase iib rct in adults with ad, by week , a higher percentage of subjects receiving upadacitinib ( . , , or mg) achieved an easi- than the group receiving placebo (p ≤ . , p ≤ . , p ≤ . , respectively) [ ] . additionally, by week , a higher proportion of subjects receiving upadacitinib ( . , , or mg) achieved an iga of or than the group receiving placebo (p ≤ . , p ≤ . , p ≤ . , respectively). of note, this study is the first to evaluate selective jak inhibition in ad patients without concomitant corticosteroid use. only two serious teaes were reported in the treatment group, including jaw pericoronitis in a subject with a history of dental infections and worsening ad in another subject [ ] . there were no dose-dependent adverse events. in a phase iii rct comparing upadacitinib and adalimumab in patients with severe rheumatoid arthritis, upadacitinib was generally well tolerated. however, the incidence of herpes zoster infection and elevations in cpk was higher in the group receiving upadacitinib [ ] . until recently, the treatment of moderate-to-severe ad relied on potent corticosteroids and systemic immunosuppressants, which can produce significant undesirable side effects. as moderate-to-severe ad can lead to poor quality of life, the development of targeted, well-tolerated immunomodulators remains important. an improved understanding of ad pathophysiology resulted in an explosion of research into new agents for this patient population. while the novel agents discussed here have demonstrated efficacy, others such as tezepelumab, apremilast, ustekinumab, and tradipitant failed to reach their primary endpoint in clinical trials [ , , , ] . as new agents come to market, the tradeoff between efficacy and safety will be important. while the jak inhibitors are effective in clinical trials and offer a much desired oral form of delivery, they are associated with a risk of serious adverse effects [ , ] . there is an fda mandated black box warning for risk of severe infection and death when using baricitinib mg in patients with rheumatoid arthritis [ ] . this potential for serious adverse events is not surprising, as jak inhibitors participate in signaling cascades that regulate both the acute inflammatory reaction and hematopoiesis [ , ] . leveraging the inhibition of specific subtypes of jak proteins-only using selective jak inhibitors (upadacitinib) in ad-may help minimize undesired side effects [ ] . however, the higher dosages likely required for the treatment of autoimmune disease may overcome the selectivity of these agents at lower dosages [ ] . agents with a wide scope of action may carry a greater risk of serious adverse events compared with agents with a narrow scope of action, such as single interleukin inhibitors [ , ] . currently, dupilumab is the only immunomodulator approved in the united states for moderate-to-severe ad, but this may change as several novel agents are successful in clinical trials. it may appear from dupilumab's performance in clinical trials that it insufficiently treats a large sub-group of patients with moderate-to-severe ad. however, the clinical landscape that these novel agents are entering may be different than anticipated, as dupilumab's meaningful clinical performance may be higher than might be expected [ ] . regardless, the benefit of developing several immunomodulators targeting distinct immune pathways is an increased probability of achieving disease control in all ad patients. additional novel therapies are currently under investigation in clinical trials (apd , ky , bermekimab, and many others). future research will determine how these novel agents compare directly and if specific immunomodulators work better for certain subtypes of ad patients. the il- -ovol -flg axis in atopic dermatitis rna sequencing atopic dermatitis transcriptome profiling provides insights into novel disease mechanisms with potential therapeutic implications atopic dermatitis endotypes and implications for targeted therapeutics the role of interleukins and/or in the pathophysiology and treatment of atopic dermatitis crisaborole and atopic dermatitis skin biomarkers: an intrapatient randomized trial atopic dermatitis is an il- -dominant disease with greater molecular heterogeneity compared to psoriasis atopic dermatitis and psoriasis: two different immune diseases or one spectrum? curr opin immunol atopic dermatitis phenotypes and the need for personalized medicine atopic dermatitis systemic immune mechanisms in atopic dermatitis and psoriasis with implications for treatment mechanisms of dupilumab treatment of atopic dermatitis with tralokinumab, an anti-il- mab two phase trials of dupilumab versus placebo in atopic dermatitis dupilumab with concomitant topical corticosteroid treatment in adults with atopic dermatitis with an inadequate response or intolerance to ciclosporin a or when this treatment is medically inadvisable: a placebo-controlled, randomized phase iii clinical trial (liberty ad cafe) dupilumab shows long-term safety and efficacy in moderate-to-severe atopic dermatitis patients enrolled in a phase open-label extension study efficacy and safety of dupilumab in adolescents with uncontrolled moderate to severe atopic dermatitis: a phase randomized clinical trial realworld experience of dupilumab treatment for atopic dermatitis in adults: a retrospective analysis of patients' records dupilumab-induced ocular surface disease (diosd) in patients with atopic dermatitis: clinical presentation, risk factors for development and outcomes of treatment with tacrolimus ointment conjunctivitis in patients with atopic dermatitis treated with dupilumab is associated with higher baseline serum levels of immunoglobulin e and thymus and activation-regulated chemokine but not clinical severity in a real-world setting dupilumab in adolescents with uncontrolled moderate-to-severe atopic dermatitis: results from a phase iia openlabel trial and subsequent phase iii open-label extension conjunctivitis in dupilumab clinical trials alopecia areata in severe atopic dermatitis treated with dupilumab drug-induced alopecia after dupilumab therapy alopecia areata after dupilumab for atopic dermatitis association of vitiligo and alopecia areata with atopic dermatitis: a systematic review and metaanalysis clinically meaningful responses to dupilumab in adolescents with uncontrolled moderate-to-severe atopic dermatitis: post-hoc analyses from a randomized clinical trial dupilumab provides important clinical benefits to patients with atopic dermatitis who do not achieve clear or almost clear skin according to the investigator's global assessment: a pooled analysis of data from two phase iii trials real-world effectiveness and safety of dupilumab for the treatment of atopic dermatitis in japanese patients: a single-centre retrospective study dupilumab: short-term effectiveness and security in real clinical practice -a retrospective multicentric study resul ts-for-tralo kinum ab-from-three -phase - -studi es-in-adult -patie nts-with-moder ateto-sever e-ad?publi sheri d= &relea seid= a randomized, placebo-controlled, single ascendingdose study to assess the safety, tolerability, pharmacokinetics, and immunogenicity of subcutaneous tralokinumab in japanese healthy volunteers efficacy and safety of lebrikizumab (an anti-il- monoclonal antibody) in adults with moderate-to-severe atopic dermatitis inadequately controlled by topical corticosteroids: a randomized, placebo-controlled phase ii trial (tre-ble) efficacy and safety of lebrikizumab, a high-affinity interleukin inhibitor, in adults with moderate to severe atopic dermatitis: a phase b randomized clinical trial anti-interleukin- receptor a antibody for atopic dermatitis phase b randomized study of nemolizumab in adults with moderate-to-severe atopic dermatitis and severe pruritus the first trial of cim , a humanized antihuman interleukin- receptor a antibody, in healthy volunteers and patients with atopic dermatitis to evaluate safety, tolerability and pharmacokinetics of a single dose in a randomized, double-blind, placebo-controlled study nemolizumab in patients with moderate-tosevere atopic dermatitis: randomized, phase ii, long-term extension study gbr , an anti-ox , improves skin gene signatures and clinical scores in patients with atopic dermatitis baricitinib in adult patients with moderateto-severe atopic dermatitis: a phase parallel, double-blinded, randomized placebo-controlled multiple-dose study baricitinib in patients with moderateto-severe atopic dermatitis and inadequate response to topical corticosteroids: results from two randomized monotherapy phase iii trials efficacy and safety of oral janus kinase inhibitor abrocitinib for patients with atopic dermatitis: a phase randomized clinical trial pfizer announces positive top-line results from phase study of investigational oral jak candidate, abrocitinib (pf- ), in patients aged and older with moderate to severe atopic dermatitis upadacitinib versus placebo or adalimumab in patients with rheumatoid arthritis and an inadequate response to methotrexate: results of a phase iii, double-blind. randomized controlled trial upadacitinib in adults with moderate to severe atopic dermatitis: -week results from a randomized, placebocontrolled trial revisiting therapies for atopic dermatitis that failed clinical trials tradipitant misses primary end point in atopic dermatitis trial lilly announces top-line phase results for baricitinib in patients with moderate to severe atopic dermatitis profile of baricitinib and its potential in the treatment of moderate to severe atopic dermatitis: a short review on the emerging clinical evidence suppression of cytokine signaling by socs : characterization of the mode of inhibition and the basis of its specificity jak inhibition as a therapeutic strategy for immune and inflammatory diseases key: cord- - wqdlha authors: nan title: oral session date: - - journal: respirology doi: . /j. - . . .x sha: doc_id: cord_uid: wqdlha nan introduction rheumatic heart disease, predominantly mitral stenosis is a chronic disease that produces an increase in the left atrial pressure and consequently venous pulmonary hypertension. preoperative lung function which could be obtained from spirometry can evaluate respiratory reserve in cardiopulmonary patients who will undergo surgery. however, data on the use of spirometry in predicting the rate and extent of regression of preoperative pulmonary artery hypertension is limited. methods we determined the usefulness of preoperative lung function by spirometry in predicting regression of pulmonary hypertension after surgical correction of mitral stenosis among patients who underwent mitral valve surgery at philippine heart center from july to december . results among the twenty patients included in the study, one had normal spirometry and another one had mild obstructive abnormality. majority of the patients ( / ) had restrictive abnormality. nineteen patients had regression of pap. among them, patients were noted to have restrictive abnormality and one with normal spirometry. there was only one patient who did not have regression of pap and found to have a mild obstructive abnormality. correlation of the severity of restrictive lung defect with the change in pap classifi cation among nineteen patients showed lack of correlation with a spearman coeffi cient of . and p-value of . . (figure ) conclusion this study showed that majority of rhd patients particularly mitral stenosis will have a preoperative spirometric abnormality of restrictive pattern. among the study group, almost all patients ( / ) will have regression of pulmonary hypertension after surgery except for one patient with obstructive lung abnormality. though results were not signifi cant, we cannot conclude that preoperative lung function is not predictive of regression of pulmonary hypertension after surgical correction of mitral stenosis due to inadequacy of sample size. thus, further investigation is warranted. introduction drug-induced interstitial lung disease (ild), particularly pulmonary fi brosis, is a serious clinical concern and myofi broblasts have been suggested to play a major role, with it recently being revealed that some of these myofi broblasts are derived from lung epithelial cells through epithelial-mesenchymal transition (emt). in this study, we used cultured epithelial cells to examine the emt-inducing abilities of drugs known to induce ild clinically. methods induction of emt in cultured lung epithelial cells were monitored by up-regulation of the expression of myofi broblast marker proteins and downregulation of the expression of epithelial cell marker proteins. the severity of lung injury and fi brosis in mice was assessed by various methods, such as histopathologic evaluation, histochemical analysis of collagen and determination of hydroxyproline. results emt-like phenotypes were induced by a , an active metabolite of lefl unomide having an inhibitory effect on dihydroorotate dehydrogenase (dhodh). smad interacting protein (a transcription factor regulating emt) and the notch-signaling pathway were shown to be involved. when the cultures were supplemented with exogenous uridine, the a -induced emtlike phenotypes disappeared. likewise, an a analog without inhibitory activity on dhodh produced no induction, suggesting that this process is mediated through the inhibition of dhodh. in vivo, administration of lefl unomide stimulated bleomycin-induced emt-like phenomenon in pulmonary tissue, and exacerbated bleomycin-induced pulmonary fi brosis, both of which were suppressed by co-administration of uridine. conclusion these fi ndings suggest that lefl unomide-dependent exacerbation of bleomycin-induced pulmonary fi brosis is mediated by stimulation of emt of lung epithelial cells, providing the fi rst evidence that drug-induced pulmonary fi brosis involves emt of these cells. we consider that this lefl unomide-dependent exacerbation of bleomycin-induced pulmonary fi brosis provides a suitable animal model of drug-induced ild, which is important to establish not only a clinical protocol for its treatment but also an assay system that will facilitate screening in order to eliminate candidate drugs with the potential to produce this type of side effect. introduction to observe the infl uence of arsenic trioxide on the bleomycininduced pulmonary fi brosis in rats and its mechanisms. methods pulmonary fi brosis was induced in sprague-dawley (sd) rats by intratracheal instillation of bleomycin(blm). the rats of the treatment group, the steroid group and model group were intraperitoneally injected with arsenic trioxide(ato), dexamethasone or normal saline(ns)respectively, while the control rats received ns both intratracheally and intraperitoneally. the effects of interference were evaluated by median survival time, hydroxyproline level in lung, semi-quantitative grading of alveolitis and pulmonary fi brosis and quantititative analysis of collagen in lung (masson's trichrome stain). apoptosis index (ai) of lung was detected by using the terminal transferase dutpdigoxygenin nick end-labeling (tunel) method and the results of the immunohistochemical staining of some cytokines were quantitatively analyzed. results ato might ( ) prolong the median survival time of blm-induced pulmonary fi brosis rats at some extent; ( ) attenuate the alveolitis and pulmonary fi brosis, reduce hydroxyproline level and collagen deposition in lung tissue; ( ) increase the ai of lung tissue at a certain phase; and decrease the levels of transforming growth factor-β (tgf-β ) and tissue inhibitor of metalloproteinase- (timp- ), increase the content of interferon-γ(ifn-γ) signifi cantly. conclusion ato might attenuate blm-induced pulmonary fi brosis in rats via increasing the ai of lung tissue. introduction combined pulmonary fi brosis and emphysema (cpfe) is a syndrome involving both emphysema and diffuse parenchymal lung disease with fi brosis on chest computed tomography (ct). the clinical characteristics of cpfe have been described; however, the differences between the syndrome and interstitial pneumonia (ip) or chronic obstructive pulmonary disease (copd) are not fully understood. the purpose of this study was to clarify the differences in respiratory resistance and reactance using a forced oscillation technique. methods the subjects included patients with cpfe, with ip, and with copd. respiratory resistance and reactance were measured using most-graph- (chest mi co., ltd., tokyo, japan), and pulmonary function tests were also performed on the same examination day. results the fev and fev /fvc values were signifi cantly lower in copd patients compared to those with cpfe and ip. there was no signifi cant difference in vc between cpfe, ip, and copd patients. the carbon monoxide transfer coeffi cient values were signifi cantly lower in cpfe and copd patients compared to those with ip. resistance at hz (r : cmh /l/s) was significantly elevated in patients with copd (cpfe, . ; ip, . ; and copd, . , respectively, p < . for cpfe vs. copd), while r was elevated in patients with ip and copd compared to those with cpfe (cpfe, . ; ip, . ; and copd, . , respectively, p < . for cpfe vs. ip and for cpfe vs. copd). the resonant frequency (hz), a parameter of reactance, was signifi cantly higher in copd patients compared to cpfe and ip patients (cpfe, . ; ip, . ; and copd, . , respectively, p < . for cpfe vs. copd and for ip vs. copd). conclusion cpfe patients exhibited no airfl ow limitation or restrictive impairment, but showed severe gas exchange abnormality similar to that in copd patients. the absence of an elevation of respiratory resistance or reactance refl ects homogenous ventilatory mechanics in cpfe, thereby differentiating it from ip and copd. these results suggest that cpfe is a distinct syndrome differing from ip or copd. pneumonectomy is a surgical removal of a lung. it poses several adverse consequences as it substantially diminishes diffusion capacity by reducing total number of alveoli and vasculature available for gas exchange. the challenge is to maintain adequate gas exchange following resection of the lung tissue. literature revealed a good prognosis for pneumonectomized infant. there is enhancement of diffusion capacity in remnant lung through generation of new pulmonary gas exchange units. this was evidenced by normal lung volumes of the pneumonectomized infants after years. in this article, we present a day old female who was noted to be tachypneic, with chest indrawing and subcostal retractions. chest roentgenogram done revealed collapsed right lung, dextrocardia with hyperinfl ated and hyperluscent left lung. d echo showed no anatomic anomaly, except for dextroposed heart probably secondary to the collapsed right lung. impression then was congenital cystic adenomatoid malformation versus congenital lobar emphysema, left lung. extensive work-up was done. chest ct scan showed overly infl ated and hyperluscent lung segment arising from left lower lobe which is characteristic of a congenital lobar adenomatoid malformation. lung perfusion scan demonstrated diminished perfusion of the left lung with differential contribution to the total perfusion of the % left lung and % right lung. patient then underwent open thoracotomy with pneumonectomy of the left lung. biopsy revealed congenital cystic adenomatoid malformation type ii. three months after the surgery, she has gained weight, not receiving any medications and is symptom free. introduction despite the importance of infection and infl ammation in the pathogenesis and management of bronchiectasis, there are few published data on lower airway microbiology and cellularity in these children. methods children attending a single centre ( to ) with non-cystic fi brosis bronchiectasis who underwent bronchoalveolar lavage (bal) within weeks of diagnosis were identifi ed. the point prevalence of infection (> colony-forming units (cfu)/ml of respiratory bacterial pathogens), its effects upon airway cellularity and the impact of clinical and demographic variables on infection risk were evaluated. results of children with bronchiectasis, ( %) had bal evidence (> cfu/ml) of infection, which was frequently polymicrobial and caused mostly by haemophilus infl uenzae, streptococcus pneumoniae and moraxella catarrhalis. in contrast, pseudomonas aeruginosa was uncommon and mycobacterial and fungal species were undetected. upper airway commensal organisms were also isolated in large numbers (> cfu/ml) from ( %) bal cultures. the median (interquartile range; iqr) bal fl uid total cell counts (tcc × /l) and neutrophil percentages were signifi cantly higher in those with, than without, infection [tcc ( - ) vs ( - ); p = . and neutrophil percentage % ( - ) vs % ( - ); p = . respectively]. only age at diagnosis was associated with infection. conclusion bal microbiology of children with newly diagnosed bronchiectasis substantially differs from adults. children have marked airway neutrophilia, particularly when bacterial loads were high. younger children were more likely to have a lower airway infection at diagnosis. the role and interactions of respiratory bacterial fl ora in initiating and progressing airway damage in bronchiectasis requires further study. the radiological defi nition of airway dilatation and bronchiectasis in children has substantial limitations. bronchoarterial ratio is a commonly used criterion to defi ne airway dilatation despite the lack of normative pediatric data. the objective of our study was to determine the range of normal bronchial to accompanying arterial diameter ratio on high resolution ct scan of the chest in children and compare it with the available adult data. methods children undergoing mdct chest for non-pulmonary conditions at a single centre were prospectively identifi ed. high resolution reconstruction was performed on those included and both airway and vessel diameters were measured in the upper and lower lobes of both lungs. mean bronchoarterial (ba) ratio was calculated for each included child and its correlation with age assessed. results forty one children were included, the mean (sd) ba ratio was . ( . ) (range . to . ). this ratio was clinically similar though statistically lower than comparable adult data [combined mean (sd) . ( . ); p = . ]. no correlation was found with age in our cohort (r = − . , p = . ). there was no difference in the ratio based on laterality or lobe. conclusion in pediatric age-group, the airway is signifi cantly smaller than the adjoining vessel. using the radiological criteria of ba ratio greater than one to defi ne bronchial dilatation would under estimate the presence and extent of bronchiectasis leading to delayed and missed diagnosis. this highlights the need to redefi ne the criteria for bronchial dilatation in children. introduction sleep disordered breathing, especially obstructive sleep apnea syndrome, has been found to be associated with endothelial dysfunction in both adult and paediatric populations. however, the role of non-apnoeic snoring on endothelial function has not been investigated. methods children aged - years with habitual snoring were recruited from our sleep disorder clinic. non-snoring controls were recruited from participants of a community growth survey. all participants underwent nocturnal polysomnography (psg) and ultrasonographic fl ow mediated dilation (fmd) evaluation on the same day. fasting blood was taken for glucose level and lipid profi le determination. subjects with an obstructive apnoea hypopnoea index (oahi) < but reported by parents to have habitual snoring (at least nights per week) in the past months were defi ned as primary snorers (ps). those having an oahi < without habitual snoring in the past months were grouped as non-snorers. children with body mass index of greater than the th percentile of the local reference were defi ned as overweight. subjects were divided into groups of normal weight, overweight, non-snorers and ps for comparisons. results in total, children, of whom were boys, with a mean (sd) age of . ( . ) years were recruited. sixty-six of them were ps. subjects with ps had signifi cantly reduced fmd than non-snoring controls for both the normal weight group (p = . ) and the overweight group (p = . ) ( table ) . multivariate linear regression model showed that primary snoring (p < . ) were independently associated with fmd after controlling for possible confounders including overweight, gender, baseline vessel diameter and log-transformed oahi. conclusion primary snoring in children is independently associated with impaired endothelial function. introduction children with cyanotic congenital heart disease live with baseline oxygen saturations in the mid s, so hence they exist on the steep part of the oxyhemoglobin dissociation curve. these patients are at increased risk for the hemodynamic variations occurring during apneas/hypopneas. longterm outcomes for children with congenital heart disease could be adversely affected since the etiology of pulmonary hypertension is believed to be secondary to the hypoxia and hypercarbia seen in chronic airway obstruction paired with the sympathetic overstimulation caused by frequent sleep arousals. methods a prospective two part questionnaire for the screening of sdb for pediatric patients was performed. part one consists validated pediatric sleep questionnaire (psq). part two consisted of subjective assessment of the subject's cardiovascular and respiratory symptom. all odd ratios of greater than with p-values less than . were considered signifi cant covariates. results a total of children met the inclusion criteria and were included in the fi nal analysis. the prevalence of sleep disordered breathing (sdb) was high at . %. among the factors analyzed, an increased frequency of pulmonary diseases (greater than times/year) was statistically correlated with increased psq scores (p = . ). likewise, early palliative repair (p = . ) was statistically associated. a high total cardiac score is almost four times associated with increased psq ratings (p = . ). conclusion increased frequency of pulmonary diseases and early palliative repair was statistically correlated with increased pediatric sleep questioner scores. a high total cardiac score is almost four times associated with increased psq ratings. hence patients with congenital heart disease and sleep disordered breathing are more likely to have worse cardiac symptoms. patient with congenital heart disease shoukl be routinely examined for the presence of sleep disordered breathing because these sub group of pediatric patients are x have more high risk for developing sleep disordered breathing. introduction atelectasis, is a common pulmonary complication of patient who underwent open heart surgery. deep breathing exercise is one of the interventions implemented to prevent the occurrence of this complication postoperatively. among preschoolers however, making them perform this breathing exercise and maintaining compliance is a challenge since children in this age group have a short attention span and may get bored easily. with this problem at hand, the investigators conceptualized an innovative technique, blowing bubbles as a breathing exercise, in order to prevent atelectasis among post open heart surgery preschoolers. methods this study is an open-label randomized control trial that compared blowing bubbles with the traditional deep breathing exercise among preschoolers who underwent open heart surgery. it took months to complete the study and there were patients screened but only qualifi ed based on the inclusion/exclusion criteria. thirty were assigned randomly to the blowing bubbles group and to the deep breathing exercise. atelectasis as documented on chest x-rays was the outcome measured. results out of the participants in the deep breathing group, developed atelectasis while in the blowing bubbles group, out had atelectasis this generated a p-value of . which is statistically signifi cant, favoring the blowing bubbles group. furthermore, risk analysis showed an absolute risk reduction of . % and a relative risk of less than which means that atelectasis is less likely to occur in the blowing bubbles group in comparison to the traditional breathing exercise group. conclusion blowing bubbles signifi cantly reduces the occurrence of atelectasis among post-open heart surgery preschoolers as opposed to deep breathing exercise. the use of blowing bubbles as a deep breathing modality incorporated through play activity is recommended among preschoolers. introduction severe acute respiratory syndrome (sars) is a novel contagious respiratory infection caused by the sars coronavirus (sars cov). in adults, a mortality rate of % has been reported, and respiratory complications can occur in up to % of survivors. the disease pattern is different in children [ , ] but prevalence of longer term respiratory complications in children is unknown. the aim of this study was to investigate the aerobic capacity of children at years after the diagnosis of sars. methods twenty-seven patients (mean age of . years) who completed both pulmonary function and maximal aerobic capacity (peak vo ) tests at and months after the acute illness were invited for re-assessment. they underwent anthropometric assessment, full pulmonary function and exercise treadmill test. subjects with abnormal hrct at months underwent repeat scanning. results at this -month assessment, subjects refused to take part, and the main reasons of refusal were work commitments or time clashes with school activities. the remaining subjects ( % female) provided complete pulmonary function and exercise data. pulmonary function test was normal in all patients. peak vo , peak oxygen pulse, and ventilatory anaerobic threshold (vat) at this assessment were signifi cantly higher than that recorded at and months. ventilatory effi ciency (ventilatory equivalents for oxygen, ve/vo ) and perfusion to the lungs (end-tidal partial carbon dioxide pressure, petco ) signifi cantly improved since months and maintained at months. though peak vo further improved at months in patients with persistent or without radiological abnormalities, their values were % and % respectively of normal controls. conclusion this study is the most comprehensive report of post-sars exercise responses in children and adolescents. improvements in aerobic capacity over a period of months after the initial illness were demonstrated, but the values remained suboptimal when compared to normal reference. introduction domestic mites are an important source of indoor allergens responsible for the development of allergic diseases worldwide. to date, there is no local epidemiology data on the allergic sensitization to domestic mites among adult patients with asthma and allergic rhinitis. methods from november to june , we prospectively recruited adult patients with asthma and/or allergic rhinitis from an urban-based specialist medical centre in penang, malaysia, carefully profi ling their allergic sensitization to domestic mites by means of skin prick tests and clinico-demographic details. of the patients [mean age (ci) years ( - ); % male] recruited, skin allergic rates to dermatophagoides pteronyssinus, d. farinae, blomia tropicalis and tyrophagus putrescentiae were %, %, % and % respectively. there was no signifi cant difference in these rates among patients with asthma, allergic rhinitis or both. there were signifi cant associations between the number of people living in the same house with rates of d. pteronyssinus (p = . ) and d. farinae (p = . ), and the frequency of bed sheet changing with the rate of tyrophagus putrescentiae (p = . ). with younger age, there were also signifi cant higher allergic rates with d. pteronyssinus (p < . ), d. farinae (p < . ), b. tropicalis (p < . ) and tyrophagus putrescentiae (p = . ). conclusion our preliminary data shows a high prevalence of allergic sensitization to domestic mites in our local adult patients with asthma and/or allergic rhinitis. the fi ndings have implication on allergen control with the view of disease mitigation. introduction a study was carried out to compare the effi cacy and sensory perception of mometasone furoate and ciclesonide aqueous nasal spray in moderate-severe allergic rhinitis. methods a single blind study of months on patient of both sexes, > years, diagnosed as moderate-severe allergic rhinitis as per aria workshop( ) , with skin test positivity to at least two aeroallergens was carried out on patients. patients were divided into two, i.e. mometasone (group a) and ciclesonide groups (group b). group a received microgram/day of mometasone furoate and group b received microgram/day of ciclesonide, nasal spray once daily in the morning. the evaluation was made at , , , , weeks by total nasal symptoms score (tnss), visual analogue scale (vas) and sinonasal outcome test- (snot- ). sensory perception of both nasal steroids was carried out on initial visit before allocating groups, employing a sensory perception questionnaire with a sensory items ( points scale). patients were given one nasal spray, and immediate and after two minutes response was noted in questionnaire. after minutes of washout period, second drug was given and response was noted in similar way. results after months, both mometasone and ciclesonide signifi cantly decreased nasal symptoms as assessed by tnss (p-value = . ) and vas (p-value = . ) and improved quality of life signifi cantly as assessed by snot- (p-value = . ). however there was no statistically signifi cant difference among two drugs. the sensory perception, in favour of mometasone was observed immediately after drug administration, than ciclesonide by providing more comfort during administration, less irritation, odor prference (all p-value . to . ). however, after minutes of drug application, there was no signifi cant difference among both drugs in strength of taste, amount of medication rundown and irritation. the overall acceptance by patients was for mometasone over ciclesonide (p-value = . ). conclusion both mometasone and ciclesonide adequately controlled symptoms of allergic rhinitis in months. the sensory perception preference for many of the sensory attributes in mometasone group were in favour of mometasone. thus, mometasone has equal effi cacy but slightly better acceptability over ciclesonide in the treatment of allergic rhinitis. results of patients, . % were male and . % females. % patients had used alternative asthma therapies: homeopathy, ayrurveda and yoga with poor results and . % had used multiple therapies prior to visit our centre. patients reported being afraid of acute attack ( . %) and hospitalization ( . %). although inhalers were used by indian patients in . % but still oral drugs were used regularly by . % patients. compared to . % in only . % were inhaler naïve (t-value . ). only / ( . %) patients were using spacer with mdi's and % ( / ) being able to demonstrate correct use. common errors seen in mdi's use were: a) slow and steady inhalation ( . %) and b) breath holding after deep inhalation ( . %). formoterol and budesonide dpi was considered most effective by indian patients in controlling disease when asked to rate their devices and drugs. when counseled by experts % were sure to be regular on treatment but month latter % remained regular (t-value . ). fear of addiction ( . %) and cost of therapy ( . %) were cited causes for noncompliance. conclusion indian patients use alternative therapy for asthma treatment before coming to tertiary centre and still prefer oral therapy. despite extensive education being afraid of attacks become noncompliant due to fear of addiction and cost of therapy. the oesophagus and airways have a common origin. refl uxrelated respiratory symptoms may be triggered by aspiration of gastric refl uxate into airways or a vagally mediated oesophago-tracheo-bronchial. this association has not been reported previously in sri lanka. the aim of this study was to describe the association between gastro-oesophageal refl ux (gor) events and respiratory symptoms in a cohort of adult asthmatics in sri lanka. methods thirty stable, mild asthmatics (american thoracic society criteria) underwent dual-sensor ambulatory oesophageal ph monitoring. respiratory symptoms (cough, wheeze, diffi cult breathing, chest tightness) during monitoring were recorded and correlated with refl ux events. results both proximal and distal gor parameters were signifi cantly higher in asthmatics than controls (p < . ; mann-whitney u-test). however, there was no difference in any parameter between asthmatics with and without respiratory symptoms. abnormal proximal acid refl ux was documented in . % and distal refl ux in . % of asthmatics. of respiratory symptoms in all asthmatics, majority ( %) were cough episodes. in total, % of coughs, % of wheeze and all of chest tightness was refl ux-associated, where in most, refl ux events preceded respiratory symptoms. of asthmatics with respiratory symptoms, acid exposure was normal in ( %), abnormally high in proximal oesophagus in ( %) and abnormally high in the distal oesophagus in ( %) and abnormal at both levels in ( %). most refl ux events in asthmatics occurred in the upright position. conclusion asthmatics have more gor and associated respiratory symptoms than non-asthmatic volunteers, with refl ux episodes preceding respiratory symptoms in most cases. distal gor and upright acid exposure was more prominent than proximal gor. in , fi rst population-based studies to determine the magnitude of the asthma problem have been carried out in bangladesh, to defi ne the prevalence of asthma and to identify the risk factors of asthma in bangladesh. after years, same study carried out to fi nd out trends of asthma in bangladesh. methods a cross-sectional study was conducted from january to august on people and same study carried out from november to april on subjects. data collected from stratifi ed randomly selected primary sampling units of all districts. face-to-face interviews were performed with housewives or other guardians at the household level using a structured questionnaire. results in , the prevalence of asthma (wheeze in the last months) was . % ( % ci: . - . ) whereas in it is . % ( % ci: . - . ). in , prevalence of other asthma defi nitions were: ever wheeze (lifetime wheeze) . % ( % ci: . - . ); perceived asthma (perception of having asthma) . % ( % ci: . - . ); doctor diagnosed asthma (diagnosis of asthma by any category of doctor either qualifi ed or unqualifi ed) . % ( % ci: . - . ). in , ever wheeze (lifetime wheeze) . % ( % ci: . - . ); perceived asthma (perception of having asthma) . % ( % ci: . - . ); doctor diagnosed asthma (diagnosis of asthma by any category of doctor either qualifi ed or unqualifi ed) . % ( % ci : . - . ).the prevalence of asthma in children ( - years) was higher than in adults ( - years) ( . % versus . %; odds ratio [or] = . , % ci: . - . ). trends of asthma in bangladesh remains, almost static over last years although at present prevalence is more in adults than children. in adults ( - years) all categories were slightly higher than in children ( - years) ( . % versus . %; odds ratio [or] = . , % ci: . - . ). it is found to be significantly higher in house-holds with one to fi ve members than in larger households (or = . , % ci: . - . ). the poor two quintiles (or = . , % ci: . - . ) and illiterate group (or = . , % ci: . - . ) and primary level of education (or = . , % ci: . - . ) were more vulnerable to asthma attacks than the highincome group and more educated people, respectively. conclusion asthma has increased from million people to million over last years although prevalence is almost similar. introduction secretory gvpla is an inducible protein and an essential signaling molecule for airway infl ammation and airway hyperresponsiveness in immunosensitized and lps-induced ali in mice. however, identifi cation of secretory gvpla in human airway diseases has not been identifi ed previously. methods donors were classifi ed as non-asthmatic, asthmatic, copd or ipf from prior medical records. identifi cation of gvpla in airway microsections was quantifi ed by immunofl uorescence analysis. expression of gvpla in was analyzed using criteria for intensity scoring in a single-blinded method. in separate studies, airway smooth muscle cells (asmc) obtained from asthmatic and non-asthmatic subjects (regional organ bank of illinois) were cultured within h from death. adhesion was assessed by measuring the eosinophil peroxidase activity of adherent eosinophils to asmc. inhibition of adhesion was assessed using neutralizing mabs against surface adhesion molecules and mab against gvpla . results gvpla was abundantly expressed in airway smooth muscle, epithelium and endothelium of patients with a history of asthma compared to non-asthmatic. low expression of gvpla was observed in tissues from copd and ipf subjects. in cultured asthmatic asmc, surface icam- and vcam- also were upregulated. activation of asthmatic asmc with methacholine caused release of gvpla , which corresponded to augmented eosinophil adhesion; mcl- g , a mab against gvpla , prevented these responses. blockade of surface β -/β -integrin on eosinophils or its counter-ligands on asmc blocked also the adhesion. conclusion our data demonstrated that gvpla is highly expressed in asthmatic asm but not in patients having, no history of asthma, copd or ipf. gvpla secreted from activated asmc augments eosinophil adhesion; mcl- g specifi cally blocked the cell-cell ligation. these data are the fi rst demonstration that the upregulated eosinophil adhesion to the surface of asthmatic asmc is linked directly to the secretory gvpla . based on our fi ndings, it is likely that the asmc, which is the natural source of gvpla , regulates airway infl ammation and airway hyperreactivity, which are hallmarks of asthma. supported by nih grant hl- and uk gsk center of excellence in asthma. introduction currently, there is still a lack of operational research analyzing the infl uence of an adequate tb curriculum in medical school. this study, aims to determine the effi ciency of integration of tb program into the medical school curriculum, measured through the knowledge, attitudes, and practices of medical clerks on tb. methods a questionnaire-based survey on the knowledge, attitudes and practices on tuberculosis was conducted among medical clerks (fourth year medical students) in the ust hospital. in total, questionnaires were randomly distributed, of which ( % response rate) of the questionnaires were returned fully accomplished. this was done over a period of one week. the questionnaire used was developed by hong, et al ; huebner, et al ; and yu, et al . and modifi ed by the present authors. results a total of . % (n- / ) of the clerks believed that sputum exam and culture are still the standard diagnostic modalities; quadruple therapy for - months as the standard treatment regimen. in total, . % (n = / ) realized the magnitude of the problem of tb in the philippines; half of them rated the directly-observed therapy, short course (dots) program as good. in order to avoid infection, % wear masks, . % keep their distance, and only . % open windows. only . % would add two drugs to the current regimen of a patient with suspected drug resistance; while . % responded with adding just one drug. conclusion the integration of tb program in the curriculum of ust medical students is effective in enhancing knowledge and improving attitudes of the medical clerks. however, there is still a need to stress the importance of other practices aside from wearing masks in order to avoid infection, and to clarify issues on drug resistance. the study was undertaken to assess the feasibility of diagnosing pulmonary tuberculosis (ptb) by collecting two sputum samples on a single day ( -day protocol) and to compare the same with the national policy of collecting two samples on consecutive days ( -day protocol). methods five hundred and thirteen individuals with cough exceeding weeks were screened for pulmonary tuberculosis (ptb) by collecting three sputum samples, viz. day- spot sample, sample collected hour after the fi rst sample and next day morning sample. for the -day protocol, performance of the fi rst and third samples were considered, while the -day protocol was evaluated using the two day- samples. staining and microscopy were undertaken by two different technicians in a blinded manner. results out of patients, patients defaulted on second day. of the total number of patients recruited, ( . %) were smear-positive. the -day protocol was capable of detecting patients ( . %), whereas in the -day protocol patients ( . %) were smear-positive (p = . ). of the drop-out patients, ( . %) were smear-positive. comparing the variation in results between spot and morning samples, collection of morning sample exhibited no signifi cant benefi t over the collection of a second spot sample. conclusion because the -day protocol does not lead to a statistically signifi cant diagnostic difference compared to the -day protocol, the latter can be adopted as an alternative protocol, particularly in subjects who are more likely to default. introduction tuberculosis, an important preventable and treatable cause of death, is a major health problem worldwide. detecting patients with active pulmonary tuberculosis is an important component of tuberculosis control as early appropriate treatment renders these patients noninfectious and interrupts the chain of disease transmission. sputum microscopy remains the test of choice as initial work-up for symptomatic patients with tuberculosis. however, in patients with a compatible clinical picture, sputum smears do not always reveal acid-fast bacilli. patients symptomatic for tuberculosis but are found to be smear-negative are recommended to undergo further tests including fi beroptic bronchoscopy and sputum induction. the latter, however, is invasive and more costly. this study aims to compare the sensitivity and specifi city of sputum induction and bronchscopy in the diagnosis of sputum smear-negative tuberculosis by means of meta-analysis. methods computer search was done to obtain studies meeting inclusion criteria. the sensitivity, specifi city and other measures of accuracy were pooled using forest plots. diagnostic odds ratios were obtained. summary receiver operating characteristic curves were used to summarize overall test performance. funnel plots and egger regression analysis were used to examine for publication bias. results five prospective studies comparing diagnostic accuracy of fi beroptic bronchsocopy and sputum induction to diagnose sputum smear negative tb were obtained. the pooled summary indeces showed that for bronchial lavage, the sensitivity is . ( % ci, . to . ) while specifi city is . ( % ci, . to . ). whereas for sputum induction, the sensitivity is . ( % ci, . to . ) and specifi city is . ( % ci, . to . ). the summary dor for bronchial lavage was . ( % ci, . to . ) while the summary dor for sputum induction was meaning sputum induction test had a higher level of overall accuracy ( % ci, to ). conclusion sputum induction has comparable sensitivity and specifi city and higher level of overall accuracy compared to bronchial lavage in diagnosing for sputum smear negative tuberculosis. introduction much of tuberculosis control is based on the current understanding of factors that infl uence transmission of mycobacterium tuberculosis and that lead to active tuberculosis among persons who acquire the infection. one of these activities, contact investigation, is intended to identify persons who have acquired tuberculosis infection from a newly discovered active case, thereby enabling targeting of preventive treatment to a group at high risk of developing active tuberculosis, this being the main goal of activity. methods the charts of close contacts of mdrtb patients enrolled in the programmatic mdrtb management of lcp phdu from january to june was reviewed. results there were contacts of culture and dst-confi rmed mdrtb patients identifi ed from january to june . among these contacts, ( . %) were traced and underwent evaluation and screening tests. among the contacts > years old, ( . %) had a positive chest x-ray, ( . %) were afb +, ( . %) were positive for mtb culture and sensitivity. in contacts < years old, ( . %) had positive chest x-ray results, but none had positive results on afb smear, and mtb culture and sensitivity. tuberculosis was identifi ed in of contacts < years old and of contacts > years old. there were mdrtb cases identifi ed ( confi rmed by culture and dst, and treated empirically), all from contacts > years old. all identifi ed mdrtb cases were treated with category iv regimens under pmdt, while other tb (non-mdrtb) cases were managed under dots. conclusion contact tracing remains a helpful tool in public health programs at the lung center of the philippines. although the average contact per index is . , . % were successfully traced, which is comparable to other studies abroad. among the screening tools, the chest x-ray was the most commonly utilized and also the most productive; afb smear, tuberculin test, and mtb culture were performed in less than %. among identifi ed contacts, mdrtb was noted in . %. introduction active pulmonary tuberculosis (tb) requiring intensive care is rare but known to be of poor outcome. the present study aimed to describe the characteristics of patients with this condition and to identify the mortality rate and risk factors that predicts in-hospital mortality. methods from january to december , patients were admitted to tuberculosis intensive care unit (tbicu) of mackay memorial hospital, taipei, taiwan. among these, patients were enrolled and were followed up for days. incidence of in-hospital deaths was documented in the medical records and all possible parameters contributing to mortality were collected for analysis. results the patients' median age was years (range - years). the median length of intensive care unit stay was days (range - days) and the median duration of mechanical ventilation was days (range - days). overall in-hospital mortality was % ( / ). sepsis and shock were independently associated with in-hospital mortality. conclusion these data indicated a high mortality of patients with active tuberculosis requiring intensive care, especially in those with sepsis and shock. introduction we have shown that two commonly used prediction model s (va and mayo) estimate poorly the probability of malignancy of solitary pulmonary nodules (spn) in the philippines. this is due to a large proportion of spn arising from tuberculosis (tb). in the philippines, and possibly for other countries with a high tb-burden, our clinical prediction model has a better estimate to the probability of spn than both the va and mayo. methods we developed a prediction model to identify malignant lung nodules based on clinical data and radiographic characteristics among patients with spn identifi ed retrospectively (october to march ) in our institution. univariate and multiple logistic regression analysis were used to identify independent clinical variables. we applied the model to a new set of spn patients (april and august ) and described its accuracy by comparing the predicted probability of malignancy with the fi nal diagnosis. we constructed receiver operating characteristic (roc) curves and reported % confi dence interval. calibration was done by dividing the sample into fi ve equal groups based on predicted probability and plotting the median probability of each quintile against the observed frequency of malignancy for that group. results seventy-six spn patients were included in the development of the prediction model, where size, margin and smoking history were found significant in the multivariate analysis. prevalence of malignancy was %. the area under the receiver operating characteristic (roc) curve was . ; % confidence interval (ci) of . - . . the equation was obtained based on the identifi ed predictors. fifty-eight patients with spn were included in the validation sample. prevalence of malignancy was %. the roc curve was . ; % c.i. of . - . . median predicted probabilities in all quintiles were lower than the observed frequency of malignant nodules, probably refl ective of the validation sample's higher prevalence of malignancy. conclusion the local clinical model appeared to be suffi ciently accurate to inform clinical decisions about the choice and interpretation of subsequent diagnostic tests. the accuracy of the local clinical prediction model was similar to that reported in its development. introduction in a high-burden country for pulmonary tuberculosis like philippines, it's not uncommon for intracthoracic masses be treated empirically with anti-tuberculosis regimen. we aim to describe patients' profi les, determine outcomes of empiric anti-tuberculosis treatment for such lesions. methods we monitored patients with intrathoracic mass given empiric antituberculosis regimen until "end-of-treatment," decision to pursue diagnosis, or mortality. a -year prospective, observational, open-label, descriptive, cohort study, in a tertiary government hospital. percentage association analysis was done at end of the study. results in total, patients presenting with intrathoracic mass lesions on chest x-ray/chest ct scan were treated empirically with anti-tuberculosis medicines without histopathologic evidence suggestive of pulmonary tuberculosis for the mass. patients' choices, clinical and fi nancial status were factors considered by physicians in the decision for empiric treatment. there were males, females, with average age years. most common chief complaints were cough ( %), pain ( %), hemoptysis ( %), shortness of breath ( %). patients had pulmonary consult within months of initial radiography. histology of mass was confi rmed within months of pulmonary consult in patients. patients had the histopathology prior to starting empiric anti-tb treatment, which revealed non-specifi c fi ndings. a total of patients were treated empirically prior to attempts for histologic diagnosis. two of these patients never had diagnostics due to fi nancial constraints. while patients went on to pursue histopathology, which revealed underlying malignancy in eight patients. malignancy was seen more on males, older age (≥ years), signifi cant smoking history, larger mass size (∼ - cm). seven patients had clinical/radiographic improvement, two patients died, three were lost to follow-up. conclusion our study suggests no role for empiric anti-tb treatment for intrathoracic masses, even in a high-burden country like philippines. we should vigorously pursue and search for defi nite histological diagnosis, as it will translate to cost-effectiveness, avoidance in delayed diagnosis, early institution of appropriate therapeutic management. we recommend further studies with larger sample size, to characterize patients' profi les, do subset analysis, identify who may need anti-tuberculosis treatment. introduction the use of viruses as targeted cancer therapy has shown signifi cant promise for novel anticancer therapy. actually, a small number of enteroviruses, such as coxsackievirus a (cva) and echovirus, have been reported to possess oncolytic activities against various human malignancies. however, a single intratumoral administration of cva in vivo induces severe progressive muscle paralysis necessitating euthanasia of mice. in this context, we discovered that coxsackievirus b (cvb) displayed a high level of tropism and lytic activities for human lung cancer cell lines as a result of screening of representative enteroviruses. cvb specifi cally destroyed both human non-small and small cell lung carcinoma via surface virus receptors of coxsackievirus and adenovirus receptor (car) at a multiplicity of infection (moi) of . , whereas it did not destroy normal lung cells at even a higher moi of . the mts cell proliferation assay also supported those results. furthermore, our in vivo study showed that consecutive intratumor injections of cvb remarkably inhibited the growth of subcutaneously pre-established lung tumors, with signifi cantly more increased survival than untreated mice (p < . ). surprisingly, in metastatic tumor mice model, intratumoral cvb injection into primary tumors in the right fl ank also signifi cantly retarded the growth of pre-established contra-lateral tumors compared with untreated mice. according to the results of fragmented parp detection assay, the oncolytic effects of cvb against tumors could be partially attributed to their apoptosis as well as cellular degenerative destruction. furthermore, fl ow cytometric analyses showed that cvb could possess an immuno-stimulatory ability through robust infi ltrated dendritic cells maturation in treated tumors. moreover, none of mice died of cvb administration, suggesting the feasibility of clinical trials in the future, although analyses of serum biochemistry revealed moderate hepatic dysfunction due to cvb administration. conclusion our fi ndings suggest that intratumor cvb administration could be a novel therapeutic modality against not only primary human lung cancer but also metastasized lesions. introduction radio frequency ablation (rfa) is a technique that employs high-energy radio frequency waves to destroy non-small cell lung cancer. the radio frequency ablation probe, le-veen multiple array needle electrodes, is placed inside a tumor and opened like a tiny umbrella with curved prongs that spring into the surrounding tumor tissue. with this tool tumor cells are somewhat heated until they boil and become inert. methods patients with medically inoperable or unresectable single nodule nsclc underwent treatments, in different centers of bangladesh. multimodality treatment was mode of management. on the basis of intention to treat, patients were divided into fi ve groups for fi ve mode of treatment. group : percutaneous rfa (n = ); group : rfa followed by radiotherapy (n = ); group : chemotherapy with rfa (n = ); group : radiotherapy alone (n = ); and group : chemo radiation (n = ) during -year period ( - ). patients' characteristics, local recurrences and overall and disease-free survivals were compared. results in total, patients were selected for study since december . mean size of tumors were ± . (range . - . cm). follow-up range was from to months, median . months. survival rate of group : only percutaneous rfa was % at year, % at years and % at years; for group : rfa and ebrt % at months, . % at year, . % at years, and . % at years; group : patients treated rfa with chemo therapy % at year, % at years and % at years; group : with radiotherapy alone % at year, % at years, and % at years; for group : similar patients treated with chemoradiation % at year, % at years and % at years. irrespective of stages, patients with tumor size cm (n = ) had an average survival ± months. local recurrence occurred in . % having tumors size cm. developed pneumothorax and had lung infections, of them had fetal. a total of patients died of co morbid diseases while died of disease progression within years following rfa and ebrt or chemotherapy or rfa alone. conclusion the rfa followed by ebrt or rfa along with adjuvant or neo adjuvant chemotherapy for inoperable nsclc has a relatively low rate of complications that are easily managed and above all survival has improved compared with other combination therapy, i.e. chemoradiation. nb: rfa plus chemotherapy was only applied in stage ii and iii. introduction patients with chronic or debilitating illness such as lung cancer usually accompanied by some form of emotional responses such as denial, anxiety, and depression. clinician should be aware of these condition for better lung cancer management. methods hamilton rating scale for anxiety and depression questionnaire were administered to all patients diagnosed with lung cancer in dept pulmonology-respiratory medicine university of indonesia/persahabatan hospital consecutively. follow-up evaluation will be done to evaluate anxiety/depression after a -month therapy. results among lung cancer patients , ( %) has anxiety, patients ( %) has depression and all patients with depression also has anxiety. these conditions commonly found in male than female ( out of male patients ( %) vs. out of female patients ( %)). further evaluation are underway to evaluate the degree of these disorders and other factors correlate with these disorder. conclusion depression and anxiety were also found in lung cancer patients and need further evaluation and attention from clinician. to compare the preoperative classifi cation of lung carcinoma made on histological specimens by fiberoptic bronchoscopy(fob)with the postoperative classifi cation made on resected specimen and how often was used term of nsclc. methods we reviewed the records patients who had a diagnosis ofthe lung cancer made by fi beroptic bronchoscopic biopsy (at yedikule chest hospital, istanbul in ) and who underwent a lung resection.postoperative histological classifi cation were made according to the who classifi cation of the lung tumours. results fifty one of squamous carcinoma, of adenocarsinoma and of carcinoid tumours were correctly typed with the small biopsy obtained by fob. forty eight patients who had a diagnosis of lung cancer established by fi breoptic bronchoscopy were labelled as nsclc, %, % and % of them were classifi ed squamous carcinoma , adenocarcinoma and other tumour type respectively with examination of tissue obtained by surgical resection. conclusion accurate cell typing by specimens obtained at fi breoptic bronchoscopy may be extremely diffi cult.if clearcut morphological criteria can not be satisfi ed , the diagnosis of "lung cancer ,non-small cell" type should be made. introduction the nsclc patients who experienced good clinical responses even sometimes dramatic responses to egfr-tkis gefi tinib or erlotinib will inevitably develop acquired resistance. however, the clinical defi nition of acquired resistance is not clear. we investigated the clinical characteristics of acquired resistance to gefi tinib in nsclc retrospectively. methods we analyzed four hundred and forty nsclc patients who had taken gefi tinib more than months duration. all clinical data were obtained from centers of korean molecular lung cancer group (kmlcg). the timing, clinical manifestations, and the association of egfr genotype were analyzed in the aspect of acquired resistance development. the mean duration of gefi tinib prescription was . + . months. signifi cant predominance in female ( . %) and non-smoker ( . %) was noted. among the patients who examined egfr genotype, the mutation rate was . % ( / ), relatively lower than expectation. the relative ratio of local vs. systemic progression is . %: . % and symptomatic progression rate is . %. the survival time after the development of acquired resistance is . + . months. conclusion these retrospectively analyzed clinical data for the development of acquired resistance to gefi tinib will help set up the clinical defi nition of acquired resistance to egfr-tki. introduction numerous studies have documented overall effectiveness and safety of chemical pleurodesis using variety of agents. although reports regarding complications post-talc pleurodesis were minimal, concerns on the adverse effect profi les remains, especially on occurrences of serious and life threatening respiratory insuffi ciency and ards following talc pleurodesis. methods records of patients admitted at lcp who underwent talc pleurodesis from january to december were reviewed and all complications post pleurodesis were noted. results a total of charts of patients admitted at lcp who underwent pleurodesis from january to december were reviewed. the mean age was ± y/o with male predominance compared to female at ( . %) and ( . %) respectively. of the total procedures evaluated, ( . %) involved all post procedure complications, ( . %) patients developed minor complications while ( . %) had major complications. there was no statistically signifi cant association noted with age, sex, smoking history, co-morbid illness, underlying disease, and method of pleurodesis, while chest tube drainage time more than days was noted to be associated with greater incidence of major complications which was statistically signifi cant. most common minor complications were fever ( . %), followed by tachycardia ( . %), chest pain ( . %) and dyspnea ( . %). the top major complications were hypoxemia, hypotension and pneumonia. there were ( . %) patients who died post pleurodesis that is believed to be related to ards following talc slurry. conclusion talc pleurodesis is an effective agent for chemical pleurodesis but not without adverse effects. cardiovascular complications are potentially avoidable by proper patient selection and preparation prior to talc pleurodesis. respiratory failure and ards are rare but serious complications that should be promptly recognized and addressed rapidly and effectively. introduction nebulized antibiotic is an established safe and effective therapy for bronchiectasis. gentamicin are considered among the most useful classes of antibiotics for treating pseudomonas aeruginosa infections.the major drawback of aminoglycosides is the need for their relatively high dose intravenous administrations which carries the potential systemic toxicity.when gentamicin is given intravenously in maximum safe doses, only relatively low sputum concentration are achievable. these limitations can be circumvented by direct delivery of aerosolized antibiotic to the airways. methods this study was carried out in nidch dhaka. in total, patients were taken initially for the study. introduction immune-modulator nutrition may decrease mortality among patients who are mechanically ventilated due to severe community acquired pneumonia (cap). methods we compared an immuno-modulator nutrition and standard feeding formula to determine the effect on in-hospital mortality as well as days mortality among mechanically ventilated patients due to severe cap. the mean number of ventilator days, icu stay, as well as clinical parameter (clinical pneumonia infection score (cpis) and pao /fio ratio from arterial blood gas) was also compared. in total, eligible patients were randomized, double blind, to receive either immuno-modulator nutrition (supportan sp) or standard feeding formula (sf). follow-up was done on day , and on cpis and pao /fio ratio. results primary outcome was mortality. no signifi cant difference noted between the two groups (p = . ; % ci: − . to . ). the day mortality on patients revealed patients ( . %) died on sf group and patient ( . %) on sp group (p = . ; % ci: − . to . ). the mean ventilator days on the sf group and sp group was . days and . days respectively (p = . ; % ci: − . to . ), although not signifi cant, it suggests a trend favoring sp group. the mean icu stay in the sp group was noted to be signifi cantly shorter ( . days) than in the sf group ( . days) (p = . ; % ci: . to . ). the cpis and pao /fio ratio were done on day , and . on day , the mean pao /fio ratio was still signifi cantly higher on the sp group (p = . ; % ci: − . to − . ); while the mean cpis was still the same with baseline (p = . ; % ci: − . to . ). on day , no significant difference was noted (p = . ; % ci: − . to . and p = . ; % ci: − . to . , respectively), as well as those on day (p = . ; % ci: − . to . and p = . ; % ci: − . to . , respectively). conclusion we found no difference on mortality between sf and sp group. however, it suggests trend of earlier extubation and signifi cant shorter in icu stay, in patients who received immuno-modulator nutrition. introduction several equations to predict lung function of individuals of different population are available. however it is desirable that lung function laboratories use reference equations that most closely describe the population they test. the objective of the study was to develop a prediction equation for the malaysian population. methods spirometry was performed on a total of "healthy", lifetime non smoker volunteers ( males and females) all measurements met the ats acceptability and reproducibility criteria. prediction equations were derived for both men and women for fvc and fev . the equations were validated on a new group of subjects (n = , males and females) who met the same inclusion and exclusion criteria as the main cohort. introduction patients with severe asthma (experiencing previous hospital admissions and/or daily symptoms) have occasionally been seen with poor or weak complaints. several studies have analyzed the psychiatric status of the patients with severe asthma, but few studies have the japan respiratory society (jrs) has proposed new predicting scores, called the i-road system for hospital acquired pneumonia (hap) in . depending on the presence of the parameters listed below, patients with hap were stratifi ed into those with high, moderate or low-risk. the high-risk group was defi ned as patients with three or more of the following risk factors: 'malignant tumor or immunocompromised status', 'impaired consciousness', 'requiring fraction of inspired oxygen (fio ) > % to maintain spo > %', 'male aged years or older, or female aged years or older' and 'oliguria or dehydration'. the moderaterisk group was defi ned as patients with any of the secondary risk factors as follows: 'crp ≥ mg/dl' and 'extent of infi ltration on cxr covers at least / of one lung'. the low-risk group was defi ned as all other patients. the aim of this study was to confi rm whether i-road is useful in predicting severity of cap and hcap. methods all patients with an admission diagnosis of cap and hcap from january -july were reviewed. clinical and laboratory features at presentation in electrical medical records were used to calculate severity scores using the curb- ( ), a-drop ( ) and i-road ( ). results consecutive patients ( % cap) of mean age . years were included in the analysis. nineteen ( . %) patients with cap and seventeen ( . %) patients with hcap died. the roc analysis for predicting mortality at days showed that i-road score has similar predictive accuracy for short-term mortality to curb- and a-drop in patients with cap, but shortterm mortality of the patients with hcap are not similar to them. conclusion the jrs i-road could be used to assess severity of cap, and gives similar results to curb- and a-drop. os - introduction numerous asthma and copd patients repeatedly return to hospital ed for urgent therapeutic care despite referral to their primary care provider. this study was aimed to identify these respective populations with frequent ed visits and assess the current therapeutic management of acute exacerbation of asthma and copd at hospital kuala lumpur, malaysia. methods the demographic and medical data was prospectively collected and recorded in march using convenient sampling, and then descriptively analyzed using spss version . appropriate statistical analysis were applied with p < . was considered as signifi cant. the study recruited patients (male . %) with . % asthmatics and . % copd. malays signifi cantly presented to ed the most ( . %) followed by indians ( . %) and chinese ( . %). most patients were between - years old ( . %) with mean age of . . about . % were smokers ( . % ex-smokers) with an average duration of smoking . years and . pack-years. for occupational data, . % were belonging to non-professional group. about . % asthma and . % copd patients had visited ed last year with average visit of . and . times and mean number of hospitalization was . and . , per year, respectively. about . % patients without scheduled appointments and . % were not on any prescribed medications for asthma or copd. among patients with prescribed medications, . % were on saba and . % on inhaled corticosteroids. respiratory infections remained as main triggering factors of admission ( . %), followed by weather ( . %) and air pollution ( . %). average duration of treatment was about minutes with mean direct therapy cost of rm per patient excluding the standard admission fee. whil hr monitoring, the level of oxygen saturation and pefr were signifi cantly improved post treatment. oxygen-driven nebulised saba and iv hydrocortisone were the mainstay of treatment. however, the use of an anticholinergic as a step up approach in nebulised treatment was underused. most discharged patients were given oral saba ( . %) and prednisolone ( . %). pefr measurement was not practiced post treatment regularly. conclusion limited number of staff contributed towards omitted monitoring steps. involvement of ed pharmacists in respective therapeutic management is highly suggested. introduction fluid volume is an important factor when considering pleural drainage. however, there is limited literature regarding accurate quantifi cation of pleural effusion by ultrasonography. in a study by visperas et al, they quantifi ed the pleural effusion volume by measuring the length, width, and depth of the fl uid, while the patient was in a sitting upright position, and the actual volume drained. they postulated a linear regression equation to quantify estimate the pleural fl uid volume that will be drained. introduction insomnia disorder is the most common sleep disorder which affected more than people in bangladesh. people develop chronic insomnia disorder with symptoms of diffi culty falling asleep for more than minutes and last for more than month. patients with insomnia disorder in bangladesh took sleeping pills each year for insomnia disorder. however, there were still some side effects about sleeping pills such as allergy, amnesia, hallucination etc. because of the side-effects of modern medicine and because of the inability of modern medicine to cure insomnia disorder, international scientifi c interest has re-focused on the traditional uses of medicinal plants to fi nd effective cure for insomnia disorder as well as hundred of other disorders. a study of the traditional health practitioners in the habiganj district of bangladesh suggested that some of the herbal medicines prepared from medicinal plants might be quite effective for insomnia disorder. methods information was collected through a series of interviews with the traditional health practitioners, rural and urban people. field notes were recorded on the medicinal plants and their uses; following the methodology of bhat et al. ( ) and martin ( ) . the identifi ed medicinal plant specimens were stored at the bangladesh national herbarium; under the author's collector series. results the following medicinal plants or plant parts were found to be used as remedy for insomnia disorder: cyrtandra cupulata ridl., bacopa monnieri (l.) pennell, ocimum gratissimum l., lawsonia inermis l., cinnamomum camphora (l.) sieb., aconitum napellus l., datura metel l., mimosa pudica l., achyranthes aspera l., piper betle l., randia dumetorum (retz.) poir., ficus glomerata roxb., nigella sativa l., agaricus albolutescens zeller, ipomoea aquatica forssk., stephania japonica (thunb.) miers, withania somnifera (l.) duna, cannabis sativa l., calamus rotang l., uraria picta (jacq.) dc., sesamum indicum l., asparagus racemosus willd., abrus precatorius l., and brassica napus l. conclusion information on indigenous use of medicinal plants has led to discovery of many medicines in use today. it is important that modern scientifi c studies be conducted on these medicinal plants towards isolation and identifi cation of compounds through which insomnia disorder can be effectively treated. introduction existing data on the association between sleep duration and blood pressure in adolescents are inconsistent and confl icting. this study aims to determine the relationship between sleep duration and -hour ambulatory blood pressure in adolescents. methods subjects aged - . years were recruited from the community. they underwent nocturnal polysomnography (psg) and -hour ambulatory blood pressure monitoring (abpm) on the same day. daytime, nocturnal and -hour average systolic and diastolic blood pressure (sbp and dbp) were converted to z score with reference to height and gender according to normal reference. a -day sleep diary was completed prior to psg. daily sleep duration was defi ned as the average of nocturnal sleep duration plus the average of daytime nap duration over week. subjects with body mass index (bmi) greater than the th percentile of the local normal reference were classifi ed as overweight. those who were overweight and had an obstructive apnoea hypopnoea index (oahi) greater than or equal to were excluded from the analysis. results one hundred forty one subjects ( boys) with a mean (sd) age of . ( . ) years were recruited. they were divided into groups according to their daily sleep duration (< . vs. . - . vs. . - . vs. > . ). subjects with shorter sleep duration tended to have higher daytime sbp (p < . ), nocturnal sbp (p = . ) and -hour sbp (p < . ). similar results were found after converting the bp data into z score (p = . , . introduction some studies have shown decreased plasma and hair zn in human asthmatics which may indicate a state of zinc defi ciency. we have shown, in a well characterized murine model of allergic airway infl ammation, that there were marked losses of zinquin-stainable (labile) zn in the infl amed airway epithelium (ae); when these mice were placed on low zn diets, there was excessive cell death in the ae, and increased airway infl ammation. we have proposed that labile zn protects the ae from premature cell death and loss of this zn contributes to the ae fragility and infl ammation in asthma. a screen of whole lung gene expression of the two major families of zip infl ux transporters and znt effl ux transporters, indicated a marked loss of znt in the infl amed lungs. the hypotheses being tested here are ) ae zn is normally stored in vesicles within the apical cytoplasm, ) znt is responsible for transporting zn into these bodies and ) loss of znt expression in asthma may result in a failure of zn to be sequestered. methods human nasal epithelial brushings were obtained from healthy, consenting donors. lung tissue was obtained from balb/c mice sensitized and aerosol-challenged with ovalbumin or saline (controls). distributions of zinc were determined by zinquin fl uorescence or in vivo selenite autometallography (se-amg). distributions of znt were determined by immunofl uorescence. results zinquin fl uorescence of human and murine ae indicated abundant labile zn with a vesicle-like pattern of staining in the apical cytoplasm. se-amg confi rmed the presence of apical zn vesicles at an ultrastructural level. there was strong immunolabelling for znt in the same region. furthermore, there was an almost complete loss of znt protein in the bronchial epithelium of mice with allergic airway infl ammation. conclusion colocalization of znt with labile zn in ae may indicate a role for this zinc transporter in replenishing zn storage pools in this tissue. loss of znt protein during airway infl ammation would then result in failure to sequestrate zn, depleting critical storage pools of zn in the lung and airways, leading to increased ae damage and cell death. this work was supported by nhmrc project grant . introduction community-acquired pneumonia remains a major cause of mortality in developed countries. there is much discrepancy in the literature regarding factors infl uencing the outcome in the elderly population. methods data were derived from a multicentre prospective study initiated by the german competence network for community-acquired pneumonia. patients with community-acquired pneumonia (n = , ; , aged < years and , aged ≥ years) were evaluated, of whom . % were hospitalised and . % treated in the community. clinical history, residence status, course of disease and antimicrobial treatment were prospectively documented. microbiological investigations included cultures and pcr of respiratory samples and blood cultures. factors related to mortality were included in multivariate analyses. results the overall -day mortality was . %. elderly patients exhibited a signifi cantly higher mortality rate that was independently associated with the following: age; residence status; confusion, urea, respiratory frequency and blood pressure (curb) score; comorbid conditions; and failure of initial therapy. increasing age remained predictive of death in the elderly. nursing home residents showed a four-fold increased mortality rate and an increased rate of gram-negative bacillary infections compared with patients dwelling in the community. conclusion the curb score and cerebrovascular disease were confi rmed as independent predictors of death in this subgroup. age and residence status are independent risk factors for mortality after controlling for comorbid conditions and disease severity. failure of initial therapy was the only modifi able prognostic factor. introduction hospital-acquired pneumonia (hap) attributes to % of all nosocomial infections. mortality rate is as high as - %. guidelines for the management of adults with hap were recently updated. despite the emergence of evidence-based medicine, the use of these guidelines in daily clinical practice is still limited. currently, there is no literature published regarding the impact of adherence to the guidelines and clinical outcomes of hap. methods a total of patients (male: %; female: %) admitted and diagnosed with hap at our center were followed up to investigate the rate of adherence of physicians on the diagnosis and treatment of hap based on level i and ii ats/idsa recommendations and to determine its association with outcome (mortality, mechanical ventilation, icu stay, hospital stay). adherence to diagnostics and therapeutic management were computed per patient. management of patients was classifi ed as adherent if it meets more than % of the guidelines that should be enforced. results in this cohort, % of the physicians adhered to the currently recommended guidelines. age, gender, and co-morbid conditions such as hypertension, diabetes mellitus, copd, ckd and cerebrovascular disease were not statistically associated with the outcome of the study. a total of % of the subjects were eventually mechanically ventilated (p = . ). a total of % of patients who adhered to the recommendations consequently died during hospitalization (p = . ). similarly, univariate analysis of variance revealed that there is no signifi cant association of adherence to length of icu stay and hospital stay (p = . , . respectively). of the level i and ii current recommendations, request of blood culture showed signifi cant association with adherence (p = . ). however, logistic regression analysis showed that there is no association of adherence in doing blood culture to mortality. conclusion this analysis showed that compliance with the currently recommended ats/idsa recommendations is %. blood culture is the most signifi cantly associated recommendation. rate of endotracheal intubation, length of icu and hospital stay and mortality however was not signifi cantly associated with adherence. introduction reportedly high arsenic level in drinking water causes increased mortality and morbidity in adult copd patients. arsenic related health hazards include respiratory symptoms with decreased lung function added to skin lesion. currently million people of bangladesh are at potential risk of consuming arsenic contaminated drinking water and a major section of them showed many symptoms including alteration of lung function. methods the present study was conducted on chronic arsenicosis patients in selected areas of bangladesh to assess lung function status by measuring fvc, fev , fev / fvc% & pefr. in total, subjects of - years of age of both sexes were selected. apparently healthy subjects were selected from non arsenic residency as well as not exposed to arsenic in their tube-well water and were grouped as healthy control. of subjects from area exposed to arsenic contaminated tube-well water, were patients of chronic arsenicosis with skin lesions were considered as experimental group, whereas subjects without skin lesions were regarded as exposed control. results the mean measured values of the lung function parameters of nonarsenic exposed healthy control and exposed control were within normal ranges. but these values were signifi cantly lower in chronic arsenicosis patients with skin lesions. the parameters showed negative correlation with age, arsenic concentration in tube-well water but positive correlation with duration of the consumption. but these relationships were not statistically significant. all the patients of arsenocosis complained about respiratory symptoms in the morning. conclusion the present study reveals that arsenicosis patients are suffering from respiratory insuffi ciency and symptomatic respiratory illnesses. in addition, populations consuming higher arsenic concentration in drinking water are at the risk of lung function impairment and ultimately may lead to respiratory disorders, though it would be better to draw a defi nite conclusion from a further study involving large sample size. introduction despite of the detailed study of community-acquired pneumonia, the role of atypical microorganisms such as m. pneumoniae, c. pneumoniae and l. pneumophilla is not still defi ned. also there are some discussions about role of the associations of these bacteria with the other so-called typical microorganisms as s. pneumoniae and h. infl uenzae as well as the place of the viral pathogens in community-acquired pneumonia ethiology structure. the aim of our research was to defi ne the etiology of the community-acquried pneumoniae in young adults ( - years, fi rst group) and to compare the results with the data gained in aged patients (< years, second group). methods the young and aged patients with community-acquired pneumonia were screened with bacteriological, disk-diffusion with mic, pcr and other methods. antimicrobial agents resistance was checked to nccls standards and the clonality of the isolates was checked by pfge and mlst for the most frequent clones. results bacterial associations were defi ned in % versus % in the second group. m. pneumoniae was identifi ed in % vs %, c. pneumoniae . % vs %. the bacterial pathogens were represented with the species s. pneumoniae ( . %/ %), h. infl uenzae ( . %/ %), m. catarrhalis ( . %/ %). among the viral pathogens the most often was metapneumovirus in young adults ( %), and infl uenzae virus in aged patients ( %). the most prevalence bacteria were genotyped and there were revealed the relations between several isolates of m. pneumoniae and s. pneumoniae existing as association in several cases of different age groups what proved the epidemiological character of the spread of this association. so, the most frequent clone of s. pneumoniae was recognized as st , as well as st . pfge typing of atypical microorganisms also revealed the spread of the several clones. conclusion some changes in etiology structure of community-acquired pneumonia seems to be connected with the changes in immunology peculiarities of different age groups, as well as with the other epidemiology reasons. introduction despite of the detailed study, the role of acinetobacter baumanii pathogen as the a ubiquitous opportunistic nosocomial pathogen is still appreciated. the most of epidemiological aspects of this infection are still discussed though the problem of the microbiology charecteristics of this pathogen are of keen microbiology interest. it is often isolated in immunocompromised hosts in different forms of hospital-acquired infections, but more often it was recognized as the main pathogen agent of hospital-acquired pneumonia. the aim of our research was to establish clinical signifi cance of a. baumanii in development of hospital-acquired pneumonia, to defi ne its epidemiology and to characterize antimicrobial agents resistance pattern. methods we made -year surveillance of all hospital-acquired pneumonias (hap) in adult patients in the main clinics of vladivostok (hospital Ð , Ð ), defi ned etiology with standard microbiology methods. all isolates of a. baumanii were tested for antimicrobial agents resistabce according to nccls. the strains with the same antimicrobial agents resistance pattern were checked to clonality by pulsed-fi eld gel electrophoresis (pfge). results during - , we studied all cases of hap in adult patients (< years) admitted to icu and revealed that a. baumanii has taken the second place in etiology structure ( . %, cultures from patients). the fi rst place was in pseudomonas aeruginosa ( . %, strains) and the third one was in stenotrophomonas maplthophila ( . %, strains). mostly ( strains, . %), a. baumanii was isolated as monoinfection, but in other cases it was isolated in association with another strains of a. baumanii, or p. aeruginosae, s. palthophila, s. aureus, e. feacalis, e. cloaceae. there were defi ned lower resistance to ciprofl oxacin. the clonality research revealed about genotype clusters what could allow to suggest the genetic relatedness of the isolates. conclusion acinetobacter baumanii should be studied to defi ne the role in hospital-acquired infections, as well as it confi rms the fact that the importance of local surveillance programs in correctly guiding empiric therapy and local intervention programs in attempt to reduce antimicrobial resistance. introduction community acquired pneumonia (cap) is the most common cause of death associated with infectious disease. locally, it is the leading cause of morbidity and the fi fth cause of mortality according to the department of health. the initial management decision after diagnosis is to determine the site of care: outpatient, hospitalization in a medical ward, or admission to an icu. the decision to admit the patient is the most costly issue in the management of cap, because the cost of inpatient care for pneumonia is up to times greater than that of outpatient care. it is a well documented fact that signifi cant variation in admission rates among hospitals and among individual physicians occurs. physicians often overestimate severity and hospitalize a signifi cant number of patients at low risk for death. because of these issues, interest in objective site-of-care criteria has led to attempts by a number of groups to develop such criteria. the two foremost criteria are the british thoracic society criteria (curb- ) and the pneumonia severity index (psi). the idsa/ats committee preferred the curb- criteria because of ease of use and because they were designed to measure illness severity more than the likelihood of mortality. patients with a curb- score > are not only at increased risk of death but also are likely to have clinically important physiologic derangements requiring active intervention. these patients should usually be considered for hospitalization. therefore, the study was done to determine and compare mortality rates of the admitted cases of community acquired pneumonia assessed by either curb- criteria or the philippine clinical practice guidelines on cap, and to determine the applicability of curb- as a site-of-care tool in the admission of patients with community acquired pneumonia either at the wards or the intensive care unit. methods all patients seen at the emergency room and out-patient department with the diagnosis of community acquired pneumonia were included in the study. thorough history-taking and physical examination was taken by the er/opd fellow whom would determine if the patient has pneumonia. subsequently, laboratories (cxr, cbc, bun, abg) was requested. randomization was done for severity assessment: one group was assessed via the curb- criteria, while the other group was assessed using the philippine clinical practice guidelines for cap. severity assessment was done by the er fellow together with the investigator not more than one hour of the patient's arrival at the er/opd. patient was followed-up by the investigator within hours of admission (ward or icu) and until discharge or death. results a total of patients diagnosed with community acquired pneumonia (cap) were included in the study. the age range for the curb group is from to years of age with a mean age of . ± . years, while in the cpg group, to years of age with a mean age of . ± . years. no significant difference were noted (p = . ). no signifi cant difference were also noted in the gender of both groups (p = . ). there was a signifi cant difference noted in the presence of comorbidities (p = . ) between the two groups, . % and . %, curb group and cpg group, respectively. the presence of previous ptb treatment, cardiovascular disease and copd, ranks as the three most common comorbidity. dyspnea ( . %), cough ( %) and fever ( . %) were the three most common symptoms noted. there were no signifi cant difference noted in these symptoms (p = . , . , . , respectively). with regards to the physical fi ndings: crackles ( . %), tachypnea ( . %), wheezes ( . %) were the three most common signs noted. no signifi cant difference were noted in most of the signs, except for "tachypnea" and "hypotension" (p = . , . , respectively). there were no signifi cant difference in the radiographic fi ndings between both groups. no signifi cant difference were also noted in the complete blood count results be it leukocytosis (p = . ), anemia (p = . ) and leukopenia (p = . ). there is a signifi cant difference in the blood urea nitrogen (p = . ). no signifi cant difference was also noted in the arterial blood gas result: hypoxemia (p = . ) and hypercapnia (p = . ). for the curb- group, more than half of the population was assessed to have a score of (in-patient), ( . %). for the cpg group, more than half was assessed to be under the moderate risk, ( . %). all of the patients assessed in the lower severity class, either thru the curb- or the cpg, had been discharged improved. the overall mortality rate per group was: . % for the curb- group, out of the patients, and . % for the cpg group, out of the patients. mortalities were noted only on those with higher severity ratings. on further determination of mortality rate per level of severity, it revealed that those with a curb- score of ≥ has a mortality rate of . % ( out of the patients), while those on the cpg, . % ( out of the patients). conclusion in this study, we determined that all of the mortality came from the higher severity levels: curb- score ≥ ( . %), cpg-high risk ( . %), none from the lower severity ratings the curb- criteria is a useful site-of-care tool, though, the usage of curb- criteria does not offer additional benefi ts compared to the use of the cpg, in fact because of familiarity of physicians with the latter, they are more adept in using it. introduction acute exacerbation has been a major complication of interstitial lung disease (ild). the rapid recognition of a bacterial pneumonia and an acute exacerbation of underlying ild appears to be clinically important for proper treatment. procalcitonin (pct), a precursor peptide of the hormone calcitonin is commonly detected at elevated levels under bacterial infection conditions. this study was to assess whether or not serum procalcitonin levels were useful as a biomarker for the differential diagnosis of ild exacerbation from bacterial pneumonia. methods we had planned a prospective observational study. our study enrolled ild patients who had presented with recently progressive dyspnea, and newly infi ltrates of the chest in underlying ild. results nine of them evidenced bacterial pneumonia with high pct level. serum pct levels in ild exacerbation group were signifi cantly lower than in the pulmonary infection group (the mean value . ng/ml vs . ng/ml, % [ci]). sensitivity, specifi city, and negative predictive value of serum pct level were . %, %, . % respectively. conclusion the fi ndings of this study suggest that serum pct value is useful in the differential diagnosis of bacterial pneumonia from exacerbation in patients with interstitial lung disease. introduction it has been well confi rmed that malnutrition and muscle wasting are important extra-pulmonary manifestations of chronic obstructive pulmonary disease (copd), which are recognized as contributing to an increase in morbidity and decrease in quality of life. myostatin, a transforming growth factorbeta superfamily member, is mainly expressed in skeletal muscle and has been characterized as a negative regulator of skeletal muscle mass. studies have showed that myostatin is implicated in several diseases involved in muscle wasting and cachexia. recently, there is evidence of myostatin secretion and circulation in animals and human blood, and more recently, studies have shown that intramuscular myostatin expression accelerated in copd patients; while levels of circulating myostatin in copd remain unclear. we therefore analyzed serum myostatin levels to investigate the relationship between circulating myostain levels and nutritional depletion and muscle wasting in copd; and the relationship between circulating myostain levels and systemic cytokines such as tumor necrosis factor (tnf)-α and interleukin (il)- in copd. methods fifty-four male patients with stable copd and twenty-one agematched, healthy, male control subjects participated in the study. total-body skeletal muscle mass (smm) were calculated according to a validated formula by using body weight, height and age. nutritional status was evaluated by anthropometric measurements and serum protein levels; the former included body mass index (bmi), triceps skin-fold thickness (tsf) and mid-upper arm circumference (mac), and the latter included serum prealbumin, transferrin and albumin. serum levels of myostatin, tnf-α and il- were detected by elisa. results out of the patients with copd, ones ( . %) had malnutrition, with bmi less than kg/m . serum levels of myostatin were signifi cantly elevated in copd patients compared with controls ( . ± . ng/ml vs. . ± . ng/ml, p < . ), and the levels were even much higher in those with malnutrition ( . ± . ng/ml). however, smm was signifi cantly decreased in copd patients compared with controls ( . ± . kg vs. . ± . kg, p < . ). all the nutritional parameters except of prealbumin were signifi cantly decreased in copd patients compared with controls, with each p < . . there is an inverse correlation between myostatin levels and smm (r = − . , p = . ) and a positive correlation between myostatin and tnf-α levels (r = . , p = . ) in copd group, but no correlation between myostatin levels and serum proteins concentrations. conclusion this study demonstrates that circulating myostatin levels were elevated in patients with copd and that the elevated myostatin levels are closely related with malnutrition and muscle wasting in patients with copd. introduction chronic obstructive pulmonary disease (copd) is defi ned by airfl ow limitation that is not fully reversible and no medication exists that clearly improves the mortality. oxidative molecules, in particular superoxide anion, are believed to play an important role in copd-associated abnormal infl ammatory response due to increase in the level of pro-infl ammatory cytokines and chemokines and pulmonary emphysema due to proteases/antiproteases imbalance and apoptosis. superoxide dismutase (sod) catalyses the dismutation of superoxide anion to hydrogen peroxide, which is subsequently detoxifi ed to oxygen and water. lecithinized sod (pc-sod) has overcome a number of previous clinical limitations of sod, including low tissue affi nity and low stability in plasma. in this study, we examine the effect of pc-sod on elastase-or cigarette smoke-induced pulmonary emphysema, animal models for copd. methods severity of pulmonary emphysema in mice was assessed by various methods, such as the number of leucocytes (neutrophils, lymphocytes and alveolar macrophages) in bronchoalveolar lavage fl uid (balf) and enlargement of airspace (increase in mean linear intercept). lung mechanics were assessed by a computer-controlled ventilator. the pulmonary level of superoxide anion was estimated by electron spin resonance analysis and the level of -hydroxy- ′-deoxyguanosine. results not only intravenous administration but also inhalation of pc-sod suppressed elastase-induced pulmonary emphysema and dysfunction. inhalation of pc-sod showed therapeutic effect against elastase-induced pulmonary emphysema and dysfunction even when it administered after the development of emphysema. inhalation of pc-sod suppressed elastase-induced increase in the pulmonary level of superoxide anion and apoptosis. inhalation of pc-sod also suppressed elastase-dependent activation of proteases and induction of expression of pro-infl ammatory cytokines and chemokines. we also found that inhalation of pc-sod suppressed cigarette smoke-induced pulmonary emphysema and dysfunction. conclusion results suggest that pc-sod protects against pulmonary emphysema through decreasing the pulmonary level of superoxide anion and resulting inhibition of infl ammation, apoptosis and activation of proteases. we propose that inhalation of pc-sod is therapeutically benefi cial for copd. introduction tiotropium is a recently developed inhaled anticholinergic in the management of copd, exhibiting a prolonged duration of action and a kinetic selectivity to specifi c muscarinic receptors, leading to a more effective bronchodilator response at once-daily dosing. we determined the effi cacy of long-term tiotropium use on clinical endpoints such as mortality, exacerbations, and hospitalizations compared to inhaled long-acting beta- agonists among patients with copd. methods search methods rcts were identifi ed from electronic databases. bibliographies and relevant reviews were also searched. the date of the last search is august , . selection criteria rcts among patients with copd comparing tiotropium monotherapy with inhaled labas with at least months follow-up were selected for inclusion. data on all-cause mortality, mortality from pulmonary causes, mortality from cardiovascular causes, rates of hospitalizations and exacerbations were identifi ed. data collection and analysis three investigators evaluated and extracted relevant data. any disagreements were discussed and consensus decisions were made. the data were analyzed using revman . studies were pooled to yield odds ratios and were reported using % confi dence intervals. results from rcts, clinical trials with a total of , patients met inclusion criteria. tiotropium did not reduce the odds of all-cause mortality (or . % ci . to . ) compared to inhaled labas. subgroup analysis also shows that tiotropium did not reduce the odds of mortality from pulmonary causes (or . % ci . to . ) but shows a trend that might increase mortality from cardiovascular causes (or . % ci to . ). tiotropium reduced the odds of hospitalizations from all causes (or . % ci . to . ) and showed a trend towards benefi t in reducing the odds of exacerbations (or . % ci . to . ). conclusion tiotropium did not reduce all-cause mortality among patients with copd compared to inhaled labas, although it showed a possible trend towards harm in causing cardiovascular mortality. it also reduced hospitalizations, although it did not decrease the odds of exacerbations among patients with copd. background patients from asia may have different outcomes compared to those from other backgrounds. we therefore examined outcomes in the subgroup of asian patients in the uplift trial. . more patients will be recruited until august in vietnam and singapore as well as in the above nine countries. this abstract contains an interim analysis. the recruited patients were mostly male ( . %) and elderly (mean age, . years). according to gold criteria, severity of airfl ow limitation was mild in . % of patients; moderate in . %; severe in . %; very severe in . %. a total of . % of patients were exposed to cigarette smoking; . % to dusty jobs. a total of . % of patients had symptoms of "chronic bronchitis -phenotype" viz. chronic cough with phlegm; . % had wheezing in the last months. a total of . % of patients were on regular medications, e.g. inhaled steroid combined with long-acting beta-agonist, theophylline, shortacting beta-agonist, tiotropium, combined inhaler of salbutamol and ipratropium, and inhaled steroid alone, in decreasing order. in the past one year, . % patients required/ were prescribed antibiotics for acute exacerbations and . % required/were prescribed oral steroids. of this cohort, % patients had unscheduled/ emergency visits to the er or were hospitalized. conclusion this interim report showed that asian copd patients are heterogeneous. a high proportion was exposed to dusty environments at their job sites and many were cigarette smokers. further studies are ongoing to fi nd out other characteristics of copd phenotypes including the infl uence of dusty job environment in the development and progression of copd in asia. introduction it is widely recognized that copd is not only a lung-based disease, but also a systemic disorder with systemic infl ammation, which further aggravates the disease progression at acute exasperation (aecopd). it is important to fi nd a systemic biomarker which is lung-specifi c and can be used to indicate the severity of the disease in the stable state (scopd) and at exacerbation. c reactive protein (crp) and tumor necrosis factor (tnf)-a have been attracted attention as they can refl ect the systemic burden of infl ammation, while they are not lung-specifi c. surfactant protein d (spd) is produced and secreted by alveolar type ii epithelial cells and clara cells. recently study has reported that spd can be used to track disease progression and predict clinical outcomes in copd. the present study was aimed to determine the value of spd as a biomarker of systemic infl ammation in staging the severity of copd and diagnosis of the exacerbation. methods we recruited three groups of subjects: patients experiencing aecopd (n = ), patients with scopd (n = ) and controls with normal lung function (n = ). elisa was used to analyze serum spd, crp and tnf-a levels. the bode scoring system was employed to evaluate health status of patients with copd, which included the four variables: body mass index, degree of airfl ow obstruction, dyspnea and exercise capacity. conclusion the present study confi rms that circulating spd levels are higher in copd and closely related with health status of the patients and severity of the disease; moreover, circulating spd can be regarded as a valid biomarker of systemic infl ammation and a potential diagnostic biomarker for aecopd. methods we reviewed all the records of bronchoscopies in our hospital from february , to january , and identifi ed patients diagnosed subsequently with primary lung cancer whose sputum cytology was negative or not performed prior to bronchoscopy. a total of patients with pulmonary tuberculosis were also identifi ed whose prebronchoscopic sputum acid-fast stains were negative or not performed. we reviewed the result of pathological examination of bronchoscopic specimens and postbronchoscopic sputum for the lung cancer patients and the result of mycobacterial culture of these specimens for the tuberculosis patients. of the lung cancer patients, postbronchoscopic sputum cytology was performed in patients and gave a positive result in ( . %) patients. the postbronchoscopic sputum was the only diagnostic specimen in ( . %) patients. meanwhile, postbronchoscopic sputum culture was performed in of the tuberculosis patients and was positive for m. tuberculosis in ( %) patients. of these patients, the culture of specimens obtained by bronchoscopy was negative in patients, of whom also had a negative result of prebronchoscopic sputum culture. conclusion postbronchoscopic sputum cytology has a limited role for the diagnosis of primary lung cancer and should not be performed in terms of cost-effectiveness. but its culture seems to provide additional information for the diagnosis of pulmonary tuberculosis and further studies are needed to determine when to obtain postbronchoscopic sputum specimens. for other malignant tumours -in ( . %) patients. in ( . %) patients with benign pathology procedures were performed for tracheomalacia -in ( . %), for tracheobronchial fi stula -in ( . %), for endobronchial lipoma -in ( . %) and for other pathology -in ( . %) patients. there were ( . %) unilateral, ( . %) -tracheal, ( . %) -tracheobronchial and ( . %) -bilateral bronchial procedures. on ( . %) occasions procedure was elective, on ( . %) -urgent and ( . %) times it was performed as an emergency. eight patients required stent replacement. stenting was performed under general anaesthesia using combination of rigid and fi beroptic bronchoscopy and in majority with intraoperative x-ray control. uncovered and covered ultrafl ex stents (boston scientifi c) have been mainly used. results there was no intra-operative mortality. eleven ( . %) patients died in hospital prior to discharge and of them died within hours after procedure. in all these patients urgent or emergency stenting was performed. tumour debulking and/or cryotherapy were required on occasions after stenting. hospital stay ranged from to (mean - . , median - ) days. in benign group there was one hospital death in a patient with tb stricture. in patients with malignant tumours total survival ranged from to (mean - . , median - ) days, in elective subgroup -from to (mean - . , median - ) and in urgent subgroup -from to (mean - . , median - ) days. all patients had signifi cant improvement of distressing symptoms. conclusion tracheobronchial stenting is rapid and effective technique of palliation in patients with malignant or in selected cases of benign tracheobronchial stenosis. it provides better outcome if performed electively. stent occlusion may be controlled by endobronchial cryotherapy. introduction in the clinical evaluation of airway disease, fi beroptic bronchosopy (fob) is a crucial tool in the diagnosis. however it is invasive, time-consuming and requires sedation. endobronchial lesions may be seen in both fi beroptic bronchoscopy and mdct virtual bronchoscopy (vb). the extensive image data acquired with vb permits the simulation of the internal as well as external appearance of the tracheobronchial tree. the objective of the study is to compare mdct virtual bronchoscopy with fiberoptic bronchoscopy in the detection and characterization of tracheobronchial (airway) pathology, particularly to determine the overall agreement in the fi ndings in both modalities. methods patients who underwent ct scan of the chest and then underwent fi beroptic bronchoscopy were included in the study. each patient was assessed into levels: trachea, carina, right mainstem bronchus, left mainstem bronchus, tracheobronchial branches. these levels were examined using virtual bronchoscopy for presence/absence of obstructive, endoluminal and mucosal lesions and compared with the actual fi beroptic fi ndings. the sensitivity and specifi city, ppv and npv of vb were determined with fob as the gold standard. results a total of patients were included in the study. sixty-fi ve (n = ; levels) levels were observed, of which / ( %) accounted for the same evaluation using fob and that of the vb. the sensitivity of vb in diagnosing endoluminal lesion was noted to be %, with specifi city of %. virtual bronchoscopy overestimated obstructive lesions with two false positive results and detected two false negative patients with endoluminal mass. none of the mucosal abnormalities (mucosal erythema, edema, etc.) are detected using vb. conclusion virtual bronchoscopy may be comparable with fi beroptic bronchoscopy in the localization, morphologic description of tracheobronchial lesions. however, it has limited capability to reconstruct subtle mucosal irregularities. consequently, it is prone to artifactual reconstruction for mucosal changes that may render a false positive fi nding. overall, virtual bronchoscopy best complements the fi beroptic bronchoscopy in thorough evaluation of the tracheobronchial pathologies and cannot obviate the need for this invasive approach in the diagnosis of early mucosal changes within the airway. results of patients ( %) were male. all patients had multiple comorbidities which include severe copd = ( %), ( %) patients each had heart failure, respiratory failure and anaemia,hypoalbuminemia = ( %), active tuberculosis = ( %), pah = ( %), cad, crf, cld in patients and age > years was in ( %) patients. all patients underwent ct thorax and fob and after localizing bleed underwent bae within h of admission. in / ( %), bae could not be done on account of technical reasons. immediate control of bleeding was achieved in / patients ( %). in total, / patients ( . %) reported no rebleed till months. none developed early rebleed (< month) while / ( . %) develop late rebleed (> months). one managed conservatively and other underwent lobectomy. only complication of bae was transient dysphagia in / ( . %). conclusion bae is safe and effective in immediate and long term control of massive haemoptysis in elderly patients with multiple comorbidities and should be considered even in such high risk group. introduction histologic specimens obtained by endobronchial ultrasoundguided transbronchial needle aspiration (ebus-tbna) often provide valuable information for diagnosis or management decisions. besides the conventional -gauge needle, a -gauge needle is now available for this procedure. the purpose of the present study was to compare the histologic specimen retrieval yields of ebus-tbna using -gauge and -gauge needles for sampling hilar/mediastinal lesions. methods sixty patients with hilar/mediastinal lymphadenopathy or a tumor adjacent to the central airway were enrolled in this study and randomized to undergo ebus-tbna using a -or -gauge needle. each histologic specimen obtained by ebus-tbna on the initial two punctures of each patient (total punctures) was interpreted separately and categorized by an experienced pathologist as follows: i, diagnostic; ii, nondiagnostic but adequate (e.g. lymphoid tissue); iii, nondiagnostic and inadequate (e.g. clot); and iv, no specimens. results median targeted lesion size in shortest diameter on ct in the group using a -gauge needle and a -gauge needle was . mm and mm, respectively. prevalence of malignancy on primary disease in each group was % and %, respectively. the specimens obtained by -gauge needle were interpreted as i in , ii in , iii in and iv in . the specimens obtained by -gauge needle were judged to be i in , ii in , iii in and iv in . the sampling yield of adequate histologic specimens (i and ii) obtained by the -and -gauge needle was % and % (p = . ). no complications were associated with the procedures. conclusion histologic specimens can be obtained with a high sampling yield by either of the needles. our study could not show any difference in sampling yield between the two needles. introduction diagnostic tuberculosis using acid fast bacilli (afb) microscopy and conventional lowenstein jensen (lj) culture remain the cornerstone but the sensitivity of these traditional methods is quite low, especially in the samples containing small number of organism. there is a need for rapid, sensitive and accurate detection of these organisms in clinical specimens to hasten the administration of appropriate antimycobacterial therapy and prevent the spread of infection in the community. sputum smear-negative pulmonary tuberculosis (ssn-ptb) is a common problem faced by clinicians. performing fi ber optic bronchoscopy (fob) and subjecting the bronchoalveolar lavage (bal) material to diagnostic methods of smear and mycobacterial culture appears to be helpful in the diagnosis of ssn-ptb. radiological and pulmonary function outcome of children with sars longer term follow up of aerobic capacity in children affected by severe acute respiratory syndrome (sars) the usefulness of virtual bronchoscopic navigation has been established for the diagnosis of small peripheral lesions. exclusive software (bf-navi) from olympus medical systems is commercially available, but because no function to display extra-airway structures has been installed, this could not be indicated for testing where the purpose is mediastinal/hilar lymph node aspiration. using an improved version of the software from olympus medical systems to permit lymph node visualization, this study evaluated the aspiration support function. methods before testing, size and position of lymph nodes for aspiration were established on mpr images of ct data. on the virtual navigation image, these were displayed in a transparent ellipse from the airway. besides rotation and back and forth movements, changes in angle of the bronchoscope tip are simulated, and a function is also available to move the virtual image fi eld up, down, left, and right. using these, the navigation image was compared with the real image, and the lymph nodes were aspirated. in patients with enlarged mediastinal/hilar lymph nodes, transbronchial needle aspiration (tbna) without using an ultrasound probe, or ebus-tbna, was selected for aspiration. results lymph nodes were aspirated under navigation in all patients. the diagnosis was primary lung cancer in fi ve patients, metastatic tumor in one patient, and sarcoidosis in two patients. depth perception was diffi cult for the transparently displayed lymph nodes, particularly # and # , and judging anterior-posterior relationships was diffi cult when nodes were superimposed. conclusion some room for improvement thus remains in the display method. however, this offers future promise as diagnostic support technology. key: cord- -jrnw i authors: hogan, kevin; shan, fei; ravichandran, monikka; bagmar, aadesh; wang, james; sarsony, adam; purtilo, james title: decidio: a pilot implementation and user study of a novel decision-support system date: - - journal: group decision and negotiation: a multidisciplinary perspective doi: . / - - - - _ sha: doc_id: cord_uid: jrnw i in this work, we add to the rich history of decision-support system research by implementing and evaluating a pilot implementation of a novel system, which we call decidio. our tool was integrated into a pre-existing decision-making process regularly conducted by teams of undergraduate students. we find an overall positive response to decidio based on the results of a tool evaluation survey that we conducted after our experiment. furthermore, we conduct a big-five factor personality survey of participants and associate personalities with interactions recorded by our tool. we find that the students who demonstrate leadership behaviors through their interactions score higher in extraversion and lower in conscientiousness than other students. our analysis also reveals that agreeableness is strongly correlated with dissimilarity between group ranking outcomes and initially indicated individual preferences. team dynamics and group decision-making are central to any organization. researchers have reviewed and elucidated what years of research on small groups and teams can tell us about the processes that contribute to team effectiveness. using that knowledge they have identified leverage points for making teams more effective such as team learning, cohesion, efficacy and group potency [ ] . furthermore, a study examining relationships among work teams with respect to team composition (ability and personality), team process (social cohesion), and team outcomes (team viability and team performance) found that interpersonally oriented personality characteristics, such as conscientiousness, agreeableness, extraversion, and emotional stability can also be important predictors of team effectiveness [ ] . in the s, decision support systems (dss) were described as "interactive computer-based systems, which help decision makers utilize data and models to solve unstructured problems" [ ] . group decision support systems (gdss) eventually evolved to consider not only the role of the ultimate decision-maker, but also the communication between everyone in the decision-making group [ , , ] . turban et al. [ ] have identified the major components that make up these systems. some of them, such as database analysis and visualization, constitute independent fields of research within computer science. others, such as support for multi-criteria decision making (mcdm), more appropriately fall under management science [ ] . in recent years, researchers have explored internet-based algorithms and workflows for decision-making at scale [ , ] . furthermore, inferring consensus among members of a group in a data-driven fashion has long been a goal in anthropology and social psychology. [ ] demonstrates the use of cultural mixture modeling (cmm) for inferring consensus among members of heterogeneous multidisciplinary professional teams in an example decisionmaking process. the findings of their study inform team decision-making based on shared beliefs and team composition. in this work, we present a pilot dss of our own design and construction, which we call decidio. while we plan to extend decidio to be a general-purpose dss, our present version of the software is only able to support a very basic collaborative ranking process. our pilot implementation was designed to support a real collaborative ranking carried out by university of maryland undergraduate students. our goals in this work are two-fold. first, we wanted conduct a user study of decidio to identify its effectiveness and potential areas of improvement. second, we wanted to use the opportunity to explore group dynamics in the particular decision process that we were supporting. the remainder of the paper proceeds as follows. in sect. , we describe the functionality of our current implementation of decidio. in sect. we present the use case for the user study of decidio and demonstrate how our tool was incorporated into an existing group decision-making process. in sects. and , we document and discuss the results of our experiment. we measure the reception of the tool by its users through a user survey, and we find the feedback to be positive overall, with some areas of improvement identified. we also use log events from the tool to create behavioral profiles of the users involved in decision-making. finally, we explore the connection between these behavioral profiles and user personalities. decidio is a web-based collaborative ranking to support groups that need to collectively rank a set of options. the tool uses the python-based flask web server for its backend and the react javascript library for its frontend. this iteration of decidio was designed to ) make the ranking of options more efficient, and ) ensure that the deliberation on team preference would fairly represent the opinions of all members on the team. the tool therefore supports the following features: . linking users and teams: decidio supports grouping users into teams. every user is assigned to a team. . adding a list of options: an administrator can add a list of options which will be visible to all the users. . individual ranking: users can individually view the list of options added by the administrator and can submit their own preferred ranking order. individual rankings are submitted for every user. . group ranking: groups can collectively choose a final set of rankings in decidio's group ranking page. updates made to the ranking by any member in a group are displayed in real-time to everyone in that group. . displaying statistics about individual rankings: decidio displays basic statistics for the group, generated from the individual ranking phase when the users are working on the group rankings. this feature helps users make decisions which encompass opinions of everyone in the group. . analysis of user behavior through logs: decidio logs highly granular interactions in the tool. based on the logged activity, we can classify users into different categories like operators, leaders, followers, etc. we describe these terms in sect. in more detail. the quality enhancement systems and teams (quest) honors program is a university of maryland program for undergraduate students. the first course in the program involves a final project in which teams of students collaborate with a campus organization on process improvement. each team is able to indicate their preference for which of the available projects they would like to work on. historically, teams had indicated this preference by submitting a hand-written ranking of projects to the course instructor after a brief period of deliberation. the instructor would then allocate the projects to fulfill these preferences to the best of her ability. our team identified this decision-making process as an opportunity to test the pilot of decidio in a real-world scenario. the tool was used by users divided into teams. there were project options which the teams had to collectively rank in order of preference. there are three main phases in the workflow that we designed for quest. we describe each phase in detail. quest students attended a special class session in which the available projects were presented by the instructor. before arriving to this session, students were required to indicate their individual preferences for projects. the instructor for the course distributed a document describing each of the projects in detail during the days leading up to the session. students used the decidio web interface to order these projects from most-desirable to least-desirable. figure shows the interface and describes its interactivity. users click on a project to select and then use the up and down arrows to re-order that project. once they are satisfied with a ranking, they click a submission button to finalize (button not shown in the screenshot). after the instructor presented each project available for selection, students had min to meet with their groups and decide on a single ranking of projects to submit to the instructor. each team sat at a separate circular table in the same classroom during the discussion. students logged into decidio via their personal laptops and navigated to the group project ranking dashboard. the important components of the dashboard are shown in fig. and fig. . this dashboard is distinguished from the individual ranking dashboard in that ) all users in a team have equal control over modifying and submitting a unified project ranking and ) users are presented with the results of individual rankings for all team members. below, we describe the flow of group ranking: . collaborative ranking. each user is able to update the team ranking with the same interaction used for the individual ranking process. when the ranking changes, this change is published to the dashboard of each team member, and the dashboard will automatically refresh to reflect the changes. . section of the dashboard for group project ranking that shows the individual rankings for each project (rows are aligned with project names not shown in the screenshot). rankings for team members are anonymized, but the user's ranking is hightlighted in red as a reminder of their submitted preferences. the tool calls attention to cases where there are large differences in project preferences or outlier ranks. staging controls at the bottom of the group project ranking dashboard. in the configuration shown, the ranking has been staged (the leftmost button toggles between "stage" and "unstage" depending on the staging status). while staged, the ranking component shown on the dashboard (similar to the individual ranking component shown in fig. ) will be read-only. the user has approved the ranking, and no other member of the team has approved. since the number of approvals falls short of the team size, decidio displays a warning icon. staging. users can choose to stage their team's ranking at any point during collaborative ranking by clicking a button on the web page. when a ranking is staged, further modifications to this ranking are frozen and the staged ranking is displayed for review by team members. any user is able to unstage the ranking after it has been staged, which will return all users to collaborative ranking. . approval and submission. when a ranking has been staged, users can click to indicate whether they approve of the ranking for submission. the tool indicates to all users the number of team members who have approved the ranking, warning users when approval is not unanimous. however, the tool does not prevent submission based on the approval status. a user can submit at any time by clicking a button on the dashboard. projects were assigned to teams outside of decidio. the rankings for each team were presented to the instructor on an administrator dashboard, which allowed for convenient export to excel. the instructor was then able to apply a technique used in previous semesters for the fair allocation of projects. every server request in decidio is recorded in a log file. a log normally contains the timestamp, user id, group id, and the action taken. actions include information like: -has a user submitted their individual ranking? -what did a user change the group rankings to? -which user approved the ranking? -which user moved the group ranking to the staging phase? from the user actions in the log file, we created an activity log that informs us of their interaction patterns with the tool. this profile was later used to classify users into groups based on their actions. results from the analysis of activity logs are described in sect. . . a survey questionnaire (see appendix) was designed and sent to the students after the group decision making activity. the goal of this survey was to . collect feedback on tool . learn their process, methods, and strategies employed for decision-making when ranking projects as a group . capture some elements of the unstructured discussion that happened in-class for group project ranking we received responses for the survey which were analyzed, and the findings from the survey are listed below. more generally, the visualizations showing the rankings of group members appeared well accepted by the students. we learned that the visualizations helped them understand the group members' project preferences that led to constructive discussions. one user (u ) described that "the chart was very helpful, because it showed majority perspectives which allowed everyone's perspective to be objectively viewed. in this way, everyone's opinions were incorporated so that one person's opinion couldn't overshadow others." from the survey, we learned that during the group decision-making process students took up roles such as note takers and facilitators. every student team had at least one member acting as the facilitator. collectively, this showed us the need and the importance of "roles" in group decision making. in general, project presentations in class prior to group ranking helped students gain knowledge on projects. group discussion that followed allowed them to communicate their understanding and validate assumptions with their group. this showed us that the presentations and discussions held in class influenced the group's final project rankings. this validated that a mental model which is an internal representation of knowledge changes with individual's understanding of the present state of a system and that the development of a "shared" understanding of the problem within groups is key in group decision making [ ] . . groups used various techniques for deciding on the final project rankings: as a standard discussion protocol was not established for quest, groups used a variety of techniques to arrive at the final project ranking. these include making a pros and cons list ( ), voting on projects ( ), brainstorming ideas, taking-turns or going around the table to discuss implications and levels of interest for each project ( ). u described their group's process as "we first started by saying our top and bottom . from there we discussed and found the projects the most people had in common." an activity log file created for every user that captured their actions as a workflow diagram was used to understand how student groups used decidio in their decision making process. we observed varied numbers of actions amongst users ranging from just to in their activity logs. from analyzing workflows in the activity logs of group members, we noticed that the workflows can be grouped into four categories based on who the users were and the actions they performed in the tool. -absentee workflow: this workflow was exhibited by users that did not participate in the group ranking activity. it showed only actions related to the submission of individual project rankings. fig. a demonstrates this workflow. -regular workflow: the regular workflow is the one where users submit individual rankings, approve and/or submit group project rankings. their flow is mostly linear and does not involve updating the project rankings, staging the project rankings and unstaging the temporary final rankings. figure b demonstrates this user's workflow. -active operator workflow: workflows containing repeated updates to project rankings indicate that the user is an "active operator" for the group. each group typically had one or two members actively updating the project order in decidio. by mapping active operators to their roles from the survey, we found that out of active operators considered themselves to be the facilitators of their groups. figure c demonstrates an active operator workflow. (a) workflow for a user who was absent during the group rankings (b) workflow for a normal user not acting as an operator (c) workflow for a user acting as the core operator. the user updates the rankings repeatedly. (d) shows an advanced workflow in a team with the most conflicts. the user is doing multiple actions along with just being the operator in this case. -irregular workflow: irregular workflows contain cycles. i.e, the users have performed staging and unstaging operations. this workflow seems to indicate that the group didn't have the approval of all its group members (no consensus) and had to revise their project rankings by going back and forth between staging and unstaging before proceeding to submit. however, we note that one group exhibiting this workflow claimed via our survey that they had a consistent consensus throughout the ranking process. for this reason, we suspect that there are other explanations for the irregular workflow, such as user errors while navigating the software. figure d demonstrates this type of workflow. bayram and aydemir [ ] examine the relations of decision styles and personality traits among groups of university students. we use a personality survey and the activity logs from our tool to carry out a similar thread of investigation. we asked students to take a test that measures their "big five" personality traits, also known as the five-factor model [ ] and collected their results. we then analyzed the responses to study the relations between personality traits of group members and group decision making. from comparing the personality trait scores of "active operators" from the logs, we learned that the active operators tend to have higher median score on extraversion and lower median score on conscientiousness. (figure b) we also explored how personality may have affected the decision outcome for each group. we came up with a metric to represent the dissimilarity between two rankings. this is calculated as the sum of squared differences between ranks for each project. for example, the dissimilarity between a ranking of - - and - - for projects a-b-c would be . the dissimilarity metric cannot fairly be compared between teams without normalization. this is because the distribution of initial rankings varies between teams (some teams naturally had more or less disagreement before the group project ranking phase began). therefore, we compute a normalized dissimilarity for each user that is the difference between that users raw dissimilarity and the average dissimilarity for that team. we looked for correlations between normalized dissimilarity and percentile scores for the big five factor personality survey. we calculated a pearson correlation coefficient between normalized dissimilarity and each of the five personality factors. the results of this analysis are shown in table . the only strong correlation that we see is the strong positive correlation between agreeableness and normalized dissimilarity. we interpret this to mean that agreeable students were less likely to see their individual preferences reflected in the rankings submitted for their group. the personality comparison between all students and active operators (see sect. . ) is partially aligned with prior research correlating big five traits with leadership [ ] . judge et. al. see positive correlations with extraversion, openness to experience, and conscientiousness; and a negative correlation with natural reactions (referred to as neuroticism in their work). the bias towards extraversion among active operators is consistent with these results, however the bias against conscientiousness in that group is not. of course, the association we make between active operation of the tool and general leadership is based in assumption and may not hold in all cases (as described in sect. . ). we also find a strong correlation between agreeableness and our dissimilarity metric. this leads us to the satisfying (and perhaps expected) observation that more agreeable participants were less likely to "get their way" when working towards a team consensus on preference rankings. we're excited by the insights into decision dynamics that the decidio pilot provided in this user study, and we plan to enhance decidio's capability of recording software interactions that are relevant to these dynamics. we recognize that, because we are documenting results from a single experiment with our software, we should be careful to draw strong conclusions from our work. there are also several limitations to identify within this one experiment. first, the log events that we collect are not sufficient to capture a rich behavioral profile of all participants in the decision study. we did not record the discussion between each team of participants, and therefore we can not make definitive conclusions about the team dynamic. it's an extrapolation, albeit a reasonable one, to connect the "operator" workflow described in sect. . to the subjective notion of team leadership, for example. we recognize that the "operator" may have been acting as a sort of team note-taker or secretary for the session rather than the leader of the discussion. second, we did not test with a control group. this nuances the results from the user survey, as we're not able to draw a comparison to a team who collaborates on a ranking with a default method (e.g., pen and paper). finally, it is difficult to generalize results about user behavior in the tool when each team consists of a different mix of personalities and individual ranking preferences. for example, a team with insignificant differences between individual preferences for projects may not have much to disagree about, even if their personalities would suggest a higher likelihood of conflict. the initial version of decidio that we present in this paper is only narrowly applicable to group decisions that involve ranking a discrete set of options. however, the ultimate vision for decidio is to build a dss that can be easily tailored by users to fit specific decision workflows. this flexibility is valuable to decisionmakers because it will allow them to incorporate automation in existing workflows without substantial modification. it is also valuable to researchers who want to experiment with a variety of workflows. in this paper, we present decidio, a software tool that supports collaborative decision making. we evaluated the tool by using it in real-time with student teams for ranking projects for a class. the results indicate that the overall reception for such a tool is positive. in summary, we learned from our tool evaluation survey that students assume roles and use various techniques when making group decisions. the activity logs showed us the various workflows used by student groups for decision-making. it was interesting to see the relations between personality traits and group decision making. we believe the results from this study will help us in the design and development of a robust decision support system for collaborative decision making. . what were the tools or techniques used by your team when making decisions or in resolving conflicts? . which of the following would you say was your team's decision-making strategy (a list of strategies such as consensus, compromise, competition, accommodating, followed by a space for open comments). did you or your team face any technical difficulties when using the tool? (yes/no question the top two things i like about this interface are the top two things i dislike about this interface are in what ways would you modify this tool to increase its usability or functionality how was the chart showing individual rankings of your team members used to stimulate discussion? how were the notes from individual rankings used when ranking projects as a team? what was your role in the team when discussing project rankings? how did the in-class presentations influence your team's project rankings? . what aspects of the projects were important to your team when ranking them? how did your team handle disagreements or objections when ranking projects? would you say everyone in the team had the chance to voice their opinions? if no, what according to you, were the challenges that kept your team from hearing out everyone's opinions? relating member ability and personality to work-team processes and team effectiveness decision-making styles and personality traits communications design for co-op: a group decision support system shared mental models in expert team decision making a foundation for the study of group decision support systems a framework for management information systems personality and leadership: a qualitative and quantitative review enhancing the effectiveness of work groups and teams a web-based group decision support system for multicriteria ranking problems an introduction to the five-factor model and its applications a group decision making support system for the web: how to work in environments with a high number of participants and alternatives identifying consensus in heterogeneous multidisciplinary professional teams multi-criteria decision making methods: a comparative study decision support and business intelligence systems key: cord- -y agnh authors: nan title: oral research communications of the (nd) ecvim‐ca congress date: - - journal: j vet intern med doi: . /jvim. sha: doc_id: cord_uid: y agnh nan sidestream dark field imaging (sdf) is a technically relatively simple method to visualize the microcirculation. however, current gold-standard, or 'consensus' analysis (ca) of sdf films takes approximately hour per film limiting the application of sdf in a clinical setting, and leading to increased expense due to analysis of low quality films. we developed a subjective point of care scoring system (bedside evaluation of the microcirculation, bem) that could provide real-time intervention points and optimize care for the critical patient. the objective of this study is to evaluate whether the bem-score correctly identifies films of sufficient and insufficient diagnostic quality as defined by ca.twenty variable-length microcirculation films taken at the level of the canine tooth were selected from a database of films with available ca. before the study, three observers were trained using an instruction video to evaluate five quality parameters: stability, content, illumination, focus and pressure. the bem was performed by viewing and scoring each film four times in immediate succession. all five quality parameters were scored ( perfect, sufficient and insufficient) according to ca analysis. only the fourth viewing was considered for analysis. bem quality analysis was only considered sufficient if no parameter was scored insufficient. repeatability and reproducibility were assessed by assessing all films in a random order three times daily for three days.bem pass-fail assessment matched ca . % of the time with individual observer agreement of . - . %. agreement of bem with ca did not change over the study period ( . %, . % and . % on days , and respectively) indicating accurate quality analysis after a single bem-score of the training video. the mean cumulative bem quality score ( . , sd . ) was very similar to ca (mean . , sd . ). however mean individual bemparameter scores differed from ca reflecting differences in observer interpretation.high levels of inter-observer agreement and the strong correlation with ca for pass-fail assessment demonstrate that bem quality evaluation can produce repeatable and reliable results. variation in individual parameter scores may reflect systematic erroneous assignment of certain parameters or individual bias towards assessment of certain features. nevertheless, this did not impact on the overall evaluation of film quality. this study provides a platform to investigate whether rapid semi-quantitative analysis of the microcirculation itself is similarly feasible. sidestream dark field imaging (sdf) is a straightforward technique to evaluate microcirculation. however, current 'consensus' analysis (ca) of sdf films is time-consuming, thereby restricting the clinical application of sdf. a subjective bedside scoring system (bem) is proposed that could rapidly provide a semi-quantitative assessment. we have previously shown that observers could accurately evaluate film quality parameters. the objective of the present study is to assess the correlation of bem with ca for quantitative microcirculation parameters. three observers were trained using an instruction video to evaluate four quantity parameters: total vessel density (tvd), capillary vessel density (cvd), perfused vessel density (pvd) and microvascular flow index (mfi). fifteen variable-length microcirculation films of sufficient quality, taken at the level of the canine tooth, were selected from a database of films with available consensus analysis. each parameter was scored ( lowest - highest) . the bem was performed by viewing and scoring each film four times in immediate succession with the final score being considered for analysis. bem was performed on each film in random order three times daily for three days. ca scores were divided into quintiles for each parameter and mean bem score were calculated for each. conversely, for each bem score, mean ca scores were calculated, per observer or per day.the mean tvd and pvd bem scores for the % quintile were lower than mean bem scores for other quintiles. mean bem score for the - % quintile was the highest mean bem score for pvd only. mean cvd, pvd and mfi values for bem score were lower than mean values for other bem scores. in parallel, although tvd never received a bem score of , the mean ca value for films with bem score were lower than for higher bem scores. the mean tvd and mfi values for bem score of were higher than mean values for bem scores [ ] [ ] [ ] [ ] . similar values were obtained on each individual study day.this study demonstrates that rapid semi-quantitative assessment of the microcirculation using the bem-score can produce repeatable and reliable results, although significant overlap exists. further studies are required to evaluate the value of this technique in a clinical setting. objective: compare two non-invasive blood pressure (nibp) measurement devices (petmap and doppler) with invasive blood pressure (ibp) measurement in normotensive, anesthetised and awaken dogs. design: prospective clinical study animals: ten female dogs aged between to months (average . months), and weighting . to . kg (average . kg) undergoing a routine spay. interventions: blood pressure measurement procedures: after the induction of general anesthesia, a catheter ( g) was placed in the dorsal pedal artery and invasive systolic (sap i ), diastolic (dap i ) and mean (map i ) arterial blood pressures were obtained. the nibp cuffs were placed on the ipsilateral front limb. five consecutive measurements were obtained with each indirect device and considered as a mean measure. the ibp was obtained simultaneously to the five nibp measurements and also considered as a mean measurement. measurements on awaken dogs were obtained four hours after surgery. doppler's systolic (sap d ) and petmap's systolic (sap o ), diastolic (dap o ) and mean (map o ) arterial blood pressure were evaluated and compared to the corresponding ibp using the bland-altman analysis. the percentage of paired measurements with a mean difference of and mmhg was also evaluated for the sap o , dap o and sap d . results: agreement between ibp and nibp measurements obtained with the petmap and the doppler was assessed with the bland-altman analysis. on anesthetised dogs, both indirect devices underestimated all direct blood pressures. the petmap bias (standard deviation) were - . mmhg ( . mmhg), - . mmhg ( . mmhg), and - . mmhg ( . mmhg) for sap o , dap o and map o respectively. the doppler bias was - . mmhg ( . mmhg) for sap d . on awaken dogs, the petmap underestimated sap i and overestimated dap i and map i . the bias were - . mmhg ( . mmhg), . mmhg ( . mmhg) and . mmhg ( . mmhg) for sap o , dap o and map o respectively. the doppler underestimated the ibp and the bias was - . mmhg ( . mmhg).on anesthetised and awaken patients, the percentage of values lying within and mmhg of the ibp was higher (or equal) for the petmap compared to the doppler. conclusion: results suggest a better performance of petmap device to predict the ibp in normotensive-anesthetised and normotensive-awaken dogs. intracranial hypertension (ich) is associated with high morbidity and mortality in canine veterinary medicine, yet remains difficult to clinically diagnose. the lack of an easily feasible and available diagnostic method has prevented clinical studies on the prevalence, cause and treatment of ich. recently, transcranial doppler ultrasonography (tcd) has been reported as a noninvasive diagnostic method in humans. however, only a few preliminary reports on the use of this technique in dogs have been published. this study evaluated the repeatability and reproducibility of tcd of the basilar and left and right cranial, cerebral arteries in healthy beagle dogs.tcd was performed using a standard ultrasound machine at the level of the basilar artery, and left and right cranial cerebral artery, in six adult beagle dogs. systolic, diastolic and average velocity, resistance (ri) and pulsatility indexes (pi) were assessed for each vessel. repeatability was evaluated by calculating the intra-class correlation coefficient (icc) between three separate, consecutive measurements in every dog. an icc was also determined for the reproducibility of these measurements on three consecutive days. during the procedures, ecg, blood pressure and clinical parameters were monitored.statistical analysis showed a highly significant repeatability of all measured parameters (systolic, diastolic and average velocity, ri and pi) for all blood vessels (n = , icc = . - . , p < . ). systolic velocity, ri and pi were also significantly reproducible for the basilar artery (n = , icc = . - . , p < . ), and the left and right cranial cerebral arteries (n = , icc = . - . , p < . ). however, no significant correlation was found between basilar and cerebral blood flow velocities.measurement of pi and ri of the basal and cranial cerebral arteries using tcd appeared to have high intra-operator repeatability and reproducibility. however, measurements performed on the basilar artery had higher between day reproducibility. since the technical skill required to assess these parameters subjectively appeared to be less complicated at the level of the basilar artery, tcd in a clinical setting is probably advocated at the basal artery.in conclusion, tcd is characterized by high intra-observer repeatability and reproducibility, making this technique a promising tool for the measurement of pi and ri, which have both been reported to be correlated with intracranial pressure. intracranial hypertension (ich) is associated with high morbidity and mortality in canine veterinary medicine, yet remains difficult to clinically diagnose. furthermore, many patients suspected to suffer from ich are treated with sedatives or anticonvulsants. besides the impact of these molecules on the patients' neurological examination, they variably influence the cardiovascular system. this study evaluated the effect of various sedatives and anticonvulsants on the pulsatility and resistance index (pi) and (ri), as measured by transcranial doppler ultrasonography (tcd) in healthy beagle dogs. additionally, we evaluated the effect of ivabradine, a specific negative chronotrope, on tcd findings. tcd was performed at the level of the basilar artery in six adult, beagle dogs. this technique was performed prior to the injection of molecules (v ), and after administration of acepromazine (ace, lg/kg iv), diazepam (dia, . mg/kg iv), medetomidine (med, lg/kg im) or ivabradine (iva, mg/kg iv). a wash-out period of at least hours was respected between the administration of each drug. during the procedure, ecg, heart rate (hr) and blood pressure (bp) were monitored. results were analyzed using repeated measures anova. correlations between the clinical parameters, and pi and ri were investigated using pearson's correlation. results were considered significant when p < . . significantly lower pi and ri values [(mean pi; % ci), (mean ri; % ci)] were obtained for med [( . ; . - . ( . ; . - . ) ]. pi for dogs after iva was significantly increased compared to dia, but did not differ significantly from other groups.hr was significantly lower after med compared to other groups, and after iva, compared to v . bp was significantly lower after ace than after iva, med or on v . these clinical parameters were not significantly correlated with pi or ri. dia and ace did not significantly influence ri or pi, however med significantly decreased ri and pi. these findings agree with previous reports describing a decrease in icp provoked by med, as pi is positively correlated with icp. this effect appears to be independent of the effect of med on hr, since iva also significantly decreased hr, yet did not significantly affect pi or ri. in conclusion, blood pressure and heart rate did not significantly affect pi and ri. hypertrophic cardiomyopathy (hcm) is the most commonly diagnosed heart disease in cats with little documentation of the effects of treatment on outcome in cats with preclinical disease. therefore, this prospective cohort study was undertaken to evaluate the effects of treatment with atenolol on outcome in cats with asymptomatic hcm. we hypothesized that ) -year mortality would be increased in cats with hcm compared to a matched control group of healthy cats, and ) administration of atenolol would reduce -year cardiac mortality in occult feline hcm.cats were enrolled over a -year time period ( to ) in a prospective, open-label, observational study. diagnosis of hcm was based on transthoracic echocardiography. cats were either treated with atenolol ( . to . mg/cat, q h, po) or did not receive treatment. decision to treat was based on owner preference, suggestion by the clinician, and animal compliance with regard to pill administration. baseline echocardiograms were analyzed, and morbidity and mortality were monitored at and months and thereafter by annual rechecks, and by phone interviews of referring veterinarians and owners over a -year time period. groups were compared by a non-paired t-test, introduction: systolic anterior motion of the mitral valve (sam) is a dynamic left ventricular outflow obstruction frequently observed in feline hypertrophic cardiomyopathy (hcm). however, several cases of sam have also been observed in cats without left ventricular hypertrophy (lvh) and this finding could be interpreted as an early stage of the disease not yet accompanied by lvh. alternatively, it could be speculated that the dynamic outflow obstruction could cause intraventricular pressure overload sufficient enough to induce lvh at a later stage. this study was conducted to test the hypothesis that sam can potentially cause myocardial stress and myocardial damage by measuring plasma ntprobnp and serum troponin-i levels in cats with sam not associated with lvh. methods: the study was based on a retrospective analysis of cats who underwent cardiac investigation of a heart murmur, performed by a boarded cardiologist. these cats were diagnosed with sam not associated with lvh (ivsd and lvfwd < . mm, both on bmode and mmode measurements) via colour doppler echocardiography. plasma ntprobnp (cardiopet test, idexx laboratories, inc.) and serum high sensitivity troponin-i (hsctni hs, idexx laboratories, inc) were measured in these patients, as well as serum urea, creatinine and thyroxin concentrations. the association between biomarkers (ntprobnp and hsctni) concentration and echocardiographic values (myocardial thickness, left atrial dimension and aortic peak velocity) was determined by using the spearman correlation coefficient (rho). results: all cats were euthyroid and did not show evidence of renal disease. mean hsctni measurement was not performed in one cat due to an unsuitable sample. eleven out of cats ( %) showed ntprobnp values above the normal reference limit ( pmol/l) with a median concentration of pmol/l (± , range - ) . five out of cats ( %) showed hsctni values above the normal reference limit ( . ng/ml) with a median concentration of . ng/ml (± . , range . - . ). there was a significant positive correlation between aortic peak velocity and ntprobnp (rho= . , p= . ). conclusion: ntprobnp is increased in cats with sam without lvh, suggesting the presence of myocardial stress, which appears to be proportional to the degree of outflow obstruction derived by the aortic peak velocity. some of these cats also present a degree of myocardial insult suggested by the increased serum hsctni. whether the increased biomarker concentrations are related to sam-induced pressure overload or to an early stage of primary myocardial disease needs to be evaluated with appropriate longitudinal studies. heart murmurs are caused by turbulent blood flow or by vibration of cardiac structures. turbulent blood flow in young animals may originate from congenital structural heart disease or from physiological phenomena. the prevalence of heart murmurs and congenital heart disease in the general (i.e. non referral) feline population are unknown. the aims of this prospective study were to determine the prevalence of heart murmurs in young cats and to determine the prevalence of congenital heart disease in young cats with heart murmurs.in total domestic shorthair cats aged to months underwent a routine physical examination prior to vaccination between may st until march st . cats were from adoption programs run by either dierenasiel breda e.o. ( / ) or dierenopvangcentrum tilburg ( / ). in cats with murmurs, the murmur was timed, graded and the point of maximum intensity was determined. subsequently, d, m-mode and doppler transthoracic echocardiography with continuous ecg monitoring was performed.heart murmurs were detected in animals ( . %). congenital heart disease was detected in animals ( . %), acquired heart disease in animals ( . %) and no identifiable heart disease in animals ( . %) with murmurs.in the animals without heart disease dynamic right ventricular outflow tract obstruction was the cause of the murmur in cases, turbulence within the left ventricle was the cause in cases.in animals with acquired heart disease, pulmonary hypertension associated with a. abstrusus was diagnosed.in the cats with congenital heart disease, isolated defects were found in cats, being tricuspid valve dysplasia in cats, dynamic left ventricular outflow tract obstruction associated with mitral valve dysplasia in cats, ventricular septal defects in cats, double chambered right ventricle in cats and pulmonic stenosis in cat. combination defects were found in cats, being ventricular septal defect and tricuspid valve dysplasia in , ventricular septal defects and double chambered right ventricle in , ventricular septal defect and atrial septal defect in cat, a ventricular septal defect and pulmonic stenosis in cat and mitral and tricuspid valve dysplasia in cats.in conclusion in this prospective study we found the prevalence of heart murmurs to be . % and the prevalence of congenital heart disease to be . % with atrioventricular valve abnormalities and ventricular septal defects being the most common. dynamic left ventricular outflow tract obstruction (dlvoto) is a common cause of heart murmurs in adult cats. the obstruction is caused by systolic anterior motion (sam) of the mitral valve. sam is typically observed in adult cats and humans with hypertrophic cardiomyopathy (hcm). many studies support the concept that structural deformities of the mitral valves and the papillary muscles could be primary causes of sam. congenital malformations of the mitral valve causing sam and dlvoto have been observed in dogs and people and are believed to exist in cats, but have not yet been reported. the aim of this study was to report the clinical and echocardiographic findings in young cats with dlv-oto.thirteen domestic shorthair kittens, between - weeks of age, presented with a systolic heart murmur between may st until march st . all cats underwent a physical examination preceding d-, m-mode and doppler echocardiography. kittens were from adoption programs run by either dierenasiel breda e.o. (n= / ) or by dierenopvangcentrum tilburg e.o. (n= / ) nine kittens were male, four were female. all kittens were asymptomatic. dlvoto caused by sam was present in all animals, uninterruptedly in eleven, only at high heart rates in two. seven cats had normal left ventricular dimensions (nlvd), six cats had concentric left ventricular hypertrophy (clvh). in five cats papillary muscle abnormalities were noted being an accessory papillary muscle in two and enlarged papillary muscles in three, two of which had clvh.twelve animals were reexamined - months after the initial examination. all animals were still asymptomatic. a heart murmur and dlvoto could no longer be detected in nine animals, five with initial clvh and four with initial nlvd. in three animals a heart murmur and dlvoto were still present. two of the cats with nlvd developed clvh. one cat with initial clvh continued to have clvh.treatment with atenolol was instigated in three cats which continued to have dlvoto and clvh. two cats were reexamined. treatment with atenolol led to complete reversal of clvh in both cases. interventional radiology techniques have been used to palliate both malignant and non-malignant causes of vascular obstruction for both intrinsic and extrinsic lesions.three dogs presented for with large, non-resectable cardiac masses obstructing venous return to the right atrium. venous return to the heart was severely obstructed leading to congestion with subsequent ascites ( ) or head swelling and pleural effusion ( ) . due to the extensive nature of the disease, an interventional palliative approach was pursued. transatrial self-expanding metallic nitinol stents were placed from the cdvc to the crvc in order to restore venous return to the heart via blood flow through the stent interstices.in all cases, stent placement was successful and resolution of clinical signs achieved. two dogs required additional stent placement in months and months, respectively, for stent occlusion. in both cases, restenting resulted in ascites resolution or substantial reduction. one dog was euthanized months following initial stent placement for general systemic decline and return of moderate ascites. the second dog remains alive months following initial stent placement on diuretic therapy with moderate ascites present. the third died of undetermined causes / months later.to the authors' knowledge, this is the first report of longterm palliative transatrial stenting for cardiac tumors affecting venous return to the heart. the stents were well tolerated in these canine patients for which surgical options were not possible. the irish wolfhound (iw) dog has a high prevalence of heart diseases, particularly dilated cardiomyopathy (dcm) and atrial fibrillation (af).during a prospective longitudinal study, irish wolfhounds were investigated by one veterinary cardiologist ( ) between and . dcm was diagnosed in about % of dogs. in % of cases, dcm was accompanied by af. af without evidence of dcm was diagnosed in dogs ( %).for pathological investigations, hearts of iws were collected and fixed in % buffered formalin. based on the most recent results from cardiovascular examination, five groups were established: normal hearts (group , n= ), dcm with sinusrhythm (group ; n= ), dcm with af (group ; n= ), dcm with af and congestive heart failure (chf) (group ; n= ), af and left ventricular reverse remodeling (lvrr) due to medical therapy after diagnosis of dcm (group ; n= ).all hearts were evaluated by one pathologist ( ) who was blinded to the clinical diagnosis. gross inspection included measurments of weight, size, and architecture of left (lv) and right (rv) ventricles. three sites of each lv, rv, and interventricular septum (ivs) were histologically evaluated, and the extend of myocardial fibrosis, adipocyte infiltration, and angiosclerosis were graded semiquantitatively.iws with dcm and chf (group ) had died significantly younger ( . ± . years) than dogs with normal hearts ( . ± . years) (p= . ). concerning gross pathology findings in hearts with clinical dcm diagnosis, lv chambers were dilated in / cases of group , while in groups and , the papillary muscles appeared grossly prominent and not flattened as in group .histopathologically, in control dogs lv and rv myocardium showed no ( / ) or mild ( / ) interstitial collagen deposits, no or single adipocytes, and normal vessels. in contrast, heterogeneous findings were seen in groups - : most hearts ( / ) showed mild to moderate multifocal myocardial fibrosis and up to moderate diffuse infiltration of adipocytes within the lv myocardium, and mild angiosclerosis, but five hearts were histologically normal. only in one dog attenuated wavy fibers were seen in the apical region of lv. ivs was normal in out of cases. rv showed mild interstitial fibrosis and mild to moderate adipocytes in most cases ( / ) of all groups.in conclusion, pathological findings in hearts of iws affected with dcm are different from other breeds. furthermore, the gross and histological findings are variable and do not correspond to the clinical diagnosis in all cases. the irish wolfhound (iw) dog has a high prevalence of heart diseases, particularly dilated cardiomyopathy (dcm) and atrial fibrillation (af). during a prospective longitudinal study, irish wolfhounds were investigated by one veterinary cardiologist ( ) between and . dcm was diagnosed in about % of dogs. in % of cases, dcm was accompanied by af. in addition, af without evidence of dcm was diagnosed in dogs ( %).for pathological investigations, hearts of iws were collected and fixed in % buffered formalin. based on the most recent results from cardiovascular examination, three groups were established: dcm with af (group ; n= ), af without evidence of dcm (group ; n= ), normal hearts (group , n= ).aim of this study was to investigate the histopathological findings in left and right atria of iws with atrial fibrillation compared to normal hearts of iws. all hearts were evaluated by one pathologist ( ) who was blinded to the clinical diagnosis. hearts were inspected grossly and two cross sections of each left (laa) and right (raa) atrial appendage were embedded in paraffin wax and stained with h&e and picrosirius red. myocardial fibrosis and adipocyte infiltration in both atria were graded semiquantitavely.mean age ± sd of all dogs at time of death was , ± . yrs. the gross and histopathological findings of the left atrial appendage (laa) were not significantly different among groups, but dogs in both af groups had raa dilation ( . to . ml, median ml volume) compared to controls ( . to . ml volume, median . ml). histopathologically, raa in control dogs showed small amounts of interstitialcollagen and single adipocytes. in contrast, raa in dogs affected with af with andwithout evidence of dcm, had mild to moderate multifocal or diffuse myocardial fibrosis, and diffuse infiltration of adipocytes which was statistically significant different from normal hearts (p= . ). in general, fibrosis and number of adipocytes were significantly increased in raa compared to laa in both groups with af (p= . ).fibrosis and the accumulation of adipocytes within the myocardium are described toresult in electrical inhomogeneity predisposing to arrhythmia.on a cellular level, right atrial fibrosis and adipocyte accumulation might be the changes responsible for the development of atrial fibrillation and atrial dilatation in this breed of dogs with an exceptional high prevalence of af and dcm. asynchronous ventricular contraction causes deterioration in cardiac function and reduces the response to medical therapy in people with heart disease. various echocardiographic techniques have been used in humans for evaluation of left ventricular (lv) synchronization in order to assess whether cardiac resynchronization therapy (crt) would be beneficial. prior studies using tissue doppler imaging (tdi) derived strain imaging have not detected lv dyssynchronization in doberman pinschers with dilated cardiomyopathy (dcm). a newer d imaging modality, speckle tracking strain analysis, is more effective in detecting lv dyssynchrony in humans. this technique has not been previously evaluated in doberman pinschers with dcm. this study therefore aims to evaluate lv synchrony in doberman pinschers with dcm using d speckle tracking strain. client-owned doberman pinschers were included. standard echocardiography was used to evaluate systolic function and left ventricular dimension in order to categorize the dogs as normal or abnormal, depending on systolic and diastolic ventricular dimensions, ejection fraction and/or shortening fraction. the operator was blinded to the echocardiographic diagnosis of each dog. each parameter was measured in triplicate. radial (rs) and circumferential strain (cs), using right parasternal short axis at the level of the papillary muscles were calculated. synchrony was assessed by measuring the difference in the qrs onset time-to-peak strain between the septal anterior and posterior left ventricular segments. to evaluate differences between groups a nested effect anova (beat within group) was performed. a p< . was considered significant. based on the echocardiographic parameters mentioned above, / dogs were considered normal and / had dcm. significant differences were found in the time to peak rs (p= . ) between normal dogs and dogs affected with dcm. mean in time to peak rs was . ms (+/- . ) in normal dogs and . ms (+/- . ) in dogs with dcm. time to peak cs did not exhibit significant differences between groups (p= . ) and was . ms (+/- . ) in normal dogs and . ms (+/- . ) in dogs with dcm. the results of this study show that the delay between the anteroseptal-to-posterior wall peak radial strain is greater in doberman pinschers with dcm than in normal dogs. further studies would be required to evaluate whether there is a difference in synchrony between dogs in occult stage and overt dcm. ventricular dyssynchrony could negatively affect systolic dysfunction as it does in people, and crt may therefore be helpful for the treatment of dobermans with dcm. patent ductus arteriosus is often treated with intra-arterial coilembolization or implantation of an 'amplatz canine duct-occluder'. for both procedures an arterial access is necessary. because of the high risk of developing a fatal hemorrhage from the arterial puncture site after removal of the large-bore introducer sheath upon completing the intervention, cardiologists generally use surgical cut-down with subsequent ligation of the femoral artery instead of percutaneous arterial puncture using seldinger's technique. the effect of commercially available chitosan patch has been tested in experimental dogs with the approval of the institute's ethical committee. on the first beagles the committee required a terminal experiment. for the selection of an appropriate introducer-sheath (i.e. smaller than the arterial diameter), the femoral artery was first imaged with ultrasound. under general anesthesia introducer-sheaths were placed in both femoral arteries using seldinger's technique. after their removal a chitosan-patch was applied on the wound according to the manufacturer's instructions: -minute manual pressure. the dogs were monitored with direct arterial blood pressure measurement, ecg, pulse oxymetry and capnography. all dogs were kept under general anesthesia for several hours and the legs were moved vigorously every minutes to mimic movements of awake animals. no macroscopic hemorrhage was noticed on the puncture sites and no signs of severe subcutaneous bleeding was suspected as the blood pressure and heart rate remained stable. after several hours the dogs were euthanized. after having shown the effective working of chitosan-patch, a permission was granted for survival experiments in beagles. in of these dogs one femoral artery was punctured with an introducer whose thickness exceeded the diameter of the femoral artery. in both dogs an uncontrollable subcutaneous hemorrhage occurred immediately after the -minute manual compression time with severe drop of blood pressure and development of tachycardia. both dogs were euthanized during anesthesia. in another beagles the size of the introducer was smaller than the diameter of the artery ( - %). no relevant hemorrhage took place in these dogs and they recovered from the procedure without any complications. similarly good outcome was found in two -month-old boerboels. from this pilot study we concluded that chitosan-patch can effectively control hemorrhage from a femoral arterial puncture site if the introducer-sheath is thinner than the artery's lumen. using seldinger's technique allows a less invasive and quicker cardiac catheterization and preservation of the femoral artery for the leg's blood supply and for repeated intra-arterial interventions. objectives were to examine longitudinal change in echocardiographic left heart chamber dimensions and cardiomyopathy classification in cats with primary myocardial disease.clinical records from - were reviewed for cats with or more echocardiographic examinations at least months apart and a diagnosis of primary myocardial disease. for each study ( from each cat), left heart chamber dimensions were measured by a single blinded trained observer in random order, and the cardiomyopathy type was classified according to predefined criteria. paired comparisons were made using the wilcoxon signed rank test and fisher's exact test. cats met the inclusion criteria. cardiomyopathy type at entry consisted of hypertrophic cardiomyopathy (hcm, n= ), dilated cardiomyopathy (dcm, n= ), arrhythmogenic right ventricular cardiomyopathy (arvc, n= ) and normal cat. overall, median left ventricular (lv) diastolic diameter and median long axis left atrial (la) diameter both increased (p= . , . respectively) whereas lv diastolic wall thickness and lv fractional shortening did not change, but changes in dimensions of > % were seen in both directions. change in cardiomyopathy type was documented in cats: hcm to normal; normal to hcm; hcm to the endomyocardial form of restrictive cardiomyopathy.the inclusion criteria led to a bias towards clinically stable cats with hcm. despite this, changes in cardiomyopathy phenotype were observed. either our criteria for the different feline cardiomyopathies should be defined more precisely, or phenotypic expression in cats with cardiomyopathy changes over time. transesophageal echocardiography (tee) has proven useful in evaluating patent ductus arteriosus (pda) morphology thereby guiding appropriate device selection. additionally, tee, in combination with fluoroscopy, has been used to guide the transcatheter coil embolization and for deployment of amplatz canine ductal occluder (acdo) in dogs. recently, we described the use of transthoracic echocardiography (tte) guidance during transcatether pda occlusion with acdo without the use of fluoroscopy, but observed problems of deployment in patients with sub-optimal acoustic windows. however, tee, can overcome issues of suboptimal tte acoustic windows and provides higher image resolution of cardiac and vascular regions. therefore, we hypothesized that tee could be used to successfully visualize the vascular structures and interventional devices to safely perform pda occlusion with acdo without requiring fluoroscopy.we recruited dogs with patent ductus arteriosus (pda) for tee-guided percutaneous ductal occlusion with an acdo. dogs were anesthetized, positioned in right lateral recumbency and the right femoral artery was accessed percutaneously (modified seldinger technique). the tee probe was advanced to a midesophageal position with minimal force to obtain a long axis -chamber view (transverse plane). the probe was then retroflexed and withdrawn to a cranial esophageal position until a cross section of the descending aorta was seen. to visualize pda to the probe was slightly straightened and turned counterclockwise, and the ultrasonic beam was oriented between and degrees.in all dogs, the guide wire and a long introducer-sheath were guided from the aorta through the pda into the main pulmonary artery by tee monitoring. the acdo was advanced through the introducer-sheath until the flat distal disk was visualized within the main pulmonary artery by tee monitoring. the distal disk was positioned against the pulmonic ostium and the coupled proximal disk was deployed within the ductal ampulla while being monitored by tee visualization.the guide wires, long introducer-sheath and acdo appeared hyperechoic on tee images and tee guidance provided images of sufficient quality to clearly monitor the procedures in real-time. real-time monitoring also allowed for immediate corrections to guide wire, catheter or device positioning. the procedures were successful and without complications in all patients.we have demonstrated that tee monitoring, like tte monitoring, can guide every step of transcatheter acdo embolization procedures without requiring fluoroscopy, thereby avoiding radiation exposure, and provides an alternative to tte-based guidance, especially when tte visualization of the pda is insufficient for safe and timely acdo deployment. right ventricular (rv) dysfunction occurs in human patients with left-sided cardiac disorders because of the mechanism of ventricular interdependence. doppler echocardiographic indices of diastolic function of the right ventricle are good prognostic markers during left ventricular (lv) failure secondary to ischemic and dilated cardiomyopathy.the aims of the present study were: to assess lv and rv diastolic function by conventional doppler and pulsed-wave tissue doppler imaging (pw-tdi) in dogs with mitral valve disease (mvd), with or without pulmonary hypertension (ph); to test if echocardiographic parameters of lv and rv diastolic dysfunction correlate to the doppler-estimated pulmonary artery systolic pressure (pasp). dogs were prospectively evaluated, including dogs with mvd. for each dog, a complete echocardiographic evaluation was carried out. dogs with mvd were divided in groups according to the acvim classification of heart failure. using the cut-off value of tricuspid regurgitation (tr) peak velocity of . m/s, presence or absence of ph was considered, standard echocardiographic and mitral and tricuspid doppler parameters (e wave and a wave), and pw-tdi parameters (systolic wave, sa; early diastolic wave, e'; late diastolic wave, a'; e'/a' ratio; e/e' ratio) for lateral and septal mitral annulus, and lateral tricuspid annulus were measured. the echocardiographic data were compared by use of anova and multiple contrast t-test with bonferroni correction. the relationship between left-sided echocar-diographic parameters and rv diastolic parameters was examined by correlation analysis. the correlation of pasp with lv and rv diastolic parameters was examined by multiple linear regression. a value of p< . was considered significant.dogs were classified as follows: healthy dogs; dogs in class b ; dogs in class b ; dogs in class c and d. no differences were found among groups regarding rv conventional doppler and pw-tdi parameters. however, a significant, weak correlation was found between some left-sided echocardiographic parameters (left atrial dimension; end diastolic and end systolic volume indexes; peak e wave and a wave velocities and e:a ratio) and some rv pw-tdi parameters. ph was diagnosed in dogs, while dogs were deemed without ph. dogs with ph had significantly different trans-mitral e and a wave peak velocity and e/e' ratio of lateral and septal mitral annulus. these two latter parameters were also correlated with pasp (r = . and . , respectively).our findings highlight the importance of considering ventricular interdependence in dogs with mvd, particularly those with ph. during the cardiac cycle, the left ventricle (lv) undergo a complex deformation, consisting of overall shortening accompanied by increase in wall thickness and twisting due to the helical orientation of the myocardial fibers. using speckle tracking echocardiography (ste), the circumferential strain (cs) as well as the twisting motion of the lv, calculated as the net difference between lv apical and basal rotation angles during the cardiac cycle, can be quantified by post-processing -dimensional short axis images of the lv. thus, the aim of this study was to evaluate the global cs and the twisting motion in small-medium sized dogs with varying severity of mr attributable to myxomatous mitral valve disease (mmvd). using a vivid-i ultrasound system, all dogs underwent echocardiography including parasternal short axis views at the basal and apical level for offline analysis of rotation, and at the midpapillary muscle level for analysis of global cs, using commercially available software (echopac). twisting motion during systole (twist sys ), early (untwist early ) and late (untwist late ) diastole were calculated as well as their rates computed as the time derivatives. furthermore, time to onset of untwist, calculated from start of electromechanical activation until peak twist sys was measured. associations between twist and untwist variables, global cs and conventional echocardiographic indices of mr severity and lv remodeling were examined by multiple linear regression analyses including dog characteristics such as heart rate (hr), sex, breed, body weight and age. global cs increased with increasing mr (p < . ). untwist early (p = . ) and its rate (p = . ) also increased with increasing mr, albeit in co-variation with certain baseline dog characteristics. time to onset of untwist increased with mr (p = . ), left atrium to aortic root ratio (p = . ) and lv internal diameter in diastole (p < . ). in conclusion, untwist early and global cs gradually increased and the onset of untwist appeared to be delayed with increasing mr severity in small-medium sized dogs with spontaneous mmvd. this hyperdynamic stage with a delay in untwist may represent lv adaptation to loading conditions in mmvd, but might also indicate mid-and subepicardial compensation for an early lv dysfunction, as reflected by delayed onset of relaxation, as timing of contraction-relaxation cross over is the most vulnerable period of myocardial fiber mechanics. systolic anterior motion (sam) of the mitral valve is the mechanical correlate of left ventricular outflow tract dynamic obstruction (lvotdo) and has been associated with hypertrophic cardiomyopathy (hcm) in most instances. however, sam without left ventricular hypertrophy or with regressing hypertrophy is increasingly recognised.the echocardiographic studies of cats, diagnosed between / and / , with sam without hcm ( cats) or sam with regressing hypertrophy ( cats) were reviewed for evaluation of the anatomic and mechanic alteration contributing to lvotdo .ventriculo-aortic and aorto-septal malalignment were suggested by the significantly narrower aorto-mitral (am) and aorto-septal (as) angle compared to a group of control cats (as = versus -p = . ; am = versus -p = . ).other anatomic alterations of the lvot constituents included false tendon inserted on the septal crest ( / ), basal septal angulation ( / ), apical displacement of the postero-medial or antero-lateral papillary muscle ( / ), bifid/accessory papillary muscle ( / ), aberrant chordal insertion on the septal crest ( / ), severe papillary muscle hypertrophy ( / ), and thickened aortic cusps with sub-aortic ancillary echoes ( / ).mechanisms of lvotdo included obstructive mitral septal leaflet ( / ), protrusion of a displaced papillary muscle ( / ), impingement of an angulated basal septum into the lvot ( / ), and mechanical lvot narrowing from hypertrophic papillary muscle ( / ). basal septal impingement into the lvot was associated with apical ballooning ( / ) without obvious apical akinesis.out of cats with lvotdo without hypertrophy, had follow-up studies; only cat responded positively to atenolol treatment. all the cats with initial hypertrophy had reverse remodelling and normalised aortic ejection velocities within month to month after atenolol treatment initiation; cat developed aortic regurgitation.these data indicate that sam is not exclusively related to hcm and may be a cause, not a complication, of left ventricular hypertrophy. therapies that delay the onset of congestive heart failure (chf) in dogs with dmvd at risk of disease progression would be clinically beneficial. increases in la/ao, lveddn and serum nt-probnp and ctni concentrations are associated with decreased survival times. activation of the renin-angiotensinaldosterone system is implicated in cardiac remodeling in canine dmvd. we hypothesised that administration of spironolactone to dogs with compensated dmvd demonstrating the above risk factors would reduce the rate of cardiac remodeling associated with progressive dmvd. dogs with acvim class b dmvd were recruited to a randomized, blinded, placebo-controlled pilot study. no dogs were receiving medications for cardiac disease. all dogs demonstrated at least one of the following risk factors: echocardiographic evidence of cardiomegaly, nt-prob-np> pmol/l, ctni> . ng/ml. no dogs had evidence of other cardiac disease or renal disease, hypoadrenocorticism, hyperkalaemia, or hyponatraemia. dogs were randomized to receive spironolactone ( mg/kg orally) or placebo sid for months. comparisons between groups were made using mann-whitney tests. repeated measures linear models were constructed to compare the rate of change of variables over time. significance was set at p< . . data were analysed based on the intention to treat. twenty dogs of varying breeds were enrolled. ten dogs demonstrated risk factors, dogs risk factors and dogs risk factor. ten dogs received placebo; age range . - . years (mean ±sd, . ± . years), body weight range . - . kg ( one dog in this group died suddenly, progressed to chf and received suboptimal spironolactone dosage. nt-probnp was significantly higher in the spironolactone group at baseline. (p= . ). nt-probnp (p= . ), la/ao (p= . ) and lveddn (p= . ) increased over time in the placebo, but not in the spironolactone, group. the rates of change of nt-probnp (p= . ), la/ao (p= . ) and lveddn (p= . ) approached, but did not reach, significant differences between groups. in conclusion, treatment with spironolactone might slow the rate of increase in cardiac size in dogs with acvim class b dmvd showing risk factors for poor outcome. decreasing the rate of increase in cardiac size might delay the onset of chf. further studies are warranted to investigate these hypotheses. cardiac dysfunction is a concern in human systemic inflammatory response syndrome (sirs) patients, where increased cardiac biomarkers and decreased cardiac function have already been described. in a previous canine sirs study, an increase of cardiac biomarkers (nt-probnp, ctnt and lactate) and their prognostic value has been established. the present study evaluated the kinetics of basic echocardiographic parameters (fractional shortening (fs) and left ventricular ejection fraction (lvef), which both reflect systolic function; and the ratio of the left atrium to the aorta (la/ao), which reflects preload) in canine sirs. our hypotheses were that ( ) fs, lvef and la/ao are altered in canine sirs and ( ) that these parameters carry prognostic information.dogs with sirs, without primary cardiac disease, presenting to the emergency service were prospectively included from january until august . cardiac ultrasonography was performed by two veterinarians in a standardized fashion at initial presentation, after (t ), (t ), (t ), (t ) hours of hospitalization until discharge or death and at a control visit (t m) over one month after discharge. dogs were classified according to their underlying disease process: infection, neoplasia, trauma, gastric-dilation and volvulus (gdv), other gi diseases, and miscellaneous diseases. statistical analysis was performed with sas. univariate analysis was used to assess normal distribution. a mixed procedure and a logistic procedure was performed accordingly (p < . ).thirty seven dogs (infection, n= ; neoplasia, n= ; trauma, n= ; gdv, n= ; other gi, n= and miscellaneous diseases, n= ) were included. twenty-eight patients survived, while did not (died, n= ; euthanasia for financial reasons, n= ; euthanasia for prognostic reasons, n= ). eleven dogs had control visits, owners declined a control echocardiography, patients were lost to follow-up and died before control visit. fs and la/ao were significantly correlated with survival to discharge, however lvef was not. additionally, lvef and fs did not change significantly during hospitalization; neither compared to t m. la/ao did however increase significantly during hospitalization. la/ao at t ( . ; . - . ) differed significantly from values at t ( . ; . - . ), t ( . ; . - . ) and t m ( . ; . - . ).unexpectedly, surviving dogs had lower fs ( . %; - ) than non-survivors ( . %; - ). la/ao was associated with survival and increased rapidly after hospitalization to values similar to t m, which probably reflects the efficacy of fluid therapy in emergency cases.in this population of canine sirs patients, no echocardiographic evidence of cardiac dysfunction was demonstrated. reports from first-opinion practice of feline arterial thromboembolism (ate) are scarce. our aim was to describe and evaluate the outcome in cats with ate presenting to three first-opinion clinics.clinical records of cats presenting with ate between - were reviewed for history, clinical findings, presence of congestive heart failure (chf) and outcome. kaplan-meier and log rank analysis was performed to evaluate associations with survival.during the study period, cats presented with ate; an overall feline incidence of . %. most cats were male ( . %) and non-pedigree ( . %). signs of cardiovascular disease prior to ate included cardiomyopathy ( %), a heart murmur ( . %), a gallop sound/arrhythmia ( . %) and hyperthyroidism ( . %). most cats presented within hours of clinical signs ( . %). median age at presentation was atrioventricular block (avb) is an arrhythmia resulting from conduction abnormalities through the atrioventricular node that leads to severe signs and sudden death.the aim of this study was to evaluate long-term intrinsic rhythm variations in dogs undergone pacemaker (pm) implantation. ninety-two dogs of different breeds with rd degree avb ( avb) ( . %), advanced nd degree avb ( avb)( . %), paroxysmal avb ( %), : avb ( . %) and avb with atrial fibrillation ( . %) were retrospectively analyzed. forty-nine ( . %) were males and ( . %) females with a mean age of . + . (sd) years and a mean body weight of . kg + . . the intrinsic rhythm was evaluated the day of pm implantation (t ), after day (confidence interval % [ci %] - ) (t ), days (ci % - ) (t ), days (ci % - ) (t ), days (ci % - ) (t ). according to the avb grade at different controls, the rhythm disturbance was considered advanced, regressed or unchanged. shapiro-wilk and kolmogorov-smirnov tests were used to test normalcy, f-test to compare means in a generalized linear model and chi-squared to examine the association between categorical variables and status at each control. sixty ( . %) dogs had no intrinsic rhythm changes, ( . %) had avb progression and ( %) had avb regression. forty-eight cases of avb remained unchanged, while regressed to sinus rhythm, to : avb and to advanced avb. eight advanced second degree avbs progressed to complete avb, regressed to sinus rhythm, to : avb and remained unchanged. five paroxysmal avbs progressed to complete avb, to : avb and remained unchanged. four : avbs progressed to complete avb, regressed to sinus rhythm and remained unchanged. all avbs with atrial fibrillation remained unchanged. chi-square test showed that changes of intrinsic rhythm were associated with the type of avb (v . , p<. ) and the time of controls (v . , p<. ), while other factors were not statistically significant. regression occurred within days while progression occurred at any times. the results showed that the degree of avb at the moment of pm implantion should not be considered a definitive diagnosis since more than / of the cases could present progression or regression. because of their potential progression, pm implantation should be considered as first choice treatment also in cases of low avbs, and further studies are needed to evaluate the cause of transitory high grade avbs. tissue doppler imaging (tdi) is a complement to conventional echocardiography for assessment of myocardial function. the aims of the study were to investigate breed differences and intraobserver-variability of colour tdi variables in healthy dogs.fifty-three privately-owned male dogs were prospectively recruited. dogs were declared healthy by physical examination, blood pressure measurement, ecg, analyses of urine and blood (haematology and biochemistry), and conventional echocardiographic d and doppler examination, as part of the eu-funded lupa-project. directly following these extensive examinations, the tdi acquisition was performed by the same experienced echocardiographer using a philips hd xe with a s - (small dogs) and s - (large dogs) mhz probe. cineloops were acquired from the right short-axis view and radial colour tdi variables at the endocardium and epicardium of the left ventricular free wall were later analysed. six other healthy dogs were included in a substudy aimed at evaluating the effect of sources of variation using a hierarchial random-effects model.ten of the examined dogs were excluded due to breathing artifacts and poor quality of the curves, leaving dogs in the study; labrador retrievers ( ), cavalier king charles spaniels ( ), and dachshunds ( ), with a mean age of . ± . years (sd). a p-value < . was considered significant in the statistical analyses. kruskal-wallis one-way analysis of variance showed that labrador retrievers had significantly higher values for endocardial and epicardial systolic (s) waves, and longer time to peak for both endocardial and epicardial e-and a-waves, compared to the other two breeds. labrador retrievers also had significantly lower heart rate (hr). further analysis of the breed differences using multiple regression analysis showed major effects of body weight and hr on endocardial and epicardial s waves, while time to peak, both endocardial and epicardial, for the e-and a-waves, were primarily affected by hr. dog was the variance component having the major effect on variability of tdi variables.in conclusion, time to peak of both diastolic waves was longer in labrador retrievers compared to the small-breed dogs. furthermore, higher s-wave values in labrador retrievers might indicate a different contractility pattern in largebreed dogs, and warrants further investigation. mitral regurgitation (mr) is the most common heart disease in dogs.dogs with a more advanced stage of this disease are likely to develop pulmonary edema of heart failure. the aim of this study was to evaluate the plasma c-reactive protein (crp) concentra-tion in dogs that underwent mitral valve repair for mr.all dogs were operated between october and october . the dogs were categorized according to the international small animal cardiac health council (isachc) classification, and physical examination, thoracic radiography, and d color flow doppler echocardiography were performed before and after surgery. the plasma crp concentration and white blood cell counts were also determined before and after surgery. cardiogenic pulmonary edema was diagnosed on the basis of clinical examination and thoracic radiography.overall, dogs (mean body weight, . ± . kg and mean age, . ± . years) were enrolled; of these dogs had cardiogenic pulmonary edema. the dogs breeds were chihuahua (n = ), cavalier king charles spaniel (n = ), maltese (n = ), yorkshire terrier (n = ), shih tzu (n = ), miniature dachshund (n = ), and others (n = ). no significant difference was found for age and body weight. the vertebral heart size and la/ao ratio significantly decreased after surgery compared with the preoperative values. before the operation, crp concentration and white blood cell counts in isachc class iiib dogs ( . ± . mg/dl and ± /ll, respectively) were higher than those in class ib ( . ± . mg/dl and ± /ll, respectively), class ii ( . ± . mg/dl and ± /ll, respectively), and class iiia ( . ± . mg/dl and ± /ll, respectively) dogs. additionally, crp concentration and white blood cell counts in class iiib dogs significantly decreased after surgery compared with preoperative values. crp concentration and white blood cell counts in the dogs with cardiogenic pulmonary edema significantly increased compared with those with non-pulmonary edema. furthermore, cardiogenic pulmonary edema disappeared within months after surgery, and the crp concentrations and white blood cell counts became normal.in conclusion, crp concentration increases in dogs with mr and cardiogenic pulmonary edema. it is widely recognized that inflammatory reaction plays a key role in the development of heart failure. consequently, these data indicate the importance of strict management for pulmonary edema and inflammation. the neurotransmitter serotonin ( -hydroxytryptamine, ht) has recently been suggested to have a role in development of myxomatous mitral valve disease (mmvd) in dogs.the aim of this study was to investigate whether serum ht concentration was associated with mmvd severity in dogs, and to assess potential associations between serum ht concentrations and dog characteristics, echocardiographic variables, heart rate, systolic blood pressure, and platelet size (mean platelet volume) in the study population. client-owned dogs with naturally acquired mmvd of varying severity were prospectively recruited for the study. dogs were classified according to mmvd severity (breeds predisposed to early onset of mmvd, but without echocardiographic evidence of the disease, or mild, moderate or severe disease). serum ht concentrations were analyzed using an elisa assay.lower serum ht concentrations were shown in dogs with severe mmvd, compared with dogs predisposed to mmvd (p = . ) and dogs with mild mmvd (p = . ). unilinear and multiple regression analyses showed that serum ht concentrations decreased with increasing left atrial to aortic root ratio (la/ao), were higher in cavalier king charles spaniel (ckcs) dogs compared to dogs of other breeds, and were higher in female dogs than in male dogs. the la/ao was the variable most strongly associated with serum ht concentration.in conclusion, the finding of higher serum ht concentrations in dogs predisposed to mmvd (ckcs) and dogs with mild mmvd suggests that alterations in ht signaling might play a role in progression of early stages of mmvd. hypersomatotropism (hs) can be a common reason for development of diabetes mellitus in the cat. remission of diabetes can be achieved with an accurate diagnosis of the hs, although diagnosis is hampered by the relative complexity of confirming hs, requiring a combination of insulin growth factor- (igf- ) or feline growth hormone measurement and intracranial imaging. unfortunately, all three have limitations as diagnostic aid and when evaluating the success of therapy, particularly radiotherapy (rt). consequently, more precise markers of hs are required. the current study aimed to evaluate physiological behaviour and diagnostic potential of serum ghrelin in feline hs. as ghrelin is an endogenous ligand of the gh secretagogue receptor, it was hypothesised production of ghrelin might be suppressed in hs and subnormal serum levels could be a marker for increased gh activity.fasted (pre-insulin) serum samples were collected from normal (age matched control), uncomplicated diabetic (dm) and hypersomatotrophic diabetic (hsdm) cats. cats were categorized into the hsdm-group on the basis of elevated igf- (> ng/ml) and demonstration of a pituitary lesion on imaging. in cats additional serum samples were obtained following rt. cats were categorized into the dm-group on the basis of low igf- (< ng/ml) and normal insulin requirements (< . iu/kg). serum ghrelin was determined using a total ghrelin elisa system validated for the cat. data were tested for normality and concentrations compared between groups using unpaired t-tests and a paired t-test for the before and after rt hsdmgroups.serum total ghrelin was not different between the hsdm ( . ng/ml+/- . ) and dm-group ( . ng/ml+/- . , p= . ). a significant difference was present between the control group ( . ng/ml+/- . ) and both the hsdm (p= . ) and the dmgroup (p= . ). serum ghrelin concentrations in the hsdm cats undergoing rt (n = ) were significantly higher following completion of treatment ( . ng/ml+/- . versus . ng/ml+/- . , p= . ).the results suggest feline serum total ghrelin is suppressed to similar levels in both the diabetic and diabetic hypersomatotrophic state compared to healthy subjects. consequently, it appears serum ghrelin levels are not helpful in determining the presence of hs in the diabetic cat. however, the results do indicate treatment of hs with rt results in an increase in serum ghrelin, suggesting the presence of an independent inhibitory effect of excess gh on serum ghrelin production. this potential inhibitory effect of gh might render serum ghrelin measurement useful as an additional tool to assess hypersomatotrophic remission after rt. further studies are however indicated. to date only few studies characterized histopathological features of the endocrine and exocrine pancreas in cats with diabetes mellitus. loss of b-cells is a consistent finding but no detailed data about the presence and types of inflammatory cells are available. we recently observed that hyperglycemia increases neutrophils in the exocrine pancreas. the aims of the present study were to assess whether diabetic cats have pathological evidence of islet inflammation or pancreatitis and to define islet lesions in comparison to a well-matched control population.formalin-fixed, paraffin-embedded pancreatic samples were collected from post-mortem examination performed on diabetic and control cats died due to any disease at the clinic for small animal internal medicine, university of zurich (switzerland) between and . control cats were selected to be matched for age, sex, breed and body weight. sections were routinely stained with hematoxilin-eosin, and doublelabeled immunohistochemistry was performed for the following markers: insulin and myeloperoxidase (neutrophils), insulin and cd (t-lymphocytes), insulin and cd (b-lymphocytes), insulin and pcna (proliferation marker), and glucagon and ki- (proliferation marker). light-microscopic cell counting and morphometric analyses were performed manually and with software (image-j), respectively. data were analyzed with contingency tables and ttests.thirty-seven diabetic cats and controls were included. the mean insulin-positive cross sectional area was approximately % lower in diabetic than control cats (p< . ), that of glucagon was similar. proliferation of insulin-positive and glucagon-positive cells and the average counts of neutrophils, t-and b-lymphocytes in the islets did not differ between groups. interestingly, the presence of (t and b) lymphocytes in general tended to be more frequent in diabetic ( / = . %) than control ( / = . %) cats. in the exocrine pancreas, a trend towards increased presence of necrosis and fibrosis was observed in diabetic cats ( / = . % vs. / = %; p= . ) but inflammatory infiltration did not differ. proliferation of acinar cells was -fold increased in diabetic cats (p< . ), notably nearby islets ( -fold, p< . ).the results confirm previous observations that loss of b-cells occurs in diabetic cats. in addition, a subset of diabetic cats shows lymphocytic infiltration of the islets that might have contributed to b-cell loss. increased necrosis and fibrosis of the exocrine tissue may suggests that the diabetes leads to pancreatitis in some cats. the increased proliferation rate of acinar cells deserves further investigation. in humans this finding has been associated with chronic pancreatitis as well as transdifferentiation into islet cells. on the basis of a relatively high prevalence of hypersomatotropism (hs) amongst cats with a diagnosis of diabetes mellitus, as well as the possible subtle phenotype of these patients and the significant implications on prognosis and treatment, screening diabetic cats for hs could be advocated. for most veterinarians serum total insulin-like growth factor- (igf- ) assessment represents the most feasible and accessible means of performing screening. however, hepatic igf- production is dependent on presence of sufficient portal insulin, which can be deficient in newly diagnosed diabetic cats, resulting in false negative results. additionally, elevation of igf- has been reported in non-acromegalic diabetic cats. alternative or additional diagnostic tests for hs, as well as to evaluate the success of treatment of hs, are therefore desirable. since feline hs is associated with tissue growth, serum type iii procollagen propeptide (piiip), a peripheral indicator of collagen turnover, was hypothesised to be a useful indicator of active disease or growth hormone bioactivity. fasted, pre-insulin, serum samples were prospectively collected from uncomplicated diabetic (dm) and hypersomatotrophic diabetic (hsdm) cats. cats were categorised into the hsdm-group on the basis of elevated igf- (radioimmunoassay, > ng/ml), followed by demonstration of a pituitary lesion on intracranial imaging and into the dm-group on the basis of low igf- (< ng/ml) and modest insulin requirements (< . iu/kg). an elisa system for piiip was developed for use in the cat. data were tested for normality and concentrations compared using the mann whitney test. correlation with serum igf- was assessed by calculating a spearman's correlation coefficient (rho).dilutional parallelism using cat serum with high and low piiip-activity indicated validity of the elisa system. intra-assay coefficient of variation calculation proved adequate precision at high and low concentrations ( . % and . %) and the assay detection limit was found to be . ng/ml. median serum piiip was . ng/ml (range: < . - . ) in the hsdm group, versus . (range: < . - . ) in the dm group (p< . ). there was a significant correlation between serum igf- and piiip (rho= . , p< . ).in conclusion, serum piiip can be measured in the cat. additionally, serum piiip seems an alternative measure of growth hormone bioactivity in cats, given the significant elevation in concentration in feline hs. further evaluation of piiip in cases with hs will help determine the exact added value of evaluating this parameter in the diagnosis of hs, as well as in the assessment of treatment efficacy. glucose and galactose are transported across the brush border membrane (bbm) of enterocytes by sodium/glucose cotransporter- (sglt ), coded for by slc a . sglt is the sole route for intestinal glucose absorption and its level of expression dictates bbm transport capacity for glucose. the relevance of sglt expression in predisposition to diabetes mellitus and obesity was investigated in dogs. the aims were to assess the effect on promoter function of known snps in the ' flanking region of canine slc a , and to search for novel snps in well defined samples of dogs with varying risk for diabetes or obesity. caco- /tc cells were shown to express sglt in vitro. the kbp fragment of canine slc a ' flanking region from - to + relative to the transcription start site was cloned from canine genomic dna, ligated into pgl basic plasmids bearing firefly luciferase as a reporter gene, used for transient transfection of caco- /tc cells, and shown to drive luciferase production significantly above control (p< . ). to determine the effect of the three known snps in this region on promoter function, new promoter/reporter constructs (all possible permutations of these three snps) were created using site-directed mutagenesis. these constructs were used for transient transfection of caco- /tc cells using renilla luciferase as an internal control. no significant differences in promoter function were seen, suggesting that these three snps do not have a significant effect on the constitutive transcription of sglt mrna in dogs.a search for novel snps in this region in dogs was made in two breeds predisposed to diabetes mellitus (samoyed, cairn terrier), two breeds that rarely develop diabetes (boxer, german shepherd dog), and two breeds predisposed to obesity (labrador retriever, cocker spaniel). genomic dna from healthy individuals of each of these breeds was obtained from the uk companion animals dna archive, with kind permission. the slc a ' flanking region was amplified from each individual by high-fidelity pcr using breed-labelled primers, gel purified, mixed in equimolar amounts and sequenced by pyrosequencing ( sequencing, gs flx, roche). the sequence of the slc a ' flanking region in all individuals of all breeds tested was identical. on this evidence, variations in slc a promoter sequence between dogs do not influence the pathogenesis of diabetes or obesity in these breeds. remission of diabetes mellitus may be achieved in up to % of cats. for remission to occur, recovery of b-cell function and possi-bly of b-cell mass is required. a novel class of antidiabetic drugs that act via the incretin system increase b-cell proliferation and glucose-stimulated insulin secretion in rodents. two strategies of incretin-based therapies, glp- analogues (e.g. exenatide shortacting (ex-sa), exenatide long-acting (ex-la)), and dpp- inhibitors (e.g. sitagliptin), are successfully used in human diabetics. knowledge about the use of incretins in cats is scarce. it was demonstrated that ex-sa and a dpp- inhibitor (nvp-dpp ) increase insulin secretion after intravenous glucose stimulation in healthy cats. the effects of these drugs after meal stimulation and the use of ex-la have not been explored in cats so far.the aims of the study were to test whether ex-sa (byetta ® , q h, sc), ex-la (bydureon ® , q d, sc) and sitagliptin (januvia ® , q h, po) can be safely used in cats, and to identify the most effective drug and dose in a dose-escalation study.nine healthy cats were used. ex-sa was given to cats at . , . , and lg/kg for consecutive days each. ex-la was given to other cats at , , and lg/ kg with single injections each. sitagliptin was given to cats at , , and mg/kg for consecutive days each. a washout period of weeks was allowed between doses. on day of each treatment block, a meal response test (mrt) was performed in all cats after a h fastby feeding % of daily energy intake with subsequent blood sampling at timepoints , , , , and minutes. insulin and glucose area under the curves (auc) were calculated for each drug dose.gastrointestinal side effects of to days duration were observed in cats of each group, irrespective of the dose. well-being and appetite were otherwise conserved. ex-sa increased insulin auc by %, %, % and %, respectively, compared to insulin auc during mrt without drug administration. ex-la and sitagliptin increased insulin auc by %, %, %, % and %, %, %, %, respectively. auc for glucose was similar in all cats, irrespective of the drug and dose. we conclude that ex-sa, ex-la and sitagliptin can be safely used in healthy cats and that ex-sa increases insulin secretion more effectively than ex-la and sitagliptin. insulin detemir is a synthetic long acting insulin analogue designed to maintain basal levels of insulin in humans with diabetes mellitus (dm).pharmacokinetic studies in dogs indicate that insulin detemir has a greater effect than other types of insulin, requiring a lower dose. the objective of our study was to evaluate its efficacy and the frequency of hypoglycemia in dogs with dm treated with insulin detemir. eight dogs were included into the study. median (range) age was years ( - ), were female ( intact, spayed), and was intact male; median (range) body weight was . kg ( . - . ). dogs with relevant concurrent diseases (e.g. hypothyroidism, hypercortisolism, neoplasia, renal insufficiency) and dogs with prior administration of diabetogenic drugs were excluded. all dogs received insulin detemir bid for at least months, re-evaluations were performed after , , , and weeks and included clinical signs, blood glucose curves (bgc) and fructosamine concentrations. median (range) insulin dose was . u/kg ( . - . ) bid at admission which was not significantly different after weeks of therapy ( . u/kg, range . - . ). initially, all dogs had markedly elevated blood glucose ( . mmol/l, . - . mmol/l), and elevated fructosamine concentrations ( lmol/l, - lmol/l). mean(±sd) glucose concentrations (mmol/l) of the bgc at each re-evaluation were . ± . , . ± . , . ± . , . ± . , . ± . ; median (range) of the glucose nadir values (mmol/l) were . ( . - . ), . ( . - . ), . ( . - . ), . ( . - . ), . ( . - . ) and fructosamine concentrations (lmol/l) were ( - ), ( - ), ( - ), ( - ), ( - ), respectively. glucose concentrations (mean) were significantly (p< . ) lower after weeks therapy than before treatment. hypoglycemia (glucose nadir < mmol/l) was a consistent problem, identified in dogs ( % of the bgc of the dogs). there were episodes (in dogs) of owners reporting clinical signs (lethargy, weakness, unsteady gait) that could have been caused by hypoglycemia. based on owner opinion, clinical assessment of the veterinarian and bgc after months of therapy, good control of the disease was obtained in ( %) and moderate control in dogs ( %). according to our preliminary results insulin detemir is effective in controlling hyperglycemia in dogs with dm. it is more potent than other types of insulin which are also used bid and therefore lower doses were used. nevertheless hypoglycemia was a common finding especially in small dogs. therefore insulin detemir should be used with great caution and dilution could be considered. spontaneous hypercortisolism is due to acth-independent hypersecretion of cortisol by an adrenocortical tumor (at) in about % of the cases. although the understanding of growth and hormonal activity of ats has expanded in recent years, the pivotal factors/acts in the pathogenesis of the at remain undisclosed.the canonical wnt-pathway plays a role in cell survival and cell cycle progression and has been shown to be involved in many different tumor types, including human and mouse ats. central in this pathway is ß-catenin. cytoplasmic and/or nuclear accumulation of ß-catenin has been demonstrated in human cortisol-secreting ats. this has been partly explained by mutations in exon of ß-catenin.in our study, the activation of the canonical wnt-pathway was investigated in adrenal adenomas and carcinomas of dogs with acth-independent hypercortisolism. fifteen normal canine adrenals served as control tissue. the mrna expression was measured for wnt-ligands (wnt , wnt , wnt , wnt a, wnt b variants and , wnt , wnt a, wnt b), wnt-ligand inhibitors (dkk , wif , sfrp ) and for wnt target genes (cmyc, axin and cyclind ). in addition, the coding region of the mrna of ß-catenin was sequenced and the localization of ß-catenin was evaluated by immunohistochemistry (ihc).the results of expression analysis of wnt-ligands and wnt-ligand inhibitors demonstrated a significant downregulation of wnt and wnt b variants and . wnt target gene cyclin d was significantly downregulated in adenomas, while cmyc and axin mrna expression did not differ between ats and normal adrenals.sequence analysis of ß-catenin revealed a mutation in / of the ats: silent mutations, most probably single nucleotide polymorphisms (snps), neutral mutation (arginine to histidine), nonsense mutation resulting in a premature stop codon and deletion of basepairs combined with a neutral mutation. the amino acid change appeared not to be tumorassociated whereas the stop codon was. there were no activating ß-catenin mutations. the ihc demonstrated accumulation of ß-catenin in the cytoplasm of part of the ats, while nuclear staining for ß-catenin was rarely present.we conclude that the canonical wnt-pathway is most likely not involved in the pathogenesis of canine cortisol-secreting ats. trilostane is the treatment of choice for canine pituitary-dependent hyperadrenocorticism (pdh) however there is controversy about the ideal treatment regime. the objective of this study was to evaluate efficacy and safety of sid vs bid trilostane treatment for canine pdh.this prospective randomised study included dogs with pdh, dogs treated with trilostane sid (initial dose - mg/kg/ hrs) and with trilostane bid ( . - mg/kg/ hrs). a history, physical exam, haemogram, biochemical profile, acth stimulation test and urinary cortisol to creatinine ratios (uccr) were performed before treatment, and at one week (sid - hrs post trilostane; bid - hrs) and , , and months after treatment ( - hrs post medication)the median (±sd) daily dose throughout the study was similar in dogs receiving sid ( . ± . mg/kg/day) or bid ( . ± . mg/kg/day) trilostane. baseline cortisol concentration (mean±sd) before trilostane and at the five reevaluations in the sid group were . ± . , . ± . , . ± . , . ± . , . ± . and . ± . and in the bid group were . ± . lg/dl, . ± . , . ± . , . ± . , . ± . and . ± . . baseline cortisol was significantly higher (p= . ) in the sid group only at six-month evaluation. post acth cortisol concentrations in the sid group were . ± . , . ± . , . ± . , . ± . , . ± . and . ± . and in the bid group were . ± . , . ± . , . ± . , . ± . , . ± . and . ± . . no statistically significant differences were found at any evaluation. uccr in dogs in the sid group were ± , ± , ± , ± , ± and ± . and in the bid group ± , ± , ± , ± , ± and ± . similarly no statistically significant differences were found throughout the study. in each of the five re-evaluation times, clinical signs (polyuria, polydipsia and/or polyphagia) persisted in % ( / ), % ( / ), % ( / ), % ( / ) and in % ( / ) of dogs in the sid group. persistence of clinical signs occurred in % ( / ), % ( / ), % ( / ), % ( / ) and % ( / ) of dogs in the bid group. mild adverse effects occurred in / and in / of the dogs treated with sid and bid trilostane, respectively.based on this study, we conclude that the results of acth stimulation test and uccr in dogs with pdh treated with both protocols are similar at most re-evaluation times. however, clinical signs resolved in a greater proportion of dogs receiving trilostane bid. using trilostane twice daily will help to reduce the number of dogs that do not have a good clinical response. the effectiveness of trilostane therapy is monitored by regular acth stimulation, which is time-consuming and expensive. therefore, a monitoring system without a stimulation protocol and with less client expense would be preferable.the aim of our study was twofold: firstly, to evaluate, if baseline cortisol, endogenous acth (cacth) or the baseline cortisol to acth ratio (cortisol/acth ratio) could replace the acth stimulation test; secondly, to evaluate, if baseline cortisol provides additional information than post-acth cortisol alone or if its measurement could be abandoned.forty-one trilostane-treated dogs with pdh diagnosed between april and december were included in the study. a total of acth stimulation tests with baseline, post-acth and delta cortisol (post-acth cortisol minus baseline cortisol) and cacth results and cortisol/acth ratios were analyzed.control of adrenal gland function was classified according to the target range of post-acth cortisol concentration as: excessive (< nmol/l; group ), optimal ( - nmol/l; group ), or inadequate (> nmol/l; group ). in a second step, control of adrenal gland function was reclassified according to baseline cortisol values only and the new classification was compared with the original one.there was a significant correlation between baseline cortisol and post-acth cortisol and a significant difference of baseline cortisol between the groups, however, with a large overlap. reclassification of the adrenal gland function on the basis of baseline cortisol revealed a misclassification in / ( %) tests.endogenous acth did not correlate with baseline or post-acth cortisol and did not differ between the groups. the baseline cortisol:acth ratio differed significantly between group and and between group and , but again with a large overlap.to determine if measurement of baseline cortisol gives additional information than post-acth cortisol alone, the delta cortisol values were analysed. delta cortisol correlated significantly with post-acth cortisol but not with baseline cortisol and differed significantly between the groups, the overlap however was large.the large overlap using only single values without taking post-acth cortisol into consideration leads to an unacceptably low correct differentiation of control of adrenal gland function. therefore, the acth stimulation test and determination of post-acth cortisol cannot be replaced by baseline cortisol, endogenous acth or the cortisol/acth ratio. however, as baseline cortisol concentration does not give additional information than post-acth cortisol alone, its determination can be abandoned. in humans, recombinant human thyrotropin (rhtsh) enhances radioactive iodine uptake (raiu) in patients with differentiated thyroid cancer. this property is particularly interesting in dogs because high doses of radioiodine- ( i) are used for the treatment of this disease. no studies have been performed in veterinary medicine to optimize i treatment of thyroid cancer.the aim of this study was to evaluate the effect of rhtsh on the uptake of i in dogs with thyroid tumors.nine dogs with thyroid neoplasia were included in this prospective cross-over study. six dogs had unilateral tumors, dog had bilateral tumors and dogs had ectopic tumors. diagnosis was based on physical examination, cytology, cervical scintigraphy and, when available, histopathology. in dogs i was administered for a baseline raiu determination in week . in week (after a wash out period of weeks), these dogs received rhtsh ( lg iv) h before i injection. in patients the order of the protocol was reversed. for each scan, the dogs received mbq ( mci) of i iv and planar scintigraphy was performed h and h thereafter for tumor raiu calculation. blood samples were taken at baseline and at , , and h after rhtsh administration for measurement of serum total thyroxine (tt ) and serum thyrotropin (tsh) concentrations.rhtsh caused no statistical significant change on thyroid tumor raiu at h (p= . ) or at h (p= . ). despite the lack of overall statistical significance, after rhtsh administration the h raiu increased in tumors and the h raiu increased in tumors. when an increased raiu was observed, i uptake with rhtsh ranged . to . times baseline uptake. in patients, the post-rhtsh raiu more than doubled compared to baseline raiu. the raiu of thoracic metastases from patients could be calculated. in thoracic metastasis the raiu doubled after rhtsh; in the other the raiu decreased after rhtsh.in euthyroid patients, rhtsh induced a significant increase in tt concentrations (p= . ), confirming the biological activity of rhtsh.this study suggests that iv administration of lg rhtsh h before i has an inconsistent effect on thyroid tumor raiu, with a marked increase in uptake in some tumors and a decrease in others. further studies are necessary to determine the best dosage, route and timing of rhtsh to optimize thyroid tumor raiu.this study was partly funded by the dutch animal cancer foundation transdermal methimazole has been suggested as an alternative treatment option of hyperthyroid cats. in a previous study we could show a good clinical effectiveness of a pleuronic lecithin organogel (plo-) based product on a twice-daily basis. a reduced dose frequency is known to improve owner compliance, however no study has yet evaluated long-term treatment responses after once daily administration.objectives of the present study were to assess whether once daily administration of transdermal methimazole in its original formulation of (plo) was an effective alternative to the twice-daily treatment during a follow-up period of up to months and to evaluate t courses during a -hour period after methimazole application in selected cats.twenty client-owned cats with newly diagnosed hyperthyroidism and with available follow-up information were included in the study. methimazole was formulated in plobased vehicle and was applied to the pinna of the inner ear at a starting dose of mg/cat q hours. cats were rechecked - weeks, - weeks, - months, - months, - months, - and - months after starting therapy. additionally, in cats t concentrations were measured every hours after gel application over a hour period week after starting therapy. after - weeks, clinical improvement was observed in all animals. a change of treatment to oral medication due to erythema of the internal pinna of the ears was necessary in one cat, while none of the other animals showed any side effects during the follow-up period. significant decreases in t concentrations were determined at all rechecks compared to pre-treatment concentrations. methimazole dosage was increased in , decreased in and remained unchanged in cats. two cats with a decrease in the dose later had to be re-increased, while one cat was changed to q hours. there was no significant change in t during the -hour period and fluctuations corresponded to variations of precision in series.these results are in accordance with those of our previous study using the twicedaily regimen. we could show that once daily administration of transdermal methimazole in its original formulation of plo is an effective treatment option for long-term management of feline hyperthyroidism. further, timing of blood sampling after gel application is not important when assessing response to treatment. increase in the prevalence of large thyroid tumors, intra-thoracic thyroid thyroid scintigraphy provides valuable information regarding both thyroid anatomy and physiology and plays an integral role in the diagnosis, staging, and management of feline thyroid disease. in this study, we performed thyroid imaging on , consecutive hyperthyroid cats that were referred for radioiodine therapy between january and december . scintigraphy was performed as part of our staging protocol in which thyroid volume is estimated for i dose estimation (vet radiol ultrasound ; : ) . in each cat, the location of each area of increased radionuclide uptake (iru) was also recorded (cervical, thoracic inlet, chest). finally, each scan was evaluated for features suggesting malignancy (multiple, extensive areas of iru, heterogeneous pattern of iru with irregular, spiculated margins, extension of tumor through thoracic inlet into the thorax, and metastasis to regional lymph nodes or lung).of the , cats, most had been recently diagnosed. in cats, however, the interval between diagnosis and i treatment ranged from > to . years; almost all of these cats had received long-term antithyroid drug treatment. the , cats were divided into groups based on interval from diagnosis to i treatment: group ( - year), , cats; group (> - years), cats; group (> - years), cats; group (> - years), cats; and group (> - . years), cats. when the estimated thyroid volumes in the groups of cats were compared, a progressive, significant (p< . ) increase in median tumor volume occurred: . cm (group ); . cm (group ); . cm (group ); . cm (group ); and . cm (group ). the prevalence of cats with areas of iru within the thoracic cavity also increased progressively: . % (group ); . % (group ); . % (group ); . % (group ); and . % (group ). finally, the prevalence of suspected thyroid carcinoma ( of the , cats) also increased progressively: . % (group ); . % (group ); . % (group ); . % (group ); and . % (group ). in contrast, no increase in prevalence of ectopic thyroid tissue was found: . % (group ); . % (group ); . % (group ); . % (group ); and . % (group ). in conclusion, our results indicate that hyperfunctional thyroid tissue continues to grow and enlarge over time. thyroid carcinoma is extremely rare in cats with recently diagnosed hyperthyroidism, but the prevalence increases dramatically over time, suggesting that transformation from benign disease is common in cats controlled medically. measurement of plasma renin activity (pra) is considered the gold standard for monitoring mineralocorticoid substitution in humans with primary hypoadrenocorticism (ph). it is the most sensitive parameter to reflect insufficient as well as inappropriate high replacement. in dogs with ph mineralocorticoid substitution is currently monitored mainly by serum potassium and sodium concentrations. the role of pra for monitoring mineralocorticoid replacement has not been investigated. the aims of the study were to measure and compare pra in dogs with newly diagnosed ph and dogs with diseases mimicking ph, and to evaluate pra in dogs with ph treated with different mineralocorticoid substitution regimes.the following groups of dogs were included in the study: dogs with newly diagnosed ph (group ), dogs that were already treated for ph (group ), and dogs with diseases mimicking ph (group ). in group pra was measured before treatment and - weeks, - weeks, and - weeks after start of therapy. in group pra was measured at least twice every to months. in group pra was measured once at initial presentation. three dogs of group and dogs of group were treated with fludrocortisone (florinef ® , bristol-myers squibb). two dogs of group and dogs of group were treated with docp (percorten ® -v, novartis). pra was measured with an enzymatic assay via trapping of angiotensin i in the service d'angiologie, chuv-nes, lausanne. results were analysed by means of non-parametric methods (p < . ).pra before treatment was significantly higher in group ( . - . ng/ l/h, median . ) than in group ( . - . ng/l/h, median . ). average pra during therapy ranged from . to ng/ml/h (median ). pra did not decrease significantly in dogs treated with fludrocortisone. pra of dogs treated with docp ( . - . ng/ml/h, median ) was significantly lower compared to dogs treated with fludrocortisone ( . - . ng/ml/h, median . ). all dogs treated with docp had normal serum sodium and potassium at all re-checks, whereas dogs treated with fludrocortisone had mild to severe electrolyte abnormalities at several occasions. there was a weak correlation between pra and serum potassium.measurement of pra is a promising tool for monitoring mineralocorticoid substitution in dogs with ph. according to our preliminary results docp is superior to fludrocortisone for mineralocorticoid replacement. phenobarbital is widely used to control epilepsy in dogs. use of phenobarbital induces hepatic enzyme activity, and may decrease serum total and free thyroxine (tt and ft ), with the exact mechanisms and prevalence of this phenomenon being unknown. the aim of the present retrospective study therefore was to investigate how many dogs treated with phenobarbital show a decrease in thyroid hormones and to give insight into potential mechanisms. for this, tt , ft , and tsh were measured in canine serum samples submitted for assessment of therapeutic concentrations of phenobarbital. in a smaller subset of dogs, albumin, total protein, and transthyretin (ttr) were also measured at the diagnostic center for population and animal health, michigan, usa.according to thyroid results, dogs were classified as 'non thyroidal illness' (nti) (tt < nmol/l, ft ! pmol/l, tsh . ng/ml); 'equivocal' (e) (tt < nmol/l, ft < pmol/l, tsh . ng/ml); 'hypothyroid' (ht) (pattern of low tt and ft , tsh > . ng/ ml); and 'normal' (n) (tt ! nmol/l; ft ! pmol/l and tsh . ng/ml).forty-five dogs were classified as nti ( . %), dogs were classified as e ( . %), were classified as ht ( . %), and as n ( %); dogs did not fit in any defined category. there was no statistically significant difference in mean phenobarbital concentrations between nti, e, ht, and n ( . ± . , . ± . , . ± . , and . ± . lmol/l, respectively). twenty dogs of each group were analyzed for albumin and total protein and compared to healthy dogs that were not receiving phenobarbital. no statistically significant difference was noticed (p> . ). the attempt to measure ttr concentrations via commercially available elisa (tsz elisa, framingham, ma, usa) gave us inconsistence performance. in conclusion, % of dogs on phenobarbital treatment were classified as nti. if group e would be included, this value could be as high as %. neither phenobarbital, nor total protein or albumin concentrations had predictive value for thyroid hormone concentrations. this study was able to define the prevalence of the phenomenon that some dogs on phenobarbital therapy have low thyroid hormone concentrations, but did not give insight into the pathogenesis. ideally, demonstration of hypothyroidism in dogs receiving phenobarbital should include assays of thyroid hormones and tsh. pheochromocytoma (pheo) is a rare malignant catecholamine-secreting tumor of the adrenal medulla. catecholamines and metanephrines in plasma and in -h urine are approved biomarkers for the detection of the disease in humans, however, the question which of the tests is best is controversial. we previously demonstrated that measurement of urinary catecholamine and metanephrine to creatinine ratios is helpful for the diagnosis of pheo in dogs and that urinary normetanephrine to creatinine ratio may be the best test to discriminate between pheo and hypercortisolism (hc).knowledge on plasma catecholamines and metanephrines in dogs is scarce and no comparison between urinary and plasma parameters has been performed. the objective of the study was to measure urinary and plasma catecholamines and metanephrines in dogs with pheo, hc and in healthy dogs and to determine the test with the least overlap between the groups. six dogs with pheo, dogs with hc ( with ath, with pdh) and healthy dogs were included. urine samples were collected into hcl containing tubes to ensure a ph < , blood samples were collected on ice, centrifuged at °c and immediately snap frozen in liquid nitrogen. all samples were stored at - °c. urinary epinephrine (u-epi), norepinephrine (u-norepi), metanephrine (u-meta) and normetanephrine (u-normeta), and plasma epinephrine (p-epi), norepinephrine (p-norepi), free and total metanephrine (pf-meta and pt-meta) and free and total normetanephrine (pf-normeta and pt-meta) were analysed by hplc. urinary catecholamines and metanephrines were expressed as ratios to urine creatinine concentrations. data were analysed by non-parametric tests (p< , ).similar to our previous findings u-epi, u-norepi, u-meta and u-normeta were significantly higher in dogs with pheo and u-norepi and u-normeta were significantly higher in dogs with hc compared to healthy dogs. comparison between dogs with hc and dogs with pheo revealed significantly higher u-meta and u-normeta in the latter group. u-normeta was the only parameter with no overlap.in dogs with pheo p-norepi, pf-meta, pt-meta, pf-normeta, pt-normeta were significantly higher and in dogs with hc p-norepi, pf-normeta and pt-normeta were significantly higher than in healthy dogs. comparison between dogs with hc and dogs with pheo showed significant higher pf-meta, pt-meta, pf-normeta, pt-normeta in the pheo group. overlap was present with all parameters, but was least with pf-normeta and pt-normeta.according to our preliminary results u-normeta, pf-normeta and pt-normeta are valuable parameters for the diagnosis of pheo, so far u-normeta has performed better than the plasma parameters. chronic kidney disease (ckd) is common in geriatric cats and hypoxia might contribute to ckd progression. vascular endothelial growth factor (vegf) is a marker of hypoxia. the aim of this study was to evaluate urinary vegf as a prognostic marker in cats with ckd compared with the established progression factors, proteinuria and hyperphosphataemia. cats were recruited through geriatric clinics held at two first opinion london practices between and . diagnosis of ckd was based on concurrent findings of plasma creatinine > mg/dl and usg < . , with persistence of azotaemia for at least weeks. vegf was measured in urine samples taken from cats at diagnosis of ckd and indexed to creatinine giving vegf: creatinine ratios (uvc). survival was compared among low (< . lg/g), medium ( . - . lg/g) and high (> . lg/g) categories of uvc using the log-rank test. multivariable binary logistic regression was used to assess whether uvc was associated with an increase in plasma creatinine concentration of at least % within year of diagnosis. cats which did not demonstrate progression but were followed for < year were excluded from the study. cases which developed hyperthyroidism, received ace inhibitors, had gross haematuria, urinary tract infections, nephrotic syndrome or evidence of bladder neoplasia were also excluded. survival data are presented as median [ % confidence interval] and other descriptive data are presented as median ( th , th percentile). significance was set at p< . . cats with low uvc (n= ) had survival of [ , ] days, while those with medium (n= ) and high uvc (n= ) had survival of [ , ] days and [ , ] days respectively. there was no difference in survival time between cats with low and medium values of uvc (p= . ), but cats with both low (p< . ) and medium (p= . ) uvc had significantly longer survival than cats with high uvc. plasma creatinine concentration increased by ( , )% in cats which progressed (n= ) and ( , )% in cats with stable renal function in the year following diagnosis (n= ). uvc was also associated with progression of azotaemia (p= . ) independently of upc and plasma phosphate concentration. the progressive group had uvc of . ( . , . ) lg/g, while the stable group had uvc of . ( . , . ) lg/g. if high uvc indicates renal hypoxia, the results of this study support the hypothesis that hypoxia is associated with progression in cats with ckd. however, further studies evaluating renal hypoxia directly would be required to verify this. the term 'triaditis' is used to describe concurrent inflammation of the liver, pancreas, and small intestine, although occasionally only two of these organs may participate. the aim of this study was to investigate the frequency of coexistence of different combinations of cholangitis, pancreatitis and/or inflammatory bowel disease in cats, and describe the clinical, clinicopathological, and histopathological findings.initially cats were included in the study. thirty-nine cats had a suspicion of 'triaditis' based on clinical signs (depression, anorexia or polyphagia, vomiting, diarrhea, and/or weight loss), while cats clinically healthy, were considered as controls. each cat on presentation underwent cbc, biochemistry profile, serum total t , spec fpl ® and ftli blood examinations. cats diagnosed with intestinal parasitism, infectious disease, neoplasia, and/or hyperthyroidism were excluded from the study. biopsies from the liver, pancreas and small intestine (duodenum, jejunum, and ileum) were collected from each sick cat during laparotomy as part of the diagnostic investigation. biopsies from healthy cats were collected during laparotomy for ovariohysterectomy. all owners had signed a consent form and the study protocol was approved by the university's and state's ethics committee.of the sick cats with a suspicion of triaditis, were excluded because of neoplasia or other conditions. of the clinically healthy cats, had histopathological evidence of inflammation in their liver, pancreas, and/or intestine and were eventually grouped together with the sick cats. collectively, histopathological evaluation of the biopsies revealed cats ( with clinical signs and without) with inflammatory lesions in at least one organ. of those cats, ( . %) had histopathological evidence of ibd, ( . %) of cholangitis, and ( . %) of pancreatitis. thirteen cats ( . %) had only ibd, ( . %) of which were symptomatic. six ( . %) cats had only cholangitis, ( . %) of which were symptomatic. one ( . %) had only pancreatitis and was symptomatic. sixteen cats ( %) had concurrent ibd and cholangitis, ( . %) of which were symptomatic; ( . %) had ibd in combination with pancreatitis, ( . %) of which were symptomatic, while ( %) had ibd, cholangitis and pancreatitis and were all symptomatic. common biochemical findings were increased activities of alt ( / ), alp ( / ), and increased total bilirubin ( / ), ftli ( / ), spec fpl ( / ) concentrations.the results of our study indicate that different combinations of concurrent inflammation of the liver, pancreas, and intestine do exist in cats. it also appears that these conditions may be subclinical in many cases. several potential pathogens are found in feline faeces, ranging in significance from incidental to pathogenic. treatment recommendations are based on accompanying clinical signs. real time pcr has enabled rapid screening of small quantities of faeces for potential pathogens, with high sensitivity and specificity. co-carriage of feline faecal pathogens may reflect a symbiotic relationship or related pathogenesis, in which case identification of common cocarriage patterns may influence treatment decisions and prognosis. the primary objective of this study was to identify co-carriage of selected feline faecal pathogens. secondary objectives were to evaluate the prevalence of individual pathogens in feline faeces, and their association with pedigree status, and a history of diarrhoea. results of a commercial -way feline diarrhoea realpcr tm panel (idexx reference laboratories, uk) from june to january were evaluated. real time pcr was performed for tritrichomonas foetus, giardiaspp., cryptosporidiumspp., toxoplasmagondii, salmonellaspp., clostridium perfringens enterotoxin a gene, feline coronavirus, and feline panleukopenia virus. additional data was recorded when available, including age, gender, breed, and history of diarrhoea. weak or borderline positive results and those from pooled faecal samples were excluded. associations of the carriage of pairs of pathogens were evaluated with a chi-squared test, statistical significance set at p < . .results of pcr panels were evaluated. the prevalence of faecal pathogens was . % (tritrichomonas foetus), . % (giardia), . % (cryptosporidium), . % (toxoplasma gondii), . % (salmonella), . % (clostridium perfringens), . % (feline coronavirus), and . % (feline panleukopenia virus).salmonella was the only faecal pathogen significantly associated with a history of diarrhoea. faecal samples from pedigree cats were significantly more likely than dsh to be positive for tritrichomonas foetus, giardia, clostridium perfringens and feline coronavirus.significant co-carriage was identified for feline coronavirus with all other pathogens except salmonella. there was significant co-carriage of tritrichomonas foetus with clostridium perfringens and giardia, and also for giardia with panleukopenia virus, cryptosporidium, and clostridium perfringens. finally, there was significant co-carriage of cryptosporidium with clostridium perfringens, panleukopenia virus with cryptosporidium, and toxoplasma gondii with salmonella.in conclusion there was a moderate to high prevalence of all feline faecal pathogens tested except toxoplasma gondii and salmonella. positive pcr results were more likely in pedigree cats, and salmonella was associated with a history of diarrhoea. significant co-carriage of faecal pathogens was common, possibly reflecting common environmental risk factors, a shared pathogenesis, or a symbiotic relationship. mycoplasma spp have been identified as causative pathogen in feline lower airway disease and are not thought to colonize the lower airways of clinically healthy cats.to challenge this hypothesis, domestic shorthair cats aged - years (median, . years), without signs of respiratory disease, housed in a shelter, underwent transoral lower airway washing with sterile saline under general anaesthesia. retrieved bronchalveolar lavage fluid (balf) was subjected to microbiological and cytological analysis.during preanaesthetic clinical examination, only minor alterations were discovered: tartar in , conjunctivitis in , flea infestation in and dirty auditory canals in cats. one animal each showed dandruff, corneal ulceration and a heart murmur / .balf-cultures of animals ( . %) were positive for mycoplasma spp. . % of examined cats had mycoplasma felis in their balf (light growth in , moderate growth in and heavy growth in animals), % ureaplasma felinum/cati (light growth in , moderate growth in cases), . % mycoplasma gateae (light growth in , moderate growth in and heavy growth in cat) and . % mycoplasma feliminutum (light growth in animal). using aerobic bacterial culture, pasteurella multocida ( . %), a-haemolytic streptococci ( . %), haemolytic e. coli ( . %) and acinetobacter iwoffii ( . %) were detected, with only samples ( . %) yielding negative results.median balf-total nucleated cell count was /ll (range, - ) with a median mononucleated cell percentage of %, a median neutrophil fraction of . % and a median eosinophil proportion of . %. only samples were neutrophil-dominated ( . and . %), indicating purulent inflammation. both specimens were positive for mycoplasma felis ( light growth, heavy growth), and one showed moderate growth of pasteurella multocida. like all of the animals included in this study, the corresponding cats remained clinically healthy during a -week followup period.balf-samples showed neither cytological nor microbiological signs indicative of upper airway contamination.in contrast to earlier studies, we conclude that -at least in cats housed in shel-ters and subjected to high infection pressure -in addition to bacteria like pasteurella spp, streptococcus spp and e. coli, mycoplasma spp can occur in the feline lower airways without causing respiratory signs. inflammasomes are intracellular multi-protein complexes that coordinate the maturation of interleukin (il)- b and il- in response to pathogens and metabolic danger signals. both cytokines are vital for the maintenance of the intestinal homeostasis and have been linked to chronic intestinal inflammation in humans. both il- b and il- are produced as inactive proforms and undergo subsequent maturation through cleavage into their active forms by caspase (casp)- , which is in turn activated by the inflammasome complex. the best characterized inflammasome subtype in human inflammatory bowel disease (ibd) is nlrp , which seems to be crucial for the regulation of intestinal homeostasis. defective nlrp signaling has been suggested to contribute to ibd. additionally, il- b, il- and casp- are upregulated on the mrna and protein level in human ibd. so far, no study has investigated the role of the inflammasome and respective down-stream cytokines in canine ibd. thus, the goal of the current study was to investigate the expression of inflammasome components in duodenal tissues from dogs with ibd compared to healthy controls. rna extraction from endoscopic biopsies (ibd group n = , control group n = ) and reversetranscriptase quantitative pcr was performed in a sybrgreenbased assay using specific primers for the following canine genes: nlrp , casp- , il- b and il- . a -fold dilution of plasmid controls for each gene was used to assess assay efficiency. relative quantification of gene expression was performed using three reference genes (gapdh, sdha, tbp). comparison between groups was performed using mann whitney u tests (graph pad prism ). significance was set at p < . . eight samples ( ibd, controls) had to be excluded due to poor cdna quality (inadequate expression of reference genes). when comparing the remaining samples in both groups, casp- (p = . ) and nlrp (p < . ) expression was significantly lower in ibd dogs than controls. in contrast, il- b (p = . ) and il- (p = . ) expression was not different between groups.down-regulation of nlrp and casp- could be part of a negative feedback loop in the pro-inflammatory environment in ibd. alternatively, this could represent general disturbances in intestinal homeostasis or failure to up-regulate "danger-signaling pathways"in inflammation. final conclusions might be difficult to draw without matching protein data, as assessing il- b and il- mrna levels cannot give insight into the ratio of "pro-cytokines"to active cytokines. thus, investigating il- b and il- protein content of canine ibd tissues is warranted in the future. the trefoil factor family (tff) comprises a group of small peptides produced in goblet cells, which are crucial for epithelial restitution and maintenance of tight junction function in the gut. in humans with inflammatory bowel disease (ibd), tff expression is up-regulated, which is thought to represent an unspecific repair mechanism. however, tffs have also been shown to be involved in the local control of disease in rodent models and in humans. so far, there has been no study investigating tff expression in the canine intestine. thus, the goal of this study was to assess tff expression in gastrointestinal tissues from dogs with ibd and healthy dogs. rna was extracted from endoscopic duodenal (ibd n = , healthy controls n = ) and colonic biopsies (ibd n = , controls n = ) and cdna generated. quantitative reverse-transcription pcr was performed for canine tff and tff in a sybr-green-based assay. a -fold dilution of plasmid controls for each gene was used to assess assay efficiency. relative quantification of gene expression was performed using three reference genes (gapdh, sdha, tbp). for statistical analysis, significance was set at p < . . overall, tff expression was significantly different across groups (kruskal wallis p < . ): in control dogs, tff expression was higher in the colon than in the duodenum (mann whitney p < . ). when comparing ibd cases to controls, duodenal tff was significantly up-regulated (mann whitney p = . ). tff expression was not different across groups (kruskal wallis p = . ). however, separate analysis of the intestinal location showed significant down-regulation of tff in the colon of ibd dogs compared to controls (t-test p = . ).this study demonstrates evidence for dysregulation of tff gene expression in canine ibd. a lack of tff could contribute to defective epithelial barrier function, causing "leakiness"of tight junctions. this increased intestinal permeability could lead to an increased antigenic load from microbes or food antigens, which could perpetuate faulty immune recognition of microbe-associated molecular patterns, thus leading to increased intestinal inflammation. up-regulation of tff in the colon could in turn signify a compensatory repair-mechanism in inflammation. further investigation of tff gene or protein expression is warranted in canine ibd. canine inflammatory bowel disease (ibd) is thought to be partially caused by an aberrant immune response towards the intestinal microbiome. in humans and mice, administration of probiotics can alleviate ibd severity and/or prevent relapse by induction of a more "tolerant"microenvironment. the aim of this study was to investigate the effect of probiotic enterococcus faecium ncimb e (ef) on gene expression and protein production in canine duodenal biopsies. samples from healthy beagles and ibd dogs were cultured ex-vivo with ef ( x cfu/ml) or sterile nutrient broth/ pbs (negative control) for hours. rna extraction from biopsies and reverse-transcriptase quantitative pcr was performed in a sybrgreen-based assay using specific primers for the following canine genes: tlr , tlr , tlr , tlr , il- a, il- , il- , tgfb, il- , ifnc and tnfa; using a -fold dilution of plasmid controls for each gene to assess assay efficiency. relative quantification of gene expression was performed using three reference genes (gapdh, sdha, tbp). protein content of ifnc, il- a and tnfa was measured in culture supernatants using commercially available canine-specific elisas. a linear mixed model for each genewith disease group and treatment set as fixed parameters -was chosen for statistical analysis using spss software. significance was set at p < . .no significant interaction between disease group and treatment was observed for any gene. only expression of il- was significantly increased in ibd dogs compared to healthy dogs (p = . ) in unstimulated samples. all other significant differences were independent of disease group, but depen-dent on treatment with ef. expression of the following genes was reduced by ef treatment: tlr (p = . ), tlr (p = . ), tlr (p = . ), tgfb (p = . ), ifnc (p = . ) and tnfa (p = < . ). no significant amounts of ifnc, il- a or tnfa protein were detected in culture supernatants.this is the first study demonstrating a profound effect of ef treatment on gene expression in ex vivo cultured canine duodenal biopsies. down-regulation of several genes of innate immune receptors and pro-inflammatory cytokines was observed, with the most significant effect on suppression of tnfa expression. effects were seen both in healthy and in ibd dogs. whether this translates to a beneficial effect in a clinical situation needs further investigation. recent molecular studies have revealed a highly complex bacterial microbiota in the intestine of cats. there is mounting evidence that microbes play an important role in the pathogenesis of chronic enteropathies, as compositional changes of the intestinal bacterial ecosystem have been associated with chronic intestinal inflammation in humans and dogs. the aim of this study was to characterize the bacterial microbiota in cats with chronic enteropathies.fecal samples were obtained from healthy cats (n= ) and cats with histologically confirmed chronic enteropathies (n= ). the bacterial composition was analyzed by massive parallel s rrna gene -pyrosequencing (yielding , sequencing tags), and selected quantitative pcr assays. differences in microbial community structure between healthy and diseased cats were assessed by the phylogenetic unifrac distance method, followed by analysis of similarity (anosim) of the distance matrix. differences in bacterial groups between the disease groups were analyzed using mann-whitney u tests. the resulting p-values were corrected for multiple comparisons using the benjamini & hochberg's false discovery rate. an adjusted p< . was considered for statistical significance.the unifrac distance metric indicated no significant clustering according to disease status. however, the relative proportions of sequences belonging to bacteroides spp. were significantly decreased in the cats with chronic enteropathies compared to the healthy cats (p= . ). the employed qpcr assays confirmed the sequencing results and also showed a significant decrease in proportions of bacteroides spp. in the diseased cats. in addition, qpcr revealed also a significant decrease in turicibacter spp. in cats with chronic enteropathies compared to the healthy cats (p= . ). no significant differences in diversity indices were observed between healthy and diseased cats.in conclusion, the here used molecular approach revealed significant reductions in bacteroides and turicibacter spp. in cats with chronic enteropathies. future studies are necessary to evaluate if these microbial changes correlate with functional changes in the intestinal microbiota. campylobacter spp. represent a common cause of gastroenteritis in humans with c. jejuni and c. coli considered responsible for the majority of clinical cases. many human diagnostic laboratories use the prospect ® campylobacter microplate assay (eia) as a sole or screening test for detection of c. jejuni and c. coli as this technique is easier, faster and cheaper than campylobacter spp. culture. c. upsaliensis can cause a diarrhoeal illness similar to that caused by c. jejuni in humans but methods routinely used for c. jejuni and c. coli detection, including the eia, are not optimised or have not been evaluated for the detection of other campylobacter species. c. upsaliensis and c. helveticus have been more commonly isolated from dogs and cats than c. jejuni and c. coli in most studies. campylobacter spp. from pets are potentially zoonotic while the pathogenicity in pets remains uncertain. the significance of c. upsaliensis and c. helveticus infections may be underestimated in human medicine due to detection methods applied.the aim of this pilot study was to assess if the eia detects c. upsaliensis and c. helveticus isolated from different pets in spiked human clinical samples. in addition, the ability of eia to detect campylobacter spp. in dog and cat faeces was assessed. ten clinical human faecal samples and two healthy dog and cat faeces confirmed negative by eia were tested by a range of culture methods to exclude presence of campylobacter spp. dilutions of eight c. upsaliensis, five c. helveticus cultures, and one c. jejuni and c. coli culture, all pcr confirmed, were added to aliquots of faecal samples to obtain a range of viable bacteria from to cfu/ml. eia was performed following the manufacturer's instructions and in duplicates. fifty out of samples tested positive by eia at various dilutions: / c. upsaliensis, / c. helveticus, / of each c. jejuni and c. coli. detection limit varied between the isolates and was lower in watery than semi-solid faeces.in conclusion, eia detected c. upsaliensis and c. helveticus in spiked faeces from human clinical cases and all campylobacter spp. tested in healthy pets. eia should not be used as a sole detection method and culture methods selected following a positive eia result should enable detection of a wide range of campylobacter spp. in addition, eia may be a useful test in pets to rule out campylobacter spp. infection and in epidemiological investigations. high-resolution manometry (hrm) is the gold standard for the evaluation of functional esophageal motility disorders in humans. no information on this non-invasive technique is available in dogs. the aims of this study were to evaluate the feasibility of hrm in dogs, generate first normal values, and to examine the influence of a standard sedation on the esophageal pressure profile.the study population consisted of healthy adult beagle dogs (mean bw . kg), the study protocol was approved by the local ethics committee. hrm was performed in sitting position after a -h fast, lidocaine jelly at % was used as a lubricant. a solid-state catheter (sierra scientific, . mm diameter) with circumferential pressure sensors spaced cm apart was inserted intranasally, measurements were started after minutes adaptation time. real-time pressure imaging during catheter intubation enabled accurate placement. each manometric protocol included water and canned food bolus swallows. the procedure was repeated minutes after standard im sedation with acepromazine and buprenorphine. data were analysed using manoview software and results (awake vs. sedated) were compared using the wilcoxon test. statistical significance was set at p< . .hrm could successfully be performed in / dogs. reasons for unsuccessful examinations were: defence reactions ( ), inability to pass through the ventral meatus ( ), reverse sneezing ( ). upper esophageal sphincter (ues) characterisation comprised: baseline pressure, residual pressure (nadir of the ues relaxation during swallowing), and relaxation duration. tubular esophageal function characterisation comprised: peristaltic con-tractile integral (pci; amplitude x duration x length of the contraction wave) and the bolus transit time (btt). lower esophageal sphincter (les) characterisation comprised: baseline pressure and residual pressure (lowest continuous second mean les pressure relative to intragastric pressure during swallow induced relaxation).the median values for water/food bolus swallows in awake (sedated) dogs were calculated i) ues: baseline pressure . mmhg ( . ), residual pressure - . / . mmhg (- . / . ) and relaxation duration . / ms ( . / ) ii) tubular esophagus function: pci . / mmhg-cm-s ( . / . ) and btt . / . ms ( . / . ) iii) les: baseline pressure . mmhg ( . ), residual pressure . / . mmhg ( . / ). significant differences were found for the ues relaxation duration (water) (p= . ) and btt (food bolus) (p= . ).in conclusion, hrm is a feasible technique for the evaluation of esophageal function in dogs. patients that require sedation can still be examined, however at this point it is not clear if sedation would affect the assessment of motility disorders in dysphagic dogs. in humans ambulatory intraesophageal ph-monitoring utilizing the bravo ® capsule is the standard test for establishing pathological gastroesophageal reflux (ger). this technique not only provides information on esophageal acid exposure, but is also able to assess symptoms associated with ger. in dogs ger is poorly understood and it is not clear if ger actually represents a clinically relevant problem.the goals of this study were to examine the canine esophageal ph milieu in health and to examine esophageal ph in dogs presenting with signs commonly attributed to ger in the veterinary literature.thirteen client-owned dogs (cod) of various breeds (median bw . kg, . - ; median age y, - ) were included. clinical signs ultimately leading to ph-monitoring comprised: lipsmacking ( ), repeated swallowing motions ( ), chronic vomiting ( ), cough ( ), retching ( ), regurgitation ( ), sudden discomfort ( ), excessive surface-licking ( ), ptyalism ( ), presumed postprandial pain ( ), refusal to eat despite interest ( ), history of esophageal foreign bodies ( ), halitosis ( ) . each dog showed a median of ( - ) signs, dogs had additional diarrhea. six healthy beagles (median bw . kg, median age . y) with unremarkable gastroduodenal evaluation served as controls (c). no prior antacid or prokinetic treatment was allowed. the capsule was endoscopically placed cm above the lower esophageal sphincter, ph data were transmitted every s to a receiver attached to the dog's collar. owners were instructed to press the individually predefined symptom-buttons on the receiver whenever indicated, and not to change the daily routine. data were analysed using the rapidph ® software, reflux was defined as a single ph-measurement < . results between groups were compared using non-parametric tests.the median ph-monitoring period (cod/c) was . / . h. the following parameters (median, range for cod/c) were evaluated: number of refluxes: ( - )/ . ( - ), number of longest (> min) reflux: ( - )/ ( - ), duration of longest reflux (min): ( - )/ . , and fraction time ph < (%): . ( . - . )/ . ( - . ). there were no differences between groups. the median number of button pushes was ( - ), dogs had reflux-positive pushes ( . , , and . % of pushes). mild distal esophagitis was noted in dog. final diagnoses were: food-responsive ibd ( ), steroid-responsive ibd ( ), allergic skin disease ( ), chronic laryngotracheobronchitis ( ), muscular dystrophy ( ) .dogs presenting with historical and clinical signs interpreted as ger may not have relevant reflux episodes. considering normal values established in humans, none of the dogs would have been classified as abnormal. the aim of the present study was to evaluate the changes of some biochemical and ultrasonographic (us) parameters in a group of dogs with naturally occurring acute pancreatitis (ap) during the therapeutic follow-up.dogs with clinical signs and abdominal us findings suggestive of ap associated with increased serum canine pancreatic lipase (cpl) activity were included into the study. in these dogs, the serum concentration of c-reactive protein (crp), amylase and lipase were also measured. severity indexes were established to semi-quantitatively evaluate the severity of clinical and us findings. in particular, a clinical score ( - ) for each of the following clinical parameters was given: presence and frequency of vomiting, appetite and general condition; an us score ( =normal, =abnormal) was assigned per each of the following parameters: pancreas (echogenicity, volume, echotexture and echogenicity of the mesentery), gastrointestinal tract, biliary ducts, lymph nodes and abdominal effusion (total score - ). all dogs were treated with fluid therapy, ampicillin-sulbactam, mg/kg iv q h, buprenorphine, . mg/kg q h, and, if needed, maropitant mg/kg sc q h. the two severity scores, serum crp, amylase and lipase concentrations were measured at diagnosis (t ) and after (t ), (t ), and (t ) days, and at discharge (td) and week after discharge (td ).nine client-owned dogs were included with a median (range) age of years ( - years). median (range) clinical and us scores were ( - ) and . ( - ), respectively, at t , and ( - ) and ( - ), respectively, at td . a significant, positive correlation was found between the clinical and us score (p< . , r= . ). the median (range) serum concentration of crp (mg/dl), amylase (u/l) and lipase (u/l) was . ( . - . ), , ( - , ) and ) , respectively, at t , and . ( . - . ), ( - , ) and ( - ), respectively, at td . on admission, serum crp, amylase and lipase levels were increased in %, %, and % of dogs, respectively while they were increased in %, . % and % of dogs, respectively, at td . serum crp and amylase, but not lipase, concentrations decreased during the follow up and were significantly (p< . ) lower at td compared to t .results suggest that us findings, and crp and amylase concentrations are correlated with the recovery from the ap. further studies are warranted to evaluate the usefulness of these parameters in the follow-up of ap in a wider population of dogs. enzyme replacement therapy is the mainstay therapy for exocrine pancreatic insufficiency (epi) in dogs. 'enteric-coated' preparations have been developed to protect the enzyme from degradation in the stomach, but their efficacy has not been critically evaluated. the hypothesis of the current study was that enteric coating would have no effect on the efficacy of pancreatic enzyme supplements for dogs with epi.thirty-eight client-owned dogs with naturally occurring epi were included in this multicentre, blinded, randomised controlled trial. dogs received either an enteric-coated enzyme preparation (test group) or an identical preparation without the enteric coating (control group) over a period of days.there were no significant differences in baseline characteristics between test and control treatment groups. body weight and body condition score increased in both groups during the trial (p< . ) but the magnitude of increase was greater for the test treatment compared with the control treatment (p< . ). by day , mean body weight increase was % ( % confidence interval - %) in the treatment group and % ( % confidence interval - %) in the control group. the dose of enzyme used increased over time (p< . ) but there was no significant treatment group difference at any time point (p= . ). clinical disease severity score decreased significantly over time for both groups (p= . ) and no significant difference was noted between groups (p= . ). no significant adverse effects were reported, for either treatment, for the duration of the trial.adding an enteric coating to a pancreatic enzyme supplement conveys a therapeutic advantage, when treating dogs with epi. when liver injury is caused by toxins that inhibit hepatocyte replication, or when the proliferative potential of hepatocytes is exhausted due to the chronic condition of the disease, hepatocyte-dependent liver regeneration is strongly impaired. in this situation another cell compartment is activated to regenerate the liver: the hepatic progenitor cell compartment. bipotent hepatic progenitor cells (hpcs) can differentiate into hepatocytes or cholangiocytes. not only are hpcs activated during severe liver disease, they may well be the cells of origin for subtypes of hepatocellular carcinoma (hcc).the polycomb group protein bmi is involved in murine hpc activation and has prognostic relevance in hcc. therefore we investigated the expression of bmi in canine liver diseases including hcc. functional consequences of deregulated bmi expression are included to reveal its feasibility in liver regenerative medicine.immunohistochemistry (ihc) and laser microdissection followed by gene expression analysis were used to investigate the expression of bmi in activated hpcs and hcc. to elucidate the role of bmi in hpcs, in vitro gene silencing experiments followed by gene expression analysis, western blot analysis, and a proliferation assay (edu-incorporation) were performed in the human hpc-like cell-line heparg.ihc and gene expression showed a strong nuclear expression of bmi in activated hpcs in canine liver diseases. keratin is a marker for hpcs and cholangiocytes, and high expression is associated with poor prognosis in hccs. bmi staining was more intense in highly malignant hepatocellular carcinomas positive for keratin compared to keratin negative hccs. bmi -silencing in vitro studies revealed a significantly reduced hpc proliferation and suggested a role of bmi in differentiation (gene expression) of hpcs.these results indicate that bmi is expressed in activated hpcs in all liver diseases tested. bmi is needed for proliferation of hpcs in vitro and is potentially involved in hpc differentiation. expression of bmi in hccs suggests a role in tumour development, potentially due to a persistent activation of hpcs. therefore, enhanced activation of bmi will lead to more progenitor cells (beneficial) but most likely also to more aggressive hcc with a hpc-signature. hepatic progenitor cells (hpc) are bipotential, forming cholangiocytes or hepatocytes. as a result, they express markers of both cell types. various markers have been used to select for hpc's yet there is no specific cell marker. cd , a transmembrane glycoprotein, has been identified as a organ stem cell marker and cancer stem cell marker, and used to select hpc's in rodents and humans. canine hpc have been shown to have gene expression of cd . this study aimed to assess if cd selection could enrich for canine hpcs.a wedge of liver from a healthy dog euthanased for behavioural reasons was digested by collagenase perfusion. hepatocytes were removed by pelleting at g for mins. the remaining non-parenchymal cells (npc) were then pelleted at g for mins. magnetic assisted cell sorting (macs) for cells positive and negative for cd was performed according to the manufacturer's instructions. cd positive and negative npc were cultured on bovine type i collagen-coated plates with hepatocyte culture media (lonza). cell morphology was monitored. rna was extracted and cdna produced from cell pellets immediately after separation and also after weeks of culture. relative gene expression of cd , cholangiocyte marker keratin (k ) and hepatocytes markers k , albumin and cyp a was performed using b mg and rpl as reference genes.the cd positive fraction was % of the npcs. morphologically, cd positive cells formed more colonies of cells with a small cytoplasm to nucleus ratio, which then transformed to hepatoblastic appearance while the negative cells produced more fibroblastic cells. compared to cd negative cells, initially cd positive cells showed a -fold increase in cd , and . -fold increase in cholangiocyte marker k as well as modest increases in hepatocyte markers albumin and cyp a and a modest decrease in k . after weeks culture, positive cells expressed more albumin, cyp a , k & k compared to cd negative cultures. cd expression had reduced to a fold increase after culture.the cd positive fraction expressed cholangiocyte and hepatocytes markers compared to negative cells initially after sorting. after weeks culture, cd positive cells formed hepatocyte-like colonies, as well as continuing to have greater hepatocyte and cholangiocyte gene expression. cd expression decreased, consistent with differentiation.a large percentage of the npc were positive for cd . cd sorting also labels haematopoietic and mesenchymal stem cells therefore subsequently using facs for other markers may further enrich for specifically the hpc compartment. until now the hepatic neoplasms in dogs are classified as hepatocellular adenomas and carcinomas, cholangiocellular adenomas and carcinomas, mixed hepato-and cholangiocellular carcinomas and hepatic carcinoids. over the past decade, many advances have been made in the characterization of primary liver tumours in man. this knowledge has resulted in a proposal for a new morphological and immunohistochemical classification of primary liver tumours which facilitates the diagnosis and categorization of these tumours including their aggressiveness and prognosis. the purpose of this study was to investigate the presence and relative incidence of the various morphological types of primary hepatic neoplasms in the dog and to determine whether the new human classification also can be applied to canine hepatic neoplasms. for this study canine primary liver tumours were examined histologically and classified using several immunohistochemical markers including keratin(k) (hepatic progenitor (stem) cell/bile duct epithelium marker), heppar- (hepatocyte marker), ema (muc ; mucine producing biliary epithelium marker), pcea (canalicular, ductular, and bile duct epithelium marker), nse and chromogranin-a (neuro-endocrine markers). in addition, the tumours were graded according to cellular and nuclear pleiomorphism and mitotic index (grade: - ) and staged with respect to absence or presence of invasive growth, intrahepatic and/or distant metastases (stage: - ). of the primary liver tumours, had a hepatocellular origin ( %). these hepatocellular tumours could be subdivided in hepatocellular tumours with < % positivity for k ( %) and tumours with > % positivity for k ( %). the hepatocellular tumours with > % positivity for k were histologically poorly differentiated and often revealed lymphatic and vascular invasion in portal tracts and all showed intrahepatic and/or distant metastasis. in contrast the hepatocellular tumours with < % positivity for k were almost always well differentiated and well demarcated and did not have evidence for vascular invasion, intrahepatic and/or distant metastasis. eight of the tumours were from cholangiocellular origin ( %). all of the cholangiocellular tumours were poorly differentiated (grade and ) and showed intrahepatic and/or distant metastases. the third group of primary liver tumours had neuroendocrine characteristics, consisted of five tumours ( %) and were classified as carcinoids. they all were histologically poorly differentiated and had intrahepatic and/or distant metastases. in conclusion, the morphological types of the primary hepatic neoplasm in the dog, including their aggressiveness and prognosis, are highly comparable to the situation in man. these finding indicate that the new human classification of primary hepatic neoplasms is applicable in the dog. doberman hepatitis (dh) is a rare inflammatory liver disease characterized by female preponderance, elevated serum transaminase activity and increased hepatic copper content. immune system involvement is suggested by the presence of lymphocyte infiltration, female predisposition, abnormal expression of major histocompatibility complex (mhc) class ii antigens by hepatocytes and association of homozygosity for the mhc ii risk allele drb * of the dog leukocyte antigen system genotype.we investigated the possibility that autoantibodies are involved in dh. serum samples from subclinical and clinical dh patients and clinically healthy control dobermans were included in an elisa assay for detection of igg autoantibodies against histones (aha). the cut-off value for positivity in the anti-histone elisa was . , determined using the mean absorbance + sd of samples from healthy controls. the values for subclinical dh cases (mean ± sd: . ± . ; % confidence interval (ci) . to . ) and clinical dh cases (mean ± sd: . ± . ; %ci . to . ) were both significantly higher than values for controls (mean ± sd: . ± . ; %ci . to . ; p< . ). no seropositivity was noted in the control group.autoantibodies are the serological hallmark of autoimmune disease. normally, the immune system has an extraordinary capacity for preventing self-antigens to stimulate an inflammatory reaction. the presence of autoantibodies is therefore the consequence of a breakdown or failure of b-cell tolerance toward the corresponding autoantigens. since the appearance of aha indicates possible presence of autoimmunity, our results support the assumption that dh is an autoimmune disease. man's best friend (canis lupus familiaris) is an ideal model organism for a broad variety of naturally occurring diseases. dog breeds have a population structure suited for genetic studies of complex disorders. haploblocks within dog breeds extend up to times longer distances than in human populations. related dog breeds often share phenotypes and causative mutations, allowing for finemapping and validation. the inbreeding and bot-tlenecks of dog populations has led to an increased incidence of genetic diseases which remained incidental in the panmictic human populations.extrahepatic portosystemic shunts (ehpss) are large abnormal venous blood vessels connecting the portal vein with a major systemic vein. it results in almost complete diversion of the portal blood past the liver, leading to lack of liver function and liver growth, and hepatic encephalopathy due to brain neurotransmitter dysfunctions. there are only reported human cases, whereas the disease is widespread in dogs. shunts are more frequently diagnosed in purebred dogs than in crossbred dogs. the inheritance is complex without sex effect.a genome wide association studied with k snps was peformed on cairn terrier cases and controls of the same breed. after quality control cases and controls were analyzed in snps. allelic association was calculated with plink and grammas of the genabel package was used to correct for genetic kinship. several chromosome regions were detected with close to significant association. overlap between the two analysis methods was found on three genomic regions covering about . mb. finemapping was conducted by analyzing more snps in a larger group of cairn terriers and in cases and controls of other breeds. the finemapping resulted in two genomic regions covering and kb that were associated with significant pvalues. comparison of haplotypes of cases from different breeds confirmed the association signals. the regions of interest are analyzed by ngs of cases and controls. historically, doxycycline has been the first line drug for the treatment of canine monocytic ehrlichiosis (cme). some studies have shown that dogs may remain carriers despite doxycyxline treatment, therefore investigation for other anti-ehrlichial agents may be warranted. rifampin was suggested as a promising alternative for the treatment of cme, though its efficacy in clearing the infection has not been thoroughly evaluated. the purpose of this study was to assess the efficacy of rifampin in achieving clinicopathological recovery and clearing the ehrlichial infection from the blood and other tissues in dogs with experimentally-induced acute cme. of the purpose-bred beagle dogs that were included in the study, dogs with acute experimental cme were treated with rifampin ( mg/kg, sid, po, for weeks), infected dogs received no rifampin (infected controls) and two dogs served as uninfected controls. fourteen days after the completion of rifampin treatment, dexamethazone ( . mg/kg, iv, once) was given to the rifampin-treated dogs. clinical score, platelet counts, anti-e. canis immunofluorsecent antibody titers (ifa) and polymerase chain reaction (pcr) detection of e. canis-specific deoxyribonucleic acid in the blood, bone marrow and spleen aspirates were evaluated between the treated and untreated infected dogs on day post-inoculation (pi) (start of rifampin), on day pi (end of rifampin) and day pi (end of post-treatment monitoring). by day pi, all infected dogs became clinically ill and thrombocytopenic, seroconverted and became pcr-positive in at least one tissue. the median clinical score and ifa titers did not differ between the treated and untreated dogs at any of the three time points. Μedian platelet counts were significantly higher in the treated compared to the untreated infected dogs on day pi ( , /ll versus , , p= . ) and day pi ( , /ll versus , /ll, p= . ) (two-sample wilcoxon rank-sum [mann-whitney] test). on day pi, treated and untreated infected dogs were pcr-positive, while on day pi, treated and untreated infected dogs remained pcr positive in at least one of the tissues tested. as administered in this study, rifampin hastened hematological recovery of the infected dogs, but was inconsistent in clearing the experimentally-induced acute e. canis infection. acute phase proteins (app) are considered one of the hallmarks of the inflammatory response. among their major functions, apps seem to modulate innate immune system efficiency. in cats, serum amyloid a (saa) and a glycoprotein (agp) are two major positive apps that are increased during inflammation. this rise is presumed to be secondary to various cytokines that are involved in the innate inflammatory response.recombinant feline interferon-x (rfeifn-x) is an immune-modulator drug that is commonly used in cats naturally infected with retroviruses, namely feline immunodeficiency virus (fiv) and feline leukemia virus (felv). several studies have been performed to clarify the clinical benefits of rfeifn-x therapy in naturally infected fiv and/or felv cats. our group has previously described that c-reactive protein (crp) increased in naturally retroviralinfected cats under rfeifn-x therapy. however, the role of apps such as saa, agp and crp in the innate immuneresponse, remains unknown.the aim of this study was to evaluate saa, agp and crp serum levels in naturally retroviralinfected cats under rfeifn-x therapy.sixteen naturally retroviral infected cats ( fiv, felv and co-infected fiv/felv stray cats) housed in a lisbonanimal rescue shelter were submitted to rfeifn-x therapy. the licensed protocol was used: courses of mu/kg sc administered once daily for days, beginning on days , and . blood samples were collected for saa, agp and crp quantification before, during and after treatment (at d , , , ) . saa was quantified by elisa (phase saa, tridelta) and agp was determined by single radial immunodifusion (agp,tridelta). feline crp was quantified by elisa (kamiya biomedical company).app serum levels were compared before and after rfeifn-x therapy. a statistically significant increase of saa and agp (p= . and p= . respectively -friedman test) was observed at d in comparison to d . these findings corroborate the significant increase of crp serum levels previously described (p < . -friedman test).all the apps tested behaved similarly, showing an evident increase in their serum values after rfeifn-x therapy. these results suggest a possible immune modulation effect induced by rfeifn-x which seems to maximize the efficiency of innate immune response. further studies correlating these findings with the cytokine profile will extend our knowledge about the efficiency of rfeifn-x therapy in naturally retroviral infected cats. canine theileriosis is a tick-born disease caused by protozoan parasites of the genera theileria that has been associated with anaemia and/or thrombocytopaenia. the clinical manifestation of this disease in the dog is poorly described. this disease of emerging importance has been diagnosed in several dogs, emphasizing the need to elucidate the specific pathogenic species and characterize the clinical manifestations of the disease.this retrospective study describes the clinical characteristics, diagnostic tests, treatment and outcome of six client owned clinically ill dogs diagnosed with canine theileriosis at the onderstepoort veterinary academic hospital in south africa during - . canine theileriosis was diagnosed by polymerase chain reaction (pcr) on whole-blood followed by a reverse line blot (rlb) hybridization assay. other tickborn diseases and neoplastic conditions were excluded.the most common clinical findings were pale mucous membranes ( / dogs), lethargy ( / dogs) and oral bleeding ( / dogs). all dogs had thrombocytopaenia with a median of . x /l (range: - ) and / dogs had anaemia with a median haematocrit of % (range: - ). the anaemia was regenerative in / dogs and non-regenerative in / dogs. one dog was positive on an in saline auto-agglutination test. bone marrow cytology and core biopsies were performed in two dogs with severe non-regenerative anaemia and showed myelofibrosis. theileriasp. were detected in four dogs and theileria equi in two dogs. imidocarb dipropionate was administered in all dogs as treatment of choice for the theileriosis. five dogs that received the complete treatment achieved clinical cure. pcr post-treatment was performed in three dogs and was negative. prednisolone and azathioprine was administered in all dogs for suspected immune-mediated haematological disorders secondary to the theileriosis. one dog was euthanased one week after diagnosis.canine theileriosis should be considered a differential diagnosis for dogs with thrombocytopaenia and/or anaemia in endemic tick-born disease areas. pcr is a versatile tool for diagnosis and treatment monitoring in theileriosis. in our study, imidocarb dipropionate was effective in sterilizing the parasitic infection. the bleeding tendency seen in the theileriosis cases is most likely secondary to the thrombocytopaenia and/or concurrent thrombocytopathy as described in canine ehrlichiosis. further studies are required to determine the possible links between thrombocytopaenia, anaemia and myeloproliferative disorder observed in canine theileriosis. a.l. proksch , s. unterer , u. truyen , r.s. mueller , k. hartmann . clinic of small animal medicine, lmu university of munich, munich, germany, institute for animal hygiene and veterinary public health, university of leipzig, leipzig, germany canine parvovirosis still is a common and severe disease, especially in puppies, and there is a need for drugs that can decrease severity of symptoms and accelerate recovery. the paramunity inducer pind-orf stimulates the immune system. therefore, the aim of the study was to investigate whether pind-orf, used as an additional drug, leads to faster recovery in dogs with parvovirosis.in total, dogs with parvovirosis were randomly assigned to two groups ( dogs each). in all dogs, infection with canine parvovirus was diagnosed by fecal elisa or polymerase chain reaction (pcr). also, all dogs had clinical signs. the study was performed as prospective placebo-controlled, double-blinded trial. all dogs received either pind-orf or placebo, and additional standardized treatment for canine parvovirosis. clinical scores, complete blood count, and serum protein and albumin were evaluated daily (day - ) and at day . viral shedding was measured on day , , , and by fecal pcr and virus isolation.no significant difference could be found in clinical scores, most blood parameters, and duration of virus shedding when comparing dogs receiving pind-orf and dogs receiving placebo. the only significant difference was an increase in lymphocyte counts observed in the pind-orf group. three dogs receiving placebo did not survive, but no significant difference between groups was determined concerning survival rate.in this study, no significant influence of the paramunity inducer pind-orf on the course of parvovirosis was determined. therefore, there is no indication to recommend pind-orf therapy in canine parvovirosis. the microscopic agglutination test (mat) is currently considered as the gold standard for the diagnosis of leptospirosis in dogs. however, it is not a perfect tool to predict the infecting serogroup as cross-reactions and paradoxical reactions do exist. the objective of this study was to determine the infecting serovar in dogs with a positive polymerase chain reaction (pcr) on one or more biological sample(s) by molecular typing and to compare the results with those provided by the highest mat titer for each dog.forty-one positive pcr biological samples ( urine samples, blood samples, one kidney sample and one cerebrospinal fluid -csf-sample) from dogs with a clinical suspicion of leptospirosis between and and at least one positive pcr on blood, urine, kidney or csf (kit taqvet pathogenic leptospira, lsi, france) were submitted to molecular typing. the genomospecies were first determined by partial rpob or partial s rrna gene sequencing. the serovar was further identified by multiple loci variable number tandem repeat analysis (mlva). three variable number tandem repeat (vntr) loci were used as markers for serovar identification.the genomospecies were leptospira interrogans sensu stricto in samples belonging to dogs, leptospira borgpetersenii in three samples (three dogs) and leptospira kirschneri in two samples (two dogs). interestingly, for one dog, we found a different species in the blood and in the urine. mlva could unequivocally determine infecting serovar in samples belonging to dogs: australis in one dog, muenchen in three dogs, fugis in one dog, canicola in two dogs, autumnalis in six dogs. for only two dogs among those , the infecting serovar identified by mlva belonged to the infecting serogroup identified by mat. for samples belonging to dogs, mlva failed to identify the infecting serovar because one or more marker(s) could not be amplified. for samples belonging to dogs, amplification profile suggested coinfection or infection with a serovar that had not been previously characterized by mlva. it must be noted that for some dogs, we were able to characterize the serovar in a single kind of sample.despite lack of sensitivity of mlva applied to clinical strains in our study, this rapid method could contribute to a better knowledge of the epidemiology of canine leptospirosis with some adaptations in the choice of markers. recently, two trichomonads have been identified in diarrheal stool of puppies: pentatrichomonashominis (ph) and tritrichomonas foetus (tf) [ ] . tf infection in cats results in a chronic colitis. however in dogs, pathogenicity of tf and ph has never been studied. so the objective of this study was to evaluate the association between trichomonads' infection in puppies and the presence of diarrhea.faecal samples were collected prospectively from puppies ( to weeks of age) in french breeding kennels. for each puppy, a rectal swab was performed and the fecal consistency was evaluated using a -point numerical scale ( = liquid feces, = hard feces) [ ]. detection of trichomonads was performed by using a commercially available system "in pouchtm tf test"(biomed diagnostics, oregon usa). evaluation of this media was done as already described [ ] . observation of motile trichomonads organisms in the system culture was considered as a positive result. nine positive culture systems, from one kennel, were frozen and single-tube nested pcr assays were performed on them in order to sequence and identify the trichomonads. . % ( / ) of the cultures were positive. . % of the puppies ( / ) had gastrointestinal troubles. puppies infected by trichomonads had significantly more digestive problems than puppies not infected ( . % vs . %; p < . ). ph was systematically isolated in the positives cultures.ph was the only trichomonads isolated in the nine culture system tested by single-tube nested pcr assay. these results show the poor specificity of the medium to distinguish tf from ph. this observation underlines the necessity to use pcr for precise identification of type of trichomonads. trichomonads are significantly associated to the presence of digestive disorders in puppies. some etiological studies on the subject (by considering the co-infection with fly snapping, fly-biting or jaw snapping are names given to a syndrome in which dogs appear to be watching something then suddenly leaping and snapping at it. fly-biting dogs are generally referred to neurologists or behaviourists because the abnormalities are often interpreted as focal seizures or as obsessive compulsive disorder (ocd). there is one published case report of fly biting presumably caused by dietary intolerance in a cavalier king charles spaniel.the aims of this case series were ) to characterize fly biting, ) perform a complete medical evaluation of dogs presented with fly biting, and ) evaluate the outcome of this behaviour following appropriate treatment of the underlying medical condition.seven dogs presented for fly-biting behaviour (fb) were assessed. all dogs underwent a complete medical and behavioural history as well as physical and neurological examinations. further investigation was performed if an abnormality was found on examination or if the history was suggestive of an underlying problem. based on clinical presentation, physical examination, neurologic examination, and laboratory test results, a diagnosis was made and a specific treatment recommended. response to treatment was monitored and evaluated following phone conversations with owners at day , and from onset of treatment. many gastrointestinal disorders were found in fb dogs which included eosinophilic and lymphoplasmacytic infiltration of the stomach and small bowel, delayed gastric emptying and gastroeosophageal reflux. complete resolution of the fb was observed in / dogs diagnosed and specifically treated for the underlying gastrointestinal (gi) disease. one dog was diagnosed with chiari malformation and responded temporarily to pain management.in conclusion, this prospective case series indicates that fly biting behaviour may be caused by an underlying medical disorder, gi disease being the most common. resolution of this behaviour is possible following specific treatment of the underlying medical condition. although several diagnostic tests have been developed to diagnose fip, there are still difficulties to differentiate between fip and diseases with similar clinical appearence in vivo. fip is an inflammatory disease, therefore, as in other inflammatory conditions, the concentrations of apps are expected to be increased. the aim of this study was to evaluate the ability of the apps to distinguish fip from other diseases.serum samples from cats presented with effusion were obtained for measurement of three apps. the diagnostic work-up was performed with respect to fip (jvim ; : ) and further diagnostic procedures were performed depending on the medical condition. cats were diagnosed as having fip and cats had another disease (cardiac , tumor , other ). serum amyloid a (saa) and haptoglobin (hp) were measured by automated analyser using feline validated assays (eiken and tridelta, respectively), alpha- -acid glycoprotein (agp) was measured using a manual method based on single radial immunodiffusion (tridelta).the median concentrations of saa, hp and agp were significantly (p< . ) higher in cats with fip compared to cats without fip (saa: . ; range . - . lg/ml; . ; range . - . lg/ml,), (hp: . ; range . - . mg/ml; . ; range . - . mg/ml,), (agp: ; range - lg/ml; , range - lg/ml).all major feline apps seem to be useful diagnostic tools to help in differentiating fip from other diseases. however, the concentration of apps in some diseases (septic processes, disseminated neoplasias) was as high as in fip. protothecosis is an uncommon disease of people and animals caused by prototheca spp., an unicellular aerobic algae. to date, about cases have been described in dogs in north america and australia. in europe, only cases have been documented in the last decades (poland, italy, greece and spain). affected dogs show signs referable to the gastro-intestinal tract, particularly the colon, but ocular and neurologic signs are also reported. the disease has an insidious onset, a slow progression and fatal course. the aim of the present study is to describe clinical and laboratory findings in cases of canine protothecosis from the north of italy, diagnosed between - . medical records were retrieved and information pertaining history, clinical and instrumental data, as well as follow-up, were collected.the median age of the dogs was years (range: - ), of them were female and were boxers. major complaints were chronic large bowel diarrhea with hematochezia and weight loss observed since a median time of months (range: to ). previous treatment with gastrointestinal diets, antiparasitic drugs and antibiotics yielded no improvement. additionally, dogs developed uveitis during the disease course. in all dogs a complete blood count, a serum biochemical profile, including protein electrophoresis, and abdominal ultrasound were performed; serum ctli, folate and cobalamin were available in dogs and urinalysis in one. the results of the above laboratory tests were normal. ultrasonography was unremarkable in dogs and showed increased colon wall thickness in the other . definitive diagnosis was obtained from endoscopic biopsies of the colon and/or rectal scrapings in dogs and from biopsies of the colon at necropsy in one. in each case spheroid, ovoid or irregularly-shaped organisms suggestive of prototheca spp. were observed. different treatments were attempted without benefit in dogs. in one dog transient improvement was obtained with itraconazole. the median survival time was months (range: - ).the present work indicates that protothecosis should be included in the list of differential diagnosis in dogs with large bowel diarrhea, especially in those with chronic refractory colitis or developing ocular signs. dogs infected with prototheca spp. have a guarded prognosis. diagnosing protothecosis in dogs over a -year period may suggest that the disease is emerging in some southern european countries. idiopathic pulmonary fibrosis (ipf) is an interstitial fibrotic pulmonary disease, mainly described in the west highland white terrier (whwt). the diagnosis is challenging and ultimately relies on lung histopathology. identification of biomarkers specific for the disease would be very helpful. ccl (mcp- ) is a chemotactic cytokine for monocytes. it is a known biomarker in human ipf. in dogs with ipf, increased ccl gene expression has been described in lung tissue. the aim of the present study was to compare serum ccl concentration in dogs with ipf versus healthy dogs and dogs with other chronic pulmonary diseases.thirteen dogs with ipf (ten whwts, two scottish terriers, one yorkshire) mean age years, range - ), nine dogs with eosinophilic bronchopneumopathy (ebp) (various breeds, years, - ), ten dogs with chronic bronchitis (cb) (various breeds, years, - ) and ten healthy whwts ( years, - ) entered the study. diagnosis was established after clinical, radiographical, bronchoscopic (and balf analysis) examinations, as well as, in dogs with ipf, either lung high resolution computed tomography (six dogs) or histopathology (three dogs) or both (four dogs). ccl concentration in serum was determined by elisa (canine cll /mcp- quantikine ® , r&d sytems). results in the different groups were then compared using non-parametric test (mann-whitney rank sum test).serum ccl concentration was elevated in dogs with ipf (median; interquartile range = . pg/ml; . - . ) compared to healthy whwts ( . ; . - . ), (p< . ). serum ccl value in ipf dogs was higher than in ebp dogs ( . ; . - . ) (p= . ) and than in cb dogs ( . ; . - . ) (p= . ).the present study shows that ( ) idiopathic pulmonary fibrosis (ipf) is a progressive interstitial fibrotic disease, described in humans and in dogs. etiology and pathogenesis of ipf are poorly known in both species, even if a genetic basis is suspected in dogs because of the predisposition of the west highland white terrier (whwt). serum transforming growth factor beta (tgfb ) concentration is elevated in both healthy whwts and whwts with ipf, as compared to healthy dogs of various breeds. in human ipf, pathways involving tgfb , a cytokine with profibrotic properties, seem to be central in the pathogenesis and are considered as potential therapeutic targets. tgfb is produced as a pro-protein and usually stored as a latent complex. activation of the latent complex is an important step that regulates tgfb function. multiple activation mechanisms have been identified including binding to integrins and thrombospondin (thbs ).the aim of the present study was to quantify tgfb expression, as well as expression of proteins involved in tgfb activation, by quantitative rt-pcr, in lung tissue from dogs with ipf versus control dogs.total rna was extracted from lung tissues from dogs with ipf ( whwts, scottish terrier, lhassa apso) and control dogs (various breeds). ipf was confirmed by histopathology on all samples. expression of tgfb , integrins (itgb and itgb ) and thbs was measured by qrt-pcr. for each gene, a relative copy number was calculated for each sample and results were normalised using two stably expressed housekeeper genes (rps and tbp). statistically significant differences between the groups were assessed using a student t-test or a mann-whitney rank sum test with significance defined as a p < . .expression of tgfb and itgb was not statistically different between the two groups. expression of itgb was significantly lower (p< . ) while thbs expression was significantly higher (p= . ) in the ipf group relative to controls.results of the present study could not confirm that increased gene expression of tgfb by lung tissue is the source of the high circulating tgfb level in ipf. this study highlights different activating pathways of tgfb in ipf lungs compared to control lungs with a shift toward an increased activation via thbs in canine ipf. obesity is the most common nutritional problem in dogs, and its detrimental effect on basal lung function parameters has been recently shown using whole-body barometric plethysmography. the -minute walk test ( mwt) has been recently demonstrated to be a non-invasive easy-to-perform test in clinical settings, able to discriminate between healthy dogs and dogs with pulmonary disease.the aim of this study was to investigate the effect of body weight loss (bwl) on pulmonary function assessed by mwt and arterial blood gas values.six experimental beagles and privately-owned dogs, all obese but otherwise healthy, were enrolled in a diet-induced bwl program. physical examination, bw and body condition score (bcs) assessment, arterial blood gas analysis and mwt were performed when dogs were obese (bcs - / ), and repeated with animals in the middle of their bwl program (overweight, bcs - / ) and at the end of it (lean, bcs / ). for the mwt, dogs were walked for minutes, along an inside m-long hallway. heart rate (hr) and oxygen saturation (spo ) were measured by pulse oximetry before the test (pre-test value), after three minutes of walk (mid-test value) and at , , , and minutes post-test.all dogs concluded the bwl program (initial bw: , ± , kg; final bw: , ± , , means±se, p , ). bwl caused a significant increase in the walked distance (lean: , ± , m; overweight: , ± , m; obese: , ± , m; means±se, p , ) and a decrease in pretest respiratory rate (rr) (lean: ± , /min; overweight: ± , / min; obese: ± , /min; means±se, p , ). resting arterial blood gas results were not influenced by bwl and neither did the pre-test hr and spo values measured by pulse oximetry. obese dogs showed significant higher hr mid-test values compared to overweight and lean dogs (lean: , ± , /min; overweight: , ± , /min; obese: , ± , /min; means±se, p , ). moreover, spo values recorded at and minute post-test were significantly higher in overweight and lean dogs, compared to obese dogs. also, hr values registered at , , and minutes post-test were all lower in overweight and lean dogs.in conclusion, obesity negatively affects the blood oxygenation level during and shortly after physical exercise in dogs, with subsequent hr increase. bwl induces a significant decrease in resting rr and it improves pulmonary function during exercise, even before achieving the targeted ideal bw. the mwt, but not pre-test arterial blood gas values, is an efficient tool to demonstrate the efficacy of bwl. there are few diagnostic laboratory methods available for evaluation of platelet function and contribution to thrombotic events in the clinical setting. the impedance whole blood platelet aggregometer multiplate ® has recently become available. although it is being marketed for monitoring effect of antiplatelet therapy, it can also be used for assessment of platelet aggregation in response to various agonists, reflecting platelet function, activity and reactivity in response to disease. the purpose of this study was therefore to investigate multiplate ® as a diagnostic tool for detection of variations in platelet aggregation in dogs with diseases known to predispose to hypercoagulability and thrombosis and to evaluate whether there is a correlation between multiplate aggregation response and the maximal amplitude (ma) measured by thromboelastography (teg).twenty clinically healthy dogs and eighteen diseased dogs with neoplasia, generalized inflammation or protein losing enteropathy ornephropathy admitted to the university hospital for companion animals, university of copenhagen, were included in the study. citrated and heparinised blood samples were collected. multiplate ® aggregations were performed on diluted heparinised whole blood for minutes using adp, collagen (col) and arachidonic acid (aa) as agonists and nacl as buffer control. results were recorded as area under the curve (auc). dilute ( : ) tissue factor teg analyses were performed on citrated whole blood.diseased dogs had significantly increased auc compared to healthy dogs for nacl buffer control (p= . ), adp (p< . ) and col (p= . ) whereas no significant difference was obtained for aa as agonist (p= . ). teg-ma was significantly higher (p= . ) in diseased dogs compared to healthy dogs. a significant correlation was not found between teg-ma and multiplate auc using adp (p= . , r=- . ), col (p= . , r=- . ) or aa (p= . , r=- . ) .these results demonstrate that multiplate ® aggregation responses are significantly increased in a population of diseased dogs with diseases known to predispose to hypercoagulability and thrombosis, but results are not significantly correlated to teg-ma. this suggests that the multiplate method can be used to detect increased platelet reactivity in dogs with diseases known to predispose for hypercoagulability and thrombosis and that multiplate provides additional information on platelet function than teg alone in this patient group. further studies are needed to determine how multiplate and teg-ma results correlate to thrombosis and whether there may be an added benefit of using them in combination. hypoalbuminaemia is a commonly identified biochemical dyscrasia. the clinical impact of this can be far reaching, particularly in severely affected animals. problems recognised to ensue include altered colloid osmotic pressure and cavity effusions, clotting abnormalities, altered carriage of drugs, hormones and electrolytes, along with acid-base disturbances.the aim of the study was to determine the incidence of side effects encountered when administering % intravenous human albumin to dogs suffering with hypoalbuminaemia. animals were presented to a specialist referral centre in hampshire, uk for various conditions resulting in hypoalbuminaemia. hypoalbuminaeamia was considered to be present when the serum albumin concentration was < g/l. a total of albumin infusions were given to dogs presenting with a serum albumin concentration of g/l or lower. albumin was given as an intravenous infusion of mg ( ml)/kg following premedication with chlorphenamine. the duration of administration was between minutes and hours. the dogs were monitored for potential adverse reactions during the administration of albumin and in the post-infusion period. potential adverse reactions included hypotension, hyperthermia, tachycardia, tachypnea, peripheral oedema, agitation/restlessness and collapse. none of the animals showed adverse reactions during the administration of albumin or in the post-infusion period. one animal demonstrated mild hyperaesthesia that resolved prior to completion of the infusion.of the animals presented, survived to discharge, animals were euthanased and died. each dog received an average of . (sd . ) albumin infusions during the period of hospitalisation. there was no significant difference in the starting albumin concentrations between the survivors and nonsurvivors. there was no significant difference in the increase in albumin concentration post-infusion between survivors and non-survivors. there was no significant difference in the number of albumin infusions between the survivors and non-survivors. the concentration of albumin pre-infusion did not negatively impact on survival and discharge from the hospital. the results of this study demonstrate no significant complications during or following administration of % human albumin solution in dogs. there was no association between the administration of albumin, number of albumin infusions or amount of albumin administered in any patient and outcome. albumin infusion may improve the chances of severely hypoalbuminaemic dogs surviving to be discharged from the hospital. the use of human albumin for this purpose enables the limited supplies of canine plasma to be reserved for dogs needing plasma transfusion for other reasons. recently, metabolic syndrome has gained attention in human medicine given its associations with development of diabetes mellitus and cardiovascular diseases. canine obesity is associated with the development of insulin resistance, altered lipid profiles, and mild hypertension, but the authors are not aware of any existing studies examining the existence of ms in obese dogs. thirty-five obese dogs were assessed before and after weight loss. the guidelines of the international diabetes federation were modified in order to produce a definition for canine metabolic syndrome (cms), which included a measure of adiposity (using a -point body condition score [bcs]), systolic blood pressure, plasma cholesterol, plasma triglyceride, plasma glucose, and urine protein:creatinine ratio (upcr). by way of comparison, total and regional body fat mass were assessed by dual-energy x-ray absorptiometry, whilst adiponectin, insulin, and high-sensitivity c-reactive protein (hscrp) were also assessed with validated assays.systolic blood pressure (p= . ), cholesterol (p= . ), triglyceride (p= . ), insulin (p< . ), and upcr (p= . ) all decreased after weight loss, whilst plasma adiponectin increased (p= . ). however, hscrp did not change with weight loss. prior to weight loss, dogs were defined as having cms. there was no difference in total or regional body fat mass between these dogs and those who did not fit the definition of cms. however, plasma adiponectin concentration was less (p= . ), and plasma insulin concentration was greater (p= . ) in cms dogs.in this study, up to a third of obese dogs suffer from cms, and this is characterized by hypoadiponectinaemia and hyperinsulinaemia. these studies can form the basis of further investigations to determine pathogenetic mechanisms and the health significance for dogs, in terms of disease associations and outcomes of weight loss. cystourethroscopy has greatly enhanced the diagnosis and treatment of numerous conditions in veterinary medicine. rigid telescopes used in female cytoscopy provide well-illuminated highly detailed images using rod lens system technology. the flexible ureteroscope has been used for male urethrocytoscopy but is limited in image quality and procedural abilities due to the fiberoptic system, diminished illumination, and smaller working channel. the purpose of this study was to describe the technique, efficacy, and complications using a novel percutaneous perineal approach to the male urethra in order to gain access for rigid cystoscopy.the perineal approach was performed ten times in nine dogs for ectopic ureter laser ablation of idiopathic renal hematuria sclerotherapy. the dogs were placed in dorsal recumbency. using fluoroscopic guidance, an gauge renal access needle was advanced trans-perineally into the pelvic urethra. guidewire access was obtained and the access site dilated to accept a fr peel-away sheath. a rigid cystoscope was then placed through the sheath to perform the procedures. urinary catheters were placed following three of ten procedures for three to eighteen hours. the only identified peri-operative minor complication included urination form the perineal site approximately six hours post-operatively once in a single dog. no signs of stranguria or pollakiuria or incisional complications were identified in any of the dogs post-operatively at follow-up examination or contact (range to days).the percutaneous perineal approach in male dogs for rigid cystoscopy appears to be a safe and effective means of facilitating endoscopic procedures. irh results in chronic upper urinary tract bleeding. in humans, ruptured renal pelvic hemangiomas/angiomas are typically the cause. although benign, anemia, ureteral and urethral obstruction(s) can ensue. with the advent of endourology renalsparing therapies like ureteropyeloscopic-guided electrocautery or sclerotherapy has replaced ureteronephrectomy. the objective is to describe the use of endoscopic-fluoroscopic-guided sclerotherapy for the treatment of irh in dogs and report the first clinical outcomes.each uvj was identified cystoscopically. once the bleeding was confirmed a retrograde ureteropyelogram was performed. a ureteropelvic junction balloon was used for ureteral occlusion and pelvis filling volumes were recorded. four dwells were performed ( % povidone iodine mixture; and sterile liquid . - % silver nitrate). a double-pigtail ureteral stent was placed.seven dogs had sclerotherapy. five unilateral, bilateral, and developed contralateral bleeding (n= units). five were right and left-sided. there were males and female. the median age and weight was years and . kg, respectively. median procedure time was minutes. there was complication of severe renal discomfort and pyelectasia in an unstented dog.cessation of hematuria occurred in / renal units (median hours). two had recurrence within weeks; both resorted to intermittent mild hematuria. two failed treatment. median follow-up time was months (range, . - ) .overall, topical sclerotherapy for irh can be safe and effective. this is the first report of local sclerotherapy for irh in dogs and could be considered a valuable endoscopic-guided therapy prior to ureteronephrectomy. further investigation is required. percutaneous nephrolithotomy (pcnl) is considered the standard -of-care for removal of nephroliths > . cm in people, minimizing morbidity and preserving renal function. success rates are reported to be - %. most veterinary nephroliths remain clinically silent and removal is only recommended for complicated stones. morbidity of nephrotomy can be severe. the objective is to describe endoscopic-guided nephrolithotomy (enl) in canine and feline patients and report clinical outcomes, hypothesizing it is safe and effective. patients that had either pcnl or surgicallyassisted endoscopic nephrolithotomy (senl) were retrospectively evaluated. a renal puncture needle and balloon-dilation-sheath combination was used for tract formation. a nephroscope provided visualization for intracorporeal lithotripsy. stone fragments were removed and a ureteral stent was placed. nine dogs and cat ( renal units) were included. four had pcnl and senl. indications included recurrent utis ( ), worsening azotemia ( ), and ureteral-outflow obstructions ( ). median weight was . kg ( . - . ). stone composition was calcium oxalate ( ), mixed struvite ( ), urate ( ), and cystine ( ). median stone size was cm ( . - ). median pre-and month post-operative creatinine was . ( . - . ) and . mg/dl ( . - . ), respectively. the median procedure time was minutes. successful removal of all stones were documented in / ( . %). procedure-related complications occurred in units, all were easily managed. median follow-up time was days ( - ). four patients are still alive. no patient died from the procedure. overall, enl can be safely performed in dogs and cats, yielding similar success rates to people. advanced endourologic experience is recommended. fgf- is a key regulator of plasma phosphate concentration. it is elevated in cats with naturally occurring ckd and increases as renal function declines. elevated fgf- concentrations are an independent predictor of survival time in human haemodialysis patients, but this association has not previously been examined in cats with ckd. this study investigated if fgf- was independently associated with survival time (all cause mortality) in cats with newly diagnosed ckd.cats diagnosed with ckd at two london-based first opinion practices between and were identified. ckd was defined as plasma creatinine concentration > lmol/l with concurrent urine specific gravity (usg) < . or plasma creatinine concentration > lmol/l on two consecutive visits. cats were excluded if no residual edta plasma was available to measure plasma fgf- concentration within days of the date of diagnosis of ckd. fgf- concentrations were measured using a previously validated human intact fgf- elisa. plasma fgf- , creatinine, phosphate and total calcium concentrations, packed cell volume (pcv), systolic blood pressure (sbp), usg and age were entered into univariable cox regression models of survival time. fgf- concentrations were logarithmically transformed due to a highly skewed distribution. statistical significance was defined as p< . . variables with p< . were carried forwards into a backwards, stepwise multivariable cox regression analysis of survival time. ninety-one cats were included in the study. at the end of the follow-up period (february ), cats had been euthanased or died (median (range) survival time ( - ) days) and cats were alive or lost to follow-up (median (range) survival time ( - ) days). median (range) age at diagnosis (n= ) was . ( . - . ) years. univariable cox regression analysis indicated that plasma creatinine (p< . ), phosphate (p< . ) and log-fgf (p< . ) concentrations were negatively associated with survival time, and that pcv (p< . ) and usg (p< . ) were positively associated with survival time. in the multivariable model (n= ), plasma logfgf (hazard ratio (hr)= . , % confidence interval (ci) for hr= . - . ; p= . ) and creatinine concentration (hr= . , % ci for hr= . - . ; p< . ) were negatively associated with survival time, and pcv (hr= . , % ci for hr= . - . ; p= . ) was positively associated with survival time.plasma fgf- concentration is a novel prognostic indicator in feline ckd, independent of other factors including plasma creatinine concentration and pcv. future studies should investigate whether belgium ragdoll breeder organizations often forewarn ragdoll cat owners that renal problems may develop due to polycystic kidney disease (pkd), chronic interstitial nephritis, familial renal dysplasia or nephrocalcinosis. in several european countries, screening of ragdoll cats for kidney disease is already performed for years, without scientific evidence. therefore, we aimed to investigate if ragdoll cats are predisposed for kidney disease based on the laboratory parameters, one ragdoll cat was diagnosed with iris stage chronic kidney disease (ckd) one of these six cats was the ragdoll cat with iris stage ckd. in one ragdoll cat, pkd could not be excluded on ultrasonography because one cyst was detected in one kidney. however, none of the ragdoll cats was genetically positive for pkd.based on this study, pkd and ckd appear to be uncommon in ragdoll cats residing in belgium and the netherlands. however, renal infarcts were seen more commonly in ragdoll cats compared to an age-matched control group spain urine markers are advocated to early detect kidney damage in the clinical practice, nevertheless histology remains the gold standard. the aim of this study was to evaluate quali-quantitative proteinuria and possible renal damage using different non-invasive tests in dogs affected by leishmaniasis.based on clinical signs and serology/cytology, affected dogs (leish) were included. fifteen healthy, non-proteinuric dogs were selected as control. upon admission, all dogs underwent to physical examination, systolic blood pressure (sbp) measurement, clinicopathological evaluation urine high resolution agarose and silver staining sodium-dodecyl-sulphate-polyacrylamide gel electrophoresis (hre; sds-page) were performed. a cut-off of kda was selected to classify bands in high or low molecular weight (hmw; lmw). data were analyzed with non-parametric statistics and roc curve analysis (roc). a difference was considered significant for p< . leish dogs presented significantly higher upc (mean , median . ) and uac (mean . , median . ). rri values were significantly higher in leish (mean . ) than control (mean . ). rri was significantly correlated to wbc (r= . ), hemoglobin (r= . ) and albumin concentrations (r= . ), usg (r= . ) and upc (r= . ). hre and sds-page protein patterns allow to distinguish p from np and control dogs. sds-page revealed a significantly higher number of bands in leish dogs ( - ) than in control ( - ). np and blp dogs presented a significantly lower number of lmw bands than p. number of bands was significantly correlated to upc (r= . ) and uac (r= . ) in humans, diabetes mellitus (dm) is an important cause of renal damage. main lesions include thickening of the glomerular basement membrane and mesangial expansion, whereas tubular atrophy and vascular hypertrophy are less frequent. in cats, although diabetes is a common endocrinopathy, it is yet unknown whether dm causes renal damage. the aim of the present study was to compare renal histopathological features and clinical parameters of kidney function in diabetic cats against a well-matched control population.formalin-fixed, paraffin-embedded kidney samples were retrieved from diabetic and control cats that died between and due to any disease at the clinic for small animal internal medicine, university of zurich (switzerland), and in which a post-mortem examination was performed. control cats were selected to be matched for age, sex, breed and body weight. serum creatinine and urea levels were analyzed if they had been measured within days before death. kidney sections were stained with haematoxilin-eosin, periodic acid-schiff (pas), masson's trichrome, acid fuchsine orange-g (afog), and periodic acid methenamine silver (pams). with optical microscopy glomerular, tubulointerstitial and vascular parameters were identified and scored using a grading scale. data were analyzed with contingency tables and t-tests.thirty-two diabetic cats and matched controls were included. with optical microscopy, scores of glomerular lesions (i.e., sclerotic glomeruli, mesangial or endocapillary hypercellularity, increased mesangial matrix, immunodeposits, glomerular basement membrane thickening, mesangial interposition), tubulointerstitial lesions (i.e., inflammation, fibrosis, tubular atrophy, necrosis and lipidosis, intratubular mineralizations) and vascular lesions (i.e., small or large artery hypertrophy) did not differ between the groups. overall, glomerular, tubulointestitial and vascular lesions were observed in . %, . % and . % of diabetic cats and in . %, . % and . % of the controls. similarly, serum creatinine and urea levels were not different between groups (creatinine: ± vs. ± lmol/l, reference: - lmol/l; urea: . ± . vs. . ± . mmol/l, reference: . - . mmol/ l).the results suggest that dm in cats does not lead to microscopically detectable renal lesions or clinically relevant renal dysfunction when compared to a well-matched control group. we hypothesize that the short life expectancy of diabetic cats and the low prevalence of hypertension are main reasons for the difference to human diabetics.early diagnosis of aki and differentiation from non-renal disease or ckd remains challenging in veterinary medicine. in human medicine ngal is used as a real time indicator of aki but few data exist in veterinary medicine. in this study plasma and urine ngal was measured in healthy dogs with normal gfr (plasma inulin clearance) and dogs with renal azotemia (creatinine > . mg/dl and/or urea > mg/dl persisting at least hours after correction of prerenal factors). based on history, clinical course, laboratory and ultrasonographic findings, azotemic dogs were diagnosed with aki (n= ) or ckd (n= ). urine and plasma ngal was measured with a dog ngal elisa kit (bioporto ® diagnostics a/s, gentofte, denmark). intra-assay variability for plasma and urine ngal was . % and . %, respectively. azotemic dogs had significantly higher plasma ngal concentrations and urine ngal-creatinine ratios compared to healthy dogs (p< . , mann-whitney u-test). median (min-max) plasma ngal concentration in healthy dogs, dogs with aki and ckd was . ( . - . ) ng/ml, . ( . - . ) ng/ml and . ( . - . ) ng/ml, respectively. using a multiple linear regression model in the azotemic dogs with ngal as dependent and age, weight, sex, aki vs. ckd, dialysis and survival as independent variables revealed a significant differ-ence only for aki vs. ckd (p = . ). in conclusion, ngal can be measured successfully in plasma and urine of healthy dogs and dogs with kidney disease. dogs with aki had significantly higher plasma ngal concentration compared to dogs with ckd. xanthine urolithiasis is a rare condition accounting for . % of all canine urolithiasis in one study. this pathology has been reported as a primary disorder in dogs, most notably in cavalier king charles spaniels (ckcs). xanthine is an intermediate product of purine metabolism, which is converted from hypoxanthine by xanthine oxidase. xanthine is only slightly soluble in urine and therefore hyperxanthinuria may lead to urolith formation. it has been speculated that some ckcs have an inherited mutation in the xanthine oxidase gene. in humans, isolated deficiency of xanthine oxidase occurs rarely and approximately % of individuals are asymptomatic, despite having significant xanthinuria. therefore we hypothesised that asymptomatic xanthinuria may be commonplace in the uk population of ckcs. in support of this, a previous case report of a symptomatic ckcs reported significant xanthinuria occurring in an asymptomatic sibling. in order to examine the prevalence of xanthinuria in ckcs, urine concentrations of hypoxanthine and xanthine metabolites as well as creatinine were measured in clientowned cavalier king charles spaniel dogs and dogs of other breeds from three first-opinion veterinary practices in the uk. urine samples were collected by free catch and purine metabolites were measured by high-performance liquid chromatography. ratios of xanthine/creatinine and hypoxanthine/creatinine from the two populations were compared by mann whitney u test and were found not to be significantly different (p= . and p= . respectively). in the control population, the xanthine/creatinine ratio ranged from . to . (median . ), while in the ckcs population it ranged from . to . (median . ). these results are markedly lower than the previously reported case of xanthine urolithiasis in a uk ckcs dog, which utilised the same reference laboratory (xanthine/creatinine ratio . ). these data suggest that asymptomatic xanthinuria is not prevalent in the uk ckcs population. key: cord- -k edtg authors: nan title: aasld abstracts (pp. a– a) date: - - journal: hepatology doi: . /hep. sha: doc_id: cord_uid: k edtg nan of well-characterized human hepatocyte cell lines could facilitate cell therapies such as htx and bioartificial livers. toward this goal, we have developed a tightly regulated human hepatocyte line. methods human hepatocytes were immortalized with a retroviral vector encoding human telomerase reverse transcriptase (htert) and green fluorescent protein (gfp) cdnas flanked by a pair of loxps. after retroviral transduction, a single cell clone was obtained using flow cytometric cell sorting followed by limiting dilution method. the resultant gfp-positive clones were supertransduced with tamoxifen-inducible cre recombinase expression cassette, mercremer. recovery of the reverted form of htert-immortalized cells was conducted by tamoxifen treatment and subsequent gfp-negative cell sorting with moflo. the expression of hepatocyte markers and albumin secretion was compared before and after tamoxifen treatment. transplantation effect of the reverted cells (lx lo ) into the liver were evaluated in a pig model of liver failure induce by an intravenous administration of d-galactosamine (d-gal). resu ts:a non-tumorigenic human hepatocyte cell line ttnt- -t was established. albumin secretion and gene expression of liver markers were increased in the reverted ttnt- -t cells. transplantation of the reverted cells via the portal vein of pigs treated with d-gal was effective to prolong the survival by providing liver support until spontaneous hepatic regeneration occurred. conclusion: we here demonstrate reversible immortalization of human hepatocytes using tamoxifen-induced crellox self-excision. the resulting cell line would be highly desirable for research and therapeutic applications. acknowledgmenk the work was supported in part by life science project of lst century, japan. background and aim: stem cells play a key-role in tissue homeostasis. haematopoietic stem cells (hscs) could migrate into the liver and transdifferentiate, becoming a "liver stem cell reserve''. we aimed to analyse: human hsc (h-hsc) ability to engraft into the mouse liver and to contribute to its regeneration after a toxic damage. materials and methods: nodiscid mice were so divided: a) chimeric not-damaged mice: mice were submitted to irradiation followed by h-hsc intraperitoneally (i.p.) injection; finally they were killed , and days after; ) chimeric damaged mice: mice were irradiated, injected with h-hscs and, days after, damaged using ally alcohol (aa), i.p.; killing was performed , and days after the damage; c) damaged not-chimeric mice: mice were damaged (with aa injection) and killed , and days after; d) not-chimeric not-damaged mice: mice were killed without any treatment. spleens (s), bone marrows (bm) and livers (l) were tested by flow-cytometry to detect h-hscs and immunohistochemistry (l only) to localize h-hscs and their hepatic derivatives. results: flow-cytometry: group a) presence of low percentage of human cells; groups c) and d) human cells undetectable; group b) presence of low percentage of human cells in bm and s while in the l they represented up to % of whole cellular population (the difference respect to the group a has high statistical significance, being alpha< . %). immunohistochemistry showed the human cell differentiation into parenchymal cells. conclusions: our results suggest that hscs could be an option to improve thie liver regeneration after a toxic injury, supporting the feasibility of bm-derived liver stem cell hypothesis. we have previously demonstrated that cd -mediated immune damage of allogeneic liver parenchymal cells is difficult to regulate due to the activity of "immunoresistant" cd + t cells. in prior studies we demonstrated that short-term interference with cd cd l (but not cd b ) costimulation transiently suppressed cdb-dependent hepatocyte rejection. recently, we have determined that targetintg lfa- alone preferentially suppresses cd dependent versus cd -dependent hepatocyte rejection. in addition, short-term immunotherapy targeting both lfa- and cd lcd l costimulation produced synergistic effects and resulted in longterm suppression of cd -dependent rejection such that hepatocyte survival up to days was achieved in the majority of recipient mice. the purpose of this study was to determine whether targeting both cd lcd l and lfa- mediated signals results in an immunoregulatory state which controls naive cd + t cells. methods: x lo fvbln (halat, hepatocytes, were transplanted into cd ko or c bl .scid (all h- b) mice, and recipients were treated with anti-lfa- mab ( . mg d - ) and anti-cd ol mab (lmg, do, , , ) . hepatocyte survival was monitored by detection of serum halat reporter product by elisa. hepatocyte recipients with longterm survival (> days) were challenged by adoptive transfer of million naive cdb' t cells (isolated from cd ko mice) which are sufficient to initiate rejection of functioning hepatocellular allografts in scid recipients. results: combined treatment with anti-lfa- mab and anti-cd l mab significantly prolonged hepatocyte allograft survival in cd ko mice such that % achieved hepatocyte survival > days posttransplant (mst> days, n= ) in comparison to either agent alone (anti-cd l mab mst= days, n= , p<o.ool; anti-lfa- mab mst= days, n= , p<o.ool). recipient mice induced to achieve hepatocyte survival > days (by short-term treatment with anti-lfa- and anti-cd l mab) received adoptive transfer of million nayve purified cd + t cells. continued survival of longterm hepatocellular allografts despite adoptive transfer of cd + t cells was observed in % ( of ) recipients. in recipients, adoptive transfer of cd + t cells was associated with loss of hepatocellular allograft function by and days following cell transfer. in contrast, control scid mice with functioning hepatocellular allografts which were reconstituted with million naive cd + t cells rapidly rejected hepatocytes with mst of days (n= ). conclusion: targeting of both cd l cd ol and lfa- not only prevents immunoresistant cdb-dependent immune damage of liver parenchymal cells, but also x lo vs. . . x lo and . . x lo vs. . . x , respectively) while at hrs it was . t . x lo vs. . . x (ns) . in the spleen, significantly higher heparanase treated cells were located within the tissue, showing proliferative activity at and hrs post transplantation. already by hrs after transplantation the proliferating index of sec increased from . in controls to in heparanase treated rats (i'<o.o ). conclusions: heparanase increases the long-term presence of transplanted cells within portal radicles, thereby facilitating their engraftment. it has also a significant effect on ec proliferation. disc o s u r e s : yaacov baruch -no relationships to disclose orit goldshmit -no relationships to disclose neta ilan -no relationships to disclose gideon shoshany -no relationships to disclose vladislav tsiperson -no relationships to disclose ella veitzman -no relationships to disclose israel vlodavsky -no relationships to disclose cell activation. arunzazu sanchez, peter n u n , insa s schroeder, valentina m factor, snorri s thorgeirsson, national cancer institute, bethesda, m d substantial evidence suggests that proliferation of hepatic stem cell progenies (referred to as oval cells) is responsible for liver regeneration when the replicative capacity of hepatocytes is impaired. it is well established that activity of the tnf-a , nf-kb, il- , and stat pathways is necessary for the regenerative response of hepatocytes following partial hepatectomy. however, much less is known about the signals mediating oval cell proliferation and differentiation. the aim of the present study was to evaluate the involvement of nf-kbistats signaling pathways in regulation of oval cell activation. high activity of nf-kb was found in regenerating liver after aaflph protocol coinciding with the proliferation of oval cells. urification of the oval cell population by magnetic beads sorting using ov antibody confirmed that the activation of both nf-kb and stat is specific for this cellular compartment. three distinct subpopulations of oval cells were identified based on intensity of ov staining by facs and named as ov dim, medium and bright. real time pcr analysis showed that they represent oval cells at different stages of differentiation along the hepatocytic lineage. ov dim subpopulation was the closest to the hepatic stem cell, as judged by high expression of c-kit. on the contrary, ov bright cells displayed the highest expression of hepatic differentiation markers, ttr, albumin, connexin and hnf- . nf-kb was uniformly activated in the entire oval cell compartment, whereas stat was phosphorylated only in the most differentiated ov bright subpopulation. furthermore, activation of stat tightly correlated with a high proliferative activity in these cells. together, these data provide the first evidence that the transcriptional activity supported by nf-kb and stat is required for oval cell activation. the differential induction of these two transcription factors suggests that they may control different stages of oval cell activation. disclosures: introduction: haematopoietic stem cells (hscs) have been shown to have greater plasticity than previously thought, with studies demonstrating that both human and rodent hscs can differentiate into hepatocytes. our group has also confirmed that human stem cell derived hepatocytes are the result of true differentiation and not the result of cellular fusion (newsome et al, gastroenterology ) . the extent to which endogenous hscs are naturally mobilized and contribute to liver repair is however uncertain. aims ) to establish whether liver injury mobilizes endogenous hscs into the circulation & into the liver. ) to establish if circulating stem cells in liver injury have altered stem cell potential. patients and methods omls peripheral blood was analysed from the following groups (n= ): normal adult controls, patients with alcoholic hepatitis, abstinent chronic alcoholic liver disease and paracetamol-induced liver injury. using a flow cytometry sorting machine, circulating cd positive hscs were quantified as a percentage of the number of mononuclear cells according to the ishage flow cytometry protocol. equal numbers of cd positive cells from each gmup were collected and cultured, to assess their in vitro stem cell properties, as judged by number of colony forming units (cf'us) produced. for patients with alcoholic hepatitis, age, sex, biochemical parameters, maddrey score and outcome (mortality) was recorded. liver biopsies from paracetamol induced liver injury and alcoholic hepatitis patients were stained for cd and c-kit markers to quantitate stem cell numbers (number/ portal triad) and compared with normal adult controls. results .levels of circulating cd positive hscs were significantly elevated in patients with alcoholic hepatitis ( . % . ; p< . ) when compared with all other groups. the corresponding cd positive values for the other groups are as follows: healthy controls ( . % . ); paracetamol liver injury ( . % . ) and abstinent alcoholic cirrhotics ( . % . ).there was no significant difference in mean mononuclear cell count between these groups. .patients surviving their alcoholic hepatitis had significantly higher levels of circulating cd positive stem cells ( . % . ; p<o.o ) when compared with those who had died ( . % . ). the surviving alcoholic hepatitis patients had significantly lower maddrey scores ( . . ; p=o.oos) than those who had died ( . ) whilst no significant difference in sex or age distribution was demonstrated between these two groups. the total mononuclear cell counts were lower in the deceased alcoholic hepatih group ( . xlox l . ) when compared with those that had survived ( . xlox . ). if cd numbers are adjusted for the total mononuclear cell counts then the increase in circulating stem cells between these two groups became even more apparent ( . ? . and . xlox cellsll . ; p< . ). .hscs from alcoholic hepatitis patients produced greater numbers of cfus compared with adult control hscs ( vs. ). .liver biopsies from paracetamol and alcoholic hepatitis patients contained greater numbers of stem cells compared with healthy controls (p< . ). control ( . cellsltriad ?o.l) , alcoholic hepatitis ( cellltriad . ) and paracetamol liver injury ( . cells/ triad . ). stem cells were only identifiedwithin the portal triads and not within the hepatic parenchyma in all of these groups. conclusions . alcoholic hepatitis is associated with increased levels of circulating hscs both in the blood and the liver. . these mobilized cells display in vifro stem cell potential at a level equal to or higher than control hscs. . increased levels of stem cell mobilization are associated with improved clinical outcome. disclosures: background klf is a ubiquitously expressed kruppel like zinc finger transcription factor identified as a tumor suppressor gene in prostate cancer (narla et al, science ) . in addition, klf is frequently lost and/or mutated in hepatocellular carcinomas (tal-kremer, aasld -# ) . klf is also an immediate early gene that is rapidly upregulated in hepatocytes following partial hepatectomy and in hepatic stellate cells after injury. its expression is regulated in a tissuerestricted manner during development (laub et al, mech dev ) . these broad roles yet defined sites of expression suggested a potentially important role of klfg in development. the aim of this project was to examine the role of klf in hepatic differentiation using an embryonic stem (es) cell differentiation system in which undifferentiated cells can be driven along tissue specific lineages under defined stimuli. materials: two targeting constructs were generated in which the second exons of klf were replaced by a neomycinllac z cassette or hygromycin cassette. klf (+/-) es cells were generated by homologous recombination through selection with a klf targeting vector containing the neomy&/lac z cassette. to obtain klf (-/-) es cells, klf (+/-) clones were subjected to the second round of homologous recombination. a l l es cell dones were confirmed to have a normal karyotype after selection. methods and resulk in the undifferentiated state, klfg (-/-)null es cells grew more slowly than wild type es cells, with doubling times up to % longer. following differentiation into embryoid bodies (eb) over days in culture, the number of ebs was reduced by > % compared with wild type ebs. the disparity in growth rate between wt and (-/-) es cells was greater in later stages than in the initial days of differentiation. this was accompanied by prolongation of the epiblast-like stage, associated with markedly delayed expression of endodermal mesodermal and ectodermal markers. next, we examined the capacity of klfg (-/-) ebs to differentiate into hepatocyte like cells by withdrawing leukemia inhibitory factor after two days, then culturing ebs under serum free conditions for days, followed by growth on gelatinized dishes. basic fibroblast growth factor and dexamethasone were added into the medium starting day and day . whereas expression in klfg (+/+) ebs of alpha-fetoprotein and albumin mrna occurred after days of differentiation, their expression was almost absent and significantly delayed in klf (-/-) ebs. an impaired ability of klf (-/-) cells to differentiate along hematopoietic and neuronal lineages was also observed. in conclusion, these data indicate a broad and proximal role of klfg in tissue specific development with specific role in hepatocellular development. cell transplantation has been recognized as a possible future treatment for liver cirrhosis. one of the major questions is which cell will be of greatest usespleen might be a major source of stem cell, if exist, since splenomegaly is a common in cirrhotic patients and even splenectomy is performed for treatment. recent advance in the isolation technique of stem cells based on the efflux of fluorescent dyes hoechst has turned out to be an efficient method to purify stem cells called side population (sp) cells. we utilized this method to isolate stem cells from spleen. we also transfused these sp cells into rat liver treated with carbon tetrachloride (cc ) to see whether these sp cells proliferate and differentiate into both hepatocytes or cholangiocytes. methods. c / j male mice and female nodlscid mice were obtained from nihon crea. egfp transgenic (tg) rat were obtained from nihon slc. splenocytes were prepared by digesting in . % collagenase solution and forcing tissue through sterile mesh. splenocytes were then resuspended at lo cellslml in hanks balanced salt solution (hbss) containing % fbs, mm hepes (hbss+), and ug/ml hoechst w or w/o verapamil and were incubated at degrees centigrade for min. splenocytes were then stained for min. on ice with fitc or pe conjugated various antibodies against sca- , c-kit, thyl. , cd and cd . splenocytes were washed in hbss+ alone times and then in hbss+ with ug/ml propidium iodide. splenocytes were analyzed and sorted on a dual-laser facstar plus flow cytometer. ( excitation: nm, emission: /bp & /bp filter & -nm short-pass dichroic mirror). we also prepared spcells from donor egfp tg rats' spleen as described above. these spleen egfp positive sp cells were directly injected into liver of anesthetized recipient nodlscid mice. the recipient nodlscid mice were injected with ug. cc intrapentoneally every once a week before and after transplantation. immunohistochemical staining were performed to identify engrafted egfp positive cells, liver specific proteins such as cytokeratinl j , afp and albumin. results. initial hst staining of low density splenocytes showed the sp fraction to be readily detectable ( . - %). these cells were verapamil sensitive and could be stained with hst after verapamil treatment. the frequency of each surface markers positive cells were as follows (table and ). two weeks after cell transplantation, donor derived egfp positive cells were engrafted. the some engrafted cells distributed in a cluster indicating donor cell proliferation. hepatic differentiation of engrafted cells were shown by double staining of egfp and rat albumin or cytokeratinld. we observed some of afp positive cells in egfp positive cells, but very few of cytokeratinl positive cells. conclusions. the adult rodent spleen had consistently detectable fraction of sp cells. the surface marker profiles were different from those of bone marrow sp cells. the splenic sp cells could be engrafted in liver and differentiate into hepatocyte like cells. our results suggest that splenic sp cells could be exploited for the repair of damaged liver. backgroundlaim : it has been reported that bone marrow cells (bmcs) can replace liver in a murine model of tyrosinaemia and correct this metabolic disease through the fusion of donor bmcs to recipient hepatocytes. the aim of this study was to test whether or not this replacement is a general phenomenon in other liver injury models. the following three models were tested; ( ) hepatitis b transgenic mouse (tgn(alblhbv)), ( ) albumin-urokinase transgenic mouse (tgn(alblp au)) and ( ) carbon tetrachloride (cc ) treatment model. as the selective liver injury models, irradiated tgn(alb hbv) and tgn(alblp au) were transplanted with lx -lx bmcs from green fluorescent protein (gfp) transgenic mice (tgn(actbegfp)) or from @-galactosidase transgenic mice (tgn(mtnlacz)). as a non-selective liver injury model, irradiated c bl/ mice were transplanted with x bmcs from tgn(actbegfp) or tgn(mtnlacz) followed by the administration of cc ( . mllkg animal weight, twice a week for weeks). a cci protocol without preparative irradiation was also tested, in which c bl mice were first administered ccl, times, then followed by transplantation of tgn(actbegfp) or tgn(mtnlacz) bmcs. after the analysis of the donor cell engraftment in the peripheral blood, these recipient mice were sacrificed and checked for donor-derived hepatocytes at - weeks post-transplantation. sixty liver sections for each animal (containing approximately . ~ ~ hepatocytes), were analyzed for gfp positive cells and the whole livers were inspected for @-galactosidase expression with x-gal cytohistochemistry. however, there were no gfp positive hepatocytes and no gross blue staining of the livers with x-gal in any of the recipient mice. gfp positive cells were only located in sinusoids or associated with larger vessels. they were readily distinguishable from hepatocytes through their morphology and were negative for albumin by immunostaining. in addition, the livers from female animals with gender mismatched bm transplantation were also tested with y chromosome fish analysis, which might be a more sensitive method to detect donor derived cells than transgenic epitope tagging. total of isolated hepatocytes were positive for y chromosome in . ~ ~ hepatocytes analyzed, although it still remains to be elucidated whether these cells arise from spontaneous fusion events or from transdifferentiation. conclusions: these results demonstrate that there is little or no contribution of bmcs to the replacement of injured livers in these models. thus, we do not believe that bm derived cells can generally lead to a cure of liver damage. background &aims: mouse embryonic stem (es) cells are clonal cell lines derived from the inner cell mass of developing blastocysts and have multi-lineage differentiation ability. we previously reported that es cells can be made to differentiate into hepatocytes possessing high metabolic activities by transfection of hepatocyte nuclear factor- beta (hnf- b). in the present study, we investigated the expression of hepatobiliary organic anion transporters and bilirubin uridine diphosphate glucuronosyltransferase (ugtlal) in undifferentiated and differentiating hnf- btransfected es (hnf- b-es) cells. materials & methods: hnf b-es cells were established from a mouse es cell line. undifferentiated hnf- b-es cells were main-tained in gelatin-coated dishes without feeder cells in dulbecco's modified eagle's medium (dmem) supplemented with % fetal bovine serum (fbs), . mm of z-mercaptoethanol( me), . mm of non-essential amino acids (neaa), mm of sodium pyruvate and ulml of leukemia inhibitory factor (lif). undifferentiated hnf- b-es cells were allowed to differentiate in dmem supplemented with % fbs, . mm -me, . mm neaa, mm sodium pyruvate, and nglml of fibroblast growth factor (fgfz) in the absence of leukemia inhibitory factor (lif). differentiating hnf- b-es cells were collected for rt-pcr analysis on day , and for western blotting on days and . results: the expression of organic anion transporting polypeptide (oatpl), multidrug resistance-associated protein (mrpl), mrp , mrp , and ugtlal was not seen in the undifferentiated hnf- b-es cells by rt-pcr, whereas all were expressed in differentiating hnf- b-es cells. protein expression for oatpl, mrpl, mrp , mrp , and ugtlal was also observed in the differentiating hnf- b-es cells by western blotting. an immunofluorescence examination revealed that oatpl was co-located with desmoplakin, a marker for the basolateral (sinusoidal) membrane, and mrp was co-localized with cd , a marker for the apical (canalicular) membrane, though they were both expressed throughout most of the cell membranes. we have used cdna microarray analysis of clonal murine hepatoblasts to identify genes that are significantly and preferentially expressed in undifferentiated hepatoblasts compared to adult mouse liver. unique stem cell genes were identified by overexpression in undifferentiated hepatoblasts compared to adult liver. genes were identified by these criteria and were designated candidate stem cell genes (cscg). cscg were distributed on all chromosomes of the mouse except chromosomes , and the y chromosome. however, chromosomes , and showed a preferential distribution of cscg compared to the total number of genes mapped on these chromosomes. approximately half of our cscg are commonly expressed in other murine stem cell populations including embryonic stem cells, neural stem cells, mesenchymal stem cells and hematopoetic stem cells, suggesting that hepatoblasts share a molecular signature with other stem cell populations. some of the commonly identified stem cell genes include: sc a , c-myc, nek , phosphodiesterase , nicastrin, smarca and smarca and pias . these genes function in a variety of pathways including ion transport, anion exchange, cell cycle control, chromatin organization, dna binding activity and signal transduction. approximately % of cscg are expressed in early endoderm, fetal liver and/or the pancreatic bud. a search for homology to known proteins indicated that some of these genes contain homology to membrane transporters, zinc finger proteins and spindle apparatus components. this class of genes is of particular interest because they may represent new hepatic lineage markers. the results of this analysis leads us to conclude that a network of pathways some of which are in common with other stem cell populations function together to maintain the liver stem cell phenotype. valentina m factor, aranzazu sanchez, ju-seog lee, tanya n hoang, snom' s thorgeirsson, national cancer institute, bethesda, m d rat liver epithelial cells (rle) were isolated from normal adult rat livers and established as a cell line . rle cells were found to express undifferentiated characteristics resembling adult liver stem cells. we have addressed cellular and molecular mechanisms controlling lineage commitment of hepatic stem cells using rle- . to induce rle differentiation along the hepatocytic lineage, differentiation protocols were developed consisting of a sequential treatment with the demethylating agent -aza-cytidine ( ac), fibroblast growth factors and (fgf), oncostatin m (osm) and hepatocyte growth factor (hgf) in the continuous presence of the synthetic glucocorticoid dexamethasone (dex). these treatments resulted in a remarkable enlargement in cell size and organelle complexity as shown by facs and confocal microscopy. morphological maturation of rle was paralleled by a decrease in cell proliferation. more significantly, rt and real time pcr analysis revealed an induction of hepatocyte specific markers such as tat, ttr, glucose- -phosphatase, and connexin . in addition mrnas encoding liver enriched transcription factors hnf lalp, hnf ru, hnf , and clebp p were notably induced along with hepatocytic differentiation. the pcr results were supported by a cdna microarray analysis. comparison of the gene expression profiles following the treatment protocols reflected an activation of the hepatocytic differentiation program as judged by increased expression of a differentiation-associated gene set (phosphofructokinase, glutathione-s-transferase) and decreased expression of a cell cycle regulated gene set. currently, transplantation studies are performed to identify the potential of the differentiated rle to repopulate and restore the diseased livers. the results indicate that cell lines derived from adult liver stem cells may provide a renewable resource for transplantation. adult liver stem cells (adulis) can be isolated from rodent bone marrow. when cultured under specific conditions in co-culture with isogeneic hepatocytes, adulis fiom days bile duct ligated (bdl) rats are transdifferentiating into a hepatocyte-like lineage and are able to produce urea from ammonia. the aim of the study presented is to describe the hepatocyte specific metabolic capacity of cultured adulis from normal or bdl rats in single or co-culture with isogeneic hepatocytes, with or without interleukin- (il- ). methods: adulis were isolated by a two-step immunoisolation procedure (i.e. beta- -microglobulin negativity and thy- positivity) from rat femoral bone marrow (male wistar rats, g) and cultured on a matrigel layer in -well polystyrene dishes at a cell density of ' cells/cm* in small hepatocyte media. isogeneic hepatocytes were isolated by a two-step collagenase perfusion technique and seeded ( , cells/cm ) on an inlay with a collagen-coated ptfe membrane (poresize: . pm) for co-culture experiments. of note, the culture media was supplemented with % isogeneic serum and dexamethason m) was administered after culture day . il- was added in the corresponding experimental groups ( nglml). after removal of the hepatocyte-inlay (in the co-culture groups) adulis cultures were exposed to . mmol nh ci for hours in dmem and urea formation determined thereafter with a colorimetric assay. cells were harvested in trizol, total rna extracted and after reverse transcription cdna used for real-time pcr determination of s(rm~) content to standardize the metabolic signal for cell number. relative ureagenesis values were compared statistically using jandel scientific. the significance level was set at pc . . results: the amount of adulis isolated from normal rat femoral bone marrow (n=lo) was . . x lo and . . x lo in animals (n= ) after seven days of bdl (p=n.s.). relative urea synthesis in cultures from normal animals was . . in single and . . in co-culture at culture days , , , and . with addition of il- to the culture media urea genesis was determined to be . . in single and . . ' in co-culture. in cell cultures from seven days bdl rats relative urea formation was . . in single and . . in co-culture. with the addition of il- to the culture media values were . . in single and . . in co-culture. addition of il- to the culture media increased the metabolic signal in all cell cultures from normal animals (anova on ranks, p< . ) but not in cultures with cells isolated from bdl animals (p=n.s.). co-culture induced stronger ureagenesis under all culture conditions examined (paired t-test: p< . ). conclusions: to exclude immunological interference from adult immunocompetent bone marrow cells cultures were strictly isogeneic (i.e. adulis, hepatocytes, and serum from the same animal). co-culturing adulis with isogeneic hepatocytes increased ureagenesis in all paired culture experiments. as there is no direct cell contact between hepatocytes and adulis paracrine soluble, so far undetermined, factors must be involved. interestingly by the addition of il- transdifferentiation was inducible in cultures of adulis from normal animals but no additional effect was detectable in the cell cultures from bdl animals. in further studies it will be necessairy to determine if cholestatic serum also induces accelerated and more pronounced hepatocyte specific metabolic capacity in adulis from normal animals. factors responsible for this transdifferentiation should then be isolated from cholestatic serum and might be used to support the failing liver in vivo potentially by activation of the adulis pool in the bone marrow and the liver. disclosures: saji, shinji tamura, yuichi yoshida, shinichi kiso, ayuko iizuka, hitoshi matsumoto, takako kawasaki, yoshihiro kamada, yuji matsuzawa, graduate school of medicine, osaka university, suita, osaka, japan background and aims: recently, the evidence that bone marrow cells (bm cells) have trans-differentiating potential into hepatic lineage cells has been described in animal transplantation experiments and human pathology of bone marrow transplantation recipients. however, the molecular mechanism underlying this phenomenon has remained unclear because of lack of effective culture system. to address this issue, we developed a novel in vitro culture system in which murine bm cells are cultured with growth factors and investigated factors required for the transdifferentiation of em cells into hepatic linage cells. methods and results: ( ) bm cells were isolated from the femora of -to -week-old male c bl/ ] mice. they were cultured in three-dimensional culture system using type i collagen gel and stimulated without or with the growth factors (egf, hgf, hb-egf, osm, bmp- , bfgf, fgf- ; ongiml) for day. to investigate the effect of these growth factors, the gene expression of albumin was examined by quantitative rt-pcr. when bm cells were cultured with hgf, osm, bfgf and fgf- , albumin was induced effectively. among these growth factors, bfgf was found to induce albumin the most effectively in the cultured bm cells. ( ) bm cells were cultured in collagen gel with bfgf ( onglml) for , , days. the gene expression of hepatocyte-specific markers (albumin, cytokeratin , alphal-antitrypsin, glucose phosphates and tyrosine aminotransferase), cholangiocyte-specific marker (cytokeratin ) and liver-enriched transcription factors (hnflalpha, hnf alpha, hnf beta, hnf alpha, gata , gata , clebpalpha, and ciebpbeta) were examined by rt-pcr. upon the stimulation of bfgf, bm cells were found to express cytokeratin , alphal-anitripsin and glucose phosphates, cytokeratin and liver-enriched transcription factors including hnflalpha, hnfjalpha, hnf beta, gata and gata . ( ) bm cells were cultured in collagen gel with bfgf ( ngiml) for days. we assessed expressions of albumin and ck proteins of cultured bm cells by immunohistochemistry. about % cells of them were positively stained for both albumin and cytokeratin . conclusions: we established a novel in vitro culture system of bm cells and demonstrated that basic fibroblast growth factor could induce the trans-differentiation of bm cells into hepatic lineage cells the most effectively. furthermore, this conversion was associated with induction of liver-enriched transcription factors including hepatocyte nuclear factors and gata family proteins. these results indicate these liver-enriched transcription factors are the major components, which induce this trans-differentiation. disclosures: ayuko iizuka -no relationships to disclose yoshihiro kamada -no relationships to disclose takako kawasaki -no relationships to disclose shinichi kiso -no relationships to disclose hitoshi matsumoto -no relationships to disclose yuji matsuzawa -no relationships to disclose yukiko saji -no relationships to disclose shinji tamura -no relationships to disclose yuichi yoshida -no relationships to disclose crtteil, france; nadine martin, hbpital henri mondor, criteil, france; dominique couchie, anne m preaux, yannick laperche, elie ; zafrani, inserm u , cre'teiz, france liver can regenerate from oval precursor cells when the replication of hepatocytes is inhibited. these cells proliferate in the periportal region, migrate in the lobule and differentiate into hepatocytes. stromal-derived factor- (sdf- ) is a chemokine which plays a major role during embryogenesis. since sdf- and its sole receptor cxcr are involved in the differentiation of progenitor cells (e.g. b lymphopoiesis, digestive epithelial cell renewal), the aim of our work was to study the expression of sdf- and cxcr in a model of hepatic regeneration from precursor cells. hepatic regeneration from oval cells was induced by treating rats with acetylaminofluorene followed by partial hepatectomy. rats were sacrificed the day of surgery (day ) and at days , , , and after partial hepatectomy. rare oval cells were observed at day . their number was moderate at day , marked at day and and declined thereafter. oval cells predominated in the periportal region and usually formed canalar structures resembling cholangioles. individual or cholangiole-forming oval cells strongly expressed sdf-i, as demonstrated at the mrna level by in situ hybridization (ish) and at the protein level by irnmunohistochemistry. interlobular bile duct epithelial cells were also positive for sdf- protein but negative for its mrna. cxcr mrna hepatic levels, as assessed by quantitative rt-pcr, paralleled the degree of oval cell proliferation. ish showed marked cxcr mrna expression in individual as well as in cholangiole-forming oval cells. in order to determine which role the sdf- icxcr couple could play in hepatic regeneration from oval cells, rats were treated or not with fucoidan ( mglkg ip, twice daily), a sulfated polysaccharide known to bind to sdf- and to block its biological effects. as compared to untreated animals, oval cell proliferation was markedly decreased in five of the seven fucoidan-treated rats. in conclusion, oval cells express sdf- and its receptor cxcr during hepatic regeneration from precursor cells. our results strongly suggest that the sdf- lcxcr couple acts in an autocrinelparacrine way to stimulate the proliferation of these precursor cells. disclosures: dominique couchie -no relationships to disclose background: bone marrow cells and embryonic stem cells are being used for cell transplantation. although these cells are known to be multipotent and capable to become hepatocyte, several problems have been pointed out, such as cell fusion and teratoma generation. thus we paid attention to side population (sp) cells, those with a verapamil-sensitive ability to efflux hoechst . sp cells have been identified in several tissues. the bone marrow sp phenotype appears to be a common feature of stem cells, but hepatic and splenic sp cells have been less well characterized. aim: we tried to separate and culture sp cells from non-parenchymal liver cells (npcs) and splenocytes, and examined whether they would obtain hepatic phenotype. methods: - -week-old female transgenic rats that ubiquitously express egfp were used to isolate non-parencymal liver cells by the standard collagenase two-step perfusion method, and splenocytes were isolated by forcing the tissue through sterile mesh, then mononuclear cells were separated by ficoll density gradient centrifugation. they were resuspended at lo cellslml in hanks balanced salt solution (hbss) containing % fetal calf serum, mm hepes (hbss+), and uglml hoechst (hst) w or wlo verapamil and were incubated at degrees centigrade for min. cells were washed twice in hbss+ and then resuspended in hbss+ with uglml propidium iodide. cells were analyzed and sorted on a dual-laser facstar plus flow cytometer. rt-pcr was performed with rna extracted from freshly isolated sp cells. isolated sp cells were cultured with male rat primary cultured hepatocytes in collagen gel sandwich. cell morphology was monitored under a phase-contrast microscope and a fluorescence microscope. the expression of albumin, cytokeratin , and cytokeratin was analyzed by immunohistochemistry. fluorescence in situ hybridization (fish) for the sry gene was performed to exclude ceil fusion. results: the rate of npc-sp was . % of isolated npcs. % of npc-sp expressed cd , while % of npc main population (mp) did. freshly isolated sp cells were smaller than mature hepatocytes. they looked like monocytes or lymphocytes. these cells did not express liver specific markers, such as albumin, alpha-fetoprotein, cytokeratin , or cytokeratin . during one-week culture with hepatocytes using collagen gel sandwich method, we could find no change in gfp-positive sp cells, but after further culture, we found several colonies consisting of gfp-positive sp cells, whose shape became polygonal. after -week-culture, most of gfp-positive cells were stained positive for albumin. npc-sp cells died within one week without hepatocyte co-culture. npc-mp cells formed colonies after weeks culture with hepatocytes, but unlike sp cells, they looked like fibroblasts and were negative for albumin. freshly isolated sp cells from splenocytes were also small and monocyte-like, and expressed no liver specific markers. spleen sp cells could culture for more than weeks in the same way as npc-sp cells, and looked like hepatocytes, but did not proliferate. after having been cultured, most of gfp-positive cells were stained positive for albumin and cytekeartin , and negative for cytokeartin ; on the other hand splenic main population cells after weeks' culture expressed those very little. conclusion: we succeeded in culturing liver and spleen sp cells. sp cells which did not express mrna of liver specific markers, such as albumin or cytokeratin , became to express those after the culture with hepatocytes. these results suggest that these sp cells have plasticity and obtain hepatic function. thus, tissue stem cells, especially sp cells, are useful for cell transplantation. spleen sp cell might be a candidate for source of cell transplantation for treatment of liver cirrhosis. miura, takashi goto, ken-ichiro mikami, kunio nakane, kazuo yoneyama, hirokazu nagai, kunihiko terada, toshihiro sugiyama, katsuyuki imai, haruki senoo, sumio watanabe, akita university, akita, japan background epimorphin, a mesenchymal cell surface-associated molecule identified as an epithelial morphogen, is detected on stellate cells in the liver. we have reported that a contact with hepatic stellate cells (hscs) promotes differentiation of hepatic stem-like cells (hslcs). here, we show the involvement of epimorphin in that process.materials and methods: hslcs and hscs were isolated from healthy adult rats using two-step collagenase perfusion and percoll gradient centrifugation, and maintained standard medium, dulbecco's modified eagle's medium with % fetal bovine serum. hslcs were cultured in stellate cell-conditioned medium, co-cultured with hscs to maintain cellcell contact or in the presence of epimorphin. phenotypical and morphologic changes were investigated by rt-pcr and with an electron microscopy, respectively. results: hslcs are polygonal in shape and assume a cobblestone appearance when cultured in standard medium. transmission electron microscopy showed that hslcs , to micro-m in diameter, have a round to ovalshaped nucleus, a few vacuoles, scant organelles and a high nucleuslcytoplasm ratio compared with normal hepatocytes. the phenotypic properties of hslcs did not change as well as their size and shape during this experiment. hslcs characterized by rt-pcr are follows: positive, c-kit, musashi- (a neural stem cell marker), alpha-fetoprotein, cytokeratinl , connexin ; negative, albumin, transferrin, tyrosine aminotransferase, gamma-glutamyl transpeptidase. hslcs cultured in stellate cell-conditioned medium had no phenotypical and morphological changes. hslcs co-cultured with hscs expressed albumin, transferrin, and tyrosine aminotransferase, which were inhibited by an anti-epimorphin antibody. furthermore, epimorphin induced the markers not only for hepatocytes including albumin, transferrin and tyrosine aminotransferase, but also for cholangiocytes including gammaglutamyl transpeptidase in addition to increased expression of connexin and cytokeratinl , with decreased expression of c-kit and musashi- . in addition, clebp beta was enhanced, which has been reported to mediate through morphogenesis by epimorphin. hslcs co-cultured with hscs piled up and subsequent development of bile-canalicui-like structures, which was dramatically inhibited by an anti-epimoirphin antibody. hslcs, close to epimorphin, stated piling up, changed their shape from flat to cuboidal, became rich in mitochondria and rough endoplasmic reticulum and formed bile-canalicui-like structures. conclusions: hslcs have a self-renewing capacity and multilineage differentiation potential. epimorphin is involved in differentiation of hslcs though a contact with hscs. disclosures: takashi goto -no relationships to disclose n order to identify new and differentially expressed genes in fetal rat liver that are specific for epithelial stemlprogenitor cells and genes involved in liver progenitor cell differentiation, we used murine cdna microarrays containing , cdnas, available at the functional genomic facility, aecom. the expression pattern of fetal liver stemlprogenitor cells was studied from embryonic day through birth, days after birth and in adult liver. the driver rnas were isolated from cells adhered to the dish after plating the cell suspension in order to remove the blood cells. reference rna was isolated from the livers of newborn rats. we found that genes present on the cdna microarrays were developmentally regulated. these genes fall in two major hierarchical clusters, according to their pattern of expression. the genes that are down-regulated during fetal liver development were distributed in functional groups and further analyzed. in this study, special attention was paid to genes that were induced in fetal liver but were not expressed (or expressed at a very low level) in adult liver. these genes are of special interest because they can serve as specific markers for identification and for isolation of liver stemlprogenitor cells. in addition, these genes represent links to understanding the fetal liver specific molecular pathways that govern cell proliferation, survival, apoptosis and differentiation. to determine which of the over-expressed genes in - day fetal liver that are down-regulated in adult liver are progenitor cells specific, we searched in the available databases whether the expression of these genes in adult liver was previously reported. seventy genes were further analyzed: the clones of interest were hybridized to radioactive labeled p cdna synthesized from fetal and adult liver rnas. for of the clones, we found that there was little or no expression in adult liver. the expression level of selected clones was analyzed further by quantitative pcr, and they were confirmed as highly induced in fetal hepatoblasts compared to adult liver. half of the clones are ests. the known genes fall in different categories, the major four being: genes related to transcription; signal transduction; morphogenesis, histogenesis and organogenesis; cell adhesion, de-adhesion and migration. some of the known genes over-expressed in fetal liver that are not expressed or expressed at very low level in adult liver are: grblo (aa ), fh (aa ), tnc (aa ), peg (aa ), hey (aa ), enah ((aa ), pkcd (aa ), lox (w ), shcbpl (aa ), magoh (aa ), manba (aa ), klf (aa ), gpc (aa ), pcolce (aa ), ppap c (aa ), nfkb (aa ), adam (aa ), akapl (aa ), tagln (bc . it should be noted, that most of the clones and all those listed here that we have identified as liver progenitor cells specific, are expressed in stem cells of embryonic, hematopoietic, or mesenchymal origin. two of the presented genes encode cell surface proteins: a disintegrin and metalloproteinase domain (adaml ) (meltrin beta), glypican . using in situ hybridization, we are currently verifying whether our putative liver progenitor cell specific genes are expressed in hepatoblasts and in rare progenitor cells that remain in the adult liver. identifying and cloning new genes that are expressed uniquely in liver stemlprogenitor cells will allow us to design a method for isolation of these cells and to study their role in liver development, growth control and regeneration. hepatocyte transplantation has been shown to be an effective treatment for liver diseases including fulminant hepatic failure and metabolic defects in liver function. however, the availability of sufficient numbers of hepatocytes with which to conduct clinical studies limits the wide-spread availability of this therapy. previously, we have shown that human placenta derived stem cells (pdsc) differentiate along neural or hepatic lineages depending on the culture conditions and suggested that these stem cells could be a source of cells for clinical transplantation. here we report on a protocol to further optimize hepatic differentiation of pdsc. a three stage culture system was applied to induce hepatic differentiation. ae cells were propagated in dmem based standard media which contains egf nglml for a week (stage i) and subsequently with growth factors such as fgf- , , , , , oncostatin m, hgf, andlor dexamethasone (dex) and insulin-transferrin-selenium (its) for weeks (stage ). the cells were then changed to media supplemented with different nuclear hormone receptor agonists for week to stimulate hepatic maturation (stage ). total rna samples were examined for hepatocyte specific gene expressions with real-time quantitative pcr (rtq-pcr). additional studies examined hepatic differentiation on different culture substrates including collagen, gelatin, fibronectin, arg-gly-asp-ser, and matrigel %, %, % were also examined. in the three stage differentiation system, % (vlv) matrigel coated plates and dexlits containing media, and phenobarbital (pb) were identified as the best conditions to upregulate liver specific gene expression. the principal human drug-metabolizing enzymes (cytochrome p- , cyp) were also examined by rtq-pcr. cypla , c , d , and a were induced with either rifampicin or pb. in parallel, expression of the relevant liver-enriched transcription factors, hnf- , clebp-a and ciebp-b mrnas were increased under conditions which induced hepatic differentiation. under slightly different conditions, differentiation of pdsc into cells which expressed pax , pdxl and nkx . , insulin and glucagon was observed. flow cytometric analysis showed isolated nayve ae cells contains a population of cells which express the embryonic stem (es) cell markers, ssea- , , tra - , and tra - . furthermore, the placental stem cells formed embryonic body (eb)-like structure when cells were cultured on matrigel. the eb-like structures retained the expression of ssea- , , tra - , and tra - . these data indicate that cells can be isolated from term placenta which express markers of es cells. under appropriate conditions pdsc expand, and differentiate into cells with characteristics of hepatocytes, neurons, or pancreatic cells. we propose that pdsc could provide a new source of cells for clinical transplantation and regenerative medicine. unlike with es cells, there should be no social, ethical or religious objections to the isolation and use of placental-derived stem cells. using the ssh technology, we have identified previously induced clones in day fetal compared to adult liver; of these clones were independent transcripts, of them represented ests and appeared to be new sequences (petkov et al., genomics - , ) . applying the rapid amplification of ' and ' cdna ends to subtracted genes (generace kit, invitrogen), we have obtained the full-length cdnas for two of the subtracted clones. one of them (clone g ) encodes a novel putative serine proteasel subtilase highly expressed in fetal liver and comparatively low in adult. the expression of c mrna was analyzed by northern blots with rna isolated from different rat tissues: fetal and adult liver, isolated day fetal hepatoblasts, brain, bone marrow, kidney, spleen, intestine, colon, stomach and muscle. on northern blot with total rna, a strong signal was detected with fetal liver/ hepatoblasts rna and a weak signal with adult liver rna, which showed that the expression of this mrna is developmentally regulated. to confirm the liver specific expression of g , quantitative rt-pcr was camed out. the results of this analysis confirmed our previous results and revealed also a very low expression of g mrna in the colon. the g cdna is nucleotides in length and codes for a novel protein of amino acids. we were able to identify in the data bases the sequences of a rat contig which contains the complete gene for g . the gene coding for g comprises , bp of the rat genome and includes exons and a long '-utr segment of , nucleotides. the initiation of the translation begins with an aug codon, nucleotides downstream from the '-end of mrna. using specific primers designed from the contig sequences, we obtained clones corresponding to the upstream promoter region and downstream of the gene in the pcr top vector (invitrogen). these two upstream and downstream clones were ligated to the c cdna upstream and downstream sequences, respectively, so that the whole gene with the ' and ' regulatory sequences was obtained in the pcr -top vector. analysis of the structure of g showed that this protein resembles others mammalian subtilases, named convertases described during the last decade: furin, pc / , pc , pc , pace , pc and pc ilpcipc and ski- isip. these proteases are synthesized as proproteins and secreted from the cell. g contains a putative signal sequence for release from the er located between amino acid and (alanine glutamine). however, it does not share the consensus cleavage sequences characteristic for the other convertases: (k,r)-(x)n-(k,r) for processing, release and secretion of the active enzyme form. at present, we do not know the processing site of the proprotein. in situ hybridization experiments showed that this serine protease is expressed in fetal liver hepatoblasts. convertases are secretory proproteins implicated in tissue specific processing of hormones, growth factors, metalloproteinase, extracellular matrix proteins, viral proteins etc. they show tissue specificity and some are implicated in development and differentiation. g is a novel convertase, it is developmentally regulated and most likely functions in processing and activation of growth factorslcytokines or extracellular matrix proteins implicated in morphogenesis. further studies of its promoter region will reveal the control sequences and transcriptional activators and repressors regulating its expression during development. college, london, uk introductioniaims: bone marrow cells (bmcs) can contribute to regeneration of the chronically damaged liver but in human studies and animal models the magnitude of this axis is highly variable. in a murine model of hepatitis b we examined whether this pathway of regeneration is enhanced by inhibiting endogenous hepatocyte regeneration. methods: month old female mice transgenic for hepatitis b surface antigen (hbs-tg) received lethal irradiation and were then transplanted with c b / j male bmcs by tail vein injection. weeks later half the mice were treated with retrorsine, a pyrrolizidine alkaloid, to irreversibly block proliferation of endogenous hepatocytes. mice were sacrificed at and months following retrorsine injections. y chromosome containing hepatocytes were identified using in situ hybridisation and phenotype markers (positivity for cytokeratins / , cytochrome p and glycogen, negative for cd ). results: in the control mice with chronic liver damage there was an increase in y chromosome positive hepatocytes over time, but the proportion remained < % of the total number of hepatocytes. however, . % (corrected count) of y chromosome containing hepatocytes could be found repopulating the livers of the mice that had received retrorsine. conclusions: bmcs contribute to the regeneration of the chronically damaged liver, but under conditions where regeneration of endogenous hepatocytes is possible this is minor. however, when chronic liver damage occurs and regeneration of the endogenous hepatocytes is inhibited, the contribution to liver regeneration from the bone marrow is significantly enhanced. beaujon, paris, france; thierry poynard, groupe hospitalier pitie-salpetriere, paris, france background portal hypertension depends in part on the development of hepatic fibrosis. thus, since fibrotest (ft) is a potential biochemical marker of fibrosis, this test was prospectively used to evaluate the presence and severity of portal hypertension in patients with different liver diseases. methods: consecutive patients ( males; % chronic viral hepatitis c, % hepatitis , % alcoholic liver disease, % transplanted, % miscellaneous) with transjugular liver biopsy had same day measurements done for hemodynamic parameters (gradient, free hepatic, wedged pressures), histological parameters (fibrosis scoring system in stages, necroinflammatory activity grades and modification of architecture in classes), and biochemical parameters via blood sample (ft for fibrosis and actitest for activity). the measurements of histological and biochemical parameters were done blind to any other characteristics. sensitivity (se), specificity (sp), predictive values (npv and ppv), spearman correlation (sc), accuracy (ac), kappa (k) and the area under the roc curves (auroc) were assessed. the main endpoint was the prediction of elevated portal pressure (epp), defined by a gradient of mm hg. the secondary endpoint was the prediction of highly elevated portal pressure (hepp) of mm hg (hepp). results: the mean ft value was . (se . ) for patients without epp, . ( . ) in patients with moderate epp and . ( . ) in patients with hepp (p<o.ol between all groups, dunnett's multicomparison test) (figure ). high aurocs of ft were obtained for the prediction of epp, . ( . ) and hepp . ( . ); a cutoff at . had a % ppv for the presence of epp (se= %, sp= %) and a . cutoff had a % npv for the exclusion of hepp (se= %, sp= %). there was a significant correlation between ft and gradient (sc= . , p<o.ool). the auroc of ft for the histological architectural disturbance (fibrosis or cirrhosis) was very high . , ( . ). there were also excellent ft diagnostic values for stages f f f ac= %; k= . ( . ); sc = . , p<o.ool; auroc= . ( . ). therefore histological staging did not give higher diagnostic values than ft for epp, auroc= . , ( . ) introduction: the prevalence of gastric varices ranges from - % in cirrhotic patients and is associated with high morbidity and mortality rates. conventional endoscopic hemostatic treatment is not effective for gastric variceal bleeding. tips can achieve initial control of bleeding but it is associated with high cost, shunt dysfunction, and increased encephalopathy. cyanoacrylate injection has been shown to be very effective with % hemostasis and low rebleeding rates of - %. in our current series of gastic varix patients at the university of virginia, injection with n-butyl- -cyanoacrylate (histoacryl) has yielded similar results (scaldwell, fda-ide). however, distal embolization after n-butyl- -cyanoaaylate injection has been reported and probably results from "beading" upon polymerization. whether other cyanoacrylates with different physical-chemical properties have less embolic risk with equal or greater efficacy remains to be determined. &to investigate and compare the efficacy and safety of two different cyanoacrylates in the management of gastric varices. meth-ods:polymerization properties of two cyanoacrylates, n-butyl- cyanoacrylate (histoacryl) and octyl-cyanoacrylate (dermabond), were compared in vitro by adding a drop of blood to different concentrations of n-butyl- -cyanoacry atel:ethiodol and octyl-cyanoacry- ate:ethiodol (ethiodol, iodinated poppy seed oil, is radio opaque and delays polymerization). the two cyanoacrylates were then compared for "beading" by injecting each cyanoacrylate solution into a flowing circular system of fresh frozen plasma and then collecting the resultant polymer. lastly, cyanoacrylate injection was tested in an animal model using the femoral vein of a pig to simulate a gastric varix. each femoral vein was injected with n-butyl- -cyanoacrylate and octyl-cyanoacrylate, respectively, and then both veins were ligated and examined for histologic change. results n-butyl- -cyanoacry ate:ethiodol ( :l) and octyl-cyanoacrylate alone had similar polymerization properties as far as initiation of polymerization to formation of a "hard substance"these concentrations were used for subsequent testing. preliminary results from the circular flowing system show that n-butyl- -cyanoacrylate forms a "beaded" and "crystallized" polymer whereas the octyl-cyanoacrylate polymer is more "stringy" and "rubbery". in the animal model, n-butyl- -cyanoacrylate had formed a large, extended thrombus in the vein with an irregular surface that appeared granular. in contrast, octyl-cyanoacrylate appeared uniform throughout and occluded the vein wall with only a s m d thrombus in the center. conclusion octyl-cyanoacrylate appears to be a viable alternative with possible lower embolic risk. vessel occlusion appears to involve a combination of polymer and thrombus formation, although interaction with the dotting cascade has not been adequately investigated. further studies in an animal model of gastric varices are in development to assess the relative safety and efficacy of these and other cyanoacrylates. disclosures: stephen evgeny farber, doron fisher, rami eliakim, nira beck-razi, ahuva angel, ella veikman, irit chermesh, camal yassin, diana gaitini, michael libas, rambam medical center, ha+, israel; soboh soboh, porria hospital, tiberia, israel; yaacov baruch, rambam medical center, haqa, israel background: current guidelines recommend that patients with liver cirrhosis, undergo egd screening every - years for the presence of ev. patients with large ev should be treated with beta-blockers and those with small ev should be rescreened. platelet count and us correlate with high risk patients but are not accurate enough to avoid endoscopy in low risk patients. barium swallow is preferred by most patients but data concerning its sensitivity is not sufficient. to evaluate the accuracy of be to diagnose esophageal varices in patients with compensated cirrhosis and portal hypertension at an early stage. patients and methods: patients with liver cirrhosis where evaluated by egd (japanese general criteria), as a gold standard and be for the presence and size (small, large) of varices. x-rays were taken within weeks of endoscopy, with % barium sulfate (e-z-hd), as suspension adjusted for double contrast studies and barium paste (e-z, %, esophageal cream) for mucous coating. results: patients diagnosed by liver biopsy; % postnecrotic, % cryptogenic, % nash, % alcohol. % were child-pugh's score a and % were child-pugh's r. the correlation between egd and be was very high; r= . , p<o.oool. there were only false negative results with be. overall sensitivity of re was %. all large varices (f -f ) were diagnosed by be. sensitivity declined with f varices to %. the positive predictive value was %. the cost of x-rays was one fourth that of egd. conclusions: re can be used as a non invasive procedure for the screening of patients with varices and compensated liver disease at a minimal cost. using be will allow to avoid universal prophylaxis with beta-blockers. studies dealing with the prevention of rebleeding have shown that hemodynamic response to pharmacological treatment of portal hypertension is adequate when the hepatic venous pressure gradient (hvpg) decreases to ? mmhg or by ? % from baseline. with beta-blockers these targets are achieved in only around % of cases. however, even with such a high rate of poor hemodynamic response, variceal bleeding occurs in few patients when beta-blockers are used for primary prophylaxis (around %). the aim of this study was to assess whether the cut-off value to define response in primary prophylaxis may be defined more accurately and to investigate whether the acute response to beta-blockers may predict evolution (avoiding a second study). methods: a total of cirrhotic patients with large varices and without pre-vious bleeding were investigated. a baseline hemodynamic study was performed in all patients. after initial measurements, propranolol was administered in patients ( . mg/kg i.v.) and measurements were repeated minutes later. subsequently, nadolol was chronically administered to prevent variceal bleeding. a second hemodynamic study was performed to months later in patients. results: during a mean follow-up of months, % of patients had a bleeding episode and % died. there was a significant correlation between acute and chronic hemodynamic response to beta-blockers (r= . , p=o.ool). using roc curve a decrease of hvpg ?lo% from baseline was the better cut-off point to predict bleeding, both for acute and chronic studies. hemodynamic responders (defining response as a decrease of hvpg to ? mmhg or ?lo%), had a significantly lower probability of bleeding (p?o.ol) and of requiring hospital admission because decompensations of cirrhosis, while survival probability was higher, both after acute and chronic beta-blocker administration. the hvpg decreased ? % in % of cases and decreased ?lo% in % (p?o.ool) after acute beta-blocker. these figures were % vs % (p?o.ool) after a chronic administration. conclusions: our results suggest that: ) a decrease of hvfg ?lo% from baseline may be the target to identify hemodynamic responders in primary prophylaxis of variceal bleeding; ) , cute hemodynamic response to beta-blockers may provide an accurate prognostic information on long-term risk of variceal bleeding. ut; william m grosse, corneliu sanda, milton taylor, lndiana university, bloomington, in treatment of chronic hepatitis c patients with type interferon (ifn-alpha) and ribavirin leads to a sustained virologic response in - % of patients. the elimination of serum hcv rna in an individual patient displays biphasic kinetics with the first order attributed to the direct antiviral effects of ifn-alpha and the second order attributed to an immune mediated clearance of infected cells by induction of th cytokines, primarily ifngamma (type ifn). we have postulated that the direct antiviral effects as well as the th response of current therapies may be enhanced by the addition of type ifn (ifn-gamma). to study this hypothesis, we examined the activity of a type ifn, infergen; (ifn-alfaconl) in combination with a type ifn, actimmune; (ifn-gamma l b ) in preclinical models of hcv. these included an infectious flavivirus system (west nile virus) and the hcv replicon. in addition, global transcriptional profiling was examined utilizing the hg-u a genechip; (affymeirix, santa clara, california) system. effective concentration (ec) studies of the l effects of ifn-alfaconl, ifn-gamma l b and the combination against the west nile virus and the hcv replicon are shown below: analysis of synergy for the combination of ifn-alfaconl and ifngamma l b in the hcv replicon using the chau-talalay methodology demonstrated very strong synergistic effects for a range of doses (c < . for all observations). initial statistical analysis (pv<o.ool; fold change . ) of global transcriptional profiling revealed that treating hcv replicon containing cells with ifnalfaconl up-regulated transcripts, while transcripts were significantly down-regulated. ifn-gamma l b treated cells had transcripts up-regulated and down-regulated transcripts. most significant was the finding that several transcripts were up-regu-lated by the combination of ifn-alfaconl and ifn-gamma l b that were not up-regulated by either ifn alone. these transcripts were involved in cell-cycle regulation, antigen presentation, apoptosis and immuno-activation. in addition, several known interferon stimulated genes were highly elevated by the combination when compared to the monotherapy treatments. these results demonstrate synergistic effects of the combination of type and type ifns for the treatment of chronic hepatitis c both on a cellular and molecular level. further study in hcv infected patients is warranted. hcv is leading cause of chronic hepatitis, cirrhosis, and hepatocellular carcinoma. clearance of hcv is associated with strong t cell immunity to hcv immunogens including the non-structural ns protein (ns ). dendritic cells (dcs) play a pivotal role in priming rare antigen specific t cells to initiate protective hcv immunity. therefore, dcs are an important target to elicit broader and more robust immune responses against hcv. to target immunogens to dcs, -mer peptides were screened from a phage display peptide library for specific binding to human dcs. a candidate -mer peptide (dc-peptide# ) was identified that bound human monocyte-derived dcs. dc-peptides bind to ligands that are strongly involved in receptor mediated endocytosis. dc-peptides could be linked to hcv ns biochemically or fused genetically with preservation of dc targeting specificity and immunogenicity. dcs pulsed with ns that has been genetically fused to dc peptide augmented t ceil proliferation > fold better thanns alone, and skewed t cells towards thl polarization resulting in elevated levels of ifn-.)i (higher than with ns alone) but not il- or il- . t cells also acquired an activated phenotype (cd +). to test in viva efficacy of ns -dc peptide fusion protein, nod-scid mice were xenotransplanted with hcv-nake t cells, and vaccinated with three separate weekly injections of autolo-gous dcs ( ) pulsed with nothing, ns alone, or the ns -dc pep-tide# fusion construct. vaccination using dcs pulsed with ns -dc peptide# fusion protein significantly increased ns -specific t cell proliferationlactivation and enhanced the expression of ifn-y, and tnf-a compared to ns alone but no detectable levels of il- or il- were observed. these data indicate that targeting hcv subunits to dcs using specific dc-peptides represents a novel vaccine approach that may facilitate targeting of immunogenic antigens to dcs to elicit specific t cell immune responses against ns of hcv. this immunotherapeutic strategy can be implemented against the broad range of immunogenic antigens of various pathogens. it has recently been reported that the administration of eta in the setting of chronic hcv infection enhances ifn-induced viral clearance ( ). the mechanism of these synergistic effects remains to be understood. our hypothesis was that eta enhances antiviral effects of ifn by increasing t cell reactivity to antigens. methods: peripheral blood mononuclear cells (pbmcs) were isolated in cpt tubes from blood of two healthy volunteers. cells were washed and then cultured in complete media -well plates in the absence of any antigen (negative control) and in the presence of immobilized anti-cd antibody (i-cd , nglml, positive control) as a nonspecific t cell stimulant. i-cd stimulated cells were treated immediately with peg ifn alpha- a at two different concentrations consistent with physiologic doses in humans ( nglml or nglml) with or without the addition of eta at two different concentrations that were also consistent with physiologic doses in humans ( . pglml or . pglml). supernatants from each of the previous conditions were collected and assessed by elisa for ifn- secretion as a marker of t cell activation. results: our findings are displayed in the figure below. there was no spontaneous ifn- detected in cells that were not stimulated. ifn-y was detected at a modest level after exposure to i-cd alone, a response that became greater after exposure of cells to peg ifn alone or eta alone. production of ifn- was substantially enhanced in cells that were exposed to a combination of peg ifn and eta compared to those exposed to peg ifn alone or eta alone. conclusion: our findings suggest that eta has a synergistic effect to that of peg ifn in promoting in vitro activation of pbmcs and ifn- production in healthy individuals. increased t cell activation with eta may also suggest that tnfa suppress t cell function and may contribute to refractoriness to inf therapy in hcv patients. the influence of absolute dose and dose in mg per kg body weight of ribavirin on sustained virologic response (svr) in interferonbased combination treatment of chronic hepatitis c as well as the influence of dose reduction is still controversial. here, we address this problem by reanalyzing data of previously untreated patients with chronic hepatitis c from a multicenter trial who were treated with interferon alfa- a plus ribavirin and amantadine or interferon alfa- a plus ribavirin (berg et al, hepatology , , - and completed therapy. thereby, we used a multivariate approach to account for correlations of the dose of ribavirin with body weight and body mass index (bmi) and known predictor variables from this data set which are low baseline hcv rna, high platelet counts, high pretreatment alt, and low y glutamyl transpeptidase (ggt) as well as hcv genotype non- . because per protocol dosage of ribavirin was weight-adjusted ( mg for body weight below kg and mg for body weight kg or more) and body weight was positively correlated with ggt and negatively correlated with platelet counts (spearman rank correlation, p<o.ol% and p= . 'x), respectively, we used a stratification with respect to genotype (gt vs. non- ), ggt, and platelet counts in the analysis of ribavirin dose. when comparing body weight, bmi, the absolute intention to treat (itt) ribavirin dose as well as the itt dose of ribavirin measured in mg per kg body weight and the respective ribavirin doses at the end of treatment (eot), a significant association with svr was found for the eot ribavirin dosage (mg per kg body weight) and bmi (p= . % and p= . %, respectively). for predicting svr, a weight-based ribavirin dosage threshold of . mg/kg was calculated using receiver operating characteristics (roc) curves. the svr rate was % ( ) in patients with a ribarivin dose of more than . mglkg as compared with % ( l ) in patients receiving equal or less than . mglkg ribavirin at eot (odds ratio . ; % ci . - . ; p=o.l%). in conclusion, the analysis of ribavirin dosage motivates new considerations of weight-adjustments of the ribavirin dosage to further increase svr in hcv-infected patients treated with combination therapy. effective and approved for treatment of patients with chronic hepatitis c virus (hcv) infection, the medications have many side effects and frequently require dose reduction or discontinuation. improved adherence to the medical regimen increases sustained response rates. data currently available regarding dose reduction, discontinuation and svr are largely derived from registration trials with experienced hepatologists at academic centers. anecdotal information suggests that dose reduction and discontinuation rates are higher and svr lower in community practice, where the majority of hcv patients are treated. actual dose reduction and discontinuation rates and svr in community practice are unknown. aim: we sought to determine dose reduction and discontinuation rates and svr in community practice in comparison with academic centers within the context of a prospective, randomized, controlled, multi-center trial. methods: patients with chronic hcv (+hcv rna) were evaluated at academic centers and community sites within the context of a randomized trial comparing peg ifn a ( . pglkglwk) + ribavirin ( - mgld) vs. peg ifn a ( . pglkglwk) + ribavirin ( - mg/d). demographic, serological (alt), virological (hcv rna level and genotype) and histological data were obtained. eligible patients were randomized to one treatment group. medications were administered for weeks (hcv gt non- ) or weeks (hcv gt ). tolerability (dose reduction rates, adverse events and discontinuation rates) through week of therapy was determined and comparisons were made between academic (ac) and community-based centers (cc). results: patients have been enrolled, in ac and in cc. patients in ac and in cc remain on therapy within the initial weeks and are not included in this report. genotype, histology, gender and age profiles were similar in the groups. * designates a significant difference p< . . by week , ( %) in ac discontinued medications in comparison to / ( %) in cc". / ( %) discontinuations were due to aefsae in ac in comparison to ( %) in cc. ( %) patients in ac who did not discontinue by wk received peg ifn dose reduction in comparison to / ( %) in cc". / ( %) patients in ac who did not discontinue by week received ribavirin dose reduction in comparison to / ( the clinical outcome in response to combination therapy for treatment of chronic hepatitis c virus (hcv) infection appears to be different for caucasian versus african american patients. combination therapy of ribavirin and interferon alpha- b has generally been found to be more effective for eliminating hcv in caucasians. the present study has been undertaken to further define this difference in response to therapy between caucasians and african americans and to determine whether the difference may be related to a difference in t cell-dependent immune responses to hcv in the two patient populations. to this end peripheral blood mononuclear cells (pbmc) were collected from patients prior to the initiation of combination therapy with ribavirin and pegylated interferon alpha- b, week , and at weeks and weeks after initiation of therapy. the pbmc were stimulated in vitro with recombinant hcv-superoxide dismutase (sod) fusion proteins for ns (sod-c c), core (sod-c - ), ns (sod-c - ), ns (sod-nss), and the relevant recombinant sod controls from yeast or bacteria (all generous gifts from dr. michael houghton, chiron). after four days, h-tymidine was added to the cultures and incubation continued for hours to measure proliferation. the cultures were harvested on day five. supernatants from identical cultures were collected for assay of th , il- and interferon gamma (infy), and t h~, il- and il- , cytokine production. t cell responses to tetanus toxoid and the mitogen phytohemagglutinin (pha) were used as positive controls for t cell response potential. to date patients have entered the study. week data has been collected from patients and normal controls. data have been collected from only patients that have completed the study through week . the results indicate that generally all patients' t cells were stimulated by pha and to lesser extent tetanus toxoid. the major cytokine stimulated by both pha and tetanus toxoid was infy. few of the patients had significant t cell responses to hcv proteins at time measured either as proliferation or cytokine production. over the period of combination therapy, most patients in which serum virus titers were reduced to non detectable levels had significant increases in t cell responses to hcv proteins. although t cell proliferation was varied among the patients, there was generally a marked increase in infy production but little production of other cytokines. responses to hcv proteins were less consistent in those patients that either did not clear the virus or in which there was resurgence of virus after initial clearance. hepatitis c virus (hcv) infection is a major world-wide health problem causing chronic hepatitis, liver cirrhosis and primary liver cancer (hcc). the high frequency of treatment failure points to the need for more specific, less toxic and more active antiviral therapies for hcv. the hcv ns serine protease is currently regarded as a prime target for anti-viral drugs, thus specific inhibitors of its activity are of utmost importance. intracellular biological processes can be specifically manipulated by anti-viral antibodies. we have recently presented the modulation of hcv ns serine protease transforming activity by non-neutralizing recombinant intracellular antibodies (intrabodies). we herein report the development of a novel bacterial genetic screen for inhibitors of ns serine protease catalysis and its application for the isolation of single-chain antibody-inhibitors. our screen is based on the concerted co-expression of a reporter gene, of recombinant ns and of stabilized single-chain antibodies (scfvs) in e. coli. the reporter system had been constructed by inserting a short peptide corresponding to the ns aib cleavage site of ns into a permissive site of the enzyme p-galactosidase. the resulting cleavable lac gene is carried on a low copy plasmid that also carries the ns coding sequence. the resultant p-galactosidase enzyme when active, conferring a lac' phenotype (blue colonies on indicative x-gal plates) while co-expression of active ns results in loss of / -galactosidase activity (transparent colonies on x-gal plates). the identification of inhibitors, as shown here by isolating ns inhibiting single-chain antibodies is based on the appearance of blue colonies (ns inhibited) on the background of colorless colonies (ns active). our source of inhibitory scfvs was a scfv library we prepared from spleens of ns -immunized mice. once isolated, the inhibitors were validated as genuine and specific ns binders by an elisa and as bone fide ns serine protease inhibitors by an in vitro catalysis assay. these antibodies are also analyzed for intracellular immunization against hcv ns serine protease, as inhibiting intracellular antibodies. single chain ns neutralizing antibodies may emerge as useful clinical reagents for the treatment of infectious diseases and cancer. our genetic screen, although applied here for the isolation of antibody-based inhibitors, should be applicable for the identification of candidate inhibitors from other sources. ntroduction:genetic heterogeneity is an important feature of hepatitis c virus (hcv) genomes with six known genotypes and more than subtypes. genotypes , and are broadly distributed in patients around the world, whereas the other types are more geographically restricted. the peptidomimetic inhibitor biln , optimized to have a high affinity for genotype ns protease, has been reported to reduce viral load in genotype hcv infected individuals. in this study, the ability of biln to inhibit the ns proteases from the other widespread genotypes and was assessed. methods: the ns protease domains and the ns -ns a proteins of genotypes la, lb, ac, b and a were cloned, expressed in e. coli and purified. protease activity was evaluated using fluorogenic depsipeptide substrates derived from the amino acid sequence at the ns a-ns b and ns a-ns b junctions. results: the activity of the ns protease domains revealed no major differences among the various genotypes. for the ns -ns a proteins, the catalytic efficiencies of the non-genotype enzymes, although higher than the ones observed for the corresponding protease domains, were similar to that observed for genotype (within -fold). differences in activity observed among genotypes were mainly related to changes in k,,, values. binding constant (k,) values for biln were similar among non-genotype proteases with k,'s ranging from - nm for the ns -ns a proteins, up to a -fold reduction in affinity when compared to genotype . hepatitis-c-infection (hcv) is associated with an increased incidence of the chronic fatigue syndrome and depressive mood changes. beside immunological changes the modulation of the serotonergic system might be related to these psychiatric syndromes. serotonin concentration, -ht uptake and the activity of the enzyme mao-b in platelets are useful peripheral parameters to monitor serotonergic activity and function in patients with a chronic hepatitis c (chc). method in a prospective controlled study biochemical measures included assays of -ht concentration and -ht uptake activity at a low physiological substrate concentration in platelets as well as mao-b activity of patients with a chronic hepatitis c were compared to age and gender-matched healthy subjects. furthermore the effect of interferon-alpha treatment on serotonergic parameters was evaluated in patients before and during treatment. results: the mean serotonin platelet concentration did not differ between controls and hcv-infected patients. however, -htuptake and the mao-b activity were significant lower in patients with hcv-infection (p<o.ool respectively, t-test, two-tailed). interferon-treatment led to an increase in it reuptake (p=o.ol), to an increase of mao-b activity (p<o.ool) and to a decrease of serotonin concentration (p<o.ol). thus, during hcv-infection serotonin concentration was stabilized by a decrease in re-uptake and reduced metabolism by lowering mao-b activity. treatment with interferon-alpha led to a decompensation of those mechanisms by increasing the mao-b activity and -ht-reuptake, followed by a decreased serotonin concentration. conclusion: our data support the hypothesis of a tryptophan depletion and serotonergic deficit in patients with chronic hcvinfection and interferon-alpha treatment. furthermore the results give evidence for a useful role of serotonin reuptake inhibitors for the treatment of the serotonergic deficiency during chronic hcvinfection and interferon-alpha treatment. chronic background: recent large prospective trials demonstrated that the combination therapy of interferon ( fn)-alphalribavirin significantly increased the ratio of a sustained virological response in patients with chronic hepatitis c in comparison with ifn monotherapy, especially in patients with high hcv-rna titer and genotype lb. however, the mechanism of beneficial effect of ribavirin is still unknown. on the other hand, interleukin (il-m), originally termed ifn-y inducing factor, is one of proinflammatory cytokines, which acts on th- cells and strongly induces intrahepatic nk or nkt cells as well as activated t cells to produce ifn-y. to clarify the effect of ribavirin in combination with ifn, special emphasis on il- , we examined the correlation between serum il- level and anti-viral effect, and compared it with ifn monotherapy in patients with chronic hepatitis c. patients and methods: all patients in this study are biopsy proven chronic hepatitis c with high hcv-rna titer (hcv-rna>loo kcopieslml before therapy) and serotype (genotype l a or lb). forty-two patients were treated with ifn alpha- b ( mu) in combination with ribavirin ( - mg) daily for weeks, following weeks with ifn alpha- b ( mu) times a week (the combination group). another patients who were treated with ifn alpha- b alone between and (before introduction of ribavirin in japan) with the same schedule are used as control (the monotherapy group). serum samples were taken before, weeks after administration and weeks after cessation of therapy. serum il- are examined by enzyme linked immuno-sorbent assay (elisa), using human il- elisa kit (mbl, nagoya, japan). the il- ratio is defined as serum il- level before administration divided by serum il- level weeks after administration. hcv-rnas are quantitatively examined before and weeks after administration. sustained viral responses are confirmed weeks after cessation of administration by rt-pcr. results: there are no differences in the background of patients between the combination group and the monotherapy group. in the combination group, the decline of hcv-rna level highly correlates with the il- ratio in patients with higher viral titer (hcv-rna> kcopieslml before therapy) despite no correlation is observed in patients with lower viral titer (hcv-rna<soo before therapy). similarly, the hcv-rna level weeks after administration controversially correlates with the il- ratio in the higher titer group despite no correlation in the lower titer group. interestingly, serum il- level itself does not correlate with the decline of hcv-rna level in both the higher and lower hcv-rna titer group. on the contrary, in the monotherapy group, the level of up-regulation of serum il- is lower than that of the combination group. furthermore, although the decline of hcv-rna also correlates with the il- ratio in the higher titer group, the level of a correlation coefficient is lower than that of the combination group. however, the sustained viral clearance weeks after cessation of treatment is not correlated with the il- ratio. it suggests that ribavirin enhances the up-regulation of serum il- level in combination with ifn therapy and the effect of ribavirin is critical for the early anti-viral response during therapy, not for sustained viral response. objective: treatment with pegylated interferon alfa and ribavirin has an efficacy in chronic hepatitis c patients with sustained response rates of about %. however, response in genotype patients with high viral load is considerably lower and is not significantly improved by pegylation of interferon. methods: in the present study, the efficacy of cifn daily dosing and induction therapy followed by combination with ribavirin in naive patients with chronic hepatitis c and genotype was evaluated. au patients had histologically proven hepatitis, elevated alt values and were viremic, the average weight was kg. patients were treated with cifn dosages of or ug qd for weeks, followed by or ug qd for weeks. treatment was continued with cifn at ug qd with ribavirin ( . or mglkgld) for another weeks. results: at weeks therapy an undetectable hcv-rna was observed in % and % in the cifn / and / ug groups, respectively. data regarding sustained response rates showed ' and % for cifn / and / ug groups, respectively. due to side effects cifn had to be dose reduced in % and discontinued in % of patients. addition of ribavirin potentiated the effect of consensus interferon in a dose-dependent manner as has been shown for other interferons previously. when viral response rates were related to the initial viral load, in the genotype i low viral load group, sr rates of and % were obtained for the cifn / and / ug groups (diff. n.s.). in contrast, genotype / high viral load patients showed sr rates for the cifn / and cifn / ug groups of and % (diff. sig.), respectively. the viral response rates obtained with daily dosing of cifn were significantly higher than an independently run control arm using cifn at ug tiw with ribavirin irrespective of the initial viral load. four patients ( %) experienced grade i thrombocytopenias, while no grade iv neutropenias or thrombocytopenias were observed. the overall tolerability in the cifn / ug qd arm was comparable to standard therapy with pegylated interferon a b and ribavirin, while the cifn ug arm was less tolerable during the high dosing period. however, the withdrawal rates were not sigruficantly affected by the higher dose of cifn. conclusions: cifn daily dosing l induction therapy in combination with ribavirin thus shows significant response rates with the highest response rates in genotype patients seen to-date. the sustained response rates for genotype i high viral load patients are higher than the ones demonstrated in the peg interferon and ribavirin registration trials. these data suggest that for difficultto-treat genotype / high viral load patients cifn with daily and higher initial dosing may be a worthwhile alternative to standard combination therapy with pegylated interferons. introduction: hcv-induced cirrhosis or hepatocellular carcinoma account for at least a quarter of all patients undergoing liver transplantation. almost % of hcv related liver transplant patients are re-infected with hcv after liver transplantation, often within days. in most of these cases, the recurrent infection leads to chronic hepatitis. these patients are in need of preventive therapy against re-infection of the transplanted liver. antibodies may be used as a stand-alone prophylactic therapy to prevent re-infection following liver transplantation or in cases of accidental exposure (e.g. needle stick injury). in addition, it may be feasible to use monoclonal antibodies in combination with other antivirals to treat chronic hcv patients. purpose: to develop an effective therapy to prevent hcv infection in liver transplant patients. methods: several human monoclonal antibodies were generated from peripheral blood b cells isolated from individuals infected with hcv genotype lb. these antibodies are directed against the hcv envelope protein (e ) of the virus and have high affinity and broad reactivity against different genotypes. the antibodies were shown to neutralize hcv in vitro in a cell-based infection assay and in vivo using the hcv-trimera mouse model. hepex-c, a single human monoclonal antibody, was further developed and studied clinically for safety, tolerability, and potential antiviral activity in phase l a and l b clinical studies in chronic hcv patients. results: in a phase l a study, single doses of . , . , . , , and mg of hepex-c were administered to a total of chronic hcv patients. these patients had varying levels of hcv-rna ( . x lo to x lo iulml) and endogenous anti-e antibodies ( to pglml). doses of hepex-c were well tolerated and no moderate or serious adverse events (sae) were reported. in out of patients, hcv-rna levels were reduced at least by half immediately following infusion and then gradually returned to initial levels. a multidose phase l b study of , , , , and mg of hepex-c in hcv chronic patients was conducted. doses were administered weekly for weeks and then times a week during the fourth week. the patients were followed for an additional months. multiple doses were well tolerated; no drug related saes were reported and no specific pattern of ae noted. out of patients from the through mg cohorts had at least log infusion related reduction in hcv-rna from pre-treatment levels following administration of hepex-c. data from the mg cohort are pending. conclusions: the good safety and efficacy data from this trial provided a basis for a phase a pilot study of the safety and efficacy of hepex-c for the prevention of recurrence in hcvinfected patients who have received a hepatic allograft for endstage liver disease. a multicenter, blinded, placebo controlled study is currently underway in liver transplant patients receiving , , , and mg doses of hepex-c. logic response rates to interferon (ifn) therapy in aa patients w i t h chronic hcv infection have been reported to be lower than that for caucasians (ca), but the effect of therapy on hepatic histology in aa patients remains to be assessed. objective: to evaluate histologic progression of disease in conjunction with anti-viral efficacy and safety in non-hispanic aa hcv genotype patients and non-hispanic ca, hcv genotype patients treated with peginterferon alfa- a ( kd) in combination with ribavirin (rbv). methods an open-label, multicenter study was conducted to evaluate the efficacy and safety of the combination of peginterferon alfa- a ( okd) and rbv in aa patients and in ca patients. all patients were required to have previously untreated chronic hcv genotype infection, elevated alt levels and. a liver biopsy obtained within the months prior to enrollment demonstrating chronic hepatitis but without cirrhosis. patients received peginterferon alfa- a ( okd) pg sc once weekly plus rbv ooo or mg orally based on body weight (< kg or = kg) for weeks, with weeks of treatment-free follow-up. histologic responses based on the knodell hai score were determined from liver biopsies obtained prior to treatment and within weeks of completion of the -week untreated follow-up period. hai activity scores range from - and fibrosis scores range from - . the histology outcome was evaluated for patients with paired biopsies only. improvement in necrointlanunatory activity was defined as point decrease, and improvement in fibrosis as point decrease. the primary efficacy endpoint was sustained virologic response (svr) with undetectable hcv rna (< iulml) at weeks. results: the intent-to-treat population included patients. paired biopsies were available for of the aa patients and of the ca patients. these patients were representative of all patients with respect to knodell hai scores. mean baseline hai activity scores were . . for aa and . & . for ca patients; mean baseline fibrosis scores were . + . and . + . , respectively. the svr rate for all aa patients was l ( %) and for all ca patients, / ( %). for those patients with paired biopsies, svr rates were / ( %) in aa patients and loll ( %) in ca patients. the majority of patients in both groups exhibited improvement in activity scores: % for the aa group and % for the ca group. more importantly, the table beiow shows that the proportion of patients with worsening fibrosis was similar in both groups, while / ( %) of aa patients and only / ( %) of ca patients showed fibrosis improvement. mean changes in fibrosis scores were - . +- . for aa and - . t . for ca patients. among aa patients who had paired biopsies, / ( %) patients who achieved svr had fibrosis improvement; and / ( . %) viral nonresponders exhibited fibrosis improvement. the only patient who had fibrosis improvement among ca was a viral non-responder. conclusions: therapy with peginterferon alfa- a ( okd) plus rbv produced improvement in necroinflanunation and fibrosis in a substantial group of aa patients in this study. although the svr of % in aa with genotype hcv is the highest response to combination therapy yet reported in this population, even patients without an svr achieved a benefit with regard to hepatic histology. higher sustained response rates (svr). however, modification of interferon-alfa by pegylation also reduces biologic potency. delivery of a bio-optimized alpha interferon in an unmodified form (consensus interferon, infergen(r)) by continuous infusion can be expected to provide sustained and constant levels of a fuuy potent protein. we hypothesize that such an approach may potentidy result in greater antiviral activity and improved tolerability by avoiding wide swings in interferon levels. methods:we conducted a phase pilot study to assess the safety, tolerability and viral kinetics of mergen ( fg/day) by continuous infusion using a subcutaneous infusion device (medtronic minimed(r) pump) in combination with ribavirin (loo mg or mg daily). the minimed model micro infusion pump is cleared for use in the treatment of diabetes. hcv rna viral levels were measured at days , , , , , , and then at weeks and . results: among nonresponders treated to date with infergen by continuous infusion with available early viral kinetics data, showed a substantial reduction in hcv viral levels (at least loglo reduction in , and loglo reduction in ). all of these patients were genotype and had less than . loglo decrease with prior treatment while had a . loglo decrease at similar time-points with other combination therapy [either pegylated interferonlrbv ( pts) or interferon-alfa/rbv ( pts)]. no serious adverse events were reported and patients discontinued ( due to moderate interferon-related side effects and due to inability to acclimate to the pump). other patients continuing on study experienced mild adverse events that have been tolerable. conclusions: consensus interferon administered by continuous delivery via the medtronic minimed pump shows early substantial reduction of hcv rna levels among nonresponder patients and shows a good safety and tolerability profile. updated data on a total of patients (including na'ive genotype patients) will be presented. background side effects of interferon-ribavirin combination therapy limit the sustained viral response achievable in a given hcv patient population. furthermore, it has been suggested that higher ribavirin doses and longer treatment duration are required to achieve a sustained response rate in patients with genotype . coupling of ribavirin to hemoglobin offers the potential of a therapeutic with improved safety and efficacy by targeting the delivery of ribavirin to key tissues infected by viral infections such as hcv. these tissues include liver parenchymal cells and macrophages, both of which possess receptors for binding and internalization of hemoglobin-haptoglobin complexes as part of the natural clearance pathway for cell-free hemoglobin. hemoglobin thus serves as a natural drug carrier for targeted therapy of such receptor-bearing tissues. aim: to evaluate the effect of a ribavirinhemoelobin coniueate (rbv-hb. hrc ) in a mouse model of viral hepatitis induced by the coronavirus, mhv- . methods: ribavirin was covalently coupled to highly purified hemoglobin hbao at a mean molar drug ratio of (ribavirin:hemoglobin). the rbv-hb was evaluated for retention of haptoglobin binding and cellular uptake in vitro, as well as the ability to recover bioactive ribavirin following enzymatic cleavage from rbv-hb. the rbv-hb was complexed to haptoglobin prior to administration to mhv- infected balblc mice, and carried one-third of the drug dose that was used for the ribavirin group. the rbv-hbtreated group was compared to control infected untreated and ribavirin-treated groups for survival, clinical behavior, viral titer, biochemistry and liver histopathology. results: rbv-hb was specifically internalized by cultured human and mouse hepatic cells but not by control non-hepatic cells. ribavirin enzymatically cleaved from rbv-hb retained in vitro bioactivity similar to unmodified ribavirin. untreated and mhv- infected mice all developed clinical and biochemical signs of acute viral hepatitis and died by day post infection (altmax iuil). livers recovered from untreated and infected mice showed greater than % necrosis. in contrast, survival was enhanced in both ribavirin and rbv-hb treated and mhv- infected mice with a marked reduction in biochemical (alt iuil) and histologic evidence of hepatic necrosis ( % ) . clinically, rbv-hb treated mice behaved normally at all time points, in contrast to ribavirin treated mice which developed lethargy and abnormal fur texture compatible with drug toxicity or ongoing viral infection. conclusions: in this study, a beneficial effect of rbv-hb was shown on the course of mhv- infection as demonstrated by prolonged sunival, improved clinical behavior, and a reduction in biochemical and histologic disease. the study provides a rationale for additional studies to examine the mechanism for the beneficial effect. ( introduction: the teravic- study targets patients with chronic hepatitis c who do not show a very early viral response at week of therapy, as defined by detectable serum hcv rna (> kjlml, pcr methodology). after weeks of therapy, these patients are expected to achieve a lower rate of sustained viral response (svr) than patients with undetectable hcv rna at week (vr ). models based on viral dynamics and data from pilot studies with conventional interferon (ifn) suggest that a treatment period longer than weeks may lead to a higher svr rate in these difficult-to-treat patients. this trial compares versus weeks of treatment with pegasys(') plus copegus('i in treatmentna'ive patients without vr . methods: this phase , randomized, parallel group, multicenter study is being conducted in spain in accordance with the principles of good clinical practice.(l) after signing the informed consent form, all patients received the study treatment (peginterferon alfa- a [ kd] [pegasys(']] pg once weekly and ribavirin [copegus(')] mg daily mg bid]) for weeks. at this time, viral response (vr) was assessed using the cobas amplicor hcv(') test v . (detection limit hcv rna iulml). patients achieving vr continued therapy for an additional -or -week period, according to their hcv genotype and viral load. patients without vr were randomized :l to continue the study treatment for either an additional weeks (total active treatment duration weeks or an additional weeks (total active treatment duration weeks ). a -week follow-up period is ongoing to determine the svr rate. results: the mean age of the patients was years, the mean weight was . kg, and % were female. the prevalence of hcv genotype or was %. vr occurred in % out of patients, ( % of those with hcv genotype or , % of those with other hcv genotypes). hcv genotype distribution, viral load, age, and body weight were similar in the randomized study groups (group- and group- ). among patients without vr , hcv rna was undetectable in "h in group- and in % in group- at week . the biochemical response rate (br) at week , defined as normal alt levels, was similar as well: % in group- and % in group- . the dropout rate after weeks was % in group- and % in group- . at the end of therapy (eot), hcv rna was undetectable in % of patients with vr . the eot vr rate in group- was % versus y in group- . the rate of br in patients with vr at eot was also higher in group- ( %) than in group- ( %). dropout rates and reasons for dropping out by the eot visit were different between groups: % in group- and % in group- . therapy was well-tolerated and no unexpected adverse events were observed. the prolongation of therapy from to weeks did not cause an increase in the frequency of neutropenia or thrombocytopenia. conclusions: pegasys(') p g weekly plus copegus(') mg bid administered for weeks offers higher rates of vr and br at eot than weeks of treatment in patients with detectable hcv rna four weeks after treatment initiation. the mglday dose of ribavirin used in the trial has been proven to be optimal in patients infected with hcv genotype or , but not in those with genotype who require mglday. this evidence was not established when the trial was initiated. "the teravic- study group also included v. ripollks background isis is an antisense phosphorothioate oligodeoxynucleotide inhibitor of hepatitis c virus (hcv). in a previous phase i study, plasma hcv rna reductions . log were observed in chronic hcv patients treated with isis for weeks. aims: the goals for this phase i study were to evaluate the safety, antiviral efficacy, and pharmacokinetics of isis given for weeks. methods: the study was conducted in noncirrhotic chronic hcv patients. following weeks of thrice weekly intravenous dosing at . mglkg ideal body weight (ibw), patients were treated for an additional weeks at higher doses given either once (group a) or twice weekly (group b). the two doses studied were (initial patientslgroup) and mglkg ibw. results: of patients enrolled into the study, had genotype hcv, had plasma hcv rna levels x lo copieslml, and all but two had previously failed interferon-based therapies. two of the group a and of the group b patients treated at mglkg ibw had plasma hcv rna reductions . log. three in group b had reductions of . - . log. hcv levels remained . log reduced at days after the last isis dose in one of these patients. seventeen patients had transient elevations in alt including all those with hcv rna reductions. peak alt levels ranged - times the upper limit of the normal range (x uln). for those with hcv rna reductions, the alt flares were temporally associated with the reductions. the alt flares were not associated with any clinical signs, symptoms, or sequelae. there were no changes in prothrombin time or albumin level. minor alkaline phosphatase ( . x uln) and bilirubin ( . x uln) elevations occurred in patients. dosing with isis was continued during alt flares, all of which resolved to baseline levels despite continued dosing. three flares, ranging from - x uln, occurred - weeks after the last dose of isis , when presumably little or no drug remained in the liver. similar alt elevations have not been observed in the clinical studies of other phosphorothioate oligodeoxynucleotides. aside from the alt flares, common adverse events in this study were mild to moderate headache, fever, chills, fatigue, nausea, myalgia and other flu-like symptoms. the fever and chills usually occurred several hours after the end of the mglkg infusions and resolved within hours. two serious adverse events that were considered possibly related to isis occurred in the study: one patient had cryoglobulinemic glomerulonephritis and one was hospitalized for precautionary monitoring of an altlastlbilirubin flare. the former event was possibly due to an exacerbation of a pre-existing condition. the isis plasma pharmacokinetics observed in this study were consistent with those seen in the previous phase i study. conclusions: isis appears to have significant antiviral activity in some chronic hcv patients. the plasma hcv rna reductions (up to . log) achieved in this study were in difficult-to-treat patients (i.e., genotype , high virus level, andlor nonresponders to interferon-based therapy). although, alt flares were observed in some patients, the results suggest the flares may not be due to a direct hepatotoxic effect of the drug. other than the alt flares, isis treatment was generally well tolerated. this study established the dose of mglkg ibw twice weekly for further clinical evaluation. a study of isis in combination with peginterferon and ribavirin for patients not achieving an early virologic response during standard peginterferon and ribavirin therapy is in progress. with the long serum half-life of albumin. the objectives of this phase / , open-label, dose escalation study were to evaluate the pharmacokinetics, safety, tolerability, immunogenicity, and pharmacodynamics of albuferon in subjects with hepatitis c virus (hcv) who had previously failed ifna containing regimens. methods: subjects were initially enrolled in sequential dose groups ( - subjects per each group at pg, pg, pg, and pg). within each dose group a minimum of and a maximum of subjects per cohort were enrolled sequentially to receive or subcutaneous (sc) doses of albuferon administered days apart. dose escalation beyond pg included single injections of pg, pg, p g pg and pg. plasma albuferon concentrations and antibody to albuferon were measured by elisa. hcv rna was measured using the amplicor hcv monitor kit (roche). ' ' oligoadenylate synthetase (oas ) mrna levels in whole blood was measured by a research-based taqman pcr assay. results: of the subjects currently enrolled, % were infected with hcv genotype with a mean baseline viral burden of million copies/ml. % of subjects enrolled in these cohorts had previously failed pegylated ifna containing regimens. albuferon pharmacokinetics showed linear increases in auco. and c, , , with mean terminal half-lives of - hours with doses of pg and higher. t, , , occurred between days and . there is an approximately % increase in auc after the second injection in the double injection cohort at pg. albuferon was well tolerated and there were no discontinuations. no subjects developed detectable anti-albuferon antibodies. adverse events were transient and most were mild to moderate. the most common adverse events were injection site erythema ( %), headache ( %), fatigue ( %), mylagia ( %) and arthralgia ( %). the mean reductions in the nadir neutrophil counts in the higher single dose cohorts ranged from - %. there was induction of oasl mrna expression in all cohorts, with approximately -fold increase in median values at day . in the single dose cohorts (= pg), % of subjects showed a maximal . log or greater reduction in hcv viral load during the first two weeks. also, % or greater reductions in alt levels were observed in % of subjects in these single dose cohorts. conclusions: in the ongoing phase study, albuferon demonstrated a favorable safety and immunogenicity profile. the pharmacokinetic profile supports dosing every - wks given its reduced clearance and extended half-life of up to hours. all cohorts showed evidence of biological activity, as demonstrated by oasl induction, with anti-viral activity evident in the higher single dose cohorts. disclosures: v balan -human genome sciences, inc.: investigator t bambury -human genome sciences, inc.: investigator g everson -human genome sciences, inc.: investigator w freimuth -no relationships to disclose h mesghali -no relationships to disclose j murray -no relationships to disclose d nelson -human genome sciences, inc.: investigator l novello -no relationships to disclose b osborn -no relationships to disclose j recta -no relationships to disclose g subramanian -no relationships to disclose m sulkowski -human genome sciences, inc.: investigator j zhong -no relationships to disclose introduction pirfenidone (pfd) is an orally bioavailable pyridone derivative that affects a variety of cytokines, including inhibition of tgfbeta, tnf-alpha, pdgf, and egf. pfd has been shown in clinical studies to improve physiologic parameters in patients with pulmonary fibrosis. we have previously shown that pfd decreased hepatic fibrosis in two different rat models of cirrhosis of hepatology : [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ) . our objective in this pilot clinical study was to evaluate the safety and preliminary activity of pfd in patients with cirrhosis of varying etiologies. methods all patients had histologic andlor clinical evidence of cirrhosis. pfd was given orally at a dose of mg tid for months. physical examination and labs including alt, ast, bilirubin, albumin and prothrombin time, platelet count were assessed at baseline and on monthly basis. hcv rna levels were measured in patients with chronic hepatitis c (cobas amplicor hcv monitor v . ). liver biopsies were obtained at baseline and after months of treatment and were read independently by two hepatopathologists who were blinded to the biopsy sequence. modified histological activity (hai) index of knodell and ishak fibrosis stage were used to assess changes in necroinflammatory scores and fibrosis stage, respectively. change in steatosis was also assessed. results a total of patients with cirrhosis due to hepatitis c ( ), ethanol (s), amyloidosis (l), autoimmune disease ( ) and budd-chiari syndrome ( ) were included. the mean age was years (range, - ) with males. liver biopsies at end of therapy showed a -point or greater reduction in the ha necroinflammatory score in % of the patients. steatosis decreased in % of the patients, was unchanged in % and worsened in %. while there was no significant reduction in the ishak fibrosis stage, improvement in interstitial fibrosis was noted. evidence of cell regeneration was seen in some patients. hcv rna levels were measured in patients with chronic hepatitis c. at months, patients had a decrease in viral load, patients remained unchanged and patients displayed an increase in viral load compared to baseline. no patient had a sustained virologic response. out of ( %) hcv patients had normalization of alt, out of ( %) had decreased alt values, did not change ( %) and patients showed a modest increase in alt ( %). pfd was well tolerated with the predominant drugrelated adverse events being nausea, photosensitivity rash, and itching occurring in % of the patients and which improved after to months of therapy. conclusions: in this pilot study, treatment of cirrhotic patients with pirfenidone for one year was well tolerated. a significant reduction in necroinflammation ( -point reduction in ha grade) and steatosis was observed in a substantial proportion of patients. a subset of patients with chronic hcv infection showed on-treatment reduction in hcv rna levels. longer treatment duration or a less cirrhotic patient population may be needed to demonstrate effects on fibrosis. these data support conducting clinical studies to evaluate a potential role of i'fd in the treatment of steatosis, or in combination therapy for chronic hepatitis c. this work was supported by grants of marnac, inc and intermune, inc. disclosures: arnulfo alvarez -no relationships to disclose gil arechiga -no relationships to disclose juan armendariz-borunda -no relationships to disclose background: viral kinetic modeling of hcv response to interferon-based therapy provides important insights into factors associated with treatment outcomes. hcv/hiv coinfected patients appear to have lower overall response rates than that observed in monoinfected subjects, but the reason for this is not clear. we speculated that kinetic responses in key parameters would be decreased in coinfected subjects. methods: hcvlhiv coinfected patients and hcv monoinfected patients prospectively matched for treatment, genotype, age (k yrs), gender, race and histology were evaluated. coinfected patients were randomized within the context of a large us. multicenter trial (actg ) to receive pegylated interferon alfa- a + ribavirin vs. interferon alfa- a + ribavirin. quantitative hcv rna (roche cobas amplicor) kinetic testing was performed at , , , , , and hours and at days , . non-linear regression and linear models were evaluated in an effort to best predict response and identify prognostic factors. results: twenty-seven subjects underwent viral kinetic sampling and evaluation. these included twelve hcvlhiv case subjects ( men, women) and matched hcv controls (some patients double-matched). the mean age of coinfected subjects was . years (range, - ). among hiv+ subjects the mean cd + count was cells/mm (range, - ). / had baseline hiv rna copieslml. mean hcv viral load was . log iulml among coinfected vs. . log iulml in controls. % of coinfected subjects had hcv genotype . the remainder were genotype . % of coinfected patients had no detectable virus weeks after completion of weeks of therapy (svr). overall svr in control subjects was . %. efficiency ( e ) of phase response (a) slope at hours, lambda (slope of phase decline) were calculated. efficiency of clearance ( e ) at hours was highly associated with actual viral clearance across all groups (p=o.ool) but a was not. regression analysis failed to demonstrate a relationship between e and baseline cd + count, hcv viral load or genotype. in contrast, # ; was significantly associated with genotype. viral kinetic parameters were not predictive of svr. conclusion: viral kinetic modeling demonstrated that the efficiency of clearance at hours was significantly associated with viral clearance during treatment. coinfection status did not affect key kinetic parameters. peg-ifn was superior to standard interferon in terms of viral clearance efficiency, particularly in the coinfected group. diminished svr in coinfected patients may be related to immune factors that are operative after reduction of viral loads to undetectable levels. the prevalence of chronic hepatitis c (hcv) infection is greater in african-americans (aa) than in caucasian-americans (ca). however, small studies and post-hoc analyses of larger clinical trials have not found racial differences in disease severity at study entry, though indicate that interferon and ribavirin combination therapy is not as efficacious in aa as in ca. it is important to identify disease and patient characteristics that differ between aa and ca in a large study designed to ascertain whether the apparent racial difference in response to therapy can be explained. aim: the study of viral resistance to antiviral therapy in chronic hepatitis c (virahep-c) is investigating reasons for the lack of sustained viral response (svr) to pegylated interferon and ribavirin therapy in previously untreated patients chronically infected with hcv genotype . a key objective is to determine whether previously reported response rate differences between aa and ca exist in a large multi-center cohort. methods: virahep-c will recruit aa and ca from clinical centers in the united states. hypothesizing that aa and ca patients differ by factors that influence svr which could explain racial differences in svr, we compare demographic, clinical, histological, virological and health-related quality of life variables (hrqol) before treatment begins. liver biopsies performed within months of study entry were assessed without knowledge of patient race by a central pathologist. results: based on the first participants recruited, age and sex distributions are similar in the two racial groups with patients averaging years of age and / being male more than % of the cohort has at least a high school education, but aa are more likely to have less than a high school education. body mass indices tend to be higher among aa than among ca (p=. ), though waistto-hip ratios are similar (mean . in each group). there are no racial differences in mode of hcv transmission, estimated duration of hcv infection, or baseline serum hcv rna levels. aa are more likely to have sub-genotype l b (p=. ).the ishak fibrosis score does not differ by race, but severe lobular inflammation is greater in aa patients (p=. ). diabetes and hypertension are more common in aa. the sf- physical component score in ca is similar to the general population and higher than among aa (p=. ). the sf- mental component score is similar in the two racial groups and comparable to the general population. summa-wlconclusion: with few exceptions, pretreatment virological, clinical and liver biopsy findings were generally similar in the two racial groups. differences in response are unlikely to be explained by these factors. lshak flbrosls score (%) severa lobular influnmation (%) hypertension (%) diabetes ( bar-llan university, ramat-gan, israel background: combination therapy with peginterferon alfa and ribavirin for weeks achieves sustained virologic response rates (svr) of - % in patients with chronic hepatitis c. however, the svr rates are highly variable according to baseline (hcv genotype) and on-treatment parameters (initial viral decline). thus, it must be anticipated that current standard therapy recommendations lead to under-treatment in some and over-treatment in other individual patients. objectives: comparison between a dynamically individualized treatment schedule according to the early virologic response versus the standard of care combination therapy with peginterferon alfa- a ( kd) (pegasys @) (peg-ifn) ( pg qw) plus ribavirin (copegus @) (rbv) ( - mg qd) for weeks. the primary aim of the study was to increase svr, while optimizing the available drugs, treatment duration, quality of life and the socio-economical burden of therapy. the secondary aim of the study was to enable a comprehensive analysis of virallhostlimmune correlates of response to treatment (ongoing). methods: all patients (n= ) were initially treated with peg-ifnlrbv for weeks and initial viral kinetics were defined according to centralized serum hcv rna quantifications (cobas amplicor@ hcv monitor v , roche molecular systems) on baseline and days , , , , , , and . after classification into viral response categories at weeks, patients were randomized (n= ) to individualized therapy (arms al, a , b , b , c, d) or continuation of standard therapy (std arm). treatment tailoring included: in rapid viral responders (rvr)discontinuation of rbv (al) or shortening of treatment duration to weeks (a ); in slow partial responders (spr)addition of histamine (bl) or prolongation of treatment to weeks (b ); in flat partial responders (fpr)addition of histamine (c); in null responders (nur)retreatment with high-dose of peg-ifn ( pg qw) plus rbv (d). svr was defined as undetectable serum hcv rna (< iulml) at the end of weeks of untreated follow-up. results: demographic and baseline virologic parameters were similar in the standard and the individualized treatment groups. according to the initial viral decline patients were categorized as rvr ( % for genotype and % for genotype - ), spr ( % and % accordingly), fpr ( % and % accordingly), nur ( % and % accordingly) or unclassified ( %). the overall svr rates for genotype patients were % for the individualized and % for the standard treatment arm (ns), and for genotype - patients % and % respectively (ns). svr rates (by itt analysis) according to hcv genotype and within each initial viral response category and arm are given in the table. conclusion: the overall sustained virologic response rates of % in genotype and % in genotype - patients with chronic hepatitis c treated with peginterferon alfa- a ( kd) in combination with ribavirin support previously presented data. individualized treatment according to initial viral kinetics appears to be clinically feasible, but did not improve the sustained virologic response rate with the drugs and dosages usable at the time of this study. nevertheless, the possibility that in rapid viral responders discontinuation of ribavirin does not decrease the sustained virologic response rate warrants future prospective trials. supported by the european community (qlk - - ), hoffmann la-roche and maxim pharmaceuticals. % % (hepatology ; (suppl) : a). the rectally administered ifn is transferred not into blood but into regional lymphatic system and reaches to the thoracic duct via intraperitoneal lymphatics (pharmaceut. res. ; , ) . therefore, the ifn suppository appears to have different antiviral mechanism from the conventional ifn injection. in this study, we performed a combination of the ifn suppository and ifn injection. the antiviral effect and immune-related markers were examined comparing with the controls (ifn injection therapy). (patients and methods) fourteen patients with chronic hepatitis c were given an ifn suppository and ifn alpha ( - m units) injection daily for weeks. after that, only ifn injection was continued three times a week for weeks. the control group contains patients with chronic hepatitis c, who received ifn alpha ( - m units) injection daily for weeks and were followed by the ifn injection three times a week for weeks. the viral loads were . - kiulml (median kiulml) in the ifn suppository group and . - kiulml (median kiulml) in the ifn injection group. the genotype population (lb/ a,zb) was / and l , respectively. there is no significant difference in the clinical background in the two groups. serum hcv rna was tested every weeks. peripheral blood nk cell activity and cd lcd ratio were investigated before and weeks after the beginning of the therapy. the ifn suppository contains low dose ifn alpha (ball- ). (results) serum hcv rna turned negative in . % of the ifn suppository group and in . % of the ifn injection group (n.s.) after weeks (end point of ifn suppository administration). the hcv rna seronegative rates of the two groups were . % and . % (n.s.) after weeks, respectively. however, while the nk cell activity was decreased in % of the ifn injection-treated patients after weeks, only % of the ifn suppository patients had decreased nk cell activity (p= . , chi-square test). furthermore, whereas serum alt levels were significantly decreased after weeks in the ifn injection group ( . + . iull vs. . + . iull, p= . , paired t test), no change was seen in the ifn suppository group ( . iu/ + . vs. . + . , n.s.). (con-clusion) the conventional ifn therapy decreased nk cell activity and serum alt levels. however, the ifn suppository combination therapy maintained augmented nk cell activity and elevated alt levels. these findings suggest that the ifn suppository continuously activates the hosts' immunity during ifn treatment. we used the ifn suppository only for weeks; however, longer administration may lead to more frequent elimination of hcv the aim of the study was to evaluate the efficacy and tolerability of induction dose pegylated-interferon and ribavirin vs pegylatedinterferon and ribavirin as treatment strategies in relapsers to standard interferon + ribavirin in chronic hepatitis c patients. methods: patients, virological relapsers after a first treatment with standard interferon and ribavirin for at least months, were randomized to receive either pegylayed-interferon alpha- b fglkg qw plus ribavirin - mg qd during weeks then peg-interferon alpha- b pglkg qw plus ribavirin - mg qd during weeks (n= pts) or peg-interferon alpha- b . pglkg qw plus ribavirin - mg qd during weeks (n= pts). efficacy assessments consisted of serum hcv rna level by pcr and serum alt at the end of treatment and after weeks of follow up (week ) and liver fibrosis with metavir score before treatment and at week . safety evaluations included adverse events and laboratory tests. results: patients were not different for baseline characteristics in induction and non induction groups including sex (male % and % ), mean age ( . liver fibrosis metavir score decreased in % of patients in non-induced group and in % of patients in induced group (p= , ) whatever the response ( % in sustained responders and % in non responders or relapsers). conclusion ) combination therapy with pegylated-interferon is efficient in half of relapsers to standard combination therapy. ) the response is similar to the response observed in naive patients. ) weeks induction dose does not increase the virological response. ) we observed a regression of liver fibrosis in % of patients whatever treatment regimen and virological response. backgroundanemia has been shown to be an important factor in impairing hrql in cancer patients receiving chemotherapy, with changes in hb directly correlated with changes in hrql (gabrilove et al., j clin oncol ). since - % of patients with hcv develop anemia as a side effect of combination ifnlrbv therapy (rebetron@ package insert), it is important to assess the relationship between hb and hrql in this population. the objectives of this analysis were to ( ) descriptively correlate changes in hb to changes in hrql in an anemic hcv-infected population; and ( ) analyze the independent relationship of hb to hrql. methods: hrql scores and hb values were obtained from clinical trial data of anemic hcv-infected patients (hb . t- . gldl) who had been receiving ifnlrbv therapy for - weeks (afdhal et al., ddw ) . during the -week double-blind phase, patients were randomized to receive either epoetin alfa , u once weekly or placebo. hrql was measured using the short form- health survey (sf- ), an accepted and validated tool that measures domains of hrql (table l) , and the linear analog scale assessment (lasa), which measures constructs of overall quality of life, energy, and activity. patients were categorized into the following groups based on their change in hb levels between randomization and week : ( ) decrease in hb; ( ) hb increase from to < gldl; and ( ) hb increase gldl. changes in hrql (by domain of each instrument) corresponding to the aforementioned hb categories were summarized (table ) . regression analyses were conducted to evaluate the independent impact of hb change on hrql improvement. the factors included in the regression model (in addition to hb change) were: age, gender, baseline hb, baseline hrql domain, fibrosis status, rbv dose change, duration of hcv therapy, and hcv rna. results: changes in hb values were directly related to changes in hrql for all domains of the sf- and the lasa (table ) . hrql changes were seen in an hb-dependent manner; patients whose hb increased g/dl had higher improvements than patients whose hb increased between to < gldl. similarly, patients whose hb decreased from randomization to week had mean decreases in hrql for most of the domains (table ) and minimal increases for others. regression analysis substantiated that the hb change was a significant independent predictor (p=. to r. ) of hrql change in all subscales of the lasa and the sf- , with the exception of bodily pain and general health. conclusions: similar to cancer patients receiving chemotherapy, improvement in hb is a strong independent predictor of improvement in the hrql of hcv-infected patients. patients on combination ifnlrbv therapy should be monitored and considered for anemia treatment to improve hrql and potentially enhance their adherence to hcv therapy. virological response. the current trial was designed to see if better results could be achieved by retreating with higher doses of peginterferon alfa- b (peg b) + weight-based ribavirin. aim to compare the efficacy, safety and tolerability of three different doses of peg b + weight-based ribavirin among interferonlribavirin non-responders. methods: patients were randomized to yr of treatment with peg b . , . or . mcglkglwk, plus ribavirin - mglkglday. treatment assignment was stratified for sex, race, hcv genotype and histologic fibrosis. treatment was stopped at wk if pcr(+). doses were reduced by % for toxicity; growth factors were not allowed. results: patients: enrollment took place between february and november , with patients recruited from centers; data forms have been received on thus far. enrollment was stopped in the low-dose group after fda approval of higher doses of peg b. the study population is % female, % african-american, % genotype l, and % f / / . efficacy: on-treatment virological response rates were dose-related at wk but less so at wk (see table) . this was partly due to a higher rate of discontinuation after a satisfactory response at wk on the higher dose. on-treatment response rates were lower among african-americans and patients with more advanced fibrosis. sustained response data will be available for most patients by october . 'tolerability: the rate of dose reduction was % on peg b . mcglkglwk, vs. % on . . rates of discontinuation were the same for peg b . and . mcglkglwk: % vs. % overall, and % vs. % for adverse events. the frequencies of subjective adverse events were similar between the two groups. some degree of iieutropenia was observed in % on . mcglkglwk, vs. % on . ; however, only patients in the study discontinued treatment for neutropenia overall. conclusions: ) thirty to percent of interferon/ of high-dose peginterferon alfa-pb + ribavirin m s l d abstracts a ribavirin non-responders achieved initial clearance of viremia on peginterferon alfa- b + ribavirin. ) doubling the peg b dose to . mcglkglwk resulted in a higher viral clearance rate at wk but a similar rate at wk. ) the higher dose of peg b . mcglkglwk was well tolerated, with a higher rate of dose reduction but an identical rate of discontinuation. beliefs about therapy and psychosocial factors may influence the course of treatment and therefore could be important for developing comprehensive medical care plans that improve treatment adherence and optimize response to therapy. objectives: ( ) to describe baseline indices of social support, depression, and self-efficacy (i.e., perceived confidence in the ability to perform health behaviors necessary for successful treatment) of patients with hcv genotype participating in a treatment trial of combination peginterferon and ribavirin therapy. ( ) to assess the degree to which baseline psychosocial measures are interrelated. methods: the sample consisted of the first patients enrolled in the virahep-c study, a multicenter, collaborative clinical trial, designed to examine reasons for non-response to hcv therapy in african american and caucasian patients. using a touch-screen computer, patients completed the -item medical outcomes study social support survey (mos-sss); the -item centers for epidemiological studies depression scale (cesd); questions about self-efficacy, and the sf- quality of life instrument. questionnaires were completed during an -week period prior to initiation of therapy. mean scores were calculated for each of the subscales of the mos-sss (l=supported none of the time, =all the time): a) tangible support (material aid, behavioral assistance); b) affectionate (expressions of lovelaffection); c) emotional-informational (expressions of understandinglencouragement); and d) social interaction (others to have an enjoyable time with). similarly, mean scores were calculated for subscales of the selfefficacy instrument (o=no confidence, = high): a) obtaining help; b) communicating with physicians; and managing c) symptoms, d) depression, e) medications. correlation analysis was used to compare each subscale with the cesd and sf- . results: of the participants in the analysis, % were african american and % were female. on average, perceived social support and self-efficacy beliefs were high at the initiation of treatment. mean scores for the tangible, affectionate, emotional, and social interaction subscales were . (sd= . ), . (sd= . ), . (sd= . ) and . (sd= . ), respectively. for self-efficacy, the mean scores were . (sd= . ) for obtaining help; . (sd= . ) for communicating with physicians; . (sd= . ) for managing symptoms; . (sd= . ) for managing depression; and . (sd= . ) for managing medications. the distribution of social support and self-efficacy scores were similar for both racial groups and genders. depressive symptoms were common in the sample at baseline with % having a score of at least on the cesd and % having a score of at least . in general, the social support and self-efficacy subscales were unrelated to the cesd and to the subscales of the sf- . conclusion: african american and caucasian study participants rate their social support and self-efficacy beliefs high in the weeks prior to initiating combination antiviral therapy for hcv, although depressive symptoms are common. social support and self-efficacy instruments may measure different psychosocial constructs as compared with other instruments used in hcv research like the sf- and cesd. as a result, social support and selfefficacy may represent new and important predictors of adherence and sustained virologic response (svr) in hcv treatment. baseline data from virahep-c will be used to evaluate factors associated with adherence and svr to determine if racial differences exist among these measures. if so, this information can be used to develop new initiatives for educating patients and families prior to initiating hcv therapy. background and aims: interferon( fn) a- blribavirin therapy is an effective anti-viral therapy for the patients with hepatitis c virus (hcv) genotype . however, the response to this therapy is not satisfactory because only about - % of the patients become sustained responder(sr)s. further, the patients receiving ifn a- blribavirin therapy have been frequently withdrawn because of severe adverse effects. the efficacy of ifn therapy is mediated by both genomic type and viral load and to immunological response of the hosts. reportedly, some amino acids were identified to modulate host's immunological response. in order to achieve more higher sr ratio after ifn a - blribavirin therapy and to decrease the number of withdrawn patients, it seems important to improve the nutritional condition and to upregurate potential immunological response by modifying the balance of amino acid. in the present study, we investigated the dynamics of a panel of amino acids during ifna- blribavirin therapy, then analyzed the effects of nutritional condition on the clearance of hcv. materials and methods: seventy patients with chronic hcv infection were included after informed consent. six-million unit of ifna- b in combination with ribavirin ( - mglday) were given during months. during the first weeks of the therapy, ifn a - b was given daily. blood samples were obtained after overnight fasting at zweeks, weeks, and weeks of the therapy and served for the analysis of amino acids. at the same time, peripheral blood mononuclear cells (pbmc) were collected and the number of ifny-and il -producing cells were measured by facs analysis. thllth ratio was calculated as following; thll results: hcv rna was undetectable in %, %, and % of the patients at , , and week of the therapy, respectively. thllth ratio decreased gradually during the therapy. thllth ratio at the end of therapy ( week of the therapy) was significantly smaller than that at the beginning of the therapy ( . . vs . . , p=o.o ). however, there was no significant correlation of thll th level with the rate of hcv eradication. total amino acids (taas) and branched chain amino acids (bcaas) decreased gradually during the therapy. even at week of the therapy, there was a significant decrease in taa and bcaa (p= . and p<o.oool, respectively). fischer ratio (fr) also showed drastic change. it changed from . (at the beginning of the therapy) to . (at week of the therapy), indicating that the balance of amino acid rapidly altered to the similar condition to the patients with liver cirrhosis. of interest, the levels of taa and bcaa at the beginning of the therapy were significantly higher in hcv rna-negative group than in hcv rna-positive group at the end of the therapy (taa: +. vs nmol/ml; p= . , bcaa: vs nmollml; p= . ). although we could not find a significant difference, fr at the beginning of the therapy was larger in hcv rna-negative group than in hcv rna-positive group at the end of the therapy ( . . vs . . , p= . ). analysis of each amino acid showed that there were significant differences in the concentration of citrulline and ornithine, both amino acid are involved in urea cycle, between hcv rna-negative and hcv rna-positive group at the end of the therapy. conclusions: interferon a-zblribavirin therapy induces malnutrition at early stage of the therapy. successful elimination of hcv rna seemed to depend much on nutrition rather than the ratio of thl/th during the therapy, suggesting that better response in interferon a-zblribavirin therapy might be possible by improving the condition of nutrition at the beginning of the therapy. in addition, adequate nutrition support would contribute to the improvement of the prevalence of hcv infection in egypt varies between % and % and approximately % are infected with hcv genotype .to date limited data exist on the effect of antiviral therapy on genotype -infected subjects. the purpose of this study was to assess the effect of interferon (standard or pegylated) in combination with ribavirin in na'ive-to-treatment subjects with chronic hepatitis c who reside in egypt. methods: in a prospective, open-label, randomized clinical trial, egyptian subjects with chronic hepatitis c documented by liver biopsy and detectable hcv rna in serum received interferon alfa b (ifn-a b) mu tiw or pegylated ifn-a b ( mcglweek) in combination with weight-based oral ribavirin ( or mg for both groups). the study design was that if hcv rna was detectable at week , the treatment was stopped but if hcv rna was undetectable at week , treatment was extended for a total of weeks. subjects were observed for an additional weeks and hcv rna status at week determined the response to antiviral therapy. safety laboratory tests were done at regular intervals. the study received irb approval. the hcv rna was done by a pcr technique with a detectability cutoff of -copieslmb results: both randomized groups were similar at baseline without statistical significant difference, ( %) were infected with genotype , mean age was . years ? . years, were men ( %), mean bmi was . kglm , mean inflammatory ha score was / and fibrosis stage . t . . of the genotype- infected individuals, have finished therapy (week ) and had completed the week follow-up (week ). the study will be completed by october . the table shows the intention to treat rates of undetectable hcv rna in genotype- infected subjects. serious adverse events that led to discontinuation of medications were observed in subjects in the standard ifni'rbv group and in llsubjects in the peg ifnirbv, one death was observed in the latter group. expected adverse events were observed in similar rates in both groups. laboratory adverse events were observed between "h and % of subjects receiving either treatment regimen depending on the week of therapy. no growth factors were used in this population. in summary: subjects with chronic hepatitis c and genotype- infection have a similar antiviral response to standard or pegylated interferon in combination with ribavirin. the safety and tolerability of the medications is similar to what has been observed for other hcv genotypes. patients infected with hcv genotype respond effectively to therapy and should be encouraged to undergo antiviral treatment. daily for weeks, followed by times a week for weeks (week ) and followed up for weeks after cessation of therapy (week ). the expression of socs- protein in the liver specimen obtained before the treatment was investigated by immunohistochemistry for socs- . results: patients with the expression of socs- protein in the liver were defined as "socs- positive group". all other patients without staining were classified as "socs- negative group". sixteen patients were socs- negative and patients were socs- positive. we compared baseline characteristics among two groups. socs- positive group had a significant lower rate of svr to ifn therapy than socs- negative group (p= . ). socs- positive group had significantly higher hcv-rna titer than socs- negative group (p= . ). we analyzed factors with ifn svr in univariate logistic regression analysis. not only hcv genotype (p=o.oool) and hcv-rna titer (p< . ), but also the expression of socs- were found to be significant predictors of ifn svr (p = . background: interferon( fn) and ribavirin combination therapy is now a standard regimen for chronic hepatitis c infection and achieves a higher sustained virological response than interferon monotherapy worldwide. but the response rate to patient with genotype l b and high viral load is still not satisfactory. some virological factors have been shown to influence the effect of interferon monotherapy in previous studies. however little is known about those influencing the outcome of combination therapy. to examine the genetic basis of the genotype l b virus resistant to combination therapy, we analyzed full-length nucleotide and deduced amino acid sequences of hcv rna. method: among patients infected with genotype l b and high viral load, patients treated with monotherapy : (group a- nullresponders, relapsers) and patients treated with combination therapy: (group b- nullresponders, relapsers) were studied. the group a consists of naive patients and group b consists of naive patients and patients who failed to previous ifn monotherapy. the group a patients were treated with - miu of ifn, there times a week for months. the group b patients were treated with miu- omiu of ifn three times a week and ribavirin mg- mg per day for months.sera were obtained from the patients at three points: months before the treatment, just before the treatment, and after or during the treatment. complementary dna was reverse-transcribed from total rna extracted from these sera, amplified by polymerase chain reaction and directly sequenced. the mutation rates during natural course of infection and during the treatment were calculated by comparing the nucleotide sequences obtained from the samples just before the treatment and months before the treatment, and just before the treatment and after or during the treatment. the deduced amino acid sequences in different region were also analyzed in each case. result: the mutation rates of natural evolution analyzed in patients were . ~ -~nt isitelyear. the mutation rates of hcv rna from nullresponders during the treatment were almost identical with those before the treatment in both groups a and bcu ( . . vs . . , p=ns and . - . vs . . , p=ns, respectively).in contrast, those from relapsers during the treatment were higher than those before the treatment in both groups ( table. no major differences were observed in the frequency or intensity of saes and aes. conclusion: the combination of peginterferon alfa- a ( kd) (pe-gasysb) and ribavirin (copegusb) was safe and effective in patients with hcv genotype . despite the use of a dose of ribavirin ( mglday) that is lower than the recommended dose for patients infected with g ( mglday), approximately half of the patients in the study achieved an svr. because the study could not be blinded, a bias might have influenced the outcome of the study as suggested by the unequal discontinuation rate. these preliminary data do not support the hypothesis that higher svr rates can be achieved in patients with hcv g l by extending treatment duration. final data will be presented. *itt population, defined as all patients who took at least one dose of study medication and had at least one hcv rna evaluation postbaseline. **safety population, defined as all patients who took at least one dose of the study medication elusive goal, particularly in previously treated patients who failed or relapsed following prior therapy. we hypothesize that response rates in these patients who are re-treated with pegylated interferon and ribavirin will be improved compared to standard interferon preparations with or without ribavirin. the present prospective study is designed to determine the efficacy and safety of treatment with peg-intron (pegylated interferon alfa- b) and ribavirin in a group of patients who failed prior therapy with interferon with or without ribavirin. methods: aatients are uresentlv enrolled in this multi-center study. the first enrolled patie& were treated with . mg/kg o~p e g -intron sc q week, and ribavirin mg po qd, which was standard at the time. the intended duration of treatment is weeks. patients have been trcated for at least weeks and week data is available in patients. adverse events: dose reduction was required in % of pts most commonly due to leukopenia and anemia. permanent discontinuation of therapy was required in % most often due to: depression or anxiety serious adverse events: ( . % of pts) included one patient each with neutropenialmrsa sepsis, optic neuritis with monocular blindness, perirectal abscess, cellulitis and multi-organ failure, cutaneous and pulmonary sarcoidosis, pneumonia, homicidal ideation, and suicide. conclusions: ) overall etr was % and svr was %. ) svr was significant in genotype non- patients and patients who failed or ;elapsed after previous monotherapy ) % a multi-centre, randomised controlled study comparing the combination of interferon and ribavirin with no treatment was undertaken. patients were eligible if they had biopsy proven mild hcv (defined as necro inflammatory scores less than and fibrosis scores less than using the ishak scoring system. interferon was administered at a dose of mu thrice weekly for weeks regardless of viral genotype. ribavirin was administered according to the patient's body weight ( kg mg/day, > kg mgl day in two divided doses). randomisation was stratified according to viral genotype ( and non- ). the primary end point was the virological outcome of treatment with sustained response defined as an undetectable hcv rna pcr months post cessation of therapy. in addition there were a number of secondary aims: . viral kinetics. serum was collected at baseline, days , , and week for quantitative rt pcr to determine hcv viral load. the ability of early phase kinetics and the presence or absence of a log drop at week to predict eventual outcome is assessed in the context of mild disease. . health economics. the collection of resource use data in hcv infected patients who have mild, moderate and cirrhotic disease was performed as an integral part of this study. this data has been incorporated into a markov chain based model to assess likely future costs of the disease and their possible avoidance by treating mild cases. response rates from this trial will form the basis of the model. . quality of life assessments. sf and euroquol data were collected at baseline, weeks and during treatment and at post treatment weeks and in order to compare quality of life between treated patients and controls before during and after therapy. results. patients received treatment and were matched with controls (no treatment). sustained viral response rates will be available at the end of july when the follow up period of the trial is complete and will be included in the presented results. end of treatment results are shown in table . % of patients infected with genotype and % of patients infected with genotype non- achieved end of treatment responses. sustained viral response rates to date are shown in table . % of patients infected with genotype and % of patients infected with genotype non- have achieved sustained viral responses so far. % of patients in the treatment group were unable to complete at least months of therapy due to side effects of medications. there were hospitalisations in the treatment group, of which were related to adverse events. patients with mild hcv have lower response rates to those with more severe histological change on liver biopsy. side effects are common and frequently result in treatment discontinuation, lowering response rates. the decision to treat patients with mild histological change must be weighed against the side effects. deferring treatment until later in the disease process does not prejudice response to therapy and may increase likelihood of success. the hcv ns b polymerase is essential for hcv viral replication and infectivity as demonstrated in a chimpanzee model. the enzyme adopts a unique molecular structure that resembles a "thumb-palm-finger" which has some features different from other known dna and rna polymerases, highlighting the attractiveness for this enzyme as a target of antiviral therapy. from an in-house high throughput screening campaign and the subsequent lead optimisation, we have identified a novel chemical series of substituted thiophene- -carboxylic acids that have good potency against hcv polymerase in vitro. x-ray crystallography studies revealed that these compounds bind to an allosteric site that is - angstrom away from the active site. further studies on selected members of the series confirmed the ability of these compounds to inhibit the sub-genomic replication of hcv in huh- cells. moreover, a representative compound was also found to have good in vitro safety index and favourable in vitro and in vivo metabolic and pharmacokinetic properties. in an open and prospective trial we investigated, if a pre-treatment with citalopram as an ssri can reduce the frequency of ifn-associated depression in hepatitis-c-infected psychiatric risk patients during methadone substitution. patients with a chronic hepatitis c were treated with pegylated interferonalpha b and ribavirin according to body weight. patients without any psychiatric history (group a) were compared to patients during methadone substitution. the methadone substituted patients were separated into two groups: the first group (group b, n = l l ) were only treated with ifn-alpha and ribavirin and the second group (group c, n= ) received a two week pre-treatment with citalopram ( mglday) before combination treatment with ifn-alpa and ribavirin was started. antidepressant treatment was continued over the study period of four months. the hamilton depression rating scale (hamd, -item) was used and major depression defined as > points. patients were followed over the first treatment months. group differences were calculated with anova for parametric and chi -test for non-parametric scales. results: hamd scores at baseline were significantly higher in the psychiatric groups as compared to the controls (p=o.olo dallas, t x background: peg plus rbv is the mainstay of chronic hepatitis c treatment. however, an upper limit in terms of safety and efficacy for dosing with peg has not been evaluated. methods: we studied a group of nake patients using either conventional weight-based dosing of peg; ( . pglkg) or double the dose ( . pglkg) plus rbv + mg/kg/day for weeks. genotype patients were randomized :l and to receive medication accordingly in unblinded fashion, with intent to enroll a total of , nayve patients n, an additional previous nr or r to any type of interferon i rbv in a non randomized arm, using only the . pglkg peg dose. values for hcv rna at week were compared to those obtained at baseline. results: to date, patients n, nr, r have enrolled in the study. patients n, nr, r have reached week . hcv rna results at week are shown in the table below. treatment was well tolerated in most patients. dose reductions were required in % of n . pglkg peg and % of n . pglkg peg patients. side effects were equivalent between the two groups as shown in the table below. serious adverse events (sae's) were less than % and equally observed in both arms of the n patients. none were directly attributed to study drug. there were patients in the wk analysis that discontinued therapy. the reasons these patients were discontinued after reaching wk were side effects ( %), +hcv rna ( %). it is interesting to note that % of the patients that were discontinued had log drop or negative hcv-rna at week and a positive hcv rna was not a reason for their discontinuation. conclusion: .op.glkg peg dosing does not appear to improve wk viral response, but we await wk results and sustained viral response rates. increased side effects as a result of doubling the interferon dose were not observed. more data is needed to verify the long-term efficacy and safety of this dosing regimen for patients with chronic hepatitis c . this study was supported by a grant from integrated therapeutics group a subsidiary of schering plough. background and aim: one of the major adverse effects of the combination therapy for chronic hepatitis c is ribavirin-induced hemolyhc anemia. however, little is known about the mechanism of this anemia. oxidative stress has been suggested as potentially important pathological mechanism in hepatitis c. this burden may cause peroxidation of erythrocyte membrane phospholipid in conspiracy with the accumulation of ribavirin triphosphate in the erythrocyte, which potentially attenuates the mobility of erythrocyte membrane. the aim of this study was to examine the change of fatty acid composition in erythrocyte membrane and the effects of vitamin e and vitamin c on fatty acid composition in combination therapy. methods: thirty-nine patients with chronic hepatitis c were enrolled in this prospective study. they were randomized to receive daily oral vitamin ( mg of vitamin e plus mg of vitamin c) (vitamin group) or none (control group), in addition to injections of million units of interferon-a- b daily for two weeks, followed by thrice-weekly for additional weeks, plus daily oral ribavirin ( or mg) for weeks. blood samples were obtained at , , , , and weeks after initiation of therapy. phospholipid was separated by one-dimensional thin-layer chromatography after extraction of total lipid from the erythrocyte ghosts. following transmethylation, fatty acid methyl esters were quantified by gas chromatograph. a-tocophenol concentrations in erythrocyte were determined by high performance liquid chromatography. plasma thiobarbituric acid reactive substances (tbars) were measured by spectrofluorometer. results seven patients were obliged to suspend or cease receiving therapy because of adverse effects including anemia by weeks after initiation of therapy. twenty-one patients have completed the assigned therapy up to now. among the kinds of fatty acid analyzed, the mean content of n- polyunsaturated fatty acid (pufa) significantly decreased at ( . . mol% vs. in a cross-sectional study we investigated mxa expression in patients with chronic hcv infection(n = ) and in patients with chronic hcv infection receiving ifn-alpha therapy (n = ) as well as in healthy controls (n = ). in a prospective study with chronically infected patients (hcv genotype ) known to be ifn non-responders, we followed mxa gene expression during combination therapy with pegylated ifn-alpha b and ribavirin. results: patients with chronic hcv infection showed higher mxa gene expression levels than healthy controls, indicating that hepatitis c virus induces ifn production. however there was no correlation between mxa gene expression and clinical parameters (viral load, alt, liver histology). patients with chronic hcv infection receiving ifn-alpha had significantly higher mxa levels than patients without treatment or healthy controls. further we addressed the question whether mxa expression in pbmcs during therapy in previous non-responders could be a predictive marker of therapy outcome. mxa expression was clearly induced in all but one patient compared to pretreatment values (median: . fold). importantly, the level and kinetics of mxa expression did not correlate with the response to antiviral therapy. surprisingly, one patient showed an unusually low pre-treatment level of mxa expression and a total lack of mxa induction during ifn therapy, which was associated with complete non-response to therapy. in a neutralization assay, we could detect neutralizing antibodies to ifn-alpha b in the serum of this patient whereas no neutralizing antibodies were found in all others patients. hepatitis c virus (hcv) infection is a common cause of transfusion acquired hepatitis and is today a major health problem throughout the world. the present study reports the prevalence of hepatitis c virus (hcv) infection in general population and in various high-risk groups from the city of hyderabad in south india. a total of out of ( . %) people (both general and risk groups) tested positive for hcv rna by rt-pcr, while anti-hcv antibody positivity, as determined by third generation eia, was found to be . % ( / ). this suggests that a number of cases go unreported, as screening of blood and blood products is done primarily by elisa. among chronic renal failure (crf) patients with history of either renal transplant or hemodialysis, % were infected with hcv alone, . % hbv alone while . % were found to be co-infected with bothe hcv and hbv. our findings implicate these viruses as the major cause of post transplant hepatitis in indian patients with crf and indicate the necessity for immediate implementation of stringent screening procedures for these viral infections. additionally we report here that tattooing and slashing (a cultural practice among one sect of muslims) increase the mode of transmission of hcv infection. in addition, we also report a high incidence of hcv infection ( background in japan, long-term treatment with glycyrrhizin, given as snmc, is used to reduce alt and the risk of hepatocel-glycyrrhizin given as stronger neo-lular carcinoma in patients with chronic hepatitis c. phase / studies confirmed the alt lowering effect of glycyrrhizin therapy in western patients with chronic hepatitis c. the treatment duration in these studies was limited to weeks. alt response was lost during follow-up. aim ) to evaluate which dose frequency is required beyond week to maintain the initial alt response. ) to evaluate the effect of snmc treatment on liver histology. methods: hcv-rna positive patients with alt > x uln, fibrosis stage or necro-inflammation score (ishak's score) who were not eligible for interferon therapy (prior non response, absolute contraindications) could enter this multi-center, randomized, open phase i clinical trial. all patients were treated weeks with six infusions weekly of ml snmc (minophagen pharmaceutical co. ltd., japan) containing mg glycyrrhizin. patients with an alt response at week (defined by a decrease of more than percent of the baseline value or alt . uln) were randomized to continue treatment in three dose frequency groups for a total of weeks. snmc was given times weekly (group l), objectives: it is important to maintain reduced serum alanine aminotransferase (alt) levels in cases with chronic hepatitis c (ch-c) that do not respond to interferon (ifn) and in those with no indication of ifn therapy. we reported previously that dietary restriction of iron intake reduces serum alt levels in such patients. we evaluated ch-c patients treated with iron-restricted diet for two or more consecutive years, mainly focusing on the balance of energy intake, physical examination, and changes in hematological indices of nutrition. methods: twenty-two patients with ch-c (males, ; females, ; mean age, year-old) that consulted our outpatient department were enrolled in this study. the inclusion criteria were as follows: ) elevation of alt levels above the upper normal limit for months or more; ) positive tests for hcv-antibody and hcv-rna; ) absence of other causes of ch (alcoholic liver disease, drug-induced liver injury, hemochromatosis) and negativity for hepatitis b surface antigen and for serum anti-nuclear and anti-mitochondria autoantibodies. twenty cases had received ifn therapy for more than months before the beginning of the study; none of them responded to ifn therapy. dietary prescriptions included iron intake mglday or less, energy intake kcallkglday, protein intake . - . glkglday, and a fat energy fraction of %. nutritional balance was evaluated based on meal records, and instructions was given when necessary. results: the average energy intake before dietary prescription was kcal( . kcallkg)lday, and it was significantly reduced to kcal( . kca lkg)lday (p < om), and then maintained stable at kcallkglday. the average protein intake before dietary prescription was . g ( . glkg)lday and it was reduced to . - . glkglday after the prescription. the average fat intake of . g ( . glkg)lday and the average fat energy fraction of % before the dietary prescription were significantly decreased to . g ( . glkg)lday; p < . and % (p < . ), respectively, after dietary instructions. the fat energy fraction was maintained at a level of % or less. carbohydrate intake did not change remarkably during the observation period, although the carbohydrate energy fraction significantly (p < . ) increased. the average iron intake decreased significantly (p < . ) from . (before) to . , . , . , . , and . mglday , , , and months after die* prescription, respectively. body mass index (bh i) before diet prescription was . on average; bmi had no significant change throughout the course. the body fat percentage was . % on average before the diet instructions, and it significantly decreased after the diet. the average values of aspartate aminotransferase and alt before diet prescription were iull and lull, respectively, and they were significantly reduced to iull and iull, respectively, after months (p < . ). serum iron levels significantly decreased after (p < . ) and (p < . ) months, while unsaturated iron binding capacity tended to increase. the average serum ferritin levels were , , , , nglml before and , , , and months after diet, respectively; there was a significant reduction (p < . ) in the values measured before and after the diet instructions. the average levels of hemoglobin, albumin and cholinesterase did not change significantly during the follow-up period. conclusions: restriction of iron intake is safe and well tolerated for a long period. the results of our present study suggest that decreased dietary intake of iron may constitute an important adjuvant therapy in patients with ch-c. chru, nice, france; c henquell, chru, clermont ferrand, france; c dizrcha, s ughetto, p dechelotte, hotel-dieu, clemont ferrand, france; h lafeuille, chru, clermont fewand, france; g bommelaer, hotel-dieu, clemont fewand, france peginterferon (pegifn) background: hcv co-infection is common among patients with hiv disease. it has been documented that hiv co-infection accelerates the course of liver disease in patients with hcv, and that liver failure is higher in co-infected patients. at this moment, there is no effective treatment for hcv non-responders to interferon therapy. mono-therapy and interferon-ribavirin combination is only effective in - % and - % interferon resistant patients respectively. treatment strategies to slow the progression to cirrhosis and to prevent liver failure in this population are needed. objective: this is a report of a study that examines the efficacy of peg ifn alfa -a (pegasys) vs pegasyslrbv mg in co-infected hcvlhiv patients that have not responded to a previous - months course ifn-alfa. the study also examines the histological benefit of treatment in this population. patients and methods: patients were randomized :l to receive either pegasys mcg weekly x weeks (group ) or pegasys mcg weekly plus mg rbv for weeks (group ). patients that have hcv non-detectable or g decrease from baseline at week (groupl), were added rbv mg. all similar responders (group ) continue treatment for a total of weeks. baseline demographics were similar between both groups. more than % of patients were nonresponders to ifn monotherapy.most patients in both groups ( %) were genotype l. the mean hiv baseline log was . (sd. ) group , vs . (sd. ) group and most patients had baseline cd levels> cells, and were in stable antiretroviral therapy. the majority of patients ( %) are non cirrhotic, with mean grading group . (sd . ), group (sd . ), and mean staging, group . (sd . ), and group . (sd . conclusions: this study is completed and pending some results, that will be available for presentation. sustained virological response(svr) (intention to treat), will be of the order of - %. ( group results are pending). in this study, patients were discontinued because adverse events and were lost to follow up, before week th.svr in patients that completed at least weeks of therapy will be of the order of - %.a significant number of end of treatment responders are relapsing at week th. histology analysis show improvement in both groups of the mean grading and staging after treatment. in responders and relapsers the fpr becomes static or regressive.these results show that pegasys lrbv therapy is effective in this population.the study also suggests that longer duration of therapy ,and higher doses of rbv should be studied in coinfected nonresponders. * -pending results, will be available for presentation. disclosures: josi. rodriguez-orengo -no relationships to disclose maribel rodriguez-torres -roche laboratories: investigator; other: grant to perform study. adverse events by week of therapy were grade to in severity and were therapy related. see table . sixteen patients who continued therapy to week , three dropped out due to adverse events ( anemia, hyperbilirubinemia and related death due to self-overdose). this patient had a history of hypothyroidism and mild untreated depression. at weeks of therapy, patient discontinued treatment due to suicidal thoughts. there was no difference between the ethnic groups regarding the drop out rate due to adverse events. hivfhcv coinfected population had a poor tolerance to pegylated interferon and ribaiirin. this was markedly increased in the first weeks of therapy. the use of high dose pegylated interferon and ribavirin led to a significant drop out rate in comparison to the low dose pegylated interferon. background during liver injury, poorly characterized factors activate quiescent hepatic stellate cells (hsc) to become proliferative, matrix-synthesizing myofibroblasts. activated hsc are the major source of liver collagen and thus, play a key role in the fibrotic response to liver injury.the sns appears to promote fibrosis in injured livers because hepatic fibrosis is increased in the spontaneously hypertensive rat, which has an overactive sns. conversely, prazosin, an adrenoceptor antagonist, inhibits fibrosis in toxin-damaged rat livers. hsc express several neuronal proteins, including glial fibrillary acidic protein (gfap). they also contain synaptic vesicles and receive autonomic fibers. therefore, our hypothesis is that hsc are hepatic neuroglial cells that produce and respond to neurotransmitters in order to become activated during liver injury. methods: hsc were isolated from normal mice and dbh-lmice that cannot produce norepinephrine (ne) due to targeted disruption of the dopamine p-hydroxylase (dbh) gene. lysates of culture-activated hsc were analysed by rt-pcr, immunoblot and hplc to determine if they express adrenoceptors, catecholamine biosynthetic enzymes andlor produce ne. the effect of adrenoceptor antagonists and ne on hsc growth in vitro was also assessed. then in vivo activation of hsc by hepatotoxic diets was evaluated in control and dbh-lmice by comparing numbers of a-smooth muscle actin (asma)+ cells with immunohistochemistry and the induction of tgfp- and collagen a- gene expression by ribonuclease protection analysis of whole liver rna. results: hsc express a-and p-adrenoceptors, tyrosine hydroxylase and dbh. hsc from control, but not dbh-i-, mice release ne. endogenous ne is an autocrine growth factor for hsc because a-and p-adrenoceptor antagonists inhibit proliferation of hsc cultured from control mice. moreover, hsc from dbh-lmice, which cannot make ne, grow poorly in culture and are rescued by addition of ne. exogenous ne also promotes hsc proliferation. inhibitor studies demonstrate that the latter effect is mediated via g-protein coupled adrenoceptors that activate mitogen activated kinases and phosphatidylinositol kinase pathways. hsc activation in response to diet-induced liver injury is inhibited in dbh-imice, as evidenced by reduced hepatic accumulation of asma (+) hsc and inhibited hepatic induction of background & aims: hepatic cirrhosis is six times more prevalent in obese individuals than in the general population, and obesity is one of the risk factors for liver fibrosis in which plasma adiponectin levels are decreased. adiponectin is an adipocytokine, which we previously identified by screening adipose-specific genes in the human cdna project. hepatic stellate cells (hscs) play central roles in liver fibrosis. when they are activated, they undergo transformation to myofibroblast-like cells, then proliferate, migrate, produce transforming growth factor-pl (tgf-pl), and various extracellular matrix proteins, and express a-smooth muscle actin (a-sma). we previously reported that adiponectin suppresses not only the proliferation and migration of hscs, but also the tgf-pl-induced fibrogenic gene expression in hscs. adiponectin could have biological significances in liver fibrosis. in this study, in order to clarify the effect of adiponectin on liver fibrosis in vivo, we tested the role of adiponectin on liver fibrosis using adiponectin-knockout (ko) mice and adenovirus mediated adiponectin expression system. methods: ( ) to investigate the anti-fibrogenic effects of physiological concentrations of adiponectin, male wild type (wt) mice and ko mice were used. mice were each injected with a dose of carbon-tetrachloride (ccl ) ( pllkglbw) intraperitoneally twice a week for weeks to induce liver fibrosis. ( ) to investigate the anti-fibrogenic effects of excessive concentrations of adiponectin, male wt mice were used. mice were injected cc ( pl/kg/bw) intraperitoneally twice a week for weeks. mice were divided into groups. control, received an injection of corn oil only; gr. , mice treated with cc for weeks; gr. , mice treated with cc for weeks after infusion of adenovirus producing adiponectin (adadn); gr. , mice treated with cc for weeks after infusion of adenovirus producing p-galactosidase (adlacz); gr. , mice treated with cc for weeks with adadn infusion at week; gr. , mice treated with cclb for weeks with adlacz infusion at week. results: ( ) ko mice showed extensive liver fibrosis with an enhanced expression of tgf-p and connective tissue growth factor (ctgf) compared to wild type (wt) mice (p< . ). the hydroxyproline content and the numbers of a-sma positive cells in mice liver significantly increased in ko mice. ( ) the fibrosis areas were significantly decreased in gr. and gr. compared to those in gr. and gr. , respectively. the hydroxyproline content in mice liver significantly decreased in gr. and gr. compared to that in gr. and gr. , respectively. moreover, in gr. , the hydroxyproline content was significantly decreased compared to that in -weeks of c c treatment even though ccl, was given for an additional -weeks (total weeks). conclusions: the findings indicate that adiponectin attenuates liver fibrosis and could be a novel approach in its prevention. disclosures: (ttg) is observed in mature scars and might promote wound repair by protecting the neomatrix from degradation by matrix metalloproteinases (mmps).however, such ecm crosslinking has the potential to hinder the matrix remodelling required for resolution of liver fibrosis. we have explored this hypothesis by examining expression of ttg and its crosslink product epsilon-(gamma-glutamyl) lysine in livers of: a) rats administered cc for weeks ( wk c c cohort)after which liver fibrosis resolves spontaneously after days; b) rats administered cc for weeks ( wk cc cohort) which develop micronodular cirrhosis; c) wk ccl treated rats allowed to recover for days after last cc dose ( wk+ d cohort) which show partial resolution of fibrosis but with persistence of a macronodular cirrhosis. although ttg was identified by immunohistochemistry within and around fibrotic bands in wk ccld cohort, no crosslinks were detectable. however, both ttg and crosslinks were detected in and around mature fibrotic bands in the wk cc cohort and in persisting fibrotic bands in the wk+ d cohort. western blotting of liver homogenates from these two cohorts using antibody against the crosslink revealed a major product of kd which was degradable to lower molecular weight products following incubation of homogenates with bacterial collagenase but was refractory to mmp- . to evaluate if ecm crosslinking in livers correlated with its resistance to mmps, micron cryostat sections of livers from the three cohorts were incubated with purified active forms of mmp- or mmp- for hr at c and any residual ecm was stained with sirius red. ecm of wk cc cohort was effectively degraded by these mmps but that of wk c c and wk+ d cohorts was only minimally degraded. hsc freshly isolated from normal rat or human liver showed no ttg expression whilst hsc activated for - days on plastic substrate expressed ttg protein (by western blotting) and mrna (by rt-pcr). there was ttg in cell lysates and in conditioned media of activated hsc. pure rat tail type i collagen incubated with conditioned media of activated hsc incorporated crosslink antigen, confirming that hsc secreted functional enzyme. however, no crosslink was found in type i collagen incubated with media from hsc which had ttg gene silenced by cell transfection with small inhibitory rna. cultured hsc which had ttg gene silenced had enhanced apoptosis (by acridine orange staining) following serum deprivation in culture. this suggests ttg or ttg activity promotes survival of these cells. we conclude that in persistent, incompletely resolving liver fibrosis there is evidence of ttg mediated crosslinking of the liver ecm and resistance to exogenous mmps. both features are lacking in ecm of fully resolving fibrosis. ecm crosslinking by ttg might limit resolution of cirrhosis. activated hsc are a potential source of ttg following liver injury and, as this protein supports their survival, it might contribute to their persistence in cirrhotic liver. we recently defined multifunctional biochemical properties of the long and frizzled variants and hypothesized that they may be inherent in the -aa-long-specific and the -aa-fz-specific modules, respectively. we thus transfected pcdnas.l-v -his vectors containing variant-specific sequencer in mhat fls hepatoma cells. this cell line stably expresses a truncated hnf protein turning off endogenous expression of liver-specific genes, such as albumin or c . consistently, mhat fls hepatoma cells transfected with an empty vector showed no endogenous c expression. by immunohistochemistry, using variant-specific and tag-specific antibodies and after analysis by confocal microscopy, long was localized in large supranuclear vacuolae suggesting protein storage/maturation in golgi structures or in beaded perinuclear vacuolae suggesting rer cysternae. in contrast, fz was strongly detected in close proximity to the plasma membrane of single cells. clusters of fz-transfected cells showed a strong and dense signal at sites of cell-cell contact, outlining single cells. these findings were confirmed by transfection of prep- vectors containing full-length long or fz forms of human c and confocal microscopy analysis after immunohistochemistry using an antibody directed against an epitope common to all c forms. immunoblot analysis of conditioned media showed that the fulllength long form was secreted into the medium but not fz. the latter was detected as a heavily glycosylated protein (> kd) in the cell layers, predominantly in the triton-x- insoluble pellet after sonication and % sds solubilization, suggesting binding to extracellular matrix proteins. finally, glycosydase analysis of fz and long n-terminal modules showed an important increase in mobility after pngase f plus sialidase a digestion. these data show that, in addition to the previously described plasma (long) and tissue (short) forms of cl , the fz form constitutes the pericellular matrix form, suggesting that the specific modules of c regulate tissue targetting through protein-protein interactions. backgr und:during liver fibrosis, hepatic stellate cells (hsc) acquire an activated phenotype, proliferate and produce an excess of collagens. mycophenolic acid (mpa) is a known immunosuppressive drug. which inhibits the proliferation of b-and t-lymphocytes by inosine mono phosphate dehydrogenase (impdh) inhibition, causing an intracellular guanosine depletion. in addition, mpa has shown to inhibit growth of mesangium cells in the kidney and of skin-and tenon fibroblasts. therefore, we hypothesize that the proliferation of hsc may also be influenced by mpa. in this study we explored whether mpa is able to inhibit the proliferation of primary isolated rat hsc in vitro. furthermore, we studied the in vitro effects, mechanism of cellular uptake, and in vivo pharmacokinetics of mpa coupled to mannose- -phosphate modified human serum albumin (m p-hsa). m p-hsa is a newly developed, hsc-specific drug carrier, homing towards the upregulated m pligf-i receptor on activated hsc. in this way we hope to achieve cell-specific delivery of mpa to the hsc avoiding undesired effects of mpa on the immune system. meth-odslresults: in primary cultures of hsc a dose dependent reduction in the number of brdu-positive nuclei was observed after h incubation with , and nm mpa, as assessed immunohistochemically. coupling of mpa to m p-hsa via a biodegradable ester linker resulted in a conjugate with a maximum drug: carrier ratio of . :l. analysis of the synthesized constructs was performed by hplc, fplc and ms. this conjugate was able to inhibit t -fibroblast growth, as detemined by brdu-incorporation (elisa) in a dose dependent manner, reducing proliferation to . . %, . t . % and . . % of control at , and uglml of conjugate, respectively. when cells were co-incubated with an excess of m p-hsa, a competitor for receptor mediated uptake of the conjugate, the anti-proliferative effect was reduced by yo. the organ distribution of the conjugate, labeled, was evaluated by iv injection of a tracer dose in rats weeks after bile duct ligation (bdl- ). . t- . % of the injected dose accumulated in the liver after min of injection. in contrast, spleen and thymic gland accumulated . f . % of the injected dose. intra-hepatic distribution was assessed in bdl- rats by immuno-histochemical double staining for hsa and specific markers for kupffer cells (ed- ), hsc (desminelgfap) or endothelial cells (his ). m p-hsa-mpa showed a non-parenchymal distribution and co-localization with hsc and kupffer cells. conclusions: mpa is able to inhibit the proliferation of primary isolated rat hsc. this suggests that stellate cells are dependent on intracellular impdh activity to proliferate. coupling of mpa to mcip-hsa, a stellate cell specific drug carrier, resulted in a pharmacologically active construct, able to inhibit fibroblast proliferation in vitro after specific uptake via the m p/igf-ii receptor. the major part of the injected conjugate accumulates in the hsc and kupffer cells of the liver, and avoiding uptake in the major resident organs for band t-lymphocytes. future studies will assess the advantage of this first hsc-selective compound in animals with liver fibrosis. background: platelet-derived growth factor (pdgf) is the most potent stimulator of migration and proliferation of mesenchymal cells. the expression of pdgf-p-receptor is increased during liver fibrosis. our aim was to investigate the effect of p -integrin subunit blockade using the specific non-peptidic inhibitor emd on migration and proliferation of hepatic stellate cells (hsc) and human foreskin fibroblast (hff). materials and methods: cell migration of human hsc and hff was assessed using a scratch assay. scratches of - pm width were made in confluent cell monolayers of cells following h starvation in serum-free medium. after wounding. cells were stimulated with pdgf-bb ( nglml) with or without emd (merck, darmstadt, germany) at increasing concentrations ( - m - - m). cell proliferation was measured as dna synthesis by brdu-incorporation. mitogen-activated protein kinase (erk , p , sapkljnk and akt) phosphorylation was evaluated by phospho-mapk-specific western blotting of cell lysates after min of stimulation. results: stimulation of human hsc cells with pdgf-bb at nglml in the absence of other growth factors resulted in pronounced stimulation of cell migration. pdgf-stimulated migration of human hsc was inhibited dose-dependently between - and - m by emd , with complete abrogation of migration at - m. surprisingly, human skin fibroblast migration was not affected by b -blockage. there was no effect of p integrin inhibition on cell proliferation as measured by brdu-incorporation, neither in human hsc-nor in hff cells. pre-incubation of hsc cells with the p integrin inhibitor at - m did not affect the activation of p mapk, p l mapk or sapkljnk. conclusions: . pdgf-bbinduced migration is strongly b integrin dependent in human hsc, but not in human skin fibroblasts. . in contrast to cell migration, hsc and hff proliferation is p -integrin-independent. . p , p l , sapkljnk and akt mitogen-activated protein kinase signalling pathways are not modified by p -integrin inhibition. . p -integrin antagonist may be an adjuvant approach to treat hepatic fibrosis. epithelial to mesenchymal transition (emt) is defined as a process, in which epithelial cells loose their epithelial characteristics and acquire typical characteristics of fibroblasts. epithelial cells are tightly attached to their neighboring cells via cell adhesion molecules and they adhere with their basal side to their underlying basement membrane matrices, whereas the apical side faces a lumen. in contrast to immobile epithelium, mesenchymal fibroblasts are specifically designed to invade extracellular matrix (ecm). this is reflected by their prominent mesenchymal cytoskeleton and by their lack of a typical polarity. in the adult organism, emt occurs in epithelia in response to injury, potentially as a means to replenish fibroblasts, which are required for repair of injury. in organ fibrosis however, enhanced conversion of epithelium into fibroblasts is considered to contribute to progression of disease, as parenchymal epithelial cells acquire phenotypic and functional properties of activated fibroblasts. recent studies provided increasing evidence that parenchymal epithelium can potentially contribute to activated fibroblasts by emt, as in mouse models of kidney fibrosis % of activated fibroblasts were found to be of tubular epithelium origin. in liver fibrosis, stellate cells are considered the principal source of activated fibroblasts, whereas the role of hepatocytes is considered minor, even though they constitute for more than % of the liver mass. here we provide evidence that the pro-fibrotic growth factors tgf-beta and egf induce expression of fibroblast-markers fibroblast specific protein- (fspl), alpha-smooth muscle actin (alpha-sma) and type i collagen in primary mouse hepatocytes in vitro. furthermore, tgf-beta and egf induce acquisition of fibroblast characteristics, migratory capacity and release of mmp- , suggesting emt of hepatocytes in vitro. additionally, progression of liver fibrosis in a mouse model of tetracarbon chloride-induced liver disease is associated with appearance of fspl positive hepatocytes, indicating emt, which suggests a role of emt in liver fibrosis. in conclusion, our results for the first time provide evidence for an active role of hepatocytes in liver fibrosis by undergoing emt. human studies -serum mcp- levels were significantly elevated in both cfld ( t pglml; p<o.oool) and ba ( , pglml; p<o.oool) vs controls ( pglml). in celd subjects serum mcp- was negatively correlated with the stage of fibrosis (r= conclusion: these results provide strong evidence for a role for mcp- in early fibrogenic events in cholestatic liver injury, ie., ductular proliferation and procollagen q(i) mrna expression, and suggest that serum mcp- may be a very good marker of the onset of cholestatic liver disease. this is the first study to clearly demonstrate elevated excretion of mcp- into bile in obstructive cholestasis, implying a potential role for mcp- in hsc and inflammatory cell recruitment to the biliary tree in cholestatic liver injury. [background and aim] angiotensin i (ang ) is considered to play an important role in hepatic fibrogenesis. however, the molecular mechanism of renin-angiotensin system in hepatic fibrogenesis has not been clarified. we previously reported that ang i up-regulated mrna expression of pro a (i) collagen and tgf-p in isolated rat hepatic stellate cells and an angiotensin converting enzyme inhibitor, lisinopril, reduced carbontetrachroride-induced rat hepatic fibrosis. ang i type i receptor blocker (arb) have shown a good clinical response in patients with hypertension, and a promising preventive effect has been described in rat hepatic fibrosis. recently, the rholrho-kinase has been demonstrated to be involved in the signal transduction pathway of the ang i type i receptor signaling downstream. thus,the aim of this study was to evaluate the role of rholrho-kinase pathway in hepatic fibrogenesis in rat. to that effect, a rat hepatic fibrosis model was produced by chronic administration with cholinedeficient, l-amino acid-defined (cdaa) diet and the effect of an arb and a rho-kinase inhibitor (y ) in this model was investigated. methods: wistar rats (male, weeks-old) were continuously fed the cdaa diet or the control choline supplemented, l-amino-defined (csaa) diet. the rats were treated with mglkg candesartan cilexetil, an arb (a kind gift by takeda chemical induustries, ltd., osaka, japan), or mglkg y , a rho-kinase inhibitor (a generous gift by mitsubishi welpharma co., tokyo, japan), once daily through stomach tube. twelve weeks after the start of administration, the liver was excised and subjected to histological examination for fatty change and fibrosis by hematoxylin and eosin staining. serum alanine aminotransferase (alt) values and hyaluronic acid (ha) levels were also measured. since cdaa diet causes hepatic steatosis and fibrosis via production of free radicals, we also studied the oxidative membrane damage by immunostaining of -hydroxynoneal (hne) adduct. results: histologic examinations showed severe steatosis and fibrosis in the liver of cdaa-fed rats and no significant change in csaa-fed rats. the liver weight of cdaa-fed rats was significantly increased than that of csaa-fed rats. both candesartan cilexetil and y remarkably reduced not only fibrosis, but also severe steatosis and the liver weight of the treated rats was significantly reduced in both treated groups. serum ha levels but not alt values significantly elevated in cdaa-fed rats compared to csaa diet fed group. the increased levels of serum ha were significantly reduced by the treatment with candesartan cilexetil or y . the number of hne-positive hepatocytes increased by cdaa diet and this increase was attenuated in the candesartan cilexetil-or y -treated groups. conclusion: these results suggests that an arb, candesartan cilexetil, and a rho-kinase inhibitor, y , show the same inhibitory effect on hepatic steatosis and fibrosis induced by chronic cdaa diet, and this free radicalinduced hepatic injury is a good therapeutic target of arbs or rho-kinase inhibitors. the rholrho-kinase may be a key enzyme system in the ang i signaling involved in the hepatic fibrosis. in liver cirrhosis, malnutrion and portal congestive enteropathy facilitate bacterial translocation from the intestine to mesenteric lymph nodes and the development of endotoxemia and spontaneous bacterial peritonitis in ascitic patients. igf-i is an anabolic hormone synthesized in the liver, whose levels are reduced in hepatic cirrhosis. igf-i possesses hepatoprotective properties and displays trophic effects on the intestine. here we investigated whether igf-i therapy could in-fluence portal pressure and bacterial translocation in experimental cirrhosis. methods: liver cirrhosis was induced in sprague-dawley rats (n= ) by oral administration of carbon tetrachloride during weeks. after this time, rats were randomized in two groups to receive subcutaneous injection of recombinant human igf-i ( microgllo g body weight in two separated doses per day) (ci-igf, n= ) or vehicle (ci, n= ), for days. eight healthy rats, receiving vehicle were studied in parallel. at the end of treatment period, animals underwent laparotomy to measure portal pressure and to collect blood and tissue samples. endotoxin quantification in blood samples was carried out with a colorimetric limulus amebocyte lysate test. liver and ileum histopathological changes were assessed in tissue sections stained with masson's trichrome, using a numerical scoring system. bacterial translocation was evaluated by culturing blood samples and mesenteric lymph nodes in appropriated culture media. results: treatment with igf-i significantly improved biochemical markers of liver damage, being the alt values significantly lower in the ci-igf group than in ci rats (p< . ). in addition we found that igf-i administration to cirrhotic rats reduced both the hepatic histopathological score ( the rate of progression to cirrhosis varies among individuals infected with hepatitis c virus (hcv) cholesteryl ester transfer protein (cetp) is a plasma glycoprotein involved in lipid metabolism which transfers cholesterol esters from hdl to vldl and ldl. obesity and steatosis are emerging as key factors in the pathogenesis of liver fibrosis in hcv. variability in function or levels of cetp may affect lipid transport and therefore steatosis. the uncommon vallval genotype results in decreased cetp plasma activity and may protect against myocardial infarction. we tested for a relationship between possession of cetp ile val polymorphisms and rate of fibrosis in white european patients chronically infected with hcv. rate of fibrosis was calculated by dividing the fibrosis score (ishak modification of knodell) by infection duration. genotyping was by reverse line blot hybridisation. a significant association was seen between rate of fibrosis and the ile val polymorphism in cetp (p = . (anova)) (figure ) . disease association showed patients possessing the val allele (which is associated with lower cetp activity) were more likely to be slow fibrosers (no cirrhosis for > years) genotype frequency p= . , allele frequency p= . , odds ratio= . . (table ) . possession of the val allele is associated with slow rate of disease progression in hcv. the functionally less active forms of cetp may result in decreased liver steatosis as a result of altered composition or increased levels of hdl, and therefore less fibrosis when a second insult such as infection with hcv is sustained. backgroudslaims: hepatitis c virus (hcv) is a major cause of chronic liver disease worldwide. however, little is known about exact mechanism of fibrogenesis by specific hcv gene or protein because the study of hcv-induced liver fibrosis has been mainly studied in human or animal model. moreover, the dynamically molecular study of hcv role in relation to liver fibrogenesis or immune response has been hampered due to lack of efficient in vitro hcv culture system. in the present study, we investigated whether hcv core protein directly influence on the liver fibrogenesis through stimulation of hepatic stellate cell(hsc) in in vitro or not. methods human and rat hscs were isolated using collagenase perfusion system and density gradient method, and other human hsc line (l ) was purchased from atcc. we established co-culture system of primary hsc and hepg -core stable cell line which hcv-core gene was transfected into hepg cell. co-culture system was divided into two way, mixed co-culture and separated co-culture system. immunocytochemical staining was performed to identify the cytokines such as transfoming growth factor pl (tgf-p ) and a-smooth muscle actin(a-sma) overexpressed from hsc in the liver fibrogenesis. a-sma, tgfpl, transforming growth factorp receptor i (tgforii), collagen type i were also quantitated by western blot analysis. the expression of mmp- and collagen type i in the culture media was measured and analyzed by each zymogram and elisa. results the expression of tgf-p and a-sma was significantly higher in mixed co-culture of hepg -core plus hsc than in hepg plus hsc as negative control. also the markers related fibrosis such as a-sma, tgf-pl, collagen type i and tgfrii, mmp- and collagen type i were highly expressed in separated co-culture of hepg core and hsc conclusions in conclusion, hcv core protein may play a direct role in the fibrogenesis via upregulation of a-sma, tgf-pl, collagen type i and tgfrii, mmp- and collagen type i. further study is needed to clarify exact signal transduction of fibrogenesis by hcv core protein in the co-culture system. background: to current knowledge, transforming growth factor beta (tgf-beta) signaling is mandatory to produce liver fibrosis. various molecular interventions designed to affect the tgf-beta system were successfully used to inhibit fibrogenesis. activated hepatic stellate cells have been considered as a major producer of extracellular matrix proteins in liver injury and fibrosis. in the present study, we wondered whether follistatin, activin inhibitory protein, reduce apoptosis and prevent liver fibrosis and whether activin plays a key role in liver fibrogenesis. methods: wistar male rats weighing around g were injected intraperitoneally with dimethylnitrosamine (dmn) (lopg/g body weight) three times a week for three weeks. either follistatin or saline were also injected intravenously three times a week. on the nd day, blood was collected and biochemical parameters were measured using the standard methods. the liver was either fixed with % bufferedparaformaldehyde for histological examination, or frozen immediately in liquid nitrogen for the rna analysis. tissue sections were either stained with hematoxyline-eosin, masson-trichrome, or subjected to immunohistostaining using antibodies against collagen type iv, alpha-smooth muscle actin (sma), fibronectin, tgf-beta. the mrna expression of activin, tgf-beta, timp were measured by rt-pcr. apoptosis was analyzed by tunel methods. wistar male rats were injected with dmn ( kglg body weight) once and liver tissues were obtained and fixed with % buffered-paraformaldehyde , , , , , , hours and days after injection for immunohistochemical staining. hepatocytes and hepatic stellate cells were isolated by collagenase perfusion method and by collagenase-pronase perfusion method and analyzed activin and tgf-beta mrna expression by rt-pcr. results: % of control rats died, whereas none of follistatintreated rats died within days. the serum level of hyaluronic acid in follistatin-treated rats were significantly reduced. ast and alp levels were also decreased significantly. apoptosis was reduced by follistatin dose-dependently. the expression of tgfbeta, timp, collagen lv and alpha-sma expression were also decreased in follistatin treated rats. we then examined activin expression in liver after dmn treatment. activin expression was observed at the maximum level in hepatocytes hours after dmn treatment. tgf-beta expression was not detectable hours after dmn administration, and it was sfxikingly increased in stellate cells hours after dmn administration but it was not detectable in hepatocytes. activin appeared in hepatic stellate cells as well as in hepatocytes hours after dh n administration. inducible nitric oxide synthase (inos) has been reported to play pivotal roles in the development of various types of liver injury and inos expression may be important in the process of fibrogenesis of nonalcoholic steatohepatitis in obesity. no-induced active substance was shown to activate matrix metalloproteinase. the inos mrna and protein activity have been found to be induce in rats on a high-fat diet. objectives we investigated whether ) induction of nos occurs in liver of mice fed high-fat diet, and ) nos increases matrix metalloproteinase activity and reduces collagen content, thus attenuates liver fibrosis. we compared fatty and fibrotic changes of hepatic tissues in inos-knockout (inos-'-) and wild-type (inos+/+) mice which were fed with high-fat diet for weeks starting from weeks old. marked induction of inos mrna occurred in inos+/' mice, but not in inos-/-mice. immunohistochemically, nitrotyrosine staining which is a footprint of no-induced active substance, showed positive in inos+'+ mice, and negative in inos-'-mice. in histopathologically showed fatty metamorphosis, but did not have any distinction between groups inos+'+ and inos-/-. the extracellular collagen content with azan staining in inos+/+ mice was markedly decreased compared with that in inos-'-mice. in gelatin zymography of matrix metalloproteinases we found that prommp- and prommp- were increased both in inos+'+ and inos-'-mice, but their active form was found only in inos+'+ mice. similar results were obtained from in situ zymography of hepatic tissue. the stronger gelatinolytic activity was found diffusely in hepatic tissues of inos+/+ mice than inos-/-mice. ( xc bl ) were subjected to either sham operation or bile-duct ligation. animals were sacrified two weeks after sur-gery and blood and liver samples obtained. bile duct ligationinduced elevation of serum liver enzymes was similar between wt and atla (-/-) mice. however, the liverlbody weight ratio was greater in wt than in atla (-/-) mice. bile duct ligated wt mice showed severe septa fibrosis, as assessed by trichromic masson and sirius red staining. in contrast, atla (-/-) mice showed minor fibrotic lesions, which were mainly located in peribiliary areas. collagen accumulation, as assessed by morphometric analysis of sirius red staining and hepatic hydroxyproline content, was markedly lower in atla (-/-) mice compared to wt mice. positive sirius red stained area in bile duct ligated wt and atla (-/-) mice were . . and . . %, respectively (p< . ). the increase in hepatic concentration of bioactive tgfb and proinflammatory cytokines (tnfa and illb) was attenuated in atla (-/-) mice compared to wt mice, as assessed by elisa. moreover, immunohistochemistry analysis revealed decreased lipid peroxidation products as well as decreased phosphorylation of c-jun and p - mapk in atla (-/-) mice compared to at (+/+) mice. chronic liver failure stimulates the onset of interstitial liver fibrosis, which eventually results in "capillarization" of the sinusoid, impeding clearance of toxic substances by hepatocyte cells. the goal of this work was to search for the therapeutical effect of adjuvant gene therapy using adenoviral vectors containing cd-nas for human urokinase plasminogen activator and human matrix metalloproteinase- (ad-hupa plus ad mmp- ) on cirrhosis and its relationship with manganese brain accumulation, striatum dopamine and its metabolites in the rat. mn+ is a wellknown neurotoxic metal which has been found accumulated in brain and blood of cirrhotic patients with hepatic encephalopathy. mnt elimination takes place via the hepatobiliary route. methods gr wistar rats underwent bile-duct ligation (bdl) for weeks and concomitantly treated with mglml of mncl in drinking water (bdl/md ). after this point, five animals were sacrificed and serum, liver and brain tissue (striatum) were obtained. of the remaining bdl/mn+ -cirrhotic animals (n= ), were injected with ad-hupa plus ad-mmp- ( x " + . ~ ~' vp/kg respectively) and rats injected with ( . ~ " vp/kg of ad-p-gal). this treatment lasted days. then, biological samples were recollected as before. an additional experimental model represented by cirrhotic rats injured chronically for weeks with cclb were also monitored for their response to this therapy. results seven wk-cc -cirrhotic animals treated with ad-hupa plus ad-mmp- (total . x 'vp/kg) were monitored at , , , , and days after combined gene therapy treatment (n= ). these animals showed improvement in liver fibrosis of up to % as compared with their ad-p-gal (n= ) treated cirrhotic counterparts. these results correlated with hydroxyproline detemiinations. furthermore, survival was determinated in additional cirrhotic animals. cirrhotic rats treated with ad-hupa plus ad-mmp- had a significantly higher probability of survival at days after beginning of treatment as compared with ad-@-gal cirrhotic rats. bdl/mn+ injured rats displayed tremors, rigidity, and gait abnormalities. ten days after treatment with combined therapeutic gene therapy, these symptoms decreased. also, liver fibrosis was evidently less ( %) as compared with ad-p-gal treatment rats. brain tissue (striatum) was recollected days after bdl/mnf animals were injected with either ad-hupa plus ad-mmp- or ad-p-gal alone. dopamine ( . mglgr) was decreased in % in ad-p-gal treated animals, as compared with . mglgr of dopamine found in ad-hupa plus ad-mmp-%treated animals. dyhydroxyphenylacetic acid (dopac a main dopamine metabolite) was as high as in ad-hupa plus ad-mmp-%treated animals ( . mglgr striatum) indicating a higher dopamine turnover in nontherapeutically treated cirrhotic animals. moreover, animals treated with ad-hupa+ad-mmp- showed a % decrease in ascitis and gastric varices as compared with ad-p-gal-treated animals. (gastroenterology , ) . while ppar-a was reported to be involved in induction of antioxidant enzymes expression and activities (life sci : , ). furthermore, in respect of hepatic fibrosis, oxidative stress induces hepatic fibrosis and many reports have demonstrated that several antioxidants can inhibit hepatic fibrosis. therefore, in the present study, we examined whether ppar-a ligands, i.e. wy- , and fenofibrates, can suppress hepatic fibrosis by attenuating oxidative stress in experimental rat model and possess a possibility of therapeutic candidate for hepatic fibrosis. methods: fibrosis was induced in male wistar rats by intraperitoneal administration of thioacetamide (taa) ( mglkg twice weekly for weeks). in the treated groups, ppar-a ligands, wy- , (wy) and fenofibrates, were fed a diet containing . % (wlw), and ppar-y ligands, pioglitazone (pio), were fed containing . % (wlw) all through the experiment. control cirrhotic rats received saline injections for weeks. after killing all rats, histological examinations (he, azan staining, immunohistochemistry of a-sma), serum value of alt and hyaluronic acid, mrna expression of ppars, acyl-coa oxidase (aco), a (i) procollagen, and antioxidant enzymes, such as superoxide dismutase (sod) and catalase. we also determined lipid peroxidation (lpo), glutathione levels, and activities of sod and catalase in the perfused liver. results: semi-quantitative analyses of fibrotic area revealed that wy co-administration with taa reduced to only % of the area of taa-treated rats. there was no significant difference in azan staining of the liver between taatreated rats and taa-treated rats. wy administration could not lower serum alt value in chronic and acute taa injury. these observations suggest that wy fails to modulate the hepatotoxicity of taa. an increased expression of ppar-cy in taatreated rats were observed, but the expression of ppar-a was abolished in taa-and taa-treated rats. wy intensively enhanced mrna levels of aco which was regulated by ppar-a, increase nearly -fold than controls, but the expression of aco diminished in taa-and taa-ppar-a activators, wy- , and fenofibrates, treated rats as well as ppar-a. the mrna levels of a (i) procollagen and tgf-/ l were strongly increased in taa-and taa-administrated rats than in controls, while they were dramatically suppressed in taa-treated rats. the catalase mrna was reduced to % of the controls in taa-and taa-treated rats, however, taatreatment prevented this decrease to % of the control levels. catalase activity increased -fold in taatreated rats than in controls, while it decreased % of the controls in taa-and taa-treated rats. in taa-and taa-treated rats an increase of lpo was observed, but not in ta-atreated rats. we c o n h e d that fenofibrates treatment could reduce hepatic fibrosis to approximately % of taa treatment for weeks by semi-quantitative analysis of fibrotic area. conclusion: our data indicate that war-a activators, not ppar-y, can markedly inhibit hepatic fibrosis in the experimental taa-induced rat cirrhotic model. we suggest that ppar-a and catalase are important in the development of hepatic fibrosis. therefore, we conclude that suppression of hepatic fibrosis by ppar-a activators is probably due to their antioxidant effects via increased activitiy of catalase which reduces hydrogen peroxide, and that fibrates, such as fenofibrates and bezafibrates, might be new candidates for the treatment of hepatic fibrosis. fibrosis is a common end-point in clinical trials of chronic hepatitis c. liver biopsy remains the gold standard for fibrosis evaluation. however, variability in fibrosis distribution within the liver (sampling variability) is a potential limit to liver biopsy. in order to assess the influence of sampling variability on the accuracy of liver fibrosis assessment with biopsy, we measured liver fibrosis on virtual biopsies of increasing length reconstituted from digitalized images of large liver sections using two different methods of fibrosis assessment. method large sections ( cmz) were performed from surgical liver samples with chronic hepatitis c and various degree of fibrosis. measurement of fibrosis on the whole section was considered as the reference value. from the digitalized image of the whole section, virtual biopsies of increasing length ( . to mm) were reconstituted. fibrosis was assessed independently on each individual virtual biopsy using both image analysis and meta-vir score. results were compared to the reference value. results: a total of . virtual biopsies were studied. using image analysis, a strong dispersion of area of fibrosis was observed for virtual biopsies smaller than omm. only % of , mm length virtual biopsies had a measured of area of fibrosis equal to reference value %. this percentage increased progressively with increasing size ( %, %, % for biopsies of mm, omm, loomm length, respectively). using metavir scoring system, % of biopsies of , cm length were correctly categorized according to the score assessed on the whole large section. it increases to % for a , cm size without any substantial benefit for longer biopsies. a same trend was observed whatever the stage of fibrosis. conclusion: sampling variability of fibrosis is a significant limit for fibrosis assessment with liver biopsy. this study suggests that a length of at least mm is necessary to valuably evaluate fibrosis with semiquantitative score. sampling variability become a major limitation for more accurate method such as automated image analysis. (msi- ) , a rna-binding protein, is highly observed in developing central nervous system and thought to be a mammalian neural stemlprogenitor cell marker. we have reported that cells positive for musashi- (msi- ) protein appeared during spontaneous resolution of rat liver cirrhosis and that some msi- -postive cells were also positive for matrix metalloproteinase (mmp)- , possibly implicating active participation of stem cells in the resolution of collagen. though msi- antigen is expected to be expressed during very early stage of differentiation in the cellular lineage of liver, the type of cells appeared in the damaged liver and expressed msi- remain to be elucidated. the present study is designed to characterize the msi- -positive cells in cirrhotic liver from the aspect of differentiation, significance and expected function of stemlprogenitor cells in the liver, especially fibrolytic function. methods: rat liver fibrosislcirrhosis was established by intraperioneal injection of cc twice a week. liver samples were obtained , and days after the last injection of -week cc intoxication. liver tissue samples were immunohistochemically stained for msi- , c-kit, nestin, a-smooth muscle actin (a-sma), ck- and mmp- . gene expression of msi- was also observed by reverse-transcription polymerase chain reaction (rt-pcr). results: neural stemlprogenitor cells, as defined by their expression of msi- andlor nestin, were not observed either in normal rat liver or after weeks of c c administration. rt-pcr analysis revealed very slight signals of msi- mrna at days after discontinuance of -week ccld treatment. on the contrary, remarkable increase of msi- mrna was observed at days after the weeks ccl treatment, then the signals decreased gradually. immunohistochemical analysis showed that a considerable number of cells positive for msi- appeared in the early recovery stage from advanced liver fibrosis, especially at day after the last injection of weeks ccl treatment. expression of msi- in liver tissue was proceeded by and partly overlapped with that of c-kit, a marker of hematopoietic stem cells. some msi- -positive cells observed around perivenular regions were as very small as oval cells, while the size of msi- -positive cells present along the resolving fibrous bands varied and some of them expressed mmp- . some ductal cells were positive for msi- but not for ck- examined in serial sections. msi- positive cells did not express hepatocytes markers such as albumin or afp. cells positive for a-sma and msi- were observed in some portions, but most of msi- expressing cells did not show positive staining for a-sma or desmin. at day , a few msi- -positive cells were observed around the remaining fibrous bands. s-adenosyl-l-methionine represses the fibrosis, constitute a good model for studying the mechanisms responsible for antifibrotic therapy. to test whether administration of s-adenosyl-l-methionine, a precursor of glutathione and an agent shown to prevent liver toxicity in a variety of settings, could repress the activity of the mouse pro-alpha (i) collagen gene in hepatic stellate cells, homozygous transgenic mice harboring the - kb to + bp of the proximal promoter of the mouse alpha (i) collagen gene cloned upstream of the escherichia coli beta-galactosidase reporter gene (lacz) were used. chronic liver injury was induced by injecting intraperitoneally mllkg of body weight of cc ( % vlv in mineral oil) three times per week for weeks. s-adenosyl-l-methionine was administered intraperitoneally at a dose of mglkg of body weight every day for weeks. control groups were given either mineral oil or s-adenosyl-lmethionine alone. hepatocellular damage and protection by sadenosyl-l-methionine was confirmed by measuring serum levels of transaminases; s-adenosyl-l-methionine lowered alt levels in the ccl -treated mice from to ull and ast from to ull (control values in the absence of cc were and ull for alt and ast, respectively). hematoxylin and eosin staining in the cc -treated mice revealed the presence of mallory bodies, lymphocyte infiltration, centrilobular steatosis, and perivenular and pericellular fibrosis, and s-adenosyl-l-methionine minimized the pathology score. masson's trichrome staining showed less collagen deposition in mice treated with cc plus s-adenosyl-lmethionine than in the cc -treated mice. histochemical analysis using x-gal staining allowed for the precise identification of the cell type in which the beta-galactosidase gene was active as driven by the pro alpha (i) collagen promoter. results indicated activation of the pro alpha (i) collagen promoter in mice treated with ccl, and repression of such activation in mice co-treated with s-adenosyl-l-methionine. immunofluorescence analysis of mice injected with cc revealed colocaliiation of alpha-smooth muscle and beta-galactosidase positive cells, suggesting that the activation of the promoter occurred only in hepatic stellate cells. these results suggest that one mechanism by which administration of s-adenosyl-l-methionine, a precursor of glutathione synthesis, could ameliorate liver fibrosis is by decreasing the responsiveness of the promoter of the alpha (i) collagen gene to a profibrogenic stimuli such as ccb. these transgenic mice should prove to be useful in further studies on how s-adenosyl-l-methionine exerts this repression of the alpha (i) collagen gene and perhaps to studies with other liver toxins such as alcohol. background endothelin- (et-i), the most powerful constrictor of the liver vasculature and stimulator of the synthesis, by kupffer cells, of a potent systemic vasodilator, platelet-activating factor, is also implicated in the fibrosis of lung, kidney and liver. thus increased hepatic concentrations of et- and its receptors in human and experimental cirrhosis suggest its major role in the pathology of chronic liver disease and its complications (fibrosis, portal hypertension and systemic hypotension). we investigated whether et- receptor antagonism, after the development of fibrosis and cirrhosis, arrestslreverses the progression of chronic liver disease. methods: chronic liver injury was induced in rats by cc treatment ( of the development of cirrhosis in group (histopathology score of . ? . vs . . , p< . ) and reversal of cirrhosis in group (histopathology score of . . vs , p<o.ol) rats. this was accompanied by reduced a-smooth muscle actin-positive cells (activated stellate cellslmyofibroblasts) in the tak- treated versus saline-treated rats receiving cc . tak- treatment caused significant amelioration of portal hypertension (p< . in both groups), systemic hypotension (p< . in both groups) and liver injury (reduced activities of serum ast, alt and ldh), and improved hepatic synthetic capacity (increased serum albumin concentration) in both groups of rats relative to the vehicle-treated rats. tak- treatment reduced collagen synthesis as evidenced by decreased hepatic hydroxyproline, collagen-a type i mrna expression, and mrna and protein expression of a potent fibrogenic cytokine tgf-p . conclusions: the results emphasize the role of et- in the development of cirrhosis and strongly suggest that blockade of its actions can be a rational therapy for chronic liver disease and its complications. subunits which are reported to be stimulatory. however p and p can form homodimers which have been described as inhibitors and stimulators of gene expression respectively. the aim of the study was to determine the role of the p subunit of nfkb in the progression of fibrosis. methods -chronic liver fibrosis was induced in p knockout and wild type control mice by administering twice weekly ccl injections for weeks. livers and blood samples were harvested at day , , , and after the last ccl injection. results -p knockout mice developed more severe liver disease as measured by serum alt's and peak fibrosis scores. the increased liver injury in p knockout mice was associated with a massive infiltrate of inflammatory cells into the liver compared to the control wild type mice. the majority of the inflammation was neutrophilic as measured by immunohistochemistry, however we also observed an increase in cd positive t cells. taqman quantitative rt-pcr analysis was used to measure collagen i, alpha-smooth muscle actin (asma) and timpl gene expression in the p knockout and wild type mice. all three genes were elevated in the mice laking p subunit of nfkb. immunostaining confirmed an increase in asma positive cells in the livers of p knockout mice compared to wild type controls. conclusion: the p subunit of nfkb may play an important role in protecting against the development of liver fibrosis and reducing liver inflammation in chronic liver injury. gnainsky, volcani center, bet dagan, israel; orna halevy, hebrew university of jerusalem, rehovot, israel; gadi spira, technion -israel institute of technology, haifa, israel; rafael bruck, wolfson medical center, holon, israel; arnon nagler, sheba medical center, tel hashomer, israel; mark pines, volcani center, bet dagan, lsrael introduction halofuginone is an inhibitor of hepatic fibrosis as demonstrated by prevention of dimethylnitrosamine (dmn) and thioacetamide (taa)-induced fibrosis. halofuginone is also responsible for the resolution of advanced fibrosis and increase in cirrhotic liver regeneration. methodslaims in this study atlas microarray technique was applied in vivo in an effort to identify genes involved in the halofuginone-dependent prevention of liver fibrosis. to that end we compared cdna array hybridization of taa-treated rat liver biopsies to biopsies of livers from rats treated with both taa and halofuginone. results from the genes of the array, were differentially expressed. one of the genes up-regulated by halofuginone was identified as protein tyrosine phosphatase of regeneration liver - (prl-l), an immediate early gene known to be induced during liver regeneration. the atlas microarray results were confirmed by northern blot analysis and by in situ hybridization. hepg cells in culture expressed high levels of prl- gene that was down-regulated upon serum starvation. halofuginone increased the prl- gene expression in the serum-starved cells in a dose and time-dependent manner. on the protein level, halofuginone caused translocation of prl- from hepg and huh- nucleus outer membranes to the cytosol as demonstrated by immunofluorescence using prl- antibodies. prl- translocation is known to be associated with alterations in cell cycle. halofuginone caused accumulation of hepg cells in the gym phase as analyzed by flow cytometry suggesting a putative g im arrest. conclusions these results demonstrate the involvement of halofuginone in the hepatocytes cell cycle through prl- gene expression and its cellular translocation. nathalie senant, universitk victor segalen bordeaux , bordeaux, france; genevieve freyburger, hdpital pellegrin, bordeaux, france; toulouse, france; alexis desmouliire, universitk victor segalen bordeaux , bordeaux, france several lines of evidence incriminate the hemostasis system in liver fibrogenesis. first, experimental and human pathological data suggest a role for micro-thrombosis in fibrosis progression. secondly, several hemostasis proteins, such as thrombin, can regulate the expression of fibrogenic mediators through signaling by cell-surface receptors. the aim of this study was thus to evaluate the effect of direct thrombin inhibition on experimental liver fibrosis. fibrosis was induced in rats by administration of cc in olive oil orally times a week for either or weeks. the thrombin antagonist ssr (sanofi-synthelabo research) was given daily orally at mglkg (a dose that has been shown to significantly inhibit thrombin in vivo) starting week after the beginning of cc intoxication. control groups received either the respective solvents or ssr alone. nine animals were used in each group. fibrosis was quantified with histomorphometrical analysis of sirius red-stained liver sections and expressed as a percentage of the surface of the section. we also measured the level of fibrogenic cell activation with quantitation of the area occupied by alpha-smooth muscle actin (asma)-positive cells. the levels of tissue inhibitor of matrix metalloproteinase- (timp-i) transcripts were analyzed by northern blot on total liver rna and expressed as timp-l/gapdh ratios following quantitative measurement with an instant imager. after weeks of cc , the area of fibrosis increased from . % . in controls to . i . % and was slightly but non significantly decreased by ssr ( . lr . %, ns). the area of asma-positive cells was however significantly decreased by ssr from . ? . to . i . % (p = . ). in animals receiving cc for weeks, treatment with ssr resulted in a decrease in fibrosis area from . t . to . t . % (p = . ). similarly, the asma-positive area decreased from . . to . i . % (p = . ). the timp-i/gapdh ratio was decreased by ssr at weeks (from . . to . . , p =om). ssr alone had no effect on the measured parameters at both time points. additionally, it did not alleviate the acute toxicity of cc as shown by the levels of serum transaminases and the area of necrosis that were not significantly modified. altogether, these data provide evidence that thrombin antagonism can reduce the extent of liver fibrosis in this model. ongoing experiments should clarify whether this results from an anticoagulant effect or an inhibition of thrombin signaling effects. center, tel aviv, israel background and aims: proliferation and "activation" of hepatic stellate cells (hscs) and production of collagen are involved in the pathogenesis of liver inflammation and fibrogenesis. ligands of nuclear hormone receptors, such as triiodothyronine (t ) and peroxisome proliferator activator receptor y (ppary) ligands have been shown to affect fibrogenesis. levels of ppary are reduced in activated stellate cells and addition of the iigand increases ppary receptor expression and ameliorates fibrosis. in contrast, t has the opposite effect on liver fibrosis. low circulating t levels reduces liver fibrosis and cirrhosis. in this study, we investigated the in vitro effects of t , ppary ligand and their combination on proliferation and activation of a rat hsc cell line. methods: transforming growth factor (tgf-pi) was used to induce myofibroblast-like phenotype in rat hscs (hsc-t ). activation of thyroid hormone and ppary receptors was induced with t and -deoxy-prostaglandinj( )(pj ), respectively. signal transduction markers and activation marker a-smooth muscle actin were determined using western blotting. collagen i expression was measured by northern blotting. results: both t and pj ( ) inhibit hsc proliferation induced by platelet-derived growth factor and by tgf-p. t inhibits cell proliferation by inducing apoptosis, while pj( ) reduces expression of proliferation marker cyclin d . both "i and pj( ) decrease expression of activation marker a-smooth muscle actin. in addition, t strongly increases both basal and tgfeinduced collagen i expression. by contrast, pj( ) decreases collagen expression and inhibits t -induced collagen production in tgfp-activated hscs. conclusion: both t and pj( ) reduce mitogen-induced proliferation of rat hscs, but have different effects on collagen i expression. these results suggest that prolierationlactivation and collagen i expression are two differently regulated processes in kato, sadakazu aiso, hiromasa lshii, keio university, tokyo, japan connective tissue growth factor (ctgf) is a profibrogenic molecule involved in several human fibrotic disorders including liver fibrosis. in human as well as experimental liver fibrosis, ctgf overexpression, through upregulation of ctgf mrna in hepatic stellate cells (hscs), is associated with the degree of fibrosis. it has been known ctgf is produced in many cell types in the live and exogenous ctgf modulates even the activation of hscs. although alcohol is the major cause of liver fibrosis, the role of ctgf in alcoholic liver fibrogenesis, has been poorly understood. cytochrome p- e (cyp el)-mediated oxidative stress, as a result of chronic and excessive ethanol consumption, has been implicated as a crucial factor in alcoholic liver fibrogenesis. the goal of a series of our studies was to clarify the effect of cyp e mediated ethanol oxidation on ctgf expression. we previously reported the results of the assay using the well-established hepg cell line constitutively expressing cypzei, which was kindly provided by dr. a. cederbaum ( mt. sinai school of medicine, ny). ctgf mrna quantitation assay by a real-time reverse polymerase chain reaction (rt-pcr) showed a significant increase in ctgf mrna levels in ethanol-treated e cells in a time-dependent manner up to hours after initial ethanol treatment. there was nearly a -fold increase in ctgf mrna levels when ethanoltreated e cells were coincubated with phorbol myristate acetate (pma), a reagent which enhances expression of cyp e . ctgf mrna levels were significantly reduced when ethanol-treated e cells were co-incubated with -methylpyrazole( mp), a cyp el inhibitor, or antioxidants, n-acetylcysteine and trolox. in the present study, we visualized the state of oxidative stress in ethanol-treated e cells by using mab f , a newly-established marker for oxidative stress. the mab f , which was generously provided by dr. k uchida (nagoya university, japan), was raised against the acrolein-modified keyhole limpet hemocyanin to verify the protein-bound acrolein in vivo. the staining, procedure was detailed elsewhere. immunohistochemical detection of proteinbound acrolein revealed e cells were stained when treated with ethanol. without ethanol treatment, no staining was observed in ethanol upregulates pro-fibrotic connective cells via cytochrome p- e -mediated e cells even at a -hour incubation period. moderate or no staining was observed when ethanol-treated e cells were coincubated with antioxidants. staining intensity by mab f is associated with ctgf mrna levels in this cell line. collectively, these data suggest ctgf mrna upregulation in e cells seems to be mediated by the state of oxidative stress. our present study first linked cyp el-mediated oxidative stress with ctgf gene regulation, thus suggesting a possible involvement of ctgf in alcoholic liver fiberogenesis. disclosures: sadakazu aiso -no relationships to disclose hiromasa ishii -no relationships to disclose mikio kajihara -no relationships to disclose ( ) human livers with biliary fibrosis. methods: changes in ntp-dase expression in rat liver were determined in normal and -wk bile duct ligated (bdl) or -wk c c rat livers and pflpm using confocal immunofluorescence, immunoblot, and northern blot. changes in ntpdase expression in human liver were determined in de-paraffinized liver biopsy specimens using confocal immunofluorescence. results: as was previously reported, ntp-dase was expressed in pf surrounding intrahepatic bile ducts in normal and sham bdl controls. in bdl rat livers, however, nt-pdase fluorescence was completely lost. no decrease in ntp-dase fluorescence was noted in cc rat livers within portal areas, although an increase in ntpdase fluorescence was seen in central areas. pf from sham bdl control animals expressed nt-pdase and the intermediate filament vimentin. "pf" from bdl animals did not express vimentin but were positive for a-smooth muscle actin (sma), suggesting that they were in fact pmf. most bdl pmf did not express ntpdase ; however, occasional cells were seen with sma and ntpdase in a pen-nuclear compartment. immunoblot analysis of pf revealed a marked decrease in ntpdase detection in bdl cells relative to sham bdl. no change was noted in ccll or c c control cells. northern blot analysis revealed no differences in ntpdase mrna levels in sham bdl, bdl, ccl, control, or cc pf. confocal micrographs of normal human biopsy specimens revealed ntpdase co-localization with vimentin in pf surrounding intrahepatic bile ducts. however, ntpdase fluorescence was either markedly decreased or lost in specimens from patients with primary biliary cirrhosis. no loss of ntpdase fluorescence was seen in biopsy specimens from patients with hepatitis c. conclusions: ntpdase expression is specifically decreased in biliary fibrosis, largely through a posttranslational mechanism. "portal fibroblasts" from bdl rats are in fact portal myofibroblasts, which lose expression of ntpdase . consistent with findings in rats, ntpdase expression is also specifically lost in human biliary fibrosis. work is now underway to determine whether loss of ntpdase in the peri-biliary compartment alters nucleotide signaling in bile duct epithelia. myofibroblasts of bone marrow origin have recently been found in a number of parenchymal organs such as the gut and kidney. we hypothesised that marrow derived myofibroblasts contribute to liver cirrhosis. methods. we sought to analyse the origin of myofibroblasts within cirrhotic liver in two scenarios: three male recipients of female liver transplants who have subsequently developed post transplant hepatitis c cirrhosis and a female recipient of a male bone marrow transplant who later developed hepatitis c induced cirrhosis. through the use of in situ hybridisation for the y chromosome we have been able to track cells of male origin. results. we have detected significant numbers of y chromosome positive cells in fibrotic areas. by combining the in situ hybridisation with immunocytochemistry these cells were found to be positive for vimentin, alpha-smooth muscle actin and negative for cd . these cells were therefore determined to be of a myofibroblast phenotype. in the liver transplant recipients, . % (corrected count . %) of the myofibroblasts were y chromosome positive. in the female recipient of the male bone marrow transplant, . % (corrected count . %) of the myofibroblasts were y chromosome positive. conclusions. within all the livers analysed we found frequent myofibroblasts within and adjacent to the fibrotic bands that are of bone marrow origin indicating an extrahepatic cell contribution to the pathogenesis of human liver cirrhosis. (hsc) is the major fibrogenic cell of the liver and a key target of potential antifibrotic therapies. hepatocyte growth factor (hgf) is antifibrotic in several models of experimental liver fibrosis, but its mechanism of action is uncertain. potential use of hgf as a therapeutic peptide is limited by its size and need for parenteral administration. to overcome these potential limitations, refanlin has been developed as a synthetic small molecule sflhgf mimetic, that has demonstrated antifibrotic properties in renal fibrosis. aim: to study the in vitro and in vivo antifibrotic efficacy of refanlin. methods: serum starved lx cells, an immortalized human hsc line, were treated with mglml of refanlin for hours. proliferation studies using tritiated thymidine incorporation were performed. rna was isolated, and a panel of fibrosis markers (al-smooth muscle actin (asma), collagen i, bpdgf-receptor, , (mmp , , ) , tissue inhibitor of metalloproteinase- , (timp , ), were assessed by real time rt-pcr analysis. cirrhosis was induced in sprague-dawley rats by if thioacetamide (taa) ( mg/kg tiw) for six weeks. in the refanlin treated group, mglkg of refanlin was administered five days per week for six weeks, concurrently with the taa. control rats received ip pbs five days per week for six weeks, along with taa. liver tissue was formalin-fixed and paraffin-embedded, then stained with % picrosirius red and computer morphometric analysis was performed for collagen quantitation using the bio-quanttm software. results: in cultured human stellate cells, there was a % decrease in asma, a % decrease in the expression of tgfb-receptor and mmp , and a % decrease in timp . there was no effect on proliferation. in vivo, fibrosis decreased by one metavir stage in rats treated with c and thioacetamide for weeks. furthermore, c led to a significant decrease in portal pressure compared with non-treated rats with fibrosis. conclusions: refanlin may have antifibrotic efficacy through its inhibition or downregulation of tgfb receptor as well as mmp . in vivo antifibrotic activity of refanlin is associated with reduced portal pressure. these experiments better define the potential targets of hgf's antifibrotic activity. ongoing studies in mechanistically distinct models of fibrosis will broaden our understanding of this agent's effects and point towards therapeutic trials in humans. kanto, aki sato, michiyo inoue, hideki miyatake, mitsuru sakakibara, takayuki yakushijin, chika oki, tetsuo takehara, norio hayashi, osaka university graduate school of medicine, suita, osaka, japan background and aim hepatitis c virus (hcv) infection induces a wide range of chronic liver injuries. impaired thl response against hcv may be involved in hcv persistence, however, its precise mechanism is largely unknown. dendritic cells (dc) are the most potent antigen-presenting cells that play essential roles in initiating as well as regulating anti-virus immune responses. blood dc are grouped as myeloid (mdc) and plasmacytoid dc (pdc). with respect to their functions, mdc produces il- and tnf-a upon stimulation and drives thl response, while pdc releases considerable amount of type-i ifn upon virus infection and mainly skews th . we previously reported that monocytederived dc is functionally impaired (kanto t. et al. j lmrnunol ) , however, the roles of blood dc subsets in the direction of thllth in hcv infection are still elusive. to address these issues, we compared the numbers and functions of mdc and pdc between chronically hcv-infected patients and uninfected donors. subjects and methods sixty-six hcv-positive patients ( chronic hepatitis and asymptomatic carriers) and agematched uninfected donors were enrolled. mdc or pdc was determined by the patterns of lineage markers, hla-dr, cdllc and cd . each type of dc was magnetically separated or sorted under facs vantage and was subjected to the functional analyses. the ability of dc to polarize naive cd t-cells towards thl or th was estimated by the pattern of ifn-ylil.- /il- production from mdc-or pdc-primed cd . results absolute numbers of mdc, pdc and their cd + progenitors are lower in hcv-infected patients than in control subjects, most significantly in those with chronic active hepatitis (mdc, pdc, cd , median, patients vs. controls; . , . , . *. vs. . , . , . /pl, p< . ). both types of dc from patients are impaired in the stimulation of allogeneic cd t-cells and the production of il- p or ifn-a compared with healthy donors. on encounter with nayve cd t-cells, mdc from the patients are less able to drive thl response, while pdc from them prime more il- producing t-cells than those from donors. exogenous il- significantly improved the patient mdcdriven thl response, however, it simultaneously increased il- producers both in mdc and pdc. in contrast, ifn-y or il- stimulated the patient mdc to drive thl without increasing mdc-or pdc-primed il- producing cells. conclusion both types of blood dc in chronic hcv infection are reduced and play decisive roles in the development of an impaired thl and an il- -rich environment, thus favoring hcv persistence. ifn-y or il- is feasible to restore the altered t-cell polarizing ability of blood dc in chronic hepatitis c. hepatitis c virus (hcv) replicates its genome in a membraneassociated complex composed of viral nonstructural proteins and rna as well as altered cytoplasmic membranes and other as yet unidentified host cell components. a specific membrane alteration, designated membranous web, was recently identified as the site of hcv rna replication in huh- cells harboring subgenomic replicons (gosert et al. j virol ; : - ) . here, we describe hcv replicons that allow the direct visualization of hcv replication complexes in living cells. methods: a transposon-mediated random insertion screen followed by selection of viable replicons was performed to identify sites that tolerate insertions in nonstructural protein a (ns a). the green fluorescent protein (gfp) coding sequence was subsequently inserted into selected sites. rna was in vitro transcribed from subgenomic replicon constructs harboring these insertions, followed by electroporation into huh- cells and selection in the presence of g . results: two sites in the c-terminal domain of ns a were found to tolerate the gfp insertion and allowed efficient initiation and maintenance of hcv rna replication. expression of a ns a-gfp fusion protein of the expected molecular mass could be demonstrated by immunoblot, indicating that the gfp was stably retained and that processing of the viral protein occurred normally. more important, expression levels were robust enough to allow direct visualization of this fusion protein by fluorescence microscopy. gfp fluorescence was found in a cytoplasmic reticular pattern and in brightly fluorescing dots, the typical distribution of hcv nonstructural proteins in replicon cells. by confocal laser scanning microscopy, gfp fluorescence was found to colocalize with other hcv nonstructural proteins in the brightly fluorescing dots, suggesting that these represent hcv replication complexes, previously identified as membranous webs. metabolic labeling of the nascent viral rna with brutp and (immuno)electron microscopy studies are underway to further validate these findings. moreover, live cell imaging studies using these replicons have successfully been initiated. conclusion: we have identified sites in ns a that allow insertion of gfp in the context of functional hcv replicons and direct visualization of hcv replication complexes in living cells. these findings have implications for the structure and function of the hcv ns a protein as well as for the architecture of the hcv replication complex. this system will allow to gain a dynamic view of the formation and turnover of hcv replication complexes and may be useful to select for cell populations permissive for hcv rna replication. infection. masahisa jinushi, tetsuo takehara, tomohide tatsumi, takuya miyagi, takahiro suzuki, tatsuya kanto, norio hayashi, osaka university graduate school of medicine, suita, osaka, japan background and aim it has been generally accepted that the pertubation of cellular immunity plays an important role in establishment and persistence of chronicity in hcv infection as well as resistance to ifn therapy. accumulating lines of evidence have unveiled that dendritic cells (dcs), most potent antigen presenting cells, are impaired in patients with hcv infection, which may be involved in disturbance of anti-hcv immune responses. we recently reported that mhc class i-related chain a and b(mical b),ligands of nk activating receptor nkgzd, are induced on dcs upon interferonaand gain their ability to antivate nk cells; their expression is severely impaired in dcs derived from hcv-infected individuals (hcv-dc) ( . immunol. immunol. - immunol. , . in the present study, we evaluated whether various types of cytokines have an effect for inducing micalb expression on hcv-dcs, thus resulting in triggering nk cell activation by dcs. methods dcs from healthy volunteers (n-dcs; n= ) or hcv-dcs (n= ) were generated from monocyte treated with gm-csf ( ulml) and il- ( ulml) for days. after stimulated with various cytokines (ifnalp, ifny, tnfa, il- , il- or il- ) for h, dcs were subjected to flow cytometric analysis of micalb expression. to investigate the involvement of each cytokine in mica/b expression on ifnalp-stimulated dcs, we employed elisa and rt-pcr to examine the cytokine expression (tnfa, il-lp, il- , il- ~ , il- and il- ) in ifnalp-stimulated dcs, and also assessed micalb expression on dcs in the presence of neutralizing antibodies for these cytokines. to further address the stimulatory capacity of dc, allogeneic nk cells were cocultured with n-dcs or hcv-dcs at a ratio of :l for h, and applied for flow cytometry of intracellular ifny expression, as well as cr release assay for the cytolysis of k target cells. in some experiments, masking antibody for nkg d or micalb was added during nkldc cocultures, and then subjected to nk cell function assays described above. results micalb were induced on n-dcs, but not on hcv-dcs, upon iifnalp(% mic positive: n-dc . % vs hcv-dc . %; p<o.ol). in sharp contrast, micalb expression was increased on hcv-dcs at levels similar to n-dcs in the presence of of onglml il- (but not other cytokines) (%mic: n-dcs . % vs hcv-dcs . %). moreover, n-dcs, but not hcv-dcs, was capable of producing il- in response to ifnalp. little differences were detected in n-dcs and hcv-dcs for the production of tnfa, il-lp, l- , il- ~ , or il- . in addition, ifnalp-mediated micalb induction in n-dcs were completely inhibited in the presence of neutralizing antibody of anti-il l il- receptorcu. even much lower doses ( nglml) of il- restored the ability of hcv-dcs to induce micalb and to activate nk cells in response to ifnalp. the ability of hcv-dcs for nk cell activation was largely diminished by adding the masking antibody of nkg d or micalb. conclusion the current study demonstrated that il- acts as an indispensable mediator to induce micalb expression on ifnalp-stimulated dcs, and that hcv-dcs lack the ability to produce il- and to induce micalb expression in response to ifnalp. since defect in il- production is responsible for impaired nk cell activities by hcv-dcs, these findings shed light on the possibility that il- could improve the ifn-mediated anti-viral immune responses in chronic hcv-infected patients. the cellular immune response contributes to viral clearance as well as liver injury in acute and chronic hepatitis c virus (hcv) infection. understanding the relative immunodominance of hcvencoded peptides is important for understanding pathogenesis as well as potential vaccine candidates. we have developed a comprehensive and sensitive method to screen immune responses to all potential hcv epitopes in hcv-exposed individuals. methods: subjects with evidence of spontaneously resolved infection (eia+/hcv rna-neg, n = ) and patients with evidence of chronic hcv infection (mean hcv rna level = . million copieslml; n = , all genotype la) had either leukophoresis or one-unit blood draw. we synthesized peptides ( mer-peptides overlapping by amino acids) that spanned the entire hcv genotype l a polyprotein; responses to pools of peptides were screened directly ex vivo by an ifn-gamma elispot assay. briefly, autologous dendritic cells (dcs) were generated from peripheral blood mononuclear cells selected by plastic adherence then cultured with gmcsf, il- and % hs for d. dcs were pulsed with peptide pools to stimulate bead-purified cd + t cells. the remaining cd + t cells ( . x lo cells/well) were stimulated the same day with the peptide pools; wells with no peptide (or siv peptides) were used as controls. only responses greater mean + sds above controls were considered positive. the frequency and vigor of cd + t cell responses were statistically greater in resolved vs. chronic infection (mean . pools out of ; median in resolved vs. mean . pools; median . in chronics; p =. ). there was an inverse trend between # peptide pools with cd + t cell responses and hcv rna level. as shown in the figure, the hcv peptide pools differentially elicited responses; specifically, resolved infection was associated with greater cd + responses to pools core b, ela, ns protease- , ns helicase- , ns helicase- , ns helicase- , ns helicase- , ns b- , ns a- , ns a- , ns b- . on the average, cd + t cells responded to . pools in resolved infection vs. . pools in chronics (p =.as). cd + t cell responses specifically directed against core , ns helicase- , ns -helicase , ns b- , ns a- were more frequent in resolved as compared to chronic infection. conclusions: comprehensive mapping of hcv-specific immune responses by overlapping pools reveals significant differences in immunogenicity in resolved vs. chronic infection. in particular, regions core b (amino acids - ), ns helicase- (aa - ) and helicase- ( - ), ns b- ( - ), ns a- ( - ) induce both cd + and cd + t cell immunity and thus represent potential vaccine candidates. supported by nih r dk . sud, geoffiey c farrell, priyanka bandara, james g kench, storr liver unit, westmead hospital, westmead, nsw, australia; geoffiey w mccaughan, aw marrow gastroenterology (and liver centre, camperdown ns w, australia; jacob george, storr liver unit, westmead hospital, westmead, ns w, australia introduction: chronic hepatitis c virus (hcv) infection is associated with an increased prevalence of type diabetes mellitus, which is known to accelerate fibrosis in nash. we hypothesized that viral-induced insulin resistance (ir) may be a mechanism for fibrogenesis in chronic hcv infection. methods and results: . to assess the influence of hcv infection on ir independent of any effect of hepatic fibrosis, hcv subjects with minimal (stage ) or no (stage ) fibrosis were compared with healthy volunteers matched by gender, body mass index (bmi) and waistlhip ratio. although the hcv subjects were younger than the healthy volunteers (p= . ), they had significantly higher levels of markers of ir including fasting glucose (p=o.ol), insulin (p=o.o ), cpeptide (p<o.ool) and homa-ir (p=o.o ). . in hcv patients (fibrosis stage to ), e examined the viral and diseaserelated factors (portallperiportal & lobular inflammation, viral genotype) which may be involved in the pathogenesis of ir in a multivariate model, controlling for other demographic and biochemical variables. by multiple linear regression analysis, independent predictors of homa-ir included bmi (p<o.ool), failed previous antiviral treatment (p<o.ool), portal inflammatory grade (p<o.ool) and genotype status (p=o.ol). genotype cases had significantly lower homa-ir than other genotypes at each stage of hepatic fibrosis. the adjusted difference in homa-ir between genotype and non-genotype was - . ( % ci: - . to - . ; p=o.ol). . we then assessed if ir was associated with increased fibrotic severity. by multiple ordinal regression analysis, independent predictors for the stage of fibrosis in the hcv subjects were homa-ir (or . , p<o.ool), portal inflammatory grade (or: . , p<o.ool), past alcohol intake (or . , p<o.ool), age (or . , p < . ), alt (or . , p= . ), platelet count (or . , p<o.ool), and serum cholesterol level (or . , p=o.ool). as cirrhosis is known to cause ir, a separate multivariate analysis was performed for the non-cirrhotic subjects. the independent predictors for fibrosis were unaltered and homa-ir remained in the model. in a subgroup of patients with estimated duration of infection, multiple linear regression analysis showed that homa-ir was independently associated with an increased rate of fibrosis progression (p= . ). conclusion: hcv infection induces insulin resistance irrespective of the severity of liver disease, and this effect appears to be genotype-specific. further, increased insulin resistance contributes to fibrotic progression. disclosures: priyanka bandara -no relationships to disclose geoffrey c farrell -no relationships to disclose jacob george -no relationships to disclose jason m hui -no relationships to disclose james g kench -no relationships to disclose geoffrey w mccaughan -no relationships to disclose background: approximately one half of hepatitis c virus (hcv) infected patients will fail to respond to current treatment regimens, pegylated interferon alfa and ribavirin. modeling of hcv rna decay in response to antiviral therapy can provide insight into viral and host determinants of viral response. aims: pharmacokinetic, pharmacodynamic, and immunologic outcomes were evaluated on co-infected patients: ) to evaluate the relationship between hcv rna decay and peg-ifn alfa b serum concentrations in hivlhcv co-infected patients and ) to evaluate association between hcv-specific immune responses and virologic outcome. methods: co-infected, therapy-nake patients were treated with peg-ifn alfa b . pglkglwk and rbv mglkglday. serum was obtained for hcv rna, hiv- rna and serum peg-ifn alfa b levels at baseline, after the first dose ( , , hours) and on days , , , ; after the second dose ( , , hours) and on days , ; and after the third dose on days , , and . peripheral blood mononuclear cells were obtained at baseline, weekly for the first month, and monthly thereafter. hcv and hiv- rna levels were determined by reverse-transcriptase poly- merase chain reaction and peg-ifn alfa b levels were measured by elisa. cd + cell proliferative responses to hcv antigens (core, ns , ns , ns ) and hiv- gag were performed at baseline, day and , and weeks , , , and . among co-infected patients, are males, the mean age was . years, are caucasian, are african-american and are hispanic. l patients were infected with genotype , / patients with genotype , and / with genotype a. results: pharmacokinetics: to date, patients have been evaluated. / patients were end of treatment responders, but of these were "late responders" (i.e. hcv rna declines after week and is undetectable by week ). data fitting during the first seven days revealed a free virion clearance rate c of . (day-l) and an infected cell clearance rate of . (day-'). the half-lives were . hours and . days, respectively. pharmacodvnamics: viron production was blocked after the first dose of peg-ifn alfa with an average maximum effectiveness (emax ) of %. we estimated that the fifty percent effective concentration (ec ) of peg-ifn alfa b, the theoretical in v i m drug concentration at which the drug efficacy is , was five-fold lower in responders compared with non-responders while the maximum (cmax) and minimum (c,,,in) concentrations did not differ significantly ( table i ). the calculated minimum ( € , , , i n ) and maximum (emax) efficacy were also significantly increased in responders. immunolonic: the mean number of cd +, cd + and cd + cells did not differ significantly at baseline or during treatment between responders and nonresponders. peripheral blood cd + hcv-specific proliferative responses did not differ significantly between responders and nonresponders except that the response to core antigen was increased in non-responders compared with responders at weeks and . hiv gag cd + proliferative responses were stronger than hcv-specific responses at all time points evaluated. conclusions: the serum peg-ifn alfa b concentration necessary for an end of treatment response is fivefold lower in responders compared with non-responders while there are no significant differences in the maximum and minimum peg-ifn alfa b concentrations in responders and nonresponders. these data suggest that host factors responsible for a viral response may be different in responders compared with nonresponders, independent of serum peg-ifn alfa b concentrations. is a significant predictor of liver disease severity in patients who are coinfected with hepatitis c virus (hcv). this accelerated liver disease is presumed to be due, in part, to hn-related immune suppression. hcv quasispecies variability is likely a marker of immune pressure on the virus. hyuotheses: . hcv quasispecies variability is decreased in those with hiv coinfection, and . treatment with highly active antiretroviral therapy (haart) is associated with increased variability, methods: hcv-infected patients with or without hiv were enrolled in a cross-sectional study. patients with genotype infection and a parenteral risk factor for hcv were included. those with injection drug use (idu) were estimated to have acquired hcv years after the onset of idu. alcohol use was determined using standard questionnaires. haart data were collected from the hiv clinic's database. only those with complete records were included. hcvquasispecies variability was determined using clonal frequency analysis of the second envelope gene hypervariable region. quasispecies heterogeneity was characterized according to complexity (the normalized number of unique quasispecies variants within a sample) and diversity (the average genetic distance between individual variants within the same sample). groups were compared using the student t-test for unequal variances, anova and the wilcoxon rank-sum test where appropriate. linear regression was used to assess the independent effects of hiv infection and haart on complexity and diversity. results: to date quasispecies data are available on patients, of whom are hivpositive. as expected, hiv+ subjects had significantly lower cd counts (mean vs cellslul, p<.oool). mean age and hcv duration were significantly lower in the hiv+ group ( . vs . , p=. , and . vs . years, p=.oo , respectively). the groups did not differ with respect to alcohol use over their lifetime or in the months prior to enrollment. quasispecies complexity and diversity are detailed in the table below. while there was no significant difference among groups by anova (p=. ), the hiv+ subjects not on haart had less complexity and diversity than the other two groups, and differences between groups and and groups and were significant (table) . both hiv infection and haart were significantly and independently associated with complexity in a linear regression model; hiv infection predicted decreased complexity (p= . ), while haart predicted increased complexity (p=. ). in addition, higher alcohol use in the prior months was independently associated with decreased complexity (p=. ). hiv infection and haart also were independently associated with decreased and increased diversity, respectively (p=.ool and. ). the cd count did not predict complexity or diversity, and the effect of haart appeared to be independent of the cd count. conclusion: hcv coinfection with hiv is associated with decreased hcv quasispecies complexity and diversity. while this effect is not completely reversed by haart, treatment of hiv is associated with significantly increased hcv complexity and diversity in our sample. furthermore, the effect of haart on hcv quasispecies variability appears to be independent of its effect on the cd count. these findings suggest that the immune pressure on hcv is enhanced in hcvlhn coinfected individuals who are on haart when compared to those who are not on haart. diversity" group (mean .t sd) (mean f sd) in the majority of cases, hepatitis c virus (hcv) becomes chronic and is associated with impaired viral-specific t cell immune responses; the mechanisms underlying viral persistence and lack of protective immunity are poorly understood. considering dendritic cells (dcs) play critical roles in initiating and modulating immune responses, we explored the effect of hcv proteins on dc genetic expression, phenotype, and function. methods: human dendritic cells (dcs) were generated following plastic adherence of monocytes from normal subjects and culture with gm-csf and il- . autologous non-adherent cells were infected with vaccinia constructs expressing various hcv proteins (core, nssa, ns b) or an irrelevant protein / -galactosidase @-gal) as the control. following induction of apoptosis with uv irradiation, these vaccinia-infected cells were co-cultured with dcs. the phenotype, gene expression profiles and functions of the dcs were analyzed. dcs were evaluated after , , and hrs of co-culture as well as after maturation with a cytokine cocktail (tnf-a, il-lp, pge , il- ) for an additional hrs. results: by facs analysis, we found no alteration in expression of co-stimulatory markers (cdso, cd , cd ,) or mhc class i or i molecules. by elispot assay, we found that the recall response of cd t t cells for cmv following pulsing of hcv-dc or control (p-gal)-dc was also not altered. however, between - % of the genes probed in the bd clontech nylon array were differentially regulated. real time pcr has confirmed increased expression of scyc (lymphotactin) in the presence of ns a in normals as well as separate biological replicates. both clontech and affymetrix gene arrays revealed ns a-induced increases in expression of il- , a chemokine with pro-inflammatory properties. functional assays reveal that dcs which had engulfed apoptotic cells containing hcv core, ns a, or ns b demonstrated comparable ability to macropinocytose as measured by uptake of dextran-fitc or albumin-fitc when compared to p-gal-dcs. however, following uptake, the hcv-dcs died at a significantly greater rate than p-gal-dcs (- %). conclusions: taken together, these results demonstrate that following engulfment of apoptotic cells containing hcv proteins, differential gene expression occurs in human dendritic cells, although the expression of mhc and costimulatory molecules and ability to stimulate memory (cmv) responses remain intact. the mechanisms underlying the surprising induction of death of dc-hcv in the macropinocytosis assay is currently under further investigation. institutes of health, bethesdu, md steatosis is a common histological feature of chronic hepatitis c virus (hcv) infection. the cause of hepatic steatosis in hepatitis c remains to be elucidated, but its association with obesity, diabetes and hyperlipidemia suggests an underlying metabolic dysfunction similar to that found in patients with nonalcoholic steatohepatitis (nash). additionally, recent data suggest an association between body mass index (bmi) and the degree of hepatic steatosis and fibrosis in hcv infection. insulin resistance (ir) is a key factor in the pathogenesis of nash and may play a similar role in the steatosis seen in chronic hepatitis c &: to compare the prevalence and severity of hepatic steatosis, visceral adiposity, j r and their relation to disease severity in african americans (aa) vs caucasians (ca) with genotype hcv infection being considered for anti-viral therapy. methods: virahep-c is a prospective study of response rates to peginterferon and ribavirin in treatment-na'ive aa vs ca patients with genotype hcv infection. all patients underwent liver biopsy within months of enrollment. biopsies were read blindly by a central pathologist and scored for inflammation and fibrosis using the histologic activity index [i-iaii and for steatosis ( - +) and features of steatohepatitis (zone ballooning, zone perisinusoidal fibrosis and mallory bodies). waist circumference and waist-hip ratio were measured as determinants of visceral adiposity. ir was determined using fasting glucose and insulin levels based upon the homa method. results: to date, patients have been enrolled and have complete liver biopsy information ( aa and ca). steatosis was present in patients ( %) with similar rates among aa ( %) and ca ( % ca). grades of steatosis were also similar between aa and ca + ( % vs %), + ( % vs %), + ( % vs %) and + ( % vs %) (p = ns). patients with steatosis had significantly higher values for homa index ( . vs . , p<o.ol), total hai score ( . vs . , p<o.oool), hai inflammation score ( . vs . , p<o.oool), waist circumference ( . in vs . inches, p<o.oool) and bmi ( . vs . , p<o.oool). there were no significant differences in amount of alcohol consumption between patients with and without steatosis. spearman's non-parametric correlations were performed to assess associations between the ordinal variables (scores for fat, steatohepatitis ballooning degeneration + perisinusoidal fibrosis + mallory bodies], total hai, inflammation and fibrosis) and one continuous variable (homa index). waist circumference, waist-hip ratio, bmi, homa index, total hai, hai inflammation and hai fibrosis all correlated with both the fat score and steatohepatitis score (p<o.ol). median homa index levels were significantly greater among aa than ca ( . vs . , p< . ), but step-wise logistic regression showed that race was not an independent predictor of steatosis after controlling for alt, ast, waist circumference, waist-hip ratio, bmi and homa index. conclusions: in patients with chronic hepatitis c and genotype , steatosis and steatohepatitis correlate strongly with the presence of insulin resistance and visceral adiposity. race is not an independent predictor of steatosis after controlling for other factors. bulk populations of antigen-presenting dendritic cells (dcs) contain myeloid dcs and plasmacytoid dcs. myeloid dcs polarize t lymphocytes to thl phenotype that produce interferon ( fn)- . plasmacytoid dcs produce abundant amounts of interferon ( fn)-alpha. both ifn-?-producing t cells and adequate amounts of ifn-alpha are essential for viral clearance. in patients with chronic hepatitis c virus (hcv) infection, dcs are infected with hcv, which is presumed to have a role in viral persistence. however the functional implication of this has not been addressed. the aim of this study is to evaluate the functional capabilities of both myeloid and plasmacytoid dcs in patients with chronic hcv infection. myeloid dcs were defined as linage-, cdllc+, hla dr+ and cd -cells, and plasmacytoid dcs as lineage-, hla dr+, cdllcand cd + cells among the peripheral blood mononuclear cells (pbmcs). the frequencies of myeloid and plasmacytoid dcs were measured in patients with chronic hcv infection and agematched control subjects by four-color flow cytometry. to assess the production of ifn-alpha by plasmacytoid dcs, these were cultured with graded doses of herpes simplex virus- ( - plaque-forming unitsldc). the frequencies of plasmacytoid dcs expressing intracellular ifn-alpha among total plasmacytoid dcs were counted by two-color flow cytometry. to evaluate the capacity of myeloid dcs to induce th polarization, dcs were cultured with autologous naive t cells for days. polarization of t cells to thl phenotype was assumed when na'ive t cells expressed intracellular ifn-y. steatosis has been reported to occur in up to % of liver biopsies in patients with chronic hepatitis c virus (hcv) infection.risk factors for steatosis include alcohol abuse and those found in nonalcoholic steatohepatitis: obesity, increasing age, insulin resistance and hypertriglyceridemia. studies have shown an association between genotype and hepatic steatosis in chronic hcv infection, and others have found an association between steatosis and fibrosis stage. previously published studies have been based primarily on cohorts of clinic referral patients and often have not analyzed for confounding variables. we herein report a population-based study of hepatic steatosis in hepatitis c. methods: in a study of alaska nativestamerican indians with chronic hcv infection, patients underwent at least one percutaneous liver biopsy as part of evaluation for treatment. all patients had a positive hcv rna by pcr and were negative for hbsag and hiv. all biopsy slides were reviewed by a pathologist blinded to patient identity, demographic, clinical and biological data. histologic activity was scored using the knodell system and fibrosis using the ishak system. steatosis was graded as , ( so%), ( - %), and (> %). patients were analyzed for a) gender, age, estimated length of infection and bmi at the time of biopsy, b) genotype, current ethanol use, hcv rna within year of biopsy, c) alt within days of biopsy, and d) histologic activity and fibrosis found on biopsy, using univariable and multivariable analysis. results: steatosis was found in / ( %) of liver biopsies; ( %) had grade ; ( %) grade , and ( %) grade . genotype distribution was as follows: genotype ( %), genotype ( %), and genotype ( %). steatosis was found in % ( ) of genotype , % ( / ) of genotype , and % ( / ) of genotype patients (p = . ). grade or was found in % ( / ) of genotype , % ( / ) of genotype , and % ( / ) of genotype patients (p = . ). there was no significant association found between steatosis and gender (p = . ); age at biopsy date (p = . ); alt (p = . ); histologic activity (p = . ), viral load (p = . ) and estimated length of infection (p = . ). there was a significant association of steatosis with bmi (< . ), fibrosis score (p < . ) and current ethanol use (p = . ). bmi occurred in % ( / ) of genotype , % ( / ) of genotype , and % ( / ) of genotype patients (p = . ). after controlling for bmi, there was no significant relationship found between steatosis and genotype. for bmi < , % ( / ) of genotype , % ( / ) of genotype , and %( / ) of genotype patients had steatosis (p = . ). for bmi , % ( ) of genotype , % ( ) of genotype , and % ( / ) of genotype patients had steatosis (p = . ). multivariable analysis was performed on variables (p . in univariable analysis) and genotype. these included age (categories < , - , - , so+), bmi (< , +), current ethanol use (yes, no), ishak fibrosis score ( - , , and estimated length of infection ( , - , - , + years) . a significant association with steatosis was found in variables: ishak fibrosis score (or . , % ci . - . , p = . ), bmi -> (or . , % ci . - . , p = . ), and current ethanol use (or . , % ci . - . , p = . ) after adjustment for hcv infection length, which itself was not statistically significant (p = . ). conclusion: contrary to a number of previously reported studies, this population-based study did not find an association between steatosis and genotype, including genotype in chronic hcv infection after multivariable analysis. we did find that ishak fi-brosis score, bmi and current ethanol use were associated with steatosis after adjustment for hcv infection length, but age and histologic activity were not associated. infection results in necroinflammatory liver disease characterized by the insidious progression of hepatic fibrosis and loss of functioning hepatocyte mass. a cell-mediated immune response with prominent lymphocytic infiltration of liver is thought to play a major role in pathogenesis, although little is known about the molecular mechanism underlying the liver injury associated with this viral infection. on the other hand, non-immune mechanisms have also been proposed as another mechanistic candidate for such sophisticated processes. the recent intensive interest is that the expression of hcv proteins seemingly alters lipid metabolism and transport in the liver in association with the reactive oxygen species (ros) mediated carcinogenesis, although the molecular basis of underlying mechanisms as well as responsible elements of hcv gene for this is yet to be established. thus, the aim of this study was to clarify whether hcv core protein expression directly alters lipid metabolism-relating enzymes to (cause steatosis, especially focusing on nuclear receptors and atp binding cassette transporter proteins expression. methods: . the complementary dna clone of full length hcv core (aa - ) was derived from serum of hcv i b patient by reverse transcription and nested polymerase chain reaction, and hcv-core expression plasmid (pcag-hcvcore) was prepared by a standard procedure. control plasmid was also prepared with p-galactosidase (pcag-lacz). . hepg cells were transfected with pcag-hcvcore or pcag-lacz, thereafter harvested for enzymatic triglycerides (tg) assay, hcv core antigen rneasurement by elisa at h or h. also, lipid metabolism-related enzymes mrna expression was estimated by semi-quantified rt-pcr; mitochondrial and peroxisomal fatty acids ,&oxidation, o-oxidation, abc transporters (mdr , mrp , bsep), microsomal tg transfer protein (mtp), ldl receptor, and nuclear receptors. resultss: . hcv core expression was evidenced at and h at the similar level. . hepatic tg was increased in hcv core expressing cells, along with down-regulation of carnitine palmitoyl transferase a(cptla), a precious protein in liver mitochondrial fatty acid@-oxidation ( % at h, % at ) and up-regulation of acyl-coa oxidase (acol), a precious protein in peroxisomal fatty acidso-oxidation ( % at h). cyp a , a precious protein in microsomal o-oxidation, and mtp, a precious protein in vldl assembly, were not detected or unchanged. superfamily (sf ) helicases and helicase-like proteins share conserved motifs. alignments reveal that several additional conserved motifs are present in the sf helicase encoded by the hepatitis c virus (hcv). the roles of two such motifs are examined here using structure-based site-directed mutagenesis. the first motif (yrgxdv) forms a loop that connects sf helicase motifs and , at the tip of which is arg . when arg is changed to ala, the resulting protein retains a nucleic acid stimulated atpase but cannot unwind rna, unwinds dna poorly, and does not translocate on ssdna. dna and rna stimulate atp hydrolysis catalyzed by r a like the wildtype but the mutant protein binds dna more weakly than wildtype both in the presence and absence of a non-hydrolysable nucleotide analogue. thus, this "arg-clamp" motif anchors the protein on nucleic acid enabling processive unwinding. the second motif (dfsldptf) forms a beta-loop between sf motifs and that connects domains and . when f in this "beta-arm" is changed to ala, the resulting protein is devoid of all activities. when f is changed to ala, the protein retains nucleic acid stimulated at-pase, but unwinds dna and rna poorly. in this case, uncoupling of atp hydrolysis and unwinding is due to the fact that the f a mutant does not release dna upon atp binding like the wildtype. the f a mutant also has a lower melting temperature than the wildtype indicating the hydrophobic pocket formed by the beta-arm and residues in domain stabilizes the protein. data support an inchworm model for helicase action and identify two new potential sites for rational hcv drug design. this work was supported by the aasld liver scholar award from the american liver foundation. tat is an early gene product of hiv- that is essential for replication and viral gene expression. this transactivating protein is secreted by hiv-infected cells and taken up by neighboring cells. tat modulates expression of specific cellular genes and may be a key player in the interactions between hiv and other infections. one of the most common coinfections observed among hiv patients is hepatitis c virus (hcv). if hiv tat has an effect on hcv replication, this could help explain the rapid development of liver disease and cancer among hiv patients. aim this study was designed to test the hypothesis that tat alters hcv replication. methods: soluble tat was added to the media of huh- cells containing a hcv replicon. replicon replication was quantitated using a ribonuclease protection assay. using an ltr-luciferase plasmid to transfect hela cells, we developed a series of controls outlining the relative oxidative state of the tat protein. results exposure to tat protein in the reduced state substantially increased hcv replicon replication. oxidized tat was found to have no significant effect on the replication of the replicon. the increase was dependant on length of exposure to tat and the concentration of tat. present work: further assays seek to define the nature of the effect by tat on hcv replication. conclusion: tat may upregulate hcv replication directly or indirectly, and thereby play a role in modulation of hcv infection and pathogenesis. elucidating the complex interactions between hiv and hcv will be critical in evaluating and developing workable treatments for the increasing number of coinfected hiv/hcv persons with liver disease. acknowledgements: this research was supported by nih grants ai , ai , ai , ca and ca . we have found previously that expression of hepatitis c virus proteins in cell lines or in the liver of transgenic mice inhibits interferon alpha induced signaling through the jak-stat pathway (heim et al., j virol, , : and blindenbacher et al., gastroenterology, , ) . the aim of the present study was to investigate if the same inhibition takes place in livers cells of patients with chronic hepatitis c. from february to april , all patients with chronic hepatitis c referred to the outpatient liver clinic of the university hospital basel were asked for their permission to use part of the liver biopsy for this study. for non-hcv controls, patients that underwent ultrasoundguided liver biopsies of focal lesions (mostly metastasis of carcinomas) were asked for their permission to obtain a biopsy from the normal liver tissue outside the focal lesion. the protocol was approved by the ethical commission of basel. written informed consent was obtained from all patients that agreed to participate in the study. after removal of a to mm long biopsy specimen for routine histopathological workup for grading and staging of the liver disease, the remaining to mm long biopsy cylinders were immediately incubated in pbs or pbs with human interferon alpha (lo iulml) for to minutes at °c. the samples were then used for the preparation of cytoplasmic and nuclear extracts and in some cases for immunofluorescence studies. in a first part, the ex vivo stimulation of biopsy tissue was validated. biopsy samples of patient with different degrees of fibrosis were incubated for , , , and minutes, and the nuclear translocation (a surrogate marker for activation) of statl was visualized by immunofluorescence. we found a transient activation of stat , with a peak after minutes of stimulation with interferon alpha. the signal was shut down in all biopsies after minutes. interferon alpha diffused readily in the biopsy cylinders regardless of the degree of fibrosis. in the second part, consecutive biopsies of patients with chronic hepatitis c and consecutive control biopsies of patients who underwent ultrasound-guided biopsy of focal lesions in otherwise healthy livers (mainly liver metastasis of carcinomas) were used for semiquantitative assessment of interferon alpha induced statl activation using gel shift assays. we found a signhcant inhibition of statl dna binding in patients with chronic hepatitis c compared to controls. as in our previous work with hcv protein expression systems, statl phosphorylation was not impaired in human liver biopsies from patients with hepatitis c. we conclude that interferon induced intracellular signaling can be analyzed semi-quantitatively in human liver biopsies ex vivo by gel shift assays. using this newly validated method, we found that signaling is impaired in liver biopsies from patients with chronic hepatitis c. the block in stat signaling is at the level of dna binding in the nucleus, whereas stat activation at the interferon receptor functions normally. methods we studied the intrahepatic and peripheral hcv-specific cds+ t cell response in a cohort of hla-a positive chronically hcv infected patients by tetramer staining, intracel-m a r ifngamma staining and cfse labeling. in addition, viral amino acid sequences corresponding to the four ctl epitopes used in the study were deduced by nucleotide sequence analysis to assess the potential role of viral escape variants. results ( ) substantial higher numbers of hcv specific cd + t cell responses were detectable in the liver compared to the peripheral blood, suggesting compartmentalization at the site of infection. in addition, intrahepatic cds+ t cells were multispecific whereas peripheral hcv specific cds+ 'i' cell responses were primarily monospecific. these results suggest, e.g., the persistence of hcv-specific t cells at the site of disease or the direct priming of t cells in the liver. ( ) epitope-specific cd + t cells that were detectable in peripheral blood as well as liver were characterized by a good peripheral proliferative capacity after peptide specific stimulation suggesting that proliferation is a prerequisite of peripheral virus-specific cd + t cells to accumulate in the liver. this is further supported by the observation in one patient that the lack of proliferation of virus-specific cd + t cells in the peripheral blood was associated with the absence of the same cds+ t cell response in the liver. ( ) despite the strong accumulation of hcv specific cd + t cells in the liver, the majority of those cells was unable to secrete cytokines after peptide specific stimulation indicating that dysfunction of intrahepatic hcv specific cd + ' i cells might contribute to viral persistence. importantly, ifn gamma producing tetramer positive cd + t cells were only detectable in patients with low viral titers or in patients with high viral titers but with sequence variations in the corresponding viral epitope, suggesting viral escape. the relative contribution of t cell dysfunction versus viral escape to viral persistence is not known. it is important to note, however, that both mechanisms can operate within the same patient. insulin resistance (ir) is a frequent feature in chronic hepatitis c while risk factors of steatosis are body mass index in patients infected with genotype and viral load in those infected with genotype . in patients with chronic hepatitis c, we adressed the following issues: ) is ir the cause or consequence of steatosis and fibrosis ? ) what are the risk factors of ir ; ) does ir play a role (and to what extent) in the occurrence of steatosis ? ) is ir involved in the progression of fibrosis ? therefore, this study was designed to assess relationships between ir, steatosis and fibrosis according to hcv genotypes in non diabetic patients. methods: non-diabetic patients with biopsy proven non-cirrhotic chronic hepatitis c had fasting serum glycemia and insulinemia measurements. ir was evaluated by using homa model assessement. groups of patients were defined according to hcv genotypes ( or ) and degree of steatosis (absent or mild vs moderate to severe). results: the groups were similar in terms of age, sex ratio, bmi and disease duration. prevalence of ir (homa higher than . ) was significantly higher in genotype patients with steatosis than that of other patients ( % vs , and % respectively, p=o.oool). ir was significantly associated with extensive fibrosis in genotype patients (p= . ) but not in genotype patients. among genotype patients, independent parameters associated with ir were age (p= . ) and steatosis (p=o.o ) but not fibrosis. independent risk factors for steatosis in genotype and genotype patients were dr (p=o.o ) and viral load (p= . ) respectively. steatosis was associated with significantly higher fibrosis score whatever the genotype (p=o.o ). among genotype patients, the median progression rate of fibrosis was significantly higher in those having steatosis and ir together than in other patients ( . vs . , p = . ). conclusions : in non-diabetic patients with non-cirrhotic chronic hepatitis c ) steatosis and fibrosis are associated with ir in genotype patients but not in genotype patients, ) among genotype patients, ir mainly depends on age but not fibrosis ) ir is a major risk factor of steatosis in genotype patients, ) the combination of steatosis and insulin resistance is a risk factor of fibrosis progression. these results suggest that ir is not the consequence but rather the cause of steatosis and fibrosis progression. . however, in the first month of life, in of these newborns, hcv rna was only detected in pbmcs and not plasma. in neonates, the sscp band patterns of pbmc-derived viral sequences were different from maternal sequences in serum or pbmc; however, they were identical to hcv rna negative strand amplified from mothers' pbmc. the latter strongly suggests that the infection was transmitted through maternal infected pbmcs. another infant harbored different hcv strains in serum and pbmc; both strains were present in the mother's serum. only of hcv-rna positive children developed hcv antibody at one year. hiv infection was found in out of hcv rna-positive and in out the hcv rna-negative infants (ns). conclusions: we have found that ) hcv strains infecting neonates may be derived from strains residing in maternal pb-mcs. ) hiv+ pregnant women who were hcv rna positive in pbmcs were more likely to transmit hcv to their infants. these data suggest that one mechanism for perinatal transmission of hcv is maternal-fetal transfusion of hcv-infected pbmcs late in pregnancy or during labor and delivery. additionally, hcv infected neonates may have a limited ability to develop hcv antibodies in the first year of life and thus there may be an underestimation of the prevalence of hcv infection by anti-hcv determination among children born to hcv rna positive mothers. (hcc) in this clinical setting is very high. however, the molecular mechanisms of how hcv related proteins may contribute to hcc is not well defined. hcv core protein, a viral structural protein, has been implicated in tumor development. the goal of this study was to characterize the transcriptional regulation induced by core protein expression with respect to generations of a malignant phenotype. meth ds:a cdna fragment encoding hcv core protein of l b genotype was subcloned into the ptre hyg vector and co-transfected with ptet-on vector (clontech) into a human huh hepatoma derived cell line using polyamine (mirus) as a carrier. stably transformed clones were selected by growth in culture medium containing g and hygromycin. clones positive for hcv core protein expression were screened by immunoblotting from cells grown in the presence and absence of tetracycline. one clone with core expression tightly regulated by tetracycline was chosen for further analysis. cell proliferation was evaluated by a modified mtt assay, at , , , and hours after induction of core protein expression. twenty-four hrs after hcv core expression, the cellular transcriptional changes were analyzed by microarray analysis using human genome u array sets (affymetrix). the microarray data were validated by real-time pcr on selected genes. results hcv core protein expression was tightly regulated by the presence of tetracycline and the protein levels were dependent on the amount of the tetracycline present in the culture medium. core protein expressing cells showed significant increase in growth compared to non-expressing cells at , , , and hours after addition of tetracycline indicating a proliferation stimulus provided by core protein. microarray analysis using human gene chip u revealed that of , genes were significantly changed (> fold), with up-and down-regulated. this screen was quite informative since genes involved in regulation of cell proliferation ( genes) and apoptosis ( genes) were changed respectively. conclusions: enhanced growth of liver-derived cells by hcv core protein is due to cellular transcriptional changes induced upon core expression; two major molecular pathway(s) are involved ) those involved in celi growth control and ) those involved in cell survival. such gene regulation by hcv core protein is important to the molecular pathogenesis of hcc daudi-cd cells were infected with pnl - , a t-tropic hiv molecular clone. hours later, uninfected and hiv-infected cells were incubated with either % high titer hcv-positive patient serum, % hcv-negative patient serum, or % fbs (no human serum). infections were continued for , , , and days; cells were harvested, stained with annexin v and propidium iodide, fixed, and apoptosis was measured by flow cytometry. annexin v is a marker of early apoptosis, and propidium iodide indicates cell death either by apoptosis or necrosis. results: six high titer hcv-positive sera and six hcv-negative sera were tested in five separate experiments, and in each case, the percentage of viable cells was higher in the hivihcv-coinfected cells compared to those infected with hiv only. to further elucidate dynamics of the course of coinfection, we did a time course consisting of harvests every eight hours beginning at day (the earliest point at which apoptosis had been observed in prior experiments) and continuing until day plus hours. the results of the five harvests from day plus hours to day plus hours are shown in the figure below. the percentages of viable cells and those undergoing apoptosis are shown as measured by flow cytometry. during this -hour interval the percentage of viable (negative for apoptosis) cells fluctuated very little in untreated cells, or in cells incubated with hcv-positive serum, or even in hn-infected cells incubated with hcv-positive serum. in striking contrast, hiv-infected cells that were incubated with hcv-negative patient serum dropped to only % viability by the end of the hours, compared to % viability in the hiv-infected cells incubated with hcv-positive patient serum. this effect was not observed when apoptosis was induced by either of two chemical inducers of apoptosis in daudi cells: peroxisome proliferator-activated receptor gamma ligand and calpain inhibitor . next, we sought to determine if the effect of apoptosis inhibition was dependent on hcv particles. when h ninfected cells were kept separate in culture from hcv-infected cells by a membrane that prevented virus passage, apoptosis in the hn-infected cells was still inhibited. conclusions: collectively, these results suggest that in our experimental conditions: ) hcv-positive sera, but not hcv-negative sera provide a protective effect to hiv-induced apoptosis in daudi-cd cells, and ) a cellular factor induced by the presence of hcv, rather than hcv particles themselves, is responsible for the inhibition. methods: serum and pbmc samples from an individual with acute hcv-infection (genotype l a ) were collected every two to three months over a time period of months beginning months after infection. pcr amplification of vrna using a set of overlapping primers for the entire hcv genome was performed and pcr-products population sequenced using an abi automated sequencer. cd + t cell responses were defined using an ifngamma elispot assay using an overlapping synthetic peptide set spanning the whole hcv-genome (genotype la). based on the hla-type the complete viral genome was also screened for putative cds+ epitopes using a web based epitope prediction program (syfpeithi). results: elispot screening with the whole hcv-genome peptide set detected only two ex-vivo ifn-gamma responses (ns - and ns b - ), although neither epitope was associated with the development of mutations. however, over the month period of observation we detected a total of mutations throughout the genome ( in el, in e , in ns , in ns , in a ns and in ns ), in addition to multiple changes in the hypervariable regions. interestingly, only five of these mutations resided within known hla-restricted optimal epitopes. however, / mutations ( %) were located within predicted epitopes based on known hla-binding motifs of the subject. in order to begin to define the rate at which these mutations develop an intermediate time point of months was also sequenced. interestingly, / ( %) of the mutations had already occurred by this time. it is likely that at least some of these mutations are the direct result of immune pressure exerted through cd + t lymphocytes. we are currently generating peptide-specific cds+ t cellines against these regions exhibiting viral evolution, providing an opportunity to determine which of these regions are associated with previously undescribed cd + responses. conclusions: hypothesizing that evolving mutations in hcv might be the result of immune pressure by ctl, longitudinal full length sequencing of hcv may represent a powerful tool to define additional hcv-specific cd + t cell responses, especially those exerting substantial selective pressure. using this approach we were able to identify a number of candidate regions where cd + t cell responses may be present and driving viral evolution. determining the extent to which viral escape from cd + responses occurs during hcv infection will elucidate its overall impact in preventing proper control of hcv. indicate that the main open reading frame of hcv contains rna structures in the corelarfp (alternate reading frame protein) and nssb (polymerase) genes. we hypothesized that one or more of these structures are cis-acting replication elements (cre)s. methods. we used custom software, thermodynamic rna folding programs, and classical comparative phylogenetic analysis to build secondary structural models. we then used directed mutagenesis in the subgenomic replicon system to seek stem-loop elements in ns b that are required for viability. the mutations we introduced maintained the sequence of the polymerase protein, i.e., they were silent, synonymous codon substitutions. structural probing was carried out on replicon rna. rnase t and lead (ii), and nuclease v , were used to identify loops and helices, respectively. results. mutations in ns bsl . blocked replication, indicating that this novel structure is an essential cis-acting replication element (cre the aims of this study were: ) to correlate mean alt level with hcv rna by pcr positivity or negativity, ) to compare clinical, demographic and risk factor data as well as viral load and genotype between persons with pnalt, persistently elevated alanine transaminase (pealt) and fluxuating alanine transaminase (fluxalt) who had at least years of data available. methods: for each person in the cohort from whom pcr results were available (n= ), we calculated the mean level of all alts measured over a -year period after enrollment. for a subset of the cohort, we selected persons who met the following criteria: positive pcr tests year apart with the first positive pcr occurring prior to date of the first alt and a minimum of alt levels measured over the subsequent years with a minimum interval of month between alt measurements (n= ). we defined a person as having pnalt or pealt when of alt levels were normal or elevated, respectively, during the -year follow-up period. persons who did not fit into either of the above categories were defined as fluxalt. we reviewed clinical data via chart review, demographic and risk factor data via interviews, as well as data on viral load (performed by branched dna assay version . ) and genotype (restriction polymorphism analysis background: hcv infection rarely presents acutely, but when it does it offers a potential early "window" for effective therapy. it has been suggested that such therapy is efficacious due to enhanced activity of t cell responses, which are most active during acute disease. methods: subjects with acute hcv infection were comprehensively mapped for cd + t cell responses with an interferongamma elispot assay using overlapping peptides, spanning the entire hcv polyprotein. responses were confirmed by establishing peptide-specific t-cell lines and intracellular cytokine staining. the screening for hcv-specific cd + t cell responses was repeated during and after therapy. responses detected in the screening assay were longitudinally studied before, during and after therapy using single peptide elispot ,as well as tetramer assays. we also studied cd proliferative responses over time in some subjects using recombinant hcv proteins. results: cd + t cell responses were detected in / subjects before therapy was initiated and were typically multispecific, with up to epitopes targeted. after the start of therapy, frequencies of hcv-specific cd + t-cells declined following suppression of hcv viremia. therapy also did not increase the breadth of the hcv-specific response as no additional specificities were detected at later timepoints, when elispot screening was repeated. in / subjects viral relapse occurred after therapy was stopped, with subjects being retreated successfully. relapse was not predicted by the presence or absence of hcv-specific cd + t-cell responses. during viral relapse, a vigorous expansion of pre-existing hcv-specific cd + t-cells was observed for most specificities, with single responses reaching almost % of cd + t cells as measured by tetramer staining. these responses were unsuccessful in containing hcv. in the two subjects who were retreated after viral relapse, we observed the identical pattern of declining cd + t cell responses as in the first treatment course. in contrast to cd + t cell responses, cd proliferative responses usually became more vigorous after virus was suppressed on therapy. however, such responses also did not protect from viral relapse. conclusions: these data suggest that although multispecific functional cd + t cell responses may be present during acute disease, this does not predict a successful outcome of antiviral therapy. rather than boosting cd + t cell responses, therapy and viral suppression appear to lead to their attenuation, even though cd + t cell responses may be restored. figure) in the fibrous septum of portal tract in cirrhotic liver. significantly less fltl immunopositivity occurred in nd liver. hepatocytes were negative for fltl. conclusion: the greater de of genes involved in immune activation, fibrosis, cellular proliferation and cell signalling indicated that these processes are more active in the cirrhotic liver that has developed hcc than the cirrhotic liver without hcc development. plgflfltl signalling has an important role in neo-vascular development within organs. the decreased expression of plgf and its receptor flt in cirrhosis with hcc implies that vascular proliferative signals although normally active in cirrhosis itself may be decreased in cirrhotic livers with hcc. prospective analysis of cirrhosis prior to hcc development is needed to indicate whether these findings represent a premalignant phenotype. background: hepatitis c virus (hcv) infection often leads to chronic liver diseases including liver cirrhosis and hepatocellular carcinoma (hcc). at least hcv proteins have been identified, which serve as viral structural and non-structural proteins required for viral replication and virion formation. several viral proteins have been implicated in hcv persistence and the development of hcc. we have previously reported that the ns protein inhibits gene expression f+om various cellular and viral promoters in liver and non-liver derived cells. thus, expression of endogenous cellular proteins was significantly reduced in ns expressing cells. in this regard, the ns protein was recently found to be an inhibitor of the pro-apoptotic cide-b protein and therefore may contribute to hepatic oncogenesis. to understand the molecular basis of repressed gene expression, we constructed successive deletion mutants of the ns protein and tested their effect on luciferase expression driven by cmv promoter. meth-ods: the cdnas encoding the full-length ( - ), n-terminal part ( - ) and internal parts of ns were generated by pcr and cloned into the pcr . vector for expression under control of the cmv promoter. a liver-derived huh- cell line was co-transfected with a plasmid encoding the luciferase reporter gene and plasmid encoding various deletion mutants of the ns gene. inhibition of gene expression was measured by luciferase activity assay at day two after transfection. cell viability was also evaluated as well. results: deletion constructs - , - , - and - exhibited a significant inhibitory effect on luciferase activity comparable to the fulllength ns protein, whereas the deletion constructs - and - lost the inhibitory effect. therefore, the minimal amino acid residues required for the inhibition of gene expression by this viral non-structural protein was mapped to residues - . interestingly, this region partially overlaps with the binding site of the ns to a newly identified cide-b pro-apoptotic protein. il plays an essential role in the antagonism of t helper differentiation and in the induction of antiviral host defence. we postulated that genetically determined attenuation of il production could provide a plausible immunological mechanism able to determine outcome of hcv infection and have investigated a recently described polymorphism in the il b gene. methods: we have extracted genomic dna from whole blood taken from hcv antibody positive patients. patients had chronic hcv with detectable hcv rna and had spontaneously resolved infection, testing hcv rna negative on several occasions. genotyping for a single nucleotide polymorphism (snp) at position (a c) on the ill b gene was performed using polymerase chain reaction and restriction digest. maximal in-vitro il- production by cultured mononuclear cells in response to sac (staph aureus cowan) stimulation was determined in cases by elisa. results: of the hcv rna positive cases ( %) were homozygous for the 'a' allele, ( %) heterozygous 'ac'; and ( %) were homozygous 'cc' whereas of the hcv rna negative cases ( %) were 'aa', ( %) were 'ac'; and ( %) were 'cc'. hcv rna negative cases were significantly more likely to be heterozygous for lac' than hcv rna positive cases (p= . ). of the patients studied for il- production, were genotype 'aa' and 'ac'. were hcv rna positive ( genotype lac' and 'aa') and hcv rna negative ( genotype 'aa' and 'ac'). maximal il- production with sac stimulation was lower in the genotype 'aa' cases (mean units) than in the genotype 'ac' cases (mean units) (p= . ). hcv rna positive cases produced significantly less il- than did hcv rna negative cases (mean units compared to units, p= . ). comparison of hcv rna positive or negative cases only, revealed a trend for higher maximal il- production with genotype 'ac' regardless of hcv outcome. conclusion: cases heterozygous for the variant 'c' allele at position of the il- p gene are significantly more likely to be hcv rna negative than those homozygous for the 'a' allele. recent data found carriage of the variant 'c' allele to be associated with greater il- production capacity and our data from a small number of cases supports this. genetically influenced enhancement of il- production appears to be a factor influencing the outcome of hcv infection. we have previously demonstrated that hepatitis c virus (hcv) core protein expression in huh- hepatoma cells increased reactive oxygen species (ros) derived from mitochondria without inducing apoptosis. the aim of this study was to investigate whether hcv core protein inhibits the rosassociated apoptosis induced by deoxycholic acid (dca). methods:: we measured ros level and -hydroxy- '-deoxyguanosine ( -ohdg) content, and evaluated apoptosis in the presence or absence of dca ( pm), using a human hepatoma-derived cell line with tightly regulated hcv core protein expression under the control of a tet-offrm promoter. cells were incubated with pm of chloromethyl ', '-dichlorodihydrofluorescein diacetate for min for measurement of ros. cellular -ohdg content was quantified with enzyme-linked immunosorbent assay. fragmented nuclei were assessed with ', -diamidino- -phenylindiole staining and dna fragmentation was evaluated by genomic dna laddering. the degree of apoptosis was quantified with enzyme-linked immunosorbent assay. we also examined whether the general caspase inhibitor (zvad-fmk) inhibited the ros-associated apoptosis induced by dca. in some experiments, cells were incubated with wm of ursodeoxycholic acid (udca) in addition to dca. the experiments were repeated or times. results:: strong core expression was detected hours after withdrawal of tetracycline from the culture medium. the expression of core protein increased the basal ros level ( . . -fold, p< . ) and -ohdg content ( . i . -f ld, p< . ) of huh- - cells without inducing apoptosis. dca stimulation produced a . -fold increase in ros content in the presence of core expression and a . -fold increase in the absence of core expression. similarly, the -ohdg content was significantly increased by dca regardless of hcv core expression ( . -fold, p= . for core expression, . -fold, p=o.o for core non-expression). nevertheless, hcv core protein significantly suppressed the ros-associated apoptosis induced by dca (w . ). also apoptosis induced by dca was almost completely inhibited by zvad-fmk. udca significantly decreased the ros (p< . ) and the -ohdg content (p=o.oos) in the core-expressing cells and attenuated dca-induced apoptosis. on-treatment virological response (otr) was defined as complete loss or greater than -fold drop in hcv viremia within - months of therapy by quantitative or qualitative rt-pcr (roche cobas amplicor v . ), based on recommended early virological testing for continued therapy. forty-six patients with at least months of continued antiviral therapy were examined thus far, including with genotype (cl) and with either genotypes or infection (c ). on-treatment response (otr) was achieved in / ( %) patients overall, including % among c and % in c groups. positive and negative control groups included healthy hcv seropositive but nonviremic subjects without history of antiviral therapy ("recovered") and healthy hcv seronegative volunteers, respectively. hcv-specific cd t cell response was examined using recombinant hcv core, ns l , ns and control proteins in standard proliferation and ifn-gamma (ifng) elispot assay at baseline (pre-treatment) and at , andlor months during antiviral therapy. results: hcv-specific cd t cell response was significantly greater in the recovered compared to the chronic patients, consistent with its expected role in natural hcv clearance. among the chronics, c patients (genotype non- ) displayed a baseline t cell response to hcv ns / that was modestly but significantly greater than c patients ( the progression of fibrosis in chronic hepatitis c virus (hcv) infection differs among individuals and determines the ultimate prognosis and thus the need for therapy. the molecular mechanisms associated with the progression of fibrosis are poorly understood. gene expression profiling technologies allow the analysis of gene networks whose expression is associated with specific pathological conditions. we used real-time quantitative rt-pcr assays to compare the mrna expression of selected genes in liver biopsies of controls (n= normal liver samples) and of untreated patients with chronic hcv infection and different stages of fibrosis according to metavir, i.e. stage flal (n= ), f a (n= ), f a (n= ), f a (n=lo), f a ( n = l l ) and f a (n= ). in order to limit the number of pcr experiments, we first studied total mrna pools which were prepared by mixing amounts of individual liver biopsies mrna of each group. this pooled sample analysis allowed the selection of genes displaying significant different expression (> -fold variation) in comparison to "normal livers". the selected genes were then studied at the individual level and their diagnostic performance was assessed using roc curves. the most informative genes were used to construct specific gene expression signatures. we identified several genes specifically involved in various stages of fibrosis. the dysregulated genes mainly encoded extracellular matrix proteases, growth factors, cytokineslchemokines, and ifncu-induced genes. we also observed a statistically significant association between hcv rna amount (as determined with the same real-time quantitative rt-pcr technology) and expression of several genes, mainly ifn-a-induced genes including stat , ifi , mix , oas and gip . understanding the correlates of protective immunity in this setting is an important first step in the development of potential vaccine candidates. methods: two recipients of frozen patellar allograft tissue procured from the same donor developed evidence of acute hcv within months of surgery. in retrospect, the donor was confirmed to be hcv antibody negative but hcv rna positive (genotype la). both patients were enrolled in a prospective study of t cell immunity requiring whole unit blood draw at baseline, , , and months. comprehensive hcv-genomewide analyses were determined by ifn-y elispot responses to overlapping peptide pools that spanned the entire hcv polypeptide (genotype la, aa, total peptides). peptide responses were defined as greater than mean plus sd compared to control wells. results: patient ( yo wf) cleared the virus spontaneously within months; when first evaluated, the pt. demonstrated cd + t cell responses to of ( %) peptide pools, with effector frequencies as high as in , (to ns helicase- , amino acids - ). ifn-y cd + t cells were detected following stimulation with of ( %) pools (highest frequency to pool ns b- , aa - ). remarkably, months later, the repertoire of the hcv-specific cd t t cell response had expanded further, and patient demonstrated responses to of ( %) pools. in contrast, patient ( yo wm) demonstrated persistent viremia ( . million copieslml, bayer assay) and lacked cd + t cell responses to any peptide pools when first evaluated; only one peptide pool (ns -helicase- , aa - ) elicited responses in cd + t cells. despite virologic clearance with antiviral treatment (pegylated interferon and ribavirin), elispot screening failed to reveal emergence of new cd + or cd + t cell responses ( months later). conclusions: comprehensive analyses of hcv-genome-wide cd + and cd + t cell responses reveal significant differences in patients exposed to the same hcv innoculum and correlate with spontaneous clearance versus chronicity. in hcv infection that resolves spontaneously, the repertoire and strength of the hcv-specific immune response may continue to expand in the first year after infection (and may target more than one-third of the hcv polypeptide). in contrast, the profile of t cell responses remains narrow, weak, and constant in the acute infection that becomes chronic, even after successful antiviral therapy. alcohol consumption exacerbates liver injury in chronic hepatitis c and enhanced oxidative stress is one possible pathophysiological mechanism. we have previously developed a hepatoma cell line with conditional, stable expression of hcv core protein and constitutive expression of cyp e . these cells demonstrate dosedependent ethanol toxicity when core protein is expressed. the aims of this study were to determine whether reactive oxygen species (ros) production and mitochondrial dysfunction are responsible for ethanol-induced cytoxicity. methods: huh- cells with conditional expression of core protein and constitutive expression of cyp e (l subclone) were exposed to . micromolar tbooh and/or ethanol ( mm) for up to hrs. cytotoxicity was measured by mtt assay or trypan blue exclusion. ros production was assayed with the oxidation sensitive fluorescent dye dcfda. mitochondria membrane potential was analyzed by flow cytometry using the dye jc- as a probe. apoptosis was detected by cellular dna content analysis with flow cytometry. results: in the presence of . pm tbooh, there was a progressive increase in cell death in huh- cells expressing no heterologous proteins ( %), cypzel only ( l%), core only(l %), or core plus cypzel ( x). addition of mm ethanol to core/ cyp e expressing cells further increased cell death to %. dna content analysis and nuclear morphology showed that this type of cell death represented necrosis and not apoptosis. effects on mitochondrial membrane potential were also examined. under control conditions, only . % of cells had depolarized mitochondria. expression of corelcyp el and exposure to tbooh depolarized mitochondria in % of cells. similar to cell death, ethanol ( mm) addition increased depolarization to % of cells. compared to control cells, core protein increased ros by a factor of . . , and the combination corelcyp el by . . . furthermore, cells expressing corelcyp el ampiified the effect of exogenous tbooh. incubation with tbooh ( . pm) had no effect on ros content of control cells. it approximately doubled the ros content of cells expressing either core or cyp e and it increased ros content of cells expressing both corelcyp el by . . fold. in all cases the increase in ros was completely blocked by the antioxidant n-acetyl cysteine ( mm). the antioxidant also completely blocked both mitochondrial depolarization and cytotoxicity. conclusions: hcv core protein and cyp el synergistically enhance ros production in hepatoma cells, amplify the oxidative stress produced by extracellular ros, and sensitize cells to mitochondrial depolarization and necrotic cell death caused by alcohol. since all these effects are blocked by antioxidants, the formation of ros is likely to be the primary event which subsequently produces mitochondrial dysfunction and cell death. sponse associated with different outcomes of hcv infection may provide important insights into our understanding of hcv pathogenesis. for this purpose, we compared the functional features of hcv-specific cd cells in patients with chronic hepatitis c ( patients, ch), chronic asymptomatic carriers of hcv with persistently normal alt and positive serum hcv-rna ( patients, as) and in subjects with resolved hcv infection, either spontaneously ( subjects, sp) or following anti-viral treatment ( subjects, rt). functional analysis was carried out with highly immunogenic peptides corresponding to ns - , ns - , ns - , ns - , ns - , containing previously identified hla-a restricted epitopes. since the different hcv genotypes were represented in the different groups of patients in different proportions, different sets of peptides designed on genotype , genotype and genotype sequences were synthesized and used to reproduce more closely the sequence of the viruses infecting each individual patient and responsible for in vivo priming of the cds response. the immunological parameters tested were: a) frequency of hcv specific, cd + t cells by tetramer staining, both ex-vivo and after in vitro stimulation with synthetic peptides; b) ifn- production by intracellular cytokine staining; c) cytolytic activity by a standard %hromium release assay. the results of our study indicate that subjects recovered from hcv infection following treatment show lower ex-vivo frequencies of circulating hcv-specific cd cells compared to ch patients but their cells are able to expand and to produce ifn- more efficiently after in-vitro stimulation. indeed, hcv-specific t cell lines were induced in % of rt subjects and in % of ch patients; moreover, ifn- production was induced in % of rt subjects compared to % of ch patients (p< . ). in the group of subjects spontaneously recovered from infection, ex vivo cd frequencies were below the threshold of tetramer detection; however, peptide stimulation in vitro was able to expand tetramer+ cd cells and to induce ifn- production in % and % of the subjects, respectively. these lower levels of reactivity of sr subjects compared to tr patients are likely due to the different time elapsed from recovery, which was approximately years in tr subjects but much longer in sp subjects, who had recovered even decades before the time of immunological analysis. finally, the group of as patients showed the lowest levels of response to hcv, in terms of both frequencies of hcv-specific circulating cd cells and cytokine secretion. in conclusion, the hcv-specific, cd -mediated response has different features in patients with different outcomes of infection, showing a hierarchy of efficiency declining from subjects recovered after treatment who displayed the best responses, to chronic hepatitis patients, subjects recovered spontaneously and asymptomatic hcv-carriers, who appear to be the least responsive as a likely result of a deeper condition of tolerance to hcv. hepatitis c virus (hcv) infection is the most frequent cause of chronic liver disease in western countries and it has been involved in the development of cirrhosis with the risk of hepatocellular carcinoma. cyclooxygenases (cox) are crucial enzymes in the biosynthesis of prostaglandins and cox- , the inducible isoform, has been implicated in inflammation, fibrogenesis and carcinogenesis. to address whether cox- may play a role in hcvrelated hepatic inflammation and fibrosis, we determined the cox- expression pattern in the liver tissue from patients with hcv-induced chronic hepatitis (low histological activity= , high histological activity= ) and with end-stage cirrhosis, searching for correlations between the expression level of this enzyme and the histological activity of liver disease as well as with the intrahepatic expression and activity of metalloproteinases (mmps). we also investigated whether structural and non-structural hcv proteins may promote cox- expression in the human hepatocytederived cell line ccl . western-blot and rt-pcr analysis for cox- demonstrated that cox- expression levels were higher in mild chronic hepatitis (mch, . fold), severe chronic hepatitis (sch, fold) and cirrhosis ( . fold) than in normal liver. moreover, pge levels were also higher in liver samples from patients with sch ( . fold) and in those with cirrhosis ( . fold) than in normal liver. besides other cell types, hepatocellular cox- immunoreactivity was markedly observed in hcv cirrhosis, and although some cox- positive hepatocytes were observed at the edge of hepatic lobules, the majority of them were mainly restricted to the regenerative nodules. in contrast, none or few cox- expressing hepatocytes located in periportal areas were observed in patients with mch and sch, respectively. interestingly, we found a significant correlation between the intrahepatic expression and activity of cox- and mmp- and - in all the histological groups of patients analyzed. cox- mrna, protein and activity was de novo induced in resting ccl cells stably transfected with hcv core and ns a, and this effect was higher ( fold and . fold) when activated with cytokines and phorbol esters, respectively. in conclusion, our results provide evidence that a virus-induced hepatocellular cox- upregulation could mediate important pathogenic events in the course of chronic hcv infection, suggesting that specific cox- inhibitors might be useful for chemoprevention and therapy of hcv-related liver disease. were nahe to hbv. thl responses to hcv proteins ns , ns and core were sought by elispot. as a control thl responses were also sought to hbsag, where results were analysed according to recovery from hbv infection or nayve to hbv. thl responses to each of the proteins was performed before and after depletion of t-regs using anti-cd (> % depletion). results: following treg depletion thl responses were revealed de novo in / and enhanced in patients with ns , and with ns respectively and and with hcv core respectively. the overall increase in the thl responses with t-reg depletion was significant for both hcv core (median increase -fold p = . ) and ns ( - backaround: in both chronic viral hepatitis b and c viral persistence is thought to be due to an inadequate antiviral t cell response, which in turn may be caused by inappropriate priming of t cells by dendritic cells. an important subset of peripheral blood dendritic cells, the plasmacytoid dendritic cell, has been identified to be the major interferon-alpha producing cell in humans. since both hepatitis b and hepatitis c infection can be successfully treated by exogenous interferon-alpha, an impairment of endogenous interferon-alpha producing cells is an attractive hypothesis for the pathogenesis of chronic viral persistence. methods: patients with acute symptomatic ( n = l l ) and chronic hepatitis c (n= ), sustained responders to interferon-alpha therapy (n= ) and patients with acute hepatitis b (n=lo) as well as healthy controls (n= ) were included in this study. plasmacytoid dendritic cells were stained for facs-analysis in peripheral blood mononuclear cells with antibodies against bdca- and cd and by exclusion of lineage marker positive cells (cd , cd , cd , cd ). in addition pdc were stained with various activation and maturation markers (e.g. cdso, cd , cd ). production of interferon-alpha was measured by elisa after stimulation with cpg. results: in acute hepatitis c, ifn-alpha production was about -fold reduced as compared to healthy controls ( pg/ pbmc vs. pg pbmc). this reduction was caused by both a significant reduction in absolute numbers of pdc ( . /~ vs. . /pl, p= . ) as well as by a reduction of ifn-alpha production per cell ( . pg/pdc vs. . pg/pdc; p= . ). in chronic hepatitis c, ifn-alpha production was still reduced by over %, although absolute numbers of pdc were similar to healthy controls. following spontaneous or treatment induced viral clearance both number and ifn-alpha secretion of pdc were not different from healthy controls. importantly, in acute hepatitis b, which runs a self-limited course in the majority of cases, also the ifn-alpha production was reduced ( pg pbmc). this reduction was also caused by both the reduction of absolute pdc count ( . ~ , p=o.l) as well as by the ifn-alpha secretion per pdc ( . pg pdc; p= . ). using a panel of dc activation and maturation markers we did not find any evidence of a more immature or more activated phenotype of pdc in acute hepatitis c. exogenous ifn-alpha administration during acute hepatitis c led to a further reduction of ifn-production by pdc. conclusions: acute viral hepatitis has a dramatic impact on frequency and function of plasmacytoid dendritic cells in the peripheral blood, indicating that pdc play an important role during this phase of viral hepatitis. however, no differences were found between patients with self-limited vs. chronically evolving acute hepatitis c or patients with acute self-limited hepatitis b. future studies have to clarify whether the reduced ifn-alpha secretion by pdc contributes to viral persistence or whether this is rather part of a physiological response to acute viral disease. it has been suggested that hepatocellular steatosis, a frequent histological feature of chronic hepatitis c, is more frequent in hcv genotype infection, and disappearance of steatosis in patients who clear hcv genotype infection after antiviral therapy suggests a possible direct role of this hcv genotype. in order to assess the direct causal role of hcv in steatosis, we studied the relationship between hcv rna load and steatosis according to the hcv genotype. methods: we studied patients with chronic hepatitis c (genotype , n = ; genotype , n = ). the serum hcv rna level was measured at the time of liver biopsy by means of a third-generation "branched dna"-based assay (versant hcv rna . quantitative assay, bayer diagnostics). steatosis was graded as absent, mild (< % of hepatocytes), moderate ( to % of hepatocytes) or marked (> % of hepatocytes). daily alcohol intake during the months prior to liver biopsy, and the body mass index (bmi), were recorded. results: steatosis was more frequent in patients with genotype infection than in those with genotype infection ( . % vs . %, ns). steatosis was significantly more severe in hcy genotype than in genotype infection (moderate or marked in . % vs . %, p=o.oool). in patients infected by genotype , the severity of steatosis was significantly related to hcv rna load but not to alcohol intake or bmi. in contrast, in patients infected by hcv genotype , the severity of steatosis was not related to the hcv rna level but was significantly influenced by alcohol intake and bmi. bivariate analysis demonstrated the effect of the hcv genotype on the association between the severity of steatosis and viral load in genotype -infected patients, and between the severity of steatosis and exogenous metabolic factors in genotype -infected patients. multivariate analysis showed that : (i, in patients infected by hcv genotype , only hcv rna load was independently related to the severity of steatosis (odds ratio (or) = . , % confidence interval (ci): . - . ; p = . ), (ii) in patients infected by hcv genotype , bmi higher than . kglm (or = . , % ci: . - . ; p = . ), alcohol intake exceeding glday (or = . , % ci: . - . ; p = . ), and histological grade (or = . , % ci: . - . ; p = . ) were independently related to the severity of steatosis. conclusion: our results suggest : (i) steatosis is a cytopathic lesion induced by hcv genotype ; (ii) hcv genotype is not steatogenic per se or at the usual in vivo expression levels, and liver steatosis is a feature of associated steatohepatitis in these patients. the effect of hcv genotype sequences and the role of their expression levc s must be tested in vitro, in order to better reflect the in vivo situation. in animal models, steatosis is associated with oxidative stress and lipid peroxidation which is known to promote fibrogenesis. this study was aimed to assess in patients with chronic hepatitis c whether steatosis contributes to fibrosis through oxidative stress. methods: markers of lipid peroxidation and antioxidant status were measured in blood from chronic hepatitis c patients and age and sex matched healthy controls. intrahepatic levels of these markers were also assessed in a subgroup of patients and controls. results: the lipid peroxidation marker malondialdehyde was significantly higher in the blood and in the liver of patients compared to controls (p= . and p=o.o respectively) while the antioxidant glutathione peroxidase was significantly lower (p= . and p = . respectively). the antioxidant superoxide dismutase was significantly higher in the blood and lower in the liver compared to controls (p=o.o and p= . respectively). autoantibodies to soluble liver antigen (sla) are specific for autoimmune hepatitis. the molecular characterization of the sla antigen has allowed the establishment of highly sensitive and specific radioligand assays. to determine serum anti-sla a specific radioligand assay was used. total rna was isolated and reverse transcribed from hepg cells. the cdna encoding sla was amplified by pcr and used as a template to express sla protein eukaryotically in a tnt coupled reticulocyte lysate system (promega corporation, southampton, uk). anti-sla was measured retrospectively in consecutive patients ( girls, median age at transplant months; range - ) with dn-aih, in whom sera were available before transplant, , , , and months post-transplant and at the time of the diagnosis of dn-aih. eight patients had biliary atresia, alagille syndrome, cryptogenic cirrhosis, alpha- -antitrypsin deficiency, druginduced acute liver failure and bsep deficiency. the patient with acute liver failure did not have pre-transplant serum specimen stored. twelve patients had developed smooth muscle andlor antinuclear antibodies, two anti-liver kidney microsomal (one atypical) and two anti-mitochondria antibody. before transplantation, anti-sla was negative in / cases, the two positive patients having cryptogenic cirrhosis and biliary atresia. post transplant, anti-sla remained positive in these two and became positive in further patients. of these, in patients anti-sla became positive at a median of months (range: - ) before the clinical diagnosis of dn-aih. in children anti-sla became detectable as early as months post-surgery. in patients anti-sla levels were highest at the time of the clinical diagnosis of dn-aih. the presence of anti-sla in dn-aih supports the autoimmune nature of this condition; the frequent appearance of anti-sla before the clinical manifestation of the disease makes it a potential predictive marker for development of dn-aih. all patients showed positive response to the therapy, with respect to remarkable release of severe meteorism, active diet, and significant improvement of liver and kidney functions. however, no difference was presented in the markers of electrolytes, blood routine and blood gas analysis before and after the mars, while the effects on serum levels of alanine aminotransferase, aspartate aminotransferase and y-gt were remained uncertain since the alt decreased from ull to ullduring a in conjunction with observations from other centres, our data show that mars treatments resulted in a ramarkable removal of bilirubin, uric acid, bun, cr and ammonia, which could therefore decrease the toxic effects that higher concentrations of these compounds exert on liver and kidney function and could thus contribute to improvements in multiple organ dysfunctions. we found additionally that the higher concentration of serum toxin before detoxication therapy, the more efticacy removal could be achieved which presents mars could be {of therapeutic results even in the very serious cases. it remains questionable whether some of useful substances characted in low molecular weight such as trhlthyrotrophin-releasing factor), gnrh), adh(anti-diuretic hormone and calcitonin will be also removed by albumin dialysis, whether the added synthesis function is necessary for an artificial liver support, and whether this encouraging survival rate applies to long term outcome remains open for further investigation. scoring system has recently been introduced to determine priority for organ allocation in liver transplantation (lt). there is limited available data on resource utilization in the post-meld era.aims: . evaluate the effect of the meld system on lt-associated resource utilization and post-lt survival. . compare the costs of lt in the periods before and after the implementation of meld. methods : patients undergoing lt at our center in the months following meld implementation(cases) were compared to those undergoing lt in the immediately preceding -month period (controzs). the outcome parameters studied were: ) resource utilization: defined as ( there were no significant differences between the two groups in terms of age, sex distribution or presence of hepatocellular carcinoma (hcc). the average meld among cases was . , compared to . in controls (p = . , ns). overall los was similar in the two groups. however, pre-lt los, especially in the intensive care unit (icu), was significantly higher in the pre-meld or control group. the pre-lt cost was also higher in this group(p= . ), translating into significantly higher total costs of lt in the pre-meld period (p=o.ol). the need for post-lt hd, pmv and pressors was no different between the two groups. this data is summarized in table . the meld score was found to be significantly correlated with bile d u d damage is a maior feature in liver graft rejection. ductopenia (dp), defined as loss of more than %-of bile ducts, is a major hallmark of chronic liver graft rejection (cr), which usually leads to graft failure within the first post transplant year. in a previous study we have shown that in patients who developed dp and cr a deficient proliferative response of canals of hering (coh) was present in the preceding biopsies showing acute rejection (ar) when compared with a control group who experienced ar but did not progress to cr. these findings support the postulation that coh represent a regenerative compartment of the biliary unit in the liver. aim of the present studv: to analyze whether preservation of coh might contribute to the reversibility of dp. patients and methods we studied groups of patients. the index group (ig, n= ) developed loss of bile ducts without progression to graft failure due to cr during a follow up of years after transplantation. the second group (crg, n= ) were all cr patients, retransplanted at a median time of months (range - months). reperfusion (rb), week ( -w), month ( -m) biopsies were studied in both groups. in the crg the last biopsies (lb) before retransplantation taken at a median time of days (range - days) were also studied. additionally, in the ig the & ( -y), nd ( -y) and * ( -y) annual biopsies were also included. bile ducts and coh were identified by immunohistology using cytokeratin . ki (mib) was applied to investigate the proliferative activity. the number of bile ducts and coh were counted per portal tract and the number of k + cells was counted as ratio of the total number of cells in these structures. clinical follow-up of the ig group was studied based on liver function tests at similar time points as the biopsies. the ig group showed damaged bile ducts and decreasing numbers of bile ducts in the course of time, leading to dp at a median of years. contrastingly, the crg developed dp at a median time of days, observed in the last biopsies taken before retransplantation. when compared with the crg, the ig showed significantly less proliferative activity in bile ducts at -w (p=o.o ) but not in rb, -m and -y, the latter was compared with the lb of the crg. coh showed an initial increase at -w in the ig, but a progressive decrease in the subsequent biopsies, reaching significant loss at -y (p= . ). in the crg, progressive loss of coh started at -w, leading to a significant loss within year. numbers of coh were consistently lower in the crg at all time points except rb, although not statistically significant. there were also no significant differences in proliferative activity both within the ig in the course of time and when compared with crg. all ig patients continuously showed abnormal liver function tests apart from the bilirubin levels, which were elevated during the first month after transplantation but were normal after -y. at -y, median serum level of alkaline phosphatase was u/l, gamma glutamyl transpherase was ull, bilirubin was micromoll and asatlalat were ull. conclusion: the ig showed a much slower course of loss of bile ducts when compared with crg, leading to graft survival of more than years. a higher proliferative activity in bile ducts at week in the crg did not prevent the progressive development of dplcr in crg. the initial increase of coh at week in the ig might be responsible for the prolonged preservation of coh in the ig. as coh are believed to represent a regenerative compartment of the biliary unit, our findings indicated that prolonged preservation of coh might contribute to the delayed occurrence of dp but apparently not to reversibility of dp. absence of reversibility of dp is supported by the abnormal liver function tests. (ltx) . recurrent hcv poses a significant and possibly increasing threat to graft and patient survival. diagnosis of acute rejection and alterations in immunosuppression (is) may significantly impact the tempo of post-tx hcv. these associations motivated us to re-examine risk factors for early acute rejection (ear) in a large and contemporary cohort of ltx recipients. methods: the study cohort comprised of consecutive adults undergoing primary ltx between / / and / / for chronic liver disease with a minimum of day graft and patient survival. recipients received triple is, typically with steroids, tacrolimus, and mycophenolate mofetil. ear was defined as biopsyproven rejection or treatment for presumed rejection within months of ltx. risk factors for ear were determined by cox proportional hazard methods. spearman rank and phi correlations were used to determine associations between factors. results: men ( %) and women ( %) underwent deceased (n = ; %) or living donor (n = ; %) ltx. the etiologies of chronic liver disease were hcv (n= ; %), aih i pbc / psc (n= ; %), hbv (n= ; %), cryptogenic (n= ; lo%), alcohol (n= ; %), and miscellaneous (n= ; %). our overall incidence of ear was % ( i recipients); recipients ( %) had biopsy-proven rejection while recipients ( %) were treated for rejection without histologic confirmation. cox univariate models showed that hcv, female gender, meld , year compared to year , and lower day - tacrolimus (tac d - ) level were positively associated with ear while asian compared to caucasian ethnicity was negatively associated with ear (table la) . factors such as recipient and donor age, recipient african american or hispanic ethnicities, donor type (deceased or living), other years ( and ) , child's score and class, pre-ltx icu location, and cold and warm ischemia times were not significant risk factors. cox multivariate models showed that hcv diagnosis and female gender remained independent and significant risk factors for ear (table lb) . hbv etiology and asian ethnicity were significantly correlated (phi coefficient . ; p = < . ) and thus, did not remain independent risk factors in multivariate analysis. while lower tacrolimus level tended to predispose to ear, meld and year were no longer associated with ear. lower tacrolimus level was significantly correlated with both higher meld score (spearman rank correlation - . ; p = . ) and later transplant year (spearman rank correlation - . ; p = . ). conclusions: hcv etiology of liver disease is strongly associated with ear after ltx. risk of ear is higher for hcv than etoh, cryptogenic, and hbv etiologies and comparable to aih / psc i pbc etiologies; this effect is independent of gender, ethnicity, year, meld, and post-ltx is. recipients with high meld scores are also at increased risk for ear, at least partly because of lower post-ltx is. it is unclear whether the strong association of hcv etiology with ear is because hcv infection results in an immunologic environment predisposing to ear or whether we are unable to accurately diagnose rejection in the setting of hcv recurrence. aim: although the donor pool has expanded in response to increasing waiting lists the quality of donor livers has suffered as a result. it remains unclear whether such marginal organs can be safely used in high-risk recipients or whether they should be implanted solely into good recipients. we aimed to define recipient selection criteria for implantation of these grafts. methods: a prospectively collected database containing patients who underwent orthotopic liver transplantation between and was analysed. donors were scored using a formula derived by logistic regression that identified covariates (graft steatosis, donor age and cold ischaemia time) that independently correlated with primary graft dysfunction. this enabled them to be stratified into either marginal or non-marginal groups. using logistic regression analysis, recipient factors independently correlated with -year post transplant survival in the marginal group (recipient age, plasma albumin and urea) were built into a mathematical model and each patient was given a score accordingly. patients with scores higher than the defined optimum cut-off value were considered as high-risk and the others with lower scores as low-risk recipients. outcomes were then evaluated in these subpopulations results: marginal and non-marginal donor groups consisted of and patients respectively. the recipient score derived from the multivariate analysis was as follows : score = . x plasma albumin+ . x age group + . x urea, with the recipient albumin level coded as for < . gldl and for . gldl, the recipient age group coded as for > years, as for - years, and as for . mgldl, and as for . mgldl. the roc curve analysis showed that the score had a good discriminating power (area under the curve . , p =. ) and the ideal cut-off value demarcating high-risk from low-risk recipients was . . therefore the recipients were classed as high-risk if they had a plasma albumin level below . gldl with either an age of over or a urea level of above . mgldl or when they had a urea level over . mgldl with an age of over . of the recipients in marginal group, ( %) were classified as high-risk and ( %) were classified as low-risk. there was a huge -year survival difference between high-risk and low-risk recipients ( . % and . %, respectively, p <. background single-center experience with pretransplant use of rabbit anti-human-thymocyte globulin suggests that despite early depletion of lymphocytes, a third of all pediatric liver recipients develop early rejection, while the remainder demonstrate clinical graft adaptation. purposelmethods: to identify potential mechanisms, pediatric liver recipients, median age . years, median followup months, received pre-and post-transplant measurements of . whole blood concentrations of tacrolimus (tac), . interdose changes in mitogen-stimulated t-and b-cell responses (slr), . dendritic cell (dc),and peripheral blood mononuclear cell subsets, and . cd + -suppressor effect on donor antigenpresenting cell types (cd fmonocytes and cd + b-cells). all patients received ratg preconditioning with a total dose of mglkg in two divided doses. the first dose was given before liver transplantation (ltx). maintenance agent was tac without steroids. in patients this was replaced with sirolimus (srl). mitogen-stimulated t and b-cell responses were compared with those seen in a historical population, who had not received ratg pretreatment. results: all measurements were performed at a median interval of days ( - days) after ltx. . in slr, the frequency of t-cells expressing the cytokines ifn-g, tnf-a, and il- decreased with increasing total exposure (auc) to tac in historical controls (n= ). this relationship was markedly dampened in ratg patients (n= ), as suggested by slopes of . , . , and . relating ifn-g, tnf-a and il- on the y-axis to tac auc. . significant decrease in cd absolute counts at week and partial reconstitution at months after ratg pretreatment (mean pretx- vs week- vs month - celllmm ). during this period, monocytes and b-cells remained stable. . dc remained unchanged, while dc frequency increased significantly, from . to . , p= . . . in coculture experiments, purified cd + -subpopulations from two recipients receiving minimal tac doses induced decreased cd expression in donor apc, but increased its expression in hla-mismatched apc. eleven of subjects experienced rejection, while subjects are being maintained on daily (n= ) or every other day (n= ) doses of tac or srl. conclusions: despite lymphocyte depletion, rejection in the setting of t-cell anergy can be explained by relative sparing of antigen-presenting cells, which can recruit alternative effector mediators. the appearance of donor-specific cd + suppressor cells in recipients on low immunosuppression suggests that these conditions may also foster a favorable immunomodulatory response toward the liver allografts. (dropout) . the objective of this study was to evaluate the impact of the hcc-adjusted model for end-stage liver disease (meld) organ allocation scheme on the intention-to-treat outcome. under the meld scheme, patients with hcc meeting the united network for organ sharing (unos) t (single lesion under cm) and t (single lesion between to cm, or to lesions none exceeding cm) criteria were eligible for an initial meld priority score of and , respectively. they were also entitled to an increase in meld score, corresponding to a % increase in mortality, for every months on the waiting list. methods: excluding patients undergoing living-donor liver transplantation, we prospectively evaluated consecutive patients with hcc listed for olt since january . the kaplan-meier probabilities of olt and dropout among patients with hcc listed under the meld system between february and january were compared with patients listed between january and january under the previous system of organ allocation. follow-up in the pre-meld group was censored on february , , when the meld system for organ allocation was implemented by unos. for patients under meld, follow-up was censored on february , , when further refinements of the meld policy for hcc were made. results: the baseline characteristics were not significantly different between the two groups. eighteen of patients ( %) in the meld group and of patients ( %) in the pre-meld group received chemoembolization or various ablation treatments before olt (p= . ). all patients in the meld group met t ( patients) or t criteria ( patients). in the pre-meld group, patients had hcc stage exceeding t but meeting our proposed expanded criteria (single lesion not exceeding . cm or no more than lesions none greater than . cm with total tumor diameter not exceeding cm) by the time of olt. the kaplan-meier cumulative probabilities for olt at , , and . months of longest followup were . %, . % and . %, respectively, in the meld group, versus . %, . %, . %, and . % at , , , and months, respectively, in the pre-meld group (p= . ). under meld, none of the patients with t lesion had received olt. the cumulative probabilities for olt for the patients with t hcc in the meld group were . %, . %, and . %, respectively at , , and . months (p=o.oool versus the pre-meld group). the cumulative probability of dropout was . % at . months of longest followup without olt under meld, whereas the cumulative probability of dropout increased from . % at months to . % at months in the pre-meld era. the difference did not reach statistical significance (p= . ) largely due to low dropout rates in the first months for both groups. among the patients who received olt, of patients in the meld group versus of patients in the pre-meld group had pathologic hcc stage in the explant exceeding t criteria (p= . ). unfavorable histologic tumor features in the explant, including either poorly differentiated grade or microvascular invasion or both, were observed in of patients in the meld group versus of patients in the pre-meld group ( i " . ). the short duration of follow-up under meld precluded comparison of intention-totreat survival or hcc recurrence between the two groups. con-clusion: the hcc-adjusted meld system significantly improved the probability of timely olt, and was not associated with selection of a greater proportion of hcc with unfavorable explant tumor histology. given the low probabilities for dropout in the first months following listing for olt even in the pre-meld era, patients with hcc might have indeed received too high a priority score in the first year under meld. disclosures: nancy l ascher -no relationships to disclose nathan m bass -no relationships to disclose randomized at d to receive maintenance is regimen with ciclosporine microemulsion + prednisone (group ) or without steroids (ciclosporine microemulsion + placebo, group ) after a days blinded oral steroid tapering period. results : patients were recruited and a total of were randomized at d (group = , group = m). there was no difference between the groups for baseline characteristics, proportion of patients with hepatitis c ( . % and . %), or cyclosporine blood levels. the incidence of treated biopsy confirmed acute rejection at months was . % in group and . % in group (p= . ), with a trend for higher incidence of grade rejection ( . % vs . % ; p= . ). this difference was maintained in hcv pos and hcv neg patients. no difference was observed between the groups in terms of adverse events, infections, incidence of hypertension and renal dysfunction. changes from baseline were similar with regards to metabolic parameters. a trend towards a better glucose tolerability was observed, less patients receiving an antidiabetic treatment in the placebo group ( vs ). conclusion : peritransplant immunosuppression with basiliximab, cyclosporine microemulsion, and steroids resulted in excellent low rejection rates in lt patients. early steroid withdrawl strategy at day is not supported by the results of this study, which showed an higher incidence of acute rejection and a trend to more severe acute rejection, only balanced by a trend to a lower need of antidiabetic treatment. to determine if an association exists between meld score and post transplant graft loss within months. methods from / / through / / , , patients underwent liver transplantation, % of whom were followed for a minimum of three months. cox regression analysis was utilized to assess the relationship between meld score and post transplant outcome. transplantation. seventy one percent of patients were positive for autoantibodies: . % were positive for anti-nuclear antibody, . % for anti-smooth muscle antibody and % for anti-liver kidney microsomal antibody. the average alt elevation was (range - ) and ast elevation (range - ). an elevated ggtp was seen in . % of patients. all patients were hepatitis c pcr negative. at the time of diagnosis, patients were being treated with cyclosporine, with f'k , and with steroids in addition to calcineurin inhibitors. after diagnosis, all patients received standard therapy with l-zmg/kg of steroids. in addition, % ( ) began hthioprine and % had their calcineurin inhibitor dose decreased. after a mean of . years of follow-up (range . - . ), % remain steroid dependent and % are off steroids. one patient was re-transplanted for biliary complications and patient required conversion to sirohus. conclusion: diagnosis of de novo am requires a high index of suspicion as auto-antibodies are often negative. steroid therapy, often with the addition of azathioprine, is effective in controlling disease. many patients, however, become steroid dependent in order to remain in remission. background. liver allografts have an improved outcome compared with other solid organ grafts, and rodent studies have suggested that activation-associated lymphocyte death may play a key role. studies from our laboratory have shown increased levels of apoptotic lymphocytes in human liver grafts compared with renal grafts and native liver. although the levels of apoptosis did not differ significantly between those who developed acute rejection (rej) and those who did not (nr), the earliest timepoint studied was days post-olt. we hypothesized that the very early postoperative period (within hours) would reveal a relationship between leukocyte apoptosis and rejection. aims. the aim of this study was to determine the amount of early leukocyte apoptosis and its relationship with the degree of lymphocyte activation, subsequent rejection status and degree of donor cell chimerism. methods. peripheral blood mononuclear cells were isolated from patients undergoing olt and were collected on the day prior, hrs after reperfusion (day ) and hrs post-olt (day ). dna and rna were prepared and real-time pcr used to quantify apoptosis (ligation-mediated pcr), lymphocyte activation (il- , ifn-gamma, il- , cd ligand, using gapdh as an internal standard) and donor cell chimerism (y chromosome dyz or donor-specific drb ). results. the mean level of circulating apoptotic cells in day recipient pbmc was higher than healthy controls ( . % t- . vs . % ? . , ~~ . ) . apoptosis was greater in nr ( . % . ) compared with rej ( . % t- . , p=o.o ). on day the pbmc from nr had increased expression of ifn-gamma (p= . ), il- (p= . ), cd ligand (p= . ) and il- (trend) compared with rej, despite no difference in lymphocyte counts. donor cell chimerism on day did not differ between the groups indicating that this was unlikely to account for increased leukocyte apoptosis in the nr group. interestingly, the level of chimerism hrs postreperfusion (day ) was significantly higher in nr ( . % f . ) compared with rej ( . % t- . , p= . ) and there was a close correlation between chimerism on day and pbmc cytokine expression on day (r= . , p= . ). conclusions. patients who did not experience rejection had a paradoxical increase in markers of lymphocyte activation at day , in association with higher levels of leukocyte apoptosis. this suggests that recipient cell death may have a role in graft acceptance and reduced acute rejection in human olt. the higher donor cell chimerism seen in non-rejectors implicates the passenger leukocytes in the process of heightened cell death. disclosures: andrew clouston -no relationships to disclose wenyi gu -no relationships to disclose julie r jonsson -no relationships to disclose elizabeth e powell -no relationships to disclose daina m vanags -no relationships to disclose amadeo marcos, bridget flynn, paulo fontes, thomas cacciarelli, wallis marsh, michael devera, obaid shakil, noriko murase, anthony demetris, john fun% thomas e stanl, university of pittsburgh, pittsburgh, pa the seminal mechanism of organ engraftment is thought to be immune activation-dependent clonal exhaustion-deletion. the conventional use of heavy immunosuppression may depress the initial step of donor-specific activation to the extent that the treatment is anti-tolerogenic. to avoid this pitfall, we have applied therapeutic principles in management of adults cadaveric liver recipients transplanted between / - / . the treatment principles were, first, host conditioning prior to transplantation, and second, minimum post-transplant immunosuppression. the host conditioning was done with one gram of methylprednisolon and a single infusion of mg of alemtuzumab, completed before liver revascularization. there were males and females in the group with mean age . . years ( - ). main causes of liver disease were hepatitis c ( %), cholestatic liver disease ( %), alcoholic liver disease ( %). daily post-transplant monotherapy with tacrolimus (trough target ng/ml) was started - hours postoperatively (starting tacrolimus dose: . + mg, median ). because of suspected neurotoxicity, patients were switched to cyclosporin. in addition sirolimus monotherapy was substituted for tacrolimus in one patient for management of nephrotoxicity. immune activation diagnosed by liver function tests or by mild or equivocal rejection in liver biopsies frequently was not treated, and tended to resolve spontaneously. clinically and pathologically significant rejection was treated with a bolus of methylprednisolone and/or a mg dose of alemtuzumab. nine patients ( . %) died sepsis; pnf; one coagulation disorder (hypercoagulable state), and one congestive heart failure. of the surviving recipients four experienced rejection during the first two months which was readily reversed with a bolus of methylprednisolon. after demonstrating the absence of immune activation in liver biopsies at days post-transplantation, weaning from monotherapy was initiated in patients (with the aim of completely stopping treatment in selected cases). seven patients experienced one episode of rejection that was reversed with single dose of methylprednisolone and/or infusion of mg of alemtuzumab. presently, patients are on once a day monotherapy, patients on every-other-day, patients on three timedweek, patients on twicelweek and one patient on once-a-week immunosuppressive regimen (latest tacrolimus dose . t . mg, median . ). the patients on cyclosporin and sirolimus are also following the same stepwise weaning pattern. no cases of new onset diabetes, renal failure or hypertension was found in these patients. mean serum creatinine level in the study group at the time of transplantation was . . mgldl and at the latest follow up . . mgldl. cmv infection was seen in % of the patient population but was easily treatable with antivirals. no ptld was seen during the follow-up period. hepatitis c recurrence was seen in over % of the patients. response to anti-hcv therapy in this group, after reduction of immunosuppression and especially during the weaning process was promissing. conclusion: by applying the principles of immunosuppression outlined above, it has been possible to drastically reduce the amount of total immunosuppression relative to any (of our) pre-vious experience with liver transplantation. to see less side effects of chronic and high dose immunosuppressive therapy, and probably to have a chance to get a better response to treatment in our hepatitis c population. the results suggest the possibility of systematically achieving drug-free tolerance after liver transplantation. background:end stage liver disease as a consequence of hepatic sarcoidosis is an uncommon indication for liver transplantation (lt). consequently, there is a paucity of information on the pre-lt findings and postoperative course of individuals transplanted for hepatic sarcoidosis. the purpose of this study was to evaluate our experience with lt for sarcoidosis. methods: cases were identified by review of the mount sinai hospital lt database. patient records were reviewed; including the pathologic analysis of the hepatic explant, to confirm that sarcoidosis was responsible for liver failure. for each case, two control patients with other causes of liver failure matched for age, gender and date of transplant were selected. data collected encompassed a mean follow up period of years (range - years) post-lt. two-tailed student's t-test was used for comparison of continuous data, two-tailed fisher's exact test for comparison of categorical data and log rank test for comparison of survival d,ita. results: hepatic sarcoidosis was the indication for lt in of adult-lt ( . %) performed from september -june . . the mean age at transplant was years and / ( %) were males. the diagnosis of sarcoidosis was established by findings of extensive, non-caseating granulomas in pre-lt biopsy specimens or in the native liver explant. in / cases, sarcoid had been previously diagnosed by biopsies of lung parenchyma or mediastinal lymph node. of patients were ama negative. the sole exception was a patient with an ama titer of : in whom sarcoid was still considered the most likely diagnosis based on liver biopsy findings of granulomas present in both portal and lobular areas and granulomas in a lung biopsy performed -years prior to lt. extrahepatic disease was limited to pulmonary involvement in patients with radiographic findings of either interstitial infiltrates ( ) or interstitial infiltrates and hilar adenopathy ( ). the mean age at transplant and gender distribution were identical in cases and controls. the indications for lt in the control group were: hepatitis c ( ), pbc ( ) and one patient each with hereditary hemochromatosis, cryptogenic cirrhosis, hepatitis b and laennec cirrhosis. no statistically significant differences between the groups were present with respect to pre-lt levels of ast, alt, alkaline phosphatase, total bilirubin, serum creatinine or prothrombin time. cases and controls had a similar prevalence of ascites and anti-hepatitis b core antibodies. in contrast, sarcoid cases were much more likely to have a diagnosis of diabetes mellitus ( % vs. %, p=. ) and less likely to have antibodies to hepatitis c ( % vs. %, p=. ). standard orthotopic lt was performed (two control patients received right trisegment grafts). rates of acute cellular rejection were % in cases and % in controls (p=o. ) with cases experiencing a greater number of acute rejection episodes per patient ( . vs. . episodeslpatient). de novo autoimmune hepatitis developed in one case and one control patient. both de novo autoimmune hepatitis and chronic rejection developed in one case patient. recurrence of hepatic sarcoidosis was diagnosed in two patients at . and . years of follow-up. among cases, the one-year graft and patient survival rates were % and five-year graft and patient survival rates were %. there was no statistically significant difference in five-year graft or patient survival between cases and controls. conclusions: end-stage liver disease as a consequence of sarcoidosis is a rare indication for lt. these patients share many features in common with those transplanted for other indications. despite the small number of patients, a relatively high rate of acute rejection and de novo autoimmune hepatitis was observed in patients with sarcoidosis. recurrence of hepatic sarcoidosis was observed. five-year graft and patient survival rates were comparable to those of patients transplanted for other indications. disclosures: sander florman -no relationships to disclose leona kim schluger -no relationships to disclose kevin m korenblat -no relationships to disclose evan j lipson -no relationships to disclose transplantation. james d eason, ari j cohen, safheesh nair, george loss, ochsner clinic foundation, new orleans, la sirolimus has been used successfully in improving renal function in olt recipients previously treated with tacrolimus and steroids. we report our experience with early sirolimus conversion in steroid-free olt recipients to determine safety and efficacy in patients never treated with steroids. methods: we performed olt over a threeyear period. steroid-free immunosuppression with rabbit atg induction and tacrolimus and mmf was used in of these patients. twenty-five of these steroid-free recipients were converted from tacrolimus to sirolimus within one week to ll months of transplant. results of these patients receiving sirolimus conversion were reviewed. results: renal insufficiency was the reason for conversion in patients, while seven patients were converted because of neurotoxicity. six patients were dialysis-dependent at the time of conversion. one-year patient survival in this high-risk group was % ( / ) compared to % in patients who remained on tacrolimus. the four deaths were in patients converted because of renal failure, three of whom were on dialysis. the incidence of rejection was % in sirolimus patients compared to % in patients who remained on tacrolimus. rejection was treated by the addition of mmf or reintroduction of low-dose tacrolimus. only one patient required steroids to reverse rejection. conclusion: early sirolimus conversion is safe and effective lawal, sandy florman, isabel fiel, ronald gordon, myron schwartz, charles miller, thomas d schiano, the mount sinai medical center, new york, ny introduction: primary non-function (pnf) fter liver transplantation occurs in approximately % of cases and is fatal without timely retransplantation. pnf has been associated with many risk factors, however the etiology remains unknown. some evidence suggests that ultrastructural changes in the liver may be causative. aim: we sought to examine the hepatic ultrastructure of donor allografts in patients with and without pnf using electron microscopy. medical center, over adult orthotopic liver transplants were performed. patients with the classic clinical presentation of pnf requiring retransplant were identified. archived pre-and postreperfusion donor liver biopsies were examined by electron microscopy in patients with pnf and in matched controls. each pnf case was matched by donor age t years, gender, cold ischemic time klhour and the donor's cause of death. all biopsies were blindly reviewed by the same pathologist. particular attention was paid to abnormalities of the mitochondria, endoplasmic reticulum and sinusoidal endothelial cells. in addition, the glycogen content of the cells was also assessed. the recipient age and creatinine, as well as the donor serum peak transaminases and bilirubin were compared.non parametric tests with p values < . were regarded as significant using the spss . program. results: overall, patients with pnf were older ( . t vs. . years, p= . ) and had higher peak alt levels ( ? vs. u/l, p= . ). there was no significant difference in recipient peak serum creatinine, donor peak serum ast, sodium or donor peak serum bilirubin. in all cases, the endoplasmic reticulum and sinusoidal endothelial cells were ultrastructurally normal. the hepatocytes had variable degrees of glycogen pooling and moderate to severe fatty infiltration. in / ( %) pnf cases vs. ly ( %) control had intramitochondrial crystalline inclusions on pre-perfusion biopsy. conclusion: liver allografts from patients with primary non-function have significant mitochondria ultrastructural changes on pre-perfusion biopsies, and may thus have some intrinsic mitochondria abnormalities. introduction: the ideal liver allocation system would allocate donated livers to patients who are most likeiy to die without a transplant, but who have the lowest predicted mortality once they have been transplanted. this mode of allocation assesses the condition of both the recipient and the donor at the time of transplantation. in this study we have constructed a self-organising map (som: this is a neural network or non-linear mode of decision analysis suitable for modelling complex multidimensional relationships) and then validated it by using the som to classify survival in an unrelated population. patients and methods: we have previously described a som consisting of ( recipient and donor) factors (inputs) constructed from ( male; median age years; median meld score ) consecutive primary liver transplants undertaken between / / and / / in the queen elizabeth hospital, birmingham, uk. using a neuron version of this som with three output functions (patient survival at months; year and years) we used the som to classify the post-transplant survival of all primary graft recipients (n= patients) over a year period from a north american centre ( male; median age years; median meld score ). the birmingham (uk) patients were first classified by the som and then the probabilities of survival (p,) at months, year and years calculated by dividing the number of surviving patients by the total number of patients in neuron i. using this som, each of the wisconsin (us) patients was classified to each of the neurons and the distribution of survival probes for each neuron compared between the two populations using the chi squared test. results: there was no significant difference in the survival probabilities of patients in each neuron when the wisconsin population was compared with the birmingham population. thus, the birmingham som was able to classify successfully the survival of the wisconsin patient population at months, year and years following transplantation by using the same donor and recipient factors ( table ) . analysis of the inter-neuronal survival probabilities demonstrated that for month and year survival, neuron was associated with a significantly lower survival probability than neurons and (p= . for months; p= . for months). further, if recipients from neuron received livers from patients classified to neuron by "computer simulated transplantation", a proportion of patients then had a lower predicted survival probability (by som re-distribution to neuron ). this analysis indicates that patient survival post-transplantation is significantly infuenced by both the condition of the recipient and donor factors at the time of transplantation. conclusions: ( )som analysis provides an efficient and automated method for assessing the probability of survival of individual patients in an unrelated population at months, year and years following liver transplantation. ( )the model not only assesses the pre-transplant condition of the patient, but also considers a wide range of donor factors when predicting the probability of survival post-transplant. ( )this unique resource can match a single liver to a population of recipients most likely to die without a transplant whilst ensuring the best possible post-transplant survival for the most suitable recipient ( )som analysis can also assess the probability of survival of individual recipents matched to a range of possible donated livers when they are being considered for transplant programmes. purpose of study: to assess the efficacy of targeted prophylaxis in patients identified to be at highest risk of if after orthotopic liver transplantation. introduction: historically, invasive fungal infection (in) has complicated up to % of cases of orthotopic liver transplantation (olt). retrospective analysis has identified a variety of risk factors associated with a high risk for the subsequent development of ifi. these include patients undergoing retransplantation, transplantation for fulminant hepatic failure (fhf), requiring haemodialysis and prolonged intensive care unit (icu) stay. prophylactic anti-fungal therapy is safe and can reduce the incidence of ifl in olt recipientri. in recent years our unit has moved towards targeting prophylaxis to higher risk transplants. we assessed the efficacy of our policy in reducing the incidence of invasive fungal infection. methods: a retrospective audit was conducted comparing two groups of adult olt recipients over two year time periods, - when targeted prophylaxis was not used (group ) and - when targeted prophylaxis was used (group ). data were collected with respect to risk factors for ifi, anti-fungal prophylaxis use and development of ifi. results: there was no difference in the overall number of risk factors for if associated with olt between the two groups. however, a higher proportion of patients in group had high risk factors for if compared to group (p= . ). there was a significant difference in the use of targeted anti-fungal prophylaxis given to high risk patients in group compared to group ( . % cf . %, p= . ), and there was a significant reduction in the number of ifis in group compared with group ( . % cf . %, conclusion: a policy of targeting anti-fungal prophylaxis to highest risk liver transplant recipients leads to a significant reduction in if this group. there remains a background incidence of infection in low risk or long term recipients in whom prophylaxis is not given. background: only few studies have described risk factors associated with cellular rejection. the diagnosis of cellular rejection requires histology. there are no data evaluating the absence of rejection in a protocol biopsy population. aim: to assess predictive factors associated for the absence of cellular rejection in a protocol liver biopsy population and to evaluate the usefulness of protocol liver biopsies. method consecutive patients transplanted on a data-base at our centre. protocol liver biopsies were performed between and days post transplantation and then when clinically indicated, during the first months. rejection was scored prospectively. the following variables were examined with respect to absence of rejection over months and in the first protocol liver biopsy: a) donor factors: age, gender, race, donorlrecipient gender match, abo match. b) pre-transplantation recipient factors: age, sex, aetiology, ascites, oesophageal varices, tips, encephalopathy grade, renal support, ventilation, total bilirubin, albumin, inr, ast, alt, creatinine, urea, c) graft and surgical factors: surgeon's visual assessment of graft, cold ischaemic time, use of venovenous by-pass, intraoperative blood transfusion and initial maintenance immunosuppression of either cyclosporin or tacrolimus in triple-dual or monotherapy. standard treatment of rejection was g iv daily of methylprednisolone x days. results: absence of rejection over months was in ( %), mild in ( %) and moderatelsevere in ( %). in the first biopsy: absence of rejection in ( %), mild in ( %), moderate in ( %) and severe in ( . %). univariate analysis showed for both first protocol biopsies and months, that variables were significantly correlated with non rejection: pre-transplantation use of renal support (haemodialysis or hemofiltration), (p= . ), cold ischaemic time > hours (p= . ), suboptimal graft visually (p= . ) and blood transfusion <= units cp= . ). no correlation was found between aetiology of liver diseases, initial maintenance immunosuppression. conclusion: a suboptimal graft with prolonged cold ischaemic time in recipients with previous need of renal support seems to be associated with absence of rejection. these data are in contrast with previous reports. these factors may be helpful in identifying patients who do not need to be submitted to protocol liver biopsy. tables and child developed abnormal transaminases and was found to have chronic hepatitis on liver biopsy and was treated with steroids. required adjusting cyclosporine dosage to maintain trough levels in the identified range (range - microgramll as per protocol). summary: there was good correlation between the trough levels taken on occasions in the stable paediatric post liver transplant group of patients. the range of c peak levels were also similar suggesting good bioavailablity conclusion: this preliminary study on long term post transplant recipients suggests that a peak c level is within the range of - microgramll. background hepatocytes and cholangiocytes release substantial amounts of adenosine triphosphate into bile, where it is rapidly degraded by membrane-bound ecto-atpase and '-nucleotidase. this degradation process leads to the generation of adenosine and inorganic phosphate (i?#. whereas adenosine is reabsorbed in a sodium-dependent manner back into hepatocytes, little is known about the fate of biliary pi. in rat, biliary pi concentration is . mm, which is about fold lower than in hepatocytes ( mm) and fold lower than in plasma ( . mm) indicating active reabsorption of pi from bile canaliculi andlor from the biliary tree. aim: the purpose of the present study was to functionally characterize canalicular p, reabsorption in rat liver and to identify the involved p, transport system(s). methods: p, transport was determined in isolated canalicular liver plasma membrane (clpm) vesicles using a rapid filtration technique. identification of putative p, transporters was performed with reverse transcriptase-polymerase chain reaction (rt-pcr) from rat liver total mrna using sodiumlphosphate cotransporter specific primers for napi-iib (gggattgggaaattcatccti ttccaacacaaggttggtca), napi- subtype pit- (catctcggtgggatgtgcitgttgctctctcctccttca) and napi-i subtype pit- (gctctaccattggcttctcglaca-gaggaagtgcctggaga) . on the protein level, phosphate transporter expression was confirmed by western blot analysis in isolated basolateral (blpm) and canalicular (clpm) rat liver plasma membrane vesicles. specific polyclonal antibodies were raised in rabbits against antigenic peptides from mouse napi-iib and human napi-iiilpit- showing > % identity with rat homologues. results: transport studies in isolated clpm vesicles demonstrated sodium-dependent p, uptake (najut > nag pmollmin; k&t > kg pmollmin). initial na+-dependent p, uptake was linear for at least sec and exhibited a clear overshoot indicating transient intravesicular concentration of p, (secondary active p, transport). initial p, uptake rates ( sec) were saturable with increasing p, concentrations and exhibited an apparent k,,, value of - km. furthermore, sodium-dependent p, transport was higher at an acidic (phout = . ; ph,, = . ) as compared to an alkaline extravesicular ph ( . ). in addition, an intravesicular negative membrane potential stimulated sodium-dependent p, transport indicating a na:p, stoichiometry of > . these data are comparable with the transport characteristics of sodiumlphosphate cotransporters napi-iib, napi-iiilpit- and napi-iiilpit- . mrnas of all these three napi's were found to be expressed in rat liver by rt-pcr. however, on the protein level only napi-iib was found to be expressed selectively in clpm, whereas napi-iiilpit- was detected in blpm. no clearcut localization of napi-iiilpit- protein could be obtained. conclusions: the canalicular membrane of rat hepatocytes localizes the sodiumlphosphate cotransporter napi-iib, which can reabsorb p, from primary hepatic bile back into hepatocytes. in contrast, napi-iiilpit- was found to be expressed at the basolat-era hepatocyte plasma membrane. the results indicate that napi-iib regulates p, concentration in bile and may play an important role in the overall p, homeostasis in rat liver backgroundlaims. organic anion transporting polypeptides (oatps) are a family of transport proteins of the basolateral hepatocyte membrane. human oatp (slc a ) is predominantly expressed in hepatocytes and is an uptake system for xenobiotics such as digoxin. the oatp gene promoter possesses an inverted repeat (ir ) element at nt - l- relative to the transcription start site, that binds and is activated by the farnesoid x receptorlretinoid x receptor (fxrlrxr). ligands of fxr include bile salts such as chenodeoxycholic acid (cdca), previously shown to activate the oatp gene. however, because oatp is only a poor bile salt but an efficient xenobiotic transporter, we investigated whether xenobiotics such as rifampicin regulate the oatp gene. rifampicin is a prototypic ligand of the xenobiotic receptor pxr (pregnane x receptor). methods. endogenous oatp mrna levels in caco cells were quantified by real-time pcr. an oatp gene promoter construct containing nucleotides - l + relative to the transcription start site (luc- ) was assayed for reporter activity in transiently transfected cells. the fxr binding site in the oatp gene (ir element) was characterized using the luciferase construct ir -tk-luc that contained a thymidine kinase promoter under the control of the irl element. results. endogenous oatp mrna levels in caco cells were induced fold by cdca ( pmolll). interestingly, incubation of cells with rifampicin ( pmolll) resulted in a . fold increase in oatp mrna levels. to study the mechanism of rifampicinmediated induction of oatp , the promoter sequence was searched for potential pxr binding sites. because the ir element, previously shown to bind the fxrlrxr heterodimer, was the only nuclear receptor binding site found, we hypothesized that the induction by rifampicin could be mediated through the fxr element. we, therefore, studied the effect of cdca and rifampicin on the ir element. in cells cotransfected with the ir -tk-luc construct and expression plasmids coding for fxrlrxr, pxrlrxr or car (constitutive androstane receptor)lrxr, fxrlrxr induced the irl element llfold in the presence of cdca and . fold in the presence of rifampicin, indicating that rifampicin is capable of activating fxr. in contrast, pxrlrxr or carlrxr did not activate the ir element in the presence of cdca or rifampicin. to confirm that an oatp promoter construct is also activated by rifampicin, huh cells cotransfected with the luc- construct and fxrlrxr expression plasmids were incubated with cdca or rifampicin. cdca induced oatp promoter activity -zfold, rifampicin - fold, confirming that rifampicin transactivates the oatp promoter. to investigate whether other xenobiotics also activate the fxr element, huh cells cotransfected with the ir -tk-luc construct and fxrlrxr expression plasmids were incubated with rifampicin, rifamycin, ru , clotrimazol, phenobarbital or pcn. a . fold (rifamycin) to . fold (clotrima- ) induction of the ir element was seen in the presence of these xenobiotics. conclusions. the human oatp gene is induced transcriptionally by xenobiotics that represent prototypic ligands of the xenobiotic receptor pxr. however, activation does not occur through pxr but through activation of fxr bound to the ir element in the oatp gene promoter. the data thus indicate that pxr ligands such as rifampicin and clotrimazol can also activate fxr and thereby induce the fxr-regulated transporter gene oatp . disclosures: may-britt becker -no relationships to disclose michael fried -no relationships to disclose diana jung -no relationships to disclose gerd a kullak-ublick -no relationships to disclose peter j meier -no relationships to disclose epidemiologie de population epi seema sonnad -no relationships to disclose preservation of canals of hering mitigates bile duct loss in liver graft rejection. ivlarius c van den michael angelis -no relationships to disclose jeffery cooper -no relationships to disclose erick edwards -no relationships to disclose richard b freeman jr -no relationships to disclose ann harper -no relationships to disclose abigail mithoefer -no relationships to disclose no relationships to disclose the data was not available. the ca - , cea, and afp levels were obtained using standard commercially available assays results: out of a total of patients with esld fifty-eight patients fulfilled the inclusion and exclusion criteria. of these, thirty-three patients had evidence of ascites and twenty-five did not. the etiology of liver disease in the two groups was similar. the mean levels of ca - , cea and afp levels in patients with ascites were not significantly different from those without ascites (ca - . % furthermore, out of these patients with esld had levels -> ulml, the upper limit of normal in this assay unitslml] vs . . conclusions: ascites does not seem to make an impact on the serum levels of ca - chhaya hasyagar -no relationships to disclose savant mehta -no relationships to disclose severe mitochondrial toxicity after liver transplantation in hiv-hcv coinfected patients liver transplantation (lt) may be the only potentially curative treatment available to these patients at this stage. however its feasibility and benefit has still to be established. severe recurrence of hepatitis c on the liver graft may complicate the post operative course as recently suggested by us and others. mitochondrial toxicity of highly active antiretroviral therapy (haart) may also play an active role on the liver graft of htv-hcv co-infected patients. we aimed to study this complication on the liver graft of hiv-hcv coinfected patients. patients and methods: between he had an history of episode of pancreatitis and haart therapy was azt- tc-nelfinavir. at m post lt, microvesicular steatosis was noted. at m a low content of liver mtdna was found (mtdnalnuclear dna = . ). other patients had microvesicular steatosis respectively at m , m and m post lt. one of these patients had low content of liver mtdna (mtdnalnuclear dna = . ). severe defect of complex iv of the respiratory chain was noted in of these patients. no deletion of mtdna was observed by southern blot or long range pcr conclusion: mitochondrial toxicity on the liver graft may become a major problem during post lt c o m e and could worsen graft lesions related to hcv recurrence on the liver graft in hiv patients daniel azoulay -no relationships to disclose henri bismuth -no relationships to disclose denis castaing -no relationships to disclose duclos-vallee -no relationships to disclose cyrille feray -no relationships to disclose michelle gigou -no relationships to disclose catherine guettier -no relationships to disclose philippe ichai -no relationships to disclose claude jardel -no relationships to disclose anne lombes -no relationships to disclose bruno roche -no relationships to disclose faouzi saliba -no relationships to disclose didier samuel -no relationships to disclose elina teicher -no relationships to disclose daniel vittecoq -no relationships to disclose a identification of sodiumlphosphate cotransporter type iib marek nowicki, usc, los angeks, ca; jorge rakela, tomasz laskus, there is growing evidence that patients with chronic hepatitis c are more likely to have significant changes in their physical and mental well being, commonly manifested as fatigue and depression, than patients with liver disease of other etiology. recently published studies demonstrated also that hcv infection is associated with cognitive dysfunction. hepatitis c virus (hcv) was reported to replicate in monocyteslmacrophages and lymphoid cells. we have recently demonstrated that leukocytes carry hcv across the blood-brain barrier and we found hcv rna in the central nervous system (cns) in some infected patients (j virol , , - ; , - ) . however, biological basis for neurocognitive abnormalities observed in hcv-infected patients remains unclear. aim: to determine the pattern of gene expression in cns in hcv-positive patients as compared to hcv-negative controls. material and methods we analyzed samples of brain tissue obtained at autopsy from hcv-positive patients and hcv-negative control patients. all were men of similar age, none was infected with hiv. all hcv+ patients and out of controls had liver cirrhosis. only deaths (one in each group) were liverrelated. the analysis of gene expression was conducted using three different techniques: differential display (genhunter inc), reverse northern, and microarray analysis (bd atlas plastic miroarray). reverse northern analysis was used for confirmation of differential display findings. analysis of microarray data was done using atlas image . (bd) and cluster . and treeview . (m.eisen; ucb). only those genes that were up or downregulated . times in reverse northern and/or microarray analysis were considered differentially expressed. results: the most striking finding was downregulation of mitochondria] oxidative phosphorylation genes in all hcv-infected patients as compared to controls; impairment of brain oxidative/ energy metabolism has been previously suggested to be the proximate cause of many disorders that impair mentation. another consistent finding in differential display and microarray analysis was downregulation of multiple ribosomal proteins genes and several genes involved in transcription regulation. these could indicate reduced metabolic activities perhaps secondary to deficiencies in oxidative phosphorylation. we also observed upregulation of several genes involved in immune response. there was upregulation of mhc class i and class i and several lymphokine receptors like interferon (alpha, beta), il- , il- , il- as well as lfa- ligand intracellular adhesion molecule icam- and ceacam . furthermore, upregulation of cd o and allograft inflammatory factor- gene (aif- ) suggested the presence of activated microglia cells and/or activated macrophages. conclusions: we found downregulation of oxidative phosphorylation genes and upregulation of genes involved in immune response in brains from hcv-positive patients when compared to hcv negative patients. our findings provide the likely substrate for neuropsychiatric symptoms and cognitive impairment associated with hcv infection. medicine, ehime, japan; emmett v schmidt, raymond t chung, massachusetts general hospital, boston , m a background/aims: we previously reported cell-based hcv replication using a novel binary expression system in which cells were transfected with a t polymerase-driven full length hcv cdna plasmid (pt -flhcv-rz) and infected with vaccinia-t (pnas ). to circumvent vaccinia-induced cytotoxicity, we sought to determine whether replication-defective adenoviral vectors expressing t or cell lines stably transfected with t could support hcv replication. because vaccinia interferes with pkr function, we further sought to define the antiviral activity of interferon-ar (ifn) in these models. methods: hours after transient transfection of cv- and huh cells with pt -flhcv-rz, cells were treated with recombinant replication-defective adenovirus vectors expressing t polymerase (ad-t pol). medium with or without iulml of ifn was changed at day post-infection and every days thereafter. cells were harvested on day , , , , and post-infection. for t -stably transfected cell lines (huh-t ), we transiently transfected with pt -flhcv-rz, then added ifn to selected cells in analogous manner. hcv positive and negative strand were measured by strand specific real-time rt-pcr. hcv core protein expression was assessed by western blotting. results: in the hcv replication system with recombinant adenovirus vectors and with t stable cell lines, no cytotoxicity was observed at days. with pt -flhcv-rz and ad-t'lpol, hcv positive and negative strand rna expression was strongest in the first days post-infection and diminished thereafter, but were expressed throughout the days. in the days after adding ifn, hcv positive strand was significantly decreased ( . . vs. . + . in cv , . t . vs. . ? . in huh , hcv/ gapdh copy ratio, pc . ) than the samples without ifn. sustained expression of hcv rna and ifn inhibitory effect was also observed in t -stable huh-t cell lines. pkr expression was strongly induced by ifn, suggesting that pkr is appropriately induced by ifn. conclusions: we have successfully substituted recombinant adenovirus vectors or t stable cell lines in our cell-based binary hcv replication system. in these systems, ifn inhibits hcv replication, and upregulates the pkr pathway. these improved binary systems are a durable and more authentic model for identification of host cellular processes critical to hcv replication. disclosures:jason blackard -no relationships to disclose raymond t chung -no relationships to disclose yoichi hiasa -no relationships to disclose norio horiike -no relationships to disclose yoshitaka kamegaya -no relationships to disclose morikazu onji -no relationships to disclose emmett v schmidt -no relationships to disclose the meld scoring system for the allocation of cadaveric donor liver for transplantation gives significant priority to cirrhotic patients with a small, t or t , hepatocellular carcinoma. patients on the wait list were given adjusted meld scores equivalent to -month mortality rates of % and % for t and t lesions, respectively based on theoretical tumor doubling times. frequently these patients have compensated cirrhosis and hence their intrinsic meld score is lower, yet they are not candidates for surgical resection secondary to the underlying cirrhosis. to assess whether the additional meld points for hcc is valid, we sought to examine the impact of the meld scoring system on a single center's waiting list one year after implementation.methods: records of all patients undergoing liver transplantation (oltx) at uthsc-san antonio from feb , through feb , were retrospectively reviewed. pathology and radiology reports as well as data from unet were collated for analysis and review. results over a -year time period following implementation of the meld system, patients underwent oltx at our center. of these were excluded from analysis because of the following reasons: status (lo), living-related recipient ( ), pediatric non-tumor ( ). the table below summarizes the pertinent findings. of the remaining patients, ( %) underwent oltx with suspected hcc ( tl, t ).none of the hcc patients had their meld score downgraded because of tumor progression (t -t ). at transplant, patients were found to have extra hepatic disease(one with known hcc and the other unknown) and the cases were aborted. sensitivity of radiological evaluation for the presence of hcc was . % and specificity %. the calculated meld score at the time of listing for oltx and at the time of oltx was significantly lower for those patients thought to have an hcc. exception points for hcc gave those patients a significantly higher average meld score at the time of oltx than patients without hcc. patients wlo hcc had a aupper; true meld of + . at the time of oltx compared to listing as opposed to hcc patients whose a-upper; true meld was - . . during the study period patients (none with suspected hcc) died on the waiting list or were too sick to transplant while new patients were listed compared to dying the prior year with new registrants ( . % vs . %). mean meld score of those dying during the study period was . (median . ) and mean time on the list was days (median days). of those patients dying. had a meld score of . conclusion: meld has effectively prioritized cadaveric donor livers to the sicker patients. however, patients with hcc are given too much priority as evidenced by all of the wait list deaths occurring in patients without hcc and lack of tumor progression (to t ) sufficient to loose meld exception points in those with hcc. likewise, the mean meld score of those dying was less than that given to patients with t lesions( . vs. ). the recent downward adjustments of meld exceptions to and for ti and t lesions, respectively, are reasonable. ongoing analysis will be needed to accurately place hcc patients in the current allocation system. there was no significant difference (p> . ) in weight gain between the sexes, those with a bm > pre-transplant and those with a bmi< pre-transplant or those on prolonged courses (> months) of steroids. weight gain was significantly greater (p< . ) in patients aged over compared to those under and those transplanted for chronic liver disease compared with fulminant liver failure. a pre-transplant bmi> was a strong indicator that the patient would still have a bmi> at years. there was no effect of immunosuppression on weight gain: corticosteroids were discontinued in . % by months and long term use of steroids was not associated with weight gain. weight gain was similar in those on cyclosporine and on tacrolimus.conclusions: a bm > o is common in the liver transplant population, but seems to unrelated to specific immunosuppression and may be more closely linked to lifestyle. most weight gain occurs after the first months, and intervention with dietary and lifestyle advice at this point could be implemented to minimise the long-term morbidity and mortality risks associated with obesity. serum tumor marker estimations are often performed as a part of evaluation for liver transplantation. there is a paucity of information on the effect of esld on the levels of these tumor markers making interpretation difficult one tumor marker, ca- , has been consistently reported to be elevated in patients with ascites from liver disease. purpose:-to compare the levels of serum ca - , cea and afp in patients with esld with or without ascites.-to compare the serum ca - levels in patients with esld vs normal controls methods: all patients referred for liver transplantation between jan and dec at our center were included in the study. men with end stage liver disease (esld) develop a plethora of debilitating symptoms, including severe muscle wasting, that render many of these patients non-suitable for liver transplantation. esld-associated hypogonadism, i.e. testosterone deficiency, may, in part, be responsible for the development and progression of many of these incapacitating symptoms. in general, hypogonadism can be effectively treated with topical testosterone replacement (ttr), which avoids the first pass effect via the hepatic system in contrast to oral anabolic steroids. ttr has been shown to effectively improve muscle mass and overall well being in patients with hiv. however, little is known about the effects of ttr in men with esld. the aim of this study was to determine the potential benefits and safety of ttr in patients with esld and muscle wasting. method:the medical records of liver transplant patients treated for at least months with testosterone gel % ( grams per day) therapy for muscle wasting (mw) from january to march were reviewed. information collected included; demographics, albumin, pre-albumin, transferring, testosterone, estrogen, lh and fsh. drug safety results were also collected and included, acute cellular rejection, cholestasis, malignancy, and patient or graft loss. tumor markers for afp, ca - , cea, psa, prolactin levels and radiographic imaging was reviewed to rule out and potential malignancy. patients not treated with testosterone but with a similar clinical setting were compared (group ). results: thirteen patients were identified with esld and mw, group (n= ), group (n= ). demographics were as follows: (group ) males, females, and mean age years; (group ) males, female, mean age years. disease etiology for group : (hcv (n= ), hcv/hiv (n=l), aih (n=l), cryptogenic (n=l)) group : hcv (n= ), hcvilaennec's (n=l). most patients in group stated a subjective improvement in muscle strength, and overall wellbeing. in group , serum albumin levels increased from day , , ( . / . / . g/dl, respectively) while those in group did not ( . / . / . g/dl) (p= . ). similar results were seen for prealbumin (days , , ) group ( / / mgldl) versus group ( / / mg/dl). in group , / patients received a liver transplant, while remains listed for olt. in contrast, / patients in group were transplanted while / died. two patients in each group were not listed at the time of evaluation due to extreme deconditioning. of those in group , one patient was transplanted and another patient remains listed for olt with an albumin greater than . gldl. this patient presently has no radiographical evidence of ascites. the two patients of group , who were not listed for lt due to extreme deconditioning, died on day and , respectively. there was no rise in the tumor marker elevations in any of the patients. after transplantation, no patients in either group suffered from rejection or graft failure. ascites accumulation, as assessed by abdominal ultrasound imaging, appeared to be less in patients receiving ttr (group ) compared to all living patients in group , who had persistent ascites. one patient of the treatment group developed marked cholestasis days after starting ttr and received a liver transplant days later. prior to starting ttr, this patient underwent weekly large volume paracentesis and suffered from marked deconditioning and recurrent bouts of hepatic encephalopathy while maintaining a meld score of - points over a -month period. conclusion: our preliminary data suggest that ttr increases muscle strength (subjective measures), stimulates albumin synthesis and improves the outcome of olt. thus, ttr (testosterone gel %) appears to be of great benefit in patients with esld and muscle wasting. further studies are needed to determine the efficacy and safety of ttr in patients with esld. percutaneous ethanol injection (pei), radiofrequency tumor ablation (rf), and laser thermal ablation (lta) are percutaneous techniques used in the treatment of unresectable hcc. percutaneous seeding of neoplastic cells along the needle track is a rare complication of these tecniques, and it has been recently suggested to consider with caution these techniques as a "bridge" treatment in cirrhotic patients with hcc candidates to lt. the aim of this study was to verify whether percutaneous ablation treatments represent a risk factor for hcc recurrence in these patients. during the period - , patients (mean age yrs) with hcc complicating liver cirrhosis previously treated with percutaneous ablation treatments underwent lt in italian centers. among the patients, had monofocal hcc, multifocal hcc. in the latter group, had monolobar disease, had bilobar disease. considering the patients with monofocal hcc, were treated with rf (associated with transarterial chemoembolization [tace] in one case), with pei (associated with tace in one case), with rf and pei (associated with tace in one case). among the patients with multifocal hcc, were treated with rf (associated with tace in four cases), with pei (associated with tace in four cases), with lta associated with tace. on the whole, nodules were treated in the patients. furthermore, additional untreated hcc nodules were found at pathological examination of the explanted liver. among the rf-treated nodules, showed total necrosis, partial necrosis, absence of necrosis. among the pei-treated nodules showed total necrosis, partial necrosis, absence of necrosis. the nodules treated with rf and pei showed total necrosis in one case and partial necrosis in the other one while the nodules treated with lta, showed partial necrosis. the mean follow-up period was months (range - months). five patients died during the follow up and the actuarial survival rate was % at one year, % at and years. three patients ( . %) had post-transplant recurrence of hcc which was the cause of death in all cases; the diagnosis of tumor recurrence was made at months from lt (peritoneal carcinomatosis), at months from lt (bone), and at months from lt (abdominal liymphnodes and bone), respectively. the patients had all been treated with pei before lt and no one of them showed recurrence of hcc at the abdominal wall level. according to our results, percutaneous ablation techniques performed before lt do not seem significantly affect both survival and tumor recurrence rate in patients transplanted because of hcc complicating liver cirrhosis. in particular, no cases of recurrence at the abdominal wall level were observed in the overall series and no one case of hcc recurrence was observed in patients treated with rf alone or in combination. background: transjugular intrahepatic portosystemic shunt (tips) is valuable in the management of portal hypertension (phtn) in patients awaiting liver transplantation (olt). recurrent phtn after olt can be refractory to medical management and portosystemic shunting may be considered in rare situations, either as a bridge to retransplantation or as definitive therapy. in this report we review our experience and outcomes with tips after olt. methods: records of primary adult olt recipients, between january and december , were retrospectively reviewed. evidence of refratory post-olt phtn was noted. those who required tips were the subject of this review. demoraphics, indications for olt and tips, evidence of allograft dysfunction and outcomes after tips were described. results: during the study period tips were placed in patients at a mean of . months after olt (range - months). there were males and females, age . l . years. hepatitis c was the primary indication for olt in and primary biliary cirrhosis in . indications for tips included refractory ascites ( ), variceal bleeding ( ) and various degree of associated hepatic vein outflow stenosis ( ). five patients had resolution of phtn and patient with refractory ascites had severe hepatic vein outflow stenosis and associated hepatitis c in the allograft. two patients required re-olt for recurrent hepatitis c. there were deaths: liver failure month after tips done in the setting of allograft dysfunction, months after tips with subsequent re-olt and organ failure, and lung cancer months after tips. bridging fibrosis was present in patients, needed re-olt and died from liver failure while waiting for olt. currently, patients are alive without evidence of phtn , and months after tips. conclusions: -tips effectively and safely controls phtn after olt. -tips in setting of a moderate to severe allograft dysfunction does not abrogate the need for re-olt and can be associated with a high mortality. -timely re-olt should be considered in the presence of fibrosis from recurrent hcv and phtn. -tips has been successful in the setting of mild-moderate hepatic vein outflow stenosis and phtn. introduction: biliary tract complications after liver transplantation (lt) are reported to occur in % to % of patients. the frequency of biliary infections is not well documented. therefore, we prospectivly obtained bile samples during diagnostic and or therapeutic endoscopic retrograde cholangiography (ercp) in all liver transplant patients from to . methods: in patients (mean age . years, range - years) a total of ercp's were performed ( . ercflpatient). all patients had a lumen adapted, end-to-end biliary anastomosis. lt was performed between . months and . years before the intervention. cholangitis was defined as the presence of cholestasis with clinical and biochemical signs of infection not explained otherwise. only in cases of interventions, positive culture results were combined with clinical signs of cholangitis. the follwoing risk factors were identified stenosis of any type, plastic endoprothesis, choledocholithiasis and previous papillotomy. patients with these risk faktors had significantly higher incidence of positive bile cultures ( . % vs %, p<o,ool; chi-square). in addition, they were more often infected with multiresistant bacteria (p< . ). . % were resistant to gentamycin, . % to ceftriaxone. vancomycin ( . % resistance) was the most effective antibiotic. imipenem ( . %), ciprofloxacin ( . %) and amoxicillin ( . %) had intermediate incidence of resistant bacteria. conclusion: in patients with biliary tract complications after lt, biliary infection is common. clinical cholangitis, however, occurs predominantly in those with risk factors. gram-positive bacteria were more commonly demonstrated than gram-negative. cocolonisation with anaerobes andlor candida can occur. ciprofloxacin and amoxicillin seem to be appropriate antibiotics for prophylaxis. selection of an empiric antibiotic therapy for patient after liver transplantation with sings of cholangitis should be directed toward agents with a low incidence of resistance or a combination therapy. disclosures: thomas buratti -no relationships to disclose adolescent health related quality of life after liver transplantation. shikha s sundaram, katie neighbors, lisa amaruso, james sinacore, estella m alonso, northwestern university, chicago, il background: adolescence is an important developmental stage, during which children with chronic diseases begin to assume some of the responsibility for their own medical care. many children who received liver transplants as infants are now reaching adolescence and their unique health perceptions should be considered in providing appropriate healthcare. the aims of this study were to ) quantify the health related quality of life (hrqol) in adolescent liver transplant recipients and compare this to a published healthy population, ) compare parental ratings of adolescent hrqol to adolescent self-reports of hrqol, and ) assess adolescent hrqol and it's relationship to disease specific disability. methods: a cross sectional mailing survey of liver transplant recipients between ages - years, surviving transplant by at least year and receiving care at our center was conducted. primary caregivers of these patients were also recruited. adolescents completed the child health questionnaire, child form (chq-cf ) and primary caregivers the child health questionnaire, parent form (chq-pf ). demographic and medical data was collected using an institutional transplant database and standard demographic survey. a disease specific disability score was calculated using the liver transplant disability scale (ltds). mean scores for chq-cf subscales, including general and mental health, physical and social functioning and self-esteem were calculated. these were compared to published normative values from a healthy population and mean chq-pf subscale scores. results: thirty-seven of surveys mailed were received for a response rate of . %. adolescent respondents had a mean age of . . years, were % female and % caucasian. cadaveric donors accounted for . % of transplants and % of patients were transplanted for biliary atresia. a majority ( . %) of respondents had private insurance and . % indicated mothers were their primary caregivers. after transplantation, adolescents had a mean global health score of . . as compared to mean normative score of . . , p= . . they had higher scores than the normative population for role behavioral, . . vs. . . , p=o.ool and mental health, . z . vs. . . , p= . . all other scores were similar between the groups. significant positive correlations between adolescent and parental scores were observed in relation to physical functioning, (r = . , p< . ), self-esteem (r = . , p < . ) and mental health (r = . , p< . ). the remaining sub-scales lacked statistically significant correlation. an inverse relationship between inpatient hospitalization during the previous months and mean global health score was observed inpatient days had a mean of . ,l- inpatient nights had a mean of . and greater than inpatient nights . . . there were no other significant correlations between subscale scores and ltds scores. conclusion: adolescent liver transplant recipients report their hrqol as equal or better than the normative population. parents may be adequate proxies for some, but not all domains of adolescent hrqol in this population. were quantitated from wild type and fxrnull mice. results:transfection of the moatp -pgl into hepg cells led to a . fold ( . ) increase in reporter gene activity over vector controls. co-transfection with the bile acid receptor fxr and addition of its ligand, chenodeoxyacholic acid (cdca), resulted in a further . ( t . ) -fold increase suggesting fxr-mediated transactivation.fxrlrxr cotransfection and addition of ligands, cdca and -cis retinoic acid decreased transactivation suggesting rxr-mediated antagonism ( jbc, : ,' ). hnf- a also transactivated moatp promoter as shown previously. mutation of ir- sequence in moatp promoter abolished fxr-transactivation. emsa analysis using rat liver nuclear extracts showed specific binding of nuclear proteins to moatp fxre which was supershifted by fxr and rxr antibodies. mrna levels for moatp in fxrnull mice were reduced by . % compared to wild-type mice ( . in wild-type vs . infxr-null mice). conclusion: based on the above data, we suggest that moatp is regulated by bile acids by binding to fxr via ir- in its promoter. , and g a encoded for amino acid changes i f, a t, and v , in the third membrane spanning domain, the second nucleotide binding domain, and the second membrane spanning domain, respectively. the full-length coding regions of the reference mrp and three mutants sequences were inserted into the baculovirus genome. sf insect cells were infected with the baculovirus stocks, and membranes were isolated from the infected cells expressing mrp or the mutants. atpase activity was measured by determining release of inorganic phosphate by a colorimetric assay. atp-dependent transport of h-e g (estradiol-p-( p-d-glucuronide)) or h-e g (estradiol-p-( p-d-glucuronide)) was determined by uptake into inside out membrane vesicles collected on filters and counted by liquid scintillation. results: the total expression levels of mrp and the three mutants in the infected sf cells were comparable by densitometry of western blots of three levels of each protein, indicating total expression in sf cells was not influenced by the mutations. mrp atpase activity was significantly stimulated by the uricosuric probenecid lmm, the cholestatic pm, and the mild choleretic e g mm. although the control and stimulated at-pase activities of the v i mutant were not different from mrpz, the i f mutant had significantly less baseline and less stimulated atpase activities, indicating impaired function. a t had less probenecid-stimulated atpase activity, but activity stimulated by e g and e g was not different from mrp . ursodiol saturably stimulated atpase activity of mrpz by % with km = pm. although the three mutants transported h-e g with affinities not significantly different from mrp (km= pm), the vmax of i f was only . % ( pmollmglmin) and the vmax of v i was % ( pmollmglmin) compared to the vmax of mrpz ( pmollmglmin); the vmax of a t was not different ( pmollmglmin). ursodiol activated transport of h-e g ( nm) with a peak effect of % at pm; higher ursodiol concentrations (up to mm) returned transport to near control values. mrpz-mediated atp-dependent transport of h-e g ( nm) in the presence of ursodiol ( oopm) for the mutants differed from mrp (lo%, %, and % for i f, a t, and v , respectively). conclusions: ursodiol markedly activated mrp transport of e g. although ursodiol has several anticholestatic effects, these data show its direct effect on transport of mrpz substrates, and may suggest activation of mrp as a target in the treatment of cholestatic liver disease. the mrp mutants showed several important differences in activity, including changes in transport vmax, and transport in the presence of ursodiol, and activation of atpase activity by ursodiol, probenecid, and the mrp substrates e g and e g. further characterization of these mrp mutants and others will lead to a better understanding of mrp structure and function and may yield new therapeutic approaches. also, although e g is an established mrp substrate, these data show that its noncholestatic isomer e g is also an mrpz substrate, implicating mrp in the disposition of other estrogen metabolites, which can be interconverted to cholestatic compounds like e g. argentina; nicholas f larusso, mayo medical school, clinic and foundation, rochester, m n previous work from our laboratory is consistent with an important role for aquaporins (aqps), a family of water channel proteins, in canalicular bile secretion principally via agonist-induced exocytic insertion of aqps into the hepatocyte canalicular membrane. to further define the pathways and molecular mechanisms for water movement across hepatocytes, our aim here was to directly assess osmotic water permeability (pf) and activation energy (ea) in basolateral (blmv) and canalicular membrane (cmv) vesicles using stopped-flow spectrophotometry. scattered light intensity was used to follow changes in vesicle volume in response to gradients induced by sucrose solutions of different osmolarities. results: the time course of scattered light for blmv and cmv fit a single-exponential function. in blmv, pf was pm.sec-' ( oc) with an ea of . kcallmol; in cmv, pf was pm.sec-' ( oc) with an ea of . kcallmol. the aqp blocker, dimethylsulfoxide, significantly inhibited the pf of both basolateral ( pm.sec-l; - %) and canalicular ( ? pmsec-'; - %) vesicles consistent with the presence of aqps in both vesicle populations. experimental data for cmv from dibutyryl camp-treated hepatocytes fit best to a double-exponential curve implying the presence of two functionally distinct cmv populations; one population had pf and ea values similar to those of cmv from untreated hepatocytes and the other population had a very high pf ( pm.sec-l, oc) and very low ea ( . kcallmol). dimethylsulfoxide completely inhibited the high pf value in this second vesicle population. in contrast, the pf of blmv was unaltered by camp treatment of hepatocytes. conclusions: our data are consistent with the notion that the canalicular but not the basolateral membrane becomes more permeable to water after a secretory stimulus due to the insertion of aqp molecules. the data suggest a molecular mechanism for the efficient coupling of osmotically active solutes and water transport during canalicular bile formation. disclosures: ariel j caride -no relationships to disclose sergio a gradilone -no relationships to disclose bing q huang -no relationships to disclose key: cord- -x zvx fp authors: ohta, yoshinori; miyamoto, kyohei; kawazoe, yu; yamamura, hitoshi; morimoto, takeshi title: effect of dexmedetomidine on inflammation in patients with sepsis requiring mechanical ventilation: a sub-analysis of a multicenter randomized clinical trial date: - - journal: crit care doi: . /s - - - sha: doc_id: cord_uid: x zvx fp background: administration of dexmedetomidine has been reported to improve inflammatory response in animals. we explored the effects of administering dexmedetomidine on the levels of c-reactive protein (crp) and procalcitonin, and thus on inflammation, in patients with sepsis enrolled in a randomized clinical trial. methods: the desire trial was a multicenter randomized clinical trial in which adult patients with sepsis were sedated with (dex group) or without (non-dex group) dexmedetomidine while on mechanical ventilators. as a prespecified sub-analysis, we compared crp and procalcitonin levels during the first days of treatment between the two groups. the -day mortality rate, albumin level, and the number of patients with disseminated intravascular coagulation (dic) were also assessed. we used generalized linear models to estimate the differences in these outcomes between groups. we also used the kaplan-meier method to estimate the -day mortality rate and the log-rank test to assess between-group differences. results: our study comprised patients: in the dex group and in the non-dex group. crp and procalcitonin levels were lower in the dex vs. non-dex group during the -day treatment period [crp—range, . – . vs. . – . mg/dl (p = . ); procalcitonin—range, . – . vs. . – . ng/ml (p = . )]. albumin levels were higher in the dex group (range, . – . g/dl) than in the non-dex group (range, . – . g/dl; p = . ). the percentage of patients with dic did not significantly differ between the groups (range, – % and – % for the dex and non-dex groups, respectively; p = . ). the -day mortality rates in the dex and non-dex groups were and %, respectively (p = . ). conclusion: sedation using dexmedetomidine reduced inflammation in patients with sepsis requiring mechanical ventilation. trial registration: clinicaltrials.gov, nct . registered on january . the inflammatory response has catastrophic consequences in patients with sepsis, including multiple organ failure and death [ ] . leukocytes secrete inflammatory mediators such as interleukin (il)- and tumor necrosis factor (tnf)-α during critical illness. these mediators can cause endothelial dysfunction, which affects vascular permeability, as well as thrombin activation, leading to hypotension, metabolic acidosis, tissue damage, and eventual organ failure [ , ] . il- and tnf-α concurrently stimulate the production of c-reactive protein (crp) and procalcitonin (pct), which are the most widely used inflammatory biomarkers in patients with sepsis in clinical practice [ , ] . although crp is a marker of the acute inflammatory response, rather than of the infection that caused the sepsis, it is used to assess the severity and progression of sepsis-induced inflammation [ ] . pct levels rise in response to a variety of proinflammatory stimuli, especially those of bacterial origin. they closely correlate with the severity of systemic inflammation and can be used to monitor the course of sepsis [ , ] . dexmedetomidine is a highly selective α -adrenergic agonist widely used for sedation of patients during mechanical ventilation [ ] . several studies have shown that it also suppresses the inflammatory response [ ] [ ] [ ] . administration of dexmedetomidine decreases il- and tnf-α levels in animals with severe inflammation [ , ] and il- , tnf-α, and crp levels in humans undergoing surgery [ ] . whether it also reduces inflammation in patients with sepsis is not known. to investigate the effect of administering dexmedetomidine on sepsis-induced inflammation, we compared the outcomes of patients with sepsis who were treated with or without dexmedetomidine for days as part of the desire clinical trial [ ] . this analysis was prespecified in the study protocol for the desire trial before patient enrollment began. the desire trial was a multicenter, open-label, randomized clinical trial that compared the sedation strategies of administering dexmedetomidine (dex group) versus not administering dexmedetomidine (non-dex group) in terms of mortality and ventilator-free days during a day period [ ] . the trial was registered at clinical-trials.gov (identifier: nct ). a total of patients were enrolled from eight intensive care units (icus) in japan between february and january , all of whom had sepsis requiring mechanical ventilation for more than h [ ] . the flow of participants through the trial is shown in the supplemental figure ( see additional file ). in the trial, sepsis was defined as systemic inflammatory response syndrome (sirs) criteria due to infection [ ] . the enrolled patients satisfied the sepsis-iii criteria due to having received mechanical ventilation and having a sequential organ failure assessment (sofa) score of or more [ ] . patients in the dex and non-dex groups received other sedatives as needed to achieve the sedation target and analgesics if necessary. in both groups, the targets of sedation depth were a richmond agitation-sedation scale score of (calm) during the day and − (lightly sedated) during the night [ ] . the treatment protocol for sepsis was based on the guidelines developed by the japanese society of intensive care medicine for sepsis management [ ] . the present study was approved by the institutional review boards at each participating center. additional study protocols, inclusion and exclusion criteria, and informed consent are described in the supplemental methods (see additional file ). to evaluate the acute phase of inflammation, this sub-analysis compared the inflammatory status of the dex and non-dex groups during the first days after the randomization. the primary outcome in this analysis was inflammation as indicated by crp and pct levels. the secondary outcomes were -day mortality, albumin (alb) level, and sepsis-associated coagulopathy. the alb level served as a marker of vascular permeability [ ] . the disseminated intravascular coagulation (dic) score, as defined by the japanese association for acute medicine, was used to assess sepsis-associated coagulopathy [ ] . the dic score comprises platelet (plt) counts, the patient/normal prothrombin time (pt) ratio, the levels of fibrin/fibrinogen degradation products (fdps), and the number of sirs characteristics. the scoring system for dic is summarized in the supplemental table (see additional file ). crp, pct, alb, and fdp levels, plt counts, and pt ratios were measured throughout the -day observation period. we also determined the number of patients with three or more sirs characteristics and/or dic (as based on the dic score) on days , , , , , , , and . primary and secondary outcomes were analyzed according to the intention-to-treat principle. continuous variables were presented as means with standard deviations (sds) or medians with interquartile ranges, and categorical variables were presented as numbers and percentages. to compare patient characteristics between the groups, we used t tests or wilcoxon rank sum tests for continuous variables and chi-square tests or fisher's exact tests for categorical variables. we used a generalized linear model (the genmod procedure) to examine the effect of administering dexmedetomidine on crp, pct, alb, and fdp levels, plt counts, and pt ratios and to account for repeated measurements in the same patient. we used a generalized linear model (the genmod procedure with logit) to determine the effect of administering dexmedetomidine on the number of patients with three or more sirs characteristics and/or dic. the variables describing patient status were the dependent variables, and treatment allocation was the independent variable with a repeated variable of patient. the cumulative incidence of mortality over the -day treatment period was estimated via the kaplan-meier method, and differences between the groups were assessed using the log-rank test. all statistical analyses were performed using jmp version . . (sas institute inc.), and sas version . (sas institute inc.) software. a two-sided p value < . was considered statistically significant. among the patients in our study, ( %) were men, and the mean age was years (sd, years) ( table ). the median acute physiology and chronic health evaluation ii score was , and the median sofa score was . there were patients in the dex group and in the non-dex group; the characteristics of the groups were well balanced. on the first day after randomization, the median and highest crp levels were . and . mg/dl in the dex group and . and . mg/dl in the non-dex group, respectively. the number of patients with a pct level of more than . ng/ml was ( %) in the dex group and ( %) in the non-dex group. the mean alb level was . g/dl in the dex group and . g/dl in the non-dex group; the number of patients with hypoalbuminemia (alb of . mg/dl or less) was ( %) in the dex group and ( %) in the non-dex group. forty ( %) patients in the dex group and ( %) in the non-dex group had dic on day . crp and pct levels in the dex and non-dex groups during the -day observation period are shown in fig. a and b . the crp level was highest on day in both the dex ( . mg/dl) and the non-dex ( . mg/ dl) groups (fig. a) . it was significantly lower in the dex group (range, . - . mg/dl) than in the non-dex group (range, . - . mg/dl) over the -day observation period (p = . ). pct levels were measured on days , , , and and were highest on day in both the dex ( . ng/ml) and non-dex ( . ng/ml) groups (fig. b) . the pct level was significantly lower in the dex group (range, . - . ng/ml) than in the non-dex group (range, . - . ng/ml) over the -day observation period (p = . ). the alb levels in the dex and non-dex groups during the days after randomization are shown in fig. c . the alb level was lowest on days - in the dex group and on days - in the non-dex group. alb levels were reduced to a lesser extent in the dex group (difference, − . g/dl) than in the non-dex group (difference, − . g/dl). the alb level was significantly higher in the dex group (range, . - . g/dl) than in the non-dex group ( . - . g/dl) over the -day treatment period (p = . ). the levels of the coagulation biomarkers and the number of patients with three or more sirs characteristics during the -day observation period are shown in the supplement table (see additional file ). plt counts were lowest on day in both groups and overall did not differ significantly between groups (range, - × /l in the dex group and - × /l in the non-dex group; p = . ). fdp levels were also similar in both groups (range, . - . mcg/ml in the dex group and . - . mcg/ml in the non-dex group; p = . ). the pt ratio was highest in both groups on day but overall was lower in the dex group (range, . - . ) than in the non-dex group ( . - . ; p = . ). the percentage of patients with three or more sirs characteristics did not differ significantly between the dex vs. non-dex group (range, - vs. - %; p = . ). the levels of the dic-associated variables were similar in both groups with the exception of the pt ratio (supplement table ). the percentage of patients with dic was also similar in both groups (range, - % in the dex group and - % in the non-dex group; p = . ). among the patients in our study, ( %) died during the days after randomization. the mortality rates in the dex and non-dex groups were % ( patients) and % ( patients), respectively (p = . ) (fig. ). we analyzed data derived from a randomized clinical trial and found that the administration of dexmedetomidine to patients with sepsis on ventilators improved crp and pct levels during the first days in the icu. it also reduced the incidence of hypoalbuminemia, but not of dic. the -day mortality rate was also % lower in the dex group than in the non-dex group, but this reduction was not significant. the original desire trial did not find statistically significant superiority of administering dexmedetomidine in terms of mortality, but the findings implied an % reduction in the -day mortality rate in patients with sepsis [ ] . because the different use of sedatives did not account for the reduction of mortality, the mechanism of the effect of administering dexmedetomidine on mortality should be explored. dexmedetomidine is a unique sedative: unlike aminobutyric acid receptor agonists, it has analgesic [ ] and anti-inflammatory [ ] [ ] [ ] effects. the latter may reflect its ability to inhibit the expression of inflammatory molecules when bound to α -adrenergic receptors on macrophages [ ] and/or to increase the concentration of norepihephrine (which suppresses the immune response) when bound to synaptic α -adrenergic receptors in the central nervous system [ ] [ ] [ ] . other possible mechanisms include the modulation of cytokine production by macrophages and monocytes; the inhibition of apoptosis and the toll-like receptor and myeloid differentiation factor /mitogen-activated protein kinase/nuclear factor-κb signaling pathways; and the stimulation of the cholinergic anti-inflammatory pathway [ ] [ ] [ ] [ ] [ ] [ ] . although the anti-inflammatory mechanisms through which the administration of dexmedetomidine suppresses inflammation remain to be fully elucidated, previous studies suggest that administration of dexmedetomidine decreases the levels of pro-inflammatory cytokines such as il- and tnf-α in patients with sepsis [ ] , as well as the levels of pro-inflammatory cytokines and crp in patients undergoing surgery while under anesthesia [ ] . in the present study, the use of dexmedetomidine for sedation reduced both crp and pct levels in patients with sepsis. this result indicates that the administration of dexmedetomidine alleviates infection-induced inflammation. we also aimed to determine whether administration of dexmedetomidine improved hypoalbuminemia and sepsis-associated coagulopathy, both of which are associated with severe inflammation. systemic inflammation increases vascular permeability, which is a major cause of hypoalbuminemia in patients with sepsis [ ] . most of the patients in our study had low albumin levels on the first day after randomization. thereafter, however, albumin levels were higher in patients treated with versus without dexmedetomidine. this finding presumably reflects reduced inflammation rather than improved nutrition: during the acute phase of inflammation, levels of albumin, which has a half-life of days, are more influenced by vascular permeabilization caused by inflammation-induced injuries to the endothelium than by nutrition [ , ] . sepsis-associated coagulopathy, which can lead to dic, is thought to result from crosstalk between the inflammation and coagulation systems; inflammation triggers coagulation, which in turn promotes inflammation [ , ] . in this study, the administration of dexmedetomidine did not affect the incidence of coagulation or dic. suppression of inflammation by administering dexmedetomidine might be insufficient for preventing coagulopathy. the administration of dexmedetomidine has been shown to reduce not only plasma inflammatory cytokine concentrations but also mortality in rats with endotoxininduced shock, and these effects were reported to be dose-dependent [ ] . a recent database study reported that mortality differed according to the time after diagnosis of sepsis; phases were categorized in that study as phase (days to ), phase (days to ), and phase (days to ) [ ] . deaths during phase and phase accounted for . % of mortality in patients with sepsis or septic shock [ ] , and one cause of the early peak in mortality was severe inflammation [ ] . therefore, we focused on both inflammation status and mortality in a -day period. crp levels correlate positively with the risk of organ failure and mortality; hence, monitoring these levels may aid in assessing the response to therapy in patients with sepsis [ , ] . pct has greater diagnostic accuracy than does crp because it differentiates infectious versus non-infectious causes of inflammation [ ] . crp is a risk factor for mortality in patients with sepsis when levels are elevated and the clearance rate is low [ ] . hypoalbuminemia has been shown to predict -day mortality in critically ill patients [ ] . the doses of dexmedetomidine ranged from . to . mcg/kg/h in this study; these are the standard approved doses in japan. although these doses are lower than those typically administered in western countries, the administration of dexmedetomidine at these lower doses successfully decreased crp and pct levels and increased albumin levels when administered to patients with sepsis for days. these changes were considered to reflect the improvement of inflammation in the first days after sepsis onset; hence, it might be associated with decreased mortality. as noted above, a point estimate of % reduction in mortality at day was observed in our study, although a level of statistical significance was not reached. one possible reason for this non-significant reduction in mortality could be due to the relatively small sample size or the lower doses of dexmedetomidine. as the anti-inflammatory effects of administering dexmedetomidine are reportedly dosedependent [ ] , a greater reduction in mortality might be observed if higher doses are used. further research should clarify the effect of administering dexmedetomidine with higher doses on patient mortality and potential adverse effects in patients with sepsis. there are two limitations in this study. first, it was an open-label study, and the endpoints were assessed by a physician at discharge. awareness of the treatment assignment (dexmedetomidine or no dexmedetomidine) may have influenced some of the management protocols. however, crp, pct, and alb levels, -day mortality rates, and sepsis-associated coagulopathy would not be affected by the judgments of physicians. although preparations containing alb can increase albumin levels, the physicians in charge followed the guidelines regarding such preparations when treating patients with sepsisassociated hypoalbuminemia [ ] . second, because our study was a subcomponent of the desire trial, sample sizes with sufficient power to detect clinically meaningful differences were not calculated and thus may have been inadequate in some cases, especially in those involving sepsis-associated coagulopathy. moreover, multiple endpoints in sub-analyses should be treated with caution owing to inflated alpha errors. however, the consistency of our findings (lower crp and pct levels and higher alb level in the dex group) attest to their validity. the administration of dexmedetomidine significantly improved crp, pct, and alb levels in patients with sepsis requiring mechanical ventilation. because the anti-inflammatory effects of administering dexmedetomidine were not associated with the reduction of mortality in patients with sepsis at days, further studies with larger sample sizes or administering higher doses of dexmedetomidine are warranted. supplementary information accompanies this paper at https://doi.org/ . /s - - - . additional file : supplemental methods. table s . scoring system for dic. table s . changes in dic and dic-associated variables. figure s . flow of participants in the desire trial. the immune system's role in sepsis progression, resolution, and long-term outcome treating patients with severe sepsis c-reactive protein: a valuable marker of sepsis procalcitonin behaves as a fast responding acute phase protein in vivo and in vitro procalcitonin as a diagnostic marker for sepsis: a systematic review and meta-analysis preliminary uk experience of dexmedetomidine, a novel agent for postoperative sedation in the intensive care unit effects of dexmedetomidine on early and late cytokines during polymicrobial sepsis in mice effects of dexmedetomidine on mortality rate and inflammatory responses to endotoxin-induced shock in rats effect of dexmedetomidine on early postoperative cognitive dysfunction and peri-operative inflammation in elderly patients undergoing laparoscopic cholecystectomy effect of dexmedetomidine on mortality and ventilator-free days in patients requiring mechanical ventilation with sepsis: a randomized clinical trial definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis the third international consensus definitions for sepsis and septic shock the richmond agitation-sedation scale: validity and reliability in adult intensive care unit patients the japanese guidelines for the management of sepsis reference distributions for the negative acute-phase serum proteins, albumin, transferrin and transthyretin: a practical, simple and clinically relevant approach in a large cohort clinical course and outcome of disseminated intravascular coagulation diagnosed by japanese association for acute medicine criteria. comparison between sepsis and trauma differential involvement of sympathetic nervous system and immune system in the modulation of tnf-α production by α -and β-adrenoceptors in mice intrathecal α -adrenergic agonists stimulate acetylcholine and norepinephrine release from the spinal cord dorsal horn in sheep. an in vivo microdialysis study the effects of noradrenaline and alpha- adrenoceptor agents on the production of monocytic products effects of dexmedetomidine on regulating endotoxin-induced up-regulation of inflammatory molecules in murine macrophages the effect of dexmedetomidine on inflammatory response of septic rats dexmedetomidine inhibits inflammatory reaction in lung tissues of septic rats by suppressing tlr /nf-κb pathway sedation improves early outcome in severely septic sprague dawley rats dexmedetomidine controls systemic cytokine levels through the cholinergic anti-inflammatory pathway survival benefits of dexmedetomidine used for sedating septic patients in intensive care setting: a systematic review glycocalyx and sepsis-induced alterations in vascular permeability coagulation and sepsis markers of inflammation and infection in sepsis and disseminated intravascular coagulation dose-and timerelated effects of dexmedetomidine on mortality and inflammatory responses to endotoxin-induced shock in rats the late phase of sepsis is characterized by an increased microbiological burden and death rate c-reactive protein levels correlate with mortality and organ failure in critically ill patients failure to reduce creactive protein levels more than % in the last hours before intensive care unit discharge predicts higher in-hospital mortality: a cohort study serum procalcitonin and c-reactive protein levels as markers of bacterial infection: a systematic review and meta-analysis serum procalcitonin and procalcitonin clearance as a prognostic biomarker in patients with severe sepsis and septic shock clinical usefulness of c-reactive protein to albumin ratio in predicting -day mortality in critically ill patients: a retrospective analysis publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we thank the following investigators in the desire trial: tomonori yamamoto, md (osaka city university, osaka, japan); akihiro fuke, md (osaka city general hospital, osaka, japan); atsunori hashimoto, md (hyogo college of medicine, nishinomiya, japan); hiroyuki koami, md (saga university hospital, saga, japan); satoru beppu, md (national hospital organization kyoto medical center, kyoto, japan), and makoto itoh, md (yamaguchi grand medical center, yamaguchi, japan). authors' contributions yo and tm had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. all authors read and approved the final manuscript. this multicenter randomized clinical trial was supported in part by a noncontractual research grant to wakayama medical university from hospira japan. the present study was supported by jsps kakenhi grants to yo (jp k , jp k , jp , and jp k ) and tm (jp , jp , jp , jp , and jp ). the funding sources had no role in the study design; collection, analysis, or interpretation of data; writing of the report; or decision to submit the manuscript for publication. the data that support the findings of this study are available from the corresponding author upon reasonable request.ethics approval and consent to participate this study was approved by the institutional review boards of wakayama medical university and each participating institution. written informed consent was obtained from the patient or patient's family before randomization. not applicable. dr. ohta has no conflicts of interest. dr. miyamoto received lecture fees from becton dickinson and pfizer japan. dr. kawazoe received lecture fees from hospira japan and pfizer japan and a scholarship from hospira japan. dr. yamamura received lecture fees from hospira japan, nipro, and asahi kasei and educational consulting fees from toray industries, csl behring, teijin pharma, and nihon pharmaceutical. dr. morimoto received lecture fees from bayer, daiichi sankyo, japan lifeline, kyocera, mitsubishi tanabe, novartis, and pfizer japan; a manuscript fee from pfizer japan; and consulting fees from asahi kasei, bristol-myers squibb, and boston scientific. key: cord- -xa a p q authors: klune, john r; dhupar, rajeev; cardinal, jon; billiar, timothy r; tsung, allan title: hmgb : endogenous danger signaling date: - - journal: mol med doi: . / - .klune sha: doc_id: cord_uid: xa a p q while foreign pathogens and their products have long been known to activate the innate immune system, the recent recognition of a group of endogenous molecules that serve a similar function has provided a framework for understanding the overlap between the inflammatory responses activated by pathogens and injury. these endogenous molecules, termed alarmins, are normal cell constituents that can be released into the extracellular milieu during states of cellular stress or damage and subsequently activate the immune system. one nuclear protein, high mobility group box- (hmgb ), has received particular attention as fulfilling the functions of an alarmin by being involved in both infectious and non-infectious inflammatory conditions. once released, hmgb signals through various receptors to activate immune cells involved in the immune process. although initial studies demonstrated hmgb as a late mediator of sepsis, recent findings indicate hmgb to have an important role in models of non-infectious inflammation, such as autoimmunity, cancer, trauma, and ischemia reperfusion injury. furthermore, in contrast to its pro-inflammatory functions, there is evidence that hmgb also has restorative effects leading to tissue repair and regeneration. the complex functions of hmgb as an archetypical alarmin are outlined here to review our current understanding of a molecule that holds the potential for treatment in many important human conditions. activation of the innate immune system is a necessary step in mounting an anti-microbial response to pathogens. clinicians have long appreciated that infectious insults and tissue injury from sterile inflammatory states produce a similar inflammatory response. recent advances in understanding the mechanisms of innate immune system activation have pointed to certain pattern recognition receptors, such as the family of toll-like receptors, as a common pathway for immune recognition of both microbial invasion and tissue injury. by recognizing either pathogens or endogenous danger signals released upon cellular stress or damage, these pattern recognition receptors are capable of alerting the host of danger by activating the innate immune system. in this review, we will describe one such endogenous danger signal, high mobility group box- (hmgb ), and its role in the pathogenesis of many disease states. pathogens have long been known to cause both local and systemic inflammation via activation of the immune system. classically, descriptions of immune regulation arose from the idea that immune cells can discriminate self from non-self, and activate innate immunity when there is foreign invasion. this model, which stemmed from work done in the s by burnet and medawar, has been modified through the years to account for new discoveries in immune cell function ( , ) . although the self/nonself model is suitable in explaining immune activation and inflammation that occurs as a consequence of clinical scenarios, such as invasion by foreign pathogens or transplant rejection, it fails to account for the inflammation which occurs in settings such as trauma or autoimmunity, which are void of non-self stimuli. in an attempt to better describe these phenomena, matzinger has proposed the concept of danger signaling ( ) . in this model, initiation of the inflammatory response occurs in response to molecular patterns that are associated with both pathogens and some normal cellular components that are released by damaged cells during both infectious and sterile processes ( ) . the concept of cellular communication by "danger signals," whether exogenous or endogenous, reconciled the paradox of immune activation in both infection and sterile injury. in the danger model, immune activation is the result of recognition of molecular patterns by cellular receptors. molecular elements from pathogens that elicit an immune response (i.e. lipopolysaccharide [lps], bacterial dna, viral rna) are specific patterns termed pathogen associated molecular patterns (pamps). these pamps are generally invariant and it is their recognition by the immune system that triggers the inflammatory response ( , ) . the cellular receptors that recognize these patterns are evolutionarily conserved and called pattern recognition receptors (prrs) ( ) . inflammatory responses following sterile injury closely mimic those seen during infection, with similar cytokine and chemokine production patterns ( , ) . several endogenous molecules that are released during both infectious and sterile inflammation, such as hmgb , heat shock proteins (hsps), s s, and hyaluronan, have been implicated as possessing the capacity to trigger the immune system through prrs, much like pamps ( ) ( ) ( ) . these signals are normal cell constituents and are released either passively by necrotic cells or actively secreted by stressed cells in response to cellular injury. while the term pamp is restricted to patterns located on pathogens, these endogenous analogues are termed alarmins ( ) . the exogenous pamps and endogenous alarmins are subgroups of the larger category of danger signals termed damage associated molecular patterns (damps) ( , ) . alarmins are of particular interest because of their role in both infectious and sterile inflammation. they are present either locally or systemically in severe sepsis, burns, infection, arthritis, and cancer ( , ( ) ( ) ( ) . alarmins are found in a variety of organelles in all cell types studied and maintain functions in normal cellular homeostasis. they are found in the nucleus as transcription factors (hmgb ), in the cytoplasm as calcium regulators (s s), in exosomes as chaperones (hsps), or as components of the cell matrix (hyaluronan). although diverse in their locations during homeostatic conditions, alarmins have many common functional characteristics. in addition to immune activation, an alarmin is released rapidly during necrosis, sequestered in apoptosis, has potential for active secretion by immune cells, and ultimately promotes homeostasis ( ) . because alarmins are a diverse group of ubiquitous molecules impli-cated in nearly all inflammatory states, understanding and ultimately modulating their activity may allow us to control the inflammatory processes. the high mobility group (hmg) nuclear proteins were discovered in in an effort to better define the specific regulators of gene expression ( ) . this group of non-histone, chromatin-associated proteins has since been characterized to be involved in dna organization and regulation of transcription. this family of proteins shares structural characteristics which make them unique from other chromosomal proteins. these characteristics include transcripts with long at-rich ′ untranslated regions as well as carboxy-terminal regions which are highly negatively charged ( ) . hmg proteins are constitutively expressed in the nucleus of eukaryotic cells. collectively, they share functional motifs that bind specific dna structures and induce conformational changes without specificity for target sequences. hmgb is a member of a subfamily of the hmg proteins. on average, hmgb is found at concentrations of molecules per cell and non-specifically binds to the minor grooves in dna ( ) . this binding is regulated by two amino acid hmg- domains (or boxes), each structurally represented as three α-helices in a characteristic l-shaped fold ( ) . the nuclear localization of hmgb and its affinity for dna is regulated through phosphorylation and acetylation, and has been found to have a dynamic relationship with chromatin ( ) . like the other members of this protein family, hmgb plays an important role in dna architecture and transcriptional regulation. hmgb first was implicated as an important endogenous signaling molecule in when wang et al. described the cytokine activity of hmgb by identifying it as a late mediator of endotoxinrelated lethality in mice ( ) . this study reported increased serum levels of hmgb from to h after endotoxin exposure, attenuation of lethality with delayed administration of an hmgb neutralizing antibody, and lethality with direct administration of hmgb ( ) . this groundbreaking work sparked renewed interest in hmgb as an important component of the immune response. the specific interactions and functions of the hmgb dna binding domains have been described. as noted above, the structure of hmgb contains two separate "boxes," the a-and b-boxes, each containing ~ amino acids in an l-shaped fold, along with an acidic c-terminal tail ( ) . these separate structural motifs appear to function differently when isolated from hmgb . several studies have identified the b-box domain as important for many of the proinflammatory properties of hmgb including cytokine release ( , ) . in comparison, the a-box does not possess the pro-inflammatory properties of the b-box and instead competes with hmgb for binding sites leading to attenuation of the inflammatory cascade ( ) . hmgb is released passively during cellular necrosis by almost all cells which have a nucleus and signals neighboring cells of ongoing damage ( ) . however, hmgb also is secreted actively by immune cells such as monocytes, macrophages, and dendritic cells ( , , ) . active secretion of hmgb is generally through non-traditional, leaderless pathways which are not routed through the endoplasmic reticulum or golgi apparatus, similar to il- ( ) . during normal cellular homeostasis the dynamic relationship of hmgb with the nucleus and cytoplasm heavily favors the nucleus. however, hmgb localizes in secretory lysosomes when hyper-acetylated on lysine residues and then is released upon appropriate signaling stimuli ( , ) . when hmgb is not acetylated, it remains localized to the nucleus and is not secreted or released, such as during apoptosis ( ) . how the acetylation of hmgb is regulated is yet to be determined but is surmised to in-volve deacetylases in the nucleus ( , , ) . in other studies, specifically with tnfα stimulated macrophages, the secretion of hmgb is dependent upon phosphorylation ( ) . while these modifications are clearly important in the release of hmgb , it currently is unclear how these specific modifications differ. stimuli for secretion of hmgb from immune cells are diverse and include pamps, cytokines, and certain states of cellular stress. macrophages release hmgb starting approximately h following exposure to lps ( , - ) but do not demonstrate the same response to cpg dna ( ) . it is notable that release due to lps is dependent, at least partially, on tnfα ( ) . hmgb also can be released in response to polyinosinicpolycytidylic acid (a model of viral infection) ( , ) , while in vitro viral stimulation has demonstrated only passive release of hmgb due to cytokines or necrotic cells ( ) . in addition to these pamps that result in the release of hmgb , endogenous molecules such as cytokines released during other states of injury can result in secretion of hmgb . while first demonstrated with ifnγ, macrophages also release hmgb in response to stimulation with tnfα, il- , and oxidative stress ( , ( ) ( ) ( ) ( ) . interestingly, the pamps and cytokine stimuli for hmgb secretion from macrophages occurs through distinct pathways ( ) . for example, while lps regulates hmgb release by hyper-acetylation, tnfα-induced secretion is mediated through phosphorylation, which directs it to the cytoplasm for release ( ) . while it was thought initially that hmgb was released only from cells of the immune system, other cells have since been demonstrated to actively secrete alarmins. the first non-immune cell to be studied for active hmgb secretion was the pituicyte, which was found to release hmgb in response to il- or tnfα stimulation ( ) . enterocytes release hmgb following stimulation with a cytokine mixture ( ) . hepatocytes also can release hmgb in response to hypoxic conditions or oxida-tive stress; this release appears to be mediated by calcium signaling changes within the cell ( ) . the inhibition of hmgb also has been an important topic for those seeking to ameliorate injury by decreasing the level of hmgb release. a variety of pharmacologic agents have been studied for their potential to inhibit release of hmgb ; however, a full discussion of pharmacologic inhibition of hmgb is beyond the scope of this paper. it is worth noting, though, that hsp , an endogenous molecule that has itself been indicted as an alarmin, has been demonstrated to inhibit hmgb release. originally, it was demonstrated that brief heat shock resulted in decreased hmgb release from lps-stimulated macrophages, but no specific pathway was identified ( ) . recently, hsp overexpression has been shown to inhibit hmgb release from macrophages in response to lps, tnfα, or oxidative stress (hydrogen peroxide). this inhibition appears to be due to intranuclear interactions between hsp and hmgb ( , ) . as noted above, prrs are a group of molecules that recognize the molecular patterns of damps. these receptors may be activated by pamps, alarmins, or both, to activate the immune system. several important receptors have been implicated in hmgb signaling, including the receptor for advanced glycation end products (rage) and members of the toll-like family of receptors (tlrs). rage is a transmembrane protein expressed at low levels in normal tissues that is upregulated at sites where its ligands accumulate ( ) . the receptor first was identified to bind advanced glycation end products in diabetes, but has since been identified to bind other ligands and is involved in multiple inflammatory states ( , ) . rage was also the first receptor demonstrated to bind hmgb ( ) . at the time, the consequences of hmgb interaction with rage were unknown, but it was discovered later that hmgb- signaling through rage promotes chemotaxis and the production of cytokines in a process that involves the activation of the transcription factor nuclear factor-κb (nf-κb) ( , ) . other rage-dependent effects of hmgb appear to involve the maturation ( , ( ) ( ) ( ) and migration ( , ( ) ( ) ( ) ( ) of immune cells as well as the upregulation of cell surface receptors ( ) ( ) ( ) . in addition to rage, the toll-like family of receptors has been demonstrated to be important in hmgb signaling. members of the tlr family share many structural similarities, both extracellularly and intracellularly, but they differ from each other in ligand specificity, expression patterns, and, in some instances, the signaling pathways they activate. generally, tlrs can recognize both damps and pamps and hence are involved in immune response to both infection and injury. members of the toll family have specific ligands, and tlr might be the most well known and for its role in the bacterial endotoxin (lps) recognition complex ( ) . tlr , tlr , and tlr have all been implicated as hmgb receptors. hmgb binding of tlr and tlr results in nf-κb upregulation ( ) ( ) ( ) , thus making it likely that hmgb stimulation of these receptors can lead to cytokine release. interestingly, hmgb -mediated tlr activation is different from that resulting from lps stimulation ( , ) . for example, when applied to cell cultures, hmgb activates both ikkα and ikkβ, whereas lps only activates ikkβ. additionally, the mapk protein activation and cytokine production profiles differ between hmgb -and lps-treated cells. there is much speculation that hmgb does not act alone in the triggering of receptor activation. proof of this concept was provided by tian et al. who demonstrated that hmgb -dna complexes activate tlr signaling ( ) . hmgb involvement in tlr activation appears to be mediated by hmgb -dna complexes rather than hmgb alone. while hmgb -dna complex stimulation of tlr is involved in maturation of immune cells and cytokine secretion ( , ) , there is some evidence that these complexes may also suppress the immune response in some cell types ( ) . in addition to the hmgb -dna interactions that activate tlr , hmgb interactions with other cytokines such as il- β, ifnγ, and tnfα lead to an increased pro-inflammatory response compared with hmgb stimulation alone ( ) . ultimately, whether other interactions or modifications of hmgb are required for pattern recognition receptor binding or activation is uncertain. as hmgb has multiple downstream signaling responses due to activation of different receptors, it also induces cell specific responses when it stimulates cells of the immune system ( figure ). hmgb induces dc maturation as measured by the increased expression of many cell surface markers as well as the secretion of inflammatory cytokines ( , ( ) ( ) ( ) . monocytes stimulated with hmgb have an increased capacity for adhesion ( ) and release numerous cytokines and inflammatory mediators ( , ( ) ( ) ( ) . this effect is augmented when administered concomitantly with other cytokines ( , ) . neutrophil stimulation with hmgb increases the interaction of mac- and rage, thus activating the adhesive and migratory function of these cells ( ) . furthermore, hmgb stimulates the production of reactive oxygen species by neutrophils through a tlr dependent activation of nad(p)h oxidase ( ) , as well as increases the activation of nf-κb which results in increased production and release of cytokines ( , ) . t cells stimulated with hmgb release cytokines and appear to have increased proliferation, survival, and th functional polarization ( , ) . the response of endothelial cells to exogenous hmgb has been studied in relation to its possible pro-inflammatory role in vascular disease. endothelial cells release tnfα, il- , and mcp- , all of which enhance the local inflammatory en-vironment ( , ) . additionally, hmgb stimulation appears to increase the expression of icam- and vcam- on the surface of endothelial cells, thus increasing the adhesion of inflammatory cells ( , ) . these effects appear to be at least partially mediated by rage, which also appears to be upregulated in hmgb stimulated endothelial cells ( , ) . in contrast to their role in promoting inflammation, the ability of alarmins to promote tissue repair and regeneration is of increasing interest ( ) . importantly, hmgb induces migration of stem cells toward inflamed regions to promote repair and regeneration ( ) . furthermore, it results in increased mesangioblast and endothelial proliferation and migration to sites of inflammation and induces transit of these cells across the endothelial layer ( , ) . myoblasts stimulated by hmgb migrate toward damaged regions and stimulate repair ( , ) . these effects on specific cell types are reflected in increased regeneration at the tissue level. in smooth muscle, hmgb induces proliferation and rapid changes in cellular architec-ture leading to cell migration ( , ) . in skeletal muscle, hmgb promotes increased myogenesis and angiogenesis ( , , ) . further confirmation of this is reflected in the finding that inhibition of hmgb signaling leads to decreased vessel density and tissue regeneration ( ) . additionally, direct injection of exogenous hmgb to peri-infarcted cardiomyocytes in mice results in increased myocytes within the infarcted area and ultimately improved outcomes by both structural and functional measures ( ) . in an animal model of wound healing, topically applied hmgb accelerates the process in diabetic mice while inhibition of hmgb signaling slows it in normal mice, thus implicating functional hmgb signaling as an important component of diabetic wound healing ( ) . the ability of hmgb to stimulate angiogenesis has been demonstrated independently in studies demonstrating that exogenous hmgb stimulates endothelial proliferation and migration ( , ) . interestingly, many of these restorative effects are mediated through the same receptors (i.e. rage) that mediate the pro-inflammatory properties of the molecule ( , ( ) ( ) ( ) ) . taken together, the regenerative properties of hmgb represent a potentially important manner by which the functions of an alarmin can be manipulated to promote healing as opposed to injury. while early work on hmgb demonstrated its role as a late mediator of sepsis ( ), more recently hmgb has been implicated as a putative danger signal involved in the pathogenesis of a variety of non-infectious inflammatory conditions including autoimmunity, cancer, trauma, and hemorrhagic shock, and ischemia-reperfusion injury. furthermore, it has been studied in a number of organ systems including liver, heart, pancreas, brain, bone, and kidney. in addition to these studies highlighting the pro-inflammatory effects of hmgb in in vivo models of multiple diseases, there is emerging evidence to suggest that hmgb- can participate in tissue repair and remodeling as well as preconditioning; all of which are increasingly being recognized as important capacities of danger signals. considerable evidence exists implicating extracellular hmgb in the pathogenesis of a variety of autoimmune diseases. anti-hmgb antibodies are present in the serum of patients with rheumatoid arthritis and drug-induced systemic lupus erythematosus ( , ) . furthermore, hmgb has been found to be overexpressed in the extracellular milieu of synovial biopsy specimens in rheumatoid and experimental arthritis ( , ) . when given via direct intraarticular injection, hmgb induces arthritis in mice, while treatment with hmgb antagonists ameliorates collagen-induced arthritis in both rats and mice ( , ) . increased extracellular hmgb also is detectable in the dermis and epidermis of skin lesions in patients with cutaneous lupus erythematosus and in biopsy specimens of the minor salivary glands of patients with sjogren's syndrome ( , ) . hmgb was initially identified as a nuclear dna-binding protein. as such, it plays a role in the transcription of several genes, some of which include those that have been implicated in cancer development including e-selectin, tnfα, insulin receptor, and brca ( ) ( ) ( ) ( ) . furthermore, cancer cells that have undergone necrotic cell death can release hmgb into the local microenvironment. extracellular hmgb can lead to chronic inflammatory/reparative responses that, in the setting of cancer, may lead to tumor cell survival, expansion, and metastases ( ) . interestingly, numerous studies suggest that hmgb- plays a role in metastasis development, and thus links it to poor prognosis in a variety of cancers including prostate, breast, pancreas, and colon ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . in contrast to its potential role in tumor growth and spread, it also has been shown that hmgb -induced tlr signaling is required for effective responses to chemo-radiation in established tumors in animal models ( ) . these findings are validated further by the observation that node positive breast cancer patients carrying a loss of function tlr allele tend to relapse more quickly after treatment with chemo-radiation as compared to patients with wild-type tlr alleles ( , ) . more recently, hmgb has been recognized as a tumor derived damp capable of recruiting and activating eosinophils. the role of tumor infiltrating eosinophils is still being elucidated as they can either limit tumor growth through destructive effector functions or promote tumor growth through immunoregulation and tissue repair/remodeling ( , ) . in addition to the evidence linking hmgb to established cancers, it has also been linked to the pathogenesis of premalignant conditions. elevated serum levels of hmgb are present in mice with chemically induced colitis. furthermore, neutralizing antibodies to hmgb decrease tumor incidence and size in colitis-associated cancer models ( ) . the sum of these findings suggests that hmgb plays a role in tumor development, growth, and spread. additionally, immune responses to established cancers prior to, as well as during, systemic treatment appear dependent upon hmgb /tlr- mediated signaling cascades. consequently, hmgb warrants further investigation as a possible therapeutic target in malignant processes. end organ dysfunction in trauma and hemorrhagic shock results from systemic inflammatory responses ( ) . barsness et al. provided indirect evidence that hmgb may be involved in the pathogenesis of end organ injury following hemorrhagic shock by linking tlr activation to the development of acute lung injury ( ) . subsequently, it has been shown that pulmonary hmgb levels are increased as early as h after the initiation of hemorrhagic shock ( ) . furthermore, hmgb neutralizing antibodies ameliorate hemorrhage-induced acute lung injury ( ) as well as gut barrier dysfunction and ultimately lead to improved survival ( ) . these findings are even more relevant given the clinical observation that circulating hmgb levels are elevated in trauma patients with hemorrhagic shock as compared with normal volunteers ( ) . additionally, hmgb has been shown to play a central role in the initiation and propagation of the inflammatory response following traumatic injury. in a mouse femur fracture model, administration of neutralizing hmgb antibodies results in decreased serum il- and il- levels. this blunted systemic response corresponds with decreased hepatic and gut barrier dysfunction as measured by serum transaminase levels and nf-κb activation, respectively. interestingly, the contribution of hmgb to end organ injury in this model appears once again to be tlr dependent, as mutants are protected when compared with wild-types. no additional protec-tion is seen when antibodies are administered to tlr mutants ( ) . the role of hmgb in the pathogenesis of acute or chronic viral illnesses remains elusive. as mentioned, hmgb can escape extracellularly upon necrotic cell death. west nile encephalitis and acute hepatitis are viral-induced pathologies associated with necrotic cell death either via direct cytotoxic effects of the virus itself or the inflammatory response to viral infection ( ) . in a recent study utilizing hepatitis b virus (hbv) transgenic mice injected with virus specific cytotoxic t lymphocytes (ctls), hmgb translocates from the nucleus to the cytoplasm of hepatocytes surrounding ctlcontaining necroinflammatory foci. furthermore, treatment with hmgb inhibitors in this model significantly decreases the recruitment of inflammatory cells ( ) . in addition to passive release from necrotic cells, hmgb can be secreted actively by inflammatory cells (monocytes, macrophages, dendritic cells, etc.). a number of viral illnesses including sars and influenza result in the elevation of proinflammatory cytokines (tnf, il- , il- , types i and ii interferon) that could be responsible for inducing release of hmgb from inflammatory cells, thus leading to the propagation of the immune response ( ) . a preponderance of evidence exists implicating hmgb in the pathogenesis of ischemia/reperfusion injury (iri) in multiple organ systems including kidney, brain, heart, and liver. much of the seminal work identifying extracellular hmgb as an alarmin that initiates the inflammatory response resulting from iri was performed using a model of partial warm hepatic iri in mice. in this model, tissue levels of hmgb are elevated as early as h following reperfusion ( ) and continue to increase for up to h following the insult. furthermore, in this same model, neutralizing antibodies to hmgb ameliorate the damage resulting from iri in a tlr -dependent manner. the importance of hmgb signaling through tlr in hepatic iri was further clarified in subsequent in vivo experiments by the generation of chimeric mice in which tlr -derived bone marrow cells were shown to be largely responsible for the initiation and propagation of the inflammatory response. in this set of experiments, mice expressing tlr mutant bone marrow-derived cells were protected from liver damage as compared to those expressing tlr wild type bone marrow-derived cells. this occurred independently of the tlr phenotype expressed on hepatocytes ( ). subsequently, it was shown that increasing the number of hepatic dendritic cells worsened liver damage in tlr wildtype but not tlr mutant animals ( ) , thus suggesting that dendritic cells are involved in the recognition of and response to damps (hmgb included) released after acute injury in this model. the molecular mechanisms of hmgb / tlr -dependent iri involve the production of reactive oxygen species in a process that appears to be dependent on calcium signaling via the calcium/ calmodulin-dependent kinases (camk) whose activation is ultimately involved in the release of hmgb ( ) . while the significant body of literature described above elucidates the role of hmgb in hepatic iri, similar work in other organ systems including the heart ( , ), kidney ( ) , and brain ( ) ( ) ( ) has provided confirmatory evidence that hmgb is involved in the initiation of the inflammatory response following iri. a well characterized effect of pathogen-associated molecular patterns (pamps), such as lps, is their ability to confer protection when administered in small doses prior to more significant insults in a process that has come to be known known as preconditioning. therefore, alarmins ought to be able to precondition against later insults as well. proof of principle of this concept has been demonstrated by hmgb 's ability to provide protection when administered as a precondition agent in hepatic iri ( ) . hmgb administration h prior to the onset of injury results in a dose-dependent protection as evidenced by decreased circulating biochemical markers of liver damage as well as decreased serum tnfα and il- levels. this preconditioning effect appears to be mediated through an inhibition of tlr signaling ( ) . there is a growing body of literature surrounding the specific functions of hmgb on cells of the immune system as well as its role in important disease states. as the mechanisms promoting the release of hmgb and the signaling pathways it activates remain to be completely elucidated, evidence that suggests its potential as a therapeutic target/agent in various models of inflammation continues to accumulate. importantly, human-subject studies which demonstrate its elevation in several disease states further indicate its importance. interestingly, in addition to its proinflammatory roles, hmgb also appears to have several regenerative effects that lead to tissue repair. understanding hmgb and its complex effects on the immune system may lead to the development of novel strategies to attenuate inflammation and/or promote tissue repair and regeneration in various clinical states. immunological tolerance. in: nobel lectures, physiology or medicine - the induction of tolerance by skin homografts on newborn rats tolerance, danger, and the extended family the danger model: a renewed sense of self decoding the patterns of self and nonself by the innate immune system innate immunity: the virtues of a nonclonal system of recognition hemorrhagic shock in endotoxin-resistant mice: improved survival unrelated to deficient production of tumor necrosis factor emerging paradigm: tolllike receptor -sentinel for the detection of tissue damage hyaluronan fragments act as an endogenous danger signal by engaging tlr hmg- as a late mediator of endotoxin lethality in mice phagocyte-specific s proteins: a novel group of proinflammatory molecules alarmins: chemotactic activators of immune responses damps, pamps and alarmins: all we need to know about danger alarmin(g) news about danger: workshop on innate danger signals and hmgb mechanisms of disease: a 'damp' view of inflammatory arthritis high-mobility group box protein (hmgb ): nuclear weapon in the immune arsenal variation of hmgb expression in breast cancer a new group of chromatin-associated proteins with a high content of acidic and basic amino acids regulation of dna-dependent activities by the functional motifs of the highmobility-group chromosomal proteins structure of the hmg box motif in the b-domain of hmg monocytic cells hyperacetylate chromatin protein hmgb to redirect it toward secretion structural basis for the proinflammatory cytokine activity of high mobility group box high mobility group box protein : an endogenous signal for dendritic cell maturation and th polarization reversing established sepsis with antagonists of endogenous high-mobility group box release of chromatin protein hmgb by necrotic cells triggers inflammation hmg- as a mediator of acute lung inflammation the nuclear protein hmgb is secreted by monocytes via a nonclassical, vesicle-mediated secretory pathway the mystery of nonclassical protein secretion. a current view on cargo proteins and potential export routes acetylation of nuclear receptors in cellular growth and apoptosis nucleocytoplasmic shuttling of hmgb is regulated by phosphorylation that redirects it toward secretion bacterial endotoxin stimulates macrophages to release hmgb partly through heat shock response inhibits release of high mobility group box protein induced by endotoxin in murine macrophages the relationship between apoptosis and high-mobility group protein release from murine macrophages stimulated with lipopolysaccharide or polyinosinic-polycytidylic acid the effects of cpg dna on hmgb release by murine macrophage cell lines the role of ifnalpha and nitric oxide in the release of hmgb by raw . cells stimulated with polyinosinicpolycytidylic acid or lipopolysaccharide potential role of high mobility group box in viral infectious diseases ifn-gamma induces high mobility group box protein release partly through a tnf-dependent mechanism regulation of monocyte migration by amphoterin (hmgb ) hydrogen peroxide stimulates macrophages and monocytes to actively release hmgb hmgb -secreting capacity of multiple cell lineages revealed by a novel hmgb elispot assay proinflammatory cytokines (tumor necrosis factor and interleukin ) stimulate release of high mobility group protein- by pituicytes hmgb is secreted by immunostimulated enterocytes and contributes to cytomix-induced hyperpermeability of caco- monolayers hmgb release induced by liver ischemia involves toll-like receptor dependent reactive oxygen species production and calcium-mediated signaling the anti-inflammatory effects of heat shock protein involve inhibition of high-mobility-group box release and proinflammatory function in macrophages nuclear heat shock protein as a negative regulator of oxidative stress (hydrogen peroxide)-induced hmgb cytoplasmic translocation and release rage (receptor for advanced glycation end products): a central player in the inflammatory response receptor for advanced glycation endproducts: a multiligand receptor magnifying cell stress in diverse pathologic settings the receptor for advanced glycation end products (rage) is a cellular binding site for amphoterin. mediation of neurite outgrowth and co-expression of rage and amphoterin in the developing nervous system cells migrating to sites of tissue damage in response to the danger signal hmgb require nf-kappab activation activation of gene expression in human neutrophils by high mobility group box protein release of high mobility group box by dendritic cells controls t cell activation via the receptor for advanced glycation end products dendritic cell activating peptides induce distinct cytokine profiles high mobility group box- protein induces the migration and activation of human dendritic cells and acts as an alarmin requirement of hmgb and rage for the maturation of human plasmacytoid dendritic cells the secretion of hmgb is required for the migration of maturing dendritic cells a novel pathway of hmgb -mediated inflammatory cell recruitment that requires mac- -integrin inflammation-promoting activity of hmgb on human microvascular endothelial cells high mobility group b-box mediates activation of human endothelium increasing numbers of hepatic dendritic cells promote hmgb -mediated ischemia-reperfusion injury defective lps signaling in c h/hej and c bl/ sccr mice: mutations in tlr gene rage is the major receptor for the proinflammatory activity of hmgb in rodent macrophages involvement of toll-like receptors and in cellular activation by high mobility group box protein high mobility group box protein interacts with multiple toll-like receptors toll-like receptor -dependent activation by dna-containing immune complexes is mediated by hmgb and rage a novel role for hmgb in tlr -mediated inflammatory responses to cpg-dna high mobility group b protein suppresses the human plasmacytoid dendritic cell response to tlr agonists hmgb develops enhanced proinflammatory activity by binding to cytokines high mobility group protein (hmg- ) stimulates proinflammatory cytokine synthesis in human monocytes role of inducible nitric oxide synthase expressed by alveolar macrophages in high mobility group box -induced acute lung injury pivotal advance: analysis of proinflammatory activity of highly purified eukaryotic recombinant hmgb (amphoterin) monocytes promote natural killer cell interferon gamma production in response to the endogenous danger signal hmgb hemorrhagic shock induces nad(p)h oxidase activation in neutrophils: role of hmgb -tlr signaling high-mobility group box (hmgb ) protein at the crossroads between innate and adaptive immunity high mobility group box protein, a cue for stem cell recruitment cutting edge: extracellular high mobility group box- protein is a proangiogenic cytokine extracellular hmgb , a signal of tissue damage, induces mesoangioblast migration and proliferation multiple effects of high mobility group box protein in skeletal muscle regeneration amphoterin stimulates myogenesis and counteracts the antimyogenic factors basic fibroblast growth factor and s b via rage binding the high mobility group (hmg) boxes of the nuclear protein hmg induce chemotaxis and cytoskeleton reorganization in rat smooth muscle cells smooth muscle cells in human atherosclerotic plaques secrete and proliferate in response to high mobility group box protein exogenous high-mobility group box protein induces myocardial regeneration after infarction via enhanced cardiac c-kit+ cell proliferation and differentiation high-mobility group box protein in human and murine skin: involvement in wound healing angiogenetic signaling through hypoxia: hmgb : an angiogenetic switch molecule high-mobility group box activates integrin-dependent homing of endothelial progenitor cells autoantibodies to nonhistone chromosomal proteins hmg- and hmg- in sera of patients with juvenile rheumatoid arthritis antibodies to hmg proteins in patients with drug-induced autoimmunity high mobility group box chromosomal protein : a novel proinflammatory mediator in synovitis high mobility group box chromosomal protein plays a role in the pathogenesis of rheumatoid arthritis as a novel cytokine successful treatment of collagen-induced arthritis in mice and rats by targeting extracellular high mobility group box chromosomal protein activity high mobility group box chromosomal protein , a dna binding cytokine, induces arthritis increased extracellular levels of the novel proinflammatory cytokine high mobility group box chromosomal protein in minor salivary glands of patients with sjogren's syndrome increased expression of the novel proinflammatory cytokine high mobility group box chromosomal protein in skin lesions of patients with lupus erythematosus a poly(da-dt) upstream activating sequence binds high-mobility group i protein and contributes to lymphotoxin (tumor necrosis factorbeta) gene regulation the high mobility group protein hmg i(y) is required for nfkappa b-dependent virus induction of the human ifn-beta gene negative regulation of brca gene expression by hmga proteins accounts for the reduced brca protein levels in sporadic breast carcinoma transcriptional regulation of human insulin receptor gene by the highmobility group protein hmgi(y) high mobility group box i (hmgb ) release from tumor cells after treatment: implications for development of targeted chemoimmunotherapy identification of high mobility group protein i(y) as potential progression marker for prostate cancer by differential hybridization analysis nuclear matrix localization of high mobility group protein i(y) in a transgenic mouse model for prostate cancer human colorectal carcinomas express high levels of high mobility group hmgi(y) proteins gene expression patterns associated with the metastatic phenotype in rodent and human tumors transcriptional profiling of cell lines derived from an orthotopic pancreatic tumor model reveals metastasis-associated genes elevated high mobility group-i(y) gene expression is associated with progressive transformation of mouse mammary epithelial cells hmg-i/y in human breast cancer cell lines high mobility group protein i(y): a candidate architectural protein for chromosomal rearrangements in prostate cancer cells amphoterin induction in prostatic stromal cells by androgen deprivation is associated with metastatic prostate cancer the interaction between hmgb and tlr dictates the outcome of anticancer chemotherapy and radiotherapy toll-like receptor -dependent contribution of the immune system to anticancer chemotherapy and radiotherapy eosinophilic granulocytes and damage-associated molecular pattern molecules (damps): role in the inflammatory response within tumors pivotal advance: eosinophil infiltration of solid tumors is an early and persistent inflammatory host response essential roles of highmobility group box in the development of murine colitis and colitis-associated cancer neutrophils as early immunologic effectors in hemorrhage-or endotoxemia-induced acute lung injury hemorrhage-induced acute lung injury is tlr- dependent hmgb contributes to the development of acute lung injury after hemorrhage anti-hmgb neutralizing antibody ameliorates gut barrier dysfunction and improves survival after hemorrhagic shock systemic inflammation and remote organ injury following trauma require hmgb treatment with hmgb inhibitors diminishes ctl-induced liver disease in hbv transgenic mice the nuclear factor hmgb mediates hepatic injury after murine liver ischemia-reperfusion hepatic ischemia/ reperfusion injury involves functional tlr signaling in nonparenchymal cells elevated high-mobility group box levels in patients with cerebral and myocardial ischemia reduced myocardial ischemia-reperfusion injury in toll-like receptor -deficient mice tlr activation mediates kidney ischemia/reperfusion injury high mobility group box protein is released by neural cells upon different stresses and worsens ischemic neurodegeneration in vitro and in vivo induction and subcellular localization of highmobility group box- (hmgb ) in the postischemic rat brain hmgb , a novel cytokinelike mediator linking acute neuronal death and delayed neuroinflammation in the postischemic brain cutting edge: highmobility group box preconditioning protects against liver ischemia-reperfusion injury key: cord- -qa uph authors: nan title: poster discussion session pds date: - - journal: allergy doi: . /all. sha: doc_id: cord_uid: qa uph nan objectives: since bradykinin is a short-lived, low-abundance mediator in the systemic circulation, the discovery of additional biochemical biomarkers correlating hae disease activity with contact system dysregulation may be useful for further elucidation of hae pathophysiology and pharmacodynamic therapeutic modulation of the contact system. results: activated pkal cleaves single chain high molecular weight kininogen to generate bradykinin and cleaved chain hmwk. cleaved -chain hmwk was measured in human plasma using both a semi-quantitative western blot assay with fluorescent detection (licor) and a novel elisa with a capture antibody that specifically binds -chain hmwk. the western blot assay was previously used to monitor pharmacodynamic activity in hae patients treated with lanadelumab, a fully human antibody inhibitor of pkal that is in clinical development for hae attack prophylaxis. lanadelumab inhibited -chain hmwk generation following contact system activation in vitro, confirming that -chain hmwk is a product of pkal activity. plasma -chain hmwk levels from hae patients during or between attacks were compared to that from healthy volunteers using both the western blot assay and elisa. roc curve analyses with both methods suggest that -chain hmwk is a trait-specific biomarker capable of differentiating hae patients from healthy volunteers. the elisa was able to differentiate samples from hae patients collected during an attack from those collected between attacks with moderate sensitivity and specificity (c-statis-tic= . ). a comparison of -chain hmwk levels in citrated plasma versus plasma that contains protease inhibitors (scat plasma) provides estimates of endogenous versus ex vivo activation. the measurement of -chain hmwk using the specific assays described may find use in further dissecting the role of the contact system in disease pathology, to identify additional indications for modulators of this pathway, and to investigate therapeutics targeting the contact system. | g protein coupled receptor kinase (grk ) regulates endothelial permeability induced by bradykinin | pharmacokinetics (pk) and pharmacodynamics (pd) of c esterase inhibitor of chronic urticaria challenges most commonly identified were the following: time of onset of disease; frequency/duration of and provoking factors for wheals; diurnal variation; occurrence in relation to weekends, holidays, and foreign travel; shape, size, and distribution of wheals; associated angioedema; associated subjective symptoms of lesions; family and personal history regarding urticaria, atopy; previous or current allergies, infections, internal diseases, or other possible causes; psychosomatic and psychiatric diseases; surgical implantations and events during surgery; gastric/ intestinal problems; induction by physical agents or exercise; use of drugs; food allergies; relationship to the menstrual cycle; smoking habits; type of work, hobbies; stress; quality of life and emotional impact; previous therapy and response to therapy, and previous diagnostic procedures/results. we included all of these aspects in our guide and as a result we developed a chronic urticaria check list. conclusions: our guide of clinical history for chronic urticaria (gur) contributes to have an easy tool in order to achieve a better diagnosis and evaluation of chronic urticaria. | clinical and diagnostic features in acquired cold urticaria patients in a coruña sanitary area, spain physicians and dermatologists/allergists; c/sa patients were more likely to visit dermatologists/allergists ( % vs. %) and less likely to visit general physicians ( % vs. %) than european patients. emergency room visits due to cu were more common in c/sa ( %, mean [sd] number= . [ . ] ) than europe ( %, mean [sd] number= . [ . ] ). conversely, hospital admissions due to cu were more likely to occur in europe ( %) than c/sa ( %), but the average (sd) number of admissions among those hospitalised was greater in c/sa ( . [ . ] vs. . [ . ]). variations were seen in subregion comparisons. mean (sd) overall wpai scores were . ( . ), . ( . ), . ( . ), and . ( . ) for absenteeism, presenteeism, work productivity loss, and activity impairment, respectively; patients in c/sa reported a higher rate of impairment (range, %- %) on all domains compared with patients in europe. conclusions: cu is associated with substantial hru and work and activity impairment in both europe and c/sa. general physicians should be considered key members of the treatment team in the care of patients with cu in these regions. objectives: cu patients (n= ) received monthly subcutaneous injections of omalizumab for up to six months. urticaria-related symptoms were assessed by both the urticaria control test (uct) and the chronic urticaria quality of life score (cu-q ol). peripheral blood was drawn prior to each injection for determining the concentration-dependent reactivity of patients' basophils to specific anti-fceri and unspecific fmlp stimulation by basophil activation test. furthermore, the impact of anti-ige treatment on ige-bearing cell populations was characterized by flow cytometry analyzing the surface expression of both fceri (e.g. on monocytes, dendritic cells, basophils) and the low-affinity receptor for ige, fcerii (e.g. on b cells, eosinophils). results: anti-ige treatment of cu patients significantly improved clinical symptoms of cu already after the first injection as evaluated by cu-q ol and uct, the latter of which correlated with an increase of basophil numbers and a decrease of basophil surface bound ige. of note, cell-bound ige on fcerii-expressing cells was not altered. furthermore, while clinical amelioration also was accompanied by reduced fceri expression on basophils, the basophil responsiveness to anti-fceri stimulation increased in % ( / ) of treated patients. in contrast, ige-independent activation of basophils by fmlp was unchanged. conclusions: clinical improvement of cu patients treated with omalizumab is associated with characteristic immune alterations in basophils, like rapid, cell-specific reduction of surface bound ige and fceri-expression as well as normalization of basophil responsiveness to fceri-stimulation. while our findings might help to better understand the mode of action of anti-ige therapy in cu, they also can shed new light on the pathomechanisms underlying cu. | omalizumab in patients with severe active chronic spontaneous urticaria (csu) heavily treated with corticosteroids and cyclosporine introduction: increased levels of blood d-dimers (d-d), the byproducts of fibrin degradation, is linked to the severity of chronic spontaneous urticaria (csu) and to poor response to antihistamines h (ah ). omalizumab (oma) is a human monoclonal anti-immunoglobulin-e antibody registered as an add-on treatment of csu in adults and adolescent (≥ years old) and with insufficient response to ah . the sunrise study assessed the efficacy of omalizumab on csu symptoms and the correlation between d-d levels and response over time to treatment with oma to explore its potential predictive value. objectives: sunrise was a french prospective non comparative phase study. included patients had to have been diagnosed with csu for at least months, be resistant to ah treatment, and have a uct score (assessed by patient over the last weeks, values from (maximal disease)to (full control)) < , indicative of a poorly controlled disease. the widely used uas score (assessed by patients over week which captures intensity of pruritus and number of hives, values ranging from (no disease) to (severe disease)) was further used to evaluate the proportion of patients achieving a well controlled disease(uas≤ ). all patients received mg oma by sub-cutaneous injections at day , weeks (w) and . blood levels of d-d were assessed (turbidimetric immunoassay) at d , w and w . response to treatment was evaluated at w by means of the uas . results: median level of d-d assessed at d in patients was increased at baseline ( ng/ml, extremes - ) and normalized as early as w reaching ng/ml ( - ) at w . correlation between d-d concentration and uas score at w was weakly positive (spearman coefficient . ). among the patients with a very high baseline de d-d level (> ng/ml) were responder (uas ≤ ) at w . conclusions: baseline d-d levels were increased in more than half of patients of this study in line with relevant literature. a fast normalization was observed with oma as early as w of treatment. d-d levels at w were weakly correlated with uas . subgroup analyses may help to better understand the link between d-d and clinical response, as these preliminary results do not yet allow the predictive use as a biomarker. the sunrise study explored for the first time in a prospective way the impact of oma on dd and found weak correlations were measured between dd level and response to oma. further studies will be needed to evaluate its predictive value for response. (crp, esr, il- , il- , il- , ccl /mcp- ), and the disease severity in patients with chronic spontaneous urticaria introduction: pru p is the primary sensitizer of some fruits and responsible for severe reactions in the mediterranean area. sublingual immunotherapy (slit) using peach extract enriched in pru p (prup -enriched-slit) brings a new perspective to treat patients with reactions to peach considering that currently the treatment of the allergy to peach is based on avoidable ingestion of fruit. we performed a pilot study to examine the immune modulation by slit in patients with peach allergy over a -year treatment period. objectives: we aimed to evaluate the effect of the slit during one year in patients with peach allergy. we analysed the capacity pru p enriched-slit to modulate immune response, from a th to th response with increases of treg cells. we studied three groups of subjects: peach allergic patients who received prup -enriched-slit for year, peach allergic patients non treated, and healthy controls who tolerated peach. monocyte-derived dendritic cells (dcs) maturation, peripheral blood mononuclear cell phenotype and lymphocyte proliferation after prup stimulation were assessed by flow cytometry from samples obtained before, and , and months during slit. results: we found statistically significant differences in dcs activation and maturation between allergic patients and controls at the basal state. when we analyzed the effect of prup -enriched-slit over time, we found a significant reduction of activation and maturation markers (ccr , cd , cd , cd and cd ) at the first month of treatment that was maintained after year. concerning lymphocytes, we observed a significant decrease of effector cells immune cells. recent studies showed that fructo-oligosaccharides (fos) increase the efficacy of oral immunotherapy (oit) in a mouse model for cow's milk allergy, however, the mechanism is unknown. objectives: investigating the effect of oit+fos on the effector response and the process of tolerance induction. methods: female c h/heouj mice ( - weeks old, n= /group) were sensitized to the cow's milk protein whey ( mg in pbs, intragastrically (i.g.)) with cholera toxin ( lg) once a week for weeks (d -d ). the mice received a diet with % fos or a control diet from d -d . oit ( mg in pbs or pbs) was provided days a week for weeks (d -d ). intradermal (i.d.) and i.g. challenges were performed to measure the acute allergic response. serum, bone marrow, caecum content, small intestines and mesenteric lymph nodes (mln) were collected at d , d and d . spleen-derived t cell fractions (whole spleen, cd +cd -and cd +cd +, using macs) were transferred to na€ ıve recipient mice at d . the recipients were sensitized and challenged as described for the donor mice. conclusions: this study shows that oit+fos results in an early induction of functional tregs and a reduction of mast cell degranulation upon challenge. the latter may be caused by inhibition of mast cell activation by galectin- and/or butyric acid. moreover, the effect of fos on bone marrow suggests possible epigenetic changes reducing development of mast cells. further research is needed to investigate if this approach may be of potential value to treat food allergies. | safety and feasibility of slow low-dose oral immunotherapy sugiura s; kitamura k; tajima n; takasato y; kato t; tajima i; ono m; tagami k; sakai k; nakagawa t; ito k aichi children's health and medical center, obu, japan introduction: slow low-dose oral immunotherapy (sloit) is an ongoing clinical trial conducted in our institute (umin registry number ). this is a type of oral immunotherapy with a low dose antigen increased very slowly. objectives: to evaluate the safety and feasibility of the protocol. results: sloit enrolled the patients who were diagnosed as severe egg, milk or wheat allergies, with a threshold dose of g (or ml) or less in the oral food challenge (ofc, -minutes boiled egg white, whole milk, udon noodle). subjects were divided into two groups, intervention (sloit) group or elimination (control) group, based on their preference. sloit group began to ingest / to / amount of the final dose of the ofc based on the severity of provoked symptoms. intake was continued everyday with an increasing dose less than . times/ month, expecting a times increase from the starting dose after months. feasibility was evaluated based on the proportion of patients who complied the protocol. safety was evaluated based on the frequency of immediate allergic reactions observed in the programmed intakes. fifty-nine patients were enrolled from april to december , and of them (egg: , milk: , wheat: ) preferred the sloit group. among them, patients ( . %) dropped out from the study protocol because of provoked allergic symptoms (n= ) or the other personal reasons (n= ). among a total of ingestions by patients who continued the protocol over months, mild symptoms were observed times ( . %), to which rescue medicine such as oral antihistamines was used in cases ( . %). no one needed an emergency visit or an adrenalin auto-injector. low threshold dose at the initial ofc ( . g or less, n= ) was associated with higher proportion of provoked allergic symptoms in the protocol (low threshold: . %, non-low threshold: . %, p=. ). the level of specific ige titer was not associated with the safety. conclusions: sloit protocol has sufficient safety and feasibility, but low threshold patients should be monitored closely. the efficacy of this protocol is being evaluated by an ofc after - months of the treatment, and the overall data will be presented after march . objectives: the aim of this phase i, randomized, non-controlled, multicenter, opened, with parallel groups clinical trial, is to evaluate the safety and tolerability of subcutaneous immunotherapy (scit), in a polymerized mixture ( / ) depot presentation. patients with rhino-conjunctivitis polysensitized to olea europaea/ phleum pratense received a schedule consisting of two weeks of initiation with three weekly injections; or a program comprising two administrations in the same day separated by minutes. both treatments continued with a maintenance period of three months with a monthly administration. the primary outcomes are the number, percentage, and severity of adverse reactions. secondary endpoint included subrogate efficacy parameters evaluation: changes in immunoglobulin titers (specific ige, igg and igg ) and changes in cutaneous reactivity at different concentrations. systemic reactions were registered, representing . % of the included patients: one grade , described as general discomfort plus dizziness and one grade i, such as rhinoconjunctivitis. there were no local reactions. all were classified as of mild intensity and took place with the cluster schedule. symptomatic treatment was not required. conclusions: both schedules with polymerized mixture of phleum pratense/olea europaea, ( / ), presented a good safety and tolerability. a statistically significant decrease in cutaneous reactivity to olive and grass allergens was observed after immunotherapy. a | design of the pivotal phase iii study to assess the efficacy and safety of subcutaneous hdm allergoid immunotherapy in patients with hdm induced allergic rhinitis/ rhinoconjunctivitis introduction: in order to comply with ema guidelines on development of allergen immunotherapy products, a clinical development program was started to obtain full marketing authorization for a allergoid subcutaneous immunotherapy (scit) product for the treatment of house dust mite (hdm) allergy. previously, the safety and tolerability of increasing doses of this allergoid scit product was evaluated in patients with hdm-induced allergic rhinitis/rhinoconjunctivitis (arc) [eudract - - ] . no safety or tolerability issues were identified for doses up to aueq. subsequently, a dose-finding study to identify the optimal, i.e. effective and safe dose in hdm arc with or without concomitant asthma was performed [eudract - - ; pfaar, allergy ] . this study demonstrated a dose response relationship with doses of aueq ( . ml of aueq/ml) up to aueq ( . ml of aueq/ml) showing significant improvements compared to placebo. the current pivotal phase iii study [eudract - - ] aims to confirm safety and efficacy of this hdm allergoid scit product at a dose level of aueq/ml ( . ml) compared to placebo after one year of treatment in patients with hdm-induced arc. objectives: the current study is a multi-center ( clinical study centers in european countries) randomized, double-blind, placebocontrolled, parallel-group study in adult patients, with moderate to severe hdm induced arc with or without mild to moderate persistent asthma. the primary outcome of the study is the difference in mean combined symptom and medication score (nasal symptoms only) (csms (n)) between aueq/ml allergoid scit and placebo treatment, assessed during the last weeks of the approximately year treatment period. results: patients from centers, (mean age . years) have been included and analyzed. the . % are men, . % presented associated asthma. a large majority of patients have received subcutaneous sit ( . %), and . % of them containing a single allergenic source. . % in polymerized formulation and . % in depot. accelerated schedule has been the most prescribed ( . %), followed by clustered one ( . %). from the patients who have completed the study, . % of them improved from persistent to intermittent rhinoconjunctivitis (p<. ) and . % from moderate/severe to mild intensity (aria) (p<. ). moreover, % of asthmatic patients at baseline, did not have any bronchial symptoms after -year treatment. the improvement in quality of life was possible to be analyzed in patients. mean values in rqlq questionnaire (total score) decreased from . to . points ( . % of score reduction) in final visit, reflecting a statistically significant improvement (p<. ). mean value of treatment satisfaction was . (sd= . ) and . (sd= . ) for physician and patients respectively. for safety assessment, out of analyzed patients, only systemic reactions were reported in patients ( . %). seven of them were classified as grade i, and one as grade ii according to eaaci grading system. strasbourg is a m chamber, located into the university hospital of strasbourg at less than to minutes to the intensive care unit. one of the characteristics of this unit is that the maximum parameters are controlled: temperature, relative humidity, ventilation rate, particles number and particles size, concentration of airborne of der p and airborne voc. mite allergens extract were nebulized through a nebulizer. airborne der p concentrations were sampled using glass fiber filters and measured with an elisa assay. particles number and particles size were monitored continuously during nebulization, using particles counters distributed inside the exposure room. the cleaning process was also controlled and validated. objectives: to validate the technical parameters of the environmental exposure chamber (eec) of strasbourg with mite allergens. results: the reproducibility was excellent for the indoor temperature, relative humidity and airflow ( cv interassay < %). three concentrations of der p were measured: , , ng/m (n= ). for all concentrations, the cv intra-assay of airborne der p was ae . %, the interassay was less than %. for the particle size . - and - lm, the cv interassay was and %, respectively (n= ). the cv of the mmad was . % (n= ). no measurable airborne der p was detected in the toilets and the medical supervision room (n= ) neither in the exposure room minutes after the end of the allergen exposure (n= ). no airborne voc was measured in the chamber and the other rooms of the clinical unit (n= ). there was no significant change in particles size and number when to persons entered the room (n= ). introduction: pathogenesis of systemic sclerosis (ssc) includes vasculopathy with endothelial dysfunction which is considered to be one of the earliest changes in the pathogenesis of ssc. several biological molecules, including e-selectin (e-sel), inter-cellular adhesion molecule (icam- ), endothelin (et- ), von willebrand factor (vwf) and interleukin (il- ) have been associated with endothelial activation. objectives: we aimed to determine if these vascular biomarkers are associated with distinct capillaroscopic ssc patterns and/or more severe disease in ssc patients. results: correlations between serum levels of all vascular biomarkers were good to moderate and statistically significant, with r indices varying between . and . , the only exception being et- which did not correlate with e-sel. good correlations (r . to . ) were also found between all biomarkers and crp. patients with severe vasculopathy, as reflected by the nfc "late" pattern, had higher levels of il- (median . vs . pg/ml, p=. ), et- (median . vs . pg/ml, p=. ), vwf (median vs iu/ml, p=. ) and e-sel (median . vs . ng/ml, p>. ), compared to patients with nfc "early" or "active" patterns. there was a significant, negative correlation between lung transfer for carbon monoxide (dlco) and e-sel, icam- (both p<. ) and vwf (p=. ). et- was higher in patients with more severe disease (dcssc, patients positive for anti-topoisomerase antibodies and patients with a history of digital ulcers-all p<. ). conclusions: serum endothelial activation biomarkers are elevated in patients with more severe ssc-associated vasculopathy and correlate with serum crp. together with nfc data they may be used for assessing vasculopathy severity in ssc. objectives: here we present the imagination findings of eye involvement in a family whose members have mws. method: clinical data was collected during the course of ongoing patient care. results: we evaluated the clinical features of patients who were referred to our center. the median age of the patients was years (range: - years). the ratio of females /males was . ( / ). all patients had arthritis with exacerbation on exposure to cold and ocular involvement, mostly in the form of conjunctivitis and far less other forms. the median age of onset of ocular involvement was years ( - y). chronic eye damage were detected in three patients. corneal involvement and clouding was detected in four patient. two conclusions: in this study, it has been shown that eye findings related to mws can vary from conjunctivitis to severe uveitis. we want to emphasize that ocular involvement in mws should be carefully assessed, since it can lead to visual impairment. | antiretroviral activity of the conjugates '-azido- 'deoxythymidine and derivatives of , -diacylglycerides case report: aids epidemics remain the critical problem due to both their emergent and long development. treatment of aids with azt reduces p antigenemia, increases cd + lymphocyte counts, reduces the frequency and severity of opportunistic infections and prolongs life. however, zidovudine and other dideoxynucleotides do not decrease the ability to isolate hiv from pbmc, and in addition, these drugs are very toxic. this phenomenon is caused by insufficient inhibition of hiv due to low levels of nucleoside kinases in ccr -positive cells, including in macrophages, which are a major reservoir of hiv. potential advantages of these liponucleotide prodrugs include: greater in vivo efficacy and lower toxicity due to a greater delivery to monocytes/macrophages, ability to bypass the initial anabolic phosphorylation due to the presence of the phosphorous center in the structure, and the prospect of improved pharmacokinetics and prolonged intracellular persistence. the aim of this work is the study of cytotoxicity and anti-hiv activity of glycerolipids derivatives of azt. evaluation of the cytotoxicity of azt and test compounds was per- | bone mineralisation defect in patients with hax- deficiency and osteopenia (z score <À ) in patients. bone mineralisation defect was found in all female patients while only one male had osteopenia (table ) . conclusions: in this study, a significant decrease ( . %) of bone mineralization was observed in patients with hax- deficiency. female patients were found more prone to bone mineralisation defect. to conclude on this subject, more studies are needed with large number of patients having not only hax- deficiency but also ela- mutations. gene mutation age ( introduction: bronchopulmonary diseases are kept as one of the actual problems of the pediatricians. nevertheless fulfilment of several scientific works on study of these diseases, presently we meet the complication of the respiratory diseases, recurrency, changing to the chronical type. objectives: the main purpose of our work to study the cytokine status and substance p, mutual connection they in frequently ill chil- results: in fic with respiratory diseases in the acute period of the disease increase of levels proinflammatory cytokines il- beta, il- , il- , tnf-alpha and substance p,decrease of levels il- and ifngamma was marked. clinical remission in these children is not accompanied by normalization of cytokine status and substance p. the high level of proinflammatory cytokines and substance p testifies to proceeding of inflammatory process that is possible connected with persistence of the infections agent. acute decrease in level of cytokines il- and ifn-gamma in these children,most likely, is caused by the presence of a immunodeficiency of cellular type. conclusions: in this connection it is necessary to carry out an adequate therapy of fic with arvi. introduction: atopic diseases are known to be characterized by a t helper (th) -skewed immunity. th -skewed immunity at birth, th -associated cc chemokine ligand (ccl)- , appears to be associated with high total ige levels but not of allergic outcomes later in life. the prevalence of asthma increases with a rapid upward trend after age ; however, there are few studies addressing the changes of ccl chemokine levels during infancy related to the development of atopic diseases in early childhood. objectives: we investigated children followed up regularly at the clinic for years in a birth cohort study. the levels of th related chemokine ccl were quantified in cord blood and age . by multiplex luminex kits. specific immunoglobulin e antibodies against food (egg white, milk, and wheat) and inhalant allergens (d. pteronyssinus, d. farina, and c. herbarum) were measured at months as well as . , , and years of age. results: a total of pairs of ccl chemokine levels from birth to age . were recruited in this study. k-means clustering was performed using r software and package mfuzz and this resulted in groups of ccl chemokine levels that declined from around to pg/ml (cluster a, n= ), from around to pg/ml (cluster b, n= ) , and raised from around to pg/ml (cluster c, n= ) . in children with raised ccl chemokine levels appeared to be associated with a higher prevalence of house dust mite sensitization at age . . furthermore, raised ccl levels during infancy were significantly associated with higher risk of asthma at age (p=. ). conclusions: raised ccl chemokine levels during infancy appear not only to be associated with an increase in the prevalence of house dust mite sensitization but also the risk of asthma in early childhood. | serum periostin is "not" a biomarker for pediatric asthma suzuki n ; hirayama j ; nagao m ; kameda k ; kuwabara y ; kainuma k ; ono j ; ohta s ; izuhara k ; fujisawa t mie national hospital, tsu, japan; shino-test corporation, kanagawa, japan; saga medical school, saga, japan introduction: periostin is a matricellular protein induced by type helper t-cell cytokines, expressed by airway structural cells and is thought to contribute to airway remodeling and progressive lung function decline in severe asthma in adults. we sought a possible clinical utility of serum periostin in children with asthma. objectives: we recruited volunteer children and adolescents (age range, to years) who were otherwise healthy except for allergic diseases including bronchial asthma. allergic diseases were classified with isaac questionnaire and serum levels of periostin were measured with elisa. abstracts | results: a total of volunteers were enrolled. among them had no allergic diseases (na), had only allergic rhinitis (ar) and the rest of had bronchial asthma (ba) and/or atopic dermatitis (ad) . serum levels of periostin in na younger than were significantly higher than the older counterpart and the levels in children < years old were similar across each age. data distribution of serum periostin in ar were very similar with that in na and we defined na and ar groups as reference population. reference values, geometric mean (+ geometric sd range), for serum periostin were ( ) and ( ) ng/ml in children/adolescents < and ≥ , respectively. there were no gender differences in serum periostin in the reference population. we then compared the serum levels of periostin in ad and/or ba with the reference group and found that serum periostin in ad and ad+ba, not ba, in < years old were significantly higher than the reference group. in addition, severity of asthma had no association with serum periostin levels in age group of < . on the other hand, the levels in ba aged ≥ were slightly higher than non-ba (statistically significant). conclusions: serum periostin is physiologically high in children and adolescents, possibly in growing age, and the levels are elevated in those with ad, not ba. serum periostin is "not" a useful biomarker for pediatric asthma. | clinical, biochemical and radiological factors for response to aspirin desensitization in patients with aspirin exacerbated respiratory disease-pilot study introduction: aspirin desensitization is regarded as an effective and well-tolerated therapy for patients with aspirin exacerbated respiratory disease (aerd). despite many studies investigating the pathophysiology of aerd, the underlying mechanism responsible for the beneficial effects of aspirin therapy has not yet been clarified. the aim of the study was to evaluate the influence of aspirin desensitization on clinical, biochemical and radiological changes in aerd individuals. objectives: this is a prospective study of twenty-one aerd patients subjected to one-year aspirin desensitization. all participants were hospitalized three times over the period of one year. at baseline and during each follow-up visit ( nd and th month) blood, urine, induced sputum (is) and nasal lavage (nl) were collected from all participants. the acquired material was processed in order to evaluate ) is and nl cell count ) concentrations of is and nl eicosanoids ) leukotriene e (lte ) in urine and ) periostin in blood. additionally, participants underwent a ct scan of the paranasal sinuses at baseline and after months of aspirin therapy. the lund-mackay score values were compared. for statistical analysis, summary statistics and repeated measures anova with post-hoc test were applied. results: twenty participants completed a one-year aspirin therapy. there was a statistically significant decrease in the number (p=. ) and percentage (p=. ) of eosinophils in is between baseline and after aspirin desensitisation. significant increase of urine lte in the course of aspirin therapy was observed (p=. ). the levels of prostaglandins and leukotrienes in is and nl as well as blood periostin level and the differential cell count in nl did not change during aspirin desensitization. in ct scan images the regression of the lesions in paranasal sinuses was observed in %, the worsening in % and in % of patients no changes were noted. in is count of eosinophils in aspirin-sensitive individuals, which may potentially be used in disease monitoring and tailoring asthma therapy. aspirin desensitization did not lead to significant changes in local eicosanoid levels in is and nl. blood periostin level is not a good marker for patient's response to aspirin desensitization. introduction: one of the main severe asthma phenotype is the "severe eosinophilic" or "eosinophilic refractory" asthma, for which novel biologic agents are emerging as therapeutical options. in this context, blood eosinophils count are one of the most reliable biomarker. objectives: the aim of our study is to evaluate the performance of a point-of-care peripheral blood counter in a clinical setting of severe asthmatics. seventy-six patients with severe asthma were evaluated, for blood cells count, by both a point-of-care and a standard analyser. results: the inter-and intra-assay variation was acceptable for leukocytes, neutrophils, lymphocytes and eosinophils. this was not the case of monocytes and basophils. a significant correlation between blood eosinophils assessed by the two devices was found (r = . , p<. ); similar correlations were found also for white blood cells, neutrophils and lymphocytes. the point-of-care device showed ability to predict blood eosinophils cutoffs used to select patients for biologic treatments for severe eosinophilic asthma, and the elen index, a composite score useful to predict sputum eosinophilia. introduction: over years ago there was revealed periostin should play an important role in pathogenesis of allergic inflammation including asthma and processes of tissue remodeling and fibrosis. its expression has been observed in the thickened basement membrane as well as in serum of asthmatic patients. thus, measuring of periostin serum levels may shed some light on these elusive asthma features. periostin has already demonstrated a convenient value in clinical studies as a companion diagnostics for lebrikizumab, tralokinumab or omalizumab treatment. however, to date, the changes of periostin serum levels following asthma therapy except for inhaled corticosteroids remain unclear. objectives: to emphasize this issue we have collected clinical and laboratory data including serum periostin of asthma patients ( males/ females) in a cross-sectional study. all patients were treated either by conventional therapy comprising inhaled corticosteroids (n= ) or by inhaled corticosteroids with additional biological therapy (omalizumab) (n= ). asthma phenotype, control, complications, comorbidities and other available biomarkers have been assessed and statistically analysed. results: we have observed a weak but statistically significant correlation between serum periostin and total ige levels (p=. ) and absolute eosinophil count (p=. ). association between periostin and total ige had nonlinear character (p=. ), and was expressed particularly in non-severe asthma patients without omalizumab treatment (p=. ). despite mutual correlation between serum periostin a total ige levels, both biomarkers showed different reaction on asthma treatment. multivariate analysis demonstrated, that only periostin levels, in contrast to all other assessed biomarkers, were significantly decreased in severe asthma patients treated by omalizumab (p=. ). this relationship was independent of asthma control (assessed by asthma control test -act), exacerbation rate, hrct or spirometry measurement results or comorbidities, except chronic rhinosinusitis with nasal polyps (crswnp) (p<. ). conclusions: we demonstrate, serum periostin levels are dependent on therapy, thus it may contribute not only to asthma phenotype stratification, prediction of treatment responsiveness, complications such as remodeling but probably more precise monitoring of therapy effect too. | usefulness of serum pteridines as a biomarker for childhood asthma kasuga s ; hamazaki t ; fujitani h ; fujikawa s ; niihira s ; shintaku h department of pediatrics, osaka city university graduate school of medicine, osaka, japan; the national institute of special education, tokyo, japan introduction: reliable and stable biomarker of airway inflammation is essential to determine intensity of asthma treatment. exhaled nitric oxide (feno) has been introduced to assess useful marker of airway inflammation but it fluctuates depending on steroid inhalation. nitric oxide is produced by nitric oxide synthase which requires tetrahydrobiopterin (one of pteridines) as a cofactor. objectives: to assess pteridines as a biomarker of childhood asthma control. results: asthmatic children were recruited for periodical asthma checkup program in japan to assess asthma control status by using objective questionnaire, respiratory function tests, airway resistance, feno, and serum pteridine levels. serum pteridine levels were measured by high performance liquid chromatography. total japanese children ( - years) were participated in this program. children who have no asthma attack over three years were divided as remission group to evaluate the long-term asthma control. the other children were divided as asthma group. furthermore, we divided asthma group for three groups by childhood asthma control test (c-act) scores to evaluate the short-term asthma control. and we had age matched children as control group. pteridine levels tended to decrease in patients who showed higher feno in asthma group. asthmatic children showed lower pteridine levels than other groups. there are significant differences between control group and remission groups and asthma groups (p<. , tukey's honestly significant difference test). but there are no significant differences between the three groups in asthma group (well-controlled group, partly-controlled groups and uncontrolled groups) which were divided by c-act scores. the low concentration of serum pteridines in children with stable asthma may indicate poor long-term control of asthma. but that not indicate poor short-term control of asthma. since pteridine biosynthesis pathways were suppressed by th mediated immune response, these results suggest that th mediated immune response was dominating the th response in asthmatic children. therefore, serum pteridines could be a novel biomarker of stable asthmatic children. introduction: asthma is a syndrome with chronic airway inflammation. the goal in the treatment of asthma is to control the inflammation. however, there has been a scarcity of useful noninvasive tests for monitoring the airway inflammation in clinical setting. metabolites of the eicosanoids pathways in induced sputum of the patients with asthma could be valuable biomarkers that can reflect the airway inflammation. objectives: to investigate eicosanoid metabolites and to find out their phenotypic differences, induced sputum supernatants from patients with refractory asthma, patients with controlled asthma, and normal control subjects were analyzed by using liquid chromatography tandem mass spectrometry. in addition, we evaluated the relationship between asthma exacerbation and eicosanoid metabolites. results: among metabolites which were measured, metabolites were detected in the induced sputum. we found that normal control subjects had higher concentrations of prostaglandin (pg) d (normal subjects vs controlled asthma vs refractory asthma, median conclusions: eicosanoid profiles in induced sputum supernatant were different between patients with refractory asthma, those with controlled asthma, and normal control subjects. our findings suggest that they could be biomarkers to differentiate refractory asthma from controllable asthma or non-asthma. this work was supported by the research program funded by the korea centers for disease control and prevention ( -er - ) . | serum periostin in asthma is related to disease severity, eosinophilia and il- introduction: introduction: asthma is a chronic inflammatory disease where more than powerful inflammatory mediators are associated with airway hyperresponsiveness, mucus hypersecretion, activation of fibroblasts and hyperplasia and hypertrophy of smooth muscles of the airways and if they do not use preventive antiasthma treatment can cause irreversible airway remodeling. objectives: the aim of this study was to determine the effect of adding montelukast to combined therapy icss/labas in patients with uncontrolled asthma by analyzing of serum level of il- , il- , eosinophils and symptom score. methods: in study we included patients, they were treated with icss/labas ( / mcg-twice daily) plus montelukast ( mgdaily). in each of them were measured serum levels of il- and il- by the elisa method, value of eosinophils were obtained with visual examination of peripheral blood smear, and assessing symptom scores with -point likert scale of breathlessness at the beginning and after months of therapy. objectives: this study has been focussed on a detailed comparison of two samplers-cyclone and chemvol-and on the parameters that could influence their efficiency. results: airborne concentrations of two key olive and grass allergens, ole e and phl p , respectively, were monitored over two years with different weather patterns, and , in c ordoba, located in south-western spain. allergenic particles were quantified by elisa assay and results were compared with pollen concentrations monitored using a hirst-type volumetric spore trap over the same study periods. the influence of weather-related parameters on local airborne pollen and allergen concentrations was also analysed. inter-year differences were observed with regard to pollen season timing and intensity. for both olive and grass, the pollen season was longer and the pollen index (pi) higher in ; that year the peak value was higher and it was recorded earlier. although a positive correlation was detected between results obtained using the two samplers during the pollen season, results for the cumulative annual allergen index varied considerably. the two samplers revealed a positive correlation between pollen concentrations and both minimum temperature during the warmer year ( ) and maximum temperature during the cooler year ( ); a negative significant correlation was observed in both cases with rainfall and relative humidity. conclusions: in summary, although differences were observed between the two samplers studied, both samplers may be suitable for allergen detection. objectives: the scientific council of rnsa was asked to update the allergy potency (ap) of plant species that can be established in urban areas. to update the allergy potency of plant species, the rnsa used scientific work on the subject, and also the opinions of allergists and botanists. the pollen grains of anemophilous species are transported by wind; they produce very large quantities of pollen grains so that the fertilization of female flowers has a greater chance of being effective. the majority of allergenic species are anemophilous. results: the pollen allergy potency of a plant species is the ability of its pollen to cause an allergy to a significant part of the population. the allergenic potential can be: low or negligible: no problem to plant them in urban garden moderate: only a few species can be planted in the same garden high: this species cannot be planted in urban places. the table presented on the poster will permit to know the level of allergy potency of more than species. conclusions: species or genus with a strong ap should be labeled as "not to be planted in habitation or residence area ", those with moderate ap should be labeled as "not to be planted in big quantities in habitation or residence area". other species with low or negligible ap may not be affected by public information. gadermaier g ; metz-favre c ; stemeseder t ; de blay f ; pauli g universit e de salzbourg, salzbourg, austria; chru strasbourg-allergologie, strasbourg, france introduction: the purpose is to study the profile of cutaneous and molecular sensitization of patients sensitized to plantain pollen living in the north-east of france. objectives: the sera of patients with seasonal pollinosis and cutaneous polysensitization including a positive test to plantain, are investigated through immunoblot (ib), elisa and immunocap. the plantain immunoblot is inhibited with plantain, grass, ash and birch pollen extracts as well as with pla l . the specific iges against pla l , phl p - and profilin are measured. results: pla l , the major plantain allergen is detected by ib in cases out of , either in glycosylated or non-glycosylated form. an allergen of kda is detected in out of cases, always and exclusively inhibited by the grass extract. the intensity of the spot is proportional to the anti-phl p / phl p ige levels, and corresponds to an allergen which is cross-reacting with grass. other cross-reacting allergens with grasses are detected at kda ( / ), and at - kda ( / ). at the molecular weights of to kda, we detected in addition to pla l , cross-reacting allergens with grass, ash and birch pollen which predominantly corresponded to profilin which was confirmed by specific ige measurements in cases. conclusions: among the patients included in this study, only % had genuine sensitization to plantago, which never corresponded to a monosensitization in our cohort. most often cutaneous sensitizations to plantain pollen were based on ige cross-reactivity with grass pollen allergens mainly through a kda allergen and/or profilin. the strong environmental grass pollen pressure, compared to the low plantain pollen exposure, seems to be at the origin of this profile of molecular sensitization. these results reinforce the superiority of molecular diagnosis in patients with pollinosis, who are polysensitized. | sensitisation to peach tree pollen in a highly exposed population results: the % of subjects were sensitized to pp, which was the most prevalent after olive tree, grass and cypress pollens, respectively. sensitization to peach fruit was %. pru p spt was tested in / pp positive cases, being % positive ( / ). specific ige to pru p was detected in / pp sensitized individuals. immunoblot showed specific ige to different components in the pp extract, being the most frequent band recognised a - kda protein. conclusions: pp is a prevalent inhalant allergen in highly exposure areas. in our population pru p was not identified as the major allergen. other pp molecular components need to be identified and their clinical relevance should be further investigated. introduction: allergic respiratory diseases increase after an exposure to airborne pollen, as asthma and allergic rhinitis, are deeply increasing and nowadays, they represent one of the major public health problems. olive pollen is one of the main causes of allergic disease in the mediterranean area, especially in northwest and west of the turkey. olive pollen has been characterized proteins with allergic activity and ole e is the major allergen of olea pollen. objectives: the aim of this study was to estimate the correlation between daily airborne olive pollen and ole e in the atmosphere. aeroallergen load of ole e detected by cascade impactor (chemvol) using prewashed polyurethane foam and pollen counts recorded by hirst trap. chemvol sampler collects particles at l/minutes and it contains impaction stages pm> micron and >pm> . lm. this sampler is being tested in the frame of the project hialine. results: generally, similar behaviour of pollen count and total allergenic load of ole e was observed during the main pollen season. nevertheless, in some occasions, before and later of main period, airborne ole e activity was recorded and some differences between pollen grain/m and allergen concentration/m were detected. pollen from different days released -fold different amounts of ole e per pollen. average allergen release from pollen was much higher in ( . pg ole e /pollen, r =. ) than in ( . pg ole e /pollen, r =. ). indeed, yearly olive pollen counts in were . times higher than in , but ole e concentrations were . times higher. these results have shown that ole e is mostly associated with olive pollen grains but aeroallergen load was not always directly proportional to airborne pollen counts. this suggests that ole e quantification is a better marker for olive allergen exposure. in conclusion, aeroallergen monitoring may contribute to a better understanding of the ole e exposure from airborne pollen. objectives: to describe the clinical profile of the patients sensitized to alt at and to assess the sensitivity of the prick test with the alternaria extract in comparison to the patients sensitized to both allergens alt a and alt a . out of the patients, ( . %) were sensitized to alternaria with specific ige of ≥ . isu to alt at or alt a . twenty patients ( females and males, age - years old) who were sensitized to alt a were selected. we analyzed the clinical profile, total ige values, other co sensitizations as well as the clinical relevance of alternaria sensitization in these patients. : of the patients sensitized to alternaria, ( . %) were sensitized to alt a , of which ( . %) were monosensitized to alt at . the mean age was lower in monosensitized (ẋ . vs . ). among the patients monosensitized to alt a , ( %) had prick test negative with the alternaria extract. eight out of patients were polysensitized to more than three different aeroallergens and were asthmatics ( persistent). the median total ige was higher in monosensitized ( ku/l vs ku/l). of these patients, alternaria sensitization has clinical relevance in ( %), of which have positive prick test to alternaria. all the patients ( / ) sensitized to both allergens have positive prick test to alternaria. ten of them were polysensitized, were asthmatic ( persistent) and sensitized patients showed clinical relevance. introduction: the role of vitamin d as a potential immune-modulator has been recently elucidated. dendritic cell, a key regulator driving towards th immune response in allergic diseases is known to be affected by vitamin d. however, the role of vitamin d in the pathogenesis of allergic rhinitis is unclear and its anti-allergic effect has not been established yet, especially in the mouse model. objectives: the aims of this study are to evaluate ) the anti-allergic effect of topically applied vitamin d in the allergic rhinitis mouse model, and ) the effect of vitamin d on dendritic cell activation. results: balb/c mice were intraperitoneally sensitized with ovalbumin (ova) and alum, and they were intranasally challenged with ova. intranasal , -dihydroxyvitamin d was given to treatment group and solvent was given intranasally to sham treatment group. allergic symptom scores, eosinophil infiltration, cytokine mrna levels (il- , il- , il- , il- , ifn-c) in the nasal mucosa, serum total and ova-specific ige, igg , and igg a were analyzed and compared with negative and positive controls. cervical lymph nodes were harvested for flow cytometry analysis. in the treatment group, allergic symptom scores, eosinophil infiltration, and the mrna levels of il- and il- were significantly reduced compared to positive control. il- mrna level, serum total ige, and ova-specific ige and igg levels showed a tendency to decrease in the treatment group, but did not reach to a significant level. il- did not show a significant difference between groups. cd c + , mhcii hi , cd + activated dendritic cells were significantly reduced in the treatment group. cd + , cd + , foxp + treg cells tended to increase in the treatment group, however it was not significant. the intranasal instillation of , -dihydroxyvitamin d has an anti-allergic effect in the allergic rhinitis mouse model. we believe that the anti-allergic effect of vitamin d is mediated by the inhibition of dendritic cell activation, and therefore decreased objectives: we wanted to assess whether treatment with cyclosporine and tacrolimus allows children with vkc to improve the level of vitamin d due to the higher summer sun exposure for good control of the ocular symptoms. objectives: our objective was to assess the expression of smad and smad proteins in patients with asthma in correlation with clinical parameters and the expression's changes in response to allergen and methacholine challenge test. the study included patients with asthma and healthy volunteers. spirometry, skin prick tests (spt), allergen and methacholine provocation tests were performed in compliance with standards. personalized clinic surveys including act tm were collected. venous blood was collected before and after provocation. the expression levels of il- and il- and smads were evaluated by qrt-pcr using isoform-specific primers. results: we showed correlation between the mrna expression of smad and the asthma control according to act tm (p<. ). the expression of smad is higher in the group of uncontrolled ( -Δct = . , p<. ) and in the group of partially controlled patients ( -Δct = . , p<. ) in comparison to the group of patients with controlled asthma ( -Δct = . ). we proved that expression of mrna of smad correlates significantly with expression of il- and il- in patients with asthma (il- r= . ; il- r= . ) and in the control group (il- r= . ; il- r= . ) (p<. ). expression of smad elevates more after methacholine provocation test (median -Δct = . ) rather than after allergen provocation test (median -Δct = . ; p=. ). we showed also that skin prick test results correlate positively with smad level after the provocation (p<. ). conclusions: the loss of asthma control is connected with expression of smad , which is part of tgf-ßrii related pathway. il- and il- correlates with smad expression, which can indicate the participation of these cytokines in the regulation of this pathway. the expression of smad elevates after methacholine and allergen provocation as well as it correlates positively with skin prick test results, which can be useful clinically. to sum up, tgf-ß-tgfßrii-smad proteins are an important mediators of inflammation in asthma. | deletion of nfatc in t lymphocytes affects th and th cell differentiation as well as il- -mediated mast cell activation in allergic asthma objectives: analysing the role of nfatc in the allergic trait of human asthma. additionally, we investigated the influence of nfatc on t cell differentiation and immunoglobulin class switch and explored its impact on mast cell differentiation in experimental asthma. with the children s hospital in erlangen, we studied nfatc mrna expression in freshly isolated pbmcs from pre-school children with and without asthma. in asthmatic children, we found increased nfatc mrna expression, especially in those with a positive skin test. these results were confirmed in the asthma bio-repository for integrative genomic exploration (asthma bridge) study, where the isoform a and d of nfatc were found significantly increased in asthmatic adults with a positive skin test. moreover, il- was also found increased in the supernatants of pbmcs of asthmatic children with a positive skin test. furthermore, mice with a deficiency of nfatc in cd + t cells display significantly lower levels of il- . additionally, these mice show reduced numbers of lung th and th cells. moreover, basic leucine zipper atf like (batf), which is known as an important transcription factor for t cell differentiation as well as immunoglobulin class switch, was found decreased in these mice. consequently, ova-specific ige and total igg levels were found significantly decreased after allergen exposure and in the absence of nfatc . furthermore, nfatc deletion also resulted in decreased mast cell numbers. we then analyzed the effect of il- on mast cell differentiation and histamine release. we observed that bone marrow differentiated mast cells incubated with ova and il- had an induced histamine release. conclusions: thus, nfatc deficiency in t cells results in defective ige production affecting ige-orchestrated mast cell activation mediated through il- . therefore, nfatc emerges as a novel target for anti-allergy intervention. | efficiency of the use of nitric oxide donors for the treatment of bronchial asthma bazarova s; djambekova g center of therapy, tashkent, uzbekistan introduction: to study the influence of nitric oxide donor-l-arginine-on indicators of endothelial system in patients with bronchial asthma. objectives: patients aged - years ( ae . years) with moderate persistent bronchial asthma were examined. ratio of men to women was / . two age-and sex-matched groups were randomly selected. main group ( patients) received nitric oxide donor -l-arginine in addition to standard background therapy (gina, ) . the medication ( ml of . % solution, tivortin, "yuria-farm", ukraine) was administered intravenously once daily for days. the control group ( patients) only received the background therapy. the efficiency was assessed with the use of conventional methods of study (clinical laboratory methods, instrumental methods: spirography, peak flow monitoring, bronchomotor tests). concentration of nitric oxide stable metabolites in exhaled breath condensate (ebc) and in blood was studied. their ratio was also assessed. results: baseline data in patients of both groups demonstrated the increase of level of nitric oxide stable metabolites in blood ( . ae . mmol/l) and in ebc ( . ae . mmol/l). after the treatment the positive clinical efficiency of inclusion of l-arginine was much higher than that in the control group (p<. ). in the main group, reduction of requirement for beta -agonists, decrease of frequency of night-time symptoms, decrease of frequency of lowest pef rate in the morning and improvement of respiratory function were observed on average on the rd/ th day compared to the control group were such improvements were evident on the th/ th day. in the main group the concentration of nitric oxide stable metabolites significantly increased in blood ( . ae . mmol /l, p<. ) and in ebc ( . ae . mmol/l, p<. ). in the control group the concentration of nitric oxide stable metabolites changed in blood ( . ae . mmol/l) and in ebc ( . ae . mmol/l), but not significantly. introduction: abpa is currently believed to be an exaggerated form of aspergillus sensitization, and is probably the first step in its development. objectives: the aim of this study was to investigate the clinical and immunologic characteristics of fungal-sensitive asthma (fa), nonfungal-sensitive asthma(nfa) and abpa. conclusions: there were different clinical and immunological features among nfa, fa and abpa. the abpa had worse function as well as higher percentage of bronchiectasis, and higher dose of oral corticosteroid. besides, the sensitivity to aspergillus was more severe in abpa. the level of sige-a.f was associated with the damage of lung function. | self-reported allergic rhinitis and/or allergic conjunctivitis associate with il rs genotypes in finnish adult asthma patients introduction: the increased prevalence of asthma and allergic diseases is a major public health problem worldwide. atopy, family history, inhaled irritants, and upper airway inflammation are known risk factors of asthma. a population-based sample of finnish adult asthma patients (n= ) and matched controls (n= ) filled a questionnaire. asthma was diagnosed based on a typical history of asthma symptoms and lung function tests. skin prick tests (spt) with aeroallergens and blood tests including analysis of interleukin (il ) rs (g/a) genotypes were performed for a subsample (n= ). objectives: our aim was to observe in adult asthmatics with and without allergic co-morbidities e.g. subject-reported allergic rhinitis and/or allergic conjunctivitis (ar/ac) association with il rs genotypes and other factors. results: the proportion of asthmatics reporting ar was . % and ac was . %. after adjustments, the presence of il rs aallele (or= . ci= . - . , p=. ) or multi-sensitization (adjusted or= . , ci= . - . , p=. ) associated with ar/ac-asthma. nasal polyps and aspirin-exacerbated respiratory disease associated also with ar/ac-asthma. conclusions: adult ar/ac-asthma could putatively be a phenotype, characterized by the presence of atopic and/or eosinophilic factors and a high prevalence of the il rs a-allele. studies on the mechanisms behind this and in other populations are needed. | immunoregulatory role of nfatinteracting protein (nip) in adaptive and innate immune responses in allergic asthma introduction: nfat-interacting protein (nip) is a th associated transcription factor. after t cell receptor stimulation, the arginine methylation domain of nip supports the interaction with nfat, thereby enhancing the production of the th cytokine il- . moreover, nip deficient mice have been shown to be deficient in il- and ifn-gamma production indicating that nip controls both th and th cytokine production and might therefore play a protective role in allergic asthma . objectives: we wanted to analyze the importance of nip in allergic asthma in pre-school children as well as adults. furthermore, we investigated the role of nip in a murine model of allergic asthma to find out more about its contribution to adaptive as well as innate immune responses in the disease. results: in the european study predicta, in collaboration with the children s hospital in erlangen, we analyzed nip mrna expression by using quantitative real time pcr in rna extracted from pbmcs isolated from pre-school children with and without asthma. in the pbmcs of the asthmatic children, nip mrna expression was found significantly increased compared to healthy control children. furthermore, nip mrna expression was also found induced in cd + t cells in adult asthmatics from the asthma bio-repository for integrative genomic exploration (asthma bridge) study. we further analyzed the importance of nip in a murine model of allergic asthma. after allergen sensitization and challenge nip (-/-) mice showed decreased airway hyperresponsiveness, inflammation and mucus production, three of the main patho-physiological features of asthma. additionally, we discovered that nip (-/-) mice released decreased th type cytokines and also expressed less st , which is the receptor for il- , after allergen challenge. furthermore, a defect in innate lymphoid cell type (ilc ) differentiation was observed in the absence of nip in allergic asthma and in bone marrow differentiated ilc s indicating a crucial role for nip in mediating asthma via ilc s. conclusions: in summary, we found that the lack of nip influences not only immune responses of the adaptive immune system but also influences components of innate immunity resulting in a abstracts | protective phenotype to allergic diseases such as asthma. objectives: in the study were included ap and healthy controls (hc). fraction of exhaled no (feno), standard lung function parameters, complete blood count and absolute count of cells, serum ige, crp, il- , il- a and periostin were measured. results: four clusters were identified by cluster analysis: cluster (c )(n= )-late-onset, non-atopic, eosinophilic asthma with impaired lung function, cluster (c )(n= )-late-onset, atopic asthma, cluster (c )(n= )-late-onset, aspirin sensitivity, eosinophilic asthma and cluster (c )(n= )-early-onset, atopic asthma. we have found higher levels of il- in all clusters ap as compared to hc (c : p=. , c : p=. , c : p=. and c : p=. ). tendency for higher levels of serum il- in c compared with c or c (p=. or p=. , respectively) was observed. periostin levels were significantly higher in c (p<. ), c (p<. ) and c (p<. ) as compared to hc. there were no differences in periostin levels between all clusters (anova, p=. ). il- a levels were significantly higher only in c as compared to hc or to c and c (p<. , for each comparison). we have found correlation between il- and crp (r=. ; p=. ) in c , il- a and periostin in c (r=. ; p=. ) and in c (r=. ; p=. ). interestingly, we have observed negative correlation between the duration of asthma and il- a (r=À. ; p=. ), but positive between the duration of asthma and crp (r=. , p=. ) in c . our results have shown higher levels of il- in all clusters as compared to hc that are associated with marker for systemic inflammation. periostin levels were significantly elevated in c , c and c as compared to hc with no differences between the clusters. a positive correlation between periostin and il- a in c and c was observed, that rising the question about their interrelationship in the pathogenesis of late-onset asthma. serum il- a was significantly higher in c in comparison with hc or c and c suggesting that th mediated immunity may be involved in early-onset, atopic asthma. these data support the concept of heterogeneity of the bronchial asthma. | eosinophil activation with autophagy and extracellular dna traps is involved in severe asthma results: il- +lps treatment significantly increased autophagy and eet levels from pbes of the study subjects (p<. for all), which were in a positive correlation (r=. , p<. ). compared to nsa patients, both untreated and il- +lps-treated pbes from sa patients had significantly higher autophagy levels (p=. and . , respectively), while only il- +lps-treated pbes from sa patients had higher eet level (p=. ). eet level from untreated pbes was correlated with serum eosinophil cationic protein level (r= . , p= . ) and fev % predicted value (r=À. , p=. ). co-culture of aec with pbes slightly increased il- production, which was significantly enhanced by il- +lps treatment (p<. ). the il- production in co-culture system was reduced by pretreatments with dexamethasone ( mm, p=. ), antibodies against major basic protein ( ng/ml), il- receptor ( mm) and il- receptor ( mm, p=. for all), but increased by cotreatment with micrococcal nuclease ( iu/ml, p=. ). conclusions: pbes from sa patients are highly susceptible to be activated to produce high levels of autophagy and eet, which could enhance and maintain airway inflammation. we suggest that steroid and anti-il- /il- receptor antibodies may be beneficial to control airway inflammation in severe eosinophilic asthma via inhibition of eet production, while dna digesting reagents may increase airway inflammation. introduction: it has been demonstrated that exposure to stress induce hyporeactivity of the hpa system by modifying the secretion of cortisol and also that psychosocial stressors such as poor social status are associated with an increased risk of childhood asthma, decreased serum cortisol and high ige response. thus, from this concept it could be postulated that a blunted hpa axis response may increase the risk for allergic inflammatory reaction. objectives: aim of this study was to evaluate the association of serum cortisol in pediatric allergic bronchial asthma and its influence on the ige immune response in a poor children community with psychosocial chronic stress. results: this was a pilot analytical case control study( ipa positive subjects and healthy control paired by age and gender, both from poor areas of barranquilla objectives: in order to characterize bp an immunoproteomics analysis was conducted, i.e. electrophoretic separation of cypress pollen extracted proteins, ige western blotting using cypress pollen allergic patient's sera and mass spectrometry (lc/ms/ms) for identification of ige-binding proteins. results: ms analysis using chymotrypsin identified in bp a peptide also found in the family of protein snakin/gibberellin-regulated protein (grp). the snakin- , an anti-microbial peptide of potato, produced as a amino-acid recombinant protein (homologous to the c-terminal part of grp), is recognized by ige from cypress pollen allergic patients with ige to bp . this ige reactivity is abolished after reduction of disulfide bridges and is inhibited by a cypress pollen extract. ige reactivity to bp is however barely inhibited by the recombinant potato snakin- . conclusions: bp exhibits a molecular mass closer to grp than to snakin and the absence or very low inhibition of the ige reactivity to bp with snakin may be explained by peptidic ige epitopes on the n-terminal part of bp . the potato snakin- share % sequence identity with peamaclein, the peach allergen pru p , also shown in citrus. these results might explain the peach/cypress and citrus/cypress syndromes described and point out bp as the cross reactive allergen. the proteins of snakin/grp family present in many fruits and vegetables might include allergens involved in pollen/food associated syndromes. introduction: exposure to high levels of grass pollen may lead to a high degree of allergic inflammation, sensitization to minor allergens, such as profilin, and development of severe profilin mediated food reactions, similar to those described due to sublingual immunotherapy (slit). objectives: our objective here was to identify genetic biomarkers in order to generate a model that can improve the classification and treatment of patients with a higher probability of developing severe adverse reactions. results: healthy subjects (group , control) and patients with mild (group ) or severe (group ) profilin mediated food reactions were studied. rna extraction was performed on ficoll-isolated pbmcs using the rneasy ® mini kit (qiagen) and its integrity was analyzed with experion rna stdsens analysis kit (bio-rad). the gene expression profile of all the samples was analyzed using the gene-chip ® wt plus reagent kit (affymetrix) and two specific software: affymetrix ® expression console ™ and affymetrix ® transcriptome analysis console (tac). finally, the microarray data was validated by quantitative real-time pcr (qpcr). the hierarchical clustering of the samples shows the separation of the patients into three clusters coincident with the three established clinical groups (control, mild and severe). genetic profile of patients with mild reactions is similar to healthy patients while severe subjects were significantly different from the other two groups. genes regulated in the severe group were related to histone modification pathways, human complement system, cell adhesion and tgf-b and its receptor. these changes may be associated with the different degree of inflammation between patients in each experimental group. in the course of our study we found out that severe patients had different rna expression patterns compared to mild and non-allergic patients. this lead to the identification of genetic biomarkers useful for the generation of a model able to predict severe reactions and/or adverse reaction during immunotherapy, thus improving the diagnosis and treatment of this type of allergic results: his-tagged recombinant allergens, namely parvalbumin, aldolase, enolase and tropomyosin from c. idella and l. crocea, as well as cod parvalbumin, were synthesized in e. coli and purified using immobilized metal-chelate chromatography. children with history of immediate-type fish allergy were included in this study and their serological ige reactivity to the fish allergen components were measured by elisa. children were positive to at least one allergen component, with nine of them being positive to parvalbumin. despite the high similarity between l. crocea, c. idella and cod parvalbumins ( . - . %), three children only reacted to l. crocea and c. idella parvalbumin but not to cod parvalbumin, while the other six children were positive to all three parvalbumins. competitive inhibition elisa revealed that c. idella parvalbumin inhibited > % of the binding of specific ige to both l. crocea and cod parvalbumin, while reciprocally only inhibition of % and % could be achieved respectively. two children were reactive to aldolase and enolase but not parvalbumin. one of them had positive sige to both enolase and aldolase from l. crocea, while the other reacted to aldolase from both species. these two children exhibited relatively mild subjective allergy symptoms (itchy skin and throat). notably, three children were non-reactive to all components tested, and two of them were outgrowing fish allergy clinically. introduction: anti-a-gal antibodies are naturally produced in response to the gastrointestinal flora. in red meat allergy, patients develop ige antibodies towards the a-gal epitope, which itself are structurally closely related to the blood group b antigen. objectives: this study aimed to explore the relationship between a-galand b-antigen-specific antibodies in red meat allergic patients compared to healthy individuals with blood group b or a/o. sera from red meat allergic patients and healthy blood donors of whom belonged to blood group b and to blood group a or o were included. ige reactivity against a-gal and the b-antigen were determined using immunocap. allergen-specific igg, igg , igg , igg , igg and ige were assessed by indirect elisa assay. statistical analysis was performed using spearman rank correlation and unpaired t-tests. results: all red meat allergic patients, of the healthy a/o and of the healthy b donors were ige positive to a-gal. however, the ige levels to a-gal were significantly higher in the allergic group compared to the healthy a/o and b individuals. the majority of the meat allergic patients, but none of the healthy individuals had ige antibodies against the b-antigen. a moderate correlation between a-gal and b-antigen specific ige was noted (r =. ). the red meat allergic patients had significantly higher igg levels against a-gal with igg and igg antibodies as the predominant difference compared to the healthy individuals. the healthy a/o ige positive individuals had significantly higher igg , igg and igg compared to the ige negative individuals. the igg response to the b-antigen followed the same pattern as to a-gal. there was a low correlation between the igg levels against a-gal and the b-antigen in both meat allergic patients and healthy a/o individuals (r =. and . ). introduction: fx , a food mixture of milk, egg white, fish, peanut, wheat and soybean, is largely used for food allergy detection. besides the fact that it is questionable if this is the better approach to identify a food allergy, the information that the test provides may represent a pitfall because a positive or negative result does not mean food allergy presence or absence, respectively. objectives: the goal of our study was to access the reason for fx request in a pediatric hospital and to analyze its suitability. methods: the fx requests, performed in a pediatric population of d. estefânia hospital over a five months' period, were analyzed, concerning demographic data, reason for request and attitude taken due to the result. this test was requested due to respiratory symptoms in patients, gastrointestinal symptoms in patients, cutaneous symptoms in patients and nonspecific complaints in patients. all of these symptoms were not directly related with food intake. a positive result was obtained in patients; of those, only were referenced to our immunoallergology department. in all of them a detailed clinical history was obtained and diagnostic tests (skin prick tests and specific ige) were performed in the ones considered suitable. food allergy was diagnosed in only one patient. conclusions: in the vast majority of patients, fx was asked for nonspecific complaints and often without a clinical history suggestive of food allergy. moreover, a positive fx test does not mean clinical reactivity or food allergy. on the other hand, the clinical history allows us to identify a suspect trigger in most of the children with food allergy. in such cases, it is preferable to request the specific ige towards the allergen, which gives a more precise and accurate result, instead of the fx . as our results showed, in the majority of the cases, the fx request was often made without complying with a reasonable criterion, implying unnecessary costs. the high number of requests verified may be explained because it is an easily accessible analysis but this attitude should be discouraged. tuppo l ; alessandri c ; pasquariello s ; petriccione m ; giangrieco i ; tamburrini m ; rafaiani c ; ciancamerla m ; mari a ; ciardiello ma istituto di bioscienze e biorisorse -ibbr-cnr, naples, italy; caam -centri associati di allergologia molecolare, rome, italy; cra, research unit on fruit trees, caserta, italy introduction: pomegranate, punica granatum l., is one of the oldest cultivated fruit trees. the fruit contains the arils, which are seeds covered by a red pulp, that is a juice sac. the arils are surrounded by the white and fleshy mesocarp. pomegranate can trigger allergic reactions, but the allergenic pattern of this fruit is still poorly characterized and only one allergen, the ltp pun g , was reported. objectives: the aim of this study was the investigation of the allergen pattern in pomegranate tissues and cultivars. reported symptoms were food impaction ( %), dysphagia ( %), heartburn ( %) and vomiting ( %). the first symptoms were more frequent in adolescents and adults ( %). children's main complaint was vomiting ( %) and cases presented failure to thrive. most patients had associated allergic diseases ( %), % had previous food allergy and % were sensitized to aeroallergens. endoscopic evaluation revealed esophageal stricture in patients. at least half of diagnostic esophageal biopsies had > eosinophils per highpower field and % showed microabscesses. food sensitization was found in % of the patients, mainly to cow's milk ( %), nuts and peanut ( %), cereals ( %) and egg ( %). considering therapeutic approach, % were treated with swallowed fluticasone and dietary elimination was recommended in %. oral corticosteroids were prescribed in patients. at present time patients had done endoscopic reevaluation, ( %) showed histologic resolution. five patients had clinical and histologic relapse during follow-up. conclusions: eoe has a balanced distribution but a distinctly clinical presentation accordingly to age group: children may present unspecific symptoms like vomiting, whereas adolescents and adults complain of food impaction and dysphagia. other atopic diseases and food sensitization is very common. introduction: air pollution, particularly ambient air particulate matter (pm), is considered as one of the most important environmental risks for human health. pm could potentially disrupt immune regulatory mechanisms and predispose exposed individuals to asthma. in contrast, children exposed to traditional farm environment seem to have a natural resistance to asthma. this phenomenon links with exposure to stable dust and subsequent immune regulatory mechanisms initiated in the airways. the underlying exposure agents and definitive pathways determining the risk of asthma are still to be identified. objectives: our aim was to investigate the effect of urban air pm (high risk environment) and farm dust (protective environment) on immune responses in finnish children. briefly, peripheral blood mononuclear cells (pbmcs) of -year-old children (n= ) were stimulated with farm dust extract ( lg/ml, stable in northern savonia, finland) and pm samples ( lg/ml, pm . - , pm - . or pm < . , nanjing, china) for hours. expression of immunogenic cd and tolerogenic ilt in circulating myeloid dendritic cells (mdcs) and plasmacytoid dcs (pdcs) and monocytes were analyzed by flow cytometry. pm samples were analyzed for polycyclic aromatic hydrocarbons (pahs), inorganic ions and elements. farm dust sample will be analyzed for microbial content. results: pm stimulation decreased the percentage of cd + monocytes and dcs among children's pbmcs, whereas farm dust stimulation increased the percentage of cells positive for this marker. the percentage of tolerogenic ilt + was decreased in all cell types after stimulation with pm. farm dust also decreased the percentage of ilt + monocytes, but not dcs. specific metals and pahs in pm associated with the studied immunological parameters. conclusions: samples from high risk and protective environments have differing capacities to influence immunogenic and tolerogenic properties in children's immune cells. the importance of these findings in relation to the risk of asthma in exposed populations will be studied further. introduction: alterations in cell surface glycosylation pattern is a common feature of tumor cells that might be related to immune evasion and malignancy. objectives: to study the capacity of the carbohydrate a (ca ) located in the surface of murine ehrlich tumor (et) cells and also in certain human adenocarcinomas to condition the phenotype and function of human dendritic cells (dcs) and the capacity to polarize t cell responses. results: nf-jb/ap- are not activated in thp cells by ca , however, this carbohydrate partially impairs the activation of these transcription factors induced by the tlr ligand pam csk. ca induces the expression of the tolerogenic marker pdl in human monocyte-derived dcs (hmodcs) as well as the production of il- and il- , analyzed by flow cytometry and elisa assays respectively. ca -activated hmodcs generate functional il- -producing cd + cd high cd -foxp + regulatory t (treg) cells that were able to inhibit the proliferation of cd + t cells from pbmcs in a dose-dependent manner. supporting the role of ca in the induction of treg cells, our in vivo data showed that the ca is present in the sera of tumor bearing mice and the percentage of foxp + treg cells is increased in the regional (inguinal) lymph nodes from tumor bearers. our results showed that ca -activated hmodcs induce the generation of foxp + treg cells both in vitro and in vivo, which might well condition the immune response against the tumor and promote the tumor escape. | assessment of changes in expression of immune system biomarkers to assist the differential diagnosis of acute bacterial infections introduction: biomarkers for acute infections include c-reactive protein, mmp- , sicam- , procalcitonin, and neutrophil band counts for bacterial infection. a rapid means of assessment of acute bacterial infections via biomarker assessment was sought. objectives: the expression of toll-like receptors (cd and cd ), complement receptors (cd and cd ), integrins (cd b and cd c), fc-receptors (cd and cd ) and l-selectin (cd l) on the surface of blood neutrophils and monocytes stimulated with inactivated e. coli, l. acidophilus, e. coli derived bacterial ghosts, e. coli lps and l. acidophilus cell walls was assayed using flow cytometry. both the percent of expression and mean fluorescence intensity (mfi) were analyzed for each molecule. results: all the bacterial components used exerted similar activation capabilities even in low concentrations. while the expression of cd b, cd c, cd , cd and cd was enhanced by both neutrophils and monocytes under activation, the expression of cd significantly increased only in neutrophils. the expression of tlr and tlr was slightly increased by neutrophils and monocytes. the expression of cd l by monocytes and neutrophils (the percent of activated cells as well as the mfi) was decreased during activation. there was a negative correlation between cd l expression and integrins (cd b and cd b). the activation index was calculated for each molecule as a ratio of expression of molecule by activated cells vs cells used as a negative control (resting). the highest values for the activation index was seen with cd b, cd c, cd , cd , cd l and cd mfi by neutrophils and monocytes, and the percent of cd expression by neutrophils. conclusions: e. coli and bacterial ghosts significantly increased the expression of cd b, cd c, cd , cd , cd l and cd by neutrophils and monocytes even in very low concentrations, suggesting use as potential biomarkers in the differential diagnosis of the etiology of acute infections. objectives: the aim of this study was to evaluate changes in peripheral blood monocyte expression of cd , cd , cd , cd , hla-dr, and cd in kidney allograft recipients. in total, patients who underwent renal transplantation from a deceased donor were enrolled in the study. the phenotype was evaluated by a multicolor flow cytometry in defined time points and in the case of complications requiring fine needle aspiration biopsy procedure. the results confirmed our pilot data, proportions of peripheral cd +cd + monocytes were downregulated during the first week after the kidney transplantation while the percentage of cd +cd + monocytes dramatically increased early after the kidney transplantation and remained high for at least four months in most patients. the expression of cd (marker of m macrophages) was limited only to a small population of monocytes (less than % in most patients) but the receiver operating characteristic (roc) curve analysis showed its potential importance by significant correlation with acute rejection with a sensitivity of % and specificity of . % (area under the roc curve . , p-value: . ). no correlation between two different m markers cd and cd has been found. the expression of cd (dc-sign) was low and did not show any changes in time or association with acute rejection. hla-dr (mhc ii) and cd (integrin associated protein) were constitutively expressed without any significant changes in patients with acute rejection of the allograft. we assume from our data that kidney allograft transplantation is associated with early reciprocal modulation of monocyte subpopulations (cd +cd + and cd +cd +). a decreased proportion of cd positive blood monocytes seems to be associated with an increased risk of acute rejection of kidney allograft. introduction: thioredoxin (trx), a -kda oxidoreductase enzyme, is well known to be a redox-active protein that regulates reactive oxidative metabolism. in addition to its anti-oxidative activ- | progranulin-dependent regulation of th airway inflammation by house dust mite allergen introduction: progranulin is a growth factor that consists of amino acids including / repeats of cysteine-rich motifs, and produced by variety kinds of cell. progranulin is involved in the regulation and maintenance of inflammatory response, and its role is wellstudied in neuronal and metabolic diseases such as neurodegeneration and type diabetes. however, the role of progranulin during the development of airway inflammation induced by inhaled allergen is still obscure. objectives: in this study, we evaluated the role of progranulin in the development of th airway inflammation induced by house dust mite allergen. results: to find the main source of progranulin, we stimulated each cell line with various doses of house dust mite allergens. the production of each cytokine, including progranulin, was estimated in culture supernatant by elisa. to investigate the role of progranulin in airway inflammation, we intranasally administrated house dust mite allergens to -week-old female progranulin knock-out mice (macrophage-specific) or littermate mice. lung inflammation and immunological parameters were evaluated at h after first sensitization with allergen or h after final allergen challenge. the production of progranulin was significantly elevated by house dust mite allergen stimulation in innate immune cells, especially in alveolar macrophages over other cells. in the house dust mite allergeninduced airway inflammation model, we found that the level of progranulin increased earlier than other pro-inflammatory cytokines. in addition, in macrophage-specific progranulin knock-out mice, airway inflammation was down-regulated in the earlier phase after exposure to house dust mite allergen. moreover, we stimulated mice with house dust mite allergen for a longer period to observe the changes in the adaptive immune response of th airway inflammation, which was found to be decreased in conditional knock-out mice. conclusions: these findings indicate that th airway inflammation induced by house dust mite allergen is dependent on progranulin. objectives: the aim of the present study was therefore to investigate the immunomodulatory effect of epinephrine on m a macrophages and its consequence on cross talk to mast cells in a human model of allergic inflammation. results: primary monocytes from healthy pbmcs were first differentiated into m a macrophages using m-csf in the presence of il- and il- cytokines. after overnight incubation with epinephrine, supernatants were collected and analyzed by elisa for il- , tnf, il- , ccl , il- and ifn-c, whereas cell surface markers including cd , cd and cd were evaluated using flow cytometry. subsequently, both m a and epinephrine-treated m a supernatants were transferred onto cord blood-derived mast cells (cbmcs) for further overnight incubation, after which ige-mediated degranulation was assessed by the ß-hexosaminidase release assay. after overnight epinephrine treatment, m a macrophages showed an increase in il- , ccl , tnf and il- production, but no ifn-c and il- expression was observed. epinephrine treatment also downregulated surface markers cd and cd and upregulated cd . when supernatants from epinephrine-treated m a macrophages were added to cbmc cultures, ige-mediated degranulation was impaired compared to cbmcs treated with supernatants of unstimulated m a macrophages. conclusions: taken together, epinephrine promoted a phenotypic shift of m a polarized human macrophages toward an m b-like regulatory phenotype that was able to reduce the ige-mediated degranulation of cbmcs. we conclude that prolonged acute stress exposure in allergic patients may attenuate symptoms of acute allergy by directing macrophages towards an immunosuppressive phenotype, which can further dampen mast cell degranulation. objectives: a murine local lymph node assay was used to investigate the effect of oa on the immune response to the known skin sensitizer hexyl cinnamic aldehyde (hca, % w/v). the ear lobes tape stripped prior to immunization. test solutions ( ll) were applied on the dorsal side of each ear on three consecutive days. female balb/c mice ( groups a mice), were exposed to the vehicle acetone:olive oil ( : ) alone, or in combination with hca, with or without oa in the concentrations , and %, or oa alone ( , and %). on day , the animals were weighed and exsanguinated by cardiac puncture. the auricular lymph nodes were harvested for single cell preparation, stimulation with cona and cytokine release of il- and il- . the earlobes were excised and fixed for immunohistochemistry. results: no group differences were found for bodyweights or bodyweight change, number of lymph node cells or il- secretion. il- showed a tendency of dose-related increase, but a significant difference were only found between hca and hca+ % oa (p=. ) in one out of the two experiments. in he stained sections, the epidermal thickness was significantly increased in groups given hca + and % oa (p≤ . ). sections immunostained with anti-ly g showed significant increase in neutrophil influx for the same groups as above (p≤ . ). oa alone showed no effects or effects significantly lower than hca + oa. objectives: we hypothesized that plasma s p levels in cf patients might be associated with cftr mutations and could influence disease presentation. results: plasma was collected with a defined standard operation procedure to impede unspecific s p release from blood cells from double lung transplanted adult cf patients as well as sex-and age-matched, non-allergic healthy controls all being fasted overnight. total plasma s p was measured by mass spectrometry and unbound plasma s p by elisa. levels were correlated with cftr mutation status, routine laboratory parameters and clinical symptoms. we observed higher total and unbound plasma s p levels in healthy controls compared to cf patients with the latter value reaching statistical significance (p=. ) after exclusion of two statistical outliers. unbound plasma s p levels were significantly higher in df homozygous cf patients compared to patients with df heterozygosity (p=. ). patients with other mutations were excluded. levels of unbound s p were positively correlated with hemoglobin and negatively correlated with triglyceride levels. additionally, we observed a positive correlation of total plasma s p levels in cf patients with hba c. gastrointestinal symptoms were more common in df heterozygous ( / ) compared to df homozygous cf patients ( / ). fecal calprotectin levels were found to be significantly higher in df homozygous compared to heterozygous cf patients (p=. ). differences in unbound s p levels were not correlated with immunosuppressive treatment after transplantation. conclusions: to the best of our knowledge this is the first clinical study directly correlating plasma s p levels with cf genotypes and clinical presentation in cf patients. we emphasize to evaluate s p as a potential novel disease biomarker as well as a therapeutic target for cf in future studies. supported by the austria science fund grant kli (to eu). ochoa-grull on j ; tejera-alhambra m ; guevara k ; guzm an-fulgencio m ; benavente cm ; mart ınez r ; p erez c ; peña a ; rodr ıguez de la peña a ; llano hern andez k ; rodr ıguez-fr ıas e ; s anchez-ram on s objectives: we show preliminary data of one study aimed to evaluate the use of this strategy in the prevention of rrti in infants and preschool children. results: patients: children ( male and female, age range - months) were included in a randomized double blind and placebo-controlled study (eudract - - ) . all of them showed negative in vivo and in vitro allergy tests. active treatment consisted in a suspension of a mixture of selected strains, grown and inactivated in optimal conditions, of s. aureus ( %), s. epidermidis ( %), s. pneumoniae ( %), k. pneumoniae ( %), m. catarrhalis ( %) and h. influenzae ( %) in physiologic saline solution with % glycerol at a concentration of formazin turbidity units (ftu)/ml (equivalent to bacteria/ml). placebo did not contain any bacteria. patient were treated for a period of months, receiving daily sublingual puffs of active or placebo and with a follow-up of other months (total period of evaluation was year). symptom (cough, dyspnea, wheeze, mucus, fever, discomfort) and medication (inhaled corticosteroids, beta adrenergics, montelukast, antibiotics) scores were evaluated since the first day of treatment to the end of the study ( year) . any adverse event was recorded to assess safety. for the comparison between both groups, t test was used. patients who received active treatment experienced an improvement of % over placebo in overall symptoms and % in medications scores (p<. ). in the combination of symptoms and medication scores the improvement was % (p<. ). no adverse events related to treatment were recorded. conclusions: immunostimulation with these selected strains of bacteria is safe and can be successfully used in infants and preschool children in order to prevent rrti. introduction: to reduce the duration and the risk of the allergen specific immunotherapy using commonly used allergen extracts, new highly immunogenic and non reactogenic vaccines are needed. objectives: the goal of the present study was to employ the ap spytag/catcher system to develop a virus-like particle (vlp) vaccine based on the major house dust mite (hdm) allergen der p and to evaluate its reactogenicity in vitro. spycatcher-ap vlps and recombinant der p , fused at the c-terminus to the amino acid spytag binding-partner, were expressed in e. coli. purified spytagged der p was mixed with spycatcher-vlps, which resulted in covalent conjugation of der p to the surface of spycatcher-vlps. excess unbound der p was removed by dialysis. dynamic lightscattering (dls) was used to analyse the size and aggregation state of vlp-der p . the ige reactivity of vlp-der p was assayed by direct elisa and by rat basophil degranulation assays. conclusions: our results demonstrate that coupling of spy-tagged der p to ap spycatcher-vlps dramatically reduces the reactogenicity of the allergen, suggesting that vaccination with ap vlp-der p may be a safe and effective treatment for hdm allergy. objectives: the qm s hybrid protein is a qm variant where cysteine amino acids have been replaced by serine. the expression of qm s hybrid protein was performed in e. coli bl (de ) after iptg induction. the purification of qm s protein was performed from inclusion bodies by a three-step chromatography process. the stability of qm s was analyzed by sds-page and total protein assay. qm s ige-binding capacity was compared with natural der p and der p by elisa-inhibition and allergenicity was studied by mediator release from rbl cells. immunogenicity was evaluated in mice by analysis of the specific igg response to der p and der p . results: qm s was expressed in complex media as inclusion bodies that were solubilized in urea. soluble protein was purified by anionic ion exchange, hydrophobic interaction, and size exclusion chromatography in the presence of a detergent. qm s purification process was shorter and more efficient than that of qm . the purity obtained was > %. elisa inhibition assay showed that qm s hybrid protein was almost unable to inhibit ige-binding to the hdm extract, less than % in all the range of concentrations tested ( . - ng/ml) and representing a -fold reduction as compared to qm . qm s showed a great reduction of the b-hexosaminidase release in rbl cells, compared to der p and der p . qm s was able to induce der p -and der p -specific lgg antibodies responses comparable with those induced by the mixture of wildtype allergens. mouse igg antibodies induced by the hybrid proteins qm s and qm showed similar ige-blocking antibodies properties to mixture of der p and der p . the stability of qm s was studied in solution at °c, °c, and - °c and lyophilized at °c, being the frozen and lyophilized forms the best conservation conditions. the qm s hybrid exhibited less ige-binding activity than qm and the natural der p and der p while retained the immunogenicity. these properties together with the improved manufacturability made qm s a good candidate for sit to hdm allergy. objectives: slit tablets of cockroach, slit tablets of parthenium, slit tablets containing both allergens together (mix) and slit bilayer tablets containing one layer with parthenium allergen and other layer with cockroach allergen, compress to single tablet were prepared. punches and dies of mm were used for compression. slit drops containing cockroach, slit drops of parthenium and slit drops containing both allergens together, were prepared and filled in ml amber colored dropper vials. results: tablet formulations were evaluated for thickness ( . - . mm), weight variation ( - mg), hardness ( . - . kg/cm ), disintegration time (not more than min.), and biologically active content ( %- % of the stated label claim). in-vitro dissolution test was performed as per usp using distilled water as the medium and the release was shown between to % in minutes. the liquid formulations were analyzed for ph ( . - . ), the biological content ( % - % of the label claim), specific gravity ( introduction: virtually all patients suffering from the common birch pollen allergy exhibit ige against the bet v relevant allergen. as such, an elisa method for the quantification of bet v was selected and validated as part of the bsp project, aiming to establish reference methods for the european pharmacopoeia. herein, we report the mapping of the epitopes recognized on recombinant bet v allergen by the two specific murine monoclonal antibodies (mabs) used for the accurate and precise quantification of bet v within birch pollen extracts. objectives: in order to investigate the ability of mabs b and h to recognize various bet v isoallergens, we first carried out immunochromatography combined with electrophoresis. epitope mapping was performed by hydrogen/deuterium exchange (hdx) coupled with mass spectrometry (ms) analysis, using a gmp-grade purified rbet v molecule. results: immunochromatography unveiled that both mab b and mab h capture most of bet v isoallergens present within birch pollen natural extracts. those two mabs cross-react with the aln g allergen from alder pollen but do not react with the cas s chestnut pollen allergen. hdx-ms experiments combined with site-directed mutagenesis evidenced that mabs b and h target two distinct epitopes. the hdx-defined b epitope is discontinuous and contains a dominating sequential element (i.e., loop ile -lys ). the hdx-defined h epitope is also discontinuous and mainly composed of regions ile -lys and arg -phe . conclusions: overall, this study provides a precise molecular characterization of epitopes within bet v recognized by mabs b and h , confirming that these two antibodies target distinct non-overlapping epitopes and recognize the vast majority of currently introduction: short or common ragweed (ambrosia artemisiifolia), belonging to the aster plant family, sheds enormous amounts of highly allergenic pollen late in the summer. due to its high allergenic potential ambrosia artemisiifolia is becoming a health threat in north america and europe. hal allergy is developing a subcutaneous immunotherapy for patients suffering from ragweed pollen allergy. a standardized ragweed pollen extract, chemically modified and adsorbed to aluminium hydroxide (al(oh) ), is being investigated for its potential use in immunotherapy. objectives: ragweed extract (re) was modified by glutaraldehyde followed by adsorption to al(oh ). in vitro, a mediator release assay (mra) using hurbl (humanized rat basophil leukemia) cells was performed. hurbl cells were pre-sensitized using individual sera of ragweed-allergic patients and challenged with serial dilutions of re and modified re starting at lg/ml followed by eight / dilutions ( - . ng/ml). antigen-specific release of ß-hexosaminidase was measured and calculated in relation to % release values. in vivo, the immunogenic potency of modified re was evaluated by measuring the induction of re-specific igg in mice. female balb/c mice (n= per group) were subcutaneously (s.c.) injected with . aueq/ml re or modified re adsorbed to al(oh) ( . mg/ml) per mouse on days , , and . control mice (n= ) were injected with matrix only. specific igg titres were determined in serum obtained at days - , and . results: the potency of modified re in mra was drastically reduced in all patients, with a mean reduction of fold or more. chemical modification resulted in a later onset of activation as well as a lowering of the maximum release of ß-hexosaminidase. in vivo, both re and modified re show comparable levels of re-specific igg antibodies in mice at day of the immunogenicity model. shown that chemical modification impairs the capacity of re to activate basophils while retaining its capability to be immunogenic. therefore, chemical modification of re may be a promising approach for the development of a safe and effective immunotherapy for ragweed allergy. objectives: the children who had taken subcutaneous conventional venom immunotherapy in our pediatric allergy outpatient clinic between and were evaluated with respect to the side effects. in addition, each child was called to ask if the patient was exposed to bee sting and the result of a sting during immunotherapy. introduction: the major unmet needs for allergen immunotherapy (ait) are improved efficacy with good tolerability, and high adherence. to achieve these, allergoids, peptides and recombinant proteins are potentially the answer but their low rate of systemic aes make selection of the optimal dose difficult. to select the dose for an ultra-short course subcutaneous birch ait, the company has adopted the use of a conjunctival provocation test (cpt), a wide range of doses and the multiple comparison procedure -modelling (mcp-mod) statistical analysis to test for a dose response and to determine the shape of the dose response curve. objectives: a range of dose regimens of su, , and su were compared with placebo with respect to reduction of total symptom score elicited by cpt after treatment. patients were administered weekly injections outside the pollen season. cpt was performed at screening, at baseline and weeks after completion of treatment. the study was undertaken in sites in germany and austria with patients. the primary efficacy analysis was performed on a modified full analysis set (fas). the mcp-mod methodology was used to test for a dose-response using the placebo and above doses to describe the shape of the dose response curve. three candidate models were pre-specified: a maximum possible effect for the agonist (emax) model, a logistic model, and a linear in log-dose model. a statistically significant dose-response (p<. ) was shown for the range of cumulative doses, which approached a plateau with the su dose. the median effective dose (ed- ) was su. only minor differences were observed between the six active treatment groups in prevalence of treatment-emergent adverse events (between . % and . % of patients with overlapping % two-sided confidence intervals), majority of which were local reactions, short-lived and mild. teaes classified as systemic reactions were seen in . % ( su group) and in up to . % ( su group) of patients in the active treatment groups, and in . % of patients in the placebo group. no treatment related saes were observed. adherence was > % in all treatment arms. the ed- was su, demonstrating that the currently marketed dose ( su) is effective. the highest su dose will be further investigated in a pivotal phase iii trial having achieved an increase in efficacy by % without differences in the onset of aes between the treatment arms. introduction: in order for allergen immunotherapy (ait) to induce long-term immunological and clinical effects prolonged administration is required. therefore adherence to treatment is crucial for its efficacy. there is currently limited data available on ait adherence beyond clinical trials i.e. in real-life clinical practice. objectives: this eaaci immunotherapy interest group endorsed survey aimed to prospectively evaluate adherence to sublingual and subcutaneous immunotherapy in adults with allergic respiratory diseases and hymenoptera venom allergy in real life practice across different european countries. in addition, the reasons for lack of adherence and discontinuation of treatment were explored. this was a prospective, multi-centre, observational survey which took place in eight countries: czech republic, georgia, germany, greece, italy, poland, portugal and spain. data collection involved an online survey that followed participants four-monthly for a period of months from the start date of ait. results: a total of participants were included in the analysis. introduction: allergic rhinitis is a multiple gene-regulated disease involved in many immune cells such as mast cells and eosinophils, and various inflammatory mediators, and mirna probably plays a critical regulatory role in its pathogenesis. therefore, studies on the functions of critical mirna and its regulatory mechanisms in activated mast cells will lay an important theoretical foundation for our understanding of ar pathogenesis and the development of therapeutic strategies. objectives: to investigate the effect of mir- a- p on mast cell activation in an ar mouse model. the number of sneezes and the frequency of nasal rubbing in ar+mir- a- p group were significantly reduced compared to those for ar+mir-nc group (p<. ). histological examination showed that inflammation in the nasal mucosa from ar+mir- a- p group was slighter than that in ar+mir-nc group. the number of mast cells in ar+mir- a- p group was increased compared to ar+mir-nc group (p<. ). the levels of histamine and il- in nasal lavage fluid supernatants, histamine in plasmas and il- in sera were significantly decreased in ar+mir- a- p group compared to ar+mir-nc group (p<. ). conclusions: upregulation of mir- a- p can reduce allergic inflammation in the nasal mucosa of ar and alleviate ar symptoms through inhibiting mast cell activation in vivo. mir- a- p probably becomes a new target for gene therapy of ar. | correlation between chronic cough and chronic rhinosinusitis in adults: nationwide, population-based, and cross-sectional study the second hospital of shandong university, ji nan, china; national university of singapore, singapore, singapore introduction: nasal polyp implies a refractory clinical course in case of chronic rhinosinusitis (crs). although hypoxia is believed to be associated with nasal polyposis, little is known about the mechanism underlying polypogenesis. objectives: the aim of this study was to assess mrna and protein introduction: nasal polyp is a multi-factorial disease commonly associated with inactive ciliary beating frequency (cbf), a condition partly attributed to the mis-localization of dnah , a component of the outer dynein arm in ciliary axoneme. so far however, there have yet to be a systematic histopathological investigation directly linking dnah localization pattern in nasal polyps. therefore, we sought to examine the localization of dnah in cilia structure of both nasal polyps and inferior turbinates from healthy individuals, and assess whether there are any localization changes that can account for the extensive inactive cbf observed in nasal polyps. objectives: the focus of this work is to compare the localization of dnah from the nasal polyps biopsies (n= ) and normal inferior turbinates (n= ) by immunofluorescence. the characterization of each sample was obtained from an average of fields at magnification. results: from the samples, we observed three distinct localization patterns of dnah in the nasal cilia. the three patterns were as follows: ) the localization of dnah in normal cilia is present throughout the entire axoneme (pattern a); ) the localization of dnah is within the axoneme except at their proximal regions (pattern b); ) the localization of dnah is restricted exclusively at the ciliary base and not present in the entire axoneme (pattern c). approximately % of the samples exhibited more than one distinct localization patterns for dnah within the observed fields. the percentage of pattern a, pattern b and pattern c were observed in . %, . %, and . % fields for samples from nasal polyps. correspondingly, . %, . %, and . % were observed for samples from healthy controls. the results indicated that the predominance of "pattern c" in nasal polyps countered by "pattern a" in inferior turbinates from healthy individuals. conclusions: our study indicated that there is a significant increase in the mis-localization of dnah among the cilia in nasal polyps as compared to controls. this mis-localization may account for the inactive cbf, a hallmark characteristic, observed in nasal polyps. zhao l ; zhi l ; jin p ; zi x ; tu y ; li a ; li t ; shi l ( . , . - . , p<. ) and +gc np patients ( . , . - . , p<. the results showed that the number of th + cells were correlated with eosinophil cells and macrophage (r=. , p<. , r=. , p <. ), but no correlation was found between th + cells and neutrophil cells. the significantly correlation were found between il- objectives: this study aimed to reveal if some features of the sinus wall and content (as homogeneity and density of the sinus content, or the continuity, thickness and density of the sinus wall), differ between the afrs and other forms of crs. we tried also to establish early diagnostic parameters for recognition of fungal rhinosinusitis on ct. results: the study included adult patients (mean age: . ae . years, m:f ratio= . : ) with clinically diagnosed crs. out of all maxillary sinuses (n= ) from study patients, ( . %) were opacified, and only these sinuses were included in further analyses. we found out that: ( ) positive fungal finding had % ( / ) crs patients and % ( / ) of these patients had severe forms of crs, ( ) patients with positive fungal finding had more often positive specific ige ab than those without fungi in sinuses ( . % vs. . %, p=. ), ( ) foci of non-homogeneity, mean and maximum densities and wall density were more common found in maxillary sinuses with present fungi than those without fungi (p=. , p=. , p=. ; respectively) and ( ) patients with crs lasting more than years had more often foci of non-homogeneity and presence of hyperattenuation centres, than patients with shorter length of crs. results: neutrophil-related gene mpo and eosinophil recruitment genes ccl and ccl showed higher expression level in acp than in controls, which were in line with the significantly elevated neutrophils and eosinophils infiltration in acp compared to control. increased cd + t cells, macrophages and cd + t cells infiltration in acp were also observed. the expression level of t-reg transcription factor foxp was significantly higher in patients with acp than in controls, but the expression of th /th /th transcription factor tbet, gata and rorc were significantly decreased in acp vs controls. we further investigated the relationships between these t-cellassociated genes in acp. the expression of foxp was positively correlated with t-bet, gata , il r and il a, while no significant correlation with rorc was evident. il was observed positively correlated with t-bet, gata , foxp , and il r. il had significant correlation with t-bet and il a. objectives: the aim of this study was to find the olfactory change pattern of crs after ess in short-term and the differences between crswnps and crssnps, secondary aim were to identify the relationship among olfactory dysfunction, ct scores and quality of life(qol). in this study, crs patients who underwent ess were evaluated preoperative by t&t recognition threshold tests, snot- score and lund-mackay ct score. patient outcomes were re-evaluated at clinical follow-up month, months and months postoperative. analysis of variance was performed and correlation was calculated, with results analysed separately for crswnp and crssnp subgroups. . subgroups of crs differed in the degree of olfactory dysfunction reported before and after the ess. a significant difference in the changes of olfactory dysfunction between the two groups was found at month postoperative. . the mean t&t and snot- scores showed significant improvement within months after ess in both crswnp and crssnp subgroups, however, no significantly recovery of olfactory dysfunction was observed at months compared to month postoperative. there is a plateau of olfactory recovery at months postoperative. . in crswnps, the mean t&t scores preoperative were correlated with lund-mackay ct score significantly(r=. , p<. ; r=. , p<. ). however, no relations were found in crssnps and the changes of olfactory dysfunction at the months postoperative with lund-mackay ct score. . olfactory scores, before and after the ess, and their changes did not correlate with sont- scores. conclusions: olfactory dysfunction was more severe in crswnps. olfaction and qol of crs patients were significantly improved after ess in both groups, but there was a plateau of olfactory recovery at months postoperative. ct scan may predict olfactory disorder, but the olfactory scores were not related with the qol. objectives: in this study, we investigated the effect of hgf, tgf-b , and pge as effective components for allergic rhinitis treatment using in vitro and in vivo mouse model studies. results: pge decreased infiltration of eosinophil in nasal mucosa. tgf-b decreased the infiltration of eosinophil in nasal tissue and increased the number of treg in spleen. however, there was no antiallergic effect of hgf in this experiment condition. in case of the combination treatment group (tgf-b +pge +hgf), eosinophil infiltrations and the expression of eotaxin- were reduced in the nasal tissue, and treg was increased in the spleen. in all treatment group, serum ige and systemic cytokine levels were not decreased due to intranasal administration rather than systemic administration. in vitro study showed that phosphorylation of map kinases such as erk, jnk, and p and translocation of p were inhibited after treatment of hgf, tgf-b and pge , suggesting their anti-allergic mechanism. conclusions: we found that tgf-b , and pge decreased allergic inflammation and these effects might be derived from changes in the frequency of treg and the activation of map kinase and p in the t cell receptor signaling pathway. furthermore, we hypothesized that tgf-b , and pge would be effective components for allergic rhinitis therapy. introduction: interleukin (il)- is implicated in suppression of allergic inflammation. the role of il- in the early-phase reaction in type hypersensitivity has been unclear, however. we investigated the contribution of il- in a mouse model of the ige-mediated early-phase reaction in allergic conjunctivitis. objectives: ige-mediated allergic conjunctivitis was induced in c bl/ -kit(+/+) wild-type mice, kit(+/+) il- -deficient mice, and kit(w-sh/w-sh) mast cell-deficient mice by means of passive conjunctival anaphylaxis. the mice were thus subjected to subconjunctival injection with anti-dinitrophenol ige (dnp-ige) followed after h by intravenous injection with dnp antigen. kit(w-sh/w-sh) mice that had received a subconjunctival graft of cultured bone marrowderived mast cells from kit(+/+) wild-type mice or kit(+/+) il- deficient mice were similarly treated. vascular permeability of the conjunctiva was examined min after antigen injection by colorimetric evaluation of the extravasation of evans blue dye. results: passive transfer of dnp-ige followed by intravenous antigen injection increased vascular permeability in the conjunctiva of kit(+/+) wild-type mice but not in that of kit(w-sh/w-sh) mice, suggesting that this effect was dependent on mast cells. vascular permeability was increased to a significantly greater extent in kit(+/+) il- -deficient mice than in kit(+/+) wild-type mice. reconstitution of kit(w-sh/w-sh) mice with kit(+/+) wild-type or kit(+/+) il- deficient mast cells restored the dnp-ige-and dnp-induced increase in vascular permeability to similar extents. our results suggest that il- produced by cells other that mast cells suppresses the mast cell-mediated early-phase reaction in ocular allergy. objectives: our aim was to evaluate the effectiveness and the safety of ccl treatment for keratoconus in children with vkc. forty-two boys (mean age . ae . years) and girls (mean age . ae years) with vkc were included in the study. tarsal, limbal and mixed vkc were detected in . %, . % and . % of the subjects, respectively. evaporative dry eye was detected in children out of ( . %), schirmer test results were < mm/ minutes in . % and < mm (severe dry eye) in out of children ( . %) and % of the subjects (n= ) had confirmed keratoconus/forme fruste keratoconus with corneal topography (sirius, cso, italy). allergic symptoms were controlled with topical steroids, cyclosporine, dual action antihistaminic/mast cell stabilizers and lubricant agents before the procedure. ccl surgery was performed under topical anesthesia. the children were followed-up at least year and preoperative and postoperative corneal topographic parameters were compared using paired sample t test. results: the visual acuity was between . and . (moderate visual loss) in . % of the subjects and less than . (severe visual loss) in . % of the children. ccl procedure was performed to eyes of children. at the end of one year, the disease was stable in all children with no differences in k and k corneal parameters before and after cxl (p>. ). there was a statistically significant improvement in maximum keratometry value after the procedure (before . ae d, after . ae . d, p=. ). in one subject, a corneal infiltrate was detected days after ccl, which was treated successfully with topical moxifloxacin. otherwise, no complications were observed in the postoperative period. conclusions: as keratoconus is common in vkc, these children should be referred to ophthalmologists for an eye examination and corneal topography. ccl seems to be a safe and effective option to halt the progression of keratoconus, which might be very aggressive in children with vkc. results: surprisingly, we found among them cases of celiac disease, cases of thyroid dysfunction (thyroiditis), cases of crohn's disease and case of ulcerative colitis, case of anterior uveitis and case of pemphigus respectively. we realized that an average percentage of % of the total of vkc cases are affected by an "autoimmune" systemic disease. limbal form of vkc was prevalent and more than % of children showed it. we can suppose that a racial and genetic predisposition to systemic diseases can coexist with vkc or that there is a group of vkc affected subjects in which the immune disorder is predominant on the allergic disease. introduction: nasal polyposis (np) is a heterogeneous inflammatory disease of nasal mucosa affecting - % of the population with a high rate of recidivism. polyps arise from nasal sinuses to nasal cavity and are often associated with a strong local eosinophilia. the pathophysiology of np remains controversial, as it seems to be a phenotypic manifestation of multiple possible immunologic processes, such as respiratory allergy, despite a lack of correlated systemic response. here we propose a multiparametric assessment of np patients, in order to shed light on the underlying mechanisms of the disease in allergic and non-allergic patients and aiming to find new predictive biomarkers. objectives: our main aim was to unravel the link between systemic and local allergic inflammation and polyp development, as well as the nasal epithelium condition in polyps and surrounding healthy tissue. methods: four groups of patients were included in the study: healthy donors with or without allergy and np patients with or without allergy. in this regard, several different approaches were followed: a metabolomics serum study, a polyp and nonpolypous nasal epithelium histology and transcriptomic study. results: as for the histological study, luna staining revealed differences in eosinophilia between allergic and non-allergic patients, especially when patients were polysensitized, including perennial allergens; and between nonpolypus tissue and polyps being higher in polyps. pas staining showed differences in epithelium integrity and submucous and goblet cell (pas positive) distribution. immunohistochemistry for cd + and cd c+ reveal a significant inflammatory infiltration in polyps. this inflammatory response was also asses by abstracts | gene expression quantitation. no differences were seen in the metabolic profile in patient sera between groups. for the first time, nasal epithelium from polyps and neighboring tissue were studied. histology techniques and image analysis revealed differences in eosinophil concentration in both mucosa and submucosa areas, as well as different features in epithelium and submucous tissue structure. some of these findings were confirmed by gene expression quantitation. conclusions: our data show an increased eosinophilia and inflammatory infiltration in polyp tissue suggesting a role for allergic inflammation in the progression of np. additionally, we provide clues for the role of inflammation in the damage on nasal mucosa and the following progression of the disease. | is specific immunotherapy effective in subjects suffering from vkc? a tertiary referral center ten years experience. objectives: our work shows the results of sit additional to usual treatments, in children suffering from vkc and followed in our tertiary referral center (lavagna hospital, genova, italy). we retrospectively analyzed the clinical data of subjects ( males and females); their mean age at the beginning of treatment was ae . years. the patients were treated both with scit (sub-cutaneous immune-therapy- . %) and slit (sub-lingual immune-therapy - . %) depending on patient's wishes. they had to be mono-sensitized to one of the usually more frequent allergens (dust-mites, grass pollen, and pellitory) which was detected by means of recombinant rast, prick test and conjunctival provocation test (cpt); these tests were performed after a complete ophthalmological and allergological history and examination. children selected for sit needed to be positive to all performed allergy tests. systemic involvement included cases of asthma, cases of atopic dermatitis and case of rhinitis; the remaining cases were asymptomatic. local involvement included only vkc cases, the % of which were of the limbal type and only subjects were suffering from the tarsal papillary type. mean follow-up was . years. all the patients included into the study completed their treatment and followed the therapeutic protocol. after one year of sit, no variation in clinical course and treatment was recorded. after the third year of sit, an average improvement in symptoms and signs score ( %) and an average decreased need for allergy systemic medications ( %.) (i.e. antihistamines and corticosteroids) was registered. also topical therapy (including steroid and cyclosporine eye-drops) was discontinued in % of children, in this group, short courses of steroid drops were necessary in less than % of children (as rescue treatment in the acute phases of the disease). these positive results after sit treatment were stable for the following years. few (only local sub-cutaneous) side effects were recorded and the treatment was generally well-tolerated. conclusions: our experience shows positive results with sit in vkc which can have sensitive-to sit-treatment subtypes. results: deaths occurred in children ( boys, %). median age at death was years (iqr - ). pamr of any cause was . ( %ci, . - . ) per children per year, with a decreasing rate over time (annual change: - . %; %ci, - . to . ). triggers were iatrogenic causes (n= , %), insect venom (n= , %) and food (n= , %). unspecified causes were frequently reported (n= , %). there was no difference in overall pamr between boys and girls (p=. ). there was no age group related differences in fatalities: preschool children (< years) (n= , %), school children ( - years) (n= , %), adolescent and toddlers (> years) (n= , %). the number of fatal cases was similar comparing the southern (n= , %) and the northern regions of france (n= , %) (p=. ). the first episode of anaphylaxis for each patient was captured to calculate incidence. we estimated incidence rate ratios using poisson regression models. results: between and there were anaphylaxis episodes in patients younger than years in hong kong. the incidence of admission for anaphylaxis increased markedly from . to . per person-years during the study period (p<. ). the incidence of food-related anaphylaxis increased significantly from . to . (p<. ). increases in anaphylaxis and food-related anaphylaxis were seen in all age groups, with the largest increase in those aged to years. at the beginning of the study period ( ), medication was a more common trigger for anaphylaxis than food ( . vs . per person-years). by , food had become the predominant trigger ( . vs . per personyears for medication). the incidence of medication-related anaphylaxis decreased significantly (p<. ). the incidence rate of anaphylaxis was significantly higher in boys than girls in the - and - year age groups, while there was no significant gender difference in the - year age group. the most common food triggers of anaphylaxis were peanuts, seafood, eggs, milk products, tree nuts & seeds (in descending order). conclusions: even though the incidence of anaphylaxis among children in hong kong is lower compared with other western countries, it has recently increased significantly, with food-related anaphylaxis predominant. | prevalence of anaphylaxis and prescription rates of epinephrine self-injector in korea based on national health insurance data results: the prevalence of anaphylaxis over the years were . %. the annual prevalence of anaphylaxis increased over the years. anaphylaxis was more prevalent in male than female ( % vs. %) and in population aged - years old. for the regional prevalence of anaphylaxis in korea, gangwon province showed the highest prevalence of anaphylaxis ( . per individuals) and relatively low prescription rates ( . %) of epinephrine self-injector for the patients with anaphylaxis. on the contrary, seoul showed relatively low prevalence of anaphylaxis ( . per individuals) and the highest prescription rates ( . %) of epinephrine self-injector for patients with anaphylaxis conclusions: the prevalence of anaphylaxis has increased annually in korea. the prevalence of anaphylaxis and prescription rates of epinephrine self-injector showed regional difference in korea. objectives: the aim of the study was to analyze the prevalence of allergic symptoms and anaphylaxis in mastocytosis patients analyzed in the registry of the ecnm. results: methods: a total of patient with mastocytosis were enrolled. in these patients, the prevalence of allergy, anaphylaxis, triggers of allergic reaction, and disease subtypes were analyzed. results: symptoms of allergy were observed in % of all patients. the most affected group were patients with bone marrow mastocytosis (bmm: . %) and indolent systemic mastocytosis (ism: . %). insect venom allergy (iva) was reported in . % of all subjects. in ism/bmm patients iva affected . % of the cases, while in other patient groups, only . % of the cases were affected (p<. ). most patients ( %) had wasp allergy, % had bee allergy, % polistes allergy, and . % allergy to more than one venom. in . % the culprit insect was not identified. food allergy was reported in . %, drug intolerance/allergy in . %, inhalant allergy in . %, and physical triggers in . % of patients. in mastocytosis patients iva is the most prevalent cause of anaphylactic reactions exceeding the prevalence of iva in the general population by far. iva affects mainly bmm and ism patients ( . % of cases). but ( . %) subjects didn't know whether adrenaline was administered. only within patients who had adrenaline autoinjectors used their autoinjectors during an anaphylaxis attack. most common symptoms were skin (n= , . %) and respiratory symptoms (n= , . %). syncope, hypotension or hypoxemia were present in cases( . %), at least three organ dysfunctions in ( . %) cases; patients ( . %) had to be hospitalized (f: , m: ).nearly a third ( . %) of the patients had stage - anaphylaxis and patients( . %) had stage - reactions. in cases ( . %), basal tryptase levels were examined and the average value was correlated with the severity. concomitant drugs being used by the patients were antihypertensives ( . %),oral antidiabetics ( . %); angiotensin converting enzyme inhibitors or angiotensin receptor blockers( . %), beta blockers( . %), diuretics( . %) and nsaid's ( . %). conclusions: male sex was noted as a risk factor for severe reactions and recurrent anaphylaxis. anaphylaxis requiring hospitalization was more frequent in the patients using oral antidiabetics or diuretics. baseline tryptase levels were higher in patients with neurological and gastrointestinal symptoms. cardiovascular symptoms were found to be higher if a cofactor was present. skin symptoms were seen more frequently and higher rate of hospitalization occurred in anaphylaxis in the presence of infections or nsaid use. this study is important to elucidate the factors affecting anaphylaxis severity. | serum levels of a, ß-pgf in combination with apolipoprotein a or cysleukotrienes are reliable biomarkers of anaphylaxis objectives: we analyzed mast cell mediators in sera derived from patients with acute anaphylactic symptoms (n= ) versus patients with acute cardiovascular or febrile reactions (n= ) and patients with a history of anaphylaxis but without displaying any symptoms when sera were taken (n= ). in addition, we identified proteins with substantial changes during anaphylaxis. matched serum samples were used to compare basal mediator levels with corresponding levels during acute anaphylaxis in the same patient (n= ). roc curve analysis was performed to determine the sensitivity/specificity of each mediator. results: serum levels of histamine and tryptase were not increased upon anaphylaxis and showed no relation to anaphylaxis severity. however, serum a, ß-pgf , a metabolite of pgd , was significantly increased in acute anaphylactic patients (~ -fold) and abstracts | correlated well with anaphylaxis severity. a, ß-pgf distinguished anaphylaxis from cardiovascular or febrile reactions and showed the highest diagnostic power observed by roc curve analysis. cys-leukotrienes (cys-lts=ltc , ltd , lte ) were increased upon anaphylaxis while apolipoprotein (apo) a was significantly decreased. the highest diagnostic power was observed with the combination of a, ß-pgf and apoa . conclusions: in conclusion, histamine might only be used to detect anaphylaxis when assessed shortly after onset of an anaphylactic response because of its short half-life, whereas tryptase is a useful biomarker if the baseline level of the same patient is known. a, ß-pgf seems to be the most reliable marker as demonstrated by the distinct increase upon anaphylaxis and could be supported by apoa or cys-lts. further investigations are needed to prove the suitability of these markers. objectives: objective of this study was to estimate the long-term bv of tryptase using certain chronic disease models and to compare it with those in food and drug allergy. results: serial determinations of tryptase concentrations (n≥ data points per patient) obtained from patients diagnosed with mastocytosis (n= ) or chronic urticaria (n= ) during a period of sometimes several years were measured by the immunocap assay and evaluated using sigmaplot software. polynomial curve fitting was performed and data points outside the % confidence interval of the curve were appointed as outliers and excluded. because the data points were not normally distributed due to long-term fluctuations in homeostatic set-point, a non-linear fitting was applied and used to compute the standard error of the estimate. these standard errors of the fit divided by the estimates themselves were used to calculate the total coefficient of variation within a subject (cv t ). the analytical cv (cv a ) was calculated based on quality control samples ( levels, n= data points) in a conventional way, while the within-subject bv (cv i ) was defined as cv l =(cv t À cv a ) ½ . eleven patients with a chronic disease were selected, of which patient was treated as a potential outlier and patients had to be excluded because of cv t <cv a . the between-subject bv (cv g ) was without the outlier . ae . % (n= data points during a period . ae . years) and with the outlier . ae . % (n= data points during a period of . ae . years). as a food and drug allergy control group additional patients were selected with an uncomprehended food (n= ) or drug allergy (n= ). this cv g was calculated under the same conditions and proved to be . ae . % (n= data points during a period of . ae . years). the long-term between-subject biological variation of tryptase concentrations of patients in chronic disease models was smaller than that of patients with an uncomprehended food or drug allergy. chronic disease models may be of interest to determine the long-term "physiological" biological variation of tryptase. vilà-nadal g; rodr ıguez-sanz a; s anchez-villanueva r; fiandor-roman a; dom ınguez-ortega j; bell on-heredia t introduction: hypersensitivity reactions during hemodialysis sessions have been reported. our aim was to study the mechanisms of the allergic or "pseudoallergic" reactions to synthetic polysulfone (ps) dialysis membranes in "ps-allergic" patients who tolerated cellulose triacetate (cta) membranes. objectives: ten patients with adverse reactions to ps and control non-allergic patients in hemodialysis were studied. ml of blood were collected and an ex-vivo hd were performed on experimental external circuits with low or high priming volumes and pediatric membranes (fx-paed helixone . m and sureflux). serum tryptase levels, basophil degranulation (hla-dr À cd + cd + leukocytes), and t cell activation (cd expression on cd + and cd + subpopulations) were analysed in pre-and post-dialysis samples. objectives: the aim was to investigate the influence of asa and alcohol on egg allergy. donor sera from egg allergic patients (i-iv) with s-ige to ovalbumin at (i) . , (ii) . , (iii) . , and (iv) ku/l were injected intracutaneously to the forearm of healthy/nonallergic volunteers. they were then orally challenged separately with: ) egg white ) egg white + asa and ) egg white + alcohol. 'time to wheal' and 'wheal size' were compared between the three experiments. results: two sera (i-ii) with the lowest s-ige to ovalbumin did not react sufficiently and where excluded from further analysis. the remaining sera (iii-iv) significantly decreased 'time to wheal' with both asa (p=. ) and alcohol (p=. ) added as co-factor compared to baseline. increase in 'wheal size' was only found with co-factors added for the less reactive serum (iii) and not for the serum with the highest s-ige (iv). introduction: eaaci have published numerous guidance documents providing evidence-based recommendations for the recognition, risk factor assessment and management of anaphylaxis. these guidelines clearly advocate intra-muscular adrenaline firstline for the treatment of anaphylaxis, and list absolute indications when an adrenaline auto-injector (aai) must always be prescribed; eg for those who have previously experienced an anaphylactic event, those who have a mast cell disorder and for those with co-existing unstable or moderate/severe asthma and a food allergy. furthermore, eaaci recommends that an aai should be prescribed to those at risk of anaphylaxis (termed relative indications), and that aais should be prescribed and carried by patients at all times. despite widespread dissemination of these guidelines, anaphylaxis hospitalizations continue to rise in many european countries. objectives: in this environment eaaci developed the anaphylaxis survey (axis) as part of its allergy awareness initiative to gain insight into guideline awareness. this survey was sent by email to eaaci members. members from countries responded. data were anonymous and analysed descriptively. results: . % (n= ) reported familiarly with the eaaci anaphylaxis management guidelines, and of these . % (n= ) reported following them. . % (n= ) responded that they would use adrenaline firstline for the treatment of anaphylaxis (although . % (n= ) would still administer it subcutaneously). however, when confronted with a list of indications, only . % (n= ) of eaaci members would prescribe an aai for all absolute indications. furthermore, although . % (n= ) of respondents considered they would prescribe an aai for those at risk, when provided with a list of relative indications, % would prescribe an aai for all of them. there was also a lack of consensus about when an aai should actually be used, with . % of respondents (n= ) considering aai use when individuals experienced breathing difficulties and felt that they were going to collapse. conclusions: these results reflect the latest findings that aais are under-prescribed in daily practice. there appears to be a mismatch between perception of guideline compliance and aai prescription behaviour. continued training, further simplification and wider dissemination of guideline messages are required. objectives: the aim of this study was to analyse the clinical practice of emergency physicians concerning the management of anaphylaxis in alsace and lorraine, a region of . million inhabitants, in france via an electronic survey. results: the response rate was . % ( ). fifty percent of physicians were female. . % ( ) ( ). in case of grade reactions, intramuscular adrenaline injection was performed by . % ( ) of physicians as first-line treatment, intravenous adrenaline injection by . % ( ), antihistamines (oral route or iv) by % ( ) and corticosteroids (oral route or iv) by . % ( ). in case of grade reactions, intramuscular adrenaline injection was performed by . % ( ) of physicians as first-line treatment, intravenous adrenaline injection by . % ( ), iv antihistamines by . % ( ) and corticosteroids (oral route or iv) by % ( ). following an acute anaphylaxis episode, only . % ( ) of physicians systematically recommended an allergy assessment, . % ( ) sometimes, and . % ( ) never. conclusions: this study highlights the discrepancies between current guidelines for the management of anaphylaxis in emergency departments and common clinical practice. our results emphasised the need for specific programs to improve clinical management of anaphylaxis in ed. conclusions: a significant number of individuals among those surveyed reported a severe allergic reaction requiring an eai, yet less than a quarter used an eai. the study also identifies most common challenges faced by at-risk individuals including eai availability, cost, and concerns over short expiry dates. objectives: to evaluate the implementation of a stock epinephrine (stock epi) program in a mall setting. stock epinephrine devices are not prescribed for a particular person and can be used in anaphylactic emergencies. methods: a mixed methods approach was used to evaluate the implementation of the stock epinephrine program regarding its acceptability and adoption by diners, food service, mall administration and security personnel; and the appropriateness, costs (included costs for personnel, epinephrine auto-injector devices, and training materials), fidelity, reach, and sustainability (measured by the national health service (nhs) sustainability model, united kingdom) of the program in this setting (hamilton, ontario, canada). the study revealed that individuals with food allergy and food service establishments were in favour of a stock epi program. a total of individuals with food allergy completed our national online survey. approximately % dine out once or twice per month, and one-third had experienced an allergic reaction. we also completed in-person surveys with diners at the mall food court. of these, % had a food allergy and % reported carrying their epinephrine auto-injector when dining out. the mean nhs sustainability score was among survey participants, well above the mean considered a sustainable program (> ). total cost of the stock epi program over a one-year period varied by ontarian stakeholders: $ for the mall, $ for fast-food restaurants, and $ for sitdown restaurants. conclusions: this is the first study to evaluate the implementation of a stock epi program. the stock epi program was well received abstracts | and sustainable. implementing a stock epi program provides enhanced access to emergency medication, however it does not replace the responsibility of individuals with food allergy to self-manage. objectives: to identify the optimal needle length for epinephrine prefilled syringe. results: three hundred seventy-two children aged month to years were enrolled. skin to muscle depth (stmd) and skin to bone depth (stbd), which can represent the minimum and maximum needle length respectively, were measured using an ultrasonography at the mid-anterolateral thigh. number of children who had stbd less than needle length (too long needle) and stmd greater than needle length (too short needle) were calculated. one hundred thirty-seven children weight < kg, children weight > - kg, and children weight > kg were enrolled: ( . %) children were male. one inch needle was too long in ( . %) children weight < kg, ( . %) children weight > - kg. it was too short in ( . %) children weight > kg. age≥ months, weight≥ kg, height≥ cm, bmi≥ kg/m and thigh circumfer-ence≥ cm, provided the sensitivity of - % in predicting the appropriateness for using inch needle for children weight < kg. in children weight > kg, thigh circumference≥ . cm provided the sensitivity of % and specificity of % for predicting the inappropriateness for using inch needle. objectives: we present a patient with a probable mdh syndrome to unusual drugs, including ah and cct. results: we report a case of a -years-old female, with history of moderate-persistent asthma and chronic urticaria, who experienced angioedema and exacerbation of urticaria hours after the administration of multiple ah (desloratadine, loratadine, cetirizine), systemic cct (hydrocortisone, methylprednisolone, deflazacort) and nonsteroidal anti-inflammatories (nsaids) (paracetamol, ibuprofen, flurbiprofen). patch tests (pt) with excipients (bial arestegui ® ) and drug provocation test (dpt) with placebo were negative. skin prick tests (spt) and intradermal tests (id) with hydroxyzine, hydrocortisone, methylprednisolone and prednisolone were positive to hydroxyzine ( mg/ml) and pt with corticosteroids (bial arestegui ® ) and hydroxyzine were negative. dpts with desloratadine and an alternative ah, dimetindene, were positive with facial angioedema and generalized urticaria within hours. lymphocytic transformation test (ltt) was positive to desloratadine, ebastine and clemastine. dpt with dexamethasone was negative, however, when administered as treatment, a reproducible reaction occurred. since dpt with montelukast was also positive, omalizumab mg was initiated to control angioedema and chronic urticaria. after year of treatment, dpt with nimesulide was negative. omalizumab dose was reduced to half after the patient found out she was pregnant. there were no further episodes after anti-ige therapy introduction and pregnancy went uneventfully. conclusions: mdh syndrome is rare, more so when the drugs reported are ah and cct. hr to ah was confirmed, but diagnostic workup remains incomplete, postponed due to the patient's pregnancy. this case is as challenging in terms of diagnosis as it is in terms of therapeutic, so much so that omalizumab was initiated as an off label therapy, maintained during pregnancy based on the premise that risk was lower than benefit. objectives: in this study, we aimed to present our patients who were admitted with oral iron hypersensitivity. conclusions: according to our clinical experience, we think that oral iron salts with different conjugates are safe and acceptable option in patients with suspected oral iron hypersensitivity. introduction: antineoplastic agents are consider nowadays an essential treatment for many kinds of cancer. the increased use of these drugs in recent years is in parallel with a high rise of hypersensitivity reactions to them. these reactions range from mild to severe and as other allergic reactions, are not predictable. a nursing protocol in the desensitization schedules with these drugs is essential in allergy daily hospitals. objectives: the aim of this study are to describe a nursing protocol during desensitization schedules with antineoplastic agents carried out in our allergy unit in order to detect symptoms suggestive an allergic reaction during drug administration and to assess a correct intervention in case of reaction. conclusions: an appropriate nursing protocol in desensitization schedules with antineoplastic agents is essential in order to achieve the correct administration of the treatment in safety conditions. | long term clinical effects of aspirin desensitization in patients with nerd: comparison of maintenance doses of mg vs mg aspirin Çelik ge ; karakaya g ; erkekol f € o ; dursun ba ; gelincik a ; celebioglu e ; y€ ucel t ; yorulmaz i ; dursun e ; tezcaner Ç ; s€ ozener zÇ ; b€ uy€ uk€ ozt€ urk s ; kalyoncu f ; aydin Ö introduction: aspirin desensitization (ad) treatment has been shown to be effective in relieving the respiratory symptoms as well in reducing recurrency of nasal polyps in patients with nsaids exacerbated respiratory diseases (nerd). however, a conflict occurs about effective maintenance doses of aspirin on clinical parameters. objectives: in this study, our aim was to compare the effects of two different maintenance doses of aspirin on clinical outcomes for years of ad. this was a multicenter study which involved tertiary centers. patients who completed at least one year of ad treatment were included to analysis. study outcomes were number of nasal surgery, sinus infections, asthma morbidity (number of severe asthma attacks, hospitalization) as well as medication uses for both clinical conditions. the study included subjects, of whom were under mg aspirin daily as maintenance treatment whereas remaining on mg aspirin for a mean of . ae months of ad duration. regardless of maintenance doses, number of nasal polyp surgery gradually decreased at ( . ae . /year) and years ( . ae . /year) compared to that of before ad ( . ae . /year) (p<. ) in all subjects and were comparable in and mg. considering asthma outcomes, decrease in asthma attacks were observed only in mg aspirin group (p<. ) at and years whereas hospitalization due to asthma and systemic corticosteroid use decreased in both groups at and years. conclusions: ad has a reducing effect on nasal polyp recurrence for at least years in patients with nerd. this effect was similar for both and mg maintenance doses of aspirin. considering both treatment arms provided decreased hospitalization due to asthma and systemic corticosteroid use, we think that at years evaluation both and mg/day aspirin has comparable effects on asthma as well. however, reducing effect of ad on asthma attacks was only existed in patients taking mg. aspirin. objectives: pregnant women with syphilis and history of immediate hypersensitivity reaction (hsr) to penicillin were enrolled. according to the risk stratification, which was based on the initial hsr, serum specific ige and skin tests, patients were re-exposed to penicillin either through desensitization or provocation. patients with a clinical history suggestive of penicillin-anaphylaxis and/or positive serum specific ige to penicillin and/or positive immediate skin test were considered at high risk and were desensitized. the remaining patients underwent penicillin provocation test. results: we evaluated pregnant women with latent syphilis and history of penicillin allergy. clinical history was suggestive of immediate hsr in out of these ( %) patients, who were desensitized. all of them had negative serum specific ige to penicillin. intradermal tests were positive in / ( %). three out of those four were desensitized with an oral protocol and reacted during the procedure. one patient had a severe breakthrough reaction with uterine contraction and did not finish the procedure. the only patient with positive intradermal test that didn't react during the rdd underwent an intravenous protocol. the remaining / ( %) patients had negative skin tests and an uneventfully rdd. there was a statistically significant association between positive intradermal tests and breakthrough reactions during the rdd (p=. ). the other / ( %) patients with inconclusive history and negative skin test were submitted to penicillin provocation, which were negative in all of them. conclusions: risk stratification based on the initial clinical reaction and skin testing to guide penicillin re-introduction was safe and effective, as well as rdd. skin testing identified allergic patients to penicillin with increased risk of reactions during rdd. | utility of basophil activation test for monitoring the acquisition of clinical tolerance after subcutaneous desensitization to brentuximab-vedotin in two patients many hypersensitivity reactions (hsrs) produced by biologic agents have been seen and their true incidence is unknown. desensitization is a method to counter hsrs from monoclonal antibodies in patients with no other adequate alternative options. objectives: we describe a successful rapid desensitization to bv in two patients with scleronodular type hl, refractory to several lines of chemotherapy and asct. this clinical tolerance to bv is easily observed through the basophil activation test (bat) as a decrease in activated basophils after desensitization was done as a treatment of hsrs. because there was no therapeutic alternative in the two patients, we planned to pursue bv administration using a rapid desensitization -step protocol. a total dose of mg of bv was given through increasing rate and concentration. the patients completed their infusion without difficulty. after desensitization to bv, bat was done in both patients. the percentage of activated stimulated basophils with bv descended in both patients. both values are similar to their corresponding negative controls. conclusions: the bat continues to be a useful in vitro tool for the study of drug allergic disease. also, the bat in flow cytometry is able to monitor an acquired tolerance induced by a desensitization treatment in hsrs to bv. however, studies involving a larger number of patients will be required to assess the safety and efficacy of this approach to bat as a method to validate rapid desensitization in patients with hsr to bv. objectives: we retrospectively reviewed desensitizations in patients with a history of ihsrs to chemotherapy agents performed in our center from january to december . the protocol consists of increases in infusion rate every to minutes, in a to steps depending on the drug. in all cases the protocol was performed without premedication (only using regular medication according to instructions for every drug). results: a total of patients with a history of (ihsrs) received desensitization protocol without premedication to chemotherapy agents. the most common involved drug was carboplatin in ( . %) patients (of these % presented positive skin test (st)), followed by paclitaxel in ( . %) patients (of these . % presented a positive st) and oxaliplatin in ( . %) patients (of these . % o the st were positive). other chemotherapy agents involved were cetuximab, rituximab, irinotecan, epirrubicin, etoposide, cisplatin and cyclophosphamide. all patients were able to successfully complete the desensitization protocol without premedication and none of them need to withdraw the drug. conclusions: this protocol for rapid desensitization to chemotherapy without premedication is safe and effective. in addition, minimizes secondary effects of the premedication in these patients that are polymedicated. | rapid desensitization for the management of hypersensitivity reaction to biologicals-infliximab and adalimumab in inflammatory bowel disease patients objectives: to identify barriers to best practice with regards to drug allergy history taking and documentation, and to elaborate the potential strategies to overcome them. results: a total prescribers responded to the survey: doctors in training . % consultants . % non-medical prescribers . % most respondents . % ( %ci . - . %) were not aware of the availability of penicillin allergy testing in our trust. among those that were aware of it, . % ( %ci . - %) had not referred any penicillin-allergic patient to immunology during the past year. barriers to accurate allergy history collection: . % ( %ci - . %) concurred that often it is not possible to draw a firm conclusion based on history alone. . % ( %ci . - . %) agreed with the statement saying that, regardless of the details of the allergy history, it is always better to "play it safe" and not to use alternative beta-lactams in patients labelled as being penicillin-allergic (figure will be attached in the poster). among the interventions proposed; practical educational sessions, an interactive questionnaire to guide allergy history taking and classification and a modified antibiotic policy to guide prescribing based on the allergy classification, were all rated as useful (average score > on a scale from -not useful at all-to -very useful). | the regulatory role of germinal center maturation during the early b cell response to inhalant allergens investigated in the piama cohort using the medall allergen microarray introduction: in contrast to common belief, igg to airborne allergens is higher in allergic subjects, even before immunotherapy. one of the confusing aspects of the allergic immune response is that not only the igg response, but also the ige response can follow more than a single trajectory (with or without gc maturation). for ige we assume that the direct isotype-switching pathway (igm to ige) is the most relevant for the initial, mature-gc independent phase of sensitization to low-dose airborne allergens (such a pollen, mite). in later phases and for higher exposure situations as well as for other immunization routes, indirect switching is assumed to be the more relevant pathway. methods: ige, igg and igg antibodies were measured using the medall allergen microarray in children from the piama cohort at age and . these results were analyzed in relation to the ige levels at age and . objectives: to find support for the hypothesis that the ige/igg ratio reflects not only exposure, but also details on immunological processes during sensitization, such as germinal center maturation. results: sigg and sigg levels to the major inhalant allergens were low at age and remained in general low at age . however, children who at that time were positive for ige an allergen had a significant increased sigg to the allergen in question. sigg also appeared, but this response was low. the sigg level at age in sigenegative children was not consistently predictive for sige at age . conclusions: the initial igg response to inhalant allergens is synchronized with the ige response. this result fits with the hypothesis abstracts | that in the initial phase of sensitization to inhalant allergens the allergen initiates a weak and incomplete germinal center response that allows parallel ige-and igg production. one of the consequences of the multiplicity of b cell developmental pathways is that the igg/ige ratio is potentially diagnostic: if a subject has sigg levels in the microgram range, and thus a high sigg/sige ratio, this indicates involvement of mature gcs and the indirect class-switching pathway for some or all of the sige in this subject. | synthetic allergoid consisted of plga nanoparticles covered with synthetic peptides from bet v objectives: the aim of this study was to test a hypothesis that the ahr signaling is critical in controlling sl homeostasis through the regulation of key sphingolipid enzymes involved in the s p synthesis. results: we found that an ahr ligand and a tryptophan photoproduct, -formylindolo ( , -b) carbazole (ficz; nm), induced a increase in s p level in a ros and ca + -dependent manner, leading to the degranulation as well as il- secretion in mast cells, when compared to those seen in vehicle-treated cells. this was concomitant with an increased level of sphk phosphorylation and with a reduction in the enzymatic activity of s p lyase, which could be reversed by the addition of an anti-oxidant, nac. moreover, s pl was found to be directly oxidized by ros in vitro and in vivo. conclusions: our findings suggested that ahr-mediated ros and ca + signals are critical for controlling sl homeostasis through regulating sphk and s pl metabolic pathways, providing a new regulatory pathway in mast cells. methods: peptide cytokine mimetics were selected by phage display technology. flow cytometry, elisa, elispot, t cell proliferation, reporter gene, mediator release, intravital microscopy and peritonitis assays were conducted to evaluate the capacity of the mimetic peptides to modulate the immune response. results: the synthetic tgf-b -like peptide was able to down-regulate the production of tnf-a, il- , ifn-c and il- , up-regulate il- , decrease basophil degranulation and induce t reg cell differentiation. furthermore, this peptide was able to decrease leukocyte rolling and neutrophil migration during an inflammatory condition in vivo. the synthetic il- -like peptide was able to decrease basophil degranulation and to inhibit the proliferation of allergen-specific t cell lines established from the peripheral blood of birch pollen-allergic patients. conclusions: the peptide cytokine mimetics tested herein, were able to modulate the immune response in the tested conditions. they, thus, represent promising novel candidates for therapeutic approaches. nonetheless, most studies focus on changes occurring early in life and there are rare data on differences in responses between allergic and non allergic subjects. objectives: we aimed to evaluate i) the maturation trajectory of the tlr antiviral pathway ii) if this trajectory varies between atopics and non atopics. peripheral blood mononuclear cells (pbmcs) were isolated from otherwise healthy atopic and non atopic subjects. atopy was assessed by medical history and skin prick testing to common aeroallergens and egg white. selected cytokines involved in the antiviral response were measured by luminex multiplexing technology in hour culture supernatants of poly:ic-stimulated pbmcs. data were analyzed by estimating the non-parametric correlation between age and cytokine expression in atopics and non atopics and comparison of regression curves for each cytokine between the groups was performed. results: the analysis comprised data from atopic and non atopic patients (mean age . years, age range - and mean . years, range - . , respectively). significant age-related increases in the production of ifn-a , ifn-c, il- b, il- a, tnf-a, and mip- b were found only in non atopics and of il- and il- in both groups. significant differences in the trajectories (slopes) of cytokine responses over time between atopics and non atopics were observed for ifn-a , ifn-c, il- , il- b, tnf-a and mip- b, with suboptimal production in atopics. conclusions: age-related increases in cytokines implicated in innate antiviral responses were observed mostly for non atopics. atopy was associated with suboptimal trl- induced cytokine responses. differences in the developmental pattern of those cytokines between atopics and non atopics may account for the reported increased susceptibility of atopics to infections. | a systems-immunology approach identifies a set of micrornas in shaping the th phenotype in allergic airway inflammation introduction: mouse allergy is a common disease in inner city households, affecting up to % of children who are exposed as determined by house dust analysis. it is associated with allergic rhinitis, atopic dermatitis and asthma and it has been reported that exposure and sensitization to mouse allergens is a strong predictor for asthmatic disease. despite a strong link between mouse exposure and asthmatic disease, the allergic immune response to mouse has been significantly understudied. to date, only one major allergen in mouse, mus m , has been identified and very little is known about the targets of the allergic immune response against mouse. objectives: using a proteomic/transcriptomic approach, we sought to identify t cell targets in mouse allergic and asthmatic patients. results: mouse urine and epithelial extracts were analyzed by d-ige/igg immunoblots using pooled sera from mouse-sensitized donors. mass spectrometry of selected protein spots identified novel antibody reactive proteins. predicted mhc binding peptides from these novel proteins and mouse homologs to mammalian allergens were screened for t cell reactivity in pbmcs from mouse allergic patients. overlapping peptides from the major mouse allergen mus m and its major urinary protein isoforms were screened in parallel. our screen for t cell responses in pbmc from mouse allergic donors demonstrated that major urinary proteins account for > % of the total t cell response but they are not the only target of mouse-specific t cell responses. reactivity to mouse peptides homologous to other mammalian allergens, specifically guinea pig, was also detected. conclusions: in summary, our data demonstrates that the cellular and serological targets of the allergic response overlap, with mus m being the major target for both t cells and antibodies. to the best of our knowledge, this is one of the first comprehensive studies of t cell epitope targets in mouse allergy, which provides important insights into cellular and serological targets. this data may form the basis for the development of a mouse-specific immunotherapeutic approach. introduction: food allergy has a complex etiology with many potential underlying factors proposed to contribute to and modify its development and progression. the use of a databases to collect and analyse all relevant data related to incidents of food allergy is essential to fully understand causal factors and improve treatment. objectives: we developed a database using sql, hibernate and java server pages (jsp) that was designed to allow allergy professionals to easily add and modify patient data, including medical history, reaction details and in vitro/in vivo test results. we then filled this database with clinical data relating to reactions to plant-based foods for patients who visited the allergy service of the regional university hospital of malaga between - . these data were then analysed in various ways. cluster analysis of skin test results was used to search for relationships between different allergens based on similarities between patient sensitisation profiles; descriptive statistics and graphical analysis were performed to search for relationships between food type, age of first reaction, number of reactions and reaction severity. results: cluster analysis placed the different skin test allergens in distinct groups, which generally correlated with the type of allergen. for example, nuts, rosacea plant-food, mites, trees and weeds formed distinct clusters. analysis of patient history data showed that the first reaction occurred most frequently between ages - , with a right skewed distribution. a relationship was also found between age at first reaction and reaction severity, being urticaria and angioedema more common when the initial reaction occurs at a younger age, and anaphylaxis when the initial reaction occurs later in life. oas remained relatively prevalent at all ranges (around a quarter of all reactions in all age groups). we found fruits to be the most frequent triggers, followed by nuts; within fruits peach and banana were the most frequent. conclusions: this preliminary study show the importance and utility of recording patient allergy information in a well-structured and easily managed database. future work is currently underway to collect a new set of patients from the same geographical area and to analyse similar data from a different area in order to identify what results are replicable within our population and which results are generalizable to other areas. introduction: cow's milk allergy is very common in children and its correct diagnosis is important to prevent possible dangerous allergic reactions. the aim of the present work was to evaluate the prevalence of allergic sensitization to both cow's milk and to its main proteins. with medcalc ® . normality distribution of data was evaluated through the kolmogorov-smirnov test. patients were divided into three age groups ( - years, - years- - years). chi-squared test was performed to verify a statistical difference between sensitization to whole milk and to its main proteins and patients' age. introduction: the order fagales represents an important cause of tree pollen allergy, which is ubiquitous in the northern hemisphere. a high degree of allergenic cross-reactivity has been observed among allergens from these plants, mainly represented by pathogenesis-related protein class (pr- ) pr- s, including inhalant and food allergens. conclusions: testing ige reactivity to a panel of pr- s unveils important associations between sensitization profiles and clinical presentation, and allows the identification of novel cluster patterns potentially useful to predict disease severity in patients with pr- allergy. results: patients were included, seven boys and four girls, with a median age at diagnosis of six months. the most common offending foods were cow's milk protein (cmp, n= ) and rice (n= ). other foods were fish, egg, chicken, wheat, carrot and potato. average time of symptom onset was . hours. the most frequent symptoms were vomiting (n= ) and diarrhea (n= ). six patients had a history of hospital admission related to this problem. seven patients had concomitant atopic diseases, being the most frequent allergic comobility atopic eczema (n= ). skin prick tests and/or specific ige to culprit foods were negative at diagnosis, except for one patient with low specific ige to cmp. another patient become sensitized to cmp during follow-up. open food challenges were performed in patients starting from six months of age. resolution was achieved in patients, at a medium age of months. results: a total of cases of immediate-type fa among children were reported, with . % involving patients younger than years of age. the major causative foods were hen's egg ( . %), cow's milk ( . %), walnut ( . %), wheat ( . %), peanut ( . %), soybean ( . %), and shrimp ( . %). the most common causative food in each age group was cow's milk ( - years), walnut ( - years), walnut and hen's egg ( - years), and buckwheat ( - years), respectively. the symptom onset time was less than minutes in %. food-induced anaphylaxis was reported in ( . %) out of cases, and the major causes were cow's milk ( . %), hen's egg ( . %), walnut ( . %), wheat ( . %), peanut ( . %), buckwheat ( . %), and shrimp ( . %). the proportion of anaphylaxis was highest in buckwheat ( . %), followed by walnut and pine nut ( . % each). korean children were hen's egg, cow's milk, walnut, wheat, and peanut, with distinctive distributions according to different age groups. anaphylaxis was reported in . % among immediate-type fa. results: a total of children with a median (inter-quartile) age of . years ( . - . ) were enrolled to the study; (male . %). their ages at diagnosis were . years ( . - . ); follow-up times were . years ( . - . ) and milk specific ige levels at diagnosis were . ku/l ( . - . ). in . % of the children there was only cma; the other children were polyallergic to different foods having most frequently egg white allergy. concomitant diseases were . % atopic dermatitis, . % were asthma, . % were allergic rhinitis. during the follow-up milk tolerance was developed in . %, . % and . % at the ages of , and years respectively. the specific ige level at the beginning of the disease was found to be a risk factor for the persistence of the disease (p<. ). conclusions: cma is frequently present with other food allergies. nearly half of the patients develop tolerance to cm up to the age of years; whereas / becomes tolerant when they are at the age of years. most frequent concomitant diseases are atopic dermatitis and asthma. objectives: two survey tools were used; a questionnaire based on similar surveys done overseas, and the validated food allergy quality of life questionnaire (faqlq). this was distributed throughout paediatric allergy clinics at two metropolitan centres. children and adolescents aged - completed the questionnaire independently, whilst parents assisted with children aged - years. results: surveys have been collected at the time of writing of which were answered by parents for young children. overall, / ( %) reported bullying, with a higher portion in older children and adolescents ( / ; %). of this group, / ( %) reported being bullied or teased because of their food allergies. from parental reports, / ( %) stated that their child had experienced bullying or teasing because of food allergies. for those not bullied, parents mentioned that this may be due to their child having friends at school, being too young for bullying or because other children at school had a good understanding of the severity of allergies and were educated by teachers. the most common location for bullying was "in the playground or sportsground" ( / ). the most common form of bullying involved being "teased, called names or someone has said mean things to me" ( / ). whilst food allergens were involved in bullying in many cases ( / ), there were no reports of children being forced to eat food to which they are allergic. of concern however, two adolescents reported experiencing an allergic reaction as a result of the bullying. the majority reported experiences of sadness from bullying ( / ) while seven stated that it had no effect. conclusions: our current research shows that % of children and adolescents with food allergies experience bullying, and that % ( / ) experience bullying specifically because of their food allergies. this indicates a significant social problem that requires addressing to positively assist those children living with food allergies. introduction: recently we demonstrated that intake of specific foods, types of fat and micronutrients was associated with inflammation and mucosal integrity in adults with eosinophilic oesophagitis (eoe). the current study aimed to compare dietary intake of these patients with dietary guidelines and intakes of the general dutch population to further investigate our hypotheses on the protective or allergy-provoking role of specific nutrients in eoe. results: the total faqlq score was low when assessed by teenagers and children ( . and . , respectively) and moderately low when assessed by parents ( . ). experience of anaphylaxis and having multiple food allergies impaired hrql according to faqlq parent form (p<. ). gender, having prescribed an adrenaline-auto injector, experience of food provocation test, peanut allergy and faim did not contribute to different hrql. hrql in kindergarten and schools were moderately diminished (sum score . in schools and . in kindergartens) (p>. ). perceived disease severity was moderately present with total faim scores being . , . and . , when assessed by children, teenagers and parents, respectively (p>. ). % of participants' reported at least some possibility of dying if child/teenagers would accidently eat a food allergen. after fulfilling faqlq and faim, all participants expressed content, ten children/teenagers decided to approach food provocation tests de novo, employees of children's schools/kindergartens were encouraged in written invitations to assess anaphylaxis training programs, and four families accepted additional psychological support. conclusions: food allergies impair hrql in children and teenagers. allergies to multiple foods and experience of anaphylaxis were associated with more severe impairment of hrql. hrqlq and faim are useful, additional tools to assess and discuss child's/teenager's/parent's fears and obstacles because of food allergy and identify further needs of support. introduction: fruit allergy is the most common cause of food allergy in children older than years and adults. regional variations have been observed in europe but there are few studies in pediatric population. objectives: in the context of a prospective and multicentric study on pollen and vegetable food allergy in spain, we enrolled patients (median age , range - , female %), who had suffered at least two episodes of immediate symptoms after ingestion of fruits and had positive skin test to the implicated fruits. immunocap isac was analyzed in all patients. our aim was to describe the clinical characteristics with the fruits involved and the usefulness of the allergens included in the immunocap isac to improve its characterization. symptoms were categorized into oral allergy syndrome (oas), systemic symptoms (ss) and anaphylaxis. results: a total of patients were included. all of them had symptoms with more than one fruit. patients had pollen sensitization. the main offending food associated with allergic reactions were peach ( %), kiwi ( %), melon ( %), apple ( %) and banana ( %). allergic patients to peach had oas, ss and anaphylaxis, were recognized prup in all patients with anaphylaxis, in patients witch oas and in with ss, also prup associated with abstracts | prup in patients with ss. for allergy to kiwi, patients had oas and ss, were recognized actd in patient with sao and patients with ss. actd in patient with ss. conclusions: in our population, the most prevalent fruit allergy was the peach, as in spanish adults. patients allergic to peach were the ones that presented the most ss and anaphylaxis, followed by allergic to apple. as previously have been reported most of them had sige to its components in isac; being prup the most prevalent ( % had prup ). only patients with ss with kiwi were sensitized to kiwi allergens .the majority of patients allergic to apple, melon and banana were not diagnosed by immunocap isac. introduction: studies have shown that asthma and allergy are prevalent among production workers processing seafood, particularly in workers processing crustaceans. a major ige-reactive proteins is the muscle protein tropomyosin. specific ige to tropomyosin is suggested as a central marker for crustacean allergy, however it is not the only protein characterised as an allergen in crab processing. objectives: the aim of our study was to characterise tropomyosin exposure and prevalence of sensitisation to allergens in workers processing king crab (paralithodes camtschaticus) and edible crab (cancer pagurus) in land based processing plants in norway. results: personal air samplers collected air from the workers' breathing zone during crab processing. workers' blood was collected for ige testing. extracts of both king crab and edible crab raw meat, cooked meat, intestines and shell were made in our lab and used for skin prick testing and immunoblotting. while processing cooked crab yielded highest tropomyosin levels in the edible crab plant, processing raw crab yielded highest levels in king crab plants. ten ( . %) edible crab and ( . %) king crab workers had positive ige test (> . ku/l blood, immunocap systems) to crab. four ( %) of skin prick tested king crab workers and ( %) of skin prick tested edible crab workers had one or more positive reactions to edible crab extracts. more workers reacted to cooked crabmeat extracts than to raw crabmeat extracts. immunoblotting showed ige binding to a large number of proteins in all four extracts of both king and edible crab. binding was found to high molecular weight proteins in all four extracts of the crab tested, and the ige-reactive proteins differed between king crab and edible crab. conclusions: workers are exposed to tropomyosin in their breathing zone during crab processing. both king crab and edible crab workers are sensitised to crab, shown with immunocap specific ige test to crab, as well as positive skin prick tests and immunoblots to four different crab extracts made in our lab. workers processing crab in norwegian processing plants have an increased risk for developing sensitisation to crab. objectives: the aim of the study was to assess frequency of skin symptoms in surgery clinic employees, to evaluate burnout as a predictor of the frequency of skin symptoms, and to determine latexspecific ige in surgery nurses with skin symptoms. results: skin symptoms were significantly more frequent in surgery nurses ( %) than in surgeons ( . %), other physicians ( ), and other nurses ( . %) (v = . ; p=. ). skin symptoms were also significantly more frequent in workers with high/medium than in workers with low emotional exhaustion ( . % vs . %; v = . ; p=. ), as well as in participants with burnout than in subjects without burnout introduction: baker's asthma sensitization pattern is changing due to the introduction of different types of grains and seeds. objectives: a year-old ecuadorian man showing ocular, nasal and pulmonary symptoms when handling grain flours (with or without seeds), while baking for the last years. he tolerated grain flours oral intake, but had oropharyngeal symptoms, rhinoconjunctivitis and dyspnea when eating sunflower and sesame seeds, mustard, and beer with alcohol. he tolerated alcohol-free beer. we performed an allergy study: prick-test with commercial extracts of pollens, dust and storage mite, fungus, animal danders, cereals, yeasts and mustard. prick by prick with patient's products: wheat, multicereals and seeded flour, sunflower seeds, regular and alcoholfree beer spirometry and niox. serial peak flow measurement at and away from work, handling tests with wheat flour and sunflower seeds. laboratory studies: specific ig e to cereals and seeds (cap-isac-microarrays). immunoblot with regular beer (at room temperature and boiled), wheat flour and sunflower seeds, and sequential chromatography. results: skin tests were positive with commercial mustard and all provided products except for the alcohol-free beer. spirometry was normal. niox: ppb. peak-flow monitoring showed a % variability during working period, remaining stable during holidays. handling tests with wheat flour and sunflower seeds were positive. specific ig e was positive for grains, malt, gluten, mustard and sunflower seed. the specific determinants were positive to s-viciline, -s globulin, several prolamins ( s-albumine, alfa-amylase inhibitors and gliadin) and ltp. immunoblot detected a band lower than kda in both regular beer extracts (not detected in alcohol-free beer) identified as barley's ltp, a band of kda in the sunflower seed extract ( salbumine), and two bands lower than kda in wheat flour extract (two kinds of alfa-amylase inhibitors). we present a non-atopic baker with occupational rhinoconjunctivitis and asthma due to prolamins (alfa-amylase inhibitor and gliadin of wheat flour together with s-albumin sunflower seed), and anaphylaxis when eating seeds ( s-albumins, s-vicilin and s-globulin) or drinking beer (sensitization to barley's ltp). it is interesting that the manufacturing process of non-alcoholic beer (high temperature and high pressure) seems to degrade barley's ltp, as suggested by both tolerance to its ingestion and loss of immunoblot band. objectives: the main objective of this study is to evaluate longitudinal change of lung function in workers employed in food preparation and distribution potentially exposed to food allergens. spirometries performed between and as part of medical surveillance of food-handlers workers were evaluated. data about occupational task, work years, smoking habits and diagnosis of atopy, asthma and copd were collected from a clinical database. differences in prevalence were calculated by chi-square test, differences in means were calculated using spirola software referred to european predicted values. results: the majority of workers were females (n= ; . %) and caucasians (n= ; . %). ( . %) subjects were current smokers, ( . %) were ex smokers, ( . %) were atopic and no one reported a diagnosis of asthma or chronic obstructive pulmonary disease. % workers were canteen service employees and % were cookery employees. mean yearly values of the pair-wise within person variation of fev and fvc were respectively À ml and À ml. . % of last observations had a fev below lln and . % of last observations had a fvc below lln. conclusions: this study may help in planning preventive programs and in facilitating early recognition and diagnosis of work-related respiratory diseases. wheat, foods and latex allergens may determine decline in fev and fvc; furthermore, in our study, a significant proportion of workers reported exposure to tobacco smoke. excessive loss in fev over time should be evaluated using a percentage decline ( % plus loss expected due to aging) that we will make afterwards adding more years of follow up spirometries. intervention of smoke avoidance are needed. | prevalence of wood dust sensitization in occupationally exposed workers in germany-what can be tested? objectives: in serum samples from patients with suspiciously allergic symptoms to wood dust overall specific (s)ige-tests with standardized wood-dust extracts coupled to streptavidin-immu-nocaps were conducted. additionally, ccd as known source of non-protein ige-target was evaluated. sensitization rates were calculated for different wood species. most frequently requested wood dust allergens were obeche (n= ), beech (n= ), oak (n= ), spruce (n= ) and pine wood (n= ) followed by - requested sige-tests to mahogany, ash, larch and maple wood. results: overall wood dust sensitization rate was about % (range: - %) with obeche, box wood and kambala as most prominent sensitization sources obtaining each more than % sensitization. no sensitizations were detectable to red cedar and meranti wood in more than requested tests, respectively. in patients at least one sige-sensitization to any wood was measured. there from were additionally tested with ccd resulting in % positive and % negative ige responses to ccd. some wood species were exclusively recognized by ccd-positive subjects: ash, maple, alder, mahogany, teak, mansonia and palisander. whereas other woods were recognized by sige of subjects with / or without sige to ccd: obeche, box wood, spruce, oak, beech, limba, pine and kambala. relevance of wood sensitization next to ccd was investigated in eight double positive subjects (wood + / ccd +). specific ige-binding to wood allergens was completely inhibited by ccd in three samples. these subjects were supposed to have no clinically relevant wood sensitization. whereas in five samples sige-binding to selected wood species was not significantly reduced by ccd. in four of these patients skin prick tests (spt) and challenge tests (bronchial and/or nasal) with corresponding wood allergens were performed. three of four challenge tests were positive with the respective wood extract and all spts with wood extracts whose sige-binding was not affected by ccd inhibition showed positive reactions. here clinical relevance of sige-mediated wood sensitization could be demonstrated. conclusions: in summary, our data demonstrate that standardized wood extracts and ccd tools are necessary for valid in-vitro diagnosis of wood dust sensitization. introduction: respiratory symptoms have been reported frequently among seafood processing workers. since seafood processing workers handle the raw material and participate in processing activities during work, they are exposed to inhalable bioaerosols. this put them at risk of developing respiratory symptoms, asthma and allergy. there is little knowledge about the respiratory health status among fish production workers on board fishing trawlers. objectives: the aim of this study was to assess the respiratory health status among norwegian fish production workers, processing fish on board fishing trawlers. the study population consisted of fish production workers, machinists, support crew members and non exposed controls, all were males. written informed consent was the fish production workers had a significantly decreased fev % predicted compared to the non-exposed control group, b=À . , % ci [À . , À . ], when controlling for age, pack-years and family history of asthma/allergy/eczema. the effect did not change when controlling for doctor diagnosed asthma or after dividing fish production workers by doctor diagnosed asthma. machinists and support crew members showed a similar decrease in fev % predicted, but the difference from the non-exposed control group was not statistically significant. furthermore fish production workers, reported a non-significantly increased prevalence of wheezing and daily morning cough compared to the non-exposed control group. conclusions: fish production workers, processing fish on board fishing trawlers, showed reduced lung function values compared to a non-exposed control group, and this finding is in accordance with previous findings in seafood industry worker populations from our research group. results: study group comprised patients with work-related respiratory symptoms suggesting wra. the research completion with sic allowed to recognise wra in persons ( oa and wea) and to exclude asthma in cases qualified to reference group (gr). workers with wea occupationally exposed do lmw-a manifested the highest level of baseline non-specific bronchial hyperresponsiveness (nsbhr) in comparison to the other groups (table ) . patients with oa exposed to lmw-a more frequently than exposed to hmw-a revealed nsbhr before sic (p=. ) with lower level of median (me) provocative methacholine concentration value causing % fall in fev (pc induced sputum (is) was obtained before and h after sic from patients ( gr and wra). in all gr samples and samples possessed before sic from wea subjects exposed to hmw-a, intermediate profile of is (neutrophils (ne)< % and eosinophils (eo)< %) dominated ( results: eg: in "granulation" exposure is relatively high and the number of different enzymes handled is low; here the risk of sensitization is highest. in contrast in the pilot plants the exposure compared to granulation in general is lower but the number of enzymes handled concurrently is higher. still the sensitization risk is lower than the range for granulation. conclusions: even though this approach may seem crude and not free from bias and potential misclassification, data does not support the hypothesis that the number of enzymes increases risk of sensitization, whereas increasing exposure level seems to be a risk factor. this suggests that each enzyme exposure acts as a risk in its own right and that the "cocktail effect" seems to be of minor relevance. phospholipids. bioinformatic studies of sequence homology conducted prior to this study showed no similarity between the mpla s and known allergens including ves v . however, the common enzymatic activity in ves v and the mpla s might still lead to crossreactivity. the goal of this project was therefore to test for possible cross-reactions between sige towards ves v and three different mpla s. methods: serum from known wasp allergic persons with sige towards ves v spanning from . ku/l to ku/l were used for inhibition studies. from each, ll serum was incubated with ll of either saline solution (negative control), lg/ml alk soluprick solution (positive control) or one of three mpla s, each in three concentrations (either . lg/ml, lg/ml and lg/ml (n= ) or lg/ml, lg/ml and lg/ml (n= )). the level of sige towards ves v was measured using the i immunocap, and a decrease in this level was calculated as %inhibition compared to the sige measured from serum incubated with the negative control. inhibition by mpla s would indicate cross-reactivity. results: the positive control caused . ae . % (n= ) inhibition of sige towards ves v . this was lower than expected but was found to be caused by a few sera where the fraction of sige towards ves v was < % of all sige towards wasp venom. in the remaining sera, %inhibition was . ae . % (n= ). for all three mpla s, no inhibition was found for any serum tested (n= ) at the highest concentration tested with %inhibition being . ae . %, . ae . % and . ae . % respectively. conclusions: no inhibition of sige to ves v was found to any of the three microbial phospholipases tested. this indicates that no cross-reaction is found between the phospholipase a in wasp, ves v , and phospholipase a from microorganisms despite the common enzymatic activity. objectives: the aim of study was to evaluate the prevalence and the impact of polyvalent ige-mediated allergy on the course of ad and the occurrence of allergic symptoms from other organs and systems in infants and young children. conclusions: polyvalent ige-mediated allergy is common in young children with ad and seems to be a risk factor for the severe course of the disease. introduction: non-steroid anti-inflammatory drugs (nsaid) are the second most common cause of drug allergies in childhood. objectives: the aim of the study is to determine the frequency of nsaid hypersensitivity in asthmatic children. results: patients who were being followed up for asthma were included in this study. the mean age of the patients was . ae . years, while . % ( ) were male. % (n= ) of the patients had a reaction history to nsaid (ibuprofen in , flurbiprofen in , diclofenac potassium in , metamizole+acetylsalicylic acid in , paracetamol+acetylsalicylic acid in and ibuprofen+acetylsalicylic acid in ). nsaid sensitivity was confirmed in ( . %; / ) patients who were tested with suspected drugs, while the provocation test was found negative in one patient who described reaction with ibuprofen. of the children who were assessed as a control group, only had a reaction history to acetylsalicylic acid and no reaction developed in the provocation test. conclusions: nsaid hypersensitivity is more common in patients with asthma. thus, these patients should be evaluated for nsaid hypersensitivity. results: from jan to dec , pediatric cases were received by kaers. of pediatric patients, . % were male, . % were female and . % were unknown. these pediatric cases included a total of adr events with an approximate average of . adr events per report. of those cases, . % were in infants (age - years), . % were in young children (age - years), . % were in old children (age - years), . % were in adolescent.(age - years) and unknown were . %. male to female ratio was : . and the mean age was . ae . years. regarding categorical ranking of reported adr agent groups, the most common group were antibiotics ( . %) followed by antineoplastic agents ( . %), vaccine ( . %), antipyretics ( . %), opioids ( . %), sedatives ( . %), antiepileptic drugs ( . %), contrast media ( . %), steroids ( . %). the most common adr symptoms were gastrointestinal system disorder in . %, skin-appendage disorder in . %, abstracts | body as a whole-general disorder in . %, central-peripheral nervous system disorder in . %. regarding seriousness of adrs, events ( . %) had episodes requiring hospitalization and were considered life threatening. of these, cases had anaphylaxis or anaphylactoid reactions. introduction: multiple drug allergy is an adverse reaction to two or more structurally unrelated drugs that appears to occur by immune mediated mechanism. patients with a history of reaction to two or more drugs often apply to allergy clinics. objectives: the aim of this study is to evaluate the test results of the patients who have a history of multiple drug allergies and underwent drug provocation tests. results: during the study period, drug provocation tests were performed in patients ( drug provocation tests). of these patients, ( . %) had a history of drug reactions to or more drugs. the mean age of the patients who had a history of reactions to two or more drugs was . ae . years, and . % (n= ) toms, and autoimmune manifestation in comparison to igm/iga responders (respectively, pneumonia: %, % and %; chronic diarrhea: %, % and %; autoimmunity %, % and %; autoimmune cytopenias: %, % and %). malignancies were found more frequently in the non-responders and igm-only responders groups in comparison to igm/iga responders (respectively, %, % and %). eleven ( %) patients died during the study time. survival analysis according to the igm/iga responder status showed that the -years estimated survival for non-responders vs igm-only vs igm/iga responders was respectively after one year %, % and %; after two year: %, % and %; after three years: %, % and %%; after years: %, % and %; after years: %, % and %; after years: %, % and %. interesting, in our series only two deaths were due to infective complications: five were consequent to malignancies, one to autoimmune cytopenias and three to not-cvid related conditions. between-infusions intervals ( - days) than pid patients ( - days). finally, a small number of patients with anti-cd -related sid was able to discontinue scig replacement therapy after recovery of spontaneous igg production. conclusions: this is, to our knowledge, the biggest single center cohort of scig-treated patients ever described. results suggest that safety and effectiveness of scig is similar in pid and sid, irrespective of the mechanisms underlying igg depletion. moreover, in sid a lower igg dosage is required and ig replacement does not always need to be lifelong, with obvious pharmacoeconomic implications. a | should we screen children with bronchial asthma for primary immune deficiencies? miteva d ; perenovska p ; papochieva v ; georgieva b ; lazova s ; naumova e ; petrova g the patient became febrile and cultures were repeated, being positive to campylobacter jejuni, resistant only to ciprofloxacin (blood) and to campylobacter coli, susceptible only to gentamicin and amoxicillin/ clavulanic acid (stools). treatment was thus switched to amoxicillin/ clavulanic acid ( / mg / h). the patient became apiretic at day and improvement of local inflammatory signs was noticed, treatment was prolonged for six weeks. one week after cessation, skin lesion worsened again in the same location, in association with fever. blood and stool cultures were repeated and gentamicin ( mg/day; iv) and cefixime ( mg / h) were started, in agreement with previous cultures results. curiously, there was no history of diarrhea, but the patient referred a period of recurrent abdominal colicly pain, before cutaneous lesions appear. conclusion: bacteremia with campylobacter species requires specific laboratory workup. diagnosis of campylobacter jejuni bacteremia should be considered in hypogammaglobulinemic patients with recurrent fever, particularly when typical copper color erysipela-like skin lesions occur. campylobacter eradication can only be achieved with prolonged antibiotic therapy guided by antibiogram in cultures. conclusions: in this study, genetic defects of five higm patients have been identified, for other patients further genetic investigation such as next generation sequence (ngs) is required. the study results can help diagnose of the disease more definitively and also can provide valuable information for genetic counseling especially for those who have a history of immunodeficiency in their families and also for prenatal testing. conclusions: mutation analysis of unc d gene can help the families with hlh patients give genetics counseling for carrier detection and prenatal diagnosis. woelke s ; valesky e ; bakhtiar s ; bader p ; schubert r ; zielen s department for children and adolescents, division of allergology, pulmonology and cystic fibrosis, goethe university hospital, frankfurt, germany; department of dermatology, venereology and allergology, goethe university hospital, frankfurt, germany; department for children and adolescents, division for stem cell transplantation and immunology, goethe university hospital, frankfurt, germany introduction: ataxia telangiectasia (a-t) is a devastating multi-system disorder characterized by progressive cerebellar ataxia, growth retardation, immunodeficiency, chronic pulmonary disease and genetic instability with an increased risk for malignoma. as described in other primary immunodeficiencies cutaneous granulomas are a known phenomenon also in a-t. still treatment indication and strategies remain controversial. objectives: from our cohort of classical a-t patients, eight patients in the aged to years presented with granulomas. histopathology of the lesions confirmed the presence of granulomatous inflammation without detection of any microbiological agent in all patients. five patients suffered from cutaneous manifestation, in two patients we detected a bone and in one a joint involvement. both patients with bone involvement (patients and ) as well as one patient with massive skin manifestation (patient ) were treated with tnf inhibitors (infliximab). the patient with granulomas in his finger joint (patient ) was bone marrow transplant (bmt) for other reasons. year led to a total remission for three years now. in patients and treatment with tnf inhibitors led to a partial regression of granulomas. treatment interruptions caused deterioration again. in the course of treatment the effects of infliximab diminished most likely caused by drug antibodies. after changing treatment to subcutaneous adalimumab a further regression could be detected. in patient granulomas totally disappeared with immune reconstitution after successful bmt. partially successful in treatment of granulomas. due to the known immunodeficiency in a-t patients, indication for immunosuppressive therapies as tnfa inhibitors should be held strictly. woelke s ; hess u ; knop v ; krausskopf d ; kieslich m ; schubert r ; zielen s of to years regarding c-reactive protein (crp), liver enzymes, abdominal ultrasound and neurological status (ataxia score). we divided the patients into two age groups of a-t patients aged to years and a-t patients aged years to years. ataxia score (r= . ), although the underlying pathomechanism is unclear. ultrasound revealed nonalcoholic fatty liver disease in only one young patient ( . %) compared to older patients ( . %). one female patient aged years died due to a hcc. conclusions: liver disease is present in almost all older a-t patients. structural changes, nonalcoholic fatty liver disease and fibrosis are frequent findings. there is a considerable risk for hcc. prospective studies are necessary using noninvasive techniques for the assessment of liver fibrosis (eg transient elastography) and to establish the risk of hcc in a-t patients. objectives: in this study, it was aimed to determine the frequency of pollen-food syndrome in children who have sensitization to pollens. results: pollen-sensitized patients were included in this study. the mean age of the patients was . ae . years, while . % (n= ) were male. in . % (n= ) of the patients, allergic rhinitis was concomitant with asthma. . % (n= ) of the patients described symptoms related to pfs. % ( / ) of them had a history of anaphylaxis with suspected food. the mean age of the patients describing pfs was . ae . years and % (n= ) of them were female. in ( . %) of these patients, skin tests performed with suspected food was positive, but in one patient the skin test was negative while specific ige was positive. suspected food was fruit/ vegetables in patients. in patients with pollen allergy, oropharyngeal symptoms related to fresh fruit, vegetables, dried fruits and nuts should be enquired. it should be noted that these patients might experience serious systemic reactions including anaphylaxis. patel nb ; vazquez-ortiz m ; lindsley s ; abrantes g ; bartra j ; dunn galvin a ; turner pj conclusions: there is no evidence that the occurrence of anaphylaxis at fc, and self-treatment with an adrenaline auto-injector device, result in adverse impact on hrql measures. the impact of a reaction at food challenge appears to confer greater benefit on the parent than the child. the relationship between confidence in management and hrql needs further assessment, since it is likely that these outcomes will be affected in different ways following therapeutic interventions. results: fifty-one patients ( females, males) (median age: . years, range - ) with cma were studied. spt to cm was . ae . mm as mean diameter. forty-eight out of fifty-one ( . %) patients underwent dm-opt ( patients refused to underwent opt due to positive spt or s-ige to dm introduction: bovine milk is the most common food allergen in children under years of age. milk allergy is treated by eliminating milk from the diet. the milk elimination diet endangers the child's energy intake and also exposes the child to shortage of multiple nutrients. this study was needed because there are no previous systematic reviews about this subject. objectives: the aim of the present study was to examine if the milk allergy or the other factors associated with milk elimination diet have an influence on child's growth. the present study was conducted according to international guidelines for systematic reviews. results: a total of studies were initially identified, of which three fulfilled our criteria. these three studies included children with cow's milk allergy and control children. in all these three studies, children with cow's milk allergy were lighter than controls. in addition, in two studies, the growth of the children with cow's milk allergy was stunted. in two studies the milk elimination was substituted with special infant formula. also in one study where both the growth and the weight were stunted, no major differences in energy or nutrient intake between cow's milk allergic cases and controls were reported. conclusions: current evidence suggests that milk allergy is associated with stunted growth in childhood, but reasons for this are unclear. in order to clarify the effect of cow's milk elimination diet on growth in childhood and the underpinning mechanisms, more studies need to be conducted. in addition, special attention to the diet and growth of children with cow's milk allergy is needed. results: a total of children were surveyed in this -year period (annual average: ). in , children ( . %) were diagnosed with food allergy, including cases of pfas, cases of egg allergy, and cases of dairy-product allergy. in , children ( . %) were diagnosed with food allergy, including cases of pfas, cases of egg allergy, and cases of dairy-product allergy. over this -year period, the prevalence of pfas increased . fold (from . % to . %). among the pfas cases, the prevalence of rosacea and apple allergy increased . -and . -fold, respectively. the most prevalent was apple allergy ( . %), followed by peach ( . %), loquat ( . %), plum ( . %), pear ( . %), and strawberry ( . %). the prevalence increased significantly for pfas but not for other types of food allergy (egg and dairy-product allergy). in the future, nationwide studies are needed to further elucidate the relationship between pfas and allergic rhinitis. | immune profile after oit in children with cow s milk allergy patients with elimination diet, group : patients with natural tolerance, group : healthy control). in all groups specified laboratory tests were performed at onset and also at month to treatment groups. in desensitization group at month of treatment we evaluated increase in total ige level, sp iga and igg antibody responses, decrease in cow's milk spige levels and an increase in il- , il- , tgf-b cytokine responses without a difference in cd +cd +fox-p % levels. il- levels were similar with pre-treatment levels whereas foxp mrna expression was similar with tolerance group. in elimination group at month treatment, there was a decrease in cow's milk spige whereas there was no change in sp iga levels and a minimal increase in igg levels. there was no change in il- and il- cytokine levels. and an increase in tgf-b cytokine response less than group , decreased il response, a foxp mrna expression differed from tolerance group was identified. objectives: although hyperuricemia has a significant prevalence in the general population, and has been related to exercise-induced asthma, could be related to bronchial asthma and nasal polyposis. hitherto, its possible association with hypersensitivity to nsaids and its convenience as biomarker have not been acquainted. conclusions: in our population, hyperuricemia has not demonstrated to be a reliable biomarker related to nsaids allergy and could not be used as a risk factor for assessing the triad nsaids allergy, asthma and nasal polyps. to study the vas of the total score was seen significant variance in: nsaid-cu ( . pt) and nsaid-pa ( . pt) (p=. ), nsaid-cu conclusions: data support that cutaneous manifestations have a common response with aerd to cox inhibitors. conclusions: this study showed that in a positive drug oral provocation test, respiratory symptoms were accompanied with nitric oxide changes in both nasal and exhaled way. barrionuevo e ; doña i ; salas m ; bogas g ; guerrero ma ; sanchez mi ; cornejo-garcia ja ; torres mj allergy unit, regional university hospital of malaga-ibima, malaga, spain; research laboratory, ibima-regional university hospital of malaga-uma, malaga, spain introduction: non-steroidal anti-inflammatory drugs (nsaids) are the most frequent triggers of drug hypersensitivity reactions, being cross-hypersensitivity reactions (chr) the most frequent. the categories included in chr are nsaids-exacerbated respiratory disease (nerd); nsaids-exacerbated cutaneous disease (necd) and nsaids induced urticaria/angioedema (niua). however, it has been reported patients with chr to nsaids who developed a combination of skin and respiratory symptomatology (blended reactions). objectives: our aim was to analyse the characteristics of patients with blended reactions and compare with those developing symptoms exclusively respiratory (nerd) or cutaneous (niua). episodes of cutaneous and/or respiratory symptoms after the intake abstracts | of ≥ different nsaids included strong cox- inhibitor (acetylsalicylic acid (asa) and/or indomethacin); ii) if they had < episodes of cutaneous and/or respiratory symptoms induced by < different nsaids, a positive drug provocation test (dpt) with asa was required; iii) if patients had respiratory symptoms accompanied or not by cutaneous involvement, a positive nasal provocation test with lysine aspirin (npt-lasa) was required. atopy was assessed by skin prick test using a panel of inhalant and food allergens. objectives: subjects with nsaids hypersensitivity were divided into two groups: a) those from to years and b) those from - years. diagnosis was established by a clinical history and controlled challenge with asa. atopic status was verified with a detailed allergological study including skin testing to inhalant allergens. clinical entities were classified in three categories: urticaria/angioedema, anaphylaxis and respiratory (asthma and/or rhinitis). cases. no differences were observed in the atopic status between both groups. there were significant differences between males/ females (p<. ). when we compared the clinical entities there were more cutaneous manifestations, mainly angioedema, in the group a) and more anaphylaxis in group b) although there were no significant differences due to sample size. conclusions: significant sex differences between hypersensitivity reactions to nsaid occurs with predominance of males in the first group (a). although there are also a predominance of clinical entities, an increase number of cases is needed to establish significance. studies on this direction are in progress. show an increase in all age groups. etiologic analysis was limited as the study was carried out using the icd- code (nhic records) and database of self reporting systems (kaers). so, further study was needed. introduction: genetic variants from the q locus are the strongest known genetic determinant for early-onset childhood asthma, and have also been associated with uncontrolled asthma despite asthma treatment. objectives: the aim of the study was to assess whether there is an association between a single nucleotide polymorphism (snp) in the q locus (rs ) and asthma exacerbations despite the objectives: our hypothesis is that the arg allele is associated with increased use of prescribed asthma medication, over a -year period. to explore this hypothesis, we have undertaken a secondary analysis of breathe, a study of gene-environment associations with asthma severity. breathe data were collected on participants with asthma, aged - years, between and , in tayside conclusions: in children and adults, the homozygous arg/arg status is associated with long-term increased prescribing for asthma medication compared to those carrying at least one gly allele. defining subgroups of individuals requiring more medicines could help predict treatment costs and develop targeted management strategies. objectives: considering the role of ptgdr in allergy, the goal of this study was to analyze the effect of ptgdr expression on cytokine levels in the a cell line. analyze ptgdr expression in a cell cultures. cytokine production assays in the culture supernatant were measured by cytometric bead assay using the bioplexpro tm human cytokine standard -plex, group i. the assays were conducted with bioplex high-throughput fluidics system, powered by the luminex technology. every sample was run at least in triplicate. the ptgdr expression in the transfected cells with the haplotypic variants differed by orders of magnitude relative to control cells (p<. ). we found significant differences in ptgdr expression between ctct and cccc haplotypic variants. the cccc (À c, À c, À c, and À c) introduction: c t polymorphism in the cd gene has been suggested in susceptibility to asthma. cd is a multifunctional receptor endotoxin, which is expressed on the surface of macrophages, monocytes and neutrophils. it is likely to play a role in the inflammation pathway. though data is available regarding association of cd gene with asthma but independent studies are in conflict. objectives: the present study was conducted to examine the association of promoter c t single nucleotide polymorphism (snp) in the cd gene for indian children with atopic asthma. we characterize the c t polymorphism in children with asthma ( ), cohort group ( ) and healthy control group ( ) by pcr rflp. association analysis was performed using v tests. we also analyzed the association of cd (c t) with total ige levels by elisa and foxp expression using flow cytometry. in this snp a base pair (bp) pcr product was generated using the standard primers. after restriction products showed that homozygous c allele was appeared as a single bp band, the homozygous t allele as bands of bp and bp, and heterozygous exhibits all three bands ( , and bp). the or of cc genotype frequency abstracts | was . in study group and . in cohort group and the or of c allele frequency was . in study group and . in cohort group. total ige level were found to be significantly higher in cc genotype compared to ct and tt genotype. foxp level is significantly higher in control group in all genotypes compared to cohort and study group. conclusions: the present study concludes that in cd gene polymorphism cc genotype was not significantly associated with asthma but other factors ie total ige and foxp showed significant association of cc genotype with asthma. on the other hand, there was significant association of c allele with asthma. | the disbalance of tlr , tlr gene expression and cytokines production in children with bronchial asthma svitich oa ; gankovskaya lv ; namazova-baranova ls ; bragvadze bg ; alekseeva aa ; gankovskii va objectives: examined were patients with bronchial asthma aged from to years and healthy children of the same age. cytokines were determined by elisa. determination of mrna expression in scrapings from the mucous membranes of the respiratory tract and in peripheral leukocytes was carried out polymerase chain reaction in real time. results: in scrapings from the mucous in patients with moderate to severe asthma found a significant increase in the gene expression of tlr , times, the gene tlr in times in comparison with the control group. in children with severe asthma also found a significant increase in the gene expression of tlr . times compared to healthy children, p≤. ). indicators of tlr gene expression in this group of patients have a tendency to increase, but not statistically significant. when comparing the indicators of innate immunity in samples with a leukocyte mass in the group of children with severe asthma showed a decreasing expression of tlr compared with the index in healthy children. also decreased the expression of tlr . in children with moderate ba similarly, a significant decrease of tlr gene expression in times. the trend towards reduced expression of tlr remains in this group, but is not reliable. in washings from the nasopharynx shows that patients with bronchial asthma il- is increased . times compared to the norm, to pcg/ml, tnf increased in times and pcg/mg in severe asthma, and . pkg/ mg-for mild, il- increased in times ( pcg/mg), pkg of . / mild blood, il- also increased . -fold and equal to . pkg/mgwith heavier with easy- . pkg/mg, normal À pkg/mg. ie is an increase in proinflammatory and anti-inflammatory cytokines. conclusions: the overexpression of tlr , tlr accompanied by increasing, the production of cytokines. this is a violation of mechanisms of innate immunity at the level of the mucous membrane of the nasal cavity on the role of inflammation in the pathogenesis of tlr. | sustained reduction in risk of experiencing asthma symptoms and using asthma medication in years following grass slittablet treatment-results from the paediatric gap trial were: wheezing, cough (for more than consecutive days), shortness of breath, chest tightness. the odds ratio for having asthma symptoms, using asthma medication, or having asthma symptoms and using asthma medication was significantly lower in the grass slit-tablet group during the followup years. for asthma symptoms, the results were: or= . , p=. days with csms< were defined as "no or minimal symptoms" and days with csms > were defined as severe symptoms. csms score was significant lower in the ilit group than in the placebo group for , and . in mean csms was . roth-walter f ; schmutz r ; mothes-luksch n ; zieglmayreer p ; zieglmayer r ; jensen-jarolim e objectives: here, we investigated whether the immune molecule lipocalin (lcn ) may discriminate between allergic and sensitized individuals, and between responding and non-responding patients. results: lcn -concentrations were assessed in sera of healthy and allergic subjects (n= ) as well as of house dust mite (hdm) allergies that underwent hdm-sublingual immunotherapy (slit) in a randomized, double-blind, placebo controlled trial for weeks. sera pre -, post-slit and at least months after slit were assessed for lcn and correlated with total nasal symptom score (tnss) obtained during chamber challenge at week in patients receiving hdm-(n= ) or placebo-slit (n= ). allergic individuals had significant lower lcn -levels than healthy controls, with women having lower lcn -levels than men in the patient cohort. hdm-allergic patients who received hdm-slit had a significant increase in hlcn months after termination of hdm-slit, whereas in subjects receiving placebo no increase in hlcn was observed. within the hdm-slit treated group, lcn -levels were significantly higher in patients whose symptoms improved during slit in contrast to those in which symptoms became more severe. hence, time-course of lcn in an allergic individual was predictive to assess clinical reactivity to hdm. objectives: here, we present the benefits of treatment in terms of nnt to prevent one additional child from having asthma symptoms and asthma medication use. children treated with grass slit-tablet had a reduced risk of asthma symptoms and asthma medication use during the -year follow-up period compared with placebo (or= . [ . , . ] for sq grass slit-tablet (n= ) vs placebo (n= ), p<. , relative risk reduc-tion= %). the risk reduction was independent of age at treatmentstart. younger children had a higher predicted probability of developing asthma symptoms and asthma medication use than older children. thus, the younger the children were at treatment-start, the greater the percentage was prevented from having asthma symptoms and asthma medication use during follow-up off treatment. for children aged at treatment-start, the risk was reduced from % to % and for those aged it was reduced from % to %. consequently, the nnt to prevent one additional child from having asthma symptoms and asthma medication use during the -year follow-up increased with age, with nnt= for children aged and nnt= for children aged . conclusions: the grass slit-tablet reduced the risk of asthma symptoms and asthma medication use during the -year follow-up period; the risk reduction was independent of age. however, the nnt increased with age as younger children had a higher risk of developing asthma symptoms and asthma medication use, emphasising the importance of treatment-start early in life. results: participants were screened for birch and grass allergy, of whom ultimately met randomization criteria and were treated with either slit-t or placebo for months. treatment was preceded by a successful baseline birch pollen challenge in the eeu where a minimum tnss of was achieved in the first of hours of pollen exposure. participants attended the post treatment challenge in the eeu, also hours in duration. no significant differences were noted in the reduction of birch-induced tnss compared to baseline between the slit-t and the placebo treated participants (the primary outcome measure). adverse events with a minimum % frequency occurred in % of participants in the placebo arm and % of participants in the active arm, with upper respiratory tract infection ( % in active arm and % in placebo arm) being the most common. oropharyngeal itch was the most common adverse event with causality at least possibly related to study medication ( % in active arm and % in placebo). no serious adverse events occurred including no anaphylaxis. objectives: here, we present a pooled subgroup analysis in adolescents from phase ii/iii-iii trials with the hdm slit-tablet ( sq-hdm dose), p in north america and to- - - in japan. results: to- - - was a randomised, dbpc phase ii/iii trial investigating the efficacy and safety of the hdm slit-tablet in japanese adolescents and adults ( to years) with moderate-tosevere hdm ar (n= , of which were adolescents). subjects were randomised to treatment with the hdm slit-tablet in doses of sq-hdm, sq-hdm or placebo for year. p was a randomised dbpc phase iii trial investigating the efficacy and safety of the hdm slit-tablet in north american adolescents and adults (≥ years) with moderate-severe hdm ar with or without asthma (n= , of which were adolescents). subjects were randomised to treatment with sq-hdm or placebo for up to year. in both trials, the primary endpoint was the average total combined rhinitis score (tcrs) during the last weeks of treatment. the pooled analysis was performed on mean values using a linear mixedeffects model. treatment with sq-hdm of the hdm slit-tablet resulted in a statistically significant reduction in the average tcrs of . ( %, p=. ) compared to placebo in the last weeks of treatment. statistically significant differences were seen for both components of the tcrs, the rhinitis medication score (difference= . , p=. ) and rhinitis symptom score (difference= . , p=. ). furthermore, treatment with sq-hdm resulted in a statistically significant reduction of the conjunctivitis symptom score compared to placebo (differ-ence= . , p=. ). treatment was well tolerated. the most frequent adverse events were mild-to-moderate local allergic reactions. the pooled subgroup analysis showed that the hdm slit-tablet ( sq-hdm) was effective in treating hdm allergic rhinitis in adolescents ( - years old). the reduction in the primary endpoint tcrs was statistically significant and comparable to what has been observed in adults. results: at the time of the data-cut for this analysis, a total of european patients were screened ( % male). % of the subjects were aged - , % were aged - , and % were adults. the mean age of the sample was . [sd . ] years, with a minimum of and a maximum of years. in europe were children. many were allergic to foods other than peanut, and most had at least one other atopic condition. even if allergic to multiple foods, patients and their families were nonetheless keen to participate in the trial. the majority of the screened patients were highly sensitive to peanut, reacting to mg (cumulative) or less of peanut protein but a significant proportion of screening failures were due to lack of reactivity to this dose. | efficacy of ir -grass pollen sublingual tablet: improvement in subjects with grass pollen-induced allergic rhinoconjunctivitis based on well days and severe days evaluation objectives: four phase ii/iii dbpc studies, in adults and one in children/adolescents, were conducted worldwide. participants were abstracts | randomised to receive the ir tablet or placebo starting months ( m) prior to the pollen season and continuing for its duration. data from the first season of the trials in adults were pooled. the well days were defined as those with not more than one moderate symptom or mild symptoms of the evaluated symptoms (sneezing, rhinorrhoea, nasal pruritus, nasal congestion, ocular pruritus, watery eyes) and no use of rescue medication. the severe days were defined as either at least one moderate symptom in subjects using rescue medication, or at least moderate symptoms or one severe symptom whether rescue medication was taken or not. for each subject, the proportions of well days and those of severe days were evaluated during the pollen period while on treatment. treatment groups were compared using a wilcoxon -sample test. introduction: the safety of subcutaneous immunotherapy (scit) has been proven in several studies, but the occurrence of side effects (se) remains a concern in daily clinical practice and understanding of their risk factors and avoidance strategies remains limited. objectives: the aim of presented study was to assess the incidence and risk factors of early and late side effects in patients undergoing scit. we conducted a year-long observation of over patients undergoing scit in our outpatient clinic. we recorded detailed information for each administration and screened subjects for both immediate and late reactions. we compiled the records with medical histories to build a database, which was analyzed using multiple logistic regression. casein is a major cow s milk allergen and very resistant to high temperatures. higher levels of ige towards caseins have been reported to associate with persistent cow s milk allergy and higher risk of adverse reactions before and during the milk oit. a follow-up study on oit to milk started in with a six-month built-up phase. seventy-six children (mean age . years) with challenge-verified cma participated the milk oit and their immunological changes were analyzed employing crd. during the year , long-term follow-up report was collected by questionnaires ( %, n= ) and blood samples ( %, n= ). specific antibody responses were characterized before oit and on long term follow up and compared to long-term questionnaire results: milk consumption (yes/no) and side-effects from milk from past months (yes/no). objectives: to define the utility of crd in long-term follow-up after milk oit. results: mean follow-up time was ( - ) years. ten patients ( %) avoided milk completely and patients ( %) reported routine consumption of dairy products. side effects after milk consumption from last months were reported by % of the patients. increased specific ige levels towards caseins were seen among patients who did not consume milk at the long-term (p=. *). there was no significant association between the long-term milk consumption and ige levels to whole milk (p=. ), caseins (p=. ), alpha-lactalbumin (p=. ) and beta-lactoglobulin (p=. ) measured before the oit in this small sample. patients who consumed milk at the longterm follow-up and reported side effects had higher specific ige levels towards caseins before oit (p=. *). conclusions: there was a high incidence of side effects even after eight years of milk consumption, which may indicate desensitization instead of true tolerance. component-resolved diagnostics may corroborate in predicting prognosis, as suggested by higher incidence of side effects among patients with high levels of ige towards caseins also in the long-term follow-up. objectives: retrospective study of patients who underwent subcutaneous ait for allergic rhinitis ( % had concomitant asthma). patients with less than months of treatment were excluded. large local reactions (wheal≥ mm) and systemic reactions were defined according to who grading system. patient's satisfaction was defined by vas score. results: the mean age of patients ( % males) was ae (range - ) years ( %< years).the most prevalent immunizing allergens were house dust mite ( %), olive ( %) mix of grasses ( %) and pets ( %). % of patients were immunized against a single allergen whereas % were immunized with≥ allergens. patients were followed for ae months. following ait the vas score decreased from . ae . to . ae . (p<. ). % of the patients declared that they will recommend immunotherapy to their relatives. systemic adverse reactions ( % class i, % class ii) were observed in introduction: metabolomics, one of the core disciplines of system biology, is a high-dimensional biology method that may allow hypothesis-free profiling of biomarkers, rather than a traditional hypothesis-driven approach. objectives: this study aimed to apply the metabolomic approach to serum to longitudinal alterations during allergy immunotherapy (ait) in dermatophagoides pteronyssinus (der p) sensitized asthmatic children. results: a robust hydroxyeicosatetraenoic acids (hetes) of inflammatory responses was found for discriminating during ait, including -hete, -hete and -hete. -hete and -hete were significantly decreased continuously from through months of ait. moreover, compared with baseline of ait -hete was detected in very low level during and months. the metabolomic profiling could clearly longitudinal alterations biochemical-metabolic profiles in der p-sensitized children during ait. these markers might be involved in asthma pathophysiology but also represent the therapeutic target for ait. background: metabolomics, one of the core disciplines of system biology, is a high-dimensional biology method that may allow hypothesis-free profiling of biomarkers, rather than a traditional hypothesis-driven approach. this study aimed to apply the metabolomic approach to serum to longitudinal alterations during allergy immunotherapy (ait) in dermatophagoides pteronyssinus (der p) sensitized asthmatic children. methods: in this longitudinal study, we recruited der p-sensitized asthmatic children with ait for months. serum samples were analyzed using a metabolomic approach based on mass spectrometry. results: a robust hydroxyeicosatetraenoic acids (hetes) of inflammatory responses was found for discriminating during ait, including -hete, -hete and -hete. -hete and -hete were significantly decreased continuously from through months of ait. moreover, compared with baseline of ait -hete was detected in very low level during and months. the metabolomic profiling could clearly longitudinal alterations biochemical-metabolic profiles in der p-sensitized children during ait. these markers might be involved in asthma pathophysiology but also represent the therapeutic target for ait. we performed desensitization with asa according to the wong protocol (doses of . , . , , , , , , , , mg of asa at intervals of - min). we pre-medicate with cetirizine mg. our patient successfully reached the necessary dose: mg of asa ( . , . , , , , , , and mg) conclusions: approximately % of patients with asthma undergo respiratory symptoms due to exposure to aspirin, meanwhile . % and . % of the population shall undergo hives when exposed to it. desensitization with aspirin is an efficient and safe treatment in patients with hypersensitivity type i, iii and iv. due to the benefits and low toxicity of the wong protocol, we recommend this protocol in order to desensitize patients with allergy to aspirin who undergo rheumatologic or cardiovascular disorders and need antiplatelet treatment. we finally recommend our patients to take mg of asa premedicated with mg of cetirizine every day. we warn that if you interrupt the administration of asa for more than hours, it shall have to be administered again under medical supervision. semedo fm ; cruz c ; reis r ; tomaz e ; in acio f horiuchi t ; takazawa t ; saito s department of anesthesiology, gunma university hospital, maebashi, japan; intensive care unit, gunma university hospital, maebashi, japan introduction: sugammadex is a synthetic c-dextrin derivative that is designed to selectively bind to steroidal neuromuscular blocking agent molecules. although sugammadex has been used in many cases of general anesthesia, there are several reports of anaphylaxis following its use. skin testing is the gold standard for detecting the causative agent of anaphylaxis. however, the test itself sometimes precipitates serious complications, including recurrence of anaphylaxis. hence, development of a novel test that can be performed in vitro without causing such complications is desired. recently, the basophil activation test (bat) has been established as a tool to detect the causative agent of anaphylaxis with high sensitivity and specificity. yet, there are few studies examining the utility of the bat in diagnosing sugammadex-induced anaphylaxis, besides our previous report. although both cd and cd c are currently used as the major markers for activated basophils, which one of them is more suitable for the bat depends on the targeted drugs. objectives: the aim of this study was to investigate whether bat could be utilized to diagnose sugammadex-induced anaphylaxis. in addition, we compared the capability of cd c and cd as markers for activated basophils. seven patients with perioperative anaphylaxis demonstrating a positive skin test for sugammadex were included. furthermore, individuals who tolerated sugammadex and had a negative skin test for allergy to this drug were enrolled as controls. results: the ratios of activated basophils in the patients were much higher than those in controls (mann-whitney u test, p<. ). cd c up-regulation. this was also true for cd . in the case of cd c, the sensitivity of bat for sugammadex was % and specificity was %, while sensitivity and specificity for cd were % and %, respectively. there were no significant differences between cd c and cd in the areas under the roc curve. conclusions: this study showed that bat is a reliable instrument to diagnose sugammadex-induced anaphylaxis. we did not find any difference between cd c and cd as markers for activated basophils in the bat for sugammadex. objectives: we report a retrospective study of patients who were referred to our allergology departments between and with a suggestive history of immediate hypersensitivity to ppis. our purpose was the analysis of the clinical presentations and the allergological investigation performed in order to confirm the diagnosis of drug hypersensitivity to ppis and to study the cross-reactivity among ppis. results: the culprit drugs were pantoprazole (n= ), omeprazole (n= ) and lansoprazole (n= ). the allergological investigation confirmed the diagnosis of hypersensitivity to ppis in patients ( by skin tests and oral challenge). we observed cross-reactions between omeprazole, pantoprazole and esomeprazole (n= ), omeprazole and pantoprazole (n= ), respectively omeprazole and esomeprazole (n= ). in patients the severity and the recurrence of the reaction did not allowed the provocation test with the culprit drug. two oral challenges allowed the use of an alternative ppi (based on the pattern of less cross-reactivity depending on the chemical structure: pantoprazole for a patient who had a grade iii anaphylaxis to lansoprazole and lansoprazole for a patient who had a grade ii anaphylaxis to pantoprazole). conclusions: a complete allergological investigation (skin tests and cautiously, oral challenge) is needed in order to confirm the diagnosis of drug hypersensitivity to ppis and to take a therapeutic decision. the diagnostic approach is limited by the low sensitivity of skin tests and the patient's background (comorbidities and severity of the reaction) which do not always allow the oral provocation test. an ige dependent mechanism may be involved in hypersensitivity reactions to ppis or their metabolites. herrero-lifona l ; muñoz-rom an c hospital quironsalud campo de gibraltar, los barrios, spain; hospital regional universitario de m alaga, m alaga, spain introduction: hypersensitivity reactions to beta-lactams are an important problem to study, especially in children, given that these antibiotics are the gold standard for the treatment of many infectious diseases in the infancy. most hypersensitivity reactions to betalactams in children are due to non-immediate response and to diagnose them is essential to perform a drug challenge test. although hypersensitivity is usually ruled out in children by drug challenge test, it is positive test up to %- %. objectives: a year-old boy is suspected to have experienced two drug reactions after the intake of amoxicillin with and without clavulanic acid for pharyngitis treatment. in the first one, he presented a maculopapular eruption in the back after one day treatment with amoxicillin-clavulanic acid. in the second reaction, two hours after the intake of amoxicillin, it appeared an itching maculopapular eruption in the back that was resolved with symptomatic treatment. in both cases, the patient tolerated treatment with cefuroxime afterwards. results: intradermal test with amoxicillin was negative in immediate and delayed reading. oral drug challenge test with amoxicillin ( mg/kg/day, total cumu- oral drug challenge test with penicillin v (total cumulative dose mg): it was well tolerated and the patient continued taking it for epicutaneous patch testing with amoxicillin in the lesion area and in an unaffected area: in the lesion area, it appeared mild erythema, but it was considered a negative result in both areas. conclusions: we report a case of an amoxicillin-induced multiple fixed exanthema: an unusual non-immediate reaction in childhood. most cases of non-immediate hypersensibility need to be confirmed by drug challenge test, given that skin testing lacks sensitivity both intradermal and patch tests. the patient presents a selective hypersensitivity to amoxicillin, being tolerant to penicillin and cephalosporins. jimenez-rodriguez t ; soriano-gomis v ; gonzalez-delgado p ; cueva-oliver b ; venegas-diaz ij ; fernandez j results: data from patients were analyzed, of which . % ( ) were women. the overall mean age was . ae . years, with no statistical difference between sexes. the . % ( ) of the patients presented symptoms with a single group of nsaids, and . % ( ) with or more different groups. the % ( ) of patients presented a history of atopy. in patients with rhinitis % had symptoms with only one nsaid and % with two or more groups of nsaid, while patients with asthma, % reacted to one nsaid and % to two or more groups. the most frequent clinical manifestations were: urticaria/angioedema in % ( ), pruritus in . % ( ), bronchospasm in . % ( ), other respiratory symptoms in % ( ) and anaphylaxis in % ( ) patients. the most frequently involved nsaids were: metamizole ( . %) and ibuprofen ( . %). skin tests were performed in only patients, of whom ( %) were positive to metamizol. dpt was performed in . % ( ) objectives: fifty patients diagnosed with "dress" ( - ), in a tertiary center were retrospectively analyzed, with cases meeting the regiscar criteria. we collected demographic, clinical, laboratory and therapeutic data from the electronic medical records. results: all cases occurred during hospitalization and in several hospital areas. the mean age was . years ( - ) with . % women and % of caucasian origin. reported clinical manifestations were skin rash ( %), fever ( . %), digestive symptoms ( . %), respiratory ( . %), neurological ( . %), head and neck ( . %), urological ( . %), ophthalmologic ( . %) and musculoskeletal ( . %). the most relevant laboratory findings were eosinophilia ( %), elevated transaminase levels ( %), lymphocytosis ( %), altered coagulation ( %) and altered renal function ( %). virus serology was positive in cases ( . %) involving hhv- , ebv, cmv and hiv. antinuclear antibodies were positive in / cases ( . %). skin biopsy, performed in cases ( . %) revealed findings suggestive of drug induced skin reaction. suspected culprit drugs were antibiotics ( %), nsaids ( %), antiepileptic drugs ( %), and antiparasitic agents ( %). one case was related to the administration of heparins and other to a monoclonal antibody. in % of cases, the episode was not related to a particular drug. treatment was accomplished by the administration of corticosteroids ( %), antihistamines ( %), and immunosuppressant drugs in cases. fluids and other medications were administered attending to symptoms. death occurred in patients, although only in case it was related to dress syndrome. the average time from reaction to death was . months. allergy evaluation, performed in cases addressed the potential role of drugs. skin tests were positive in / patients ( . %) and basophil activation test was negative ( / cases). results: from patients admitted with possible diagnosis of scar, only met the inclusion criteria ( f/ m, age - , average . years-old). they were all admitted to a medicine ward. five patients had diagnosis criteria of dress, of sjs and of ten. as for the drugs related with the reaction, antiepileptic drugs were the most frequent ( patients); allopurinol ( ), betahistine ( ), ciprofloxacin+nimesulide ( ) were the causative drugs in the remaining patients. average time to the beginning of symptoms was . days ( patients unknown). in patient the cause was unknown (he had criteria of ten and also diagnosis of malaria and was transferred to another hospital). there were no deaths. objectives: the objectives of the present study were to determine the efficacy of nfeno to: . establish the diagnosis of rhinitis; and . discriminate allergic rhinitis (ar) from non-allergic rhinitis (nar). material and methods: prospective and controlled study with healthy subjects, which included patients with rhinitis. ar and nar were phenotypically defined according to positive or negative prick test results, respectively; the control group was collected from people without upper or lower respiratory tract disease and the prick test was negative. in all sample included the following measurements were performed: feno and nfeno (novario analyzer) were performed; spirometry; eosinophil counts in blood and nose (by nasal brushing); bilateral nasal endoscopy; and acoustic rhinometry. results: we included cases (ar= , nar= and controls= ), with a mean age of (sd . ) years, % men. the table below shows the results of the variables analyzed by group. patients with rhinitis compared to controls had significantly greater feno production, as well as a higher proportion of eosinophils in blood and nose, but not in nfeno production. however, when the two subgroups of rhinitis were compared, ar patients had significantly higher feno and nfeno than nar, in addition to blood and nose eosinophils. there were no differences in acoustic rhinometry values between groups. conclusions: although nfeno does not appear to identify patients with rhinitis, it may be useful in discriminating ar from nar. in routine clinical practice, it could help guide to identify an ar in cases with inconclusive results of the complementary tests commonly used in its diagnosis. introduction: fractionated exhaled nitric oxide (feno) is used as a marker of eosinophilic airway inflammation in asthma, whereas clinical presentation of nasal no (nno) is unknown. objectives: the objective of this study was to evaluate the factors influencing nno levels. in patients with chronic nasal symptoms, total-nasal-symptom-scores (tnss) were calculated; skin-prick-test conclusions: in conclusion nasal no is useful in allergic inflammation in the absence of sinus obstruction in nasal cavity. however, its value is limited with paranasal sinus ostium occlusion. were recruited across australia and the uk via a patient panel. the aim was to assess which ar treatment attribute(s) drove patient preference. results: table shows the willingness to pay (wtp) for each attribute. all attributes were significant predictors of treatment choice, except administration method. however, patients in both countries showed a considerable preference for treatments that were more efficacious, fast acting and affordable. conclusions: although treatment relief remains of primary concern, time to treatment benefit and cost could dictate treatment preference. these data may be of value in optimizing the acceptability of future ar treatments and informing trial endpoint selection. australia ( izquierdo l; chiriac am; molinari n; demoly p introduction: allergic rhinitis is a frequent disease with an important impact on quality of life. self-administrated control assessment tests can help achieve a better management of this disease. however, none of these tools has been validated in teenagers. test in its original version, following the same protocol as the original study in adults. we designed a multicentre, observational, cross- conclusions: while the number of included patients is low, the first results are promising. indeed, a significant improvement of the rhinitis control score was found between d and d . this led us to the hypothesis that this questionnaire could be used as is to estimate the control of the allergic rhinitis in teenagers. analyses concerning the validation of the questionnaire itself do not reach at the moment the threshold of significance, the recruitment is on-going, to increase its power. objectives: the objective of this study was to evaluate the role of serum vitamin d in patients with symptomatic allergic rhinitis and active asthma during the allergy season and observe the effect of montelukast mg daily as treatment. results: this study included asthmatic and seasonal allergic rhinitis patients following a single-blind, placebo run-in period of - days, patients were randomized to oral montelukast mg (n= ) or placebo (n= ) daily during the -week, double-blind, active-treatment period. the serum vitamin d was also evaluated in both the groups. the serum vitamin d levels were found to be higher in patients taking montelukast compared to placebo after weeks (p<. ). montelukast reduced the daily rhinitis symptoms score: difference between montelukast and placebo (p<. ). similar improvements were seen in daytime nasal symptoms (p<. ) and nighttime symptoms (p<. ). conclusions: montelukast provides significant relief from symptoms of seasonal allergic rhinitis, while also conferring a benefit for asthma, in patients with both allergic rhinitis and asthma. further, it has a beneficial role in improving vitamin d levels. venegas-diaz ij ; jimenez-rodriguez t ; canto-reig vj ; lindo-gutarra m ; soriano-gomis v ; gonzalez-delgado p ; cueva-oliver b ; fernández j allergy section. general hospital alicante. isabial, alicante, spain; allergy section. general hospital alicante. isabial-umh, alicante, spain introduction: local allergic rhinitis is an accepted entity, which only can be recognized by nasal provocation test (npt) in patients with clinical rhinitis with negative skin tests or specific ige (sige). our aim was study this entity in our patients in alicante, spain. objectives: patients with symptoms of rhinitis with skin tests, and sige negative for common aeroallergens were selected, since . half of them ( ) most were young adults, % belonging to the range of age between - years; more than % had family history of atopy; the mean age of onset of symptoms was years and up to . % had had symptoms before the age of years; . % were nonsmokers. regarding comorbidity, . % of the patients presented with concomitant symptoms of conjunctivitis and . % of asthma. symptoms in . % of the patients were persistent and most of moderate ( %) to severe ( . %) intensity. the majority of patients ( . %) presented perennial symptoms and a tpn positive to mites in . %, to salsola pollen in % and to cypress pollen in . %. but patients ( . %) were simultaneously positive to allergens. conclusions: local allergic rhinitis represents an important proportion of patients with clinical rhinitis with negative skin tests and sige. we have to pay attention to identify clinical and demographic factors of ral and to use npt to demonstrate it. objectives: we report the extent of sinus involvement at baseline (bl) in pts with bilateral np refractory to intranasal corticosteroids from a dupilumab phase a study (nct ). ct scans from enrolled pts, adults < years with nasal polyp score of ≥ / , were pooled and analyzed at bl. for opacification, standard lund-mackay (lmk) scoring ( =normal, =partial opacification, =total opacification) in maxillary, anterior/posterior ethmoid, sphenoid, frontal sinuses was used. ten sinus scores plus bilateral ostiomeatal complex (omc) score ( =not occluded, =occluded) were summed to a bilateral total lmk ( - ). zinreich modified lmk score (zlmk), providing more granularity on opacification degree, was evaluated post-hoc; each sinus was given a - score based on opacification % from mucosal thickening ( = %, = %- %, = %- %, = %- %, = %- %, = %); omc results: the prevalence of asthma at the age of years was . %. % of them had an act tm value below , ie uncontrolled asthma, median . (range - ). independent risk factors for uncontrolled asthma at the age of were current doctor diagnosed rhinitis (adjusted or, aor . ; % ci . - . ), wheeze triggered by exercise (aor . ; . - . ) and cat at home (aor . ; . - . ). if at least one of the parents had higher education the risk of uncontrolled asthma was decreased (aor . ; % ci . - . ). six children reported hospitalisation due to asthma during the last months (ie . %) at years of age. hospitalisation was more common in individuals with uncontrolled asthma (or . ; . - . ) or when mites (or . ; . - . ) or pollen (or . ; . - . ) was reported as trigger factors. also, oral corticosteroids (betamethasone), in the last months increased the risk for hospitalisation (or . ; . - . ). to have a parent with asthma ( % compared to %, or . ; . - . ) or higher education ( % compared to %, or . ; . - . ) was numerically less common for children who were hospitalised for asthma but did not reach statistical significance. conclusions: uncontrolled asthma was associated with current allergic rhinitis, having a cat and exercise as trigger factor. at least one parent with higher education reduced the risk. hospitalisation due to asthma was more common in individuals with uncontrolled asthma. abstracts | adolescent asthma in relation to severity and gender-data from a prospective population based cohort study introduction: asthma often debuts early in life, but recent studies show that the development of asthma is a dynamic process with disease turnover throughout child-and young adulthood. objectives: to describe adolescents' asthma with focus on severity and gender. the study population consisted of adolescents participating in the cohort, followed since birth up to years of age with questionnaires and clinical investigations. blood samples from adolescents ( . %), sera analyzed for specific ige against common inhalant allergens. asthma at years was defined as fulfilling at least of the following criteria: symptoms of wheeze and/or breathing difficulties in the last months, ever doctor's diagnosis of asthma and/or asthma medicine occasionally or regularly last months. uncontrolled asthma was based on parental information on symptoms of asthma in the last months prior the -year follow-up, including or features: nocturnal asthma, activity limitation, wheeze times and hospitalization due to acute asthma. we looked into phenotypes; late-onset, defined as asthma at , or , but not at , and years of age and persistent, defined as asthma at , or and , or years of age. severe asthma, defined as asthma as above combined with prescribed and dispensed corticosteroids used within the last months plus uncontrolled asthma and/or lung function (fev < % of predicted). results: at years of age, . % (n= ) fulfilled the study definition of asthma, . % late onset and . % persistent asthma. persistent asthma was more frequent among boys than girls . % vs . % (p=. ). overall ige sensitization was common among adolescents with asthma, . % were sensitised to common inhalant allergens, and equally common in late-onset and persistent asthma ( . % vs . %, p=. ). however, more boys than girls were sensitised ( . % vs . %, p<. ). in total . % (n= ) adolescents had severe asthma, . % (n= ) boys and . % (n= ) girls (p=. ). the overall prevalence of severe asthma in the cohort was estimated to . %. severe asthma did not significantly differ among adolescents with late-onset compared to persistent asthma ( / , / , p=. ). conclusions: among adolescents with asthma, late-onset (age ≥ years) and persistent asthma were equally common. persistent asthma were more common among boys. there were no difference in asthma severity, or proportion of ige sensitization among adolescents with late-onset or persistent asthma. however, data investigating associations with wheeze and asthma in later childhood are scarce. objectives: our aim was to explore the association of maternal milk fatty acid composition with childhood wheezing phenotypes and asthma up to age years. breast milk was collected weeks and months post-delivery in the ulm birth cohort study (n= and n= , respectively). concentrations of - carbon atom chain length fatty acids were measured by high-resolution capillary gas-liquid chromatography. to control for constant sum constraint, concentration data were transformed using the centered log ratio method. compositional biplots and correlation matrices were used to group fatty acids based on within sample correlation. adjusted risk ratios with parent-reported wheezing phenotypes and doctor-diagnosed asthma were computed using a modified poisson regression. results: we observed no straightforward evidence of associations between overall breast milk fatty acid composition and specific wheeze phenotypes or doctor-diagnosed asthma. conclusions: despite our use of sophisticated statistical methodology, our results may have been biased toward the null by several cohort-specific factors associated with breast milk collection and fatty acid composition. to overcome potential selection bias by maternal lifestyle, further research should investigate fatty acid intake during the first year of life including sources other than breast milk among children who were never or not exclusively breastfed. introduction: fall is the most common season for asthma exacerbation. previous studies found that exposure and sensitization to house dust mites (hdms) can exacerbate asthma. the seasonal variation in indoor hdm concentration is highest in the fall, correlating with the incidence of asthma exacerbation. most of the studies conducted to date have focused on the effect of hdm exposure on the incidence of acute asthma exacerbation, but reports about the effect of hdm sensitization are few. thus, we aimed to determine whether sensitization to hdms acts as a risk factor of asthma exacerbation in the fall. in addition, we investigated whether asthma exacerbation in the fall had any distinctive features by comparing levels of various cytokines and chemokines with those in other seasons. objectives: we enrolled children aged - who visited the emergency department because of acute asthma exacerbation from january to december ( . %, males; mean age, . ae . years). they were treated in accordance with the standardized treatment protocol. blood samples were collected from the children during the course of treatment. by using residual sera from the blood samples, we measured the levels of total immunoglobulin e (ige), hdm-specific ige (sige), eosinophil cationic protein (ecp), and various cytokines and chemokines, and classified them according to season. we compared the date divided into fall group (from september to november, n= ) and other season group (from december to august, n= ). ci, confidence interval; or, odds ratio; der f-sige, dermatophagoides farinae -specific immunoglobulin e; der p-sige, dermatophagoides pteronyssinus-specific immunoglobulin e; ecp, eosinophil cationic protein; ige, immunoglobulin e. data are presented as n (%) or as meansaesems and median (range). p value refers to the difference between the fall and "other season" groups and was calculate by the chi-square statistics, fisher's exact test, student's t-test, or wilcoxon rank-sum test. a adjusted for total ige. results: this retrospective study obtained archived nasopharyngeal aspirate (npa) samples from patients aged below years who were hospitalized for acute respiratory illnesses in a university-affiliated hospital during the periods september-november and january-april . their clinical information was retrieved from computerised record. hrv was detected by rt-pcr, and isolates were sequenced to determine the genogroups and serotypes. ninety patients whose npa was positive for hrv and patients being negative for an extended panel of respiratory viruses by multiplex pcr method were identified. mean age of these groups was . years and . years respectively. hrv infection was significantly associated with asthma exacerbation (or . , results: a total of children were included: . % were boys; . % aged months to years, . % aged - years, . % aged - years and . % aged - years; . % were hospitalized, results: the long-term remission (≥ years without treatment) rate years after initiating early anti-inflammatory therapy was . % (intermittent asthma, %; mild persistent asthma, . %; moderate persistent asthma, . %; severe persistent asthma, . %). longterm remission rates improved compared with past asthmatic conva- objectives: the aim of this study is to explore the potential value of feno level for diagnosing chronic cough in children. objectives: in this study, we aimed to compare the efficacy of classical spirometry and impulse oscillometry (ios) in evaluation of late reversibility in children who received treatment with the diagnosis of atopic asthma. we enrolled patients aged - years who were diagnosed with atopic asthma. exclusion criteria were having received asthma treatment during the previous two months, having acute asthma exacerbation findings, having any other respiratory disease or cardiac disease that may affects the lung function test results. allergic sensitization was determined by skin prick test performed according to eeaci guidelines. lung function test measurements were performed at enrollment and after two months of inhaled steroid treatment. conclusions: classical spirometry is more valuable compared to ios in evaluation of late airway hyperreactivity in children with atopic asthma in children older than seven years age. | computer bronchophonographyfrequency analysis of the respiratory cycle. objectives: we performed mct in children with symptoms suggestive of asthma and without respiratory symptoms. after each inhalation step oscillometry and spirometry was performed. parameters analysed for ios were z , r , r , x , x and ax (the integrated impedance reactance at r and above) and fev for spirometry. a fall of % in fev from baseline after mtc was considered as a positive challenge. pc -fev and pc r , x and ax were calculated. results: a total of patients, female, with a mean age of . (ae . ) years were enrolled. had a ≥ % fall in fev after mtc. the mean variation in fev was % (- . %/ + . %), the mean variation in z , r , r , x , x , ax and fres were . % objectives: the objective of our study was to synthesize cationic peptides and study their antiviral activity (aa) in vitro. results: peptides were synthesized by solid phase method with different structures (linear, helical and dendrimeric). cytotoxicity of the peptides was studied by mtt assay using hela cells. objectives: the aim of the study is to evaluate the changes of il- results: subjects aged - years were enrolled in this study, which were divided into groups: patients with diagnosed moderate to severe ba ( st group), ba patients with rvi ( nd group), subjects with rvi only ( rd group) and healthy volunteers ( th group). all patients with ba from group and received inhaled corticosteroids. clinical blood test revealed increase of eosinophils in patients with ba and ba accompanied with rvi up to % and %, respectively. fev was decreased in st and nd groups to % and % compared % and % for rd and th groups, respectively. conclusions: this study is alarming for asthmatic nosocomial hazards in this govt. hospital. identification of ige specific reactive components of predominant fungal allergens and cross-reactivity among each other, delined in this study could minimize the hazard of therapeutic and diagnostic use of these cross-reactive components, in fungal allergen-specific immunotherapy. objectives: we conducted a longitudinal prospective study to examine the development, composition and diversity of the gut microbiota in healthy and allergic children. we followed children from months to years of age with clinical evaluation; specific ige levels and skin prick testing. fecal samples were collected at , , months and years. s rrna sequencing was used to profile the gut microbiome using illumina miseq. the composition and diversity of the gut microbiome were assessed using quantitative insights into microbial ecology (qiime). comparisons between groups were made using the lefse pipeline; non-parametric factorial kruskal-wallis test, unpaired wilcoxon rank test and linear discriminant analyses (lda) with score > . . to assess the interaction effect, the likelihood ratio test (lrt) was applied using r statistical program. p<. was considered significant after correction for multiple testing. results: to achieve our aim we divided balb/c mice into groups: mice with viba ( st group), mice with viba treated with nonspecific sirna against gfp (sigfp) ( nd group) and against il- (siil- ) ( d group). th group was intact mice. groups - were i.p. sensitized on days , , with ovalbumin (ova) mixed with aluminum hydroxide and i.n. challenged with ova on days - . the same mice were i.n. infected with tcid /mouse rsv strain a on day . mice from group and were i.n. treated by sirnas on days - in dose lg/mouse. on day hyperresponsiveness (ahr) to methacholine was measured. on day and lungs were removed for histological analysis. viral rna (vrna) load and il- gene expression were evaluated by qpcr in lungs. bronchoalveolar lavage (bal) was collected for differential cell count by light microscopy. so i.n. administration of siil- suppressed il- gene expression in lungs by % compared to sigfp treated mice. there were no significant changes in body weight and lung vrna amounts between mice received sigfp and siil- . mice treated with siil- demonstrated the tendency to improve lung function compared to mice of group - , that expressed in % reduction of specific resistance of airways and % increase of peak expiratory flow. bal cell count revealed decrease of total cell number, eosinophils and lymphocytes in mice received siil- by %, % and % compared to sigfp treated mice, that indicate reduction of inflammation, that was confirmed by histopathological studies showed % leukocyte reduction. downregulation of il- resulted in -and . -fold decrease of bronchial epithelium metaplasia and hyperplasia. and femur length measurements were collected from routine antenatal screenings. these and derived head to abdominal circumference ratio and estimated fetal weight were converted into z-scores adjusted for gestational age and gender and categorized as "low" (≤ sd below mean), "normal," or "high" (≥ sd above mean). ad cases were children with parent-or pediatrician-report of physician ad diagnosis assessed yearly up to age years and supplemented by clinical diagnoses during dermatological exams at . , , and years. modified poisson regression models were used to compute risk ratios (rr) adjusted for potential confounders. conclusions: these results provide further evidence for a role of fetal growth as an influence on atopic disease outcomes. unlike previous studies, our data suggests several patterns of fetal growth beginning as early as the st trimester may influence ad outcomes. objectives: we aimed to examine the role of eosinophil cationic protein (ecp), eosinophil derived neurotoxin (edn) and total immunoglobulin (ig) e as a bio-marker of disease severity. we examined the difference in level of total ige, ecp and edn between the two groups and whether any correlation existed between disease severity and ecp or edn. objectives: we aimed to identify the subgroup of ad patients with a good clinical response to probiotic treatment. we recruited children who suffered from moderate to severe ad with the scoring ad (scorad) index of or higher. after weeks of washout period, all patients were given lactobacillus plantarum cjlp at a dosage of colony-forming units once a day for weeks. we measured eosinophil counts in the peripheral blood, the proportion of cd + cd + foxp + regulatory t (treg) cells in cd + t cells, serum total ige levels, and specific ige to common allergens before the start of the treatment (t ) and at discontinuation (t ). logistic regression models were used for the statistical analysis. seventy-six patients ( boys and girls) with a mean age of . ae . years completed the study. there were responders and non-responders after probiotic treatment. the median scorad was reduced from . (range . - . ) at t to . (range . - . ) at t in the responder group (p<. ). in multivariable logistic regression analysis, a good clinical response was significantly associated with high total ige levels (aor . , % ci . - . ), increased expression of , and high proportion of cd + cd + foxp + cells in cd + t cells (aor . , % ci . - . ). in responder group, the proportion of cd + cd + foxp + cells of cd + t cells were significantly increased after weeks of treatment (p=. ), while the levels of tgf-b mrna expression were decreased (p=. ). there were no differences in total ige levels between t and t (p=. ) conclusions: the therapeutic effect of l. plantarum cjlp on ad is more pronounced in children with high total ige levels, objectives: the objective of the study was to examine the effect of a specific synbiotic mixture of short-chain galacto-, long-chain fructo-oligosaccharides (scgos/lcfos, ratio : ) and bifidobacterium breve m- v on the severity of ad and correlation to serum chemokines in infants with moderate to severe ad and elevated ige. in an exploratory randomized, double-blind, placebo-controlled trial the effect of extensively-hydrolyzed whey-based formula without intervention. serum obtained prior to start and at the end of intervention were analysed using luminex. six chemokines and nine ratio's thereof were correlated to ad severity (sample size= ). introduction: dyshidrotic eczema is one of the most common skin conditions. contact allergy is often associated with dyshidrotic eczema although the exact impact and the influence of contact allergens in different forms of dyshidrotic eczema remain unknown. hypersensitization to nickel is one of the most common contact allergies associated with pompholyx. the standard of care protocol is to use a medical treatment with topical corticosteroids and calcineurin inhibitors to treat the symptoms, together with occlusive barrier creams to avoid skin exposure to the allergens. after the symptoms have been cleared with the topical treatment, the recommendation is to use occlusive barrier creams to prevent recurrence of the symptoms. objectives: a new emollient with specific metal-scavenging agents and no occlusive ingredients has recently been developed and made commercially available. the aim of this study was to evaluate the effect of such cream to provide relief for patients with dyshidrotic eczema associated with nickel allergy. results: thirty-two subjects with dyshidrotic eczema and a positive patch test ppt (contact sensitized) reaction to nickel were selected. these were divided into two randomized groups, group-a was given nickel-scavenging cream (skintifique creamtm, paris) after medical treatment, (n= ) and group-b followed the standard protocol for pompholyx, (n= ). hand eczema was scored according to the dyshidrotic eczema area and severity index (dasi). dasi scores were evaluated at the beginning of the study (day- ), after the medical treatment (day- ) and two months after the end of medical treatment (day- ). results show a significant difference in the efficacy of treatment between the two groups at day- . a higher percentage of at least % reduction of initial dasi score ( . %) and a higher percentage of total clearance ( %) in patients using nickel-scavenging nonocclusive moisturizing cream was observed as compared to standard-of-care occlusive creams ( . % and %, respectively). objectives: the goal of this study was to investigate whether long-term emollient therapy is associated with alterations of skin barrier function and shifts of the skin microbiome in infants at high risk for developing ad. we prospectively enrolled newborns with a family history of ad to be randomized to either emollient treatment group or control group. at months of age, we tested the skin barrier (transepidermal water loss/tewl, water capacitance/cap, ph) and skin microbiome ( s rdna sequencing of skin swabs from cheek, dorsal and volar forearm). results: the emollient group (n= ) had significantly lower skin ph compared to controls (n= ) (p=. ), but without a statistically significant difference in tewl or cap. the emollient group had higher numbers of different bacterial taxa (chao richness) at cheeks (p=. ), dorsal forearms (p=. ), and volar forearms (p=. ) as compared to controls. both streptococcus pneumoniae and s. salivarius statistically significantly contributed to the observed skin microbiome differences between patient groups. s. salivarius was significantly more abundant in emollient subjects at all sampling sites (p=. ). we then analyzed our previous larger cohort of older children with ad and also observed higher s. salivarius proportions in ad patients with treated and less severe disease (p=. ). objectives: to evaluate the effect of overnight treatment with a temperature-controlled laminar airflow (tla) device in children/adolescents with severe eczema over a -month period. in an open-label study, subjects aged - years (median years) with longstanding severe eczema attended visits during the run-in period lasting - weeks (median . weeks) to optimize eczema management. the run-in was followed by a month treatment period using overnight tla device (airsonett ® , sweden), which included study visits. we used scorad-index results: the median duration of eczema was . months (interquartile range - . ). all subjects were sensitised to ≥ perennial allergen, and had multiple comorbidities ( / rhino-conjunctivitis, / food allergy, / asthma). there were no significant changes during the run-in period in any of the outcome measures. we observed a significant improvement in scorad after the -month tla-treatment period, from . [ . - . ] to . [ . - . ] , p=. . iga improved significantly from a median of [ - ] to [ ] [ ] [ ] , p=. . improvement in symptoms was paralleled by a significant reduction in medication usage. by months, there was a significant improvement in . ] to [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , p=. ), and an improvement in cdqli (marginal, p=. ). however, we observed no changes in poem (p=. ) . post-hoc cluster analysis of the patterns of changes in scorad over the month treatment period identified two clusters, with participants classified as responders and as non-responders. introduction: intestinal degradation has been shown to determine allergenicity of food allergens. however, it is unclear how allergens are degraded inside pivotal immune cells such as dendritic cells (dc), and how this affects the subsequent immune response to these allergens. in our studies, we determined whether we are able to measure uptake and degradation of allergens inside dc and whether differences in above mentioned factors exist between allergens. objectives: using mouse bone marrow-derived dc and fluorescent-labeled proteins, we studied the cellular uptake of the peanut proteins ara h , , , and . results: first, we observed that dc uptake of ara h was much higher than ara h , and . using blocking reagents and receptor binding assays for various uptake routes in dc, we observed that one of the principal routes of uptake for ara h was the mannose receptor. other uptake routes, and the routes of uptake for ara h , and are currently under investigation. second, using proteins coupled to beads we observed that intracellular protein degradation was higher for ara h and ara h than for ara h and . finally, cd +t cells from ara h , , or sensitized mice were added to matching allergen-pulsed dc. we observed that while ara h , and to lesser extend ara h elicited strong th type responses, ara h did not elicit any t cell responses. conclusions: together, we show that allergenicity of (peanut) proteins may be, at least partly, determined at the level of allergen uptake and breakdown inside the antigen presenting cell. these findings may be relevant to risk evaluation of existing allergens but also of novel or modified proteins. this also illustrates the usefulness of in vitro, cell based assays to examine initial processes of allergenic sensitization to proteins. | sensitising capacity of unmodified and acid hydrolysed gluten through the skin-a comparative study in na€ ıve vs tolerant brown norway rats ballegaard ar; madsen cb; bøgh kl national food institute, technical university of denmark, søborg, denmark introduction: allergic sensitisation to foods may occur in infancy without prior oral exposure to the offending food. this has led to the assumption that food allergy sensitisation may occur through alternative routes, such as the skin, supported by the observed correlation between skin barrier disruption and food allergy. recently, concerns have been raised regarding the safety of use of cosmetic and personal care products containing hydrolysed wheat proteins, since these products have been shown to induce allergy towards acid hydrolysed wheat through the skin, and even to cause an abrogation of the already established oral tolerance against unmodified wheat. objectives: the aim of the study was to compare the sensitising capacity of an unmodified and an acid hydrolysed wheat product via slightly damaged skin, in order to evaluate differences in conditions necessary for skin sensitisation in na€ ıve vs tolerant individuals. brown norway rats were raised and bred on either ( ) a diet free from wheat, resembling individuals with a na€ ıve immune system, or ( ) a conventional wheat containing rat chow, resembling individuals tolerant to wheat. results: in the na€ ıve rats both products were able to induce a statistically significant specific antibody response after application of the products on the slightly damaged skin, whereas in the wheat tolerant rats, only the acid hydrolysed wheat product was able to induce a statistically significant antibody response. for both the na€ ıve and the wheat tolerant rats the response was dose-dependent. in the na€ ıve rats both products were able to sensitise through the skin, inducing a specific ige response, whereas in the tolerant rats only the acid hydrolysed product were able to induce a specific ige response, though this ige response was much lower than in the na€ ıve rats. results from competitive elisas demonstrated that new epitopes had developed as a result of acid hydrolysis, though original epitopes were maintained at the same time. this may explain why only the acid hydrolysed wheat could induce specific antibody responses in the tolerant animals. conclusions: this study showed that the sensitising capacity through the skin of two different wheat products is heavily influenced by the tolerance status of the immune system and the degree of modification of the wheat products. results: using a germ-free c h/hen mouse model of food allergy, we examined the presence of a major peanut allergen, ara h , in the blood after intraperitoneal injection in previously sensitized and control (non-sensitized) mice using an untargeted, quantitative proteomic approach. previously sensitized mice underwent physiological (core temperature decrease, clinical symptoms) and biochemical (mast cell protease increase, ara h specific ige positivity) changes associated with severe allergic reactions. we were able to confidently detect multiple peptides derived from the ara h protein after intraperitoneal injection in both control and ara h sensitized mice. however, the ara h protein was present at - fold higher levels if mice were previously sensitized, suggesting increased transit across the peritoneal mesothelium with sensitization. an untargeted proteomic approach also allowed changes in the blood proteome of mice undergoing a severe allergic response to be examined. we identified proteins with significantly altered quantity in serum between control and sensitized mice and were therefore apparently associated with the allergic response. we demonstrate the applicability of untargeted proteomics to the study of the allergen transport and proteomic changes which co-occur with a resultant allergic reaction. the transit of allergens into the bloodstream is heavily dependent upon previous sensitization. we are continuing this work to examine the specificity of observed increases in trans-mesothelial transport and to address transport of allergens after intragastric challenge. | iga to cow's milk differs between breast milk and serum for its epitope specificity objectives: we sought to assess whether the profile of epitopespecific iga differs between mother's serum and bm. we also examined how infants' food epitope-specific iga develops in early infancy and the relationship of iga epitope recognition with development of cow's milk allergy (cma). results: . we measured iga specific to an array of overlapping peptides in major cow's milk allergens (alpha s -, alpha s -, betaand kappa-caseins and beta-lactoglobulin). diversity of peptide-specific iga (ie epitope diversity) was determined in paired maternal and infant sera as well as breast milk samples in mother-infant dyads within the first postpartum months utilizing peptide microarray. microarray data was converted to z-scores and filtered for noise. peptide epitopes were determined based on jaccard distance between neighboring peptides, and intra individual correlation between sample types was estimated using phi coefficient. comparisons between groups and individuals was done using non-parametric tests. we noted marked discordance in epitope recognition in paired breast milk and maternal serum samples. at least one shared epitope was recognized by both milk and serum samples ranging from % of mothers for alpha-s casein to % for kappa-casein. epitopespecific iga was detectable in infants' sera starting at less than months of age. sera of mothers with a cma infant had increased binding of epitope-specific iga to cow's milk proteins compared to those with a non-cma infant (p<. for all five proteins). conclusions: these findings support the concept that mothers' milk represents a product of the mucosal immune system that has an antibody repertoire distinct from that of peripheral blood. results: multiple ige-binding proteins were detected in the different wn preparations and many of which were dissemblance in dblotting. profiles of detectable proteins (peptides) of raw, roasted and boiled wn extracts were profoundly different in emi analysis. introduction: consumption of tree nuts is on the rise due to their beneficial health effects. however, tree nuts can led to severe allergic reactions in sensitized patients. thermal processing can modify the structure and function of food proteins and may alter (increase or decrease) their allergenic properties. knowledge about the effects of thermal processing on tree nuts such as cashew or pistachio is rare and based on traditional in vitro immunoassays. objectives: to elucidate the influence of thermal treatments (boiling and heat / pressure) on the ige reactivity of cashew and pistachio proteins, by means of traditional in vitro immunoassays and mediator release assays (mra). results: the allergenicity of untreated and treated cashew and pistachio nuts was evaluated by ige-elisa, ige-immunoblot and elisa inhibition assays using sera from spanish patients with clinical allergy to cashew and pistachio. rat basophilic leukaemia cell line transfected with the a-chain from the human high-affinity ige receptor fceri, was sensitized with a pooled sera and used for mra. sensitized cells were stimulated with untreated and treated protein extracts, in order to investigate the capability of untreated and treated cashew and pistachio proteins to cross-link ige on effector cells. the results showed that heat and pressure treatment at the harshest conditions considered in this study produced a higher decrease of the ige-binding capacity of cashew and pistachio proteins than boiling without pressure or soft conditions of heat and pressure. interestingly, although the treatments of heat and pressure seemed to affect cashew allergens to a greater extent than pistachio allergens (evaluated by ige-elisa and elisa inhibition), the results of mra using the cell line rbl- indicated that cashew proteins treated with heat and pressure, still retained some capacity to cross-link ige. introduction: previous research has indicated an important role for dietary non-digestible oligosaccharides in decreasing the incidence of atopic dermatitis in children at risk of allergy. it is assumed that these prebiotics promote colonization of beneficial bacteria in the gut. children with atopic dermatitis receiving a diet of galacto-and long chain fructo-oligosaccharides (scgos/lcfos) with bifidobacterium breve m- v had enhanced serum galectin- levels. galectin- has ige-binding capacities and can hereby suppress degranulation of mast cells and basophils. next to their function in the gut, oligosaccharides may also affect other immune cells directly, since they were found in plasma and urine. objectives: we investigated whether non-digestible oligosaccharides or galectin- can have a direct effect on immune cells, by determining the effect on basophil degranulation in peanut-allergic patients. whole heparinized blood samples were collected from peanut-allergic adult patients and incubated for hours with either a mixture of . % : scgos/lcfos or scfos/lcfos, or galectin- ( or lg/ml) at °c in the presence of il- ( . ng/ml). after hours, a basophil activation test (bat) was performed. basophils were stimulated for minutes at °c with increasing concentrations of whole roasted peanut extract or human anti-ige. degranulating basophils were determined as cd + cells and calculated as percentage positive cells. results: in each patient, the concentration of anti-ige or peanut extract that induced maximal degranulation in the untreated control sample was used as reference value to compare degranulation of the samples pretreated with scgos/lcfos, scfos/lcfos, or galectin- . pre-treatment of whole blood with scgos/lcfos resulted in an average decrease in degranulation of approximately %, while a significant reduction of % was observed after pre-treatment with scfos/lcfos (p<. ). pre-treatment with lg/ml galectin- decreased basophil degranulation with %, whereas lg/ml galectin- caused a significant decrease of % (p<. ). no differences were observed in the ec , indicating that the basophils are not becoming less sensitive to the peanut extract or anti-ige. the prebiotic mixture scfos/lcfos and galectin- can contribute to decreased degranulation of basophils in a igemediated bat assay using whole blood. further analysis is warranted to define the exact working mechanism of these oligosaccharides. introduction: the intestinal mucosa plays a key role in the development of food allergies. we studied the interaction between intestinal epithelial cells (iecs) and pbmcs of peanut-allergic patients in a transwell co-culture model. exposure of iecs to a mixture of galacto-and/or long chain fructo-oligosaccharides (scgos/lcfos) in combination with synthetic cpg dna (tlr ligand),modulated the cytokine response of activated pbmcs, driving away from the allergic phenotype. objectives: our aim was to compare the efficacy of scgos/lcfos with a scfos/lcfos mixture and to evaluate these effects in an allergen-specific co-culture model. iecs (ht- , human colon adenocarcinoma) were grown on transwell filters until confluence. iecs were apically exposed to . % : scgos/lcfos or scfos/lcfos either or not in combination with . lmol l À cpg dna to mimic presence of dna of beneficial bacterial in the gut. these iecs were co-cultured with basolateral pbmcs from peanut-allergic patients, either activated with anti-cd /cd ( hours) or peanut-extract (pe, days).cytokines ifn-c, il- , il- and tnf-a were measured in the basolateral supernatant and t-cell polarization of the pbmcs was determined (th , th , treg and tfh). results: apical exposure of iecs to cpg dna increased basolateral ifn-c and il- production by anti-cd /cd activated pbmcs (p<. ), and was enhanced by both oligosaccharide mixtures (p<. ). cpg exposure in transwells with pe stimulated pbmcs also increased ifn-c and il- production, which was further enhanced by scfos/lcfos (p<. ). in this pe-specific model, percentages of th and treg cells increased upon cpg exposure of iecs, and th frequency was increased by scfos/lcfos (p<. ). cpg dna exposed iecs suppressed il- and tnf-a production by anti-cd / cd activated pbmcs. both scgos/lcfos and scfos/lcfos reduced tnf-a production in combination with cpg dna (p<. ). tfh cells can produce il- , inhibiting class-switching to ige . upon cpg exposure of iecs, we observed an increase in tfh cells (p<. ) and similar tendency for cd + il- + cell frequency in anti-cd / cd activated pbmcs. conclusions: epithelial exposure to both scgos/lcfos and scfos/lcfos enhances the cpg dna induced th and regulatory il- response in an anti-cd /cd co-culture model, whereas only scfos/lcfos was effective in an peanut-specific co-culture model. introduction: in areas of spain with high level of grass pollen exposure, % of grass allergic patients were sensitized to profilin, and most of them developed severe profilin mediated food reactions. this specific population of patients constitute an ideal model to study the relation among respiratory and food allergy objectives: our aim here was to analyze the links between epithelial barrier integrity and inflammation in oral mucosa. methods: allergic patients and controls were included in the study. allergic patients were stratified into mild or severe according to their clinical history and response to profilin oral challenge test. immunohistochemistry (ihc) for cd c, cd , cd , claudin- ; and dapi nuclear staining were performed in formalin-fixed, paraffin embedded sections of oral mucosa biopsies. rt-pcr was performed to analyze il b and il gene expression and the number of circulating cd + cells in pbmc was measured by flow cytometry. additionally, basophil activation test was carried out in whole blood samples upon profilin stimulation and the ec was calculated. results: regarding epithelial barrier integrity, claudin- expression resulted inversely proportional to pollen-associated food allergy severity. furthermore, by dapi staining, we noticed a lower number of epithelial cells in allergic patients than in non-allergic, and the gene expression of il b and il resulted significantly increased in oral mucosa from severe group. as for immune response in oral mucosa, the number of cd c and cd + cells resulted significantly higher in severe group. in allergic patients, double ihc for cd c-cd showed an increase colocalization of t cells and apcs in the interface between epithelium and connective tissue. a decrease in blood circulating cd + cells was detected in allergic patients compared to non-allergic. as for the basophil sensitivity, ec in severe patients was -times lower than in mild. our results show that damage in oral mucosa epithelium, probably induced by high grass pollen exposure, might allow profilin to penetrate inside oral mucosa and induce inflammation with local recruitment of immune cells. furthermore, analyzing the immune response developed by effector cells, basophils from severe group result more sensitive to profilin as they react to a lower allergen concentration. these data explain the differences in food allergy severity between mild and severe group and propose oral mucosa as a new sensitization route. introduction: th cells producing the hallmark cytokines il- , il- and il- have been found to constitute the majority of the allergen-specific th cell responses in allergic diseases. subpopulations of the th responses have been described with an early primed th subtype characterized by production of il- and il- , and a highly differentiated th subtype, which in addition produce at least il- . objectives: we aimed to investigate the polarity of tree nut and peanut allergen-specific th cells in subjects with confirmed tolerance or allergy to multiple nuts, and hereby detect differences in allergenspecific th cell responses within the same study population. we also wanted to stress the question whether a th phenotype dominates in asymptomatic sensitization. methods: pbmcs from donors all assessed for clinical reactivity to hazelnut, walnut, cashew nut, pistachio nut and peanut was stained with cfse and stimulated ( cells/ml) with and without whole nut extracts ( - lg/ml) for days. allergen-specific cd + t cell phenotypes and cytokine release was analyzed with flow cytometry and luminex, respectively. the allergen-specific th cells of the allergic donors showed a trend of more highly differentiated il- +il- + th cells and higher abstracts | release of il- than in the tolerant donors. unexpected, except in the cashew nut stimulated cells, no difference was found in the relative percentage of the less differentiated th cells (single il- + allergen-specific cd + t cells) when comparing allergic with tolerant donors. when subdividing the tolerant donors into asymptomatically sensitized or ige-negative (< . kua/l), increased frequency of highly differentiated il- +il- + allergen-specific th cells were found in asymptomatically sensitized compared to tolerant-ige-negative donors. interestingly, a positive association of the allergen-specific ige level and the frequencies of allergen-specific il- +il- + and il- + th cells were found in hazelnut, pistachio nut and cashew nut but not in walnut and peanut allergic subjects. conclusions: an overrepresentation of allergen-specific highly differentiated il- +il- + th cells and an elevated il- production were observed in allergic subjects compared to subjects that tolerated the nuts. we furthermore found a trend that subjects asymptomatically sensitized to nuts differed from tolerant-ige-negative subjects by having relatively more highly differentiated il- +il- + allergen-specific th cells. introduction: it remains largely unknown which features of food proteins that render them allergenic vs tolerogenic. however, it has been suggested that the protein-chemical features affects protein uptake in the intestine, and that protein uptake route may impact on the risk of sensitisation. objectives: the aim of this study was to investigate the interplay between protein-chemical characteristics, the allergenic vs tolerogenic properties and the intestinal uptake of two protein products. the allergenic vs tolerogenic capacity of a heat-treated whey product, consisting of partly denatured and aggregated proteins, was compared to an unmodified whey product in: ( ) results: though this study showed that both unmodified and heattreated whey had immunogenic, sensitising and eliciting capacities as well as tolerance inducing capacity, significant differences between the two products were observed. the heat-treated product was found to have a lower allergenicity combined with high tolerogenicity compared to the unmodified product. competitive igg elisas indicated that heat-treatment of whey induced de novo epitopes while the original epitopes were maintained. newly established methods to study in vivo intestinal uptake were successfully applied to compare the uptake kinetics of the two products in different small intestinal tissues and serum. collectively the in vivo and in vitro uptake experiments suggested that uptake kinetics and the major intestinal uptake route differed between the heattreated and unmodified product. conclusions: this study showed that heat-treatment, which induces partly protein denaturation and aggregation, changes the immunological properties and intestinal uptake of a whey protein product. the heat-treated product was found to have a lower allergenicity combined with high tolerogenicity compared to the unmodified product, which highlights this products promising potential for induction of cow's milk tolerance. objectives: in this study, we enumerated tregs in esophageal tissue of patient with eoe, gerd and normal controls. ten patients with eoe, patients with gastroesophageal reflux disease (gerd), and patients with normal endoscopy and normal esophageal tissue were included. tregs were enumerated in paraffin embedded esophageal biopsy blocks, using immunohistochemistry assay. tregs were identified as foxp +, cd + cells. results: tregs were counted in high power fields (hpf, ) for patients and the average of hpf was recorded. the number of tregs in esophageal tissue of patient with eoe (mean . cells/ hpf) was significantly more than gerd(mean . cells/hpf) and control groups(mean . cells/hpf) (p value <. ). conclusions: there is an increase in number of regulatory t cells in esophagus of patients with eoe in comparison to gerd and control groups. the presence of these cells might be due to eosinophilic inflammation and help controlling the inflammation. objectives: to evaluate whether anti-cd (daratumumab) treatment results in a reduction of total and specific ige levels. results: samples from patients with relapsed/refractory multiple myeloma, treated with daratumumab monotherapy or daratumumab plus lenalidomide-dexamethasone in the umc utrecht between april and august , were tested for total ige levels as well as presence of specific ige against common inhalant allergens. in patients with detectable ige at baseline, the total and specific ige levels were evaluated during treatment up to weeks. of eight patients receiving treatment, four had detectable ige levels at baseline. one patient demonstrated sensitization to common inhalant allergens. for this patient, levels of total ige gradually decreased during weeks of treatment (from to ku/l; %), as well as specific ige against timothy grass ( . - . ku/l; %) and house dust mite ( . - . ku/l; %). a second patient, not sensitized to common inhalant allergens but with ige levels of ku/l at baseline, also demonstrated a decrease in ige levels, to ku/l ( %). the last two patients had total ige levels < ku/l at baseline, which dropped below detection limit after eight weeks of treatment. conclusions: this proof of concept demonstrates that (specific) ige depletion occurred during treatment with anti-cd (daratumumab). anti-cd could potentially play a role in the management of severe ige-mediated diseases. objectives: following individual and assessment, patients established and stable on omalizumab have been commenced on home therapy. training and education in self-administration has been provided. a service assessment has been carried out to review the ongoing safety, quality and patient experience of the service. results: to date, over doses of omalizumab have been self administered in the community with no adverse events or incidents related to home therapy. conclusions: self-administration of omalizumab at home by patients offers the potential to improve quality of life while also providing efficiency savings. introduction: chronic idiopathic/spontaneous urticaria (csu) is a chronic urticarial subtype, defined as itchy hives that last for at least weeks, with or without angioedema, and that have no apparent external trigger. although csu is more frequent in adult populationup to . %- %-, it can affect children and generally has a prolonged duration and has a detrimental effect on patients' quality of life. before the fda and ema approval of the anti-ige monoclonal therapy omalizumab for adults and children years and above, nonsedating h -antihistamines were the only agents licensed for use in patients with csu. however, a majority of patients did not respond to these drugs, even when they were administered at three to four times their licensed dose. objectives: we present pediatric patients (≥ years old) with csu non-responding to antihistamines, treated with omalizumab. results: at the diagnosis of csu, the patients were , , years old, respectively. a trial with non-sedating h -antihistamines, administered up to three to four times their licensed dose, were performed for all patients, without clinical efficacy. omalizumab was started at , , years, respectively. before anti-ige therapy, the urticaria activity score (uas) was , , respectively, indicating poor symptom control. omalizumab therapy was administered every weeks for months at the dosage of mg s.c. after month of therapy, all patients were symptom free with uas ; the patients remained asymptomatic for all the months of duration of monoclonal therapy and antihistamines were discontinued. by now, after , , months respectively from discontinuation of omalizumab, all patients are asymptomatic with uas . introduction: mepolizumab is a humanized monoclonal antibody directed against il- , and is licensed for the treatment of severe asthma in patients aged > years (eu only adults) with an eosinophilic phenotype as an add-on treatment. we were interested to know whether the substance has an antiallergic effect, too. objectives: here, we report the case of a year old man (non- results: in march he was switched from omalizumab to mepolizumab ( mg/month) weeks after the last omalizumab because of two asthma exacerbations under omalizumab in the last months and eosinophils/ll blood under mg prednisolone/day. after two injections of mepolizumab his fev increased from % to % pred., the act from to points, feno decreased from to ppb and the amount of prednisolone from mg to mg/day. but -the patient reported new nasal symptoms after the nd injection of mepolizumab, mainly blocked nose which has not been observed under omalizumab. he agreed to be challenged in the mobile gae²len exposure chamber* with house dust mite allergen for min. the total symptom score increased from to points after min exposure time remaining stable till the end, the positive nasal inspiratory flow decreased from to l after min and l after min, the fev decreased from % to % pred. following the inhalation of salbutamol the fev reversed. conclusions: mepolizumab has an anti-asthmatic effect but the anti-allergic efficacy seems to be small or absent. methods: all patients treated with omalizumab for severe allergic asthma or chronic spontaneous urticaria at the department of respiratory medicine and allergy at aarhus university hospital (n= ) were grouped after their home municipality. the number of omalizumab treated patients/inhabitant in these municipalities was correlated to the distance to the treatment centre at aarhus university hospital. results: mean distance to the treatment centre was . km for all inhabitants in the central region, while patients treated with omalizumab lived in average . km away. we found a negative linear correlation between the number of patients treated with omalizumab/inhabitant and the distance from the municipality to the treatment centre (slope: À . %ci: À . to À . ), p=. , n= ). conclusions: patients living at long distance from the treatment centre are less likely to be offered omalizumab treatment for severe allergic asthma or chronic spontaneous urticaria. objectives: demographics, clinical characteristics, and response to mepolizumab, were evaluated for atopic and non-atopic subgroups. sensitization to any one of the following; house dust mite, dog dander, cat dander, alternaria, or cockroach was considered as atopic, as assessed by specific serum ige of ≥ . ku/l. mensa (nct ) was a gsk sponsored study. results: of the severe asthma patients, ( %) were considered atopic, ( %) were considered non-atopic and atopic status was missing for ( %) patients. the majority of atopic patients (n= ) were sensitized to ≥ antigens. compared to the non-atopic sub-group the atopic sub-group was younger with a mean age of vs years of age, had a longer mean duration of asthma ( . vs . years), and a higher total baseline ige level ( u/ml vs u/ml). mean number of exacerbations in the months prior to the study was similar in the atopic and non-atopic subgroups ( . vs . ) as was the mean baseline peripheral blood eosinophil level ( cells/ll vs cells/ll). with mepolizumab an % reduction in eosinophils was achieved by week irrespective of atopic status and maintained throughout the treatment period. mepolizumab reduced the rate of exacerbations relative to placebo by % in the atopic subgroup and by % in the non-atopic subgroup. conclusions: the mensa study recruited an equivalent portion of atopic and non-atopic severe asthma patients. the atopic population was younger and had a longer duration of asthma than the non-atopic subgroup. while the baseline total ige level was > times greater in the atopic subgroup, the pharmacodynamic and efficacy response to mepolizumab treatment was similar. introduction: a treatment goal in the management of oral corticosteroid (ocs) dependent severe asthma is to reduce daily ocs use due to the side effects associated with long term use. anti ige treatment is used in atopic patients to reduce daily ocs. this analysis characterizes ocs reduction and asthma control in the sub-set of atopic and non-atopic ocs-dependent severe eosinophilic asthma (sea) patients from the -week sirius ocs reduction study. objectives: sirius study participants (n= ) were sub-grouped by atopic status in a post-hoc analysis; demographics, clinical characteristics, and response to mepolizumab were evaluated. sensitization to any one of the following; house dust mite, dog dander, cat dander, alternaria, or cockroach was considered as atopic, as assessed by specific serum ige of ≥ . ku/l. sirius (nct ) was a gsk sponsored study. results: of the ocs-dependent sea patients, ( %) were considered atopic ( % female), ( %) were considered non-atopic ( % female), atopic status was missing for patients ( %). compared to the non-atopic sub-group, the atopic sub-group was younger; mean age of vs years of age, while the mean duration of asthma was the same irrespective of atopic status ( years). the mean ocs daily dose and acq- score at baseline were similar between subgroups ( . mg vs . mg and . vs . , in the atopic and non-atopic subgroups respectively). the mean baseline peripheral blood eosinophil level was comparable in both subgroups ( cells/ll vs cells/ll) while the total ige level was higher in the atopic subgroup ( u/ml vs u/ml). mepolizumab lead to a ≥ % reduction in eosinophils by week irrespective of atopic status and eosinophil reduction was maintained throughout the study. mepolizumab reduced the ocs dose in the atopic group and non-atopic subgroups (odds ratio of a greater ocs reduction category of . ( % ci . , . ) and . ( % ci . , . ), respectively) and led to improvement in asthma control with a change in acq- of À . ( % ci À . , . ) in the atopic subgroup and À . ( % ci À . , . ) in the non-atopic subgroup. in an ocs dependent sea population mepolizumab reduced eosinophils independent of ige level and atopic status. in this limited post-hoc analysis, mepolizumab was an effective ocs sparing agent while improving asthma control in both atopic and non-atopic patients. patients who responded to retreatment had a similar mean time to response between the st dosing period ( . weeks) and nd dosing period ( . weeks). of all patients who were retreated (n= ), symptom control (uas ≤ ) after two doses was achieved in % ( st period) and % ( nd period) of patients; complete response (uas = ) occurred in % ( st period) and % ( nd period) of these patients. omalizumab was well-tolerated during both dosing periods. conclusions: omalizumab retreatment is safe and effective in patients with ciu/csu who respond to initial treatment and relapse after withdrawal, with most patients regaining symptom control after a nd course of omalizumab. : total ige reactivity of the grass allergoid formulation was diminished compared with native unmodified extracts. a difference in igg profiles was observed and indicated enhancement of accessible reactive igg epitopes across size distribution profiles of the grass allergoid formulation. detailed analysis of the epitope specificity showed retention of six lol p igg binding epitopes in the grass modified extract. all epitopes were mapped on the solvent exposed area of lol p homology model accessible for igg binding. one of the epitopes was identified as an "immunodominant" lol p igg binding epitope ( -ifkdgrgcgscfeik- ) and classified as a novel epitope. lastly, lol p igg antibodies showed functional capacity to block up to % of ige binding sites which provides evidence in protective function of immunotherapy induced antibodies against native allergens. the structural and immunological changes which take place following the grass allergen modification process were further unravelled revealing distinct igg immunological profiles. the results from this study support the concept that modification not only enhances the safety profile of scit but allows shorter-course objectives: design targeted sirna delivery system into liver cells. results: liposome surface was modified by lactose derivatives with different structures: lac(c ) and (lac) lac(c ) . the basic physicochemical and biological properties of the carriers have been examined. it is shown that glycoconjugate introduction has no effect on the physico-chemical characteristics. however the carbohydrate modification of the liposomal surface leads to increasing in transfection efficiency on a specific cell line hepg . moreover, the introduction of mono-carbohydrate derivative increases the transfection efficiency better than using a branched derivative of lactose. in the pharmacokinetic study target effect also was shown. unmodified liposomes start to be detected in the liver at minutes after administration, whereas modified liposomes were detected at minutes after administration. similarly, the excretion of modified liposomes from the liver was more slowly. also worth noting the high concentration of modified liposomes in the liver. furthermore liposomes modified by carbohydrates reduces the intensity of its accumulation in the lung. conclusions: it was shown that increasing attraction of drugs to the liver cells can be achieved by using liposome modification with lactose derivative. | sialylated fetuin-a is a candidate predictive biomarker for successful grass pollen allergen immunotherapy objectives: to identify new biomarkers of ait efficacy, pre-treatment sera obtained from grass pollen allergic patients responding or not to sublingual ait were differentially assessed by d-dige or label-free mass spectrometry. the role of fetuin-a in allergy physiopathology was studied by using gene silencing in a mouse asthma model, human dendritic cell stimulation assays and surface plasmon resonance. results: using comparative proteomics, we provide evidence for an increased o-linked sialylation of fetuin-a in sera collected before treatment from patients exhibiting clinical responses, when compared with low responders. whereas feta may either inhibit or promote chronic inflammation, no specific role in allergy had been ascribed to it until now. in ovalbumin-sensitized mice, silencing of the fetuin-a gene increased airway hyperresponsiveness and th responses. fetuin-a, but not its non sialytated counterpart, synergizes with lps and grass pollen or mite allergens in a tlr -dependent pathway to enhance the proallergic profile of human monocyte-derived dendritic cells. conclusions: quantification of sialylated fetuin-a glycoforms in the blood before treatment allows to identify patients more likely to benefit from grass pollen immunotherapy. validation of the hypothesis that this marker associated with "an inflammation status" can be used to predict ait efficacy is ongoing in larger cohorts of patients. introduction: kawasaki disease (kd) is a vasculitis that mainly affects small to medium-sized vessels, particularly the coronary arteries, and is a leading cause of acquired heart disease in children. previously, we found that the development of kd is associated with an elevation of both th and th immunity. gene hypomethylation is abstracts | an important form of epigenetic regulation, which results in increased gene expression. because m macrophages are associated with inflammation and th immunity while m macrophages are associated with immune regulation and th immunity, we hypothesize that kd is associated with hypomethylation of both m and m macrophage related genes. objectives: our objective was to investigate the methylation profile of m and m related genes in patients with kawasaki disease. twenty-four patients with kd and age-matched healthy controls (hc) were included in this study. in patients with kd, blood was sampled hours before ivig therapy (kd ) and days after ivig therapy (kd ). after dna extraction, samples were analyzed using human methylation bead chip (illumina) to examine the methylation ratios of genes related to m macrophages ( genes, cpg sites) and m macrophages ( genes, cpg sites). cpg sites with more than % difference in methylation levels and a pvalue less than . between groups were considered significant. objectives: primary aim of the study is the identification of differentially expressed genes (deg) associated with allergic rhinitis (ar) by using genome-wide transcriptomics data from blood immune cells. this set of candidate genes will then be used to define gene networks relevant for onset, severity and potential treatment outcome of house dust mite associated ar. with different ethnicity or populations exposed to a different environment is currently in preparation. introduction: allergic patients display abnormal immune responses to harmless antigens, leading to various symptoms from hay fever to life-threatening conditions. these responses include abnormal type immunity polarization and induction of allergen-specific memory t and b cells, resulting in development of allergy instead of immune tolerance. allergen-specific immunotherapy (ait) is currently the only causative treatment of allergic disorders. yet, in depth understanding of the underlying differences in allergen-specific cd + t cell and treg responses between allergy and tolerance and their changes during immunotherapy is lacking. objectives: we investigated whole-genome transcriptomics of circulating birch (bet v ) and grass (phl p a)-specific cd + t cells in allergic patients before and at , , and months of ait, as well in non-allergic healthy controls in corresponding seasonal time points. detailed immunophenotyping with flow cytometry and cd + mhc class ii tetramer staining with low rna/single cell next generation sequencing were performed. results: at baseline, out of the pollen season, there were more allergen-specific cd + t cells in allergic patients than in controls. at this time, over genes were significantly changed in allergenspecific as compared to total cd +t cells in patients, yet we found substantial differences in signal transduction and inflammatory response gene expression when compared to healthy controls. during ait we noted significant increase of allergen-specific cd + cells in patients with subsequent gene expression changes in the immune tolerance pathways. finally, we found increase in allergen-specific treg cells in patients upon ait, but not in tolerant controls in corresponding seasons. of interest yet, at early ait time points, allergenspecific treg cells displayed gene profiles suggesting their insufficient suppressive functions. conclusions: in summary, in vivo allergen exposure causes profound changes in the transcriptomic profiles of allergen-specific t cells. these gene profiles seem to be deficient at baseline in allergic patients, but ait is skewing them into the tolerant controls levels. introduction: the variability of the pharmacological response to beta (b )-agonists may be due to the polymorphism of the gene of results: singled out statistically significant differences of the genotype distribution. the gly/gly homozygous allele was discovered twice as often in the group with an insufficient response to b -agonists than in the group with a good response ( vs %, p<. ), while the distribution of heterozygous allele was detected the opposite pattern ( vs %, p<. ). in the arg/arg genotype distribution, there were no considerable differences in both groups ( % in each group). in the subgroups of children, receiving the high doses of the inhaled glucocorticoids, there was a trend for the prevalence of gly/gly homozygous allele prevalence. we have discovered the association of the gly/ gly genotype of the adrb gene with an insufficient effect of broncholytic therapy by means of short-term b -agonists; we also revealed the participation of the gly allele in the phenotype formation with the severe run of bronchial asthma and tolerance towards the therapy both by b -agonists and inhaled glucocorticoids. mckenna oe ; posselt g ; lackner p ; schmitt a ; h€ ollbacher b ; briza p ; wessler s ; gadermaier g ; ferreira f universit€ at salzburg, salzburg, austria; georg august-universit€ at g€ ottingen, g€ ottingen, germany introduction: an excess of million people worldwide have a reported allergy to birch pollen. proteases in such allergen sources have been suggested to contribute to primary sensitisation and exacerbation of allergic disorders. until now the protease content of betula pendula, a species endemic to the northern hemisphere, has not been studied in detail. hence, we aim to identify and characterise pollen and bacterial derived proteases found within betula pendula pollen. objectives: birch pollen transcriptome was constructed via de novo transcriptome sequencing. reads were assembled using the trinity software suite.. analysis of the birch pollen proteome was achieved via mass spectrometry and use of zymographic gels with the embedded substrates gelatinase and casein, which enabled visualisation of proteolytic activity. further to this, protease activity was quantified using a fluorescently labelled casein substrate protease assay. results: by using mass spectrometry, we were able to identify up to proteases within birch pollen. we could cluster the proteases into specific families based on their distinct proteolytic activities. further comparative analysis of the proteome and transcriptome revealed the relationship between transcript levels and the proteins they encode. zymographic methods enabled distinct visualisation of proteolytic activity for both casein and gelatin substrates. using fluorescently labelled casein, the birch pollen protease activity was quantified as . lg/ml when compared to a trypsin standard curve. additionally, bacterial isolates of the birch pollen were identified, and the proteolytic activity analysed. we report successful discovery of pollen and bacterial derived proteases endogenous to betula pendula. whilst none of the known birch pollen allergens have been recognised as a protease, we aim to investigate the role of tight junction degradation within epithelial cells and further enhance understanding of proteolytic activity on immune-polarization. objectives: to investigate the frequency and reasons of shortand long-term reintroduction failure in adults after a negative fc. method:: these are preliminary results of an ongoing prospective study. after a negative fc, patients receive standardized aftercare consisting of an introduction scheme to introduce the food at home and consultation by phone for advice and support hours, - weeks and months after the fc. short-term data about the frequency that patients failed introduction, defined as not completing the introduction scheme or patient-reported allergic complaints repeatedly during introduction, was obtained using a telephone interview. long-term data ( - months after negative fc) about frequency and reasons of reintroduction failure in daily diet, defined as not eating the food or only eating products with traces of the food, was obtained using a patient-reported questionnaire. results: from until now patients were included (mean age: years, male: %), who underwent a total of fcs with: hazelnut ( %), other nuts ( %), fruit ( %), composite meals ( %), fish and crustaceans ( %), cow's milk ( %), hen's egg ( %) and other ( %). in ( %) of the negative fcs, introduction using an introduction scheme was advised. in %, patients did not receive standardized aftercare for different reasons, eg negative fc with a composite meal. in %, introduction with an introduction scheme failed. long-term information was available for fcs. introduction failed in fcs ( %), including patient that even avoided traces of the food. patient-reported reasons for introduction failure were (n= ): symptoms after ingestion of the food (n= ), fear for allergic reactions (n= ) and not like the taste of the food (n= ). conclusions: short term introduction with an introduction scheme failed in %. however on the long-term in almost one third of the negative fcs, patients failed to reintroduce the food in daily diet, despite careful aftercare. it is recommended to give these patient even more intensive and tailored support. introduction: in order to help allergic patients manage often severe symptoms, food manufacturers are required to list allergens on labels and take precautions to avoid inadvertent contamination of foods with allergens. existing tools using generic immunoassays do not provide precise identification or quantification of specific food allergens. furthermore, existing elisa immunoassays are not able to be run simultaneously and are often unreliable. objectives: our goal was to develop and validate an accurate, sensitive and high throughput immunoassay that would enable simultaneous quantification of multiple allergens in foods. fluorescent beads coupled to allergen specific monoclonal antibodies were used to develop a multiplex array for simultaneous quantification of major allergens from peanut (ara h ), milk (bos d ), egg (gal d ), and shrimp tropomyosin (pen a ). target allergens were detected using biotinylated antibodies and streptavidin conjugated fluorochrome. the array was quantified using highly purified natural allergens as standards. allergen content was measured in various samples including samples spiked with purified allergen and allergen incurred food matrices. the results were compared to elisa. a multi laboratory validation was performed to validate the performance characteristics of the assay. results: there was a high correlation between the multiplex array and allergen specific elisa. the limit of detection of the array was as low as pg/ml. no significant cross reactivity was observed between the various food allergen assays. the recovery of allergen from spiked samples was generally between and %. inter and intra assay variability was observed to be less than %. in conclusion, an accurate, sensitive and reliable multiplex array for major food allergens was developed and validated. the flexibility of the microsphere technology allows for further expansion to produce a comprehensive array for the most important food allergens. this quantitative multiplex array may help to reduce the risk of inadvertent contamination of food. objectives: our aim was to create a food allergy web-based educational program for both schools and restaurants professionals. results: an interactive platform that hosts a free learning program, conclusions: the program and the toolkit are currently available online and are being implemented in schools at the north of portugal. we expect that fac program will give us an important insight on the professionals' knowledge about food allergy. additionally, acting as free integrated service and awareness effort, this program could be an educational tool easily adapted and disseminated, which may improve professionals 'commitment and skills to deal with food allergy in the community. | development of parallel reaction monitoring (prm) methods for soy and milk detection: consideration of allergen-derived ingredients chen s ; krawitzky m ; yang ct ; downs m university of nebraska-lincoln, lincoln, united states; thermo fisher scientific, san jose, united states introduction: the presence of undeclared food allergens poses both regulatory and health risks. in order to assess the magnitude of these risks, accurate quantitative detection methods are required. for some allergenic foods, the food industry uses not only the allergenic source but also a number of source-derived ingredients. some detection methods (both immunoassays and mass spectrometry methods) may fail to accurately detect and quantify these allergen-derived ingredients if they are not taken into consideration during development. objectives: the objective of this work was to select peptide targets for parallel reaction monitoring (prm) mass spectrometry methods that are suitable for detecting a variety of soy-and milk-derived ingredients. six soy-derived and six milk-derived ingredients were obtained for this study. the ingredients were extracted ( mmol l À tris-hcl, ph . , with mol l À urea, mmol l À dtt, and % pvpp) and subjected to in solution trypsin digestion. discovery proteomics analysis was conducted by lc-ms/ms using a q exactive tm plus orbitrap tm running in top data-dependent acquisition mode. peptides were identified using proteome discoverer . and relative, labelfree quantification was conducted on high-confidence (fdr< . ) peptides. selected peptides were subsequently analyzed in a targeted prm mode. results: the relative abundance of identified peptides varied among both the soy-derived and milk-derived ingredients. in the case of soy ingredients, for example, there were particularly marked decreases in the abundances of numerous peptides, across different proteins, in a hydrolyzed soy protein isolate. in the milk ingredients, variation in peptide abundance could be more directly attributed to differences in product protein fractionation (eg a decrease in abundance of whey proteins in a sodium caseinate product), although some peptides and proteins maintained consistent abundance across ingredients. after applying specificity and performance criteria, peptides from soy proteins and peptides from milk proteins were selected for further analysis in a targeted prm method. conclusions: peptide abundances vary widely among ingredients derived from allergenic foods. consideration of these peptide differences during ms method development by incorporating discovery proteomics may lead to more versatile and widely-applicable quantitative detection methods for food allergens. introduction: milk and its derivates are usual ingredients in many food products, which must be excluded by cow's milk allergic (cma) patients. oit protocols in patients with cma appear to be safe and effective in inducing desensitization and milk introduction in the diet. objectives: we conducted a survey in cma patients after successful completion of an oit programme, to assess their dietetic profile after introduction of fresh milk and dairy products (unrestricted diet) we considered cma patients (pts), males and females, age - (median . ), who successfully completed the oit protocol. these patients were on an unrestricted diet for milk and derivates, and they had been recommended to assume at least ml of fresh milk or yogurt every day. patients were given an ad hoc questionnaire to assess the milk/dairy products intake at least months after oit completion. results: from our investigation all of the pts have been assuming milk protein everyday without significant reactions after oit. % of the interviewee ( pts) referred to be drinking fresh milk at least three times a week, in a quantity of ml or higher. of note, % have to add cocoa powder ( pts) or coffee ( pts) to mask milk taste. dislike of milk taste was the cause of the refuse to take fresh milk in pts (over patients that didn't take milk at all); pts who didn't drink milk had at least ml yogurt instead, almost every day. fresh cheese was eaten at least once a week by % of all the pts; hard cheese was eaten as main course almost once a week by %. % of patients consumed biscuits and sweet baked products containing milk/derivates at least once a week, % every day. pizza was also present in the diet of the majority of pts ( %), once a week/month. ice cream was appreciated by all the patients and regularly assumed especially during the summer time. conclusions: taste seems to be the main factor that directs the daily choice of milk derivates or milk containing products. all pts easily consume baked products containing milk/derivates, and the majority of them accept fresh milk as advised in order to maintain unresponsiveness. our survey confirms that oit is effective in expanding food choice, but for some patients the change of dietetic habits is hampered due to taste reasons. a more detailed, qualitative and quantitative analysis of the milkunrestricted diet will derive from the -days food diary given to these patients. | frozen-defrosted dried skimmed milk is a suitable product for sublingual immunotherapy for cow's milk allergy introduction: sublingual immunotherapy (slit) is a promising treatment for cow's milk allergy (cma) due to its favourable safety profile. however, its efficacy is limited-probably due to the small volumes and doses that can be delivered sublingually, especially in children. milk products with preserved allergenicity that allow higher protein concentrations in smaller volumes might potentially improve the efficacy of slit for cma. dried skimmed milk (dsm) could fulfill these characteristics. in addition, once dsm is reconstituted, freezing individual vials from the same batch for further administrations could increase dose-consistency throughout the treatment, which would help ensure safety. however, little is known about whether processing to produce dsm, and further freezing-defrosting, may alter its allergenicity. objectives: to evaluate the allergenic protein composition of dsm, including once frozen-defrosted, in comparison to fully-allergenic usually consumed fresh milk. methods: sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page) followed by silver staining was performed following the laemmli method to determine the soluble protein composition of the following products: fresh pasteurized milk (friesland campina, amersfoort, the netherlands), dsm (marvel, the premier foods group ltd, london, uk) and frozen-defrosted dsm to identify all protein bands present. western blot with anti-whey and anti-casein antibodies was performed to identify the specific allergenic proteins. results: no significant differences were found amongst the milk products tested, with sds-page displaying all the bands corresponding to the major allergenic proteins in milk (alpha-lactalbumin, beta-lactoglobulin and alpha-, beta-and kappa-caseins) and the western blot showing recognition to all proteins with similar intensity. the major allergenic proteins present in unprocessed milk are well-preserved in dsm, even after freezing-defrosting, making it a convenient product for sublingual immunotherapy. results: nineteen children were randomized into the low dose group (n= ) and the elimination group (n= ). there were no significant differences in background between these groups. after weeks of therapy, the rate of passing the oral food challenge test with / th of a whole egg was significantly higher in the low dose group ( / ( %) vs / ( %), p=. ). ovomucoid-specific ige levels in the low dose group after weeks were significantly lower than those at baseline. adverse events associated with both therapies did not occur during the study period. conclusions: these results show that low dose ingestion of egg is safe and effective for tolerance or desensitization induction in children with egg allergy, without the need for dose elevation. | another brick in the wall: toward a national food allergy strategy for canada introduction: the world is experiencing an apparent epidemic of food allergies. with rising prevalence and increasing global spread, basic scientists continue to search for causes while clinical and social scientists continue to study the consequences. these include life-long chronic illness, fear and anxiety, social exclusion and stigma, all of which are underscored by inequalities across vulnerable groups (eg, low income families, immigrants, indigenous peoples). concomitantly, consumer organizations and patient support groups attempt to influence policy in order to maximize choice and minimize risk for individuals and families affected by food allergy, both directly and indirectly. this includes food labeling legislation, food safety regulations, and policies and practices in public places such as schools, restaurants and transportation modes (eg, airplanes). objectives: in canada, with the support of + years of science undertaken by the allergy genes and environment (allergen) networks of centre of excellence in allergic disease, we are leading a national team that aims to establish the building blocks for a national food allergy strategy. conclusions: the greatest challenges to building a national food allergy strategy are not those related to the basic or clinical science, but rather the activities and commitment of individual stakeholders. while gaps remain in the science, the challenges of transdisciplinary integrated knowledge translation hinder progress. we present lesions learned regarding culture shifts that will facilitate the progress we need to maximize choice and minimize risk for canadians affected by food allergy. | component resolved diagnostics reduces diet restrictions by half among finnish school children savolainen j ; mascialino b ; pensamo e ; hermansson l ; silvan m ; borres mp ; korhonen k university of turku, turku, finland; department of allergology, uppsala, sweden; thermo fisher scientific-immunodiagnostics, turku, finland; university of turku, uppsala, sweden; thermo fisher scientific-immunodiagnostics, lieto, finland introduction: there are - special diets because of food allergy in finnish schools. the finnish allergy program - was launched to reduce problems and costs induced by allergies. one of the special aims was to reduce diets caused by food allergy will by %. the h€ ark€ atie social and health care service region schools have required doctor's certificates for diets for over abstracts | years. all diets are listed in a register and checked on a regular basis. objectives: the purposes of this study were to evaluate whether it is possible reduce the special diets when the special diet system appears to be working well and to assess the added value of immu-nocap ® isac allergen component diagnostics in the intervention. results: there were children attending the schools in the h€ ark€ atie region. there were children with diet due to food allergy. children were recruited to study from the diet register and contacted by a nurse's phone interview. there were children who refused the study leaving children for the assessment of the diet. children were not following any diet and in children the diet was not regarded necessary by the study nurse. children agreed to take part in the study and were referred to laboratory tests for food specific ige and isac. children dropped out leaving children in the study. after the food specific ige results were available, children were contacted by physician. based on the results and/or interview a free diet was allowed for children. children were eating small amounts of the food and were encouraged to increase the use of the foods. children were advised to avoid the foods only if they caused symptoms. only children were advised to continue diet. after the results of isac were available, children conclusions: the study confirmed that it is possible to have diets decreased over % in accordance to the finnish allergy program. additionally, the study showed that food allergic children can benefit from the use of component resolved diagnostics. | omalizumab treatment for severe food allergy caused by lipid transfer protein: a preliminary case series mari a; zennaro d; ferrara r; bernardi ml; alessandri c caam-centri associati di allergologia molecolare, rome, italy introduction: lipid transfer proteins (ltp) are allergens from plantderived foods causing symptoms ranging from oas to anaphylaxis. ltp are present in almost all kind of plant species used for human feeding. ltp allergic patients suffer of reactions to a broad variety of foods, with a very personal reactivity profile which can involve few or many foods. in addition, patients who start to record severe reaction to several foods begin to be afraid of eating any other related or non-related food, leading to a poor diet. omalizumab (ozm) has been documented to be effective in treating food allergies with sensitization to other allergens. objectives: to document the approach for recruiting, studying, monitoring ltp allergic patients, and do a preliminary evaluation of the clinical impact of ozm therapy. results: six adult patients with documented reactions to plantderived foods in the last months and diagnosed to be ige positive to multiple ltp by using multiplex testing, namely isac at the beginning and faber during the follow up, were recruited. ozm was offered as an off label treatment adopting an open label study design. a questionnaire was submitted to each patient before, during and after the treatment. foods listed as "no more eaten" where considered for reintroduction, starting from those excluded because of fear, going for those with an increasing risk of reactions. re-introduction was done at home after receiving detailed instructions, having all rescue medication at hand. the allergist was connected real time with the patients using one or more ict tools. one patient dropped out because was not complying with the scheduled reintroduction. three patients completed the treatment with a successful re-introduction of all or almost all excluded foods, in two cases peach was reintroduced. the last two patients reintroduced %- % of the excluded foods, including some of those previously causing reactions. the attempt of re-introducing the most risky foods failed causing local allergic reactions promptly controlled by the therapy. all foods re-introduced were tolerated once the treatment was stopped. conclusions: ozm seems to be a promising treatment for severe ltp allergics, improving their qol. starting from the recruitment phase to the re-introduction, the overall procedure looks quite complicated and deserve much resources. ige sensitization to ltp, carefully defined before treatment, can be monitored during the ozm course as the drug doesn't interfere with faber test ige detection. | oral immunotherapy with peach-juice in lipid transfer protein (ltp) allergy: is it possible to reach tolerance? introduction: food allergy to rosaceae fruits and nuts, due to sensitization to lipid-transfer protein (ltp), is frequent in the mediterranean area countries. based on milk allergy oral immunotherapy (oit) protocols, a study is proposed to obtain an oit regimen in patients allergic to ltp. objectives: we included patients with anaphylactic reactions due to ltp-food allergy, from january/ to october/ . skin prick test (spt) was performed with a food and inhalant battery, ltp bial-aristegui ® ( . mg/ml), prick by prick (pbp) with a specific commercial peach-juice (dilutions to endpoint), and determination of pru p ige levels (immunocap). the presence of pru p protein in the peach-juice, was confirmed by sds-page and elisa method, and quantified with anti-pru p . we elaborated an oit guideline with progressive administration of peach-juice, - - - drops ( drops= . ml), sublingually, starting concentration chosen according to the endpoint spt results, up to ml daily dose. the dose reached at the allergy service, was continued at home, daily, for - weeks. all the increasing doses were performed at the allergy service, after pbp with peach-juice and ltp control spt. after a time, an oral challenge up to ml peach-juice was performed. patients were instructed on the importance of maintaining regular intakes and avoiding cofactors. results: patients started this protocol ( male/ female), aged - (media . ). peach-juice analysis in agarose gel electrophoresis, showed a kda band quantified as . lg/ml of ltp. there was no difference between wheal diameter on spt for ltp bial-aristegui ® and pbp with commercial peach-juice along all the study. average concentration on pbp to endpoint: / ( ), / ( ), / ( ). pru p ige level average: . ku/l. none anaphylactic or serious reactions during the oit protocol appeared. only five patients ( %) reported mild occasional symptoms (oral pruritus and mild located urticaria). patients reached ml daily dose ( . %), and of them ( %) completed oral food challenge with peach-juice up to ml, with good tolerance. this pattern also allowed us to reintroduce withdrawn foods from the diet due to previous reactions, with good tolerance. results: children (age - years) sensitized to dog dander extract (median . ku a /l), with or without known dog induced allergic airway disease, were included. nasal provocation testing with dog dander extract was performed. measurement of ige to dog dander extract and to can f -can f was performed with immunocap. an ige level ≥ . ku a /l was considered positive. among all children sensitization to can f ( %) and can f ( %) was most frequent. corresponding numbers for can f , can f , can f and can f were %, %, % and % respectively. based on the results from the nasal challenges three groups were identified; no (n= ), mild (n= ) and strong reaction (n= ). the median ige levels to dog dander and to all allergen molecules were higher in the strong reaction group than in the mild and the no reaction group. among children with a strong reaction, ige to can f was found in % ( / ) compared to % ( / ) among children with no reaction (p=. ). ige to can f showed a similar pattern (p=. ). % ( / ) of the children with a strong reaction were sensitized to can f compared to . % ( / ) of the patients with no reaction (p=. ). no associations were found between the ige levels to can f , can f and can f and the no reaction or strong reaction groups. using multiple regression analysis, with all allergens in the model, sensitization to can f showed a statistically significant difference between the groups. conclusions: molecular allergology may improve diagnostics of dog allergy in children. sensitization to the lipocalin can f was significantly associated to a strong positive nasal reaction implying its usefulness as a marker of clinically relevant dog allergy. tsolakis n ; malinovschi a ; nordvall l ; janson c ; mattson l ; lidholm j ; borres m ; alving k uppsala university, women's and children's health, uppsala, sweden; uppsala university, medical sciences, uppsala, sweden; thermo fisher scientific, uppsala, sweden introduction: cat allergy is common worldwide and a major trigger of asthma in many countries. molecular patterns of cat sensitisation vary between individuals but their relationship with allergic inflammation has not been extensively studied. objectives: the aim was to investigate the prevalence of ige to different cat allergen components and their relationship to type- inflammation and bronchial responsiveness in young asthmatics. conclusions: ige sensitisation to cat serum albumin (fel d ) and cat lipocalins (fel d , fel d ) , but not to secretoglobin (fel d ) or cat dander extract, were independently associated with feno and b-eos count. we suggest that cat serum albumin and cat lipocalins can be used as markers for increased risk of type- inflammation in young asthmatics, as shown in multiple regression analyses. | complete sequence and recombinant production of horse dander allergen equ c lidholm j; lundgren t; larsson h; mattsson l thermo fisher scientific, uppsala, sweden introduction: horse dander is an increasingly important cause of respiratory allergy. equ c was one of the first horse allergens to be recognised but only a small part of its amino acid sequence has been reported. objectives: the aim of this study was to determine the complete sequence of equ c and express it as an immunoreactive recombinant protein. methods: equ c was purified by size exclusion, hydrophobic interaction, anion exchange and reversed phase chromatography. recombinant equ c was expressed as a hexahistidine tagged protein in e. coli and purified by immobilized metal ion affinity and ion exchange chromatography. ige antibody reactivity to natural and recombinant equ c and other horse dander allergens was determined in sera of subjects allergic to horse. results: a putative equ c sequence predicted from genomic data revealed a lipocalin protein of amino acids with a highest sequence identity among known lipocalin allergens of % to can f . n-terminal sequencing and mass spectrometric analysis of purified natural equ c confirmed . % ( / residues) of the predicted sequence. recombinant equ c displayed ige antibody binding activity comparable to that of purified natural equ c (r=. ). of the horse allergic subjects studied, ( %) showed ige antibody binding to equ c , ( %) to equ c , ( %) to equ c and ( %) to equ c . the complete sequence of equ c was established. as a fully immunoreactive recombinant protein, it represents an important addition to the panel of allergens useful in the diagnosis of allergy to horse. | component resolved diagnosis using guinea-pig allergens elucidates allergen sensitization profiles in allergy to furry animals objectives: to identify major guinea-pig allergens and to evaluate their potential as reliable markers for a specific ige-diagnosis in comparison to dander extracts. results: forty-three patients with a clinical history of allergy to guinea-pig and patients allergic to cat and/or dog were recruited for the study. major guinea-pig allergens were identified by ige-immunoblot and n-terminal sequencing of ige-reactive proteins. corresponding cdnas were cloned and allergens were expressed as recombinant proteins in e. coli. specific ige to animal dander, fel d and can f were determined, specific ige to fel d , can f and to guinea-pig allergens were quantified by elisa. two new guinea-pig lipocalin allergens, cav p and cav p , were identified in guineapig dander. the combination of guinea-pig allergens, the new allergens and the previously isolated lipocalins cav p and cav p , enabled the identification of out of patients sensitized to guinea-pig. the vast majority of the patients had specific ige to cav p ( %). cav p shares % sequence identity with fel d and can f and was found to be cross-reactive with these cat and dog allergens. in the group of cat and/or dog allergic patients, % had also specific ige to guinea-pig dander. nearly half of those ( %) had ige to cat serum albumin fel d or to fel d ( %) and to can f ( %), explaining the high degree of cross-reactivity to guinea-pig dander. only % of the cat/dog allergic patients with a positive isle test to guinea-pig dander had specific ige to any of the non crossreactive guinea-pig allergens cav p , cav p or cav p . however, none allergen has been characterized from mongolian oak. objectives: in this study, we tried to characterize a major allergen from mongolian oak. results: a molecule homologous to pathogenesis-related protein , a putative que m , was cloned by rt-pcr and its recombinant protein along with que a , an allergen from white oak (q. alba) was produced. cloned que m sequence shares . %- . % amino acid sequence identity ( . %) with pr- -like allergens from various plants. allergenicity and diagnostic value of recombinant que m abstracts | , que a and bet v proteins were compared by elisa using sera from oak sensitized subjects. specific ige to recombinant que m , que a , and bet v were detected in . %, . %, and . % of serum samples from korean tree pollinosis patients. recombinant que m was able to inhibit ige reactivity to que a and bet v , indicating its strong cross-reactivity. activation pattern of basophils from five patients was similar in terms of cd c expression and protein concentration of challenged bet v and que m . objectives: over the course of one year, all patients who were seen at our immunoallergology clinic for the first time underwent spt with our standard series, to which four olive tree cultivar extracts were added (arbequina, blanqueta, hojiblanca e picual). we then recorded wheal size diameters, considering a wheal > mm to correspond to a positive test. we recorded individual sessions of spts, in which presented at least one positive result. two hundred and thirtysix of these patients ( . %) had a positive spt for olive tree pollen, only one of them being monosensitized. when looking only at pollen-sensitized patients, twenty-two patients ( . %) tested positive solely for olive tree pollen. in all allergic patients, the most frequent cultivar sensitization was to the cultivars hojiblanca ( . %) and arbequina ( . %), followed by the cultivars picual ( . %) and blanqueta ( %). twenty-six patients ( % of all olive pollen sensitizations) had a positive spt for the conventional extract and negative spt for the cultivars; patients ( . %) had a positive spt for both. we noted that . % (n= ) of patients sensitized to olive tree pollen had a negative spt with the conventional extract and positive with one of the cultivar extracts. the cultivar hojiblanca was the most frequent in this group ( . %, n= ), followed by the arbequina cultivar ( . %, n= ). in the group as a whole, there was a positive correlation between the results of the spts with the conventional extract and each of the cultivar extracts. this correlation was weaker with the cultivar hojiblanca (r=. ). conclusions: some patients, sensitized only to the pollen of certain olive tree cultivars, are not identified with the conventional extract. spt with the hojiblanca cultivar could identify most of these patients in our country, and therefore should be considered in patients with a history of pollinosis and a negative spt for the common extract of olive tree pollen. | structural and immunological comparison of heat treated pru p and art v , the non-specific lipid transfer proteins of peach and mugwort pollen wildner s ; stock l ; regl c ; alessandri c ; mari a ; huber c ; stutz h ; gadermaier g objectives: recombinant art v . and pru p . were expressed in e. coli rosetta-gamib plyss and purified using cation exchange chromatography. proteins were analyzed in gel electrophoresis and mass spectrometry. proteins were incubated at °c in time intervals up to min using buffers at ph . and . . physico-chemical properties of native and heated allergens were analyzed by circular dichroism spectroscopy, dynamic light scattering and size exclusion chromatography (sec). using sera from italian patients sensitized to pru p and art v (n= ), ige binding to native and heat-denatured allergens was investigated in elisa. results: highly pure recombinant pru p and art v were obtained as non-tagged proteins from e. coli. identity and formation of disulfide bonds was verified by mass spectrometry. circular dichroism showed high thermal stability of both proteins at acidic ph. the alpha-helical fold of art v was lost upon heating for min at ph . while pru p was already altered after min. purified pru p and art v are monomeric molecules with a hydrodynamic radius of . and . nm, respectively. structural relaxation is observed upon heat treatment which is not attributed to protein aggregation as determined by sec. the ige reactivity to both allergens was largely unaffected upon heating at ph . . notably, ige reactivity to art v was already significantly decreased upon min heating and was completely abrogated to both proteins after min denaturation at neutral conditions. conclusions: even though the fold of pru p is more compact compared to art v , susceptibility to structural changes upon thermal treatment at neutral conditions are more pronounced which do however not directly translate to lower ige binding capacities. particularly the buffer environment needs to be considered when formulating ltp-containing products which undergo heat treatment. objectives: we sought to determine the ige binding capacity and potential diagnostic value of a recombinant hybrid molecule. results: the codon-optimized nucleotide sequences of a hybrid molecule comprising the full sequences of blo t and der p at the amino and carboxyl ends respectively, here named bp- , was cloned into a plasmid vector and expressed in escherichia coli as a xhis tag protein. two hundred and thirty three sera from colombian (n= ) and cuban (n= ) allergic patients were tested by elisa for ige reactivity. thirty seven sera from non-allergic subjects and negative skin test (spt) to mites were used as controls. all subjects provided written informed consent to their participation in this study. hdm allergy was diagnosed on the basis of clinical symptoms in combination with mite extract spt. potential diagnostic value of bp- specific ige was determined by receiver operating characteristic (roc) analysis and area under roc curve (auc) calculated. positive serum ige values to hybrid molecule were defined as optical density (od) higher than . (mean od plus standard deviations in nonallergic subjects). in respiratory allergic patients, the overall frequency of positive ige reactivity to bp- was . %, in non-allergic subjects the frequency was %. serum ige levels to bp- were positively correlated to spt to b. tropicalis (spearman r=. , p=. ), and to d. pteronyssinus (spearman r=. , p=. ). using spt to mite extracts as gold standard, the sensitivity and specificity of serum ige levels to bp- were . % and . % respectively, with an auc of . ( % confidence interval . - . ). conclusions: these data suggest that bp- could be a useful reagent for identifying allergic patients sensitized to b. tropicalis and/or d. pteronyssinus. | igg, ige and igg specific antibodies to molecular allergens of aspergillus fumigatus introduction: in clinical allergy, alongside with skin prick tests, in vitro determination of specific ige for a particular patient contributes to the diagnosis and helps to estimate the risk associated with different food allergens. however, with commercial methods of specific ige antibodies detection (component-resolved diagnosis, crd), the clinician is typically limited by the list of the available allergens. objectives: to overcome this limitation, we developed two component-resolved diagnostic tests for food allergy in which natural extracts can be used. in the first developed method, the crd is performed using immunoaffinity capillary electrophoresis (iace) coupled with matrixassisted laser desorption/ionization mass spectrometry. meanwhile, the second method is based on in-tube immunomagnetic separation (ims) with mass spectrometry identification (mass spectrometry or peptide mass fingerprinting). in both techniques, magnetic beads coated with antihuman ige antibodies are used to extract the ige antibodies from the blood serum of the allergic patient. then, the immunocomplex, obtained on the magnetic beads, is used to quantify the total ige level or to probe the ige binding with standard allergens or natural allergenic extracts. afterwards, the identification of the extracted proteins, ie potential allergens, is performed by mass spectrometry with or without ce separation. after optimisation, the proposed methods have been successfully applied to a commercial blood sample of a patient with a known allergy to cow's milk, with results confirmed by standard tests. as a proof-of-concept, the sensitization profile of a patient suffering from protein contact dermatitis to the cow's whey fraction has been determined. we confirmed the presence of circulating ige antibodies binding lactoferrin and bovine serum albumin. cross-reactivity tests were also performed using goat and sheep milk and revealed the patient sensitivity to serum albumins from these two milks. such approaches open the possibility for direct identification of ige-bound allergens molecular mass and structure. these methods allow the discovery of yet unknown allergens and could be useful for precise personalized allergy diagnosis, allergens epitope mapping, and cross-reactivity studies. objectives: the objective of this study was to investigate the validity of cord blood ige for predicting atopy at years of age. methods: a total of children born in participated in the longitudinal investigation of global health in taiwanese schoolchildren (lights) cohort. total ige was measured in umbilical cord blood at birth. perinatal history was collected from medical records in the chang gung memorial hospital, taiwan. total and specific serum ige and questionnaires were carried out at years of age. receiver-operating characteristic (roc) curves were used to determine the validity of cord blood ige for predicting atopy at years of age. logistic regression models were applied to assess the association between cord blood ige and atopy at years of age. results: cord blood ige levels was significantly associated with total serum ige level at years of age (r=. , p<. ). the cord blood ige levels in atopic children aged years (meanaesd, . ae . ku/l) were significantly higher than those in nonatopic children ( . ae . ku/l) (p<. ). the area under the receiveroperating characteristic (roc) curve of cord blood ige for predicting atopy at years of age was . . the sensitivity, specificity, and positive and negative predictive values of cord blood at the optimal cutoff of . ku/l on the roc curve for predicting atopy were . %, . %, . %, and . %, respectively. higher cord blood ige levels (≥ . ku/l) was associated with a higher likelihood of atopy at years of age (or= . ; % ci: . - . ; p<. ). our results indicate that cord blood ige is a potential predictor of atopy at school age, with an optimal cutoff of . ku/l. bogomolov a vinnitsa national pirogov memorial medical university, vinnitsa, ukraine introduction: allergen sensitization is being diagnosed by commonly available methods in clinical practice-skin prick tests (spts) and specific immunoglobulin e test (sige). recently, a new thermographic (th) method for the assessment of spt was developed, and it was demonstrated that the th measurements of forearm temperature distribution during spt, supported by a mathematical model, offer a new quantification method of allergen-induced skin reactions. objectives: the aim of this study is a comprehensive comparison of the th method with spt and sige techniques. the group of patients who were participated in this study consist of patients. among them were patients ( . %) with allergic rhinitis and patient ( . %) with asthma, . % of them were men and . % were women aged - years (mean age . ae . years). spt and sige testings were performed by the standard techniques. for th analyses, set of thermograms of both forearms were acquired after prick and analyzed with the use of developed software. all results were converted into categorized scale for comparison. after counting patients who were true positive (tp), true negative (tn), false positive (fp), and false negative (fn), the sensitivity, specificity, and accuracy were calculated according to the following formula using the results of spt as the standard; sensitivity=tp/(tp+fn), specificity=tn/(tn+fp), and efficacy=(tp+tn)/(tp+tn+fp+fn). the results showed high correlation coefficients between the methods equal to . - . . the sensitivity and accuracy of the th assessment in respect of both the classical methods is at a good level ( . - . ). the acceptable level of specificity . - . was also achieved for the majority of allergic reactions. the best accordance was observed between th and sige results (r=. ), while th-spt was the most divergent pair r=. . in case of particular allergens, the biggest correlation was . , while the smallest value amounted to . . the results of diagnostic indicators of thermographic measurement of skin reactivity in comparison with the classical methods of determining the sensitivity to allergens show the prospect of using the method in routine practice. the main advantages of this method are its higher measuring ability and objectivity, by which the possibility of making error in diagnosis is significantly reduced. introduction: chronic urticaria symptoms may be worsened by factors such as temperature, exercise, hormones and stress. a salicylate rich diet has been reported to worsen symptoms in these patients. the mechanism by which natural salicylates do this is unclear but, like aspirin, is thought to be due to their ability to interfere with the arachidonic pathway via cyclooxygenase inhibition. studies have shown that low dose aspirin increases serum il- levels in patients with antiphospholipid syndrome. il- is important in basophil and mast cell function, inducing mediator release and cd c upregulation in the absence of ige stimuli. objectives: the gold standard for diagnosing salicylate exacerbated chronic urticaria is by challenge testing. there is no in vitro laboratory test approved for routine diagnosis. this study investigated whether il- levels are raised in patients with chronic urticaria and if these levels were affected by salicylate intake. we aimed to find an optimum method of measuring il- levels by comparing levels in serum and salivary samples. the quantikine human il- enzyme linked immunosorbent assay (elisa) was validated and used on both saliva and serum of patients with chronic urticaria and normal controls. this was a case control study of medicated patients with chronic urticaria and controls at university hospital southampton, to see whether there were any correlations with il- , and degree of salicylate intake (based on a questionnaire). introduction: since the introduction of molecular components in allergy, a big challenge of allergy diagnostics is to connect clinical symptoms with optimal test use and correct interpretation of results. objectives: the aim of the study was to ( ) develop an algorithm that would meet that need, and ( ) to evaluate the effect of introduction of algorithm to clinical practice. the algorithm was developed which groups clinical symptoms into six categories: rhinoconjunctivitis/ asthma, oral allergy syndrome (oas), urticaria/angioedema, eczema, anaphylaxis, and a combination of symptoms and combines them with knowledge of possible allergen specificity. this information is combined with two basic allergen mixtures (panels), reflex testing of selected food molecular components and accompanied by interpretative comments. the introduction of our algorithm led to less inhalation screenings, more food screenings and an increase in the requested molecular components. the oas was seldom recognized or used as a symptom by specialists. the reduction in costs, by using the possibility that the disease presentation may be a consequence of an relatively not dangerous oas, was therefore not achieved. all pr- positive proteins in various allergen sources showed also positivity for birch antigen. the screening based on this algorithm has potential to enable clinicians/general practitioners with a tool to increase the pre-test probability of allergy for the most frequently occurring allergens. allergy diagnostics may be more efficient if pr- component of birch (r bet v ) is included in early screening and can help in early recognition of oas. helbling a department of otorhinolaryngology-head and neck surgery | clinical and immunological evolution of patients who failed milk-oral immunotherapy there is lack of evidence on evolution among failures. objectives: to analyze clinical and immunological evolution of patients who failed milk-oral immunotherapy. data were obtained from medical records of a cohort of patients who failed moit in the past years in hospital infantil universitario niño jesus ( %) patients failed during build-up phase [ ( %) due to adverse events (ae) and ( %) to family decision. failed during maintenance phase: ( %) due to eosinophilic esophagitis, ( %) to family decision, to psychiatric disorder and (range - ). the most frequent aes were cutaneous and gastrointestinal symptoms. / ( %) patients underwent a second moit and was successful in . the second moit was performed between and years after the first one. there was no statistical differences between specific ige(ku/l) levels at baseline and months after the moit end portugal introduction: fish allergy is common in countries where consumption is high. parvalbumins present in fish muscle are the major allergens. allergy to multiple fish species is caused by parvalbuminspecific cross-reactive ige. cross-reactivity with parvalbumin from baltic cod retrospective study of patients with fish allergy followed in our immunoallergology department. fish tolerance acquisition was evaluated by oral food challenge. statistical analysis was performed using spss version (descriptive statistics, student test results: pts were included ( male, female), children and adults (age ae years). ( %) had previous history of rhinitis, ( %) of asthma and ( %) of eczema age of first contact with fish averaged . ae . months (min , max ) and the possible types of contact were: oral in ( %), cutaneous in ( %) and inhalation of cooking fish vapours age of first clinical manifestation (excluding the pts who developed allergy in adulthood) was at ae months (min , max ) the clinical manifestation of the reaction was: angioedema/urticaria ( %), gastrointestinal symptoms ( %), eczema ( %), respiratory symptoms ( %), oral allergy syndrome ( %), cardiovascular symptoms ( %) age at the first immunoallergology out-patient clinic consult averaged ae years (min . , max ) and time from first symptom to first thermo-fisher) was evaluated before and after acquisition of tolerance to at least fish. before tolerance, sige (ku/l) averaged roc curve (area under curve . ) showed that, for gad c ku/l, pts had a sensitivity of . % and specificity of . % that they would have a negative oral food challenge to a fish an sige< . ku/l had sensitivity of % of a negative challenge ku/l had specificity of . % of a positive challenge. conclusions: fish allergy is a common allergy in early childhood however, acquisition of tolerance is possible. rgad c appears to be a good marker for fish tolerance and could help allergologists as to when start testing for fish tolerance key: cord- -us wwmp authors: nan title: abstracts for the ipna congress, august - september , shanghai, china date: - - journal: pediatr nephrol doi: . /s - - - sha: doc_id: cord_uid: us wwmp nan first days after the diagnosis. dwi-mri was performed without application of contrast medium and without general anaesthesia. results: dwi-mri examination confirmed the inflammatory infiltration in kidney parenchyma in all our patients ( %). on the other hand, static renal scintigraphy confirmed inflammation only in children ( %). six months later, none of the two follow-up examinations showed any signs of inflammation or scarring in children examined so far. conclusion: in conclusion, nuclear magnetic resonance (dwi-mri) imaging seems more beneficial and accurate in the diagnostics of acute pyelonephritis when compared with static renal scintigraphy. moreover, dwi-mri provides more accurate information on the extent of kidney damage. objective: to evaluate the most proper radiologic investigation algorithm in detecting high grade vesicoureteral reflux (vur) and renal cortical scarring after first febrile urinary tract infections in infants aged less than one year . methods: a total of infants aged less than one year with a first febrile urinary tract infection who completed the diagnostic follow up of renal bladder ultrasound (rbus), voiding cystourethrography (vcug) and late months technetium dimercaptosuccinic acid renal scan (dmsa) were enrolled in the study.the most proper radiologic investigation algorithm that could highly detected both high grade vesicoureteral reflux and renal scar in infants after the first febrile urinary tract infection considering high benefit, low cost, low radiation exposure were assessed. results: abnormal renal bladder ultrasound (rbus) was identified in ( . %) infants. vesicoureteral reflux (vcug) was identified in ( . %) with high grade reflux (grade and ) in ( . %) infants.abnormal renal parenchyma including renal scar was identified in ( . %) infants.the top down approach with late months dmsa scan showed high benefit in detecting all abnormal renal parenchyma including renal scars, with high sensitivity ( %) in detecting high grade vesicoureteral reflux (vur) whereas reducing the unnecessary investigation for low grade vur ( . %) and radiation exposure per patient ( . msv). conclusion: currently, there is no ideal diagnostic radiologic investigation after a first febrile urinary tract infection in infants and children.the study suggest performing the top down approach with late months dmsa scan that could detect all renal scars and highly detection of high grade vur. abstract# p-sat association between postvoid urine bladder volume and urinary tract infection in infants and children: a retrospective cohort study orpheus monakil, ivy avilla department of pediatrics, da la salle university medical, philippines objective: to determine the association between post void urine bladder volume residual and urinary tract infection(uti) in children. methods: medical records of pediatric patients aged to years old with diagnosis of urinary tract infection were reviewed. demographic data, urinalysis and urine culture results and kidney and urinary bladder(kub) ultrasound findings were tabulated and analyzed using the % confidence interval. relative risks were computed with a level of significance of p value < . . results: a total of patients were included in the study. five hundred forty-four( . %) belongs to age group < years old. majority were females with a . : male to female ratio. escherichia coli is the most common organism isolated. patients with post void urine bladder residual are at risk for having growth in the urine culture. in sub group analysis for age and sex, statistically significant results were noted among patients belonging to the - years with the rr of . , % ci ( . , . ) p-value of . and males with rr . ( % ci . , . ) p value . . conclusion: there is an association between the occurrence of urinary tract infection and the presence of post void bladder volume residual. males and those patients aged to years of age are more at risk for urinary infection. objective: to evaluate if a relationship exists between renal ultrasound and voiding cystourethrography (vcug) findings among children with uti and determine whether the renal ultrasound findings/results can serve as a guide if a procedure such as vcug is needed to be done in the patient. methods: medical records of infants and children diagnosed as having uti who underwent renal ultrasound and vcug were reviewed. demographic data, urine culture and results of imaging studies were tabulated and analyzed. kappa statistics was used to determine the agreement between renal ultrasound and vcug results. mcnemars test was utilized to determine the statistical significance of the agreement. level of significance was place at p value of < . . results: a total of patients were included in the study. thirtyeight( %) had vesicoureteral reflux. there were more females with a male to female ratio of : . while cases with reflux had a : . male to female ratio. most common chief complaint was fever. e. coli is the most commonly isolated etiologic organism from the urine. twenty( . %) patients had primary vur while ( . %) were secondary. fifty two of children had abnormal sonogram; of duplex collecting system (dcs) diagnosed during postnatal usc on objective: the aim was to evaluate the relationship of laboratory investigations, therapeutic delay time (tdt), and therapeutic response time (trt) with acute renal damage and to verify these parameters in the presence of non refluxing and refluxing urinary tract infection (uti). methods: a prospective study was conducted in children. all patients received voiding cystourethrography (vcug) and dimercaptosuccinic acid (dmsa) renal scintigraphy. statistical analyses were applied to assess all parameters with dmsa renal scintigraphy. results: abnormal dmsa renal scintigraphy was detected in / ( . %) patients. there were no significant differences in peak temperature, tdt and treatment duration. however, white blood cells (wbc) count, percentage of serum polymorphonuclear cells (%pmn) and trt had significant differences at p-values . , < . and . , respectively. the area under roc curve for wbc count, %pmn and trt was . ( %ci . - . ) at p-values . , . ( %ci . - . ) at p-values < . and . ( %ci . - . ) at p-value . , respectively. overall, the optimal cutoff value for %pmn was . with sensitivity . % ( . - . ) and specificity . % ( . - . ). the optimal cut-off value for trt was hours with sensitivity . % ( . - . ) and specificity . % ( . - . ) . in patients with no vesicoureteral reflux (vur), there was significant difference in trt at p-values . . the area under roc curve for trt was . ( %ci . - . ) at p-value . . the optimal cut-off value for trt was hours with sensitivity . % ( %ci . - . ) and specificity . % . in vur patients, there were no significant differences in tdt, %pmn and trt between normal and abnormal dmsa renal scintigraphy at p-value . , . and . , respectively. conclusion: %pmn ≥ % and trt ≥ hours predict renal damage in the first episode of uti. however, in patients with no vur, trt ≥ hours predict renal damage. dmsa renal scintigraphy in the first episode of uti should be considered in those patients. susceptibility data. knowledge of local antimicrobial susceptibility all children with the first episode of febrile urinary tract infection traditionally. nowadays it has been revealed that the presence of renal scar is more important than the presence of vur regarding renal and patient outcome. our aim was to assess the relationship between the severity of vur and the severity of dmsa scan changes which is performed in the first week of the first febrile uti. methods: children with the first febrile uti who were admitted in ali asghar children hospital were evaluated prospectively. all dmsa scans have been observed and graded by our nuclear medicine specialist without any knowledge of presence or absence of vur. renal damages in dmsa scan were classified to grades as follows: grade : normal kidney, grade : decreased uptake in one pole with intact border, grade : decreased uptake in two poles with intact borders, grade : diffuse decreased uptake with intact border, grade : decreased uptake in one pole with scar, grade : decreased uptake in two poles with scar, grade : multiple scars, grade : diffuse decreased uptake with one pole scar, grade : diffuse decreased uptake with multiple scars. then dmsa findings in patients with no vur, with low grade vur and high grade or dilating vur were compared with each other. results and conclusion: one hundred and six patients with the first febrile uti were included in this study, thus kidneys were evaluated for the presence or absence of vur and dmsa grading. the mean age of our patients was ± . years old. . % of our patients were male. . % of kidneys did not have any vur, low grade vur (grades , , ) was seen in . % of kidneys and high grade vur grades , ) was found in . % of kidneys. . % of patients with low grade vur and/or without vur had dmsa scoring. abstract# p-sat fibronection in reflux nephropathy, is it a marker of grade of reflux? nahid rahimzadeh tehran university of medical science, associated professor, tehran, iran objective: vesicoureteral reflux (vur) is one of the most common urinary tract abnormalities in patients with urinary tract infection. nowadays noninvasive diagnostic methods are suggested to recognize vur and its severity. methods: we measured urinary and serum fibronectin in children with vur. results: the mean serum fibronectin was . ± . in children with low grade vur versus . ± . in children with high grade vur (pv> . ). the mean urinary fibronectin was also . ± . in low grade vur and . ± . in high grade vur (pv> . ). thus we didn't find any association between the severity of vur and the amount of fibronectin in serum and urine of patients. we also didn't find any relationship between dmsa changes at the acute phase of uti and serum and urine fibronectin. conclusion: in contrast to some previous studies, we showed the serum and urinary fibronectin cannot preclude the severity and grade of vur and hence it is not suitable surrogate marker for imaging techniques for vur diagnosis. abstract# p-sat the use of serum procalcitonin level in the prediction of high grade vesicoureteral reflux in urinary tract infection nahid rahimzadeh tehran university of medical science, associated professor, tehran, iran objective: procalcitonin is a reliable and specific marker of bacterial infection such as urinary tract infection. some authors suggest measurement of serum procalcitonin as a predictor of vesicoureteral reflux. we investigated this association in children who admitted because of acute pyelonephritis. methods: forty eight children with the first febrile uti were included. twelve patients had low grade vur, nine patients had high grade vur ((≥ ) and twenty seven patients didn't have any vur in their imaging assessment. results: there was a significant association between high grade vur and higher levels of procalcitonin (pv= . ). the sensitivity of procalcitonin level ≥ . ng/ml was % and specificity was % for diagnosis of high grade vur. conclusion: we concluded that serum procalcitonin concentration is a sensitive and promising predictor of high grade vesicoureteral reflux. hydronephrosis, parenchymal scarring and to study the rate of resolution of vur on follow up. methods: this was a retrospective study conducted by reviewing case records of all infants and children with primary vur who had minimum follow up of years, at our nephro-urology clinic over the last years.the imaging evaluation (renal ultrasound, voiding cystourethrogram, dmsa scan) was done based on the indian society of pediatric nephrology guidelines. severity of vur was classified as mild (grade i, ii), moderate (grade ii, iii) and severe (grade v) results: of the children screened for primary vur, with complete data were included for analysis. the mean age was . ± . months with male to female ratio of . : . the age at presentation was significantly lower for moderate to severe vur as compared to mild vur (p= . ). thirty children ( %) had abnormal antenatal scans. majorities ( %) of children were diagnosed to have vur during evaluation for urinary tract infection.among patients, six had solitary kidneys and thus the total number of systems evaluated was . of these, systems had vur ( % had mild, % had moderate and % had severe vur). hydronephrosis was seen in % of patients with vur. of these, % were unilateral and % were bilateral.there was no significant difference in the presence of hydronephrosis and grade of vur. there was no significant difference in presence of scars between mild and mod-severe vur. at the end of years of follow up, complete resolution of reflux was seen in %, % and % of children with mild, moderate and severe vur respectively. conclusion: severity of vur did not necessarily correlate with hydronephrosis and parenchymal scarring. over a year follow up, complete resolution of reflux was seen in nearly % of children irrespective of the grade of reflux. abstract# p-sat growth in children with dilating vur -a follow up of the swedish reflux trial per brandstrom, sverker hansson pediatricuronephrologic center, university of gothenburg, gothenburg, sweden objective: the swedish reflux trial included children, - years of age, with vur grade - , diagnosed after uti in and prenatal urinary tract dilatation in . dmsa was abnormal at start in children ( %). the children were randomized to antibiotic prophylaxis, endoscopic injection with deflux™ or surveillance. there have been reports on growth retardation in children with vur and catch up after vur resolution. the mechanism behind these findings is unclear. the children of the swedish reflux trial constitute a high risk group with dilating vur, recurrent febrile uti and high prevalence of renal parenchymal defects. we have searched the growth pattern of these children for differences related to gender, treatment group, uti recurrence, vur grade at follow up or renal defects on dmsa. methods: height and weight z-scores, compared to standardized swedish growth charts, were registered during the year follow up in of the children in the trial and at outpatient visits thereafter in patients to the age of . years (median, range . - . ). change in height z-score between first and last visit was used to measure growth over time. results: the first and last recorded height and weight z-scores were all within normal range. there was a larger gain of height in children with renal defects compared to those without (z-score difference . vs. . , p= . ). there were no differences in growth related to gender, treatment group, vur-grade at follow up or recurrent uti. conclusion: the children of the swedish reflux trial constitute a high risk group with dilating vur, recurrent febrile uti and high prevalence of renal parenchymal defects. they have normal weight, height and height gain at follow up for up to years. there was no sign of growth inhibition in these children related to dilating vur. the larger height gain seen in those with renal defects seem to be due to their slightly shorter stature at study start, although within normal range, which could be related to more severe urinary tract and renal problems during their first - years of life. engin kose, caner alparslan, serdar saritas, cengizhan elmas, fatma mutlubas ozsan, onder yavascan, nejat aksu tepecik training and research hospital, pediatric nephrology, izmir, turkey objective: the management of vesicoureteral reflux (vur) is varied and remains controversial. conservative therapy is based on the understanding that vur can resolve spontaneously, mostly in young patients with low-grade reflux. in this study, we wanted to evaluate the spontaneousresolution rate of low-grade vur (grades i and ii) in children. methods: children with low-grade (i-ii) vur treated in our hospital from may to may were prospectively studied. patients with low-grade (i-ii) vur and those who showed normal dmsa findings were included into the study. initially, a dmsa scintigraphy was performed in all patients and those who experienced acute febrile urinary tract infection (uti) during the follow-up period. treatment success was defined as complete vur resolution. no patients were prescribed antibiotic prophylaxis. all parents were informed by being given an explanation of the clinical significance of personal hygiene methods used after urinating or defecating. our institutional review board approved to collect the data, retrospectively. statistical analysis was made by using ibm spss . software. results: the study sample comprised infants ( boys and girls) all of whom showed low-grade reflux (grades i-ii). bilateral reflux was seen in ( . %) of cases. median age at diagnosis was months (range: - months). median follow-up time was months (range: - months). the spontaneousresolution rate of reflux was . % ( out of renal units). the frequency of febrile uti was . ± . episode/year (median: . episode/year). during the follow-up no patients with febrile uti experienced scar on dmsa scintigraphy. conclusion: infants with low-grade reflux show a low risk of febrile uti and a high spontaneous resolution rate without antibiotic prophylaxis. therefore, these children should be managed primarily by conservative therapy. ji-nan sheu , , hai-lun sun , , shan-ming chen , , yu-hua chao , , min-sho ku , , pen-fen liao , ko-huang lue , pediatrics, chung shan medical unversity hospital, taichung, taiwan school of medicine, chung shan medical university taichung, taiwan objective: to assess the usefulness of procalcitonin (pct) as a marker for predicting dilating (grades iii-v) vesicoureteral reflux (vur) in young children with a first febrile urinary tract infection (uti). methods: children aged≤ years old with a first febrile uti were prospectively evaluated. serum samples were tested for pct measurements upon admission to a tertiary hospital. all children underwent renal ultrasonography (us), m tc-dimercaptosuccinic acid renal scan, and voiding cystourethrography. the diagnostic characteristics of pct test for acute pyelonephritis (apn) and dilating vur were calculated. results: of children analyzed ( boys and girls; median age, months), ( . %) had apn. there was vur in ( . %), including ( . %) with dilating vur. the median pct value was significantly higher in children with vur than in those without (p< . ). using a pct cutoff value of ≥ . ng/ml, the sensitivity and negative predictive value for predicting dilating vur were . % and . %, respectively, for pct, and . % and . %, respectively, for the combined pct and us studies, whereas the positive and negative likelihood ratios were . and . , respectively, for pct, and . and . , respectively, for the combined studies. by multivariate analysis, high pct values and abnormalities on us were independent predictors of dilating vur. conclusion: pct is useful for diagnosing apn and predicting dilating vur in young children with a first febrile uti. a voiding cystourethrography is indicated only in children with high pct values (≥ . ng/ml) and/or abnormalities found on a us. objective: to evaluate the accuracy of acute m tc-dimercaptosuccinic acid (dmsa) scan in predicting dilating vesicoureteral reflux (vur) among young children with febrile urinary tract infection (uti). methods: the medical records of children (age≤ years), presenting with febrile uti between january and december , were retrospectively reviewed. the sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio of acute dmsa scan in predicting dilating vur in young children with febrile uti were calculated. results: a total of children were included, of which ( . %) had abnormal dmsa results and ( . %) were identified as vur on micturatingcystourethrography (mcu). among all the patients, the number of dilating vur was ( . %). the rate of abnormal results on dmsa of dilating vur group was significantly higher than the rates of non-vur and low-grade vur groups (p< . ). in age< months group and age≥ months group, the sensitivities of dmsa in predicting dilating vur were . %, . % respectively, while the negative predictive value were . %, . % and negative likelihood ratio were . , . , respectively. conclusion: for children of age≤ years with febrile uti, acute dmsa scan possesses certain values in excluding dilating vur. the possibility to detect dilating vur by mcu is rather low when the result of dmsa is negative. cakut: voiding disorders abstract# p-sat mono-symptomatic and non-mono symptomatic nocturnal enuresis: a clinical evaluation mitra naseri , mehran hiradfar dr sheikh children hospital/pediatric nephrology department, mashhad university of medical sciences, mashhad, iran dr sheikh children hospital/pediatric surgery department, mashhad university of medical sciences, mashhad, iran objective: nocturnal enuresis is divided into mono-symptomatic nocturnal enuresis(mne) and non mono-symptomatic nocturnal enuresis(nmne).this study was conducted to review clinical and ultrasonography findings in enuretic children, and compare organic and functional pathologies of lower urinary tract (lut) in children with mono-mne with those who have nmne. methods: neurologically normal children with chief complaint of enuresis enrolled in the study including boys and girls, aged - years old, ( . %) with mne and ( . %) with nmne. urine analysis, urine culture and kidney bladder ultra sonography was done for all .some patients underwent voiding cystoureterography (vcug), urodynamic study (uds), or both. results: patients were divided in to groups: mne, nmne daytime incontinence and nmne +daytime incontinence. constipation, encopresis and urge incontinence were significantly more frequent in patients with nmne +daytime incontinence (p= . , . , . respectively) . bladder wall thickness was the most common us findings..one patient with mne and with nmne+ daytime incontinence had vesico -ureteral reflux(vur) )(p= . ).posterior urethral valve was reported in one patient with nmne. evidences of bladder dysfunction were noted in about half of the patients who underwent uds, with higher prevalence in cases with nmne + daytime urinary incontinence(p= . ). bowel symptoms and vur were significantly more prevalent in cases with nmne +daytime incontinence. conclusion: we recommend doing vcug in enuretic children who have daytime incontinence.in addition our study revealed that symptoms suggestive of over active bladder are not good indicators for bladder dysfunction. abstract# p-sat correspondence between urinary calcium, ca + concentration and osmolality in enuretic children agata korzeniecka-kozerska, tadeusz porowski department of paediatrics and nephrology, medical university of bialystok, bialystok, poland objective: among many factors predisposing to enuresis hypercalciuria may play an important role. hypercalciuria is be observed in patients both in patients with nocturnal polyuria and without. hence, we decided to assess urine concentration of calcium (mmol/l) and ca + (mmol/l) in patients with monosymptomatic enuresis and answer the question if patients with enuresis present calcium balance disturbances methods: the study was conducted on children ( enuretic aged median . ( . - . ) yrs diagnosed with monosymptomatic enuresis after months of unsuccessful non farmacological treatment and healthy children aged median . ( . - . ) yrs. we collected -h urine samples from all children enrolled to the study. calcium concentration, ca + , ph, osmolality of urine and additionally daily sodium excretion were estimated and compared between two groups. statistical analysis were performed using statistica ver. . (statsoft,tulsa, ok). the mann-whitney u test was used for comparisons between two independent parameters. correlations were made with spearman test. a p value of < . was considered to be statistically significant. results: there were no differences in age, gender and parameters of physical development between both studied groups and between girls and boys among groups. urinary calcium concentration in enuretic children did not differ compared to reference group ( p= . ). we found statistically significant differences in urinary ca + concentration (p= . ) and osmolality (p= . ) between both studied group. ca + in urine correlated negatively with age and parameters of physical physical development only in enuretic patients. additionally, positive correlation was found between ca + and calcium concentration (r = . ; p< . ) and between ca + and osmolality (r= . ; p< . ) in urine of enuretic children. positive correlation was also observed between ca + and daily natrium excretion (r= . ; p< . ) in enuretic children. conclusion: disturbed calcium balance may play an important role in pathogenesis of monosymtomatic enuresis. it's a need to assess calcium and natrium excretion in enuretic children. abstract# p-sat usefulness of the application of questionnaires to detect attention deficit hyperactivity disorder (adhd) and other psychiatric disorders in children with functional voiding disorders sandra gautreaux pediatric nephrology, complejo asistencial universitario de leon, spain objective: although the relationship between functional voiding disorders (fvd) and the presence of a psychological problem remains controversial, the greater frequency of adhd among children with this condition is well known. the purpose of this study was to determine the diagnostic performance of the application of questionnaires to detect adhd and other psychiatric disorders in children with functional voiding disorders in general pediatrics consultations methods: the study was conducted on children between and years of age ( males) diagnosed with fvd (patient group) and children of the same age ( males) who had no urinary symptoms (control group). the parents of these children responded to the questions in two standardized questionnaires: the strengths and difficulties questionnaire (sdq) to screen for mental health disorders and the questionnaire for the detection of adhd of the dsm-iv psychiatric disorders of american academy of psychiatry manual. the variables obtained from the questionnaire responses were compared between the two groups of children using the student's t-test for unpaired samples when variables were quantitative and the chi-square test if the variables were qualitative. it was considered significant when p< . results: no significant differences were found between the two groups in the sdq questionnaire in any of its sections (emotional symptoms, conduct problems, hyperactivity, peer problems and prosocial behavior) or global assessment test, in which only patients of each group had an abnormal result. the questionnaire for the detection of adhd, presented an altered overall result of . % and . % patients in the control group (p=ns). there were also no differences between the two groups on the results of this test concerning the inattention or hyperactivity-impulsivity sections. conclusion: the results of the application of questionnaires to detect adhd and other psychiatric disorders in children with fvd are similar to those of the general population. the routine application of this type of questionnaires to all the patients in pediatrics consultations does not seem necessary. abstract# p-sat characterization of voiding dysfunction in chidren with attention deficit-hyperactivity disorder jun yonug kim, kun hee lee, jung won lee department of pediatrics, hallym university kangnam sacred heart hospital, seoul, korea objective: attention deficit hyperacitivity disorder (adhd) has been associated with impairment of frontal inhibitory function and catecholaminergic system. adhd is diagnosed in ~ % of children. children with adhd seem to suffer from various forms of urinary problems such as nocturnal enuresis, dysfunctional voiding and diurnal incontinence. however, no data exist to confirm in korean adhd children. we investigate the clinical findings of voiding dysfunction in adhd children. methods: between october and march , a total of children ( children with adhd and the other children with upper respiratory infection as control group) were enrolled in gangnam sacred heart hospital, hallymuniversity. adhd children were diagnosed under diagnostic and statistical manual of mental disorders (dsm)-iv criteria. a comprehensive survey of voiding and defecating were administered. results: the patient group included boys and girls, and the control group boys and girls. mean age were . +/− . year in adhd group and . +/− . in control group. children with adhd had statistically significant higher incidence of enuresis (p= . ), urgency (p= . ), urge incontinence (p= . ) and constipation (p= . ). there was no significant differences in straining, intermitteny, holding maneuvers (p> . ). conclusion: children with adhd in korea have significantly higher rates of enuresis, urgency, urge incontinence and constipation than those without adhd. the psychological correlates of primary nocturnal enuresis weiran zhou, xiaomei liu, ying shen nephrology, beijing children's hospital, beijing, china objective: previous studies based on clinical samples have reported that enuresis in children is associated with behavioural problems and reduced self-esteem, anxiety, but the relationship remains controversial. this study investigated psychological correlates of enuresis in a group of children suffering primary nocturnal enuresis(pne). methods: this survey involved parents and their children with pne aged - years. clinical datas of enuresis were collected through parents' reports and individual administrations to all children. parents completed the child behaviour checklist. children completed piers harris children'sself concept scale, the screen for child anxiety-related emotional disorders (scared)and depression self rating scale for children (dsrsc) . results: of the children, are boys and are girls. are monosymptomatic primary nocturnal enuresis and, are nonmonosymptomatic. children accord with the severest form of bedwetting(>= times/week). . %(n= )children have behaviour problems and, girls get higher scores in withdraw and internalizing problems than boys. boys are more aggressive. . %(n= ) get positive results through scared. . %(n= ) get positive results in dsrsc. children with the severest form of bedwetting are likely to have more complex form of psychological problems. they have greater social problems, get higher scores in behaviour problem (p= . ) and lower scores in piers harris children's self concept scale (p= . ). but children with or without the severest form of bedwetting have no significant difference in scared . mne have no significant difference with nmne in scores of all the three children's self-evaluated scales. conclusion: most children with pne had different psychological problems. the severer the symptoms are, the more complex the psychological correlates are. these preliminary findings support the view of enuresis closely related with psychological problems. psychological problems are affected by many factors except for enuresis, so further researches need to be conducted to determine whether there is a causal relationship between psychopathology and enuresis. the current situation of treatment of primary nocturnal enuresis in children xiaomei liu, lu chen, weiran zhou nephrology, beijing children's hospital, beijing, china objective: we would like to discuss the treatment of primary nocturnal enuresis in children. methods: children, diagnosed with primary nocturnal enuresis, paid outpatient visits to beijing children's hospital from january to may , are enrolled in the study. the information of previous clinical experience, compliance and expected treatment goals are collected and analyzed. results: children, with the mean age of . ± . are enrolled. children have visited doctors before, have unsatisfied clinical experience, such as late intervention, less standardized treatment and over-treatment. . % have poor compliance with doctor's suggestion of behaviour therapy and alarm therapy. children have been suggested to take medicines such as chinese traditional medicine ddavp, but . % of them refused the suggestion anxious of the side effects or stop the usage on their own. the primary expected treatment goal of parents is to improve the symptoms, accounting for . %. excluding the underlying diseases, alleviating parents' burden, treating the symptoms of hyperactivity or inattention and avoiding adverse effects on intellectual and fertility are also included. for children, they'd like to improve the symptoms so they won't be published by parents or laughed by their fellows. most parents ( . %) preferred medicines as the first choice. . % parents and children are inconsistent with the behavior therapy (the rate of newly diagnosed and non newly diagnosed children were . %, . % respectly. χ test p> . ). ( . %) don't accept alarm therapy (the rate of newly diagnosed and non newly diagnosed children were . %, . % respectly. χ test p> . ). conclusion: children with primary enuresis need early intervention and standardized treatment. the effect of treatment largely depends on cooperation and joint participation of children and parents. this study found that the compliance of behaviour training and alarm therapy is lower than medicine. the goals of children and parents, living conditions and other factors should be fully considered in the treatment of enuresis to improve short-term remission rates and long-term cure rate of the disease. beware of the sleeping bladder in monosymptomatic nocturnal enuresis (mne) britt borg, konstantinos kamperis, birgitte mahler, soren rittig pediatrics, aarhus university hospital, skejbv, denmark objective: bladder reservoir function in children with nocturnal enuresis is assessed by maximal voided volumes (mvv) registered on frequency-volume charts. although a degree of association is evident, mvv does not always reflect the nocturnal bladder reservoir function in mne. we aimed to evaluate the nocturnal bladder reservoir function during the night in children with apparently normal mvv. methods: data from children aged - treated for mne in a tertiary referral centre was analyzed. data from children was excluded due to reduced mvv according to iccs standardization and due to lack of home recordings. the remaining were divided into two groups, based on whether mvv was above (n= ) or below (n= ) the average nocturnal urine production during wet nights (nupw) . first morning voids were not included in mvv values. results: % of the children with mne and a normal bladder capacity had an average nocturnal urine production during wet nights below their mvv, one third of these had nupw below % of mvv expected for age. these children did not differ significantly in terms of demographic characteristics, frequency of wet nights or treatment time needed to achieve dryness. urine output during dry nights was not statistical significant between the groups (p= . , mean diff.= . ml). the group with mvv>nupwet shared significantly higher mvv to mvv expected for age ratios (mean diff= . , p< . ). urine output during wet nights was lower in the group of children with mvv>nupw (diff: . ml, p< . ) . conclusion: children with mne and apparently normal bladder reservoir function during daytime may experience wet nights with urine volumes well below their mvv and mvv expected for age. the fact indicates bladder reservoir function abnormalities during sleep that is not assessed by day recordings. physicians treating children with mne should consider anticholinergic treatment. one year experience of a multidisciplinary investigation on nocturnal enuresis in a brazilian tertiary care facility objective: to characterize a cohort of children, - yrs old, with nocturnal enuresis, defined by iccs criteria on the basis of a multidisciplinary evaluation including renal, neurological, psychological and physical therapy approaches. chronic clinical conditions and genetic disorders constituted exclusion criteria. methods: after irb approval, families were invited to participate in the project through press releases, children completed quality of life evaluation through clinically validated questionnaires, followed by a one -day multidisciplinary clinical evaluation. sleep, urinary and intestinal diaries were evaluated. urinary sonography, nocturnal polysomnography, urinary and blood analysis were scheduled. results: / participants (pts)were male ( , %), mean age ± yrs. twenty two children were excluded due to noncompliance /chronic clinical conditions. / pts were evaluated. / parents of children/adolescents, answered the cbcl questionnaire, / ( %) of which resulted in scores compatible with clinical psychological conditions. monosymptomatic enuresis (moe) was diagnosed in / children ( . %). in the moe group, / pts were diagnosed with intestinal constipation; / pts with obstructive sleep apnea, / pts with hipercalciuria and / were characterized with adhd. area and velocity of center or pressure displacement (vm) were used for postural control evaluation and resulted in , ± , cm and , ± , cm.s- , respectively; / pts were also assessed for postural alignment exhibiting pelvic anteversion ( , ± , grades) and head protusion ( , ± , grades). these results corroborate with a smaller range of motion found for hip flexion ( , ± , grades) and hip extension ( ± , grades) assessed using a goniometer. conclusion: multidisciplinary evaluation of enuretic children may be the key to optimize therapy on the basis of the underlying etiology of the process abstract# p-sat weight depending dosing of desmopressin (ddavp) in nocturnal enuresis pauline de bruyne , ann de guchtenaere , charlotte van herzeele , ann raes , jo dehoorne piet hoebeke , erik van laecke , johan vandewalle paediatric nephrology, ghent university hospital, ghent, belgium department of urology, ghent university hospital, ghent, belgium objective: in children as well as in adults, a uniform starting dose of desmopressin is prescribed. this uniformity is based on the inability to detect a weight-dependent dose-concentration correlation as this correlation is probably blurred by the wide intra-and interindividual differences in plasma concentration for a fixed desmopressin dose. recently, a smaller variation in plasma concentration was shown for the oral lyophilisate formulation of desmopressin (compared to tablet formulation). therefore, this study assessed a possible correlation between weight-corrected dose and plasma concentration for both formulations. methods: children with monosymptomatic nocturnal enuresis were recruited in a tertiary centre. two tests were performed on two separate days (at two weeks interval) in identical, standardized conditions: on day desmopressin tablet μg and on day desmopressin oral lyophilisate μg was administered. plasma concentrations were measured at one, two and six hours post dosing. the nonparametric spearman's rank correlation coefficient was used for assessing the correlation between weight corrected dose and plasma concentration. results: mean (sd) age and body weight of the patients were respectively . ( . ) years and . ( . ) kg. a positive correlation between plasma concentration of ddavp was found for the oral lyophilisate formulation at hours (p-value , ) and hours (pvalue , ) post dosing. this is not the case for the tablet formulation. results are shown graphically in figure and . figure and : correlation of dose corrected by weight to plasma concentrations at and hours post dosing conclusion: to the best of our knowledge, this is the first pharmacokinetic study showing a significant dose (normalized for size) -concentration correlation for desmopressin. nevertheless, this correlation was only significant for the oral lyophilisate group. this result is clinically important as it is a strong indication for more predictable plasma concentrations for the oral lyophilisate formulation, and thus preventing elevated concentrations of desmopressin. objective: increased nocturnal urine production and/or bladder hyperactivity in primary nocturnal enuretic (ne) patients could possibly be associated with autonomic nervous system dysfunction. reports of studies on autonomic nervous system dysfunction in ne are limited. to investigate autonomic nervous system function in enuretic children by performing ambulatory blood pressure monitorisation (abpm) for hours. methods: children with primary ne were enrolled in this study and they get hour abpm. their results were compared with healthy children. urinalysis,urine electrolyte levels, urinary culture and urinary system ultrasound were carried out in all the children. they also requested to have a diary about daily fluid intake and volume of daily urine. results: the enuretic group consisted of children (m/f: / ) and the control group of healthy children (m/f: / ). the mean ages were . ± . years and . ± . years, respectively. the mean -hour bp and daytime dbp did not differ between the groups however, the mean systolic bp was significantly higher in enuretic children (p< . ). the mean nighttime systolic bp, dbp and map were significantly higher as well in the patient group. daytime bp load did not found to be elevated in both groups.elevated night time systolic bp load was observed in patients and was not observed in control group ( . % vs %) (p< . ). nighttime diastolic bp load was elevated in of patients, compared with of control subjects (p< . ). the nocturnal bp dip was significantly reduced in the patient group compared with control group for diastolic blood pressure ( . % vs . %, respectively; p= . ). patients with elevated night time bp load was found to have higher frequency of urinary incontinence per week as well as per night while compared with enuretic children with normal night time bp load (r= . , p< . ; r= . , p< . respectively). conclusion: nocturnal bp loads were significantly higher in children with enuresis. these subtle abnormalities of circadian blood pressure regulation, loss of nocturnal dip and observation of decreased nocturnal pulse rate may reflect autonomic nervous system dysfunction and pathogenesis of en. objective: bladder dysfunction and especially oab plays a major role in nocturnal enuresis, not only in the non monosymptomatic (nmne) but as well in the monosymptomatic patients (mne) . if the enuresis is related to a mismatch in nocturnal diuresis and maximal functional bladder capacity, then the bladder volume should be a major parameter, but is sofar not taken as a parameter for subtyping into nmne in the iccs standardization. maximal voided volume in a diary is the golden standard, although relation with outcome is poorly studied. methods: aim of the study was to evaluate the optimal parameter for estimation of bladder volume as maximal voided volume in a diary, during forced diuresis, bladder volume during uroflow + uroflow), correlating with cystomanometry (if indicated). studypopulation patients age to years, > / days wet, only cystomanometries. results: if we compare the data from the bladder volume against the reference frame from rittig (aarhus), then , % of patients had a mvv in diary < , % percentile demonstrating that a majority of patients had a small for age voided volume in their diary. correlation between mvvdiary, mvv forced diuresis, bladder capacity (uroflow+ residu) and cystomanometry show that there is a strong correlation between the , but especially for the last parameters (r . - . , p < . ),but results with mvv diary are worse (r . - . , p . - . ) . there is no sex or gender difference in this observation. correlation with response to therapy at year shows a superior correlation with mvv forced diuresis and during uroflow than mvv diary (p . ). since cystomanometry is only performed in refractory cases, this voided value had no correlation with clinical outcome. conclusion: bladder volume can be estimated in several ways, each with their advantages and pitfalls. our data demonstrate that the alternative non invasive methods during force diuresis and in center during uroflow correlate best to each other and to the cystomanometricvalues. but as well to the one year outcome (p . ). abstract# p-sat evaluating nocturnal diuresis (polyuria) claire debusschere, delphine guenter, sophie wouters, johan vandewalle, ann raes, joke dehoorne pediatric, nephrology, gent, belgium objective: nocturnal enuresis is more than bedwetting, but a symptom of a disorder involving multiple pathogenetic factors in circadian rhythm of diuresis/solute excretion and bladder dysfunction. where the sum of diaper weight and morning voided volume, is the standard to evaluate nocturnal diuresis (polyuria), it does not give indices about pathophysiology. the aarhus concept : in center studies during standardised intake, offers the advantage of standardized conditions, and reliability of the values, but is restricted to specific research centres in limited patients for budgetary reasons). the ghent concept : a home based hours concentration prophyle with time daytime and nighttime collections offers an alternative. this one day test was not validated against days diuresis nighttime registration, and was criticized since waking up the patient overnight might increase diuresis and solute excretion, as is demonstrated in sleep deprivation aim of the study: to validate nocturnal diuresis and solution excretion to evaluate nocturnal polyuria against days nighttime diary and days daytime diary. methods: to the study the incidence of nocturnal polyuria, and to evaluate the value of the morning osmolality in the study of nocturnal polyuria. results and conclusion: children ( m), mean age y ( - y) , h diuresis +/− ml, daytime +/− ml nighttime +/− ml, no sex difference. correlation between volumes in diary and h concentration prophyle during h (p . ), night (r . p . ) and day (p . ). only % of patients have a nocturnal polyuria (&gt; %ebv= absolute nocturnal polyuria), but up to % have a nocturnal diuresis higher than % ebv and &gt; than their mvv (relative polyuria). there is no correlation between early morning osmolality and nocturnal diuresis-rate (nocturnal polyuria). objectives, methods and results: we present a months old albanian female with fever, urinary retention and constipation. this problems has occurred one week before hospitalization. no history of trauma. life history has no remarkable data. no history of uti or constipation before. physical examination: weight and stature on centile. no respiratory problems. the big overfilled bladder was palpated. on the left sacral region, was a tumorous mass very painful and worm. perianal reflex, bulbocavernosus were weak. other reflexes were normal. there were a hard stools in the rectum. other systems examination was unremarkable. high es rate and pathological urine sed with infection indicators. other laboratory examination was unremarkable. ultrasound examination resulted with dilatation of the left kidney pyelon ( mm), distended and overfilled bladder lumen (> ml) with thin bladder wall. rectum distended and full with fecal masses.lateroposterior there is a sonolucent cystic formation with (volume ml). that cystic formation was supected for ureterocellae first. the urinary catheter and rectal clismas were done. that formation was abscess and it was drained. and two weeks after was better. voiding cystourethrogram and computer tomography was done and resulted that are no anatomical defects in the urinary tract. because of the collapsed bowels there's not good visualization of the region around the sigma and rectum. irigografy resulted: dolihosigma and suspected for hirschprung. two months later the abscess relapsed and needed drainage again. conclusion: since the abscess has repeated the next step will be biopsy. hirschprung, tailgut cysts and other presacral masses should be included in the differential for patients with recurrent abscess in the perisacral space with clinical manifestation of urinary retention and constipation. abstract# p-sat treatment failure to enuresis alarms: challenges and factors influencing adherence to treatment indra ganesan , jessica xj hooi , jasmine jy goh , yh ng , sm chao nephrology service, kk women's and children's hospital, singapore, singapore department of pediatrics, kk women's and children's hospital, singapore, singapore objective: the study aims to identify factors influencing treatment failure to enuresis alarm and the factors influencing adherence to treatment. methods: all patients aged to years referred to the voiding clinic in kk women's and children's hospital, singapore with primary nocturnal enuresis who opted for enuresis alarm treatment, over year period from - , were prospectively studied. data, via direct interview and parental questionnaire was collected on demographics, age at presentation, presence of family history, frequency of nocturnal enuresis per week and per night, on whether child awakens after wetting, or associated constipation in the child and parental perception of why primary enuresis happens. results: seventy-nine of ( %) children with primary nocturnal enuresis with complete data were included. mean age at presentation was . ± . years and ( %) were male. twenty-five children had a family history of nocturnal enuresis in a st degree relative. eighteen children had constipation. fifty-one ( %) children achieved the targeted consecutive dry nights. in the remaining children, the main reasons for treatment failure were non adherence to usage of enuresis alarms mainly due to an inability to wake up to the alarm in deep sleep ( %) and underlying neurobehavioural conditions ( %) (adhd, autism, depression and a chromosomal disorder). the only significant clinical factor predicting treatment failure was the presence of an underlying neurobehavioural condition (or . , and developmental delay . factors such as male gender, family history in first degree relatives, frequency of enuresis, arousal when wet, and the presence of constipation, were not significant. conclusion: in our population, % of children achieved nocturnal urinary continence with enuresis alarms. treatment failure of enuresis alarms is higher in the presence of an underlying neurobehavioural condition and developmental delay. non adherence to treatment is mainly due to inability to arouse from deep sleep. long-term follow-up of children with nocturnal enuresis -do enuretics become nocturics? an-sofie goessaert , bente schoenaers , olivier opdenakker , karel everaert , johan vandewalle urology, ghent university hospital, ghent, belgium ghent university, ghent, belgium pediatric nephrology, ghent university hospital, ghent, belgium objective: although an overlap between both nocturnal enuresis (ne) and nocturia is known, research on the occurrence of both conditions in one patient is lacking. this study aims to investigate the prevalence of nocturia and other urinary symptoms in patients who have suffered from ne. methods: a questionnaire was sent to patients treated more than years ago in the university hospital of ghent for ne evaluating the history and current status of enuresis and validated questionnaires on urinary incontinence (iciq-ui) and overactive bladder symptoms (iciq-oab). medical files of all subjects were analysed on the history of enuresis. all subjects were asked to sign an informed consent. results: of the ( %) subjects who completed the questionnaire, reported nocturia ( %), with a sex ratio (m/f) of / in the nocturic group versus / in the non-nocturic group, mean age is versus years old, respectively. comparing the nocturic and nonnocturic group, retrospective analysis of the history of enuresis shows an older age at which the subjects were cured ( vs . , respectively) and a higher percentage of non-monosymptomatic ne ( % vs %, respectively) in the nocturic group. no differences in past treatment for ne were found between both groups. prospective analysis shows a significantly higher prevalence (p< . ) of voiding frequency during daytime, urge and urinary incontinence in nocturics compared to nonnocturics. with an increase in number of nocturic episodes per night, the percentage of female subjects increases (p< . ) and the percentage of subjects with non-monosymptomatic ne increases as well (p< . ). conclusion: over one out of former enuretic patients develops nocturia, often accompanied by other urinary symptoms and with significant bother. cure of nocturnal enuresis does not necessarily equals cure of the urological pathology and some of the nocturic patients, who remain to suffer from bothersome symptoms, might benefit from continuous treatment for the underlying urological condition, such as overactive bladder syndrome or nocturnal polyuria. objectives, methods and results: a year old girl was admitted to our hospital due to unusual pattern of voiding. when she wanted to urinate, she was writhing in pain; she cried, became pale and sweated. since the newborn period parents have observed sudden episodes when the girl started to cry and curled up her legs. she stopped when she began to urinate. the girl's father occasionally had pains in the jaw between yawning. the girl's voiding was like parents described: when she was trying to begin urinating, she was squatting on the toilet seat, crying and became pale and sweated. when voiding occurred the girl seemed to relax. the voiding volume was small and the urinary stream was weak. all investigations results were normal. according to the clinical course we assumed that the girl had an unusual expression of paroxysmal extreme pain disorder (pepd). the diagnosis was confirmed by the detection of the heterozygous pathogenic mutation in the scn a gene, a missense mutation in exon . the same mutation was also confirmed in her father. the girl was started on carbamazepine and the pain attacks almost disappeared. pepd is a rare autosomal dominant neuropathy linked to mutation in the scn a gene which encodes voltage-gated sodium channels. abnormal pain sensitivity occurs due to changes in the properties of the channels. pepd's onset is in the neonatal period with the most characteristic clinical features being attacks of excruciating pain in the rectum, genitalia, face and limbs. in literature we did not find any citation of patients with attacks triggered by the voiding stimulus. carbamazepine has been effective in relieving symptoms but the response is often incomplete ( ) ( ) ( ) , as in our patient. conclusion: the case described is interesting because of the rare clinical expression of pepd with pain triggered by voiding. the same mutation was recently found in patients with sfn ( ) . the study of functional importance of this mutation showed that the result of the mutation is increased frequency of firing pain-signaling neurons ( ) . rita pavione rodrigues pereira , vera herminakalika koch , simone nascimento fagundes , aline rossi , juliane de oliveira marques vieira , clarice tanaka physical therapy, university of são paulo, são paulo, brazil communication disorders and occupational therapy, university of são paulo, são paulo, brazil objective: to assess the postural control in children and teenagers with enuresis compared to a control group methods: enuretic (eg) patients ( boys and girls) with mean± sd of . ± . years, ranging from to years old, and . ± . of bmi were paired with assyntomatic kids (cg) of equal age, gender and bmi. three trials of seconds were collected while standing on a forceplate at hz of frequency with standard position of feet in four different sensorial conditions: ( ) open eyes and stable surface; ( ) closed eyes and stable surface; ( ) open eyes and unstable surface, and; ( ) closed eyes and unstable surface. the analized variables were area (a) and velocity (vm) of center of pressure displacement (cop). student t-tests were used to compare variables between groups for each sensorial condition. the level of significance was % for all the analysis. results: when compared to cg, the eg revealed larger area of cop displacement in the condition ( ) (mean± sd of , ± , cm for cg and , ± , cm for eg; p= , ), and in condition ( ) (mean± sd of , ± , cm for cg and , ± , cm for eg; p= , ). no difference in vm were identified. conclusion: when compared to assymptomatic control group, the enuretics children and teenagers presented larger area of cop displacement under normal sensorial input (condition ) and when vestibular input alone was offered (condition ). the hip and spine mobility is diminished in enuretic children and teenagers rita pavione rodrigues pereira , vera herminakalika koch , monica maria ribeiro goncalves , thais de souza milhoratti , daniela castro pacheco , clarice tanaka physical therapy, university of são paulo, são paulo, brazil communication disorders and occupational therapy, university of são paulo, são paulo, brazil objective: to assess the hip and spine mobility in children and enuretic teenagers compared to a control group. methods: enuretic (eg) patients ( boys and girls) with mean ± sd of . ± . years, ranging from to years old, and . ± . of bmi were paired with assyntomatic kids (cg) of equal age, gender and bmi. the range of motion of hip flexion and extension was measured using a goniometer. spine flexibility was measured using schober e stibor test and bank of wells. student t-tests were used to compare variables between groups. the level of significance was % for all the analysis. results: when compared to cg, the eg revealed diminished range of motion of hip extension bilaterally ( ± . for eg and ± . for cg at right side; p< . ; ge . ± . for eg and . ± . for cg at left side; p< . ). no difference was found for hip flexion range of motion, however compared to cg, eg showed lower values bilaterally ( . ± . for eg and . ± . for cg at right side; . ± . for eg and ± . for cg at left side). the spine flexibility did not presente any difference for schober ( . ± . for eg and . ± . for cg; p = . ), and stibor ( . ± . for eg and . ± . for cg; p= . ) and bank of wells ( . ± . for and . ± . for cg; p= . ). conclusion: when compared to assymptomatic control group, the enuretics children and teenagers presented diminished range of motion of hip extension suggesting transversal misalignment of the pelvis. more concern about enuresis children: an epidemiological study of primary nocturnal enuresis in elementary schools in shanghai yibing zheng , yinv gong , hong xu , keli wang , , zhonghui ni , , dandan he , nephrology and rheumatism, shanghai, china xuhui health bureau, shanghai, china minhang center for disease control and prevention, shanghai, china objective: ( ) to assess the prevalence of primary nocturnal enuresis (pne) and its risk factors in children of elementary school age in shanghai. ( ) to evaluate the impact of enuresis on these children and their parents, and to identify the methods and effectiveness of managing enuresis. methods: a randomly selected cross-sectional study was conducted in four elementary schools in two districts inshanghai. the parents of these children were asked to complete questionnaires anonymously which included items about the presence and frequency of enuresis, its risk factors and its perceived impact and management. the distress caused to the family by enuresis and the outcome of any management was evaluated using a -point visual analogue scale (vas). pns was defined as an involuntary voiding of urine during sleep, with a frequency of more than two times a week for three consecutive months, in the absence of congenital or acquired defects of the central nervous system. results: a total of questionnaires were distributed. the overall response rate to the questionnaire was . %, girls . % and boys . %. the prevalence of pne declined with age from . % at years old to . % at years old. of all enuresis children, . % had daytime urinary symptoms and . % had a positive family history. . % of parents were concerned and . % were very concerned about enuresis. . % of children were worried about and . % were very worried about enuresis. only . % of pne children sought for treatment and the common strategies ( . %) were adjusting lifestyle such as restriction of water intake at night, . % used alarm clock and . % were take medication. . % of parents felt that the current treatment was effective. conclusion: we conducted a relatively scientific epidemiological survey on the prevalence of pne in two districts in shanghai. we find enuresis still has great impact on children and their parents, but only a small part of them will seek for treatment. and only half of the parents feel that the current treatment is effective. therefore, it would be desirable to create a series of standardized management and follow-up processes for enuresis children. abstract# p-sat renal manifestations of tuberous sclerosis: a descriptive analysis sophy korula , alka ekbote , naresh kumar , sumita danda , indira agarwal , swasti chaturvedi paediatrics, christian medical college, vellore, india clinical genetics, christian medical college, vellore, india objective: to describe the renal manifestations in children - years of age diagnosed with tuberous sclerosis complex (tsc) at a tertiary hospital in south india. methods: data of children with tsc who presented to christian medical college vellore hospital from january onwards, were analysed by a retrospective chart review. the cases were identified from outpatient records and underwent ultrasonography, urine analysis and serum creatinine to recognize renal involvement. results: twenty-five children with tsc were identified. two children did not imaging studies available and were excluded from the analysis. the age of included children ranged from days to years with a median of years. seventy four percent ( / ) were males. ten of the children had evidence of renal involvement ( . %). of the ten children with renal involvement, six had angiomyolipoma ( %), five had renal cysts ( %) and one had suspected renal cell carcinoma. in two children both angiomyolipoma (aml) and cysts were noted. none were symptomatic. one child was found to have proteinuria and another had reduced creatinine clearance of . ml/min/m with normal bp and urinalysis. the rest of children had no evidence of proteinuria and had normal creatinine clearance. conclusion: we conclude that all children with tsc should be screened for renal involvement and regular follow up should be arranged. abstract# p-sat sonographic growth charts for kidney length in normal korean children: a prospective observational study objective and methods: kidney length was measured by sonography in a prospective observational study of normal children from to years of age. results and conclusion: there was a good correlation between kidney length and somatic values including age, weight, and height. the rapid growth of height during the first years of life was intimately associated with a similar increase in kidney length. the values of weight and height showed good correlation with kidney length in children from to years of age. height should be considered the important factor to correlate with kidney length. for the children aged years or older, the regression equation was obtained: kidney length (cm) = . + . x height (cm). for the younger than years, the equation was: kidney length (cm) = . + . x height (cm). objective: the outcome of children with unilateral nonfunctioning mcdk. methods: children ( pts with right mcdk), afunction confirmed by renal scan, boys, mean age of years (range . month - . years), mean observation period of . years with a range of . month - . years. prenatally diagnosis was made in %. abnormalities of the contralateral kidney were found in / pts ( %) -dystopia (n= ), hydronephrosis due to ureterovesical obstruction (n= ), vacter syndrome (n= ). in pts mcdk had been removed (in period - ) . collected data include egfr (calculated by cystatin c), urine protein/creatinine ratio, microalbumin/creatinine ratio, a microglobulin (a m)/creatinine ratio, urine beta- microglobulin (b m), urine ngal, urine nag, blood pressure (bp), renal length. results: hypetrophy of the contralateral kidney (length > sds) was detected in / pts ( %) to years of age. complete involution (in %) or decrease of size (in %) of mcdk occured in the first years. hyperfiltration (defined as egfr of ml/min/ . m ) was seen in pts ( %). none of pts demonstrated decreased egfr, proteinuria (mean value of . mg/mmolcreatinine), microalbuminuria (mean value of . mg/mmolcreatinine).urine a m (mean value of . mg/mmolcreatinine), urine b m (mean value of . mg/l), urine nag (mean value of . ukat/mmolcreatinine), urine ngal (mean value of . ng/l) were in a normal range. all pts were normotensive -bp defined as < th percentile for age and gender. the combination of hepatoblastoma with renal failure due to congenital dysplastic kidneys in children is extremely rare. we report two children in renal failure since birth due to congenital cystic dysplastic kidneys. hepatoblastoma was subsequently diagnosed in both of them. methods and results: case a male infant was born at weeks gestation with an antenatal diagnosis of bilateral dysplastic kidneys and bladder outflow obstruction secondary to a prolapsing ureterocele, anhydramnios, and pulmonary hypoplasia. he underwent surgical repair of other congeniatal abnormality after birth. peritoneal dialysis was initiated at months. treatment with erythropoietin (epo) was commenced at weeks of age. case a male infant with congenital cystic renal dysplasia, bilateral vesicoureteric reflux pulmonary hypoplasia and oligohydramnios was born at weeks gestation. peritoneal dialysis was commenced at day due to anuria from birth. epo was commenced at months of age. both of them required high dose epo to maintain adequate haemoglobin. hepatoblastoma was diagnosed in both of them at - years, following an incidental finding in abdominal imaging done for different reasons. conclusion: hepatoblastoma has been reported in association with cystic renal dysplasia in children in the literature to date. none of these children had evidence of impaired renal function prior to the diagnosis of hepatoblastoma. in our report both the child were treated with high dose erythropoietin prior to diagnosis of hepatoblastoma. erythropoietin (epo) is the primary regulator of erythropoiesis through specific interaction with its receptor (epo r). epor expression has been demonstrated in common paediatrictumour cells and such expression is reported to promote tumour cell survival through release of angiogenic growth factors. angiogenesis is the primary requirement for tumour growth. epo production has been observed in patients with hepatomas and in the hepg- cell line in hepatoblastoma. we report two cases of hepatoblastoma detected incidentally in children with established renal failure and propose a putative role of epo in the development and / or progression of hepatoblastoma in this population. objective: hypercalciuria is the most common metabolic cause of renal stone. long term immobilization is associated with hypercalciuria and bone loss. the effect of short term immobilization on hypercalciuria was the main objective of this study. methods: in a prospective study all orthopedic patients less than years with pelvic fracture who were assigned for immobilization with traction were enrolled in this study. serum (calcium, phosphorous, alkaline phosphatase, sodium, potassium, uric acid, bun, creatinine)and fasting urine calcium, creatinine, sodium, potassium and uric acid were checked within hours of hospitalization and also in st, nd and rd weeks of immobilization and then after to months of mobilization. student's t-tests used for statistical analysis. results: fifty five patients male and female with the mean age of . ± . years were studied. urine calcium /creatinine (u ca/cr)* ratio before immobilization u ca/cr was . ± . . one, two and weeks following immobilization u ca/cr ratio was . ± . , . ± . and . ± . respectively.multivariate tests revealed a significant rise in u ca/cr ratio during hospital stay when this value checked before immobilization and throughout immobilization as soon as end of st week and following in nd and rd week ( objective: importance of renal biopsy(rb) in diagnosis and treatment of kidney disease is the same for children as for adults. however there are some differences between institutions in practice of this invasive method. the aim of this study is to identify the current status and complications associated with the renal biopsy of childhood kidney disease. methods: a retrospective study was conducted based on medical records from all patients who had undergone native renal biopsies with -gauge needles from april to november in our center. we analyzed the number of experiments, sex, age, indication, the types of harvest (percutaneous or open) and anesthesia (general or local), histopathological findings, and complications. results: a total of renal biopsies were performed in patients ( boys, girls). the mean age at first procedure was . years. about % of the indications for a biopsy showed moderate proteinuria and hematuria in the annual urinary screening program in japan, and approximately percent of those were refractory childhood nephrotic syndrome. open renal biopsies were practiced in only cases, and the rest of children underwent percutaneous ultrasound-guided kidney biopsies. the most procedures of patients aged or younger were executed under general anesthesia due to the non-cooperation of them. about % of the biopsy-proven kidney diseases showed immunoglobulin a nephropathy, and approximately percent of those were henoch-schonlein purpura nephritis. for the post biopsy complications, out of all performances administered hemostatic agents for moderate hematoma, but none of them required blood transfusion or surgical intervention. conclusion: we suggested that renal biopsy could be supportively performed under local anesthesia in the patients more than the upper grades of elementary school. in addition, patients aged or younger, including months, could undergo the percutaneous ultrasound-guided renal biopsies without procedural and general anesthesia complications. therefore, our results revealed that this procedure was considered safe even in infants. abstract# p-sat fifteen years review of indications and results of renal biopsy in children from a single center in egypt there were insufficient biopsies. in pathologically diagnosed specimens primary glomerulonephritis was the most common finding (n= , . %) followed by secondary glomerulonephritis (n= , . %) and end stage renal disease (n= , . %). the most common causes of primary glomerulonephritis were minimal change disease (n= , . %), diffuse proliferative glomerulonephritis (n= , . %), focal proliferative glomerulonephritis (n= , . %) and focal segmental glomerulosclerosis (n= , . %). lupus nephritis (n= , %) was the most common cause of secondary glomerulonephritis followed by hemolytic uremic syndrome (n= , . %) and amyloidosis (n= , . %). only one mortality has been reported as a complication of renal biopsy (uncontrolled bleeding). conclusion: this study introduces the first biopsy based epidemiological information of pattern of renal diseases in egyptian children from a single tertiary pediatric center in which minimal change disease was the most common histopathological finding and steroid resistant nephrotic syndrome was the most frequent indication for biopsy. results: a total of children were enrolled in the study. most of them ( %) had isolated microhematuria, and were proved mild lesion of glomeruli ( %) by renal biopsy. about % of them, however, might have progressive glomerulonephritis, such as iga nephropathy, focal segmental glomerulosclerosis, alport syndrome and so on. these asymptomatic children were found urine abnormalities due to either school urine screening study, health examination, or during diagnosis of non-renal diseases. in center a, iga nephropathy was the most case diagnosed, while in center b and c, minor glomerular abnormalities was the most case diagnosed. the difference among three centers was significant and this variation might be due to different indications of renal biopsy. conclusion: our findings confirm that urinalysis may help early detecting progressive glomerulonephritis in asymptomatic children. children with isolated microhematuria has relatively low risk of severe pathologic lesion of glomeruli, thus isolated microhematuria per se might not be suggested as indication of early renal biopsy. long-term follow-up with appropriate further examination is of great importance for these asymptomatic children. abstract# p-sat twenty-three-year review of disease patterns from renal biopsies: an experience from a pediatric renal center there were episode of peritonitis with an incidence of episode per . patient/months. the commonest organisms isolated were gram negative rods ( . %), followed by staph aureus ( . %). sixteen ( . %) were culture negative and ( . %) were fungal peritonitis. catheter removal related to peritonitis was performed in patients in whom only one patient returned back to pd. exit site infection ( episodes) and tunnel infection were reported in and patients respectively. catheter malfunction was the most common non infectious complication seen in ( . %) children. other noninfectious complications include haemorrahgic effluent ( . %) children while catheter leak, umbilical hernia and inflow pain where seen in ( . %) children each. at the end of the study ( . %) children remained pd active, ( . %) transferred to hd, ( . %) transplanted, ( . %) suspended from pd, ( . %) lost follow up and ( . %) children died. conclusion: in the setting of our country with limited resources and investment, capd is efficient and successful with complications comparable to most parts of the world. attempts to produce pd fluids locally and to train and educate health care workers will greatly improve the use of pd in developing countries. profile and response to therapy in patients with idiopathic membranous nephropathy from march to december . renal biopsies were studied for light microscopy, immunofluorescence and electron microscopy. antibodies to the m-type phospholipase a receptor (pla r), bovine serum albumin (bsa), and cationic bsa were measured by western blotting with patient sera (when available) and then detecting for both totaligg as well as specifically for the igg subclass. results: renal biopsies were performed during the study period, out of which patients had membranous nephropathy. five were secondary to sle and patients ( . %) had idiopathic membranous nephropathy. mean age at presentation was . +/- . years with % having hematuria and . % hypertension at presentation. estimated gfr was . +/- . . renal biopsy showed findings consistent with membranous nephropathy on light microscopy with with< % of the interstitium showing tubular atrophy and interstitial fibrosis. immunofluorescence studies showed granular igg and c along the peripheral capillary walls. electron microscopy showed subepithelial deposits, with formation of basement membrane spikes between the deposits. few intramembranous deposits were also present. subendothelial and mesangial deposits were not present. there were no antibodies to bsa or cationic bsa detected in any of the five sera available. one of the five patients had circulating antibodies to pla r. all patients received prednisolone, angiotensin converting enzyme inhibitors and oral calcium supplements. two patients continued to have nephrotic range proteinuria inspite of prednisolone and were started on cyclosporine. none of the patients developed any complications. conclusion: immunosuppressive therapy is beneficial in children with idiopathic membranous nephropathy. anti-pla r antibodies can be seen as early as years of age. abstract# p-sat hypercalcemic crisis and nephrogenic diabetes insipidus due to vitamin d intoxication methods: twenty-three children ( kidneys) with first uti with p-fimbriatede.coli were enrolled in the study. children were aged between few months and years. all children were treated with adequate antibiotic therapy. dmsa scintigraphy was performed in a few days after infection and control scintigraphy was performed months to months later. dmsa findings were categorised as normal, generally diminished uptake of activity, focally diminished uptake of activity and clearly pathologic with renal scars. results: the first dmsa scintigraphy immediately after infection was normal in kidneys ( . %), generally diminished activity was found in kidneys ( . %) and focally diminished activity in kidneys ( % ). renal scars were present in kidneys ( . %) . on the control scintigraphy kidneys ( . %) had normal findings. generally diminished activity were found in kidneys ( %) and focal diminished uptake in kidneys ( . %). significantly higher number of scars, in kidneys ( . %), despite of antibiotic treatment were found on the control scintigraphy (p< . ). conclusion: dmsa scintigraphy demonstrated that the infection with p-fimbriatede.coli can result in permanent renal damage, which clearly points to uti with p-fimbriatede.coli as a risk factor in renal damage. our results confirm obligatory scintigraphic follow-up of children with positive p-fimbriatede.coli infection. objective: efficacy of mannitol with furosemide was compared with that of albumin with furosemide in the treatment of diuretic resistant oedema in childhood nephrotic syndrome. methods: forty patients fulfilling the criteria for "resistant oedema" in nephrotic syndrome cases were enrolled in this descriptive cross sectional study. resistant oedema was diagnosed based on failure to achieve therapeutic response to diuretics or a weight loss of < % body weight daily. all nephrotic syndrome patients with severe oedema, age year to years of both sexes were hospitalized and were managed with fluid restriction, no added salt and bed rest. beside these mg/kg/day oral furosemide or combination of furosemide and spironolactone, were given for days to achieve desired diuresis. those patients who did not get response were divided into two groups (group-a, group-b) in consecutive fashion. the group-a study population, was with intravenous mannitol . - gm/kg/day in single daily dose over - hrs followed by intravenous furosemide mg/kg/day for days. the group-b study population was with intravenous albumin, . - gm/ kg /day in single daily dose over - hrs followed by intravenous furosemide mg/kg/day in every alternate day, total doses. conclusion: this boy presented with rhabdomyolysis, myohemoglobinuria and arf. (similar pr similar presentation can be rarely seen in human being, but often seen in dogs). blood exchange transfusion in time must be necessary for preventing "water fall effect" established, for it can eliminate inflammatory factor and toxic products such as bun, ccr, and creatinasein blood effectively. blood tranfusion in combination with azithromycin and clindamycin must be a good choice replace the "babesia-infected" rbc and eliminate pathogens in blood. beta- -microglobulinuria in human immunodeficiency virus infected children objective: to determine whether hiv infection in children is associated with increased urinary excretion of β -microglobulin, which is a marker of tubular defect. methods: a prospective observational study was done of hiv infected children attending outpatient immunology clinics to investigate urinary β -microglobulin excretion by measuring urine β -microglobulin to creatinine ratio. in addition serum sodium, potassium, urea, bicarbonate and creatinine levels were documented and urine dipstick test was done to quantify proteinuria. results: thirteen ( ) children aged months to months (mean +/- months) were enrolled. all children had normal estimated glomerular filtration rate. eleven children were on different haart regimes (see table ), one was receiving nevirapine prophylaxis and one was not on any treatment. the duration of haart use was - months (mean of +/- months). seven ( ) children were on cotrimoxazole for pneumocystis jiroveci prophylaxis and on anti-tuberculosis drugs, namely rifampicin, ethambutol, isoniazid and pyrazinamide. none received any nephrotoxic drugs. the hiv viral load was > copies/ml in children and < copies/ml in children. of hiv-infected children, ( %) had no abnormal urine protein excretion and nine ( %) had elevated urinary levels of β -microglobulin.of note only ( %) of the children with β -microglobulinuria had associated proteinuria. ten children ( %) had metabolic acidosis with the mean serum bicarbonate (co ) level of . mmol/l ( range - mmol/l). conclusion: proteinuria is believed to be the earliest finding for the diagnosis of hiv associated renal diseases. in our study β microglobulinuria and metabolic acidosis were the prominent findings suggesting that hiv induces tubular dysfunction in children without clinical evidence of renal disease. objective: acute kidney injury (aki) is an important cause of mortality in sub saharan africa because access to renal replacement therapy is limited. there are few reports on haemodialysis in childhood aki in the sub region. we therefore performed a preliminary review of data on children who received intermittent haemodialysis for aki in our centre. method: a retrospective review of case records and haemodialysis registers of children in aki who received haemodialysis in our centre from january to december . results: children, including a child aged years, received haemodialysis for aki over the period but full details were available for children and were further reviewed for this study. there were males ( . %). the children were aged - ( . +/- . ) years. the primary aetiology of aki was related to intravascular haemolysis (ivh) with massive haemoglobinuria (n= ), septicaemia (n= ), acute glomerulonephritis (n= ), malignancies (n= ), malaria (n= ), hiv (n= ) and haemolyticuraemic syndrome (n= ). the aetiology of ivh was secondary to glucose- -phosphate dehydrogenase (g pd) deficiency in patients, autoimmune haemolyticanaemia in and was unknown in the others. one of the patients with ivh secondary to g pd deficiency also had malaria. the number of sessions of dialysis ranged from to sessions per patient with a modal value of objectives, methods and results: a twelve-day old, formula-fed, full term neonate with unremarkable perinatal history was admitted for poor oral feeding and significant ( %) weight loss. physical examination was otherwise unremarkable. investigation showed normal anion gap metabolic acidosis, hyperkalemia ( . mmol/l), hyperurecemia ( . mmol/l) but normal creatinine ( umol/l). metabolic screen and other investigation was unremarkable. on further questioning parents has been feeding baby with goat milkbased formula since day . baby was switched back to normal cow milk-based formula with prompt resolution of metabolic disturbance and without recurrence of acidosis on follow-up. conclusions: goat milk is becoming increasing popular to parents because of the myths associated (organic, easier digested, hypoallergenic, better nutrient content etc). however there is good evidence suggesting against these misbelief and there are even reported morbidities associated with ingestion of goat milkbased formula. with increasing appealing but not necessarily accurate information available on the internet, what the public need is education. objective: there have been great inroads made in controlling the scourge of hiv in south africa. the national pmtct program has reduced the mtct rate to . % and children infected prior to these interventions are now on effective treatment programs. these children are now surviving longer and so we are seeing increased numbers of hiv related renal pathology presenting to our clinics. before the widespread availability of arv's in south africa these children would have been denied access to our program but now we are able to offer them crrtand a transplant. the biggest challenge facing our program is one of the social disintergration of much of our indigent population. the vast majority of our patients come from social backgrounds that are incompatible with adhering to the rigours of a chronic renal program. this is compounded when the care givers are themselves ill or when the child has a second serious illness such as hiv to deal with. methods: we would like to present our experience with admitting hiv positive children with ckd to our chronic program and will highlight the challenges that face these families and their health care providers. we will describe the social issues affecting each family and how they impact on the child's care. results: all families had serious social issues on top of having to deal with their hiv disease. all families had extreme difficulties in adhering to our program. / died as a result of non adherence and of the remaining children only is really coping well with the program. / children have no living parents and is foster care. the rest are either with a single parent or with a family relative. conclusion: the huge difficulties facing these patients is forcing us to rethink the criteria that should be applied to admitting these patients to our program. restricting the program to children with these problem seems cruel and we feel that all options should be considered before denying these children access to life saving care. abstract# most of the patients presented during autumn and winter. the incidence of apsgn has decreased in the past years in shenyang, but the proportion of the patients with acute kidney injury (aki) or nephroticrange proteinuria was increased. the proportion of children with macroscopic hematuria remained almost the same during these years. macroscopic hematuria resolved in - weeks and non-nephroticproteinuria resolved in - weeks. the treatment of apsgn patients with nephrotic-proteinuria was the same with the children with primary nephrotic syndrome and prednisone was withdrawn in - months. some aki patients have been followed up for years and no patients with chronic renal failure. all patients with microscopic hematuria at onset and % patients with microscopic hematuria after years. conclusion: the incidence of apsgn was decreased during recent years. the proportion of apsgn patients with aki or nephrotic-range proteinuria was increased. the short-term prognosis of apsgn was good and minority of the patients persisted with microscopic hematuria. abstract# p-sat analysis of clinical manifestations and prognosis in children of acute poststreptococcal glomerulonephritis objective: crescentic glomerulonephritis (gn) is characterized by severe infiltration of massive inflammatory cells into glomeruli and crescent formation. although renin angiotensin system (ras) is the key player in renal injury, the impact of direct renin inhibitor on glomerular crescent formation is not elucidated yet. methods: to examine whether direct renin inhibitor ameliorate renal injury in crescentic gn, we investigated renal injury induced by antiglomerular basement membrane (gbm) antibodies in wistar kyoto rats treated with direct renin inhibitor, aliskiren. in addition, using cultured glomerular mesangial cell (mcs) and parietal epithelial cell (pecs), we examined whether recombinant renin could induce monocyte chemoattractant protein- (mcp- ) expression and cell proliferation, respectively. results: an anti-gbm nephritis model developed progressive proteinuria and glomerular crescent formation, accompanied by increased expression of mcp- and (pro)renin receptor. interestingly, (pro)renin receptor expressed strongly in the crescent formation area in diseased glomeruli. proteinuria was significantly reduced by the treatment of aliskiren. then, aliskiren markedly ameliorated renal injury (% glomerular crescent: . +/− . %) compared to vehicle treatment ( . +/− . %). excretion of urinary protein in a group of rats treated with aliskiren were significantly reduced compared to vehicle-treated rats. aliskiren treatment markedly decreased mcp- and (pro)renin receptor mrna levels in the diseased kidney. next, primary cultured mcs stimulated by recombinant renin showed significant increases of mcp- mrna expression. furthermore, primary cultured pecs showed an increase in recombinant renininduced cell proliferation. conclusion: these data suggest that therapeutic strategy of direct renin inhibitor may prove beneficial for crescentic gn by the suppression of the ras activation and the decrease of inflammation and cell proliferation in glomerular crescent via (pro)renin receptor. an update on management of acute glomerulonephritis in children objective: to analyze the clinical effects, safety, and significance of leflunomide combined with hormone in the treatment of children with refractory nephrotic syndrome. methods: collected cases patients in our hospital in children with refractory nephroticsyndrome,and randomly divided into cases of the control group and treatment group. control group was treated with mycophenolatemofetil (mmf)andhormone,the treatment group was treated with leflunomide (let) and hormone.measured and compared the changes before and after treatment of h urinary protein excretion,tc,alt,cr,bun clinical efficacy and complications. results: the two groups after months of treatment, h urinary protein, plasma albumin, total serum cholesterol, serum creatinine and blood urea nitrogen and other indicators were significantly better than before treatment and has a statistically significant (p < . ); the overall response rate in the control group and treatment group were . % and . %. conclusion: the application of leflunomide combined with hormone treatment of children with refractory nephrotic syndrome can make the disease to be effectively alleviated, the clinical results were satisfactory, safe, and fewer complications, it is worthy of promotion. objective: post-streptococcal acute glomerulonephritis (psagn) is a familiar disease in children. misdiagnosis might occur when it is presented with atypical symptoms. here we report a -year-old girl presented with acute heart failure which was finally diagnosed comorbidity of psagn and graves' disease. methods: retrospectively review the history of the patient. the girl was admitted to our hospital with cough, shortness of breath and chest tightness, without any other obvious symptoms and history of illness. the examination of cardiac color ultrasound showed mitral insufficiency with severe mitral regurgitation and heart enlargement. other examinations also found she had hypertention, mild anomalies of urinalysis, hypocomplementemia, hypoalbuminemia, hyperthyroidism and elevated antistreptolysin o. first we diagnosed her illness as rheumatic disease. after two weeks treatment with rest, fluid and sodium restriction, controlling blood pression, diuresis and methimazole, the girl recovered very well. she had no any symptom with normal urinalysis and blood pressure, the result of reexamination of cardiac color ultrasound was normal, her hypocomplementemia and hyperthyroidism were improved significantly. finally she was diagnosed as co-morbidity of psagn and graves' disease. conclusion: psagn with atypical symptoms at presentation should be paid more attention, especially when it is also has co-morbidity. abstract# p-sat report of a child with idiopathic cryoglobulinemia idiopathic cryoglobulinemia is rare to see in child. here we report a child with typical manifestations of cryoglobulinemia. the subjected child was male, years and months, he had repeated rashes, itching, desquamation on his fingertips for more than two years, accompanied with recurrent miliary reddish rashes on the trunk and limbs for more than one year, transient arthralgia for weeks, and edema and oliguria for days before he was admitted to our hospital. he was treated as atopic dermatitis all the time. but the rashes were recurrent. erythema could be seen after desquamation. weeks before admission, he had arthralgia on the right knee, days later on left knee without swelling, both were retrieved spontaneously. x-ray of the knees revealed no abnormal. ten days before admission, edema and decreased urine output was notice without gross hematuria. physical examination in local hospital revealed blood pressure / mmhg, needlelike erythematous maculopapules in his hands and feet. urine test revealed protein g/l, rbc /ul, no casts. serum bun was . mmol/l, cr umol/l, tco mmol/l, c . g/l. he was sent to another hospital days later. there, prednisone mg per day was given. as a result, the urine output increased gradually, but serum bun and cr remained high, so he was referred to our hospital. renal biopsy indicated membrane proliferation glomerular nephritis with abundant microthrombus. the diagnosis of cryoglobulinemia was suggested. after that serum cryoglobulin and serum protein electrophoresis were tested days after prednisone was given, both were normal. etiological examinations, included hepatitis virus a, b, c, d, e, g were all negative; antibodies of hiv, syphilis, toxo, cmv, rvb, rsv, hsv, eb, adv, and rickett's organism were all negative, mp-igm : . antinuclear antibodies of sle, anca and antiphospholipid antibodies were all negative. so idiopathic cyoglobulinemia was more favored. the treatment of prednisone mg per day was continued after admission. he restored gradually. prednisone was taped down gradually. now prednisone has been stopped for more than one month, he seems well during that period of time. methods: children with hsp over years of age were enrolled in the study. they were evaluated for demographic, anthropometric, clinical and laboratory data including urinalysis, complete blood count, serum albumin, creatinine, iga levels. in addition, anti-tissue transglutaminase iga (elisa), anti-endomysium iga (ifat), antigliadin (gaf x, deaminated) iga (ifat) and anti-gliadin (gaf x, deaminated) igg (elisa) antibody levels were determined. seropositive patients were evaluated by endoscopic small bowel biopsy. the rate of cd seropositivity in hsp patients was compared to the rate in healthy turksih children by the test for the statistical significance of two percentages. results: celiac serology was evaluated in children ( male, mean age . +/- . years) with hsp. there was no patient with growth failure or having symptoms associated with cd like abdominal pain, abdominal distention or diarrhea. in addition, none of the patients had iga deficiency, anemia or hypoalbuminemia. celiac serology was positive in ( %) children. endoscopic evaluation was performed in patients and one of them was diagnosed as cd. prevalence of cd in children with hsp was significantly higher compared to healthy turkish children (p< . ). conclusions: celiac seropositivity was % in children with hsp and this rate is significantly higher than the rate in healthy children. although the number of children with hsp is small in this preliminary study, this result suggests that celiac screening may be considered in children with hsp. ( ) groups. the glomerular and tubulointerstitial lesions were scored by katafuchi criteria and oxford classification of igan,respectively. results: .the baseline data of different clincal or pathological groups were no significant differences (p more than . ),but h protienuria were significant increased in grade and groups than grade group(p less than . ). .according katafuchi critiria,the severity scores of glomerullar and tubulointerstitial lesions were positively correlated with either different clincal or pathological groups(p less than . ). .according to oxford classification, only the severity scores of mesangial hypercellularity and segmental glomerulosclerosis/adhension were positively correlated with different clinical groups(p less than . ),but the severity of mesangial hypercellularity, endocapilarity hypercellularity, segmental glomerulosclerosis/adhension,tubular atrophy/interstitial fibrosis and cellular/fibrocellular crecents were all positively correlated with different pathological groups (p less than . ). [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] were evaluated retrospectively. patients were analyzed comparing those hospitalized during the first and the second ten-year period.the long-term prognosis was evaluated in / patients ( %) with hsp nephritis followed-up for to years (mean . ± . years) based on urine analyses, serum creatinine and blood pressure measurements. results: of patients (mean age . ± . years, range - years, m: f ratio . ) with palpable purpura ( %), other symptoms were more common during the first ten-year period including arthralgias ( % vs. %, p= . ), gastrointestinal symptoms ( % vs. %, p= , ) and renal involvement ( % vs. %, p= . ). among patients ( %) with hsp nephritis, had isolated hematuria and/or non-nephrotic range proteinuria ( %), nephritic syndrome ( %) and nephritic/nephrotic syndrome ( %). hematuria and/or nonnephritic proteinuria was less common (p= . ) in the second tenyear period while the incidence of nephritic/nephrotic syndrome was insignificant (p= . ). recurrences of purpura had patients within years. patients had renal biopsy including one with % of crescents and one another with iga nephropathy diagnosed seven years after initial presentation of hsp. long-term prognosis was favourable in most patients with abnormal urine analyses in ( %), in one with hypertension but normal serum creatinine and in all with nephritic/nephrotic syndrome at disease onset. conclusion: clinical evaluation of patients with hsp nephritis treated at our institution showed a good long-term prognosis. urine and blood pressure abnormalities in followed-up patients were associated with nephritis at disease onset. -up (f-up) . egfr was estimated using schwartz formula; decline in renal function was defined as the slope of egfr over the f-up. results: % were males, with mean age at renal biopsy of . ± . y and a median f-up of . y (iq range . - . y); more than % presented with egfr > ml/min/ . m . end-stage renal disesase (esrd) was reached by % of children, % loss of initial egfr by %; % reached the combined end point (esrd or % loss of initial egfr). at renal biopsy % presented with mesangial proliferation (m ), % with endocapillary proliferation (e ), % with segmental glomerulosclerosis (s ) and % with tubular atrophy/interstitial fibrosis (ta/if; t / ). patients with segmental sclerosis and ta/if showed a significantly worse egfr slope over the f-up (s vs s p= . ; t vs t / p= . ). at univariate linear regression, clinical data at renal biopsy (egfr, proteinuria and map) were not associated with renal function decline, while data at - and - months and ta-proteinuria and map significantly predicted egfr slope.a multivariate linear regression model (including proteinuria and map at - months together with the difference of egfr at renal biopsy and at - months as independent variables) performed well in predicting egfr slope (r = . ). this model was used to derive a formula able to estimate egfr slope with good performance (mean bias between estimated and really observed egfr slope of . ± . ml/min/ . m ). conclusion: the oxford classification of igan was well applicable to this pediatric population. a formula was developed that estimates renal function decline over the f-up based on proteinuria, map and egfr loss after - years of observation, which will need a validation on other cohorts. sixteen-year experience with pediatric iga nephropathy and validation of the oxford classification as a risk predictor (m ), segmental sclerosis (s ), endocapillary proliferation (e ), and tubulointerstitial fibrosis (t or t ) was ( . %), ( . %), ( . %), and ( . %), respectively. there was no significant decrease in gfr within the entire cohort. however, five patients showed decreased renal function, and of them, two reached stage iii or iv ckd. the five patients' changes in the k/doqi ckd stage were to , to , to , to , and to . their pathological classifications were haas /m s e t , haas /m s e t with global sclerosis, haas /m s e t , haas /m s e t , and haas /m s e t with global sclerosis. in the oxford classification, global sclerosis was the only factor correlated with decreased renal function, whereas the haas classification showed no significant correlation with renal function. conclusions: global sclerosis was correlated with decreased renal function. however, in our cohort, there was no significant decrease in renal function during the follow-up period (p = . ). thus, we could not clearly correlate the haas and oxford classifications with renal outcome. the value of the oxford classification as a predictor of renal outcome remains unclear in korean children with iga nephropathy. meng-jie jiang, xiao-yun jiang, ying mo, li-zhi chen, li-ping rong pediatric, the first affiliated hospital of sun yat-sen university, guangzhou, china objective: to analyze the clinicopathological characteristics of primary immunoglobulin a nephropathy (igan) manifested as macroscopic hematuria in children. the clinicopathological characteristics of cases with primary igan manifested as macroscopic hematuria were analyzed retrospectively. according to the lasting time of macroscopic hematuria, cases were assigned to group a (no more than seven days) and cases were assigned to group b (more than seven days). results: the manifestations comprised: acute glomerulonephritis ( % in group a, . % in group b), nephrotic syndrome ( % in group a, . % in group b), hematuria and proteinuria ( . % in group a, . % in group b) and isolated hematuria ( . % in group a, . % in group b). . % cases in group a and . % cases in group b were accompanied with abnormal renal function. there was no significant difference between group a and b (p> . ). the urinary lysozyme or β -mg increased ( . % in group a, . % in group b). in group a, subclass ii was the most common histopathological type ( . %), followed by iii ( . %) and i ( . %) while the predominant histopathological types in group b were subclass iii ( . %), iv ( . %), ii ( . %) and i ( . %). none in group a and . % cases in group b showed crescent. besides, only one glomerulosclerosis was in group a while ( . %) cases of glomerulosclerosis were in group b. the difference between group a and group b was statistically significant (p< . ).no differences were found in balloon stenosis between group a ( . %) and group b ( . %), as well as the renal tubular and interstitial damage ( . % in group a, . % in group b). . % cases in group a and . % cases in group b were found with simple iga deposition in mesangial area. there was no significant difference between group a and group b (p> . ). the children with primary igan manifested as macroscopic hematuria lasting for more than seven days are easily appearing renal tubular damage, crescent formation and glomerulosclerosis. subclass iii and iv are the most common histopathological types. a case report of iga nephropathy accompanying crohn's disease akihiko shirasu , akira ashida , hideki matsumura , hyogo nakakura , tomoki aomatsu , atsushi yoden , motoshi hattori , hiroshi tamai , pediatrics, hirakata city hospital, hirakata, japan pediatrics, osaka medical college, takatsuki, japan pediatric nephrology, tokyo wemen's medical university, tokyo, japan there have been several reports of iga nephropathy accompanying crohn's disease in which the clinical course of the two diseases was linked. we recently experienced a case of iga nephropathy with deterioration of renal function complicated by crohn's disease. a - year-old boy diagnosed as having crohn's disease underwent total colectomy at the age of years. the patient was referred to pediatric gastroenterology unit at the age of , and thereafter maintained a state of remission form crohn's disease while receiving -aminosalicylic acid ( -asa). two months prior to referral to our pediatric nephrology unit, when the patient was years old, a school health examination had revealed microscopic hematuria and mild proteinuria. at that time, laboratory tests suggested deterioration of renal function. renal biopsy was performed and histological examination by light microscopy demonstrated focal segmental mesangial proliferation and moderate tubule atrophy with a diffuse interstitial inflammatory infiltrate consisting predominantly of lymphocytes. immunofluorescence assays revealed + diffuse granular staining for iga and + staining for c in the mesangium. therefore, the patient was diagnosed as having iga nephropathy and chronic interstitial nephritis. the -asa therapy was stopped considering the possibility that it had induced interstitial nephritis. the renal function of the patient has since remained quiescent for months. patients with crohn's disease who present with abnormal urinalysis findings commonly have urological complications, such as urolithiasis and urinary tract infections. however, the possibility of renal parenchymal disease including iga nephropathy should also be considered, even if there is no apparent aggregative linkage of urinalysis findings with gastrointestinal symptoms of crohn's disease. the duration of heavy proteinuria determined long-term outcome of henoch-schönlein purpura nephritis in children results: among the patients, ( . %) cases presented with hematuria and nephrotic syndrome (ns); ( . %) with hematuria and nephrotic range proteinuria (> mg/kg/ h); ( . %) with hematuria and moderate proteinuria ( ~ mg/kg/ h). the typical pathological features, such as the diffuse glomerular mesangial and endocapillary proliferation, mesangial interposition, and double contour formation, were shown in all specimens. moreover, the podocyte hypertrophy, shedding, and cytoplasmic absorption dropletswere also observed in most specimens under light microscopy. the percentage of small cellular crescents varied from . - %. patients were followed up for to years, and all had recovered. conclusion: the predominant clinical manifestation of iskdc grade vi hspn in children was ns accompanying with hematuria. the well outcome might be associated with the prompt use of steroids and/or immunosuppressive drugs at the onset of iskdc grade vi hspn with very mild glomerulosclerosis and tubulointerstitial lesion. in our future study, all patients should be followed for five or ten years, and more specimens should be observed under electron microscope to investigate whether the podocyte lesions of iskdc grade vihspn should be taken into account in the clinical pathological report and a future new histologic classification of hspn. objective: the aim of the study was to assess efficacy of immunosuppressive treatment in children with iga nephropathy (igan) and henoch-schoenlein nephritis (hsn) based on clinical manifestation and histopathological oxford (o-c) and who (who-c) classifications. the study group consisted of children with igan- and hsn - , (mean age . ± . years) , treated with azathioprine (aza) mg/kg/day - months with prednison (pred) mg/kg/day (nephrotic syndrome-ns), mg/kg/day (nephritic syndrome -nps) weeks, gradually diminished within months. it recognize clinical remission at normal renal function and absence of proteinuria at the end of treatment. in all patients we estimated: proteinuria, gfrs (calculated using schwartz's formula) at the onset of study and after months. they had performed renal biopsy on average . ± . years after the onset of illness and at the end of treatment. we were analyzed the histopathologic evaluation of renal biopsy specimens using the who-c (grade i-v) and oxford classification : (mmesangial hypercellularity, e-endocapillary hypercellularity, ssegmental sclerosis, t-tubular atrophy/interstitial fibrosis; absent = , present= ). results: in patients with igan we observed: ns- , nps- ; with hsn : ns- , nps- . after the treatment aza/pred we noted clinical remission in all children with igan and % with hsn. gfr was normal before and after treatment. at the onset of illness igan patients had: grade iii- , grade iv- according to who-c; hsn had: grade ii - , grade iii- , grade iv - ; at the end of therapy we observed positive effect in who-c only in ( %) igan patients and in ( %) hsn , without progression properly ( %) and ( %). in o-c of igan patients we observed nobody with total regression of changes, only children had m or e or s after treatment. in patients with hsn we noted total regression of changes in ( %), in other -m or e or t . conclusion: aza/pred therapy used in children with igan and hsn can make clinical remission in both groups, but histopathological regression-more frequent in hsn. oxford and who classifications are very useful for estimation of efficiency of treatment. -year follow-up of pediatric hennoch schönlein purpura with renal involvement elena tudorache , christine azema , stéphane decramer , georges deschênes , tim ulinski pediatric nephrology, armand trousseau hospital, paris, france pediatric nephrology, chu toulouse, toulouse, france pediatric nephrology, robert debré hospital, paris, france objective: the aim of this study was to determine the long-term outcome in children with hsp nephritis who underwent a renal biopsy and to identify possible correlation between disease parameters and treatment. we included retrospectively all patients with renal biopsy proven iga nephropathy related to hsp of three pediatric nephrology centres over a -year period. results: patients were included. nephrotic range proteinuria was present in % with grade ii, % with grade iii and % with grade iv lesions. renal function was impaired in %. significant proteinuria > mg/l was found in / patients years post renal biopsy, in / patients at years and in / patients at years. there was no correlation between risk for proteinuria at , , or years with initial histological lesions. there was a tendency to higher residual proteinuria in patients with nephrotic proteinuria at disease onset and also for patients who were not treated with steroid pulses at disease onset with vs. mg/l (p= . ) at three months, vs. mg/l (p= . ) at one year, vs. mg/l (p= . ) at five years, and vs. mg/l (p= . ) at ten years. there was a tendency to less proteinuria in the long term for those with early steroid pulses (< days vs. > days after proteinuria onset (p= . ).in patients with acei/arb treatment within days after renal disease onset, compared to those who were treated later (>one month), proteinuria was significantly lower at (p= . ) and months (p= . ). among control kidney biopsies, % show fibrosis of different degree unrelated to initial histology. conclusion: there is a risk to underestimate long term disease severity in patients with low iskdc classes. there is need for prospective long term studies to explore the benefit of early acei/arb and/or steroid pulses. abstract# p-sat good outcome of biopsy-proven henoch-schonlein purpura nephritis in children in shanghai single center objective: severe hsp nephritis considered a risk factor for chronic kidneys disease development especially in patients with nephrotic syndrome (ns). methods: we present our experience with tacrolimus (tac) as a steroid sparing agent for a treatment of severe hsp nephritis in years boy. our patient has been observing at the republic center of pediatric nephrology minsk for years. he presented with a typical purpuric rash with recurrences after infections. one year later during acute pneumonia macrohematuria, proteinuria ( - . g/ h) occured and ace inhibitors (iace) were prescribed. despite this, boy developed nephrotic range proteinuria ( . - . g/ h), biochemical protein g/l, albumin g/l, cholesterin , mmol/l. renal biopsie showed mesangial proliferation with iga deposits. prednisolon (pred) mg/daily with heparin failed to decrease proteinuria and activity. cyclosporin a mg/daily plus pred on alternate day were started and followed during months with positive dynamic (proteinuria , g/ h, decreased clinical and laboratory activity) after which pathogenic treatment was stopped. arterial hypertension (ag) was treated by iace. months later proteinuria ( . g/ h) and activity increased again. with the presence of ns resistance to steroids combined with hematuria and ag, medrol ( mg/daily) plus tac mg twice daily were prescribed. duration of tac therapy was months. tac was succesfully withdrawn with no rebound disease activity observed (during months). at present the patient receiving iace only. our results indicate that tac may be a promissing steroid sparing agent for treatment of severe hsp nephritis. anti-proteinuric effect of cyclosporine a treatment for iga deposit diseases objective: to evaluate the therapeutic effect of cyclosporine a (csa) on nephrotic-range proteinuria in children with immunoglobulin a (iga) deposit diseases in mesangium such as iga nephropathy (igan) and henoch-schonlein purpura nephritis (hspn). methods: fifty four children ( children with igan, children with hspn) who were diagnosed with iga deposit diseases in mesangium at renal biopsy were analyzed retrospectively. all the patients developed nephrotic-range proteinuria (> mg/m /day) for more than months. the starting dose of csa was mg/kg per day that was given in two divided doses, and the drug level was maintained between and ng/ml. the degree of proteinuria was measured before and after csa treatment. steroids were tapered off and stopped gradually after initiation of csa. results: mean duration of csa treatment was . +/- . months (range . - . months). mean follow-up duration was . +/- . yr (range . - . yr) from the beginning of csa treatment. the mean ratios of protein to creatinine decreased from . +/- . to . +/- . after csa treatment for months. thirty-two ( . %) patients achieved complete remission. renal function was preserved in all patients months after csa treatment. there were no severe complications in patients with csa treatment. conclusion: our findings indicate that csa is an effective agent to treat nephrotic-range proteinuria of iga deposition glomerular diseases such as igan and hspn and the duration of csa treatment should be at least more than months for efficacy. objective: to observe the therapeutic effects of hemoperfusion combined with corticosteroid in treating children with henoch-schonlein purpura. methods: a total of patients ( inthe hemoperfusion group (hp) and inthe control group) were included and followed up for months. both groups were treated with corticosteroids and other supportive therapy. patients in the hp group received hours of hemoperfusion each day for consecutive days. clinical features at the acute phase, relapses in a year and renal involvement at , , , months were compared. the blood levels of iga and such cytokines as, tnf-alpha-il- , il- , ltb were measured by elisa technique before and , , days after hemoperfusion. results: hemoperfusion significantly reduced the severity and duration of abdominal and joint pains. for patients with renal involvement at acute phase the hp group had quicker relief than the control (log rank p= . ). for patients without renal involvement at acute phase the hp group had less occurrences of renal involvement compared with the control during follow-ups(log rank p= . ). the rash was also alleviated after hemoperfusion though the difference was not significant. patients' levels of iga were elevated compared with the healthy control before treatment ( day ) patients'levels of cytokines also significantly increased compared with the healthy control on day , they began to decrease day after hemoperfusion and there were significant differences among those groups. less relapses were seen in the hp group compared with the control (p= . ). conclusion: hemoperfusion combined with corticosteroid was more effective than corticosteroid alone in improving extrarenal symptoms, alleviating and preventing renal involvement. the effects may be achieved by iga and cytokine reduction after hemoperfusion. the treatment of henoch-schonlein purpura nephritis in children combined with mycophenolate mofetil and corticosteroid nephritic syndrome type, cases( . %). about histological degrees, cases were in grade (mesangial proliferation, all accompanied by < % crescent formation), case was in grade (moderate to severe mesangial proliferation, accompanied by % crescent formation). treated with new therapy, cases were complete remission ( %), cases were improved, and one died. the complete remission rate of this therapy was significantly higher than that of the past treatment. objective: steroid pulse therapy (spt) has been reported to be effective for improving urinary abnormalities and preventing renal deterioration in patients with iga nephropathy. however, some patients are refractory to spt or have relapse after spt, resulting in renal impairment. the efficacy of tonsillectomy combined with spt has been discussed. the aim of our study is to evaluate the efficacy of tonsillectomy combined with spt in childhood iga nephropathy. methods: children, aged to years, who had been followed up for more than years after the first biopsy between and , were enrolled in this study. all patients received spt (methylprednisolone, ~ mg/kg intravenously times per week for consecutive weeks). patients received tonsillectomy combined with spt (group a), and patients received spt alone (group b). tonsillectomy was performed one month before or after spt. the therapy was followed by oral prednisolone and tapered off for to months, with warfarin, dipyridamole and ras inhibitor. all of patients underwent repeat biopsy. clinical features and pathological findings were retrospectively analyzed. results: the disappearance rate of proteinuria was . % for group a vs % for group b at year, and that of hematuria was % vs . % at years. for group a, all the cases which of urinary abnormalities had improved by the treatment could maintain remission, but for group b, . % of the cases had recurrence of proteinuria and . % had recurrence or did not achieve disappearance of hematuria at the last observation. histlogically, the percentage of glomeruli that showed crescents was significantly reduced in both groups. but the cases which still showed crescent formation at the second biopsy were % for group a vs . % for group b. conclusion: the differences of recurrence rate for urinary abnormalities after the treatment and disappearance rate of crescents at second biopsy may suggest that tonsillectomy can improve the long-term prognosis. objective: to observe the efficacy and security of tripterygium wilfordii polyglycosidium (twp) in treating children with severe henoch-schonlein purpura nephritis (hspn). methods: children failed to intravenous pulse methylprednisolone for days for their severe hspn entered our study and were given oral twp for - month. we evaluated the efficacy and security of twp through examinations of urinalysis, blood routine, function of liver and renal, myocardial enzyme series, level of sex hormone and electrocardiogram (ecg) before treatment, - month after giving twf and weeks after stopping medication respectively. results: proteinuria disappeared in all patients. the remission time was weeks in children, weeks in , weeks in respectively. during treatment, elevated glutamic-pyruvic transaminase and glutamic-oxaloacetic occurred in patients and returned to normal after stopping medication. abnormal findings in examination of ecg were observed in patients, one with left ventricular high voltage, another with knot parallel rhythm of the heart. after stopping medication, one patient still had t wave change in ecg. we didn't find any abnormalities of blood routine, renal function and level of sex hormone. conclusion: the twp has good efficacy and security on the treating children with severe hspn. the efficacy and side effects of glucocorticoids in treating children with henoch-schonlein purpura kai-yun liu, ling lu pediatrics, irst affiliated hospital of anhui medical university, anhui, china objective: to observe the efficacy and safety of glucocorticoid in the treatment of children with henoch-schonlein purpura. methods: patients with hsp were divided into mild and severe group according to clinical manifestations. children in mild group were given hydrocortisone sodium succinate (hcss) therapy. children in severe group were given methylprednisolone ( mp ) therapy. a follow-up record system was set up for every patient. we observed the recovery time of clinical symptoms and side effects of glucocorticoid. results: symptoms of skin rashes, joint and gastrointestinal in all children were disappeared within months of treatment. the urinalysis in of patients with renal involvement returned to normal in weeks. the other patient failed to mp therapy was given oral tripterygium and got normal urinalysis in weeks after disease onset. the body mass index (bmi) values in all children after glucocorticoid treatment were significantly higher than before treatment. after stopping medication, there was no significant difference in bmi value compared with before treatment and between two groups. during the treatment, patient in each group had ecg abnormal, and their ecg returned to normal after stopping drug. we didn't find any abnormalities of blood routine, renal function and level of sex hormone. objective: to investigate the role of th /treg imbalance in the pathogenesis of childhood henoch-schonlein purpura(hsp). and further explore the immunomodulatory affects of compound/lycyrrhizin(gl) on the th /treg deviation in hsp. methods: hsp patients were chose as gl-treated group, another patients were used as conventional therapy group. besides ( . - )ml/kg/l was enjected in l-treated group, other treatments were same, any steroid or immunosuppressants treatment was prohibited. age and sex-matched healthy children were used as healthy controls. blood samples of patients were obtained at the acute stage and after days treatment. using intracellular staining, the frequency of peripheral cd +cd -il +(th ) and cd +cd +foxp + treg cells was detected by flow cytometry all patients received methyl-prednisone pulses iv ( g/ . m for consecutives days) and subsequently oral prednisone with gradual withdrawal in six months, and mmf at dose of - mg/kg/ h for months. results: after six months of therapy all patients but one had persistent microscopic hematuria (me), only / patients had recurrent ma. patients with grade ii hspn showed significant reduction or normal proteinuria. only / patients with grade iii hspn had proteinuria still > gr/ h, / patients had proteinuria < g/ h, in / proteinuria was normal. mean period of follow-up was years. after one year, only patient had recurrent ma, patients showed persistent me. two patients with persistent proteinuria > g/ h showed a significant reduction (< g/ h in pts, normal in pt). proteinuria did not reappear in all patients.the effect persisted after years and after therapy withdrawal. no side effects was recorded. conclusion: our experience shows the efficacy and safety of mmf in hspn and has to be confirmed by larger controlled studies. the analysis of blood perfusion therapeutic effect on cases of allergic purpura cheng guo-qiang xi 'an children's hospital urology department, xi'an, shanxi, china objective: to observe the auxiliary therapeutic effect on severe allergic purpura. methods: children with severe allergic purpura were randomly divided into the control group ( cases) and the treatment group ( cases). the children of control group were treated with conventional therapy (anti-inflammatory, anti-allergic, anticoagulation and symptomatic treatment). the children of treatment group were treated with conventional therapy and blood perfusion. two groups of patients were both treated for days, and were followed up for months. the amelioration time and the regression time of clinical symptoms such as abdominal pain, bloody stool, rash, joint symptoms, visible hematuria and proteinuria, was compared in two groups before and after the treatment. the amelioration time of the clinical symptoms of children in the treatment group, such as acute abdominal pain, bloody stool, rash, joint symptoms, abdominal pain and bloody stool, visible hematuria, proteinuria, and other clinical symptoms, was shorter than the time in the control group (p < . ), and the late symptoms such as joint symptoms, abdominal pain and bloody stool iterations was also less than those of the control group (p < . ). methods: iga nephropathy model was established in male sprague-dawley rats. at week , rats in the model group were randomly assigned to either remain in the model group (n= ), or to receive treatment with rednisone (n= ), , (oh) d group (n= ), or prednisone plus , (oh) d (n= ). at week , serum interleukin- level was detected by elisa, and the level of treg cells in the blood was assayed using a flow cytometry method. results: ( ) the proteinurine and the number of blood cells in urine from rats in the model group was significantly higher than in rats in the control, prednisone, , (oh) d , and prednisone plus , (oh) d treatment groups (p < . ). ( ) serum interleukin- in the model group was significantly increased compared with control and treatment groups (p < . ), and the levels were decreased in turn in the prednisone treatment group, , (oh) d treatment group, and prednisone plus , (oh) d treatment group. in addition, the , (oh) d and prednisone plus , (oh) d treatment groups showed lower levels than the prednisone treatment group (p < . ). ( ) the level of treg cells in the model group was significantly decreased compared with the control and treatment groups (p < . ), with the levels showing a slight increase in the prednisone treatment group, a larger increase in the , (oh) d treatment group, and the greatest increase in the prednisone plus , (oh) d treatment group when compared with the model group. furthermore, the , (oh) d group and prednisone plus , (oh) d treatment groups showed higher levels than the prednisone treatment group (p < . ). conclusion: a th /treg disorder exists in rats with iga nephropathy, with the levels of interleukin- increased and the levels of treg cells decreased. vitamin d can regulate the th /treg balance and reduce the level of protein and blood in the urine in rats with iga nephropathy. objective: to explore the therapeutic effect of prednisone (pred) combined with mycophenolate mofetil (mmf) and cyclosiporin a(csa) in children with severe purpura nephritis (hspn). methods: we collected patients with severe hspn (from iskdc iiia to i) whose proteinuria symptom of nephrotic syndrome did not significantly relieve after weeks which treated with oral pred and mmf ( - mg/(kg.d)); and (or) the gross hematuria did not disappear after courses which treated with large doses of methylprednisolone. all patients were treated with oral csa - mg/(kg.d) to induce remission therapy for - months, then gradually reduced csa to - mg/(kg.d). the follow-up was - months. results: combined therapy with immunosuppressant treated a month later, gross hematuria were disappeared in all patients, patient ( %) was partial remission (urinary protein and urine erythrocyte continued to decrease %- % than before), patients ( %) were significantly remission (urinary protein and urine erythrocyte continued to decrease over % than before), -hour urinary protein was . ± . mg/kg, urine erythrocyte was . ± . × /ml. months later, patients ( %) were significantly remission, patient was complete remission (urinary protein was completely negative, urinary sediment red blood cells < /ml), -hour urinary protein was . ± . mg/kg, urine erythrocyte was . ± . × /ml. months later, patients ( %) were significantly remission, patient was complete remission, -hour urinary protein was . ± . mg/kg, urine erythrocyte was . ± . × /ml. patients were complete remission at last and the median duration of complete remission was . ± . months. patients had not been reached complete remission, which follow-up was - months. patients were relapse during withdraw or reduction, other side effects included hairy ( patients objective: increasing evidence suggest that the cosmc( -beta- galactosyltransferase-specific molecular chaperone ) might play a vital role in the pathogenesis of iga nephropathy (igan). however, the mechanism is not clear. methods: we investigated whether cosmc gene( c galt c )methylation is an important mechanism in igan in children. methods (m:f= : ) primaryigan children and (m:f= : ) healthy controls were enrolled randomly. the methylation status of the c galt c was detected using bisulfite-specific polymerase chain reaction (bsp)-based sequencing analysis. results: the male patients had obviousely high methylation percentage than the male controls(p= . ). three significant hypermethylation sites were identified in the male patients: cpg site (p = . ), site (p = . ), andsite (p = . ). in the female groups,the patients and the normal controls all had high level methylation without significance (p= . ). conclusion: methylation of c galt c might have the vital significance in the susceptibility to the male igan patients. objective: the aim of this research is to investigate the value of serum and urinary tgf-β and mmp- level, the noninvasive and easy repeatable biomarker, for assessing the severity and disease progression in igan children. methods: children with biopsy-proven igan and normal children(control group) were enrolled between july and january .(fingure )the igan group was divided into clinical groups according to their clinical features: isolated hematuria group (ih group, patients), hematuria and proteinuria group (hp group, ), and nephritic syndrome group (ns group, ). patients were divided into two groups according to their lee's pathologic classification: grade i+ii (lee's i+ii, patients), grade iii+ iv (lee's iii+ iv , ) groups. igan group was classified according to the renal function into two groups(renal failure group vs normal group). igan group was also divided into four groups according to their immunophenotype: iga( patients),iga+igg( ),iga+igm( ),iga+igg+igm( ) group. results: the level of tgf-β and mmp- inserum and urinary of the igan group was significantly higher than that in the control group (p< . ). both the level of tgf-β and mmp- inserum and urinary of the three clinical groups in the igan children were not statistically different. the serum tgf-β and mmp- levels were significantly higher in lee' s iii+ iv group compared to that in lee's i+ii group(p< . ). the difference was not statistically significant between urinary tgf-β and mmp- levels in the two lee's group.the serum tgf-β and mmp- levels of renal failure group were significantly higher than that of normal renal function group in igan children(p< . ),and the urinary tgf-β and mmp- levels of the two group were not statistically significant different. the serum and urinary tgf-β and mmp- levels were not statistically different in all immune classification. conclusion: the serum tgf-β and mmp- plays an important role in the severity and progression of children with igan. tgf-β and mmp- may be two more noninvasive and easy repeatable biomarkers to be used in evaluating the progression of igan in children. abstract# p-sat glomerular ace expression is enhanced in pediatric iga nephropathy yusuke seki, maki urushihara, takahiro tayama, takashi nagai, ariunbold jamba, shuji kondo, shoji kagami department of pediatrics, the university of tokushima graduate school, tokushima, japan objective: angiotensin converting enzyme (ace) is a homolog of ace and is thought to be a potent counter-regulator against ace activity. while renin-angiotensin system (ras) plays a critical role in the progression of iga nephropathy (igan), the role of ace has not been investigated in pediatric patients with igan. this study was performed to examine the relationship between ace expression and the development of pediatric igan. methods: we performed immunohistochemical analysis of ace and ace in kidney tissues from patients with pediatric igan and patients with minor glomerular abnormalities (mga) using specific antibodies and examined the correlation with clinical parameters and pathological findings. in addition, we elucidated the effects of various cytokines on ace expression in cultured human mesangial cells (mcs) by quantitative real time pcr and western blot analyses. results: ace expression levels in glomeruli (r = . , p < . ) and tubules (r = . , p = . ) were positively correlated with the mesangial hypercellularity score, while ace expression levels in glomeruli (r = . , p = . ) and tubules (r = . , p < . ) are not. multiple regression analysis showed that the mesangial hypercellularity score correlated with ace expression level in glomeruli and urinary protein-creatinine ratio (r = . , p < . ). in igan patients not treated with a ras blocker (ace inhibitors or angiotensin ii type receptor blockers), ace expression levels in glomeruli were significantly increased compared to patients with mga (p < . ). iga patients treated with a ras blocker did not show this increase in ace exrepssion. furthermore, ace mrna and protein expression was enhanced by interleukin- beta, a pro-inlammatory cytokine, and suppressed by transforming growth factor-beta , a pro-fibotic factor in the progression of igan. conclusion: these data indicate that ace expression in glomeruli is associated with mesangial hypercellularity in the active phase of pediatric igan. abstract# p-sat increased serum interleukin- and peripheral th cells in children with henoch-schonlein purpura nephrology (hspn) xiaoshan shao nephrology, guiyang children's hospital, guizhou, china objective: interleukin (il)- and th cells have been involved in many autoimmune diseases. the aim of this study is to investigate the involvement ofil- and th cells in the pathogenesis of childhood henoch-schonlein purpura (hspn). methods: serum and supernatant levels ofcytokines and chemokines were analyzed by enzyme-linked immunosorbent assay (elisa). using intracellular staining, the frequency ofperipheral th and th cells was studied by flow cytometry. results: children with hspn had significantly higher serum levels of il- , il- and transforming growth factor-beta than healthy controls. the il- levels in culture supernatants of peripheral blood mononuclear cells with anti-cd and cd antibody stimulation were much higher in patients with hspn ( . +/− . vs. . +/− . pg/ml, p = . ). thepatients also had more th cells ( . +/− . % vs. . +/− . %, p = . ) but not th cells in peripheral blood. moreover, il- could promote human endothelial cells to produce chemoattractants il- and monocyte chemotactic protein- . the increased frequency of peripheral th cells and serum il- levels are shown in childhood hspn that may in part contribute to vascular inflammation, suggesting cellular immunity is likely to be involved in the process of hspn. expression and significance of tgf-beta, smad , fn, ub and smurf in the renal tissues of children with iga nephropathy chen li-zhi, jiang xiao-yun, ling yi-hong, mo ying, sun liang-zhong pediatrics, the first affiliated hospital of sun yat-sen university, guangzhou, china objective: in this study, we investigated the expression of tgf-beta , smad , snon, fn, ub and smurf inthe renal tissues in children with igan, in order to explore the potential cross-talk between ubiquitinproteasome pathway and tgf-beta signaling and even their role in the progressive renal fibrogenesis of igan. methods: sixty children with igan were divided into three groups according to their clinical features: isolated haematuria group (ihgroup, patients), hematuria and proteinuria group (hp group, ), and nephrotic syndrome group (ns group, ) . patients were also divided into three groups according to pathologic grades: grade ( patients), grade ( ) and grade ( ) groups. six normal renal specimens (four was non-tumor kidney tissues from patients who had renal tumor and underwent nehprectomy, another two was healthmismatched donor renal tissues before renal transplantation) were used as the control group. the expression of ub, smurf , tgf- , smad , snon, and fn in renal tissues were determined by immunohistochemistry (two-step powervisiontm) and semi-quantitatively analyzed by the software of image-pro plus . . the degrees of glomerular and tubulointerstitial lesions were scored according to the katafuchi semi-quantitative criteria. results: the expression of tgf-beta , fn, ub and smurf inigan kidneys was significantly higher than that in the control group(pless than . ), while the increased expression of smad was only found in glomeruli but not in renal tubular interstitium(p less than . ). the highest expression of tgf-beta , fn, and ub were found in the ns and grade groups(p less than . ), smurf in the ih and grade groups(p less than . ), while the lowest expression of smad was found in the grade group(p less than . ), closely associated with different clinical and pathological groups. (p less than . ) conclusion: these results demonstrate that upp and tgf-beta /smads signaling pathway were both activated in children with igan.both upp and tgf-beta /smads signaling pathway may play an important role in the progress of glomerular sclerosis, renal tubular injury and renal interstitial fibrosis in children with igan. abstract# p-sat objective: the proteasome (ps) plays a key role in the activation of transcriptional factors, cytokines and presentation of hla-i restricted peptides. in immune mature cells, particularly dendritic cells, the ps, under the action of interferon gamma and alpha, becomes an immunoproteasome (ips), by substituting catalytic units beta , beta , beta with other low molecular weight proteins (lmp and lmp ) and an endopeptidase-like complex (mecl- ). this modification confers an optimal catalytic property for professional presentation of specific peptides to mhc class i. our group previously demonstrated that adult patients with iga-nephropathy (igan) have an increased expression of ips catalytic subunit, which correlated with the severity of renal disease.aim of this study was to investigate the switch from ps to ips in children with primary igan and with henoch-schoenlein purpura (hsp), a vasculitis sharing with igan several immune system abnormalities. methods: peripheral lymphomonocytes (pbmc) from children with igan, with hsp and healthy control subjects (hc), isolated by centrifugation gradient, were tested with real time prc (taqman) to assess quantitatively the mrna levels of ps alpha subunit (constitutive), of the active subunit of ps (beta , beta , beta ) and of ips (lmp , lmp and mecl- ). results: objective: recent studies suggest that dysregulated innate immunity plays an important role in the pathogenesis of iganephropathy (igan). interleukin- subfamily and its receptor, interleukin- receptor alpha- (il- r ), were recently identified as immunomodulators in human diseases, acting as mediators of mucosal host defense. however, the potential role of il- r in the pathogenesis of igan has not been explored. methods: in the current study, one hundred ninety four patients with igan and normal controls were genotyped for coding polymorphisms of the il- r gene and the association between the polymorphisms and igan was investigated. local expression of il- r was examined in patients with igan and healthy controls using immunohistochemistry. results: our case-control analysis showed that genotypes of rs were associated with childhood igan. individuals with the cc genotype of rs had about three fold reduced risk of igan compared with those with the gg genotype in the codominant model (p= . ) and those with the genotypes containing g allele (gg or gc) in the recessive model (p= . ).after bonferroni correction, the association between rs cc genotype and reduced risk of developing igan remained significant. furthermore, the renal expression of il- r was significantly higher in healthy controls compared with subjects with igan. conclusion: our data suggest that the cc genotype of rs polymorphism in il- r gene is associated with the reduced risk of igan, and this genetic association was supported by the higher renal expression of il- r in healthy controls compared with patients with igan. abstract# p-sat toll-like receptor gene polymorphisms contribute to development of proteinuria in childhood iga nephropathy henoch-schoenlein purpura (hsp) is the most common form of immune-mediated systemic vasculitis in children, which mainly affects skin, joints, gastrointestinal tract and kidney. the overall prognosis of hsp is favorable, but the long-term outcome is dependent on the degree of renal involvement. the incidence of renal involvement varies from to % and there have been some reports showing that nephritis might be related to an older age at onset, persistent purpura (> month), severe abdominal pain, and relapsing disease.recently, several studies have shown that galactose-deficient iga (gd-iga ) is recognized by anti-glycan antibodies, resulting in the formation of the circulating immune complexes and their mesangial deposition causing renal injury in hsp nephritis and serum galactose-deficient iga levels were highly inherited in children with hsp nephritis.regarding the treatment of hsp, one randomized double-blinded controlled study recently showed that patients with abdiminal pain or arthralgia may benefit from early treatment with prednisone, but the drug has not been proven to be capable of preventing the development of renal symptoms. however, it was effective in altering the course of renal involvementmild henoch-schoenlein purpura nephritis (hspn) generally does not require aggressive treatment due to a favorable course of the disease, but severe nephritis has a high risk of progression to end stage renal failure. although several intensive therapies, such as intravenous high-dose methylprednisolone pulse, immunosuppressive/cytotoxic drugs, fibrinolytic therapy, anticoagulants, antiplatelet agent and plasma exchange, have been used in children with severe hspn, treatment of hspn still remains controversial due to the rarity of randomized controlled studies in this field. expressions and significance of mtor, p s k and e-cadherin in glomeruli of children with iga nephropathy objective: to investigated the expressions of mtor, p s k , and e-cadherin in glomeruli of children with igan to explore the role of mtor/p s k signaling pathway in the progressive renal glomeruli fibrosis of igan. methods: seventy-two children with igan were divided into three groups according to their clinical features: isolated hematuria group (ih group, patients), hematuria and proteinuria(hp group, patients), and nephritic syndrome group (ns group, patients). patients were also also divided into three groups according to their pathologic grades: grade ii( patients), grade iii( patients) and grade iv( patients). six normal renal specimens were used as control group. the expressions of mtor, p s k , and e-cadherin in glomeruli were determined by immunohistochemistry method and the relationship between these indexes and the clinical pathology indexes were analyzed. results: the highest expressions of mtor and p s k inglomeruli were found in the ns group, both of which in tubulointerstitium were higher in grade iii and iv group than that in grade ii group and control group while the lowest expressions of e-cadherin was found in the grade iv group. the glomerular lesion level degree was positively correlated with expressions of mtor and p s k inglomeruli. the quantitative urinary protein of h was positively correlated with expressionsss of mtor in glomeruli. the concentration of serum iga was negatively correlated with the expressionss level of mtor in glomeruli. there was no significant correlation between the expressions of ang ii, mtor, p s k , e-cadherin and α-sma in igan glomeruli and their courses from duration of illness as well as iga depositional strength. conclusion: the mtor/p s k signaling pathway was actived in the children with igan and it may play an important role in the progress of renal glomeruli fibrosis in children with igan. abstract# p-sat iga from hsp patients trigger apoptosis and inhibit cytoskeletal proteins in huvec objective: henoch-schonlein purpura (hsp) is the most common form of small-vessel vasculitis in children, and its etiology is believed to be associated with immune injury. a polymorphism in the gene encoding heat shock protein - (hsp - ) is known to be associated with immune diseases. the purpose of this study was to investigate the correlation between the hsp - gene polymorphism (+ a/g) and hsp in children. the polymerase chain reaction-restriction fragment length polymorphism (pcr-rflp) method was used to detect the hsp - polymorphism in cases of children with hsp and controls, and the association of this polymorphism with hsp and hsp nephritis (hspn) was analyzed. results: in patients with hsp, the a/a, a/g, and g/g genotypic frequencies at the + a/g position of hsp - were . %, . %, and . %, respectively. in the control group, the a/a, a/g, and g/g genotypic frequencies at the + a/g position of hsp - were . %, . %, and . %, respectively. thus, the g/g genotypic frequency in the hsp group was significantly higher than that in the healthy control group (χ = . , p< . ). the frequencies of the a and the g allele were . % and . %, respectively, in the hsp group and were . % and . %, respectively, in the control group. the frequencies of the a/a, a/g, and g/g genotypes in patients with hsp were . %, . %, and . %, respectively. in hspn, the frequencies of the a/a, a/g, and g/g genotype were . %, . %, and . %, respectively. conclusion: the + a/g polymorphism in the hsp - gene is associated with hsp in children. the g/g homozygous genotype may be a genetic factor that predisposes individuals to hsp, but it is not significantly associated with the development of renal impairment. abstract# p-sat investigation of the correlation between tumor necrosis factoralpha gene polymorphism and henoch-schonlein purpura in children fei zhao , , songming huang , , huaying bao , guixia ding , ying chen , hongmei wu , aihua zhang nephrology, nanjing children's hospital, nanjing, china institute of pediatrics, nanjing medical university, nanjing, china objective: to investigate the association between serum tumor necrosis factor-α (tnf-α) gene polymorphism and the occurrence and development of henoch-schoenlein purpura (hsp) in children. the polymerase chain reaction-restriction fragment length polymorphism (pcr-rflp) method was utilized to detect and compare the genotype and allele frequencies at the tnf-α - locus in hsp child patients and non-hsp child patients. furthermore, the relationship between the genotypic and allelic frequencies at the tnf-α - locus and the susceptibility to hsp and henoch-schonlein purpura nephritis (hspn) was analyzed. results: . the g/g, g/a, and a/a genotype frequencies at the tnf-α gene (− g/a) locus in the hsp group and the control group were . %, . %, and . % and . %, . %, and . %, respectively; among them, the a/a genotype frequency in the hsp group was higher than that in the healthy control group, with a statistically significant difference (x = . , p < . ). the g and a allele frequencies in the hsp group and the control group were . % and . % and . % and . %, respectively. the a allele frequency in the hsp group was higher than that in the healthy control group, with a statistically significant difference (x = . , p < . ). . the g/g, g/a, and a/a genotype frequencies in the hsp non-renal impairment group and the nephritis group were . %, . %, and . % and . %, . %, and . %, respectively, but these differences were not statistically significant (x = . , p > . ). the g and a allele frequencies in the hsp non-renal impairment group and the nephritis group were . % and . % and . % and . %, respectively; the difference in the frequency of the a allele in the hsp non-renal-damage group and the nephritis group was not statistically significant (x = . , p > . ). conclusion: the tnf-α (− g/a) gene polymorphism was associated with hsp in children. a/a homozygosity may be a genetic predisposing factor for hsp; however, this factor was not significantly correlated with the development of kidney damage. abstract# p-sat objective: the nephrotic syndrome (ns) is characterized by proteinuria, hypoalbuminemia and generalized edema. although the pathophysiological mechanisms of ns remain unknown, studies with animal models and patients have associated the ns with changes in immune response. the present study investigated the expression of molecules related to cell activation, such as the beta- integrin (cd ) and cd on peripheral blood leukocytes and renal production of reactive oxygen species in rats with ns induced by doxorubicin. meathods: male wistar rats, - g, were divided into two groups: animals receiving intravenous injection of doxorubicin ( . mg/kg) (dox, n= ) and control animals that received saline (con, n= ). the animals were sacrificed at days , , and after injection, and hour urine and blood samples were collected for biochemical and immunological analyzes. the phenotypic analysis of leukocytes was performed by flow cytometry. the expression of cd in monocytes, cd +, cd + and nk cells and the expression of cd in monocytes were measured. in renal tissue samples, the oxidative activity was evaluated by tbars production and antioxidant activity of sod and catalase. results: the dox group animals showed significant increase in cellular cd expression and in the percentage of cytotoxic t lymphocytes, nk cells and monocytes that expressed cd as well as raised cd expression on peripheral blood monocytes when compared to the con group. the increased production of reactive oxygen species in renal tissue of dox group animals was positively correlated with the cd expression on monocytes and serum levels of creatinine. conclusion: these findings indicate a potential link between increased activation of peripheral monocytes and kidney damage in animals with ns. additional studies analyzing the effects of the blockade of integrins and co-stimulatory molecules may offer new therapeutic opportunities to treat human ns. abstract# p-sat cyclosporine a protects podocyte via upregulating the expression of cofilin- li xiaoyan, zhang xiaoyan, li xuejuan, wang xuejing, wang suxia, ding jie pediatric, peking university first hospital, beijing, china objective: podocyte foot process is dysregulated in nephrotic syndrome. the effacement of podocyte foot processes typically arises owing to perturbations in the actin cytoskeleton. calcineurin inhibitor cyclosporien a (csa) is currently used in the treatment of nephrotic syndrome. recent data suggest that the effects of csa on nephrotic syndrome are independent of its effects on the immune system. they identified that csa can stabilize the actin cytoskeleton through stabilizing synaptopodin in podocytes and thereby reduce proteinuria directly. other studies also showed that csa induced cofilin phosphorylation and promoted stress fiber generation in proximal tubular cells. however, whether the antiproteinuric role of csa is played by regulating cofilin- in podocyte has not been studied. methods: acute podocyte injury and nephrotic syndrome were induced by puromycin aminonucleoside (pan) injection in rats with or without csa. cultured podocytes were exposed to pan with or without csa treatment. cofilin- , nephrin, synaptopodin expression were determined by western blot or immunofluorescence. the cofilin- specific effect was determined using cofilin- sirna. results: csa reduced proteinuria, restored expression of cofilin- , nephrin, syanptopodin and repaired foot process effacement of pan induced nephropathy in vivo. in vitro studies showed that exposure of csa restored the expression of cofilin- and nephrin which decreased by pan. csa also repaired actin cytoskeleton impaired by pan. the protective effect of csa was disappeared partially when cultured podocytes were exposed to cofilin- sirna. objective: to find a probably mechanism of immune disorder in rsv nephropathy in rats which resembled the change of minimal change nephrotic syndrome. methods: . rsv mrnas (g, f, m , ns , ns ) and proteins (g and f) were detected with fluorogenic quantitative rt-pcr and indirect immunofluorescence assay (ifa) to find the evidence of viral persistence. . dc-sign mrna and protein were detected with rt-pcr and ifa to find the trend of its change. . the levels of il- /il- and cd /cd were measured by elisa and flowcytometry. results: the course could be divided into two stages: . first stage ( d- d) the mrna of rsv f, g, m , ns- and ns- in kidneys, lungs and spleens expressed and arrived at the highest on d, which accorded with the expression of rsv f and g proteins in ifa. the positively fluorescent luminance and mrna of dc-sign expressed stronger than that in the control, especially from d (ct kidney = . ± . ) to d (ct kidney = . ± . ). compared with the control, the secretion of il- in renal tissues was rising from d ( . ± . pg/ml) to d ( . ± . pg/ml). the expression of cd and cd in peripheral blood was lower than that in normal control. . second stage ( d- d) rsv mrna and viral proteins in the tissues were persistently expressed; it showed that partial rsv survived through immune escape. after d, the fluorescent luminance of dc-sign was gradually reduced in the three tissues. the expression of dc-sign mrna in kidneys, lungs and spleens on d (ct kidney = . ± . ) and d (ct kidney = . ± . ) was higher, except that in spleens on d (ct= . ± . ) was significantly lower than the control. the secretion of il- in tissues decreased after d ( . ± . pg/ml), but that of il- gradully increased after d ( . ± . pg/ml). although the expression of cd and cd in peripheral blood was increased gradually after inoculation, the level was still lower than that in normal control. conclusion: there was rsv persistence in rats which likely attributed to the rsv-induced immune escape. rsv interacts with dc-sign to make dcs inhibit the immune ability of cytotoxic t cells, caused t cell immune dysfunction and finally induced the immune tolerance. abstract# p-sat evaluation of the migratory and regulatory profile of leukocytes from peripheral blood in pediatric patients with idiopathic nephrotic syndrome objective: dynamic regulation of the podocyte cytoskeleton plays an important role in maintaining the glomerular filtration barrier. severe glomerular disorders are associated with perturbed organization of the podocyte actin cytoskeleton. the therapy is based on immunosuppressive agents, in particular cyclosporine a, whose beneficial effect seems also related to the stabilization of the actin cytoskeleton in podocytes. previous studies of our group demonstrated, that the mtor inhibitor everolimus (ev) might similarly involve the recovery of the actin cytoskeleton in a puromycin (pan) experimental model of proteinuric disease. methods: in the present study, inhibitory effects of ev on mtor complex (mtorc ) and − (mtorc ) were analyzed by western blotting in human differentiated podocytes. downstream of mtorc the activity of rhoa (gtpase pull-down assay) and myosin light chain (mlc) was studied. to identify further signaling pathways affected by ev, we performed affymetrix microarray expression analysis followed by verification using real-time rt-pcr. results: biochemical studies revealed a substantially decreased phosphorylation level of both mtor effector proteins mtorc (reduced p-akt) and mtorc (reduced p-p s k) by ev. objective: notch constitutes an evolutionarily conserved intercellular signaling pathway that determines cell fate in various organs. activation of notch and notch has been implicated in human glomerular diseases. notch was reported to play a critical role in development of glomerular diseases; however, a function of notch remains unclear. our aim of the study is to clarify notch pathway's contribution to developing proteinuria and glomerulosclerosis. methods: we injected either jagged antagonistic antibody (mab) or notch agonistic mab or notch agonistic mab intraperitoneally to mice with adriamycin (adr) nephropathy, a model of nephrotic syndrome and focal segmental glomerulosclerosis, and evaluated the levels of proteinuria and the ratios of sclerotic glomeruli. next, we treated cultured podocytes with adr in the presence or absence of notch agonistic mab, and we assessed the effect on cell survival and examined the pathways involved. then, we evaluated a correlation between notch activation and podocyte loss in human kidney specimen of nephrosis, minimal change disease (mcns) and focal segmental glomerulosclerosis (fsgs). results: administration of notch agonistic mab ameliorated nephrosis and glomerulosclerosis in mice with adr nephropathy, even when notch agonistic mab was administered therapeutically after the onset of nephrosis. in vitro, notch agonistic mab protected adr-damaged podocytes from apoptotic cell death. the specific knockdown of notch led to increased apoptosis in damaged podocytes. notch rescued damaged podocytes from apoptosis through akt pathway. human kidney specimens of nephrosis showed a positive linear correlation between the number of podocytes expressing activated notch and the number of residual podocytes. the glomeruli with mcns showed more activated notch and more podocytes, conclusions: whereas those with fsgs showed less activated notch and less podocytes. notch pathway has a pivotal role in preventing apoptosis of damaged podocytes. specific activation of notch may represent a novel clinical strategy for the amelioration of nephrosis and glomerulosclerosis. abstract# p-sat proliferation and apoptosis of tubular cells in initial and advanced stages of focal segmental glomerulosclerosis (fsgs) objective: to analyze processes of proliferation, apoptosis and ciliogenesis in proximal tubular cells during initial and advanced stages of fsgs associated with cystogenesis. methods: normal kidney tissues and tissues of fsgs kidneys were immunohistochemically analyzed using ki- proliferation marker and caspase- apoptotic marker. diameters of dilated and cystic proximal tubules were measured and correlated with proliferation index of tubular cells. data were analysed by the kruskal-wallis and dunn's post hoc test and expressed as mean+/−sd. significance was accepted at p< . . results: normal kidney tissue showed absence of proliferation in proximal tubules. initial stages of fsgs were characterized by intermingling areas of healthy non-proliferating proximal tubules, and pathologically changes, mildly dilated ( um diameter) proximal tubules showing proliferation index of . %. advances stages of fsgs displayed different stages of cystogenesis: while mildly dilated tubules (diameter +/− . um) contained , % of proliferating cells, their number increased to , % in cysts with diameters from +/− . um to +/− . um, and then decreased to , % in cysts with diameter +/− . um. while in the largest cysts proliferation index was lowest and the primary cilia short and distorted, in distal tubules and collecting ducts, primary cilia were extremely long and branching. apoptotic caspase- positive cells were observed within the tubular and interstitial cells. conclusion: deterioration of proliferation and apoptosis, and primary cilia formation characterizes cystogenesis in fsgs kidneys. we suggest that changes in primary cilia length might cause alterations in transfer of signaling pathways which control proliferation, differentiation and apoptosis of proximal tubules cells. advanced stages of fsgs are associated with cyst formation and increased proteinuria leading to nephrotic syndorme objective: to investigate effect of prednisone on the expression of ezrin and neph in rats with adriamycin-induced nephrosis. methods: adr model was induced by a tail intravenous injection of adr.the rats were divided into three groups, which were control group, model group and prednisone group. serum index and h urinary protein were measured at and weeks. observe pathologic changes of renal tissues at weeks. the expression of ezrin and neph in glomerulus was evaluated by immunohistochemistry respectively. results: compared with control group, at weeks, h urinary protein and total cholesterol in model group and prednisone group were significantly increased(p< . ),albumin and total protein were significantly decreased(p< . ),which indicated that the model was successfully established;compared with control group, at weeks, the expression of ezrin and neph in the model group were significantly decreased(p< . ).compared with the model group, the expression of ezrin and neph in prednisone group were significantly increased(p< . ), h urinary protein and total cholesterol were significantly decreased(p< . ),albumin and total protein were significantly increased(p< . ), renal pathology and ecm/ga were significantly increased(p< . ). conclusion: the expression of ezrin and neph were reduced in rats with adriamycin-induced nephrosis which were negatively related to proteinuria and renal pathological damage. prednisone can reduce the proteinuria and relieve the renal pathological damage by improving the expression of ezrin and neph . objective: the activation of the complement system plays an important role in various kidney diseases, such as antibody-mediated rejection or membranous glomerulopathy. the majority of the circulating complement components are produced in the liver. but in the last decade the local production of complement components by other cells is highly debated. the aim of our study was to proof the ability of human podocytes to produce and secrete complement components. methods: immortalized human podocytes were analyzed with western blot (wb), immunofluorescence (if) or/and pcr for their ability to produce components (c / c q, c , c , c , c ) inhibitors (factor h, mcp, cd , cd ) and activators (factor b, properdin) of the complement system. secretion of components was measured in the medium, and functionality of c was tested in a specific c convertase assay. stimulation of the cells was done with interferon-γ, interleukin and human albumin. results: pcr-studies revealed that human podocytes express on mrna level the components c , c , c , c , the inhibitors factor h, mcp, cd and cd , and the activators properdin and factor b. on protein levels c , c , factor b, properdin, factor h, cd and cd were detected. in immunofluorescence all the components showed either intra-plasmatic, perinuclear or peri-membranous distribution. in addition, we could show that podocytes secrete the factors c , c , c , c , factor b and factor h into the medium. the secreted c was clearly functionally active and could further enhanced by stimulation with interferon-γ. objective: to construct the eukaryotic expression plasmid and its shrna plasmids of il- of mice, and to investigate their ability of expression or inhibitory effects on il- . methods: the rna from spleen cells of bal b/c mouse was reversed to cdna, and the full-length cds fragment of il- was amplified. the target segment was cloned into the expression vector plvx-ires-zsgreen , then, the recombinant plasmid plvx-il- -ires-zsgreen was obtained. three pairs of shrna chains targeting il- gene and one pair control shrna chain were designed and synthesized, then annealed to form double strand ,and inserted into the expression vector plvx-shrna . three shrna plasmids and one control plasmid were constructed ,which were called shrna /shrna /shrna /shrnac, respectively. these plasmids were identified by restriction analysis and sequencing, and then they were transfected or co-transfected into t cells in mediation of liposome. the transcription levels of il- mrna were detected by fluorescent quantitative pcr, while expression levels of il- protein were detected by elisa. results: restriction analysis and sequencing proved that the recombinant plasmid were constructed correctly. the plasmid of plvx-il- -ires-zsg reen could expression il- ; when cotransfected with expression plasmid, il- expression levels were significantly reduced in the group of shrna /shrna /shrna as compared with the shrnac group, and the group of shrna had the least expression. conclusion: il- eukaryotic expression plasmid and its specific shrna plasmids were constructed successfully, and plasmid shrna had the best inhibitory effects. abstract# p-sat reno-protective effect of all-trans retinoic acid on adriamycininduced nephropathy mice xiaoli wang, jingjing cui, qiu li nephrology and immunology department, children's hospital of chongqing medical university, chongqing, china objective: to investigate the reno-protective effect of all-trans retinoic acid on adriamycin-induced nephropathy mice. methods: balb/c mice were randomly divided into nephrosis(a single adriamycin . mg/kg,n= ) and control(tail intravenous injection the same amount of saline,n= ). after two weeks nephrosis divided into atra-treated(intraperitoneal injection all-trans retinoic acid mg/kg, three times a week,n= ) and adr nephrosis. then, we chose five mice each group randomly after treatment weeks and weeks to collect -hours-urine, blood, kidney for detection. results: all-trans retinoic acid significantly decreased -h urinary protein excretion, serum tc and tg(p< . ). fas/fasl shows by immunohistochemistry and fluorescence quantitative pcr is decreased sifnificantly(p< . ). conclusion: all-trans retinoic acid has anti-apoptosis on adriamycin induced nephropathy mice to protect kidney damage and delay fibrosis process. abstract# p-sat molecular mechanism of ers induced by lipid accumulation in human mesangial cells (hmcs) objective: dehydroxymethylepoxyquinomicin (dhmeq) is a novel nf-κb inhibitor that potently inhibits the dna-binding activity of nf-κb, resulting in therapeutic effects for various pathological conditions. to elucidate the pathogenetic role of nf-κb in minimalchange nephrotic syndrome (mcns), we examined whether dhmeq could ameliorate the nephrosis in mice induced by puromycin aminonucleoside (pan), which is considered to be an animal model for mcns. methods: mice were injected with dhmeq or only vehicle hours before pan injection on day . mice without pan injection served as controls. the dhmeq or vehicle was injected on consecutive days. the daily urine was collected from day to day , and the urinary concentrations of albumin and creatinine were measured. some mice were sacrificed days after pan-injection, and their serum concentrations of cholesterol, total protein, albumin and il- were measured and the pathological changes of the kidneys were observed. results: pan injection without dhmeq in the mice induced albuminuria which gradually increased up to day and gradually decreased thereafter. in contrast, pre-treatment with dhmeq was associated with no significant increase in the amount of albuminuria during the first weeks. in the serological tests, pan-injection induced an increase in the cholesterol level, a decrease in the total protein, a decrease in the albumin and an increase in the il- in the serum compared to controls days after injection, but dhmeq ameliorated these changes. an electron microscopic analysis indicated an effacement of the foot processes of the podocytes in the pan-injected mice, but this was rarely observed in the pan-injected mice pre-treated with dhmeq. further immunohistochemical analysis showed that dhmeq can inhibit the pan-induced translocation of nf-κb from cytoplasm into nucleus. conclusion: these results suggest that dhmeq can be a candidate therapeutic agent for mcns, because the activation of nf-κb of podocytes may be associated with pan-induced nephrosis. knocking-down stim gene expression inhibits some podocyte molecules jingjing yan, meigui wang, siguang lu the first people's hospital, lianyungang, jiangsu, china objective: to study the effect of knocking-down stim on nephrin,podocin,cd- ap and α-actinin- in murine podocytes in vitro. methods: conditionally immortalized murine podocyte cells were cultured in rpmi medium at °c permissive condition.then the cells were shifted to non-permissive condition at °c and cultured for ten-fourteen days, and were transfected with stim small interfering rna(sirna) using transfection reagent lipofectamine .transfection efficiency was measured by flow cytometer and inhibitory effect of stim sirna was determined by rt-pcr and western blot at fourty-eight, senventy-two hours after transfection respectively. results: ( )the transfection efficiency of fam-sirna was about . %. ( )after transfection with specific sirna,the expression levels of stim mrna and protein were down-regulated by . % and . % respectively. ( ) the expression levels of nephrin,podocin and α-actinin- mrna were decreased by %, %, % respectively, whereas cd- ap showed no-change.both podocin and α-actinin- protein were decreased by %, % respectively. objective: one of the most common causes of nephrotic syndromes in children is the minimal-change-glomerulonephritis (mcgn). typically, mcgn results in foot processes effacement of podocytes. their plate-shaped flattening very likely results in dysfunction of the filtration barrier and may underlie the increase in urine albumin concentrations. notably, mcgn often disappears at the onset of puberty, thus in parallel with increasing peripheral hormone levels. this is particularly true in girls. methods: podocytes were studied by western blot analysis, immunofluorescence and by radioimmunoassay for their ability to secrete and bind estrogens. results: podocytes express estrogen receptors both, estrogen receptor alpha and beta, suggesting that increasing levels of estradiol during puberty potentially maintains and restores morphological integrity of podocytes. this protective function could be mediated by stabilization of the podocyte cytoskeleton by estradiol, as evidenced in vitro by the increase in phosphorylation of cofilin, very similar to the effects of estradiol in neurons. furthermore, we show that dissociated podocytes express aromatase, the final enzyme of estrogen synthesis, and that podocytes in fact synthesize estradiol, as evidenced by measuring estradiol content in the supernatant. conclusion: as it was shown that estrogen synthesis in cells other than those in gonads becomes stimulated during puberty, an autocrine mechanism of estrogen action could underlie decreasing frequency of mcgn at the onset of puberty. overexpression of pgc- α inhibits aldosterone-induced podocyte phenotypic changes and detachment by blocking mitochondrial dysfunction objective: to explore the role of heparanase in the pathogenesis of rat respiratory syncytial virus (rsv) nephropathy. methods: ~ g sprague-dawley(sd) rats (n= per group) were inoculated with × (plaque-forming units, pfu) rsv and sacrificed on days , , and postinoculation (rsv ,rsv ,rsv l and rsv ). five normal sd rats inoculated with dulbecco's minimum essential medium were served as normal control. the expression level of heparanase protein and mrna in kidney of each group was determined by immunohistochemical staining and real-time quantitative rt-pcr respectively. the proteinurina was measured and the relationship between the expression level of heparanase and the hour urinary protein was studied. results: rats with rsv nephropathy exhibited higher proteinuria by comparison with normal rats. there was a significant difference between each group(rsv >rsv >rsv >rsv ). compared with normal control, rats with rsv nephropathy showed up-regulated expression of heparanase protein in glomeruli. the expression level of heparanase protein in rsv and rsv group was higher than that in rsv and rsv group. there was a linear positive correlation between the expression level of glomerular heparanase protein and the quantity of urinary protein(r = . ,p< . ).compared with normal control group, the expression level of heparanase mrna in kidney f r o m r s v , rsv , rsv a n d r s v g r o u p w a s elevated(rsv >rsv >rsv >rsv ).there was a linear positive correlation between the expression level of renal heparanase mrna and the -hour urinary protein(r= . ,p< . ). the increased heparanase in kidney may be important to the loss of glomerular negative charge in glomerular basement membrane and is involved in the pathogenesis of rsv nephropathy. podocyte morphology andautophagosomes were viewed using electron microscopy. podocyte numerical density was estimated by weibel-gomez method. expressions of autophagy markers and ersassociated proteins were analyzed by western blot. results: the expression level of ers-associated protein grp was up-regulated from day to day post-injection. the results also showed that autophagosomes were massively accumulated and the autophagy marker lc was up-regulated in the models on day and . furthermore, rapamycin was given to phn rats to further explore the role of autophagy in the process of complement-dependent podocyte injury. results revealed that rapamycin, which enhanced autophagy in podocyte, could reduce proteinuria, lighten podocyte lesionsand prevent podocyte loss on day . conclusion: taken together, our results demonstrated that ers plays an important role in completment-dependent podocyte damage, and in another aspect, autophagy induced byers can alleviate injury as a protective mechanism. this provides an important basis for a thorough understanding of the role of autophagy in the process of podocyte damage and the pathogenesis of mn. abstract# p-sat the cytoprotective role of autophagy under oxidative stress in human podocyte objective: autophagy is a ubiquitous catabolic process involving selective degradation of cellular components. it shows cytoprotective effects in different cell types and helps to maintain cell homeostasis. some studies demonstrated that cell stress, generated by starvation or some chemical reagents, can initiate autophagy which responsively resists harmful stimuli at the early stage. however, little is known about autophagy in human podocytes under oxidative stress. since the apoptosis and autophagy pathways share some common molecules, we investigated the role of autophagy induced by puromycin aminonucleoside (pan) in human podocytes. methods: human conditional immortalized podocytes were treated with pan, the generation of reactive oxygen species (ros) was measured by immunofluorescence. then, autophagy was assayed by immunofluorecence staining for lc puncta and western blotting for lc . in addition, the mammalian target of rapamycin (mtor) and its substrates which play critical roles in autophagy inhibition were investigated for elucidating the mechanism of pan induced autophagy. podocyte apoptosis was assessed by flow cytometry (yo-pro- /pi and active caspase assays). to study the effects of autophagy on podocyte apoptosis, -methyladenine ( -ma) and chloroquine were used to inhibit autophagy. results: autophagy was detected in pan-treated podocytes in a dose and time dependent manner and prior to apoptosis which was accompanied with increased ros generation. lc aggregates were observed in the cytoplasm and the expression of lc ii was significantly elevated. intriguingly, phospho-mtor and its substrates (phospho-p s kinase and phospho- e-bp ) increased when the autophagy was activated. when autophagy was inhibited by ma and chloroquine, podocyte apoptosis increased significantly. conclusion: pan induced both apoptosis and autophagy in human podocytes. our results suggested that this in vitro model will be useful for the study of crosstalk between apoptosis and autophagy in podocytes. autophagy may be the adaptive cytoprotective mechanism for podocytes under oxidative stress. further studies directed at identifying the role of mtor are essential. abstract# p-sat impact of angptl knock-out on adriamycin-induced nephropathy mice objective: idiopathic focal segmental glomerulosclerosis (fsgs) is associated with recurrence after transplantation due to a circulating permeability factor or factors (n engl j med, : - , ) . we have shown the effects of fsgs plasma and its fractions on glomerular permeability in vitro and in vivo and have used state-of-the-art proteomics to identify cardiotrophin-like cytokine- (clcf ), a member of the il- family, as a candidate for the active substance. we hypothesize that a new model of fsgs can be based on the effects of clcf in mice. methods: rclcf (r&d systems) was injected intraperitoneally (ip), one dose, μg/kg, or infused by minipump for days, μg /kg/day. a construct containing clcf- was administered by electroporation. all studies were done in c bl mice. urinary albumin/creatinine, pjak , pstat , patk, and perk in peripheral blood cells (pbc) and in kidney homogenate were measured and glomerular histology was assessed. results: albuminuria was induced promptly by rclcf after either injection or electroporation. peak albuminuria occurred by days of expression and was - fold increased vs. baseline. ip administration of rclcf- increased pjak and pstat of pbc within min. and renal pjak and pstat remained upregulated for at least hours after injection. kidney pjak and pstat as well as perk/ and pakt were markedly increased after days of infusion. mesangial matrix was increased at that time. conclusion: we conclude that clcf mimics many of the renal effects of the active fraction of plasma from patients with idiopathic fsgs and may play an important role in its etiology. its relationship to other candidates such as circulating urokinase receptor (supar) is not known. a murine model based on administration or overexpression of clcf may permit us to define mechanisms of injury and to test potential therapeutic agents prior to use in clinical trials. over-expression of myo e in mouse podocytes enhance cellular endocytosis, migration, and adhesion objective: to investigate the effects of tacrolimus (fk ) on hepatocyte growth factor and transforming growth factor β in kidneys of fsgs rats. methods: establish unilateral nephrectomy combined adriamycin double tail vein injection of fsgs model in rats divided to model group and treatment group ,then treatment group rats were treated withtacrolimus weeks. the protein expression and site of hgf and tgf-β in renal of each group were assayed by western blot and immunohistochemistry after animals were sacrificed. urine protein, serum albumin, blood lipoids and kidney function were tested automatic biochemical analysis system. results compared with the normal control group , model group and treatment group rats h urinary protein excretion , serum creatinine , blood urea nitrogen , cholesterol significantly increased serum albumin significantly reduced severe renal pathological changes and tgf-β protein expression was significantly increased , and the differences were statistically significant ( p < . ) ; compared with the model group , in experiments weekend , the treated rats h urinary protein excretion , relevant serum biochemical indicators of renal pathological changes varying degree of improvement in renal tissue hgf protein expression was increased and tgf-β protein expression was decreased , the above differences were statistically significant ( p < . ). objective: the cellular mechanisms of kidney injury caused by obstructive nephropathy are interstitial inflammation, fibrosis, and apoptosis. rodent models can be used to simulate obstructive nephropathy in the human kidney. we developed shear-thinning hydrogels for the local delivery of il- to abate the progression of inflammation and fibrosis that leads to ckd. methods: injectable dock-n-lock gels were developed as previously reported (fig. ) . il- was added to the gel or phosphate buffered saline solution at a concentration of . ug/ul. study design: eight cohorts were studied ( , , days, n= ): healthy, sham operation, healthy injected with msa, healthy + gel, unilateral ureteral obstruction (uuo), uuo + il- , uuo + gel, uuo + gel/il- . ul of il- solution, gel, or gel/il- was injected into the left kidney via retroperitoneal approach days after the initial uuo or sham operation. histology: immunohistochemistry (ihc) was performed on paraffin sections to identify macrophages and apoptotic cells, and trichrome stain was used to evaluate fibrosis. cells and total area were quantified for ihc and total fibrotic area was quantified for trichrome. results: comparing the treatment groups to the untreated uuo, macrophage infiltration and apoptosis were significantly reduced at day and . by day , adding the il- via gel injection reduced macrophage infiltration more than il- alone and il- alone did not reduce apoptosis. fibrosis was decreased by day in all three treatment groups (fig. ) . conclusion: injectable hydrogels were synthesized that permit facile local delivery of immunotherapy to both healthy and obstructed kidneys. renal inflammation and scarring was reduced in an animal model of ckd by using an injectable hydrogel for drug delivery. logistic regression reveled that apd was the main parameter significantly associated with surgery treated upjo cases (roc plot was . ). a possible threshold of mm apd may be used as a cut-off value of surgery treated upjo group with a sensitivity of % and a specificity of %. conclusion: apd dilatation was the strongest predictor of surgery treated upjo. pt and renal length also significantly discriminate the two groups and correlate with apd, only with lower predictive power. our findings expand the clinical knowledge in the field of prenatal consult by highlighting a threshold of apd, which predicts the need for surgery in prenatally detected hn cases. abstract# p-sat survival and renal outcome in fetuses with lower urinary obstruction (luto) with and without intra-uterine vesicoamniotic shunting.a ten years experience of a cohort. objective: ureteropelvic junction obstruction (upjo) is the most common cause of hydronephrosis in children. the significant role of the surgical relieving of high grade obstruction is indisputable. nevertheless, the effect of pyeloplasty on the function of the involved kidney remains controversial, especially in upjo with significantly reduced relative renal function (rrf) before surgery. to evaluate the effect of pyeloplasty on the relative function of kidneys in children with upjo and decreased rrf. methods: the records of children who underwent pyeloplasty for upjo during a year period in schneider children's medical center of israel were reviewed. the study group included children who underwent pyeloplasty for upjo and had an initial rrf < %. children with bilateral upjo, solitary kidney or other genito urinary abnormalities were excluded. the control group included children with non obstructive hydronephrosis and an initial rrf< %. results: the average initial rrf in the study group was % (range - %), and the final renal function was % ( - %). in the control group, the initial rrf was % ( - %), and the final function was % ( - %). the final rrf of the study group was significantly higher comparing to the control group (p value< . ). in the subgroup of patients with upjo and initial rrf< % ( patients) the average initial function was % ( - %) and the final function was % ( - %). in the control subgroup with initial rrf< % ( patients) the initial average function was % ( - %) and the final function was % ( - %). conclusion: pyeloplasty is associated with an improvement of renal function in children with upjo and an initial rrf < %. this is also true for patients with rrf< % before surgery. our results support the need for pyeloplasty in children with upjo and reduced rrf. objective: common cause of chronic kidney disease (ckd) in children. kidney damage occurs in utero, and kidney disease progresses postnatally. the objective of this project was to identify clinical biomarkers, in particular antenatal variables, which predicted long-term renal outcome in boys with puv. methods: this was a retrospective cohort analysis. primary outcome was the development of end stage renal disease (esrd) as defined as starting dialysis or preemptive transplantation. clinical variables studied included antenatal factors, postnatal renal function, and modifiable variables. continuous data for the two outcome groups were compared, receiver-operating characteristic (roc), kaplan-meier, and logistic regression analyses were conducted to assess the robustness of each candidate biomarker as a predictor of outcome. results: in this cohort cases reached the primary outcome of end stage renal disease at a mean age of . ± . yrs. compared to those who didn't, those who progressed to esrd had younger age at diagnosis ( . ± . vs . ± . yrs, p< . ), valve ablation ( . fsgs rate was found as % in biopsied subjects. nephrotic syndrome was defined by edema, massive proteinuria (> mg/m per hour or a protein/creatinine ratio > . mg/mg), hypoalbuminemia (< . g/dl), and hyperlipidemia. remission was defined as a urinary protein excretion below mg/m per hour or a protein/creatinine ratio below . mg/mg for three consecutive days. steroid resistance was accepted as no achievement of remission in spite of treatment with prednisolone, mg/kg per day for weeks. if steroid resistance was seen, patients were also treated with cyclosporine a (csa) ( - mg/kg per day for least months) and, thereafter, if required, with cyclophosphamide(cp) ( . - . mg/kg per day for - weeks). renal failure was defined as a glomerular filtration rate (gfr) below ml/min per . m body surface area, and esrd was defined as a gfr below ml/min per . m or the necessity for any renal replacement therapy. bidirectional dna cycle sequencing analysis of entire coding exons and adjacent intronic segments of nphs gene was performed.nphs gene mutation analysis has been also performed in healthy children. results: pathogenic nphs mutations were found in patients ( %) from the totally srns children group. mutation rate was % in familial group, and . % in sporadic group. a total of mutations were determined in the nphs gene, and of which were characterized as a novel mutation presented at hgmd databank. in the mutation positive nphs group, most of the mutations were found out to harbor in exons , , and while no mutation were found in exon of the respective gene. patients with p l, r q, r x, r h, s a, a t, v g, h d, ivs + g>a, c. - inst, c. delg mutations were progressed to end-stage renal disease (esrd). also, age at onset of proteinuria (years) was . +/- . in the mutation (-) (n= ) group; . +/- . in the mutation (+) (n= ) group. for the mutation negative patients, effects of other disease causing genes involving nphs , wt , trpc , cd ap, and actn for different molecular subtypes of srns may be considered. nphs mutation screening was performed for all the patients who had proteinuria up to two years of age. as a causative srns gene, we should consider nphs gene mutation screening in early diagnosis and the follow-up of the clinical course. conclusion: in relation to homozygous or compound heterozygous nphs mutated patients who have the lack of response to standard steroid therapy we suggest to perform nphs gene mutation analysis for every child (if consent can be obtained) soon after the first episode of ns. for the newly diagnosed patients, the crucial certain determination of the causative disease gene mutation will enable clinicians to avoid redundant immunosuppressive therapeutic trials. we then performed next generation sequencing in the affected patients and in one of their unaffected relatives. exome enrichment was conducted using the agilent sureselect human all exon v + utrs capture kit. the multiplex libraries were then sequenced on an illumina hiseq instrument with a x bp read length. results: we unexpectedly identified a novel lmx b mutation segregating with the disease in the family. subsequently, we screened additional unrelated families from our international cohort of autosomal dominant fsgs and found mutations of the same residue in families. none of the probands had any sign of dysplasia of nails, patellae or elbows, iliac horns or glaucoma, or any ultrastructural changes suggestive of nail-patella-like renal lesions. lmx b encodes a homeodomain-containing transcription factor that is essential during development. a lmx b in silicohomology model suggests the mutated residue plays an important role in strengthening the interaction between the lmx b homeodomain and dna. both mutations are expected to diminish such interactions. conclusions: our data demonstrate that isolated fsgs could be due to mutations in genes also involved in syndromic forms and highlights the need to include these genes in all next-generation sequencing diagnosis approaches in fsgs. .in / patients mutations were identified by ngs (detection rate %). in / patients sequence variants were found in two different genes ( %) suggesting oligogenic inheritance. in of these patients the causative mutation was located in a gene following an autosomal dominant inheritance pattern. these patients showed a more severe form of the disease compared to affected family members who showed only the causative mutation without additional modifier variants. one additional patient of this cohort with pierson syndrome had two single heterozygous mutations in nphs and lamb , respectively (both genes following an autosomal recessive pattern of inheritance). a further patient showed two mutations in nphs and the non-neutral polymorphism p.arg gln in nphs . structural and/or functional analysis of all mutations identified in patients with mutations in two genes suggested impaired protein function of the particular gene products. conclusion: the influence of modifier genes or digenic inheritance seems to play an important role in the pathogenicity of srns. the application of ngs is therefore of special interest and highly efficient in the diagnostics of patients with srns. abstract# p-sat mutation analysis in japanese patients with congenital and infantile nephrotic syndrome objective: mutations in podocyte genes (nphs , nphs , wt , and lamb ) are associated with congenital (< months) and infantile ( - months) nephrotic syndrome (ns). the purpose of this study is to investigate the frequency of causative mutations in these genes in ns manifesting in the first year of life in japan. methods: all exons and exon-intron boundaries were investigated in consecutive, unrelated patients from regional pediatric kidney disease centers, by pcr-direct sequencing. results: we detected disease-causing mutations in . % ( of ) patients ( % in congenital and % in infantile) (table) . objective: hypercoagulability along with thrombosis are prevalent complications of nephrotic syndrome. in cases of refractory nephrotic syndrome, intracardiac thrombus, although rare, is a serious complication because of its association with morbidity and high mortality herein, we report a case of a patient with a right atrial thrombus associated with nephrotic syndrome who responded well to corticosteroid therapy and attained quick remission. case presentation: a -year-old japanese boy was referred to our hospital for a right atrial thrombus associated with idiopathic nephrotic syndrome diagnosed month ago. the patient had attained the partial remission within the days of the corticosteroid therapy initiation. he was asymptomatic otherwise at the time of admission. the patient's vitals were stable and laboratory values were almost within the normal range. an echocardiogram showed a large isolated hyperechoic mass in the right atrium, which originated from the superior right atrial wall. the mass measured × mm in diameter and traversed through the tricuspid valve in a to-and-fro motion. the patient underwent emergency surgical thrombectomy on day and anticoagulation therapy was started days after the operation. the subsequent hospital stay was uneventful, and the patient was discharged on day . objective: nephrotic syndrome features proteinuria and severe sodium retention which is implicated in ascites and edema formation. previous works realized in nephrotic rats (pan) clearly highlighted that, the increase of sodium absorption in the ccd is associated with an increase activity of the na/k atpase; sodium absorption is independent of aldosterone, activation of epithelial sodium channel enac is not necessary and sodium absorption is inhibited by amiloride. our hypothesis is that, in nephrotic syndrome, another apical sodium channel sensitive to amiloride and independent of saar pathway is implicated in sodium absorption in the ccd. methods: transcriptome of ccds from control rats (ct) and pan treated clamped rats (adx pan) was analyzed using a high-resolution quantitative and comparative analysis of gene expression. subsequently, transcriptional (rt-qpcr) and proteic expression (western blot and immunohistochemistry) of channel were analyzed. sodium handling in vivo and in vitro microperfused collecting ducts in different conditions (ph and . , apical zinc . mm and amiloride . mm) was analyzed. results: metabolic study confirmed previous results: sodium absorption and ascites were similar in pan and adxpan rats suggesting that sodium absorption in nephrotic syndrome was independent of saar. transcriptome analyses highlighted an increased expression of accn mrna only in adx pan at day . rt-qpcr confirmed an increased expression of accn only in the ccd of adx pan (about eight time compared to adx ct). subsequently, protein shows an increase expression of accn (adx pan . +/- . vs adx ct . +/- . , p . ) and immunohistochemistry on microdissecated ccd highlighted a strong apical expression of accn only in adx pan rats. schimke immuno-osseous dysplasia (siod) is a rare autosomalrecessive multisystem disorder, characterised by: disproportionate growth deficiency, defective cellular immunity, nephrotic syndrome and progressive renal disease.siod is caused by bi-allelic mutations of smarcal gene, which encodes the hepa-related protein (harp), a member of the snf family of atpases, acting as chromatin remodelers within multi-protein complexes. a -year-old patient was hospitalized in november , after detection of proteinuria ( . g/day). at our first clinical examination: height-weightgrowth retardation, thinning hair, thin and hypopigmented skin, arched palate and normal neuro-psychological development.serological examination showed proteinuria ( . g/day), hyperchol. (col tot mg/dl, ldl-col mg/dl) and lymphocyte deficiency ( . %).renal function and complement levels were normal. lymphocyte subpopulations showed a decrease of t lymphocytes and an increase of nk cells(cd + cd +).the patient had also a detour back-lumbar scoliosis and normal kidneys in size, but with reduced corticomedullarydifferentiation. we started therapy with ramipril . mg/day. the hrs urine exams performed monthly showed persistent proteinuria ( - mg/day). at the end of april , for the persistence of proteinuria, we performed renal biopsy, which showed focal and segmental glomerulosclerosis. at discharge, she started therapy with irbesartan mg/day with significant reduction of proteinuria ( mg/day). after months of therapy, thepatient did not present proteinuria and her renal function was normal. the molecular genetic study of smarcal gene revealed that patient was compound heterozygous for two mutations: a novel missense mutation in exon , inherited by mother, and a nonsense paternally-derived mutation in exon , leading to a truncated smarcal protein. our data allow us to diagnose a schimke immuno-osseous dysplasia (siod). in most patients, life expectancy is limited to childhood or early adolescence, due to the onset of stroke, infections,hematopoietic bone marrow failure and renal failure. only patients with milder and late onset forms can survive until adulthood. gain of glycosylation in integrin-alpha- causes nephrotic syndrome and lung disease objective: congenital nephrotic syndrome and interstitial lung disease is a rare multiorgan disorder, characterized by disrupted basement membrane structures. itga gene mutations were recently identified as the genetic cause of this disorder, but the disease mechanism remains poorly understood. methods: we describe a patient who presented with neonatal respiratory distress, glomerulosclerosis, proteinuria, pulmonary hypoplasia and alveolar glycogenosis, who died months after birth due to respiratory insufficiency. a genome-wide screening for deletions and duplications revealed a large homozygous region that included the itga gene. we sequenced the gene and then conductedin vitro characterization studies to investigate the effect of the variant on the protein function. results: a novel homozygous missense mutation was identified in the coding region of the itga gene, which introduces an n-glycosylation motif to the protein sequence. thereby, the mutant integrin alpha- protein becomes hyperglycosylated. functional studies demonstrated that the conformation of integrin alpha- is affected and the mutant alpha- precursor is targeted for degradation. consistent with these findings, alpha- integrin was not detected in the patient glomeruli. furthermore, integrin alpha- protein expression was absent in murine podocytes that lack endogenous integrin alpha- and transfected with mutant itga . conclusion: our findings underscore the role of the integrin alpha- beta- complex as the main regulator of podocyte basement membrane integrity. here, we show that hyperglycosylation of the integrin alpha- subunit, causing the complete lack of alpha- -beta- expression on the basement membrane, is a new pathogenic mechanism underlying congenital nephrotic syndrome and interstitial lung disease. itga mutation screening was directly implemented in dna diagnostics, facilitating early diagnosis, recurrence risk estimation, and genetic counselling. the clinical study on pkhd gene-based testing for the diagnosis of arpkd objective: in order to study the implications of pkhd gene-based testing for arpkd diagnosis in clinical practice, we performed a prospective study to apply pkhd -based genetic testing to the suspected arpkd patients. methods: suspected arpkd patients from unrelated families were detected on mutations of pkhd gene by pcr direct sequencing. these patients were evaluated by combining the testing results and their clinical materials. results: in the detected children, mutations (p s, v a, q h, l x) were novel and mutations (t m, r w, r c, n s, a v, q r, q r) were previously described. of the variants were definite pathogenic mutations. two pathogenic mutations in both chromosomes were found in out of families ( %), which greatly aid to making definite diagnoses. the families with perinatal presentation consisted of fetuses and couples. one definite pathogenic mutation (s c) was found in the wife of family no. , however, it was still difficult in conforming the diagnosis owing to lack of the pathogenic mutation from the husband. for the other families, only some potential mutations were found.two in four children with congenital hepatic fibrosis were detected two pathogenic mutations in both chromosomes, and their liver functions were obviously lower than the other two children without pathogenic mutations. conclusion: pkhd gene-based testing is an effective means for the diagnosis of arpkd, at the same time it could improve the understanding of this disease by analysing the testing results and their clinical materials. objective: to present a case of schimke immuno-osseous dysplasia (siod) which is the first to be reported from egypt. methods and results: this article presents a case from egypt with mild form of siod presented at the age of . years with disproportionate short stature, srns (focal segmental glomerulosclerosis), laboratory evidence of cellular immune deficiency and radiologic characteristics of spondyloepiphyseal dysplasia and died at the age of . years with bone marrow failure and severe pneumonia. conclusion: we emphasize that siod is to be considered in children with growth retardation, srns and bone abnormalities and that inherited nephrotic syndrome may be presented in late childhood or even adolescence and siod suspected patients even before full picture development should be closely monitored for proteinuria, hypertension, cellular immunity and opportunistic infections especially with the need to start immune suppressive therapy for nephrotic syndrome. abstract# p-sat denys-drash syndrome presenting with polycystic kidneys objective: denys-drash syndrome (dds) is characterized by a congenital or infantile nephrotic syndrome due to diffuse mesangial sclerosis, male pseudohermaphroditism and a strong predisposition to develop wilm's tumors and gonadoblastoma's. the syndrome is caused by a dominant mutation in the wt gene. we report a case of dds associated with renal cysts, which has never been described so far. we report a case of dds in a months old girl presenting with proteinuria and bilateral cortical cysts on renal ultrasound. autosomal recessive polycystic kidney disease was excluded by a normal liver biopsy. a kidney biopsy showed diffuse mesangial sclerosis. at the age of months, she developed a unilateral wilm's tumor, which was treated by heminephrectomy and chemotherapy. the renal cysts were still present on ultrasound. histological examination of a cyst (located in the resected specimen, but separate from the wilm's tumor) showed one layer of flattened epithelial cells, without any evidence of malignancy. the combination of diffuse mesangial sclerosis and a wilm's tumor pointed to the diagnosis of dds. genetic analysis showed a de novo heterozygous missense mutation c. g>a (p.asp asn) in the wt gene, previously described in patients with dds, confirming the diagnosis. because polycystic kidneys have never been reported in dds, we explored several genes responsible for these renal manifestations, such as hnf- β, pax , pkd and pkd . remarkably, we identified a heterozygous missense variant c. a>g (p.lys glu) in the pkd gene. mutations in pkd lead to autosomal dominant polycystic kidney disease (adpkd). the pathogenicity of the newly identified missense variant in our case was evaluated by different mutation prediction software programs and was classified as being 'likely pathogenic'. the same variant was found in the patient's mother, having no renal cysts on ultrasound and in the grandfather, having bilaterally renal cysts. conclusion: this is the first case of dds in combination with polycystic kidneys. we hypothesize that pkd c. a>g variant might be an incompletely penetrant allele that can cause a severe phenotype of adpkd in association with a wt gene mutation. the phosphatase and tensine homolog (pten) gene is a tumor suppressor gene located on the long arm of chromosome ( q - ). the pten protein is broadly expressed in cells throughout the body, acting as both lipid and protein phosphatases, and regulates intracellular signaling via various pathways. reduced pten protein resulting from a pten gene mutation may enhance cell proliferation, resist from apoptosis. in addition, it has became clear that, in vascular endothelial cells, pten gene abnormalities lead to increased expressions of vascular growth factors, such as angiotensin ii (ang ii), that are essential to angiogenesis. recent reports revealed a germline mutation of the pten gene to cause several syndromes with generalized, multiple hamartomatous lesions of tridermic origin. thus, the new concept of pten hamartoma tumor syndrome (phts) has been proposed. to the best of our knowledge, we describe here for the first time a case of focal segmental glomerulosclerosis (fsgs) with phts. a -year-old girl was found to have proteinuria and hematuria on health examination and referred to us for persistent urinary abnormalities. igm nephropathy were diagnosed by renal biopsy, and she started taking an angiotensin-converting enzyme inhibitor. however, proteinuria was not reduced, and an oral angiotensin ii receptor blocker (arb) was administered. proteinuria persisted and she underwent renal biopsy again, yielding a diagnosis of fsgs. despite continued oral arb treatment, proteinuria is ongoing with a urine protein-to-creatinine ratio of approximately . , and mild renal impairment. at age years, years ago, a neck mass prompted a detailed examination which revealed multiple thyroid nodules, ovarian cysts (mucinous cystadenoma), hemangiomas in the plantar and femoral regions, spinal cord lipoma, and renal nodular lesions, necessitating follow-up. subsequently, additional workup detected a pten gene heterozygous mutation (exon codon cga(arg) tga(stop)) and she was diagnosed with phts. methods: a -day-old girl, the first child of non-consanguineous chinese parents, was hospitalized due to edema, gross proteinuria, and progressive renal failure. she was delivered spontaneously at weeks of gestation with a birth weight of gand a body length of cm. during the delivery, she was experienced mild asphyxia. placental weight was large, and the amniotic fluid was meconium-stained. pregnancy was unremarkable and had included routine prenatal ultrasound evaluation. the family history of proteinuria or renal failure was negative. on admission, the findings from physical examination showed the patient had bilateral microcoria and limb hypotonia. results of serological testing for torch infections were negative. since pierson syndrome was suspected, a kidney biopsy was performed when she was aged days. meanwhile, all coding exons of lamb were analyzed by using pcr and direct sequencing. results: electron microscopy revealed some glomerular basement membranes were thick and thinning, with splitting of the lamina densa. in addition, the foot processes of podocytes were diffusely effaced, and the number of podocytes increased. two different novel nonsense mutations (trp x and gln x) of lamb were detected in the patient. these mutations were inherited from her parents respectively. conclusions: newborn with unexplained renal insufficiency or nephrotic syndrome should consider pierson syndrome. our report extends the genotypic spectrum of pierson syndrome. a familial wt mutation associated with incomplete denys-drash syndrome we report a familial wt missense mutation in exon ( c>t, r w) in three members of one family. patient , a years old boy, was born at ambiguous genitalia ( , xy karyotype), penoscrotal hypospadias and bilateral inguinal hernias. he was found proteinuria on the preoperative examination and renal biopsy showed diffuse mesangial sclerosis. patient , a years old, is the older sister of patient , who has normal genitalia. she was found proteinuria and renal biopsy showed focal mesangial sclerosis. wilms's tumor was not found in both of them. a wt mutation was detected in both the two patients and their farther. the patients are considered as incomplete dds and they can inherit mutations from their father. so, this finding will provide new evidence for a better understanding of dds and further familial studies in patients of dds are need. ying chen , songming huang , , guixia ding , , hongmei wu , aihua zhang , nephrology, nanjing children's hospital, nanjing, china institute of pediatrics, nanjing medical university, nanjing, china objective: to investigate the correlations between peroxisome proliferator-activated receptor (ppar)-α, ppar-γ, and ppar-γ coactivator- α (pgc- α) gene polymorphisms and susceptibility to primary nephrotic syndrome (pns). methods: patient genotypes were determined using the polymerase chain reaction-restriction fragment length polymorphism (pcr-rflp) technique for the pro ala and val met polymorphisms of the ppar-γ gene, the gly ser polymorphism of the pgc- α gene, and the leu val polymorphism of the ppar-α gene. the gene polymorphisms in cases of pns in children and normal controls (nc) were analyzed and compared to examine the differences in the clinical metabolism index, proteinuria, renal pathological types, and hormone treatment responses among pns children with different genotypes. results: the ppar-γ pro ala and pgc- α gly ser mutations were not associated with the occurrence, blood pressure, total cholesterol, a decrease in glomerular filtration rate (gfr), urine protein excretion at the onset of disease, renal pathological type, or hormone treatment response in children with pns. although the homa-ir values for children with the a allele did not differ significantly from those of children with the pp genotype of the ppar-γ gene, their insulin levels were decreased and their isi values were significantly increased (p= . and . , respectively). the triglycerides (tg) levels of children with the aa genotype of the pgc- α gene were significantly increased (p= . ). in addition, the ppar-γ (val met) and ppar-α (leu val) gene polymorphisms did not show any mutations in the cases of pns in children or the nc children. conclusion: the pro ala mutation of the ppar-γ gene may be correlated with a decrease in insulin secretion and an increase in insulin sensitivity and the pgc- α (gly ser) gene polymorphism may be a causative genetic factor for the triglyceride abnormalities in children with pns. the relationship between endothelin- gene polymorphisms and primary nephrotic syndrome in children objective: nphs mutations have been reported in cns. however, no hot mutation has been described in chinese family. in this study, nphs mutations were analyzed in a chinese family with two siblings died of cns. methods: genomic dna samples were extracted from peripheral blood of the proband, her parents, and unrelated normal individuals. all exons of nphs were detected by polymerase chain reaction(pcr) and direct dna sequencing. results: the proband, a -day-old girl, weighed g at birth. the placenta was one time heavier than usual. she was hospitalized with edema of legs, heavy proteinuria(+++), and hematuresis(+++). two compound heterozygous mutations were identified in exon (c. c>t, p.p s), which was detected in her father, and in exon (c. t>c, p.v a), which was also detected in her mother. these two new mutations were not found in the chinese controls. conclusion: new compound heterozygous nphs mutations (c. c>t and c. t>c) were identified in a chinese family with two siblings of congenital nephrotic syndrome, which were suggested to be the causative mutations in this family. the compound heterozygous mutations (c. c>t and c. t>c) lie between ig and ig domain which has a free cysteine residues. these mutations might cause misfolding and defective intracellular transport, with consequent absence of the mutant nephrin on the plasma membrane. abstract# p-sat sporadic myh -related disease: a case report and mutational analysis of myh gene .genetic analysis confirmed that these three cases had intron (+kts) mutation.after confirmation of fs, cytogenetic analysis showed xy in girls though phenotypically there were females.abdominal ultrasound in them showed normal uterus with streak gonads and gonadectomy was done for both and histologically reported as dysgerminoma stage i. familial girl aged entered esrd and received live related renal transplant from her mother. the sporadic girl aged years also entered end stage renal disease rapidly and died. the third was a nephrotic boy aged years with fs. he had bilateral hypoplastic testes. his chromosome was xy. renal biopsy showed mcd with igm deposits and partially responding to therapy. a six year old girl presented at the emergency department with a history of episodes of vomiting in hours. she had a history of polyuria and polydipsia with a current daily intake of liters. physical examination revealed signs of mild dehydration. plasma electrolytes revealed hyponatremia ( mmol/l), hypokaliemia ( . mmol/l), metabolic acidosis with normal anion gap ( mmol/l), hypophosphatemia ( . mmol/l), hypouricemia ( umol/l) and normal serum creatinine ( umol/l). urinalysis confirmed the na, k, ph and acid uric losses: na ( mmol/l, fractional excretion %), k ( mmol/l, ttkg ), tubular phosphate reabsorption of %, and fractional excretion of uric acid of %. cystine level in leucocytes was normal. she was discharged six days later with oral supplementation of potassium and phosphorus. laboratory studies weeks later revealed surprising findings with persistent hypokaliemia ( mmol/l), metabolic alcalosis (hco mmol/l), hypomagnesemia ( . mmol/l), and hypocalciuria (calcium/creatinine . mmol/mmol). we therefore sequenced the slc a gene and we found that she is compound heterozygous for known missense mutations (p.thr met and p.gly ser). conclusion: gs can have atypical presentations including severe polyuria; it should be suspected in case of severe hypokaliemia even in the absence of the other classical features. this case report emphasizes the need for repeated laboratory tests in unclear tubular disorders, especially outside of confusing intercurrent illness. a single basepair mutation causes cystinosis in the majority of western cape patients. conclusion: renaltube is being used by pediatric nephrologists over the world for the study of their patients with primary tubular disorders. renaltube will likely contribute to a better care of these children and to a better scientific understanding of primary tubular diseases. the creation and development of this sort of international collaborative efforts must be encouraged within the pediatric nephrology community. objective: to study molecular mechanism of hypercalcemia-induced nephrogenic diabetes insipidus (ndi) by identification of proteins in inner medullary collecting duct (imcd) responsible for this syndrome. methods: the effect on rat kidney medullary collecting duct of early onset ndi resulting from parathyroid hormone-induced hypercalcemia was studied using proteomics and phosphoproteomics in native inner medullary collecting duct (imcd) cells. imcd tryptic peptides and phosphopeptides were identified and quantified by mass spectrometry using a label-free methodology. the major findings were confirmed by selected reaction monitoring study, immunoblot, and immunohistochemistry. results: a total of , peptides corresponding to , proteins and , phosphopeptides of proteins were identified, with significant changes in abundance of proteins and phosphopeptides in early onset ndi versus vehicle controls. gene ontology terms and pathway analysis revealed that hypercalcemiaaffected proteins and phosphoproteins are associated with integrin signaling, and actin cytoskeleton organization. immunoblot and selected reaction monitoring lc-ms/ms studies confirmed the hypercalcemia-regulated proteins (agrin, arcp b, capg, erm, itgb , lamb , and lamc ) and phosphoproteins (myh , add , dync li , cgnl , aqp ). hypercalcemia induced changes in abundance of vasopressin-regulated phosphorylation of aquaporin- (aqp ) at ser and ser , but not total aqp , and decreased abundances of slc a urea transporters ut-a , ut-a , and phospho-ser -ut-a . the major findings were also identified in imcd of rats with vitamin d-induced hypercalcemia. filamentous actin aggregation was firstly demonstrated in imcd of rats with hypercalcemia-induced ndi from both pth and vitamin d. conclusions: early increasing in water excretion in response to hypercalcemia are dependent of changes in abundances of aqp phosphorylations, ut-a and its phosphorylations are consistent with prior literature pointing to key roles of the integrin signaling and the actin cytoskeleton in maintenance of collecting duct function. objective: to study molecular mechanism of hypokalemia-induced nephrogenic diabetes insipidus (ndi) by identification of proteins in inner medullary collecting duct (imcd) responsible for this syndrome. methods: the effect on rat kidney medullary collecting duct of early onset ndi resulting from hypokalemia was studied using proteomics in native inner medullary collecting duct (imcd) cells. imcd tryptic peptides were identified and quantified by mass spectrometry using a label-free methodology. the major findings were confirmed by selected reaction monitoring study, immunoblot and immunohistochemistry. results: a total of , peptides corresponding to proteins were identified with significant changes in abundance of proteins in early onset ndi versus vehicle controls.gene ontology terms and pathway analysis revealed that hypokalemia-affected proteins are associated with generation of precursor metabolite and energy and regulation of actin cytoskeleton. immunoblot and selected reaction objective: inherited distal rta (drta) is a rare condition and is almost always observed in children as a primary entity. mutations in genes encoding transporter or channel proteins operating along the renal tubule may result in a variety of functional defects. the identification of the molecular defects in drta may provide a basis for future design of targeted therapeutic interventions and, possibly, strategies for gene therapy of these complex disorders. for this reason, we evaluated mutations in slc a and atp v b genes. methods genomic dna from pediatric patients diagnosed with drta was extracted from peripheral blood samples. sequencing was performed for five exons of slc a ( , , , , ) and two exons of atp v b ( , ). all the selected exons are considered hotspots for mutations associated to this tubular disorder. results silent mutations were identified in both studied genes. the mutation c. t>c was identified in exon of slc a in one patient and the second variation (c. t>c) was found in exon of atp v b in two patients. although previously described, these silent variations are not highly frequent in the overall population. also in slc a , exon , two nonsynonymous variations were identified in the same patient (p.pro leu and p.val ile). the p.val ile variation was also found in three other patients. it has been shown that these variations are rare polymorphisms in the population, but they have already been associated to diego group erythrocyte antigen. in exon of atp v b the variation p.met ? was presented in twelve patients and the mutation p.thr ile was found in six patients. although they occur in the coding region of atp v b , these variations have been described as highly frequent in the population. dent's disease is an x -linked renal proximal tubulopathy associated with mutations in clcn (dent's type ) and ocrl (dent's type ).ocrl mutations also cause the oculocerebrorenal syndrome of lowe. we report the case of a year old boy with dent's disease associated with a novel hemizygous change, c. t>c p.(met ) in exon of ocrl. our patient presented at years of age with incidental finding of non-nephrotic range proteinuria. he had elevated urinary beta - microglobulin, retinol binding protein and hypercalciuria. he was developmentally normal and is otherwise of good general health. slit lamp examination and vision were normal. he had normal renal function but had very poor renal accumulation of mtc-dmsa on renoscintigraphy. genetic testing identified a hemizygous change, c. t>c p.(met ), in exon of ocrl, which affects the translation initiation codon. his healthy year old brother who was also found to have low -molecular weight proteinuria and hypercalciuria, is currently being investigated. to the best of our knowledge, the hemizygous change, c. t>c p.(met ?) in exon of the ocrl gene which was identified in our patient with dent's disease represents a novel variant which has not been previously reported in a dent's disease patient. abstract# p-sat enamel-renal syndrome associated to splenic and ovarian calcifications: a case report sameh mabrouk, noura zouari, houda ajmi, jalel chemli, menair tfifha, saida hassayoun, saoussen abroug , abdelaziz harbi pediatrics, university hospital of sahloul, sousse, tunisia enamel-renal syndrome (omim ) is a rare condition characterized by amelogenosis imperfecta and nephrocalcinosis.we report a new pediatric case of this rare association with the particularity of associated splenic and ovarian calcifications. this report concerns a -year-old girl, born to consanguineous parents (first degree cousins). she has no family history of nephrocalcinosis or kidneydisease. her unique brother, aged years, is in good health and has no dental or renal problems. she was first seen at the age of years in dentistrydepartment because of dental abnormalities, the diagnosis of amelogenosis imperfecta was made and the patient was further investigated. a renal ultrasound showed a bilateral medullary nephrocalcinosis. ct confirmed bilateral nephrocalcinosis which was associated to ovarian and splenic calcifications. besides this young girl has a normal growth, her puberty began at the age of years. laboratory findings including serum electrolytes, urea, creatinine, calcium, phosphate, parathormone and alkaline phosphatase were within normal ranges. on urine examination we found a hypocalciuria, with normal sodium and phosphate excretion. the patient is regularly seen in both dentistry department and pediatrics. the aim of this report is to highlight the important role of pediatricians as well as dentists in recognizing this rare and uncommon syndrome. objective: ipex syndrome, a hereditary (x-linked) immune dysregulation with autoimmune polyendocrinopathy and enteropathy, as the basic manifestations, presents a rare and severe disease. the objective of this case report is to highlight the pleomorphism of the syndrome. methods: the authors report the case of a male infant, with a family history of three male siblings affected by ipex syndrome. the patients' medical records were reviewed in order to describe the case of the youngest one. results: during the follow-up of the youngest of three siblings, who presented eczema and intestinal manifestation, without compromised pancreatic and thyroid function, different from other two siblings, it was noticed the pattern of dent's disease. we registered hypophosphatemia, hypercalciuria, glycosuria, low molecular weight proteinuria and ultrasound revealed second stage bilateral nephrocalcinosis. in this child there was no apparent glomerular involvement, as it was seen in the eldest sibling. conclusion: dent's disease is an x-linked renal proximal tubulopathy associated with mutations in the chloride channel gene clcn (xp . ), which is next to foxp gene on the x chromosome (xp . -q . ). it seems that in this sibling mutations occurred in exons of both of these genes. this case is to remind on pleomorphic potential of mutations that occur near the coding regions of the foxp gene. objective: multiple target organ defects (mtod) is a subgroup of pseudohypoaldosteronism (pha) type i and salt wasting is more severe in this form of pha i. it has a poorer outcome than the renal form, and therapy must be maintained throughout life. here, we reported an infant with mtod who had severe hyperkalemia resistant to classical treatment of pha. hyperkalemia was normalized only by peritoneal dialysis (pd). case: a month-old boy was admitted to our hospital with persistent vomiting, metabolic acidosis, and severe hyperkalemia. there was consanguinity between parents and he had a healthy sister and brother. there was no history of medication. physical examination revealed the signs of volume depletion and acidosis. results: in laboratory examination, blood urea nitrogen was mg/dl, creatinine . mg/dl, sodium meq/l, potassium . meq/l, and chloride meq/l. blood ph was . , base excess - meq/l, and hco meq/l. urinary analysis revealed low specific gravity ( ) with ph . , and normal urinary sediment. urinary sodium was meq/l, potassium meq/l, and plasma renin activity . ng/ml ( . - . ), aldosterone pg/ml ( - ), cortisol . mg/dl ( - . ), and acth . pg/ml ( - ). renal ultrasonography did not show any abnormalities. sweet-test showed high sodium waste from sweet glands ( meq/l). the patient diagnosed as mtod. severe hyperkalemia persisted and was resistant to all treatment options for pha, including high-sodium and low-potassium diet, fluid resuscitation, potassiumbinding resins, indomethacin, fludrocortisone, and hydrochlorothiazide. nutritional status of the patient was also not good, and parents did not accept gastrostomy. hyperkalemia was corrected only after pd treatment, and his nutritional status improved dramatically. conclusion: in the case of type iv renal tubular acidosis resistant to therapy, mtod could be considered as a cause of acidosis. if the classical treatment options fail to correct hyperkalemia in these patients, pd may be a reasonable choice to normalize severe hyperkalemia. gülsün gülay yılmaz erta yilmaz , pediatric nephrology, md, antalya, turkey akdeniz univercity, prof. dr, antalya, turkey tuberous sclerosis, which has an autosomal dominant hereditary disease with a high rate of spotaneous mutation, especially occupies the nervous system and many other organs like kidney, heart and lung. the case presented here was initially diagnosed as congenital heart and polycycystic kidney diasease, because of its characteristics which were quite different than expected for tuberous sclerosis. finally, it was evaluated at our pediatric department together with its dermatological and radiological aspects and defined as a tuberous sclerosis of delateddiagnosis. the case was discussed with its former and actual findings and presented as a warning for early diagnosis. abstract# p-sat the effect of bone marrow stem cells mobilization on expression of hif- α and egf in ischemia/reperfusion-induced renal injury objective: to investigate the therapeutic effects of bone marrow stem cells which has been mobilized by g-csf and stem scf on expression of acute tubular necrosis hypoxia inducible factor- a (hif- α) and epidermal growth factor (egf), and to investigate the mechanism of scf and g-csf on the treatment of ischemia/reperfusion-induced renal injury. methods: male sprague-dawley rats that are - weeks old were randomly allocated into groups (n = ineach group): control group (group a), ischemic-reperfusion group (group b), scf + g-csf + ischemic-reperfusion group (group c) and scf + g-csf + control group (group d). detection index: hif- α was measured by immunohistochemistry technique, the expression of egf and cd + cells in kidney was measured by strept avidin-biotin-peroxidase(sabc) and egf mrna by rt-pcr . results: ( ) at days postoperative, the cd + cells of group b and c was conspicuous higher than group a and d(p< . ), group c was higher than group b(p< . ). they gradually descended from days with the time prolonged. ( )at days postoperative, there was significant difference of the expression of hif- α between group a and d (p< . ). the expression of hif- α of group b and c showed higher positive reaction at days postoperative then decent to normal. at each time the expression of hif- α of group c was significant higher than other groups (p< . ). ( )the egf expression of group b and c showed higher positive reaction at days postoperative and decent to normal with the time prolonged, group b peaks at days and higher than group a, group c peaks at days, and it is the highest (p< . results: in contrast to model group, atn treated with adscs displayed: cells expressing green fluorescent protein were dectected in injured tubule in kidney . treatment group were significantly higher than model group, p< . ; renal damage is lighter; kidney damages were relative gently and histopathologic lesion scores was relative lower; while ki- positivece cells in treatment group were more than those in model group (p< . ); the expression of bax, bcl- and cell apoptotic index(ai) in treatment group was lower than those in model group , p< . , but bax/bcl- ratio was higher than those in model group. conclusion: allogenic adscs transplantation can accelerate proliferation of renal tubular epithelial cell and suppress apeptosis injury through up-regulating the ratio of bcl- / bax and down-regulating the expression of bax protein in acute kidney injury. objective: previously we showed that pretreatment with the antidepressant fluvoxamine (flu) improves postischemic survival and ameliorates functional and structural kidney damage after renal ischemia/reperfusion (ir). in heart ir injury flu is protective through activating the sigma- receptor (s r) -nitric-oxide synthase (nos) system. here we studied the intrarenal vasoregulatory effect of flu and analyzed the renal s r-nos cascade. methods: male wistar rats were were treated i.p. either with ( ) vehiculum (veh); ( ) flu ( mg/bwkg; flu); ( ) flu+ s r antagonist ne- ( mg/bwkg; fn); ( ) flu+ non-selective nos blocker l-name ( mg/bwkg); ( ) flu + selective endothelial (e) nos blocker l-nio ( mg/bwkg); ( ) flu and selective neuronal (n) nos blocker -ni ( mg/bwkg). minutes later rats were either harvested or subjected to minutes of ischemia followed by hours of reperfusion. sham-operated animals served as controls (n= /group). renal s r, akt, enos and nnos protein levels were measured, the alteration of renal capillary diameters was determined in vivo using muliphoton microscopy. results: ir induced renal vasoconstriction, which was ameliorated by flu. this increase was neutralized by all nos blockers, mostly by -ni. after ir all measured protein levels increased. s r expression was similar in all treatment groups. akt and enos levels were lower, while nnos levels were higher in the flu treated group compared to veh and fn. the acute vasodilatative effect of flu minutes after treatment was suspended by l-name and -ni and even reversed by l-nio. s r, akt and enos protein levels were elevated min after flu treatment, while nnos levels remained unchanged. discussion: pretreatment with the s r agonist flu -used chronically without notable side-effects -improves postischemic renal perfusion through the activation of s r -nos system in a time and nos isoform specific manner. based on this data one can hope to find a new therapeutic target in the treatment of renal ir damage through the modulation of the s r. methods: sd rats were randomly divided into model group, intervention group and normal group, rats in each group. intraperitoneal injection with gentamicin for days to establish renal tubular injury rat model. then the intervention group rats were transplanted with × /ml bm-mscs via tail vein. days after transplanted with bm-mscs, took blood and kidney specimen of rats for testing. serum creatinine (scr), urea (bun), malondialdehyde (mda), superoxide dismutase (sod), glutathione peroxidase (gpx), heme oxygenase - (ho- ) were detected by spectrophotometry. he staining was used to evaluate the change of renal tissue pathology, then score the renal tubular injury according to the nangaku semiquantitative scoring method. tunel method was used to detect the apoptosis of epithelial cell rate in renal tubular, while immunohistochemistry was used to detect the proliferation of renal tubular epithelial cells (pcna labeling index). results: . scr and bun of intervention group rats were lower than those in the model group, the difference was statistically significant (p < . ); . renal tubule pathological score of intervention group rats were lower than those in the model group, the difference was statistically significant (p< . ); . apoptosis ratio of renal tubular epithelial cell in intervention group rats were lower than the model group, the difference was statistically significant (p< . ); . the pcna labeling index of intervention group rats were higher than those in the model group, the difference was significant (p< . ); . the mda level was significantly reduced in intervention group rats than in the model group (p < . ); . the sod, gpx and ho- inintervention group rats were significantly increased than those in the model group (p < . ). conclusion: antioxidant factors such as sod, gpx and ho- were significant increased after bm-mscs transplanted into rats. it means that bm-mscs may have antioxidant effect to heal the renal tubular damage. the effect on regeneration and repair in renal tubular epithelial cell after injury deal with at r antagonist pd objective: to study the effect of proliferation of renal tubular epithelial cell after injury deal with at r antagonist pd ,and to explore the function and mechanism of at r in the regeneration and repair after acute kidney injury. methods: to establish the human renal proximal tubule cells (hk- cells) hypoxia /reoxygenation model. hk- cells were divided into two groups. ( ) ( ) these results suggest that the renal proximal tubule epithelial cells after hypoxia/reoxygenation can be simulated tubular epithelial cell process damage; ( ) the proliferation of renal tubular epithelial cell after injury was inhibited by pd .at r may play an important role in the regeneration and repair in the kidney by means of promoting the proliferation of renal tubular epithelial cells. ( ) arb have no significantly inhibit the proliferation of renal tubular epithelial cell after injury, suggesting that at r may not have major role in regeneration and repair after acute kidney injury. the effect and mechanism on regeneration and repair in renal tubular epithelial cell after injury by the inhibitory proliferation effect of acei and arb objective: to study the effect of regeneration and repair of renal tubular epithelial cell after injury deal with fosinopril and valsartan, and to explore the function and mechanism of acei and arb induced acute kidney injury by suppressing proliferation. objective: ischemia-reperfusion injury (iri) is a major cause of acute kidney injury (aki) and both innate and adaptive immunity contribute to the pathogenesis. t cell immunoglobulin- (tim- ) has been reported as an important regulatory molecule and plays a pivotal role in several inflammatory diseases. however, it keeps unknown whether tim- is involved in renal iri. to investigate the expression of tim- on kidney mononuclear cells (kmncs) from mice with renal iri and explored its role in the pathogenesis of renal iri. methods: the left renal pedicle was clamped in c bl mice for min, followed by reperfusion. animals were sacrificed at baseline, day , . flow cytometry was used to quantify tim- expression on kmncs ,cd + t cell,cd + t cell,foxp + tregs and cd + b cell. the levels of tnf-α, ifn-γ, il- and il- in kidney tissue were measured using elisa. results: at day , the increased expression of tim- on kmncs ,cd + t cell,cd + t cell,foxp + tregs in the injured kidney from mice with renal iri compared to those from uninjured kidney tissues and baseline (p< . ). percentage of tim- + cells in kmncs showed an inverse correlation with kidney injury score and kidney tnf-α level. similar negative correlations were found between kidney injury score and tim- levels on cd + t, cd + t cells. consistently, tim- expression on cd + t cells was further increased in mice at day . tim- expression on foxp + tregs negatively correlates with kindey tnf-α. conclusion: tim- might participate in the proceeding of renal iri by regulation on various cd + t cell subsets. tim- might be a potential new marker for assessing severity of renal iri. expression of galectin- and tim- in kidney of mice with renal ischemia reperfusion injury objective: t cell immunoglobulin- (tim- ) is a surface molecule expressed on various immune cells which plays a central role in immune regulation. identification of galectin- (gal- ) as a ligand for tim- has established that the tim- /gal- pathway has been linked to several inflammatory diseases by regulating adaptive and innate immunity. to study the expression of gal- and tim- in kidney of mice with renal ischemia reperfusion injury (iri). methods: thirty c bl male mice were randomized into renal iri groups with and without recombinant gal- . the left renal pedicle was clamped in c bl mice for min, followed by reperfusion. animals were sacrificed at baseline, day , , , after iri. gal- and tim- mrna levels in kidney tissues were determined using real-time rt-pcr. expression of gal- in kidney were detected by immunohistochemistry staining .the levels of tnf-α, ifn-γ,il- and il- in kidney tissue were measured using elisa. results: the expression of gal- and tim- mrna in the injured kidney tissues increased significantly compared with uninjured kidney tissues and baseline (p< . ). compared with the uninjured control and baseline control, the expression of tnf-α and ifn-γ increased significantly in the injured kidney. the expression of gal- and tim- mrna was positively correlated with renal il- and il- level (r= . , r= . respectively; p< . ), but negatively correlated with kidney tnf-α and ifn-γ level (r=- . ,r=- . respectively,p< . ). after recombinant gal- treatment for three days, the kidney injury ameliorated and inflammatory cytokines (tnf-α and ifn-γ) decreased. the expression of gal- and tim- in kidney tissues increase in mice with kidney iri. tim- /gal- pathway are closely related to inflammatory process in renal iri. objective: we previously found that rgc- (response gene to complement- ), a key factor in regulating cell cycle, plays an important role in dealing with epithelial-mesenchymal transition (emt). this study aimed to evaluate the effects of rgc- regulating cell cycle in renal tubular epithelial cells injury and repair. methods: ( ) objective: autophagy is a lysosomal degradation pathway that is essential for cellular stress adaptation and normal homeostasis. increased level of autophagy has been reported in the post-ischemic kidneys by static analysis. this study aimed to understand the dynamics of epithelial autophagy in kidneys following acute ischemic injury and during renal repair. methods: taking the advantage of differential ph sensitivity of rfp (pka . ) and egfp (pka . ) fluorescence, we generated a new strain of cag-rfp-egfp-lc mice to distinguish early autophagic vacuoles from autolysosomes and to monitor autophagic process in the kidneys with ischemia-reperfusion injury (iri). results: renal epithelial cells responded to nutrient deprivation with easily detectable fluorescent puncta that represented autophagic vacuoles and corresponded to lc -ii and atg protein levels. the majority of the egfp lost its fluorescence in the acidic environment of the autolysosomes where bright rfp signals remained. in normal kidneys, few egfp and rfp puncta were present in the nephron. iri led to dynamic changes in autophagic process in the proximal tubules with the number of egfp puncta reaching the peak at day and returning to the control level at days whereas rfp puncta persisted at a high level through days post injury, indicating autophagy initiation at day but autophagosome clearance at days as kidneys were recovering. since rfp puncta persisted in cells with recent autophagy, we examined ki expression and found significantly lower proliferation in cells that contained rfp puncta, suggesting that autophagic cells were less likely to divide for tubular repair. furthermore, % proximal tubular cells with mtor activation indicated by p-s kinase expression contained no rfp puncta. inhibition of mtorc activity with rapamycin caused a -fold decrease in cell proliferation. conclusion: our results highlight the dynamic regulation of autophagy in post-ischemic kidneys and suggest a role of mtor in autophagy resolution during renal repair. abstract# p-sat novel mechanisms by which heparin can regulate the vascular activity of angiotensin ii (ang-ii) and fibroblast growth factor- (fgf- ) and affect the outcome of acute kidney injury (aki) objective: critically ill children treated with extracorporeal membrane oxygenation (ecmo) and/or cardiopulmonary bypass (cpb) frequently develop hypertension, endothelial dysfunction, and acute kidney injury (aki). these patients show high serum levels of ang-ii and fgf- , and are treated with heparin to prevent clotting disorders. however, the mechanisms by which heparin may affect the vascular activity of ang-ii and fgf- are not clearly understood. we carried out this study to determine whether heparin can modulate the vascular activity of ang-ii and fgf- by affecting the rho-a, rac- , src, and pkc signaling pathways. methods: normal fvb/n mice were injected with adenoviral vectors carrying a secreted form of human fgf- or lac z vectors, and treated with heparin ( , u/kg) or control buffer (n= per group). vascular contractility was studied in pressurized isolated resistance-sized mouse mesenteric arteries, in the presence and absence of ang-ii and fgf- . the activation of the src, rho-a, rac- , and pkc signaling pathways were assessed by pull-down assays and western blots, both in vivo and in vitro. permeability changes were explored in cultured human renal glomerular endothelial cells (hrgec) using fitc-dextran. results: heparin significantly enhanced the fgf- -induced activation of rho-a and rac- in the kidney and isolated mouse mesenteric vessels. in addition, heparin antagonized the ang ii-induced contractility of isolated mouse mesenteric vessels through rho-a and pkc-dependent pathways. these changes were reverted by fgf- , and abolished by the rho kinase inhibitor y . both heparin and fgf- , acting in a synergistic manner, increased the permeability of hrec by activating the rho-a and src signaling pathways. conclusion: we conclude that heparin and fgf- , acting in a synergistic manner, can modulate the activity of ang-ii in the kidney, isolated resistance vessels, and cultured hrgec. these findings clearly identify novel mechanisms by which heparin, acting alone or in combination with fgf- , may affect the control of blood pressure, renal perfussion, and capillary permeability in critically ill children treated with ecmo and cpb. abstract# p-sat cisplatinum (cis) toxicity in immortalized human kidney (hk- ) proximal tubular epithelial cells is independent of dna strand breaks and has implications for biology and therapy of renal cell carcinoma (rcc) results: viability of huh- and hk- cells decreased similarly after ic doses of cis with morphology and mtt assays. many dna damage genes, including atm-related genes, were expressed less at mrna and protein levels in both cell types. however, p expression decreased in hk- cells. comet assays showed extensive dna strand breaks in huh- but not in hk- cells. atm promoter activity increased in only huh- cells. also, s and g /m populations were depleted by facs in huh- but not hk- cells. conclusion: hk- cells transformed by hpv e / oncogenes displayed independence from cis-induced dna breaks and atmmediated cell cycle arrest. such independence from genotoxicity will help explain mechanisms imparting resistance to chemo-or radiotherapy and invasiveness in rcc. abstract# p-sat renal neutrophil gelatinase-associated lipocalin and kidney injury molecule- expression in children with acute kidney injury on henoch-schonlein purpura nephritis yue du, jinjie guo, ling hou, yubin wu, tingting sun paediatrics, post graduate trainee, china objective: to evaluate serum, urinary and renal neutrophil gelatinaseassociated lipocalin(ngal) and kidney injury molecule- (kim- ) in children with aki on hspn by prifle or hspn with nephroticrange proteinuria. methods: we performed a prospective single-center evaluation of serum, urinary and renal ngal and kim- in a cohort of children. we recorded any relevant data including age, gender, weight, hemoglobin(hb), serum creatinine(scr), cystatine c(cysc), serum beta -mg, albumine, urine beta -mg, urine protein in all patients. each patient's estimated creatinine clearance was calculated using the original schwartz formula. blood sample and five ml of urine sample from each participating patient were collected for ngal and kim- using an enzyme-linked immunosorbent assay. analysis of proteins ngal and kim- using sabc immunohistochemical assay. results: twenty five patients were enrolled in the study. nine patients with aki-on-hspn(a-on-c) and six were done renal biopsy, sixteen patients with hspn with nephrotic-range proteinuria and ten were done renal biopsy. blood cystatinc, beta -mg , scr, ngal and kim- were increased significantly in patients with a-on-c than those with hspn, and so do urine ngal, kim- and beta -mg. there was no significant difference of proteinuria between the patient with a-on-c and the patients with hspn. immunohistochemical results showed that ngal and kim- were expressed in proximal tubule and their expression were significantly higher in a-on-c group than in hspn group. the correlation analysis showed that urine ngal and kim- were negative correlated with gfr and they were uncorrelated with proteinuria. conclusion: blood, urine and renal ngal and kim- were significantly increased in patients with a-on-c than those with hspn, and they were negative correlated with gfr. we may conclude that ngal and kim- may diagnose a-on-c patients more sensitive than scr. abstract# p-sat objective: neonatal period is an important stage in the development of renal function at the children. the frequency of renal damage in infants undergoing resuscitation is high, but non-specific clinical symptoms and low information existing survey methods impede their timely diagnosis. purpose -evaluation of diagnostic importance of determining the level of carbonic anhydrase ix (ca ) in the urine of newborns in critical states. methods: we evaluated human carbonic anhydrase ix in the urine of newborns who had asphyxia at birth and receiving treatment in the intensive care unit -the main group. the control group consisted from healthy newborns ( people). for the study used a sample of newborn urine collected at - days of age. carbonic anhydrase was determined using enzyme immunoassay kit. results: human carbonic anhydrase ix (ca ) -trans membrane protein, the main physiological function of which is to regulate the ph by the reversible hydration of carbon dioxide. the main pathogenic factor causing kidney damage of fetus is chronic fetal hypoxia. there is a single study hif-i alpha (hypoxia inducible factor-i alpha) in the blood, increased expression of which occurs during hypoxia. this is connected with damage of tubules and interstitial cells of the kidneys, their proliferation, synthesis of cytokines and extracellular matrix. in this case, activity of ca is reduced in the blood. normally, ca is missing in the urine, so its definition can be a marker of early renal dysfunction. the authentic increase of ca level in the main group was revealed in comparison with the control group ( and β -mg, , / , / / / / μg/g cr. levels of each marker were very high in nb and m children, and subsequently decreased gradually. urinary α -mg levels reduced the quickest, and became the same as at >= years old by months after birth. conclusion: renal tubular function can be evaluated in children < years old using these normal values. the most stable and useful marker from early infancy seems to be urinary α -mg. urinary biomarkers for gentamicin-induced acute kidney injury in the neonatal intensive care unit objective: gentamicin (gm) is an aminoglycoside frequently used in the neonatal intensive care unit (nicu). gm is nephrotoxic and may cause acute kidney injury (aki). serum creatinine (scr) appears to be an insensitive and unreliable marker for detecting aki. to determine whether urine biomarkers are useful for early detection of gm-induced aki in neonates in the nicu. methods: prospective, clinical, observational study. forty-six neonates ( m/ f) without pre-existent kidney disease were divided in a gm group (n= ) and a reference group (n= ). demographics, vital signs and clinical conditions were recorded. only neonates with a bladder catheter in place were included. urine samples were collected every two hours. biomarkers (gsta - , gstp - , kim- , nag, ngal) were determined. residual blood samples were used to measure scr. results: the gm and reference group were comparable for gestational age, weight and mortality. neonates treated with gm are admitted longer than neonates in the reference group. treatment with gm resulted in higher scr compared to the reference group ( . [ . - . ] vs. . [ . - . ]; p< . ). higher levels of scr correspond with higher urinary excretion of all biomarkers, especially in neonates treated with gm. the average time until the highest peak was shorter for all biomarkers compared with scr (p< . ). there was no difference in produced urine volume between the gm and the reference group. conclusion: higher scr levels correspond with higher urinary excretion of all biomarkers, especially in neonates treated with gm. gstp - seems the most useful marker for early detection of aki in neonates. seong heon kim, sang wook mun, su young kim . pediatrics, pusan national university children's hospital, yangsan, korea objective: spontaneous tumor lysis syndrome (stls) before cancer treatment is rare and develop mostly in burkitt lymphoma and non-hodgkin lymphoma. here we report a case of stls secondary to tcell acute lymphoblastic leukemia(all) which presented with renal stone and subsequent aki. methods and results: a -year-old boy was admitted to our hospital for generalized tonic clonic seizure. one month ago, he visited other hospital for episodic right-sided flank pain and evaluations revealed microscopic hematuria, hyperuricemia and stone on right uretero-pelvic junction. his blood pressure was / mmhg and he did not have any dysmorphic features and he had developed normally. physical examination showed tender hepatomegaly ( cm below costal margin) and no splenomegaly. his initial laboratory findings were as follows : bun . mg/dl, creatinine . mg/dl, uric acid . mg/dl, ldh iu/l, wbc , /ul, hb . g/d l, platelet k /u l. there was no blast on his peripheral blood smear test. emergent hemodialysis was started because of aki, hypertension and seizure. his renal function, blood pressure, uric acid and electrolyte abnormalities gradually improved with appropriate therapy after times of hemodialysis. but serum uric acid level increased again (from . mg/dl to . mg/dl), so allopurinol was added on. the cause of aki was unclear and we thought that aki presumed to be secondary to acute uric acid nephropathy caused by stls. after few days, bone marrow biopsy was done and demonstrated normocellular marrow without evidence of malignancy. after day of hospitalization, abdominal pain with hepatomegaly was getting worse than before and uncontrolled high fever occurred. % of blasts were seen on his peripheral blood smear and subsequent second bone marrow biopsy demonstrated acute t cell lymphoblastic leukemia. then, he was referred to division of pediatric hemato-oncology on our hospital and induction chemotherapy was started. conclusion: stls with aki is very uncommon initial presentation of leukemia and stls presenting with renal stone is extremely rare. in a clinical situation of marked hyperuricemia with acute kidney injury, we need to consider occult malignancy and stls. the application of serum beta- -microglobulin (beta- -mg) and cystatin c(cysc)concentration to evaluation of renal function impairment in patients withneonatal jaundice yanan xin, cairong jiang, junfeng yang, hui xu, yuan zhang the fourth hospital of baotou, baotou, china objective: to explore the application of serum beta- -microglobulin (beta- -mg) and cystatin c(cysc)concentration to evaluation of renal function impairment in patients with neonatal jaundice. methods: neonates with hyperbilirubinemia from jan. of to dec.of in pediatric department and full term infants were chosen as research object, hyperbilirubinemia divided into mild group (bilirubin< . umol/l) and moderate severe (bilirubin> . umol/l) group according to the level of bilirubin. the different of sex and age were not significant between neonates with hyperbilirubinemia and control group. serum beta- -mg, cysc, cr and bun were measured in the two groups. results: serum beta- -mg and cysc in neonates of hyperbilirubinemia were significantly higher (p< . ) than healthy neonates, meanwhile, serum cr and bun were significantly lower (p< . ) than healthy neonates. after treatment, serum beta- -mg and cysc of neonates with hyperbilirubinemia were significantly lower (p< . ) than pretreatment. however, serum beta- -mg were higher (p> . ) abeta-d cysc were significantly higher (p< . ) than normal group. but there was no significant difference between mild and moderate severe group in the level of serum beta- -mg, cysc, cr and bun(p> . ). the result implied that neonates with hyperbilirubinemia suffered for renal function to varying degrees. howerer, the damage can partially recovered after energetic treatment. clinical and pathological analysis of iga nephropathy with acute kidney injury minguang chen, xiaohua ye, qing yang nephrology, yuying children's hospital, wenzhou, china objective: to investigate the incidence, etiology, clinical pathological characteristics and prognosis in primary iga nephropathy(igan) children with acute kidney injury(aki). methods: retrospectively analysis the clinical and pathological manifestations and follow-up results of chlidren with primary igan and aki in our department from january, to jun, . results: there were cases with aki in chlidren with igan( . %), the peak serum creatinine were from . umol/ to umol/l. histological changes: with the formation of crescent in cases, diffuse endocapillary proliferation in example, cases of renal tubular injury, cases of red blood cell and protein cast, cases with acute interstitial nephritis. multivariate logistic regression analysis showed: with massive proteinuria were independent risk factors of igan in children with aki (or = . , % confidence interval was . - . , p< . ). the etiology of aki except with massive proteinuria, include: . iga nephropathy with severe glomerular damage, including crescentic glomerulonephritis and diffuse endocapillary proliferation; complicated acute interstitial nephritis; drugs causing decreased glomerular filtration rate; . renal tubular injury induced by gross hematuria. all of the patients were not on dialysis, hormone therapy in cases (including cases of methylprednisolone pulse therapy), cases combined with cyclophosphamide treatment. except cases no significant improvement, the renal functiones of all patients recovered or improved within - months after treatment. follow-up from month to years, cases had renal function improved, but were lost to follow-up and after years enter to the chronic renal failure, case with renal function loss after months and repeated renal biopsy showed glomerular sclerosis of . % during the follow-up period. conclusion: aki is not uncommon in children with igan, the causes are varied and massive proteinuria is independent risk factor among them. we should adopt different treatment strategy according to different causes and the short term prognosis is good. abstract# p-sat biopsy proven acute interstitial nephritis in children objective: biopsy proven acute interstitial nephritis (ain) is an uncommon cause of acute renal failure in children. the cause of ain most is commonly due to medications such as antibiotics or infections. we reviewed our experience of biopsy proven ain in children. the biopsy database of all native renal biopsies over a year period was reviewed. all biopsies which listed acute interstitial nephritis were selected and clinical and laboratory data were extracted from clinical records. results: cases of ain from biopsies,( . %) was identified. median age . years, range - / cases presented with acute renal failure without an obvious cause. / cases had non specific constitutional symptoms and oliguria was reported by patients. antibiotics were the most common medications implicated ( / patients) three patients were on multiple medications with one having chronic epilepsy and the other crohn's disease. five patients required short term dialysis ranging from to days. patients were treated with corticosteroids and at last follow up, had reduced gfr - ml/min/ . m . conclusion: acute interstitial nephritis is uncommon in childhood but when it occurs, antibiotics are the single commonest cause. there is significant morbidity associated with the illness with not all patients making a full recovery. abstract# p-sat acute kidney injury as presentation of burkitt's lymphoma eva greta ter haar , anne uyttebroeck , marleen renard , veerle labarque , djalila mekahli pediatric nephorlogy, university hospital leuven, leuven, belgium pediatric hemato-oncology, university hospitals leuven, belgium objective: acute kidney injury (aki) has become increasingly prevalent. approximately - % of children admitted to pediatric tertiary care centers present with this life-threatening condition. the most common causes are post-operative septic shock, organ or bone marrow transplantations and intrinsic renal disease. the latter comprises multiple disorders, but tumor invasion due to a lymphoproliferative malignancy is very exceptional. methods and results: we report two cases of aki caused by infiltration of burkitt's lymphoma. both four-year-old male patients presented with abdominal pain, nausea, vomiting, weight loss and overall weakness since a few weeks. clinical examination showed hepatosplenomegaly and impressive bilateral nephromegaly. both had malignant hypertension. blood analysis showed severe renal impairment in both patients. the first had creatinine of . mg/dl (egfr ml/min/ . m ), urea of mg/dl and uric acid of . mg/dl. the second had creatinine of . mg/dl (egfr ml/min/ . m ), urea of mg/dl and uric acid of mg/dl. lactate dehydrogenase was extremely elevated in both cases ( u/l; u/l respectively). urinary sediment was normal. ultrasound showed bilateral nephromegaly in both patients (patient :+ sd and + sd; patient : + sd and + sd, for right and left kidney respectively). mri demonstrated a homogenous renal enlargement with features of an infiltrative lesion. bone marrow was inconclusive and diagnosis of burkitt's lymphoma was confirmed by a renal biopsy. after starting chemotherapy according to the inter-b-nhl ritux protocol, both children developed a tumor lysis syndrome and required hemodialysis. at last follow-up both children still had hypertension. nevertheless, renal size and function were normalized. conclusion: lymphomatous infiltration due to burkitt's lymphoma is a rare cause of aki. however, it should be considered in a patient presenting with unexplained renal failure and bilateral nephromegaly with normal urinary sediment. renal biopsy may be needed to confirm diagnosis. abstract# p-sat does malnutrition interact with acute kidney injury in children? objective: to investigate the interaction between malnutrition and acute kidney injury (aki) assessed by prifle criteria and to assess the effects of these factors on the outcomes of pediatric intensive care unit (picu) patients. methods: prospective cohort study conducted on children. outcome variables: mortality, need for dialysis, picu free days (the number of days alive from icu discharge to day ) and ventilator-free days (the number of days alive and breathing without assistance from admission to day ). exposure variables: malnutrition on admission (who growth standards) and any change in prifle criteria during the first icu days. results: of patients (median age = iqr = months, girls) enrolled, ( %) were malnourished and ( %) developed aki. among the malnourished, / cases ( %) had aki, while this complication occurred in / ( %) of patients without malnutrition resulting in a risk ratio of . ( %ci . - . ). the days mortality rate was / cases ( %) and aki was associated with higher risk ( / versus / cases -rr= . %ci . - . ). concurrent malnutrition and aki was present in / cases ( %) producing a tendency (p= . ) to a further increased risk of death (rr= . %ci . - . ). / ( %) patients needed dialysis and malnutrition increased the risk for this outcome (rr= . %ci . - . ). aki was associated with significantly higher icu free days ( ± vs. ± ) and ventilator-free days ( ± vs. ± ) but concomitant malnutrition did not reduce either of these outcomes. conclusion: malnutrition and aki are common in children admitted to the icu and the presence of malnutrition is associated with increased risk of developing aki. the need for dialysis was increased in malnourished patients and more powered studies are demanded to test whether the tendency to higher mortality observed in patients with concomitant aki and malnutrition is confirmed. urine erythropoietin level is associated with kidney and brain injury in critically ill neonates yanhong li, jie yan, xiaozhong li department of nephrology, children's hospital affiliated to soochow university, suzhou, china objective: erythropoietin (epo) is a glycoprotein hormone produced predominantly in the kidneys. the protective effect of exogenous epo in hypoxic-ischemic brain injury has been thoroughly examined in neonates. however, the metabolism of endogenous epo in neonates remains unclear. we aimed to evaluate the concentration of urinary epo (uepo) in critically ill neonates and to identify possible clinical and laboratory variables that may be associated with uepo levels. methods: the concentrations of epo, cystatin-c, microalbumin, and α -microglobulin in the first available urine sample during the initial hours of life were measured in critically ill neonates. clinical and laboratory data were collected for each neonate. results: there was a positive correlation between uepo levels and urinary levels of cystatin-c (r = . , p = . ), microalbumin (r = . , p < . ), andα -microglobulin (r = . , p < . ). the concentration of uepo was elevated in neonates who developed acute kidney injury (aki) during the first week of life compared with those without aki (p = . ) and was also elevated in neonates with brain injury, as demonstrated by ultrasound or magnetic resonance imaging, compared to neonates without brain injury (p = . ). an increased log uepo level was associated with the occurrence of aki (odds ratio of . , p = . ) and brain injury (odds ratio of . , p = . ). conclusion: an increased urinary epo level in the early postnatal period is significantly associated with kidney and brain injury in critically ill neonates. abstract# p-sat acute kidney injury following extracorporeal membrane oxygenation support and concomitant hemofiltration -the role of diuretics objective: fluid overload (fo) is common during extracorporeal membrane oxygenation (ecmo) and can be managed by continuous hemofiltration (hf) and/or diuretic therapy. although combination therapy of hf and diuretics in particular can be most effectively for fo removal during ecmo, it may also increase the risk for prerenal acute kidney injury (aki) post-ecmo. our objective was to describe the incidence of aki post-ecmo in patients treated with ecmo and hf who received concurrent diuretics. methods: in this cohort study all neonates (≤ days after birth) treated with ecmo and concomitant hf between and were included. patients were divided into two groups based on diuretic regimen: group- , patients who received no or one single diuretic dose during ecmo and group- , patients who repeatedly received diuretics. both groups were compared using mann-whitney u test for nonparametric data and chisquare test for categorical data. aki was defined as the highest serum creatinine (scr)-based rifle class reached on post-ecmo day up to post-ecmo day (risk, injury, or failure being %, % or % of median scr reference values for age). results: neonates received ecmo support with hf, died immediately following decannulation and others were lost to followup since they were transferred back to their referring hospitals within days post-ecmo. of the patients in group- , ( %) qualified as risk and ( %) as injury. of the patients in group- , ( %) qualified as risk, ( %) as injury and ( %) as failure (group- vs. group- , p= . ). patients in group- had an increased ecmo duration (p= . ) and number of ventilator days (p= . ). no differences were observed in baseline characteristics (e.g. age at the start of ecmo, underlying diagnosis, severity of illness scoring using the pim and prism risk adjustment systems), hf flow rate, and fluid balance between both study groups. conclusion: the incidence and severity of aki immediately post-ecmo was significantly higher in patients who repeatedly received diuretics in addition to hf during ecmo. valentina sitnikova, yuliya pashkova, tatiana zvyagina, elena kulakova, alexandra nastausheva voronezh state medical academy, voronezh, russia objective: it is actually to find the new markers of kidney damage and spread them in practice. cystatine c (cys) is one of these, but there are only few data about it in children with urinary tract infection (uti) according to the age. the aim of our study was to evaluate serum concentration of cys in children with uti of different age. we investigated patients ( girls and boys) with uti from month to years among them children were under years old. methods: concentration of cys were measured by immunoenzime method (elisa) with test-system biovendor (check republic). results: the mean cys concentration in children with uti under year was . ± . mg/l, in older children it was lower: . ± . mg/l, p= . (mann-whitney). in girls before year cys concentration was . ± . mg/l and in boys of the same age it was . ± . mg/l, p> . . in girls over year cys concentration in serum was . ± . mg/l, in boys - . ± . mg/l, p> . . the results of our study showed that among children with uti serum concentration of cys was higher in children of the first year of life and did not depend on sex. probably, higher level of cys in infants connects with low glomerular filtration rate in children of this age. microalbuminuria can prognosticate outcome in the critically ill children biplab maji, surupa basu, rajiv sinha paediatrics, post graduate trainee, kolkata, india objective: microalbuminuria [albumin creatinine ratio (acr) > mg/g] increases in acute inflammatory conditions as a result of glomerular endothelial dysfunction. the study evaluated its prognostic potential in the critically ill child. methods: an ongoing prospective observational study (oct -mar ) of random urine acr (mg/g) estimated on day and day of pediatric intensive care unit (picu) admission, of a tertiary care pediatric hospital. demographic, laboratory data, vasopressor use, mechanical ventilation, length of stay, outcome and pelod scores were recorded. results: of children, children (median age . years, % male) recruited. the commonest cause of admission was pneumonia, infection associated hemophagocytic lymphohistiocytosis followed by meningitis. day acr (median . mg/g) significantly correlated with day total leukocyte count (p= . ). both day and day acr correlated with pelod scores [median ] (p= . & p= . respectively) and duration of mechanical ventilation (p= . and p= . respectively). both median day acr, and day acr were significantly different between survivors (n= ) and non-survivors (n= ) (p= . and p< . , respectively). roc curve analysis for mortality prediction revealed the highest area under curve (auc) of . for acr , followed by . for acr and . for pelod scoring (p> . , non-significant for auc comparisions) (fig. .) . a cut-off value of day acr of . mg/g had a positive predictive value of . % for negative outcome conclusion: microalbuminuria is an early inflammatory marker that correlates with organ dysfunction. significant levels reliably predict negative outcome early into intensive care admission, as accurately as pelod scores, which can help counsel patients, plan treatment and triage, and allocate resources judiciously. abstract# p-sat an unusual presentation of congenital nephrotic syndrome caused by wt mutation ann raes, sofie maebe, joke dehoorne, bert callewaert, johan vande walle pediatric nephrology, university hospital, gent, belgium objective, methods and results: a caucasian girl was admitted at the age of days because of progressive lethargy, poor feeding, oliguria en peri-orbital edema. extreme hyponatremia ( mmol/l), severe renal insufficiency (creat . mg/dl, p . mg/dl), low plasma albumin ( . g/dl), respiratory compensated metabolic acidosis (arterial ph . pco mmhg, bicarbonate . mmol/l, be - . mmol/l) and massive proteinuria ( g/l). clinical examination was normal without anomalies of the external genitals or other dysmorphic features. despite supportive therapy (sodium, bicarbonate, albumin and furosemide) she progressed to respiratory failure and renal failure with need for mechanical ventilation and peritoneal dialysis. congenital infections and thrombosis was ruled out. histological examination showed diffuse mesangial sclerosis (dms). the combination of congenital nephritic syndrome and dms on biopsy was suggestive for mutations in the wilms' tumor (wt ) gene. genetic analysis showed normal female karyotype and conformed a heterozygosity for the c. c>g or p.his gln mutation within the zinc finger domain. after a long and complicated icu episode, a stable situation with home choice peritoneal dialysis was achieved. due to the important risk for comparision of auc of pelod with acr , p= . for comparison with acr ) for the prediction of mortality in the pediatric intensive care unit. development of wilms' tumor, bilateral nefrectomy was performed and kidney transplantation will be planned. we present an unusual case of congenital nephrotic syndrome with extreme hyponatremia at presentation and fast progression to esrd, due to mutation in wt gene. several genes have been implicated in congenital nephrotic syndrome. genetic testing is mandatory and can add important information such as risk of malignancy. renal histology can play an important role in the approach for appropriate mutational screening. mutations in the wt gene are associated with denish drash syndrome and frasier syndrome, but also with isolated and sporadic steroid resistant nephrotic syndrome. in the last category the majority of patients is female, the age of onset and time to esrd is variable, although the vast majority of cases are older at presentation and time to esrd is longer than in our case. objective, methods and results: a -year-old girl, affected by b thalassemia major, was admitted for proteinuria detected at the emergency unit. fever, hyporexia and diarrhea had been present in the last three days. on physical examination she presented with decreased skin turgor and hypertension. laboratory examinations showed: hyponatremia ( meq/l), hypokalaemia ( . meq/l), hypophosphatemia ( . mg/dl), hyperazotemia ( mg/dl), reduced creatinine clearance (crcl = ml/min/ . m ) and metabolic acidosis (hco - . mmol/l). urine analysis revealed: proteinuria, glycosuria, hypercalciuria, hyperuricuria, hyperphosphaturia and aminoaciduria. she had been under treatment for five years with deferasirox (dfx) mg/kg/die. we stopped dfx and gave supplementation of potassium, phosphate, sodium bicarbonate and sodium chloride with electrolyte and renal function (crcl ml/min/ . m ) normalization in days. after one month only minimal proteinuria persisted. conclusion: in so far a fanconi syndrome (fs) has been reported in patients ( children), while mild renal insufficiency (ri) has been documented only in children. in our case dehydration seems to be responsible for the ri, while an interstitial nephritis cannot be excluded. close monitoring of renal function should be done in children on dfx. objective: to test the hypothesis that neutrophil gelatinase-associated lipocalin (ngal) and interleukin- (il- ) are early biomarkers for aki in critically ill patients and evaluate the predictive value of them in patients with established aki at inception of crrt. methods: children from picu and health examination center in guangzhou women's and children's medical center were divided into four groups: critically ill patients with aki recevied crrt group (group ), critically ill patients with non-aki recevied crrt group(group ) , critically ill patients with aki don't recevie crrt group (group ),healthy control group (group ). . ml venous blood and urine specimens were collected and was kept under - °c.from each patient in picu untill they were discharged, transferred or die . serum creatinine (scr) and urine ngal and urine il- were analyzed . results: compared with group and group , the urine ngal and urine il- increases obviously in group and group (p< . ). there is no significance of urine ngal and urine il- between group and group .(p> . ).the concentration of urine ngal increased more than times obviously days before diagnosed of aki under the akin standard with auc . (p < . ) , and the concentration of urine il- increased more than times day before aki with auc . (p < . ). the auc was . (p < . ) when they were combined. the level of urine ngaland il- at initiation of rrt were higher in in non-survivors compared to survivors. conclusion: urine ngal and urine il- are useful indicators to predict and early diagnose aki. the level of urine ngal and il- at initiation of rrt.were negative correlation with the outcome of renal prognosis and survival rate . objective: the aim of this study was to evaluate the rate of early kidney injury in infants with congenital heart disease (chd). neutrophil gelatinase associated with lipocalin (ngal) which can be measured both in serum (sngal) and in urine (ungal), is at the moment the most promising marker directed to discover early kidney injury within the glomeruli and distal and proximal tubules. less known is cathepsine l as a marker of tubule necrosis. methods: the study group consisted of patients ( boys and girls) with congenital heart disease. all patients were under years of age (mean . months). blood and urine samples were obtained during routine checkups. all patients had normal serum creatinine level at the day of collecting samples. the control group (n = ) was age-and gender-matched. levels of sngal, ungal and cathepsine were compared in whole group. the study group was divided depending on the nature of the defect (cyanotic/acyanotic) and the treatment (surgical/conservative treatment). results: chlidren with congenital heart disease had significantly higher concentration of sngal, ungal and urine cathepsine than the control group. no significant difference was observed in the urine cathepsine and urine and serum ngal level between patients with acyanotic and cyanotic chd. there were also no significant differences in patients who underwent surgery and on conservative treatment in ngal level (both in urine and serum). cathepsine level was significantly higher in group after surgical treatment. conclusion: patients with chd are at higher risk of early kidney damage. this process is independent on the etiology and nature of the defect. ngal determined in the serum and urine of these patients may be used to detect kidney injury or monitoring disease progression. urine cathepsine is more efficient marker of early kidney injury in patients after cardiac surgery. abstract# p-sat tim- expression in kidney mononuclear cells and its relationship with foxp + tregs from mice with renal ischemia reperfusion injury yamei wang, yuhong tao, li ye department of pediatrics, west china second university hospital, chengdu, china objective: foxp + tregs participate in the repair of renal ischemia reperfusion injury. t cell immunoglobulin- (tim- ) plays a pivotal role in several inflammatory diseases by modulation of foxp + regulatory t (treg) cells. to detect the expression of tim- in kidney mononuclear cells (kmncs) from mice with renal iri and analyze the relationship with foxp + tregs, to explore the role of tim- in repair of renal iri. methods: the left renal pedicle was clamped in c bl mice for min, followed by reperfusion. animals were sacrificed at baseline, day , , , after iri. tim- expression in kmncs were determined using real-time rt-pcr and flow cytometry. the percentage of foxp + treg in cd + t cells was quantified by flow cytometry. the levels of tnf-α、ifn-γ、il- and il- in kidney tissue were measured using elisa. the correlation among tim- expression, foxp + treg and cytokine level was analyzed. results: the expression of tim- expression in kmncs from injured kidney at acute stage(day ) was significantly higher than those from uninjured kidney at acute stage and lower than those from injured kidney at repair stage (day , , ). the percentage of foxp + treg in cd + t cells was up-regulated with time. compared with the uninjured kidney, the expression of tnf-α and ifn-γ increased significantly in the injured kidney at acute stage and the expression of il- and il- increased significantly in the injured kidney at repair stage. the tim- expression in kmncs at iri repair stage was positively related with the level of foxp + treg, il- (r= . , r= . respectively; p< . ), but negatively related with the level of tnf-α and ifn-γ. conclusion: the increased expression of tim- in kmncs may take part in the repair of renal iri and contribute to the development of foxp + treg. objective: (d+)hus is a critical health problem in argentina since it is the main cause of acute renal failure in children and the second cause of chronic renal failure. fecal contamination of food and drinking water by asymptomatic cattle is often the source although secondary infection through personto-person contact may also occur. occasionally in (d+) hus, the onset among affected siblings occurred within a short time of each other. to evaluate the risk and clinical severity of illness for childhood (d+)hus in siblings. methods: we retrospectively analyzed the clinical records of children with d+hus that were admitted in our pediatric department between march and december . results: (d+) hus occurred in siblings in of the families studied ( %). patients had an affected sibling with diarrhea and progressed to hus ( %). family cases: mean age: months, were girls. the mean duration of interval between hus episodes was days. second family members had prolonged oligoanuria ( vs days) and a most of them developed neurological complications. long-term renal complications were more frequent in this group, but differences were not statistically significant. conclusion: these findings emphasize the potential for extensive intra-familiar transmission of stec, especially between siblings. a second family member might also develop an even more severe hus episode, so siblings should be kept under close surveillance. objective: kawasaki disease (kd) is a common cause of systemic vasculitis in children. other than well known complications like coronary artery aneurysm, there have been few reports of this disease involvement in renal system. according to the study from wang jn et.al, % ( out of ) of the patients who suffered from kd showed renal inflammatory foci in dmsa renal spect which suggested a possibility of renal scar formation subsequent to kd. therefore, this study was performed to verify the renal inflammation following kd. methods: from march to october , patients who were diagnosed as kd at national health insurance service ilsan hospital were enrolled to the study. all of the patients underwent dmsa renal spect to evaluate renal involvement during their acute phase of kd. echocardiography was performed to assess cardiac involvement such as coronary artery aneurysm. complete blood cell counts, aspartate amino-transferase, alanin amino-transferase, albumin, c-reactive protein, and bun/creatinine were measured. also urine β microglobulin was measured to assess renal tubular function. addition to fever of more than five days of duration, of the following symptoms, rash, conjunctival injection, changes of lips or oral mucosa, erythema and swelling of hands and feet and cervical lymphadenopathy, was the diagnostic criteria for kd. results: among the patients, % showed increased white blood cell s (wbc) and % showed elevated ast/alt level. serum albumin was below . g/dl in % of the patients. all of the patients presented normal renal function test. in urinalysis, hematuria and pyuria were observed in % and % respectively. echocardiography revealed coronary artery aneurysm in % of the patients. urine β -microglobulin was elevated in %. regardless abnormal findings in urinalysis and elevated β microglobulin, no significant findings were observed in dmsa renal spect. conclusion: according to the study, mild abnormality in the urinalysis and elevated β -microglobulin were the only findings of renal involvement in kd. however there was no aggressive renal manifestation which could be detected in dmsa renal spect. objective: in this study, the question remains if ngal is a culprit or only bystander in aki due to sepsis in children. methods: twenty seven children, (m- , f- ) admitted to intensive care diagnosed with sepsis, severe sepsis or septic shock were enrolled in this study. the concentration of ngal, protein c and s, antithrombin iii and basic parameters were measured in the plasma at diagnosis and after days of treatment. results: mean creatinine concentration in septic children at admission was higher than in reference group (p < . ). there was statistically significant difference in aptt, prothrombin time, prothrombin ratio, thrombocytes count, heart rate, and systolic blood pressure between study groups in first and after days (p< . , p< . , p< . , p< . , p< . , p< . respectively). the pc concentration in the septic patients was significantly lower than those of the references (p< . ), and during intensive days treatment raised (p< . ). also protein s concentration rose during the treatment (p< . ), and was lower in septic children then reference group (p< . ). ngal concentration was significantly higher in study group on the admission day comparing with reference group (p< . ). plasma ngal was correlated at admission and after days of treatment with protein c (respectively: r=- . , p< . ; r=- . , p< . ). multivariate regression revealed that ngal was significantly predicted by creatinine (β= . , p< . ) and protein c (β=- . ; p< . ), yielding a model r = . (p< . ). conclusions: it is possible that kidney binding of pathogenic antibodies stimulates local expression of ngal, which plays a crucial role in the pathogenesis of aki. objective: the aim of the study was to assess the impact of perinatal risk factors (prfs) on serum ngal level in term neonates. methods: the study group consist of term neonates with prfs, and healthy neonatescontrol group (cg). serum ngal (elisa) was measured in samples of cord blood (cngal) and peripheral blood (pngal) taken within first days of life, and stored in - °c until elisa procedure was performed. prfs were divided into groups: . pathology of pregnancy or mother: diabetes (d) n= , infection (i) -elevated crp or wbc n= , positive vaginal culture (vc) n= , hypertension (ht) n= , others n= ; . labor pathology: instrumental delivery (id) n= , premature rupture of membranes, > hours (prom) n= , fetal distress (fd) n= ; . neonatal pathology: intrauterine infection (ii) n= , cakut n= , perinatal asphyxia (pa) n= . the results were shown as median; values of cngal, pngal were logtransformed before analysis. statistical analysis was performed with t-student, manova tests with help of statistica . statistical significance: p< . . results: in term neonates, median cngal was . ng/ml vs . ng/ml in cg. mean log cngal was significantly higher (p< . ) vs cg, pngal was ns. mean log cngal correlated positively with mean log pngal (r= . , p< . ). univariate analyzes of log ngal in neonates with chosen prfs vs neonates without particular factor showed significantly higher (p< . ) mean log cngal in id and fd group (median cngal: . vs . and . vs . ng/ml respectively), whereas in ii group significantly higher were mean log cngal and mean log pngal (median cngal . vs . ng/ml, pngal . vs . ng/ml). multivariate analysis showed that the impact of id was significant in groups: d (f= . ; p< . ), i (f= . ; p< . ), prom (f= . ; p< . ) and fd (f= . ; p< . ). conclusion: . intrauterine infection may have a significant influence on ngal in cord and peripheral blood whereas fetal distress and instrumental delivery only in cord blood. . the instrumental termination of pregnancy has an import impact on ngal level in cord blood of neonates whose mothers had diabetes or infection, with prom or fetal distress. objective: acute kidney injury (aki) is a common problem and associated with significant morbidity and mortality in neonates. pediatric-modified rifle (prifle) classification system was developed to standardize the definition of aki in children. we aimed to evaluate the performance of prifle score diagnosis, severity and prognosis of aki in term and preterm neonates. methods: in this retrospective study, charts of patients who were admitted to neonatal intensive care unit (nicu) over a year period were reviewed for development of aki. a diagnosis of aki was determined for patients ( . %) according to the prifle criteria results: of the patients included in this study, of them were girls and -were boys. mean age was . days (min-max: - ), mean birth week was . ± . weeks (min-max: - ), mean birth weight was ± gr (min-max: - gr), length of nicu stay was . ± . (min-max: - days). two hundred fifty four patients with aki were classified according to prifle criteria. ninetyeight patients ( . %) achieved an 'r' level of aki severity, patients ( . %) an "i" level, patients ( %) an "f" level, patients ( , %) an "l" level. the most common etiologies of aki -were prematurity, congenital heart disease, hypoxic ischemic injury, sepsis and usage of nephrotoxic agents. patients classified with a higher prifle score had a longer nicu stay and required a greater number of mechanical ventilation (p< . ). renal replacement therapy (rrt) was needed for patients ( . %). mortality rate was % and all deceased patients were classified as prifle 'i','f' or 'l',p < . ) conclusion: using prifle criteria in neonates with aki is an efficient way to assess the severity and prognosis of the disease. objective, methods and results: i present a case of a years albanian old boy, th centile of development. presented with abdominal pain, vomiting. four days after, was addmited in the surgery clinic for uregent apendicitectomy. wbc: . , se: /, bun: . , cre: , urine: normal. after the intervention medications that were used were: gentamycin, metronidazol, cephtriaxon, h blocators. two days after he was better. thereafter he had polyuria and frequent urinating. the fifth day he had oliguria to seventh day, when he couldn't urinate. nativ rtg of abdomen resulted normal. he was transferede to pediatric clinic-nephrology department as an akute kidney injory. he looked very sick, consious, stratified tongue, ecg: b/min, bp: / mmhg, breathing sounds were normal, periferal edemas and cold extremities. lab resultrs: cre: , bun: . , k: . , na: , egfr: . ml/min oer . m . ultrasound resulterd with urinary stasis: hydronephrosis, huge bladder. first was suspected for acute obstruction and aki couse of a medication. we changed a bladder cathether which we find out that was blocked and took out ml urine/ h. we dialysed him for three days and cre was stabilized to , when we stoped dialyse. bp was stabile, his weight droped from kg to . kg. he had proteinuria g/ h. schintigraphy was done (biopsy we couldn't do) and resulted: egfr was % less than adecuat for age, suspected for nephritis tubulointestialis. he had some toxoalergic exanthema spread to the body. repeted us resulted with ascaridosis in the gallbladder, which was treated with mebendazole and in the feces were found the parasites. imune ab were negativ, ige: positive, periferal blood smear had eosinophils, wastage of na and mg with urine. cre after four weeks was , bun: , negative proteinuria. no changes of uveitis in the eyes. importance of this case is cause this is the first case in kosova that was dialysed and has recovered and now is free of dialyse (all other cases have traveled abroad until then). conclusion: we have to think for parasites as a cause of a tubulointesticial nephritis but also of a abdominal pain or fatigue. surgery team should have a close cooperation with pediatricians, in order to identifye in time complications of the surgery. urine output in first hours after birth in relation to akin criteria saroj kumar patnaik, gaurav aggarwal, uday kumar, vempati venkateshwar, shamsher singh dalal pediatrics, command hospital air force, bangalore, india objective: applicability of akin urinary output (uo) criteria in neonates during first hours of life remains contentious since nonpassage of urine during this time has traditionally been considered 'normal'. we hypothesize that 'physiological' oliguria in first hours of life is mostly prerenal in origin related to poor fluid intake during transition and uo criteria should be applicable in the st hours of life too. we aimed a) to investigate pattern of uo in babies admitted to nicu with underlying morbidity but regulated fluid intake versus roomed-in babies in postnatal ward on breastfeeds in first hours of life; b) to relate uo till hrs of life with development of aki methods: prospectively timing of first void and hourly uo from birth till hours age was compared between consecutive postnatal ward and nicu admissions. neonates with structural malformations and requiring ventilatory/vasopressor support were excluded. outcomes-primary : time of first void after birth secondary: uo in st hrs in relation to subsequent aki results: amongst eligible postnatal breastfed babies (mean bwt . kg ; sga ; lscs born) and nicu admissions (median birthweight . kg,mean ga wks ( - wks); prematures ( < wks); sga ( elbw) recruited after informed consent, first voiding was significantly earlier for nicu babies (mean( %ci) (hrs) postnatal . ( . , . ) vs nicu . ( . , . ) hrs). nonvaginal delivery(lscs . ( . , . ) vs vaginal . ( . , . ) and normal birthweight (aga . ( . , . ) vs sga . ( . , . ) ) had a trend for earlier voiding. % babies voided within hrs of birth -more in nicu babies ( . % nicu vs . % postnatal (p< . ) (fig) .asphyxia with mas in nicu and iugr and poor feeding in postnatal ward had delayed first void beyond hours. postnatal and nicu neonates anuric in st hrs met stage i akin creatinine criteria. asphyxiated babies anuric beyond hours in nicu developed stage iii aki. conclusion: 'physiological' anuria in st hrs of life is misnomer and is related to fluid intake. most babies are nonoliguric by h; anuria > h needs investigation. akin urinary criteria should be applicable in neonates. odillha morales maglalang-reed nephrology, philippine children's medical center, quezon city, philippines objective: the precise mechanism of renal injury among dengue patients is not known. patients who have atn will usually require early dialysis. however, on admission to the hospital, it is difficult to distinguish dss patients with atn from patients with reversible prerenal causes that will respond to simple hydration. our understanding of the complex pathogenesis of tubular injury in dengue aki is very limited that until it is sufficiently increased, therapeutic strategies will continue to fail.therefore we sought to explore the limitations of serum creatinine in this setting. general objective is to determine the clinical and diagnostic factors which are predictive for the need for dialysis among dss patients at pcmc. specific objective is to determine if the following factors are predictive of the need for dialysis: decrease in estimated creatinine clearance by % or < ml/min/bsa with urine output of < . ml/kg/hr. x hours or anuria of hours, assess the usefulness of urinary sediment scoring (uss) in predicting the need for dialysis, methods: this retrospective study covered newly admitted cases of dengue shock syndrome lll and lv at the philippine children's medical center between january to december . results: data from patients were available for analysis. comparison of the demographic characteristics between patients who required dialysis and those who did not showed no significant difference as proven by all p values > . . of the differentclinical and laboratory parameters, there was a significant difference in the hr, rr, o saturation, bicarbonate and base excess as proven by all p values < . . the hr an rr were significantly higher among those who needed dialysis than those who did not o saturation, bicarbonate and base excess were significantly lower among those who needed dialysis than those who did not. the estimated creatinine clearance was significantly lower among those who needed dialysis than those who did not. urine sediment score (uss) ≥ was significantly higher among those who needed dialysis than those who did not. conclusion: our data indicate that a decrease in estimated creatinine clearance by % or < ml/min/bsa with urine output of < . ml/kg/hr. x hours or anuria of hours is not predictive of dialysis among dss-induced aki as well as other clinical and laboratory indices. but rather, relatively lower serum creatinine level among dssinduced aki who needed dialysis is associated with greater urine sediment scorecompared with those who did not. a uss ≥ correlated with atn and was predictive of early dialysis.however, estimated crea < is the only factor predictive of dialysis, since this is the only one that was positive after logistic regression. abstract# p-sat pre-operative fgf predicts acute kidney injury in pediatric cardiac surgery patients: a prospective study mark r hanudel, myke federman, barbara gales, georgina ramos, vicky campbell, kristen ethridge, mary scotti, brian reemtsen, isidro b salusky, katherine wesseling-perry pediatrics, ucla, los angeles, usa objective: fibroblast growth factor (fgf ) is a phosphaturic hormone that predicts renal disease progression in ckd. however, in the setting of aki, there is a paucity of prospective data on fgf , especially in the pediatric population. thus, we prospectively measured fgf levels in pediatric patients undergoing cardiopulmonary bypass (cpb) and assessed the ability of fgf to predict aki. methods: pediatric patients, age newborn to years, without underlying ckd, undergoing cardiac surgery requiring cpb were eligible for the study. plasma fgf levels ( nd generation cterminal, immunotopics) were measured pre-operatively and at , , , , , and hours post-reperfusion. serum creatinine was obtained at baseline and daily post-reperfusion. aki was defined by the akin criteria, estimated gfr was calculated using the schwartz formula, and cardiac surgery complexity was classified via rachs- score. results: of the enrolled patients, developed at least stage aki. gender, weight sds, height sds, baseline egfr, cardiac surgery complexity, and cpb duration did not differ between the aki group and the non-aki group. patients who developed postoperative aki were younger than those who did not. preoperative fgf levels were inversely related to age (r = - . , p = . ). pre-operative fgf levels were significantly higher in patients who developed aki than in those who did not; this remained significant upon correcting for age. post-operatively, fgf levels increased in all patients. conclusion: pre-operative fgf levels predict the development of post-operative cpb-associated aki. fgf levels increase in non-ckd patients undergoing cpb, even in patients without significant changes in serum creatinine, suggesting that fgf may be a more sensitive marker of aki than serum creatinine. non-aki pateints p value objective: improved perinatal care increased not only the survival rate but also the frequency of acute kidney injury (aki) in newborns. we aimed to determine the frequency, etiology, clinical course and mortality of aki in a third level neonatal intensive care unit (nicu). methods: medical records of all patients admitted to a nicu in western turkey during - were evaluated and those having aki within - days of life were determined. birth weight, gestational age, mode of delivery, gender, maternal morbidity, hospitalization period, accompanying morbidities and mortality of all patients; and primary disease causing aki, highest serum creatinine and prognosis of patients with aki were recorded. results: there were patients (m/f: / ) and ( , %) had aki of which % developed during - days of life mostly due to birth asphyxia, hypovolemia, cardiac disease, sepsis and urinary system anomalies. aki incidence and total mortality rate were higher in patients with birth weight < g and with gestational age < week. however, mortality in patients with aki was increased independent on birth weight ( , % in < g vs , % in > g; p= , ) and gestational age ( , % in < week vs , % in > week; p= , ). mortality tended to increase in the presence of aki independent on the underlying cause, but this was significant only for sepsis ( , % vs , %, p< , ; or , ) and cardiac diseases ( , %vs , %, p= , ; or , ) . hospitalization period was increased if aki was present ( , vs , days, p< , ). serum creatinine in deceased patients with aki was higher than those who survived ( , vs , mg/dl, p< , ). chronic kidney disease was developed in ( %) patients of whom had urinary tract anomalies and had birth asphyxia. conclusion: aki incidence in nicu was %, and % of aki developed during the first week of life. aki is associated with low birth weight, prematurity, birth asphyxia, sepsis, hypovolemia, cardiac diseases and urinary tract anomalies. mortality in patients with aki is increased independent on the birth weight, gestational age and underlying etiology. objective: cisplatin (cddp) is one of the antineoplastic agents widely used for solid tumors in adults and children. an excessive dose due to medical error causes severe nephrotoxicity, ototoxicity and myelosuppression. previous reports described the effects of plasma exchange, sodium thiosulfate, n-acetylcysteine and other interventions. however, the strategy for over-dose patients, as regards the selection or intensity of therapies and the target of cisplatin removal, remains uncertain in children. a year-old girl was admitted for headache and vomiting. she was found to have a right cerebellar tumor and underwent total extirpation of this medulloblastoma. next, we administered chemotherapy mainly using cddp. however, she developed renal insufficiency and hearing loss on the fourth day. we then realized that we had been administering cddp mg/m for days, instead of the intended day. we promptly discontinued the cddp and began plasma exchange and sodium thiosulfate administration. nonoligiric renal failure was confirmed by a urea nitrogen value of . mg/dl and creatinine level of . mg/dl. with cycles of plasma exchange and weeks of sodium thiosulfate, renal function improved and the cddp concentration decreased from . to . mg/ml. after month, the concentration was . mg/ml. we switched from cddp to carboplatin, and chemotherapy was continued for courses and then radiation therapy was added. ultimately, she had mild renal insufficiency and moderate hearing loss. we evaluated the relationship between renal function and the cddp concentration. severe renal failure and hyponatremia were observed at a cddp concentration of mg/ml or more. creatinine clearance of ml/min/ . m was maintained at a cddp concentration below . mg/ml. conclusion: in children with a cddp over-dose, plasma exchange and sodium thiosulfate administration are effective. also, monitoring of cddp concentrations is recommended in patients with acute renal failure. in over-dose patients, early severe renal failure can be prevented when the cddp concentration is reduced to less than . mg/ml with these therapies. abstract# p-sat peritoneal dialysis in children with acute kidney injury: a developing country experience om p mishra , aditya k gupta , vishal pooniya , rajniti prasad , narendra k tiwary , franz schaefer pediatrics and medicine, institute of medical sciences, varanasi, india division of pediatric nephrology, heidelberg university medical centre, heidelberg, germany objective: peritoneal dialysis (pd) is the preferred and convenient treatment modality for acute kidney injury (aki) in children and hemodynamically unstable patients. the present study analyzed the efficacy of pd in patients with aki and factors contributing to mortality. methods: the outcome of acute pd was studied in children ( males) with aki, aged month to years, at a tertiary care centre of a teaching hospital in india. results: there were patients less than year of age, patients - years of age, and patients more than years of age. per the rifle criteria, patients were classified at the risk stage; , at the injury stage; and , at the failure stage at the time of the decision to start pd. hemolytic uremic syndrome was the most common cause of aki ( . %), followed by septicemia ( . %) and acute tubular necrosis ( . %). treatment with pd was highly effective in lowering retention markers (blood urea decreased by % and serum creatinine by % during the course of dialysis therapy, both trends significant at p < . ). overall mortality was . %. deaths occurred - days after hospitalization. significantly higher proportion of non-survivors had fluid overload ( . % vs %, p= . ) and septicemia ( . % vs . % , p< . ) than survivors at presentation. the risk of mortality by multivariate analysis was higher when patients were anuric [odds ratio (or) . , % confidence interval (ci) . - , p< . ), had septicemia (or . , % ci . - . , p< . ), or severe infectious complications (or . , % ci . - . , p< ). conclusion: because of its simplicity and feasibility, acute pd is still an appropriate treatment choice for children with aki in resource-poor settings. septicemia and severity of aki are contributory factors to high mortality in pediatric acute kidney injury. outcome of acute kidney injury managed in a regional paediatric nephrology centre shivaram hegde, sabina pahari paediatric nephrology, university hospital of wales, cardiff, uk objective: this study reviewed the aetiology, treatment modalities and outcome of children with aki managed in our tertiary paediatric nephrology unit. method: retrospective analysis of referral practices, aetiology, and management of children treated for aki over the last years. children primarily treated in intensive care units were excluded. outcomes noted as complete recovery, residual renal injury, renal replacement therapy (rrt) dependency or death. they were followed up until their renal function normalised and any proteinuria or hypertension resolved. result: out of the total children aged months to years, % were under years. haemolytic uremic syndrome (hus) was the commonest aetiology in cases ( %), of them secondary to ecoli and with atypical hus. obstruction was second most common ( ) and renal function improved following relief of obstruction. supportive management sufficed in ( %) cases and ( . %) received renal replacement therapy (rrt); peritoneal dialysis being the commonest mode. most children needing dialysis were oliguric ( ). at discharge there were no deaths, patients showed complete recovery of renal function, one was dialysis dependant and renal function was improving in the rest. at months we found normal renal function in ( %) children and chronic kidney disease (ckd) stage ii in ( %) and ckd stage iii in . the dialysis dependent child underwent renal transplantation. based on the data from patients currently under follow up (for - months, mean months), ( %) children have recovered completely and have developed ckd; stage i in and stage ii in . conclusion: prognosis following aki was excellent in our patients, probably because of lack of multiorgan dysfunction. hus was the commonest cause and urgent renal imaging needed when obstruction is suspected. oliguric patients are more likely to require dialysis and need early referral to the regional unit. all cases should have long-term follow up to ensure renal recovery and detect delayed complications. clinical course and outcome of acute kidney injury (aki) due to childhood haemolytic uremic syndrome (hus): a single centre experience shivaram hegde, sabina pahari paediatric nephrology, university hospital of wales, cardiff, uk objective: clinical data, along with the management and outcome of children with aki due to hus, caused by shigatoxin-producing ecoli (stx-hus) are described. method: we analysed the data of children with stx-hus induced aki, managed in our unit over the last years. outcomes noted as complete recovery, residual renal injury, dialysis dependency or death. all patients were followed up at least for a year and further monitoring continued until their renal function normalised and any proteinuria or hypertension resolved. methods and results: stx-hus was the commonest cause of aki in our unit, accounting for of the total cases ( . %) treated for aki during this period. patients were less than years of age. all children presented with blood in stool and with oligoanuria. all showed microangiopathic haemolytic anaemia and thrombocytopenia. positive stool cultures (for ecoli ) were obtained in and had ecoli lipopolysaccharide serum antibodies. patients required dialysis (peritoneal dialysis in , haemodialysis in and both modes in ) and one child needed plasma exchange. the remaining responded to supportive management. morbidities encountered included bowel perforation ( ), hypertension ( ), seizures ( ) and diabetes mellitus ( ) and three of these children needed intensive care management. at discharge there were no deaths, none with dialysis dependency or complete renal recovery but all showing improving renal function. at months we found normal renal function in ( %) and chronic kidney disease (ckd) stage ii in and ckd stage iii in . a year old girl with an unknown myopathy presented for the third time with clinical and laboratory features of rhabdomyolysis. on day two of admission, her renal function deteriorated with decreased urine output, increasing creatinine of μmol/l and ck of , iu/l. she was commenced on haemodialysis and started on calcium supplements, as her calcium levels were . mmol/l. three week into her illness, she was symptomatic with high blood pressure of mm of hg leading to a generalised seizure. her serum calcium was . mmol/l. the ct brain did not reveal any evidence of haemorrhage or infarction. there were no other trigger factors identified for the seizure and the hypertension, apart from the hypercalcaemia. the hypercalcaemia was managed with low calcium dialysate, calcitonin and sevalamer. despite the above treatments, she continued to be hypercalcemic and developed erythematous palms and soles and an injected conjunctiva. in view of the refractory hypercalcaemia, she received two doses of intravenous pamidronate ( . - mg/kg) when the creatinine was mmol/l. following this, her calcium levels normalised to . mmol/l. her renal function improved and was discharged a week later. there was no nephrocalcinosis seen on follow up. bisphosphonates are used in children with caution, as there is little evidence on its safety and efficacy. they act by binding to the surface of calcium phosphate crystals and inhibiting osteoclast formation, aggregation and dissolution. it is nephrotoxic causing acute tubular necrosis and collapsing focal segmental glomerulosclerosis. pamidronate is usually used in children with chronic kidney disease but this was the first time it was used in a child recovering from acute kidney injury secondary to rhabdomyolysis. there were no complications with the use of pamidronate in our patient. chronic kidney disease during long-term follow-up in children treated with neonatal extracorporeal membrane oxygenation: do we need to worry? objective: acute kidney injury (aki) is a common complication in children receiving extracorporeal membrane oxygenation (ecmo) support. as aki may cause loss of a significant number of functioning nephrons, these children are at risk of developing chronic kidney disease (ckd) post-ecmo. therapeutic interventions might be needed to prevent further renal function deterioration or comorbidity of ckd in these patients. the objective of our study was to determine the prevalence of ckd during long-term follow-up (fup) of children treated with ecmo. methods: this was a cross-sectional study performed between and . all children previously treated with neonatal ecmo who visited our fup clinic at the age of , , , , and years were screened for ckd. if more check-ups were available per patient, only the latter one was used for the study. ckd screening included height (ht) and blood pressure measurements (bp), and laboratory parameters including serum creatinine (scr) (schwartz formula [ . *ht (cm)/scr (mg/dl)] or mdrd formula were used to estimate gfr) and urinary protein/creatinine (up/c) ratio. ckd was suspected in patients with hypertension (> th percentile of reference values according to height and age), abnormal egfr (< ml/min/ . m ) or proteinuria (up/c ratio > mg/mmol creatinine). patients were excluded if scr was lacking. results: to date, children visited the fup clinic. of these, ( %) were excluded because of pre-existent kidney disease and ( %) because of missing scr data. hence, children ( % female) were screened for ckd. the number of patients per fup age category was < years, between - years, and > years. bp was within normal ranges in all children. in ( %) children either an abnormal up/c ratio or egfr was observed. up/c ratio was increased (median [iqr - mg/mmol creatinine]) in ( %) children, of which was explained by low muscle mass. only ( %) children had an abnormal egfr but all > ml/min/ . m . conclusion: the prevalence of ckd and its clinical implication in children previously treated with neonatal ecmo seems to be limited. future research will focus on identifying risk factors for ckd following ecmo support. abstract# p-sat years clinical retrospective analysis in children of acute poisoning inpatient man jiang, qiu li nephrology and immunology department, children's hospital of chongqing medical university, chongqing, china objective: acute poisoning is the common critical and emergency disease in children. since childhood is the special life stage with continuous growth, clinical features are different from the adult and changes were happened in resent years. the change rules, clinical features, treatments and the outcomes of acute pediatric poisonings inpatients were investigated in this article. methods: retrospective evaluated the cases of pediatric acute poisonings admitted to the children's hospital of chongqing medical university. cases were divided into groups by ages, or divided into groups based on different origins (urban or suburban), different causes and routes of poisonings in different groups were calculated. the clinical manifestations, treatments and prognosis in acute intoxication were also studied. results and conclusion: pediatric acute poisoning mainly happened in - years old children ( . %), there was no statistical difference between genders. the common causes of poisonings were pharmacological poisoning ( . %), food poisoning ( . %), animal bites and stings ( . %) and pesticide poisoning ( . %). in the resent five years, pharmacological poisoning rose to be the top reason of poisonings, and was mainly composed by children≤ years old (p < . ),and urban children were more than children from suburban(p < . ). neurological and psychiatric drugs were the most common ( . %) in drug poisoning. rural children with animal bites and stings, pesticide poisonings and rodenticide poisonings were more than the urban children (p < . , p < . , p < . ). the main poisoning causes in - years old group and > years old group children were food poisoning ( . %) and pesticide poisoning ( objective: little is known about cardiac surgery-associated acute kidney injury (cs-aki) in children in developing regions of the world. the study aimed to determine the prevalence of cs-aki, associated factors and its impact on mortality and utilization of hospital services. methods: hospital records of children aged - years that underwent cardiac surgery (other than device closure procedures and pacemaker insertion only) at an indian hospital between and were reviewed. cs-aki was defined as a rise in serum creatinine of ≥ . mg/dl in any hours and or by urine output less than . ml/kg/hr for an -hour period in the first days after cardiac surgery. results: the study included children with a median age of year ( . - ), of which ( . %) were neonates and . % had single ventricle. about % of the children had rachs- or interventions. cs-aki occurred in children ( . %), most often in the first hours after cardiac surgery. on univariate analysis cs-aki was associated with sepsis and intra and post-operative hypotension. in-hospital mortality was -fold higher in children who developed cs-aki. cs-aki was associated with - days longer duration of mechanical ventilation, inotropic support and icu stay. conclusion: cs-aki occurs in children in developing countries but at a lower frequency mainly due to older children with less complex congenital heart disease undergoing cardiac surgery. cs-aki was associated with higher in-hospital mortality and increased utilization of hospital services. factors associated with cs-aki included intra and post-operative hypotension and sepsis. objective: data on long term effects of newborns after acute kidney injury is limited. the aim of the study was to evaluate long term effects of acute kidney injury (aki) in neonatal period. methods: inclusion criteria were as follows: oligo-anuria or plasma creatinine > . mg/dl during first three postnatal days or > . mg/dl after third postnatal day or ≥ % increase in plasma creatinine within hours during hospitalization in neonatal period. three hundred sixty children who had aki during neonatal period (between january and december ) and survived to hospital discharge were invited; of them accepted to participate. patients' characteristics during aki and during follow-up were recorded; a physical examination and laboratory studies, including acr (urine microalbumin/creatinine ratio) were performed. schwartz formula was used to estimate gfr; hyperfiltration was defined as a gfr > ml/min/ . m . hypertension was defined as blood pressure ≥ th percentile for age, gender and length. results: the mean age on evaluation was . ± . years. . - . - . % of patients. all these children were dialyzed for more than days on acute phase of the disease. at time of discharge from hospital proteinuria remained in ( . %), hypertension -in ( . %) patients. after year, years and > years period proteinuria was detected accordingly to . - . - . %, hypertension to . - . - . % of patients. after > years from the onset of disease hypertension was detected more often in the group of children who were < years old on acute phase of the disease ( % vs . %, p= . ). in the group of patients who hadn't proteinuria on the acute phase, after > years period proteinuria was observed to % of them. after year period renal impairment of various degree was observed to . %, after years -to . %, after > years-to . . on admission his mean arterial pressure was mmhg, his creatinine was . , potassium . and sodium . usual medical management for aki was initiated but even by late d he continued to be anuric with a rising creatinine. his uric acid was grossly elevated at mg/dl. dialysis was considered but as the parents were not in favour of it they were offered the option of rasburicase. rasburicase was given on late d and within hrs he started to produce urine which peaked at ml/kg/hr by d . the creatinine also showed a concomitant fall and by discharge (d ) it was . mg/dl and normalized at . mg/dl by d . uric acid was . mg/dl on d and . mg/dl on d . case : years old boy with multiple special needs was transferred from another hospital intubated, anuric and in multi organ failure (mof). creatinine was elevated at . mg/dl and uric acid was also found to be raised at . mg/dl. in view of mof along with disseminated intravascular coagulopathy (dic) dialysis was considered a risky process and parents were offered the option of rasburicase. rasburicase was given on d of admission and although the repeat uric acid was . mg/dl and he did produce ml of urine within hours no further improvement in renal parameters was noticed. dialysis (sled) was initiated on d . although the creatinine improved with sled he continued to be oligo-anuric and died of mof by d . conclusion: although rasburicase seemed to work in case , it was not beneficial in case . the exact mechanism for rasburicase is still hypothetical and the few case reports have all documented positive results. although it seemed to have worked in case , to the best of our knowledge case is the first documented case wherein it did not work. proper randomized control trial is needed before advocating rasburicase as a novel therapy for aki. results: age, sex, diagnosis, baseline and post-surgery hemoglobin, total leukocyte count, platelet count and biochemistry were recorded. baseline and post-operative, urea (mg/dl), creatinine (mg/dl), urine output (ml/kg/hr) and inotrope dose were also recorded daily. the duration of cpb was noted. post-operatively cardiac, renal, hepatic, neurological and respiratory dysfunctions were recorded. conclusion: fifteen ( . %) children developed aki stage i, one child ( . %) developed aki stage ii and four children developed aki stage iii ( %). all patients with aki had a longer stay in hospital. eight children required dialysis for aki; two required dialysis to maintain the fluid balance post operatively. none developed chronic renal impairment. using stepwise regression, younger age (< year), weight < kg, pump failure, sepsis and duration of cpb more than minutes were significant risk factor for developing aki. results: most of the patients were male, with less than days old and weighing less than kg.in the majority of cases ( %), arf was diagnosed in the first days after surgery, demonstrating influence of the procedure itself. all of them were treated by peritoneal dialysis(pd) for a mean time of hours; . % of them died. there was no statistical significant difference between age, time on extracorporeal circulation and duration of dialysis, comparing the patients who survived and the deceased ones. conclusion: acute renal failure is a common complication in children with congenital heart disease and pd is a safe dialytic method. the mortality rate is high and influenced by aspects related to the child, underlying disease, type of surgery and many other associated aspects. abstract# p-sat acute kidney injury epidemiology and associated factors in a pediatric intensive care unit. conclusion: acute kidney injury (aki) is associated with significant morbidity and mortality in pediatric patients with critical illness. the main causes associated to aki were sepsis and shock. we found no association with cardiac surgery, probably explained by the low level of complexity that is performed in our center. almost half of our patients with aki were in failure and the mortality was high as previously reported. objective: fibroblast growth factor- (fgf- ), a phosphaturic hormone involved in calcium phosphate homeostasis, appears to predict renal disease progression in adults with non-diabetic ckd (fliser, jasn ) . this study aimed to determine renal survival according to fgf- serum levels in children with ckd stage ii-iv. methods: children participating in the escape trial (age . ± yrs, gfr ± ml/min/ . m ; underlying renal disease: hypo/dysplasia ( %), glomerulopathies ( %), hereditary or other ( %)) were analyzed. all patients received fixed dose ace inhibition and were followed prospectively by -monthly examinations for up to years. the study endpoint was defined by egfr loss > % from baseline, gfr < ml or start of renal replacement therapy. fgf- levels were determined at baseline (c-terminal human fgf- elisa (immutopics, san clemente,ca,usa objective: the long-term outcome of patients born with unilateral renal agenesis (ura) and of those who underwent therapeutic unilateral nephrectomy (un) remains a topic of concern and debate. children with a solitary functioning kidney (sfk) have an increased risk of developing hypertension, albuminuria and chronic kidney disease in later life. the purpose of this study was to identify whether plasma symmetric dimethylarginine (psdma) is an useful biomarker reflecting the level of renal injury in children with solitary functioning kidney (sfk). methods: we measured circulating psdma in patients with sfk and no other urinary defects. patients were subdivided for two groups: primary sfk (psfk)-unilateral renal agenesis (ura) and secondary sfk (ssfk) after unilateral nephrectomy. the control group (c) consisted of healthy children, aged mean . ± . yrs. immunoenzymatic elisa commercial kits was used to measure psdma concentration. data analysis was performed using computer program statistica . . results: the age and sex of studied children did not differ from healthy controls (p> . ). plasma sdma levels in sfk children were higher than in healthy participants (p< . ). there was no difference in psdma concentrations between psfk and ssfk patients (p> . ). sdma plasma levels correlated significantly with c cr (r= - . , p< . ) in all participants. roc analyses performed in order to define the diagnostic efficiency of serum creatinine and psdma in identifying children with c cr < ml/ min/ . m among sfk and healthy participants revealed no difference between all two aucs (p> . ). conclusion: in children with a solitary functioning kidney increased psdma levels were observed, however the sensitivity and specificity of this marker in detecting the decrease in c cr was not better than creatinine. objective: renal osteodystrophy encompasses a variety of skeletal disorder ranging from high turnover lesions of secondary hyperparathyroidism (shpt), to low turnover lesionsof diverse etiology that are usually associated with normal or reduced pth levels. so our aim was to assess by dexa which is a precise , rapid and noninvasive procedure the degree of osteopenia in patients with crf. methods: children aged ( - . ) years, on conservative treatment and on hemodialysis were included in the study bmd of lumbar spine and wrist were measured by (dexa) and compared with age and sex matched controls. results: shows that out of patients, ( %) are osteopenic ( %) on hemodialysis and ( %) on conservative treatment, of these ( . %) had severe osteopenia as regard bmd of the spine, while dexawrist shows ( %) are osteopenic, ( %) on regular hemodialysis and ( %) on conservative iii, of these ( . %) had severe osteopenia ,correlation between z-score spine in the osteopenic group and different biochemical parameters shows non-significant correlation except -ve correlation with duration and age of the patients, while z-score wrist of the same group shows +ve correlation with bicarbonate. our result shows that group with ipth >= pg/ml are more osteopenic than those with lower ipht levels, although difference did not reach level of statistical significance p > . . conclusion: we can conclude that osteopenia is frequent in patients with crf more in the dialyzed group, with longer duration of the disease, older age and severe acidosis, irrespective of the severity of the disease. although, degree of osteopenia is not correlated with biochemical findings of (shpt) but still patients with (shpt) are more osteopenic and have lower cortical bone density. mineral and bone disorders were defined according to k/doqi guidelines. results: during the study period % of stage i-iv ckd patients and all esrd patients and renal allograft recipients had at least one type of mbd. high turnover bone disease with hyperphosphatemia, hyperparathyroidism and hypocalcemia was the most frequent type of mbd in stage i-iv ckd and esrd patient. adynamic bone disease was seen in only one esrd patient. hypophasphatemia was the most common disorder in renal allograft recipients. vitamin d deficiency/insufficiency was seen in % of stage i-iv ckd, % of esrd patients and all renal allograft recipients. all patients with stage i-iv ckd and esrd were treated with calsitriol and renal allograft recipients were treated with vitamin d supplementation. conclusion: mineral and bone disorders especially high turnerover type is common in children with ckd and esrd. although successful kidney transplantation corrects many of the metabolic abnormalities associated with the development of mbds, renal allograft recipients had increased risk of vitamin d deficiency/insufficiency. objective: calciphylaxis is a complication of chronic kidney disease that characterized by necrotic lesion in the skin and in histological examination reveals microcalcification of medium sized blood vessels. materials and methods: we report on a -month old girl with end stage renal disease due to diffuse mesangial sclerosis referred for tenckhoff catheter implantation. laboratory tests on admission were: bun = mg/dl, cr= mg/dl, uric acid = mg/dl, calcium= mg/dl, phosphate = mg/dl, alkaline phosphatase= , pth= pm/l,vitd= mg/ml. calciphylaxis process started when she received calcium gluconate iv the day before surgery and continued progressively when oral calcium carbonate and oral calcium gluconate were given. hourly peritoneal dialysis was started and all calcium containing medications were stopped. but the process continued progressively. surgical detriment of the necrotic tissue of right wrist was done. comfeel dressing had no effect and the circulation of tissue was poor. therefore the left wrist was kept as control. pamidronate . mg/kg/day prescribed for days and then once a week for weeks. after one week of starting pamidronate skin lesion began to heal, circulation improved and after six weeks all skin lesions completely recovered. as shown in figure one debridement cause skin scar on right wrist. conclusion: pamidronate is effective to stop calciphylaxis in children with advance renal insufficiency and severe calcium-phosphate imbalance. medical or surgical debridement are not suggested and lesions will recover without scar by pamidronate objective: fibroblast growth factor (fgf ) is a key player in kidney-bone axis and regulation of calcium and phosphate homeostasis. most of the recent research has focused on fgf in chronic kidney disease and there is paucity of data in healthy children. hence we initiated a study on the various biomarkers of calcium-phosphate metabolism including fgf in healthy children and present here the interim report of our findings as of now. methods: a total healthy school children and adolescents aged - years, were enrolled in this cross-sectional study, after a written consent from their parents. height, weight and pubertal staging were assessed. blood was collected and calcium, phosphate, pth and vitamin d were estimated by standard methods. plasma c-terminal fragment of fgf was quantitated using a commercial elisa kit (immutopics, usa). three day dietary recall was done to calculate mean daily calcium, phosphate and protein intake. results: of the children enrolled % were males. the mean age was . yrs, mean height was cms and mean weight was kgs. the mean blood biochemistry values of the children tested so far for ca, p, pth and vitamin d shown in table . the parameters of the children were normal for their respective ages however fgf levels were found to be lower compared to reports in literature. conclusions: from the results available as of now all of the children had normal biochemistry for their ages. the fgf levels were found to be lower than reports in the literature. whether it can be attributed to the dietary differences from the children of the west needs further investigation. testing of the entire cohort will reveal if this lower fgf is a universal phenomenon among all children in our study. on the contrary, all dxa parameters showed a decreased in their mean zscore bmd values that reached statistically significance. finally, multivariate stepwise regression analyses showed that estimated glomerular filtration rate at the beginning of the study was the best predictor of the difference in bmd z-scores measured at lumbar spine. additionally, values of ipth at the beginning of the study and the change of ipth throughout the study predicted the . % of the difference in z-score of sos measured at radius with an inverse relationship. conclusion: the use of two different techniques have shown bipolar changes of bone properties after renal transplantation. reversal of renal osteodystrophy and consequently correction of many of the underlying metabolic abnormalities, mainly normalization of ipth, strengths cortical bone as this is best illustrated by qus assessment. however, reduction in bmd, is predominantly considered as an adverse effect of steroid immunosuppression. age . yr) (group ), patients with ckd stage on pd or hemo (mean age yr, mean time on dialysis yr) (group ) and patients with ckd stages - (mean age yr, mean gfr ml/min/ . m ) (group ). ohd levels were deficient in % and insufficient in % of the group patients, % were deficient and % were insufficient in group , and % were deficient and % were insufficient in group . results: intact pth (ipth) was above the target level by different ckd stages in % of the group patients, in % of the group and in % of the group and showed an inverse correlation with ohd levels (p< . , r=− . ). there was inverse correlation with age in the complete cohort of patients (p= . , r =− . ) height standard deviation score (sds) was associated with ohd only in group (p= . , r= . ). there was direct correlation between ohd levels and gfr in group and . conclusion: our data suggest that ohd deficiency is common in pediatric renal transplant and ckd children of any stage even in an area with year-long sunshine, especially in adolescents. hyperparathyroidism was also frequent in all groups. it would be advisable to monitor vitamin d status in these patients. ) years, with ckd ( on hd, on pd and tx) mean age ( . - . ) and healthy children, mean age . ( - . objective: the aim of our study was to analyze twelve single nucleotide polymorphisms (snp) of gene lrp potentially associated with osteoporosis risk in children with routine steroidotherapy in the course of the idiopathic nephrotic syndrome. methods and results: glucocorticosteroids are important risk factors for drug induced osteoporosis. decrease in bone mineral density (bmd) and increased risk for pathological fractures are caused by direct division of steroids at the cellular level by inhibiting the replication of osteoblasts and stimulation of its apoptosis. also proven its effects on the inhibition of type i collagen synthesis. lrp is one of the wnt signaling pathway proteins coreceptors involved through the rank-rankl system in regulation of the osteoblasts function. lrp is included to the osteoporosis phenotype genes group and its selected single nucleotide polymorphisms can be responsible for bmd decrease in patients with glucocorticoid therapy. the study group was composed of children with idiopathic nephrotic syndrome, boys and girls beetwen the age of five to twelve years old , with osteoporosis and with normal bone mass density. study also included the control group consists of healthy individuals at the same age not treated with glucocorticoids. the analysis was carried out with polimerase chain reaction (pcr) and taqman molecular probe designed for single nucleotide polymorphisms (snps) nearby investigated mutations in lrp gene that can be connected with osteoporosis fenotype. odds ratio value (or) was based on frequencies of single nucleotide polymorphisms in lrp gene and its haplotype analysis. the results showed significant differences in or value among the three groups. it was also found the differences in the lrp gene structure. based on gabriel algorytm single nucleotide polymorphisms pairs analysis in children with osteoporosis and nephrotic syndrome we proved the correlation between selected snps pairs presence and decretion of bone mineral density in studied group. objective: growth hormone (gh) and insulin-like growth factors are essential for normal growth and development. chronic renal failure (crf) results in major changes in the circulating growth hormone /insulin-like growth factor (igf) system. our aim isto study: to assess clinical and laboratory parameters of growth and osteodystrophy including igf and igfbp as part of the somatotropic hormone axis in egyptian children suffering from crf on conservative therapy. methods: egyptian children ( boys and girls) with a mean age of . y ( . to . y) suffering from crf on conservative therapy and controls were included in the study. ht, wt and tsf were measured ,pubertal staging was assessed and followed up for a period of months. at the end of the follow up period serum for igf and igfbp , renal function, electrolytes, ca, p ,and alkaline phosphatase and acid base balance were measured and an x-ray of the left hand and wrist was done to determine their bone age by tanner and whitehouse. results: our study shows that children suffering from crf in egyptian conservative therapy have growth retardation with a mean ht of - . sds, a mean wt of - . sds. tsf mean was - . sds. on the average the patients had a delay of . y (+/- . ) in their bone age. their height was retarded more than their bone age with a height age/bone age of . (+/- . ). alkaline phosphatase as a markers of renal osteodystrophy is significantly correlated to the height, height age , bone age and to the ph. the mean igf sds (- . +/- . ) did not differ from that of controls while the mean igfbp sds ( . +/- . ) was significantly higher in patients with crf than in controls. height and weight were significantly correlated to igf but not igfbp . there is a significant correlation between igfbp level and the glomerular filtration rate. conclusion: the imbalance between normal insulin-like growth factor-i (igf-i) and markedly increased igfbp plasma levels plays a pathogenic role for growth retardation in children with chronic renal failure. the lower the gfr the higher the igfbp level. the latters inhibitory action may provide hope for improving growth in cases of crf by reducing the level of igfbp or displacing igf from it. objective: anemia is one of the most common complications of chronic kidney disease (ckd) and renal transplantation. this study evaluated the prevelance and the etiology of anemia in children with stage i-iv ckd, end-stage renal disease (esrd) and renal allograft recipients. methods: between and , we prospectively followed pediatric stage i-iv ckd, esrd patients and renal allograft recipients. anemia was defined according to k/doqi guidelines as hb is less than the fifth percentile of the normal, adjusted for age and sex. results: during the study period . % of stage i-iv ckd, % of esrd patients and . % of renal allograft recipients developed anemia. the mean hb levels were . +/- . g/dl, . +/- . g/dl and . +/- . g/dl in stage i-iv ckd, esrd patients and renal allograft recipients, respectively. the mean hb levels were significantly lower in esrd patients as compared to stage i-iv ckd patients and renal allograft recipients (p< . , p< . ). erythropoetine (epo) deficiency was the most frequent cause of anemia in stage i-iv ckd and esrd patients, followed by iron deficiency. in addition to epo and iron deficiency, bone marrow suppression and parvovirus infection were the causes of anemia in renal allograft recipients. erythropoietic stimulating agents were used in % of stage i-iv ckd, % of esrd patients and % of the renal allograft recipients. conclusion: although anemia is one the most common problems seen in children with ckd and esrd, the prevelance is also high in renal allograft recipients. these patients should be evaluated and treated accordingly to the underlying causes. abstract# p-sat determinants and prevalence of anaemia among preschool children in highly focussed states of india results: about more than % child is anaemic among all eag states. the prevalence of severe anaemia is . % in rajasthan followed by uttar pradesh ( . %) and madhya pradesh ( . %). those children aged to months are times significantly more likely to be severe anaemic as compare to the to months aged children. those mothers have severe anaemia, their children are also found to be severe anaemic ( times more than not anaemic mothers). mothers who are highly educated and belong to richest quintile their children are less likely to be anaemic. the finding of the study shows that demographic and socio-economic indicators play significant role in determining the prevalence of anaemia in eag states which needs focused programme to reduce the prevalence of anaemia in preschool children. abstract# p-sat impaired renal growth hormone mediated jak/stat signaling in juvenile rats with chronic kidney disease objective: linear growth retardation is a major problem in children with chronic kidney disease (ckd) and is ascribed to gh insensitivity. treatment with exogenous gh has been accepted as standard therapy in children with ckd and short stature. however, concerns have been raised in the past on the potential fibrogenic effects of gh. there is no information regarding renal ghr signaling pathway in ckd. methods and results: to investigate this pathway, surgically / nephrectomized (ckd) and pair-fed control (c) juvenile ( wk old) rats were sacrificed after weeks of ckd. serum creatinine and albumin excretion were significantly elevated (associated with glomerulomegaly and early fibrosis) while body weight and length gain were reduced in ckd rats. serum igf-i levels were decreased in ckd, even though serum gh levels were unchanged. kidney ghr mrna and protein levels were reduced and phosphorylation of jak and stat was significantly impaired. supressor of cytokine signaling (socs ) mrna was increased in association of increase in renal il mrna. renal igf- mrna was unaltered in ckd. thus, in the remnant kidney of ckd growth retarded juvenile rats there is impaired gh mediated jak /stat signaling. this defect may be due to a reduction in gh receptor expression and signaling together with an increase in socs expression. conclusion: we suggest that the insensitivity of the remnant kidney to gh may serve to protect against the potential adverse renal effects of exogenous gh in ckd patients. objective: concerns have been raised about possible adverse effects of growth hormone(gh) in short children with chronic renal diseases. six cases of short children with chronic renal diseases ckd were studied in our hospital, the microalbuminuria as a sensitive parameter of early glomerular damage was detected during the treatment of recombinant human growth hormone. the individual growth response to gh was also observed. methods: of the cases, male were , female , the onset age ranged from to years old, all were diagnosed as growth retarded children with various chronic renal diseases. the dosage of gh was . iu/kg/d. the follow-up period was from months to years. microalbuminuria was measured by a commercially available elisa kit, as a sensitive parameter of early glomerular damage in children being treated with recombinant human growth hormone. serum insulin-like growth factor igf-i concentration and igfbp were also measured before and during the treatment with gh. results: there was no statistically difference on the level of microalbuminuria compared with that of pretreatment. linear growth were . cm/month with an increment in height sds by . at the end of the first year of gh treatment. growth retardation in children with ckd is associated with normal to slightly low concentrations of (igf)-i and igfbp . objective: iron deficiency anaemia is common in chronic haemodialysis patients and is the most common factor of resistance to erythropoeitin treatment. kdoqi clinical practice guidelines and recommendations for anaemia in ckd suggest maintaining hb levels between - g/dl, tsats > % and serum ferritin above ng/ml. our unit's previous practice provided - mg/kg/week of elemental iron intravenously to our haemodialysis population and monitored blood parameters monthly. from july , we changed our practice to withhold routine administration of iv iron, unless blood parameters (monitored fortnightly) suggested iron deficiency. we assessed the change in our practice in safely reducing the frequency of iv iron administration in our haemodialysis population. methods: we included all children attending our haemodialysis unit (july ). we used %hypochromia of > %, correlating with hb level of < g/dl as a marker for initiating iv iron sucrose ( mg/kg/week) until improvement of the above parameters. serum hb and %hypochromia were monitored at the start of change-over and fortnightly thereafter. all patients received routine erythropoietin at recommended doses of between - units/kg/week. results: at initiation of change-over, there were patients with mean hb . g/dl, mean %hypochromia . % and mean tsats . %. from july -mar , four patients required iv iron therapy (mean hb . g/dl, mean %hypochromia . %, mean tsats . %). three patients had weeks and one patient had weeks of iv iron sucrose mg/kg/week to achieve normalisation of serum hb (mean . g/dl), %hypochromia (mean . %) and tsats (mean %). at time of reporting (mar ), there were patients with mean hb . g/dl, mean %hypochromia . % and mean tsats . %. two patients received transplants. conclusion: a novel change in our practice has resulted in a safe reduction of iv iron therapy in our population of children undergoing haemodialysis. from our findings, we suggest avoiding routine iron infusions in paediatrichaemodialysis, which is unlikely to have an adverse effect on the incidence of anaemia and will reduce the risk of inadvertent iron overload. abstract# p-sat reversible portal ascitis after bilateral nephrectomy in infant with polycystic kidney disease we report here on a newborn with moderate renal failure and severe hypertension due to autosomal recessive polycystic kidney disease (arpkd). antihypertensive therapy associating minoxidil, labetalol, amlodipine and lasilix were not able to control adequately blood pressure. due to massive kidney enlargement, inadequate respiratory function and inability to tolerate enteral nutrition, parenteral nutrition was initiated at months to maintain adequate calories intake. at months of life, the infant presented severe viral pneumonia complicated by cardio respiratory arrest . he required cardio respiratory resuscitation and hospitalization in icu for several days. unilateral right nephrectomy was decided after this severe complication in order to avoid similar accidents due to massive kidney volume and to improve respiratory and nutrition status. one week after unilateral nephrectomy, we noted rapid increase volume of the left kidney and important ascitis having the biological characteristics of portal hypertension. repeated aspiration of more than ml of portal ascitis was performed every day. in parallel daily perfusion of albumin for more than weeks and complete parenteral nutrition did not succeed in treating ascitis. faced to resistant ascitis and persisting difficulties in maintaining enteral nutrition and adequate respiratory ventilation , left nepherctomy was decided and performed. automated peritoneal dialysis was rapidly initiated in our anuric infant (weight after binephrectomy kgs). portal ascitis disappeared in hours with rapid normalization of respiratory ventilation and return to normal and well tolerated enteral nutrition. conclusion: to our knowledge, this is the first case reported of portal ascitis noted after palliative unilateral nephrectomy to facilitate pulmonary expansion and gastrointestinal function in arpkd. ascitis was resistant to daily albumin perfusion and repeated aspirations but was completely reversible after bilateral nephrectomy and initiation of peritoneal dialysis. early bilateral nephrectomy at months of life was probably the ideal choice to avoid many complications in our infant due to abdominal and thoracic compression by massive kidney compression. ethical considerations, therapeutic possibilities, and parent consent should be discussed in such challenging and very difficult cases. abstract# p-sat serum hepcidin levels and anemia in pediatric chronic kidney disease objective: hepcidin restricts the availability of iron from its stores for erythropoiesis resulting in a functional deficiency of iron and hyporesponsiveness to erythropoiesis stimulating agents. the objectives were to estimate the serum hepcidin in children with chronic kidney disease stage ii to iv and correlate it with hemoglobin, iron status (serum ferritin and transferrin saturation), inflammation (c reactive protein) and estimated glomerular filtration rate (egfr). methods: it was a cross sectional study. children aged to years with ckd stage - on stable dose of iron and or erythropoetin for the last weeks were included. children with anemia due to other causes, severe acute infection, chronic cardiac or respiratory conditions and those who received parenteral iron and or blood transfusion in last weeks were excluded. hemoglobin, serum ferritin, transferrin saturation, c reactive protein were assessed. serum hepcidin levels were estimated using a elisa based kit in the cohort as well as in age and sex matched normal children to estimate the levels in normal population. multivariate regression analysis was used to assess the relationship between hepcidin and hemoglobin, iron status, inflammation and egfr. results: forty children were recruited into the study. the mean age of children was . + . years. around %, % and % of children had ckd stage ii, iii and iv respectively. the mean serum hepcidinlevels in children with ckd ( . + . ng/ml) was significantly higher than controls ( . + . ng/ml). conclusion: serum hepcidin levels showed an increasing trend with decrease in egfr, but this was not statistically significant. the mean haemoglobin was . + . g/dl, the mean ferritin was . + . ng/ml , the mean transferrin saturation was . + . %. anemia and absolute iron deficiency was seen in % of our cohort and worsened with increasing stages of ckd. serumhepcidin levels did not correlate significantly with haemoglobin, ferritin or with c-reactive protein. objectives, methods and results: presenting a -year old armenian patient who developed a secondary amyloidosis on top of a familial mediterranean fever (fmf) and moved to germany years ago. at the time of the move the patient had already a terminal renal insufficiency and received intermittent hemodialysis. despite the therapy with colchicine moderate attacks of the fmf occurred with an interval of weeks and inflammatory parameters were permanently elevated. the dosage of colchicine was titrated up to mg per day. as a consequence diarrhea occurred and the dosage had to be decreased. over the course the amyloidosis progressed and affected all internal organs including heart and bowel. the combination of inflammation, uremia and amyloidosis led to malnutrition (bmi kg/m ). at the age of years the most severe colitis with peritonitis and paralytic ileus occurred. the treatment with colchicine was paused in assumption of a toxic effect. after improvement of the diarrhea but still persisting abdominal pain the colchicine treatment was slowly started again. shortly afterwards a very severe attack of the fmf developed with an accompanied cardiovascular insufficiency. the treatment with a single high-dose of methylprednisolone and the inhibition of interleukin with anakinra ( mg/kg, given after dialysis) led only to a short remission. the high-dose methylprednisolone treatment was therefore repeated three times and anakinra was given on a daily basis. since then no new attack of the fmf occurred and the combination of lowdose colchicine and anakinra improved the general status of the patient the elevated inflammatory parameters including serum amyloid a have almost normalized. objectives: invasive aspergillosis is almost exclusively occurs in immunocompromised hosts. the central nervous system (cns) is one of the most frequent sites of invaziveaspergillozis after the lungs. we report a case of invasive aspergillosis in a boy with end stage renal failure. methods and results: a -year-old boy was admitted to the hospital for abdominal pain, fewer and cough. he suffered from chronic kidney failure (crf) known for a year and he was on peritoneal dialysis for seven months. he was initially treated with iv. ceftriaxone for lobar pneumonia, intraperitonealceftazidime and cefazolin for peritonitis. the peritoneal fluid was also cultured for fungus and mycobacteria and all cultures were negative. on the seventh day, the patient complained for lower extremity weakness, and bilateral hyperactive deep tendon reflexes and positive babinski reflex were found. cranial magnetic resonance imaging (mri) was normal, but the spinal cord was compressed between c -t by a solid mass which was originated from right lung on spinal mri. computed tomography-guided tru-cut lung biopsy was performed for the solid mass. repeated peritoneal fluid culteres were also negative. two days later, when unconsiousness and convulsions were seen, intraparenchymal multiple hemorrhagic abscesses were found on his second mri. typical hyphae of aspergillusfumigatus was present in pathologic specimens and galactomannan test was positive. cerebral abscesses were evaluated as cns involvement of invasive aspergillosis. anti fungal therapy was began immediately as amphotericin b and caspofungin. the peritoneal catheter was removed and continuous veno-venous hemodiafiltration was performed. however his condition kept deteriorating and death ensued on the fourth day of anti fungal therapy. conclusion: invasive aspergillosis may rarely occur in immunocompetent patients and diagnosis may be missed or delayed due to lack of the particular clinical signs. we should be careful about diagnosis of fungal infections in patients with crf since early treatment before the invasion and dissemination of aspergillosis to adjacent tissues and/or organs offers a higher survival chance for the patient. questionnaire and to find a way to increase reliability for healthy children aged - years especially, according to iranian culture. objective: we lunch this study to compare the parent and children's behavior problem in pediatric patients suffering from ckd referring arak amir kabir hospital. methods: to perform this case control study, we recruit children with ckd and compared them with other non affected children age between to years old. the child behavior checklist cbcl / for child behavior assessment and general assessment function gaf for the evaluation of their parent's behavior were completed by the parent's data was analyzed using qualitative variables and chi-square formula. results: among patients with ckd, case . % showed behavioral problem while this figure was case . % in the control group, denoting a significant difference p- . . moreover children / % in the case group and children . % in the control group had internalizing problem p- . . children % with ckd and children . % in the healthy group had externalizing problem which was also a significant difference p- . . as a significant p- . the parent's average stress and behavior scores in case and control were . & . , respectively. conclusion: the higher prevalence of behavioral problem in the children suffering from ckd and their parent's functional impairment highlights the important of early treatment and subsequently prevention of future behavioral problem in their sibling. abstract# p-sat development in -year-old children with and without ckd objective: ckd is a pathophysiologic process with multiple etiologies, resulting in the inexorable attrition of nephron number and function and frequently leading to esrd. a number of studies have suggested that children with ckd have problem in development than other children our goal was to compare development of children with ckd with normal children within the common age range for the disease. methods: in this descriptive-analytical study, we selected children with -year-old children whom were diagnosed with ckd as our case group and studied their developmental status by ages and stages questionnaire (asq). the control group was selected from -year-old children who attended the clinic for reasons other than ckd. conclusion & application to practice: the eleven key areas of responsibility used to measure sc in a periodic evaluation demonstrated a strong correlation to the increasing extent of qpdo. additionally, as the nurses progressed to becoming expert a direct correlation to the qpdo was notable. the study became the foundation for staff training and developing a competency appraisal framework in renal nursing practice thereby promoting quality assurance procedures while attaining qpdo. objective: urinary incontinence is a child health problem that affect both the child and the family in psychological and social aspect and that leads to a decrease in quality of life of the child and his caregiver. patients with higher ckd stage had significantly lower qol score in all domains in the child-self reports, but not parent-proxy reports. whereas there was no difference between patents with stage i and stage ii. according to gender, boys had a tendency to present better qol than girls, but there was no significant difference between these two groups. age discrepancy was not a significant factor to decide qol in children with ckd. in addition, there was significant difference between parent-proxy reports and child-self reports and qol scores in the child-self reports was significantly higher than in the parent-proxy reports, especially in the domains of emotional, school functioning and psychosocial health score. conclusion: residual renal function in children with ckd is a important factor to decide qol. in addition, emotional and psychosocial support for their parents can be necessary to improve qol in children with ckd. abstract# p-sat results: the mean period of post-transplant follow-up was . +/- . years(range: . - years). in the first year of transplantation, ( . %) recipients had obesity obese patients had higher serum ggt levels than non-obese patients ( . +/- . u/l vs . +/- . u/l, p= . ). there was a positive correlation between bmi and ggt and tg levels in obese patients (r= . , and r= . , p< . respectively). patients with dyslipidemia were found to have significantly higher mean ggt level ( . +/- . u/l vs. . +/- . u/l, p= . ) and bmi ( . +/- . vs. . +/- . p= . ). we could not find any correlation between bmi, and gender, post-transplant follow-up, duration of crf, primary disease, donor status and graft loss. in the first year of transplantation, gfr was significantly lower in obese patients than non-obese recipients (p< . ) conclusion: our data has suggested that, even within its normal range, elevated serum ggt concentrations and hyperlipidemia are closely associated with obesity in transplanted patients and obesity has negative effects on graft functions. the relationship between the graft function and the serum and urine ngal in children with renal transplantation tehran university of medical science, associated professor, tehran, iran objective: the evaluation of graft function long term after transplantation is important. serum creatinine is the most common used marker for graft function in renal transplantation. the level of serum and urine ngal may predict graft function in renal transplant recipients. methods: we evaluated pediatric renal transplant recipients by measurement of serum and urine ngal, serum creatinine concurrently. the gfr of the patients was also estimated by schwartz formula. results and conclusion: the time after transplantation was - years (mean: . +/- . years). the mean serum ngal was +/- . ng/ml ( . - ) . the mean urine ngal was . +/- ng/ml ( - ). we didn't find any association between serum creatinine, gfr estimated by schwarz and serum ngal. we also didn'y find any association between urine creatinine, gfr estimated by schwarz and serum ngal. glomerular filtration rate measured by dtpa scan of fourteen patients were available. we also didn't any association between gfr measured by dtpa scan and serum and urine ngal. abstract# p-sat racial disparities in paediatric kidney transplantation in australia glomerulonephritis and late referral were more common in non-caucasian patients. among patients who did receive a transplant, caucasians had overall better hla matches to their graft and were less sensitised. conclusion: caucasian australian paediatric patients have greater access to kidney transplantation, particularly from living donors, and are likely to have the better graft survival. some racial disparities may be inevitable due to differences in kidney diseases, however further work is required to understand barriers to live donation and address disparities. abstract# p-sat cost-effectiveness of renal transplantation in paediatric and adult transplant recipients. [ . - . ] ), were associated with a lower inscription probability months after reaching esrd. the national inscription rate was % with a significant center variability (median % [iqr - ]) that remained after adjustment on patient characteristics (p< . ). preemptive transplantation rate explained % of the inter-center variability (p= . ). probability of transplantation months after inscription decreased with time of waiting list inactivity (p< . ) and with the probability of finding a compatible transplant considering patient's hla and abo groups. underweight (bmi <- sd) was associated with lower transplant probability (or . [ . - . ]). at months, % of patients were transplanted with a significant center variability (median % [iqr - ] that remained after adjustment (p= . ). conclusion: as expected patients' characteristics contribute to intercenter variability as well as centers' attitude towards the inscription of younger children, management of specific primary renal diseases and preemptive transplantation. despite national allocation rules we found a significant inter-center variability in the probability of being transplanted after inscription on the list, which was not explained by either the patient or center characteristics of our study. abstract# p-sat ten year outcomes of paediatric renal transplantation: the irish experience objective: focal segmental glomerulosclerosis is the most common cause of steroid-resistant nephrotic syndrome in children and adolescents. within years of initial presentation, - % of patients will progress to end stage kidney disease requiring kidney transplant. recurrence rate after transplantation is high and may be associated with early graft loss. methods: we analysed demographic and transplant data collected by the australian and new zealand dialysis and transplant registry (anzdata) on children and adolescents with a diagnosis of primary fsgs who were years of age or younger at the time of transplant. kaplan-meier analysis was performed to compare graft survival according to recurrence of fsgs and donor characteristics. results: during the -year period from st january to st december , transplants were performed in patients (age range - years, median years). twenty seven patients developed recurrent fsgs, with one child developing recurrent disease in grafts (overall recurrence rate %). the median time to recurrence was days, with loss of graft function in / transplants ( %). median graft survival in patients with recurrence was significantly shorter than in patients with no recurrence ( . years vs > years, respectively; p< . ). there was no significant difference in recurrence rate in recipients receiving deceased donor (dd) versus live donor (ld) transplants (p= . ) and median graft survival was significantly better in recipients with live donors ( . yrs vs . yrs for dd, p< . ) conclusion: the rate of recurrent fsgs and graft loss in this retrospective cohort study of children and adolescents transplanted within the australasian region, was similar to previously reported studies. however, in contrast to previous studies, there was no significant difference in rate of recurrence for live versus deceased donors. additionally, live donor recipients had longer median graft survival compared to deceased donor recipients. outcomes of calcineurin inhibitors conversion to mammalian target of rapamycin inhibitors in children with renal transplantation nuntawan piyaphanee, suroj supavekin, anirut pattaragarn pediatrics, siriaj hospital, bangkok, thailand objective: to study outcomes of pediatric renal transplant recipients who underwent cni elimination and conversion to mtor inhibitors. methods: we performed retrospective analysis of all pediatric renal transplant recipients who underwent cni elimination and conversion to mtor inhibitor at siriraj hospital, a tertiary care center in thailand. indications for conversion were defined. graft function prior and post conversion, history of acute rejection, and cni elimination failure were reviewed. results: nine of pediatric renal transplant recipients underwent complete cni conversion to mtor inhibitor. triple-drug regimen including prednisolone, cni and mmf/mpa was basically prescribed to the recipients. eight with tacrolimus and with cyclosporine were conversed to everolimus. mean ages at transplantation, conversion and last follow up were . ± . , . ± . and . ± . years, respectively. everolimus was initiated within months in patients. each patient due to cni induced hemolytic uremic syndrome, posttransplant diabetes mellitus, graft impairment with early onset nephrocalcinosis and graft impairment with renal artery stenosis. everolimus was initiated after months in patients due to chronic cni nephrotoxicity, chronic allograft nephropathy (can) and unfavorable graft functions with history of delay graft function. median duration from transplantation to cni conversion was . months (range . - ) and median time from conversion to the last follow-up was months (range - ). mean creatinine clearance (crcl) prior to the cni elimination was . ± . , as compared to mean crcl of . ± . ml/min/ . m at last follow up (p = . ). three patients had acute rejection (ar) before the conversion, but only patient had ar post cni elimination. there were no patients with graft loss or cni-elimination failure. conclusion: conversion from cni to everolimus was safe without increasing risk of acute rejection in pediatric kidney transplant patients who experienced early and late cni associated complications. objective: due to a severe shortage of suitable deceased-donor kidneys for children awaiting kidney transplants (kt), we have performed a series of abo-incompatible (abo-i) living kt since . historically, abo-i kt was performed using several session of plasmapheresis (pp) to remove existing anti-a or anti-b antibodies, followed by splenectomy to prevent rebound of antibodies. because splenectomy had risks of surgical complications including bleeding and pancreatic pseudocyst, we introduced a new protocol, for abo-i kt, in january . the new protocol without splenectomy utilizes the anti-cd monoclonal antibody (rituximab) and pp. this study retrospectivery examined the efficacy and safety of this protocol. methods: eight de novo abo-i kt ( males and females) were performed between january and december . the mean age at transplantation was . ± . years (range . - . years). the immunosuppressive protocol consisted of cyclospolin or tacrolimus, mycophenolate mofetil, and methylprednisolone. all patients received induction therapy with basiliximab. the preconditioning protocol included pp or double filtration plasmapheresis (dfpp) and a single dose of rituximab (average dosage mg/m ). all patients who underwent kt achieved a isoagglutinin titer less than : with - sessions of pp/dfpp treatment before transplant. results: the patients were followed for to months with a mean follow-up of months. patient and graft survival rates were %. one non-adherent patient experienced antibody mediated rejection. figure ). in the rtr who had graft loss, there was no significant difference in graft survival time ( . , . years, dsa negative vs dsa positive), grade rejection ( . , . episodes per patient), grade rejection ( . , . episodes per patient) or c d staining ( %, % patients). one patient in each group had bk virus associated nephropathy. two patients had plasma cell infiltrates on biopsy and lost their grafts within months of dsa detection. results: fifty-one kidney recipients (male cases; female cases) were enrolled in this study. the median age was years, the youngest kidney recipient was years old with a body weight of . kg). there were recipients less than equal years, including one children with congenital renal dysplasia and one with congenital renal artery malformation. about . % kidney recipients came from guangdongprovince. about to pediatric patients accepted renal transplatation each year from to , but there were in , which showed a significant increase than in each previous sigle year.the policy that children had a kidney recipients priority may contribute to this increase. the kidney donors were cadaveric kidneys( . %) and living kidneys( . %), only one patient accepted auto-renal-transplatation. all kidney recipients were survival to present with the treatment of glucocorticoid and or immunosuppressants,such as csa, fk , mmf,ect. only two patients accepted retransplatation due to losing function of the renal grafts. conclusion: renal transplantation in children increased significantly in in our hospital, and it seemed an effective treatment to children with esrd. recent adult studies have shown that low levels of immunosuppression (is) are associated with dndsa. however, limited data is available on significance of dndsa and its management in paediatric population. to assess relationship between dndsa with renal function, histological findings, immunosuppression levels and graft outcome in paediatric renal transplant recipients (rtr). in our centre, at the time of the study, dsa were tested if deterioration in graft function was found necessitating renal biopsy. methods: retrospective review of all rtrs in a single tertiary nephrology centre tested for dndsa. data collected included dndsa, histological findings, egfr as marker of renal function, baseline immunosuppression, subsequent treatment and outcome. results: / patients had dsa tested; / had dndsa detected. median time for measured of dndsa was . years post-transplant (range . - . ).histology: / biopsies in dndsa+ve subgroup had antibody mediated rejection (abmr) of which were active abmr ( were c d positive) compared to / in dndsa-ve subgroup. the following treatments were used in the dndsa+ve group: increase in is+ pulsed methylprednisolone (mp) ( patients), increase in existing is ( ), rituximab ( ), pulsed mp ( ), sirolimus added+pulsed mp ( ) . in one patient no change was made. at last follow up, in / patients with dndsa an improvement in egfr was observed. on re-testing for dndsas, / patients tested negative, / had lower and / increased levels. / had not yet had repeat dndsa testing. conclusion: despite previous reports of dndsa conferring poor prognosis, in our cohort with allograft dysfunction and positive dndsa an improvement in renal function was observed in %. however, larger prospective studies are required to further evaluate these findings. abstract# p-sat anuria since birth: does it impact outcome of kidney transplant in infants? shefali vyas, maria isabel roberti pediatric nephrology, saint barnabas medical center, livingston, usa objective: scarcity of data exists for allograft outcomes and urological problems in children with long term de functionalized bladders. however, even less is known about the outcome of infants anuric since birth and whose bladders underwent "forced rehabilitation" after a successful renal transplant. methods: in this retrospective study we compared urological events and allograft outcome in infants with esrd mainly due to urological problems. they were grouped according to the history of pre-txp urine out put: group a with urine output prior to txp and group b anuric since birth (all had visible small bladders by ultra sonogram). results: there were no significant differences regarding birth history or ethnicity . group a had boys ( %) and group b had all girls; all but one child in group b received lrd txp. all received induction followed by triple therapy (tacrolimus, steroids and mmf). group a: / had v-u reflux and / were on pd prior to txp (mean time= mos). all patients in group b were started on pd in the neonatal period (mean = . days). pre txp native nephrectomies were done in patients ( in group a and in group b). group a had acute rejections and none in group b. conclusion: anuric young infants had higher rates of post txp utis and v-u reflux, a direct consequence of their inherent small bladders. however, the year graft survival, patient survival and gfr remained excellent in anuric infants (group b )compared to young infants transplanted with higher rates of v-u reflux and dysfunctional bladders pre txp. abstract# p-sat kidney transplantation in a child with bladder dysfunction who underwent prior bladder augmentation: a case report tepecik training and research hospital, pediatric nephrology, they were divided into groups; pts with esrd on dialysis (d), / with history of kidney transplant, and kidney transplant recipients with good graft function (t). all subjects were tested for anti-hla antibody month prior to and month and months after administration of the combination vaccine of influenza a/ h n . results: among the t group, no pt tested positive for either anti-hla class i or class ii antibodies before or after influenza a/ h n vaccine. in the d group, of the pts with a history of graft failure who were sensitized before immunization; showed no change in class i & ii, one patient had mild increase in class i after vaccination, and one patient had an increase in class i by %. [figure] conclusion: none of the t pts had clinical evidence of either cell mediated or humoral rejection after the influenza a/h n vaccine. in the d group, no pt had any statistically significant increase in anti-hla antibody following vaccination. our study suggests that influenza a/h n vaccination may be safe and tolerable in pediatric dialysis pts with or without a failed kidney allograft. the effect of dipping blood pressure status on structural and diastolic heart function in renal transplant recipients mitra basiratnia , gholamhossein ajami shiraz nephrology urology research center, shiraz university of medical sciences, shiraz, iran department of pediatric cardiology, shiraz university of medical sciences, shiraz, iran objectives: non dipping has been linked to cardiovascular disease in adults, however the impact of non-dipping on cardiovascular status of the adolescents with renal transplantation has not been well established. the aim of this study was to evaluate the influence of non dipping status on left ventricular mass index and diastolic function in subjects with renal transplantation. methods: sixty six stable renal transplant patients ( females, males), aged to years (mean . ± . years) were enrolled in this study. cardiac function assessed by tissue doppler echocardiography and blood pressure measurement performed using ambulatory method. dipping was defined as at least % bp decline during the night and was calculated as (mean daytime -mean night time/mean daytime)*% . left ventricular mass (lvm) was calculated by standard dimensional directed m-mode echocardiography according to the formula of devereux and was indexed to height in meters to the . power to allow the comparison between recipients of different sizes. left ventricular hypertrophy was defined as lvmi> . g/m . in patients younger than years and g/m . in patients > years. data analysis was performed by spss- . a p< . was considered statistically significant. results: non-dipping was identified in ( %) patients. five recipients were systolic non-dippers, diastolic non-dipper, and both systolic and diastolic non-dippers. left ventricular hypertrophy (lvh) was found in . % of the renal allograft recipients. lvh was present in % of the systolic nondippers and . % of the systolic dippers (p= . ) . forty five percent of the diastolic non dippers and . % of the diastolic dippers had lvh (p= . ) . there was no correlation between systolic and diastolic dipping status and lvh, respectively (p= . , p= . ). there were no significant differences in terms of diastolic function [measured by early diastolic inflow velocity (e), e/a ratio, and early diastolic mitral inflow velocity to earlydiastolic annular velocity (e/ea)] between dipper and non dippergroups(p= > . ). conclusion: non dipping is common among renal transplant recipients, but is not always related to diastolic dysfunction and lvh. prospective longitudinal studies are required to determine the impact of dipping status on diastolic and structural heart function in renal transplant recipients. parsa yousefi chaijan, parvin soltani, farshid haghverdi, masood fazelimoslehabadee nephrology, arak university of medical sciences, arak, iran objective: nephrolithiasis in renal grafts is a relatively common phenomenon which can induce organ damage; hence early diagnosis and management of predisposing factors can preclude subsequent complications. the aim of this analytic cross-sectional study is to determine the contributory factors to nephrolithiasis after renal transplantation. method: renal-transplanted patients ( - years old) were enrolled in the study, being divided into two groups of transplanted patients suffering from nephrolithiasis (within first years after surgery) and transplanted patients free from renal stone with the same age and gender and similar gfr. data were collected and arranged in excellmicrosoft program and the statistic analysis was carried by spss v . pvalue < . were considered statistically significant. result: the studied showed that male gender (p = . ), age group of - years (p= . ), hyper cholesterolemia (p= . ), hyper triglyceridemia (p= . ), rd year after surgery (p= . ), hyperuricosuria (p= . ) , hypocitraturia (p= . ) and anemia (p= . ) were significantly more common in patients with nephrolithiasis. conclusion: it is better to evaluate hyperuricosuria and hypocitraturia in kidney donors, moreover all patients had better undergo serial sonography for early screen and management of renal stone as well as treatment for hyperlipidemia and anemia. it also seems prudent to further assess the donors of transplanted patients suffering from renal stone and possbile relation between cni & nephrolithiasis ( regardinghyperuricusuria) objective: epstein-barr virus-associated smooth muscle tumor (ebv-smt) in immuno-compromised patients has recently been reported. but there were no evidence about the treatment of ebv-smt. we report a -year-old girl treated for multiple ebv-smt by using rituximab. methods: case report results: she was suffering from end stage renal disease due to congenital nephrotic syndrome induced by wt mutation. renal transplantation (tx) was performed at the age of years, and immunosuppressive therapy was performed her. soon after performing tx, she was infected cytomegalovirus(cmv), bkv and ebv. she was reduced in amount of immunosuppresive therapy, and she recovered from viremia of cmv and bkv. her ebv titer did not become negative, but we did not perform any medication because of no symptom. four years after tx, she was pointed out cm of cholecystic polyp in a protocol abdomen ultrasonic examination. we soon performed cholecystectomy and extirpation of swelling mesenteric lymph nodes. the pathological finding of cholecystic polyp was ebv encoded small rna (eber) positive smooth muscle tumor but there was no finding about post-transplant lymphoproliferative disorder in mesenteric lymph nodes. positron-emission tomography (pet) showed accumulation of cm mass around th of thoracic vertebra and ct scan showed three small masses in the lung and one in the liver. we diagnosed her suffering multiple infection of ebv-smt. immunosuppression therapy was reduced, but there was no change about size of her tumor. rituximab was administered for keep away from repetition of tumor after proving infection of ebv only in b cells by using flow cytometry. after medication of rituximab, the ebv dna counts were normalized. ultrasonic examination detected three small masses in liver and one lymph node around main artery. but her mass around th of thoracic vertebra was disappeared and whole body ct scan detected only one small residual mass in the lung. we report a case of an ebv-smt presenting multiple infections, which was treated with rituximab. rituximab may be an effective treatment for multiple ebv-smt but careful observation is also needed for the reappearence of ebv-smt. the usefulness of monitoring of epstein-barr viral load after renal transplantation in pediatric recipients with ebv seronegative objective: the purpose of this study are to establish a protocol for monitoring epstein-barr virus (ebv) infection for identification of pediatric renal transplant recipients with a high risk of developing posttransplantlymphoproliferative disorder (ptld) and to predict the development of ptld. methods: peripheral blood mononuclear cells (pbmcs) and plasma ebv loads were measured by nested pcr (n-pcr) and real-time pcr (r-pcr) every - months after grafting in pediatric recipients who were seronegative for ebv before grafting ( with ebv-associated symptoms, including with ptld (group a); with asymptomatic persistent high ebv loads in pbmcs of > , copies/ug dna for over months (group b); and with neither ebv-associated symptoms nor persistent high ebv loads in pbmcs (group c). ebv-ctls were also measured in patients without ebv-associated symptoms. results: the ebv genome detected by n-pcr was present in plasma in ( %), ( %), and ( %) in groups a, b and c (p< . for a vs. b and a vs. c). ebv loads detected by r-pcr in pbmcs were significantly higher in groups a (p< . ) and b (p< . ) compared to group c. ebv genomes in plasma were detected by n-and r-pcr in only the cases with ptld. one patient with lymphadenitis in group a and patient in group b had ebv-dna in plasma based on n-pcr, but the viral loads using r-pcr were < copies/ml. the ctls' percentage was significantly lower in group b when ebv loads first rose above copies/ugdna. conclusion: plasma ebv loads (over copies/ml) estimated by r-pcr and ctls' monitoring may be useful to distinguish ptld from other ebv-associated diseases or asymptomatic viremia, and to avoid ptld as patients with asymptomatic persistent high ebv loads had higher ebv loads and lower percentages of ctls. abstract# p-sat risk factors for post-transplant lymphoproliferative disorder (ptld) in children with kidney transplantation (ktx) -a single center survey since the introduction of tacrolimus (tac) since pre-transplant evaluation showed complete obstruction of ivc/ iliac vein below diaphragm, she had been managed with peritoneal dialysis for years until january when she received a living donor kidney allograft from her mother. the graft was transplanted in a left orthotopic position. venous drainage was to the left ascending lumber vein. in addition, a venous bypass was made using donor ovarian vein between graft vein and splenc vein after splenectomy. such double venous drainage was working very well after transplantation. there was no surgical complication and the serum creatinine (s-cr) during the hospital stay was . mg/dl. at second month after the transplantation, she developed an increase of s-cr with edema and hypertention. however, biopsies of kidney allograft performed at nd and th month after the transplantation revealed no evidence of acute rejection. hypertention was difficult to control even with a maximum dose of calcium blocker, and a temporary increase of the s-cr up to . mg/dl was noted when angiotensin ii receptor blocker was administrated. by the ultrasonography, the maximum arterial blood flow of the kidney allograft was high enough ( cm/s) to suggest renal arterial stenosis. moreover, severe renal arterial stenosis was clearly shown for about mm length from the anastomosed site of aorta by the contrasting ct.for the treatment of artery stenosis of the kidney allograft, percutaneous transluminal renal angioplasty (ptra) was performed at th month after the transplantation. the stenotic lesion was expanded using the special dilatation balloon from . mm through . mm in diameter. because intravascular ultrasonography showed no intimal thickening of the blood vessel, a vascular stent was not placed. after the ptra, s-cr was decreased to . mg/dl, and the blood pressure became controllable by antihypertensive agents. moreover, the angiography performed months after the ptra revealed no progression of arterial stenosis. the s-cr of this patient is now stable in . mg/dl. post-transplant encapsulating peritoneal sclerosis in children: a single center experience kei nishiyama tokyo women's mdical university, pediatric nephrology, tokyo, japan objective: a substantial proportion of encapsulating peritoneal sclerosis (eps) cases develop after renal transplantation (rt), an entity known as post-transplant eps. although risk factors for eps include prolonged pd, recurrent peritonitis, decreased ultrafiltration and prolonged administration of hypertonic glucose or icodextrin, the pathophysiology of post-transplant eps is largely unknown. however it has been postulated that the use of calcineurin inhibitors (cnis) after transplantation may promote eps, as these drugs are considered profibrotic. a recent scottish study showed that the contribution of post-transplant eps might be even as much as % of the total eps patients. by contrast pediatric cases are very rare. therefore we examined the incidence of post-transplant eps in pediatric renal transplant recipients. methods: in this study, we retrospectively investigated clinical records from consecutive pediatric renal transplant recipients in our center between to , who performed pd before transplantation. clinical parameters and pd-related risk factors of eps were collected at the time of rt. transplant-related variables were also collected. eps cases who met ispd diagnostic criteria including clinical feature and either radiologic and/or histopathological confirmation were examined. results: the median duration of pd was . yr (range . to . ). twelve patients ( . %) had at least one episode of peritonitis. ten patients ( . %) were administered hypertonic glucose and/or icodextrin. the median follow-up period after transplantation was . yr (range . to . ). all patients were administered cni, and patients discontinued corticosteroid during the follow-up period. although patients had ultrafiltration failure at the time of rt, there was no case who developed post-transplant eps. conclusion: the case of eps after rt was not seen in this study. possible explanation of this result might be associated with shorter durations of pd and small sample size. since post-transplant eps is rare but carries a high mortality, caution should be paid to developing post-transplant eps even in pediatric patients with a relatively long pre-transplant duration of pd. asli kantar, kaan gulleroglu, esra baskin, umut bayrakci, zafer ecevit, hande arslan, aydincan akdur, gokhan moray, mehmet haberal pediatric nephrology, baskent university, ankara, turkey objective: viral infections remain a significant cause of morbidity and mortality following renal transplantation. although cytomegalovirus is the most common opportunisticpathogenesis in transplant recipients, numerous other viruses may affect clinical outcome. viral infections are potentially severe complications of transplantation, as they not only induce specific diseases, but they also favor the development of allograft damage, opportunistic infections and acute rejection. we evaluated the major viral infections seen following kidney transplantation and allograft outcomes in our pediatric patients. methods: we evaluated retrospectively pediatric renal transplant recipients for the occurrence of viral infections and compared outcomes among these patients. patients were divided in to two groups those who developed an infection and those who did not. inthese groups, we recorded induction therapy used at transplantation, immunosuppressive therapy given at discharge, acute rejection rate, patient and graft survival rates. results: the mean age of the patients was . ± . years. viral infection was found in patients. cytomegalovirus infections were the leading causes; ebv and bk virus were following causes in our study. any significant correlation could not be shown between viral infections and immunosuppressive therapy. we did not observe any correlation between acute rejection and viral infections. lowest gfr at th month was shown in patients with bk virus infection. a significant correlation was shown between viral infection and graftloss (r: . p: . ). conclusion: viral infections are common after kidney transplantation. patients should be monitored more carefully for provide against damage in transplanted kidney. objective: anemia is a frequent condition in kidney transplant recipients and it has a negative long term impact on graft and patient outcomes. recently it has been shown that treatment with angiotensinconverting enzyme inhibitors (acei), angiotensin ii receptor blockers (arb) and mtor inhibitors could be the leading causes of anemia in renal transplant recipients.to study the association of hemoglobin (hb) and ferric parameters with gfr, immunosuppressive drugs, acei, arb and clinical features of kidney recipients. method: hospital records of (f/m: / ) kidney recipients were reviewed retrospectively. the mean age of the study group was . ± . years. the mean follow-up was . ± . months. results: thirty six ( %) patients were found to be anemic. mean hb levels of anemic and non anemic patients were . ± . mg/dl vs . ± . mg/dl respectively. ferritin and iron levels as well as transferrin saturation index, rdw and mcv did not differ among the groups. anemia was not found to be correlated with immunosuppressive or antihypertensive drugs including acei and arb. donor status did not also have any influence on anemia. mean gfr of patients at posttransplant months and year follow-up was found to be significantly lover than patients without anemia ( . ± . vs . ± . ml/min/ . m respectively). graft loss was also found to be significantly higher in anemic patients ( % vs %, p< . ). conclusion: in this study we examined the prevalence of anemia and its risk factors in kidney transplanted patients. its incidence is quite high in our patients. we found that anemia in kidney recipients is neither related to iron status nor medications like acei, arb or immunosuppressive drugs. the major determinant of hb level, especially during the first year of transplantation is the graft function. the most important conclusion of this study is the considerable controversial impact of anemia on graft survival. there was no significant effect on blood pressure ; patients ± modigraf® administration days in the converted group. in the whole series, mean creatinine level was . ± . mg/dl throughout the observational period, and no rejection episodes were detected. blood pressure was well controlled and no proteinuria was seen. the equivalent dose ratio between modigraf® and liquid tacrolimus was . . conclusion: modigraf® appears to be a safe and sustainable way to administer tacrolimus in kidney transplanted infants. in our experience required modigraf® dose was . times the oral liquid tacrolimus one, and therapeutic levels were attained in one week. objective: prescribing of medications in paediatric practice is problematic as many drugs remain unlicensed. this is especially true of immunosuppressive medications. however, there is now a licensed product for tacrolimus called modigraf® with data available on bioavailability. we undertook a single centre prospective study of conversion to modigraf®, an oral liquid available in granule formulation ( mg and . mg) that allows for dosing according to body weight. methods: all paediatric renal transplant recipients (rtr) under the care of a single centre were considered for conversion to modigraf® from their current tacrolimus regimen. inclusion criteria included all rtr under years of age who were on tacrolimus suspension. exclusion criteria included recipients of multi-organ grafts, patients with lactose intolerance and patient choice to continue with their current suspension. patients were then seen by the multi-disciplinary team. after equivalent dose conversion, patients were monitored with blood tests one week after conversion with subsequent doses adjusted accordingly. patients continue to be monitored with blood levels over a month period after conversion with renal allograft function, renal allograft loss and side-effect profiles recorded. results: forty-three ( % of ) rtr were considered for conversion to modigraf®. the families of four patients requested to stay on their current tacrolimus suspension, three patients were deemed unsuitable due to lactose intolerance and three patients were excluded due to low doses (incompatibility with the granule dosing). thirty-three patients were then converted to modigraf® and closely monitored. after blood level monitoring one week after conversion, % ( ) patients had their doses increased due to lower than anticipated -hour trough tacrolimus levels. there was stable renal allograft function without renal allograft loss after conversion. conclusion: conversion to modigraf® immunosuppression can be safely undertaken in paediatric rtr, although regular monitoring in the immediate period of conversion is required to provide accurate immunosuppression dosing. escort trial -effects of strict control of blood pressure in pediatric renal transplant recipients -baseline characteristics of patients from a randomized controlled trial tomas seeman, jiri dusek, nadezda simankova, karel vondrak, jakub zieg dpt. of pediatrics, university hospital motol, prague, czech republic objective: arterial hypertension is a known risk factor for impaired graft survival in patients after renal transplantation (rtx). strict control of blood pressure (bp < th percentile) delays progression of chronic kidney diseases in children (escape trial). it is not known whether strict bp control has renoprotective effect also in children after rtx. the aim of this randomized controlled trial was to investigate whether strict bp control can protect kidney graft in children after rtx. methods: all children from our pediatric renal transplantation center were screened for eligibility for the study (children - years at least year after rtx, no acute rejection in the last months, egfr> ml/min/ . m , hr mean bp > th percentile using ambulatory blood pressure monitoring abpm). altogether children fulfilled the inclusion criteria. they were randomized to intensified bp control group (intens, target hr map < th percentile, n= ) or standard bp control group (stand, target hr map - th percentile, n= ). all antihypertensive drugs are allowed to reach the target bp. the study period is years. the primary endpoint is the yearly change in egfr (schwartz formula, ml/min/ . m /year), the secondary endpoints are graft failure, change in proteinuria, left ventricular mass and safety of strict control of bp. results: the baseline characteristics of the patients are given in the allelic variants. tac dose (mg/kg/day) and tac exposure normalized for dose (tac co/d) (ng/ml/mg/kg/day) were analyzed with respect to cyp a genotype and for interaction with azoles and corticosteroids, for a period of one year post-transplant. over time, tac co/d was significantly lower in recipients with a cyp a * /* genotype compared to those being homozygous for the cyp a * allele ( . +/- . versus . +/- . ng/ml/mg/kg/day, p= . ). the dose requirement was significantly higher in children with a cyp a * /* genotype compared to those being cyp * /* ( . +/- . versus . +/- . mg/kg day, p= . ). the tac co/d was significantly higher for patients receiving azoles (n= ) than those not receiving azoles (n= ) ( . +/- . and . +/- . ng/ml/mg/kg/day, p= . ) and consequently the required tac dose was lower in patients receiving azoles overtime ( . +/- . versus . +/- . mg/kg/day, p < . ). in children receiving steroids without azoles the tac co/d was significantly different between the cyp a * /* and cyp a * /* genotypes, respectively ( . +/- . vs. . +/- . ng/ml/mg/kg/day, p= . ) but the tac co/d was not different for those receiving steroid versus those not receiving steroid with cyp a * /* genotype ( . +/- . and . +/- . ng/ml/mg/kg/day, p= . ). conclusion: in conclusion, the tac dose is influenced by the cyp a genotype and drugs such as azoles, while steroids may not impact tac dose. while therapeutic drug monitoring of tac remains necessary, integrated knowledge of patient genotype and comedication use provides the opportunity to refine tac dosing in children receiving kidney transplant. abstract# p-sat basiliximab induction therapy in pediatric renal transplantation, a double blind clinical trial hasan otukesh tehran university of medical science, associated professor, tehran, iran this is an open, single center, randomized study to compare induction therapy with basilixamb with no induction therapy in children with renal living transplantation. in this trial pediatric renal transplant recipients enrolled randomly to one group with basiliximab as induction therapy and another group without basiliximab induction therapy. both group received prednisolone, cyclosporine and cellcept. we assessed graft function at months after transplant and compared this item between these two groups. in the congress the data and results of this randomized trial will be presented. abstract# p-sat legalization of the organ donation and optimal utilization of young pediatric donor kidneys into pediatric recipients in china objective: china has started to establish a new national system for organ donation and transplantation since march by the ministry of health and the red cross society of china. the aim of this study was to describe our initial experience of pediatric renal transplantation using organ donations from pediatric patients no more than years old. methods: the procedure of organ donation includes: . judgment of brain death, or circulatory death, or brain death followed by circulatory death by doctors; . organ donation informed consent form signed by family (children's parents); . approval by the hospital ethics committee; .organ donation to the red cross society and allocation by the china organ transplant response system (cotrs). the red cross society has been commissioned by the ministry of health to run this system. clinical data of children who underwent renal transplantation using organ donations from pediatric patients no more than years between september and march were retrospectively analyzed. results: the age at transplantation for these patients was . years to years and the weight was kg to kg. among these cases, donors were used aged from days to years and all diagnosed with circulatory death. recipients received en bloc kidney transplantation and the other recipients received one single kidney according to the size of both recipient and donor. the duration of follow-up after the transplantation was month to months. patient survival rate was % and graft survival rate was / ( . %, one graft loss due to the hemorrhagic complication and the other one due to the thrombosis). at latest follow-up, the median serum creatinine level was umol/l and the median egfr was ml/(min· . m ). conclusion: organ transplantation legislation is necessary to ensure the rights and obligations of donors, recipients and medical institutions. we believe young pediatric donors can be expanded further to increase the number of pediatric renal transplants. this pediatric to pediatric combination on the one hand efficiently lower the discarding ratio of the kidneys from small donor, and give more chances to the younger recipient on the other. to assess the normalization of serum (oh)d level (> ng/ml) after standard treatment dosing among primary hypertension (ph) and chronic kidney disease (ckd) methods: we enrolled patients aged - yrs we collected retrospective data on age, sex,race, cause of kidney disease, egfr, ht, wt, bmi, bp z-scores, lipid panel, (oh) d level, pth, calcium, phosphorus, magnesium, medications, type and dosing of vitamin d supplements and follow up serum vitamin d level three months post treatment. results: mean age (yrs) was ( . ± . ). white( ) prevalence of vitamin d deficiency was ( %); % had level < ng/ml. mean pretreatment (oh) d (ng/ml) was ( . ± . ) after completion of standard treatment almost % patients had (oh) d level < ng/ml; ph( . ± . ) and ckd( . ± . ). none were in toxic range. conclusion: the standard treatment dose of vitamin d doesn abstract# p-sat mineral metabolism in european children with end-stage renal disease marjolein bonthuis the netherlands pediatrics, nephrology and dialysis unit results: hypocalcaemia was found in % of hd, % of pd, and % of transplanted patients, with a mean time on transplantation of . years. hyperphosphataemia was found in % of hd, % of pd, and % of transplanted patients. pth was outside target in % of hd, % of pd and % of transplanted patients. in dialysis patients, calcium and pth were inversely associated with age; % of adolescents were hyperphosphataemic resulting in a significantly higher risk compared to - year olds (or: . , %ci: . - . ). patients transplanted pre-emptively had a lower risk of hypocalcaemia compared fgf is modulated by calcium in children under chronic peritoneal dialysis azocar , maria l. ceballos , angelica m. rojo luis calvo mackenna children's hospital human intact fgf- levels (pg/ml, immutopics) were determined through a -site elisa kit. klotho levels were determined by a solid phase sandwich elisa kit (pg/ml). descriptive statistics, univariate and multivariate analysis were performed methods: we measured serum calcium, phosphorus, intact parathyroid hormone, alkaline phosphatase (alp), -hydroxy vitamin d ( d ), , -hydroxy vitamin d ( , d ), and fgf- from children (male:female = : , mean age . years) with ckd stage i-v predialysis in korea with . - year intervals since . results: hypocalcemia was observed in . %, . %, . %, . % and . % of patients with cdk i to v (the rest is the same as above) %, . %, . %, . % and . %. d level was below fgf- (ru/ml) was . , . , . , . and . . serum p had positive correlation with alp (p < . ), ipth (p = . ) and fgf- levels (p < . ) and was inversely correlated with urine phosphorus conclusion: the prevalence of hypocalcemia, hyperphosphatemia and hyperparathyroidism increased as ckd progressed. serum ipth and fgf- increased and , d level decreased in proportion to the progression of ckd malaysia national transplant resource centre, national transplant resource centre, kuala lumpur, malaysia objective: to analyse the cost-effectiveness of paediatric and adult living related renal transplantation (lrt) and deceased donor renal transplantation (drt) the time horizon was the lifetime of transplant recipient from transplant to death. data for survival analysis was obtained from national renal registry. statistical analysis was performed using stata se version . . the costs was discounted at % p.a. results: we reviewed medical records. there were children ( lrt, drt) and adults ( lrt, drt). the paediatric recipients mean age was . +/- . (lrt) and . +/- . years (drt), whereas the adult recipients mean age was . +/- . (lrt) and . ± . years (drt). the and -year patient survival rates for both paediatric lrt and drt were % and % respectively. the and -year patient survival rate for adult lrt was . % and % respectively, whereas adult drt was . % and % respectively. mean cost per paediatric transplant at first year was rm , (lrt) and , (crt), from second year onwards was at , per year (lrt) and , per year (drt) . the total lifetime cost was rm , (lrt) and , (drt) their serum creatinine, egfr, cholesterol, ldl, proteinuria, full blood counts and liver function were profiled to compare the pre-/post-conversion changes. common adverse effects, acute rejection, opportunistic infection and need of treatment for hypercholesterolaemia and proteinuria were investigated. results: we have eligible patients with m: f = : . the mean age at renal transplantation was sirolimus was started at a mean age of . +/- . , at a mean time period of +/- . years after renal transplantation, and used for a mean duration of we observed new onset hyperlipidaemia in patients ( %) and needed statin treatment. we found significant proteinuria (spot pr/cr > . mg/mg) in ( %) patients and needed acei treatment. there was no adverse effect on blood counts and liver function. there was no opportunistic infection observed after conversion to sirolimus in the study period. there was one acute cellular rejection (ia) one month after conversion to sirolimus and responded to pulse methylprednisolone. conclusion: converting from a cni based immunosuppressant protocol for paediatric renal transplantation patients to a sirolimus based one was effective and the benefit was shown up to months post-transplantation one patient received a desensitisation regime with rituximab and plasmaexhange pre-transplant and iv immunoglobulin post-operatively. surgical complications occurred in patients; lymphocoeles, ureteric leaks and renal vein thromboses. early post-operative medical complications included hypertension ( ), pulmonary oedema ( ), seizures ( ), reaction to basiliximab ( ), sepsis ( ), acute tubular necrosis ( ), delayed graft function ( ), acute rejection ( ) and diabetic ketoacidosis ( ). primary ebv infection occurred in patients - developed ptld. there were ( %) graft failures; renal vein thrombosis ( ), acute humoral rejection ( ), acute tubulointerstitial nephritis and tacrolimus toxicity ( ), de-novo acute glomerulonephritis ( ), chronic rejection ( ) and non-compliance ( ). graft survival rates were % at one year, % at years, % at years and % at years. patient survival was % at years. conclusion: our outcomes compare well with international figures a desensitisation program for paediatric renal transplant patients in nsw one child received atg in addition. results: complications/ patient outcomes: : yo boy, donation from mother. dsa antibodies mfi . no complications. no infections. good renal function, creatinine at yrs. : yo boy, previous transplant from biological father. donation from foster father. dsa antibodies mfi . post operative complication of pseudomonas pneumonia/bronchiectasis, cmv, acute cellular rejection x . good renal function creatinine at yr. : yo boy, donation from father. dsa antibodies mfi . early e-coli urine infection. no other complications, creatinine at yr. : yo girl, recipient of liver transplants. maternal donor with positive b cell cxm and dsa mfi . no complications. good renal function four of them had subsequently increasing needs in bicarbonate and/or sodium supplementation, and f was reintroduced in of them. conclusion: f is effective in most cases of severe tubulopathy after rtx. however, side-effects can occur. further prospective studies are needed to validate this indication methods: eighty-one (f/m: / )pediatrictransplant patients were included to the study.demographic characteristics and laboratory parameters were recorded.risk factors for hyperuricemia and the effects of plasma uric acid levels at rd and t h months, st and th years on allograft outcomes were evaluated. results: mean age was . ± . years.mean follow-up time after transplant was . ± . years. hyperuricemia was detected in . % of patients. a significant negative correlation was found between th month uric acid leveland th year of gfr value (r = - . , p = . and r = - . , p = . ). a significant positive correlation between th and th months uric acid levels and th year plasma creatinine level was demonstrated conclusion: uric acid levels may have predictive value in the long term assessment of renal function.posttransplanthyperuricemia can be used as a long term prognostic marker of poor renal outcome.patients with hyperuricemia should be monitored closely for renal functions abstract# p-sat tuberculosis in paediatric renal transplant patients -single centre experience methods: retrospective descriptive folder review of tb in paediatric renal transplantation at red cross children's hospital, university of cape town from - . results: paediatric renal transplant with tb identified. male : female . ages . - . yrs(mean . ; median . ). all patients screened for tb prior to transplant polycystic kidney disease, dysplasia, chronic glomerular nephritis, unknown cause, systemic lupus erythematosis and all patients were on steroids and had recent intensification of immunosuppression. tb treatment included conventional drugs in all but case. levels of calcineurin inhibitors were affected in / patients and required increased dosing(up to times baseline) according to levels in all. rejection was seen in patients(all biopsy proven). successful treatment of tb in all patients with retention of graft. graft and patient survival % post treatment. conclusion: tb is a significant problem in paediatric renal transplants in developing countries. our series shows that with careful investigation and diagnosis of tb as well as careful monitoring of immunosuppressant levels objective: to evaluate the reliability, validity and feasibility of the persian version of the pediatric quality of life inventory (pedsql tm . tm . ) generic core scales in iranian healthy students ages - and chronically ill children ages - . methods: we followed the translation methodology proposed by developer to validate persian version of pedsql tm . tm . generic core scales for children. six hundred and sixty children and adolescents and their parents were enrolled. sample of healthy students were chosen by random cluster method between regions of isfahan education offices and chronically ill children were recruited from st. alzahra hospital private clinics. the questionnaires were fulfilled by the participants. results: the persian version of pedsql tm . tm . generic core scales discriminated between healthy and chronically ill children (healthy students mean score was . better than chronically ill children, p< . ). cronbachs alpha internal consistency values exceeded . for children self reports and proxy reports of children - years old and - years old. reliability of proxy reports for - years old was much lower than . . although, proxy reports for chronically ill children - years old was more than . , these reports for healthy children with same age group was slightly lower than . . constructive, criterion face and content validity were acceptable. in addition, the persian version of pedsql tm . tm . generic core scales was feasible and easy to complete. conclusion: results showed that persian version of pedsql tm . tm . generic core scales is valid and acceptable for pediatric health researches. it is necessary to alternate scoring for - years old objective: bisphosphonates are widely used in the management of children with steroid induced osteoporosis (sio). with the increasing use of bisphosphonates, there have been reports of abnormal radiological findings in the growing skeleton. therefore, their use in pediatric patients remains controversial. the present study was conducted to evaluate the long term follow-up results of radiographic features especially metaphyseal sclerotic lines, associated with pamidronate therapy in pediatric patients with nephropathy. methods: twenty two children with nephropathy receiving oral calcium and pamidronate (mean duration: . months, dose: mg daily) were evaluated restrospectively. all patients had soi because of chronic glucocorticoid therapy for the treatment of nephropathy. biochemical tests, long bone radiography and bone mineral density (bmd) were performed before the treatment of pamidronate and followed up several years later. the physeal growth rates were estimated by measuring the distance that the sclerotic lines moved on the radiographs during the corresponding time intervals. results: the mean follow-up period was . years. in all patients, the well-defined sclerotic lines at the metaphyseal ends were observed and progressively moved from physeal plate to diaphysis on the radiographs of long bones. the mean moving rates of the sclerotic lines was . mm per year and in twelve patients, the lines disappeared. and the mean growth rate of height was . cm per year. conclusion: our long-term follow-up results suggest that the metaphyseal sclerotic lines associated with pamidronate treatment tend to disappear without affecting the skeletal growth. bisphosphonate treatment for soi in pediatric patients with nephropathy seems to be safe although further studies for larger number of patients are needed abstract# p-sat clinical effectiveness and safety of the high dose active vitamin d therapy on severe hyperparathyroidism in children with esrd eun gu kang, su-yon kim, joo hoon lee, young seo park department of pediatrics, asan medical center children's hospital, seoul, korea objective: a potent inhibiting effect of active vitamin d on parathyroid hormone is well known, but there is uncertainty on the dose to be used in hyperparathyroidism. the aim of this study is to assess the effectiveness and safety of high dose active vitamin d treatment on severe hyperparathyroidism in children with end stage renal disease (esrd). methods: fifty-four patients underwent dialysis for more than year between may and feb in asan medical center. among them, patients who were administered high dose of active vitamin d (dose of alfacalcidol mcg/day to mcg/day) with severe hyperparathyroidism(intact parathyroid hormone (ipth) > pg/ml) were selected. changes of ipth, plasma albumin-corrected calcium, phosphorus and , (oh) vitamin d were analysed. results: fourteen patients ( boys and girls) with median age of . years ( - years) were included. the mean duration of dialysis was ± months and the median duration of the high dose alfacalcidol therapy was months( - months). the ipth level significantly decreased in patients ( %) from . ± . to . ± during the high dose alfacalcidol therapy (p< . ). serum phosphorus ( . ± . mg/dl vs. . ± . mg/dl, p= . ) and calciumphosphorus product ( . ± . mg /dl vs. . ± . mg /dl , p= . ) were not significantly changed and , (oh) vitamin d was low or normal after therapy. plasma albumin-corrected calcium significantly increased ( . ± . mg/dl vs. . ± . mg/dl, p= . ). four patients ( %) had persistent severe hyperparathyroidism despite treatment with high dose of alfacalcidol, which was controlled after kidney transplantation ( patients) or after parathyroidectomy ( patients).conclusion: high dose active vitamin d therapy controlled severe hyperparathyroidism in the most children with esrd without significant adverse events. clinical features and treatment of ckd-mbd in children with ckd i-v predialysis objective: vitamin d is known to have multiple effects on the cardiovascular system, renal function, hyperparathyroidism and growth, its deficiency is common in adults and children with chronic renal disease (ckd), but data in kidney transplant children are scarce. the aim of the present study was to investigate the vitamin d status in groups of children and adolescents with ckd and to establish the association between (oh) vitamin d ( ohd) levels, age, hyperparathyroidism, short stature, and renal function. methods: we recruited children: renal transplant patients with a functioning graft for at least months (mean age yr, mean graft abstract# p-sat the expression and significance of il- 、ip- and il- in serum and synovial fluid with juvenile idiopathic arthritis. objective: to detect the disparity of three cytokines about interleukin- (il- ),interferon-inducible protein (ip- ) and in peripheral blood(pb) and synovial fluid(sf) of patients with juvenile idiopathic arthritis (jia). method: serum concentrations of the three cytokines were measured in patients with systemic-onset jia(sjia), polyarticular jia(pjia) and healthy controls using enzyme-linked immunoabsorbent assays (elisa). patients being no marked arthritis symptom or only temporary arthralgia enrolled in probable sjia group. sf from patients with sjia, pjia were examined for cytokine levels. objective: the aim of the present study is to evaluate serum concentrations of ghrelin and leptin, and their associations with fat mass and insulin homeostasis in children undergoing chronic dialysis. methods: the study population consisted of patients on maintenance dialysis ( pd and hd) aged between - years and age-and sex-matched healthy children. serum levels of total ghrelin and leptin were measured in all patients and controls. fasting serum glucose and insulin levels were also measured in the patients; insulin resistance was estimated by the homeostasis model assessment of insulin resistance (homa-ir). nutritional status was assessed by measuring body mass index (bmi), triceps skinfold thickness (tsf) and multi-frequency bioimpedance analysis (bia). body fat mass was estimated by the bia method. results: the mean total ghrelin level was significantly higher in the patients than the controls ( ± vs. ± pg/ml, p< . ). higher total ghrelin levels in dialysis patients were significantly associated with younger age (p= . ), lower bmi-sds (p= . ) and lower bia-based fat mass-z score (p= . ). the mean leptin level was also higher in dialysis patients compared to the controls but the difference was not statistically significant ( . ± . vs. . ± . ng/ml). however, the ratio of leptin levels to fat mass was significantly higher in dialysis patients than the controls ( . ± . vs. . ± . , p= . ). serum levels of leptin in dialysis patients positively correlated with bmi-sds, tsf-z score and bia-based fat mass-z score (p< . for all). serum leptin levels also had a positive correlation with serum insulin (p= . ) and homa-ir (p< . ), and an inverse correlation with total ghrelin level (p= . ). conclusion: children on maintenance dialysis have high levels of total ghrelin that are closely related to decreased fat mass and poor nutritional status. in contrast to ghrelin, leptin is associated with increased fat mass and insulin resistance; however, these patients have inappropriately elevated leptin levels in relation to body fat mass that may be related to wasting. objective: this study investigated the influence of social support and other psychosocial factors upon mortality, adherence to medical care recommendations, and physical qol amongst hemodialysis patients. method: hd patients were examined using the qol questionnaire to determine self-reported inclinations. logistics regression through weighted k was used to analyze data. results: . % of patients reported health had interfered with their social activities demonstrating a strong associated with risk towards all-cause (sp= . ) and cause-specific mortality including cardiac diseases (sp= . ). these patients had a greater risk of withdrawing (sp= . ) from treatment, non-adherence to phosphorus (sp= . ) greater than . mg/dl and increased risk towards an albumin of less than . g/dl (sp= . ). patients reporting dissatisfied with family support ( . %) were at highest risk to non-adherence to intra-dialytic weight gain (sp= . ), shortening the dialysis session (sp= . ) and increased risk of potassium level greater than meq/l (sp= . ). however, patients reporting dissatisfied with staff support ( . %) revealed a higher risk of decreased physical qol (sp= . ). conclusion: this study demonstrated that physical qol was not only affected by medications and other laboratory work-ups but also with additional psychosocial support. the study led to the development of programs empowering patients and families to participate in their treatment plans. the program includes various counselling approaches directed to patient, families, and health team. objective: the aim of the study was to analyze health-related quality of live (hrqol) in children with chronic kidney disease (ckd) dependent on the ckd stage, treatment modality and selected social life elements in families of the patients. furthermore, potential differences between self-and parent/proxy reports and the factors influencing them were assessed. methods: ckd children (on hemodialysis-hd, peritoneal dialysis-pd and conservative treatment-ct) and their parentproxies were enrolled into a cross-sectional national study. a semistructured interview form was used to determine the demographic and social characteristics of the participants. we used the pediatric quality of life inventory (pedsql) . generic core scales to assess the hrqol in children. results: hrqol scores for all ckd groups were significantly lower in all domains compared with population norms, the lowest one being in the hd group. in ct children, hrqol did not depend on the ckd stage. children with ckd reported problems with education and emotional functioning. both parents assessed the hrqol of their children differently depending on their involvement in the care. there are differences between the hrqol scores of the children and their parents. conclusion: the hrqol in children with ckd is lower than in healthy children. this is already observed in the early stages of the disease. the disease itself influences the child's mental state. children on hd require special support on account of the lowest demonstrated overall hrqol. children's lower rating of the quality of life observed by their parents may render the patients unmotivated and adversely affect their adjustment to life in later years. it may also create conflicts between the parents and the children. objective: chronic medical illness is a significant risk factor for the development of psychiatric disorders. the aims of the study were: to investigate the level of anxiety in children with chronic kidney disease (ckd) and to identify factors associated with the presence of that emotional problem. methods: ckd children on hemodialysis (hd, n= ), peritoneal dialysis (pd, n= ,) and on conservative treatment (ct, n= ), and healthy subjects (n= ) were enrolled in the study. we used state-trait anxiety inventory (stai) for adolescents and stai-c for children. socio-demographic and physical factors were assessed. results: there was a significantly higher level of anxiety-state among hd children ( - years) compared with other groups of participants of the same age. the level of anxiety among adolescents ( - years), both anxiety-state and anxiety-trait, was significantly higher in the hd group compared with other groups, which did not differ among themselves. in the hd adolescents, there was a correlation between the anxiety-state and the duration of the disease as well as with the number of hospitalizations. pd adolescents in the mainstream education had higher levels of anxietystate and anxiety-trait compared with home schooled patients. conclusion: even though children and adolescents with ckd are at risk of developing a variety of emotional disorders, the level of anxiety among the researched group, with the exception of hd patients, was not significantly different than the level of anxiety among healthy subjects. adolescents on hd who present a high level of anxiety should undergo long-term psychological treatment. ipek akil objective: compare medication adherence and kidney graft loss rate before and after transition in a single-center cohort of pediatric patients. methods: records of the patients transplanted in our center between and were screened and patients who remained in the program by their th birthday were included in the analysis. adherence and graft function were assessed for the period of years prior and years after transition. undetectable and/or sub-therapeutic levels of calcineurin inhibitors and their level variability were used as measures of adherence. graft survival analysis was performed for the period of years before and years after transition. results: out of screened patients, were eligible and of them were transitioned (tg -transitioned group). the remaining patients were used as a comparison group (cg), of them did not reach the age of transition by the time of the analysis. the median age at transplantation was . [ . - . ] years in the tg and . [ . - . ] years in the cg, median age at transition was . [ . - . ] years. overall, there was no significant difference in adherence within tg before and after transition (p= . for low drug levels and p= . for drug levels variability); however, patients with lower pre-transition adherence (tertile i) showed improvement of their adherence following transition when compared with those with high pre-transition adherence (tertile iii), p= . . there were graft losses per . patient-years in tg vs losses per . person-years in cg (p= . ). the peak graft loss in all pediatric transplant recipients in our center (n= losses) occurred years (sd . years) prior to the transition. conclusion: at our institution, transition was not associated with worsening adherence or graft loss. this may be in part do to the fact that the transition occurred at a later age than in other institutions. a report on -years experience in the use of mtor-inhibitor (sirolimus) in paediatric renal transplantation patients with calcineurin inhibitor (cni) toxicity the management of children with end-stage renal disease (esrd) deu to congenital urological abnormalities is more problematic and difficult than in patients with esrd due to other causes. kidney transplantation in neurogenic bladder patients with small capacity and defunctionionalized urinary bladders is a challenging issue in the field of pediatric transplantation. in these patients with severe bladder dysfunction, augmentation cystoplasty can protect the transplanted kidney by reducing intravesical pressure and creating an appropriate capacity. -year-old boy who presented urinary tract infection with fever at year-old and while his investigation, stage chronic kidney disease secondary to bilateral grade reflux disease was found (blood urea: mg/dl, creatinin: . mg/dl, creatinin clerance: ml/min/ . m ). his mixiocystoureterographic and urodynamic study were showed bladder wall irregularity and trabeculation; decreased bladder capacity and compliance, respectively. at -month of followup he was putted into dialysis programme about years. thereafter, normal bladder capacity was achieved after bladder augmentation implementation. he was achieved renal transplantation from his mother, after -month of augmentation operation. now, he still got uneventfull follow-up period about months. consequently, bladder augmentation application with timely and rationally could be a chance to kidney transplantation in children with bladder dysfunction. the effect of anti-hla antibodies on renal graft functions esra baskin , asli kantar umut bayrakci , kaan gulleroglu , mahir kirnap , , feza karakayali , , aysegul haberal , , gokhan moray , , mehmet haberal , pediatric nephrology, baskent university, ankara, turkey general surgery, baskent university, ankara, turkey immunology, baskent university, ankara, turkeyobjective: the identification of suitable donor kidneys for transplant candidates with high levels of circulating antibodies against human leukocyte antigen (hla) is a major challenge and results in adverse graft outcome. methods: seventy four kidney transplanted children without any shown hla antibody in the pre-transplant period were enrolled in the study. their anti hla antibody status was checked by luminex during post transplant period and its relation with the graft function and prognosis of the patients is studied. results: mean age of the patients was . ± . years. mean follow-up time was . ± . years. pre-transplant cytotoxicity tests and pra was negative in all patients. nine ( . %) patients were found to have anti hla antibodies after kidney transplantation. mean time for the detection of antibodies was found as ± . months. patients with anti hla antibodies were similar with patients without antibodies in the terms of age, sex, hla mismatch, transfusions and immunosuppressive drugs as well as the presence of viral infections. mean serum creatinine level was found to be higher in patients with anti hla antibodies. the antibody mediated rejection rate was found to be . % ( / ) in patients without anti hla antibodies while it was . % ( / ) and remained dialysis dependent. all were dialysis dependent by months post diagnosis. time from anca gn diagnosis to kidney transplant (mean±sd) was ± months (range - months). all patients received induction therapy and maintenance immunosuppression with prednisone, mycophenolate mofetil, and tacrolimus. median duration of follow up post transplantation was . years (range . - . ). egfr at last follow up was . ± . ml/min/ . m (range . - . ). patient lost her transplant to biopsy-proven, severe acute cellular rejection due to complete non-adherence to medications after months of stable transplant function. no patient had recurrence of vasculitis. conclusion: short-term patient and allograft survival in paediatric patients with eskd secondary to anca gn is excellent despite aggressive disease, with no recurrence of vasculitis post transplant.abstract# p-sat en-bloc kidneys from infant donors less than kg transplantation into pediatric recipients at school age objective: given the shortage of donor kidneys in china, the use of grafts from deceased infant donors (weight < kg) is a potential approach to expand the donor pool. in this study, we reviewed the results of the first cohort of en bloc kidney transplantation of infant donors to pediatric recipients at school age in our center.methods: from february to march , infant en bloc kidney transplants in pediatric recipients were performed in our center. en bloc kidneys from infant donors (maastricht category iii) who died of severe congenital disease were recovered and donated to the red cross society of tianjin and allocated to our center by china organ transplant response system (corts). donor age ranged from to days with weight ranging from . to . kg. recipients included females and males with age ranging from to yr. the en bloc graft was implanted extraperitoneally in the right iliac fossa. the distal end of the donor aorta was anastomosed end-to-end to the internal iliac artery, while the donor vena cava was anastomosed to the external iliac vein. the donor ureters were implanted separately onto the bladder with double-j stents placement. after the operation, the recipients received basiliximab as an induction therapy. maintenance immunosuppression consisted of tacrolimus and myfortic. prophylactic anticoagulation with heparin was used for the first week after transplantation. results: patient survival was %. complications included delayed graft function in patient (managed by pd for one week), urine leak in , and anticoagulation-related hemorrhage in . due to discontinued anticoagulation, one graft was lost early from vascular thrombosis. of the remaining recipients, all had immediate and excellent long-term function with average creatinine of . ± . mg/dl at months follow-up (range - months). conclusion: this is the first report of en bloc kidney transplantation from infant donors into pediatric recipients in china. many improvements by our transplant teams had improved the survival of patients and grafts. based on our experience, albeit very limited, we concluded that favorable outcomes can be obtained from en bloc transplantation from infant donors. objective: to describe the rates and outcomes of renal transplantation in children with intellectual disability (id). methods: we performed a retrospective analysis of all children receiving a first kidney alone transplant in the united network for organ sharing (unos) dataset from january , to october , . recipients with definite, probable, and without id were compared using chi-square and fisher's exact tests. kaplan meier curves were constructed for patient and graft survival. results: over the study period, children with definite ( ) or probable ( ) intellectual disability underwent first renal transplant accounting for % of all first pediatric renal transplants (total n= ). children with definite or probable id did not significantly differ from other recipients on the basis of gender or ethnicity but tended to be younger. children with definite id had higher rates of structural kidney disease and lower rates of glomerulonephritis. children with id were not significantly different than children without id with respect to rate of preemptive transplant, donor source, or number of episodes of acute rejection. graft and patient survival were similar between children with definite or probable id and without id. in cox regression, intellectual disability was not significantly associated with patient or graft survival. conclusion: in this first large-scale study, % of all first pediatric renal transplants are performed in children identified as having intellectual disability. early outcomes after transplant appear to be equivalent between children with and without id. further research is needed on long-term outcomes and quality of life effects of transplant in this population. mariana guerra duarte rosa de lima, ana cristina simoes e silva, nadine marcia de faria, eleonora moreira lima pediatrics, universidade federal de minas gerais, belo horizonte, brazilobjective: the aim of this study was to evaluate the clinical course of children and adolescents undergoing renal transplantation at federal university of minas gerais between and and to identify possible factors that could interfere with graft survival. methods: a retrospective observational cohort study through analysis of medical records of patients below years submitted to renal transplant were performed. data were analyzed in spss, version . . the results were expressed by descriptive variables and survival analysis was performed using the kaplan-meier method. comparisons between subgroups were made using the log-rank test. p level was set at below %. results: we analyzed patients who underwent transplants. the mean age was . ± . years. the main causes of chronic kidney disease were cakut ( . %) and glomerular diseases ( . %). most patients were submitted to dialysis before transplantation ( . %) with a mean duration of . ± . months. deceased donor was used in . % and the average cold ischemia time was . ± . hours. dialysis after renal transplantation was performed in . % of cases. the median survival of patients , and years was . %, . % and . %. there were four deaths in this population, two after graft loss. twelve patients lost their grafts ( . %). the median survival of the graft was . years and , and years survival was . %, . % and . %, respectively. no statistical difference was detected in graft survival between the deceased versus. living donor recipients, the different age groups, the occurrence of hypertension or not, the preemptive transplantation vs. preceded by dialysis (p= . ) and those with more than three versus less than three hla mismatches. a significant reduction in graft survival was associated with cold ischemia time associated with h, need for dialysis after transplantation, early acute or late rejection and creatinine greater than mg per dl after the first year os transplantation. conclusion: in our center, graft survival was similar to that described in the literature. however, further studies are needed to address the variables that negatively impacted the results of transplantation. objective: the aim of this study is to assess whether there is an increase in anti-hla antibodies after the influenza a/h n vaccine given to pediatric pts with esrd on dialysis (d) and with kidney transplant (t). methods: pediatric pts were enrolled. mean age was . years old, % female, % male, % african american, % hispanic.objective: ptld is the most common malignancy and important complication of pediatric solid organ transplantation. the rates of pltd have been increasing through s in ktx recipients. we conducted a survey of ptld in children who received ktx since the introduction of tac. methods: from , ktx was performed in recipients at our center. among them, we analyzed data from children who had undergone ktx since the introduction of tac and retrospectively studied incidence of ptld and risk factors, including immunosuppression protocol and pre-ktx ebv serology. results: we retrieved the data of pediatric recipients since ( boys, median age at ktx . years, living ktx , pre-emptive ktx , ebv-seronegative ). among them, cases ( ebvrelated, non-ebv) of ptld were diagnosed in recipients ( . %), and all cases were ebv-seronegative at ktx. the median duration from ktx to the onset of ptld was months (range: - months). the most common presenting symptom of ptld was abdominal complaints in cases, followed by fever in , superficial lymphadenopathy in and nasal congestion in . immunosuppressants were reduced in all cases; the subsequent treatment consisted of antiviral agents + ivig ( / ), anti-cd monoclonal antibody ( / ), and anti-cd monoclonal antibody + chemotherapy ( / ). only one recipient died due to ptld. assessing the correlation between ptld and immunosuppressants in ebv-seronegative recipients (median age at ktx . years, cya , tac , mzr , mmf , il- receptor antibody ), a significantly higher incidence of ptld was associated with tac ( / ) than cya ( / ) [or . , p= . ] in multiple logistic regression analysis. we compared the incidence of ptld, median age at ktx, and rate of ebv-seronegativity in eras (a: - , b: - , c: - ) of the study period and found %/ . yrs/ % in a, %/ . yrs/ % in b, and %/ . yrs/ % in c. thus the incidence of ptld increased with the increase in ebv-seronegative recipients. conclusion: in our study, maintenance treatment with tac (compared with cya) is associated with a higher risk for developing ptld. attention should be paid to the increase in the ebv-seronegative recipients.abstract# p-sat acute graft dysfunction and encephalitis post renal transplant: the role of epstein-barr virus objective: epstein-barr virus (ebv) has been described as a rare cause of acute kidney injury and encephalitis in children. methods: we report a case of a year old renal transplant recipient who developed acute graft dysfunction and a significant neurological insult with evidence of primary ebv infection. results: the patient had been diagnosed with posterior urethral valves prenatally and received a live related renal transplant aged years. seven months post-transplant he presented fluid overloaded, oliguric, with significant uraemia and hyponatraemia. there was a history of lower urine output and sore throat days before admission with evidence of anaemia with red blood cell fragments, thrombocytopenia, mild monocytosis, raised ldh, alt and splenomegaly on presentation. haemodialysis was commenced. primary ebv infection was subsequently detected by serology and pcr.renal biopsy showed a picture of acute glomerular thrombotic microangiopathy(figure above) and acute tubular injury secondary to haemoglobinuria.scanty eber+ lymphocytes containing ebvencoded small nuclear rna were also present. within days of presentation patient deteriorated neurologically developing a reduced conscious level, dysarthria, decreased motor power peripherally and an inability to upward gaze. an mri brain demonstrated increased t signal and mild diffusion restriction in in the caudate nuclei, putamina and ventro-lateral thalami. this picture has been previously described in ebv encephalitis. there was a gradual neurological improvement and by day of admission, and doses of i.v. methylprednisolone, the patient had a full neurological recovery. the number of ebv copies has subsequently decreased on lower dose of immunosuppression. by week after presentation he was no longer dialysis dependent with creatinine -fold higher than the previous baseline. conclusion: this is the first report of acute graft dysfunction and encephalitis due to primary ebv infection in renal transplant recipient.abstract# p-sat indoleamine , -dioxygenase (ido) as a new immunological marker in kidney elisa loiacono , barbara votta , alessandro amore , licia peruzzi , maria paola puccinelli , roberta camilla , luca vergano , giuliana guido , maria elena donadi , rosanna coppo nephrology, cittàdella salute e dellascienza. regina margherita children's hospital, turin, italy nephrology, cittàdella salute e dellascienza, turin, italy nephrology, sapienza university of rome, rome, italyobjective: the enzyme indoleamine , dioxygenase (ido), induced by interferon-gamma (ifn-gamma) and toll-like receptors (tlrs) ligands in dendritic cells, degrades the essential aminoacid tryptophan (trp) to kinurenine (kyn). its activity is estimated by the ratio of kyn to trp concentration (kyn/trp).t-cell activation and proliferation are affected by trp deprivation and accumulation of kyn. therefore, activating ido during immune responses counter balances mechanism of negative feedback loop of ifn-gamma and acts as a tool to downregulate overwhelming immune activation. ido activation has been reported to be increased in acute rejection and downregulated in vitro by the immunesuppressants adopted for organ transplantation. objective: to determine the prevalence of mycophenolic acid (myfortic) use as part of the immunosuppressant regime in our current paediatric renal transplant recipients in a single tertiary paediatric nephrology centre and examine the demography of these cases. method: case note and pharmacy record review of all paediatric renal transplant recipients' history, immunosuppressant medication and current renal allograft function in january . indication for medication switch from mycophenolatemofetil to enteric-coated mycophenolic acid tablets (myfortic) was noted. data presented as median (range). results: ( male) out of a total of patients with renal transplants are currently receiving myfortic in our centre. age and time from transplant was . ( . - . ) years and . ( . - . ) years. the most common cause of end stage renal disease requiring transplantation in this subgroup was posterior urethral valves in / cases. two of these recipients had abo incompatible living related transplants. current egfr was . ( . - . ) ml/min/ . m . / patients receiving myfortic were also receiving prednisolone and tacrolimus as part of their immunosuppression regime. one patient was on tacrolimus and myforctic only (history of idiopathic intracranial hypertension). dosage of myfortic varied based on patient size from mg twice daily to mg twice daily. the indication for carrying out a medication switch from mycophenolatemofetil to myfortic was related to gastrointestinal symptoms in all cases; specifically diarrhoea in cases, abdominal pain in cases and both symptoms in cases. these symptoms improved on myfortic with renal allograft function remaining stable, however in view of neutropenia in one patient her myfortic is currently suspended and under review. we have found that enteric-coated mycophenolic acid (myfortic) was a well-tolerated alternative in paediatric renal allograft recipients who developed gastrointestinal symptoms whilst receiving mycophenolatemofetil. its usage should be considered in such patients who are able to take tablet preparations. ferretti alfonso, ilaria luongo, bruno minale, gabriele malgieri, carmine pecoraro nephrology and urology, santobono children' hospital, naples, italyobjective: uti represent one of the main complications after kt and have an important role in graft funcion impairment. this retrospective report is aimed to evaluate the incidence of uti in a group of patients attending our hospital for post transplant usual medical controls. methods and results: we incuded in our study children who underwent kt between and : m and f, mean age . +/- . . four children received a graft from a living related donor and from a deceased donor. first morning sterile urine sample to the microbiology laboratory was obtained when attending the hospital for its usual medical control or immunesuppressive drug detection levels. results: in patients ( . %) esrd was secondary to cakut. thirty-six patients ( %) presented at least one episode of uti occurred in the first months after kt, mainly in females ( . : ) . uti developed in the first period were caused mainly by gram negative bacteria ( %). e. coli was the main agent ( . %), the other uropathogens involved were: proteus ( %), enterobacter cloacae ( %), pseudomonas aeruginosa ( %), candida albicans ( . %) and klebsiella ( . %). later infections were caused mainly by candida, klebsiella, proteusansdenterobacterfaecalis. one patient at the th month post-transplantation manifested uti caused by corinebacterium urealyticum associated with concretions of baldder mucosae. eight patients ( m and f) experienced the graft loss: patients were affected by cakut and had febrile uti posttx. one patient left the second graft by a an acute deterioration of renal function during an uti by bkv. conclusion: uti in kidney transplanted children represent a main complaint as demonstrated by the high incidence ( %) in total population mainly in females. a significant role is played by primary uropathy and immunosuppression as demonstrated by the high frequency also in non uropathic patients. the role of uti in longterm outcome of kt remains controversial. factors associated with elevated pulse wave velocity in children after renal transplantation objective: even after successful transplantation children with underlying chronic kidney disease (ckd) still carry a high cardiovascular risk. this is also documented by cardiovascular death being the second leading cause of death after transplantation in this patient cohort.methods: in a cross-sectional approach renal transplant recipients at three german transplant centres were enrolled. we measured pulse wave velocity (pwv), a strong predictor for cardiovascular events, as our primary end point. in all participants we assessed classical (e.g. blood pressure, cholesterol) and non-classical (e.g. crp, pth) cardiovascular risk parameters. results: patients were ± years of age and had received their transplant ± years ago. pwv-sds adjusted to height was . ± . . in order to identify predictors of elevated pwv, we performed a univariate screen and introduced factors with a p-value below . into a stepwise forward linear regression analysis. we found that systolic blood pressure in the ambulatory blood pressure measurement and gfr independently predicted pwv-sds (table) . conclusion: our results show a large variability in aortic stiffness in children after renal transplantation. we found elevated pwv to be associated with classical as well as non-classical risk factors. the wide range of cardiovascular comorbidity seen in these patients highlights the need for individualized risk factor monitoring and management. objective: renal transplantation is the optimal treatment for end-stage renal disease in children,. however, it remains technically challenging in small recipients, especially with adult-sized graft. we report on two -year-old children, undergoing living donor kidney transplantation, and describe our management after failure to close the abdominal wall. method: both children weighed < kg and received their father's kidney. the recipient/donor weight ratios were / and / . surgical procedure was an extra peritoneal approach to the iliac fossa, with vascular anastomosis on the aorta and vena cava. they recieved intensive fluid replacement during surgery to optimize hemodynamic status and graft perfusion. after initial successful reperfusion, all attempts to close the abdominal wall (even simple skin closure or superficial muscle layer closure) led to graft hypoperfusion, diagnosed on graft colour change and doppler ultrasound. closure with resorbablevicryl?mesh gave the same results and failure. finally, we had to close with a synthetic non resorbable plate (goretex?), without skin closure.results: the first patient presented acute tubular necrosis and required continuous hemofiltration from day to . the second one had immediate diuresis and with a decrease of serum creatinine to μmol/l at day . in both cases, kidney was successfully replaced intra abdominally at day , with superficial closure of facia and skin in one child and with vicryl? mesh and skin in the second one. no effect on clinical graft perfusion or doppler parameters were observed after final closure. in patient , a limited necrotic area x cm, on direct contact with the goretex?plate, was noticed during the second surgery procedure but it remained very superficial. finally, with a follow-up of respectively year and month, recipients and grafts are doing well without any other events and a serum creatinine of - μmol/l. conclusion: in conclusion, in small patients kidney size discrepancy and tissue oedema can lead to renal allograft compartment syndrome. in this situation, goretex? plate is an option for initial wound closure and graft salvaging. objective: amr in the transplant is one of the most complicated form of rejection, which do not respond to the standard therapy. survival of the transplant exposed to amr is still low. this is a clinical report of an amr-treatment in children in our centre. methods: girls with amr after the deceased donor renal transplantation were observed of age , , , from to in our centre. all had a negative "cross-match" at the time of transplantation, the quantity of discordant antigens varied from to . for girl it was the transplantation. children had an immediate function of the graft, -delayed. induction of the immunosuppressive therapy: polyclonal antibodies and methylprednisolone, maintenance: tacrolimus, prednisolone, mmf. children had high level of preexisting antibodies (more than %) at the time of transplantation. there were morphological confirmation and decrease of the graft function for the moment of amr. the treatment of amr included: pulse therapy of methylprednisolone, polyclonal antibodies, rituximab, immunoglobulin iv. function of the graft was evaluated by the cr levels, gfr, the level of dsa.results: the cr of children was ± umol/l for the moment of developing of amr. function of the graft has been restored to satisfied: cr fall to ± umol/l, there were no proteinuria. it was noted a significant reduction of dsa i and ii class in from patients. conclusion: thus, treatment of an amr of the graft with methylprednisolone, rituximab and immunoglobulin intravenously let us achieve % -year graft and recipient survival after deceased donor kidney transplantation in children. since the risk of amrdevelopment is high in children with high levels of preexisting antibodies, addition of one-time rituximab and immunoglobulin intraveneously in therapy seems reasonable.abstract# p-sat tacrolimus granules use in kidney transplanted infants. dose and safety.ramon vilalta, enrique lara, alvaro madrid, marina munoz, sara chocron, gema ariceta paediatric nephrology, hospvalld'hebron, barcelona, spainobjective: tacrolimus in infants has been administered as an extemporaneously compounded oral liquid made by hospital pharmacy. modigraf® is a new tacrolimus formulation available as sachets containing granules ( . mg and mg), that are made up with water, prepared by parents or caregivers. modigraf® is considered at least as safe and practical than the compounded oral tacrolimus liquid. furthermore, it is easier to be stored and ready to use, and promotes patient's autonomy, preventing potential medication errors. kidney transplanted infants, de-novo and converted from oral liquid to modigraf® were evaluated to assess its safety and adequate dose. methods: after induction with basiliximab or atg, de novo's patients were treated with modigraf® associated with mmf and with tapered steroids. infants with similar immunosuppression regimen were converted from oral tacrolimus to modigraf®. target tacrolimus through level was - ng/ml. mean patients' age at transplantation was . years old, and mean follow-up period with modigraf® was ± months.results: in the de-novogroup the stable modigraf® dose needed to reach target levels was . ± . mg/kg/day. in the converted group, the initial oral tacrolimus liquid dose was . ± . mg/kg/day, whereas modigraf® stable required dose was higher: . ± . mg/kg/day (p = . ). target levels of tacrolimus were reached after key: cord- - e yylk authors: alleg, manel; solis, morgane; baloglu, seyyid; cotton, françois; kerschen, philippe; bourre, bertrand; ahle, guido; pruvo, jean-pierre; leclerc, xavier; vermersch, patrick; papeix, caroline; maillart, Élisabeth; houillier, caroline; chabrot, cécile moluçon; claise, béatrice; malak, sandra; martin-blondel, guillaume; bonneville, fabrice; caulier, alexis; marolleau, jean-pierre; bonnefoy, jérôme tamburini; agape, philippe; kennel, céline; roussel, xavier; chauchet, adrien; de seze, jérôme; fafi-kremer, samira; kremer, stéphane title: progressive multifocal leukoencephalopathy: mri findings in hiv-infected patients are closer to rituximab- than natalizumab-associated pml date: - - journal: eur radiol doi: . /s - - -y sha: doc_id: cord_uid: e yylk objectives: to compare brain mri findings in progressive multifocal leukoencephalopathy (pml) associated to rituximab and natalizumab treatments and hiv infection. materials and methods: in this retrospective, multicentric study, we analyzed brain mri exams from patients diagnosed with definite pml: after natalizumab treatment, after rituximab treatment, and hiv patients. we compared t - or flair-weighted images, diffusion-weighted images, t *-weighted images, and contrast enhancement features, as well as lesion distribution, especially gray matter involvement. results: the three pml entities affect u-fibers associated with low signal intensities on t *-weighted sequences. natalizumab-associated pml showed a punctuate microcystic appearance in or in the vicinity of the main pml lesions, a potential involvement of the cortex, and contrast enhancement. hiv and rituximab-associated pml showed only mild contrast enhancement, punctuate appearance, and cortical involvement. the cd /cd ratio showed a trend to be higher in the natalizumab group, possibly mirroring a more efficient immune response. conclusion: imaging features of rituximab-associated pml are different from those of natalizumab-associated pml and are closer to those observed in hiv-associated pml. key points: • nowadays, pml is emerging as a complication of new effective therapies based on monoclonal antibodies. • natalizumab-associated pml shows more inflammatory signs, a perivascular distribution “the milky way,” and more cortex involvement than rituximab- and hiv-associated pml. • mri differences are probably related to higher levels of immunosuppression in hiv patients and those under rituximab therapy. progressive multifocal leukoencephalopathy (pml) is a rare demyelinating disease of the central nervous system caused by reactivation of the jc polyomavirus (jcv). jcv is a ubiquitous polyomavirus, present in nearly % of the adult population [ ] . primary infection is asymptomatic and leads to viral persistence in infected hosts in different sites such as bone marrow and kidneys. jcv reactivation is triggered by a decrease in immunity [ ] , more particularly in cell-mediated immunity [ ] . pml incidence increased notably during the s with the hiv pandemic supporting the hypothesis of the essential role played by cell-mediated immunity [ , ] . nowadays, pml is emerging as a complication of new effective immunosuppressive and immunomodulatory drugs [ ] . natalizumab is used as a treatment for multiple sclerosis (ms) and is associated with an increased risk of pml, estimated at / to / , based on three identified risk factors (treatment duration longer than months, anti-jcv antibody index, and prior administration of immunosuppressive therapies) [ ] . anti-jcv antibody levels in serum are indeed used to stratify pml risk in anti-jcv antibody-positive ms patients [ ] . natalizumab is a monoclonal antibody targeting the alpha- integrin that inhibits transmigration of t cells, including cd t cells, to and in the central nervous system, which can explain in part its role in pml through a decrease of immune control of jcv in the brain [ ] . two other characteristics are that natalizumab forces the migration of hematopoietic stem cells from the bone marrow in which jcv may be persistent and the upward regulation of b cell maturation factors that promote jcv growth [ ] . rituximab, an anti-cd monoclonal antibody targeting b cell activity and currently used for hematological malignancies and autoimmune disorders, is also associated with a moderately increased risk of pml estimated at / , [ ] . rituximab acts by depleting b cells and modifying t cell activity, all of which supports a role of rituximab in pml development [ ] . knowledge of the mri pattern of pml is essential when this diagnosis is suspected, especially in populations considered at risk, because the prognosis remains poor and is based on early treatment [ ] , which consists exclusively so far in restoring the immune system. in the classic form widely described in the hiv population, pml manifests itself as white matter (wm) lesions affecting the u-shaped subcortical fibers with a decreased signal on t weighted sequences and an increased signal on t -weighted sequences. on diffusion-weighted images (dwi), the signal is generally increased with restricted diffusion on borders corresponding to active demyelination. low signal on magnetic susceptibility sequences in u-fibers adjacent to the wm lesions of pml has been recently described and appears in relation to intracellular accumulation of iron in macrophages and glial cells during myelin degeneration [ ] . those lesions are often not enhanced and have little or no mass effect [ ] . previous studies have shown differences in the mri pattern with natalizumab-associated pml (table ) . indeed, with natalizumab, there are various inflammatory signs such as contrast enhancement and small punctuations in or adjacent to lesions with an increased signal on t -weighted images and a perivascular distribution called "the milky way" [ , , ] . the lesions have ill-defined boundaries towards wm and sharp boundaries towards gray matter (gm), with cortical gm more frequently involved [ ] . a hypothesis to explain these results would be the difference in the level of immunosuppression induced by hiv and natalizumab. in this study, we first aimed to compare the mri presentation of rituximab-associated pml to natalizumab or hivassociated pml, and also analyze biological parameters to assess if the differences in mri could be the consequence of different immunosuppression levels. this retrospective study was approved by our institutional review board. inclusion criteria were ( ) a "definite" pml diagnosis according to the american academy of neurology criteria [ ] including clinical and imaging-compatible features and detection of jcv dna in the cerebrospinal fluid or in brain tissue by polymerase chain reaction (pcr) or immunohistochemistry; ( ) hiv-infected patients or patients treated with immunomodulatory or immunosuppressive drugs such as natalizumab or rituximab, possibly in association with other drugs and whatever the initial illness; and ( ) consent was provided for in the hospital's charter. exclusion criteria were patients diagnosed with pml from other causes than hiv infection or associated with other drugs than natalizumab or rituximab and those under years of age. the occurrence of immune reconstitution inflammatory syndrome (iris) or an opportunistic infection was not a cause for exclusion. classical demographic data such as gender, age at the time of diagnosis, and underlying illness were collected, as well as cd and cd numbers. between and , patients from centers in france and luxembourg were retrospectively identified (fig. ). of these patients, fulfilled all the inclusion criteria and were therefore included: patients had relapsing-remitting ms and were treated with natalizumab, patients were treated with rituximab ( had a hematopoietic malignancy, an autoimmune disorder, and an immune deficiency), and patients had an hiv infection. all patients underwent a multisequence mri protocol. due to the study's multicenter design, the explorations were carried out with diverging sequences, magnetic fields strength, acquisition parameters and parameters related to spatial resolution. we chose to define the first brain mri performed at suspicion of pml as the reference examination for all comparisons. all mris were unblinded and reviewed by a junior radiologist (a trainee) with the assistance of an experienced senior neuroradiologist. to compare pml lesions, we described the location (frontal lobe, parietal lobe, occipital lobe, temporal lobe, basal ganglia, supra-or infratentorial or both), involvement of cortex and/or deep gm, distribution (unilobar involving a single lobe, multilobar involving more than one contiguous lobe, widespread involving more than two contiguous lobes or noncontiguous lobes or bilaterality), boundaries (sharp towards wm and gm, ill-defined towards wm and gm), lesion characteristics (aspect on t -weighted images defined as homogeneous or microcystic corresponding to small lesions in or adjacent to the main pml lesions with an increased signal called the milky way; the presence or absence of a hyposignal on t */swi/swan-weighted images, signal on dwi, and statistical analysis was performed using r software, version . , via the gmrc shiny stat application of the strasbourg university hospital ( ) and using the xlstat software in its addinsoft version. we compared the mri findings between the three groups using the chi-square test and between the nat/ritux, nat/hiv, and ritux/hiv groups using the chi-square test with holm correction. we compared biological data between the three groups using the shapiro test and between the nat/ritux, nat/hiv, and ritux/hiv groups using the student t test with holm correction. median patient age (for all groups) was . years (range, . in the patient groups, the median age was . years for the natalizumab group (range, - ), . years for the rituximab group (range, - ) and . for the hiv group (range, - ). forty men ( . %) and women ( . %) were included in the study: men ( . %) and women ( . %) in the natalizumab group, men and women ( % each) in the rituximab group, and men ( %) and women ( %) in the hiv group. the imaging results are summarized in table and table . there was a statistically significant difference in supratentorial involvement between the three groups ( . % in the natalizumab group, % in the rituximab group, and % in the hiv group (p = . ), especially when comparing the natalizumab group vs the hiv group (p = . ) and the rituximab group vs the hiv group (p = . ) with fewer supratentorial lesion locations in cases of pml occurring in an aids context. concerning gm involvement, there was a significant difference between the three groups for the cortex (p < . ) and for the basal ganglia (p = . ). post hoc analysis was only contributive for cortex involvement and showed a difference between the natalizumab group vs the hiv/rituximab groups with more cortex involvement in cases of pml that occurred under natalizumab treatment than the other two groups (p = . for natalizumab vs rituximab and p = . for natalizumab vs hiv). analysis of the edges towards both wm and gm (fig. ) showed significant differences between groups. indeed, lesions were more frequently clearly defined towards gm and ill-defined towards wm in the natalizumab group with no significant difference between the rituximab and hiv groups. the milky way aspect on t -or flair-weighted images ( fig. ) was significantly different between the three groups (p = . ) and more often seen in the natalizumab group vs the rituximab group ( . % for natalizumab and % for rituximab [p = . ]). on dwi, the vast majority of pml lesions had an increased signal ( . % for natalizumab, . % for rituximab and % for hiv). we isolated cases with a peripheral signal in restriction of diffusion (corresponding to a decrease of the signal on adc mapping), called the demyelination front. for this parameter, we observed a significant difference between natalizumab/rituximab ( . % for natalizumab, . % for rituximab [p = . ]) and natalizumab/hiv ( . % for natalizumab, . % for hiv, [p < . ]) but none between the rituximab and hiv groups. (fig. ) . lesions with a peripheral contrast enhancement showed a significant difference between the three groups (p = . ) and tended fig. flow chart illustrating the patient selection and inclusion process. pml = progressive multifocal leukoencephalopathy, aan = american academy of neurology to predominate in the rituximab group ( % in the rituximab group vs . % in the natalizumab group and % in the hiv group). lesions with micronodular enhancement were significantly different between the three groups (p = . ), with more cases in the natalizumab group versus the rituximab group (p = . ). there was no difference between natalizumab and hiv groups even if there were more lesions of this type in the natalizumab group ( . % vs % in the hiv group). finally, for distant enhancement, there was a difference between the three groups (p < . ), specifically between natalizumab and rituximab (p = . ) and the natalizumab and hiv (p = . ) groups, with more of this type of enhancement in the natalizumab group (fig. ) . non-enhanced lesions were significantly different between the three groups (p = . ), higher in the hiv groups with %. cd /cd data were available for patients in the natalizumab group, in the rituximab group, and in the hiv group (fig. ) this study aims to describe the mri characteristics of pml associated with rituximab and natalizumab and in hiv infection while comparing imaging findings with the level of immunosuppression. we therefore compared cd /cd ratios and found lower ratios in hiv-related pml compared to other groups, as well as a lower cd /cd ratio in the rituximab group compared to the natalizumab group. this suggests that immunosuppression in rituximab is not as severe as in hiv-pm but still stronger than in natalizumab-pml. one of the characteristics of pml under natalizumab described in previous studies [ , ] is the description of inflammatory signs such as microcystic lesions on t -weighted images giving a milky way appearance [ , ] . we found significantly more milky way lesions in the natalizumab group compared to the rituximab group but no significant difference between the natalizumab and hiv groups, even if they tended to predominate in the natalizumab group. the other "inflammatory" sign usually attributed to natalizumab-pml is contrast enhancement, estimated at to % of patients in the literature [ ] . in the present study, it accounted for . % of the natalizumab group. a difference was observed between the three groups, especially when the enhancement was micronodular, similar to the milky way perivascular distribution predominating in the natalizumab group compared to the rituximab and hiv groups. by inducing a lower degree of immunosuppression compared to hiv, natalizumab-associated pml has more inflammatory signs. this could be due to the mode of action of this drug, which is a more selective immunomodulating agent [ ] . we found more supratentorial involvement in drug-related pml than in the hiv-associated form where the brainstem and cerebellum are more likely to be affected. cortical involvement and the typical aspect of the edges (sharp towards gm and ill-defined towards wm) are found preferentially in the natalizumab group, as also found in previous studies [ , ] . there is no obvious explanation for these characteristics in relation to a difference in the level of immunosuppression. the proportion of hyposignal seen on t *-or swanweighted images at the cortical-subcortical junction adjacent to pml lesions (fig. ) did not differ between pml groups, in agreement with other studies [ , , ] ; this sign seems nonspecific in pml for the underlying cause of immunosuppression. a demyelination front on diffusion-weighted images is often found with pml in the hiv group and in the rituximab group but more rarely in the natalizumab group. if the demyelination front is related to the active nature of the disease, we can hypothesize that the pml associated with rituximab is more like hiv-pml than natalizumab-pml, possibly due to closer immunosuppression levels [ ] . the main limitations of this study are its retrospective and unblinded design as well as the limited number of patients analyzed with complete clinical, biological, and available imaging data. this is explained by the relative rarity of pml even in large referral centers. secondly, due to the multicenter design of the study, the explorations were performed on different mris, both . t and t and with nonstandardized protocols, and there were some inevitable variations in mri acquisition parameters between patients [ ] . regarding the demographic data, we note that the age of the patients differs according to the group, with a tendency to younger patients in hiv and natalizumab groups. this may constitute a selection bias and is explained by the epidemiological data of the pathology studied, with ms and hiv affecting younger people compared to hematological malignancies. fig. in several cases of natalizumab-associated pml showing in (a) on flair-weighted images, we can see gm and especially cortical involvement of the left parietal lobe adjacent to the wm lesion. the left thalamus is also the site of a demyelinating lesion. in b, we observe on t -weighted images the milky way aspect with microcystic lesions with an increased signal. in c, clear sharp edges towards gm and ill-defined edges towards wm of the demyelinating lesions. in d, e, and f, brain mri from a patient with natalizumab-associated pml showing in (d) a demyelinating right frontal lesion on flair-weighted image with (e) contrast micronodular enhancement in the lesion and (f) remotely in the right temporal lobe. finally, we can see an increased signal on diffusion-weighted images (h) with no rim in restriction on adc mapping (g) mri interpretation was made difficult by the coexistence of inflammatory lesions in the natalizumab group related to ms as well as by the coexistence of opportunistic infections (notably cerebral toxoplasmosis for three patients in the hiv group) and the occurrence of immune reconstitution inflammatory syndrome (in three fig. an example of a hiv-pml case with an infratentorial right cerebellar demyelinating lesion on a. in b, no contrast enhancement of this lesion. diffusion-weighted images and adc mapping of a patient showing an increased signal on diffusion (c) with a rim of demyelination in restriction of diffusion (d) fig. box diagram of the extent of the cd /cd ratio of patients by group patients in the hiv group after initiation of antiretroviral therapy). concerning inclusion criteria, the vast majority of patients in the natalizumab group had already received immunosuppressive treatments before natalizumab treatment was initiated, as had those in the rituximab group, who often had several treatments acting on immunity before or at the same time as rituximab. however, in the present study, we did not make any distinction in the groups according to these possible treatments. their impact on the mri pattern of pml lesions is therefore not excluded. two other factors may have come into play in the mri pattern of pml under rituximab that we did not consider: first, the initial disease of the patient, which could be responsible for the development of pml, especially in the case of hematopoietic malignancies [ ] . secondly, the rigorous mri follow-up of patients in the natalizumab group made it possible to detect pml at an earlier stage than in the hiv and rituximab groups. adequate assessment of the quantitative and functional aspects of the global immune response is still a challenge in immunocompromised patients. in hiv-infected patients, the cd /cd ratio is considered to be a good marker of the remaining immune response but may not be as relevant in other immunosuppressed groups such as patients treated with natalizumab or rituximab, irrespective of the underlying disease. the cd /cd ratio does not incorporate the full level of immunosuppression-due to the diversity and complexity of the immune system; in our study, it indirectly and partially reflects the patient's immune status. imaging features of rituximab-associated pml generally look more similar to those of the classically described pml with hiv than those related to natalizumab. those similarities may be explained by a higher level of immunosuppression in hiv patients and patients treated with rituximab compared to patients treated with natalizumab. statistics and biometry nicolas tuzin kindly provided statistical advice for this manuscript. informed consent written informed consent was not required for this study because patient consent was provided for in the hospital's charter. ethical approval institutional review board approval was obtained. • prospective • observational • multicenter study progressive multi-focal leucoencephalopathydriven from rarity to clinical mainstream by iatrogenic immunodeficiency the chameleon of neuroinflammation: magnetic resonance imaging characteristics of natalizumab-associated progressive multifocal leukoencephalopathy progressive multifocal leukoencephalopathy and immune reconstitution inflammatory syndrome (iris) human polyomavirus reactivation: disease pathogenesis and treatment approaches anti-jc virus antibodies: implications for pml risk stratification stratification and monitoring of natalizumab-associated progressive multifocal leukoencephalopathy risk: recommendations from an expert group pathogenesis of progressive multifocal leukoencephalopathy and risks associated with treatments for multiple sclerosis: a decade of lessons learned progressive multifocal leukoencephalopathy and monoclonal antibodies: a review progressive multifocal leukoencephalopathy secondary to rituximab-induced immunosuppression and the presence of john cunningham virus: a case report and literature review outcome and survival of asymptomatic pml in natalizumab-treated ms patients imaging manifestations of progressive multifocal leukoencephalopathy common and uncommon imaging findings in progressive multifocal leukoencephalopathy (pml) with differential diagnostic considerations magnetic resonance imaging pattern in natalizumab-associated progressive multifocal leukoencephalopathy immune reconstitution inflammatory syndrome unmasking or worsening aids-related progressive multifocal leukoencephalopathy: a literature review. front immunol : low signal intensity in u-fiber identified by susceptibility-weighted imaging in two cases of progressive multifocal leukoencephalopathy natalizumabassociated progressive multifocal leukoencephalopathy in patients with multiple sclerosis: lessons from cases inflammatory natalizumab-associated pml: baseline characteristics, lesion evolution and relation with pml-iris mri pattern in asymptomatic natalizumab-associated pml pml diagnostic criteria: consensus statement from the aan neuroinfectious disease section punctate lesion pattern suggestive of perivascular inflammation in acute natalizumab-associated progressive multifocal leukoencephalopathy: productive jc virus infection or preclinical pml-iris manifestation? brain magnetic susceptibility changes in patients with natalizumab-associated progressive multifocal leukoencephalopathy neuroimaging of natalizumab complications in multiple sclerosis: pml and other associated entities punctate pattern: a promising imaging marker for the diagnosis of natalizumabassociated pml susceptibility-weighted mr imaging hypointense rim in progressive multifocal leukoencephalopathy: the end point of neuroinflammation and a potential outcome predictor progressive multifocal leukoencephalopathy: diffusion-weighted imaging and pathological correlations imaging working group of the observatoire français de la sclérose en plaques. ofsep, a nationwide cohort of people with multiple sclerosis: consensus minimal mri protocol progressive multifocal leukoencephalopathy and anti-cd monoclonal antibodies: what do we know after years of rituximab publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgments french network for ocular and cns lymphoma (loc) and nord-est neuro-oncoly (neno) organisation.funding the authors state that this work has not received any funding. guarantor the scientific guarantor of this publication is stephane kremer. the authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article. key: cord- -kx jfssi authors: elmelhat, ahmed; elbourai, essam; dewedar, hany; elgergawi, taghrid; alkhanbouli, maryam; ahmed, salwa; malik, zoiya; nugud, alaa; mohammed, shadha; mohammad, hozaifah; husain, abdullah title: comparison between prophylactic versus therapeutic doses of low-molecular-weight heparin in severely ill coronavirus disease patients in relation to disease progression and outcome date: - - journal: nan doi: . / sha: doc_id: cord_uid: kx jfssi introduction: the predominant coagulation abnormalities in patients with coronavirus disease (covid- ) suggest a hypercoagulable state and are consistent with uncontrolled clinical observations of an increased risk of venous thromboembolism. aim and objectives: to compare the effect of prophylactic versus therapeutic doses of enoxaparin in the treatment of severe cases of covid- infection. materials and methods: this was a retrospective observational study conducted at latifa hospital, dubai. fifty-nine patients enrolled from march to june and divided into groups: patients who received the prophylactic dose of enoxaparin (group ) and patients who received the therapeutic dose of enoxaparin (group ). results: the mean age of all cases was . ± . years, while the mean weight was . ± . kg. males represented . % of cases. blood group “o” was the most frequent blood group ( . %). none of the cases were smokers or using alcohol. bronchial asthma, lung diseases, diabetes mellitus, hypertension, ckd, cardiac disease, thyroid disease, and immunodeficiency were present in . , . , , . , . , . , . , and . % respectively. there was no significant difference between both study groups regarding personal and medical characteristics, except for hypertension where . % of group (therapeutic) cases were hypertensive compared to % of group cases (prophylactic). there was a significant difference between both study groups regarding inflammatory markers improvement duration, duration of mv and o support duration, with longer duration among (therapeutic) group cases compared to group cases (prophylactic). there was a highly significant difference between both study groups regarding icu admission, as % of group cases were admitted compared to % of group cases. similarly, . % of group cases needed mv compared to only % of group cases, which was statistically significant. there was no significant difference between both groups regarding bleeding tendency and mortality (p value . ). conclusion: our results showed that use of prophylactic dose of enoxaparin might have some benefits compared to the therapeutic dose in terms of less duration of icu and hospital stay, duration of oxygen support, need and duration of mv, and normalization of inflammatory markers. however, there was no significant difference between the regimens regarding the mortality. smokers or using alcohol. bronchial asthma, lung diseases, diabetes mellitus, hypertension, ckd, cardiac disease, thyroid disease, and immunodeficiency were present in . , . , , . , . , . , . , and . % respectively. there was no significant difference between both study groups regarding personal and medical characteristics, except for hypertension where . % of group (therapeutic) cases were hypertensive compared to % of group cases (prophylactic). there was a significant difference between both study groups regarding inflammatory markers improvement duration, duration of mv and o support duration, with longer duration among (therapeutic) group cases compared to group cases (prophylactic). there was a highly significant difference between both study groups regarding icu admission, as % of group cases were admitted compared to % of group cases. similarly, . % of group cases needed mv compared to only % of group cases, which was statistically significant. there was no significant difference between both groups regarding bleeding tendency and mortality (p value . ). conclusion: our results showed that use of prophylactic dose of enoxaparin might have some benefits compared to the therapeutic dose in terms of less coronaviruses are enveloped, single positive-strand rna viruses belonging to the large subfamily coronavirinae, which can infect humans as well as animals [ ] . sars-cov- , one of the covs known to cause human disease, was identified in december after sequencing clinical samples from a cluster of patients with pneumonia in wuhan, china [ ] . the disease caused by sars-cov- is named coronavirus disease . it can present as asymptomatic, mild, moderate, severe, and critical. given the novelty of the virus, there is still much to discover. since its first report in december in wuhan, china, co-vid- was declared a pandemic by the world health organization (who) on march , [ ] . the most common complications noted in patients who died of covid- were sepsis ( %), respiratory failure ( %), ards ( %), septic shock ( %), acute cardiac injury ( %), heart failure ( %), coagulopathy ( %), secondary infection ( %), and acute kidney injury ( %) [ ] . a progressive increase of inflammation and an unusual trend of hypercoagulation have been observed in patients with severe and critical covid- disease. this hypercoagulable state has been termed thrombo-inflammation or covid- -associated coagulopathy by some experts. it appears to be distinct from disseminated intravascular coagulation (dic), though dic has also been reported in severely affected patients. uncontrolled clinical observations of an increased risk of venous thromboembolism are consistent with observations of a hypercoagulable state [ , ] . this was a retrospective cohort study of adult patients admitted to latifa women and children's hospital (lwch), dubai, uae, between march and may during the covid- pandemic and diagnosed with severe covid- pneumonia. the probability of morbidity and mortality was assessed by apache ii score and sepsis-induced coagulopathy (sic) scores that ranged from to and to , respectively. all patients admitted to latifa women and children's hospital, dubai, uae, during the study period and diagnosed with severe covid- infection were included in the study. to begin with, there were patients diagnosed as having severe co-vid- , and patient was excluded from the study, as the patient did not receive enoxaparin; therefore, the final sample consisted of patients. during the study period, there were admissions in latifa hospital that met the inclusion criteria. the patients included in the study had major or (or more) minor criteria as shown in table . the exclusion criteria included mild-to-moderate co-vid- pneumonia and patients with bleeding diathesis. the data were collected from the computerized registry database. patients were categorized into groups; the first group (prophylactic dose group) included patients who received the prophylactic dose of enoxaparin ( mg once per day), while the second group (therapeutic dose group) included patients who received the therapeutic dose of enoxaparin ( mg/kg twice per day). demographic data, including age, weight, sex, nationality, and blood groups, were collected from all study participants. comorbidities like diabetes mellitus, hypertension, cardiac disease, chronic pulmonary diseases, ckd, immunodeficiency, or risk factors such as smoking and alcohol consumption were included as well. the data on the levels of inflammatory markers (crp, procalcitonin, wbcs count [< × /µl], lymphopenia [< × /µl], and thrombocytopenia [< × /µl]), lactate dehydrogenase (ldh), and ferritin; renal function tests; liver function tests; ddimer; and coagulation profile were collected at the time of admis- no ( ) sion and discharge to evaluate the time taken to improve compared with clinical improvement. data were revised, coded, entered on a computer, and analyzed using spss package version . quantitative data were tested for normality with the shapiro-wilk test and described as mean, standard deviation (sd), or median/interquartile range according to data distribution. the student t test and mann-whitney test were used for comparing quantitative variables between study groups. qualitative data were expressed as frequencies (n) and percentage (%). the χ and fisher exact tests were used to test the association between qualitative variables. p value ≤ . was considered significant. the primary objective was to compare the effect of the dose regimens of enoxaparin (prophylactic and therapeutic) on the outcome including the morbidity and mortality. the secondary objective was to observe the clinical outcome by measuring various variables including the duration of hospital stay, the need and duration of icu admission, the need and duration of oxygen supply, the need for mechanical ventilation, and the development of side effects such as bleeding tendency. during the study period, patients with severe co-vid- pneumonia were tested, of which patients were included in the first group (prophylactic dose group) and patients were included in the second group (therapeutic dose group). the mean age of all patients was . ± . years, ranging between and years, while the mean weight of study cases was . ± . kg, ranging between and kg. of the patients, . % of cases were males. more than half of the cases were of indian ethnicity ( . %). blood group "o" was the most frequent blood group among cases ( . %). none of the cases were smokers or alcohol consumers. bronchial asthma, lung diseases, diabetes mellitus, hypertension, ckd, cardiac disease, thyroid disease, and immunodeficiency was present in . , . , , . , . , . , . , and . %, respectively. except for hypertension which was present in . % of cases in group (therapeutic dose) compared to % of cases of group (prophylactic dose), as shown in table , there was no other significant difference between both study groups in regard to personal and medical characteristics ( table ) . table shows the clinical presentation and the laboratory findings in all patients. probability of morbidity and mortality and tendency for sepsis-induced coagulopathy were assessed by apache ii and sic scores, with a mean of . ± . and . ± . , respectively. there was no significant difference between the groups regarding the apache ii and sic scores with p values . and . , respectively. the most common presenting symptom was fever in cases ( . %). all patients ( %) had positive crp, while procalcitonin was positive in cases ( . %); leukopenia, cases ( . %); lymphopenia, cases ( . %); thrombocytopenia, cases ( . %); abnormal ldh, cases ( . %); abnormal ferritin, cases ( . %); abnormal d-dimer, cases ( . %); abnormal renal function test, cases ( . %); abnormal liver function test, cases ( . %); and abnormal coagulation profile, cases ( . %). multilobar involvement was seen in cases ( . %) in chest x-ray. as shown in table , there was a significant difference when it came to tachypnea, hypotension, and the need for inotropic support between the study groups. the significant difference in the laboratory findings in the groups regarding the abnormal ferritin and liver function tests is also shown in table . therapeutic total p value mean ± sd/ median (iqr)**/n (%) mean ± sd/ median (iqr)**/n (%) mean ± sd (min-max)/ median (iqr)**/n (%) clinical outcome is shown in table ; out of patients, patients died and cases ( . %) needed icu admission. the median for the duration of enoxaparin use was days; ldh, ferritin, and d-dimer started to improve in , , and days, respectively. median duration for oxygen support and mechanical ventilation was and days, respectively. the median of hospital stay and chest x-ray improvement was and days, respectively. there was a significant difference between both study groups in enoxaparin duration, time to ferritin and ddimer improvement, and the duration of mv and o support duration, with longer duration among group cases (therapeutic dose) compared to group (prophylactic dose) in all the above-mentioned variables. there was a highly significant difference between both study groups regarding icu admission, as % of the group cases were admitted compared to only % of the group cases. similarly, . % of the group cases needed mechan-ical ventilation compared to only % of the group cases, which was statistically significant. there was no significant difference between the groups regarding the bleeding tendency and mortality (p value . ). the continuous increase in the number of people infected with covid- virus has helped to improve our understanding of the disease pathogenesis. it has been observed that there are coagulation abnormalities suggesting a hypercoagulable state. fifty-nine patients met the criteria to be included in our study. our study compared the effect of different dose regimens of the anticoagulant enoxaparin (prophylactic and therapeutic) that was administered to patients with severe covid- infection, and we compared the clinical outcome as well as improvement in laboratory parameters in both groups. the prophylactic dose used was mg once per day, while the therapeutic dose used was mg/kg twice per day. data were collected retrospectively from the patients' electronic files after getting approval from our ethical committee for the study. dubai inhabitants represent different nationalities; we found that the most affected ethnic group was indians, while the local emirati patients represented . % from all studied patients. the mean age was . years, and the mean weight was . kg. males were more commonly affected than females, and the most common blood group documented for the affected patients was "o" blood group. the most common presenting symptom in all patients was fever, while gastrointestinal symptoms, mainly diarrhea, were the least presenting symptoms. both apache ii and sic scores were used to assess probability of death, comorbidities, and tendency to develop coagulopathy, and the mean of . ± . and . ± . , respectively, was found. in all patients, crp was found to be highly positive, while procalcitonin was positive in . %; most of them showed minimal risk for infection, and this observation might need further investigation to compare the reliability of both inflammatory markers for diagnosis and follow-up. lymphopenia was the most common finding in the full blood count of the patients. in the chest x-ray, multilobar involvement was a constant finding in almost all patients. in this study, there was no significant difference between the groups regarding demographic data. regarding the risk factors, there was no significant difference between both groups except for hypertension, which was higher in the therapeutic group. none of the tested patients were smokers or alcohol consumers. we found that there was a longer duration of hospital stay including icu admission, oxygen support, and mechanical ventilation in the therapeutic group cases. in addition, it took a longer duration for the inflammatory markers ldh, ferritin, and d-dimer to improve in the therapeutic group rather than in the prophylactic group. there was no significant difference between both groups regarding the duration of improvement of chest x-ray findings. both dose regimens were observed to be safe, and bleeding tendency was observed in only cases and it was not major bleeding. additionally, both groups showed no significant difference regarding bleeding tendency (p value . ). in this study, both study groups showed no significant difference regarding mortality (p value . ). because covid- is an emerging infectious disease, the optimal treatment for affected individuals has not yet been established. an early study out of the hubei province in china [ ] suggested that in the absence of venous thromboembolic prophylaxis, % of covid- patients developed lower extremity deep venous thrombosis, which is higher than the - % incidence seen in placebo arms of early studies of vte prevention in medically ill hospitalized patients [ ] [ ] [ ] . in these early studies, use of pharmacologic vte prophylaxis reduced the incidence of vte by up to % without an increase in major bleeding. our results are comparable with the recommendations published earlier by cattaneo et al. that higher doses of low-molecular-weight heparin may not be necessarily more effective than prophylactic doses, considering that anticoagulant doses of heparin are not indicated for treatment of other types of thrombotic microangiopathies, which possibly share some pathogenic mechanisms with the covid- microangiopathy and in some cases might be even dangerous as it can contribute to hemorrhagic component of microangiopathy [ ] . a report from the national institute for public health of the netherlands recommended to initiate low dose prophylactic dose of low-molecular-weight heparin in all patients with suspected or confirmed covid- infection irrespective of risk scores [ ] . connors et al. [ ] suggested to manage covid- -associated coagulopathy as it would be for any critically ill patient and to follow the established practice of using thromboembolic prophylaxis for critically ill hospitalized patients and standard supportive care measures for those with sepsis-induced coagulopathy or dic as current data do not suggest the use of full-intensity anticoagulation doses unless otherwise clinically indicated. however, this study has several limitations. the small sample size and the short duration as we included patients' data for only months, from march to may . the study did not show the follow-up of the patients and if they developed any long-term morbidities after discharge. thromboembolic disease was only suspected clinically, and there was no definite diagnosis by chest ct scan. although thromboembolic disease was not detected in the studied patients, no ultrasound doppler or ct pulmonary angiography scan was done to confirm or rule out venous thromboembolism. to the best of our knowledge, this is the first study published to compare the dose regimens in the management of covid- patients. in conclusion, our results showed that use of prophylactic dose of enoxaparin might have some benefits compared to the therapeutic dose in terms of less duration of icu and hospital stay, duration of oxygen support, need doi: . / and duration of mechanical ventilation, and normalization of inflammatory markers. however, there was no significant difference between the regimens regarding improvement of chest x-ray findings, bleeding tendency, and mortality. further studies are needed to confirm or refute. coronaviridae study group of the international committee on taxonomy of v. the species severe acute respiratory syndromerelated coronavirus: classifying -ncov and naming it sars-cov- a novel coronavirus from patients with pneumonia in china who. coronavirus disease (covid- ) situation reports clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study thrombo-inflammation and the hypercoagulability of cov-id- prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia a comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. prophylaxis in medical patients with enoxaparin study group efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: randomized placebo-controlled trial randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients pulmonary embolism or pulmonary thrombosis in co-vid- ? is the recommendation to use highdose heparin for thromboprophylaxis justified? diagnosis, prevention, and treatment of thromboembolic complications in covid- : report of the national institute for public health of the netherlands covid- and its implications for thrombosis and anticoagulation this work is dedicated to the spirits of all the martyrs of doctors around the world. all data were collected and analyzed retrospectively in this study. the study was approved by the dubai scientific research ethics committee (dsrec) of the dubai health authority (dha) with reference no. dsrec- / _ . the authors have no potential conflicts of interest to disclose. there was no funding. a.e.: design, conception, data acquisition, manuscript drafting, critical analysis, and final approval. key: cord- -bfc h b authors: shanthakumar, swaroop gowdra; seetharam, anand; ramesh, arti title: analyzing societal impact of covid- : a study during the early days of the pandemic date: - - journal: nan doi: nan sha: doc_id: cord_uid: bfc h b in this paper, we collect and study twitter communications to understand the societal impact of covid- in the united states during the early days of the pandemic. with infections soaring rapidly, users took to twitter asking people to self isolate and quarantine themselves. users also demanded closure of schools, bars, and restaurants as well as lockdown of cities and states. we methodically collect tweets by identifying and tracking trending covid-related hashtags. we first manually group the hashtags into six main categories, namely, ) general covid, ) quarantine, ) panic buying, ) school closures, ) lockdowns, and ) frustration and hope}, and study the temporal evolution of tweets in these hashtags. we conduct a linguistic analysis of words common to all hashtag groups and specific to each hashtag group and identify the chief concerns of people as the pandemic gripped the nation (e.g., exploring bidets as an alternative to toilet paper). we conduct sentiment analysis and our investigation reveals that people reacted positively to school closures and negatively to the lack of availability of essential goods due to panic buying. we adopt a state-of-the-art semantic role labeling approach to identify the action words and then leverage a lstm-based dependency parsing model to analyze the context of action words (e.g., verb deal is accompanied by nouns such as anxiety, stress, and crisis). finally, we develop a scalable seeded topic modeling approach to automatically categorize and isolate tweets into hashtag groups and experimentally validate that our topic model provides a grouping similar to our manual grouping. our study presents a systematic way to construct an aggregated picture of peoples' response to the pandemic and lays the groundwork for future fine-grained linguistic and behavioral analysis. covid- (also known as the novel coronavirus) is a truly global pandemic and has affected humans in all countries of the world. while humanity has seen numerous epidemics including a number of deadly ones over the last two decades (e.g., sars, mers, ebola), the grief and disruption that covid- has already inflicted is incomparable. at the time of writing this paper, covid- is still rapidly spreading around the world and projections for the next few months are grim and extremely disconcerting. the learnings from covid- will also enable humankind to prevent such epidemics from transforming into global pandemics and minimize the socio-economic disruption. in this work, our goal is to analyze the societal impact of covid- in the united states of america during its early days, understand the chain of events that occurred during the spread of the infection, and draw meaningful conclusions so that similar mistakes can be avoided in the future. though twitter data has previously been shown to be biased [ ] , twitter has emerged as the primary media for people to express their opinion especially during this time and our study offers a perspective into the impact as self-disclosed by people in a form that is easily understandable and can be acted upon. we summarize our main contributions below. we collect , tweets from twitter between march th to march th , a time period when the virus made its first significant inroads into the us and quantitatively demonstrate the disruption and distress experienced by the people. we group the hashtags into six main categories, namely ) general covid, ) quarantine, ) school closures, ) panic buying, ) lockdowns, and ) frustration and hope, to quantitatively and qualitatively understand the chain of events. we observe that general covid and quarantinerelated messages remain trending throughout the duration of our study. in comparison, we observe calls for closing schools and universities peaking in the middle of march and then reducing when the closures go into effect (e.g., #closenycschools). we also observe a similar trend with panic buying with essential items particularly toilet paper becoming unavailable in stores (e.g., #panicbuying, #toiletpapercrisis). we conduct a linguistic analysis of the tweets in the different hashtag groups and present the words that are representative of each group. we observe that words such as family, life, health, and death are common across hashtag groups. additionally, for example, if we consider the school closures category, we observe that unigrams (e.g., teacher, learn) and bigrams (e.g., home school, kid home) reflect the most discussed issues. we also conduct sentiment analysis to unearth the overall sentiment of the people. our investigation reveals that people reacted positively to school closures and negatively to the lack of availability of essential goods due to panic buying. we next adopt a state-of-the-art semantic role labeling approach to identify the action words (e.g., fear, test) that are uniquely representative in each hashtag group. these action words help understand peoples' actions in each group. we leverage a lstm dependency parsing model to analyze the context of the above-mentioned action words (e.g., verb deal is accompanied by nouns such as anxiety and stress). finally, we develop a scalable seeded topic modeling (seeded lda) approach to automatically categorize tweets into specific topics of interest, especially when the topics are rarer in the dataset. we experimentally validate our seeded lda model and observe that it provides a grouping similar to our manual grouping. our study summarizes the critical public responses surrounding covid- , paving the way for future fine-grained linguistic and graph analysis. in this section, we discuss our methodology for data collection from twitter to investigate the societal impact of covid- in the united states during its early days. we collect data using the twitter search api. the results presented in this paper are based on the data collected from march to march , . we track the trending covid related hashtags every day and collect the tweets in those specific hashtags. we repeat this process to collect a total of , tweets during this time period. we group the hashtags into six main categories, namely ) general covid, ) quarantine, ) school closures, ) panic buying, ) lockdowns, and ) frustration and hope to quantitatively and qualitatively understand the chain of events. we collect data on per day basis for the different hashtags as and when they become trending. table i shows the number of tweets in each category, while table ii shows the grouping of some of the representative hashtags by category. we observe that the total number of tweets as grouped by hashtags is , , which is higher than the total number of tweets. this is because tweets can contain multiple hashtags and thus the same tweet can be grouped into multiple categories. we present some example tweets in table iii to illustrate the types of communications occurring on twitter during this period. alongside, people also rallied to support workers working hard to keep essential services running. with the beginning of april approaching, many people started to worry about their next month's rent. due to the data collection limits imposed by twitter, we are able to only collect and analyze a portion of the tweets. though we started collecting data as quickly as we conceived of this project, we were unable to collect data during the first week of march. though we ran our script to collect data as far back as march , because of the way twitter provides data, we obtained a limited number of tweets from march to march . additionally, due to the rapidly evolving situation, it is likely that we have inadvertently missed some important hashtags, despite our best efforts. as is the case with most studies based on twitter data, we also acknowledge the presence of bias in data collection [ ] . having said that, the goal of this study is to provide a panoramic summarized view of the impact of the pandemic on people's lives and aggregate public opinion as expressed by them. due to the nature of this study, we are confident that the results presented here help in appreciating the sequence of events that transpired and better prepare ourselves from possible future waves of covid- or another pandemic. in this section, we present observations and results based on our linguistic analysis of the tweets. we study the popularity and temporal evolution of individual hashtags and hashtag when are we going to #cancelrent in this state? hundreds of thousands are filing for unemployment and can't pay rent. sure, we can't be evicted, but what's preventing companies from coming after us after this is over? groups. we explore the word-usage (i.e, unigram and bigram) frequencies for each hashtag group to understand the main points of discussion. we then conduct a sentiment analysis to understand the prevailing sentiments in the tweets. we adopt a semantic role labeling approach to identify the action words (i.e., verbs) as well as the corresponding contextual analysis of these action words. finally, we develop a scalable seeded lda based topic model to automatically group tweets and validate its effectiveness with our manual grouping. figure a shows the top hashtags observed in our data. as expected, we see that hashtags corresponding directly to covid or coronavirus are the most popular hashtags as most communications are centered around them. we observe that hashtags around social isolation, staying at home, and quarantining are also popular. figure b shows the most popular hashtags by date. similar to figure a , we observe that hashtags related directly to covid and social distancing trend most on twitter. the figures and the number of tweets highlight how the pandemic gripped the united states with its rate of spread. we investigate the evolution of the number of tweets in various hashtag groups over time. to calculate the number of tweets in each hashtag group, we count the number of mentions of hashtags in that group across all the tweets. if the tweet contains more than one hashtag, it is counted as part of all the hashtags mentioned in it. as the number of tweets for hashtag groups vary significantly, we plot the groups that have similar number of tweets together. similar to figure , we observe from figure a that the total number of tweets in the general covid and quarantine categories are relatively high throughout the time period of the study. interestingly, from figure b , we observe that panic buying and calls for school closures peak around the middle of in this section, we present results from a linguistic word usage analysis across the different hashtag groups. our goal is to identify the words that are uniquely representative of the particular group. to accomplish this, first, we identify and present the most commonly used words across all the hashtags. to construct the group of common words across all hashtags, we remove the words that are same or similar to the hashtags mentioned in table ii as those words are redundant and tend to also be high in frequency. we also remove the names of places and governors such as new york, massachusetts and andrew cuomo. after filtering out these words, we then rank the words based on their occurrence in multiple groups and their combined frequency across all the groups. we observe words such as family, health, death, life, work, help, thank, need, time, love, crisis. in table iv , we present some notable example tweets containing the common words. while one may think that health refers to the virusrelated health issues, we notice that many people also refer to mental health in their tweets as a possible consequence to social distancing and anxiety caused by the virus. we also observe the usage of words such as death and crisis to indicate the seriousness of the situation. supporting workers and showing gratitude toward them is another common tweet pattern that is worth mentioning. second, we present the most semantically meaningful and uniquely identifying words in each hashtag group. to do this, we remove the common words calculated in the above step from each group. from the obtained list of words after the filtering, we then select the top words. due to space constraints, we only present results for four hashtag groups. figure gives us the uniquely identifying and semantically meaningful words in each hashtag group. in the general death. we must act very fast. first, we take care of the health care and emergency workers. then, we take care of whoever is in charge of keeping netflix and hulu running or it's going to get ugly #distancesocializing #coronavirus covid group, we find words such as impact, response, resource, and doctor. similarly, for school closures, we find words such as teacher, schedule, educator, book, and class. the panic buying top words mostly resonate the shortages experienced by people such as roll and tissue (referring to toilet paper), hoard, bidet (as an alternative to toilet paper), wipe, and water. top words in the lockdown group include immigration, shelter, safety, court, and petition, signifying the different issues surrounding lockdown. we analyze words that co-occur to understand the contextual information surrounding the words. co-occurring bigrams capture pairs of words that frequently co-occur in each group. to do this, we first filter out stop words and perform stemming and lemmatization. we calculate the overall frequencies of each word and its frequency within each class and calculate the bigram association using pearson's chi squared independence test, which determines if pairs of words occur together more than they would randomly. we select the top bigrams with the highest collocation statistics that are most intuitive for the human reader. figure shows the top bigrams for each group. we can clearly see how bigrams give better understanding compared to unigrams. bigrams such as 'toilet paper', 'panic buy', 'wash hand' clearly articulate the intents of the tweets in the panic buying group. similarly, in the lockdown group, we see 'stay home', 'work home', and 'minimize spread' emerging as top bigrams capturing what people are talking about in that group. to understand the sentiment across the different hashtag groups, we perform a comparative sentiment analysis. we use a pre-trained sentiment analysis model [ ] , which has . % accuracy on stanford sst test dataset and apply it to our dataset. our model, roberta base model, classifies the data into five sentiment categories: strongly positive, positive, neutral, negative, and strongly negative. we present the results in figure . since the neutral category is not useful for our analysis, we exclude it and scale the rest of the categories to %, normalizing for the number of tweets in each category. we notice that the school closures group has a significantly higher number of positive tweets that capture the overall positive sentiment around the closure of schools. in contrast, the panic buying group has a higher number of negative tweets showing the frustration in relation to panic buying. overall, we observe strongly positive tweets when compared to strongly negative tweets in all categories. this is especially interesting in the quarantine and frustration and hope groups, where more tweets are showing support for quarantine and hopefulness. we use allennlp bert based model [ ] to run semantic role labeling and identify the action words (verbs), which capture the actions people are referring to in the tweets. to identify the uniquely representative verbs in each group, we identify all the verbs in each group and use tf-idf vectorization to remove the common verbs across the groups. we then compute the verb frequency of remaining verbs in each group. figure shows the verbs and their frequencies. the results capture the top verbs defining each group. for example, the school closures group has close as its top verb which signifies the closing of schools while learn, read, and teach emphasize the actions corresponding to learning online because of the pandemic. in comparison some words such as mean and post are challenging to understand without additional context, so we present examples tweets containing these words to understand the context in which they are used in table v . all tweets with mean have a similar context but post is used in two different contexts. one refers to send and the other refers to the post pandemic period. along the same lines, verbs in other groups also signify people's actions during the pandemic. the panic buying group captures actions such as buy, wash, hoard, sell, and to further analyze the context in which the action words discussed in section iii-e are used, we analyze the words associated with them using dependency parsing. dependency parsing breaks down each sentence into linguistic dependency structures organized in the form of a tree. we focus on identifying the nouns that are connected to the action words. in the dependency parse, the action words/verbs form the root of the parse and the dependencies are in the left and right subtrees. to identify the nouns associated with the verbs, we traverse the dependency parse to the sub-tree where the action word of interest is present and then extract the corresponding noun. we also analyze the link associated with noun and verb and find that "nsubj" (nominal subject), "pobj" (object of a preposition) and "dobj" (the direct object) are the most related link tags that contribute to the action words. figure gives some notable dependency parse subtrees with the action word and the corresponding noun. we can see that by decoding the parse structure, we can identify additional contextual information such as the nouns they refer to. we use the allennlp implementation of a neural model for dependency parsing using biaffine classifiers on top of a bidirectional lstm [ ] . we parse the sentences associated with the top verbs in figure and find their associated nouns to understand what the action verbs are used to signify. tables vi, vii, viii, ix represent the different nouns associated with the most prominent action words in each group, respectively. general covid being the diverse group, it contains a myriad of tweets from offering support to the fear of getting infected. apart from the verb-noun combinations that we expect to see in the group (such as test virus, confirm case, offer support), the other most notable verb-noun combinations in this group are: deal stress, deal anxiety, fear system, and fear safety. and in other groups, the verb-noun combinations narrow down on the specific actions relevant to the group. for instance, in school closures, the action word close mostly talks about closing the schools for benefit of students, and action word offer co-occurs with teaching aids through online sources. in the panic buying group, tweets about the panic experienced by people is captured by verb-noun pairs such as stop madness, buy paper, find store. in the lockdown group, some interesting combinations surface such as believe information, guess trust, which captures the possible distrust people have with the lockdown measures. nouns such as insanity also help in capturing peoples' reaction to the lockdown measures. in this section, we use seeded lda [ ] to categorize the tweets and check the closeness of these automatically obtained groups with our manual grouping using the hashtags. as we are specifically interested in isolating the tweets in specific topics of our interest than general topics identified by a topic model, we leverage a seeded variant of lda, seeded lda [ ] to guide the topic model to discover them. seeded lda allows seeding of topics by providing a small set of keywords to guide topic discovery influencing both the document-topic and the topic-word distributions. the seed words need not be exhaustive as the model is able to detect other words in the same category via co-occurrence in the dataset. our goal with seeded lda is to i) present a way to automatically categorize tweets into specific topics of interest, especially when the topics are rarer in the dataset, ii) passively evaluate the effectiveness of our word analysis thus far, and iii) develop a scalable approach that can be extended to millions of tweets with minimal manual intervention. we develop a seeded lda model to categorize tweets into the five hashtag groups: i) general covid, ii) school closures, iii) panic buying, iv) lockdowns, and v) quarantine by seeding each group with seed words from our analysis in section iii-b. we leave out the frustration and hope topic due to the inherent polarizing nature of the keywords and the lack of identifying keywords that are unique for the topic. we select the top few words from our words in figure as seed words for our seeded lda model. table x gives the seed words for the different covid categories. we include k unseeded topics in our model to account for messages that do not fall into these topic categories. after experimenting with different values of k and manually evaluating the topics, we find that k = gives us the best separation and categorization. we use α = . and β = . to give us sparse documenttopic and topic-word distributions where fewer topics and words with high values emerge, so we can classify the tweets to the predominant category. we train the seeded lda models for iterations. we first use the documenttopic distribution to get the best topic for each tweet. if the best topic of the message is one of the seeded topics which correspond to the categories, then, we classify the tweet into that category. in the event that a clear best topic does not emerge, we randomly assign the tweet to one of the topics that have the same document topic distribution. ) analyzing effectiveness of seeded lda model: to check how closely the hashtag groups match with the seeded lda groups, we measure the accuracy by comparing the document topic distribution from the lda against the grouping determined by the hashtags. we do this by calculating the confusion matrix which gives us four metrics such as true positives, true negatives, false positives, and false negatives to further calculate accuracy, precision, recall, and f scores, which gives the value of correctness. the results we obtained are shown in the table xi . this endeavor helps in determining the effectiveness of our word analysis (seeds) and our seeded lda model. also, to verify that our model had best results in the groups that we are interested in, we calculate the precision, recall, and f scores for the school closures, panic buying, lockdowns, and quarantine groups. we exclude general covid and frustration and hope groups as they are too general, and we are interested in isolating the more specific covid groups. table xii shows the results of each group. by examining the result, we observe that the manual grouping of the hashtags have significant match with the seeded lda groups. we also note that the seeded lda model is able to correctly isolate the tweets in rarer groups where there is less data, such the school closures group. this shows the effectiveness of our model to analyze rarer groups in the data. additionally, from the precision of classification for the quarantine group, we observe that the false positives were significantly low and further adds credibility to our model. iv. related work in this section, we outline existing research related to modeling and analyzing twitter and web data to understand social, political, psychological, and economic impacts of a variety of different events. due to the recent nature of the outbreak, there is little to no published work on covid- . we primarily focus on discussing work that analyze twitter communications. ahmed et al. focus on the conspiracy theories surrounding the novel coronavirus, especially in relationship with g [ ] . the authors analyze twitter communications and discuss the possibility of using bots for propagating misinformation and political conspiracies during the pandemic [ ] , [ ] . in comparison, the authors in [ ] conduct infodemiology studies on twitter communications to understand how information is spreading during this time, while the the stigma created by referencing the novel coronavirus as "chinese virus" is investigated in [ ] . twitter has been used to study political events and related stance [ ] , [ ] , human trafficking [ ] , and public health [ ] , [ ] , [ ] , [ ] , [ ] . several work perform fine-grained linguistic analysis on social media data [ ] , [ ] , [ ] . v. discussion and concluding remarks in this paper, we studied twitter communications in the united states during the early days of the covid- outbreak. as the disease continued to spread, we observed panic buying as well as calls for closures of schools, bars, cities, social distancing and quarantining. we conducted a linguistic word-usage analysis and identified the most frequently occurring unigrams and bigrams in each group that provide us an idea of the main discussion points. we conducted sentiment analysis to understand the extent of positive and negative sentiments in the tweets. we then performed semantic role labeling to identify the key action words and then obtained the corresponding contextual words using dependency parsing. finally, we designed a scalable seeded topic modeling approach to automatically identify the key topics in the tweets. discovering, assessing, and mitigating data bias in social media roberta: a robustly optimized bert pretraining approach simple bert models for relation extraction and semantic role labeling deep biaffine attention for neural dependency parsing incorporating lexical priors into topic models covid- and the g conspiracy theory: social network analysis of twitter data coronavirus goes viral: quantifying the covid- misinformation epidemic on twitter what types of covid- conspiracies are populated by twitter bots?" first monday creating covid- stigma by referencing the novel coronavirus as the ?chinese virus? on twitter: quantitative analysis of social media data conversations and medical news frames on twitter: infodemiological study on covid- in south korea all i know about politics is what i read in twitter: weakly supervised models for extracting politicians' stances from twitter bumps and bruises: mining presidential campaign announcements on twitter the impact of environmental stressors on human trafficking using twitter to understand the human bowel disease community: exploratory analysis of key topics how social media will change public health detecting and characterizing mental health related self-disclosure in social media predicting depression via social media characterizing sleep issues using twitter fine-grained analysis of cyberbullying using weakly-supervised topic models a socio-linguistic model for cyberbullying detection weakly supervised cyberbullying detection using co-trained ensembles of embedding models key: cord- -qqrhvlm authors: shoghri, ahmad el; liebig, jessica; jurdak, raja; gardner, lauren; science, salil s. kanhere school of computer; engineering,; wales, university of new south; sydney,; australia,; data ,; scientific, commonwealth; organization, industrial research; brisbane,; science, school of computer; technology, queensland university of; civil, department of; engineering, systems; university, johns hopkins; baltimore,; usa,; innovation, research center for integrated transport; sydney, unsw title: identifying highly influential travellers for spreading disease on a public transport system date: - - journal: nan doi: nan sha: doc_id: cord_uid: qqrhvlm the recent outbreak of a novel coronavirus and its rapid spread underlines the importance of understanding human mobility. enclosed spaces, such as public transport vehicles (e.g. buses and trains), offer a suitable environment for infections to spread widely and quickly. investigating the movement patterns and the physical encounters of individuals on public transit systems is thus critical to understand the drivers of infectious disease outbreaks. for instance previous work has explored the impact of recurring patterns inherent in human mobility on disease spread, but has not considered other dimensions such as the distance travelled or the number of encounters. here, we consider multiple mobility dimensions simultaneously to uncover critical information for the design of effective intervention strategies. we use one month of citywide smart card travel data collected in sydney, australia to classify bus passengers along three dimensions, namely the degree of exploration, the distance travelled and the number of encounters. additionally, we simulate disease spread on the transport network and trace the infection paths. we investigate in detail the transmissions between the classified groups while varying the infection probability and the suspension time of pathogens. our results show that characterizing individuals along multiple dimensions simultaneously uncovers a complex infection interplay between the different groups of passengers, that would remain hidden when considering only a single dimension. we also identify groups that are more influential than others given specific disease characteristics, which can guide containment and vaccination efforts. human mobility continues to play a vital role in spreading infectious diseases within a population [ ] [ ] . ongoing population growth and the high reliance of individuals on public transport services in highly populated cities provide a suitable platform for contagious diseases, such as measles, the recently emerged coronavirus and influenza, to spread widely and rapidly [ ] [ ] [ ] . for example, individuals travelling on a bus are in close enough proximity to infect each other and can carry the infection to distant locations across the public transport network [ ] [ ] . additionally, some pathogens may remain in the environment (e.g. a bus) for a prolonged period and can infect susceptible individuals after the infectious person has left the area [ ] [ ] . furthermore, transport services shorten distances and times and strongly connect different suburbs, potentially exposing communities to a high infection risk [ ] . the risk of disease spread due to human movement is evident from the current novel coronavirus outbreak in china and internationally, with chinese authorities shutting down public transportation within the affected area [ ] . the recent uptake of smart travel cards and the availability of this data have created an unprecedented proxy to elicit different travelling behaviours and to study their effects on disease spread [ ] [ ] . the analysis of such data is critical to understand the spreading dynamics of a disease and consequently to develop effective containment strategies [ ] . previous studies investigated several spreading dynamics of infectious diseases, however, to the best of our knowledge none of the studies has incorporated different aspects and dimensions of mobility behaviour simultaneously. in this paper we study three aspects of mobility behaviour, i.e. the degree of exploration, the distance travelled and the number of encounters of passengers using the sydney bus network in the context of infectious disease spread. by considering the three dimensions simultaneously, we identify previously unknown mobility behaviours. the high spatiotemporal resolution of the dataset allows us to construct a time resolved physical human contact network to simulate disease spread. specifically, we trace the infection flows between groups of passengers who display different mobility behaviours to investigate the change in the spreading dynamics. in addition, we investigate how changes in the infection probability and the time pathogens remain suspended in the environment affect the spreading of the disease. this study identifies the most influential passenger groups in a disease spread scenario for different disease characteristics and types. our simulation results identify four dominant transmission paths between the mobility groups that should become a focus of containment efforts. in addition, we find that highly connected passengers who regularly visit the same places have the highest spreading power when pathogens do not remain in the environment. however, with an increase in the suspension time of pathogens, highly connected passengers who visit new locations become the most efficient spreaders. an increase in the infection probability on the other hand, amplifies the spreading power of all mobility groups, especially for passengers who regularly visit the same places and travel short distances, until reaching a saturation point at a probability of . . the remainder of the paper is organised as follows: we begin by discussing relevant previous work in section ii. in section iii we present our framework for modelling infectious diseases on human contact networks. we explain the approach for classifying the individuals based on their movement behaviour and introduce the dataset that we use for our case study. in section iv we run extensive trace driven simulations to investigate the underlying interactions and disease transmission dynamics between the different groups of passengers. furthermore, we study the effect of changing the infection probability and the time pathogens remain in the environment on the transmission dynamics. finally, we identify the most influential mobility behaviours for various disease characteristics, which can guide intervention strategies. section v concludes the paper. studies of epidemiology have long recognized that human mobility plays a key role in fostering severe disease epidemics that may result in high rates of morbidity and mortality [ ] . furthermore, these studies have acknowledged the importance of identifying the most influential individuals, as it can aid to predict outbreaks before their occurrence [ ] [ ] . health related datasets and detailed patient mobility profiles present informative data that may be used to reflect the status of a disease and its progression [ ] [ ] . however, accessing such information is challenging due to privacy concerns and other related issues [ ] [ ] . in the absence of health related data, previous work has studied alternative data sources. an important body of research has explored the use of call detail records (cdrs) and data from the global positioning system (gps) to build epidemiological models and to study the spatial transmission of various diseases in a population at both city and country levels [ ] [ ] . in [ ] cdr and gps datasets were exploited to extract two types of mobility behaviours. the authors used the recurrent mobility and the total mobility characteristics to group individuals into returners and explorers. returners are individuals who can be characterized by their most visited locations as these dominate their movement behaviour, whereas explorers are individuals who often visit new places and cannot be characterized by their most frequently visited locations. the statistical measure used to compute the total mobility of an individual is the total radius of gyration r g , defined as [ ] : where l is the set of all visited locations by the individual, r i is the coordinates of the visited location i, n i is the individuals visitation frequency of location i, r cm is the centre of mass of all visited locations and n is the total number of visited locations. the authors also defined the k-radius of gyration, denoted r g (k) , which is similar to the overall mobility formula, with the difference that the set of locations l is reduced to the k most visited locations. the value of r g (k) represents the recurrent mobility of the individual. the correlation between the recurrent and the total mobility values distinguishes between the two mobility patterns, namely returners and explorers. if the recurrent mobility of an individual dominates the total mobility, that is r g (k) > r g / , the individual is classified as a returner. otherwise, the individual is an explorer. the authors of [ ] found that explorers have more impact on disease spread than returners. their experiments consisted of , individuals chosen randomly from a pool of , individuals. to study the impact of each mobility behaviour on the spreading, different proportions of returners and explorers were used. the extent of disease spread is computed through the global invasion diffusion threshold r * . this experimental setup presents three main limitations. first, changing the proportion of the mobility groups alters the topology and the characteristics of the network being studied. second, the contact links connect geographical areas rather then actual human physical encounters. third, their study of spreading power was performed on a static network in which if a link existed at any point in time that link is considered present during the entire period of study. these limitations make the experiments theoretical as they study a snapshot of a possibly unrealistic contact network. several other limitations emerge when cdr and gps datasets are used in the context of disease spread [ ] [ ] . most importantly, these datasets lack accurate localization of the individuals due to the distant positioning of cellular towers and poor satellite signals [ ] . hence, these datasets do not guarantee the existence of real physical encounters between the individuals [ ] . in addition, individuals who are tracked via gps may be driving a car and hence are not in physical contact with other individuals [ ] . recent studies of epidemiology showed an increasing interest in dynamic networks that guarantee the existence of real physical human contact when studying disease spread [ ] . a well suited source of data to study the spreading dynamics of diseases in dense cities are public transit records [ ] . several studies have confirmed the presence of a risk factor between the use of bus transportation services and the spreading of many airborne diseases such as tuberculosis, measles and influenza [ ] [ ] . the authors of [ ] stated that bus routes "are veins connecting even the most diverse of populations" and showed that individuals who reported regular use of buses are more likely to be infected by tuberculosis. in fact, the congregated and enclosed setting of buses presents a suitable environment for any contagious respiratory disease to spread widely. the infectious pathogens can easily be transmitted onward among passengers through coughing and sneezing [ ] . in addition, natural and artificial air flow can move suspended pathogens through space. this makes all individuals in an enclosed space like a bus susceptible. in our previous work [ ] we confirmed the existence of explorers and returners in the public bus transit dataset of sydney, australia. furthermore, through extensive simulations, we showed that explorers are generally more influential in spreading a disease through the network in comparison to returners. also, long distance travellers were found to be more influential than short distance travellers. however, when only long distance travellers are considered returners showed a greater propensity in spreading the disease over explorers. the work proved the presence of a deeper and more complex interplay between various mobility aspects when it comes to spreading a disease on a public transport system. in our previous work we did not consider the connectivity aspect of the individuals, which holds critical information in contact based spreading scenarios. further, our simulations only considered direct encounters between passengers and assumed an infection probability of . while disease transmission is possible through direct encounters (i.e. the infected and the susceptible individual are present in the same place at the same time), pathogens can remain in the environment for an extended period of time [ ] [ ] . therefore, an infectious person can infect susceptible individuals without a direct encounter. contact networks where only direct encounters are considered are commonly called spst (same place same time) networks. networks that in addition to direct contacts capture indirect encounters caused by suspended pathogen are called spdt (same place different time) networks. previous studies have shown that considering the suspension time of pathogens changes the underlying topology of the contact network and alters the spreading dynamics of contagious diseases significantly [ ] [ ] . this paper addresses the limitations of our previous work through the addition of the connectivity dimension and by considering different suspension times of particles and infection probabilities. we identify groups of passengers that have a high potential to spread a disease through a public bus network. although there are several studies that recognized the importance of human mobility data to identify the most influential individuals in a network, none of the studies tried to use a comprehensive mobility dataset to extract patterns along different movement aspects simultaneously and study the detailed interaction between the different patterns. in particular, we consider the passengers' total mobility, recurrent mobility and connectivity. the impact of each group on the spreading will be evaluated as all the infectious activities occurring in the background of the simulations are traced. to understand the disease spread dynamics on a public transport network we construct spst and spdt contact networks from the smart card data and run a susceptible-infected-recovered (s-i-r) disease spread model on top. at the beginning of the simulation all bus passengers, except a given number of randomly chosen seed nodes, are susceptible. the seed nodes are infectious and able to transmit the disease to susceptible individuals. when a susceptible individual encounters an infectious individual or, in the case of spdt networks, comes in contact with pathogens that remain in the environment, the susceptible individual moves to the infectious state with a given probability. the individual remains infectious for a given period of time before recovering from the disease. once in the recovered state the individual is no longer susceptible and remains in the recovered state until the end of the simulation. figure exemplifies the s-i-r disease spread simulation on the bus network. we demonstrate how the spreading dynamics are affected by changing two key parameters, namely the probability of infection, denoted β and the suspension time of pathogens, denoted d t . the case d t = corresponds to an spst disease spread scenario and hence a susceptible passenger will be infected only if both individuals meet on the same bus at the same time. when d t > the infectious particles remain on the bus for an additional time d t , allowing the infectious passenger to infect susceptible individuals after disembarking. while simulating the empirical movements of individuals, we track all encounters and infection transmissions. at every encounter the identification number of the two passengers in contact are recorded. similarly, when an infection is transmitted the identification numbers of the infectious and the susceptible individuals are recorded. to understand how different mobility behaviours influence the transmission paths of the simulated disease we classify the bus passengers into different mobility groups. we modified the opportunistic network environment (one) simulator [ ] to carry out our trace driven simulations and spread a disease on a large scale real-world transport network. before running the disease simulations on the constructed networks, we cluster the bus passengers into different groups, based on their mobility behaviour. to do so, we simultaneously consider the degree of exploration, the distance travelled and the number of encounters during the period of study. first, we plot passengers' mobility profiles in three-dimensional space, with the x-axis corresponding to the passenger's total radius of gyration, the y-axis corresponding to the k-radius of gyration (i.e. the recurrent mobility) and the z-axis corresponding to the number of encounters. next, we cluster the individuals into two groups along each dimension. the degree of exploration is divided into returners and explorers, the distance travelled into short distances and long distances and the number of encounters into low connected and highly connected individuals. classifying our passengers along the three dimensions results in = different types of movement behaviours. in order to identify each of the groups, we normalize the values of the three dimensions between [ , ] and use the approaches detailed in the following subsections. ) returners and explorers: to split the population based on the degree of exploration, we project all the points onto the xy-plane and use the bisector method to differentiate between returners and explorers. when plotting the passengers' total mobility and recurrent mobility values on the cartesian plane, points along the x-axis correspond to explorers as their recurrent mobility does not dominate their total mobility and points along the y = x line correspond to returners whose total mobility can be well represented by their recurrent mobility as r g (k) ≈ r g . our clustering approach results in . % explorers and . % returners. ) short distances and long distances: to cluster the passengers based on their travelled distance, we project the points onto the x-axis and apply a standard k-means clustering algorithm [ ] with k= . this results in two groups, namely, passengers who travel short distances and have a relatively low radius of gyration ( %) and passengers who travel long distances and have a relatively high radius of gyration ( %). ) low connected and highly connected individuals: in order to cluster the passengers based on their degree centrality (i.e. the number of encounters) we use a similar approach as in the previous section. we project the points onto the z-axis and apply the standard k-means clustering algorithm [ ] with k= , which splits the population in low connected passengers ( . %) and highly connected passengers ( . %). specifically, we differentiate between passengers who encounter a high number of other passengers and those who experience fewer encounters with other passengers during the month of study. the public transport dataset consists of , , trips made by million bus users. the dataset is recorded in the greater sydney area of new south wales, australia during the month of april in . each trip record records the following information: the passenger's smart card identification, the bus number in use and the time and location the passenger entered and exited the bus. sydney for a short time or travellers who lost or damaged their card. as infrequent travellers cannot be classified accurately due to the lack of sufficient data records, we remove these passengers from our analysis. in order to explore how a threshold on the number of trips affects the total number of passengers included in our analysis, we plot in fig. the population size against varying threshold values between and the maximum number of trips observed in the data. the population size drops rapidly with the increase of the threshold especially at low values. this is due to the high number of passengers who use the bus only occasionally (see fig. ). for our analysis, we set the threshold to trips per month. that is, individuals who travelled less than times with the bus during april are excluded from the analysis. the threshold of trips is chosen so that the passengers have travelled at least on half of the days of the month. the final dataset has , , records belonging to , bus passengers. in fig. we compare some key topological aspects of the original and the resulting networks. figure .a shows the distribution of connected component sizes for both networks. we notice that the two networks have similar structures, with a giant component and several smaller components. there are fewer components of size one in the resulting network, which can be attributed to the fact that the original network contained many infrequent travellers who were isolated from the rest of the network. this observation also applies to the isolated components consisting of less than eleven individuals. figure .b shows the degree distribution of the original and the resulting networks. the degree of a passenger is the total number of direct encounters experienced during the month of april. we notice that the degree distributions of the original and the resulting networks increase linearly until reaching maximum values of , and , respectively. then both distributions drop exponentially. the drop in the frequencies of the resulting network is due to the removal of passengers who travelled less than trips. the difference between the two distributions is especially clear at low degree values as passengers with few number of trips are less likely to have higher number of contacts. in this section, we present the identified mobility patterns and discuss the results of our disease spread simulations. the different groups resulting from our classification and clustering tasks are visualized in fig. . all subfigures display the same plot from a different angle. each point in fig. corresponds to one individual in the dataset and its coordinates represent the values of the three-dimensional movement behaviour of the corresponding passenger. in the coming figures and tables we refer to the groups using the notation {degree of exploration} {connectivity} {distance travelled}. the pie chart in fig. summarizes the percentage of each of the eight classified groups of passengers in the network. we notice that highly connected returners who travel short distances constitute the major portion ( . %) of the population. this group of individuals are regular commuters who tend to use public transportation to commute between home and work during peak hours and rarely explore or visit other places during the month. . % of public transport users are classified as low connected returners who travel short distances. we believe that these individuals regularly travel to specific locations that are less crowded or during off-peak hours, for example people who go to shopping malls in the afternoon. on the other hand, explorers are individuals who in addition to their regular commute visit other places, for example going to malls to shop or going to touristic attractions for leisure. the following subsections present and discuss our simulation results. for every experiment, we randomly choose individuals who are infectious at the beginning of the simulation and can transmit the disease to susceptible individuals. individuals remain infectious for five days (which is the average infectious period for influenza [ ] ) before recovering. every experiment is simulated times and the results averaged. in our first experiment we set the infection probability β to and the pathogen suspension time d t to , corresponding to an spst disease spread scenario. this experiment serves as a baseline for comparison to other parameter settings that are explored in further simulations. in table i , we present the total number of encounters and the total number of infections that were transmitted and received by every mobility group. in addition, we compute the average number of encounters, the average number of transmissions and the average number of infections received per individual for each group. dividing the total number of infections caused by a given group by its population size results in the average number of infections that one individual from that group causes during the simulation period. this average value of infections is not constrained to a specific target group but to all groups in the network. similarly, dividing the total number of infections received by a given group by its population size, results in the average number of infections that one individual of that group receives during the simulation period. interestingly, the averages of received infections per individual is nearly the same across all the groups with a value just divide individuals into explorers and returners, but to distinguish them further along other dimensions such as the distance travelled and the connectivity as their spreading abilities differ. in order to visualise the disease transmission dynamics between the groups we use a chord diagram (see fig. ). the diagram shows cumulative disease flows between the different groups. the eight different groups are represented by circle segments, with each group being associated to a unique colour. for example, the red segment corresponds to highly connected explorers who travel long distances (see label "a" in fig. ) . the links indicate the volume of disease transmissions between any two groups and are assigned the same colour as the source group. the thickness of each link is proportional to the average number of people that one individual from the source group infects in the target group. for example, the link labeled "b" shows the volume of disease flow transmitted from the group of highly connected explorers who travel long distances (red segment) to the group of highly connected returners who travel short distances (blue segment). links that start and end at the same segment represent disease transmissions between individuals of the same mobility group. for scaling purposes, we multiply all average number of infections caused per individual by and show the resulting values in the chord diagram. the diagram in fig. clearly identifies four dominant infection paths. these occur amongst highly connected returners who travel long distances (cyan segment) with individuals causing on average . infections within their own mobility group and highly connected returners who travel short distances (blue segment) with individuals causing on average . infections within their own mobility group. highly connected explorers who travel long distances (red segment) infect on average . highly connected returners who travel short distances (blue segment) during the simulation period. highly connected explorers who travel short distances (orange segment) infect on average . highly connected returners who travel short distances (blue segment). furthermore, low connected returners who travel short distances form a group that is prone to receive infections, but less likely to infect individuals from other groups (see the incoming non-pink links that occupy the majority ( %) of the pink segment in fig. and table i ). on the other hand, highly connected explorers who travel long distances have caused the greatest number of infections per individual on average. however, this group is less likely to get infected in comparison to other groups (see red segment in fig. ) . we observe that the disease transmissions from highly connected explorers who travel long distances dominate this group's activity as the red outgoing links going to all other groups constitute the majority of the segment with more than %. that is, even a low number of infected individuals of this group would be sufficient to infect other groups and spread the disease through the entire network. highly connected explorers who travel long distances infect . individuals on average during the simulation period. highly connected returners who travel short distances receive a high number of infections and mostly infect individuals within their own group (see blue segment in fig. ). this behaviour is expected, as this group consists of regular commuters who display consisted movement behaviour. highly connected returners who travel long distances (see cyan segment in fig. ) display a similar behaviour of mostly infecting individuals within their own group. highly connected explorers who travel the mobility groups are represented by differently coloured circle segments (e.g. the red segment, labelled "a", corresponds highly connected explorers travelling long distances). links represent disease flow between mobility groups and are coloured by the source group. the link with label "b" shows the average number of infections that highly connected explorers who travel long distances transmit to highly connected returners who travel short distances. "c" refers to the start of the link coloured by the receiving group. "d" refers to the end of the link coloured by the transmitting group. "e" refers to the relative infection transmissions, receptions and overall total for each segment. long distances spread infections to all other groups (see red segment in fig. ) , although the average number of encounters is lower than groups who infect specific target groups. our results highlight important interactions between the eight identified groups and shed light on disease spread dynamics that should be given more attention while monitoring a disease and applying prevention measures. to understand how different disease types and characteristics change the spreading dynamics between the eight groups, we perform two additional experiments. in this experiment, we run the simulations with different suspension times of pathogens, i.e. d t = , , and minutes, while keeping β = . for each value of d t we construct a matrix that shows the difference in the average number of infections caused and received by each mobility group in comparison to experiment (β = , d t = ). positive values refer to a gain in disease transmissions, whereas negative values indicate a loss. the rows of the matrix correspond to the groups that cause the infections and the columns correspond to the groups that receive the infections. figures .a and .b show the matrices for a suspension time of minutes and minutes, respectively. the matrix in fig. .a shows that the average number of infections caused per individual increased or remained the same for the four groups of explorers (top four rows of the matrix). the spreading potential of the four groups of returners (bottom four rows of the matrix) generally decreased. as the suspension time is increased to minutes, we observe further increases in the average number of infections caused by explorers and further decreases for returners (see fig. .b). we highlight that the increase in d t weakens the spread of infections within (self-loops) the two groups of highly connected returners. the loss in the infection power of returners coincides with an increase in infections caused by explorers, especially for highly connected explorers who travel long distances. since almost every individual of the population is infected at the end of the simulation period, we conclude that an increase in the time that pathogens remain in the environment favours the infection power of explorers. that is, explorers are even more influential in an spdt disease spread scenario. we only show the results for d t = and as no change in the behaviour was seen for d t = and , the values for explorers keep increasing and those of returners decrease. in the third experiment, we vary the infection probability β, while setting the pathogen suspension time d t = . the considered probabilities are . , . , . , . , . , . and . to understand the effect of the infection probability on the disease spread we construct matrices that show the differences in the average number of infections caused per individual between each two consecutive values of β. the average number of infections caused per individual increases rapidly for all groups with an increase of β from . to . . this result is visualised in fig. with all matrix elements being positive. when β is increased from . to . we see only a slight increase in the spreading power of all groups. further increases of β to . and do not result in significant changes in spreading powers. figure shows that all individuals who travel short distances experienced the most increase in the number of received infections, whether they are low or highly connected. this pattern can be seen through the dark coloured columns of the short distances groups. the observation is due to these groups constituting the highest percentages in the network allowing them to have the highest total number of encounters (see fig. and table i ). in addition, the increase in the probability of infection strengthens the self-loops of the groups (infections within the same group), especially those of the short distance returners. we conclude that increasing the infection probability favours the spreading power all mobility groups. the increase of spreading power is relative to the interaction between each pair of mobility groups. for increasing infection probabilities each element in the matrix increases until ultimately reaching the values presented in section iv-b in which the probability is set to . this is the first study to identify mobility patterns along three dimensions simultaneously, namely the degree of exploration, the distance travelled and the number of encounters. we found previously unknown mobility patterns that were thoroughly investigated to understand the spreading dynamics of contagious diseases on a city wide public transport system. we ran extensive disease spread simulations with varying values for the infection probability and the suspension time of pathogens. our results show that characterizing individuals along multiple dimensions simultaneously uncovers a complex infection interplay between the different groups of travellers. furthermore, the infection probability and the suspension time of pathogens play different roles in the spread. highly connected passengers who regularly return to the same places play the most important role in the spreading when pathogens do not remain in the environment. however, with an increase in the suspension time of pathogens, highly connected passengers who visit new locations are the most influential. unlike the suspension time, increasing the infection probability does not affect particular mobility groups, but increases the infection power of all groups especially for returners who travel short distances. our simulation experiments are abstractions of the real-world and flexible to adapt to different contexts. we presented a framework that can be applied to model any disease that is spread through a physical contact network. our findings are especially beneficial to advise health authorities on the design of more efficient intervention and containment strategies depending on the characteristics of the emerging diseases. we plan to open-source the modified simulator in order to be used broadly for similar types of datasets and scenarios. impact of indirect contacts in emerging infectious disease on social networks disease and mobility: a neglected factor in epidemiology investigating physical encounters of individuals in urban metro systems with large-scale smart card data the roles of transportation and transportation hubs in the propagation of influenza and coronaviruses: a systematic review wuhan shuts public transport over outbreak airborne biological hazards and urban transport infrastructure: current challenges and future directions bernard mans, and frank de hoog. indirect interactions influence contact network structure and diffusion dynamics connecting mobility to infectious diseases: the promise and limits of mobile phone data big data for infectious disease surveillance and modeling a comparison of spatial-based targeted disease containment strategies using mobile phone data commentary: containing the ebola outbreak-the potential and challenge of mobile network data beyond doctors: future health prediction from multimedia and multimodal observations quantifying the impact of human mobility on malaria integrating rapid risk mapping and mobile phone call record data for strategic malaria elimination planning impact of human mobility on the emergence of dengue epidemics in pakistan using mobile phone data to predict the spatial spread of cholera quantifying seasonal population fluxes driving rubella transmission dynamics using mobile phone data the impact of human mobility on hiv transmission in kenya unveiling spatial epidemiology of hiv with mobile phone data returners and explorers dichotomy in human mobility using gps technology to quantify human mobility, dynamic contacts and infectious disease dynamics in a resource-poor urban environment on the use of human mobility proxies for modeling epidemics efficient detection of contagious outbreaks in massive metropolitan encounter networks giving tb wheels: public transportation as a risk factor for tuberculosis transmission how mobility patterns drive disease spread: a case study using public transit passenger card travel data the one simulator for dtn protocol evaluation scikit-learn: machine learning in python key: cord- -jle lmn authors: rommereim, d. n.; rommereim, r. l.; sikov, m. r.; buschbom, r. l.; anderson, l. e. title: reproduction, growth, and development of rats during chronic exposure to multiple field strengths of -hz electric fields date: - - journal: fundam appl toxicol doi: . /toxsci/ . . sha: doc_id: cord_uid: jle lmn reproduction, growth, and development of rats during chronic exposure to multiple field strengths of -hz electric fields. rommereim, d. n., rommereim, r. l., sikov, m. r., buschbom, r. l., and anderson, l. e. ( ). fundam. appl. toxicol. , – . a study with multiple exposure groups and large group sizes was performed to establish whether exposure to -hz electric fields would result in reproductive and developmental toxicity. a response model was developed from previous results and tested in groups of rats exposed to electric fields at various field strengths. female rats were mated, and sperm-positive animals randomly distributed among four groups: sham-exposed or exposed to , , or kv/m, -hz vertical electric fields. animals were exposed for hr/day throughout the experiment. during gestation, exposure to the higher field strengths resulted in slightly depressed weight gains of dams. offspring were born in the field and remained with their dams through the suckling period. numbers of pups per litter and pup mortality did not differ among the exposure groups. dams exposed at kv/m lost slightly more weight through the lactation period than the control group. male pups exposed to higher field strengths gained slightly less weight from to days of age than did sham-exposed animals. at weaning, two f( ) females per litter (randomly selected) continued on the same exposure regimen were mated at weeks of age to unexposed males, and euthanized at days of gestation. uterine contents were evaluated, and all live fetuses were weighed and examined for external, visceral, and skeletal malformations. fertility and gestational weight gain of f( ) females were not affected by exposure, nor was prenatal viability or fetal body weight. no significant increase in the incidence of litters with malformations was observed. although no developmental toxicity was detected, exposures produced physical changes in the dams, evidenced as a rust-colored deposit on the muzzle and ears (chromodac-ryorrhea) that increased in incidence and severity at and kv/m. incidence of chromodac-ryorrhea was not significantly different between sham-exposed rats and those exposed at kv/m. buschbom, r. l., and anderson, l. e. ( ) . fundam. and appl. toxicol. , - . a study with multiple exposure groups and large group sizes was performed to establish whether exposure to -hz electric fields would result in reproductive and developmental toxicity. a response model was developed from previous results and tested in groups of rats exposed to electric fields at various field strengths. female rats were mated, and sperm-positive animals randomly distributed among four groups: sham-exposed or exposed to , , or kv/m, -hz vertical electric fields. animals were exposed for hr/day throughout the experiment. during gestation, exposure to the higher field strengths resulted in slightly depressed weight gains of dams. offspring were born in the field and remained with their dams through the suckling period. numbers of pups per litter and pup mortality did not differ among the exposure groups. dams exposed at kv/m lost slightly more weight through the lactation period than the control group. male pups exposed to higher field strengths gained slightly less weight from to days of age than did sham-exposed animals. at weaning, two f| females per litter (randomly selected) continued on the same exposure regimen were mated at weeks of age to unexposed males, and euthanized at days of gestation. uterine contents were evaluated, and all live fetuses were weighed and examined for external, visceral, and skeletal malformations. fertility and gestational weight gain of f| females were not affected by exposure, nor was prenatal viability or fetal body weight. no significant increase in the incidence of litters with malformations was observed. although no developmental toxicity was detected, exposures produced physical changes in the dams, evidenced as a rust-colored deposit on the muzzle and ears (chromodacryorrhea) that increased in incidence and severity at and kv/m. incidence of chromodacryorrhea was not significantly different between sham-exposed rats and those exposed at kv/m. o society of toxicology. effects on survival, growth, and development used to detect effects of electric field exposure of laboratory animals (mice and rats) exposed on reproduction and development in a larger to electric fields during gestation or neonatal species (sikov el al., ) . swine were life have previously been reported (icnicker-chronically exposed to a kv/m, -hz bocker«a/., ; marino el al., marino el al., , ; electric field over two generations. maternal sikov el al., ) . however, the magnitudes weight gain during pregnancy, number of of observed changes were small, and effects embryonic implants, and number of offhave been inconsistent across studies. spring per litter were not affected. survival more recently, a multigeneration screening rates of the offspring and their growth curves study utilizing hanford miniature swine was were also indistinguishable between groups. however, comparison of offspring from dams exposed or sham exposed for months showed mean body weights of male fetuses and mean body weights of female piglets to be less in the exposed group. in addition, an increase in frequency of malformations was observed in fetuses of exposed females. a clear association of the changes with exposure, per se, could not be demonstrated because of a number of inconsistencies in response patterns and the possibility of interacting factors . subsequently, rats were used to investigate the possible effects of electric field exposure on development and reproduction. two, essentially identical, multiple-generation rat experiments were conducted . copulatory behavior, gestational weight gains, pup weights at birth, and their subsequent growth curves were not affected by exposure. in one of the replicate experiments, there was a statistically significant decrease in fertility and a significant increase in the fraction of litters with malformed fetuses among exposed animals. however, in the second replicate, no significant developmental effects were detected in fetuses of dams exposed throughout gestation. a clear association of reproductive or developmental changes with exposure could not be demonstrated. effects detected in the first experiment were not seen in the second and were attributed to either normal biological variation or a response threshold near kv/m for induction of malformations. accordingly, in the study reported here we tested for a treatment-related response, utilizing multiple exposure groups, including -cv/m (effective field strength) as used in our arevious experiments; kv/m which was :wice as strong as that used in the previous ,vork and had been shown to be tolerated by •ats (rommereim et al, ) ; the lowest evel of exposure ( kv/m) was chosen to deineate the response curve at lower field strengths or possibly to determine a no-obierved-effect level; and the fourth group was sham-exposed as a control. additionally, the chance of obtaining equivocal results due to biological variation was minimized by using large group sizes with the initial group populations of female rats per treatment group. to obtain a statistical power of . or greater in comparisons of malformation incidence between groups, the study was designed to obtain a minimum of litters for teratological evaluation per exposure group. exposure system. rats were exposed to -hz electric fields on systems consisting of five parallel-plate electrodes. the metal plates were rectangular and electrically insulated from one another. when energized, they provided uniform (± %), vertical, -hz electric fields at the strengths utilized in this experiment. four such exposure systems (racks), electrically isolated from each other, were located within one room. four tiers of rat cages were provided on each system; each tier contained eight polycarbonate modules, each with six individual rat cages ( . cm wide, . cm long, cm high). during parturition and litter-rearing, rats were housed in modules divided into three compartments, so that the cages were then twice as large as the standard cages. floors of the cages were made of wire mesh and were an integral part of the lower electrode so that rats were in electrical contact with the reference ground. a small amount of antron iii (a conductive carpet material from e. i. dupont co.) was placed in the cages during the period in which litters were delivered and reared. the exposure system design minimizes sources of phenomena associated with electric fields of intensities used in this experiment (dietrich and patterson, ) . current conduction, transient charge, and transient energy through the water system to a rat while drinking were tested, and values were below known levels of perception. electrode voltages and spacing were such that flashover from rats within cages did not occur. corona, as detected by radio noise, was not present. harmonic distortions of input voltages were less than . %. cage floor vibration velocity was less than . mm/sec measured at the voltages used in this study. rats were exposed to one of four field strengths ( , , , kv/ m) for hr daily, days per week. animals and their respective exposure regimens were rotated weekly from one system to another to limit the potential effect of rack location within the room on rat growth and development. personnel performing animal care, manipula- tions, or evaluations were not aware of an individual rat's exposure status. animals. the experiment was conducted using charles river (sprague-dawley-derived) rats obtained from the raleigh, north carolina, facility. approximately female and male rats were received at weeks of age and were group-housed in standard wirebottom cages for weeks of quarantine and acclimation. midway through the acclimation period, five females and five males were randomly selected for evaluation of health status. gross necropsy and examination of histologic sections from major organs did not disclose any unusual lesions. cultures of nasopharynx, lung, and cecum for bacterial pathogens were also negative. serum was tested and found not to contain antibodies to sendai virus, h-l virus, rat coronavirus (rcv/sda), or mycoplasma pulmonis. all female rats were identified by ear tattoo and weighed. animal rooms were illuminated on a -hr light, -hr dark cycle (lights on from hr to hr). cage board beneath the cages was changed daily. room temperature and relative humidity were recorded continuously: the ranges were - "f and - % rh, respectively. food and water were provided ad libitum to all animals at all times. for breeding, male rats were individually housed in standard hanging wire cages, and two females were placed with each male overnight. following a breeding session, females were vaginally lavaged with physiological saline, and smears were prepared and examined for presence of sperm. those animals found to be positive were weighed and randomly assigned (blocking on weight) into four groups, and exposure was begun on the day of mating. experimental protocol. as indicated, the four treatment groups, each on an individual system, were shamexposed or exposed to -hz electric fields of , , or kv/m. the experimental design of the study is outlined in fig. . in each group, females were mated and started on exposure over a period of consecutive days. these females were designated as "f o pregnancy." they were allowed to complete gestation, deliver, and rear their offspring (the f| generation) through weaning. rats that had copulated but had not delivered by days after the expected delivery date (i.e., days after coitus) were killed, and their absence of pregnancy and associated ovarian status were evaluated. the f, pups were sexed, counted, and weighed as a litter (by sex) at and days of age. litters were randomly reduced to a maximum of eight offspring (six females and two males, when possible) at days of age and maintained with their dams until weaning at days of age. dams and offspring were weighed individually at , , and days after birth. at weaning, two f, female offspring were randomly selected from each litter for continued exposure. these f, females were identified by ear tattoo, individually caged, and weighed at , , and weeks of age. (the f o dams, f, males, and other excess f, female offspring did not continue in this experiment.) ten f o dams, selected at random, were sampled to determine health status in the same manner as for the original health screening; no evidence of health problems was detected. for the breeding of the f, females, a new group of males was obtained from charles river laboratories. they underwent quarantine and health screening as described for the initial shipment of animals. when the f, females were months of age, two females from different treatment groups were placed with one male for the last hr of the daily dark period. during the dark period, movement of animals to breeding cages by technicians was facilitated with low-intensity red-light illumination. after the -hr period, females were examined for the presence of sperm. all females were then returned to their respective exposure systems, and exposures continued until the day of termination. the day on which sperm was detected was designated dg. mating procedures were repeated for up to consec-utive days for females in which sperm was not detected. females that were determined to have mated were not returned to males. after the breeding phase of the experiment was completed, females in which sperm was not detected were euthanized ( days after the last day of possible mating), and their pregnancy status was determined (salewski, ) . body weight was recorded at , , , and days of gestation (dg). animals were killed at dg for teratological evaluations. teratologic evaluation: maternal and fetal examination. females that mated were killed on dg with carbon dioxide. their body cavities were opened, and the uterus, ovaries, and abdominal and thoracic viscera were examined visually. corpora lutea were counted, and maternal liver and uterus were weighed. uteri were externally examined for hemorrhage, removed from the peritoneal cavity, and incised longitudinally to expose their contents. all live and dead fetuses and resorption sites were recorded. apparently nongravid uteri were dissected and placed in a % ammonium sulfide solution to detect possible implantation sites (salewski, ) . live fetuses were individually weighed as were their placentas. each fetus was examined for external malformations. half the live fetuses in each litter were then decapitated, and their heads were fixed in bouin's solution for examination of craniofacial structures by a modification of the sectioning methods described by wilson ( ) . all fetuses in each litter were examined for thoracic and abdominal visceral abnormalities by a modification of the methods described by staples ( ) and sexes were determined by internal examination. the fetuses were eviscerated and fixed in ethanol, and skeletons were stained with alizarin red s (staples and schnell, ) for examination. statistical methods. sample size determination for this study was based on an assumed angular dose-response model. the model was arcsin yp, = . + . f, where p] is the proportion of litters with one or more malformed fetuses at field strength f, kv/m. the intercept and slope estimates were calculated from results of previous studies where p, was approximately . at kv/m and . at kv/m. if this model were valid, then for this study the predicted proportion of litters with one or more malformed fetuses would be approximately . at kv/m, . at kv/m, . at kv/m, and . at kv/m. data from continuous-type variables were evaluated by analysis of variance (anova), utilizing the general linear model (glm) procedure from the statistical analysis system (sas, ) . repeated measures, such as maternal weight measurements, were analyzed by repeatedmeasures anova. fetal body weights, with the litter as the experimental unit, were analyzed by nested anova, which takes into account effects of treatment, litter, and sex. data calculated as a response proportion, e.g., proportion of implants resorbed, were analyzed by anova after arcsin transformation of the proportion (freeman and tukey, ) . when significant treatment effects were detected by anova, intergroup differences were delineated utilizing tukey's multiple comparison test (tukey, ; kramer, ) . orthogonal contrasts were used to test for a trend in the response with increased exposure intensity. results that differed at the p < . level were considered to be statistically significant. rates of rat breeding per group were analyzed by an actuarial life-table method (culter and ederer, ) . the response criterion was the day an animal mated. response curves were tested by a generalized wilcoxon test (breslow, ) to determine differences among groups. data from binary-response-type variables (e.g., number of pregnant females, number of malformed fetuses, number of litters with malformed fetuses) were evaluated by x test. when the x test was significant, pairwise comparisons were made using fisher's exact test (siegel, ) . the cochran-armitage test was conducted to test for linear trend of response with increased field strength (cochran, ; armitage, ) . the p f program of bmdp statistical software (dixon, ) was used for tests of binary response data. of the mated female (f o ) rats per group, the pregnancy rate was to % among the four groups (table ) . exposure had no detectable effect on the percentage of animals that maintained pregnancy. the initial random assignment was blocked on weight; therefore essentially the same mean initial body mass existed in the four groups (table ) . gains in body mass throughout gestation appeared to decrease with increasing field strength for the two higher-level exposed groups of f o females. although approaching significance by the trend test (p = . ), this decrease was not statistically significant, as the overall test for equality of means indicated no significant differences among groups (p = . ). parturition did not occur in four pregnant dams, three of which (each from a different exposure group) had one pup per litter and a fourth died, with a pup lodged within the birth canal. mean litter size and pup mortality incidences in the period between and days of age and between and days of age were similar in all groups. the sex ratio (mean percentage of male pups) in each litter was not different among the treatment groups. pup mean body masses were similar among the groups for both sexes at and days of age (table ) . growth curves were similar for all groups within sex, although male pups exposed at the two higher field strengths tended to gain slightly less weight (p < . ) in the period between and days of age than did those in the other groups. mean weight gains of female pups (females selected to continue on experiment after days of age) did not differ among the groups. mean body weights of dams at day after parturition were similar in the four groups. rats exposed at kv/m lost significantly more weight during lactation than did those of the other groups (table ) . throughout the postweaning period measures of toxicity or animal well-being were equivalent among groups for the selected female rats that continued on study. only two rats died during this period, of causes unrelated to exposure (broken tooth, bladder stones), and mean body weights among the groups were the same. breeding procedures began when the f, female rats reached weeks of age. approximately equal numbers of females were mated daily from each group, and curves, calculated from the cumulative numbers of rats mated daily, did not differ among groups. over a day period, mating was detected to have occurred in to % of the rats in the four groups, the pregnancy rate of which varied between to %. these values were not significantly different among groups (table ) . mean numbers of consecutive daily mating periods were approximately equal among groups. mean body weights at day of gestation were not significantly different among groups data expressed as means ± se except as noted. * one rat removed due to technician error. ' mean number of daily periods paired with males to achieve copulation. d days of gestation; data shown only for rats that were pregnant. ' gestational weight gain minus uterine weighl / liver weight divided by dg body weight x . • p < . versus sham-exposed, tukey's test. " data expressed as means ± se except as noted. * one dam aborted before litter evaluation. c one dam was excluded from evaluation due to dental malocclusion. j data expressed as mean of litter means. (p = . ). mean weight gain through pregnancy was not affected by exposure, and extragestational weight gain (an indicator of dam well-being through pregnancy) was also not affected by exposure. in teratological examinations, mean gravid uterine weights were not affected by treatment (p = . ). absolute mean liver weight was significantly less (p = . ) in rats exposed at the highest field strength than in the sham-exposed group. however, ratios of mean liver weight to body weight did not differ. no significant differences were observed among treatment groups with respect to the total number of corpora lutea per dam, implantation sites per dam, or preimplantation loss as indexed by implantation sites per corpus luteum (table ). postimplantation embryonic death was not affected by exposure, as indicated by the fact that none of the measures of implant resorption differed among groups. mean number of live fetuses per litter was less in rats exposed to the kv/m field, but it was not statistically different from the control group {p = . ). mean fetal body weight and placental mass were the same among the groups. the sex ratio (number of males/litter) appeared to increase with field strength but did not differ significantly among groups (p = . ) and was within the range of expected variation. a total of fetuses in litters were examined. in all cases, the number of litters examined per treatment group exceeded the litters required for a statistical power of . or greater for comparison of malformation incidence. a wide variety of malformations were recorded, as would be consistent with the large number of litters examined (table data presented as no. of fetuses affected/no, of litters affected. * a single fetus may be represented more than once if multiple defects were present. * p < . versus sham-exposed, x test. ). several malformations were recorded in litters from exposed groups which did not occur in the sham-exposed animals: anotia, acaudal or vestigial tail, edema, imperforate anus, umbilical hernia, retrognathia, cleft palate, rib agenesis, cleft sternum, fused ribs, and kinked tail. however, the incidence of each was low and did not differ significantly between sham-exposed and exposed groups. the predominant major vessel malformation observed was a retroesophageal aortic arch with abnormal origin of the right subclavian artery. vertebral agenesis occurred in the sacral region. malformation incidence was low overall, with the exception of fused sternebrae, which occurred in one fetus in the sham-exposed group versus eight in one litter of the kv/m group and seven in one litter in the kv/m group. incidence of fused sternebrae was significantly higher (p < . ) on a per fetus but not on a per litter basis. evaluation of total malformation incidence on a per fetus basis showed a significantly higher number of malformed fetuses in the " data are presented as no. of fetuses affected/no, of litters affected. b a single fetus is represented more than once if multiple defects were present. * p < . versus sham-exposed, x test. group exposed at kv/m than was observed in the other groups. however, on a per litter basis the total incidence of malformations did not differ significantly among groups. the mean percentage of malformed fetuses per litter was the same among the treatment groups (p = . ). a few incidences of fetal variations were significantly higher for specific site/exposure group combinations, but no clear correlation of increasing incidence with increasing field strength was evident. for example, incidence of dilated ureter was significantly higher in fetuses of dams exposed to kv/m electric fields on both a per fetus and a per litter basis ( table ). the associated variations of renal pelvic cavitation were also higher on a per fetus basis. incidence of an additional ossification site at the first lumbar vertebra was significantly higher per fetus (but not per litter) in animals exposed to kv/m; the incidence was not higher in rats exposed to kv/m. likewise, significantly increased incidences of reduced ossifications in skull, sternum, and vertebrae were recorded on a fetus and litter basis in rats exposed at kv/m. incidence of this condition in rats exposed at higher field strengths did not differ from that of the sham-exposed group. during routine observation of the f o dams, a rust-colored deposit (chromodacryorrhea) was observed on the muzzles and ear hair. subsequently, the deposits were also observed on f| females during the months of exposure following birth and the incidence and severity of chromodacryorrhea were recorded at termination. a statistically significant trend (p < . ) toward an increased incidence of deposits was recorded with increasing field strength in both lactating and pregnant animals. seventy-eight percent of nursing dams exposed at the highest field strength had detectable amounts of such deposits (table ) . further details on these observations are reported elsewhere (leung el al., ). note. number (%) scored within each category. " amount of deposits defined by subjective scores as: , without deposits; , slight amounts, light dots; , moderate areas on nose or ears, approximately to mm in diameter, , moderate areas on nose and ears, each approximately to mm in diameter, , significant areas on nose and ears, approximately mm in diameter or larger, with interrupted areas extending from nose to eyes; , large areas on entire head and ears. * significantly different from controls (p < . ). throughout the study there were no indications of disease or confounding factors unrelated to exposure other than an occasional transient reduction in body mass of individual animals as a result of water-dispenser malfunction. effects of this transient deficiency are judged to be minimal. in general, mean body weights were consistent among the groups, and body weight gains were comparable to those in previous experiments. our observation of slightly reduced gestation body weight gain of f o dams exposed at kv/m was unexpected. in our previous work, gestational body weight gain in females exposed to kv/m did not differ from that of sham-exposed animals (rommereim et ai, ) . differences between the two experiments may be explained in that dams in this study received no acclimation to the electric field prior to breeding in contrast to a month exposure in the previous experiment. reproductive outcome was largely unaffected, as indicated by the fact that the mean number of live pups per litter did not differ significantly among the groups. the reduced gestational weight gain of the dams in the high exposure group is consistent with a numerically lower, albeit nonsignificant, number of live pups per litter in the high exposure group; however, a chance association is an equally plausible explanation. overall, no evidence of detrimental effects on survival or growth of the offspring was observed in animals exposed to electric fields. no maternal mortality was associated with electric field exposure; only two deaths occurred and those were attributable to factors other than the field. most of the rats that did not deliver at the expected time were not pregnant, and three of the f o dams that did not litter had only a single large pup in utero. the low incidence of this situation and its distribution among groups indicate that it is not attributable to electric-field exposure. the weight loss of lactating dams exposed to the kv/m field was slightly greater than that in other groups. however, the weight loss was not proportional to increased field strength and is therefore not considered of consequence. in the f, generation females, measures of reproductive capability were unaffected by exposure: the percentage mating and rate at which rats mated (cumulative proportion on consecutive days) did not differ among the treatment groups. although not statistically significant, the number of live fetuses per litter was numerically less ( . pup per litter) in rats exposed to kv/m than in other groups (table ). this deficit is not accounted for by prenatal death; rather, it reflects fewer than normal ovulations (indicated by the number of corpora lutea per dam) and thus fewer implantation sites per dam. the electric field may have decreased the number of ovulations, but chance is an equally tenable explanation, as the values did not differ significantly. low fetal body weights generally provide an excellent indicator of deleterious effects. equivalence of this parameter among groups gives no indication of fetal toxicity. the lack of malformation differences between groups, with the litter as the basis for comparison (fig. ) , indicates that exposure was not teratogenic. it should be noted that the number of affected fetuses was significantly elevated in the kv/m group and a specific malformation (fused sternebrae) occurred at a significantly higher incidence in fetuses exposed to and kv/m (table ). however, these findings do not provide credible evidence of electric-field exposure effects because the incidence of fused sternebrae in the and kv/m groups was limited to one litter in each group. nor was this finding unique to litters exposed to electric fields, as fused sternebrae also occurred in an unexposed fetus. historical control incidence of fused sternebrae approximates incidences recorded in the sham-exposed group ( in fetuses, in litters). examination of mating records among litters with malformations did not reveal significant relationships of sire or grandam to litters with malformations or to type of malformation. two litters with malformations in the kv/m group were sired by the same male rat; both litters had a single malformed fetus with affected ribs. this male sired two additional litters in this group that had no malformed fetuses and two litters in other exposure groups that were likewise without malformations. litters with incidences of fused sternebrae were sired by different males. two litters in the kv/m group had the same grandam, and each had one affected fetus but with different malformations. no other litters with malformations had the same grandam. because the f o generation was purchased from an animal supplier our genetic information is limited, but from the available data, no significant relationships are evident. although a few types of malformations differ between groups, these findings are not considered to be treatment-related effects because of the absence of increased incidence in ( ) total number of litters with one or more malformed fetuses (litters rather than fetuses are the unit of analysis (manson et ai, ) ), ( ) specific malformation or category of malformations when compared by litters, or ( ) any response by increasing field strength. the teratologjcal assay yields several parallels with results of our previous replicate experiment. in the earlier experiments (rommereim et ai, ) incidences of litters with malformed fetuses (combined data from replicate experiments) from -month-old f, dams were . % for controls and . % in litters from animals exposed at kv/m. in the results reported here, malformation incidence was doubled in rats exposed at kv/ m as predicted by the statistical model (fig. ) . however, lack of a comparably increased percentage of affected litters in animals exposed at kv/m invalidates the hypothesis that increased field strength would result in increased numbers of terata. results of this experiment clearly demonstrate that developmental changes did not increase with field strength exposures above kv/m, mediating against the existence of a threshold for altered development. one could argue that there is a window of effect around the kv/ m exposure level. at this time, however, a biological explanation for such an event does not exist. the only overt sign of an effect of electric fields in adult rats was a significant increase at and kv/m in the incidence and severity of a rust-colored deposit on the face and ears of mature rats exposed to or kv/m (fig. ) . these deposits occurred in the absence of any detectable effects on body weight. the material is thought to originate in the harderian gland, located within the eye-socket, behind the eye. phenomena of a similar nature have been documented in rats as a response to various stressors and were called chromodacryorrhea by harkness and ridgway ( ) . this effect appears to indicate a physiological response to exposure, perhaps to chronic irritation or stress, but the mechanism for stimulating production of the exudate by electric fields is unknown at this time. because a significant increase in the incidence of chromodacryorrhea was not reported in earlier experiments, it is probable that exposure at kv/m (twice that used in the previous work) intensified a subtle effect, prompting closer investigation and, thus, detection at kv/m. occasionally, the severity of chromodacryorrhea in individual shamexposed females was equal to that of exposed rats (table ) . furthermore, not all exposed rats displayed the colored deposits, making detection of a subtle effect among groups difficult at the lower field strengths. a similar chromodacryorrhea response has been reportedly produced by various stressors (scialli, ) , and stress in rodents has been shown to produce adverse effects on implantation and embryo viability, resulting in terata when sufficiently intense (cook et ai, ; rozenzweig and blaustein, ; barlow et ai, ) . additionally, the incidence of chromodacryorrhea in rats exposed at and kv/m but not at kv/m clearly indicates a response to electric field exposure; however, the fields were not stressful enough to produce developmental toxicity. the incidence of chromodacryorrhea was not significantly elevated in litters with malformations (p = . ). if the chromodacryorrhea produced by electric field exposure is an indicator of stress, then stress is a potential factor which may have contributed to the developmental values are significantly different (p< . ) from sham-exposed rats compared to rats exposed to or icv/m. changes reported in the earlier studies. for example, when combined with other factors (disease, diet, housing, etc.), electric field induced stress may have acted synergistically to produce the developmental changes observed in the swine experiment. the effects of electric fields on developmental integrity when combined with stressors have not been specifically examined. tests for linear trends in proportions and frequencies the relation between maternal restraint and food deprivation, plasma corticosterone, and induction of cleft palate in the offspring of mice a generalized kruskal-wallis test for comparing k samples subject to unequal censorship some methods for strengthening the common x tests effects of high-frequency noise on prenatal development and maternal plasma and uterine catecholamine concentrations in the cd-i mouse maximum utilization of the life table method in analyzing survival design and testing of a small-a nimal electric field exposure facility, final report, epri project - electric power research institute bmdp statistical software univ transformations related to the angular and the square root exposure of mice to a strong ac field-an experimental study extension of multiple range tests to group means with unequal numbers of replications brown-colored deposits observed on hair of female rats chronically exposed to -hz electric fields teratology test methods for laboratory animals the effect of continuous exposure to low frequency electric fields on three generations of mice: a pilot study power frequency electric field induced biological changes in successive generations of mice reproduction and development in rats chronologically exposed to -hz electric fields rats successfully reproduce and rear litters during chronic exposure to -kv/m, -hz electric fields cleft palate in a/j mice resulting from restraint and deprivation of food and water farbemethode zum makroskopischen nachweis von implantations-stellen am uterus der ratte sas user's guide: statistics. version sas institute inc is stress a developmental toxin? non-parametric statistics for behavioral sciences studies on prenatal development in rats exposed to -hz electric fields developmental studies of hanford miniature swine exposed to -hz electric fields detection of visceral alterations in mammalian fetuses refinements in rapid clearing technic in the koh-alizarin red s method for fetal bone the problem of multiple comparisons methods for administering agents and detecting malformations in experimental animals key: cord- -ka wc authors: nan title: ecr book of abstracts - b - scientific sessions date: - - journal: insights imaging doi: . /s - - -x sha: doc_id: cord_uid: ka wc nan analysis of breast mri a dedicated cad software was used (computer-aided analysis). it enables semi-automatic analysis of enhancement characteristics of the whole tumour ( d analysis of early vs. delayed phase) and the "hot-spot" (i.e. voxel with highest washin/washout ratio). potential of breast mri characteristics vs. classical prognostic factors to predict disease-related death was investigated separately and in combination using cox regression. to identify significant and independent predictors for disease-related death, backward feature selection was applied (p entry /removal: < . /> . ). results: two-hundred and twenty-three patients were included (disease-related death: n= / . %; censored: n= / . %; loss to follow-up: n= / . %). mean follow-up was . years. if tested separately, cr analysis identified significant potential both for breast mri and classical prognostic factors to predict diseaserelated death (p < . ). if breast mri characteristics and classical prognostic factors were used in combination, predictive performance could be further increased significantly (p < . ): after feature selection five classical prognostic factors (tnm stage, tumour typing, her neu score) and six breast mri characteristics (hot-spot: time to peak enhancement, washout ratio; d analysis: tumour volume; tumour voxels showing washout plus weak/intermediate washin and tumour voxels showing plateau and weak washin) remained in this final model as significant and independent coefficients (p < . ). conclusion: breast mri has a significant potential to predict disease-related death in breast-cancer patients. it not only can be used as a stand-alone tool for this task but also adds significant predictive value to classical prognostic factors to stratify this endpoint. s a c d e f g b thursday metabolic syndrome, diabetes and cardiovascular disease. there is a need to find a biomarker which proves to be reliable, non-invasive and easy to perform in clinical practice. methods and materials: our aim was to know whether serum alanine aminotransferase (alt) is a reliable biomarker of liver fat content in nafld, and to determine if the current threshold of normality for alt is appropriate to assess the presence of liver fat. this is a cross-sectional, randomised, prospective, population-based study. we studied healthy subjects with alcohol consumption less than g/ week. quantification of liver fat content was by spectroscopy h mr t. % of liver fat content as the upper limit of normal for the diagnosis of hepatic steatosis. results: there was an excellent positive correlation between liver fat content and serum levels of alt (r = . , p < . ). results of the backward step-wise regression analysis showed that serum alt was the most important predictor of hepatic steatosis (ß coefficient= . ). all subjects with alt values > u/l had hepatic steatosis (ppv: %) and none of the subjects with alt < u/l had steatosis (npv: %). roc curves were created; the best cut-off value for the diagnosis of nafld was alt: u/l (sensitivity: . %, specificity . %, ppv: . %, npv: . %). conclusion: serum alt levels could be a reliable biomarker of nafld if the upper limit of normal for alt is set at u/l. absolute quantification of phosphorus compounds in the liver on a clinical t scanner purpose: hepatic energy metabolism plays an important role in insulin resistance and liver diseases. the aim was to establish a robust and fast method to detect and to quantify liver atp content in molar concentrations for use in a clinical setting, i.e. large cohort studies. methods and materials: healthy volunteers (n= ; ± years; bmi: . ± . kg/m²) consented to the approved protocol. all experiments were performed on a -tesla mri scanner (philips achieva . t x-series, the netherlands). p spectra were acquired using a -cm diameter p surface coil, with the built-in h body coil used for noe enhancement and decoupling (tr: sec; acquisition time: minutes). localisation in the liver was achieved using isis. separately, intra-and interday variability were measured on volunteers. the absolute quantification was established using matching phantoms and an external reference (mpa). results: all peaks were well resolved with the mean snr (γ-atp) of . the concentrations were found to be . ± . mmol/l (phosphomonoester), . ± . mmol/l (phosphodiester), . ± . mmol/l (inorganic phosphate) and . ± . mmol/l (γ-atp). the intra-and interday reproducibility was . %, respectively, % (pme) %, respectively, % (pde), %, respectively, % (pi) and %, respectively, % (γ-atp). conclusion: the absolute quantification for large cohort studies has been successfully established on a clinical scanner. the obtained concentrations from this study agree with the concentrations from previous studies. thus, the current method can reliably detect concentration changes above % in phosphorus compounds in human liver. differential portal venous flow response to terlipressin in normal and cirrhotic rats: non-invasive assessment using phase-contrast mri m. chouhan, a. bainbridge, n. davies, r. mookerjee, r. jalan, s. walker-samuel, m. lythgoe, s. punwani, s.a. taylor; london/uk (manil.chouhan@gmail.com) purpose: portal venous flow (pvf) measurement using phase-contrast mri (pc-mri) is technically feasible at . t. the purpose of this study was to assess the sensitivity of pc-mri to expected changes in portal flow after terlipressin administration and study the functional response in normal and cirrhotic rats. methods and materials: eight sprague-dawley rats were randomised to bile duct ligation (bdl) procedure (n= ) or sham laparotomy (n= ). after weeks, pvf was measured using respiratory-gated d pc-mri ( mm slice thickness, ° flip angle and cm/s velocity encoding) with a . t agilent system. terlipressin (known to reduce pvf) was administered intravenously at a dose of mcg/ g and pc-mri measurements repeated sequentially for - minutes post-administration. bulk pvf was normalised to explanted liver weight, obtained after termination of the experiment. data were analysed using paired and unpaired student t-tests. results: baseline liver weight normalised mean pvf in sham ( . ± . ml/ min/ g) vs bdl ( . ± . ml/min/ g) rats was not statistically significant (p= . ). the reduction in pvf post-terlipressin was significant in sham (mean reduction of . ± . ml/min/ g; p < . ), but not in bdl (mean reduction of . ± . ml/min/ g; p= . ) rats. significant differences in post-terlipressin nadir pvf in sham ( . ± . ml/min/ g) vs bdl ( . ± . ml/min/ g) rats were, however, demonstrated (p < . ). conclusion: expected reductions in pvf were detected non-invasively using pc-mri in both normal and cirrhotic rats. data are suggestive of a lower baseline pvf in cirrhotics, which go on to demonstrate a different, more labile haemodynamic response to terlipressin compared with normal rats. the incidence of biological effects from . tesla (t) mri compared to . t: an observational study in consecutive outpatients f. alghamdi, p. bertrand, l. barantin, m.a. lauvin, x. cazals, f. domengie, r. bibi, d. herbreteau, j.-p. cottier; tours/fr (faisal.gh. @gmail.com) purpose: to compare the acute biological effects of a . tesla (t) magnetic resonance imaging (mri) to . t mri methods and materials: after mri examination, patients ( with . t mri and with . t mri) were presented with a verbal rating scale questionnaire consisting of symptoms related to mri examination. chi-square tests were used to assess the relationship between the strength of the magnetic field (mf) and the incidence of the symptoms. a p value of <. was considered significant. results: there was no statistically significant relationship between the strength of the mf and the incidence of the symptoms related to static mf exposure, such as vertigo (p =. ), nausea (p =. ), headache (p =. ), and a metallic taste (p =. ). a warm feeling induced by radiofrequency (rf) was significantly higher in the . t mri (p <. ) with a significant correlation between the mean specific energy absorption rate (sar) and a warm feeling in the . t mri (p <. ). numbness/ tingling related to the gradient mf was significantly higher in the . t mri (p =. ). conclusion: the thermal effect induced by the rf and the numbness/tingling induced by the gradient field were significantly higher in the . t mri than in the . t mri. there was no statistically significant difference between the symptoms related to static mf exposure from the . t mri and . t mri. double echo sequences both effects can be separated one from the other. we present an extension of this concept to multi-echo measurements. methods and materials: brain perfusion measurements were performed in patients as part of an ongoing study investigating the reproducibility of perfusion parameters on a tesla mr scanner (siemens magnetom verio). three slices were recorded with a temporal resolution of s by means of a four echo flash sequence (tr = ms, te = . / / / ms, alpha = ¼ °). evaluations of contrast to noise ratios (cnr) during the bolus passage of omniscan (ge healthcare) through different tissues were done with an inhouse software written in idl (exelis vis). results: the cnr is improved by a factor of about . calculating delta-r * from four echoes compared to calculations based on two echos. signal intensity estimations for te = do not significantly benefit by the increased number of echoes. conclusion: multi-echo measurements allow for a larger dynamic range of t * shortening compared to single or double echo sequences, at the same time giving more signal. by extending the concept to keyhole and/or epi sequences, covering of entire tumours could be achieved. we select patients with uni-or bi-lateral endoprostheses from consecutive referrals for whole body (wb) pet/mr imaging (mmr, siemens healthcare). simultaneous wb-pet/mr scanning was performed at min p.i. of mbq [ f ]-fdg: min/bed including dixon water fat segmentation (dwfs)). mr-ac was performed using a) original mr-images (dwfs), b) as a) with implant-induced air-pockets filled with soft-tissue, c) as b) superimposed with co-registered endoprostheses from ct and d) as a) with implant-induced airpockets filled with metal. pet reconstruction after mr-ac (a-d) used aw-osem ( iterations, subsets, mm gaussian) on -matrices. mean/max standardised uptake value (suvbw) was calculated from interest volumes with % isocontour levels over the hips, pelvic muscle and bladder. results: in patients we found and uni-and bi-lateral endoprosthesis, respectively. associated mr artefacts were much larger than the implants: . % versus . % of the attenuating voxels in (a) of the central hip region. mr-ac using (b) and (c) recovered fdg-distribution pattern compared to uncorrected pet (noac) images and (a), while (d) resulted in severe overestimation (> % suvmax). the relative changes in suvmax/mean in the reference regions (bladder, pelvic muscle) from (b-d) compared to (a) were insignificantly small. conclusion: endoprostheses cause pet/mr artefacts and bias pet quantification. artefacts and bias can be corrected by automated inpainting with a single softtissue composition prior to mr-ac, thus restoring quantitative activity distribution. author disclosures: t. beyer: founder; cmi-experts gmbh. in vitro comparison of ultrasound-based elastography techniques s. franchi-abella , j.-m. correas , c. elie ; le kremlin-bicêtre/fr, paris/fr (stephanie.franchi@bct.aphp.fr) purpose: ultrasound elastography techniques are based on two different physical principal: strain and shear wave velocity (swv). the purpose of this study was to assess the performance of these two techniques in vitro on a calibrated elasticity phantom using five ultrasound diagnostic imaging system to improve clinical comprehension and use of elastography. an operator performed all acquisitions on a tissuemimicking phantom developed for elastography calibration (cirs a) containing spherical inclusions embedded in an homogeneous background (bg) of known elasticity ( ± kpa). two inclusions were harder than the bg and two were softer ( ± kpa, ± kpa, ± kpa and ± kpa). protocol was performed using high-frequency linear transducer on four different inclusions. qualitative assessment was done on elastograms. semiquantitative measurements were based on the ratio of strain or elasticities between the bg and each inclusion and were compared with theoretical ratio. quantitative evaluation was performed with swv techniques. results: all techniques are adequate when assessing whether or not an inclusion is harder or softer than the bg. semi-quantitative ratio of stiffness between two structures is not reproducible and strongly depends on the manufacturer. it is more accurate for swv techniques. direct quantitative evaluation of stiffness using swv exhibits biases for soft targets but can still be used to precisely measure stiffness if bias is taken into account. conclusion: limitations and advantages of the different elastography techniques must be known while performing an elastography acquisition in clinical practice. static magnetic fields in . and t mr scanners do not influence perception of pain and touch compared with placebo exposition a. pomschar, k. kamm, r. ruscheweyh, r. laubender, m.f. reiser, a. straube, b. ertl-wagner; munich/ de (andreas.pomschar@med.uni-muenchen.de) purpose: potential biological effects of static magnetic fields have been in the focus of public debate with the european physical agents (electromagnetic fields) directive / /ec having the potential to seriously limit mr imaging in europe. data on potential effects are still very scarce. we aimed to investigate the influence of homogeneous static magnetic fields in . and tesla mr scanners on pain and touch perception compared with placebo exposition. methods and materials: healthy volunteers (age: ± . years, females) underwent three experimental sessions on separate days in randomised order, using field strengths of t (placebo scanner), . t and t. participants were blinded to field strength. no imaging sequences were acquired. in each session, a quantitative sensory and pain testing programme was performed before and after a -min exposure to the static magnetic field. it included thresholds for mechanical detection, mechanical pain, pressure pain, heat pain and phasic heat pain intensity ratings. a linear mixed-effects model was used for statistical analysis. results: for . and t compared with the placebo control, statistical analysis revealed no significant effect of the magnetic field for all tested qualities, thresholds for mechanical detection (p= . / . ), mechanical pain (p= . / . ), pressure pain (p= . / . ), heat pain (p= . / . ) and phasic heat pain intensity ratings (p= . / . ). conclusion: short exposure to static magnetic fields in clinical . t and t mri scanners had no significant effect on pain and touch perception compared with a placebo exposure. plaque has formed correlating with cardiovascular risk factors. the present study aims at investigating whether there are differences in the carotid wall thickness and echogenicity between patients with ibd and well-matched healthy controls by high-resolution ultrasonography of the carotid arteries. methods and materials: ibd patients ( male, mean age: . yrs, crohn/ ulcerative colitis: / , smokers) and healthy controls ( male, mean age: . yrs, smokers) underwent high-resolution ultrasonography of the carotid arteries. the following variables were recorded in bilateral common carotid arteries: ) imt at , and mm from the carotid bulb, ) emt (the distance between the common carotid wall and the internal jugular vein) and ) ec. results: common carotid artery imt ( . < p < . , t-test) and emt (p < . , t-test) were significantly higher in ibd patients compared with controls. no difference in ec was found between ibd patients and controls. no difference in imt, emt and ec was found between crohn's and ulcerative colitis patients. smokers ibd patients had significantly higher imt and emt values than smokers controls ( . < p < . , t-test). conclusion: ibd appears to be a risk factor for development of early atherosclerosis as showed by greater values of carotid imt and emt in ibd patients compared with healthy controls irrespective of smoking history and type of ibd disease. purpose: to evaluate the accuracy of the preliminary ct interpretation made by the radiology residents in the emergency department. during four periods of consecutive days, attending radiologists prospectively recorded any disparity between their own ct interpretation (reference standard) and the preliminary interpretation delivered by the emergency radiology residents. disparities were recorded during both regular hours and on-call time. a misinterpretation was considered major when potentially life-threatening within hours after admission. the total number of ct performed during the survey was recorded and further classified into neuroradiological and body examinations. a rate of disparities was calculated for all ct examinations and also for body and neuroradiological cases. results: a total of emergency ct examinations were performed during the survey: ( %) were body ct and ( %) neuroradiological cases. disparities were reported in ( . %) of all ct examinations: . % ( / ) were major misinterpretations ( body, neuro). there were / ( . %) disparities reported in body ct versus / ( %) in neuroradiological examinations (p= . ). no significant difference was found when comparing disparities recorded during regular working hours ( / ( . %)) versus on-call period ( / ( %)), p= . . our results show that disparities occur most frequently in emergency body ct examinations, but major disparities represent a small proportion of all misinterpretations. the detailed analysis of our data allows comparison and purpose: detection of abdominal injury is a very important component in trauma management, so an accelerated assessment of liver and spleen injuries including their degree of severity is necessary. there is a good case to believe that in stress situations this subjective performance results in diagnostic mistakes. structured objective scores as the organ injury scale (ois) drawn up by the aast are a valuable guidance for objective trauma assessment. aim of our study was to evaluate retrospectively whether a structured approach using the ois differs to real-time-diagnosis. methods and materials: the ois was applied by an experienced radiologist on ct data of patients which underwent ct laparotomy after abdominal trauma. these results were correlated with the original text of the initial ct findings. finally, we compared both with the intraoperative findings gathered from the surgery report. results: regarding the original ct report we found a mean divergence of . ± . to the ois found in the surgery report for liver injuries ( . ± . for spleen injuries). in comparison with the structured approach, where we detected a divergence of . ± . ( . ± . for spleen injuries). there was no significant difference, but we detected a lower rate of over-diagnoses in both approaches. conclusion: a structured approach to abdominal trauma using an imaging checklist does not lead to a significantly higher detection rate, but reduces the rate of overdiagnoses and may be more precise in grading the severity grade plus streamlines the emergeny-ct-procedure. comparison of efficacy and safety between distal embolisation and augmented embolisation techniques for treating blunt splenic injuries with active haemorrhage within a two-year period, consecutive patients of bsi in whom haemodynamics was stable but ct showed contrast extravasation were included in this prospectively study. we randomised them into distal embolisation group and augmented embolisation group. they were followed up twice by ct at week and months after embolisation. we compared their demographics, injury grades, clinical parameters, hemograms, successful rates and splenic infarct volumes between the two groups. embolisation failure was defined as persistent hypotension that required surgery or detection of splenic contrast extravasation on follow-up ct. complication was defined as post-embolisation splenic infarct or splenic abscess. results: all underwent first follow-up ct, underwent second follow-up ct. of patients, received distal embolisation, received augmented embolisation. their basic demographics, ct injury grades, clinical parameters and hemograms did not differ. their mean systolic blood pressure was significantly elevated after embolisation. two ( / , %) of the distal embolisation group failed and required a second augmented embolisation. none of the augmented group failed but the difference did not reach statistical significance. the mean splenic infarct volume purpose: to evaluate whether radiographers' experience in breast imaging helps in reducing significant artefacts when acquiring dynamic breast-mri. methods and materials: one experienced radiologist prospectively evaluated a total of breast-mri examinations performed by three different radiographers (r , r and r ) over the period september -june ( examinations each). r had a -year experience in breast-mri and years of experience in breast imaging; r and r had no specific training in breast imaging, and -(r ) and -year (r ) experience in breast mri. for each examination the radiologist, who was blinded to radiographer's experience, was asked to assess the presence or absence of significant artefacts, defined as motion artefacts affecting image quality and/or diagnostic evaluation. the prevalence of significant artefacts in r , r and r examinations was tested with the chi-square test. results: significant artefacts were found in / examinations ( . %;ci %= . - . %). in particular, significant artefacts affected / examinations ( . %;ci %= . - . %) performed by r , / examinations ( . %;ci %= . - . %) performed by r and / ( . %, ci %= . - . %) performed by r , with a significant difference between r and r (p < . ). conclusion: artefacts potentially affecting image quality and diagnostic evaluation are less frequent in breast-mri examinations performed by those radiographers who combine experience in breast imaging with specific experience in breast-mri. a possible explanation is a better understanding of disease specific problems and of the importance of empathise with the patient. accuracy of ultrasonographic diagnosis of acute appendicitis in pregnant women n. kokhanovsky, a.-r. zeina, n. reindorp, a. levit-kantor, y. glick, a. nachtigal; hadera/il (nataliakoh@hotmail.com) purpose: to assess the reliability and value of the sonographic examinations in the diagnosis of acute appendicitis in pregnant women. we obtained sonographic examinations performed on pregnant women with suspected acute appendicitis retrospectively for months (sep. -feb. . the average age of study subjects was . years, with an average gestational age of weeks. sonography was the first imaging modality employed. surgery or clinical follow-up was the gold standard for the evaluation of sonographic performance. all examinations were performed using grey-scale graded compression in the left lateral decubitus position. the sonographic criteria for acute appendicitis were detection of a noncompressible, blind-ended, tubular, structure measuring greater than mm in maximal diameter. results: patients had positive sonographic findings of acute appendicitis ( . %). sonographic findings were correlated with surgical findings and clinical follow-up. the diagnosis was confirmed in all patients ( %). in the patients with negative sonographic findings of acute appendicitis, the result for patient ( . %) proved false-negative, whereas the remaining ( . %) improved on clinical follow-up. accordingly, sensitivity was . %, specificity was % and overall accuracy was . %. moreover, in out of the patients with negative sonographic findings for acute appendicitis, a different pathologic finding such as acute pyelonephritis was identified. conclusion: our experience suggests that ultrasonographic examination with the optimal study protocol is a highly accurate method for the diagnosis of acute appendicitis in pregnant women and should be performed as the first imaging test. purpose: to exploit the ever increasing quantity of routinely acquired imaging data generated in clinical practice for research, we propose an infrastructure for the automated anonymization, extraction and processing of image data stored in clinical data repositories. methods and materials: as proof of principle, we used this infrastructure to implement a pipeline for measuring brain volumes in clinical mri. this fully automated system consists of four steps: subject selection using pacs query, anonymization of privacy sensitive information and removal of facial features, quality assurance on dicom header and image information, and biomarker extraction. examinations were selected based on mri protocol: dementia ( ), multiple sclerosis ( ) and a general healthy elderly population study ( ) . we evaluated the effectiveness of the infrastructure in accessing and successfully extracting biomarkers from routinely acquired clinical imaging data. to prove the validity, we compared brain volumes from dementia and multiple sclerosis patients with the healthy population. results: success rates of . %, . % and % are achieved for the three protocol groups, respectively, indicating large amounts of routinely acquired clinical imaging data can be used for research purposes. in line with the literature, tive statistics, t-student tests for comparing groups, and mann-whitney tests for verifying hypothesis and item relations. results: most radiographers completely agree ( . %) or partially agree ( %) that evidence-based radiology makes part of their job requirements, but only . % consider it absolutely useful for developing their skills. most research projects and papers ( . %) are done by radiographers during their degree to develop their knowledge and quality of services rendered. age and academic degree do not have statistical significance (p < . ) for evidence-based radiology; however, there is a slight increase for radiographers with higher academic degrees and for those who have greater access to research papers and literature. conclusion: evidence-based practice is not applied by most radiographers as a work method; however, the underlying knowledge on this thematic suggests it would be well received and developed to enhance skill, knowledge and the department general quality. radiographers quality assurance work: resistance and cooperation r. gullien, j.g. andersen, a.e. haakull; oslo/no (uxraul@ous-hf.no) purpose: explaining the radiographer-chosen improvement initiatives in quality assurance work (qaw), adjustment and progression of these initiatives and changing possible resistance to cooperation. methods and materials: different implementation strategies and improvement initiatives were used in the qaw to prevent a feeling of insecurity, threatening, uneasiness, less valuable, to avoid conflicts and to enable education, training, self-assessment, improve oneself. manager implements measurements, strategies and improvement initiatives. the employees came up with suggestions of actions, brainstorm. voting was performed and top three were selected. combination of suggested and specific initiatives over time: continuous individual feedback over time (baseline, after implementation, follow-up), individual assessment measured by experience in mammography, theoretical and practical training, lectures, examples, individual positioning training, reading guidelines and articles, individual feedback on positioning technique, tailored training for new employees, different checklist for employees (new/"old", inexperienced/experienced), checklist for updating knowledge, self-study, workshops, training in self-evaluation, new internal guidelines, frequent feedback if necessary, practical training with supervisor, temporarily get another kind of work, meetings and discussions, inform about qaw when job interview. results: positive changes in cognition, self-knowledge, personal skills, confidence in the situation, comfortable, demystified, attitude change; related to knowledge and awareness. teamwork manager and employee with focus on improvement work and differentiate between work and employee. conclusion: using various strategies are beneficial, different methods to meet different needs. top-down, bottom-up, threat-relaxation, tentative-participation, resistance-cooperation. dialogue and cooperation between staff and management; between the radiographers are essential for success. radiographers' knowledge about adverse reactions to iodinated contrast media a. santos, l. capitolina, i. silva, a. saraiva; coimbra/pt (adelinosantos@estescoimbra.pt) purpose: eudravigilance-pharmacovigilance is a data processing network and management system for reporting and evaluating suspected adverse reactions of medicinal products in the european economic area. the main purpose of this paper is to assess the level of knowledge of radiographers relatively adverse reactions of iodinated contrast media (icm). methods and materials: an original electronic survey was used, which is composed of four dimensions of study to gauge radiographers' knowledge regarding the chemistry of icm (i), potential adverse reactions (ii), possible procedures to be taken in emergency situations (iii) and actions to be taken under the national pharmacovigilance system (iv), in a first phase. and throughout various european countries (northern, central and mediterranean), in a second stage. results: only . % of respondents were able to correctly answer the four questions on chemistry of icm. however, a significant relationship between those who know the classification of adr and who has knowledge of chemistry icm still exists. concerning the procedures to be taken in case of adr, we found that only . % of subjects were able to correctly identify usual emergency procedures in this type of situation and, regrettably, only % of the sample proved able to correctly identify all adverse reactions suggested by the questionnaire. the only method that enables epidemiological continuing surveillance safety of all drugs is the spontaneous reporting of adverse events. this pioneer b- : fast search for radiology cases in hospital systems via contentbased image retrieval g. langs , r. donner , m. holzer , d. markonis , h. mueller , e. birngruber ; vienna/at, sierre/ch (georg.langs@meduniwien.ac.at) purpose: efficient and quick access to comparable cases and corresponding radiology reports is crucial during radiological assessment and increases quality. currently, in most cases search queries within a pacs are limited to meta data. brain volumes (expressed as percentages of intracranial volume) were found to be significantly smaller in patients scanned under dementia ( . %) and multiple sclerosis ( . %) protocols, when compared with healthy controls ( . %). conclusion: this demonstrates that quantitative image biomarkers can be reliably extracted from routinely acquired clinical imaging data. this enables secondary use of clinical images for quantitative biomarker discovery at a hitherto unprecedented scale. interactive methods improve radiology long-term learning j.c. pueyo, j. etxano, p. slon, r. zalazar, j. ros, l. garcía del barrio, g. bastarrika, a. villanueva; pamplona/es (jetxano@unav.es) purpose: personal remote response systems (clickers) have shown to be an interesting tool to encourage participation. the aim of this study is to evaluate whether the use of clickers improves learning and retention of radiology within a group of medical students. methods and materials: medical students attended radiology lessons. each lesson was about radiological images. at the beginning of each lesson, students have a pdf with all the images corresponding to that day. at the end of each lesson, there were five interactive questions of those images using clickers. three months later, there was an examination with multiple-choice questions. half of the questions were images that had already been interactively worked with clickers. the other half were images of the pdfs not worked with clickers. incorrect answer value was - . . to evaluate the difference in the degree of learning achieved between both methods, we analysed the index of correct and false answers of each group. results: the averages of the correct answers were significantly higher in the group of interactive teaching than in the passive education group ( vs %, p < . ). the percentage of incorrect answers of the interactive teaching group was significantly lower than in the other ( . vs. . p < . ). the percentage of unanswered questions was significantly lower in the interactive group ( % vs . % p < . ). conclusion: interactive learning with remote response devices (clickers) is an effective method in teaching radiology, because it significantly improves learning and retention of knowledge. purpose: to evaluate diffusion-weighted (dwi) and dynamic contrast-enhanced (dce) magnetic resonance imaging (mri) for diagnosis of recurrent papillary thyroid cancer (ptc) in comparison to ultrasound and peroperative and histopathological findings. methods and materials: twenty-eight patients with suspicion for recurrent ptc underwent t mri, including dwi (b= - - - - - sec/mm ) and dce-mri ( runs; seconds each; pre-, during and post-contrast). interpretation criteria were: b -dwi for detection of soft tissue lesions and lymph nodes (ln); characterisation with apparent diffusion coefficient (adc) calculated from all (adcavg), low (adclow) and high b-values (adchigh); characterisation by dce-mri with arterial slope (as), area under the curve (auc) and c-peak. the adc and dce-parameters of tumoural and benign lesions were compared with a mann-witney u test. receiver-under-the-operator-curve analysis determined a threshold from which the accuracy of functional mr-imaging was compared to ultrasound in correlation to histopathology. results: only adchigh and as showed statistical difference between recurrent tumour and benign lesions (adchigh: p= . ; as: p < . ). per-neck region, b -dwi combined with as yielded highest sensitivity of % with % specificity. ultrasound showed a sensitivity of % and specificity of %. per patient, functional mri corrected ultrasound in only patients for diagnosing tumour recurrence. however, functional mri findings correctly changed treatment planning in of patients [excluding tumour recurrence (n= ), mediastinal metastatic ln (n= ), laryngeal metastasis (n= ), ipsilateral nodal skip metastasis to level ii (n= ), contralateral nodal metastases (n= )]. conclusion: combining b -dwi with dce-mri may show additional value to ultrasound for diagnosing and planning treatment in recurrent ptc. diagnostic evaluation of patients with squamous cell cancer of the head and neck after free flap reconstructions -the usefulness of functional imaging techniques m. członkowski, a. trojanowska, p. trojanowski, j. klatka, a. drop; lublin/pl (m.czlonkowski@interia.pl) purpose: to evaluate patients operated on head and neck squamous cell cancer and reconstructed using free tissue transfer flaps methods and materials: we evaluated patients with t tumours of oral cavity, oropharynx, hypopharynx and larynx. all patients underwent surgical resection of the tumour and reconstruction with free tissue transfer flap: musculocutaneous, fasciocutaneous, osseous and osseocutaneous. patients underwent post-operative radiotherapy. in the whole group we performed ct and/or mr study , and months after the completion of therapy. in patients suspected for recurrence based on ct/mr findings, mr diffusion-weighted imaging and ct perfusion were additionally performed. in case of positive findings these patients were qualified for surgery. results: in out of patients imaging study was suggestive for recurrence ( nodal and local). in this group additional functional imaging was performed. mr dwi and ct perfusion findings were indicative of nodal recurrence in two cases and patients were operated on. recurrence was not proven on histology in either case. in patients with suspected local recurrence additional functional imaging was performed in cases and the recurrence has been proven histologically in cases. conclusion: we have to be aware that functional imaging may be of little value in patients reconstructed with free flaps. although diagnostic imaging plays a prime role in post-treatment follow-up, positive findings must be evaluated with caution. careful reading together with ent surgeon is vital. purpose: chronic bronchitis (cb) is usually caused by smoking and characterised by chronic inflammation and remodelling of the airway wall, commonly in large airways. the study purpose is to determine differences in airway wall thickness (awt) and wall area percentage (wa%) between subjects with and without cb symptoms. methods and materials: heavy smokers with cb symptoms (cough, mucus, dyspnoea and wheezing) and heavy smokers without cb symptoms were randomly selected from , participants in a lung cancer screening trial. airway walls were measured on images in thin-slice low-dose ct with a dedicated software tool, for airways with a luminal diameter ³ mm in selected bronchi (rb , rb , rb , lb + and lb ). differences in measurements between the groups were assessed by t-test. the association between cb symptoms and awt and wa% was analysed using multiple linear regression adjusted for age, body mass index, smoking habit, amount of emphysema, and lung function. results: mean awt measured at bronchi was . ± . mm and . ± . mm in subjects with and without cb symptoms, respectively (p < . ). wa% was ± % and ± %, respectively (p < . ). with adjustment for confounders, a significant positive association between both airway wall measurements (awt and wa%) and cb symptoms was found for airways with a luminal diameter from to mm (p < . ). in airways with a luminal diameter ³ mm, no significant association was found (p> . ). conclusion: patients with chronic bronchitis symptoms have thicker airway walls of airways between and mm diameter, not in larger diameter. value of inspiratory and expiratory lung volume und lung density for detection of bronchiolitis obliterans syndrome ( ). there was a significant lower variation between the different kernels using ir when compared to fbp. image noise was reduced by % when compared to fbp. conclusion: variation of quantitative emphysema chest ct parameters between different reconstruction kernels is significantly reduced with ir when compared to fbp and may increase the robustness for therapy planning. assessing pulmonary perfusion in emphysema: automated quantification of perfused blood volume in dual-energy ctpa f.g. meinel, a. graef, s.f. thieme, f. bamberg, c. neurohr, m.f. reiser, t.r.c. johnson; munich/ de (felix.meinel@med.uni-muenchen.de) purpose: to determine whether automated quantification of lung perfused blood volume (pbv) in dual-energy computed tomography pulmonary angiography (de-ctpa) can be used to assess the severity and regional distribution of pulmonary hypoperfusion in emphysema. we retrospectively analysed consecutive patients (mean age ± years) with pulmonary emphysema, no cardiopulmonary comorbidities and a de-ctpa negative for pulmonary embolism. automated quantification of global and regional pulmonary pbv was performed using the syngo dual-energy application (siemens healthcare). we further quantified the global and regional percentage of voxels with a ct density <- hu. emphysema severity was rated visually and pulmonary function tests were obtained by chart review. results: global pulmonary pbv showed a moderate but highly significant negative correlation with residual volume (rv) in % of predicted rv (r=- . , p= . , n= ) and a positive correlation with forced expiratory volume in second (fev ) in % of predicted fev (r= . , p < . , n= ). global pbv values strongly correlated with diffusing lung capacity for carbon monoxide (dlco, r= . , p < . , n= ). pulmonary pbv values decreased with visual emphysema severity (r=- . , p= . , n= ). moderate negative correlations were found between global pbv values and parenchymal hypodensity in a per-patient (r=- . , p < . , n= ) and per-region analyses (r=- . , p < . , n= ). conclusion: de-ctpa allows simultaneous assessment of lung morphology, parenchymal density and pulmonary pbv. in patients with pulmonary emphysema, automated quantification of pulmonary pbv in de-ctpa can be used for a quick, reader-independent estimation of global and regional pulmonary perfusion, which correlates with pulmonary function tests. author disclosures: t.r.c. johnson: equipment support recipient; siemens healthcare. research/ grant support; bayer healthcare. purpose: brain death has adverse effects on lung perfusion and ventilation with possible damage of lung parenchyma pre-transplantation. we wanted to assess brain dead subjects treated with a new drug regime with hrct as a pre-transplant work-up. methods and materials: eleven pigs were decapitated (dc) assuring brain death, attached to ventilator and treated with a new drug regime optimising circulation thereby preventing lung edema. thirteen non-decapitated pigs (n-dc) attached to ventilator, supported with conventional treatment served as controls. all were monitored h and thereafter examined with chest hrct. images were analysed by two radiologists using a pre-defined questionnaire assessing parenchymal and airway changes. in consensus, an overall conclusion inferred presence of edema, infection/atelectasis or airway pathology. severity was estimated with a subjective scale. results: after h there were no significant differences between the groups regarding mean arterial pressure (map), arterial oxygen/fraction of inspired oxygen (pao /fio ), amount of infused fluid, urine production or clinical signs of edema. out bos. lung volume (vol), mean lung density (mld), th , th , th , th , th percentile (p -p ), peak, full width half maximum (fwhm), percentage of high (>- hu, hav) and of low attenuation values lav) were assessed with dedicated software (mevis pulmo). measurements of patients with/without bos and patients without bos with normal (fev > % of baseline, bos )/slightly reduced values for fev (fev - % of baseline, bos -p) were compared with independent t-test. results: vol, mld, p , p , p , p , peak, and fwhm (p² . ) in expiration scan as well as difference in volume between inspiration and expiration (p < . ) were significantly different in patients with/without bos. in inspiration, p (p= . ), fwhm (p= . ) and lav (p= . ) showed significant differences at higher levels. comparing patients with bos and bos -p, p might be used for distinction (p= . ). conclusion: expiratory lung volume and density showed significant differences in patients with/without bos. p value might be used as an imaging biomarker for early detection of bos. author purpose: the aim of this study was to prospectively evaluate the diagnostic value of density mappings for detection of bos following lung transplantation. methods and materials: ct examinations were carried out in lung transplant patients in full inspiration / expiration using a -row mdct ( kvp, rotation time . s, pitch . , collimation . mm, reconstruction increment mm, standard reconstruction kernel). / examinations were performed in patients with / without bos (bos : , bos p: , bos : , bos : , bos : ). the assessment of at was performed using both, a threshold-based method in expiration (hu range: - hu to - hu) and density mappings of hu values in inspiration and expiration after registration applying a threshold of - hu to - hu and hu differences ² hu between expiration and inspiration. with both methods, measurements of patients with / without bos were compared with independent t-test. results: at quantified with density mappings was significantly different in patients with / without bos. mean at was % in patients with bos and % in patients without bos. comparing patients with and without bos at might be used for distinction (p= . ). at quantified with the standard threshold-based method also showed differences between both groups, but with a lower significance (p= . ). conclusion: measurement of at with density mappings of hu-values showed a significantly better distinction between patients with / without bos than the standard threshold-based method. non-invasive focal therapy of organ confined prostate cancer: phase i study using magnetic resonance guided focused ultrasound technology and excision pathology for efficacy assessment a. napoli, v. panebianco, m. anzidei, f. boni, v. noce, l. bertaccini, g. cartocci, f. ciolina, c. catalano; rome/ it (alessandro.napoli@uniroma .it) purpose: to assess safety and initial effectiveness of non-invasive high-intensity t mr-guided focused ultrasound (mrgfus) treatment of localised prostate cancer in a phase i, treat and resection designed exploratory study. methods and materials: on the basis of a power analysis, patients with biopsyproven focal t prostate cancer (low-to-intermediate risk: gleason max + ), confirmed on a previous multiparametric mr exam, including dynamic contrast enhanced (dce) imaging, underwent mrgfus. all patients were scheduled to laparoscopic prostatectomy; mrgfus treatment was carried out on mr identifiable lesions (max ) using a patient-specific energy and real-time mr thermometry monitor for correct location. non-perfused volume (vpv) in the post-ablative mri was than compared with excision pathology for necrosis assessment. results: no significant complications were observed in all subjects during or immediately after the procedure. procedure was validated by pathologist that demonstrated extensive coagulative necrosis at the site of sonication surrounded by normal prostatic tissue with inflammatory changes; these features positively compared with immediate post-ablative mri scan and npv. at histology patients were free of residual viable tumour within the treated area; in the remaining patient, % of residual tumour was observed within the npv. there was a variable amount of isolated cancer tissue within non-treated parenchyma that was identifiable neither at mri nor at biopsy. to determine the impact of axial traction during mr imaging of the ankle cartilage at . t in volunteers with respect to motion artefacts, image quality and cartilage surface delineation. methods and materials: optimised coronal and sagittal t -weighted (w) turbo spin echo (tse) sequences with a drive pulse (in-plane spatial resolution . mm), a sagittal fat-saturated intermediate-weighted (imfs) tse sequence and a d gradient echo sequence were acquired at . t in volunteers with and without axial traction of kg. joint space width was measured at four locations in the tibiotalar joint. motion artefacts, general image quality, delineation of the cartilage surface, cartilage matrix and the confidence of diagnosing cartilage pathology were evaluated independently by two radiologists. differences were assessed using a wilcoxon test. results: with axial traction, joint space width increased significantly ( . ± . mm vs. . ± . mm). consequently, delineation of the cartilage surface was rated superior in / volunteers (p < . ). no differences were found in motion artefacts, general image quality, and artefacts within the cartilage matrix (p> . ). comparing the different sequences, cartilage surface and matrix was best visualised by the t -w tse sequences with a drive pulse (surface average of all regions and readers in sag t -drive vs. imfs on a four-point scale . ± . vs. . ± . , p < . ). conclusion: axial traction of kg increases the joint space width at the tibiotalar joint, and thus better visualises the articular cartilage surface. highest spatial resolution and visualisation of both cartilage surface and matrix were achieved by a t -w tse sequence with a drive pulse. s c a d e f g b results: all affected subjects were women between and years old (mean age: ). ischiofemoral space was significantly narrower in patients with ischiofemoral impingement when compared with control subjects ( . ± . mm vs . ± . mm, respectively; p < . ). quadratus femoris space was also significantly narrower in affected subjects ( . ± . mm vs . ± . mm; p < . ). inclination angle was not statistically different (p> . ). the degree of oedema and fatty infiltration was inversely proportional to values of ischiofemoral and quadratus femoris space. the interobserver agreement (ĸ) was . for ischiofemoral space, . for quadratus femoris space and . for inclination angle. conclusion: ischiofemoral impingement can be accurately diagnosed following anatomic and imaging mr criteria. us-guided viscosupplementation of the hip: therapeutic efficacy in patients affected by femoro-acetabular impingment c. martini , f. lacelli , e. fabbro , g. ferrero , g. serafini ; genoa/it, pietra ligure/ it (chiarapio@libero.it) purpose: us-guided viscosupplementation is a safe and effective therapy for symptomatic osteoarthritis (oa) of the hip and it allows to replace nsaids therapy and to delay prosthetic intervention. femoro-acetabular impingement (fai) is a cause of oa. the purpose of this work is to evaluate the efficacy of viscosupplementation as therapy of oa in patients affected by femoro-acetabular impingement. methods and materials: patients selected by orthopaedists for hip pain and plain films signs of oa (degrees ii-iv of k-l) underwent viscosupplementation ( ml of intermediate weight hyaluronic acid for three times every days). each patient was evaluated before the treatment and , , and months after the treatment by means of vas and oxford score. hence, these patients were divided into responsive (increase oxford score=/> and/or reduction vas /> ) and non-responsive (increase oxford score< and/or reduction vas < ). then we retrospectively evaluated the plain films of the hip these patients had done before the therapy, in order to find the signs of fai. results: / ( . %) patients were included into the "responsive" group; / ( . %) in the "non-responsive" one. in the "responsive" group we found signs of fai on the plain films of / patients ( . %); in the "non-responsive" in / ( . %). conclusion: despite viscosupplementation is an effective therapy of oa, there is an high prevalence of non-responsive among patients affected by fai. a new way to measure lower limb length and alignment using d models based on biplanar linear radiography: a comparison with measurements on supine ct scans and upright full-length radiographs r. guggenberger, c.w. pfirrmann, p. koch, f. buck; zurich/ch (romanguggenberger@yahoo.de) purpose: to compare lower limb length and alignment angle on supine computed tomography (ct), upright full-length radiography (ufr) and d models based on upright biplanar radiography (blr). methods and materials: irb-approved study involving consecutive patients ( male, female; mean age . years; range - years) scheduled for total knee replacement. lower limb length and alignment angles were measured on ct, ufr and d models based on blr using standard and extended length measurements by two independent readers. measurements of different modalities were compared by paired t-tests, pearson correlation coefficients and bland-altman analyses. results: mean limb lengths were mm (sd± . mm, range - mm), mm (sd± . mm, - mm), mm (sd± . mm, - mm) and mm (sd± . mm, - mm) for ct, ufr and d models using standard and extended measurements, respectively. mean alignment angles were . ° (sd± . °, range - °- °), . ° (sd± . °, - °- °), . ° (sd± . °, - °- °), respectively. length and angle measurements differed significantly when comparing standard d models to ct and ufr, respectively (p < . ). pearson correlation coefficients were . , . , . and . for limb length and . , . and . for angle measurements in ct, ufr and d models, respectively. bland-altman analyses for ct and ufr compared to d models showed a small positive mean difference in length using standard measurements ( . mm, sd± . ; . mm, sd± . ) and a small negative mean difference in angle measurements (- . °, sd± . ; - . °, sd± . ). no bias for length measurements was seen using extended measurements. conclusion: upright d models allow for lower limb length and alignment angle measurements comparable supine ct scans and ufr. stable or unstable tear of the medial meniscus of the knee: can weight-bearing mri solve the problem? a. la marra, s. mariani, e. costantini, a. conchiglia, a. barile, c. masciocchi; l'aquila/ it (alicelm@hotmail.it) purpose: to assess the role of . t, dedicated low-field standard and upright-mri in the evaluation of stable or unstable tears of medial meniscus in comparison with arthroscopy. we retrospectively reviewed and analysed mri exams (group a) of normal knee and mri exams (group b) of knee with clinical evidence of tears of the medial meniscus. in the same session, after conventional . t and "dedicated" . t supine mri exam, the patients underwent upright weight-bearing examination with the same dedicated mri unit. in all cases sagittal and coronal se t -w were used. all patients underwent arthroscopy within days from mri exam. results: in group a, no statistically significant anatomical modifications of shape, intensity and position of the medial meniscus between standard . t, dedicated supine and upright mri were observed. in group b, the images acquired in the supine position (dedicated and . t mri) documented in cases a traumatic tear (group b ) and in cases a degenerative tear (group b ). in group b , weightbearing mri showed presence of unstable tear only in out cases. in group b , weight-bearing mri showed a degenerative unstable meniscal tear only in out of cases. arthroscopy confirmed weight-bearing mri diagnosis in all cases. conclusion: our preliminary results show that upright weight-bearing mri has wide potentials for the study of dynamic modifications in case of meniscal stable or unstable tear. periosteal high volume image-guided injection of recalcitrant medial collateral ligament injuries: a retrospective case series analysis o. drumm, o. chan, p. malliaras, d. morrissey, n. maffulli; london/uk (odrumm@yahoo.co.uk) purpose: we evaluate a novel injection method, periosteal high volume imageguided injection, in the management of recalcitrant medial collateral ligament (mcl) injury of the knee. the injection, comprising ml of local anaesthetic with - mg of hydrocortisone, is directed at the periosteal attachment of the mcl. patients in total received the intervention between june and november at a london hospital. each was asked to complete a study-specific questionnaire including a visual analogue scale (vas) and the international knee documentation committee (ikdc) subjective knee form (to describe symptoms pre-injection and at follow-up). results: % of patients responded (n= ). three patients were omitted according to the exclusion criteria. . % of patients (n= ) were professional athletes. mean duration of symptoms was . (sd= . ) months. patients reported a mean improvement on the vas of . % (sd= . ). there was a significant improvement in ikdc scores (mean difference of %, sd= . ) pre-and post-injection (p= . ). . % of patients (n= ) had returned to their previous level of sport at follow-up including all the professional athletes. knee symptoms returned to normal in % (n= ), and improved substantially in a further . % (n= ). the remaining . % (n= ) experienced an initial improvement but symptoms recurred. conclusion: periosteal high volume image-guided injection is a useful treatment for recalcitrant mcl injury, a common sports injury that can result in lengthy periods of missed training and competition. results are encouraging, particularly amongst the professional athletes studied. ischiofemoral impingement, do you want to believe? r. prada, r. oca, a. rocha, l. fernández, m. costas, g. tardáguila; vigo/es (roqueoca@hotmail.com) purpose: to find out if there are anatomic and imaging mr criteria to diagnose ischiofemoral impingement. methods and materials: mris of the hip were retrospectively reviewed from august to september . a total of ischiofemoral impingement were diagnosed and normal patients were included as control. ischiofemoral space, quadratus femoris space and femoral inclination angle were measured independently by two blinded musculoskeletal radiologists. the degree of oedema and fatty infiltration in the quadratus femoris muscle were also assessed visually. differences in ischiofemoral space, quadratus femoris space and femoral inclination angle were studied between pathological and control cases. the interobserver reliability was obtained for quantitative variables. purpose: to assess the value of oral effervescent powder administration for ct evaluation of the oesophagus, quantitatively and qualitatively. methods and materials: patients ( m/ f, mean age y) referred for thoracoabdominal staging ct were included in this prospective irb-approved study. contrast-enhanced imaging was performed on a -slice ct-scanner after oral administration of g effervescent powder immediately before image acquisition. oesophageal distension was assessed at three levels (proximal/middle/distal) by volumetry of the inner (id) and outer diameter (od). two blinded readers separately evaluated oesophageal distension in the corresponding segments on a three-point scale. at an interval of two weeks, both readers in consensus decided on the number of diagnostic oesophageal segments in each patient in terms of the possibility to decide upon a potentially underlying pathology. findings were compared with results from a matched control group. quantitative and qualitative results were compared (t-test, mann-whitney u test). inter-observer variability was calculated (weighted-cohen-κ). results: id and od were significantly larger in all oesophageal segments after effervescent powder administration as compared to the control group (p < . ; mean id: . vs. . , mean od: . vs. . ). further, oesophageal distension was rated significantly better, with a good inter-observer variability (mean weighted κ= . ). at consensus evaluation, oesophageal segments ( %) were rated as diagnostic in the effervescent group, versus segments ( %) in the control group (p < . ). conclusion: correctly timed oral administration of effervescent powder results in good distension of the oesophagus, allowing readily assessment of the wall at contrast-enhanced ct as compared to studies without effervescent powder. de (marcandre.weber@med.uni-heidelberg.de) purpose: to prospectively evaluate whether dynamic contrast-enhanced (dce) mri can assess vascularity within pseudarthrotic clefts and predicts clinical outcome better than the clinical non-union scoring system (nuss). methods and materials: sixty-four patients (mean age, . years) with nonunion of an extremity fracture in computed-tomography received -tesla mri including dce (coronal t -weighted fat-saturated vibe, tr/te= . / . ms, measurements, mm slice thickness) after . mmol/kg body-weight of gadoterat. we assessed vascularity within the pseudarthrotic cleft using a region-of-interest analysis. signal intensity curves were subdivided into those with more intense contrast-agent uptake in the pseudarthrotic cleft than in normal adjacent muscle tissue (vascularised non-union) and those with similar or less uptake. the pharmacokinetic parameters of the tofts model (ktrans, kep, iauc, ve) were correlated to the clinical outcome at one-year follow-up (n= ). results: despite inserted osteosynthesis material, dce parameters could be evaluated in n= at first visit. sensitivity/specificity of vascularised non-unions as indicator of good clinical outcome was . %/ . % compared to . %/ . % using nuss. logistic regression revealed non-significant impact of nuss on clinical outcome (p= . , odds ratio= . ). at first examination, median iauc (initial area under the enhancement curve) was . in patients with good outcome compared with . in non-responders (p= . ), while ktrans, kep, and ve were not significantly different. using a receiver operating characteristic analysis, sensitivity/specificity of iauc at the optimal cut-off value of . to predict outcome was . %/ . %. all pharmacokinetic parameters did not change significantly at the one-year control (n= ). purpose: imaging-guided thermal ablation has become the therapy of choice among the different treatment strategies of symptomatic osteoid osteoma lesions. in this descriptive, prospective study, our objective was to evaluate typical post-procedural mr-imaging characteristics following mr-guided laser ablation of osteoid osteoma. methods and materials: patients with osteoid osteoma treated with mr-guided laser ablation underwent follow-up mr-imaging immediately after the procedure as well as after , , , , and months. imaging protocol included fatsaturated t w spir tse, non-contrast and contrast-enhanced t w tse images and subtraction images. mr images were jointly reviewed by two radiologists, regarding the appearance of treated areas, nidal enhancement and presence of side effects such as bone oedema and soft tissue enhancement. imaging was correlated to clinical status. results: mean follow-up time was . months. patients showed a postprocedural target-sign appearance with subsequent "positive inward fusion" of the different zonal compartments. post-procedural mr-imaging can support evaluation of therapeutic success. characteristic mr findings correlated well with the clinical status. conclusion: interpretation of post-procedural follow-up mr-imaging after laser ablation of osteoid osteoma may contribute to understanding of histopathological post-therapeutic changes and cornerstones of therapeutic success. s c a d e f g b results: the mean value of dmax obtained by surgical specimen was . mm (range - ) versus . mm (range - . ) of dmax measured through mdct. if the dmax values were stratified into three groups (group smaller than mm, group between and mm, group bigger than mm), a correlation with mdct results of . , . and %, respectively, was found. conclusion: mdct is an accurate technique to obtain an appropriate preoperative definition of dmax, within the limits of tumour bigger than mm. the revaluation of each case with dmax smaller than mm will supply additional information about the discrepancy (retraction of the stomach following immersion into formalin, diffusion in the submucosal layer). percutaneous endoscopic gastrostomy (peg) and jejunostomy (pej) placement guided by ct fluoroscopy with or without simultaneous endoscopy in otherwise untreatable patients c. de (christoph.trumm@med.uni-muenchen.de) purpose: percutaneous endoscopic gastrostomy (peg) or jejunostomy (pej) is substantial for patients with swallowing disorders to maintain enteral nutrition or to palliatively decompress intractable small bowel obstruction. endoscopic placement can be impossible due to previous (gastric) operation, obesity, hepato-splenomegaly, peritoneal carcinosis, inadequate transillumination or obstructed passage. computed tomography (ct) fluoroscopic guidance with or without endoscopy can enable the placement of a peg/pej if endoscopically guided placement fails. methods and materials: consecutive patients were referred to our department for feeding support (n= ) or decompression (n= ). reasons were: ent tumour (n= ), oesophageal cancer (n= ), mediastinal mass (n= ), and neurological disorders (n= ). decompression tubes were placed because of cancer (n= ) or crohn's disease (n= ). the following approaches were chosen: i. ct fluoroscopy and simultaneous gastroscopy (n= ), ii. ct fluoroscopy and inflation of the stomach via nasogastric tube (n= ), and iii. direct puncture under ct fluoroscopic guidance (n= ). results: ct fluoroscopy-guided peg/pej was feasible in of patients. no procedure-related mortality was observed. one tube was misplaced into the colon in a patient with a history of gastrectomy. no complication was seen after removal. minor complications were dislodgement (n= ), peristomal leakage (n= ), wound infection (n= ), superficial skin infection (n= ) and tube obstruction (n= ). conclusion: ct fluoroscopy-guided peg/pej is feasible and safe, and provides adequate feeding support or decompression. it offers the benefits of minimally invasive therapy even in patients with contraindications to established endoscopic methods, combining the advantages of both techniques. long-term complications -mainly tube-related problems -are easily treated. ct assessment of post-resection arterial stumps for right-sided colorectal cancer: a potential marker of quality of resection? t.l. kaye, d.g. jayne, n.p. west, d.j.m. tolan; leeds/uk (thomas.kaye@leedsth.nhs.uk) purpose: there is evidence that the quality and extent of colonic resection affects tumour recurrence rates and patient survival. this is currently evaluated by pathological analysis of the resected specimen. analysis of post-resection arterial stumps via routine follow-up ct could act an alternative in vivo marker. methods and materials: staging and follow-up ct scans from patients with right-sided colorectal tumours were analysed. pre-operative arterial anatomy and post-operative arterial stumps were demonstrated using multi-planar reformats and volume rendering techniques. methods of stump identification, stump length and stump orientation were recorded. results: ileocolic ( . %), middle colic ( . %) and right colic artery ( . %) identification was comparable with catheter angiogram studies. mean time interval between staging and analysed follow-up ct was months. post-resection ileocolic stumps were consistently identified ( . % of cases). in the vast majority of cases this was via a thrombosed vessel ( %). there was a wide variation in ileocolic stump length ( . - . mm, mean . mm, standard deviation . mm). conclusion: to the best of our knowledge this is the largest study to date demonstrating arterial stumps post colonic cancer resection. it is the first to consistently identify stumps years after colonic resection using routine surveillance (portal venous) ct. ct-based stump length analysis may therefore have potential as an in vivo marker of extent and quality of surgical resection. prospective study of using balloon duodenography catheters in ct enteroclysis for small bowel diseases k.c.h. lau, l.m.f. tee; hong kong/hk purpose: to determine the usefulness of using balloon duodenography catheters (bdc) for ct enteroclysis (cte), with a comparison of small bowel distension in using bdc and nasogastric catheters (nc). one of the limitations of cte is the suboptimal distension of the bowels, especially the distal ileum. using bdc, there is less reflux of contrast into the stomach and should have more contrast in the distal small bowel. the study protocol was approved by the ha kwc research and ethics committee and all patients gave written informed consent for the examination and this study. from may to july , cte was performed in consecutive patients with random allocation of patients using bdc and patients using nc. all catheter insertions and cte examinations were performed according to department protocol. small bowel distension was differentiated into four regions (proximal jejunum, distal jejunum, proximal ileum and distal ileum) and given a score from to ( -< mm, - - mm, -> mm). results: distension of proximal and distal ileum was better with bdc than nc (p < . : statistically significant difference). no significant difference was present for others sites (p> . ). conclusion: our study shows statistically significant better distension of the proximal and distal ileum, with the use of bdc when compared with nc. this is of particular use, as the distal ileum is a common site of small bowel diseases. with better bowel distension, this would suggest that using bdc would help to further improve the accuracy of cte. role of preoperative imaging with multidetector computed tomography (mdct) in the management of patients with gastroesophageal reflux disease (gerd) symptoms, candidate to sleeve surgical revision m. rengo, d. caruso, f. vecchietti, m.m. maceroni, g. silecchia, a. laghi; latina/ it (marco.rengo@gmail.com) purpose: to evaluate if multidetector computed tomography (mdct) can be helpful and useful in the decision-making process in sleeve patients with gastroesophageal reflux disease (gerd) symptoms and to demonstrate the reproducibility and accuracy of the technique. methods and materials: twenty-three patients submitted to lsg, complaining upper gi symptoms and/or weight regain and scheduled for a sleeve surgical revision were investigated. all patients underwent mdct scan, upper gi barium swallow study and endoscopy. mdct was compared with barium and endoscopy features as concern: oesophageal dilatation, neo-fundus development and volume, hiatal hernia, sleeve size in toto and atrum dilatation. all patients underwent laparoscopic sleeve revision. surgical findings were considered "as gold standard". results: a total of patients with hiatal hernia, neo-fundus or sleeve dilatation underwent surgical correction. all findings identified at mdct were confirmed by intraoperative findings. the presence of hiatal hernia was significantly underestimated by both barium and endoscopy with a sensitivity of . % and %, respectively (p= . , p= . ). conclusion: mdct is an accurate method for the detection of hiatal hernias and quantification of gastric volumes and can be considered as non invasive method to guide surgery. purpose: the maximum tumour diameter (dmax) is a prognostic factor in patients with gastric cancer, considering its dependence on the depth of invasion. the aim of our work has been to evaluate the accuracy of mdct in the preoperative definition of dmax in patients with gastric cancer, assuming surgical specimen measurements as gold standard, in order to obtain a pre-surgery prognostic evaluation. methods and materials: pre-surgery ct examinations of patients (mean age . , range - ) with diagnosis of gastric cancer were evaluated retrospectively and in a blind fashion by a radiologist with expertise in the oncologic field. the dmax measured was obtained through d multiplanar curved reconstruction (adw . ge healthcare). the results were compared with macroscopic data after surgery. s a c d e f g b thursday b- : pilot study to assess the diagnostic performance of mri in the identification of adhesions between the abdominal wall and small bowel loops, using a time-efficient protocol a. gupta, a. hansmann, p.f.c. lung, r. tandon, r. ilangovan, m. marshall; purpose: abdominal adhesions following surgery are the commonest cause of small bowel obstruction and may complicate subsequent surgery. accurate identification of adhesions has been reported using mr fluoroscopy sequences. we report our results utilising a time-efficient protocol. methods and materials: patients scheduled for open colorectal surgery and who had undergone previous abdominal surgery were recruited over months (mean age , range - ). the abdomen was divided into segments prior to mr and surgery enabling accurate correlation. using a . t scanner (siemensavanto), t sagittal, axial, sagittal true-fisp s cine sequences were obtained (slice thickness cm), in inspiration, expiration and abdominal strain. scanning time was min. adhesions were identified by finding angulation, fixation or altered peristalsis. readers analysed the images independently, providing a consensus opinion on the number and location of adhesions. laparotomy was the gold standard. results: abdominal segments were evaluated with adhesions identified in % at laparotomy and % on consensus mr. segments demonstrated adhesions on mr; % correlated at surgery, whilst the remainder were found in adjacent segments ( %). using a x table, sensitivity was %, specificity %, with positive and negative predictive values of % and %, respectively. overall accuracy was %. conclusion: our results suggest utilisation of a time-efficient mr protocol in identifying adhesions between the bowel and anterior abdominal wall is feasible in a busy unit, and may represent a non-invasive application in the research of adhesion-preventative techniques. reader performance rose during our study and further improvements may be realised in a larger trial. : - : room f oncologic imaging new biomarkers for tumour quantification purpose: patients with lung cancer often suffer additional chronic lung diseases, and often these patients present with fdg avid mediastinal lymph nodes due to inflammatory reasons rather than malignancy. fdg-pet is the leading imaging modality for n-staging in lung cancer patients; however, in patients with doubtful fdg-pet status, d ct histogram analysis might give an additional value to diagnostic imaging. in this investigation d ct histogram analysis was used to identify metastatic lymph node involvement in lung cancer patients in correlation to fdg-pet/ct. methods and materials: lymph nodes from patients aged - years diagnosed with lung cancer were investigated. fdg-pet/ct was performed prior to surgery/biopsy according to clinical schedule. lymph node assessments were acquired using fdg-uptake and d ct histogram analysis on the basis of non-enhanced ct scans. for computing the histograms, the lymph nodes were segmented by a semi-automatic algorithm; the segmentation result was corrected manually if required in certain cases. both imaging findings were correlated with the results from the histological gold standard study. results: positive and negative histologically proven lymph nodes were successfully analysed by d ct histogram. the histological positive lymph nodes presented a median ct hu value of . while histological negative lymph nodes presented a median ct hu value of . . findings were independent of the fdguptake value. conclusion: d histogram analysis seems to be a very promising and valuable imaging surrogate for n-staging stratification in patients with lung cancer with doubtful glucose uptake in fdg-pet. evaluation of crohn's disease recurrence in patients with ileocolic anastomosis: value of computed tomography enterography with water enema f. paparo, m. revelli, c. puppo, i. garello, l. bacigalupo, l. rollandi, r. piccazzo, a. garlaschi, g.a. rollandi; genoa/ it (francesco.paparo@galliera.it) purpose: to investigate the value of computed tomography enterography with water enema (cte-we) in the assessment of the status of the anastomotic site in patients with crohn's disease (cd) who had previously undergone ileocolic resection. were retrieved from our institutional radiology database, and reviewed in consensus by two gastrointestinal radiologists. the presence of cd anastomotic recurrence and its phenotype (inflammatory, stricturing, penetrating) , and the presence of inflammatory lesions involving other bowel segments beside the anastomotic site were recorded. endoscopy and medical records were used as reference standards. results: ct signs of cd recurrence were detected in patients, including: ( . %) isolated anastomotic recurrences, ( . %) anastomotic recurrences + synchronous inflammatory lesions (sils), ( . %) inflammatory lesions not involving the anastomotic site. phenotypes of the cd anastomotic recurrences were: ( . %) inflammatory (non-stricturing non-penetrating), ( . %) stricturing, ( . %) penetrating. no relation was found between the phenotype of cd recurrence and the type of the anastomosis (ll, tl, tt) (p = . ; chi-square test). conclusion: cte-we allowed a complete characterisation of the anastomotic site and the detection of sils, which had a relatively high prevalence in our study cohort ( . %). crohn's disease activity: correlation of inflammatory mediators with overall small-bowel motility s. bickelhaupt , s. pazahr , j.m. froehlich , r. cattin , h. bouquet , g. rogler , p. frei , a. boss , m. patak ; zurich/ch, biel/ch, berne/ch purpose: active crohn's disease (cd) increases the level of inflammatory markers of which c-reactive protein (crp) and calprotectin are commonly used to monitor disease activity. the aim was to evaluate the correlation between crp and calprotectin levels and overall small bowel motility in patients with crohn's disease assessed with mri. methods and materials: patients with crohn's disease ( f/ m, mean y) were included in this irb-approved prospective study. mri ( . -t, philips achieva) was performed after a -h preparation of ml mannitol-solution ( %). cine t w- d-ssfp motility acquisitions (tr . /te . / ms slice repetition time) were performed in free breathing over - sec. randomly chosen small-bowel segments were analysed in two abdominal quadrants using dedicated mr-motility assessment software (motasso). contraction frequency, amplitude, luminal diameter and amplitude diameter ratio (occlusion ratio, adr) were evaluated as well as crp (ngl/ul) and calprotectin (ug/g) levels. pearson's correlation was calculated. results: calprotectin was determined in mean days (sem± . ) before, crp days (sd± . ) before mri. a significant inverse linear correlation was found between the contraction frequency and both the level of crp (r=- . , p= . ) and calprotectin (r=- . , p= . ). expansion of the mean small bowel diameter significantly correlated with calprotectin levels (r= . , p=< . ) but not with crp (r= . , p= . ). the absolute amplitude of the contractions did not correlate neither with the level of crp (r=- . , p= . ) nor with calprotectin (r=- . , p= . ). the ratio describing relative luminal occlusion during contraction (adr) significantly correlated with calprotectin (r= . , p= . ) and with crp (r= . , p= . ). alterations of overall small bowel motility during active phases of cd significantly correlate with the level of calprotectin and crp. author disclosures: h. bouquet: employee; fromer employee of sohard ag. s c a d e f g b measured on fdg-pet. treatment response was evaluated after three cycles of platinum-based chemotherapy, according to recist. the predictive value of texture and pet parameters have been investigated by multivariate analysis. results: fourteen out of patients were non-responders ( progressors, stable disease). combining heterogeneity and suv in a unique parameter (heterogeneity*suv), the latter was significantly higher in responders than in non-responders (medians . vs . , respectively; p < . ) and showed a high predictive value: odds ratio (probability of response) of third vs first tertile was (p . ). responses in first tertile were / , in the second / , in the third / (p . , p for trend . ). tumour heterogeneity alone showed a significantly weaker predictive value, while suv alone was not predictive of treatment response. conclusion: the combination of texture features of tumour heterogeneity on cect and the metabolic information provided by fdg-pet has the potential to be an independent predictor of response to first-line chemotherapy in advanced nsclc. in particular, tumour suv combined with heterogeneity provides an additional value compared with tumor heterogeneity alone. purpose: to assess whether tumour heterogeneity, quantified by texture analysis on contrast-enhanced ct (cect), can predict the response to chemotherapy in advanced non-small cell lung cancer (nsclc). fifty-three pre-treatment cect studies of patients with advanced nsclc who had undergone first-line chemotherapy were retrospectively reviewed and analysed. treatment response was evaluated after three cycles of platinum-based chemotherapy, according to recist. tumour uniformity on ct images has been assessed by a three-step method: image thresholding; multiscale filtering by laplacian-of-gaussian filter; quantification of texture features on filtered images using first-order statistics. the predictive and prognostic values of resulting texture parameters have been investigated by multivariate analysis. results: thirty-one out of patients were non-responders ( progressors, with stable disease). average overall survival was months ( - ), minimum follow-up was months. in the adenocarcinoma group (n= ), the tumour uniformity multiplied by the grey-level of unfiltered images (gl*uni index) has been shown to be the unique independent variable predictive of treatment response. dividing the gl*uni index ( . - . ) into tertiles, lesions in the second and the third tertiles had a -fold higher probability of treatment response compared to those in the first (p . ). tnm stage, sex, age and performance status did not show predictive value. no association between texture features and response to treatment was observed in the non-adenocarcinoma group. gl*uni index was not prognostic. conclusion: texture features of tumour heterogeneity on cect images in advanced lung adenocarcinoma has the potential to be a predictive indicator of response to platinum-based chemotherapy. textural analysis of lymphoma on unenhanced computed tomography: initial evidence for a relationship with tumour glucose metabolism, stage, end of treatment status and survival s. babikir, b. ganeshan, a.m. groves, i. kayani; london/uk (b.ganeshan@ucl.ac.uk) purpose: to provide initial evidence in lymphoma for a relationship between tumour heterogeneity, as assessed by ct texture analysis (ctta), and tumour glucose metabolism, stage, end of treatment status (eots) and survival. methods and materials: this retrospective, pilot study comprised consenting lymphoma patients with consecutive routine f-fluorodeoxyglucose (fdg) pet-ct scans. texture analysis using texrad, (a commercially available texture analysis software), of non-contrast-enhanced ct images with lesions involved: ) image filtration extracting fine, medium and coarse texture-scales, and ) texture quantification using proportion positive pixels (ppp), standard-deviation (sd), and kurtosis (k). corresponding tumour fdg uptake (standardised uptake value (suvavg and suvmax)), clinical-stage and eots from pet-ct and clinical reports were collected. survival was assessed by optimised kaplan-meier analysis. results: , , and patients had stages i, ii, iii and iv, respectively. fine to coarse textures correlated with suvavg (baseline-scan: sd at coarse-scale, rs= . p= . ; interim-scan: ppp at medium-scale, rs=- . p= . ) and clinical-stage (baseline-scan: k at fine-scale, rs= . p= . ). baseline coarse textures predicted eots (ppp at coarse-scale, p= . ; k at coarse scale, p= tumour vascularization imaging without contrast agents: the potential of ivim-mri m. iima , o. reynaud , t. tsurugizawa , l. ciobanu , j.-r. li , f. geffroy , b. djemai , d. le bihan ; kyoto/jp, gif-sur-yvette/ fr (mamiiima @gmail.com) purpose: to investigate the potential of ivim mri to evaluate perfusion and diffusion in a l glioma rat brain tumour model using a . t mri scanner. methods and materials: fischer rats were studied. ivim mri images were acquired with b values ( b values; to s/mm², b values; . to s/mm², and b values; to s/mm²). the signal attenuation curve was first fitted using a biexponential diffusion model to estimate slow and fast components fraction (fslow, dfast and dslow) of the pure diffusion part of the signal (for b> s/mm²). then, the diffusion component was removed from the signal and the remaining signal was fitted using the ivim model for b< s/mm² to get estimates of perfusion fraction, f, and pseudo-diffusion, d*. fitting was performed on a roi basis and on a pixel-by-pixel basis to generate diffusion and perfusion maps. all rats were killed and histology (cd ) was obtained for comparison with ivim parameters. results: ivim maps clearly highlighted areas with high and low fraction perfusion within tumours which were generally heterogeneous, as confirmed by histology. interestingly, we found a negative correlation between the ivim perfusion fraction and fslow, suggesting that cell density in high perfused areas is less than in other tumour parts and normal brain tissue. conclusion: this study confirms that ivim mri can delineate high perfusion areas in tumours and provide information on tissue structure from diffusion parameters. intravoxel incoherent motion (ivim) diffusion-weighted mri for monitoring the therapeutic efficacy of a vascular disrupting agent (ckd- ) in rabbit vx liver tumours i. joo, j. lee, j. han, b. choi; seoul/kr purpose: to evaluate the diagnostic value of intravoxel incoherent motion (ivim) diffusion-weighted imaging (dwi) in the quantitative assessment of therapeutic efficacy of a vascular disrupting agent (vda) (ckd- ) in rabbit vx liver tumours. in vx liver tumour-bearing rabbits ( in the treated group and in the control group), ivim-dwis were performed at a t scanner using b values before and hours, hours, days, and days after ckd- administration. apparent diffusion coefficient (adc) and true diffusion coefficient (d), pseudo-diffusion coefficient (d*), and perfusion fraction (f) of tumours were compared between the control and treated groups and among time points. correlation between change in tumour size and ivim-dwi parameters was analysed to determine which ivim-dwi parameters can be predictors for tumour response. the treated group showed a significantly larger increase in adc at hours, a decrease of d* at hours, and a decrease of f at hours and hours, than did the control group (p < . ). in the treated group, compared to baseline values, d* and f significantly decreased at hours and then recovered at hours and d significantly increased at hours (p < . ). in addition, the greater decrease in f at hours correlated with the smaller increase in tumour size during the days (rho= . , p= . ). conclusion: the therapeutic effect induced by vda could be effectively evaluated using ivim-dwi, and f could be an early predictive indicator for tumour response. texture analysis on contrast-enhanced computed tomography combined with fdg-pet in predicting the response to chemotherapy of advanced non-small cell lung cancer m. ravanelli, f. ferraroni, d. farina, m. morassi, p. tessitore, p. rossini, r. maroldi; brescia/ it (marcoravanelli@hotmail.it) purpose: to assess whether tumour heterogeneity, quantified by texture analysis on contrast-enhanced ct (cect), combined with fdg uptake at pet-ct can predict the response to chemotherapy in advanced non-small cell lung cancer (nsclc). pre-treatment cect studies and fdg-pet studies of twenty-six patients with advanced nsclc who had undergone first-line chemotherapy were retrospectively reviewed and analysed. tumour heterogeneity was measured by texture analysis on cect images; mean suv from each patient was s a c d e f g b thursday b- : scatter amplitude is a good landmark for tumour localisation and treatment assessment in time-domain diffuse optical tomography during neo-adjuvant chemotherapy in breast cancer m. van purpose: neo-adjuvant chemotherapy response may be monitored in a noninvasive way using multi-spectral diffuse optical tomography (dot). a clinically feasible measurement method in these d volumes is proposed and compared with previously published whole breast measurements. methods and materials: twelve breast cancer patients were included, which received neo-adjuvant chemotherapy. four dot scans were obtained: before therapy, after and weeks and pre-operative ( weeks) . deoxyhaemoglobin (hb), oxyhaemoglobin (hbo ) and percentages water and lipids were measured in volumes as measured in dce-mri scans before therapy, centred on areas of high scattering amplitude and approximate location in pre-treatment dce-mri and/ or x-ray mammography. patients were divided in responders and poor responders based on post-operative pathological assessment. results: responders (r) and poor responders (pr) showed statistically significant (p < . ) different development of hb values at , and weeks within measurement volumes relative to the first dot scan: . / . (r/pr, weeks), . / . ( weeks), . / . ( weeks) . for hbo results were similar, but only significant for and weeks: . / . ( weeks), . / . ( weeks), . / . ( weeks) . percentages water and lipids were not significantly different. whole breast measurements did not show statistically significant differences for hb and hbo between responders and poor responders. conclusion: using the scatter amplitude to determine the tumour location in dot volumes enables the measurement of hb and hbo such that these parameters differ significantly between responders and poor responders. this potentially allows effectiveness assessment of neo-adjuvant treatment in breast cancer patients already at weeks. software validation of metastatic sarcoma lesion assessment using ct volumetric density tumour trajectory l.r. purpose: recent studies suggest that tumour assessment methods accounting for both tumour density and volume (sact, mass, choi) add value beyond assessing axial dimensions (recist) or selective regions of interest (roi). we have developed a comprehensive tumour response method termed total volume of viable tumour (tvvt) that assesses rate of change in hounsfield unit (hu) density over treatment course (tumour trajectory), thereby quantifying viable tumour burden as a volume of interest (voi). steeper trajectories may translate to earlier determination of response versus progression. we evaluated the efficacy of experimental volume/hu (tvvt) software and criteria within our picture archiving and communication system (carestream health, rochester, ny) to circumscribe, segment and characterise volumetric density distribution throughout all parts of measurable lesions on ct. comparison of response and tumour trajectory assessment between recist criteria and tvvt was performed in a test set of patients with various sarcomas under radiologist supervision. histograms depicting range and absolute hu for whole tumor volumes were analysed on a subset of patients. results: preliminary investigation shows feasibility of semi-automatic segmentation to outline and quantify density distribution in whole tumour volumes. initial assessment of our set of metastatic lesions suggests that hypervascular sarcomas are a worthwhile study cohort. histogram shifts appear to correlate with qualitative visual estimates of tumor necrosis whereas recist diameters demonstrate little or no differences. conclusion: comprehensive tumour analysis using volumetric density algorithms such as tvvt should more accurately reflect tumour burden and trajectory over selective linear or roi measurements, leading to improved image-based tumour staging and response assessment. semi-automated quantification of whole tumour burden should decrease inter-observer measurement variability, enabling more convenient, reliable imaging results for multiple contiguous vascular metastases. . ). median (range) overall and disease-free survival was ( - ) and ( - ) months, respectively. medium texture-scale predicted overall (baseline-scan: k, p= . , interim-scan: k, p= . ) and disease-free survival (baseline-scan: k, p= . , interim-scan: k, p= . ). suvmax predicted disease-free survival (baseline-scan: p= . ). clinical-stage did not predict eots and survival. conclusion: evidence provided suggests that ctta offers an objective measurement of lymphoma severity on ct. the potential risk stratification and prognostic assessment implications may allow optimal selection of pet-ct candidates in lymphoma. author disclosures: b. ganeshan: shareholder; shareholder and director of texrad ltd, an imaging software company that is developing and commercialising the texture analysis software considered in this study. improvement in both sensitivity and specificity of readers with next generation of mammography cad v. nikitin, i. lossev, a. filatov, n. bagotskaya; longmont, co/us (vadim.nikitin@parascript.com) purpose: the purpose of the study was to compare radiologist performance for screening mammography with and without parascript® accudetect® computeraided detection (cad) software. each of mammography cases (including cancer cases and normal cases) was reviewed by radiologists without and with cad (accudetect, version . ). the mammography cases were obtained with ge senographe essential and philips microdose mammography l full-field digital mammography systems. each radiologist initially interpreted a case without cad noted the findings and assigned bi-rads category , or to the case. for each radiologist, the unassisted interpretation was "locked" before the radiologist turned on the cad marks. after turning on the cad marks, the radiologist could add, remove or adjust the findings noted on the unassisted interpretation as well as change the bi-rads score for the case. sensitivity and specificity calculations for unassisted and cad-assisted interpretations were based on the bi-rads category assignment dichotomization: (bi-rads = ) versus (bi-rads = or ). results: average increase in sensitivity due to assistance of cad is . %, which translates into . % of those initially missed cancers that were recognised with cad assistance. average increase in specificity due to assistance of cad is . %. both increases in sensitivity and specificity are statistically significant. the study demonstrates that both sensitivity and specificity of radiologists increased with assistance of accudetect cad system. assessing the contribution of hypoxia to r * differences between cancerous and normal prostate tissue a. johnson, a. latifoltojar, v. hamy, h. fitzke, k. shmueli, s. punwani; london/ uk (aj @cam.ac.uk) purpose: r * bold mri is proposed as a potential tool for mapping tumour hypoxia in prostate cancer. however, r * has a complex relationship with tissue oxygenation that remains unexplored in prostate cancer. r * is the sum of r (primarily reflecting tissue structure) and r ' (highly sensitive to static magnetic field inhomogeneities, e.g. from deoxyhaemoglobin). whilst r * changes are observed for prostate cancer, they may reflect tissue structure or oxygenation differences. this study aimed to clarify the nature of r * change by quantifying and comparing r * and its components (r and r ') for cancerous and normal prostate tissue. methods and materials: twenty patients underwent . t multi-parametric (mp) prostate mri (dwi, dce and t -weighted), supplemented by dual echo-time t * and t quantitation and followed by biopsy. tumour and healthy regions of interest (identified on mp-mri and confirmed by biopsy) were contoured in consensus by two experienced observers on matched t -and t *-weighted images. mean r *, r and r ' were calculated and compared between cancerous and normal tissue using the student's t-test. results: r * and r were significantly greater for cancer than normal tissue (r *: ± s- [mean ± sd] vs. ± s- respectively, p = . ; r : ± s- vs. ± s- respectively, p < . ). no significant difference was found in r ' ( ± s- vs. ± s- respectively, p = . ). conclusion: prostate tumour r * values predominantly reflect differences in r (tissue structure) and not r ' (tissue hypoxia). s c a d e f g b men for diagnosis, especially when receptors have to be studied in defining the origin of axillary lymph node metastases. purpose: aim of this study was to determine the diagnostic performance of gadofosveset-enhanced mri for axillary lymph node staging in breast cancer patients. methods and materials: ten women diagnosed with invasive breast cancer underwent both non-enhanced and gadofosveset-enhanced dt -weighted mri. a radiologist, blinded for clinical data, evaluated all lymph nodes with regard to size, morphologic features and gadofosveset uptake. lymph nodes depicted on mri were matched with nodes removed during surgery. nodal status was investigated by a blinded pathologist. sensitivity, specificity, ppv, and npv values were calculated. results: a total of lymph nodes were extracted during sentinel lymph node biopsy or axillary lymph node dissection of which were matched with lymph nodes depicted on mri. histopathological examination resulted in macro-metastases and micro-metastases. with contrast-enhanced mri, lymph nodes were rated as true positive, as true-negative, as false positive, and as false negative. this resulted in an overall node-by-node sensitivity, specificity, ppv and npv of, respectively, % ( % ci - ), % ( % ci - ), % ( % ci - ) and % ( % ci - ). if ignoring micro-metastases, mri showed a sensitivity of % ( % ci - ) and a specificity of % ( % ci - ). calculated ppv and npv were % ( % ci - ) and % ( % ci - ), respectively. conclusion: this feasibility study concerning gadofosveset-enhanced mri of axillary lymph nodes showed promising initial results. these results warrant larger studies to confirm these promising results. to assess sensitivity and specificity of prone breast fdg-pet-ct for detection of lymph node metastases and to compare it with t ce-mri of the breast. methods and materials: patients with breast cancer were included in this irb-approved prospective study. all patients underwent t ce-mri and fdg-pet-ct of the breast in the prone position. patients were injected with ca. mbq f-fdg. ct data were only used for attenuation correction. in mri lymph nodes were considered positive for malignancy if there was enlargement > cm, thickened cortex, loss of fatty hilum, matted nodes or an irregular node contour. in pet-ct a lymph node was classified as positive when fdg-uptake was greater than blood-pool activity. the evaluation of nodes was performed on a patient-bypatient basis. all nodes were histopathologically verified. results: fdg-pet-ct achieved a sensitivity of % and a specificity of %. ppv was . (ci . - . ), and npv was . (ci . - . ). diagnostic accuracy was . . ce-mri had a sensitivity of % and a specificity of %. ppv was . (ci . - . ) and npv was . (ci . - . ). diagnostic accuracy was . . nodes were positive and nodes were negative for malignancy. the mean suvmax of lymph node metastases was . (range . - . ). conclusion: fdg-pet-ct improves identification of lymph node metastases as compared with t ce-mri. in patients with lymph nodes classified as malignant by fdg-pet-ct of the breast a sentinel lymph node biopsy can be omitted and surgeons can proceed immediately to alnd. purpose: to evaluate accuracy of us and us-guided-fnab for diagnosing axillary metastasis in breast carcinoma patients and to determine applicability of the bi-rads categorisation. we retrospectively reviewed data on patients who underwent preoperative or prechemotherapy axillary us for axillary staging from january to december . us-guided fnab was performed if lymph nodes showed any suspicious findings according to the bi-rads categorisation: even cortical thickening with preserved hilum, category a (c a); even cortical thickening with compressed hilum or uneven cortical thickening with preserved hilum, c b; uneven cortical thickening with compressed hilum, c c; hypoechoic mass with loss of hilum, c . us and fnab findings were compared using sentinel lymph node biopsy (slnb) and axillary lymph node dissection (alnd) data. results: of patients, ( . %) showed suspicious nodes on us and underwent us-guided fnab. of these patients, ( . %) showed positive, ( . %) showed negative, and showed insufficient findings on fnab. of patients, patients either with normal axillary us (n = ) or without positive findings on fnab (n = ) underwent slnb. of these patients, ( %) had metastatic lymph node. of patients with positive fnab findings, underwent neoadjuvant chemotherapy and underwent alnd. the sensitivity, specificity, ppv and npv of us were . %, %, . % and . %, respectively. the ppv of us was . % in c a, . % in c b, . % in c c, . % in c . the sensitivity, specificity, ppv and npv of us-guided-fnab were . %, %, % and . %, respectively. conclusion: axillary us showed high specificity and npv. a categorisation similar to bi-rads could be applicable for assessing axillary metastasis in breast cancer patients. improving diagnostic yield in axillary lymphadenopathy sampling: core biopsy and vacuum-assisted core biopsy r. salvador, x. salvador, i. miranda, o. dominguez, l. romero; barcelona/es (rafasalvador@telefonica.net) purpose: to analyse and compare the tolerance of the method and the results obtained by sampling axillary lymph nodes with two different devices: large-needle (cb) and vacuum-assisted core biopsy (vacb), directed to patients where previous fine needle aspiration (fnab) has failed to obtain material, or those with different cancers to determine the origin of the metastasic node. methods and materials: consecutive patients, suspicious or proved to have breast cancer were included, all of them with enlarged lymph nodes and signed the informed consent. the two groups were alternatively sampled by large needle ( g) core biopsy and vacuum-assisted needle ( g) biopsy to obtain cylinders in each procedure. eleven patients in each group. the size of the sample (weight), as well as the time of the procedure from the injection of anaesthetic to the final collection of the samples was recorded. discomfort, as well as the acceptance of the method was also recorded and scored in a -grade scale. results: the size of the samples obtained by vacuum-assisted method was bigger than that by core-needle (between twice and three times bigger). but the time for both procedures was similar (always - minutes). no differences were found in pain or any discomfort and tolerance of the method. conclusion: vacuum-assisted axillary lymph node biopsy is a procedure to obtain samples at least as safely as with core-needle biopsy and deserves bigger speci-s a c d e f g b thursday methods and materials: breast cancer patients between and underwent preoperative axus. suspicious nodes as per protocol were biopsied, negative axillae proceeded to sentinel lymph node biopsy (slnb). patients were stratified based on number of abnormal nodes identified on axus ( , , > nodes) and the number on final histology was noted. sensitivity, specificity, positive predictive and negative predictive values for axus-fnac/core biopsy were calculated. results: ( . %) patients had positive axillary nodes on final histology with detected by axus-fnac (sensitivity . %, specificity %, ppv %, npv . %). patients with nodal metastases identified by axus-fnac had a mean nodal burden of . nodes on histology (sem= . , % ci= . - . ; node identified on axus= . nodes on final histology, nodes on axus= . nodes, > nodes= . nodes) with correlation between axus and histology node numbers (r= . , % ci= . - . , p-value< . ). axus-fnac detected . % of node positive patients. mean nodal burden of patients diagnosed on slnb with negative axus or fnac was . nodes. the z trial questioned the role of axus in preoperative axillary staging of breast cancer in cases with ² positive sln. in this study, a single fnac positive node correlated with . nodes on final histology suggesting that axus continues to be essential in guiding appropriate management of the axilla in breast cancer. would have undergone mastectomy due to ci, while mri determined additional mastectomies, increasing mastectomy rate from % to % (p < . ). in the ci group, patients had multifocal, multicentric, synchronous or bilateral cancers, ( %) at mammography and ( %) at ultrasound; mastectomies were due to false positives at both conventional tests ( / , . %). in the ci and mri group, patients had multifocal, multicentric, or synchronous bilateral cancers, ( %) at mammography, ( %) at ultrasound, and ( %) at mri ( only mri-detected synchronous bilateral cancers) (p < . ); mastectomies were due to mri false positives (rate / , . %, not significantly different from ci group, p= . ). conclusion: mri was more sensitive than ci for multifocal, multicentric, or synchronous bilateral cancers. the additional mastectomy rate due to mri was %. adding mri, the percentage of young patients conservatively treated remained near to %. by using solely ci or using ci and mri, the inappropriate mastectomy rate was equal or lower than %. imaging features in mammography and breast ultrasound are related to her- receptor over-expression of primary invasive breast cancer a. adams , k.g.a. gilhuijs , k.e. pengel , c.e. loo , w.p.t.m. mali , s.g. elias ; utrecht/nl, amsterdam/nl (a.adams@umcutrecht.nl) to investigate what mammography and ultrasound imaging features are related to over-expression of the her- receptor in invasive breast cancer. these features could give insight in molecular basis of imaging phenotype, facilitate prebiopsy patient recruitment for early-phase her- targeting molecular imaging trials, and ultimately aid in predicting therapy response and prognosis. methods and materials: mammography and breast ultrasound imaging features of early invasive breast cancers were scored according to the th edition of the bi-rads lexicon, her- status was determined on surgical specimens. relevant imaging features to predict her- over-expression were first identified by conducting a systematic review and meta analysis, and then applied in multivariable logistic regression models. results: her- over-expression was found in cancers ( %). on multivariable analysis, the presence of microcalcifications (or . , % ci . - . ) on mammography, and posterior mass attenuation (or . , % ci . - . ) on ultrasound were strong, independent predictors. less strong predictors were breast density category / (or . , % ci . - . ) and mass presence (or . , % ci . - . ) on mammography, and circumscribed mass margin (or . , % ci . - . ) imaging of axillary lymph nodes in breast cancer patients: how do enhancement kinetics of contrast-enhanced lymph nodes apparent on dynamic mr-mammography correlate with standardised uptake value of f-fdg pet/ct? j. krammer, c.g. kaiser, a. schnitzer, s.o. schönberg, k. wasser; mannheim/ de (julia.krammer@umm.de) purpose: focusing on contrast-enhanced lymph nodes (ln) apparent on dynamic mr-mammography (dmrm) we intended to answer the following questions: ) is there a correlation between the maximum standardised uptake value (suvmax) of f-fdg pet/ct and maximum signal-intensity increase as well as type of signal-intensity curve ( - ) on dmrm? ) do contrast-enhanced ln negative on f-fdg pet/ct have a significantly lesser signal-intensity increase and/or lower curve grading on dmrm compared to f-fdg pet/ct positive ln? methods and materials: breast cancer patients who underwent both f-fdg pet/ct and dmrm were analysed. the mean study interval between the examinations was days. the signal-intensity increase and curve type of axillary ln ³ . cm in short-axis and with predominant contrast enhancement on dmrm were analysed and correlated with the suvmax on f-fdg pet/ct. results: ln in patients were f-fdg pet/ct positive. there was no correlation between the maximum signal-intensity increase and suvmax of these ln (r= . , p= . ). ln in patients did not show an appropriate correlate on f-fdg pet/ct (not visible or suvmax²blood pool). these ln did not reveal a significantly lower curve grading or lesser signal-intensity increase compared to ln positive on f-fdg pet/ct. there is no association between the uptake of f-fdg and the vascularisation of axillary ln on contrast-enhanced dmrm as signal-intensity increase and curve type do not correlate with suvmax. unspecific contrast-enhanced ln on dmrm negative on f-fdg pet/ct can frequently show enhancement kinetics equivalent to those rated positive on f-fdg pet/ct. ultrasound elastography in the diagnostic assessment of axillary lymph nodes in women presenting to a breast imaging centre l. sim, l. leong; singapore/sg (gdrssj@sgh.com.sg) purpose: to evaluate the performance of elastography in distinguishing benign and metastatic axillary lymph nodes. methods and materials: women with sonographically visible axillary lymph nodes undergoing biopsy at our breast imaging centre were evaluated independently with conventional ultrasound, elastography and combined ultrasound and elastography (ceus). the elastogram was classified as benign or malignant, based on the strain pattern, the length and area ratios of the lesion seen on elastography versus ultrasound. validation of radiological diagnosis was by histopathology. the sensitivity, specificity, ppv, npv and accuracy of each test were compared individually and with ceus. to obtain a parameter for diagnostic performance, roc curves were plotted. results: of the axillary lymph nodes biopsied, had metastases and were benign. the sensitivity, specificity and accuracy of conventional ultrasound were . %, . % and . %, respectively. the sensitivity, specificity and accuracy of elastography were . %, . % and . %, respectively, and that of combined ultrasound and elastography were %, . % and . %, respectively. the sensitivities of all tests were similar but the specificity and accuracy obtained by elastography and ceus were significantly better than conventional ultrasound (p < . ). elastography correctly diagnosed % of histologically benign lymph nodes which were deemed malignant on ultrasound. conclusion: the use of elastography alone or combined with ultrasound has a higher specificity and accuracy than conventional ultrasound in evaluating axillary lymph nodes. given the high specificity of elastography, biopsy could have been avoided in % of cases classified as malignant on ultrasound but benign on elastography. the z respiratory syncytial virus-related encephalitis: brain mr study with diffusion imaging a. pak, s. suh, g. son, y. lee, h. seo, k. kim, b. eun, n. lee, h. seol; seoul/kr (suppy@korea.ac.kr) purpose: respiratory syncytial virus (rsv) is a common pathogen of acute respiratory infection causing significant morbidity and mortality in childhood. among the major complications, encephalitis has been sporadically reported. we describe the incidence, clinical and mri imaging findings of rsv-related encephalitis in this report. we retrospectively reviewed the medical records and imaging findings of patients with rsv-positive enzyme assay, admitted at the paediatric department in three urban tertiary-care hospitals of our medical centre for years. there were cases with a diagnosis of rsv-bronchiolitis. among them, ( / , . %) had taken brain mri due to neurologic symptoms. of ( . %) showed positive imaging findings. of positive mr imaging cases revealed non-rsv related pathology such as sdh, diffuse brain atrophy due to status epilepticus, periventricular leukomalacia, pre-existed ventriculomegaly, hypoxic brain injury. results: there were three rsv-related encephalitis. the incidence of this entity is . % ( / ) for rsv positive enzyme assay, . % ( / ) for brain mri examination, and . % ( / ) for abnormal mri findings. the imaging findings of rsv-related encephalitis are as following: rhombenmesencephalitis pattern, rhombenmesencephalitis with acute disseminated encephalitis pattern, and limbic encephalitis pattern. conclusion: encephalitis rarely occurs with rsv bronchiolitis. however, when brain mr is needed in suspicion of neurologic involvement, rsv encephalitis is not uncommon among abnormal mr cases and mimics other viral and limbic encephalitis on imaging study. physicians should be aware of this entity for proper diagnosis and neurologic care of rsv-positive patients. cortical-juxtacortical lesions in clinically isolated syndromes: distribution and diagnostic value j.p. salazar, c. auger, d. pareto, r. mitjana, m. tintore, j. corral; barcelona/es purpose: to evaluate presence and spatial distribution of cortical-juxtacortical lesions in patients with a clinical isolated syndrome (cis) by using mri-based lesion probability maps and to determine its impact to demonstrate lesion dissemination in space (dis) according to the mcdonald criteria for multiple sclerosis (ms). methods and materials: cis patients aged between and years old (mean . years) who underwent brain and spinal cord t mri within the first five months after symptoms onset. the following sequences were obtained: ) pd and t -weighted; ) t -fast flair; ) un-enhanced and contrast-enhanced t -weigthed; and ) d double inversion-recovery. cortical-juxtacortical lesions in each patient were identified, manually outlined and segmented into a binarized mask. a cortical-juxtacortical mri-based lesion probability map was obtained. the mcdonald criteria for dis were assessed in each patient. results: cortical-juxtacortical lesions were identified in patients ( %). frontal lobe was the most affected area with an incidence of % of the lesions. temporal and parietal lobes had also a significant incidence ( % and % purpose: the aim of this study is to explore whether cns hemodynamic disturbances, detected in patients with clinically isolated syndrome (cis), correlate with executive function. methods and materials: thirty cis patients and forty-three healthy subjects matched for age, gender, education level, fsiq, and place of residence were administered computerized tests of visuomotor learning and set-shifting ability. regional cerebral blood volume (cbv), cerebral blood flow (cbf), and mean transit time (mtt) values were estimated using the dynamic susceptibility contrast-and irregular mass shape (or . , % ci . - . ) on ultrasound. the area under the roc curve was . ( % ci . - . , p < . ), and . after adjustment for over-optimism. post-test probabilities of her- over-expression were - % for cancers with calcifications, without posterior mass attenuation, and - % for cancers without calcifications, with posterior mass attenuation. conclusion: microcalcifications on mammography, and posterior acoustic attenuation of masses on ultrasound were predictors of her- /neu over-expression, indicating that imaging characteristics reflect molecular expression patterns in breast cancer. purpose: to study regional changes in brain metabolites during early hiv infection compared with later stage hiv infection and hiv-seronegative controls. enhanced t *-weighted mri (dsc-mri) technique in regions of interest in normal appearing white matter (nawm) and normal deep grey matter (ndgm) structures bilaterally, that serve as integral components of brain circuits responsible for visuomotor learning and executive functions. results: cis patients showed significantly elevated reaction time (rt) on both tasks, while their cbv values were globally increased. significant, positive correlation coefficients were found between error rates on the inhibition condition of the visuomotor learning task and cbv values in both thalami and occipital, and periventricular nawm, bilaterally. on the set shifting condition of the respective task significant positive associations were found between cbv values in the semioval centre and periventricular nawm bilaterally and error rates, between cbf values in both thalami and error rates, and between cbf values in the left parietal nawm and right caudate and rt. conclusion: impaired executive function in cis patients, including inhibition and set shifting abilities, correlated positively with elevated regional cbv values thought to reflect active widespread brain inflammatory processes. the "central vein sign": is there a place for susceptibility-weighted imaging in possible multiple sclerosis? t. kau, m. taschwer, m. schönfelder, j.r. weber, k.a. hausegger; klagenfurt/ at (t.kau@gmx.at) purpose: susceptibility-weighted imaging (swi) may have the potential to depict the perivenous extent of white matter lesions (wmls) in multiple sclerosis (ms). we aimed to assess the discriminatory value of the "central vein sign" (cvs). in a lesion-based t mri study, wmls in patients were prospectively included applying the following criteria: ) at least one circumscribed lesion > mm, ) not more than eight non-confluent lesions > mm. flair images served as gold standard for the identification of wmls which were classified as periventricular, subcortical, or infratentorial. only defined wmls with a maximum diameter of > mm were correlated with their swi equivalent for cvs evaluation. results: five patients fulfilled the revised mcdonald criteria for ms and nine patients were given an alternative diagnosis with non-ms-wmls most probably representing focal gliosis. a total of lesions > mm ( ms-wmls and non-ms-wmls) were detected. consensus reading found a central vein in out of ms-wmls ( %) and in one out of nine non-wmls ( %), respectively. the cvs proved to be a highly significant discriminator (p < . ) between ms-wmls and non-ms-wmls with a sensitivity, specificity, positive and negative predictive values, and accuracy of %, %, %, %, and %, respectively. the frequency of cvs positive lesions was highest in the periventricular zone ( / ), even more markedly in ms-wmls alone ( / ). inter-rater agreement was good (kappa= . ). conclusion: even though the cvs is not exclusively found in ms-wmls, swi may be a useful adjunct in patients with possible ms. single-and multi-voxel proton spectroscopy in patients with pyogenic brain abscess p. the study was primarily designed to find the optimal dose range of br to detect malignant focal liver lesions. secondary objectives were the evaluation of the safety profile and comparison with contrast-enhanced mri (ce mri). methods and materials: patients ( f, m, mean age: y) with known hcc or liver metastases were examined in three centres during a time period of three months. each patient underwent a baseline and at least three contrast-enhanced us (ceus) with ascending dose levels ( . ml, . ml, . ml) of br . ce mri was done weeks prior or post-study examination. lesions were recorded in on a liver map, with respect to localisation, size and suggested lesion type. examination quality was documented and safety parameters were assessed. results: the number of lesions detected with br ceus increased with dose, while the number of missed lesions and the lesion size decreased. despite the increasing contrast enhancement no other image quality parameter showed a substantial difference. no significant changes were found for the analysed safety parameters and no serious adverse events were reported. conclusion: we finally conclude that the recommended dose level of br is between . ml and . ml for which the lesion detection was comparable to the ce mri. in addition, we found a higher number of especially small lesions with higher doses of br which might be due to a higher sensitivity of ceus for the detection of liver metastases. however, this is an interesting and debatable finding. histopathological characteristics of the primary hcc and recurrence were obtained by a review of the pathologic reports. the association between the variations in histopathological and imaging characteristics of primary and recurrent hcc was estimated using linear regression analysis. the initial recurrence was extrahepatic in ( . %, lung, bone, lymph nodes, brain, spleen, adrenal), intrahepatic in ( . %) and both intrahepatic and extrahepatic (peritoneum, lung, bone, lymph nodes) in ( . %) patients. of patients with initial or late intrahepatic recurrence, ( . %) showed a variation in imaging characteristics between the primary hcc (hypervascular) and the recurrence (hypovascular), ( . %) showed a variation in histopathological char- during - patients with - hccs were treated with radiofrequency ablation (alone or combined with ethanol injection) . patients had complete ablated tumours at mo. ct was followed-up serially, using alternated ceus (one sulphur hexafluoride-based microbubbles injection per lobe) and ct every months. the following patterns of recurrence were considered: a, enhancing tissue within the lesion; b, enhancing tissue adherent to the lesion; c, enhancing tissue within the same liver segment of the treated nodule; d, enhancing tissue within a different segment (progression heidelberg/de (gregor.pahn@med.uni-heidelberg.de) purpose: quantitative assessment of image quality and radiation exposure reduction potential of a next-generation solid-state mdct detector with fully integrated readout electronics in comparison with its predecessor. methods and materials: using standard ct image quality phantoms and an automated quantitative image quality analysis software developed in-house, image quality and radiation exposure (re) of an mdct system (somatom definition flash, siemens) either equipped with ufc™ or new "stellar" detectors has been assessed for different combinations of acquisition and reconstruction parameters. subsequently, measurements and analysis were repeated for "stellar" detectors without altering parameters apart from noise-weighted reduction of tube currenttime product resulting in image noise levels equal to those achieved when using their predecessor. results: image noise of both detectors was comparable for small absorption crosssections (Øwater= cm) while being - % lower for large ones (Øwater= cm) when using "stellar" detectors. ct number stability and uniformity declined with increasing subject cross-section, particularly at kvp, though not as much for "stellar" detectors. when noise of "stellar" acquisitions was increased to ufc™ levels, re reduction of - % was achieved. for the "stellar" detector cnr was slightly higher (same re) or slightly lower (reduced re), while spatial resolution was always equal for both detectors (up to lp/cm at mtf %). conclusion: overall image quality improves when a next-generation mdct detector is employed instead of using its predecessor. for acquisition settings intrinsically acteristics (from moderate to poor differentiation), but no association was found between imaging and histopathological variations. the most common pattern of recurrence was extrahepatic location, followed by intrahepatic recurrence and both intrahepatic and extrahepatic diffusion. variations in dynamic-imaging characteristics of intrahepatic recurrence were not associated with variations in histopathological characteristics. films strips were scanned before and after irradiation with the epson perfection v photo scanner in reflective mode. the reference dosimetry system was calibrated in terms of air kerma in air. the measured reflectance change is converted into air kerma using a calibration curve. air kerma was converted into absorbed dose using the appropriate ratio of mass-energy absorption coefficients water-to-air for a given beam quality, defined by half-value layer following the aapm tg- protocol. results: dose values for each of the five ctdi phantom film positions were obtained by averaging dose profiles from each film piece over the length of cm, and were used to calculate weighted ctdivol. the average difference for six scanners between calculated and listed ctdivol was . % with a maximum observed difference of . %. conclusion: in contrast to ionisation chamber measurement, the proposed method requires only a single exposure, does not need stem effect correction, and provides an acceptable accuracy in comparison to ct scanner listed ctdi values. measured dose profiles allow for measurements of dlp and peak doses at the same time. associated with high image noise the new detector exhibits much lower noise levels, offering great potential for radiation exposure reduction without adversely affecting overall image quality. munich/de (zsuzsanna.deak@med.uni-muenchen.de) purpose: to evaluate the dose reduction potential of hir and ir in comparison with fbp. methods and materials: an anthropomorphic cardiac phantom (qrm corp., germany) was scanned using a -row mdct scanner (ct hd; ge-healthcare, usa). the phantom's calcification insert was replaced with a model simulating a stented aortic aneurysm with endoleak and intraluminal thrombus. images were obtained at tube voltages of kv, kv and kv using automated tube current modulation with incrementally increasing noise indices (ni= , , , , , , ) adjusted to a primary reconstruction slice thickness of . mm. after acquisition, images of . mm slice thickness were secondarily re-reconstructed with fbp, hir (asir® with % blending, ge-healthcare) and ir (veo®, ge-healthcare). twenty-one radiologists blinded to image reconstruction methods independently analysed the detectability of simulated vascular pathologies (endoleaks < cm² and intraluminal thrombus < mm). contrast-to-noise ratio was measured for the stented aorta. a two-by-two purpose: to compare two low-dose scanning protocols, and to estimate effects on the signal, noise, effective radiation dose (ed), quality of acquired data. methods and materials: patients were divided into three groups. the scanning protocol was kvp mas in first group, kvp mas in second group, and kv mas in third group, special reconstruction algorithms have not been used. for quantitative and qualitative evaluation we used visual scores ( - ), mean arterial attenuation, noise, contrast-to-noise ratio (cnr) in three arterial segments and ed. results: the bmi ranged from to kg/m and were not significantly different between groups (p= . , . , . , respectively). the mean intraarterial attenuation in , , groups was ± hu, ± hu, ± hu, respectively, but significantly higher in second group (p= . ). noise in second group ( ± hu) was significantly higher than that in third group ( ± hu, p= . ), and first group ( ± . hu, p= . ). the cnr in second ( . ± . ) and third ( . ± . ) groups was significantly lower than that in first group ( . , p= . ). image quality was comparable between three techniques, except aorto-iliac segment in second group. effective dose was . ± . mzv, . ± . mzv and . ± . mzv, respectively, differences were significant (p= . ). conclusion: average radiation dose reduction up to % was achieved using " kv" and " mas" protocol providing sufficient image quality. application of the kv protocol in people with bmi> is limited, especially in evaluation of aorto-iliac segment due to higher noise and attenuation levels. while at mas protocol such limitation is not observed. this allows to recommend it as the preferred protocol for low-dose runoff cta in case of special reconstruction algorithms. purpose: to assess the quality of ct images reconstructed with sinogram affirmed iterative reconstructions (safire) and comparing their performances with iterative reconstructions in image space (iris) and standard filtered back projection (fbp) algorithms on a siemens somatom definition flash. results were used to optimise a dual energy (de) abdominal protocol. methods and materials: fbp, iris and the strength levels in safire (s -s ) reconstructions were characterised in contrast, noise and spatial resolution for medium-smooth filters using a tungsten wire in air, water and catphan phantoms. standard deviation (sd), contrast-to-noise ratios (cnr), noise power spectra (nps), modulation transfer function (mtf), and the non-prewhitening matched filter signal-to-noise ratio (snrnpw), a quasi-ideal observer metric in the frequency domain assumed to be the most reliable image quality reference, were calculated for all kernels and used for dose saving evaluations. results: the highest cnr in de protocol resulted with a composition factor of . . compared to fbp, the average sd reductions were ± % with safire s and ± % with iris kernels. a shift towards low frequencies in the nps was found for all iterative filters, giving to images a different texture. differences between mtf values were within % in all fbp-iterative coupled filter comparisons. the optimal kernels, from snrnpw analysis of abdominal protocol, resulted i -s for safire and i- for iris with a potential dose reduction of % and %, respectively. conclusion: iterative reconstructions and de acquisition strongly improve image quality reducing the noise and improving the contrast without affecting the spatial resolution. the impact of tube voltage, scan direction and beam collimation on the performance of automatic tube current modulation systems in paediatric and adult ct n. buls , j. schoenaers , g. van gompel , k. nieboer , j. purpose: to reduce the radiation dose exposure and contrast medium volume using low-kv ct angiography protocol ( kv; ml) in the evaluation of abdominal aorta, maintaining high diagnostic performance. a total of patients with abdominal vascular disease were prospectively enrolled. all patients underwent mdct scan examination of abdominal aorta (brilliance ict, philips). patients were scanned using lowdose radiation protocol ( kv; automated tube current modulation) and ultralow-contrast volume ( ml; ml/s; mgi/ml) and a control group of patients underwent standard ct-angiography protocol ( kv; automated tube current modulation) and standard contrast volume ( ml). density measurements were performed on abdominal aorta, renal arteries and common iliac arteries. the radiation dose exposure (dose length product, dlp), the intravessels density and the signal-to-noise ratio (snr) were calculated, compared and statistically analysed. results: all exams were considered diagnostic, allowing the correct visualisation of main aortic branch and vascular wall. higher density measurements were obtained in low-kv protocol: mean attenuation value of abdominal aorta hu, renal arteries hu and common iliac arteries; in comparison to control group: mean value of abdominal aorta hu, renal arteries hu and common iliac arteries hu. a reduction of % (p < . ) of radiation dose exposure in low-kv protocol ( dlp; . ctdivol) was obtained among control group ( dlp; . ctdivol). conclusion: low kv protocol and ultra-low contrast medium volume ( ml) reduce the radiation exposure (over %) and the renal damage, allowing a relevant reduction of contrast material volume, enabling to evaluate more easily young patients or patients with renal failure. an international multi-centre comparison of the non-contrast mr angiography technique time-spatial labelling inversion pulse (time-slip) against contrast-enhanced ct angiography for assessing renal artery stenosis: the renal artery contrast-free trial ( (t.vogl@em.uni-frankfurt.de) purpose: to compare contrast-enhanced magnetic resonance angiography (mra) with conventional digital subtraction angiography (dsa) for detecting stenoses and planning of therapy in patients with peripheral artery occlusion disease (paod). in this retrospective study, patients ( women/ men; mean: years) with established paod underwent both imaging modalities in a maximum interval of days. dsa was the standard of reference. the pelvic and leg arteries were divided into anatomic segments, which were graded on a scale from to ( =no stenosis, =stenoses < %, =stenoses ³ %, =occlusion). the pelvic and leg vessel systems were categorised with the tasc ii-score into five grades (none, tasc-a, tasc-b, tasc-c and tasc-d) for detecting whether the therapeutic consequences would be the same for both imaging modalities. iodine load reduction in ct aorta angiography with gemstone spectral imaging: comparison with standard ct aorta angiography x. luo, j. wu, j. sun, m. chen; yangzhou/ cn (luoxianfu@gmail.com) purpose: to compare quantitative and subjective image quality between computed tomographic aorta angiography (ctaa) with a gemstone spectral imaging (gsi) technique with reduced iodine load and standard ctaa. methods and materials: patients underwent ct scanning on hdct (discovery ct hd, ge healthcare). all cases were randomised into two groups: standard ctaa ( - kvp) with mg/kg per body weight of iodine (n= ) and gsi scanning ctaa (image reconstruction at kev) with the same injection volume as in the standard protocol but composed of contrast medium and saline in a : . fashion (n= ). signal intensity and noise of aorta were measured; signal-to-noise ratio (snr) and contrast-to-noise ratio (cnr) were calculated. a five-point scale was used to subjectively evaluate vascular enhancement and image noise. results: compared with standard ctaa, gsi ctaa demonstrated higher signal intensity in all aorta arteries (all p < . ), inferior noise only in segmental arteries (p < . ), higher snr and cnr (both p < . ), and compatible effective dose (p > . ). the five-point score was higher in the standard ctaa protocol (p < . ). the inter-reader agreement regarding the dichotomized diagnostic versus nondiagnostic scale was similar (p > . ) between two groups. conclusion: gsi ctaa with image reconstruction at kev allows a significant reduction of % iodine load while improving intravascular signal intensity, maintaining snr and with comparable radiation dose. >/= % and cta </= %). on average measured stenotic severity (n= arteries) was similar between nc-mra ( ± %) and cta ( ± %) (p= . ). purpose: we aim to assess the expansile differences between the ishimaru zones of the aortic arch throughout the cardiac cycle. this study further focuses on the implications of this variation in diameters of the aorta for sizing endovascular procedures. cardiac gated ct examinations of atherosclerotic ascending, arch and descending aorta, performed for a number of reasons, were evaluated. presence of calcified and non calcified plaques in the arch was used as markers for atherosclerosis. patients with acute aortic syndromes, connective tissue syndromes and aortitis were excluded. the best systolic and diastolic images were interrogated and true transverse slices were obtained using a d workstation. differences between the systolic and diastolic images for the short axis, long axis and an average of the two were calculated. results: a total of zones were evaluated in patients. the average variation between diastole and systole diameters was . zone - . mm; . zone - . mm; . zone - . mm; . zone - . mm. conclusion: while the average variations were well under mm for all zones the maximum was noted in zone ( . ) and the least in zone ( . ). the study shows limited variations in atherosclerotic aortas supporting the theory of reduced expansibility in them secondary to the disease process. this in turn suggest that we need not undertake gated examinations of the aorta prior to endovascular procedures thus avoiding the hazards of radiation. purpose: to compare low-pitch retrospectively ecg-gated (gated) and high-pitch non-ecg-triggered (non-gated) multidetector ct (mdct) protocols in terms of measurements of the aortic root and the aortic valve and consequently prosthesis sizing in transcatheter aortic valve implantation (tavi). methods and materials: consecutive tavi candidates underwent mdct examination with retrospectively gated helical scanning of the aortic valve region followed by a non-gated whole aorta ct angiography. eleven anatomical structures within the aortic root and the aortic valve which are deemed to be crucial for tavi planning were measured throughout the cardiac cycle and compared with measurements from non-ecg-gated scans. differences in annular dimensions measured in both types of scans were tested in terms of relevance for prosthesis sizing. results: substantial differences in measurements were found for the aortic root at the right coronary ostium level (p < . ), the sinotubular junction and the aortic sinuses diameter (p < . ). the maximal annular dimensions occur in early systole. measurements of diameters in high-pitch scans agree only to diastolic images. however, measurements of annular perimeter in non-ecg-triggered highpitch scans agree to systolic images. the highest agreement in prosthesis sizing according to measures from both ct protocols in systole and diastole was noted if annular perimeter was followed. conclusion: even though the results of annular perimeter are comparable at first glance, only a dedicated gated cta protocol offers the full potential to perform all measurements at the optimal time point and should be recommended for prosthesis sizing in tavi. purpose: to examine possible relationships between severity of aortic valve calcification, the degree of aortic-valve-regurgitation (avr) and occurrence of mace events after transcatheter-aortic-valve-implantation (tavi). methods and materials: patients ( men, . ± . years) with symptomatic aortic stenosis were included in this study. patients received a corevalve® aortic valve prosthesis and in patients an edwards sapien™ prosthesis was implanted. prior to tavi, all patients underwent a thoracic-pelvine ecg-gated-ctangiography for therapy planning. the aortic-valve calcification score (as) and aortic-valve calcium volume (av) was measured and compared to post-procedural avr measured by echocardiography and to the -day incidence of major-adversecardiac-events (mace). the overall incidence of mace after tavi was . %. there was no significant correlation between the amount of as and av and mace after tavi (both p> . ). post-interventional avr did not correlate with pre-procedural measured as and av (both p> . ). patients with post-procedural avr showed no significant differences in as and av than patients without evidence of avr after tavi ( thursday target noise sd . and fbp reconstruction) and referred to follow-up chest ct within two months were enrolled. aec (sd ) integrated with aidr d was used in follow-up chest ct protocol (group b), the raw data of which were reconstructed again with fbp (group c). the max/min mas of each subject and their correlation with bmi were investigated to validate whether system could personalise tailor tube current. the chest images were divided into upper, middle and lower parts which were evaluated separately by two radiologists with -point scale ( -good, -acceptable, -poor). image noise was measured in these parts with -mm diameter roi placed on specific anatomic structures. effective dose (ed) was compared. . mpr and d reconstruction images were created, and reviewed by two experienced radiologists with blinded, who measured the tracheal lumen to determine the presence of central airways narrowing. the d reconstruction of confidence was graded on a -point scale from (no confidence) to (highest of confidence. the mpr noise was assessed by measuring the sd of the pre-sternal soft tissue. the dlp was used to compare radiation doses. results: the mpr image noise was ranked higher for ct images of kv protocol than kv protocol. there was no significant difference in confidence between kv and kv protocol (p > . ). excessive central airway collapse (reduction > %) was seen in patients with tracheomalacia and remaining subjects had centre airway stenosis. dlp of kv protocol was . mgy.cm and kv protocol was . mgy.cm. the -slice dynamic volume ct is a promising method for diagnosing central airway narrowing. the kv protocol performs as well as the kv protocol for the d dynamic imaging in small bmi objects. purpose: the purpose of this study was to examine the influence of different arm positioning on automatic tube current modulation of multi-slice ct on chest image quality and radiation dosage. methods and materials: sixty patients underwent scanning by using care dose d thorax ct protocol in which both arms were raised above the shoulder region using standard-position (group ) and postural manoeuver (group ), respectively. objective and subjective image quality was assessed. individual recorded the ctdiv values and the tube current-time product per exposed section. effective radiation dose was calculated. results: compared with the image quality in the standard-position group, the image quality in the postural manoeuver group was decreased on subjective image quality but within acceptable diagnostic limits. the average effective dose in the postural manoeuver group was . msv; the dose in the standard-position was % lower than this. conclusion: both arms were raised above the shoulder region scanning using care dose d thorax ct protocol can reduce the overall dosage to patients and the image quality without adverse influences, and may be more feasible in clinical practice. the effectiveness of lead apron for radiation protection in ct n. weber, p. monnin, c. elandoy, s. ding; lausanne/ch (nicolas.weber@hesav.ch) purpose: to determine the effectiveness of lead shielding for radiation protection in ct. methods and materials: three -cm diameter ctdi (pmma) phantoms, of cm long, placed side by side, were scanned over a length of cm with a ge ct scanner. absorbed dose was estimated with thermoluminescent dosimeters positioned in the middle, and at two levels in periphery of the phantom ( cm inside): top and bottom. additionally, the dose was measured on the surface of the phantom ("skin dose"). tld were placed over a length of . cm, with . cm in the scatter field. three acquisitions were performed: ) without lead apron, ) with a lead apron at cm from the edge of the primary field and ) with a lead apron at . cm. results: in scattered radiation, no significant difference of dose was found between without shielding and with the apron at cm, in the middle of the phantom. however, in the presence of the apron the dose is lowered by as much as % at the bottom of the phantom, whereas the skin dose is increased by % (tunnel effect). this indicates that the scanner a retrospective study was conducted in two radiology departments from public hospitals using a sample of patients under years submitted to head ct examinations between and , performed with different equipments: somatom emotion (n= ), somatom emotion (n= ) and somatom emotion (n= ). the influence of patient age and cephalic perimeter were considered. multiple data analysis was used in order to assess radiation dose levels and the concordance of these with diagnostic reference levels. the results were obtained for four different paediatric groups, divided according to patient age: less than year; to years; to years and to years. the mean values obtained of dose length-product from some groups are lower than the diagnostic reference levels ( mgy.cm from to years and mgy.cm from to years). however, until years the values are higher than the recommendations ( mgy.cm for less than year and mgy.cm from to years). conclusion: this work identifies possible gaps and all possible methods should be applied to reduce the radiation dose provided without deteriorating image quality. a set of recommendations are needed to optimise the radiation dose since the children have a superior radiosensitivity. dose values in eye lens in paediatric brain computed tomography: influence of different protocols c. carriço , m. inácio , a. kristiansen , m. larsen , j. santos , s. holm , g. paulo ; coimbra/pt, odense/dk (catarina.carrico@hotmail.com) purpose: the number of head computed tomography (ct) examinations in paediatrics had an exponential increase. taking into account the highest radiosensitive of children tissues and organs, radiology departments should permanently optimise ct protocols in order to minimize exposure, especially to more radiosensitive thursday body mask is classified into classes (fat, water, air, and outliers) by a multivariate gaussian intensity model, regularized by a markov random field. to increase robustness to image variability, the statistical model parameters are automatically updated with the em algorithm. the air voxels are rejected from the mask and the adipose tissue segmentation is refined using a new -class gaussian intensity model. to separate sat from vat, an intra-abdominal mask is created by calculating the convex hull around the water tissue (water fraction of at least %). the adipose tissue quantification is, even under heavy motion, visually satisfactory. it is, moreover, highly consistent over the two datasets of each subject, as demonstrated by the high icc (r= . ) and the small difference in fat, sat, and vat percentage of total body volume of . %, . %, and . %, respectively. conclusion: an automatic adipose tissue quantification method based on spatially regularized multivariate gaussian mixture models is demonstrated to provide consistent measurements for sat and vat. computational texture analysis in interstitial lung disease: comparison of descriptors and classification accuracy j. ofner , c. purpose: to evaluate and compare sequential ct to spiral ct examinations of the brain in terms of radiation dose and image quality. the study was carried out prospectively on patients referred for brain ct. radiation dose and image quality data were gathered from an equal number of ct examinations performed with either sequential (n= ) or spiral (n= ) techniques. radiation dose data in terms of ctdivol and dlp were recorded by the scanning radiographers at the end of each examination. a ct brain image evaluation set was compiled which was evaluated by four radiologists. the radiologists evaluated the quality of the images by visually grading the reproduction of anatomical structures as outlined in eur : european guidelines on quality criteria for ct. results: mean ctdivol and dlp readings were significantly higher (p < . ) for sequential scans over spiral scans (ctdivol: . mgy vs. . mgy and dlp: . mgycm vs. . mgycm). the mean image quality grading scores for all criteria for the sequential technique were significantly (p < . ) higher than those obtained by the spiral technique. conclusion: spiral acquired ct brain images have lower radiation doses. the quality of the images produced using this technique, however, produces images of a lower quality to those obtained using the sequential technique. further research is recommended investigating whether the level of image quality produced by the spiral technique is sufficient for diagnosis in order for patients to benefit from associated radiation dose reductions. termined the number of alerts triggered, based on the currently used, exclusively study description-based threshold method. the default setting of this threshold is twice the median for each separate descriptor. then, logical combinations of study description and protocol were made and linked by a rsna radlex elements, for a total of % of all examinations. the mapped data sets were then used to determine the number of alerts triggered when using a threshold method based on a combination of study description and acquisition protocol. the impact of both strategies on relevant dose information was assessed. results: considering only the relevantly mapped scans, we found a % decrease, from to alerts, using the radlex-based alert triggering. of these, ( %) were not previously reported by the old method. the new alerts could all be attributed to patient or examination-related factors. of the alerts ( %) that were no longer reported, none were found to have any clinical relevance. the combination of study description and acquisition protocol in the threshold method for ct dose measurements helps to decrease the number of alerts, while maintaining patient safety. purpose: to optimise ct protocols and parameter settings, by comparing the radiation dose between different ct scanners of the same type. methods and materials: using dedicated software (dosewatch®), dose information from ct examinations performed on two -slice lightspeed vct scanners over an -month period was prospectively evaluated. we compared the administered radiation doses for equivalent acquisition protocols on the machines, and identified acquisition protocols in which there was a significant dose variation. for these protocols, we performed a rigorous imaging parameter check, including comparison of the number of examinations, acquisition types, number of irradiation events, ma, kvp, scanning length, exposure time and pitch factor. these data were then linked to the protocol setup. results: we found significant parameter variations in out of ct acquisition protocols. in cases, the variations could not be attributed to a difference in the acquisition protocol set-up, and a thorough inspection did not lead to any improvement. for acquisition protocol (helical skull), we found that the noise index was erroneously configured on one of the ct machines. after correction of this parameter, the median dose length product (dlp) on this machine was reduced from mgy.cm to mgy.cm ( % decrease), based on measurements during months prior to correction ( cases) and months after correction ( cases). the use of a patient dose managing system for ct can identify suboptimal parameter settings, and helps to significantly reduce the radiation dose without loss of relevant diagnostic information. it (marco.moschetta@gmail.com) purpose: to assess the reliability of d analysis ct software in determining urinary stones volume and density. methods and materials: ct images of patients for a total of urinary stones ( calyceal, pelvic, ureteral) were evaluated. all exams were performed using a mdct with a low dose protocol and without injection of contrast material. ct scans were independently evaluated by two expert radiologists. for each stone, volumetric [sv (stone volume) = l (length) x w (width) x t (thickness) x π x . ] and densitometric [selecting a roi on axial plane] measurements were calculated. the obtained data were then compared with the measurements performed by the d analysis ct software (vitrea fx . ). differences between the two systems were evaluated by the analysis of variance (anova) test. the interobserver agreement was calculated using the cohen's kappa (k) test. the volumetric and densitometric measurements of urinary stones obtained without d analysis software showed a lower interobserver agreement (k = . ) than that resulting from the use of the software (k = . ). statistical significant differences were found between volumetric and densitometric measurements as performed with and without the d software for each urinary stone (p < . ). conclusion: volumetric and densitometric evaluation of the urinary stones provided by d analysis software is reliable and reproducible and could significantly influence the therapeutic choices. the dslicer open-source platform for segmentation, registration, quantitative imaging and d visualisation of biomedical image data s. pujol , s. pieper , r. . overall image quality, identifiability of vessels and homogeneity of liver parenchyma were graded by two experienced radiologists in consensus using a -point rating scale with a true non-contrast ct (tnc) scan as standard of reference ( =no difference; =minimal, non-relevant difference; =visible but diagnostically irrelevant difference; =relevant difference; =obvious difference). image noise was measured in liver parenchyma, retroperitoneal fat and aortic lumen. wilcoxon signed-rank non-parametric test was used to assess statistical significance. the nvnc was superior compared to the standard vnc regarding overall image quality and identifiability of vessels ( . vs. . /p < . and . vs. . /p < . ), whereas no significant difference was observed concerning the homogeneity of the liver parenchyma (nvnc: . /svnc . ). there was no significant difference regarding image noise with an average value of . hu (nvnc) and . hu (svnc), respectively, compared to . hu (tnc). the new algorithm provides a better image quality and an improved assessment of vessels and small structures. the nvnc images represent adequate substitutes for tnc images, rendering an omission of non-contrast acquisitions feasible, corresponding to a substantial dose reduction. image quality of monoenergetic low-kev datasets for lower extremity dual-energy ct angiography s. sudarski, d. schneider, p. apfaltrer, s.o. schönberg, t. henzler; mannheim/ de (sonja_sudarski@gmx.de) purpose: to compare image quality of conventional -kev polyenergetic images (peis) and monoenergetic images (meis) for dual-energy ct angiography (de-cta) datasets of the lower extremity. we retrospectively evaluated de-cta datasets obtained from patients ( men, ± years). meis were calculated in -kev intervals from to kev using the -and -kev image data. attenuation and image noise were measured in the external iliac, femoral, popliteal and one lower leg artery. contrast-to-noise ratio (cnr) and signal-to-noise ratio (snr) were calculated for each vessel. differences in these parameters were compared between the different monoenergetic datasets. the two best meis were compared to -kev-peis. results: snr and cnr of -and -kev meis were highest when compared to other low-kev meis. in -kev meis, cnr in external iliac, femoral and popliteal arteries was higher compared to peis (+ %, + % and + %; p < . ), while cnr did not change in lower leg arteries (p> . ). snr in external iliac and lower leg arteries was equal in -kev meis and peis, while in femoral and popliteal arteries it was lower (- %, - %; p < . ). -kev meis showed a higher cnr in lower leg arteries compared to peis (+ %; p < . ), while snr did not differ (p> . ). in the other three arteries, -kev meis showed significantly not only higher cnr but also lower snr. purpose: persistent sub-centimetre ggo are pre-malignant. hrct improves detection of small nodules and low dose ct (ldct) reduces patient exposure but both decrease cnr essential for characterisation of small ggo. we investigate the use of adaptive iterative dose reduction (aidr) in low dose hrct (ld-hrct) for diagnosis of small ggo. methods and materials: ldct ( kv, mas, x . mm) was used in stages: ) computer-simulated lung nodules , and mm spheres each of ct# , - and - hu; ) identical synthetic nodules, placed in an anthropomorphic chest phantom and ) in vivo pulmonary nodules ( ggo, solid); . mm diameter ( . - . ), mean ct# - hu ( to - ). raw data reconstructions are as follows (slice thickness/overlap mm): . / . , / , / , / , / , / , / , / . and / with fbp. in vivo images were also reconstructed with aidr. ct# and cnr were determined for each protocol. results: ct# accuracy decreases with increased slice thickness for all nodules: / reconstructions decrease ct# > - hu for mm solid (+ hu) nodules and ~ - hu for mm ggo (- hu and - hu), spearman's coefficient = - . , p < . . hrct (< . / . mm) has accurate nodule ct# (error< % purpose: to investigate whether optimisation of volume-doubling time (vdt) cutoff for fast-growing nodules in a lung cancer screening trial can improve accuracy of lung cancer diagnosis. methods and materials: all subjects underwent at least two low-dose computed tomography (ct) scans during the baseline-round screening and regular secondround screening in year of the nelson lung cancer screening study and were referred to a pulmonologist because of a solid nodule with volume ³ mm and vdt < days. histology was the reference for diagnosis, or, to confirm benignity, stability of the nodule volume on subsequent ct scans for at least two years after referral to a pulmonologist. nodule volume and vdt were semi-automatically calculated by software. reduction of false-positive rate was evaluated at maintained sensitivity for lung cancer diagnosis with the vdt cut-off of days as reference. results: fast-growing nodules were included ( individuals), of which nodules ( %) were malignant. mean follow-up of non-resected benign nodules was . (range . - . ) years. the optimal vdt cut-off for the -month follow-up ct in the baseline round was days. using this cut-off, false-positive referrals reduced by % ( versus false-positive referrals). for the regular secondround screening, vdts varied more among malignant nodules, precluding lowering of the vdt cut-off of days. conclusion: lowering the vdt cut-off of the -month follow-up ct in baseline lung cancer screening from to days may reduce false-positive referrals, without apparent loss in sensitivity. mia, invasive adenocarcinoma, and the extents of invasive carcinoma component were quantified. association between imaging parameters and pathologic classification was examined. results: patients ( %) were pathologic stage a, and were b and the other one was a. of all tumours, were ais ( %), were mia ( %), and were invasive adenocarcinoma ( %). based on univariate analysis, tumour size in lung setting, uniformity, and entropy were able to significantly separate tumours according to pathologic classification, whereas tdr, volume, mass, or suvmax were not. on multivariate analysis, uniformity and entropy were remained as independent factors to stratify the pathologic subgroups of patients (odds ratio [or] = . , p =. , and or = . , p =. , respectively). conclusion: texture parameters on ct imaging metrics, reflecting tumour heterogeneity, appear to help stratify pure ggn lung adenocarcinoma. non-solid, part-solid or solid? classification of pulmonary nodules in thoracic ct by radiologists and a computer-aided diagnosis system c. purpose: classifying pulmonary nodules into solid, part-solid and non-solid is crucial for patient management. a computer algorithm is compared to a radiologist on a large data set obtained from a multi-center lung cancer screening trial. methods and materials: low-dose chest ct scans ( x . mm, - kvp, mas) with part-solid, non-solid, and solid nodules with a diameter between and mm were randomly selected from two sites participating in the dutch-belgian nelson lung cancer screening trial. the set contained scans, including part-solid, non-solid and solid nodules. the nodule-type recorded in the screening database was used as a reference standard. an automated classification system for characterisation of nodules was designed using morphometric features. the accuracy of the computer algorithm was evaluated in three ways: classifying nodules ( ) as solid or subsolid, ( ) as solid, part-solid or non-solid, and, ( ) for the subsolid lesions only, as part-solid or non-solid. an experienced thoracic radiologist independently performed the same classification. the accuracy of the automated system to differentiate between solid and subsolid nodules was . , compared to . for the radiologist. the computer classified the nodules as solid, part-solid or non-solid with an accuracy of . versus . for the radiologist. the software reached an accuracy of . in differentiating part-solid from non-solid nodules, where the radiologist had an accuracy of . . conclusion: a novel automated characterisation tool for pulmonary nodules shows promising performance and could aid radiologists in selecting the appropriate workup for pulmonary nodules. ( ), additional to bled aneurysm ( ) and additional coiling ( ). aneurysms ranged in maximal size between and mm (mean/median mm). aneurysms were located in the cavernous sinus (n= ), supraclinoid internal carotid artery (n= ), anterior communicating artery (n= ), middle cerebral artery (n= ), pericallosal artery (n= ) and posterior circulation (n= ). patients were preloaded with aspirin and clopidogrel (multiplate test control). clinical and angiographic follow-up was done at -to -month intervals after treatment. results: single stents were placed in cases, stents in and flow-diverter stents in . in cases no additional coil aneurysm occlusion was performed. seventeen procedural complications occurred ( %): thrombo-embolic, in-stent thrombosis, haemorrhages, side-branch occlusions and technical device problems. most had no clinical sequel, but patients died ( %) and patients had permanent neurological deficit ( %). five aneurysms ( %) needed second additional stenting during follow-up. mean follow-up was months (range - months). conclusion: endovascular intracranial aneurysm occlusion with stent assistance is a delicate procedure with a higher complication rate compared to regular coil occlusion. however, this technique is useful in complex otherwise difficult or untreatable intracranial aneurysms. in-stent restenosis occurred in / cases ( . %) and solved with angioplasty in / cases ( %) or re-stenting in / ( %). primary patency rate was . %; secondary patency rate %. neurological events occurred in . % of cases. results were analysed correlating neurological complications with the operator's experience, plaque morphology and patient's age. neurological disorders were . % in asymptomatic patients and . % in symptomatic ones (p= . ) and they proved to be higher in older patients (> y) . % vs . % of patients < years (p < . ). the overall neurological adverse events were . % in the presence of complex plaque morphology and . % in case of stable plaques (p < . ). friday within months after the procedure. a total of high signal lesions on dwi were serially numbered and the signal change on conventional mri in the follow-up was evaluated. the quantitative parameters on dwi (location, volume and value of apparent diffusion coefficient: adc) for each lesion were measured. we used fisher exact test and the mann-whitney u test to compare differences between two groups; statistical significance was assigned when p < . . results: there was statistically significant difference in the presence of dwi lesions (multiple: % versus single: %, p= . ). in each lesion, the volume was significantly small ( . ± . cm versus . ± . cm , p= . ) and the permanent signal change was less observed in multiple antiplatelets use ( . % versus . %, p= . ). there was negative correlation between the volume and the value of adc (r=- . , p <. ). conclusion: periprocedural use of multiple antiplatelet agents is expected to reduce the volume of thromboembolism and permanent signal change in the follow-up. purpose: the treatment of vertebral split fractures remains controversial, consisting of either corset or internal fixation. the aim of this study was to evaluate ct-and fluoroscopy-guided percutaneous vertebroplasty in the management of vertebral split fractures. methods and materials: institutional review board approval and informed consent were obtained for this study. sixty-two consecutive adult patients who had posttraumatic vertebral split fractures (a according to the ao classification) without neurological symptoms were prospectively treated by percutaneous vertebroplasty. all these procedures were performed by an interventional radiologist under computed tomography (ct) and fluoroscopy guidance using only local anaesthesia. postoperative outcome was assessed using the visual analogue scale (vas) and oswestry disability index (odi) scores. results: vertebroplasty was performed on thoracic and lumbar vertebrae. the filling of the vertebral body was satisfactory in % of the patients, with seven discal cement leakages ( %). the mean vas measurements ± standard deviation (sd) significantly decreased from . ± . preoperatively to . ± . at day, . ± . at month, and . ± . at months (p < . ). the mean odi scores ± sd had also a significant improvement: . ± . preoperatively and . ± . at the -month follow-up (p < . ). radiological union was observed within the months following vertebroplasty in all the cases. the results of our study showed that type a vertebral fractures could be successfully treated by ct-and fluoroscopy-guided percutaneous vertebroplasty with an excellent functional recovery. long-term results of microsurgical and endovascular therapy of intracranial aneurysms in patients following subarachnoid haemorrhage k. bojanowski , j. baron , b. kostkiewicz , m. zawadzki , j. walecki ; warsaw/pl, katowice/pl (jerzy.walecki@cskmswia.pl) purpose: the aim of this paper was to evaluate long-term clinical outcomes and radiologic findings in patients following microsurgical treatment and endovascular embolisation of intracranial aneurysms. methods and materials: a total of subjects aged - ( women and men) were evaluated. patients were divided into two groups according to the type of procedure they underwent: patients had open surgery and patients had undergone endovascular embolisation. the assessment was performed from months to years after treatment. all patients underwent a follow-up cerebral arteriography and clinical evaluation. results: a total occlusion or a neck remnant was discovered in a majority of patients following microsurgical procedures and endovascular treatment ( % and % in contrast to % and %, respectively). no recurrent aneurysms were revealed. the mann-whitney u test did not reveal any statistical significance in long-term treatment results regarding self-reliance (p-value= . ). the amount of blood extravasated following the rupture of an aneurysm was a significant independent factor influencing the clinical outcome and determined the long-term results in both groups (p-value< . ). a correlation between a patient's age and the clinical outcome following a microsurgical procedure was proved. the outcome was better in younger patients (p-value< . ). this was not observed in patients after endovascular treatment. conclusion: microsurgical and endovascular therapy are comparable methods for treating cerebral aneurysms; however, embolisation is correlated with a higher rate of complications in elderly patients. the final clinical outcome depends on the amount of extravasated blood following a subarachnoid haemorrhage. embolisation of cerebral aneurysms with hydrogel-coated coils: systematic review and meta-analysis a. pałys, z. serafin, w. lasek; bydgoszcz/pl (serafin@cm.umk.pl) purpose: hydrogel-coated coils for endovascular treatment of cerebral aneurysms were developed to reduce the risk of aneurysm recurrence and the rate of retreatment. the aim of this review was to verify the efficacy and safety of hydrogel-coated coils. methods and materials: a literature search was performed by two independent researches for papers published up to august on follow-up results of intracranial aneurysm embolisation with hydrogel-coated coils. analysis included aneurysm presentation at follow-up compared to initial treatment result, the rate of rebleeding and retreatment, and specific complications. pooled rates of major recurrences and total recurrences were calculated. results: of articles on the use of hydrogel-coated coils for embolisation of cerebral aneurysms, ( aneurysms) were included. significant heterogeneity was found regarding patients populations, methods of aneurysm coiling, follow-up schedules, and recurrence definitions. a cumulative follow-up rate was % ( % ci, - %, range - %). pooled major recurrence rate was % ( % ci, - %, range - %) and pooled total recurrence rate was % ( % ci, - %, range - %). control groups consisting of aneurysms treated with bare platinum coils were analysed in only in four articles ( aneurysms). pooled major recurrence rate for bare platinum coils was % ( % ci, - %) and was significantly higher than this for hydrogel-coated coils. conclusion: embolisation of cerebral aneurysms with hydrogel-coated coils results in lower rate of major recurrence, than with bare platinum coils. more high-quality standardised prospective studies are needed to define specific indications for the use of hydrogel-coated coils. effect of antiplatelet therapy on radiographic outcome of positivity on diffusion-weighted imaging in elective endovascular coiling of unruptured cerebral aneurysm t. . males (n= ) were followed retrospectively over months; males (n= ) were followed prospectively over weeks. the diagnosis of pt was confirmed with ultrasound and power doppler (average thickness of prospective subjects . mm, average neovascularisation . on modified ohberg scale). all subjects were injected under real-time ultrasound guidance with ml of . % marcaine mixed with mg hydrocortisone followed by a mean of ml normal saline at the interface between the pt and hoffa's body, adjacent to the area of neovascularisation. the same supervised rehabilitation programme was followed by all patients. the visa-p questionnaire was administered for pre-injection severity and at follow-up. results: there was instant resolution of neovascularisation in all subjects. the visa-p score statistically significantly improved from a mean of . to . for (p < . ), which is likely to be clinically significant. the retrospective data increased by . points compared to . in the prospective subjects followed over a shorter time period. over % of the prospective subjects agreed/strongly agreed that their symptoms/strength had improved, with over % returning to their required level of sport within weeks. purpose: our aim was to investigate the potential impact of visceral fat assessment by dxa in the clinical management of patients submitted to different therapeutic programs for obesity. we prospectively recruited patients affected by obesity and submitted to medical and/or surgical treatment. body mass index (bmi) and body composition were analyzed with anthropometric and whole-body dxa evaluations simultaneously performed at baseline and after one year. a new software available to estimate android visceral fat was applied to last-generation dxa equipment. results: ninety-one patients ruled out the study. among patients ending the follow-up period ( -males, -females, . ± . -year-old, . ± . -kg/m ) bmi decreased in / - . % controls, while regained in / - . %. an opposite trend between bmi and total fat mass/non-bone lean mass (tfm/tlm), android ratio (afm/alm), and android visceral/subcutaneous fat (v/s) was found in / - . %, / - . % and / - . %, respectively. bmi was significantly correlated with tfm/tlm and afm/alm (r= . and . respectively), while it was far from a statistically significant connection with v/s (r= . , p= . ). although slightly better correlations were demonstrated between tfm/tlm (and afm/alm) and v/s, these were extremely low (r= . , p= . purpose: to prospectively evaluate dual gradient-echo mri with dixon-based generation of fat-/water-images (mridixon) for quantification of the muscle-fat content (mfc) in-vitro and in patients with achillodynia compared to asymptomatic volunteers. methods and materials: mridixon was used to measure the mfc of phantoms containing titrated mixtures of organic muscle/fat from - % as well as of the gastrocnemius (dixongastro) and tibialis anterior (dixontibialis) muscles in patients ( women; mean age, ± years) with achillodynia and in matched asymptomatic volunteers ( women; mean age, ± years) at . t. accuracy of mridixon in quantification of mfc was assessed in-vitro as well as in-vivo using single-voxel mr-spectroscopy (mrs) as the standard of reference. dixongastro and dixontibialis were related to visual grading of the mfc (grades - ) in both muscles (visualgastro and visualtibialis). results: correlation of mfc derived from mridixon, phantoms and mrs was excellent with correlation coefficient (r ) ranging from . to . and mean measurement bias ranging from - . to + . %. mean dixongastro/dixontibialis was . ± . / . ± . in patients and . ± . / . ± . in volunteers. visualgastro/ visualtibialis ranged from to / to and to / to , respectively. no significant difference was seen for dixontibialis between patients and volunteers (p=. ), whereas dixongastro was significantly higher in patients (p <. ). both, visual-gastro and visualtibialis did not differ in patients and volunteers (all, p>. ). conclusion: mridixon allows for accurate quantification of mfc and demonstrates a significantly higher fat content in the gastrocnemius muscle in patients suffering of achillodynia than in asymptomatic volunteers, outer performing visual assessment of mfc. and disappeared after more than months. the unloading-findings were more severe at the patella and femur than at the tibia (p < . ). high scores of severity were associated with confluent and patchy patterns (scr= . , p < . and kt= . p < . ). conclusion: bone marrow changes at the knee related to disuse are most prominent - months following unloading when both patchy and confluent hyperintense patterns are present. manifestations of unloading are most prevalent within the patella and the femur and associated with increased vascularity. methods and materials: from whole body f-fdg pet/ct datasets including a dedicated head and neck investigation protocol of consecutive patients (mean age: ± years) with histopathologically proven pharyngeal and laryngeal malignancies virtual d f-fdg pet/ct panendoscopies were reconstructed using an investigational software application. the feasibility to completely assess specific spaces of the upper airways by a virtual "fly-through" and to detect primary tumours was tested; the time for an automated segmentation of the virtual f-fdg pet/ct panendoscopies was measured. the nasopharynx, oropharynx, laryngopharynx, epiglottis, subglottis and the tracheobronchial tree were accessible in all , the laryngopharynx, aryepiglottical folds, piriform sinus, glottis, and oral cavity in , , , and patients, respectively. in all patients with restricted fiberoptical evaluation due to a primarily intubation the subglottical space was entirely accessible via virtual panendoscopy. the primary tumour was depicted in / patients ( %). the mean processing time for virtual f-fdg pet/ct panendoscopies was ± s. conclusion: virtual f-fdg pet/ct panendoscopy of the upper airways is technically feasible and can detect pharyngeal and laryngeal malignancies. the tool allows for a complete evaluation of the subglottical space when optical panendoscopy is incomplete due to intubation. it may be used for planning endoscopy-guided biopsies and surgery in the future. centrations were determined dynamically before and after exercise using a whole body mri-system (achieva, t, philips healthcare). point-resolved spectroscopy (press) was used to acquire spectra from a voxel in the m. vastus lateralis. the total creatine (t-cr) peak was used as internal reference. post-exercise acquisition of spectra started approximately minutes after cycling. results: exercise-induced elevations of acetylcarnitine levels were similar in both groups (Δpost-pre . ± . mmol/kg wet weight (ww)). however, post-exercise acetylcarnitine kinetics were significantly different (p < . ). in sedentary subjects, the concentration continued to increase during recovery towards a plateau at minutes ( . ± . mmol/kgww). in contrast, the acetylcarnitine concentration started to decrease from . ± . mmol/kgww at minutes after exercise in the trained subjects towards . ± . mmol/kgww at minutes. conclusion: we demonstrate the dynamic character of acetylcarnitine in a situation of changing substrate demand/supply. the current protocol can differentiate between two metabolically different groups, which opens a window towards investigation of acetylcarnitine in relation to metabolic flexibility and insulin resistance. in vivo differentiation of muscle precursor cells using mr relaxometry n.c. chuck, f. azzabi zouraq, d. eberli, a. boss; zurich/ch (natalie.chuck@usz.ch) purpose: to assess the differentiation process of muscle precursor cells (mpcs) applying magnetic-resonance-imaging (mri) relaxometry and diffusion measurements in a mouse model in correlation with histology, immunohistochemistry and organ bath. methods and materials: human mpcs were isolated from biopsies of the m.rectus abdominis. the mpcs were mixed with a collagen carrier and injected subcutaneously in nude mice. animals with collagen-only-injections served as controls. mri was conducted on a . t small-animal-scanner (bruker biospec) at time points between day and post-injection. relaxometry measurements comprised t and t measurements using multi-echo-spin-echo (te - ms) and saturationrecovery-sequences (recovery time - ms) and t * quantification with a multi-echo-gradient-echo-sequence (te = . ms, Δte = ms, echoes). diffusion imaging was performed with a spin-echo-sequence including diffusion gradients with b= . and s/mm . relaxation times and adc values were measured in the skeletal muscles. evaluations were performed with custom-made matlab scripts. animals were harvested after days and the engineered muscle tissue was assessed by histology, organ-bath and immunofluorescence. results: relaxation and diffusion properties of the engineered tissue could reliably be measured at all time points. relaxometry measurements revealed a decrease of t , t and t * relaxation-time during differentiation (initial measurement: t . ms± , t : . ms± , t *: . ms± ; final measurement: t : . ms± , t : . ms± , t *: . ms± . ), thereby approaching the physiological relaxation properties of muscular tissue. adc showed a decrease from . mm / s± . to . mm /s± . . cell differentiation and myofibre formation was confirmed by histology, immunohistochemistry and contractility confirmed by organ bath. conclusion: we demonstrated that mri relaxometry measurements are able to describe the differentiation of muscle precursor cells. this method might offer the possibility to non-invasively assess the effectiveness of cellular therapies for muscular disorders in near future. purpose: to evaluate diagnostic accuracy of diffusion-weighted magnetic resonance imaging (dwi) in predicting response to neo-adjuvant chemo-radiotherapy (ncrt) in patients with locally advanced cervical carcinoma using apparent diffusion coefficient (adc). cervical lesions adc were correlated with post-surgical histopathology. methods and materials: women (figo>ib bulky) underwent mri and dwi prior to, after weeks and at the end of ncrt, using . t scanner. cervical lesion volume and adc were measured at each assessment. radical hysterectomy was performed weeks after mri. treatment response was determined based on histopathology and was classified as complete response (cr), residual (rd) or stable disease (sd). mean adcs (madc), adc increase and volume reduction (vr) rates were compared using histopathology as reference standard results: according to histology, / ( %) had cr, / ( %) had rd < cm. patients presented sd. before therapy, in the study population madc was . ± . x -³ mm²/s but it was lower in sd ( . ± . x -³ mm²/s). after weeks of ncrt, madc correlated with tumour response: a) in cr with % percent change ( . ± . x -³ mm²/s vs . ± . x -³ mm²/s; p < . ); b) in rd with % percent change ( . ± . x -³ mm²/s vs . ± . x -³ mm²/s; p < . ). tumour volume decreased in cr and rd with reduction rate of % and %, respectively. at the end of crt, no significant differences on adc between for comparison of quality data, chi-square and odds ratio were used. results: in subjects ( %), benign ( . %) and malign ( . %) lesions were detected. six subjects underwent operation ( %) for adrenal carcinoma, renal carcinoma, pancreatic mucinous cystadenoma, intradural schwannoma ( ), and enchondroma of the femur. in one subject, tuberculosis pneumonia was detected and medical treatment was given. in subjects focal nodular hyperplasia of the liver, and in one an unclassified solid mass in spleen were encountered and they are in follow-up. the most common incidental lesions were liver cyst ( ), liver haemangioma ( ), renal cyst ( ), and thyroid nodule ( ). no significant difference was observed for the incidence of benign and malign lesions between subjects aged ³ years and < years (p= . and p= . , respectively). conclusion: % of the population screened by wb-mri underwent further surgical and medical treatment. wb-mri is a useful and non-invasive tool for the detection of incidental lesions in asymptomatic subjects. purpose: to assess the value of elasticity parameters on breast sonoelastography by influence of menopause factor. methods and materials: female patients (premenopausal vs postmenopausal: vs ) with breast lesions were conducted routine ultrasound and elastographic ultrasound preoperatively. the elastic parameters of strain ratio (sr, sr was calculated using the same-level and normal-appearing breast region as reference; sr was calculated using the subcutaneous fat as reference) were then obtained, with the pathologic diagnosis served as golden standard. the sensitivity, specificity, and area under the curve were analysed by receiver operating characteristic (roc) curve with or without the influence of menopause factor. purpose: to assess if stiffness as measured by shear-wave elastography (swe), could be an early biomarker of response to chemotherapy in a breast cancer model. a human invasive ductal carcinoma was implanted subcutaneously in athymic female mice. after weeks of growth, tumours were removed for baseline pathological analysis and were treated by oral chemotherapy during weeks. ultrasound was performed every week before and during treatment, using a superficial -mhz probe. maximum diameter and mean elasticity value of the tumor were measured. kinetics of changes in diameter and elasticity before and under treatment were calculated as the slope of diameter or elasticity over time. at the end of the treatment, tumours were removed for pathological analysis. results: before treatment, we observed a progressive stiffness increase along tumour growth (slope: . kpa/week). under chemotherapy, we observed an early stabilisation of tumour stiffness (slope: - . kpa per week). furthermore, a significant decrease of elasticity values was seen after four weeks of treatment (p= . ). we also observed an early progressive decrease of diameter showing that there was a good response to treatment. after five weeks of treatment, we observed modifications of the pathological features of the tumor, i.e. mainly a decrease of cellular density. conclusion: in our model, we observed an early stabilisation of tumour elasticity with an inversion of elasticity slope under treatment showing that swe could be an interesting tool to assess early tumor response to chemotherapy. purpose: shear wave elastography (swe) can differentiate benign from malignant solid breast masses. small, low-grade cancers can have benign (low) mean stiffness values but often show a ring of slightly stiffer tissue around the lesion. we aimed to establish whether taking the presence of a ring sign to indicate malignancy improves the discriminatory performance of swe in screen detected solid breast masses. the ring sign was defined as the presence of stiffer borders on at least aspects of the lesion. the presence or the absence of the ring sign was independently assessed by two breast radiologists, blinded to pathology outcomes, in a consecutive series of screen-detected solid masses. a third radiologist arbitrated in discordant cases. the discriminatory performance of swe using a threshold mean stiffness value of kilopascals (kpa) was compared with taking either a threshold mean stiffness of kpa or a ring sign as positive. results: of masses, were benign and were malignant. in ( %), the ring sign findings of two radiologists were concordant. for mean stiffness threshold of kpa, sensitivity was % and specificity was %. when either mean stiffness over kpa or a ring sign was counted as positive, sensitivity was % and specificity was %. the increase in sensitivity was statistically significant (fisher's exact test, p= . ). the drop in specificity was not (p= . ). the ring sign can improve the sensitivity of shear wave elastography in differentiating benign from malignant screen-detected solid breast masses. purpose: the purpose of our study was to investigate arterial spin labelling (asl) mri for functional assessment of transplanted kidneys at . t and t. methods and materials: renal allograft recipients (mean age . ± . years) were included in this study. asl mri was performed at . t (n= ) and t (n= ) using a single-slice paracoronal fair truefisp sequence ( averages, inversion time ms, slice thickness mm, matrix x ). for quantification of asl perfusion, t relaxation times were determined at . t and t using the variable flip angle approach. rois were drawn by a single reviewer on asl parameter maps for quantification of cortical perfusion. asl perfusion was correlated with allograft function as determined by the estimated glomerular filtration rate (egfr) and compared between patients with good or moderate allograft function (group a; egfr > ml/min/ . m²) and patients with heavily impaired allograft function (group b; egfr ² ml/min/ . m²). results: asl perfusion and egfr were comparable at . t ( . ± . ml/ min/ . m² and ± ml/ g/min) and t ( . ± . ml/min/ . m² and ± ml/ g/min). asl perfusion was significantly higher in group a ( . ± . ml/ g/min) as compared to group b ( . ± . ml/ g/min) (p < . ). asl perfusion values exhibited a significant correlation with egfr (r= . , p < . ). a total of patients were enrolled at centers in japan. all patients provided written informed consent before entering the studies. unenhanced ultrasound, contrast-enhanced ultrasound, and contrast-enhanced mr images were independently assessed by three blinded reviewers, who viewed the different images in a randomised sequence and were also blinded to subject characteristics. the observation period for safety assessment was days after the contrast agent administration. results: among patients included in the diagnostic analysis, the accuracy of contrast-enhanced ultrasound ( . %) was significantly higher than that of unenhanced ultrasound ( . %) and contrast-enhanced mri ( . %) (both p < . ). sensitivity and specificity of contrast-enhanced ultrasound ( . %, . %) were also superior to unenhanced ultrasound ( . %, . %) and contrast-enhanced mri ( . %, . %) (sensitivity: p= . and p= . ) (specificity: both p < . ). the incidence of adverse events was . %, with adverse drug reactions in . % (all mild). conclusion: compared with unenhanced ultrasound and contrast-enhanced mri, contrast-enhanced ultrasound with sonazoid ® (perflubutane) microbubbles achieved significantly better diagnostic accuracy and specificity for breast lesions without causing serious adverse reactions. methods and materials: in a retrospective study, patients with non-tumorous increased signal intensity of the kidneys on dwi sequences (b= s/mm ) and corresponding adc-decrease was identified. as a control group served patients without clinical signs of renal infection. all patients underwent routine mri-protocol of the abdomen including epi-sequence for the dwi (b. / / ), t w haste, t w vibe post-contrast (dotarem). confirmation of renal infection was established on the basis of clinical criteria. t w-and t w-images were assessed and compared to dwi for the presence of altered signal and the degree of the visibility of pathology was graded on an three-point scale. in all patients with positive dwi-findings, a renal infection could be confirmed while none of the patients in the control group showed a suspicious signal pattern on dwi. t w-imaging and contrast-enhanced t w-imaging displayed obvious pathologic signal in / ( %) and / ( %) patients, slightly pathologic signal in / ( %) and / ( %), respectively. no pathologic change was seen in / ( %) and / ( %). the median visibility score of for the dwi-imaging and the t w-images was significantly higher than the median visibility score of for the t w-imaging (p= . (dwi vs. t w) and p= . (t w vs. t w). no significant differences were found between the visibility scores of t w imaging and dwi. conclusion: dwi of the kidneys seems to be highly sensitive for the detection of infections within the kidney. purpose: to investigate feasibility dynamic-contrast-enhanced (dce)-mri assessment of kidney function and renal masses on a single slice compared with investigation of the whole organ or tumour. methods and materials: fourteen patients with renal tumours ( renal cell carcinomas, angiomyolipoma, oncocytoma) before and after partial nephrectomy underwent dce-mri at t (magnetom verio, siemens healthcare sector) with a time-resolved angiography with stochastic trajectories (twist)-sequence (voxelsize . x . x . mm , temporal resolution . mm) with half-dose gadobutrol (bayer healthcare pharmaceuticals). kidney datasets and tumour datasets were assessed using in-house built idl-software pmi . . using -compartment-models with semi-automated segmentation, renal perfusion and filtration as well as tumour perfusion and permeability were calculated for a single central region-of-interest on a single slice or the whole organ or tumour. statistical analysis was performed with paired t-tests and pearson´s correlation coefficient. results: there were no significant differences between single slice / whole kidney (plasma-flow . ± . vs. ± . ml/ ml/min, plasma-volume . ± . vs. . ± . ml/ ml, glomerular-filtration-rate . ± . vs. . ± . ml/ ml/ min) as well as between single slice/ whole tumour (plasma-flow . ± . vs. . ± . ml/ ml/min, plasma-volume . vs. . ml/ ml and permeabilitysurface-product . ± . vs. . ± . ml/ ml/min). correlations between single slice and whole organ/ tumour was were excellent and significant for all parameters (r = . to . , p < . ). conclusion: single slice assessment of kidney function and renal masses with dce-mri does not show significant differences to the more time-consuming analysis of the whole organ/ tumour. incorporation of single slice analysis of dce-mri data in future studies appears feasible and justifiable. in vivo sodium ( purpose: renal allograft rejection is associated with chemokine ligand (ccl )dependent glomerular and interstitial macrophage recruitment. ccl blockade with the oligonucleotide/spiegelmer mnox-e - 'peg inhibits leucocyte recruitment. the purpose of this study was to evaluate mr renography and diffusion-weighted imaging (dwi) for assessment of this novel chemokine-directed therapy in an experimental murine animal model. methods and materials: an orthotopic renal transplant mouse-model with acute allograft rejection (balb/c into c /bl ) was used. animals were treated with low-dose cyclosporin a in combination with mnox. animals did not receive treatment. syngenic controls (c /bl into c /bl ) were performed. imaging was conducted at t with a dedicated mouse coil. diffusion-weighted imaging was performed with b values ranging to s/mm . mr renography was performed with a twist-sequence with a temporal resolution of . seconds following a bolus of µl gadobutrol in µl nacl. significance between subgroups was assessed with wilcoxon´s rank-sum test. results: syngenic allograft showed substantially higher plasma flow ( . ± . ml/ ml/min) and significantly lower (p < . ) adc ( . ± . mm /s) than native kidneys ( . ± . ml/ ml/min and . ± . mm /s). allograft-adc of treated animals ( . ± . mm /s) was substantially higher than of untreated animals ( . ± . mm /s). cortical plasma flow ( . ± . ml/ ml/min) was significantly lower (p < . ) for untreated animals compared to treated animals ( . ± . ml/ ml/min). volume of distribution and mean transit time did not show significant differences between the subgroups. conclusion: chemokine-directed treatment ameliorates acute renal allograft rejection. functional mri is able to non-invasively assess these therapy effects in this experimental model and holds high potential to become an alternative to invasive organ biopsy. assesment cisplatin-induced interstitial nephropathy using diffusion-weighted mri r. del vescovo, f. giurazza, r.l. cazzato, c.l. piccolo, r.f. grasso, b. beomonte zobel; rome/it (r.delvescovo@unicampus.it) purpose: to assess the potential of noninvasive diffusion-weighted magnetic resonance imaging (dw-mri) to depict interstitial kidney changes in patients (pts) under cisplatin-based chemotherapy. we analysed adc maps of oncologic patient ( woman and men; mean age years; % affected by advanced lung cancer) treated with cisplatin-based chemotherapy comparing with age-and sex-matched control group's adc maps. the creatinine clearance (crcl) used to determinate renal function was based on the formula of crockfort (normal value > ml/min). the adc values were calculated using a roi positionated manually on the cortex of each pole in axial and coronal images. for statistical analysis t-test was used. a p value of less than . was considered significant. results: there was no anatomical difference visible with conventional mr imaging of the cortex and medulla relationship. in pts treated with cisplatin there was a reduction of adc values in the cortex, but no significant changes in medulla. the adc values of healthy volunteer were significantly higher comparing with patients treated with cisplatin (p < . ). there was no significant difference between the adc values of left and right kidney in each patient except in one who present a unilateral ureteral obstruction. no significant correlation was found between the creatinine clearance and adc values obtained in both groups. conclusion: dw-mri may allow a noninvasive detection of changes in kidneys in pts with interstitial nephropathy during and after chemotherapy treatment. purpose: to investigate the feasibility of reconstructing anatomic connectivity of sacral plexus using t-mr diffusion tensor imaging (mr-dti) with three-dimensional ( d) tractography approach. t-mr-dti was performed on women volunteers. the sequence was acquired on oblique axial plane parallel to the sacrum, from the level of the l nerve to the coccyges. main diffusion directions reflecting the fibre orientation were determined using a sense-ssepi with diffusion-sensitised gradients (b mm s- ) along directions. a deterministic bre-tracking algorithm was used to show fibre architecture, compared with anatomic atlas. three rois were placed at different levels of the spinal cord nerves: one in the middle of each tract-of-interest, accompanied by "and" selection rois at both ends of the nerve tract roi. diffusion-weighted ssh-epi images are processed on a dedicated workstation for data pre-processing with medinria deterministic software. results: tractography of the sacral plexus was feasible for all volunteers, giving d insight into the general anatomy and organisation of the nerves l to s . main artefacts in fibre reconstruction, caused by bladder over-distension, by presence of air in rectum and by constant small movements due to breathing and/or spontaneous contractions of pelvic organs, never invalidate the feasibility of tractography. fibres were reconstructed from medulla to the pelvic course of main branches of sacral-plexus nerves. emerging branches of pudendal nerve were found in volunteers. conclusion: t-mr-dti allows a precise anatomic reconstruction of lumbar-sacral plexus. these findings are encouraging for using dti as a mean to investigate sacral-plexus, especially in female pelvis. te= . ms to . ms; tr= ms; averages; measurement time= : min). all hr images were corrected for inhomogeneous sensitivity of coil. the na-snr values are given on a pixel-by-pixel basis for mm from the renal cortex in the direction of the medullary pyramid. the t * maps were calculated by fitting the na signal decay mono-exponentially on a pixel-by-pixel basis using least squares fitting routine written in idl. results: the mean cortico-medullary na-snr for all healthy kidneys increased from the renal cortex ( . ± . ) towards the renal medullary pyramid ( . ± . ). the cortico-medullary increase ranged inter-individually from . to . %. the mean na-t * of all volunteers was . ± . ms. the feasibility of ultra-high field, hr na-mri of healthy human kidneys was demonstrated. moreover, high na-snr provided by . t allowed the in vivo measurements of na-t * times in human kidneys for the first time. arterial spin labelling for the prostate: initial experience at t mri s. takahashi , n. aoyama , t. kimura , k. kitajima , y. ueno , s. sato , k. sugimura ; kobe/jp, otawara/jp, osaka/jp (staka@med.kobe-u.ac.jp) purpose: to assess the value of asl-perfusion mri for the prostate using dynamic contrast-enhanced (dce) study findings as the reference standard. methods and materials: male patients (mean age . ± . years) with suspected prostate cancer were prospectively included in this study. single-slice d-pulsed asl images were acquired during our routine prostate screening protocol on a t mri unit, including the dce study. first, roi was drawn for the obturator muscle on a control image of asl sequence (scont.ref). then, rois were drawn for the femoral artery, the obturator muscle, the normal pz and the regions where dce showed early enhancement on the tagged asl image. these values were divided with scont.ref, yielding an asl ratio (aslr). analysis of the variance was performed to assess differences in aslr for each tissue or region. a radiologist scored the degree of enhancement on dce and compare to the contrast ratio of aslr and the visual assessment of asl signals. results: a mean aslr of the femoral artery was . ± . %, where those of the normal pz and the obturator muscle were . ± . %, and . ± . %, respectively. on the other hand, the enhanced regions on dce showed a mean aslr of . ± . %. visual assessment of the asl image detected out of well-enhanced regions. contrast ratio of aslr demonstrated significant positive correlation to the degree of enhancement on dce (spearman; r= . , p=. ). conclusion: asl may allow detecting the region of the higher tissue blood flow in the prostate without contrast materials. purpose: aim of this study was to investigate the feasibility of contrast-enhanced tesla mri of the female pelvis. methods and materials: healthy female volunteers were examined on a t whole body mr system (magnetom t, siemens) utilising an -channel transmit/ receive radiofrequency body coil. the examination protocol included ) t w fs d flash, ) dynamic t w fs d flash, ) t w tse sequences. for qualitative image analysis of t w mri, the delineation of pelvic anatomy, pelvis vasculature, tissue contrast and overall image quality was assessed and for t w mri the zonal anatomy of the uterus and the conspicuity of the ovaries were evaluated (fivepoint-scale analysis: = excellent to = non-diagnostic). image impairment due to various artefacts was assessed. contrast ratios between junctional zone and myometrium were obtained via roi analysis for t w mri. results: of all three sequences, d flash mri offered best overall image quality (mean contrast-enhanced . ) and highest tissue contrast (mean contrastenhanced . ). for the t w sequences, d flash imaging was rated with higher scores for all assessed structures than d flash mri. t w tse imaging provided a moderate to high conspicuity of the zonal anatomy of the uterus with mean scores ranging from . for endometrium to . for myometrium. overall image impairment was rated strongest for t w mri ( . ) and least for d flash mri (mean . ). our results indicate the successful transformation of the associated high snr into high spatiotemporal resolution t w pelvis mri at t and valuable non-contrast diagnostics of pelvis vasculature. de (david.schneider@stud.uni-heidelberg.de) purpose: high vessel attenuation as well as a high contrast-to-noise (cnr) ratio is a prerequisite for highly diagnostic cervical and cerebral ct-angiographic examinations. the purpose of this study was to evaluate the value of calculated low-kv-monoenergetic dual-energy ct (dect) angiographic datasets. methods and materials: patients ( men, mean age ± ) that underwent dect-angiography of the cervical (n= ) or cerebral vessels (n= ) were retrospectively included in this study. and -kv dect data were used to calculate low-kv monoenergetic image datasets from to kev ( -kev intervals). vessel and soft tissue attenuation and image noise were measured in various regions of interest and the cnr was subsequently calculated. differences in image attenuation and cnr were compared between the different monoenergetic datasets. vessel attenuation and cnr of the best monoenergetic datasets were then compared to conventional -kv polyenergetic datasets. results: in comparison to conventional polyenergetic -kv datasets, above all, -kev monoenergetic cervical datasets yielded to a significant increase in vessel attenuation and cnr (+ %, + %; all p < . ). for cerebral vessel assessment, in particular -kev monoenergetic datasets improved vessel attenuation and cnr (+ %, + %; all p < . ) when compared to conventional -kv datasets. conclusion: calculated -kev monoenergetic image data significantly improves vessel attenuation as well as the cnr of cervical dect-angiographic studies, whereas -kv monoenergetic datasets are favourable to improve vessel attenuation and the cnr of cerebral dect-angiographic studies. thus, lowering the amount of iodinated contrast-material might become feasible using monoenergetic-low-kv images, which is particularly important for combined perfusion and angiography protocols. purpose: single case reports suggest that black blood mri (t -weighted fat and blood suppressed sequences with and without contrast injection; bb-mri) may visualise intracranial vessel wall contrast enhancement in primary angiitis of the central nervous system (pacns). in this single-centre observational pilot study we prospectively investigated the value of bb-mri in the diagnosis of large artery pacns. methods and materials: in this prospective, mono-centric study patients with suspected large artery pacns received a standardised diagnostic programme including bb-mri. patients without any evidence of pacns and without intracranial stenosis served as control group. vessel wall contrast enhancement was graded (grade - ) by two experienced readers blinded to clinical data and correlated to the final diagnosis. results: four of included patients received a final diagnosis of pacns. all of them showed moderate (grade ) to strong (grade ) vessel wall contrast enhancement at the sites of stenosis. a moderate (grade ) vessel wall ce grade was also observed in of the remaining patients in whom alternative diagnoses were made: arteriosclerotic disease (n= ), intracranial dissection (n= ), and moyamoya disease (n= ). none of the patients in the control group had vessel wall contrast enhancement. conclusion: our pilot study demonstrates that vessel wall contrast enhancement is a frequent finding in pacns and its mimics, but it is absent in patients without evidence of intracranial vascular disease. larger trials will be necessary to evaluate the utility of bb-mri in the diagnostic workup of pacns. purpose: the availability of endovascular services is increasing, but still not available in the majority of tpa centres. the aim of this study was to describe the relations between nihss and large vessel occlusions in patients with hyper-acute ischaemic stroke. a prospective single hospital registry based on consecutive patients admitted for tpa work up with routine cta was started on july , ; this analysis is based on patients admitted before december . bispebjerg university hospital has a tpa-service with a catchment area of app. . mio. inhabitants on even dates. ct scans are performed using -section mdct (brilliance- , philips healthcare) with cta from the aortic arch to the vertex. all images were systematically reviewed by a blinded neuroradiologist; sensitivity, specificity, positive predictive value and negative predictive value were calculated at all levels of nihss. results: five-hundred and seventy-three patients with acute ischaemic stroke were entered into the registry. at a nihss score equal to or larger than , the sensitivity was equal to . %, the specificity was . % the positive predictive value was . % and the negative predictive value was . % in predicting an acute occlusion. conclusion: if the cut off is set at nihss , there is a % risk of missing an occlusion and a % risk of transporting a patient with a tpa drip for no reason. the relation is between occurrence of large vessel occlusions and nihss is a continuum. contribution of the temporal maximum intensity projection ( purpose: the goal of retrospective study was to compare possibilities to measure the extent of mca occlusion (thrombus length) in patients with acute stroke and predictive value for recanalization and clinical outcome after systemic therapy. we analysed patients with mca occlusions ( males, average age . years, range - years) detected with multimodal ct examination (non-contrast ct, perfusion ct and conventional cta). conventional cta (slice . mm) and temporal maximum intensity projection (tmip) datasets (slice . mm) reconstructed over the full time span from volume ct perfusion were used for thrombus length measurement. results of used techniques were compared and correlated with results of systemic thrombolytic therapy ( hours recanalization and -month clinical outcome). results: there was no statistically significant difference in measurement results using conventional cta and tmip, but in subjects ( %) measurement of thrombus was not possible using conventional cta due to unclear peripheral border of thrombus. we proved statistically significant correlation of whole extent of thrombus and recanalization success (p= . ). the involvement of m section was main negative factor for recanalization (p= . ). the strong significant correlation of thrombus length and -month clinical outcome was proved (p= . ) with cut-off value of mm. conclusion: our results confirm the benefits of detailed evaluation of cerebral arteries using tmip datasets, which enable to measure thrombus length in all subjects in comparison to conventional cta. the thrombus length was established as negative factor for recanalization and clinical outcome after systemic thrombolytic therapy. that with an optimised mr-protocol, mural inflammatory changes of superficial extracranial and intradural arteries can be detected in patients with gca. methods and materials: patients with suspected gca underwent . tesla mri, including fat saturated (fs) t w scans pre-and post-contrast, optimised for assessment of intradural vwe, and high-resolution fst w scans to evaluate superficial extracranial vessels. temporal artery biopsies were available in cases. vwe of intradural and extracranial vessels was evaluated by two observers results: in patients, gca was diagnosed clinically, in biopsy proven. a clear vwe of superficial extracranial vessels was detected in cases. clear vwe of the intradural internal carotid artery (ica) was detected in cases, with corresponding vessel wall thickening. slight enhancement of the right medial cerebral artery was seen in case. in one patient with gca, no vwe of intradural or extracranial vessels was detected. one patient who did not receive a temporal artery biopsy presented with vwe of intradural and extracranial arteries, but the final clinical diagnosis was connective tissue disease. conclusion: vwe of extracranial vessels is a frequent finding in gca. additionally, vwe of intradural arteries, mainly the ica, can be found. therefore, high-resolution mri seems to be a feasible technique to visualise vasculitic involvement of the extra-and intracranial arteries in gca. purpose: to measure cerebrovascular reserve using fmri (cvr fmri) in patients with severe stenosis of the middle cerebral artery (mca) to identify those at risk of haemodynamical stroke. methods and materials: among patients with severe intracranial arterial stenosis, patients ( females; . ± . years) had a stenosis of the right (n= ) or left (n= ) mca only. cvr fmri was performed using bold contrast with a block-design hypercapnic challenge (co %) at t. averaged end-tidal co pressure (etco ) was used as regressor for statistical analyses. we measured %bold/mmhg etco on segmented grey matter of mca territories. we calculated a laterality index with limca =(left_cvr-right_ cvr)/(left_ cvr+right_ cvr). li were compared to those obtained in volunteers that provided a % confidence interval for | limca |< . . basal perfusion was measured using dynamic susceptibility contrast. results: basal perfusion measurements were symmetrical in all patients. no adverse reaction to hypercapnia was detected. cvr values ranged from . to . with m±sd= . ± . . among these patients, three patients had a normal |limca|< . ranging from . to . ( . ± . ), and four patients had an abnormal |limca|> . ranging from . to . ( . ± . ). all abnormal li values identified the mca territory ipsilateral to the stenosis. conclusion: these preliminary results show that among patients with severe stenosis of mca, several patients have abnormal |limca| in the territory ipsilateral to the stenotic artery, suggesting significant cvr impairment that might be at risk of haemodynamic stroke. cvr fmri should be considered to better define treatment strategy, including intravascular stenting. purpose: in this study, we aimed to evaluate the endothelial functions in patients with nonalcoholic fatty liver disease (nafld). in this observational case-control study, a total of patients with nafld and age and sex-matched healthy controls were enrolled. in both patients and controls, levels of asymmetric dimethylarginine (adma), systemic endothelial function (brachial artery flow-mediated dilation) (fmd) and carotid artery intima-media thickness (c-imt, mm) were measured. endothelial functions of the brachial and carotid arteries were evaluated by vascular ultrasound. results: carotid intima media thickness was significantly higher in patients with nafld than controls ( . ± . versus . ± . mm, p < . ). the average c-imt measurements were found in groups of control, simple steatosis and nafld with (borderline and definitive) nash as . ± . , . ± . and . ± . mm, respectively. the differences between groups were significant (p < . ). measurement of brachial artery fmd was significantly lower in patients with nafld compared to controls ( . ± . versus . ± . %, p < . ). fmd measurements in groups of control, the simple steatosis and nafld with nash as . ± . , . ± . and . ± . %, respectively, and the differences were statistically significant (p < . ). the increase in c-imt and decrease in fmd were independent of metabolic syndrome and it was also more evident in patients with simple steatosis and nash compared to controls. conclusion: our data suggested that nafld is associated with endothelial dysfunction and increased early atherosclerosis compared to healthy subjects. purpose: this study aimed to assess image quality and radiation dose of ct angiography (cta) in kidney donors obtained with automated kvp selection and sinogram-affirmed iterative reconstruction (safire), using scans with fixed kvp and filtered back projection reconstruction algorithm as the comparison. methods and materials: mean attenuation, contrast-to-noise ratio (cnr) and signal-to-noise ratio (snr) at abdominal aorta, right renal artery (rra) and left renal artery (lra) were measured in kidney donors who had undergone cta with tube current modulation, kvp, filtered back projection reconstruction algorithm (group a) and were compared with bmi-matched kidney donors who had undergone cta with automated kvp selection and safire (group b purpose: cerebral small vessel disease (svd) is a common cause of cognitive impairment. white matter hyperintensities (wmh) and lacunar infarcts are the commonest magnetic resonance imaging (mri) parameters observed in clinical practice. the relationship between these findings on mri and cognitive impairment remains unclear. the aim of our study was to determine the relationship between lacune count, total lacune volume and location of lacunes with cognition. methods and materials: patients with lacunar stroke and wmhs were recruited to the prospective scans study. baseline data (n= ) was used for this analysis. multimodal mri and neuropsychological testing were performed. lacunes were identified and counted by a neuroradiologist on a t image, then mapped using an automated region growing technique. lacunar volume was calculated from the resulting masks, and lacunar location automatically determined by projection onto standard atlases. t wmh volume and brain volume were also measured. results: in multiple regression controlling for wmh volume and brain volume, both the lacune number and the total volume were related to a significant decrease in executive function (number: beta=- . , p < . ; volume: beta=- . , p < . ) and processing speed (number: beta=- . , p < . ; volume: beta=- . , p < . ). lacunes in the thalamus were associated with impaired processing speed performance (p < . ). one can infer a number of things relating to cognitive impairment when looking at an mri scan of a patient with cerebral small vessel disease. ) the number of lacunes are a better predictor of cognitive status than diffuse wmh and ) thalamic lacunes, in particular, are associated with impaired processing speed. purpose: to perform qualitative and quantitative analysis of altered haemodynamics of liver cirrhosis patients after tips-stent-graft implantation and volunteers using time-resolved flow-sensitive d mri at t. our study group consisted of liver cirrhosis patients including an examination before and after stent-graft implantation as well as volunteers. d liver flow characteristics in the arteries and portal vein were evaluated using flow-sensitive d mri at t mri with a spatial resolution of . x . x . mm³ and temporal resolution of . ms. hepatic flow visualisation was performed using d streamlines and time-resolved particle traces. quantitative evaluation included retrospective extraction of regional maximum and mean velocities, flow volume, vessel area as well as pulsatility and resistance indices. results: d streamlines and particle traces visualisation in the arterial and portal venous system could successfully be performed for almost all patients and volunteers. quantitative results reveal maximum and mean velocities tend to be lower in mri compared to doppler ultrasound, area showed significant lower values for us (p < . ). comparing the changes after tips-stent-graft implantation the data results demonstrated an increase of velocities and flow volume in the venous system as well as hepatic artery. conclusion: flow-sensitive d mri enabled a qualitative and quantitative evaluation of arterial and portal venous haemodynamics of liver cirrhosis patients before and after tips-stent-graft implantation including a volunteer group. flow-sensitive d mri may be a standardised method with complete volumetric and functional coverage of the blood flow haemodynamics providing additional information in patients after tips-stent-graft implantation. on a -point-scale. signal-to-noise ratio (snr) and contrast-to-noise ratio (cnr) was calculated with roi measurements. results: snr of the common carotid artery and middle cerebral artery was . ± . and . ± . (group a) versus . ± . and . ± . (group b). cnr was . ± . and . ± . (group a) compared to . ± . and . ± . (group b). subjective iq was excellent in both groups (mean score . ± . versus . ± . ). differences between the two groups were not significant. the osdr algorithm xcare™ does not compromise iq of head and neck cta. its application can be recommended for cta in clinical routine to protect the thyroid gland and ocular lenses from unnecessary high radiation. precision of pulmonary vein diameter measurements assessed by ce-mra and steady-state-free precession imaging f. henes, p. bannas, m. regier, j. buhk, k. müllerleile, g. adam, m. groth; purpose: to evaluate inter-and intraobserver reliability of pulmonary vein (pv) diameter measurements by contrast-enhanced magnetic resonance angiography (ce-mra) and ecg-gated d unenhanced steady-state-free precession sequences (ssfp). methods and materials: ce-mra and ssfp of pv in patients were evaluated. pv diameters were measured in transverse and coronal orientation at predefined levels by two independent readers. intraclass correlation coefficient (icc) and bland-altman analysis (ba) were used to assess inter-and intraobserver reliability and variances. f-test was performed for comparison of intra-and interobserver variances. pearson´s correlation coefficient and ba were used to compare ce-mra and ssfp. a t-test was used to determine possible significant differences between the measurements. results: there was moderate correlation (r = . , transverse; r = . , coronal) without significant difference in diameter measurements between ce-mra and ssfp (p = . , transverse; p = . , coronal). intraobserver limits of agreement (lag) ranged between ± . cm (transverse) and ± . cm (coronal) for ce-mra versus ± . cm (transverse) and ± . cm (coronal) for ssfp. interobserver agreement showed lag ranging between ± . cm (transverse) and ± . cm (coronal) for ce-mra versus ± . cm (transverse) and ± . cm (coronal) for ssfp. only transverse ssfp measurements revealed icc > . . intra-and interobserver variances did not reveal significant differences between ce-mra and ssfp in any orientation (all p-values > . ). conclusion: ssfp and ce-mra enable comparable precision of pv diameter measurements. however both methods revealed a wide range of intra-and interobserver agreement, which has to be thoroughly considered in the clinical use. the application of ct angiography with whole brain perfusion imaging in the evaluation of patients with transient ischaemic attack h. shi, f. yang, x. ma, w. guo, s. dong, m. qiao; beijing/cn (shihuiping@yahoo.com) purpose: to investigate the -row low-dose volume ct perfusion imaging combined with ct angiography in the evaluation of cerebral microcirculation changes of transient ischaemic attack (tia). sixteen cases of tia patients (male , female ) underwent row of dynamic volume ct perfusion imaging combined with ct angiography during ml mgi/ml contrast agent injection and acquired the blood flow perfusion parameters such as regional cerebral flow (rcbf), regional cerebral volume (rcbv), mean transit time (mtt), time to peak (ttp) and delay time (dly) and dynamic d-cta images. the measured region including the ischaemia side local lesions and the corresponding healthy side brain tissue perfusion parameters. the dynamic d-cta images were reconstructed to show vascular stenosis site and vascular collateral circulations. the stenosis of one side middle cerebral artery in cases, one side posterior cerebral artery in cases. the cbf, cbv, mtt, ttp and dly in stenosis and healthy side had statistically significant difference (p < . ) and the parameters were . ± . and . ± . ml/ ( g •min), . ± . and . ± . ml/ g, . ± . and . ± . s, . ± . and . ± . s, . ± . s and . ± . s. the one-stop ctp/cta imaging technique significantly improves the accuracy and efficiency in the evaluation of cerebral arteries stenosis, infarct localisation and abnormal blood perfusion and is a perfect imaging tool for the tia diagnosis. comparison of high pitch ( ) and standard pitch ( . ) ct angiography using -slice dual-source ct in patients with peripheral arterial disease k. choo, j. park, j. kim, j. roh; busan/kr (speedsmile@hanmail.net) we investigated the effect of high-pitch ( ) ct angiography with good image quality on qualitative and quantitative parameters and reduced the radiation dose in patients with peripheral arterial disease. methods and materials: eighty patients were divided into two groups; the protocol was high pitch in patients group and standard pitch in the other patients group. for quantitative analysis we calculated the mean arterial attenuation, the mean difference between maximum and minimum attenuation values, contrast-tonoise ratio (cnr) and figure of merit (fom). in addition, visual scores were used for qualitative evaluation. results: there were no significant intergroup differences in mean arterial attenuation (high pitch vs. standard pitch: . ± . vs. . ± . hu) and in the mean difference between maximum and minimum attenuation (high pitch vs. standard pitch: . ± . vs. . ± . hu). both the mean cnr and the mean fom were not significantly different (high pitch vs. standard pitch: . ± . vs. . ± . , . ± . vs. . ± . , respectively), and there was no significant intergroup difference in visual scores. the mean dose-length product was significantly lower at high pitch than at standard pitch ( . ± . vs. . ± . . mgy·cm). the high-pitch protocol ct angiography with -slice dual-source ct allows for reduction of the radiation dose by approximately % versus standard pitch protocol ct angiography with -slice dual-source ct without deterioration of vascular enhancement and image quality. differential diagnosis of cervical artery dissection and intra-arterial thrombosis using mri and mra m. dreval, m. krotenkova, l. kalashnikova, l. dobryinina, r. konovalov; purpose: this study aimed at exploring mri and d-tof mra in differential diagnosis of intra-arterial thrombosis and cervical artery dissection (internal carotid artery and vertebral artery) in different periods of disease using the contrast index. a total of patients with extracranial artery dissection manifested by ischaemic stroke or isolated headache ( men, woman, mean age . ± . years) and patients ( men, woman, mean age . ± . ) with ischaemic stroke due to intra-arterial thrombosis were studied. scanning protocol included d-tof mra sequence for extracranial internal and vertebral arteries and t fat suppression (f/s) sequence for neck in axial plane. mrt/mra were carried in dynamics and obtained data were analysed in time intervals: - days, - days, - days, - days, - days and - days. intramural haematoma (imh), intra artery thrombus (iat) and m. sternocleidomastoid signal intensity was measured and contrast index calculated. results: after statistical analysis of the data with the use of non-parametric statistical methods (mann-whitney u test) it was revealed that value of the contrast index of imh was higher than that of iat within - time interval ( to days) (p < . ). the contrast index did not differ significantly within first days and during months. the subjective visual analysis showed the same results. conclusion: mri sequences as t f/s and d-tof mra could be useful for differential diagnosis of imh and iat within the interval of days to months of the disease. impact of organ-specific dose reduction on image quality of head and neck ct-angiography r.s. lanzman, l. schimmöller, p. purpose: assessment of coronaries on patients with high heart rate (hr) using present generation ct is challenging due to an increase of vessel motion. the purpose of this study was to evaluate the performance of a novel coronary motion compensation algorithm on patients with a hr > bpm. prospective or retrospective ccta scans on patients with minimum hr of (mean: ) where acquired using a discovery ct hd (ge healthcare, waukesha, wi) and reconstructed using conventional ccta reconstruction algorithm (std) and novel coronary motion compensation algorithm, snapshot freeze (ssf). two senior cardiovascular radiologists evaluated diagnostic image quality of coronary segments in a blinded manner using a -grade scale ( non-diagnostic, excellent). coronary segments were assessed. results: overall number of diagnostic segments was higher using ssf compared with std ( % vs. %). overall average score of ssf reconstructed segments was significantly higher compared with std reconstruction ( purpose: to evaluate the feasibility and imaging quality of double prospectively ecg-triggered high-pitch spiral acquisition mode for coronary computed tomography angiography (ctca) in patients with atrial fibrillation (af). methods and materials: patients ( women, men; mean age . ± . years) were enrolled for ctca examinations using a dual-source ct with × × . mm collimation, . s rotation time and a pitch of . . double high-pitch mode was prospectively triggered first at % and later at % of the r-r interval within two cardiac cycles. image quality was evaluated using a four-point scale ( = excellent, = non-assessable). results: from coronary artery segments, . % ( / ) was rated as score of , . % ( / ) as score of , . % ( / ) as score of and . % ( / ) was rated as 'non-assessable'. the average image quality score was . ± . on a per segment basis. mean dose-length product (dlp) for ctca was . ± . mgy·cm, the effective dose was . ± . msv ( . - . msv). in patients with af, double prospectively ecg-triggered high-pitch spiral acquisition could be a feasible and valuable scan mode for ctca with a consistent dose below msv as well as diagnostic imaging quality. coronary artery calcium scoring from dual-source chest ct: purpose: to assess the concordance between ungated, high-pitch (thoracic) and ecg-gated (cardiac) examinations in the assessment of coronary artery calcium (cac) score. methods and materials: smokers (mean heart rate: . bpm) underwent dual-source ct examinations with acquisition of two sets of images during the same session: (a) an ungated, high-pitch scan over the entire thorax (pitch: . , temporal resolution: ms) (group ); (b) a prospectively ecg-gated scan over the cardiac cavities (group ). two operators independently analysed the cac load on both examinations and categorised the population according to the agatston score. results: the interobserver reproducibility was good for both techniques (group : kappa= . , group : kappa= . ). the mean absolute values of the agatston score did not significantly differ between groups (p= . ). there was good reproducibility between the two techniques in classifying the population according to the commonly used cutoffs (kappa: . ). the ungated technique adequately categorised out of the patients ( ); in the discordant cases ( / ; ), the ungated studies yielded lower scores than gated studies, with no more than one score category misplaced by the ungated studies. bmi and heart rates did not significantly differ between concordant and discordant scores (p= . , p= . , respectively). differences in cac scores between techniques were correlated to differences in the cac scores at the level of the right coronary artery (r= . ; p=. ). conclusion: despite the mean heart rate of the studied population, a good concordance in assessing the cac scores was found between ungated, high-pitch and ecg-gated examinations. diagnostic accuracy of free-breathing coronary cta using dualsource ct high-pitch acquisition: comparison of single and double scans with conventional angiography m.c. so , w.l. chin , c.m. wong , c.w. tai , m.w. leung ; hong kong/hk, singapore/sg (ninamc_so@yahoo.com.hk) purpose: to retrospectively investigate whether two subsequent prospectively ecg-gated high-pitch ct acquisitions can increase the diagnostic accuracy of coronary ct angiography (ccta) for free-breathing patients compared with a single acquisition and conventional angiography. methods and materials: twenty-one patients ( male, female, mean age . years) with heart rates < bpm unable to hold their breath underwent two immediately subsequent free-breathing ccta scans in dual-source ct prospectively ecg-triggered high-pitch mode, followed by conventional angiography within month. ccta data and conventional angiograms were evaluated by segment by two different observers. ccta image quality was rated on a four-point scale ( = excellent to = unevaluable) with ³ % diameter stenosis considered significant. purpose: radiation exposure reduction in cardiac cta using a novel iterative reconstruction algorithm (aidr d) with automatic exposure control (aec). methods and materials: patients were examined on a -row detector ct (aquilionone, toshiba medical systems) using kv, - cm z-axis, ms acquisition time, . mm slice thickness and mm fov. contrast medium injection was performed using a standardised protocol with . mg iodine per kg body weight. group (g ) consisted of patients (bmi= . ± . kg/m , hf= . ± . bpm) examined using bmi adapted tube current ( - ma) and a fbp reconstruction algorithm in combination with advanced noise reduction filters. in group (g ) patients (bmi= . ± . kg/m , hf= . ± . bpm) were examined using the novel reconstruction algorithm aidr d. for aec a target noise of hu was predetermined. analysis was performed using circular regions of interests placed into the descending aorta (da), left ventricular lumen (lv) and myocardial wall (mw). signal-and contrast-to-noise-ratio (snr, cnr) were calculated. doselength-products (dlp) were recorded and effective doses were estimated. results in g and g were compared using an unpaired t-test. results: both snr and cnr differed significantly in both groups: snr in g and g were . ± . and . ± . , respectively, in da (p= . ) and . ± . and . ± . , respectively, in lv (p < . ). cnr in g and g were . ± . and . ± . , respectively (p < . ). effective dose was in g ( . ± . msv) % less than in g ( . ± . msv; p < . ). conclusion: aidr d with aec allows for significant radiation dose reduction compared with advanced fbp reconstruction with bmi-adapted exposure. image quality parameters in the aidr d group were superior to the reference group indicating further dose reduction potential. purpose: the verbal interaction between the child and the radiographer in the radiographic examination is an unexplored, but important area of clinical practice. the aim of this study was to investigate the nature of that interaction between child and radiographer and the extent to which it varied as a function of the child's age. the participants in the study were female radiographers and children ( - years) examined for acute injuries. the verbal interactions of child and radiographer during the examination were videotaped and analysed using the roter interaction analysis system (rias). descriptive and non-parametric statistics were used to analyse the interaction data. the results revealed that % of the verbal interaction was carried out by the radiographer either to the child or to an escorting parent, while % was carried out by the child and % by the parent. of the radiographers' communication directed to children, % was categorised as task-focused exchange and % as socio-emotional exchange. of children's utterances, % was categorised as a task-focused exchange and % involved socio-emotional exchange. the distribution of task-focused and socio-emotional utterances varied with regard to children's age. more frequent utterances and more frequent socio-emotional exchange were found for interactions involving younger children. conclusion: these findings reinforce the need for radiographers to be flexible and sensitive in their interactions with children and to recognise the child's individual and developmental capabilities when engaging them in radiographic procedures. requesting x-rays at the right time to utilise the capacity of the radiology department: an everyday challenge m. mowinckel-nilsen; os/no (milh@helse-bergen.no) purpose: historic data shows that delayed ordering of x-rays makes it difficult to optimally utilise the capacity of the radiology department in a small orthopaedic hospital. what could be done to improve this? methods and materials: a method called patient-focused redesign (developed by leicester royal infirmary, adapted to norwegian conditions by ringerike hospital hf) was used as a tool to find a better workflow in ordering x-rays. a multidisciplinary team was assembled, and a project outline was made with a process demarcation. the team prepared a communication plan, mapped the current workflow, had a creative phase redesigning a new workflow, and measured the situation before the new workflow was tested in the hospital. an analysis of the old and new workflow was made. evaluation was done after the new workflow had been in place for . years; new measurements were done to see the effects of the changes in the workflow. results: numbers of steps in the workflow were halved, saving time for several professions. x-ray examinations not ordered on time were reduced by . %. examinations ordered a week or more before the images were taken, which is within the desired timeframe, were increased by . %. conclusion: patient-focused redesign is a good method for finding better and more efficient workflows; it can save time, increase the exploitation ratio of the equipment, and ultimately increase the quality of the radiographic service. discrepancies between ct and conventional angiogram results were resolved by consensus together with a third observer. sensitivity, specificity and accuracy of single and double high-pitch scans were calculated on a per segment basis. estimated effective radiation doses were calculated using dose length product x . . results: ccta images were diagnostic for % ( / ) and % ( / ) of segments for single and double scans, respectively, and sensitivity, specificity and accuracy were %, %, % and %, %, %, respectively. the mean estimated effective radiation dose was . msv and . msv, respectively. in patients with heart rates ² bpm, free-breathing ccta using dual source ct double scans in high-pitch acquisition mode was associated with high diagnostic accuracy for the assessment of coronary artery stenosis at a very low effective radiation dose. author disclosures: w.l. chin: employee; siemens medical solutions. one beat coronary ct angiography using slices multidetector ct scanner in patients with atrial fibrillation to evaluate image quality and ionising radiation doses of ct coronary angiography using -slices multidetector ct in patients with atrial fibrillation (af). methods and materials: patients that have persistent af with median heart rate of bpm underwent coronary ct angiography using -slices multidetector ct with adaptive iterative dose reduction system. all ct examinations were performed using a one-beat prospective gating; in patients, that presented heart rate > bpm, was used a broad phase window width ( - % of r-r). the effective dose was assessed for every patient. coronary arteries were subdivided into segments using the american heart association's (aha) model. image quality was evaluated by two expert radiologists on a workstation (vitrea, toshiba) using a -score grading system: score (absence of motion artefacts), score (presence of mild artefacts), score (presence of moderate artefacts) and score (presence of severe artefacts). median score of both radiologist and inter-rater reliability (k coefficient) were assessed. results: image quality was judged excellent (score ) in . % of coronary artery segments ( / ), good (score ) in . % ( / ), fair (score ) in . % ( / ) and low (grade ) in . % ( / ). mean effective dose was . msv (range between . and . msv). inter-rater reliability was excellent (k= . ). conclusion: high image quality and low ionising radiations effective doses demonstrate that the newest generation of ct scanner overcome the limitation at coronary ct angiography that atrial fibrillation poses so far. influence of aidr on accuracy of plaque characterisation and lumen assessment during ct coronary angiography a. ursani, h. mehrez, h. kashani, n. paul; toronto, on/ca (ali.ursani@uhn.ca) purpose: to determine the impact of adaptive iterative dose reduction (aidr) on accurate lumen assessment in a custom-built arterial plaque phantom. methods and materials: custom-built cm coronary artery phantom with x . mm (g ) and x mm (g ) vessels, lumen stenosis , , , , and % due to hu and hu plaque; and x . mm (g ) and x mm (g ) vessels with lumen stenosis , , % due to - hu and hu plaque. the lumen measured + hu. volume ct (vct) was performed; spatial resolution μm with low-and high-resolution kernels (fc , fc , fc ), kvp and ma. . / . mm axial images were reconstructed ± aidr. in-line histography mapped average plaque ct# (hu) and average lumen ct# (hu) and vessel profile. in was measured and image contrast (c) calculated. results: lumen stenosis contrast data for soft filter kernel fc and calcified plaque hu: without aidr: g : %= / ; %= / ; % = / ; % = / ; g : % = / ; % = / ; %= / ; %= / . with aidr: g : %= / ; %= / ; %= / ; %= / . g : %= / ; %= / ; %= / ; %= / aidr improved mean contrast ~ % for calcified plaque and % for non-calcified plaque for all reconstructions with - % luminal stenosis (paired t-test, p² . ). aidr improved accurate representation of % lumen stenosis in . mm vessels. conclusion: aidr improves plaque image contrast by - % and visualisation of high-grade stenosis in . mm coronaries. this promises superior performance for accurate coronary plaque characterisation and lumen assessment. results: analysis of the results for the area under the curve (auc) demonstrated statistically significant differences in the accuracy of fracture identification between groups (p value < . ), when categorised with respect to post-graduation clinical experience. radiographers with greater and less than years clinical experience scored mean az scores of . and . , respectively. a trend in increased performance and increased clinical experience was also demonstrated with a mean increase of . % and . % in terms of sensitivity and specificity, respectively. conclusion: radiographers with increased clinical experience performed the most accurately with respect to auc, sensitivity and specificity findings. hospital category did not influence the radiographer's performance in this investigation: university teaching centre versus large regional centre. the acceptable standard following post-graduate image interpretation training is - % in terms of accuracy of skeletal fracture identification. graduate training programmes/cpd modules in clinical decision making are recommended as is a survey on a national scale to incorporate a larger sample size. purpose: to accurately measure the workload of radiographers and sonographers for the first time in the uk and compare them with that of consultant radiologists in a dgh. reporting data for sonographers, radiologists and reporting radiographers at a large dgh was taken from electronic records. these were converted into an rvu score using an adapted version of the pitman-jones rvu system. reporting workload was calculated by dividing the total rvu scores by the number of pa spent reporting images by members of each group. results: there were sonographers working . pa/week, reporting radiographers worked pa/week, and consultant radiologists working . pa/ week during the period april -march . sonographer workload amounted to , . rvu per pa per year (rvu/pa/year). radiographer workload was to , rvu/pa/year. crude consultant radiologist workload was , rvu/pa/ year, but they spend . % of their time on non-reporting activities, giving a net score of , rvu/pa/year. the reporting radiographers and sonographers make a valuable and significant contribution dealing with the increasing radiology workload. however, radiologists are more productive per pa. differences in pay grades makes costeffectiveness between the groups more equal. radiographer's expectations for role development: a national survey in view of radiography students in final year of graduation c.m. mendes, a.f.c.l. abrantes, r.p.p. almeida, l.p.v. ribeiro, s.i. rodrigues; purpose: to investigate the role development expectations of graduate radiographers with a view to predicting the potential impact of a misalignment of these expectations on quality of the service delivery and staff retention. a self-applied questionnaire development by williamson and mundy ( ) in uk was validated for the portuguese language by the backtranslation method with permission of the authors and assigned to radiography students in final year of graduation in the portuguese health schools. a total of valid questionnaires, in the likert scale format, utilised attitude questions in relation to main themes of research (expectation, valence and knowledge) and were interpreted and statistically analyzed through descriptive statistics and spearman's rho correlation. the radiography students stated an expectation for role development opportunities with . % indicating that these expectations would be realized within ( . %) and ( . %) years of graduation. a significant and strong positive correlation (r= . , p= . ) between job satisfaction and expectation for role development in years after graduation was seen. farther, there were no significant differences between the health schools for the expectation, valence and knowledge. conclusion: there is an expectation and value assigned for role development opportunities. expectation is seen to be intrinsically linked with job satisfaction suggesting that misalignment of this would have a potentially negative impact on motivation and retention of the future radiography workforce. however, there is risk management in computed tomography using an incident reporting system m. antoniutti, s. doratiotto; treviso/it (sdoratiotto@alice.it) purpose: improving the management of patient safety by adopting best management practices for the governance of the system and the corporate network. methods and materials: analysis of the critical situation in the diagnostic computed tomography (ct) performed in - with incident reporting system (ir) using the instrument of audit and definition of improvement actions. results: improving actions have been taken together with a method of monitoring the most critical issues with greater severity or frequency of occurrence in the ct process. critical areas: high number of booking errors from the radiological studies of central booking, inappropriate requests by general practitioners (gps). improvement action (ia): organization of the audit with gps, the final shared document has been spread through the internet site. high number of patients not adequately prepared for the examination (non-hydrated, non-fasting, incomplete clinical information, and incomplete filling of the informed consent form examination). ia: a letter from the chief of radiology was sent to all departments to alert that requests for ct must be sent in. radiology correctly completed and audit with gps. errors found in pacs. ia: correction of pacs errors and permanent organization of audit. conclusion: this project helped the development of effective interventions closely related to the understanding of the organization's critical work in the ct process with the need to streamline the planning ct scan of the list to avoid an incongruous workload and to give each patient the right welcome. internal audits and permanent working groups have been proposed to actuate effective remedial actions. is a radiographer-led immediate reporting service for emergency department referrals a cost-effective initiative? m. hardy , b. snaith ; bradford/uk, wakefield/uk (m.l. hardy @bradford.ac.uk) purpose: demand for both emergency department (ed) and radiology services continues to increase across the uk while simultaneously, healthcare organisations are being asked to evaluate the quality of care provided and constrain service costs. national guidance on radiograph reporting times recommends ed radiographs are reported on day of patient attendance but in practice, delays in reporting persist. this study considers whether a radiographer-led immediate reporting service for ed referrals could provide a cost-effective service improvement solution. a pragmatic multi-centre randomised controlled trial was undertaken. patients were recruited and randomly assigned to an immediate or delayed reporting arm and treated according to group assignment. patient health gain was measured in terms of change in utilities derived from eq- d responses at baseline and -week follow-up. resources used and the costs of an immediate reporting service were analysed at the patient level and compared to standard reporting practices. results: radiographic examinations were performed ( patients). discordant radiographic interpretations were identified (n= / ; . %). interpretive errors were significantly reduced within immediate reporting arm. no significant difference was noted in the relative improvement in patient perceived health status between the arms of the study. the average cost saving per patient in the immediate reporting arm £ . . conclusion: radiographer-led immediate reporting of ed radiographs is a cost-effective service development and its universal introduction could make a significant contribution to the current drive to increase service productivity within current budget constraints. an investigation into the ability of irish radiographers: in the identification of wrist and scaphoid fractures a.p. tyrrell , l. rainford ; kilkenny/ie, dublin/ie (louise.rainford@ucd.ie) purpose: to investigate the ability of irish radiographers in identifying and locating wrist/scaphoid fractures, to add to the evidence base for role expansion. in total, radiographers across two university teaching and two large regional hospitals in ireland participated. the computer application ziltron demonstrated plain film wrist radiographs in a free-response operating characteristic (froc) study. the data set contained abnormal images (fracture (s) present) and normal (non-fracture). "truth" was determined by the radiology report. fracture were categorised: obvious to subtle. statistical analysis was performed by jafroc application. friday provides insight into the influence of technology on the professional development and practice in this field. in august , a postal questionnaire was distributed to hospital sites across the uk operating both a radiography and trauma service. information was sought relating to: the type of trauma and radiography service operated; details of the rads operated, including education and audit to support radiographer participation; the mandatory/voluntary status of the rads; and the imaging technology operating within the organization. results: a total of (n= / ; . %) responses were received within the defined timeframe. analysis of the data is ongoing but will include a descriptive summary of current practice across the uk with regard to "red dot", commenting and reporting by radiographers and assessment of the impact on the implementation of digital imaging technology across the uk on service levels compared to an earlier survey undertaken in . conclusion: radiographer contribution to the interpretation of trauma images is an expectation of uk radiographer practice. whether the profession has moved forward in its readiness to progress beyond "red dot" and embrace commenting is yet to be seen and this presentation will provide an insight into practice boundaries and variations that exist. : purpose: diagnostic value of dynamic contrast-enhanced perfusion mri in detection and characterisation of endometrial cancer, correlated with tumour grading, being the histopathological analysis as the standard of reference. a total of patients with histologically proven endometrial carcinoma underwent a dedicated pelvic mri examination ( . t system, achieva, philips), using high-resolution pelvic phased array multicoil. each patient scan a lack of social recognition of the radiographer, suggesting the need to promote measures to increase the profession recognition. job satisfaction among radiographers in switzerland: a national survey n. richli meystre, p. lehmann, n. mamboury; lausanne/ch (nicole.richli@hesav.ch) purpose: the technological improvements in radiology over the past decade have resulted in an important rise in demands for radiological examinations and treatments. an increasing number of well qualified radiographers are needed and healthcare authorities are worried about the growing shortage of radiographers. job (in)satisfaction has been highlighted as a contributing factor to turnover, respectively, to long-time retention. the aim of this survey was to appreciate workplace conditions and job satisfaction among radiographers. methods and materials: all radiographers working in switzerland were invited to participate with an online questionnaire. different factors contributing to job satisfaction were scored from - (very unsatisfied) up to + (very satisfied). results: radiographers completed the questionnaire. the response rate is estimated at %. % are working in diagnostic, % in nuclear medicine and % in radiooncology. % are working for more than years in the same place. the overall job satisfaction level was scored at . . the highest levels were reached for the diversity of job activities (+ . ), the quality of radiology facilities (+ . ), teamworking (+ . ) and autonomy (+ . ). the lowest levels were reached for collaboration with radiologists (+ . ), salary (+ . ) and career opportunities ( ). conclusion: radiographers in switzerland are rather satisfied about their job and the workplace conditions. in order to avoid shortage, efforts should be taken to increase the number of radiographer students and in supporting returnees. jobenrichment measures are seen as a necessity for retention in a profession with low career opportunities. progression of quality improvement works in radiography by radiographers r. gullien, j.g. andersen, a.e. haakull; oslo/no (uxraul@ous-hf.no) purpose: to visualise the ongoing progression over years in quality improvement work in radiography by radiographers and share our experiences. methods and materials: ) as a basis through the entire improvement work, the national quality assurance manual (qam) that specifies how to measure the quality assurance work was used. ) practiced the method in the department as basic measurement individual and overall measurements (static/snapshot). ) individual and overall measurements recorded several times over a period to see changes (dynamics/moving range) (local). ) implemented targeted improvements. ) measured inter-variability among the quality control (qc) radiographers. ) training the qc radiographers to avoid differences between them. ) national meeting with representatives from all counties (national). ) comparison across the counties and input to the audit of the qam. ) cooperation with hospital outside norway, benchmarking the system, comparison across countries (international). results: radiographers were trained by self-assessment: their knowledge was updated, their skills were developed, their attitude to regular audit was changed and improved, their own performances against international and national standard and objectives were reviewed. targeted initiatives against unacceptable variances in performance are necessary. time set aside to allow radiographic quality assurance work, analysing, evaluating and act accordingly. qc radiographers have the responsibility of ensuring the essential quality improvement and assurance work. conclusion: progression is from snapshot/static to dynamics/moving range, from general to focused measures, from local to national, from national to international. quality improvements became more and more complex over time. advancements and developments are important in addition to the continuous implementation of basic training and instructions. radiographer contribution to the interpretation of trauma radiographs: a survey of uk practice b. snaith , m. hardy , e. lewis ; wakefield/uk, bradford/uk (bev.snaith@midyorks.nhs.uk) purpose: radiographer abnormality detection schemes (rads) were introduced in the uk in the mid- s with the development of the "red dot scheme". this presentation reports the findings of a new survey and establishes the current position of rads (including "red dot", commenting and reporting) across the uk and was with the obturator in cases and with the internal pudendal in one case. the angle of origin of the uterine artery on the right side showed a mean of . ° (sd: . , range: °- °). on the left side the angle showed a mean value of . ° (sd: . , range: °- °). the uterine artery arises typically directly from the iia anterior division. atypical origins like origin from the iia main stem or from the iia posterior division should be searched for when the artery could not be found in its typical location. fibre tracking evaluation of sacral nervous pathways d architecture in women affected by endometriosis m. sergi, v. vinci, s. bernardo, p. sollazzo, m. saldari, l. manganaro; rome/it (mariaeleonora.sergi@gmail.com) purpose: to evaluate feasibility of tractography to study sacral nerves in women affected by pelvic endometriosis. we enrolled groups of patient: women with us diagnosis of endometriosis and a control-group of women. with t mri, we reconstructed nervous pathway postprocessing dti images. we analysed main parameters: d architecture of nervous pathways and fractional anisotropy values (fa). we analysed fibres length and branches morphology, thereafter we assigned to each a range of values obtaining main classes of pathways: st class (normality, - ), nd class (mild alteration, - ) and rd class (severe alteration, - ). results: analysing d nervous pathways, we obtained a homogeneous distribution of the control group ( pt) in the first class (normal pathways). all cases of endometriosis of the posterior compartments ( / patients) presented an abnormal pathway ( rd class), while remaining cases with anterior-medial localisation were equally distributed in st and nd class. we obtained low fa values in both groups; however, in case-control group range values were included between . and . while in patient groups fa values were lower between . and . . conclusion: fibre tracking allowed a complete evaluation of the female pelvis defining the global situation of the patient and leastly formulating a potential explanation to symptoms. fibrotic reaction, adhesions and nerves growth stimulation factors may explain both of the altered branch morphology and the lower fa values. we suggest tractography as a complementary tool for the female pelvis study, representing the only non-invasive way to study nervous pathways. purpose: to verify whether mri accuracy in diagnosing deep infiltrating colorectal endometriosis (dice) can be improved using an association of two selected findings. laparoscopy or histopathology was taken as the gold standard. methods and materials: imaging database of our institute was retrospectively reviewed. t -weighted mr images were evaluated by two experienced radiologists using two criteria. first, not thickened or thickened intestinal wall surrounded by fat-plane interface represents a normal result; nodules/hypointense plaque-like lesions in the adjacent fat-plane joint to thickened intestinal wall are considered an abnormal result. second, not thickened or thickened intestinal wall surrounded or not by fat-plane interface represents a normal result; nodules/hypointense plaque-like lesions in the adjacent fat-plane joint to thickened intestinal wall showing "radiating retracting shape" are considered an abnormal result. a third radiologist looked in medical history for laparoscopy and histopathology. mri results were compared with laparoscopy or histopathology findings by x tables and were statistically analysed (k statistics). . years) with clear symptoms attributable to pelvic floor dysfunction. all patients were given a questionnaire designed to obtain physiological data (age, gender, bmi) and pathological (diabetes, comorbidities, previous pelvic surgery). the mri provided a morphological study with t -weighted sequences in the axial sagittal and coronal plane and an cinematic fiesta (fast imaging employing steady-state acquisition) in the sagittal plane at rest and during the phase of maximum straining, to measure the line pubo-coccygeal (pcl), the line h (pelvis diastasis) and the m (lower pelvis). results: bmi correlated significantly with h (p = . ) and pcl (p = . ), while age correlated with h (p = . ) and m (p = . ). the parity but not the number of children causes a significant increase in pelvic lowering (p = . ) as well as previous pelvic surgery (p = . ). the pathophysiological changes are predictive of morphometric parameters obtained with mri. because of its fast acquisition a cinematic sequence could be advisable in all study protocols of female pelvis. origin of the uterine artery in females using three-dimensional reconstructed contrast-enhanced mr angiography before uterine purpose: to describe the patterns of origin of the uterine artery from the internal iliac artery (iia) before uterine artery embolisation (uae) using three-dimensional ( d) reconstructed contrast-enhanced mr angiography (ce-mra). the study was retrospectively performed on females (mean age . year). pre-embolisation ce-mra was performed before uae. d images were reconstructed using syngo-vesselview application. for each uterine artery the point of origin was identified and the angle which the artery makes with its main stem of origin was calculated. the uterine artery was detected in ( . %) of the ( patients) arteries. the artery originated directly from the iia anterior division in arteries of the detected arteries ( . %), from the iia bifurcation point in arteries ( . %), from the iia main stem in arteries ( . %) and uterine artery ( . %) originated from the iia posterior division. the uterine artery originated indirectly from the anterior division with a common segment in arteries ( . %). the common origin friday measured on the mr console and compared among positions. the obstetric conjugate and the sagittal inlet and outlet were both assessed in the midsagittal plane. results: mr pelvimetry in the different positions proved feasible in all subjects, yielding diagnostic quality images in every volunteer and pregnant woman, although the hand-to-knee positions were found difficult to maintain. in the hand-to-knee position, pelvic inlet reduced from . cm to . cm and obstetric conjugate from . cm to . cm. in contrast, sagittal midpelvic diameter enlarged from . cm to . cm, pelvic outlet anteroposterior diameter from . to . cm and sagittal pelvic outlet diameter from . cm to . cm. our results showed that a hand-to-knee birthing position expands sagittal midpelvic diameter, pelvic outlet anteroposterior diameter and sagittal pelvic outlet diameter, suggesting facilitation of labour and delivery. retrospective analysis of elements that can predict short-and longterm outcome in patients affected by uterine leiomyomas and treated with mrgfus purpose: to retrospectively evaluate predictive factors to obtain an optimal treatment of uterine fibroids treated using magnetic resonance guided focused ultrasound (mrgfus). methods and materials: fibroids ( ± mm) in symptomatic women (age average ± ) were treated using mrgfus (exablate ) combined with a t mr unit (ge). t si and t si of fibroids were measured on pre-treatment examination before and after administration of gadolinium (gd-bopta, bracco); also the distance between centre of myoma and skin, skin thickness, maximum diameter and volume of fibroids were recorded. the day of treatment the non-perfused volume (npv) was recorded at the end of the treatment. it was considered treatment time in terms of energy (j) used and duration of single sonication. all parameters were related to final npv and volume shrinkage at months to established short-and long-term results of treatment. results: difference between t si of the fibroids and healthy myometrium significantly correlates with volume shrinkage ( %) and npv ( %, r= . ). t si on pre-treatment studies, distance between skin surface and centre of myoma ( ± mm) and skin thickness ( ± mm) show a mild correlation with volume reduction at months ( + mm, respectively r=- . p= . and r= . p= . ).moreover, there was positive correlation between measured parameters, sonication duration and energy necessary to obtain a > % npv ( ± %, r= . , p= . ). conclusion: si ratio on t w of uterine fibroids and myometrium on screening mri should be considered as predictor of positive outcome for mrgfus treatment. : purpose: we evaluated feasibility of t system in the detection of endometriosis implants in the douglas pouch, in order to offer a precise preoperative diagnosis of deep infiltrative endometriosis involving this particular region. methods and materials: from october and april , we enrolled women coming with either ultrasound or anamnestic suspect of endometriosis. pelvic mri examination was performed on t system. we theoretically divided female pelvis in three compartments and concentrated on the posterior one, evaluating, in particular, the uterosacral ligaments and the specific signs of posterior cul-de-sac obliteration. results: mri diagnosed posterior cul-de-sac obliteration in / patients. we detected in / cases nodular endometriosis implants in pcs; signs of fibrotic plaque on the uterine serosal surface were identified in / cases; / cases showed a tethered appearance of the rectum, / cases presented an elevation of the posterior vaginal fornix. in / cases strands between uterus and intestine was clearly depictable, at last, involvement of utero-sacral ligaments (usls) and signs of utero-sacral ligaments involvement were identified in / cases. moreover, glandular-like collection localised behind uterus was identified in / cases. mri findings were compared with laparoscopy, thus obtaining a sensitivity value of %, and specificity value of % conclusion: precise preoperative mapping of posterior cul-de-sac region is essential for a preoperative planning. in our work t mri revealed excellent in the evaluation of posterior cul-de-sac obliteration associated with an optimal evaluation of the utero-sacral ligaments, due to the higher contrast spatial resolution. diffusion-weighted magnetic resonance imaging of the female pelvis: do apparent diffusion coefficient values of the fat tissue change over the menstrual phases? purpose: to establish whether the apparent diffusion coefficient (adc) measured with dwi in the pelvic fat tissue of healthy reproductive-age women significantly varies from the proliferative to the periovulatory phase of the menstrual cycle. methods and materials: women ( - years) , not assuming oral contraceptives nor referring any vaginal discharge or abnormalities of their menstrual cycles, underwent pelvic dwi ( . t, -channel coil, sagittal scans, b values: and mm/sec ) both at the th day after the beginning of the menstruation and repeatedly every day in the periovulatory phase; among these latter examinations, the one corresponding to the th day before the subsequent cycle was retrospectively selected. an adc value resulting from the average of three measurements obtained at slightly different position was calculated for each examination within a circularshaped, -mm diameter region of interest totally included in the adipose tissue of the ischiorectal fossa. the statistical significance of the differences between the adc values measured in the two menstrual phases was determined using the student's t-test per paired data. the adc values measured in the pelvic adipose tissue in the proliferative phase of the menstrual cycle (mean: . mm /sec, range: . - . ) were higher than those obtained in the periovulatory phase (mean: . mm /sec, range: . - . ). the difference was highly significant at statistical analysis (p < . ). the adc values measured with dwi in the pelvic adipose tissue of healthy reproductive-age women are significantly higher during the proliferative than in the periovulatory phase of the menstrual cycle. purpose: to evaluate alzheimer's disease premature diagnosis based on spectroscopy mri. we carried out a prospective study on patients ( women and men) whose ages ranged to years (mean age ± ). every patient presented mild or moderate cognitive impairment according to reisberg score ( - grade). standard brain mr and spectroscopy brain mr were performed using a t intensity mri device (archieva tx, philips healthcare, best, the netherlands). spectroscopy mr was focused in posterior parietal and frontal lobes gray substance using a unique volume ( x x mm) and two different echotimes, te ( and ). morphology and volume of temporal lobes were evaluated through flair coronal images which were used to quantify temporal horn width and so classify patients in four groups. jmrui (java magnetic resonance user interface) was used to calculate quantitative parameters in mr spectroscopy. mr was used to measure: calculation of naa (n-acetyl aspartate), cr (creatinine), cho (choline) and mi (myo-inositol) metabolites ratios. we used analysis of variance to compare metabolite ratios between the different patient groups previously defined. results: we found significant differences (p ² . ) between groups in naa/cho concentration (p= . ), both in long and in short eco times and frontal and parietal anatomical regions. no other significant differences between groups were found. conclusion: mr spectroscopy could increase efficiency in alzheimer's disease premature diagnosis as well as turning out to be a useful additional tool for the clinician next to clinical history. differentiating multiple system atrophy and parkinson's disease on t mri: a novel use of decision tree s. rajandran nair, l.k. tan, n. ramli, s.y. lim, k. rahmat, h. mohd nor; kuala lumpur/my purpose: differentiation of multiple system atrophy (msa) and parkinson's disease (pd) remains a clinical challenge. the purpose of this study was to develop a decision tree using parameters obtained from standard mri and diffusion tensor imaging (dti) to distinguish these clinical entities. we performed standard mri brain and dti at . t on pd and msa patients. linear, volumetry and dti (fractional anisotropy, fa and mean diffusivity, md) of putamen, substantia nigra, pons, middle cerebellar peduncles (mcp) and cerebellum were measured. a three-node decision tree was developed, with the aim of % specificity at node , % sensitivity at node and highest combined sensitivity and specificity at node . results: mean mcp width, anteroposterior diameter of pons and mean fa mcp with cut-off values of . mm, . mm and . respectively, were selected for the decision tree from nine parameters (mean width, fa and md of mcp; anteroposterior diameter of pons; cerebellar fa and volume; pons and mean putamen volume; mean fa substantia nigra compacta-rostral) that showed statistically significant (p < . ) differences between msa and pd. the decision tree accurately classified out of msa patients with an overall % sensitivity, % specificity, % ppv and % npv. the decision tree could be used as a diagnostic algorithm in the differentiation of msa and pd. subthalamic nuclei tesla t -relaxometry correlated to updrs scores in pre-deep brain stimulation ( purpose: degeneration within the subthalamic nucleus (stn) in parkinson's disease (pd) is a potential marker for targeting dbs. we aimed to investigate whether pre-and postoperative unified parkinson's disease rating scale (updrs) scores are related to t relaxation (t r) of the stn and whether there is a correlation of laterality between clinical assessment and t r. methods and materials: patients and controls were examined at tesla by a multicontrast spinecho sequence. stn and control volumes relaxation times were analysed updrs scores were determined during "on" and "off" pre-and postoperatively. follow-up checks (median years) subjects had stable disease (sd), had progression of disease (pd) and developed ad. baseline metabolic ratios ( h mrs) between the groups of patients indicated significant differences in the left frontal lobe in mi/h ratio, between patients with sd ( . ) and dp ( . ) (p = . ). in groups of patients with dp and ad there was a significant difference in naa/cr ( . vs. . ), (p = . ). conclusion: mi and naa seem to be very sensitive biomarkers for conversion from mci to ad. the significance of our metabolic ratio results needs further study. purpose: uric acid has been associated with focal vascular brain disease such as lacunar infarcts and white matter lesions. however, it is unknown whether uric acid also relates to global brain changes such as brain atrophy. we therefore studied the relation of uric acid with brain atrophy and whether this is coupled with worse cognitive function. in persons of the population-based rotterdam study (mean age . years), we studied the relation of uric acid levels with brain tissue atrophy and cognition, using linear regression models, adjusted for age, sex and putative confounders. brain atrophy was assessed using automated processing of mri. cognition was assessed using a validated neuropsychological test-battery and we computed compound scores of cognitive domains. results: higher uric acid levels were associated with white matter atrophy (difference in z-score of white matter volume per standard deviation increase in uric acid: - . ( % confidence interval: - . ; - . )). this was particularly marked when comparing hyperuricaemic to normo-uricaemic persons (z-score difference: - . (- . ; - . )). worse cognition was primarily found in persons with hyperuricaemia (- . (- . ; - . )). conclusion: hyperuricaemia is related to white matter atrophy and worse cognition. the neural correlates of anomia in the conversion from mild cognitive impairment to alzheimer's disease e. pravata' , j. tavernier purpose: language impairment is frequently observed in patients with alzheimer's disease (ad; in this study, we investigated the extent and distribution of brain atrophy in subjects with conversion from mild cognitive impairment (mci) to ad with and without naming difficulties. methods and materials: this study was approved by the institutional review board and was hipaa compliant. all subjects or their legal representatives gave informed consent for participation. ninety-one subjects from the alzheimer's disease neuroimaging initiative (adni) with (n= ) and without (n= ) naming impairment as per the boston naming test (bnt) underwent brain magnetic resonance (mr) imaging months before and at ad diagnosis. structural mr images were processed using voxel-based morphometry. longitudinal and cross-sectional comparisons between groups were performed to assess differences in gray matter (gm) loss patterns. results: during the -month prior to diagnosis, ad patients with naming difficulties showed distinct areas of greater gm loss in the temporal lobes, cingulate gyri, and precunei than patients without naming difficulties. gm volume in the left fusiform gyrus (brodmann area ) was greater in patients without naming impairment. this study provided evidence of distinct patterns and dynamics of brain atrophy in ad patients with naming difficulties when compared with those with intact language, as early as months prior to ad diagnosis. language deficits and their neuroanatomical correlates should be taken into account in the design of a structural imaging biomarker for the early detection of ad. gender differences in grey matter atrophy patterns in the mild cognitive and early alzheimer's disease m. spampinato , e. pravata' , b. langdon , k. patrick , r. parker ; charleston, sc/us, gainesville, fl/us (emanuele.pravata@gmail.com) purpose: to investigate gender-specific differences in grey matter (gm) volume loss patterns in amnestic mild cognitive impairment (amci) patients with and without progression to alzheimer's disease (ad) using mr voxel-based morphometry (vbm). we included amci patients ( males, females; age ± years), with (n = ) and without (n = ) conversion to ad, from the alzheimer's disease neuroimaging initiative (adni) cohort. three-dimensional mprage brain scans obtained one year before conversion from amci to ad and at ad diagnosis were available. the general linear model was performed to evaluate for differences over time in cognitive decline from the clinical dementia rating (cdr) scale. optimised vbm with spm was used to assess gm volume differences by performing cross-sectional and longitudinal group comparisons with two-sample and paired t-tests. results: both male and female ad converters showed significant cognitive decline at cdr (p < . ). total gm volumes significantly differed between all groups of males and females (p < . ). compared to stable amci, male ad converters showed atrophy progression one year prior to ad diagnosis in the limbic, temporal, parietal, frontal, insular lobes and deep gray nuclei, while female ad converters showed only one area of significant gm loss in the right uncus (p < . fwe-corrected). the extent and distribution of regional gm volume loss in amci to ad converters is strongly influenced by the gender. this finding has potential implications for therapeutic approaches in ad and should be taken into account in clinical trials. purpose: excessive daytime sleepiness (eds) is an important non-motor symptom of parkinson's disease (pd). the underlying neuropathological mechanism accounting for eds is not well understood. the purpose of the present study was to determine regional grey matter (gm) volume changes in pd patients with eds. scale ess ³ ) (eds-pd), age and disease duration-matched pd patients (epworth sleepiness scale ess ² ) and age-matched healthy controls were enrolled in the study. the χ and student's t tests were used to test for differences in demographic and clinical characteristics between groups. differences in gm volume between groups were evaluated by applying the voxel-based morphometry (vbm) method. results: total calculated levodopa equivalent dose was higher in eds-pd when compared to pd patients (p < . ). comparison of eds-pd with pd patients and controls showed increased gm volume bilaterally in the hippocampus, the parahippocampal gyrus, the fusiform gyrus and in cortical areas in the temporal, frontal and parietal lobes (p < . ). conclusion: eds-pd patients present increased regional gm volume in the mesolimbic/mesocortical dopamine pathway, which is activated during sleep. drug-induced gm volume increase through a process of neuronal plasticity may represent the underlying mechanism. purpose: olfactory dysfunction is the second most frequent feature of pd, occurring in - % of patients. recent studies suggest that the olfactory system is among the earliest brain regions involved in pd. diffusion-weighted imaging (dwi) and diffusion tensor imaging (dti) consent quantitative measures of the microstructural integrity of nuclei and fibre tracts. our aim was to assess fractional anisotropy (fa) changes of the olfactory tract in early pd patients (hoehn ed yahr stage - . ) and to correlate fa values with the clinical score of the olfactory deficits methods and materials: a case control study was conducted on pd patients responding to uk pd society brain bank for probable pd and healthy controls that underwent mri ( . t, avanto, siemens, erlangen, germany). we performed t weighted mprage, t and pd weighted tse and epi (on non-collinear directions at b and s/mm to assess dti) sequences. fa was computed with standard formulas. all subjects underwent upsit (university of pennsylvania smell identification test) results: we found a significant difference between fa values of the gyrum rectum subcortical white matter of pd patients and healthy controls ( . ± vs. . ±; p < . ). a significant difference was also found in upsit values between the two groups (p < . ). our results suggest that early olfactory dysfunction in patients with pd may be a primary consequence of damage to the olfactory tract. diffusion tensor imaging reaches the diagnostic sensitivity to assess early olfactory dysfunction in pd patients quantitative evaluation of myocardial perfusion reserve at and . tesla in comparison to invasive measurement of fractional flow reserve for detection of coronary artery disease t. walcher, k. ikuye, w. rottbauer, j. woehrle, p. bernhardt; ulm/ de (peter.bernhardt@uniklinik-ulm.de) purpose: fractional flow reserve (ffr) is considered as the standard invasive diagnostic tool to determine haemodynamic significance of coronary artery disease (cad). adenosine-perfusion cardiac magnetic resonance imaging (cmr) at . and tesla has been proven to be capable to noninvasively determine myocardial perfusion reserve, but has not been compared against each other and validated against ffr as standard reference. methods and materials: patients ( . ± . years) with suspected cad were included into the study. all patients were scanned at both field strengths, . and tesla, including adenosine and rest perfusion imaging. coronary x-ray angiography including ffr measurement in the left anterior descending (lad), circumflex (cx) and right coronary artery (rca) was then performed in all patients. myocardial perfusion reserve was calculated in myocardial segments for each field strength and compared to the ffr measurement of the supplying coronary artery. ffr ² . was regarded as relevantly reduced. in coronary arteries ( lad, cx, rca) a ffr ² . was found. receiver operator curve analysis yielded higher area under the curve for t in comparison to . t cmr ( . vs. . , p < . ) resulting in higher sensitivity ( . vs. . ) and specificity ( . vs. . ). conclusion: quantitative evaluation of myocardial perfusion reserve at and . tesla is capable to detect haemodynamic significance of coronary artery stenosis. in our cohort, the diagnostic accuracy at t seems to be superior to . t. dynamic stress computed tomography perfusion imaging for the detection of functionally significant coronary lesions purpose: to evaluate the performance of hyperaemic myocardial blood flow (mbf) derived from stress computed tomography perfusion (ctp) imaging in the detection of functionally significant coronary lesions defined by fractional flow reserve (ffr) ² . in a prospective cohort of patients with stable chest pain. coronary computed tomography angiography (ctca) and ctp were performed in patients ( males/ females; mean age ± years) referred to invasive angiography. a second-generation dual-source ct scanner (somatom definition flash, siemens) with a dynamic ecg-triggered axial shuttle mode was used. this technique provides an arterial input function and myocardial time-attenuation curves fitted to a -compartment model to give mbf. hyperaemia was induced by infusion of adenosine ( µg/kg body weight). three to minutes into the infusion, ml of contrast were injected. gantry rotation time was ms, collimation x . mm, tube voltage kv and the tube current-time product was mas/rotation. purpose: the use of ct-scans in assessment of coronary artery disease is rapidly growing. more selective referral of stable angina patients with intermediate probability of coronary artery disease (cad) to ct coronary angiography (ctca) may temper the health care spending on cardiac ct-scans. the value of updated algorithms using "in-office-evaluation" and calcium score (casc) is investigated. we evaluated retrospectively symptomatic stable angina patients who underwent "in-office-evaluation", unenhanced ct-scan for calculation of casc and ctca. outcome of our study was non-invasive diagnosis of obstructive cad (³ % lumen diameter narrowing) by ctca. two algorithms were developed. first algorithm used "in-office-evaluation" consisting of chest pain typicality, sex, age, risk factors and ecg. the second algorithm used both "in-office-evaluation" and casc. discrimination of both models was tested using the area under the roc curves (auc). patients were classified to low (< %), intermediate ( - %) and high pre-test probability (³ %) of obstructive cad. testing with casc or ctca was deemed appropriate in patients intermediate probability of cad. net reclassification improvement (nri) of algorithm was calculated in patients with intermediate probability of cad according to algorithm . results: discrimination of cad was significantly higher using algorithm compared with algorithm (auc: . vs. . , respectively). the "in-office-evaluation" algorithm reduced both unenhanced ct-scan and ctca by %. an additional % of ctca-scan was reduced using algorithm subsequently with nri of %. conclusion: updated algorithms using both "in-office-evaluation" and casc may reduce referral of stable angina patients to ctca by %. dynamic ct perfusion imaging for the detection of myocardial ischaemia: a first experience with a d semi-automated evaluation software u. ebersberger , r.p. marcus , u.j. schoepf , p. blanke , y. wang , l. geyer , a. purpose: to evaluate the performance of a d semi-automated evaluation software for its accuracy and time saving potential for ct perfusion myocardial blood flow (mbf) and blood volume (mbv) assessments compared to manual evaluation as well as to spect. methods and materials: dynamic, time-resolved myocardial perfusion ct datasets acquired using a dual-source ct system (somatom definition flash, siemens healthcare, forchheim, germany) were assessed both manually and by use of the semi-automated prototype for mbf and mbv, based on the aha -segment model. time required for each assessment was recorded. results were compared to spect as the standard of reference. results: segments were evaluated. ( . %) were excluded due to insufficient coverage. a comparison of mbf and mbv measurements using the prototype versus manual assessment showed high correlation (spearman's rank correlation coefficient = . / . , p < . ). mean evaluation time for mbf and mbv analysis was . ± . minutes with manual assessment and . ± . minutes with the use of the prototype (p < . ). conclusion: d semi-automated assessment of dynamic myocardial perfusion ct highly correlates with manual assessment. significantly decreased assessment time appears promising for the integration of myocardial perfusion ct in clinical workflows. friday protocol (adp): clinical examination, mdct-ca; the positive cases were recovered and underwent ca. if mdct-ca was negative for significant cad the patient was dismissed from the ed and taken under follow-up for years. the costs of every protocol and the amount of costs for individual methods were calculated. based on the results, the two diagnostic paths were compared about cost/effectiveness ratio. results: at timi score only % of the patients resulted with high risk, whereas mdct-ca was judged positive in % of the cases. mdct-ca compared to ca revealed an accuracy of . %, ppv and npv were % and %. the adp revealed lower costs than the protocol with only hospitalization ( € against €), and showed better cost/effectiveness ratio. at -year follow-up . % of the patients resulted well being. the adp can help better than timi score to rule out patients with undifferentiated chest pain. moreover, cost analysis demonstrated a better cost effectiveness ratio in comparison to the hospitalization, also confirmed with a long-term follow-up. purpose: transient ischaemic dilation (tid) in the setting of abnormal spect myocardial perfusion imaging (mpi) has been linked with increased cardiovascular risk. however, the significance of tid in the setting of an otherwise normal mpi study has not been clearly established. coronary computed tomography angiography (ccta) was utilised to evaluate the prevalence of atherosclerotic lesions and the severity of coronary stenosis in patients with tid with or without associated myocardial perfusion defects on spect-mpi. the study population consisted of patients who had undergone both ccta and stress/rest cardiac spect. in patients with tid coronary cta was used to evaluate each coronary segment for the presence and composition of atherosclerotic plaque and the degree of coronary stenosis. findings were compared with a : matched-pair control cohort without tid. results: tid was identified in a total of patients from a screening population of consecutively imaged patients. findings demonstrated that compared to tid negative risk-factor matched controls (n= ), tid positive patients had no significant differences in the presence and extent of atherosclerosis or the degree of coronary artery stenosis as evaluated by ccta. similarly, there were no significant differences in ccta measures of coronary artery disease (cad) in tid positive patients with normal perfusion compared to tid negative patient with a normal perfusion study (n= ). these results suggest that the presence of tid with an otherwise normal spect study does not reliably predict an increased risk for or the extent and severity of coronary artery disease. - ] ) underwent wb-cta ( x . mm) with an adapted contrast injection protocol (iomeprol- , mgi/ml; + ml@ ml/s). coronary arteries were divided into segments and the extra-coronary arteries into segments, detected stenoses were graded using a -point scale. an atherosclerosis burden score (abs) was generated for each individual and correlated to traditional cv (framingham risk index; fri). abs and fri were compared using kaplan-meier analysis, roc analysis and stepwise multivariable cox regression models. results: at baseline mean abs was . ± . and mean fri was ± . ; . ± . m after wb-cta all patients received an interview to determine health status. according to kaplan-meier curves, mean event-free time was of . ± . m for abs< , . ± . m for <abs , with a statistically significant difference between the three groups (p= . ). mean event-free time was ± . m for fri mild-risk group and . ± . m for high-risk group without significant differences between the two groups (p= . ). for the prediction of cv events, in the highrisk group abs showed an accuracy of . , meanwhile fri of . (p= . ). multivariable analysis showed that only age (p= . ), abs score (p= . ) and therapy (p= . ) were independent predictors of hard cv events. conclusion: wbcta-derived abs reflects real atherosclerotic burden and provides superior risk stratification and event prediction with respect to fri; hard event prediction was significantly associated with age, abs and therapy. purpose: detection of patients with "high-risk-cad" consisting of left main (lm) and/or three-vessel cad ( vd) is important because optimal medical treatment combined with revascularisation has shown to improve prognosis in these patients. diagnostic performance of ct coronary angiography (ctca) to detect or exclude "high-risk-cad" is assessed. the discrimination of "high-risk-cad" by ctca is compared with duke risk score and calcium score. methods and materials: we evaluated retrospectively symptomatic patients with stable angina without prior revascularisation ( ± years, % women) who underwent invasive coronary angiography (ica) and ctca between and . vessels were considered obstructive in the presence of ³ % lumen diameter stenosis. results: "high-risk-cad" determined by ica was present in % ( / ). sensitivity of ctca to detect "high-risk-cad" was % ( % ci: %- %), specificity was % ( %- %), positive predictive value was % ( %- %) and negative predictive value was % ( %- %). the "high-risk-cad" discrimination by ctca was significantly (auc: . ) higher compared with duke risk score (auc: . , p < . ) and calcium score (auc: . , p < . ). conclusion: ctca accurately rules out "high-risk-cad" in patients with stable angina. ctca provides incremental value in the discrimination of "high-risk-cad" compared with the duke risk score and calcium score. results: % of the total radiation dose was applied during the pre-and postinterventional ct-series leaving only % to being applied by the ct-guided intervention itself. single slice acquisition was associated with lower doses compared to continuous ct-fluoroscopy ( mgy*cm vs. mgy*cm, p < . ). overall, the use of kv during the interventions led to significantly lower radiation doses compared with kv (mean: mgy*cm vs. mgy*cm, p < . ). third quartile of radiation doses varied considerably for different interventions depending on complexity. conclusion: to our knowledge, these data represent the largest sample of ctguided interventional procedures. therefore, we suggest preliminary reference levels for each subgroup based on the third quartiles of our analysis. the radiation dose applied can be reduced using kv instead of kv for the intervention and by preferring single-slice acquisition over ct-fluoroscopy whenever possible. ( tumours) presenting local recurrences of sts of the trunk or limbs were selected from our institutional database. two radiologists visually assessed possibility of cryotherapy according to common inclusion criteria: maximal diameter size of the tumour ² cm, distance to skin > mm, distance to neurovascular structures at least mm, potential access, absence of articular involvement and planned cryoablation covering the entire lesion volume. characteristics of patients eligible for cryoablation were comparing with not selected patients. results: mean tumour size was mm ( - ). most frequent histological subtypes were unclassified sarcomas (n= ), liposarcomas (n= ), or myxofibrosarcomas (n= ). surgical treatment consisted in wide excision (n= ), or combined treatment (n= ). after surgery, the severe complications rate was . %. since relapse, mean follow-up was . months with a median overall survival of . months and median recurrence-free survival of . months. a subgroup of patients was identified and comparison with other patients showed that trunk, shoulder and pelvic girdle locations (p = . ), locally aggressive (p= . ) and deep (p= . ) tumours, ² cm (p= . ), and liposarcoma and myxofibrosarcoma subtypes (p= . ) were indicative of eligibility for cryoablation. conclusion: eligibility criteria as defined are useful for plan cryoablation as a technically feasible alternative to surgery for treatment of local relapse of sts. robot-assisted radiofrequency ablation of liver tumours: early experience b.j.j. abdullah, c.h. yeong, k.l. goh, b.k. yoong, g.f. ho, c. yim; kuala lumpur/my (basrij@ummc.edu.my) we report our preliminary experience of rfa of the liver tumours using a robotic-assisted guidance system. methods and materials: patients with lesions were treated using the robio ex (perfint healthcare, ma, usa) robotic positioning system. all the lesions were smaller than . cm diameter. all the procedures were performed under general anaesthesia. following baseline ct scans, the lesions were identified. the puncture site and trajectory were then determined on robio ex workstation. the angulation of the needle, depth of lesion, the fluoroscopic dose as well as the accuracy of placements was determined. the performance level of procedures was documented for each biopsy on a five-point scale ( - : excellent-poor). results: all the tumours were targeted successfully. one lesion in patients required minor readjustment. patients ( lesions) had needle placement with no cranio-caudal angulation, whereas patients ( lesions) had cranio-caudal angulation of up to . the orbital angulation ranged from to . the depth of needle ranged from . to . cm from skin surface. performance levels were all except in one patient ( ). the fluoroscopic (dlp) and total dose (ctdivol) for the entire procedure were ± mgy.cm and . ± . mgy, respectively. post-rfa ct scans showed successful ablation of the targeted lesions. no immediate complications were noted. conclusion: robotic-assisted planning and needle placement appear to be technically easier, it requires fewer number of needle passes, fewer check scans using logistic regression, ccs more than was the predictor of presence of oms (odds ratio . , . - . in % confidence interval). the prevalence of oms was significantly higher in patients with more than % stenosis and in patients with mixed and non-calcified plaques. the prevalence of oms on de-mri and significant coronary disease on ctca are not uncommon even in asymptomatic patients with type diabetes. ccs more than is the only predictor of oms. author epicardial fat volume and coronary artery disease at ct: racial differences in african american and white patients with acute chest pain p. apfaltrer , a. schindler , u.j. schoepf , j. nance , u. ebersberger , r. vliegenthart ; mannheim/de, charleston, sc/us (paul.apfaltrer@umm.de) purpose: thoracic adipose tissue likely promotes coronary artery disease (cad). possibly, differences in cad risk between races are influenced by racial differences in thoracic adipose tissue. we compared ct-derived measures of thoracic fat and potential correlations with cad between african american and white patients. methods and materials: age-and-gender-matched black and white patients ( black: mean age ± yrs, % men; white: mean age ± yrs, % men) who underwent thoracic dual-source ct for chest pain evaluation were retrospectively included. epicardial adipose tissue (eat) volume and mediastinal adipose tissue (mat) volume were quantified using an automated analysis algorithm. peri-coronary fat thickness (pft) was measured on reconstructed sections orthogonal to the right coronary artery centreline. non-calcified and calcified plaque volume was quantified by applying a threshold-based automated algorithm. cad was defined as % or greater coronary artery stenosis. patients with cad showed significantly higher eat than those without cad ( . ± . cm vs. . ± . cm , p < . ). significant correlations were observed between eat measurements and calcium volume (r= . ; p < . ). the relationship between race and extent of adipose tissue remained significant after adjustment for cardiovascular risk factors. conclusion: measures of thoracic fat were generally higher for symptomatic white than for black patients suggesting a differential relationship between thoracic adipose tissue and cad pathophysiology by race. purpose: the imactis navigation system with electromagnetic needle holder tracking was developed to allow interactive display of the needle trajectory in a d volumetric ct volume, allowing the radiologist to choose optimal entry point and track to the target during ct-guided percutaneous interventions. the ctnav trial compares the accuracy of the needle placement using standard ct procedure (ct group) and using the navigation system procedure (nav group). methods and materials: prospective, randomised, comparative, open, controlled study conducted between june and january in grenoble university hospital on patients who had to undergo a percutaneous ct procedure. patients were randomised to have normal procedure (ct group) or navigation system assisted procedure (nav group). the main outcome was the distance between the planned trajectory and the effective needle trajectory after the first placement attempt. significance was set at . friday dynamic contrast-enhanced mri (dce-mri) and histology, we assessed the impact of this therapeutic approach on the tumour vasculature. methods and materials: rats bearing breast cancer bone metastases were imaged using vct and dce-mri prior to and days after the onset of therapy; untreated (n= ) and treated (integrin inhibitor monotherapy; n= ) or together with antiresorptive agent (combination therapy; n= ) to assess osteolysis and functional mri parameters, respectively. mean vessel diameter and sma and collagen-iv-positive vessel area fraction were assessed histologically. results: compared to the control group, bone defect healing at the osteolytic site occurred in rats receiving monotherapy and even more frequent after combination therapy as shown by vct. in addition, we observed a profound effect of mono-and combination therapy on the tumour vasculature determined by dce-mri parameters amplitude and exchange rate constant. both therapy regimens induced elevated vessel permeability/perfusion in bone metastases, but opposite to monotherapy, combination of agents additionally elevated the blood volume. immunofluorescence analysis of osteolytic lesions revealed more tumour blood vessels after combination therapy and equally immature vasculature as compared to monotherapy. conclusion: upon treatment with integrin inhibitor monotherapy or in combination with an antiresorptive agent, vessel remodelling could be assessed by dce-mri. interestingly, the degree of vessel remodelling could be correlated with bone defect healing, so we conclude the existence of a strong interaction between tumour angiogenesis and bone turnover in lytic osseous lesions. purpose: islet transplantation is a less invasive/safer/repeatable option than surgical pancreas transplantation for type diabetic patients; it can be performed after kidney transplantation (iak), alone (ita) in patients without chronic renal insufficiency, or as an autotransplantation (iat) after pancreatectomy (immunosuppression unnecessary). steatosis is a consequence of islet engraftment: its meaning is controversial. our longitudinal study aimed to assess steatosis incidence at ultrasound after islet auto-and allo-transplantation, and to identify any relationship with graft function. ultrasound was performed at baseline/ / / months in islet-transplanted patients ( iak/ ita/ iat). steatosis first detection/ prevalence/duration/distribution were recorded. steatosic (s) and non-steatosic patients (ns) were compared for the following parameters at baseline/ / / months: insulin independence rate, ß-score, c-peptide, glycated-haemoglobin, exogenous insulin requirement, fasting plasma glucose, infused islet mass. results: steatosis was found in / patients, % ( / ) allo-transplanted, % ( / ) auto-transplanted (better outcome), with first detection at months, highest prevalence at year ( cases). s-patients had a significantly higher infused islet mass (ie/kg: s= . ; ns= . ) and worse basal metabolic conditions (ß-score: s= . ± . ; ns= . ± . ), but better islet function at the time of steatosis first detection (ß-score: s= . ± . ; ns= . ± . ), after which a progressive islet exhaustion, along with steatosis disappearance, was observed. conversely, in ns patients these parameters remained more stable in time. conclusion: steatosis at ultrasound is significantly less detectable in auto-transplanted-patients with better clinical outcome. it seems to be related to stressed islets' overworking activity (higher ß-score values when steatosis appears), and a higher infused islet mass. steatosis presence precedes metabolic alterations and (structural insight) was adapted in order to allow calibrated bone density and bone structure analyses of the vertebral bodies, using an underlying light weight calibration phantom with design for coronary calcium scoring (image analysis phantom® purpose: to validate a magnitude-based method, transposable on any imaging system and for all current clinical fields ( . and . t) for liver fat volume fraction (fvf) quantification without dominant component ambiguity problems. methods and materials: mr imaging was performed at . and . t using a multiple-angle multiple-gradient echo acquisition. a quantification algorithm correcting for relaxation time effects using a disjointed estimation of t and t * of fat and water and accounting for the nmr spectrum of fat was developed. validations were performed in a prospective comparative study with histology on patients with chronic liver diseases. results: mr-estimated fvf and histological results were strongly correlated (ρ= . ). roc analysis showed that fvf allowed the diagnosis of a mild (cut-off = . %) and a moderate steatosis (cut-off= . %) with a sensitivity/specificity of %. water relaxation times (t and t *) were found significantly reduced in patients with iron deposition (p < . ), whereas water t was found significantly increased in patients with cirrhosis (p < . ). conclusion: this method that can be performed at . and . t on all imaging systems provide an accurate quantification of the fvf in patients with chronic liver disease. fvf could be a relevant biomarker for the clinical follow-up of patients with nafld as well as to quantify steatosis in the full spectrum of chronic liver diseases. interestingly, thanks to the separated estimation of fat and water relaxation times, detection of cofactors such as iron deposition or cirrhosis in patients with nafld could be achieved. combination of liver intravoxel incoherent motion imaging with mr fat quantification at . t to distinguish between pure steatosis and nash purpose: to evaluate the combination of liver intra-voxel incoherent motion imaging (ivim) and a mri fat quantification method at . t to make the distinction between nash and pure steatosis. a multi-angle multi-gradient echo acquisition combined with a dedicated algorithm was used to quantify liver fat volume fraction (fvf), corrected for water and fat relaxation times and accounting for the nmr spectrum of fat. ivim was performed using a single-shot se-epi sequence, in free breathing, with b-values ( - - - - - - - - - - s.mm - ) and a weighted signal averaging procedure. three orthogonal diffusion gradients were sequentially applied. a ms tr, ms minimum te; axial slices of mm thick; × mm² fov; × matrix were used. ivim parameters (pure molecular diffusion coefficient (dslow), perfusion-related diffusion coefficient (dfast) and perfusion fraction (f)) were estimated. mr imaging was performed on a healthy volunteers group (n= ), and on patients with histologically confirmed pure steatosis (n= ) or nash (n= ). results: wilcoxon test showed that dslow was significantly lower when fat is present (fvf > . %) (p < . ). dslow and dfast were found significantly reduced between subjects with pure steatosis (brunt= ) and nash (brunt> ) (p < . ). conclusion: fat vesicles in pure steatosis restrict molecular diffusion without modification of micro-perfusion. in nash, fibrosis still increase the restriction of molecular diffusion compared to patients with pure steatosis and decrease the microperfusion as illustrated by the decrease of perfusion-related diffusion coefficient. these preliminary results suggest that combining mri fat quantification and ivim could be a none invasive mean to distinguish between pure steatosis and nash. quantification of steatosis hepatitis and liver iron overload in a population-based study using magnetic resonance imaging j.p. kühn , d. purpose: to describe hepatic biochemistry in biopsy-proven nafld states using p-mrs and to evaluate its diagnostic performance for distinguishing non-alcoholic steatohepatitis (nash). methods and materials: the cohort consisted of healthy controls (n= ), and nafld patients with liver biopsy, as follows: simple steatosis (ss, n= ), nash with non-significant fibrosis (nash-nsf, n= ) and nash with significant fibrosis (nash-sf, n= ). p-mrs was performed on a t mri to obtain signal intensities for phosphomonoesters (pme), phosphodiesters (pde) and component glycerophosphocholine (gpc), total adenosine triphosphate (atp) and component α-atp, and inorganic phosphate (pi). these were expressed as percentages relative to total phosphate and compared using one-way anova with post hoc bonferroni test. receiver operating curve (roc) analysis was performed to determine cut-off values with highest youden index. statistical significance was declared at α< . . results: compared with controls, all nafld groups had higher pde (p < . ). ss and nash-nsf had decreased pme (p= . - . ), increased gpc (p < . ), normal total atp (p= . - . ) and decreased pi (p= . - . ). nash-sf had normal pme (p= . ) normal gpc (p= . ), decreased total atp (p= . ) and normal pi (p= . ). α-atp was significantly decreased in both nash groups and identified as a potential diagnostic marker. the computed area under the roc was . , and an α-atp threshold of < . % gave a % sensitivity and % specificity for the identification of nash. conclusion: p-mrs shows observable spectroscopic patterns within the nafld spectrum. α-atp is a potential diagnostic marker for distinguishing nash from ss. clinical implications of fatty liver on hepatic diffusion-weighted imaging studied in healthy subjects h. dijkstra, a. handayani, p. kappert, m. oudkerk, p.e. sijens; groningen/nl (h.dijkstra @umcg.nl) purpose: to evaluate the diagnostic implications of fatty liver on dwi by assessing the hepatic fat fraction (hff) and t * of healthy subjects in eight liver segments in order to eliminate patient-related confounding factors such as cirrhosis and fibrosis. methods and materials: eleven healthy volunteers were examined with dwi (seven b-values) and two series of in-and out-of-phase dual-echo spoiled gradient echo sequences (spgr) to obtain the hff (dixon's method). a third spgr series was acquired to calculate t * relaxation. dwi data were analyzed using the ivim model: molecular diffusion (dslow), microperfusion (dfast) and the respective fractions (fslow/fast). for each subject, four circular regions-of-interest (ø . mm) were drawn in each segment according to the couinaud-bismuth classification. data with low snr< were excluded. ivim parameters were compared between groups of low (² . %), intermediate ( . ²hhf< %) and high hhf (> %). linear correlations between hhf, dwi parameters, and t * were assessed. results: in each segment, dslow decreased with increasing hff. dslow averaged over all segments differed significantly (p < . ) between low ( . × - mm /s), intermediate ( . × - mm /s) and high hff ( . × - mm /s). both dslow and t * decreased with hff (r = . ; r = . ). dfast and fslow/fast showed small intergroup differences (p < . ). conclusion: increasing hepatic fat fractions caused significant reduction of the molecular diffusion and shortening of t *. this implies that hepatic dwi hindered by fat leads to apparent fluctuations of the molecular diffusion and hypointensity on dwi images; this may induce false diagnoses such as fibrosis or cirrhosis. (p < . /p < . ), whereas there was no significant correlation between bat volume and the amount of subcutaneous adipose tissue (p= . ). bat activity was an independent, negatively influencing variable for liver fat content (p= . ). conclusion: bat significantly correlates with body fat composition, especially visceral fat mass considered relevant for the development of metabolic syndrome, and seems to be an independent regulator of hepatic steatosis. in-phase/opposed-phase mri and mr spectroscopic measurements for the quantification of liver fat content in morbidly obese patients h. agreement for the three individual liver segments (ii, iv and vii) had upper/lower limits of + . /- . %, + . /- . % and + . / - . % and insignificant biases of . % (p= . ), - . % (p= . ) and - . % (p= . ), respectively. conclusion: ip/op imaging and mrs are reliable methods for the assessment of lfc. ip/op imaging is superior in terms of processing time and liver coverage and provides information for cases with larger regional fat differences and is helpful for lipid assessment in the left liver lobe where mrs is impractical. purpose: pancreatic islets transplantation (islets-tx) is a promising treatment for patients with type- diabetes. neoangiogenesis of transplanted islets is a crucial phenomenon for engraftment and was investigated with dce-mri in mice. the aim was to use dce-mri in clinical islets-tx to evaluate the relationship between early vascular changes, islets loss and long-term clinical outcome. methods and materials: diabetic pts were enrolled. dce-mri was performed at baseline and days after islet-tx with a d-t w-tfe dynamic sequence (temporal resolution: sec; dynamics) acquired during gadolinium bolus injection. k-trans was assessed by dce-mri datasets. three patients received ferucarbotran labelled islets and were monitored with t *sequences (before islets-tx, days and each month after). unlabelled islets were infused in the remaining three patients. glycated haemoglobin, blood glucose, daily insulin request and stimulated c-peptide were monthly assessed in order to calculate beta-score ( - ) purpose: brown adipose tissue (bat) mass and activity is considered a significant factor for the development of adiposity and metabolic syndrome in humans, and represents a natural target for the modulation of energy expenditure. we evaluated the correlation of bat activity and active volume as detectable on fdg-pet/ct scans with abdominal body fat composition and liver fat estimation. methods and materials: fdg-pet/ct examinations in individual patients were screened for bat, resulting in patients and controls for subsequent analysis, matched for exam date and therefore ambient temperature, age, and gender. in addition to bat volume and activity, an automated segmentation was used to determine visceral fat and subcutaneous fat as well as lean tissue in the abdomen. liver fat was estimated in patients with non-contrast-enhanced ct. spearman rank correlation between parameters and a multi-variate model for liver fat excluding influencing parameters was calculated. results: bat volume and activity showed a significant inverse correlation with total adipose tissue (activity p < . /volume p= . ) and visceral adipose tissue in studies, which were mainly underpowered and of heterogeneous study design, different parameters were studied. most frequently studied parameters were tumour diameter or volume, ktrans, kep, ve, and apparent diffusion coefficient (adc). other parameters were analysed in only two or less studies. tumour diameter, volume, and kinetic parameters did not show any pretreatment differences between responders and non-responders. in two studies, pretreatment differences in adc were observed between study groups. at early response monitoring significant and non-significant changes for all parameters were observed for most of the imaging parameters. conclusion: evidence on distinguishing responders and non-responders to neoadjuvant chemotherapy using pretreatment mri, as well as using mri for early response monitoring, is weak and based on underpowered study results and heterogeneous study design. thus, the value of breast mri for response evaluation has not yet been established. s a c d e f g bfriday the role of magnetic resonance imaging in assessing residual disease and pathologic complete response in breast cancer patients receiving neoadjuvant chemotherapy: a systematic review r. prevos , m. smidt , v. gadovist®) was injected intravenously at a dose of . mmol/kg bw and six dynamic t w gre sequences (vibe) were collected. the contrast kinetics of all malignant lesions were analysed quantitatively on a pixel by pixel basis using a computer-aided detection system (icad). the signal enhancement pattern was coded by three colour intensities and three colour hues. pharmacokinetic changes were analysed based on the tofts model including vascular permeability and extracellular volume fraction. results: in comparison to the baseline mri, follow-up examinations showed a significant tumour size reduction of % on average. a decrease of colour hues and colour intensities demonstrated significant changes in contrast kinetics. vascular permeability revealed a statistically significant decrease (p < . ). however, extracellular volume fraction changes revealed only a slight decrease under chemotherapy (mean decline of %). the cad analysis provides a reliable evaluation of tumour size, contrast kinetics, vascular permeability and extracellular volume fraction within a reasonable time. this form of cad analysis provides a fast and reliable assessment of early treatment response, enabling a fast modulation of therapy for non-responders. purpose: to assess the use of recist, mrecist and volumetric measurements in patients with invasive ductal carcinoma (idc) with initially marked necrosis on neoadjuvant chemotherapy (nact). in prospective analysis of patients, patients were selected based on marked intralesional necrosis and examined times on mri: before the beginning, after the nd cycle and upon completion of nact (anthracycline/taxane-based regimen). the lesions were measured in axial plane according to recist and mrecist. the volumes of the entire lesion and of the viable tissue were computed. results: the longest diameters measured according to recist and mrecist and the appropriate volumes were significantly different initially, after the nd cycle and upon the completion of nact (p < . for all). the size of the lesions was significantly different with/without the necrotic areas. differences in tumour diameter and volume change (delta; %) between recist and mrecist were not significant after the nd cycle and upon completion of nact (p> . for both). according to either recist or mrecist, including the volume measurements, the same number of patients were classified in the same response category, i.e., early response -pr ( . %); late response -pr ( . %). conclusion: to our knowledge, this is the first trial testing the use of mrecist in extrahepatic setting. there was no significant difference in changes of diameters or the corresponding volumes according to recist vs. mrecist. further research in larger groups needs to assess the use of the tools in the follow-up of new nact protocols. purpose: to assess the potential value of fibrosis quantification using t mapping in hypertrophic cardiomyopathy (hcm) in comparison to late contrast enhancement imaging, circumferential strain and lv thickness. methods and materials: seventeen patients with hcm, and controls subjects were prospectively included. all patients underwent cardiac mr with the following sequences: ) cine sequence, ) tagging sequence cspamm tr/te= . ms/ . ms; matrix , fov , temporal resolution . ms, distance between tag: mm, short axis. ) molli sequence (tr/te= . ms/ . ms; matrix - , thickness: mm) acquired before and , , min after gadolinium injection (dotarem, . mmol/kg). ) late gadolinium enhanced sequence min after injection. t values were assessed in blood and in the segments of the mid-lv slice. statistical analysis were performed for patients and for segments with (+) and without (-) enhancement on lge. r , Δr , Δr ratio were calculated (partition coefficient of gd, λ). results: in hcm, λ was significantly different between patient with ( . ± . ) and without ( . ± . ) enhancement on lge (p < . ). no significant difference was measured in λ value between control and hcm without delayed enhancement (p= . ). we did not found any correlation between lambda and circumferential strain (r= . ; ci (- . ; . ); p= . ). on the other hand, we found a significant correlation between lv wall thickness and circumferential strain ( . ; ci ( . ; . ); p < . ). in hcm, fibrosis is a focal process. in our study, there were no correlation between the presence of fibrosis and circumferential strain, but we found a significant correlation between lv wall thickness and circumferential strain. purpose: there is no consensus on surveillance strategies of reconstructed breasts after breast cancer, and it is routinely based on clinical examination alone. this study aims to assess the incidence and radiological presentation of breast cancer recurrences after deep inferior epigastric perforator (diep) flap reconstruction for women with a history of breast cancer. methods and materials: consecutive women who underwent diep flap reconstruction after breast cancer from to were included in this retrospective study. all had annual screening for recurrence and we reviewed their follow-up records in our institution. the date and site of recurrences -ipsilateral or controlateral to the reconstructed breast, regional and metastatic disease -were retrieved. clinical and radiological presentations -on mammography, ultrasound, and mri -were further analysed. results: of patients presented relapses, with a mean delay of . years (sd= . ) after diep reconstruction; ( %) were ipsilateral, while ( %) were controlateral and ( %) metastatic. ipsilateral recurrences had a tendency to occur earlier ( . years, sd= . , p= . ) and presented at a clinically patent stage. purpose: to assess the potential value of segmental quantification of myocardial fibrosis using t mapping in dilated cardiomyopathy (dcm) in comparison to late contrast enhancement imaging and circumferential strain. methods and materials: seventeen patients with dcm, and controls subjects were prospectively included. all patients underwent cardiac mr with the following sequences (parameters set according to recommendation of the scmr): ) cine sequence, ) tagging sequence cspamm tr/te= . ms/ . ms; matrix , fov , temporal resolution . ms, distance between tag: mm, short axis. ) molli sequence (tr/te= . ms/ . ms; matrix - , thickness: mm) acquired before and , , min after gadolinium injection (dotarem, . mmol/kg). ) late gadolinium enhanced sequence min after injection. t values were assessed in blood and in the segments of the mid-lv slice. statistical analysis were performed for patients and for segments with (+) and without (-) enhancement on lge. r , Δr , Δr ratio were calculated (partition coefficient of gd, λ). results: in dcm, λ was not significantly different between patient without ( . ± . ) and with at least one segment showing enhancement on lge ( . ± . ; p= . ). in all dcm, λ was significantly higher compared with the value obtained in control subject (p < . ). we found a significant correlation λ and circumferential strain in each segment (r= . ; ci ( . ; . ); p < . ), and between λ and lvef (r= - . ; ci (- . ;- . ); p < . ). conclusion: in dcm, fibrosis was a diffuse process involving all the myocardium. there was a correlation between the quantity of fibrosis, circumferential strain and lvef. . ). the correlation between us and cmr end-dyastolic and stroke volume indexes was significant but with a very low coefficient, while the correlation for the ejection fraction was acceptable. the icc was unsatisfactory for all volumes and good for the ejection fraction. the widest bland altman plot range was found for the end-diastolic volume index. in conclusion, metrics of lv volume index and function showed significant systematic inter-modality differences. in particular, the us volumes were systematically underestimated. this suggests that serial measurements of volumes and function in ti should be performed using the same method and, if available, the more reproducible cmr technique. author disclosures: c. tudisca: research/grant support; the miot project receives "no-profit support" from industrial sponsorships (chiesi farmaceutici s.p.a., apopharma inc. and bayer-shering). this study was also supported by: "ministero della salute". . obtained min after injection of . mmol/kg of gadolinium. lge was quantified automatically and defined as area of myocardium with signal intensity sd above the mean signal of remote myocardium. indexed end-diastolic left ventricular mass (iedlv mass) was assessed and lge extension was defined as percentage of total iedlv myocardium mass. patients were followed prospectively for a mean of . ± . months, during which period occurrence of vt and icds were recorded. purpose: noncompaction of the left ventricle myocardium (lvnc) is a rare cardiomyopathy characterised by multiple and excessive trabeculations, deep intertrabecular recesses and thickened ventricular myocardium. this condition is considered mostly congenital but acquired forms have also been described. aim of the present study is to assess lvnc prevalence in β-thalassaemia patients and its potential association with cardiac siderosis methods and materials: transfusion-dependent patients with β-thalassaemia ( major and intermedia, mean age . ± . years, mean bsa . ± . kg/m ) presenting for cardiac and abdominal iron assessment by mri ( . t scanner, avanto, siemens-germany) were studied. cardiac iron overload was assessed by t * black-blood gradient-multiecho sequences; cardiac functional and morphological characteristics were evaluated using ssfp acquisitions. risk factors for lvnc were noted and none of the patients had neuromuscular or congenital heart disease. results: patients ( %) fulfilled the preassigned strict criteria for lvnc on cardiac mri. there were no statistically significant differences between patients with and without lvnc with respect to demographics, haemoglobin levels, splenectomy status, systemic, hepatic, and cardiac iron overload indices, iron chelation therapy. patients with lvnc showed a significant lower cardiac functional performance (ejection fraction; volumes impairment). conclusion: patients with β-thalassaemia have a higher prevalence of lvnc than normal individuals suggesting an underlying iron deposition mechanism to explain this condition in absence of conventional risk factors. these data seem to be crucial regarding an entity with adverse cardiac outcomes, especially in patients with β-thalassaemia where cardiac disease remains a primary cause of mortality. ranged from . mm to . mm (mean = . mm). involvement of internal carotid artery (n = , %) was more common than external carotid artery (n = , %). petrous segment of ica was the most commonly involved segment (n = , %), followed by cervical segment of ica (n = , %) and maxillary artery (n = , %). conclusion: carotid blowout syndrome following rt were more common in our study subjects with advanced t and n stage of npc, local recurrence and repeated rts. pseudoaneurysms were identified in most patients. ica involvement was more common and petrous segment of ica was the most commonly involved segment. of the patients with involvement of pns, one presented with orbital extension. nasopharyngeal and oropharyngeal involvement was seen in two cases. in cases ( %), the primary tumours seen as diffuse enhancing mucosal thickening. in five cases ( %), the primary tumours seen as an enhancing mass lesion. in one case ( %), the primary tumour was undetectable. bone destruction was noted only in cases ( %). conclusion: nasal-type nk/t-cell lymphomas of the sinonasal regions often presents with diffuse mucosal thickening rather than mass lesion. and they can mimic inflammatory disease such as sinusitis. radiologists should be familiar with these findings indicative of the possibility of nktl, and should perform a histopathologic confirmation to establish a diagnosis. results: a significant relationship between symptoms and morphological manifestations was found (disk displacement (p < . ), osteoarthritis (p < . ) and effusion (p = . )). in the group without reduction there were significant increases in the risk of experiencing symptoms (p = . ) in the group with reduction the risk was marginal (p = . ). significant correlation between age and osteoarthritis (p = . ) and age and effusion (p = . ) was found. there was no correlation between sex and morphological manifestations. significant increases in the risk of experiencing symptoms were found in the group with morphological manifestations (disk displacement (p = . ), osteoarthritis (p < . ) and effusion (p < . )). statistically marginal results were verified with multivariate analysis. conclusion: mri morphological manifestations of the tmj correlate with the presence of symptoms, therefore mri has a crucial role in the diagnosis of treatment of tmj dysfunction. purpose: to compare image quality of fbp, asir and veo reconstructed ct images of the neck in tumour patients with a contrast-enhanced scan. methods and materials: consecutive regular contrast-enhanced tumour staging ct-scans (discovery hd , ge; helical, . s, kv, - ma mod., ni ) of the neck were reconstructed using fbp, asir and veo; n= . image quality at three defined heights (lymph node levels=lnl , , ) were independently rated by radiologists blinded to the reconstruction algorithm. readers rated image quality including artefacts, contrast and noise using a semi-quantitative scale of to (lower than was defined as non-diagnostic) yielding a summary score for each height. wilcoxon´s test was used for statistical testing. icc was calculated. purpose: maxillary sinus pyocele is a true chronic abscess found in drugrefractory sinusitis. the purpose of this study is to define this new entity and its mri-characteristics. we retrospectively reviewed mri datasets for patients with "pseudotumoral sinusitis" on ct (including bilateral cases). the mri datasets were scored by two radiologists for morphological features, t and t -weighted signal intensities, contrast enhancement and the degree of impact on the sinus mucosa and the retromaxillary fat. these features were compared with per-operative findings. results: we observed a content presenting t low signal ( %), heterogeneous t low signal ( %), a capsule with contrast enhancement ( %) containing microabscesses ( %), a mass effect on the lateral nasal wall ( %) and retromaxillary fat stranding ( %). eighteen pyoceles were treated endoscopically, with confirmation of a maxillary sinus abscess in all cases. furthermore, we suggest a staging system for maxillary sinus pyocele. conclusion: maxillary sinus pyocele presents specific mri characteristics. this entity must be suspected on sinus ct scan and recognised on mri. surgical endoscopic sinus surgery is needed. these findings therefore merit further investigation. purpose: to compare mr imaging at . -and . -t in the same individuals for performance in the diagnosis of cartilage lesions of the knee. this prospective study was approved by our institutional review board, and informed consent was obtained from all patients. from december to february , mr examinations of the knee at both . -and . -t were performed in symptomatic patients ( men, mean age y, range - y) who underwent subsequent knee arthroscopy. three blinded independent readers graded all articular surfaces seen at mr using the noyes classification system. with arthroscopy as the reference standard, the sensitivity and specificity of the . -and . -t mr protocols for detecting cartilage lesions were calculated. differences between the . -and . -t exams were compared using bootstrapping statistics (p < . ). results: for all readers and grades of cartilage lesions combined, the respective sensitivity, specificity, and accuracy of mr for detecting cartilage lesions (n= ) were %, %, and %, respectively, at . -t and %, %, and %, respectively, at . -t. for detecting and correct grading of cartilage lesions, the readers performed significantly better with . -t than with . -t (p= . ). conclusion: a comprehensive mr protocol at . -t significantly improves diagnostic performance for evaluating the articular cartilage of the knee in symptomatic patients, when compared with a similar protocol performed at . -t. purpose: the purpose of this study is evaluation of correlation between relative signal intensity of mr images in retrodiscal tissue, superior and inferior heads of pterygoid muscle in tmd patients with types of anterior disc displacement and condylar flattening. in this cross-sectional study, mr images of patients who had anterior disc displacement were evaluated. after relative signal intensity measurement for retrodiscal tissue, superior and inferior head of lateral pterygoid muscle, the correlation between relative signal intensity and types of anterior disc displacement and also condylar flattening was evaluated. results: the correlation between relative signal intensity of mr images and type of anterior disc displacement in retrodiscal tissue (p-value= . ), superior head of lateral pterygoid muscle (p-value= . ) and inferior head of lateral pterygoid muscle (p-value= . ) was not significant. there was also no statistically significant correlation between relative signal intensity of mr images and flattening of condylar head in retrodiscal tissue (p-value= . ), superior head of lateral pterygoid muscle (p-value= . ) and inferior head of lateral pterygoid muscle (p-value= . ). we found that although mri is a non-invasive procedure in the diagnosis of tmd, probably relative signal intensity of mr images in retrodiscal tissue, superior and inferior head of pterygoid muscle is not a good predictor for type of anterior disc displacement and flattening of condylar head. it seems that this cannot be used as a diagnostic marker for tmd progression. high resolution d mr imaging of the temporomandibular joint: feasibility and comparison with d sequences u. navarro, m. ravanelli, d. farina, e. botturi, r. maroldi; brescia/it (navarrougo@gmail.com) purpose: to assess the feasibility of high-resolution d mr imaging of the temporomandibular joint (tmj) and to compare d and standard d techniques. methods and materials: ten volunteers underwent a tmj mr study with surface coils including a proton density (pd) fat-saturated d sequence "space" and d pd fat-saturated sequences acquired on parasagittal and paracoronal planes. twenty tmj were imaged and analysed. the contrast between articular disk (ad) and bilaminar zone signals was measured on parasagittal images and normalised by the ad signal. capability of d sequences to depict eight small anatomical structures of the tmj ( on parasagittal and on paracoronal plane) was assessed and compared to that of standard d sequences. results: contrast between bilaminar zone and ad in d and d sequences was . and . , respectively (p . ). fifty-eight out of structures assessed in parasagittal plane were detectable on d sequences, / on d sequences (p . ). among the structures assessed on paracoronal images, were recognised on d sequences, on d sequences (p . ). conclusion: high resolution d mr imaging of tmj is feasible with d pd fatsaturated space sequences. the detectability of anatomical structures, potentially key for joint functionality (ligaments) is enhanced in comparison to standard d sequences, especially on paracoronal plane. results: aea was identifiable in / on the axial plane, / on coronal and / on sagittal. in % of patients, the aea canal run inside the skull base (condition # ), in % of cases a pneumatised cell was interposed between the canal and the skull base (condition# ), % of the pneumatised cells above the aea canal were supraorbital cells, % supra-bullar recesses and % frontal sinuses. in these cases, the average distance between the aea canal and the skull base was . mm (range . in patients with kl grade - knee oa, dgemric was acquired at t using a d-spgr sequence before and months after ha treatment. to evaluate patient symptoms, the knee injury and osteoarthritis outcome score (koos) questionnaire was recorded at baseline and follow-up. we analysed matching anatomical rois in the medial and lateral knee compartment in both examinations, using the t relaxation times as a measure of cartilage quality. outcomes of dgemric and koos at baseline and follow-up were compared using paired testing to evaluate the symptomatic and potential structural effects of ha. results: outcomes of dgemric at follow-up (pooled median t ms) did not improve significantly compared to baseline (pooled median t ms) in any of the analysed anatomical cartilage rois. patient complaints improved significantly in koos subscales: pain, daily-, and sports activities. conclusion: using dgemric, no improvement in articular cartilage quality can be detected months after ha. however, patient complaints decreased significantly after ha. therefore, the results of this study suggest that the working mechanism of ha is not acting through an improvement of sgag content in the cartilage. purpose: to analyse the spatial resolution of different reconstruction kernels and acquisition protocols including a prototypic high-resolution protocol in flat-panel (fp) and multi-detector (md) ct to evaluate contrast and cartilage depiction quality of fpct and mdct arthrography. a cone-beam image quality phantom was used to compare resolution and different reconstruction kernels of standard mdct ( and kv), standard binned ( x ) and prototype high-resolution unbinned ( x ) fpct protocols ( s and s runs each). with the resulting fpct kernel best matching the standard mdct kernel (u u), joint phantoms with differently sized cartilage defects were scanned. ct numbers and noise in iodine contrast and phantom cartilage tissue were measured, and contrast-to-noise ratios (cnr) were calculated. depiction quality of cartilage defects was qualitatively rated by two independent radiologists. results: a sharp reconstruction kernel for all fpct protocols best matched the resolution of the standard mdct kernel. high-resolution s x binning fpct showed superior resolution in higher frequencies than . lp/mm. the cnr were highest in s fpct, followed by s fpct binned and mdct protocols. interreader agreement for depiction quality of cartilage defects was substantial and high in joint phantoms ( . and . , respectively; p < . ). the best ratings of cartilage defect depiction quality were seen in fpct s, followed by fpct s and mdct acquisitions. conclusion: fpct arthrography offers superior cnr and cartilage defect depiction quality to mdct, and spatial resolution for small structures is higher when applying high-resolution acquisition protocols. subjects with risk factors for oa (incidence cohort) and subjects from the control cohort. right knee t mris were analysed at baseline and months. coronal flash sequence was used to measure cartilage volume at baseline, multi-echo spinecho sequence to generate t maps at baseline and months. regression models were adjusted for age, gender and bmi and were applied to compartments (medial femur, lateral femur, medial tibia and lateral tibia). results: global t measurements increased in all cohorts over months. baseline t were significantly greater in the progression cohort compared to incidence and control cohort (p < . ), whereas -month follow-up data showed significantly greater measurements in the incidence cohort (p < . ). most pronounced t changes over time were observed in the incidence cohort (p < . ), changes in the progression cohort were not significant. mean volume did not significantly differ between the cohorts, but progression cohort subjects showed the highest volumes in all compartments. purpose: the goal of the study was to demonstrate the benefits of t mapping to the assessment of lumbar disc repair after the adct. methods and materials: patients, male and female, age range - , with a single-level degenerative disc disease (ddd) were studied. all patients had a standard lumbar microdiscetomy performed and - weeks after the surgery underwent the adct. prior to the surgery, one month later and , and months after the adct each patient had a mr examination on the . t mr scanner. patients completed a -month long follow-up protocol. t mapping revealed the level of ddd and the adjacent levels. the evaluation of signal intensity was carried out using pixel value software. results: each patient during the -month long follow-up reported a significant relief of pain: vas score ranged - , odi score - %. in the mr examination held after the adct, changes in signal intensity seen on t -weighted mr images were reported. t mapping showed signs of the disc repair regardless of the lack of changes in disc dimensions. mild increase of t with improved homogeneity of the structural morphology of the nucleus pulposus was observed on t after the adct. conclusion: t mapping may be used for evaluating the changes of the molecular composition and structural integrity of the intervertebral disc after the adct and other novel restorative therapies. it has also the potential to be valuable in the detection of the early degeneration in the intervertebral disc. purpose: to evaluate the feasibility of t * and t gd mapping to assess glenohumeral cartilage, and to establish baseline values of healthy glenohumeral cartilage at t. methods and materials: forty asymptomatic volunteers (mean age: . ± . years) without shoulder abnormality were included. the mri protocol comprised a three-dimensional ( d) double-echo steady-state (dess) sequence for morphological cartilage evaluation, a d gradient-echo (gre) multiecho sequence for t * assessment, and a dual-flip-angle d gre sequence for t gd mapping. statistical assessment involved descriptive statistics establishing mean t * and t gd values ± standard deviation and the one-way analysis of variance (anova) to identify any significant differences between the t * and t gd values of various regions of the glenohumeral joint. intra-class correlation (icc) analysis comparing repetitive t * and t gd measures of ten randomly selected individuals was used to assess intra-and inter-observer reliability. purpose: to evaluate the efficacy of the treatment of uterine adenomyosis using magnetic resonance imaging-guided focused ultrasounds (mrgfus) with a new specific technical plan. twenty-four patients aged between and years (mean age . ), with symptomatic adenomyosis and uterine fibroids were treated with mrgfus in our department, from october to july . this study evaluates the findings on patients affected by adenomyosis alone. symptomatology was assessed through the symptom severity score questionnaire. one single treatment was performed with an average energy delivered to each patient equal to j (with a minimum value of j and maximum of j). the longest treatment duration was minutes. the plan employed was characterised by high density and reduced size of the spot length (ranging from to mm) with the shortest cooling time between the sonifications. results: the evaluation of the non-perfused volume on the c.e. t -weighed sequences performed weeks after treatment, measuring each single slice, showed a maximum retraction of the necrotic area of % and a minimum of % with a mean value of . %. after six weeks, the symptomatic score showed a reduction of about % if compared to the pre-treatment one. the treatment with mrgfus allows a resolution of the symptoms and a reduction of the treated area, maintaining the integrity of the uterus, in a pathology which, up to now, has limited therapeutic perspectives. is uterine artery embolisation in large sized myoma as efficient as in normal sized myoma: a retrospective comparative study in patients h. choi , g. jeon , m. kim , j. lee , j. yoon , s. hwang ; seongnam/kr, seoul/kr (piscean @hanmail.net) purpose: the purpose of this study was to evaluate the effectiveness, safety and complications of uterine fibroid embolisation (ufe) when applied to myomas of large volume. a total of retrospectively collected patients who underwent ufe for symptomatic uterine fibroids without adenomyosis between january and february were included in this study. patients were divided into two groups: patients were selected with large fibroid burden group, defined as a dominant fibroid with a longest axis ³ cm or a uterine volume of ³ cm and remaining patients with control group. fibroid infarction and volume reduction with mri, complications and patients' satisfaction score were evaluated. results: the large fibroid group consisted of (mean age . ± . ) women and (mean age . ± . ) women included in control group. there were no statistical difference in average % volume reductions of dominant fibroid as % in large group and . % in control group, the mean satisfaction score at immediate follow-up (average . months) and mid-term follow-up (average . months) and procedure related complications or major surgery following ufe. conclusion: uterine fibroid embolisation is a safe and effective treatment method which can be utilised in the treatment of myomas of large volume. the size of myoma is not a definite contraindication or poor prognosis factor for embolisation. : leiomyomas in women (average age . years) were treated with mri-guided focused ultrasound (mrgfus). the treatment is carried out using the ablative properties of the hifu system under t mri guide. symptoms were scored using severity score (ss) and quality of life was determined using the ufs-qol score. pre-treatment measurements of leiomyoma volume were obtained by mr images. after treatment, non-perfused volume (npv) was calculated from t -w contrast-enhanced mr sequences. the average volume of treated fibroids was . ± . mm . follow-up images were obtained , and months after treatment and served to determine leiomyoma shrinkage. qualitative and quantitative relations between fibroid volume, npv ratio at treatment, and -month shrinkage were measured. results: mrgfus treated patients demonstrated a significant change in usf-qol score: mean ss score values were . ± . (pre-treatment), . ± . (threemonths follow-up), . ± . (six-months follow-up) and . ± . (twelve-months follow-up). fibroids volume changed from . ± . mm (before treatment) to ± . mm (at months follow-up). we encountered a statistically significant difference between the two values (p = . ). mean post-treatment vnp was . ± . mm , about % of total fibroid volume (p= . ). conclusion: mrgfus therapy of leyomioma results in a significant relief of symptoms and greater than % total fibroid ablation. the procedure is carried out in a totally non-invasive manner and features a high-safety profile. results: mri-guided focused ultrasound treatment was technically successful in of patients ( . %). in patients treatment was not possible due to bowel loops in the beam pathway that could not be mitigated (n= ), patient movement (n= ) and system malfunction (n= ). average non-perfused volume ratio was ± % (range, to ). mean applied energy level was ± j, and mean number of sonications was ± . no major complications occurred. two cases of first degree skin burn resolved within one week after the intervention. of the baseline characteristics analysed, only the planned treatment volume had a statistically significant impact on the non-perfused volume ratio. purpose: placenta percreta (pp) is a recognised cause of severe postpartum haemorrhage, with high risk of blood transfusions and emergency hysterectomy with maternal morbility and mortality. our purpose is to evaluate the role of bilateral occlusion balloon catheter insertion in to both internal iliac arteries (iia) before elective caesarean to prevent haemorrhage and to preserve the uterus. this is one of the longest cohort of women treated with prophylactic balloon occlusion and prevents caesarean hysterectomy in abnormal placentation. methods and materials: twenty-two pregnant women who were identified as having a pp by us were treated prophylactically with bilateral occlusion balloon catheters placed in the anterior trunk of both iia prior to elective caesarean. the balloons were inflated immediately after the baby delivery and deflated four hours later. patients with peri-operative bleeding were treated with uterine artery embolisation (uae), blood transfusion or hysterectomy. for each patient, estimated volume of blood lost and transfusion required was recorded. results: abnormal placentation was confirmed histologically as percreta ( ), acreta ( ) and increta ( ). estimated median blood lost during the delivery was noted . l (range . - l). postpartum haemorrhage occurred in nine patients, six had successful embolisation and three required hysterectomy. no foetal or mother death occurred. conclusion: prophylactic occlusion balloon catheter insertion in both iia prior to elective caesarean deliveries in patients with abnormal placenta contributes to successful treatment, reduced blood lost and preserved the uterus in this high risk group of women. results: a total of transcatheter embolisation procedures of bilateral uterine arteries with or without extra-uterine feeding arteries were performed as the firstline treatment, and with a technical success rate of % ( / ). embolisation was incomplete in two patients who had an extra-uterine blood supply or a dominant draining vein; the former recovered from menorrhagia during our close observation, while the latter underwent a successful second embolisation procedure. clinical success was achieved in the remaining eight patients after a single procedure and there was no recurrence of bleeding. only one minor complication occurred: rupture of the proximal ua. recovery to their normal menstrual cycle was seen in all eight of the clinically successful patients, one of whom subsequently had an uneventful intrauterine pregnancy carried to term. . years ± . years) underwent a pre-therapeutic fdg-pet/ct scan and a fdg-pet/ct after the second cycle of nact. histopathology served as the reference standard. suvmax of cancer lesions before and after the second cycle of nact were measured. two evaluation algorithms were used: (a) pcr: sinn score and , npcr: sinn score - ; (b) pcr: sinn score , npcr: sinn score - . the absolute and relative decline of the suvmax (Δsuvmax, Δsuvmax (%))was calculated. differences of the suvmax and of the suvmax decline between pcr and npcr lesions were tested for statistical significance (p <. ). to identify the optimal cut-off value of Δsuvmax (%) to differentiate between pcr lesions and npcr lesions a receiver operating curve (roc) analysis was performed. results: using evaluation algorithm a the Δsuvmax was . (pcr group) and . (npcr group) (p = . ); the Δsuvmax (%) was % and %, respectively (p = . ). on roc analysis an optimal cut-off Δsuvmax (%) of % was found. using evaluation algorithm b the Δsuvmax was . (pcr group) and . (npcr group) (p = . ); the Δsuvmax (%) was % and %, respectively (p = . ). on roc analysis an optimal cut-off Δsuvmax (%) of % was found. conclusion: fdg-pet/ct early differentiates between pcr and npcr after two cycles of nact. in our study we prospectively enrolled consecutive patients (m:f= : , mean age years) affected by hcc: patients at presentation and at restaging. in all cases we performed a whole body cho-pet and compared findings with referring ct (n= ) and/or mri scanning (n= ), for a total of paired scans. the reference standard for validating imaging results was either histology ( patients), or a multidisciplinary work-up. for every modality we determined diagnostic accuracy on a scan-based and on a site-based analysis. results: on a scan-based analysis cho-pet and ct/mri demonstrated an accuracy of . % and %, respectively, whereas on a site-based analysis the two modalities demonstrated a sensitivity and accuracy, respectively, of . % and . % for pet, and . % and % for ct/mri. in both analyses, no statistically significant difference was found on t-test. in / patients, hcc showed either loco-regional involvement (n= ) or distant metastases (n= ). all extra-hepatic lesions were properly detected by cho-pet (accuracy %), whereas ct/mri missed a large part of them (accuracy . %) and this most likely due to the limited field of view during acquisition. in cases ( . %), pet information determined a change in treatment planning. conclusion: according to our findings, cho-pet has a comparable accuracy with ct/mri in hcc. the principle advantage of the modality appears its ability to detect extra-hepatic lesions, which can lead to treatment modification. furthermore, in-/opposed-phase sequence (dixon) used for attenuation correction in mr/pet were evaluated. in all images, the diagnostic confidence in identification of nodules was rated on a -point scale ( =certain; =uncertain). additionally, the involvement of each lung lobe (primary/metastatic) was assessed. ct scan in inspiration served as reference. the diagnostic performance of each modality was compared in a lesion-and lobe-based analysis. the diagnostic confidence was compared using wilcoxon test. results: lung nodules were evaluated. in the lesion-based analysis, sensitivity (false negative rate) of ctex, vibein, vibeex and dixon was % ( %), % ( %), % ( %) and % ( %). in the lobe-based analysis reflecting the clinical assessment, sensitivity (false negative rate) was % ( %), % ( %), % ( %) and % ( %), respectively. in ct and mri diagnostic confidence was rated higher in inspiration (mean score ctin/ctex . purpose: to evaluate the relationship between quantitative ct-perfusion parameters and tumour volume with glucose metabolism parameters, in staging of lung cancer patients with fdg pet/ct whole body study. methods and materials: thirty-one patients with biopsy-proven lung cancer, referred for cepet/ct staging, were prospectively enrolled in our study. ctp was performed with following parameters: kv; mas; scan , during intravenous injection of ml of contrast-agent, flow rate: ml/sec. ctp and cepet/ct data were used to calculate a range of tumour vascularity parameters (blood flow, blood volume and mean transit time) and tumour glucose uptake (suvmax), and finally correlated with tumour volume using a commercially available software. four patients were excluded due to the advanced stage of the tumour. ct perfusion parameters were then statistically analysed and compared with those of fdg-pet. results: perfusion parameters were calculated with a dedicated software (perfusion . ; advantage; ge) and a quantitative map of arterial perfusion was generated. patients were divided into two groups according to tumour volume, with a cut-off of cm . linear regression was performed among two groups and statistically significant correlations (p < . ) were found between bf and suvmax (negative correlation) and between mtt and suvmax (positive correlation) for tumours with volume > cm . these findings may be due to the inadequate blood inflow typical of larger tumours, with a significant increase of anaerobic metabolism and glucose consumption. conclusion: cepet/ct perfusion is a feasible technique that offers informations related to the biological tumour behaviour that can be used for planning treatment and for an accurate evaluation of tumour response after therapy. retention as pib positive (pib+) or pib negative (pib-). data of the unidirectional influx k_ from a subset of ad patients and controls were used for correlative analysis. data were analysed using regions of interest (roi) analysis. results: we found a strong, positive correlation across brain regions between k_ and epib (r= . ; p < . ). epib values were significantly lower in posterior cingulate (p < . ) and parietal cortices (p= . ) in pib+ subjects compared with pib-although the group difference were stronger for rcmrglc in cortical areas (p < . ). strong positive correlations between epib and rcmrglc were observed in all cortical regions analysed, especially posterior cingulate and parietal cortices (p < . ). this study suggests that a single dynamic pib-pet scan may provide clinical estimates of pathological (amyloidosis) and functional changes (impaired blood flow) in ad. this dual information might be valuable both in early diagnosis of ad and evaluation of treatment strategies, but our results emphasise the need for further research. purpose: to assess the diagnostic accuracy of diffusion kurtosis imaging (dki), dynamic susceptibility-weighted imaging (dsc) and short echo time chemical shift imaging (csi) for grading gliomas, as separate techniques and in a multimodal approach in order to determine the best discriminative parameter (s). methods and materials: patients with cerebral gliomas ( f/ m; age range: - , median age: ) underwent dki, dsc and csi on a t mr scanner. diffusion parameters: mean diffusivity (md), fractional anisotropy (fa), mean kurtosis (mk); perfusion parameters: mean relative regional cerebral blood volume (mean rrcbv), mean relative regional cerebral blood flow (mean rrcbf), mean transit time (mtt) and relative decrease ratio (rdr), and twelve csi metabolite ratios were compared between high-grade gliomas and low-grade gliomas (mann-whitey-u, p < . significance, bonferroni corrected). sensitivity, specificity, diagnostic accuracy and optimal thresholds were determined for the techniques separately and combined. results: mk, md, mean rrcbv, mean rrcbf, rdr, lips/cho, lips/cre, myo/sum and cre/sum showed statistically significant differences among tumour grades, with mean rrcbf as the best discriminative parameter. the combination of mean rrcbf, mk and myo/sum to grade gliomas showed diagnostic accuracy, sensitivity and specificity of %, whereas combining mean rrcbv, md and lips/cho gave a diagnostic accuracy, sensitivity and specificity of %, % and %, respectively. conclusion: combining the parameters mean rrcbf, mk and myo/sum to determine the glioma grade was pathognomonic in this study. the best performing parameters, when used individually, were found to be mk and mean rrcbf. additive value of arterial spin labeling in differentiating primary central nervous system lymphoma from glioblastoma multiforme: an observer performance study k. yamashita, t. yoshiura, a. hiwatashi, o. togao, k. kikuchi, k. yoshimoto, h. honda; fukuoka/jp (yamakou@radiol.med.kyushu-u.ac.jp) purpose: to determine whether asl has an additive diagnostic value to the conventional mr images in differentiating primary central nervous system lymphomas (pcnsls) from glioblastoma multiformes (gbms). methods and materials: mr images of patients including with pcnsl and with gbm were retrospectively studied. two independent neuroradiologists took part in reading sessions. in the first session, the observers read only conventional mr images (t -weighted image, t -weighted images, post-contrast images, and dwi with apparent diffusion coefficient maps). in the second session, they read asl cerebral blood flow (cbf) maps along with the conventional images. the confidence level for the diagnosis (pcnsl versus gbm) was graded on a -point scale. interobserver agreement as well as sensitivity, specificity, accuracy, positive predictive value (ppv), and negative predictive value (npv) were assessed for the two readers. purpose: organ-based tube-current modulation (obtcm) is a technique developed to lower ct radiation dose to anterior dose-sensitive organs. this irb-approved observational study aimed to establish the location of breast tissue in a female patient in supine position with arms raised over their shoulders. a secondary purpose was to look for possible thresholds of chest diameter and woman's age below or above which the breasts lie in a central location with subsequent possible benefit from obtcm. methods and materials: informed consent was obtained in consecutive women included. from standard chest ct acquisitions, one / mm image set with fov of mm and x and y coordinates at were obtained. from the gantry rotation centre (x=y= ), the outer and inner angles limiting the breast tissue were measured and compared to the angles ( °), where obtcm delivers lowered and increased dose to the organs. results: outer angles of breast tissue were < ° for one breast in only two patients. inner breast angles were > ° in / patients for at least one breast. no threshold of chest diameter or age was found to predict a central enough location of the breast for obtcm to be beneficial. conclusion: our data show that the angular position of breast tissue is higher than the limit where reduced versus increased radiation dose is delivered in obtcm. this system should therefore not be applied to ct chest examinations in adult women lying supine. purpose: to evaluate the effect of an organ-based tube-current modulation (obtcm) and bismuth shielding on image quality and breast radiation dose in women undergoing low-dose chest ct. methods and materials: low-dose chest ct was obtained from women, who were randomly assigned to a control, obtcm, breast shield, or breast shield plus obtcm group. axial slice images from aortic arch, carina, and inferior pulmonary vein were used to analyse image quality. three radiologists scored the image quality in terms of artefact and noise, and then designated the overall image quality as optimal (does not affect the diagnostic accuracy) or suboptimal (affects the diagnostic accuracy). noise levels were measured in the anterior and posterior lung in each image. a phantom dose study was conducted to measure the radiation dose. results: images with artefacts or noise were more frequently obtained in the breast shielded groups. the overall image quality was not significantly different among the four groups. measured noise levels in the anterior lung were significantly higher in the breast shielded groups than the control group; however, no statistical significance was found among the four groups in the posterior lung. in the phantom dose study, a - . % dose reduction in the breast was achieved using the breast shield and/or obtcm protocol. the radiation dose in the female breast may be reduced using the breast shield or obtcm during low-dose chest ct with acceptable image quality. the obtcm reduced the radiation dose in the breast without inducing image quality deterioration. the solid parts of gliomas and compared between high-and low-grade gliomas. all the parameters were also normalised to the corresponding values in contralateral normal appearing white matter (nawm) and compared between high-and lowgrade gliomas. a receiver operating characteristic (roc) analysis was performed for statistical analysis. results: there were significant differences in adcfast and adcslow values between high-and low-grade gliomas (p < . ). the α value was significantly lower in high-grade gliomas than that in low-grade gliomas (p < . ). in addition, the adcfast, adcslow and α values that were normalised to the values in the contralateral nawm were all significantly different between high-grade and low-grade gliomas (p < . ). conclusion: ivim imaging with biexponential and stretched-exponential model is a useful tool in grading cerebral gliomas. the α value may be the best parameter for distinguishing high-from low-grade cerebral gliomas. purpose: this study aimed to determine which combination of acquisition and iterative reconstruction parameters for low-dose mdct at low tube voltages yields image quality and diagnostic confidence equivalent to current clinical standards in thoracic imaging. methods and materials: thoracic images of eight sedated and mechanically ventilated pigs were acquired with mdct during mid-inspiratory breath hold using standard ( kvp, mas) and low-dose protocols at low tube voltages ( / kvp) and current-time products ( / / mas). using lung and soft-tissue kernels, images of all acquisitions were reconstructed with filtered backprojection (fbp); low-dose acquisitions were also reconstructed iteratively (levels and , idose, philips healthcare). three independent blinded readers sorted the resulting image data sets per animal according to diagnostic image quality (best to worst), and sorted images were statistically clustered. additionally, ct numbers and noise have been determined in lung parenchyma, liver, muscle and aorta of all image data sets. results: interreader-agreement was moderate-high (κ= . - . ). for any fixed set of acquisition parameters fbp-images were ranked lowest while those reconstructed iteratively (idose ) were ranked highest independent of reconstruction kernel. the image series could be clustered into homogeneous clusters of equivalent diagnostic quality: iteratively reconstructed images acquired at kvp/ mas (idose / ), kvp/ mas (idose ) or kvp/ mas (idose ) were ranked equivalent to fbp-images acquired using standard protocol. iterative reconstruction did only affect ct numbers at very low dose ( kvp/ mas) while image noise could be reduced by up to ~ %. conclusion: using low-kvp and low-mas protocols combined with iterative image reconstruction, radiation exposure of thoracic mdct could be reduced by - %. purpose: to determine utility of adaptive iterative dose reduction using threedimensional processing (aidr d) for pulmonary nodule identification on low-dose -detector-row ct using different scanning methods in phantom study. a chest ct phantom including simulated pulmonary nodule was scanned on a -detector-row ct using non-helical wide volume scan (wvs) and helical scans as -detector-row ct ( hs) and -detector-row ct ( hs) at nine different tube currents. all data sets were reconstructed using aidr d and filter back projection (fbp). to determine the capability of overall identification, two chest radiologists independently evaluated lesion conspicuities by five-point scoring system. at the each scanning method, gold standard was defined as the data set of standard tube current ( ma) reconstructed by fbp. interobserver agreements of detection and the capability for radiation dose reduction on each scan method were assessed by kappa statistics and roc analyses. results: interobserver agreements were almost perfect or substantial at all data sets (κ> . ). when applied aidr d, area under the curves of data sets equal to or higher than ma on wvs, ma on hs, and ma on hs had no significant difference with standard data sets (p> . ). on the other hand, when applied fbp, radiation dose reduction was limited in comparison with the data sets applied aidr d at all scanning methods. conclusion: aidr d was more useful for low-dose chest ct examination for nodule screening than fbp, and wvs can reduce more radiation dose than hs and hs on -detector-row ct. methods and materials: ctpa studies planned with frontal topogram only (protocol ) were compared with ctpa studies planned with frontal and lateral topograms (protocol ).optimal scan length was defined from lung apex to lung base. excess scan length beyond these landmarks was measured. mean organ doses to thyroid, liver and stomach were estimated using standard conversion factors. results: the mean excess scan length was significantly lower in protocol compared with protocol ( . ± . mm vs . ± . mm,p < . ). the mean excess scan length below lung bases was significantly lower in protocol cohort compared with protocol ( . ± . mm vs . ± . mm,p < . ), as were the mean organ doses to stomach ( . ± . mgy vs . ± . mgy,p < . ) and liver ( . ± . mgy vs . ± . mgy,p < . ).a trend towards reduced over-scanning above the apices in protocol was observed compared with protocol ( . ± . mm vs . ± . mm,p= . ), with a trend towards lower mean thyroid organ dose in ( purpose: volumetric measurement of a nodule is more sensitive in the detection of tumour growth than axial diameter measurement. the purpose of this study was to assess the accuracy of lung nodule volumetry using adaptive iterative dose reduction (aidr) d in comparison with filtered back-projection (fbp) in an anthropomorphic thoracic phantom on -detector row ct. conclusion: pulmonary haemorrhage during fine-needle lung biopsy is a frequent event. it protects against pneumothorax in patients with pre-existing comorbidities, especially for long needle trajectory, for bleeding greater than mm developing along the needle track. feasibility and safety of ct-guided percutaneous radiofrequency, microwave or cryoablation of the pulmonary and mediastinal unresectable tumours adjacent to the heart and large vessels c. pusceddu, l. melis, g. meloni; cagliari/it (clapusceddu@gmail.com) purpose: to verify the feasibility and safety of radiofrequency ablation (rfa), microwave ablation (mwa) and cryoablation (cra) under ct guidance in the treatment of cancer adjacent to the heart and large vessels. methods and materials: patients (mean age of years) with unresectable primary and secondary pulmonary and mediastinal tumours ( nsclc, invasive thymoma, mesothelial sarcoma and metastases) were treated by ct-guided rfa ( cases), mwa ( cases) and cra ( cases). all the tumours were in contact or distant from the large vessel wall or the pericardium less than cm. all ablations were performed under conscious sedation and local anaesthesia. vital signs of the patients were non-invasively monitored continuously. the therapeutic outcomes were evaluated by contrast-enhanced ct after month. in two patients, an electrode is penetrated in the pericardium without any consequences. results: in all cases, the procedure was technically successful. no intraprocedural arrhythmia occurred. morbidity consisted of cases of pneumothorax, cases of pleural effusion and case of asymptomatic thickening of the pericardium. in the ct control after month, there was a complete necrosis in cases and a partial (from to %) necrosis in the remaining cases. conclusion: indifferently from the energy source used to obtain the tumour necrosis, the treatment of the pulmonary and mediastinal unresectable tumours adjacent to the heart and large vessels is feasible and safe because the blood flow cause a "heat-sink" effect adjacent to such structures that prevent undesired thermal damage. factors influencing local tumour control in patients with neoplastic pulmonary nodules treated with microwave ablation ( were placed in lateral position with the biopsy side down (group b). statistical analysis was performed comparing pneumothorax rate between the two groups. the rate of pneumothorax requiring intervention was also assessed. the effect of other variables (patients demographic characteristics, lesion characteristics, lesion distance from the skin and biopsy technique) was evaluated in both groups. results: pneumothorax occurred in group a ( . %) versus ( . %) in group b (p= . ). pneumothorax requiring treatment was noticed in cases ( . %) in group a, versus ( %) in group b. emphysema and lesion size were independent risk factors for pneumothorax in group a. emphysema was also independent risk factor for pneumothorax necessitating a drainage catheter insertion in group a. no independent risk factor was recognised for pneumothorax or pneumothorax requiring intervention in group. purpose: the aim of this study was to evaluate the feasibility of percutaneous transthoracic needle biopsy of pulmonary nodules under xperguide cbct navigation guidance. between february to july , we evaluated patients with a pulmonary lesion. all patients had a diagnostic conventional chest ct and after underwent percutaneous transthoracic needle biopsies of pulmonary nodules under xperguide cbct navigation guidance.the mean size of the lesion was on average . cm. immediately after fnab an additional cbct was performed to evaluate any complications; moreover, a follow-up expiratory chest radiograph was obtained. calculation of radiation dose of the procedure and statistical analysis were performed. results: technical success rate was achieved in % of cases. forty-six lesions were diagnosed as malignant, were benign, and were indeterminate. all malignancies diagnosed by fnab were confirmed by history and imaging. the overall accuracy, sensitivity, specificity, positive predictive value and negative predictive value were . %, %, %, % and %, respectively. in the patients with a lesion equal or less to cm undergoing xperct-guided lung biopsy the average effective dose was . msv (range . purpose: this study aimed at reviewing the results and the safety of embolisation in patients affected by haemoptysis of pulmonary arterial (pa) origin. all consecutively patients treated for haemoptysis of pa origin during years ( to ) were reviewed. age, underlying disease, and haemoptysis volume were recorded. ct-scan and pulmonary angiography of each patient were reviewed for the description of the pa lesion (aneurysm, false aneurysm, irregularity of the pa or abrupt interruption) and the material of embolisation used for the treatment. results: forty-three patients ( women, men; mean age: years) were treated during this period. aetiologies were tuberculosis (n= ), lung cancer (n= ), necrotizing pneumonitis (n= ), aspergillosis (n= ), behcet disease (n= ) and others (n= ). five abnormalities of pa were found: pseudo aneurysm of the pa (papa) (n= ), aneurysm of the pa (apa) (n= ), irregularity of pa (n= ), early interruption of pa (n= ), one pavm, and no abnormalities in patients. materials used for embolisation were coils (n= ), onyx (n= ) and covered stent (n= ). two early recurrences, short-term recurrences, and one long term recurrence after embolisation were recorded. they were treated by surgery (n= ) percutaneous microwave ablation of lung tumours c. pusceddu, l. melis, g. meloni; cagliari/ it (clapusceddu@gmail.com) purpose: to assess the feasibility and safety of percutaneous ct-guided lung tumour microwave ablation. methods and materials: consecutive patients ( men, women, mean age years) underwent ct-guided percutaneous microwave ablation (mwa) of unresectable lung tumours ( primary nsclc and metastases) mean size . cm ( . - cm). the study cohort was selected according to the following criteria: ) maximum tumour size less than cm in diameter, ) less than metastatic tumors, ) patients with a normal coagulation status and ) provision of written informed consent. all procedures were performed with ct guidance under conscious sedation and local anesthesia. one or two straight microwave antenna ( or -gauge) were placed directly into the tumour for - minutes. follow-up included contrast-enhanced ct at , , months and then at -month intervals; stable or reduction size and the absence of tumour enhancement ct images were considered indicative of complete tumour necrosis. results: in all cases, the procedural was technically successful. morbidity consisted of cases of partial pneumothorax ( . %) which were resolved spontaneously within days. at a mean follow-up of months (range - ), we recorded a . % of complete response (tumour necrosis = %) and a . % of partial response (tumour necrosis range %- %). our preliminary results show that percutaneous ct-guided microwave ablation is feasible and safe for the treatment of primary and secondary lung tumour. further follow-up and a prospective controlled trial is necessary to validate the procedure. week before the ablation and at hours, , , and months post ablation. thin section ct volumetric measurement of the lesions was performed at the same time periods as a second parameter for comparison. the lesion mri enhancement intensity in each study was estimated, and the ratio to the paraspinal muscle enhancement intensity at the same level was measured (lesion muscle signal (lms ratio). the correlations between post ablation follow-up ct volume of tumours and ce-mri lms ratio at the follow-up periods were assessed. results: the preablation tumour volumes ranged between . and . cm (mean: . cm³, sd: . ). lms ratio was noted in preablation due to high contrast enhancement of the tumour and in -h post ablation due to the inflammatory response associated with the thermal ablation and due to tumour residue or progress. weak correlation was detected between the lms-ratios and ct-volumetric changes in -h post ablation. strong correlation between the lms ratios was estimated between the follow-up periods of months (spearmanr: . ,p= . ), months (spearmanr: . ,p= . ), months (spearmanr: . ,p < . ) and months (spearman r: . , p < . ). conclusion: ce-mri follow-up of the mw ablated lung tumours can be used effectively to assess the tumour response to ablation using lms ratio as a parameter of assessment. purpose: to compare image quality between standard-dose filtered back-projection (fbp) and low-dose iterative reconstruction (ir) protocols in computed tomography (ct) of the cervical spine. methods and materials: forty patients investigated by ct of the cervical spine for chronic neck pain and/or cervical radiculopathy were prospectively randomised into two groups: standard-dose ct ( kvp, mas) with fbp, or low-dose ct ( kvp, mas) with ir. image noise, signal-to-noise (snr) and contrast-tonoise (cnr) ratios were measured. two radiologists, blinded to ct parameters, independently assessed the following anatomical structures at c -c and c -c levels, using a four-point scale: intervertebral disc, content of neural foramina and dural sac, ligaments, soft tissues and vertebra. they subsequently rated overall image quality using a ten-point scale. volume ct dose index (ctdivol) and doselength product (dlp) were recorded. imaging quality of reduced radiation dose lumbar spine ct with iterative reconstruction c.-j. lin, s. hung, w. guo, t. wu; taipei/tw (bcjlin@gmail.com) purpose: the purpose of our study was to investigate the diagnostic accuracy of ct scans of the lumbar spine (ctls) acquired with lower mas and kilovoltage reconstructed with an ir algorithm. we prospectively recruited patients for ctls. patients were classified into three groups. the radiation dose reduction was set to % of the original estimated dose with alternative tube currents and kv in group a, and kv in group b. images were reconstructed with idose level reconstruction algorithm. for group c, the standard mas and kv with filtered back projection (fbp) algorithm was employed. the snr of the intervertebral disc (ivd), dural sac (ds) and psoas muscle (pm), and the cnr of the ivd and ds were compared across groups. two radiologists independently rated the quality of each reduced-dose image as either equivalent (' ') or inferior (' ') to the rater's subjective 'standard' ctls. results: there were decreased snrs of all rois in group a but only ds showed statistical significance. there were significant decreased snrs in ivd, ds, and ps in group b. there was a weak correlation between snr and bmi in all groups. the cnrs for groups a, b and c were . + . , . + . and . + . , respectively. the mean image quality scores for groups a, b and c were . , . , and . , respectively. conclusion: with the aid of the ir algorithm, it is feasible to provide diagnostic ctsl imaging with a % radiation reduction using lower mas. multidetector computed tomography of the cervical spine: optimisation of iterative reconstruction strength levels purpose: it was reported previously that trabecular bone structure parameters could add significant information for predicting bone strength beyond bone mineral density. in the past, trabecular bone structure analysis was limited by the spatial resolution of clinically available mdct scanners. recent technical improvements have made it possible to determine trabecular bone structure parameters of the spine using clinical mdct. therefore, the purpose of this study was to assess trabecular bone structure parameters obtained from clinical mdct as well as xtreme-ct (hr-pqct) as standard of reference and to investigate whether clinical mdct can predict vertebral bone strength. methods and materials: fourteen thoracic vertebral bodies were harvested from formalin-fixed human cadavers ( women and men; age: ± years). all specimens were examined using xtreme-ct (isotropic voxel size of μm³) and a clinical whole body mdct (interpolated voxel size: x x μm³, spatial resolution: x x μm³). trabecular bone structure analyses (histomorphometric and texture measures) were performed in the xtreme-ct as well as mdct images. vertebral failure load was determined in an uniaxial biomechanical test. results: xtreme-ct and mdct-derived trabecular bone structure parameters showed correlations ranging from r= . to r= . (p < . ). correlations between trabecular bone structure parameters and failure load amounted up to r= . (p < . ) using the xtreme-ct images, and up to r= . (p < . ) using the mdct images. correlation coefficients obtained with xtreme-ct and mdct were not significantly different (p> . ). the spatial resolution of clinically available whole body mdct scanners is suitable for trabecular bone structure analysis of the spine and to predict vertebral bone strength. contrast-to-noise (cnr) ratios were measured. two radiologists independently and blindly evaluated the following anatomical structures at both c -c and c -c levels, using a four-point scale: intervertebral discs, content of neural foramina and dural sac, ligaments, soft tissues and vertebrae. they ultimately rated the overall diagnostic image quality using a ten-point scale. as the strength level of irs increased, the image noise decreased linearly, while the snr and cnr both increased linearly (all p² . ). for the intervertebral discs, the content of neural foramina and dural sac, and for the ligaments, the subjective image quality scores increased linearly with increasing ir strength levels (all p² . ). in contrast, for the soft tissues and vertebrae, the image quality scores decreased linearly with increasing strength level of irs (all p < . ). finally, the overall diagnostic image quality scores increased linearly with increasing ir strength levels (both p < . ). the optimal strength level of irs in cervical spine mdct depends on the anatomical structure to be analysed. for the intervertebral discs and the content of neural foramina, high ir strength levels are recommended. relationship among facet joint fluid ( years) affected with low back pain underwent mri of lumbar spine using sagittal t -and t -weighted fast spin-echo and axial t *-weighted gradient-echo sequences. for each level from l to s , disk degeneration was graded using the thompson scale ( - ), while the fjf was graded as (absent), (monolateral), or (bilateral): per-patient disk degeneration and fjf were calculated summing the scores of the spine levels. spearman correlation coefficient, multivariate regression analysis, friedman mcnemar tests were used. data were reported as median and interquartile interval (ii). the degeneration of l /l (median ; ii - ) was lower than that of both l /l (median ; ii - ; p= . ) and l /s (median ; ii - ; p= . ). the fjf of l /s (median ; ii - ) was lower than that of both l /l (median ; ii - ; p= . ) and l /l (median ; ii - ; p= . near-perfect correlations of suv values were found for the myocardium (suvmax/ mean: r = . / . ); good correlations were found for the liver (r = . / . ), subcutaneous fat (r = . / . ), bone marrow (r = . / . ), psoas muscle (r = . / . ) and the suvmax of the blood-pool (r = . ). correlations between mrac and ctac were non-significant for suvmax and suvmean of the lung and the suvmean of the blood-pool. the mean suvmax and suvmean in mrac-pet compared to the respective ctac values was significantly lower in all organs (p < . ) but in the myocardium (suvmax) and the psoas muscle (suvmax/mean). results: sixty-three patients were referred for a pre-treatment fdg pet-ct; age range was - years (mean age years). pet-ct had a major impact on patient management in %, a minor impact in % and no impact in %. in patients with a major impact; had unsuspected nodal involvement, had occult metastases, had synchronous tumours and had negative nodes on pet-ct. these findings either altered radiotherapy treatment planning or treatment intent. during the follow-up period until august , % developed disease recurrence following completion of therapy ( % isolated local relapse and % distant (± local) disease). conclusion: fdg pet-ct can have a major impact on patient management in locally advanced cervical carcinoma, by detecting occult disease or characterising indeterminate findings on mri, resulting in an alteration in radiotherapy treatment planning and/or treatment intent in up to one-third of patients. is there a role for standard uptake value in the prognostic evaluation of lung nodules? purpose: we report about our approach in imaging patients with cervical cancer using an integrated simultaneous pet/mri device. goals were the introduction of a stable and effective protocol for whole body and dedicated pelvic examination and rating of image quality. methods and materials: ten patients with primary (n= ) cervical carcinoma or tumour recurrence (n= ) were included. patients underwent a simultaneous pet/ mr, pet/ct and conventional mr examination. mr and pet image quality were rated on a likert score system ( - ) by three radiologists and a nuclear physician. pet data were simultaneously visually compared by two nuclear physicians and a radiologist. purpose: brca and bra mutation carriers may be more susceptible to radiationinduced cancer because of their role of tumour suppressor genes in radio-induced dna damage repair and signalling. heterozygous mutations of a tm , a major kinase initiating the response to radio-induced dna double-strand breaks, is likely to be involved in lymphoma as well as in breast cancer in high-risk patient (hrp) treated for a hodgkin disease. thus the standard two-view mammographic screening annually recommended with mri in hrp must be adapted. recent literature data were analysed. individual radiosensitivity was assessed by radiobiological effects and epidemiological studies. radiophysical and radiological mammographic data about calcifications detection and reduction of exposures were also taken into account. high-resolution diffusion-weighted imaging of pancreatic ductal adenocarcinoma using d reduced field of view single-shot echo planar imaging at . tesla c. ma, y. li, h. wang, s. chen, j. lu; shanghai/cn (mengqihi@gmail.com) purpose: to demonstrate the feasibility of high-resolution dwi of pancreas using d reduced field of view (rfov) single-shot echo-planar sequence in the evaluation of pancreatic ductal adenocarcinoma. methods and materials: normal volunteers and patients with histopathologically proven pancreatic ductal adenocarcinoma by surgery were included in the study. high-resolution dwi of pancreas was obtained using a multi-section d rfov single-shot echo-planar sequence on the axial plane (fov × cm , matrix × ). adc of the normal pancreas in control group and pancreatic ductal adenocarcinoma group were measured. mann-whitney u-test has been used to compare adc values between tumoral tissues and normal pancreatic tissues of the volunteers. results: on the high-resolution dw images, all pancreatic ductal adenocarcinoma demonstrated high signal intensity relative to the surrounding pancreatic parenchyma. the mean and standard deviations of the adc values (× - mm /s) were as follows: pancreatic ductal adenocarcinoma (n = ), . ± . ( . - . ), and normal pancreas in normal volunteers (n = ), . ± . ( . - . ). adc of the pancreatic ductal adenocarcinoma were significantly higher compared with those of normal pancreas (u = . , p = . ). conclusion: rfov dwi shows advantages in higher resolution ( . × . mm ) and blurring reduction compared to full fov dwi of the pancreas. it makes a statistically significant difference on the adc measurements of the pancreatic ductal adenocarcinoma when comparing to the control group. this approach is promising to benefit the early diagnosis of pancreatic cancers. purpose: to prospectively evaluate the application of arfi implemented with virtual touch tissue quantification in the study of pancreatic cystic lesions, using different analysis methods, compared with the final diagnosis (pathological or by mri/eus findings). methods and materials: patients with pancreatic cystic focal lesion (diameter > cm and located at a depth < . cm) were included in the study and underwent conventional us. for every patient measurements with virtual touch quantification roi were performed. in order to distinguish mucinous (potentially malignant) from serous cystic lesions (mainly benign) the result "xxxx/ " was considered meaning simple liquids (reportable to water), and the accuracy of virtual touch tissue quantification in differentiating cystic-pancreatic lesions was calculated. to consider the lesion as containing complex fluids (potentially mucinous), two different reading methods have been applied: at least two numerical values when performing five measurements; prevalence of numerical values irrespective of the number of measurements. sensitivity, specificity, positive and negative predictive values and accuracy were calculated for the differential diagnosis between mucinous versus non-mucinous cystic lesions. results: sensitivity, specificity, ppv, npv and accuracy in the group of cystic lesions using the first reading method were, respectively, . %, . %, . %, . %, . %. sensitivity, specificity, ppv, npv and accuracy in the group of cystic lesions using the second reading method were, respectively, . %, %, %, . %, . %. conclusion: arfi with virtual tissue touch quantification can have a role in noninvasive characterisation of pancreatic cystic lesion during the conventional us examination. purpose: to evaluate the efficacy of ct perfusion for detection of malignancy in pancreatic masses. methods and materials: patients (pts) who presented with a mass in the pancreas were enrolled in this institute review board-approved prospective study after informed consent and underwent biphasic cect with perfusion ct of the pancreas. pts were followed up and results of cytopathological diagnosis obtained. final diagnosis consisted of malignancy (adenocarcinoma) in , various benign masses in and neuroendocrine tumour in pts. control group consisted of pts who were referred for ct for an indication other than pancreatic pathology. perfusion parameters were calculated using software mistar . (apollo imaging software). ct perfusion parameters were compared between the control and study groups as well as results of cytopathological diagnosis using anova and dunnett -sided t-test for statistical analysis. results: all perfusion parameters except extraction (e) were significantly different between adenocarcinoma and benign groups. all perfusion parameters except permeability (ps) were also statistically significantly different between adenocarcinoma group and controls. blood flow (bf), blood volume (bv), extraction fraction product (efp), ps and peak enhancement intensity (pei) showed decreasing trend in values, whereas rest of the parameters showed an increasing trend from normal to benign to adenocarcinoma. neuroendocrine tumours had different perfusion values with significantly elevated bf, bv, pei and earlier time to peak (ttp). one patient with pancreatic tuberculosis had perfusion values paralleling adenocarcinoma but with relatively earlier ttp. conclusion: perfusion ct seems to be a useful tool for differentiating between malignant and benign pancreatic masses. comparison after the acquisition of axial t w and t w sequences and coronal mrcp, diffusionweighted mr imaging was performed using an axial respiratory-triggered spin-echo echo-planar sequence with multiple b values ( , , , sec/mm²) in all diffusion directions. adc value was calculated by using a dedicated software fitting the curve obtained from the corresponding adc for each b value. fitted adc values were calculated by two observers in conference for each cystic pancreatic lesion and for normal pancreatic parenchyma. imaging results were correlated with surgery, ercp, and/or imaging follow-up. results: final diagnoses included intraductal papillary mucinous tumour (ipmt) (n= ), serous cystoadenoma (n= ), and mucinous cystoadenoma (n= ). fitted adc value was . x - mm /sec for normal pancreatic parenchyma, . x - mm /sec for ipmt, . x - mm /sec for serous cystoadenoma, . x - mm / sec for mucinous cystoadenoma. fitted adc values were significantly higher in mucinous neoplasms than in serous cystoadenomas (p < . ). our results suggest that diffusion-weighted t mr imaging with b-multiple se-epi may be helpful to differentiate mucinous from serous cystic pancreatic lesions. further investigations in larger series of patients are necessary to confirm our data. purpose: cardiac magnetic resonance imaging (cmr) using a comprehensive approach consisting of adenosine perfusion and late gadolinium enhancement (lge) at . tesla has established for detection of relevant coronary artery disease (cad). little is known about the potential advantages of tesla cmr to detect relevant cad. aim of our prospective study was to compare a clinical routine cmr protocol performed at both . and tesla in patients with suspected cad undergoing coronary x-ray angiography. methods and materials: patients ( . ± . years) with suspected cad were included into the study. all patients were scanned at both . and tesla including functional imaging, adenosine stress and rest perfusion, and lge. cmr images were analysed by two blinded readers in consensus. x-ray angiography served as the reference method. results: diagnostic accuracy of the combined analysis of perfusion and lge imaging yielded better values at . and tesla than the analysis of perfusion images alone. sensitivity and specificity at tesla were superior to . purpose: the purpose of this study was to evaluate the prevalence of pathological cardiac mri findings in subjects with mild coronary calcifications. methods and materials: asymptomatic volunteers were selected from a large population-based screening study in accordance with their agatston calcium score (group : agatston score: , n = , age . +- . ; group : agatston score: - , n = , age . +- . ). all subjects underwent cardiac mri at . t. the mri protocol included a) functional assessment of the left ventricle, b) assessment of adenosine stress-/rest perfusion and c) quantification of late gadolinium enhancement (lge). results: a stress-induced perfusion deficit was present in / subjects ( . %), whereas lge was seen in / subjects ( . %). group (agatston score: ): in this group none of the subjects showed a perfusion deficit, whereas in seven subjects lge was observed ( . %). two of the seven subjects showed an ischaemic-type pattern of lge ( . %) indicating chronic infarction. group : median agatston score of group was (q , ; q , ). in this group a perfusion deficit could be observed in one subject ( . %), whereas lge was observed in ten subjects ( . %). however, all of these lge patterns were assessed as non-ischaemic. the prevalence of stress-induced myocardial ischaemia in subjects with mild coronary calcifications score is low, whereas the frequency of non-ischaemic lge is relatively high. long-term follow-up will clarify whether these cardiac mri findings contribute to cardiovascular risk stratification in asymptomatic subjects. purpose: to determine the feasibility of ct-based myocardial perfusion imaging to differentiate ischaemic and infarcted myocardium as compared to magnetic resonance imaging (mri). we prospectively enrolled subjects with suspected coronary artery disease, who underwent adenosine-mediated stress myocardial perfusion imaging by dynamic dual-source ct ( kv, mas/rot) and t-mri. myocardial blood flow and volume (mbf and mbv, respectively) were derived from ct images, using a model-based parametric deconvolution method for myocardial segments. these were related to perfusion defects visually assessed during rest/stress and delayed mri acquisitions. conventional measures of diagnostic accuracy and differences in mbf/mbv were determined in a blinded fashion. results: among enrolled subjects, (mean age ± years, % men) completed the protocol. the prevalence of ischaemic and infarcted segments detected by mri was moderately high ( . % and . %, respectively purpose: patients with extra-cardiac arterial disease (ecad) are at high risk of coronary heart disease. we examined the prevalence of silent, significant coronary artery disease in patients with stenotic or aneurysmatic ecad. methods and materials: cardiac asymptomatic ecad patients without contraindications for computed tomography (ct) and magnetic resonance imaging (mri) underwent coronary ct angiography (ccta) and adenosine perfusion mri (apmr). calcium scoring was performed based on non-contrast ct. ccta was positive when ³ % lumen diameter stenosis in a coronary artery was found. patients were referred to a cardiologist when ccta showed a stenosis in the left main coronary artery (or equivalent), or when apmr showed inducible myocardial ischaemia. results: in total, patients (mean age yrs; % male) were included. patients were divided into categories: stenotic (n= ) and aneurysmatic ecad (n= ). ccta was positive in % in stenotic and % in aneurysmatic ecad. no ccta was performed in % due to excessive calcium. two patients, stenotic and aneurysmatic ecad had left main stenosis. apmr was positive in % in stenotic and % in aneurysmatic ecad. eighteen percent of stenotic and % in aneurysmatic ecad have been referred to the cardiologist. a cardiac intervention was performed in % of stenotic and % in aneurysmatic ecad. significant stenosis or high calcium score was found in % in stenotic, compared to % in aneurysmatic ecad. none of these outcomes were statistically significant. conclusion: silent, significant coronary artery disease is highly prevalent in patients with ecad, either stenotic or aneurysmatic. purpose: to evaluate non-linear image blending in comparison with linear image blending in late phase dual-energy computed tomography (dect) for the visualisation of delayed myocardial contrast enhancement in acute myocardial infarction (mi) and to identify optimal parameters for non-linear image blending. methods and materials: acute reperfused mi was induced in seven pigs by temporary occlusion of the left anterior descending or left circumflex artery. two hours after reperfusion contrast-enhanced late phase dect ( kv/ kv) was performed. dect data were post-processed with linear and non-linear image blending techniques. contrast and percentage signal difference between healthy and infarcted myocardium as well as the blood pool of the left ventricle were computed for the linear and non-linear techniques including the low and high kv images. data were compared using repeated measures anova and post hoc t-tests. results: non-linear blending showed the highest signal differences for all contrasts and analyses. repeated measure anovas confirmed these differences to be statistically significant for the different post-processing techniques (p-value ranging from < . to . ). paired-samples post hoc t-tests proved the significance of these results (p-value ranging from < . to . ). the ideal settings for nonlinear image blending can be deduced from the ct values of the regions of interest in the linearly blended images with the weighting factor . . conclusion: non-linear image blending improves the visualisation of acute mi in dect. non-linear image blending in late phase dect of acute mi is superior to linearly blended images as well as source images obtained at kv or kv. purpose: to assess feasibility and reliability of the juvenile arthritis mri scoring system (jamris) for the wrist to evaluate early-stage disease activity, and to compare reliability of jamris for the wrist for early-stage disease with the validated paediatric-targeted mri scoring system (ptmris) for children with more progressive stage of disease. methods and materials: mri datasets from juvenile idiopathic arthritis (jia) patients with wrist involvement were evaluated independently by three readers using jamris and ptmris. assessment of early-stage disease activity in jamris was achieved through extending soft tissue scoring items (synovial hypertrophy, tenosynovitis) and specifying the grading of bone scoring items affecting < % of the bone (bone marrow changes, bone erosions). intraclass correlation coefficient (icc) or cohen's kappa was used to assess inter-and intrareader reliability. icc of each jamris scoring item was compared with the icc of its equivalent in ptmris. results: three jamris scoring items (synovial hypertrophy, bone marrow changes and bone erosions) showed moderate to good reliability: icc varied from . to . for interreader reliability and . - . (reader ) and . - . (reader ) for intrareader reliability. reliability of tenosynovitis was moderate to poor with cohen's kappa varying from . to . (interreader) and . to . (intrareader). jamris and ptmris showed similar results of interreader reliability. conclusion: early jia disease activity in the wrist can be reliably evaluated with three-out-of-four features of the simple and accurate jamris scoring system. correlating clinical disease assessment and responsiveness to change will be needed to validate jamris for the wrist as outcome measure and disease monitoring tool. showing equivocal findings or a bone injury outwith the clavicle. in those found to have clavicle fractures, follow-up radiographs were performed in individuals ( %). orthopaedic fixation was not performed in any of the identified cases. conclusion: despite a high pick-up rate of fractures, clavicle radiographs do not appear to substantially alter clinical management. in our centre, immobilization is the usual management for suspected traumatic clavicle injury, regardless of radiographic appearance. we suggest that, in the context of an experienced paediatric emergency department team, radiographs are reserved for patients causing concern at follow-up and are not required routinely at presentation. (an) is an eating disorder characterised by alteration of bone metabolism (osteopenia) and of body composition (reduction and abnormal distribution of fat mass-fm and lean mass-lm), due to oestrogen deficiency and self starvation. the aim of our study was to address bone metabolism and body changes in a cohort of patients with an by using dual-energy x-ray-absorptiometry (dxa). prospective study on patients with an, submitted to dxa at baseline-t and after months-t . we evaluated total and regional fm and lm percentages, as well as lumbar bone mineral density-bmd and z-score, linking them to clinical variables: menarche/amenorrhea/hormonal therapy and physical activity. results: among the / - . % patients that completed the study the t clinical condition was as follows: bmi= . ± . kg/m , low levels of fm percentage ( . ± . %), osteopenia (z-score:- . ± . sd, with higher values related to physical activity-p= . ). at t : significant increase in bmi-p= . , with lm reduction and fm increase (more evident in the trunk-p < . ); regarding bone, no significant changes were observed, though a tendency in terms of improvement associated with resumption of menses was manifested. after one year, significant conclusions on bone metabolic condition could not be reached. by contrast, weight recovery was associated with the increase of fm and a distortion of its distribution, more evident in trunk region (potential and adjunctive risk factor for the relapse of the psychiatric condition). the complexity of these clinical findings suggested that dxa, a low-dose and low-cost technique, could have a key role in long-term monitoring of an patients. replacing conventional spine radiographs with dual-energy x-ray absorptiometry (dxa) in children with suspected reduction in bone density e. adiotomre, l. summers, p. broadley, i. lang, g. morrison, a. offiah; purpose: children have greater lifetime risks of radiation-induced complications compared to adults. in children with osteogenesis imperfecta conventional radiographs are obtained to assess spine morphometry, while dxa assesses bone density. in adults dxa is used for both. we aim to establish whether idxa can replace spine radiographs in assessment of paediatric vertebral morphometry. methods and materials: an -month prospective study of consented children ( to years old) with and without suspected reduction in bone density, who had lateral spine radiographs and lateral dxa scans on the same day, was conducted. three observers will independently assess all images (blinded to corresponding results of radiographs and dxa) using a modified abq technique. random images will be interpreted twice. diagnostic accuracy and inter-and intraobserver reliability of dxa will be compared to the gold standard of radiography. patient/carer experience, dxa radiation dose compared to radiographs and health economics will be assessed. results: interim analysis of the first recruited patients showed had or more vertebral fractures. the fracture detection sensitivity for dxa was . % and specificity . %. the overall accuracy for vertebral fracture detection with dxa was . %. the overall agreement between radiographs and dxa was . %. the modified abq technique has limitations in children and a more reliable scoring system is required. compared to radiography dxa does not appear to be worse for morphometry and given the reduced dose and comparable image quality, dxa should be recommended for morphometry in children pending more robust analyses. (n= ) had ddh necessitating or more ultrasound examinations, of which % (n= ) required treatment. there was one case of missed hip dislocation, representing . % of unexamined patients. no patients with iic hips at presentation with conservative management represented with a dislocated hip. radiographs in the treated group demonstrated a satisfactory outcome in %. one patient represented with a dislocated hip following erroneous cessation of harness treatment and went on to develop early avascular necrosis. two patients were lost to follow-up. conclusion: a delayed approach to managing ddh in infancy allows those patients with ultrasonographically immature hips the opportunity to develop normally without invasive treatment and identifies patients which would most benefit from treatment. this reduces the demand on resources that a ddh screening programme which treated patients more promptly would incur. within the same financial constraints, this allows more patients to be selected for screening. a delayed approach results in a satisfactory outcome with no subsequent late dislocation in those treated appropriately. purpose: in cases of hip complaints in the paediatric population it is common practice to acquire both ap and frog-leg lateral (fl) radiographs. the combination of these views has a diagnostic yield, but also doubles the radiation exposure. in our observation, the fl view alone is often diagnostic. we therefore investigated the diagnostic accuracy of obtaining a solitary fl view as compared to a combination of the ap and fl views. methods and materials: children aged - years who were sent in for hip radiographs between september and january were included in the study. cases of related trauma or a history of hip pathology were excluded. radiographs were retrospectively assessed by two independent radiologists. radiologists were blinded for the ap radiograph while assessing the fl radiograph and vice versa and radiographs were presented in a random order. we used the kappa test to calculate interobserver agreement and agreement between the assessment of both views and the solitary fl view. results: children (mean age . yrs) met the study criteria and were included for analysis. children had a normal exam and were considered abnormal. calculated interobserver agreement using the kappa test was . . agreement between the solitary fl view and the combination of the ap/fl view was . . the diagnostic accuracy of the fl radiograph in case of hip complaints in children is as high as the current standard of both ap and fl views. and healthcare centres. statistical analysis was made using descriptive statistics, mann-whitney and kruskal-wallis tests in order to verify correlation between items. results: radiographers consider that it is essential the implementation of a quality control program in the radiology department, but there is lack of information in this field, and . % do not know what a quality control program is. % of radiographers claim their institutions do not have quality control programmes or accreditation. however, . % had received education on quality and % make regular personnel radiation measures. also, despite there is no lack of radiological protection equipment in most departments, . % claim they are in poor condition. conclusion: quality control programs are essential to the radiology department and radiation safety guidelines must be implemented. despite that some radiology departments have radiological protection equipment often applied by radiographers, their effectiveness and condition must be checked regularly. purpose: applying control charts to demonstrate the importance of implementing a radiological imaging quality control system. research conducted in a public hospital comprising a total of randomly selected exams ( chest studies, abdominal studies and foot studies) grouped in samples, each one with exams. the conformities and non-conformities found were used to establish three types of quality control charts based on the evidence collected, namely the proportion of conformities and non-conformities (p), the total number of non-conformity exams (np) and the total number of non-conformities in each sample (c) in order to suggest corrective actions for improvement. results: considering all exams, % are non-conformities and % are within conformities. of chest studies, % were within conformities and % were non-conformities; of abdominal studies, % were within conformities and % were non-conformities. foot studies had an almost even distribution of conformities and non-conformities with and %, respectively. conclusion: this research allowed the identification of different types of nonconformities found in radiological images which have impact on imaging quality. therefore, the existence of adequate quality control of radiographic imaging is essential. a review of diagnostic imaging frequency to aid research exploring the issue of consent for higher dose paediatric examinations j.l. portelli , j. mcnulty , s. mohan , p. bezzina , l. rainford ; msida/mt, dublin/ie (jonathan.portelli@um.edu.mt) purpose: concerns have grown in recent years in relation to potential radiationrelated risks associated with diagnostic imaging examinations performed on paediatrics (< years). this retrospective cohort study aims to provide an insight into the use of potentially higher dose computed tomography (ct) and fluoroscopyguided examinations in paediatrics, in two national clinical centres of comparable catchment areas in malta and ireland. methods and materials: retrospective data, of higher dose diagnostic imaging examinations performed in paediatrics in , was collected from departmental logbooks and radiology information system (ris) databases of the participating centres. this data included details pertaining to patient's age, type of examination and relevant examination kv, mas, dap, fluoroscopy time, ctdi and dlp (if available). data were categorised according to age and examination type, and effective dose estimates for ct were calculated. results: in alone, at least , ct examinations, , fluoroscopy-guided procedures and cardiac catheterisation interventions were performed on paediatrics across both centres. particular complex fluoroscopy-guided interventions had an associated dap exceeding , cgy.cm , while effective dose estimates for ct examinations indicated that some paediatric patients may receive a moderate (> - msv) or high radiation dose (> - msv). conclusion: paediatric patients may undergo examinations that potentially involve a high dose of ionising radiation. further research to explore the debated issue of benefit-risk communication and consent in paediatric imaging is therefore justified and encouraged, particularly as the study's findings also indicate that repeat or multiple imaging examinations of different anatomical areas are commonly performed in ct. purpose: to estimate the lifetime attributable risk (lar) of cancer incidence for individual organs following radiation exposure during pci in the context of two opposite sides of angiographic spectrum of coronary occlusive disease: st-elevation myocardial infarction (stemi) and chronic coronary total occlusion (cto). we identified all consecutive patients treated with pci for stemi (n= ) and for cto (n= ) in a tertiary care centre in years. the lars of cancer incidence for six organs (colon, liver, lung, red bone marrow, stomach and thyroid) were estimated using the biological effects of ionising radiation (beir) vii model. the estimated lars of cancer incidence for individual organs was found to markedly increase as the age of the patient decreases and was significantly higher for the lung (additional risk up to / . person's lifetime exposure in cto and / . in stemi patients, respectively, p < . ) and for the red bone marrow (up to . / . and . / . , respectively, p < . ). in both the groups, the estimated lar of cancer incidence for stomach, colon, liver and thyroid was similar and very low. conclusion: in pci procedures, the lung was the organ with the highest radiation absorbed. according to beir-vii model, the number of additional cancer cases for individual organs was on average two times higher in patients treated with pci for cto and the highest lars were for lung and red bone marrow cancers. project retake: quality assurance of radiation hygiene by maintaining image quality purpose: to reduce the extent of retake while maintaining image quality. the research was conducted in two digital x-ray labs, data for six months were analysed by quantitative method. patient data: id, information of retakes was stored at modality, post-examination. random patients, undergoing standard x-ray examinations, were selected each month. a standard examination contains two or three exposures, front oblique and/or lateral. radiographers were encouraged to choose a cause for retake. analysis contained: type of examination, number of projections, number of exposures and retake reason per patient. the causes are systemised in the modality, ready to select if there is a retake. reject options were radiographer, patient or student failure. there was an average of retaken images out of examinations. that is to say, % margin of error. % of the standard examinations were retakes; the reject option was radiographer failure. rest % was patient or student failure. as a result of this a pgmi test is established for the digital labs to test quality assurance. results after this quality assurance give a reduction of retakes per month. a reduction of % retakes due to radiographer failure. conclusion: environment, method, monitoring and feedback, influence radiographer result and radiation dose to patients. radiographers using digital x-ray need quality assurance as in mammography. pgmi usage will give feedback to maintain image quality and reduce radiation dose. implementation purpose: to evaluate the importance that radiographers give to quality control programs, radiological protection and the verification of radiological protection criteria. a -item quality control assessment and radiological protection questionnaire was applied to radiographers working on public hospitals s a c d e f g b saturday viability was tested by performing two tests on the lateral position of the lumbar spine, with a phantom. the results obtained using the aluminum filter resulted in a reduced variation in relative dose rate ( %) compared to not using the filter as well as a % reduction in dose to the entrance surface of the skin. regarding the image quality, it has been found that the use of filter presents significant reasons the optimisation of this parameter. these results indicate that the use of the filter should be considered as a good practice in the lumbar spine radiography to achieve dose reductions. antero-posterior (ap) pelvic radiography: collimator errors and their effects on radiation dose h. brookfield , a.s. manning-stanley , a. england ; liverpool/uk, salford/uk (aengland@liverpool.ac.uk) purpose: to investigate the range of collimator errors in x-ray rooms and to calculate their possible effects on the radiation dose for ap pelvis examinations. a collimator test tool was suspended at three heights ( , and cm) above the table bucky in nine x-ray rooms. heights corresponded to the patient thickness (mean, ± sd) in patients. the x-ray beam was visually collimated to the inner boundary of the test tool and exposed to radiation. differences between the visualised field size and the resultant x-ray field size (corrected for magnification) would indicate any collimator errors. on the pelvic phantom minimum textbook collimation was set and then changed in order to simulate a range of possible collimator errors. phantom examinations used a standard technique with exposure termination using outer aec chambers. dose-area-product (dap) was recorded. results: out of nine x-ray rooms all but one produced a smaller irradiated area than was visually set. errors ranged from a % reduction in irradiated field size to a slight over irradiation by . %. with the possibility that these errors could be larger in other institutions a range of (- % to + %) errors were simulated. increasing the field size by cm (superior/inferiorly) increased the dap by %. laterally, a cm increase caused a % rise. increases of cm in both planes raised dap by %. in this study collimator errors were minimal and favoured under irradiation. small errors can affect dap and are more dose significant in the superior/inferior plane. breast shielding significantly reduces breast dose during lumbar spine radiography n. mekiš, d. Žontar, d. Škrk; ljubljana/si (nejc.mekis@zf.uni-lj.si) purpose: as use of protective shielding for the patient in conventional radiography varies widely in practice, the study aimed at providing objective answer about the effect of lead rubber sheet shielding for a specific case of breast dose during the lumbar spine radiography. influence of the body mass index on the breast dose was also investigated. the study was conducted both on an anthropomorphic phantom and on a cohort of female patients, randomly divided into two equal groups. in both cases lumbar spine imaging was conducted in ap and lateral projection with and without the lead shield (in case of the patient study the shielding was used in one group only). the dose was measured by thermoluminescent dosimeters (tld) placed at the centre of the breast. results: using the lead shielding dose to the right breast was reduced from . ± . mgy to . ± . mgy (p < . ) and the dose to the left breast from . ± . mgy to . ± . mgy (p < . ), compared to the unshielded breast. on average, the breast dose was reduced by approximately %. no correlation between the body mass index (bmi) and the breast dose was found. conclusion: based on the results, we can conclude that the use of breast shielding is recommended in lumbar spine radiography. despite the low-dose exposure even without shielding, the dose can be further reduced. moreover, the quality of the x-ray image is not affected by the use of the lead shield. an approach for portuguese diagnostic reference levels for bedside chest radiography a. sousa, s. serém, j. santos, g. paulo; coimbra/pt (sarajoanacs@hotmail.com) purpose: bedside chest radiography represents the most commonly performed examination. taking into account the different protocols and equipments it is important to develop diagnostic reference levels, in order to promote a patient safety culture and consequently health care best practice. this research was carried out in two imaging department centres from the same geographic region (hospital a and hospital b). in phase one, the exposure parameters and entrance skin dose (esd) value of bedside standard patients' chest radiography were collected. to optimise the obtained dose values in hospital b more bedside standard patients' chest radiography were collected on phase two, using parameters of hospital a, that had already went through an optimisation process. results: in phase one hospital a esd value was statistically lower ( . μsv) in comparison to hospital b ( . μsv). in phase two hospital b decreased significantly the esd value ( μsv) in comparison with the phase one, but with no significant differences with hospital a. conclusion: patients in hospital b at phase one were % more exposed to ionising radiation than patients from hospital a for the same procedure. the implementation of optimised protocols at phase two reduced the dose levels in . % in the hospital b. the regional drl for bedside chest radiography was set at μsv. an investigation into the relationship between the exposure index value and image quality m.-l. butler, l. rainford; dublin/ie (marielouise.butler@ucd.ie) purpose: 'exposure creep' is a documented phenomenon in computed radiography (cr) where radiation dose is given unnecessarily to patients due to cr's processing capabilities. manufacturers have responded by developing an exposure index (ei), which is a measurement of detector dose and hence relates to noise in the image. this study aimed to identify how the ei value relates to image quality in clinical practice. methods and materials: three imaging suites and five radiographic examinations were included: ankle and wrist series (antero-posterior (ap) and lateral); ap and lateral lumbar spine; ap pelvis and postero-anterior (pa) chest projections. in total, examinations were documented with a minimum of patients for each projection. twelve patient images representative of each projection were selected according to their agfa lgm value; low, median and high lgm values and images recording lgm values closest to the manufacturers' guidelines. three observers, experienced radiographers (minimum of years working clinically), reviewed the images for noise and overall exposure of the image. in addition the observers indicated what ei value they judged appropriate to image presentation. results: no significant difference in image quality was noted across the categories of lgm when considering noise (chi-square ( )= . , p= . ) or exposure (chi-square ( )= . , p= . ). lgm values judged by observers as representative of image quality were lower than those recorded clinically. no correlation with lgm and clinical image quality was identified in this study. further research is recommended to include additional manufacturers and radiographic examinations. attenuation of anode heel effect with an aluminum filter and their influence on patient dose in lumbar spine radiography j. soares, r. dores, p. sousa, s.i. rodrigues, l.p.v. ribeiro, a.f.c.l. abrantes, r.p.p. almeida; faro/pt (joana.soares. @hotmail.com) purpose: study the attenuation of anode heel effect with an aluminum filter, thereby optimising the image quality, without increasing the patient dose exposure. this study was performed in a radiology department with a conventional radiology equipment. the filter construction was based on the radiographic study of the lumbar spine in a lateral position, and used the following technical parameters: kv, ma, ms and . cm of sid. experiments were performed to study the behaviour of anode effect along the longitudinal anodecathode axis. measurements of dose rate using the detetor unfors xi rf was carried out. this detector also allowed performing the equipment quality control. in order to standardise the variation in beam intensity of x-ray filters were used with different thicknesses of aluminum to reduce the value of the dose rate and to determine the thickness of the filter construction. after construction of the filter, the stereological approach enables the quick estimation of rv parameters with high accuracy and reproducibility from mr images. automated computerized software for diameter and volume measurements of pulmonary metastatic disease: preliminary evaluation e. lotan, d. aharoni, s. raskin, b. boursi, r. berger, e. konen; ramamt gan/il purpose: serial ct scans of metastatic tumours are vital in assessing the efficacy of cancer treatment. we evaluated the performance of a novel automated computerized software system that integrates registration, segmentation and tumour measurement into a single process to expedite recist measurement with the addition of volume measurement. methods and materials: measurements of long and short-axis of lung metastatic lesions in sequential patients with metastatic renal cell carcinoma were manually obtained twice by radiologists. those measurements were compared with automated software measurements (carestream health, rochester, ny). in addition, the software automatically identified the lesions' contours and volumes; the readers could accept the automated measurement or correct it manually. intraobserver correlation was assessed by intraclass correlation coefficient (icc), and interobserver reliability by the concordance correlation coefficient (ccc) and bland-altman limits of agreement. purpose: clinical guidelines for follow-up of pulmonary nodules depend on nodule type and therefore accurate characterisation of nodules is important. a novel computer-aided diagnosis (cad) system to distinguish solid, part-solid and nonsolid nodules is presented and evaluated on a large data set from a lung cancer screening trial. methods and materials: the automated characterisation system is based on a previously published nodule segmentation algorithm. four different parameter settings were used to extract the solid part, non-solid part and solid core of the lesion. for each segmentation, volume, mass, average density, th percentile and th percentile of densities inside the segmentation were used as features. a k-nearestneighbour classifier was used to classify nodules. the accuracy of the system to differentiate between solid and subsolid nodules, between solid, part-solid and non-solid nodules and between part-solid and non-solid nodules was evaluated. a data set consisting of low-dose chest ct scans ( x . mm, - kvp, mas) with solid, part-solid and non-solid nodules was collected from a screening trial. the nodule type recorded in the screening database was used as the reference standard. experiments were performed in leave-one-nodule-out cross-validation. the accuracy of cad to differentiate between solid and subsolid nodules was . . differentiation into solid, part-solid and non-solid nodules gave an accuracy of . . cad had an accuracy of . in differentiating part-solid from non-solid nodules. automated characterisation of pulmonary nodules shows good performance. this can aid radiologists to decide on appropriate workup in clinical practice. author purpose: right ventricular (rv) volume and ejection fraction (ef) assessment is of clinical value. this procedure, based on manual delineation of the endocardial contours on mr images, is time-consuming due to ventricle's complex shape. we introduce a stereological method for estimating rv parameters from mri data without the need for image segmentation. methods and materials: twenty-two consecutive patients with coronary artery disease underwent cardiac mri. stereological estimations involved the automatic placement of a systematic grid of test points with random orientation over shortaxis images. all points hitting the rv were counted using the semiautomatic point selection process. the optimum point spacing of the grid was defined. the software automatically provided the rv volumes and ef. two independent observers evaluated the measurement reproducibility. stereological estimations were compared with those determined by manually tracing rv contours. results: acceptable estimations of rv parameters with a mean coefficient of error of . ± . % were obtained by counting an average of only points per image. the mean time of stereological analysis was . ± . min, whereas the intraobserver and interobserver variability was . - . % and . - . %, respectively. the mean differences between stereology and manual tracing for estimating the end-diastolic volume, end-systolic volume and ef were small and equal to . ± . ml, . ± . ml and - . ± . %, respectively. the parameters obtained by the two methods were not significantly different (p> . ), and they were strongly correlated (r> . ). performed after standardised preparation. d-motility-acquisitions (dynamic- d-t -fiesta; tr . /te . /fov / mm) covering the entire small bowel were performed in free breathing over sec. image analysis for the assessment of small bowel motility was performed both manually and with the software. the time consumption and reproducibility were compared using coefficient of variance and paired student`s t-test. results: single regions of interest were analysed two times by hand and two times using motasso with a dedicated displacement provider. mean small bowel contraction frequency was . contractions per minute (sd+- . ) for manual and . (sd+- . ) for motasso analyses; the mean luminal diameter was . mm (manual, sd+- . ) and . mm (motasso, sd+- . ), respectively. the variability of repetitive measurements (coefficient of variation) was . % (sd+- . ) for manual and significantly lower (p < . ) for motasso-assisted measurements ( . %, sd+- . ). the mean duration needed for a single small-bowel motility assessment was . min for manual (sd+- . min, range - min) and high significant lower (p < . ) for motasso-assisted measurements ( . min, sd+- . , range - min). the use of motasso proves highly reliable and fast measurements of small bowel motility in free breathing mri. reproducibility was significantly higher for motasso-assisted than for manual measurements, while the time needed for the single measurement could be tremendously reduced using motasso. purpose: plaque treatments carry considerable risk, and hence, adjunct techniques are necessary to help doctors in making a confident decision about the necessity of such procedures for a patient. mostly, symptomatic patients face a greater risk of cardiovascular diseases, and hence, classification of the plaque into symptomatic and asymptomatic is necessary. therefore, we have developed a non-invasive computer-aided diagnostic technique for the same. methods and materials: carotid artery images were acquired using multi-detector row ct angiography (mdcta). the region of interest (roi) was segmented manually from the images, and the rois were used to extract texture-based and discrete wavelet transform-based features. significant features were used to train and test support vector machine (svm) classifiers of various kernel configurations. the svm classifier with a polynomial kernel of order presented the highest accuracy of %, sensitivity of . %, and specificity of . %. we formulated a riskscore, which is a combination of all the features, in order to monitor the variations in features, and also to more objectively classify the two classes. conclusion: a technique that uses the ct images to identify symptomatic and asymptomatic plaques would add more value to this modality in the area of atherosclerosis management. we have proposed and demonstrated the efficiency of one such technique in this work. the classification accuracy is high, and the technique is non-invasive, fast, highly objective, cost-effective and user-friendly. therefore, it can serve as a valuable adjunct tool that can be used by clinicians in deciding treatment options for patients. automated labelling framework applied on full and partial spine ct scans d. major, j. hladuvka, f. schulze, k. bühler; vienna/at (david.major@vrvis.at) purpose: the spine is often a frame of reference for diagnosis. for this purpose its parts have to be labelled in upper body ct scans which is a time-consuming task. an automated framework is introduced for detecting intervertebral disk and vertebra centre points and its labels in ct data containing the spine fully or partly considering clinical resource constraints. the framework uses a machine learning-based classification approach for detecting spinal canal centre point candidates as a first step. intervertebral disk-, rib-and sacrum centre point candidates are extracted next to the spinal canal by the same classification approach. intevertebral disk centre point labelling is started relative to either ribs or sacrum depending on detection certainty. the labelling run is done iteratively along the spine by obtaining best matches of trained local appearance models to detected three intervertebral disk and spinal canal centre point candidate clusters. vertebra centres/labels are derived from the intervertebral disk ones. the framework has been trained on and tested on solutions. accordingly, dedicated software was developed. we evaluated its clinical performance in a series of brain tumours imaged with state-of-the-art t-mri. methods and materials: seventeen enhancing brain tumours were investigated (magnetom trio/ t; dynamic t -weighted-sequence/twist: temporal-resolution: . s, in-plane-resolution: . * . * . mm , ml dotarem@ ml/s; anatomicsequence/mprage: in-plane-resolution: . mm ). post-processing was performed to test a dedicated commercially available cad-tool. amongst other pre-processing features it implements [ ] elastic d-motion-correction (dynamic-contrastenhanced scans), [ ] co-registration of dce-and anatomic-scans ( d and d), [ ] identification of regions-of-interest ( d-roi), [ ] identification of appropriate arterial-input-function (aif). output data include quantitative pharmacokineticparameters (two-compartment tofts-model: k trans , k ep , ve, etc). and fitted/unfitted enhancement-curves ([mmolgd/l]). all pre-preprocessing features and the quality of fitted curve-data were evaluated by an experienced neuroradiologist and scored on confidence-scales ( =not appropriate to =excellent). pharmacokineticparameters were correlated with final diagnosis (benign/malignant: roc-analysis). results: motion-correction was technically successful in all cases. co-registration in d (mean-score[ms]: . ) and d (ms= . ) as well as identification of the aif (ms: . ) reached excellent ratings. placement of d-rois was difficult in one lesion (score= ). yet, in total it was performed appropriately (ms= . ). overall quality of fitted curve-data reached good scores (ms= ), resulting into a high diagnosticaccuracy for the differentiation of benign vs. malignant tumors (auc= % [k ep ]). the software showed an excellent clinical performance. this should help to further promote quantitative pharmacokinetic-analyses and might broaden its application in clinical practice in the future. rapid semi-automated volumetry of pleural effusion in mdct m.p.f. botelho, f.d. gonzalez-guindalini, h. chalian, v. yaghmai; purpose: to evaluate precision and reproducibility of volumetric semi-automated quantification of pleural effusions in mdct. this study was irb approved. we evaluated consecutive pleural effusions in adult patients undergoing contrast-enhanced mdct of the chest. two independent blinded readers used a semi-automated segmentation software for estimation of volume and recorded quantification time. manual volumetry was obtained as the reference. we evaluated the volumetry for precision, time for assessment and inter-rater agreement, as well as percentage of over-and under-segmentation. statistical analysis encompassed paired t-test, bland-altman plot and lin's concordance correlation coefficient. the mean semi-automated and manual volumes were . ml (sd . ml) and . ml (sd . ml), respectively (p= . ). semi-automated volumetry showed significant inter-rater agreement, with bland-altman precision of . % (upper and lower limits of . % and - . %, respectively). the mean semi-automated volumetry was accurate when compared to manual volumetry, with bland-altman precision of . % (upper and lower limits of . % and - . %, respectively), and lin's concordance correlation coefficient (ρc) = . . there was a mean of . % over-segmentation using the semi-automated software. the average user time for semi-automated volumetry was . sec/case, whereas those for manual volumetry were sec/case (p < . ). conclusion: rapid and accurate semi-automated volumetry of pleural effusions in mdct is feasible and reproducible. purpose: to present a paradigm shift in computer-assisted image interpretation and to assess its application in ct colonography. a novel segmentation-free scheme has been developed with the hypothesis that accurate colon segmentation is neither necessary nor an end clinical objective for delivering efficient support such as colon centreline, electronic colon cleansing (ecc) and computer-aided detection of lesions (cad). methods and materials: thick regions are expanded until they encompass statistically significant representations of the colon wall and its surroundings (air, tag, soft/hard tissue). from these regions, a coarse colon centreline is inferred through topological analysis guided by anatomic constraints; ecc is obtained by determining a transposing function depicting the distribution of voxels in a given air-region, and applying said function to tag-regions depicting statistically similar colon wall surroundings; unlike surface shape analysis, a cad identifies local hyper-density concentrations from implicit surfaces flux, at a given depth related to the targeted lesion size. the complete schemes were retrospectively tested on and patients datasets for {centreline; electronic cleansing} and cad, respectively. results: colon centreline extraction was accurate in % of combined cathartic and tagged datasets. cad performance was similar to that in the literature, specifically a sensitivity of % [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] for lesions at least mm featuring a false-positive rate less than per-patient. the presented novel paradigm in computer-assisted image interpretation prevents traditional limitations arising from "accurately segmenting" a specific organ for further processing. to our best knowledge, this is the first attempt to design and validate such a paradigm shift in ct colonography. purpose: the role of mesorectal vasculature in rectal cancer is poorly understood. aim of our study was to determine impact of tumour growth as well as neoadjuvant chemoradiotherapy on mesorectal vasculature. methods and materials: ten patients with locally advanced rectal cancer underwent (re)staging mri. dynamic contrast-enhanced mri with blood pool contrast agent (gadofosveset) was performed. maximal intensity projections (mips) were used to assess macrovascular structure. number, diameter and length of vascular branches were determined in mesorectum surrounding tumour and normal rectal wall. same parameters were used to compare pre-and post-chemoradiotherapy mips. the mesorectal microvascular function was studied using relative enhancement-time curves, and expressed as area under the initial minutes of the enhancement curve (auc). results: a significantly higher number of vessel branches was found in tumourneighbouring mesorectum compared to mesorectum around normal rectal wall (p= . ). furthermore, vessel diameter in tumour surroundings was . mm larger (p= . ). the average auc in tumour-neighbouring mesorectum was also higher ( . and . , respectively (p= . )). comparison of pre-and post-crt mips revealed % lower vessel branching after crt (p= . ). moreover, the vascular diameter of . ± . mm at the primary staging was significantly decreased to . ± . mm after crt (p= . ). in contrast, crt resulted in significantly increased auc values. conclusion: there is a significantly enhanced vascular structure and function in the tumour-surrounding mesorectum, which may have an important prognostic value for rectal cancer patients. furthermore, chemoradiotherapy induces remodelling of the mesorectal vasculature. value of d fse cube sequence at t mri in preoperative local staging of rectal cancer r. scandiffio, p. vagli, p. bemi, a. mantarro, l. faggioni, r. balestri, p. buccianti, e. neri, c. bartolozzi; pisa/it (rossellascandiffio@libero.it) purpose: to compare a standard t w imaging, based on d acquisitions, with d fse cube sequence in the local staging of rectal cancer at t mri. methods and materials: patients with rectal cancer were prospectively evaluated at t mri before and after neoadjuvant chemotherapy. sagittal, coronal, axial and oblique d t w fse images and an additional d t fse cube sequence were obtained. each d dataset was processed with multiplanar and curved planar reconstructions along the rectal centreline. two experienced radiologists, using, respectively, d or d sequences evaluated t and n parameters, with specific attention to measurement of the distance lesion-puborectal muscle and mesorectal fascia, and lesion extension. all t and n parameters were evaluated independently and grouped for statistical analysis. linear cohen k values were calculated to quantify agreement between mri and histopathological data. image quality was evaluated using a linear qualitative scale. results: global sensitivities for t parameters were % and % for d and d images, while n category lesion accuracy values were % and %, respectively. accuracy in measuring the distance from pubo-rectal muscle to lesion border was % and % for d and d, respectively. image quality was considered very good on d images, and good on d images. conclusion: no significant differences between d and d images were observed for t and n staging. t w fse cube demonstrated higher accuracy than d in determining the distance between lesion and pubo-rectal muscle, which represents a key factor in planning surgical resection. purpose: spatial vascular heterogeneity decreases from periphery towards tumour core in solid tumours and is related to cancer viability. this pattern is not present in rectal tumours. the aim of this study was to determine whether rectal tumour spread into layers of rectum, affects tumour vascular function compared to that of normal rectal wall. tumours were segmented into luminal, mural and extramural regions. normal tissue counterparts were defined (mucosa, muscularis propria and mesorectal fat). initial slope (slopei) and area under the first s of enhancement curve (auc ) were determined from relative signal enhancement-time curves. pixel parameter values and mean parameter values were compared per patient and for entire patient group. the correlation between kinetic parameters of tumour segments and of corresponding normal tissues was determined. results: for each patient, both the slopei and auc were significantly higher for luminal tumour pixels compared to mural and extramural tumour pixels (p < . ). mural pixel parameter values were significantly higher than the extramural pixels (p < . ). for the patient group the mean auc for the luminal, mural and extramural tumour region was ± , ± and ± , respectively. there was a strong and significant correlation between the parameters of tumour segments and those of corresponding normal tissues (pearson's correlation coef-ficient= . , p= . ). purpose: patients with complete response (cr) after crt might be considered for less aggressive treatment like a wait-and-see strategy. few studies investigated the value of dwi-mri for predicting cr after crt, but none included lymph nodes in the analysis (ypt n ). the aim of the present study was to retrospectively determine the additional value of dwi-mri to conventional (t -weighted) mri for predicting cr after crt. methods and materials: eighty locally advanced rectal cancer patients underwent crt followed by restaging mri and operation. mri consisted of conventional sequences and dwi. two readers with different levels of experience independently scored conventional images for cr and, in a second reading, combined conventional and dwi-mri images. a -point confidence level score was used to generate roc curves. differences in performance were calculated by comparing areas under the roc curves (auc). interobserver agreement, sensitivity, specificity and positive predictive values (ppv) were calculated. histology served as reference standard. results: ten of patients ( %) had a pathologic complete response (ypt n ). comparison of the roc curves showed significant improvement of the auc only for the experienced reader from . to . (p= . ). sensitivity improved from - % to - %. specificity and ppv improved only for reader from to %, resp., to %. interobserver agreement improved from . to . . conclusion: adding dwi to conventional mri improves diagnostic performance of experienced readers and increases interobserver agreement for identification of cr. sensitivity and ppv remain low, with a considerable risk of over-and undertreatment. purpose: transanal endoscopic microsurgery (tem) is a minimal invasive technique for local resection of t and selected t tumours and is also an emerging option for good-responders after chemoradiation. in most centres follow-up includes regular mri. this study aimed to describe the mr morphology of the rectal wall during follow-up in patients that received tem. methods and materials: forty-nine patients underwent a post-tem mri in our centre. for patients only one post-operative mri was available. for patients > mris were available. the mr morphology of the tem-site was studied on the consecutive mr examinations. patients were primary treated with tem, patients underwent chemoradiation followed by tem. results: we identified three morphological patterns: ( ) rectal wall thickening with or without fibrosis, ( ) a notch at the tem-location, and ( ) irregular delineation of the rectal wall. multiple patterns could occur within one patient. patients ( %) had rectal wall thickening, patients ( %) a notch, and patients ( %) irregular delineation of the rectal wall. in addition to these patterns, oedema (due to chemoradiation) persisted in post-chemoradiation tem-patients. ten patients had dehiscence after tem post-chemoradiation (n= %). six luminal recurrences occurred; had rectal wall thickening, a notch, and an irregular rectal wall. sinogram-affirmed iterative reconstructed simulated ecg-gated ultra high pitch ct pulmonary angiography in the acute setting: effect on dose and image quality s.j. co , s. nicolaou , j. mayo , t. liang , d. hou , k. krzymyk ; vancouver, bc/ca, topanga, ca/us (co.steve@gmail.com) purpose: to evaluate the effect of a simulated ecg-gated computed tomographic pulmonary angiography (ctpa) at kv on image quality and radiation dose. retrospective study includes patients referred for ctpa with pitch . . patients were scanned with a standard kv protocol and patients were scanned with a simulated ecg-gated kv protocol that introduces a specialized cardiac bowtie filter. all other scanning parameters were kept constant. images were reconstructed with filtered back projection and iterative reconstruction (safire, siemens). central pulmonary vessel attenuation and background noise were quantitatively measured and signal-to-noise (snr) and contrast-to-noise (cnr) were calculated. two radiologists performed qualitative assessment grading visualisation of the pulmonary vasculature and noise level (likert scale). volume ct dose index and dose length product were recorded and effective dose was calculated. purpose: to evaluate the impact of iterative reconstructions on the diagnosis of acute pe on low-dose ct angiograms. methods and materials: patients were prospectively enrolled in a study designed to compare low-dose and full-dose images simultaneously available from the same dataset. the examinations were acquired with (a) both tubes set at similar energy ( kvp) and (b) the total reference mas (i.e., mas) split up in a way that % was applied to tube a while % was applied to tube b. three series of images were generated: (a) full-dose images (generated from both tubes), reconstructed with fbp (group ), used as the standard of reference, (b) low-dose images (generated from tube a; % dose reduction) reconstructed with fbp (group ), then with an iterative reconstruction algorithm (safire) (group ). results: all patients showed significant decrease of qs (mean . to . , p <. ), rlr and aopa between initial and f/u ct-pa. in / patients complete pe lysis was found. there was good correlation between reduction of qs and regression of rlr (r=-. ; p <. ) and aopa (r=-. ; p <. ), respectively. rlr and aopa changes (r=. ; p=. ) correlated poorly. patients with initial qs > showed higher reduction of qs at f/u, but no significant difference was found concerning the reduction of rlr between patients with initial qs > and ² (p=. ). the time interval between initial and f/u ct-pa differed between patients with and without complete lysis ( . vs. . weeks, p=. ). conclusion: clot resolution is associated with improvements of rlr and aopa, but the time to complete resolution is variable and not predictable. rlv and aopa are independent markers of right heart burden in patients with pe, but they correlate poorly with each other. clinical significance of high density thrombi on non-enhanced ct scan in patients with pulmonary thromboembolism k.s. beck, b. lee, h. kim, d. han; seoul/ kr (sallahbar@gmail.com) purpose: to evaluate the incidence and significance of occasionally detected high density thrombi of pulmonary embolism (pe) on non-enhanced chest ct scans. we retrospectively evaluated the non-enhanced and enhanced ct findings of patients with pulmonary embolism, and the incidence of high density thrombi was calculated. then in both iso-density thrombi (group ) and high-density thrombi (group ) groups, embolic burden score, ventricular septal bowing, and diameter of right ventricle (rv) and left ventricle (lv) were evaluated and compared using independent sample t tests. purpose: to investigate the general applicability of a kv protocol for routine ct pulmonary angiography (ctpa) in unselected patients. methods and materials: thirteen patients suspected of having pulmonary embolism underwent ctpa with a novel kv protocol ( mas, pitch . ) on a -slice ct device. ten patients who were investigated with the standard protocol ( kv, mas, pitch . ) served as the control group. images were reconstructed with sinogram affirmed iterative reconstruction with medium regulation strength in both groups. ml of contrast material ( mgi/ml) was injected at ml/s. ctdivol, dlp, signal intensity in the pulmonary trunk and segmental arteries and corresponding snr values were compared. images were assessed for diagnostic quality and artefacts. results: chest diameter was not significantly (p> . ) different between the groups. ctdivol ( . vs. . mgy) and dlp ( vs. mgycm) were by % and % lower at kv (p < . ); iodine attenuation was significantly higher (e.g. segmental arteries vs. hu), but so was image noise, resulting in no significant differences in snr. photon starvation artefacts from dense contrast material in the venous system and high image noise in bigger patients were the main drawbacks at kv. conclusion: kv ctpa seems feasible in clinical routine and results in a dose reduction of more than % compared to a kv protocol at equal snr; however, patient selection is advisable. artefacts from inflowing contrast material will require dedicated injection protocols or the use of low-iodine contrast material. purpose: pulmonary hypertension (ph) is a disease characterised by an elevated pulmonary arterial pressure (pap) and is diagnosed invasively via right heart catheterization (rhc). we explored whether timing measures from dynamic contrast-enhanced computed tomography (ct) can be used as a non-invasive method to determine ph. methods and materials: patients ( with and without ph) were examined with a novel dynamic contrast-enhanced ct sequence following their diagnostic or follow-up rhc. x-ray attenuation over time curves were recorded for several regions of interest (rois) in the main pulmonary artery and in the ascending aorta and subsequently fitted with a spline fit. time differences between the contrastmaterial bolus peaks were measured. distances between the rois were measured in a simultaneously acquired thorax ct to calculate the bolus propagation speeds. we compared our results to haemodynamic parameters acquired during rhc. results: time differences between peaks showed good correlation (spearman correlation coefficients ³ . ) with mean pap, pulmonary vascular resistance and gas exchange parameters. discrimination between patients with and without ph was achieved by evaluating time differences (sensitivity/specificity %/ %, % confidence intervals: - % and - %, respectively) and bolus speeds (sensitivity/specificity %, % confidence intervals: - % and - %, respectively). ) . lesions located in the vertebral body were excluded, while lesions in proximity to joints or neurovascular bundles were included. treatment success was determined at clinical and imaging follow-up at , , and months post-treatment. a visual analog pain score (vas) was used to assess changes in symptoms. results: treatment was carried out using a variable number of sonications (mean ± . ) with a mean energy deposition of ± j. there were no treatment-or anaesthesia-related complications. a statistically significant (p= . ) difference was noted between the overall pre-and post-treatment mean vas scores ( . ± . and . ± . , respectively). six of the treatments were conducted on patients with typical osteoid osteoma and all were completely clinically successful. the patient with giant osteoma had pain recurrence after weeks, requiring surgery. at imaging, oedema and hyperemia associated with typical osteoid osteoma gradually disappeared in all lesions. no apparent relationship between nidus vascular extinction and successful outcome was found. conclusion: mrgfus ablation represents an effective and totally non-invasive therapeutic option for osteoid osteoma management, without treatment-related adverse events. purpose: radiographic damage was recently identified as a feature of poor prognosis in polyarticular juvenile idiopathic arthritis (pjia). however, most radiographic studies did not differentiate pjia from other subtypes of jia and little is known in pjia persisting into adulthood. we set out, therefore, to describe radiological peripheral involvement in young adults with pjia as compared to rheumatoid arthritis (ra) patients. methods and materials: all consecutive pjia patients followed in a transition program were included. age, sex, disease duration, and treatment information were collected. laboratory tests and standard radiographs of the hands and wrists, feet and hips were then analysed by two independent radiologists blinded to the diagnosis. a ra control group (< years), matched for sex and disease duration, was recruited. düsseldorf/de (rotem.lanzman@med.uni-duesseldorf.de) purpose: the purpose of our study was to investigate changes in kidney perfusion following renal denervation using arterial spin labelling (asl) mri at . t. methods and materials: patients (mean age ± years) undergoing interventional renal denervation were included in this study. in each patient, between and ablations were performed per renal artery. asl mri was performed at . t using a single-slice fair truefisp sequence in the coronal plane ( averages of label and control pairs, inversion time ms, slice thickness mm, matrix x ) prior to and within hours following renal denervation. patients refrained from fluid intake for at least hours prior to the examination. following post-processing, rois were drawn by a single reviewer on asl parameter maps for quantification of cortical perfusion. both kidneys of each patient were used for statistical analysis. results: image acquisition was completed successfully in all patients and perfusion was determined for kidneys in patients. in patients, asl perfusion increased by at least % following denervation, while in one patient asl perfusion decreased following intervention. mean asl perfusion following renal denervation ( . ± . ml/ g/min) was significantly higher than prior to denervation ( purpose: to evaluate trochlear morphology as a potential risk factor for patellofemoral osteoarthritis, determined by morphological and quantitative measurements of cartilage degeneration using t magnetic resonance imaging (mri) of the knee. methods and materials: mr images of right knees of randomly selected subjects, aged - years, from the osteoarthritis initiative (oai) progression cohort were screened for trochlear dysplasia, defined by a pathological trochlear depth. out of subjects, n= demonstrated a shallow trochlea (depth ² mm; %). in these, and also in a random sample of controls with normal trochlear depth (n= ), we calculated the facetal ratio and assessed knee structural abnormalities using a modified whole-organ-mr-imaging score (worms). cartilage segmentation was also performed and t relaxation times and patellar cartilage volume were determined. anova and multivariate regression models were used for statistical analysis of the association of mri structural measures and trochlear morphology. results: knees with a shallow trochlea showed higher patellofemoral degeneration (worms mean ± standard deviation, . ± . versus . ± . ; multivariate regression, p < . ) and lower patellar cartilage volume than controls ( ± mm versus ± mm , p < . ). knees with a pathological facetal ratio showed increased patellofemoral worms scores ( . ± . versus . ± . , p < . ). t values at the patella were significantly lower in the dysplasia group. however, significance was lost after adjustment for cartilage volume (multivariate regression, p= . ). conclusion: trochlear dysplasia, defined by a shallow trochlea, is associated with higher worms scores and lower cartilage volume, indicating more advanced osteoarthritis at the patellofemoral joint. reliability of tomosynthesis for semiquantitative assessment of knee osteoarthritis features by radiologists with different levels of expertise purpose: to describe early x-ray findings in the hands and evaluate progression of destruction after five years correlated to clinical parameters in early psoriatic arthritis (psa). in men and women with psa fulfilling the caspar criteria hand x-rays were available from the -year follow-up and either inclusion or the -year visit. x-rays were scored by the wassenberg scoring system. results: median symptom duration at inclusion was months. % had polyarticular and % mono/oligoarticular psa. at the first evaluation % had wassenberg score zero. at the -year visit median score was . in patients ( %) the score was still , in between and , in between and , in between and , and patient each had a score of , , , and . at baseline women had significantly higher disease activity than men, but similar x-ray score. at years men had improved considerably in function and disease activity score, but had greater x-ray progression ( % vs %, p= . ). male gender was a significant predictor of x-ray progression. longer symptom duration at entry predicted x-ray progression (p= . ) and prevented minimal disease activity (p < . ). conclusion: after years of psa, most patients still have no or very little hand joint destruction. symptom duration at inclusion and male gender were the main predictors of x-ray progression, preserved function at baseline was protective. despite worse clinical outcome with higher disease activity scores, women had less x-ray progression than men. purpose: cortical thickness mapping is a technique that uses clinical computed tomography (ct) imaging to plot the distribution of cortical bone thickness in d. given our understanding of their relationships with bone mineral density, we performed a study to investigate the effects of age, weight, and osteophytes on cortical bone distribution in the proximal femur. we analysed ct imaging data from a cohort of women aged ± years, selecting one hip from each randomly according to side. a dicom analysis tool (stradwin) was used to contour each hip semi-automatically and create a d surface mapped with individual cortical thickness values. statistical parametric mapping was then performed to investigate model effects of age, weight and osteophytes on cortical thickness. results: cortical thickness was generally thinner with advancing age, but was preserved in characteristic load-bearing regions at the medial femoral neck and lateral subtrochanteric cortex. greater weight was also associated with significantly thicker cortex per kilogram at these same sites. including osteophytes in the model showed that increasing severity was detected as increasingly thick cortical bone around the articular margin at the femoral head-neck junction. conclusion: these results demonstrate, for the first time, the effects of age, weight and osteophytes on cortical bone thickness in the proximal femur. it will be essential for future analysis of bone in this region to take these effects into account. conclusion: raw-data-based iterative reconstruction significantly improved image quality in very-low-dose prospectively ecg-triggered coronary dsct angiography when compared to standard reconstruction using fbp. along with substantial reduction of radiation exposure, iterative reconstruction also shows a trend towards higher accuracy in coronary stenosis detection compared to fbp. methods and materials: patients underwent evaluation of the rv function on . t employing a -element coil. acquisition was performed using a real-time radial ssfp sequence ( projections) in a multislice breath-hold and free-breathing setting with a spatial resolution of x mm (matrix ; slice mm) and a temporal resolution of ms (tr . ms). through-time radial grappa reconstruction was performed off-line (matlab) incorporating fully sampled ( projections) calibration data acquired prior to the undersampled datasets. segmented cartesian cine ssfp was acquired at identical slice positions in multiple consecutive breath-holds with a spatial resolution of . - . x . - . mm, mm slices and ms temporal resolution (tr ms). free-breathing and breath-hold real-time datasets were evaluated for rv size and function and compared with segmented cine ssfp. this hipaa-compliant study was approved by the institutional review board and patients gave informed consent. patients underwent delayed phase cardiac ct on a second-generation dect scanner. late iodine enhancement data were compared with late gadolinium enhancement images from t cardiac mri. dect greyscale images were reconstructed as kv, kv and weighted-average (wa; linear blending) images from low and high kv data incorporating %, % or % of kv data. in addition, a colour-coded map of myocardial iodine distribution was calculated from dect data. two independent blinded radiologists reviewed all images for late enhancement areas in standard cardiac views and rated subjective image quality. results: dect data from kv, wa- % and wa- % showed identical results for the correct identification of myocardial scarring ( % sensitivity, % specificity and % accuracy). however, wa- % received the best subjective image quality rating and average measured infarct size correlated best with mri. colour-coded iodine distribution maps were prone to artefacts ( % sensitivity, % specificity, % accuracy), overestimating quantity of scars while underestimating lesion size by % compared to mri. conclusion: linear blending of delayed phase cardiac dect data improves image quality for the detection of myocardial scar tissue compared to mri. colour-coded myocardial iodine distribution maps were prone to artefacts and showed inferior diagnostic performance. influence of iterative reconstruction on coronary calcium score in cardiac computed tomography k. jaspers , j.a.c. van osch , j.m. groen , m.j.w. greuter ; groningen/nl, zwolle/nl (m.j.w.greuter@umcg.nl) purpose: to investigate the relation between the percentage of iterative reconstruction (ir) and coronary calcium score in cardiac computed tomography (ct). a phantom containing cylindrical calcifications with varying size and density was inserted into a thorax phantom (qrm thorax, qrm, germany) with artificial lungs and spine. the phantom was scanned with a clinical acquisition protocol on a -slice ct (lightspeed vct xt, ge). each scan was repeated five times. the images were reconstructed with filtered backprojection (fbp) and increasing percentages of ir of - %. the amount of calcium was determined as an agatston score. the influence of percentage ir on both total agatston score (tas) of the phantom as well as the individual calcium score (ias) for each calcification was investigated. purpose: to demonstrate that diffusion-weighted imaging (dwi) is able to pick up intracranial recurrences of medulloblastoma (mb) with higher sensitivity than contrast-enhanced (ce) series. methods and materials: all mri examinations of children with histologically proven mb were retrospectively evaluated. routine follow-up examinations were performed initially months after operation and thereafter, every months for the next years. then, controls were done yearly. concomitant cranial and spinal mri included t , t , and flair in the axial plane, followed by t after gadolinium (gd) in orthogonal planes for the brain. additional dwi was performed. subsequent spinal imaging included sagittal t -en t -weighted images. results: eleven recurrences were observed in patients. in patients recurrent disease was observed at the resection site in of which subarachnoid spread was also observed, with recurrence in loco only in patients. five patients had recurrent disease away from the resection cavity, of them in the frontal areas and intraventricular recurrences at the supratentorial level. in patients ce-series scored better than dwi; in patients results on dwi and ce-series were equivocal. in patients, recurrences were better demonstrated on dwi; some of them were only observed in retrospect. the results of our retrospective study demonstrate that dwi is a powerful technique allowing for early diagnosis of recurrent disease in mb patients. dwi especially demonstrates non-enhancing metastatic lesions earlier than celesions. dwi should therefore be included in surveillance imaging protocols of mb patients, especially in the group of high-risk patients. radiation-induced telangiectasia in the long-term survivors of intracranial germ cell tumours: whole-ventricle vs whole-brain radiation l. li, s. mugikura, t. murata, t. kumabe, k. jingu, t. fujii, e. mori, s. takahashi; sendai/jp (liliyanzhen @gmail.com) purpose: telangiectasia on mr images were reported to be seen in patients who received intracranial radiation. to determine the relationship between the radiation field/dose and the prevalence of telangiectasia on mr images, we compared whole-ventricle alone (wv) and whole-ventricle plus whole-brain (wb) radiation groups in the long term survivors (more than years) of intracranial germ cell tumours (gct). we compared the number of telangiectasia on t *weighted mr images (t *wi) between wv (n= ) and wb (n= ) groups. total dose of radiation between two groups was not significantly different ( . evaluation of diffusivity in pituitary adenoma in the sella turcica with d turbo field echo with diffusion-sensitized driven-equilibrium preparation: initial experience a. hiwatashi , t. yoshiura , o. togao , k. yamashita , k. kikuchi , h. honda , m. obara ; fukuoka/jp, tokyo/jp purpose: to evaluate the feasibility of d turbo field echo (tfe) with diffusionsensitized driven-equilibrium (dsde) preparation, which is a novel non-epi technique for diffusion-weighted imaging, for pituitary adenoma in sella turcica. methods and materials: this prospective study included thirteen patients ( females and males, age - years) with pituitary adenomas were imaged with d tfe with dsde preparation. among them four were prolactin-producing (prl), three were growth hormone-producing (gh) and six were non-functioning tumours (non). motion probing gradients were conducted at one direction (a-p) with b values of and s/mm . the imaging voxel size was . x . x . mm . the apparent diffusion coefficients (adcs) were measured in the pituitary adenoma and the normal pituitary gland. results: in each patient, a pituitary adenoma was clearly visualised on d tfe with dsde preparation and adc maps without obvious geometrical distortion. adc of the pituitary adenoma ranged from . to . x - mm /s (mean ± standard deviation, . ± . x - mm /s), and was higher than that of the normal pituitary gland ( . ± . x - mm /s) without statistically significant difference (p > . ). adc in prl ( . ± . x - mm /s) was significantly higher than that in gh ( . ± . x - mm /s) and in non ( . ± . x - mm /s) (p < . ). conclusion: with its insensitivity to field inhomogeneity and high spatial resolution, d tfe with dsde preparation was feasible to evaluate the diffusivity in the pituitary gland. adc measurement using this new technique may help characterise hormone activity of pituitary adenomas. author disclosures: m. obara: employee; makoto obara. and . gy in wb groups). in the wb group, axial sections of the ventricular level were considered to have received significantly higher dose of radiation ( . gy, high-dose field) than the other upper and lower levels ( . gy, low-dose fields). in the wb group, we compared the number of telangiectasia on t *wi between ventricular level and the other upper and lower levels. results: telangiectasias were observed in ( %) patients. the number of telangiectasia in the wb group was significantly higher than the wv group (average . in wb and . in wv, p = . ). in wb group, the number of telangiectasia was significantly higher in the ventricular level than the other upper and lower levels (p < . ). conclusion: radiation-induced telangiectasia appears to occur in at least % of patients who undergo cranial irradiation. larger radiation exposure and higher radiation dose were associated with higher number of telangiectasia lesions. preoperative classification of cerebral tumours by applying whole brain vpct: which parameter to use in order to achieve the highest prognostic value? results: typical features of fibroadenomas were "lobulated shape" (or= . ), "sharp margin" (or= . ), "internal septations" (or= . ), "hyperintense signal in t w" (or= . ) and "persistent curve-type" (or= . ; all: p < . ). diagnostic accuracy increased significantly (p < . ), if features were assessed in combination. highest values were then observed, if the following feature combinations were present: "sharp margin and persistent curve type" (or= . ), "plateau and internal septations" (or= . ). overall accuracy of breast mri for the differential diagnosis of fibroadenomas vs. breast cancers revealed excellent auc ( . , cross-validated sample). conclusion: in breast mri fibroadenomas show typical morphologic and dynamic characteristics. particularly, if multiple breast mri characteristics are assessed in combination, differential diagnosis vs. breast cancer is possible with excellent accuracy. purpose: to compare lesion detection and characterisation by the combination of one-view breast tomosynthesis (dbt) and one-view digital mammography with two-view digital mammography (mx). the study included consenting women with breast lesions classified as suspicious at mammography and/or ultrasound. a clinical performance study comparing two-view (cc, mlo) mammography, and the combination of dbt in mlo view and mx in cc-view (dbt+mxcc) was conducted with six breast radiologists. data were analysed per-lesion, using lesion localisation fraction -llf (the percentage of lesions correctly localised). lesion detection was determined by calculating the total number of lesions rated above bi-rads . lesion characterisation was evaluated by counting malignant lesions rated above bi-rads and benign lesions scored bi-rads or . lesion detection and characterisation for all lesions, and stratified for malignant and benign lesions, were compared between dbt+mxcc and mx using analysis of variance (anova). p-values < . were considered statistically significant. the non-inferiority margin was set at %. results: overall, dbt+mxcc was superior to mx alone in terms of number of lesions correctly detected and characterised (llf difference: + . %, - % ci: + . %; p-value = . ). dbt+mxcc superiority was confirmed for benign lesions (llf difference: + . %, - % ci: + . %; p-value < . ), while noninferiority was achieved for malignant lesions (llf difference: + . %, - % ci: - . %; p-value < . ). purpose: to estimate the inter-reader reproducibility of dbt added to d-dm in comparison to that of d-dm alone. a series of breasts ( women, aged ± years) underwent dbt (giotto, ims, italy) as an adjunct to d-dm. after an agreement on how to report d-dm and dbt, independent readers (r , r , r ) with > years of experience in d-dm and > year of experience in dbt evaluated all studies. each reader evaluated the breast density and assigned a bi-rads score using only d-dm. after days, they repeated the evaluation adding dbt to d-dm. the inter-reader reproducibility was estimated using the quadratically weighted cohen's kappa. the breast density reported at d-dm by the most experienced reader was: % in ( %). considering the b , b , b , b , and b bi-rads scores, the same reader assigned the followings: , , , , and using d-dm; , , , , and using d-dm plus dbt. for each pair of readers, d-dm plus dbt resulted in a higher inter-reader reproducibility than that of d-dm alone: kappa value for d-dm ranged from . to . while that for d-dm plus dbt ranged from . to . . purpose: based on a novel approach, digital breast tomosynthesis (dbt) may simultaneously acquire d and d images of the breast. variable dose geometry is used to give a sufficient dose in the central projection for that image to be a d mammogram ( d-cp). we investigated whether d central projection ( d-cp) obtained with dbt is equivalent to digital mammography (dm) in terms of image quality. we retrospectively evaluated asymptomatic patients who underwent dm and dbt with d-cp for screening. two experienced radiologists in consensus reviewed the dm and d-cp images in separate sessions. readers were asked to subjectively score image quality on a - scale in terms of a) artefacts ( =absent to =significant artefacts), b) noise ( =absent to =very high noise) and c) fibro-glandular-breast-tissue-to-fat-contrast ( =poor to =excellent). the comparison between d-cp and dm scores was performed with a wilcoxon signed-rank-test on a per-breast basis. results: there was no significant difference between dm and d-cp in terms of artefacts, with median scores of . for both techniques (p> . ). a significant difference (p < . ) was found between dm and d-cp concerning noise and contrast (median were vs and vs , respectively). conclusion: although dm is superior to d-cp in terms of image noise and contrast, both techniques showed a reduced incidence of artefacts. clinical studies should be performed to assess whether this qualitative difference has clinical relevance. the role of additional ultrasound and tomosynthesis after normal digital mammography: comparison between both techniques p. slon, j. etxano, i. purpose: to increase the diagnostic accuracy of mri in the detection and local staging of bladder tumours by using fluid-attenuated inversion recovery (flair) sequences. methods and materials: patients with bladder tumours detected by us underwent mri using . t superconductive magnet. we performed tse t -weighted and t -weighted and flair sequences on axial scans. the contrast to lesion ratio was always evaluated. all the patients underwent cystoscopy with transurethral biopsy and had subsequent cystectomy. in comparison with other sequences, flair sequence was more sensitive in the detection of bladder neoplasms. this sequence demonstrates the hyperintense signal of bladder neoplasms from the filled bladder lumen with no signal. the sensitivity in the identification of bladder neoplasms was % with flair sequences, . % with tse t -weighted sequences and . % with tse t -weighted sequences. that was due to the higher signal-to-lesion ratio of flair sequences in comparison with the others. in fact, on flair sequences the mean value of contrast to lesion ratio of bladder neoplasm was . while on se t -weighted sequences and tse t -weighted sequences was, respectively, . and . . flair sequences allowed the detection of small papillomas (< mm). tse t -weighted sequences were more sensitive than other sequences in the study of bladder wall infiltration. conclusion: flair sequences were more sensitive in the detection of bladder neoplasms, thanks to their higher contrast-to-lesion ratio and were helpful in the visualisation of small papillomas, especially when multifocal. while the inter-reader reproducibility of d-dm resulted only moderate, the adjunction of dbt allowed to reach a substantial reproducibility. the use of dbt added to d-dm can reduce inter-reader variability and allow for more reliable readings from different radiologists. the oblique coronal scans were parallel to the plane of the bladder neck. patients underwent also voiding mr-cystourethrography performed with t -weighted spoiled d gradient-echo acquisitions on sagittal plane performed after the filling of bladder lumen with contrast-material-enhanced urine. the entire mr examination lasted no longer than minutes. we detected patients with abnormality of smooth muscular structures of the bladder neck and with bladder neck cyst. mri allowed a perfect evaluation of the different smooth detrusor muscles of the bladder neck. in patients with urinary bladder neck dysfunction, we detected hypertrophy of posterior smooth muscular structures of bladder neck and kyphosis of prostatic urethra. patients were able to perform voiding mr-cystourethrography that showed the characteristic radiological features. conclusion: mri with voiding mr-cystourethrography could be performed in male patients with bladder outlet obstruction in order to visualise the aspect of the b- : purpose: the non-invasive investigation of urinary bladder carcinoma by magnetic resonance (mr) virtual cystoscopy was evaluated by us and compared with conventional cystoscopy. methods and materials: thirty consecutive patients, presenting with gross haematuria and trans abdominal ultrasound suggestive of mass in the bladder were taken up for study. all patients underwent conventional cystoscopy and ciss d mr imaging and the images reconstructed for virtual cystoscopy using volume rendering technique. lesions were detected and the number, size, location and morphologic features of lesions were noted. subsequently, patients underwent conventional cystoscopy, and the findings were noted. the final diagnosis of the cases was established by histopathology. results: sixty-five lesions were seen in mr virtual cystoscopy and in conventional cystoscopy. the smallest lesion identified on mr virtual cystoscopy was mm. overall sensitivity and specificity of mr virtual cystoscopy for lesion detection were . and %, respectively. for lesions greater than mm, the detection rate was %.pearsons correlation test showed a good between virtual and conventional cystoscopy for maximum and minimum diameters of the lesion ( . and . , respectively). location of the lesions and their morphological characteristics were found to correspond by both methods. conclusion: mr virtual cystoscopy is an effective tool in the detection of urinary bladder tumours, especially those larger than mm. when bladder lesion is less than mm a sessile conventional cystoscopy is better than mr virtual cystoscopy. purpose: to evaluate the diagnostic accuracy of a diagnostic imaging technique called voiding mr cystourethrography. methods and materials: normal volunteers and male patients with bladder outlet obstruction (evaluated with urine-flow velocity recording) underwent voiding mr cystourethrography. the mr examination was performed with . t superconductive magnet. the filling of the urinary bladder with paramagnetic contrast agent was obtained by the i.v. administration of furosemide followed by ¾ of the normal dose of a paramagnetic contrast agent. during the micturition two consecutive t -weighted spoiled d gradient-echo acquisitions on sagittal plane were performed. d row images were post-processed with mip algorithm. patients performed retrograde and micturating conventional cystourethrography in the month preceding mri. results: homogeneous opacification of the bladder lumen was always obtained. patients were unable to perform the mr examination. in all the volunteers and in all the patients studied ( pts), a perfect evaluation of the male urethra with mri was obtained and its visualisation with mip reconstructed images was considered comparable to that obtained with conventional cystourethrography. site, length and number of urethral strictures were accurately determined. the analysis of d sagittal scans allowed a better evaluation of the morphology of the urethral strictures in comparison with conventional cystourethrography. conclusion: voiding mr cystourethrography demonstrates the morphology of the bladder neck and urethra during the micturition and can substitute standard cystourethrogram, avoiding radiation exposure to the gonads and urinary catheterization. image quality on liver ct based on sinogram-affirmed iterative reconstruction algorithm b. schulz, b. bodelle, p. siebenhandl, m. beeres, f. al-butmeh, c. frellesen, t.j. vogl; frankfurt a. main/de (mail@borisschulz.com) purpose: to evaluate efficiency of sinogram-affirmed iterative reconstruction technique, regarding noise and image quality on contrast-enhanced computed tomography (ct) of the liver. methods and materials: ct examinations were performed upon patients ( slice ct, kv, mas, activated tube current modulation, . mm collimation). each examination was reconstructed at standard filtered back projection (fbp) and different safire strengths in mm images in transversal direction with soft tissue kernel. image noise was defined as standard deviation (sd) of hounsfield units (hu) in air, and signal-to-noise ratio (snr) of the liver was defined as mean liver hu per liver sd. subjective image quality was evaluated by three raters using a -point scale ( =non-diagnostic image quality, =excellent image quality). results: average image noise was . hu (fbp), vs. . hu (safire ), vs. . (safire ) . hu (safire ), . hu (safire ), . hu (safire ). snr of the liver consecutively increased when using the iterative reconstruction algorithms from . (fbp) to . (safire ) to . (safire ) to . (safire ) to . (safire ) to . (safire ). the differences in image noise and snr of each safire-strength to fbp was statistically significant (p < . ). subjective image quality was voted . (fbp) vs. . (safire ) vs. . (safire ) vs. . (safire ) vs. . (safire ) vs. . (safire ). conclusion: sinogram-affirmed-based iterative reconstruction technique significantly reduces image noise and increases snr for examinations of the liver. however, subjective image quality decreases with strong iterative strengths. bladder neck. these anatomical information are useful to determine the causes of voiding obstruction and diagnose urinary bladder dysfunction. mri findings of radiation-induced changes in the urethra and periurethral tissues in patients with prostate cancer c. marigliano , o.f. donati , o. akin , d. goldman , j. eastham ; rome/it, new york, ny/us purpose: the aim of this study was to assess radiotherapy (rt)-induced changes in the urethra and periurethral tissues in patients with prostate cancer (pca). this retrospective study included men (median age, y; range, - y) who underwent external-beam radiotherapy (ebrt) and/or brachytherapy for pca. on endorectal-coil mris of the prostate obtained within d before rt and - months (median, months) after rt, two readers independently measured the urethral length (ul) and graded the margin definition (md) and signal intensities (sis) of the urethral wall, the levator ani and obturator internus muscles and the muscles of the genitourinary diaphragm on -point scales. results: mean ul decreased significantly from pre-to post-rt mri for both readers (from . to . mm and . to . mm, [p < . , both]). inter-reader agreement for ul was excellent for pre-and post-rt mri (icc= . and . , respectively). both readers found significantly decreased md and increased si in the urethral wall and pelvic muscles on post-rt mri (p? . ). inter-reader agreement was fair for md (?= . , pre-and post-rt) and si of the urethral wall (?= . , pre-and post-rt) and ranged from slight to moderate for si of the pelvic muscles (?= . - . , pre-rt and?= . - . , post-rt). si changes in the obturator internus muscle were greater after ebrt (p= . - . ), while si changes in the levator ani muscle were greater after brachytherapy (p= . ). conclusion: after rt of the prostate, mri shows urethral shortening, decreased urethral margin definition and increased si of the urethral wall and pelvic muscles. mri anatomic evaluation in patients with persistent urinary incontinence after advance male sling: a work in progress study with a t system v. zampa, d. pistolesi, s. ortori, l. faggioni, m. marletta, c. bartolozzi; pisa/it (virnazampa@hotmail.com) purpose: retrourethral transobturator sling is a new functional treatment of stress urinary incontinence after prostatectomy consisting in repositioning the urethral sphincter into the pelvis. overall success rate is - %; however, a failure rate of - % is reported. the aim of this study was to retrospectively analyse morphologic changes visible on mri after sling procedure in incontinent patients and compare with the continent ones, in order to detect possible factors explaining the different clinical outcome. methods and materials: patients treated with advance sling were enrolled: / had clinical recovery while / had persistent incontinence. mr protocol performed with a t system included d t w sequence (cube) and a high temporal resolution fiesta for dynamic mri. on the t w sequence, the length of the bulbus posterior to the sling and the distance of the sling from a line parallel to the symphysis pubis (lsp), were measured. mann-whitney test was used to analyse the results. results: in the incontinent patients the length of the bulbus posterior to the sling was < mm (range - mm) while in the continent ones was > mm ( - mm) (p < . ). the sling position was located posterior to the lsp in / incontinent patients ( - mm) and almost coincident in / continent patients (p= . ). conclusion: based on our results, the length of the bulbus posterior to the sling seems to strongly correlate with continence. although our results must be confirmed in a larger series, surgeons should consider this element in planning the proper position of the device. of the patient and type of examination semiautomatically. in addition, abdominal ct examinations were performed with a standard tube potential of kvp. radiation doses (ctdivol) were noted for all examinations. signal-to-noise ratio (snr) was determined in the contrast-enhanced lumen of the abdominal aorta (a), liver (l) and spleen (s). subjective iq (lesion detectability, diagnostic confidence) was rated on a -point scale ( _non diagnostic; _excellent) by two readers. results: whereas noise level was slightly elevated when using tps algorithm compared to the standard protocol ( . vs. . hu, p < . ), no significant differences in snr ( . ± . vs. . ± . [a], . ± . vs. . ± . [l], . ± . vs. . ± . [s]) were observed between the two protocols. subjective iq (mean score of . versus . , respectively) was good to excellent in all examinations. tps lowered the ctdivol significantly as compared to standard abdominal ct ( . ± . mgy vs. . ± . mgy, p < . ). conclusion: attenuation-based tps lowers the dose of abdominal ct in clinical routine by up to % while maintaining high subjective and objective image quality. second generation dual-energy ct of the abdomen: radiation dose comparison with -and -row single energy acquisition c.n. de cecco, a. darnell, n. macias, g. muscogiuri, c. ayuso, a. laghi; rome/it (g.muscogiuri@gmail.com) purpose: this study was designed to compare the radiation dose in abdominal dual-energy (de) and single energy (se) acquisitions obtained with a dual-energy ct (dect) and a -row ct (sect). a total of patients divided into two groups underwent precontrast and portal abdominal -row ct examination. in group a, de portal acquisition was performed; group b underwent se portal acquisition. group c was compound of subjects from group a studied with -row sect. in each group, the portal phase dose length product (dlp) and radiation dose (msv) were calculated. results: a significant radiation dose increment (p < . ) was observed in group a . ± . msv in comparison to group b . ± . and group c . ± . msv. no significant difference (p> . ) was reported between se -and -row acquisitions. a significant positive correlation between radiation dose and bmi was observed in each group (group a, r = . , p < . ; group b, r = . p < . ; group c, r = . , p= . ). in clinical practice, abdominal de modality delivers a significant higher radiation dose to the patient compared to -and -row se acquisition. the radiation increment can be justified if a real advantage in patient diagnosis is obtained using de information. can iterative reconstructions improve the detection of small hypervascular liver nodules with dual-energy ct? l. facchetti , l. berta , l. mascaro , f. pittiani , l. romanini , r. maroldi ; brescia/it, milan/it (facchettil@gmail.com) purpose: to optimise dual-energy ct (dect) protocols with sinogram iterative reconstruction (safire) algorithms for improving small hepatocellular carcinoma (hcc) detection. a dect arterial acquisition of a cirrhotic patient was reconstructed using the standard filtered back projection (fbp-b f) and iterative reconstructions both for the whole dose protocol (de composition . ) and for -kv acquisitions. each one of the iterative medium-smooth filter (i -i -i ) was reconstructed at different strengths (s -s -s ) for a total of image series. for each series, virtual spherical lesions were simulated in random positions on the liver. a lesion-to-liver contrast (llc) of + hu was selected for de-composition . and + hu for kv, according to a preliminary study on hccs acquired with dect. four expert radiologists performed a detectability test and rated the overall quality, noise and sharpness ( -point scale) in all images. results: / lesions were detected with fbp-b f. in all the iterative reconstructions, the strength- kernels led to detect ± . / lesions. the highest image quality ratings were . ± . (b f), . ± . (i -s de-composition . ) and . ± . for i -s de-composition . , without a statistical difference (anova test). all subjective ratings in the kv series were defined as suboptimal ( . ± . ). conclusion: iterative reconstructions increase the sensitivity of the detection of sub-centimetric low-contrast lesions, even in the -kv series delivering half dose. the i -s reconstruction was considered the best for the routine protocol. efficacy of a liver detection algorithm for noise reduction in abdominal ct n. ardley , k. buchan , k. lau ; clayton/au, melbourne/au (nicholas.ardley@southernhealth.org.au) purpose: the liver, an inherently low contrast structure, appears 'noisy' on routine ct of abdomen. this may impede liver lesion detection. the development of a specific ct liver detection algorithm delivers higher radiation exposure to the liver with the aim of improving quantum noise, and correspondingly less radiation to the remaining abdomen. the aim of this study was to assess the efficacy of this algorithm on reducing noise in the liver. methods and materials: consecutive patients for abdominal ct with same level of iterative reconstruction were included. there was no exclusion. the ct liver detection algorithm was enabled in the last of these patients. region of interest in hounsfield units and standard deviation (sd) were measured in the left and right lobes of liver, spleen, psoas and bladder for all patients. radiation doses were also recorded. the results of the two groups were compared. results: sd reflected noise. in the liver detection algorithm group, there was a sd reduction by . % in the right liver, . % in the left liver and . % in spleen. no significant change of sd was seen in psoas and bladder. a . % overall radiation dose reduction was noted in this group. the application of this newly developed ct liver detection algorithm demonstrated a reduction in noise in the liver and spleen with no significant noise changes in the remaining abdomen. there was an added benefit of overall radiation dose reduction. author disclosures: k. buchan: employee; philips healthcare. impact of modified abdominal ct protocols for obese patients with filtered back projection and hybrid iterative reconstruction technique on image quality, radiation dose and low-contrast detectability: a phantom study s.t. schindera , d. odedra , d. mercer , s. thipphavong , p. chou , z. szucs-farkas , p. rogalla ; basle/ch, toronto, on/ca, biel/ch (sschindera@aol.com) sunday data were collected in a time period of - minutes for the t w sequences. volunteers underwent subsequent t w respiratory-gated mrc on a t mri. for qualitative analysis a -point scale was used. contrast ratios were calculated for quantitative assessment. results: contrast-enhanced t w mrc at t showed a homogeneous depiction of the intra-and extrahepatic biliary tract with a maximum enhancement minutes post-contrast. vibe and flash ir provided a good image quality for the intra-(vibe . , flash ir . ) and extrahepatic bile ducts (vibe . , flash ir . ). quantitative analysis revealed high cr values for flash ir (cr . intrahepatic and . extrahepatic) due to a strong signal decrease of hepatic tissue and vessels. t w tse at t revealed a poor image quality without diagnostic potential ( . intrahepatic, . extrahepatic). t vibe and flash provided superiority in the depiction of the intrahepatic bile ducts, while t mrc was superior in the delineation of the extrahepatic biliary tract. conclusion: our results demonstrate the feasibility of contrast-enhanced imaging of the biliary ducts at t, particularly t w flash with inversion recovery enables high-quality assessment of the biliary tract. purpose: volume rendering d-magnetic resonance imaging (mri) is able to show auditory pathways between the cochlea and the cerebellopontine angle in children with negative auditory brainstem responses and cochlear nerve structures undetectable by conventional high-resolution (hr) mri. methods and materials: twelve children (mean age ± . mo) with confirmed severe hearing loss by abr (auditory evoked brainstem responses) underwent hr-ct and hr-mri of the petrous bone. in addition, three-dimensional t -weighted turbo spin-echo axial slices were obtained at . t and maximum intensity projections and d volume reconstructions were performed for visualisation of the cochlear anatomy. results: abnormal cochleovestibular anatomic findings such as incomplete partition type i (n= ), incomplete partition type ii (n= ), narrow internal auditory canal (n= ), splitting of the internal auditory canal and concomitant anomalies of the posterior labyrinth (n= ) were detected by hr-ct and hr-mri. interestingly, volume-rendered d inner ear reconstructions detected varying but communicating structures of the cochlea and the brainstem in all cases. after cochlear implantation all twelve children showed obvious hearing reactions. conclusion: in contrast to conventional hr-mri, d-mri volume-rendering reconstructions are useful to detect aberrant and even tiny auditory path structures derived from the cochlea. children with severe hearing loss and hr-mri-based findings of missing cochlear nerve structures should be further screened with volume rendering d-mri during cochlear implantation evaluation. purpose: cochlear nerves aplasia represents a rare but possible congenital cause of sensori neural hearing loss (snhl) in children. early identification and accurate diagnosis are mandatory to correctly select auditory brainstem implantation (abi) candidates. the purpose of the study was to evaluate the contribution of a complete pre-operative radiological assessment based on ct and mri to prevent misdiagnosis and erroneous treatments. purpose: to correlate patient diameters and subjective image quality in low-voltage and standard-voltage ct of the upper abdomen in the same patient population, with the goal of identifying cutoff patient diameters for selecting patients for lowvoltage scans. methods and materials: patients underwent mdct of the abdomen with arterial phase at kv with angular dose modulation on -row mdct (test group). this was compared to a previous -kv scan on the same scanner. mean interval between scans was days. patient transverse and sagittal diameters were measured at celiac axis level, and the mean was calculated. two radiologists by consensus graded image quality on a -point scale ( =excellent; =good; =moderate; =poor; =non-diagnostic; was the chosen cutoff quality). image quality was correlated to the transverse, sagittal and mean diameter by means of an anova test. results: patient diameters were unchanged across exams (all p=ns). in -kv scans, image quality was significantly correlated to sagittal (p= . ) and mean diameters (p= . ), while a trend to significance was observed for transverse diameter (p= . ). in -kv scans, image quality was not significantly correlated to patient diameters (all p=ns), and all patients received grade or . in -kv scans, a subjective grade corresponded to a transverse diameter of mm and a sagittal diameter of mm. conclusion: subjective image quality in low-voltage scans appears to be more influenced by patient size than at standard voltage scans. for our protocol, cutoff diameters for adequate image quality are transverse mm and sagittal mm. author disclosures: g.a. zamboni: speaker; guerbet. preliminary application of spectral ct imaging in the differentiation of hepatic tumours w. chen, x. ye, c. zhou; beijing/ cn (wenchen @yahoo.com.cn) purpose: to investigate the value of spectral ct imaging in differential diagnosis of hepatic tumours. this prospective study was institutional review board approved with patient consent. thirty-eight patients with hepatic tumours ( men, women, lesions), including patients with hepatocellular carcinoma (hcc), with hemangioma (hh) and with metastatic tumour (mt), underwent plain scan of spectral ct imaging and conventional contrast ct scan. contrast-to-noise ratio (cnr) of different energy levels and homologous kev of optimal cnr were calculated by the spectral analysis software. the authors also chose three regions ( - kev, - kev and - kev) and calculated the slope rates of spectral curves. one-way anova followed by lsd post hoc tests were performed to compare parameters among hcc, hh and mt groups. the homologous kev of optimal cnr of hcc, hh and mt groups were . ± . , . ± . and . ± . , respectively. the slope rate of - -kev region in hcc group ( . ± . ) was significantly higher than that in hh group ( . ± . ). there were significant differences between hcc, hh and mt groups in the slope rates of - -kev and - -kev regions (p < . ). the slope rates were . ± . , . ± . and . ± . , respectively, in - -kev region and . ± . , . ± . and . ± . , respectively, in - -kev region. the - -kev monochromatic imaging of spectral ct imaging is the best for detection of hepatic tumours and slope rates of spectral curves may be useful in differentiation of hepatic tumours. purpose: to assess the feasibility of magnetic resonance cholangiography (mrc) using biliary secreted gadoxetic acid at tesla (t) and to compare it to t -weighted (w) mrc at t. methods and materials: healthy volunteers were examined on a t mr-system. t w tse, t w vibe and flash with inversion recovery (ir) were acquired in coronal orientation. for dynamic imaging gadoxetic acid was administrated and s c a d e f g b -gkr= * a.u. (p < . ); wipi values were: b-gkr= * cm /sec, -gkr= * cm /sec (p> . ), -gkr= * cm /sec (p < . ). -gkr mean diameters decreased in / patients, -gkr ceus parameters (pe, wir, wipi) decreased in all patients. conclusion: a reduction in pe, wir and wipi at months after gkr suggested a depletion in tumour vascularization due to radiotherapy-induced necrosis. our preliminary results showed the feasibility of ceus perfusion analysis for um, which could provide reproducible, reliable and earlier parameters for the assessment of tumour response to gkr. evaluation of lacrimal drainage system obstruction using combined multidetector ct and instillation dacryocystography m. shweel, a. elshafaey, m. nasar, r. mohyeldien; elminia/eg (mohshweel@yahoo.com) purpose: to assess the use of combined multidetector computed tomography and instillation dacryocystography (ctdcg) in detection of the level of lacrimal drainage system (lds) obstruction. methods and materials: twenty-one patients with one-sided epiphora were our candidates for ctdcg. axial source and post-processing images were assessed for clear viewing and the ability to detect the level of lds obstruction. to our knowledge, no previous studies used this combination in the assessment of the lds obstruction. results: all patients tolerated the examination well. various levels of lds obstruction were detected, common canaliculus in ( %) patients, lacrimal sac in ( . %), junction between lacrimal sac and nld in ( . %) and nld obstruction in ( . %) patients. the most common ctdcg findings were dilated opacified lacrimal sac with no opacification of the nasolacrimal duct (nld) in / ( . %) patients. curved planner reformation (cpr) was excellent to detect the nasolacrimal duct (nld) obstruction. conclusion: ctdcg is a non-invasive patient friendly procedure that adds benefit in documentation and preoperative planning. parotid gland tumours shear wave elastography: a preliminary study s. espinoza-boireau, i. khettab, a. lacan melki, p. halimi; paris/fr (sophie.espinoza@gmail.com) purpose: to assess the feasibility of parotid gland tumours shear wave elastography. to establish normal parotid gland elasticity. to evaluate elasticity for the most common benign parotidian tumours (pleomorphic adenoma, warthin's tumour) and malignant tumours. methods and materials: prospective study including consecutive patients with parotid gland tumour. they all underwent share wave elastography to measure tumour elasticity and contralateral normal parotid gland elasticity. the results were confronted with histological analysis or fine-needle aspiration cytology. results: elasticity measure was feasible in all cases. mean normal parotid gland elasticity was kpa (n= ; - ). benign tumours elasticity was . ± kpa (n= ). malignant tumours elasticity was ± kpa (n= ). pleomorphic adenomas elasticity was . ± kpa (n= ). warthin's tumours elasticity was . ± . kpa (n= ). conclusion: benign and malignant tumours seem to behave differently under shear wave elastography. complementary studies are required to establish relevant threshold values allowing proper elastography lesions discrimination. does heterogeneous echogenicity of the thyroid parenchyma influence the detection of multifocality and bilaterality for papillary thyroid carcinoma on preoperative ultrasound staging? s. herh, e.-k. kim, h. moon, j. kwak; seoul/kr (jinnyhs@hanmail.net) purpose: this study was to evaluate whether heterogeneous echogenicity of the thyroid parenchyma can influence the diagnostic performances of ultrasonography (us) in detection of multifocality and bilaterality of papillary thyroid carcinoma (ptc). between december and january , patients had preoperative staging us for ptc, and underwent total or near-total thyroidectomy. seven experienced radiologists performed preoperative us for t and n staging. underlying parenchymal echogenicity of the thyroid gland, multifocality, and bilaterality of the thyroid nodules were also evaluated. patients were divided into two groups according to the underlying echogenicity of thyroid parenchyma on us. to evaluate the diagnostic accuracy of preoperative staging us according to the underlying thyroid echogenicity, diagnostic performances including sensitivity, with cochlear implantation without benefits. all the children performed pre-operative functional tests, temporal bone ct and brain/cerebellum-pontine angle (cpa) mri. results: mri showed in all cases the absence of the cochlear branch of the eighth nerve bilaterally ( / ). unilateral facial nerve aplasia was present in one patient. associated inner ear malformations were present in / patients, in particular common cavity in / , incomplete partition type in / and semicircular canals malformations in / . no brain anomalies were showed. ct scans better depicted the labyrinthine malformations, adding information about facial nerve canal and internal auditory canal (iac) size. / ct showed normal inner ear structures and iac size. providing accurate information about cochlear nerve and brain anomalies is crucial in the pre-operative assessment of snhl patients. mri is the only radiological technique that is able to directly demonstrate the presence or the absence of cochlear nerves. ct is not fundamental and provides complementary information; a negative ct pattern cannot exclude a cochlear nerve malformation. purpose: to test whether the size of the cochlear nerve measured in the internal auditory canal using three dimensional ( d) and multiplanar reconstruction (mpr) high-resolution mri affects the speech recognition outcome following cochlear implantation. the study was retrospectively performed on patients with longstanding hearing loss (mean age of . years). mri was performed using a t -weighted space sequence. mpr and d reconstructions were performed using d and inspace applications, respectively. the preoperative cross-sectional surface area of the cochlear nerve was measured by drawing a region-of-interest around the circumference of the nerve. speech recognition (sr) was tested using the freiburger-monosyllabic-words (mswt) and numbers-tests (nt) preoperatively, postoperatively, at -, -and -month follow-up. sr and size assessment were performed in a double-blinded fashion. the correlation between the sr and nerve size were tested using spearman's rank correlation test. purpose: gkr efficacy in the treatment of um, a hypervascular tumour, is conventionally assessed by clinical and ultrasound findings. previous reports showed that, in case of hypervascular lesions (hcc, melanoma metastasis, etc). changes in vascularization precede diameters reduction after treatment. hence, our aim was to evaluate ceus in the quantitative assessment of tumour response to gkr. methods and materials: ten patients, who underwent gkr, were enrolled. ceus was performed (sonovue bracco) with iu- atl (philips) and - mhz linear probe at baseline, at and months after gkr (bgkr, -gkr, -gkr). two main tumour diameters and different quantitative parameters related to blood volume (area under the curve in the wash-in phase; wash-in perfusion index -wipi; peak enhancement -pe) and blood flow (mean transit time; wash-in rate -wir; rise time -rt; time to peak) were evaluated using a dedicated software (sonotumor bracco). purpose: to determine the value of semiquantitative strain elastography for the evaluation of chronic thyroiditis. the study was conducted on consecutive patients with chronic autoimmune thyroiditis and healthy controls. semiquantitative strain elastography was performed to calculate the strain index value (strain ratio of the strap muscles to the thyroid parenchyma) to assess thyroid stiffness. for each lobe, measurements were obtained from upper, middle and lower part of the thyroid parenchyma. mean strain ratio values of patients and healthy controls were compared by the mann-whitney u-test. validity was analysed by receiver operating characteristic (roc) curves. the median strain ratio value of patients with chronic autoimmune thyroiditis ( . ) was significantly higher than that of healthy controls ( . ; p < . ). the optimal cut-off value for the prediction of diffuse thyroid pathology was . . for this cut-off value, thyroid stiffness had % sensitivity, . % specificity, % positive predictive value (ppv) and . % negative predictive value (npv) for the presence of diffuse thyroid pathology. this cut-off point was exceeded by . % of the patients with and . % of the subjects in control group. si values showed mild positive correlation with the tsh levels (spearman r coefficient = . ). however, this difference did not reach statistical significance (p= . ). conclusion: semiquantitative strain elastography seems to be a useful method for the assessment of chronic thyroiditis. further studies are warranted in larger patient groups to determine the reliability of sonoelastography in patients with chronic thyroiditis. purpose: to retrospectively assess the detection rate of intracranial hematomas achieved with the use of curved mips of the meningeal spaces, compared to reading transverse ct sections only. this retrospective study was approved by the institutional review board of our institution, which waived informed consent. consecutive patients who underwent ct imaging for cranial trauma (n = ; men and women; mean age, ± y; range, - y) were included. four curved mips of the meningeal spaces with different thicknesses were rendered for each patient. four radiologists independently evaluated all cases. hematomas of less than mm thickness were considered 'thin' throughout this study. the radiologists were blinded to patient names, and patient and group order was randomised. the results were compared to a standard of reference built by two experts. logistic regression with repeated measurements was used for statistical analysis. results: intracranial hematomas were confirmed in patients. for all readers, the reading time for hematoma detection was significantly shorter ( - times, p <. )) for curved mips. the mean lesion-based detection rate of all readers was % ( / ) for transverse sections and % ( / ) for curved mips. for thin hematomas, the mean detection rate rose from % ( / ) with transverse sections to % ( / ) with curved mips. specificity, positive predictive value (ppv), negative predictive value (npv), and accuracy were calculated and compared among the two groups. results: of the patients, underlying echogenicity of thyroid was heterogeneous in patients ( . %), and homogenous in patients ( . %). forty-four ( . %) of the patients had multifocal lesions in one lobe, and ( . %) had bilateral lesions on pathologic examination. diagnostic performances of preoperative staging us did not show significant differences in detecting multifocality and bilaterality between patients with homogenous and heterogeneous parenchymal echogenicity. conclusion: heterogeneous echogenicity of underlying thyroid parenchyma does not significantly influence the detection of multifocality and bilaterality for ptc on preoperative us staging. role of elastography in the characterisation of thyroid nodules f. sogaro, p. tessitore, a. scrimieri, f. pittiani, a. borghesi, r. maroldi; purpose: this study aimed at evaluating the reliability of elastography in predicting malignancy of thyroid nodules. methods and materials: patients with thyroid nodules, who underwent to grey-scale ultrasonography (us), elastography and fnc (fine-needle cytology), were prospectively enrolled from february to august . for each nodule, grey-scale us parameters (hypoechogenicity, absence of halo sign, absence of colloid) were examined. findings at elastography were classified according to rago criteria ( ). cytological diagnosis were classified according to the siapec-iap criteria in tir , tir , tir , tir and tir . the diagnostic performance of grey-scale us and elastography were compared with cytological findings. tir and tir with indeterminate cytology were excluded from the study. results: nodules were included: tir , tir and tir . according to rago criteria nodules were score , nodules score and nodules score . the sensitivity, specificity, positive predictive value (ppv), negative predictive value (npv) of elastography were %, %, %, %, respectively. the combination of grey-scale us parameters (hypoechogenicity with absence of halo sign and colloid) showed % sensitivity, % specificity, % ppv and % npv. conclusion: elastography is not useful in the differentiation of malignant and benign thyroid nodules. however, elastography had a high probability in predicting cytological benign diagnosis (high vpn). moreover, elastography demonstrated a superior performance than the combination of grey-scale us parameters. the new approach to thyroid elastosonography -time-strain curvesmay aid the differentiation of nodules r.z. slapa, b. migda, w.s. jakubowski, j. bierca, j. slowinska-srzednicka; warsaw/pl (rz.slapa@gmail.com) purpose: to evaluate a new linear/non-linear approach to strain elastosonography of thyroid nodules, based on the analysis of time-strain curves and to compare it with classical elasticity score and thyroid strain ratio methods. methods and materials: during - , patients scheduled for thyroidectomy ( with multinodular goitre and with single thyroid nodule) were evaluated with b-mode and power doppler ultrasound of the whole thyroid. during ultrasound examination, dominant nodules were examined with strain elastosonography with aplio xg with linear - mhz transducer. the stiffness of each thyroid nodule was evaluated with classical features of strain elastosonography qualitatively (with elasticity scores) and semi-quantitatively with thyroid tissue strain/nodule strain ratios with application of elasto q. moreover, a novel, original approach to elasticity data based on evaluation of time-strain curves was applied. results: papillary carcinomas, benign nodules. classical elastosonographic analysis with elasticity score and elasticity ratio on statistical analysis did not show significant difference between cancer and benign nodules (p-value, respectively, . and . ). on linear/non-linear analysis of time-strain curves excellent differentiation (p= . x - ) was possible with new parameter: the relative length of non-linear relaxation. with threshold . : sensitivity %, specificity . %, area under roc= . . the analysis of linear and non-linear elastosonography data may greatly improve differential diagnosis of thyroid nodules. further large-scale studies evaluating the usefulness of linear/non-linear elastosonography phenomena (involving evaluation of vioscoelasticity, e.g. shear wave spectroscopy) in differential diagnostics of thyroid cancer are warranted. methods and materials: this hipaa compliant retrospective study was irb approved. we included patients who had undergone emergent ct scans of the abdomen and pelvis for abdominal pain with tube current modulation, automated kvp selection and safire (scan a) and compared their abdomen and pelvis ct scans with tube current modulation, kvp, filtered back projection reconstruction algorithm (scan b). ctdivol, dlp, effective dose (dlp x k) and image noise values were compared between two protocols. paired samples wilcoxon test was used for analysis and p < . was considered significant. results: the median ctdivol were . mgy and . mgy for scans a and b, respectively (p= . ); the median dlps for scans a and b were . mgycm and . mgycm (p < . ), respectively. the median effective dose was . % lower with scan a compared with scan b ( . msv vs. . msv, p < . ). the median image noise was significantly lower with scan a using safire ( . vs. . , p < . ). results: kv were automatically selected in patients, kv in patients and kv in patients of the autokv group. patient diameters increased with higher kv settings. the average ctdivol ( . vs. . mgy) and dlp ( vs. mgycm; p < . ) in the entire autokv group were %/ % lower than in the group with fixed kv. this effect was even more pronounced in the patients in whom kv were selected (ctdivol . mgy, - %; dlp mgycm, - %). enhancement of parenchymal organs gradually increased with lower kv, while image noise was at a stable level. conclusion: software-based automated selection of the tube potential allows for significant dose savings in thoraco-abdominal trauma ct while image quality is maintained or even improved. especially younger patients involved in accidents may benefit the most from this development. usefulness of low-dose ct with or without adaptive statistical iterative reconstruction ( purpose: to determine the usefulness of low-dose ct in the diagnosis and exclusion of acute appendicitis and to compare with low-dose ct taken with asir. conclusion: curved mips of the meningeal spaces have the potential to shorten the detection time for epi-and subdural hematomas, increase sensitivity, especially for thin hematomas, and reduce the required operator experience for detection. author disclosures: h. ringl: patent holder. simple and easy way using time-intensity curve of perfusionweighted images to find penumbra in stroke patients within . hours of onset due to the carotid artery occlusion t. mori, t. iwata, y. miyazaki, m. nakazaki, y. takahashi; kamakura/jp (morit-koc@umin.net) purpose: the aim of our study was to investigate whether or not time-intensity curve (tic) of pwi can find penumbra in stroke patients with acute carotid artery occlusion. methods and materials: included were patients ) who were admitted within . hours of onset between january and january , and ) in whom emergency mra suggested the affected carotid artery occlusion. we assessed, nihss on admission (nih adm), dwi-aspect score, tic types, successful recanalization (sr), nihss on the th day (nih th ), and in-hospital death. early neurological improvement (eni) was defined as nih adm-nih th > . tics were generated on region of interests set at symmetrical positions of the bilateral mca territories. according to the time to peak (tp) and the peak signal (ps) comparing the affected side (a) with the contralateral side (c), we classified tic into four types and defined type as tpa>tpc and psa<psc/ , type as tpa>tpc and psc/ <psa<psc, type as tpa>tpc and psa>psc, and type as tpa=tpc. relationship between tic types, in-hospital death and eni were assessed. results: eighty-seven patients were analysed. there were , , and patients in tic type , , and , patients underwent reperfusion therapy (rt) and sr was achieved in patients, and patients died. tic type was the only determinant of in-hospital death (p < . ) and sr coupled with tic type was the determinant of eni (p < . ). conclusion: tic type means penumbra and type predetermines poor clinical outcome. author purpose: iterative reconstruction (ir) is a promising noise reducing technique with the potential to reduce radiation-dose with preserved study interpretability or improve image-quality at similar radiation-dose. one of the major drawbacks of ir is a longer reconstruction time which may be problematic in the emergency setting. the purpose of the current study was to compare reconstruction time and speed of ir and filtered back-projection (fbp) in two commonly encountered emergency imaging scan-protocols: total body trauma ct and pulmonary cta. methods and materials: fifteen patients underwent a total body ct after a traumatic event and twenty-five adults underwent a cta for evaluation of pulmonary embolisms on a -slice ct-scanner. all data were reconstructed using fbp and two ir-levels (idose , philips healthcare). quantification of reconstruction time and speed was done with a self-written plug-in for imagej (us national institutes of health). the mean delay in reconstruction time on total body trauma cts was . ± . and . ± . seconds for idose -levels and , respectively, and on pulmonary ctas . ± . and . ± . seconds for idose -levels and , respectively. the mean reconstruction time and speed for total body trauma cts were . ± . , . ± . and . ± . seconds, and . ± . , . ± . and . ± . slices/s for fbp, idose -levels and , respectively, and for pulmonary munich/de (sonja.kirchhoff@med.uni-muenchen.de) purpose: in the past years the number of clinical-pathological autopsies decreased significantly due to various reasons. forensic autopsies are disposed not only with regional differences but, however, also with on an average decreasing frequency. especially in patients who died during trauma room management or emergency operation during critical care, no imaging could possibly be performed. therefore, after termination of all clinical procedures a critical analysis of death and evaluation of the standards of medical care is often not possible, although especially regarding medical quality management it is highly desirable. at least to partly close this information gap we performed a post mortem computed tomography (pmct)study. in this prospective study whole body pmct was performed in patients who died during trauma room management or emergency surgery leaving all installed foreign material, e.g. tube, drainage in place. the pmct findings were compared with clinical findings and if available with autopsy reports as well. results: between and patients were enrolled, of whom underwent additional autopsy. the major clinical diagnosis which had finally led to the termination of resuscitation procedures was confirmed by the pmct findings. the autopsy report showed a high correlation in the corresponding cases to the pmct-findings. conclusion: pmct offers the possibility to improve quality management during trauma room management regarding the decision for terminating resuscitation efforts by verifying the important clinical findings. in addition, pmct findings support specifically the autoptic reporting. purpose: to assess how the portrayal of radiology in medical tv shows is perceived by the general population. a survey was conducted among adult patients scheduled for a radiological examination, technologists and radiologists. the survey gathered information regarding tv watching habits and interest in medical tv shows. questions addressing the accuracy in portraying radiology in comparison to reality ( - scale), appearance of radiological examinations and radiological staff were asked in regard to house m.d., er, and grey's anatomy. the online survey conducted among radiologists and technologists from two different academic institutions served as reference standard. results: a total of patients and professionals ( technologists, radiologists) participated. a moderate and significant correlation was found between the interest in medical tv shows and the perception that clinical reality was accurately portrayed in the group of patients (r= . , p= . ) and technologist (r= . , p= . ) but no correlation was found for radiologist (r= . ). while > % in all survey groups noted the appearance of radiological examinations regularly to > /show, the appearance of radiological staff was perceived by . - . % of patients, . - . % of technologists and . - . % of radiologists. er was ranked more accurate than grey's anatomy or house m.d. the more interest in medical tv shows prevails in patients and technologists, the more are modern medical tv shows perceived as accurate in the portrayal of radiology. radiological examinations are frequently utilised, but imaging is less often performed by radiological staff. this retrospective study includes patients under years-of-age with clinically suspected acute appendicitis, who underwent unenhanced low-dose ct on a mdct. patients (group a) underwent a low-dose ct patients (group b) underwent a low-dose ct with asir. results: normal appendix was identified in ( . .%) in a versus ( . %) in b. in a ( . %) versus ( . %) in b were diagnosed with appendicitis. in a ( . %) studies versus ( . %) studies in b the appendix was not identified. in those where the appendix was not identified a conventional ct was performed. no one had appendicitis during one month follow-up for negative studies. the sensitivity and specificity of ct low-dose were . % and %, respectively, and for low-dose ct with asir . % and %, respectively. the sensitivity increased to % for the total protocol for both techniques. the effective dose mean was . msv ± . instead of . msv ± . . conclusion: the low-dose ct is a suitable technique for the diagnosis or exclusion of acute appendicitis in young or middle-aged people, making possible inclusion as a radiological imaging test in the diagnostic algorithm of acute appendicitis. introduction of the asir improves the low-dose ct technique with a higher sensitivity for appendix evaluation which increased the diagnostic confidence, slightly lowering the dose. the purpose: to evaluate image quality of paediatric chest ct acquired at kv. methods and materials: consecutive children undergoing chest ct studies on a dual-source ct system were prospectively evaluated with a -kv scanning protocol. all scanning parameters were kept similar to those usually selected for standard -kv protocols, except the milliamperage. always selected according to the patient's weight, ref mas were increased by a factor of . to maintain comparable levels of radiation dose between newly introduced -kv and routine -kv protocols. image quality at kv (group ) was compared to that of a paired paediatric population (group ) based on the age (± yr), weight (± kg) and administration of contrast material, previously scanned at kv on the same ct unit and prospectively stored in our database. group and group images were reconstructed with filtered-back projection. results: objective noise in group was significantly lower than that measured in group ( . ± . hu vs . ± . hu; p= . ). subjective image quality of lung and mediastinal images in group did not significantly differ from that of group (p= . ). in group , the mean dose-length-product was . ± . mgy.cm (< yr; mean weight: . kg) (n= ); . ± . mgy.cm ( - yr; mean weight: . kg) (n= ), . ± . mgy.cm ( - yr; mean weight: . kg) (n= ) and . ± . mgy.cm ( - yr; mean weight: . kg) (n= ). conclusion: paediatric chest ct at kv provides similar objective and subjective image quality to that achievable at kv. results: from the records in the database, various anthropometric data were extracted, e.g. body mass and body length of more than patients, thoracic diameters and the volumes, densities and masses of lungs and mammalian glands of more than patients of all age groups. these data were compared to the anthropometric data of the mathematical mird phantoms provided by the finnish centre for radiation safety stuk. it can be shown that in mathematical mird phantoms of all age groups, body mass, body length and thoracic diameters are overestimated, whereas lung volumes and lung masses are underestimated. purpose: to assess the radiation dose delivered during dual-source chest ct examinations. we prospectively recorded the dose-length-product (dlp) of consecutive children, evaluated in age groups: group (< yr; n= ; %) (mean weight: . ± . kg), group ( - yr: n= ; %) (mean weight: . ± . kg), group ( - yr: n= ; %) (mean weight: . ± . kg) and group ( - yr; n= ; %) (mean weight: . ± . kg). all ct examinations were performed with a dual-source ct system using a dual-source, single-energy scanning protocol obtained with thin collimation, high pitch and high temporal resolution, a weight-adapted selection of the kilovoltage and milliamperage, and systematic reconstruction of images using filtered-back projection. results: patients were scanned with a pitch of . (n= ; %) or . (n= ; %), at kv (n= ; %) or kv (n= ; %) with a milliamperage ranging between and mas. the mean duration of data acquisition was . ± . ms. ct examinations consisted of contrast-enhanced (n= ) and noncontrast (n= ) studies, obtained in the context of acquired (n= ; %) or congenital (n= ; %) bronchopulmonary disease, cystic fibrosis (n= ; %), cardiovascular disease (n= ; %), oesophageal atresia (n= ; %) and miscellaneous causes (n= ; %). all examinations were of diagnostic image quality. the mean dlp value in each age category was . ± . mgy.cm ( purpose: to standardise the scan protocol for ct scanners of participating centres in a multi-centre study (clinicaltrials.gov nct ) for the prevention of radiologically defined bronchiectasis in cf infants by ensuring the maximum image quality at the minimum radiation dose. methods and materials: three different sized phantoms (qrm, germany) were used to assess scanners' performance of automatic exposure control (aec). ctdi and dlp were recorded. the phantoms contained various inserts to assess slice-sensitivity-profile, in-plane spatial resolution, noise and the hounsfield unit (hu) scale. scans were made for several dose levels and reconstruction kernels. images were analysed with custom-made software (matlab, usa) to obtain the standard deviation of the noise, point-spread-function (psf) and slice thickness. results: eight different scanners with slices or more from manufacturers (ge, philips, siemens and toshiba) were assessed. despite differences in aec's performance, we obtained approximately the same dose level at each center by recommending site and age-specific aec reference levels. a constant image quality was only possible by matching the different reconstruction kernels measured psfs at full-width-at-half-maximum. in fact, large part of the differences between scanners was related to reconstruction kernels. the relatively high noise images corresponded with reconstructions using a kernel with edge enhancement such as the siemens b kernel or the ge lung kernel that are routinely used in chest imaging. conclusion: objective measurements on ct images allowed for matching of scan protocols among ct scanners of different manufacturers. use of routine protocols might introduce a bias in the (automated) image analysis. cystic fibrosis lung disease in children: correlation between mri and hrct scores c. purpose: high-resolution computed tomography (hrct) is known to be a sensitive means of detecting lung disease in cystic fibrosis (cf), with a significant radiation exposure. magnetic resonance imaging (mri) becomes increasingly important in the assessment of cf lung disease. the aim of this study was to establish the agreement between mri and hrct scores in a paediatric population. methods and materials: hrct and t and post-contrast t mri images were acquired on the same day from cf patients (median age . years; range . - . years). two radiologists with either > (hdlp) or years (cs) of ex-were analysed and compared with the corresponding real scan length. for selected ct scanners, radiation doses achieved during the scanograms were reconstructed using mathematical mird phantoms. results: depending on the patients´ age, many scanograms considerably exceed the real scan region, thus unjustifiably raising the radiation exposure of the patient. the radiation doses due to ct scanograms are not neglectible as, e.g. the whole body dose achieved during a thorax scanogram can exceed the whole body dose caused by a conventional chest x-ray examination by a factor of . conclusion: an optimisation of scanogram lengths by defining specific anatomical landmarks for standard ct protocols, the optimisation of scanogram exposure parameters in paediatric ct examinations and their implementation into national and international guidelines seems to be necessary to fulfil the alara concept in paediatric ct. we established reference values for cardiac valve diameters in extreme preterm infants, based on bsa. biological variation, inaccuracy in assessment of patient characteristics, inter-operator variability, and limited spatial resolution may account for substantial variability in heart valve diameters found in this cohort. asymmetric lung perfusion in congenital heart disease: impact of differential pulmonary arterial anatomy and pulmonary vascular resistance o. kondrachuk, t. yalynska, r. tammo, i. iershova, n. rokytska; kiew/ua purpose: asymmetry of lung perfusion is relatively common in patients with congenital heart disease. the aim of the study was to evaluate the influence of differential pulmonary arterial anatomy and pulmonary vascular resistance on blood flow distribution in patients with asymmetric lung perfusion. we retrospectively identified consecutive patients with congenital heart disease who had asymmetry of lung perfusion on phase-contrast mri. the mri examinations were performed on . t scanner. results: fourteen patients had left lung hypoperfusion (blood flow to the left lung < %) and three patients right lung hypoperfusion (blood flow to the right lung < %). branch pulmonary artery (bpa) regurgitant fraction (rf) was significantly greater in lung with decreased perfusion ( . ± . % vs. . ± . %, p < . ). there was moderate negative correlation between bpa rf and bpa differential pulmonary blood flow (r = - . , p = . ). moderate positive linear relationship between bpa size and bpa differential pulmonary blood flow was also found (r = . , p = . ). there was no significant correlation between bpa rf and bpa size. conclusion: both bpa anatomy and bpa rf are the significant factors for determining right and left lung flow split. according to prior reports, bpa rf reflects differential pulmonary vascular resistance. consecutively at kvp, kvp, kvp and kvp, respectively, with constant mas settings using a dual-source ct. differences in calculated dual-energy ratios (deratio) between the tissues and iodine or gold were determined for different de spectra. the attenuation of gold has increased at higher kvp-settings compared to kvp, while the attenuation of all other specimens decreased. the calculated de ratios at / kvp, / kvp and / kvp, respectively, were . , . and . for iodine, . , . and . for gold, . , . and . for compact bone, . , . and . for muscle. the difference between the de ratios / kvp, / kvp and / kvp, respectively, were . , . and . for iodine and bone, . , . and . for gold and bone, . , . and . for iodine and muscle, . , . and . for gold and muscle. conclusion: de ratio of gold remains relatively stable along the energy spectrum of diagnostic ct and allows a reliable material differentiation between gold and bone at contiguous low tube voltage settings ( kv and kv). thus, gold might have potential as a contrast agent for dect. potential use of intra-articular diluted high-relaxivity gadoliniumbased contrast agent for magnetic resonance arthrography ( purpose: gadobenate dimeglumine (gd-bopta) is a high-relaxivity contrast agent that tightly binds to plasmatic proteins, currently used in several clinical applications. our aim was to test in-vitro different concentrations of gd-bopta to be potentially used to perform mra. methods and materials: gd-bopta (multihance, bracco) was diluted in saline (nacl . %) to achieve different concentrations ( mmol/l, mmol/l, mmol/l, . mmol/l, . mmol/l). five ml of these solutions was injected in sterile pipes and was added with . ml of fresh synovial fluid withdrawn from a -year-old male knee. in a separate pipe (reference), . ml of synovial fluid and ml of gadopentetate dimeglumine mmol/l (gd-dtpa; magnevist) were injected. pipes were imaged using a t -weighted sequence (te= . msec, tr= msec, slice thickness . mm, fov x mm) at . t. for each pipe on each slice, signal intensity (si) was calculated. results: mean gd-dtpa si was ± . mean gd-bopta si was ± (+ % to reference) at mmol/l; ± (+ %) at mmol/l; ± (+ %) at mmol/l; ± (+ %) at . mmol/l; ± (- %) at . mmol/l (p <. ). at post hoc analysis, all one-to-one comparisons were significantly different with exception of and mmol/l (p=. ). conclusion: versus gd-dtpa, a + % peak si was achieved with half gd-bopta concentration. a similar si between the two agents was achieved at . mmol/l. gd-bopta high relaxivity and its potential binding with synovial fluid glycoproteins could explain these results. this may improve visibility of intra-articular tears when evaluated using gd-bopta mra. purpose: to optimise the contrast injection protocol for ct coronary angiography (ctca) to achieve more efficient utilisation of contrast agent by investigating the impact of reducing the volume of contrast agent on the attenuation of coronary arteries and sinus. methods and materials: a total of subjects with low heart rate (² beats/min) and suspected coronary artery disease were randomly divided into three groups with subjects in each group. the patients in groups a, b and c were injected with a volume of . , . , and . ml/kg of contrast agent, respectively. in all cases, injection rate was . ml/s, followed by ml saline flush at the same rate. ct values within the ascending and descending aorta, left main and right coronary artery orifices and coronary sinus were measured and the differences of contrast enhancement among the three groups were evaluated. the mean injection volume of contrast agent in groups a, b and c were . , . and . ml, respectively (p < . ), and the scan delay time were . , . and . s, respectively (p < . ). the ct values within the coronary sinus were . , . and . hu for groups a, b and c, respectively (p < . ), perience in paediatric pulmonary disease scored independently hrct, using the scoring system developed by helbich et al, and mri using two scoring systems developed by helbich et al and eichinger et al. readers were blinded to clinical and functional data and to the other reader's findings. the agreements were assessed using the intraclass correlation coefficient (icc) and the bland-altman plot for the two readers and the two methods. the inter-reader agreement was excellent for the hrct scores (icc= %), good for mri with the eichinger score (icc= %), but less for mri with the helbich score (icc= %). there was a very good correlation between hrct and mri-eichinger scores (icc= %), but less between hrct and mri-helbich scores (icc= %). the good inter-reader agreement and the high correlation between hrct and mri-eichinger scores support the use of lung mri for the follow-up of lung disease in paediatric cf patients. methods and materials: a total of consecutive patients, with clinical vascular aortic disease, were evaluated on mdct slices scan (philips-brilliance p, nl) using low-kv protocol ( kv), high pitch ( . ) and automated tube current modulation. low contrast medium volume ( ml) was administered at ml/s. density measurements were performed at abdominal aorta, renal arteries and common iliac arteries. we also calculated the radiation dose exposure (dose length product, dlp). our results were compared with patients investigated with standard contrast medium volume ( ml) and standard ct-angiography protocol ( kv; mas). the noise level (signal-to-noise ratio, snr), the radiation dose (expressed as dlp) and amount of iodinate contrast were analysed and statistically compared between two different groups. results: in all of the patients we obtained an adequate vessel opacification of aorta and renal arteries. mean attenuation value in aorta was hu, in iliac arteries was hu and in renal arteries was hu, without significant attenuation difference with the control group (aorta hu; iliac arteries hu; renal arteries hu). the radiation dose exposure (meandlp: ) was significantly lower (reduction of the %) in the low-kv protocol than standard examinations at kv (mean-dlp: ). the noise level calculated in low-kv protocol (meansnr ) was not significantly higher than the value obtained in standard protocol (meansnr ). conclusion: low-dose ct-angiography protocol represents a feasible technique that allows a significant reduction of contrast material and radiation dose exposure without losing diagnostic accuracy being useful also in these patients with renal failure. purpose: the use of low concentrated contrast material might be advantageous in terms of viscosity. therefore, the purpose of this study was to evaluate the use of low concentrated contrast material ( mg iodine/ml) for coronary ct angiography in routine patients. methods and materials: consecutive patients who were referred for routine coronary cta were scanned on a nd generation dsct scanner (definition flash, siemens). patients received a standard contrast injection protocol as follows: iopromide mg/ml (ultravist, bayer) with an injection rate of ml/s (iodine delivery rate . g i/s) followed by a saline chaser with the same flow rate. contrast enhancement in the coronaries was measured proximal and distal in all coronaries. results were compared to our standard protocol with iopromide mg/ml and flow rate of . ml/s (iodine delivery rate . g i/s). start delay was evaluated for both groups using the test bolus method. comparison between both groups was performed using sample t-test. results: coronary enhancement reached diagnostical attenuation in both protocols. overall comparison between enhancement with mg/ml (mean hu ± hu) revealed no statistical significant differences with mg/ml (mean hu ± hu) (p= . ). attenuation levels in lad dist and cx dist were significantly higher in the low concentrated contrast material group (lad dist vs hu, p < . and cx dist vs hu, p= . , respectively). conclusion: the use of low concentrated contrast material is feasible in coronary cta. higher flow rates are necessary, but lower viscosity might improve attenuation in the distal segments. the impact of mr contrast agent concentration on bolus geometry g. jost, h. pietsch; berlin/ de (gregor.jost@bayer.com) purpose: in contrast-enhanced mr-angiography, the luminogram is obtained during the first passage of gadolinium-based contrast agents (gbca). the bolus concentration in conjunction with the r -relaxivity determines the vascular signal enhancement. the aim was to investigate the impact of a molar gbca concentration on bolus geometry compared to a . molar agent, systematically. methods and materials: göttingen minipigs were injected intravenously with gadobutrol and gd-dtpa in a crossover setting ( . mmol/kg, ml/s). dynamic ct measurements ( kv, maseff, Δt= . s) at the thoracal region were performed without table feed. time-density curves were determined and fitted by a gamma-variate function in the vena cava, the pulmonary artery and the ascending and descending aorta. ct-signals were transformed to gd-concentrations on the basis of phantom measurements. the administration of molar gadobutrol led to a narrower (significantly lower full width half maximum) and steeper (significantly higher peak values) bolus and ct values within the ascending and descending aorta, and the coronary artery were higher than hounsfield units in all three groups. conclusion: application of the . ml/kg protocol in ctca, a steady contrast enhancement in coronary artery, can be achieved using -slice volume ct. the influence of the contrast media protocol and the scan mode on arterial enhancement in cardiac ct e. talakic, d. stocker, p. täubl, r. maderthaner, f. quehenberger, h. schoellnast, m. tillich; graz/ at (emina.talakic@medunigraz.at) purpose: to assess the influence of contrast media protocol and scan mode on arterial enhancement in cardiac ct. methods and materials: patients (mean age, ; range, - years) who underwent cardiac ct were retrospectively divided into groups related to scan mode ( -slice helical ct or -slice volume ct) and contrast media concentration ( , or mgi/ml) -group :, helical, ( ml); group : helical, ( ml); group : helical, ( ml), and group : volume, ( ml). injection rate was ml/sec in all patients. roi measurements were performed in the aorta (coronary arteries level) and cardiac chambers to assess enhancement, and in the superior vena cava (svc) to measure the standard deviation of the attenuation values for assessment of inflow artefacts. spearman correlation and wilcoxon test were used for comparison. results: patients in group showed significantly higher mean aortal enhancement than patients in group or ( hu versus hu and hu). group showed significantly higher aortal enhancement than group ( hu). group showed significantly lower enhancement in the right atrium and ventricle than group . no significant difference in the standard deviation of attenuation was seen within the svc. conclusion: in cardiac ct, the volume mode led to significantly higher aortal enhancement and lower contrast within right atrium and ventricle compared with helical mode. scan mode, iodine dose and flow rate had no influence on heterogeneity of contrast within the svc. multislice ct angiography with direct intra-arterial ultra-low-dosecontrast injection for the evaluation of renal graft failure: initial study m. guzinski, j. kurcz, j. garcarek, m. sasiadek; wrocław/pl (guziol@wp.pl) purpose: to present initial experience with direct intraarterial ultra-low-dosecontrast ct angiography (ia-cta) and its application in assessing renal graft artery in patients with renal graft failure. methods and materials: ia-cta of renal graft was performed in patients with renal graft failure (gfr m/s. pig-tail catheter f was placed in ipsilateral common iliac artery via common femoral artery. subsequently, spiral cta of pelvis was performed simultaneously to intraarterial administration at ml/s of - ml of contrast diluted with saline to - ml. results: excellent contrast enhancement of renal graft arterial tree was observed in all patients. no complications associated with arterial access occurred. mean creatinine/grr levels prior to the ia-cta were . mg/dl and . ml/min, respectively. on the th day following the study, mean creatinine/gfr levels amounted to . mg/dl and . ml/min, respectively. renal function deterioration was demonstrated on the rd day after the procedure (creatinine . ml/dl, gfr . ml/min); nevertheless, it was not statistically relevant (p < . ). contrast-induced nephropathy occurred in only one patient ( . %) with transient creatinine elevation by %. after detailed vessel analysis graft arterial stenting was performed in patients, which improved renal function. the remaining patients were treated conservatively. conclusion: trans-catheter ultra-low-dose-contrast ia-cta for imaging of renal graft arteries can be an effective method with low-risk of nephrotoxicity, which allows detailed graft arterial tree imaging, especially prior to interventional treatment of arterial-related renal graft insufficiency. feasibility in low kv ct angiography of the abdominal aorta: assessment of image quality, radiation exposure and contrast material volume c.r.g.l. talei franzesi, d. ippolito, p.a. bonaffini, v. bartolo, c. trattenero, s. sironi; monza/it (ctfdoc@hotmail.com) purpose: to assess the image quality, dose reduction and amount of iodinate contrast injected using low-kv ct angiography protocol for the study of abdominal aorta disease. shape compared to . molar gd-dtpa in all investigated vessels. the respective gd-concentrations (mggd/ml) for gadobutrol vs. gd-dtpa were . ± . vs. . ± . (vena cava), . ± . vs. . ± . (pulmonary artery) and . ± . vs. . ± . (ascending and descending aorta). the area under the bolus curve analysis yielded no significant differences between the gbcas. conclusion: a molar gbca concentration leads to a more compact bolus shape with significant higher peak concentrations in the major thoracal vessels compared to a . molar agent. this might be especially relevant for the acquisition of d angiograms and for quantification of tissue perfusion. author disclosures: g. jost: employee; bayer pharma ag. h. pietsch: employee; bayer pharma ag. transarterial chemoembolisation (tace) in malignant liver metastases: evaluation of a fast c-arm ct acquisition protocol with a robotic multi-axis c-arm system t.j. vogl , m. von roden , e. mbalisike , s. zangos ; frankfurt a. main/de, forchheim/ de (t.vogl@em.uni-frankfurt.de) purpose: to evaluate potential contrast savings and reduction of motion artefacts in c-arm ct acquisitions with a higher rotational speed during interventional procedures. methods and materials: patients (mean . yrs, range - ) were treated with transarterial chemoembolisation (tace). prior to the injection of the embolisation material, a c-arm ct with a new, fast acquisition protocol was performed. a robotic multi-axis c-arm angiographic system (artis zeego, siemens-healthcare, forchheim/germany) was used with a rotational speed of up to °/s. in this configuration, a c-arm-ct with a rotational trajectory of ° was acquired in s versus s in a commercially available c-arm system. two different injection protocols were applied and evaluated regarding sufficient tumour visualisation and spatial resolution of the vessel tree in the resulting d-dataset. results: injection protocol ( ml contrast, ml nacl, flow rate ml/s, x-ray delay s, injection site: common hepatic artery) resulted in d images with a very good spatial resolution of the vessel trees but poor visualisation of tumours/metastases. injection protocol ( ml contrast, ml naacl, x-ray delay s) resulted in d images with excellent spatial resolution and good visualisation of tumours/ metastases. from prior experience with a standard s protocol the corresponding c-arm ct acquisition would have required a contrast load of ml and . ml, respectively. thus, the contrast saving of the fast acquisition protocol was % and %, respectively. the fast c-arm ct acquisition protocol provides an interesting possibility to save contrast media during tace with excellent spatial resolution of the vessel tree and good visualisation of hypovascular tumours. purpose: functional mri of cerebrovascular reserve (cvr fmri) using vasoreactivity to hypercapnia may identify patients at risk of haemodynamical stroke among those with severe stenosis of the middle cerebral artery (mca). however, quantification remains challenging because of numerous methodological settings and their limitations. we aimed to provide a laterality index (limca) to better identify abnormal cvr in clinical practice. methods and materials: volunteers ( females; . ± . years) without cervico-encephalic arterial stenosis had a cvr fmri using bold contrast with a block-design hypercapnic challenge (co % mixed with: o % (n= ) or air (n= )), using nasal canula (n= ) or mask (n= ), . t (n= ) or t (n= ). averaged end-tidal co pressure (etco ) was used as a physiological regressor for statistical analyses with a general linear model (spm ). we conducted regions of interest (roi) measures of %bold signal change/mmhg etco on segmented grey matter of the mca territories. we calculated a laterality index with limca=(left_cvrmca-right_ cvrmca)/(left_ cvrmca +right_ cvrmca). % confidence intervals ( %ci) were calculated. no adverse reaction to hypercapnia, including panic, anxiety, headache, or fatigue, was detected during and after cvr fmri. cvr values ranged from . to . with m±sd= . ± . %bold/mmhg etco . the mean laterality index was . with an interval of fluctuation that covered . . the standard deviation was . . thus, %ci was ± . for mca. li values were independent of age, gas mixture, sex, inhalation modality, and mr strength. conclusion: subjects without cervico-encephalic arterial stenosis have an absolute value of limca below . with a % probability. in purpose: non-invasive quantitative phase contrast mr angiography (qmra) has been utilised for several clinical indications, e.g. intracranial stenosis and aneurysms. the aim of this study is to validate the flow measurements of qmra (nova, vassol inc., chicago) by comparing the obtained velocities with qmra and doppler ultrasonography (dus) in-vivo. to our knowledge, no previous reports have addressed this issue. methods and materials: we retrospectively examined consecutive patients ( women, men; mean age years, range - years) with stenosis of arteries supplying the brain using qmra and dus. velocities were measured in a total of arterial segments ( extra-and intracranial). results: overall there was a good correlation between velocity measurements with both techniques being statistically significant in all six extracranial and five out of seven intracranial segments. velocities were % higher in extracranial and % higher in intracranial segments obtained with dus comparing to those with qmra. the reversal of flow direction in the aca was detected consistently with both methods. conclusion: this preliminary study shows a rather good correlation between the velocities employed with qmra and dus. qmra represents a robust mri technique for flow measurements in a reasonable time, which can be integrated in the cerebrovascular mri work-up, especially when intracranial dus is technically not feasible. however, further in-vivo and in-vitro studies are needed to assess the need for technical optimisation of this technique. purpose: sensitive documentation of ischaemia is needed in clinical tia. we aimed to compare the sensitivity of dti, dwi and asl in the detection of acute ischaemia and further to investigate if chronic ischaemic changes after weeks in the form of gliosis always follow. methods and materials: the first consecutive patients included during first months of an mri-protocol (dwi, dti and asl within hours of symptoms) and weeks follow-up protocol (t and dwi). patients were included by stroke consultants. lesion volumes on dwi, dti and follow-up t were compared. hyper-or hypoperfusion on asl was recorded. one senior neuroradiologist assessed the sequences in random order to prevent bias. results: fourteen patients had acute ischaemic lesions: in the posterior fossa and in the cerebral hemispheres corresponding to % of referred patients. thirteen of these developed gliosis in the affected area and of these was noted only on dti and only as post-ischaemic hyper-perfusion on asl. mean lesion volume was . ml. mean difference between volume on dwi and gliose volume was . ml = % and between dti and gliose volume . ml= % and dti volume were significantly closer (p= . ). conclusion: these preliminary results indicate that tia causes a gliosis lesion consistently, and that the initial lesion as well as the extent of the permanent changes is better described using dti. asl seems to be able to contribute to the detection of tia as this may be sole mri-sign in some patients increasing detection rates with %. monday parameter for assessment of ischaemia. we analysed the ability of ttp maps to predict eventual infarcts in patients with mild stroke presentations. we retrospectively reviewed consecutive patients presenting with acute stroke in less than hours from onset. patients presenting with a nih stroke scale score < were subjected to subgroup analysis. ttp perfusion deficit with delays of more than seconds was considered significant for underlying ischaemia. the perfusion parameters were compared to follow-up imaging at to hours. results: patients met inclusion criteria. patients had identifiable thrombus. the ttp map had the highest sensitivity in detecting the small infarcts ( %), followed by cbv and cbf. importantly, ttp analysis provided very high negative predictive value ( %). however, there was a relatively lower specificity ( %) and a tendency to overestimate the infarct size. conclusion: ttp perfusion is highly sensitive in predicting small regions of ischaemia. high negative predictive value is helpful in differentiating stroke from mimics. purpose: to study the influence of the temporal sampling rate of ctp acquisitions on cerebral perfusion maps with noise-free synthetic data sets created with a digital phantom. methods and materials: noise-free synthetic data sets were created with a digital phantom which consists of a skull derived from a human skull phantom combined with arterial input and venous output functions, white matter (wm) and grey matter (gm) time-attenuation curves (tac) obtained from patients. by manipulating the time tags ctp protocols with a total scan duration of s and a temporal sampling rate of -, -, -and s were simulated. the -s protocol was used as reference standard. the -, -and -s protocols were shifted with s to measure the influence of missing peak points of the curve, resulting in , , extra data sets, respectively. cbf, cbv and mtt maps were calculated using pma (asist-japan). mean values of gm and wm of the protocols were compared with the reference protocol. de (kolja.thierfelder@med.uni-muenchen.de) purpose: our aim was to evaluate if the extent of volumetrically determined blood flow-volume mismatch in recently introduced whole brain ct perfusion (wb-ctp) can predict if a stroke is younger than . hours (time window for thrombolysis). we retrospectively analysed cerebral blood flow (cbf) and volume (cbv) maps and clinical data of acute stroke patients. ct perfusion images were acquired with extended brain coverage of cm in the z-axis. mismatch extent was defined as the fraction of cbf perfusion deficit without corresponding cbv abnormality and was determined volumetrically using osirix v. . imaging software. a logistic regression analysis was performed to predict time from symptom onset of < . hours. four mismatch extent categories, cbf perfusion deficit and cbv infarction volume were entered as predictors into the model. results: mean time from symptom onset was min± min. mean mismatch extent was . %± . %. after correcting for age and gender, a mismatch extent of ³ % was highly predictive for a symptom onset of < . hrs (n= , or: . , p= . ). other categories of mismatch extend (³ % (or: . , n= , p= . ), < % (n= , or: . , p= . ), < % (n= , or: . , p= . ) as well as cbf perfusion deficit volume (p= . ) and cbv infarction volume (p= . ) failed to predict time from symptom onset. conclusion: a large (³ %) volumetrically determined mismatch in wb-ctp is a predictor for the time from symptom onset in the critical time window. wb-ctp mismatch might, in these cases, help to identify patients eligible for thrombolysis when symptom onset is unknown (e.g. wake up stroke). whole brain ct perfusion: volumetric assessment of perfusion deficits in patients with acute ischemic stroke k.m. thierfelder , l. purpose: whole brain ct perfusion (wb-ctp) eliminates the major drawback of restricted brain coverage in standard -slice ctp. our aim was to assess reliability and reproducibility of a newly introduced volumetric assessment method of perfusion deficits in wb-ctp in patients with acute ischemic stroke. methods and materials: consecutive patients underwent -row wb-ctp with extended scan coverage of . cm in the z-axis using adaptive spiral scanning technique. volumetric analysis of cerebral blood volume (cbv), cerebral blood flow (cbf), mean transit time (mtt), time to peak (ttp), and time to drain (ttd) was performed twice by two experienced readers using dedicated imaging software with at least -week intervals between readings. inter-and intrareader agreement for individual perfusion parameter maps was assessed by intraclass correlation coefficients (icc) and bland-altman analysis. results: interreader agreement was highest for ttd (icc: . ), followed by cbf ( . ), mtt ( . ), cbv ( . ), and ttp ( . ). intrareader agreement was also highest for ttd (icc: . ), followed by mtt ( . ), cbf ( . ), cbv ( . ), and ttp ( . ). the perfusion deficits showed the highest absolute mean volume in the time-related parametric maps and did not differ significantly within this group, while mean cbf perfusion deficit volume was significantly smaller (each with p < . ). conclusion: volumetric assessment in wb-ctp in acute stroke patients is reliable and reproducible. it therefore might serve for a more accurate assessment of prognosis of stroke outcome and definition of flow-volume mismatch. ttd had the highest agreement and therefore might be a suitable parameter to define tissue at risk. time-to-peak (ttp) maps using whole brain ct perfusion in minor stroke: a diagnostic tool beyond penumbra measurement s. chakraborty, m.e. ahmad, j.k. wasserman, k. keyhanian, d. dowlatshahi, g. stotts; ottawa, on/ca (santanoo@gmail.com) purpose: the use of thrombolysis in minor stroke or fluctuating symptoms is controversial. treatment decisions may be influenced by identifying patients with large areas of tissue at risk and distinguishing stroke mimic. whole brain ct perfusion in toshiba aquilon® ct scanner allows possible assessment of these parameters and is not limited to selective brain coverage as in previous generations of ct scanners. dynamic chest x-ray examination for regional ventilation function must be equivalent to lung scintigraphy. performance evaluation of automatic chest radiograph reading for detection of tuberculosis (tb): a comparative study with clinical officers and certified readers on tb suspects in sub-saharan africa p. maduskar , l. hogeweg , b. van ginneken , h. ayles ; nijmegen/nl, london/uk (p.maduskar@rad.umcn.nl) purpose: digital chest radiography (cxr) is used in high burden countries for suspect screening, active case finding and in prevalence surveys for tb diagnosis. an observer study was conducted to compare performance of automatic software with that of clinical officers and certified expert readers. a dataset of digital cxrs ( × , . mm, delft imaging systems, the netherlands) was collected at kanyama clinic, lusaka, zambia. sputum culture was used as reference. an observer study was conducted with four clinical officers who read x-rays in kanyama clinic, and with two readers certified to read cxrs according to crrs standard (university of cape town, south africa). a software system for detection of tb (cad tb- . , diagnostic image analysis group, the netherlands) analysed all the cases. human readers and software scored all the images between and . we report area under the receiver operating characteristics curve (az) with % confidence intervals and pairwise comparisons from bootstrap estimates. p < . was considered significant. there was no significant difference between any reader and the software, except for one clinical officer who performed significantly worse than automatic reading. conclusion: automatic computer reading has similar performance as clinical officers and certified readers. the software has potential of being used as a point-of-care decision tool, to diagnose tb or select subjects that should undergo further tests. diagnostic imaging costs before and after digital tomosynthesis implementation in patient management after suspected thoracic lesions on chest radiography e. quaia, e. baratella, g. grisi, r. cuttin, g. poillucci, s. kus, m. cova; purpose: to evaluate diagnostic imaging costs before and after digital tomosynthesis (dts) implementation in patients with suspected thoracic lesions on chest radiography (cxr). over a period of four years four-hundred-and-sixty-five patients ( males, females; age, . ± . years) with suspected thoracic lesion (s) after cxr underwent dts. two readers prospectively analysed in consensus dts images. each patient underwent ct when a pulmonary non-calcified lesion was identified by dts, while ct was not performed when a benign pulmonary or extrapulmonary lesion or pseudolesion was identified. diagnostic imaging costs (including material, staff, and imaging system depreciation) were evaluated during the -month preceding dts implementation and during the -month after dts implementation. the average imaging cost per patient was calculated by normalising the costs before and after implementation of dts by the number of indeterminate cxr examinations in each of these periods. results: in / patients who underwent dts after suspicious cxr, dts showed thoracic lesions and pleural lesions, while in the remaining / patients lesions were ruled-out as pseudolesions of cxr. in the -month preceding dts implementation, the proportion of patients who presented suspected thoracic lesions and underwent ct was / ; after dts implementation, this proportion became / . the average differential per-patient costs of cxr, dts, and ct examinations were . , . , and . euros, respectively. the perpatient change in diagnostic imaging costs before vs after dts implementation was - . euros. conclusion: per-patient diagnostic imaging costs decreased after dts implementation in patients with suspected thoracic lesions. within each cross-sectional image the mean (adcmean), minimum (adcmin) and maximum adc (adcmax) was determined by two independent radiologists. an additional roi was placed into the cerebrospinal liquid and set as the reference tissue. statistical analysis included the wilcoxon test and p-values < . indicated statistical significance. results: the highest adc values were determined for the group of adenocarcinomas (adcmean, . x - mm /s; adcmax, . x - mm /s). significantly lower mean adcs were found for the squamous cell carcinomas (adcmean, . x - mm /s; p < . ) and small cell lung cancers (adcmean, . x - mm /s; p= . ). determination of the adc values did not reveal any difference between squamous cell and small cell carcinomas (p> . ). conclusion: diffusion-weighted mri with adc measurement at . t reliably enables the differentiation of adenocarcinoma from other histological subtypes in primary lung cancer and might therefore be of distinct value in the preoperative management of patients suffering from primary lung cancer. non-contrast-enhanced perfusion mri for preoperative assessment of lung function in patients with non-small-cell lung cancer ( purpose: knowledge about lung function defects is important for predicting functional outcome and optimising surgery in nsclc. fourier decomposition mri (fd-mri) has been introduced as a method to assess regional lung perfusion without contrast agents. this study evaluates fd-mri for preoperative assessment of lung perfusion in nsclc patients with dynamic contrast-enhanced mri (dce-mri) as standard of reference. methods and materials: patients with nsclc were examined at . t. timeresolved images of the lungs were acquired in coronal and sagittal plane using a d-bssfp sequence. fourier decomposition was used to detect and separate periodic changes of lung proton density caused by respiratory and cardiac cycles. perfusion-weighted images were calculated by pixel-wise integration of the cardiac spectral line. fd and dce data were analysed visually for perfusion defects. perfusion proportions of pulmonary lobes were calculated quantitatively by regions-of-interest analyses. results: fd-mri provided diagnostic quality in cases, but failed in one patient. sensitivity, specificity and accuracy of fd-mri for visual detection of perfusion defects were %, %, and %. quantitative evaluation of perfusion proportions provided good linear correlation between fd-mri and dce-mri for both upper lobes and both entire lungs (r= . - . ). accuracy of fd-mri in the lower lobes (r= . - . ) and the middle lobe (r= . ) was compromised by artefacts from cardiac pulsation. conclusion: fd-mri is useful to detect regional lung perfusion defects in nsclc patients before surgery. for perfusion quantification, fd-mri is sufficiently accurate in both upper lobes and for bilateral comparison, but, in its present form, inaccurate in the middle lobe and both lower lobes. lung ultrasound in the elderly population: investigating the limit between physiological and pathological patterns a. chiesa, f. ciccarese, g. gardelli, f. feletti, u. regina, m. zompatori; bologna/it (ciccarese.f@gmail.com) purpose: the senile lung undergoes paraphysiological changes which have been described in several radiological and ct studies, but never investigated through ultrasound. the aim of the present study was to evaluate a group of elderly-nonsmoker-healthy patients in comparison with young subjects, by using ultrasound examination. methods and materials: elderly subjects (> years-mean age: . ± . ) and young subjects (< years-mean age: . ± . ) were submitted to lung ultrasound examination. we analysed the anterior, lateral and posterior surface of each lung to evaluate the presence/absence of a-lines and b-lines. fisher test was chosen to compare data obtained in the two groups. results: absence of a-lines was found in / - . % of elderly versus / - . % of young subjects (p < . ). presence of b-lines was detected in / - . % of elderly, with a higher prevalence in posterior lung fields; the number of b-lines was² per field (pf) in / - . %, > pf in / - . %; both ² and > pf-depending on the evaluated field in / - . %. by contrast, / - . % young subjects showed b-lines (² pf in all of cases)-p= . . to avoid misdiagnosis, we should consider that physiological ultrasound lung findings could be different among old and young people. the majority of old individuals did not present a-lines; moreover in a high percentage, b-lines were observed (² pf in most of them). these results could be explained by a reduction of impedance between lung parenchyma and soft tissue (absence of a-lines) and by an increased thickness of interlobular septa (presence of b-lines). further studies should be proposed to define a cut-off between normal and pathological pattern. digital x-ray optical densitometry in assessment of respiratory function in patients with copd exacerbation n. gorbunov, v. laptev; novosibirsk/ru (n_gorbunov@hotmail.com) purpose: to evaluate respiratory function in patients with exacerbation of chronic obstructive pulmonary disease (copd) before and after treatment by means of a digital x-ray optical densitometry. the study group comprised patients ( females, males; mean age ± . years, range - years). all of them were admitted to the clinic with an exacerbation of copd with different ( - ) stage. high-resolution digital radiographic device with a line x-ray sensitive silicate receiver was used. lowdose digital x-ray examination of the chest was performed both in inspiration and in expiration phases before and after treatment. regional and common pulmonary optical density was evaluated with further quantitative analysis of respiratory function. for these purposes the optical density gradient (odg) was used. all results were verified by high-resolution computed tomography (hrct). the optical density gradient before and after treatment has been changed. there was a . - . times increasing value of optical density gradient due to treatment of copd exacerbation. for patients with the first stage of copd the . % odg increasing was estimated. for the second stage of copd odg increasing was . % and for the third stage of copd it was . %. there was a significant correlation between pulmonary optical density gradient and hrct density gradient before and after treatment (r> . ; p < . ). a digital x-ray optical densitometry by means of functional highresolution digital radiography allows optimising an evaluation of therapy response in patients with copd exacerbation combined with radiation exposure reduction. diffusion purpose: despite the improvement in technique/expertise, pancreatic surgery remains burdened with a high complication rate. our aim was to report our year single-centre experience about the clinical relevance and the interventionalradiological management of the early postoperative complications (treatment/ prevention) on patients submitted to pancreatic surgery. in - , patients were submitted to pancreatic surgery (duodenum-cephalopancreatectomy, total-pancreatectomy, distal-pancreatectomy). patients were classified on the basis of the complication severity into classes (clavien-dindo-classification): class- =none, class- / =conservative treatment, class- a=endoscopic/interventional-radiological, class- b=surgery, class- =intensive care, class- =death. interventional-radiological management was as follows: ptc/biliary-drainage in case of biliary-fistulas (bile in surgical drainage, normal bilirubin levels, undilated biliary ducts at us) under us/fluoroscopic-guidance (right approach, puncturing along the course of the sixth-segment portal branch with g chiba-needle, or left approach if aerobilia/ adequate volume of left hepatic lobe); embolisation (microcoils/pva-particles) or covered-stenting (viabahn-gore) in case of bleedings of gastroduodenal/splenic arteries; percutaneous drainage (us/ct-guidance) of liquid/infected collections. pancreatic-islet-intraportal-autotransplantation was performed in case of totalpancreatectomy to prevent diabetes. results: patients were classified as follows: / ( %) class- , / ( %) class- , / ( %) class- , / ( %) class- a, / ( %) class- b, / ( %) class- , / ( %) class- . / (class- a) and were successfully treated as follows: / ptc/biliary-drainages, / liquid/infected collection percutaneous-drainages, / bleedings ( embolisations, coveredstenting), / endoscopic-procedures. / underwent pancreatic-isletintraportal-autotransplantation. one bleeding/ biliary-fistula needed treatments. conclusion: in experienced centres of pancreatic surgery, complication rate can be reduced. complications can be, however, successfully diagnosed, managed and prevented by interventional-radiological procedures, limiting their clinical relevance and avoiding a high-risk surgical re-treatment. purpose: to evaluate technical feasibility and clinical efficacy of retrievable covered stents in treating post-surgical biliary leakage. methods and materials: from april to date, patients ( males, females; mean age years, range - years) were retrospectively studied. patients underwent placement of retrievable covered stents for treat post-surgical bile leaks. in cases the procedure was performed by interventional radiologist using percutaneous trans hepatic access and in cases by means of hybrid procedure (ptbd + ercp) with both interventional radiologist and endoscopist. the leaks involved cystic duct stump (n = ), common bile duct anastomosis (n = ), left extra hepatic duct (n = ), right extra hepatic duct (n = ) and biliary confluence (n = ). results: technical success with correct stent releasing was achieved in cases; case required post-dilatation ballooning. immediate clinical and lab test improvements were observed in all patients. post-operative imaging proved leak resolution in all cases. no early complications were observed. in case late stent migration was reported days after the procedure. twelve stents were removed without complication after a mean time of days, with complete leak resolution. one stent comparison of assessment of preoperative pulmonary vasculature in non-small cell lung cancer patients by non-contrast-enhanced and d contrast-enhanced mr angiography at t and by contrastenhanced thin-section mdct using a -detector row system y. ohno , s. seki , m. nishio , h. koyama , t. yoshikawa , s. matsumoto , s. satou , k. sugimura ; kobe/jp, ohtawara/jp (yosirad@kobe-u.ac.jp) purpose: to prospectively and directly compare pulmonary vasculature assessment before surgical treatment of non-small cell lung cancer (nsclc) patients by non-contrast-enhanced (non-ce) mr angiography, d ce-mr angiography and thin-section ce-ct. methods and materials: a total of consecutive pathologically proven and clinically assessed stage i nsclc patients ( males, females; mean age: years) underwent thin-section ce-ct, non-ce-mr angiography and ce-mr angiography, and surgical treatment. the capability for anomaly assessment of the three methods was independently evaluated by two reviewers using a -point visual scoring systems, and final assessment for each patient was made by consensus of the two readers. interobserver agreements for pulmonary arterial and venous assessment were evaluated with the kappa statistic. assessment of variations in overall pulmonary vasculature by the three methods was compared by means of receiver operating characteristic analyses on a per-patient basis. finally, sensitivity, specificity and accuracy for detection of anomalies were directly compared among the three methods by means of mcnemar's test. results: interobserver agreements for pulmonary artery and vein assessment were substantial or almost perfect ( . ²κ² . ). for pulmonary arterial and venous variation assessment, non-ce-mr angiography, d ce-mr angiography and thinsection ce-ct showed no significant differences (p> . ) in terms of area under the curve, sensitivity, specificity and accuracy. conclusion: pulmonary vascular assessment of nsclc patients before surgical resection by non-ce-mr angiography can be considered equal to that by d ce-mr angiography and thin-section ce-ct. in vivo micro-ct and f-fdg micro-pet imaging of spc-raf and spc-myc transgenic mouse models of lung adenocarcinoma t. rodt, c. von falck, m. luepke, k. hueper, r. halter, s. dettmer, c. boehm, j. borlak, f. wacker; hannover/de (rodt.thomas@mh-hannover.de) purpose: to report on micro-ct and micro-pet imaging of spontaneously developing lung tumour in spc-raf and spc-myc transgenic mice. technical considerations regarding periprocedural management and imaging technique are addressed; tumour quantification techniques are presented. dosage measurements are reported and potential adverse effects discussed. methods and materials: wild-type control, spc-raf and spc-myc transgenic mice were examined in vivo using micro-ct (n= ) and f-fdg micro-pet (n= ). specific periprocedural management was established. different respiratory gated and ungated micro-ct protocols were compared. a quantification routine for tumour load and growth was validated and examined in a follow-up study. f-fdg micro-pet of orthotopic lung tumour was obtained; quantification was performed on lesion and lung region basis. findings were correlated to histology. thermoluminescence dosemeter measurements and dosage calculations for micro-ct and micro-pet were performed. results: no procedure-related deaths occurred for up to days of follow-up. respiratory gated micro-ct protocols yielded better image quality compared with ungated protocols. intra-and inter-observer variability of the quantification routine were . and . %, respectively. tumour quantification showed significant difference (p= . ) between spc-raf transgenic and control animals in follow-up. longitudinal tumour development correlated to cross-sectional histological data from literature. micro-pet yielded a tumour-to-non-tumour ratio of . in spc-myc transgenic animals. micro-ct dosage ranged from to mgy. the estimated dosage calculated for micro-pet was mgy. conclusion: micro-ct and f-fdg micro-pet provide quantitative data on morphology and metabolism in orthotopic lung tumour. the techniques can safely be applied in animal model phenotyping and therapeutic studies. monday pancreatic cancer). watts for minutes was applied using bipolar endoluminal rf device (habib™ endohpb, emcision ltd., london, uk), placed in a block using guidewire technique. rfa is followed by self-expanding or balloon-mounted metal-stent (ms) placement. drainage catheter was repositioned for follow-up. results: duct patency restorated in ( . %) cases; in ( . %) case procedure filed because of guidewire conduction failure. all cases of balloonoplasty required the repeated procedure followed by stenting. biliary patients maintained stent patency as long as they are alive. the mean stent patency was . ± . ( - ) days. there was no -day mortality, haemorrhage or pancreatitis following rfa. one complication (bile duct perforation) was observed in a post-balloonoplasty patient on repeated (rfa&stenting) procedure; this case was managed percutaneally. percutaneous rfa treatment appears to be safe and effective in the management of inoperable biliary and wirsung duct block. randomised studies with prolonged follow-up are warranted. conclusion: viatorr plays an important role in tips scenario but its outcomes are strictly related to technical aspects such as intrahepatic tract completely covered, no concern about liver transplant, device never advanced in the portal vein for more than cm, -mm viatorr has to be considered the best compromise. was removed days after the procedure, during an open re-do for intra-abdominal bleeding. three stents are still in place. conclusion: placement and removal of retrievable covered stents appear to be technically feasible and could represent an excellent option in treating biliary disorders. bioabsorbable biliary stent in the percutaneous treatment of benign biliary stricture: preliminary experience g. mauri, c. michelozzi, v. pedicini, d. poretti, m. tramarin, f. melchiorre, g. cornalba, g. brambilla; milan/it (vanni.mauri@gmail.com) purpose: to report the outcome of patients treated with a novel bioabsorbable biliary stent for benign biliary strictures. methods and materials: ten bioabsorbable polydioxanone biliary stents (ella-dv biliary stent, ella-cs, czech republic) were deployed in patients with increased level of bilirubin due to postsurgical benign biliary stricture. this stent is made of polydioxanone, a material that allows to obtain a high radial force, but that is reabsorbed by the body within months. all patients had stricture recurrence after multiple standard bilioplasty ( to ). all patients were followed with clinical visit, ultrasound and serum bilirubin level. the procedure was successfully performed in all patients and immediate restoration of the normal caliber of the biliary duct was obtained. no immediate or late complications occurred and no patients had recurrence of the initial stricture (median follow-up months, range - months). conclusion: percutaneous bioabsorbable biliary stent placement is feasible and effective in the treatment of benign biliary strictures and in which standard bilioplasty has failed. in the future, this novel treatment may replace percutaneous bilioplasty a retrievable biliary stent placement as soon as long-term follow-up data will be available. to have a y-configuration for the biliary drainage of both lobes of liver, we used two pieces of covered stent system: one covered main piece stent and one contra-lateral covered stent. before and days after y-covered stent insertion, cholangiograms were obtained through the ihd for the evaluation of biliary drainage of both lobes of liver. we checked the blood bilirubin levels before, week after and every month after the stenting. results: they were patients including women and men. they had inoperable intrahepatic cholangiocarcinomas in and two metastatic biliary obstructions due to breast and stomach cancers. obstructive types were in i, in ii, in iiia and in iv. the placement of the y-shaped covered stent was successful in all cases. the mean follow-up period was about months. all cases had showed adequate biliary drainages in the follow-up tubograms. the bilirubin levels had been normalised weeks after being the y-covered stent inserted except one patient. there were no clinical infectious signs during the follow-up period. mean patency rate was about . months ( days). a newly designed y-shaped covered stent would be clinically effective for the palliative treatment of hilar obstructive malignant carcinoma of liver. the comparison of balloon-occluded retrograde transvenous obliteration for gastric varices using liquid and foam sclerosants j. koizumi , k. myojin , c. itou , n. mori , t. sekiguchi , t. hara , t. ichikawa , y. imai , b. janne d'othée ; isehara/jp, baltimore, md/us (jkoizumi@is.icc.u-tokai.ac.jp) purpose: liquid ethanolamine oleate which has been used traditionally for balloonoccluded retrograde transvenous obliteration (brto) of the gastric varices (gv) may cause severe complications including haemolysis, allergy, etc. if overdosed. thus, we introduced foam sclerotherapy to reduce the dose and compared the safety and efficacy of brto using liquid and foam sclerosants. methods and materials: forty-three patients with gastric varices were performed brto since october ' . of these, three patients were excluded because simultaneous tace or pse was performed. twenty patients using liquid ethanolamine oleate with iodine contrast (eoi) before march ' and twenty patients using polidocanol foam (pof) after may ' were included in this study. the success rates, side effects and complication rates were compared among the two groups. results: complete stasis of the gastric varices was obtained in all patients of both groups. abdominal symptoms during brto were significantly (p < . ) higher in eoi ( %) than pof ( %). postprocedure fever (> . ) was also significantly (p < . ) higher in eoi ( %) than in pof ( %). in both groups total bilirubin increased and platelet counts decreased significantly (p < . ). however, the decrease ratio of platelet counts was significantly (p < . ) higher in eoi (- . ± . %) than pof (- . ± . % purpose: digital linear tomosynthesis has recently been introduced not only for mammography but also for chest and musculoskeletal indications. the clinical utility in musculoskeletal applications has been validated in only a few reports. the purpose of the current study was to evaluate the clinical utility of tomosynthesis in suspect occult hip fracture. in a retrospective review tomosynthesis hip examinations on women and men performed for further evaluation of suspect hip fracture were retrieved from the radiology archive. three observers scored the tomosynthesis scans separately from the radiography examinations, into the categories no proximal femur fracture, suspect proximal femur fracture (femoral neck, trochanteric, or greater trochanteric avulsion) or definite proximal femur fracture. ct, mri or clinical outcome was used as reference. results: observer variation was moderate to substantial for three observer pairs regarding radiography (k= . - . ) and improved to substantial to almost perfect for tomosynthesis (k= . - . ). eleven patients were operated on for femoral neck fracture. tomosynthesis detected ten of these, and the eleventh patient was operated on without diagnostic confirmation from any imaging modality. one patient had been operated with dynamic hip screw for intertrochanteric fracture. the remaining trochanteric fractures were incomplete and were treated conservatively. there were no false-positive tomosynthesis diagnoses reported. there were no significant falsenegative tomosynthesis diagnoses. the distinction between incomplete/complete trochanteric fractures and greater trochanteric avulsions is sometimes difficult. purpose: advanced core decompression (acd) is in clinical evaluation for patients with avascular necrosis (avn) of the hip. in opposition to standard core decompression, acd uses an expandable reamer allowing optimal debridement of necrosis after drilling a core to the femoral head. the bone defect is filled with a bone graft substitute. we aimed to constitute the therapeutic success of acd based on mri. methods and materials: twenty patients ( males, females, mean age . years) underwent t mri of the hip prior to, days and . - years after acd. the protocol included tirm, pd/t w tse, high-resolution t w, dess and t w vibe sequences. sequences were evaluated regarding delineation of necrosis, bone, graft and transformation zone in between. the volume of necrosis was measured before and after acd. results: avn prior to acd as well as the defect filled with the graft after acd and the residual necrosis could be imaged with reproducible high quality at t. t w and pdw sequences provided best contrast to measure the volume of necrosis. each patient showed a reduction of necrosis after acd ( . % to . %, mean . , sd . ). the granulation zone around the graft could especially be visualised by t w tirm and pdw sequences. the arrangement of different layers correlated with histological findings. conclusion: structural changes and reduction of necrosis after acd can be monitored by mri. acd does significantly reduce the volume of necrosis in avn of the hip. the mre study after oral administration of peg solution provides an accurate assessment of small-bowel involvement, allowing an evaluation of disease activity in patients with known cd, reducing the radiation exposure in young patients. metal artefact reduction in hip prosthesis with iterative reconstructions f. morsbach , s. bickelhaupt , g. wanner , a. krauss ; b. schmidt , h. alkadhi , zurich/ch, forchheim/de purpose: to evaluate the effect of a novel iterative frequency split-normalised (ifs) metal artefact reduction (mar) on image quality of computed tomography (ct) in hip-prosthesis. in the first study-part, an artificial hip-phantom with steel and titan-based shafts, using three inlays of water, fat and contrast-media placed in the pelvis, was used to test and optimise the ifs algorithm. image quality and accuracy of ct number measurements of inlays were determined. in the second study-part, consecutive patients with unilateral (n= ) or bilateral (n= ) hipprosthesis were included. datasets using filtered back projection (fbp), ifs and a previously published mar algorithm using linear-interpolation were reconstructed. two readers evaluated axial, coronal and sagittal ct image reformations for overall image quality and evaluated image quality of pelvic organ depiction; ct numbers in the urinary bladder, gluteal muscle and subcutaneous fat were measured. results: ex-vivo experiments revealed the best image quality for ifs. measurements of ct numbers of the inlays were more accurate for ifs. in patients, we found a significant improvement in overall image quality for all reformations (p < . ) and a significantly increased image quality of pelvic organs (p < . ) for the ifs algorithm. ct numbers of the bladder (p < . ) and muscle (p= . ) were significantly less variable for ifs as compared with images reconstructed with fbp and the linear interpolation mar algorithm, whereas we found no significant difference for fat (p= . ). the ifs algorithm significantly reduces metal artefacts from hipprostheses, increases image quality and improves measurement accuracy of ct numbers as compared with fbp and linear interpolation mar algorithms. purpose: computed tomographic (ct) colonography is a technique for detecting bowel cancer or potentially precancerous polyps. because retained fluid and stool can mimic pathology, ct data are acquired with the patient in both prone and supine positions. radiologists then match endoluminal locations between the two acquisitions to determine whether pathology is real. this process is hindered by the fact that the colon can undergo large deformations that often occur during repositioning of the patient. automated registration between datasets could potentially improve efficiency and diagnostic accuracy. we have developed software to establish correspondence between prone and supine endoluminal surfaces. an initialisation step generates image patches at the positions of haustral folds using depth map renderings and is optimised by virtual camera registration. additional neighbourhood information is then included in a markov random field model to establish landmark-based correspondences. subsequently, the complexity of the registration task is reduced by mapping both prone and supine surfaces onto a cylindrical domain in which correspondence is established using non-rigid image registration. monday recurrences in patients ( hepatic and lung metastases) but missed a mm sessile polyp and flat lesions. ctc quality was inadequate in the % of patients. conclusion: ctc can be effective and represents a valid alternative to colonoscopy for surveillance for colorectal cancer recurrence after surgery. ct colonography: comparative study of experienced vs nonexperienced radiologists using d flythrough approach with and without cad software f. vecchietti, m. rengo, d. caruso, c.n. de cecco, d. bellini, a. laghi; latina/it (fabrizio.vecchietti@gmail.com) purpose: to compare performances of different experienced readers using a primary d flythrough approach with and without the use of a cad analysis. methods and materials: three readers evaluated patients with endoscopically proved polyps (ranging from mm to mm) and different colonic preparations ( fluid tagging, full cathartic preparation). dataset analyses were performed on a ge adw . workstation equipped with vcar colon software. per-polyp sensitivity, inter-reader agreement, mean reporting time and false positive were evaluated for each approach. results: less experienced readers increased per-polyp sensitivity, respectively, from % and % for d analysis to % and % for primary d+cad analysis with a significant difference (p= . and p= . ) while no significant differences were found for the expert reader (p= . ). less experienced readers were faster when assisted by cad but no significant differences were found on mean reading time for all readers (p= . / . / . ). mean false-positive findings for cad standalone analysis were (+- ). all readers decrease false positive when assisted by cad especially less experienced ones. inter-reader agreement was higher among all readers when assisted by cad ( methods and materials: seventy-five consecutive patients were prospectively randomised into two groups. both groups followed a low residue diet for two days before the examination. both preparations were based on fluid tagging, using a iodinate contrast medium (gastromiro). group received ml of fluid tagging agent the day before the study. group received ml of fluid tagging agent the day of the exam and ml of a laxative agent (lovol-esse) the day before the study. patient acceptance was evaluated using a visual assessment scale. quality of bowel preparation was evaluated using quantitative (tagged fluid density and number of untagged residue per segment) and qualitative (homogeneity per segment on a point scale) scores. results: bowel preparation was complete in all patients. no statistical significant differences for tagged fluid density, number of residue and tagging homogeneity between the two groups were founded. a significant higher patient acceptance was founded in group (p= . ). the preparation based on the combination of a laxative and a fluid tagging agents was better accepted. adding a laxative agent to a fluid tagging preparation did not improved image quality but was associated with an higher patient acceptance. moreover, the if a laxative agent is added to a fluid tagging bowel preparation the amount of iodine can be reduced. considering the latter as a reference method, ctc examinations were retrospectively and blindly initialisation, the method significantly improved the cylindrical registration (p < . ), achieving a mean error of . mm measured at reference points. the proposed method can successfully establish correspondence between prone-supine locations on the endoluminal surface derived from ct colonography. the ability to rapidly and automatically match polyps between acquisitions will facilitate ct colonography interpretation. (t.n.boellaard@amc.uva.nl) purpose: to evaluate whether a single intravenous alfentanil bolus has a clinically relevant analgesic effect compared with placebo in patients undergoing elective ct colonography. a prospective multi-centre randomised double-blind placebo-controlled trial was performed in consenting symptomatic or surveillance patients scheduled for elective ct colonography. patients were randomised to receive either a bolus of . μg/kg alfentanil (n= ) or placebo (n= ). the primary outcome was the difference in maximum pain during colonic insufflation on an -point numeric rating scale (one-sided t test). we defined a clinically relevant effect as a maximum pain reduction of at least . points. secondary outcomes included total pain and burden of ct colonography ( -point scale), most burdensome aspect, side effects and recovery time measured by the aldrete score. results: maximum pain scores during insufflation were lower with alfentanil as compared with placebo, . versus . (p < . ). total ct colonography pain and burden were also significantly lower with alfentanil ( . vs. . and . vs. . , respectively). with alfentanil fewer patients rated the insufflation as most burdensome aspect ( . % vs. . %; p= . ). no clinically relevant desaturations occurred. episodes with desaturations < % spo and dizziness were more common with alfentanil ( . % vs. . %; p < . and . % vs. . %; p < . ). aldrete scores in the alfentanil group were significantly lower immediately after the procedure, but similar at and minutes. purpose: to evaluate the accuracy of contrast material-enhanced computed tomographic colonography (ctc) for follow-up after curative surgery for colorectal cancer without evidence of disease recurrence. methods and materials: patients underwent ctc and colonoscopy (within months) after colorectal cancer surgery. patients with the suspicion of disease recurrence underwent pathologic confirmation. patients performed bowel cleansing and faecal tagging; bowel distention was achieved using co . both prone and supine scans, one after intravenous contrast material administration during the portal phase, were obtained using a -detector ct ("brilliance" philips with idose). images were reconstructed with a section thickness of . mm, transferred to a workstation and interpreted by one radiologist with experience reading several hundred ctc cases. sensitivity, specificity, positive predictive value (ppv), and negative predictive value (npv) of ctc for anastomotic and non-anastomotic colonic lesions (metachronous or flat lesions and polips) were determined and compared to endoscopy. results: ctc detected all anastomotic recurrences, all metachronous lesions (sensitivity and specificity= %) and a perianastomotic recurrence. in patients ctc depicted / polips > mm (sensitivity= . %, specificity= %, vpp= %, vpn= . %, accuracy= . %) and in patient detected of flat lesions (sensitivity= . %, specificity= %). ctc enabled detection of extracolonic prevalence and distribution was related to patient gender (p> . ). in sigma, advanced disease (grade / ) shows a significant positive correlation with reduced colonic distension (p < . ). no correlation was found between severity of sigmoid diverticula and symptoms onset. conclusion: prevalence and severity of diverticular disease increased over time in all colonic segments. an elevated number of asymptomatic diverticula is present in the right colon. an high percentage of patients with severe sigmoid diverticular disease remain asymptomatic. accuracy of water enema-mdct in colon cancer staging: a prospective study c. feasibility study of low-dose ct colonography using model-based iterative reconstruction: preliminary findings in patients v. vardhanabhuti, c. roobottom; plymouth/uk (vvar@me.com) to compare image quality on computed tomographic (ct) images acquired at standard dose (sd) and low dose (ld) using adaptive statistical iterative reconstruction (asir) and model-based iterative reconstruction (mbir) techniques. methods and materials: patients were prospectively recruited for the study with informed consent. they underwent standard dose (sd) and low-dose (ld) ct colonography. low-dose parameters were based on our phantom study with using vendor-specific automatic tube current modulation known as noise index. both sets of scans were reconstructed with asir and mbir. objective and subjective image qualities were assessed as well as diagnostic accuracies for significant lesions (e.g. polyps, cancer, etc). effective doses for each scans were recorded. results: objective image analysis supports significant noise reduction and superior contrast-to-noise ratio with low-dose scans using mbir technique (p < . ) despite being acquired at lower doses. subjective image parameters were equivalent for ld mbir and sd asir for both colonic and extra-colonic findings. diagnostic accuracies for polyp detection and other significant lesions were comparable. dose recorded were substantially lower for mbir (range - % reduction compared with asir) with mean average being . msv in our population group. conclusion: mbir shows superior reduction in noise whilst maintaining image quality and most importantly substantial dose reduction can be achieved. more patients are being recruited to substantiate diagnostic accuracies data with full results to be presented at the ecr . reviewed by two readers separately respectively having a degree of initial and advanced experience (for both primary d view). calculated values were sensitivity, specificity, nvp, pvp for patient-to-segment and both without and with the use of the cad system (im d-turin) as the second reader. ]of sensitivity, specificity, nvp, pvp reported by the novice radiologist were respectively: %, %, % and %, while the values obtained by the radiologist with advanced experience were equal to %, %, %, %. with the use of cad as a second reader the novice player has achieved an improvement of the sensitivity to %, while the skilled reader did not obtain a significant increase of' diagnostic accuracy. the sensitivity and npv of ctc for flat lesions depend on the experience of the radiologist reader. cad seems to be an effective aid for the novice radiologist only. (thomas.knogler@meduniwien.ac.at) purpose: to predict early treatment response with three-dimensional texture features (tf) in patients with hodgkin lymphoma (hl) after radio-chemotherapy extracted from contrast-enhanced ct. methods and materials: patients with histologically proven hl were included in this study. contrast-enhanced ( )f-fdg pet/ct was obtained on a dedicated pet/ct scanner. volumes-of-interest and long-and short-axis diameter were manually defined on hl manifestations prior and post-radio-chemotherapy on the ct image stack. three-dimensional texture features derived from the grey-level histogram, co-occurrence matrix, run-length matrix and absolute gradient were calculated for the vois. a stepwise logistic regression with forward selection was performed to find classic radiologic features (i.e. lesion diameter, lesion volume) and tf, which correctly classify treatment response (i.e. full response and partial response). classification in pet/ct was used as reference. results: difference in short axis diameter best fit as classic feature with a sensitivity of %, a specificity of . % and an accuracy of . %. combination of "s_ _ _ _entrp" and difference of "vertl_fraction" best fit as tf with a sensitivity of . %, a specificity of . % and an accuracy of . %. conclusion: texture features extracted from contrast-enhanced ct in patients with hl are superior in differentiation between responders and non-responders without the need for pet examinations, compared to classical radiological features. however, pet/ct as state-of-the-art imaging technique has a sensitivity and specificity > %, so that further research with larger patient number is needed to investigate this new method. (melvin.danastasi@med.uni-muenchen.de) purpose: to evaluate the agreement between true tumour volume and tumour volume derived from (i) a new formula based on longest lesion (recist) diameter, (ii) a new formula based on longest diameter and longest orthogonal (who) diameter. methods and materials: baseline and follow-up cts were available in patients with metastastic colorectal cancer from the randomised phase ii multicenter ciox trial. target lesions were defined at baseline and followed over time. lesions were evaluated by (i) semi-automated volumetry using siemens syngo.via and (ii) volumetric assement using a newly developed formula based on manual measurement of the longest diameter and the longest orthogonal diameter. true, who-and recist-based volumes were calculated. we compared the agreement of the true volume to the who-and recist-based volume. we also compared the agreement between 'true' and who-based volume relative changes by means of the intraclass correlation. results: a total of lesions were evaluated. using a variance components model it was shown that the difference between true and recist-based volume is statistically significant (p < . ) indicating a substantial constant bias. purpose: tumour treatment by retargeted truncated protein derivatives of the human tissue factor (ttf) results in tumour vessel infarction, necrosis and subsequent tumour growth retardation and regression. a novel method of gadofosvesetenhanced mri, that enables the visualisation of the response to this treatment in real-time, is introduced. methods and materials: dynamic gadofosveset-enhanced mri ( t) was performed in eight tumour-bearing (u ) nude mice. in the course of an ultrafast t -weighted gradient echo sequence, a gadolinium-based blood pool contrast agent (gadofosveset trisodium) was injected intravenously via a tail vein catheter. after the maximum contrast intensity inside the tumour was obtained, µl of ttf-ngr (a retargeted ttf derivative which binds to cd -overexpressing tumour endothelial cells) were injected intravenously via a second tail vein catheter (n = ; saline solution as control: n = ), and the contrast behaviour of the tumour was monitored by region of interest (roi) analysis. results: following the injection of ttf-ngr (approx. sec. after the beginning of the sequence), the contrast intensity inside the tumours of the treated mice decreased more instantly and more strongly than in the tumours of the control mice (auc . ± . vs. . ± . au). conclusion: gadofosveset-enhanced mri allows for the visualisation of the therapeutic response of tumours to anti-vascular treatment in real-time. considering the intended clinical application of ttf-ngr, this method might be a simple and quick surrogate parameter for the monitoring of the therapeutic response to vascular disrupting agents in humans. purpose: the specific growth pattern of pleural mesothelioma along the pleural surface makes therapy monitoring using common measurement criteria, such as recist . , difficult. therefore, byrne et al. developed modified recist criteria for pleural mesothelioma. in this study we evaluated the accordance between experienced and less experienced readers for recist . , recist . , mre-cist, and who. methods and materials: a total of baseline and follow-up-ct scans from patients from a clinical multi-centre pleural mesothelioma trial were retrospectively evaluated by different experienced radiologist (about year and more than years), who selected target lesions independently according to mrecist, recist . , recist . and who criteria. ct scans were then re-measured after an interval of greater than one month. the inter-and intra-reader variability using the different response criteria was analysed. results: both, the intra-reader-and inter-reader variability were best when using mrecist ( % limits of agreement of - . / . and of - . / . ) compared 'with recist . , recist . and who. further, regarding the objective response (pr = partial response, sd=stable disease and pd = progressive disease), mre-cist showed the most reliable intra-observer outcome with only one differently classified examination and the most reliable inter-observer outcome with four differently classified examinations. conclusion: our results suggest that mrecist is most reliable for treatment response evaluation of pleural mesothelioma between experienced and less experienced readers compared with recist . , recist . and who. to confirm these findings, the inclusion of further readers and more patient data is warranted. use of multimedia structured reporting for tumour response assessment d. munich/de (wieland.sommer@med.uni-muenchen.de) purpose: the aim of this study was to define the role of mri in the pretherapeutic prediction of treatment response in patients with liver metastases of neuroendocrine tumours (net) undergoing radioembolisation. in patients with proven hepatic metastases net, mri was performed at baseline ( t mri scanner, gd-eob-dtpa). furthermore, pet-ct examinations with somatostatin-specific tracer ga-dotatate were performed at baseline. the following imaging predictors were defined: patient age/gender, proliferation marker ki- , tumourload (%), vascularisation of metastases, tumour necrosis and haemorrhage. the status of somatostatin receptor was defined by analysing mean and maximum suv in pet-ct. as primary end point we defined the progression-free survival (pfs) using recist criteria in mri follow-up examinations (every months). the effects of the predictors on the progression-free survival were analysed using kaplan-meier statistics. results: the mean follow-up time was ± days. the mean pfs was days ( %ci - ). hypovascular metastases showed significant earlier progress ( vs. days; p < . ). a proliferation marker < % was significantly associated with a longer pfs than a proliferation marker between - % and > % (p < . dimensions system d (hologic®). the distribution among the acr density patters was studied. all women underwent a "combo" study, which consisted of a d-dm ( projections) and d-dbt ( projections). the increase in the detection of additional breast cancers due to the d-tomosynthesis studies has been evaluated. chi-square test with spss for windows ( . chicago, il) has been used to evaluate if there were any statistically significant differences (p < . was considered statistically significant). the clinical, radiologic and pathologic findings are described. results: among all acr density pattern, breast cancers were diagnosed with the d-dm studies (detection rate . %). additional cancers were diagnosed due to the d-dbt imaging findings (four in acr density patter , one in acr density pattern and two in acr density pattern ). the global detection rate increased to . %. no statistical differences were found regarding the detection rate among all density patterns. conclusion: in our group of patients the use of d-dbt combined with conventional d-dm increased the rate of breast cancer diagnosis from . to . %. no statistical significant differences were found among all acr density patterns. d-dbt may be useful not only in dense breasts (acr and ) but also in medium density breasts (acr ). exams. we present a structured reporting system, called vision, which captures a radiologist's measurements and key images in an efficient manner to generate disease timelines and automate the calculation of recist. we analysed serial radiology reports from ten patients with cancer to determine if radiologists reported tumour measurements, saved measurements in pacs, and whether there was correlation of tumour metrics between exams. in addition, we created a structured reporting solution that uploads screen captures and audio descriptions of image findings to a computer server where each finding is labelled with anatomy and pathology terms, presented in a multimedia structured report, and can be used to calculate recist. results: the analysis of baseline and subsequent radiology reports revealed that radiologists reported measurements in % of cases, saved measurements in % of baseline and % of follow-up studies, and correlated measurements between exams in only %. the application of vision enabled a means to record tumour measurements in % of cases by providing a visual record of where target lesions were previously measured, facilitating the linking of image findings between examinations and displaying the findings in disease timelines. the vision structured reporting system provides a means for more reproducible tumour response assessment. to identify the potential of breast mri vs. standard prognostic factors to predict tumour recurrence after successful treatment of primary breast cancer. methods and materials: consecutive patients receiving staging mri and subsequent guideline-approved therapy of primary breast cancer at our academic breast centre were investigated. standard prognostic factors including tnm staging, tumour typing, tumour grading, progesterone/estrogen receptors, her neu score and associated dcis component were assessed. follow-up was performed (endpoint: "tumour-recurrence" after complete remission). for analysis of breast-mri a dedicated cad software was used (computer-aided analysis). it enables semi-automatic analysis of enhancement characteristics of the whole tumour ( d analysis of early vs. delayed phase) and the "hot-spot" (i.e. voxel with highest washin/wash-out ratio). potential of breast mri characteristics vs. standard prognostic factors to stratify the endpoint separately and in combination was investigated using logistic regression. to identify significant and independent predictors, backward feature selection was applied (p entry /removal: < . /> . ). results: patients were included (endpoint: n= / . %, loss-to follow-up: n= / . %). if tested separately, logistic regression identified moderate potential for breast mri (aucmri= . , p= . ) and standard prognostic factors (auc-standard= . ; p= . ) to stratify the endpoint. if breast mri characteristics and standard prognostic factors were combined, predictive performance could be increased considerably (auccombined= . , p < . , sensitivity= . %, specificity= . %). feature selection identified one standard prognostic factor (m-stage) and four breast mri characteristics (hot-spot: wash-in, washout-ratio; d-analysis: tumour voxels showing wash-out plus weak wash-in, tumour voxels showing plateau and weak wash-in) as the most significant and independent predictors of tumour recurrence. purpose: to estimate the influence of breast density on diagnostic performance of dbt added to dm (dm+dbt), focusing on recall rate reduction. methods and materials: seventy-five women were recalled for findings on dm screening examination and further investigated according to usual protocols (additional dm views, ultrasonography, and/or core needle biopsy). the final conventional assessment was: cancers ( invasive ductal carcinoma, invasive lobular carcinomas) and negative/benign cases. before this conventional work-up, -or -view dbt was obtained (giotto, ims, italy) for an off-line further evaluation. two independent readers, blinded to final conventional assessment, retrospectively assigned a bi-rads score to each lesion on both dm only and dm+dbt. breast density was scored according to acr categories from to . χ test was used. results: none of the cancers was missed on dm+dbt by each of the two readers; of readings, ( %) had an increased bi-rads score. of readings of benign/negative cases, density was acr in ( %), acr in ( %), acr in ( %) and acr- in ( %); the bi-rads score was increased in ( %), unchanged in ( %) and decreased in ( %). bi-rads was decreased for / ( %) acr , / ( %) acr , / ( %) and / ( %) acr (p= . ). conclusion: breast density does not influence the capability of dbt, as added to dm, to decrease the bi-rads score of negative/benign cases recalled for further assessment at screening dm. recall rate reduction by adding double reading digital breast tomosynthesis (dbt) to digital mammography (dm) l.a. carbonaro , r.m. trimboli , n. verardi , k. khouri chalouhi , g. di leo , f. sardanelli ; san donato milanese/it, milan/ it (luca.carbonaro@gmail.com) purpose: to estimate the reduction in recall rate induced by adding double reading dbt to dm. methods and materials: during weeks of screening-activity, women with at least one mammographic suspicious finding were further investigated according to usual protocols (additional views, ultrasonography, and core needle biopsy). before this standard exams, -or -view dbt was acquired (giotto, ims, italy). of a total of , dm screening-exams, were initially recalled (recall rate of . %) for suspicious findings. two independent readers (who did not perform initial standard reading and blinded to final diagnosis) retrospectively evaluated dm and dbt. each lesion was scored according to bi-rads classification, considering , a-b-c, and as recalls. results: two dbts (two findings) were excluded for technical problems. at combined dm+dbt evaluation each of the two readers recalled / ( %) women; considering each case judged as bi-rads - by at least one of the two readers as recalled (double reading), a total of cases were recalled with a reduction in recall rate of / ( %). of readings of cancers ( idcs, ilcs), we had bi-rads upgrade for ( %), confirmation for ( %), and downgrade for ( %). of readings of negative cases, we had a bi-rads upgrade in ( %), confirmation in ( %), and downgrade in ( %). no cancers were missed. the use of double reading dbt as an adjunct to dm could allow for a reduction of recall rate by %, from . % to . %. detection rate for suspicious lesions of digital breast tomosynthesis in combination with digital mammography or d central projection imaging c. zuiani , p. clauser , v. londero , c. molinari , r. girometti , a. taibi , s. vecchio , m. bazzocchi ; udine/it, ferrara/it, bologna/it (clauser.p@hotmail.it) purpose: based on a novel approach, digital breast tomosynthesis (dbt) may simultaneously acquire d and d images of the breast. variable dose geometry is used to give a sufficient dose in the central projection ( d-cp) for that image to be a d mammogram. we aimed to assess the detection rate for suspicious lesions (acr-birads - ) of dbt associated with digital mammography (dm) or d-cp. methods and materials: asymptomatic women who performed dm and dbt with d-cp as screening examinations were included. two experienced radiologists, blinded to final diagnosis, evaluated images in separate sessions according to two different strategies of reading: dm+dbt (set-a) and d-cp+dbt (set-b). they assessed breast lesions as benign or suspicious in case of acr-bi-rads scoring of - and - , respectively. discordant cases were reviewed in consensus. purpose: the aim of this study was to demonstrate the diagnostic significance of digital mammography with tomosynthesis ( d) versus digital mammography ( d) in the group of histologically proven multicentric breast cancer. in the group of patients examined in this study, -d mammography showed suspicious breast lesions. all patients were sent to the oncology institute of vojvodina for further examination and biopsy. at our institution after initially clinical breast exam, d and d mammography were performed in the same act. all imaging procedures were performed on hologic selenia dimensions equipment. two radiologists independently read mammograms and core needle biopsy were performed in all birads and groups. all patients had fibroglandular or heterogeneously dense breasts (acr and acr ). results: in the group of patients, pathologic findings revealed unifocal and multicentric cancers for a total of malignant foci. all unifocal cancers were detected by both methods. with d mammography, additionally suspicious lesions were found and using d mammography suspicious mass were found. both d and d mammography showed the same lesions but d mammography showed "new" lesions which were obscured on d mammography. overall sensitivity was % ( / ) for d mammography and % ( / ) for d mammography (p < . ). results showed that in % of multicentric foci were in situ carcinomas (dcis). conclusion: d mammography was more sensitive than d mammography for the detection of multicentric foci in fibroglandular or heterogeneously dense breasts. the role of tomosynthesis after normal mammography according to acr density patterns j. etxano, p. slon, i. after a standardised preparation with l of oral water over min, the patient is asked to empty the bladder. initially the patient receives intravenously (iv) mg of furosemide. contrast administration consists of a fixed iv volume of - ml iobitridol mgi/ml followed by ml saline solution injected at a rate of - ml/s. after min and subsequently every min first low-radiation scouts are acquired breast tomosynthesis versus digital mammography: evaluation of diagnostic potential in women with abnormal screening mammograms m. a. shaaban; cairo/eg (marwaadelmm@hotmail.com) purpose: to compare the diagnostic potential of digital mammography with tomosynthesis. methods and materials: women with abnormal screening mammograms, findings, and definite imaging or histopathological diagnosis were included. the screening mammography interpretation consisted of direct comparison of the tomosynthesis (dbt) examination with full field digital mammography (ffdm) images. the study radiologists subjectively rated the equivalence of the image quality of both the dbt and the ffdm examinations with no use of additional mammography, magnification views or comparison mammography. the next step was categorising the findings in both ffdm and dbt separately according to birads classification and the statistical analysis evaluated the p values of dbt and ffdm as well as their sensitivities. results: all findings categorised as birads according to mammography showed reduction in number,particularly for masses, when examined with tomosynthesis. the image quality of tomosynthesis was subjectively rated as equivalent ( . %) or superior ( . %) to digital mammography in . % of the total of findings; the test was highly significant (p < . ). for masses, tomosynthesis image quality was rated as equivalent in . % or superior in . % of findings. masses were % of findings in which tomosynthesis had superior image quality. the ffdm sensitivity was of . % compared with . % for dbt. the diagnostic potential of digital breast tomosynthesis is superior to that of full-field digital mammography by evaluating their image quality and their sensitivity. based on a subjective analysis, dbt showed a significantly higher image quality compared with digital mammography in all finding types, especially in the characterisation of masses. purpose: to compare discordant screen-detected cancers in ffdm (" d-mode") versus d plus tomosynthesis ( d+ d or "combo-mode") in a population-based screening program. methods and materials: oslo tomosynthesis screening trial (otst), a large prospective study comparing ffdm with d plus tomosynthesis in breast cancer screening, is part of the norwegian screening program. women - are invited biannually to mammography using independent double reading. the two main arms of otst have independent double reading. one d arm is modified with cad and one combo-arm with synthetic d. the four arms are read by independent radiologists. from . . to . . , screen-detected cancers were found. results: cancers detected: arm a (conventional ffdm) , arm b ( d+cad) , arm c ( d+tomo) , and arm d (synthetic d+tomo) . merging arm a and b (" d-mode") and c+d ("combo-mode"), cancers were detected by " d-mode" and by "combo-mode" ( . % relative increase). discordant rate (screendetected cancer with tp score by only one reader) was . % ( / ) for " d-mode" and . % ( / ) for "combo-mode". for cancers manifesting as spiculated mass or distortion (n= ) the discordant rate was . % ( / ) for " d-mode" and . % ( / ) for "combo-mode". for cancers with microcalcifications the values were . % ( / ) and . % ( / ), respectively. conclusion: combined ffdm and tomosynthesis showed a % relative increase in cancer detection as compared with ffdm. discordant cancer rate was approximately the same or higher for "combo-mode" as compared with " d-mode". independent double reading should be the standard of care when tomosynthesis is implemented into mammography screening. purpose: within narrow limits, the ct estimated size influences the prognosis for spontaneous passage of a ureteral calculus. in the present experiment, we tried to reduce the inter-reader variability in urinary calculus size estimation by measuring the variability before, immediately after and late after a training session. a retrospectively generated anonymous urinary calculi ct image data bank consisting of unenhanced ct-stacks demonstrating ureteral or kidney calculi was used. eleven readers, radiologists and residents (mean experience years) independently estimated the largest axial diameter of the calculi in three sessions: baseline, post-training and follow-up. immediately before the post-training session each reader received training on eight calculi aimed at reducing inter-reader variability without affecting the mean reader size estimate. follow-up session was performed four to eight weeks later without further training. results: per-calculus standard deviation between readers was . , . and . mm and inter-reader limits of agreement were ± . , ± . and ± . mm for baseline, post-training and follow-up session, respectively. friedman test showed significant difference for per-calculus standard deviation (p < . ). pairwise wilcoxon signedranks test showed increased variability in follow-up session compared to baseline (p < . ) and post-training session (p < . ). the small reduction in variability in post-training session compared to baseline was not statistically significant. the small statistically non-significant reduction of inter-reader variability from the tested training protocol had no long-term effect, where an increase in variability was seen. other approaches such as reader-independent urinary calculus size estimation seem more promising for reduction of inter-reader variability. purpose: to assess the added value of functional sequences, using diffusionweighted imaging and apparent diffusion coefficient value, to conventional mri imaging examination in the differential diagnosis from benign and malignant focal liver lesions. methods and materials: a total of patients with known focal liver lesions including benign ( angiomas, fnh, abscesses) and malignant ( metastases, hccs, cholangiocarcinomas) underwent . -t mri examination (achieva, philips). the study was performed with a phased array multi-coil using a conventional protocol that included also diffusion-weighted imaging (dwi) with different b-values. the rois were manually drawn on focal liver lesions and on surrounding normal hepatic parenchyma in adc maps, and statistical analysis of adc mean values was performed. results: lesions were proved either by follow-up (benign lesions) or biopsy (malignant lesions).following mean adc values were obtained for different types of benign lesions: angiomas ( . ± , x - mm /sec), fnh ( . ± , x - mm /sec), abscesses ( ± , x - mm /sec) while in the neoplastic lesions were: metastases ( , ± x - mm /sec), hccs ( , ± , x - mm /sec) and cholangiocarcinomas ( ± x - mm /sec). in normal hepatic parenchyma, mean perfusion values were ( , ± , x - mm /sec). a statistical higher values (p < . ) were obtained in diffusion parameters among benign than those of malignant lesions ( ± , vs ± , x - mm /sec). conclusion: diffusion-weighted images offer useful quantitative information (by evaluation of adc maps) that differs significantly in solid and malignant liver lesions, due to tumour different vascularity and cellularity. purpose: to identify the best mr sequences for pancreatic adenocarcinoma conspicuity and determine whether mr signal and apparent diffusion coefficient (adc) values correlate with pathological findings. methods and materials: consecutive patients with pathologically proven pancreatic adenocarcinoma who underwent mri ( . or t) before surgical resection were included. fat-suppressed (fs) t -weighted gradient-echo (gre), fs t -weighted fast-recovery fast spin echo, d fs dynamic t -weighted gadolinium-enhanced gre during arterial, portal and delayed phases and diffusion-weighted imaging (dwi) with b values of and or sec/mm were obtained. two observers reviewed mr sequences for size, signal characteristics and lesion conspicuity using a four-point rating scale. adc of tumours were calculated. histological characteristics (differentiation, fibrosis, necrosis) were correlated with mri features. results: % of pancreatic adenocarcinomas were hypointense on d fs t gre arterial phase, which was the best sequence for tumour conspicuity, followed by portal phase. dwi was not useful for delineating % of tumours. maximum diameter at pathological examination ranged from to mm (mean mm). it was best correlated with mr tumour size on dwi. no correlation was found between adc (mean value : . x - mm /sec) and differentiation, fibrosis or necrosis. all homogeneous hyperintense lesions on delayed phase ( % of tumours) were predominantly fibrous tumours. conclusion: d fs t gre arterial phase sequence is superior to dwi for pancreatic adenocarcinoma conspicuity but it underestimates the size of the tumour. dwi is the best sequence for size evaluation when the tumour is correctly delineated. quantitative data analysis of the diffusion-weighted mr-images in the differential diagnosis of metastatic liver disease of colorectal and pancreatic aetiology y. savchenkov, s. bagnenko, g. trufanov, v. fokin; st. petersburg/ru (yura_savchenkov@mail.ru) purpose: to develop differential diagnosis metastatic liver disease on the basis of quantitative data analysis of dwi. methods and materials: metastatic liver lesions colorectal ( lesions) and pancreatic ( lesions) aetiology were analysed in patients. we used dwi with the factors b- , , , , s/mm . all measurements were carried out within a single axial slice (for each pulse sequence separately). we used the coefficients, calculated on the basis of the ratio measured values in several organs, in different parts of the liver or in one and the same region of the liver. the most informative in the native study is the ratio of si lesionb /si aorta b , si lesionb /si aortab и si lesionb /si liverb (р< . ). somewhat less informative demonstrated is the ratio of si lesionb /si liverb и adc lesion - - (р< . and р= . purpose: in clinical practice, the apparent diffusion coefficient (adc)-map is supposed to eradicate the t -shine-through effect (t -ste) potentially affecting the diffusion-weighted (dw) signal of focal liver lesions (flls) at higher b-value. we investigated whether this assumption is valid. methods and materials: included were forty-five patients with focal liver lesions ( malignant and benign) detected on a . t system (cysts and haemangiomas were excluded from analysis). dw examination was performed using a single-shot echoplanar sequence with b values of , and sec/mm , leading to the generation of (a) the adc-map, using a -point regression analysis and (b) the exponential adc-map (e-adc-map), using the b /b images ratio, which provides a diffusion-weighted image with complete eradication of t -relaxation time effects. by performing an analysis of differential signal patterns, two experienced radiologists in consensus estimated the prevalence of the t -ste when combining dw images with the adc-map or e-adc-map. purpose: to develop a novel spectral reconstruction algorithm for digital breast tomosynthesis (dbt) that results in reduced artifacts and improved image quality. methods and materials: current reconstruction algorithms assume that the xray source emits a mono-energetic x-ray beam, resulting in artifacts and possibly sub-optimal image quality. to avoid this, a mathematical model of dbt acquisition that includes the spectral nature of the x-ray source was developed, resulting in a large scale non-linear inversion problem which we solve using an iterative, gradient descent method. the resulting algorithm was tested using breast phantoms with lesions resembling masses and calcifications. the breast phantoms were imaged with a clinical dbt system using the automatic exposure control system. the resulting spectral reconstructions were compared to the system's filtered backprojection (fbp) reconstruction, which assumes a mono-energetic x-ray source. the signal difference-to-noise ratios of the masses in the spectral reconstruction were all superior to those of fbp by a mean factor of . . in addition, the masses exhibited better homogeneity and no artifacts in the direction of x-ray tube travel, typically seen in dbt images. the microcalcifications also resulted in improved signal difference and without artifacts seen in the fbp reconstructions. subjective comparison of images of heterogeneous breast phantoms showed an overall improvement in image quality, substantial reduction of artifacts, and lower noise. conclusion: spectral reconstruction can improve image quality and reduce artifacts in dbt images. this new algorithm also allows for investigation of novel acquisition techniques that could result in further improvements in dbt imaging. purpose: phase-contrast radiography is an emerging technique for producing medical imaging with more soft tissue contrast than traditional absorption radiography. the goal of this study is to evaluate the feasibility of phase contrast imaging using grating interferometer for clinical use. we developed a prototype of phase contrast x-ray imaging system using micro-focus x-ray source, grating interferometer and cmos detector. the source contains a tungsten anode x-ray tube that can operate from kv at . ma and focal spot size of . mm. a specification of phase grating was . um period, ni . um height and x mm area; and analyser grating was . um period, au . um height and x mm area. with application of phase retrieval algorithm, phantoms such as acryl ball, honey bee and goldfish images were obtained. we compared with images of conventional absorption radiography and evaluated the phase intensity by phase stepping method. results: phase contrast image shows a detailed view of the edge of the acryl ball. on the phase contrast image there are dark and light lines running along the hole. these lines represent the phase-contrast edge enhancement effect. a similar effect is evident at the honeybee and goldfish images. the phase contrast edge enhancement effect is visible in the phase contrast radiography, but not in either of the absorption contrast image. the phase contrast imaging using grating interferometer will ultimately provide a novel x-ray imaging system that enables with high contrast, which can be valuable in medical imaging such as breast, cartilage and vessels. first in-vitro results of microbubbles as a scattering contrast agent for x-ray dark-field imaging measured at a first pre-clinical x-ray phase-contrast and dark-field ct scanner purpose: dark-field and phase-contrast imaging, which generate contrast from ultra-small angle scattering and refraction of x-rays in matter, have been shown to increase soft-tissue contrast and provide complementary information to conventional absorption-based imaging. to further improve image quality and explore possible alternatives to commonly applied iodine-based contrast agents, the use of microbubble-based ultrasound contrast agents as an x-ray scattering dark-field contrast medium was investigated. methods and materials: using the first pre-clinical phase-contrast and dark-field ct scanner with polychromatic x-ray source and grating interferometer installed on a rotating gantry, absorption, phase-contrast and dark-field images of microbubblebased contrast-agent samples were acquired in-vitro. for quantitative comparison, the contrast-to-noise ratio relative to a reference was calculated for varying detector resolutions ( - micrometer) in absorption and dark-field images. results: it was possible to generate an improved contrast-to-noise ratio in the darkfield image compared to the absorption-based image ( . versus . , pixel size micrometer) by exploiting the x-ray scattering through microbubbles. with larger pixel sizes ( micrometer), the relative contrast gain increased to . for dark field, whereas, with . , it remained in the same order of magnitude for absorption. the proved feasibility of microbubble-based dark-field contrastenhancement with clinically compatible pixel sizes, together with the large potential of the introduction of grating interferometry into a clinical environment as shown by the successful implementation of the technology into a rotating gantry, strongly promote the use of microbubbles as a dedicated dark-field x-ray contrast agent and warrant further investigation in an experimental in-vivo setting. images. four thicknesses of the combined phantoms were imaged with a digital mammography unit. of each thickness, four images were acquired under automatic exposure control. images were displayed under standard clinical conditions: first on two megapixel medical grade monitors calibrated to the dicom gsdf standard, then on a megapixel colour monitor, displaying the images in green-scale. greenscale was chosen as this wavelength matches a peak in human visual response. reading was performed with the sara software which displays each cdmam cell under random rotation, reducing reader memorization. readers performed a -alternative forced choice task; five readers scored all images. results: threshold gold thickness (tgt) increased as beam quality and thickness increased, indicating a reduction in object detectability with increasing object thickness. results obtained for the grey-scale display had a higher tgt compared to green-scale results; tgt values obtained with green-scale display were between % and % lower than grey-scale display tgt. p values for the different diameters obtained from wilcoxon matched pairs tests ranged from < . to . for cm and < . to . for cm. conclusion: observer performance measured by c-d curves was equal or better for images displayed in green-scale rather than grey-scale, indicating potential benefit for using green-scale displays in medical applications. volumetric breast-density measurement using spectral mammography purpose: volumetric breast density (vbd) quantification is useful for assessing diagnostic accuracy and the risk of developing breast cancer. the purpose of this study is to evaluate spectral imaging as a method to improve the accuracy of vbd measurements compared to conventional non-spectral methods. the vbd is the volumetric fraction of fibro-glandular tissue in the breast. to measure vbd in a conventional non-energy resolved mammogram, assumptions have to be made on the breast thickness. spectral imaging, on the other hand, enables simultaneous measurement of breast thickness and glandularity by employing the spectral difference in x-ray attenuation between adipose and fibro-glandular tissue. spectral mammograms were acquired in a single exposure using a photon-counting mammography system. the vbd was measured by material decomposition based on calibration to tissue-equivalent material. for reference, vbd was measured with a conventional non-spectral method in a similar group of patients. results: spectral mammograms of patients, aged - years, were examined. the correlation in vbd between contralateral breasts was r= . . patients were examined with conventional methods, which returned a correlation between contralateral breasts of r= . . the vbd distribution was similar in the two groups as measured with the two different methods. conclusion: spectral imaging provides an efficient measure of vbd. the vbd distributions over the group of patients were comparable in the spectral and nonspectral measurements, but the correlation between contralateral breasts was tighter using spectral imaging, which indicates higher consistency. purpose: the feasibility of monochromatic dual-energy x-ray absorptiometry (dexa) using multilayer reflector for precise measurement of bone mineral density (bmd) was examined. methods and materials: a multilayer mirror was fabricated to select an x-ray peak with an energy of kev and . kev generated from an x-ray tube with a tungsten target. experimental set-up of monochromatic dexa was installed by dual-energy of monochromatic x-rays source and czt detector. the performance of the system was evaluated using a dexa phantom, spectrometer and radiation dosimeter. we compared the image quality and the attenuation reduction characteristics of the phantom to determine precision of bmd on conventional polychromatic and monochromatic dexa. purpose: high vessel attenuation and a high contrast-to-noise (cnr) ratio are prerequisites for highly diagnostic abdominal ct angiography (cta) examinations. we compared image-quality of standard kev polyenergetic images (peis) with calculated low-kev monoenergetic images (meis) in dual-energy cta studies of the abdomen. methods and materials: datasets of fifty patients ( men, ± years) who underwent abdominal dual-energy cta were retrospectively evaluated. the -and -kev dual-energy image data was used to calculate meis in -kev intervals from kev to kev. vessel attenuation and image noise were measured in three regions-of-interest (infrarenal aorta, external iliac artery and superior mesenteric artery) and the signal-to-noise ratio (snr) and cnr were subsequently calculated. differences between measurements in meis and peis were evaluated using the student's t-test. results: snr and cnr of -kev meis were highest compared to meis at other low-kev levels. when comparing meis at kev to peis, vessel attenuation and image noise were significantly higher in meis in all three regions-of-interest (+ %, + %, + %; p < . and + %, + %, + %; all p < . ). snr was slightly increased in -kev meis (+ %, + %, + %; p < . ). cnr was also significantly higher in meis when compared to peis (+ %, + % and + %; p < . ). purpose: it was shown in mice the exposure to a high fat (hf) diet during early development increased the susceptibility to high-fat diet-induced hepatic steatosis and decreased markers of hepatic mitochondrial function. we aim to investigate whether early exposure to a hf diet also increases the susceptibility to cardiac fat storage and diminishes cardiac mitochondrial function and ejection fraction. methods and materials: male and female c bl mice were fed a hf diet ( % kcal fat) or standard chow diet ( % kcal fat (lf)), starting at least weeks before conception and continuing during gestation and lactation. from weaning onwards, all offspring were fed the hf diet, generating two groups: hf/hf and lf/ hf. cardiac function and myocardial fat content were measured in male offspring at weeks of age (n= ) using magnetic resonance imaging and spectroscopy on a t mr system (bruker biospin gmbh). cardiac mitochondrial respiration was determined in parallel groups (n= ), using high resolution respirometry (oroboros instruments). results: at weeks of age, the hf/hf group showed significantly higher cardiac lipid content (p= . ) compared to the lf/hf group. no significant differences in cardiac mitochondrial function and ejection fraction were detected. conclusion: mice exposed to hf feeding during early development were more susceptible for high-fat diet-induced cardiac lipid accumulation. this was not (yet) accompanied by decreased mitochondrial function and/or decreased ejection fraction. cardiac and hepatic iron and heart function by mr in thalassaemia major patients treated with combined deferiprone and desferrioxamine regimen versus monotherapies: a multi-centre, observational and prospective study c. lge was significantly smaller in follow-up compared to the first examination (p= . ). in multivariate regression analysis, rv oedema was the only parameter that was associated with a significant improvement of rv-ef. conclusion: the significant decrease of lge in the follow-up examination implies that the area of hyperenhancement might represent necrosis. we furthermore conclude that the extend of rv scar is too small to permanently impair rv-ef function in the majority of patients in follow-up. purpose: the factors governing periprocedural myocardial injury (pmi) and its influence on the prognosis at follow-up are not completely clear. we used delayed enhancement magnetic resonance imaging (lge mri) to assess myonecrosis after pci. methods and materials: forty-three patients with stable coronary artery disease were studied with . t mri before and after (within h) stenting of bifurcation lesions. the left ventricular function and lge were assessed. we performed angiographic measurements of the vessel diameters, and bifurcation angles pre-and post-intervention. systolic-to-diastolic increase of t was above average in lateral (p < . ) and apical (p < . ) segments. conclusion: t relaxation times of normal myocardium differ significantly between diastole and systole at . t. their strong correlation facilitates translation of diastolic and systolic t normal values. regional deviations from the mean systolic-to-diastolic increase of t might be associated with regional differences in myocardial perfusion. author disclosures: g. reiter: employee; siemens. a. greiser: employee; siemens. are the preferential patterns of myocardial iron overload preserved at the cmr follow-up? results: for each group there was a significant improvement in the global as well as in regional t * values. for the whole patient population as well as for both groups, at basal the mean t * value over the anterior region was significantly lower than the mean t * values over the other regions, and the mean t * over the inferior region was significantly lower than the t * values over septal and lateral regions. the same pattern was present at the fu, with a little difference for patients with mild-moderate mio. in conclusion, a preferential pattern of iron store in anterior and inferior regions was present at both basal and fu cmrs, with an increment of t * values at fu due to a basal cmr-guided chelation therapy. the anterior region seems to be the region in which the iron accumulates first and is removed later. the effect of partial volume averaging on peak velocity measurements in phase contrast magnetic resonance angiography (pcmra) j.c.l. rodrigues , k. minhas , g. pieles , c. bucciarelli-ducci , r. tulloh , n.e. manghat , c.j. occleshaw , m.c.k. hamilton ; bristol/uk, auckland/nz purpose: ecg-gated pcmra is an established non-invasive in vivo method to measure blood flow. by default, the siemens argus pcmra flow analysis software calculates a voxel averaged peak velocity. the voxel with the highest velocity in the data set is first determined. this value is then averaged with this the velocities of its neighbouring voxels to generate the voxel averaged peak velocity. this may underestimate peak velocity. the aim of this study was to determine if voxel averaging leads to a lower calculated peak velocity. methods and materials: peak velocity measurements in different anatomical locations in subjects (healthy volunteers, congenital and acquired heart disease patients) were analysed by default voxel averaging method and single voxel technique and compared. the effects of flow velocity, scan protocol (breath hold versus free breathing) and scanner type (siemens symphony versus siemens avanto) were also assessed. statistical significance was defined as p < . . results: there was a highly significant mean percentage increase in peak velocity of . % when peak velocity was calculated by single voxel compared with voxel averaging technique (p < . ). significant increases in peak flow were observed by single voxel compared with voxel averaging regardless of patient type, anatomical location, cmr scanner or scan technique in terms of breathing command (p < . ). disabling the voxel averaging technique had no effect on the volume of flow recorded. the use of voxel averaging produces a consistent underestimation of peak velocity. at peak velocities > m.s - , the error may be clinically significant, e.g. misclassifying the severity of aortic stenosis. for this reason, it is recommended that for the assessment of peak velocity by pcmra voxel averaging should not be used. purpose: to evaluate foetal brain maturation during twin pregnancies complicated with twin-to-twin transfusion syndrome (ttts). methods and materials: over a period of years, we retrospectively evaluated mris of women with monochorionic twin pregnancies complicated with ttts. mri scans were realized at an average of weeks of gestation. all pregnancies complicated with ttts and successfully treated with fetoscopic laser were included. eighty-eight foetal brains were analysed and compared with an mri brain atlas and with the co-twin. biparietal brain diameter, cerebellar transverse diameter, sulcation, operculation, and myelination were analysed. results: among the foetuses, ( . %) developed severe brain damage (unilateral brain atrophy, clastic lesion of corpus callosum with cyst) and showed unusual delay of brain maturation. in others cases of successfully treated ttts, we found no difference in brain maturation between twins. conclusion: brain maturation during twin pregnancies with treated ttts is well preserved except in cases with a severe vascular complication. purpose: very preterm infants suffer a wide range of neurodevelopmental disabilities. the purpose of the study was to assess the relationship between body growth and white matter (wm) microstructure maturation, in very low-birth weight, extremely preterm infants. methods and materials: twenty-seven extremely premature infants (gestational age: . ± . weeks) with normal brain us studies and normal mri at term equivalent age ( . ± . weeks) were enrolled in the study. using a diffusion-weighted sequence, fractional anisotropy (fa) was measured bilaterally in fibre tracts with the region-of-interest method. the effect of sex and the relationship between somatometric measurements (birth and body weight, crown to heel length and head circumference) and fa was evaluated using a general linear model. two-tailed student's t-test was used to assess differences between small for gestational age (sga) and appropriate for gestational age (aga) infants. results: a positive correlation was found between body weight and fa in the anterior corona radiata, the posterior limb of internal capsule, the external capsule, the inferior fronto-occipital fasciculus, the superior longitudinal fasciculus, the middle cerebellar peduncles and the fornix. decreased fa was observed in the superior longitudinal fasciculus and the fornix in sga infants (p < . ). conclusion: in extremely premature infants body growth correlates with changes in wm microstructure. compromised growth at term equivalent age is associated with microstructural abnormalities in areas related to attention, language, memory and executive functioning. the "tail sign" in the differential diagnosis of vermian pathologies in foetuses under weeks: role of foetal mri p. relationship between body growth and regional brain volume changes in extremely premature small for gestational age babies l.c. tzarouchi, a. drougia, a. zikou, a. charisiadi, p. kosta, l. astrakas, s. andronikou, m.i. argyropoulou; ioannina/gr (ltzar@cc.uoi.gr) purpose: extremely low birth weight and/or low gestational age has been associated with alterations in brain development. the purpose of the study was to assess whether early body growth catch-up reflects regional brain volume (rbv) changes by evaluating small for gestational age (sga) extremely premature babies (gestational age< weeks) at term equivalent age. methods and materials: twenty-five extremely premature infants (ga: . ± . weeks) with normal brain us studies and normal mri at term equivalent age ( . + . weeks) were enrolled. thirteen were appropriate for gestational age at birth and at term (aga), sga at birth and aga at term (sga+) and sga at birth and term (sga-). t -weighted high-resolution d images were segmented using the spm . and volumes of individual gm areas were calculated using the ibaspm toolbox. two-tailed student's t-test was performed to test for differences in rbv between groups. results: there was no difference in rbv between aga and sga+ (body growth catch-up at term). in sga-(persistent body growth restriction at term), areas of late maturation (frontal lobes, caudate nucleus) presented lower rgmv. there was no difference in rbv between aga and sga-in brain areas of early maturation (occipital cortex, thalami) (p < . ). in extremely premature babies, body growth catch-up is associated with rbv catch-up at term equivalent age. rbv changes start from areas with great potential for early maturation. quality control in digital mammography: radiographers practice at hospitals of lisbon c. tomás, c. gonçalves, c.i.s. reis; lisbon/pt (claudiatomas @gmail.com) purpose: to investigate quality control/(qc) guidelines in use for digital mammography/(dm) in hospitals, to identify radiographer's practice in qc concerning dm and to identify the causes of exam rejection/repetition. methods and materials: questionnaires were developed and applied to radiographers working in dm (computed-radiography or direct-digital-mammography/ (ddm)) in hospitals to characterise the qc practices (guidelines in use, performed tests, tests frequency). rejected/repeated analyses was performed in one hospital with ddm equipment using the checklist proposed by the international atomic energy agency/(iaea). results: guidelines for qc are followed by % ( ) of the radiographers: % follow american-guidelines, % the portuguese, % the european/euref and % other guidelines. there is more than one guideline followed by radiographers in three institutions. the qc tests performed by radiographers in the same institution (proposed by iaea to test image acquisition and display systems) were not the same and in the right frequency. the main causes for mammography image rejection/repetition were improper positioning in % of the analysed images due to non-inclusion of pectoral muscle in mediolateral oblique projection and inner and outer quadrants asymmetry for craniocaudal projection. conclusion: in this group of hospitals with dm, there is no uniformity of qc practices. this can have impacts in mammography costs. this may be justified by the absence of certification programs concerning mammography departments. continuous education and training programs frequency to work with dm are not mandatory and also qc is not required by law in portugal. an investigation into the psychological anxiety of maltese women before and after a mammogram c. falzon; sta lucija/ mt (valeview@maltanet.net) purpose: to investigate whether there is a difference in anxiety levels between maltese women with and without a family history of breast cancer, before and after a mammogram. the study involved the participation of maltese women aged years and over. the women were divided into two groups; group without and group with family history of breast cancer. anxiety levels pre-and finally, mri made correct diagnosis in of foetuses with expansive formations, whereas in one of these cases we suspected a choledochal cyst and it was a gastric duplication and in another patient we diagnosed an ascites and it was an intrabdominal cystic lymphangioma. conclusion: our preliminary results suggest that mri has a supplemental value to sonography in anatomic evaluation and characterisation of gi abnormalities. ultrafast imaging sequence mri is helpful to confirm, refine or exclude us diagnosis. it also provides useful informations in prenatal counselling and perinatal management. purpose: in order to achieve high image quality with breast cancer screening mammography, the european guideline recommends training programs dedicated to radiographers. those training programs are very helpful for practitioners but back at their workplace it might be difficult for them to apply the achieved knowledge in their daily practice. to support radiographers to transfer good mammography practice in their daily screening activity, an online portfolio is realized by each radiographer during the following months after the training session. methods and materials: every month, the trainee radiographer posts about mammography examinations including the quality self-assessment on a dedicated electronic platform. experienced radiographers from the screening program of western switzerland comment the picture quality as well as the accuracy of the self assessment. tips and tricks, to improve quality, are also given. results: actually portfolios have been completed. the majority of the radiographers appreciated the personalized comments given by the experts. they found the tips very helpful and they say the portfolio helped them to continuously improve the quality of the performed mammograms. nevertheless, some radiographers were upset because of the high time investment necessary to the realization of this kind of portfolio. conclusion: in western switzerland, where there are many decentralized breast cancer screening units, the online portfolio is an interesting tool to support radiographers with the development and the transfer of competences in their daily practice. purpose: this study aimed at measuring patient satisfaction in mammography exams and satisfaction-related factors. methods and materials: research was conducted in several private practice clinics with a total of subjects using the myasthenia gravis questionnaire for assessing patient satisfaction concerning four dimensions: structure (physical environment), process (performing the exam), discomfort (physical and psychological) and general satisfaction (present and future). results: overall patient satisfaction was high ( %), with technical performance (process) and psychological discomfort having the major influence on patient satisfaction. exam costs and age had very low, or no impact, on satisfaction. also, the greater patient's education levels, the greater were their demands for process requirements, unlike patients with lower education levels which presented higher satisfaction levels. the great amount of patients of high age groups and respective pathologies may have influenced results when related to satisfaction and education level. the numbers of mammography exams have increased over the years and therefore it is essential to assess patient satisfaction so that improvements can be made. impacts of digital mammography in radiographers practice l. painho, t. . the anode-filter combination always used was w/rh. global iq was p (perfect) for cc, while in mlo the mean was g (good). the radiographers experience varied between and years. the compression force depends on breast compressed thickness. it can vary between and n for breast thickness range of to mm. the technique suffered changes when the analogue was compared with digital technologies: the energy is higher, the intensity is lower and the anode-filter has changed from mo/mo to rh/rh and w/rh. breast symmetry absence on cc projection, inframammary folds absence and skin folds presence were the criteria not achieved more frequently in this study, according to european guidelines on quality criteria for diagnostic radiographer images. iq of all exams was classified as appropriated (perfect and good ( out )). nevertheless, it is noticeable that some variation exists concerning the radiographer practice when comparing breasts with the same features. the radiographers experience and training can also affect the results. imaging ethics b. hofmann; oslo/ no (b.m.hofmann@medisin.uio.no) purpose: the benefits of modern medical imaging technology are obvious. however, the ethical challenges are less acknowledged. the purpose of the study is to highlight and to address core ethical challenges with modern medical imaging. a review of literature in radiology reveals a series of ethical challenges in modern medical imaging that are analysed with standard methods in modern bioethics. the ethical challenges are divided into four categories, i.e. challenges with ) existing, and ) new imaging techniques, ) altered use of existing imaging techniques, and ) challenges with basic concepts and end points in diagnostic imaging. a series of ethical challenges are identified within these categories, such as (radiation) safety, rationing, and justice ( ), implementation without evidence-based outcome ( ), reduced diagnostic accuracy, patient autonomy ( ), and challenges with underuse, overuse, and futile imaging ( ). conclusion: behind great benefits of modern imaging, a series of ethical challenges can be identified. while praising the benefits, the challenges need to be appraised to maintain confidence and trust in the profession, as well as a sound and fruitful development in the field. post-mammogram were measured using the well-established state and trait inventory for adults (stai) developed by c.d. spielberger. results: there was a significant difference (p . ). a negative correlation was obtained when the mean s-anxiety scores (pre: group , r=- . and group , r=- . and post: group , r=- . and group , r=- . ) of both groups were compared with age. the factor causing anxiety in women was mainly related to the procedure because their anxiety diminished significantly after the mammogram. the correlation showed that those who scored high pre-mammogram anxiety also scored high post-mammogram anxiety. no significant difference in the anxiety levels between the two groups existed before and after the mammogram. a negative correlation existed between age and s-anxiety of the women, resulting in younger women being more anxious than older women. ergonomic and environmental assessment in digital mammography room: impact on radiographers' activity s. costa, e. oliveira, f. serranheira, s. viegas, c.i.s. reis; lisbon/pt (stefaniebcosta@gmail.com) purpose: to investigate ergonomic-characteristics of the equipment, environmental conditions and its impact on radiographers' activity and to identify opportunities to optimise the practice and reduce the probability of wrmsds occurrence. radiographer's mammography procedures were observed and organized in tasks time-scale-graphic. interviews were applied to radiographers working in digital-mammography to characterise the practice (work patterns, mammographic equipment, exam room, environmental conditions) and to identify the presence of wrmsds symptoms. postural analyses were evaluated through video and pictures acquired during mammography positioning. measurements of angles were done with meazure . . software and classified according to the european standard/en - : +a : . results: the task-time scale showed that the average duration of each exam is minutes and also that the task which took more time was the indications given to the patient. . % of the radiographers referred that the most exhaustive procedure is the positioning of mlo-view and short-stature patients ( . %). in this specific case, the anatomical areas that can suffer more wrmsds are neck, arms and back presenting an angle of . º, . º and . º, respectively. the visual contact with the patient was compromised only during the right-mlo-view acquisition. considering the environmental conditions the illuminance values are not in accordance with the guidelines. the ergonomic characteristics of the equipment do not provide comfort to the radiographers. in order to reduce the probability of work-related musculoskeletal disorders in mammography positioning and patient safety, new equipment features should be developed. environmental conditions are adequate concerning the international references for temperature and humidity but not for illuminance. accuracy of students, and radiographers, with and without, mammography post-graduation in interpretation of mammography images r.b.j. cópio , k.b. azevedo , a.f.c.l. abrantes , l.p.v. ribeiro , r.p.p. almeida , c.a. silva ; faro/pt, evora/pt (rita.copio.rc@gmail.com) purpose: to evaluate the sensitivity, specificity and diagnostic accuracy of radiographers with and without mammography post-graduation and last year students of the radiography course in the interpretation of mammography images. a grid of socio-demographic characteristics and view-dex software (viewer for digital evaluation of x-ray images) for the interpretation of mammography images by participants were used. each of the cases was built with the four basic images. after viewing images, the participants showed their level of confidence about the presence of abnormal radiological findings in relation to the case. the results obtained showed values of sensitivity of %, % and % for the last year students, radiographers without post-graduation and post-graduate radiographers, respectively. for specificity, the values were %, % and % for the same groups, respectively. with regard to diagnostic accuracy, the values obtained were % for the group of students in the last year, % for the group of radiographers without post-graduation and % for post-graduate radiographers. the mean response time was . seconds to the last year students, . seconds for radiographers without post-graduation and . seconds to post-graduate radiographers. the sensitivity, specificity and diagnostic accuracy varies between each group. however, there are not significant differences between them. also, participants with a higher formation have higher average response time. purpose: to compare different formats of llama-derived nanobodies as alternatives to monoclonal antibodies for specific in vivo near-infrared fluorescence (nirf) imaging of lymphomas in a mouse model. we used ecto-enzyme art on lymphoma cells as model target and compared three different formats of art -specific nanobodies with a conventional antibody ( kd): a monovalent llama nanobody ( kd), a bivalent diabody ( kd), and a bivalent fc-fusion protein ( kd). all constructs were labeled with alexafluor and injected in nude mice, bearing art -positive and art negative tumors. circulating and excreted conjugates were monitored in plasma and urine and in vivo nirf-imaging was performed over h. tumor tissue penetration and target binding were analysed by facs and fluorescence microscopy. results: in vivo nirf-imaging revealed specific labeling of art -positive tumors but not of art -negative tumors with all af -conjugates. the smaller nanobody and diabody revealed rapid renal elimination with highest signal-to-background ratios of art -positive tumors. the larger fc-fusion protein and conventional antibody revealed long circulation times in plasma, resulting in unspecific background signals. facs and immunohistochemistry of tumors revealed deeper penetration and more homogenous labeling of tumor tissue with the nanobody and diabody than with the fc-fusion protein and conventional antibody. conclusion: renally excreted small nanobody-formats (< kd) can be used for specific in vivo imaging of lymphomas with a significantly higher signal-tobackground ratio than larger antibody-constructs (> kd) that are retained in circulation. therefore, single domain and bivalent nanobodies seem particularly suited for short-term diagnostic imaging, whereas reformatted nanobody-fc fusion proteins appear suited for long-term applications. the design of a dual-functional imaging contrast agent for targeting to tumour endothelial marker (tem ) q. quan , x. huang , j. xie , y. yan , h. gao , g. zhang , x. in control kit+/+ mice, the fmt signal for annexin v peaked at hours after myocardial infarction with subsequent decrease at hours and days after onset of ischemic injury. kitw/w-v mice revealed an increased and prolonged in-vivo apoptosis signal, which was associated with progressive decline in heart function. bone marrow reconstitution was able to reduce cardiomyocyte apoptosis and rescue kitw/w-v mice from progressive heart failure. in-vivo apoptosis signal was verified after killed by apoptosis staining using immunohistochemistry (tunel) and flow cytometry (caspase- ). hybrid acquisition of x-ray computed tomography allowed exact localisation of the fmt signal to the left-ventricle and facilitated organ segmentation and attenuation correction. flow cytometry and determining the dissociation constant. for detecting apoptosis in vivo, cal- tumour-bearing mice were treated with pdt and injected with the annexin v probe two days and two weeks after therapy. the fluorescence intensity of the tumours was evaluated semiquantitatively over time. the annexin v probe showed nearly the same absorption ( nm) and emission ( nm) spectrum like the free dye and possessed a high binding affinity to apoptotic cells (kd-value nm). therapeutic efficiency of pdt could be detected in vivo in the tumours via apoptotic cells shortly after therapy. our probe accumulated significantly stronger in treated tumours at two days in contrast to two weeks after therapy. conclusion: in summary, we could successfully image the therapeutic efficiency of pdt with the new designed fluorescence optical annexin v probe. apoptotic cells could be detected in the tumour short time periods ( days) but not longer time ( weeks) after pdt. bimodal nirf nanoparticles as an optical and mri contrast agent for imaging cells of the mononuclear phagocyte system j. purpose: even though approaches for multimodal imaging of targeted structures like in tumours have been suggested, fewer investigations have been made on bimodal optical and mr-imaging of inflammatory diseases via passive targeting of cells of the mononuclear phagocytic system (mps). however, non-targeted nanoparticles (np) could represent a simple and effective labelling tool being rapidly phagocytized from the blood stream by mononuclear cells which are then migrating to the site of inflammation. for the production of bimodal np iron oxide cores were enclosed by a near infrared (nir)-fluorochrome (ir ) and surrounded by a starchmatrix. the spectroscopic and mr-imaging properties of the bimodal particles were determined in agarose phantoms and in vivo using a near infrared fluorescence (nirf) small animal imaging system and . and t-mri, respectively. in vivo optical and mr-imaging was performed on mice with hind leg oedema. results: a specific nirf-(average fluorescence signal . scaled counts/s for µg/ml np) and mr-signal ( . t: r = mm- * sec- , r = mm- * sec- , r *= mm- * sec- ) was detected for the bimodal np in vitro. in vivo-mr and nirf-imaging studies confirmed specific signalling of the particles within oedema. conclusion: our bimodal non-targeted fluorescent iron oxide np successfully labelled cells of the mps in vitro and in vivo without specific target recognition by antibodies. additionally, the ability of specific nir-signalling and mr-tracking of mononuclear cells makes them suitable for application as a simple and potent nirf-optical and mri contrast agent for visualisation of inflammatory diseases. purpose: quantitative t -weighted perfusion imaging is promising. however, current software solutions are still semi-automatic and results are therefore potentially prone to observer-related bias. surprisingly, this aspect of dce-mri is still poorly investigated. we aimed to systematically address this matter using a dedicated imaging protocol and semi-automatic workflow for quantitative pharmacokinetic analysis. an ultra-fast high-spatial and high-temporal resolution protocol was used for t -weighted perfusion imaging (magnetom aera @ . t; dynamic view-sharing d gradient-echo-sequence/twist: temporal-resolution: . s, in-plane resolution: . mm , ml gadovist @ ml/s, acquisition time: s). for the assessment of pharmacokinetic parameters (k trans , two-compartment tofts-model, fast arterial-input-function) a dedicated semi-automatic software solution was used. enhancing intracranial tumours were independently evaluated two times by one experienced neuroradiologist (> mri, -year experience in dce-mri). results of pharmacokinetic parameters for each reading were documented in a database. variability of k trans measurements was assessed by means of reproducibility (concordance correlation coefficient), precision (pearson ρ), accuracy (bias correction factor/cb), reliability (intraclass correlation coefficient), repeatability (coefficient of repeatability/cr) and systematic bias (bland-altmann plot: regression coefficient/rc). methods and materials: patients (mean age years, range - ) gave informed consent for this prospective research ethic committee-approved study and underwent two consecutive brain ct-scans, with normal radiation dose (nd) (ctdivol mgy, . msv) and % reduced dose (rd). nd scans were reconstructed using filtered backprojection (fbp), while rd scans were reconstructed using fbp and two idose levels, id and id . image quality was assessed with grading and ranking by six neuroradiologists. mean hounsfield units (hu) and noise were measured. data were analysed using linear mixed models, and the tukey method for multiple comparisons. results: for all reconstructions image quality was graded adequate for clinical use. image quality was graded good/excellent in % of cases for nd, % of cases for id , % for id , and % for rd. for all quality parameters id and id were graded better than rd (p < . and p < . ) but worse than nd (p << . ). pooled ranking results were equivalent despite considerable variation in individual assessments. hu were identical between reconstructions. image noise was similar in nd, id and id but higher in rd. purpose: to determine whether mri susceptibility-weighted imaging can assist in discriminating between inflammatory pathologies and high-grade glioma. methods and materials: susceptibility-weighted imaging (swi) was performed at . t (siemens medical systems) and images were reviewed retrospectively in patients with cerebral inflammatory pathologies and patients with histologically proven high-grade gliomas. only gliomas without mr findings of haemorrhage on t wi were included in the study. the morphological pattern of the susceptibility signal and the anatomic positional relationship between the contrast enhancement areas and susceptibility signals were retrospectively reviewed by consensus of reviewers. the swi morphological pattern was scored as: patchy, nodular, dot-like or linear and designated as inside or outside the zone of contrast enhancement. results: in total, clinically proven inflammatory diseases ( parasitic granulomas, inflammation-demyelinating and neurovasculitis) and lesions were reviewed. patchy, nodular, dot-like susceptibility were demonstrated in both inflammatory and neoplastic lesions, whereas linear susceptibility signals were only identified in the inflammatory diseases. nine of ( %) susceptibility signals were situated outside the contrast enhancement areas in inflammatory pathologies with no susceptibility signals found outside the border of the contrast enhancement areas among all the high-grade gliomas. conclusion: on swi, linear susceptibility signal and/or susceptibility signal located outside the area of contrast enhancement was more frequently presented in inflammatory processes and not found with the high-grade gliomas. this finding may reflect a different pathophysiologic mechanism and distinction of bleeding/ microbleeding occurrence and presentation in inflammatory pathologies compared to high-grade gliomas. inter-session reproducibility of cerebral blood flow ( the morphology of s - disc, l and s body and lumbar spinous processes were evaluated. the positions of aortic bifurcation (ab), right renal artery (rra), superior mesenteric artery (sma) and conus medullaris (cm) were described. comparing with wsl, the diagnostic error in numbering vertebral segments on lumbar mri was evaluated. in lumbarisation, all patients revealed a well-formed s - disc with squared s body. a rhombus-shaped l body in sacralisation and a rectangular-shaped s body in lumbarisation were found. l had the longest spinous process. the most common sites of spinal and paraspinal structures were ab at l body ( . %), rra at l body ( . %) and l - disc ( . %), sma at l body ( . %) and t -l disc ( . %), and cm at l body ( . %). they were located higher in sacralisation and lower in lumbarisation. on lumbar mri, the diagnostic error in evaluation of vertebral segmentation was . %. purpose: the presence of intravertebral gas in the lumbar and thoracic spine, usually secondary to trauma, is a well-recognised radiological phenomenon (kümmel's disease). however, intravertebral gas within a cervical vertebral body is a common but unknown process. we present a series of patients with gas in the cervical vertebral bodies, not associated with traumatism. the aim of this study is to describe this radiological finding and its possible aetiology. methods and materials: our study group included patients who underwent a routine neck ct examination for reasons not related with the cervical spine. all the patients presented air within a cervical vertebral body. we analysed several factors such as age, sex, location of the gas, history of radiotherapy, chemotherapy, the presence of degenerative disease, previous infections or corticosteroid therapy. results: the mean age was years (age range - ), men and women. the main affected body was c ( %), followed by c ( %). most of the lesions were adjacent to the inferior endplate of the vertebral body. most subjects showed degenerative changes ( %), although none had gas within intervertebral discs. % of the patients received radiotherapy. none of the patients had a history of trauma, infection or treatment with corticosteroids. the presence of gas within a cervical vertebral body seems to be a common but unknown process. this phenomenon could be related with cervical degenerative disease. further studies should be conducted to verify this hypothesis and to elucidate the nature of this finding. the study comprised of n= intracranial tumours, among these meningeomas (n= ), solitary metastasis (n= ), as well as who grade ii -iv tumours (n= ). compared to reference tissue, meningeomas were significantly stiffer. metastases were either slightly firmer or softer than reference tissue. who grade ii and iii tumours (n= ) were softer than white matter in all cases. the highest loss of tissue stiffness was represented by who grade iv tumours. viscoelasticity parameters were supplemented by a histopathology work-up. in summary, high who grade tumours were significantly softer than tumours of lower staging, the range of metastatic viscoelasticity was slightly higher than primary brain tumours. mre was well tolerated by all patients. conclusion: mr elastography of cerebral tumours at tesla reliably quantifies tissue firmness for preoperative planning. according to our histology correlated preliminary results, tumour viscoelasticity may be an additional diagnostic parameter for non-invasive tumour differentiation. intra-and inter-scanner test-retest reliability of whole-brain arterial spin labeling perfusion mri b. wu, x. wu, x. lou, m. ge, l. ma; beijing/cn ( @qq.com) purpose: perfusion mri can be used to identify and monitor patients with acute ischaemic stroke. the objective of this study was to investigate whether it is possible to pool together whole brain arterial spin labelling (asl) perfusion imaging data at different times, or from different scanners, located at two different sites. eight healthy subjects were scanned on two different . t scanners with d pseudo-continuous labelling technique. scans were repeated intra-session and inter-session after - days. the asl data with two postlabelling delay time (pld) of . and . seconds were acquired. high-spatial-resolution whole brain t -weighted images were also acquired for image registration and normalisation into a standardised space within the spm . the cerebral blood flow (cbf) values of grey matter, white matter, frontal lobe, parietal lobe, occipital lobe, temporal lobe, putamen, posterior cingulate, and thalamus were extracted for comparison, using wfu pickatlas tool. the intra-and inter-scanner reliability was evaluated with the intraclass correlation coefficient (icc purpose: to quantify the changes of myocardial transverse relaxation times (Δt *) induced by hyperoxic respiratory challenge at different field strengths in an intraindividual comparison of healthy volunteers. methods and materials: blood oxygen level-dependent (bold) cardiovascular magnetic resonance (cmr) data were acquired in ten healthy volunteers ( women; men; median age years, range - years) at . t and . t. medical air ( % o ), pure oxygen and carbogen ( % o , %co ) were alternatively administered in a block-design temporal pattern to induce normoxia, hyperoxia and hyperoxic hypercapnia, respectively. parametrical t * relaxation time maps were computed, average t * values were derived from region-of-interest analysis by two independent and blinded readers in standard myocardial segments on short axis slices per patient. results: inter-and intra-reader correlations of t * measurements were good (icc= . and icc= . , both p < . ). under normoxia, the mean t * values were . + . ms at . t and . + . ms at . t. both hyperoxic gases induced significant (p < . ) relaxation time increases Δt * (oxygen: . t, . + . ms; . t, . + . ms; carbogen: . t, . + . ms; . t, . + . sm). as opposed to . t, the magnitude of Δt * response was higher at . t and under carbogen as compared with oxygen breathing (p < . ). the myocardial Δt * response to hyperoxic respiratory challenge can reliably be quantified with bold cmr. the magnitude t * increases significantly with a higher field strength as well as with carbogen as compared to oxygen breathing. future studies are warranted to investigate the potential diagnostic role of bold response in assessing patients with coronary cardiomyopathy. we retrospectively reviewed the imaging features and enhancement pattern of the selectively involved white matter tracts in sixteen ( ) genetically proven cases of leukodystrophy with brainstem and spinal cord involvement and elevated brain lactate (lbsl). all patients were presented with slow progressive cerebellar sensory ataxia with spasticity and dorsal column dysfunction. mri of the brain and spine and mrs of the brain were done to all patients. results: in all cases, mri showed signal abnormalities in the sensory and pyramidal white matter tracts in addition to inhomogeneous signal abnormalities in the periventricular and deep white matter, brain stem, cerebellar connections and dorsal columns of the spinal cord. the subcortical u fibres were spared in all cases. proton mrs showed consistent elevation of the lactate within the abnormal white matter. in eleven cases, diffusion restriction was found in most of the length of the corticospinal and sensory tracts in addition to involvement of the superior and inferior cerebellar peduncles and the mesencephalic trigeminal tracts. these parts of the white matter tracts also displayed heterogeneous enhancement after gadolinium administration. purpose: the purpose of this study was to evaluate the role of dti in assessing cervical spondylotic myelopathy (csm). we prospectively evaluated patients with symptomatic csm. the joa (japanese orthopedic association) myelopathy score was used to assess the clinical situation, dividing patients into groups with minimum myelopathy (mim), moderate myelopathy (mom) and severe myelopathy (sem). all patients underwent examination on a . t mri scanner (verio, siemens). dti of the spinal cord was performed in directions (b-value of and ). fractional anisotropy (fa), apparent diffusion coefficients (adc), eigenvalues (e , e . ) were measured. results: mean patient age was . y/- , sd. according to the joa classification, patients were classified into the mim group and into the mom and into the sem group. significant differences were seen in adc ( . ± . vs . ± . ) values and fa ( . ± . vs . ± . ) when comparing normal with pathological levels as well as in e ( . ± . vs . ± . ) and e . ( . ± . vs . ± . ), respectively. significant elevation of adc and reduction of fa was seen in absolute vertebrostenotic segments. significant elevation of e and e . were seen in vertebrostenotic segments compared with normal. conclusion: our results suggest a high sensitivity of dti metrics in the assessment of csm. significant increases in longitudinal and transverse diffusion were seen in our results which might represent a novel biomarker of csm. molli was performed at a mid-ventricular slice location pre-and - min ( min intervals) post-contrast administration. t values of the blood pool and the myocardium were measured for each time point and ecv assessment was based on myocardial Δr assessment (pre and post) in relation to Δr blood pool and incorporation of the haematocrit. results: while pre-contrast t values were similar (p= . ), post-contrast t values were significantly shorter at any measured time point post-injection after gadobutrol application (p < . ). myocardial ecv data though calculated for both agents did not show significant differences (p> . ). in addition, ecv data related to both agents did not show any significant differences over the assessed time course of - min p.i. (p> . , gadobutrol; p> . , gadoterate meglumine). conclusion: gadobutrol leads to a significantly higher shortening of myocardial t values as compared to gadoterate meglumine. the ecv assessment which is independent of the ca properties can be adequately evaluated as early as min p.i. in normal myocardium. purpose: existence of vortical blood flow in the main pulmonary artery as diagnostic criterion for diagnosis of pulmonary hypertension was analysed in -dimensional ( d) vector field and streamline representations. methods and materials: subjects with known or suspected pulmonary hypertension ( patients with and without pulmonary hypertension, age ± years) underwent right heart catheterisation and time-resolved, d phase contrast imaging of the main pulmonary artery. blood flow patterns were visualised as d velocity vector fields projected on -dimensional anatomical images ( d-vectors) and as d streamlines using d-flow software (siemens). relative period of existence of vortical blood flow within the cardiac cycle (tvortex) was evaluated. comparison of methods for using tvortex as diagnostic criterion for pulmonary hypertension was performed by receiver operating characteristic analysis. results: areas under the curve for diagnosis of pulmonary hypertension did not differ significantly (p= . ) and were . ( %-confidence interval . to . ) in case d-vector vortex detection and . ( %-confidence interval . to . ) in case of streamline vortex detection. the optimal tvortex cut-off value maximising sum of sensitivity and specificity was tvortex= . for both visualisations. resulting %-confidence intervals for sensitivity and specificity were . to . and . to . in case d-vector vortex detection and . to . and . to . in case d streamline vortex detection. conclusion: main pulmonary artery blood flow patterns provide an accurate tool for the diagnosis of pulmonary hypertension with the optimal tvortex cut-off value . . s a c d e f g b conclusion: using mbir significantly reduced the need for vessel-wall boundary corrections compared to other reconstruction algorithms, particularly at the side of calcifications. thus, mbir improves the feasibility of automated plaque assessment in ccta and potentially its clinical applicability. calcium score of small coronary calcifications on multi detector computed tomography: a phantom study j.m. groen , k.f. kofoed , m. zacho , r. vliegenthart , t.p. willems , m.j.w. greuter ; groningen/nl, copenhagen/dk (m.j.w.greuter@umcg.nl) purpose: to assess the feasibility of a new phantom which enables establishment of a calcium scoring protocol for multidetector computed tomography (mdct) that yields calcium scores comparable to electron beam tomography (ebt) values and to physical mass. methods and materials: a phantom containing small calcifications ranging . - . mm was scanned on ebt using a standard coronary calcium protocol, and on a -row mdct scanner using different scanning, reconstruction and scoring parameters (tube voltage - kv, slice thickness . - . mm, reconstruction kernel fc -fc and scoring threshold - hu). the agatston and mass score were compared and the influence of the parameters was assessed. results: on ebt, the agatston and mass scores were - , and - mg, respectively. on mdct, the agatston and mass scores were - , and - mg, respectively. the agatston score on mdct differed % between and kv, % between . and . mm and % between fc and fc . more calcifications were detected with a lower tube voltage, a smaller slice thickness, a sharper kernel and a lower threshold. an acquisition protocol with kv and two reconstructions protocols could be defined. this protocol yielded agatston scores as close to ebt as possible, as well as mass scores as close to physical mass as possible. purpose: Τo report -year results of a prospective randomised controlled trial investigating angioplasty with paclitaxel-coated balloons (pcb) versus plain balloon angioplasty for the treatment of failing arteriovenous dialysis access either a fistula (avf) or a graft (avg). this was a non-inferiority hypothesis trial registered in clinicaltrials.gov (nct ). enrollment criteria included an angiographic and clinical diagnosis of dysfunctional dialysis access due to at least one stenotic lesion in patients with avf or avg circuits. forty patients were randomised to undergo either pcb dilatation (n= ) or standard pta (n= ) of a venous outflow stenotic lesion. regular angiographic follow-up was scheduled every months. study primary endpoints included technical success (defined as residual stenosis of the treated lesion > % without any significant dissection) and -year primary patency of the treated site (defined as angiographic visualisation of a patent lesion with < % restenosis and no need for any additional repeat procedure within the previously treated lesion due to failing access). results: baseline variables were comparably distributed among the two groups. technical success was % for both groups. additional post-dilation with a highpressure balloon was necessary in / ( %) of the pcb-treated cases. at year, cumulative target lesion primary patency was significantly higher after pcb application ( % in pcb group versus % in pba group, p < . , hr ( %ci) = . ( . - . )). conclusion: pcb angioplasty might have a place in our quiver for the treatment of stenotic venous outflow lesions of failing dialysis access. for better trade-off of high temporal resolution, less noise and streak artefacts. this is combined with an automatic segmentation and suppression of catheter-induced streaks. this preliminary study included in vivo porcine models. images were evaluated by experienced cardiologists with respect to noise, temporal resolution and artefact susceptibility. results: an enhancement of temporal resolution was shown by a decreased fullwidth at half maximum of catheter cross sections using sr d-fd-ct as compared to static reconstructions. motion-map-processing of individual phases increased the contrast-to-noise ratio for each heart phase, e.g. in the left ventricle by an average of %. visual impression confirmed a significant streak reduction. conclusion: first results show the potential of sr d-fd-ct for pragmatic dinterventional imaging. sr d-fd-ct allows for dynamic segmentation of cardiac chambers and valves. purpose: for quantitative measurement of left ventricular myocardial perfusion, stability of hu-values in dynamic ct-scans is essential. a phantom study is used to evaluate this stability over slices and time using the philips ict -slice scanner. methods and materials: seven time series of ct-images with slices ( mm) over seconds of a catphan phantom were acquired using the ict at kvp/ mas. six different regions of interest (roi) were placed into the water regions of the phantom for all slices and time steps. five rois were arranged in a star-like pattern in order to enable evaluation of intra slice variability. one roi covered the entire water-region. stability over time and slices as well as within each slice was statistically examined. the absolute difference in the mean values of the entire water roi in all seven phantom studies was maximum . hu. the examination of the inter-slice variability revealed a drift of maximal . hu/slice. over time, a maximal drift of . hu/s could be observed. the maximum intra-slice difference of the mean values was at hu. this slightly higher value is due to beam hardening artefacts in the rois close to the high-density /bone simulating/ structure in the phantom. purpose: to evaluate the impact of iterative image reconstruction algorithms including adaptive statistical (asir) and model based (mbir) on the feasibility of automated plaque assessment in coronary computed tomography angiography (ccta) as compared to filtered-back-projection (fbp) reconstructed algorithm. methods and materials: three ex-vivo human hearts were imaged by ccta and reconstructed with fbp, asir and mbir. an automated plaque quantification software (vitrea cardiac solutions, mn) was applied for each of the algorithms to fit the outer and inner vessel-wall boundaries. each coronary cross section, in which the automated software detected wrongly the boundaries, was corrected in a random and blinded fashion. the percentages of corrections were compared between the reconstruction algorithms using chi-square-test. results: a total of ccta cross sections with . mm increments were assessed which equals to co-registered triplets (fbp/asir/mbir). any boundary corrections were performed in a total of cross sections ( . %), including outer (n= ) and inner (n= ) vessel-wall. the percentage of corrected cross sections was lower for mbir ( . %) as compared to asir ( . %, p= . ) and fbp ( . %, p < . ), and marginal between asir and fbp (p= . ). regional agreement of performed corrections existed between reconstruction algorithms (kappa= . ). the benefit of mbir above fbp was associated to the presence of moderate and severe calcification (or: . and . , p < . , respectively). were reviewed to classify arterial involvement according to: ) tasc ii, ) graziani's morphological classification, ) joint vascular society council calf and foot scores. clinical results (healing, non-healing, major amputation) were compared to baseline clinical data and angiographic results. results: percutaneous procedures were performed; the immediate technical success rate was . %. preprocedurally, the mean±sd calf and foot scores were . ± . and . ± . , respectively; patients ( . %) were in graziani's morphological classes to ; in ( . %) cases tasc ii was inapplicable, for the absence of femoro-popliteal lesions. post-procedurally, mean calf and foot scores were . ± . and . ± . , respectively, and . % of cases were into the graziani's classes and , whereas tasc ii was inapplicable in all cases. healing and major amputation rates were . % and . %, respectively; only pre-and post-procedural foot scores were significantly associated with the clinical outcome (p <. ). conclusion: endoluminal revascularization represents a valuable treatment option in diabetic patients with cli. in this population, tasc ii is inadequate to describe peripheral arterial involvement. pre-and post-procedural foot scores represent the most significant angiographic parameter to evaluate treatment success, thus aggressive treatment of foot arteries should be attempted whenever possible. months results of a randomised trial comparing mono-or dual-antiplatelet therapy in interventionally treated patients with peripheral arterial disease f.f. strobl , j. schmehl , k. brechtel , t. zeller , c.d. claussen , g. purpose: in this trial, peri-and postinterventional dual antiplatelet therapy significantly reduced rate of target lesion revascularisation after months. it is not known whether this effect persists after stopping clopidogrel. thus, we conducted an additional follow-up after months. in this double-blinded, randomised trial, we enrolled patients who were treated with pta or stenting in the upper leg. patients received pre-and postinterventional dual therapy with aspirin and clopidogrel. the other patients received same doses of aspirin and placebo instead of clopidogrel. clopidogrel/placebo was stopped after months and patients remained on aspirin only. tlr and mortality rate were reevaluated months after the intervention. results: we initially enrolled patients ( male, ± y), in each group in the study. months after the intervention, clopidogrel and placebo patients could be reevaluated. at months, clopidogrel patients had significantly lower rates of tlr compared to placebo patients: ( %) vs. ( %), p= . . after stopping clopidogrel/placebo, there was no more significant difference in tlr months after study inclusion with ( %) clopidogrel vs. ( . %) placebo patients (p= . ). mortality was vs. at months (p= . ) and vs. at months (p= . ). conclusion: in contrast to the first follow-up months after the intervention according reduction of tlr, this advantage of dual antiplatelet therapy does not persist after stopping clopidogrel. prolonged dual therapy (> months) should be evaluated and considered in patients with high risk for restenosis. comparing d angiography, d rotational angiography, and preprocedural ct image fusion with d fluoroscopy for endovascular repair of thoraco-abdominal aortic aneurysm v. tacher , m. lin , p. desgranges , t. grünhagen , a. luciani , j.-p. becquemin , j.-f. deux , a. rahmouni ; creteil/fr, briarcliff manor, ny/us, best/nl purpose: to evaluate the feasibility of pre-procedural arterial phase computed tomography image fusion with intra-procedural fluoroscopy (or image fusion: if) road-mapping in endovascular repair of thoraco-abdominal aortic aneurysm (evr-taaa) compared to current road-mapping methods ( d and d angiographies) in terms of x-ray exposure, injected contrast volume, and procedure time. methods and materials: single-institution prospective study (internal institute approved), on patients, informed written consent provided, and treated for evrtaaa. all interventions were performed on the same angiographic system. patients were consecutively placed in three groups in a seven-month period: " d angiography" ( da) ( patients), " d rotational angiography" ( da) ( patients) and "image fusion" (if) ( patients). injected contrast volume, x-ray exposure (dose-area-product: dap) and procedure time were recorded. to compare the groups in terms of the above measures and general patient characteristics, statistical tests using fisher's exact, kruskal-wallis and mann-whitney were performed. results: patient characteristics and stenting types were similar between all three groups with no statistically significant differences (p-value> . ). the if lower limb multilevel treatment with drug eluting balloon: -month results from the "debellum" trial f. fanelli, a. cannavale, p. lucatelli, a. wlderk, c. cirelli, f.m. salvatori; rome/it (fabrizio.fanelli@uniroma .it) purpose: to report -month results of the "debellum"-drug-eluting balloon evaluation for lower limb multilevel treatment-trial performed to evaluate the efficacy of drug-eluting balloon-deb versus conventional balloon catheter-ncb in the treatment of peripheral arterial disease. methods and materials: fifty consecutive patients (mean age ± years) with symptomatic peripheral arterial disease were randomised between deb ( patients- lesions) (inpact®-medtronic) and ncb ( patients- lesions). inclusion criteria were native single or multiple stenosis or occlusion (mean lesion length . ± . cm) in the femoro-popliteal or below the knee (btk) regions. dilatation was performed in each group either for native lesions ( deb; ncb) or post-stent implantation ( deb; ncb). primary end points were late lumen loss (lll) at and months. secondary end-points were target lesion revascularisation (tlr), amputation and thrombosis rate. results: one-hundred-twenty-two lesions were treated: . % in the femoropopliteal area; . % btk; . % total occlusions. lll was . ± . mm (deb) vs. . ± . mm (ncb) (p < . ) at months and . ± . mm (deb) vs. purpose: this study aimed at assessing retrospectively the middle-term clinical outcome of the femoropopliteal chronic total occlusion (ctos) treatment by means of directional atherectomy (da). methods and materials: between january and march , patients ( limbs, patient age ± years) were included in the study with mean follow-up of months ( - ). femoro-popliteal cto in patients with severe intermittent claudication (n= ; . %) or critical limb ischaemia (cli) (n= ; . %) were treated with silverhawk or turbohawk atherectomy followed by angioplasty in ( . %) cases. clinical and uscd follow-up was set at , and months and yearly thereafter. immediate technical success, disease-free patient survival and target lesion revascularisation (tlr) rates were assessed with kaplan-meier analysis. results: technical success rate was % with a lesion length of ± mm. limbsalvage and survival rates were . and . % at years, respectively. at , and months disease-free patient survival was . , . and . %. whereas adjunctive pta was performed in % cases to improve the angiographic result, % required an associated tibial vessel treatment. no perioperative mortality was observed. one complication ( %) occurred. conclusion: percutaneous directional atherectomy is a safe and effective technique in lower limb revascularisation. preliminary results supported by short-mid term data encourage use of da with silverhawk and turbohawk catheter in the femoro-popliteal obstructive lesions also in traditionally "forbidden districts". longterm data are missing. predictive value of angiographic scores for the integrated management of the ischaemic diabetic foot purpose: treatment of lumbar artery fed type endoleaks (laft e) after abdominal endovascular aneurysm repair (aevar) exhibits high failure and recurrency rates. we report our preliminary results of ct-guided direct sac puncture, followed by embolisation with the liquid embolic agent ethylene vinyl alcohol copolymer (onyx®). methods and materials: male patients (mean age ± yrs) with laft e were included after failure of conservative treatment. all received ct guided direct sac puncture under local anaesthesia, followed by ct fluoroscopic embolisation with onyx ® or ®. follow-up examination included contrast-enhanced ultrasound (ceus) and dual-phase ct angiography every months for at least years (ongoing). results: technical success was achieved in all cases, requiring dual puncture of the aneurysm sac in cases ( . %). average duration of the procedure was ± min. in mean . ml of onyx ® were used per procedure. in cases onyx ® was additionally used for complete filling of the endoleak. repeat intervention was necessary in cases ( . %) due to new endoleak development in the follow-up period of ± months. the procedure failed permanently in case. complications such as major bleeding, spinal ischaemia or non-target embolisations were not observed. conclusion: completely ct-guided treatment of laft e is a feasible and safe treatment alternative. difficulties lay in the determination of the necessary amount of onyx and the end point of the intervention. several punctures as well as repeat intervention might be necessary to achieve permanent endoleak occlusion. purpose: treatment of type endoleaks after endovascular aneurysm repair (evar) can be challenging. we describe a technique for direct embolisation with the liquid embolic agent ethylene vinyl alcohol copolymer onyx by direct catheter access to the endoleak, and present first results. methods and materials: patients ( male, female, mean age +- yrs) with a type a (n = ) or a type b (n = ) endoleak were treated. in cases, it was applied as stand-alone procedure, and in cases in combination with stent graft extension. access was trans-brachial for type a endoleaks, and trans-inguinal for type b endoleaks. a multi-purpose catheter was placed between the aortic wall and the stent graft to access the endoleak, followed by coaxial introduction of a dimethyl sulfoxide (dmso) compatible micro-catheter into the endoleak, and consecutive onyx embolisation. results: technical success was achieved in all cases. a mean volume of ml +- ml of onyx was used. in cases, additional coils were used as an anchor for onyx. patient developed reperfusion of the endoleak during follow-up of +- months, which was successfully treated with the same technique. non-target embolisation, catheter encasement, or anaphylactic reactions to dmso were not observed. the described technique is feasible, safe, and effective for treatment of type a and b endoleaks with excellent technical success rates, and low relapse rates. it can be used as stand-alone procedure or easily be combined with stent graft extension. conclusion: image fusion road-mapping for evrtaaa is feasible and is associated to a statistically significant reduction in contrast volume and a trend towards dap reduction while maintaining similar procedure time. the medium term follow-up was months. cross-tabulations were checked with chi-squared test, or by fisher's exact test. survivorships were analysed by kaplan-meyer product limit method and by cox semiparametric regression. results: technical success was achieved in . %. / presented endoleaks during the follow-up (type = , type = and type = ). during the follow-up there were mortalities, mean time . months (range - ). in survival rates there was no difference between hybrid procedures group (p= . ) and elective or emergency group (p= . ). there was a statistical difference on survival between the group that had endoleaks during the follow-up (p= . ) and who had had necessity of a second endovascular interventional (p= . ). statistical difference on survival was also seen between patients who developed type and endoleaks (p= . ). conclusion: tevar is a safe and effective treatment. the presence of endoleak, special type and the necessity of a second endovascular intervention reduces significantly the survival. selective coverage of the left subclavian artery without recanalization in patients with patent vertebro-vertebral arterial communications during tevar: a single centre study m. lee; seoul/kr (eterna @yuhs.ac) purpose: to evaluate the safety and effectiveness of selective coverage of the left subclavian artery (lsca) without recanalization during tevar in patients with patent vertebro-vertebral arterial communications and to assess morphologic change of the vertebral artery (va) after the procedure. methods and materials: among patients who underwent tevar, patients requiring lsca coverage without pre-emptive recanalization were retrospectively analysed. the patients' ages ranged from to years. vertebro-vertebral arterial communications in all patients were evaluated by contrast-enhanced computed tomography (cect), time-of flight magnetic resonance angiography, or conventional angiography. neurologic complications such as spinal cord ischaemia (sci) or cerebrovascular accidents (cva) were analysed. pre-and post-procedural changes in vas were evaluated on follow-up cect. the overall -day mortality was . % ( / ). none of the patients had an sci or stroke of posterior circulation alone. cva from embolic infarctions occurred in two patients ( . %). transient left arm ischaemic symptoms were present in patients ( . %), but none required secondary interventions. delayed development of type i endoleak occurred due to stent deformity in one patient, who underwent surgery. one patient required re-intervention after a pseudoaneurysm developed at the distal margin of the previously placed stent-graft at ten-month follow-up cect. hypertrophy of the right va after tevar was seen in of patients ( . %); two patients showed bilateral hypertrophy of vas. conclusion: lsca coverage without recanalization can be safely performed during tevar in patients with patent vertebro-vertebral communications. hypertrophy of the right va was noted in . % of patients after lsca coverage. purpose: double-bundle reconstruction with stump preservation has revolutionised the surgical treatment for anterior cruciate ligament (acl) injury. however, poor revascularization at the osteoligamentous interface (oi) of the tibia tunnel remains a major cause of graft complications. in this study, we applied dynamic contrastenhanced (ce) magnetic resonance imaging (mri) to quantify the oi enhancement values of the tibia tunnels and acl stump. we aimed to determine the relationship between graft complications and oi and stump enhancements. methods and materials: from october to april , patients were enrolled in our study (mean postoperative duration, . months). all patients underwent one . -t mri study with the imaging pulse-sequence protocol of proton density-weighted imaging (wi), t wi, pre-enhanced and post-enhanced t wi, and dynamic ce mri. graft complications, including cystic degeneration and tear, were evaluated using pre-enhanced mri, and peak enhancement (epeak) values were acquired from a dynamic ce study. the receiver operating characteristic (roc) analysis was used to obtain optimal cut-off values for complicated grafts. results: our study included patients (mean age, . years). nine patients ( . %) had cystic degeneration and ( . %) had complete posterolateral (pl) bundle tear. mean epeak percentages for graft with or without complications were . %/ . % for anterior--medial (am) bundle, . %/ . % for pl bundle, and %/ . % for stump, respectively. roc analysis yielded the optimal epeak cut-off values of %, %, and % for am bundle, pl bundle, and stump, respectively. conclusion: graft complications were directly associated with higher tibial oi values but inversely associated with higher stump values. purpose: to test if the posterior cruciate ligament (pcl) index is predictive of rotational knee kinematics during pivoting activities and anterior tibial translation (att) in patients after anatomic single-bundle (sb) anterior cruciate ligament reconstruction (aclr). sixteen patients with sb-aclr were prospectively evaluated with d-motion analysis during ( ) descending and pivoting, and ( ) landing and pivoting. the side-to-side difference of tibial rotation range of motion (ssdtr) between the aclr and the contralateral intact knee was calculated. att ssd was measured with a kt- arthrometer. mri was used to measure the pcl index for the study group and a control group. linear regression models were used with pcl index as predictor of ssdtr for each task and side to side anterior translation differences. unpaired sample t-test was used to compare pcl index group means between the study and control group. the level of significance was set at α= . . results: pcl index of the aclr knee was significantly lower compared to the healthy control knee (p < . ). the pcl index was predictive of low ssdtr during pivoting after descending and landing tasks (r = . , p= . and r = . , p= . respectively). pcl index was not predictive of att with n or maximum manual force (r = . , p= . and r = . , p= . respectively). the pcl index after anatomic sb aclr is predictive of rotational kinematics during dynamic pivoting activities. these results suggest that after anatomical aclr the pcl index can serve as an indicator of tibial-femoral position and may predict dynamic tibial rotation. microstructural evaluation of the cruciate ligaments with mr diffusion tensor imaging (dti): correlations with knee stability l. di clemente , d. tortora , v. panara , m. savastano , v. calvisi , p. palumbo , a. tartaro , a.r. cotroneo , m. caulo ; chieti/it, l'aquila/ it (lorisdiclemente@gmail.com) purpose: the evaluation of knee stability is currently based on tibio-femoral sagittal plane motion measurement as evaluated using the kt- arthrometer. conventional mri cannot evaluate knee stability. the aim of the study was to assess the use of mr-diffusion tensor imaging (dti) as a tool for a microstructural examination of the anterior and posterior cruciate ligaments and to correlate dti finding with clinically evaluated stability. methods and materials: subjects ( females) without previous history of knee injuries underwent mri using conventional and dti sequences. fractional anisotropy (fa) values were calculated in each anterior and posterior cruciate ligament within different rois placed in the lower, middle and upper portion of the ligaments. knee stability was assessed using kt- arthrometer in progressive active displacements: lbs, lbs, manual maximum displacement and under quadricipital muscle contraction. statistical analysis was performed using independent t-test and kendall tau rank correlation test, where appropriate (p < . ). results: fas of the acl (mean: . ± . ) were significantly lower compared with the pcl (mean: . ± . ) (p < . ), whereas no side differences were noted. a significant negative correlation between fa and kt- arthrometer values at lbs was present in the pcl (r=- . ; p= . ). no correlations were observed between the fa and kt- values in the acl. conclusion: functional assessment of the microstructural organisation of the cruciate ligaments with dti expands mri applications beyond simple morphological studies and could help bridge the gap between imaging and clinical evaluation of knee stability. the schatzker classification for tibial plateau fractures and the amount of articular depression were assessed using mdct. magnetic resonance images were evaluated for crucial and collateral ligament injury, meniscal tears and patellar retinaculum lesions. statistics included logistic regression and analysis of covariance. results: associated soft-tissue injuries were identified in % of the patients. logistic regressions revealed a significant impact of increasing amounts of tibial plateau fracture depression on the incidence of meniscus lateralis tears (p = . ) and lesions of the anterior cruciate ligament (p = . ). analysis of covariance demonstrated a significant correlation between the amount of articular depression and the absolute number of soft-tissue injuries (p = . ). conclusion: articular depression is a potential predictor of specific meniscal and ligamentous injuries in acute tibial plateau fracture. due to the high incidence of associated soft-tissue lesions, magnetic resonance imaging is generally recommended, especially in cases with distinct tibial plateau fracture depression at mdct imaging. anatomical risk factors in patients after patellar dislocation: a casecontrol study using mri t. köhlitz, s. scheffler, t. jung, e. wiener, b. vollnberg, g. diederichs; berlin/ de (bernd.vollnberg@charite.de) purpose: to assess anatomical risk factors in patients after lateral patellar dislocation (lpd) and controls using mri. methods and materials: mr images of knees after lpd and of age-and gender-matched controls were analysed. the presence of trochlear dysplasia was assessed by evaluation of trochlear inclination, facet asymmetry, and trochlear depth; patella alta was evaluated by insall-salvati-index and caton-deschampsindex; and lateralized force vector was measured by the tibial tuberosity-trochlear groove (tt-tg) distance. results: compared with controls, dislocators had significantly lower values for all three parameters of trochlear dysplasia (- %, - %, - %) and significantly higher values for patella alta (+ %, + %) and tt-tg (+ %) (all p < . ). trochlear dysplasia was observed in dislocators ( %), of whom ( %) additionally had patella alta and ( %) an abnormal tt-tg. as isolated risk factors, patella alta ( %) and abnormal tt-tg ( %) were rare. only dislocators ( %) had no anatomical risk factor. trochlear dysplasia in conjunction with abnormal tt-tg or patella alta is associated with a -fold and -fold higher risk. conclusion: most dislocators have anatomical risk factors, varying in severity and constellation. trochlear dysplasia is the main risk factor for lpd, while patellar alta and abnormal tibial tuberosity-trochlear groove distance may be additional factors. patient-specific evaluation of risk factors following lpd may help future management. early changes of trabecular bone structure in asymptomatic subjects with knee malalignment t. baum, j. penzel, m. sauerschnig, e.j. rummeny, k. wörtler, j.s. bauer; munich/ de (thbaum@gmx.de) purpose: knee malalignment is a risk factor for knee osteoarthritis (oa). the purpose of this study was to investigate whether alterations of trabecular bone structure can already be found in young, asymptomatic subjects with knee malalignment. methods and materials: forty-eight asymptomatic subjects ( females, males; age: ± years) without history of knee injury or surgery were included in this study. based on mr measurements, knee joint alignment of both lower extremities was assessed and subjects were divided into four groups (each including subjects, i.e. knees): neutral (up to ° varus/valgus), mild varus ( °- °), severe varus (greater °), and valgus ( °- °). a t -weighted d-flash sequence (spatial resolution: . x . x . mm³) was obtained of each knee at . t to determine histomorphometric and texture parameters of the trabecular bone in the medial/ lateral femur/tibia (mf,lf,mt,lt). the calculated parameters were compared between the four groups in each compartment using anova including bonferroni correction for multiple comparisons. purpose: we performed a randomised, double blinded, placebo controlled study to assess the effectiveness of lllt in patients with knee pain related to meniscal pathology. the study trial number is isrctn . we only included symptomatic patients with tiny focus of grade attenuation (seen only on . thickness sequences) or intrasubstance tears with spot of grade signal intensity approaching the articular surface. none of the patients in the study group underwent arthroscopy or new mri investigation. a paired samples t-test was used to detect significant changes in subjective knee pain over the experimental period within groups, and anova was used to detect any significant differences between the two groups. results: pain was significantly improved for the lllt group than for the placebo group (f= , p < . ). pain scores were significantly better after lllt. four ( . %) patients did not respond to lllt. at baseline, the average lysholm score was ± . for the lllt group, and . ± . for the placebo group [p> . ]. four weeks after lllt or placebo therapy, the laser group reported an average lysholm score of . ± . , the placebo group scored . ± . . at months, the laser group had an average lysholm score of . ± . , an after one year they scored . ± . (f= . , p= . ). treatment with lllt was associated with a significant decrease of symptoms compared to placebo. in patients with small meniscal tears who do not wish to undergo surgery, lllt should be considered as a non-invasive alternative. is not clear, i.e. whether meniscal injury leads to cartilage degeneration or vice versa. therefore, we aimed to evaluate the impact of meniscal tears on adjacent, morphologically intact knee cartilage using t relaxation time, a sensitive biomarker for early cartilage degeneration, and compare with healthy controls. methods and materials: sixty-nine subjects without evidence of oa were recruited from the osteoarthritis initiative. thirty-five subjects ( -women) with a normal medial meniscus were used as controls (age ± , bmi ± ). thirty-four subjects ( -women) had either a simple (non-displaced tear; n= , age ± , bmi ± ) or complex tear (displaced tear; n= , age ± , bmi ± ) of the posterior horn of the medial meniscus. none of the tear-subjects had morphological lesions of the medial tibio-femoral cartilage. t -measurements were performed in the whole medial tibia (mt) and the medial femur compartments (mf), and in tibio-femoral subregions adjacent to the torn meniscus (smt & smf). multiple linear-regression models were used to compare mean t -values of individuals with meniscal tears with normal controls. purpose: patients with good or complete response after neoadjuvant chemoradiation have excellent long-term outcome. minimal invasive treatment (i.e. transanal endoscopic microsurgery (tem) and wait-and-see policy) are increasingly considered as an alternative to major surgery. with this prospective cohort study we aimed to evaluate long-term outcome of strictly mr-based selected patients who have been treated with minimal invasive treatment. methods and materials: eight weeks after chemoradiation, endoscopy and restaging mri were performed (including diffusion-weighted mri for yt-staging and gadofosveset-enhanced mri for yn-staging). complete responders were selected for wait-and-see policy and good responders with small tumour remnant for tem. both treatment groups underwent intensive -to- monthly follow-up, using mr imaging (dwi+gadofosveset), cea, ct of thorax and abdomen and endoscopy was performed. long-term outcome was estimated with kaplan-meier curves. results: forty-one patients were included, thirty-three in the wait-and-see group and eight in the tem-group. mean follow-up was months (range - ). for the tem-group, patients had ypt and had ypt . two patients, both in the wait-and-see group, developed a local recurrence within two years and underwent surgery, leading to a -year local recurrence rate of %. both recurrences were detected on (dwi-)mri in an early stage. the cumulative probabilities of -year disease-free survival and overall survival were % and %, respectively. no recurrences occurred in the tem-group. conclusion: both selection and follow-up of good and complete responders after chemoradiation for rectal cancer with mri is feasible. long-term outcome so far is excellent. (dwi-)mri seems to be a reliable tool for early recurrence detection. diffusion-weighted-based volumetry in the assessment of response in patients with rectal cancer treated with neo-adjuvant therapy: feasibility study s.f. carbone, m. palumbo, v. ricci, l. pelliccia, e. cacchiarelli, l. volterrani; siena/it (fracarb@gmail.com) purpose: to establish the reproducibility of volumetric magnetic resonance diffusion (vdwi) and compare it with the conventional volume (vc) in the assessment of response in patients with rectal cancer treated with chemoradiotherapy (crt). we retrospectively examined patients (mean age . years) with rectal cancer who have performed mri before and after ± days of the crt after undergoing anterior resection of the rectum. after surgery, yptn and trg (tumour regression grading) according to mandard classification were obtained. we considered patients with trg - responder and non-responder patients with trg - . two radiologists, blinded, have extrapolated the volume vc and vdwi lesions pre-and post-crt. the inter-observer agreement and the agreement between vc and vdwi pre-and post-crt were calculated by intraclasscorrelation coefficient (icc). the inter-observer agreement for vc and vdwi was . and . respectively, while the correlation between vc and vdwi investigating pre-crt was . and in the post-crt in . . after crt, vc shows a correlation with the trg of rho = . (p < ), while a significant linear relationship was evident between vdwi and trg with rho = (p < . ). post-crt the vdwi shows a significant difference between responders and nonresponders (p = . ). the vdwi is a reproducible quantitative technique in assessing the response to crt in patients with rectal cancer and shows a better correlation with the residue of the disease compared with the vc. therapy response assessment in locally advanced rectal cancer: comparison between functional dynamic and diffusion parameters in mri r. fusco, v. granata, m. petrillo, m. sansone, a. petrillo; naples/it (roberta.fusco@unina.it) purpose: we investigated the diagnostic performance of dce-mri and dw-mri in evaluating neoadjuvant chemo-radiotherapy (crt) response in larc. we compared a semiquantitative dynamic feature, the standardised index of shape (sis) and the diffusion parameters obtained using intravoxel incoherent method. purpose: to compare image quality and detection of clinical findings of the new warp sequence versus conventional optimised mr sequences in patients with total knee arthroplasty (tka). methods and materials: forty-two patients with tka underwent . t mri in this prospective study. slice-encoding metal artefact correction (semac), view-angle tilting (vat), and increased bandwidth were combined by the "warp"-turbo spin echo sequence. twenty-four patients underwent ct as a reference standard. coronal stir-warp and sagittal intermediate-weighted (pd) warp-sequences were compared to standard sequences optimised with high readout bandwidth (stir-hibw/pd-hibw). signal void was quantified. qualitative criteria (depiction of anatomy, distortion, blurring, noise) were assessed on a five-point scale ( , no artefacts; , severe artefacts) by two readers. clinical findings (e.g. periprosthetic osteolysis) were noted. a t-test (quantitative data) and a wilcoxon signed rank test (qualitative data) served for statistics. results: signal void areas were smaller for stir-warp than stir-hibw (mean; . cm / . cm ), and for pd-warp than pd-hibw ( . cm / . cm ; p <. for all comparisons). depiction of anatomic structures was better on stir-warp versus stir-hibw ( . - . vs. . - . ; p <. ), and on pd-warp versus pd-hibw ( . - . vs. . - . ; p <. ). distortion and image noise were lower for warp than for the standard sequences (p <. ), while blurring was similar for both techniques. there was a statistically significant advantage for detection of clinical findings for stir-warp versus stir-hibw ( and findings; p <. ) and for pd-warp versus pd-hibw ( and findings; p <. ). the warp sequences showed a statistically significant improvement for most image criteria. detection of clinically relevant findings was markedly increased. : purpose: to determine the diagnostic accuracy of mr in patients with rectal carcinoma by comparing post-chemoradiation mr imaging with pathological specimens. we enrolled patients with a locally advanced rectal cancer. all patients received chemoradiation therapy before surgery. those patients underwent a neoadjuvant chemoradiation therapy followed by mr scans. the mr images were analysed by a team of two expert radiologists to whom clinical and histo-pathological findings were unknown. results: following neoadjuvant chemoradiation therapy, we observed ( %) patients with a rectum disease staged ² t and ( %) patients with a disease staged > t , after mr images analysis. post-treatment histological staging (tnm) analysis revealed patients with a disease > t and patients with a disease ² t . by arranging the kappa cohen test to find the agreement value between post-chemoradiation mr staging and histological response, we found that with a disease confined to the sierosa (² t ) the agreement was . %. we found an agreement of . % between mr and histology for a disease ² n and an accord of . % for a disease more advanced than n (> n ). conclusion: mr is critical in discovering a t disease; moreover, with morphologic mr imaging we do not have always the opportunity to discern a few residual cancer cells hidden in the fibrotic tissue that could cause a crm involvement on histology. monday fascia infiltration was present on the surgical specimen. in patients reticular (n= ) or linear-shaped (n= ) mesorectal enhancing strands were observed. reticular-shaped mesorectal enhancing strands were predictors of mesorectal fat infiltration (odds ratio, . ; % confidence intervals, . - . ; p < . ) but not of mesorectal fascia infiltration ( . ; . - . ; p= . ). the enhancing strands reaching the mesorectal fascia represent a predictors of mesorectal fascia infiltration ( . , . - . ; p < . ). the evidence of enhancing strands reaching the mesorectal fascia represents a predictor of mesorectal fascia infiltration and should suggest to intensify the crt. purpose: to show the utility of mdct assessing the tumour response in locally advanced colon cancer treated with neoadjuvant chemotherapy. methods and materials: consecutive patients who underwent this therapy during a -month period were included. all tumours were staged before treatment using mdct or pet-ct scan, and after neoadjuvant treatment other scan was performed by calculating the differences in tumour volumes making use of a dedicated software for semiautomatic volume segmentation, to assess tumour response before surgery. maximum standard uptake value (suv max) by pet-ct between the time of initial diagnosis and after neoadjuvant chemotherapy was also measured. surgical-related complications and oncological outcomes were obtained. results: tolerance to chemotherapy was excellent in . % of patients and . % completed the entire chemotherapy initially planned. after neoadjuvant treatment, . % reduction of tumour volume was observed by ct-scan and up to . % decrease of suvmax (standard uptake value) was achieved by pet/ mdct. none of the patients showed tumour progression during the preoperative treatment, and all of them underwent the previously planned surgical procedure. four patients developed postoperative complications. median time between the end of chemotherapy and surgery was days. conclusion: preoperative chemotherapy induces a tumour response that can be measured by imaging methods (mdct). assessment of the variation in the contrast-to-noise ratio across a range of ct scanners in a multicentre perfusion ct study of colorectal cancer (prospect): a phantom study m. lewis, v.j. goh; london/uk purpose: to determine the effect of ct scanner models, iterative reconstruction (ir) and phantom size on cnr of perfusion ct scans. methods and materials: a -cm diameter water phantom containing different iodine contrast inserts from . mg/ml to mg/ml was scanned on seven ct scanners from four manufacturers using the perfusion ct acquisition protocols of a multi-centre clinical trial in colorectal cancer (prospect). all acquisition protocols employed kv and ~ mm reconstructed slice. images were reconstructed with filtered back projection and iterative reconstruction, where available. ct numbers and background noise levels were measured and displayed ctdivol values noted. a sub-set of measurements was obtained on a -cm diameter phantom. the relationship between ct number and iodine density was determined for all datasets and cnr values calculated. results: a linear relationship between ct number and iodine density was observed, with small variations between ct scanners. no change in linearity was observed with ir of different 'strengths'. ctdivolvalues varied by a factor > . for the lowest density insert, cnr varied from . to . . with ir, cnr increased by a factor of . to . depending on ir'strength'. cnr decreased by ~ % in the cm phantom. the cnr varied by a factor of . across the range of scanners utilised in this mutlicentre study. the variation was largely due to image noise differences. ir does not affect contrast enhancement and can be used to achieve a given cnr at a reduced dose. author disclosures: v.j. goh: equipment support recipient; siemens healthcare, ge healthcare, texrad. research/grant support; nihr hta grant. methods and materials: consecutive patients with larc were enrolled. patients underwent dce-mri and dw-mri ( . t, magnetom simphony tim, siemens, erlangen). an expert radiologist performed a manual segmentation of the whole lesion on a derived series obtained subtracting the basal and the th post-contrastographic series and on dwi with b value= . sis and pure diffusion coefficient, pseudo-diffusion coefficient and perfusion fraction were calculated pixel by pixel. after surgery, tumour regression grade (trg) was obtained. patients with trg - were considered responders and patients with trg - - were considered non-responders. the value changes of each parameters from baseline to presurgical scan were assessed and correlated with the trg. sensitivity, specificity, roc analysis were applied. youden index was used to obtain the optimal cut-off value. mc-nemar test was performed to underline statistical difference. results: seven patients were classified as responders and as non-responders at histology. the diffusion parameter (fraction perfusion) showed a sensitivity of %, specificity of % and area under roc . (optimal cut-off value . %); sis showed a sensitivity of %, a specificity of % and area under roc . (optimal cut-off value . %). a p value of < . was obtained comparing sis vs diffusion parameter. conclusion: sis can achieve the best results in discriminating patients responders from non-responders. reproducibility of mri texture analysis in primary rectal cancer s. gourtsoyianni , g. ljungqvist , a. khan , r. glynne-jones , b. ganeshan , k. miles , v. goh ; london/uk, northwood/uk, falmer/uk (sgty @gmail.com) purpose: this study aimed at assessing the feasibility and reproducibility of mri texture analysis in rectal cancer. methods and materials: following irb approval, patients ( male, mean . years) with primary rectal cancer underwent two baseline mris. t -w axial sequences were exported for texture analysis (texrad, university of sussex). a laplacian of gaussian band-pass filter was applied to highlight different spatial scales (fine ( . ), medium ( . - . ) and coarse ( . ) texture). texture was quantified as entropy (e), uniformity (u), kurtosis (k), skewness (s) and standard deviation of the histogram (sdh) and recorded as for absolute scale values for each tumour. greater heterogeneity is represented by higher e, greater k, s and sdh and lower uniformity. overall group median values were recorded and reproducibility (testretest agreement) was assessed using bland-altman statistics. results: all tumours were greater than stage ii; mean length . cm. good reproducibility was achieved across all filters ( . - . ) for e, u and sdh with mean differences ranging from - . to + . for e; - . x - to + . x - for u; and + . to + . for sdh; and within subject coefficients of variation from . - . % for e, . - . % for u, and . - . % for sdh. there was greater variability for k and s: mean differences ranged from + . to + . for k; and + . to + . for s; within subject coefficients of variation from . - . % for k, and . - . % for s. conclusion: mri texture analysis is feasible in rectal cancer and a reproducible technique in the trial setting. predictors of mesorectal fascia infiltration on spectral pre-saturation inversion-recovery (spir) mr imaging sequence after gadolinium injection in patients with rectal carcinoma after neoadjuvant chemoand radiation therapy e. quaia, l. de paoli, a. gennari, b. cabibbo, m. cova; trieste/it (quaia@units.it) purpose: to retrospectively assess the value of spectral pre-saturation inversionrecovery (spir) mr imaging sequence after gadolinium injection to identify predictors of mesorectal fat and mesorectal fascia infiltration in patients with locally advanced rectal carcinoma after neoadjuvant chemo-and radiation therapy (crt). methods and materials: sixty-five consecutive patients (mean age: . years, range: - years, m:f : ) with locally advanced rectal carcinoma underwent crt followed by surgery. mr imaging was performed before and after completion of crt using t -weighted fast spin-echo and t -weighted spir sequences before and after gadolinium injection. mr images were assessed by two radiologists in consensus. the evidence of reticular (interwoven strands within the mesorectal fat creating a meshwork) or linear-shaped enhancing strands (strands travelling separately through the mesorectal fat) on mr images were retrospectively correlated to the histopathological findings. results: after crt the disease was either limited to the rectal wall (n= patients) or presented mesorectal fat infiltration (n= conclusion: cedm has a potential impact on the characterisation of breast lesions. intensely enhancing lesions are strongly indicative of a malignant nature, yet, overlap of enhancement patterns still exists and therefore further studies with a larger number of studied population are recommended. clinical feasibility of contrast-enhanced dual-energy mammography (cedem) with a tungsten (w)/titanium (ti) anode/filter combination: a prototype report t. knogler , r. leithner , m. hörnig , f. semturs , m. waitzbauer , g. langs , p. homolka , k. pinker-domenig , t.h. helbich ; vienna/at, erlangen/ de (thomas.knogler@meduniwien.ac.at) purpose: to test the feasibility of cedem with a w/ti anode/filter combination for high energy images in a clinical setting. methods and materials: fifteen female patients with breast lesions were included in this study. cedem was performed with a mammomat inspiration prototype (siemens, germany) before and after i.v. administration of -ml iomeron® (bracco, italy) per kg b.w. at a rate of . ml/sec. dual-energy images were acquired with - kvp and a w/rhodium (rh) anode/filter combination for lowenergy and kvp and a w/ti anode filter combination for high energy. weighted subtraction images were computed for diagnostic work-up. images were assessed by two readers with respect to lesion-enhancement and image quality. a histological work-up was performed in all lesions. results: histopathology revealed eight malignant lesions and seven benign lesions (size range from to mm). all malignant lesions enhanced and were seen from both readers on weighted subtraction images. benign lesions did not enhance thus they were not visualised on weighted subtraction images. image quality was rated excellent from both readers. based on the visibility of the lesion cedem allowed an accurate differentiation of benign and malignant breast lesions. conclusion: cedem with a w/ti anode/filter combination is suitable and feasible. lesion visibility and image quality were excellent. further research is needed to determine the value of cedem in a clinical setting. diffusion-weighted-based mri: volumetry and apparent diffusion coefficient s.f. carbone, m. palumbo, t. carfagno, v. ricci, l. pirtoli, l. volterrani; siena/it (fracarb@gmail.com) purpose: to assess the diagnostic accuracy of volumetric magnetic resonance diffusion (vdwi) and apparent diffusion coefficient (adc) in the assessment of response in patients with rectal cancer treated with chemoradiotherapy (crt). we retrospectively examined patients (mean age . years) with rectal cancer, who have performed mri before and after ± days of the crt after undergoing to anterior resection of the rectum. after surgery, yptn and trg (tumour regression grading) according to mandard classification were obtained. we considered responders patients with trg - or with a negative follow-up recurrence in the next months (only three cases). two radiologists, in consensus and using commercial software, have extrapolated pre-and post-crt vdwi of the lesions and calculated the adc. results: the adc did not show significant differences between responders and not-responders (p = . pre-crt, p = . post-crt); the vdwi of responders was significantly lower in both pre-crt (p = . ) and in post-crt (p = . ) compared with not-responders vdwi. the accuracy in the evaluation of response was of and %, respectively, for the adc and vdwi. the vdwi is more reliable than adc to assess the response to crt in patients with rectal cancer. computed tomography of the bowel: a prospective comparison study between four techniques m. revelli, f. paparo, l. bacigalupo, a. garlaschi, l. cevasco, e. biscaldi, g. rollandi; genoa/it purpose: our purposes were to compare the grade of bowel distension obtained with four different ct techniques dedicated for examination of small intestine (ct-enteroclysis and ct-enterography), colon (ct with water enema), or both (ct-enterography with water enema) and to assess patient tolerance towards each protocol. we recruited four groups of patients. each group corresponded to a specific ct technique, for a total of consecutive patients ( male, female; mean age . ± . years). ct studies were evaluated in consensus by two gastrointestinal-dedicated radiologists who performed quantitative and qualitative analysis of bowel distension. presence and type of adverse effects were recorded. results: ct-enteroclysis provided the best distension of jejunal loops (median diameter mm; range - mm) compared with all other techniques (p < . ). frequency of patients with an adequate distension of the terminal ileum was not significantly different among the four groups (p= . ). at both quantitative and qualitative analysis ct with water enema and ct-enterography with water enema determined a greater and more consistent luminal filling of the large intestine compared with the one provided by both ct-enteroclysis and ct-enterography (p < . for all colonic segments). adverse effects were more frequent in patients from the ct-enteroclysis group (p < . ). conclusion: ct-enteroclysis allows an optimal distension of jejunal loops, but it is the most uncomfortable ct protocol. when performing ct with water enema, an adequate retrograde distension of the terminal ileum was provided in a high percentage of patients. ct-enterography with water enema provides a simultaneous optimal distension of both small and large bowel. s c a d e f g b excellent ( . / . ), but worse for vee ( . / . ). correlations of small arbitrary rois were lower for all parameters. conclusion: perfusion and permeability parameters of dce-mri of rcc are influenced by roi-size and positioning. the best inter-and intraobserver correlation showed definition of whole tumour roi with morphological sequences or plasma flow maps. evaluating tumours or monitoring antiangiogenic therapy, perfusion parameters are more reliable, while permeability parameters are more susceptible to interobserver variability. can a contrast-enhanced ultrasound nephrostogram be used instead of a fluoroscopic nephrostogram: preliminary findings m. daneshi, k. patel, d. huang, m. sellars, p. sidhu; london/uk purpose: the use of contrast-enhanced ultrasound (ceus) has extended beyond traditional uses, and the possibility to delineate percutaneous tubes and drains is achievable. we have compared the traditional fluoroscopic nephrostogram using iodinated contrast agents with ceus nephrostogram to ascertain the accuracy, utility and convenience of the ceus nephrostogram. the standard conventional nephrostogram was performed immediately prior to the ceus nephrostogram. the ceus nephrostogram technique involved diluting . ml of sonovue with ml of normal saline and introduced into the renal collecting system via the nephrostomy tube. digital cineclips and still images were recorded to allow accurate retrospective comparison by two independent reviewers to the reference standard. results: twelve nephrostomies in patients (median age yrs, range - yrs, females and males) were performed and reviewed. the renal pelvicalyceal system was visualised in both ceus and fluoroscopic nephrostograms in / ( %) with one nephrostomy tube identified as being misplaced. the entire ureter was visualised in / ( %) with a ceus nephrostogram compared with / ( %) using traditional nephrostogram. fluoroscopic nephrostogram showed drainage of contrast into the bladder in / ( %) cases compared with / ( %) using ceus. conclusion: preliminary results suggest that ceus nephrostogram is a feasible method to confirm the correct positioning of the nephrostomy tube, image the ureters and determine if there is satisfactory drainage into the bladder. ceus nephrostogram is a suitable alternative for the traditional nephrostogram in patients with contraindications to iodinated contrast agents or if the procedure needs to be performed at the bedside. vena cava anomalies associated with horseshoe kidney on mdct t. ichikawa, j. koizumi, s. kawada, y. imai; isehara/jp (tamaki-i@mars.sannet.ne.jp) purpose: the incidence of vena cava (vc) anomalies in horseshoe kidney (hsk) patients is relatively high because of embryogenesis. we evaluated prevalence and variation of anomalous inferior vena cava (ivc) and superior vena cava (svc) in hsk patients detected using ct. methods and materials: seventy-one patients with hsk and patients with normal kidney (nk) who underwent chest ct were evaluated of prevalence and variation of anomalous svc and patients with hsk and patients with nk who underwent abdominal ct were evaluated of prevalence and variation of anomalous ivc. we reviewed axial ct images with -mm reconstruction interval and compared prevalence of anomalous vc between hsk and nk patients using chi-square test. results: anomalous svc was identified in patients ( . %) in hsk patients: double svcs and persistent left svc without right svc and patients ( . %) in nk patients: double svcs and persistent left svc without right svc. anomalous ivc was identified in patients ( . %) in hsk patients: preisthmic ivc with retrocaval ureter, double ivcs, left ivc, and ivc with azygos continuation and patients ( . %) in nk patients: double ivcs, left ivc, and one ivc with azygos continuation. there was a significantly higher prevalence of anomalous vc in patients with hsk than in those nk on mdct (p < . ). conclusion: hsk patients were frequently found anomalous vc and detection of those anomalies in hsk patients is important during central venous catheter procedures and operation. or excision biopsy. qualitative analysis of cine loops was assessed for each ceus examination by two observers and consensus reached on the pattern and timing of tumour enhancement. perfusion quantification of the lesions was performed where possible, with time-intensity curves were analysed. results: distinct differentiation on enhancement patterns was observed between leydig cell and germ cell tumours. all leydig cell tumours displayed intense early enhancement which persisted for longer than the normal testicular parenchymal enhancement. the germ cell tumours showed loss of the normal linear vascular pattern, but with a more rapid washout of contrast. quantitative analysis confirms the observation, with longer full width at maximum (fwhm) and slower contrast outflow on the time-intensity curves observed in leydig cell tumours comparing to germ cell tumours. with improved diagnostic confidence, testicular-sparing excisions were performed for lesions following pre-operative ceus analysis and unnecessary orchidectomies avoided. we describe, to date the first, consistent differentiating characteristic ceus enhancement pattern in rare benign leydig cell tumours. this observation increases diagnostic confidence, thus allows for testicular-preserving options to be considered. purpose: to describe us and colour-doppler findings in testicular lymphoma and their mimics. we reviewed the us and colour-doppler findings in pts with pathology-proven lymphoma of the testis and compared them with those in patients in whom lymphoproliferative disease was suspected on clinical and us grounds and pathology showed only inflammatory changes. results: lymphoma patients' age range was - years. six had testicular involvement in systemic disease or recurrence; four had primary disease. one had bilateral involvement. seven testes in patients were diffusely involved ( homogeneously; heterogeneously); four had nodular hypoechoic lesions which, in testis, were multiple. all lesions, either focal or diffuse, were hypervascular, with vessels of normal rectilinear shape. in patients with nodular lesions, there was no distorsion of vascular course at the point where vessels entered the mass. findings suggested an infiltrative process, and were confirmed at pathology. the remaining seven patients had history and us features suggesting testicular lymphoproliferative disease. all had hypoechoic focal hypervascular lesions containing vessels with rectilinear course that were eventually proved inflammatory changes ( chronic focal orchitis, idiopathic granulomatous orchitis, brucellosis, tuberculosis). conclusion: in patients over and/or with known lymphoproliferative disease, the presence of hypoechoic, hypervascular testicular lesion with absence of vascular distorsion must suggest lymphoma. care must be taken since, albeit rarely, inflammatory lesions may present the same imaging pattern in the absence of clinical signs and symptoms of inflammation. purpose: to assess the influence of region of interest (roi) size and positioning on parameters of perfusion and permeability and inter-and intraobserver variability of dce-mri of renal cell carcinoma (rcc) and metastases. methods and materials: patients with rcc and patients with metastases were examined with dynamic contrast-enhanced (dce) mri at . t with a half body weight-adapted dose of gadobutrol. analysis with a two-compartment exchange model provided four parameters: plasma flow (fp), plasma volume (vp), permeability-surface-product (ps) and interstitial volume (vee). arterial input function and retrospective respiratory triggering were applied. rois of the whole tumour, circular edge and an arbitrary vital region were defined on morphological sequences and on parametric plasma flow maps. consider tube current modulation (tcm). the aim of this study was to include tcm effects in mc dose simulations and to validate this approach. methods and materials: all measurements were performed on a somatom definition flash scanner (siemens healthcare, forchheim, germany) using three anthropomorphic phantoms: adult alderson-rando, -year-old child and -yearold child. the phantoms were scanned with a trunk protocol using an online tcm system (caredose , siemens healthcare, forchheim, germany). organ dose values were measured using calibrated thermoluminescent dosimeters (tld) for each phantom. mc simulations were performed using impactmc software (ct imaging gmbh, erlangen, germany) based on the d voxelised data derived from acquired ct images. the tool was modified to take tcm curves into account. the current values for different tube positions were extracted from the raw data using manufacturer software. simulated dose values were compared with tld measurements on a chip-by-chip basis. results: for mc calculations without taking tcm data into account the mean differences between measured and simulated dose values amounted to %, %, % for adult, -year-old child and -year-old phantoms, while modelling with tcm reduced the mean differences to . %, . % and . %, respectively. conclusion: mc dose estimates including tcm data were in good agreement with measurements. this technique can significantly improve the accuracy of d-dose assessment. monday kev; pixel size . µm), or at a laboratory set-up with a conventional x-ray tube (n= , kvp, ma, pixel size µm). tomographic images were reconstructed and compared to histopathology. independent readers determined vessel dimensions and signal-to-noise ratios (snr) between gb-pci and absorption images. results: in total, sections were included in the analysis. images from both setups provided sufficient contrast to differentiate vessel layers. there was a strong positive correlation between pci and histology with respect for lumen, intima and vessel wall area for both synchrotron and laboratory-based measurements (pearson's r > . and p < . for all). synchrotron-based images were characterised by significantly higher snrs than laboratory-based images (p < . ). both gb-pci set-ups had superior snrs compared to corresponding absorption-based images (p < . ). inter-reader reproducibility was excellent, with iccs > . for synchrotron and > . for laboratory-based measurements. conclusion: our results demonstrate the feasibility of gb-pci for carotid atherosclerotic plaque imaging using both synchrotron and laboratory-based experimental set-ups. the technique holds promise for accurate vessel wall characterisation. single contrast medium dose peripheral mr angiography is feasible without subtraction using two-point dixon fat saturation purpose: to investigate the feasibility and image quality of subtractionless firstpass single contrast medium dose ( . mmol/kg) peripheral contrast-enhanced magnetic resonance angiography (mra) using two-point dixon fat-saturation ( dixfs) compared with conventional subtraction-based mra with regard to vesselto-background contrast, signal-to-noise ratio (snr) and subjective image quality. methods and materials: patients ( m, f; mean age±sd, ± ) with known or suspected peripheral arterial disease underwent single contrast medium dose ( . mmol/kg body weight) . -t mra using dixfs during first arterial passage of contrast material. results were compared with data obtained using a conventional, subtraction-based approach. a phantom study was performed to assess signal-to-noise ratio (snr) of both mra techniques. vessel-to-background (vtb) contrast and snr were measured and compared with the paired samples t-test. two experienced observers scored subjective image quality. fisher's exact test was used to compare subjective image quality. agreement regarding subjective image quality was expressed in quadratic weighted κ values. results: patient data showed improved vtb contrast in all anatomical locations with dixfs versus the conventional, subtraction-based mra method (all p < . ). subjective image quality was uniformly higher with dixfs when compared with subtracted images. in all cases this was significant (p < . ), except the aortoiliac arteries for observer (p= . ). phantom studies indicated a % higher snr with the dixon technique ( . vs . ). conclusion: this study demonstrates the feasibility of single contrast medium dose subtractionless lower extremity mra using dixfs method. both objective and subjective image quality are better compared with subtraction based mra of the peripheral vascular tree. correlation of cardiovascular risk factors and occult atherosclerotic findings using whole body magnetic resonance imaging of the vascular system in an asymptomatic patient collective: initial results s. mangold, e. randrianarisoa, p. krumm, c. bretschneider, a. seeger, k. rittig, b. balletshofer, c.d. claussen, u. kramer; tübingen/ de (stefanie.mangold@med.uni-tuebingen.de) purpose: to evaluate the prevalence of atherosclerotic disease, myocardial infarction and cerebrovascular disease in asymptomatic patients with cardiovascular risk profile including whole body magnetic resonance imaging (wb-mri) of the cardiovascular system into the framework of a comprehensive prevention concept. methods and materials: prospectively, patients without any known cardiovascular disease ( men, woman, mean age . ± . years) but suffering from cardiovascular risk factors such as arterial hypertension [aht], impaired glucose tolerance, hyperlipidaemia and obesity, were clinically assessed including family history, blood collection, blood pressure assessment and oral glucose tolerance test. furthermore, the carotid intima-media thickness [cimt], potentially indicative for atherosclerotic disease was assessed by ultrasound and a wb-mr angiography ( . t, avanto, siemens medical solutions) containing an examination of the of renal artery using respiratory triggered (rt) or breath held (bh) in reference to dynamic contrast mra (cmra). methods and materials: patients were involved (median age years). rt and bh nc mras using pg were obtained at t (discovery mr , gehc) using inflow inversion recovery (ifir) d fiesta with fan beam k-space view ordering in a coronal plane. cmra with d efgre was obtained as reference [ . mmol/kg gd-chelate, injection ml/sec]. evaluation, image quality, artefacts ( undiagnostic- excellent) and visualisation of aorta and renal arteries were ranked with -point scale. contrast was calculated (si artery/surrounding tissue). wilcoxon signed rank test and student's t test with bonferroni correction was used for statistical evaluation. results: all ncmras were diagnostic ( . - . ). scores for image quality and artefacts of rt ncmra were better than those of bh ncmra (ns) although visualisation of aorta was slightly better with bh than rt ncmra. rt ncmra provided better visualisation of distal renal arteries and better contrast than those with cmra (p < . ). contrasts of aorta and proximal renal arteries were slightly better in cmra than those in ncmras (ns). conclusion: with pg, homogenous si in aorta was obtained in ncmra. when image quality of rt ncmra is not enough to evaluate arteries, bh ncmra can be used as substitute. purpose: to evaluate the quality, the diagnostic performance and the radiation exposure of low-kv ct angiography protocol ( kv) with ultra low-contrast medium volume ( ml) in the assessment of the aorta disease. methods and materials: seventy patients with thoracic or abdominal aortic disease were prospectively examined with mdct scan (brilliance ict, philips) using ultra low-dose radiation protocol ( kv; automated tube current modulation) and ultra low-contrast volume ( ml; ml/s; mgi/ml). in the thoracic aorta assessment we performed ecg-gated retrospective protocol, necessary for the evaluation of ascending aorta. density measurements were performed on ascending, arch, descending, abdominal aorta, renal arteries and common iliac arteries. a control groups of patients who underwent standard ct-angiography protocol ( kv; mas) and standard contrast volume ( ml) were also evaluated. the obtained data in terms of radiation dose exposure (dose-length product, dlp), administered contrast and intravessels density were compared and statistically analysed. results: in every ct-exam we could correctly visualise and evaluate main branch of thoracic and abdominal aorta. no significant difference of density measurements was achieved between the low-kv protocol: mean attenuation value of thoracic aorta hu, abdominal aorta hu and renal arteries hu; and control group: mean value of thoracic aorta hu, abdominal aorta hu and renal arteries hu. the radiation dose exposure in low-kv protocol was significantly reduced (p < . ) in comparison with control group, obtaining the following value for thoracic scan: dlp and abdominal scan: dlp, while in control group we obtained for the thoracic scan: dlp and for the abdominal scan: dlp , respectively. conclusion: low-kv protocol provides a comparable diagnostic performance with standard protocol, decreasing significantly the radiation dose exposure (over %) and allowing also a significant reduction of contrast material volume ( ml), preserving renal function. x-ray phase-contrast imaging of arterial vessel wall: translation from synchrotron radiation to a conventional lab-based x-ray source h. hetterich , m. willner , s. fill , f. bamberg , j. herzen , m. stockmar , f. pfeiffer , m.f. reiser , t. saam ; munich/de, garching/ de (holger.hetterich@med.uni-muenchen.de) purpose: phase-contrast imaging (pci) is a novel x-ray-based technique that provides excellent soft tissue contrast but so far was depending on synchrotron radiation. the aim of this study was to evaluate the feasibility of visualising human carotid arteries by grating-based pci (gb-pci) at two different experimental setups: ( ) applying synchrotron radiation and ( ) using a conventional x-ray tube. methods and materials: five ex-vivo carotid artery specimens were examined with gb-pci either at a synchrotron facility using a monochromatic x-ray beam (n= ; developed for adult trauma patients in and a novel approach based on recent literature and our additional observations. results: of the years considered, cases met the inclusion criteria. in cases a nahi was assumed. cases showed sdhy. only one sdhy case was assumed to be related to an accident. the new classification system for traumatic sdhy in children will be introduced and discussed. conclusion: as demonstrated for different sdhy appearances, neuroradiologists should be aware of the possible presentations of nahi. in addition, investigation of sdhy's may allow for new insights into the pathogenesis of phenomena such as the shaken baby syndrome. apparent kurtosis coefficient (akc) in brain: a feasibility study in paediatric populations i. d'errico, a. ciccarone, m. esposito, m. mortilla, c. fonda; florence/it (igni @hotmail.it) purpose: diffusion-weighted imaging (dwi) depends on the b-values employed in acquisition. at low b values (lower than s/mm ) the signal attenuation is bi-exponential and is influenced both by diffusion and perfusion. at high b values (higher than s/mm ) the signal attenuation is influenced by restricted water diffusion and hence follows a non-gaussian distribution. diffusion kurtosis imaging (dki) provides quantifiable information about the deviation from gaussian distribution in water diffusion process. our purpose was to apply dki method to paediatric patients with different pathologies (tumours, ischaemia) and to establish its feasibility in detecting brain diseases. we examined patients from newborn to -year-old. diffusion weighted imaging was performed with b values from to with step s/mm . fitting all b values we were able to discriminate diffusion and kurtosis parameters. a home-made software performed all fitting and dwi, adc, akc maps. results: akc maps revealed additional information for tissue characterisation. in ischaemia, akc demonstrated more details of pathologic tissue changes and provided information about prognosis. in tumours, akc maps were used for discriminating low-grade from high-grade lesions revealing a better accuracy than conventional diffusion parameters. conclusion: akc maps are non-invasive methods that are well tolerated by paediatric patients and that provide a more detailed characterisation of neural tissue in the clinical context. their application in pathological conditions such as ischaemia and tumours provides additional information about microstructural tissue changes, differential diagnosis and prognosis. which t pulse should be used to study the preterm brain with a tesla scanner? d. tortora, v. panara, p.a. mattei, s. salice, m. tagliamonte, c. briganti, a.r. cotroneo, a. tartaro, m. caulo; chieti/it (domenicotortora@hotmail.it) purpose: the loss of contrast on mr t -weighted images obtained at tesla ( t) may negatively influence the detection of punctate hyperintense lesions, which are indicative of periventricular leukomalacia (pvl) in preterm neonates. in this t mr study we compared the sensitivity of different t -weighted sequences in identifying pvl. the presence of non cystic-pvl was retrospectively evaluated in tesla ( t) mr brain studies of preterm neonates acquired at term-corrected age. in neonates with pvl, t hyperintense punctate lesions were counted by two neuroradiologists in consensus on different axial t -weighted sequences: mm inversion recovery (ir), spin echo (se), reformatted d-fast field echo (ffe) and mm reformatted d-ffe. sequences were presented randomly. statistical differences of the number of hyperintense lesions detected by the different sequences were evaluated using the student's paired t test (p < . ). results: the greater number of t hyperintense punctate lesion was identified using the mm axial reformatted d-ffe sequence ( lesions), which resulted to be the most sensitive sequence in identifying pvl lesions (p < . ). axial mm ffe, ir and se sequences identified , and hyperintense punctate lesions, respectively. no statistical differences were found between mm-t sequences (p> . ). conclusion: when using a tesla mr scanner mm axial reformatted t - d-ffe is the most sensitive t -weighted sequence for detecting punctate hyperintense lesions which may affect the brain of preterm neonates. brain and the heart was performed. a vessel score, determined from the sum of arteriosclerotic changes of all evaluated vessel divided by the number of vessels with a range from , normal to , stenosis > %, was introduced and score's association with risk factors was assessed. results: the mean mri score was . ± . .the wb-mr angiography-based score was significantly associated with the body mass index [bmi] (p= . ) and aht in combination with an elevated bmi (p= . ). no significant associations were found for age (p= . ), sex (p= . ), impaired fasting glucose (p= . ), hyperlipidaemia (p= . ) and cimt (p= . ) . no patients with myocardial infarction and patients with cerebrovascular disease were found. conclusion: wb-mr angiography allows the detection of occult atherosclerotic disease in asymptomatic patients with cardiovascular risk profile especially in cases of aht and/or obesity. : purpose: to evaluate image quality and radiation dose of ultra-low-dose ct examinations of the inner ear performed using adaptive statistical image reconstruction (asir) in infants candidate to cochlear prosthesis implantation. we evaluated infants ( males, females, age - months, mean months) with sensorineural deafness who underwent ct of the inner ear before cochlear prosthesis implantation. out of them, were imaged on a -row ct scanner (discovery ct hd, general electric, milwaukee, wi) using an ultra-low dose protocol ( kv, ma, . s gantry rotation time) and a model-based iterative reconstruction algorithm (asir™), while in the remaining ct had been performed on a -row scanner before the introduction of the -row ct equipment at our institution, using a regular paediatric protocol ( kv, ma, . s gantry rotation time) with conventional filtered backprojection. dose-length product (dlp) values were obtained from dose reports generated from the scanner at the end of each examination. image quality was rated in blind by two radiologists using a likert scale ( =non-diagnostic through =excellent). results: none of the examinations were rated as non-diagnostic. image quality was comparable between the -and the -row ct group ( . ± . vs . ± . , respectively; p= . ). dlp was significantly lower in the -row ct group ( . ± . vs . ± . mgy*cm, respectively; p < . ). conclusion: compared with a regular paediatric protocol, ultra-low-dose ct of the inner ear with asir allows for markedly reduced radiation dose with preserved image quality. traumatic subdural hygromas in children between and years: a retrospective ct and mri study m.l. hahnemann , a. schmeling , m. schlamann , m. forsting , h. pfeiffer , d. wittschieber ; essen/de, münster/de purpose: non-accidental head injuries (nahi) represent a leading cause of death in infants. in this context, the role of traumatic subdural hygromas (sdhy) as possible acute or chronic finding in child abuse, especially in shaken-baby-syndrome, is not well understood and still a matter of debate. by modern imaging techniques, the present study aimed to investigate the characteristics of sdhy. methods and materials: from the years - , we retrospectively analysed the images of all children between and years who were suspected to have a craniocerebral injury and got an initial cranial computer tomography at the university hospital essen. in cases where additional mr examinations existed these mr images were also analysed. all skeletal and cerebral pathologies, demographic data, and, if existing, related clinical anamneses and findings were recorded. all sdhy cases were classified according to both a classification system originally s c a d e f g b is a major cause too (n= ). spearman rho correlations between radiographer's time of experience and frequency of mri exams repetitions were poor and not significant (r= . ; p= . ). the correlations between radiographer's tiredness and frequency of mri exams repetitions were negative, weak and not significant (r= - . ; p= . ). the patients' movement may disrupt the examination or degrade the images with artefacts. the level of experience does not influence the repetitions of mri exams, it seems that senior radiographers do not have improvements in performance as it should be expected. it is recommendable to do training courses regularly to improve the performance and systematically evaluate. several features will need to be identified which would decrease the mri exams repetitions. functional mapping of the visual word form area with frequent words of the portuguese lexicon: an fmri study c. ferreira , p. martins , g. cunha , n. canário , c. nunes , a.c. miranda , j. ribeiro , s. afonso , m. castelo-branco ; coimbra/pt, aveiro/pt (c_dferreira@yahoo.com) purpose: the visual word form area (vwfa), part of the fusiform gyrus in the temporal lobe underlies word form encoding. impairment of this region causes reading deficits, including alexia. the aim of this study is to functionally map vwfa at the individual subject level using frequent words of the portuguese lexicon, to develop a paradigm potentially useful for clinical patients. methods and materials: functional magnetic resonance images (fmri) were acquired in from nine subjects. the visual paradigm used consisted of blocks ( seconds block duration): baseline (checkerboard stimuli), blocks of frequent words and of pseudo-words ( words/pseudowords per block). general linear model analysis was performed using brainvoyager qx to identify brain regions encoding word form. results: an area corresponding to vwfa could be mapped in both hemispheres in all subjects at a statistical threshold of . , corrected for multiple comparisons. seven of the cases had predominant activation in the left hemisphere, one has equivalent activations bilaterally and one subject has predominant activation in the right hemisphere. the number of activated clusters was significantly larger in the left hemisphere at the group level (p = . , wilcoxon signed rank test). conclusion: bilateral activation was replicated in vwfa in all subjects, with a clear left hemispheric dominance demonstrating the robustness of the paradigm, making it potentially useful in a clinical setting, e.g. pre-surgical mapping. a survey of the various methods and techniques employed in myocardial stress testing k. borg grima , l. rainford , p. bezzina , d. o'leary ; msida/mt, dublin/ie (karen.borg-grima@um.edu.mt) purpose: literature suggests a range of pharmacological stress agents and radioactive tracers, together with a variety of defined protocols that may be used in conducting myocardial stress testing prior to cardiac scintigraphy imaging. an online survey was performed to evaluate current practice. methods and materials: a survey was developed comprising of twelve questions, by using 'survey monkey', which aimed to identify the variances present in conducting myocardial stress testing and in clinical protocol details if available. professional groups working in nuclear medicine, such as the medical-physicsengineering community and virtual radiopharmacy, were targeted. access to the survey remained open for eight months. forty-three members, including both radiographers and medical physicists responded from across europe and australasia. spss was used to evaluate the results obtained, based on chi-square tests and comparisons between multiple responses. results: the majority ( %) of the participants were from united kingdom, % from other european countries and % from australasia. in centres pharmacological stress testing was performed either alone or in conjunction with exercise stress testing. the results indicated that % of the participants were aware of local stress test protocols; however, guidelines indicating which patients were not suitable for pharmacological stress tests may require clarification. conclusion: results suggest that for pharmacological stress testing there is a need for increased awareness of protocols, and across all responders the need for improved knowledge and understanding of local protocols was identified. this initial survey justifies further research towards increase protocol compliance and standardisation of practice during myocardial stress testing. templates were built taking into account the age of patients. artefact movements and eddy current distortions were removed. mean diffusivity (md) and fractional anisotropy (fa) were quantified together to the three principal directions of diffusion (eigenvectors) with their own eigenvalues (tensor diagonalization). so analysis of single fibre orientation for each voxel with a bayesian algorithm was executed. voxelwise statistical analysis of the fa, md and axial diffusivity data was carried out using tbss between focal cortical abnormalities sites and normal ones. results: different pattern of cortical organization and white matter projections are evidenced depending of lesional load and extension, site and age. in focal cortical abnormalities the tbss analysis revealed significant differences (p < . ) between affected cortical sites and normal ones. conclusion: different fa data were collected. the reductions of fa, the associated elevation of diffusivity in altered contiguous or distal area are evidenced. : purpose: the magnetic resonance imaging (mri) uses the magnetic field effects to its functioning. this study aimed to clarify the emf directive / /ec discussion which imposes limits to electromagnetic fields (emf) regarding the occupational exposure. methods and materials: it was explored policy documents, regulations, guidelines, laws and other official documents on this subject. to understand the reason of this controversy, the evidence of consequences from the emf exposure over professionals was analysed. from the information obtained an online survey was developed, with national and international coverage, towards professional groups considered involved in the controversy. the opinions were analysed by the force field analysis diagram, through the policymaker k -health™ application to speculate the influences, forces, power and strategies developed in this process. results and conclusion: from respondents % do not know the esr's position, the directive and its contents. % know the safety measures to apply in the mr room and report adverse events for lack of compliance with safety standards, being the levels of sar, the most topic referred. they do not know the limits imposed and have no opinion about the directive's controversy ( %). the political impact is considered neutral ( %) against the negative clinical and economic impacts ( %) that falls over the equipment manufacturers ( %). the professional societies have most decision, followed by physicists, doctors, manufacturers, government decision-makers and health-managers. the manufacturers, radiographers and supervisors have median influence, and the patients have weak influence over this process. on this matter influences and pressure strategies over the european commission and council were recognised. radiographers perceptions of magnetic resonance imaging: a study of the causes that lead to the repetition of exams t.r. filipe , l.p.v. ribeiro , r.p.p. almeida , s.i. rodrigues , k.b. azevedo , c.a. silva , a.f.l. abrantes ; faro/pt, Évora/pt (tiagofilipe__@hotmail.com) purpose: to know how often repetitions of mri exams and sequences occur in radiology departments. a self-applied questionnaire was used as instrument and assigned to radiographers who performed mri exams to determine which were the causes that lead to the repetition. the questionnaires were interpreted and statistically analysed through descriptive statistics and spearman's rho correlation. results: at a % confidence interval, the major results suggest that the patient's movement during the mri exams is the main cause to repeat this exams (mean of . on a -point likert scale). however, there are causes related to the radiographer's and the results showed that the introduction of wrong imaging parameters s a c d e f g results: the percentage of depression among mri technologists included in our sample was found to be % which is considered to be much more than the percentage ( %) found among the dentists in usa ( . %) and among community population in saudi arabia. conclusion: it was found that there is a strong relationship between the incident of depression among mri technologists and the incident is higher among technologists working for more than years. development and implementation of a synthetic data evaluation scenario for image fusion algorithms based on discrete wavelet transform and principal component analysis v. weiss; wiener neustadt/ at (volker.weiss@hotmail.com) purpose: successful image fusion reduces the amount of data without significantly reducing the amount of relevant information. this study aims to answer the question whether the image fusion results were calculated successfully and what successful image fusion actually means. the study presents two new approaches for the quantitative evaluation of image fusion schemes. it provides the development and implementation of a synthetic data evaluation scenario for image fusion algorithms based on discrete wavelet transform (dwt) and principal component analysis (pca). furthermore, it presents a medical application visualising and comparing fused axial ct slices, reconstructed from a ct volume data set with identical position but calculated with different convolution kernels. the study provides a ground truth data-based performance evaluation, as well as a comparison of the dwt and pca to each other by computing and visualising significant differences in their performance. results: in the present study, the dwt, compared to the pca, turns out to be the more powerful and therefore more suitable image fusion method, both qualitatively and quantitatively. conclusion: according to estimates of certain surveyed medical specialists, to whom the results have been shown, a serious diagnosis solely on the basis of fused images is conceivable. the fused images would also be conceivable for documentation purposes and printouts for the referring physicians. finally, storing fused image series instead of individual series would reduce the amount of memory required in long-term archives by half. image registration and fusion of ct and micro-ct of a sheep's cochlea s. leitner; berndorf/at purpose: the sheep's cochlea seems to be most similar to human ones. hence, it is of great interest in the fields of developing cochlea implants and improving operation techniques of electrode implantation in ent-(ear-nose-throat) surgery. methods and materials: for investigating the sheep as a suitable large animal model, data sets of high resolution micro-ct and ct of its cochlea were acquired. the research on inner-ear diseases and ent-surgery methods require image processing methods, such as image registration and image fusion. in this thesis, the micro-ct data set was registered with the ct data set in a common coordinate system using two different software packages. the registration was successful with both types of software. in order to evaluate the results visually, the fused multimodal data were represented by means of colour overlay as well as d rendering techniques. the basis of image-registration of these two modalities was laid and serves as comparison between the image information of the high resolution micro-ct and the conventional ct in order to overcome an interpretation gap between these two modalities. the appropriate d visualisation of the vestibule-cochlea system by means of the highest resolution image devices and medical image processing methods support fundamental research on macro-and micro-mechanical processes of hearing and basic understanding for developing therapeutic and preventive methods for ear diseases. purpose: scout images are essential in neuroradiology. though these images may have limited diagnostic quality, they visualise larger parts of the body. therefore, certain radiologic findings may be visualised only or largely in the scout images and truly constitute unexpected radiologic findings (uf). impact related to spinal location and imaging modality on to the incidence and distribution of uf remains unknown. methods and materials: patients undergoing ct and patients undergoing mri of spinal column between / / and / / are included. uf reported in the original dictations are separated into groups: scout only (i), scout+diagnostic images (ii) and diagnostic images (iii) only. in addition to type of imaging and spinal location, locations and organ system of these findings are recorded. results: there were uf in ct and in mri group. in both groups, patients with uf were significantly older than the ones without uf, with a slight female preponderance. majority of uf in ct were seen in diagnostic images. uf seen only in scout images of ct were exception although these were significant findings. uf distribution in mri was more even. equal numbers of uf were seen in groups ii and iii. approximately % of uf seen in mri were present in group i. conclusion: scout images of neuroradiologic studies may harbour significant number uf. this is especially true in mri where % of uf seen only in scout images. although uf seen solely in scout images of ct is rare, these are predominantly significant findings. comparison of a -channel-with a -channel head coil using snr measurements c. vandulek, d. kaczur, e. vinczen, i. repa; kaposvár/hu (cvandulek@gmail.com) purpose: one of the key attributes characterising the quality of an mri head coil is the signal-to-noise ratio (snr). the purpose of this study was to compare a -channel-with -channel head coil using standardised snr measurements. the measurements were performed on a . t mri scanner. the snr measurements were performed on the coils' phantoms and on volunteers. the snr protocol consisted of axial t fse and t fse measurements. analysis of the snr calculations was performed using roi's positioned in the phantoms and the brain tissue of the volunteers. the results of the snr measurements of the phantoms show that the snr of the -channel coil is double that of the -channel head coil. however, the snr of the volunteers showed only a % increase of snr with the t fse measurement, and a % increase with the t fse on the -channel coil. there were no artefacts observed on either measurements of the phantoms and human volunteers. conclusion: this study confirmed a difference of the snr between the -and -channel head coil. while the phantom measurements showed a twofold increase of snr between the two coils, this rate was not confirmed on the human volunteers. the results of this study amplify the advantage of using the -channel coil for neuroradiological examinations (e.g. fmri, mrs), whereas the -channel coil is sufficient for routine brain examinations. psychological effect of chronic exposure to high magnetic field on mri technologists n.m. mishah, w. hamed; jeddah/sa (nabeel @hotmail.com) purpose: the purpose of this study is to measure the incident of depression among mri technologists since they are chronically exposed to high magnetic fields that may carry occupational hazard on central nervous system and on their brain chemicals. this may cause a long-term psychological side effects such as depression. the data and the statistical information of this project were based on beck depression inventory bdi, version which is used by healthcare professionals as depression screening tool. the questionnaire of depression screening tool was delivered to all mri technologists working in major hospitals within large cities in makkah region. the total completed questionnaire received was and only was accepted with a rejection rate of . %. the received data were analysed using a computer-aided statistical tool then the percentage of depression found among mri technologists included in our study will be compared to previous study conducted on dentists in usa and among community population in saudi arabia. s c a d e f g b conclusion: regorafenib significantly suppressed tumour perfusion and vascularity quantified by dce-ct in experimental colon carcinomas in rats with good to moderate correlations to an immunohistochemical gold standard. tumour response biomarkers assessed by dce-ct might be a promising future approach to a more personalised and targeted cancer therapy. author disclosures: k. nikolaou: research/grant support; bayer healthcare, germany. c.c. cyran: research/grant support; bayer healthcare, germany. contrast-induced nephropathy in patients undergoing intravenous contrast-enhanced computed tomography and the relationship with risk factors: a meta-analysis s.i. moos, j. stoker, s. bipat; amsterdam/nl (s.i.moos@amc.uva.nl) purpose: to summarise the incidence of contrast-induced nephropathy (cin) and to study associations between cin and risk factors in patients undergoing intravenous contrast-enhanced computed tomography (cect). we searched the medline, embase and cochrane databases from till july . two reviewers checked inclusion criteria and extracted data. mean cin incidence and associations between risk factors and cin were pooled by random-effect approach. results: twenty-three articles with , patients (mean age . years, mean egfr at baseline . ml/min) were included. cin was defined as absolute or relative ( . µmol/l/> %) serum creatinine increase, mostly within hours. all studies included a high proportion of patients with risk factors; chronic kidney disease (ckd) in % of all patients, diabetes mellitus (dm) in %, hypertension (ht) in % and congestive heart failure (chf) in %. the mean incidence of cin was . % ( % ci: . %- . %). data analysis showed an increased risk for cin in the presence of dm ((odds ratio . ( % ci: . - . ), p= . )) and ckd ( . ( % ci: . - . ), p= . ). ht and chf were not associated with an increased risk (p= . , p= . ). the mean incidence of cin after cect was . % and is associated with dm and ckd. the incidence of cin is mostly reported in studies with a high proportion of patients with risk factors. therefore, the reported cin incidence and associated risk factors for cect might be overestimated compared to the cin incidence in a general population undergoing cect. purpose: to determine whether contrast agent (ca) dose reduction to one-half and one-quarter of the standardised dosage allows for preserved image quality of renal mr angiography at t. methods and materials: mr examinations were performed in healthy subjects on a t mr system (magnetom t), utilising a custom-built -channel rf body coil. dynamic d flash data sets were obtained pre contrast and sec after the application of contrast agent. examinations were performed at three different time points for injection of three dosages of ca (gadobutrol, bayer healthcare): ( ) . mmol/kg body weight (bw), ( ) . mmol/kg bw and ( ) . mmol/kg bw. contrast ratios (cr) were measured pre and post contrast in the aorta and both renal arteries in correlation to adjacent psoas major muscle. qualitative analysis with regard to delineation of the pre-contrast and post-contrast renal arterial vasculature was performed by two radiologists using a five-point-scale ( =excellent to = non diagnostic). results: non-enhanced t w mri provided an inherently high signal intensity of vasculature, yielding a good overall pre-contrast arterial delineation (mean . ). the application of contrast agent showed improved vessel delineation in qualitative and quantitative analysis for all three dosages, yielding comparable results in subjective ratings of qualitative analysis (mean . gd . ; mean . gd . ; mean . gd mean . ). quantitative analysis of contrast ratios showed only minor increase of mean values with increasing gadolinium dosage (mean . gd . ; mean . gd . ; mean . gd mean . ). conclusion: t ce-mra allows for a significant dose reduction to one-quarter while maintaining high image quality. diagnostic accuracy of dynamic gadoxetic-acid-enhanced mri and pet-ct in patients with liver metastases from neuroendocrine neoplasms purpose: to evaluate the diagnostic accuracy of dynamic gadoxetic-acid-enhanced mri parameters in comparison to standardised uptake values (suv) from both patients with proven liver metastases of neuroendocrine neoplasms (nen) up to three regions of interest (rois) were defined in metastases (> cm) and liver tissue in morphological images. corresponding rois were defined in the dce-mri dataset and in the pet-ct dataset. diagnostic accuracy for all perfusion parameters were evaluated for the differentiation between metastases and liver tissue: arterial and venous plasma flow (apf and vpf), extracellular mean transit time (exmtt), extracellular volume (exvol), intracellular uptake rate (ur) of gd-eob-dtpa and arterial flow fraction (aff) as well as suvs derived either from f-fdg or from ga-dotatate-pet-ct. results: area under the curve for different dce-mri parameters was between auc= . (extracellular mean transit time) and . (arterial plasma flow -sensitivity: . %, specificity: . %, cut-off value: . ml/min/ ml). sensitivity and specificity of suvmean derived from ga-dotatate were . % and . %, respectively (auc = . ). suvmean derived from f-fdg-pet-ct showed a sensitivity and specificity of . % and cp class liver damage groups. chi square test was used for statistics and p < . was considered statistical significant. results: in poor hbp cases (n= ), er of hbp and sdp were . ± . and . ± . . in control cases (n= ), er of hbp and sdp were . ± . and . ± . . er of hbp and sdp in cp-a poor hbp (n= ), cp-b poor hbp (n= ), cp-c poor hbp conclusion: in most of the poor hbp image cases, sdp image improve parenchymal and vascular contrast except cp-c liver damage cases results: we found characteristic signal criteria in all analysed plaque components. applying these criteria gb-pci had a good sensitivity for the detection of fc/nc, iph and ca (all > %) and excellent specificity and accuracy (all > %) with good inter-reader agreement ([[unable to display character: &# ;]]³ . , p < . ). there were excellent correlations for quantitative measurements of fc, nc and ca between gb-pci and histopathology (r³ . ). inter-reader reproducibility was excellent with icc³ . for all measurements. conclusion: gb-pci can identify and quantify atherosclerotic plaque components in a lab-based set-up with excellent correlation to histopathology. imaging of the therapeutic efficiency of photodynamic therapy with a new designed fluorescence optical annexin probe k. haedicke, s. gräfe, f. lehmann, w.a. kaiser, i. hilger; jena/ de (katja.haedicke@med.uni-jena.de) purpose: photodynamic therapy (pdt) destroys tumour tissue via generating reactive oxygen species after administration of a photosensitizer and illuminating the tumour with light. next to many other molecular processes, apoptosis occurs in the tumour after this therapy. we designed a new fluorescence optical probe based on annexin v to detect this therapeutic effect after pdt in vivo via non-invasive near-infrared fluorescence optical imaging. methods and materials: annexin v was labelled with the near-infrared dye dy- -nhs and characterised spectroscopically. binding affinity of the probe to apoptotic tongue-squamous epithelium carcinoma (cal- ) cells was analysed by purpose: to evaluate the potential of the reconstruction algorithm idose to preserve image quality in brain-ct acquired with % reduced radiation dose and to evaluate image quality assessment methods. interaction of magnetically labelled multipotent mesenchymal stromal cells and e-/p-selectins monitored by magnetic resonance imaging in mice j. salamon, k. peldschus, d. wicklein, c. lange, h. ittrich, u. schumacher, g. adam; hamburg/ de (j.salamon@uke.de) purpose: this study's purpose was to analyse the influence of e-and p-selectins on the migratory pattern of magnetically labelled multipotent mesenchymal stromal cells (msc) in e-/p-selectin deficient (ko) and wildtype (wt) mice using mri and fluorescence microscopy. methods and materials: murine msc were labelled with fluorescent iron-oxide micro-particles and carboxyfluorescein succinidylester. the ability to bind selectins and the expression of typical msc markers were assessed by flow cytometry. labelled msc were injected into ko-and wt-mice applying doses of × cells intracardially, × cells intravenously and × cells intraperitoneally. mice underwent sequential mri at . t using high-resolution t * d and d coherent gradient-echo sequences and histological evaluation after days. results: expression of typical msc markers and binding abilities to e-/p-selectins were found similar after labelling. after intravenous cell injection in ko-mice significant snr decrease was assessed solely in the liver from day to ; wt-mice revealed an increasing snr decrease of liver, spleen and bone marrow within days. after intraperitoneal injection no significant snr changes were observed in ko-mice; wt-mice showed an increasing snr decrease of liver, spleen and bone marrow within days. after intracardiac injection multiple susceptibility artefacts could be detected no longer then day in ko mice but persisted up to day in wt-mice. fluorescence microscopy confirmed mri findings. conclusion: this study demonstrates that msc retain their binding ability to e-/p-selectins after magnetic labelling. e-/p-selectin deficiency in mice significantly alters the distribution of magnetically labelled msc. de (holger.haubenreisser@medma.uni-heidelberg.de) purpose: to prospectively compare the image quality of cranial computed tomography (cct) with thin slice widths using traditional filtered back projection (fbp) and sinogram-affirmed iterative image reconstruction (safire). methods and materials: consecutive studies ( men; . ± . years) referred for cct were prospectively included. each cranial ct raw data set was reconstructed with fbp and safire with decreasing slice widths ( mm- mm). objective image quality was assessed by measuring image noise in three predefined regions of the brain (white matter, thalamus, cerebellum) using identical regions of interest (rois). subjective image quality was assessed by experienced radiologists by ranking the reconstructed data sets with respect to overall image quality. the mann-whitney u-test and cohen's kappa were used for statistical analysis. results: image noise was statistically significantly reduced in all safire images at identical slice widths when compared to the images reconstructed with fbp ( . ± . hu vs. . ± . hu at mm slice width) (p < . ). mean signal attenuation for each region and slice width remained constant between the two reconstruction methods (p> . ). snr was comparable between mm safire images and mm fbp images. subjective image quality of safire images was rated consistently higher than that of the fbp images (p < . ). interobserver agreement was excellent between both radiologists (cohen's k = . - . ). conclusion: iterative image reconstruction significantly reduces image noise, while increasing image quality. in cct this may be used to decrease slice width and thus reduce partial volume effects, which may lead to increased diagnostic accuracy. purpose: the aim of our study is to demonstrate the effectiveness of d mri in the diagnosis of lumbar radiculopathy in comparison with clinical and neurophysiological data. methods and materials: patients with l or s monoradiculopathy caused by a posterolateral or intraforaminal disk herniation underwent mri examination after preliminary clinical assessment and electromyography (emg). we performed conventional spin-echo and d coronal ffe sequences with selective water excitation (proset imaging). using d coronal ffe sequences indentation, swelling and tilting angle of the nerve root were evaluated. the tilting angle was compared with the asymptomatic contralateral side of the nerve root. all the data were processed using epi info . software (cdc, atlanta, ga, usa) and were compared by means of fisher exact test. results: proset sequence revealed abnormal tilting angle in patients ( . %; p < . ), monolateral swelling or indentation of roots and spinal nerves in patients ( . %; p < . ). in patients emg demonstrated an involvement of more than one nerve roots, whereas the proset revealed only one involved root. in patients the nerve alterations were revealed only by emg. conclusion: emg has an improved ability to highlight the early changes of the roots caused by mechanical and biochemical alterations due to compression. proset imaging demonstrates high sensitivity in identifying the exact level of the involved root and can provide a useful tool to plan surgical treatments. purpose: to investigate the utility of dti in detecting nerve injury or neuropathic changes in proximal nerve segments in patients with peripheral neuropathy. methods and materials: twenty-four age-matched individuals with (n= ) and without (n= ) peripheral neuropathy underwent dti of a defined sciatic nerve segment. patients and controls were evaluated by clinical examination and nerve conduction studies at baseline and six months after the initial dti scan. four patients were scheduled for a second scan six months after the initial mri. results: the mean fa value was significantly lower in sciatic nerves from patients with peripheral neuropathy as compared to controls. sciatic nerve fa values positively correlated with clinical disability scores and electrophysiological parameters of axonal damage, i.e. the compound muscle action potential amplitudes of the peroneal and tibial nerve at baseline and six months after mri scan. no correlation was found with axial and radial diffusivities. conclusion: dti-derived fa values are a sensitive measure to discriminate healthy from functionally impaired human sciatic nerve segments. this technique might be potentially useful in estimating the proximal axonal degeneration burden in patients with peripheral neuropathies. purpose: the purpose is to describe the imaging features of the involved brainstem and spinal cord tracts in cases of leukodystrophy with brainstem and spinal cord involvement and brain lactate elevation (lbsl). the importance of craniovertebral and cervicomedullary angle on cervicogenic headache g. Çoban , i. Çöven , e.b. Çifçi , e. yıldırım , c.a. yazıcı , b. horasanlı ; konya/tr, ankara/tr (drgokcencoban@gmail.com) purpose: many studies indicated that cervicogenic headache (ch) may originate from cervical structures innervated by the upper cervical spinal nerves and the trigeminal nerve branches. studies to date have not investigated whether the narrowing of the craniovertebral angle (cva) and cervicomedullary angle (cma) affects the nerve branches and causes pain. the aim of this study was to investigate the effect of the narrowing of the cva and cma values on the occurrence ch. methods and materials: between january and may , patients with the diagnosis of ch were included in the study. the pain scores in patients were carried out using a visual analogue scale from to (pain groups purpose: to assess the image quality after image-based processing of low-dose single-rotation intra-procedural d-fd-ct (sr d-fd-ct). multiple rotation contrast-enhanced d-fd-ct is associated with many c-arm projections (~ projections) and a high amount of contrast agent (ca). in this feasibility study, we used a single-rotation of the c-arm (artis zee biplane, siemens ag, healthcare sector, germany) accompanied by cardiac pacing acquiring a reduced number of low-dose projections (~ - purpose: to demonstrate that myocardial microvessels detection is feasible at high-resolution susceptibility-weighted mr imaging (swi). methods and materials: fourteen wistar rats underwent ex vivo cardiac mr imaging on a . tesla scanner using a cryogenic device. thin, tubular hypointensities within the myocardium of normal rat hearts at high-resolution susceptibility-weighted mr imaging (group , n= ) were presumed to be intramyocardial microvessels.to prove that these "strand-like" structures were microvessels, a reference map of the myocardial macrovessels (group , n= ) after direct intracoronary injection of barium sulphate, a viscous contrast media was defined. then, a superparamagnetic contrast agent (ferumoxsil, lumirem ®), an intravascular contrast agent, was injected to stack up the distribution of intramyocardial microvessels (group , n= ). for groups and , d fast imaging with steady state in precession ( d fisp) sequences was performed. the results of images in group (spatial resolution: μm) and group (spatial resolution: x x μm ) were qualitatively compared. results: after intracoronary artery injection of barium sulphate, the main coronary arteries were visible up to the third-order branches (group ). beyond this level, the coronary microvasculature was opacified with ferumoxsil (group ) as demonstrated by the presence of ferumoxsil inside the microvessels on mr-matched histological sections. the regional distribution of microvessels was similar between groups and . conclusion: myocardial microvessels appear as "strand-like" structures on highresolution mri without injection of contrast media. this provides new methods for evaluation of neovascularization in preclinical models of myocardial infarction. purpose: to prospectively compare the image quality and homogeneity of cardiac t -weighted dark blood images using a dual-source parallel radiofrequency (rf) transmission mr system with rf shimming at . t and conventional mr imaging at . t. methods and materials: dual-source parallel rf transmission . t mr system with local rf shimming was used to obtain t -weighted dark blood images in patients and compared with standard mri at . t. snr was determined in the interventricular septum (is), the lateral wall (lw), the right ventricular cavity (rv) and left ventricular cavity (lv) in the anterior wall (aw), posterior wall (pw) and in the left ventricular cavity (lv) in two-chamber orientation. (kerstin.bauner@med.uni-muenchen.de) purpose: to assess dynamic t shortening effects of equimolar doses of gadobutrol and gadoterate meglumine in myocardium and the effect on extracellular volume fractions (ecv) in an animal model. methods and materials: rabbits underwent cardiac mri under general anaesthesia on a . tesla scanner using an -element knee coil. exams included ssfp cine imaging as well as pre-and post-contrast myocardial t -mapping using a modified look locker inversion recovery (molli) technique. each animal was scanned twice with a -h interval after receiving either . mmol/kg gadobutrol methods and materials: twenty-five breast lesions classified suspicious in mammography or ultrasound (birads / ) were included in this prospective irb-approved study. all patients underwent t mri (siemens magnetom, erlangen, germany) using a dedicated -channel breast coil and a high temporal and spatial resolution d t -weighted sequence (twist, fat-sat, . mm isotropic, temporal resolution sec, examination time min) with a single dose of contrast agent (dotarem, guerbet). one patient had to be excluded due to insufficient data quality. two readers trained in different institutions independently assessed lesion morphology and enhancement kinetics and classified them according to bi-rads. lesion size, localisation and image quality were assessed. sensitivity, specificity, diagnostic accuracy and interrater agreement (kappa statistics) were calculated for both observers. the histopathological diagnoses were used as the standard of reference. results: there were three benign and malignant lesions. mean histopathological size was mm (range - mm). on the basis of lesion morphology and enhancement patterns, all lesions were correctly classified as benign (n= ) and malignant (n= ) by t ce-mri. sensitivity, specificity and diagnostic accuracy were %. interrater agreement for bi-rads ratings was excellent ( . ). kappa agreement for single bi-rads descriptors ranged between . and . conclusion: high spatial and temporal resolution imaging in clinical practice is feasible using t mri, revealing excellent diagnostic accuracy and interrater agreement. purpose: to study a potential role of quantitative mri (qmri) using t /t ratios to differentiate benign from malignant breast lesions, assess contralateral breast involvement and monitor response to treatment. a cross sectional study of women with breast lesions were scanned with the mixed-tse pulse sequence, which is multispectral in t and t , therefore, affords maps of t /t . patients were grouped according to histopathological stage of disease: untreated malignant tumor, treated malignancy and benign disease. qmri assessment of the same quadrant of contralateral breast that did not have cancerous lesion was performed and compared to the breast that was subjected to chemotherapy and/or radiation therapy in order to monitor response to treatment. results: elevated t /t means of . ± . (n= ) were observed for biopsy proven malignant lesions and . ± . (n= ) for malignant lesions that were treated prior to qmri with chemotherapy and/or radiation as compared to . ± . (n= ) for benign lesions. the higher stage of cancer determined by histopathology analysis was also strongly associated with higher t /t ratio (p= . ). estrogen and progesterone receptors negative status was strongly correlated with higher t /t ratio p= . and p= . , respectively. her /neu receptor status showed no significant correlation with t /t ratio (p= . ). the t /t ratios provide measures that strongly correlate with histopathological findings. this quantitative information of tissue properties can provide basis for improving the specificity of diagnostic breast imaging and serve as a tool to assess response to treatment and contralateral breast involvement. improved differentiation of breast tumours using novel imaging system based on co-registered opto-acoustic tomography and ultrasound p. otto , k. kist , n.c. dornbluth , t. stavros , d. herzog , b. clingman , j. zalev , p. lavin , a. oraevsky ; san antonio, tx/us, southborough, ma/us, houston, tx/us (ottop@uthscsa.edu)purpose: a novel system called imagio combines ultrasound and opto-acoustics (oa) to more accurately distinguish malignant from benign tumours. we analysed readers' ability to assess probability of malignancy (pom) using oa versus conventional diagnostic ultrasound (dus) alone. methods and materials: patients with breast masses were assessed with oa and dus. all the masses were biopsied. histology was the gold standard. oa employs near-infrared laser pulses at two different wavelengths (to provide contrast between oxygenated haemoglobin in benign lesions and de-oxygenated haemoglobin in malignant lesions) to illuminate tissues through a fibreoptic bundle incorporated into a prototype duplex hand-held ultrasound probe. it detects the laser-generated ultrasonic pressure waves that are then used for reconstruction of two-dimensional oa images. oa maps of total haemoglobin and blood oxygen purpose: to assess metabolic imaging of breast tumours with breast f-fdg pet-ct and compare it with t ce-mri. methods and materials: suspicious breast lesions were included in this irb-approved prospective study. all patients were examined with f-fdg pet-ct and t ce-mri of the breast. the mri protocol consisted of a t -w and a contrast-enhanced high-resolution d-t -w sequence with a single dose of contrast agent (dotarem®, guerbet). all patients were subjected to prone f-fdg pet-ct scanning. ct data were used for attenuation correction. breast pet-ct was assessed for f-fdg-avidity of lesions. tumours were classified as positive when f-fdg-uptake was greater than blood-pool activity. lesions within tissues demonstrating moderate/high physiologic background activity were considered positive if the activity was greater than the adjacent physiologic activity. t ce-mri was assessed for lesion morphology and enhancement kinetics and classified according to bi-rads®. all lesions were histopathologically verified. results: pet-ct had a sensitivity of %, a specificity of % and diagnostic accuracy of %. ce-mri had a sensitivity of %, a specificity of % and a diagnostic accuracy of %. there were benign and malignant lesions (mean lesion size . mm; range - mm). the false-negative lesions in pet-ct were small lesions (mean . mm), had a very low suv (mean suvmax . ) or were adjacent to tissue with high physiologic activity or low grade idcs. conclusion: t ce-mri is superior to pet-ct for assessment of breast lesions, but dedicated breast pet-ct is a valid alternative in patients, who are unsuitable for mri. high spatial and temporal resolution breast imaging at purpose: to validate a contrast-enhanced (ce) combined high spatial and temporal resolution imaging protocol for the assessment of breast tumours at tesla in clinical practice. the aim was to evaluate the safety and efficacy of cra as local therapy for breast carcinomas with bone metastases. methods and materials: sixteen cra breast lesions, mean size . (range . - . cm) in thirteen consecutive patients, mean age ( - ) with core-needle biopsy-proven breast carcinoma and bone metastases were enrolled in this study. patients had one lesion and three patients had lesions. under local anaesthesia and mild conscious sedation, the tumour and surrounding breast tissue were ablated with percutaneous ct-guided cra. cryoablation consisted of cycles each of minutes of freezing followed by a -min active thawing phase and a -min passive thawing phase for each one. ten patients underwent one cra session and two patients cra sessions. one patient is treated with two sessions for the same lesion. results: all cra sessions were successfully completed and all breast tumours were ablated. morbidity consists in transient and mild ecchymotic changes and post-procedural oedema seen in two cases and alteration in skin pigmentation seen in the point of insertion of the cryoprobes in other two cases. the therapeutic outcomes were evaluated by contrast-enhanced tc or mri at -, -and -month interval. purpose: stereotactic vacuum-assisted biopsy (vabb) is the first choice technique to characterise suspicious microcalcification clusters; however, considerable proportion of understaged invasive cancer (idc) at subsequent surgical histology has been reported. bles, thanks to a radiofrequency excisional system, remove a larger not fragmented histological sample ( x mm, weight g). our aim was to prospectively assess bles diagnostic and eventually therapeutic efficiency in a selected cohort of patients with suspicious microcalcification cluster. methods and materials: from september , patients with small microcalcification cluster, < cm, staged a- b according to bi-rads classification system, were proposed for excisional biopsy with bles. written informed consent was obtained.results: up to now, patients underwent bles at our centre; of them ( %) had malignant lesion, were idc and ( %) in-situ (dcis) carcinoma. rationale of the study was to completely remove microcalcification clusters, obtaining enough surrounding tissue for histological margins' evaluation. complete histological concordance was obtained in % of atypical hyperplasia. all patients with dcis underwent surgical excision: upgrading to idc resulted in only / ( % underestimation proportion); among dcis cases, surgical excision demonstrated complete removal of the lesion by bles in / patients ( %). conclusion: in our experience, bles is a valid, simple and safe alternative to vabb, providing better diagnostic performance evaluated as histologic accuracy with lower underestimation rate compared to previously reported for vabb. in selected cases, particularly in small microcalcification clusters, bles may represent an interesting new therapeutic strategy considering the high rate of complete lesion removal. purpose: the objective of the study is to assess the use of "intact" breast lesion excision system as the primary method for histopathology diagnosis in suspicious small and borderline lesions as well as the unclassified microcalcifications. methods and materials: cases were included (feb-august ). inclusion criteria: small lesion less than mm, unclassified microcalcifications, asymmetric densities, focal distortion. results: cases were successfully done, . % ( / ) cases were done under ultrasound guidance and . % ( / ) cases were done under stereotactic guidance. . % ( / ) lesions were removed using the mm probe and . % ( / ) lesions were removed using the mm probe size. the main indication was complete removal of a small mass ( / ) followed by biopsy of unclassified microcalcifications, either without mass ( / ) or associated with a mass ( / ). asymmetry and distortion were the indications in ( / ) and finally clustered micro cysts ( / ). as regards the histopathology after total excision; . % ( / ) of lesions were benign and only . % ( / ) of lesions were malignant. fibroadenoma was the commonly encountered benign lesion in the study group, it was encountered in . % ( / ), followed by papilloma found in . % ( / ), followed first experiences with a self-test for dutch breast screening radiologists as a quality assurance tool j. timmers , a. verbeek , r. pijnappel , m. broeders , g. den heeten ; nijmegen/nl, utrecht/nl, amsterdam/nl (j.timmers@lrcb.nl)purpose: to evaluate the use of a self-test as a quality assurance tool for screening radiologists in the dutch breast cancer screening programme. methods and materials: screening radiologists were invited to voluntarily complete a test set of screening mammograms. the following grading criteria were assigned regarding the most suspicious lesion: location, level of suspicion, bi-rads, laterality, type (well defined mass, ill defined mass, spiculated mass, microcalcification clusters, architectural distortion and asymmetric density) and mammographic density are assigned. also, several reader characteristics, such as years of experience and number of cases read per year, were to be completed. case and lesion sensitivity and specificity were determined for all readers. the spearman correlation coefficient was used to determine correlation between reader characteristics and performance measured by the area under the receiver operator characteristics (roc) curve (auc). results: radiologists completed the test set ( %). the mean age was (range - ) and on radiologists read on average , (range - , ) screening mammograms per year. the median auc value was . , case sensitivity %, lesion sensitivity was % and specificity %. the auc was not correlated to reader characteristics. the test-set revealed interobserver variation in assigning lesion types. conclusion: overall, a good performance was seen among all screening radiologists. readers are able to determine their educational needs and compare it with peers during training or audits. it is therefore a useful quality assurance tool. medical education should be dedicated to reducing interobserver variation. transition from analogue to digital screening mammography significantly increases the proportion of women referred twice for the same lesion l.e.m. duijm, h. wiersma; eindhoven/nl (lemduijm@hotmail.com) to determine the effect of transition from analogue to digital screening on the proportion of women referred twice for the same lesion and to assess screening outcome. we included , consecutive analogue screens (obtained between january and april ) and , consecutive digital screens (obtained between july and july ). review of the screening mammograms of women who had been referred twice was performed to determine whether their initial and second referral comprised the same lesion. during -year follow-up, radiology reports, surgical correspondence and pathology reports of each referred woman were collected. results: the overall positive predictive value (ppv) of referral was . % at analogue screening and . % at digital screening (p < . ). among women who had only been assessed by analogue screens, ( . % of referrals) had been referred twice for the same lesion. these referrals included malignancies (ppv . %). among the , women who received their first digital screen following one or several previous analogue screens, ( . % of digital referrals, p < . ) were referred again for a lesion for which she had been referred previously at analogue screening. these second referrals included malignancies (ppv . %, p= . ). conclusion: implementation of digital screening significantly increased the proportion of women referred twice for the same lesion. their ppv was significantly lower than the one found in women who had been referred repeatedly for the same lesion during analogue screening. purpose: to determine the impact of audits as a quality assurance tool to improve breast cancer screening performance. the dutch centrally organised breast cancer screening programme offers biennial mammography to women aged - years. a team of the national expert and training centre for breast cancer screening with peer radiologists conducts audits of all reading units every years as part of the quality assurance programme. data on screening outcomes are assessed and a on statistical significance and clinical relevance are: age, mass, calcifications, parenchymal deformity and asymmetric density. conclusion: with our nomogram we developed a tool to assist screening radiologists in determining the chance of malignancy based on mammographic findings. we propose cut-off values for assigning bi-rads categories in the dutch screening setting based on our nomogram which will need to be validated in future research. these values can easily be adapted for use in other screening programmes. purpose: automated d-breast ultrasound (abvs) is investigated as a six-monthly addition to annual breast cancer screening with mri+mammography (mm) in highrisk women (ltr> %). abvs, an inexpensive radiation-free technique, allows more frequent screening and temporal comparison. this study assesses effects of additional abvs examinations at baseline. the study population consists of women in whom abvs and mm were performed on the same day. all abvs and mm examinations were read by one of breast radiologist. the recall rate (rr), biopsy rate (br), cancer detection rate (cdr), sensitivity and specificity of abvs and mm screening were analysed. results: based upon mm, patients were recalled for further examination (rr= %). with abvs of these patients were also recalled, as well as other women. consequently, the rr increased to / . biopsies were deemed necessary in patients after mm and increased to with abvs added, an increase from %- %. additional abvs findings were resolved with targeted ultrasound. in total cancers were found by mm (cdr . %, sensitivity %, specificity %). two of these cancers were also detected by abvs (cdr . %, sensitivity % specificity %). the two missed cancers were retrospectively visible, but misinterpreted due to post-operative scarring. conclusion: adding abvs to high-risk mm screening increased rr and br at baseline. whether these negative effects are reduced when radiologists gain more experience and whether they are balanced by earlier detection of breast cancer due to the six-month interval of abvs remain to be determined.radiological review is performed ( interval cancers, screen detected stage-ii cancers and consecutive recalled cases). the audit is completed with a report, summarising the results and giving recommendations. this study compares four audit series ( - / - / - / - ) . results: recall rates (subsequent screens) increased from , , to per , respectively, in the four series. detection rates also increased from . , . , . to . per . distribution of tumour size and lymph-node status of invasive tumours remained stable (p= . ). the percentage interval and screen-detected stage ii cancers classified as "missed" during the review did not change ( % to %, p= . ). review of consecutive recalled cases showed an increasing number of cases the audit team would not have recalled with a higher recall rate of the screening radiologists. conclusion: we found audits are helpful in controlling the balance between (false positive) recalls and detected breast cancers. it also serves as a learning and feedback tool as it triggers discussion between screening radiologists. overall, it can be seen as an important quality assurance tool. purpose: according to current dutch guidelines, all women following a positive screening mammogram are referred for a full hospital assessment including surgical outpatient clinic and radiology department. till , all women with a positive screening mammogram in our screening region were only referred for further assessment to our radiology department. purpose of this study was to determine how often surgical consultation in women with a positive screening mammogram could be avoided by a radiological pre-assessment. methods and materials: all women with a positive screening mammogram, n= , referred to our radiology department from to were included. data were prospectively collected by a senior breast radiologist. in-hospital follow-up data were available till september . descriptive statistics were used. percentage of patients only assessed by a radiologist was determined. negative predictive value for malignancy was calculated from the in-hospital follow-up. results: of women ( %) were only assessed at the radiology department without further surgical consultation. during follow-up, of these women ( %) developed a malignancy in the same breast. at least of these malignancies were located at a different location than the original screening findings which led to the initial referral. the estimated negative predictive value for malignancy was . %. conclusion: by referring women with a positive screening mammogram to the radiology department for a pre-assessment, a surgical consultation was avoided in %, with an estimated negative predictive value for malignancy of . %. purpose: to determine the ability of t mapping of liver on gd-eob-dtpaenhanced mr imaging (mri) for estimating liver function and to compare the estimated liver function to the model for end-stage liver disease (meld) score. methods and materials: patients underwent gd-eob-dtpa-enhanced mri on a t system. patients were classified into two groups: meld score < (n= ) and meld score ³ (n= ). two turboflash sequences (ti = ms, ms) were acquired before and minutes after gd-eob-dtpa administration to obtain t maps. t relaxation times were determined indicating gd-eob-dtpa liver-uptake and correlated to the meld score. results: significant changes between t relaxation times of non-enhanced mri ( ms ± ms) and gd-eob-dtpa-enhanced mri ( ms ± ms) were observed (p < . ). t relaxation time for non-enhanced mri showed no significant differences (p= . ) between the group with meld score < ( ms ± ms) and the group with meld score ³ ( ms ± ms). after administration of gd-eob-dtpa t relaxation time of patients with meld score < ( ms ± ms) and patients with meld score ³ ( ms ± ms) shows a significant difference (p= . ). the shortening of t relaxation time was significantly lower for patients with a higher meld score (p= . ). conclusion: patients with advanced liver disease showed significantly lower changes in t mapping. therefore, evaluation of changes in t mapping of the liver parenchyma may serve as a useful method to determine whole liver function, to improve the estimation of segmental liver function and finally to define the grade of liver disease. liver dysfunction induced by amiodarone therapy: evaluation by sequential ct studies y. sonoyama, t. tajima, t. shiga, n. hagiwara, s. sakai; tokyo/jp (y-sonoyama@rad.twmu.ac.jp)purpose: to evaluate the relationship between the sequential changes of ct attenuation of the liver (ctl) and liver damage after administration of amiodarone (amd) for treatment of refractory ventricular arrhythmias. this was a retrospective study of patients ( men, women: age range - , mean ) with amd administration. serum level of drugs (amd and desethylamiodarone (d-amd), a metabolic product of amd), the percentage of rises in serum alanine transaminase (alt) level (alt%) and total administered dose of amd at evaluation ct were evaluated and compared with the ctl. as regards to patients who underwent ct before the initiation of amd administration, the medication periods and total administered doses of amd were compared with changes in ctl.results: there was a mild correlation between ctl and mean medication period (p= . , r= . ). there was a strong correlation between ctl and serum level of amd (p < . , r= . ), whereas there was a moderate correlation between ctl and serum level of drugs (amd) (p < . , r= . ). there were significant correlations between total doses of administered drug and the ctl (p= . , r= . ) and between alt% and the ctl (p= . , r= . ). conclusion: ctl was demonstrated to correlate with total administered doses of amd, alt%, medication periods and serum level of drugs, especially of d-amd. serial changes in ctl can be a sensitive less-invasive biomarker in patients treated with amd. the estimated population dose per caput is msv, which is lower than corresponding dose in usa ( msv) or in australia ( . msv). the highest average contribution is from ct, %. from plain radiography, fluoroscopy and interventional radiology the proportional fractions are %, % and . % respectively. from diagnostic nuclear medicine procedures, the estimated mean effective dose per caput is . msv. heart and bone examinations contribute % and %, respectively. conclusion: there were high variations between countries in frequencies (for example, in thorax radiography about ten-fold between spain or portugal and germany) and typical effective doses (for example, in ct head four-fold between denmark and luxembourg). this presentation will review the available data in europe using graphs in which countries can be identified. furthermore, the procedures contributing most to the population dose are highlighted. purpose: to assess the feasibility of the volumetric estimation of the left liver lobe, with d ultrasound, with mri comparison and surgical specimen. methods and materials: the data of consecutive patients referred for giving their left liver lobe to a child were reviewed (living donor transplantation program). the measurements of the d volumes of the segments ii and iii were performed retrospectively with comparison of the same evaluation performed with mri (the reference and routine technique for the preoperative assessment of the liver size). all the examinations were done twice by experts radiologists and radiologists in training. the results were statistically analysed (variance test, gage r&r and bland-altman). d and mri measurements were compared and related to surgically proved volume quantification. results: intra-and inter-observators reproducibility was poorly conclusive (for us and mri): gage r&r analysis is related to a prr of % for us and % for mri. bland-altman analysis was giving an underestimation of volume measurements with us (bias from - ml to - ml). agreement limits (- . sd to + . sd) for the observators were included between - . ml and + ml (from - . % to + . %). conclusion: correct estimation of the left liver lobe volume performed with d or mri is related to a low repeatability and a low reproducibility for both techniques. bland-altman analysis is also related to significative differences of volume measurement in both techniques. an accurate formula for a quick estimate of liver volume in polycystic liver disease m. chrispijn, t.j.g. gevers, j.p.h. drenth; nijmegen/nl (melissachrispijn@gmail.com)purpose: polycystic liver disease (pld) patients have severe hepatomegaly. primary aim of treatment is total liver volume (tlv) reduction. the gold standard to assess tlv is ct volumetry which involves manual delineating of the liver outline. this is time consuming and requires expertise. there is a clear need for an easy and fast approach to estimate tlv in routine practice. methods and materials: all pld patients with ³ ct scan were considered for inclusion. we measured the liver in transverse (t), anterioposterior (ap) and craniocaudal (cc) directions and performed ct liver volumetry. we had access to an inception and a replication cohort. we performed multiple linear regression to predict tlv using the three dimensions in the inception cohort. liver volumes were transformed logarithmically. the goodness of fit of the prediction model was assessed and stated as r . finally, we validated the prediction model in our replication cohort. results: the inception cohort included pld patients (median tlv ml (range - ml)). all three diameters were significantly correlated with tlv (p < . ). the linear regression model resulted in the following formula: predicted tlv = , +( . *t)+( . *ap)+( . *cc). our model predicted tlv accurately in the inception cohort (r = . adjusting and measuring ct dose in severely obese patients r. marcus, f. bamberg, k. neumaier, m.f. reiser, t.r.c. johnson; munich/ de (roy.marcus@med.uni-muenchen.de) purpose: ct in morbidly obese patients remains a challenge with respect to dose and image quality. automatic adaptation of parameters results in high dose length products which do not reflect the actual dose due to the shielding by the fat. aim of this study was to determine the actual dose and image quality. methods and materials: an alderson phantom was equipped with thermoluminiscent detectors. scans were performed using three set-ups: (i) 'obese' phantom in -cm circumferential fat (simulating cm/ kg patient) with a dual--source protocol at x kvp with current modulation; (ii) obese phantom with automatic potential and current modulation; (iii) slim phantom with automatic potential and current modulation; dose was calculated according to ircp- and based on dlp. image quality was assessed subjectively and by image noise. patient-specific whole body voxel model for accurate monte carlo ct dose estimation n. saltybaeva, y. smal, d. kolditz, w. kalender; erlangen/ de (natalia.saltybaeva@imp.uni-erlangen.de) purpose: the accuracy of ct dose estimates based on monte carlo (mc) techniques is limited as data is only available for the scanned volume. the purpose of this study was to generate and to validate whole body voxel models using the patient ct images extended by established voxel phantoms. methods and materials: measurements were performed on a somatom definition flash scanner (siemens, forchheim, germany) using the anthropomorphic rando-alderson phantom. the absorbed dose was measured using a set of calibrated thermoluminescent dosimeter (tld) chips for thorax protocols with tube voltage of , and kv. whole body voxel models were built as a combination of the patient ct images and the icrp adult male reference voxel phantom. mc simulations were performed using the impactmc software (ct imaging gmbh, erlangen, germany) for only the scanned volume and for the combined whole body model. measured and simulated dose values were compared for each tld chip. results: at kv, the dose values obtained by mc simulations based on only ct images differed from tld measurements by % on average with a maximum difference of % for the border slices, while the whole body model allowed for a mean difference of %. the difference between measured and calculated results was reduced by %, % and % for , and kv, respectively, when using the whole body voxel model instead of the ct-scanned volume only. the proposed whole body voxel model for monte carlo simulations significantly improves the accuracy of patient-specific ct dose estimates. purpose: accurate patient dose estimation using ct imaging is important particularly as the modality is being increasingly used. body habitus varies and the use of monte carlo simulations for "standard man" phantoms does not provide accurate dose estimation for non-standard patient sizes. the study proposes an algorithm for dose estimation for an individual patient from simulated data from mathematical phantoms. the algorithm interpolates doses simulated for ornl mathematical phantoms accounting for differences on patient and phantom sizes. four patient models were produced using anthropomorphic phantoms (representing -and -year-old children) with and without an additional fat-equivalent layer. all phantoms were scanned at and kv (trunk protocol). doses were measured with tld dosimeters. additionally, dicom images were segmented for organs and data were used as input for dose simulation. all simulations were performed with validated tool (impactmc). doses for phantoms and patients were estimated from the mc simulations using the proposed algorithm. calculated and measured doses were compared. the algorithm improved accuracy in dose estimation by , , , and % for small thin, small thick, large thin and large thick phantom sizes, respectively, compared with estimates based on ornl phantoms only. for patient data the accuracy in lung dose estimates improved from to %, and from to %, for -and -year-old patients, respectively. conclusion: the proposed algorithm improves dose estimation accuracy for individual paediatric patients. it is simple and suitable for implementation in software tool for dose calculation. purpose: the combined availability of dicom radiation dose structured report and active personal dosimeters in interventional radiology (ir) can support the optimisation of radiation protection, both of patient and staff. methods and materials: for nine months, interventionalists performing interventional cardiology procedures have used a personal active dosimeter (doseaware, philips) worn over the apron. information is displayed in real-time and transmitted to a database. the patient dosimetry report (allura fd , philips) has been also automatically collected for all procedures. a matlab routine integrates both information on procedure data and patient and staff exposures, providing a tool aiming to identify high and/or non-optimised exposures.results: on a sample of coronary angiography and percutaneous angioplasty procedures the derived mean kap (sd, maximum) per procedure was . ( . , . ) gycm . the first operator mean (range) personal equivalent dose was ( . ÷ . ) µsv/procedure. the mean (sd) scatter equivalent dose measured on the c-arm at the machine isocentre level per unit of kap was . ( . ) µsv/gycm . the availability of the dicom structured patient dosimetry report and the technology advancement of personal dosimetry can conveniently support the optimisation radiation protection process in ir. the described experience supports the initiative of isemir project (iaea, austria) that recommends the development of active dosimetry technology for a better monitoring of operators in ir and the development of a dicom operator structured dosimetry report as prerequisite to define and develop software platforms aiming to combine patient and staff exposure information. : purpose: the purpose of this study was to evaluate the additional diagnostic benefit of high-resolution steady state vibe imaging in peripheral mra. in this retrospective irb-approved study patients ( women, men, age . ± . ) were included who had undergone a peripheral mra exam after injection of . mmol/kg gadobutrol including a large field of view mra, time-resolved mra of the calf station and steady state d vibe sequence ( t siemens timtrio, . mm isotropic spatial resolution, pat , : min tacq per station) prior to the time-resolved mra. one board-certified radiologist rated image quality of the vibe sequences on an ordinal three-point scale and analysed the images for additional diagnostic findings. descriptive statistics and demographic patient data were used for further evaluation. the image quality of the vibe sequences of the pelvis, upper and lower leg was excellent in up to %, % and %, respectively. poor image quality was only detected in the upper ( %) and lower leg ( %). the vibe sequence yielded an additional diagnostic benefit in % of the patients overall. there was no significant difference in terms of additional findings between men and women ( % and %, p= . ). the patient sample revealed a distribution of % inpatients and % outpatients with additional pathology found in approximately % for each group. conclusion: steady-state d vibe sequences in peripheral mra yield additional relevant diagnostic findings in % and above in patients older than years irrespective of gender and patient status.author disclosures: h.j. michaely: consultant; bayer healthcare. in set-up iii, measured and calculated dose agreed well ( . vs. . msv). set-ups i and ii showed a discrepancy of % between measured and calculated dose ( . vs. . msv and . vs. . msv). image quality in set-ups i and ii was rated sufficient, compared to the excellent image quality in set-up iii. set-up.i. showed a lower image noise ( vs. hu) and lower dose ( %) than set-up ii. conclusion: morbidly obese patients receive higher dose in ct examinations, which is required to achieve diagnostic image quality. calculations based on dlp and standard conversion factors overestimate the dose by approx. % in kg patients, while the actual equivalent dose remains within the reference limits. the effects of head size/shape, head positioning, and bow-tie filter selection on peak tissue doses from brain perfusion -slice ct k. perisinakis , i. seimenis , a. tzedakis , a.e. papadakis , j. damilakis ; iraklion/gr, alexandroupolis/gr (kostas.perisinakis@med.uoc.gr) purpose: to determine peak doses to skin, eye lens, brain parenchyma and cranial red bone marrow (rbm) of adult individuals subjected to low-dose brain perfusion -slice ct studies, and investigate the effects of patient head size/shape, head position and bow-tie filter selection. methods and materials: peak doses to radiosensitive tissues were measured in individual-specific head phantoms subjected to the standard low dose brain perfusion ct on a -slice ct scanner using a novel monte carlo simulation software. the effects of head size/shape, head position during acquisition and bow-tie filter on resulting peak doses were investigated. the effects of head mis-centering and use of narrow bow-tie filter on image quality were assessed. the mean peak doses to eye lens, skin, brain and rbm were found to be , , and mgy, respectively. patient head size/shape was found to have minimal effect on peak doses, since maximum differences were less than %. bow-tie filter selection and head mis-centering were found to have a considerable effect on peak tissue doses with minimal image quality deterioration. the use of the narrower bow-tie filter available resulted in % reduction of peak tissue doses. conclusion: typical peak doses to skin, eye lens, brain and rbm from the standard low dose brain perfusion -slice ct exposure are well below the corresponding thresholds for induction of deterministic effects. the use of narrow bow-tie filters may considerably reduce peak absorbed dose to all above radiosensitive tissues with minimal degradation of image quality. detector dose vs image quality in radiography with digital detectors: a visual grading analysis r. decoster, h. mol, d. smits; brussels/be (robin.decoster@hubrussel.be)purpose: the introduction of digital detectors in the radiology predicted a dose reduction. due to the dynamic range, radiographs of sufficient quality can be produced with a lower detector air kerma (dak). however, this reduction was not observed. some authors indicate a creep toward higher dak, explained by better appreciation of the radiographs due to a higher contrast-to-noise ratio. to investigate the relation between the dak and the appreciation of image quality by radiologists, anterior-posterior (ap) radiographs of the knee and radiographs of the pelvis where collected randomly in radiologic centres. a visual grading analysis (vga) with a five-point scale was used to judge the image quality of seven anatomic structures. the mid-point of the scale was equalised to diagnostic image quality. six radiologists scored both datasets, in a controlled environment, with viewdex®. every observer received an instruction and a training dataset. to determine intra-observer variability twenty radiographs were repeated. results: the intra-observer variability was not significant (p> . ) in both datasets. the knee ap obtained a vga score of . , the pelvis obtained vga score of . . in both cases, the inter-observer correlations are high and significant. the correlation between the vgas and the dak (cr . µgy- . µgy; dr . µgy- µgy) was not significant in either dataset. neither were other analyses based on technical parameters. the vga revealed a mean image quality higher than diagnostic necessary. based on the dak, an overexposure is suspected. the relation between the dak range and the appreciation of the radiograph needs further investigation. (m.a.m.dekker@rad.umcg.nl) purpose: skin autofluorescence (af) is a non-invasive marker for advanced glycation endproducts (ages) and predicts cardiovascular disease (mortality) in diabetes and renal disease. we examined whether skin af is increased in subclinical atherosclerosis and whether it is associated with the degree of atherosclerosis independent of diabetes and renal function. methods and materials: cross-sectional study of patients referred for primary (pp;n= ) or secondary (sp;n= ) prevention. skin af was measured using the age-reader and the degree of atherosclerosis was assessed based on ultrasonographically detected plaques in carotid and femoral arteries (in pp only), and computed tomography-derived coronary artery calcium score (cacs . ], respectively; p = . and < . ). in controls and pad, skin af was higher in those with crp above median compared with below. in a multiple regression analysis, the association of skin af with the atherosclerosis categories was independent of age, gender, diabetes, framingham risk score, and kidney function. conclusion: skin af is increased in subjects with subclinical and clinical atherosclerosis, independently of known confounders. these data suggest that ages are associated with the burden of atherosclerosis. author disclosures: a.j. smit: founder; diagnoptics. evaluation of metabolic changes within the normal appearing grey and white matters in children with growth hormone deficiency: magnetic resonance spectroscopy and hormonal correlation j. bladowska, a. zimny, a. zacharzewska, t.m. gondek, a. banaszek, t. Żak, a. noczyńska, m. sąsiadek; wroclaw/pl (asia.bladowska@gmail.com) purpose: the pathogenesis of idiopathic growth hormone deficiency (ghd) in children, including possible cerebral metabolic alterations, remains unclear. the aim of the study was to evaluate the metabolic changes within the normal appearing brain in children with ghd using mr spectroscopy (mrs) and to correlate mrs measurements with hormonal concentrations. methods and materials: seventy-one children with ghd (mean age . yrs) and healthy controls (mean age . yrs) were enrolled in the study. the mrs examinations were performed on . t scanner. voxels were located in the posterior cingulate gyrus (pcg) and the left parietal white matter (pwm). the naa/cr, cho/cr and mi/cr ratios were analysed in both groups. there were also evaluated correlations between the metabolite ratios and hormonal concentrations: growth hormone (gh) in two stimulation tests and gh during the night, as well as igf- (insulinlike growth factor) and igfbp (insulin-like growth factor-binding protein) levels.results: there was statistically significant (p < . ) decrease of the naa/cr ratios in pcg and pwm in children with ghd compared to the normal subjects. other metabolite ratios showed no significant differences. we found also statistically significant positive correlations between naa/cr ratio in pwm and igfbp level, as well as gh concentration in stimulation test with glucagon. the reduction of naa/cr ratios may suggest loss of neuronal activity within normal appearing grey and white matters in children with ghd, thus mrs could be sensitive marker of cerebral metabolic disturbances associated with ghd and additional indicator for therapy with recombinant gh. purpose: the microstructure of tissues and white matter tracts in vivo may be studied with dti. the alterations involving the cerebral cortex associated in various degrees with subcortical white matter abnormalities often affect the projection white matter tracts. the white matter in cortical brain abnormalities is evaluated with diffusion tensor imaging (dti) and tract-based spatial statistics (tbss). methods and materials: patients ( year- year range) males and females) with different pattern of cortical alterations were studied. the dti data was processed in fsl. for each dti exam, brain extraction only of images with b value equal to zero was performed so that a mask of entire brain was created. gadoxetic acid-enhanced hepatobiliary phase mri and high b-value diffusion-weighted imaging (dwi) in the differential diagnosis between benign to malignant liver lesions p. arcuri, g. fodero, s. roccia, s. molica, v. arcuri; catanzaro/it (arppaolo@alice.it)purpose: the aim of our experience was to evaluate the value of gadoxetic acidenhanced hepatobiliary phase imaging and high b-value dwi in the differential diagnosis between benign and malignant liver lesions. methods and materials: twenty-four malignant liver lesions (fourteen small hcc and ten metastatic lesions) and twelve benign lesions (five fnh, four adenomas and three regenerative nodules in cirrhotic liver) were studied. a retrospective evaluation was made. the qualitative analysis was obtained by the evaluation of two radiologists of the lesions's signal intensity compared with that of the surrounding liver parenchyma on hepatobiliary phase images and dwi (b-value= s/mm ). the contrast-to-noise ratio (cnr) and relative contrast enhancement of lesions on hepatobiliary phase images and the apparent diffusion coefficient (adc) values were assessed (by rois) for quantitative analysis. statistical analysis was performed by the mann-whitney u test. p value less than . was considered statistically significant. in the qualitative analysis, nineteen malignant lesions ( %) and three benign lesions ( %) were hypointense on hepatobiliary phase images; five malignant lesions ( %) and nine benign lesions ( %) were iso-or hyperintense in the same phase. twenty malignant lesions ( %) and four benign lesions ( %) were hyperintense in dwi; four malignant lesions ( %) and nine benign lesions ( %) were iso-hypointense in dwi. in the quantitative analysis the mean relative contrast enhancement ratio of the malignant lesions was higher than that of benign lesions. conclusion: hypointensity on gadoxetic acid-enhanced hepatobiliary phase images and hyperintensity on dwi (b-factor= s/mm ) suggest malignant lesions rather than benign hepatocellular nodules. gadoxetic acid-enhanced mri of the liver: correlation between gadoxetic acid uptake and serum hepatic enzymes levels e. talakic purpose: to evaluate observer performance involving absolute visual grading analysis of image criteria using visual grading characteristic curves (vgc) and ordinal regression analysis during ct examination optimisation. methods and materials: images obtained from current and optimised head ct protocols (n= ) from suites were presented using viewdex on advantage workstations for evaluation by radiologists (n= ), grading the visibility of anatomical structures sourced from the european guidelines on quality criteria for ct. results: vgc analysis in terms of the area under the curve showed no significant differences (p> . ) from the . threshold value, indicating similar image quality between data sets. ordinal regression analysis indicated no significant (p> . ) change in image quality in suites and but discriminated between the data sets for suite and (p < . ). analysis on individual criteria indicated a difference (p < . ) in image quality between the protocols for all criteria in suite but no difference (p> . ) in suite . discussion: vgc curves demonstrated general trends between protocols. findings of ordinal regression analysis not only indicate significant differences in image quality but also identify specific anatomical criteria contributing to those differences. the importance of selecting the most appropriate method of analysis in optimisation techniques is highlighted as findings influence protocol implementation based on clinical requirements. conclusion: an overall % radiation dose saving was achieved as a result of optimisation of the head ct protocols. optimised protocols were implemented for initial diagnosis for three suites and only for follow-up cases excluding initial diagnosis for the remaining suite. : measuring hepatic functional reserve using low temporal resolution gd-eob-dtpa dynamic contrast-enhanced mri: a comparison study with galactosyl-human serum albumin scintigraphy and indocyanine green retention k. saito , j.r. ledsam , s.p. sourbron , t. hashimoto , y. araki , s. akata , k. tokuuye ; tokyo/jp, leeds/ uk (um jrl@leeds.ac.uk) purpose: to investigate if tracer kinetic modelling of low temporal resolution dynamic contrast-enhanced (dce) mri with gadoxetic acid (gd-eob-dtpa) has the potential to replace technetium m galactosyl human serum albumin (gsa) scintigraphy and indocyanine green (icg) retention for the measurement of liver functional reserve. methods and methods: patients ( males, females; mean age y) awaiting liver resection for various cancers underwent dcemri, gsa-scintigraphy and icg as part of routine pre-operative evaluation. examinations were conducted within a single month. underlying liver disease was present in patients. the gd-eob-dtpa mri sequence acquired images: pre-contrast, double arterial phase, portal phase, and minutes after injection. gsa-scintigraphy images were acquired every s following contrast injection. contrast uptake rate (ur) and extracellular volume (ve) were calculated from dce-mri, and the ratio of gsa radioactivity of liver to heart-plus-liver and percent of contrast uptake at minutes (lhl and lu , respectively) from gsa-scintigraphy. icg retention at minutes, child-pugh cirrhosis score (cps) and post-operative inuyama fibrosis biopsy criteria were also recorded. statistical analysis was with spss . purpose: to investigate dynamic contrast-enhanced computed tomography (dce-ct) for monitoring the effects of regorafenib on experimental colon carcinomas in rats by quantitative assessments of tumour microcirculation parameters with immunohistochemical validation. methods and materials: colon carcinoma xenografts (ht- ) implanted subcutaneously in female athymic rats (n= ) were imaged at baseline and after a one-week treatment with regorafenib by dce-ct ( slice dual source ct). the therapy group (n= ) received regorafenib daily ( mg/kg bodyweight) via gavage. quantitative parameters of tumour microcirculation (plasma flow, ml/ ml/min), endothelial permeability (ps, ml/ ml/min), and tumour vascularity (plasma volume, %) were calculated using a -compartment uptake model. dce-ct parameters were validated with immunohistochemical assessments of tumour microvascular density (cd- ), tumour cell apoptosis (tunel), and proliferation (ki- ). results: regorafenib significantly (p < . ) suppressed tumour perfusion ( . ± . to . ± . ml/ ml/min) and tumour vascularity ( . ± . to . ± . ml/ ml/min). significantly lower microvascular density was observed in the therapy group (cd- ; ± vs. ± , p < . ). in regorafenib-treated tumors, significantly more apoptotic cells (tunel; , ± , vs. , ± , , p < . ) and significantly less proliferating cells (ki- ; , ± vs. , ± , , p < . ) were observed. dce-ct tumour perfusion and tumour vascularity correlated significantly (p < . ) with microvascular density (cd- ; r= . and . ) and inversely with apoptosis (tunel; r=- . and - . ). arterial phase, portal venous phase, hepatovenous phase, equilibrium phase, and hepatobiliary phase which was minutes after gadoxetic administration. a test bolus was used to optimise the contrast injection protocol. signal intensity of the liver parenchyma in all phases was defined using region-of-interest (roi) measurements for enhancement calculation. serum hepatic enzyme levels (bilirubin; cholinesterase, che; aspartat-aminotransferase, ast; alanine-aminotransferase, alt; gamma-glutamyl-transpeptidase, ggt; alkaline phosphatase, ap) were available in all patients. spearman correlation test was used to test the correlation between liver enhancement during the different phases and serum hepatic enzyme levels.results: at late time points after contrast injection all serum hepatic enzymes were correlated with liver enhancement. bilirubin and che showed stronger correlations than the other serum hepatic enzymes and they became correlated at earlier time points. the strongest correlation was observed between bilirubin and enhancement during the hepatobiliary phase and between che and enhancement during the hepatobiliary phase. bilirubin showed negative and che showed positive correlation. the spearman correlation coefficient was - . for bilirubin and . for che. conclusion: in gadoxetic acid-enhanced mri of the liver gadoxetic uptake during the hepatobiliary phase is strongest correlated with bilirubin and che serum levels, whereas the other serum hepatic enzymes show weak or moderate correlations. purpose: aim of the study is to evaluate the use of mrcp using hepatospecific contrast media (gd-eob-dtba) to confirm biliary leak suspect and treatment planning. methods and materials: consecutive patients ( males, females -average age years), during months (april to may ) underwent mrcp study using gd-eob-dtba due to clinical suspect of biliary leak. using an . t mri scanner, t -weighted d gre pulse sequences before and in hepatospecific phase, after gd-eob-dtba injection, were performed. all patients with biliary leak underwent endoscopic, interventional radiology (ir) or surgical approach for treatment. results: biliary leak was clinically suspected in patients and underwent abdominal surgery ( laparoscopic cholecystectomy, various hepatic resections, resection of a pancreatic-duodenal mass) after days (av; range to ). in / biliary leak was found at minutes (av; range to minutes) from gd-eob-dtba injection, from intrahepatic ducts ( / ) site, cystic duct stump ( / ), both intrahepatic and principal biliary duct ( / ) and from a biliodigestive anastomosis ( / ). biliary leak was confirmed and successfully treated by percutaneous transhepatic cholangiography ( / ), endoscopic approach ( / ), ir and endoscopic "rendez-vouz" technique ( / ) and by surgical laparotomy ( / ). in / patients, no biliary leak was found and only clinical monitoring was performed, with good outcome. any adverse reaction or technical problem occurred during the mrcp examination. conclusion: mrcp with gd-eob-dtba is an high sensitivity, safe and fast examination to confirm the suspect and to locate precisely a biliary leak, concurring best planning for treatment. n-acetylcysteine for the prevention of contrast-induced nephropathy in rats m.f. İnci , i. Şalk , o. solak , Ü. vurdem , r. İnci ; kahramanmaraş/tr, sivas/tr, kayseri/tr (drfatihinci@gmail.com)purpose: to date, there is no effective treatment of contrast-induced nephropathy (cin). n-acetylcystein (nac) has yielded some promising results recently in the prevention of cin. in this study, the structural effects of nac on cin were analysed. methods and materials: forty adult wistar albino male rats were randomly allocated to four groups. the first group was the control group (n= ) which received only distilled water; second group was the contrast group (n= ) which received cm; the third group was the contrast plus nac group (n= ) which received cm and was treated with nac; and the last group was nac group (n= ) which received only nac. at the end of the rd day, the right and left kidneys were removed and reserved for histopathological examination. all tissue sections were examined with light microscope looking for histopathological changes by the same experienced pathologist, without knowledge of the prior treatment. histopathological examination was conducted in a blinded fashion, and glomerular injury scores, arteriolar injury scores and tubulointerstitial injury scores were calculated. results: there was a significant difference among the scores of glomerular injury, arteriolar injury and tubulointerstitial injury in all groups (p < . ).the scores of glomerular, arteriolar and tubulointerstitial injury of the group- and group- were not significantly different from each other (p < . ). renal injury scores in group- key: cord- -hah vmk authors: kabiri, aliakbar; darzi, aref; zhou, weiyi; sun, qianqian; zhang, lei title: how different age groups responded to the covid- pandemic in terms of mobility behaviors: a case study of the united states date: - - journal: nan doi: nan sha: doc_id: cord_uid: hah vmk the rapid spread of covid- has affected thousands of people from different socio-demographic groups all over the country. a decisive step in preventing or slowing the outbreak is the use of mobility interventions, such as government stay-at-home orders. however, different socio-demographic groups might have different responses to these orders and regulations. in this paper, we attempt to fill the current gap in the literature by examining how different communities with different age groups performed social distancing by following orders such as the national emergency declaration on march , as well as how fast they started changing their behavior after the regulations were imposed. for this purpose, we calculated the behavior changes of people in different mobility metrics, such as percentage of people staying home during the study period (march, april, and may ), in different age groups in comparison to the days before the pandemic (january and february ), by utilizing anonymized and privacy-protected mobile device data. our study indicates that senior communities outperformed younger communities in terms of their behavior change. senior communities not only had a faster response to the outbreak in comparison to young communities, they also had better performance consistency during the pandemic. in december , a novel coronavirus began spreading across the world. as of may , there have been more than , , confirmed cases and more than , have lost their lives to disease. non-pharmaceutical interventions (npi) have been considered one of the most effective strategies in fighting against this outbreak in the absence of vaccinations. therefore, on march , the u.s. government declared a national emergency followed by the coronavirus guidelines for americans on march , which highlighted the importance of the social distancing practices. in addition to the national emergency, states across the u.s. instituted stay-at-home orders by mid-april to reinforce the preventive measures. despite all the efforts conducted to flatten the curve, covid- continues to spread at an alarming pace, which indicates the importance of appropriate npi planning, especially during the reopening phase. earlier studies revealed the linkage between the transmission of covid- and sociodemographic characteristics at both the community and individual level. with a specific focus on the work status variable by difference age groups, a study carried out by papageorge et al. found that younger workers were more likely to begin teleworking while older workers tend to not work instead (papageorge, et al., ) . in another study, which leveraged novel gps location data, engle's team analyzed the influence of covid- and social distancing restrictions on individual mobility behavior. the results suggested that counties with larger shares of population over are more responsive to pandemic prevalence and restriction orders (engle et al., ) . some research discussed the differences in social distancing behavior between different sociodemographic groups (fang, et al., ; lee, et al., ; sun, et al., ) . a preliminary analysis indicated that states in the u.s. differ in mobility metrics, such as percentage of staying home, miles traveled per person, and percentage of out-of-county trips, when grouped by income levels or population density (lee, et al., ) . a more detailed analysis by zooming in on different communities in the united states was conducted by the authors, which showed notable disparities between the mobility patterns of people from different income levels (sun, et al., ) . many studies have shown that being elderly is one of the high-risk phenotypes of covid- (raifman m and raifman j, ; covid, c. d. c., & team, r., ; liu, , yancy, ; lewnard and lo, ) and age structure is closely related to the progression of the pandemic (dowd, et al., ) . therefore, we aim to investigate the mobility behavior by age group during the pandemic. related research shows that elderly people have fewer close contacts with nonhousehold members based on an online survey (canning, et al, ) . a second study analyzed the connection between age, social distancing behavior, and the progression of the pandemic . another study treated age as an important consideration when analyzing social contact behavior (block, et al., ) . this research explored the disparities in response to mobility-related, non-pharmaceutical interventions between communities of different age groups. several aspects of mobility patterns including percentage of people staying at home and social distancing index, have been investigated in this paper to illustrate how different age groups behave during the pandemic. emergence of mobile device location data has helped many researchers to study the mobility behavior of individuals across the world. in this study, we utilized a panel mobile device location data integrated from several data vendors. this integrated dataset consists of more than million devices across the u.s. and enabled us to calculate several mobility metrics at census tract level using previously developed algorithms . we performed statistical methods, including pairwise t-test and post-hoc analysis, to investigate the differences in temporal mobility behavior patterns between different age groups, which are derived from the mobile device location data. in the following sections, we first describe the datasets used for our study and explain the methodology used for our analysis (section ); then, we illustrate findings from our analysis (section ); and finally, we discuss conclusions and future directions (section ). mobility metrics are the key feature in this study. the research team created a robust and representative data panel by integrating multiple mobile device location data sources, which capture the person and vehicle movements. after creating the data panel, we went through comprehensive data cleaning steps considering consistency, accuracy, completeness, and timeliness of the observations in the data panel. we then identified activity locations using the spatio-temporal clustering of raw location data. this step of identifying activity location mainly helps infer the residential and work location of anonymized devices at the census block group level with privacy protection taken into account. after home and work identification, we extracted trips from raw location points using a previously developed recursive algorithm . the trip identification algorithm provides trip-related information, including trip origin and destination, departure time and arrival time, and travel distance of each trip. to estimate the percentage of people staying at home, we considered all anonymized devices with no trips made longer than one mile from their designated residential location as devices staying at home for that calendar day. the last step was to employ a multi-level weighting algorithm to expand the sample observed in our mobile device data to the population level. the final results of our computational algorithms were extensively validated using several independent data sources, including the national household travel survey (nhts) and american community survey. additionally, the algorithms were peer-reviewed by an external expert panel . basic mobility metrics, including percentage of people staying at home, number of trips per person per day, number of work trips and non-work trips per person per day, miles traveled per person per day, and percentage of out-of-county trips per day, were calculated using the aforementioned method. it is worth mentioning that the percentage of people staying home is defined as the number of people without any trip longer than one mile in a day. however, as none of these metrics could represent the different aspects of human mobility patterns, a single metric is introduced to portray the extent of social distancing practices for each census region. the social distancing index (sdi) was calculated as a score-based index to measure the accordance of both residents and visitors to social distancing guidelines (pan, et al., ) . a score between and has been assigned to each region by considering the temporal changes in five basic mobility metrics, e.g., percent of staying at home, daily work trips, daily non-work trips, trip distance, and percent of out-of-county compared to baseline days before the start of the covid- pandemic. the research team designed a weighting scheme for integrating the five metrics by considering the importance of each metric based on both conceptual guidelines of social distancing definition and real-world observations. in this study, the community categories are defined based on the median age of census tracts. we first sorted the census tracts by median age in ascending order and then picked the top and bottom % as young and senior communities, respectively. the performance of following social distancing for both groups are quantified as the percentage change of mobility metrics between the study period (weekdays from march to may , ) and predefined baseline (weekdays in january and february ). the base value of each mobility metric of each census tract will be the mean value of the metric in the baseline period. utilizing the daily percentage changes for both groups, a t-test was conducted to evaluate the significant difference between two communities, and consequently reveals the mobility difference between different age groups toward the outbreak of the pandemic. communities have different inherent characteristics that lead to distinct mobility patterns, thus comparing the absolute value of mobility metrics does not fully illustrate their response to the pandemic. therefore, as we were most interested in capturing the changes in behavior among different age groups during the pandemic, we examined the temporal changes of the mobility metrics compared to the pre pandemic baseline. as an example, young people may have a higher rate of work trips in comparison to the elderly, and this is their internal characteristic. on the other hand, if we only consider the percentage changes of each parameter, it shows the exact effort that each group exerts to prevent the pandemic. in other words, percentage changes can help us capture the exact performance that each group has, regardless of the characteristics of each group. these values are completely comparable. in ; we then evaluated the potential differences in social distancing performance of two senior and young communities in these time intervals. moreover, understanding the reaction time to mobility interventions such as the national emergency declaration in different groups, as well as how well they maintain social distancing during the pandemic, are some important questions that need to be addressed. we utilized a posthoc, pairwise t-test to capture the rate of changes within the groups on different days. in this section, we analyzed the temporal changes in percentage changes of two mobility metrics, namely, percentage of people staying home and the social distancing index from march to may , . we calculated the percentage changes in each weekday of the study period in comparison to a baseline before the pandemic, when everything was as usual without any external treatment related to the pandemic, such as the national emergency declaration or stay-at-home order. the baseline is defined as all the weekdays in january and february . it is worth mentioning that only the values of weekdays are considered. the value of mobility metrics of each age group is the daily mean value of all the census tracts in that group, while for the baseline, it is the mean of all weekdays in january and february. based on the daily percentage changes of each mobility metric, two graphs ( figure ) are produced to show the temporal changes of each age group. based on figure , after the national emergency declaration by the federal government on march , both senior and young communities began performing social distancing in both aspects of mobility. they continued improving their performance until mid-april and then stopped enhancing their behavior. this phenomenon is called social distancing inertia . after this time, the trend shifts backwards, indicating that people-no matter what group they belong to-stop improving and even violate social distancing. by digging more into each age group, we saw that in terms of percentage changes of people staying home, senior communities have higher values in all days (figure .a) . in other words, the senior communities outperform the younger communities in staying at home. this finding is crucial, since the literature indicates that older people are more likely to get sick by covid- in comparison to younger people. considering these two points, we will have a good gauge for moderating the harsh sequences of the outbreak of covid- . the same pattern was observed for the social distancing index (figure .b) , which also supports that senior communities contribute more in performing social distancing. in addition to the temporal change of mobility metrics, a t-test method is adopted in this section to statistically analyze the significance of difference between two groups. based on a day-to-day comparison of the mean values of both metrics, we have found that in almost half of the days before the national emergency declaration the difference is not that significant, as shown in figure . on the other hand, in the days after march , the difference between young and old groups is statistically significant. this test confirms that there is a difference between the behavior of senior communities and young communities against the pandemic. older people are more likely to take better actions in this situation. in addition, in each time period discussed in section , a t-test is conducted to show whether there is any statistically significant difference between the behavior changes of the young and senior groups, of which the null hypothesis of the t-test is defined as no significant difference ( furthermore, figure shows the distribution of social distancing index of the two age groups in each time period and how it changes over time. it is obvious that in the pre-pandemic period, the two groups are similar to each other, yet later, a significant gap appears between the groups. moreover, they differ in spread. older people have a more dispersed distribution towards higher values, meaning that overall, they outperform the younger group. in this section, we investigated the within group changes in young and senior communities over time. we employed pairwise two-sample t-tests to compare the metrics' value day by day. to offer a more detailed look into the differences, we chose the top and bottom census tracts in terms of median age and performed a post-hoc analysis on each pair of the days within each group on both metrics discussed in the previous section-the percentage of people staying home and social distancing index-to see where the difference comes from. our results indicated significant differences in clusters of consecutive days. figure shows the results of these census tracts. based on figure , the percentage of people staying at home were similar among the two groups from march to march . however, a sudden shift was observed in the following days for the older age group. this observation indicates quicker response to the pandemic and national emergency declaration in the elderly group compared to the young group. this indicates that this group is responding to the pandemic and national emergency declaration very fast. on the contrary, in the younger group we saw that even until march , the pandemic and the executive order were not significantly considered. still, until march there are a lot of green cells, which indicates that there is not that much difference between the younger group's behavior before and after the national emergency declaration. therefore, we can conclude that senior communities were more responsive to the mobility interventions. furthermore, our analysis revealed that senior groups were more consistent in terms of changing their behavior and practicing social distancing. we observed continuous red cells for the elderly group, which indicates a significant change to their pre-pandemic behavior, while several fluctuations were noticed by the young group. thus, it concludes that senior communities maintain social distancing better than younger communities. the next two graphs (figure .c and .d) also confirm that there is a difference between the response time of the older group and the younger group. it is worth mentioning that the sdi value is made up of many mobility metrics that are discussed in the data description. therefore, its value is very important and considers mobility behavior of different regions from many different aspects, and this makes it more trustworthy. the covid- pandemic crisis has affected the daily lives of almost all people. in order to prevent the rapid transmission of the disease, people began changing their mobility patterns by staying home and having less trips voluntarily, or through different restrictions imposed by state and federal governments. because different people have different characteristics and consequently different behaviors, communities might have distinctive responses to the pandemic. in this paper, we quantitatively investigated the differences between the mobility patterns of senior communities and young communities using privacy-protected, anonymized mobile device location data by comparing the percentage change of mobility metrics, such as social distancing index (sdi) and percentage of people staying home, during the pandemic in comparison to the days before the pandemic to capture the different behaviors of these two groups. the results show that after the national emergency declaration started, both younger and older communities performed social distancing until mid-april, but that as time goes by, they do not maintain their previous social distancing efforts as they did in the first days of the pandemic. furthermore, our analysis shows that elderly groups reacted to the pandemic faster than young groups. as soon as the national emergency declaration was deployed, these people changed their behavior by staying home and maintaining a higher value of social distancing index. also, elderly people had a constant performance and kept up their efforts in almost all days. on the other hand, young communities show a disparity in how they behave on different days during the pandemic. furthermore, we analyzed the overall performance of both groups by using a day-by-day analysis and also through five different critical time intervals such as pre-pandemic, behavior change, etc., and found that in all of these time intervals, there is a significant difference in how these two groups perform social distancing in order to control the spread of the covid- . future research can shed light on the evolution of the pandemic and how different age groups would return to their normal mobility patterns. the impact of current practices by age group is another future direction that is worth further analysis to understand whether the effort that each group is implementing is enough to prevent the outbreak, or if it is still inadequate. moreover, this paper can be improved and expanded in many directions. for instance, the current definition of people staying home could be biased towards high-density urban areas. people in urban areas can access shopping in a shorter distance compared to people living in rural areas; thus, it is possible to capture more people staying home in urban areas. therefore, we can divide each age group into two sub-groups-urban and rural areas-and capture the effect of this factor on age groups. finally, this paper reveals that the orders and regulations imposed by policymakers do not result in the same behavior changes in different communities with dissimilar socio-demographic characteristics. for instance, as the results of this paper reveals, stay-at-home orders and travel restrictions have different implications on young and senior communities in terms of mobility behavior shifts. elderly groups were more agile in adapting to the new guidelines and the changes in their behavior showed a higher compliance rate. therefore, such data-driven insights from human behaviors are of paramount importance for decision makers to better understand different aspects of their decisions. social network-based distancing strategies to flatten the covid- curve in a post-lockdown world the association between age, covid- symptoms, and social distancing behavior in the united states severe outcomes among patients with coronavirus disease (covid- )-united states demographic science aids in understanding the spread and fatality rates of covid- staying at home: mobility effects of covid- human mobility restrictions and the spread of the novel coronavirus ( -ncov) in china. no. w observed mobility behavior data reveal social distancing inertia human mobility trends during the covid- pandemic in the united states scientific and ethical basis for social-distancing interventions against covid- clinical features of covid- in elderly patients: a comparison with young and middle-aged patients ipums national historical geographic information system: version university of maryland covid- impact analysis platform quantifying human mobility behavior changes in response to nonpharmaceutical interventions during the covid- outbreak in the united states socio-demographic factors associated with self-protecting behavior during the covid- pandemic. no. disparities in the population at risk of severe illness from covid- by race/ethnicity and income covid- and income profile: how people in different income groups responded to disease outbreak, case study of the united states covid- and african americans changes in contact patterns shape the dynamics of the covid- outbreak in china data analytics and modeling methods for tracking and predicting origin-destination travel trends based on mobile device data an interactive covid- mobility impact and social distancing analysis platform we would like to thank and acknowledge our partners and data sources in this effort: ( ) amazon web service and its senior solutions architect, jianjun xu, for providing cloud computing and technical support; ( ) computational algorithms developed and validated in a previous usdot federal highway administration's exploratory advanced research program project; ( ) mobile device location data provider partners; and ( ) partial financial support from the u.s. department of transportation's bureau of transportation statistics and the national science foundation's rapid program. this research received partial financial support from the u.s. department of transportation's bureau of transportation statistics and the national science foundation's rapid program. key: cord- -wgseqk t authors: liu, chang; liu, yunchao; feng, hua; zhao, baolei; chen, yumei; huang, huimin; wang, pan; deng, ruiguang; zhang, gaiping title: pcv cap proteins fused with calreticulin expressed into polymers in escherichia coli with high immunogenicity in mice date: - - journal: bmc vet res doi: . /s - - - sha: doc_id: cord_uid: wgseqk t background: porcine circovirus type (pcv ) is the main causative agent of porcine circovirus diseases (pcvds) which causes huge yearly economic losses in the swine industry. capsid protein (cap) is the major structural protein of pcv that can induce a protective immune response. therefore, developing a novel and safe subunit vaccine against pcv infection is needed. results: in this study, the cap gene was bound to the truncated calreticulin (crt) ( – aa/ – aa) at the n/c terminal, and then the crt-cap fusion genes were expressed in escherichia coli (e.coli). the size-exclusion chromatography and dynamic light scattering (dls) data showed that the purified recombinant crt-cap fusion protein (rp f) existed in the form of polymers. immunization with rp f stimulated high levels of pcv specific antibody and neutralization antibody in mice, which were almost identical to those induced by the commercial subunit and inactivated vaccines. the lymphocyte proliferation and cytokine secretion were also detected in rp f immunized mice. according to the results of pcv -challenge experiment, the virus loads significantly decreased in mice immunized with rp f. the data obtained in the current study revealed that rp f had the potential to be a subunit vaccine candidate against pcv in the future. conclusions: we have successfully expressed cap-crt fusion proteins in e.coli and optimized rp f could form into immunogenic polymers. mice immunized with rp f efficiently induced humoral and part of cellular immune responses and decreased the virus content against pcv -challenge, which suggested that rf p could be a potential subunit vaccine candidate. porcine circovirus (pcv) is a circular single-stranded dna virus belonging to the family circoviridae [ ] . there are three major genotypes of pcv, namely pcv , pcv , and pcv . pcv is nonpathogenic [ ] , and pcv is associated with several diseases, collectively named as porcine circovirus associated disease (pcvad), which causes reproductive failure and huge economic losses all over the world [ ] . pcv is a recently identified circovirus that induces cardiac pathology and multi-systemic inflammation [ ] . in april , a new circovirus with a distinct relationship to other circoviruses was found in hunan province, china and designated as pcv (doi: https://doi.org/ . /tbed. ). at present, at least five commercial vaccines have been licensed, including the circovac® vaccine (merial), ingelvac circo-flex® (boehringer ingelheim), circumvent® (intervet/ merck), porcilis® pcv (schering-plough/merck), as well as fostera™ pcv (pfizer animal health inc.) [ ] . it has been reported that all the commercial vaccines were able to reduce clinical symptoms and improve reproduction to some extent in pcv positive farms, while they failed to eradicate this virus from farms [ , ] . as pcv infection may initiate immunosuppression and also cause subsequent failure of the immune response in pigs [ ] , thus, a more effective vaccine should be developed to prevent pcv infections in swine herds. the balb/c mouse is one of the animal models, as it has a clear background and frees from external interference, it is the most extensively used in pcv inactivated or subunit vaccine researches [ , ] . the genome of pcv consists of two major open reading frames (orfs): orf and orf . orf encodes two viral replication-associated proteins, rep and rep' [ ] ; orf encodes a capsid protein (cap), which is the primary immunogenic protein of pcv . cap contains critical epitopes for inducing a protective immune response, so it has been used as the target for vaccine development [ ] . the cap protein has been expressed in multiple protein expression systems (e.g., insects, mammalian, yeast, and e. coli cells) [ , ] in vitro, whereas only baculovirus insect expression system generates two commercially available pcv vaccines [ ] . however, low yield and high cost still exist for large scale preparation. compared with insect expression, escherichia coli (e.coli) is an efficient prokaryotic expression system as many significant benefits in terms of low cost, ease-of-use and scale preparation. generally, immunogenic protein with high-molecularweight can induce stronger immune response than lowmolecular-weight protein [ ] . calreticulin (crt) is a highly conserved endoplasmic reticulum luminal ca +binding protein and found to be involved in cellular processes (e.g., calcium storage and chaperone function) [ ] . numerous studies primarily focused on its roles in protein folding and polymerization [ , ] . recombinant truncated crt in polymers, as compared with monomers, can induce higher level of immune response [ ] . furthermore, crt fused foreign proteins also formed into polymers and showed excellent immunogenicity of the foreign proteins [ ] . in the present study, high-yield cap-crt fusion protein was expressed in e.coli, and the recombinant protein, rp f could form into immunogenic polymers. mice immunized with rp f efficiently mounted humoral and cellular immune responses, and decrease the infection rate against pcv -challenge, suggesting that rf p could be a potential subunit vaccine candidate. the cap-crt fusion proteins (rp c, rc p, rp f and rf p) were successfully expressed in e. coli, whereas all of them led to inclusion bodies (ibs) at °c ( the purified rf p by ni-nta was eluted from the superdex pg ( / ) gel filtration column. the target protein was presented as the first and highest peak, which beyond the detection limit of the column, suggesting that rf p could form high-molecular-weight polymers ( the third peak also recognized anti-his mabs, revealing that only a small fraction of rf p might exist in the form of monomer (fig. b, c lane ) . to examine the morphology of high-molecular-weight polymers, the purified rf p was analyzed under a tem. the observed result revealed that rf p was assembled into a spheroidal particle with a diameter of nm, whereas the size distribution of the particles was not exactly the same, as shown in fig. a , suggesting that there might be some incompletely assembled protein fragments. the dls result indicated that the average hydrodynamic diameter of rf p was about nm (fig. b) . the sizes of rf p particles observed using the two methods were not consistent, probably attributed to the hydration radius detected by dls was larger than the theoretical or real value. the results of the antigenic analysis showed that rf p could recognize clinical positive serum and anti-pcv mabs a , which indicated that rf p had the similar characters as intact particle (fig. ) . compared with clinical positive serum, the mabs a showed a relative weaker ability to recognize rf p (fig. b) . however, the rf p exhibited a high background interference of clinical negative serum, which probably associated with the complexity of the field sample (fig. a ). indirect elisa was performed to evaluate pcv -specific humoral immune response induced by rf p in mice. figure a shows that compared with the pbs group, pcv -specific antibodies appeared at dpi in all groups and increased with the advancement of the immune process. the antibody levels of mly and blg groups were overall higher than those of rf ph and rf pl groups before virus challenging, but the contrary phenomenon happened after that. during the entire immune process, the levels of rf ph group were higher than those of the rf pl group, whereas there was no significant difference between them. no antibody was produced in the pbs group before the challenge, and the antibody level increased immediately at days after challenge and reached peak at days. whether the antibodies generated by immunized mice could neutralize the virus, na was adopted to further detect the pcv -specific humoral immune response. the results indicated that all immune groups produced neutralizing antibodies except the pbs group, which were consistent with the results of indirect elisa. the na titers of rf ph groups were higher compared with those of mly and blg at and dpi (fig. b) . after the challenge, na titers in the pbs group increased rapidly and reached : at weeks. besides, the na level in other immune groups decreased at dpi ( week after challenge); it returned to the level of pre-challenge at dpi and remained unchanged until the completion of the test. three mice in each group were sacrificed to isolate lymphocyte for lymphocyte proliferation and cytokine and anti-his mabs (c) by elisa, and the results are expressed as mean od value ± sem, the statistical significance differences between each group was analyzed by two-way anova statistical analysis, *p < . , **p < . , ***p < . , ns represented not significant quantification through pcv strain df- stimulation. the lymphocyte proliferative responses were detected in all immunized groups aside from the mock group. the sis of rf ph, mly and blg groups were significantly higher than that of the pbs group (p < . ), and there was no significance between the four immunized groups (p > . ) (fig. f) . the results suggested that cytokine levels were slightly higher in all the immune groups than the mock group, whereas there was no regular correlations and significant difference in the values (fig. a-e) . pcv dna extracted from different tissues of all experimental groups post-challenge was quantified using realtime fluorescent quantitative pcr. figure suggested that excepted kidneys, the pbs group showed a significantly higher viral load than the other groups. the amounts of virus in the spleens and lungs of the immunized groups were lower than that in the pbs group (p < . ), and it showed no difference between the immunized groups (fig. c, d) . the rf p groups exhibited the highest viral loads in the livers (fig. b) , but the date are shown as mean ± sem, statistical differences between each group was measured by one-way anova, *p < . , **p < . , ***p < . , ns represented not significant lowest in the hearts (fig. a) . there was no difference among all groups in the kidneys (fig. e) . all the results revealed that mice immunized with rf p could effectively reduce viral loads in organs against the pcv challenge. pcv , an agent of pcvds, acts as a vital economical viral pathogen affecting the global swine industry. vaccination has been demonstrated as a feasible means to control pcvad. in this study, the cap-crt fusion proteins which could form into high immunogenic polymers were first produced in e. coli. though there are multiple protein expression systems for protein expression in vitro, each system exhibits features and advantages, it also has limitations such as low yield and high cost which hinder the development of the recombinant protein into a truly useful vaccine. meanwhile, e. coli prokaryotic expression system has been extensively adopted for recombinant protein production in laboratories and industry for its simplicity, rapid growth rate and relatively low cost. studies on cap proteins focus on their abilities to selfassemble into virus-like particles (vlps) and thus exert immune effects as an entire virus, which also prove that large molecular particles have stronger immune effects than monomer proteins [ ] . however, the expression of recombinant proteins in e.coli often results in insoluble and/or nonfunctional ibs which may due to rapid synthesis and lack of post translational modification. crt has been shown to be able to self-assemble effectively and acts as a chaperone to help dissolve and form the correct structure [ ] . three fourths design of cap-crt fusion proteins formed into ibs, only the rf p transformed into soluble macromolecular particles in vitro by optimizing the expression conditions. however, the observations of tem and dls revealed that the particle radius was not the same, probably attributed to the dls of hydrated radius larger than the theoretical or actual size. besides, compared with other vlps reports, the rf p did not form vlps. the balb/c mouse is one of the animal models, as it has a clear background and frees from external interference, it is the most extensively used in pcv inactivated or subunit vaccine researches [ , ] . though mice may not be an ideal animal model to resemble pcv infection as observed for pigs, pcv can infect and replicate in some mouse strains including balb/c mouse when used with the appropriate inoculating dose and administered route. in the present study, the balb/c mouse model was used to assess the immunogenicity and protective capabilities of an experimental vaccine based on the recombinant cap-crt fusion protein expressed in e.coli. the cap-crt fusion protein (rf p) induced production of pcv -specific elisa antibodies and neutralization antibody against pcv were detected, the pcv -specific elisa antibodies were positively correlated with the fig. protection from pcv strain df- challenge in mice. all of the mice were challenged with μl of . tcid /ml of the pcv strain df- at dpi and examined for days. spleens were isolated and the genomes were extracted to measure the content of pcv using quantitative real-time pcr. date are shown as mean ± sem, statistical differences between each group was measured by one-way anova, *p < . , **p < . , ***p < . , ns represented not significant neutralization antibodies, which was consistent as described in zhu [ ] . the specific antibody levels of protein groups were lower than those of commercial vaccine groups before virus challenge, but it went opposite after the virus challenge. the neutralizing antibody levels of protein groups were slightly lower than commercial vaccine groups during the immune process. both the protein and the commercial vaccine groups induced only part of the cellular immune response. under the stimulation of pcv , t lymphocytes proliferated significantly, whereas various cytokines were irregularly secreted. pcv infections mainly induce fetal and neonatal mortality, and the level of viruses in the tissues of pcv infected mice is a good indicator of the antiviral effects of any vaccine, and it primarily occurred in the lymphoid tissue and spleen [ ] . after the challenge test, the viral loads in the spleens of mice in the protein and commercial inactivated vaccine group were significantly lower than those in the mock group. it was also slightly effective in the organs of the heart, liver and lung, which was not completely consistent with wang's research, pcv mainly deposited in the lungs [ ] . the humoral immune response showed no significant difference between protein groups and commercial vaccine groups. overall, the humoral and cellular immune levels of rf p groups were similar to the two types of commercial vaccine groups, and the aggregate performance of rf p was closer to blg subunit vaccine. our results clearly verified that the cap-crt fusion protein (rf p) elicited humoral and part of cell mediated immune responses comparable to commercial inactivated and subunit vaccines, and protected mice against epidemic pcv strain df- challenge. to sum up, this paper first describes that the pcv cap protein fused with truncated calreticulin (rf p) could be soluble expressed into immunogenically polymers in e. coli. vaccination of mice elicited humoral and part of cellular immune responses comparable to the commercial inactivated and subunit vaccines, and significantly reduced the viral loads in tissues subsequent to a viral challenge. besides, the immune effect of cap-crt fusion protein requires further verifications in pigs as the natural hosts of pcv . the rf p can potentially develop a subunit vaccine against pcv infection. pk- cells (atcc™ ccl- ) were cultured in dulbecco's modified eagle medium (dmem; gibco) containing % fetal bovine serum (fbs, hyclone), iu/ml penicillin and mg/l streptomycin (invivogen, france) at °c in a % co atmosphere. pcv strain df- (genbank accession number: jn ) was grown in pk- cells and utilized for virus neutralization assay (na) and experimental challenge. thirty female balb/c mice of weeks old weighing - g were chosen arbitrarily and purchased from the experimental animal center of zhengzhou university. the experimental mice were randomly separated into five groups and given days to acclimate the housing environmental conditions (temperature: ± °c, humidity: ± %, lighting: h light/dark cycle). the mice were allowed free access to clean water and food. the animal experiments were carried out according to the animal experiment committee of henan academy of agricultural sciences (approval number syxk - ). all animals received humane care in compliance with good animal practice according to the animal ethics procedures and guidelines of china. all sections of this report adhere to the arrive guidelines for reporting animal research [ ] . as shown in fig. a , complete cap gene of pcv (gen-bank accession no. ay ) was fused with the truncated calreticulin ( - aa/ - aa) (genbank accession no. eu ) at n/c terminal using × ggggs or × ggggs linker. all these four recombinant fragments, named rp c/rc p/rp f/rf p, were synthesized after codon optimization by genscript. all the plasmids were inserted into pet- a in bamhi and xhoi sites and then transformed into e. coli bl (de ) competent cells, respectively. all the positive clones were cultured in luria-bertani (lb) medium containing mg/l kanamycin and induced for protein expression with . mm iptg at °c for h. the parameters of protein expression were optimized according to iptg concentrations ( . mm, . mm), induction temperature and time ( °c for h, °c for h). protein expression was verified by sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page). the optimal harvest cells were suspended in lysis buffer ( mm pb, mm nacl, % (w/v) glycerol, % (w/v) triton x- , mm edta, mm dtt, ph . ) and then lysed by sonication ( cycles of s on/ s off, amp %)). after centrifugation, the precipitation was removed and the supernatant of rf p was purified by ni-nta affinity chromatography. after washing the ni-nta column (invitrogen, usa) with wash buffer ( mm pb, mm nacl, mm imidazole, ph . ), rf p was eluted with elution buffer ( mm pb, mm nacl, mm imidazole, ph . ). protein fractions were analyzed by sds-page. the purified rf p was enriched and analyzed by sizeexclusion chromatography with superdex prep grade (pg) ( / ) gel filtration column (ge healthcare, usa). the samples were eluted using lysis buffer at a flow rate of ml/min and detected at nm wavelength. the collected fractions were identified by sds-page and western blot and then quantified using bca protein assay kit (tiangen, china) . the purified rf p was observed under a transmission electron microscopy (tem) using the negative staining method and dynamic light scattering (dls) according to the previous study [ ] . indirect enzyme-linked immunosorbent assay (elisa) was performed to test the antigenicity of rf p with swine clinical positive/negative serum and mouse anti-pcv monoclonal antibodies (mabs) a (abcam, usa). the elisa procedure was operated as routine. thirty female balb/c mice were randomly divided into groups (n = ). the mice were inoculated subcutaneously with μg and μg of rf p as group rf ph and group rf pl, respectively; μl of commercial inactivated circovac® vaccine (merial), subunit vaccine ingelvac circoflex® (boehringer ingelheim) and pbs were classified as positive and negative controls, named as group mly, blg and pbs, respectively. the rf p was diluted in μl of pbs and then emulsified with μl of complete freund's adjuvant for the first immunization, and subsequently with μl of incomplete freund's adjuvant for booster at an interval of weeks. at days after the first immunization, mice from each group were sacrificed for both lymphocyte proliferation assay and cytokine production. in order to reduce the pain of mice to the greatest extent, cervical dislocation was chosen to kill them. it is the fastest method to make the spinal cord and brain spinal cord disconnected, so that the central nervous system instantly lost control of the whole body, which is in line with the requirements of animal welfare. the rest alive mice received μl of . (tcid )/ml pcv strain df- , and they were monitored for the following days. next, the mice were sacrificed for pcv content in different organs. blood samples were collected from the tail veins each week. the serum samples taken at each point post immunization were monitored for specific antibodies using porcine circovirus type elisa antibody test kit (keqian, china). operation steps followed the manufacturer's instructions. the abilities of all serum samples to neutralize the pcv strain df- were assessed using virus na. in brief, μl sera pretreated at °c for min were diluted in a serial two-fold way from : to : and mixed with an equal volume of virus ( tcid ) at °c for h. the serum-virus complex was transferred into confluent pk- cells in each well and then incubated at °c for h. since no visible cytopathic effect was verified, immunoperoxidase monolayer assay (ipma) was performed to ascertain the presence of the virus [ ] . virus neutralization titer was expressed as the highest dilution as log na in which no higher than % reduction of virus replication was detected as compared with the virus control. spleens of mice from each group were removed at days post inoculation (dpi). the spleen lymphocytes were isolated by lydroxypropylmethyl cellulose (solarbio, china) and then resuspended in rpmi medium containing % fbs. lymphocyte proliferation assay was performed by cell counting kit- assay (beyotime biotechnology, china) as previously described [ ] . t lymphocyte proliferation was represented as the stimulation index (si), the ratio of the mean reading of stimulated wells to unstimulated ones. the supernatants from the spleen lymphocytes employed in the proliferation assay were removed and adopted to analyze cytokines. the assays were performed using commercially available mice ifn-γ, il- , il- , tnf-ɑ and gm-csf elisa kits (uscn life science, china) following the manufacturer's instructions. pcv dna from different organs (heart, liver, spleen, lung and kidney) of all groups at days post-challenge was quantified by real-time fluorescent quantitative pcr as previously described [ ] . the viral load was calculated according to the standard curve plotting ct values against different dilutions of a standard plasmid. graphpad prism version . (usa) analysis of variance (anova) was performed. the data is expressed as the mean ± sem. statistical significance was found by two-way or one-way anova at*p < . , **p < . , ***p < . ; ns represents no statistical significance. all the experimenters were not blinded to any stage of the experiment. supplementary information accompanies this paper at https://doi.org/ . /s - - - . additional file . porcine circoviruses: a review studies on epidemiology and pathogenicity of porcine circovirus porcine circovirus type associated disease: update on current terminology, clinical manifestations, pathogenesis, diagnosis, and intervention strategies detection of a novel circovirus pcv in pigs with cardiac and multi-systemic inflammation commercial porcine circovirus type vaccines: efficacy and clinical application ten years of pcv vaccines and vaccination: is eradication a possibility? can porcine circovirus type (pcv ) infection be eradicated by mass vaccination? vet microbiol porcine circovirus type (pcv ): pathogenesis and interaction with the immune system enhanced protective immune response to pcv subunit vaccine by co-administration of recombinant porcine ifn-gamma in mice genetic and immunogenicity analysis of porcine circovirus type strains isolated in central china identification of the essential and non-essential transcription units for protein synthesis, dna replication and infectious virus production of porcine circovirus type open reading frame of porcine circovirus type encodes a major capsid protein construction and immunogenicity of recombinant swinepox virus expressing capsid protein of pcv immunogenicity and immunoprotection of porcine circovirus type (pcv ) cap protein displayed by lactococcus lactis calreticulin attenuated microwave radiation-induced human microvascular endothelial cell injury through promoting actin acetylation and polymerization calreticulin: one protein, one gene, many functions functional analysis of recombinant calreticulin fragment - : implications for immunobiological activities of calreticulin in health and disease self-oligomerization is essential for enhanced immunological activities of soluble recombinant calreticulin calreticulin as a hydrophilic chimeric molecular adjuvant enhances igg responses to the spike protein of severe acute respiratory syndrome coronavirus production of escherichia coli-based virus-like particle vaccine against porcine circovirus type challenge in piglets: structure characterization and protective efficacy validation calreticulin inhibits prion protein prp-( - ) aggregation in vitro baculovirus expression of the nterminus of porcine heat shock protein gp improves the immunogenicity of recombinant pcv capsid protein distribution of porcine circovirus cap antigen in the lymphoid tissue of pigs affected by postweaning multisystemic wasting syndrome improving bioscience research reporting: the arrive guidelines for reporting animal research nanoparticle orientationally displayed antigen epitopes improve neutralizing antibody level in a model of porcine circovirus type porcine parvovirus capsid protein expressed in escherichia coli selfassembles into virus-like particles with high immunogenicity in mice and guinea pigs differentiation of pcv and pcv by a multiplex real-time pcr assay publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we thank dr. yinbiao wang at xinxiang medical college for english writing help. we thank dr. shujun chai at henan academy of agricultural sciences for providing high-level quality of animal care. we thank dr. hongying chen, and mr. guanpeng guo for their assistance in obtaining the pcv isolates df- from the henan agricultural university. additional file . the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. the animal experiments were carried out and approved by the animal experiment committee of henan academy of agricultural sciences (approval number syxk - ). all animals received humane care in compliance with good animal practice according to the animal ethics procedures and guidelines of china. not applicable. the authors declare that they have no competing interests. key: cord- -vh ma k authors: smaldino, paul e.; jones, james holland title: coupled dynamics of behavior and disease contagion among antagonistic groups date: - - journal: biorxiv doi: . / . . . sha: doc_id: cord_uid: vh ma k disease transmission and behavior change are both fundamentally social phenomena. behavior change can have profound consequences for disease transmission, and epidemic conditions can favor the more rapid adoption of behavioral innovations. we analyze a simple model of coupled behavior-change and infection in a structured population characterized by homophily and outgroup aversion. outgroup aversion slows the rate of adoption and can lead to lower rates of adoption in the later-adopting group or even behavioral divergence between groups when outgroup aversion exceeds positive ingroup influence. when disease dynamics are coupled to the behavior-adoption model, a wide variety of outcomes are possible. homophily can either increase or decrease the final size of the epidemic depending on its relative strength in the two groups and on r for the infection. for example, if the first group is homophilous and the second is not, the second group will have a larger epidemic. homophily and outgroup aversion can also produce dynamics suggestive of a “second wave” in the first group that follows the peak of the epidemic in the second group. our simple model reveals complex dynamics that are suggestive of the processes currently observed under pandemic conditions in culturally and/or politically polarized populations such as the united states. behavior can spread through communication and social learning like an infection through a community (bass, ; centola, ) . cavalli-sforza and feldman, who pioneered treating cultural transmission in an analogous manner to genetic transmission, noted that "another biological model may offer a more satisfactory interpretation of the diffusion of innovations. the model is that of an epidemic" (cavalli-sforza and feldman, , - ) . the biological success of homo sapiens has been attributed to its capacity for cumulative culture, and particularly to the rapid and flexible adaptability that arises from social learning (henrich, ) . adoption of adaptive behaviors during an epidemic of an infectious disease could be highly beneficial to both individuals and the population in which they are embedded (fenichel et al., ) . coupling models of behavioral adoption and the transmission of infectious disease, what we call coupled contagion models, may thus provide important insights for understanding dynamics and control of epidemics. while we might expect strong selection-both biological and cultural-for adaptive responses to epidemics, complications such as the potentially differing time scales of culture and disease transmission and the existence of social structures that shape adoption may complicate convergence to adaptive behavioral solutions. in this paper, we explore the joint role of homophily-the tendency to form ties with people sim- ilar to oneself-and outgroup aversion-the tendency to avoid behaviors preferentially associated with an outgroup. several previous studies have considered the coupled contagion of behavior and infection, usually focused on cases where the behavior is one that decreases the spread of the disease (such as social distancing) and sometimes using the assumption that increased disease prevalence promotes the spread of the behavior (tanaka et al., ; epstein to analyze. to help us make sense of the dynamics, we will first describe the dynamics of infection and behavior adoption in isolation, and then explore the full coupled model. we model infection in a population in which individuals can be in one of three states: susceptible, infected, and recovered. when susceptibles interact with infected individuals, they become infected with a rate equal to the effective transmissibility of the disease, τ . infected individuals recover with a constant probability ρ. this is the well-known sir model of epidemics (tolles and luong, ). the baseline model assumes random interactions governed by mass action, and the dynamics are described by well-known differential equations (see supplemental materials). this model yields the classic dy- namics in which the susceptible and recovered populations appear as nearly-mirrored sigmoids, while the rate of infected individuals rises and falls ( figure s ). the threshold for the epidemic is given by the basic reproduction number, r , which is a measure of the expected number of secondary cases caused by a single, typical primary case at the outset of an epidemic and occurs when r > . for the basic sir model in a closed population, r = τ ρ . our analysis will focus on scenarios where individuals assort based on identity. in this case, assume that individuals all belong to one of two identity groups, indicated with the subscript or . let w i be the probability that interactions are with one's ingroup, i ∈ { , }. it is therefore a measure of homophily; populations are homophilous when w i > . . it is important to recognize that groups can differ in their homophily (morris, ) . for example, if groups differ in socioeconomic class and group tends to employ members of a group as service workers, homophily will be higher for group ; a member of group is more likely to encounter members of group than the reverse. we can update the equations governing infection dynamics for members of group , with analogous equations governing members of group . we assume the disease breaks out in one of the two groups, so the initial number of infected in group is small but nonzero, while the initial number of infected in group is exactly zero. without loss of generality, we have assumed that group is always infected first. when homophily is low, the model exhibits standard sir dynamics approximating a single unified population. when an infection breaks out in group , homophily can delay the outbreak of the epidemic in group . homophily for each group works somewhat synergistically, but the effect is dominated by w . this is because the infection spreads rapidly in a homophilous group , and if group is not homophilous, its members will rapidly become infected. however, if group is homophilous, its members can avoid the infection for longer, particularly when group is also homophilous. if only group is homophilous, the initial outbreak will be delayed, but the peak infection rate in group can actually be higher than in group , as the infection is driven by interactions with both populations (figure ). we also considered the case in which the transmissibility of the infection can be reduced to very near the recovery rate, so that r is very close to . in this case, homophily can protect groups where infection did not originally break out by keeping members relatively separated from the infection group ( figure s ). we model behavior adoption as a susceptible-infectious-susceptible (sis) process, in which individuals can oscillate between adoption and non-adoption of the behavior indef- initely. we view this as more realistic than an sir process for preventative-but-transient behaviors like social distancing or wearing face masks. to avoid confusion with infection status, we denote individuals who adopted the preventative behavior as careful (c), and those who have not as uncareful (u ). unlike a disease, which is reasonably modeled as equally transmissible between any susceptible-infected pairing, where behavior is concerned, susceptible individuals are more likely to adopt when interacting with in- group adopters, but less likely to adopt when interacting with outgroup adopters. we model the behavioral dynamics for members of group are as follows, with analogous equations governing members of group : members of group i may spontaneously adopt the behavior independent of direct social influence, and do so at rate α i . this adoption may be due to individual assessment of the behavior's utility, to influences separate from peer mixing, such as from media sources, or to socioeconomic factors that make behavior adoption more or less easy for certain groups. for these reasons, we assume that groups can differ on their rates of spontaneous adoption. in reality, it is possible for groups to differ on all four model parameters, all of which can influence differences in adoption rates. for simplicity, we restrict our analysis to differences in spontaneous adoption. uncareful individuals are positively influenced to become careful by observing careful individuals of their own group, with strength β. however, this is countered by the force of outgroup aversion, γ, whereby individuals may cease being careful when they observe this behavior among members of the outgroup. the behavior is eventually discarded at rate δ, representing financial and/or psychological costs of continuing to adopt preventive behaviors like social distancing. this model assumes no explicit homophily in terms of behavioral influence. on the one hand, it seems obvious that we observe and communicate with those in our own group more than other groups. on the other hand, opportunities for observing outgroup behaviors are abundant in a digitally-connected world, which alter the conditions for cultural evolution (acerbi, ). for simplicity, we do not add explicit homophily terms to this system. instead, we simply adjust the relative strengths of ingroup influence and outgroup aversion, β/γ. when this ratio is higher, it reflects stronger homophily for behavioral influence. numerical simulations that illustrate the influence of outgroup aversion are depicted in figure . in all cases, the behavior is first adopted by group . in the absence of outgroup aversion, both groups adopt the behavior at saturation levels, with group being slightly delayed. when outgroup aversion is added, the delay increases, but more importantly, overall adoption declines for both groups. this decline continues as long as the strength of outgroup aversion is less than the strength of positive ingroup influence. a phase transition occurs here ( figure c ,d). although group may initially adopt the behavior, adoption is subsequently suppressed, resulting in a polarizing behavior that is abundant in group but nearly absent in group . because all individuals have either adopted or not, u = − c , these coupled equations can be replaced by a single equation through substitutions. for intuitive reasons, we leave them as two coupled equations. we also consider the case in which one group has a higher intrinsic adoption rate, which could be driven by differences in personality types, norms, or media exposure between the two groups. when α > α , the equilibrium adoption rate for group could be considerably higher than for group , even when ingroup positive influence was greater than outgroup aversion ( figure e , f). note that these differences arise entirely because of outgroup aversion. when γ = , both groups adopt at maximum levels. outgroup aversion has a strong influence on adoption dynamics. it can delay adoption, reduce equilibrium adoption rates, and even suppress adoption entirely in the later- adopting group. as we will see, when the behavior being adopted influences disease transmission, quite complex dynamics can emerge. before we explore the coupled dynamics of this system, we must add one more consideration to the model. we focus on the adoption of preventative behaviors that decrease the effective transmission rate of the infection, such as social distancing or wearing face masks. we model this by asserting that the transmission rate is τ c for careful individuals and τ u for uncareful individuals, such that τ u ≥ τ c . when considering the the model has six compartments, with two-letter abbreviations denoting the disease and behavioral state ( figure s ). the coupled dynamics for members of group are as follows, with analogous equations governing members of group , such that the full system is defined by coupled differential equations. a list of all parameters is presented in table . behavioral adoption is independent of infection status in this model. this may not be a realistic assumptions for some systems, such as ebola, where the both the infection status of the adopter and the perceived incidence in the population are likely to influence behavior. the assumption is more realistic for infections like influenza and covid- , where infection status is not always transparent and decisions are likely to be made on the basis of more abstract socially-transmitted information. to make the behavioral adoption most meaningful, we focus on the case where instantaneous and universal adoption of the careful behavior would decrease the disease transmissibility so that r < . that is, if everyone immediately adopted the behavior, the epidemic would fizzle out. however, behavior adoption does not typically work this way. we have already observed that under assumptions of between-group variation and outgroup aversion, a behavior is likely to be adopted neither instantaneously nor universally. the question we tackle now is how those socially-driven facets of behavioral adoption influence disease dynamics. figures s , s ). in the absence of either ho- mophily or outgroup aversion, our results mirror previous work on coupled contagion in which the adoption of inhibitory behaviors reduces peak infection rates, flattening the curve of infection. due to differences in spontaneous adoption rates, however, group may see a higher peak infection rate even when the infection breaks out in group , because the inhibitory behavior spreads more slowly in that group ( figure a ). homophilous interactions further lower infection rates. if group alone is homophilous, the infection rate declines in that group, while peak infections actually increase in group ( figure c ). this is because group adopts the careful behavior early, decreasing their transmission rate and simultaneously avoiding contact with the less careful members of group , who become infected through their frequent contact with group . if group alone is homophilous, on the other hand, the infection is staved off even more so than if both groups are homophilous ( figure b , d). this is because members of group avoid contact with group until the careful behavior has been widely adopted, while members of group diffuse their interactions with some members of group , and these are less likely to lead to new infections. outgroup aversion considerably changes these dynamics. first and foremost, outgroup aversion leads to less widespread adoption of careful behaviors, dramatically increasing the size of the epidemic. moreover, because under many circumstances there will be between-group differences in equilibrium behavior-adoption rates, this can lead to dramatic group differences in infection dynamics. in the absence of outgroup aversion, we saw that homophily in group could lead to an almost total suppression of the epidemic. not so with outgroup aversion, in which the peak infection rates increase relative to the low homophily case ( figure e , f). this occurs because homophily causes a delay in the infection onset in group . behavioral adoption slows the epidemic initially in both groups. however, when the infection finally reaches group , behavioral adoption has decreased past its maximum due to the outgroup aversion, causing peak infections in both groups to soar. the dynamics are particularly interesting for the case where group is homophilous. recall that this is the group in which the epidemic first breaks out. because of homophily and rapid behavior adoption, the epidemic is initially suppressed in this group. however, due to slower and incomplete behavior adoption, the infection spreads rapidly in group . as the infection peaks in group while group decreases its behavior adoption rate, we observe a delayed "second wave" of infection in group , well after the infection has peaked in group ( figure g ). this effect is exacerbated when both groups are homophilous, as the epidemic runs rampant in the less careful group ( figure h ). as shown in the supplementary material, the timing of the second wave is also delayed to a greater extent when the adopted behavior is more efficacious at reducing transmission ( figure s ). it is well known that disease transmission is influenced by behavior. what is often overlooked is how behavior itself changes within heterogeneous cultural populations. both population structure and social identity influence who interacts with whom, af- fecting disease transmission, and who learns from whom, affecting behavior change. we have highlighted two of these forces-homophily and outgroup aversion-and shown their dramatic influence on disease dynamics in a simple model. homophily is often treated as though it were a global propensity for assortment by type (e.g. centola, ). however, homophily is frequently observed to a greater or lesser degree across subgroups, a phenomenon known as differential homophily (morris, ). there are several different interpretations of homophily in these simple models. when the homophily of group is less than group , group can be interpreted as "frontline" workers, who are exposed to a broader cross-section of the population by nature of their work. outgroup avoidance of this group's adopted protective behavior can arise if there are status differentials across the groups. prestige bias is a mechanism that can drive differential uptake of novel behavior by different groups (boyd and richerson, ) , for which there is quite broad support (jiménez and mesoudi, ) . when both groups are highly homophilous and outgroup aversion is strong, the resulting dynamics suggest the case of negative partisanship (abramowitz and webster, ), in which differences in the relative size of the epidemic will be driven purely by differences in the adoption rates by the two groups, including those differences induced by outgroup aversion. homophily has three main effects in our coupled-contagion models. when homophily is strong, it can protect the uninfected segment of the population (i.e., group ) if the transmissibility of the infection is sufficiently low ( figure s ) or if outgroup aversion is negligible ( figure ). however, when r is high enough and outgroup aversion induces group differences in behavior adoption, strong homophily among group can lead to larger, albeit delayed, epidemics in the initially-uninfected segment of the population. finally, when homophily is asymmetric and higher in group , it can substantially reduce the size of the epidemic in that group because the protective behavior spreads rapidly at the outset of the epidemic when there is the greatest potential to reduce the epidemic's toll. incorporating adaptive behavior into epidemic models has been shown to significantly alter dynamics (fenichel et al., ) . prevalence-elastic behavior (funk et al., ) is a behavior that increases with the growth of an epidemic. while it may be protective, it can also lead to cycling of incidence, which can prolong epidemics. similarly, the adoption of some putatively-protective behaviors that are actually ineffective can be driven by the existence of an epidemic when the cost of adoption is sufficiently low (tanaka et al., ). we have shown in this paper that group-identity processes can have large effects, leading groups that would otherwise respond adaptively to the threat of an epidemic to behave in ways that put them, and the broader populations in which they are embedded, at risk. the context of the ongoing covid- pandemic provides some interesting and timely perspective on the relationship between behavior, adaptive or otherwise, and transmis- infection rates. we expect that such a situation will not induce strong prevalence-elastic behavioral responses, and that the sorts of identity-based responses we describe here will dominate the behavioral effects on transmission. in terms of social interaction and adoption dynamics, group identity exerts its influence by way of homophily, a powerful social force. aral et al. ( ), for example, showed that homophily accounted for more than % of contagion in a natural exper- iment on behavioral adoption. the effect of homophily on diffusion dynamics can be variable. for example, homophily can slow down convergence toward best responses in strategic networks (golub and jackson, ). this can be critical when the time scales of learning and infection are different. homophily can also lower the threshold for desirability (or the selective advantage) required for adoption of a behavior. creanza and feldman ( ) showed that homophily and selection can have balancing effects-the selective advantage of a trait does not need to be as high to spread when it is transmitted assortatively by its bearers. in the case of our coupled-contagion model, strong homophily interferes with the adaptive adoption of protective behavior. centola ( ) showed that homophily can increase the rate of adoption of health behaviors, but his experimental population could assort only on positive cues, and had no ability to signal or perceive group identity. when homophily promotes negative partisanship (abramowitz and webster, ) with respect to the adoption of adaptive behavior, it can lead to quite complex outcomes, as we have outlined in this paper. how do we intervene in a way to offset the pernicious effects of negative partisanship on the adoption of adaptive behavior? while it may seem obvious, strategies for spreading efficacious protective behaviors in a highly-structured population with strong outgroup aversion will require weakening the association between protective behaviors and par- ticular subgroups of the population. given that we are writing this during a global pandemic in which perceptions and behaviors are highly polarized along partisan lines, attempts to mitigate partisanship in adaptive behavioral responses seem paramount to support. the models we have analyzed in this paper are broad simplifications of the coupled dynamics of behavior-change and infection. it would therefore be imprudent to use them to make specific predictions. the goal of this approach is to develop strategic models in the sense of holling ( ) , sacrificing precision and some realism for general understanding of the potential interactions between social structure, outgroup aversion, and coupled contagion (levins, ; smaldino, ) . such models provide a scaffold for the development of richer theories concerning coupled disease and behavioral contagions. epstein, j. m., parker, j., cummings, d., and hammond, r. a. ( ) . coupled contagion dynamics of fear and disease: mathematical and computational explorations. line model assumes random interactions governed by mass action, and the dynamics are described by the following well-known differential equations describing the proportion of the population in these three compartments: this model yields the classic dynamics in which the susceptible and recovered populations appear as nearly-mirrored sigmoids, while the rate of infected individuals rises and falls ( figure s ). figure s . classic sir dynamics. here τ = . , ρ = . . the threshold for the epidemic is given by the basic reproduction number, r , which is a measure of the expected number of secondary cases caused by a single, typical at the outset of an epidemic and occurs when r > . r is essentially the ratio of the rate of additional infections to the rate of removal of infections through recovery and possibly death. for the classic sir model, the calculation is quite simple. we assume that s ≈ at the time of initial outbreak, and we are interested in the case where the rate of new infections exceeds the rate of recovery: appendix b. the sir model with homophily we extend the sir model to explore scenarios where individuals assort based on identity. in this case, assume that individuals all belong to one of two identity groups, indicated with the subscript or . let w i be the probability that interactions are with one's ingroup, i ∈ , . it is therefore a measure of homophily; populations are homophilous when w i > . . homophily can be asymmetric between groups, because members of one group may be more likely to have interactions with the outgroup than the other group. for example, low ses individuals, who often work service jobs, may be unable to avoid interactions with the outgroup. we can update the equations governing infection dynamics for members of group , with analogous equations governing members of group : as illustrated in figure s , when an infection breaks out in group , homophily can delay the outbreak of the epidemic in group . homophily for each group works somewhat synergistically, but the effect is dominated by w . this is because the infection spreads rapidly in a homophilous group , and if group is not homophilous its members will rapidly become infected. however, if group is homophilous, its members can avoid the infection for longer, particularly when group is also homophilous. we also explored a scenario where r for the basic model was very close to , indicating a small epidemic (we used r = . ; figure s ). when homophily was low (w = . ), the populations mixed a lot. the proportion of infected individuals in group briefly fell, as the majority of new infected individuals were in group . however, the groups quickly matched their pace and experienced the outbreak in tandem. when homophily was high (w = . ), not only did group experience a delayed outbreak, it also experienced a substantially lower peak infection rate, because the total number of infected individuals at the start of its outbreak was so much lower than that experienced by group . thus, homophily can serve not only to delay an epidemic, but also to reduce it in the cases of homophily and the sis behavioral adoption model with outgroup aversion. the adopted behavior decreases the effective transmission rate of the infection due to measures like social distancing. we model this by asserting that the transmission rate is τ c for careful individuals and τ u for uncareful individuals, such that τ u ≥ τ c . when considering the interaction between groups, we use the geometric mean, so the transmissibility between su and iu is √ τ u τ c . the model has six compartments, with two-letter abbreviations denoting the disease and behavioral state ( figure s ). the coupled dynamics for members of group are as follows, with analogous equations governing members of group , such that our system is defined by coupled differential equations: here we present an extended version of the full model analysis presented in the main text, that includes intermediate homophily of w i = . . analysis with no outgroup aversion is shown in figure s , and with outgroup aversion is shown in figure s . the figures illustrate how homophily and outgroup aversion can interact to produce unintuitive dynamics. when both forces are present, an infection that begins in group can peak earlier and stronger in group , followed by a smaller peak in the group where it began. in the main text analysis, we assumed that the adopted behavior reduced the transmission to below the threshold for r < . in other words, if everyone immediately and universally adopted the behavior at the start of the outbreak, it would not become an epidemic. although we view this as a reasonable assumption (that is, the efficacy of the behavior is reasonable, not the expectation that it will be either immediately or universally adopted), it is also worth examining what happens with the spread of behaviors that reduce transmission, but not below epidemic levels. figure s illustrates the model su sc figure s . illustration of the model dynamics. (a) transition probabilities between compartments for members of group . for simplicity these probabilities do not include the influence of homophily. (b) homophilous interactions. members of group i have physical contact with members of their own group with probability w i and members of the outgroup with probability − w i . dynamics for varying levels of behavior efficacy (τ c ) with and without outgroup aversion and for both weak and strong homophily. without outgroup aversion (γ = ), the effect is clear: the more efficacious the behavior, the smaller the epidemic. this occurs because the behavior spreads effectively. with outgroup aversion, two things happen. first, the more effectively the behavior reduces transmission (that is, the smaller τ c is), the smaller the overall epidemic, but with an effect that is much stronger in group . in group , the effect of increased behavior efficacy is relatively small, because adoption is reduced and delayed. second, the better the be- havior reduces transmission, the bigger the delay in when group experiences a "second wave." this illustrates how complex the dynamics of disease transmission can become when even simple assumptions about behavior and group structure are considered. more effective behavior adoption figure s . coupled dynamics of the full model for varying levels of behavior efficacy, τ c = { . , . , . }, where only the last case would provide r < if immediately and universally adopted at the start of the outbreak. we provide analyses with and without outgroup aversion and for both weak and strong homophily. darker lines are group , lighter lines are group . parameters used: τ u = . , ρ = . , α = . , α = . , β = . , δ = . the secret of our success: how culture is driving human evolution, domesticating our species, and making us smarter intergroup behavior and social identity. the sage handbook of social psychology: concise student edition the strategy of building models of complex ecological systems prestige-biased social learning: current evidence and outstanding questions why we're polarized the strategy of model building in population biology substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sars-cov ) uncivil agreement: how politics became our identity estimating the infection and case fatality ratio for coronavirus disease (covid- ) using age-adjusted data from the outbreak on the diamond princess cruise ship the effect of opinion clustering on disease out- breaks models are stupid, and we need more of them social identity and cooperation in cultural evolution key: cord- -s aj authors: solano, gloria i.; segalés, joaquim; collins, james e.; molitor, thomas w.; pijoan, carlos title: porcine reproductive and respiratory syndrome virus (prrsv) interaction with haemophilus parasuis date: - - journal: veterinary microbiology doi: . /s - ( ) - sha: doc_id: cord_uid: s aj abstract the interaction of bacteria and virus has been well demonstrated in the pathogenesis of respiratory disease in swine. the interaction between porcine respiratory and reproductive syndrome virus (prrsv) and haemophilus parasuis has not been studied. we initiated studies to evaluate a possible effect of the prrsv on the pathogenesis of polyserositis caused by h. parasuis. a group of three week old piglets were distributed in groups. group i ( pigs) was inoculated with prrsv and h. parasuis. group ii ( pigs) was inoculated with h. parasuis alone. group iii ( pigs) was inoculated with virus alone and group iv ( pigs) was inoculated with culture media. lesions consisted of a severe fibrinous polyserositis affecting of animals in group ii and a mild fibrinous pleuritis in of animals of group i. three of ten animals dually infected with the two agents died during the course of the study. these animals had pulmonary congestion and focal lung hemorrhages. no other animals died from other groups. group iii and iv had no macroscopic lesions. microscopically group iii had interstitial pneumonia. immunomodulating virus effect may explain the differences in terms of lesions severity between groups i and ii. septic shock was suspected as cause of sudden death. glasser's disease caused by haernophilus parasuis is manifested in conventional herds as fibrinous polyserositis in s- week-old piglets as described by nielsen and danielson ( ) . stress conditions such as weaning or transport have been suggested as risk factors for the presentation of the disease (menard and moore, ). there has been a recent increase of fibrinous polyserositis outbreaks in the usa. possibly because of the high health status and immunological naive pigs produced using new technologies such as medicated early weaning (mew) described by wiseman et al., . altematively, the increase in incidence may reflect widespread infection by prrs virus. a putative immunosuppresive agent related to respiratory disease complex in swine (done et al., . christianson and joo. ) . prrsv has been suggested to increase the severity of secondary bacterial outbreaks increasing mortality and poor doing animals in nurseries and growers , with a major economical impact in the last five years (collins et al.. a; benfield et al., ; kerkaert et al., ) . field observations suggest an increase in atrophic rhinitis. polyserositis and bacterial meningitis in prrs infected pigs (collins, b) . prrs virus infection may predispose pigs to secondary infections by damaging non-specific respiratory defenses through the destruction of alveolar macrophages that may be substituted by immature cells (molitor, ) and by inducing inflammation in the nasal mucosa galina, ; rossow et al.. ) . experimentally prrs has been shown to predispose pigs to streptococcus suis meningitis (galina et al., a; galina et al.. b) . infection of susceptible pigs with prrs virus. followed days later by intranasal challenge with s. suis, resulted in central nervous clinical signs and meningitis. other workers have suggested interaction between prrs virus and a low-virulence strain of actinohacillus pleuropneumoniae, resulting in increased clinical signs and lesion severity (wensvoort. ) . interaction between prrs virus and other viruses has also been demonstrated. pigs coinfected with porcine respiratory coronavirus (prcv) and prrs virus developed severe clinical signs (van rieth et al.. ) whereas results were variable when pigs were coinfected with swine influenza virus and prrs virus (brun et al., ) . the objective of the present study was to evaluate the possible in vivo interaction between prrs virus and h. parasuis in young pigs. thirty piglets, between and days of age were obtained from five litters of a prrs virus and h. parusuis seronegative herd. after arrival. piglets were maintained with a special antibiotic schedule for three consecutive days ' while they were allowed to acclimate before the initiation of the experiments. medication was withdrawn six days one ml of prrsv strain vr- with a titer of lo tcid /ml (passage level ) grown in cl cells was used for intranasal inoculation '. characterization of this isolate has been previously described . a strain of haemophilus parasuis serotype (strain, ) was used . this strain has previously been shown to be virulent for spf pigs (rapp- gabrielson and gabrielson, ) . piglets were inoculated intratracheally with . ml of h. parasuis containing ' cpu/ml. briefly, after sedation with a xylacine and ketamine combination a laryngoscope was used to introduce an endotracheal tube . bacterial suspension was slowly administered during inspiration. thirty piglets were randomly assigned to two groups of piglets each (groups i and ii) and two groups of piglets each (groups iii and iv). an equal number of animals from each litter were allotted to every group. the groups were inoculated according to table . virus inoculation in groups i and iii was three days after arrival. bacterial inoculation was on day , five days after the initial viral challenge. the timing of exposure was based on previous results (molitor et al., ; rossow et al., ) that showed a profound damage of alveolar macrophages on day post-virus infection. rectal temperatures and clinical signs were recorded daily. complete post-mortem examinations were made when piglets from each group either died or when their condition was determined critical based on the presence of two or more signs of recumbency, acute central nervous system signs and hypothermia at which time they were euthanized with ml of intravenous injection of sodium pentabarbithal '. animals without severe signs were euthanized five days after bacterial inoculation. blood samples from all animals were collected on day of arrival, at the time of bacterial inoculation and at necropsy for serological measures of prrsv antibody titer. necropsy was performed on each animal. samples from lung, trachea, nasal turbinates, heart, kidney, tonsil, thymus, spleen, ileum, liver and mediastinal, retropharyngeal, inguinal and mesenteric lymph nodes were collected. one lung and trachea were suspended in % neutral buffered formalin and perfused with the same fixative at cm of pressure until the lung volume approximated thoracic limits as previously described by others (rossow et al., . ; hayatdavoudi et al., ) . the trachea was ligated with string and the lung was fixed for h. transverse sections of dorsal, cranial and middle lung lobes were collected for microscopic examination. all other tissues were fixed by immersion in formalin. fixed samples were dehydrated. embedded in paraffin, sectioned at mm and stained by hematoxylin-eosin. tonsilar swabs collected on the day of arrival and post-mortem swabs of cerebro-spinal. ascitic and pericardic fluids. trachea, lung and joint were immediately plated on chocolate agar plates and blood agar plates with a nurse strain of staphylococcus aweus. after h of incubation at °c with % co, isolated colonies were taken for further biochemical testing. acid tests were performed. were frozen at - °c. urease. nad dependent growth. gram stain and levulinic isolates were then subcultured on pplo media. samples serum samples were tested for anti-prrsv antibodies by an inmmunofluorescent antibody test (ifa) using vr- prrsv infected cl cell monolayer as the antigen and a fluorescent labelled antispecies conjugate as the indirect stain (yoon et al., ) . repeated measures of variance were used for comparing rectal temperatures among groups. an additive linear model for categorical data was performed to analyze lesions and mortality. significant difference was considered when p < . . ' beuthanasia d-special, schering plough animal health. kenilworth. nj. there were no clinical signs following viral challenge. on the groups challenged with the virus (groups i and iii> only a mild increase in rectal temperature was seen ( p > . ). after the haemophilus parusuis inoculation (groups i and ii), pigs developed central nervous signs such as padling, nystagmus and tremor. pigs challenged with bacteria only (group ii) were more severely affected since they presented more than one central nervous sign. there was a significant difference in mean rectal temperature among groups following bacterial challenge. groups dually infected with prrsv and h. parusuis (group i) or h. parusuis alone (group ii) had higher mean temperatures than controls (group iv) or the group infected with virus only (group iii) ( p < . ) (fig. ) . over the days , , and the difference was most pronounced one day after bacterial challenge (day ). the group infected only with h. parusuis (group ii> had a higher mean temperature than the other groups ( p < . ). was observed only in the group coinfected with virus and bacteria (group i). the mortality between groups i and ii was different ( p < . ). animals challenged only with bacteria (group ii) had more severe and generalized polyserositis, characterized by large deposits of fibrin and fibrinous adherences of lung to thoracic cavity. animals dually challenged with virus and bacteria (group i) had less severe and more localized lesions. the group inoculated with prrsv only (group iii) or the controls (group iv) had no macroscopic lesions. microscopic results are summmarized in table . in group i only, one animal had fibrinous pleuritis. in group ii, of animals had localized or generalized fibrinous polyserositis (table ) and variable amounts of inflammatory cells, consisting of a mixture of monocytes, lymphocytes and polymorphonuclear neutrophils (pmnn) (fig. ) . four of animals in group i and of animals in group ii had meningitis, characterized by fibrinous exudate with macrophages and pmn cells (fig. ) . no interstitial pneumonia characterized by a mild macrophage and lymphocyte cell infiltration and thickened alveolar septa was present in all groups infected with the virus (group i and iii) (fig. ) . catharral-purulent bronchopneumonia consisting of many pmn in alveoli were also seen in group i ( animals) and group ii ( animals) (fig. ) . dead animals from group i ( animals) had intense lung congestion and one of them had pulmonary hemorrhagic zones. two of those animals had bacterial colonies in tonsils. however, no microscopic evidence explaining the sudden death (such as necrotic foci and/or hemorrhages in other organs) were seen. haemophilus parasuis was isolated from of animals in the prrsv-h. parusuis group (group i> and of animals in group ii. bacteria were isolated from joint, trachea, lung, cerebrospinal fluid (csf), pericardial and peritoneal fluids (table ) . animals were serologically negative to prrs virus on the day of arrival. all animals challenged with prrs virus seroconverted by -l days post exposure. typical viral this study is the first experimental report examining a putative interaction between prrs virus and huemophilus parusuis. infection with h. parusuis alone resulted in more severe clinical signs and lesions, but decreased mortality, compared to animals receiving the dual viral-bacterial challenge. animals infected only with h. purasuis showed a higher prevalence of polyserositis, characterized by pleuritis, pericarditis, polyarthritis, peritonitis and meningitis. in contrast, animals with the combined prrs virus-h. purusuis challenge had only pleuritis and meningitis, or meningitis alone. catharral-purulent bronchopneumonia was found in six animals from both groups inoculated with the bacteria. since no other microorganisms were isolated from these lungs, these findings strongly suggest that h. purusuis can be associated with pneumonia in appropriately susceptible animals. a possible explanation of the difference between the group dually infected with the virus-bacterial challenge (group i> and the bacterial challenge alone (group ii) in terms of lesions could be the immunomodulating effect of prrs virus. previous reports (molitor et al., ; ohlinger et al., ; galina et al., a) have shown that by days post-infection the virus produces a marked decrease in the percentage and functional ability to release superoxide anion in alveolar macrophages. in contrast, a sharp enhancement of humoral and cell-mediated functions at the systemic level were also found. the fact that group ii animals had more severe lesions as compared to animals previously challenged with prrs virus (group i), may be explained by this enhanced response at the systemic level. a trend of increased mortality was seen in group i; however, this difference was not statistically significant between group i and ii, probably due to limited size. the animals that died had congestive and hemorrhagic pulmonary lesions, with no other pathological lesions recorded. the fact that bacteria were isolated from several different fluids of these animals, together with the rapid occurrence of death may suggest septic shock as the cause of death. it is possible that the local immunosuppresive effects of the virus allowed for rapid bacterial proliferation in some animals that then died. the fact of observing increased mortality in group i and enhanced polyserositis lesions in group suggests that the virus has several effects on the pigs simultaneously. local destruction of phagocytic cells in the lung may lead to a rapid increase of bacterial numbers and death in some animals. in contrast, surviving animals then tend to develop more localized serositis as bacterial lesions because viral infection results in an increased systemic response which may minimize bacterial spread from the lung. some degree of bacteremia, however. did occur. since bacterial reisolation rates ( %) were the same for groups i and ii. bacteria were isolated from peritoneal. joint and pericardiac fluids as previously reported (little, ; morozumi and nicolet, ; morikoshi et al.. ). cerebrospinal fluid was an excellent sample for isolation of the bacteria when the animals show central nervous signs. in summary, infection of susceptible pigs with prrs virus followed by h. parusuis intratracheal challenge did not result in an increased bacterial polyserositis as compared to the group where h. parusuis was the unique challenge. these findings are in contrast to field observations wahle et al.. ; done and paton. ) where endemic prrs has been reported to produce an increased occurrence of polyserositis due to h. other management factors. such as comingling pigs from different sources, herd health, lack of immunity and other factors precipiting disease should also be considered when interpreting field observations. these results suggest that sudden death may be an important manifestation of this interaction. porcine reproductive and respiratory syndrome prrs: role of togavirus and other infectious agents in the respiratory disease of pigs swine infertility and respiratory syndrome (mystery swine disease). mn swine conference for veterinarians newly recognized respiratory syndrome in north american swine herds isolation of swine infertility and respiratory syndrome virus (isolate atcc vr- ) in north america and experimental reproduction of the disease in gnotobiotic pigs comparative pathology of viral respiratory infections in pigs porcine reproductive and respiratory syndrome: clinical disease, pathology and inmmnosuppression interaction between streptococcus suis serotype and prrs virus in specific pathogen free piglets effect of prrs virus on the clearance of streptococcus suis serotypte by pig alveolar macrophages possible mcchanims of viral-bacterial interaction in swine. swine health prod factors determining degree of inflation in intratracheally fixed rat lungs financial impact of chronic prrs haemophilus infection in pigs epidemiology and management of glhsser's disease in spf herds modulation of host immune response by sirs virus immune responses to prrs virus characterization of haemophilus parasuis isolated in japan morphological variations of huemophilus parusuis strains an outbreak of gl'dsser's disease. studies on etiology, serology and the effect of vaccination in vivo and in vitro studies on the immunobiology of prrs prrs virus and secondary disease prevalence of haemophilus parasuis serovars among isolates from swine experimental porcjne reproductive and respiratory syndrome virus infection in one, four and week old pigs pathogenesis of porcine reproductive and respiratory syndrome virus infection in gnotobiotic pigs experimental reproduction of haemophilus parasuis in swine: clinical, bacteriological and morphologic findings clinical effects of dual infections with prrs virus. prc virus and swine influenza virus porcine reproductive and respiratory syndrome health and immunological aspects of early weaning an indirect fluorescent antibody test for the detection of antibody to swine infertility and respiratory syndrome virus in swine sera key: cord- -uhrhsrky authors: lee, seul bee; choi, han seul; son, sejung; hong, young mi title: cardiac function in kawasaki disease patients with respiratory symptoms date: - - journal: korean circ j doi: . /kcj. . . . sha: doc_id: cord_uid: uhrhsrky background and objectives: respiratory symptoms are often observed in children with kawasaki disease (kd) during the acute phase. the association of respiratory viruses in children with kd was investigated using multiplex reverse transcriptase-polymerase chain reaction (rt-pcr) and tissue doppler echocardiography. subjects and methods: kd patients were included from january to june . we compared groups (group : n= , kd without respiratory symptoms; group : n= , kd with respiratory symptoms; and group : n= , febrile patients with respiratory symptoms). laboratory data were obtained from each patient including n-terminal pro-brain natriuretic peptide (nt-probnp). echocardiographic measurements were compared between group and group . rt-pcr was performed using nasopharyngeal secretion to screen for the presence of viruses in groups and . results: the incidence of kd with respiratory symptoms was . %. the duration of fever was significantly longer, and coronary artery diameter was larger in group than in group . tei index was significantly higher and coronary artery diameter larger in group than group . coronary artery diameter, c-reactive protein levels, platelet count, alanine aminotransferase levels, and nt-pro bnp levels were significantly higher and albumin levels lower in group compared with group . conclusion: nt-pro bnp was a valuable diagnostic tool in differentiating kd from other febrile viral respiratory infections. some viruses were more frequently observed in kd patients than in febrile controls. tei index using tissue doppler imaging was increased in kd patients with respiratory symptoms. respiratory symptoms are frequently observed in children with kd during the acute phase. ) ) jordan-villegas et al. ) reported that patients with kd who carry respiratory viruses more frequently showed coronary artery dilatation and were more often diagnosed with incomplete kd. some studies ) ) ) determined that specific respiratory viruses were associated with kd. however, other authors insisted that the detection of viruses in kd may not have any associative implications. ) tissue doppler imaging (tdi) may be a superior method to measure the tei index in children because it is less affected by heart rate variability. ) the myocardial performance index (tei index) evaluates global left ventricle (lv) systolic and diastolic function. it is correlated with severity and clinical outcome in children with cardiac disease. ) there haven't been any reports about an association between respiratory infection and cardiac function in kd patients. in this study, we compared laboratory findings in kd patients with febrile patients having a viral infection. another purpose of this study was to investigate the association of respiratory viruses and cardiac function in children with kd. this prospective study was performed on kd patients ( males, females) at ewha womans university mokdong hospital from january to june . we compared groups (group : n= , kd without respiratory symptoms; group : n= , kd with respiratory symptoms; and group : n= , febrile patients with respiratory symptoms). respiratory symptoms included cough, rhinorrhea, sputum, and sore throat. to diagnose kd, we used the american heart association criteria. ) diagnosis of the complete type of kd included fever of more than days and at least four of the following: ) changes in extremities including palm and sole erythema or edema, ) polymorphous exanthema, ) bilateral bulbar conjunctival injection without exudates, ) changes in the lips and oral cavity including erythema, cracked lips, strawberry tongue, and diffuse injection of oral and pharyngeal mucosa, and ) cervical lymphadenopathy over . cm in diameter. children who had a fever lasting or more days and fulfilled two or three principle clinical criteria were regarded as having incomplete kd after other possible causes of fever were excluded. all kd patients were treated with a single dose of intravenous immunoglobulin (ivig, g/kg for - hours) and high dose aspirin ( mg/kg three times per a day) until having an afebrile status for more than days, after which low dose aspirin ( mg/kg/day) was administered. the ethics committee of ewha womans university mokdong hospital institutional review board approved this study. written informed consent was obtained from the parents of all patients. laboratory data obtained from each patient included complete blood count, erythrocyte sedimentation rate (esr), and levels of alanine aminotransferase (alt), aspartate aminotransferase (ast), serum total protein, albumin, c-reactive protein (crp), n-terminal pro-brain natriuretic peptide (nt-probnp). echocardiography was performed using an ie machine (philips medical system, andover, ma, usa) with an s transducer on kd patients and febrile patients who were suspected of having kd during their admission period. standard parasternal and apical views were acquired. complete d and m-mode echocardiogram, pulsed color-flow doppler, and tdi were obtained. we measured the following lv parameters by m-mode echocardiography: interventricular septal wall thickness, posterior wall thickness, and lv end diastolic dimension at the chordae tendinae level. ejection fraction was determined by using the biplane simpson formula, and fractional shortening was calculated using lv internal dimensions. the diastolic function was assessed with pulsed doppler mode from the apical window. early diastolic velocity (e), late diastolic velocity (a), e/a ratios, and deceleration time were measured using conventional pulsed wave doppler echocardiography (ie machine, philips medical system, andover, ma, usa). tdi velocities were obtained at the basal septum from the apical four-chamber view. the doppler beam was aligned as parallel as possible to the direction of the maximum annular motion. tdi was performed to obtain longitudinal myocardial velocity with high quality. a narrow sector angle was used, and image depth was adjusted to allow for a high frame rate ( - frames/s) with care taken to avoid angulations. the sweep speed was at least mm/s. the peak systolic myocardial velocity (s'), early diastolic myocardial velocity (e'), and late diastolic myocardial velocity (a') were obtained. we calculated the tei index using tdi, which combines systolic and diastolic lv time intervals, using the formula (a-b)/b, where a is the interval between the closing and the opening of the mitral valve, and b is equal to the left ventricle ejection time (lvet) (fig. ). isovolumetric relaxation time (ivrt) was measured from the end of the s' wave to the onset of the e' wave, and isovolumetric contraction time (ivct) was measured from the end of the a' wave to the onset of the s' wave. the coronary artery was measured at the parasternal short axis view (fig. ) . coronary arteries were defined as abnormal if the internal lumen diameter was greater than mm in children younger than years old, ) if the internal diameter of a segment measured at least . times that of an adjacent segment, or if the coronary lumen was clearly irregular. ) a giant aneurysm was defined as an internal lumen diameter of greater than mm. ) we collected the nasopharyngeal secretion of kd patients with respiratory symptoms and control febrile patients with respiratory symptoms using nasal and throat swabs on the first day of hospitalization. reverse transcriptase-polymerase chain reaction (rt-pcr) was ibm spss statistics version . (spss inc., chicago, il, usa) was used for all statistic analyses. data were expressed as mean±standard deviation. echocardiographic findings were represented as adjusted mean±standard deviation after adjustment for covarients such as crp and fever duration. the kruskal wallis test and the wilcoxon rank sum test were used to compare laboratory data between kd patients and the control group. a p value of less than . was considered statistically significant. a total of kd patients diagnosed with kd were enrolled in the study. the clinical characteristics of kd patients with and without respiratory symptoms are shown in table . in this study, patients ( . %) were included in the kd group without respiratory symptoms (group ), and patients ( . %) were included in the kd group without respiratory symptoms (group ). there were no significant differences in age and sex between group and group . fever duration was significantly longer in group than in group ( . ± . days vs. . ± . days). in group , conjunctival injection was found in . % of the patients, cervical lymphadenopathy over . cm in . %, skin rash in . %, lip and/ or oral mucosal abnormality in . %, palm and/or sole erythema and edema in . %, and bacillus calmette-guérin (bcg) site injection in . % of cases. in group , conjunctival injection was found in . % of the patients, cervical lymphadenopathy in . %, skin rash in . %, lip and/or oral mucosal abnormality in . %, palm and/or sole erythema and edema in . %, and bcg site injection in . % of cases. other features, such as polymorphous skin rash, lip and oral mucosal abnormalities, hand or foot erythema, and edema, were more frequently observed in group (p< . ), and the rate of incomplete type kd was significantly higher in group than group ( . % vs. . %, p= . ) ( table ) . there were no significant differences in age and sex between group and group (data not shown). there were no significant differences in laboratory tests including those for hemoglobin (hb), white blood cell count (wbc), percentage of segmented neutrophils (seg %), platelet count, esr, crp, and levels of ast, serum total protein, albumin, and nt-pro bnp between groups and . alt was significantly higher ( . ± . iu/l vs. . ± . iu/l) in group compared with group . the nt-pro bnp value was higher in group compared with group ( . ± . pg/ml vs. . ± . pg/ml, table ). platelet count ( . ± . x /l vs. . ± . x /l), crp ( . ± . mg/dl vs. . ± . mg/dl), and alt ( . ± . iu/l vs. . ± . iu/l) were also significantly higher in group than in group . albumin level was significantly lower in group than in group ( . ± . g/dl vs. . ± . g/dl). other laboratory tests including those for hb, wbc, seg %, esr, ast, and total protein showed no significant differences between group and group ( table ). there were no significant differences in positive rates of pcr between group and group ( . % vs. . %). group had a higher positive rate for adenovirus than group ( . % vs. . %, p= . ). the control group had a significantly higher positive rate for viral pcr for parainfluenza virus ( % vs. . %, p= . ). for other various viruses including coronavirus, parainfluenza virus ( and ), influenza (a and b), respiratory syncytial virus (a and b), rhinovirus (a, b, and c), metapneumo virus, and bocavirus, there were no significant differences in positive rates of respiratory virus pcr ( table ) . ejection fraction and fractional shortening were not significantly different between group and group . there were no significant differences in late diastolic myocardial velocity (a') ( (table ) . however, ivct ( . ± . ms vs. . ± . ms) and tei index ( . ± . vs. . ± . ) were significantly higher in group compared with group . coronary artery abnormality was more frequent in group compared with group ( . % vs. . %, not shown in the table ), and coronary artery diameter was significantly higher in group compared with group ( . ± . mm vs. . ± . mm) ( table ) . response to intravenous immunoglobulin between kawasaki disease patients without respiratory symptoms and those with respiratory symptoms ivig responders showed improvement in fever and other symptoms after ivig administration. if kd patients showed fever (higher than o c) after hours of ivig infusion, they were regarded as non-responders, then retreated using a second ivig. there were no significant differences in the number of ivig responders, family history, recurrence, and retreated cases of kd between group and group ( table ). kd is the most common cause of acquired heart disease among children in developed countries, but the etiology of kd remains unknown. among many factors that might be associated with kd, infections are considered to be one of the predisposing factors of kd. ) burns et al. ) reported significant and consistent seasonal variations in kd patients with a higher incidence in winter and a lower incidence in late summer and fall. in korea, kd showed the highest incidence in summer and winter and the lowest incidence in february and october. ) ) the monthly fluctuation in the incidence of kd and the detection of viruses suggests the etiologic importance of the precedence of infection in the development of kd. according to tsai et al. ) during the acute stage of kd, % of family members of kd patients had acute illnesses, and % of them had clusters of infectious disease. these results provide more evidence that kd is strongly associated with infectious disease. it appears that some pathogens are a cause of kd, but no specific pathogen has been found to be a definite cause of kd. ) ) ) many studies have been carried out to identify the infectious agents responsible for kd. ) ) chang et al. ) have suggested that several viruses, such as enteroviruses, adenoviruses, rhinoviruses, and coronaviruses, are associated with kd. the kd patients in their studies had significantly higher positive rates for virus isolation and pcr for those viruses compared with the control group ( . % vs. . %, p< . ). jordan-villegas et al. ) stated that respiratory symptoms were frequently observed in children with kd during the acute phase. the association rate of kd with antecedent respiratory illness, including rhinovirus, adenovirus, influenza, parainfluenza, and respiratory syncytial virus, has been reported to range from . % to . %. in our study, adenovirus, respiratory syncytial virus, rhinovirus, and bocavirus were found in kd patients. group had a higher rate of positive results for adenovirus than group ( . % vs. . %, p= . ). the control group had a significantly higher positive rate for parainfluenza virus ( % vs. . %, p= . ). in this study, we assumed that some viruses were strongly associated with kd occurrence. the etiology of kd is still being debated, but the evidence suggests the following: ) monthly clustering and seasonality, ) ) geographic prevalence, ) ethnic tendency, ) a high association between kd and infectious disease, and ) higher incidence rates among -month to -year-old children who have low maternal antibodies and are more susceptible to infections in general. ) ) chang et al. ) found that heterogeneous infectious agents, such as common viruses, may trigger kd in young children with certain genetic backgrounds or susceptibility. on the other hand, kim et al. ) reported that virus detection rates using multiplex rt-pcr were . % in kd patients and . % in the control group. there was no significant association between respiratory viruses and kd. kd with respiratory viruses is frequently misdiagnosed as a simple viral infection before other symptoms appear, so the diagnosis can be delayed. kd may be misdiagnosed as another febrile disease such as adenoviral infection, measles, rubella, and scarlet fever. ) according to ye et al. ) nt-pro bnp had the highest diagnostic value for kd among other factors including cytokines, crp, and esr, which were recommended indexes by the american heart association. they found that nt-pro bnp is a reliable marker for the diagnosis of kd and the prediction of ivig treatment effect. dahdah et al. ) reported that nt-pro bnp level was significantly higher in incomplete kd groups than in febrile patients (p< . ). nt-pro bnp was a useful marker for the diagnosis of kd in patients less than months of age. ) our study demonstrated that nt-pro bnp is a valuable diagnostic tool in differentiating kd from other febrile table ). the clinical manifestations of adenovirus, especially conjunctival injection, throat injection and prolonged fever, are somewhat like those of kd. kd is frequently misdiagnosed as pharyngoconjunctival fever caused by adenovirus because of the clinical similarity of the two diseases, ) so infusion of ivig may be delayed. jordan-villegas et al. ) has shown that . % of kd patients had adenovirus in their respiratory tract, and of kd patients with concomitant adenovirus infection had incomplete kd. although virus pcr shows higher sensitivity and detects a relatively low level of virus, viral quantification was not done in this study. jordan-villegas et al. ) found that children with kd who had respiratory virus infections had a higher incidence of coronary artery dilatation than kd patients without viral infections, and the former group were more often diagnosed with incomplete kd. according to vijayan et al. ) coronary artery dilatation was more frequently observed in incomplete kd than in classical kd ( . % vs. . %, p< . ). these findings were similar with our study. fever duration was significantly longer, and coronary artery diameter was larger in group than in group . the rate of incomplete kd was significantly higher in group compared with group . we could not find other articles studying the relevance of respiratory infection and cardiac function in kd patients. the tei index combines the systolic and diastolic functions of ventricles in an index of global myocardial performance. ) it correlates with the severity and clinical outcome in children with cardiac disease. ) ) the tei index could be used as an accurate tool for estimating myocardial function in kd patients. ) according to ajami et al. ) after ivig treatment in kd patients, the tei index changed from . ± . to . ± . . the tei index could be used to detect early global myocardial dysfunction when other cardiac function indexes are in the normal range. ) there are several limitations to our study. first, diagnosis of kd was mostly dependent on clinical manifestations since not every patient had coronary artery dilatation. also, we could not collect nasopharyngeal swab samples from all kd patients with respiratory symptoms because the respiratory virus pcr test was quite expensive. kd patients with respiratory symptoms whose parents did not agree to have their kids test for virus pcr were excluded in this study. group patients were assumed not to have concomitant viral infections. rt-pcr results for all kd patients would help identify the relationship between respiratory viruses with echocardiographic findings in kd patients. second, adenoviral infection could not be distinguished from kd by laboratory tests. although there are other ways to diagnose viral infection, including adenovirus, such as by using a virus culture or a neutralized antibody, we only used virus pcr to detect respiratory viruses in this study. third, the sample size was relatively small. pcr is a relatively easy way to detect respiratory viruses in children, but in this study, whether a virus coexists with or causes kd cannot be distinguished. viral culture and the quantification of viral loading could help distinguish whether a specific virus simply coexists with or causes kd. in conclusion, nt-pro bnp is a valuable diagnostic tool in differentiating kd from other febrile viral respiratory infections. kd patients with respiratory symptoms had a higher tei index than kd patients without respiratory symptoms, suggesting myocardial dysfunction. further studies are needed to clarify this relevance. a new infantile acute febrile mucocutaneous lymph node syndrome (mlns) prevailing in japan kawasaki syndrome kawasaki disease in children evaluation of the temporal association between kawasaki disease and viral infections in south korea viral infections associated with kawasaki disease kawasaki syndrome results of the nationwide epidemiologic survey of kawasaki disease in and in japan the male predominance in the incidence of infectious disease in children: a postulated explanation for disparities in the literature kawasaki disease: an evidence based approach to diagnosis, treatment, and proposals for future research human adenovirus infection in kawasaki disease: a confounding bystander investigation of kawasaki syndrome risk factors in colorado concomitant respiratory viral infections in children with kawasaki disease detection rate and clinical impact of respiratory viruses in children with kawasaki disease tissue doppler septal tei index indicates severity of illness in pediatric patients with congestive heart failure diagnosis, treatment, and long-term management of kawasaki disease: a statement for health professionals from the committee on rheumatic fever, endocarditis, and kawasaki disease, council on cardiovascular disease in the young epidemiological features of kawasaki disease in korea seasonality of kawasaki disease: a global perspective transmission of acute infectious illness among cases of kawasaki disease and their household members the role of infection in kawasaki syndrome kawasaki disease: what is the epidemiology telling us about the etiology? epidemiological features of kawasaki disease in taiwan temporal and geographical clustering of kawasaki disease in japan value of the n-terminal of prohormone brain natriuretic peptide in diagnosis of kawasaki disease natriuretic peptide as an adjunctive diagnostic test in the acute phase of kawasaki disease clinical characteristics and serum n-terminal pro-brain natriuretic peptide as a diagnostic marker of kawasaki disease in infants younger than months of age coronary artery dilatation in incomplete kawasaki disease tei-index in patients with mildto-moderate congestive heart failure doppler echocardiographic index for assessment of global right ventricular function evaluation of myocardial function using the tei index in patients with kawasaki disease key: cord- -yppi a authors: nan title: th european congress of pathology, ljubljana, slovenia, september - , date: - - journal: virchows arch doi: . /s - - - sha: doc_id: cord_uid: yppi a nan introduction formation of terminal villi with syncytiocapillar membranes is necessary for optimal maternal-foetal exchange and especially for oxygen diffusion. immature placentas with little number of syncytiocapillar membranes may worse foetal nutrition and gas exchange. the aim of this study was to estimate the role of villous tree immaturity in the development of intrauterine hypoxia. materials and methods placentas from singleton pregnancies were investigated. according to ultrasound and doppler velocime-try data, apgar score, placentas were divided into groups with chronic hypoxia ( ), iugr ( ), acute intrauterine hypoxia ( ), from normal pregnancies ( ). estimation of the degree of maturity according to gestational age was made on routine histological slides. vascular endothelial growth factor (vegf) and placental growth factor (plgf) concentration in placental tissue homogenates were investigated by elisa method in placentas. results the frequency of placental immaturity was -fold higher in placentas with hypoxia in compare with control group. preterm maturation of placental tree accompany with severe foetal hypoxia, a very high mortality and morbidity. concentration of vegf in placental tissue was elevated in placentas with terminal villi deficiency, and concentration of plgf was elevated in placentas with synchronous immaturity. conclusion due to importance of the placental maldevelopment it is necessary to devise methods of its early diagnostics and investigate mechanisms of villous tree development. determining of vegf and plgf may be useful for this purpose. molecular analysis of hereditary hemochromatosis g weirich, r langer, h nina, n jörg, h hoefler institute of pathology technische universität münchen, munich, germany hereditary hemochromatosis (hh) is an autosomal recessive disorder, common in individuals of northern european descent (prevalence close to : ) . hh is characterized by increased iron absorption and iron deposits in various organs. hh patients may develop liver and pancreas cirrhosis, primary liver cancer, diabetes mellitus, and cardiomyopathy. in the majority of cases, hh is caused by mutations of the hfe-gene on chromosome p. hfe encodes an mhc class-i gene, a putative negative regulator of iron uptake. three hfe mutation are common, c y, h d and s c. patients with a homozygous c y genotype most often endure a severe clinical course, whereas homozygotes for h d may develop mild forms of the disease. heterozygotes are usually symptom-free, but show elevated serum ferritin levels. it has been speculated that secondary iron overload (heavy alcohol, chronic hepatitis, ?-thalassemia) may be a critical co-factor in those heterozygotes that develop symptoms of hh. hh not associated with hfe mutations is much less common. within this heterogeneous group of non-hfe hh, three subtypes have been attributed to genetic alterations. juvenile hemochromatosis (hfe ) is a rare but severe disorder mapped to chromosome q. hfe has recently been mapped to the transferring receptor gene (tfr ) on chromosome q . hfe follows an autosomal dominant trait and is associated with mutations of the ferroportin gene (slc a ) on chromosome . except for juvenile hemochromatosis, hfe, hfe and hfe are amenable to mutation analysis. the advent of modern high throughput technologies such as denaturing high performance liquid chromatography (dhplc) has sparked clinical mutation screening programs, which also include screening of patients suspected to be affected by hh. in addition, dhplc-based mutation screening can also be performed using archival formalin-fixed, paraffin embedded tissues (ffpe). we present here results from hfe-analyses of ffpe from autopsy cases using dhplc and direct sequencing. introduction diseased tissues contain all the information on the genetic and epigenetic changes that caused the disease and determine its outcome (prognosis). recent developments in genome and proteome research offer the opportunity to unravel this information and provide new insight into the molecular pathogenesis of diseases. aims: we are establishing a unique human tissue resource for genome research based on a collection actually comprising . mio paraffin-embedded and frozen tissue samples stored at the temperature of liquid nitrogen. materials and methods this collection is being expanded by national and international interdisciplinary cooperations. blood samples, patient history, laboratory parameters, treatment and outcome information are included in addition to tissues. special emphasis is placed on quality control and compliance with ethical and legal criteria. all protocols follow established standard operating procedures in accordance with guidelines of the fda and recommendations of european countries. informed consent is obtained from patients and appropriate security measures guarantee patient confidentiality. results to make this resource available to a wider scientific community, we generate disease-specific gene libraries and produce tissue micro arrays. well defined expandable cell lines and nude mice xenografts are established for characterization of gene function. conclusion proper access to collections of diseased human tissues is currently a major limiting factor for genome research in medicine. there is an urgent need of tissue banks that meet highest quality and legal criteria. introduction neural cell adhesion molecule (ncam) is highly expressed on cells of the murine metanephrogenic mesenchyme at early stages of kidney development. during further development, ncam can still be detected on epithelial cells of comma and sshaped bodies as well as on interstitial mesenchymal cells. during maturation of the fetal kidney ncam gradually disappears from all epithelial structures and is confined to small areas of interstitial medullary cells. in the adult murine kidney ncam expression is virtually absent. materials and methods in the present study ncam expression was analyzed by immunohistochemistry and western blots in adult human kidneys, including healthy kidneys and kidneys with different glomerular diseases associated with incipient interstitial fibrosis (if). ncam positive cells were characterized by triple immunofluorescence staining using antibodies against human ncam combined with a panel of antibodies against neurofilaments, a smooth muscle actin (asma), hla class ii, cd and cd , and dapi for nuclei staining. digital pictures from every fluorescence channel were taken and superimposed for the specific staining using the analysis dokutm software from soft imaging systems. results in adult human kidneys, ncam expression was restricted to rare interstitial cells with a dendritic morphology, long cytoplasmatic extensions and elongated nuclei, which were localized predominantly in the outer medulla. in comparison to healthy kidneys, the number of ncam-positive interstitial cells increased in the initial phases of if in different forms of glomerulonephritis. western blot analysis of renal tissues with incipient if showed the exclusive expression of the kda isoform of ncam; other isoforms were not detectable. staining with antibodies against neurofilaments clearly differentiated nerve cells from ncam-positive interstitial cells, which are neurofilament negative. they are also asma negative, though the number of the asma+ cells increased at the early stages of if. however, some of the ncam-positive cells clearly express the stem cell markers cd and cd . conclusion these data indicate that a subpopulation of ncampositive interstitial cells may be renal progenitor cells, which can participate in the initial phases of if. introduction cell migration from the host to the transplanted organ results in chimerism ( ) , and seems to be associated with chronic transplant rejection ( , ). however, early detection of recipient cells might provide an important clue for anti-rejection therapy. materials and methods cases from sex-mismatched renal transplants (male kidney into female receiver) with consecutive biopsies (one, six, and twelve months) were analysed by fish and immunohistology (c-kit and smooth muscle actin). in additional cases of renal transplants each at day and twelve months after transplantation, glomeruli were microdissected and a rt-pcr for c-kit and ß-actin was performed. umbilical vein endothelial cells served as positive control. results glomeruli: transplant glomerulopathy shows increasing numbers of y-positive cells with progression of the sclerosing lesion. by lm -rt-pcr, increased c-kit transcription is observed compared to controls, while immunohistology is negative. arteries: recognition of vascular lesions as chronic transplant vasculopathy was easily possibly by fish, but not by light microscopy. tubuli/ interstitium: infiltrates of acute interstitial rejection change sizes from focal/large to disseminated/small over time. chimeric cells are seen in tubulitis but also in tubular epithelium with ischemic damage. conclusion transplant glomerulopathy is a lesion of chronic rejection associated with the appearance of c-kit positive, recipient cells. chimeric cells can be demonstrated in transplant vasculopathy and in damaged tubular epithelium, possibly homing to ischemic lesions as part of a repair process. . lancet ; : ; . liver transp ; : ; . transfusion ; : introduction the aim of our demonstration is to call attention to a unique pediatric case with as yet unknown ultrastructural changes in the glomerular basement membrane (gbm). case report the full-term female patient - g/ cm -has been developing well with the exception of early (intrauterine?) unilateral intraocular hemorrhage, which necessitated the enucleation of the bulbus at the age of month. nine months later, varicose enlargement of the left saphena vein was observed, and microscopic hematuria was detected. later selective proteinuria and mild hypertension was found. at the age of year an open renal biopsy was performed. light microscopy showed thick-walled and dilated capillaries of glomerular tufts. collagen iv staining demonstrated corrugated positivity in the gbm, also seen in col iv alpha chain. chains alpha and appeared normal. immunofluorescence gave only strong global igm positivity. electron microscopy showed peculiar mostly circular splitting of the gbm lamina densa with inclusions of small amorphous densities as well as of some remnants of cellular organelles. analogous changes were observed in adjacent arterioles. at present, the year-old child with signs of somatic underdevelopment is being treated for mild hyperazotemia, anemia and renal hypertension. her body shows some asymmetry, the skin is thin, pink, but no areas of hyperextensibility are seen as well as any hypermobility of joints. nmr investigation of the brain disclosed a slowly growing mass in the left thalamus. conclusion the classification of the case among connective tissue disorders is difficult, type iv of ehlers-danlos syndrome seems to be the closest. chronic renal thrombotic microangiopathy (tma) following radiation: study of cases introduction there is evidence for roles of the cip/kip family of cdki (p , p ) in mediating growth arrest in glomerular cells. mature podocytes, highly specialized cells with a complex cellular structure (interdigitating foot processes) leave cell cycle and may undergo nuclear division, but not cytokinesis, because this would involve the breakdown of the actin cytoskeleton. it has been recognized that mesangial cells proliferate and accumulate matrix in re-sponse to certain forms of injury. the aim of the current study was to elucidate the role of cdki expression in human glomerular diseases. material and methods the analysis was performed on groups of renal biopsies (every consisting of cases): minimal change disease (mcd), membranous glomerulonephritis (mgn), mesangioproliferative proliferative glomerulonephritis: iga (igan) and igm nephropathy (igmn). we examined the expression of p , p , ki and pcna by immunohistochemistry. adult nephrectomy specimens (n= ) without evidence of glomerular disease served as controls. morphometric analysis was additionally done in mcd, igan and igmn cases. color sampling was performed to extract "brown" nuclei stained for p and all nuclei of glomerular cells. then the number of segmented "brown" nuclei was calculated per area of glomerular profiles and related to the number of all nuclei. results immunostaining for p was abundant in normal podocytes and some mesangial cells. there was no evidence of p and proliferation markers ki and pcna in normal glomeruli. in mcd and mgn expression did not change. in contrast there was a marked decrease in staining intensity for p in mesangial cells in patients with igan and igmn. the ratio of stained for p nuclei was . % and . % for mcd and igan, igmn group, respectively (p= . ). interestingly also podocytes focally -in sclerotic portions of glomeruli -revealed a marked decrease of p . this loss of immunostaining occurred predominantly in mesangial cells and podocytes expressing ki and pcna. this was accompanied by the de novo nuclear immunostaining for p . conclusion the decrease in p level is required to induce podocyte and mesangial cell proliferation. also the increase of p was observed. thus changes in cell cycle regulatory molecules play central role in determining the renal response to injury and may underlie the development of progressive glomerulosclerosis. understanding mechanisms regulating cell proliferation may target future therapies on these molecules. comprised microhaematuric patients. the thinning was global in patients, and segmental in . the third cohort contained nonhaematuric patients who had a globally thinned gbm and focal proliferative lupus gn or minimal change np, respectively. in summary, cases of global tbmnp ( + nm; controls: + nm; p<. ), and cases of segmental tbmnp ( + nm; p= . ) were verified. conclusion tbmnp manifests with either a globally or a segmentally thinned gbm. tbmnp is not infrequently associated with other glomerular diseases. the clinical and morphologic data should be considered simultaneously when the diagnosis of tbmnp is made. supported by otka t- (budapest, hungary) grant to i.b. simultaneous quantitative gene expression analysis in human renal biopsies in patients with lupus nephritis (lgn) introduction inflammatory flares, enhanced proliferation and delayed apoptosis are important pathomechanisms in lgn. these are associated with increased expression of genes previously studied by semi-quantitative immunohistologic detection of an individual gene product. the aim of this study was to perform a simultaneous quantitative comparison of expression of genes tentatively relevant to pathogenesis of lgn. material and methods renal tissue samples, fresh frozen ( ) and formalin-fixed ( ), obtained by percutaneous biopsy of patients with lgn (who class ii, iii and iv) were used. formalinfixed zero transplant biopsies served as controls. from µm thick sections, glomeruli were laser-microdissected, rna was extracted and transcribed. a real-time, quantitative pcr analysis was performed using vcam- , fractalkine as markers of inflammation, il- , pdgf-ßr as markers of proliferation, bax, fas ligand and tnf-r as regulators of apoptosis and ß-actin as housekeeping gene. results frozen biopsies allowed detection of all genes; formalinfixed only of some. there was no correlation between levels of gene expression and age, sex, proteinuria or activity/chronicity indexes. who class ii cases showed increased levels of vcam- , pdgf-ßr and bax but not fractalkine as compared to controls. who class iii and iv cases showed higher expression of fractalkine, il- and pdgf-ßr than who class ii cases. in who class iii cases, il- , and fractalkine levels were clearly, while bax levels were slightly higher than in who class iv cases. conclusions . real-time quantitative pcr is useful for a simultaneous analysis of gene expression in frozen samples of human renal biopsies. . in this limited study, class ii lesions, as expected, showed lower expression of genes in comparison with classes iii and iv. however, class iii lesions seemed to exhibit higher expression levels of genes involved in proliferation, inflammatory cell infiltration and apoptosis regulation compared to class iv, possibly relating to a different pathogenesis of those two classes. haemorrhagic glomerulonephritis (gn) and massive pulmonary haemorrhage in goodpasture syndromeunique case report introduction diagnostic use of ttf- as an organ specific marker for thyroid and lung origin of carcinomas was documented mostly in tissue sections, while the information on ttf- in cytology samples is still insufficient. the aim of the study was to analyze the expression of ttf- by immunocytochemical detection in cytology samples. we obtained material by fine needle aspiration biopsies (fnab) of primary and metastatic neoplasms ( cases). first, methodological approach with ttf- was tested in thyroid tissue ( goiters, adenomas, carcinomas). afterwards, we analyzed primary and metastatic lung adenocarcinomas, primary and metastatic extrapulmonary adenocarcinomas, primary lung tumors and metastatic lung carcinomas of other types and metastatic carcinomas of different types. additionally, metastatic malignant melanomas were also included in the study. finally, we tested metastatic tumors of unknown origin. results all primary and / metastatic lung adenocarcinomas stained positive with ttf- . two of metastatic tumors of unknown origin stained positive, however primary tumor was not found. except for thyroid samples, normal lung, metastatic microcellular and macrocellular carcinoma of lung origin, none of other primary or metastatic tumors stained positive for ttf- . conclusion in fnab specimens, ttf- can confirm thyroid origin of carcinoma and more importantly, determine the lung origin of metastatic or primary adenocarcinoma. therefore, ttf- could be used for early identification of primary site (pulmonary vs. extrapulmonary) in fnab of metastatic adenocarcinomas skipping further expensive investigations. comparable to the digital radiology, recent significant developments in the microscopic slide scanning, data storage technology can contribute to the development of digital histology laboratory techniques. the aim of the study is to evaluate this technology in a routine setting. methods in the daily routine in a university pathology department to slides were prepared from to cases in a day. from the usual paraffin blocks µm sections were prepared and processed. the bar-coded slides were digitized and stored on a digital slide server. commercial short and long term storage may be used. the evaluation of the slides was done in local and remote access. for specific tissue types (colon, gastric) automated tissue component segmentation and analysis modules were developed. for the d reconstruction of serial sections a dedicated program was developed. results the daily prepared slides ( - pcs) could be scanned in the night. the virtual microscopy analysis yielded concordant results with the optical microscopy analysis. teleconsultation based on digital slides and virtual microscopy was applicable in selected cases. the automated algorithms could classify gastric biopsy specimen cases with high accuracy ( %). d reconstruction yielded a more detailed insight and diagnosis. reports including the low resolution digital slide image, high resolution selected field of views, alphabetical report were sent in e-mail to the referring specialists in higher safety and speed as compared to the traditional way. conclusions the digital histology laboratory technology improves the specialisation in pathology allowing remote access to selected tissue types, the reporting process' safety and efficiency. experiences in the production of digital slides by an automated high-resolution scanner system after automated slide preparation introduction this study aims to investigate the expression of ret/ptc and p in the local normal, benign and malignant thyroid lesions in order to shed light on the pathogenesis of papillary carcinoma and explain the high prevalence of this condition among the nodular hyperplasia (multinodular goiter) cases in the local population. archival blocks from follicular adenomas, nodular hyperplasia and papillary carcinoma cases were retrieved from husm pathology department files. they were studied by immunohistochemistry for the presence of ret/ptc and p mutant protein. normal tissues from cases served as controls. results . % normal thyroid tissue, % follicular adenomas, . % nodular hyperplasia cases and . % papillary carcinomas expressed ret/ptc mutation. ret/ptc expression in papillary carcinoma was not associated with coexistence of nodular hyperplasia lesion. p is expressed by % of papillary carcinoma. no association was found between p expression of nodular hyperplasia with or without coexisting papillary carcinoma. p , not ret/ptc was an excellent predictor of tumour lymph node metastasis and capsular invasion. it is also a significant prognosticator of survival outcome. conclusion ret/ptc mutation is highly prevalent in local papillary carcinoma, indicating a significant role in the pathogenesis of this tumour; with no apparent role in tumour behaviour and survival outcome. p on the other hand appear to be a significant factor in the latter events. the two genes appear to act in two different pathways; the former being the initiator, and the later perpetuator of papillary carcinoma. vascular invasion in pleomorphic adenoma of salivary gland: a possible consequence of fna biopsy introduction benign intravascular invasion in association with pleomorphic adenoma (pa) of salivary glands is uncommon. in none of the reported cases has it been associated with subsequent development of metastases. it may cause a diagnostic and therapeutic dilemma in salivary glands, which appears otherwise benign. no explanation of the etiopathogenesis has been offered in previously reported cases. aim: we suggest that pre-operative procedures undertaken such as fine needle aspiration (fna) of the salivary gland may cause iatrogenic seeding of tumour cells. materials and methods two cases of pa of the parotid gland showed vascular invasion. both presented with a palpable nodule in the parotid gland. one patient had two fnas the other one prior to surgery. both underwent superficial parotidectomy. results histologically both tumours were pas positive with little chondromyxoid component but both were rich in myoepithelial cells. clusters of myoepithelial and epithelial cells were seen within muscular and thin walled blood vessels, both outside the capsule and within the tumour. in spite of genuine vascular invasion there was no cytological evidence of atypia or malignancy. our speculation is that the previous fnas may have caused spillage of pa cells within vessels giving an impression of a potentially malignant tumour. conclusion we recorded two cases of pa with associated vascular invasion. we speculate that preceding operative procedures such as fna may be relevant to the pathogenesis. extra-cellular signal-regulated erk- /erk- pathway activation in human salivary gland mucoepidermoid carcinoma: association to aggressive tumor behaviour and tumor cell proliferation a handra-luca, a lesot, jc bertrand, p fouret université paris vi ufr pitié-salpętrire, paris, france information on oncogenetic events in salivary gland mucoepidermoid carcinoma is so far limited. activation of extracellular signalregulated kinases erk- and erk- is strongly correlated to cancer. using an antibody specific for phosphorylated (active) erk- /erk- , we examined human salivary gland mucoepidermoid carcinoma samples by immunohistochemistry. the comparison in paired tumor and normal tissue samples showed that phosphorylated erk- /erk- expression was higher in tumor cells as compared to surrounding normal salivary parenchyma. using a threshold below which > % of normal samples expressed phosphorylated erk- /erk- , we showed that ~ % of mucoepidermoid carcinomas expressed high levels of phosphorylated erk- /erk- . those tumours where erk- /erk- pathway was activated had a more aggressive tumor behaviour as compared to the group where this pathway was inactive. the association of erk- /erk- phosphorylation to a worse prognosis was independent of histological grade. erk- /erk- phosphorylation was associated with an increased tumor cell proliferative index. there was no relationship between erk- /erk- phosphorylation and her- /neu expression. in conclusion, erk- /erk- pathway is active in salivary gland mucoepidermoid carcinoma and this activation is associated to a more aggressive tumor behaviour and a higher proliferative activity. these data suggest that deregulation of erk- /erk- pathway contributes to mucoepidermoid carcinoma phenotype and, possibly, represent a target for new anticancer drugs. introduction adenocarcinoma of the nose and paranasal sinuses is rare but has been shown to occur with increased frequency in workers exposed to wood dust. histologically the tumours resemble adenocarcinoma of the gi tract and show the same spectrum of histological types and differentiation. therefore tumours at this site may present a diagnostic problem in distinguishing between primary and metastatic disease. immunostaining has shown colonic adenocarcinomas to express cytokeratin ck and carcinoembryonic antigen (cea) but not cytokeratin ck . lung and squamous carcinomas of the head and neck are usually ck positive and ck negative. this prompted assessment of the immunohistochemical expression of ck , ck and cea in a retrospective series of primary nasal adenocarcinomas. the aims of the study were to establish the pattern of expression of ck ck and cea in primary sinonasal adenocarcinoma and to compare it with that seen in colonic adenocarcinoma. materials and methods cases of primary sinonasal adenocarcinoma were available from archival files. these were reviewed and classified into histological subtypes including papillary, tubular, mucinous and signet ring. representative paraffin sections were immunostained for ck , ck and cea. results normal respiratory epithelium included in the sections was positive for ck and negative for ck and cea. / ( %)of tumours expressed ck . all of the tumours expressed ck and all but one of the tumours expressed cea, with showing only focal positivity. there were tumours designated mucinous or signet ring type only one of which expressed ck . conclusion primary sinonasal adenocarcinomas express ck and cea. there is variable expression of ck , which may help to distinguish between primary sinonasal adenocarcinoma, which are positive, and metastatic colonic adenocarcinoma of papillary and tubular subtype, which are negative. poorly differentiated mucinous tumours are indistinguishable by immunohistochemistry alone. provisional extracellular matrix -indicator of oral squamous cell carcinoma (oscc) progression and target for therapy introduction pleomorphic adenoma is the most common tumour of the parotid gland. histomorphologic features and peculiarly tumour capsule play a major role in recurrences of parotid pleomorphic adenomas. cytogenetically, pleomorphic adenomas are characterized by recurrent chromosome rearrangements. the aim of this study was to correlate cytogenetics and histopathology features in pleomorphic adenomas in order to define cytogenetical characteristics of tumours with high risk of recurrence. material and methods histological and cytogenetical studies were performed in patients with pleomorphic adenomas of the parotid gland treated in our institution during the period may -november . structural and numerical chromosomal abnormalities were: rearrangement of chromosome (breakpoint at q - ), rearrangement of chromosome (breakpoint at q ), translocation between chromosome and : t( ; )(q ;q ), hyperdiploidy. results the studied population was distributed into histological subtypes according to seifert classification. hypocellular (stroma rich) pleomorphic adenoma was reported in %, hypercellular pleomorphic adenoma was reported in % and "classic" in %. thirty patients ( %) had normal karyotype while ( %) had clonal chromosomal abnormalities. chromosome rearrangement tumours and hyperdiploid ones tend to be hypocellular. tumours showing chromosome abnormality tend to be hypercellular. conclusions as recurrences most likely appear in hypocellular tumours, patients with hyperdiploidy and chromosome abnormalities could have a greater risk of recurrence because of their histomorphological characteristics. because of the lack of patients, not sufficient statistical significance was demonstrated. introduction pleomorphic adenoma is the most common tumour of the parotid gland. the main issue of pleomorphic adenoma surgery is postoperative recurrence. histomorphologic features and peculiarly tumour capsule play a major role in recurrences of parotid pleomorphic adenomas. the aim of this retrospective study was to define histomorphological characteristics of pleomorphic adenoma for better understanding of recurrence processes. this work corresponds to the preliminary prospective study of a long term follow-up for detection of recurrence. material and methods histological study was performed after reviewing of slides originating from patients with pleomorphic adenomas of the parotid gland. these randomly selected patients underwent parotid surgery in our institution during the period may -november . results the studied population was distributed into histological subtypes according to seifert classification for better analysis. hypocellular (stroma rich) pleomorphic adenoma was reported in %, hypercellular pleomorphic adenoma was reported in % and "classic" in %. thinness of capsule was significantly related to hypocellularity. pseudopodias and satellite nodules were reported in % of this series. conclusions due to capsular characteristics, surgical exerecise should avoid dissection in the vicinity of the tumour to minimize the risk of surgical induced recurrence. according to these findings, enucleation surgery on a pleomorphic adenoma should not be performed anymore. these tumours should now be followed up in order to detect and define risk factors of recurrence. trend of nasopharyngeal cancer at the ibadan cancer registry ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) increase in the incidence of npc over the last here decades. overall, the mean age was . years (age range to years). the females had a mean age of . years (age range - years) while the mean age for the males was . years (range - years). the peak age group of incidence for the females was - while in the males it was the - age group with an almost an equal incidence in the preceding three decades. the ratio of regaud to schmincke type cancer reversed with increasing age amongst the females with the schmincke type being more common in the first decade but this was not reproduced in the males. conclusions there is a steady rise in the incidence of nasopharyngeal cancer over the last three decades. the two main histological types showed differential variation between the sexes suggesting a biological effect in manifestation of this disease. there is a need for health education and increased physician awareness at all levels of health care to stem this trend and especially to detect a role of epstein barr virus infection in aetiopathogenesis of the nasopharyngeal cancer. lactate dehydrogenase (ldh) in peripheral blood lymphocytes (pbl) of patients with solid head and neck tumours b jakovljevic lactate dehydrogenase(ldh)is intracellular enzyme, which take part in process of anaerobic glycolyse. it is located in all cells, but in higher amount in the stromal cells. ldh activity increased in the malignant cells, as well as in the peripheral blood lymphocytes (pbl) of patients suffered from head and neck tumours. the authors present results of their investigations in activity of intracellular ldh in pbl, spontaneous ldh releasing from pbl and correlation between spontaneous releasing of ldh and increasing of intracellular level of ldh in patients with solid head and neck tumours. spontaneous releasing of ldh in all the patients with solid head and neck tumours were to times higher then in the health controlling group. there are correlation between clinical stage of the tumours and spontaneous releasing of ldh. the authors concluded that measuring of level of spontaneous released ldh from pbl, can prove the presence of head and neck tumours in the very early stage. introduction squamous cell carcinoma (scc) constitutes more than % of the malignancies from the head and neck. thereafter, the survival of patients in stage iii-iv is between %- % at years. as most stromal types, head and neck squamous cell carcinomas (hnscc) harbour deregulation in the expression levels of many proteins that participate in critical biological pathways leading to cancer development. the aim of the study was to evaluate the correlation between several molecules implicated in cell cycle and apoptosis in an attempt to define their importance as prognostic indicators in hnscc. material and methods hnscc specimens from stage iii-iv patients were collected prior to chemotherapy. we constructed a tissue-microarray with paraffin-embedded tumours to analyse, by inmunohistochemistry, the expression levels of proteins implicated in cell cycle arrest and apoptosis (p , cyclin-d , cyclin-a, rb, hdm , topoisomerase, chk , cdc , survivin, bcl- , cdk- , cdk- , cyclin d , cyclin e, cyclin b , p , p and p ). results alterations in the expression levels of proteins that participate in the g /s checkpoint were frequent. rb and p proteins were absent in % and % of the tumours, respectively, whereas high expression of cyclin d , cdk- and cdk- was observed in %, % and % of the cases, respectively. on the other hand, des-regulation of markers implicated in the apoptosis were also evident as shown by over-expression of bcl- protein in % of the tumours. this last observation seems to be related to bad prognosis. conclusions definitive conclusions from our results concerning expression levels of each marker isolately, according to tumour location and in relation to survival are still being evaluated. p and mib expression in basaloid squamous cell carcinoma of the larynx inversely correlates with p expression patients, two showed an inverse correlation between p and ki- expression and p expression. conclusion an inverse correlation between p and ki- and p and p was demonstrated in cases. image analysis of dnac showed aneuploidy in all cases. the present study shows that overexpression of p , and ki- , together with a down-regulation of p kip correlates with biological aggressiveness and consequent shortened survival in bscc of the larynx. the dna status doesn't correlate with any of the analysed parameters since all tumours in our series displayed an aneuploid pattern. altogether patients were operated on at the department of transplantation and surgery of the semmelweis university in the past four years, because of clinical symptoms of hyperparathyroidism. chronically impaired renal function was found in cases. the removed parathyroid glands showed histologically hyperplasia in , adenoma in and carcinoma in cases. the oxyphil/chief cell ratio and occasional mitotic and apoptotic figures were determined. the oxyphil component predominated both the hyperplastic and tumorous lesions. apoptosis and mitosis were rarely seen in hyperplasias ( - %) more frequently in adenomas ( - %) whereas in carcinomas - % of the tumor cells showed signs of mitosis and - % were apoptotic. immunohistochemical detection of p , bcl and bax revealed diversity between the various lesions. cytoplasmic p positivity could be observed in the majority of adenomas and in some of the oxyphil cells of the hyperplasias. the carcinomas and about one sixth of the adenomas showed nuclear p positivity. bcl was detected in the cytoplasm of the tumor cells of adenomas and in lower extent in the oxyphil cells of hyperplasias. colocalistion of bcl and bax was found randomly in all types of lesions. no significant differences in the p , bcl and bax spectrum were found regarding the primary and secondary (i.e. renal failure) parathyroid alterations. the very low incidence of carcinomas, the low mitotic and apoptotic ratio in adenomas and hyperplasias point to the potent antiproliferative defense mechanism in the parathyroid cell-population. this may be also reflected in the cytoplasmic co-localisation of various gene products which regulate cell death and cell proliferation. introduction at present the significance of occult axillary lymph node metastasis (om) in early breast cancer patients is not known. the aim of the study was to evaluate the prognostic role of om in stage i breast cancer. materials and methods we studied patients with t breast carcinoma who underwent axillary dissection and originally had negative lymph nodes by routine microscopic examination. patients who developed distant metastases within years after surgery (m group) were compared to age-matched patients who were disease free for years (nm group). we examined lymph nodes by three deeper h&e levels and one section stained with immunohistochemistry for keratin. results we detected om in / patients. all had micrometastases (< . mm). om was identified in patients ( %) in the m group and in ( %) in the nm group (p= . ). micrometastases larger than . mm were x more common in the m group ( / vs. / , p= . ) . tumors in the m group were significantly more often of higher grade, had a higher mitotic index (mi) and showed lymphovascular invasion. the two groups did not differ in size, histologic type, estrogen receptor status or type of treatment. in multiple logistic regression, only high mi and presence of micrometastases larger than . mm showed an independent significant correlation with the occurrence of distant metastases. axillary micrometastases are associated with occurrence of distant metastases and are important prognostic factor in t breast cancer patients. this was not significant for om smaller than . mm. the presence or absence of myoepithelial (me) cells has been considered as an important feature in the differential diagnosis of papillary breast lesions. the aim of this study was to evaluate the usefulness of monoclonal antibodies: alpha-actin (smooth muscle actin) and s- protein, which are known as good markers of me cells in breast tissue. material and methods the distribution of me cells in formalinfixed paraffin-embedded tissue sections of intraductal papillomas and papillary carcinomas were immunohistochemicaly stained by abc method. results alpha-actin reacted strongly and consistently with the me cells in all papillomas. in papillary carcinomas there were no alpha-actin reactive me cells. rare isolated me cells were present in two cases, but they were inconspicuous and these reactions were also considered negative. the me cells failed to express s- protein in four papillomas, while majority were weak positive. all the papillary carcinomas were s- protein negative. conclusions consistency and uniformity of me cells reaction is important because benign and malignant papillary lesions often coexist in the same tissue section. although vascular smooth muscle in the papillary fronds and stromal myofibroblasts may mimic me cells, the number of alpha-actin immunoreactive cells is much smaller and their distribution more irregular. s- protein has broad spectrum reactivity and it is of little value in the differential diagnosis of papillary breast lesions. alpha-actin is more specific marker than s- protein for recognition of me cells in breast tissue. introduction the utilization of lymphatic mapping for breast carcinoma has made intraoperative evaluation of sentinel lymph node (sln) attractive, because axillary lymph node dissection can be performed during the initial surgery if sln is positive. the aim of our study was to evaluate the accuracy of intraoperative sln examination by imprint cytology (ic). material and methods slns from women were examined. for intraoperative cytological examination, touch imprints from bisected slns were prepared, air dried and stained with quick staining method (hemacolor-merck). slns were than formalinfixed and embedded in paraffin. histological sections were evaluated with h&e stained levels and cytokeratin immunohistochemistry (ck-ihc). results histological examination of the sln revealed ( , %) cases with metastatic deposits: ( . %) macrometastases, ( . %) micrometastases and ( . %) cases with isolated tumor cells or clusters (itc) detected by immunohistochemistry. sensitivity and specificity of intraoperative ic was % and %, respectively. ic was significantly more sensitive for detection of macrometastasis: they were detected in out of cases ( %). ic generally failed to detect micrometastases or itc: only one case of micrometatasis was cytologically suspicious for malignancy. out of histologically negative slns, one ic diagnosis was false positive. conclusions ic is a simple and quick method of intraoperative screening for the presence of sln macrometastases in patients with breast cancer. if sln micrometastases and itc are used to determine the need for further lymphadenectomy, more sensitive intraoperative methods, such as rapid ck-ihc on touch preparations, will be needed to avoid second operation. introduction fine-needle aspiration cytology (fna) is an established, highly accurate method for diagnosing breast lesions. however, in recent years there has been increased use of core biopsy (cb) as a diagnostic alternative. this study aimed at comparing the value of fna and cb in palpable and non palpable breast lesions. materials and methods the material consisted of fna samples performed in our institution between and . correspoding histology results from lesions including cb were available for comparison. quality assessment parameters were calculated using metodology detailed in the national health service breast screening programme guidelines. results high specificity ( %) and sensitivity ( %) and low inadequacy rates were found for cb. fna showed high sensitivity ( %). low specificity ( %) for fna due to inclusion of many cell-poor lesions was particularly seen in the submitted material sampled by physicians lacking experience with fna procedures. conclusion cb may be an alternative method for preoperative diagnosis when experienced cytopathologists are not available. cb is superior to fna in fibrotic and collagenous lesions such as lobular carcinoma and radial scar. fna is most accurate when immediate assessment by cytopathologist is performed for evaluation of material adequacy so that additional aspirations can be performed if necessary. atypical ductal hyperplasia (adh): practical relevance in diagnostics and therapy introduction in contrast to ductal hyperplasias, adh belongs to intraductal neoplasias. adh can be distinguished from non-high grade dcis (among other criteria) by its size. therefore, a question that is asked quite frequently is whether such small findings can be removed with sufficient security by minimal invasive biopsy (mib). we prospectively investigated: . relative frequency of adh without associated intraductal or invasive carcinoma . relevance of such small findings in mib specimens. materials and methods between between and between , breastlesions could be clarified by means of mib in the interdisciplinary team. excisions were carried out in all invasive carcinomas and all dcis as well as in all cases with minimal parts of intraductal nonhigh grade neoplasias (with the differential diagnosis adh vs. dcis). additional adhs were diagnosed in excision specimens as incidental findings associated with other targets (except for dcis and invasive carcinomas). the mib-and operation specimens have been examined prospectively by two team pathologists according to the criteria of page and tavassoli. results we diagnosed altogether adhs and dcis. the proportion of adh in all operated intraductal neoplasias (adh+dcis) was . % ( / ). findings with the differential diagnosis of adh vs. dcis could be found in cases of mibs ( , %).the following excision specimens showed in of cases ( %) non-high grade dcis and in of cases adh ( %). the other adh were coincidental findings in excision specimen of benign lesions. conclusions adh is a very rare finding. in adh-like findings in mib specimens even specialised breast-pathologists cannot exclude a non-high grade dcis with sufficient security when applying strictly the most common morphological definitions. the high rate of % of dcis in the specimen of the following operation highlights the indication for clarifying by excision (according to the european guidelines for quality assurance in mammography screening). multifocal stromal invasion in microinvasive squamous cell carcinoma of the cervix -how to measure and stage these lesions o reich, h pickel dpt. obstet/gynecol, university of graz, graz, austria objectives about % of microinvasive squamous cell carcinomas of the cervix have more than one invasive focus at time they first break through into the cervical stroma. it is unclear how the lateral extent of lesions with multiple invasive foci should be measured to distinguish figo stage a and a carcinomas from clinically occult stage ib disease. we believe that three presentations of multiple invasive foci should be distinguished. type i shows plump and coherent infiltration of the cervical stroma at different sites in one ore more step-serial sections. they originate from the squamous epithelium outside the transformation zone or from metaplastic cervical gland epithelium. all foci are contiguous with the epithelium. in this case, the largest lateral spread of each individual invasive focus should be measured. these measurements are added up to determine the total of horizontal spread. the normal tissue separating the different early invasive foci is not measured. in type ii the origin of invasion cannot be seen in all early invasive foci but the greatest lateral extension can be seen in one of the step-serial sections. lateral extension is defined as the maximum distance from one most lateral point of the border between the invasion and the adjacent tissue to the other. the lateral extension of type ii includes the normal tissue separating the early invasive foci. type iii shows the same pattern as type ii, but the maximum horizontal spread cannot be measured in a single step-serial section. in such lesions the width needs to be measured across all the step-serial sections involved and the second dimension must be calculated by knowing the distances between the sections. conclusions these growth pattern of stromal invasion should be considered when measuring the width of early invasive squamous cell carcinomas with multiple invasive foci. lesions with multiple invasive foci taken together measuring more than mm in lateral extension should be classified as stage ib. introduction cyclooxygenases regulate the production of prostaglandins and play a role in tumor development and progression. the aim of this study was to investigate the prognostic impact of expression of the cyclooxygenase isoforms, cox- and cox- in primary breast carcinomas as well as in primary ovarian carcinomas. materials and methods cox isoform expression was determined by immunohistochemistry. results expression of cox- was detected in % of ovarian carcinomas and was associated with reduced overall survival in univariate analysis (p= . ) as well as multivariate analysis ( . ). there was no correlation with other tumor parameters such as grade, stage or type. in contrast, cox- was no prognostic parameter in ovarian carcinoma. expression of cox- was detected in % of breast carcinomas and was significantly associated with several clinicopathological parameters, such as positive nodal status (p< . ), larger tumor size (p< . ), poor differentiation (p< . ), vascular invasion (p= . ) and negative estrogen receptor status (p= . ). in univariate survival analysis a significant association between elevated cox- expression and decreased disease-free survival (p= . ) as well as decreased overall survival (p= . ) was observed. in multivariate analysis expression of cox- was of borderline significance for disease-free survival (rr( %ci) . ( . - . ) ). conclusions our data suggest that increased expression of cox- may play a role in progression of primary breast carcinomas as well as ovarian carcinoma. it remains to be investigated if treatment with selective inhibitors of cox- may be an additional therapeutic option for patients with gynecological tumors. simple endometrial hyperplasia: bcl- , hldf expression and clinical behavior ii the endometrial hyperplastic processes is characterized by major variety of clinical outcomes. the main feature of "spontaneous endometrial hyperplasia" is complete normalization after total curettage (lindahl b., willen r. ) ; there is also proof of recurring hyperplasia. the purpose of present research was to carry out clinical and morphological correlations between various types of endometrial hyperplasia and expression of pro-(hldf) and antiapoptotic (bcl- ) proteins. human leukemia cell differentiation factor (hldf) with molecular mass . kd, having dna/rna hydrolyzing activity, was originally allocated from hl- cell line of promyelocyte leukemia medium, processed by retinoid acid or c -ceramid (kostanyan i.a. et al., ) . previously we have shown that hldf is a useful tool for apoptosis visualization in prostate (babichenko i.i. et al., ) . we performed analysis of patients with histologically documented simple endometrial hyperplasia without atypia: women ( %) had spontaneous recovery after total curettage, in ( %) patients endometrium recovered after gestagen treatment and in ( %) cases persistent recurring hyperplasic process was observed during - years. immunohistochemical research showed that in samples of recurring hyperplasia hldf was expressed in cytoplasm of glandular epithelium, while in sections with spontaneous or aftertreatment recovery, hldf was revealed as a thin line on the surface of glandular cells. bcl- protein was found only in the cytoplasm of glandular cells in all investigated groups. thus expression of the hldf factor in cytoplasm of glandular cells in endometrium allows revealing the disturbance of apoptotic processes in cells and predicting the subsequent recurrence of simple hyperplasia. surface epithelial changes in endometrial adenocarcinoma b djordjevic, d mihailovic, d dimov, l velickovic, v zivkovic, z mijovic institute of pathology, university of nis, nis, serbia and montenegro introduction epithelial changes on the surface of endometrial adenocarcinoma (eac) show greater maturation and better differentiation than the underlying adenocarcinoma. these changes are relatively common and can be misdiagnosed as benign surface changes on curettings, including endometrial metaplasias (em), papillary syncytial change (psc), or microglandular hyperplasia (mgh) . the aim of this study was to investigate surface epithelial changes in eac. material and methods cases with eac ( endometrioid, serous, clear cell and mixed types) were studied. results ( %) of the eac showed surface epithelial changes: four with microglandular pattern simulating mgh; with syncytial aggregates of eosinophilic cell, frequently with papillary or squamoid appearance, simulating em or psc; and with mixed patterns. surface epithelial change often demonstrated focal conjunction with a frankly malignant gland or a fibrovascular core and ranged from rare foci to diffuse surface involvement. cytologic atypia was less pronounced than that of the underlying eac and varied from mild to moderate. mitoses were very rare. in some scanty curetting specimens, distinguishing these surface epithelial changes from benign changes was difficult, as was a diagnosis of eac. conclusion in postmenopausal women with curettings showing features of em, mgh, or psc, caution should be exercised in making that diagnosis, particularly psc, in the absence of evidence of benign shedding, and any associated cytologic atypicality should raise the possibility of the underlying eac. prevalence of cervical neoplastic lesions in egypt: a national cervical cancer screening project. final report introduction reducing morbidity and mortality is one of the main objectives of the health and population policies in egypt. however, data from egyptian studies provide widely varying estimates of the prevalence of pre-malignant and malignant cervical lesions. the main goal was ( ) to define the prevalence of pre invasive and invasive cervical cancer among egyptian women, and ( ) to identify risk factors including hpvs and associated co-factors, as bacterial vaginosis, hsv, cmv, chlamydia, schistosomiasis. the study was a community based full-scale cross sectional, household survey that included women aged between and years conducted between and . however, women with complete data were included in the study ( %). the bethesda classification was used for cervical cytology. three percent of cases were unsatisfactory. normal, metaplastic, infectious, and neoplastic lesions represented . %, . %, . % and . %, respectively. the most common type of infection was bacterial ( . %). neoplastic conditions, were categorized into ascus and agcus ( . %), ascus ( . %), agcuc ( . %), lgsl . % ( . %), hsil ( . %) invasive squamous and invasive adenocarcinoma ( . % for each). colposcopic-guided biopsy was performed on cases representing . % of the epithelial abnormalities. for standardization, a score of ten points including koilocytic atypia ( ) , binucleation ( ), papillomatosis, dyskeratosis, acanthosis and basal cell hyperplasia ( point for each), was applied to qualify a lesion as hpv-related ( points out of ten). unsatisfactory biopsies were encountered in . %. normal biopsies including inflammatory and metaplastic changes and atypical metaplasia represented . % and . %repectively. cervical intraepithelial lesions (cin) ( . %), further categorized as cin i ( . %), cin ii ( . %), cin iii/cis ( . %) were identified. endocervical lesions represented . % and were divided into endocervical glandular dysplasia (egd) ( . %) and adenocarcinoma in situ (ais) ( . %). combined dysplasia was found in . %, while invasive squamous cell carcinoma (sqcc) and lymphoma accounted for . %of the biopsies. on histological basis, hpv was found in association with cin i, cin ii, cin iii/cis and sqcc in . %, . %, . % and % respectively. neither egd nor ais showed evidence of hpvs. in situ hybridization (ish) using the broad spectrum hpv probe recognizing hpvs , , , , , , , , and was tested on biopsy specimens starting from the atypical metaplastic changes and was found to be positive among . %, negative in . % and non significant in . %. interestingly, . % of atypical metaplastic changes were positive. further subtyping with probes / , / and / revealed positivity in . %, . %, and . % of cases respectively. noteworthy, multiple infections with hpv / and / ( cases) and hpv / and / ( cases) were identified. to examine the main determinants of cervical cancer, multiple regression analysis was conducted using high-grade lesions as the dependant variable and risk factors as independent variables. this showed that the only determinant was hpv infection. when the regression analysis was conducted without hpv as one of independent vari-ables, history of treatment from schistosomiasis was found to have or of . ( %ci . - . ) but the model was not statistically significant. conclusion in the egyptian population, the prevalence of the precursor lesions of the invasive carcinoma is % while invasive lesions account for . % of the population. the prevalence of hpv histologically is . % and by ish . %. however, detection of hpvs by ish in this study cannot be precise due to technical limitations and limited number of probes used. evaluation of hpvs using pcr technology will be subject to another study. possible role of irf- in the genesis of endometrial adenocarcinoma. a series of such tumours was investigated using immunohistochemical techniques. relatioships were sought with thymidine phosphorylase (tp), conventional histological features and prognosis. malignant endometria were, by and large, deprived of irf- , as of the cases ( . %) were negative for this antigen. only of the cases were expressing irf- in inner tumour areas. at the invading tumor front, however, irf- was depressed in tumour cells in % of cases. this phenomenon was independent of the extent of lymphocytic response, but it was a strongly associated with tp expression. tp up-regulation and host's lymphocytic response in the area were directly associated. irf- derepression by invading tumor cells was associated with poor prognosis. this prognostic parameter was independent of stage. it is concluded that down-regulation of irf- is a constant finding in endometrial tumorigenesis. however, derepression of irf- may occur in a subset of tumours, and this event is associated with tp up-regulation and aggressive tumor behaviour. morphometric study of gnrh analogue/ hmg/hcg effects on ultrastructure of human endometrial epithelium in the early luteal phase introduction there is a little information about the effects of ovulation induction drugs on morphometry of human endometrium especially at electron microscopic level. the aim of the present study was to determine the effects of long protocol (gnrh analogue/hmg/hcg) on the ultrastructure of human endometrial epithelium at lh+ . material and methods endometrial biopsies were obtained from fertile women (n= ) as well as infertile women (n= ) who had undergone this protocol at lh+ . quantitative and qualitative studies on endometrial epithelium were performed by transmission electron microscopy (tem) and morphometry and the results were statistically compared between the two groups. results qualitative results revealed presence of nuclear channel system (ncs), sub vacuole of glycogen and giant mitochondria (gm) in both groups. similarly, in quantitative analyses, the volume fractions (vv) of glycogen, mitochondria and rough endoplasmic reticulum to cell and the also the vv of euchromatin to nucleus were statistically not different between two groups (p> . ). conclusion these results suggest that ovulation induction by long protocol is not associated with retarded or advanced endometrial epithelial development. introduction historically the diagnosis of mitochondrial encephalomyopathies relied, on the presence of ragged red fibres (rrf) as well as finding ultrastructural abnormalities in mitochondria. currently accurate diagnosis requires a multidisciplinary approach but the usefulness of electron microscopy has been questioned. the aim of this study was to define the diagnostic role of electron microscopy in comparison to histology and histochemistry. patients and methods thirty-five patients who fulfilled a clinical phenotype for mitochondrial encephalomyopathies, were separated into two groups. the paediatric group, which included cases, with an age range of days to years old and the adult group which included cases, with an age range of to years old. all patients underwent a muscle biopsy which was examined by histology, histochemistry and electron microscopy. results in the paediatric group, cases exhibited rrfs, cases showed rrfe and cases had cox abnormalities. electron microscopy revealed the presence of mitochondrial abnormalities in cases and mitochondrial aggregates in others. in cases light microscopy was normal, but in of these electron microscopy was abnormal. in the adult group all patients, showed cox abnormalities, cases had rrfe and others had rrfs. electron microscopy revealed the presence of mitochondrial aggregates in cases and structural abnormalities in cases. conclusions electron microscopy examination is a useful independent diagnostic tool in the investigation of mitochondrial encephalomyopathies. it is particularly helpful, in the paediatric cases, where the classic light microscopical findings are often not well developed. introduction tumour-associated tissue eosinophils (tate) have been observed in human tumours and experimental tumour models, but the mechanism by which eosinophils induce tumour cell damage remains poorly understood. aims: electron microscopy is an essential technique in evaluating sublethal and lethal cellular injuries. therefore, gastric carcinomas were studied by light and electron microscopy, focusing on the relationship between eosinophils and tumour cells and on the nature of tumour cell death. material and methods fresh tumour tissue was obtained in the operating room for immediate fixation and processed for both light and electron microscopy examination from until . results a light microscopy review of cases of resected gastric carcinomas identified cases ( of intestinal-type and of diffusetype) with a massive tate. in cases of intestinal-type adenocarcinomas, eosinophils formed varied-sized aggregates in the tumour stroma. some were seen passing through the neoplastic epithelium, and others were found lying within neoplastic tubules. in cases of diffuse-type carcinoma, eosinophil clusters were seen to surround single tumour cells. with electron microscopy, performed in these cases, tumour cells in intimate contact with eosinophils revealed sublethal and lethal cellular injuries. in particular, sublethal injuries, such as cytoplasmic vacuoles and indiscernible cell membrane, occurred at the contact region. eosinophil "satellitosis" was associated with lethal damage of tumour cells including brush border disorganization, dilation of nuclear envelope, rough endoplasmic reticulum and golgi apparatus forming empty spaces or vacuoles, small condensed chromatin particles, irregular distribution of nuclear pores. these lethal injuries were compatible with non-apoptotic (non-lysosomal vesiculate) cell death. the adenocarcinoma cells, not contacted by eosinophils remained morphologically well preserved. conclusions these morphological data suggest the hypothesis of a direct relationship between eosinophil infiltration and induction of non-apoptotic tumour cell death in some cases of gastric adenocarcinoma. a deeper insight into the molecular mechanisms acting as cytokines that stimulate specific eosinophil functions may assist in the development of novel therapies to better treat human malignancies expression of p and c-erbb- oncoproteins in chronic schistosomal urinary bladder lesions o hammam, h el baz, m wishahi theodor bilharz research institute, giza, egypt this study was conducted in a trial to better understand the genetic mechanisms underlying the proliferative, premalignant and malignant changes frequently displayed in chronic schistosomal cystitis (ch.sch.c.) and schistosomal associated transitional cell carcinoma (sch.tcc) of the bladder. tissue exepression of p (tumor suppressor gene) and c-erbb- (oncogene) was assesed immunohistochemically in bladder urothelial specimens of a well characterized cohort of male egyptian patients ( ch.sch.c; sch.tcc and normal urothelial specimens as controls). both p and c-erbb- oncoproteins were not expressed neither in morphologically normal nor in the hyperplastic epithelium. overexpression of nuclear p and membranous c-erbb- was detected in % of ch.sch.c cases in whom premalignant changes (metaplasia and dysplasia) were displayed. while, in the sch.tcc cases they were detected in % and % of cases respectively. on stratifying these patients according to the well recognized prognostic parameters (histopathological grade, stage, tumor size, multifocality and growth pattern) p was positively correlated with all the forementioned parameters. in contrast c-erbb- was only correlated with tumor size and growth pattern. in conclusion, the results of the current study may suggest the early involvement of both p and c-erbb- in the initiation of the premalignant changes occuring with ch.sch.c and the progression of these changes to malignancy. moreover, the high incidence of p and c-erbb- expression among sch.tcc cases with poor prognostic parameters (higher grade, stage; bigger tumor size; tumor multifocality and nonpapillary growth pattern) may point out to the possibility of using these biomarkers as early predictive markers in ch.sch.cyst. cases displaying premalignant lesions and as poor prognostic indicators for sch.tcc. introduction cd is a neutral endopeptidase which participates in the peptide hidrolysis in the renal proximal tubules. its immunohistochemical detection has been considered useful in the differential diagnosis of renal carcinomas because of its expression in - % of clear cell renal and papillary renal cell carcinomas and its absence in chromophobe renal cell carcinoma (chrcc), a histotype positive for parvalbumin, a protein of the distal nephron. material and methods we studied immunohistochemically chrccs including four with aggressive features (two with sarcomatoid transformation, one with renal vein involvement and one with pancreatic metastasis), for cd and parvalbumin developing the reactions with different methods (abc, envision peroxidase detection and labeled polymer-ap dako envision systems) to prevent false-positive staining due to endogeneous biotin. western blotting was done to confirm the results. as control we stained clear renal cell carcinomas with both antibodies. results cd immunoreactivity was observed in ( %) primary chrccs, three with aggressive features, using all the developing systems. all chrccs were positive for parvalbumin, but not the sarcomatoid areas. western blotting confirmed the specificity of the immunoreactivities. conclusions ) about % of chrcc express cd ) cd is not specific for clear cell and papillary carcinomas of the kidney; ) a panel including both cd and parvalbumin is useful in the differential diagnosis between chrcc and clear renal cell carcinoma; ) three out of four tumors with aggressive features stained for cd , but further studies are needed to highligh the prognostic significance of cd in chrcc. introduction tenascin (tn) is an extracellular matrix glycoprotein, which is expressed during embryogenesis at the epithelial-stromal interface. tn is decreased in normal adult tissue but reexpressed in inflammatory, reparative and neoplastic processes. tn seems to be involved in neoangiogenesis, promotion of invasion and metastasis of malignant tumors. the aim of the study was to investigate the expression of tn in carcinoma in situ (cis), invasive and superficial papillary bladder cancer. material and methods cases of bladder cancer were selected ( who grade i, grade ii, grade iii tumors, cis). we investigated the different staining patterns of tn by immunohistochemistry using a monoclonal antibody against tn (t h ). results immunhistochemical evaluation revealed stromal and cytoplasmic staining. stromal staining was found at the borders of invasive tumors and in the lamina propria of most cis. tn staining of blood vessels was located at the tips of the papillae or in invasive tumor. cytoplasmic tn expression was present in all bladder cancer specimens. in cis positive cells were present in all cell layers or distributed in a pagetoid pattern while adjacent normal urothelium showed staining of superficial cells. in who grade i papillary tumors tn staining was located in superficial cells, in grade ii tumors scattered positive intermediate cells were present, while in grade iii tumors tn was expressed focally in all cell layers. most invasive tumor cell nests showed extensive tn staining. conclusion expression of tn in bladder cancer seems to be associated with dedifferentiation and invasive potential. introduction synchronous, antecedent or subsequent appearance of secondary primary malignancy (spm) in patient with primary renal cell carcinoma (prcc) is yet considered to be extremely rare. recent surveys tend to confirm at least their higher if not even significant incidence. this study was performed to determine the incidence of spm in the patients with prcc as well as its localization and time of appearance in relation to prcc. material and methods of patients who underwent surgery for renal malignancies at department of urology, sestre milosrdnice university hospital during the period from to , data of were available in croatian national cancer registry. there were patients with prcc ( males and female patients) ranging in age from - years (median . years). results and conclusion in our series there were ( . %) patients with spm. secondary malignancies in descending order of frequency were cancer of prostate ( . %), colon ( . %), lungs ( . %), bladder ( , %) and skin ( . %). there were . % antecedent, . % synchronous and , % subsequent spm. only one patient had more than one synchronous second malignancy (urinary bladder, prostate and colon). spm in patients with prcc are of great importance for both the clinician and pathologist. therefore, the clinician should maintain lifetime high-technique follow-up of the patients with prcc. the knowledge of such an existence should raise an interest in pathologist for elucidating etiologic factors. namely, it seems that the frequency of spm in patients with prcc is much higher that previously expected. introduction in our recent studies we showed increased oxidative stress with p gene alterations in urinary bladder lesions in people living in radio-contaminated areas of ukraine, after the chernobyl accident. the aim of the study was to examined whether base and nucleotide excision repair is activated in bladder urothelium by chronic low doses of ionizing radiation in male patients with benign prostate hyperplasia and females with chronic cystitis living more than years in cs contaminated areas. materials and methods bladder biopsies from patients were submitted for histological examination and biopsies from patients -for immunohistochemical study of -hydroxy- 'deoxyguanosine ( ohdg), -oxoguanine-dna-glycosylase (ogg - ), apurinicapyrimidinic endonuclease (ape ) and xeroderma pigmentosum a (xpa). results chronic proliferative atypical cystitis with multiple areas of dysplasia and carcinoma in situ was observed in % of patients from radio-contaminated areas with greatly elevated levels of ohdg, ogg - , ape and xpa in bladder urothelium. conclusion these findings support the hypothesis that significant activation of dna damage repair (base and nucleotide excision repair) is induced by long-term low dose of ionizing radiation. the levels of dna oxidative adducts pointing to mutagenic and carcinogenic potential were in line with the histopatologically diagnosed urothelial lesions. introduction urinary cytology (uc) and cystoscopy remain the standard methods for initial diagnosis and monitoring of recurrences in urothelial tumors. low sensivity of uc and invasiveness of cystoscopy led to develop different ancillary methods to improve sensitivity of uc. specific genetic alterations occurr in bladder cancers (bc), represented by aneuploidia of chromosome , , and loss of chromosome . the aim of the study was to evaluate the use of thin layer techniques applied to uc diagnosis associated with multicolour interphase fluorescence in situ hybridization (fish) for early identification of initial bc and recurrences. methods a total of voided urine specimens were collected, before resection of bladder cancer, from patient with previous bc and flogistic control patient. the samples were processed with thin prep (tp) monolayer technique and cytospin preparation (cs) and in cases with morphological alterations, was performed fish urovysion (vysis) assay, consisting of four probes ( , , and p ) . cytomorphology. results in general tp technique was better for cytomorphology, cleaner background little overlapping, with difficulties when only few urotelial cells are present and in cases of contamination with squamous cells. f i sh technique was positive in all carcinomas, with multiple gain of chromosomes , , , while none of negative controls was aneusomic. only five cases in group of patients in follow-up with minimal atipia, showed fish positity, with prevalence of loss of chromosome ( %) compared to gain of chromosomes ( %). conclusions these preliminary findings suggest that the association of tp preparation with fish anlysis can improve the efficience of uc to detect bc and predict its recurrence. chromophobe renal cell carcinoma: the variant with the best outcome? introduction few large series comparing conventional, papillary and chromophobe renal cell carcinomas (rcc) have been published. most have been heterogeneous, including rcc subgroups of different stage and/or grade. the purpose of this study was to examine the clinico-pathologic features of a series of chromophobe rccs comparing their outcome with that of conventional and papillary rccs in a grade and stage matched fashion. materials and methods the clinico-pathologic features of chromophobe rccs, papillary and conventional rccs were examined, focussing on the following parameters: patient age and sex, tumor size, stage ( ptnm), fuhrman grade, and histology. survival was analyzed using the kaplan meier method. the most important prognostic factors were identified using the cox model. results for patients with localized disease at diagnosis; median, -year, and -year disease specific survivals (dss) were similar for chromophobe ( mths, and -yr dss: %) and papillary ( mths, and -yr dss: . %) tumors. conventional rcc patients had a significantly worse outcome ( mths, -yr dss: . %; -yr dss: . %). the best outcome in low grade (g +g ), low stage (pt +pt ) tumors was observed in chromophobe rccs. in multivariate analysis, conventional (nonpapillary) rcc histology was the major independent adverse prognostic factor whether or not stage and grade were included in the cox models. conclusion chromophobe rcc is a rare rcc variant of good prognosis. this favorable prognosis is maintained when low grade (g +g ) / low stage (pt +pt ) tumors are specifically examined. introduction c-kit is a transmembrane tyrosine kinase receptor, expressed at high levels in hematopoetic stem cells, mast cells, melanocytic cells, germ cells and the interstitial cells of cajal. recently, it has been shown that for certain tumors (especially gastrointestinal stromal tumors and mast cell diseases) c-kit mutation or activation is a major pathogenetic event. only one previous study has been published regarding c-kit expression in normal renal tissue, and none regarding renal neoplasms. in this preliminary report of an ongoing study, we investigated the expression of c-kit protein via immunohistochemistry in various normal and neoplastic renal tissues. material and methods our material included eight fetal kidneys ( - weeks of gestation), seven normal adult kidneys, two cases of renal dysplasia, and renal tumors: renal cell carcinomas, two nephroblastomas, three oncocytomas, one mesoblastic nephroma and one angiomyolipoma. staining intensity was recorded in a three-grade scale. results all fetal kidneys showed cytoplasmic staining of proximal tubules (++). henle loops were also positive (++), especially in older embryos. cytoplasmic and membrane staining (++) of renal tubules was also observed in all normal adult kidneys. the two cases of renal dysplasia studied, had c-kit expression in their normal but not in their aberrant tubules. of the renal cell carcinomas, all conventional type cases (n= ), one sarcomatoid and one papillary type case were negative, while one chromophobe and one granular type were positive (++ and + respectively). all oncocytomas were positive (+++ to ++), and quite interestingly the mesoblastic nephroma was also positive. the angiomyolipoma and the two nephroblastomas were negative. conclusion we conclude that c-kit is expressed in normal fetal and adult renal tubules, as well as in a subset of renal tumors. the expression of c-kit in the latter group may prove to have diagnostic significance and therapeutic implications. background relapsed/refractory acute myeloid leukemia (aml) is characterized by a deteriorating clinical course and resistance to therapy. biological mechanisms responsible for resistance remain unclear, since consistent molecular characteristics of aml at relapse and refractory disease have not yet been reported. methods we explored paired bone marrow biopsy specimens of patients (at diagnosis and relapsed/refractory aml after high dose chemotherapy) in an immunohistochemical study using anti human ki- antigen (mib- ) antibody to determine the proliferation fraction of leukemic blasts. gene expression was analyzed in a different sample set ( at diagnosis and relapsed/ refractory aml) using a "relapse specific" cdna microarray covering genes, selected by literature and suppression subtractive hybridization. microarray results were validated using quantitative real time pcr, immunohistochemistry and immunoblotting. results recurrent and refractory aml blasts demonstrate a highly significantly increased (p< . ) proliferation fraction compared to primary diagnosis. mrna levels of proliferation markers cd and pcna were elevated . -fold and . -fold, respectively, in relapsed and refractory aml compared to diagnosis. enhanced activation of the raf/mek/erk mitogen-activated protein kinase cascade was indicated by increased mrnas of b-raf ( . -fold), cyclin d ( . -fold), mkp- ( . -fold), c-fos ( -fold) , and egr- ( . -fold). additional immunohistochemical and immunoblotting analyses demonstrated an elevation of biphosphorylated erk / protein in recurrent aml, confirming enhanced activation of the raf/mek/erk pathway. conclusion our results provide for the first time evidence that high dose chemotherapy selects or induces leukemic blasts with increased proliferative potential via enhanced activation of raf/ mek/erk cascade. introduction diffuse large b-cell lymphoma (dlbcl) is the most common of the non-hodgkin's lymphomas (nhl), comprising approximately % of newly diagnosed cases. in order to define the role of angiogenesis in dlbcl, mrna and protein expression of the two most important angiogenic growth factors, vegf and bfgf, and two vegf receptors, vegfr- /flt- and vegfr- /kdr were evaluated by real time quantitative pcr (rtq-pcr) and immunohistochemistry in dlbcl. methods we analyzed dlbcl cases, low-grade follicle center lymphomas (fls) and cases with chronic lymphocytic leukemia (cll) for expression of vegf-a, bfgf, vegfr- /flt- and vegfr- /kdr. we used a real-time reverse transcriptionpolymerase chain reaction (qrt-pcr) method to quantify mrna levels of these angiogenic markers using an abi qrt-pcr system. protein expression of these angiogenic markers was assessed by immunohistochemical staining. the results of the current study show that both the mrna and protein expression of vegf and bfgf varied considerably among dlbcl patients, which do not correlate to the microvessel density. vegf mrna expression showed significant correlation with bfgf mrna expression. the vegfr- /kdr mrna expression was higher than vegfr- /flt- mrna expression in dlbcl but their expressions were strongly correlated. histological staining of both vegf receptors in dlbcl sections showed strong staining of both receptors on the microvessel endothelial cells but not on the tumor cells. our data suggest that vegf plays a role in the pathophysiology of dlbcl however autocrine/paracrine stimulation by vegf does not seem to be relevant in dlbcl. the expression of vegf and its receptors raises the possibility of using angiogenesis inhibitors as a novel therapeutic strategy. introduction ecm regulates cellular differentiation, life span, migration and contributes to lymph node compartmentalisation. the aim of this study was analysis of occurrence and distribution of embryonal fibronectin (fn), tenascin (tn) isoforms and laminin chains (ln) in reactive lymph nodes (rln) and follicular lymphoma (fl). material and methods shock frozen tissue of rln and routine material of fl and rln. primary antibodies: all fn variants (ist- ), ed-a fn (ist ), (bc- ), all tn-c variants , tn-cl (bc- ), ln-alpha -( h ), ln-alpha -(bm ), ln-alpha -( c ), ln-beta -( e ), ln-beta -(c ), ln-gamma -( e ), ln-gamma -chain (gb and d b ). apaap-technique. results rln: all fn's, ed-a fn and tn-cl were demonstrated in lymphatic / blood vessels and as reticular depositions in the stroma; spot-like depositions in the follicle center and ribbon-like at the border follicle centre / mantle zone. ln-alpha , -alpha , -beta , -beta and -gamma -chains were positive mainly in lymphatic and blood vessels with depositions in the stroma. ln-gamma -chain was restricted to follicular dendritic cells and ribbon-like codeposited with tn-cl at the border follicle centre / mantle zone. fl: in contrast to normal follicles, a total loss of ln-gamma -chain is regular observed in neoplastic follicles. conclusions . a provisional ed-b fn / tn-cl / ln-gamma chain matrix membrane controls the traffic follicle centre/mantle zone. . in analogy to thymic t cell maturation, a role of ln-gamma -chain (ln- ) can be assumed for b cell maturation mediated by ln-gamma -chain (ln- ) positive follicular reticulum cells. . the loss of ln-gamma -chain indicates neoplastic follicular structures in follicular lymphoma. follicular lymphoma grading by mann and berard are predictive of overall survival and time to treatment failure, however, only grade has favorable os and ttf follicular lymphomas (fl) are a heterogeneous group of tumors, varying in clinical features, immunophenotype, and cytogenetics. who recommends grading of fls by using the method of mann and berard, which recognizes three grades. the aim of this study was to examine whether mann and berard's grading has prognostic significance in patients with follicular lymphoma who were not uniformly treated. samples from patients with follicular lymphoma with follow up ranging from - months (median months) were included in the study. forty-three patients ( %) achieved a complete response (cr), ( %) partial response (pr), while ( %) were considered non-responders during the follow up period of months. twenty-seven ( %) patients died, patients ( %) from dissemination, from transformation to other lymphoma type and ( , %) patients died from non-lymphoma related causes. os rate was significantly worse in patients with ann arbor stage iv than patients ann arbor stage i-iii (p= . ). patients with lower ipi score did significantly better than those with a higher ipi score for os (p< . ) and ttf (p< . ). grade fl patients had longer os (p= . ) than grade and patients. a trend for longer ttf was also found (p= . ). cox regression analysis showed that these results were independent of stage, but were not independent of ipi score. higher grade was also associated with the presence of b symptoms (p= . ) and larger size of the primary tumor (p= . ). follicular lymphomas (fl) are a heterogeneous group of tumors, varying in clinical features, immunophenotype, and cytogenetics. the aim of this study was to examine interrelationship and prognostic significance of bcl and cd protein expression for overall survival (os), and time to treatment failure (ttf). samples from patients with follicular lymphoma were evaluated by immunohistochemistry. bcl- and cd expression levels were determined semiquantitatively. since almost all cases expressed bcl- , fls were designated either "low expression level-group" (llg and +, patients) or "high expression level group" (hlg, + and +, patients) . based on cd expression, fls were designated either "negative" ( patients) or "positive" ( patients). patients with high levels of bcl- expression had favorable overall survival (os) (p= . ) and ttf (p= . ) compared to patients with low levels of bcl- expression. cox regression analysis showed that the results for os, but not ttf were independent of ipi score. patients with cd -negative follicular lymphomas also had worse os (p= . ) and ttf ( . ). our results suggest that expression of cd and strong expression of bcl- protein could be indicators of welldifferentiated follicular lymphoma since such cases were associated with lower histological grade and better clinical outcome. "borderline lesions" with clinicopathologic features in between lyp and alcls. lyp nature (neoplastic vs reactive) is matter of debate because of its benign clinical course and variable molecular findings (t-cellular clonality in less than % of cases). borderline lesions have a favourable outcome similar to lyp but, due to their rarity, limited data are available on their biologic features and clonal status. the aim of this study was to compare possible divergences in the search for clonality in the same individual skin lesions using respectively dna extracted from laser microdissected cd + cells and dna from whole paraffin sections. materials and methods lyp and borderline skin lesional biopsies were tested for tcr-gamma rearrangements by means of pcr on dna extracted respectively from whole-tissue and a pool ( - cells) of cd + cells microdissected using the zeiss-palm robot-microbeam system. results and conclusions pcr analysis of whole-tissue dna documented tcr-gamma monoclonal rearrangement in / cases ( / borderline, / lyp); tcr analysis on dna extracted from microdissected cd + cells showed monoclonal rearrangement in / cases ( / borderline, / lyp). we confirm that pcr analyses on dna extracted by microdissected cd + cells enhance the rate of monoclonality detection mainly in lyp lesions, in which the limited number of atypical cd + cells and predominant reactive cellular background may be responsible for negative or ambiguous signalling when dna extracted by the whole lesion is tested. malignant testicular lymphoma accompanied with complete av block -case report m a -year-old male patient was admitted, with the signs of complete av block and bradycardia accompanied by syncopes. a complete lab examination with us, ct and mri was done which all confirmed a massive tumorous infiltration into the root of mesenterium, presence of lymphadenomegaly around it, as well as nonhomogeneous and unclearly demarcated infiltrative lesion of myocardial septum. the patient completed his anamnesis by imparting that his right testicle was slightly enlarged and periodically painful. semicastration was indicated and the removed tissue was prepared for pathohistologic analysis. the testicle had only peripherally preserved normal tissue, whereas the tumor was clearly demarcated, . cm in diameter. five-micrometre-thick tissue sections from the paraffin-embedded tissue were stained with h&e. the cells were quite variable in their morpholoric features and size. the nuclei were generally hypochromatic, with irregular chromatin distribution. the nuclear morphologic properties varied and included pleomorphic mono-and multinucleated giant tumour cells with multiple nuclear lobulations. nucleoli were conspicuous. also, numerous benignappearing lymphocytes and plasmacytoid elements were scattered throughout the background. this histologic picture could correspond either to spermatocytic seminoma or lymphoma. since the patient needed an urgent therapy, histochemically (pas-) and immunohistochemically (lca +, cd +, cd +), the diagnosis of lymphoma was confirmed. the patient received ct (chop protocol), which resulted in a satisfactory clinical response. in this case, it is interesting to point to the most probable infiltration of the myocardium by the diagnosed lymphoma which elicited the cardiologic symptoms and from which the diagnosing of the patient's disease was to start. diffuse large b-cell lymphoma of bone: an analysis of differentiation-associated antigens with clinical correlation l de leval * , k braaten, m ancukiewicz, e kiggundu, t delaney, h mankin, n lee harris * department of pathology, university of liège, belgium, massachusetts general hospital, boston, ma twenty-nine patients with diffuse large b-cell lymphomas (dlbcl) presenting with bone involvement, including localized primary bone lymphomas (group i), multifocal primary bone lymphomas (group ii) and patients with extraskeletal disease at diagnosis (group iii) were studied. the tumors were subclassified according to the criteria of the who classification and evaluated by immunohistochemistry for expression of antigens associated with germinal center (gc) and non-gc stages of b-cell differentiation (bcl- , cd , mum- , vs c, cd , bcl- and cd ). the presence of a bcl- /igh gene rearrangement was investigated by pcr. all cases were characterized by similar clinicopathologic and morphologic features, and had similarly good overall outcome. the patients ( m, f, median y) had tumors in long bones ( ), axial skeleton ( ), and limb girdles ( ) and multiple sites ( ) . most tumors ( ) were centroblastic, with multilobated cells in cases. almost half of the tumors ( / , %) were bcl- +cd + («gclike»), / cases ( %) were bcl- +cd -(«indeterminate» phenotype) and / cases ( %) were cd -bcl- -(«post-gc like»). the «indeterminate» phenotype was seen only in primary bone lymphoma. mum- was frequently expressed in gc-like and non-gc-like categories. we found no evidence of plasmacytic differentiation by cd and vs c immunoreactivity was distinctly rare ( / cases). cd was detected in tumors, all cd -. bcl- was expressed by % of the tumors but only / cases tested had a bcl- /jh rearrangement by pcr. a survival analysis showed that gc-like tumors had a longer overall survival duration compared to non-gc-like tumors (p= . ). in conclusion, a "gc-like" immunophenotype, characterizes roughly half of large b-cell lymphomas of bone and is associated with an improved survival. ultrastructural characteristics of liver-associated lymphocytes in chronic delta hepatitis b aliev, s khodjaev institute of virology, tashkent, uzbekistan liver sinusoids contain a heterogenous population of lymphocytes including 'pit cells' discovered by wisse in . however, ultrastructural patterns of liver-associated lymphocytes (lal) in delta hepatitis are still not well identified. in present work we investigated lal in chronic delta hepatitis (chd) with electron microscopy. liver biopsies from with chd were fixed in , % glutar aldehyde, postfixed with % osmium teroxide and embedded in epon. ultrathin sections were stained with uranyl acetate and lead citrate. ultrastructural study revealed migration of lymphocytes between hepatocytes in chd. they have heterogenous population of lymphocytes varying in morphology. some of them were large granular lymphocytes and could be natural killer cells. some of lal could correspond to a t lymphocyte. in electron microscopic study of lal we also observed presence of plasma cells and the pattern of intracellular membrane systems common to cells that secrete protein: well developed granular endoplasmic reticulum, large juxtanuclear golgi complex. a centriole occupies a position just marginal to the golgi. the chromatin in the nucleus of these cells is characteristically condensed into large masses just within the envelope. our results demonstrate a heterogenity of lal in chronic delta hepatitis including the presence of b cells. hepatic steatosis in relation to serum apolipoprotein level in egyptian patients with hcv and hcv-associated hcc: histopathological, biochemical and clinico-sonographic study t aboushousha chronic hepatitis c is a known risk factor for cirrhosis and hepatocellular carcinoma (hcc). liver steatosis is common in hcv patients suggesting that specific mechanisms might be involved. the aim of our study was to assess variability in serum apolipoproteins in relation to hepatic steatosis in hcv patients of genotype with or without hcc. material included egyptian subjects; (hcv), (hcv-associated hcc), and controls. clinical examination for stigmata of chronic hepatic affection and ultrasonography for assessment of liver size, surface, echogenicity and the presence or absence of a focal lesion were done. histopathological examination of liver biopsies was done for assessment of hepatitis activity index (hai) and stage as well as the grade of hepatocytic steatosis (hs). biochemical study included liver function tests, lipid profile and assessment of apolipoproteins. results showed a significant decline in apo-a, apo-b, apo-cii, apo-ciii and apo-e lipoprotein in hcv and hcv-associated hcc groups compared to the control group. analysis of hai in hcv patients showed significant association of hs with periportal necrosis, but not portal inflammation or lobular degeneration. in patients with hcv associated hcc, hs was significantly associated with portal inflammation and lobular degeneration, suggesting a correlation between virus activity and hepatocytic neoplastic changes. we concluded that steatosis should be searched for in patients with chronic hcv, being an important cofactor in accelerating the development of hepatic fibrosis and in increasing necroinflammatory activity. a correct therapeutic approach to steatosis would slow down the evolution of chronic hepatitis. introduction nonalcoholic fatty liver disease (nafld) is defined as a constellation of clinical conditions characterized by predominantly macro vesicular steatosis. it can be extremely difficult to reach the diagnosis of nash in the absence of correct clinical data. exclusion of excess alcohol intake is notoriously difficult and requires a desialylated transferin (the method rarely present in laboratories). aim: histomorphologic investigation of liver biopsies from patients with mild laboratory test abnormalities and steatosis complicated by necroinflamatory changes. a pilot study of morphometric characteristics of lipid droplets in nash and alcoholic hepatitis were also performed. material and methods forty liver biopsies with steatosis and inflammation were examined using the method of dixon. ten of these biopsies were morphometrically analysed regarding the lipid droplet features. following morphometric parameters were estimated: ) diameter, ) perimeter and ) area. we used olympus micro image-image analysis software v. . . . the presence and distribution of mallory hyaline was the most variable parameter. morphometric analyses confirm a statistically significant differences for all parameters tested in nash and alcoholic hepatitis, and were more pronounced in nash. conclusion in the cases of fatty change with necro-inflammatory changes and pericellular fibrosis in liver biopsy and presence or absence of mallory hyaline, morphometric analysis of lipid droplets can help in reaching the diagnosis of nash, if testing of desialilated transferring is not possible. the raf/mek/erk (mapk) signal transduction cascade is an important mediator of a number of cellular fates including growth, proliferation and survival. the braf gene, one of the human isoforms of raf, is activated by oncogenic ras, leading to cooperative effects in cells responding to growth factor signals. this study was performed to elucidate a possible function of braf in liver tumours. methods mutations of braf and kras were evaluated in hepatocellular carcinomas (hcc) and in cholangiocarcinomas (cc) by direct dna sequencing analyses after microdissection. the presence of active intermediates of the mapk pathway was assessed immunohistochemically. the results obtained were correlated with histopathological variables and patient survival. results activating braf missense mutations were identified in / cc ( %) and in one case of tumour surrounding liver. kras mutations were found in out of ( %) cc examined and in two cases of tumour-surrounding non-neoplastic liver tissue. in hcc, neither braf nor kras mutations were detected. all cc with kras mutations had an intact braf gene. we failed to observe a correlation between braf or kras mutations and histopathological factors or prognosis of the patients. conclusions our data indicate, that braf gene mutations are a relatively common event in cc, but not in hcc. disruption of the raf/mek/erk (mapk) kinase pathway -either by ras or braf mutation -was detected in about % of all cc and is therefore one of the most frequent defects in cholangiocellular carcinogenesis. prognosis and treatment of cholangitis after cholecystectomy n akhtar, ae kuzmenko, vv khatsko, ga grintsov, am dudin, yg kolkin donetsk medical state university, donetsk, ukraine introduction the purpose of our research was to study prognostic tests of cholangitis after cholecystectomy (ce) for prophylaxis and optimal treatment. materials and methods for years patients with so called "postcholecystectomic syndrome" (pces) were treated, ( %) had a clinical picture of acute cholangitis (ac), which was shown by pains in the right hypochondrium, yellowness of skin and scleras, shivering, high hyperthermia and leukocytosis. patients ( women and men) were - years old, of them more than years. initial operation (ce) was made in various hospitals in terms from months to years ago. the diagnosis was verified by: clinical, laboratory and immunological researches, peroxidation of lipids (pol), ultrasonic research, computerized tomography, fibrogastroduodenoscopy, endoscopic retrograde pancreatocholangiography, transdermic and transhepatic cholangiography, fibrocholangiograpgy, bacteriological researches of bile and blood. results according to investigations, in patients the reason of infringement of bile flow was choledocholithiasis (in a combination with stenosis of big duodenal papilla (bdp) or without it, in -stenosis of bdp, in -cicatricial stricture of hepatocholedochus, in extended stenosis of bdp and a terminal part of the common bile duct (cbd). laboratory prognostic tests (risk factor) ac concern: hyperbilirubinemia, increase of activity of alanine transpeptidase, aspartate transpeptidase, hypoproteinemia, dysproteinemia, decrease of a level of protrombin lower than %, leukocytosis, anemia, increase of the contents of urea in blood, bacteriocholia, concentration of molecule of average weight were higher than . unit, decrease of level of vitamin e, high contents of immunoglobulin m on a background of a low parameter immunoglobulin g. conclusions at the presence of risk factors prognosis was frequently in contrary to expectations and mortality reached to - %. all patients with acute cholangitis after cholecystectomy represented a complicated problem and demanded a complex approach. revealed prognostic tests of the development of acute cholangitis are necessary for taking into account for its prophylaxis and optimum treatment. structural alterations in c-myc oncogene, copy number and expression have been implicated in the pathogenesis and progression of several human neoplastic diseases. however, the biologic significance of c-myc gene in human hepatocellular carcinoma (hcc) is unconfirmed. in the present study we correlated c-myc gene amplification and protein expression with the clinicopathologic features. in hcc cases c-myc amplification in tumour tissue was determined using a differential pcr, a procedure for evaluation of gene amplification in comparison with a dopamine d receptor gene. the c-myc gene was amplified in out of tumor specimens ( %). amplification of c-myc was more frequent in younger male patients with hbv infection and in less differentiated tumors. all cases demonstrated positive staining using anti-c-myc monoclonal antibody with increasing percentage of immunoreactive cells in less differentiated tumors. however, the high protein expression was not statistically correlated with c-myc amplification. histological sectioning of brush bristles allows improved diagnosis of biliary tract and bronchial lesions g bussolati, g accinelli, l macri dept. biomedical science and human oncology, turin, italy brushing of thin ducts such as those of the biliary tract, pancreas and bronchial tree is often used by endoscopists in order to obtain diagnostic material proving the nature of related lesion. the material is spread on slides. cytological examination folows. preservation of the material so obtained is often sub-obtimal, partly because of the presence of fluids such as bile affecting cell preservation, partly because spreading of delicate cells may result in crushing artifacts. to circumvent such problems, we devised an original procedure, where brushes were not smeared, but instead immediately embedded in immersed methanol. then the tube with alcool and brush was sent to the laboratory. in order to induce formation of a glue surrounding the brush, this was immersed while wet into egg albumen (a mixture : of egg albumen and glycerol), then returned to methanol. for paraffin embedding, the metal handling was cut away and the brush was introduced as such into a cassette. sections parallel to the long axis were cut until the metal wire was almost reached, then the block was rotated and new section was obtained from the opposite side. sections were stained in haematoxilin-eosin and with the papanicolau procedure. small fragments of the mucosa, of inflammatory cell aggregates or of related carcinomas were observed. these resulted optimally fixed and allowed a definite histological diagnosis which proved mandatory for proper therapy. advantages and prospects of this novel procedure will be illustrated and discussed. is telomerase catalytic subunit gene re-expression an early event in gallbladder carcinogenesis? were to determine whether a.) differences in the levels of htert exist among different grades of gallbladder epithelial abnormalities, and b.) htert gene re-expression has any role in gallbladder carcinogenesis. material and methods the expression of htert was analysed in gallbladder tissue samples: normal epithelia, reactive hyperplasias, low grade dysplasias, high grade dysplasias and in adenocarcinomas by immunohistochemistry. at least nuclei were quantified per slide and the number of positive signals per nucleus was expressed as a htert index. results the mean htert index increased progressively with the degree of gallbladder epithelial abnormalities: from . (standard deviation= . ) in normal epithelia, . (sd= . ) in hyperplastic epithelia, . (sd= . ) in low grade dysplasia, . (sd= . ) in high grade dysplasia to . (sd= . ) in adenocarcinoma. according to the htert expression, three groups of gallbladder epithelial changes were found: .) normal and hyperplastic gallbladder mucosa, . low grade dysplasia, and .) high grade dysplasia and adenocarcinoma of the gallbladder. the differences between the groups were statistically significant (p< . ). conclusions we believe that occasional presence of htert in normal and reactively hyperplastic gallbladder mucosa merely reflects its regenerative capacity. nevertheless, significantly higher htert indices in low grade as well as high grade dysplastic epithelium and gallbladder adenocarcinoma are most probably the consequence of htert re-expression -an early event in the multistep process of gallbladder carcinogenesis. spontaneous intestinal perforation vs. necrotizing enterocolitis: different entities clinically and pathologically g de hertogh, p van eyken, m miserez, h devlieger, k geboes k u leuven, leuven, belgium introduction necrotizing enterocolitis (nec) is the most common neonatal surgical emergency. however, during recent years an increasing number of laparotomies has been performed for spontaneous intestinal perforation (sip) in premature infants. the aims of this study were to compare the clinical and pathological features of sip and nec and to identify parameters useful to make the differential diagnosis. materials and methods we reviewed the clinical files and biopsies from infants indexed as "necrotizing enterocolitis" or "intestinal perforation" between and . results twenty-six patients had sip and had nec. patients with sip had lower gestational age and birth weight. they presented early with abdominal distension. frequent radiological signs were dilatation of bowel loops and pneumoperitoneum. perforation was in the small bowel in all cases. % survived. patients with nec presented later with more systemic symptoms. pneumatosis intestinalis was present in more than half. the colon was involved more frequently than the small bowel. % survived. cases of nec were characterized by necrosis, inflammation and reparative tissue changes with or without pneumatosis intestinalis. in contrast, the bowel in cases of sip was not necrotic and showed little inflammation. its most distinguishing characteristic was the presence of one or more defects in the internal layer of the muscularis propia. the myenteric nerve plexus and interstitial cells of cajal had developed normally. conclusions spontaneous intestinal perforation and necrotizing enterocolitis differ in their clinical and histopathological characteristics. in our cases, sip was always associated with segmental absence of the intestinal musculature. impact of epitope retrieval in detection of cd (c-kit) in gastrointestinal stromal tumors (gists) using manual and automated immunohistochemical (ihc) procedures introduction gastrointestinal stromal tumours are solid tumours associated with c-kit and pdgf-r expressions. the recent introduction of gleevec/glivec, an effective inhibitor of the activated c-kit and pdgf-r has stimulated interest in standardizing the immunohistochemical detection of c-kit in gist-tissues, assuring an appropriate selection of patients for therapy with gleevec. aims: the dakocytomation anti-human c-kit antibody, code a , was investigated in four different set-ups: ) without heat-induced epitope-retrieval (hier), ) with hier, ) preabsorbing the primary antibody with the synthetic peptide used for generation of the primary antibody and ) testing on fresh versus archival tissue sections. materials and methods tissue sections were obtained from different cases of gist, confirmed by morphology and ihccharacterisation (c-kit, cd , s , sma, desmin). the ihc was performed manually as well as on automated platforms including the techmate™ and the autostainer instruments. results the use of hier consistently displayed a stronger and more uniform staining pattern as compared to an ihc protocol without hier. in few cases the expression of cd was found faintly positive in ihc without hier. automated and manual ihc methods displayed similar staining patterns. the specificity of detecting cd in a protocol using hier was confirmed by preabsorption of the primary antibody with immunogen. storing of fresh cut sections for more than months demonstrated a decrease in ihc cd staining intensity. conclusion epitope retrieval enhances the cd staining intensity in gist-tissue. the specificity of the cd detection in gist's can be confirmed by complete blocking of the positive staining in a parallel set-up, using preabsorption of the antibody by a synthetic c-kit peptide. introduction - % of gastric cancer patients worldwide are under and the clinicopathological features are different from the older age group. here we characterise some of the genetic changes in cases of early onset gastric cancer (eogc). methods using dna isolated from microdissected material, a panel of polymorphic microsatellite markers near known or presumed tumour suppresser genes was used to evaluate loss of heterozygosity (loh). microsatellite instability (msi) status was ascertained using polymorphic microsatellite markers in cases of eogc and in an additional biopsy cases. corresponding immunohistochemistry was performed for p , smad , ecadherin, mlh , msh and msh . ebv status of the carcinomas was determined using eber -mrna in-situ hybridisation. results the most common losses were at loci adjacent to cdh ( %), tp ( - %), runx ( - %) and smad / dpc ( - %). less frequently, losses were detected at p , q , and loci adjacent to apc, p ink a, pten, and tff. no msi was detected in the cases examined. immunohistochemistry revealed abnormalities for e-cadherin in % and p in %. all tumours examined were ebv negative. conclusion common events in eocg are genetic alterations in cdh , tp and runx whereas other loh findings were infrequent. protein abnormalities of e-cadherin and p were commoner than losses near the corresponding gene. in contrast to gastric cancer in older patients, msi does not appear to occur in young patients. these findings confirm that unique genetic alterations lead to gastric cancer in the young and highlight the need for further investigation to elucidate the mechanisms by which they occur. introduction a place of foveolar hyperplasia (fh) in benign epithelial gastric polyps (begp) classification, as well as its role in a development of hyperplastic polyps (hp) is still a matter of controversy. aims: two questions are to be studied: . does fh, hp, adenoma (a) and carcinoma (ca) represent a continuum in terms of ki- proliferative activity ? . are there any differences of the means of ki- labelling index (li) in hyperplastic areas of hp when comparison is made between hps without other lesions (hp-nos) and with hps with different focal lesions such as intestinal metaplasia (hp-im), dysplasia (hp-d) and/or carcinoma (hp-ca)? materials and methods begp from patients were selected to perform ki- immunohistochemical analysis. there were fh, hp (including hp-nos and hp-im, hp-d and/or hp-ca) and a. as controls cases of normal mucosa (n), cases of regenerative fh (fh-r) and cases of ca were used. paraffin sections were studied immunohistochemically for ki- li with application of mib- antibody. the data were analysed using one-way anova models. results it has been found that the means of ki- li between all the groups studied differed significantly (p< . ). ki- li for fh was high ( . ) and did not differ significantly from fh-r ( . ), a ( . ), and areas of low grade dysplasia in hp-d ( . ), but was significantly higher from n ( . ) and hp ( . ). conclusions .we hypothesize that fh may probably represent an early event in begp formation. .there were no significant differences of ki- li results for hyperplastic areas in hp ( . ) independently if there were focal im, d and/or ca simultaneously, or not. introduction among the malignant tumors that occur in stomach, carcinoma is overwhelmingly the most important and common ( - %). the aims of this study were to report how we histologically evaluate gastric carcinoma (gc) on endobiopsies, using who and lauren classifications. additionally, we tried to detect the rhabdoid features in specimens with diffuse gc. the study included gastric endobiopsies, gc being diagnosed in cases ( %), mostly in men ( cases - %). endobiopsies, routinely embedded, were stained by hematoxylin-eosin, giemsa, pas and alcian blue (ph . ). immunohistochemical studies were performed using vimentin and cytokeratin antibodies for detection of rhabdoid features. results and conclusions the highest incidence of gc was in - -year-old aged patients ( %). using lauren classification, cases were categorised as diffuse type ( %), intestinal type ( %) and ( %) mixed type gc. each of these three types were also histologically analyzed according to who classification: intestinal type gc (formed by recognizable well/moderately differentiated glands) and diffuse type gc (consisting in poorly cohesive cells diffusely infiltrating the gastric wall with little or no gland formation). in diffuse type gc with rhabdoid features we evidentiated vimentin and cytokeratin in cells with an eccentric nucleus and a paranuclear inclusion. finally, we pointed out that is very easy to diagnose gc by lauren and who classifications, but is difficult to evidence the mixed type gc due to reduced size of endobiopsies. recognition of the rhabdoid phenotype in diffuse type gc is important because this feature is associated with poor prognosis and unresponsiveness to conventional therapy. gastrointestinal tract. the patient had a -year history of dyspepsia, diarrhorea, mild diabetes mellitus and cholelithiasis. one hour after the admission, he died in hypovolemic shock. taken tissues from all organs were fixed in % formaldehyde and embedded in paraffin. laboratory sections were stained with: he, ab-pas, van gieson, grimelius, masson's argentaffine reaction and bsp methods, using antibody to somatostatin. results cafe au lait spots, multiple skin neurofibromas, mental retardation, skeletal deformities and a variety of tumours arising in the brain (craniopharyngioma), follicular thyroid adenoma and duodenal somatostatinoma, were found during autopsy. duodenal bleeding ulcer of gigantic size, was covered with coagula. in the bottom of the duodenal ulcer was discovered duodenal carcinoid of the glandular architecture, intermingled with solid acinar and trabecular growth pattern; its cells contained somatostatin. marked increase in number and thickness of nerve fibres also was seen, leading to disordered motility and to striking hypertrophy of the muscularis propria. conclusion having in mind that the patient has the sister, and that this disease has hereditary character, we will invite the sister as soon as possible and she will be in the future the target of our investigation. increased expression of muc and muc and decreased expression of muc in colorectal adenoma-carcinoma spectrum: a tissue array study introduction mucin-type glycoproteins are widely expressed in the gastrointestinal tract. little is known concerning the relationship of altered mucin antigens in colorectal polyps. the aims of this study were to determine the different patterns of mucin distribution of muc , muc , muc ac and muc and compare their patterns of expression with respect to histopathologic criteria of malignant potential in colorectal carcinogenesis by tissue array using immunohistochemistry. peritoneal dialysis (pd) is an alternative to hemodialysis for the treatment of end-stage renal disease. the long term exposure to dialysis solutions causes progressive peritoneal fibrosis and functional decline of the peritoneum. the pathologic process that leads to fibrosis is not well understood and most studies have focused on mesothelial cells, probably because they are easy to obtain from peritoneal effluents. the aims of this study were to establish diagnostic markers of peritoneal fibrosis and pathogenic clues to explain the fibrogenic process. the study was focused on submesothelial fibroblasts from normal controls and pd patients. materials and methods parietal peritoneal biopsies were collected from three patient groups: normal controls (n= ), non-pd uremic patients (n= ) and uremic patients on pd (n= ). in order to study myofibroblastic differentiation and mesothelial-to-mesenchymal transition, alpha-smooth muscle actin, desmin, cytokeratins, and ecadherin were analyzed. we also evaluated cd expression by submesothelial fibroblasts. results fibroblasts from normal controls and non-pd, uremic patients showed no myofibroblastic nor mesothelial markers, but an intense expression of cd . the opposite immunophenotypic pattern was present during pd-related fibrosis. expression of mesothelial markers (cytokeratins and e-cadherin) by fibroblastlike cells and alpha-smooth muscle actin by mesothelial and modified mesothelial cells are evidence that mesothelial-to-mesenchymal transition occurs during pd. loss of cd expression was another helpful indicator of fibrosis. conclusion the immunophenotype of submesothelial fibroblasts varies depending on the existence of a fibrogenic condition. this information results useful for the differentiation between quiescent and activated fibroblasts. in addition, it shows interesting information regarding the origin of this cell population. immunohistochemical and genetic high-throughput analysis of gastrointestinal stromal tumors tract. they are characterized by diffuse immunohistochemical positivity for c-kit protein (cd ). the aims of this study were to assess the immunohistochemical and genotypic features of a large series of gist using tissue microarray technique. methods gist were retrieved from the files of dpt of pathology of our institutions and a tissue microarray (tma) was built. immunohistochemistry for cd , actin, desmin, s , nse, mib was performed. interfase fish analysis was carried out for the following genes: mdm , egfr, c-myc, ccd and her- . results % of the tumors resulted positive for cd , % for desmin, % for actin, % for s , % for nse, % for mib . a significant difference between gastric and non-gastric gist was observed for cd , desmin and s . age, size, necrosis and nse positivity significantly correlated with aggressive behavior of the tumors. moreover, an amplification of c-myc, mdm , egfr, ccd in tumors was found. the tumors were all but two borderline or high risk tumors. cases of coamplification were also detected in clinically malignant or histologically high risk tumors. conclusion useful parameters for prognostic evaluation of gist are age, size and necrosis. furthermore, the observed amplification of c-myc, mdm , egfr suggests a role of rb-ccd pathway in the acquisition of malignant phenotype in a subset of gist. digital slide and virtual microscopy based routine and telepathology evaluation of routine gastrointestinal biopsy specimen l berczi introduction the aim of the study was the evaluation of a recently developed digital slide and virtual microscope system, its comparison with optical microscopy on routine gastric biopsy specimen in local and remote access mode. materials and methods h/e stained routine gastric, duodenal and colon (altogether ) biopsy specimen were selected, scanned and evaluated by two specialists on an optical (om) and virtual microscope (vm). the overall concordance of vm to a consensus diagnosis (con) was . % and % of the om to con. the clinically important concordance was % and % respectively. the two methods showed concordance in % and clinically important concordance in . %. the reasons of the discordance was image quality (one case), interpretation difference ( cases). the overall hard disc place for a gastric biopsy was between to megabytes. the scanning time was between to minutes on a commercial microscope (axioplan , carl zeiss, germany) and to minutes on an automated slide scanner (hi-scope, dhistech ltd., budapest) conclusions remote evaluation of the digital slides through internet shows the advantages of the previously used static and dinamic telepathology methods. the digital slide and the virtual microscope are real alternative techniques in the computerization of the histology laboratory and in teleconsultation services. the expression pattern of the muc glycoproteins muc , muc and muc ac may be useful in classifying the various types of intraductal pancreatic neoplasms (ipmns). recent studies have revealed that muc is expressed in ductal pancreatic carcinomas (pdac) only. this study investigates whether muc is expressed in ipmns and in particular in those with invasive components. in addition, muc reactivity was studied in panins of both ipmn and pdac. methods paraffin blocks from resection specimens from pdacs and ipmns ( invasive) were investigated immunohistochemically ([ihc] antibody clone ig ) and by in-situ hybridization ([ish] digoxigenin labeled oligomer nucleotide specific for sequences corresponding to repeat domains of muc ). the normal pancreas is muc negative. of pdacs were positive for muc in both ihc and ish. only ipmns were muc positive, and these cases were of the oncocytic type. invasive ipmn components of the dac type ( / ) and one of muconodular type ( / ) showed muc expression at both the protein and the rna level. in ipmns associated panin lesions of all grades were negative, whereas in pdacs a few panin lesions were positive. conclusions muc neoexpression in the pancreas seems to be a feature of invasive ductal neoplasms (ipmn, pdac), with the exception of oncocytic ipmns. the aberrant expression, in particular the shift from the negative intraductal to the positive invasive component in ipmns, is so far unexplained, but it may be related to the genetic alterations known in ipmns and pdacs. introduction hypermethylation of cpg islands represents an important epigenetic mechanism for silencing of tumor suppressor genes during carcinogenesis. in this investigation, the prevalence of hypermethylation of the dna mismatch repair gene hmlh and of the recently identified hpp gene was investigated in adenocarcinomas of the upper gastrointestinal tract. materials and methods using methylation-specific real-time pcr and fluorescence-labeled dna-probes, hypermethylation of hmlh and hpp was investigated in barrett's-esophagusassociated adenocarcinomas, cardiac carcinomas and in gastric carcinomas. additionally, hmlh protein expression was investigated by means of immunohistochemistry. in a subset of cases the presence of dna-microsatellite instability was tested. hypermethylation of hmlh was found in % of barrett's carcinomas, % of cardiac carcinomas and in % of gastric carcinomas, whereas hypermethylation of hpp was found more frequently in all tumor types ( % vs. % vs. %). in gastric cancer, hpp hypermethylation was found more frequently in tumors with concomitant hmlh hypermethylation ( %), than in those without hmlh hypermethylation ( %, p= . ). complete loss of hmlh protein expression which was present in carcinomas ( cardiac and gastric) was invariably correlated with hmlh hypermethylation and with microsatellite instability. conclusion our data indicate that microsatellite instability and loss of the mismatch repair protein hmlh , which is mainly caused by hmlh gene hypermethylation, is more prevalent in the carcinogenesis of the stomach and the cardia than in the esophagus. moreover, in gastric cancer hmlh hypermethylation is correlated with hypermethylation of the hpp gene. antral g-cells in sporadic fundic gland polyps patients: an immunohistochemical study introduction malignant melanoma is an increasing neoplasm in the western world. advanced tumors gain metastatic potential and are responsible for high mortality rates. during tumor progression a downregulation of the transcription factor ap- a and the receptor thyrosine kinase c-kit was observed. however, mechanisms leading to a loss of both proteins are unknown. besides genetic changes post-transcriptional downregulation by caspase- and - is recently discussed. aims were: i) to investigate malignant melanoma for ap- a and c-kit genetically and by protein expression, ii) to study the implication of activated caspases. methods ssms, nms and metastases were analyzed by direct sequencing analysis for all exons of ap- a and c-kit genes and by immunohistochemistry for the respective proteins and cleaved (activated) caspase- and - . results four tumors showed point mutations in the activation motif of ap- a (exon ). no genetic alterations were detected in the c-kit sequence. immunohistochemistry revealed a progressive loss of dermal ap- a and c-kit expression when comparing ssms with nms and ms which was paralleled by a strong expression of caspase- in the primary melanomas and ms, the later were also characterized by caspase- expression. conclusion tumor progression in melanoma is characterized by a loss of ap- a and c-kit. caspase- probably contributes to this down-regulation, as it was recently shown in vitro. the activation of caspases in melanoma might not only induce apoptosis but could be substantial for tumor growth. introduction in cancer patients, tumor-expression of the angiogenic factor vascular endothelial growth factor-a (vegf-a) correlates with high tumor vascularity and increased metastatis, but how these latter two relate is unclear. we investigated the mechanisms of vegf-a -enhanced metastasis of the human melanoma cell line mel . methods stably transfected mel cells, expressing vegf-a or egfp, were injected into the internal carotid artery or tail vein of nude mice to establish brain or lung metastases (colonization models). subcutaneous tumors were grown to examine spontaneous metastasis to lung. tumors and metastases were examined by (immuno)-histochemistry. results in colonization models, vegf-a expression did not give tumor cells a colonization advantage. metastases originated predominantly by clonal expansion of single cells. in contrast, spontaneous metastasis from subcutaneous tumors was enhanced in tumors with vegf-a expression, this enhanced metastatic potential was induced by a distinct architectural transformation of the s.c. tumors: while mel -egfp and parental mel tumors showed extensive necrosis, mel -vegf-a tumors presented a micronodular growth pattern, with nodules protruding into sinusoidal dilated vasculature. these micronodules proved to be polyclonal, had tissue characteristics and caused metastatic embolism in the pulmonary artery with subsequent metastatic outgrowth. conclusion vegf-a may enhance spontaneous metastasis not simply by increased single cell shedding into the circulation by an increased tumor vascularity but by induction of a micronodular transformation of a tumor resulting in enhanced shedding of (polyclonal)tissue fragments into the circulation. this step of tumorintravasation is probably a rate limiting factor in development of metastasis. correction of cytogenetic disturbances in patients with relapsing genital herpes la lebedinskya, op abaza donetsk medical state university, donetsk, ukraine introduction serious forms of relapses of genital herpes (gh) are accompanied by disturbances of chromosomal apparatus of lymphoid cells (l.a. lebedinskya, ) . correction of the given infringements is the important problem of practical public health service. the aim of our research was development of a complex method of correction of cytogenetic infringements in patients with gh. materials and methods we had investigated and treated patients (complex treatment) with gh in the age of - years, with frequency of relapses of one time in . - months. the control group was made by healthy persons, same age group. cytogenetic disturbances in t-lymphocytes of peripheral blood surveyed determined by metaphase method. complex method of treatment of patients with gh included acyclovir mg times per day before clinical recovery and phytopreparation "bacplan", received by an original way from quercus cortex. phytopreparation "bacplan" shows immunomodulation, anti-inflammatory and antimutagen properties. preparation "bacplan" appointed per os . g per day within days. external - % solution of bacplan in the form of lotion on affected body parts time in day. results average frequency of cells with aberrations of chromosomes (ac) in t-lymphocytes of peripheral blood of patients with gh before treatment were much higher in comparison with parameters of control group (accordingly . ± . and . ± . % p< . ). in patients were marked disturbance of chromosomal and chrmotoid types. in . % cases aberration of chromosomes were registered in - chromosome pairs. after complex treatment of average frequency of cells with ac in patients has decreases to days to . ± . % (p< . ) and practically come nearer to control parameter ( . ± . %). conclusions thus, use of viral specific preparation acyclovir in combination with phytopreparation "bacplan" reduces frequency of structural infringements of chromosomes in t-lymphocytes of patients with gh. different expression patterns of s- versus s- b in primary skin melanoma j timar, n udvarhelyi, z orosz national institute of oncology, budapest, hungary differential diagnosis of melanoma involves immunohistochemistry where s- is a traditional marker which is recently completed by gp /hmb , mart- and tyrosinase. the s- family of ca-binding proteins comprises the a ( - ) and b isoforms. recent microarray analysis identified s- b as the melanocyte lineage marker. in this work we have compared the expression patterns of s- proteins using antibody recognizing both isoforms versus that which is specific for s- b in human skin primary melanoma samples. there were expression patterns observed: focal, herogenous and diffuse for both antibodies. the most frequent expression pattern was the diffuse one ( - %) while the least frequent was the focal pattern ( - %) in case of both antibodies. when the individual cases have been analysed for the expression patterns for the two antibody we found % discrepancy. in about half of these cases ( %) the discrepancy was minor (heterogenous versus diffuse staining pattern), but in almost a third of the cases ( %) it was found to be considerable (focal pattern versus heterogenous or diffuse). we have concluded that the expression patterns of s- and s- b proteins in human melanoma are frequently different. since gene expression studies identified s- b as linage marker, it is highly recommended to use monospecific antibody for routine diagnosis. furthermore, s- b is validated as sensitive serum marker for melanoma progression accordingly it is another indication for the use of anti-s- b antibody in the routine diagnosis. introduction primary cutaneous b-cell lymphomas represent subtypes of extranodal b-cell lymphomas with distinct clinicopathologic features. they account for approximately % of primary cutaneous lymphomas. the most common forms include follicle cell lymphoma, marginal zone lymphoma, immunocytoma, and diffuse large b-cell lymphoma. we report cases of primary cutaneous diffuse large b-cell lymphomas, one in the left gluteal region ( / cm in diameter), and the other in the left leg ( / cm in diameter), both appearing clinically ulcerated. materials and methods routine paraffin embedding and usual stainings, followed by immunohistochemistry were used. results microscopy evidentiated in the papillary and reticular dermis a diffuse pattern of growth of cells with a moderate degree of morphologic variation, with moderate, slightly basophilic cytoplasm and round-ovalar nuclei, with vesicular aspect owing to margination of chromatin at the nuclear membrane, - nucleoli, and frequent mitoses. gomory staining revealed a network of reticulin with reduced intervening spaces. immunohistochemistry evidentiated a diffuse positivity of vimentin and cd (l ), s positivity in few cells, desmin negativity, mic negativity, cd (berh /ki- ) negativity, actin negativity in tumor, but positivity in vessels, ema negativity and pcna positivity in almost % of the cells. conclusion final diagnoses of primary cutaneous diffuse large bcell lymphomas were considered correlating the clinical, morphologic, and immunophenotyping features. although prognosis of most primary cutaneous b-cell lymphomas is favorable, with -year survival rates over %, diffuse large b-cell lymphoma is more aggressive. we appreciated an unfavorable prognosis of both cases, but especially in the patient where the lymphoma occurred in the lower leg, as this location is associated with a more aggressive behaviour. in malignant melanoma cd protein expression is associated with metastatic tumors, higher clark levels and tumor thickness according to breslow n department of pathology, the norwegian radium hospital, norway cd antigen is a kd a cell surface zinc metalloendopeptidase and is expressed by a variety of normal and neoplastic lymphoid and non-lymphoid tissue including melanomas. kanitakis et al. (melanoma res ; : - ) have recently demonstrated that cd expression is significantly more common in metastatic than primary melanomas. we have evaluated biopsies from patients with primary and patients with metastatic melanoma. formalinfixed/paraffin-embedded tissues were studied by immunohistochemistry using mab c from novocastra laboratories and envision+® from dakocytomation. overall, cd was expressed in / samples, but the percentage of cd -positive cell was significantly higher in metastatic tumors (p= . ) and also in primary tumors with higher clark level (p= . ) and tumor thickness according to breslow (p= . ). even though the intensity of expression was associated with depth of invasion (clack levels p= . , breslow p= . ), there was no definitive difference between primary and metastatic tumors (p= . ). we conclude that cd expression in malignant melanoma is associated with tumor progression. sclerosing adenosis of the skin g sclerosing adenosis is a lesion that occurs in the breast; rare cases have also been reported in other organs such as prostate and skin. we report a case of sclerosing adenosis of the skin incidentally found at the periphery of a basal cell carcinoma. a -year-old man had a polypoid lesion of the scalp measuring . cm in diameter. the lesion was surgically removed and, at histology, it was composed of a nodular basal cell carcinoma. below the basal cell carcinoma, there was a well circumscribed but not encapsulated lesion constituted by small, packed glands separated by cellular stroma, reminiscent of sclerosing adenosis of the breast. some glands showed open lumina bordered by cells with eosinophilic, granular cytoplasm while other glands were arranged in solid clusters or elongated cords. two distinct layers of cells were seen bordering the glands: a luminal layer of cuboidal cells and an outer layer of basal cells with scanty cytoplasm and spindle nuclei. at immunohistochemistry the outer cell layer was positive for actin, calponin, caldesmon and keratin antibodies showing therefore myoepithelial cell differentiation. the luminal layer was positive with low weight keratin; moreover luminal cells were decorated by gcdfp- antibody, a marker of apocrine differentiation. to the best of our knowledge this is the first case of sclerosing adenosis of the skin showing apocrine metaplasia of luminal cells. the case here reported is an additional example of the existence of occasional similar lesions between skin and mammary gland. immunolocalization of human sperm protein in skin cancer introduction a variety of cancer	estis (c\t) antigens has been found to be expressed in healthy testis and in a wide range of human malignancies, including melanoma. the effectiveness of these antigens as target for active specific immunotherapy has been largely demonstrated. recently a new human c\t, called sperm protein (hsp ) has been investigated in multiple myeloma and ovarian cancer. the aim of this study was to investigate the expression of hsp in healthy skin and melanocytic skin lesions, in order to evaluate the usefulness of this antigen to develop effective specific immunotherapeutic procedures. methods the authors assessed the immunolocalization of hsp in paraffin embedded formalin fixed specimens of healthy skin (n= ) and tissues representing cutaneous melanocytic lesions [common nevi (n= ), spitz nevi (n= ), blue nevi (n= ), atypical nevi (n= ) and melanomas (n= )]. results hsp was not detected in healthy skin. it was recognized with a high frequency in cutaneous melanocytic lesions in some cells of the dermal stroma, often containing melanin, compatible with melanophages. a higher expression of hsp was observed in hyperpigmented nevi. conclusion the emergent complex function of hsp suggests the necessity of further studies to investigate the relation between melanophages and hsp . although hsp was not detected in healthy skin, its limited detection in resident melanophages recognized in cutaneous lesions, and not in tumoral cells precludes its applicability as target in skin cancer immunotherapy. introduction crimean congo haemorrhagic fever (cchf) is endemic in many countries in asia, africa and europe. the virus, which causes cchf, is a nirovirus from the bunyaviridae family. although primarily a zoonosis, sporadic cases and outbraces of cchf affect humans. case report a -year-old female patient was hospitalized due to sudden onset of fever, headache, vomiting and abdominal pain. during the next days, her condition became worse, she was unconscious, anuric, cyanotic with multiple edema on extremities, large vaginal coagulums and with appearance of haemorrhagic secretion in aspired fluid from the respiratory tract. three days after admission, due to sudden onset of cardiac arrest, patient died. pathologic findings: severe bleeding from the mucous membranes and internal organs were found, particularly emphasized in the liver, kidneys, heart, brain and other organs. widespread hepatocellular necrosis with focal microvesicular steatosis and multiple intracytoplasmatic microvesicular inclusions were the most striking morphological findings. diffuse necrosis of renal tissue was also found. recent haemorrhages in lungs, cardiac muscle, suprarenal gland, spleen, and gastric mucosa were found. lymphoid depletion was detected in lymph nodes. the rt-pcr method for detection cchf virus has been applied in analysing serum and tissue samples. serological testing and testing from paraffin embedded tissue were positive. conclusion autopsy pathologic findings of cchf include widespread haemorrhages of the skin, mucous membranes, pleura, peritoneum. necrosis is frequent in all organs and tissues, often of ishaemic nature. autopsy results of our patient showed similar pathologic findings and by pcr method we confirmed etiopathogenesis of this disease. the modern morphological characteristic of placenta in syphilis z parpiev , g reymnazarova , b magrupov dermatology and venerology, tashkent, uzbekistan first tashkent medical institute, tashkent, uzbekistan we investigated the placentas in three cases of intrauterine death caused by inherited syphilis. grossly, they were small and medium lobular, showed a marked sclerosis of large vessels and they looked white-muddy. the umbilical cord was also sclerotic and showed obliteration of vessels. their weight corresponded to term of gestation, whereas their area was smaller and their thickness greater than in normally proceeding pregnancy, but these differences were not significant (p> . ). results light microscopic investigation revealed avascularized stroma and sclerotic villi with vessels showing obliterating angiopathy. these changes were combined with processes of compensatory character, such as sharply extended subsyntitially located capillaries and large number of small vesels. conclusion in the morphological study of placenta, the attributes of damaged placental tissue and development of compensatory reactions directed towards the maintenance of necessary balance in the mother-placenta-fetus system were revealed. in placenta, contrary to the descriptions of the last years, we found no significant increase of its weight and change in this connection fetus-placenta of factor. the basic changes in placenta were characterized by the development of productive vasculitis with obliteration of the vascular lumina and presence of avascularized terminal villi. the thickening of vessel walls of the main villi as a result of proliferative endarteriitis can be considered as a characteristic attribute for syphilitic infection. the latent membrane protein (lmp ) of epstein-barr virus is one of two postulated viral oncogenic proteins. previous reports have suggested that sequence variations, and in particular a base pair deletion variant called cao, may define different disease populations. we developed a cocktail of rat monoclonal antibodies that were specific for the non-wild type lmp and compared the presence of the antibody staining with lmp dna sequence analysis on clinical samples of nasopharyngeal carcinoma, peripheral t-cell lymphoma, hodgkin's disease and lymphoblastoid cell lines from normal volunteers and patients with npc. results and conclusion our results demonstrate specificity of the monoclonal cocktail for detecting the wild-type lmp and the ability to sub-differentiate between the mediterranean type of lmp and the cao-lmp . visceral leishmaniasis primarily diagnosed in duodenal biopsy: report of three cases f pardal, a silva, v velasco, m teixeira serviço de anatomia patológica, braga, portugal introduction visceral leishmaniasis (kala-azar) is a zoonosis caused by a flagellate protozoan, of the genus leishmania, which is transmitted to man from reservoir animals (like a dog), by a vector of the genus phlebotomus. generally it affects the mononuclear phagocytic system of the bone marrow, liver and spleen. the gastrointestinal system is rarely involved. diagnosis of the infection depends on microscopic identification of leishmanias amastigotes in tissues or blood cultures or by serologic means. aims: visceral leishmaniasis is a rare disease in patients without immunodeficiency, the authors report three cases diagnosed primarily in duodenal and gastric biopsy from immunocompetent patients. materials and methods from the files of pathology department of s. marcos hospital five cases of visceral leishmaniasis have been collected in a years period, all from immunocompetent patients, namely without hiv infections. the authors describe three of the five cases, which were primarily diagnosed by gastro-duodenal biopsy. lately, was noted the presence of amastigotes in other tissues. after histologic diagnosis resulted a full clinic diagnosis of systemic leishmaniasis with advanced stage of disease. conclusions pathology department files reveal a significant percentage of visceral leishmaniasis diagnosed by gastroduodenal biopsy, three of five cases. thus, in no endemic countries for this opportunistic infection and in immunocompetent patients, gastrointestinal biopsy can, eventually be a rapid and sensitive method of diagnosis, since most of the patients present at an advanced stage of disease. impact of the sudden acute respiratory syndrome (sars) on the pathology laboratory: a singapore experience ar chang, a wee, sm chong, t ming pathology department, national university hospital, national university of singapore, singapore the sudden acute respiratory syndrome (sars) is a new global health problem that has received unprecedented attention. the predominant route of infection is by droplets and close contact with an infected person poses the highest risk of being infected with the sars virus. the majority of cases among health care workers have occurred in doctors and nurses who have cared for sars patients. pathologists and laboratory personnel are regarded as low risk for infection because they are infrequently in direct contact with patients. however, they receive specimens, including sputa, bronchiolo-alveolar lavage samples, excised tissues, blood and body fluids from infectious cases. two further possible sources of infection are during autopsies and the onsite processing of fine needle aspiration specimens for immediate diagnosis. not uncommonly, few clinical details are attached with a specimen to alert the laboratory so universal precaution must be in place and all specimens regarded as infectious. but with a new infection such as sars where information on its natural history, infectiousness and mode of transmission are still evolving, greater vigilance and a pro-active approach are needed. during the period march -may singapore was faced with a potentially serious sars epidemic and to minimize the chance of personnel in the pathology department, national university hospital being infected and thus compromise the diagnostic service a contingency plan was implemented. this report describes the impact of the plan on the department. sars is a global disease and pathologists in countries who have not encountered it may find the information useful for preparing their laboratory for the eventual arrival of sars. angiotropic large cell lymphoma of the central nervous system -report of four cases introduction angiotropic large cell lymphoma (alcl), or intravascular lymphoma, is a rare form of high grade non-hodgkin's lymphoma, predominantly of b-cell lineage. it is characterized by extensive proliferation of lymphoma cells within the lumina of small blood vessels particularly of the cns and skin with tendency to disseminate into multiple organs. because of nonspecific manifestations the clinical diagnosis of alcl is difficult as well as the morphological diagnosis, which may be problematic and subtile. methods we studied four cases of alcl with dominant neurologic symptoms in the form of vasculitis, dementia and cauda equina syndrome. the diagnosis was made by autopsy in three cases and by brain biopsy in one case. in one autopsy case, the alcl was associated with aids in a -years old hemophilic boy. results microscopically, in all cases, small blood vessels of the cns were distended by collections of large atypical lymphoid cells which obstructed the vascular lumina. tumor cells cytoplasm was amphophilic, the nuclei were large, irregular with prominent nucleoli. mitoses were numerous. in the vicinity, there were small zones of spongy edema, reactive gliosis and foci of total or selective necrosis. in an autopsy case with diagnosis 'vasculitis' (female -years) there was dissemination into multiple organs. immunohistochemistry shows strong positivity for cd and cd , and the negative reaction for cd , cd ro and factor viii-related antigen. based on the above findings the diagnosis of angiotropic large b-cell lymphoma was made. conclusion the antemortem diagnosis of alcl of the cns may be established by brain biopsy with application of immunohistochemistry. evaluation of cell death in animal model of brain contusion treated by hyperbaric oxygen therapy e vlodavsky, j soustiel rambam medical center, haifa, israel cerebral contusion (cc) remains the most important consequence of traumatic brain injury and has unexplained unique evolving clinical course.the aim of this study was to evaluate the extent of apoptosis in perilesional area of cc and to examine the effects of hypoxia and hyperbaric oxygenation therapy (hbot).the model of cc was based on the technique of cortical dynamic deformation (shreiber et al., ) on sprague-dawley rats. one group of animals afterwards was placed in closed chamber and exposed to mild hypoxemia, simulating posttraumatic hypoxemia. both groups of animals (hypoxia-exposed and non-exposed) were treated by hbot. brains were cut through produced lesion and paraffin sections were stained by tunel method and for active caspase- . apoptotic cells (ac) were counted in five successive perilesional layers of . mm each. it was shown that in the group of rats that were exposed to hypoxia, the width of perilesional area and the number of ac were significantly higher than in non-hypoxic animals, raising from . % to . % at . mm (p< . ).one treatment by hbot induced significant decrease both in the radius of perilesional area and the number of ac in both groups of animals (in hypoxia-exposed animals this effect was even more pronounced).the results of our study prove the role of perilesional area in the 'growth' of cc. hypoxemia caused profound increase in cell death extension. hbot shows marked positive effect in both hypoxic and nonhypoxic animals. we used quantative pathologic monitoring of number of ac to develop the optimal regimen of hbot in animal model of cc. introduction surgery for seizures consists of surgical procedures made in the central nervous system to treat drug-resistant epilepsy. different lesions may be the cause. aims: we review the cases diagnosed between the years and in our hospital. materials and methods the surgycal specimens were stained with hematoxilin-eosin and neural or glial immunostains after paraffin embeding. results the most frequent lesion is mesial temporal sclerosis ( - % of the cases). other causes are tumors; dysembrioplastic neuroepithelial tumor (dnt), neuronal tumors and glial tumors. less frequent lesions are phacomatosis, malformative lesions like cortical dysplasias or vascular malformations, vascular or trauma lesions and inflammatory or unspecified lesions. mesial temporal sclerosis consists of neuronal loss and gliosis in sectors ca , ca , ca and dentate gyrus. between and we diagnosed cases; were women and were males. dnt is a very infrequent, intracortical tumor composed of glia and neurons, usually associated with cortical dysplasia. in our experience we diagnosed cases; women and men. we have found other tumors associated with epilepsy; cases of ganglioglioma ( women and men), cases of gangliocytoma ( women and men), and astrocytic tumors ( protoplasmic astrocytomas, mixed astrocytoma and fibrillary astrocytomas). we also diagnosed other processes associated with epilepsy: cases of cortical dysplasia, of glial scar, of gliosis or unspecified changes and cases of vascular malformation. conclusion pathology associated with seizures is very diverse; a multidisciplinary and experienced team is needed. expression of sperm protein , a novel cancer-testis antigen in human nervous system tumours introduction human sperm protein (hsp ) is a highly conserved protein originally isolated from a rabbit epididymal sperm membrane and testis membrane pellet. recently, hsp has been included in the cancer/testis antigens (ct) family and showed to be expressed in multiple myeloma and ovarian cancer. the aim of the study was to investigate the immunolocalization of hsp in specimens of nervous system malignancies, in order to establish the usefulness of this antigen as target for tumour-vaccine strategies for nervous system tumours. methods the authors assessed the expression pattern of hsp in formalin-fixed and paraffin embedded surgical specimens of nervous system malignancies, including neuroectodermal primary tumors ( astrocytomas, glioblastomas multiforme, oligodendrogliomas, and ependymoma); meningeal tumours; and peripheral nerve sheath tumours ( schwannoma, and neurofibroma), using a standardized immunohistochemical procedure. results hsp was found to be expressed in a low number of tumoral cases (nearly %), with a major expression in astrocytomas histological group ( %). no case among peripheral nerve sheath tumours was found to be immunopositive for hsp . the expression pattern was found heterogeneous in all of the positive samples and it does not correlate with the degree of malignancy. conclusions the low frequency and the heterogeneous distribution of hsp suggest the useless of this antigen as unique target for immunotherapeutic strategies. however, the present study shows firstly the immunolocalization of hsp in some cells of nervous system tumors tissues. the emergent complex function of hsp renders necessary further studies to understand the link between positive-cells and this protein. in vitro fddnp labeling of pathological protein aggregates in the cns of selected "conformational" disease cases introduction a molecular imaging probe - ( -{ -[( -fluoroethyl) (methyl)amino]- -naphtyl}ethylidene)malononitrile (fddnp), is a highly hydrophobic, fluorescent substance, known to label senile plaques and neurofibrillary tangles (nft) in the brain of alzheimer disease (ad) patients. the aims of this study were to evaluate in vitro fddnp labeling of protein aggregates in selected "conformational diseases" of the brain and to determine if they fulfill the tinctorial and polarizing optics criteria for amyloid. material and methods brain sections of patients with confirmed ad, variant ad (vad), amyloid angiopathy (aa), sporadic creutzfeldt-jakob disease (cjd), variant cjd (vcjd), gerstmann-sträussler-scheinker syndrome (gss), pick disease (pid) and progressive supranuclear palsy (psp) were labeled with fddnp, congo red (cr) and pas. analysis was performed using fluorescent microscope (fddnp), and light microscope (cr and pas) with polarizing optics (cr). results in addition to senile plaques and nft in ad and vad fddnp reliably labeled: prion plaques in cjd, vcjd and gss, lewy bodies in vad and vascular amyloid in aa. it did not label pick bodies in pid, and globoid nft in psp. with the exception of fddnp positive hirano bodies in ad and lewy bodies in vad, cr and pas stained all the fddnp positive deposits. all cr positive aggregates also showed birefringence. conclusion in our study, fddnp labeled all protein aggregates that were shown to posses tinctorial and birefringent characteristics of amyloid, but also some that cannot be classified as amyloid. aside from its potential for in vivo diagnostics of some neurodegenerative diseases, fddnp may prove useful in labeling certain pathological protein aggregates in vitro. work supported by mŠzŠ grants - and l - . aim to investigate the development and clinical significance of vascularization in adenomatous alveolar hyperplasia (aah) and peripherally located adenocarcinomas of the lung. material and methods histological slides obtained from patients with aah, and from patients with potentially curatively operated lung adenocarcinomas including normal lung parenchyma are immunohistochemically stained with an anti cd antibody, and subject to quantitative image analysis. syntactic structure analysis measures the absolute and relative features of vessels including the vessel-associated cellular densities. these data are compared in between and associated with tumor volume, post surgical tnm stage, and the patients' survival. results aah displays an increased level of vascularization characterized by regular size and increased number of newly formed vessels. spatial agglutination (clusters formation) of vessels is common in aah. the tumor vascularization (volume fraction vv) amounts to % in aah and to % in lung carcinomas, and increases in advanced tumor stages (pt , pn ). aah displays the lowest, advanced tumor stages the highest numerical vascular density. minimum diameter and circumference of vessels maintain. the density of epithelial cells decreases with increasing distance from the vascular surface in both aah and adenocarcinomas. it is the highest in advanced tumor stages. according to multivariate statistical analysis the patients' survival is closely associated with the pn-stage, tumor volume, cell type and the numerical density of tumor cells within a distance < m to the nearest neighboring vessel. conclusion aah is characterized by probably non-reversible changes in vascular density and spatial vessel clustering. vascularization of pulmonary adenocarcinomas becomes altered in advanced tumor stages. of prognostic significance is the distribution of tumor cells in relation to the nearest neighboring vessel only. changes in vascularization probably play an important role in genesis and development of pulmonary adenocarcinomas. cellular and connective elements between bronchial glands in sarcoidosis: a quantitative analysis z kosjerina, v kosjerina ostric institute of lung diseases, sremska kamenica, serbia and montenegro objective objective of the study was to quantify the inflammatory and connective cells, as well as connective fibres between the bronchial glands in pulmonary sarcoidosis (s). material the study included the bronchobiopsy samples obtained from sarcoid patients. the control group (cg) included young healthy subjects who lost their lives in an accident, having the bronchus sampled at autopsy. the quantity of inflammatory and connective cells was measured by the stereometric numerical density method and the quantity of the connective fibres by the volume density method. results in the examined group the total quantity of all cellular elements between the bronchial glands in s was estimated to range from . /mm to . /mm or . /mm on the average. in the cg, the quantity ranged from . /mm to . /mm , or . /mm on the mean. besides cellular elements, connective fibres were also registered between the bronchial glands. in s, the connective fibres made % of the interstitium volume and only % of it in the cg. this difference is statistically significant. conclusion in sarcoidosis, the total quantity of all cellular elements between the bronchial glands exceeds their quantity in the cg for . times. the most numerous are lymphocytes in both groups, but in s their quantity is . times as high as their quantity in the cg. the quantity of the connective fibres is times as high as their quantity in cg. these differences are statistically significant. depending on the lung cancer stage and type vs. - % by conventional cytology) at an acceptably reduced specificity ( % vs. %, for aqc and conventional cytology, respectively). the role of the aqc cytology test in a comprehensive approach to detection of early (non-invasive and minimally invasive) lung cancers will also be discussed. introduction characterization of bronchial preneoplastic lesions is based upon cellular atypia and disturbed tissue architecture. depending on the individual experience, the grading of such lesions varies considerably. we evaluated immunohistochemical staining for p and mib- in regards of their value in routine diagnostics of bronchial biopsies. material and methods bronchial biopsies ranging from normal bronchial epithelium to invasive squamous cell carcinoma have been stained with antibodies against p and mib- . the biopsies have been divided into groups: squamous cell metaplasia with basal cell proliferation to low grade dysplasia, high grade dysplasia, and carcinoma in situ. for comparison, normal bronchial epithelium and invasive carcinoma have been included. in normal epithelium % of the cells showed positivity for p . with increasing degree of atypia, the number of posititive cells per nuclei increased to % in carcinoma in situ. almost linear progression has been found in the proliferation activity assessed by immunohistochemical staining with mib- . in normal epithelium the activity was < . %, and the number of positive cells increased to % in carcinoma in situ. in bronchial preneoplastic lesions an increasing accumulation of p and mib- can be found in accordance to the degree of atypia. this provides additional and valuable information to facilitate differentiation between low grade and high grade lesions. in regards of an increase in less invasive diagnostic and therapeutic methods, immunohistochemical staining with p and mib- adds valuable information for a correct grading of these lesions, and is therefore of considerable clinical importance. pitfalls in diagnosis and assessment of lymph node metastases in lung cancer -a morphometrical analysis of pulmonary and mediastinal lymphnodes t gumprich, k junker, km müller institut für pathologie, bochum, germany introduction besides histological subtype and tumor size, metastatic spread in pulmonary and mediastinal lymphnodes in lung cancer is also an important factor concerning therapeutic strategies. prior to resection of the primary tumor a thorough staging of pulmonary and mediastinal lymphnodes is performed using computer tomography -but lymphnodes will be judged by size only. in an autopsy study of ten cases with advanced lung cancer, lymphnodes have been dissected. lungs have been resected en bloc, and were cut in horizontal sections according to computer tomographic layers. lymphnodes have been measured and histologically examined. lymphnodes were judged as normal with a transversal diameter of not more than mm. in the histological examination metastases were found in % of normal-sized lymphnodes, while % of enlarged lymphnodes presented as negative. using other parameters did not yield better specifity or sensitivity. discussion: there is a wide range of what maybe the normal size of a lymphnode which is influenced especially by the study collective. we found a variety of size-influencing factors (pneumoconioses, silicosis, previous infections). furthermore, there are differences in size of lymphnodes in collectives from rural and industrial populations. the high number of metastases in normalsized lymphnodes is explained by the highly advanced stage of disease in our study collective. conclusions for imaging diagnostics, sufficient size parameters for lymphnodes are not existing. we are convinced that preoperative staging of lymphnode status is important. in many cases the radiological evaluation on the lymphnode stations is not sufficient to differentiate between reactive enlargement and metastatic involvement. mediastinoscopy is still needed in preoperative diagnostics, because it allows taking biopsies with following histological examination. expert system dedicated on diagnosis in thyroid pathology introduction encoutering diagnostically difficult cases, pathologists usually asks consultations from more experienced colleagues or uses materials in form of journal articles, textbooks, atlases etc. these sources can provide the information in a passive way. usage of expert systems (special computer programs) let pathologists obtain the information in an interactive way and have more accuracy in the diagnosis. our purpose was to create an expert system capable to improve histological diagnostics in area of thyroid tumors and tumor-like conditions. materials and methods materials for our work consisted of more than cases of thyroid tumors and tumor-like conditions (near pictures), representing thyroid diseases. every case was described by two experts according to histologic features and then entered in pc data base. results our computer program can act in two principal ways. these are ) diagnostics -expert system propely, ) learningvirtual textbook. ) using the expert system, pathologist enters new data in pc and marks so many features as he can. then he obtains the information about all the possibilities of probable diagnosis and some other results. entering more features can help to narrow the borders of probable diagnosis. ) applying our program as a virtual textbook, it is possible to learn better the known significance of pathological features, to take a look on the descriptions the experts made etc. the program can also function as a virtual trainer and examiner. conclusion our computer program increases the diagnostic quality in the area of thyroid pathology by means of high capability of information integration and improving pathologist's qualification during his learning. introduction xenin is a biologically active -amino-acid peptide extractable from the gastro-entero-pancreatic system. the aim of our study was to identify the unknown cellular source of xenin and to analyze the expression of xenin in neuroendocrine tumors. methods normal tissue of humans, rhesus monkeys and dogs and a large series of neuroendocrine foregut and midgut tumors were investigated by immunohistochemistry, confocal laser scanning microscopy, immuno-electronmicroscopy and high pressure liquid chromatography, assessed by radioimmunoassay. results in all three species, xenin was expressed in a subpopulation of gastric inhibitory (gip)-cells of the upper intestine. immunoelectronmicroscopy demonstrated presence of xenin in secretory granules ( ± nm diameter). xenin immunoreactivity and extractable xenin was found in of duodenal neuroendocrine tumors, including gastrinomas, somatostatinomas, non-functioning and enterochromaffin cell tumors. in contrast, xenin was absent from gastric, pancreatic, ileal and bronchial neuroendocrine tumors. conclusions the localization of xenin in ultrastructurally characterized secretory granules supports the concept that xenin represents a further endocrine regulatory peptide. the finding that xenin expression distinguishes between endocrine tumors arising in the duodenum from those of nonduodenal origin may be useful for topographical tumor classification and the differential diagnosis of neuroendocrine tumors of the upper gut. (supported by dfg) introduction the tall-cell variant (tcv) is known as a rare but aggressive form of papillary thyroid carcinoma (ptc) with increased incidence of local recurrence and mortality. it is defined as papillary thyroid carcinoma with at least % of specific cellular changes within the tumor cells and occurs in - % of all ptcs. materials and methods in our series of paraffin embedded and h&e stained tumor tissues, tall cell morphology was exactly defined for the first time and then cases of ptcs, including all stages and variants, were investigated concerning tall cell morphology and associated changes within the tumors. results in contrast to previous reports, cases ( , %) were classified as tcv in our series. taken together with minor tumor parts, cases ( , %) presented with tc morphology. these parts were in a high percentage associated with fibrosis and lymphocyte rich areas and showed a higher mitotic activity than usual ptcs. discussion the differences in the occurrence of tcv and tcmorphology between the presented series and previously reported cases might result from until now not clearly defined tall cell morphology as well as from similarities to ptcs, such as the oxyphilic variant, which is extremely rare in our series, and maybe also from often described squamous changes within ptcs. due to these data it is not clear which tumor parts have relevance for prognosis and which tumors should be treated more aggressively than others. in accordance with previous reports concerning the prognostical impact of this variant, we think that the occurrence of tc morphology plays a major role in both development of extrathyroidal growth and metastatic disease. myocardial extensions around venae cavae as a potential substrate of atrial fibrillation altered endothelial permeability secondary to ischemiareperfusion e stefanovic, v kanjuh, n tasic dedinje cardiovascular institute, belgrade, serbia and montenegro introduction during open heart surgery some damages to myocardial capillary endothelium occur, with the consequence to the regarding structure and function of cardiomyocytes as well. cardioplegia (cpl), long term hypoxia and reperfusion are strong contributing factors for these lesions. the aim of the study is to assess ultrastructural changes and permeability of endothelium of myocardial capillaries due to hypoxia and reperfusion during open heart surgery. the study included consecutive patients (pts) who underwent open heart surgery. samples were taken from right ventricle anterior wall and apcal region. biopsies were taken at the end of cardioplegic period, during ischemic period and during period of reperfusion. all patients were divided in two groups depending on duration of period of ischemia or cardioplegia-group (clp< min) and group (clp- - min). all samples were analyzed by electron microscope using quantative stereological analysis. volume fraction of the pinocyte vesicles (pv), mitochondria (m) and endoplasmatic reticulum (epr) were calculated. results endothelium ultrastructure analysis showed increase in permeability of the capillary wall. the worse damage was found after min. of cpl usage: edema of the endothelial cells, widening of the cell junction and other degenerative changes of cardiomyocytes. analyses of result confirmed that the more significant damages were found during reperfusion in group . conclusion our study showed significant changes in endothelial permeability and function after ischemia and reperfusion. disturbances of transendothelial transport may play certain role in the development of heart failure after open heart surgery. the authors compared the clinico-pathological and immunohistochemical features of acute postinfarction cardiac rupture and control (with near the same clinical age without rupture) cases. material and methods cryostat sections of both groups from infarction/rupture and controls were stained with oil red o, sudan black b (bdh chemicals) and were reacted to anti-c-reactive protein (crp), to complement c a and c b- (dakopatts). clinico-pathological findings myocardial rupture occured in elder women with relative smaller weight of heart, thrombosis of one main coronary artery, location in the anterior wall at the first infarction within the first week. microscopically the main observation is the large amount of granular lipid deposition in the area of myocardial rupture even in the cytoplasm of the necrotic myocardial fibers using oil red o and sudan black b staining. immunohistochemistry: the anti-crp and c b- antibodies showed intense staining around the area of the rupture. the inflammatory cells were neutrophils in high numbers in both group. eosinophils were represented in low percentage (below %). conclusion the postulation is, that the granular myocardial lipids in the area of infarction/rupture are phospholipids (mainly mitochondrial cardiolipin), which through binding crp induce pathologic complement activation. in experimental heart infarctions complement target (recombinant etc.) molecules could reduce the neutrophil chemotaxis to the area of necrosis and the size of the infarction. nuclear factor-κb regulates apoptosis of intimal smooth muscle cells introduction apoptosis contributes to reduce intimal smooth muscle cell (smc) hyperplasia following angioplasty or during atherogenesis. nuclear factor (nf)-kb is involved in the regulation of many smc functions. aim of the work was to verify the role of nf-kb in bax-dependent smc apoptotic cascade and its possible targeting for novel biologically based therapies of vascular hyperplasia. methods apoptotic proteins were evaluated by immunohistochemistry and western blotting and nf-kb using a anti-p (rela) antibody recognizing its active form. apoptosis was induced in rat aortic neointimal smcs after endothelial injury in vivo and in vitro by propyonil-l-carnitine (plc). in vivo, expression of constitutive nf-kb activity of smcs of neointima was higher compared to underlying and normal media. treatment with plc associated to reduced neointimal relative volume and increased apoptotic rate of intimal smcs compared to controls. increased apoptotic rate associated to bax overexpression and rela reduced immunopositivity. in vitro, plc reduced g to s phase progression of intimal but not of medial smcs. hoechst staining, flow cytometry and ligation-mediated pcr showed increased apoptotic rate of intimal cells treated with plc together with bax overexpression and the release of cytochrome c. sn , an inhibitor of nf-kb nuclear translocation, induced an increase of apoptotic rate in intimal but not in medial smc cultures, prevented the apoptotic effect of plc and upregulated the cytoplasmic bax expression and the release of cytochrome c. conclusions our studies with inhibitors of nf-kb strongly suggest that this nuclear factor plays a crucial role in the control of intimal smc apoptosis. alpha-actin isoform distribution in normal and failing human heart: a morphological, morphometrical and biochemical study introduction two sarcomeric actins, α-cardiac (α-ca) and αskeletal (α-ska), are coexpressed in adult myocardium and represent the preponderant thin filament actin isoforms of cardiomyocyte contractile units. in the human heart, the relative amount of α-ska mrna increases steadily during development and after birth and becomes the predominant isoform in adults but data in the literature concerning hypertrophy and failure are scarce and controversial. aim of the work was to determine how and where α-ska isoform accumulates during heart development, ageing and with disease. methods by using monospecific antibodies, we investigated by immunohistochemistry and western blotting the distribution of α-ska, α-ca and α-smooth muscle actin (α-sma) isoforms. results at weeks of fetal life, α-ska was localized in a small proportion of subendocardial and papillary muscle cardiomyocytes, whereas a diffuse α-ca staining was observed, associated with a focal expression of α-sma. in normal adult subjects, α-ska positive cardiomyocytes were distributed in a transmural gradient with the highest proportion located subendocardially. in myocardial hypertrophy and cardiomyopathies, the amount of α-ska was increased and a diffuse staining was seen in all layers of ventricular myocardium, with the exception of idiopathic dilated cardiomyopathies. cardiomyocytes were always negative for α-sma. as expected, fibroblasts in post-infarct scars expressed α-sma and tgf-β , but were negative for these proteins in interstitial fibrosis. conclusions changes in the distribution of actin isoforms in hypertrophy and failure provide new insight into the mechanisms by which the heart adapts to work overload and help to define their role in these pathological situations. introduction arrhythmogenic right ventricular dysplasia (arvd) has received much interest, since it may cause sudden cardiac death (scd). yet, pathogenesis remains controversial, not at least because adipose and fibroadipose types are considered different entities by some. the present study has looked into the histopathologic features of hearts with arvd with a particular eye for a clue to pathogenesis. clinical history review and heart macroscopic/microscopic examination (with histochemical/immunohistochemical techniques) were performed on patients dying suddenly with arvd. twenty-three, m/ f were young ( - years) and , m/ f adults ( - years). results )one young had family history of scd. )one adult had cardiovascular antecedents. )seven patients had died during exercise. )both young and adults presented adipose (n= vs ) and fibroadipose (n= vs ) types, whilst each variant basically showed similar overall architectural arrangements. ) occasional inflammatory infiltrates were present in fibroadipose, but not in adipose type. ) left ventricular involvement occurred in young and adult heart. ) coexistent left ventricular pathology was occasionally identified. conclusions ) arvd can be manifest in young and older persons, either as adipose or fibroadipose variants. ) both types are morphologically identical, except that some may have additional fibrosis, occasionally accompanied by small inflammatory aggregates. subtle differences hard to interpret as features distinguishing different entities. ) preferential and almost selective involvement of the right ventricular wall suggests a congenital nature of the disease, particularly since recent insights in right ventricular development have showed "regionalization" of genetic expression in the formation of cardiac chambers. fatty/fibrofatty tissues may appear ab initium through an alternative mesenchymal pathway. a new method of quantitative functional morphology for systemic examination of the cardiac muscle t ghevondyan , h guski , g avtandilov national institute of health, yerevan, armenia medical faculty of humboldt university of berlin, berlin, germany introduction determination of the vital capacities of heart muscle has special importance for cardiac surgery. morphological methods could be the most trustworthy in this respect. but it was not possible yet to extract this information from myocardial specimens. the aim of this study was to elaborate a method, which will be able to determine the volume of vital reserve of myocardium taking into account all known morphological changes and alterations. the investigation was carried out on heart muscle tissue of healthy people, who died accidentally and of patients who died from myocardial infarction. the myocardium of white rats (normal, physically trained, during pancreonecrotic shock) was used. methods of histology, electron microscopy, cytoenzymochemistry, morphometry, micromechanography, statistics and mathematical modelling were used. results most informative parameters were chosen for characterisation of the microcirculatory bed and of the paths of ultracirculation. the property of contractility has been taken as a systemforming criterion. a mathematical model was elaborated, which allows to unite the most important structural changes and alterations from tissue, cellular, ultracellular and macromolecular levels of the heart muscle. the role of endomyocardial biopsy in end-stage heart failure introduction endomyocardial biopsy is considered to be an important diagnostic procedure for the evaluation of patients with end-stage heart failure. the aim of this retrospective study was to evaluate the role of apoptosis, proliferation markers, volume density of interstitium, and myofibril volume fraction for the prognosis in patients with end-stage dilated cardiomyopathy (dcm). methods endomyocardial biopsy was performed during openheart surgery in pts with end-stage dcm. patients were divided into groups, one with shorter survival ( ± months, mean ± standard deviation) and another with survival of more than years after operation. the tunel method was used for the detection of apoptosis, and immunohistochemical methods were used for the evaluation of inhibitor of apoptosis (bcl- ), and proliferation markers (pcna, ki- ). results the increased percentage of apoptotic myocytes, decreased expression of bcl- , pcna and ki- antigen, but lower myofibril volume fraction and lower volume density of interstitium was found in the group with early mortality compared to that with longer survival. conclusion morphometrical analysis of the endomyocardial specimens of the patients with terminal heart failure due to dcm may enable us to get access to crucial information about the status of the myocardium, which may help us to predict the prognosis and optimal treatment of patients with end-stage heart failure due to dcm. introduction trafficking studies in bone marrow transplantation (bmt) more often use fluorescent reporter molecules like the green fluorescent protein (gfp). dendritic cells (dc) represent an interesting population for trafficking analysis, because they undergo steps of maturation, which seem to be related to their localization in the tissues. the aim of this study was detection of ex vivo expanded dcs, transduced to express gfp, in tissues of mice that had received an allogeneic bmt. material and methods tissues of recipient mice were pretreated by fixation in % formalin followed by % sucrose, before embedding in oct and freezing on dry ice. in addition tissues were also fresh frozen and exposed to formaldehyde vapor as cryostate sections. the gfp signals were validated using an anti gfp antibody. additional markers investigated were cd c, cd , cd , h- kb and h- kd. results vapor fixation of slides showed equal properties in containing gfp in comparison with the immersion method. gfp+ dcs were detected in small bowel, lymph nodes, thymus and spleen for up to days after i.v. injection. many of these gfp+ cells were positive for cd c. the gfp signals could be validated on fluorescence and light microscopic level using anti gfp antibodies. conclusions allogeneic dcs survive in bmt recipients for up to days. they migrate into small bowel, mesenterial lymph nodes, thymus and spleen without causing gvhd. the visualization of survival and migration in bmt settings will provide new insights into the immunological role of dcs in vivo and might contribute to the optimization of dc based treatment strategies. breast hamartoma: cytologic, pathologic and immunohistochemistry study of cases introduction breast hamartomas enter the differential diagnosis of breast masses, necessitating an accurate diagnosis. it is still not quite clear into which group of lesions these masses should be categorized. the aim of our study was to investigate the cytologic, histologic and immunohistochemical profile of breast hamartoma in order to obtain a detailed picture of this somewhat unusual lesion. materials and methods this study presents cytological, pathological and immunohistochemical analysis of patients with breast hamartoma. the immunohistochemical panel included: estrogen and progesterone receptors, her -neu protein, p- , ki- , ckmnf , vimentin, alpha-sma. results the patients ranged in age between and years. all patients presented with a palpable unilateral mass. the aspirates contained sheets of both bland ductal cells and lobular units. adipose tissue was present in varying amounts. typical macroscopical and microscopical features were noted. immunohistochemical studies showed estrogen and progesterone receptor positivity in epithelial cells as well as in the stromal cells, in all hamartomas. her -neu protein over expression was noted, p- expression was not observed. ki- showed a - % positivity in epithelial cells in most cases. conclusions the finding of intact lobular units and a relative paucity of stroma in an aspirate from a well-circumscribed breast lesion, may suggest the diagnosis of hamartoma. typical macroscopical and histological features of breast hamartoma were noted. the immunohistochemical profile appears to be similar to that of normal and fibrocystic breast tissue, raising the possibility of a spectrum of lesions. introduction ck-pattern in nos breast carcinoma has been studied extensively, including high molecular weight types, such as ck- , present in rare cases. published data on ck- -expression in less common subtypes of breast carcinoma are limited the aim of this study was to learn more about the immunohistochemical profile of ck- in cmf, a systematic analysis on ck- -reaction in a consecutive series of this variant of breast carcinoma was undertaken, including correlation with some traditionally recorded tumor characteristics. forty-three consecutive cases of cmf were examined for ck- . extent of staining was assessed semiquantitatively and reported as a percentage; its correlation to tumor size and receptor status was calculated. results sixteen ( , %) of the cases comprised ck- labelled tumor cells. though ck- + tumors were less commonly receptor+ and tended to be larger than ck- -cases, statistically significant differences were not obtained (p= . and p= . , respectively). conclusion no specific immunohistochemical profile typifying cmf has been identified. nevertheless, most cmf seem prone to exhibit immunophenotypic aberrations with higher incidence of vimentin+, c-erb-b +, and p- +, lower incidence of her + and er/pgr+. we here demonstrate that ck- -expression can be added to this list. though not statistically significant, a trend towards an inverse relation between basal cell characteristics and receptor expression and a positive correlation between ck- + and tumor size was demonstrated. introduction residual disease leads to most local recurrences, especially in patients treated with breast conserving therapy. this study was undertaken to identify whether assessment of excisional biopsy margins accurately predicts the presence or absence of residual tumor in the lumpectomy bed. material and method the margin status of consecutive lumpectomy specimens followed by re-excision, taken from an equal number of patients with primary breast carcinomas ( infiltrating, in situ), were evaluated microscopically and classified as 'positive' if the tumor was found at the inked margin, 'negative' if the entire tumor was found in > . cm from the inked margins, 'close' if it was within . cm of the inked margins, but did not transected them and 'indeterminate' if biopsy specimen was not inked or the tissue was fragmented. the tumor size and grade of the initial biopsy were also analyzed, as potential predictors for residual disease. results residual tumor was found in % of the patients ( / ): in %( / ) of the cases with negative, in %( / ) with positive, in % ( / ) with close and in . %( / ) with indeterminate margin status. in %( / ) of the 'positive margins' and in %( / ) of the 'close margins' cases no tumor was found in re-excised specimens. in %( / ) of the cases the residual disease was composed entirely of an in situ component of the same histologic type as the initial biopsy. no relationship was found between tumor size or grade and residual disease. conclusions for breast tumors histologically negative margins in biopsy specimens do not guarantee complete excision. 'close' margins may be considered almost equal to 'positive' ones. residual in situ carcinoma in the immediate vicinity of the previous biopsy site seems to represent the advanced edges of the tumor, apparently difficult to be excised completely and most likely responsible for the locally recurrent disease. introduction syringomatous adenoma of the breast is a benign lesion of the nipple, which may be confused with an infiltrating carcinoma. the presence of the myopithelial cells and the immunohistochemical profile is still controversy in the literature. we present the case of an years old patient, with an left nipple mass. materials and methods after excision, the excised tissue was fixed and paraffin embedded and h-e stained. we performed also immunohistochemical staining: with cytokeratin, actin, er, pr, p . the excised tumor measured cm, had ill-defined margins and yellow color.microscopically, the lesion consisted of tubules and strands, composed of small and uniform basophilic cells, diffusely infiltrating the stroma of the nipple. the tubules were lined by two layers of cells, had a comma-like appearance and their lumen was usually open and round. the tumor cells lack pleomorphism. squamous differentiation resulted in keratotic cysts. immunohistochemically, the luminal layer of epithelial tumor cells was cytokeratin-positive and the peripheral myoepithelial cells were actin-positive. the tumor cells were negative for er, pr, p . conclusion syringomatous adenoma of the breast is a benign rare lesion. the pathologist must not confuse it with an tubular carcinoma or with an adenosquamous carcinoma. we demonstrated in this case the presence of the myoepithelial cells. the role of smooth muscle myosin heavy chain in diagnosing sclerosing adenosis of the breast with an infiltrative pattern introduction sclerosing adenosis (sa) of the breast can produce an infiltrative pattern mimicking invasive carcinoma. immunohistochemical markers for myoepithelial cells, such as smooth muscle myosin heavy chain (smmhc), have been shown to stain basal myoepithelial cells in normal mammary glands and fibrocystic changes. absence of myoepithelial cells is associated with invasive carcinoma; however, we have observed occasional attenuation of smmhc staining in sa. studies evaluating the role of smmhc in sclerosing adenosis have not been performed. the intent of this study is to further evaluate the staining pattern of smmhc in sa with an infiltrative pattern. materials and methods twenty cases of sa with an infiltrative pattern were identified, h&e stained, and immunohistochemistry performed for smmhc (m , dako corp), µg/ml, as primary antibody, using a polymer based envision+ detection system (dako corp). normal-breast tissue positive controls and negative isotype matched igg controls were used. cases were then classified into one of three categories: positive (staining > % of myoepithelial cells), intermediate ( % - %), or attenuated (< %). results three of the first ten cases ( %) showed attenuated staining with smmhc. the remaining seven cases demonstrated positive staining of myoepithelial cells. all cases exhibited positive staining within normal lobules, serving as an internal control for each case. ten additional cases of sa have been identified and are being stained with smmhc for evaluation. conclusions preliminary findings show that smmhc yields inconsistent results when applied to sa with an infiltrative pattern. such lesions can have features similar to invasive carcinoma on h&e, and application of smmhc could produce misleading results. co-expression of erbb family members in human breast cancer: her- /neu is the preferred dimerization candidate in nodal-positive tumors introduction overexpression of members of the erbb receptor family has been asssociated with malignant transformation and the amplification of her- /neu in tumor tissue is now an established prognostic factor in breast cancer. in order to initiate signal transduction, erbb receptor monomers need to form homo-or hetero-dimers. the composition of these dimers is thought to greatly influence both quality and quantity of downstream signalling pathways, and to ultimately determine the elicited biological response. material and methods the protein expression pattern of all four erbb receptors egf-r, her- /neu, her- and her- , and expression of their putative ligands egf, tgf-a and hrg was investigated in women with invasive breast cancer by membrane isolation and western blot analysis. results the co-expression of all four erbb family members was detected in , % of cases, and of all of the three investigated ligands in , %. while we did not observe a correlation between egfr and her- /neu or her- protein expression, egfr and her- (p= . ), and her- and her- (p= . ) were clearly coexpressed. the strongest overall correlation, however, was found between her- /neu and her- (p= . ) and between her- /neu and her- (p= . ). this was particularly true in nodal-positive tumors (p< . and p= . , respectively) whereas in nodalnegative tumors the co-expression was either less significant (her- /neu and her- : p= . ) or not significant at all (her- /neu and her- ). the co-expression of egfr/her- was associated with the expression of all three ligands, whereas the her- /neu/her- was correlated with hrg (p= . ), thereby indicating a functional relation between specific receptor-dimer combinations and putative ligands. conclusion taken together, we have performed a comprehensive survey of erbb system expression in breast cancer, and have demonstrated the presence of a co-regulated receptor/ligand system in vivo. her- /neu appears to function as the preferred coexpression partner in nodal-positive tumors, thus rendering him the most likely dimerization candidate in malignant breast tumors. introduction members of the ap- family of transcription factors (c-jun, junb, jund, c-fos, fosb, fra- and fra- ) are able to form jun-jun or jun-fos dimers which bind to the regulatory sequences of target genes. in a prior study on mammary carcinomas, we found that high fra- and reduced fosb expression are associated with indicators of poor prognosis. as most of the proteases involved in degradation of the extracellular matrix and basal membrane (matrix-metalloproteinases, members of the upa/paisystem) are regulated by ap- complexes, we assumed that the expression of single ap- proteins might also be important for the process of invasion of breast cancer cells. method in order to analyze the influence of the single fos family members (c-fos, fosb, fra- and fra- ) on the invasive behavior of mammary cancer, we performed western blot analysis of mmp and mmp and of the members of the plasminogen activator system pai- , upar, and pai- -upa-complexes in breast cancer samples, and correlated the expression of these proteins with that of the ap- proteins. results interestingly, c-fos, fra- (phosphorylated form), and fra- correlated with mmp expression levels. high expression of fra- was also significantly associated with that of pai- and the sds-insoluble upa/pai- complex. on the other hand, the expression of fosb was significantly associated with high levels of mmp . conclusion our results indicate that a shift in ap- protein expression, especially high expression of fra- and fra- , might be involved in invasion of breast cancer cells. (supported by deutsche krebshilfe, no. - -ba ) immunohistochemical study of estrogen receptors and progesteron receptors in primary breast carcinomas and their axillary lymph node metastases nh aksoy, he pestereli, s karaveli akdeniz university school of medicine, department of pathology, antalya, turkey estrogen receptors (er) and progesteron receptors (pr) was investigated in primary breast carcinomas and their axillary lymph node metastases to determine if the malignant cells retained or changed this phenotypic feature during the metastatic process. the data were also compared with the tumour size, histologic type, grade and age. immunohistochemistry with the er (dako- d -n ) and pr (dako-pgr -n ) on formalin-fixed paraffin embedded tissue was used. the er status in primary tumours and lymph node metastases was concordant in patients ( , %) and discordant in ( , %). six of these eleven patients had er-positive primary tumours and er-negative lymph node metastases. the pr status in primary and lymph node metastases was concordant in patients ( , %) and discordant in patients ( , %). ten of these twenty-four patients had prnegative primary tumours and pr-positive lymph node metastases. we observed higher pr positivity in axillary lymph node metastases. the parameters, tumour histology, grade and age showed no statistically significant relation with receptor status. there was a significant correlation between the tumour size and the number of axillary lymh node metastases. the discordance of hormone receptors status between the primary tumour and lymph node metastases might be due to the heterogenity of tumour cells or loss of the phenotypic features of metastatic cells. breast carcinoma in a cancer hospital p arapantoni -dadioti , o tzaida , v leodara , g sotiropoulou , e trichia , pk sotirakoglou pathology department metaxas cancer hospital of piraeus, piraeus, greece department of mathematics and statitics agriculture university of athens, athens, greece a total of cases of infiltrating breast ca, diagnosed in our hospital during the last decade, was studied. the material concerned mastectomies with ispilateral lymph nodes dissection specimens. the patients were classified according the tnm staging system, based upon the primary tumor size (t), the presence of regional axillary nodal involvement (n) and distant metastases (m). this categorization revealed a preponderance of patients with t tumors. the overall decade rate for t , t and t tumors was , , %± , %, , %± , % and , %± , %, respectively. there was a statistically significant difference between the three groups (p< , ). the annual distribution of these groups revealed that since the mean group rate had a tendency to approach the corresponding decade rate, a finding suggesting some degree of stabilization of these proportions. on the other hand, the lymph node metastases were more common in the t tumors. the mean rate for t n+, t n+ and t n+ was , %± , %, , %± , % and , %±- , %, respectively; the difference is statistically significant for the t n+ and t n+ (p< , ) as well as for t n+ and t n+ (p< , ). the annual overall rate of patients with lymph nodes metastases, independently of t (tn+) was , %± , %. in conclusion, there is no tendency of early patient presentation and a more careful intimate medical care. the infiltrating breast cancer in our material, is represented mainly by thet tumors and the great majority of patients come to the hospital in an advanced stage regarding the t and n. introduction breast cancer is a genetically complex disease, which involves the accumulation of various structural and numerical aberrations. in the present study, we assessed the numerical status of chromosomes and x in primary invasive breast carcinomas in relation to clinicopathological parameters, patients' overall survival, and indices of cell growth (c-erbb- , topoisomerase iia) and survival (caspase- , bcl- ). material and methods the number of copies of both chromosomes was detected by interphase chromogenic in situ hybridization with pericentromeric probes on paraffin embedded sections. er, pr, cerbb- , topoiia, caspase- and bcl- expression was immunohistochemically detected (abc/hrp). the results were statistically assessed by univariate and multivariate analysis. results polysomy of chromosomes and x was detected as the predominant aberration ( . % and . % respectively). gain of chromosome copies was associated with high nuclear grade (p= . ), increased tumor size (p= . ), advanced stage (p= . ), the expression of topoiia proliferation index (p= . ), and worse overall survival by multivariate analysis (p= . ). the levels of chromosome x polysomy were elevated in ductal carcinomas of high histological grade (p= . ), in high nuclear grade tumors (p= . ), and were associated with the expression of topoiia (p= . ) and loss of caspase- protein (p= . ). in addition, gain of chromosome x copies was an independent predictor of impaired prognosis of ductal carcinomas (p= . ). conclusion polysomy of chromosomes and x was observed as the predominant alteration in phenotypically aggressive breast tumors, characterized by poor differentiation, increased growth potential and impaired prognosis, whereas gain of chromosome x in particular, is probably implicated in cell survival. expression of survivin, bcl- , p and bax in breast carcinoma and ductal intraepithelial neoplasia (din a) f kayaselcuk , tz nursal , a polat , t noyan , s yildirim , a tarim , g saydaoglu introduction survivin is a recently discovered member of the family of proteins that inhibits apoptosis. this anti-apoptotic compound can be detected in most types of cancer and expression is associated with a poor prognosis. we immunohistochemically investigated the expression of survivin in breast carcinomas and intraductal epithelial neoplasia of breast to determine whether expression of this protein is associated with clinicopathological parameters such as grade, stage, mitotic rate. the study involved patients with invasive ductal carcinoma (idc) and patients with intraductal epithelial neoplasia with mild, moderate and severe, florid ductal epithelial cell hyperplasia. survivin, bax, bcl- , and p monoclonal antibodies were administered by immunohistochemical method. findings were analyzed with statistical methods. results in of cases ( . %) of breast carcinomas and of cases ( . %) of intraductal epithelial neoplasia with mild, moderate and severe ductal epithelial cell hyperplasia stained positively for survivin. none of the histological parameters analyzed were significantly correlated with survivin expression in breast carcinomas. in the carcinoma cases, survivin expression was positively correlated expression of bcl- , but was not correlated with expression of p , bax, c-erbb- and estrogen, or progesterone receptors. some of the intraductal epithelial neoplasia cases with moderate or severe ductal epithelial hyperplasia stained positively for both survivin and p . the breast carcinomas exhibited significantly increased expression of survivin, p , and bcl- than the breast with intraductal epithelial neoplasia. survivin was not correlated with any of the clinicopathological parameters studied, however, it could be a useful tool in early carcinomas and florid, severe ductal epithelial hyperplasia. introduction certain non-malignant and pre-malignant lesions cause dilemmas for the most appropriate management following lncb. the aim of this study was to determine the accuracy of lncb in diagnosising the most frequent non-conclusive findings: benign papillary lesions (bpl), radial scars (rs), fibroepithelial lesions with stromal hypercellularity (flsh), atypical ductal hyperplasia (adh) and intraductal carcinoma (dcis). material and methods in a retrospective review of , imaging guided lncbs ( - ), we found: ( . %) bpl - with surgical correlation (sc) and with mammographic follow-up (mf); rs ( %) with sc in and mf in ; ( . %) flsh all with sc; ( . %) adh -with sc in , and ( . %) dciswith sc in . results ) bpl: patients without changes in mf. at surgery: bpl - with adh and invasive carcinomas ( with mammographic histologic discordance and diagnosed years post lncb). ) rs: without mammographical changes and rs ( with adh). ) flsh: at surgery, fibroadenomas, benign and malignant phyllodes tumours. ) adh: at surgery, ( . %) adh, ( %) dcis, ( . %) invasive carcinomas - of which microinvasive. ) dcis: at surgery, ( . %) dcis; ( . %) microinvasive, and ( . %) invasive carcinomas. conclusions ) diagnosis of bpl at lncb seems accurate when correlating with image findings. ) rs at lncb can be followed mammographically. ) flsh at lncb always requires surgical excision. ) adh and dcis diagnosed at lncb need complete removal of lesion, due to frequent underdiagnosis. introduction estrogen receptor beta (erb) is known to be present in breast tumors; its prognostic and pathophysiological roles, however, remain to be established. the aim of this study was to investigate erb protein expression in a well documented series of invasive breast carcinomas. materials and methods standard immunohistochemistry with a specific monoclonal antibody (clone ppg / , serotec) was performed on paraffin sections; % of strongly immunostained carcinoma cells was used as a cutoff point to classify tumors as erb-positive. statistical correlations were sought with clinicopathological variables (including hormone receptor status) and patients' disease-free and overall survival. cell proliferation was immunohistochemically assessed by topoisomerase iia (topoiia) index. statistical analysis was univariate and multivariate. results erb immunoreactivity was detected in the majority of specimens ( . %)and was positively linked with era immunoreactivity (p< . ) and increased topoiia index (p= . ). a significant favorable impact of erb immunopositivity emerged with regard to disease-free and overall survival in both univariate (p= . , p= . , respectively) and multivariate (p= . and p= . respectively) statistical analysis; progesterone receptor expression was also found to exert an independent favorable influence on patient's survival with less statistical significance though (p= . and p= . ). on the contrary, patients' survival was not significantly impacted by era status. conclusions because of the positive association between erb immunoreactivity and topoiia expression, the presence of erb in breast cancer cells may be considered an indication of increased proliferation. nevertheless, erb immunoreactivity emerges as a valuable, independent indicator of favorable prognosis. aims to determine diagnostic value of lncb in patients with ilc using ec and ck sse . retrospective review of cases diagnosed as ilc either at lncb or at surgical biopsy (sb), between and . immunohistochemical (ihq) study with ec and ck sse was performed at both lncb and sb. three immunoprofiles were established: ec-ck sse + (ihq of ilc); ec + ck sse -(ihq of ductal carcinoma -idc) and ec + ck sse + (ihq of mixed ilc-idc). initial diagnosis at lncb was correlated with final diagnosis (morphologically and immunoprofile). discordant cases were analysed in order to determine usefulness of ihq at lncb. results in lncbs initially diagnosed as: ) ilc ( patients), final diagnosis was ilc in cases (ec-ck sse +) and idc in case (ec+ ck sse -); ) invasive carcinoma probably lobular type (ilcp) ( patients), final diagnosis was ilc in cases (ec-ck sse +), idc in (ec+ ck sse -) and mixed ilc-idc in (ec+ ck sse +); ) idc ( patients), final diagnosis was ilc in all cases (ec-ck sse +), of them ilc pleomorphic-type. in all discordant cases, immunoprofile at lncb was concordant with final diagnosis conclusion % of patients diagnosed as ilcp at lncb corresponded finally to idc or mixed idc-ilc. . % of patients finally diagnosed as ilc were initially interpreted as idc at lncb. our findings suggest that ec and ck sse are of great value to help characterise breast carcinomas at lncb, and improve management of patients. background her- status became an important prognostic and predictive factor in breast carcinoma. there are two main techniques of evaluation her status: immunohistochemistry (ihc) for the protein expression and fluorescence in situ hybridisation (fish) for amplification of her gene. the aim of the study was to compare the results obtained by ihc and fish methods in determination of her status in breast cancer. materials and methods two hundred breast cancer specimens were examined. ihc and fish were performed in every case. ihc was performed with dako herceptest, fish with oncor-qbiogene reagents. ihc results were classed into groups, accordingly to the intensity of membrane staining ( , +, +, +). fish results were divided into three main categories: na -no amplification, la -low amplification and ha -high amplification. the number of copies of chromosome was also assessed. results over % of cases described by ihc as + exhibited also amplification of her /neu gene. remaining cases were positive with ihc, but presented no gene amplification. this might be due to the subjective assessment of the membrane staining or to the procedure of material fixation. another possibility is that overexpression of the protein was caused by mrna stability or disorders in receptor circulation. the majority of cases classed by ihc as + were also negative by fish (over %). nearly one fifth of ihc + were found to exhibit gene amplification. remaining cases showed no amplification of her /neu gene, combined with aneuploidy of chromosome . all cases described by ihc as / + showed no amplification. conclusions ihc is well-established method of assessing her status in breast cancer. nonetheless, group of cases described as + should be additionally examined using fish method because the results are more reliable. in order to improve accuracy and gain the highest quality of her status evaluation, in those cases both methods should be applied. dcis of the breast with excessive cancerization of the lobules simulating invasive carcinoma b nielsen institute of pathology, randers, denmark a -years old woman had a right sided mastectomy with axillary dissection performed, because of suspicious mammografic microcalcifications and finding of malignant cells by fine needle aspiration. grossly, an cm large suspicious area with accentuaded consistency and multiple pale-yellow flecks, representing comedonecrosis, were found. multiple sections representing the suspicious area showed dcis. the ducts were dilated and contained malignant cells and central necrosis. in areas classical cancerization of the lobules were present. furthermore, in multiple microscopic areas the stroma of the lobules were oedematous and infiltrated by lymphocytes. the acini were slightly dilated and covered by one or two layers of malignant epithelial cells, but the central lumen was preserved. the morphology greatly simulated invasive ductal carcinoma. however, by immunohistochemistry the myoepithelial cells were showed to be preserved and the lobular unit were well demarcated with preserved circumscription. the axillary fat contained lymph nodes all without metastasis. it was concluded that the alterations represented a variant of lobular cancerization, earlier described by tavassoli ( ) . spindle cell tumors of the breast are rare entities with difficult differential diagnosis. we report four spindle cell tumors: a metaplastic carcinoma, a fibromatosis, a malignant spindle cell myoepithelioma and an inflammatory pseudotumor. the metaplastic carcinoma occurred in a -year-old woman as a . x . x cm nodule with scarce bland clear cells proliferation and very important desmoplastic reaction; immunohistochemical stains revealed positivity for cytokeratins (mnf ) and vimentin and negativity for actin and desmin. the fibromatosis occurred in a year-old man as an x x cm tumor with bland spindle cell morphology; very little atypia and rare mitoses were identified and immunohistochemical positivity for vimentin was demonstrated. the malignant spindle cell myoepithelioma occurred in a -yearold woman as x x cm nodule with central necrosis; histopathologic examination revealed a malignant spindle cell proliferation with many mitoses and atypical cells; focal positivity for mnf , vimentin, actin and s was identified. the inflammatory pseudotumor occurred in a -year-old woman as a highly cellular spindle cell proliferation with fascicular pattern admixed with myxoid areas and inflammatory cells -type i-ii mammary inflammatory pseudotumor. one important criterion which should be kept in mind in the process of evaluation of a spindle cell tumor of the breast is that these tumors may have deceptive histopathologic appearance -some of them have bland looking morphology despite of their biological behavior (our example of metaplastic carcinoma) and others with worrisome morphology were diagnosed as benign or intermediate malignancy entities (inflammatory pseudotumor). introduction calcitonin receptor (ctr) belongs to the g proteincoupled receptors and it binds calcitonin (ct), which acts on bone and kidneys to maintain calcium homeostasis. however, both of ct and ctr have also been identified in a large number of tissue and cell, suggesting it might has any unrecognized roles. although ctr expression has been found in several breast cancer cell lines and in primary breast cancer, quantitative analysis of ctr expression in matched normal breast tissue and primary breast cancer has not been explored up to date. here we present the detection and quantitation of ctr gene expression in matched normal breast tissue and breast cancers, by using laser capture microdissection. materials and methods fourteen breast cancers and matched normal epithelium from the same patient were laser capture microdissected to obtain pure cell groups and to submit to quantitative analysis by using one step real time rt-pcr. results both normal breast epithelium and cancer cells expressed ctr. as compared with paired normal epithelium, decreased ctr expression was found in of cases breast cancer ( . %) while increased ctr expression in cases ( . %) and no change in cases ( . %). conclusion our investigation revealed that ctr expression was constantly expressed in normal breast tissue and breast cancers. to the best of our knowledge, this is the first report, which revealed that ctr rna expressed in normal breast epithelium. downregulation of ctr is a common phenomenon in the breast cancer, suggesting that it may have important roles on the development of breast cancer. effect of neoadjuvant chemotherapy on her status in patients with breast carcinoma s popovska, t betova medical university-pleven, pleven, bulgaria introduction neoadjuvant chemotherapy is the standard of care for patients with locally advanced breast cancer and is being evaluated in patients with earlier-stage operable disease. the effects of chemotherapy on biological markers such as an oncoprotein expression are not well known. the aim of the study was to determine whether her expression was modified by neoadjuvant chemotherapy. methods forty-nine patients with t - n - m breast cancer were treated in a prospective trial utilizing fec regimen. matched pairs of pre and post-chemo therapy breast tissue were evaluated immunohistochemically for her status using herceptest kit (dako). results her overexpression was observed in / patients ( %). the her status of ( . %) patients was unchanged after chemotherapy. modification was found in cases-decreasing in , increasing in and loss of expression in patient. her status was not changed significantly following primary chemotherapy. conclusions our results showed that, in most patients her status is stable parameter in patients with breast carcinoma after primary treatment with neoadjuvant chemotherapy. the microvessel density in female breast cancer among younger and older age groups introduction breast cancer remains one of the most important oncologic problems worldwide. it seems that breast cancer first detected by the age of - years follows more aggressive clinical course than tumors developing later. young females with breast cancer more frequently present with axillary lymph nodes metastases. expression of the estrogene receptors is less frequent, and the histological grade is usually higher among this group. the main purpose of our study was the evaluation, quantification, and comparison of the angiogenesis in breast cancer among young women, below the age of years and older patients, above years. material and methods tissue samples of breast cancer from patients aged years and less ( cases), and from patients older than ( cases) were studied. ten specimens of non-neoplastic breast tissue from the normal breast in the tumor vicinity (younger patients) served as a control. microvessels were visualized immunohistochemically with use of cd- antibody and counted within the areas of the highest density ("hot spots"). six separate high power fields (hpf), . mm each, were studied in each case. results and conclusion the average microvessels count per hpf in the breast cancer tissue in younger group was higher than in the older age group and non-neoplastic tissue. the differences were statistically significant. the increased density of proliferating microvessels seems to play a role in the aggressive clinical behavior. total frozen section diagnoses have been performed mainly on sentinel lymph node of the mammary gland.the aim of the study was to analyze our result, and estimate whether the telepathology is of practical use or not. material total cases including lymph nodes diagnosed using telepathology. results and conclusion we failed to find carcinoma metastasis in out of sentinel lymph nodes of breast. it was very minute metastasis, and was not contained in the transmitted pictures. our transmission speed is kb that takes about seconds for each picture. there exists a limitation about the transmittable pictures within a restricted time. improvement of transmission speed may solve this problem. in two cases, while telepathologically negative of sentinel node, we found metastasis in the other dissected nodes by permanent section examination. the method of sentinel node identification should be improved. there was a confounding of the specimens that occurred between two patients on the same day. it was a case that happened at the beginning of telepathology. since the surgeon and the technicians are far away from the pathologist, and communication is done by the telephone, it is important for each party to keep in close contact with each other. our result is fairly good considering the limitation of the telepathology. although some issues are still remaining, we conclude that telepathology is now of practical use. pigmented mammary paget disease in a year old man-a case report ar monsef esfahani hamedan university of medical sciences, hamedan, islamic republic of iran mammary paget disease results from intraductal mammary paget carcinoma that extends to the epidermis of the nipple and areola through a lactiferous duct or from invasive breast carcinoma that reaches the epidermis via direct extension from the dermis. pigmented mammary paget disease is a rare clinicopathologic variant of mammary paget disease. it may mimic malignant melanoma clinically and histophatologically. it seems that involvement of the dermo-epidermal junction by neoplastic cells of the mammary paget carcinoma seems to be a prerequisite for the development of the clinical pigmentation. we report a case of pigmented mammary paget disease. the patient was a -year-old male who complained of an erythematous, pigmented scaly plaque around his right nipple measuring x cm with mild fissuring of two year duration. the histopathology revealed pagetoid spread of large cells in the epidermis with pigmentation of basal cells and melanocytes. the ihc confirmed the mammary paget disease and excluded malignant melanoma and squamous cell carcinoma. frozen section evaluation of sentinel lymph nodes in breast cancer introduction the use of sentinel concept as the newest approach in surgical treatment of breast cancer, apart from tumorectomy, means the extirpation and analysis of one or more regional lymph nodes which receives lymph drainage from primary tumor (guardian lymph nodes -sentinel nodes). the presence or the absence of secondary deposit in them is considered the most important predictor of the positive secondary deposit status of the other axillary lymph nodes. depending on histological analysis of sentinel node, the operation is finished with or without the axillary lymph node dissection. materials and methods sentinel concept in surgical treatment of the breast cancer is applied only in the cases where the largest dimension of the tumor is not more than cm (pt ). marking of the sentinel node is conducted before the operation by a combined method, the usage of patent blau color and technetium m as a radio marker. sentinel lymph nodes identity, before sending to a pathohistological analysis, is checked by gamma detection probe. two groups of prospective tests (a and b) were formed with cases each. sentinel lymph nodes from group a in the first stage of the testing were treated by pathohistological method (one hematoxylin and eosin preparation) and then microscoped. the cases in which secondary deposit was not noted, were subjected to a serial cutting and immunohistochemical staining by the ema markers, specific for intraductal epithelium of a breast. sentinel nodes from group b were submitted fresh for frozen section investigation, where they were approached with a series of cuttings and immunohistochemical analysis by the ema markers. the nodes without secondary deposits were fixed in formalin, paraffin embedded and, with the application immunohistochemistry (ema), submitted to serial cutting (similar to the second phase in group a) as a precaution. results in the first stage paraffin samples (group a) were first examined by h&e method, and additionally with immunohistochemistry (using ema). with this additional examination secondary deposits were found in cases ( %). this can only prove already known fact about statistically significant higher sensitivity and specifity of immunohistochemistry compared to h&e. in the second stage (group b) new samples of sn, first investigated by frozen section investigation, were examined by immunohistochemichal method (using ema). in addition, these samples were serially cut and treated like paraffin samples by immunohistochemistry method. the results of these two analysis were identical. facts mentioned above show that sensitivity and specifity of the frozen section analysis using immunohistochemical method (ema) is % (high percentage is probably the consequence of a relatively small number of samples). discussion acquired data suggested that implementation of one of the used methods (serial frozen section analysis with immunohistochemistry) from the sentinel concept is an efficient histo-morphological method in the evaluation of sentinel lymph nodes that make valid intraoperative staging of breast carcinoma possible. the authors came to significant data in both groups of tests and determined sensitivity, particularity and the efficiency of the applied methods. conclusion application of the suggested method would spare a considerable number of patients with pt breast cancer of subsequent axillary lymph node dissection and thus reduce the number of postoperative complications and long term morbidity. introduction needle core biopsy (ncb) of palpable lesion and stereotactic biopsy (smb) of non-palpable mass are the major preoperative methods of breast tumor diagnosis. the aim of this study was to evaluate methods accuracy and to emphasize the main detectable prognostic factors. materials and methods core biopsies ( ncbs and smbs) were performed between january and december . in / cases, the correlation between biopsy results and subsequent surgical excision was available. results the lesion diameter was < cm (in % of the ncbs and % of the smbs). with smb, the average number of tissue core obtained per lesion was . at histology, in % of ncb and in % of smb diagnosis of malignancy was given. the dcis/idc ratio was / for ncb and / for smb, respectively. grade and type of the invasive and in situ carcinoma were determined in both biopsy and definitive excision, and the results compared. the agreement for overall grade was in % with smb and in % with ncb. at surgical excision, / dcis showed foci of idc. in % of smb cases no residual neoplastic tissue was found. conclusions the accuracy of both methods is very high. smb shows highest reliability and accuracy, because of the increased quantity of tissue obtained. the possibility to assess tumour size is limited. the preoperative assessment of the other prognostic factors (type and grade, tumour markers) are key determinants in planning the optimal breast lesions management. expression of mcp- mrna and macrophage infiltrates in invasive breast carcinoma introduction monocyte chemotactic protein- (mcp- ) has been detected in many human tumors; however, its chemoattractant role for macrophages in breast carcinomas is still questionable. the aim of this study was to determine the possible correlation between tumor-associated macrophages (tam) and the number of mcp- mrna in the invasive breast carcinoma. material and methods tissues obtained from surgical specimens of invasive breast carcinomas and cases of normal breast tissues were frozen in liquid nitrogen and kept at - o c until they were used for quantification of mcp- mrna by rt-pcr. the expression was calculated as a number of mcp- cdna copies per copies of g- -phd mrna. paraffin embedded sections from breast carcinomas were immunohistochemically processed for cd staining. positively stained tumor associated macrophages (tam) were counted on three "hot spots" (x ) and mean value was calculated. results the result of rt-pcr showed that in all cases of breast carcinomas ( / ) and the majority of normal breast tissues ( / ) the number of detected mcp- cdna copies was above the detection limit. furthermore, carcinomas showed higher levels of mcp- mrna ( . ± . ) then normal breast tissue ( . ± . ). the value of tam within a single carcinoma was very inconsistent ( . ± . ). statistical analysis did not find a significant correlation between mcp- expression and macrophage infiltrations (r= - , ) . conclusion mcp- is an important factor in the recruitment of macrophages. however, the results indicate that mcp- is probably not the only and/or crucial factor involved in macrophage attraction to tumor locus in breast carcinomas. comparison of mitotic index, growth fraction (evaluated by ki- ), er, pr, cathepsin d, p , and bcl- status between primary breast cancer and corresponding axillary metastatic sites introduction it has been postulated that the equilibrium of different clones within a tumor is eventually overcome by a biologically dominant one with enhanced metastatic potential. therefore, the metastatic tumor should be composed of more aggressive tumor cell clones than the primary one. we analyzed mitotic index, proliferation antigen ki- , estrogen receptors (er), progesterone receptors (pr), cathepsin d activity, protein p , and bcl- oncoprotein status in order to explore the assumed differences in the clonal composition between the primary breast cancer and axillary metastasis. materials and methods er, pr, p , bcl- , ki- , and cathepsin d statuses in patients with the primary ductal invasive carcinoma of the breast and at least one axillary metastatic lesion were analyzed by immunohistochemistry (ihc -dako lsab system). mitotic index was assessed by counting the number of mitoses in primary and metastatic lesions. statistical analysis included t-test for dependent samples, linear correlation analysis, and roc-curve based contingency table analysis. results we found higher mitotic index (p= . , r= . ), higher growth fraction (ki- , p= . , r= . ), and higher level of overexpression of bcl- (p= . , r= . ) in axillary metastatic lesion than in primary breast tumor. there were no significant differences in er (p= . , r= . ), pr (p= . , r= . ), cathepsin d (p= . , r=- . ), and p (p= . , r= . ) status. higher mitotic and ki- rates were associated with lower er and pr expression, whereas higher cathepsin d level was associated with lower bcl- expression, both in primary tumor and metastasis. between the paired primary tumor and axillary metastatic lesions, samples had concordant er, pr, p , and cathepsin d status when analyzed by ihc. tumor clone with enhanced metastatic potential might be characterized with higher mitotic index and overexpression of both ki- antigen and bcl- oncoprotein. basaloid breast carcinoma with pleomorphic lipoblastlike giant cells and neuroendocrine differentiation js reis- filho , liposarcomatous differentiation in breast neoplasms is a rather infrequent phenomenon and so far restricted to rare cases of malignant phyllodes tumour and true liposarcomas of the breast. the terms lipid-rich and lipid-secreting breast carcinomas encompass breast tumours in which neoplastic cells accumulate or secret lipid; however, lipoblasts are not usually seen. recently, we have observed a distinctive type of breast carcinoma in which pleomorphic lipoblast-like cells were seen admixed with the carcinomatous component. an -year-old female presented with a cm hard lump in the right breast with palpable nodes in the right axilla. mammography and ultrasound disclosed two irregular dense central masses in the right breast, measuring cm in aggregate, and an enlarged axillary node measuring approximately cm. a diagnosis of breast carcinoma was made and the patient received neoadjuvant tamoxifen despite the lack of estrogen receptor (er) in the primary tumour. four months later, her disease had progressed and she underwent right mastectomy with axillary dissection.. histologically, both the primary tumour and the / lymph node metastases were characterised by a high-grade carcinomatous component which imperceptibly merged with pleomorphic lipoblast-like cells. immunohistochemistry demonstrated epithelial differentiation in the carcinomatous and liposarcomatouslike components (epithelial membrane antigen, cytokeratins / , / , , and mnf ) . both components were also positive for vimentin, s- protein, and focally for chromogranin, gcdfp- , and e-cadherin. hormone receptors (estrogen, progesterone and androgen receptors), her /neu, p , smooth muscle actin, desmin, synaptophysin were negative. based on the histological and immunohistochemical profile, we believe that this case represents a breast carcinoma with basaloid phenotype and showing divergent differentiation (liposarcomatous and neuroendocrine), features that have to our knowledge not been documented to date. collagenous spherulosis arising in an adenomyoepithelioma of the breast: a hitherto unrecognised association js reis-filho , , lg fulforf , b crebassa , s charpentier , sr lakhani collagenous spherulosis (cs) is a benign epithelial and myoepithelial breast lesion characterised by the accumulation of basement membrane material in the form of eosinophilic or rarely basophilic spherules that exhibit concentric and radiating fibrillar patterns. cs is an incidental finding that usually occurs in association with benign proliferative and pre-invasive lesions. adenomyoepithelioma is a biphasic neoplasm of the breast, composed of both luminal epithelial and myoepithelial cells. despite the shared histogenesis, cs has never been described in association with adenomyoepithelioma. we report a case of a year-old female who presented with cs of the breast arising in an adenomyoepithelioma. the differential diagnosis included adenoid cystic carcinoma. immunohistochemistry with antibodies for cytokeratins (cks) , and / , smooth muscle actin (sma), calponin, smooth muscle myosin heavy chain (smmhc), p , collagen iv, oestrogen receptor (er), progesterone receptor (pgr), ki , and c-kit was performed. myoepithelial cells of the adenomyoepithelioma and the cells surrounding the collagen spherules of cs showed a similar profile (cks and / , sma, calponin, smmhc, p , and s reactivity), luminal cells of both lesions also showed overlapping immunophenotypes (ck , er and pgr positivity). collagen iv highlighted the spherules in cs. ki labelling indices were similar in both lesions. c-kit expression was restricted to the adenomyoepithelioma and no expression was observed in the cs. the association is important to recognise as it could potentially lead the unwary to a misdiagnosis of adenoid cystic carcinoma, cribriform carcinoma or cylindroma of the breast. introduction lymphoepithelioma of the nasopharynx is an undifferentiated carcinoma with a prominent lymphoid infiltrate. tumors, with histologic features similar to nasopharyngeal lymphoepithelioma in other locations are referred as lymphoepithelioma-like carcinoma.(lec). in differential diagnosis of this lesions, medullary carcinoma and lymphoma must be considered. in this study, we report a case of lec of the breast which is very rare tumor.. material and method a -year-old female was noted to have a lesion of the right breast on mammography. an excisional biopsy was performed and sections revealed a well-demarcated elastic mass of cm in diameter. routine histologic examinations and immunohistochemical analysis were performed and compared with reported cases in literature. results clinical features, macroscopic and microscopic findings, immunohistochemical analysis were consistent with lec of the breast. on immunostaining, the tumor cells showed strong staining for epithelial membrane antigen (ema) and low weight cytokeratin (lcw).lymphoid cells stained positively for leucocyte common antigen (lca).the tumor cells showed no staining for cd . staining for uchl - and l demonstrated that there were more t cells than b cells. the tumor cells were immunohistochemically negative for epstein-barr virus (ebv). introduction this retrospective study was performed to investigate the role of dna-ploidy and s-phase fraction in determining prognosis in advanced breast cancer. methods the study included female patients with breast cancer, investigated for the period - . the nuclear dna-content has been measured by cas- (beckton dickinson, image analysis) on intraoperative cytologic samples of the tumour (imprints). the tumours have been divided into diploid, tetraploid, aneuploid and hyperdiploid. results of all patients had aneuploid and multiploid histogram, whereas % of them had developed distant metastases. lymph metastases have been registered in % of the cases with diploid histogram. s-phase has been considerably higher in patients with aneuploid than those with diploid histogram. the survival of of all patients has been analyzed as to the type of their histogram and as to the presence of metastases in lymph nodes and distant organs. the results showed that breast cancer patients ( . %) with aneuploid histogram and metastases in lymph nodes had a survival of less than years, compared to the better survival rate of those patients with diploid histogram and no metastases in lymph nodes. the higher s-stage has correlated to the metastases in lymph nodes and distant locations. conclusion the analysis of all results proved that the dna-morphometry could successfully be used as an independent criterion for evaluation of the biologic behaviour of breast cancer tumours and their prognosis. hypercholesterolemia impairs angiogenesis in patients with breast carcinoma and therefore lowers the risk of metastasis bh introduction angiogenesis plays a key role in tumor progression and it is also necessary for the development of distant metastasis. previous experimental studies indicate that both diet-induced and genetic hypercholesterolemia (hch) impairs angiogenesis. our aim was to investigate the effect of hch on angiogenesis induced by breast carcinoma and to elucidate the possible mechanisms by which it inhibits the progression of the cancer. material and method fifty-one patients with invasive ductal carcinoma were included in the study. of cases had hch and had no hch. all patients were followed for a mean of months after radical mastectomy. the intratumoral microvessel density (mvd) was evaluated immunohistochemically using anti-cd antibody and correlated with clinicopathologic parameters. also the expression of bfgf and vegf were examined immunohistochemically and graded semiquantitatively. results mvd was significantly correlated with tumor grade, vegf and bfgf expression, recurrence, lymph node metastases (lnm), distant metastases (dm) and survival (p< . ). patients without hch had significantly higher mvd ( . . ) than those with hch ( ) (p< . ). in addition the risk of lnm and dm were found higher in cases without hch when compared to cases with hch (p< . ). both bfgf and vegf expression showed significant negative correlation with hch (p< . ). conclusion we suggest that, hch impairs angiogenesis by suppressing bfgf and vegf expression and therefore lowers the risk of metastases in cases with invasive breast carcinoma. the cd antibody (calla) is usually expressed in lymphoblastic acute leukemia and in follicular center cells of lymph nodes. it is also used in breast cancer cell culture to differentiate epithelial cells from myoepithelial cells. usually the smooth muscle actin (sma) is used to identify myoepithelial cells in breast lesions, but this antibody is also positive in blood vessels. this study compares the expression of cd and sma as a marker of myopepithelial cells in breast lesions. we have compared breast lesions, both benign and malignant ( adenosis, fibroadenomas, intracystic papillomas, hamartoma, gynecomastia, intraductal carcinomas, invasive ductal carcinomas, tubular carcinomas, mucinous carcinomas, invasive lobular carcinomas, medullary carcinomas, phyllodes tumors). the antibodies used have been cd ( c, : , dako) and sma ( a , : , biogenex) . results we observed cd expression in the cell membrane of myoepithelial cells and also in some stromal myofibroblastic cells. sma expression was observed in the cytoplasm of myoepithelial cells, in some stromal myofibroblastic cells and also in smooth muscle cells. proliferative breast lesions and benign tumors contain myoepithelial cells expressing cd and sma. in malignant lesions the myoepithelial cell component is lost. conclusions the cd is a myoepithelial cell marker and yields a good, reproducible staining in the studied cases. we think that the use of cd combined with sma is helpful in the differential diagnosis between benign and malignant lesions (epitheliosis vs intraductal carcinoma, tubular carcinoma vs atrophy, adenosis vs invasive ductal carcinoma, papilloma vs intracystic papillary carcinoma). introduction the identification of myoepithelial cells in breast lesions remains of diagnostic value for the discrimination between benign and malignant lesions. p is a p homologue, which is expressed in epithelial basal cells of different organs. the aim of the present study has been to investigate the immunohistochemical expression of p in breast lesions. materials and methods we examined immunohistochemically formalin-fixed, paraffin-embedded, archival breast samples, which consisted of benign lesions and malignancies ( in situ carcinomas, invasive ductal carcinomas, nst and invasive carcinomas special type). the monoclonal antibodies anti-p (biocare medical/menarini), anti-a-smooth muscle actin (biogenex) and anti-s- protein (biogenex) were used. results in all cases, p expression was nuclear. in all benign lesions, there was an almost continuous basal rim surrounding the epithelial structures, whereas it was present but discontinuous in the in situ carcinomas. all invasive ductal carcinomas, nst, were devoided of p staining. p immunoreactivity was noted in a minor fraction of neoplastic cells in / ( . %) in situ papillary carcinomas and in / ( . %) invasive papillary carcinomas. the stromal cells were negative to p . there were s- positive luminal epithelial cells in almost all cases, whereas many fibroblasts of the stroma were positive to smooth muscle actin. conclusion it appears that p is a more sensitive and specific myoepithelial marker than those currently used, with no staining of stromal myofibroblasts. the observed staining in scattered cells, only in papillary neoplasms, might be a clue to the speculated different histogenesis of this specific type of breast tumors. prediction of aggressive outcome in t n m breast cancer introduction small tumour size at the time of diagnosis is one of the most significant prognostic factor of favourable outcome in invasive breast cancer. however, unpredictable breast cancer recurrences and deaths also occur among the group of patients with t n m breast cancers. aims: we set out to identify the clinically useful prognostic features predicting unfavourable outcome in patients with t n m invasive breast cancer. the study comprises cases of invasive ductal or lobular carcinomas diagnosed and treated in turku university hospital and jyväskylä central hospital during the years - . twenty-seven patients had an aggressive disease with a recurrence or death of breast cancer. the prognostic factors of each of the patients with aggressive disease were compared with control patients matched by tumour size, age at diagnosis and histological type of tumour. the follow up time was - years. the clinicopathological prognostic factors of the patients were surveyed. results the prognostic features indicating unfavourable outcome were immunohistochemically detected high ki- expression, high p expression, low estrogen receptor expression and positive her /neu chromogen in-situ hybridization. the number of mitotic figures (mitotic activity index, mai), histological type of the tumour or number of studied axillary lymph nodes did not provide prognostic information. conclusion our study summarizes the immunohistochemical features and criteria predicting unfavourable outcome in t n m invasive breast cancer. detection of overexpression of c-erbb through immunohistochemical and amplification of her /neu established by fish in breast cancer. a comparative study introduction the prognostic and predictive implications of oncogene her /neu activation are very controversial, due to the extensive variation of results, mainly due to the different methods applied. activation of her in node positive patients as an independent prognostic factor has been established and correlated with tumour sensitivity to different therapeutic agents. the overexpression of this membrane receptor has converted it into a new therapeutic aim, requiring the application of a more suitable methodology for each case. objectives to evaluate the most suitable method (immunohistochemical vs. fish) to determine her activation and its correlation with other prognostic factors. material and methods a study of cases of invasive breast carcinoma. histological type: % infiltrating ductal carcinoma; age: - , hormonal receptors: . % (rh+), . % (rh-); histological grade (bloom-richardson mod): . % (g ), . % (g ), and . % (g ). immunohistochemistry was performed in patients with (herceptest dako), and with anti c-erbb (dako : ). scores were used for evaluation: absence of membrane staining ( ), faint and incomplete in > % of tumour cells ( +), weak to moderate in > % ( +), strong complete in > % ( +). fish study was performed on paraffin sections through path vision system with evaluation of nuclei. a good correlation between immunohistochemical overexpression and amplification by fish was observed, especially in cases evaluated as ( +) / ( %), and as ( ) / ( %). no amplification by fish occurred in . % of ( +) / and in . % of ( +) / . % of negative hormonal receptor tumours showed amplification, while only . % of positive receptor tumours amplified. none of the tumours classified as (g ) showed amplification. conclusions we emphasise the necessity to study gene amplification through fish in cases with weak immunohistochemical overexpression ( +). introduction cell cycle progression is governed by cell cycle regulators and inhibitors such as cyclin dependent kinases (cdks), p , p /waf and p /kip . the purpose of this study was to correlate the immunohistochemical expressions of p , p /waf , p /cip and p cdc , with its clinicopathologic prognostic parameters in human breast cancers. materials and methods paraffin-embedded tissue sections from patients with human breast carcinomas were examined for immunohistochemical staining. primary antibodies used in immunohistochemical staining were mouse monoclonal antibody to human p , p /waf , p /cip and p cdc . results the expression rates of p , p /waf and p cdc were . %, . % and . % in breast carcinomas, respectively. in normal breast tissues, p , p /waf and p cdc were not expressed. the expression rate of p /cip was . % in breast carcinomas and % in normal breast tissues. the correlation between the expression of p and p /waf was noted(p= . ). the expression of p /cip was correlated with that of progesteron receptor(pr) (p= . ). the expression of p /waf was correlated with that of estrogen receptor (er) (p= . ) and pr (p= . ). no correlation was demonstrated between survival in patients and expression of p , p /waf , p cdc and p /cip . conclusion the loss of normal cell growth cycle by abnormal cyclin dependent kinases, inhibitors and steroid hormones may play an important role in human breast carcinogenesis. the p dependent p pathway, p gene loss and cdc overexpression were important in development and progression of human breast cancer. withdrawn p- interobserver variability in determination of her protein overexpression by immunohistochemistry using herceptest assay - cases study material and method among cases evaluated in population screening project total cases from all centers were selected and presented to representatives of those centers. the immunohistochemically stained slides came from all laboratories. all ihcs were done using fda-approved dako herceptest. evaluation was performed without knowledge of the original results the results from each researcher were coded. the study lasted hours. the average concordance was nearly %, while the lowest concordance was and the highest - %. this wide range of the results might be due to several things. firstly, the experience in ihc evaluation varied among the participant of the study. secondly, the quality of the stains differed significantly. thirdly, the researchers worked under time pressure and the material was selected to include more cases considered 'difficult' ( + according to dako herceptest or technically inadequate). conclusions to achieve higher concordance among the obtained results, evaluation should be performed by the experienced pathologists. * -participants from: bialystok, bydgoszcz, gdansk, gliwice, kielce, krakow, lublin, lodz, olsztyn, poznan, szczecin, warsaw and wroclaw. the population screening project study was supported by roche-polska. a morphometric analysis of early invasive breast carcinoma using serial sectioning and d reconstruction technique introduction mechanism of early invasion of breast ductal carcinoma has not been completely investigated not only from the genetic point of view but also morphologically. one of the reason is that starting sites of invasion from ductal carcinoma in situ (dcis) might be extremely diminutive that routine histopathological examination should hardly reveal them usually. thus, we examined a large number of complete serial sections from breast carcinomas so as to find out destroyed sites of duct wall from which carcinoma cells have started on invasion. also we reconstructed d images from the sections so as to visualize the sites and to measure the size of those. materials and methods used were three surgical specimens of breast cancer having extensive intraductal components with multiple invasive foci. after formalin fixed and paraffin embedded, six blocks from three cases were selected and sectioned serially in µm thickness. total amount of the serial sections reached sheets (mean / block) indicating . µm in actual thickness. after he stained, invasive lesions connected with dcis were searched and the lesions were reconstructed as d images with a computer-assisted- d-reconstruction system. results although numerous sections containing multiple invasive foci were examined, areas which connected with dcis to invasive lesion through the destroyed site of duct wall were only three. the site were approximately µm, um and µm in diameter respectively, should be called as 'hole' of the duct wall. invasive lesions were extended along the ducts with the holes. conclusion the holes, starting sites of invasion, were apparently smaller than surrounded invasive lesion. histological and immunohistochemical profile of invasive pleomorphic lobular carcinoma y erhan introduction invasive pleomorphic lobular carcinoma (iplc), a distinct subtype of invasive lobular carcinoma (ilc), shares the typical histologic patterns of classical ilc, but the nuclei are more pleomorphic and increased mitotic activity is a prominent feature. we reviewed cases of iplc and compared them with cases of clssical ilc. immunohistochemical analysis was performed in all cases for estrogen (er) and progesterone receptors (pgr), p , c-erbb- , and ki . in this series, the average patient age was . years (age range, - years) for iplc and . years (age range - years) for ilc. tumor size ranged from to . cm (mean size . cm) for iplc and . to cm (mean size . cm) for ilc. axillary lymph node metastasis was detected in % of iplc, and % of ilc. fifty percent of iplc and % of ilc cases had extranodal extensions (p< . ). tumor cells were large with eccentric pleomorphic nuclei and eosinophilic granular cytoplasms. high mitotic activity was observed. immunohistochemically er and pgr positivity in iplc was % and %, and in ilc % and %, respectively. iplc cases showed %, and ilc cases % p positivity (p< . ). c-erbb- was detected in % of iplc, and % of ilc. ki mean rates were % and % for iplc and ilc. conclusion iplc exhibits distinct histologic fetures, higher expression of p protein and ki rate in comparison with classical ilc. the aggressive clinical course of patients with iplc is supported by higher rates of axillary lymph node metastasis and extranodal extensions. introduction c-kit is a proto-oncogene that codes for a transmembrane tyrosine kinase receptor: cd . once activated, c-kit propagates signalling events throughout the cell via multiple signal transduction pathways. it was described an activating mutation in exon of c-kit gene in gastrointestinal stromal tumours (gist), which can be blocked by using a tyrosine kinase inhibitor (sti ). phyllodes tumours (pt) are rare biphasic breast tumours that similarly to gists show a monoclonal stromal proliferation and high recurrence rates. aims: to study the immunohistochemistry expression and prevalence of activating ckit mutations in pt in order to explore whether this disease could be a potential target for treatment with sti . we analysed pt ( benign and malignant) by immunohistochemistry for c-kit expression and direct sequencing of exons , , and of c-kit gene for evaluate the mutational status. c-kit expression was detected in out cases ( / benign and / malignant). no mutations were found for exons , and . in exon we found the same silent alteration in out of cases. conclusions although c-kit expression is a frequent finding in pt of the breast, we did not find activate mutations similar to those described in gists. recently, the role of cyclin d expression in breast cancer had received attention. it causes the activation of cyclindependent kinases in g phase and phosphorilation of the retinoblastoma gene, required for entry of cell into s phase of the cell cycle. recent investigations confer the role of cyclin d once again in g phase. the aim of this study was to analyse the expression of cyclin d in human breast cancer cells and to compare its value with the estrogen receptors and histological parameters. material and methods immunohistochemical analysis for cyclin d and estrogen/progesteron receptors (er/pr) was performed on formalin-fixed infiltrating ductal breast carcinomas. scoring was done using semiquantitative system. the stainining score was ranged from - (called cyclin d -negative) and score larger or equal to (called cyclin d -positive). results according to the staining score % of the breast carcinomas were cyclin d positive, and those carcinomas were associated with higher nuclear and histological grade, while only % were er-positive. conclusion these reslults suggest that higher expression of the cyclin d is related with poor prognostic parameters. c-erb b overexpression in breast cancer with negative lymph nodes background it is known that c-erb b overexpression in advanced breast cancer represents a predictive factor of tumoral agressivity. the aim of this study was to assess the involvement of c-erb b and other prognostic factors expression (hormonal receptors, egfr, pcna) in breast cancer with negative lymph nodes. methods we investigated histopathologically and immunohistochemically selected cases with g ductal invasive carcinoma and no lymph nodes involvement, from breast cancers. we used a monoclonal antibody panel (estrogen and progesteron receptors, egfr, c-erb b , pcna) in formalin fixed paraffin embedded tissues. results we found a significant increased c-erbb overexpression associated with a low er and pgr expression and minimal microangiogenesis as expressed by egfr. the average of proliferative rate assessed by pcna was . %. conclusion immunohistochemical c-erbb overexpression in negative lymph nodes breast cancer, may suggest an early amplification of its encoding gene, which can predict an aggressive biological behaviour (invasion and metastasis), so that this type of patients would benefit of humanized anti-her /neu monoclonal antibody treatment. introduction aspiration cytology of the breast is one of the three components of the triple test for breast cancer diagnosis. ultrasound (us) guidance increases the complete sensitivity of this technique. the aim of this study was to compare the results between a group of mammary lesions aspirated with or without us using the european quality assurance guidance. material and method we analyzed mammary lesions by aspiration cytology with or without us guidance. one group was formed by breast aspirates from women older than fifty years old, included in an screening programme, with palpable and non palpable lesions, using us guidance. another group was formed by breast aspirates from outpatients origin of all ages only with palpable lesions using no us guidance. we analysed and compare the results between both groups using using the european quality assurance guidance for breast screening pathology. results in both groups the positive predictive value of the c results were % (false positive rate= %). the complete sensitivity of us guided aspirates were . % and for the non guided aspirates were %. we compare the rest of values and analyze our deviations from the standards. conclusion the quality of our breast aspiration practice is between the margins of the standards in both techniques, with an increment in the sensitivity with us guidance and a light loose of specificity in the screening group (probably because of patients age characteristics). ultrastructural study of intercellular junctions in metastatic and non-metastatic breast cancer introduction functional and morphologic characteristics of inter-cellular junctions are involved in tumor dissemination. the purpose of this study was to investigate whether the number of intercellular junctions in breast cancer is predictive for the presence of lymph node metastases. materials and methods infiltrating duct carcinomas were the subject of this study, of them without (g ) and with metastatic disease (g ) in axillary lymph nodes. the number of intercellular junctions was counted, and the length of the cell-to-cell contact surfaces was measured in randomly taken electron micrographs. the number of desmosomes/ µm of cell membrane apposition has been statistically compared between both groups. results cell junctions in tumors with lymph node metastases were usually smaller and poorly developed. there were no statistically significant differences in the number of intercellular junctions between both groups [g = %, ( , %; %). g = , % ( , %; %). p= , ]. conclusions although intercellular junctions are more rudimentary in tumors that metastasize, their number is not significantly reduced. therefore, it will be necessary to combine number, size and development of cell junctions in a single parameter to attempt prediction of tumor dissemination. supported in part by grant fis / . introduction numerous publications have been devoted to effects of myoepithelial cells on biology of breast cancer. the cells are thought to be able to inhibit invasion of neoplastic cells by production of inhibitors for serine proteases. some authors suggest that, acting in a paracrine way, myoepithelium can affect breast cancer cells. present study aimed at analysis of the relation between presence of myoepithelial cells (smooth muscle actin, sma) in the structure of a ductal breast cancer and expression of the recognized prognostic factors (er, pr, her- , tgf alpha, ki and p ) in the cancer cells. the studies were performed on samples of primary ductal breast cancers originating from females, including cases at g , cases at g and cases at g grade. immunocytochemical reactions were performed using antibodies directed to sma, er, pr, her- , tgf alpha, ki and p . the study showed that the highest content of myoepithelial cells was noted in tumours of g grade while the lowest content of the cells was observed in tumours of g grade (kruskal-wallis anova rank test, p= . ). in the entire group (g -g ) a positive correlation was detected between the presence of myoepithelial cells and intensity of her- expression (gamma correlation, p= . ) and a negative correlation with proliferation intensity measured by expression of ki antigen (gamma correlation, p= . ). no relation was observed between manifestation of myoepithelium and expression of the other studied variables. our studies confirmed the potential for paracrine communication between myoepithelial cells and cells of ductal breast cancer. immunohistochemical vegf expression in breast carcinomas. correlation with prognostic factors a matilla, l vicioso, l pérez, m Álvarez, i ramírez dpto. anat. patológica. universidad de málaga, malaga, spain introduction vegf (vascular endothelial growth factor) is considered as one of the most important angiogenic factors in breast cancer and its expression in tumor cells correlate with microvessel density. several studies have proposed that vegf may be a relevant prognostic factor. aim: to study the immunohistochemical expression of vegf in different histological types of breast cancer and its relation to established prognostic and predictive factors. we have analyzed carcinomas ( of invasive ductal type, lobular, mucinous, papillary and ductal in situ). immunohistochemical staining was performed on formalin fixed, paraffin sections, using an avidin-biotin immunoperoxidase technique. a rabbit polyclonal antibody for human vegf was used at a : dilution. immunoreactivity was scored from to +. results ( , %) of all invasive carcinomas showed vegf expression (ductal: %, mucinous: %). all but lobular carcinomas were negative or weakly positive. both papillary carcinomas showed strong positivity. staining in dcis was generally absent or weak. vegf positivity correlated inversely with nodal involvement (p= . ) and re status (p= . ). there were no correlation of vegf staining with tumor size, histological grade, p and c-erbb- . conclusion expression of vegf is characteristically weak or absent in lobular carcinomas and them no relevant as a prognostic factor in this type of carcinomas. as vegf staining correlate with absence of nodal involvement, its prognostic value may be mainly due to facilitate invasion of blood vessels, more than to lymphatic spread. introduction squamous carcinoma accounts for approximately % of all primary vulvar carcinomas. although the anatomic localization of this tumor allows early diagnosis and considerably easy surgical accessibility, the prognosis for these patients remains relatively grim. the explanation for this finding should be sought in the fact that most of the patients are diagnosed in the advanced clinical stage of the disease. since radical vulvectomy (a complex and debilitating procedure) is often a therapy of choice, the recent studies have been focused on determining reliable prognostic parameters that would allow individualized, and hopefully simpler therapeutic modalities to be applied in a certain group of patients with the same effectiveness. the aim of this study was to determine the most important clinical and histopathological parameters that influence the prognosis and outcome of patients with invasive squamous carcinoma of the vulva in order to offer them the most suitable form of therapy. moreover, it was designed to assess the clinical significance of dna content analysis by flow cytometry. patients and methods cases of squamous cell carcinoma of the vulva, diagnosed between . and . were selected. in order to assess the influence of the various prognostic factors on survival, the study included clinical and pathohistological parameters as well as the results of flow cytometric dna analysis of paraffinembedded tumor samples from all cases. clinicopathological parameters focused on the age of patients, clinical stage of the disease, menstrual status, diameter and localization of the tumor, histological grade, nuclear grade, combined histological and nuclear grade, depth of tumor invasion, tumor growth pattern, presence of giant cells in the tumor and the form of therapy, while the flow cytometric dna analysis comprised dna ploidy, proliferative activity and dna index. five-year survival of our selected population of patients was , +/- , %. the results of univariate statistical analysis confirmed that statistically significant prognostic parameters included the age of patients (p= , ), clinical stage of the disease (p= , ), histological grade (p= , ), nuclear grade (p< , ) and the depth of invasion (p< , ). on the other hand, the results of multivariate statistical analysis showed that only combined histological and nuclear grade (p= , ) and the depth of tumor invasion (p< , ) can be considered independent, statistically significant prognostic parameters. conclusion the age of patients at the time of diagnosis, clinical stage of the disease, histological grade and nuclear grade are considered to be the parameters of crucial relevance for the prognosis of patients with squamous cell carcinoma of the vulva. however, only combined histological and nuclear grade, as well as the depth of tumor invasion were proven to be independent statistically significant parameters relevant for the outcome of patients with this disease. can a pleomorphic vulvar leiomyoma be a tumor with local aggressive behavior? a case report vulvar leiomyoma is uncommon and its pleomorphic or bizarre form is especially rare. bizarre vaginal and vulvar (bartholin's gland area) leiomyomas were reported in only few cases. this tumor is hard to differentiate from leiomyosarcoma. the main criterion to make a distinction between them is the mitotic activity, which is less than per hpf in the former. case report a -year-old female was referred to the clinic for the evaluation of paravaginal tumor in distal vaginal third and right vulvar area with a history of month duration. she had no history of any earlier disease, and other examinations revealed normal findings. macropathology: the tumor was a large solid mass measuring x . cm in diameter. the tissue was yellow and seemed partly necrotic. micropathology tumor consisted mostly of spindle cells arranged in bundles with round or oval nuclei and large prominent nucleoli or showed hyperchromatism in places where there were cells with giant nuclei. cytoplasm was eosinophilic, elongated with small vacuole. there were areas where cells had two or more nuclei with the earlier mentioned polymorphism. areas of hyaline or myxoid degeneration of the stroma were found. mitoses were not found although the tumor was examined by three independent pathologists from different countries. the tumor margin looked infiltrative. the tumor was immunohistochemically positive for vimentin, smooth actin and desmin. cytokeratin mnf , ema, s- , cd- , and cd- were negative. conclusion we describe a vulvar smooth muscle tumor with marked polymorphism, without mitoses, with myxoid changes in the stroma and with infiltrative margins. because of all these characteristics the tumor was considered biologically aggressive and additional surgery with resection of the tumor site and regional lymphadenectomy was performed. three years after the last surgery the patient is alive and well. trophoblast apoptosis and proliferation in preeclamptic placentas d staribratova , z zaprianov , d dikov , v sarafian plovdiv medical university, plovdiv, bulgaria hospital center lagny introduction preeclampsia is a specific disorder of pregnancy with an increased risk for both neonatal and maternal mortality rates. it is associated with shallow invasion of the placental cytotrophoblast within uterus developing decidual vasculopathy and results in dereased blood flow. the aim of the present report is to determine whether hypoxia influences the rates of apoptosis and proliferation and to compare them with those of normal controls. materials and methods samples were taken from liveborn, singleton preeclamptic pregnancies and normal controls. we used routine light microscopy, immunohistochemical and quantitative studies for bcl- , and bax (to assess apoptosis) and pcna (to assess cellular proliferation). bcl- -and pcna-positive trophoblast cells were counted in a minimum of high-powered fields, of consecutive sections free from any infarction of at least paraffin blocks. results while increased apoptosis has been estimated in study groups, the rates of proliferation seems to be unaffected. placental pathologic features of preeclampsia d staribratova , z zaprianov plovdiv medical university, plovdiv, bulgaria introduction the clinical and placental features of preeclampsia are subject of an extensive study. clinical evidence suggests that this pregnancy specific disorder may be demographically heterogenous. our purpose is to record the range of the most common pathologic features in placental specimens from a gypsy cohort and to compare them with those in nonethnic bulgarian population. review of preeclamptic placentas from liveborn singleton deliveries of gypsy mothers and matching controls from bulgarian population revealed histologic lesions that were considered as belonging to one of the following groups: ( ) vascular lesions; ( ) acute or chronic inflammation and ( ) coagulation-related lesions. for each separate case, additional demographic and reproductive history was collected from the patients' charts. all placentas were studied by previously published standard protocols. nonparametric statistical analysis was applied. results in gypsy preeclamptic group, lesions related to coagulation ( % vs %) and vascular lesions ( % vs %) were more frequent. inflammatory features were equally distributed among the two groups ( %). introduction versican is a chondroitin sulfate proteoglycan, which belongs to the aggrecan gene family. it has not been studied in epithelial ovarian cancer before. the aim of this study was to clarify the relation between versican and hyaluronan in epithelial ovarian cancer and to find out if versican expression affects prognosis in these patients. materials and methods localization of versican was studied immunohistochemically in primary epithelial ovarian cancers and their metastases, as well as in normal ovary specimens. the staining was scored according to the percentage area of strong versican signal of total peri-and intratumoural stroma as low or high. epithelial staining of the tumours was scored as positive or negative. results low and high levels of strong stromal versican staining were observed in and carcinomas, respectively. a low level of strong stromal versican was found to be a significant marker for early figo stage and mucinous histology. stromal versican staining correlated significantly with stromal hyaluronan staining. cancer cell-associated versican positivity was seen in tumours and correlated with clear cell histology and early figo stage. the -year prognosis of patients decreased with increasing stromal versican levels for overall survival. the -year prognosis for recurrence-free survival was slightly better when cancer cells were positive for versican. in cox's multivariate analysis neither stromal nor cancer cell-associated versican had any prognostic value. conclusion enhanced stromal versican expression correlates with hyaluronan accumulation and is associated with unfavourable disease outcome, but it is not an independent prognostic marker in epithelial ovarian cancer. cytobrush-collected malignant cervical epithelial cells display a cancer-specific gene expression pattern in cdna array analysis g hudelist , introduction although it is well known that persistent high-risk hpv infections are the principal causative agents of cervical cancer, the discrepancy between high infection rates and the relatively low rates of high-risk hpv positive women who actually develop carcinoma of the cervix suggest that development of cervical cancer is a multistep process involving additional factors and mutational events. therefore, differentially expressed genes in normal and malignant cervical epithelial cells and the feasibility of gene expression profiling on cervical cells obtained by regular cervical swabs were investigated. material and methods cervical epithelial cells obtained by regular cytobrushes from women with high-risk hpv positive invasive cervical cancer and from hpv negative women without suspicious pap smears were pooled and subjected to cdna array analysis. dot blotting was then performed to detect the proteins which corresponded to the most highly up-regulated genes in the cdna array analysis. results mrna expression of c-erbb- , c-kit, vegfr- , n-myc, k-ras, cyclin-dependent kinase inhibitor (p ink a), cyclin d , nm -h , nm -h , c-met, kgf, kgfr, and stat was increased in malignant samples. several genes associated with antiapoptosis, such as bcl- like protein, cell structuring and/or cell attachment were also upregulated in tumoral cells. conversely, decreased gene expression was observed for members of the transforming growth factor receptor superfamily (tgf-beta), interleukin (il- ), insulin-like growth factor binding proteins (igfbps) and for members of the integrin family. conclusions we identified a mrna and protein expression pattern that might have an important role in the pathogenesis of invasive cervical carcinoma and appears to be specific for malignant cervical epithelium. we hypothesize that the presence of a cancer-specific gene-expression signature assessed by cdna array analysis or immunohistochemical techniques could eventually turn out to become an additional tool to evaluate the dignity of routinely obtained cervical swabs. prognostic features and molecular markers in ovarian borderline tumors e nistor , ad stanescu , cd vrabie , e ionica bucur hospital, bucharest, romania v. babes institute, bucharest, romania university of bucharest, bucharest, romania introduction ovarian cancer represent the fourth most common cancer in women. borderline ovarian serous tumors (bsot) affect women of childbearig age and their prognosis is outstanding. the aims of this study were to characterize the group of patients with bsot and evaluate the significance of various molecular markers expression versus serous papillary ovarian carcinomas (spoc) material and methods we analyzed a total of cases including: cystadenoma, borderline and cystadenocarcinoma. for the bsot the median age was years. eight women with bsot underwent radical surgery and two fertility sparing surgery. the recurrence of disease appeared in one case with fertility sparing surgery. all the cases were analyzed on haematoxilin-eosin stained and immunohistochemistry (the indirect tristadial streptavidin-biotin method) for estrogen receptor (er), progesteron receptor (pr), p protein (p ), proliferative activity (ki ) and carcinoembrionic antigen (cea). results the immunostaining demonstrated a significant increase in the expression of er ( %) and a decrease for p ( %) and ki ( %) in bsot vs spoc (er- %, p - % and ki - %). conclusions the main differences between bsot and spoc was regarding the expression of p and ki . there was no significant correlation between ki and the known histologic parameters of prognostic significance. transvaginal ultrasound and ca serum levels are the most effective diagnostic techniques for the follow up of patients treated conservatively for bsot. introduction gonadoblastoma with dysgerminoma or other germ cell tumor occurs almost exclusively in girls and young women with underlying gonadal disorder. the aim of this study was to review biopsy examinations of the tumours, stage, treatment strategy, follow up and outcome of five girls with gonadoblastoma and germ cell tumours. material and methods retrospective review of patients with gonadoblastoma and germ cell tumours was performed. the patients were , , , and years old. the first -year-old girl (karyotype, xx, normal ovary bilateral) with gonadoblastoma, dysgerminoma and choriocarcinoma had iiic stage disease. she was treated by chemotherapy with cisplatinum and radiotherapy. four patients had gonadoblastoma and dysgerminoma. the second -year-old girl (mixed gonadal dysgenesis, karyotype, , xy) had stage ib and was treated by chemotherapy with cisplatinum. two patients were treated with surgery only: year-old girl (streak gonads, karyotype, , xy) -stage ib and year-old girl (karyotype , xx, der / , xx, - ) -stage ia. the -year-old patient (karyotype, , xx, normal ovary bilateral) -stage ia disease, had adnexotomy only, but because of recurrence (stage iiic) months after the original diagnosis, she was treated by chemotherapy. results our review confirmed the original diagnosis of gonadoblastoma and dysgerminoma and in one case gonadoblastoma, dysgerminoma and choriocarcinoma. all patients were followed up for to months. only one patient, who was initially treated with surgery only (stage ia), had disease recurrence, but achieved durable remission with chemotherapy and further surgery. the latest examinations revealed that all patients were in good health. conclusions because the gonads are often replaced by a tumour, a diagnosis of the underlying abnormality may be impossible. gonadoblastoma is regarded as in situ malignancy, and there is a high possibility for development of invasive germ cell tumour such as dysgerminoma. young girls with unilateral encapsulated gonadoblastoma and dysgerminoma can be treated only by unilateral oophorectomy or salpingo-oophorectomy and subsequent careful follow up to prevent damage of contralateral ovary and preserve the fertility. the patients with gonadoblastoma and mixed germ cell tumor are treated in accordance with other tumour structures. the paper is sponsored by ministry of health of the czech republic (international grant agency) no - , cz introduction cadherins and their associated cytoplasmic protein catenins are cell adhesion glycoproteins that are altered in tumor progression the aim of this study is to reveal the altered expression of e-cadherin, p-cadherin, α-catenin and β-catenin in cervical squamous cell carcinoma progression from dysplastic lesions (low grade squamous intraepithelial lesion-l-sil, high grade squamous intraepithelial lesion-h-sil) to invasive squamous cell carcinoma. material and method immunohistochemical method was used in formalin-fixed, paraffin embedded representative tissue sections of l-sil (cin i), h-sil (cin ii-iii) and invasive squamous cell carcinomas. the presence of immunostaining and the pattern of distribution of e-cadherin, p-cadherin, α-catenin and β-catenin were analyzed. results e-cadherin was detected in . %, . %, . % of l-sil, h-sil and invasive squamous cell carcinomas respectively. the difference was statistically significant (p= . ). the expression of p-cadherin and α-catenin was reduced significantly from l-sil through invasive carcinoma (p= . for p-cadherin, p= . for α-catenin). β-catenin expression was revealed in all lesions with nearly the same frequency, . % l-sil, . % h-sil and . % invasive carcinomas. conclusion loss of adhesion proteins, e-cadherin, p-cadherin and α-catenin is observed in cervical squamous cell carcinoma progression. the presence of β-catenin in h-sil and invasive carcinomas might suggest its role in tumor progression by its effect in wnt signaling pathway in cervical carcinomas. introduction p, e-cadherin and their cytoplasmic domains alpha and beta-catenins are epithelial cell adhesion complexes. their alteration is important in tumor progression. beta catenin is also involved in wnt signaling cascade which regulates cell proliferation. we investigated the altered pattern of cadherin/catenin complex in cervical squamous cell carcinomas. we also tried to find out if there was a correlation between adhesion proteins and clinicopathologic variables (stage, depth of invasion, lymph node metastases) and hpv status. material and methods e-cadherin, p-cadherin, alpha catenin and beta catenin expression in squamous cell carcinomas were investigated by immunohistochemical method. the presence of hpv / infection was detected by in situ hybridization. results there were large cell keratinizing, nonkeratinizing and small cell subtypes of squamous cell carcinoma. lymph node metastases were found in carcinomas. hpv / infection was detected in of carcinomas, all were large cell keratinizing except one. no correlation was found between the hpv status and cadherin and catenin expression of the tumors. e-cadherin was negative in carcinomas, p-cadherin was positive in only carcinomas. strong cytoplasmic beta catenin positivity was revealed in carcinomas. alpha catenin reactivity was seen in of carcinomas. neither cadherins nor catenins expressions were correlated with other clinicopathologic variables. conclusion our results reveal that e-cadherin and p-cadherin expressions are lost in squamous cell carcinomas. however alpha and beta catenin immunopositivity in cervical squamous cell carcinomas might suggest catenins' role in tumor progression in a different way other than their activity in cell adhesion. prognostic significance of karyotype analysis in ovarian carcinomas e introduction traditional prognostic factors of ovarian carcinoma (oc) include disease stage, age, histologic grade and residual disease after surgery. at present it is quite difficult to predict the survival benefit of platinum analogues based chemotherapy. the aim of this study was to evaluate the clinicopathological / cytogenetic profile in a series of ocs and the reliability of karyotype in predicting benefit of chemotherapy and prognosis. materials and methods a series of ocs ( serous, undifferentiated, endometrioid, mucinous and one mixed carcinomas) was investigated for grade ( / : % vs / : %), stage (i/ii: % vs iii/iv: %), residual disease after surgery ( %), chemotherapy ( %), remission ( %) vs progression ( %) after chemotherapy and follow-up (mean: , range: - months). cytogenetics were performed on direct preparations using the qfq banding technique and describing abnormalities according to iscn. karyotypes were classified as diploid/near-diploid ( %) and complex (hyperdiploid, multiple cell lines, fragmented chromosomes) ( %). statistical analysis using chi-square and fisher test was done. statistical analysis demonstrated that low stage (p= . ) and low grade (p= . ) were predictors of good prognosis, while residual disease correlated with a poor outcome (p= . ). diploid/near-diploid karyotype correlated with a favourable prognosis (chi-square: . ). complex karyotypes appeared much more frequently associated with chemoresistance ( % vs %). conclusion our results confirm the correlation between grade, stage, residual disease and prognosis of ocs. in addition, these data suggest that a diploid/near-diploid karyotype might predict benefit of chemotherapy and favourable prognosis. introduction the aim of this study was to critically assess the progression-and recurrence rates of microinvasive (mic) stage ia cervical carcinoma, based on medline search, and to compare these data with our own experience on these tumours in ljubljana medical centre. in the published studies covering the years - , a total of . squamous cell mics were reported, including . stage ia lesions, . in stage ia , and cases of occult stage ib, classified according to figo or sgo classifications. our experience in ljubljana is based on the management of stage ia squamous cell carcinomas (scc), accumulated in the past years and early invasive adenocarcinomas (ac) collected in years. results in the reported . scc mic cases, lymphatic space involvement was recorded in ( %) cases, and in of those, the disease recurred, and progressed to death in patients. in series, mics were associated with ( . %) recurrences. in seven series, ( . %) cases of death due to cancer were reported. lymph node metastases were found in ( . %) cases. even when stage ia and ia carcinomas were treated with conservative surgical approach, very low risk of recurrence ( . %), lymph node disease ( . %), or death caused by cancer ( . %) was reported by these studies. most authors conclude that mic with the depth of invasion < mm, without confluent growth or lymphatic invasion can be safely treated with conization. during - lymphadenectomy was included in operations of mic in ljubljana. the pelvic lns were invariably free of cancer. the -year survival was %, while patients were lost to follow-up. in medline search . cases of stage ia acs were analysed in a -year period. lymph node metastasis were found in ( . %) of cases with lymphadenectomy, complicated with recurrent disease in ( . %) cases compared to the scc mic, the risk of recurrence in ac was considerably higher, . % and progression to death . % ( cases analysed by Östör, ). in our ac patients diagnosed in stage ia there was no recurrence or death of disease. conclusions according to the world literature and our own experience, the prognosis of mic of both squamous and glandular type is very favourable. this suggests that conservative management of stage ia cervical cancer is indicated and safe when strict evaluation of tumour extension and surgical margins of the cone are assured. agnor counts, histological and immunohistochemical characteristics of placenta in preterm delivery with live and dead newborns g burkadze, g turashvili, n meckhvarishvili tbilisi state medical university, tbilisi, georgia introduction the pathology of placenta constitutes one of the most poorly understood domains of general pathology. the significance of histological characteristics of preterm delivery is disputable. the aim of this study was to investigate histological and immunohistochemical characteristics and agnor counts of placenta in preterm delivery with alive and dead newborns. we studied placental tissues in preterm deliveries of live (first group) and dead (second group) newborns (n obstetrics clinic of tsmu, tsmu, - . paraffin sections were stained using h&e, agnor (bio-optica) and immunohistochemistry by ki- , cd , cd , bcl- (dako). results in the first group the number and area of chorionic villi was times lower, the number and area of villous vessels . times higher, the number of villous lymphocytes is . times higher, neutrophils . times higher, hofbauer cells . times lower, syncytiotrophoblasts . times lower (their area was the same), syncytial knots times lower (their area is times higher). the width of nitabuch layer was times greater, decidual tissue . times greater, the number of decidual cells was . times higher, decidual lymphocytes . times higher, neutrophils . times higher, macrophages . times lower, agnor(+) syncytiotrophoblastic cells . times lower, agnor granules did not differ, agnor(+) decidual cells times higher, agnor granules . times higher, ki- (+) syncytiotrophoblasts and cytotrophoblasts times higher. conclusion preterm delivery shows incoordination between proliferation and involution of placental tissue. in death of newborns, morphological changes reflect non-efficacy of adaptative-compensative reactions of chorion-decidual system. institute of pathology, charité university hospital, berlin, germany clontech laboratories inc., paolo alto, california, usa introduction the ubiquitously expressed actin-binding protein gelsolin is known to play a role in modulation of the actin network and regulation of cell motility and cell growth. decreased gelsolin expression occurs in transformed cells and in carcinomas of the colon, bladder, breast, lung and prostate. in the present study we analyzed expression of gelsolin in matched human normal and tumor tissues using a cancer profiling array. we found a decreased expression of gelsolin in cancer tissue of female reproductive organs including ovary. further we examined the expression of gelsolin in human benign and malignant ovarian tissues by immunohistochemistry, observing a diminished expression of gelsolin in borderline tumors and ovarian serous carcinomas compared to epithelium of normal ovaries and benign adenomas. in addition, low levels of gelsolin protein were observed in four of six ovarian carcinoma cell lines in contrast to immortalized ovarian surface epithelial cells. re-expression of gelsolin in the ovarian carcinoma cell lines oaw and es- resulted in a suppression of tumor cell survival in vitro. finally, we showed an up-regulation of gelsolin in ovarian cancer cell lines after inhibition of both dna methylation and histone deacetylation using -aza- 'deoxycytidine and trichostatin a, respectively. conclusion our results suggest that the gelsolin gene has a potential function as a class ii tumor suppressor gene in human ovarian epithelium. steroid cell tumor of the ovary: presentation of two cases i lekka, o tzaida, v leodara, a lountou, p arapantoni-dadioti, i iakovidou pathology department, metaxas cancer hospital of pireaus, piraus, greece two cases of steroid tumor of the ovary, diagnosed at our department during the last five years among a total of ovarian tumors, are presented. steroid cell tumors, previously classified as lipid or lipoid cell tumors are rare neoplasms of sex-cord-stromal origin derived in almost all cases from ovarian stromal lutein cells or from leydig cells and rarely from adrenal rest cells. they have been subclassified as steroid cell tumors not otherwise specified (nos), stromal luteomas and leydig cell tumors. in our report we present two cases of the nos subtype: one occurred in a -yearold woman and the other in a -year-old postmenopausal woman. both patients presented with a pelvic mass and signs of virilization (resulting effect of elevated serum testosterone). both tumors were composed of characteristic eosinophilic-granular or vacuolated (lipid rich) neoplastic cells lacking crystals of reinke and expressing the appropriate immunohistochemical phenotype. based on thorough pathological examination and evaluation of several findings such as tumor size, necrosis, haemorrhage, cellular atypia, mitotic activity, we classified the first case as a malignant and the second as a benign one. various aspects of the clinical and pathological presentation, differential diagnosis and treatment of these tumors are discussed. choriocarcinoma following term pregnancy uncommonly choriocarcinoma follows a normal pregnancy. the aim of this study was to stress the importance of a correct and rapid diagnosis which will allow a high rate of success in therapy for this neoplasm. material and methods histopathologic and immunohistochemical studies were performed to an endometrial curettage and a hysterectomy specimen. case report a -year-old female presented with uterine bleeding three months after a normal delivery from a term gestation in which placenta was not submitted for study. endometrial curettage was performed, and it showed a dimorphic population of atypical cytotrophoblast and syncytiotrophoblast cells. cytotrophoblast cells had pale cytoplasm with single nucleus, eosinophilic nucleoli and prominent mitotic figures. syncytiotrophoblast appeared as large multinucleated cells with polygonal basophilic cytoplasm. extensive necrotic and hemorrhagic areas were found. there was no presence of placental villi. neoplastic cells expressed strongly ß-hcg and cytokeratin. with a diagnosis of choriocarcinoma, hysterectomy was performed and showed areas of normal proliferative endometrium, and hemorrhagic areas with nests of trophoblastic neoplastic cells infiltrating among myometrial muscle. there was no involvement of cervix or adnexa. treatment was completed with chemotherapy, and one year after diagnosis the patient has not evidence of disease. conclusions the modern treatment with chemotherapeutic drugs is highly effective in complete cure of choriocarcinoma. therefore a quick histological diagnosis has a very important role to reduce the risk of metastasis disease, even avoiding surgery to preserve reproductive function. the mechanism of action and the histological features of uterine leiomyomas (ul) treated with gnrh are still a matter of debate. recent reports suggest that neovascularization induced by specific angiogenic molecules may play a role in the response to gnrh. also a reduced proliferative activity was observed and postulated as a possible histopathological feature of ul treated with gnrh. the aim of this study was to assess the possible role of angiogenesis and to quantify the percentage of proliferative cells in uterine leiomyomas in response to treatment with gnrh from premenopausic patients. material and methods a total of patients were studied, with two groups comprising samples each, including patients treated with gnrh and age-matched control patients. clinical (age, length of treatment, assessment of response to treatment by ultrasonography) and histopathological dates (microvessel density (vessels/mm ) and cellular proliferation assesed by ki- stain in cells were studied. the study group showed cd = , vessels/mm (mean) and ki- = , (mean). the control group showed cd = , vessels/mm (mean) and ki- = , . conclusion the leiomyomas treated with gnrh showed a) high number of microvessel density, b) low proliferative activity and c) significant reduction in size compared with patients without treatment. introduction evaluations of expression of apoptosis related oncogenes are being increasingly called upon in an attempt to better understand the carcinogenesis of cervical carcinoma and to provide possible prognostic information. the aim of this study was to analyze the expression of bcl- , p and mdm- oncoproteins and cellular proliferative marker ki- in early stage cervical carcinoma, with an emphasis on their association with human papillomavirus (hpv) infection, recurrence rate and lymph node status. material and methods using immunohistochemistry, radical hysterectomy specimens with cervical carcinoma (pt b /pt b ) were studied. evaluation of expression of p , bcl- , mdm- and ki- was performed in surface area, center and invasion front of the neoplasms. the hpv presence was determined by card in situ hybridization. results and conclusion in the invasion front bcl- was expressed in ( %), p in ( %) and mdm- in ( %) cases. hpv infection was detected in ( %) cases. carcinomas with a higher ki- labeling index were more frequently hpv positive than hpv negative ( . % vs . %, p< . ). no association was found between p , mdm- or ki- and either lymph node status or recurrence rate. negative staining for bcl- was associated only with the presence of lymph node metastasis ( % vs %, p= . ), and not with the recurrence rate. significant correlation among expression of bcl- , p , mdm- oncoprotein and ki- values was also observed. these results suggest that further study of a larger series is needed to confirm whether bcl- , either alone or in combined evaluation with other markers, could be a useful marker to identify more aggressive behavior in early stage cervical carcinoma. introduction during the past three decades, the incidence of cervical invasive primary adenocarcinoma (aca) has increased. at the same time, incidence of squamous cell carcinomas of the cervix decreased, due to early detection of their well documented precursors lesions. the aim of this study was to determine if dysplastic endocervical cells (ec) have neoplastic potential as a precursor lesions of adenocarcinoma in situ (ais) of the cervix. the malignant potential was determined by assessing the ploidy status, proliferative activity and c-myc expression in normal, dysplastic and malignant ec separately. patients and methods serial sections from patients with diagnosed ais or primary invasive aca were analyzed. one representative slide of cervix which showed normal, dysplastic and malignant endocervical glands simultaneously was chosen from each patient. determination of ploidy status and s-phase by flow cytometry and expression of c-myc oncoprotein by immunohistochemistry in normal, dysplastic and malignant ec was done. results the morphologicaly normal ec were diploid, with normal proliferative activity and no expression of c-myc oncoprotein. the dysplastic and malignant ec had a significant proportion of cells with aneuploidy, higher proliferative activity and c-myc oncogene overexpression. the χ test showed significant association of malignant ec with aneuploidy (p= . ) and high proliferative activity (p= . ). as one third of dysplastic ec are aneuploid, with high mitotic activity, they probably have malignant potential. dysplastic endocervical cells had statistically significant association with c-myc oncogene expression (p= . ). conclusion our results support the existence of pre-malignant glandular lesions while the immunohistochemical detection of cmyc oncoproteine could be helpful in detection of ec with malignant potential even without dysplastic morphologic changes. introduction the attempts to determine the prognostic significance of c-erbb- oncoprotein expression (ope) and its relation to human papillomavirus (hpv) infection in cervical cancer have yielded controversial. the aim of this study was to evaluate the patterns of c-erbb- ope in early stage cervical carcinoma and to assess its prognostic value by exploring its relationships to various clinicopathological characteristics, hpv status and recurrence rate. materials and methods radical hysterectomy specimens from cervical carcinoma patients (pt b / b ) were investigated immunohistochemically for c-erbb- presence. the c-erbb- score (range: - ) was determined in the surface area, center and invasion front of each carcinoma. card in situ hybridization was used for hpv detection. results and conclusion strong c-erbb- ope was detected in , , and cases in the invasion front, center and surface area of the tumor, respectively. there was a significant difference in positive staining rate of c-erbb- between squamous cell, mixed carcinomas and adenocarcinomas ( %, % vs %, p= . ). c-erbb- ope was significantly higher in carcinomas with abundant than in tumors with less abundant peri-tumoral lymphocytic infiltration ( . % vs . %, p= . ). in hpv positive carcinomas ( ), c-erbb- was detected more frequently in type / versus type / lesions ( % vs . %, p= . ). no association was found between c-erbb- expression and recurrence rate, lymph node metastasis or any other clinicopathological variable investigated (age, tumor diameter, depth of invasion, grade, vascular invasion). therefore, immunostaining for c-erbb- is unlikely to be of use as a prognostic indicator in early stage cervical carcinomas, while further study is warranted to examine relationships between hpv infection and c-erbb- ope. the predictive values of estrogen (er) and progesterone receptor (pgr) status and cell proliferation kinetics in cervical carcinomas are still unsettled. the purpose of this study was to clarify the associations among er/pgr status and ki- expression and to determine their relationship to human papillomavirus (hpv) infection, recurrence rate and other clinicopathologic parameters (age, tumor diameter, depth of invasion, histotype, grade, vascular involvement, inflammatory infiltrate, lymph node status) in early stage cervical carcinomas. materials and methods er, pgr and ki- immunostaining was performed in cervical carcinoma radical hysterectomy specimens (pt b /pt b ). er/pgr staining was scored in a semiquantitative fashion, while to evaluate the cell proliferation, the ki- labelling index (li) was assessed in the surface area, center and invasion front of each tumor. hpv status was determined by card in situ hybridization. results and conclusion er positivity was detected in ( %), while pgr positivity in ( %) carcinomas. er/pgr values were in correlation with ki- li in all three tumors' compartments (p< . ). in contrast to er/pgr status, ki- li was strongly associated with hpv infection (p< . ). no relationship was found between pgr or ki- immunoreactivity and either recurrence rate or any other clinicopathological variable investigated. nevertheless, reduced er expression was significantly associated with larger tumor diameter (p= . ) and poor differentiation (p= . ), as well as lymphovascular involvement (p= . ) and lymph node metastases (p= . ). these results suggest that er, pgr and ki- expression are closely related to neoplastic cell proliferation, probably induced by hpv infection. their determination may provide additional prognostic information in early stage cervical carcinomas. immunohistochemical assessment of heat shock protein expression in epithelial ovarian carcinomas: relationship with apoptotic markers as over-expression of bcl- and p purpose heat shock proteins (hsps) occupy a central role in the regulation of intracellular homeostasis and especially hsp and hsp are potent antiapoptotic proteins. overexpression of hsp protects cells from stress-induced apoptosis. the aim of this study was to determine the distrubition pattern of hsp -expression in ovarian carcinomas by immunohistochemistry and to evaluate its relationship with the prognostic parameters and over-expression of bcl- and p proteins. materials and methods thirty-five patients with ovarian carcinoma were included in the present study. expression of hsp was assessed by immunohistochemistry. the relationship between expression of these proteins and other prognostic markers such as stage was evaluated. results hsp was expressed in all of ovarian cancer cells with different intensity. the staining was localized in the cytoplasm and/or nuclei. there was a negative correlation between stage and both intensity of hsp positivity and bcl- positivity (respectively: r= - , ; p< . ; r= - . , p< . ). intensity of hsp positivity was statistically associated with bcl- positivity (r= . , p< . ). there were no significant associations between p positivity and bcl- positivity, intensity of hsp or stage of ovarian carcinoma. conclusions these data show that the intensity of hsp positivity was significantly stronger in early stage than in advanced stage ovarian carcinomas. hsp expression detected by immunohistochemistry was correlated with bcl- expression but not with p protein expression. background avb integrin and pinopodes have been proposed as new markers of endometrial receptivity. there is also a very limited experience on the responses of these markers to hormonal therapies. the aim of this study is to evaluate the effect different hormone replacement treatment on these markers. design we studied fertile controls and women with ovarian failure receiving hormone replacement therapy (estradiol valerate (ev) and vaginal progesterone (vp), group e+ep). those women were divided randomly into two subgroups of patients. group e+p received ev for days and vp alone for days. group e+p+ep was given e+ep therapy but including episodic vp on days and . all women underwent two endometrial biopsies during a single menstrual cycle (days + to + and four days later). avb integrin was detected in frozen tissue using the envision system. pinopode formation was evaluated in tissue fixed in glutaraldehide using a zeiss dsm a scanning electron microscopy. both avb integrin and pinopode formation were semiquantitatively evaluated. results patients in group e+p+ep showed markedly decidualized endometria in the midluteal biopsy and a significant increase of avb integrin expression (p= . for both parameters). no significant changes in pinopode formation were observed in midluteal biopsies. no differences were observed in late luteal biopsies. conclusions avb integrin expression and pinopode formation are signs of endometrial maturation related to progesterone action but their significance in terms of endometrial receptivity in the clinical setting remains to be shown. supported by grant pi (fondo de investigaciones sanitarias). gestational trophoblastic diseases (gtd) are extremely rare conditions, especially the ones associated with ectopic pregnancies (ep). case reports only three cases ( . %, / ) of gtd associated with ep were diagnosed at the department of histopathology and clinical cytology in the last years. the first patient, age underwent salpingectomy for clinical suspicion of tubal pregnancy, whereas in the second, age hysterectomy with bilateral salpingo-oophprectomy (hsop) was performed for a clinical diagnosis of ovarian endometriosis. the third patient, age underwent hsop for malignant ovarian tumour which metastasised to lungs. pathological findings: chorionic villi were found in the tubal lumen of the first patient, showing marked hydropic degeneration, reduced/absent vascularisation and excessive trophoblastic cell growth. diagnosis of partial hydatiform mole was established, and the patient remained under surveillance for the hcg level. atypical trophoblastic cells, which penetrated the full thickness of the tubal wall and invaded the ovarian blood vessels of the second patient, led to the diagnosis of an invasive mole. the third patient was diagnosed with choriocarcinoma due to the presence of a tumour consisting of malignant trophoblastic cells that infiltrated the right ovary, tube and uterine cornu. the last two patients received chemotherapy and have been well for and months, respectively. conclusion due to extremely low incidence of gtd associated with ep, these entities are rarely clinically recognised. therefore, a careful histopathologic examination of the adnexal masses is essential for the establishment of the correct diagnosis and further treatment of the patients. in an organized screening programme for cervix cancer the diagnosis atypia (ascus) has always been a problem. the subsequent histological examination shows different diagnoses, such as negative, inflammation, cin i-iii (sil) and carcinoma. in the county of funen, a well-organized screening programme has existed since .using the cytological diagnosis of atypia, we distinguish between atypia (asc-us) probably inflammatory and atypia (asc-h) probably dysplasia. in previous studies on papsmears we have shown histological follow-up diagnoses for atypia (asc-us): negative . % and cin i-iii . %, and for atypia (asc-h): negative . %, cin i-iii % and carcinoma , %. since june we have implementated liquid-based cytology (lbc) thinprep, cytyc. the aim of this investigation is to show the histological follow-up diagnoses of cytological atypia when using lbc-technique. the total number of lbc-samples in were examined. the recommandations for atypia are a repeated cervical sample, and for persistent atypia or atypia colposcopy, cervical biopsies and abrasion within months. in a total of , smears, including , lbcsamples, were examined. the diagnoses of the lbc-samples were: negative , %, inadequate , % (a reduction of % compared with pap-smears), atypia , % and cin i %. preliminary histological follow-up diagnoses for atypia and were: negative % and cin i-iii %. conclusion thinprep shows two significant advantages: a markedly reduced number of cytological atypia diagnoses ( %) compared with pap-smears and a higher diagnostic quality with fewer false positive diagnoses. introduction ovarian sertoli-leydig cell tumors (slct) are very rare sex cord-stromal tumors and among them, tumors with heterologous sarcomatous elements are exceptional. aims: a unilateral ovarian stage ic slct with heterologous mesenchymal elements is presented. materials and methods a -year-old woman, para , was admitted to hospital with severe abdominal pain. at laparotomy, resection of a large right ovarian cyst was carried out. histological examination revealed a slct, and subsequently surgical staging was performed. no adjuvant therapy was given. at years followup she was well and without signs of recurrence. routine staining of slides from paraffin blocks and immunohistochemistry (ihc) were available. results gross examination revealed a x x cm large multilocular ovarian cyst with smooth interlocular septa and outer surface. microscopy disclosed a slct of intermediate differentiation with a very few leydig cells. major areas consisted of a hypocellular stroma with edema, hemorrhage and necrosis. in a few sections small foci of cartilage were seen. in a number of sections groups of small cells with indistinct cytoplasm and hyperchromatic nuclei were present. mitotic and apoptotic figures were common. ihc revealed a positive reaction for desmin, myf and myogenin, indicating rhabdomyosarcoma of embryonal type. conclusion the most important prognostic factors of slct are stage and grade of differentiation. variants of slct with immature skeletal muscle are often fatal. ihc with myf or myogenin with a high sensitivity and specificity for rhabdomyosarcoma, combined with inhibin is very important in differing immature sertoli cells from rhabdomyoblasts, in order to diagnose the rhabdomyosarcoma and to grade the slct correctly. expression of the nerve growth factor (ngf) receptors trka and p shows biological diversity in ovarian, breast and mesothelial malignancy b davidson , r reich , p lazarovici , va florenes , m skrede , b risberg , c bedrossian , jm nesland the norwegian radium hospital, oslo, norway department of pharmacology, hebrew university, jerusalem. israel department of pathology, northwestern university, chicago, il, usa neurotrophins and their receptors are known to have a central role in biologic processes in the nervous system. however, recent studies have additionally highlighted the role of ngf and its receptors trka (inducer of proliferation) and p (inducer of apoptosis) in the development and progression of malignant tumors, including those of non-neural origin. we studied protein expression of p and activated phosphorylated trka (p-trka) in serous ovarian carcinomas ( effusions, solid tumors), breast carcinomas ( effusions, solid tumors) and malignant mesotheliomas (mm) ( effusions, biopsies) using immunohistochemistry and immunoblotting. p-trka was expressed in ovarian carcinoma cells in effusions in only / ( %) specimens, compared to / ( %) solid tumors, while the opposite was true for p . in contrast, p-trka membrane expression was higher in effusions (p= . ) of mm patients, while the opposite was true for p (p= . ). in addition, p-trka (but not p ) expression was significantly higher in peritoneal mm compared to their pleural counterparts ( / vs. / positive tumors; p= . ). in breast cancer, p-trka expression in effusions was significantly higher than in primary tumors (p< . ) and lymph node metastases (p= . ), while p expression was lower in both effusions (p= . ) and primary tumors (p= . ) compared to lymph node metastases. our results provide the first evidence regarding the role of nfg receptors in tumor progression through site-specific changes in expression. specifically, they may provide biologic evidence for the uniformly and rapidly fatal outcome of breast cancer patients with effusions and of mm patients. the significance of mast cells in the differential diagnosis of uterine smooth muscle tumors bh ozdemir aim to assess the role of the mean mast cell count in the differential diagnosis of uterine smooth muscle tumors. material and method twenty-cases of ordinary leiomyoma, cases of atypical leiomyoma, cases of leiomyosarcoma, cases of mitotically active leiomyoma and cases of cellular leiomyoma were included in the study. the morphological features and clinical presentation was evaluated retrospectively. toludine blue stain was used to highlight the mast cells in the endometrium, myometrium and smooth muscle tumors. at least high power fields were counted. results considerable variation in mast cell numbers was found among smooth muscle tumors (p< . ). the intratumoral mean mast cell count was found significantly higher in ordinary leiomyomas ( . ), when compared with other tumors, including atypical leiomyoma ( . . ), mitotically active leiomyoma ( . ), cellular leiomyoma ( . . ) and leiomyosarcoma ( . . ) (p< . ). no significant differences were found between these tumor groups in regards of the mean mast cell count of endometrium and myometrium adjacent to the tumor. in the endometrium, a drop in the number of mast cells has been demonstrated with advancing age, particularly after menopause (p< . ). in addition cases showed eosinophilia, cases showed basophilia and cases showed allergic reactions to different causes. a significant positive relationship was found between the intratumoral, myometrial mast cell number and basophilia. conclusion these data suggest that intratumoral mast cell quantitation may allow the differential diagnosis in uterine smooth muscle tumors. ovarian carcinoma is the most frequent cause of death in the world among gynaecologic malignancies. diagnosis is usually late, and the biological behaviour is highly variable, depending on several factors such as the histopathological grading, the local and/or peritoneal spread and the proliferation rate. we choose a list of genes involved in cell growth and proliferation (igf , igfbp , ctnnbeta , cdk- c, fgfr ). among these, so far, we analyzed igfbp gene and studied loss of heterozygosity (loh) in tumour tissue in order to identify potential relevant genes in ovarian cancer homeostasis. twenty cases of formalin fixed, paraffin embedded ovarian carcinomas from the archives of the department of pathology of padova university and five effusions (from peritoneal or pleural recurrences) of ovarian carcinomas, were selected for this study. genomic dna and tumour dna for each case were extracted from blood cell, tumour or not-cancer surgery biopsy. loh was searched using published single nucleotide polymorphism (snps) in igfbp gene. pcr product covering the snps from genomic and tumour dna were dhplc separated. three of the twenty patients whose tumour dna was obtained from paraffin material, were heterozygous at nucleotide c/a (dbsnp ref. n. ) and a/c (dbsnp ref. n. ) of the igfbp gene in genomic dna. analysis of tumour dna failed to reveal loh (preserved heterozygosity). in effusion cases, one of five patients showed heterozygosity at the same nucleotides. in these patients, loh was also not identified. our preliminary results suggest that dhplc analysis for loh is feasible, rapid and maybe of potential interest in the identification of genes involved in ovarian cancerogenesis. the progression of low grade squamous intraepithelial lesion (l-sil) to high grade squamous intraepithelial lesion (h-sil) occurs in around % of cases. there are no morphologic changes to predict this progression. aims: to study whether the ki immunostaining pattern and labeling present upon diagnosis of l-sil is able to predict the regression or persistence/progression of the lesion to h-sil of the cervix over a two year period following diagnosis. materials and methods cervical biopsies from patients diagnosed cytologically as cervical squamous intraepithelial lesion (sil) were used. biopsies were performed immediately after the cytological diagnosis resulting in l-sil and h-sil. ki immunostaining was performed on all cases and was classified as suprabasal immunostaining pattern (sbip) for cases without ki- immunoreactive cells in the upper two thirds of the epithelium thickness, or dispersed immunostaining pattern (dip) for cases with ki- immunoreactive cells in the upper two thirds of the epithelium thickness. nuclei in hpf including the total thickness of the epithelial layer of each sample were counted to determine the mean number of cells which reacted against ki- antibody. in situ hybridization was used to demonstrate the presence of hpv and its typing. chi square test, fisher's exact test and student t test were used for statistical analysis with significance set at p< . . results of the biopsies performed cases resulted in l-sil ( s-bip and dip patterns) and in h-sil. % of the l-sil cases that resulted in a s-bip pattern showed persistence/ progression of the lesions while % of the cases that resulted in a dip pattern showed persistence/progression of the lesions. the difference between these values where statistically significative (p< . ). regarding ki- labeling index (li) in l-sil cases, we found that % of the cases ( out of ) with a ki- li less than % persisted/progressed, while % of cases ( out of ) with ki- li over % persisted/progressed. in this case there was also a statistically significative difference (p= . ). we found no statistical differences (p= . ) regarding hpv "in situ" hybridization. % of the cases ( out of ) where hpv was detected by in situ hybridization persisted/progressed while % of the cases did not show hpv by hybridization. conclusions the l-sil cases which showed dip and high ki- li were significantly related with persistence or progression to h-sil of these lesions, while l-sil cases which showed sbip and low ki- were significantly related to regression of the lesions. therefore, we conclude that ki- immunostaining pattern may be of prognostic value to predict regression or persistence/progression of l-sil. introduction sclerosing stromal tumor (sst) of the ovary is a rare tumor. it was first described by chalvardjan and scully in as a distinct subtype in the thecoma-fibroma group. most ssts occur in young patients below the age of years. the most common clinical symptom in patients is menstrual irregularity. in differential diagnosis, thecoma, fibroma, and hemangiopericytoma must be considered. aim: in this report, cases of sst of the ovary were described and compared with other ovarian tumors. material and methods two cases of ovarian sst were examined. the first case occurred in a -year-old female. at operation, the patient was found to have the ovary replaced by a tumor mass measuring x x cm. the second case occurred in a -year-old woman and the tumor mass measured x x cm. the surgical material was fixed in % formaldehyde solution and prepared for paraffin sections. in addition to h&e staining, immunohistochemical analyses were performed. results the clinical features, gross features, light microscopic findings and immunohistochemical results were described and compared with literature. the findings were consistent with sst, which is a very rare tumor of the ovary. the tumor cells showed positive staining for vimentin and desmin. we discuss the results and differential diagnosis. unususal chorangioma of the placenta -a case report w pokieser , w umek , r jahn , w ulrich institut of pathology, lainz hospital, vienna, austria institut of pathology, department of obstetrics and gynecology, university of vienna, austria chorangiomas (ca) are common lesions, occurring in of placentas. it is not clear whether ca are hyperplasias, hamartomas, or true neoplasms. depending on their size and location, they may be devoid of symptoms or may cause difficulties for the infant and the mother. we describe a case of manual removal of the placenta in association with ca. on gross examination the tumor had a nodule-in-nodule appearance and was histologically composed of two well defined nodules. the larger, outer one had the appearance of an usual chorangioma; the inner nodule showed highly cellular vascular proliferation. this architecture might represent a morphological variant of the same disease. in the present case, the placenta had to be removed manually. it remains unclear if this was due to impaired contractility of the uterine wall or due to a lack of decidualisation, following a worse vascular support in the surrounding area of the ca. it can´t be excluded that placenta accreta was caused by strictures after cesarian section which had been performed at the first delivery two years ago. on the other hand a placenta with a nodule form of ca could be less elastic than a placenta with regular architecture. however manual removal of the placenta may be regarded as a further complication of ca's larger than cm in diameter. are muc and muc ac reliable markers in the differential diagnosis of primary and metastatic ovarian carcinomas? a ensari , d ergun , a yorganci , a sertcelik , f ortac , n kursun ankara university medical school, department of pathology, ankara, turkey ankara university medical school, department of gynaecological oncology, ankara, turkey numune hospital gynaecology department ankara university medical school, department of biostatistic, ankara, turkey introduction aberrant expression of mucin glycoproteins has been observed during malignant transformation of human ovarian epithelium. however, there is limited information regarding the expression of these mucin proteins in primary and metastatic ovarian carcinomas. the aim of this study was to examine immunohistochemical expression of muc and muc ac mucin proteins in primary and metastatic carcinomas of the ovary in order to assess their value in the differential diagnosis. materials and methods forty eight ovarian tumours comprising surface epithelial carcinomas ( endometrioid, clear cell, serous papillary and mucinous type) and metastatic carcinomas of gastrointestinal primaries were included in the study. the age of the patients, the histological type and grade of the tumours were evaluated in relation to the expression (percentage distribution and staining intensity) of muc and muc ac studied immunohistochemically. results muc was expressed in ( . %) primary ovarian tumours while muc ac was expressed in ( %) primary tumours in comparison to % expression of muc and . % expression of muc ac in metastatic ovarian tumours. the differences in muc expression between non-mucinous ( . ± . ) and metastatic tumours ( . ± . ) and metastatic and mucinous tumours ( . ± . ) were statistically significant (p< . ). the difference in muc ac expression was statistically significant (p< . ) between non-mucinous ( . ± . ) and mucinous tumours ( . ± . ). conclusion muc proves to be highly reliable in the differential diagnosis of primary and metastatic mucinous tumours of the ovary. deregulation of sfrp and sfrp rna-expression in endometrial stromal sarcoma introduction endometrial stromal sarcomas (ess) are very rare uterine tumours. whereas histology and immunohistochemistry of this tumour are well documented, little is known about molecular mechanisms involved. to characterize ess-altered genes, we generated a genome-wide library by ssh-hybridisation and used it to produce cdna arrays. particular emphasis was also placed on data obtained from qrt-pcr analyses. materials and methods using ssh-library a gene-bank with app. different clones was established. total rna was extracted from frozen tumour tissue and used for cdna hybridisation. qrt-pcr analyses were performed both on frozen and paraffin-embedded tissue samples. results after cdna-array analysis more than genes were selected, sequenced and rearranged to different functional groups. among the most strongly deregulated genes were secreted frizzledrelated protein- (sfrp ) and sfrp . these are putative genes that regulate wnt-signalling pathway and can influence different cell events including cell proliferation. compared to post-menopausal endometrium the expression of sfrp and sfrp was increased in low-grade ess, but decreased in aggressive ess form. these results were additionally verified on paraffin embedded tissue probes by qrt-pcr analysis. conclusion deregulation of sfrp and sfrp expression appears to be one of the crucial features of ess. whereas in low-grade ess these two genes are up-regulated, their down-regulation could be associated with high-grade form of ess. therefore a sfrp and sfrp may not only represent useful markers for early ess diagnosis but may also have prognostic impact and help to distinguish between low-and high-grade ess. (this work was supported by lore-saldow -research fund) introduction fgt-cs is a highly malignant neoplasm with poor response to current chemotherapy. the proto-oncogen c-kit encodes a transmembrane-tyrosine-kinase (t-k) receptor involved in cell diferentiation, that has been found to be expressed in certain solid tumors and may play a role in their tumorigenesis. a t-k inhibitor specific for c-kit (sti ) has been reported to have therapeutic effects in tumors expressing the aberrant forms or high quantities of target protein. contradictory results are reported in the literature about the expression of c-kit in cs. the aim of this study was to investigate the immunoreactivity for c-kit in cs. immunostaining with anti-c-kit (cd ) polyclonal antibody (dako) was evaluated in cs ( endometrial, ovarian, cervical and tubal). only cases with membrane staining were considered to be positive. results c-kit was expressed in cases: in cases only in the carcinomatous component ( endometrial, tubal), in case only in the sarcomatous component (endometrial) and in case in both components (ovarian). positivity was focal and less than % of cells in all cases. conclusion cs of the female genital tract rarely express c-kit. it is unlikely that patients with these tumors will benefit from treatment with the currently avalaible t-k inhibitors. uterine heterologous sarcoma with the component of osteosarcoma on the base of lipoleiomyoma -a case report uterine homologous and heterologous sarcomas are rare neoplasms that are usually misdiagnosed as a component of malignant mixed mullerian tumor (mmmt). we present a case of a -year-old woman who had a heterologous sarcoma with a component of osteosarcoma on the base of lipoleiomyoma, that can be differentiated from mmmt by the absence of epithelial component. in heterologous sarcomas, the other components of neoplasm are rhabdomyosarcoma, chondrosarcoma, osteosarcoma, liposarcoma and combined forms. these neoplasms are misdiagnosed as endometrial stromal sarcomas or as a component of mmmt. they are more agressive than mmmt. immunohistochemical detection of er-β in ovarian sex cord-stromal tumors introduction since the discovery of a second subtype of estrogen receptor, er-beta (er-β), in , approximately years after the cloning of er-α, several reports have been published regarding the tissue distribution of this receptor. in mammals so far studied er-β predominates in the ovary. high expression of er-β was observed by in situ hybridization or immunohistochemistry in granulosa cells of the ovarian follicles. the aim of the present study was to examine immunohistochemically the expression of er-β in ovarian sex cord-stromal tumors. materials and methods ten cases of ovarian granulosa-stromal cell tumors (five adult granulosa cell tumors, two juvenile granulosa cell tumors, and sclerosing stromal tumors) and two cases of sertoli-leydig cell tumor were immunostained for er-β (polyclonal erb , biogenex). representative sections from ten cases of ovarian carcinomas were immunostained for comparison. results positivity for er-β was observed in % to % of the nuclei in adult granulosa cell tumors and % to % of the nuclei in sclerosing stromal tumors. only - % of the nuclei from juvenile granulosa cell tumors were positive for er-β. in sertoli-leydig cell tumors positivity was more extensive in areas of diffuse growth. four cases of ovarian carcinomas exhibited positivity. conclusion positivity for er-β is a common finding in ovarian sex cord-stromal tumors. these findings might have therapeutic implications. adult fibrosarcoma of the vulva ol mejia mejia instituto nacional de cancerología, bucaramanga, colombia introduction sarcomas are rare and unusual lesions of the vulva. the aim of this study was to present a case with analysis of clinical, morphologic and immunohistochemical findings. materials and methods a -year-old female patient presented a rapidly growing of a mass in the pubis and left labium major of vulva of x x cm associated with a second satellite lesion ( months later) in the right inguinal area of x x cm. results histologic examination of both lesions disclosed a malignant neoplasm composed of uniform and orderly spindle cells with occasional epithelioid cells, oriented in curving or interlacing fascicles, forming a herringbone pattern with mitotic figures ( / hpf) and areas of necrosis and hemorrhage. the immunohistochemical profile showed strong reactivity for cd and vimentin, and focal and weak reactivity for smooth muscle actin. immunoexpression for s , nse, bcl- , hmb- , melana, ae ae and desmin was lacking. discussion and conclusions we present a case of a malignant mesenchymal tumor of vulva. due to histological features and behavior, pathologists must discard others spindle cell tumors, such as malignant melanoma, malignant peripheral nerve sheath tumor, monophasic synovial sarcoma or leiomyosarcoma. fibrosarcoma is a diagnosis of exclusion and a wide immunohistochemical panel is useful to make differential diagnosis. introduction serous tumors of borderline malignancy (stbm) of the fallopian tube are exceedingly rare. we report a case of stbm of fallopian tube in a -year woman. material and methods a -year old woman was found to have right adnexal mass on her routine gynaecologic examination. serum ca- was not elevated. at laparoscopy a swollen fallopian tube was removed. during the operation a fine needle aspiration was performed. the cytological findings of the adequate giemsa-stained smears were recorded. haematoxylin and eosinstained sections from the routinely fixed and paraffin embedded surgical material were histologically analysed. results a papillary tumor, with maximal diameter of cm in the dilated part of the fallopian tube toward the fimbrial end, was found. histologic features of the tumor were similar to the atypical proliferative serous tumor of the ovary. two years after the operation the patient is well, without evidence of the disease. conclusion to the best of our knowledge only four cases of stbm of fallopian tube have been reported. our case is unusual due to lack of any symptoms. recent studies have suggested that in the setting of an unknown primary, cdx- immunostaining may be used in identifying a metastatic carcinoma as colonic in origin. aim: we sought to evaluate the immunoreactivity of cdx in a series of primary and metastatic ovarian mucinous neoplasms. materials and methods cases of mucinous tumour of the ovary, including benign cystadenomas, borderline mucinous tumours and mucinous adenocarcinomas, were tested for cdx immunoreactivity. cases of serous and endometrioid lesions as well as cases of ovarian metastases from colonic adenocarcinoma were also evaluated. results cdx immunoreactivity was detected in / ( %) cases of primary ovarian mucinous tumour. particularly, / ( , %) cases of cystadenomas, / ( , %) cases of borderline tumours and / ( , %) cases of adenocarcinomas were immunostained. immunoreactivity was usually related to an intestinal morphology. no immunoreactivity was observed in serous or endometrioid lesions whereas all five cases of ovarian metastases from colonic adenocarcinoma were immunoreactive for cdx . conclusions cdx immunoreactivity may be detected in the majority of benign, borderline and malignant ovarian mucinous tumour whereas serous and endometrioid lesions are unstained for this marker. cdx immunoreactivity is not useful in distinguishing between primary and metastatic ovarian mucinous carcinomas whereas it may be useful in the distinction between endocervical and intestinal type of mucinous tumour of the ovary, which may have clinical relevance. an ovarian primary should be added to the list of cdx positive metastatic carcinoma in the setting of an unknown primary. expression of p ink a in serous lesions of the female genital tract c heffron introduction a spectrum of serous lesions including benign, borderline and malignant tumours and endosalpingiosis commonly arise in tissues of the female genital tract. p ink a is a tumour suppressor protein which functions as a cyclin dependent kinase inhibitor and plays a vital role in the cell cycle control at the g /s phase transition. although well recognized as a discriminator of benign and potentially malignant squamous and glandular cervical lesions, the expression of p in ovarian lesions and their mimics is less well established. the aim of this study was to evaluate p ink a expression in serous lesions of the female genital tract and to investigate its potential diagnostic utility. methods immunohistochemical analysis of p ink a (mouse monoclonal anti-p antibody) was performed on cases of serous epithelial lesions of the female genital tract (n= ) comprising endosalpingiosis, borderline serous cystadenomas of ovary and peritoneum, benign serous cystadenoma of ovary, serous adenocarcinoma of ovary and peritoneum and normal fallopian tube epithelium. results all cases of endosalpingiosis were positive (definite cytoplasmic staining with occasional nuclear positivity) for p ink a expression, as were all normal fallopian tube epithelium samples. varying degrees of p ink a expression were found in the serous neoplasms examined, with no clear pattern associated with any histological subtype. conclusion diagnostic difficulties may arise in the distinction between benign serous glandular lesions and more sinister potentially malignant serous neoplasms. in this study the pattern and degree of expression of p , although showing some differences, does not allow definitive classification of these lesions. epithelioid trophoblastic tumor [ett] is an unfrequent gestational trophoblastic disease [gtd], whose epithelial-like cells derive from chorionic-type intermediate trophoblast. ett mostly shows a benign behaviour, but metastases have also been reported, and pathologic prognosticators are not as yet recognized. the kinase-inhibitor p kip has been seen to be lacking in malignant gtds, while different growth factors, such as the c-kit receptor, have been related to growing trophoblasts of p -null embryos. since c-kit is said to promote trophoblast growth and invasiveness, this study was aimed at immunolocalizing p and c-kit in ett, as compared to a proliferation antigen. materials and methods -after a preterm birth of a living infant, a -year-old woman underwent hysterectomy for a postpartum metratonia. the patient had an antecedent miscarriage. a cervical ett was found, and immunohistology was performed on paraffin sections, using c-kit, p , and ki antibodies, following a microwave antigen-unmasking. positive reactions were recorded either as a focal or diffuse immunostaining. an escavated, hemorrhagic, endocervical lesion was found, which focally infiltrated the myometrium. light microscopy showed poorly limited nodules of epithelial-like cells, arranged in cords and nests, with interposed hyaline material, extensive hemorrhages, and necrotic areas. atypical mononucleate and syncytiotrophoblastic cells occasionally occurred. immunohistology revealed a diffuse presence of c-kit-expressing tumor cells. the p nuclear staining was focally observed to be negative or weak, and ki was totally unlabeled. in conclusion, this slowly-growing ett is lacking in p , but the c-kit over-expression substantiates trophoblastic survival and invasiveness. carcinosarcomas of the corpus uteri r balan, c amalinei, c cotutiu histology department, university of medicine and pharmacy, iasi, romania the aim of our study was to analyze the clinical and morphological characteristics of carcinosarcomas of the corpus uteri. carcinosarcomas of the corpus uteri were studied in postmenopausal women. paraffin-embedded material was stained with hematoxylin and eosin, trichromic, reticulin and pas staining. antibodies against ema, cytokeratins, vimentin, desmin, and pcna were also used. the size of tumor, depth of myometrial invasion, presence of vascular invasion, necroses, cellular atypia and differentiation, and mitotic activity were analyzed. all tumors were characterized by large size, foci of hemorrhage and necrosis. morphological and immunohistochemical analysis proved biphasic structure of the tumors. epithelial component was represented by adenocarcinomas with high ( cases) and moderate ( case) degree of differentiation. all presented homologous pattern -leiomyosarcomas. no metastasis was encountered at the time of diagnosis. as ema was intensely positive, both in malignant epithelium and in the majority of stromal component, we conclude that carcinosarcomas of the corpus uteri represent combination tumors with both elements originating from a single common stem cell. this conclusion was emphasized by the presence of pas positive residues in both components. knowledge evaluation among albanian women on risk factors of cervix cancer k kule , n filipi institute of public health, unit of cancer, department of epidemiology, tirana, albania university hospital 'mother tereza', tirana, albania aim this study evaluates the rate of awareness of women on risk factors and the preventive ways for the cervix cancer. methods the data were obtained through the questionnaire in a sample of women aged - years randomly selected throughout albania (random cluster sample). the questionnaire included questions on: social-demography, sexual behavior, women health, and sources of the health information. results only % of interviewed women were informed on paptest. in % of cases it was the doctor notified the women of the cluster for this screening as an examination of cervix cancer prevention. the pap-test examination had been performed by only % of the women who had prior knowledge on pap-test. in about % of cases the examination was performed for diagnostic reasons and not for prophylactic control reasons. in proportion to total only . % had performed the test, which presents a very problematic situation. among the women who performed pap-test, % were aware of the need of periodical check-up every - year, but % of them never performed it. the reason for not doing periodical screening seemed to be the daily routine and fear of the unknown events. % of women who performed pap-test were from the cities. only % of women use contraceptive methods of the family planning. about % of women had undergone at least one abortion. conclusions the study supports the concept that information on health services as well as health education of women at risk plays an important role in early detection and prevention of cervix cancer. expression of checkpoint proteins p , hus- and rad- and its relation with apoptosis in ovarian epithelial tumours introduction eukaryotic cells show surveillance mechanisms (checkpoints) of genomic integrity. an impaired checkpoint has been linked to genomic instability, and, in higher eukaryots has been associated to risk of cancer. the genes to be studied are involved in the mitotic checkpoint and dna damage checkpoint (like p , the tumour supressor gene frecuently mutated in human cancers). these proteins are also involved in the checkpoint responding to incomplete dna replication (replication checkpoint) termed the rad/hus group of proteins. failure of this checkpoint progress can result in genomic instability, and, in higher eukaryotes may lead to tumorigenesis or certain degenerative disease states. material and methods we have obtained antisera against recombinant hhus and hrad . for this we will clone and overexpress in bacteria and immunize animals to obtain antisera. we will carry out extensive analysis of the expression levels of several proteins by western blot analysis. we looked for possibles associations among hus- and rad- immunohistochemical expression and prognosis in ovarian carcinomas prior to chemotherapy. we studied, in addition to the levels of expression of the mentioned proteins, the localization and modifications of these proteins in epithelial ovarian tumours (benign, borderline and carcinomas) in order to establish the probable relationship between these proteins and ovarian carcinogenesis. results increased levels of checkpoint hus- protein was related to malignant transformation across all types of ovarian carcinomas (p< , ). similar results were observed with the expression of rad- protein, however was not statistically significant (p> , ). in univariate survival analysis, the expression of hus- and rad- protein were not significantly correlated with shorter survival and shorter free period of illness (p> , ). there were positive correlation between the apoptotic index, p and bax and the expression of checkpoint protein hus- (p< , ), but none relation was detected with rad- expression (p> , ). conclusions -the expression of hus- is higher in ovarian carcinomas and low in benign and borderline tumours. -the expression of hus- shows a positive correlation with the apoptotic index and with the pro-apoptotic factors (p and bax). -there was not statistical significant differences in the expression of hus- and rad- among the different histological types of ovarian tumours. -there was a positive correlation between the expression of hus- protein with other prognostic factors such as the figo stages, and the histological grade. unilateral gonadoblastoma associated with , xy pure gonadal dysgenesis (swyer's syndrome): a case report with numerous microcalcifications. the patient underwent bilateral salpingoophorectomy and total hysterectomy. the authors underline the importance of the correct diagnosis and the need of bilateral salpingoophorectomy for preventing the possible progression of the gonadoblastoma into malignant germinal cell tumor. histological and electron microscopic identification and analysis of uncommon particles in tissue after use of orthopaedic implants introduction deposits of solid products occur widely in tissue either from endogenous sources due to pathological changes, or from exogenous sources. after use of orthopaedic implants, particles produced by wear are commonly recognizable and identifiable in tissue by the surgical pathologist. foreign body related tissue re actions may contribute to aseptic loosening of implants, which is regarded as one of the most significant complications in orthopaedic surgery. in the present study we report on very uncommon particles in periprosthetic tissue after aseptic loosening of metallic implants. our study was performed to identify particles in periprosthetic tissue and to clarify whether they may contribute to the loss of implants. materials and methods periprosthetic tissue including joint capsule, acetabular and femoral interface membranes of cases of aseptic loosened cementless total hip replacements was histologically investigated. four cases with present uncommon particles were selected for electron microscope investigation and dispersive x-ray analysis. results in four cases the histological investigation revealed uncommon green to yellow coloured foreign bodies. by the use of electron scanning microscopy and energy dispersive x-ray analysis, these particles were identified as deposits rich in chromium, phosphorus and oxygen. this detection indicates the presence of solid corrosion products derived from implant surfaces. conclusion particles produced by wear and/or corrosion are associated with an alteration of the environment and the development of periprosthetic osteolysis which may result into the loss of the implant. the surgical pathologist should be aware that corrosion products may occur. their identification is helpful to determine implant failures. paratesticular lipoleiomyosarcoma: a case report l kachko, r shaco-levy, i sinelnikov, j goldstein department of diagnostic pathology, soroka medical center, beer-sheva, israel introduction leiomyomatous differentiation in liposarcoma is a rare phenomenon and may occur as a well differentiated liposar-coma with an intrinsic malignant smooth muscle component, so called " lipoleiomyosarcoma" or in the context of "dedifferentiated" liposarcoma. material and methods we have studied a paratesticular lipoleiomyosarcoma in a man years old. gross examination revealed tumor nodules dispersed between identifiable testis and epididymis, the largest of which measured x x cm. the specimen cut surface revealed smooth yellow tissue with distinct areas of gray myxomatous change. microscopically the specimen consisted of a well differentiated lipoma-like, sclerosing liposarcoma with mature adipocytes and fibrous septa containing spindled and floret-like cells. the smooth muscle accounted for about % of the total tumor mass and consisted of fascicles and bundles of spindle cells with very little atypia or pleomorphism. mitotic activity was moderate at most and focal in distribution. the cells colored well with immunohistochemical stain against sma. results and conclusions an extraordinary rare combination-type tumor is presented. only two previous examples of paratesticular lipoleiomyosarcoma have been published. the nature of combination-type tumors and dedifferentiated liposarcoma is addressed. the existence of two lines of tissue differentiation in the same tumor suggests the possibility of two separate tumors arising together or two lines of differentiation appearing from one pluripotent precursor cell. the differential diagnosis includes angiomyolipoma, which should be hmb positive. expression of estrogen receptor (er) and progesterone receptors (pr) in renal angiomyolipoma n savelov, g chemeris, i sokolova cancer research center, moscow, russian federation introduction angoimyolipomas are the most common mesenchymal tumours of kidney. they are more common in female. possibly estrogen and progesterone influence on tumours growth. we investigated the expression of estrogen receptors (er) and progesterone receptors (pr) in renal angiomyolipomas. materials and methods renal angiomyolipomas from patients were tested. the expression of er and pr was studied immunohistochemically. the expression of hmb- , alpha-smoothmuscle actin and vimentin was also studied in all cases. results most angiomyolipomas were of classic morphology with one exception. in that case, classical angiomyolipoma was combined with cystic hamartomatous lesions and involvement of regional lymph nodes. the vast majority of cells in the cases with typical morphology expressed alpha-smooth-muscle actin. expression of hmb- was diffuse or focal. in the case with cystic hamartomatous lesions, an inverse correlation of expression of hmb- and alpha-smooth-muscle actin was observed in both renal and extrarenal components. of the tumours, two tumours were only er positive and three tumours were er and pr positive. in four cases, focal immunoreactivity for er was mainly observed in the spindle shaped cells. in two cases, the immunoreactivity for pr was diffuse, but less than percent of cells were positive. er and pr positivity was diffuse, strong and widespread only in the case with cystic hamartomatous lesions. conclusion to our knowledge, estrogen and progesterone are not critical players in all angiomyolipoma growth, but only in the specific cases. myofibroblastic tumors are sometimes difficult to be distinguished from smooth muscle tumors. recently, cd , a cell surface metalloprotease, was shown to be present in myofibroblasts within the stroma of infiltrating cancers. to clarify the specificity of cd expression in myofibroblasts, we performed immunohistochemical studies on myofibroblastic and smooth muscle tumors. methods and materials consisted of myofibroblastic and smooth muscle lesions, ranging from reactive to benign and malignant tumors. all myofibroblastic lesions arose in soft tissue and smooth muscle tumors in soft tissue and organs. using paraffin sections, immunohistochemical staining for cd (clone: c , serotec) was carried out by an automated stainer (benchmark, ventana). results significant cd -expression was demonstrated only in malignant or borderline lesions, including malignant fibrous histiocytoma ( of cases), low grade myofibroblastic sarcoma ( of ), inflammatory myofibroblastic tumor ( of ), and leiomyosarcoma ( of ). however, no positive reaction was seen in reactive lesions and benign tumors, such as scar ( case), nodular fasciitis ( ), su-perficial fibromatosis ( ), desmoid ( ), leiomyoma ( ), vascular leiomyoma ( ), angiomyolipoma ( ), and glomus tumor ( ) . furthermore, the intensity of staining was almost parallel to the microscopic anaplasia. conclusion the present study demonstrated that cd expression is not specific to myofibroblasts, but seems to be related to the biologic aggressiveness of myofibroblastic and smooth muscle tumors. therefore, cd expression may be a potential predictor of malignancy in these tumors. correlation of metallothionein (mt) and antigen ki- expressions with grade of malignancy (g) in some soft tissue sarcomas dysplasia may be found in the bones during the childhood and adolescence. they can cause pathologic fractures and deformities of involved bone. rarely, some of them (fibrous dysplasia), undergo malignant transformation. the aim of this study is to analyse all the cases of tumor-like lesions of bones in children and adolescents, during the period time - . the study was performed at the institute for pathologic anatomy, school of medicine belgrade. the data source was the bone and joint tumor registry. the study was a retrospective analysis of patients who had tumor-like lesion before the age of . results solitary bone cyst was the most common lesion ( patients). the median age was years for fibrous dysplasia and solitary bone cyst, years for aneurysmal bone cyst and eosinophilic granuloma, and years for non-ossifying fibroma. male to female ratio was : . for fibrous dysplasia, : . for aneurysmal bone cyst, . : for solitary bone cyst, . : for eosinophilic granuloma and : for non-ossifying fibroma. the most common sites were femur for fibrous dysplasia and aneurysmal bone cyst, humerus for solitary bone cyst, tibia for non-ossifying fibroma and bones of scull and vertebrae for eosinophilic granuloma. the most frequent symptoms and signs were pain, pathologic fractures and swellings. conclusion the results of our study mostly correspond to those of the current literature. extraspinal myxopapillary ependymoma. case report and literature review introduction ependymomas are glial tumors that on rare occasions occur in subcutaneous locations dorsal to the sacrum and coccyx. case report a -year-old woman presented with a soft tissues tumor in the intergluteal region. mri revealed a cm large mass, with solid and cystic areas, located below the coccyx, without bone alteration. surgical excision was performed. pathological features grossly, the tumor was encapsulated and showed solid, spongy and myxoid areas with a peripheral hemorrhagic focus. histologically it consisted of medium-sized cuboidalcolumnar cells, with round-oval nuclei, granular cromatin and eosinophilic cytoplasm. tumor cells showed myxopapillary and cystic-papillary growth pattern or were arranged on fibrovascular stalks, with a central hyalinized wall vessel, surrounded by a single layer of cuboidal cells. tumoral necrosis and hemorrhage were observed. the peritumoral stroma was highly hyalinized. the immunohistochemical stains showed vimentin(+), s- (+), gfap(+) and keratins(-). discussion and conclusion extraspinal ependymoma (ee) is a rare tumor usually localized subcutaneously in sacrococcygeal region of young adults; most are of myxopapillary type. ee may arise from normal remnants of the neural tube or from abnormal remnants resulting from embryologic malformations. ee has a greater propensity to metastasize than its intraspinal counterpart, because of easier accessibility to lymph channels. in a study of cases, elson found a metastases incidence of % and no clinical or histologic data was found to predict the biological behavior of the tumor. the differential diagnosis must be done with choroid plexus papilloma, myxoid chondrosarcoma, chordoma, meningioma, adenoid cystic carcinoma and paraganglioma. introduction fungal infections of bone represent about , - , % of all osteomyelitis cases. the disease most often affecting the feet -mycetoma pedis, is also known as madura foot. in our geographic regions mycetoma is extremely rare. it is endemic in tropical and subtropical countries. case report we present a case of mycetoma pedis -madura foot. the patient was a years old woman. the clinical signs were pain, indurations and local redness with a long history of years. the surgical material was routinely stained with hematoxylin-eosin (he). pathologically, a granulomatous inflammation of the bone was confirmed. all pathological characteristic pointed to fungal infection in the form of mycetona pedis. special stains (pas, grocott's hexamine-silver and giemsa) for fungi were performed: and the diagnosis of a mycetoma was confirmed. for the definitive microbiological analysis tissue inoculation on the sabouraud dextrose agar laboratory media was done. pseudoallesheria boydiia sexual staging of monosporium apiospermum was isolated. after microbiological verification of fungal infection the patient was treated surgically. seven months after first operation the patient developed similar clinical signs again. the diagnostic procedure was repeated and mycetoma was confirmed again. the surgical therapy was performed as a therapy of choice because pseudoallesheria boydii does not react to treatment with antimycotic drugs. spindle cell lipoma is a rare entity with an uncertain histogenesis; although the current classification includes this tumor in the lipomatous neoplasms, the immunohistochemical and electron microscopic data suggest a much closer link to the fibrous solitary tumor. we report the case of a years woman with a / / / cm nodule in the scapular area; the histopathologic examination revealed a tumor proliferation consisting mainly of giant cells, most of them multinucleated with floret-like appearance. the stroma consisted of an abundant collagen deposition with rope-like fascicles and prominent myxoid changes, most striking in the periphery of the tumor. the tumor proliferation was contiguous with nearby adipose tissue with no capsule in-between. immuno-histochemical tests revealed diffuse positivity for cd ; pcna was positive in % of the cells. smooth muscle actin, desmin and s -protein were negative in tumor cells. the patient is well with no recurrence of the tumor one year after the resection. despite the highly pleomorphic histopathologic appearance the tumor is benign with an uneventful clinical behaviuor. expression of p protein in gct of bone with lung metastases introduction the giant cell tumor of bone (gct) is a local osteolytic tumor with variable degrees of aggressiveness. in rare cases pulmonary metastases can be observed. the stromal cells are the neoplastic components of the gct, and are probably responsible for biological behavior of the tumor. in the last years cases of gct with lung metastases were diagnosed at the institute of pathology, school of medicine, belgrade. both tumors displayed characteristic histological appearance of gct: a high number of osteoclast-like multinucleated giant cells and two mononuclear cell types. the first one resembles a monocyte, the second are fibroblast-like stromal cell. mononuclear cells had benign cytological characteristics without polymorphism and mitosis. to elucidate the mechanism of metastasing, we searched for the molecular abnormalities of p . we examined the expression of p in stromal cells immunohistochemically. unexpectedly, both tumors were p negative and we could not show correlation between p expression and metastasing of gct to the lung. conclusion although p positivity in other tumors is closely associated with aggressive biological behavior we could not confirm this association for gct. trichoblastic fibroma or primary soft tissue adamantinoma? introduction benign extragnathic tumors that may mimic the histological features of odontogenic ameloblastoma (and ameloblastic fibroma) include trichoblastic fibroma and primary osseous and soft tissue adamantinoma. trichoblastic fibroma is a rare ectomesenchymal tumor of hair germ involving most often the dermis and subcutis of the head and neck. the mean age at presentation is , years.the youngest case reported was that of a shoulder tumor in a year old female. its occurrence in the soft tissue of the upper arm has not been documented. primary soft tissue adamantinomas are extremely rare with isolated cases reported in the region of the jaw and the leg ie. close to sites where odontogenic and primary osseous adamantinomas occur, respectively. no cases involving the upper arm have been reported. we report a case of a benign appearing adamantinoid tumor involving the deep soft tissue of the upper arm. a year old black male presented with a slow growing mass involving the deep soft tissue of the left upper arm without associated cutaneous or osseous abnormalities. results the adamantinoid features in this benign appearing biphasic tumor included nests and acini of palisading columnar epithelium exhibiting reversed nuclear polarity, areas reminiscent of stellate reticulum and an intimately associated spindle cell proliferation. conclusion our favored diagnosis was a trichoblastic fibroma but we discuss the complete differential diagnosis of all tumors with adamantinoid features with respect to clinical, morphological and immunohistochemical characteristics. intraosseous lipoma -a case report intraosseous lipoma is a rare benign tumor of mature adipocytes arising in the medullary canal, most often diagnosed incidentally. most of these tumors occur in the long bones, with propensity for the proximal femur, fibula, and tibia. ribs, calvarium, sacrum, metatarsus and calcaneus are other frequent sites. we report a case of a -yearold female with a histologically verified solitary intraosseous lipoma involving the distal part of the right fibula. radiographically the tumor was a lytic benign-appearing lesion with sharply demarcated borders surrounded by a zone of sclerosis. computed tomographic scan showed the lesion to have features of adipose tissue. the examination was made on surgically removed distal part of the right fibula. for histological verification of intraosseous lipoma, resected bone was decalcified, embedded in paraffin and stained with standard staining with hematoxilin-eosin. histopathologic examination revealed mature adipose tissue with widely scattered trabeculae of bone and central calcifications. this case emphasizes the characteristics of intraosseous lipoma, and highlights the need for clinicopathologic and roentgenographic correlations. fasl, c-erbb , cyclin d , p and tgfb expression in osteosarcomas: evaluation of relationship with clinicopathologic parameters introduction fasl, c-erbb , cyclin d , p and tgfb are molecules which were shown to be related to prognosis of tumors. in this study expression of these molecules were evaluated in osteosarcoma (os) cases. the correlation between the expressions and age, gender of the patients, location, grade, and histologic subtype of tumors were investigated. material and method fasl, c-erbb , cyclin d , p and tgfb expressions were detected immunohistochemically. results thirty-six os cases ( osteoblastic, fibroblastic, five chondroblastic) were included in the study. twenty-two were males and were females. os were located in the extremities ( ), jaw ( ), pelvis ( ), vertebra ( ). twenty-five of were high grade and were low grade tumors. fasl and p were detected in . % of the cases, tgfb in . %, c-erbb in . %, and cyclin d in . %. there were statistically significant correlations between fasl and tumor grade (p: . ), fasl and tgfb (p= . ), fasl and c-erbb (p= . ), p and tgfb (p= . ). no correlation was found among other parameters. conclusion expression of these molecules and detection of correlation between some molecules show that pathogenesis of os is a complex mechanism regulated by several molecular factors. better insight into tumorigenesis may help to provide new therapeutic approaches and idntification of patients with better prognosis. a rotter , s kovac , v pisot , r trebse institute of pathology, medical faculty, university of ljubljana, ljubljana, slovenia valdoltra orthopedic hospital, ankaran, slovenia introduction granulation tissue with macrophages is usually found around loose total hip prosthesis (thp), usually explained with deposition of wear debris from thp. however, we often found a lot of hemosiderin (an insoluble form of storage iron) in macrophages. the aim of this study was to evaluate the amount of hemosiderin in granulation tissue around thp removed after relatively short period of duration, and compare it with an interface tissue around thp of very long duration. we assessed the interface tissue around the loosened thp of the longest duration described ever (judet's thp was removed after years) and compared it with the granulation tissue around thp of short duration (less than six years). at histology h&e, giemsa, and weigert-van gieson staining were used. for the demonstration of hemosiderin perls' reaction and for macrophages cd were used. we compared the results of histologic evaluations performed according to modified mirra's classification: semi quantitative assessment of neutrophils, mononuclear histiocytes, chronic inflammatory cells, giant-cells, metal particles, polymethacrylate globules, necrobiosis, bone chips, necrosis and necrotic debris. but, we also included the assessment of the intensity of hemosiderin deposition. results comparison of granulation tissues of short duration thp to that of -year duration revealed a surprising difference in the amount of hemosiderin particles with intensive intracellular hemosiderin deposition in mononuclear macrophages and giant cells in the first group. in the -year-old thp there was predominantly hypocellular tissue with very little amount of mononuclear macrophages containing slight amount of intracellular hemosiderin deposition and no multinucleated giant cells at all. conclusions we don't know why hemosiderin deposition is more evident in early loosening of thp. hemosiderin deposition may give rise to accumulation of macrophages, perhaps increasing the process of osteolysis and granulation tissue formation. but more 'aggressive' forms of loosening may also cause recurrent bleeding. whether the higher level of hemosiderin is the cause or the result of the loosening of thp is to be determined. the types of tumor and peritumor stroma and biological behavior of fibrohistiocytic tumors introduction tumor-host interaction induces different types of tumor and peritumor stroma which may reveal some aspects of tumor biology. the aim of this study was to establish a correlation between different types of tumor and peritumor stroma of fibrohistiocytic tumors (fh tumors) and their biological behavior. the presence of colagenous-reticular (cr), myxoid (myx) and mixed (mx) tumor and peritumor stroma was determineted on selected paraffin sections stained by masson-trichrome, silver impregnation, alcian blue with and without hialuronidase pretretment and pas reaction of fh tumors: benign (bfh), dermatofibrosarcoma protuberans (dfsp) and malignant (mfh), all graded in three degrees of malignancy. the collected data were statistically evaluated by means of student t proportion test. results the difference in presence of myx and mx tumor and peritumor stroma in relation to the cr type was statistically significant between mfh and bfh (p< , ) or dfsp (p< , ). with an increasing malignancy grade of mfh percentage of tumors with cr tumor stroma was decreasing and percentage of tumors with myx and mx tumor stroma was increasing. however, mfh of g and g malignancy grade did not differ in distribution of peritumor stroma types, but , % of mfhg had myx and mx peritumor stroma. conclusion while myx and mx types of tumor and peritumor stroma are associated with agressive, cr type of tumor and peritumor stroma is associated with benign and less agressive fh tumors. dynamic angiogenic models of human soft tissue tumors transplanted into immunodeficient nude mice introduction animal models were used to study the vascular neogenesis of tumors. we undertook experiments using human sarcomas transplanted into the subcutaneous pad of immunodeficient nude mice. the aim of this study was analysis of: the microvasculature present within the tumor before the transplant; the early stages of the neovascularization; and the types of vascular connections established between the host and the tumor graft. material and methods implants of . - . cm in size of a ewing's sarcoma (es), an osteosarcoma (os) and a fibrosarcoma (fs) were analyzed. the study was successively followed for , , hours, one, two, three and four weeks. he, pas and immunohistochemistry for angiogenic factors were complemented with electron microscopy. after - hours, the implants over-expressed several angiogenic factors. at this stage, the tumors initiated an active angiogenic remodeling in the surrounding stroma where capillary congestion and microhemorragies occurred. endothelial sprouting of the host capillaries was seen. vascular co-option between the endothelial cells, newly formed endothelial cells and the tumor cells was observed. no clear basal lamina was seen. tumor-endothelial cell mosaics and vascular mimicry were detected only in the es and os. conclusions vascular expression and neogenesis varies considerably from the fast es to the fs while the os reproduces patterns that are common in all three. based upon present experience it seems evident that each tumor shows a different type of neovascularization. these models provide excellent examples of all the systems that are involved in the recapillarization of a sarcoma. this work has been supported by grants fis / and fis / from the ministry of health, madrid, spain. prognostic significance of intratumoral neoangiogenesis in childhood osteosarcoma and ewing sarcoma d mikulic , i ilic , m coric , l batelja , j stepan , s seiwerth institute of pathology medical faculty, zagreb, croatia childrens hospital, zagreb, croatia introduction intratumoral neoangiogenesis quantified by microvessel density (mvd) has been shown to be a strong prognostic indicator in a number of malignant tumors, primarily carcinomas. its association with prognosis in bone sarcomas has been subject to less extensive research. the aim of our study was to investigate clinical significance of neoangiogenesis in osteosarcoma and ewing sarcoma. patients and methods a retrospective immunohistochemical study was performed. patients with osteosarcoma and patients with ewing sarcoma were included. sections from diagnostic biopsies were immunostained using factor viii and cd (dako) antibody and microvessels were counted at x magnification on three microscopic fields showing highest mvd per patient. mvd was correlated with overall and event-free survival by kaplan-meier and log-rank analysis. the difference between the mean microvessel counts in patients with or without metastasis and alive or dead was assessed by mann-whitney test. results in patients with osteosarcoma significant statistical difference was found as regards the death risk and risk of development of metastasis between patients with high (> vessels/field) and low (< vessels/field) microvessel counts (log-rank test p= . and p= . , respectively). in patients with ewing sarcoma a trend was noted for the patients with lower (< . vessels/field) microvessel counts to have better outcomes than patients with higher vessel counts, however, the difference was not statistically significant. conclusion these findings strongly suggest that neoangiogenesis quantified by microvessel density is predictive of metastasis and poor prognosis in osteosarcoma. valorization of its role in patients with ewing sarcoma awaits further studies. epithelioid sarcoma -clinicopathological findings in cases m demiryont epithelioid sarcoma is a soft tissue sarcoma of unknown histogenesis with a predilection of young adults and hand/forearm location.the tumor is often multinodular showing central necrosis. epithelioid sarcoma has a high potential of local recurrence and metastasis. six cases were presented. five patients were male with a mean age of . tumor locations were finger, hand and forearm. cytokeratin and vimentin were positive in all cases. four cases showed positivity for cd . desmin and cd were negative. ki- (mib- )proliferation index was - % in cases. initial surgery performed in all of the patients has been local excision with negative margins.three patients received radiotherapy or chemotherapy after the primary excision.except for one patient who was lost to follow-up, local recurrence was detected in all the patients in a period of months to years.three patients died with distant metastasis. epithelioid sarcoma can be easily identified with its typical features, but it can be confused with non-tumor lesions in patients having a long clinical history and a small tumor. radical surgery and regional lymph node dissection may bring benefit; the incidence of the lymph node metastasis is high. radiotherapy and chemotherapy can be added to therapy in the recurrent or metastatic state of the disease. introduction intramuscular hemangiomas are relatively uncommon but significant lesions, and their unorthodox location and infiltrative pattern often raise the question of malignancy to clinician and pathologist. we present the histomorphological and immunohistochemical data of a hemangioma in a -year-old man who presented with an enlarging painful soft tissue mass of his right upper leg. methods the complete local excision of tumor arising in the quadriceps muscle was done. sections of formalin-fixed, paraffinembedded tissue material were stained with he, van gieson, pas, ptah, gomori's reticulin and trichrome, and immunohistochemically for detection of factor viii-related antigen. results grossly, the lesion ( x , cm) was poorly circumscribed, reddish brown and partially haemorrhagic. microscopically, it was composed both of small, capillary-sized and large, cavernous vessels lined by endothelial cells and surrounded by connective and mature adipose tissue. the adipocytic component wasn't prominent. many cavernous spaces were separated by dense fibrous tissue and some of them were thrombosed. foci of hemosiderin deposits and moderate lymphocytic infiltration were also noted. the small vessels in some areas hadn't discernible lumina so that areas appeared solid. mitotic figures and intraluminal papillary tufting were not seen, but infiltration of skeletal muscle bundles and rarely perineural spaces were present. the muscle fibres showed atrophy, degenerative changes and signs of regeneration. the cells lining both cavernous and capillary-sized vessels showed expression of factor viii-related antigen. conclusions presented case of tumor arising in the quadriceps muscle show histomorphological and immunohistochemical features of mixed type hemangioma with pronounced infiltrative pattern. alveolar soft part sarcoma: a review of cases at national cancer institute from colombia ol mejia mejia instituto nacional de cancerología, colombia, bucaramanga, columbia aims to review the histology and immunohistochemistry of alveolar soft part sarcoma with comparison of clinical features. material and methods histology slides, paraffin blocks and files of patients were reviewed. results and discussion there were patients retrospectively analysed, female and male, between year and years old. the initial symptom was mass. the most frequent location was thigh ( %), followed by the leg, orbit, chest wall, trunk, arm and forearm. six patients had haematogenous metastases at the time of diagnosis (lung , brain , lung and bone ). histologically, all tumours were composed of nests of medium sized cells arranged in pseudo-alveolar or lobular patterns, separated by fibrovascular stroma. pas & pas diastase were positive in all cases, with rhomboid or rod-shaped crystals. immunohistochemical staining for myo d showed cytoplasmic positive in cases ( %), desmin in and smooth muscle actin in cases. conclusion alveolar soft part sarcoma is an uncommon neoplasm. the microscopic picture is a constant and typical feature of the lesion, and immunohistochemistry is a useful complementary method for diagnosis. a jiménez sánchez, em huertas valero, ja ramos Ńíguez, r baeza guixot, p sánchez cańizares hospital francesc de borja de gandia, gandia, spain introduction malignant epithelioid schwannoma is a rare variant of malignant nerve sheath tumor (mpnst) that often causes differential diagnostic problems with other neoplasm. material and methods a -year-old woman presented with a palpable tumor located in the supraclavicular region. the lesion was partially resected. grossly, the tumor was firm, gray to whitish and slighty nodular. standard histological procedure and inmunohistochemical study was performed. results microscopic examination revealed a solid proliferation of moderately large, rounded epithelioid cells, with pleomorphic nuclei, prominent nucleoli and atypical mitoses. in peripheral areas the tumor showed smaller cells with nuclei arranged in palisades and central necrosis. immunohistochemical studies showed vimentine, s- protein, and cytokeratine positivity and hmb- negativity. the histopathology and the immunohistochemical results were consistent with mpnst, but a ssx /syt gene fusion was detected by molecular analysis, a characteristic chromosomal change of synovial sarcoma (ss). conclusions spindle cell tumors with epithelioid areas can be difficult to diferentiate by histologic pattern alone. cytogenetic analysis and molecular studies may reveal the diagnosis by demonstrating a characteristic chromosomal abnormality or molecular rearrangement. ssx/syt gene fusion results from the t(x; )(p . ;q . ). the translocation fuses the syt gene from the chromosome long arm to either of highly homologous genes on the chromosome x short arm, ssx or ssx . the translocation t(x; ) is currently regarded as a specific molecular marker of ss. our case shows, that we might consider that ss may have a larger histologic spectrum than previously thought. a case of idiopathic retroperitoneal fibrosis (ormond's disease) and renal supracapsular liposarcoma t georgiev , e nakov , r gajdarski department of pathology, faculty of medicine, sofia, bulgaria department of pathology, military medical academy, sofia, bulgaria background idiopathic retroperitoneal fibrosis is an uncommon inflammatory disease characterized by proliferation and fibrosis of retroperitoneal tissue complicated by obstruction and encasement of retroperitoneal structures. case report we describe a -year-old female patient who underwent a gynecologic operation for left ovarian cyst in october . a periaortic mass alongside with peritoneal nodules were biopsied which revealed endometriosis, necrotic xantomatous nodules and ormond's disease. the last diagnosis was rejected and tumor misinterpreted as malignant fibrous histiocytoma. the course of the disease progressed and on computed tomography a left renal supracapsular tumor measuring / / cm together with a diffuse retroperitoneal fibrosis was demonstrated. in november , a tumor localized in the adipose capsule of the left kidney was removed together with the kidney weighing , kg. the kidney was markedly atrophic. a parallel excision of ten retroperitoneal tissue masses with a size up to / / cm was performed. our final histological diagnosis was highly differentiated liposarcoma. four months later the abdominal ct and the tumor markers were normal. conclusion the symptoms in our case were not specific for renoureteral obstruction and included abdominal pain and mass, weight loss and ascites during the year prior to second operation and finally urinary symptoms. we interpret our case as a slowly growing perirenal lipomatous tumor gradually compressing the kidney and causing slowly progressing retroperitoneal fibrosis. a rare case of thoracic angiomatosis in an adult and review of the literature n lapidus, d andrejev, a arro north-estonian regional hospital, tallinn, estonia introduction angiomatosis is a rare condition in which large segments of the body are involved by proliferating vessels. the majority of angiomatoses present during childhood or infancy. a diffuse angiomatosis affecting thoracic organs is a rare, frequently fatal disorder. the origin of the lesion is unknown. the lesion consists of thin-walled sometimes bloodless capillary blood vessels. the definite diagnosis is usually made by open lung biopsy or autopsy. in our paper we are presenting the rare case of angiomatosis of pleura and lung in -years old woman and the review of the literature. the patient was presented to the hospital with complaints to the pain in the right chest, dyspnea, weakness. the lesion manifested on chest radiographs and ct scans with unilateral pleural fluid and nodular pleural thickening. thoracocenthesis was performed and light brown fluid was drained. cytologically the effusion contained erythrocytes and lymphocytes. further ml more fluid was obtained. the openlung biopsy revealed the extensive diffuse angiomatosis affecting visceral and parietal pleura and subpleural lung tissue. the lesion consisted of bloodless, thin walled, endothelium channels. factor viii-related antigen and cd were the most reliable immunocytochemical markers in highlighting the endothelia. the palliative methods of treatment were not effective, and the patient was treated by total pleurectomy. conclusion diagnosis is based exclusively on histologic finding as the only possibility of diagnosis. open pleurectomy is the most succesful treatment in preventing reaccumulation of the effusion. background chronic inflammation with remodelling of the airway wall structures is an essential characteristic in asthma patients. lysosomal proteinases are involved in extracellular proteolysis, which leads to matrix changes of subepithelial connective tissue in the airway wall. the aim of the study was to localise the expression of different cysteine proteinases and their endogenous inhibitors in lung tissue of asthma patients. material and methods we included ten specimens of bronchial biopsies of asthma patients and lung tissue specimens of fatal asthma case. tissue specimens were fixed in formalin and embedded in paraffin. h&e slides were used for morphological examination. immunohistochemistry was performed on an automated stainer (benchmark, ventana, tuscon, az, usa). we used monoclonal antibodies to visualize cysteine proteinases (cathepsin b, h, l and s) and their inhibitors (stefin a and b, cystatin c) (krka, ljubljana, slovenia). results cathepsin b showed the most intense and wide distributed positive reaction. it was localized in the respiratory epithelium, macrophages, lymphocytes, mucous glands and smooth muscle cells. cathepsin h showed intense reaction localized in the respiratory epithelium, macrophages, lymphocytes, mucous glands, but not in the smooth muscle cells. cathepsins l and s showed positive reaction only in macrophages. the positive reaction of all three inhibitors was weaker compared to cysteine proteinases; it was observed in the respiratory epithelium, macrophages and mucous glands. conclusion these results suggest involvement of cysteine proteinases and their endogenous inhibitors in asthma, showing distinct immunoreactivity and different distributions in the lung tissue of asthma patients. since the inhibitor expression is less intense we can speculate that remodelling of the extracellular matrix may be also a consequence of imbalance between cysteine proteinases and their inhibitors. the correlation between aberrant connexin mrna expression induced by promoter methylation and nodal micrometastasis in non-small cell lung cancer jt introduction reduced connexin (cx) gene expression has been shown in most of lung tumors and lung cancer cell lines. although aberrant cx gene expression was linked with lung tumorigenesis, our understanding to the mechanism was still limited. we hypothesized that the evidence of aberrant cx gene expression was gradually intensified from adjacent normal lung tissues surrounding tumors towards to tumor tissues. materials and methods in this study, lung tumors and adjacent normal tissues were collected to examine cx mrna expression by reverse transcription-polymerase chain reaction (rt-pcr). results our data showed that cx mrna expression in adjacent normal lung tissue was significantly correlated with nodal involvement (p = . ), but the similar trend was not observed in tumor tissues. to verify whether lack of cx mrna expression was resulted from promoter methylation, pcr-based methylation assay was performed for cx promoter methylation analysis. high frequency of promoter methylation was observed in cx mrna negative patients ( of , . %) compared with cx mrna positive patients ( of , . %, p < . ). to elucidate whether aberrant cx gene expression is originated from adjacent normal lung tissues, lung tumors and each of five adjacent normal tissues with various distances from tumor tissues were collected to examine cx mrna and protein expression by rt-pcr and western blot, respectively. as the results shown, cx mrna and protein expressions were gradually decreased from adjacent normal lung tissues to tumor tissues with a positive correlation to the distance from tumor tissues. gel shift assay data also revealed that shifted band binding with ap was only observed in adjacent normal tissues which were far from the tumor tissues. conclusion these results indicate that promoter methylation may interfere with ap binding to promoter to cause aberrant cx gene expression. thus, cx mrna in adjacent normal tissue surrounding lung tumor simply detected by rt-pcr may be act as a molecular marker of nodal micrometastasis in nsclc. introduction an adenoma-carcinoma sequence is recognised in peripheral lung. atypical adenomatous hyperplasia (aah) and bronchioloalveolar carcinoma (bac) are the pre-invasive precursors of invasive adenocarcinoma, which frequently has a 'residual' peripheral bac component. the biology of this neoplastic progression is poorly understood. the aim of this study was to examine the expression of the tumour suppressor gene fhit, cd v , e-cadherin, beta-catenin, mmp- , timp- , and the cell cycle marker mcm at different stages in the proposed sequence. materials and methods sections from formalin-fixed, waxembedded tissue blocks of aah, bac and invasive adenocarcinomas, stained immunohistochemically for the above molecules, were scored semiquantitatively. in invasive tumours, any bac component was scored separately. for mcm a labelling index was determined as the ratio of immunopositive to total cells counted. results fhit protein is abundant until the disease becomes stromally invasive (p< . ). cd v levels are high in aah and bac, but fall in invasive disease (p= . ). e-cadherin and beta-catenin levels rise between aah and bac (p< . ), and remain well expressed thereafter. mmp- and timp- expression is relatively low in aah, rises in bac but falls when tumour becomes stromally invasive (p < . ). the bac component of invasive tumours expresses some molecules in a manner similar to pure bac but mirrors expression in invasive tumour for others. mcm counts increase from . %(low grade aah) to . % in invasive adenocarcinoma (p= . or less) conclusion in peripheral adenocarcinogenesis, loss of fhit is a relatively late event, while cd v loss occurs earlier. fhit loss has potential as a surrogate marker of invasion. e-cadherin and beta-catenin expression probably reflects changes in lesion architecture. mmp- /timp- may be implicated in bac but down-regulated as stromal invasion develops. increasing cell cycle entry is consistent with neoplastic progression. immunohistochemical study of squamous and adenosquamous cancer of lungs g methods using formalin-fixed and paraffin-embedded tissues, we examined by immunohistochemistry tenascine, collagen iv, cd , mmp , mmp , timp , timp , cd , bcl , p , pcna, ki , cyclin d in cases of lung carcinoma - squamous and adenosquamous with (first group) and without (second group) metastases. results the positive staining with tenascine was observed in all cases of squamous and adenosquamous carcinoma, but the most strong expression was found in extracellular matrix and tumor cells of carcinomas of first group. the overexpression of mmp and mmp was found in cases with metastases in tumor cells and stromal cells. the reaction was localised on periferical zone of tumor complexes. at the same time reaction with timp was low in tumor of second group and very low -in first group, reaction with timp was moderate in metastatic tumor and low -in second group. overexpression pcna and ki changed from % to % in group and from % to % in group. the increase expression of cyclin d was only in adenosquamous lung carcinoma. the overexpression of p was found only in metastatic tumors. conclusion there are some difference between squamous and adenosquamous lung carcinomas in expression of proliferation markers, and cyclin d , but no difference in expression of metalloproteinases and their inhibitors. we found more prominent differences in groups of metastatic and nonmetastatic tumors. lack of her- /neu amplification or overexpression in malignant pleural mesothelioma (mpm) introduction the her- /neu receptor, a member of the epidermal growth factor receptor (egfr) family, represents a novel therapeutic target for the newly marketed recombinant anti-her monoclonal antibody herceptin®. mpm mortality continues to rise steeply ( % to % per year) with no known curative modality. approximately % of mpms have high levels of expression of egfr. two recent studies have reported expression of her- /neu in mpm but there was no analysis of overexpression or amplification. in this study, the amplification/overexpression of her- /neu gene has been evaluated in a series of consecutive mpm biopsy specimens. materials and methods the tumour specimens had been formalin-fixed and paraffin-embedded. immunohistochemistry (ihc) for her- /neu overexpression was performed using the dako herceptest kit. only membrane staining intensity and pattern were evaluated using a to + scale with + being the lower limit for a positive test. amplification of the her- /neu gene was tested with the fluorescent in-situ hybridisation (fish) method (ventana inform her- /neu probe) in out of the cases. cases were considered as amplified by fish when the mean number of fluorescent signals per nucleus was greater than four. results of the mpms evaluated for the overexpression of the her- /neu receptor, all scored on the ihc test and all cases additionally assayed by fish were negative. conclusions although the sample size was limited, these findings suggest that mpm do not overexpress or amplify her- /neu, which therefore should not be considered a prognostic and predictive marker in mpm. (this work was funded by the alessandria branch of the italian league against cancer). morphological changes of bronchial glands at the localisation of preceding biopsy introduction at the location of preceding biopsy, in sero-mucous bronchial glands, there are certain changes of regenerative type. hyper-plastic and meta-plastic squamous epithelia partially or wholly fills the acinus and duct of secretory glands. aims: regenerative atypical characteristics found in repeated materials can be misinterpreted as epidermoid or muco-epidermoid carcinoma. material and methods the research used materials made by re-biopsy of bronchia, with regeneratory changes in bronchial glands. presence of morphological parameters was examined semiquantitatively, and then processed with methods of descriptive statistics. results in . % lobular architectonics of the lesion was preserved; fibrin exudates were present in . % cases; granulocytes in stroma were present in . % cases; granulation tissue in . % cases; planocellular metaplasia of duct and acinus was present in every single case. in . % cases mucin-secreting cells were found in squamous epithelia. the squamous cells were diskeratotic in % cases; with polymorph nuclei in . % cases; hyper-chromatic in %; multi-nuclear in . %; with visible nucleolus in . %, and with mitotic activity in . % cases. in . % cases the squamous cells were located in the fibrous tissue. mucus in interstitium was present in . % cases; cystoid formations were present in . % cases. the changes are built of solid material, undifferentiated and/or squamous cells located in the granular tissue or in the fibrin. infiltrates of granulocytes are found in fibrin, stroma, and squamous epithelia. epithelial cells in regeneration show atypical cell characteristics in small percentage and therefore are hard to differentiate from carcinoma. immunohistochemical expression of her- /neu in patients with lung carcinoma g petrusevska , b ilievska, s banev, s smickova institute of pathology, skopje, republic of macedonia the her- protein or p her is a membrane receptor with tyrosine kinase activity encoded by he /neu gene. overexpression of her- /neu has been observed in many human cancer, including lung cancer. there are different reports about the expression of this protein in different lung cancer. the aim of the study is to determine the expression of her- protein in the spectrum of lung cancer (adenocarcinoma, squamous cell carcinoma and small cell carcinoma). the study population consisted of two groups: patients that have undergone to surgical treatment and patients that have undergone to fiber-optic bronchoscopy and biopsy for primary diagnosis.tissue specimens were neutral formaline fixed and paraffin embedded. standard histochemical and immunohistochemical staining were used for diagnosis. expression of her- /neu protein was determined by immunohistochemical staining with hercep testtm (dako). the results were graded - as negative and - as positive. overall incidence of her- /neu overexpression was , % ( of ). higher incidence was found in patients with adenocarcinoma , % ( of ); squamous cell carcinoma , % ( of ) and small cell carcinoma % ( of ). no statistical significant difference was seen with age and gender. her- /neu overexpression was more relevant for patients with advanced tumor: all patients with squamous cell carcinoma were in stage b and , and % with adenocarcinoma were in stage a and b. these results are satisfactory and encourage us to continue this work in the follow-up study to evaluate her- /neu role as predictive and prognostic factor for patients with lung cancer. we applied immunohistochemistry on six neuroendocrine lung carcinomas using moabs specific for extracellular matrix proteins and integrins; moreover transwell test migration assays evaluated the rate of transendothelial migration of ae- neuroendocrine carcinoma cell line throught a monolayer of eahy endothelial cell line expressing laminin-α -chain to establish wheather this protein may favour in vivo vascular invasion and metastasis. results %, %, %, %, % and % of vessels were respectivelly distributed within the parenchyma of these tumors. studies on contignous sections demonstrated that parenchymal vessels were positive for all ecmps, but laminin-α -chain, which was respectively expressed in %, %, %, %, % and % of parenchymal and in %, %, %, %, % and % of stromal vessels of these tumors. in all cases about % of neoplastic cells were α positive. preliminary results of transwell test migration assay indicate that the pretreatment of the ae- cell suspension with anti laminin-α -chain and anti α -integrin moabs reduced their migration through the eahy monolayer. conclusions as known α -integrin is a receptor of laminin-α chain, therefore the up-regulation of this protein in a large number of vessels during tumor angiogenesis may favour metastasis increasing neoplastic cell adhesiveness to newly formed vessels. brain death as a cause of primary lung graft disfunction in an isolated rabbit lung model ma introduction early lung dysfunction observed after lung transplantation has been attributed to an increase of vascular permability. factors involved in this mechanism are unknown. our hypothesis was that brain death (bd) is a preconditioning factor that induces primary lung graft dysfunction. methods twenty-four rabbits were randomized to control (crl) or induced bd (increasing intracraneal pressure above systolic pressure for minutes) groups and were ventilated in volume controlled mode (tidal volume ml/kg, positive end expiratory pressure (peep) cmh o and respiratory rate (rr) to obtain normocapnia) for minutes. isolated lungs were perfused with ml/min (constant flow) and ventilated in pressure controlled mode (peack pressure cmh o, peep cmh o and rr ) for minutes. pulmonary edema and lung injury were assessed by weight gain, change in ultrafiltration coefficient before and after ventilation; and extent of hemorrhage (scored by histology: intensity of alveolar hemorrhage, percentage of alveoli with hemorrhage and number of vessels with perivascular hemorrhage) mean values ( samples per lung) of the indices of hemorrhage showed above were scored ( to ) and added to obtain a score of overall lung hemorrhage (range to ) for each lunch. data are expressed as mean and % confidence interval and were compared with paired t test. conclusions under these experimental conditions bd contributes to pulmonary edema and lung hemorrhage. expression of cyclooxygenase- in nonsmall cell lung carcinomas n akyürek introduction cyclooxygenase (cox) is an inducible enzyme that catalyses the conversion of arachidonic acid to prostaglandins and thromboxanes. cox- is induced by cytokines and growth factors and has been shown to be important in carcinogenesis. the aim of this study was to investigate the expression of cox- and clinicopathologic factors in nonsmall cell lung carcinomas (nsclc) with regard to survival times. materials and methods seventy-seven nsclc specimens were evaluated for cox- expression by immunohistochemical method. staining patterns were assessed semiquantitatively and correlated with tumor histologic type, tnm stage and prognosis. chi-square and kaplan-meier survival analysis was performed. results cox- was not expressed in the normal bronchial epithelium. cox- expression was detected in ( . %) nsclc. expression of cox- was significantly higher in adenocarcinomas than in other histologic subtypes (p= . ). there was no significant relationship found between cox- expression and age, gender, tnm stage, and prognosis. conclusion this study suggests that an increase in cox- expression may be associated with the development of adenocarcinomas. but, prognostic significance of cox- expression is controversial. prognostic significance of cyclin-dependent kinase inhibitor p and bcl- protein in nonsmall cell lung cancer introduction the expression of p , which is known a cyclindependent kinase inhibitor, has considerable value for the prognosis of cancer patients. bcl- gen product (bcl- protein) is implicated in oncogenesis by its ability to prolong cell death through the inhibition of apoptosis. we studied the expresssion of p and bcl- protein to investigate their association between clinicopathologic factors and prognosis in nonsmall cell lung cancer (nsclc) materials and methods patients with nsclc were included in our study.there were patients( men, women), patients had adenocarcinoma (ac) and had squamous cell carcinoma (scc).tumors were examined immunohistochemically with p and bcl- protein expression, using formalin-fixed, parafinembedded tissue. for the evaluation of p expression, the number of nuclear staining was counted and showed as a percentage.bcl- protein was primarily identified in the cytoplasm of tumor cells. statistically, correlation between immunoreactivity and the clinicopathologic factors were evaluated. results p immunoreactivity was observed in ( %) of cases. there were ( %) scc, ( %) ac. statistically, these findings were found significant (p= , ). percentage of p positive nuclei, the average being %. positive bcl- immunostaining was found in ( , %) of cases. cases ( , %) of scc and ( %) of the ac were positive. these findings were not found significant (p= , ) conclusions there is no correlation between p and bcl- expression and clinical parameters, clinical stage, pathologic grade and prognosis. our study suggest that p immunreactivity in nsclc may provide prognostic information. pulmonary hamartoma -report of four cases introduction neuroblastoma is a malignant tumor of early childhood and is very rare in adults, thus we report this case. case report we describe a case of a -year-old man, never before notably ill. basic laboratory values were not significantly anomalous except of mild anaemia and high erythrocyte sedimentation rate. an x-ray scan showed a spherical opacity cm in diameter in the top right pulmonary field paramediastinally. ct displayed a low-density tumor x , x , cm in the apex of the right hemithorax. the tumor was well circumscribed and seemed to be in a subpleural localisation. it was subsequently punctioned with chiba and core needle under ct control. cytological and histological material did not contain any malignant cells. on mr scan there was a well encapsulated extrapulmonary tumor without destruction of ribs, probably of benign origin. tumor extirpation was indicated. the lesion was growing out of spinal chord. it was completely removed. grossly, the tumor looked like an old hematoma. histologically, it had the typical appearance of neuroblastoma -malignant tumor which is found in more than % of cases in patients under years of age. a scintigrafical examination and trephine biopsy showed massive bone marrow infiltration by neuroblastoma. conclusion a -year-old man was confirmed to have a typical early childhood tumor -neuroblastoma in a subpleural localisation. despite the poor prognosis of this tumor in adults and a wide bone marrow infiltration, the patient is well and without signs of disease after surgical resection and two cycles of chemotherapy over months after the initial diagnosis. measurements of dna amount and nuclear size by image cytometry: are these two features sufficient for diagnosis of early lung cancer? background lung cancer represents % of all cancers, but is responsible for nearly % of cancer related deaths due to the fact that it is most often detected in a very late stage. it has been proposed that selected nuclear features could be used to assist lung cancer detection in an early, operable stage. it was shown that both dna amount (dna ploidy) and nuclear size are key features for positive diagnosis in oral, laryngeal, bronchial, and gastric epithelial tumors. we used image cytometry to assess the potential of this approach using nuclei of epithelial lung cells from sputum samples. experimental design sputum samples were obtained by induction method, using hyperosmolar salinic solution, from lung cancer patients and high risk individuals. the cells were fixed and after breaking mucosa with mechanical and chemical treatment, they were cyto-centrifuged onto the microscopy slides. cell nuclei were stained by a dna specific and stoichiometric (feulgen-thionin) stain and dna amount (ploidy) and nuclear size of (on average) cell nuclei from each sample were measured by a high resolution image cytometer. the results showed that there were no statistical differences between the dna ploidy values between control and cancer cases, as very few cancerous cells were found in the sputa of lung cancer patients. interestingly, there was a measurable increase in the mean nuclear area of diploid cells from cancer patients in comparison to control cases. conclusions despite the slight difference in the size distribution the nuclear size feature alone does not provide effective discrimination between the negative and positive populations. pulmonary blastoma: report of cases d yilmazbayhan, mg gulluoglu istanbul university, istanbul faculty of medicine, department of pathology, istanbul, turkey introduction pulmonary blastomas (pb) are rare lung tumors having unique histomorphological features. although they were once regarded in the same group of lung neoplasms with well differentiated fetal adenocarcinomas, recently the two tumors were seperated from each other. we aim to discuss the morphological features and the changes of morphology on recurrences of pulmonary blastomas. we present ten cases of pb, six of which were biphasic, two were pleuropulmonary, and two were cystic. biphasic pb patients were five males and one female, with an age range of - . two female patients with pleuropulmonary blastoma were and years, and cystic pb patients were and years old female and male children, respectively. results one of our most striking histomorphological findings was that four of the biphasic pbs accommodate mature epithelium, not fetal epithelium. one of the other two cases presented with a fetal adenocarcinoma and the tumor recurred as a biphasic pb. one of the cystic pb, which arised in a background of congenital bullous emphysema, recurred with pleomorphic cells forming solid groups. the other cystic pb was diagnosed as congenital cystic adenomatoid malformation. conclusion because of the changing morphological features and composition of epithelial component, classification of the pulmonary blastomas should be reviewed. (romano et al., faseb j. : , ). aim of our study was to investigate in vivo expression of -lo in human mesothelioma. materials and methods immunohistochemical analyses were conducted in five micron sections from human pleural mesothelioma ( epithelial, biphasic and one fibrous type). -lo expression was evaluated using a -lo polyclonal antibody. results immunohistochemical staining was observed in all cases. the staining pattern was cytoplasmic in cases ( epithelial, biphasic and fibrous type), both nuclear and membranous in one case of the epithelial type, both nuclear and cytoplasmic in cases ( epithelial and biphasic type), nuclear, cytoplasmic and membranous in two cases of the epithelial type. conclusion these results are consistent with our in vitro data showing -lo expression in mm cells and strongly suggest that -lo may play a relevant role in the pathobiology of malignant pleural mesothelioma. the present study is scheduled to analyze the intratumoral expression of vascular endothelial growth factor (vegf) in human lung cancer and to determine the relation with microvessel density (mvd), e-cadherin expression and clinicopathological parameters. a -years old male presented with chest discomfort, dyspnea, weakness. heart function tests were normal. ct examination revealed a well demarcated mass in the anterior-superior mediastinum as well as pleural and pericardial effusions. there was no clinical/radiographic evidence of tumor elsewhere. a surgical excision of the mass was performed. grossly, the mass was round, well demarcated, measured x . x cm. the cut surface showed solid whitish or reddish with yellowish foci areas and cystic areas filled with mucinous fluid. histologically, the tumor consisted of sheets and nests of atypical squamoid cells intermingled with gland-like lumens. areas of clear cells were also present. in the tumor stroma, abundant amounts of mucin, foci of necrosis, lymphatic invasion, intense inflammation and cholesterol granulomas were observed. in some areas, the tumor cells were seen in contact to the lining of the cystic cavities. the latter were lined by a single layer of cuboidal or flattened or stratified epithelium with morphological features of squamous cells. at the periphery of the tumor, rare lymphoid follicles, residual thymic elements or degenerative hassall's corpuscles were seen. these histologic features were more consistent with a mucoepidermoid carcinoma arising in association with a thymic cyst. the patient died two months after chemotherapy administration. mucoepidermoid carcinoma of thymus is a rare entity and, to our knowledge, very few cases have been described in the international literature. however, in case of absence of metastatic disease or other common primary tumors of thymus, the diagnosis of a mucoepidermoid carcinoma should be taken into consideration. tissue array for immunohistochemical profiling of intrathoracic localized fibrous tumors ultrastructure of bronchial mucosa in chronic obstructive bronchitis n zoirova, s ariphkhanova uzbek institute of medical rehabilitation and physical therapy, tashkent, uzbekistan the purpose of this investigation was to determine ultrastructural peculiarity of bronchial mucosa in the patients with chronic obstructive bronchitis (cob). the study was performed in bronchial biopsy samples obtained from patients with cob. material was fixed in , % glutaraldehyde, postfixed with % osmium tetroxide and embedded in epon. ultrathin sections were stained with uranyl acetate and lead citrate. morphological three types of cob have been reported, including chronic catarrhal, catarrhal sclerotic and sclerotic forms. catarrhal cob was characterized with significant increasing of goblet cell count as compared to the bronchial mucosa in controls. hyperplasia of endoplasmic reticulum and golgi complex was observed. in the goblet cells, numerous secretory droplets were crowded together where they have been deposited from the surrounding cytoplasm. in ciliated cells, few cilia were seen in longitudinal section extending from the apical pole of epithelial cells, fragmentation of the endoplasmic reticulum and appearance of autophagosome were detected. in other types of cob, number of cell rows was decreased with different secretory activity of goblet cells. interepithelial migration of lymphocytes with the damage of the basement membrane was described. our findings demonstrated more aggressive changes of bronchial mucosa in sclerotic cob. chest trauma-induced rupture of benign mediastinal teratoma followed by a possible implantation of the tumor into the parietal pleura: a case report introduction mediastinal teratomas rarely rupture. an unusual case of chest trauma-induced rupture of benign mediastinal teratoma followed by a possible implantation of the tumor into the parietal pleura is reported. case presentation in a -year old woman, a pre-employment plain chest radiograph and ct of the chest revealed a large mediastinal tumor. two smaller tumors were located on the left parietal pleura. on operation completely obliterated left pleural space and three well-encapsulated tumors were found. microscope examination revealed three well-differentiated teratomas with no evidence of malignancy. three years before the detection of the tumor the patient had a blunt chest trauma, with a left-sided chest pain and shortness of breath, which gradually disappeared. at the time the plain chest radiograph was analyzed as normal. retrospectively an unusual mediastinal line, adjacent to the aortic arch, was disclosed. this line could be due to a small mass in the mediastinum. the left diaphragm was elevated, and a small leftsided pleural effusion could have been present. we suspect that teratomas located on the parietal pleura were caused by implantation of the tumor cells after the rupture of the mediastinal teratoma into the pleural space during blunt chest trauma. conclusion the chest trauma seen in presented case, could be at least a trigger, if not the only cause of the mediastinal teratoma rupture. the rupture was probably followed by both, obliteration of pleural cavity and possible implantation of benign tumor into the parietal pleura. the introduction malignant mesothelioma is an aggressive tumor with adverse prognosis (median survival - months) both in treated and untreated patients. in fact, only few patients survive more than two years. the identification of prognostic factors is critical to evaluate life-expectancy and crucial to approach novel therapeutical strategies. the study was performed to evaluate the use of mib- and p kip antigens as prognostic indicators of survival in malignant mesotheliomas. materials and methods a series of surgical biopsies of patients with known follow-up were immunohistochemically examined. the results were compared with survival data and correlated with clinical and histological parameters. for immuno-histochemistry, sections were stained for mib- and p kip antigens using abc method. number of positively stained nuclei was evaluated in consecutive high magnification fields ( neoplastic cells were considered the minimum number to include the case in the study). results mib- , which is largely expressed in sarcomatoid mm (p= . ), is more represented in patients with shorter (< months) then in subjects with medium ( <months< , p< . ) and longer (> months, p< . ) survival. on the other hand, p is more expressed ( ± . ) in patients with longer (p< . ) then in subjects with shorter survival. pearson's analysis showed no significant correlation between mib- expression and p , but this was predictive of survival in the entire population (r= . , p< . ). conclusion the findings suggests that p and mib- expression, although reliable attribute of mm, represent independent markers of prognosis in malignant mesothelioma. familial clustering of malignant mesothelioma without direct contact to asbestos. a genetic study introduction very few papers dealt with clustering of familial malignant mesothelioma (mm). most of these, who developed mesotheliomas, presented work or domestic history of exposure to asbestos, but only in very few of them asbestos did not demonstrated any association. the aim of this study was to contribute to the hypothesis of a genetic predisposition in the pathogenesis of the mesothelioma. methods we report two cases of pleural malignant mesothelioma that affected two young sisters as part of a nine-member family with enviromental exposure to asbestos. they were affected by marfan's syndrome and both developed pleural malignant deciduoid mesothelioma with long survival. we have performed comparative genomic hybridization (cgh) analyses of tumor samples to identify critical chromosomal regions involved in the onset of mm. we found similar chromosomal changes in both cases and in particular we found losses at q -q and q . -q chromosome. conclusions early onset s. and same genetic impairments in the two sisters suggest that genetic factors may induce the onset of this cancer in those subjects who are exposed even to small environmental amounts of asbestos. however, the specific chromosomal changes we found might provide evidence for locations of relevant suppressor genes of familial mm. video assisted versus needle biopsy of the pleura in patients with pleural effusion results correlation was found between p- -posivity tracheal mucosa and tnm classification system: p- index: control group= %, group t = %, t = %, t = %. conclusion the opinion that the presence of p- oncoprotein reflects mutation of the p- gene is commonly accepted. other data published evaluating the relationships between p- and tnm-stage, g-stage, tumor size and site, age and sex, did not reveal any dependencies, although some studies have suggested such correlations. our analysis had shown a correlation between tnm stage and p- index of tracheal mucosa, but is significant only between control group and t , and control group and t . authors expect such results that show the correlation between prognostic factors in laryngeal malignant epithelium and tracheal epithelium. undifferentiated nasopharyngeal carcinoma (lymphoepithelioma). report of four cases v blažičević, m mrčela, Ž kotromanović clinical hospital, osijek, croatia background nonglandular nasopharyngeal carcinomas are much more common in some areas of the orient than the other parts of the world. they are subtyped as keratinizing squamous cell carcinoma (type ), nonkeratinizing carcinoma (type ) and undifferentiated carcinoma (lymphoepithelioma). we present on four undifferentiated nasopharyngeal carcinomas and detail clinical and histopathological characterisation of these rare cases. methods all our patients were male, white and - years old. initial complaints were various: hearing loss, epistaxis, headache, and dysphagia. examination of the nasopharynx showed us entirely normal features, or fullness, surface granularity, or obvious carcinoma. but, all our patients had cervical lymph nodes metastases, two of them bilateral. involved lymph nodes were typically posterior of the sternocleidomastoid at the level of the angle of the jaw. results histologically, lesions show cytologically uniform cells with ovoid vesicular nuclei prominent nucleoli and indistinct cell borders resulting in a syncytial pattern. an inflammatory infiltrate rich in lymphocytes and occasionally containing prominent eosinophils is usually a component of lymphoepithelioma, but diagnosis is based solely on the nature of the neoplastic epithelial component. neoplastic cells are negative for lca, but positive for cytokeratin and ema. conclusion undifferentiated nasopharyngeal carcinoma (lymphoepithelioma) is very rare. about % to % of patients are initially seen with cervical lymph node metastases from an occult primary. such lesions may be different or impossible to distinguish from lymphoma on haematoxylin and eosin stained sections, particularly when the lesion appears as a lymph node metastasis from an occult primary. ancillary methods like immunohistochemistry and molecular techniques or detection of serum antibodies against viral proteins may be necessary. "atypical" pleomorphic adenoma of the parotid gland introduction pleomorphic adenoma is a benign, epithelial tumor, composed of cells that demonstrate both epithelial and mesenchymal differentiation, with the absence of abnormal cytomorphologic features. we present the case of -years old white women, with a mass localized in the superficial, lower part of the right parotid gland. on clinical examination, the lesion was nodular, painless swelling, of smooth surface, measuring x mm in diameter. the tumour was excised, fixed in formaline, embedded in paraffin and the sections were stained with he, pas and alcian blue. the tumour was composed of both epithelial and mesenchymal-like tissue, with a complete capsule at the periphery. there was no neoplastic tissue within or extending through the fibrous capsule. on the other hand, the epithelial component expressed mild, limited, abnormal cytomorphologic features, such as enlarged, pleomorphic and hyperchromatic nuclei. conclusions presence of prominent cytomorphologic atypias and capsular involvement in a pleomorphic adenoma causes concern about malignant transformation, but a lesion with mild or focally limited cytological atypias is designated as atypical pleomorphic adenoma and indicates an increase likelihood of malignant transformation if the tumor recurs. gene expression profiles were determined in fresh-frozen samples of mucoepidermoid carcinoma (mec), acinic cell carcinoma (acc), salivary duct carcinoma (sdc), and adenoid cystic carcinoma (adcc), using cdna microarrays containing cdna fragments of cancer-related human genes. the validity of findings was checked by means of real-time reverse-transcript polymerase chain reaction studies. seventy-five genes were found to be more than . times overexpressed and less than . times underexpressed than in samples of normal parotid gland. five genes, namely fibronectin (fn ), tissue metalloproteinase inhibitor (timp ), biglycan (bgn), tenascin-c (hxb), and insulin-like growth-factor-binding protein (igfbp ) were overexpressed in all of the types of carcinoma studied. sixteen genes, including mothers against decapentaplegic homolog (madh /smad ) and prostate-specific membrane antigen (psm/psa) were underexpressed in all types of carcinoma studied. average-linkage hierarchical clustering undertaken in relation to selected genes showed that high-and low-grade mecs formed one group of tumours, acc/sdc another. significance analysis of microarray findings identified genes related to the mec group, associated with the acc/sdc group. our results indicate genes that may be involved in carcinogenesis in the salivary glands. gene expression in normal and malignant salivary tissues was also found to be similar in several respects to gene expression in normal and malignant pancreatic and prostate tissues. rare tumours in the sinonasal tract p nagy, f salamon national medical center, dept. of pathology, budapest, hungary introduction sinonasal neoplasms include numerous groups of different histogenetic types. the epithelial tumours have the highest prevalence among them in the daily routine, but we can encounter such lesions, which may cause diagnostic difficulties. the purpose of this study is to determine the least frequent tumours in our sinonasal biopsy files. we collected those kinds of tumours which occurred only once in our series. we reviewed our archive material of a year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) five cases were selected. the histologic slides were re-examined. he, special stains, immunohistochemistry and electronmicroscopy were applied. the cases in the order of their occurrence: . fibrous solitary tumour, we supported our original opinion by cd immunostaining performed retrospectively. . chordoma, in addition to the morphologic features the s and cytokeratin co expression were pathognomic. . pnet, in this problematic case finally the cd positivity proved to be diagnostic. . intestinal-type adenocarcinoma, the mucocele-like appearance and the highly differentiated colonic type epithelial structures reminiscent of adenoma caused our dilemmas. . meningeoma, the immunohistochemical results were not convincing. we established the diagnosis by means of electronmicroscopy. conclusions the incidence of sinonasal neoplasms is low. the recognition of the unusual lesions in this region is a challenge for the pathologist. ancillary techniques may be necessary in the diagnostic process. squamous cell carcinoma: diagnostically problematic variants f salamon, p nagy national medical center, dept. of pathology, budapest, hungary the diagnosis of squamous cell carcinoma (scc) is seldom problematic. although it may cause difficulties for the pathologist to verify its uncommon varieties. the aim of this study was to distinguish the rare variants of scc from the conventional ones in our laryngeal tumour file and to present the most instructive cases. material and methods we reviewed our archive material of a year period ( ) ( ) ( ) ( ) ( ) . four cases were selected. the histologic slides of the preoperative biopsies and the surgical specimens were re-examined as well. he, special stains, immunohistochemistry and electronmicroscopy were applied. results . " carcinosarcoma" with rhabdomyosarcomatous differentiation. this case represents a unique example of the spindle cell carcinoma category. . verrucous carcinoma with verrucous hyperplasia. the interpretation of the latter term is a complicated issue. by virtue of our patient's follow-up we encountered this dilemma. . papillary squamous cell carcinoma (pscc). this -year long case history is a well-documented instance of a papilloma-papilloma with dysplasia-carcinoma sequence. . adenosquamous carcinoma. it was not easy to justify the clinical suspicion of malignancy preoperatively. furthermore we faced a differential diagnostic problem when we evaluated the removed larynx. conclusions in all the cases we managed to establish the definite diagnosis only by the thorough examination of the surgical specimens. additionally we found special features as far as the morphology and histogenesis are concerned. so we can confirm the subheading of the corresponding afip fascicle for this tumour group: diagnostically problematic variants. intraocular leiomyoma: case report introduction intraocular leiomyomas are rare tumours probably arising from the ciliary body smooth muscle. they represent a diagnostic dilemma and must be differentiated from neural tumours and, more importantly, from amelanotic melanoma. they occur more frequently in women, usually between the third and sixth decades of life. case report we report the case of a year-old woman with gradual loss of vision in her right eye. slit-lamp examination and binocular ophthalmoscopy showed a large and pigmented ciliary body mass located in the inferior quadrants. a and b ultrasound examination revealed a multicavitary tumor with low internal reflectivity measuring x . x . mm. enucleation of the affected eye was decided. histopathological examination showed a solid neoplasm composed of interlacing and tightly packet of spindleshaped cells with little intervening collagen. nuclei were oval with blunted ends with no significant atypia. mitotic activity was negligible. immunohistochemical stains for smooth muscle actin, hhf- , vimentin and desmin were positive. no stain was noted for s- protein, ae -ae cytokeratin, cam . cytokeratin, hmb- , glial fibrillary acid protein, neurofilaments, neuron-specific enolase and synaptophysin. final diagnosis was leiomyoma and the patient is free of disease two years after surgery. conclusions intraocular leiomyomas are of clinical concern since they are difficult to differentiate from more aggressive neoplasms, especially amelanotic melanoma. in this particular case, the situation was even more complicated because the lesion was clinically pigmented. once removed, the diagnosis was not difficult and was based on conventional histopathological examination along with confirmatory immunohistochemistry. results twenty-six of cases were male and were female. follow-up was available for cases and ranged between to months. eight cases died and had recurrences. the recurrent tumour histology changed from type to in cases, remained unchanged in . none of the clinical parameters were correlated with the survival. the type of therapy seemed to have no impact on survival. according to who classification cases were type , were type and were type and it showed correlation with survival (p= . ). lymphocytic infiltration, which, was added to who system, were seen by cologne classification in of tumours, but did not have an impact on survival. cellular morphology and atypia suggested by hsu's classification had no significance as well, although most of the tumours were classified as type a (% , ). ebv infection was found to be present in of cases. however no correlation with other parameters was found. conclusion in accordance to literature we concluded that who classification is the only parameter that has an impact on survival in npc. vascular endothelial growth factor expression and microvessel count in laryngeal squamous cell carcinoma -related antigen. paraffin embedded tumour specimens were stained with vegf and f-viii using immunohistochemical methods. vegf staining was evaluated as negative (<% of tumour cells) or positive (>% of tumour cells). staining intensity was graded mild, moderate and severe. for evaluation of f-viii staining, average counts of the three most vascular areas on an x field were recorded. statistically correlation between immunoreactivity and the clinicopathologic factors of laryngeal carcinomas was evaluated. results vegf expression in the tumour cells was found positive in all cases (% ). staining intensity was detected as severe of cases, moderate of cases, mild of cases. in evaluation of f-viii staining, average mvc of all cases was found , . statistically, no association was observed between the vegf expression, f-viii of carcinoma cells and histologic grade, tnm stage, tumour size and tumour site. association was observed between the vegf expression and mvc (p= , ). in additional, significant correlation was observed between the vegf percentage of positive tumour cells and staining intensity (p= , ). conclusion our data suggest that in laryngeal squamous cell carcinomas, vegf expression and mvc of carcinoma cells are not prognostic markers. acinic five cases of acinic cell adenocarcinoma, diagnosed in our laboratory during a period of years, are presented. four of them concerned salivary gland tumours of the parotid gland, the main site of their development, and the fifth was found as an endobronchial mass. the patients ranged from to years of age and the greatest stromal diameter varied from , to , cm. microscopically all neoplasms had the typical morphological features consistent with acinic cell adenocarcinoma. this neoplasm has distinct clinicopathological features and a rather indolent biological course, in spite of its malignant potential, responsible for the prevalence of the term carcinoma instead of "stromal". a broad histo-and immunohistochemical investigation was performed confirming the diagnosis. a review of the available reference is reported. relationship of p oncoprotein expression with histological grade and outcome of patients with oral squamous cell carcinoma introduction an alteration in the p tumour suppressor gene is the most frequent genetic abnormality in human cancers. overexpression of the p oncoprotein and histological differentiation were investigated in routinely formalin-fixed and paraffin embedded squamous cell carcinomas of the oral cavity. p oncoprotein was detected in all specimens with the monoclonal antibody do- . p oncoprotein expression was scored in the following way: score < %, score - %, score > % positive cells. results and conclusions using histological differentiation, all specimens are divided in three groups: group i -well-differentiated ( cases), group ii -moderately differentiated ( cases) and group iii -poorly differentiated carcinomas ( cases). in the first group % specimens were negative, %highly positive for the p oncoprotein. in the second group, positive detection of the p oncoprotein was observed as low in , % of cases, moderately in % and highly positive in , %. in the third group % expressed low positivity for the p oncoprotein and % of the cases had moderate and high positivity respectively. patients' survival was monitored for a five years. in the group with the highestp oncoprotein expression , % of the patients survived years or longer and , % survived less than years. mutation in the p tumour suppressor gene is highest in the well-differentiated squamous cell carcinomas, and its expression decreases in poorly differentiated carcinomas. immunohistochemical prognostic factors in laryngeal squamous cell carcinoma introduction the molecular mechanisms of growth and progression of laryngeal carcinoma are not studied well. the aim of the present study was to investigate the prognostic significance of over expressions of p protein, cyclin d , c-erbb , and markers of cellular proliferation (ki- and pcna). materials and methods primary tumours were studied on a series of patients. all patients were treated between the years and . the expression of p was analysed with monoclonal do antibody, cyclin d (clone dcs- ), c-erbb (polyclonal antibody hercep test), proliferate activity with ki- (clone mib- ) and pcna (clone pc ) results overexpression of the p protein was found in % of patients, cyclin d in %, and c-erbb -in % of patients with laryngeal squamous cell carcinomas. the reverse relationship of cyclin d with -year survival of patients (p< . ) was revealed. overexpression of the p protein was correlated with lymph node metastasis (p< . ). the value of pcna index in patients with metastasis is significantly higher than those in patients without metastasis (p< . ). the pcna index was correlated with the stages of the tnm. high level of the ki- index and the pcna index really decreases -year survival in patients. no significant correlations were found between positive p , cyclin d , c-erbb , ki- and pcna immunostaining and anatomical localization and histological grade. conclusions immunohistological examination of c-erbb is not a valuable prognostic factor in laryngeal carcinoma. high proliferation index (ki- and pcna) and expression of cyclin d correlate with worse prognosis of the disease. overexpression of the p protein is correlated with progression of laryngeal cancer. introduction warthin's tumor (wt) is a well-recognized benign neoplasm of salivary gland. granulomatous inflammation occurring in wt is a rare phenomenon. it has been suggested that prior fine needle aspiration (fna) biopsy might be the triggering factor. mycobacterial infection has also been reported as a cause of granulomatous change seen in wt. we report six cases of wt with granulomatous inflammation to analyse the possible relationship to prior fna. materials and methods a computerized search of pathology file of chang gung memorial hospital yielded cases of wt from to . granulomatous inflammation was described in six cases ( . %). fna cytology was performed in two cases before surgical excision. clinical history, histology and cytology slides were reviewed. ziel-neelsen stain was performed. results all tumours occurred in parotid gland. there were men and women. their age ranged from to yrs (mean ) and the tumor size ranged from to cm (mean ) in maximal dimen-sion. all six cases showed typical features of wt accompanied by multiple granulomas composed of epitheloid histiocytes and multinucleated langhans giant cells with or without necrosis. no acid-fast bacilli were found in any of these cases. history of prior fna was identified in two cases. both specimens also showed granulomas and features of wt. conclusions the pathogenesis of granulomatous inflammation in wt remains speculative. prior fna has been suggested to be the cause. however, this hypothesis cannot be supported by our observation of granulomas in the cytology specimens of two of our cases. it is most likely an immunologic reaction to the tumor, but a ziehl-neelsen stain should be performed to exclude the possibility of mycobacterial infection. malignant peripheral nerve sheath tumor masquerading as an allergic nasal polyp introduction approximately % of all malignant peripheral nerve sheath tumours (mpnst's) occur in the head and neck. of these, % are sporadic. the mean age at presentation is years. sinonasal tumours are extremely rare and whilst they share the morphology of mpnst's at other locations, they tend to be of low grade at this site. we describe a unique case of a high grade mpnst clinically simulating an allergic nasal polyp in an otherwise healthy child without identifiable risk factors. methods a year old black boy presented with an obstructive nasal mass, which was first felt months earlier. the clinical diagnosis was an "allergic polyp" and the mass was excised without antecedent roentgenographic investigations. results the x x cm tumor was unencapsulated but circumscribed, lobulated and friable. histologically, predominantly highgrade sarcomatoid and epithelioid areas were seen. however, differentiating features of peripheral nerve sheath tumor were also found. these included alternating hypercellular and hypocellular areas, palisading nuclei, perithelial accentuation of cells and serpentine, buckled nuclei. in low-grade areas, axons were demonstrated by silver staining. of the broad panel of immunohistochemical stains done, only s protein positivity was observed. the latter was uncharacteristically prominent. conclusion the young age of the patient, the tumor location and clinical presentation as an allergic polyp, the predominantly high grade microscopic appearance and the strong s protein positivity of this mpnst are unusual and hence worthy of documentation. follicular dendritic sarcoma in a black teenager -report of a south african case and literature review t n c) . histologically, the tumor cells were large with a low nuclear:cytoplasmic ratio, vesicular chromatin, and prominent nucleoli. the cells were arranged in organoid and trabecular patterns in a background of extensive necrosis and mitotic figures. ultrasound biopsy of the liver revealed metastatic disease. the patient died within weeks of surgery. the cause of death was unknown. no post-mortem examination was conducted. immunohistochemical expression of antikeratin ae /ae , chromogranin, and synaptophysin was evaluated. electron microscopy was performed. the tumor cells stained with anti-keratin ae /ae , chromogranin, and synaptophysin. electron microscopy revealed dense core granules. these findings, along with the morphologic criteria, fit with a lcnec. conclusion lcnec is a rare tumor in the larynx. recognition at this site is essential so that proper patient management can be initiated. analysis of blood serum lymphocytic phenotypes in chronic hepatitis c infected patients with advanced fibrosis and periodontium diseases introduction few studies focus on periodontium diseases in the course of chronic viral hepatitis c. the aim of this study was analysis of the relationship between the stage of periodontium disease and a number of lymphocytic phenotypes in blood serum of patients infected with chronic hepatitis c and advanced fibrosis. the study included patients (mean age of , years), whose blood serum revealed the presence of hcv-rna, demonstrated with rt-pcr method, while biopsies helped to reveal chronic hepatitis with septal fibrosis or cirrhosis. periodontium inflammation was assessed according to the following criteria: inflammation limbus, swelling, gingival pocket depth, presence of supragingival and subgingival calculus and gomphiasis. each criterion was assigned or point, cumulatively from to points. flow cytometry analysis included monoclonal antibodies: cd , cd , cd , cd /cd /cd , cd provided by becton-dickinson. analysis of morphological parameters and fluorescence was performed with cellquest computer software. results all patients with advanced liver fibrosis were found to show signs of advanced periodontum diseases (mean cumulative value of , points). the diseases most frequently encountered included: bleeding and calculus (n= ), deep gingival pockets (n= ) and gomphiasis (n= ). the degree of periodontal disease depended on the total number of t lymphocytes (p< , ) and on the number of t helper lymphocytes (p< , ). no significant dependencies were found between the degree of a periodontal disease and nk cells, b-lymphocytes or t suppressor. conclusion degree of periodontum disease in patients infected with hepatitis c is dependent on low values of t and t helper lymphocytes in blood serum. adenomatous ductal proliferative foci accompanied the warthin tumour in parotid gland t ohuchi , adenomatous ductal proliferation (adp) and intercalated duct hyperplasia (idh) which are two new similar disease concepts in the field of salivary gland have been reported recently focusing on the relationship of precursor lesion to some salivary gland tumour, differential diagnosis, and possibility of dedifferentiated lesion. we report here a case of warthin tumour accompanied by the foci of the adenomatous ductal proliferation in the parotid gland and these epithelial foci exhibited the histological and immunohistochemical findings resembling tubular type of basal cell adenoma. a -yearold female received the resection of warthin tumour in the parotid gland, which was diagnosed as a benign parotid gland tumour. macroscopically, this tumour showed two small legions in the parotid area, x mm and x mm in sizes respectively. the bigger legion was a typical warthin tumour consisted of papillary epithelial projections into cystic spaces associated with variable number of lymphocytes. papillary projections were lined by eosinophilic two cell layers having luminal columnar cells and basal polygonal to triangular shaped cells. on the other hand, histologically, the smaller legion resembled tubular type of basal cell adenoma. this lesion showed ductal proliferation with some admixed acinar cell complexes having a fibrous capsule in its half area. ductal proliferation consisted of bilayered structure (inner luminal cells were strongly positive for cytokeratin and weakly positive for s- protein). some stromal areas around the ductal components appeared to be cellular with spindle shaped cells strongly positive for s- protein immunohistochemistry. introduction malignant rhabdoid tumour of the oral cavity is very rare. to our knowledge, there has been one reported case of malignant rhabdoid tumour of the tongue so far. patient and methods a case of an -year-old female with malignant rhabdoid tumour of the tongue is presented. a patient presented with the induration of the anterior third of the tongue of months duration. the surface was bulging, berry-shaped and bleeding, suggestive of an animators lesion. the radial excision of the tongue was performed. results histopathological analysis revealed a solid tumour measuring cm in the largest diameter. the tumour was composed of epithelioid, eosinophilic cells with "rhabdoid" features; some of these cells contained rounded eosinophilic cytoplasmic inclusions that displaced the nuclei to the periphery. most of the cells showed strong diffusely distributed vimentin immunoreactivity and focal epithelial membrane antigen and keratin immunoreactivity. angioinvasion was present at the periphery of the tumour. following pathological report re-excision of the tongue was done and the patient received chemotherapy. seven month after the diagnosis, respectively, the patient showed no signs of tumour recurrence or metastases. conclusion although there has been a contradiction whether malignant rhabdoid tumour represents a distinctive clinicopathological entity or a phenotypic pattern shared by heterogeneous neoplasms, most of the authors support the diagnosis of "rhabdoid tumour" because the morphological pattern is attended by aggressive biological behaviour. a case of sarcomatoid salivary duct carcinoma ex pleomorphic adenoma in buccal mucosal region results and conclusion correlation of the presence of merkel and langerhans cells as well as the extent of mononuclear cellular infiltrate in the perimatrix according to the degree of ossicular defect and the destruction of the bony walls were made. we found that these cells are predominantly seen in the cholesteatoma with aggressive and destructive growth. they were seen in the less degree in the skin. the role of high-resolution flow cytometry in the grading of mucoepidermoid carcinomas malignancy with poor prognosis, but occasionally arises in the various mucosa of general site including nasal or paranasal sinuses and oral cavity. it shows wide variety in cellular morphology and histological architecture and, therefore, can be easily disregarded as other neoplasm in such instance above. we describe herein a series of malignant melanoma arising in the head and neck mucosa, which diagnosis was corrected in our review, and discuss its histological and immunohistochemical characteristic as well as important clues for diagnosis. materials and methods six cases were selected from the pathology files of kurume university hospital. histological sections were routinely processed, stained with h&e, and observed with a light microscope. immunohistochemistry and special stains were done as needed. among these, two arose in ethmoid sinus and the others in nasal cavity, inferior nasal choncha, tongue and palate, respectively. age ranged between and years old (average . ). the tumours showed undifferentiated morphology with anaplastic or sarcomatoid appearance and cellular population included ovoid, polygonal and spindle cells, occasionally intermingled with those with rhabdoid or plasmacytoid features. immunoreactivity for hmb , melan-a and cd , know as melanoma-related markers, considerably varied for each case, while that for s protein was relatively stable and useful for initial screening. melanin deposition was easily passed by, especially if it appeared in the stroma rather than neoplastic cells themselves, but quite important as well as intraepithelial spread of atypical melanocytes. if resected together, also mucosal tissue should be examined carefully. tenascin expression in salivary gland tumors: an immunohistochemical study in cases introduction tenascin is an extracellular matrix glycoprotein, which interacts with other extracellular matrix proteins and cells. it is reported that tenascin expression is detected in different localizations of normal salivary gland tissue and in most of salivary gland tumours. it is accepted as an indicator of invading potential in a report. the aim of this study is to detect whether tenascin expression patterns relate with type and malignancy of salivary gland tumours. material and method cases of salivary gland tumours: warthin's stromal, mixed stromal, myoepithelioma, basal cell adenoma, basal cell adenocarcinoma, acinic cell carcinoma, adenoid cystic carcinoma, malign mixed stromal were included in our study. antibody anti-tenascin was applied to the paraffin sections. results tenascin expression was observed in all tumours. most invasive expression was observed in mixed tumours, generally in extra cellular matrix localization and in the pattern of coarse clusters. warthin's tumours demonstrated dominantly epithelial tenascin expression, sometimes in globular pattern. in malignant salivary gland tumours tenascin expression is relatively rare compared with benign ones. conclusion our findings suggest that tenascin expression may show variations in patterns and localizations in different kind of salivary gland tumours. tenascin expression is not a feature of invasive potential but may be responsible of epithelial mesenchymal interactions, stromal growth, cell differentiation and production of mixoid and chondroid matrix. links between nucleolar and extracellular matrix proteins: tenascin and ki- in vocal cord biopsy m krstulja department of pathology, medical faculty of rijeka, rijeka, croatia introduction it is postulated that cancerogenesis goes through interchange of differentiation and proliferative processes. the aim of this study was to investigate morphogenesis and proliferation in the epithelial compartment of hyperplastic, dysplastic and neoplastic vocal cord mucosa with simultaneous expression of tenascin and ki- . materials and methods vocal cord biopsies were analysed: invasive squamous cell carcinomas, in situ squamous cell carcinomas, hyperkeratoses with low dysplastic change, papillomas and nodules with hyperkeratosis. immunohistochemistry was performed for each marker separately as well as simultaneously for both markers. results tenascin was expressed in differentiated and neoplastic tissues, decorating the membrane/cytoplasm of cells in carcinoma and dysplastic mucosa, but only the intercellular epithelial junctions in papilloma and hyperkeratosis. ki- , a nucleolar protein, decorated nuclei, nucleoli and chromosomes of cells engaged in mitosis in homotypic and heterotypic bioptic tissue. a double staining for tenascin and ki- revealed synchronous decoration of cytoplasms and nuclei in invasive squamous cell carcinoma ( / ), in cells of in situ squamous cell carcinoma ( / ) and occasionally in cells of dysplastic hyperkeratosis ( / ). simultaneous staining was not found in homotypic tissue. neoplastic cells in mitosis had tenascin stained membranes/cytoplasms or were tenascin negative. in dysplastic hyperkeratosis basal cells in mitosis had rarely tenascin positive membranes ( biopsy only). conclusion the observation that tenascin (a marker of morphogenesis) and ki- (a marker of proliferation) express simultaneously in neoplastic epithelial cells makes a difference regarding homotypic proliferation. introduction anaplastic thyroid carcinoma with an osteoclastoma like component is a rare type of thyroid neoplasm. the origin of the osteoclastoma like element has been a source of controversy, with conflicting theories emerging from the literature, some supportive of an epithelial origin with others favouring macrophage/ histiocytic lineage. ret/ptc is a fusion transcript associated with papillary thyroid carcinoma but not previously described in a tumour of this type. our aim was to examine more closely the osteoclastoma like component and assess the histogenesis of this tumour. materials and methods electron microscopy, histochemistry and a broad immunohistochemical panel were performed. in addition pure populations of each constituent cell type comprising the tumour were isolated using laser capture microdissection. after rna extraction, each of these was examined by rtpcr for chimeric transcripts of ret/ptc- and ret/ptc- . at this stage of our study, due to small differences in each epulis type, no far-reaching conclusions can be drawn. further studies of cd and mdm- protein in the same group of patients seem to be justified since in the authors' opinion, they will explain biological behaviour of that type of tumours. conclusions great proliferation activity of the cells in all types of epulides analysed with pcna, with low ki- and lack of p activity, was observed. adenoid cystic carcinoma and polimorphous low grade adenocarcinoma of salivary glands. a morphometric study c giardina results nuclei of plga resulted significantly larger and with a more regular shape than nuclei of acc. multivariate analysis discriminated the % of nuclei by utilizing variables: nuclear area and variables obtained by the nuclear asymmetry evaluation. conclusion morphocytological differences could have a discriminating power between plga and acc, they seem to be more important than architectural differences and could be related to their different biological behaviour. oral synovial sarcoma -a report of two cases and a review of the literature introduction the head and neck region constitutes the second most common site of involvement for synovial sarcomas, accounting for up to % of all cases. intra-oral synovial sarcomas are rare, with only cases having been reported. the aim of this study is to report additional cases of intra-oral synovial sarcoma, which occurred in the floor of the mouth and retromolar areas respectively in middle-aged black males and to review the clinico-pathologic features of all previously reported intra-oral cases. the current cases were immunohistochemically stained with ema, cd , bcl- , vimentin, cam . , mnf , ck , s- protein, hba , cd and calretenin; and subjected to ultrastructural studies. the literature was reviewed over a period of years, examining a total of cases of oral synovial sarcoma. the intra-oral cases differ from lesions occurring in other sites only in respect of a more marked male predilection, and a generally painless presentation. this is the first report demonstrating calretinin immunopositivity in intra-oral synovial sarcomas. even though in the oral cavity possible earlier detection, easy accessibility and small size renders them more amenable to surgical excision, their biological behaviour remains aggressive with a poor long-term prognosis. conclusion this study clearly demonstrates the histomorphologic, immunohistochemical and cytogenetic similarity of intra-oral synovial sarcomas to that of synovial sarcomas in general. the unusual intra-oral location often results in these lesions being misdiagnosed. these tumours should be considered, as both primary and metastatic tumours, in the differential diagnosis of intra-oral spindle cell malignancies. thirty nine years long follow up of the patient with dermatofibrosarcoma protuberans background dermatofibrosarcoma protuberans (dfsp) is an infiltrative, aggressive, nodular stromal with a great potential to relapse, that appears early in the life, in % of cases at the head and neck region. during last ten years there were five patients with the dfsp at the clinic for maxillofacial surgery of the military medical academy that makes . % of all cases with mesenchimal malignancy. here we present the most extreme case of the dfsp. case report s.s. was years old when she injured a small subcutaneous stromal at the right side of her forehead. ten years later it was cm wide and excised for the first time, as well as two years later when the relapse of the same size, this time involving the bone, was removed and the patient went through radiation therapy. after four corrective operations in a meantime, at her age of and the relapse cm wide from the right frontal region was removed. three years later, at her age of , stromal sized cm was excised from her right buccal mucosa. two years later, at her age of , local relapse was widespread into the right parotid gland, superior eyelid and frontotemporoparietal region including dura. two years after extensive ablative surgery and delicate reconstruction with scary compromised local cutaneous flaps, the relapse from the previously hardly mutilated right forehead region together with dura was removed. six years later, at her age of , the right orbit was exenterated together with excision of adjacent temporoparietal tissues. one year later the local relapses from the right infraorbital and buccal region were removed. two years after another stromal cm sized from the periorbital region was removed. after two years, at her age of , the lesion from her cheek was removed. it has been her tenth, but obviously not the last surgery. almost one year later there were no signs of local relapse or regional metastases at her routine postoperative check up. in spite of such a great mutilation of face and psychological disturbances connected with it, this is a case of successful surgical management of the dfsp. few times some differential diagnostic dilemmas appeared, but careful and detailed revision of all specimens definitely confirmed the dfsp. multiple and multifocal malignancy -a case report background it is well known that one either benign or malignant stromal can appear multifocally, as well as the fact that histologically different tumours can exist coincidentally. there is just a few papers concerning on how many different concomitant tumours can appear in the human body. this is a case of years old male with several tumours of different malignancy degree and morphologically benign or semimalignant cutaneous lesions. case report during previous years three times he underwent surgical excision of epitheliomas of the scalp, body and limbs. the third one has been removal of the epithelioma of the right frontoparietal region. at his age of because of the stromal sized cm in the right parotid salivary gland, followed by paralysis of the frontal and paresis of buccal branches, along with laboratory finding of . leukocytes, right-sided radical parotidectomy and suprahyoid dissection of the neck has been performed. pathohistologic analysis confirmed malignant mixed stromal of the parotid salivary gland. postoperative irradiation therapy has been applied in fraction and total dose of gy. nine months later the patient has been operated again because of an exulcerated, cm diameter cutaneous lesion of interscapular region, which has proved to be the infiltrative squamous carcinoma g- grade. at the same time the chronic lymphoproliferative disease in the form of chronic lymphocytic leucosis a grade has been diagnosed (although the reactivity following the neoplastic process could not be excluded), but specific haematological treatment has not been indicated. nine months later nine cutaneous facial lesions have been removed: malignant mixed stromal of the left auricle, senile keratosis from the left temporoparietal region, chronic dermatitis from the forehead, squamous carcinoma g- and seborrhoic keratosis one inch inferiorly, two lesions, sebaceous adenomas from the right zygomatic region, corneal squamous carcinoma g- from the right parietal region, baseocellular carcinoma from the left one and adenoid type of baseocellular carcinoma from the right supraclavicular region. the patient has been operated without complications and came five times for monthly control in a good general condition, without relapse, regional or distant metastases. later on we ascertained that the patient suddenly died during a sleep seven months after surgery. conclusion pathohistologic examination of removed tissues and revision of the former specimens undoubtedly excluded the spreading of the one and same stromal in different regions, but proved multifocal appearance of tumours of the same embryologic -ectodermal origin in very different structures. melanoma of the oral cavity -a case report background melanoma is a capricious malignancy followed by reputation of aggressive growth and dissemination, able to originate from any tissue containing melanin. in less than % it appears at mucous membranes. here we present a case of such localization. case report during last ten years there were patients with primary cutaneous head and neck melanoma who underwent surgery because of secondary deposits at the neck, but only one patient, r.m., years old (pale skin, dark hair and eyes, never working outside), who appeared four years ago with inoperable intraoral melanoma involving tongue, base of mouth, mucosa of the left cheek, retromolar region, tonsillar fossa and soft palate, including a single pendular mass from the left palatoglossal arc that almost completely narrowed his isthmus faucium. the first pigmentation he noticed eight months before his first admittance suffering of disturbed swallowing for few weeks. although there was no sign of regional or distant metastases, only the last-mentioned mass has been removed and pathohistologically verified as melanoma. patient was able to breathe normally, and continuing with his previous way of life. he received dtic during the first four postoperative months. one year later, smaller mass from the same location has been removed again. routine laboratory analyses, radiographic examination of the lungs, ultrasonographic examination of the neck and abdomen never revealed any changes. the third reduction under the same circumstances took place one year later and has been followed with minimal doses of adjuvant immunotherapy. conclusion this is a rare case of such a large, inoperable intraoral melanoma that has been three times reduced at the place of its exophytic growth into throat, otherwise demonstrating no signs of regional or distant spreading, as well as any disturbances in patient's general condition during last four years. introduction recent studies have shown that stromal reaction in cancer has an important diagnostic and prognostic significance. cd -positive stromal cells and myofibroblasts may play an important role in host response to cancer. the aim of this study was to analyse the expression and significance of cd , alfa-smooth muscle actin (sma), and tgfbeta in epithelial hyperplastic lesions (ehl) and squamous carcinoma (sc) of the larynx, and tried to reveal the mechanism of myofibroblast formation in sc. we investigated samples of resected larynxes with sc, laryngeal biopsies of ehl and sc, and samples of normal laryngeal mucosa. immunohistochemistry was performed with antibodies against sma, cd , cd , tgfbeta and tgfbeta receptor. the expression of tgfbeta mrna was detected by rna in situ hybridisation. results stroma of normal mucosa and ehl contained scattered cd -positive cells, but there were no sma-positive myofibroblasts. stroma of sc contained sma-positive myofibroblasts but there were no cd -positive stromal cells. in normal mucosa and ehl, tgfbeta and its receptor were present in epithelial cells and scattered stromal and inflammatory cells. in sc, tgfbeta , its receptor and tgfbeta mrna were found in stromal cells, inflammatory cells and some stromal myofibroblasts. conclusions disappearance of cd -positive cells and appearance of sma-positive myofibroblasts in the stroma is associated with transformation of laryngeal ehl to sc. this pattern of stromal reaction is limited to invasive carcinoma and should be regarded as an additional marker of invasion. our results also support the hypothesis based on experimental studies that tgfbeta may be one of the mechanisms of transformation of stromal cells to myofibroblasts in sc. introduction loss of heterozygosity (loh) on short arm of chromosome p is frequently found in squamous cell carcinoma of larynx and hypopharynx (lhscc). this is a region where potential stromal suppressor gene, frequently changed in pulmonary cancer, the fhit gene, is located. we wanted to determine whether there is presence of molecular and/or immunohistochemical changes in fhit gene in patients with lhscc. materials and methods dna was isolated from stromal and adjacent normal tissue using standard procedure. non-isotopic loh analysis was performed with micro satellite markers d s , d s , d s , d s , d s . formalin fixed tissue samples were stained immunohistochemically with antibody against fhit protein and reactions scored according to % of nuclear positivity in stromal cells. results loh at p was detected in ( . %) and microsatellite instability (msi) in ( . %) tumours, which were mostly moderately differentiated ( . %). introduction permeation of fixatives into tissue for optimal dna preservation for molecular pathology studies is related to tissue type and fixative but also to glycosaminoglycan content of the ground substance. this may alter with age, warranting further study. the aim of this study was to assess nuclear dna preservation related to age and fixation agent. materials and methods fresh standardised testicular tissue samples from dogs - months (i), months - years (ii) and years and over (iii) were used for immediate dna extraction (t ), extraction after hours (t ) and after days (t ) of immersion in formaldehyde-based and formaldehyde-free, commercially available fixatives. dna extraction used standard protocols, commercially available kits (qiaamp minikit, qiagen, the netherlands), standard primers for the betaglobin gene preserved between species (myo /my , digene/abbot, usa) and quantitative pcr (realtime light cycler, roche, amplification cycles). in formaldehyde free fixatives, initial loss of extractable dna in t samples of young (i) animals was % as compared to % in older (ii+iii) animals (p< . , student t-test). the same, with a significantly poorer result (p< . ) was found in formaldehyde based fixation, with loss of % in young (i) as compared to % (p< . ) in older (ii+iii) animals. at days, further loss to % of t values occurred in all age groups (p< . ), with formaldehyde free fixatives retaining the proportional age associated difference. in formaldehyde based fixatives at t , loss to % of t values was found (p< . ), again without statistically significant differences between age groups. the g a polymorphism of ccnd correlates with susceptibility and prognosis of breast cancer in taiwan cp yu a frequent g a polymorphism of ccnd gene located on the splice donor site on exon -intron boundary is implicated in influencing cyclin d mrna splicing and production of two distinct mrna transcripts. although cyclin d is believed to perform an important role in cell cycle progression, this g a single nucleotide polymorphism (snp) seems to be a critical modulator of its functions. it has been reported that the prognostic significance and mrna splicing regulatory effect of g a varies with tumor type and ethnic diversity. to explore the association between the ccnd g a polymorphism and the breast cancer susceptibility as well as other prognostic parameters, we employed infiltrating ductal carcinoma (idc) cases and native controls in this study. there is obviously correlation between the genotype distribution of these two groups (p= . ), and the aa genotype reveals a higher association and risk than the ag+gg genotypes (p= . with c test and or . , % ci . - . , p= . ). moreover, there is no statistical significance found between genotype or allele frequencies and tumor stage, grade, nodal involvement, or patient'¦s age. however, the trend tests of ccnd g a genotype distribution or allele frequencies to the increasing of tumor grade or tumor stage are significantly different when comparing the a vs. g allele (p= . in both tumor grade and stage) or aa vs. ag+gg genotype groups (p= . and . in tumor grade and stage, respectively) but no significance when comparing gg vs. ag+aa or ag vs. aa+gg genotypes. these results suggest that ccnd g a polymorphism correlates with idc susceptibility, and a allele reveals an increased risk in carcinogenesis of idc and worse prognosis. the new hope*-fixative as an enhancement in molecular pathology e during the last years the growing demand for the detection of prognostic and diagnostic biomarkers has been slowed down to a large degree by the use of formalin and its influence onto antigenic structures and nucleic acids, although other reasons also exist. with regard to morphology a limitation in the possibilities, compared to frozen sections, takes place. with the introduction of the hopefixation to date both has become possible; substantially enlarged possibilities concerning the detection of dna, rna and proteins together with a formalin-like morphology. this will be demonstrated by presenting several examples like preservation of nucleic acids (dna, rna), the detection of those by pcr and rt-pcr, in situ hybridization and the preservation and delectability of proteins by immunohistochemistry. we conclude that hope-fixation opens up new possibilities, especially within the growing number of diagnostic and prognostic biomarkers. *hepes-glutamic-acid-buffer-organic-solvent-protection-effect introduction high-risk human papillomaviruses (hpv) represent a major risk factor for the development of cervical cancer. quantitative real-time pcr for viral load determination of hpv in archival cervical cancer specimens could be of clinical and prognostic relevance. the aim: we investigate the prognostic value of hpv status and viral load. furthermore, we compared the applicability and sensitivity of three molecular hpv-detection methods. materials and methods all examinations were carried out from formalin-fixed, paraffin-embedded tissue of cervical carcinomas. hpv status was detected by signal amplified chromogenic in situ hybridization (sa-cish), conventional polymerase chain reaction (pcr), and detection and additional quantitation was performed using real-time pcr. results patients with low viral load of hpv in stage i carcinoma had a significantly better prognosis than hpv -negative patients (p= . ). additionally, high viral load of hpv in patients indicating a higher stage carcinoma strongly tended to benefit prognosis compared to hpv-negative patients. our evaluation of the molecular hpv-detection methods showed a higher sensitivity of real-time pcr and conventional pcr compared to sa-cish. conclusion it appears that cervical cancer patients can be distinguished in a hpv -negative subgroup revealing a worse prognosis, and a lower-stage subgroup with low viral load, respectively a higher-stage subgroup with high viral load, both indicating a better survival, maybe due to an altered immune status caused by hpvinfection. these findings are crucial to accord each patient the individual therapy, and point out the importance of quantifying viral load and the necessity of real time-pcr in hpv-diagnosis. laser capture microdissection in -d coculture models as a novel tool to study tumor-stroma-interactions introduction cellular adhesion, migration and invasion are essential processes in tumor progression and do include actions by malignant cells as well as by the stromal microenvironment. in vitro, these interactions can be studied in coculture models. in conventional coculture systems, the different cell types are grown together in glass-slide based chambers with medium. in situ analysis can be easily performed, however, for mutational or gene expression analyses the cell compartments have to be dissociated and sorted. we present a novel technique for co-culturing fibroblasts and carcinoma cells and separating them without cross-contamination. methods our method is based on cell cocultivation on a . µm thin membrane followed by laser microdissection of tumor and stroma cells. for identifying the tumor cell compartment, immunolabeling for the laminin gamma chain was performed, a marker that is expressed only in epithelial tumor cells. dna and rna was isolated from the microdissected cells. rna quality was tested by rt-pcr for a housekeeping gene transcript and for the laminin gamma chain gene transcript. results co-cultivation on the membrane did not influence growth behaviour and cell morphology. the rna quality from the microdissected co-cultured and immunostained cells could be successfully proved by rt-pcr. laminin cdna was amplificable only in tumor cells and not in the co-cultivated fibroblasts indicating no cell-cross-contamination during microdissection. conclusion our technique provides a suitable tool to study tumor -stroma interactions at the dna or rna level for expression profiling and genetic analyses. p expression in prostate cancer and its correlation with microvessel density i pavlenko, a matsionis rostov regional bureau of pathology, rostov on don, russian federation introduction angiogenesis is important in the development and progression of all cancer types, including prostate adenocarcinoma (pca). increased vascularization may be influenced by p status. the aim of this study was to evaluate mvd in prostate cancer and its relationship with p nuclear accumulation. methods paraffin-embedded tissue from patients with well-, moderately and poorly differentiated prostate carcinoma was examined immunohistochemically using monoclonal antibodies against cd , vegf and p (clone do- ). a modified semiquantitative weidner score and computerized image analysis was used to assess mvd. results expression of immunohistochemically detected p protein was found in of cases ( %). p nuclear accumulation was observed in two different groups of cancers -poorly differentiated pca with high vegf expression and high mvd, with high level of serum psa ( cases) and moderately differentiated pca without significant microvessels with low serum psa ( cases). we suppose p mutation in the first group of patients which leads to increased angiogenesis as the result of loss of wild-type p induced anti-angiogenic control. in our opinion p detection in the second group of p + patients is the result of overexpression due to stabilization but not mutation. conclusion p overexpression is observed due to either mutations or protein stabilization. increased angiogenesis seems to be influenced by p mutations, while low mvd is observed in cancers with non-mutated p . immunohistochemistry alone is not able to detect p mutations, additional techniques are need for this purpose, especially in patients with p nuclear accumulation. malignancy-associated x chromosome loh in foregut endocrine neoplasms: further evidences in lung tumors introduction association of x chromosome allelic losses (loh) with tumor malignancy has been found in foregut-derived gastropancreatic endocrine neoplasms, but not in midgut carcinoids. also lung endocrine tumors originate from the embryological foregut. they are classified into "typical" carcinoids (tc), "atypical" carcinoids (ac), large cell neuroendocrine carcinomas (lcnec) and small cell lung carcinomas (sclc), in order of increasing malignancy the aim of this study was to investigate x chromosome loh and its association with malignancy in a series of endocrine tumors of the lung. materials and methods dna extracted from tcs, acs and lcnecs from female patients was pcr-amplified using fluorescently-labeled primers for microsatellite markers spanning the whole x chromosome. for loh evaluation, amplimers were analysed in an automatic dna sequencer (ceq , beckman coulter). all samples were formalin-fixed, paraffin-embedded and dna from tumoral and non-tumoral adjacent tissue was available results allelic losses were absent in tcs, while loh on x chromosome was found in of acs ( %) and in of lcnecs ( %). allelic losses were generally wide, involving all or most informative markers investigated conclusions allelic losses on x chromosome, absent in benign "typical" carcinoids, progressively increased their frequency from intermediate-grade "atypical" carcinoids to high-grade lcnecs. therefore the observation that x chromosome loh is associated with malignancy, already demonstrated in gastro-pancreatic endocrine tumors, is extended to another group of foregut-derived endocrine neoplasms, the lung endocrine tumors we investigated formalin-fixed, paraffin-embedded tissue samples. from each paraffin-block four times one to two µm sections in three steps and two µm sections were cut and put to . ml reactiontubes. one tube of the thin sections and the thick sections were exposed to heat/cold shocktreatment, one tube had a proteinase-k treatment for only three hours instead of overnight, and the thin cuts in another tube were treated with a riboliser. dna amount and purity measured by spectrophotometry after extraction. pcr was performed with routinely used srdna-primers. results over all we obtained best results with cutting up thin sections and proteinase-k treatment overnight. this tissue yielded the best purification, the highest dna amounts and strongest bands in agarose gelelectrophoresis. second best were thick and thin sections with heat/cold shock-treatment and proteinase-k treatment overnight. conclusion the mechanical opening of the mycobacterial wall using a standard microtome is a feasable way to obtain higher dna-amounts -purity and -complexity resulting in stronger signals following pcr. impact of tumour suppressor gene pten on cell cycle and apoptosis in prostate cancer cell lines introduction the progression of prostate cancer from androgenresponsive to an androgen-unresponsive status remains the greatest problem in the treatment of this disease. aims: to study the relationship between telomerase activity and gene expression after bicalutamide treatment in prostate cancer cells. material and methods androgen-responsive (lncap) and androgen-unresponsive (du- ) prostate cancer cell lines treated with µm bicalutamide for hours were analysed by affymetrix hg-focus array chips and their expression pofile was compared with control. the decrease of telomerase activity which was associated with increase of p waf /cip and decrease of dyskerin and hsp were found in lncap cells only. dna damage-responsive genes were upregulated in both cell lines. in lncap cells, the increase of p waf /cip was associated with induction of p -dependent gene expression (gadd α, bax, mdm- and trail-r ). we have also found induced transcription of pro-apoptotic genes represented by bnip -like, bcl- , cbx and tradd and the decrease of anti-apoptotic protein, survivin. in du- cells, we observed an increase of mt p , trail-r , gadd , gadd α expression together with a decrease in expression of survivin and the pro-apoptotic bnip gene. conclusion the decrease of telomerase acivity in lncap cells after bicalutamide treatment could be explained by changes in expression of p waf /cip , dyskerin and hsp . bicalutamide upregulates dna-damage genes in androgen-responsive as well as androgen-unresponsive prostate cancer cell lines. this work was supported in part by msm and nc/ - . introduction bicalutamide, an androgen antagonist used in the prostate cancer treatment, has a significant cytostatic effect on cancer cells. the aim of this study was to analyse the changes of bcl- family members after bicalutamide treatment in androgen-responsive (lncap) and androgen-unresponsive (du- ) prostate cancer cells. comparing the toxicity and potential carcinogenicity of two antiestrogens. a short-term study with microarray analysis in female rat liver introduction tamoxifen and toremifene are triphynylethyle antiestrogens used in the treatment of breast cancer. tamoxifen is genotoxic hepatocarcinogen in the rat, whereas toremifene is not. in humans, long-term tamoxifen treatment causes an increased risk of endometrial cancer. the major difference between the genotoxicity of the two drugs is the formation of liver dna-adducts in tamoxifen-treated rats. differential gene expression in rat liver after administration of antiestrogens was studied by microarray analysis. materials and methods equimolar doses of antiestrogens were given p.o. to six week old female sprague-dawley rats for days. total rna was isolated using trizol reagent. equal amounts of total rna from four animals in the same group was pooled and then purified from mg total rna using mg oligo(dt)cellulose. our cdna array contained approximately cdna clones selected from the tigr rat gene index. the samples were hybridized to rat cdna array scanned with a gms scanner (afflymetrix). image analysis was performed using the genepix pro software. normalization was performed using lowess normalization. the results from rat cdna array were evaluated according to 'significance analysis of microarrays' (sam). results sam plot for tamoxifen vs. control revealed significant genes from which were positive significant (up-regulated, red) q < %, . particularly the nadph-cytochrome p oxidoreductase and microsomal epoxide hydrolase were upregulated genes which are apparently related to tamoxifen-induced carcinogenesis. sam plot for toremifene vs. control revealed significant genes from which were positive significant q < %, . conclusion microarray technology gives important information of the toxicity as well as carcinogenicity of antiestrogens in experimental conditions. the ret proto-oncogene tyrosine kinase receptor is activated by a ligand complex comprising glial cell line-derived neurotrophic factor (gdnf) and gdnf family receptor alpha- (gdfralpha ). they are expressed in multiple organs during development and also in some types of human tumors in adults. the aim of this study is to investigate ret, gdnf and gdfralpha expression in normal tissue and tumors derived from the gastrointestinal tract, circumstance that we have not found it published in the literature. material and methods ret, gdnf and gfralpha expression was analyzed in samples of fresh frozen and formalin-fixed tissues from tumoral zone, and adjacent non-affected tissue of biopsies from patients with gastrointestinal cancer using rt-pcr and immunohistochemical methods. results presence of ret, gdnf and gfralpha transcripts in most of normal tissues was confirmed by rt-pcr. immunohistochemical study showed positive staining in citoplasms of glandular epithelium of the mucosa, ganglionar cells and muscular fibers (only gdnf) of esophagus, stomach, duodenum, colon and rectum but not in jejunum and ileum. gastric oxyntic cells were negative. sixty four gastrointestinal tumors ( adenocarcinomas and cases of gist) were also studied. by immunohistochemistry, % of cases showed citoplasmic immunoreactivity for gdnf; % for ret and % for gfralpha . these findings were confirmed by rt-pcr. there was not association with microscopic type, size, grade or duke stage. our study shows ret, gdnf and gfralpha positive protein and mrna expression in normal tissues and in the majority of tumors derived from the gastrointestinal tract. there is no association with microscopic type, size, grade or lymph node metastasis. this expression gives no prognostic information in the clinical management after two years follow-up of our patients. expression analysis of ret and its gdnf/ gfralpha ligand complex in breast cancer introduction the ret proto-oncogene tyrosine kinase receptor is activated by a ligand complex comprising glial cell line-derived neurotrophic factor (gdnf) and gdnf family receptor alpha (gfralpha ). they are expressed in multiple organs during development and also in some types of human tumors in adults. in this study we evaluated the expression of ret, gdnf and gfralpha in normal mammary tissue and different types of breast cancer. material and methods ret, gdnf and gfralpha expression was analyzed in samples of fresh frozen and formalin-fixed tissues from tumoral zone, and adjacent non-affected tissue of mastectomies from patients with different types of breast cancer ( dic, lic, medullary carcinoma, mucinous carcimoma, papillary carcinoma and fibrosarcoma) using rt-pcr and immunohistochemical methods. results normal breast ductal epithelium express ret, gdnf, and gfralpha . by immunohistochemistry, , % of breast tumors showed citoplasmic immunoreactivity for ret, , % for gdnf and , % for gfralpha . rt-pcr confirmed mrna expression in , % of cases for gdnf, , % for ret and , % for gfral-pha . by chi-square analysis, ret expression was associated with less tendency to the regional lymph nodes metastases (p< , ) and low grade differentiation (p< , ). there was not association with microscopic type, size or stage. conclusions we found that ret and its gdnf/gfralpha ligand complex are expressed in normal breast tissues and in a high percentage of different types of breast tumors using immunohistochemistry and rt-pcr. univariant analysis also revealed that only ret expression was associated with less tendency to the lymph nodes metastases and low grade dics (highly differentiated tumors). the short time follow-up of our patients (less than two years) gave no information about clinical outcome. telomerase activity in chronic b-lymphocytic leukemia r telomerase, the enzyme that elongates telomeres, contains an rna template complementary to ttaggg repeats that permits de novo synthesis of telomeric dna onto chromosomal telomeric ends. recent findings have suggested that activation of telomerase is one of the most common and fundamental steps in cancer genesis, although reactivation or telomerase up-regulation alone might be insufficient for cells to proliferate indefinitely. telomerase expression seems to be concomitant with the attainment of immortality of cancer cells, but there are contradictory reports about telomerase activity in early and late b-cll stages. in order to investigate the telomerase activity in patients with cll and its correlation with the clinical stage, frozen blood lymphocytes samples from patients with cll ( males, females), and age matched controls ( males, females) were investigated for telomerase activity using the 'telomerase pcr elisa-plus kit' from roche, based on the telomeric repeat amplification protocol. binet and rai stages were evaluated at the time of sample collection, and re-evaluated after - months. results were analyzed with a commercial statistic software package. the study showed that peripheral lymphocytes telomerase activity from b-cll patients is significantly higher ( , times; p< , ) compared to normal lymphocytes. the age and sex of patients does not influence the telomerase activity, while it is age dependent in healthy controls (pearson correlation - , ; p< , ). the study also showed that telomerase activity is increased more significantly in advanced stages of the disease, and correlates with the disease course. introduction deltan-p isoforms may act as oncogenes, owing to their ability to bind to p -reporter genes without inciting their transcription, thus blocking the p -driven cell cycle arrest and apoptosis. a novel mechanism, linking p and wnt pathways has recently been proposed. briefly, in vitro studies have suggested that deltan-p may block the phosphorylation of beta-catenin, leading to its nuclear accumulation and triggering beta-catenin-responsive transcription of genes related with proliferation and oncogenic biological behaviour. to test this new mechanism, the authors evaluated the co-expression of deltan-p and beta-catenin in a large cohort of human neoplasms. methods two sections of tarp- multi-tumour tissue microarray, composed of normal tissue cores and human neoplasms (breast (n= ), colon (n= ), lung (n= ), prostate (n= ) and ovary (n= ) neoplasms, melanoma (n= ), and glioblastoma (n= )) were subjected to immunohistochemistry with deltan-p and beta-catenin monoclonal antibodies. p nuclear expression and b-catenin membranous, cytoplasmic, membranous+ cytoplasmic, and nuclear localisation were independently evaluated by three of the authors. results p expression and beta-catenin nuclear localisation were found in . % and % of squamous cell carcinomas, . % and % of breast carcinomas, . % and % of lung adenocarcinomas, . % and . % colon adenocarcinomas, % and . % of prostate adenocarcinomas, . % and % of ovary carcinomas, . % and . % of malignant melanomas, and . % and . % of glioblastomas, respectively. no statistically significant association between p and nuclear beta-catenin expression was found for all tumours. conclusions at variance with squamous cell carcinoma cell lines, p -driven nuclear accumulation of beta-catenin is an unusual phenomenon in human neoplasms. caution should be exercised when translating the results of studies performed on cell lines to human neoplasms. four gist had no identificable kit sequence alteration in exon . mutations in c-kit seemed to be associated with favorable response to sti- (p= , ). conclusion kit mutations in exon are common in diseminated gastrointestinal stromal tumors and appear to be associated with response to sti- . the use of macro-array to study the effect of intestinal trefoil factor on gene expression in caco- derived enterocytes intestinal trefoil factor (itf) is a member of the trefoil family of peptides. it increases resistance to apoptosis, enhances mucosal healing and restitution in vivo and promotes migration of intestinal epithelial cells in vitro. the aim of this study was to investigate the influence of itf on gene expression in intestinal epithelial cells. the human colon carcinoma cell line caco- develops structural and functional characteristics of normal enterocytes when kept in culture. enterocyte-like caco- cells were treated with recombinant itf during hours. rna was isolated and labelled cdna was synthesised. the cdna probe was hybridised to the human unigene set colony filters (rzpd). after several washing steps, the amount of signal was measured using a phospo-imager. spot intensities were measured and signal quality was evaluated. using a fold increase or decrease as a cut off, comparison of the gene expression between un-stimulated caco- cells and cells stimulated with itf using the macro-array technique revealed a few hundred genes that were potentially differentially expressed. our data show that the macro-array is a powerful technique to screen for differen-tial gene expression as a result of trefoil administration, helping to study signalling cascades. however, it is necessary that the huge amount of data obtained is filtered through repeated hybridisations, only to retain the relevant changes and these data must be confirmed using other methods like quantitative real-time pcr and eventually studies at protein level. introduction melanoma therapy still remains without notable success of any pharmacological agent. gastric pentadecapeptide bpc is a peptide with various pharmacological effects on different organ systems including wound healing and inflammation. its possible effect on cell growth and differentiation was not investigated on human cancer cell lines. human melanoma cells were maintained in rpmi- medium supplemented with % fbs and antibiotics. cells were grown to confluency in humidified incubator ( % air atmosphere, %.co ) at °c. upon reaching confluency, cells were maintained in chemically defined medium (cdm). bpc was added in the culture medium in the various concentrations ( pg. and ng, respectively) for a period of hours. cell morphology was observed daily under light microscope and the photomicrographs were taken. after harvesting cells were prepared in etoh for flow cytometry analysis. results microscopy did not reveal any changes upon treatment with bpc after h comparing to controls. flow cytometry showed % of cells (p> . ) were in g -g phase. control cells had total s-phase fraction of . %. however, upon introduction of bpc , in concentration of pg/ml, the percentage of cells in sphase was decreased by % compared to controls. moreover, the concentration of ng/ml bpc lowered total s-phase fraction by % comparing to controls and by % comparing to bpc in picogram values (p> . ). conclusion we assume that gastric pentadecapeptide bpc could act as a inhibitory agent during g -s transition state of cell cycle thereby preventing dna synthesis and cell growth. introduction histones play an important role in the structural and functional properties of chromatin. their protective role against radiation-induced damage of dna is well established. the aim of this study was to evaluate relation between expression of histones genes and radiosensitivity of brain gliomas in vitro. five human glioma cell lines obtained from dsmz (germany) were irradiated with gy and gy doses (co- ) and further grown for , and hrs. the expression of genes coding for histones h , h a, h b, h , h was measured with real-time quantitative rt-pcr assay (taqman). radiosensitivity of the cell lines was assessed with cytokinesis-block micronucleus assay. cell lines were regarded as radioresistant and radiosensitive at micronuclei per binucleate cell ratio (mn/bnc) < . , and > , respectively, as measured over a dose range of - gy. results the global number of copies of histone mrna did not differ in both groups. in radiosensitive cell lines (gamg, -mg-ba) expression of h b was highest in / cases, while in radioresistant (gos- , -mg-ba, u- -mg) h predominated in / cases. in both groups significant decrease of global histone genes expression after gy dose was found. relative increase of h and h b fractions after irradiation was observed. conclusion overall expression of histone genes does not seem to influence radiosensitivity of glioma cells. probably, more important is the profile of expression, e.g. differences between h and h b genes. this profile may be a useful adjunctive criterion in the choice of treatment protocol for brain glioma. introduction the detection of breast cancer (bc) micrometastasis in effusions is difficult since the malignant cells are rare and spread amongst the normal population. rt-pcr for human mammaglobin (hmam) has been described as a new, sensitive method for use in bc cell research. some authors have proposed using this assay for screening bc effusions for bc micrometastatic disease. the aim of this study was to investigate the possible application of rt-pcr for hmam for assessing bc cells in effusions and compare this methodology with cytological examination. the study was performed on fluid specimens ( bc, other types of cancer and without known carcinoma). the samples were analyzed by staining with ee, papanicolau technique, and by nested rt-pcr for hmam. results / ( %) cases of bc pathology were positive using nested rt-pcr for hmam. all cytology positives were also positive by nested rt-pcr. in contrast, bc cases that were positive in the molecular test were negative according to the staining assay. hmam was also detected in / ( %) specimens of other types of cancer and only / ( . %) samples of non-neoplastic origin. conclusion nested rt-pcr for hmam was more sensitive than cytology in determining bc micrometastasis in effusions. positivity was not restricted to samples from bc patients as specimens from other tumors and only . % of patients without cancer were also positive. this test could be helpful in investigating neoplasticity in effusions. introduction hepatic ischemia-reperfusion injury results from implementation of pringle's manoeuvre to prevent blood losses in patients undergoing liver segment resection. reoxygenation after the ischemic period leads to failure of hepatic microcirculation, leucocyte invasion and kupffer-cell activation. subsequent production of inflammatory cytokines and ros (reactive oxidative species) are triggered, thus causing oxidative stress and damage of liver parenchyma. the goal of our study is to evaluate markers associated with the severity of this particular type of oxidative stress at the gene expression level. we have analyzed liver tissue biopsies at different timepoints obtained from patients undergoing liver segment resection. in each case, the first sample is taken before clamping, the second sample is taken after minutes of ischemia, and the third sample is taken after minutes of ongoing reperfusion. we compared mrna levels of several genes (sqstm , hspa a, gpx , sod , hmox) in every set of samples by quantitative rt-pcr analysis. significant elevation of hspa a at timepoint was detected in of cases. this finding suggests that hspa a may represent a useful marker for oxidative injury of hepatic tissue. at the same time, we show that the detection of changes in gene expression within minutes of reperfusion is possible by quantitative rt-pcr from a single biopsy. we hypothesize that individual differences in gene expression may reflect severity of the inflicted ischemia reperfusion injury as well as patient prognosis. the clinical significance of our preliminary results is currently under investigation. automated tissue microarray evaluation and normalization using a dna scanner oridis-biomed gmbh, graz, austria institute of pathology, graz, austria introduction tissue microarray (tma) immunohistochemistry is gaining importance in drug target validation. hundreds of tissue samples on a single slide enable simultaneous immunohistochemical assessment of protein expression. correlation of expression levels of the target antigen with clinical parameters can facilitate determination of disease relevance and therapeutic potential. the aim of this study was to extend the scope of this technology, we developed a robot for automated tma production. we further assessed the use of a dna microarray two color laser scanner for automated analysis of tma immunohistochemistry and the use of an internal reference antigen for standardization to the tissue content. the tma robot was developed in cooperation with an engineering company. a breast carcinoma tma was stained with an estrogen receptor (er) antibody. lung carci-nomas tmas were double stained with combinations of rabbit and mouse antibodies. immunoreactivity was detected with fluorescently labeled secondary antibodies. the slides were evaluated using a cdna array scanner and software. fluorescence intensity for er ihc on a breast carcinoma tma correlated positively with independent assessment of the diagnostic er immunoreactivity score, suggesting that ihc quantitation can be achieved with the dna array scanner. double ihc on lung tmas demonstrated that one antigen reference can normalize tumor marker ihc signals for the cellular content of tma cores. ihc signal normalized in this fashion correlated with clinical parameters in agreement with published results. manifestation of metallothionein (mt) correlates rather with cell differentiation than with intensity of proliferation. introduction metallothioneins (mt) are proteins which are supposed to play role in the cell cycle. numerous publications describe positive correlation between intensity of mt expression and proliferative potential of cells. our study aimed at examining the relationship between mt expression and intensity of proliferation, measured using ki antigen. the studies were performed on samples of ductal breast carcinomas of g , g or g grade of differentiation as well as on samples of normal epithelium and planoepithelial carcinoma of uterine cervix. paraffin sections of the examined cases served to perform immunocytochemical reactions using mouse monoclonal antibodies to mt and ki . double staining reactions were also performed using the same antibodies. the performed studies showed that mt expression in breast cancers of g grade was significantly lower than in cancers of g or g grades (p= . ). in the case of ki , the least intense expression characterized cancers of g grade and the most intense reaction was noted in cancers of g grade (p= . ). no relation between mt and ki expressions was observed in g and g groups of breast cancers (p> . ) while in the g group as well as in the entire group of breast cancers (g to g ) a positive correlation between the two expressions was noted (p< . ). analysis of reactions in the non-keratinising stratified flat epithelium and in the planoepithelial cancers of uterine cervix showed no correlation between expressions of mt and ki . however, mt expression was detected only in the least differentiated cells of the epithelium. conclusion our showed that mt expression tends to correlate more with cell differentiation extent than with proliferative potential of the cells. is the activation of akt a prognostic parameter in colorectal cancer? akt (protein-kinase b, pkb) is a serine-threonine kinase that is activated mainly by insulin, igf- receptor and erbb family receptor signaling in a pi -kinase dependent manner, and is implicated in tumor proliferation in breast, ovarian, pancreatic and gastrointestinal cancers. the phosphorylation of its substrate proteins result in increased growth and decreased susceptibility to apoptosis. the activation of the pi k-akt pathway is downregulated by pten phosphatase, and mutations or a loss of pten activity results in a high constitutive activation of the kinase. the aim of the present study is to investigate the levels of the activation of the pi k-akt pathway in a series of colorectal carcinomas and to evaluate its role on tumor resistance to chemotherapy. we achieved surgical colorectal carcinoma specimens at pt stage. all patients received at least two chemotherapy lines based on platinum and cpt- after surgery. levels of activation of akt were tested by immunohistochemistry in primary tumors using a polyclonal antibody that recognizes the phosphorylated akt at ser . in the series, ( . %) showed staining for phosphoakt in tumor cells. phos-phoakt was detected in tumor as clusters of cells related to necrotic foci and differentiated areas and correlated with less response to chemotherapy. these results point out that . activated akt is often overexpressed in human colorectal carcinomas and .activated akt can be a parameter of chemotherapy resistance in colorectal cancer. mutational analyses of the ret proto-oncogene in slovenian men families introduction alport syndrome (as) is a progressive inherited nephropathy, characterized by irregular thinning, thickening and splitting of the glomerular basement membrane (gbm), associated with hearing loss and ocular symptoms. as is caused by col a mutations in its x-linked form and by col a and col a mutations in its autosomal recessive form. the mutations in col a and col a have been reported in familial benign hematuria (bfh). aims: we screened col a , col a and col a genes in slovenian families with x-linked as and in slovenian families diagnosed with bfh to determine pathogenic mutations, to correlate them with clinical features and to confirm or provide precise diagnosis. materials and methods genomic dna was isolated from blood. screening for mutation was done by the optimised ssca after pcr amplification of each exon of col a , col a and col a and changed samples were sequenced. we found six different mutations in col a gene in as suspected patients. one of the mutations was present also in three families with bfh. in col a gene three and in col a four mutations, all in heterozygous state, were identified only in patients with bfh. eleven of the mutations are new and private. four rare variants of unknown pathogenesis and many polymorphisms were found in the col a and col a genes. a mutation was detected in % of as patients and in % patients diagnosed with bfh conclusions our study broadened the spectrum of mutations in col a , col a and col a and demonstrated the involvement of the col a and col a genes in the pathogenesis of bfh. introduction prion diseases are a group of fatal neurodegenerative disorders. the commonest human prion disease is creutzfeldt-jakob disease (cjd). sporadic cjd is genetically characterized by a lack of pathogenic mutations in prnp gene but methionine/ valine polymorphism at codon determines the susceptibility to sporadic and other non-genetic forms of cjd. homozygosity for either methionine or valine increases the risk for acquiring cjd. aims: we searched for changes in prnp gene of healthy populations and scjd cases and compared genotypes of codon in order to prove differences among populations and non-familiar origin of scjd cases and also to confirm the influence of codon homozygosity on the disease development. material and methods blood samples from six populations (slovenian, afro-american, pima indian, cheyenne indian, finnish, german) and brain or blood samples from scjd slovenian cases were collected and dna was extracted. pcr-ssca was performed and changed samples were sequenced. introduction tumour suppressor gene rassf encodes different isoforms, derived from alternative splicing and differential promoter usage. the major transcripts a and c are expressed in all normal tissues, but transcript a is missing all cancer tissues. loss of expression is mainly corellated with methylation of the cpg island promoter sequences of rassf a but mutations in exons have also been found. we examined the status of promoter methylation and potential changes in the coding region of the rassf a gene in colon cancer tumours. materials and methods isolated dna from tumours of colon cancer was used for exon amplification of rassf a gene. for identification of mutations and polymorphisms ssca was used. abnormal patterns on ssca plates were sequenced. for determination of methylation status of the cpg islands we used cobra method. results cobra analysis revealed the hypermethylation of cpg islands. sequencing analysis of exons showed different nucleotide changes. we identified c>a mutation (r s), g>c mutation (d h), g>t mutation (a s), g>a mutation (r h), g>a mutation (r q) and c>a mutation (l i). r s, d h, r h and l i mutations have not been published yet. conclusions these results indicate that hypermethylation of the promoter of rassf a gene in colon tumours and missense mutations in protein itself could be involved in tumorigenicity of colon cancer. introduction pineal lesions are rare and comprise , - % of all intracranial tumors. various histological types of tumors arise in the pineal region. the aim of this study was to determinate histological types, immunohistochemical expression, age and sex distribution of lesions in pineal region. twenty-four expansive lesions in the pineal region, obtained between and , were analyzed. formalin-fixed, paraffin embedded surgical specimens were stained routinely and immunohistochemically for panel of antibodies; synaptophysin, neuron specific enolase, neurofilament, chromogranin a, glial fibrillary acid protein, cytokeratin, carcinoembrional antigen, β-hcg, human placental antigen, α-fetoprotein and ki- . results histology revealed six germinomas, seven pineocytomas, three pineoblastomas, five glial cysts and one ganglioglioma, pilocytic astrocytoma and epidermoid cyst. the study group consisted of females ( , %) and males ( , %) ranged from to years of age. all germinomas were in male patient while glial cysts were diagnosed in female patients. slightly female predominance was observed in pineal parenchymal tumors. immunoreactivity for neuron specific enolase, synaptophysin, neurofilament and for chromogranin a was positive in the pineocytomas, and partially expressed in pineoblastomas. the mean ki- index in pineoblastomas and germinomas were significantly higher than in pineocytomas. germinomas showed focal immunoreactivity for β-hcg, human placental antigen, α-fetoprotein and low immunoreactivity for cytokeratin and carcinoembrional antigen. conclusion the most common tumors are pineal parenchymal tumors and germ cell tumors. glial pineal cysts are also common. occasionally other types of tumor are found. immunohistochemistry is an important method in differential diagnosis of pineal tumors. immunohistochemical study of the metastatic brain tumors with accent of the role of thyroid-transcription factor- introduction the exact diagnosis of the metastatic brain tumors /mbt/ is challenge for the surgical pathologist especially in a case of unrecognized primary site. the aim of this study was to determine reliable immunohistochemical panel based on the histological features of the mbt. materials and methods sixty five cases with solitary mbt operated in neurosurgical department of the hospital were examined from the time period - ; thirty nine were of unknown primary origin ( %). immunohistochemical studies were performed using antibodies to ck-s, ema, nse, synaptophysin, psa, vimentin, s- protein, hmb , ttf- and gfap. results diagnosis of the mbt of unknown origin were as follow: squamous cell carcinoma - cases from total , small-cell undifferentiated - from , large cell undifferentiated - from , adenocarcinoma - from , adenosquamous - from , clear cell - from , papillary carcinoma - from , tubular - from , spindle cell - from , unclassified - from . the primary site of adenocarcinoma, undifferentiated small and large cell and clear cell carcinoma was established by using ttf- (positive in from lung cancer, . %), neuroendocrine markers, ck- and psa. after the investigation only three tumors were of unknown origin ( . %). the origin of the rest unknown before studies of mbt, confirmed with radiographic and endoscopic data were: lung - from total, breast - from , kidney - from , skin- from , thyroid gland - from , stomach - from , prostate - from . the colon, testis and ovary, at one case each, were known before operation. conclusions immunohistochemistry remains important and still very helpful method in determining primary origin of the mbt generally in undifferentiated neoplasmes and adenocarcinomas. among the most reliable tumor markers should be included ttf- , for its frequent expression in the lung cancer, predominant among mbt. brain calcification simulating brain tumour. a case report a shmeleva, s romodanov neurosurgery institute, academy of medical science of ukraine, kiev, ukraine objectives the aim of this study was to describe the plural calcifications in the brain. the patient was a -year-old man. he had a severe headache and disorientation, he felt weakness in the left arm. the patient was mentally handicap. st scan showed a tumour located in the deep parts of the right temporal lobe. with a working diagnosis of tumour, the patient underwent the operation. the surgical specimens were prepared by standard histological techiques. results macroscopically, the lesion appeared as a stone. a histological examination demonstrated a massive deposits of calcium in the parenchyma of the brain. calcification developed as small granules in the vessels and calcospherites of various dimensions were formed by confluence. there were zones of haemorrhage, neuronal loss, edema and proliferation of astrocytes. conclusions this patient is an interesting clinical case of dementia characterized pathologically by diffuse calcification. carcinoid tumour metastatic to the orbital muscle. a case report introduction optical contrast is sensitive to monitor dynamic and functional changes, such as blood concentration, tissue oxygenation, and cellular swelling. optical imaging has been widely employed in clinical applications including the investigations of functional neuroanatomy and neuroactivity. due to the overwhelming scatter of light during the propagation inside biological tissues, past attempts to visualize brain architectures non-invasively with the optical contrast have been severely restricted by the unsatisfactory spatial resolution. the aim of this study was to investigate the feasibility of a novel non-invasive transcranial imaging of the structure and function of brain in vivo accomplished with laserinduced photoacoustic tomography (pat). material and methods pat visualized the tissue structures in rat/mouse brain based on the high sensitive intrinsic optical contrast while utilizing the diffraction-limited high spatial resolution of ultrasound. results two-dimensional (or three-dimensional) rat (or mouse) brain structures, with and without lesions, were imaged clearly. in response to whisker stimulation, functional cerebral hemodynamic changes in cortical blood vessels around the whisker-barrel cortex were also mapped successfully. pat imaged hyperoxia-and hypoxia-induced cerebral hemodynamic changes as well. conclusions this study demonstrates that (i) structural pat of soft tissues lesions in the brain presents high intrinsic contrast, (ii) functional pat based on intrinsic optical signals can map the hemodynamic changes in the cerebral cortex and (iii) in contrast to other previously used optical methods, this technique enables completely non-invasive neuroimaging with high spatial resolution transcranially. this novel functional neuroimaging technique, will help to advance the research in neurophysiology, neuropathology, and neurotherapy significantly. microscopic disorders of cortical development of brain and the etiopathogenetic relevance of their detection in patients with temporal lobe epilepsy due to hippocampal sclerosis introduction hippocampal sclerosis (hs) represents a common structural basis of temporal lobe epilepsy (tle). however, the etiological factors and mechanisms leading to its development still remain unexplained. the aim of this study was to identify the disturbed neuronal migration and differentiation (nmd) in the temporal lobe resected for hs and to evaluate its potential role in the individual pathogenesis of hs. we present neuropathological findings in the resected hippocampus and the pole of the temporal lobe in patients with hippocampal sclerosis with an attention paid to the histopathological identification of defects of nmd in the temporal lobe. the morphological findings were correlated with the results of clinical examinations and the patients´ histories. results 'initial precipitating injuries' that are thought to cause the development of hs (febrile seizures in early childhood, head injury or meningoencephalitis) were present in the history of patients. in the remaining cases, no predisposing factors were found. defects of nmd were observed in cases; in three of these, no predisposing factors were identified in the patients´ histories. we suggest that in these cases, hs arises due to previously undetected disorders of cortical development. a latent neocortical malformation may also contribute to the development of hs in patients with an initial precipitating injury in anamnesis. conclusion histopathological examination of resected epileptic brain tissue can provide insights into the individual pathogenesis of epileptic disorders, especially by the detection of microscopic disorders of cortical development. supported by: gacr / /d , vz fnm , vz msmt and introduction cerebellar liponeurocytoma is a newly recognized rare clinicopathological entity of the posterior fossa, with advanced neuronal/neurocytic and lipomatous differentiation. the term 'cerebellar liponeurocytoma' was recently adopted by the who group to replace several other different terms used up to now. this tumour shows many morphological similarities to medulloblastoma and neurocytoma, but according to available literature has more favorable prognosis then typical medulloblastoma. we report a case of cerebellar liponeurocytoma in a -years-old woman who developed typical symptoms of a posterior fossa tumor. computed tomography (ct) scan disclosed a heterogeneous tumor mass in the left cerebellar hemisphere. the lesion was totally resected. methods the surgical specimen was rinsed in saline solution and fixed in % paraformaldehyde in phosphate buffer at ph . for hours, embedded in paraffin and prepared for histological and immunostaining. results microscopically, the tumor was composed of small less differenerentiated, round or oval closely packed medulloblastomalike cells and vacuolated cells with macrovesicular lipid accumulations giving in some large areas an appearance indistinguishable from mature fat cells. glial and neuronal differentiation was histopathologically and immunohistochemically (gfap, nse, nf) noted. these cellular components were intermixed in different proportions without distinct separation. many tumor cells of all types showed single or multiple smaller lipid vacuoles in their cytoplasm. conclusion our case provides evidence that mature adipose-like tissue in these tumors appears as result of progressive lipidization of neuroectodermal tumour cells rather than as result of adipose metaplasia. introduction determination of proteins taking place in the control of proliferation in normal cells helps a better understanding of cellular transformation and proliferation mechanisms. object although they do not arise from a tissue normally thought to be a target tissue for progesterone, meningiomas show a number of epydemiologic and clinical features which suggest that females sex hormones can play a role in their development (higher incidence of meningiomas in woman, rapid progression of symptomas and icreasing in size during the pregnancy and during the luteal phase of the menstrual cycle, as well as significant association of meningiomas with obesity and breast carcinomas). the aim of our study was to investigate the progesterone receptor contents of bening meningiomas (who gr. i), which is completly excised and evaluated possible relationship between receptor content and sex and age of the patients, histological tipe of meningiomas and localisation of tumor. material and methods tissue samples, fixed in formalin, and embedded in paraffin were evaluated immunohistochemically for progesterone receptors using specific monoclinal antibodies. the correlation between number of positively nuclei and progesteron status was determined by the analitic statistical test mann-whitney. % of the meningiomas tested were positive for progesterone receptors. progesterone receptors in the benign meningiomas in the male patients was significantly higher when compared to the female patients (p< , ). neonatal intractable seizures revealing diffuse and bilateral cortical dysplasia. a case report s bellefqih , c rambaud , t lacaze , jj hauw , g lyon , d seilhean groupe hospitalier pitié-salpétrire, paris, france hôpital antoine-béclre, paris, france cerebral cortical dysplasia is generally focal and sometimes related to tuberous sclerosis. it is believed to result from disrupted neuronal migration during cortical development. we report an unusual case of neonatal diffuse and bilateral cortical dysplasia revealed by refractory epilepsy. a male infant, born at weeks' gestational age (ga) without familial history of neurologic disease, presented at birth a convulsive encephalopathy, associated with severe hypoxia with pulmonary hypertension and iterative hypoglycemia. a foetal goitre was attributed to hyperdose therapy for maternal graves' disease between and ga. the patient died at weeks of life from respiratory failure after intensive care. all the iso-and allocortical areas examined were normal at gross examination, but microscopically dysplastic. there was disorganization of the laminar architecture and presence of large multipolar neurones diffusely distributed over the cortex. they showed positive immunoreactivity with neurofilaments and synaptophysin, and were negative with gfap and vimentin. numerous ectopic neurons were found in the white matter. in addition, c shaped thickened inferior olive was noted. the cerebellum, including dentate nuclei, and other brain stem nuclei were normal. focal cortical dysplasia lesions are localized malformation of the isocortex with positive gfap and vimentin in dysplastic neurons. in this case, the dysplastic lesions were diffuse and astrocytes were normal. no genetic investigation was available, but the negative immunostaining of large cells by gfap does not favour the diagnosis of tuberous sclerosis. the pathogenesis of this exceptional disease remains obscure but the responsibility of the foetal thyroid disorder cannot be excluded. structural genomic abnormalities of chromosomes and in myxopapillary ependymomas in an attempt to clarify the chromosomal status of these tumors and identify commonly aberrant regions in the genome we have combined molecular/cyto/genetic methods to study genomic abnormalities in mpe. comparative genomic hybridization analysis of / tumors identified concurrent gain on chromosomes and as the most frequent finding. the majority of the tumors were also studied using microsatellite analysis ( markers for chromosome and markers for chromosomes ) and interphase-fish with centromeric probes for chromosomes and . our combined results were consistent with polysomy and in cases, polysomy either or with partial gain in the other chromosome in cases, tetrasomy or partial gain either or with complex rearrangement in the other chromosome in cases. in the remaining cases allelic imbalance alone of either chromosome or was identified. other numerical abnormalities observed included gain of chromosomes , , , , , , , q, and x and loss of chromosomes and . the combination of gains of genetic material from chromosomes and seems to be common in mpe and may represent genomic events of importance in the development of the tumor. nonsymptomatic nontumor cysts of the pineal gland: frequency and morphological characteristics the effect of bcl- protein and ki- expression on the prognosis of medulloblastomas introduction medulloblastoma is the most common primary central nervous system tumor in childhood and accounts - % of all intracranial neoplasms in children. aim: in this study the correlation between the patients survival and prognostic factors (ki- and bcl- ) and the tumor size in ct scan were evaluated. material and method selected cases were analyzed. immunohistochemical staining was applied as polyclonal antibody for ki- (dako-a- ) and monoclonal antibody for bcl- (bcl- / /d novo castra) on paraffin blocks.fisher's qhisquare, correlation and mann-whitney-u tests were used for the statistical analyses. results the ages of these patients were ranged between - (mean . ).the size of the tumoral mass varied between to centimeter. patients were alive without illness. patients were lost due to tumor. we could not found a statistical revelance between neither immunohistochemical staining (bcl- , ki- ) nor tumor size on survival rates. conclusion due to radiotherapy and chemotherapy following surgery, the survival rates of medulloblastoma has increased despite the agresiveness of the tumor. there are reports showing no correlation between expression of the bcl- with the outcome of patients. further investigation about the correlation of the prognostic factors with the outcome is required. introduction results of glioma treatment are still unsatisfactory. an accurate histopathological study supplemented with examination of tumour parameters, like proliferation potential and apoptosis may be invaluable in designing an individualised therapy. the aim of this study was to analyze clinical data and histo-clinical correlations in recurrent brain tumours of astrocytic origin. one hundred surgically removed supratentorial gliomas were studied (mean age: . yrs). histological grade was determined according to who classification and the daumas-duport scale (st.anne/mayo). proliferation activity was measured using the pcna index and agnor count. the expression of bcl- protein was examined with immunohistochemistry. results and conclusion the initial symptoms of glioma were headaches and vomiting ( %), paresis ( %), epilepsy ( %) and aphasia ( %). the tumour location was predominantly in the left hemisphere, in the temporal ( %), parietal ( %) and frontal ( %) lobes. the pcna index correlated with who grade (giiindex %, giii - - % and giv - %). for grades i, ii, iii and iv progression free survival (pfs) was: . , . , . and . months respectively. the agnor count did not correlate with who grade, daumas-duport grade or pfs. bcl- expression was observed in single cells in gi and gii tumors, in % and % of cells in giii and giv, respectively. the daumas-duport scale is simple and useful in prognosing. bcl- expression does not correlate in a linear manner with tumour grade. as gliomas are extremely heterogeneous, for better characterization of the clinicopathologic correlations new prognostic factors are needed. introduction schilder's type of myelinoclastic sclerosis is rare variant of multiple sclerosis in children and young adults. usually, brain lesions occur in the white matter like solitary, or less often multifocal, acute plaques ranged in diameter more then cm. case report the -year-old female patient was referred to our hospital with progressive right-sided hemiparesis, motor dysphasia and frontal lobe syndrome. symptoms started days earlier with acute headache and no febrile state was reported. mri of the head revealed two oval lesions with hyperintensity in t weighted images of left frontal and parietal lobe. the first diagnostic impression was of glioblastoma multiforme. results from standard blood and urine tests, tumor markers and cytological analysis of bone marrow were normal. analysis of csf and culturing csf and serum for bacterial, viral, protozoan and fungal infections were negative. analysis of csf revealed increased immunoglobulins, ocb and increased intratecal synthesis of igg. a stereotactic biopsy was performed one month after first symptoms. neuropathology findings. the biopsy after neurosurgical treatment yielded five needle cores of grayish cerebral tissue. hematoxylin and eosin-stained sections of paraffin embedded tissue showed demyelinating white cerebral tissue with relatively sharply defined margins. lesion was infiltrated by macrophages (cd immunopositive cells and luxol fast blue negative) and large reactive astrocytes with ki and pcna nuclear positivity. around blood vessels were scattered perivascular cd and cd lymphocyte. silver impregnation and nf immunostaining showed that the axons within the plaque are attenuated but not destroyed. conclusion clinical and pathological findings suggested a demyelinating disease destroyed huge parts of white matter in before health mid-aged women, without previous infection or vaccination. accordingly we diagnosed schilder's type of ms. stereotactically guided brain biopsy: six years' experience of pathologic interpretations from turkey e erden , a okcu heper , a savas ankara university, school of medicine, pathology department, ankara, turkey ankara university, school of medicine, neurosurgery department, ankara, turkey introduction stereotactic biopsy is a widely used procedure in brain lesions. the aim of this study was to analyse the reasons of the discordance between the results of the intraoperative crush preparations (icp) and final permanent paraffine preparations (fppp) of stereotactically guided brain biopsies (sgbb) in our hospital, and find out the clinical benefits of this procedure. total ct and/or mri guided brain biopsies performed between - were analysed retrospectively. icp and fppp preparations were evaluated and discordant cases were detected. then we evaluated the reasons of discrepancies. results the correct diagnosis was achieved by stereotactic biopsy in . % of the patients. of them were diagnosed as neoplasia and were diagnosed as non-neoplastic pathology. there was discordance between icp results and fppp diagnosis in . % of the stereotactically diagnosed patients. the patients diagnosed as neoplasia were treated by rt and/or kt and the non-neoplastic pathologies were taken in suitable treatment and follow-up scheme. conclusion to improve the diagnostic accuracy of the sgbb, the following items should be taken into consideration: the quality of the icp with giemsa staining is very important. in the biopsies from the lesions, which are suspected as neoplasia having, microscopic features such as gliosis, edema, hemorrhage must be interpreted as non-diagnostic. the number of the biopsies must be increased in the presence of necrosis. epitheloid and pleomorphic cellular groups can mimic benign and malignant pathologies. interpretation of the icp and the fppp should be done by the same pathologist. intraneural capillary haemangioma of spinal nerve root. case report p xirou , s barbanis , i efstratiou , p sevastiadou , i tsitouridis papageorgiou general hospital, department of pathology, thessaloniki, greece papageorgiou general hospital, department of radiology, thessaloniki, greece intraneural haemangiomas of the spinal nerve roots are rare. the few cases reported in the literature are usually of the capillary and less often of the cavernous type. these lesions occur in adults, mainly males and the majority of them are located in the cauda equina. a case of intraneural capillary haemangioma involving one lumbar nerve root is reported. the patient, a year old male, presented with a -year history of severe intermittent low back pain. magnetic resonance imaging detected an intradural, extramedullar, space occupying mass at the level of l -l , causing displacement of cauda equina roots. laminectomy and complete removal of the lesion were performed without neurological problems. on gross examination the resected specimen was a redbrown, well demarcated, lobular mass, measuring . cm in greatest diameter. remnants of a nerve root were recognized at the periphery. histological examination showed that the lesion was located within the endoneurium. it consisted of multiple small dilated capillaries, often showing incomplete lobular pattern, dispersed within normal nerve fascicles. the endothelial lining showed neither nuclear atypia nor mitotic activity. in the substrate mild edema and focal inflammatory lympocytic infiltrations were found. haemangiomas of the spinal nerve roots often pose a challenging diagnostic problem, and knowledge of their existence is relevant since they can mimic other more frequent tumors of the region. introduction sensorimotoric polyneuropathy has rarely been reported as a presenting paraneoplastic neurological disorder associated with anti-hu antibodies. electrophysiological studies suggest a dysfunction of axon-schwann cells, but the exact pathological mechanisms remain unclear. case report a -year old woman with short history of weight loss and parastesias in the legs was admitted to the hospital. triparesis and dyspnea were found. mri scan showed leukencephalopathy, eeg revealed diffuse encephalopathy. sensorimotoric axonal polyneuropathy was present in emg, and small lesion in the lung was found on the ct scan. anti-hu antibodies were present in the serum and in the cerebrspinal-fluid. autopsy revealed macrocellular adenocarcinoma of the lung with neuroendocrine differentiation and sensorimotoric neuronopathy/ encephalomyelitis. methods the brain, spinal cord, sensory ganglia and a part of sural nerve were fixed in formalin, paraffin embedded and stained with h&e. other part of sural nerve was prepared for immunofluorescence, semi-thin and ultra-thin sections. results axonal degeneration without any inflammatory reaction and a very few signs of regeneration were found in the sural nerve. the inflammatory destruction of spinal ganglia neurons, axonal degeneration in dorsal columns and motor neurons inflammatory destruction in the spinal cord were found. neuronal degeneration, glial proliferation, perivascular inflammatory infiltrates and some cd + lymphocytes surrounding single neurons were a common finding in the brain. conclusions this study shows that inflammatory destruction of the spinal ganglia neurons and motor neurons in the spinal cord was the main cause of clinically rapidly progressive sensorimotoric polyneuropathy in the anti-hu positive patient with macro cellular lung carcinoma with neurendocrine differentiation. isolated extranodal spinal rosai-dorfman disease. a case report ai freitas rc silva l costa, v velasco, p monteiro, m teixeira, f pardal de oliveira hospital de sao marcos-serviço de anatomia patológica, braga, portugal introduction sinus histiocytosis with massive lymphadenopathy was first described in , by rosai and dorfman, as an idiopathic histiocytic disorder, which typically involves lymph nodes. lately, involvement of many other organ systems has been documented, either alone or in association with nodal manifestations. nowadays, rosai-dorfman disease is a wellrecognised clinico-pathologic entity. extranodal disease has been reported in % of the reported cases, occasionally representing the first and exclusive manifestation of the disease. although central nervous system involvement has been well documented, the spinal canal is affected only exceptionally. we report a case of an isolated extranodal spinal rosai-dorfman disease with review of the literature. the authors describe a old woman with a history of spastic hemiparesis in which radiology disclosed a dural-based intramedullary spinal cord lesion at c level. the authors describe the histologic and immunohistologic features of the lesion and discuss the differential diagnosis. conclusion isolated cns rosai-dorfman disease without contemporary lymph node involvement can be a diagnostic challenge. pathologists must be aware of this disease in order to make a correct diagnosis and avoid diagnosis of malignant histiocytic lesions. ezrin immunoreactivity: is it a usefull marker for the prognosis and grading of astrocytoma? ie gurer , ga gökhan , t uçar akdeniz university scholl of medicine department of pathology, antalya, turkey akdeniz university scholl of medicine department of neurosurgery, antalya, turkey introduction the actin-binding protein ezrin is supposed to increase the invasiveness of the malignant cells. in this study, the value of ezrin immunoreactivity (ir) was invastigated as a grading and prognostic parameter in astrocytomas. material and method ezrin ir was studied in low grade and high grade astrocytomas. the mean age of the patients was . . monoclonal ezrin antibody (ms- -r neomarkers) was applied on the sections of the paraffin-embedded tissues. immunostaining intensity of ezrin was estimated as semiquantitatively. when no staining was visible the score of , mild staining scored as , moderate , and severe staining scored as . also positive stained areas were evaluated as percantage ( %, - %, above % staining areas). statistically man-whitney u, kruskal wallis and spearman tests were used. results there was no correlation between prognosis and neither the grade nor the staining intensity of ezrin ir. conclusion there are controversial reports especially about the prognostic value of ezrin ir in different types of tumors. there is one report about the association of ezrin ir with the increasing malignancy of astrocytic tumors. results of our study revealed no evidence of correlation between prognosis and ezrin ir for grading of astrocytomas. we conclude that ezrin is not a usefull factor for the prognosis and grading in astrocytomas. introduction hereditary cystatin c amyloid angiopathy (hccaa), an autosomal hereditary disease uniquely found in iceland, usually leads to early death of young adults from cns vascular complications following a disease progress of several years. histopathological characteristics are cystatin c amyloid deposits in meningocerebral blood vessels, narrowing, splitting of media, segmental fibrinoid necrosis and microaneurysms of small arteries and arterioles. associated changes: hemorrhages, infarctions and reparative reactions depending on length of the disease course. this study is a part of an investigation mapping the distribution of cystatin c immunopositive deposits outside the cns in hccaa. material and methods formalin fixed, paraffin embedded autopsy material from patients, females and males, was studied by conventional light microscopy (he, congo red; thioflavin s) and immunohistochemistry (avidin-biotin-peroxidase) with cystatin c antibodies (abc-complex kit from vector). for electron microscopy and specific identification of cystatin c deposits specimens were fixed in macdowell's fixative and embedded in l.r. white resin and immunogold labelled (colloidal gold labelled protein a. sigma). results and conclusion cystatin c immunoreactive deposits were found in most organ systems outside cns. the deposits were primarily located in the adventitia and perivascular tissue of small blood and lymphatic vessels and vascular smooth muscle; in subepithelial connective tissue of intestinal surface epithelium and glandular epithelium; in peripheral nerves. cystatin c immunoreactive blood vessels were not obviously damaged as those in the cns possibly reflecting environmental factors different in these two separate locations not yet identified and characterized. details of cystatin c deposition in the vascular walls will be demonstrated. neurological disorders are among the most prominent clinical manifestations of antiphospholipid syndrome (aps). they are predominantly related to thrombo-occlusive vascular events in central nervous system, vasculitis playing little or no role. case report a -year-old female with a history of seven spontaneous abortions presented with sudden onset of pain and numbness in her right and later left foot followed by pruritic rash over her hands and back and livedo reticularis around knees. emg showed signs of axson injury in multiple nerves. laboratory tests showed lymphopenia and antiphospholipid antibodies of igg class in medium titer at the begining and in low titer three months later. anca, ana, ena, anti-dna were negative, platelet count, complement, lupus anticoagulant and tumor markers were normal. sural nerve biopsy revealed active necrotizing arteritis of small epineural arteries. intimal circular fibrinoid necrosis was accompanied by pyknosis, karyorexis and myofibroblast proliferation in media. inflammatory infiltration by lymphocytes, macrophages, plasma cells and segmented leucocytes was present in intima, but was most prominent in adventitia. thrombosis in organization was observed. vasculitis was present also in arterioles and venules. immunofluorescence showed scarce focal granular deposits of igm, iga class, and complement components c and c q in media of small epineural arteries, together with abundant fibrin deposition. it has been suggested that aps can not be the cause of vasculitis and that vasculitis in aps is associated with an independent underlying disease, such as systemic lupus erythematosus. except for suspected aps, our patient did not fulfill the criteria for any systemic autoimmune disease that could present with vasculitis. immunoautoradiographic characterization of serotonin transporter in human pineal gland m the mechanism that regulates human pineal gland melatonin synthesis is not completely clear. in fact, several studies performed on animals demonstrated the possible role of serotonin and the involvement of its receptors -ht( c) and -ht( a) in the modulation of this process even if is not clear how it is realized. the aim of our study is to verify the presence of serotonin transporter (sert) in the pinealocytes, a molecule involved in the reuptake of -ht from synaptic space, and to represent the action site of i.r.s. antidepressant drugs. we tested with immunoautoradiographic method (iarg) frozen slices conserved at - c o , derived from twenty cadaveric epiphysis ( men, women) by utilizing a mouse monoclonal anti-sert antibody followed by a secondary biotinilated anti-mouse igg antibody, consecutively linked with an avidine/[ h]-biotine complex for a precise localization of the researched molecule. the tritium sensitive films were exposited to treated slices in special cassetes. after thirty days of exposure at - c o , the films have been developed and fixed to obtain auto radiographic images in which the radioactivity distribution followed a continuum pattern in sequential slices of each subject. it was the expression of sert presence in epiphysis. this is the first study that demonstrate the presence of sert in human epiphysis. we suppose that serotonin in human is not only a melatonin precursor synthesized in the pinealocytes but it is involved in the neuroendocrine regulatory mechanism of the gland. loss of heterozygosity (loh) studies allow to identify sites harbouring tumor suppressor genes involved in tumor initiation and progression. this study was performed to establish the frequency of loh on chromosome q in glioblastoma. cases of glioblastoma were examined ( women, men; age: - years). two cases were secondary glioblastoma. in all cases the representative neoplastic tissue and normal brain tissue were cut out with lancet from respective paraffin blocks. dna was isolated with proteinase k with phenol/ chloroform extraction and isopropanol precipitation. polymorphic markers were localized close to three supressor genes pten (d s , d s ), lgi (d s ), dmbt (d s ) which are known to be lost or mutated in glioblastoma. the fith marker was d s q . . fragments were pcr-amplified and analysed using automated sequencer abi . signals from neoplastic and normal tissue were calculated. result under , was scored as loh. in cases at least one marker from chromosome q was lost. cases with loh were men, both secondary glioblastomas showed deletion in q. the mean patients' age with and without qloh was similar. cases showed loh only in pten locus. in cases deletions were stated in two or more loci, what might suggest loss of longer part of chromosome . cases with loh in q revealed additional changes in different chromosomes: loh in p ( cases), p ( ), q ( ), p ( ), q ( ), q ( ), q ( ), p ( ). our results are similar to the other studies, showing changes in q in about % of glioblastoma. histopathological changes of the skin in systemic lupus erythematosus ta vervekina, ba magrupov, gsh shamukhitdinova tashkent, uzbekistan introduction morphologic examination of the skin is of great importance for the diagnosis of various nosologic forms of rheumatic diseases. the aim of the present study was to evaluate histopathologic changes in skin biopsies of patients with systemic lupus erythematosus (sle). material and methods skin biopsies of patients ( women and men; age range from to years) with preliminary diagnosis of sle, based on clinical data and laboratory analyses, were studied with the purpose to specify the differential diagnosis. biosy tissue specimens were fixed in % neutral formalin, embedded in paraffin, and serial sections were stained with haematoxilin-eosin, picrofuxin, and the combined rhitter-olesson staining. after treatment of the specimens with . % trypsin, direct immunofluorescence technique was carried out for detection of immunoglobulins g and m at the dermo-epidermal junction (lupus band-test). results our study established the presence of hyperceratosis with formation of keratic clogs, epidermal atrophy with vacuolization of basal cells, vasculitis, eosinophilic degeneration of collagen and an atrophy of appendages. specific immunostaining for immunoglobulins g and m at the dermo-epidermal junction was observed in all except in cases. we did not observe inflammatory cell infiltrates in dermis in any case. conclusion the pathogenesis of skin histologic lesions in sle is most likely associated with immunological reactions and therapy carried out earlier. structural peculiarities of different nevuses and their prognostic value e stupina first tashkent medical institute, tashkent, uzbekistan for the time being the causes of skin melanoma have not been clearly understood. development of skin melanoma was related to preceding pigment formations in % to % of patients. among a variety of investigation methods histologic one is basic to establish the final diagnostic. complex morphologic study was carried out on skin biopsies with different types of pigment nevuses and melanomas. of them biopsies were selected for the thorough pathomorphologic investigation. light microscopy, electron microscopy and morphometric method were used. serial sections for light microscopy were stained with hemotoxylin and eosine, picrofuchsin-fuchselin by van-gizon, combined staining by riter and oleson. the findings have shown that the rate of pigment skin neoplasms of all the biopsy material of a specialized institution came to , % among neoplastic and , % among non-neoplastic skin lesions. pigment nevuses more frequently occurred in females aged to years applied for medical aid, while melanoma in ones above years. intradermal nevus was diagnosed in , % of cases, its proliferative activity was expressed in % of patients. in , % of patients skin melanona was assigned to - th grade of invasion according clark's classification. each form of pigment nevus had morphometric peculiarities, significantly differing in dimensions of the cell, nucleus and their ratio. the most reliable parameter of malignization was the length of the nucleus and cell axial section circle. of frequently occurred nevuses intraepidermal (borderline) one was more predisposed to malignization which was evident from significant increase of all morphometric parameters. introduction cutaneous ciliated cysts are a rare type of skin cyst, usually presenting themselves in women between the nd and th decades of life. their origin is unknown and has been related to müllerian remnants based on similarities of the epithelium to the fallopian tube, but the occurrence of cases in men has given rise to the possibility of a sweat gland origin. case report a year-old woman complained of an asymptomatic, longstanding, lesion located in the skin of the thigh. once removed it was seen to correspond to cyst with clear fluid inside. histopathological examination revealed a dermal cyst with ciliated cuboidal epithelium, usually double layered, but with some pseudostratified areas. occasionally, papillary projections were seen in the lumen. there was no evidence of cellular atypia or mitotic activity. immunohistochemical staining with oestrogen and progesterone receptors was strongly positive throughout the lesion. the clinical and histopathological findings fit in with the diagnosis of a typical cutaneous ciliated cyst of the lower limbs (cutaneous ciliated cyst). this is a rare cyst usually arising in the lower limbs of young women. its origin is unknown and the demostration of sex-hormone receptors has been used to favour the müllerian origin. nevertheless, some cases have been reported in men, which has diverted attention towards sweat glands as a possible origin of the cyst. the real incidence of the sex-hormone receptor if unknown, since it has not been clear in most published cases. introduction p protein is essential for the regulation of cell proliferation and its aberrant accumulation is usually seen in malignant tumors but, also, occurs in squamous epithelium of inflammatory skin diseases characterized by hyperproliferation. the aim of this study is to elucidate the role of the p tumorsuppressor protein in the pathogenesis of different hyperproliferative, non-malignant and malignant skin diseases, and association between p overexpression and cell proliferation. we also investigated the influence of ageing on p and ki- protein expression. material and methods hundred and fifty skin specimens, consisting cases of each, normal skin (ns), psoriatic skin (ps), keratoacanthomas (ka), basal cell carcinomas (bcc), squamous cell carcinomas (scc) were examined immunohistochemicaly to assess p and ki- protein expression. results p immunostaining of ns, ps, ka, bcc and scc was positive in . %, . %, . %, % and . % cases, respectively. p and ki- positive cells were present in basal (ns) and suprabasal layers (ps), and not only in cancer nests of ka, bcc and scc, but also in dysplastic and even morphologically normal epidermis adjoining cancers. the positivity of p and ki- protein differed significantly among the groups, with no differences in p expression between ns and ps, and in ki- expression between ps and ka. within all groups, there was a significant correlation between p and ki- protein expression. localisation and age were significantly related to p and ki- expression in all groups, except for localisation in ps, and age in bcc. conclusions our findings suggest that p overexpression occurs widely in neoplastic and non-neoplastic skin lesions. it is associated with the cell proliferation in normal, as well as, in changed epithelium. p accumulation is an age related process and significantly related to sun exposure, especially in ns and ps, as well as in ka and scc. we also suggest that p overexpression begins in the early stage of carcinogenesis, before the appearance of malignancies in skin, and may be a useful predictor for the detection of nonmelanocytic skin cancer. background maspin, a member of the serine proteinase inhibitor (serpin) family, has been recently pointed to as a tumor suppressor gene and angiogenic inhibitor. objectives of this study were to investigate role of maspin and beta-catenin in basal cell carcinoma (bcc). we studied immunohistochemically their expression in basal cell carcinomas together with trichoepitheliomas (te) and normal skin controls. microvessel count (mvc) was also done using fviii-related antigen. we examined the correlation of nuclear and/or cytoplasmic maspin expression with histological type, age, gender, invasion of safety margin, as well as stromal reaction (lymphocytic or fibroblastic. all primary antibodies (maspin, beta catenin and fviii-related antigen) as well as detection kit (abc peroxidase/dab quick test), were purchased from novocastra labs.uk. maspin expression was strongly cytoplasmic and membranously expressed in te and down-regulated in nodular bcc. nuclear maspin expression was found in . % of our cases. it was statistically positively correlated with invasion of safety margin (p= . ) and with infiltrative type (p= . ) and negatively correlated with a mvc > (p= . ). cytoplasmic maspin was correlated to a strong fibroblastic stroma (p= . ). beta-catenin expression was found in both te and bcc with the same intensity and was only correlated to younger age(p= . ). conclusion cytoplasmic maspin expression could differentiate between te and nodular bcc nuclear maspin expression could be related to aggressive behaviour of bcc and is realted to lower mvc (< ). introduction trichilemmal carcinoma (tc) is rare skin tumour occurring in the sun-exposed areas (largely on the face or ears) of the elderly. clinically, it may be mistaken for a squamous cell carcinoma, basal cell carcinoma, nodular melanoma or keratoacanthoma. although the histological picture suggests a high-grade malignant neoplasm, tc has an indolent course, and conservative surgical excision with clear margins is curative. aim: histological and histochemical examination of rare cases of tc of the skin. materials and methods we report two patients (males) with tc on the ears, presented as slow-growing nodules. tumour biopsy specimens were routinely fixed and processed. deparaffinized sections were stained by he, pas, pas-d. results histologically tumour cells showed a solid and a lobular growth patterns in continuity with the epidermis, with foci of pilartype keratinisation and peripheral palisading. tumour nests were mostly composed of large atypical cells with clear cytoplasm containing pas-positive, and diastase sensitive materials. these cases were treated only with surgical excision, and there has been no evidence since of local recurrence or metastasis. conclusion we believe that careful histopathological examination of pillar appendage tumours will help to classify the wide range of clinically and histologically different tumours and to establish the exact diagnosis. introduction pigmented cutaneous metastases from breast carcinoma are uncommon and may simulate malignant melanoma both clinically and morphologically. we report a case of a -year-old female who developed multiple cutaneous pigmented metastases twelve years after radical mastectomy for left breast carcinoma. materials and methods hematoxylin-eosin and immunohistochemically (streptavidin-biotin method) stained slides from three different regions of the chest skin and from the scalp plaque. results numerous darkly pigmented plaques and nodules have been developed over a -month period on the back of the chest spreading anteriorly to the right subcostal region together with large, focally eroded scalp plaque. histopathological examination revealed full thickness dermal infiltration and superficial subcutaneous fat involvement with cords and nests of neoplastic epithelial cells showing ductal structures and intracytoplasmic lumina in some areas. irregular nests and single tumor cells at epidermodermal junction were accompanied with melanophages in papillary dermis. immunohistochemically all tumor cells were cytokeratin positive and cytokeratin negative while epidermal and most superficial dermal nests showed hmb- and melan-a reactivity as well. scalp metastasis displayed less pronounced epidermotropism and only focal, single cell hmb- and melan-a positivity. conclusion epidermotropic breast carcinoma metastases may mimic malignant melanoma not just clinically and morphologically but also immunohistochemically and that might be related to the location of metastatic lesions. immunolocalization of lactoferrin in pigmented lesions of the skin g barresi, g giuffre, f fedele, m grosso, v barresi, g tuccari department of human pathology, university of messina, messina, italy lactoferrin (lf) expression has been immunohistochemically investigated in formalin-fixed paraffin-embedded bioptic skin samples ( nevi, melanomas, vulgaris or seborrhoic pigmented warts, pigmented basal cell carcinoma; specimens of normal skin were utilized as control. on µm thick sections, depigmentation and antigen retrieval procedures were performed. lf immunoreactivity was revealed by a rabbit anti-human lactoferrin (dako, denmark, : ), incubating all sections at c overnight; successively, bridging antibody and pap complex for min at room temperature (rt) were applied. for the demonstration of peroxidase activity, the sections were incubated with - ' diaminobenzidine tetrahydrochloride-h o substrate solution for min at rt in darkness; slides were then slightly counterstained with mayer's haematoxylin. quantification of lf immunoreactivity was performed using the intensity-distribution (id) score based on both the percentage and the staining intensity of positive neoplastic cells. an evident cytoplasmic immunoreactivity for lf was encountered in melanocytes, either in nevi or in melanomas; no ap-preciable differences were found among junctional, intradermic or compound nevi as well as between spindle or epitheliod cells melanoma. basal cell carcinomas were always unstained, even if some degree of positivity was found in areas which showed squamous differentiation; sheets and whorls of keratin also exhibited a strong immunoreactivity, when encountered in warts. if the lf immunoexpression could represent the result of an endogenous synthesis by cells in order to have greater availability of iron for their metabolism or to modulate an unspecific inflammatory or anti-oxidant response remains to be fully understood. cutaneous melanomas were detected at an increasing rate worldwide. even thought many patients are diagnosed at an early stage, the death rate continues to rise due to the increasing incidence of more advanced lesions. the aim of this study is to detect in cases of malignant melanomas. materials and methods analysis were performed in paraffinembedded cases of cutaneous malignant melanomas ( cases in situ and cases invasive melanomas). apoptotic index (ai) was determined using the in situ end-labeling technique(tunel), who quantify apoptotic cell death at single cell level and tissues. discussion and conclusion ai was high in the cases of in situ melanomas, but in invasive melanomas (nodular melanomas, superficial spreading melanomas with vertical growth phases, acral lentiginous melanomas etc) ai was decreased in tumor cells. we considered that usually apoptotic cells represent ~ % of tumor cells. at cases of cutaneous malignant melanomas in which ai was high ( %), frequently at in situ melanomas, the prognostic is good, when in the others cases in which apoptosis is missing or is very rare in cells ( %), the prognostic is reserved. this nonmorphologic technique to evaluate the prognosis of melanoma must be regarded as investigational and cannot yet be recommended for routine application. all necessary pathologic data, such as tumor location, size, depth, ulceration, mitotic activity and growth phase, can be obtained by examination of standard microscopic preparations of malignant melanoma as stained with hematoxylin and eosin. introduction small vessel vasculitis is a group of disorders of unknown etiology, possibly associated with connective tissue disease (ctd). the aim of this study is to find correlation between clinical, morphological and immunological changes in the skin and muscle biopsies of the patients with ctd, where small vessel vasculitis is the main finding. we analyzed skin and muscle biopsies from patients with ctd: dermatomyositis, systemic sclerosis, syndroma raynaud, vasculitis, sle, polyarteritis nodosa. were females, and males. the age of the patients was between - . standard histological and histochemical stainings (he, pas, van gieson-elastica) were done. small vessel vasculitis was found throughout skin and muscle biopsies, characterized with thickening of the basal lamina, tiny fibrinoid necrosis (if present), swollen endothelial cells and perivascular edema with lymfocytes. the muscles were necrotic with regeneration and fibrosis and reduction in the intramuscular capillaries. the changes were positive on pas and elastic tissue staining. direct immunofluorescence technique was done with antihuman igg, igm and iga antibodies. granular or linear immunofluorescent deposits were found at the dermo-epidermal junction zone and in the vessel walls. antinuclear antibodies were done by indirect immunofluorescence technique using serum from same patients of which % were positive. lymphoid cells around the vessels and in healthy muscle fibers were positive for markers for t cells (cd ro and cd ). conclusion there is correlation between morphological and immunohistochemical changes. the presence of immunologic deposits in the vessels suggests possible autoimmune etiology. cutaneous angiomyolipoma introduction angiomyolipoma is a benign tumor almost exclusively seen in the kidney. cutaneous angiomyolipoma (aml) is a very rare benign vascular tumor that consists of a proliferation of blood vessels, smooth muscle bundles, and mature fat tissue. aml occurs more often in adult male patients and is often seen in acral locations. case report a -year-old man who had a -year history of a painless, solitary, noninvasive nodule on the right auricle lobule. the patient had no signs of tuberous sclerosis. material and methods the lesion was cm in diameter and clinically appeared to be a lipoma. the lesion was excised. skin specimens was fixed in % buffered formalin, routinely processed, and embedded in paraffin. it was examined by routine light microscopy with histochemical and immunohistochemical stains. results on sections, the lesion was a well-circumscribed nodule in the dermis. there was fibrous pseudocapsule around it. the nodule was composed of an intimate mixture of mature adipose tissue, blood vessels, and bundles of smooth muscle cells. combination of different types and sizes of vessels were particularly evident. cellular pleomorphism, mitotic figures, and mucoid degeneration were absent. reactivity for hmb- was negative. the histopathological diagnosis was angiomyolipoma. conclusion amls are very rare at extrarenal locations. in , argenyi presented the first report of cutaneous angiomyolipoma in the upper helix of the ear. the reported lesions were located at acral sites. as most cases of angiomyolipoma were long-standing lesions located at acral sites, and therefore exposed to external forces, some angiomyolipoma could be considered to be a degenerated with replacement by fatty tissues. the primary b-cell cutaneous lymphoma is a low frequent disease in a general hospital. its nodal equivalent has very different behaviour and prognosis. aims: to study the incidence, behaviour and follow up of the b-cell cutaneous lymphomas in our hospital over a period of years. material and methods in a total of cases between and we have cases of b-cell cutaneous lymphoma. the skin biopsies were diagnosed acording eortc classification. we did histological and immunohistochemistry studies. these included cd , cd , cd , cd , cd , bcl- and ki . results eith cases of were salt and cases were folicular lymphomas. the ages are between and and is no sex predominance. salt lymphomas were located two in the face and six in the trunk. all the cases of folicular lymphoma were in the face. the immunohistochemistry study in salt lymphoma showed positivity for cd and cd and negative for cd , cd and cd . the expression of ki was very low. the reactive foliculars centers were demostrated with the negativity of bcl- . the folicular lymphomas showed positivity for cd and cd and the number of positive cells for ki was bigger. conclusions in a general hospital in our country the incidence of b-cell cutaneous lymphoma is very low. the majority of the cases arrive with surgical excision, that is a good therapeutic approach. the general pathologist must be aware with reactive limphoid infiltrates because the majority of the cutaneous lymphomas are low grade neoplasies. background cd expression is a distinct feature of both b and t cell activation. the presence of cd + large atypical lymphoma cells in a cutaneous infiltrate has been considered a characteristic feature of lymphomatoid papulosis/cutaneous cd +. recently, however, cd expression has also been described in some nonneoplastic infiltrates of de skin. design twenty skin biopsy specimens from patients with scabies were evaluated. of these, the lesions had been present for more than months in cases. the diagnosis of scabies was based on the presence of characteristic clinical features and the demostrations of sarcoptes scabiei mite. for each biopsy, a panel of histopathological and inmmunophenotypic features was independently assesed by two pathologists. cd , cd , cd , cd and s- protein expression was evaluated in each case. results cd + cells, either in isolation or in small clusters, were seen in biopsy specimens ( / ; %). cd + cell clusters were located in the papillary and superficial reticular dermis and tended to show a perivascular pattern. all biopsy specimens obtained from long-standing (> months) scabies lesions demonstrated the presence of cd + cells. in contrast, no cd expression was observed in lesions of less than months duration. cd + large cells can be detected in skin inflammatory lymphoid infiltrates associated with scabies, particularly in long-standing (> months) lesions. cutaneous cd expresion, therefore, is not an exclusive feature of neoplastic lymphoid proliferations. probably as the result of persistent antigenic stimulation, cd expression can also be detected in activated lymphoid cells of nonneoplastic infiltrates associated with insect bites, viral and bacterial infections and peculiar drug reactions. introduction malignant transformation of melanocytes is a multistep process characterized by distinct histopathological stages. differentiation between naevi, especially dysplastic naevi and melanoma, can sometimes be difficult to assess by conventional histopathological analysis. the aim of this study was to analyse the differences in proliferative activity and apoptosis between intradermal naevi (in), dysplastic naevi (dn) and cutaneous melanoma (cm). materials and methods fifteen in, dn and cm (thickness less than . mm) were immunohistochemically stained for ki- which was used as a proliferative marker, whereas bcl- and p were used, respectively, as an anti-apoptotic and apoptotic marker. statistical analysis showed a signifficant difference in proliferative activity and the overexpression of p (p < . ), while observed differences in bcl- expression were not statistically significant between these three groups. conclusion proliferative and antiapoptotic activity showed a progressive growth from benign to malignant melanocytic lesions. the strongest expression of p in dn suggests that its overexpression could be the first step in the loss of cell cycle regulation and possible malignant transformation of melanocytes. introduction it is now known that myofibroblastic transdifferentiation in glomerulus takes place during mesangial activation. material and methods we analyzed functional disorders (filtration, concentration insufficiency) and kidney biopsies of patients aged from to years with various forms of glomerulonephritis. we used standard histological, immunohistochemical, immunofluorescence methods as well as electron microscopy in our research. for studying myofibroblastic transdifferentiation we stained tissue immunohistochemically for alpha-smooth muscle actin (alpha-sma) and then carried out a quantitative analysis of the results. results seventy patients had myofibroblasts in kidneys. we found out that level of alpha-sma expression correlates with decrease of glomerular filtration. while disorders of concentration a lot of myofibroblasts appear in kidney interstitium. but we have not found any correlation between clinical forms of glomerulonephritis and those cell growth we had seen. and we should mention that for patients without glomerular or interstitial fibrosis we didn't reveal any changes in cells phenotype. conclusion so we conclude that myofibroblastic transdifferentiation must be considered as an early symptom of kidney sclerosis and can be used as a prognostic criterion. cc tsai , hc hsu dept. of pathology, far eastern memorial hospital, taipei, taiwan, republic of china dept. of pathology, national taiwan university hospital, taipei, taiwan, republic of china introduction to early detect renal and metabolic diseases, a mass urine screen in elementary and high school students was started in in taiwan. we retrospectively reviewed the nephropathologic features to elucidate its value. materials and methods one hundred students, boys and girls, who were found to have hematuria and/or proteinuria by this urine screen program and received renal biopsy, formed the basis of this study. the glomerular pathology was divided according to disease severity into two groups. results group i diseases ( %) showed minor histologic alterations, including minimal glomerular change in cases and mesangial cell proliferation in . among them, children had electron microscopic examination, ( %) had thin glomerular basement membrane (tgbm) disease. group ii diseases ( %) had more severe glomerular changes, including iga nephropathy in cases, membranous nephropathy (mn) in , lupus nephritis in , focal sclerosis in , chronic glomerulonephritis in , and type i and type ii membranoproliferative glomerulonephritis in one case each. these findings confirm that glomerular diseases often progress silently. we found a high frequency ( %) of iga nephropathy and mn in group ii diseases and a close association of mn with hepatitis b virus infection. conclusion we conclude that mass urine screen in school children and renal biopsy are very useful for the early detection of the progressing glomerular diseases and provide great opportunity for early therapeutic intervention and long-term follow-up to better understand the natural courses of glomerular diseases, including tgbm disease. introduction the purpose of the study was to establish a correlation between morphometric kidney biopsy parameters and routine laboratory findings in patients with nephrotic syndrome. material and methods kidney biopsies of patients with nephrotic syndrome were studied using standard techniques of paraffin sections stained with haematoxylin and eosin, picrofuxin van gieson and pas reaction. direct immunofluorescence on snap frozen sections was performed using commercially available antibodies against iga, igm and igg. of the patients, ( . %) were men and ( . %) women, with an average age of . ± . years. biopsy study revealed different types of chronic glomerulonephritis of various incidence: membranous gn ( ), mesangioproliferative gn ( ), mesangiocapillary gn ( ), focal segmental glomerulosclerosis ( ) and terminal sclerosing gn ( ) . morphometric analysis using the semi-automatic image analyser »integral- mt« included cross-section surface areas of the glomeruli and glomerular capillaries, the numerical density of total number of cells per glomerulus, numerical density of mesangial cells, cross-section surface area and numerical cells density of the proximal and distal tubules and cross-section surface area of the peritubular capillaries. routine clinical laboratory analysis included the level of proteinuria, serum creatinine and creatinine clearance, erythrocyturia, leukocyturia and cylinders in urine. a correlation of clinical laboratory parameters with mathematical morphometric models was established for each type of gn associated with nephrotic syndrome. the role of proliferation, growth arrest and apoptosis in the carcinogenesis and prognosis of renal cell carcinoma ga gökhan , g karpuzoglu , t köksal akdeniz university school of medicine department of pathology, antalya, turkey akdeniz university school of medicine department of urology, antalya, turkey introduction nuclear grade and stage are insufficient to predict the clinical behaviour of renal cell carcinoma (rcc). therefore additional prognostic factors are needed. in this study we investigated the role of proliferation, growth arrest and apoptosis in the carcinogenesis and prognosis of rcc using ki , cyclin a, bax, p and bcl- . material and methods formalin-fixed paraffin embedded tissue blocks from patients were studied. cases were divided into low/high grade and low/high stage. apoptotic index (ai) was evaluated as morphologically in h&e stained sections. proliferation index (pi) was detected by using ki and cyclin a immunostaining. ai, pi, p , bcl- and bax expressions in tumor tissue (tt) and in adjacent non-tumoral tissue (ant) and associations with clinical and histopathological parameters were analysed statistically. results the mean indices for apoptosis, ki and cyclin a were: . ± . ( - ), . ± . ( - ) and . ± . ( - ) in tt as well as . ± . ( - ), and . ± . ( - ) in ant, respectively. the number of cases in which the expression of p , bax and bcl- were detected was: ( . %), ( . %), ( , %) in tt, and ( %), ( , %), ( %) in ant, respectively. statistically, there was a significant relationship between the values of tt and ant for ai but not for the pi and the other parameters. only ai and pi significantly correlated with the grade. conclusion in this study the role of pi as a prognostic indicator in rcc was again confirmed. our observations suggest that apoptosis, cyclin a, bcl- and bax may have roles in the carcinogenesis of rcc and that ai may be used as a prognostic indicator. introduction isolated microscopic hematuria (imh) in children always raises the question of the necessity of renal biopsy. many authors consider imh as minor abnormality where glomerular changes are not expected, but general agreement has not yet been achieved. the aim of this study was to evaluate contribution of renal biopsy to diagnosis of glomerular disease in imh. material and methods biopsy was performed in children with imh of proven glomerular origin. mean duration of imh prior to biopsy was . years. biopsy specimens were examined by light (lm), immunofluorescence (if) and electron microscopy (em). results patients ( . %) were found to have glomerular abnormalities. on lm patients had normal glomeruli (ng), mesangial proliferative glomerulonephritis (mepgn), focal segmental glomerulosclerosis (fgs) focal glomerulonephritis (fgn) and membranoproliferative glomerulonephritis (mpgn). if revealed cases as iga nephropathy. em discovered gbm changes consistent with alport syndrome in patients and diffuse thinning of gbm in . in children, subepithelial hump-like deposits were found and considered as the sign of acute postinfectious glomerulonephritis in resolution. one of cases of mpgn showed to be type ii (ddd). on follow-up, of children with alport-like gbm changes developed full clinical picture of the syndrome. further surveillance is needed to confirm the significance of em findings in others. conclusion in children with imh renal biopsy is justified and should always be analyzed by light, immunofluorescence and especially electron microscopy, because em was decisive for final diagnosis in about % of all cases. mesoblastic nephroma of adult. report of a case introduction mesoblastic nephroma is a very uncommon tumor in adults, similar to the congenital mesoblastic nephroma of infancy, first described by bolande et al. microscopically the tumor consist in uniform spindle cells proliferations with numerous vascular spaces, nest of glomeruli, renal tubules that often cystic and dysplastic and lack of nuclear anaplasia or mitotic activity. case report a -year-old woman was admitted to the emergency services for acute abdominal pain in september . she was diagnosed with acute pancreatitis. in cat (without urologic symptoms) a solid mass in the upper pole of the right kidney was founded. with a clinical diagnosis of renal cell carcinoma a radical nefrectomy was performed. follow-up was without event and had no recurrence years afterwards. the right kidney weighed grs. and was unremarkable except for a cms-diameter circumscribed, yellow-tan, solid tumor in the upper pole. microscopic ex-amination revealed a tumor composed of spindle cells, mostly smooth-muscle cells and fibroblast, with numerous vascular structures and some areas of renal tubules with clear cytoplasm. in some places there was atrophic tubules. no mitotic figures were identified. immunohistochemistry findings: the majority of spindle cells were positive for actin, desmin and smooth-muscle actin, and vimentin. and the tubular epithelium stain for ema and keratins. conclusion a combination of histological and immunohistochemical findings is useful to distinguish mesoblastic nephroma from other tumor of the kidney with spindle cells. introduction hyperparathyroidism occurs in patients with chronic renal failure and is usually associated with multiglandular parathyroid hyperplasia. clonal analysis has suggested that in renal hyperparathyroidism glands initially grow diffusely and polyclonally. mechanism of monoclonal proliferation observed with appearance of nodular hyperplasia is not well understood. it might be induced by certain genetic disorders such as overexpression of prad/cyclin d induced by dna rearrangement of the parathyroid hormone gene. the aim of this study was to analyse the expression of cyclin d in normal and hyperplastic, diffuse and nodular parathyroid glands in order to ascertain the possible difference. materials and methods hyperplastic parathyroid glands, from uremic patients who underwent surgery during the period - , were analysed. immunohistochemistry for cyclin d protein was performed on normal parathyroid glands and selected hyperplastic, of diffuse and of nodular type. overexpression of cyclin d was considered to be present if % or more of the sample showed positive nuclear staining. results in normal glands, the mean value of nuclear positivity was . %. overexpression for cyclin d was present in / ( %) diffuse and / ( %) nodular hyperplastic glands. no significant difference was found. conclusion in comparison to normal, hyperplastic glands (nodular as well as diffuse) overexpress cyclin d protein. these results indicate that overexpression of cyclin d is not limited only to neoplastic proliferation, as the most studies showed, respectively this genetic abnormality is not the only responsible mechanism for the monoclonal proliferation. proteins of extracellluar matrix as predictors of glomerulonephritis outcome s Čužić , m Šćukanec-Špoljar , b jelaković , z sonicki , d kuzmanić , m laganović pliva inc., pharmaceutical industry, zagreb, croatia klinički bolnički centar "zagreb", croatia Škola narodnog zdravlja "andrija Štampar", zagreb, croatia introduction chronic renal insufficiency develops only in those cases of glomerulonephritis in which the lumina of postglomerular capillaries in the renal cortex are narrowed due to expansion of the extracellular matrix (ecm). aim of the study was to compare the composition of interstitial ecm proteins with clinical data in various forms of primary glomerulonephritis (gn). material and methods we examined renal biopsies from gn patients, while normal renal tissue was obtained from nephrectomy due to small renal tumour. specimens fixed in b and/or dubosque fixative were analysed by immunohistochemistry (appap-method) using a monoclonal antibodies against tenascin (tn), fibronectin (fn), collagen i, iii and iv (coi, coiii, coiv) (dako). the same fixatives were used for control renal tissue. evaluation of fibrin was performed on frozen sections by immunofluorescence. clinical data were: proteinuria and serum creatinine level, obtained by standard laboratory methods, immunotherapy and ace-genotype. results fifty patients had proteinuria at time of biopsy and of them continued to have it during the follow-up period. patients with persistent proteinuria had more often interstitial fibrosis with elevated content of coi and coiv. only % of patients who responded well to immunotherapy had deposits of fibrin. there were patients with elevated creatinine at biopsy with similar composition of ecm as patients with proteinuria. majority of patients with interstitial fibrosis had ace-genotype ii although this genotype wasn't the most common in the cohort. conclusion our study showed that persistent proteinuria could be linked to interstitial fibrosis and fibrin deposits. patients with ii ace-genotype are more prone to develop interstitial fibrosis. introduction haemorrhagic fever with renal syndrome (hfrs) in slovenia is caused by two hantavirus agents -puumala and dobrava serotypes. there is still a lack of clinical and pathological information, especially about the dobrava virus associated disease. the aim of this study was to analyse and compare the clinical course, outcome and pathological features of hfrs caused by these two virus serotypes. the clinical course of patients ( women) aged ± years (range - ) treated in the nephrological department for serologically confirmed hantavirus associated hfrs was analysed, a serological diagnosis was made using immunofluorescence test and enzyme-linked immunosorbent assay. kidney biopsy specimens of patients were analysed by light microscopy, immunofluorescence and electron microscopic techniques. a semiquantitative scale for gradation of cumulative tubulointerstitial lesions and interstitial haemorrhagic lesions was applied (scores - ). results seventeen patients ( . %) had puumala and ( . %) dobrava virus infection. all patients were febrile and had proteinuria, and other clinical features were: nausea and vomiting ( % of patients), oliguria ( %), abdominal pain ( %), headache ( %), haemorrhages ( %), myalgias ( %), diarrhea ( %), neurological and ophthalmological abnormalities ( %), hypotension ( %). pancreatitis ( %) and elevated transaminases ( %) were observed only in patients with the dobrava serotype. none of the patients in this study died and there was none with permanent haemodialysis dependence. comparison of clinical and pathological features of dobrava and puumala diseases is given in the a need for haemodialysis and the creatinine level at discharge were not associated with the age of patients. those patients who needed haemodialysis, had clinical haemorrhages or had elevated creatinine at discharge, also had higher haemorrhagic and cumulative tubulointerstitial lesion scores, but differences were not significant. elevated serum creatinine above basal levels was present at discharge in patients ( %), range - µmol/l and some patients remained with chronic renal insufficiency. conclusion our results show that dobrava virus infection is associated not only with a significant mortality, comparable to hantaan virus infection, but also with a worse clinical course of renal disease than puumala. the histopathology of the kidney in dobrava and puumala is characterised by haemorrhagic necrotising tubulointerstitial nephritis involving particularly the outer medulla, with quantitative and not qualitative differences between these two infections. renal parenchymal malakoplakia after kidney-pancreas transplantation. case report introduction malakoplakia is an unusual chronic inflammatory disease rarely involving parenchyma of the transplanted kidney. it represents an unusual host response, probably due to leucocyte bactericidal defects to an infecting agent, usually gram-negative organisms, of which escherichia coli is the commonest. malakoplakia in renal transplant is very rare (to date only six cases have been reported) and is associated with a high rate of graft loss and significant mortality. case report we report a -year-old female recipient of kidneypancreas allografts immunosupressed with tacrolimus (prograf, x mg) and mycophenolate mofetil (cellcept, x mg). the patient had suffered from recurrent urinary tract infections. three years after transplantation she was admitted to the hospital with decreased kidney graft function. percutaneous kidney needle biopsy was performed and diagnosis of malakoplakia was established. histologically, on the inflammatory background many mi-chaelis and gutmann bodies were present and confirmed ultrastructurally. the patient was treated with antibiotics and simultaneously immunosuppression (tacrolimus) was reduced. gradually, her renal function improved (with serum creatinine of umol/l). for the entire following year, the patient has been monitored regularly and her renal and pancreas function are stable and both her allografts remain in situ. morphometric study of transbronchial biopsies in pulmonary transplantation e conclusion in our series of tbb for transplant pathology, the aa and nv are the most important morphometric parameters of the biopsy to reach the diagnosis of ar. conversely, the nf does not show significant statistical difference between diagnostic biopsies and nd biopsies. the importance of glomerular deposits of von willebrand factor in human renal allografts bh ozdemir aim to evaluate the role and prognostic importance of glomerular endothelial cell alteration in human renal allografts. material and methods we examined patients with renal transplantation among whom showed acute rejection (ar) and chronic rejection (cr). biopsies were immunostained for von willebrand factor (vwf), fibronectin (fn) and cd . glomerular staining for vwf and fn was graded in a semiquantitative manner using the - + scale. results in the cr group there was markedly increased expression of vwf and fn in the glomeruli, whereas only of ar cases showed intense (grade ) glomerular vwf (gvwf). a significant difference was found between patients with ar and cr with regard to gvwf (p< . ). a positive correlation between the degree of gvwf and early interstitial fibrosis was found in cases with ar in follow-up biopsies (p< . ). the presence of transplant glomerulopathy was found significantly earlier in cases with grade gvwf in ar group (p< . ). we found strong correlation of both intraglomerular fn expression and macrophage infiltration with the degree of gvwf both in ar and cr groups (p< . ). the outcome of grafts that showed intense (grade ) gvwf was significantly worse than the outcome of those grafts with grade and glomerular vwf during the follow-up (p< . ). conclusion increased gvwf deposition in cases with ar is in risk of early transplant glomerulopathy, early interstitial fibrosis and early graft loss. in conclusion, it may be beneficial to use new therapeutic approaches such as anticoagulant medicine for the treatment of ar and cr in future. introduction acute renal allograft rejection is the most important threat to graft survival, and must be diagnosed and treated as early as possible. clinical, radiological and histopathological confirmation of the diagnosis is essential. several factors are being investigated as potential diagnostic markers for acute rejection (ar), and one of these is the hepatocyte growth factor (hgf). the aim of this study was to investigate the presence/density of hgf in core needle biopsies from renal allografts with ar using immunohistochemical staining. the study involved cases of kidney recipients whose allografts were investigated for an initial ar episode without any other pathology. all the patients received cyclosporine-a anti-rejection treatment. each archived slide was reexamined according to the modified banff classification, and patients were categorized as type i ar (group ; n= ), type ii ar (group ; n= ) and type iii ar (group ; n= ). normal histopathological findings in graft biopsies were obtained as controls (group ; n= ). the clinical findings of patients were reviewed from archived records. the sections were stained immunohistochemically with monoclonal anti-hgf antibody. the mesenchymal cells (interstitial macrophages and glomerular endothelium) that showed cytoplasmic positivity were then counted using ocular micrometer. the results were statistically analyzed using mann-whitney u test. results on analysis of the groups' mean cell count, the only significant finding was higher concentration of hgf in the ar patient group than in the control group (p< . ). concerning all other parameters studied, the only significant differences were higher blood urea nitrogen and creatinine levels in group compared to group (p < . ). conclusion our results showed that presence/density of hgf increases in favor of acute rejection and accompanies the histopathological findings. therefore we suggest that density of hgf, excreted in renal allograft tissue, may be a useful marker for supporting ar diagnosis. graft biopsies after renal transplantation in children: differences between fk and cya immunosuppression materials and methods biopsies were examined. besides light microscopy (lm) and electron microscopy (em), igg, iga, igm, fibrinogen, c and c d were detected by immunofluorescence (if). immunohistochemistry (ihc) was performed using cd , cd ro, cd , and cd antibodies to study the presence of different types of cells in acute rejection. banff's classification was used to evaluate the samples. results graft rejection was found in ( . %) biopsies -hyperacute rejection (har) ( . %), borderline changes (bch) ( . %), acute rejection (ar) ( %), and chronic rejection (chr) ( . %). cya and fk nefrotoxicity (tox) was present in ( . %) biopsies. c d ( biopsies from patients) showed linear positivity of peritubular and glomerular capillaries in patients, with har and ar. these three grafts failed and the same pattern was seen in the excised grafts. in all ar cases, ihc proved the prevalence of cd ro+ cells in rejection infiltrates, including tubulitis. the rejection infiltrate contained from % to % of monocytes-macrophages. em showed disjunction and tubular epithelia regression in tubulitis. ar and tox findings in patients receiving immunosuppression with fk were compared with a group given cya. no significant differences in the rate of toxic manifestation were found between the groups of patients on fk and those on cya. more frequent findings of toxicity were noted in fk patientsb iopsies (p= . ). ar was found more frequently both in the patients (p= . ), and in the biopsies (p= . ) of cya-treated subjects. conclusion fk seems to be more potent suppressant than cya in spite of its persistent toxic effect. the paper is sponsored by ministry of health of the czech republic (international grant agency) no: ne/ - . introduction bk polyomavirus causes a variety of infections in the urinary tract, involving transitional and renal tubular epithelium in immune suppressed patients, including transplant recipients. it can cause irreversible loss of graft function. we report a case of polyomavirus infection in a transplant recipient diagnosed by renal biopsy, urinary cytology and electron microscopy of the urine. patient and results a -year-old female patient underwent renal transplantation, and received immunosuppressive treatment with tacrolimus, mmf and prednisolone. serum creatinine level increased and hydronephrosis was observed in ultrasonography in the rd month. a renal biopsy was taken. no glomerular or vascular changes were observed. some tubular epithelial cells displayed pleomorphism, hyperchromatism with chromatin irregularities and clumping, and intranuclear inclusion bodies. no immunostaining was detected with anti-cmv, hsv and ebv antibodies. cytopathic tubular lesions in biopsy, many decoy cells in urinary cytology and intranuclear viral particles in electron microscopy of the urinary sediment proved the bk-polyomavirus infection. as the high serum creatinine levels persisted, despite alternative immunosupressive therapies, two more renal biopsies were taken, and acute rejection banff grade ib and iia was diagnosed respectively. the patient is still under a novel antiviral treatment as the focal tubular cytopathic changes were present in the latter biopsy. serum creatinine levels were still high, even though urinary cytology is normal. conclusion as we have seen in this case, the differential diagnosis between rejection and infection in renal transplant biopsies is critical and complicated for both clinicians and pathologists, as well as patients. introduction the analyses of serums or tissue specimens from the patients with autoimmune diseases are dispersed between microplate reader elisa techniques and immunofluorescence (if) microscopy techniques. the number and the complexity of if morphological parameters are becoming greater, as well as their association with some of the clinical conditions. the quantity of the morphological signs and the notice capability exceed the possibilities of the experts who are not morphologists. the aim of this paper is to present compilation of if morphological slides and their association with the clinical conditions, indicating the real position of this kind of diagnostics. material and methods more than serums and tissue specimens from different locations were used as study material. the methods used were indirect iif microscopy with commercial and own antigens, microplate reader elisa techniques (mpr-elisa) and direct if microscopy. the study showed that the morphology of antinuclear and anticytoplasmic antibodies, using hep- kits was easily examined, wider, and associations with some clinical conditions could be easily done. the antigens for mpr-elisa techniques derived from recombinated genetic technology, unlike those produced from extraction showed better correlation with indirect if microscopy. the own antigens originating from the domestic animals and human cadavers, used for indirect if microscopy in bullous diseases, had the same value as the commercial ones. conclusion in order to emphasize the importance of this paper, we can conclude that, undeservingly, very few papers from this area are being presented in the pathological congresses and are left to other specialities. the gastrointestinal stromal tumors (gist) are rare tumors. there have been few factors identified that predict survival and biological behavior. this study analizes the experience in two university hospitals. forty nine patients with gist were identified from the tumor registry of both institutions. a retrospective review of patient clinic data, tumor and treatment variable was done. expression of p and cellular proliferation antigens (ki /pcna) was also analyzed with overall survival as the main outcome variable. statistical analysis was performed by log rank test and cox regression model. significance was defined: p< . . as results we found that median age was years (range - years). twentyfive patients were women ( %) and were men ( %). hispanics were predominant race with patients ( %) followed by caucasians with patients ( %) and african american patients ( %). the stomach was the most common site of presentation ( %) followed by small bowel ( %). mean tumor size was cm (range - cm). complete resection was performed in patients ( . %). actuarial -year survival was . % with a median follow-up of months . univariable analysis identified overexpresion of p (p= . ), cellular progression antigens (ki /pcna) (p= . ), high grade (p= . ), tumor size bigger than cm (p= . ), and incomplete resection (p= . ), as significant negative factors, hispanic race (p= . ) and good performance status (p= . ) were significantly associated with prolonged survival. on multivariable analysis, overexpression of p was the only independent negative factor. in conclusion, p is the most significant negative prognostic factor for survival in gist. introduction granulomatous gastritis (gg) is a poorly understood entity, reportedly identified in less than % of all gastric biopsies. a precise definition of granulomas has rarely been given, in particular mg, well-described in intestinal disorders, have not been focused on in gastric lesions. aims: we summarize our experience with gg, including mg, and record prevalence as well as associated background morphology. materials and methods among gastric biopsies from . patients ( . gastroscopies), gg was diagnosed in patients. groups of histiocytes producing conspicuous alteration of gastric architecture were classified as well-defined granuloma (wdg); subtle collections of histiocytes failing to distort surrounding glands were labelled mg. the background morphology and presence of microorganisms were recorded. results the distribution of types of granulomas were as follows: mg only patients, mg and wdg patients, wdg only patients. the background morphology of cases with only mg/wdg with/ without mg included chronic gastritis (n= / ); chronic active gastritis (n= / ); ulcus (n= / ); lymphocytic gastritis (n= / ); carcinoma (n= / ); otherwise normal morphology (n= / ); h. pylori (n= / ). conclusion in concert with previous reports, we identified gg in less than % of all gastric biopsies. since the identification of mg requires assiduous histologic examination, such subtle features may be overlooked; hence our calculated prevalence of gg is a minimun value. the functional relation between mg and wdg is uncertain. however, their coexistence in a proportion of gg could support a precursor function of mg in the development of wdg. additionally, the background pathology of biopsies with mg and wdg were comparable. intravascular signet ring-like cells cd /lysozyme positive in gastric ulcer due to chronic use of nsaid, diagnostic implications in endoscopic biopsy and surgical management of an unusual invasive cancer mimicker j nuncio, j arista-nasr, b martinez pathology department, instituto nacional de ciencias medicas y nutricion salvador zubiran, mexico city, mexico a -year old man treated with naproxen during two years was admitted because of hypovolemia and peritoneal irritation. a panendoscopic study was performed and an ulcer localized at the large curvature of the stomach was disclosed. the microscopic examination of the endoscopic biopsy reveled invasive intravascular and stromal neoplastic signet-ring cells. because of the subsequent poorly differentiated carcinoma diagnosis, a gastrectomy was performed. in the specimen the ulcer showed necrosis, edema, fibrosis, chronic inflammatory infiltrate with lymphocytes and plasma cells. additionally atypical cells with irregular and hyperchromatic nuclei or vacuolated cytoplasm were seen in the lamina propia and infiltrating the muscular layers; isolated signet-ring-like cells were also seen. there was no involvement in regional lymph nodes. histochemical study with periodic acid-schiff, mucicarmin, and colloidal stains revealed mucosubstances in these cells. a poorly differentiated carcinoma was initially diagnosed. however the immunohistochemical studies were positive for histiocytic markers (cd- , s- protein and lysozyme) and negative for epithelial markers (cytokeratin, and ema). the positivity mucus stains in the histiocytes could be explained in this case by phagocytosis of mucous substances released from broken hyperplastic glands in the vicinity of the ulcer. to our knowledge, atypical histiocytic infiltration in gastric ulcers has not been previously described; thus, it should be included in the group of gastric carcinoma mimickers; with this basis, the pathologist must to be careful in the assessment of vascular permeation or stromal infiltration by neoplastic cells overall in endoscopic specimens. ileal mucosa changes after total colectomy in patients with juvenile polyposis and familial adenomatous polyposis a tertytchnyi , a talalaev , d sotnikov , v lukin russian state medical university, moscow, russian federation centre of children's health, russian academy of medical science, moscow, russian federation introduction we studied follow-up ileal mucosa biopsies from patients with juvenile polyposis and patients with familial adenomatous polyposis who had been previously underwent total colectomy with mucosal proctoectomy with the creation of straight ileoanal anastomosis. patients' age ranged from to years (mean . years). the follow-up ranged from months to years (mean . months). aim of this study was to identify the long-term changes in ileal mucosa after total colectomy in patients with polyposis coli syndromes. methods the biopsy specimens have been taken from the posterior wall of terminal ileum. paraffin sections were stained with h&e, van gieson, periodic acid schiff (pas) and gomori's aldehyde fuchsin -alcian-blue (gaf-ab) stains. six biopsies were subjected to electron microscopy analysis. results on histological examination ileal mucosa revealed focal shortening of villi and lengthened crypts. the villi were lined by increased number of goblet cells. mucin histochemical studies demonstrated partial conversion of the epithelium to a colonic sulfomucin mucin profile by positive gaf-ab staining in cytoplasm of goblet cells. only out of patients had increased number of mononuclear cells in lamina propria. the electron microscopy examination revealed shortening and rarification of microvilli of absorptive enterocytes. conclusion follow-up biopsies show incomplete and focal neocolonic transformation of ileal mucosa. nevertheless, in most of the cases ileal mucosa preserved its architectural and histochemical characteristics. we failed to identify evidences of chronic inflammation that made us suggest that chronic terminal ileitis is not a common long-term event in patients with polyposis coli syndromes after total colectomy. eosinophilic gastroenteritis with pleural outflow and ascites. a case report introduction in our region eosinophilic gastroenteritis is a very rare disease. etiology is unknown. case report a -year-old female patient was admitted to the clinic due to slight cough, right side pleural outflow and ascites, without other symptoms. gynaecological ultrasound, ultrasound of the upper abdomen, ct refer to ascites besides normal findings of abdominal and pelvic organs. laboratory examinations were normal except peripheral blood eosinophilia and increased values of ca . cytological findings of pleural outflow and ascites revealed a great number of eosinophilic granulocytes but without malignant cells. patohistological findings during explorative laparotomy resected parts of both ovaries, a lymph node, a hyperplastic part of pylorus, a knot from a small bowel designated as a tumor, and an appendix were taken out for a patohistological examimation. both ovaries reveal normal ovarial parenhima. a regional lymph node showed reactive changes with hyperplastic follicles and prominent germinative centers. the main histological finding reveals pyloric stromal edema and a dense infiltrate of eosinophilic granulocytes throughout the muscle layer as well as eosinophils situated in perivascular spaces which is accompanied with swelling of endothelium of capillary blood vessels. eosinophilic granulocytes were found in the smooth muscle layer of intestine as well as in the subserosal tissue. lumen of the appendix was obliterated and the muscle layer and the subserosal tissue contained eosinophils. conclusion from our review it is visible that eosinophilic gastroenteritis can represent a great diagnostic problem especially when it is accompanied with pleural outflow and ascites and increasing values of tumor markers. that can possibly mislead a diagnostic procedure to the neoplastic rather than the immunological or allergic disease. three years after surgery the patient is well. expression of tnf-alpha and il- in patients with chronic pancreatitis n shirinskaya , v akhmedov emergency hospital, omsk, russian federation omsk medical academy, omsk, russian federation introduction to study the serial levels of tnf-alpha and il- in patients with chronic alcoholic and chronic relapsing pancreatitis. methods consecutive patients with chronic pancreatitis admitted to the emergency hospital ( patients with alcoholic pancreatitis and -with chronic relapsing pancreatitis) were studied. serum levels of tnf-alpha and il- , were determined on and days after admission and in remission by immunoenzyme multiplied. results in group of the patients with chronic alcoholic pancreatitis on day one after admission the high levels of tnf-alpha ( , ± , pg/ml) and il- ( , ± , pg/ml) were marked with the subsequent consecutive decrease of these values for days (tnfalpha- , ± , pg/ml, il- - , ± , pg/ml) and in the period of remission (tnf-alpha- , ± , pg/ml, il- - , ± , pg/ml). in patients with chronic relapsing pancreatitis the low levels of cytokines on days one after admission (tnf-alpha- , ± , pg/ml, il- - , ± , pg/ml) were marked with the deferred peak of values on day (tnf-alpha- , ± , pg/ml, il- - , ± , pg/ml), and decrease in the period of remission ± , pg/ml, pg/ml) . conclusion the deferred peak of cytokines levels (on days) in patients with chronic relapsing pancreatitis can testify indirectly about more expressed cytokines disturbance. the majority of glomus tumors are benign neoplasms that occur in the dermis of extremities. however, rare case have been reported in the visceral locations, most often in the stomach. case report the tumor occurred in a -year-old male who presented ulcer-like pain. ct scan diagnosed a submucosal tumor. there was no endoscopic biopsy specimen. a wedge resection of stomach was performed with a frozen section study that conclude to a carcinoid tumor glomus tumor was confirmed by further study of multiple sections of a surgical specimen and by immunhistochemical study. conclusion correct identification of this essentially benign, very rare gastric tumor can prevent unnecessary radical operative procedures. composite carcinoid-adenocarcinoma of the ileum associated with transitional cell carcinoma of the urinary bladder i venizelos , d sioutopoulou , z tatsiou department of histopathology, athenes, greece it is well known that sometimes carcinoid tumor is associated with other tumors. approximately % of carcinoid tumors in the small intestine are associated with non-carcinoid neoplasms, most frequently adenocarcinomas of the gastrointestinal tract. the concurrent occurrence of carcinoid and other tumors in various organs is extremely rare. here, we present a case of a -year-old male who was admitted to our hospital with a -month history of haematuria. on cystoscopy a large tumor of the urinary bladder has found. a total cystectomy was performed. during the operation, while exploring the abdomen, a tumor with maximum diameter cm was found in the terminal ileum, from which a biopsy was taken. microscopically, the bladder tumor was a papillary transitional cell carcinoma grade ii and the tumor of the ileum fulfilled the criteria for a composite carcinoid adenocarcinoma. the carcinoid component was positive for chromogranin and nse and negative for ema, cea and ca - whereas the adenocarcinoma component was positive for ema, cea and ca - and negative for chromogranine and nse. -months after the operation there is no metastasis radiologically and the patient is in a good condition. due to the small number of tumors reported as composite carcinoid-adenocarcinoma there is need for larger number of similar cases as well as long term follow-up to determine their natural history and prognostic significance. we describe the first reported case of composite carcinoid-adenocarcinoma of the ileum associated with carcinoma of the urinary bladder. mutational analysis and expression of cdx homeobox gene in cases of colorectal carcinomas e pilozzi, m rapazzotti onelli, c fidler, v ziparo, js wainscoat, l ruco istopatologia ospedale sant'andrea facolta, roma, italy introduction cdx is a transcription factor specifically expressed in normal intestinal epithelium. it plays a role in the regulation of cell proliferation and differentiation. experimental evidences suggest that it could have a pro-oncogenic effect since cdx overexpression up-regulates bcl- and reduces p ; it is up-regulated by ras activation and its ectopic expression has been reported in intestinal metaplasia, in carcinomas of the stomach and in barrett's esophagus. despite these observations the role of cdx in colorectal carcinogenesis is not yet fully understood. in fact it has been shown to be down-expressed in colon cancers at mrna and protein level. the aim of the study was to investigate the presence of cdx gene mutations. materials and methods twenty cases of sporadic colon carcinomas were collected. total rna and dna from neoplastic and normal tissues were extracted. cdna was synthesized and used as template in rt-pcr using oligonucleotide for cdx and â-actin. cdx three exons were pcr amplified and directly sequenced. results we found lower expression of cdx in tumour samples in four out of ten cases. sequencing showed a transversion g>c ( / cases) of exon and a t>c transition in exon ( / cases) that, being present in the corresponding normal tissue, were regarded as polymorphisms. no base substitution was observed in exon three. conclusions our results showed that cdx expression is reduced in colon carcinoma. however cdx was not found to be mutated suggesting that alterations, other than base substitution, may affect cdx gene in colon cancer. we are now looking at cpg islands methylation in the same cases since methylation could be a likely explanation of the low expression of cdx . aim this study investigates tgfbeta , tgfbeta and tgfbeta proteins expression in patients with colorectal carcinoma and evaluates their correlation with classic prognostic markers and patients' survival. design the study comprised patients with colorectal carcinoma. according to astler-coller system, tumors were of stage a, -b, -c and -d, whereas tumors were low-grade and high-grade of malignancy. on paraffin sections the streptavidin-biotin technique, using antibodies to tgfbeta , tgfbeta and tgfbeta (santacruz, usa) was employed. staining results followed morphometric analysis and were correlated with clinicopathologic parameters. results tgfbeta protein was expressed in / ( %) carcinomas whereas tgfbeta and tgfbeta proteins were detected in all tumors examined. normal colonic mucosal epithelial cells expressed less tgfbeta (p< . compared to neoplastic cells) and less tgfbeta (p> . compared to neoplastic cells), but not at all tgfbeta . statistical analysis revealed higher expression of tgfbeta in low grade carcinomas (p= . ) and higher tgfbeta presence in advanced stage tumors (p= . ). tgfbeta expression was related with higher disease free survival and higher total survival (p< . respectively). tgfbeta presence was correlated with worse prognosis (p< . ). cox analysis revealed that besides tumor grade and stage, tgfbeta expression constituted independent prognostic factor. conclusions this study shows that in cases of colon adenocarcinoma there is different expression of tgfbeta , tgfbeta and tgfbeta . tgfbeta may be implicated in the pathogenesis of these tumors since it is expressed only within neoplastic and not normal cells. tgfbeta is related with higher disease free survival, higher total survival and constitutes an independent prognostic factor. in the late stages, tgfbeta seems to be involved in tumor progression and it is related with worse prognosis. cdx is useful in distinguishing primary colorectal adenocarcinoma form pulmonary, mammary and pancreatic adenocarcinomas metastatic to the colorectum g groisman, a meir, m amar hillel yaffe medical center, hadera, israel background the large bowel may be the site of metastasis from a number of tumors including pulmonary, mammary and pancreatic adenocarcinomas. the histological distinction of primary colorectal adenocarcinoma from these metastatic lesions may be difficult. the aim of this study was to evaluate the utility of the intestinal marker cdx in distinguishing primary colorectal adenocarcinoma from pulmonary, mammary, and pancreatic adenocarcinomas metastatic to the large bowel. design routinely processed mucosal biopsies of adenocarcinomas involving the colorectum [ primary, metastatic (lung , breast , pancreas )] and control cases of primary lung, breast, and lung adenocarcinomas were immunohistochemically stained for cdx (biogenex, san ramon, ca, usa). the intensity and extent of the staining were recorded semi-quantitatively. results cdx diffussely and strongly stained the normal colorectal epithelium as well as all cases of primary colorectal adenocarcinoma. in contrast, all cases of metastatic lung, breast and pancreas adenocarcinoma as well as all control cases were cdx negative. conclusions cdx immunostaining is useful in discriminating primary colorectal adenocarcinomas from pulmonary, mammary and pancreatic adenocarcinomas metastatic to the large bowel. we recommend its use as a component of any antibody panel put together to discriminate between primary and secondary colorectal tumors. infiltrative and proliferative activity in central versus peripheral parts of colorectal cancer introduction growth of primary and metastatic tumour is accompanied by formation of stroma composed of connective tissue and new blood vessels. colorectal cancer is a malignancy characterised by marked desmoplastic reaction both in primary tumour and in its secondary foci (metastases). presented report was aimed to describe quantitatively microvessel density in primary tumour and lymph node metastases from this neoplasm. materials and methods study material included cases of colorectal cancer with metastases to the regional lymph nodes. investigated group comprised women and men (aged - yrs); tumours were t and four were t according to tnm classification. microvessels were highlighted using monoclonal anti-cd antibodies. vessel counts were performed in five fields of each primary and metastatic focus (x ; . mm ). numbers of blood vessels in colorectal tumour were counted in areas free from prominent necrotic foci and non-specific granulation tissue due to process of reparation. vessel density in nodal metastases was determined in fields occupied by neoplastic cells forming their own connective tissue stroma. results in the primary tumour group mean vessel density was . vessel/mm (median value . ; range - ). in metastatic foci the same parameter was . vessel/mm (median value . ; range - ); no statistically significant difference was detected. only slight correlation was found between the microvessel densities in primary and metastatic tumours (r= . ; p= . ). conclusion presented results seem to prove the similar pattern of neovascularisation in both groups, whereas marked differences in this process can be observed between subsequent analysed cases. early diffuse-type gastric carcinoma, especially signet ring cell carcinoma, often shows the superficially spreading growth pattern, and one of the unsolved questions concerning the histogenesis of this type of carcinoma is whether it is monoclonal or multiclonal in origin. we have performed human androgen receptor gene assay (humara assay) based on the random inactivation phenomenon of x chromosomes in female and reported that most of this type of carcinomas were of monoclonal origin ( / cases). however, this method demonstrated only probability of monoclonality in each lesion. recently, % of diffuse-type gastric carcinomas have revealed mutations of the e-cadherin gene at the early stage of their progression, and in-frame skipping of exon has been seen frequently. thus, we performed an immunohistochemical analysis of early signet ring cell carcinomas using e-cad delta - , which is a specific antibody against a peptide spanning the fusion junction region between exons and of mutant ecadherin. e-cad delta - specifically reacts with tumor cells expressing e-cadherin mrna lacking exon . seven of cases were positive for this antibody. in each positive case, the paraffin blocks of the tissue slices that included the whole tumor were analyzed using e-cad delta - . although some signet ring cells with abundant mucin in the upper and/or lower layers of a layered structure did not react with this antibody, tumor cells were confirmed to express e-cadherin mrna lacking exon- by reverse transcriptase-polymerase chain reaction with paraffin-embedded formalin-fixed tissues. these findings suggest that they are of monoclonal origin ( / cases) and support our previous data using humara assay. e tsikou-papafragou , t papadaki , m tsamouri , e nikolaou , c barbatis korgialenion-benakion hospital, athenes, greece evangelismos hospital, athenes, greece introduction malt lymphoma is the commonest primary gi lymphoid malignancy but for correct diagnosis and classification, immunohistochemical and molecular analysis have been proven necessary. the aim of this study was to demonstrate the value of current methodology for diagnosing gimls by presenting four unusual cases. materials case . a years old male with common variable immunodeficiency. an obstructive ileal tumor cms was resected and multiple biopsies were taken along the gi tract from nodular areas. case . female years old with generalised lymphadenopathy, lung shadows, dyspepsia and duodenal nodularity. case . female age underwent gastrectomy with initial diagnosis of high grade b lymphoma. case . female age , had gastrectomy/ splenectomy for relapsed gastric lymhpoma which had been diagnosed as malt type. methods immunophenotypical analysis for detection of cd , cd a, cd , bcl- pr, bcl- pr, cd , cyclin d , cd , cd , cd ro, cd , ki- and genotypic analysis for the clonal igh, tcva genes (case ) and the igh/bcl- rearrangement (case ). results per case: . atypical burkitt lymphoma with diffuse lymphoid hyperplasia of the gi tract (cd / / a+, bcl- +/ -, ki %). . generalised follicular b lymphoma, grade according to the who classification with involvement of the duodenum. . diffuse large b cell lymphoma with aberrant cd ro expression. rearrangement of the igh genes and not of the tcva gene. . cd -mantle cell lymphoma with anaplastic foci in the spleen. clonal rearrangements of the igh and concomitant igh/bcl- gene rearrangements involving tonsils, stomach, spleen and abdominal lymph nodes. conclusion all cases represent unusual types of gimls easily misclassified or graded without thorough immunophenotypic and molecular analysis. the incidence of gastric cardiac adenocarcinoma has increased in the last decades. gaining insight in the pathogenesis of this lesion is hampered by the limited knowledge of the origin and histology of cardiac mucosa (cm). currently, the location, extent and even the existence of cm are controversial. aims: we studied the development of the gastro-oesophageal junction (goj) in embryos, fetuses and infants to clarify whether cm is a normal structure at birth and where it is located. materials and methods twenty-one autopsy cases were evaluated. age range: weeks gestational age (ga) - months. the distal oesophagus and proximal part of the stomach were embedded entirely. serial sections were stained with haematoxylineosin and alcian blue/periodic acid-schiff. the following parameters were measured: length of abdominal oesophagus; length of columnar-lined oesophagus; length of cm; distance from cm to angle of his. results cm was present in all evaluated sections. its mean length varied throughout gestation. a maximum value was reached at a ga of weeks ( , mm). after term delivery, it was very short ( , - , mm). cm was proximal to, or straddled the angle of his in all cases. during gestation, the mucin staining pattern of the cm was to a high degree similar to that of the developing pyloric mucosa. conclusions cm develops during pregnancy and is present at birth as a normal structure. if the angle of his is taken as a landmark for the goj, cm is located in the distal oesophagus. gastric mucosa-associated lymphoid tissue (malt) and non-malt lymphomas: clinicopathological study of cases s taban, a dema, n tudose university of medicine and pharmacy, timisoara, romania introduction histologic features of low-grade b-cell malt lymphoma of the stomach have been well described in recent years, but its relationship with the more common large b-cell gastric lymphoma has not been clarified. the authors investigate clinicopathological differences among low-grade and high-grade gastric lymphomas. methods clinical and histopathological aspects of consecutive gastric lymphoma cases found in gastrectomy specimens were studied: cases of low-grade malt lymphoma (lg malt lymphoma), cases of high-grade malt lymphoma appearing in low-grade malt lymphoma (hg/lg malt lymphoma), cases of high-grade malt lymphoma (hg malt lymphoma) and cases of diffuse large cell lymphoma (dlcl). results mean age were as follow: lg malt lymphoma- , years; hg/lg malt lymphoma- , years; hg malt lymphoma- , years; dlcl- , years. there was a male predominance of malt lymphoma patients (male to female ratio- / ). macroscopically, the most common pattern of lg malt lymphomas was the superficial spreading type with or without ulceration, whereas hg malt lymphomas and dlcl exhibited a solitary tumor-forming lesion. b-cell immunophenotype was confirmed in cases, only one case of dlcl was a t-cell lymphoma. conclusions in our study, the prevalence of high-grade malt and non-malt lymphomas was , %. our results suggests that some gastric lymphomas with high malignancy can arise through blastic transformation of the lg malt lymphomas, this process(change) seems to take about ten years at least. background the recently described serrated adenocarcinoma accounts at least . % of colorectal malignancy. it develops from serrated polyps. dna microsatellite instability (msi) is more common in serrated adenocarcinomas than in conventional adenocarcinomas, but the frequency of msi-low and msi-high in these tumours is unknown. materials and methods an unselected series of serrated adenocarcinomas were included. msi status was evaluated using panel of five markers d s , d s and d s ) . a tumour was considered to present msi-high if two or more markers showed msi, msi-low with one marker, and mss when none of the markers showed msi. results dna msi was observed in . % ( / ) of serrated adenocarcinomas, . % ( / ) being msi-high and . % ( / ) msi-low. msi status showed no association with gender, age, location, size, dukes stage, grade or mucinocity. msi-positive serrated adenocarcinomas tended to have better prognosis ( -year survival . %) than mss cancers ( -year survival . %), but this was not statistically significant (p= . , log-rank). conclusions serrated adenocarcinomas show prevalence of msilow higher than that reported for colorectal cancers ( to %), supporting idea that serrated carcinomas are formed through a pathway differing from other carcinonomas. absence of any association of msi and clinicopathological features could be due to homogeneity of these neoplasms although a more extensive material is necessary to show more conlusively absence of any association. a trend for better prognosis in msi -positive serrated adenocarcinomas probably reflects the biological behaviour of msi observed earlier in colorectal carcinomas in general. thyroid hormone receptor beta- expression in colorectal cancer is associated with polypoid growth type and k-ras mutations t hörkkö, tj karttunen, p jernvall, mj mäkinen department of pathology, university of oulu, finland background the action of thyroid hormones is mediated via their receptors (tra , tra , trb and trb ). trb expression is abnormal in cancer cells in vitro and in some malignant neoplasms, but the role trb in colorectal carcinogenesis is unknown. materials and methods trb expression pattern was evaluated by immunohistochemistry in operated colorectal cancers and correlated with k-ras mutations and clinicopathological features. results in normal mucosa, cytoplasmic trb immunoreactivity was seen mainly in the superficial parts, while nuclear reactivity was most prominent in the cryptal epithelium. in tumours, nuclear expression was observed in % of cases and cytoplasmic staining in %, both mostly co-existing. cytoplasmic staining for trb was more common in polypoid ( %; / ) than in flat carcinomas ( %; / ; p= . ). k-ras mutations were more common in tumours with cytoplasmic expression of trb ( . %; / ) than in those without ( %; / ). in lymph node metastases, occurrence of nuclear staining of trb was more pronounced than in the primary lesion (p= . , wilcoxon). conclusions expression of trb is present in normal colorectal mucosa and is mostly retained in carcinomas, suggesting that thyroid hormones and their receptors may be involved in the physiological regulation of normal colorectal epithelium and in the pathogenesis of colorectal cancer. association of expression with k-ras mutations indicate occurrence of functional linkage between trb and ras signaling. observations of a high expression in lymph node metastases and in polypoid cancers offer new clues to factors affecting metastatic cascade and growth pattern of colorectal cancer. gastric mucosal calcinosis in chronic renal failure patients materials and methods a review of the records for crf patients who underwent endoscopic biopsy revealed gmc (patient group) and non-gmc (control group) cases. for each subject we recorded the number and sites of biopsies, and reassessed for inflammatory activity, mucosal atrophy, intestinal metaplasia, lymphoid aggregates, helicobacter pylori, amyloid deposition, and gastritis type. age, sex, cause of renal failure, time from renal failure diagnosis to biopsy, type of dialysis, indications for endoscopy, saca use, and serum levels of calcium, phosphorus, calciumxphosphorus product and parathyroid hormone were also recorded. the gmc cases were classified according to pattern of deposition (nodular, granular, mixed) and disease severity (mild, moderate, severe). results the incidence of gmc was . %. in gmc group there was male preponderance ( %). compared to the control group, the gmc group had a significantly higher number of corpus biopsies; a significantly lower number of antral biopsies; a significantly lower frequency of mucosal atrophy; and a significantly lower parathyroid hormone level (p< . for all). none of the gmc patients had used saca. conclusion unlike previous reports, these results show that gmc is not linked with saca use or female gender in crf patients. there was also no correlation with mucosal injury. these findings suggest that gmc is probably a metastatic process, not a dystrophic one. the value of histology in diagnosis of inflammatory bowel disease (ibd) v tzioufa, g karayannopoulou, i venizelos, a asimaki, e vrettou, c kalekou, t kehaya, a kriaka, e nenopoulou, k patsiaoura aristotle university of thessaloniki, greece in patiens with colitis colorectal biopsy is helpful in the differential diagnosis between ibd and other forms of colitis and also between ulcerative colitis (uc) and crohn's disease (cd). however the histological features in biopsy specimens are not always sufficient for a definitive diagnosis and there is need to establish more sensitive and specific criteria for the distinction between uc and cd. a retrospective blind evaluation of biopsy specimens from patients with the endoscopical diagnosis of colitis was undertaken in order to assess the value of histology in the diagnosis of ibd and the degree of inter-observer agreement. twelve experienced pathologists participated in the study. twenty histopathological features according to a modified version of the british society of pathology guidelines for the evaluation of colorectal biopsies in suspected ibd were studied and the results were statistically analysed. the clinical diagnosis after follow up was uc in cases, probably uc in cases, ibd cases, cd cases and nonspecific colitis cases. higher than % agreement (by all or participating pathologists) on the diagnosis of uc based only on histologic parameters was reached in of the cases for which clinical follow up proved the diagnosis of uc. unanimous agreement on the diagnosis of non-specific colitis was reached in of the cases. our results indicate that although detailed assessment of a combination of histopathological features and the experience of histopathologist are important for the diagnosis of ibd, the final diagnosis depends on combination of histopathology with the clinical and endoscopical evaluation. s taban, a dema, n tudose university of medicine and pharmacy, timisoara, romania aim the authors presented two cases of polipoid tumor lesions (gastric and anal) with pseudomalignant changes. multiple sections from the stomach and anal mucosa were analysed by light microscopic and immunohistochemical methods. in the gastric hyperplastic polyp, there was surface ulceration with granulation tissue and acute and chronic inflammation. within the stroma were numerous atypical cells with bizarre cytomorphology and atypical mitoses. the second case was a fibroepithelial polyp of the anus with collagenous stroma covered by squamous epithelium. stromal cells with two or more nuclei were found and showed atypical nuclear features. in both cases, mast cells were frequently observed and sometimes intimately related to the stromal cells. immunohistochemical study revealed that the stromal cells stained positive for vimentine and negative for actine, desmin, cytokeratin, s- protein and leukocyte common antigen, so considered to be fibroblastic cells. clinical follow-up was available. none of the patients followed developed metastases or recurrences. prognostic value of nm and c-erbb- expression in colorectal cancer v delektorskaya, a perevoschikov, ne kushlinsky cancer research centre, moscow, russian federation increased expression of genetic markers is observed in a variety of malignancies, including colorectal cancer (crc). overexpression of these markers in the primary tumor is known to predict outcome after colonic resection. in this study we aimed to evaluate the expression level of the nm and c-erbb- proteins in crc and its correlation to prognosis and liver metastasis. protein expression was examined immunohistochemically in formalin-fixed, paraffinembedded tissue from colorectal patients. crc showed a high level of nm protein expression in % of primary tumors and % of liver metastasis. expression of c-erbb- was observed in % of primary carcinomas and % of distant metastasis. the positive expression of protein markers in primary lesion was significantly higer in the cases with liver metastasis than in those without metastasis. no significant relationship was observed between nm and c-erbb- expression and other clinicopathological parameters. these results suggest that nm and c-erbb- expression play an important role in the progression of crc and could provide additional information for the development of liver secondaries. introduction sporadic gastric carcinomas (gcs) with high level microsatellite instability (msi+) tend to be poorly differentiated adenocarcinomas with abundant lymphocytic infiltration and are associated with a relatively good prognosis. the aim of the study was to define whether the nature and the activation status of lymphocytes infiltrating neoplastic epithelial cells (iels)of msi+ gcs could be involved in an increased apoptosis of tumor cells and could be consistent with a tumor-specific immune response. materials and methods tumor cells apoptosis and immunophenotype of iels were investigated by immunohistochemistry in msi+ gcs. for comparison, a series of msi-gcs with similar histological features was investigated, including cases, which were positive for epstein barr virus infection (ebv+). results msi+ and msi-/ebv+ gcs displayed a significant higher mean number of cytotoxic iels than msi-/ebv-tumors (cd : . and . versus . ; cd : . and . versus . ; tia- : . and . versus . ; p< . ). in addition the activated iels were more frequent in msi+ than in msi-/ebv-gcs (mean granzyme b immunoreactive iels: . versus . ; perforin . versus . ; p< . ). the percentage of apoptotic tumor cells, evaluated with the m cytodeath antibody, was higher in both msi+ and msi-/ebv+ gcs than in msi-/ebv-gcs ( . % and . % versus . %; p< . ). the lymphoid infiltration in msi+ gcs was significantly higher than that of msi-gcs (except for ebv+ gcs) and this might explain the increased apoptotic index and the relatively better prognosis of these tumors. introduction goblet cell carcinoid (gcc), also known as mucinous carcinoid or adenocarcinoid, is a rare tumor of appendix, which exhibits both endocrine and adenocarcinoma differentiation. different mucin phenotypes are associated with neoplastic transformation in epithelial tissue in various organ systems. muc apomucin is a mucin gene product specific to intestinal goblet cells. muc is suggestive to inhibit cell-to cell adhesion. in the present study, we retrospectivelly studied the clinicopathological features and immunohistochemical expression of muc , muc and muc a in gcc. materials and methods three appendiceal gcc were retrieved from our pathology files from to . medical records and histologic slides were reviewed. the expression of muc , muc and muc a was assessed by immunohistochemistry. results all three cases were males and the age ranged from , and yrs. two patients presented with acute appendicitis. the other one had ruptured diverticulitis and renal cell carcinoma. two patients had appendectomy, and one patient had right hemicolectomy and right radical nephrectomy. histologic examination showed infiltrative small nests and glands of tumor cells with goblet cells and mucinous cytoplasm. perineural invasion was noted in one case. the tumors had invaded through the appendiceal wall to subserosa in two cases and to adjacent cecum in one case. the tumor cells are positive staining for synaptophysin. there was strong and diffuse reactivity in the tumor cells with muc , muc and muc a antibodies in all three cases. follow-up ranged from month, months, and months. all were alive and without recurrence. conclusions these observations suggest that there is no differential expression of muc , muc and muc a in gcc and both muc and muc may play a role in cancer cell growth and invasion. gastric parietal cell carcinoma: report of three cases ml gomez-dorronsoro, r beloqui, i amat, p de llano, a cordoba, b larrinaga, e borobio hospital de navarra, pamplona, spain gastric parietal cell carcinoma is an infrequent newly recognised variant of gastric carcinoma with only cases published in the literature. the present study describes the findings in three cases of gastric parietal cell carcinoma consisting of parietal cells. we have used light and electron microscopy, and histochemical stains. we have studied three cases, two men and one woman, aged between and years. the tumour size ranged from , to , cm. the surgical specimens were stained with hematoxylin-eosin, alcian blue and ptah. small pieces of formalin fixed tumor tissue were collected in one case, and fresh tissue fixed in glutaraldehyde in another both for electron microscopy. involvement of the gastric wall was observed in all tumours. the tumour pattern was characterised by an arrangement of tumour cells in sheets, elongated cords or in diffuse poorly cohesive sheets interspersed with a lymphocytic infiltrate. tubular differentiation was only focally present in one of the cases. all the cases were composed by a large number of parietal-like cells with abundant eosinophilic cytoplasm, with a mixture of signet ring cells population in one of the cases. alcian blue stain was negative throughout the tumour, whilst ptah stained many tumour cells. ultrastructurally the tumour cells were characterised by abundant mitochondria, tubulovesicles, intracellular canaliculi and intercellular lumina filled with microvilli. the three tumours presented are primary gastric carcinoma with cytological and ultraestructural patterns of parietal cell differentiation. they represent a morphologically distinct type of carcinoma, which has been said to have a favourable prognosis. aim the aim of study is to investigate do really cd + cells have cytotoxic or suppressor influence upon gastric epithelium. material and methods we have examined biopsies from patients with peptic ulcer and -with gastritis only. samples were formalin fixed, paraffin-embedded, stained with h/e, toluidineblue, gimsa stain, pas reaction. comparative immunohistochemical analysis of cd + lymphocytes, proliferative markers: mib- and pcna were performed. we evaluated the amount of cd + cells in mm and the proliferative activity of epithelium per nuclei. biopsies were examined electronmicroscopically for the detection of cell-to-cell interactions and subcellular alterations of gastric epithelium. results distribution, amount and characteristics of cd + cells are different in mucosa around ulcer and in gastritis (g.) cases without ulcer. in active g. around ulcer cd + cell are , ; without ulcer - , , but in inactive g.- , . in helicobacter pylori-infected subjects cd + are located in addition at the lymphatic follicles. we have not proved any rise of apoptosis, exfoliation or ultrastructural injuries of epithelial cells in the areas of collections of tlymphocytes of this subtype. in sites of increased amount of cd + cells there is high proliferation activity of epithelium ( , - , %) due to the broadening of labeled nuclei zone with mib- antibody. conclusions the amount of cd +cells correlates with activity of gastritis as this kd glycoprotein realize molecular reactions between mediators or against h.pylori, food and other antigens in lamina propria, but it has no external direct domain upon gastric epithelium, capillaries or glandulocytes. the incidence of gastric cancer decreases worldwide. despite declining (due to intestinal type), incidence still remains the second cause of death amongst all malignancies worldwide. diffuse type of gastric cancer shows constant incidence. therapy and prognosis directly correlate with extent of the disease and reliable prognostic factor is still lacking. the aim of the study is to establish a value of two morphometric methods -nuclear area and microvessel density and their influence to the survival of the patients with advanced gastric cancer. patients who had undergone gastric resections for gastric cancer were analysed in this study. we estimate size of the tumor, histologic type (according to lauren's classification), stage, nuclear area (median value of nuclear areas in cancer cells measured with computerised nuclear morphometry) and microvessel density (median value of f viii-positive microvessels in five x power field) for each case. statistical analysis was performed and p-values lower than , were considered significant. nuclear area shows statistical significant correlation with size of the tumor, tumor stage, tnm classification and metastases in regional lymph nodes, microvessel density does not. in univariate analysis to survival, size of the tumor, tumor stage and tnm classification have p< , . nuclear area only in intestinal type of gastric cancer correlates with survival (p< , ). in multivariate analysis, size of the tumor, tumor stage and tnm classification have an influence on survival. reliable prognostic factors in patients with gastric cancer are still stage and size of the tumor. diffuse type of gastric cancer is still an enygma. spreading and metastazing of intestinal type of gastric cancer could be predicted using a nuclear-area method as a support in therapy planning and prognosis. the role of microvessel density in prognosis is unreliable. f iordanidis, e vrettou, e nenopoulou, p hytiroglou, c papadimitriou pathology dept. medical school. aristotle univ., thessaloniki, greece introduction the kit receptor normally becomes dimerized and its tyrosine kinase phosphorylated (activated) upon the ligand binding, then enabling it to phosphorylate other proteins in the signal transduction pathway that ultimately carry the proliferation signal into the nucleus. the aim of this study was the evaluation of ki- (mib- ), proliferative cell index, in correlation to c-kit stain intensity, histological grade and immunophenotype in gists. we studied a series of gists (c-kit positive) in correlation to age, anatomic location, size, morphological features, mitosis and necrosis. also we stained with vimentin, cd- , smooth muscle actin (sma), s- protein and ki- with abc method on paraffin sections. results the average age of the patients was years (ranging from to ), included male and female patients. were located in the stomach, in the small intestine, in the colon and in the esophagus. microscopically the tumors showed a fusiform cytology and of them showed a mixed fusiform-epitheloid cytology. the average tumor size was , ± , cm (range , - cm). we found necrosis in tumor with size> cm. the tumor cells expressed vim %, cd %, sma %, s- % and ki- ranging from - %. the most gists showed c-kit positivity in % of tumor cells with a small minority showed more focal staining in as few as % to % of tumor cells. the stain intenisty was mild to moderate. conclusion in our study, the ki- expression was associated with tumor size and not with c-kit staining profile, other immunophenotypic features or histological parameters. expression of pcna and ki- protein in colorectal carcinomas. correlation with tumor grade v zivkovic, a nagorni, v katic, j gligorijevic, b djordjevic, m milentijevic, z mijovic institute of pathology, medical school, nis, serbia and montenegro introduction the prognostic significance of pcna and ki- proliferation markers in colorectal carcinomas is debatable. therefore, we evaluated immunoreactivity of the tumor for pcna and ki- antigen in colorectal carcinomas with different histological grades. methods the paraffin embedded tissues were immunostained for pcna and ki- antigen by employing streptavidin-biotin(lsab) method. results pcna was positive in % of carcinomas and localized in the nuclei of malignant cells.immnunoreaction for ki- was demonstrated in all carcinomas and mainly and strongly expressed in the nucleoli.positive staining for pcna and ki- correlated positively with increasing grade. the labelling index was significantly higher in the poorly differentiated carcinomas than in the well differentiated tumors. conclusion the expression of pcna and ki- proliferation markers clearly shows differences between colorectal carcinomas of varying differentiation grades and it is useful as a diagnostic and prognostic parametar. introduction collision tumours have been thought to arise from the accidental meeting and interpenetration of two independent tumours. here we present three cases of gastroesophageal junction tumours that could fill these criteria. we employ molecular and genetic techniques to ascertain the clonality of these tumours in order to determine whether they represent true collision tumours. methods p immunohistochemistry was performed, and p sequence analysis was carried out on rt-pcr material derived from fresh frozen tissue. mutations were subsequently confirmed in paraffin embedded material. standard and laser microdissection techniques provided tumour-enriched samples from which dna was isolated. analysis of loss of heterozygosity was performed using the microsatellite markers d s , d s , d s , d s , d s , d d , d s , tp , p alu and bat . results p immunohistochemistry was positive for both tumours in each case. all three tumours possessed a p point mutation that was identical in both components. polymorphic microsatellite analysis confirmed shared losses of heterozygosity with an identical pattern of retention and loss at six loci in each component. genetic differences were also observed between tumour components. conclusion a comparison of immunohistochemistry, p sequence and the pattern of loh for a spectrum of polymorphic microsatellite markers for three possible collision tumours suggests that both components are derived from a single precursor cell that undergoes divergent differentiation in the evolution of the tumour. the evidence presented here refutes the "collision hypothesis" and introduces a new histopathological entity of a cardia tumour with distinct diffuse signet ring cell and squamous components. a nasierowska-guttmejer, w michej department of pathology, cancer centre, warsaw, poland introduction gists are the most common mesenchymal tumors of the gastrointestinal tract. they are histologically heterogenous group and a practical diagnostic criteria for gists is c-kit (cd ) expression by immunohistochemistry. the aim of this study was to present morphological pattern of radically operated and disseminated gists. material and methods material included gists treated between and in cancer center, warsaw. thirty pts. had been radically operated of gastric gists and pts. -intestinal gists. fifty three pts. had peritoneal and liver dissemination. the histopathological diagnosis based on the type of cells, mitotic activity and tumor size. the immunohistochemical expression of cd (dako), cd (dako), sma (dako) and s p (dako) were performed in each of the case. results . microscopic spectrum. majority ( %) of cases had heterogenous pattern-spindle and epithelioid cells with high mitotic activity-more than mitoses per hpf. the intestinal and disseminated tumors had generally spindle cell histology with variable myxoid matrix or extracellular collagen globules reffered to as skeinoid fibers. the majority of gastric gists were composed of epithelioid, polygonal cells with perinuclear vacuolization. .the immunohistochemical analysis revealed strong and diffuse cd expression in of cases, whereas cd was expressed in cases. four cases were negative for cd and positive for cd . a minority of the tumors expressed smooth muscle actin which was focal. conclusions the heterogenous histologic pattern of gists cd (+) correlated with dissemination, diameter over cm and more than mitoses per hpf. carcinosarcoma of the esophagus: two cases of the unusual neoplasm m malinowska, a nasierowska-guttmejer department of pathology, institute of oncology, warsaw, poland introduction esophageal carcinosarcoma comprise approximately - % of all esophageal tumors. this is the first published report in poland of the unusual malignant neoplasm consisted of both carcinomatous and sarcomatous components. materials and methods two patients with esophageal tumors were presented. they were analyzed using endoscopic, histological and immunohistochemical procedures. an endoscopic examination showed polypoid tumors in the lower esophagus. esophagogatrectomy with lymph node dissection was performed. the resected specimens were fixed in % formalin and paraffin embedded tissue sections were stained with routine hematoxylin and eosin. immunohistochemical analysis for vimentin, cytokeratin, p and mib were performed. results histologically, the neoplasms consisted of two components, squamous cell carcinoma and sarcomatous components. in case , the sarcomatous component was with no specific differentiation and in case resembled malignant fibrous histiocytoma. a gradual transition between two components was found. in case regional introduction the cyclin-dependent kinase inhibitor p is a critical downstream effector in the p pathway and this protein acts as tumor suppressor in a negative cell cycle regulation. aims: we investigated the prognostic influence of p waf /cip reactivity in gastric carcinomas in relation to the p expression. materials and methods the expression of p waf /cip and p protein was revealed immunohistochemically in gastric carcinomas. staining patterns were assessed semiquantitatively and correlated with clinicopathologic variables and survival times. median follow-up time was months (range - months). chisquare and kaplan-meier survival analysis were performed as statistical analysis. results the p waf /cip protein was detected in ( %) and p protein in ( %) of cases. p waf /cip expression was significantly higher in stages i and ii carcinomas than in stages iii and iv carcinomas (p= . ). in tumors without lymph node metastasis, p waf /cip expression was significantly more frequent in tumors with lymph node metastasis (p= . ). low p waf /cip expression significantly associated with p protein expression (p= . ). the survival rate of patients with p waf /cip -positive tumors was significantly better than those without p waf /cip expression (p= . ). in patients with p positive tumors showed significantly poorer prognosis than in patients with p negative tumors. conclusion the status of p waf /cip expression may have prognostic value in gastric carcinomas and evaluation of the expression of both p and p waf /cip might provide more prognostic information. introduction the normal motility of the gastrointestinal tract depends on the enteric nervous system, the smooth muscle layers, and the interstitial cells of cajal (iccs). the aim of this study was to investigate both the distribution of interstitial cells of cajal and the pathohistology of the enteric nervous system in colonic inertia. materials and methods large bowels were obtained from patients with colonic inertia. the patients have been treated surgically with total abdominal colectomy and ileorectal anastomosis. control large bowel specimens were collected from patients with non-obstructing neoplasia. colonic specimens were investigated with monoclonal anti-neurofilament antibody and cd antibody and compared with those of control patients. the analysis of iccs included registration of the number and process length of the myenteric and muscular iccs. in the patients with colonic inertia the myenteric plexus showed moderate or severe hypoganglionosis compared with the control group. the apparently normal axon bundles in the myenteric plexus stained markedly less than normal ones with monoclonal antibody. myenteric iccs were evident as single cells or cell clusters closely related to the small myentric ganglia. the iccs did not form the typical networks seen in the normal bowel. muscular iccs were markedly reduced in number compared to the number seen in normal bowels and were mainly expressed at the innermost layer of the circular muscle layer. conclusion the enteric nervous system and iccs are altered in colonic inertia and may play a crucial role in the pathophysiology of colorectal motility disorders. immunohistochemical detection of the hmlh and hmsh proteins in hereditary and sporadic colon cancer tissues germline mutations of hmlh and hmsh mismatch repair genes (mmr) are associated with hereditary nonpolyposis colon cancer (hnpcc). somatic impairment of these genes can be detected in sporadic colon cancers (cc). all these tumours are characterised by microsatellite instability (msi). the aim of this study was to correlate the results of immunohistochemical detection of hmlh and hmsh protein with results of mutational and msi analyses. patients and methods there were included: cc samples from hmlh /hmsh germline mutation carriers, cc samples from non-carriers, and cc samples from patients not subjected to mutational analysis. immunohistochemistry was performed using mouse monoclonal antibodies (anti-hmlh , clone g - ; anti-hmsh , clone g - , pharmingen, usa). msi was analyzed at abi prism genetic analyzer, mutational analysis by dna sequencing. results loss of nuclear protein expression was detected in all tumours from mutation carriers, all of these exhibiting a high grade of msi (msi-h), and in of msi-h tumours from the other patients. none of the tumours with stable microsatellites or a low level of msi exhibited a nuclear protein loss. immunohistochemical analysis was able to detect msi-h tumours with a % specificity and a % sensitivity. conclusion immunohistochemical detection of hmlh and hmsh proteins is a specific method of detection of tumours with mmr gene inactivation and might be used as a screening method of hnpcc. the msi-h cases with retained nuclear protein expression might express non-functional protein or carry another mmr gene defect. suppported by nc - . study of mucin changes in colorectal adenomacarcinoma sequence m danciu , ms mihailovici , m stan , a trifan , c sfarti , s khder , am gruia university of medicine and pharmacy, iasi, romania institute of gastroenterology and hepathology, iasi, romania introduction mucins are known to have a protective role for the colorectal epithelium against extrinsic noxious factors (including carcinogens), changes of its characteristics being an early process in the adenoma-carcinoma sequence. aims: quantitative and qualitative evaluation of mucin changes in hyperplastic polyps (hp), adenomatous polyps (ap) with different degrees of dysplasia and adenocarcinomas (ac) of colon. material and methods we selected colorectal endobiopsies ( hp, ap and ac). thin serial sections were stained with hematoxylin-eozin, van gieson and alcian blue (ab) ph (for strongly sulphured mucins) and ph . (for acid mucins: weakly sulphured mucins, hyaluronic acid and sialomucins). observations were made only on intracellular mucins. intensity of the stain was analyzed and compared with non-tumoral (normal) adjacent mucosa. results and discussions normal mucosa and hp showed a preponderance of sulphomucins (ab ph ) comparing with sialic acid (ab ph . ). in ap (especially in those harboring high-grade dysplasia) we detected sialomucins in . % cases and the depletion of sulphomucins ( . %). in ac sialomucins were identified in . % cases, while sulphomucins only in . % cases. significant depletion of sulphomucins occurs in ap with moderate and severe dysplasia and in ac, but it was also observed in ap with mild dysplasia. this suggests the possibility that without a proper mucin secretion consisting mainly in strongly sulphured mucins, colorectal epithelium is more vulnerable to environmental carcinogens. histological this study is a continuum of the analysis until . we analyzed biopsy and operative materials from the stomach and small bowel. we used the following histochemical stainings: he, van gieson, reticulin, as well as immunohistochemical stainings with the following antibodies: ckws, lca, s , actin, desmin, nse, chromogranin, synaptophysin, vimentin. results and conclusion the analyzed group of cases consists of patients of age between - years with male predominance ( : ). four of the analyzed ten cases were located in the stomach and in the small bowel. cases were benign, histologically composed of bundles of spindle cells with slightly pleomorphic nuclei and eosinophilic granular cytoplasm, with hyalinised collagen between the cells. the mitoses were either rare or absent. immunohistochemical analyses were most frequently positive for s , actin, desmin and synaptophysin. three of the cases were ranked as malignant, using the following diagnostic criteria: size of the neoplasm, existence of metastases and histological appearance with anaplastic spindle cells arranged in bundles and whorls with high mitotic index ( mitoses per hpf) and marked positivity for actin, desmin and vimentin. what is the relation of age, gender and histological types to the subsite location of colon carcinoma? introduction characteristics that determinate the anatomic site within the colon where the carcinoma is most likely to occur would be very useful in choosing optimal factories for screening of colon cancer /cc/. aims: to study any association of gender, age or histological types with cc in the left or in the right colon. materials and methods retrospectivitaly are studied cases of cc in nmtb between and .the age and the gender of patients were determined. localization, histological type and tnm staging of the cancer are identified on the histological slides. results cases of cc at the age between - years old are diagnosed. gender, age and histological type were independently significantly associated with the frequency of the development of right and left colon carcinoma. the gender distribution of cc is in benefit of male independently of sub site location as they are suffered of cc in the younger age in comparison with the female. independently age, gender and localization prevails the histological type adenocarcinoma with different morphological and functional differentiation. one cc in the left colon is developed on the background of fap. solitary are the cases with congenital fap and lynch ii. in the most cases cc was diagnosed in advanced stage. solitary is the cases with tis and t . conclusion we consider: /cc is more frequently in the male colon; /in cc predominate histological type of adenocarcinoma; /cc is developed in the middle and in the age advanced in years; / cases with multicentrical cc with metachronic carcinoma are solitary. introduction cathepsin b (cb) and l (cl) are cysteine peptidases with capacity of degrading extracellular matrix. cb expression in colorectal cancer (crc) has been related with tumor progression. there are no data about the cl immunohistochemical expression. the aim of this study was to analyse the expression of both cb/l in crc and to relate these findings with clinicopathological data. material and methods epithelial and stromal immunohistochemical expression of cb and cl was studied in and samples respectively. cb was analysed in adenomas. global and local infiltrating edge data were recorded. clinico-pathological parameters were correlated with the immunohistochemistry. results cb/l expression in normal epithelium was apical, with scarce macrophages in the lamina propria. an increase of both cb/l was observed in tumoral stroma, with higher cb at the infiltrating edge. the both global and deep stromal cb increased according to the t (p< , ). neoplastic epithelial cb revealed a basal stain whereas cl was occasional. epithelial cb tended to show high expression in t (like high grade dysplasia) and low expression in t that increased progressively in t - (p= , ) . no differences were evidenced either as a function of n state, gender, site, differentiation or histological type. conclusions cb/l immunoexpression in colon have a distinctive pattern which is altered in carcinoma. whereas increased cb stromal expression ise related with local progression, epithelial positivity seems to play an important role in the first steps of carcinoma. high stromal cl isassociated with carcinoma but cl epithelial expression seems not to be contributory. introduction new approach on estrogen and progesteron receptors of the gastric signet ring cell carcinoma explains its histogenesis and poor prognosis. the pointed out facts are the reason for this study. material and methods the material was obtained from surgically resected stomach, together with ovaries. after two months from gastrectomy right mastectomy has been done. the specimens were fixed in % formaldehyde and embedded in paraffin. the sections were stained with he, pas, hid-ab ph= , methods and abc using estrogen and progesteron antibodies (dako). results histologically, mucin-producing signet ring carcinoma that diffusely infiltrates the antral wall and the ovaries known as krukenberg tumor, has been found. histochemically, type b signet ring cell carcinoma was discovered: cells contained blue positive (sialo) mucin. ductal type of breast carcinoma with lymph node metastases also was found. immunocytochemically, estrogen and progesteron positive receptors were discovered in cancer cells of the stomach, breast and ovaries. introduction primary gastric low-grade marginal zone b cell lymphoma of malt type is a distinct disease entity with a characteristic histological presentation and clinical behavior. the development of gastric malt lymphoma is dependent of h.pylori infection. many reports have stated that the cure of h.pylori infection can induce a complete remission of low-grade gastric malt lymphoma. we performed a prospective study to evaluate the outcome of patients with low-grade gastric malt lymphoma and the histological characteristics before and after therapy. we prospectively enrolled patients with h. pylori positive low-grade gastric malt lymphoma (stage i e except one patient in stage ii e). paraffin sections were stained with: he, giemsa, pas and immunohistochemical lab methods. the patients were examined by endoscopic ultrasound before and after eradication therapy. results endoscopically, enlarged gastric folds, erosions or ulcerations, hyperaemia or intragastric nodularity, with preferential localization in the antrum, were described. histologically, the neoplastic cells infiltrated between pre-existing lymphoid follicles, then colonized the lymphoid follicles. the resemblance of these cells to the centrocyte has led to the term "centrocyte-like (ccl)" cell-neoplastic component of malt lymphoma. in some cases the cells had monocytoid appearance, but plasma cell differentiation also was prominent. typical lesion for malt lymphoma -"lymphoepithelial lesion", was frequent, representing infiltration of the glandular epithelium by clusters of neoplastic lymphoid cells with associated destruction of gland architecture and morphological changes within the epithelial cells, including increased eosinophilia. after the eradication of h.pylori, the patients were regularly followed-up with endoscopic and histological assessment. patients achieved complete remission within weeks, one had partial gastrectomy induced by ulcer with severe dysplasia, but with regression of malt lymphoma (within weeks), but the remission of the patient with stage ii e was achieved within months. lamina propria appeared "empty" with gland loss. scattered lymphocytes and plasma cells were seen within the lamina propria and there were nodular collections of small lymphocytes. lymphoepithelial lesions were scanty or absent. conclusions the time taken for achieve remission of gastric malt lymphoma in these patients varied from to months. the only significant prognostic variables were stage and tumorgrade. comparative evaluation of the prognostic value of muc and muc antigens in colorectal adenocarcinoma introduction during the last decade, information accumulated regarding the experssion of human mucins. muc belongs to the group of membrane bound mucins. it is assumed to play various roles in tumor immunology. muc is marker of goblet cell or mucinous differentation of adenocarcinoma. the significance of muc and muc as prognostic markers in colorectal adenocarcinoma with mucinous differentation and mucinous adenocarcinomas was studied because previous investigations revealed inconsistent results. materials and methods tissues from operated patients with mucinous or mucinous differentiation of colorectal adenocarcinomas were investigated. all specimens were classified according to who and tnm classification, including lymph node status and distant metastases at the time of the surgical intervention. formalin-fixed paraffin-embedded colorectal cancer tissues were cut ( µm) and deparaffinized acording to standard histological techniques. classical he, histochemical pas and hid-ab ph= , and immunohistochemical bsp techniques were applied. the obtained results were evaluated by the x test. results the muc immunoreactivity showed a strong correlation with tumours progression (as suggested by advancing tnm stages) and also de-differentiation (as reflected by tumorous grading). localization and histological grading were also statistically signifficant. on the other hand, muc did not show any association with the data concerning prognosis. conclusions according to our data, only muc presents as an independent prognostic factor of colorectal adenocarcinoma. muc should therefore be considered as a potential target of immunotherapeutic strategies. sporadic form of colon cancer of a -year-old boy i stojanovic, v katic, j gligorijevic, k katic, m andjelkovic-matic institute of pathology, medical faculty of nis university, nis, serbia and montenegro introduction sporadic form of colon cancer is one of the most frequent cancers in adults, but very rare in children; thus we report this case. case report we describe the case of a -year-old boy who had the agressive sporadic coecal cancer, surrounded by nodular lymphoid hyperplasia.the boy underwent to partial colectomy cum omentectomy during the night with clinical diagnosis "acute abdomen". the surgical-pathological stage was: stage iii (t nlmo). the patient received postoperative therapy, but he died with liver metastases eight months from surgery. materials and methods formalin-fixed paraffin-embedded coecal cancer and surrounding nodular tissue were cut and deparaffinized according to standard histological techniques. he, pas, hid-ab ph , and immunohistochemical lab techniques were applied. results fungous advanced carcinoma, mm in diameter, induced stenosis and clinical symptoms of occlusion. histologically, it was poorly differentiated adenocarcinoma with high mitotic index(high activity of ki- ) and neuroendocrine differentiation; cancer cells were diffusely positive for p protein. immunological reaction to muc , muc ab and muc , as well as to b lymphocytes, was negative. microscopic examination of surrounding malt showed large, confluent lymphoid follicles without germinal centres within lamina propria, causing nodular appearance of the overlying mucosa. b lymphocytes were markedly depressed in this nonhereditary form of colon cancer. conclusions the authors have suggested that antibody deficiency, environmental, endocrine and genetic factors cooperated in the development of this nonhereditary coecal carcinoma. the histological findings in the gastroesophageal junction of fetuses introduction the histopathological concept of the gastroesophageal junction has been changed by american pathologists providing the evidence that the gastric cardia is not a physiological structure. instead, it develops through glandular metaplasia of the squamous epithelium of the distal esophagus due to gastroesophageal reflux. methods, results and conclusion the development of the esophageal and gastric mucosa in the gastroesophageal junction was studied in fetuses of - weeks of the gestational age. during the th - th week, the esophageal multilayered epithelium was covered by a continuous layer of columnar mucous ciliated cells which were present only focally till the th week and disappeared later. before the th week, the gastric mucosa was formed by pits only. the glands started as proliferating tubules in the basal parts of the pits in the th week. further, they differentiated into oxyntic glands. the mucosa of the corpus was fully developed in the th week. the cardiac mucosa was absent in all the fetuses examined between the th and st week of gestation. this supports the view that the gastric cardiac mucosa is not a physiological structure but that it results from glandular metaplasia of the distal esophageal mucosa due to gastroesophageal reflux. mr jalali nadoushan , a dievan beigi , n fallah , b mofid shahed university, tehran, islamic republic of iran shahid beheshti university of medical sciences, tehran, islamic republic of iran introduction there is not enough studies about relationship between colon cancer and abo and rh blood groups in compare to gastric cancer. therefore in this study we will examine abo and rh blood groups distribution and correlation of them with pathologic stage of colon adenocarcinoma. methods data on age, sex, abo and rh blood types and pathologic stage (wall thickness involvement and involvement of lymph nodes) of the patients with colon adenocarcinoma; were under surgical operation, were collected from three tehran hospitals. and also data on abo and rh blood groups from healthy persons from above hospitals collected by randomized selecting as control group. results the distribution of abo blood groups in patients was different from control group; however, blood group a in patients was . % higher than the corresponding control. there was no significant association between abo blood groups and pathologic stage of colon adenocarcinoma. the distribution of rh in patients was likely equal with control group; although, there was a significant relationship between rh (+) and wall thickness involvement (p< . ) and involvement of lymph nodes (p< . ). conclusion -abo blood group a is more common in patients with colon adenocarcinoma. -rh(+) has correlation with poor prognosis in colon adenocarcinoma. introduction vascular endothelial growth factor (vegf) is a cytokine involved in tumor angiogenesis. compelling data implicate that deregulation of p protein function may be associated with increased neovascularization and aggressive tumor growth. the aim was to investigate the prognostic significance of vegf overexpression and microvessel count (mvc) at the deepest invasive site in colorectal carcinoma tissue as well as their relationship with p protein expression in tumor tissue. material and methods surgical specimens of operated colorectal carcinomas were studied by immunohistochemical methods for detection of vegf and p protein in tumor tissue and cd positive microvessels. median folow up was . month (range, - months). results vegf expression and nuclear p protein overexpression were found in , % and % of colorectal carcinoma. vegf and p protein positive status was identical in . % of tumors. the dukes stage c and high mvc were significantly more frequent in vegf positive tumors ( . % and . % respectively) comparing with vegf negative tumors ( . % for both dukes stage c and high mvc). hypervascularity significantly correlated with advanced dukes stages, but not with the p protein expression. survival analysis showed that vegf and p protein expression as well as hypervascularity of colorectal carcinomas correlated with poor survival (p= . ). conclusion vegf is an important angiogenic factor in colorectal carcinoma, and its expression being dependent on p protein expression. our data suggest that combined analysis of vegf, p protein and mvc may be useful for predicting the more aggressive biological behaviour of colorectal carcinoma. occult involvement of lymph nodes in the splenic hilus and along the splenic artery in patients with proximal gastric carcinoma m bjelovic introduction the aim of this study was to find out the incidence of occult metastatic involvement in lymph nodes in the splenic hilus (lymph node group according to jrsgc) and along the splenic artery (lymph node group according to jrsgc) as well as to identify pathological features that might be prognostic factors associated with involvement of these lymph nodes in the patients with proximal gastric carcinoma. material and methods total of patients with advanced proximal gastric carcinoma and up to positive perigastric lymph nodes (t /t n category) have been studied in the period between and . histopathological features (tumor size, macroscopic and histologic type, grade of differentiation, depth of penetration, invasion of intramural lymphatics and veins) as well as lymph node involvement have been routinely examined according to tnm and jrsgc systems. detection of microcarcinosis (occult lymph node involvement) in lymph nodes groups and has been performed by multiple serial sectioning and using immunohistochemistry (monoclonal antibodies against cytokeratins and , lsab+ technique) and classified according to modified kikuchi criteria. results occult lymph node involvement in lymph node group has been observed in patients ( , %). three of them ( , %) had only single cell micrometastases (g type of microcarcinosis) and patients ( , %) had micrometastatic deposits greater than microns (g type of microcarcinosis). occult lymph node involvement in lymph node group has been observed in patients ( , %) expressing single cell micrometastases in one case and micrometastatic cell clustering (up to microns in diameter) in another case. conclusion occult involvement of lymph node groups and could be expected in lymph node positive patients with more than three positive perigastric lymph nodes. in the patients with advanced proximal gastric carcinoma examined pathological tumor characteristics could not be associated with the involvement of lymph node groups and . lymph node micrometastases in patients with gastric carcinoma: immunohistochemical evaluation introduction for patients who underwent curative resection for gastric carcinoma, lymph node status seems to be a major prognostic factor of disease recurrence. contrary to histologically overt lymph node metastasis, the biological significance and prognostic relevance of micrometastatic lymph node involvement are still controversial. we examined frequency and distribution of micrometastases in lymph nodes obtained from patients with advanced gastric carcinoma ( , lymph nodes per patient) without primarily histologically overt lymph node metastases. identification of lymph node micrometases was performed using multiple serial sectioning and immunohistochemical detection of cytokeratin and positive cells. the results were correlated to tumoral histological type, growth pattern, depth of penetration and vascular invasion. results the overall detection rate of micrometastases showed their occurence in more than half of examined patients ( / or , %) and in , % of examined lymph nodes ( / ). most of them were so-called single cell micrometastases ( , %), followed by cluster-type of micrometastases up to microns ( , %) and few greater than microns ( , %). the incidence of micrometastases was , % ( / ) in lauren`s diffuse type of carcinoma contrary to % ( / ) in lauren`s intestinal type of carcinoma. in addition, there was no significant difference in occurence of micrometastases in cases with and without penetration of muscular layer, contrary to cases with serosal tumoral involvement and obvious vascular invasion. conclusion detection of micrometastases might influence tumour stage migration to tnm stage iii in further % of examined patients with primarily stage ii determined diseases. the frequency of micrometastases seems to be closely correlated to poorly differentiated carcinomas, especially lauren`s diffuse type of carcinoma and higher pt stages, including serosal involvement. however, possible independent prognostic significance is still to be elucidated after survival analysis of larger series of these patientss ubgroups. introduction gastrointestinal stromal tumors (gists) are the most common mesenchymal tumors of the gastrointestinal tract with the stomach as the most common site. the term 'gist' is preferentially used for the tumors that express cd and cd /c-kit and the latter has been suggested as a specific marker for gists. as gists constitute a group of phenotypically heterogenous mesenchymal neoplasms with uncertain biological behaviour, we reevaluated their histogenetic differentiation and proliferative status. material and methods we reexamined clinically, histologically and immunohistochemically cases of paraffin-embedded gists noted in the tumor registry of clinical centre of serbia between and , and especially in regard to their proliferation, measured by mitotic index and immunohistochemically by ki- and pcna expression scores. in addition, evaluation of malignancy of gists was based on mitotic count greater than / hpf and/or tumor size greater than cm and extra-gastrointestinal spread. results most of gastric gists were composed of spindle cells ( %), epithelioid cells ( %) or both cell types ( %), and nearly % showed obvious clinical malignant behavior. immunohistochemical examination showed strong cd expression in %, cd in , % (two of cases exlusively cd positive) in nonmyogenic and non-neurogenic tumors. in addition, in gists with cd expression, focal expression of s- was found in , %, focal sma in % and desmin in , % of cases. ki- and pcna indices were correlated to mitotic index and other criteria of malignancy. conclusion phenotypic differentiation of gists toward smooth muscle were found to be correlated with proliferative indicators of poor prognosis more consistently than those toward partial/focal neurogenic differentitation or uncommited type. deep topographic compartments of colorectal adenocarcinomas: down-regulation of mlh /msh expression results in lack of physiologic cell kinetic balance background topographic tumor cell selection is not well characterized in colo-rectal adenocarcinomas (crc). the contribution of mlh- /msh- expression to cell kinetics by topographic compartments remains unknown in sporadic crc. design we selected ( low-grade, high-grade) consecutive sporadic crc, including stage i, stage ii, and stage iii. mitotic figure counting, ki- index, g +m phase fraction, in situ end labeling (isel) of dna fragments, and mlh- /msh- immunoexpression were scored by topographic tumor compartment (above muscularis propria vs. muscularis propria). statistical correlation between proliferation and apoptosis variables was performed in each topographic compartment. variables were studied by topographic compartments and considered statistically significant if p< . . physiologic correlations were preserved only in the superficial compartment for mitotic figures, ki- expression, isel index, and mlh /msh expression. g +m phase fraction correlated with mlh- expression only in superficial compartments (p= . ) and msh- expression only in deep compartments (p= . ). conclusions superficial compartments of sporadic crc are characterized by high cellular turnover and maintained cell kinetic balance. mlh- and msh- expression in sporadic crc is inefficient (no g +m phase fraction differences by topographic compartments) and is dissociated (only one gene product correlates with g +m), eventually resulting in mutation accumulation and cell progression. gastro the biologic behaviour of gists has been difficult to predict based on the original criteria proposed in the early s. many isolated histological features, such as site, size, extent of bowel-wall involvement, necrosis, cellularity, mitotic counts, atypia, etc., had to be evaluated and integrated into a single and reproducible result that had also to be as accurately predictive as possible. therefore numerous studies have been performed in order to reach the ideal combination of factors that may predict these tumors correctly. gists were diagnosed either originally or retrospectively after reviewing diagnoses of git spindle cell tumors, examined in our pathology department between the years - . all tumors were defined as gists only when displaying c-kit (cd ) immunopositivity. additional immunohistochemistry was performed to corroborate the diagnosis. we reclassified the tumors according to different proposed classifications and correlated the results with the clinical followup available for these patients. the followup periods ranged between - months for gastric gists (mean- . months, median- . months) and - months for patients with small-bowel gists (mean- . months, median- months). while the median disease-free survival was . months for patients with malignant gastric gists, it was only months for patients with small-bowel malignant gists. the results of the study show that all classifications stratified the patients in a very similar manner although some were more accurate than the others and more user-friendly and therefore probably also more reproducible. the relative high rate of deaths occuring in the smallbowel gist group ( %) as compared to the . % death rate in the gastric gist patients, strengthens the supporters of different criteria to be applied to the gists arising in these different sites. another important issue that has imerged in our study was the much higher incidence ( %) of malignant gists developing in the younger age group ( - years), compared to . % malignant gists in the age group of above years, making this feature to be probably of major significance. it should therefore be considered whether age should be a built-in criterion when evaluating the biological potential of a gist. introduction gastric ulcer disease is the most important disease of the digestive tract becouse this illnes have big frequecy and circle gastric ulcus presents many histologic features characteristics which may be precancerous lesions. gastritis is lesion which is always associated with gastric ulcer. epithelial metaplasias are transformation of one kind of epithelium to other type epithelium and circle gastric ulcus it is very frequency changes of epithelium. the aim of this study was to to find frequency of appearance epithelial metaplasias circle gastric ulcus, types of metaplasias and grade of gastritis. also we searched changes of epithelial mucins. we had citochemistry examination endocrine g, ec and d cells and we wanted to describe immunohistochemicaly feature characteristics in different kinds of epithelial metaplasias. material and methods for examination we use biopsy material:surgery and endoscopic of patients with gastric peptic ulcer. we use standard he method for identification micromorpholic changes; ab-pas (ph , ) and hid-ab method for illustration biochemistry alteration about mucins;grimelius ( ) and masson citochemistry methods; immunocytochemistry avidin-biotin peroxidasa (abc) with antiserotonin, antigastrin, antisomatostatin. results we found cases completly mature intestinal metaplasias (im), cases incompletly im; case imature im and case imature im with displasia. also we detected composition completely and incompletly im in cases, composition incompletly and pyloric metaplasia in cases.we find pyloric metaplasias in cases, colons metaplasia in cases. composition colons and incompletly mature im were detected in cases;composition pyloric and incompletly mature im in case.summary the bigest frequency of appearance metaplastic alteration were in older patients.histologicaly claracteristics metaplasias were imitation some segments of digestive tract. metaplasias include many biochemicaly alterations and it can be present with changes in secretion of mucins.gastric metaplasia is dynamic process with changes both in epithelial and endocrine cells. conclusion metaplasias in gastric mucosa circle gastric ulcer is sign very important alteration.standardisation of research this alteration may be very important guider about prognosis for patients with gaster ulcer disease. choice of immunohistochemical method for detection of defect mismatch repair system c fenger, o nielsen, tp hansen department of pathology, odense, denmark colorectal cancer (hnpcc) and in % of sporadic colorectal cancers, and in the latter the defect is associated with a better prognosis but posssibly also a higher risk for metachronous cancer and a different response to adjuvant chemotherapy. screening for such defects can be done by testing for microsatellite instability, but immunohistochemistry gives similar results with less costs. the aim of this study was to select the optimal antibodies and methods for immunhistochemical detection of proteins involved in the mmr system. material and methods twelve antibodies ( against hmlh , against hmsh , against hmsh and against pms ) were tested using different dilutions and hier-techniques on a material consisting of paraffin embedded tumours from patients with well defined mutations and from controls. the results were evaluated semiquantitatively. the following clones, dilutions and pretreatment regimens were selected: introduction colon's metaplasia may be variant of intestinal metaplasia in the gastric mucosa circle gastric ulcer.it is important precancerous stadium because % colon's metaplasias of gastric mucous membrane transverse in gastric carcinoma. aims: we want to find frequency of appearance colon's metaplasia in gaster mucosa with ulcer disease.also we want to describe histologicaly, histochemicaly and immunohistochemicaly feature characteristics colon's metaplasia in gastric mucosa. materials and methods for examination we use biopsy's matherial:surgery's and endoscopic of patients with gastric peptic ulcer. we use standard he method for identification micromorfologic changes; ab-pas (ph , ) for illustration biochemistry alteration about mucins;grimelius citochemistry method;imunocytochemistry avidin-biotin peroxydasa with antiserotonin, antigastrin and antistomatostatin. results we find two cases so-called colon's metaplasia gastric mucous membrane. it was males in vi decade of life.both of them were detected near parts with intestinal metaplasia and atrophic gastritis. histology's design metaplastic epithelium appear big changes than normal gastric mucosa watched on cellular and tissue level;it was alike epithelium of colon. there was winding and arborescent cryptas, and wasn't find villosity. cells in cryptas were voluminous and they group. predominant componentof cells were goblet cells. cylindric cells also was alike goblet cells. we didn't see paneth's cells. histochemycaly we detected sufficiently sulphomucins and less sialomucins. g cells and ecl cells were insufficient; ec cells were less multiplied. conclusions colon's metaplasia is sign of big intracellular alteration and we can detect this with changes in secretion of mucin. colon's metaplasia gastric epithelium is dynamic process with changes both in epithel and endocrine cells. upregulated expression of relp, a reg-like protein, in inflammatory, metaplastic and neoplastic gastrointestinal mucosa lc andersson we screened expressed sequence tag (est) databases to detect genes specifically expressed in the gastrointestinal tract. we identified a gene, called relp (regenerating protein (reg) family-related protein). the relp cdna encodes a amino-acid preprotein with a -amino-acid signal peptide. the amino acid sequence of relp is - % identical and - % similar to the previously characterized members of the reg protein family. the reg proteins, which all belong to the family of c-type lectins, have been implicated in cell proliferation, migration and differentiation in the gastro-intestinal tissues. the relp gene spans . kilobases and maps to chromosome p - . , whereas the genes of the previously known reg proteins cluster on chromosome . dot-blot hybridisation revealed expression of relp mrna mainly in the gastrointestinal tract, but also in prostate, and testes. immunohistochemical staining demonstrated expression of relp in mucosal neuroendocrine cells of in the small intestine and in the parietal cells of normal gastric mucosa. regenerating borders of gastric ulcera, the goblet cells of inflammatory mucosa in ulcerative colitis and crohns disesase, showed a strongly upregulated expression of relp. areas of intestinal metaplasia in the stomach and esophagus also displayed a robust content of relp. more-over, relp was strongly expressed in mucocellular and mucinous tumors of the gastrointestinal tract. the orthologous gene for mouse relp was also cloned. conclusions relp represents a novel marker of inflammatory, metaplastic and neoplastic changes in the gi-tract. current approach to the biopsy diagnosis of gastrointestinal stromal tumors (gists) -is it possible to predict clinical behaviour? introduction gists are the most common gi mesenchymal tumors showing cd positivity. although according to accepted criteria none of them are 'benign', their metastatic risk depends on the tumor size (ts) and mitotic count (mc). aim: reclassification of a series of gists using morphological and immunohistochemical analysis of paraffin-embedded material and evaluation of the relevant clinical data. material and methods patients with gists fulfilled the criteria of fletcher et al. ( ) . in addition to histological stainings, primary antibodies against vimentin, desmin, actins, s- protein and cd (all dakocytomation) and cd (immunotech) were used for the immunoanalysis. results majority of the tumors was localized in the stomach (n= ) and small intestine (n= ), one in the colon and two were extragastrointestinal. in relation to the accepted mc and ts criterias, of cases were of low and one of very low risk category. tumors belonged to intermediate risk category, mostly due to ts in contrast to low mc. the inclusion of cases into high risk category was based predominantly on the mc (> / hpf and ts - cm /n= / and > cm /n= /; in the last one it was > - / hpf in contrast to ts < cm). conclusion a prediction of clinical behaviour of gists requires a correct histopatological analysis related to initial staging data. although the categorisation of the gists into different risk categories uses both criteria of ts and mc, the significance of the mitotic activity evaluation in our set of cases seems to be higher. multiple gastric composite carcinomas (adenocarcinoma and endocrine carcinoma) with adenosquamous differentiation y kapran , n akbas , m aksoy , f dizdaroglu university of istanbul, istanbul medical faculty, pathology department, istanbul, turkey university of istanbul, istanbul medical faculty, general surgery department, istanbul, turkey a case of multiple gastric composite carcinomas composed of endocrine carcinoma and adenocarcinoma with adenosquamous differentiation is presented. tumours showed a composite architecture both within the site of origin and in lymph node metastasis. a year-old woman had a diagnostic upper gastrointestinal system endoscopic evaluation for her long term dyspeptic complaints. after determination of two concurrent tumours in the stomach she underwent total gastrectomy operation. gross examination of the stomach revealed a polypoid lesion in the anterior wall and an ulcerous lesion in the posterior wall of the corpus. also there were multiple minute nodular lesions both in the corpus and fundus. histopathological examination of the polypoid tumour revealed a well-differentiated tubular adenocarcinoma admixed with an endocrine carcinoma proved immunohisto-chemically. ulcerous lesion was composed of a poorly-differentiated adenocarcinoma showing adenosquamous differentiation admixed with an endocrine carcinoma. other nodular lesions were composed of endocrine tumours having different levels of invasion in the wall of stomach. non-tumourous mucosa harboured atrophic gastritis. this is a unique case of multiple composite carcinomas devoloped in the setting of atrophic gastritis worth to discuss. introduction one of the most common malignant soft tissue tumours in adults is malignant fibrous histiocytoma. these tumours are accepted as an aggressive tumour and mainly treated surgically. primary and metastatic malignant fibrous histiocytomas of the gastrointestinal tract are rarily described. our case is a -year-old woman who had a retroperitoneal malignant fibrous histiocytoma that had metastased to the lung after months following an adequate initial treatment. four months later, because of having recurrent attacks of vomiting and nausea, gastroscopic examination was performed. multiple nodular lesions in her stomach were seen and microscopic examination of these lesions revealed spindle-shaped, pleomorphic tumour cells. the positive immunoreactivity for anti-vimentin and anti-cd justified the diagnosis of malignant fibrous histiocytoma's metastases. total gastrectomy was performed following that diagnosis and she died after month due to renal failure. conclusions this case is presented because of the rarity of distant metastases of malignant fibrous histiocytoma to the stomach and to discuss the entities that should be considered in the differential diagnosis of these tumours. role of p ink a in gastrointestinal stromal tumours introduction the classification based on c-kit/cd expression reordered the formerly rather confuse category of gist. p ink a (p ) is a tumour suppressor gene of the cyclin d-cdk , /ink /rb/e f pathway, altered in > % human neoplasms. it is located on chromosome p , a region consistently involved in dna losses found in malignant gists. aims: we studied the role of p in gists. materials and methods cd -immunoreactive mesenchymal tumours with morphological and clinical features consistent with gist were studied, excluding smooth muscle (desmin+, cd -) and schwannian (s- +, cd -) neoplasms. cases ( gastric, small intestinal and colorectal; males, females; age at diagnosis: - years; follow-up: - -mean: . -months) were considered. immunohistochemistry, rna extraction with semiquantitative rt-pcr and methylation specific pcr (msp) were used. kaplan-meier method followed by log-rank test, and univariate and multivariate analyses with a proportional hazards model were performed (malignancy criteria adopted for uncensored events: recurrence, invasion of adjacent organs, peritoneal dissemination, metastases and death of disease). results a tumoral cell fraction with low/absent p immunoreactivity > % was associated with malignancy; semiquantitative rt-pcr confirmed this result. by msp, cases (all underexpressing p , six malignant) showed p promoter methylation. low/absent p immunoreactivity, together with size, cellularity, mitotic count and presence of coagulative necrosis resulted associated with malignancy by univariate analysis, with the former factor being the only prognostic one selected by multivariate analysis. conclusions p downregulation is implied in gist progression; p promoter methylation is one of its causes; p assessment opens possible perspectives in gist prognostication. introduction regenerative abilities of gastric mucosa glandular epithelium cells are the main mechanism which condition its right function both within the range of gastric mucosa integrity and normal activity of its epithelial cellular elements. the aim of the work was to evaluate dependence between proliferative activity of gastric mucosa glandular epithelium and sex, age, chronic inflammation type and helicobacter colonization. the examinations were conducted on paraffin blocks from gastric oligobiopsies taken from women (of average age- ) and men (of average age- ).to the examinations were rated only cases where oligobiopsies were taken from at least two gastric prepyloric parts (antrum) and corpus with recognized unspecific chronic gastric mucosa inflammation. chronic gastritis was graded according to modified whitehead's classification. helicobacter pylori (hp) was evaluated according to the sydney system. examination of the cells with pcna proliferative antigen expression were conducted separately for foveolar area glands and for glands below gastric mucosa foveolar area. all the measurements were performed separately for gastric mucosa prepyloric part and gastric corpus. in tissue sections, in which were carried out proper immunocytochemical reactions, measurements of the pcna positive cells number in circular, oblique short, oblique long and oblong gastric glands sections were conducted five times. the statistic analysis also included age, presence of hp colonization, gastric mucosa inflammation type and the area where an oligobiopsy section was collected. results no significant differences were found in proliferative activity depending on the place of collecting a section, age and hp colonization, while a higher proliferative activity was found in superficial chronic gastritis, particularly in gastric mucosa prepyloric part. conclusions . chronic superficial inflammation coexists with significantly higher proliferative activity of gastric mucosa glandular epithelium, particularly with connection to its prepyloric part. . changes in gastric mucosa glandular epithelium proliferative activity do not depend on its age and histotopography and hp colonization. introduction chromogranin-a-plus (cha) and d cells exist almost in the whole alimentary canal and in pancreas. these cells have an influence on secretory functions and normal gastric mucosa histostructure. up to now investigations confirmed participation of these cells in e.g hcl and gastrin secretion regulation and in some of the proliferative states of gastric mucosa. the aim of the study was to estimate participation of cha and d cells in microscopic superficial (gchs) and deep (gch) gastric mucosa inflammation's indices. material and methods paraffin blocks from gastric oligobiopsies was the material which was collected from women (of average age- ) and men (of average age- ). to the examinations were classified only the cases where oligobiopsies were taken from at least two areas of gastric prepyloric part (antrum) and corpus, with diagnosed unspecific chronic gastric mucosa inflammation. chronic inflammations were graded according to modified whitehead's classification. helicobacter pylori (hp)was evaluated according to the sydney system. neuroendocrine cells of gastric pylori were counted after proper immunohistochemical identification in circular, oblique short, oblique long and oblong gastric glands sections. all measurements were conducted separately for gastric mucosa prepyloric part and gastric corpus. the results of quantitative researches were analysed with the use of statistic methods. in gastric mucosa antrum there were twice more cha and d cells in comparison with corpus. gastric mucosa inflammation type did not have a significant influence on cells localization in gastric mucosa. the number of cha cells diminished in gchs gastric antrum among patients who were over years old, whereas the same number increased in corpus inflammations of this type. the increase of cha cells number was found in gchs gastric antrum with hp colonization. in these cases d cells number diminished. conclusions . in gchs gastric antrum with hp colonization cha cells number significantly increases while d cells number decreases. . quantitative changes of cha and d cells run differently in gchs and gch both in prepyloric part and in gastric corpus. response to preoperative chemoradiation on rectal adenocarcinoma: histopathological effects and relationship with level of p and pcna expression introduction adjuvant chemoradiotherapy delivered before surgery has been used to improve control and to reduce the likelihood of local recurrence in selected patients with rectal cancer. although the status of p gene and the expression of pcna has been widely studied in these tumors, little is known about their value to predict the responsiveness of rectal cancer to chemoradiation. the aim of this study was to to assess effects of preoperative chemoradiation in advanced rectal adenocarcinoma. we examined the histopathologic effects of chemoradiotherapy on rectal tumors and correlated the efficacy of treatment with the level of p and pcna proteins expression in pretreatment biopsies. results three patients showed no primary tumor in the resection specimen. another eight carcinomas showed a good response to chemoradiation with only small nests of viable tumor cells. grouping these two categories, we considered that the tumor response had been total or subtotal in cases ( %). nuclear accumulation of p protein was detected in ( %) specimens. thirty five tumors showed a high pcna index ( %). no obvious relationship seemed to exist between pretreatment, p immunostaining and response to chemoradiotherapy. tumors with high pcna index were more likely to respond to chemoradiation: / ( %) versus / ( %)(p= . ). conclusion knowledge of proliferative activity of rectal cancer, as determined by pcna immunostaining, should be useful in predicting the likelihood of response to preoperative chemoradiation. introduction mitotic count and tumor size are the main predictors of outcome in gastrointestinal stromal tumors (gist). however, they are not always useful in individual cases. the aim of the present study has been to assess whether mitotic counts performed using phosphorylated histone (phh ) antibody, expressed from the early steps of mitosis, could improve the prediction of prognosis in these tumors. materials and methods sections from gist were stained with phh antibody (upstate biotechnology, lake placid, ny; : , dilution). mitoses were counted per high power fields ( x, olympus bx). in addition, the h&e-based mitotic counts and tumor size were obtained from the pathology reports. patient outcome was recorded as the endpoint. conclusion in the present series, phh -based mitotic counts allow a better prediction of prognosis than h&e-based counts or tumor size. thus, phh antibody could be applied in the pathological classification and grading of these tumors, and in the more precise definition of cases with higher risk of progression. immunohistochemical expression of cyclooxygenase- (cox- ) in human colorectal cancer introduction recent studies have implicated metabolites of arachidonic acid, such as prostaglandin e( ) in colorectal carcinogenesis. cox- , a key enzyme in arachidonic acid metabolism, is present in the majority of colorectal cancer (crc). its overexpression seems to be associated with worse prognosis. the aim of this study was to examine the relationship between the expression of cox- in human crc and the clinicopathological characteristics of the tumor. materials and methods paraffin embedded tissue samples from patients (m: , f: , median age: yrs) with crc (tnm staging: i -iv), who underwent radical surgical treatment in thessaloniki cancer hospital "theagenio" from / / until / / , were evaluated. tumor sections were stained for cox- using a rabbit polyclonal antibody against human cox- and the staining was graded on a scale - , using mononuclear cells as reference. results cox- expression was found in tumor epithelial cells in . % of crc ( / cases) with diffuse mainly, cytoplasmic staining and in inflammatory cells, vascular endothelium and fibroblasts. low cox- expression (grade - ) was found in . %, high cox- expression (grade - ) in . % of cases and the remaining were negative. there was no correlation between clinicopathological characteristics of patients and intensity of cox- expression, although there was a slightly better overall survival rate in low expression group of patients (p:ns) . conclusions this small study shows that cox- protein is overexpressed in most cancer cells in colorectal carcinomas and may be related to overall survival. the expression of bcl family proteins in b-chronic lymphocytic leukemia introduction b-chronic lymphocytic leukemia (b-cll) is a neoplastic disease caused primarily by defects in the apoptosis mechanism. apoptosis is the process of programmed cell death or cell suicide. the bcl- proteins are a family of proteins involved in the response to apoptosis. some of these proteins (such as bcl- and bcl-xl) are anti-apoptotic, while others (such as bad or bax) are pro-apoptotic. materials and methods our study includes peripheral blood specimens from patients with b-cll and healthy individuals (as a control group). using western blot analysis, we examined the levels of bcl- , bcl-xl, bax and bad protein expression. the level of bcl (p= , x - ), bax (p= , ) and bad (p= , ) proteins were significantly increased in all analyzed patients while the level of bcl xl protein (p= , ) showed no difference between patients and healthy individuals. differences between the levels of analysed protein expression in group of patients had no statistical significance. conclusion increased level of expression bcl , bax and bad protein represents the most striking feature of b -cll cells. the variations in expression of only one protein of the bcl family can not represent the prognostic factorr in b-cll. introduction kikuchi -fujimoto disease (kfd) is a distinctive type of necrotizing lymphadenitis with unknown cause, has a selflimited clinical course and affects usually the cervical lymph nodes of young women. although kfd occurs most often in young women, only two cases have been reported during pregnancy. in one of these cases kfd developed initially years before. case report we report a case of a -year-old pregnant woman on her th week of gestation who was admitted with a history of swelling in the right side of the neck and fever of days duration. on physical examination a cm cervical lymph node was palpable. microscopically, the excised lymph node showed large areas of necrosis and extensive karyorrhexis. no neutrophils or plasma cells or eosinophils were identified. it was found an admixture of nonphagocytic histiocytes and t-lymphocytes in the necrotizing area. there was a predominance of cd + cells over cd + cells. the patient received no treatment and months later had no symptoms. later she delivered a healthy boy. five years ago the patient presented similar clinical history and histological diagnosis of the excised cervical lymph node. we present the second reported case of recurrent kfd during pregnancy and the third case of kfd developing during pregnancy. conclusion from our case and the other two reported cases it seems that if kfd occurs in a pregnant woman there is no need to terminate the pregnancy as there was no effect on both mother and fetus. monitoring of patients with follicular lymphoma carrying t( ; )(q ;q ) by real time quantitative pcr introduction follicular lymphomas (fl) are characterized by t( ; )(q ;q ) in a majority of patients. the identification of the translocation is utilized to monitor the disease behavior, and, specifically, to detect minimal residual disease (mrd). qualitative pcr is routinely used but without specification of the tumor cell quantity. real time quantitative pcr (rq-pcr) may be employed to address this issue. aims: rq-pcr was introduced to monitor mrd in patients with fl bearing the t( ; )(q ;q ). materials and methods samples of primary tumors, bone marrow and peripheral blood (bm/pb) specimens were taken in the course of the disease and were used for the t( ; )(q ;q ) assessment. for translocation screening, fish on interphasic nuclei was applied. qualitative pcr was used to detect the break in the major breakpoint region (mbr) of the bcl- gene ( q ). relative quantity of cells bearing mbr t( ; )(q ;q ) was performed by the rq-pcr. fifteen samples of primary tumors and bm/pb in duplicates were investigated with appropriate controls. the relative quantity of cells with t( ; )(q ;q ) was significantly higher in the primary tumors than in the bm/pb samples. the changes of the bm/pb infiltration were found during the course of the disease and included shifts toward the tumor progression or disappearance of the tumor cells. rq-pcr is a technique suitable for monitoring the disease response to the therapy or the disease progression and it is superior to morphology and immunohistochemistry. supported by: iga-mzcr-nc/ - , research project fn-motol/ . phosphatase activity dependent apoptotic effect of transforming growth factor beta in ht human lymphoma cells introduction transforming growth factor beta (tgfb ), a multifunctional cytokine, has antiproliferative and/or proapoptotic effect on lymphoid cells. the continuously proliferating lymphoma cells could be resistant to the endogenously produced tgfb . aims: to study the responsiveness of lymphoma cells using exogenously activated tgfb . the apoptotic effect and depolarization of the mitochondria was detected by flow cytometry, the different gene expression was studied by rt-pcr. the amount, the activity (western blot) and the localization (confocal microscopy) of the signal elements (smads, phoshpo-smad , erk / , jnk, p mapk) and other proapoptotic and survival proteins (bcl- , blc-xl, bid, bax, bad, nfkb, phospho-ikb) were also studied. the role of pp a phosphatase, mek kinase and caspase activity was estimated by different inhibitors (endhothal, okadaic acid, pd , z-vad-fmk, z-ietd-fmk, z-lehd-fmk) in vitro. results ht b cell lymphoma cells lost their sensitivity to the antiproliferative action of exogenous tgfb , but the cells were killed by apoptosis. smad phosphorylation, nuclear localization and the increased expression of tgfb induced early gene (tieg) proved the rapid activation of smad signal. the role of pp a phosphatase activation followed by decreased expression of active phospho-jnk and phospho-erk / was supported by the antiapo-ptotic effect of pp a inhibitors and the proapoptotic effect of specific mek inhibitor. the apoptosis was induced primarily through the mitochondrial pathway. it seems that both main iniciator caspases (caspase and ) took part in the apoptotic response. conclusion these data suggest that exogenous tgfb had double but interrelated actions on ht cells: a) suppression the survival signals produced by protein kinases, which b) allowed the smads to induce apoptosis. therefore, it is possible that the lost sensitivity of malignant lymphoid cells to proapoptotic regulators (such as tgfb ) could be reactivated especially by lowering the survival threshold. the work was supported by otka (t ), ett ( / ett ( / , / , fkfp ( / ) and békésy foundation ( / ). clinicopathological study of chromosome abnormality related hematological disorders introduction cytogenetic abnormalities sometimes determine the subtype of hematological disorders and are common in myelodysplastic syndromes (mds). although chromosome abnormality is frequently observed in mds, the specific characters of this type are not determined. in this study, we examined the clinicopathological characters of hematological disorders associated with chromosome abnormality. aim of this study is to assess whether these disorders are classified in special subtype or not. we selected hematological disorder cases with chromosome abnormality from the bone marrow files of the department of pathology, nagoya university hospital. clot sections of aspirated bone marrow were examined histopathologically. immunohistochemical study was performed using paraffin embedded tissues. results patients, males and femals respectively, with monosomy , with der ( ; ) and with other abnormalities were studied.the median age of the patients was . years (range, - years). pancytopenia was observed in , bicytopenia in and monocytopenia in cases. past history of aplastic anemia was in cases. histopathologically, they were cases of mds, of aml, in all and of others. hypoplastic mds (< % cellularity) were found in cases, of ra, of raeb, of raeb-t and case of mds with fibrosis. all cases of acute leukemia had dysplastic multi-lineage features other than blasts. histopathological characteristics were weak erythroid dysplasia, increased micromegakaryocytes and hypocellular tendency. these characteristcs were common in patients with monosomy and other abnormalities. concusion hematological disorders with chromosome abnormalities share similar clinicopathological characteristics. expression of topoisomerase i and topoisomerase ii alpha as an independent prognostic factor and evaluation of the overall survival in nhl e catalano cooper hospital/university medical center, camden, usa introduction topoisomerase ii alpha and topoisomerase i (topo i and ii alpha) are the key targets for some anti-cancerous drugs that inhibit these enzymes. the purpose of this paper is to examine the expression of topo i and topo ii alpha in different types and stages of nhl's the response of treatment with the overall survival. materials and methods immunohistochemistry techniques with anti-topo i and topo ii alpha were used. the results were evaluated with a semi-quantitative method. results and conclusion cases were studied with topo i and topo ii alpha. we include % of follicular lymphomas, % diffuse, % follicular and diffuse and high grade %. the stage of these tumors were stage i, %; stage ii, %; stage iii %; stage iv, %. the results show a higher intensity expression of the topo ii alpha, and topo i indices, in the higher grade nhl. there appears to be a similar expression between the intermedium and indolent nhl. the survival indicates that the large cell nhl's show a higher response rate and better survival than the mixed or small cell type. the expression of these two enzymes may be useful for selecting the appropriate chemotherapy in nhl. our data, although small, suggests an excellent correlation in response to treatment and longer survival in the nhl that have a high expression of topo i and topo ii alpha. mantle cell lymphoma (mcl): ki- antigen and chromosome ploidy in an estimate of the tumor progression introduction mcl belongs to prognostically unfavorable lymphomas. however, the behavior may vary and it is difficult to predict it. a more aggressive course tends to be associated with blastic and anaplastic subtypes. numerical chromosomal changes and proliferative activity may be of importance to improve the prediction. aims: risk of the tumor progression with the assessment of ki- antigen-positive cell count and ploidy status of chromosome . materials and methods patients with mcl characterized by t( ; )(q ;q ) and by overexpression of cyclin d . the proliferative activity was evaluated immunohistochemically (ihc) by double staining for ki- antigen and cd (to rule out counting admixed ki- positive t-lymphocytes). ploidy status of chromosome was evaluated by interphasic fish. results and conclusion trisomy and polysomy of chromosome ( patients) was associated with blastic/anaplastic forms of mcl with the same frequency as with the common variant. a finding of > % ki- and cd positive cells was associated with the blastic variant of the disease - patients. of them died of the disease progression, one of unrelated cause and one is alive with the disease. of the remaining patients in whom the follow up was available, died of the tumor, and the proliferative activity, measured by counting the ki- positive cells was < %. the assessment of proliferative activity with immunohistochemical demonstration of ki- antigen seems to be useful in prediction of clinical behavior of mcl supported by iga-mzcr-nc/ - , research project fn-motol/ . morphological criteria for differentiation of lymphocyte predominance hodgkin's lymphoma from lymphocyterich classical hodgkin's lymphoma aims to reveal morphological features of differential diagnosis between lymphocyte rich classical hodgkin's lymphoma (lrchl) and nodular lymphoid predominance (nlphl). retrospective analysis of lymph node biopsies (age - ) with histological diagnosis of "nodular paragranuloma" or "hodgkin's disease, lymphocytic and histiocytic variant". immunological data were available in all cases. all patients presented with the early stages of disease. we used the following morphological criteria: growth patterns (nodular, nodulardiffuse or diffuse), distribution and cytomorphology of tumor cells ("popcorn", lacunar, classical, mummified cells), cellular composition of reactive background, presence or absence of secondary and atrophic follicles. the results of morphological algorithm were compared with immunology data in every case. results among biopsies, cases ( %) were classified as nlphl. cases were attributed to lrchl, including cases which were characterized by interfollicular sheets of cells resembling lacunar cells ("cellular phase of nodular sclerosis"), cases had rare classical cells within expanded mantle zone ("follicular variant" of hodgkin's disease). all cases lrchl exhibited secondary follicles. there were no cases of lrchl with "pure" diffuse growth type; both nlphl and lrchl had nodular or nodular and diffuse pattern. cases corresponded morphologically to nlphl or lrchl and this division was confirmed with immunological analysis.. conclusion we proposed the algorithm of morphological criteria for differentiation of nlphl from lrchl bone marrow sinusoids in acute lymphoblastic leukemia (all) v rugal russian institute hematology, st.petersburg, russian federation introduction bone marrow sinusoids regulate the development of hemopoietic precursors and migration of stem cells and mature blood cells in blood stream. the purpose of the investigation was to study endothelium of bone marrow sinusoids in disordered hemopoiesis in all. pretreatment bone marrow trephine biopsy sections from patients with all were studied using morphometric and ultrastructural methods. results development of myelosuppression in all was accompanied by considerable changes in the morpho-functional status of sinusoid endothelium. most vessels became thinned, endothelial cells were flattened. in such vessels cells of endothelium came apart with formation of gaps between cells. the basement membrane was interrupted. however, blast migration continued to be transendothelial. there were vessels in which the structure of endothelial cells was identical to that of blast cells. there were no signs of endo-and exocytosis in such cells. intranuclear virus-like inclusions were found in endothelial cells of sinusoids of patients with all. the above data suggest the involvement of endothelial cells in the disordered haemopoiesis in all. defects of the bone marrow sinusoids in leukemia can be the cause of the early release of blasts into circulation. blast transformation of endothelial cells does not contradict the suggestion about existence of a common cell precursors of the endothelial and hemopoietic cells. complex diagnosis of follicular lymphomas e toth, e csernak, z melegh, n udvarhelyi, t schneider, a rosta, z szentirmay national institute of oncology, budapest, hungary introduction the second most common type of non-hodgkin lymphomas is follicular lymphoma (fl). moreover, follicular lymphomas are the most common type of the low grade lymphomas. in hungary they comprise about - % of all the lymphomas but its occurrence shows increasing tendency. our aim was to survey and revise fls diagnosed in the last years in the national institute of oncology. we studied the diagnostic relevance of histology, immunohistochemistry and the detection of immunoglobulin heavy chain (igh) and bcl- gene rearrangements. materials and methods we surveyed cases which were diagnosed as follicular or centrocytic, centroblastic lymphoma before. after the histological re-examination immunohistochemistry (cd , cd , bcl- , cd , bcl- , cd , p , cyclin d and ki- ) was performed on each case. we studied the igh and bcl- (mbr) gene rearrangement both with conventional and real-time pcr methods from the paraffin embedded blocks. the classification was made according to the new who classification. results after the revision of the cases we found follicular, diffuse large b-cell, mantle cell and marginal zone lymphoma, paragranulomas and follicular hyperplasias. the grade of the fls showed relation to the expression of different antigens. cd and bcl- expression decreased with the grade. p expression was very rare and occurred only in grade cases. the proliferation index with ki- showed good correlation with the grade of fls. the igh showed types of pattern: monoclonal, polyclonal and a sharp line in a polyclonal background. grade and grade - fls were monoclonal almost in the same ratio. we could detect bcl- gene rearrangement in % of the fls ( % grade - , % grade ). all the grade cases which showed bcl- gene rearrangement belonged to grade a group while all the grade b cases were negative. conclusion in agreement with others we found that grade , and a fls showed similar morphological, immunohistochemical and genetical features while gr b fls are more similar to diffuse large b-cell lymphomas. considering the diagnostic relevance of the different methods we can conclude that histology alone is not sufficient. % of our cases were solvable with the help of immunohistochemistry and in % of the cases the diagnosis based on the molecular pathological results. in the remaining % even with the help of all diagnostic tools no unambiguous diagnosis could be reached. the bcl- and p oncoproteins play important roles in carcinogenesis. mutation of the p gene is considered the most common genetic aberration in many cancers including hematologic malignancies. ki- , a proliferation antigen, evaluates the proliferative activity of a lesion. angiogenesis is also critical for tumor proliferation and has a prognostic value. the vascular density of tumor directly correlates with poor outcome in many malignancies. the aim of this study was to investigate correlation between ki- , p and bcl- immunostaining in b cell lymphomas and to identify any relation between these markers and microvessel density (mvd) and histopathological parameters including stage and tumor grade. materials and methods low grade and high grade non-hodgkin lymphomas (nhl) were immunohistocemically stained with p , ki- , bcl- and factor viii. the results were analysed statistically. results there was no correlation between stage and ki- li, mvd, p and bcl- expression. the cases which showed immunoreactivity for bcl- had decreased mvd counts compared with the cases negative for bcl- . p immunoreactivity was correlated with mvd. microvessel counts were significantly higher in patients with high grade nhls. statistical analysis showed association between ki- li, p , bcl- expression, mvd and histological grade. conclusions the levels of ki- , bcl- and p expression and microvessel counts were closely related with the grade of nhls. our findings suggest that apoptosis, angiogenesis and proliferative activity can be used as prognostic indicators in nhls. diffuse large b-cell lymphoma of the maxillary sinus complicated with blastomycotic leptomeningitis sinus; however such a lesion is more likely to arise from an infraorbital lymph node, part of the facial lymph node group. case presentation we present a patient with diagnosed diffuse large b cell lymphoma of the maxillary sinus as well as involvement of the infraorbital region, who suffered from infective complications. -years old male was admitted at the clinic of hematology because of tumor mass in nasal cavity. ct-scan showed tumor mass filling right maxillary sinus. surgical biopsy was done. histochemical and immunohisto-chemical findings suggested a diagnosis of diffuse large b cell lymphoma. other clinical investigations showed i-e clinical stage. treatment with four cycles of chop and mab-thera followed. after that adjuvant radiotherapy was delivered. because of increased body temperature and meningeal symptoms, this therapy was interrupted. microbiological investigations showed positive hemoculture for escherichia coli and staphylococcus aureus, and positive finding of blastomyces in cerebrospinal fluid, while serological analyses revealed positivity for cmv and ebv. beside severe antibiotic, antimycotic and antiviral treatment, the patient suffered from sepsis with main features of suppurative leptomeningitis and acute hepatitis. conclusion this case implies the conclusion that the clinicians should have in mind the possible presence of immune disregulation in patients with nhl, that could complicate the administered chemotherapy and radiotherapy. aim the aim of this study is to determine the most frequent pattern of involvement by nhl of head and neck and to correlate it with clinical outcome of the disease. material and methods a retrospective review was performed on patients with nhl during five years period. paraffin sections stained with standard histochemical and immunohistochemical stainings were histologically analyzed for classification of the nhl accordingly to the who classification of lymphoid neoplasms. clinical histories were used for clinical follow-up. results in fifty cases out of patients with nhl the disease was primary localized in the head and neck region. male-female ratio was , . twenty four cases were primarily nodal, primarily extranodal and had extranodal/nodal expression of the disease. diffuse large b cell lymphoma comprised % of the group: nodal, extranodal and extranodal/nodal. three of these cases were cd + and alk- -. six cases ( %) with b-cll nhl had nodal manifestation. malt-zone lymphoma ( %) showed extranodal involvement in cases and extranodal/nodal in cases. b-lymphoblastic lymphoma ( %) showed cases with nodal, one extranodal and one extranodal/nodal involvement. two cases with burkitt's lymphoma ( ) had typical mandibular localization. follicular lymphoma comprised %, with two nodal and two extranodal involvement. t cell nhl-s comprised % of the group with three nodal, one extranodal and one extranodal/nodal involvement. there was no significant predilection for clinical expression of the nhl of head and neck, and no difference between the mean survival of the groups for these parameter. expression of the bcl- family proteins, caspase (cpp ) and poly adp-ribose polymerase (parp- ) in multiple myelomas v zolota , m melachrinou , i xagoraris , a mouzaki , p aroukatos , d koumoundourou , ds bonikos dept. pathology, univ. patras med. school, patras, greece dept. laboratory hematology and transfusion medicine, univ. patras med. school, patras, greece introduction multiple myeloma (mm) is a malignancy of the bone marrow characterized by the clonal expansion of plasma cells with low proliferative activity. aberrant expression of genes regulating apoptosis/survival seems to be essential in the development of multiple myeloma. the aim of this study was to investigate the immunohistochemical expression apoptosisregulating proteins in bone marrow of patients with initially presented multiple myeloma. methods the expression of bcl- , mcl- , bak, bax, cpp and parp was examined on paraffin sections of bone marrow biopsies obtained from equal number of patients with newly diagnosed mm, using commercially available monoclonal and polyclonal antibodies and lsab technique. specimens containing > % immunostained tumor cells were considered positive. results bcl- , bak and bax positive immunostaining was detected in %, % and % of cases respectively. most positive tumors showed high percentage of tumor cells immunoreactive for the above proteins: > % for bcl- , > % for bak and > % for bax. the mean value for bcl- /bax ratio was . , and the mean bcl- /bak ratio was . . mcl- expression was detected in a small percentage of tumors ( %). cytoplasmic expression of cpp was observed in , % of cases and the number of positive cells was low. nuclear expression of parp was seen in , % of cases and no association was found with the other apoptosis-related antigens, bcl- /bax or bcl- /bak ratio. conclusion the above data demonstrate an overexpression of bcl- , bax and bak in myeloma plasma cells and an increased bcl- /bax ratio. cpp does not seem to mediate any apoptotic event in mms. the role of overexpression of parp remains to be elucidated. immunoexpression of bcl- family members, p , caspase (cpp ), and poly adp-ribose polymerase (parp- ) in diffuse large b-cell lymphomas introduction diffuse large b-cell lymphomas (dlbcl) represent a biologically and clinically heterogeneous group. although these tumors are curable with chemotherapy, their response to treatment varies. apoptosis-related proteins may play an important role in the chemosensitivity or chemoresistance of tumors. the aim of this study was to investigate if the expression of apoptosis-regulating proteins in dlbcl could be indicative of tumor chemosensitivity. methods formalin-fixed, paraffin-embedded tissue from cases of dlbcl [ nodal, extranodal, splenic ( centroblastic, immunoblastic, burkitt's-like, anaplastic, tcrbcl, primary mediastinal)] were immunostained with monoclonal [bcl- (dako), mcl- , cpp (neomarkers), p (biogenex)] and polyclonal [bax, bak (dako), parp (neomarkers)] antibodies using lsab method. specimens containing > % immunostained tumor cells were considered positive. clinical data were available for cases ( chemosensitive, chemoresistant). results bcl- , mcl- , bax, bak, p , cpp and parp positive immunostaining was detected in . %, . %, . %, %, . %, . % and . % of cases, respectively. mcl- , bax, bak and parp were overexpressed in > % of tumor cells in most cases. there was a significant association between the expression of bcl- and mcl- (p = . ). a higher immunoexpression of bcl- ( . % vs . %), mcl- ( . % vs %), bax ( . % vs %), p ( . % vs %) and cpp ( . % vs %) was observed in chemoresistant cases. parr expression was higher in chemosensitive cases ( . % vs . %). in the p -negative group of cases ( cases) those with a strong ( +) parp expression showed a significant better response to treatment (p = . ). a significant chemosensitivity was also detected in the group ( cases) with strong ( +) bax and weak (+) or negative (-) p immunostaining (p = . ). conclusion apoptosis-related proteins, though overexpressed in dlbcl, were not associated with response to treatment. a p (-)/parp( +) or p (+ or -)/bax( +) tumor status may reflect sensitivity to chemotherapy. introduction non-hodgkin lymphomas (nhl) are a heterogenous group of lymphoid malignancies classified according to their morphological, immunophenotypical and genotypical characteristics as well as their clinical behaviour. however, the progression of these diseases may be influenced by various others factors such as apoptosis, proliferation and angiogenesis. aim: a possible correlation between bcl- expression, apoptosis, disease outcome and overall survival in patients with nhl was analysed. material and methods nhl devided in low-(n= ) and highgrade (n= ) were immunohistochemicaly analysed for bcl- expression, while low-and high-grade nhl were procesed for terminate tdt mediated dutp nick end labeling (tunel) method in order to determine the apoptotic index of tumor cells. results were obtained by image analyser and statistically processed. results the expression of bcl- protein, as an antiapoptotic marker was significantly higher in low-compared to high-grade nhl, p= . , whereas the apoptotic index obtained with the tunel method demonstrated inverse results, p< . . in highgrade nhl, partial remission was observed in patients whose tumors expressed significantly higher values of bcl- , (p= . ), while complete remission was observed in a group with a lower expression of bcl- . furthermore, patients with lower bcl- expression showed longer overall survival p= . , whereas patients with a higher apoptotic index showed shorter survival, p< . . in both low and high-grade groups of nhl, bcl- has been found as an independent predictor of patients disease relaps, p< . . conclusion the expression of bcl- is a strong independent predictor of disease progression in nhl patients. the heterogeneity of anaplastic large cell lymphomas (alcl) o mederle, m raica dept. of histology and cytology, university of medicine and pharmacy, timisoara, romania introduction the aim of this study was to investigate the expression of cd and the distribution of the reticular network on the alcl. material and methods twelve cases of lymphomas were analyzed using morphologic and immunophenotypic features. the patients ( male and female) were from to years. five patients presented with generalized lymphadenopathy and seven with involvement of extranodal sites. alcl was composed of large cells that grow in a diffuse pattern and involve the lymph node sinuses. the tumor cells have an abundant eosinophilic or pale cytoplasm. the nuclei were irregular with indentation, multilobated, round to oval. multinucleated cells with wreath-like configurated nuclei were commonly seen. alcl cells may closely resemble cells of malignant histiocytosis. additional features include reed-sternberg-like cells, reactive infiltrate, partial lymph node involvement with localization of tumor cells in the paracortical region resembling hodgkin's diseases. tumor cells are cd +. the regular expression of cd antigen in both carcinoma and alcl (both are anaplastic large cell tumors) has important implication for the differential diagnosis of these tumors. leukocyte common antigen (cd ) positivity excludes an embryonal or any other non-hematopoietic tumor, but its absence does not rule out alcl (a significant portion of alcl are cd negative). antibodies to cytokeratin label embryonal carcinoma but not alcl. thus, if cytokeratin is expressed in an anaplastic large cell tumor simultaneously with cd antigen, it is most likely to be an embryonal carcinoma conclusion this study confirms the view that alcl are heterogeneous group of lymphomas and the cd is a useful marker for the diagnosis. leiomyosarcoma of the meckel's diverticulum. we describe a -years-old male developing a well differentiated leiomyosarcoma of the meckel's diverticulum synchronously with b-cll. the patient suffering disuria and malaise was admitted at the clinic for surgery. clinical examinations showed leucocytosis ( . x /l) with lymphocytosis ( %), anemia (hgb = g/l) and thrombocytosis ( x /l). ct-scan found a tumor mass near the urinary bladder and enlarged spleen. the fnab from the tumor mass revealed neoplastic tissue composed of ribbons of spindle-shaped cells with hyperchromic and pleomorphic nuclei and variable amount of cytoplasm, surrounded by a fine reticulin network. mitoses were rare ( - on hpmf). immunohistochemistry showed positivity for sm-actin and desmin. s- , cd and cd were negative. a leiomyosarcoma was diagnosed. three weeks after the biopsy a large tumor mass ( g) from the vicinity of the urinary bladder was extracted, together with incidental meckel's diverticulum. at the same time a splenectomy was performed because of splenomegaly ( g). pathohistologic examination of the tumor mass confirmed the previous diagnosis, and the pcna proliferative index was estimated to - %. the analysis of the meckel's diverticulum revealed a disturbance of the muscular layer structure caused by a tumor proliferation with the same histological features, infiltrating into the serosa. the pathohistologic examination of the extracted spleen showed partially presence of b-cll infiltration (monoclonal positivity for lambda-light chains, cd , cd , cd , cd ). follow-up shows that the patient is in binet a stage, and still in a good shape without any further treatment. it remains unclear which of the neoplasms developed first. introduction synchronous composite low grade b-cell lymphomas involving the same site is rare and few cases have been reported. we describe three cases of composite lymphoma. material and methods histological, immunohistochemical and molecular study. results the three neoplasms showed different morphological and phenotypic areas: case . years-old female with large splenomegaly. the splenectomy showed a blastoid mantle cell lymphoma (mcl) with nodular pattern, positive to cd , cd a, cd , cd and cyclin d , and a splenic marginal zone b-cell lymphoma cd , cd a and igd. the mcl progressed, with liver and bone marrow involvement, treatment failure and death months after diagnosis. case . years-old female with cervical and inguinal lymphadenopathy. a nodular mcl cd , cd and cyclin-d positive, p negative, was observed. the internodular areas demonstrated a small lymphocytic lymphoma (sll) expressing cd , cd a, cd , cd , and p . progression to peripheral blood involvement of sll, and gastric and nodal relapses of mcl two and four years after diagnosis. case . years-old female with nodal follicular lymphoma expressing cd , cd , bcl- , igd-kappa restriction. the internodular areas showed a lymphocytic lymphoma with plasmacelular differentiation, cd , cd a, cd , igd, and bcl- positive. igh showed a biallelic arrangement, and bcl- /jh rearrangement was obtained, suggesting the presence of two different clones. alive with disease after first chemotherapy cycle. conclusion morphology and immunophenotypic profiles may allow the identification of each component in composite lymphoma. molecular studies can recognize different clones originating the neoplastic compartments. introduction aitl accounts for about % of peripheral t-cell lymphomas (ptcl), presents with advanced stages at diagnosis and follows aggressive clinical course. in - % of cases oligoclonal or monoclonal b-cell populations are detected, usually associated with ebv infection. we describe three cases of aitl with clonal b-cell lymphoma non-related to ebv infection. histological, immunophenotypical, including ebv (lmp- , ebers), and molecular study. results three cases of aitl in three female, , and yearold patients were diagnosed. all of them showed atypical lymphocytes with aberrant t-cell phenotype (cd /cd + with loss of cd ), associated with vascular and dendritic proliferation, the latter showing t-cells cd +. in addition, a population of b-cells with plasmacelular differentiation and immunoglobulin light chain restriction ( kappa/ lambda) was identified. ebv was not demonstrated in these populations. tcrgamma and igh clonality was observed in two cases. the first patient presented isolated nodal aitl involvement, and she is in complete remission after chemotherapy six months after diagnosis. the second patient presented nodal aitl and developed skin involvement two months after the diagnosis. the third patient presented with an atypical ganglionar t-cell proliferation, developing cutaneous ptcl with associated clonal b-cell proliferation one year later and ganglionar ptcl with ailt features two years after the first biopsy. the three biopsies showed identical tcrgamma gene rearrangements in this case. conclusion aitl can show different morphological patterns. alternative mechanisms non-related to ebv infection may be involved in the development of b-cell lymphomas in aitl. introduction histopathological confirmation of clinical suspicion of sarcoidosis is based on finding of non-caseating granulomas in biopsy material, usually in prescalene lymph nodes. reactive sinus histiocytosis seen in relation to various inflammatory and noninflammatory diseases can mimic pregranulomatous phase of sarcoidosis. differentiation of sinus histiocytosis based on histopathological features alone can be impossible. aim of this study is immunohistochemical determination of lymph node cellular response in granulomatous sarcoidosis, pregranulomatous phase of sarcoidosis and reactive sinus histiocytosis using panel of antibodies. materials and methods patient groups under study, each contained patients include those with clinical and histopathological picture of sarcoidosis; the group of patients with clinical picture of sarcoidosis and histologically detectable sinus histiocytosis without granuloma formation and finally, the group free of clinical suspicion of sarcoidosis with 'reactive' sinus histiocytois in lymph nodes. lymph node biopsy tissue processed routinely and stained immunohistochemically using triple-layer apaap protocol with purified antibodies sp and sp from mycobacterium tuberculosis and monoclonal antibodies cd , cd , cd , cd , cd . intensity of immunostaining assessed semiquantitatively by two independent observers using the scale from to + results an increased cd :cd ratio, moderate increase of immunopositivity of cd and slight decrease of immunopositivity of cd , cd , and sp noted in psh when compared with rsh. the most notable difference between studied groups is the intensity of immunostaining with sp and cd antibodies. conclusion both immunostainings were more intense in lymph nodes with sarcoid granulomas and pregranulomatous sinus histiocytosis and can be used in differentiation of these lesions. haemophagocytic syndrome followed by a large b-cell lymphoma showing only bone marrow involvement: case report haemophagocytic syndrome (hps) is a rare disease characterized by generalized histiocytic proliferation showing phagocytosis of hematopoietic cells. it occurs mainly in adults associated either with an acute viral infection, or with non-hodgkin's lymphomas. the latter are usually t-or nk-cell lymphomas. the present case concerns a patient with hps followed by a large b-cell lymphoma showing only bone marrow involvement. this constellation is extremely rare in western countries and has been reported mainly in asia. the patient was a year old male admitted for persistent fever. peripheral blood examination showed pancytopenia. bone marrow biopsy showed haemophagocytosis by proliferating macrophages often situated into dilated marrow sinusoids. no viral infection was detected. the patient was treated with haemopoietic growth factors and showed improvement. after months his blood cell count began to fall again and a second bone marrow biopsy showed, apart from haemophagocytosis, a focal, mainly intrasinusoidal, infiltration by large b-cell lymphoma cells immunopositive for cd and cd ra. epstein-barr virus rna was not detected. dissemination of lymphoma to other sites was not apparent. the patient was treated with cycles of chop and mab-thera and showed remission. some authors believe that these rare cases represent a peculiar "asian" variant of intravascular lymphoma characterized by hps and early involvement of bone marrow without dissemination to other organs. this variant has a poor prognosis and might constitute a distinct biological and clinical disease entity which merits separate consideration because of the problems posed in the initial diagnosis and therapeutic approaches. introduction mycosis fungoides is a mature t-cell lymphoma presenting in the skin and characterised by epidermal and dermal infiltration of small to medium size t-cell with cerebriform nuclei. it is a rare disease wich accounts for no more than , % of all non hodgkin lymphomas. case report a year-old man was refered to the clinic of hematology because of the nodular red dermal tumours on the trunk. these lesions persisted for one year. the blood and bone marrow had not been involved. lymph nodes were normal. the patient had the so called d' emblee lesions, presenting with skin tumours to cm of diameter. the initial diagnostic lesions were rare limited patches and plaques. extracutaneous dissemination did not occur. formaldehyde fixed and paraffin embedded histological sections, taken from surgically resected skin tumours, were stained with he, giemsa, trichrome and immunohistochemical stains. morphology: epidermotropic infiltrates consisted of medium size cells with cerebriform nuclei. a minority of larger cells with similar nuceli and with many mitotic figures also were present. so called pautrier microabscesses consisted of aggregates of cerebriform cells in the epidermis (highly caracteristic for mycosis fungoides) were numerous. in the dermis, infiltrates were band like and diffuse, associated with inflammatory infiltrate consisting of small lymphocytes and eosinophils. conclusions in spite of the presence of bad prognostic factors (very old patients, extent of disease and tumorous form) he had a very indolent course of the disease. the role of the observed inflammatory small lymphocytes and eosinophils is probably very important for the excellent prognosis of mycosis fungoides in this patient. low expression of p protein combined with altered p and rb/p expression status is associated with increased expression of cyclin a and cyclin b in diffuse large b-cell lymphomas introduction reduced p expression combined with alterations in rb or p status, may have cooperative effects resulting in uncontrolled tumor cell proliferation and aggressive malignancies in experimental mouse models and in humans. the aim of this study was to investigate p expression in relation to a) the expression status of p , rb, p , and b) proliferation profile (ki , cyclin a, cyclin b ). expression of cell cycle regulating proteins was investigated immunohistichemically, in cases of de novo diffuse large b-cell lymphomas (dlbcl). results p expression was low/null in large tumor cells in / and intermediate/high in / cases. increased expression of p was observed in / cases. decreased expression of rb/p was found in / and / cases, respectively. low/null p expression was correlated to increased p expression (p= . ). there was a correlation between increased p and decreased rb/p expression levels (p= . ). these findings suggest a tendency for concurrent alterations of cell cycle regulators p , p and rb/p in dlbcl, which might result in impaired tumor growth control. indeed, combined p /p /rb/p expression status analysis, with respect to proliferation profile showed that: ) three alterations in the combined p /p /rb/p status were correlated with increased expression of cyclin b (p= . ) and ) two or three alterations were correlated with increased expression of cyclin a (p= . ). conclusions these findings suggest combined impairment of a complex cell-cycle control network involving the cdk inhibitor p , as well as p and rb pathways, which exerts a cooperative effect resulting in enhanced tumor cell proliferation. introduction the aim of this study was to examine a) cyclins d , e and d expression in relation to other proliferative features (ki , cyclin a and cyclin b ), apoptosis status and p , rb, p , p expression and b) whether distinct clusters of proliferation and apoptosis could be identified in dlbcl. materials and method immunohistochemical expression of cell cycle regulating proteins were studed in seventy-nine cases of de novo diffuse large b-cell lymphomas (dlbcl). results overexpression of cyclins d , e was found in / ( %) and / ( %) cases, respectively, whereas cyclin d was not detected. in / cases, overexpression of cyclins d and e was mutually exclusive, proposing different underlying pathways that induce deregulated expression of these cyclins. in / cases, cyclin d overexpression was equally exclusive with rb/p aberrant expression status, supporting an oncogenic role for cyclin d and suggesting that pathogenetic effect of cyclin d overexpression occurs through perturbation of rb pathway. combined alterations of p and rb/p /cyclin d expression profile were significantly correlated to higher mean values of cyclins a (p= . ) and b (p= . ) indicating that concurrent impairment of p and rb pathways induces increased tumor cell proliferation. cluster analysis of apoptosis and proliferation status permitted separation of dlbcl into distinct groups with low and high apoptotic activity, as well as into groups with low, intermediate and high proliferative activity. conclusions in the present study, identification of separate groups with respect to proliferation and apoptosis profile indicates that groups with discrete cellular kinetic properties can be defined in the dlbcl population. immunotopographical distribution of protein networks involved in cell-cycle and/or apoptosis regulation is useful in thymic histophysiology understanding. the aim of this study was to examine a) p and rb growth control pathways, b) proliferation, c) apoptosis in relation with age. materials and methods p , p , rb, p , ki , p , bcl , bax, bak, cyclin d , cyclin a, and cyclin b expression, and apoptotic index (ai) were investigated in adult, adolescent, infant and newborn normal thymuses, with immunohistochemistry. results and conclusions rb, ki , cyclins a and b expression was elevated in cortex with a decreased tendency toward medulla. apoptotic cells were mainly detected in cortex/corticomedullary junction, but rarely in hassall's corpuscles. mean values of ki and cyclins a, b immunoreactivity were . %, . %, . % (newborns), . %, . %, . % (infants), . %, . %, . % (adolescents), . %, . %, . % (adults), respectively. mean values of ai were . %, . %, . %, . %, respectively. most of hassall's corpuscles were p -positive. p expression paralleled aging, suggesting a role of p in cellular senescence. p was detectable within medulla, but not in subcapsular thymocytes expressions of ki , cyclin a and cyclin b were inversely related to p . p and p showed primarily subcapsular cortical epithelial cell localization. our findings suggest: a) thymocyte apoptosis is mainly p -independent, b) p function as negative cell cycle regulator seems redundant to other negative regulators (p / ), and c) p expression is chiefly p -independent. hassall's corpuscles were p -positive. bcl was principally detected in medullary thymocytes. expression of bax/bak was widely distributed, suggesting an advanced role in thymic apoptosis, compared to bcl . paraffin-embedded bone marrow biopsies of patients were examined by a standard panel approach and evaluated semiquantitativelly. the course of the disease was recognized by evaluation of instrumentalized questionnaires. results a/ mds with less than % of blasts (n= ) /either of myelo-(n= ), megaloblastic (n= ) or bilinear profile (n= )/ -aml evolution appeared in % of patients, b/ mds with more than % of myeloblasts (n= ) -aml diagnosis was established in % of cases. conclusion although the therapeutical aml managment requires 'clinical verification', the identification of the mds blastic proliferation higher than % is of a great clinical importance. however, the clinical manifestation of aml may be influenced by a delay of the increase of blasts in the peripheral blood. introduction there is increasing evidence that bcl and cd expression may be related to apoptosis and cell cycle progression. materials and methods to examine immunohistochemically the expression profile of bcl and cd in cases of de novo diffuse large b-cell lymphomas, in relation to a) the apoptotic index (ai) b) the proliferation-associated proteins ki , cyclins a and b c) the expression of bcl , p , rb, p , p . results and conclusions expression of bcl , cd and bcl was detected in / ( %), / ( %) and / ( %) cases, respectively. the bcl /cd patterns were as follows: bcl +/ cd + ( cases, %), bcl +/cd -( cases, %), bcl -/cd -( cases, %) and bcl -/cd + ( cases, %). significantly positive correlations were found between bcl /ki (r= . , p= . ), bcl /cyclin a (r= . , p= . ), bcl /ai (r= . , p= . ), cd /ki (r= . , p= . ) and cd /ai (r= . , p= . ). high expression of bcl was correlated with null/low bcl expression (hi-square-test, p= . ). these findings indicate that increased expression of bcl and cd is associated with increased apoptosis and proliferation in diffuse large b-cell lymphomas. association between increased bcl expression and enhanced apoptosis might be due to null/low bcl immunoreactivity, since previous in vitro data revealed that bcl overexpression induces apoptosis accompanied by bcl and bcl-xl downregulation. significant correlation was found between increased ai and bcl +/cd + pattern (t-test: p= . , mann-whitney test: p= . ). this result combined with positive correlation between ai and bcl and cd immunostaining may be in accordance to previous studies showing that expression of these proteins has favorable effects on the clinical outcome of these neoplasms. primary non-hodgkin lymphomas of bone: morphologycal and immunohistocehmical aspects introduction primary non-hodgkin lymphoma (nhl) of bone (plb) is a rare clinic-pathologic entity that accounts for approximately % of all malignant bone tumors and - % of all extranodal nhl. we analyzed morphological and immunohistocemical aspects of plb presented as solitary localized bone tumor. methods paraffin embedded biopsy specimens of all patients were diagnosed by the histomorphology and by immunohistochemistry using a wide panel of monoclonal antibodies (ema, lca, nse, tdt, cd , hla-dr, cd a, cd , cd , surface and cytoplasmic ig, cd , cd , cd , cd , cd , cd , cd , bcl , bcl and ki- ). the median age of our pts. was (from to ) with slight female predominance. various sites were involved: tumors were in tubular long bones, in pelvic bones and in spine with infiltration of soft tissue and without bone marrow involvement. all cases were classified as diffuse large b-cell lymphoma (dlbcl) according to morphology and immunophenotype. patohistological analyses showed markedly polymorphous cellular infiltrate with large cells with complex nuclear contours and multilobated nuclei, together with centroblasts-like cells and immunoblasts. all tumors were associated with some degree of fibrosis. immunologic studies showed strong expression of pan-b markers and hla-dr, weak expression of cd and cig (mostly igm) in half of tumors. bcl was positive in all cases as well as bcl . the plasmacytic differentiation was observed in / of cases. the proliferative fraction was high, > % cells in all patients. conclusion our analysis revealed that all plb were of dlbcl type with characteristic morphology and immunophenotype. further study will show the outcome of patients with plb, as well as the validity of various prognostic parameters. peripheral t-cell lymphoma with perifollicular growth pattern expressing cd inflammatory cells. ptcls with nodular or perifollicular growth patterns are very rare. only cases have been reported in the literature. we report an unusual case of ptcl showing perifollicular growth pattern with expression of cd and bcl- . the patient was a -year-old male who presented with a generalized lymphadenopathy, fever, and weight loss. hepatosplenomegaly and polyclonal gammopathy were not identified. cervical lymph node biopsy was performed. the histology showed nodular effacement of nodal architecture with proliferation of atypical lymphoid cells which mainly infiltrate perifollicular area. interfollicular area also showed proliferation of atypical lymphoid cells and high endothelial venules with a few immunoblasts and eosinophils. neoplastic cells were medium-sized, with irregular nuclei and clear cytoplasm. immunohistochemically, the neoplastic cells were cd +cd +cd +cd -cd +cd -cd -bcl- +bcl- +, demonstrating helper/inducer t-cell origin. the cd was strongly expressed mainly in the perifollicular tumor cells, whereas the normal germinal center (gc) cells showed down-regulation of cd . the distribution of cd + perifollicular tumor cells was closely related with cd + follicular dentritic cells (fdcs), suggesting cd up-regulation might be induced by the proliferating fdcs. tcr-gamma gene rearrangement using pcr-sscp was monoclonal. this case could be classified as ptcl, unspecified, and should be discriminated from other lymphomas, including marginal zone b-cell lymphoma and follicular lymphoma. further studies are necessary to clarify the distinction of this tumor from angioimmunoblastic t-cell lymphoma. introduction cd + anaplastic large cell lymphomas (alcls) frequently involve extranodal sites, mainly skin and gastrointestinal tract, but primary bone alcls are exceedingly rare. the aim of this study was to detail the morphofunctional features and outcome of cases of primary bone cd + alcls. materials and methods all the patients (m:f : , median age years, range: - ), but (with simultaneous occurring skin lesions) presented with bone confined lymphoma (osteolytic lesions of jaw, rib, sternum, iliac and pelvic bones). biopsies from all cases were analysed. results and conclusion according to the who lymphoma classification, all cases were cd + alcls ( / common type, / small cell predominant variant). lymphoma population showed a t ( / ) or "null" ( / ) phenotype, expressed cytotoxic associated molecules (tia , granzyme b and/or perforin); cd /alk was positive in / cases, whereas / expressed cd . tcr-gamma clonal rearrangement was detected in / cases. all patients received polychemotherapy; at last follow up they all are alive, in complete remission (mean: months, range: - ). in our cases, the morphofunctional features of the lymphoma population were similar to their nodal counterparts, including cd expression in the younger patients. on such bases, the hypothesis must be considered that primary bone cd + alcls represent the first extranodal site of presentation of a systemic disease. in contrast with similar reported series, our patients run a favourable prognosis and in the single positive case, cd expression does not negatively influence outcome. however, larger series of similar cases must be analysed before definitive conclusions can be drawn. introduction follicular dendritic cells (fdc) form a meshwork in the lymphoid follicle and take part in the regulation of the germinal centre reactions. fdc also interact with the neoplastic lymphoid proliferations. in b-cell chronic lymphocytic leukaemia/small lymphocytic lymphoma (b-cll/sll), fdc structures are reduced. the aim of this study was to evaluate the presence and patterns of follicular dendritic cells b-cll/sll using several anti-fdc antibodies. materials and methods formalin-fixed paraffin-embedded lymph nodes diagnosed as b-cll/sll according to the who criteria were studied using cd , cd , and cna. antibodies after microwave oven antigen retrieval results in cases ( %) fdc meshworks were identified in none of the reactions. in specimens ( %), fdc meshworks were exceptionally rare as follicle remnants at the lymph node periphery or as small irregular clusters not reminding of the normal follicle meshwork. in cases ( %) fdc formed either frequent small irregular clusters, or rings at the follicle periphery, or regular follicular meshworks. reticular structures in a given case were most frequent in cna. stain, scarcer in anti-cd , and anti-cd stains. the majority of cases showing fdc was obtained by cna. ( cases), cd ( cases) and cd ( cases). conclusion fdc structures were absent or scarce in up to % of b-cll/sll cases which can be used as an auxilliary diagnostic criterion. the positive cases showed small irregular clusters, rings at the follicle periphery, or normal follicular meshworks. best results were obtained with cna. antibody. this may be due to better antigen preservation or to non-specifity. introduction myelodysplastic syndromes (mds) are clonal haematopoietic stem diseases characterised by dysplasia and ineffective haematopoiesis. the dysplasia may be often associated with an increased number of myeloblasts in peripheral blood and bone marrow, which represents an important prognostic factor. immunohistochemical detection of blast cells in bone marrow histological sections using cd antigen and its correlation with smear blast count and mds classification are not well established. we report a quantitative study of cd blast cells in mds and acute myeloid leukaemia with multilineage dysplasia (amlmd), and analyse the relationship with both cytologic smear and clinical diagnosis. we have studied bone marrow biopsies diagnosed of mds ( with refractory cytopenia with multilineage dysplasia (rcmd), with refractory anemia with excess blast (raeb) type i and with raeb type ii) and with amlmd. we added controls and calculated the cd blast cells mean per high power field (hpf). cytologic smears were reviewed. results the results were: controls showed - blasts/ hpf, rcmd - / hpf, raeb i - / hpf, raeb ii - / hpf and amlmd - / hpf. conclusions -cd + blast cells density is a good parameter in the histological diagnosis of mds and has a close correlation (p< , ) with smear count results -cd does not distinguish between rcmd and raeb i. -more than blast cells/ hpf raise the diagnosis of raeb ii. more than blast cells/ hpf raise the diagnosis of amlmd. the extrapolation of these features to "dry tap" aspiration remains to be established. inroduction bone marrow angiogenesis has been recently implicated in the pathophysiology and course of various haematological malignancies. little is known, however, about the significance of this phenomenon in hairy cell leukaemia (hcl). methods we evaluated various morphometric characteristics of microvessels, highlighted by means of anti-cd immunohistochemistry, in the bone marrow of patients with typical hcl, before and after treatment with interferon-α. overall bone marrows from hcl patients and twenty control bone marrows were examined. microvessel density (mvd) and several size-and shape-related parameters were quantitated in the region of most intense vascularization using image analysis. results mvd, size-related parameters and the percentage of branching microvessels were higher in hcl than in controls and in partial/non-responders in comparison to complete responders. acvievement of complete response was accompanied by smaller calibre microvessels. interferon-α induced a decrease in mvd and branching values in cases with diffuse marrow involvement. in univariate analysis, progression-free survival was adversely affected by mvd and branching. multivariate analysis indicated that factors related to the size of the microvessels and mvd/ branching independently affected progression-free survival. mvd/ branching was also related to the likelihood of complete response. conclusions our data suggest that the generation of bone marrow microvessels connotes an increased risk for progression and interferon-α treatment failure in hcl. furthermore the prognostic significance of angiogenesis requires the concomitant assessment of mvd, the size of microvessels and the complexity of the microvascular network. key words: hairy cell leukaemia, bone marrow, angiogenesis, morphometry introduction inflammatory pseudotumors are uncommon and enigmatic benign lesions which may develop at several anatomical sites and recent studies demonstrated the frequent presence of epstein-barr virus (ebv) in them. the occurence of inflammatory pseudotumor in the spleen is rare. a case of inflammatory pseudotumor of the spleen is presented and its relationship to epstein-barr virus (ebv) is examined. material and method the case was a -year-old woman in whom a solitary splenic mass was discovered as part of the workup of idiopathic thrombocytopenic purpura. splenectomy was performed. results grossly, the removed spleen, weighing g, contained a tan-white, circumscribed mass, measuring . x x cm. microscopically, the mass was composed of a heterogeneous cellular population of acute and chronic inflammatory cells. plasma cells predominated, but lymphocytes, neutrophils, eosinophils, interlacing fibroblast-like spindle cells and rare multinuclear giant cells were found. amorphous, acidophilic material was present focally with the plasma cell proliferation. plasma cells presented light chains polyclonality. lymphoid cells were mature and mainly of t-lineage. spindle cells exhibited histiocyte phenotype (cd +++). immunohistochemical stain for ebv was negative. conclusions inflammatory pseudotumor of the spleen is a benign tumorous lesion that has been described in only a few cases in the world literature (< cases). its etiology and pathogenesis is unknown and association ebv is not always present. recognition of this rare entity is important, as the clinical manifestations and imaging features could be indistinguishable from a lymphoproliferative disorder or another malignancy of the spleen. introduction the diagnosis of nodal non-hodgkin's lymphoma (nhl) in montenegro has been done only in clinical center of montenegro -incidence of diagnosed nhl can be considered as the incidence in epidemiological sense.the use of monoclonal antibodies since , has improved our ability to diagnose and to treat nhl. aims: by revision of immunohistologically diagnosed cases of nhl between - , we wanted to estimate (a) the frequency of particular clinico-pathological types of nhl, (b) hypothesis about geo-socio-economic influences on patterns of nhl, and (c) the influence of immunophenotypisation of nhl on speciffic chemo-and immunotherapy. materials and methods nhls were diagnosed with the use of he, giemsa, mgp, pas, gomori, lca, bcl , tdt, cd , cd , cd , cd a, cd , cd , and ema stained slides and classified according to the working formulation criteria. results between ' and ' we diagnosed nhl. low, intermediate and high grade malignancy comprised , %, , % and , % respectively. the highest incidence was estimated in : , / . the nhls of fcc origin constitute , % of all our nhls. in % of patients ( ) low grade malignant nhls were highly cd +. nine patients recieved mabthera+chop/or +cop therapy during the last three years.all patients have been in remision. conclusion the estimated pattern of nhl -the most frequent nhl derivated from fcc-is comparable with geographic and socio-economic description of montenegro as ''underdeveloped, ecological, farming european country''.the high frequency of cd + and initial therapeutical results indicate future prospective patho-clinical studies of this issue. i oehri, m baumann, g cathomas kantonales institute for pathology, liestal, switzerland background the multicentric castleman's disease (mcd) is a lymphoproliferative disease with increased risk for non-hodgkin lymphoma. in aids patients, mcd is usually associated with human herpesvirus (hhv ), the infectious agent of kaposi's sarcoma but in contrast to kaposi's sarcoma, hhv infected cells in mcd show evidence of lytic viral infection. similar to other immunosuppression-associated lymphoproliferative diseases it has been suggested that anti-cd antibodies may be useful in the therapy of these lesions. aim of the present study was the analysis of cd expression in hhv associated mcd and their association with lytic viral infection. material and methods formalin fixed, paraffin embeded lymph nodes were analyzed by a double immunofluorescence assay using antibodies against viral proteins and cd . hhv proteins which were analyzed include the latent viral protein lana (orf ) and the viral interleukin (vil- ) and the orf , both associated with lytic hhv infection. results eleven lymph nodes of seven hiv-infected patients with mcd were analyzed. in the mantle zone of the lymphoid follicle, , %, , % and % of cells show positivity for lana, vil- and orf , respectively (p < , ). by double immunofluorescence, % of hhv infected cells showed co-expression of lana/vil- and lana/vorf and % showed co-expression of lana/vil- , respectively. in addition, there was statistical significant correlation between vil- and lana as well as vil- and vorf (p < , ). of the hhv infected cells, , % showed cd expression and no difference between the three viral proteins analyzed were observed ( , %, , %, , % of lana, vil- and vorf , respectively). conclusion the present data support the concept that hhv runs, in contrast to kaposi's sarcoma, through a lytic viral infection in lymph nodes of patients with mcd. however, only a small subset of infected cells show co-expression of cd , independent of the state of viral replication. this small number of infected cells expressing cd indicate little effect of anti-cd therapy. based on the evidence of lytic hhv infection, however, anti-viral drugs inhibiting hhv replication may be more efficient. anaplastic large cell lymphoma -pathological and immunohistochemicals aspects the who classification of nonhodgkin lymphoma (nhl) included also the cathegory of t and null anaplastic large-cell lymphoma (alcl). alcl is a very rare nhl (about %), with the systemic-aggressive variant, and the cutaneous variant. the presence of the t( ; ) and the formation of alk protein identified one subgroup of alcl with a good prognosis. the aim of our study is to analyze the histopathological and immunohistochemical characters of the alcl diagnosed in our department in the last years. cases of t and null alcl (m/f= / , more half of them younger of years) were clinical and immunohistochemical analyzed (by abc indirect methods, with a large panel of monoclonal antibodies). the pattern of lymph node infiltration was diffuse ( cases), parafollicular ( cases) and only with sinus infiltration - case. the pathological subtypes were common ( cases), lymphohistiocytic ( cases), small cell variant ( case), sarcomatous ( case), eosinophils-rich ( case) and neutrophil-rich ( case). immunohistochemically, the malignant cells presented with t-fenotype ( cases) and null ( cases); case (m, y) presents histiocyte markers (cd +cd +ema+alk+). all cases of alcl were cd +, but only cases were ema+ ( cases were cd ro+cd +alk-ema-). / of cases were alk+ ( -t and -null), with a nuclear and a membranous pattern. cases were bnh + ( cases alk+). only case presented cd expression(cd +ema+alk+bnh +). of the cases with t fenotype expressed cd markers (both were cd +cd -). the pcna and ki proliferation markers were positive in a very large percent of the malignant cells (between and %). numerous reactive t-lymphocytes presented a helper fenotype (cd >cd ), and leu- + cells were very rare. the null and t-cell alcl pose numerous problems of differential diagnosis and immunohistochemicals methods are very useful for diagnosis and prognosis of these nhl. myeloid sarcoma - cases analysis f vasilescu , c dobrea , , e niculescu-mizil , a colita , l caban , r stoia , d ostroveanu , a iofciulescu , d terzea , c iosif 'v babes' national institute, bucharest, romania dpt of haematology, 'fundeni' clinical institute, bucharest, romania myeloid (granulocytic) sarcoma (ms) -also known as "chloroma", is a localized tumor of primitive myeloid cells, that can present before, simultaneously with, or after the diagnosis of acute myeloid leukaemia (aml). rarely, ms may represent the first sign of blastic transformation of myelodysplastic syndrome (mds) or chronic myeloproliferative disorders (cmpd). the aim of this study is to present our experience in the diagnosis of ms. in the last years, we diagnosed cases of ms (m/f= / , between and year-old, with , years median). a large panel of monoclonal antibodies (lymphoid and myeloid cell markers) was used for the diagnosis of ms and for the differential diagnosis with nonhodgkin lymphomas (nhl). the tumor localizations were: lymph nodes ( cases, including a bulky inguinal tumor), lymph node and skin ( case), paravertebral ( cases), testis ( case). in our cases, patients presented with ms before the aml diagnosis (f, y, paravertebral ms, months before aml-m , and m, y, years after nhl diagnosis, presented with an inguinal lymph node ms, months before aml-m ). in cases, ms was diagnosed simultaneously with aml (aml-m ; aml-m ; aml-m ), and in cases after aml (m, y, ms with testis localization, years after aml-m ; f, y, lymph node and skin ms, years afteraml-m ). in one case (f, y), years after successful treatment of an acute lymphoblastic leukaemia (all), the patient presented with a lymph node ms, considered as a blastic transformation of a chronic myelo-monocytic leukaemia (cmml). the diagnosis of ms may be very difficult if this tumor precedes the myeloid proliferative disorders, and the differential diagnosis with nhl may pose a lot of problems. introduction b-pll is an infrequent disease, considered by the who lymphoma classification as an aggressive condition and characterized by the presence of b symptoms, massive splenomegaly without significant lymphadenopaty and peripheral lymphocytosis with more than % prolymphocytes. herein we report cases of b-pll to show the wide clinical and genotypic spectrum of this disease. case reports patient . a -year old male with a history of petechiae and ecchymoses of year evolution. a cbc showed significant lymphocytosis with > % prolymphocytes. physical examination revealed an enlarged cervical lymph node and splenomegaly. lymph node biopsy was diagnosed as infiltration by b-pll (cd +, cd a+, igm+, cd -, cd -, cd -and cyclin d -). a bone marrow biopsy showed infiltration by b-pll. cytogenetic analysis of the bone marrow showed a burkitt's variant translocation t( ; ) (p ;q ) molecular analysis of the lymph node showed igh rearrangement and germline bcl- and bcl- by pcr. he was treated with four cycles of fludarabine ( mg/m ) and rituximab ( mg/m ) and is in clinical and cytogenetic remission at year of follow-up. patient . a -year old female with a month history of multiple cervical lymph node enlargement and fever. physical examination was normal and she had no lymphocytosis on the cbc. lymph node biopsy showed infiltration by a non-hodgkin's lymphoma with a prolymphocytic morphology (cd +, cd a+, igm+, cd -, cd -, cd -and cyclin d -). bone marrow biopsy showed focal infiltration by b-pll. cytogenetic analysis of the bone marrow revealed a normal female cariotype and normal fish patterns were found for the following probes: chormosome centromere, q (c-myc), chromosome centromere, q (d s ), q . (igh) and p . (p ). she was initially treated with chop and then switched to fludarabine having achieved a good clinical response after one cycle each. discussion. the association between b-pll and translocation t( ; ) (p ;q ) has been reported in very few cases, however direct involvement of c-myc alterations affecting specifically q has been proposed as an important factor in the pathogenesis of b-pll. in patient , the observed genetic alterations could be of significance to define the genetic spectrum of b-pll. case corresponds to a b-cell prolymphocytic lymphoproliferation with isolated lymph node involvement and no leukemic component. to our knowledge this presentation has not been reported previously and it is not considered in who classification. morphological and immunohistochemical characteristics of this case are fully compatible with a b-pll. even though it has been considered that some cases of b-pll could in fact represent a morphological variant of mantle cell lymphoma, in this case the negativity for cd and cyclin d partially rule out this possibility. bcell prolymphocytic lymphoproliferations constitute an heterogeneous group of disorders in which c-myc rearrengement can be present. in this group of neoplasia therefore, the nodal involvement can be either predominant or the only clinical manifestation, thus we propose to consider the term b-cell prolymphocytic lymphoma/ leukemia instead of b-pll to denote these disorders. background alcl is a particular type of t-cell non-hodgkin's lymphoma originally characterized by a peculiar morphology and the consistent expression of cd . this entity is frequently associated with the translocation t( ; ) (p ;q ) or some of its variants resulting in the overexpression of the chimeric protein npm/alk (alk+), even though in the current classification alk-negative cases are also considered within this group. ebv is classically and constantly associated with certain specific types of lymphoma but its association with alcl is not considered a characteristic feature of this disease. the aim of this study was to investigate the frequency of the alcl-ebv association in a population of adult mexican patients. results eighteen patients with a morphological and immunohistochemical diagnosis of alcl with nodal involvement were included. immunohistochemical and ish analysis was performed for cd , cd , cd ro, cd rb, cd , cd , cd , ema, lmp- , alk.and eber . mean age was years and the male-tofemale ratio was . : . immunohistochemistry and in situ hybridization results are summarized in the next table. all the so considered ebv positive cases expressed lmp- and eber . conclusion in contrast to the information available in the literature we found a high incidence of the alcl-ebv association / ( %). the high incidence of alk-/ebv+ cases / ( %), with morphological and immunophenotypical characteristics of alcl gives rise to the possibility that this is a different subset of t-cell lymphomas with anaplastic morphology in which ebv plays a pivotal roll in the oncogenesis and evolution. these disorders have been considered so far to be alcl /alklymphomas. the high incidence of ebv infection in mexico leads to the development of peculiar lymphoid proliferations as well as associations (ebv/alcl) different from those considered to be frequent in world literature. lazzi s , bellan c , de falco g , schuerfeld k , micheli p , bartolommei s , pileri s cdk is a member of the cdc -like family of kinases. its cyclin partners are members of the family of cyclin t (t , t a and t b) and cyclin k. cdk /cyclin t complex is very important in the differentiation program of several cell types, controlling specific differentiative pathways. limited data are available regarding the expression of cdk /cyclin t in haematopoietic and lymphoid tissues. the aim of this paper is to analyze the expression of cdk /cyclin t complex in lymphoid tissue, in order to assess its role in b and t cell differentiation and lymphomagenesis. in reactive lymph nodes cdk /cyclin t expression was found by immunohistochemistry in germinal center and in b and t cell blasts in interfollicular areas, suggesting a role for cdk in the activation and differentiation of b and t cells. the staining of cdk and cy-clint complex in malignant lymphomas seems to reflect their normal counterpart, as it is highly expressed in lymphomas derived from germinal center cells, such as follicular lymphomas and classical hodgkin's lymphomas and from activated t cells, (i.e. anaplastic large cell lymphomas). diffuse large b-cell and burkitt's lymphomas showed a wide range of values. no expression of cdk and cyclin t was detected in marginal zone and mantle cells lymphomas. however, at rna level we found an imbalance in cdk /cyclin t ratio in follicular lymphoma and diffuse large b cell lymphomas with germinal center phenotype, and in the cell lines of classical hodgkin's lymphomas, burkitt's lymphomas and anaplastic large cell lymphoma, in comparison with reactive lymph nodes. here we report cdk /cyclin t complex deregulation in neoplastic conditions for the first time, representing a step towards better understanding of through which molecular mechanism cdk /cyclin t complex acts on the activation and differentiation program of lymphoid cells and the role of its deregulation in malignant transformation. introduction hairy cell leukaemia (hcl) is a chronic lymphoproliferative disease characterized by the presence of neoplastic b cells with hairy cytoplasmic projections in spleen, bone marrow and peripheral blood. complete or near-complete remission can be achieved by recent chemotherapy protocols. these treatment methods are quite different from the chemotherapy protocols used for the treatment of other lymphoproliferative diseases. an absolute and correct diagnosis, i.e. detection of hcl cells by specific methods, is necessary for the achievement of complete or near-complete remission by special chemotherapy programs. detecting intracytoplasmic tartrate resistant acid phosphatase (trap) enzyme activity in the peripheral blood and bone marrow aspirates is a classical, simple, sensitive and quite specific method for the detection of hcl cells and in the diagnosis of hcl. however, this method is insufficient in some cases. for example, the most of the hcl patients are leukopenic and there are a few number of neoplastic cells in their peripheric blood. an adequate number of neoplastic cells cannot be obtained by bone marrow aspiration because of the increase in reticulin fibbers of the bone marrow. in such cases, bone marrow trephine biopsy is almost the only and the most important method in diagnosis and follow-up of this disease. specific detection of trap enzyme activity in bone marrow trephine biopsy materials is not possible because of the effect of tissue fixation and processing on these materials. in conclusion, a new method for detecting trap enzyme activity in bone marrow trephine biopsy materials and for conforming the diagnosis of hcl is needed. a recently developed anti-trap antibody has been started to be used as an immunohistechemical marker in the diagnosis of hcl. the aim of this study was to investigate the specificity and the sensitivity of anti-trap antibody immunoreactivity in bone marrow trephine biopsy materials in the diagnosis of hcl. material and methods we divided the cases into two groups; a study and control group. the study group included the cases diagnosed as hcl by clinical, haematological and histopathological investigations. the cases in the control group were the cases characterised by non-hcl neoplastic or reactive lymphoid infiltrations, which raised the suspicion of hcl in the differentia l diagnosis. immunohistochemical staining techniques were applied to paraffin block sections of biopsy materials with anti-trap antibody. results and conclusion we found that there is a statistically highly significant difference between trap immunoreactivities of the study and the control groups, and hcl can be diagnosed by trap immunoreactivity in the bone marrow trephine biopsy materials with the specificity of , % and with the sensitivity of %. cathepsin l participation in collagen degradation during the recovery from experimental hepatic fibrosis v ryvnyak introduction cathepsin l is one of the most important lysosomale cysteine proteinase, indispensable for proteolitic processes. the enzyme is capable to degrade the main components of the intercellular matrix. aims: . to determine the participation of cathepsin l in collagen degradation in liver and to reveal the intracellular and/or extracellular localization of the enzyme activity. . to determine which cells of fibrotic liver are sources of cathepsin l. methods biochemically cathepsin l activity and hidroxyproline level was determined in normal, ccl -induced fibrotic rat liver and at , , , , days after discontinuation of treatment. the activity of cathepsin l in fibrotic rat liver at the th and st days was investigated electron-histochemically. cbz-phe-arg- mbna (bachem) served as the substratum. results biochemically in fibrotic liver an increase of cathepsin l activity as compared with normal liver was revealed. during fibrosis regression the maximums of enzymatic activity at the th day ( %) and at the st day ( %) after cessation of ccl -treatment were fixed. at the th day of recovery some diminution of cathepsin l activity was noted. at the th day after toxin abolition enzyme activity was close to control. a close correlation between cathepsin l activity and liver hidroxyproline level was found. electron-histochemically reaction product was revealed in the kupffer cells and fibroblast phagolysosomes containing fragments of collagen fibrils. we also found extracellular localization of cathepsin l in both terms of investigation. the reaction product was noted on the hepatocyte, kupffer cell and fibroblast plasmalemma and on adjacent collagen fibrils. conclusions cathepsin l is directly implicated in collagen resorbtion during liver fibrosis regression. detected extracellular activity of cathepsin l suggests that in addition to the intracellular proteolysis, cathepsin l is secreted by hepatocytes, macrophages and fibroblasts in intercellular space and can take part in extracel-lular collagen degradation. ryvnyak victor laboratory of morphology "nicolae testemitanu" state university of medicine and pharmacy bd. stefan cel mare, kishinev, md- moldova victorrivneac@yahoo.com introduction the solitary necrotic nodule (nns) of the liver is an uncommon lesion with a round appearance near the surface of the liver, with a dense collar of hyalinised collagen surrounding a necrotic core. case reports we present three cases of nns. two patients underwent surgery to remove liver metastasis. we suggest a relationship with the previous hepatic surgery and with the microwave tissue coagulator. the other case have an history of abdominal traumatism by a seizure. the radiological image of nns was misinterpreted as a tumor and the diagnosis by fnac or frozen section could not exclude a metastasis. the potential risk of a malignant secondary tumour existed, and that was why limited liver resection was recommended. several pathogenetic mechanisms have been avocated (infection, parasitic, traumatic, ischaemic, post chirurgical, iatrogenic, etc.) , all of them having an identical morfological appearance. conclusion nns is a rare non-tumorous lesion that might be misinterpreted as a tumor. the correct diagnosis can only be histological. it is important to differentiate the nns from metastases due to the great influence on the treatment. the significance of morphometrical analysis in staging of fibrosis in liver biopsies from patients with chronic hepatitis c a matsionis , e romanova , y kirichenko , y ambalov , p povilaitite rostov regional bureau of pathology, rostov on don, russian federation rostov central hospital, rostov on don, russian federation introduction prognosis of the course of chronic hepatitis c (chc) depends on fibrosis stage and its progression temps in the liver. semi quantitative methods are currently regarded as a routine diagnostic procedure. but it is obvious that these methods are subjective. morphometrical analysis with calculation of fibrosis index (fi) is an alternative method of evaluation. the aim of the study was to compare data obtained after morphometrical analysis of collagen formation to semi quantitative methods results and find out accordance with fibrosis stage. materials and methods liver biopsies from chc patients were used. we applied v.j.desmet ( ) semi quantitative method and software sigmascan pro . for morphometrical analysis of sections. all sections were stained by masson trichrome method for the detection of collagen. fibrosis index (fi) was calculated as collagen area divided all section area. results , % of patients had clinically significant level of liver fibrosis (desmet f , f , f ). f desmet stage was corresponding fi , - , , f desmet (moderate fibrosis) -fi , - , and high level of fibrosis (f and f ) -if , - , . / cases ( , %) showed differences between semi quantitative and morphometrical results. four patients ( , %) without fibrosis by semi quantitative methods showed if corresponding moderate fibrosis (f ). conclusion our results suggest that morphometrical analysis is beneficial in the evaluation of fibrosis stage and should be used for prognosis and monitoring the course of chronic viral hepatitis. introduction hepatic mucinous cystadenomas with mesenchymal stroma have been recognized as rare neoplasms that occur only in females and have recently been postulated as being hormonally dependent. because of the similarity of these neoplasms to ovarian mucinous cystadenomas, we compared the immunohistochemical profiles of these neoplasms arising in two different organs. the aim of this study was to establish whether these two tumors were phenotypically similar. materials and methods we employed the following immunohistochemical stains, estrogen receptor, progesterone receptor, inhibin, ck , ck and alcian blue/ periodic acid-schiff, to cases of ovarian mucinous cystadenomas and to cases of hepatic mucinous cystadenomas with mesenchymal stroma. results both the ovarian and hepatic neoplasms showed similar results with all of these stains. conclusions phenotypically, we have been unable to establish any difference between these two neoplasms. there appear to be two possible explanations for the origins of these tumors: one is that of a displaced ovarian anlage in the developing liver and the other would be that some of the primitive hepatic stem cells are capable of acquiring ovarian characteristics assessment of periodontum condition in hepatitis c infected patients with rapid and slow dynamics of advanced fibrosis p radlowski aim analysis of the relationship between the stage of periodontium disease and the extent and dynamics of fibrosis in patients infected with chronic hepatitis c. the study included patients whose blood serum revealed the presence of hcv-rna via rt-pcr, while biopsies showed chronic inflammation and either septal fibrosis, or liver cirrhosis. fibrosis was evaluated according to scheuer's point scale, with azan-staining method and the authors' own modifications. fibrosis dynamics (fu/y) was evaluated as a quotient of the number of points assessing fibrosis and the number of years of the disease. periodontitis was determined by the following criteria: inflammation limbus, gum swelling, gingival pockets depth, presence of supragingival and subgingival calculus and gomphiasis. each criterion was assigned either or point within the cumulative scale of - points. results all patients with advanced liver fibrosis were found to show signs of periodontosis. the patients whose periodontium condition scored points with the mean value of fu/y amounting to , , while those who scored points showed mean values of fyu/y equalling , . the group of patients with high values of periodontium disease showed significantly higher values of periodontum disease stage (most frequently assessed at points) compared with the group of nine patients with low fu/y values (mean value = p < , ). periodontium score of the patients with cirrhosis and bridge fibrosis showed similar values. conclusion the degree of periodontal disease was found to be dependent on the pace of fibrosis dynamics. molecular evidence for a toxic memory effect in chronic liver disease c stumptner, k wagner, h denk, k zatloukal institute of pathology, university of graz, graz, austria introduction alcoholic liver disease shows a toxic memory effect: patients with a history of alcoholic hepatitis show even after prolonged withdrawal from alcohol rapid reappearance of alcoholic hepatitis upon reexposure to alcohol. this type of liver injury can be mimicked in a mouse model by feeding , . after months of ddc intoxication mouse livers revealed ballooned hepatocytes containing numerous mallory bodies. within four weeks of recovery from intoxication most mallory bodies disappear but rapidly reappear within three days of reintoxication indicating the existence of a toxic memory effect. the aim of this study was to investigate the molecular basis of the toxic memory effect. materials and methods cdna-libraries were generated from normal and ddc-intoxicated mouse livers by subtractive suppressive hybridization. these gene libraries were used to produce cdna-arrays for expression profiling. rna was isolated from mouse livers at different stages of intoxication, recovery and reintoxication and hybridized to the cdna-arrays. expression profiles were analysed by genesight-and imagene software. results and conclusion results obtained demonstrated several groups of genes differently expressed in short-term intoxicated naive and reintoxicated mice. these genes comprised cyp a as well as genes involved in the cellular response to oxidative stress and methionine metabolism. the sustained elevated level of cyp a during recovery and the enhanced induction upon reintoxication could explain why certain drugs lead to enhanced liver toxicity upon repeated administration even after long drug-free intervals. introduction tgf-beta, fas, fasl molecules take part in the regulation of apoptosis. fas is a cell surface receptor present in most of the cells. fasl can be secreted from the surface of the cells and when it binds to fas, they activate the caspases to trigger the apoptosis. although the mechanism of tgf-beta is not clear yet, it plays a role in tumorigenesis. tgf-alpha may indicate inhibitory or stimulatory functions in conjunct with the stage of the tumors and cooperation with oncogenes and growth factors. we aimed to evaluate the correlation among the expressions of fas, fasl, tgf-beta molecules in hcc. material and method in this study fifty cases diagnosed as hepatocellular carcinoma (hcc) between the - years were included. tgf-beta , fas, fasl expressions were evaluated immunohistochemically. results fas, fasl expressions were observed together in % of tissue samples with hcc and % of the nontumoral liver tissue samples. it was noticed that fas and fasl staining were more densely in the lymphocytes of the tumorous areas and neighboring normal tissues than the control group. there was no statistically significant correlation between fas, fasl, tgf-b staining except the positive correlation between the tgf-beta and fas. the poor differentiated cases weakly expressed fas, fasl and tgf-beta . where as the majority of the cases stained cytoplasmic positive, some cases stained either cytoplasmic or membraneous positive. conclusion in hcc, tumor cells use variable pathways for apoptosis. the lymphocytes near the tumorous tissue have an important role in this process. dynamics of liver histology in patients with chronic hepatitis c after interferon-alpha and ribavirin therapy introduction interferon-alpha therapy for chronic hepatitis c improves hepatic inflammation and may change the evolution of disease to cirrhosis and hepatocellular carcinoma. accurate assessment of liver fibrosis is necessary for morphologic diagnostics. the aim of this study was to evaluate the effect of interferon-alpha and ribavirin on liver histology; to compare the semi-quantitative (according to ishak) and quantitative methods for evaluation of fibrosis. materials and methods twenty-two patients ( males, females at mean age years) with chronic hepatitis c were studied. within to months from the pre-therapy biopsy and at least months after the end of treatment patients were followed with second liver biopsy. histological activity in paired liver specimens was assessed by knodell modified score. fibrosis was evaluated according to ishak staging system. in addition, fibrosis was quantified in masson trichrome stained sections using morphometric image analysis. interferon-alpha (mean dose me) and ribavirin were administered for to months. patients were classified as complete sustained responders (n= ), relapsed after therapy cessation (n= ) and "non-responders" (n= ). results after treatment reduction of the histological activity score (at least one grade) was observed in patients ( %). lobular and periportal necroinflammatory lesions were decreased in both responders and non-responders (p< . ). after therapy, dynamics the fibrosis degree and calculated fibrosis ratio were not significant. fibrosis stage was improved in only sustained responders ( %); remained unchanged in patients, and progressed in patients ( %). conclusions improvement of liver histology after interferon-alpha and ribavirin treatment was constricted to the patients who achieved hepatitis c virus eradication. morphometry was the informative method for evaluation of fibrosis dynamics in addition to fibrosis assessment with semi-quantitative classification systems. introduction liver biopsy is one of the diagnostic procedures for neonatal hepatitis (nh)and intrahepatic bile duct paucity (ihbp). in this study we aimed to evaluate the prognostic benefits of quantitative analysis of histopathological changes in nh and ihbp. material and methods we studied liver biopsies in which were nh and were ihbp. the relationships between histopathological and prognostic parameters were analyzed. hepatic histopathological changes such as portal and periportal fibrosis, portal and lobular inflammation, bridging necrosis with fibrosis, pericellular fibrosis, giant cell transformation and extramedullary hematopoesis were evaluated and according to their absence ( ) or presence ( ) a histopathological score was assessed. the sum of these data was accepted as total pathological injury score. clinical prognostic parameters consisted of the patients height, presence or absence of hepatosplenomegaly and ascites, serum levels of alt, albumin, bilirubin, and the value of protrombine time. the sum of these data was accepted as the clinical score. the patiens were also divided into two groups whose clinical scores were < as good prognosis and ≥ as bad prognosis. for statistical analysis pearson's chi-square, mann-whitney-u and roc curve tests were used. results we found a statistically significant negative relation between prognosis and total pathological injury score (p= . ), so as pericellular fibrosis (p= . ). conclusion during the interpretation of liver biopsies of nh and ihbp, scoring of histopathological changes should be done in order to assess the clinical prognostic outcome. moreover, the presence of pericellular fibrosis should be evaluated and reported. immunohistochemical analysis of hepatocellular carcinoma and intrahepatic cholangiocellularcarcinoma using markers supposed to indicate respective levels of diffentiation of the hepatic cell lineage k ishida, m endoh, j takeyama, k sakamoto, m watanabe, t moriya, h sasano department of pathology, tohoku university hospital, sendai, japan it is widely recognized that there are diagnostically problematic cases among primary hepatic tumors. they cause difficulties in distinguishing between hepatocellular carcinoma (hcc) and intrahepatic cholangiocellularcarcinoma (cc). meanwhile, recent progression of study on hepatocyte-diffrentiation has revealed that both mature hepatocyte and biliary epithelial cell should originate from the common cell lineage called as hepatic-progenitor-cell (hpc), bipolar-cell (bc) and/or intermediate-hepatocyte-like-cells. thus, we performed immunohistochemical analysis for hcc and cc using markers supposed to indicate respective levels of differentiation of the hepatic cell lineage, in order to identify the origin of the tumors particular in the diagnostically problematic cases. materials and method surgical specimens of cases of hcc and cases of cc were used. ordinary immunohistochemical staining was performed with following antibodies; hepatocyte monoclonal antigen (hep), c-kit, ck , ck and ck . the results were compared from the view of the histopathological findings and immunohistochemical reactions. results rate of positive (> %) and focal positive (> %) were hep; hcc %, cc %, c-kit; hcc %, cc % and ck ; hcc %, cc; %. ck and ck were similar as previously reported. in addition noteworthily, double positive for hep and ckit was observed on two cases of cc having apparent glandular formation. conclusions ) hcc had a lower positive rate for hep compared with previous reports. ) cc with positivity for hep might exist. ) according to the c-kit staining pattern, we considered that there might be a peculiar variant of tumor cells in cc differentiating both hepatocyte and biliary epithelial cell. introduction proteus anguinus, the sole species of the european cave salamander and the remarkable cave dweller of underground waters in the karst of slovenia is well adapted to poor and discontinuous food supplies. remarkable accumulation of lipid droplets and glycogen deposits in the liver beside slow metabolism allow proteus to survive for long periods without food. the aim of this study was to establish morphological changes in the liver during starvation with particular emphasis on mobilization of the liver energy reserves. material and methods the liver was examined after food deprivation periods of one, four and eighteen months, respectively using light and transmission electron microscopy. glycogen and proteins concentrations were determined spectrofotometrically. total fat in the liver was estimated by folch method. results intense depletion of glycogen was present during first month of starvation. the glycogen wasn't formed in clumps typical for normal liver tissue. after eighteen months of fasting glycogen was re-synthesized, dense glycogen deposits appeared. lipid droplets were less condensed. numerous peroxisomes formed clusters with small and round mitochondria. particular mitochondria increased in size and lost cristae. lysosomes and autophagic vacuoles were numerous, too. dilated intercellular space included electron dense granular material. conclusions carbohydrate and lipid reserves in the liver of proteus serve for metabolic needs during food deprivation. while in many other vertebrates fasting causes depletion of liver carbohydrates, these reserves are maintained in large amounts in proteus. results of our study confirm that a detailed morphological analysis of the liver could be a relevant informative method to prove metabolic adaptability of this organ. evaluation of t lymphocyte subpopulations in chronic hepatitis-relationship with histological lesions ci iosif, f vasilescu, g butur, dc terzea, c dobrea, f andrei, c ardeleanu 'victor babes' national institute, bucharest, romania background intrahepatic t lymphocytes are believed to be involved in immunopathogenesis of chronic viral hepatitis. the aim of this study was to assess the correlation between morphological lesions and t lymphocyte subpopulations in liver and peripheral blood (pb) of patients with chronic hepatitis. methods and results liver biopsy specimens from patients serologically confirmed ( hbv and hcv) were studied by histopathological and immunohistochemical methods. t cell subtypes (cd , cd , cd ) were tested by using monoclonal antibodies on tissue samples and by flow cytometry in pb. results in pb, % of patients have t lymphocyte cd + decreased and % of them have augmented values of t lymphocytes cd +. in liver biopsy the prevalent subpopulation were cd + cell, being approximately twice higher than cd + cells. the observed histological lesions were quantified by ishak score as moder-ate\severe chronic hepatitis. conclusions decreased subpopulation of cd + t lymphocyte might contribute to the severity of liver disease. relatively more frequent cell type was cd positive t cell, having a significant association with a higher inflammatory activity in both types, b and c virus hepatitis. the role of survivin in regulation of proliferative and apoptotic activity of hepatocellular carcinoma introduction imbalance between proliferation and apoptosis is an important factor in progression of hepatocellular carcinoma (hcc). aims: the percentage of proliferative (pi) and apoptotic cells (ai) in hcc compared to non-tumor liver was investigated. the role of unprocessed as well as active form of caspase- , which is an important apoptotic protein was of great interest for this study. expression of survivin, an inhibitor of apoptosis was investigated, too. material and methods twenty patients with hcc were included in the study. two samples were obtained from each patient, one of hcc and one of the surrounding non-tumor liver. mib- antibody was used to determine the proliferative activity. immunohistochemical staining for the detection of active form of caspase- was used to determine the percentage of apoptotic cells and for detection of procaspase- and survivin expression, as well. results ai was higher in hcc ( , ± , ) compared to nontumor liver ( , ± , ), but the proliferative activity in hcc was much higher than apoptotic activity. % of hcc showed positive staining for pro-caspase . positive correlation between expression of pro-caspase and active form of caspase proved to be statistically significant. % of hccs were survivin positive. stronger expression of survivin was detected in hcc compared to non-tumor liver. positive correlation between survivin expression and the grade of tumor diferentiatiation as well as a significant association between survivin expression and both ai and pi was also detected. conclusion our results indicate that survivin promoting cell proliferation in hcc has an important role in hcc progression. the histopathological effects of offloading on liver of rat embryo a khaki , aa khaki , j solimany rad faculty of veterinary medicine of tabriz islamic azad university, tabriz, islamic republic of iran faculty of medicine science.tabriz medical science university, tabriz, islamic republic of iran introduction ofloxacin is an antibiotic from fluroqinolne with a wide range and widely used in various infection diseases. since there is little information about ofloxacin side effect on liver of rat embryo. this preliminary study was planed to see what kind of changes occurs in development of liver in rat embryo. the aim of present study was to determine the histopathological effects of offloading on liver of rat embryo. material and methods fourty nine wistar rats were selected and randomly divided into two groups; control (n= ) and test (n= ). the test group has been received mg/kg (po) ofloxacin daily during pregnancy. however, the control group just received plate. after delivery, liver tissue of neonatal in both groups were taken and prepared for light microscopy. staining method was h&e. results microscopic study of liver tissue specimens showed that in the test group hepatocytes were vesiculated. degeneration and vacuolated pycnotic nuclei were seen when compared to control group. weight of neonatal in test group was reduced when it was compared with the control group (p< . ). conclusion since ofloxacin had side effects on liver of rat embryo, it is not suggested to be used during pregnancy in human. introduction while the underlying etiology of hcc has been well characterized the molecular mechanisms of hepatocarcinogenesis are poorly understood. the extremely poor prognosis of hcc and the limited value of the current standard clinical markers underscore the need for improvent of diagnosis and treatment of this deadly disease. aims: we performed gene expression profiling using cdna microarrays in order to identify novel molecular markers and therapeutic targets for the treatment of hcc. material and methods we used the method of subtractive suppressive hybridization (ssh) to generate cdna libraries that are highly enriched with clones representing genes both up-and downregulated in the diseased liver tissue. the expression pattern of clones representing ~ genes was analyzed in surgically resected hepatocellular carcinomas, focal nodular hyperplasias, one adenoma, and cirrhotic livers by competetive hybridization on custom made cdna microarrays using a pool of non-neoplastic human liver as reference. the expression data were verified independently by quantitative rt-pcr (taqman). results we found genes which were consistently deregulated in more than one third of the hccs under investigation. of these, genes had been previously implicated in hcc, whereas known genes as well as novel genes (with unknown function) had not yet been linked with liver cancer. conclusions the present study revealed a number of genes specifically deregulated in hepatocelluar carcinoma. future work will aim to evaluate the medical relevance of the encoded proteins which will ultimately help to identify potential new markers for better diagnosis/ prognosis of hcc and new targets for therapeutic intervention. introduction actinomycosis is a suppurative and granulomatous chronic infectious disease caused by actinomyces sp. and most commonly affecting the cervicofacial area. aim: to study the clinical characteristics of patients with actinomycosis, with regard to clinical history, presentation, method of diagnosis and comparing to the literature. patients and methods from january to july , a retrospective review was performed on all cases of histologically proven actinomycosis. results ten patients were studied, men and women, - years old. two patients had a history of surgical procedures and/or dental manipulations. two patients had a long history of diabetes mellitus. locations were the liver (patient n ), the feet articulation (patient n ), the lung (patient n ), the jugular lymph node (patient n ), the skin (patients n and ), mandibular (patient n ), the psoas muscle (patient n ), the appendix (patient n ) and the large bowel (patient n ). three patients showed a tumoral presentation (patients n , and ) and two patients had a tuberculosis disease presentation (patients n and n ). the patient n had a clinical presentation of an inflammatory large bowel disease. one patient was diagnosed by cultures positive to a. israelii on microbiologic study and the others patients by surgical biopsy and detection of an actinomycosic granuloma. special stains were used in all cases. three patients received the classic initial regimen of iv. conclusion actinomycosis is an uncommon disease in our country. in these cases gastrointestinal locations were predominant. two uncommon locations were present. there was no iud associated infection. tuberculosis endemic in our country can mislead the diagnosis. further autopsy hazards: mycobacterium tuberculosis in the autopsy room r flavin, s o briain st. james hospital/tcd, dublin, ireland introduction tuberculosis has been the major occupationally acquired disease in the autopsy room. the risk of encountering tuber-culosis at autopsy has fallen with the decreased incidence of the disease and greater emphasis has been placed recently on the hazards of viral diseases. however, tuberculosis may still be found at autopsy. the aim of this study was to assess the magnitude of exposure to mycobacterium tuberculosis at autopsy in a large general hospital setting. methods retrospective search of the autopsy records from - . the patient record and histological slides were reviewed. the quantity of mycobacteria was assessed from the ziehl-neelson stains as scanty, moderate or abundant. results cases of active mycobacterium tuberculosis were identified in the -year period in which autopsies were performed ( per autopsies) of which cases were unsuspected ( %). these included cases of miliary tuberculosis and with pulmonary infection. cases contained abundant organisms. patients tended to be middle aged and male with complex clinical histories. patients were dead on arrival at hospital. conclusion the risk of unexpectedly encountering tuberculosis at autopsy continues and has implications for the health of autopsy room staff, autopsy room ventilation and design, protective equipment and for the involvement of the public health service. introduction the course of chronic hepatitis c virus infection is difficult to predict. although the disease is frequently asymptomatic, the development of fibrosis and cirrhosis are the major complications. among patients suffering from chronic hepatitis c (chc), special group are young drug abusers. immunological toxicity of narcotics modulates the total immunologic response to the viral infection with characteristic morphologic expression of this disease. the aim of this study was to asses which pathological features are associated with liver fibrogenesis and are predictive to fibrosis in chc drug abusers. methods eighty liver biopsies with chc from drug abusers ( actively consumers; free from drugs - months before liver biopsy and free for more than one year before performing liver biopsy) stained by he, trichrom masson, perls and reticulin were analyzed semi quantitatively using standard questioner for determination of patohistological features for histological activity index. results of fibrosis were correlated to all of them. results the fibrosis was , and in this group of young patients (mean age , years). there were no correlation between any of the patohistological parameters and fibrosis, even for lobular necrosis. conclusion histomorphological changes and the extent of fibrosis are in correlation to the duration of drug consumption. morphological expression of immune toxicity of narcotic drugs in chc patients make this disease special entity to which it is not possible to apply standard histopatologic parameters, nor the parameters predicting liver fibrosis. introduction epithelial tumors of the conjunctiva are rare diseases in europe. in sub-saharan countries, an increasing incidence was observed in connection with the hiv epidemic. the definite causes of these tumors are not known. aims: based on tumor material from africa, we search for possible cancerogenic agents and its pathogenetical interaction in conjunctival carcinoma. materials and methods conjunctival specimens of patients from three african centers with the following histological lesions were examined: papilloma ( case), pinguecula ( ), conjunctival intraepithelial neoplasia ( cin i, cin ii, cin iii), squamous cell carcinoma (scc, cases). immunohistological reactions for p and p were done. of tested patients were hiv positive. results and conclusion of the benign and precancerous lesions were associated with histological signs of a solar damage. of the cases showed immunohistologically an overexpression of p , among them all scc. this finding might indicate a p mutation as mostly seen in solar induced skin cancer too. % of the cases with cin iii and scc had an overexpression of p . corresponding findings are known from transformed or neoplastic cervical epithelium in strong correlation with an active hpv (type , ) oncogene expression. no significant differences occurred between hiv positive and hiv negative cases in comparison to the frequency of different histological lesions as well as the p and p expression. the average manifestation age for cin iii and scc in hiv positive cases ( resp. years) was years lower than that of hiv negative cases ( resp. years). the results suggest a multifactorial tumorgenesis (uv radiation, oncogenic viruses, hiv infection) for the conjunctival carcinoma in africa. introduction botryomycosis is an enigmatic pyogranulomatous infection, which may be caused by a variety of non-filamentous bacteria including staphylococcus aureus and pseudomonas aeruginosa. while the exact pathogenesis remains elusive, it is acknowledged that the interrelationship of host and agent factors is fundamental. we describe the clinicopathological features of a rare and particularly mutilating case of delayed onset post traumatic craniofacial botryomycosis. methods an immunocompetent -year-old black male presented with multiple sinuses draining granules involving the frontal, parietal, orbital and maxillary areas. nodulo-fibrous thickening was also present. this had evolved over a three-year period. apart from the history of a head injury requiring cranioplasty years earlier, no other predisposing factors were found. results the diagnostic features of clumped bacteria (cloxacillin sensitive staphylococcus aureus), splendore-hoeppli phenomenon, granulomata and intense fibrosis were confirmed histologically. there was no response to intravenous cloxacillin and the patient died before surgical debridement could be done. conclusion this case report serves to highlight several points. firstly, it illustrates that when considering the diagnosis of post traumatic botryomycosis, the time interval between the traumatic event and the onset of clinical features may span decades. we submit that this is due either to the small size of the bacterial load or their low virulence. secondly, it is our contention that the poor response to antibiotics is due to the severe, impenetrable fibrosis. finally, the destructive nature of the disease underscores the urgency in diagnosis and treatment. tuberculous meningitis in adulthood introduction tuberculous meningitis is a very frequent clinical manifestation of postprimary tuberculosis in childhood as the result of hematogenous dissemination of a pulmonary lesion; in adult patients tuberculous meningitis occurs less frequently, mainly associated with extrapulmonary disease, consequent to the rupture of a subependymal tubercle. case reports we report cases of tuberculous meningitis in adulthood diagnosed by autopsy examination -median age , yrs -in an autopsy series of tuberculous patients in years. all but one of the patients had disseminated disease (lung, lymph nodes, liver, spleen and kidneys). none of the patients presented subependymal tubercles. one patient had dual mycobacterial infection -miliary tuberculosis due to mycobacterium tuberculosis in all the extracranial affected organs and tuberculous meningitis with mycobacterium avium-intracellulare (mac). cerebrospinal fluid examination revealed high cellularity and high albumin concentration in all cases; glucose levels were low, except in one case with normal glucose content -the mac infected patient. one patient had associated systemic lupus erythematosus (sle) and low cd + cells count. the histopathologic appearance consisted of a granulomatous meningitis with giant cells and epithelioids in three cases and polymorphous inflammatory infiltrate including numerous positive bacilli in ziehl-neelsen stain in mac infected patient. conclusion the overall appearance suggested a hematogenous spread of the infection, the immune status correlating with the occurrence of the meningeal disease; in our series we had an immunodepressed patient (sle) and another patient with miliary tuberculosis and superimposed mac infection. also, mac meningitis had a different clinical and histopathologic appearance. introduction clinical presentation and lesion morphology are often suggestive, but not conclusive for mycobacterial (mb) infections. rapid and accurate specific diagnosis is mandatory since appropriate therapy can be chosen only on the basis of the precise identification of the causative agent. one of the most promising tools for rapid and sensitive identification of mb species is represented by amplification of specific sequences of the s rrna mb specific gene on the fragmented dna (max bp) obtained from fixed tissues. methods dna was extracted from cases selected from the archives of the department of pathology, university of padova, with histopathologic features of granulomas, caseous necrosis, and langhans-type giant cells. ziehl-neelsen staining for acid-fast bacilli and pcr/direct sequencing of a bp variable region of the mb s rrna gene were performed. h rv genome was employed as positive control. results mb specific sequences have been identified in of samples analyzed ( %). in two dna samples ( %) an inserted dna product was detected and it is currently under sequencing, while in one sample ( %) no evidence of mb infection has been gained. agreement with ziehl-neelsen was present in cases ( %). conclusion our study suggests that pcr is a rapid, sensitive method for the diagnosis of mb in routinely processed formalinfixed, paraffin-embedded histological specimens and is highly recommendable in cases of chronic inflammation without definite evidence of granulomatous inflammation. introduction cladosporium bantianum is a pigmented highly neurotropic fungus which can be identified easily in tissue sections due to their golden brown colour. cerebral lesions caused by this fungus are rare. case reports we present six cases diagnosed at our institute over a period of yrs. . there were males and female. all patients belonged to the second to fourth decade and had presented with symptoms of space occupying lesion. radiological investigations revealed well circumscribed lesions with ring enhancement. the smallest lesion measured . x . cm and largest measured x . x cm. only two of the six cases had detectable predisposing debilitating illness. one yr. old male had past history of liver tuberculosis and had taken anti-tuberculosis treatment and a yr. old female had systemic lupus erythematosus and was on immunosuppressants. we received four surgically excised specimens and two autopsy specimens of the entire brain. histopathology revealed necrotic areas, micro-abscesses and mainly foreign body type of giant cells. lying within the giant cells as well as freely within the tissue were numerous golden brown to deep brown spherical forms of cladosporium bantianum measuring - microns in diameter and their hyphal forms measuring - microns in diameter, - microns in length with septae and occasional branching. these were confirmed by gomori's methenamine silver stain for fungus and species identification was carried out by culture studies. all the four patients with surgical excision showed recurrence within - months. three succumbed to the disease and one is still alive. conclusion cladosporium bantianum can affect both healthy as well as immunocompromised individuals. it has a fatal outcome. cases are being presented because of the relative rarity. necrobiotic changes of skeletal muscle simulating myxoid sarcoma. report of a case with immunohistochemical and electron microscopic studies kw min , is seo deaciness hospital, oklahoma city, usa wishard memorial hospital, oklahoma city, usa background skeletal muscles are known to undergo bizarre reactive changes in response to traumatic injuries and may produce pseudosarcomatous lesions which may give diagnostic challenges to pathologists. such lesions usually produce proliferative myositis in which atypical spindle cells of fibroblastic and myofibroblastic nature predominate and may simulate the appearance of fibrosarcomas and myofibrosarcomas. however with proper setting of previous trauma history, their true nature can be easily appreciated. we are reporting an unusual case of myxoid cellular lesion found in the abdominal rectus muscle involved in a post hysterectomy abdominal hernia which simulated the appearance of an extraskeletal myxoid chondrosarcoma (emc). its true reactive nature was recognized by electron microscopic (em) study. design light brownish gelatinous material aggregating . x . x . cm was found around the sheath of rectus abdominis muscle of a year old female during a repair surgery of posthyterectomy ventral hernia. the tissue was fixed in buffered formalin and a representative portion of the tissue was fixed in phosphate buffered . % glutaraldehyde and post fixed in osmium with en bloc staining with uranyl acetate. epon embedded thin sections were stained with uranyl acetate and lead citrate. for immunochemistry, paraffin sections were stained for s protein, myosin, and actin by routine abc-peroxidase techniques. results on routine examination, the lesion was characterized by loosely arranged spindly to epithelioid cells in bundles with abundant myxoid stroma. the lesional cells varied in size with frequent bizarre hyperchromatic nuclei. mitosis was rare. the cells showed weakly positive diffuse cytoplasmic stain for all of above antibodies. with the initial impression of emc, an expert opinion confirmed the diagnosis of grade ii emc. however, em revealed the lesional cells to be consistent with skeletal muscle cells having of varying stages of degeneration and regeneration. no ultrastructural characteristics seen in the tumor cells in emc were present. the attending physician was advised of careful follow-up and close observation without any additional treatment. the patient remains with no evidence of disease by year follow-up in spite of incomplete excision of the lesion. discussion and conclusion the myxoid gelatinous material found in the abdominal rectus muscle presented herein showed histopathologic characteristics of emc, however, electron microscopic studies revealed the lesion to be necrobiotic process of the rectus muscle. evidence of no disease in years of follow-up with incomplete excision supports the conclusion the lesion was not malignant as em study indicated. this case exemplifies another variety of pseudosarcomatous reaction of skeletal muscles important in the differential diagnosis in the pathologic evaluation of cellular myxoid lesions. peritoneal psammocarcinoma. a case report with ultrastructural study is seo background psammocarcinoma (pc) is a very rare variant of low grade serous tumors that appears to arise from the peritoneum and ovaries. this tumor has been defined as a serous neoplasm displaying ) destructive invasion, ) no more than moderate nuclear atypia, ) no areas of solid epithelial proliferation except for occasional nests no more than cells in diameter, and ) at least % of papillae or nests are associated with or completely obscured by psammoma bodies. pc shares some clinicopathologic features with serous tumor of low grade malignant potential (lmp), but may have been under-recognized at surgery and gross examination. the present case was incidentally found during a routine hysterectomy procedure for leiomyomas. the pc involved the omentum, peritoneum and diaphragm. we report, to our best knowledge, the first electon microscopic (em) findings of pc. design tumor tissue was fixed in buffered formalin for routine examination. in addition, a representative tissue was fixed in phosphate buffered . % glutaraldehyde and post fixed in osmium with en bloc staining with uranyl acetate for em study. results this tumor met the diagnostic criteria of psammocarcinoma. there were numerous psammoma bodies with or without nests of epithelial proliferation with minimal nuclear atypia. more than % of papillae were either associated with or completely replaced by psammoma bodies. multifocal involvement was noted on the surfaces of both ovaries and fallopian tubes. ultrastructurally, the tumor cells showed markedly villous surfaces with abundant long slender villi. their length/diameter ratio (ldr) was with some variation of their diameter. the cytoplasm contained abundant cytoplasmic organelles and intermediate filaments. intracytoplasmic lumens were absent. decalcified psammoma bodies resembled cut surfaces of geode. discussion and conclusion our case met the proposed criteria for this tumor that arose de novo in peritoneum. ultrastructurally, this tumor shared some findings with serous tumors (junctional complexes, irregular microvilli), but differed by the lack of prominent desmosomes and frequent intercellular lumens. pc differed from mesothelioma in that significantly greater microvillus ldr, prominent desmosomes, tomofilaments, intracytoplasmic lumens, external lamina and glycogen were rountine findings in the latter. our findings justify classification of pc in the group of serous epithelial tumors arising from the coelomic mesothelium. application of electron-and immunoelectron microscopy in the differential diagnosis of pituitary adenomas m maksymowicz, w olszewski department of pathology, institute of oncology, warsaw, poland aim evaluation of practical implementation of electron microscopic techniques in diagnosis of pituitary adenomas. material and methods material consists of consecutive cases of surgically resected pituitary tumors. in pituitary adenomas diagnosed clinically, there were patients with symptoms of acromegaly, patients with hyperprolactinemia, cases of cushing's syndrome and case of tsh hypersecretion. there were clinically nonfunctioning tumors. all cases were diagnosed by histological examination and immunohistochemical identification of known pituitary hormones (growth hormone, prolactin, acth, tsh, fsh, lh and alpha-subunit). the cases evaluated at light microscopy level as pituitary adenomas were examined with electron microscopy and immunoelectron microscopy using a postembedding immunogold technique. results immunohistochemical investigation showed that about , % of specimens of pituitary adenomas contained more than one pituitary hormone. additionally, immunopositivity was discovered in % of tumors from patients with clinical and biological signs of silent pituitary adenoma. ultrastructural analysis provided proper diagnosis of selected cases, e.g. silent corticotroph adenoma or distinction between densely-and sparsely granulated growth hormone secreting adenomas. double labeling immunoelectron microscopy using gold particles of two different sizes greatly facilitated the distinction among mixed growth hormone/ prolactin, mammosomatotroph and acidophil stem cell adenomas. conclusions electron microscopy analysis was valuable to provide a useful informations regarding the diagnosis. our results confirmed practical value of who recommendation for five-tier evaluation of pituitary adenomas (clinical, neuroimaging, histological, immunohistochemical and ultrastructural) . on the basis of our results and the published data, diagnostic postoperative algorithm for proper pathologic management has been proposed. apoptosis, sarcomere disruption and myofibrilar degeneration in skeletal muscles of stable copd patients: an ultrastructural study md ferrer introduction in patients with chronic obstructive pulmonary disease (copd), the diaphragm muscle shows signs of injury, even during clinical stability. in addition, these patients have a markedly increased susceptibility to additional diaphragm injury following inspiratory loading. we have hypothesized that, if sytemic factors play a role in diaphragm injury, limb muscles may also be affected. the purpose of this study is to investigate whether apoptosis occurs in the diaphragm and quadriceps of copd patients, and to evaluate fiber injury in non-respiratory muscles. methods samples from both diaphragm and quadriceps muscles were obtained in patients undergoing thoracotomy for a lowstage lung neoplasm (ln) and stratified into two cohorts according to pulmonary function: ln+copd (n= ) and non-copd patients (ln+non-copd, n= ). in addition, samples form quadriceps muscle in healthy age-matched volunteers were also included (control group). all samples were processed for ultrastructural analysis. the proportion (%) of normal nuclei (nn) and those showing early (ean) and advanced (aan) signs of apoptosis were determined in all samples. digital images of longitudinal fiber sections ( x) were used to determine the area fraction (%) of abnormal myofibrilar structures (aab). results the level of apoptotic signs in the diaphragm of both copd and non-copd groups was minimal and very similar to that of control limb muscle. in contrast, quadriceps muscle of both copd and non-copd groups showed a two-and three-fold increase respectively in the apoptotic nuclei when compared to controls, mainly due to ean. apoptotic bodies were not found. in control quadriceps aab was , ± , %, mostly due to sarcomere disruption, while quadriceps in copd patients was associated with an increased aab ( ± %, p< , ) including myofibrilar disorganization and degeneration. conclusions in patients with copd, the diaphragm is not altered by apoptotic phenomena. muscle remodeling through apoptotic mechanisms as well as through structural changes, such as sarcomere disruption and myofibrilar degeneration, seem to be enhanced in the quadriceps muscle of these patients, regardless of the severity of pulmonary function impairment, suggesting that additional factors such as the degree of physical inactivity either related to the disease or to the preoperative status could also be involved. background renal chromophylic (papillary) carcinoma (cprc) has a propensity for storing hemosiderin in tumor cells. by transmission electron microscopy (tem), some tumors show a prominent lysosomal component, while in other cases, cells contain mostly isometric lipid vacuoles. it has been proposed that the latter would merely represent a papillary variety of clear cell renal cell carcinoma (ccrc). the aim of this study has been to analyze the lysosomal content in chromophylic (papillary) renal cell carcinoma by both immunohistochemical study of cd expression and tem, and to compare these results with those of conventional ccrc. design cases of cprc (n= ) and ccrc (n= ) are the subject of the study. the presence and relative amount of lysosomes and isometric fat vacuoles was investigated by tem (n= ). immunostaining with cd antibody (pg-m , dako, denmark) was performed in representative sections. the presence, distribution and percentage of cd staining in tumor cells was compared with tem data. results expression of cd was observed in all cases of cprc. the mean percentage of positive cells was % ( - %). distribution of positive cells was diffuse in % of cases. of the tem cases, contained abundant fat vacuoles, but only had extensive isometric vacuolation by light microscopy. electrondense lysosomes were less abundant than fat in cases, of which had massive cd expression. detailed examination of fat vacuoles in these cases suggested they were membrane-bound and of probable lysosomal origin. cd expression was also observed in cases of ccrc, all of them with focal distribution, involving a mean of % tumor cells ( - %). these differences were statistically significant (p< . ). conclusions diffuse cd expression is typical of cprc and may be a useful auxiliary diagnostic criterion. the isometric fat vacuoles in cprc are often membrane-bound and of probable lysosomal origin. these findings support the notion that the lipidcontaining, vacuolated variety of cprc is different from ccrc. introduction any lesion in prostate is followed by different proliferative activity of cells. one of the markers, which relate to proliferative activity, is ploidy. it can be determined by cytometry, morphometry or by other methods. aims: study of dna ploidy status in different lesions of prostate by morphometry. materials and methods samples from patients with atrophy, benign prostatic hyperplasia (bph), squamous cell metaplasia (scm), atypical adenomatous hyperplasia (aah), basal cell hyperplasia (bch), prostatic intraepithelial neoplasia (pin) and prostatic carcinoma were processed in formalin, dehydratated in graded alcohols, embedded in paraffin, stained by feulgen-stain. integral optical density was assessed by morphometry on image analysis system. integral optical density of lymphocyte was counted as c ploidy. integral optical density at different prostatic lesions was divided on c. results average ploidy at atrophy was . , bph - . , scm - . , bch - . , aah - . , low grade pin was . . average ploidy at high grade pin was . , high grade carcinoma - . , moderate grade carcinoma - . , low grade carcinoma - . . conclusion increase of ploidy status from atrophy to bph, scm, bch, aah, pin and to carcinoma was observed. regarding to ploidy lesions may be divided in benign and neoplastic processes, with cutoff point between them as . . pseudohyperplastic prostatic adenocarcinoma in transurethral resection of the prostate j arista-nasr, b martinez, j nuncio instituto nacional de ciencias medicas y nutricion salvador zubiran, mexico city, mexico background the pseudohyperplastic prostatic adenocarcinoma (phpa) is a recently described variant of adenocarcinoma, studied in needle biopsies and prostatectomy specimens. phpa is characterized by malignant glands that simulate benign hyperplastic glands of variable size with complex architecture, papillary enfolding, luminal undulations branching or cystic dilations, columnar cells with macronuclei and nucleoli enlargement. the aim of this study was to define the frequency and microscopic aspect of phpa in specimens originated in transuretral prostatectomy (tup). specimens of transurethral prostatectomy were analized from the surgical pathology department at incmynsz. cases were initially diagnosed as benign glandular hyperplasia (bgh) and as conventional adenocarcinoma (cc) results cases ( . %) with phpa were identified in specimens diagnosed as bhg. these specimens demonstrated phpa in two microscopic areas of mm. both patients are well and free of disease and years after diagnosis. the review of cases diagnosed as cc, three specimens had microscopic segments of phpa. in the outcome the patients developed early bone metastasis. the histopathology study revealed papillary projections, nuclear enlargement, crawled glands, macronucleoli ( / ); cystic glandular dilatation, straight luminal borders, pink amorphous secretions ( / ); nuclear hypercromasia and transition to small cell carcinoma ( / ) . other changes observed were corpora amylacea, double nucleoli and mitoses. conclusions the phpa is a rare neoplasm observed in tup specimens and is observed in only few areas. the false negative frequency in bgh is . %, and % in usual adenocarcinoma. the outcome for these cases is related to the main conventional adenocarcinoma component. vascular endothelial growth factor: an important angiogenic mediator in chronic urinary bladder lesions o hammam, h el baz, a el baz theodor bilharz research institute, giza, egypt vascular endothelial growth factor (vegf) is an overriding growth factor mediating tumor anigogenesis. this study was performed to assess vegf levels of expression in both serum and tissue in benign, premalignant and malignant urinary bladder lesions with or without schistosomal infestation in a trail to study the angiogenic phenotype of these lesions and to address any possible role of vegf as a prognostic biologic marker of bladder cancer. also the impact of schistosomal infestation on the vegf level of expression was assessed.the study included patients: chronic cystitis cases ( schistosomal and non-schistosomal), cases with schistosomal premalignant lesions (metaplasia, dysplasia and leukoplakia) and cases with bladder carcinoma ( schistosomal sqcc, schistosomal tcc and non-schistosomal tcc). eight cases with normal urothelium served as controls. vegf serum concentration was measured by the enzyme immunoassay (elisa) while, its tissue expression was detected by immunohistochemical staining.. significantly higher levels of vegf where detected in the premalignant and malignant cases in tissue (p< . & p< . respectively) and in serum (p< . ) compared to controls. also an aberrant increase in vegf serum and tissue levels was recorded in malignant cases compared to those with chronic cystitis (p< . & . respectively). schistosomal infestation was found to have a positive impact on vegf tissue and serum levels. tissue vegf positive rates was % in all the premalignant and malignant schistosomal associated cases. on stratifying malignant cases according to their histopathological grade and stage, an evident stepladder increase in vegf serum and tissue levels was recorded. vegf serum levels were well correlated with their corresponding tissue level which may indicate that vegf serum levels are reflecting intratumoral angiogenic status. although both vegf serum and tissue levels were positively correlated with tumor histopathological grade and stage, yet this correlation was more evident with the tissue expression (r= . , r= . , p< . in tissue, while r= . , r= . , p< . , p= . in serum with grade and stage respectively). in conclusion, our data indicate that vegf expression level in both serum and tissue may be used as a valuable angiogenic marker for prediction of prognosis. this may help in selecting patients for more intensive surgical or chemotherapeutic approaches. serum vegf concentration may be used as a non-invasive prognostic parameter especially in high risk patients who need continuous follow up. microvessel density in urothelial tumors of the upper urinary tract m raica , c suciu , f baderca , r minciu 'victor babes' university of medicine, department of histology&cytology, timsoara, romania 'victor babes' university of medicine, department of urology, timsoara, romania background angiogenesis in tumors of the urinary bladder is relatively well studied, in spite of some conflicting results and usually correlates with bad prognosis. few data are available about microvessel density (mvd) in urothelial tumors of the upper urinary tract (uut). our purpose was to investigate the mvd in patients with urothelial tumors of the uut and to check for its relationships with stage, grade, and survival. patients, material, and methods there were investigated patients with urothelial carcinoma of the uut. routine-stained slides were reviewed by two independent pathologists for the final diagnosis, t stage, and grade. only cases with invasive and mixed papillary-invasive tumors were included. two cases had lymph node metastasis. additional slides were stained for fviii, cd , and cd . mvd was estimated using the hot-spot method and mean value, calculated on consecutive fields from the tumor area and from the deeper connective tissue (x ). all cases had a follow-up of minimum years. results best results were obtained with cd and cd . in the tumor area, mean values of mvd were . for t , . for t , and for t . the hot-spot method consists of choosing the field with maximum density of blood vessels, and results showed for t , . for t , and . for t . the comparison between mvd and g showed a significant increase from g to g in the mean values and maximal density as well: . / for g , . / . for g , and . / . for g . no relationship was found between mvd and n positive cases. nine patients with high mvd died within years. the extra-tumor mvd had no prognostic significance. conclusions our results show a strong correlation between tumor areas mvd, t, g, and survival. mvd had no value as a predictor of lymph node metastasis. is there any prognostic significance for her protein in urothelial tumors of the upper urinary tract? of her protein in urothelial tumours of the upper urinary tract, and its relationships with the stage and grade. the final purpose was to conclude on the prognostic value of her protein in patients with tumours of upper urinary tract. patients, material and methods there were investigated cases with tumours of the upper urinary tract. routine he stained slides were reviewed for the pathologic diagnosis and grade. additional slides were stained with her- /neu (dako herceptest). interpretation of results was based on the score system (from to + ) already used in breast cancer. results obtained with her- /neu were compared with stage and grade. results eight from cases were positive for her protein ( . %). no relationship was found between her overexpression and 'g'. all but one case with g had a + score for herceptest. conclusions the overexpression of her protein does not correlate with tumour stage, and has no predictive value for lymph nodes metastasis. it strongly correlates with 'g'. introduction some authors consider postatrophic hyperplasia (pah), a glandular hyperplasia that mimics some patterns of prostate carcinoma (pca), without any correlation with neoplastic and preneoplastic condition of the prostate. the association of pah with pca recently suggested (mucci et al., ; tsujimoto et al., ) induced us to analyze the role of pah as precursor of pca. material and methods formalin fixed and paraffin embedded archival sections ( selected patients undergoing radical prostatectomy -mean age = . yr) were studied. twenty cases ( with pah and without pah) were selected for each group: a) bph (benign prostatic hyperplasia), b) pca-ghs< (gleason histological score) and c) pca-ghs=> . slides were immunocytochemically treated with psa, ße , cd , vimentin, cd , ar, nse, chromogranin a, pgp . , p , bcl , ki /mib , incubated with streptavidin-biotin complex (sbc) and revealed by diaminobenzidine (dab). immunohistochemical investigations revealed the presence of basal cells ( ße ) only in pah. the nuclear cell cycle proliferation (mib /ki ) and p mutation were quite similar in number of positive nuclei between pah and pca-ghs< . the chromogranin a were positive in pah, randomly in pca-ghs< , and in nests in pca-ghs=> . vimentin stained nests in pah, whereas were negative in pca. the bcl were positive in pah and negative in pca-ghs< . conclusion these findings suggest a strong overlapping of cell cycle nuclear proliferation and mutation markers, supporting a possible role of pah as a precursor of pca. eosinophilic cystitis: clinico-morphologic aspects d staribratova , d staikov , d dikov , v belovejdov , d staikov plovdiv medical university, plovdiv, bulgaria hopsital centre -lagny, paris, france collaborative study called for review of archived urinary bladder biopsy specimens with inflammatory lesions for the period - . features consistent with the diagnosis of eosinophilic cystitis were identified in cases, thus positioning it at th place with an incidence of , % from all inflammatory lesions. the distribution of clinical signs manifested in these patients often deceptive of interstitial cystitis or tumor processes is as follows: polakisuria, hematuria, suprapubical pains are evident in / , %/ patients; / , %/ presented with acute obstructive pyelonephritis as a result of bladder wall remodeling and case / , %/ revealed combined features of gastroeneteritis and cystitis. inflammed bladder wall and reduced bladder volume is estimated in / , %/ cases, ulcerations in / , %/ papillomatous and solid pseudotumoral lesions are / , %/ and / , %/ respectively. as all clinical signs are nonspecific, the only way to set a proper diagnosis is through bladder biopsy. morphologic confirmation is based on the standard protocols. histochemical (positive ziehl-neelsen stain) and ultrastructural identification of charcot-leyden's crystals are evident in some cases. adenocarcinoma of the male urethra in association with nephrogenic metaplasia f hostalet , je hernández , ja ruiz , a romero department of pathology, 'vega baja' hospital, orihuela, spain. department of urology, 'vega baja' hospital, orihuela, spain. we describe a case of adenocarcinoma of the urethra associated with so-called nephrogenic metaplasia in a year-old male patient that showed a polypoid tumor of the proximal penile urethra. histopathology examination of the biopsy specimen revealed two distinct patterns. the first showed a tumor composed of papillary fronds and glands lined by columnar epithelial cells with eosinophilic and clear cytoplasm, and contained atypical nuclei with frequent mitotic figures. this tumor was interpreted as adenocarcinoma. the second pattern was different, it consisted of small tubules some with mild cystic changes lying in an edematous stroma. the tubules were lined by a single layer of flattened cells with faintly eosinophilic cytoplasm and bland nuclei, mitotic figures were not identified. this area was interpreted as nephrogenic metaplasia and showed a direct transition into the adenocarcinoma. the immunohistochemical study revealed the presence of low-molecular-weight and some high-molecularweight keratins in both types of lesions. the adenocarcinoma cells also showed nuclear staining for p , in contrast, the cells of nephrogenic metaplasia were negative. the nephrogenic metaplasia as well as the adenocarcinoma cells were not stained with psa and pap. the histogenesis of adenocarcinoma of the lower urinary tract remains unclear. the association and direct transition of the nephrogenic metaplasia into the adenocarcinoma in this case suggest the proposed histogenetic pathway that the urethral adenocarcinoma may arise by malignant transformation of nephrogenic metaplasia. introduction benign prostatic hyperplasia (bph) is associated with a shift in sex hormone balance towards an increase in the oestrogen:androgen ratio. this is accompanied by elevated levels of oestrogen receptor alpha (er), predominantly in the stroma. recently, we described a simple, in vitro model to create moderate upregulation of er in human, prostatic stromal cells. the aim of this study was to investigate the hypothesis that in bph upregulated er and the action of androgens differentially regulate expression of several stromal growth factors. materials and methods eight human, prostatic stromal cell strains were subjected to a procedure to upregulate er alpha by exposing them to micro mol beta-estradiol for days, followed by passage and growth in the absence of steroids. four cell strains received instead n mol of dihydrotestosterone for hr. immunoexpressions of er alpha, ar, and six growth factors (fgf- , fgf- , igf- , tgf-beta , ngf and enos) were quantified by flow cytometry. results expression of er was significantly increased above control ( out of cell strains). expressions of all six growth factors were elevated but not significantly so. however, there was a significant positive correlation between the change in er (expressed as percentage of control) and the change in fgf- and fgf- . exposure of four cell strains to dihydrotestosterone reduced the expression of er and all six growth factors in comparison with oestrogen-treated cells. this reduction was significant for er and fgf- . conclusion upregulated er in prostatic stroma have a greater modulating effect on synthesis of certain growth factors than the direct action of androgens and hence may play a major role in the development of bph. the diagnosis of prostatic adenocarcinoma in needle core biopsy is based on major and supportive criteria. one of the supportive criteria is the presence of retraction clefting around neoplastic glands. the aim of our study was to analyze needle core prostatic biopsies in order to determine the frequency of periacinar clefting spaces in tumors and non-tumorous prostatic tissue. materials and methods we analyzed a consecutive series of prostatic cancer cases diagnosed by needle core biopsy to determine the frequency and extent of periacinar clefting. all tumors consisted of at least neoplastic glands. specimens were fixed in % buffered formaldehyde, embedded in paraffin, cut at µm thickness and routinely stained with hematoxylin and eosin. clefting was analyzed on neoplastic and normal glands in three different high power fields. results one third or more of analyzed glands with clefts affecting more than % of circumference were significantly more common in tumors ( . %) than in benign glands ( %). more strict criterion that designated as positive cases with at least % of neoplastic glands (fifteen out of thirty) with clefts that affected more than % of circumference revealed clefts in the malignant cases only ( . %) but not in benign cases ( %). fifteen or more glands with clefts regardless of their extension were also more prominent in malignant cases ( . %) than in benign cases ( . %). conclusion we conclude that retraction clefting represents a reliable criterion for diagnosis of prostatic adenocarcinoma. analyze the causes of ureteral obstruction in a series of patients managed at the department of urology, timisoara county hospital between and . there were selected only those particular cases of ureteral obstruction, others than cases with lithiasis, stenosis of the ureteropelvic junction and transitional cell carcinoma. an additional case was send for evaluation from another institution was also included in the study. for three of the selected cases we performed additional histochemical (alcian-blue-pas) and immunohistochemical study (anti-ck, anti-psa, anti-vimentin, anti-smooth muscle actin, abc and lsab system, visualization with dab). results we identified cases of ureteral obstruction due to unusual pathological lesions. they occurred in men and women. the mean age of the study group was years (range and years). there were malignant and benign lesions that produced ureteral obstruction. in cases, the compression was extrinsic and only in cases the obstruction was intrinsec. the site of ureteral obstruction was in the lower ureter in cases, in the lower and the middle ureter in patients and in the upper ureter in cases. the pathological lesions were: ureteritis cystica - cases, nephrogenic adenoma of the ureter - case, retroperitoneal fibrosis - case, reproperitoneal sarcoma - case, pelvic endometriosis - case, prostate cancer metastasis - case, signet ring cell carcinoma of the colon invading the ureter - case. conclusions after discarding the more common causes of extrinsic or intrinsic ureteral obstruction, the proliferativemetaplastic lesions of the urothelium, the retroperitoneal fibrosis and sarcoma, the endometriosis and metastatic/invasive carcinoma should be considered in the diagnosis. immunohistochemical study of androgen receptor and tgf alpha in human benign and malignant prostate a petrescu , g berdan , c ardeleanu , v jinga , s persu prof. dr. th. burghele hospital, bucharest, romania victor babes institute, bucharest, romania aims that androgen receptor(ar)and tgf alpha might be prognostic of hormonal response and biological behaviour in prostate carcinoma. methods ar and tgf alpha were studied in paraffin sections from men ( treated for prostate cancer and for bph by open, transurethral prostatectomy or prostate biopsy) no patient had undergone previous treatment for the prostate disease. the sections were stained with he to establish morphological characteristics (gleason score) and then were studied with indirect immunoperoxidase method applying monoclonal antibodies to ar(f . . biogenex) and antitgf alpha (clone , biogenex). results were semiquantified using histoscore.nuclei were graded for intensity of ar staining ( -absent, -weak, -moderate or strong) and the percentage of these intensity levels and a total intensity score were determined. we compared the ar and tgf alpha characteristics of prostate cancer (pca) with bph. results increasing gleason grade was correlated with decreasing intensity score and greater heterogeneity of ar staining and increased (+++) tgf alpha immunoreactivity. conclusions our data indicate that ar and tgf alpha content could be useful predictors of endocrine response and biologocal behaviour of prostate cancer. and ductus deferens samples), patients in group b were orchiectomised for the diagnosis of prostate cancer, teratocarcinoma of the testis and/or epididymal cyst (normal epididymal and ductus deferens samples) and subjects in group c were treated by radical prostatectomy or cystectomy for prostate or urinary bladder cancer ( samples of seminal vesicles without inflammatory changes). results hpv dna was detected in ( %) of patients in group a (hpv types , , , , , ) , in ( . %) patient in group b(at present unclassified type) and in ( . %) patients in group c(hpv types , and ).neither koilocytes nor dysplastic changes were observed. conclusion our data confirmed the presence of hpv, both lowand high-risk types, in the male genital tract. they support the idea of a male reservoir of hpv infection. spermatogenetic function of the testis in patients of different varicocele grades É magyar , e erdei , i lellei national medical center, pathology, budapest, hungary national medical center, andrology, budapest, hungary introduction varicocele is one of the main reasons of male infertility. surgical repair may improve sperm quality. the aim of this study is to investigate a grading system of varicocele and its correlation with the histological appearance using a multiple biopsy method. materials and methods bilateral double testicular biopsies of young infertile grade - varicocele patients were examined histologically. spermatozoa numbers counted in ten round shaped tubules, severity of atrophy and presence of maturation arrest was recorded. distribution pattern of observed spermatozoa numbers was evaluated. results grade and cases showed normal distribution. in grade cases five peaks were found indicating group inhomogenity. lower grade varicoceles presented with milder histological changes (mild atrophy or normal spermatogenesis) while in higher grade varicoceles more marked alterations (moderate-marked atrophy and/or maturation arrest) were seen. conclusion grade varicocele cases represent an inhomogeneous group, which should be divided into more categories. modification of the grading system is required. spermatogenetic activity of varicocelic patients cannot be predicted from clinico-radiological examinations so before art a diagnostic testicular biopsy is recommended. synchronous double urogenital cancer -a case report s we present a case of synchronous double urogenital cancer, comprised of invasive transitional cell carcinoma of the urinary bladder and adenocarcinoma of the prostate. cystoprostatectomy was performed in a -year-old male patient with previous cytological diagnosis of transitional cell carcinoma of the urinary bladder and no evidence of prostatic malignancy on preoperative clinical investigations. gross analysis of the urinary bladder revealed a cauliflower tumor mass filling the entire lumen and infiltrating the wall of the bladder. the size of the prostate was slightly increased. histological analysis of the urinary bladder specimens showed poorly differentiated transitional cell carcinoma, with only a few foci of preserved papillary architecture, infiltrating deeply into the muscle layer of the bladder wall. the specimens taken from the prostate gland for the purpose of staging of the neoplasm excluded the existence of infiltration of the prostatic urethra with the previously described neoplasm, but foci of moderately differentiated adenocarcinoma (gleason score ) of the prostate were discovered in its vicinity. the subsequent extensive sampling of the prostate showed organ confined adenocarcinoma. the review of the literature showed that the reported prevalence of synchronous existence of double primary malignant neoplasms of the urinary tract (transitional cell carcinoma of the bladder and prostatic adenocarcinoma) varies between % and %. the prevalence is noted to rise with increasing age. this leads to a conclusion that during standard cystoprostatectomy analysis, extensive sampling of the prostate is needed, even in the absence of macroscopic changes and preoperative clinical data suggesting prostatic neoplasm. multiple synchronous renal cell tumors d passetchnik rostov state medical university, rostov on don, russian federation rostov regional hospital , rostov on don, russian federation introduction the use of the nephron-sparing surgery demands detection of multiple renal cell tumors. materials we performed a retrospective analysis of nephrectomies and autopsies performed in our clinic. results of renal cell tumors ( , %) were multifocal. most of the patients were men. twelve cases were present where the histological subtype of the largest tumor was clear cell. satellite tumors were clear cell carcinoma ( ), papillary adenoma ( ), angiomyolipoma ( ), renomedullary fibroma ( ), bellini duct carcinoma ( ) . six multiple renal cell tumors were found in t , two in t , four in t a stage of the primary tumors. four patients had bilateral neoplasms. in thirteen cases only multiple papillary adenomas and carcinomas were found. usually tumors were no more than cm in diameter. in six cases multiple tumors originated on a background of nephrosclerosis of various genesis (chronic pyelonephritis, gouty nephropathy, amyloidosis). conclusion when conservative surgery of kidney cancer is performed, it should be remembered that % of patients with renal cell tumor have multiple neoplasms, which may cause local recurrence. the origin of multiple renal cell tumors may be bound up with hereditary predisposition or nephrosclerosis creating multifocal tumor field. introduction prostate cancer is a leading cause of cancer-related deaths in men and is the most common malignancy in american males. the heterogeneity of prostate cancer defines the current clinical challenges. one challenge is to identify in early, still potentially curable, stages of prostate cancer, molecular markers that predict aggressive or metastatic behavior. prostate cancer is characterized, like many other cancers, by molecular and genetics aberrations involving chromosome . parkin, mapped at the long arm of chromosome , is a amino acid protein with a molecular mass of kda, an ubiquitin-like domain at its amino terminus and two ring finger motifs flanking a cysteine-rich region. our aim was to investigated whether parkin alterations play a role in development and progression of prostate carcinoma materials and methods we examined parkin expression, by western blot analysis in eight prostatic carcinomas derived cell lines as well as in normal prostate, and in three prostatic intraepithelial neoplasias (pin) and in twenty primary prostatic carcinomas by immunohistochemistry. results parkin protein was undetectable in six out of eight prostate cancer cell lines tested and barely detectable in the remaining two whereas normal prostate showed a substantial expression. preliminary results using immunohistochemistry showed that parkin expression was absent in pin lesions, and in the prostatic carcinomas analyzed. conclusion our findings suggest that parkin might be a useful tool to detect early alteration in prostate cancer. the kdr/flk- receptor of vascular endothelial growth factor in urothelial bladder cancer: relation with clinicopathologic parameters and patients' survival introduction the impact of different angiogenic inducers and inhibitors in the switch of angiogenesis in urothelial bladder cancer, is not clarified. kdr/flk- is a receptor-tyrosine kinase that binds specifically vascular endothelial growth factor (vegf) on vascular endothelium, mediating its full biologic spectrum. although kdr/flk- expression was at first reported to be restricted to the classic endothelium there is increasing evidence that kdr/flk- is also expressed by normal and tumor cells other than endothelial. aims: as data about kdr/flk- protein in urothelial bladder cancer is very limited, we investigated its expression in a series of urothelial carcinomas in relation with clinicopathologic parameters and patients' survival. moreover, prompted by studies suggesting that kdr/flk- may have broader functions apart from angiogenesis we evaluated kdr/flk- expression in relation with markers of cellular proliferation and apoptosis (ki- , p , bcl- ). materials and methods immunohistochemistry (abc-hrp) was performed for the detection of kdr/flk- (mouse/a- , sc- , santa cruz), ki- , p and bcl- using monoclonal and polyclonal antibodies. statistical analysis was univariate (pearson's x , mann-whitney test, log-rank test) and multivariate (cox's model). results kdr/flk- expression was observed in the cytoplasm of cancerous cells in / cases. no significant associations were observed between kdr/flk- expression and clinicopathologic parameters, ki- , p and bcl- expressions. on the other hand, widespread kdr/flk- expression in more than % of cancerous cells, was associated with patients' increased survival, in univariate and multivariate analysis (p= . , p= . , respectively). conclusion although non endothelial kdr/flk- expression has not yet been elucidated, its association with better patients' survival may be related with the failure of non-endothelial kdr/flk- to mediate angiogenic and mitogenic effects, that has been reported in some previous in vitro studies. timp- protein expression in relation with cellular proliferation, apoptosis and survival of urothelial bladder cancer patients introduction the role of tissue inhibitors of matrix metalloproteinase (timps) in cancer progression remains a controversial matter since apart from the well established inhibitory action of timps on mmps, several new functions are now attributing to timps such as growth promoting activity, involvement in apoptosis control and in angiogenesis. the aim of this study was to elucidate the role of timp- in urothelial bladder cancer, we investigated its expression in a series of urothelial carcinomas in relation to clinicopathological parameters, patients' survival and the expression of the ki- proliferation index. materials and methods immunohistochemistry (abc-hrp) was performed for the detection of timp- and ki- proteins, using monoclonal and polyclonal antibodies. statistical analysis was univariate and multivariate. results timp- stromal cell expression was observed in / cases and associated significantly with urothelial carcinomas of high histologic grade (p< . ) and advanced stage (p= . ) as well as with poor patients' survival (p= . ). timp- expression in cancerous cells was found in / cases. timp- either stromal or cancerous cell expression correlated significantly with ki- expression (p= . , p= . respectively). conclusion the association of timp- with ki- supports the growth promoting activity of timp- . moreover, timp- expression in stromal cells may be a valuable marker of adverse prognosis in urothelial cancer patients. gleason score is important predictor for differentiation and biological potential of prostate cancer. nodenegative (p n ) prostate cancer is the best result after radical prostatectomy which is indicated in patients with localised prostate cancer. the aim of the study was to analyze gleason score in patients with nodal metastases of prostate cancer (pc). material and methods we analyzed cases of radical prostatectomies due to localised prostate cancer in the period - in clinic of urology in clinical centre of serbia, belgrade. nodal metastases (stage of disease), average age of the patients, grade and gleason score of tumors and premalignant lesions were analysed. immunohistochemical staining was performed and pathological analyzed. we used statistical analysis anova and h test. results the average age of the patients was . years (range - , pick - ). most cases ( %, p< . ) were in pt a n m , in pt b n m ( . %), in pt bn m ( . %), in pt bn m ( . %), in pt an m ( . %). positive nodal status was present in cases: ( %) in pt bn m -iliac (right , left ), obturatory (right l, left ) and cases in pt bn m -iliac left and obturatory ( right and left). we found gleason score in cases ( . %) in pt bn m versus cases ( . %) without nodal metastases. gleason score was found in cases ( . %) in pt bn m versus one case without nodal metastases (p> . ). gleason score was present in . %, in . %, in . %, in . %, in . %. grade tumors were found in cases ( %), grade in ( %), and grade in ( %). hg pin was present in cases ( . %), lg pin in ( . %). conclusion gleason score differ, but not significantly in prostate cancer with nodal metastases. pelvic lymphadenectomy is necessary for staging purposes in prostate cancer. radical prostatectomy is the most adequate method in surgical treatment of localised prostate cancer. immunohistochemical and molecular evaluation of c-erbb gene amplification and c-erbb protein overexpression in prostate cancer the amplification of oncogene c-erbb and overexpression of c-erbb protein found in some human cancers is associated with more aggressive development of tumor. the previous data suggested an independent role of c-erbb protein as a prognostic factor in human breast cancer. however, the role of c-erbb gene and its protein product in prostate cancer cells still remain unclear. the aim of our study is to show what is the role of c-erbb protein in prostate cancer and to examine association between c-erbb gene amplification and its protein product expression in the histologicaly graded prostate tumor. we have analyzed c-erbb gene amplification by rt pcr and c-erbb protein expression by immunohistochemistry in cases of paraffin embedded slides. the tumors were divided according to who by mostofi classification: cases of g -well differentiated cancer; cases of g -moderately differentiated cancer; and cases of g poorly differentiate cancer. these groups are equivalent to - , - and - gleason classification respectively. results the correlation between c-erbb protein expression and well, moderately and poorly differentiated cancer respectively existed (p< . ). there was no significant correlation between c-erbb gene amplification and c-erbb protein expression in all examined groups. our results suggest that the c-erbb protein expression is an independent factor on the c-erbb gene amplification in prostate cancer cells. it is possible that there are other ways, except gene amplification, for overexpression of c-erbb protein in prostate cancer. comparison of needle biopsy and surgical specimen in prostatic carcinoma s nordling, j vasama department of pathology, university of helsinki, helsinki, finland in finland carcinoma of the prostate is the most common form of cancer in men. the number of radical prostatectomies is increasing in most countries. the radical prostatectomy is normally preceeded by a needle biopsy. at the university central hospital of helsinki radical prostatectomies were performed between and . in patients, the preoperative needle biopsy was available. in many cases the preoperative psa value was also available. the mean psa value dropped from to less than ng/ml. the percentage of seminal vesicle invasion dropped from to . except for the earlier years, the men gleason score was about point higher in the radical prostatectomy specimen than in the biopsy. the mean gleason score has increased, while the stage and psa values have decreased indicating that the criteria for the gleason grading has changed ovewr the years. this makes the comparison of treatment results very difficult. introduction distinguishing atypical adenomatous hyperplasia (aah) from small foci of prostatic adenocarcinoma in needle biopsies of the prostate often presents as a challenge for pathologists. the aim of the study was to establish characteristic immunohistochemical patterns in benign and malignant prostatic lesions so they can be used to classify foci of aah as benign or malignant. materials and methods using immunohistochemistry, prostatic needle biopsies from forty-five patients were evaluated for cytokeratin , p and alpha-methylacyl-coa racemase (p s). twenty-five of these biopsies were benign and twenty contained prostatic adenocarcinoma. results % of the benign prostatic biopsies were positive for cytokeratin and p and % were negative for p s. only one case of benign prostatic tissue was focally positive for p s. when evaluating cases with adenocarcinoma % were positive for p s and % were negative for cytokeratin and p . p s immunostain showed consistently positive staining in areas of low and intermediate grade adenocarcinoma and areas with high grade pin. high-grade prostatic adenocarcinoma was frequently negative for p s. sensitivity and specificity for cytokeratin /p were % and % while sensitivity and specificity for p s were % and %. conclusion cytokeratin was as sensitive and as specific as p and can be used interchangeably in cases of aah. the combination of the two antibodies did not improve sensitivity or specificity. a combination of negative cytokeratin or p with positive p s may be helpful in positively identifying prostatic carcinoma in cases of aah. myofibroblastic stromal reaction in prostatic adenocarcinoma introduction reactive stromal changes that occur in different human cancers probably are involved in local tumor spreading and progression. it seems that myofibroblast plays very important role in stromal reaction to certain types of human cancer. we have analyzed prostatic carcinomas in radical prostatectomy specimens to determine the proportion of myofibroblasts around normal and neoplastic acini. myofibroblast showed positive staining for alpha-smooth muscle actin (sma) and vimentin. positive cells were counted in the hot spots areas under high power magnification (hpf). results were expressed as negative (-) for no staining, (+) for positive staining in up to % of stromal cells, (++) in - % of cells and (+++) for more than % of positive cells. stromal blood vessels were counted in ten hpf. the degree of desmoplasia was also analyzed by mallory staining and expressed semiquantitatively as weak, moderate and strong. results and conclusions highly increased number of myofibroblast was observed around neoplastic acini in ( . %) cancer cases, moderate in ( . %) and sparse in ( . %) cases while there were occasional myofibroblastic cells adjacent to normal acini. there was a positive correlation between the degree of stromal desmoplasia and the proportion of sma and vimentin positive cells in adjacent stroma. the number of vessels in the adjacent stroma was also significantly increased in comparison with normal glands (p< . ). it seems that myofibroblasts are present in the stroma and may play a significant role in the desmoplastic stromal reaction in prostatic adenocarcinoma. results among the srcc, ( %) showed no epithelial differentiation, and in the other cases the epithelial component was conventional rcc in cases ( %), papillary ccr in ( %), and chromophobe rcc in ( %). there was no sex predominance and the average patient age at the time of diagnose was years. sixteen cases ( %) presented an advanced stage at the time of diagnose, and ( %) died of disease. the immunohistochemical study showed that cases were positive for c-kit ( . %), diffusely (> % of the sarcomatoid cells positive), moderately ( - % of the cells), and focally (< % of the cells). conclusion the high expression of c-kit in srcc in our series and the existence of target therapy against cells expressing this marker (imatinib (sti- , gleevec, novartis, basel, switzerland) suggests its potential use in the clinical management of these patients in order to improve their prognosis, especially in disseminated cases. does hpv play a role in the development of bladder tcc? a comparison of pcr and immunohistochemical detection methods the role of human papilloma virus (hpv) in the development of bladder carcinomas remains controversial. varying techniques have been used to identify this virus in transitional cell carcinoma (tcc). here we used two different methods to detect the presence of mucosal hpv in tcc samples. the first, immunohistochemistry, involved using a polyclonal antibody that reacts with the l capsid protein of most known papilloma viruses. the second method is used on a general primer-mediated polymerase chain reaction (pcr) assay. this involves using type-specific oligonucleotide probes to identify different mucosal hpv genotypes from a bp pcr product from the l region of the hpv genome. the two methods produced contrasting results, % of the samples were positive for hpv antigen and % were positive for hpv dna. the reason for such conflicting results is that polyclonal antibodies are not specific and are likely to cross react with other antigens. pcr is specific, more sensitive, and it is widely used to detect hpv in a variety of clinical samples. the results obtained in our study implies that hpv does not play a role in the development of bladder carcinoma, and pcr remains to be the best method to detect hpv in tcc. does tgf-α prevent carcinoma spreading? o gladskikh introduction most human carcinomas including prostate cancer are associated with stromal reaction typified by changes in growth factor expression and over-accumulation of extracellular matrix. our study deals with the differential tgf-α production in neoplastic focuses and in adjacent paraneoplastic stroma in prostate. materials and methods tissue samples from radical prostatectomies were examined. to verify malignant material or benign the immunohistochemical staining against high molecular weight cytokeratin was performed on sections and in heterogeneous primary cultures of the same specimens. the immunohistochemical identification of tgf-α was also performed. the elisa technique for quantitative analysis of tgf-α soluble form in culture supernatants was applied. results majority of selected cancer cases were histologically estimated as small-sized glands with large desmoplastic fibromuscular stroma. the immunohistochemical staining for tgf-α in malignant focuses was much more significant than in neighbouring benign areas on sections in contrast to, the cultures obtained from neoplastic or paraneoplastic portions of prostate tissue which stained positively for tgf-α without any difference. considering that immunohistochemistry shows only latent tgf-α we evaluated its bioactive form in culture supernatans. we found dramatically high supernatant levels of active tgf-α in benign cultures compared to the cultures from the malignant areas. conclusion our data demonstrate that desmoplastic alterations in benign areas adjacent to malignant glands was associated with elevated expression of tgf-α active form. so significant alteration in factor production and accompanied tissue remodeling can be considered as a protective reaction of surrounding stroma against tumor invasion. introduction primitive neuroectodermal tumors (pnets) represent a family of neoplasms, of presumed neuroectodermal origin, that mostly presenting as bone or soft tissue masses in the trunk or axial skeleton in adolescents and young adults. the aim of this study was to report a case of pnet arising from kidney which is a rare localization. methods a year-old-man presented with abdominal pain and abdominal mass. the imaging methods revealed a mass nearly replacing the right kidney and he underwent a right nephrectomy. on gross examination the tumor measured cmx cm with cystic areas and necrosis. microscopically, it was a highly cellular neoplasm of consisting sheets of small-round-to-oval cells with irregular nuclei. immunohistochemical stains were positive for vimentin and cd . microscopic and immunohistochemical findings were compatible with pnet. conclusion although rare, pnet must be included in the differential diagnosis of renal tumors especially in children and young adults. we present a case of renal pnet as an unusual case and discuss the differential diagnosis pathologic stage of urinary bladder cancer at presentation in a non-selected patient population in a high-incidence region of the united states introduction most studies of pathologic stage in bladder cancer (ca) are retrospective, using selected, usually hospital-based, patient populations. the aim of this study was to determine the pathologic stage of bladder ca at initial presentation in a nonselected patient population in a high-incidence region of the northeastern united states. materials and methods all patients newly presenting with bladder ca in the state of new hampshire (u.s.a.) from july to december were identified through the state tumor registry. slides were classified according to who and isup criteria. results of cases, were diagnosed as non-malignant or technically inevaluable, leaving ca cases. ( . %) were carcinoma-in-situ (stage tis). ( . %) were papillary, of which ( . %) were low-grade and ( . %) high-grade. of the low-grade cases, only ( . %) were invasive, all limited to lamina propria (stage t ). of the high-grade cases, ( . %) were noninvasive (stage ta), ( . %) invaded lamina propria (stage t ), and ( . %) invaded muscle (stage ). cases ( . %) had no papillary component and all were invasive; ( . %) were stage t and ( . %) were stage t . cases ( . %) were nonurothelial, including squamous cell ca, small cell ca, and adenoca; of these presented as stage t and as stage t . overall, cases ( . %) were invasive (at least t ) at the time of presentation. this population-based series establishes the distribution of bladder tumor stage at initial presentation and documents a smaller percentage of invasive cancers than most hospital-based series the relationship between mitotic index and nucleolar organizer region with histologic grade in transitional cell carcinoma of urinary bladder mr jalali nadoushan, t rezaei nour, n fallah, sk foroutan shahed university, tehran islamic republic of iran background and object transitional cell carcinoma (tcc) of urinary bladder is the second most common cancer of the genitourinary tract, that the prognosis and treatment is related to several parameters such as proliferative cell markers. in this study relationship between two proliferative cell markers: -mitotic index(mi)& -agnor and tumor grade were studied. methods and materials in a cross sectional descriptive study paraffin blocks of patients with tcc of the urinary bladder in the period from to from pathology department of shahid mostafa khomeini hospital, were obtained and from each one micron sections were provided. tumor grade on basis of who/isup grading system, was determined and number of mitosis on tumor cells were counted. in the other section, after one-step silver nitrate staining, the number of nor also on tumoral cells were counted and the mean of it in each cell were determined. results the high grade tumors possessed more agnor per nucleus than did the low grade ones. significant relationship between tumor grade and mi (p= . , rs= . ) and agnor (p= . , rs= . ), and also between mi and agnor (p= . , rs= . ) were found. introduction the human epidermal growth factor receptor (her ) is overexpressed not only in breast, but in a range of other tumor types including, ovarian, salivary gland, endometrial, pancreatic, non-small cell lung (nsclc) and bladder cancer. however, non-standardisation in her status evaluation or population selection has generated conflicting results among the incidences of her expression in individual tumor types and bladder cancer. the aim of the present study was to evaluate her overexpression and gene amplification with standardized routinely performed assays (dako herceptest, fish-vysis, cish) on a selected population of poorly differentiated urothelial carcinomas of the bladder. materials and methods we analyzed formalin-fixed, paraffin embedded tissue samples of urothelial carcinomas of the bladder at g /pt - as well as cases at g / ptis ( )and pta- ( ) using herceptest to verify the her -status. staining and scoring was performed according to the manufacturers instructions. according to diagnosis of her , all herceptest positive ( +) tissue samples were used for further evaluation with fluorescence in situ hybridisation (fish; vysis) and chromogenic in situ hybridisation (cish) to approve the expected gene amplification. this procedure is in agreement with the standardized guidelines for breast cancer. results ( %) cases were considered as her positive ( + and +) in the primary tumor and therefrom cases ( %) + positive and cases ( %) + positive. out of the cases with + positivity, only two cases showed a fish/cish positivity. no polysomy for chromosome was detected. our results indicate that her may not only be a useful prognostic parameter in poorly differentiated invasive bladder cancer, but accurate determination of overexpression and verification of gene amplification may also have therapeutic importance. the prognostic importance of tumor volume (tv), nontumor volume (ntv), tv/ntv, fibronectin distribution, β-hcg and psa expression in localized prostatic adenocarcinoma bh ozdemir, an sar, fp uyar, b demirhan, a dirim baskent university, faculty of medicine, departments of pathology and urology, ankara, turkey aim to assess the importance of fibronectin (fn) distribution, β-hcg and psa expression in localized prostatic adenocarcinomas with regard to tumor volume (tv), non-tumoral volume (ntv), tv/ntv and with other clinicopathological prognostic parameters. material and method fifty-one radical prostatectomies were whole mounted, serially sectioned and examined for tv, ntv, tv/ntv, capsular invasion, vascular invasion, seminal vesicle invasion and gleason score. the fn distribution, β-hcg and psa expression were examined immunohistochemically. a fn-positive staining was defined as a constant diffuse, or pericellular demarcation of fn-positive fibers surrounding tumor cells at the invasive border. in lack of such staining pattern, fn-negative staining was recorded. results both tv and tv/ntv showed very strong positive correlation with grade, capsular invasion, vascular invasion, seminal vesicle invasion, β-hcg and psa expression (p< . ). β-hcg was detected only in cases ( . %). a significant relationship was found between β-hcg expression and grade, capsular invasion, vascular invasion, seminal vesicle invasion, psa expression (p< . ). the fn-positive staining reaction was significantly associated with lower incidence of capsular, and seminal vesicle invasion (p< . ). tv and grade was found higher in tumors with negative fn staining (p< . ). psa expression showed significant relationship with grade, vascular and capsular invasion (p< . ). ntv statistically showed no relationship with all parameters. conclusion these data suggest that, tv, tv/ntv, fn distribution, β-hcg and psa expression in prostatic adenocarcinoma have strong prognostic importance irrespective of gleason score. the fn distribution could be important for the invasion of the tumor cells during cancer progression. these may allow stratification of patients to type of treatment and may allow selection of expectant management for men with localized prostatic adenocarcinoma. neuroendocrine differentiation in prostate cancer: correlation with biochemical failure after radical prostatectomy s cerovic introduction focal neuroendocrine differenatiation (ned) is a commom feature of prostate cancer (pc), occuring in %- % tumors studied. published results of the evaluation of ned as a prognostic factor in pc after radical prostatectomy (rp) have been contradictory. the aim of this study was to correlate ned in pc in relation to biochemical failure after rp. materials and methods radical prostatectomy specimens from pc patients without preoperative hormonal or radiation therapy were followed for to months. neuroendocrine (ne) cells were identified using a panel of immunohistochemical ne markers: chromogranin a, serotonin, and neuron-specific enolase. ned was scored as ne-negative ( to +) or ne-positive ( to +) per hpf. biochemical progression (bp) was defined as a prostate-specific antigen (psa) level greater than . ng/ml in two consecutive measurements. kaplan-meier method was used to estimate bp-free survival time for each risk group. the cox proportional hazards regression analysis was the model for bp time using pathological and clinical variables. results the total of ( %) patients developed bp after rp. the average time for bp was months. the preoperative psa serum level range < ng/ml in % of the patients. postoperative staging confirmed that ( %) of patients had pt stage and ( %) of patients had pt stage. ned demonstrated in the ( %) pc patient with bp. the average time for bp was months. tumor volume (p< . ), pathological stage (p < . ), tertiary gleason grade (p= . ) and nedf (p< . ) significantly affect the level of postoperative psa progression. conclusion the expression of ned in pc correlates with tumor volume and tertiary gleason grade and represents an independent prognostic factor of bp after rp. expression of vascular endothelial growth factor (vegf) and correlation with microvessel density in benign hyperplasia and prostate carcinoma nj aim the present study is scheduled to evaluate the levels of vegf expression in benign prostatic hyperplasia (bph) and prostate carcinoma and to correlate them with angiogenesis. material and method formalin-fixed, paraffin-embedded tissue sections from patients who underwent radical prostatectomy or transurethral resection of the prostate were studied. our material consisted of cases of bph and cases of prostate carcinoma. microvessel density (mvd), as determined by cd , and expression of vegf were investigated by immunohistochemistry using the monoclonal antibodies cd (dako) and vegf (neomarkers), respectively. results expression of vegf was detected in / ( , %) cases of bph and in all ( %) invasive prostate carcinomas. cytoplasmic immunoreactivity for vegf was detected in epithelial and stromal cells. vegf expression was stronger in carcinomas, when compared to bph (p< . ), while it was minimal to absent in normal adjacent prostate tissue. a positive correlation between vegf expression and gleason score was found (p< . ). microvessel density (mvd) was higher in bph and prostate carcinomas, when compared to normal adjacent prostate tissue. a statistically significant association was noted between vegf and mvd expression (p< . ). our results indicate that generation of new capillary blood vessels begins in bph and keeps progressing in invasive prostate carcinoma. vegf seems to be a key functional regulator of angiogenesis in the prostate gland. the relationship between histologic grade and abo blood groups in transitional cell carcinoma of the urinary bladder b mofid , mr jalali nadoushan shahid beheshti university of medical sciences, tehran, islamic republic of iran shahed university, tehran, islamic republic of iran introduction according to the statistics of , the urinary bladder cancer is the fifth common cancer in iran. the majority of urinary bladder tumors are transitional cell carcinomas. different factors are effective in the prognosis of these patients. one of these factors is the histologic grade. another factor is to determine the abo blood groups and the relationship of it with the histologic grade. thus, this study is conducted to shed some lights on this issue. materials and methods a cross sectional study was conducted in patients with urinary bladder transitional cell carcinoma during - . results of patients, were female ( . %) and were male( . %). the mean age of patients was . +/- . there was no significant statistical relationship between of histologic grade and abo blood groups. there was no significant differences between the abo blood groups frequency in patients with urinary bladder transitional cell carcinoma and general population. conclusion although the existing differences between asian, european and american studies might be due to racial effects, it is better to carry out more studies in this respect in order to comment in this area with more confidence and certainty. introduction a variable degree of mucin secretion may be present in prostatic carcinoma (pc), but true mucinous tumors are rare. prostatic mucinous carcinoma (pmc) is a variant of high-grade adenocarcinoma, with a . % rate of prostate-specific antigen (psa) elevation and a similar rate of response to endocrine therapy. the aim of this study was to report on a case of pmc with signet ring cells treated with radical prostatectomy (rp). materials and methods a -year-old man presented with acute urinary retention and long history of difficult voiding. the serum psa was . ng/ml. the transperineal biopsy of the prostate gland was done and the histology showed a poorly differentiated pc with large lakes of extracellular mucins. isotope bone scan was normal and a ct-scan did not show evidence of extracapsular spread of the tumour. radical prostatectomy was performed. patient died seven month after rp. results histopathologically, over % of the prostate samples were infiltrated by a poorly differentiated pc with mucinous and signet ring patterns. mucin secretion is evident as large pools of mucin and periodic-acid-schiff-positive diastase-resistant intraluminal and citoplasmic globules. immunohistochemical staining for psa and prostate-specific-acid phosphatase was positive, and negative for carcinoembryonic antigen and cytokeratin . conclusion the diagnosis of pmc with signet ring cells requires exclusion of an extra-prostatic origin, mainly within digestive tract. since only small number of mpc cases treated with rp have been reported, treatment and prognosis of this tumour remain unclear. introduction cd is a well-known marker for hematolymphoid neoplasms and is expressed as well in various nonhematopoietic tissues and solid tumors. a systematic study of cd expression in tgcts, however, is lacking. the aim of this study was to investigate the immunoreactivity for cd in the different patterns of tgcts. material and methods immunostaining with mab against cd (clone c ) in unselected cases of primary ( cases: classical seminoma (cs); pure embryonal carcinoma (ec); mixed-non-seminomas; spermatocytic seminoma (ss) and metastatic ( cases) tgcts. in mixed tumors, the different histological patterns were evaluated separately. results cd was expressed in ( %) out of cases in the cs component, in ( %) of teratomas, in ( %) of endodermal sinus tumors (est), in ( %) of cases of choriocarcinoma (chc) or syncytiotrophoblastic giant cells (stgc) and in ( %) of ec. cd was focally positive in ( %) of cases of intratubular germ cell neoplasia (itgcn) and was negative in one ss. conclusions except for ec and ss, cd is expressed in the majority of histological types of primary and metastatic tgcts. cd is useful to highlight minute foci of est, chc or stgc in ec. a tgct is to be taken into account in the differential diagnosis of a cd positive metastatic tumor of unknown origin. further studies are needed to evaluate the eventual significance of cd as a prognostic factor or as a potential therapeutic target in tgcts. introduction it is generally accepted that the prognosis of renal cell carcinoma (rcc) differs according to the histological type, and, whatever the histological type, the tumor stage and nuclear grade are considered the main prognostic factors. however, in many cases of conventional renal cell carcinomas (crcc), these parameters are insufficient to predict the clinical behaviour of these tumors. therefore, several studies have focused on the evaluation of new markers. the cd proteins form a broadly distributed family of cell surface adhesion molecules involved in cell-cell and cell-matrix interactions. de novo expression of cd s and its variant isoforms has been associated with aggressive behaviour in various tumours. the aim of this study was to analyse the prognostic value of cd s and cd v in renal cell carcinoma. materials and methods the expression of cd s and cd v was immunohistochemically evaluated on rcc: were crcc, papillary, cromophobe and collecting duct carcinoma. the expression was compared to usual clinicopathological parameters. results in normal renal tissue no staining was observed. the cd s molecule was upregulated in crcc ( %), papillary, one cromophobe and collecting duct carcinoma. only tumors were focally cd v positive. the statistical analysis showed the correlation between cd s expression and fuhrman nuclear grade (p< , ) as well as ki proliferative index (p< , ). conclusion the expression of cd s molecule appears to mediate a more agressive phenotype to rcc. amplification of cerbb expression in bone metastasis of prostatic cancer: a pilot immunohistochemical and cytogenetic study introduction her- -neu expression is reported to increase in androgen-independent prostatic cancer. consequently, it has been suggested that trastuzumab, an antibody targeting the extracellular domain of her- , could be used in this setting. the possibility of assessing her- expression by immunohistochemistry could be used as a rationale for the treatment of advanced cases with this drug. the aim of this study was to assess whether her- expression is increased in bone metastases of prostatic cancer compared to the respective primitive tumors, and to determine whether this overexpression could be related to gene amplification. materials and methods in this pilot study, primary tumor needle biopsies and bone metastases from patients diagnosed with prostatic cancer were immunostained wit c-erb-b antibody (dako, glostrup, denmark), and the results scored using a threetiered system. in addition, in a bone marrow sample from one of the cases, her gene amplification was investigated using fish. results there was a significant increase in her- expression in four cases, with the same level of expression in primary and metastatic tumors in the remaining three patients. in addition, fish showed no amplification of her gene. conclusion her- overexpression is not a constant event in prostate cancer metastatic to bone. preliminary evidence suggests that in cases with overexpression, it is not related to gene amplification. a larger study will be required, however, to definitively determine the real therapeutic meaning of these findings. introduction sgs are known to occur in association with a variety of hematologic and solid neoplasms. concerning rcc-associated sgs, only isolated case reports have been published. the aim of this study was to disclose the prevalence and clinical significance of sgs in a series of rccs from a single institution. clinicopathologic review of consecutive cases of rcc surgically treated at the hub between january- and march- . immunohistochemical staining with cd , panb and pant antibodies. results sgs were seen in cases, both within the tumor and/or in the nontumor tissue nearby. patients were females and males aged to (median ) years. tumors were conventional clear cell rccs and chromophobe rccs. there were pt , one pt and one pt b. two tumors were fuhrman grade and were grade . in each case, the lymphocytes in the sgs were predominantly t cells. one patient was already known to have a crest syndrome. in another one sarcoidosis was subsequently diagnosed. in the remaining no systemic disease has been found to date. conclusions sgs are found in about . % of rccs. morphology and immunohistochemistry allow no distinction between local sarcoid-like reactions and sarcoidosis. the clinical profile of the patients and the pathologic features of the tumors are not different from those of rccs unassociated with sgs. the finding of tumorassociated sgs must be reported to the clinicians in order to rule out a systemic granulomatous disease, thus avoiding misinterpretation of clinical symptoms or overstaging of tumors. metanephric adenoma in the kidney coexistent with paraganglioma in the bladder: a case report s seckin, i paker ankara numune teaching and education hospital, department of pathology, ankara, turkey we report a case of metanephric adenoma in the kidney and paraganglioma in the bladder in a year-old woman. the patient presented with hematuria. abdominal usg and bt revealed a mass in the lower pole of the kidney and in the posterior wall of the bladder. left nephrectomy and transurethral resection of the mass in the bladder were performed. the tumor in the kidney which measured x x cm. had a yellow to white cut-surface and welldefined margin. histological examination demonstrated a monomorphous population of small cells with bland cytology arranged generally in tubular and occasionally in papillary structures. no atypia and mitotic activity were present. immunohistochemically tumor was diffusely positive for ema, focally positive for pancytokeratin and negative for vimentin. the tumor in the bladder was characterized by well-defined nests of cuboidal cells with granular cytoplasm which were seperated by highly vascularized fibrous septa. sustentacular cells were demonstrated with anti-s protein immunohistochemically. we didn't encounter the coexistence of these two tumors in the literature. we think that it is a coinsidence. co-occurrence of extra-adrenal myelolipoma, renal cell carcinoma and thymoma -a case report k steplewska, d sabat, w zajecki department of pathomorphology, medical university of silesia, zabrze, poland a case of never reported in literature of co-occurrence of a very rare tumour -extra-adrenal myelolipoma (eaml) with two other neoplasms, was presented in the report. -year man after a short hospital stay due to heart ischaemic disease died with the symptoms of acute circulatory insufficiency. an autopsy, which confirmed clinical diagnosis, was performed. a tumour of the size x x cm, which compressed the heart and aorta, was found during the mediastinum autopsy. the tumour was covered with a sack, lobular, gray and beige at the cross-section with blood extravasation, necrosis foci and calcifications (histopathologic result -medullary thymoma). the compressed heart was moved to the middle, right side of the chest. in the adipose capsule of the left kidney, near the lower pole, an encapsulated solid fatty tumour of the size x x cm was found. the tumour was connected to the kidney. histopathologic result -myelolipoma. the tumour was composed of fat cells with normal marrow hematopoietic elements including megakaryocytes. the third tumour, cm of diameter, was found on the front surface of the right kidney (histopathologic result -multilocular cystic clear cell, renal cell carcinoma). none of the tumours was diagnosed during the patient's life. signet ring cell carcinoma of the prostate: pathologic and immunohistochemical analysis of two cases m kowanski, t zabkowski military medical institiute, warsaw, poland introduction signet ring cell carcinoma of the prostate is extremely rare and was first described by giltman in . to date, there have been cases reported in the literature. we evaluated two cases formaline fixed paraffine embedded tissue by histochemical (mucicarmine, alcian blue) and immunohistochemical methods (psa, psap) to confirm our histological diagnosis. results both our cases were high grade adenocarcinomas gleason score ( + ) and were positive for psa and psap. one case contain a small amount of acid mucin, but both were negative for neutral mucin. the combined results from our and from previously reported cases: psa positive in . % ( / ), mucicarmine stain positive in . % ( / ) and alcian blue stain positive in . % ( / ) of cases. conclusion signet ring cell carcinoma is variant of high grade adenocarcinoma of the prostate but results of histochemical and immunohistochemical staining are variable. the isup classification of urothelial tumors was followed by a modified who classification in . the purpose of this study has been to assess the value of both systems in the prediction of progression, in a large series of cases with detailed follow-up. material and methods "superficial" (pta + pt ) urinary bladder tumors are the subject of this work. all tumors were reassessed strictly adhering to published criteria. progression (increased grade or stage) was used as the end-point. results with a relative risk (rr) of for g , progression rr for g was . ( . - . ) and for g . ( . - . ) (p< . ). with a risk of for pta, rr for pt was . ( . - . ) and for pt . ( . - . ) (p< . ). when combining grade and stage, rr for pta (g + ) was . ( . - . ) and for pt (g + ) was . ( . - . ) (p< . ). conclusions strictly adhering to the who grading and staging criteria, both systems result in a very efficient prediction of progression of urothelial carcinoma. grouping g and g into a single high grade category does not improve these results. "superficial" infiltration (pt ) introduces a relevant risk of progression when restrictively identified, thus suggesting that pt should not be lumped with pta for therapeutic purposes. neuroendocrine expression in prostate cancer l velickovic , v katic , v savic , b djordjevic , s zivkovic institute of pathology, nis, serbia and montenegro military hospital, department of surgery, nis, serbia and montenegro introduction presence of neuroendocrine (ne) cells that are suggested to be important regulators of cell growth and differentiation represents uncommon finding in benign and neoplastic prostate epithelium. in order to correlate cellular expression with histological differentiation in benign epithelium and primary prostate cancer, expression of chromogranin a (cga) had been determined. materials and methods he and immunohistochemical analysis with antibody against cga was performed in order to determine the coexistence of ne differentiation in tissues of twelve patients with prostatic adenocarcinoma (pc). results ne differentiation was found in ( , %) tumors. among them, ( , %) had cga positive cells scattered or focally distributed, ( %) intermediated and intensive. there was a significant correlation between the extent of ne features and gleason score (p< , ). these data support the concept that ne differentiation in human prostate cancer has a positive correlation with histological differentiation, i.e. patients with gleason score > had higher cellular expression of cga. the p retinoblatoma gene protein and p expression in transitional cell tumors s ramón y cajal , c corbacho , v fernández, j guinea, c parada, r sánchez hospital vall d´hebron, madrid, spain clínica puerta de hierro. madrid, spain background the retinoblastoma family of proteins (p , p and p ) are implicated in cell cycle regulation, differentiation and apoptosis. p (retinoblastoma supressor gene) alterations seem to be correlated with worse prognosis in urothelial neoplasms, and the status of the other two proteins has been less studied. p mutations are usually associated with intranuclear accumulation of p protein, and have also been correlated with worse prognosis in urothelial neoplasms. design formalin-fixed, paraffin-embedded archival tissue from low-grade and high-grade transitional tumors was immunostained with polyclonal and monoclonal antibodies against the retinoblastoma family of proteins, and with monoclonal antibody against p protein. the avidin-biotin-peroxidase (abc) method was utilized with every antibody (dako, clone rb for p ; santa cruz, clone sc- for p ; santa cruz, clone sc- for p and dako, clone do- for p ). immunostaining was scored quantitatively by pathologists, following previously described criteria, to study p , p and p . nuclear and/or cytoplasmic location was determined by pathologists to study p . results p expression: among low-grade tumors, ( . %) showed nuclear positivity and ( . %) showed a granular cytoplasmic pattern of staining. among high-grade tumors, ( . %) showed nuclear expression and ( . %) showed a granular pattern of staining. p expression: among low-grade tumors, ( . %) showed positivity and among high-grade tumors, ( . %) stained positively. we found no stadistically significative differences regarding p and p immunohistochemical stainings. conclusion due to granular cytoplasmic pattern of staining for p is more frequent among high-grade transitional neoplasms, we propose that p granular cytoplasmic immunohistochemical pattern of staining may be considered a marker of tumor progression in transitional cell tumors. the prognostic value of p cytoplasmic positivity among low grade cases, as well as the prognosis of tumors with p overexpression and p granular cytoplasmic pattern will be discussed. are there any relationship between bellini duct carcinoma and urothelial cell carcinoma? ( ) aexudative -at , productive -at , and mixed -at ., from them ( ) infiltrative -at and destructive -at patients, aexudative type of inflammation was also diagnosed at patients with nonspecific defeat of prostata. patomorfological data's not always can help in diagnostic of tuberculosis of prostate it ties with patomorfose of tuberculosis under influence of treatment. cancerogenesis in prostate: ploidometric differential diagnostics avtandilov background the problem of unification in diagnostics of various prostate tumours and tumour-like lesions has gained a special significance in the modern oncology. aim: use the ploidometry research for studying the epithelial cell clones in the prostate, forming the different stages of cancerogenesis. methods computer ploidometry test was carried out for nuclei of epithelial cells in biopsy specimen of the prostate, taken from patients in different stages of cancerogenesis. histological preparations of micron thickness, stained by feulgen's technique, were subject of the research. nuclei's ploidy was defined by means of the computer image analyzer "imager-ch" ("avtan-san" software version). the integral brightness of nuclei of small lymphocytes, found in histological sections, was tested to define the "tissue ploidy standard" ( c), which, in its turn, was used for obtaining the data on ploidy of epithelial cell nuclei of the prostate gland. inter-phase cell nuclei of clones with normal and hyperplastic prostate gland, areas of prostate intraepithelial neoplasia (pin-i-low grade -and pin-ii-high grade) and adenocarcinoma in different stages of dedifferentiation (well, moderate, poorly) were the subjects of investigation. the research determined that while the cancerogenesis progressed, the proliferative activity (indirect type information) of prostate gland cells and the ploidy of nuclei naturally increased. introduction calcitriol and its analogues affect function of several normal and neoplastic cells, including cells of medullary thyroid carcinoma originating from parafollicular cells. in the cells expression of calcitonin gene takes place, yielding due to alternative splicing calcitonin (ct) and calcitonin gene related peptide (cgrp). the aim of this study was examination of effects of calcitriol and of its two analogues, pri- and pri- on proliferation of two cell lines in vitro and on expression of calcitonin gene. the studies were performed on mtc - (rat cell line) and tt (human cell line) cells originating from medullary thyroid carcinomas. the cells were cultured with calcitriol or its analogues at (- ) to (- )m for days. the estimated variables included: cell number, proliferation-associated antigens (ki- , pcna), ct and cgrp levels in medium (ria), amounts of the two hormones and of their mrnas in the cells (immunocytochemistry or hydridocytochemistry accompanied by image analysis). results calcitriol and its analogues exerted low antiproliferative effect, more evident in mtc than in tt cells. pri- affected production and secretion of the two hormones. evident correlation was noted in tt cells, positive for ct and negative one for cgrp. in mtc cells, the effect was slightly less intense. pri- exerted a similar effect in the two cell lines but only at higher concentrations of the analogue. on the other hand, calcitriol manifested its activity only in mtc cells. effects of studied substances were also examined on cgrp/ct ratio of secreted hormones, which reflected corresponding ratio of alternative splicing of ct gene transcript. in tt cells the ratio decreased in presence of either analogue and in mtc cells the effect was observed following culture with calcitriol and the two analogues. conclusions calcitriol and its analogues exert a weak antiproliferative effect and an effect on alternative splicing of calcitonin gene. allelotyping analysis of gep endocrine tumors mixed medullary-papillary carcinomas are rare neoplasms and must be distinguished from medullary carcinoma with entrapped follicles, papillary variant of medullary carcinoma and solid growth pattern of sclerosing variant of papillary carcinoma. these mixed tumors could arise from uncommited stem cells; it is also possible that these neoplasms could be collision tumors. the aim of our study was to show that these mixed tumors have some particular features. we studied cases of thyroid carcinoma and for diagnosis we used immunohistochemical analyses for thyroglobulin, calcitonin, cea, chromogranin and cytokeratin . we found cases of mixed medullary-papillary carcinoma. these mixed tumors are not so frequent but the admixture of papillary and medullary components confer a different prognosis and a potential response to radioactive iodine treatment. results only four hereditary ( / ) tumours showed genomic imbalances. mtc appeared as sporadic forms. in of the sporadic tumours we detected dna sequence copy number changes (mean: per tumour, range: - ). the minimal common regions for the most frequent gains were narrowed down to q -q , p , and q ( percent), q -q , p , and q ( percent), p -p , p . -p , and q ( percent), and p pter, q -q , and p . -p ( percent). eight high-level amplifications were observed in four samples. p was affected twice. the minimal common regions for the most frequent losses were observed for p ( percent), and q ( percent). conclusion only limited genomic alterations could be detected by cgh for hereditary mtc, which share a germline mutation of the ret proto-oncogene as initial step of cancerization. additional genetic alterations, which are responsible for the progression of these tumours, are not identified yet. in contrast, sporadic mtc revealed a recurrent pattern of genomic imbalances. our data are in accordance in part with the few cytogenetic data, which are reported in the literature and can help to rule out parts of the genome on which further studies should focus on. immunohistochemical analysis of tumor infiltrating immunocytes in thyroid tumors v zolota, p aroukatos, s sidira, d koumoundourou, d papachristou, cd scopa dept. pathology, univ. patras med. school, patras, greece introduction the presence of host inflammatory cells within or at the periphery of human tumors has long been recognized and is commonly viewed as representing a host tumor immune response. in the thyroid gland, the occurrence of chronic lymphocytic thyroiditis (clt) in thyroid cancers has been reported and considered by some authors as a favorable prognostic sign. the inflammatory cell population in consecutive thyroid tumors ( papillary, occult, follicular, myeloid carcinomas and follicular adenomas), accompanied with chronic non-specific thyroiditis, were characterized imunohistochemically, using a panel of monoclonal antibodies against t-cells (anti-cd , anti-cd , anti-cd ), b-cells (anti-cd ), macrophages (anti-cd ) and dendritic cells (anti-s- ). the extent of lymphocytic infiltration was graded as: +(subtle), ++(moderate) and +++(intense and diffuse lymphoid aggregates). results were similar in cell block, although involucrine was negative in three pc. expression of mib- and p is variably detected in benign and malignant proliferative lesions. interestingly, galectin- , ck- and involucrin are invariably detected in papillary carcinomas, although heterogeneous positive expression was observed into the same lesion. conclusions our findings show that galectin- (p< . ), ck- (p< . ) and involucrin(p< . ) are useful to identify papillary carcinoma from other thyroid lesions; however, heterogeneous positive pattern expression is not useful for preoperative diagnostic of conventional cytology. introduction pheochromocytomas are rare neuroendocrine tumors that are highly vascular. their malignancy is extremely difficult to estimate on the basis of histopathological features. vascular endothelial growth factor receptor (vegfr- ) is a marker for lymphatic endothelium. its ligands vegf-c and vegf-d are expressed in many neuroendocrine tissues. our aim was to investigate the expression and the potential role of vegf-c, vegf-d, and vegfr- in various pheochromocytomas. materials and methods thirty-three pheochromocytomas, six of them metastasized, were studied using immunohistochemistry. thirteen tumors exhibited histologically suspicious features, such as necrosis, mitosis count over / hpf, vascular or capsular invasion, but they not metastasized, and were thus called borderline tumors. results and conclusions vegf-c immunohistochemical positivity was found in most pheochromocytomas. the expression of vegf-c was heterogenous and varied also within different tumor groups (benign, borderline, and malignant tumors). however, it tended to be stronger in extraadrenally located tumors. vegf-d positivity was also found in most tumors studied ( / ). interestingly, all malignant tumors (n = ) were totally negative for vegf-d. vegfr- expression was found in out of tumors, but the staining was mostly weak. the expression of vegfr- did not seem to correlate with the expression of vegf-c or vegf-d. in conclusion, vegf-c, vegf-d, and vegfr- are expressed in various pheochromocytomas, however, the diagnostic value of these markers needs further investigations. mixed corticomedullary tumor of the adrenal gland. a case report corticomedullary mixed tumors of the adrenal gland are quite rare, with only seven well-documented cases reported in the literature. we report the light microscope and immunohistochemical features of one case of this rare tumor. the patient is a -year-old woman who presented with hypertension, hirsutism, gain weight and ammenorhoea of -month duration. the surgically resected specimen consisted of a well-circumscribed, single adrenal mass, weighing , gr, and mm in diameter, surrounded by a rim of uninvolved adrenal cortical tissue. paraffin-embedded cut sections were stained by both hematoxylin-eosin and pas.the expression of inhibin, melan a, chromogranin a, synaptophysin, s- protein and acth was examined using the pap method, with appropriate antibodies being applied. the tumor was composed of cords and nodules of adrenal cortical cells intimately admixed with pheochromocytes. immunohistochemical investigations highlighted these two cellular components. the adrenal cortical cells revealed inhibin and melan a immunopositivity, whereas the pheochromocytes were strongly reactive with chromogranin a, synaptophysin, and acth, and the sustentacular cells with s- protein. thus, we report one additional case of mixed corticomedullary tumor of the adrenal gland. introduction the study of apoptotic markers seems to be important in understanding the pathogenesis of chronic inflammatory processes of the thyroid gland. aim: intensity determinations of bcl- and fas immunohistochemical reactions with the quantitative assessment of bcl- and fas gene expressions in inflammatory affected thyroid glands. the specimens were taken from women aged to . the type of inflammation and the intensity of lymphocytic infiltration were assessed according to the mizukami and the waterhouse and doniach classifications, respectively. the expression of bcl- and fas antigens was determined immunohistochemically. moreover, bcl- and fas genes were quantitatively analysed by rt-pcr assay using taqman technology. results intensity of immunostaining for bcl- antigen in patients with chronic thyroiditis was stronger than in patients without lymphocytic infiltration. an increase in the intensity of lymphocytic infiltration did not affect bcl- mrna levels. fas antigen got stained in subjects with mixed inflammation; a presence of oxyphilic cells enhanced the stain reaction. in the case of oxyphilic thyroiditis, the changes in fas antigen were accompanied by a concomitant increase of fas mrna levels. small differences, between various samples of the same specimen, in bcl- and fas mrna and protein levels were found in patients with focal thyroiditis. these differences were related to the intensity of lymphocytic infiltration. conclusions the thyroid gland is characterised by a high degree of antiapoptotic activity. each type of thyroiditis has its own characteristic pattern of bcl- and fas expressed as mrna and as protein. the use of galectin- and cytokeratin in differential diagnosis of thyroid tumors with follicular growth pattern a ryska aim to study the use of galectin- (gal) and cytokeratin (ck ) in differential diagnostics of thyroid tumors with follicular growth pattern. material and methods a series of thyroid lesions ( follicular adenomas (fa), follicular carcinomas (fc), follicular variants of papillary carcinoma (fvpc)) was studied retrospectively by immunohistochemistry using monoclonal antibodies. results the staining intensity of either antibody was evaluated as positive or negative using different thresholds ( , and % of positive cells). generally, the intensity of staining of gal was much higher than that of ck . using % threshold, / fa showed positivity of gal and none was positive in ck . in fc, / tumors were gal positive, / were also ck positive. among fvpc, all cases were gal positive and / were also ck positive. using % threshold, only / fa was gal positive, none was ck positive. among fc, however, all tumors were both gal and ck negative. on the other hand, / of fvpc were gal positive and / were ck positive. the sensitivity, specificity, negative and positive predictive value of gal were . ; . ; . ; . for % threshold and . ; . ; . ; . for % threshold, respectively. for ck it was . ; . ; . ; . for % threshold and . ; . ; . ; . for % threshold, respectively. conclusions the use of gal and ck may be helpful in differentiating fvpc from benign lesions. however, the use of these markers in differential diagnostics of fc from fa is of little value. moreover, due to low intensity of staining, its use in preoperative diagnostics (e.g. in fnac cytoblock specimens) seems to be questionable. adrenal cortical adenoma in association with cushing's syndrome -case report introduction morphological feature of adrenal cortical adenoma by itself doesn't allow reliable distinction between tumors associated with any particular endocrine syndrome. without being aware of the clinical setting and/or endocrinological data, it may be impossible to distinguish them from an incidental nonhyperfunctional macronodule. the aim of this investigation was to represent the only case of adrenal cortical adenoma in association with cushing's syndrome in our material. we have analyzed the only case of adrenal cortical adenoma with cushing's syndrome according to its morphological changes, laboratory data, ct-scan as well as mri of adrenal gland. results gross examination showed a small ovoid adenoma. on section, it appeared yellow to golden yellow with dark brown foci, blood and degenerative changes. microscopically, tumor contained cells with pale, lipid-rich cytoplasm, compact eosinophilic cytoplasm, arranged in trabeculae, short blunt cords, as well as in rounded nests. nuclei were somewhat vesicular with a single small dot-like darkly stained nucleolus. discussion and conclusion our data indicate that being aware of characteristic histologic feature in terms of architectural pattern and cell type for cortical adenoma associated with cushing's syndrome, this could be the purpose of more comprehensive discussion. correlation of histopathology and sequential analysis of gene expression in follicular thyroid neoplasms sj diaz-cano , , s arif , a blanes barts and the london school of medicine, university of london, uk university of malaga school of medicine, malaga, spain background the expression profile and diagnostic relevance of nuclear features, inflammation, and stromal changes have not been systematically evaluated in follicular thyroid carcinomas (ftc). design we selected ft neoplasms ( adenomas, minimally invasive carcinomas, widely invasive carcinomas, and anaplastic carcinomas), classified using standard criteria. histological variables including anisokaryosis, chromatin pattern, nucleolus, nuclear pleomorphism, nuclear/cytoplasmic ratio, necrosis, stromal changes, and tumor interstitial lymphocytes (til) were studied by histological diagnosis (significant if p< . ). oligo(dt)-primed double strand cdna was produced from total rna, and libraries were produced from normal thyroids and ftc. sequential analysis of gene expression (sage) was performed (ftc/control expression factor≥ , significance≤ . ). results til were absent in / neoplasms. minimally invasive carcinomas were distinguished from adenomas by conspicuous nucleolus, increased nuclear/cytoplasmic ratio, and coexistence of apoptosis and myxoid changes in adenomas. the most specific variables of high-grade carcinoma were coagulative necrosis, and nuclear hyperchromatism and pleomorphism. ftc sage showed ubiquitin c and sequestosome down-regulation, and tumor protein translationally controlled and malate dehydrogenase up-regulation. this sage profile correlated negatively with proinflammatory molecules expression (interleukin- beta, chemokine xc-receptor , interferon-induced transmembrane protein , protein tyrosine phosphatase c), brca , and protein phosphatase . the correlation was positive with proliferation markers (myb, mitogenactivated protein kinase , cyclin-dependent kinase , brca /cdkn a interacting protein, and ras oncogene family). conclusions proliferation up-regulation and apoptosis downregulation results in prominent nucleolus and high nuclear/ cytoplasmic ratio for low-grade carcinomas and hyperchromatism and nuclear pleomorphism for high-grade carcinomas. tumor down-regulation of proinflammatory molecules explains til absence. papillary carcinoma of the thyroid with bone formation. a case report introduction papillary carcinoma is by far the most common type of thyroid malignancy. however, ossification in papillary carcinoma is very rare. a case of papillary carcinoma of the thyroid metastatic to cervical and supraclavicular lymph nodes with associated bone formation and extensive calcification is presented. case report a year-old male with a history of gastric carcinoma was admitted to hospital presenting with lumbal pain. a computed tomography scan revealed a calcified nodule, measuring in mm diameter in the thyroid. total thyroidectomy and modified neck dissection were performed. the thyroidectomy specimen showed a well circumscribed, calcified, rock-hard nodule measuring x x cm. histologic examination of the hard nodule after decalcification showed spicules of bone formation and papillary carcinoma. foci of metastatic papillary carcinoma with bone formation were also seen in the cervical and supraclavicular lymph nodes. there was also bone marrow formation both in the thyroid nodule and in the metastatic lymph nodes. immunohistochemically, the tumour cells were positive for thyroglobulin. conclusion ossification in papillary carcinoma of the thyroid is an unusual finding. the mechanism of bone formation is not clear. the presence of ossification both in primary and metastatic tumoral masses suggests that ossification is not a dystrophic process in the preexisting benign thyroid tissue but somehow related to the papillary carcinoma in the present case. introduction c-kit gene encodes for a transmembrane tyrosine kinase receptor which is expressed in a variety of human normal tissues and malignancies, being small cell lung carcinoma one of the most frequent among the latter group. the search for c-kit expression in human tumors bears clinical implications since several tyrosine kinase inhibitors have been proposed in the treatment of c-kit positive tumors. the aim of our study was to investigate c-kit protein expression in a series of merkel cell carcinomas (mcc) and of other extrapulmonary poorly differentiated neuroendocrine carcinomas (pdnecs). merkel cell carcinomas (mcc) of the skin (from patients, of them with follow up information available), and cases of extrapulmonary pdnecs from different sites (bladder - cases, colon - cases, gallbladder and pancreas - cases, parotid - case) were analyzed by means of immunohistochemistry for c-kit protein expression. only a membranous staining was considered specific, and scored according to the percentage of positive cells. results c-kit protein was demonstrated in / ( %) mcc, and in / ( %) of other pdnecs. in mcc, a correlation, slightly below statistical significance (p= . ), was observed between the presence of c-kit expression and clinically aggressive behaviour. conclusion our data indicate that c-kit expression may play a role in the growth regulation of extrapulmonary pdnecs. therefore this group of tumors may be considered as a possible target for tyrosine kinase inhibitors therapy. carcinoid tumors in the thyroid gland. primary or metastatic? report of two cases m volante , m bongiovanni , p filosso , g bussolati , m papotti dept. biomedical science and human oncology university of turin, turin, italy dept. thoracic surgery university of turin, turin, italy introduction the occurrence of well differentiated endocrine tumors (carcinoid) in the thyroid gland is unfrequent and may represent both a differential diagnostic problem with medullary carcinoma, and a potential pitfall in the searching for its primary or metastatic origin. our aim was to determine the differential morphological and immunohistochemical profile of two cases of carcinoid tumors localized in the thyroid -one metastatic from the lung, and the other of unknown origin. materials and methods the first collected case had a clinical history of an atypical lung carcinoid diagnosed two years before, while the other lacked a clinical, instrumental and laboratory history suggestive of a possible primary carcinoid elsewhere. paraffin embedded material was histologically reviewed and analyzed by immunohistochemistry for thyroglobulin, calcitonin, cea, chromogranin a, s- , ttf , and ki- . results the first case (f/ ) presented as multiple nodules in both lobes, composed of poligonal eosinophilic cells arranged in the typical organoid pattern. foci of necrosis were present. the morphological features overlapped with those of the primary lung tumor. the second case (m/ ) presented as a single nodule in the left lobe, morphologically resembling typical carcinoid without necrosis. both cases were negative for thyroglobulin, calcitonin, s- and cea, positive for chromogranin a and ttf , and low proliferating (ki- < % in both). conclusion our data suggest that, even in the absence of a clinically detected primary tumor, the occurrence of a carcinoid tumor in the thyroid gland should be firstly considered metastatic in origin, the lung being the major candidate for the primary localization (as determined by ttf immunostaining). telomerase expression and proliferation activity in gastroenteropancreatic tumours s vural, y kapran, m gulluoglu, u cevikbas, f dizdaroglu university of istanbul, istanbul medical faculty, department of pathology, istanbul, turkey intruduction gastroenteropancreatic endocrine tumours have a variable prognosis and the prediction of biological behavior based on histopathology is not always possible. telomerase is a reverse transcriptase that synthesis telomere dna to stabilize telomere length.telomerase activity is increased in different human cancers. the aim of this study was to determine whether the expression of telomerase (htert) correlates with the histological typing of endocrine tumours and ki- proliferation index. material and methods formalin-fixed, paraffin-embedded tissue sections from gastroenteropancreatic endocrine tumours and normal pancreas were stained immunohistochemically for human telomerase reverse transcriptase (htert) and ki- antigen. results cases were diagnosed as well-differentiated endocrine tumour, were well-differentiated endocrine carcinoma and were poorly-differentiated endocrine carcinoma according to who classification of endocrine tumours. the percentage and intensity of positive neoplastic cells were assessed for each case. expression of htert was observed in one well-differentiated endocrine tumour ( %), in well-differentiated endocrine carcinomas ( . %) and in poorly-differentiated endocrine carcinomas ( %). there was a significant correlation between the expression of htert and histopathological diagnosis (p< . ). also the correlation of htert expression and ki- index was statistically significant (p< . ). conclusion immunohistochemical detection of htert expression in gastroenteropancreatic endocrine tumours may be a helpful tool in addition to morphological findings and ki- index in predicting the malignant potential of these tumours. proliferation, p expression and apoptosis in pituitary adenomas: relationship to tumor behaviour introduction pituitary adenomas are known to vary considerably from the stand point of their intrinsic aggresiveness that might imply a different therapeutical approach. the aim of this study was to estimate the relationship between proliferative activity (ki ), p expression, apoptosis and pituitary tumor behaviour. materials and methods immunohistochemical analysis of ki and p expression were performed in paraffin-embeded pituitary adenomas: functioning; non-functioning; invasive adenomas. apoptotic index (ai) was determined in adenomas by the in situ end-labeling technique (tunel). results ki expression in all adenomas was . % (significantly higher in functioning comparatively with non-functioning pituitary adenomas - . ± . % versus . ± . %). we noticed a positive correlation between the proliferative activity and the tumoral invasiveness (ki labeling index . ± . % in invasive and . ± . % in non-invasive adenoma). p nuclear positivity was identified in % of the invasive adenomas and only in % noninvasive adenomas, with a positive correlation between p and proliferative activity (ki : . ± . in p positive versus . ± . % in p negative tumors). apoptosis was found in % of tumors, higher in some of the invasive ones, with a positive correlation between the proliferation rates and apoptotic indices (ai: . ± . in total versus . ± . in invasive pituitary adenomas). also, some differences were recorded in functioning and non-functioning adenomas (ai: . ± . versus . ± . ). conclusions the data suggest that the assessment of proliferation, p expression and apoptosis might be used to evaluate tumor behaviour and susceptibility of adenomas to therapy. differentially expression of nesp in langerhans islets of the human pancreas and overexpression in endocrine pancreatic tumors nodules, while others recommend to do it only if clinical changes are present. this study was done to determinate the usefulness of systematic repetition of fna in patients with benign cytology result in the initial fna. materials and methods data were collected from patients referred to endocrinology service for evaluation of thyroid nodular disease between and . all patients underwent repeated fna of thyroid nodule. age of patients was . + . years, . % were females, % had uninodular goiters, nodule size was . + . cm. time elapsed between both fna was . + . months. results at second fna, aspirations had benign cytology, were non diagnostic, suggestive of follicular neoplasm and had malignant cytology results. excluding non-diagnostic aspirations, we get % of discordant results. uninodular goiters as compared to multinodular have a higher rate of discordant results. we did not find other variables between groups of concordant and discordant results. twenty-two patients with benign cytology underwent thyroid surgery, without any histological malignant result. conclusion -uninodular goiters with an initial benign cytology have a significant rate of discordant results after repetition of fna. however, in % of these cases the first diagnosis was based on limited material. -our results show that cases of thyroid carcinoma out of patients with nodular goiter were misdiagnosed by initial fna cytology. therefore we recommend systematic repetition of fna cytology in all patients with uninodular goiter. immunocytochemistry in fna biopsy material objective assessing diagnostic value of immunocytochemical methods in destained cytology smear specimens prepared from fine needle aspiration (fna) biopsy material. material and methods investigated material comprised samples from fna biopsies that were diagnosed in - . alcohol-fixed cytology smears were typically stained with hematoxylin-eosin. for immunocytochemical studies, preparations were first destained using alcohol series. following this, chosen antibodies were used either separately, or as a panel ckmnf, ema, lca, tg, ct, hmb- , s- , chr, nse, er, pr, cd (dako lsab system, peroxidase). results immunocytochemical staining was helpful in % of cases. initial diagnosis was confirmed in cases. immunocytochemical staining was important particularly in confirming diagnosis of poorly differentiated neoplasms. it was also helpful in identifying the primary site of metastatic carcinoma in fna cases. in ( %) cases diagnosis based on the investigated method failed. precise diagnosis was not possible either due to negative staining with single marker/panel or when only single cells were stained positive. conclusion immunocytochemical methods in destained smears allow basic as well as discriminating diagnosis even in cases of poor availability of cytologic material. fine needle aspiration of lesions in the thyroid bed. e chmielik, b szczesniak-klusek, d ponikiewska, e stobiecka, d lange oncology center, department of pathology, gliwice, poland introduction clinical suspition of recurrent thyroid carcinoma based on ultrasound examination of thyroid bed with correlation to increased thyreoglobulin level or calcitonin level and/or radiomarker uptake on scintigraphy can be supported or dismissed by fine needle aspiration biopsy (fnab). the aim of this study was assesment of specificity and possitive predictive value of ultrasound-guided fnab of the lesions in the thyroid bed after total thyroidectomy for diagnosis of recurrent thyroid carcinoma. material and methods ultrasound guided fnab of thyroid bed lesions of diameter . - . cm performed by pathologist in patiens after thyroidectomy. immunohistochemistry stain for calcitonin was performed using dako antibody in cases. the recurrent papillary carcinoma was diagnosed in ( . %) patients, the recurrent follicular carcinoma in ( . %) patients, hürtle cell carcinoma in ( . %) patients and medullary carcinoma in ( . %) patients (immunocytochemistry stain for calcitonin confirmed diagnosis in patients). pathologic correlation was able in cases: postoperative examinations confirmed recurrent carcinoma, and cytologic diagnoses were falsenegative. in the remaining patients granulation, purulent inflammation and benign lesions were diagnosed. in ( . %) cases material was nondiagnostic. specifity of the method was . %, possitive predictive value . %. conclusions ultrasound-guided fine needle aspiration biopsy performed by pathologist is valuable and specific method in the diagnosis of recurrent thyroid carcinoma in thyroid bed. introduction fine-needle aspiration (fna) is one of the most useful methods in the diagnosis of benign goiter. in consideration of the goiter; it is the most frequent lesion in the thyroid tissue, significance of fna as a diagnostic method become greater. material and methods in cases diagnosed as goiter we analyzed: ) sex distribution, ) age distribution, ) correlation between clinical and cytological diagnoses and ) goiter classification in accordance with cytological characteristics. results goiter was five times more frequent in females than males ( women, men). the majority of the patients were between and . the youngest was , and the oldest years old. almost % of cytologically diagnosed goiters had the same clinical diagnosis, in only . % of all patients tumor was suspected clinically. we confirmed high correlation between clinical and cytological diagnosis. according to the cytological characteristics all goiters were classified in categories: goiters with and without degenerative changes. hi-square test confirmed statistically significant difference in the presentation of such goiters (hi-square test= . ; p< . ). fna permits a substantial reduction or even elimination of other diagnostic procedures, such as imaging, with consequent saving in time and money. furthermore, benign cystic lesion may be cured by fna (a diagnostic and unexpected therapeutic value). samples, furthermore it is difficult to predict at patient's bedside which ancillary methods, if any, will be necessary. the aim of this study was to demonstrate the value of a universal short-term storage cell medium in processing fnab samples for different ancillary methods. materials and methods after diagnostic smear preparation, the needle and syringe were washed out with the short-term storage cell medium in fnab samples, obtained from to . microscopic smear analysis determined the choice of ancillary method used. cell suspensions were then processed as required for each individual ancillary method. results we used ( %) fnab samples stored in the medium for ancillary methods, while samples ( %) were discarded due to the clear morphology-based diagnosis or sample inadequacy. immunocytochemistry was performed on samples. for various membrane, cytoplasmic and nuclear antigens, adequate immunoreaction without background was obtained in samples stored in the medium overnight ( ) or over the weekend ( ). immunophenotyping by flow cytometry was performed in fnab samples where up to lymphoma antigens per sample were successfully determined when the samples were stored in the medium overnight. high quality flow cytometric dna histograms were obtained from all fnab samples suspended in the short-term storage cell medium. conclusion the short-term storage cell medium that we have been using, allows effective and easy processing of fnab samples for several ancillary diagnostic methods. it preserves cell morphology, various membrane, cytoplasmic and nuclear antigens as well as dna content. fine needle aspiration cytology of ovarian lesions introduction an improved understanding of the pathogenesis of cervical hpv-induced lesions has significantly changed the approach to diagnosis and treatment. the pap smear is still the most effective cervical cancer screening test. however, molecular testing for the presence of high risk hpv-dna increases the ability to identify women with an increased risk for cancer and true cancer precursors. the aim of the present study was to evaluate high risk hpv-dna test systems in cervical cytological material and the correlation with pap smear cytology. materials and methods we analysed routinely processed cytological cervical specimen. material was taken consecutively for pap smear cytology and for hybrid capture (hc) hybridisation assay (digene). the cytological report showed mild to severe dysplasia ( cases were scored as pap i/ii). after performing the hc-assay, dna was extracted from the same sample. hpv-dna detection with conventional pcr using consensus primer (my /my ), followed by subtyping of hpv and was carried out. from the specimens showing dysplasia ( . %), koilocytosis has been observed in % of pap smear cytology. hpv-high risk positivity with the hc hybridisation assay was detected in % and % showed positivity for hpv-dna content with conventional pcr. subtyping of hpv-positive cases resulted in hpv- positivity in %, . were positive for hpv and . % showed a coexistence of hpv and . conclusion our results indicate that hpv-detection with highly sensitive and widely used molecular methods show a good concordance with cytological findings. fine needle aspiration findings of two different types of gastrointestinal stromal tumor mg gulluoglu , d yilmazbayhan , y kapran , k acarli , f dizdaroglu istanbul university, faculty of medicine, department of pathology, istanbul, turkey istanbul university, faculty of medicine, department of general surgery, istanbul, turkey introduction gastrointestinal stromal tumors (gist) are the most common mesenchymal tumors of the gastrointestinal tract, derived from interstitial cells of cajal. the cytologic features of these neoplasms in fine needle aspiration (fna) have been described in several articles. aims: cytologic and histologic features of two gist cases one of which presented with liver metastasis and other with an intrathoracic mass mimicking lung carcinoma radiologically are presented comparatively. sixty year-old male patient with a previous history of gastric gist has had an fna from a liver mass. in the cytologic examination, epithelioid cells with round-oval nuclei, large cytoplasms and indistint cytoplasmic borders, forming three dimentional groups with thin fibrovascular stroma were observed. the other patient was a seventy two year-old female who had an fna from an intrathoracic mass. branching fascicles of spindle cells with indistinct cytoplasmic borders in a necrotic background were observed in the cytologic examination. mesenchymal origin was verified by vimentin immunopositivity. by detailed computerized tomographic evaluation, it was revealed that the mass originated from the gastroesophageal junction. both tumors were resected and histologically examined. cytologic and histologic findings correlated including immunocytochemical and immunohistochemical results which were positive cd and cd , and negative s and smooth muscle aktin immunoreactions. conclusion as they share common histomorphological features with other types of mesenchymal tumors of the gastrointestinal tract, cd immunopositivity is the only diagnostic marker to differentiate these tumors from other tumors of mesenchymal origin. cytologic diagnosis also requires detection of this marker in the neoplastic cells. peritoneal fluid cytology of sarcomas k zachou , e tzartza , a orologa , a skenderi , k patsiaoura , e kostopoulou , k boni hippokratio hospital of thessaloniki dept. cytopathology, thessaloniki, greece hippokratio hospital of thessaloniki dept. pathology, thessaloniki, greece material and methods peritoneal fluid smears of female patients of all ages, were studied. results cases were cytologically diagnosed as malignant ( , %), the majority of which was characterized as adenocarcinomas. histological diagnosis was available for cases. sarcomatous component was reported in only cases, cases were malignant mixed müllerian tumors (mmmt), one was leiomyosarcoma, one rhabdomyosarcoma and one liposarcoma. the cytological findings in the equivalent cases were « abnormal» neoplastic cells in isolation, with enlarged and hyperchromatic nuclei. adenocarcinoma cells were identified in peritoneal fluid smears of patients with mmmt. conclusion cytological diagnosis of sarcoma is rare. even when these «abnormal» cells are found, it is very difficult to give a definite diagnosis of sarcoma, based directly on the cytomorphological characteristics of peritoneal smears. however, such a possibility should be kept in mind by the cytopathologist to avoid missing the diagnosis. r bokun, z tatomirovic, v skuletic institute of pathology, military medical academy, belgrade, serbia and montenegro purpose the aim of this study was to show that imprint cytology is a valuable method in the evaluation of bone tumors as well as to determine its diagnostic accuracy in primary and secondary bone tumors. materials and methods from thirthy three surgical specimens of bone tumor imprints were made, air-dried and stained by may-grunwald-giemsa method. the cytologist gave detailed description of the smears, concluded whether the lesion was malignant and suggested a final diagnosis if it was possible. results were compared with the corresponding histopathologic diagnoses. results out of cases with primary malignant bone tumors (chondrosarcoma , ewing sarcoma , ameloblastoma , synoviosarcoma , malignant osteoclastoma , malignant fibrous histiocytoma , malignant schwannoma , leiomyosarcoma ) the cytologist recognized malignancy in of them and in suggested the final diagnosis. in patients with metastases (squamous cell carcinoma , anaplastic carcinoma , malignant melanoma ), the cytologic and histopathologic diagnoses correlated in all cases. conclusion cytologic analysis of the imprints of bone tumors is valuable as early orientation for the clinicians since the final histopathologic diagnosis needs time because of the decalcination procedure. the correlation of cytologic and histopathologic diagnoses was better for the secondary bone tumors because cytologist was more familiar with their morphology. the value of combined fine needle aspiration and needle core biopsy in diagnostic assessment of pancreatic tumors p sevastiadou , p xirou , s barbanis , i efstratiou , e athanasiou , i tsitouridis papageorgiou general hospital, department of cytology, thessaloniki, greece- papageorgiou general hospitaldepartment of cytology, thessaloniki, greece papageorgiou general hospital, department of radiology, thessaloniki, greece introduction due to the anatomical location of the pancreas, it is often difficult to obtain sufficient diagnostic material from pancreatic lesions. the aim of this study is to present the results and our experience from ct guided fine needle aspiration (fna) and needle core biopsy (ncb) from pancreatic tumors. materials and methods fna using gauge needles and ncb using and gauge needles were performed in patients with pancreatic tumors. both procedures were done under computerized tomography guidance, without complications. twenty one tumors involved the body and the tail of the pancreas results the diagnosed cases were adenocarcinomas, neuroendocrine tumors, lymphoma and pseudocysts. diagnosis was reached in cases by both fna and ncb and in cases by ncb only. other cases were "diagnosed" as suspicious for malignancy by fna only. finally in cases no diagnosis was reached by both methods, due to insufficient material. conclusion according to our experience, we believe that the combination of fine needle aspiration with needle core biopsy of pancreatic tumors under ct guidance improves the diagnostic accuracy. value of fine needle aspiration cytology in subtyping mucinous breast carcinoma background subtyping of mucinous breast carcinoma into pure and mixed type has prognostic implications. aims of the study were to evaluate a) the usefulness of fine needle aspiration biopsy (fnab) in differentiation between pure and mixed mucinous carcinomas, and b) to correlate key cytological features with survival. material and methods we reviewed fnab of women with mucinous breast carcinoma treated at the institute of oncology from to . key cytological features analysed were cellularity, amount of mucin, presence of capillaries, cell pattern, cytoplasmic characteristics and nuclear pleomorphism. type of mucinous carcinoma was determined histologically after resection of the tumour. association of cytological features with cancer specific survival was evaluated by univariate and multivariate analysis. results histological analysis revealed cases ( %) of pure and cases of mixed mucinous carcinoma. nuclear pleomorphism and amount of mucin in fnab differed significantly between the two subtypes of mucinous carcinoma. whereas cellularity of cytological samples, presence of capillaries, cell pattern and cytoplasmic characteristics were not related to prognosis, nuclear pleomorphism and absence of mucin in cytological samples were associated with poorer cancer specific survival. furthermore, the absence of mucin in fnab samples retained independent prognostic significance also in multivariate analysis. conclusions higher grade of nuclear pleomorphism and small amount or even absence of mucin in fnab favor the diagnosis of mixed mucinous cell carcinoma and are features associated with poorer prognosis. cardiac lipoma in a mexican patient -multidisciplinary approach in a right atrium tumor j nuncio , g najera-hernandez , g garcia-ramos pathology department, instituto nacional de ciencias medicas y nutricion salvador zubiran, mexico city, mexico internal medicine and neurology departments, fundacion medica sur, mexico city mexico primary tumors of the heart are rare. lipomas account for approximately % of all neoplasms of the heart and represent % of benign cardiac tumors. symptoms may be produced by large lipomas, but more often the patients are asymptomatic and the diagnosis is made by chance. recently, the ready availability of high-definition noninvasive imaging, such as echocardiography, computed tomography, and magnetic resonance image, has allowed easier diagnosis. therefore, more cases have been reported. to date up to cases of lipoma have been described. this case describes the multidisciplinary approach to the diagnosis of this rare entity with the use of open heart biopsy from right atrium, to sustain the correct diagnosis. after exhaustive internet-based search, this is the first case reported in latin-american literature, a condition not previously informed from in vivo patient in mexico. the cardiac hydatid cysts are rare cases, representing , - % from all human hydatid cysts. they are commonly located in the left or right ventricle and exceptionally in the interventricular septum. because the symptoms and clinical signs of the cardiac hydatid cysts are non-specific, the diagnosis may be difficult. material and methods we report an intramyocardial hydatid cyst, diagnosed at cardiology center iasi, with an early history of atypical chest pain, the death occuring through anaphylactic shock, secondary to the hydatid cyst endocavitary rupture. the study was made on necropsiy specimens, and the diagnosis was established by using routine morphological techniques. results the gross examination evidentiated an hydatid cyst of about cm in diameter, communicating through a small orifice with the left ventricular cavity and through a slit-like fissure with the right ventricular chamber. the systemic embolism was revealed, only grossly, by the presence of small "hydatid daughters" at the level of the ascending aorta and the pulmonary embolism was confirmed only histologically, by the presence of anhiste membrane emboli in the peripheral pulmonary vessels. the study revealed the morphological aspect defining hydatid cyst, emphasising the necessity of an early diagnosis due to a high risk of death through complications. a case report of arrhytmogenic right ventricular dysplasia -cause of sudden death c borza, d butcovan, c grigoriu, v astarastoaie university of medicine and pharmacy iasi, romania arrhytmogenic right ventricular dysplasia (arvd) is a new form of cardiomyopathy probable more frequent than commonly reported. arvd is a heart muscle disorder of unknown cause that is characterized clinically by an electrical instability associated with secondary ventricular arrhythmia and pathologically by fibrofatty replacement of the right ventricular myocardium. it is a rare but important cause of sudden unexpected cardiac death in young, otherwise healthy persons, especially those that are exercise related. we report a case of cardiac sudden death in a years old man without personal and familial cardiac history. the study was made on a necropsic biopsy specimens from the medico-legal laboratory. the diagnosis was made using routine histological techniques. grossly, we revealed a fibro-fatty right and left ventricular wall myocardial replacement and a focal white thickening of the left ventricular endocardium. histologically, we evidentiated a fibro-fatty myocardial replacement of the right and left ventricle suggesting an arrhythmogenic ventricular dysplasia of cardiomyopathic type and an endomyocardial fibrosis supported by the presence of a subendocardial fibrosis, affecting internal one third of the myocardium. there were no evidence of coronarian and valvular lesions and hypertensive cardiac changes, as well. the study revealed the morphological features defining a fibro-fatty myocardial replacement and an endomyocardial fibrosis evidentiating the case particular features, as well. registered. repeated biopsy revealed ongoing mc in / pts, latehealing mc in / pts, focal-healing mc in / pts, healed mc in / pts, and dilated cardiomyopathy in / pts. amount of cellular infiltrate, degenerative and/or necrotic changes, and fibrosis was reduced in , , and pts, respectively, remained the same in , , and pts, respectively, and increased in , , and pts, respectively (p< . , between groups). the significant reduction was achived in the amount of cellular infiltrate and degenerative and/or necrotic changes, contrary to the amount of fibrosis. applied immunomodulatory therapy made substancial reduction of inflammation with "relative" increase of fibrosis. conclusion interferon-α, as main immunomodulatory agent, has favourable effects on myocardial histology and contractility in patients with biopsy-proven myocarditis. morphological changes in heart died of a heart attack of a myocardium v ubaydullaeva the centre of emergency medical aid, tashkent, uzbekistan diseases cvs take conducting place among the most actual problems of modern medicine. from them it is possible to count the main thing ihd. ihd -the special form of pathology cvs including group of diseases which, according to definition the cart, are treated as follows: «dysfunction sharp or chronic, arising owing to relative or absolute reduction of supply of a myocardium by arterial blood». despite of significant number of the morphological researches devoted ihd, morphogenesis separate displays of it, in particular, ami, and also mechanisms of indemnification and decompensation of hearts are investigated insufficiently. in connection with, the purpose of the present research definition morphofunctional conditions of various departments of heart was above-stated at diagnostics of an intimate ischemia. material and methods for achievement of an object in view researches of hearts died of a heart attack of a myocardium have been lead (have been carried out), and also have been investigated morphometric parameters, such as: weight of a cardiac muscle, pure weight of heart, weight right and left ventricles, an index right and left ventricles, an index of blood supply of a myocardium. all received data have been processed statistically on personal computer with use of standard software package windows excel. results summarizing macro-and the microscopic changes which have been found out by us in a cardiac muscle, it is possible to make the conclusion that the long reorganization occuring in a cardiac muscle in conditions increasing hypoxy, results in an exhaustion processes, to use of all possible resources cardiomyocytes and causes development decompensation. introduction cardiac myxoma, the most common primary tumor of the heart, has a varying clinical presentation and immunohistochemical profile. an abundant mucopolysaccharidic matrix exists, including mucin, within the cardiac myxoma. this study elucidates the clinical presentation and expression of mucin genes in cardiac myxoma. materials and methods from december to february, , the retrospective study included consecutive patients with cardiac myxoma underwent surgical excision. detailed clinical parameters were reviewed as well. mucin genes, additionally, muc , muc and muc ac, have been studied by immunohistochemical method. the expression was scored from to . results ( %) women and ( %) men with a mean age of +/- years comprised the control group. the presentation included asymptomatic ( %), dyspnea ( %), stroke ( %), chest pain ( %), fever ( %), syncope ( %) and tricuspid regurgitation ( %). we divided these patients into two groups; group a contained the myxoma located in the left atrium, group b included three ( %) recurrent myxomas and ( %) myxomas other than in left atrium. they did not differ with respect to many pathological scores, such as vascular proliferation, inflammation, cellularity, and hyaline. however, although less calcification and thrombosis occurred, more congestion was found in group b (p < . ). moreover, muc / ac had a higher expression than muc (p < . ). interestingly, the group a displayed a stronger mucin expression than group b did. conclusion preliminary results demonstrate invaluable and different pathological patterns, including mucin genes, between the myxoma coming from the left atrium and the other sites. introduction nowadays understanding of atherogenesis, russell ross' response-to-injury paradigm, considers atherosclerotic lesions as "a protective, inflammatory-fibroproliferative response" to harmful stimuli. among these stimuli are the major risk factors, which contribute for atherosclerotic cardiovascular complications. arterial blood flow impairment is associated with the progression of intimal atherosclerotic lesions. that is why most of the research work is concentrated upon intima, while adventitia is neglected. several lines of evidence clearly show that adventitia is not an innocent bystander in atherogenesis. the aim of the present study is to evaluate morphologically adventitial changes in atherosclerotic arteries. the cellular components and adventitial thickness are followed in postmortem human coronary arteries. results mononuclear cellular infiltration (lymphocytes, mast cells), neoangiogenesis and collagen overproduction are established in this part of adventitia, that corresponds to atherosclerotic lesion. morphometric analysis reveals increased adventitia/media thickness ratio. the adventitial thickening represents an example of negative vascular remodeling, because of hampering the compensatory enlargement of the affected artery. on the other hand the cellular processes involved in adventitial thickening could be responsible for atherosclerotic lesion initiation. we need further arguments into the cell biology of atherosclerosis, viewed as a vascular healing process, involving also the adventitia, to provide new insights into atherogenesis and alternative therapeutical strategies respectively. study on postmortal autolytic changes of the myocardial blood vessels. experimental study l kostic-banovic , v katic , r karadzic , j stojanovic , g ilic , m zdravkovic , a antovic department of forensic medicine nis, nis, serbia and montenegro department of pathology nis, nis, serbia and montenegro introduction modern forensic medicine practice has not yet been given the methods of investigation that would enable answering with sufficient accuracy to the question of death occurrence time. present work is an attempt to make contribution to that very complex and significant problem in forensic medicine. the investigation has been done on wister rats. the sacrifice was exerted by strangling. to respond on questions how both temperature of microenvironment and passed time influence on coronary arteries, the experimental animals were divided into groups: i ( c), ii ( c) and iii ( c). every group had subgroups, depending of passed time from the sacrifice, beginning of hour, through , , , , , and up to hours. control animals were autopsied and myocardial sections were taken immediately after sacrificed animals. formaldehyde fixed and paraffin embedded blocks were cut and stained by he, van gieson and gomori methods. results in groups ii and iii almost all blood vessels of heart muscle had fragmented walls in the animals examined upon hours after sacrifice. the vessels were almost normal in the group i also up to hours after sacrifice. basal membranes of blood vessels were observed upon hours after sacrifice at the temperature of c. fragmented basal membranes in ii and iii group were found, in the form of spider's web residues. total hemolysis of erythrocytes was upon hour after sacrifice in iii temperature group. however, contours of erythrocytes could be recognized upon hours after sacrifice in i experimental group. conclusion autolysis of myocardial vessels is influenced by two factors: time interval from the death and micro environmental temperature. the temperature exerted more profound influence on autolysis than time interval. the observed autolytic changes could be used in the expertise of the time of death occurrence. introduction heart transplantation remains the only therapeutic option for pediatric patients (pts) with severe, end stage myocarditis. the aim of this study was to determine the presence of viral genome in native heart and the frequency of viral recurrence after heart transplant in pts with myocarditis. material and methods from march to november , heart transplants were performed in children ( month to years m/ f) at our institution. histology/immunohistochemistry was carried out in all native hearts; among inflammatory cardiomyopathy, cases were active myocarditis and dilated cardiomyopathy/ chronic myocarditis. foci of active myocarditis were also found in one case of hypertrophic/restrictive cardiomyopathy and one case of congenital heart disease respectively. retrospective pcr (polymerase chain reaction) and sequencing analysis for detection of cardiotropic viral genomes was performed in native hearts ( %) and in all serial post-transplant biopsies from viral pcr positive cases. results pcr amplified a viral product in native hearts ( %). pcr analysis on postransplant serial biopsies disclosed the same viral infection in of ( %). early enteroviral recurrent myocarditis with identical genotype was demonstrated in cases at month after transplant. fatal outcome occurred in / pts with viral recurrent myocarditis when prompt molecular diagnosis was not available; misdiagnosis of acute rejection in histological monitoring may have concurred in the fatal outcome. conclusion viral myocarditis frequently relapses after heart transplantation in children and is a risk of fatal outcome. molecular study in native hearts is mandatory to improve diagnostic accuracy allowing to a more strict surveillance after transplantation. sudden cardiac death induced by acute viral myocarditis introduction most commonly the sudden cardiac death (scd) is defined as unexpected death from cardiac causes early after of without the onset of symptoms. data suggested that scd is a multifactorial catastrophe involving in most instances myocardial lesions that we confirm by this report. materials and methods five cases were autopsied in institute for forensic medicine because they have died from scd. the mean age was , years, including one boy ( years) and one girl ( years). all specimens were fixed in % formalin. paraffin sections were cut and stained by: he, van gieson and ab-pas, ph= , . results clinical symptoms lasted short time: fatigue, dyspnea, palpitations and precordial discomfort, accompanied by fever. macroscopically, the hearts were normal or enlarged, with dilatation of chambers. the ventricular myocardium was typically flabby and mottled by either pale foci or minute hemorrhagic lesions. histological finding: myocarditis was characterized by an interstitial mononuclear predominantly lymphocytic inflammatory infiltrate and by injury of focal necrosis to myocytes adjacent to the inflammatory cells; focal aggregates of macrophages and microhaemorrhages, often surrounding the conduction system, were also observed. scattered incipient fibrosis inside the areas with disappeared myocytes was one of the features of myocarditis. conclusions the ultimate mechanism of death in viral myocarditis was fatal arrhythmia induced by inflammatory mononuclear infiltrates of the conduction system. surgical pathology of primary cardiac and pericardial tumors in the paediatric age background primary cardiac and pericardial tumors (cpt) are rare at all ages and even less common in infancy and adolescence. aim of this study is to assess the prevalence and pathologic features of paediatric cpt consecutively examined in a single institution. among surgically removed cpt collected at our cardiovascular pathology unit in the time interval - , ( %) occurred in the paediatric age (< yrs). we retrospectively analysed them by histotype, age and clinical presentation, location, type of surgery and outcome. they were male and female pts, age ranging from days to years (median months). the majority of cpt were diagnosed before the age of year ( %), including prenatal diagnosis by foetal echocardiography. in the remaining pts, clinical presentation of cpt was congestive heart failure in , cardiac murmur in , systemic embolism in , and constitutional symptoms in , whereas four were completely asymptomatic and the mass was an incidental finding at echocardiography ( ) or during cardiac surgery for congenital heart disease ( ). pct were located most frequently in the right ventricle ( ), followed by right atrium ( ), left atrium ( ), left ventricle ( ), tricuspid valve ( ), pericardium ( ) and ventricular septum ( ) . all had surgical resection except one who underwent cardiac transplantation. as far as histotype, myxoma was the most frequent ( ), followed by rhabdomyoma ( ), fibroma ( ), angioma ( ), pericardial teratoma ( ) and hematic cyst ( ). no recurrence was found at echo during follow-up and only one pt died three years after cardiac transplantation due to cerebral malignancy. with the improvement of cardiac imaging techniques, cpt have increasingly been detected even early during life. despite the benign histotype, cpt carry the risk of heamodinamic, embolic and arrhythmic complications. prompt surgical resection is indicated in all symptomatic pts and in those with tumour related obstruction. among surgically resected primary cpt in the paediatric age rhabdomyoma is less frequent than expected since it often does not require surgical resection due to its potential spontaneous regression. in vivo histologic diagnosis of primary malignant cardiac and pericardial tumors c basso, m valente, g thiene institute of pathology, padua, italy background primary cardiac and pericardial tumors (cpt) are rare and even less common are malignant ones. aim of our study was to assess the prevalence and histotype of malignant forms among a consecutive series of primary cpt examined in a single institution. in the time interval - among consecutive pts who had an in vivo diagnosis of primary cpt, either by surgical pathology and/or endomyocardial biopsy investigation, ( . %) had a malignant form. they were female and male pts, age ranging from to yrs (mean ± ). besides gross and histologic examination, tumour histotype was defined by immunohistochemistry using a large panel of antibodies and by transmission electron microscopy. primary malignant cpt comprised extracardiac ( pericardial mesothelioma and pulmonary artery sarcoma) and intracardiac masses. the latter group consisted of angiosarcoma of the right atrium +/-right ventricle ( ), undifferentiated sarcoma of the left atrium ( ), fibrosarcoma of the right atrium ( ), malignant fibrous histiocytoma of the left atrium ( ), b cell lymphoma of the right atrium ( ) and leiomyosarcoma of the right ventricle ( ) . in four ( %) a preoperative histologic diagnosis was achieved by transvenous endomyocardial biopsy (all right-sided). four malignant primary cpt, all located in the left atrium, had a preoperative misdiagnosis of myxoma. surgical resection was performed in all but two pts. all pts died with a maximum survival time of months. conclusions primary malignant cpt are rare and represent . % of all primary cpt in our series. the prognosis is poor and generally measured in months independently from the tumour histotype and from surgical resection and chemotherapy. endomyocardial biopsy is a safe procedure to achieve an in vivo diagnosis in the setting of right intracavitary masses. introduction primary sarcomas of the aorta are extremely rare neoplasms, described in occasional single case reports and antemortem diagnosis is difficult because of their polymorphous presentation. the tumours are classified into intimal and mural types according to their location and clinical behaviour. we describe a case of intimal sarcoma arisen in the thoracic aorta of a -years-old woman with multiple embolic abdominal metastases (spleen, kidney, adrenal). case report in november the patient was hospitalized for the embolic occlusion of the left popliteal artery. the recent clinical history revealed irritative cough, dispnea and fever. the laboratory tests reported anemia (hemoglobin: . mg/dl) and the ves was . electrolities, liver function tests and fibrinogen were within normal limits. the antiphospholipid antibody and lupus anticoagulant were negative. a ct-scan showed an intraluminal thrombus-like mass in the thoracic aorta and multiple geographic infarctions of the spleen suggestive for a primary aortic tumor. she died before undergoing to surgery, for left ventricular failure. results post-mortem examination showed mild atherosclerosis and a mass with grayish-yellow, solid, rubbery and mixoid aspects, attached to the wall of the aorta, just after the origin of the left subclavian artery. histologic sections disclosed a spindle-shaped sarcoma cells with pleomorphic nuclei in a myxoid stroma; necrosis was abundant. at immunohistochemistry tumor cells resulted positive for vimentin, actin and cytokeratins. conclusion the preoperative diagnosis of sarcoma of the aorta is possible but it should be supported with imaging techniques; the definitive diagnosis need to be confirmed histologically and immunohistochemically. arterial allografts cryopreservation antigenicity in pigs m santos background coronary surgery requires vascular grafts. donor fresh arterial grafts are useless because of rejection vasculopathy. cryopreservation can be a good way for banking purposes and may limit rejection. the aim of this study was to assess the utility of arterial cryopreservation in increasing the quality of grafts, in an animal model in pigs. material and methods small arteries, less than mm in diameters were implanted in pigs. three groups were done: group (n= ): fresh autograft (au) and fresh allograft (al) one in each side; group (n= ): cryopreservated au and cryopreservated al; group (n= ): fresh al and cryopreservated al. all animals got aspirin for three months and group also cyclosporine a. the implanted grafts were embedded in paraffin and microscopically studied with hematoxilin/eosin and elastic stains for morphology and morphometrics. a basic immunohistochemical study with cd and mac was also performed. results the patency rate of cryopreservated al and au was %, as it was in the fresh au. the inflammatory reaction, evaluated by cd and mac was present in all al arteries, and absent in au cases. in group , the infiltration was lower in cryopreservated, than in the fresh ones. conclusions in our series of pig's arteries, cryopreservation increases vascular patency and the inflammatory response is lower than in fresh arteries. this fact is independent of the immunosupressive therapy. introduction glandular cardiac myxomas are very rare tumors of uncertain histogenesis, displaying glandular structures within otherwise typical myxomas. origin of glands has been attributed to epithelial differentiation of a cardiomyogenic precursor cell or to entrapped embryonal rests. we studied four cases of glandular myxomas ( sporadic and one familial) to define the immunophenotypic profile of the glandular elements. materials and methods histology and immunohistochemistry were performed on serial sections. broad spectrum cytokeratin, cytokeratin (ck ), cytokeratin (ck ), cea, ema, chromogranin a, calretinin, thyroid transcription factor- (ttf- ), ki- and p were investigated. results three patients were males, aged , , , respectively and the fourth a y.o. woman. the glands were either scattered within myxomatous stroma ( cases) or in groups. in the latter case the glands featured villous projections, irregular profile, active inflammation or focal low grade dysplasia, and showed expression of acidic and neutral mucins (mostly sialomucins). cytokeratin and co-expression was found, similarly to foregut derivatives. there were scattered chromogranin-positive neuroendocrine cells in one case and ki- immunostaining showed a very low proliferative activity. there was no reactivity for ttf- , calretinin or p . none of the patients had adenocarcinoma or other neoplasm, either at diagnosis or at - years follow-up. conclusions our findings indicate that glandular component of cardiac myxoma is morphologically heterogenous. the isolated glands suggest a possible divergent (epithelial) differentiation of myxoma cells, but other findings point to the possibility of entrapped foregut rests with mature neuroendocrine and mucous cell populations. work partially supported by grants from the italian ministry of education (rome, to mp) and the associazione italiana per la ricerca sul cancro (milan). infection and immune inflammation peculiarities in atherosclerosis i zota, e foca, e melnic pathology department, the state university of medicine and pharmacy n.testemitanu, chisinau, republic of moldova introduction during the last decade the basic postulate of atherosclerosis etiology and pathogenesis has changed. this review presents a spectrum of data regarding the link between infection and immune inflammation development in atherosclerosis. material and methods this study has been carried out on the human aorta, coronary heart vessels collected from early performed autopsies and on the carotid arteries gathered during surgical vessels remodeling of persons. the patients with cardiovascular insufficiency on atherosclerosis background from to years were taken into study group. chlamydia pneumoniae was detected by routine microscopy on shtive fixed material, and by immunohistochemical reaction performed on cryophilic specimens marked with fits antibodies. hsp- and tnf-α implication have been studied trough immunohistochemical reaction using monoclonal antibodies. this material was fixed in % formaldechyde solution. results chlamydia pneumoniae has been detected in endothelial cells, macrophages, smooth muscle cells of fatty streaks and fibrous plaques. its detection incidence decreases in advanced arterial lesions. we also determined that chlamydia pneumoniae infection is capable to induce immune reaction against hsp- which can be considered like a target in autoimmune reaction. they produce an cytotoxic effect on the endothelial cells followed by permeability disturbances, faciliting the atherosclerotic lesions progress. among the inflammation mediators in increased quantity tnf-α have been detected being localized on the surface and in depth of atherosclerotic plaque around the foam cells. conclusions our outcomes demonstrate the toxic and infectious factors existence which can be considerated decisive in atherosclerosis pathogenesis. this data give us the reason to elaborate other diagnosis and treatment strategy. introduction primary tumours of the heart are rare, the majority are benign, myxomas representing - %. hemangiomas are extremely rare, with an incidence of . %- . %. they usually occur in adults, mostly are an incidental finding. we present a man with asymptomatic cavernous hemangioma of the left atrium. case report transthoracic echocardiogram of a -year-old man with arterial hypertension, otherwise healthy, with normal ecg and chest x-ray, revealed a wide based isoechogenic tumour, measuring . x . cm, located in the moderately enlarged left atrium, attached to interatrial septum and anterior wall, adjacent to mitral valve annulus, sparing oval fossa. it showed minimal mobility but did not cause any obstruction of the blood flow or mitral regurgitation. macroscopically, surgically removed tissue was spongy, partly haemorrhagic. microscopically, there were cavernous venous structures, filled with blood and focally thrombosed. focally, a few smaller capillary channels were found. there was no endothelial atypia and no papillary hyperplasia. discussion and conclusion histologically, hemangioma of the heart has two major differential diagnostic possibilities. in case of a myxoid background, it is possible to be misdiagnosed as myxoma, but in hemangioma there are no myxoma cells and no ring structures. grossly, opposite to myxomas, hemangiomas are rarely attached to the oval fossa. papillary hyperplasia, which is reactive endothelial proliferation in hemangioma, may lead to misdiagnosis of angiosarcoma. angiosarcoma can be excluded only when the whole tumour is examined and no marked endothelial atypia, cellular areas of spindle cells with poorly formed vascular channels, and necrosis are found. compression, obstruction, effusion and bleeding are responsible for clinical picture. symptoms depend also on the location, size and invasiveness. the natural history is unpredictable, for this reason surgical intervention is mandatory. introduction the limb-body wall complex is a congenital syndrome, which includes limb defects, abdominoschisis associated with facial and neural tube malformations. some authors believe that the limb-body wall disruption is separate from amniotic band syndrome. others suggest that both belong to a wider spectrum, with a possible overlap between these two categories. in the present study, we describe a case of lbwc and based on our findings we suggest a new pathogenic mechanism. case report a years-old cap-verdean female gave birth at weeks to a pair of twins. one foetus showed multiple malformations incompatible with life. physical examination showed partial lower extremity amputations. a large omphalocele was also noted. there was a large lumbosacral meningocele and the head showed micrognathia and high-arched palate. there was right hydronephrosis secondary to right ureteral obstruction and cloacal anomaly. the lungs were hypoplastic. the histology of the internal organs was characteristic for the developmental stage and cytogenetic testing revealed a normal male karyotype. discussion and conclusion we believe, that early amniotic bands may lead to vascular insults, proximally and distally by altered haemodynamics. the lower limbs were partly amputated as a result of the continued growth associated with altered vascular supply. the same mechanism may explain the other findings as well. vascular disruption by virtue of altered haemodynamic state may give rise to thromboemboli, which may affect the growth of external/internal structures, distant from the site of disruption. however, this vascular lesion was masked by continued growth of the foetus. therefore, the abs may precede and may cause the lbwc. two cases of pleuropulmonary blastoma k vuopala , h tuominen , r jauhola , p valmari , r herva lapland central hospital, rovaniemi, finland oulu university hospital, oulu, finland pleuro-pulmonary blastoma (ppb) is a malignant tumour of childhood. the most common clinical sign is respiratory difficulty. ppb appears as a pulmonary and/or pleural-based mass and is characterized histologically by a primitive, variably mixed, blastematous and sarcomatous appearance. no metastases have been reported in neonatal cases. we describe two cases that presented ppb. the first was a term male infant of a g p mother. the pregnancy was uneventful. after normal delivery, a male infant with severe respiratory distress was born. by ultrasound examination, a thoracic mass were identified. there was no response to the intensive care. the infant died at the age of . hours. at autopsy, a tumour of g, measuring x cm was found in the left lung. in addition, there was a smaller mass, of cm diameter in the mediastinum. micro-scopically, the tumour masses consisted of ppb. the second case was a -year-old female with persistent fever and respiratory difficulties. in ct scan, the lower lobe of the left lung was replaced with a tumour mass. during operation, the tumour was seen to be infiltrating to the mediastinum and was partially resected, followed by intense chemotherapy. histologically, the diagnosis of ppb was given. the child has shown no sign of the disease during follow-up of six months. the ppb is regarded as the pulmonary dysontogenetic analogue of wilms' tumour, neuroblastoma, and hepatoblastoma. the first case showed its highly aggressive nature, with mediastinal metastases found at birth. causes of intrauterine foetal death associated with placental pathologic features v blažičević , v Štitić , m mrčela clinical hospital osijek, croatia general hospital karlovac, croatia introduction improvements in antenatal and intrapartum care have reduced perinatal mortality, but the rapid advances in intensive neonatal care have had a dramatic effect in reducing neonatal deaths so that stillbirths have become relatively more important. the aim of this study was to identify the relationship between placental lesions and stillbirth. materials and methods we analysed the causes of intrauterine foetal death after the th week of pregnancy during the years - at the departments of obstetrics and gynaecology of the clinical hospital osijek and general hospital karlovac. a complete autopsy was made on each stillborn, including investigation of the placenta, cord and foetal membranes. histological specimens were studied from all internal organs of the foetus and from the placenta, cord and membranes. haematoxylin and eosin stain is used in routine causes, pas staining to assess thickening of the basement membrane and trichrome staining to assess stromal fibrosis of the villi when it was necessary. results there were stillbirths who died before labour - placentas of them were examined and weren't. abnormalities were found in ( . %) placentas and 'normal' placentas were ( . %). autopsy findings in stillborn foetuses: asphixia ( . %), maceration only ( . %), major malformations ( . %), vitium cordis ( . %), anencephalia ( . %), others ( . %). placental pathologic findings: infections ( . %), single chronic and acute infarction ( . %), multiple chronic and acute infarctions ( . %), placental failure for other reasons ( . %), chronic ischemic change ( . %), infections associated with circulatory disturbances ( . %), retroplacental haematoma ( . %), massive subchorial thrombosis ( . %), chorangiosis ( . %), umbilical cord tumour ( . %), intervillous thrombus ( . %), chorionic cysts ( . %). conclusion the most of women with a stillborn infant were quite healthy and did not reveal any risk factors when assessed on clinical grounds. there were patients in whom evident foetal growth retardation had been overlooked at the maternal health centre before the death of the foetus. the importance of routine ultrasound screening for detection of unrecognised risk patients and placentas is emphasized. introduction microscopic diagnosis of oligobiopsy material taken during endoscopic examination plays an important role in diagnosing syndromes of absorption disorders, especially in case of celiac disease. the aim of the study was a morphologic evaluation of the small intestine mucosa and comparison of the used from many years shiner/shmerling classification with a new modified marsh classification. materials and methods during the study, bioptates if small intestine evaluated in the chair and department of pathomorphology in zabrze in the years - were analysed again. out of the bioptates were with i of villous atrophy, with ii, with iii and with iv. study material was from the paediatric hospitals in zabrze and bytom. during routine histopathologic diagnosing, villus atrophy was evaluated in the shiner/ shmerling scale. presently, the marsh scale is being introduced into histopathologic diagnosing. it takes into consideration not only features of villus atrophy and glandular crypts proliferation but also intraepithelial lymphocyte infiltrations. another evaluation of villus atrophy was performed according to the modified marsh classification. the received results are presented in the modified marsh classification: type - ( . %), type - ( . %), type - ( . %), type a - ( . %), type b - ( . %) and type c - ( . %). our study allowed to compare two classifications used in the evaluation of the atrophic and proliferous processes and to select from the shiner/shmerling degree i a group of cases (type and according to marsh), which had no equivalents in the so far used scale. moreover, it was shown that the sub-groups of the type of destructive changes did not correspond fully with the so far used shiner's degrees ii-iv. it enables fast comparison of the atrophy degree with the results received before the introduction of the new modified classification. moreover, a routine application of precise descriptions of histopathologic results of small intestine mucosa in syndromes of absorption disorders facilitates retrospective selection, from the so far used shiner's degree i, of the cases corresponding with marshal types and . conclusions application of the modified marshal classification for an evaluation of the small intestine mucosa in celiac disease enables accurate presentation of atrophic and proliferous changes including selection of type and , which have no equivalents in the so far used shiner/shmerling classification. embryonal rhabdomyosarcoma: a case report s kocmanovska -petreska, b ilievski, p cvetkovski, l spasevska, s kostadinova -kunovska, s duganovska institute of pathology, faculty of medicine, skopje rhabdomyosarcoma is an aggressive malignant skeletal muscle neoplasm arising from embryonal mesenchyme. the head and neck region is the most common site for this tumour in children. neonatal presentation of this tumour is rare. we present an autopsy case of a female newborn having a large tumour mass ( x x cm) in the frontal region, covering the entire upper half of the face. similar subcutaneous noduli with diameter , cm, cm and cm were found on the left cheek, and another with diameter , cm, , cm, cm and cm on the right cheek. the histological examination showed a tumour composed of large spindle cells with myoblastic features and small round to elongated undifferentiated cells. associated with the spindle cells is various numbers of large round or globular cells with hyperchromatic nuclei surrounded by acidophilic granular or homogeneous cytoplasm. cross-striations were found in the spindle cells. imunohistochemically tumour cells were positive for desmin and vimentin. the final diagnosis was embryonal rhabdomyosarcoma. immunohistochemical staining helped to make a proper diagnosis. introduction apoptotic cell death represents an important mechanism for the precise regulation of cell numbers in normal tissues. various apoptosis-associated regulatory proteins may contribute to the rate of apoptosis in neoplasia. the present study analyses the inter-relationship between the expression of the pro-apoptotic bclx (s/l) protein and histological type and stage of wilms tumour. materials and methods bcl-x (s/l) expression was investigated using an indirect immunoperoxidase technique, applying antibodies to bcl-x (s/l) protein. correlation of semi quantitatively scored bcl-x (s/l) levels with histological type and tumour stage was performed for cases of wilms tumours ( classical and anaplastic). results the expression of bcl-x (s/l) protein was present in most cases of wilms tumour ( %). generally, bcl-x (s/l) was expressed in the blastemal and epithelial components of wilms tumour. in most cases, the expression of bcl-x (s/l) was moderate. blastemal bcl-x (s/l) expression decreased with tumour stage. there was no correlation between histological type and expression of bcl-x (s/l) protein. diffuse expression of bcl-x (s/l) protein was observed in cases of anaplastic wilms tumour. these two cases were stage i and of unfavourable histology. in cases of wilms tumour, no immunohistochemical staining was observed. so, these results cannot indicate whether absence of bcl-x (s/l) could play a role in the development of anaplasia. conclusion according to clinical follow-up, the results of our morphologic and immunohistochemical analysis suggest that decrease of the blastemal bcl-x (s/l) protein could be associated with the capacity of wilms tumour for local and distant spread. expression of alpha, beta and gama catenins in wilms tumour s radojevic background loss of catenins is suggested to promote tumour invasion and distant metastasis in tumour development. the aim of this study was to determine the expression of catenins in wilms tumour and their relationship with histological type and stage of wilms tumour. materials and methods catenins expression was investigated using an indirect immunoperoxidase technique, applying antibodies to alpha, beta and gama catenins. correlation of semiquantitatively scored adhesion molecule levels with histological type and tumour stage was performed on cases of wilms tumours ( classical and anaplastic). results beta and gama catenins were present in most cases ( % and % respectively) and were usually coexpressed. anaplastic type of wilms tumour displayed higher beta catenin and lower gama catenin level in comparison with other types. nuclear positivity, in each case, was found to be very strong, but was usually present only in % of tumour cells. beta and gama catenin expression was not correlated with stage of wilms tumour. alpha catenin was present in % cases of wilms tumour. stage iii displayed higher alpha-catenin levels than stage i/ii, suggesting that impairment of their function might exist without actual loss from tumour cells. conclusion our results suggest that the level of catenin expression is associated with histological type of wilms tumour, regardless of tumour stage. observed nuclear expression of beta catenin indicates that the activation of wnt-signaling pathway is crucial step in wilms tumour genesis. comparison of apoptosis and fas, fas-l and bcl- expression in wilms' tumor m ergin, a uguz, s erdogan, g gonlusen, n tunali cukurova university school of medicine dept. of pathology, adana, turkey background apoptosis is a complex process involving many genes that play role as antiapoptotic or apoptotic factors. it controls normal homeostasis of tissues. expression of these genes vary from one type of tumour to another type. the aim of this study is to evaluate the expression of bcl- , fas and fas-l and apoptosis in wilms' tumour (wt). method thirty paraffin embedded tissue specimens were included. immunohistochemical study was performed for bcl- , fas and fas-l and in-situ end-labelling technique (isel) for apoptosis. results the expression of these proteins varied among the tumours. there was no statistically significant correlation between the expressions of bcl- , fas, fas-l and. apoptotic index. conclusion apoptosis is an important mechanism in the growth of the tumours. we suggest that not only bcl- , fas and fas-l play role as regulators of apoptosis in wt but also other apoptotic and antiapoptotic genes involve this process. further investigations are necessary to understand the molecular mechanism of the progression of wt. uncommon tumours of the neuraxis in childhood j vila-torres hospital universitari sant joan de déu. department of pathology, barcelona, spain case a year-old girl presented with seizures and weakness in the left part of de body of -year duration. ct scan showed a mass that filled the right ventricle, with a strong mass effect, peritumoural oedema, midline shifting and slight ventricular enlargement. a partial excision was carried out and the pathological diagnosis was that of choroid plexus carcinoma. the patient died six months later due to adjuvant therapy side effects. in the last who classififcation of brain tumours, grade iii choroid plexus carcinoma is defined as a choroid plexus tumour showing features of malignancy: nuclear pleomorphism, frequent mitosis, high nuclear/cytoplasmic ratio, increased cellular, density, blurring of the papillary pattern, poorly structured sheets of tumour cells, necrotic areas, and often diffuse brain invasion. all those tumours classically displaying a papillary pattern must be considered in the differential diagnosis. case a month-old child presented with respiratory distress since months old. on rx and ct scan, a tumour in the left hemithorax was seen, with right shifting of the mediastinum. the tumour was partially removed. pathological diagnosis was that of spinal canal invasion by a soft tissue lipoblastoma. eight months after surgery the tumour relapsed, infiltrating the epidural spinal canal from c to d . the tumour was fully excised by means of microsurgery techniques, without neurological deficits. this case is an example of invasion of the vertebral canal by a soft tissue tumour previously removed. lipoblastoma is a rare fatty tumour occurring in children in the extremities or less commonly in the trunk or retroperitoneum. the tumour is benign but may recur. grossly, lipoblastoma showed a distinct lobulated pattern of yellow-grey myxoid tissue, histologically composed of highly vascular fat in a myxoid stroma resembling embryonic white fat. differential diagnosis, based on clinical-pathological grounds, include fibrolipoma and myxoid liposarcoma. case a year-old boy presented with partial complex seizures for year duration. nmr showed a discrete hypodense corticalsubcortical lesion in the left frontal lobe. neither oedema nor mass affect was detected on ct scan. the tumour was completely removed by surgery and the pathological diagnosis was that of dysembryoplastic neuroepithelial tumor. this is an intracortical grade i tumour composed of oligodendrocyte-like cells. macroscopically, is a nodular outward expansion of the superficial cortex. histologically, a low-power view of a perpendicular section of the cortical surface shows the characteristic pattern of multiple intracortical nodules and internodular tissue, both containing mucin. also seen, is a specific glioneuronal component of vertical columns of neu-rites transversing the cortex, sheathed by oligodendrocyte-like cells accompanied by mucin and with 'floating neurons' (cortical ganglion cells seen in individual small pools of mucin). case a year-old boy presented with diplopia and proptosis. the nmr showed a hypodense, diffuse lesion in the left temporal and parietal lobes that produced a slight collapse of the left lateral ventricle. two weeks later the patient developed symptoms of time and space cognitive disturbances, language difficulty and seizures. a biopsy was done and the pathological diagnosis was that of gliomatosis cerebri. this is a rare primary brain tumour characterized by a diffuse proliferation of neoplastic glial cells that typically involve multiple brain areas with preservation of brain structures. the diagnosis depends on both histologic and radiologic features. on nmr there is a uni or bilateral diffuse involvement of the white matter extending to the cortex with poor mass effect. microscopically, there is a proliferation of monomorphous astrocytes, grade ii or iii, infiltrating the brain parenchyma freely. some undifferentiated cells show 'naked' nuclei while others look like 'rod' structures. in cases of low cellularity and cytologically bland astrocytes, it may be extremely difficult to make the differential diagnosis with reactive gliosis. gc is associated with a poor prognosis. introduction production of materials for dental implants is of great social importance and is related to the progress in material technology. main directions of development in this discipline concern an accurate choice of implant material in order to fix an implant in a bone tissue firmly and to decrease tissue reactions. new direction of research on implant materials is powder metallurgy. in comparison with the so far used technologies, it has many advantages, such as homogenous fine grained material structure, possibility to make composites including biologically active implants, and also ability to overgrow the implant with bone tissue. aim of the study was morphological analysis of healing of dental alveolus canals filled with metal implants. evaluation of tissue reactions in bones and surrounding soft tissue from several types of metal implants. material and method the experimental study was performed on mixed breed rabbits of - g weight. after premedication with atropine with relanium, surgical procedure was performed in each animal. one of the incisors was extracted and after the canal was formed, metal implant was inserted. the first group (d ) consisted of animals whose dental alveolus canals were filled with cylinder of x mm made of pressed co-cr-mo alloy covered with calcium triphosphate. the second group (d ) consisted of animals whose dental alveolus was filled with implants of cylindrical shape of a size x mm made of pressed co-cr-mo alloy. the third group (d ) consisted of animals whose dental alveolus canal were filled with a titanium screw of a size x mm. the control group (k) consisted of animals whose dental alveolus canal was left only with blood clot. the postoperative wounds were sutured with dexon thread. the clinical and observations and histopathological introduction correct reconstruction of bone defects is a serious problem in orthopedics and in maxillo-facial surgery. hence, numerous experiments and clinical studies on a usage of natural and artificial materials being a scaffold enhancing a reconstruction of bone tissue (i.e. carbon fibre, hydroxyapatyte granulate). deproteinized bovine bone is a new material. it was elaborated in at the mineralogy faculty, mining and steel academy in kraków. the technology of natural animal bone tissue enables its use in filling bone defects, accelerates reconstruction of bone tissue and minimizes unfavorable tissue reactions through total immersion into the reconstructed bone. it gives no incorrect immunological response of the body to the implanted xenogenic tissue. the aim of the study is to evaluate healing processes of the defects made in rat femoral bones and filled with deproteinized bovine bone and to compared it with spontaneous healing. material and method the experiment was conducted on wistar rats divided into groups ( rats per group). the surgically made bone defects were filled with the study material. the animals, whose defects filled with blood clots spontaneously, made up a control group. the healing process in bone tissue was examined clinically and morphologically after , , , , and days after the experiment. results in histopathological estimation, the healing speed of the defect in femoral bone filled with blood clot (control group) was compared to the healing of the defect filled with deproteinized bovine bone (study group). no inflammatory reaction to the implant was observed. moreover, acceleration of the healing of the defect filled with deproteinized bovine tissue was observed. bovine bone was, in the study group, totally immersed in the body's bone tissue, i.e. was surrounded by the arisen on its surface sponge bone. in the last periods of the observation, on the borders of the observed synostoses no osteoblast cell activity was observed and normal bone marrow was found between osseous trabeculae. conclusions osseous wounds filled with deproteinized bovine bone heal without any inflammatory complications. no negative systemic reactions proves that the applied material was properly prepared for implantation. histopathologic studies showed that deproteinized bovine bone accelerates regeneration process of a damaged bone tissue. withdrawn p- the effect of specific inhibitors of caspases on apoptosis of thymocytes induced with paclitaxel although caspases are involved in molecular mechanisms of the execution phase of apoptosis, the precise mechanisms of their involvement in paclitaxel induced apoptosis are still not identified. the aim of this study was to investigate and compare the effects of inhibitors of caspases ( mmol/l) on apoptosis of rat thymocytes induced by paclitaxel ( mmol/l) and colchicine ( mmol/l). the effect of z vad and specific inhibitors of caspases (caspase , and ) after , and hours of incubation of thymocytes with paclitaxel and colchicine were analyzed. after incubation cells were fixed, processed for lm and em, and the percentage of apoptotic cells (apoptotic index) was determined. general inhibitor of caspases zvad and inhibitor of caspase led to a significant decrease of apoptotic index after hours of incubation with paclitaxel (from . % to . % and . %). inhibitor of caspase and caspase lowered the apoptotic index after hours incubation with paclitaxel from . % to . % and . % respectively. inhibitor of caspase did not affect the apoptotic index in controls, while the other used inhibitors reduced it. inhibitors of caspase , and and zvad had similar effects on apoptosis of thymocytes induced by colchicine. these results show that apoptosis induced by paclitaxel is caspase dependent, and that it, due to the effect of inhibitor of caspase , probably involves mitochondria. caspase activity might also be involved in mechanisms of induction of apoptosis of thymocytes by paclitaxel. effects of concurrent administration of lithium and gentamicin on the histoembryogenesis of rat fetus during the developing periods this study was planned to investigate the effects of gentamicin and littium on rat histoembryogenesis and to determine the effects, if any, of lithium as a potent gentamicin inhibitor. the rats were exposed subcutaneously to -mg/kg gentamicin on days - of gestation. lithium administered orally at doses mg/l on days - of gestation. fetuses were collected on day and compared with those of the untreated, and saline treated control as well as with those of the gentamicin and lithium treated groups. all control and cases embryos groups were killed and their tissues were obtained. then prepared for paraffin block, sectioning, h-e staining and light microscopic studies. we fond that gentamicin caused growth retardation versus lithium which dosn't did so. lithium has a state like control but no wary exactly. furthermore, concurrent administration of gentamicin and lithium caused regularity in histoembryogenesis cycle and the normal growth beside the lithium or gentamicin. of course the recent result is not exactly comparable to those of controls. t- toxin, a solitary hypergranular mcs were situated on the external wall of blood vessels. however, on days , and the number of perivascular mcs was increased. more than percent of these mcs showed degranulation. conclusion our results suggest that perivascular localisation and later degranulation of mcs may play an importantant role during the acute reaction in the heart of rats poisoned by t- toxin. effects of bromadiolone on rodent liver: pathohistological findings o- , o- takeda k, p- takeyama j, p- talalaev a, p- talan-hranilovic j, p- tammi m, p- tammi r, p- tanase c, p- tanaskovic italy author index the numbers are the abstract numbers p- o- gruia am o- , p- o- , p- sever m, p- sever-prebilic m skender gazibara m, o- , o- , m, p- p- , p- , p- , p- , p- , p- , p- srebotnik kirbis i, o- arrhythmogenic right ventricle dysplasia and sudden cardiac death. controversial aspects p- basal cell characteristics in breast carcinoma with medullary features (cmf) acknowledgement: dr chu is supported by nhri-ex - sc, nhri-ex - sc and bmrp . all chosen antibodies gave a specific and reproducible staining. there were no false positive or negative results. the panel can be recommended for screening for defects in the mmr-system. immunoexpression introduction several cytological features are taken into account in infiltrating duct carcinoma of the breast. the aim of this study has been to assess the prognostic value of the nucleolar area by means of ultrastructural morphometry. materials and methods forty-six cases of ductal carcinoma of the breast were included in the current study. all biopsies were processed for electron microscopy and electron micrographs were taken at x , magnification. nucleolar area measurements were done using sigmascanpro software and statistical analyses were performed. nucleolar area measures were categorized in terciles. a kaplan-meier estimation was performed to assess those measures related with disease-free interval. measures that reached statistical significance were dichotomized at the cut point with maximum likehood in a cox regression model and then were included in a multivariate analysis. results statistically significant differences were found in terciles per area (p= . ) and per variation coefficient (p= . ). in terms of nucleolar area measurements, any given nucleolar area with a standard deviation . , showed a relative risk for recurrence of . ( . - . ) (p= . ).conclusions ultrastructural morphometry shows that nucleolar features, particularly those related to size heterogeneity, have a significant impact on prognosis. determination of ploidy in different lesions of prostate a ibraeva , m alchinbaev , a seitaliyeva scientific center of urology, department of pathology, almaty, kazahstan scientific center of urology, almaty, kazahstan immunohistochemical correlation between pattern of postatrophic hyperplasia and carcinoma of the prostate ar botticelli penile leiomyosarcoma-morphological and immunohistochemical study g berdan, a petrescu, c ardeleanu prof. dr. th.burghele hospital, bucharest, romania introduction our case is about a years old male patient who was admitted with the diagnosis of a penile tumor, reason why a total penectomy was performed. material and methods fragments of the tumor and penile tissue were fixed in formalin %, embedded in paraffin and sections were stained with he and vg. immunohistochemical tests have been done: actin, vimentin, s , ae -ae , hmb , pcna. results on macroscopic examination, the tumor was bulky, ulcerative nodular, occupying the glans and the distal part of the shaft; it was gray white coloured, with hemoragic areas. microscopic examination revealed a tumorous proliferation of elongated cells with moderate nuclear pleomorphism and mitosis (typical and atypical), organised in a fascicular pattern, well vascularised; the tumor was superficially ulcerated and invaded the corpora cavernosa. the tumor was diffusely positive for actin and vimentin, focally positive for s , negative for ae -ae and hmb , and pcna was %. conclusions the morphological appearance and immunhistochemical results led us to the diagnosis of penile leiomyosarcoma, moderately differentiated. do human papillomaviruses infect proximal parts of the male genital tract? introduction human papillomaviruses (hpv) play an essential role in the pathogenesis of squamous cell carcinoma of the uterine cervix. the male urogenital tract is considered to be a reservoir of hpv infection. our previous finding of hpv in the squamous metaplastic epithelium with dysplasia in the epididymis prompted us to start a study focused on the presence of hpv in the male genital tract. aims: verifying the presence of hpv in the epididymis, ductus deferens and seminal vesicles. materials and methods samples from three groups (a, b, c) of patients were analysed by means of nested pcr for the presence of hpv dna extracted from a paraffin-embedded tissue sections. types of hpv were determined by dna nucleotide sequencing of the pcr products. group a consisted of patients (mean age , age range - , except for one patients years old), group b consisted of patients (mean age , age range - , except for two patients and years old) and group c consisted of patients (mean age , age range - ). patients in group a were surgically treated for non-tuberculous epididymitis ( epididymal introduction glucagonoma is an alpha-cell pancreatic neoplasm with incidence of one in million; the malignancy rate is unknown. the clinical, pathologic, immunohistochemistry and electron microscopy characteristics are described in a mexican cohort of patients. material and methods we reviewed the pathology archives of incmynsz and hocmnsxxi for pancreatic tumors with neuroendrocrine morphology and expression of immunohistochemistry markers for neuroendocrine and glucagon-related peptides. complete clinical history and follow-up were achieved. results six cases of glucagonoma were obtained. electron microscopy was available in two cases. three man and three women with median age of . years, were admitted with glucagonoma syndrome complaints. the tumor localization was: head of pancreas ( / ) and tail ( / ), with average size of . cm. two cases showed hepatic metastasis. the histopathologic study was constant with contrasting architectural, cytologic and mitotic count in all the cases. expression of neuroendocrine markers was observed in all cases, with positive glucagon stain, and negative for secretion markers (insulin, pp, serotonin, calcitonin). in electron microscopy, dense core granules were identified in two cases. discussion there are cases of glucagonoma described in english literature; no one is originated from latin american population. in this series, the neoplasms have equal prevalence for female and male patients, all from elderly group. the morphologic feature extremely varies in each tumor, the malignancy criteria were correlated in two cases with vascular invasion and this coincides with metastasis. a peculiar finding are the only expression of glucagon in tumoral cells, and two malignant cases with liver metastasis. estrogens regulate the development, maturation, and function of various organs, including the thymus. therefore it is suggested that estrogens play important roles in the development of human thymoma. however there is no study about influences of sex steroids to human thymoma. in this study, we examined the immunohistochemical localization of sex steroid receptors for estrogen (er)α and erβ, progesterone (pr)-a and pr-b, and androgen (ar) in human thymoma (n= ), and correlated these findings with various clinicopathological parameters. we used reverse transcription polymerase chain reaction (rt-pcr) and realtime pcr to further study the expression of these receptors in thymoma cases. results immunoreactivity for all sex steroid receptors was detected in the nuclei of thymoma epithelial cells. the percentage of immuno-positive cases and h-score values for each receptor (mean±sd) were: erα, . % and . ± . ; erβ, . % and . ± . ; pr-a, . % and . ± . ; pr-b, . % and . ± . , and ar, . % and . ± . , respectively. results of real-time pcr were consistent with those of immunohistochemistry especially results for erα, pr-b, and ar. a significant positive correlation was detected between immunoreactivity for erα and pr-b. erα immunoreactivity was inversely correlated with tumor size, clinical stage, who classification and ki- labeling index. in addition, the status of erα immunoreactivity was significantly associated with a better clinical outcome in thymoma patients. conclusions sex hormones receptors express in human thymoma, and especially erα may be related to sex, clinical stage and pathological cell type. galectin- immunodetection using a biotin-free system in a series of oxyphilic (hurthle) cell tumors of the thyroid m volante , f bozzalla , r depompa , c pecchioni , a bartolazzi , m papotti dept. biomedical science and human oncology university of turin, turin, italy s. andrea hospital, university of rome, rome, italy introduction galectin- was reported to distinguish follicular and papillary carcinomas of the thyroid from adenomas, but controversial results were obtained in oxyphilic cell tumors, possibly related to endogenous biotin reactivity. the aim of this study was to assess the role of galectin- immunodetection in a large series of benign and malignant oxyphilic tumors. materials and methods galectin- expression was retrospectively analysed in thyroid oxyphilic (hurthle) cell tumors, including adenomas [oa], carcinomas [oc], oxyphilic variant of papillary carcinoma [optc] and in control cases of goiter with oxyphilic changes and hashimoto's thyroiditis. a purified galectin- monoclonal antibody and a biotin-free immunoperoxidase procedure were used in paraffin embedded specimens. results of ocs were focally ( cases) or diffusely ( cases) positive. / optc were focally ( cases) or diffusely ( cases) reactive. overall, malignant oxyphilic tumors were positive in % ( / ). oa had a focal reactivity in % ( / ) of cases, with a preferential subcapsular immunostaining. sensitivity and specificity were % and %, respectively. control oxyphilic goiters were negative ( / ), as opposed to hashimoto's thyroiditis (oxyphilic cells positive in / cases). conclusion the role of galectin- immunoreactivity in the differential diagnosis of benign and malignant follicular lesions is confirmed also in oxyphilic cell tumors. the focal immunoreactivity observed in adenomas may be probably related to a true expression of galectin- , as confirmed by mrna expression by means of in situ hybridisation, and could be related to early malignant changes in tumors still lacking the currently accepted morphological signs of malignancy. introduction fine-needle aspiration (fna) is a very useful method for diagnosing various lesion in the thyroid gland, among them hashimoto's thyroiditis (ht). although many methods may be used, fna is a necessary diagnostic procedure nowadays in order to confirm the diagnoisis of ht. material and methods durind a period of years citologically aspirates were citologically analyzed, stained with he and mgg. the main cytological guidelines in the diagnostic procedure were: . lymphocytic cellularity of smears, . oncocytic follicular cells, . a lot of cellular debris. results from aspirates analyzed ( , %) were diagnosed as ht. there was a high statistical significance in sex and ages for the genesis of ht (χ = , ; p= , ). we analyzed correlation between clinical and cytological diagnosis: in cases initial clinical diagnosis was "thyroiditis", and among them ( %) were cytologically confirmed. from patients with an fna diagnosis of ht the same diagnosis was susspected clinically in cases ( %). several authors noted a high incidence of thyroid carcinoma in patients with ht. we researched association of ht and thyroid tumors, and we did not confirm that ht is a premalignant lesion (χ = , , p< , ). conclusion ht and its association with other lesions could be clearly diagnosed with fna, and we recommend fna as a first line investigation in ht. colposcopic and cytologic findings in hpv infection of the uterine cervix r zivadinovic, v lilic, b djordjevic, s petric gak nis, university clinical center, nis, serbia and montenegro introduction uterine cervical carcinoma is a sexually transmitted disease. hpv infection, especialy types , and oncogene is directly associated with occurrence of preinvasive and invasive changes in the uterine cervix ranging from - %. cyto-pathologic effect of this virus presence in a cell is called koilocytosis and occurs by the effect of fragment e on cytokeratin building protein.koss observed these changes back in , describing them as irregular cavities in cell protoplasm, but only later these cytologic findings were related to hpv infection. in our retrospective study we analyzed colposcopic and cytologic findings of examinees in which the diagnose of hpv infection was established by biopsy. material and methods the mean age of examinees was , , and in regards to parity and menarche there was no statistically significant difference between experimental and control group, since coefficient t was lower than , p< , . therefore we concluded that the sample was representative. results sensitivity of cytology in detection of hpv infection of the uterine cervix was , % and the specificity was %. positive predictive value was % and negative %. the most frequent colposcopic findings in the uterine cervix in case of hpv infection were aceto-white epithel in % and mosaic in %. other colposcopic findings were significantly lower (punctate %, leucoplakia , %). in examinees with colposcopically diagnosed hpv infection in external genitalia, the infection was also present in the uterine cervix in , % which was statistically significant for x = , >(x ( ; , )= , ). conclusion based on the results presented above, we concluded that sensitivity of cytology in the detection of hpv infection of the uterine cervix was low and that it was necessary to combine that method with colposcopy and directed biopsy. in case of colposcopically diagnosed condylomas of the external genitalia and presence of pathologic colposcopic findings of the uterine cervix (aceto-white epithel, mosaic), the presence of hpv infection in the uterine cervix can be expected with high probability. fine needle aspirate of papillary thyroid carcinomas in correlation with histological diagnosis material and methods cases of thyroid aspirates were studied in correlation with histological findings. the patients were - years old (mean age , ). cytological diagnosis was made according to morphological criteria such as arrangement of cells, nuclear atypia and special features (colloid, giant cells, psammoma bodies). cytological diagnosis was in agreement with the histological diagnosis in cases ( , %). cases were follicular adenomas and one hürthle cell tumor. in cases of disagreement between cytological and histological diagnosis the cytomorphological findings were analysed. conclusion cytological evaluation of papillary thyroid carcinomas is of high diagnostic accuracy, although overlapping of cytological criteria between the various pathological entities may lead to false evaluation. the value of universal short-term storage cell medium in processing fnab samples for ancillary diagnostic methods introduction the application of ancillary methods to fnab samples is mainly impaired by a limited quantity of cells in the introduction changes in the collagenous matrix may participate in the pathogenesis and progression of human aortic valve stenosis (as). we investigated the expression, localization, rate of synthesis and composition of type i and iii collagens in as. methods type i and iii collagen mrna expression and the immunohistochemical localization of the collagen antigens were studied from as and normal aortic valves. the concentrations of various type i (pinp, picp, ictp and synthetic peptide sp ) and iii (piiinp and iiintp) collagen antigens were measured by radioimmnoassays in soluble tissue extracts and trypsin solubilized calcified and noncalcified matrices of as samples, and healthy aortic valves of different ages. results the synthesis of type i collagen, localized in the myofibro-blasts adjacent to calcified nodules, was - -fold higher in as compared to controls. the proportion of collagen in total protein fraction was % in the healthy valves, % in the noncalcified matrix and % in the calcified matrix of as valves. in calcified valves the ictp content was -fold higher than in the age matched controls and -fold higher than the young control group. in the controls, ictp (r=- . , p< . ) and iiintp (r=- . , p< . ) decreased with age, whereas sp /ictp ratio increased (r= . , p< . ). conclusions type i collagen synthesis was increased in as. localization of this collagen adjacent to calcified nodules and the profile of the c-telopeptide cross-linking indicate that the ectopic aortic valve calcification may have similarities to bone matrix mineralization.introduction the objective of this study was to determine the potential value of digital thermography (dt) for the assessment of micro-and macroangiopathies of lower limbs in diabetes mellitus (dm). we have studied patients (pts) with dm ( male). pts had dm type i, pts had dm type ii, with age varying from to years. thermograms were acquired using an original pc-interfaced thermograph, averaged and reformatted to x -bit images. analysis included filtering, background cutoff, obtaining x-and y-axis profiles and averaged temperature curves (atc), determination of local maximums and minimums of the atcs, definition of anatomic regions, building regions of interest (roi). results following thermogram patterns were found: . asymmetric unilateral hypothermia of st toe (in % of dm i cases; probably indicating microangiopathy); . bilateral symmetrical hypothermia of both feet at the level of distal phalanges (in % of dm i cases); . unilateral hypothermia of foot ('thermo-amputation'); . unilateral hyperthermia of foot and tibial region; . focal hyperthermic regions (diameter = .. cm; indicating potential subsequent ulceration). atcs and symmetric left-right roi comparisons helped distinguishing between macro-and microvascular disease, between neuro-and angiopathy in dm, evaluating therapy effectiveness. dt was most valuable in surgical cases, permitting ( ) to locate the optimum level of amputation and ( ) to detect early the inflammation. conclusion dt results correlate well with pathomorphology, and depend upon dm type, dm duration, and presence of local inflammation. immunomodulatory treatment improves myocardial histopathology and function in patients with biopsyproven myocarditis aim the aim of this study was to determine the impact of immunomodulatory treatment (interferon-α) on myocardial histopathology and contractility in patients with biopsy-proven myocarditis (mc). methods a total of consecutive pts ( / male, mean age + years, baseline ef= . + . %) underwent endomyocardial biopsy which established diagnosis (using modified dallas classification) of mc (active mc in / pts, focal-active mc in / pts, borderline mc in / pts, and healing mc in / pts). all patients received interferon-α (sc application, miu, time pw, for months) on top of conventional triple therapy for heart failure. rebiopsy was performed in all patients after the termination of interferon-α treatment, and both baseline ef and repeated biopsies were analyzed. semiquantitatively we comapred the amount of cellular infiltrate, degenerative and/or necrotic changes, and interstitial fibrosis. repeated biopsies were than classified as improved, no change and/or deteriorated, for each histopathological variable (by pathologists, in a blinded manner). results by the end of interferon-α treatment ef improved significantly ( + . % vs. . + . %), and no deaths were introduction tumor necrosis factor (tnf)-alpha has been recognized as important physio-pathogenic factor in the initiation and continuation of inflammatory cardiomyopathies. experimental and preliminary human studies have demonstrated that tnf-alpha plays a crucial role in enteroviral-induced myocarditis. the aim of this study was to investigate the expression of tnf-alpha and both its receptors (tnfri and tnfrii) in the endomyocardial biopsies of patients (pts) with viral and non-viral myocarditis. myocardial expression of tnf-alpha was then correlated with different clinical and pathologic findings. material and methods tnf-alpha expression was investigated in endomyocardial biopsies obtained from pts with myocarditis and from control subjects by using reverse transcriptase (rt)polymerase chain reaction (pcr) and immunohistochemistry. viral etiology was diagnosed by pcr in cases. immunohistochemistry was also used to analyse both tnf-alpha receptors (ri and ii). score - was used to grade morphological findings. tnf-alpha mrna and tnf-alpha protein was significantly more present in viral myocarditis than in non-viral myocarditis ( / vs / , p= . ). remarkable immunostaining was observed for both receptors, particularly for tnfri. histological analysis revealed that myocardial necrosis (score . vs . p= . ) and cellular infiltration (score . vs . p= . ) were more prominent in tnf-alpha positive cases. among tnfalpha positive cases, tnf-alpha mrnas were greater in pts with more impaired cardiac function. conclusion our findings indicate that the expression of tnfalpha plays an important role in the pathogenesis of viral myocarditis of any etiology and may influence severity of cardiac dysfunction. cytokine effects are more strictly linked to overexpression of tnfri. recurrence of viral myocarditis after cardiac transplantation: a retrospective study in a pediatric population introduction the objectives of this study was tot verify comparatively clinical age reported antecedents and the morphological aspect of the intestinal mucosa in patients sensitive to gluten, hospitalised at iomc (alfred russescu hospital) in the last years. celiac disease is an inflammation most frequently affecting the proximal small intestine, depending on the presence of gluten in the diet, whose pathogenesis seems to be immunological in nature. methods cases were divided in three groups following clinical manifestations types at hospitalisation time: typical digestive, untypical digestive and extra digestive manifestations. intestinal biopsies, made with crosby probe, in children aged between . and years (one single case was diagnosed as late as at the age of ), regardless of gender. then we analysed morphologically (he usual and pas histochemical staining) and immunohistochemically (lymphocytes b, t with possible subtypes). the lesions counted according to the marsh score were at the first biopsy: - marsh i infiltrating lesions (normal mucosa architecture, villi epithelium infiltrated with lymphocytes; lymphocytosis score: lymphocytes / enterocytes); - marsh ii infiltrating lesions (almost normal villi, enlarged crypts with immature epithelium and infiltrated with lymphocytes); - marsh iiia destructive lesions (partial villi atrophy (va) shortened, flattened villi, slight infiltration with intraepithelial lymphocytes and hyperplasic crypts); - marsh iiib destructive lesions (subtotal va clearly atrophied villi, still recognizable, widened hyperplasic crypts containing immature epithelial cells with a higher growth rate and influx of inflammatory cells); - marsh ilic hyperplasic lesions (total va completely absent villi, with severe atrophy, atrophied, hyperplastic glands and infiltrating lesions). the immunohistochemical tests have indicated the prevalence of t lymphocytes (uchl , cd , cd , cd , gama-delta) both in the luminal epithelium with various degrees of aggression in lamina propria and also spread in stroma. b lymphocytes (l ) are distributed prevalently nodular in stroma. conclusion in conclusion, it is cd t cells that are present in particular in the control of the gluten immune response in patients with marsh i and marsh iii lesions. clinical morphological analysis of early forms of polyarteritis nodosa h mazur- introduction polyarteritis nodosa is a necrotic vasculitis of small and medium size arteries of not fully recognized aetiology. however, it occurs mostly in adults, it can also occur in children. the cutaneous form is one of the types of polyarteritis nodosa. it occurs in children very rarely. polyarteritis nodosa is diagnosed on the basis of histopathologic results and clinical criteria established by the america college of rheumatology. the aim of the study was to present cases of polyarteritis nodosa in children. case reports three cases of cutaneous polyarteritis nodosa in year old girls and case of general form of p.n. in a -year old boy at the beginning a tumour of pancreas head was suggested in the latter case. the final diagnoses in all cases were defined on the basis of histopathologic results the morphologic studies showed: skin and subcutaneous tissue specimens of mm diameter and mm thick were evaluated. epidermis and corium were of normal structure. abundant inflammatory infiltration consisting of neutral and acidophilic granulocytes, lymphocytes and plasmatic cells were observed on the boarder of corium and subcutaneous tissue. the infiltration was situated mainly in arterial walls and surrounding fibrous and fatty connective tissue. different degrees of change advancement were observed in the walls of the vessels. some changes were characteristic for an early stage of a disease and were demonstrated as swelling of the vessel wall and surrounding tissues (degeneration stage). in the oedematous wall fibrin concrement and only a few inflammatory cells were present. other cells included abundant transmural inflammatory infiltrations (inflammatory stage). vessel endothelium underwent desquamation and thrombi begun to appear in the arterial lumen. only in few vessels, the process of considerable advancement of changes was observed -a repair process with consecutive fibrosis and thickening of arterial wall with considerable narrowing of its lumen. the described children were treated successfully with corticosteroid therapy and antistreptococcal prophylaxis with long-term remission. comparative morphologic analysis of the small intestine mucosa in a course of coeliac disease p- effects of sildenafile on ipsilateral testis damage following testicular torsion in rats g kale , ih gol , d orhan , n kale hacettepe university, medical school, ankara, turkey gazi university, medical school, ankara, turkey introduction testicular torsion results in damage of the gonad and it is a surgical emergency. testicular torsion evokes infertility as a result of ischemia. the aims of this study were to determine the effects of a vasodilatator agent sildenafile on the testicular damage following testicular torsion. materials and methods forty-two rats included to the study were divided into groups: group ; control, group ; sham, group : torsion (detorsion is performed hours after torsion and orchiectomy is done at the th hour), group ; torsion, detorsion and sildenafile ( mg/kg), group ; torsion and sildenafile ( mg/kg), group ; sildenafile ( mg/kg) without torsion, group ; sildenafile ( mg/kg) without torsion. testicular specimens were examined histopathologically for johnsen tubular score and tubular diameter. the differences of these parameters between groups were evaluated statistically. results johnsen tubular score and tubular diameters were fond to be significantly different in control and torsion groups (p< . ). johnsen tubular score and tubular diameter were significantly higher in the torsion groups which were given sildenafile, and these parameters were again higher in the group which have taken sildenafile at a higher dose (p< . ). conclusion it is concluded that, by inhibiting cyclic guanosin monophosphate specific phosphodiesterase and resulting in vasodialatation, sildenafile reduces the testicular damage caused by torsion (ischemia). introduction autopsy studies in adult patients who had died of sepsis revealed a profound, progressive, apoptosis-induced loss of cells of the adaptive immune system (hotchkiss et al, new engl j med, ; : - ) . in neonatal sepsis and chorioamnionitis, thymus modifications and shrinkage have been exhaustively described (toti et al, hum pathology ; : - ), while morphology of the spleen has not. the aim of this study was to describe the morphology of the spleen in neonates with early onset sepsis and with chorioamnionitis. material and methods the study population has been described previously (toti et al, hum pathology ; : - . ten preterm or full-term neonates who died because of proven sepsis within hours after birth (mean gestational age±sd, . ± . weeks); foetuses spontaneously aborted ( ± . weeks) because of extensive ascending chorioamnionitis. controls included foetuses with induced termination of pregnancy ( ± . weeks) and babies who died suddenly in the perinatal period, without evidence of chorioamnionitis. spleen cell populations were studied by means of immunohistochemistry. results early onset sepsis in the neonates occurred with severe spleen depletion, involving both b and t lymphocytes. in particular, cd +, cd r + and cd + cells were dramatically diminished in the spleen of neonates with sepsis, in comparison to controls. foetuses with chorioamnionitis also showed spleen cell depletion. conclusion these results indicate that preterm and term neonates show an inflammatory reaction similar to that of adult patients, and that chorioamnionitis is associated with an unspecific inflammatory response comparable to that of sepsis. introduction hemophagocytic lymphohistiocytosis (hlh) is a disorder of an immunological disturbance with proliferation of cells of the mononuclear phagocyte system, with the histiocyte as a central cell. it includes two different conditions: primary or familial hlh, an autosomal recessive disorder in which most patients develop the disease very early in life, and secondary hlh associated with neoplastic, autoimmune and a variety of infectious diseases, occurring as sporadic cases throughout life period. clinically the disease is characterised by the occurrence of a hemophagocytic syndrome of prolonged fever and splenomegaly with laboratory signs of cytopenias, lipid, coagulation and liver abnormalities. hemophagocytosis is readily identified in bone marrow, spleen or involved lymph nodes. central nervous system spread of the disease may be present early, but is frequently seen later during the course of the disease. the aim of this study was to presentat an autopsy case of a months old boy. case report signs of hlh were present right after birth. he was treated by the treatment protocol hlh- . the disease later progressed with cns involvement. a complementary bone marrow donor was not found in time. tissue samples collected at the autopsy were proceeded with standard histological and immunohistochemical methods. results severe bleeding in the right lung with other signs of coagulopathy were found as the main cause of death. hepatosplenomegaly was a prominent feature. we detected hemophagocytosis in the bone marrow, liver and central nervous system. conclusions the diagnosis of hlh must be based on clinical, laboratory and cyto/histological findings. the pathogenesis of familial hlh is still not completely understood. introduction a changeable number of goblet cells in intestine epithelium is rarely a matter of consideration among other morphological factors of small intestine mucous membrane atrophy in celiac disease. it is also not evaluated in the current classifications of goblet cell condition in celiac disease. the aim of the study was to evaluate a number of goblet cells in small intestine epithelium with reference to the degree of atrophy in celiac disease. morphological analysis of bioptates of small intestine mucous membrane, taken for a routine histopathologic diagnosis from patients aged from to years, was performed. the patients were diagnosed and treated in paediatric university hospitals in zabrze and bytom in the years - . specimens were stained with haematoxylin and eosin (h.e.) and alcian blue-pas (ab-pas). villous atrophy was evaluated according to the modified marshal scale. results the following types were defined: type - cases, type - cases, type - cases, type a - cases, type b - cases, type c - cases. then, a number of goblet cells per enterocytes of small intestine epithelium of each oligobioptate were calculated. the received results were evaluated statistically with u mann-whitney test. the average number of goblet cells in small intestine epithelium was calculated in relation to the degree of atrophy with the modified marsh scale: type - . (+/- . ), type - . (+/- . ), type - . +/- . ), type a - . (+/- . ), type b - . (+/- . ), type c - . (+/- , ). the analysis used significant relations between an average number of goblet cells in small intestine epithelium and a degree of mucous membrane atrophy in celiac disease. moreover, a correlation according to rang spearmann test showed a coefficient r= . for p< . . conclusions significant relation between a number of goblet cells in epithelium and a degree of small intestine mucous atrophy in celiac disease. it allows an introduction of a new objective quantitive parameter in the evaluation of atrophic lesions. introduction microscopic evaluation plays an important role in diagnosing small intestine inflammatory diseases. defining a degree of villous and brush border atrophy, enterocytes changes, elongation of glandular crypts allows a correct evaluation of treatment clinical effects and child's body response to the applied selective diet. development of immunomorphological studies contributed to confirmation of the autoimmunological basis of several diseases and of the influence of exogenous factors on their development. due to the new approach, evaluation of the changeable character of inflammatory infiltrations including mast cells and marking activity of enteroendocrinal cells have become very important diagnostic elements. the aim of the study is to examine a changeable intensity of infiltrations from mast cells of small intestine mucosa in children in the course of celiac disease. material and method oligobioptates of small intestine mucosa taken in endoscopy from patients (age - years) at the department of pathomorphology in zabrze in the years - . the patients were diagnosed and/or hospitalised in paediatric university hospitals in zabrze and bytom. a degree of villus atrophy was evaluated according to the modified marsh classification. tissue material in paraffin cubes from the routine oligobiopsy of the patients with celiac disease was qualified for immunohistochemical study. immunohistochemical reactions revealed a presence of brown dyed mass cells in intestine mucosa. the cells were evaluated by counting their number in high power fields (magnification x) in each oligobioptate. the received results were calculated statistically with mann-whitney u test. results mean number of mass cells in intestine mucosa was calculated in relation to the degree of villus atrophy according to the modified marsh classification: type (status normalis) - . (+/- . ), type - . (+/- . ), type - . (+/- . ), type a - . (+/- . ), type b - . (+/- . ), type c - . (+/- . ). the analysis showed significant relation between a number of mass cells and a degree of mucosa atrophy in a course of celiac disease. moreover, a correlation after the rang spearman test showed a coefficient r= . for p< . . conclusions significant relation between a number of mass cells and a degree of small intestine mucosa atrophy in a course of celiac disease was shown. defining (marking) a number of mass cells in small intestine mucosa in a course of celiac disease allows an introduction of quantitive method of atrophic changes evaluation as a new objective parameter, especially in cases difficult to diagnose. morphological analysis of tissue reactions in mandible after dental implants of the pressed cocrmo alloy introduction schistosomiasis mansoni infection increases the level of prostaglandins and leukotrienes that are secreted mainly by macrophages within the granulomas. these mediators have a pronounced role in mediation and modulation of inflammation. most non steroidal anti-inflammatory drugs (nsaids) act mainly by inhibiting the cyclooxygenase pathway of arachidonic acid metabolism, thereby diverting it towards the lipoxygenase pathway. these leukotrienes are important in maintenance of acute and chronic inflammatory condition. methods in present study, we used mofebutazone (cylcooxygenase and lipoxygenase inhibitor) and tenoxicam (cylcooxygenase inhibitor) either alone or in combination with praziquantel (antibilharzial drug) in mice infected with schistosomiasis mansoni. we study their effects on liver pathology as pcna (proliferating cell nuclear antigen), granuloma diameters, percent of degenerated ova and type of granuloma after & weeks after infection. results shown that infection increased the percent of positive nuclei in granuloma and in hepatocytes to be about % & % at weeks and these percentages were reduced to be about % & % at weeks after infection respectively. treatment with mofebutazone and tenoxicam produced a reduction in pcna to be about % & % in granuloma and % & % in hepatocytes at weeks and more reduction occurred after weeks after infection. also, mofebutazone tended to produce more protection to isolated hepatocytes (% viability of hepatocyte) than tenoxicam in schistosomiasis mansoni infected mice. combined therapy with praziquantel produced more reduction in pcna and more protection to hepatocytes. it is evident from the present study that, mofebutazone when combined with praziquantel has shown good tolerability more than tenoxicam which was associated with an improvement in pcna, granuloma diameter, % viability of isolated hepatocytes, liver function tests, a fact that would seen to advocate the use of mofebutazone in bilharzial patient. patterns of injury in car and motorcycle accidents jm suárez peńaranda, c bellido, r rico, mt alvarez iglesias, m rodríguez calvo, i muńoz, l concheiro institute of legal medicine, santiago de compostela, spain introduction the role of the forensic pathologist in road-traffic accidents is to detect atypical injuries that could suggest an alternative cause of death, demonstrate natural diseases capable of creating sudden incapacity, and to collect samples for toxicological examinations. the main objective of this work is to study the different patterns of injuries in car and motorcycle fatalities. material and methods we have studied the autopsy reports of deaths related to road traffic accidents ( involving cars and motorcycles). a complete autopsy was performed in every case including toxicological investigation. results the most common cause of death was head injury, responsible for % and . % of deaths in car and motorcycle accidents, respectively. cranial base fractures were more commonly found in passengers rather than in drivers, both for cars and motorcycles ( % vs. % and . % vs. %, respectively). the distribution of cranial vault fractures was similar with percentages of and . for car and motorcycle drivers, versus and per cent for the respective passengers. nevertheless, brain injury was even more frequent in car accidents, accounting for % of the cases, and in motorcycle fatalities, where every single case showed some degree of brain injury. conclusion our results confirm the importance of head injury in road-traffic accidents, especially when motorcycles are involved, being the most common cause of death. although all motorcycle victims wore a helmet at the time of the accident, it did not seem to provide an effective protection, probably because of the high speeds involved. the incidence of cranial fractures and brain injury is higher for passengers than for drivers, probably due to the lack of attention to the traffic of these latter, and the fact that drivers are usually holding the handlebar or wheel at the moment of the accident. heat-induced epitope retrieval in immunohistochemistry c espersen, b crillesen, b jepsen, jw hansen, th veie, h winther, j askaa department of immunohistochemistry, dakocytomation a/s, glostrup, denmark introduction heat-induced epitope retrieval (hier) has dramatically changed the applicability of immunohistochemistry in routine pathology. hier has increased the number of primary antibodies useful on formalin-fixed paraffin-embedded material and in general improved the histochemical staining. the aim of this study was to compare various buffers for hier on a broad range of primary antibodies. materials and methods hier using four different buffers (citrate ph ; tris/edta ph ; dakocytomation target retrieval solution, high ph, code no. s and dakocytomation target retrieval solution ph , code no s ) for pre-treatment of formalin-fixed paraffin-embedded material has been compared using more than different primary antibodies and the envision+tm visualisation system.results hier with citrate buffer retrieve epitopes recognised by the majority of the tested antibodies. however, in several cases the epitopes could not be detected using this method but were retrieved using tris/edta and/or target retrieval solution, code no. s . also retrieval by means of the target retrieval solution, high ph can be used however, the morphology quite often was partly destroyed. furthermore, some antibodies could only be used after enzymatic pre-treatment whereas hier abolished the histochemical staining. conclusion although hier using citrate ph buffer is a standardised and widely used technique, it is in numerous cases sub-optimal or even obliterate the immunohistochemical staining. in general more epitopes can be retrieved using tris/edta ph or dakocytomation target retrieval solution. bone morphology and calcemia in ovariectomised (ovx) wistar rats l markovic postmenopausal oestrogen deficiency results in bone loss (osteoporosis) in humans and experimental animals. wistar rats provide a useful experimental model of post-menopausal osteoporosis. to demonstrate the histomorphometric and histological changes of bone weeks after bilateral ovariectomy in rats and to investigate the impacts of different hormone replacement therapies on the bone. specimens of proximal femur were embedded undecacified for histomorphometric analysis and of distal femoral metaphysis were procured for pathologic examinations. three weeks after ovx the femoral bmd, mean cortical thickness decreased significantly while the number of osteoclasts increased significantly as compared with sham group. the trabeculae became thinner and irregular which changed the bone microstructure in three dimensions. after treatment with different preparations, the above parameters restored to various extents to the sham operation levels. bilateral ovariectomy induced increased osteoclast activity and bone turnover, therefore caused accelerated bone loss. treatment with combined sex hormones preparation could inhibit bone absorption and stimulate bone formation. this investigation was supported by mstd of srbia. vilnius pathological anatomy in the first half of the th century d sabat department of pathomorphology, medical university of silesia, zabrze, polandthe beginnings of pathological anatomy as a separate medical subject were connected in the area of the republic of poland and lithuania with the vilnius university. the first post mortem was done in vilnius by a priest, stefan bisio only in year. at the end of the th century, jakub briotet, a surgeon and anatomist, created a modest anatomical surgery (study). in , jan piotr frank and his son józef arrived to vilnius and became professors of the university. jan piotr frank became the head of the teaching hospital and józef frank the head of the chair of pathology. in november , he started lecturing for students, which he recalled in his "memoirs": several days after my father, i also started a course with a dissertation "de meliori pathologiam tradendi modo" in this speech i put the main stress on a significance of the explanations at the patient's bed-side and of a good knowledge of pathological anatomy… when in , józef frank became the head of the teaching hospital, he founded the first anatomo-pathological study (surgery). most of the samples kept in spirit in the frank's study were eaten by the starving french soldiers during the retreat of napoleon's army. besides frank's study at the vilnius university at the chair of anatomy, there still existed the study founded by briotet. in , the emperor alexander i destined the ruins of the spaska's orthodox church for an anatomical theater. after seven-year redecorations, the building was opened in . besides the theatre itself, dissection room and veterinary institute, it also included a zoological, veterinary and anatomical museum. the growing anatomical museum had, in , preparations including anatomopathological preparations. after closing down the vilnius university and foundation of the academy of medicine and surgery, pathological anatomy was made an individual subject of study. the first lecturer of pathological anatomy in vilnius was ludwik siewruk. he held the classes till and then he took charge of the chair of anatomy at the moscow university. his successor was jan leonow who continued his work until the tsar's authorities closed down the academy of medicine and surgery in . after the academy had been closed down, all the exhibits of the vilnius anatomical museum, including anatomopathological preparations were moved to the anatomical museum of kiev university. few of them remained in the vilnius medical society. introduction t- toxin, a mycotoxin produced by fusarium fungi, is a well-known cardiotoxin that cause myocardial injury, capillary damage, haemorrhage and focal polymorphonuclear cell infiltration. mast cell (mc) is one of the the earliest multifunctional effector cells of the immune system and important constituent of microvasulature in the heart. aim: we wanted to investigate appearance and localisation of mast cells in the heart of t- toxin-poisoned rats. materials and methods adult female wistar rats were poisoned with a single injection of ld- of t- toxin ( . mg/kg sc). rats were divided into two groups: ( ) control group and ( ) t- toxin group. t- toxin was produced in laboratory conditions from fusarium sporotrichoides fungi. animals were sacrificed after the end of the day , , and of the study. cardiac mcs were counted in whole visual fields, magnified by -fold on paraffin section stained with haematoxylin and eosin (he) and giemsa methods. results in the heart of rats treated with t- toxin, blood vessels were congested with thickned walls, and a large number of mononuclear cells was present nearby. hours after administration of introduction bromadiolone is one of the most commonly used rodenticides. this coumarin anticoagulant blocks multiple steps in the coagulation cascade. it is absorbed through the gastrointestinal tract and accumulated in the liver, mainly. the aim of this study was to investigate pathohistological alterations in the liver after oral application of bromadiolone in rodents. materials and methods adult wistar rats and swiss mice, of both sexes, were fed with a ready-to-use baits of low bromadiolone concentration ( . %), for first three consecutive days. animals were sacrificed every day during the one week period, starting with h after the beginning of the experiment. liver paraffin sections were stained by haematoxillin and eosin (he) method. results the pathological alterations detected in all animals ranged from diffuse degeneration to a focal necrosis of hepatocytes and massive circulatory changes. parenchymal degeneration, diffuse oedema and hyperemia were predominant in the liver of animals sacrificed on the first three days of experiment. dissolution of cytoplasm with nuclear pleomorphism in round or ovoid hepatocytes were seen. thickening of the blood vessels with necrosis of endothelial cells were particularly prominent from the fourth to seventh day of experiment. the most interesting finding is the presence of massive hemorrhages with a focal mononuclear cell infiltrations. the majority of hepatocytes were irregular, with macronodular fat transformation of cytoplasm. these changes were the most intensive in male mice on the day of the study. conclusion multiple oral ingestion of bromadiolone induced prominent pathohistological alterations in rodent liver, especially mice. mobile telepathology -a new intringuing tool s seiwerth, l batelja institute of pathology medical faculty, zagreb, croatiathe mobility of information, patient data and images introduced by telemedicine/ telepathology systems designated a completely new viewpoint in pathology. mostly two areas of diagnostic work are so far covered by telepathology service -second opinion/expert consultation and frozen section diagnosis. frozen section diagnosis, is still a very important issue. smaller hospitals, with no sufficient material for a resident pathologist often could benefit by introduction of telepathology. as in many of these hospitals surgery requiring frozen section diagnosis is not performed on a daily basis the telepathology system is not in full use, producing an unfavorable cost-benefit ratio. also establishing a fully equipped frozen-sections lab yields additional costs and personnel cutting frozen sections only occasionally often produce suboptimal. in this the introduction of a mobile telepathology unit could solve some very important problems. the unit should include a fully equipped mobile frozen sections lab including a macro stand and a microscope with ccd tv color camera and a notebook (laptop) computer. the telepathology software used must be stabile and versatile like the pharos/issa system (vamstech, croatia) used by us. by such a system and synchronization of operation schedules hospitals in a radius of up to km around the referral center could be covered without exceeding standard working hours. the issa-server based system option alerting the consultant and referring pathologist by sms that a consultation case is in his mailbox at the server ads additional time effectiveness. a novel high throughput marker validation tool j korbelik, j matisic, c macaulay b.c. cancer agency, vancouver, canada high throughput genetic and expression screening is generating many possible diagnostic markers and therapeutic targets for wide variety of clinical conditions. the rapid validation of these markers is a challenging process. tissue microarrays can be used for the evaluation of many of these markers. however, they have drawbacks and unresolved issues, which are result of the sampling and sectioning problems. we introduce a novel microarray technique based on cell suspensions. multiple slides can be made, all of which are equally representative of the initial samples. a manually operated mechanical device was designed that can deposit distinct spots on the glass slide. each spot of cells deposited in this manner may correspond to unique source. controlling the number of cells per spot their uniformity and size can be achieved by modifying the viscosity of the cell solution or precisely regulating amount of fluid deposited. a fully automated analysis of quantitatively stained microarray samples has been performed to quantify the number of cells per spot, the size of spots, and how reproducible these parameters are. cellular material used in the experimental arrays constructed to date has been acquired from cell lines and liquid prepared lung and cervical specimens. a variety of molecular markers can be evaluated, with minimal cost. fish probes have been tested on cytology microarrays constructed from different lung cell lines. using cell suspensions generated by the dissociation of tissue would enable the creation of more representative samples for clinical marker/target validation or evaluation. key: cord- -n tp nx authors: ko, jae-hoon; müller, marcel a.; seok, hyeri; park, ga eun; lee, ji yeon; cho, sun young; ha, young eun; baek, jin yang; kim, so hyun; kang, ji-man; kim, yae-jean; jo, ik joon; chung, chi ryang; hahn, myong-joon; drosten, christian; kang, cheol-in; chung, doo ryeon; song, jae-hoon; kang, eun-suk; peck, kyong ran title: serologic responses of mers-coronavirus-infected patients according to the disease severity date: - - journal: diagnostic microbiology and infectious disease doi: . /j.diagmicrobio. . . sha: doc_id: cord_uid: n tp nx abstract we evaluated serologic response of middle east respiratory syndrome coronavirus (mers-cov)-infected patients according to severity groups: asymptomatic infection (group ), symptomatic infection without pneumonia (group ), pneumonia without respiratory failure (group ), and pneumonia progressing to respiratory failure (group ). none of the group patients showed seroconversion, while the seroconversion rate gradually increased with increasing disease severity ( . %, . %, . %, and % in group , , , , respectively; p = . ). group patients showed delayed increment of antibody titers during the fourth week, while group patients showed robust increment of antibody titer during the third week. among patients having pneumonia, % of deceased patients did not show seroconversion by the third week, while % of the survived patients were seroconverted (p = . ). since the first reported case of middle east respiratory syndrome coronavirus (mers-cov) in (zaki et al., ) , small and large outbreaks have occurred, resulting in mers-cov infections and related deaths to date (who, ) . to understand this fatal respiratory viral infection, several serologic investigations have been conducted (corman et al., ; min et al., ; park et al., ; payne et al., ) . however, practical analysis of serodiagnostic parameters for clinical usage was limited in previous studies, due to insufficient sample size or clinical information. we managed mers-cov-infected patients, which is the largest number of patients as a single center during the korean mers outbreak (total patients identified) kim et al., ; park et al., ) , and reported that mers-cov-infected patients experienced distinct clinical courses, ranging from asymptomatic infection to severe pneumonia requiring mechanical ventilation . based on these findings, we evaluated serologic response of mers-cov-infected patients according to the disease severity to investigate potential role of serodiagnostic parameters as prognostic markers. among mers-cov-infected patients who were admitted to samsung medical center, a -bed tertiary care university hospital, during the korean mers outbreak , we obtained sera from patients. mers-cov infections were confirmed on the diagnostic microbiology and infectious disease ( ) [ ] [ ] [ ] [ ] [ ] [ ] basis of real-time reverse transcriptase polymerase chain reaction (rrt-pcr) assays targeting upstream of the e gene (upe) and the openreading frame gene a (orf a) (corman et al., a; madani, ) . epidemiologic investigation data and electronic medical records were reviewed to obtain exact exposure date, symptom onset, clinical course, and outcome data for the patients. one or residual serum samples per week of illness were used for serologic testing during hospitalization periods. follow-up serum samples obtained at outpatient clinics were also tested up to months from symptom onset. the institutional review board of samsung medical center approved the present study. the clinical course of mers-cov-infected patients was assessed weeks after symptom onset and patients were divided into disease severity groups: asymptomatic infection (group ), symptomatic infection without pneumonia (group ), pneumonia without respiratory failure (group ), and pneumonia progressing to respiratory failure (group ) . for practical purposes, respiratory failure was defined as the need for mechanical ventilation. only patients in group experienced fatal outcomes ( / , . %), and interval from symptom onset to death was days in median ). proportion of underlying immunocompromising conditions including diabetes, solid cancer, or hematologic malignancies was not different between groups . the distinct clinical presentation of the severity groups are presented in supplementary figs. and , and supplementary table , in addition to the previous report . seroconversion status was determined based on neutralization activity: if none of the serum samples from a mers-cov-infected patient, necessarily including sera obtained after the third week of illness, showed neutralization activity, the patient was considered to have negative seroconversion; if none of the serum samples obtained by the end of the third week of illness showed neutralization activity and no samples were available for neutralization tests thereafter, the patient was considered to have an indeterminate response (i.e. interpretation not applicable); if any serum showed neutralization activity, the patient was considered to have positive seroconversion. patients with an indeterminate response were excluded from calculation of the seroconversion rate. this definition is based on the premise that no patients had previous exposure to mers-cov, as this was the first mers outbreak in korea as a non-endemic country. during the outbreak, mers-cov exposure dates and symptom onsets were clearly identified in most patients, owing to thorough contact investigation and monitoring of exposed individuals park et al., ) . mers-related symptoms included fever, myalgia, cough, sputum, and diarrhea. to provide a common point of reference, we used 'days post onset of illness (dpoi)' to evaluate mers-covinfected patients. for asymptomatic patients, the day of diagnosis of mers-cov infection was considered as day of symptom onset . anti-mers-cov elisa igg and iga (euroimmun, lübeck, germany) were based on soluble mers-cov spike protein s domain expressed in hek- t cells (muller et al., , muth et al., ; raj et al., ) . sera were tested according to the manufacturer's instructions with : dilutions. secondary detection was done with peroxidase-labeled anti-human igg and iga. cutoff values of od ratio . for elisa igg and . for elisa iga were applied in the present study, as these values exhibited optimal performance in predicting neutralization activity . anti-mers-cov ifa igm (euroimmun) was performed with slides carrying vero cells infected with full mers-cov (corman et al., b; meyer et al., ; muller et al., muller et al., , . sera were tested according to the manufacturer's instructions with : dilutions. weekly positive ifa intensity was considered cutoff intensity value of ifa igm, which exhibited optimal performance in predicting neutralization activity . mers-cov prnt was performed as previously described muller et al., muller et al., , . pre-dilution before setting up the log dilution series was : , defining : as the lowest possible significant titer for categorizing a sample as positive . for comparison of clinical variables between groups, one-way analysis of variance (anova) or kruskal-wallis test was used for continuous variables, and chi-square or fisher's exact test was used for categorical variables. six-week survival probability was calculated using the kaplan-meier method. the cox proportional hazard model and logrank test were used to examine the association of seroconversion status with the -week mortality of mers patients having pneumonia. all pvalues were -tailed, and those b . were considered to be statistically significant. r- . . for windows (rstudio, boston, ma, usa) was used for all statistical analyses. seroconversion status of mers-cov-infected patients is summarized in table . none of the group patients showed seroconversion, and the seroconversion rate gradually increased with increasing disease severity ( . %, . %, . %, and % in groups , , , and , respectively; p = . ). seroconversion was observed from to dpoi ( dpoi in median), mostly during the third week of illness ( . % of seroconverted patients with a known timeline). group patients showed slightly delayed timing of seroconversion compared to group patients ( . and . dpoi in median, respectively, without statistical significance), and seroconversion during the fourth week of illness was exclusively observed in group . serologic responses of seroconverted patients are depicted according to the severity groups with -day intervals in fig. . serologic response occurred from the third week of illness, and antibody response is weaker in patients with mild symptomatic patients (group ) than patients with pneumonia (groups and ). group patients showed robust increment of antibody titer during the third week (compared to the nd week, the median od ratios of elisa igg and iga increased more than -fold, and ifa igm and prnt increased from negative to + and : , respectively), and the titers did not significantly increase thereafter (in comparison of the median values of third week and fourth week, no statistical significance was observed). meanwhile, group patients showed delayed and continuous increment of antibody titers from the third week: the median values of each serologic test were significantly higher during the fourth week compared to those of the third week in group (all p b . ). in comparison between groups and , antibody titers of group patients during the third week were numerically lower than those of group , although only elisa igg showed statistically significant difference (p = . ). the antibody titers of group patients continuously increased, showing numerically higher titers compared to those of group patients during the fourth week (without statistical significance). detailed serologic test results for each patient are presented according to timeline and severity groups in supplementary tables to . as seroconversion rates were low in mild severity groups ( % in group and % in group ), outcome analysis was performed in patients having pneumonia (groups and ). only % of deceased patients showed seroconversion by the end of the third week of illness, while % of survived patients seroconverted (p = . , table ). this difference also could be discriminated by elisa igg (with od ratio cutoff value of . , p = . ) and elisa iga (with od ratio cutoff value of . , p = . ). ifa igm response was not significantly different between survivors and non-survivors (with intensity cutoff value of weakly positive, p = . ). in a kaplan-meier analysis comparing seroconverted patients and non-converted patients by the third week of illness, seroconverted patients showed significantly higher survival probability compared to patients with negative seroconversion (fig. , p b . by log-rank test). negative seroconversion in pneumonia patients by the third week of illness showed a hazard ratio of . ( % ci . - . , p = . , by the cox proportional hazard model) in predicting -week mortality. since previous hospital-associated outbreaks of mers occurred in endemic countries, where primary infections flow from community into hospitals, detailed clinical data of each patient were hard to obtain (corman et al., ) . however, during the korean mers outbreak, the first outbreak in a non-endemic country, epidemiologic links and entire clinical course of each patients could be clearly identified park et al., ) . owing to the detailed epidemiologic and clinical information about patients, we could find out different serologic response depending on disease severity and outcome. although different seroconversion rates depending on disease severity can be inferred from previous serologic investigation (min et al., ) , the number of evaluated mers patients was limited to and neutralization testing was not performed. in that study, a robust increment of elisa igg titer with a -fold increase in od ratio was exclusively observed among patients with severe pneumonia, while mild infections exhibited a modest increment in od ratio, if any. likewise, we noted that asymptomatic mers-cov-infected cases did not show serologic response including prnt within months, and the seroconversion rate increased with the disease severity. although the number of asymptomatic patients was limited to in the present analysis, it is less likely that asymptomatic patients will experience seroconversion considering that even group patients with obvious mers-related symptoms showed low seroconversion rate of %. this finding correlates with another serologic study that evaluated rrt-pcr-confirmed mers patients (choe et al., ) . in that study, antibody titers in of patients with mild illness were undetectable. in addition, most contact surveys of mers-cov could not detect additional rrt-pcr-negative prntpositive mers-cov infections (breakwell et al., ; buchholz et al., ; choi et al., ; . these findings imply that serologic surveys to detect subclinical infections among asymptomatic individuals would not be effective. serologic response was delayed in group patients, and negative seroconversion by the third week of illness was associated with fatal outcome among patients with mers pneumonia (hr . , % ci . - . , p = . ). delayed commencement of serologic response in severe disease was also suggested by previous report by park et al. (park et al., ) . although seroconversion timing was not statistically significantly delayed in group patients in the present study, delayed increment of igg, iga, and igm titers after the third week was demonstrated in group . however, the delayed serologic response in group could not be used as predictor for respiratory failure, as respiratory failure progressed during the nd week of illness ( dpoi in median). meanwhile, negative seroconversion in mers pneumonia by the third week of illness was associated with fatal outcome in the present analysis. impaired serologic response in deceased patient was also noted in the paper of corman et al., but insufficient clinical information, especially day of symptom onset, hampered more detailed analysis in association with timeline (corman et al., ) . in this study, we could obtain exact clinical information including day of symptom onset, and figured it out that seroconversion status by the third week of illness (by dpoi) can serve as a prognostic marker. another important point is that mers-cov-infected patients in the present analysis died later than previous reports, probably owing to antiviral therapy or aggressive critical care including extracorporeal membrane oxygenation (ecmo). the median interval from symptom onset to death was days in the present study, which is much longer than . days in previous reports (zumla et al., ) . although rapidly deteriorating mers cases would die before the third week of illness, there certainly is a population that benefit from prognosis prediction by serologic response. aggressive managements including ecmo should be considered for pneumonia patients without seroconversion by the third week of illness. although seroconversion status can be confirmed by neutralization tests, it cannot be readily performed worldwide (corman et al., table seroconversion status of mers-cov-infected patients according to the disease severity group. classification by the disease severity group asymptomatic (n = ) group symptomatic (n = ) group pneumonia (n = ) group resp. failure (n = ) ). in the present analysis, seroconversion status of the third week assessed by elisa igg and iga was similar with that by prnt. these elisa tests can be practically used for predicting poor prognosis of mers pneumonia in the field of patient management. as a retrospective study, serum samples of each patient could not be collected with same interval. however, we applied strict criteria for seroconversion, excluding patients who did not have follow-up samples after the third week of illness as indeterminate response. in the previous report with the same patient population, we also suggest predictive factors for disease progression using clinical variables within days from symptom onset . together with the present paper, these factors could be used complementarily in managing mers-cov-infected patients. in addition, although we identified that seroconversion status by the third week was associated with fatal outcomes of mers pneumonia, we could not perform multivariate analysis due to limited sample size. this finding need to be further evaluated with enough patient numbers of mers pneumonia. in conclusion, in a serologic investigation of mers-cov-infected patients, mild cases showed low seroconversion rates, while fatal cases showed impaired serologic responses. this work was supported by a samsung biomedical research institute (sbri) grant [#smx ]. cd reports funding by eu grants antigone (ga no. ) and prepare (ga no. ). there are no potential conflicts of interest relevant to this article to report. lack of transmission among close contacts of patient with case of middle east respiratory syndrome imported into the united states contact investigation of a case of human novel coronavirus infection treated in a german hospital mers-cov outbreak following a single patient exposure in an emergency room in south korea: an epidemiological outbreak study mers-cov antibody responses year after symptom onset clinical presentation and outcomes of middle east respiratory syndrome in the republic of korea viral shedding and antibody response in patients with middle east respiratory syndrome coronavirus infection detection of a novel human coronavirus by real-time reverse-transcription polymerase chain reaction assays for laboratory confirmation of novel human coronavirus (hcov-emc) infections the characteristics of middle eastern respiratory syndrome coronavirus transmission dynamics in south korea serologic evaluation of mers screening strategy for healthcare personnel during a hospital-associated outbreak suggested new breakpoints of anti-mers-cov antibody elisa titers: performance analysis of serologic tests. suggested new breakpoints of anti-mers-cov antibody elisa titers: performance analysis of serologic tests predictive factors for pneumonia development and progression to respiratory failure in mers-cov infected patients case definition and management of patients with mers coronavirus in saudi arabia antibodies against mers coronavirus in dromedary camels comparative and kinetic analysis of viral shedding and immunological responses in mers patients representing a broad spectrum of disease severity mers coronavirus neutralizing antibodies in camels, eastern africa survival probability according to the seroconversion status was evaluated in mers-cov-infected patients having pneumonia, whose seroconversion status during the third week of illness is identifiable. seroconverted patients showed significantly higher survival probability compared to patients with negative seroconversion (p b . by log-rank test) presence of middle east respiratory syndrome coronavirus antibodies in saudi arabia: a nationwide, cross-sectional, serological study infectious middle east respiratory syndrome coronavirus excretion and serotype variability based on live virus isolates from patients in saudi arabia control of an outbreak of middle east respiratory syndrome in a tertiary hospital in korea kinetics of serologic responses to mers coronavirus infection in humans persistence of antibodies against middle east respiratory syndrome coronavirus dipeptidyl peptidase is a functional receptor for the emerging human coronavirus-emc who, middle east respiratory syndrome coronavirus isolation of a novel coronavirus from a man with pneumonia in saudi arabia middle east respiratory syndrome we would like to express our sincerest condolences to the patients and families who suffered from the mers outbreak. we also greatly appreciate the hcp and staff members at samsung medical center and all other hospitals who worked together to overcome the mers outbreak. finally, we would like to thank jinseob kim for statistical advice and figure development, as well as mingu kang for ifa testing. supplementary data to this article can be found online at http://dx. doi.org/ . /j.diagmicrobio. . . . key: cord- -osstpum authors: nan title: abstracts oral date: - - journal: am j transplant doi: . /j. - . . .x sha: doc_id: cord_uid: osstpum nan abstracts evl (target - ng/ml), aza or mmf with standard (sd) or reduced (rd) csa. data at months post-tx is presented here. results. the proportion of patients with cmv events, including serious adverse events and laboratory evidence of cmv infection, has remained low and broadly similar following introduction of cc administration of evl and use of concomitant rd-csa. cmv syndrome and cmv organ involvement occurred in < % of recipients receiving evl in each of the studies. the highest rates of all cmv parameters occurred with mmf + sd-csa or aza + sd-csa. conclusion. the low incidence of cmv infection and cmv-related events observed in heart tx patients receiving fd-evl and sd-csa as de novo immunosuppression has been maintained in newer regimens of cc-evl with rd-csa. cmv syndrome and cmv organ involvement are rare with evl-based immunosuppression after cardiac tx. the low rate of cmv infections in evl-treated patients may contribute to improved long-term outcome and a lower incidence of cav; confirmatory data are awaited. fibronectin-α β interactions enhance p mapk phosphorylation and metalloproteinase- expression in cold liver ischemia/reperfusion injury. sergio duarte, xiu-da shen, takashi hamada, constantino fondevila, ronald busuttil, ana j. coito. the dumont ucla transplant center. expression of endothelial fibronectin (fn) is an early event in liver ischemia/reperfusion (i/r) injury. we have recently shown that cs peptide facilitated blockade of fn-α β leukocyte interactions regulates metalloproteinase- (mmp- ) expression in steatotic orthotopic liver transplants (olt). this study tests the function of the cs peptide therapy upon mmp- , and further dissects putative mechanisms, in an alternate model of cold ischemia/reperfusion (i/r) injury. methods and results: cs peptides were administrated through the portal vein of sprage-dawley (sd) rat livers before and after h cold storage ( µg/rat). sd recipients of olts received an additional dose of cs peptides h post-olt. cs therapy significantly increased the d olt survival rate ( % vs. %, n= /gr, p< . ). cs peptides reduced sgot levels (u/l) at h ( ± vs. ± p< . ) and h ( ± vs. ± , p< . ) post-olt. cs treated olts showed good preservation of lobular architecture, contrasting with severe necrosis and sinusoidal congestion in controls. moreover, cs treated livers were characterized by a profound decrease in t ( ± vs. ± , p< . ), nk ( ± vs. ± , p< . ) and ed ( ± vs. ± , p< . ) cells as early as h after i/r. neutrophils, as indicated by mpo activity ( . ± . vs. . ± . , p< . ) were depressed by cs therapy. this correlated with decreased mrna expression of tnf-α ( . ± . vs. . ± . , p< . ) and cycloxygenase- ( . ± . vs. . ± . , p< . ) . leukocyte transmigration is dependent upon adhesive and focal matrix degradation mechanisms. mmp- , which is inducible and expressed by infiltrating leukocytes, was profoundly depressed in h cs- peptide treated olts, at both mrna ( . ± . vs. . ± . , p< . ) and protein ( . ± . vs. . ± . , p< . ) levels. moreover, mmp- activity evaluated by zymography was reduced by ∼ -fold in the cs- group. interestingly, phosphorylation of mitogen-activated protein (map) kinase p ( . ± . vs . ± . , p< . ) was selectively downregulated in the h cs- treated olts. in conclusion, this work supports a broad regulatory role for fn-α β interactions on mmp- expression by leukocytes, likely mediated through activation of p mapkinase, and matrix pathological breakdown associated with leukocyte infiltration. this data provides the rationale for the development of novel therapeutic approaches in cold liver i/r injury. ischemia reperfusion injury is the most common cause of acute kidney injury in both native and allograft kidneys. the pathogenic mechanisms of renal ischemia reperfusion injury include changes at the level of the microvasculature as well as the tubules. within the microvasculature, leukocyte-endothelial interactions likely play a role and contribute to the well-established microvasculature dysfunction (e.g., endothelial permeability) and alterations in endothelial-leukocyte interaction occur during ischemic acute kidney injury. our previous studies have demonstrated that t cells modulate renal ischemia reperfusion injury in a murine model, we hypothesized that t cells could mediate changes in renal vascular permeability during ischemia reperfusion injury. we performed a min bilateral renal ischemia followed by reperfusion in c bl wild type mice and in t cell deficient (nu/nu) mice with or without t-cell adoptive transfer from their wild type littermates and evaluated rvp by evans blue dye extravasations (ebde). the time course studies of rvp showed marked increases in renal ebde within the early - hrs after ischemia. cd positive pan t-cells but neither cd nor cd t cells were found to infiltrate into post ischemic kidney within hrs, and comparison was made with other leukocytes using immunohistochemistry technique. gene microarray analysis demonstrated that the gene for tnf-α (tnfaip ), a potent mediator of microvascular permeability as well as a t cell product, was increased in the kidney early after ischemia. tnf-α, ifn-γ and il- protein by an intracellular cytokine staining technique was found increased early in peripheral circulating t cells and later in renal t cells after renal ischemia. the rise in rvp was significantly attenuated in t cell deficient mice nu/nu at hrs compared to the wild type littermates and this attenuated rvp in t cell deficient mice was restored after adoptive transfer of splenic t cells from wild type littermates into these nude mice. these data demonstrate that t cells traffic early into post ischemic kidney, produce tnf-α and other cytokines that can increase rvp, and directly participate in the increased rvp during acute ischemia reperfusion injury. t cell-endothelial interactions are a likely mechanisms underlying the pathophysiologic role of t cells in renal ischemia reperfusion injury . background: ischemia/reperfusion injury (iri) is a major cause of organ dysfunction after intestinal injury and transplantation. the interaction between the innate and adaptive immune systems has become a major area of focus in this field. our preliminary work showed that mice undergoing intestinal iri experienced worse survival and tissue injury in conjunction with increased infiltration of pmn and cd + cells as compared to sham mice. the purpose of this study was to investigate the role of the t cell in intestinal iri through the use of genetically deficient mice. methods: under anesthesia, male c bl wild-type mice (wt) and cd knockout mice (cd ko) underwent min of warm intestinal iri by clamping of the sma. separate survival and analysis groups were performed. intestinal tissue was harvested at h and h. tissue was analyzed by histology, cd immunostaining, myeloperoxidase activity (mpo), and semi-quantitative pcr for several cytokines/chemokines. results: wt had significantly worse survival compared to cd ko ( % vs. %, p= . ), and worse histopathological injury mostly involving mucosal sloughing. wt had higher mpo activity than cd ko ( . ± . vs. . ± . at h, p= . , and . ± . vs. . ± . at h, p= . ) and increased cd + cell infiltration. there was also increased mrna production of cytokines/chemokines in wt vs. cd ko at both timepoints; specifically, the data with respect to b-actin at h was: il- ( . conclusion: this study demonstrates for the first time in the intestine that cd + t cells are important mediators of iri. in the absence of cd + t cells, better outcomes were associated with less pmn infiltration implying a link between the innate and adaptive immune systems. an alteration in chemotactic signaling potentially effected by cd + t cells may play a role in this process. these results confirm the important function of cd + t cells in intestinal iri and justify further investigation into their complex role in this process. messenger rna assessment in urine sediments from renal transplant patients is rapidly evolving as a non-invasive diagnostic tool. t cells, macrophages, and often b cells are present in rejecting kidney grafts. we questioned whether urinary mrna levels of markers representing these cell types ((regulatory) t cells: cd ε, foxp , cd , tgf-ß; macrophages: cd , s a ; b cells: cd ) are associated with rejection. materials in our institute urine samples a year from over renal transplant patients are being collected for mrna quantitation purposes. urine sediments are pelleted and stored in rna-preserving solution. we initially investigated the effect of incubation time of urine on mrna integrity. next, in a case-control study urine samples taken at time of biopsy-proven rejection were compared to samples taken during stable graft function. median time of sampling ( days versus days posttansplant) did not significantly differ between groups. rna ( . ± . µg) was extracted using rneasy spin columns. message of the markers mentioned above was quantified with q-pcr and normalized. results incubation of urine for h or longer at room temperature after acquisition resulted in a % decrease in s rrna signals (p< . ). however, storage of urine for up to h at ºc did not result in decreased mrna expression. in the case-control study, all markers tested showed the highest expression levels in urine rejection samples. when corrected for multiple comparisons, only tgf-ß ( -fold, p= . ) and foxp ( -fold, p= . ) expression was significantly increased in rejection samples compared to non-rejection samples. tgf-ß levels highly correlated with foxp levels (r = . , p< . ), suggesting a mechanistic relationship in vivo between the two molecules. conclusion rna integrity in urine samples stored at ºc is maintained for at least h. detection of increased tgf-ß and foxp message in urine from patients with a kidney transplant represents a means for indicating occurrence of graft rejection. this implies that mrna urinalysis renders a suitable molecular tool for non-invasive patient monitoring in clinical practice. the data furthermore suggest that rejection is associated with tgf-ß-mediated immune mechanisms in which regulatory t cells play a role. the significance of b cell and plasma cell infiltration in renal allografts remains controversial. we previously established that transcript sets associated with ifng effects or t cells reflect the inflammatory burden in renal allografts. in the present study, we identified b cell associated transcripts (bats) and immunoglobulin transcripts (igts), reflecting b cell and plasma cell infiltration, respectively. using microarrays, we analyzed bat and igt expression in relationship to histologic lesions, diagnosis, and renal function in renal allograft biopsies. immunostaining confirmed that bat and igt expression was associated with b cells and plasma cells in the graft. expression of bats and igts was increased in biopsies with rejection ( . ± . , . ± . ) compared to non-rejection ( . ± . , . ± . ), but was not different between t cell ( . ± . , . ± . ) and antibody mediated rejection ( . ± . , . ± . ) and also occurred in some non-rejecting biopsies (recurrent gn). bat and igt scores correlated strongly with time post transplant (fig ), which was best modeled as a dichotomous relationship: biopsies ≤ months did not express bats or igts above the level of control kidneys. other inflammatory markers were not time dependent. in biopsies ≥ months, bat and igt expression correlated with interstitial inflammation, tubular atrophy, and interstitial fibrosis. in a multiple regression analysis, only time post transplant and interstitial inflammation were independently related to bat and igt scores. when correcting for time post transplant, bat and igt scores did not correlate with renal function at the time of biopsy or future function months post biopsy. bats and particularly igts are a time dependent feature of injured and inflamed renal allografts. corrected for the effect of time, bats and igts do not correlate with outcomes, indicating that b cell and plasma cell infiltrates have no specific role for the mechanism of injury independent of the inflammatory burden. their accumulation in late allografts may indicate emergence of specialized lymphoid compartments in tissues with long standing low level inflammation. pearson correlation coefficient between pbts expression and renal function pbts egfr at %change in egfr from biopsy months after biopsy baseline to biopsy biopsy to months after qcats - . * - . * - . * - . grits - . ** - . ** - . ** - . irit_d - . - . - . . irit_d - . ** - . ** - . ** . * irit_d - . ** - . ** - . * - . kt . ** . . ** - . * p< . , ** p< . thus the pbts have prognostic value. surprisingly, the transcripts in the biopsy with greatest prognostic value for future gfr or recovery of gfr were not related to rejection (cytotoxic t cell or ifng associated) but to the degree of injury response. we propose that the common pathway linking various injuries (immune and non immune) to gfr is through the degree of injury response these events induce in the epithelium, particularly those in the irit_d set. early rejection from anamnestic response in offspring-to-mother or husband-to-wife kidney transplant. kwan tae park, song chul kim, duck jong han. surgery, asan medical center, seoul, korea. accelerated rejection can be developed in the immediate post-transplant period resulting from anamnestic response due to the exposure to fetal hla antigen during the previous pregnancy in case of offspring-to-mother or husband-to-wife. however, accelerated rejections in these groups have been rarely reported. cases of offspring-to-mother (offspring group) and cases of husband-to-wife (spouse group), who has been sensitized to spouse via their children, underwent kidney transplants from january of to august of at our institution and retrospectively reviewed. control group was female kidney recipients transplanted at the same period from living related donors other than offspring and from living unrelated donors other than husband. acute rejection (ar) rate within months after transplant were . % ( / ) in offspring group and . % ( / ) in spouse group. the ar rates were not different between the two groups, however they were significantly higher than control group in both groups, namely . % ( / ) for offspring control and . % ( / ) for spouse control. the mean onset of ar was . day ( - ) and it was significantly later than that of control groups ( . day, p< . ) and % of ar were accelerated rejections within days after transplant. proportion of acute humoral rejection was significantly higher in both groups than control group ( . % vs . % in offspring group, % vs % in spouse group). most of the ar was successfully reversed by steroid pulse and/ or plasmapheresis, ivig, rituximab. any risk factors for the ar such as number of pregnancy, preoperative cdc cross matching, pra, immunosuppressant and antibody induction couldn't be identified. serum creatinine level in ar patients were higher than ar free patients by postoperative month, but last follow up creatinine level didn't show any statistical difference ( . mg/dl in ar vs . mg/dl in ar free). year graft/patient survival rate were not different between ar and ar free groups and study and control groups. risk of higher rejection rate accompanied with higher accelerated and humoral rejection was identified in female kidney recipients from offspring or spouse donor in comparison with control group. considering the anamnestic response of this cohort of female recipients, more prudent preoperative screening and careful immediate postoperative immune monitoring are required for the avoidance of rejection and impaired graft survival. kaplan-meier survival curves showed that ∆upc > . were associated with decreased patient and allograft survival. these data show for the first time that regardless of the histopathology, ∆upc > . one month after rejection is associated with poor patient/allograft outcomes. from histology to microarrays the histopathological hallmark of t cell mediated rejection (tcmr), is interstitial infiltration. assessing infiltration by histology is arbitrary, limited in reproducibility, and has never been assessed against independent standards. we recently reported that a set of cytotoxic t cell-associated transcripts (qcats) could quantitatively assess the t cell burden in tissue. objective of the present study was to re-examine the current diagnostic criteria in relationship to the qcats. in renal allograft biopsies, we assessed how histology predicts the qcat burden. an independent diagnostic threshold for qcats was established in control samples. applying this qcat threshold revealed current diagnostic criteria for histology to be flawed; the threshold for interstitial infiltration is too high ( % specificity, % sensitivity), the types of infiltration to be considered (i.e. i-banff) are wrongly defined, and tubulitis is not increasing diagnostic accuracy. changing the criteria by lowering the histological threshold for cortical infiltration from % to %, taking into account all interstitial cellular infiltration (= i-total) and ignoring tubulitis increased sensitivity to % with a decreased specificity of %. but, this includes biopsies having interstitial infiltration without qcats, indicating that histology might not discriminate between 'active' and 'inactive' infiltration. both the refined histological and the qcat threshold had prognostic value in terms of future renal allograft function. we propose a refined histological scoring system that better predicts the active t cell burden and outcome than the current banff criteria for renal allograft rejection. there has been an increasing and well justified interest regarding the long term renal consequences of kidney donation. the collective evidence suggests, however, that kidney donors enjoy a normal life span and their lifetime risk of esrd may not be different from non-kidney donors. assessing kidney function utilizing serum creatinine is not without limitations. therefore, to better assess kidney function, yeas ago, we began a large effort to measure gfr using the plasma disappearance of iohexol and first void urinary albumin/creatinine ratio (acr) in randomly selected kidney donors who donated at our institution. results: we have performed over donor uninephrectomies since the inception of our program in . of these, donors underwent iohexol gfr at our general clinical research center. microalbuminuria is defined as acr between - mg/g and macroalbuminuria as acr> mg/g. the mean age was . ± . years, . ± . years have elapsed since donation, hemoglobin was . ± . g/l, systolic blood pressure (sbp) was . ± . mmhg and diastolic blood pressure (dbp) was . ± . mmhg. . % of donors had a gfr greater than ml/min/ . m and . % had a gfr between - ml/min/ . m . the detailed renal profile of these donors is shown in the table below. multivariate analysis that adjusted for age, gender, ethnicity, time from donation, sbp, dbp and body mass index (bmi) identified age at donation, female gender and bmi as independent predictors for gfr< ml/min/ . m and time from donation and systolic blood pressure as independent predictors for micro and macroalbuminuria. conclusion: this is the largest effort describing measured gfr in previous kidney donors. it is reassuring to find out that the majorities have a preserved gfr and only a minority has albuminuria. the risk factors for reduced gfr and albuminuria are analogous to what has been described in the general population. cystatin c levels and long-term donor health markers cystatin-c < (n= ) psychosocial and physical health of lkds following donation is of utmost importance. unfortunately, this issue has been neglected to a large extent. we sought to examine the current practices regarding psychosocial follow-up of lkds after surgery across transplant (tx) centers. we conducted a -question online survey regarding this practice and issues related to lkd. the survey was e-mailed via listservs of professional tx societies. several questions allowed for more than one response. characteristics of the tx centers that participated in the survey are found in table . only . % actively follow donors regarding mental health, substance abuse, or quality of life issues after donation. the professionals most often involved are social workers ( %) and nurse coordinators ( %). the majority of follow-up is conducted via phone ( . %); though appointments ( . %) and questionnaires ( . %) are also utilized. % initiate follow-up with donors - weeks post-operatively, whereas only % of programs maintain contact at both - months and months. . % offer post-operative psychosocial support; % only under certain circumstances. this support is provided by social workers ( %), psychologists ( %), and/or psychiatrists ( %). support is available indefinitely in % of programs. . % assume the costs of post-operative medical and psychosocial care indefinitely; . % for a specified period of time. . % bill the recipient's insurance and . % bill the donor's insurance. . % of centers accept donors without health insurance and only . % purchase insurance on behalf of donors to cover post-operative health care needs. the results of this survey clearly demonstrate that post-operative psychosocial follow-up of lkds is uncommon and that current practices are widely variable. without routine follow-up of donors, tx centers are less likely to capture post-operative psychosocial issues that may result from organ donation. standardized post-operative follow-up of lkds should become a mandatory part of their care, which will require increased support from health care policy makers. the role of hepatitis c and race in patient and graft survival in combined kidney and liver transplantation. dilip moonka, ravi k. parasuraman, kim a. brown, alissa kapke, dean y. kim. gastroenterology, henry ford health systems, detroit, mi; nephrology, henry ford health systems, detroit, mi; biostatistics, henry ford health systems, detroit, mi; transplant institute, henry ford health systems, detroit, mi. the influence of hepatitis c (hcv) and race are not well understood in combined kidney-liver transplant (klt). hcv has a negative impact on patient and graft survival in liver recipients whereas african-american (aa) race is a negative prognostic factor in kidney recipients. aim: to determine the influence of hcv and aa race on patient and graft survival in klt. methods: the unos public use database was used to identify patients undergoing klt who had known hcv ab status. % were aa and % were non-hispanic white (nhw). . % were hcv ab positive. groups were assessed for patient and graft survival. results: there is a significant gradient in patient survival and both kidney and liver survival from nhw patients without hcv to aa patients with hcv (table) . the patient survival at five years drops from % to % along this gradient. there is also a % drop in liver and an % drop in kidney graft survival. on pairwise testing, the difference in patient survival at yr between all patients without hcv and those hcv ab positive drops from % to % (p= . ). the difference in yr survival between all nhw and aa patients (regardless of hcv status) drops from % to % (p= . ). on multivariate analysis, hcv and the combination of hcv and aa race remains associated with diminished survival but race alone does not. conclusions: patients with hcv who undergo a klt transplant are at increased risk for poor overall survival and poor survival of kidney and liver grafts. this effect appears even more pronounced in aa patients. this knowledge is critical to individual centers in assessing risk and benefit from klt in these groups and these groups represent an opportunity for improved interventions. kidney: pediatrics background: pediatric renal transplant recipients have excellent short-term outcomes but long-term success is compromised by complications of chronic immunosuppressive medications and chronic allograft nephropathy. studies show that calcineurin inhibitors and steroids can be individually avoided in pediatric renal transplantation. building on that experience we designed this study to optimize short and long-term renal allograft function with minimal chronic immunosuppression using a steroid-free, calcineurininhibitor withdrawal protocol in low risk pediatric renal transplant recipients. methods: unsensitized pediatric recipients of a first living donor kidney transplant received doses of campath- h ® ( . mg/kg), day pre-and post-transplant. subjects received tacrolimus and mmf immediately post-transplant until week - when they underwent protocol renal biopsy and were changed to sirolimus and mmf if rejection free. the planned subjects have been enrolled; this report describes the clinical outcomes of the with year of follow up. results: the mean subject age is . yrs; . % are female and . % caucasian. at transplant, / were cmv seronegative and / were ebv seronegative. protocol therapy was discontinued in eight subjects due to: rejection ( ), mouth ulcers ( ), leukopenia ( ) , unrelated ( ). clinical acute rejection (ar) occurred in subjects ( %) and had subclinical ar; ar was cellular rejection in subjects, and humoral in at days post-transplant who had an undetected positive crossmatch to class ii hla. there were two graft losses, one due to recurrent fsgs and one due to medication non-adherence. there were no cases of ptld and no deaths. leukopenia occurred in subjects ( . %). there were infections of which were urinary tract infections ( . %) and were pneumonia ( . %). conclusions: minimization of immunosuppression using a steroid-free, calcineurinwithdrawal protocol in low risk pediatric renal transplant recipients appears to be well tolerated with acceptable rates of clinical ar and no serious infections months after transplantation. male; % white). substantial increases in bmiz were observed within the first mo.; no changes were seen from to mo. baseline bmiz category (<- . , - . to + . , >+ . ) influenced the pattern of change. subjects with low bmiz (<- . ) at baseline experienced the greatest increases in bmiz, but overweight was rare; increases tended to result in a bmiz in the healthy range. those with high bmiz (>+ . ) at baseline demonstrated no significant change in bmiz post-tx. younger age at tx (highest risk for those to y. at tx) more remote date of tx, and baseline bmi between the th and th percentiles were significant independent risk factors for unhealthy weight gain both at mo. and persisting at mo. post-tx. weight gains occur early after tx and tend to persist. counseling focused on prevention of weight gain should be a routine part of post-tx care, with the most intense efforts concentrated on the highest risk patients: young, healthy weight children. avoidance of early weight gains may have an important impact on bmi over the long term. referral. lindsey a. pote, jennifer trofe, erin h. wade, jorge baluarte, alden doyle, simin goral, karen warburton, robert grossman, jo ann palmer, roy d. bloom. pharmacy, hosp of the univ of penn; nephrology, univ of penn; transplant surgery, children's hospital of philadelphia. intro: few data exist on outcomes in pediatric kidney recipients who transition to an adult transplant program. purpose: to examine outcomes in pediatric kidney recipients who transition to an adult transplant program and to identify characteristics associated with non-adherence related graft loss. methods: retrospective, single center analysis of pediatric kidney recipients who transitioned to an adult program. results: for the cohort overall, transition to the adult program occurred a mean of ± . months following transplantation. mean serum creatinine at transition was . ± . mg/dl and mean patient age . ± . years. % of patients received living donor kidneys. within ± . months of transition, ( . %) of patients experienced graft loss. causes of graft loss included admitted non-adherence (n= ), recurrent disease (n= ), chronic progressive graft dysfunction (n= ) and bk nephropathy (n= ). graft loss occurred a mean of ± months post transition for non-adherent patients and . ± months for adherent patients (p=ns). the characteristics of the cohort is shown in the table according to whether or not patients had documented non-adherence related graft loss. conclusions: ) graft loss commonly occurs within years following transition and is attributable to both patient non-adherence and late referral by the pediatric transplant program, ) non-adherence related graft loss was more common in males, ) factors unassociated with non-adherence include ethnicity, prior transplantation, age at transplant, & duration of dialysis, ) the development of collaborative pediatric-toadult transition clinics may enhance adherence and lead to improved graft outcomes in this population. this -year, prospective randomized pilot study compares the effect of conversion to sirolimus (srl) vs. continued mycophenolate meofetil (mmf) in patients with chronic allograft nephropathy (can), on histological progression. we present -year data on safety and renal function. participants > year post-transplant with can (banff ≥ci , ct ) on tacrolimus, mmf and prednisone were randomized to continue mmf or convert to srl (target - ng/ ml). tac dose was minimized (target - g/l), and renal biopsy performed at baseline, , years. -month interval monitoring included adverse event (ae) reporting, egfr (schwartz) and immunosuppressant levels. / (mmf= , srl= ) have completed -year follow-up. baseline gender, ethnicity, previous acute rejection episodes, can grade, proteinuria (upcr) were similar. srl had lower baseline egfr ( ± vs. ± ml/min/ . m , p= . ). aes were reported (mmf= , srl= ), serious ae (sae: mmf= , srl= ). common saes were similar: dehydration & elevated creatinine ( ), gastroenteritis ( ) and rejection (ar). episodes ( patient) of ar occurred in mmf group and ( patients) in srl group, all attributable to non-adherence. there were no sustained change in electrolytes, hg and total wbc counts in the st year, except neutrophil counts were lower in the srl group ( mo: mean . vs. . , p< . ). platelets were significantly lower at months (srl) but not thereafter ( month: mean ± vs. ± x e ). cholesterol and tg increased early (p< . ), but only cholesterol persisted after years (mean . vs. . mmol/l, p< . ). in srl group only, upcr increased over years (∆upcr ± mg/mmol, p< . ). this was not associated with hypoalbuminemia at years. egfr was lower in srl vs. mmf after months (p< . ), but the rate of change in egfr from baseline was similar between groups (- ± vs. - ± ml/min/ . m , p=ns). serious adverse events did not differ significantly between the srl and mmf groups. sustained srl treatment was associated with mild neutropenia, hypercholesterolemia and proteinuria after years. egfr was reduced at baseline compared with mmf, and both groups had similar rates of decline in gfr over time. allograft recipients. maarten naesens, oscar salvatierra, li li, minnie sarwal. department of pediatrics, stanford university school of medicine, stanford, ca. background: in contrast to adult kidney recipients, little is known about the long-term evolution of tacrolimus pharmacokinetics in pediatric kidney transplant recipients. methods: one-hundred five pediatric recipients of a kidney allograft, all treated with a corticosteroid-free immunosuppressive protocol, were included. the evolution of tacrolimus doses and exposure was recorded at , , , , and months after transplantation, as well as all pre-dose trough levels (c ; n= ) obtained in the first years after transplantation. results: dose-corrected tacrolimus exposure (c /dose/kg) increased in the first years after kidney transplantation in pediatric recipients (table , figure ). this decrease in dose requirement by time was only significant in children older than years at the time of transplantation ( figure ). in addition, the younger patients had significantly higher dose requirements compared to older recipients, which translated in marked underexposure in - % of patients < years of age in the first days after transplantation. conclusion: pediatric kidney transplant recipients exhibit maturation of tacrolimus pharmacokinetics with time after transplantation. this can not be explained by differences in corticosteroid use, as all patients were treated with a corticosteroid-free protocol. the higher dose requirements for younger recipients and the absence of tacrolimus maturation in the youngest recipients suggest that age-dependent changes in tacrolimus intestinal first-pass effect, metabolism or distribution play a role. whether age-specific tacrolimus dosing algorithms will improve outcome needs further study. determinants of dose-corrected pre-dose trough levels (c /dose/kg) aih may present as acute hepatitis in % of patients (pts) and result in alf. early administration of corticosteroids may obviate the need for liver transplantation (lt), but features which identify aih in pts with alf have not been determined. aim: to identify clinical and histological features which distinguish alf due to aih. methods: / pts in the alf study group registry had no evidence of viral, metabolic, vascular, and drug/toxic liver injury. all had alf defined by acute disease, encephalopathy, and coagulopathy. based upon admission clinical features, / had probable aih, and were considered "indeterminate." liver biopsies (lbx) available from pts were reviewed by a blinded expert hepatopathologist. clinicopathologic correlations were analyzed retrospectively. results: all lbx available from pts with suspected aih had classical histologic features of aih. moreover, / ( %) lbx from pts with indeterminate alf also had aih features: extensive necrosis ( %), fibrosis ( %), cirrhosis ( %), interface hepatitis ( %), and plasma cell-rich inflammation ( %). of all lbx with aih features, centrilobular lesions associated with acute, severe aih (am j surg path ; : ) were frequent: plasma cellrich central venulitis ( %), exclusive centrilobular necroinflammation ( %), and pericentral dilatation/congestion ( %). clinical characteristics and outcomes of the pts with aih based upon laboratory and histologic findings differed significantly from pts whose alf remained indeterminate: aih pts were older ( v y), predominantly female ( v %), and had longer jaundice-encephalopathy interval ( v d) , lower alt ( v u/l), higher globulins ( . v . g/dl), lower creatinine ( . v . mg/ dl), and a higher prevalence of ana ( v %) and asma ( v %) (all p<. ). although spontaneous survival did not differ, more aih pts underwent lt ( v %), and more survived month after enrollment ( v %; p<. ). conclusions: using histologic criteria to classify pts with indeterminate alf, aih accounted for at least % of the alf study group registry, and represented % of indeterminate alf. lbx should be performed in all patients with alf of obscure etiology, in particular to identify centrilobular necroinflammatory lesions, which appear to be specific indicators of acute and severe aih. (u- from niddk). ( ) ( ) ( ) ( ) ( ) . mikel gastaca, miguel montejo, lluis castells, antonio rafecas, antonio rimola, ramon barcena, federico pulido, magdalena salcedo, martin prieto, manuel de la mata, jose r. fernandez, jose m. miro, the spanish lt in hiv-infected patients working group. hospital de cruces, bilbao, spain; hospital vall d´hebron, barcelona, spain; barcelona, spain; univ. of barcelona, barcelona, spain; hospital ramon y cajal, madrid, spain; hospital de octubre, madrid, spain; hospital gregorio marañon, madrid, spain; hospital la fe, valencia, spain; hospital univ. reina sofia, cordoba, spain. background and aim: we report on the preliminary results of the prospective multicenter spanish study in hiv- infected patients who underwent olt. methods: the prospective multicenter spanish study fipse-olt-hiv -gesida - was initiated in january . inclusion criteria follows the rules previously described in the spanish consensus document. hiv-infected patients transplanted between january and december were included in this study. results: olt were consecutively performed in hiv- infected patients in the period of the study. median (iqr) follow-up is ( - ) months. median (iqr) age was years ( - ), % of the recipients were male and former drug abuse was the most common hiv- risk factor ( %). % of the patients were transplanted due to hcv-related cirrhosis and % due to hbv cirrhosis. median (iqr) meld score was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . pre-olt median (iqr) cd cell count was ( - ) cells/mm and %patients had undetectable plasma hiv viral load. immunosuppression was based on tacrolimus in % of the patients. haart was re-started in a median (iqr) time of ( - ) days after olt and was based on efavirenz in % of the cases. acute rejection occurred in patients ( %). twenty patients died ( . %) mainly due to hcv recurrence ( %). antiviral therapy with peg-interferon plus ribavirin was initiated in patients obtaining a sustained viral response in of them ( %). patient survival ( % confidence intervals) at , , and years was % ( - %), % ( - %), % ( - %) and % ( - %), respectively. conclusion: for selected hiv- infected patients under haart therapy, olt is a safe and effective procedure at mid-term. as in the hiv-negative population, hcv recurrence is the mayor cause of concern and response to antiviral therapy is still disappointing. hepatitis c virus and objectives: describe the -year experience of a university hospital treating chronic hepatitis c relapse, histologically diagnosed after liver transplant. material & methods: from september through july , all the patients subject to liver transplant with histological diagnostics of chronic hepatitis relapse were submitted to antiviral treatment. treatment was suspended if there was a severe adverse reaction to the drugs used, non-adherence, severe rejection or no response after at least months. hcv positive serology patients, alt increase ( , x nl) and hepatic biopsy with metavir rating showing structural and/or periseptal or parenchymatous portal inflammatory activity /= were included. from to , all patients were treated with conventional interferon and ribavirine, regardless of the genotype. from october on, patients with genotype were treated with ribavirine and pegylated interferon and genotype were treated with conventional interferon and ribavirine. results: patients were treated during this time period, thirty-seven male ( . %). their average age was . . % were genotype , . % were genotype . average time between transplant and beginning of treatment was months. average treatment was ( - ) months. . % received conventional interferon, . %, pegylated alpha a and . %, pegylated alpha b. . % had one or more cellular rejection episodes before vhc relapse diagnostics and were treated with corticosteroids. sustained virological response (svr) occurred in . %. three patients had a virological response at the end of treatment (evr) and have not completed six months post treatment. out of patients with svr, . % were genotype , . % genotype and . % were not genotyped. considering genotypes, svr was detected in . % with genotype , in % with genotype . srv was detected when we examined hepatic biopsy, in . % of the f /f patients ( out of ), . % of the f patients ( ), . % of the f patients ( ) . survival period of years for svr patients was % ( out of ) and . % for patient without svr (p = . -kaplan-meier). five-year survival was . % for patients with genotype and % for patients with genotype . conclusions: our results show it is possible to get good five-year survival rates for treated patients. however, handling adverse reactions and long term treatment still pose difficulties in pursuing better svr rates. the impact of alcoholic liver disease (ald) and background: although liver transplant survival benefit has been shown to be associated with meld score, disease-specific analyses have not been reported. we evaluated, using srtr data, the effect of ald and/or hcv infection on transplant waitlist and post-transplant mortality, and survival benefit of deceased donor liver transplants. methods: , patients age ≥ , who were listed between sept and dec , and followed until dec , , were classified into cells according to hcv or ald status: hcv+, ald-: , ; hcv+, ald+: , ; hcv-, ald+: , ; hcv-, ald-: , ). cox regression was used to estimate waiting list mortality and post-transplant mortality separately. survival benefit, which encompasses both pre-and post-transplant events, was assessed using sequential stratification; an extension of cox regression which matches transplant recipients by meld and organ procurement organization to patients on active on the waitlist at the time of transplant. results: hcv significantly (p= . ) increased waitlist mortality, with a covariate-adjusted hazard ratio (hr) for hcv+ vs. hcv-of hr= . (p= . ). the impact of hcv+ was greater among ald+ candidates (hr= . ; p< . ), but was also significant among ald-candidates (hr= . ; p= . ). the contrast between ald+ and ald-waitlist mortality was only significant among hcv+ candidates (hr= . ; p= . ). post-transplant mortality was significantly higher among hcv+ vs. hcv-recipients (hr= . ; p=. ); there was no difference between ald+ vs. ald-recipients. survival benefit of liver transplantation was significantly lower among hcv+ compared to hcv-recipients with meld - , but significantly higher for hcv+ recipients with meld scores of ≥ . a diagnosis of ald did not influence the survival benefit of transplantation at any meld score. conclusion: despite higher waitlist mortality, hcv+ recipients had significantly lower liver transplant survival benefit than hcv-recipients, within categories defined by meld score. in contrast, transplant survival benefit was not influenced by ald. transplanted for hbv-related cirrhosis. giuseppe tisone, daniele di paolo, ilaria lenci, laura tariciotti, andrea monaco, manuele berlanda, linda de luca, giuseppe iaria, alessandro anselmo, irene bellini, mario angelico. hepatic surgery and transplantation, university of rome tor vergata, rome, italy. background and aim: post-transplant active immunization with hbsag vaccine is a potential prophylaxis strategy against hbv-recurrence after liver tranplantation due to hbv-related disease. previous studies showed conflicting results using standard vaccines, whereas the use of the new adjuvant -deacylated monophosphoryl-lipid-a (mpl) significantly increased patient's immunization rate. we investigated the efficacy of a long-term ( months) accelerated (monthly doses) vaccination schedule using the mpl-adjuvanted vaccine administered with and without concomitant hbig. methods: patients (m/f: / ) transplanted for hbv-related cirrhosis ± months earlier were recruited. all were hbsag and hbv dna negative in serum and cccdna negative in liver tissue; ( . %) were co-infected with hcv and ( . %) with hdv. study protocol consisted of consecutive monthly intramuscular vaccine doses (hbsag mg plus mpl mg) given together with lamivudine ( mg/daily). each of the initial doses (first cycle) was administered within days after iu hbig i.v. infusion, while the last doses were given after complete hbig withdrawal (second cycle). hbsab titre was determined before each vaccine dose and during the follow-up. all patients were maintaiened on low-level immunosuppression. preliminary results: all patients completed first vaccination cycle; ( . %) patients received adjuvanted vaccine doses (first and second cycles) and were monitored during months follow-up after vaccination end. no side effects occurred, nor evidence of hbv recurrence. at the end of first cycle all patients achieved an anti-hbs titre > iu/l (mean ± iu/l) and ( . %) a titre greater than iu/l. at the end of follow-up / ( . %) and / ( . %) had an anti-hbs titre greater than (mean ± ui/l) and iu/l, respectively. conclusions: nine months after hbig withdrawal more than half of the patients reached and maintained a protective anti-hbs titre (> iu/l). this intensive schedule using the mpl-adjuvanted vaccine, given in combination with hbig and lamivudine, seems to be more effective than previous hbv vaccination protocols, although a longer follow-up is needed to assess its final effectiveness. heterologous immunity via alloimmune responses to hepatitis c virus replication after liver transplantation. hideki ohdan, masahiro ohira, yuka tanaka, kohei ishiyama, nobuhiko hiraga, michio imamura, kazuaki chayama, toshimasa asahara. surgery, hiroshima university, hiroshima, japan; internal medicine, hiroshima university, hiroshima, japan. the immunosuppressive environment in liver transplantation (lt) recipients infected with hcv is believed to be associated with the progression of hcv reinfection. in the present study, we simultaneously monitored hcv levels and alloimmune status in hcv-infected lt recipients. for evaluating the immune status of hcv-infected lt recipients, we employed a mixed lymphocyte reaction (mlr) assay using a cfselabeling technique. the kinetics of the stimulation index of anti-donor reactive cd + t cells clearly mirrored that of the hcv rna titer, and a significant reverse correlation was observed between the parameters (r = . ). we did not observe a similar relationship between the stimulation index of an anti-third party cd + t cells and the hcv rna titer (r = . ). one possible explanation for this phenomenon might be that cytokines outputted by t cells responding to allostimulation display the anti-hcv activity either directly or indirectly through the activation of bystander immunocytes. to investigate such possibilities, we performed a transwell culture assay comprising a mlr culture in the upper chamber and genomic hcv replicon cell culture in the lower chamber to mimic the anatomical features of the interaction between hcvinfected hepatocytes and alloreactive t cells that infiltrate the portal area in the liver. when one-way mlr was performed using one-halpoidentical combination in the upper chamber, hcv replication was significantly suppressed in the lower chamber containing hcv replicon cells. hcv replication was further suppressed when mlr was carried out with a complete allogeneic combination. this inhibiting effect was dependent on their ifn-γ secreting activity. in addition, a similar result was obtained when ifn-γ-secreting nk/nkt cells stimulated with il- were cultured in the upper chamber. in conclusion, there was a close relationship between the anti-donor and the anti-hcv immune status in the lt recipients infected with hcv. cytokines such as il- and ifn-γ may be produced in response to allostimulation, and even these cytokines do not cause graft rejection, display anti-hcv activity. the elucidation of such a possible heterologous immunity via alloimmune responses to hcv replication might lead to the establishment of a novel method to prevent the progression of hcv reinfection in hcv-infected lt recipients. hepatitis c e region diversity after liver transplantation: a report from the hepatitis c iii trial. juan f. gallegos-orozco, hugo e. vargas, georges netto, gary l. davis, , and . % are morbidly obese . the goal of this study was to quantify the effect of bmi on access to transplantation (att), likelihood of receiving a transplantation (lrt), turndown rates (tr), and survival benefit (sb). methods: att was defined as either registering for the deceased donor waiting list or receiving a live donor transplant, and was analyzed based on the usrds registry using logistic regression. lrt was based on time spent in active status on the waiting list before receiving a transplant, and was analyzed based on the unos waiting list dataset using cox proportional hazards time-to-event analysis. tr was defined as the relative likelihood of being turned down for an organ offer by a provider other than the patient, and was analyzed based on the unos organ turndown dataset using negative binomial regression. sb was defined as survival after kidney transplantation versus survival on the deceased donor waiting list, and was analyzed based on the unos waiting list dataset using a time-dependent cox survival benefit model. all models were adjusted for known factors influencing those outcomes. lgbp lsg lsg mean follow-up (months) . (range - ) (range - ) . ( , ) patients > months since operation (n) / / / mean % ewl at > months (range - ) (range - ) ( , ) transplant candidate at > months / / / underwent transplant / / / complications developed in two patients (both with cirrhosis) and there was no mortality. mean follow-up was . months, and mean ewl at months or later was % (esrd), % (cirrhosis) and . % (esld). obesity associated comorbidities were improved or resolved in all patients. serum albumin and other nutritional parameters months or later after surgery were similar to preoperative levels in all groups. at most recent follow-up, out of patients ( %) have reached our institution's body mass index (bmi) limit for transplantation and are awaiting transplant; one patient with esld has undergone a successful lung transplant and one patient with cirrhosis has undergone a successful liver transplant. factors that contribute to inequitable access to the transplantation network (unos/ optn) include socioeconomic status, geographic location and delayed referral. the goal of the meld allocation system was to assign priority to the sickest candidate and assure equitable access to liver transplantation (lt). the meld has been validated as a reliable marker for liver disease severity. at the time of referral to the transplant center or listing a high meld (hm) is an indirect measure of delayed referral. therefore, the aim of this study is to identify factors associated with a hm at the time of listing for lt. method: using the unos database, we identified all adult candidates listed for lt from to . patients who received meld upgrade (i.e. hcc, fhf) and those listed for multi-organ transplant were excluded. the data collected included demographics, insurance payor, diagnosis, and meld score. meld score at time of listing was categorized as low (< ) and high (> ) and insurance type as private, medicaid and government (excluding medicaid) . results: during the study period , candidates were added to the lt waiting list. of these, there were , ( . %) males with a median age of (range - ) . caucasians were , ( . %), hispanic ( . %), african americans ( . %) and the rest ( . %). the underlying liver disease was hepatitis c ( . %), alcohol ( . %), alcohol/hepatitis c ( . %), pbc/ psc ( . %), cryptogenic ( . %) and others ( . %). age, gender and liver disease etiology were not associated with a hm at listing. a hm was associated with ethnicity: aa ( . %), hispanic ( . %), caucasian ( . %)[p< . ] and insurance type: medicaid ( . %), government ( . %) and private ( . %)[p< . ].there was no strong interaction between ethnicity/race and insurance in combination as predictors of hm i.e. both were independent. conclusion: ( ) aa and lt candidates with medicaid insurance are more likely to have a hm score at initial listing ( ) hispanics had the lowest rate of private insurance compared to caucasians with the highest rate. the above results suggest that type of insurance and ethnicity are independently associated with a hm (i.e. sicker patients) at listing. since a hm score is associated with increased mortality, implementation of strategies that result in timely and equitable access to the transplantation network regardless of the insurance type or ethnicity of the candidate(s) should be a priority. marked increase in the use of inactive status on the kidney transplant waiting list. kim nguyen, valarie ashby, , further wait time accrued only after active status was restored. on / / , the optn implemented a change in policy that provides for the accrual of waiting time during the entire interval that wl candidates are designated as s . methods: we investigated the impact of this policy change on the patterns of s designation, using the srtr/optn database. initial and subsequent status on the wl were determined for , candidates placed on the ki tx wl from / / - / / . the probability of becoming active (including receiving a living donor tx) on the wl was calculated for those who were s at listing before and after the policy change. results: table shows trends in the use of s before and after the policy change. of the , candidates listed as s before the policy change, % became active within months and % within year of wl. for the , candidates listed as s after the policy change, the corresponding figures are % and % respectively. figure demonstrates that, since the implementation of the new policy, the % of patients initially wl in s at most us tx centers has increased. conclusion: since the implementation of this policy, the number and % of pts wl as s at most ki tx centers, and the duration of s for those initially wl as s has increased dramatically. the implications of this practice on access to ki tx and survival warrants further investigation. can abstracts ( %) patients were retransplanted, and ( %) patients had panel reactive antibody > . the mean cumulative thymoglobulin dose administered was . mg/kg, and the primary maintenance immunosuppression started prior to discharge was a sirolimuscontaining regimen ( %). at the end of the follow-up period, ( %) patients had functioning grafts and ( %) patients experienced graft loss. of the patients with graft loss, ( %) patients experienced graft loss secondary to death. no pertinent differences were identified between groups. the graft survivals for african american recipients with african american or caucasian donors were % vs. % at year and % vs. % at year . conclusions: our study results suggest that donor race does not adversely affect graft outcomes in african american cadaveric kidney recipients with modern immunosuppression. donor racial differences may not play a primary role in the inferior graft outcomes of african american cadaveric kidney recipients. cardiac evaluation before kidney transplantation: are we screening too often or not enough? krista l. lentine, m. a. schnitzler, j. j. snyder, d. c. brennan, p. hauptman, p. r. salvalaggio, b. kasiske. evaluation for ischemic heart disease (ihd) is a common but non-standardized practice before kidney transplant. we retrospectively studied pre-transplant cardiac evaluation (ce) practices among a national sample of renal allograft recipients. methods: we examined usrds data for medicare beneficiaries transplanted in - with part a and b benefits from dialysis initiation through transplant. clinical traits defining "high" expected ihd risk were defined as diabetes, prior ihd, or > other coronary disease risk factors. pre-transplant ce were identified by billing claims for noninvasive stress tests and angiography. we quantified individuals with claims for coronary revascularization procedures between ce and transplant, and abstracted post-transplant acute myocardial infarction (ami) events from claims and death records. results: among , eligible patients, . % ( . % of high-risk and . % of lower-risk) underwent ce before transplant. overall, . % of patients who received ce also received pre-transplant revascularization, including only . % of lower-risk patients studied by ce ( table a) . the adjusted odds of transplant without ce (higher or for no ce, table b ) increased sharply with younger age and shorter dialysis duration. increased likelihood of transplant without ce also correlated with black race, female sex, and certain geographic regions. post-transplant ami rates in patients transplanted without ce allow assessment of whether ce was appropriately deferred in those who indeed face low ihd-risk after transplant. among patients transplanted without ce, the -yr incidence of post-transplant ami was % and % in lower and high-clinical risk groups, respectively, but varied by clinical traits within these groups. in lower-risk patients transplanted without ce, blacks patients faced increased ami-risk compared to whites (adjusted hr . , % ci . - . ). conclusions: observed ce practices demonstrate a low yield of pre-transplant revascularization but also raise concern for socio-demographic barriers to evaluation access. women who become pregnant in the first two years after kidney transplantation have a higher risk of graft loss. nadia zalunardo, olwyn johnston, caren l. rose, john s. gill. division of nephrology, university of british columbia, vancouver, bc, canada. existing information regarding the risks of pregnancy is derived from voluntary data sources. using medicare claims files from the usrds ( usrds ( - , we examined pregnancies (defined by presence of an inpatient icd- billing code for pregnancy or pregnancy-related complication) in the first years after kidney transplantation (ktx) among women aged - years whose primary insurance payor was medicare (n= , ) . patients were followed until graft failure, death or december , . there were pregnancies identified in women during the first post-transplant years. women who became pregnant during the st or nd post-transplant year had a shorter time to graft loss than women who became pregnant during the rd year (figure). to minimize the survivor bias among women who became pregnant during the rd posttransplant year, we determined the association between the timing of pregnancy and graft survival among the subset of women (n= ) who had graft survival of at least two years using a cox multivariate regression adjusted for age, race, cause of esrd, donor source, calendar year of transplant, dialysis vintage, maintenance immunosuppression, and gfr at months after ktx. pregnancy in the st year (hr . , % ci . - . ), and second year (hr . , % ci . to . ) was associated with an increased risk of graft loss compared to pregnancy during the third post-transplant year. we concluded that women who are able to wait should be counseled to become pregnant after the second post transplant year. the aging donor and recipient populations have led to new challenges in simultaneous kidney-pancreas transplantation (skpt). the purpose of this study was to retrospectively review our single center experience in skpt with respect to extended (ex) donor (d) and recipient (r) criteria. methods: over a month period, we performed skpts with enteric drainage ( portal venous drainage). ex ds were defined as age < (n= ), > (n= , mean age . yrs), or donation after cardiac death (dcd, n= ). all dcd donors were managed with extracorporeal support. ex rs were defined as age > (n= , mean age . yrs) or those with a pretransplant serum c-peptide level > . ng/ml (n= , mean . ng/ml). all rs received depleting antibody induction ( ratg, alemtuzumab) with tacrolimus, mmf, and tapered steroids ( steroid-free). results: a total of ds ( %) and rs ( %) met the above ex criteria. median waiting time was months, mean pancreas preservation was hours, and median length of stay was days. with a mean follow-up (f/u) of months, patient (pt) ( % ex d vs % non-ex d), kidney ( % ex d vs % non-ex d) and pancreas graft survival ( % ex d vs % non-ex d) rates were similar between d groups (all p=ns). the incidences of delayed kidney graft function ( % in each group) and early pancreas graft loss due to thrombosis ( % ex d vs % non-ex d) were also comparable between d groups. with regard to r groups, pt ( % vs %, p= . ) and kidney ( % vs %, p=ns) graft survival (gs) rates were slightly lower in the ex r group compared to the non-ex r group, respectively. however, death-censored kidney gs rates ( % ex r vs % non-ex r) were comparable between groups. uncensored pancreas gs rates ( % ex r vs % non-ex r) were similar. the incidences of acute rejection, surgical complications, infection, and other morbidity were comparable regardless of d or r group. at year (or latest) follow-up, renal and pancreas functional parameters were similar between d groups. however, the ex r group demonstrated slightly compromised renal and pancreas allograft function and a greater need for oral hypoglycemic agents. conclusion: intermediate-term outcomes in skpt from selected ex ds or rs have comparable outcomes, although ex r criteria may represent a risk factor for pt survival and functional outcomes. conclusion: spk recipients with functioning pancreas grafts have significantly improved kidney and patient survival compared to ld ka and dd ka. however, early pancreas graft failure results in kidney and patient survival rates similar to ka recipients. spk provides optimal outcomes for patients with dm , but long-term risk associated with early pancreas loss may be a consideration when selecting spk vs ka transplantation. the impact of long-term metabolic control on renal allograft and patient survival in type diabetes. christian morath, martin zeier, bernd dohler, jan schmidt, peter p. nawroth, gerhard opelz. nephrology, university of heidelberg; transplantation immunology, university of heidelberg; transplantation surgery, university of heidelberg; endocrinology, university of heidelberg. it is a matter of debate whether pancreas allografts independently contribute to renal transplant and patient survival in type diabetics who received a simultaneous pancreas kidney transplant (spk). using the data of the collaborative transplant study (cts), we studied type diabetic recipients of deceased donor kidneys (ddk), living donor kidneys (ldk), or spk performed during two time periods: to and to . we analyzed graft and patient survival rates for a maximum of years. ddk recipients showed inferior graft and patient survival compared to ldk and spk recipients in both time periods. ldk recipients had a superior graft survival rate initially, but the survival rate of kidneys in spk recipients reached the level of ldk toward the end of the follow up period. the results of patient survival paralleled those of kidney graft survival: an early advantage of ldk as compared to spk faded away during follow up. multivariate analysis, in which pretransplant cardiovascular risk assessment was appropriately considered, showed that patient survival of spk recipients was superior to that of ldk recipients beyond the tenth year after transplantation (hazard ratio hr = . , p = . ). this was reflected by a lower cumulative cardiovascular death rate in recipients of spk ( . %) compared to recipients of ddk ( . %) or ldk ( . %) . the early survival benefit of ldk compared to spk is lost during long-term follow up, probably related to improved glycemic control in spk recipients. proposal for a grading rejection schema in pancreas allograft biopsies from a multidisciplinary panel of pathologists, surgeons and nephrologists. .normal .indeterminate septal inflammation that appears active but the overall features do not fulfill the criteria for mild cell mediated acute rejection. active septal inflammation involving septal structures and/or focal acinar inflammation. -grade ii / moderate acute cell mediated rejection multifocal (but not confluent or diffuse) acinar inflammation with spotty acinar cell injury and drop-out and/or minimal intimal arteritis -grade iii / severe acute cell mediated rejection diffuse, (widespread, extensive) acinar inflammation with focal or diffuse multicellular /confluent acinar cell necrosis.and/or moderate or severe intimal arteritis and/or transmural inflammation -necrotizing arteritis chronic active cell-mediated rejection. chronic allograft arteriopathy (arterial intimal fibrosis with mononuclear cell infiltration in fibrosis, formation of neo-intima) .antibody mediated rejection =c d positivity + confirmed donor specific antibodies + graft dysfunction -hyperacute rejection -accelerated antibody mediated rejection severe, fulminant form of antibody mediated rejection with morphological similarities to hyperacute rejection but occurring later (within hours or days of transplantation). -acute antibody mediated rejection specify percentage of biopsy surface with interacinar capillaries positive for c d. .chronic allograft rejection/graft sclerosis stage i (mild graft sclerosis) < % of the core surface stage ii (moderate graft sclerosis) - % of the core surface. stage iii (severe graft sclerosis) > % of the core surface . other histological diagnosis e.g. cmv pancreatitis, ptld, etc. a simple, reproducible, clinically relevant and internationally accepted schema for grading rejection should improve the level of diagnostic accuracy and positively affect patient care. rank test). similar results were obtained when death was included as a cause of graft loss (data not shown). conclusion: par is associated with worse long term kidney graft survival than kar. it is likely that patients that experience par within the first year have also experienced undiagnosed sub-clinical kar. this adds associative data to the argument that the likelihood of concordance between par and kar is high and therefore, the need for increased monitoring of kidney function after par is warranted. the most efficacious immunosuppressive (immuno) regimen for spkt is debated, and information on the best regimen to prevent amr is particularly scarce. we performed a retrospective comparative cohort study that included spkt patients (pts) transplanted in - , who received maintenance immuno with tac, mmf and steroids. two groups were compared: pts who received induction with alemtuzumab (alem) (n= ) and pts who were induced with basiliximab (basilmab) (n= ). donor and recipient characteristics were similar. kt acute cellular rejection (acr) was more frequent with basilmab ( -yr . % vs . %, p= . ), but the incidence of biopsy-proven kt amr was similar ( -yr % with basilmab vs . % with alem, p=ns). no differences in prevalence were detected considering early amr (< th day) or late amr (> th day) separately. multivariate analyses showed that the only significant risk factor for amr was female gender (adjusted hr . , p= . ). the biopsy-proven kt rejection was associated with clinical pt rejection in out of the amr cases ( %), without differences between the groups. post-rejection kt graft survival was similar in both groups ( -yr basilmab/alem . / . %), but deathcensored kt survival was lower with alem ( / . %, p= . ). the predominant cause of kt loss in pts induced with basilmab was death-with-function (n= ), while in pts induced with alem acute or chronic amr was the most common cause of kt attrition (n= ). pancreas survival was similar between both groups. more pt losses due to ar occurred in alem-treated group than in the basilmab group ( vs ) . nearly all early episodes resolved with treatment and were not associated with worse graft survival. conversely, late amr episodes carried a worse prognosis, with decreased -yr kt ( . % vs . %, p< . ) and pt graft survival ( . vs . %, p< . ). late amr was associated with graft loss in multivariate cox models (kidney loss hr . , p= . and pancreas hr= . , p= . ) . amr is common in spkt recipients. acr is better prevented with alem than with basilmab, but no relevant difference is found between alem and basilmab in amr. late (as opposed to early) amr episodes are associated with significant reduction in spkt survival rates despite treatment. preventive and/or different treatment strategies are required to address late amr in spkt. intraoperative fluorescence imaging (ifi) in pancreas transplantation (pt) to determine vascular patency and allograft perfusion. edmund q. sanchez, srinath chinnakotla, marlon f. levy, robert m. goldstein, goran b. klintmalm. baylor regional transplant institute, dallas/ft. worth, tx. thrombotic complications of pt are well known. we report ifi using the spy device to assess immediate vascular patency and allograft perfusion. our controlled experience is presented here. methods: pts were imaged intraoperatively using the spy device under our irb approved study. indocyanine green solution ( . mg/ml) was injected into central venous catheters after completion of the vascular anastomoses of whole pancreaticoduodenal allografts. the pancreas transplants were performed in the retroperitoneal portal and enteric drained technique described by boggi, et al. imaging of the allograft vasculature, perfusion of the pancreas, and perfusion of the duodenal segments was performed and recorded intraoperatively. all video sequences were archived for later review. results: ifi on pancreas transplants ( simultaneous pancreas-kidney and pancreas after kidney) was performed and video sequences were recorded. all pancreas allografts demonstrated intraoperative vascular patency and complete pancreatic and duodenal perfusion. there were no side effects seen. all pancreas transplants had immediate graft function. one patient was re-explored on postop day due to persistent acidosis and hypotension. repeat ifi demonstrated vascular patency and perfusion, despite an ischemic external physical appearance. there were no vascular complications that required reoperation, nor were there any graft thromboses. characteristic slow venous outflow was seen in each case. conclusion: ifi with the spy device is a simple and effective method to determine immediate patency and perfusion of the whole pancreaticoduodenal allograft. its use is beneficial in re-exploration to rule out infarcted pancreas allografts. further development in quantification of vascular flow rates and allograft perfusion indices by this device is abstracts in progress. once these are established, this information will be studied in a controlled fashion, and will be compared with clinical outcomes. we have demonstrated safety and developed a protocol for using the spy device in ifi of pancreas transplants. tolerance/immune deviation i tolerance without immunosuppression: exploiting epigenetic regulation as a new approach to achieving donor-specific allograft tolerance. liqing wang, ran tao, joel a. friedlander, wayne w. hancock. pathology & immunology, children's hospital of philadelphia & upenn, philadelphia, pa. given toxicities of all current immunosuppressive agents, plus complications of malignancy, infection and chronic rejection, maintaining the search for new approaches to tolerance induction is essential. while weaning of immunosuppression is fraught with risks and costimulation blockade has not yielded the expected boon, use of a broad histone deacetylase inhibitor (hdaci), such as trichostatin a (tsa) or suberoylanilide hydroxamic acid (saha), promotes foxp acetylation of foxp and binding to target genes, leading to enhanced treg suppressive function, and wks of therapy with hdaci and low-dose rapamycin can induce allograft tolerance. we now show that in addition to acetylation, modulation of a second major epigenetic mechanism, dna methylation, has salutary effects, such that combined use of an hdaci and a dna methyltransferase inhibitor (dnmti, e.g. -aza- deoxycytidine) has potent effects. microarray analysis of the effects of hdaci on tregs showed down-regulation of multiple genes associated with dna methylation, including dnmt, methyl-cpgbinding domain and associated proteins, leading us to test the effects of dnmti use on treg function. dnmti administration decreased foxp gene methylation, enhanced treg gene expression, and increased treg suppression in vitro, and led to a dose-dependent prolongation of cardiac allograft survival (balb/c->c bl/ ) in vivo (p< . ). the combination of hdaci and lower doses of dnmti, administered for just wks, led to permanent engraftment (> d, p< . ), and the permanent acceptance of second donor allografts but acute rejection of third-party (cba) cardiac allografts indicated induction of donor-specific tolerance post-epigenetic therapy. analysis of long-surviving cardiac allografts showed a minor infiltrate consisting primarily of foxp + tregs and an absence of chronic rejection (transplant arteriosclerosis, myocardial fibrosis), whereas combined epigenetic therapy led to only minor prolongation of allograft survival in treg-depleted recipients. in summary, brief use of clinically approved agents (an hdaci plus an dnmti), can synergistically enhance treg function and induce tregdependent donor-specific allograft tolerance without use of any immunosuppression. we conclude that insights gained through epigenetic targeting may provide completely new approaches to the taming and regulation of otherwise powerful immune responses post-transplantation. a novel epigenetic approach to generate mouse and human cd + cd + foxp + regulatory t cells. girdhari lal, nan zhang, william van der touw, yaozhong ding, jonathan s. bromberg. gene and cell medicine, mount sinai school of medicine, new york city, ny. background: constitutive foxp expression is required for stable and suppressive cd + cd + regulatory t cells (treg) . we previously showed that demethylation of an upstream cpg island of the foxp promoter is characteristic of stable and suppressive treg. using dna methyltransferase inhibitors, we present a novel method to generate antigen-specific treg from mouse and human cd + cd -t cells. methods: naïve cd + cd -t cells and natural treg (ntreg) were purified from wild type or foxp -gfp transgenic mice. human naïve cd + cd -t cells were purified from pbmc. t cells were cultured with irradiated antigen presenting cells in the presence of il- , anti-cd ε mab, tgfβ or the dna methyltransferase inhibitor -aza- '-deoxycytidine (zdcyd), which demethylates the upstream promoter. foxp expression was determined by flow cytometry and qrt-pcr. results: naïve t cells cultured under stimulatory conditions with zdcyd express increased foxp mrna ( fold) and intracellular foxp protein ( % of cells vs % without zdcyd). foxp expression is synergistically enhanced with tgfβ ( ± . % vs . ± . % zdcyd alone or . ± . % tgfβ alone), similar to ntreg ( . ± . %). tgfβ in combination with other dna methyltransferase inhibitors (procainamide, hydralazine, rg ) also induces foxp . zdcyd plus tgfβ induced treg stably express foxp and similar surface markers and cytokine mrna as ntreg. zdcyd plus tgfβ induced treg suppress proliferation of cd + cd -t cells, prevent cd + cd -cd rb hi induced colitis in scid mice, and enhance islet allograft survival. zdcyd plus tgfβ induce foxp expression in antigen-specific wild type or t cell receptor transgenic cd + t cells stimulated with alloantigen or peptides, and in naïve cd + cd -t cells. in vivo administration of zdcyd preferentially preserves thymic cd + cd + foxp + treg generation. zdcyd alone or zdcyd plus tgfb induce strong foxp expression in human cd + cd -t cells compared to tgfβ alone. zdcyd plus tgfβ induced human treg suppress the proliferation of naïve cd + cd -t cells, whereas tgfβ-induced treg do not. conclusion: dna methyltransferase inhibitors induce stable and suppressive foxp + treg from peripheral cd + cd -t cells. these finding have important implications for understanding t cell development and differentiation, and provide a clinically applicable technique for manipulating epigenetic regulation for the generation of treg for tolerance. macrophages driven to a novel state of activation can promote tolerance. katharina kronenberg, seiichiro inoue, james a. hutchinson, beate g. brem-exner, gudrun e. koehl, hans j. schlitt, fred fandrich, edward k. geissler. surgery, university of regensburg, regensburg, germany; surgery, university hospital schleswig holstein, kiel, germany. background: the use of immunomodulatory cells in organ transplantation (tx) is a promising tolerance-induction strategy. here we describe a novel macrophage population capable of enriching t regulatory cells (treg) and promoting tolerance. methods: balb/c bone marrow, spleen and blood mononuclear cells were cultured with m-csf for days, with a hr pulse of ifn-γ on day ; the resultant adherent cells are referred to as ifnγ-induced monocyte-derived cells (ifnγ-mdc) . residual lymphocytes from these cultures were recultured with the adherent ifnγ-mdc for an additional days. ifnγ-mdc were phenotyped by facs and immunomodulation of lymphocytes was determined by cell counting and facs analysis for tregs. mouse heterotopic heart tx was used for in vivo testing. results: ifnγ-mdc highly express cd b/c, f / and pd-l . compared to classically-activated (m ) macrophages, ifnγ-mdc express less cd /cd , but higher cd c. ifnγ-mdc profoundly delete activated, but not resting, lymphocytes (> %), with cell contact (via transwell system) and caspases (via inhibitors) being essential. most interestingly, ifnγ-mdc highly enrich lymphocytes for cd + cd high foxp + treg ( ± %; n= ). the same, or higher, proportions of treg developed when ifnγ-mdc were produced from macs-purified cd b + and cd + cells ( : ) . ifnγ-mdc culture supernatant showed increased il- (elisa) vs. monocyte control cultures ( ± pg/ml vs. < pg/ml, respectively; n= ), suggesting il- as one potential mediator. ifnγ receptor signaling and cd interactions are required for treg enrichment, as confirmed using ifnγ receptor and cd knock-out mice (c bl/ mice). ifnγ-mdc derived from cd b + cells and lymphocytes of ova-transgenic otii mice showed enrichment of treg by -fold with high-affinity ova peptide ( - ) vs. treg levels using a low-affinity ova peptide (ova - ), suggesting ag-specific treg cells can be enriched with ifnγ-mdc. finally, a single post-heart tx (d+ ) i.v. injection of x donor (c h)-derived ifnγ-mdc prolonged allograft survival in balb/c recipients from . ± . d in controls (n= ) to . ± . d (n= ; p= . ). conclusions: ifnγ-mdc are a novel macrophage population capable of deleting activated t cells and highly enriching remaining lymphocytes for tregs. therefore, ifnγ-mdc could be useful in a clinical setting for promoting transplant tolerance. plasmacytoid dc therapeutic potential is independent of ido induction due to elevated dap expression. tina l. sumpter, bridget l. colvin, zhiliang wang, andrew l. mellor, angus w. thomson. , starzl transplantation institute, dept. of surgery, university of pittsburgh, pittsburgh, pa; immunology, university of pittsburgh, pittsburgh, pa; immunotherapy center, medical college of georgia, augusta, ga. optimizing the mechanisms of pdc tolerogenicity may facilitate their use in the development of cell-based tolerance induction strategies. pdc may undermine t cell function via inducible expression of ido, a tryptophan catabolizer that enhances t cell apoptosis. ido is negatively regulated by dap . in some systems, loss of dap correlates with immunostimulatory activation of pdc, while in others, its absence correlates with enhancement of pdc tolerogenicity through induction of ido. in these studies, we characterized the ability of wt and ido-deficient pdc to attenuate murine heart allograft rejection in order to define the contribution of ido and its regulation by dap relative to the immunoregulatory potential of pdc. methods: pdc and control myeloid (m) dc were generated from bm cultures of wt or ido ko c bl/ (b ; h b ) mice. wt mdc, pdc or ido ko pdc were pulsed with alloag (balb/c; h d ), stimulated with cpg, and then injected i.v. into syngeneic (b ) recipients d before heart transplant. donor ag-specific activation of t cells was analyzed by mlr and elisa. dap expression was evaluated by rt-pcr and abrogated with sirna. results: administration of ido ko pdc d before transplant prolonged graft survival beyond that seen with control mdc, but not to the extent seen with wt pdc, suggesting involvement of ido. pdc cultures from ido ko mice exhibited a more mature phenotype than their wt counterparts with reduced expression of co-regulatory molecules (e.g., icosl). although ido ko pdc induced enhanced t cell alloactivation compared to wt pdc, use of the ido inhibitor -mt indicated that wt pdc do not produce functional ido. further analyses showed wt pdc exhibited high levels of dap mrna expression. silencing dap had no effect on the ability of wt pdc to activate allogeneic t cell proliferation, but significantly enhanced ifnγ secretion. addition of -mt to mlr with dap -silenced pdc increased t cell proliferative responses to alloag, verifying ido induction in dap -silenced pdc. conclusions: these data underscore the prophylactic potential of pdc for cell-based therapy that may be independent of ido, due, in part, to elevated dap expression. additionally, our data support a role for dap in both immunostimulation and immunoregulation by pdc. rapamycin preferentially blocks the expansion of potentially tolerogenic plasmacytoid dendritic cells in vivo. heth r. turnquist, angus w. thomson. , starzl transpl inst and dept of surgery; dept of immunol, univ of pittsburgh sch of med, pittsburgh, pa. rapamycin (rapa), a 'tolerance-sparing' immunosuppressant with anti-proliferative properties, inhibits myeloid (m) dendritic cell (dc) differentiation/maturation in vitro. rapa decreases cd c + dcs in the mouse spleen and suppresses the expansion of total cd c + dc following administration of the dc growth factor, fms-like tyrosine kinase ligand (flt l). however, the influence of rapa on plasmacytoid (p) dc,the principal type- ifn producers in the body, known to regulate innate and adaptive immune responses, and reported to promote experimental transplant tolerance, has not been evaluated. methods: dc were propagated from bone marrow for days (d) in flt l, in the absence or presence of a clinically-relevant dose of rapa ( ng/ml). in addition, dcs were mobilized in c bl/ mice by i.p. flt l ( mg/d for d; d - ). untreated and flt l-treated groups also received rapa ( . mg/kg/d i.p.; d - ). on d , dc were isolated by density gradient centrifugation and/or cd c + positive selection. mdc (cd c + cd b + ) and pdc (cd c lo cd b -b + ) were identified by flow cytometry. results: rapa suppressed pdc and mdc generation in vitro; rapa-dc-treated cultures had only % of the pdc and % of the mdc found in control conditions. in normal mice, both mdc ( % of control) and pdc ( . %) numbers were reduced significantly by rapa administration. rapa, when given concurrently with flt l, blunted the typical profound expansion of mdc. specifically, flt l and rapa-treated mice displayed a ± x increase over control (steady state) numbers compared to a ± x increase in mice treated with flt l alone. flt l-induced expansion of pdc was to a much greater extent impacted by rapa, as absolute numbers of pdc increased only . ± . x over control numbers compared to ± x increase in absolute splenic pdc in flt l-treated mice. conclusion: these data identify rapa as a selective suppressor of pdc generation, as described for corticosteroids. this has significant implications, given the use of rapa following organ transplantation, and the suggested importance of secondary lymphoid tissue pdc for promotion of transplant tolerance mediated by treg. due attention to these disparate effects of rapa on regulating cell populations will be necessary to optimize therapeutic regimens for safe promotion of tolerance. the liver is tolerated better than other transplanted organs. this may reflect the inherent tolerogenicity of liver dendritic cells (dc) and interactions with foxp + regulatory t cells (treg). recent studies have shown that cd expression on dc correlates with induction of foxp + treg, and can be enhanced in the presence of transforming growth factor-β (tgf-β) and retinoic acid (ra), both of which are produced in the liver. this study evaluates cd expression on liver plasmacytoid (p) and myeloid (m) dc and the potential of liver dc subsets to induce tregs. methods: pdc and mdc were magnetically isolated from livers and spleens of c bl/ mice and co-cultured with cfse-labeled allogeneic (balb/c) cd + cd -t cells. after or d of co-culture, t cells were assessed for cfse dilution and intracellular foxp expression. rhtgf-β and either all trans or cis-ra were added to co-cultures. cd expression was evaluated by flow cytometry. results: cd expression was elevated on liver pdc and mdc compared to spleen pdc or mdc, with higher expression on liver mdc. pdc from the liver and the spleen were poor inducers of foxp in cd + cd -t cells compared to mdc. foxp induction was enhanced with tgf-β when splenic pdc were used as stimulators. however, when liver pdc were used as stimulators, tgf-β had no effect on foxp induction. ra (either all trans or cis) enhanced induction of foxp + cells in cd + cd -t cells in the presence of tgf-β when splenic pdc but not liver pdc were used as stimulators. tgf-β and tgf-β with ra also enhanced foxp induction in cd + cd -t cells when either spleen or liver mdc were used as stimulators, though splenic mdc were superior inducers of foxp . conclusions: many studies have focused on naturally-occurring foxp + tregs in systemic tolerance. our data show that liver mdc and pdc are poor inducers of foxp in t cells, even in the presence of tgf-β and ra. these data suggest that the inherent tolerogenicity of liver dc subsets may be independent of treg induction or that liver dc interact with treg through alternative mechanisms. background: t cell-mediated immune rejection occurs in organ transplantation. in addition to mhc-tcr signaling, t cell activation requires costimulation from antigen presenting cells. b molecules (cd /cd ) and cd are critical costimulatory molecules in t cell activation. insufficient or lack of costimulation results in inactivation or tolerance. we hypothesized that blocking the costimulation pathway using small interfering rna (sirna) expression vector can prolong allogeneic heart graft survival. method: vectors that express hairpin sirnas specifically targeting cd and cd were prepared. recipients (balb/c mice) were treated with cd and/or cd sirna vectors, and days prior to heart transplantation. control groups were injected with a blank vector and sham treatment (pbs). after sirna treatment, a fully mhcmismatched (balb/c to c /bl ) heart transplantation was performed. result: allogeneic heart graft survival (> days) was approximately % in the mice treated simultaneously with cd and cd sirna vectors. in contrast, allogenic hearts transplanted into recipients treated with blank vector and pbs stopped beating within days. hearts transplanted into cd or cd sirna vector-treated recipients had an increased graft survival time compared to negative control groups, but did not survive longer than days. real time pcr and flow cytometric analysis showed an upregulation of foxp expression in spleen lymphocytes and a concurrent downregulation of cd and cd expression in splenic dendritic cells of sirnatreated mice. an mlr, using splenic dendritic cells (dcs) isolated from tolerant recipients, showed a significantly lower t cell proliferation capacity in cd -and cd -sirna vector-treated mice, compared to control groups. tolerant dcs from cd -and cd -treated recipients promoted cd +cd +foxp + regulatory t cell differentiation. finally, tissue histopathology demonstrated an overall reduction in lymphocyte interstitium infiltration, vascular obstruction, and edema in mice treated with cd and cd sirna vectors. conclusion: this study demonstrates that the simultaneous silencing of cd and cd genes has synergistic effects in preventing allograft rejection, and may therefore have therapeutic potential in clinical transplantation. costimulation blockade (cob) of the cd /b pathway has long been suggested as a means of attaining indefinite, well-tolerated, antigen-specific prophylaxis from allograft rejection. although effective in rodent models, cd /b blockade is not alone sufficient to prevent rejection in more robust primate models. the relative presence of allocrossreactive memory t cells is one mechanism of cob resistant rejection. lfa -ig is an approved agent for the treatment of psoriasis, shown clinically to deplete tem cells in psoriatic lesions. we hypothesize that lfa -ig specifically targets cob resistance cells, including heterologous alloreactive t cell memory, while avoiding interference of peripheral mechanisms that foster cob-mediated allograft acceptance. rhesus monkeys underwent mhc mismatched renal allotransplantation. ctla -ig was given mg/ kg iv on days - , , , , , , and mg/kg iv on days , , , . lfa -ig, ( . mg/kg iv) was given on day - , , , then weekly ( wks). sirolimus was given orally ( mg/kg) days - and donor specific transfusion ( ml/kg iv) on day - . animals were followed by polychromatic flow-cytometry to quantify t cell subsets. lfa -ig synergized with ctla -ig successfully preventing renal allograft rejection in this model and leading to indefinite survival in / animals (table) . this enhanced survival was associated with a significant reduction in tem cells in animals treated with lfa -ig compared to animals without lfa -ig treatment (figure). lfa -ig withdrawal led to tem re-population and rejection. this therapy regimen, all clinically available agents, promotes cob-mediated graft acceptance without the use of calcineurin inhibitors, steroids, or gross t cell depletion. the aim of this study was to investigate the immunological pathways that regulate t cell dependant allograft responses in the hope of finding novel immunomodulatory compounds. islet (and skin) allografts were transplanted into full mhc-mismatched wild type (wt) and baff-transgenic (baff-tg) recipient mice. allograft function/ rejection was monitored by blood glucose levels and/or confirmed by nephrectomy. histology, splenocyte populations & t cell functions were analyzed. the b cell activation factor from the tnf family (baff) is critical for b cell survival. t cells express baff receptors suggesting that baff may also play a role in t cell responses. contrary to expectations, we found that baff-tg mice accepted a full mhc-mismatched islet allograft for > days. in addition, baff-tg mice also showed delayed skin graft rejection. this was due to a t cell intrinsic change in allo-responsiveness as shown by a failure of purified baff-tg t cells to reject an allograft in adoptive transfer experiments. however, baff-tg t cells were not anergic per se as they proliferated normally to mitogens in vitro and to antigenic challenge in vivo. intriguingly, baff-tg mice harbored an increased frequency of t regulatory cells in the periphery as compared to wt mice. elimination of cd + t cells restored normal allograft rejection to baff-tg mice, demonstrating that the increased number of treg cells were responsible for their altered allo-immunity. in a second approach, baff-tg t cells depleted of cd + cd + t cells were adoptively transferred to transplanted rag recipients, and in this case the baff-tg cd + cd -t cells rejected their allograft. proliferation assays showed that excessive baff was not promoting treg expansion by driving proliferation in the periphery. adoptive transfer of gfp expressing syngeneic splenocytes did not exhibit enhanced survival in the presence of excessive baff. however, analysis of treg cells in the thymus of baff-tg mice showed an increased intrathymic frequency. together these results demonstrate that baff-tg mice harbor an expanded number of treg cells that prevent th -type immune responses including allograft rejection. furthermore, we demonstrate that manipulating baff levels may provide a means to generate immunosuppression free dominant allograft tolerance. we have previously reported the outcome of pig-to-baboon thymokidney transplants from galt-ko miniature swine using an immunosuppressive regimen designed to facilitate the induction of tolerance. although the results were superior to results using hdaf thymokidneys, there was a high rate of early post-operative complications. we investigated whether the elimination of steroids and whole body irritation (wbi) from the treatment protocol would decrease the complication rate in the perioperative period. methods: baboons received thymokidney transplants from galt-ko miniature swine. the immunosuppressive regimen was based on the previously published protocol, but eliminated steroids and substituted rituximab for wbi. it consisted of thymectomy day - , splenectomy day , atg, rituximab, mmf and anti-cd mab. renal function was assessed by serum creatinine levels. evidence for baboon thymopoiesis in the pig thymus was assessed by facs and immunohistochemistry. results: one animal died due to a drug reaction at pod with normal renal function and no evidence of infection. the remaining baboons showed no signs of rejection although igm deposition was observed, likely due to preformed non-gal nab. there were no deaths due to rejection. although early infectious complications were not seen, late complications leading to mortality were still observed, including systemic cmv infection (pod ), pleural effusions (pod , ) , ards with pulmonary hemorrhage (pod , ) and acute myocardial infarction (pod ). two animals showed evidence for early thymopoiesis in the pig thymus by facs and immunohistochemistry. cd +/cd + thymocytes were seen in the thymic grafts, indicating t cell development was supported by the pig thymus. the average survival of the steroid-free group was days including the animal with the drug reaction and days excluding it, compared to . days in the regimen that included steroids/wbi. conclusions: a steroid-free and wbi free regimen designed for the induction of tolerance across the pig-to-baboon xenogeneic barrier had fewer early post-operative complications than previous regimens. greater than -day average survival of recipients of life-supporting xenogeneic thymokidneys was observed without rejection. this regimen also appears to permit baboon thymopoiesis in the pig thymus. purpose: the effects of human decay accelerating factor (hdaf) addition to the galactosyl transferase knock-out (galt-ko) background in transgenic pig kidney xenotransplantation in baboons has not been previously studied. methods: baboon recipients of galt-ko (n= ) or galt-ko/hdaf (n= ) pig kidneys received flolan, heparin and/or aspirin. steroids (s), cobra venom factor (v), atg (a), mmf (m), and/or a low-dose cd blockade (c) regimen were given. results: pre-transplant (tx) anti-non-gal antibody (ab) titers were inconsistently associated with early galt-ko kidney xenograft failure. high d-dimer levels hours post-tx were closely associated with early galt-ko graft loss but not when assessing levels of c a, btg, or increased cd p expression on circulating platelets. regimens lacking mmf and/or cd blockade elicited by day - large anti-donor non-gal ab responses . post-operative creatinine levels for the galt-ko/hdaf recipients were lower along with superior graft survival compared to galt-ko; d-dimer, anti-donor non-gal ab, c a, btg, and f + measurements are in progress for the galt-ko/hdaf recipients. galt-ko/hdaf v,a,m,s,c > * tbp . ; . * graft survival at time of abstract submission as graft still functioning at time of abstract submission; tbp --to be processed ! --anuric; non-life supporting, but appeared viable, pink, and well-perfused until day conclusion: early failure of vascularized galt-ko organs is closely associated with activation of coagulation pathways; whether this is triggered primarily by anti-non-gal ab or by other mechanisms is not addressed by our study. preliminary results using galt-ko/hdaf pig kidneys show promise in attenuating or possibly preventing these and/or other such mechanisms. the established efficacy of cd -based costimulation blockade with mmf to prevent induced anti-non-gal antibody elaboration is confirmed by our preliminary findings. recovery of cardiac function after pig-to-primate orthotopic heart transplant. christopher g. a. mcgregor, william r. davies, keiji oi, henry d. tazelaar, randall c. walker, krishnaswamy chandrasekaran, guerard w. byrne. mayo clinic, rochester, mn. xenotransplantation has been proposed as a method to alleviate the shortage of donor organs. we report survival of up to weeks of three orthotopic transplants after pig-tobaboon cardiac xenotransplantation. pig-to-baboon orthotopic transplantation was performed using an adult baboon recipient and cd transgenic pig. the recipients were treated with an α-gal polymer to block the effects of anti-gal antibody and with atg induction and a tacrolimus and sirolimus based maintenance immunosuppression. heart function was continuously monitored by intramyocardial electrocardiography and every - days by serial echocardiography. standard hematological, serum chemistry and cardiac troponin levels were monitored every - days. the animals survived , , and days in a healthy condition. mortality was a result of pneumonitis, respiratory failure and bowel infarction respectively. one recipient (survival days) showed impaired perioperative left ventricular function with an ejection fraction of % on echo. over the next two weeks, the ejection fraction in this animal returned to normal ( %) and troponin levels normalized. this study shows the longest survival of orthotopic cardiac xenografts to date with recovery of impaired heart function after early ischemia reperfusion injury. this significant improvement in ventricular function suggests that the normal reparative processes appear to function across the xenotransplantation barrier, supporting the potential clinical potential of cardiac xenotransplantation. purpose: to determine whether the galactosyl transferase gene knock-out (galt-ko) protects pig lungs from hyperacute lung rejection (halr) by human blood. the effects of adding human decay accelerating factor (hdaf) to the galt-ko background will also be examined for the first time. methods: heparinized fresh human blood was used to perfuse galt-ko pig lungs (n= ). lung function was assessed by flow, pulmonary vascular resistance (pvr), oxygen transfer, and tracheal edema using pre-defined survival endpoints. historical wild-type (wt) pig lungs (n= ) provide context for analysis. additionally, two pig lungs expressing galt-ko/hdaf were recently examined, one of which received treatment with xigris. results: median lung survival in galt-ko lungs was minutes (range min to > min) vs. minutes in wt lungs (range min to min, p= . ); / galt-ko/hdaf pig lungs survived > min. pvr at minutes for galt-ko lungs was ± mmhg-min/l vs.wt lungs ( ± mmhg-min/l at minutes) vs. mmhgmin/l for each galt-ko/hdaf lung. complement activation (∆c a) at minutes was significantly lower with galt-ko (∆c a ± ng/ml) than wt lungs (vs. ± ng/ml, p= . ). galt-ko was also associated with reduced platelet activation: only ± % of circulating platelets express cd p at min. vs. ± % in the wt group (p= . ); ∆βtg at min [ ± iu/ml (galt-ko) vs. ± iu/ ml (wt)], and less thrombin formation (∆ f + ) at minutes (galt-ko: ± . nm vs. wt: ± nm). ∆c a, % of circulating platelets expressing cd p, ∆βtg, and ∆ f + measurements are in progress for galt-ko/hdaf. platelet sequestration was delayed as mean % of the initial platelets remaining in the galt-ko lung perfusate was ± % at min vs. ± % in the wt lung group (p= . ). neutrophil sequestration was also diminished in galt-ko ( ± % residual) vs. wt lung ( ± % residual, p= . ). conclusion: galt-ko pig lungs are significantly protected from several facets of halr: complement and coagulation cascade activation, neutrophil sequestration, and platelet activation are all partially attenuated by this modification alone. preliminary results suggest that galt-ko/hdaf lungs offer even further protection. disseminated intravascular coagulation is associated with tissue factor expression on recipient platelets and monocytes. chih che lin, , , mohamed ezzelarab, corin torres, david ayares, anthony dorling, david k. c. cooper. thomas e. starzl transplantation institute, university of pittsburgh, pittsburgh, pa; revivicor inc., blacksburg, va; department of immunology, imperial college london, hammersmith hospital, london, united kingdom; department of surgery, chang gung memorial hospital, kaohsiung, taiwan. purpose acute humoral xenograft rejection (ahxr), frequently associated with disseminated intravascular coagulation (dic), remains a challenge in pig-to-primate xenotransplantation (tx). a previous in vitro study showed that recipient platelets and monocytes were induced to express tissue factor (tf) after incubation with porcine endothelial cells, and we speculated this may contribute to thrombosis. the present study investigated whether circulating (extragraft) monocytes and platelets express tf and whether this relates to the development of dic after pig tx. methods baboons (n= ) received an aortic patch or kidney from either a wild-type (wt) or α , galactosyltransferase gene-knockout (gtko) pig, with or without immunosuppressive therapy. baboon monocytes and platelets were isolated from blood before and after tx. surface tf phenotype was determined by flow cytometry. functional tf activity was determined by clotting time assays after mixing monocytes and platelets with recalcified factor vii (fvii)-deficient plasma with or without added fvii. before tx, monocytes and platelets did not express tf or display tf-dependent procoagulant activity. after gtko aortic patch tx, the baboons were euthanized by day without developing dic. however, by day , circulating platelets (but not monocytes) expressed tf and promoted tf-dependent clotting in recalcified plasma. in the absence of immunosuppression, wt kidneys survived < day before the onset of dic, at which time tf activity was detected on both platelets and monocytes. after gtko kidney tx in immunosuppressed baboons, platelets expressed tf as early as day . in contrast, monocytes began to express tf only at the onset of dic. this study links expression of tf on recipient monocytes and platelets with the development of dic. expression on platelets appeared to predict the subsequent development of dic, whereas that on monocytes was associated with the onset of dic. whilst our observations do not establish a causal relationship, they provide the basis for further study. international human xenotransplantation inventory. antonino sgroi, leo buhler, megan sykes, luc noel. surgical research unit, department of surgery, geneva university hospital, geneva, switzerland; transplantation biology research center, massachusetts general hospital, boston, ma; world health organization, geneva, switzerland. background: xenotransplantation carries inherent risks of infectious disease transmission to the recipient and even to society at large, and should only be carried out with tight regulation and oversight. a collaboration between the international xenotransplantation association, the university hospital geneva and the world health organization has established an international inventory (www.humanxenotransplant. org) aiming to collect basic data on all types of xenotransplantation practices on humans that are currently ongoing or have been recently performed. methods: we collected information using publications in scientific journals, presentations at international congresses, internet-based information, and declarations of ixa members. an electronic questionnaire is available on the website www. humanxenotransplant.org, which can be filled out and sent to the office in geneva. results: we identified a total of recent or current human applications of xenotransplantation, eight were currently ongoing and one will start soon. the source animal was: pig (n= ), sheep (n= ), calf (n= ), rabbit (n= ), blue shark (n= ), hamster (n= ), and unknown (n= ). all trials transplanted xenogeneic cells, i.e. islets of langerhans (n= ), hepatocytes (n= ), kidney cells (n= ), chromaffin cells (n= ), embryonic stem cells (n= ), fetal (n= ) and adult cells (n= ) of various organs. the treatments were performed in different countries, in europe, in russia, in asia, mexico, in usa and in africa. six countries had no national regulation on xenotransplantation. conclusion: several clinical applications of cell xenotransplantation are ongoing around the world, often without any clear governmental regulation. this information should be used to inform national health authorities, health care staff and the public, with the objective of encouraging good practices, with internationally harmonized guidelines and regulation of xenotransplantation. cells from α , -galactosyltransferase gene-knockout pigs additionally transgenic for human membrane cofactor protein demonstrate resistance to human complement-mediated cytotoxicity. hidetaka hara, cassandra long, mohamed ezzelarab, peter yeh, carol phelps, david ayares, david k. c. cooper. surgery, thomas e. starzl transplantation institute, university of pittsburgh, pittsburgh, pa; revivicor, inc., blacksburg, va. purpose: ( ) to compare the antibody binding and complement-mediated cytotoxicity (cdc) of human sera to pig peripheral blood mononuclear cells (pbmc) and porcine aortic endothelial cells (paec) from (i) wild-type (wt), (ii) α , -galactosyltransferase gene-knockout (gtko), (iii) human membrane cofactor protein transgenic (mcp) and (iv) gtko/mcp pigs. ( ) to investigate the effect on binding and cdc of human sera following activation of paec. methods: pooled human serum was tested by flow cytometry for binding of igm and igg ( % serum concentration) and cdc ( % serum concentration) to pbmc and paec from wt, gtko, mcp, and gtko/mcp pigs. paec from all pig types were activated by ifn-γ, and again tested for antibody binding and cdc. results: there was higher binding of igm and igg to wt and mcp than to gtko and gtko/mcp pbmc and paec, but there were no differences in binding (i) between wt and mcp cells or (ii) between gtko and gtko/mcp cells. cdc of wt pbmc and paec was significantly greater than of gtko, mcp, and gtko/mcp pbmc (wt %; gtko %; mcp %; gtko/mcp %) and paec (wt %; gtko %; mcp %; gtko/mcp %) (both p< . ). importantly, there was no lysis of gtko/ mcp paec. after activation of paec, although cdc was increased against wt and gtko paec, mcp and gtko/mcp paec demonstrated significant resistance to lysis (wt %; gtko %; mcp %; gtko/mcp %). conclusions: ( ) cdc of all types of genetically-engineered pbmc and paec was significantly lower than of wt pbmc and paec, with lysis of gtko/mcp paec being significantly lower than to gtko or mcp cells. ( ) paec from both mcp and gtko/mcp showed resistance to lysis even after activation of the cells. ( ) organs from gtko/mcp pigs should provide considerable protection against cdc. role for cd -sirpα signaling in human t cell proliferation in response to stimulation with porcine antigen presenting cells. hiroyuki tahara, hideki ohdan, kentaro ide, toshimasa asahara. department of surgery, hiroshima university, hiroshima, japan. we have previously proven that genetic induction of human cd on porcine cells provides inhibitory signaling to signal regulatory protein(sirp) α on human macrophages; this provides a novel approach to preventing macrophage-mediated xenograft rejection. a recent report indicated that the similar cd -sirp system negatively regulates the functions of both t cells and antigen presenting cells(apcs) in humans. we hypothesize that the interspecies incompatibility of cd may also act as an additional barrier of t cell-mediated xenograft rejection. we have analyzed the frequency and proliferative activity of human t cells responding to either porcine or allogenic apcs by using in vitro mixed lymphocyte reaction (mlr) assay with a cfse-labeling technique. irradiated stimulator porcine or human peripheral blood mononuclear cells(pbmcs) were cultured with cfse-labeled responder human pbmcs. by fcm analysis, the number of division precursors was extrapolated from the number of daughter cells of each division and from the mitotic events, and precursor frequencies in cd + and cd + t cell subsets. using these values, stimulation index(si) was calculated. the frequencies of alloreactive and xenoreactive cd + t cell precursors were almost identical, . ± . % and . ± . %, respectively (n= - , for each type of precursor). however, the si of xenoreactive cd + t cells was significantly higher than that of alloreactive cd + t cells, indicating a stronger reaction by a single xenoreactive cd + t cell. in the presence of human cd -fc(containing the extracellular domain of human cd fused to the fc portion of human ig, µg/ml), the si of xenoreactive cd + t cells was significantly reduced to a level similar to that of alloreactive cd + t cells (n= , p< . ), although the frequencies of their precursors were absolutely uninfluenced. the frequencies of alloreactive and xenoreactive cd + t cell precursors were also identical, i.e. . ± . %, . ± . %, respectively (n= - ). the si of both alloreactive and xenoreactive cd + t cells did not differ: however, that of xenoreactive cd + t cells was significantly suppressed in the presence of human cd -fc (n= , p< . ). these results suggest that the t cell responses to porcine cells are stronger than those to allogeneic cells because of the interspecies incompatibility of cd . moreover, genetic manipulation of porcine apcs to induce human cd expression might attenuate human t cell-mediated xenograft rejection. reactivation of human cytomegalovirus (hcmv) is a potential risk following the clinical application of pig-to-human xenotransplantation. since little is known about undesirable side-effects arising from hcmv infection of porcine organs, we investigated the capabilities of various hcmv strains to infect porcine endothelial cells (pec) and putative immunological consequences thereof. pec from different anatomical origins were incubated with the hcmv laboratory strains ad and tb /e or a clinical isolate at a multiplicity of infection (moi) ranging from . to . viral replication kinetics, evolution of cytopathology, and lytic end points were analyzed. consequences of pec infection on human nk cell activation were evaluated using xenostimulation assay assessing nk cell ifng secretion and cytotoxicity. infection was evident and a maximum percentage of infected cells was reached at a moi of . hcmv replicated in all tested pec types, with a fraction of infected cells ranging from % to %. ad infection of a (microvascular ec) resulted in cytopathic effect (cpe) development by dpi and in lysis of % of the cells at dpi. contrary, no cpe was observed in ped (aortic ec) up to dpi. infection of a with tb /e was non-lytic and resulted in accumulation of both extra-and intracellular virus. virus titers reached a maximum at dpi, peaking at levels -fold higher than residual input virus. we then determined whether infected pec supported a complete replication cycle and produced viral progeny. after dpi pec supernatants and lysates revealed the production of significant amounts of virus. preliminary results showed that coculture of human nk cells and infected pec resulted in increased nk killing and ifng production. altogether, these findings provide evidence that pec are permissive and support the complete productive replication cycle of hcmv. however, cpe are cell-type and strain dependent. moreover, pec infection leads to modification of the xenogeneic cytotoxicity mediated by human nk cells. our findings allow a better estimation of the potential role of hcmv cross-species infection following xenotransplantation and may be crucial to guide future clinical trials. chronic rejection/injury: innate and adaptive immunity i testing for donor-specificity of antibodies post-transplantation increases the predictability of chronic rejection. mikki ozawa, arundhati panigrahi, paul i. terasaki, narindar mehra. one lambda, inc., canoga park, ca; new delhi, india; terasaki foundation laboratory, los angeles, ca. purpose: post-transplant hla antibodies have been shown to be linked to chronic graft failure, yet some recipients do well in the presence of antibodies. we investigated whether testing for donor-specificity of antibodies improves the predictive value of antibodies in regards to chronic rejection. methods: in a prospective study of renal transplant recipients, post-transplant sera were tested for hla and mica antibodies, and positive sera were tested by single antigen beads to determine whether the antibodies were donor-specific. one year after testing, biopsy and clinical data on the graft status were collected. patients who did not have follow-up or died with function were excluded from analysis. results: of the patients with follow-up and abdr typing info, ( %) were found to have antibodies. sixteen of those had donor-specific a, b, or dr antibodies (dsa), while had non-donor specific ab's (ndsa). sixty patients had only dp, dq, cw, or mica antibodies, and were grouped into "donor-specificity unknown", as these typing were not available at the time of this report. table summarizes the antibody groups and transplant outcome one year later. interestingly, the mean serum creatinine values at the time of antibody testing were very similar among the groups, regardless of the presence of antibody or the type (ranged . to . mg/dl). one year later, however, a striking % of dsa patients had either returned to hemodialysis, were regrafted, had died, or had biopsy-proven chronic rejection, compared to only % in ndsa patients and % in those who were negative (dsa vs. neg, p= . ). mica antibodies also showed significant association with graft failure or can (p= . ), and donor mica typing is underway. conclusion: in this prospective study of renal patients, dsa detected posttransplantation were highly correlated with chronic rejection. inclusion of specificity analysis in post-transplant antibody monitoring would significantly improve the predictability of chronic rejection. donor cd t cells within solid organ transplants contribute to graft rejection. thet su win, sylvia rehakova, margaret negus, kourosh saeb-parsy, martin goddard, eleanor bolton, andrew bradley, gavin pettigrew. university of cambridge; papworth hospital, united kingdom. this study examines the contribution of donor cd t cells within heart allografts to the development of graft vasculopathy, by providing help to recipient b cells for generating effector autoantibody responses. b mice were transplanted with mhc class ii-disparate bm hearts. the allo-and auto-antibody responses were quantified, and their contribution to allograft vasculopathy assessed by incorporating b cell deficient mice as recipients. the role of donor cd t cells in providing help for autoantibody was examined by removing cd t cells from donor hearts before transplantation by three approaches: treating with anti-cd mab, administering gy lethal irradiation, and using bm donors that are genetically deficient in t cells. the contribution of donor cd t cells to autoanitbody development was further assessed by challenge with bm cd t cells two weeks prior to transplantation. bm heart grafts developed progressive vasculopathy and were rejected slowly (mst= days, n= ). the contribution of antibody-mediated effector mechanisms was confirmed by histopathological evidence (fibrinoid necrosis and vascular proliferation), by complement c d staining, and by a reduction in the severity of vasculopathy and long-term graft survival in b cell deficient recipients. surprisingly, no alloantibody was detected, but recipients instead developed autoantibody. the autoantibody response was completely dependent upon the provision of help from donor cd t cells; it was abrogated by transplanting cd t cell deficient hearts. to further confirm an effector role for autoantibody in vasculopathy development, b mice were primed for humoral autoimmunity, but not for alloimmunity, by injecting with highly purified bm cd t cells prior to transplantation. heart grafts were rejected more rapidly (mst= days, n= , p< . ), and demonstrated severe vasculopathy. finally, bm-chimeric recipients that lacked mhc class ii expression only on b cells did not develop autoantibody, suggesting that cognate interaction between the donor cd t cells and mhc class ii of recipient b cells is crucial for post-transplant humoral autoimmunity. our results demonstrate the novel finding that help for autoantibody production is provided by graft-versus-host cognate recognition of recipient b cell mhc class ii by donor cd t cells. this autoantibody contributes to the development of vasculopathy independently of alloantibody. allograft rejection. gang chen, huiling wu, jainlin yin, josette m. eris, steven j. chadban. collaborative transplantation research group/renal medicine, university of sydney/rpah, sydney, nsw, australia. toll like receptors (tlrs) are innate immune receptors that play an important role in innate immunity but also provide a link between innate and adaptive immunity. myd is a key tlr signal adaptor. a recent clinical study reported that activation of innate immunity in heart-transplantation recipients through tlr contributes to the development of chronic rejection after cardiac transplantation. in this study, we aimed to determine whether tlr -myd signaling is required for the development of chronic allograft damage using tlr -/and myd -/mice in a murine model of chronic cardiac allograft rejection. methods: cardiac transplants were performed: b .c-h- bm (b .h- bm ) hearts to wt, myd -/and tlr -/mice (all c bl/ -h- b -single mhc class ii mismatch) as allografts (n = - /group) and c bl/ to c bl/ isografts (n = ). blood and tissue were harvested at day after transplantation. cell infiltration, fibrosis and vasculopathy were assessed histologically (grade - ). cd + foxp + cells in the blood and spleen were measured by flow cytometry analysis. results: all hearts remained pulsatile until sacrifice. histology of tlr -/and myd -/recipients showed protection from leukocyte infiltration ( . ± . & . ± . vs . ± . , p < . ), fibrosis ( . ± . & . ± . vs . ± . , p < . ) and vasculopathy ( . ± . & . ± . vs . ± . ) at day post transplantation compared to wt recipients. by facs, the ratio of cd + foxp + regulatory t (treg) cells to total cd + cells at day post transplantation in spleen was significantly increased in tlr -/and myd -/recipients versus wt allograft and isograft mice ( . ± . & ± . % vs . ± . & . ± . %, p < . ). conclusion: absence of tlr and myd signaling reduces chronic allograft damage in a murine model of chronic cardiac rejection. one mechanism of protection may be enhancement of regulatory t cell function. promotion of treg generation via the tlr / myd pathway may be one important consequence of cross-talk between innate and adaptive immunity. pathway: implication in transplant arteriosclerosis. thibaut quillard, stéphanie coupel, flora coulon, juliette fitau, maria-cristina cuturi, elise chiffoleau, béatrice charreau. inserm u , itert, nantes, france. endothelial cell (ec) activation, injury and apoptosis are the key events associated with transplant arteriosclerosis (ta) and chronic allograft rejection (cr). notch is a major signalling pathway controlling vascular function and injury. nonetheless, the involvement of notch, at endothelial level, in both ta initiation and progression remains unknown. using a fully mhc mismatched rat cardiac allograft model of cr, we found that ta at day correlates with a strong decrease in both expression and activity of the notch pathway in transplant as compared to tolerant and syngeneic controls. the present study investigates the contribution of notch activity to ec survival. in this purpose, a recombinant adenovirus, encoding the notch intracellular domain (nicd) and the reporter gfp cdnas was constructed and used to maintain notch activity in cultured primary human arterial ec. our results demonstrate that nicd protects ec from cell death induced by tnfα in the presence of chx or by anoïkis as measured by annexinv and dna content staining. nicd mediates cytoprotection through the regulation of key-apoptosis molecules. using an apoptosis-dedicated qpcr array, we found that out of a panel of apoptosis-related genes were significantly regulated. nicd upregulated bcl , bcl a and bcl-xl ( . -, . -and . -fold compared to noninfected cells, respectively). in addition, pro-apoptotic genes bim, drp , bok and cd were markedly downregulated in transduced cells ( . -, . -, . -and . -fold decrease, respectively). western blotting analysis confirmed the induction of protective molecules (bcl and bcl-xl) and the inhibition of pro-apoptotic proteins (bad, bak and bax). consistent with these data, nicd conducted phosphorylation of akt as well as a reduction of pten expression, suggesting that the cytoprotective activity of nicd may be mediated by recruitment of the pi k survival pathway. to conclude, our findings indicate that ta correlates with a decreased notch signaling in transplant and that activation of the notch pathway in vascular ec prevents apoptosis by promoting protective gene expression and survival pathway. these data suggest that controlling notch activity may prevent ec dysfunction associated with ta and cr. donor age intensifies the early immune response. christian denecke, xupeng ge, irene kim, daman bedi, anne weiland, anke jurisch, steven mcguire, johann pratschke, stefan g. tullius. div. of transplant surg, bwh, transplant surg res lab, boston; dept. of surgery, charite berlin, germany. increasing numbers of organs from elderly donors are currently utilized for transplantation. advanced donor age may not only be associated with physiological impairments but also with a modified immune response of the recipient. we hypothesized a more potent early immune response following the transplantation of elderly donor organs and we analyzed the immune response in a mouse heart transplant model. young b mice received heart allografts from , and mths old bm donors. the recipients immune response and intragraft changes were analyzed. elderly, non-manipulated hearts contained overall significantly elevated frequencies of cd + and cd + t-cells and dcs (cd c + ) ( mths vs. mths: cd + : . % vs. . %, cd + : . % vs . %, cd c + : . % vs. . %, p< . ). following engraftment of mths old heart grafts numbers of activated dc's (cd c + i-a b+ and cd c + cd + ) had significantly increased in recipient spleens (day :p< . ). in parallel, frequencies of effector/memory phenotype t-cells (cd + cd high cd l low and cd + cd high cd l low ) were significantly elevated with increasing age ( vs. vs, mths: cd + cd high cd l low : . % vs. . % vs. . %, respectively, p< . ). in addition, tregs (cd + cd + foxp + ) were also elevated ( vs. vs, mths: . %vs. . %vs. %,p< . ) t-cell alloreactivity, as measured by ifnγ-production, increased with donor age ( mths vs. mths vs. mths: . ± . vs . ± . vs. . ± . ifnγ-producing spots/ x cells, p< . ). mixed lymphocyte reaction (mlr) at day revealed a gradual increase in splenocyte proliferation with advancing donor age (p= . ) indicating an enhanced immunogenicity of older organs. immunohistochemical staining confirmed augmented cd + and cd + t-cell infiltrates and an intense ki positivity of gics in mths old heart grafts, emphasizing an intensified immune response towards organs from old donors. in summary, old native heart transplants contain an overall higher number of passenger leukocytes contributing to an increased immunogenicity of these organs. after transplantation, a more potent dc and t-cell activation and intragraft t-cell infiltration was observed in elderly organs. nox and chronic kidney allograft interstitial fibrosis. shannon reese, madhu adulla, surmeet bedi, jose torrealba, deb hullett, arjang djamali. nephrology, uw madison, madison, wi. to determine the role of oxidative stress (os) in kidney allograft fibrosis, we are developing strategies that would decrease the generation of reactive oxygen species (ros) instead of using ros scavengers, the standard approach to antioxidant therapy so far. we therefore started to examine the expression of nadph oxidase (nox) subunits (nox , nox , p and p phox) and their distribution in human and rat kidney allografts with chronic interstitial fibrosis (iftanos). using double-staining immunofluorescent studies in human allografts (n= ) we showed that nox was present in injured tubules costained with αsma ( figure . ) similarly, interstitial macrophages (cd + -nox + ) and myofibroblasts (αsma + -nox + ) but not cd + t cells or s a + fibroblasts expressed high nox levels, suggesting that nox is involved in the pathogenesis of allograft fibrosis via epithelial-tomesenchymal transition (emt), macrophage and myofibroblasts activation. we then examined the coexpression of nox , nox and p phox in normal and transplant kidneys with iftanos and showed that these molecules were upregulated in the latter group and that nox and nox were associated with p phox expression. these results were confirmed in the fisher to lewis rat kidney transplant model (figure . ). immunoblot analyses at weeks and months showed that nox and nox levels were increased in the allogeneic (n= ) compared to syngeneic transplants (n= ). greater nox levels were composite tissue allotransplantation (cta) is a recently introduced option for limb replacement and reconstruction of tissue defects. as other allografts, a cta grafts can undergo immune-mediated rejection, and standardized criteria are required for characterizing and reporting severity and types of rejection. this manuscript documents the conclusions of a symposium on cta rejection held at the ninth banff conference on allograft pathology in la coruna, spain on june , , and proposes a working classification scheme, the banff cta- , for the categorization of cta rejection. this classification was derived from public international consensus discussions regarding all published scoring systems for cta rejection. given the current limited clinical experience in cta, a formal histological classification was established for acute skin rejection with the understanding that other types of rejection involving other tissues will be developed with periodic review of this emerging field. it was agreed that the defining features to diagnose acute skin rejection would include inflammatory cell infiltration with epidermal and/or adnexal structure involvement, epithelial apoptosis, dyskeratosis, and necrosis, and that severity of rejection will be graded under five categories. this classification refines proposed schemas, represents international consensus on this topic, and establishes a working collective classification system for cta reporting. the role of skin biopsies in diagnosing clinical rejection in hand composite tissue allotransplantation (cta). christina l. kaufman, , ruben n. gonzales, kadiyala v. ravindra, , brenda w. blair, joesph f. buell, , warren c. breidenbach. , , christine m. kleinert institute, louisville, ky; kleinert kutz and associates, louisville, ky; jewish hospital transplant center, louisville, ky; surgery, university of louisville, louisville, ky. aim: traditionally allograft biopsy has dictated treatment of allograft rejection. we hypothesize that histological grade of the biopsy may over diagnose rejection in cta hand cta is unique in that the organ is external and early signs of rejection can be viewed directly. skin is the first tissue in the cta graft to show rejection. methods: for this study, rejection by defined by requirement of treatment. these episodes were compared with histological grade, and hand appearance. we reviewed skin biopsies taken during , and years of follow up. results: three observations surfaced. first, a rejection grading scale for cta is still evolving. a review of the literature showed at least four different criteria are in use. the criteria used to grade biopsies at our center changed over the year follow up. bias towards calling higher grades of rejection, and more aggressive treatment occurred in the first two patients. a re-read of random biopsies taken from the first two patients showed a down-grade of rejection to grade ii or i in five cases. secondly, concomitant cmv infection in the last patient prevented the aggressive treatment of rejection. despite high grade histology, the swelling, rash and redness responded to topical immunosuppression. systemic treatment was not necessary. analysis indicated that swelling and/or rash, and the percentage of skin involvement seemed to be more informative markers of existing (or resolving) alloreactivity than was histology. the biopsies taken from the graft shown below showed a grade iii histology. thirdly, changes in hand function were not associated with changes in biopsy grade. conclusion: the histologic grade of skin biopsies from hand allografts appears to over estimate rejection. alterations in immunosuppression shoud be based on appearance of the allograft, and clinical course as much as on the histologic grade of the biopsy. expression of molecular mechanisms of lymphozyte trafficking correlates closely with skin rejection in human hand transplantation. theresa hautz, bettina zelger, gerald brandacher, hans g. mueller, andrew w. p. lee, raimund margreiter, stefan schneeberger. dept. of general and transplant surgery, innsbruck medical university, austria; dept. of pathology, innsbruck medical university, austria; dept. of dermatology, innsbruck medical university, austria; div. of plastic surgery, university of pittsburgh. introduction: to understand in greater depth the molecular mechanisms involved in skin rejection in hand transplantation, we investigated key molecular markers of lymphocyte trafficking, cellular rejection and antibody mediated rejection in human hand transplantation. methods: a total of skin biopsies taken from three bilateral hand transplants were assessed by h&e histology (grades as per previously a published classification - b) as well as immunohistochemistry using antibodies for following markers: lymphocyte function-associated antigen (lfa)- = cd a, intercellular adhesion molecule (icam)- = cd , selectin e = cd e, selectin p = cd p, ve-cadherin = cd , human leukocyte antigen (hla) ii (dp, dq, dr), psoriasin = s a and c d. levels of expression were assessed ( , +, ++, +++) and read in the light correlated with the rejection as well as time after transplantation. results: rrejection ranged between grade and a with an average score of . . in healthy skin, none of the markers investigated was consistently up-regulated. upon rejection, cd , cd e and cd p staining in endothelial cells was significantly increased. expression of cd e and cd p correlated well with severity of rejection. the majority of infiltrating lymphocytes stained positive for cd a. interestingly, also kerationcytes were highly positive for cd a at the onset of rejection. cd was detected on endothelial cells, but its occurrence did not correlate with rejection. psoriasin expression was observed in keratinocytes in a basal and focal pattern and correlated well with rejection. for c d, no consistent staining pattern was observed indicating that antibody mediated rejection did not play a role in these patients. conclusion: molecular markers involved in lymphocyte trafficking are up-regulated upon skin rejection after hand transplantation and represent promising target for prophylaxis and treatment of rejection in composite tissue allotransplantation. investigation of the immunomodulatory phenotype of infiltrating lymphozytes in skin rejection of human hand allografts. theresa hautz, gerald brandacher, bettina zelger, hans g. mueller, andrew w. p. lee, raimund margreiter, stefan schneeberger. dept. of general and transplant surgery, innsbruck medical university, innsbruck, austria; dept. of pathology, innsbruck medical university, austria; dept. of dermatology, innsbruck medical university, austria; div. of plastic surgery, university of pittsburgh. introduction: skin rejection has complicated the postoperative course in human hand transplantation. to better define the characteristics of the lymphozytic infiltrate human hand transplant biopsies have been investigated for expression of foxp and indoleamine , -dioxygenase (ido), a key regulatory enzyme to induce t-lymphocyte unresponsiveness. methods: a total of skin biopsies taken from three bilateral hand transplant recipients during the first years after transplantation were assessed by h&e histology (graded as per previously published classification - b) as well as immunohistochemistry for ido and foxp . levels of expression were assessed ( , +, ++, +++) and interpreted in the light of clinical courses, time after transplantation, severity of rejection as well as markers for lymphozyte migration. results: overall, rejection ranged between grade and a with an average score of . . ido was found constitutively expressed in the endothelium independent of rejection. ido expression in the cellular infiltrate was significantly increased upon and correlated well with severity of rejection (rejection grade , . +/- . : rejection grade , . +/- . p< . ). foxp positive t-cells were mainly found in severe rejection (rejection grade , . +/- . : rejection grade , . +/- . p= . ). ido expression correlated well with foxp expression, although the overall staining intensity for foxp was lower. a strong tendency towards higher expression of ido as well as foxp towards later time-points after transplantation was observed (year -foxp . +/- . , ido . + /- . [n= ] , year -foxp . +/- . , , year -fox . +/- . , ). expression of ido correlated closely with expression of e-selectin, p-selectin, icam and lfa- . conclusion: characteristics of the cellular infiltrate indicate a strong tendency towards self limitation of the alloimmune response towards the skin with both time after transplantation as well as severity of rejection in human hand transplantation. further studies are warranted to clarify the clinical relevance of these findings. prospective analysis of the immunologic profile of a hand transplant recipient in the first year. kadiyala v. ravindra, warren c. breidenbach, joseph buell, suzanne t. ildstad. department of surgery, university of louisville, louisville, ky; kleinert, kutz, and associates, louisville, ky; institute for cellular therapeutics, university of louisville, louisville, ky. introduction: a major obstacle to the wider application of hand transplantation is the long term complications associated with immunosuppression. minimization of immunosuppression is an important goal in all transplant recipients. currently there are no accurate tools to evaluate the immunological responsiveness which might help tailor the level of immunosuppression for an individual patient. the response of recipient lymphocytes to pha, candida, and alloantigen may represent laboratory tool towards this end. it has been reported that these responses are hierarchical with response to alloantigen being the first to be lost, followed by candida and finally pha. a year old male received a proximal forearm transplant in november . immunosuppression included induction with a single mg dose of alemtuzumab and maintenance with tacrolimus and mycophenolate mofetil. the patient developed an episode of cytomegalovirus infection followed by acute rejection after reduction of his immunosuppression during the rd post-operative month. these were successfully treated with ganciclovir and topical tacrolimus & steroids respectively. blood samples were drawn at selected time points, and subjected to phenotyping of lymphocyte subsets and immune monitoring for circulating peripheral blood regulatory t cells (t reg ) and proliferative responses to phytohemagglutinin (pha), candida, and alloantigen. results: alemtuzumab induction resulted in profound lymphopenia. at week and month, the response to pha was intact (stimulation index and respectively), but response to alloantigen and candida suppressed (si < ). a similar immunologic profile persisted up through months. at year, the pha and candida responses are robust (si and respectively), but alloresponses have not returned. current immunosuppression consists of tacrolimus ( - ng/ml) and mycophenolate mofetil ( mg b.i.d.). there is no gross evidence of acute or chronic rejection. conclusions: induction with alemtuzumab alters the recovery of immune response: recovery to candida was delayed beyond months and to alloantigens beyond a year. in light of this, further reduction of immunosuppression may be contemplated in future hand transplants without the risk of rejection. composite tissue allotransplantation has achieved significant clinical advances despite an adequate preclinical model to study technical and immunosuppressive strategies. we have developed a non-human primate model of facial composite tissue allografts (cta). unilateral lower hemi-facial cta (bone, muscle, skin) transplants were performed between mismatched cynomolgus monkeys. immunosuppression consisted of days of continuous iv tacrolimus monotherapy followed by tapered daily im doses. six animals received prophylactic gancyclovir. all animals had serial transplant biopsies. ten transplants have been performed, with one loss secondary to line infection on day without evidence of rejection. two ctas had evidence of chronic rejection (day , ); with development of alloantibody after days. five ctas had prolonged survival (day , , , , ) , but developed ptlds resulting in experimental endpoints. all animals had clinically normal grafts, but animals showed histological evidence of mild rejection not treated with any additional immunosuppressive therapy. ptld tumors were analyzed using short tandem repeats (str) to define donor or recipient origin. str analysis demonstrated donor origin of ptld tumors and recipient origin in animal. none of the ptld animals had clinical evidence of rejection of skin, bone, or muscle. ebv was not detected in the serum of tested animals, and ganciclovir therapy had no effect on the development of tumors. tacrolimus levels of ptld animals were higher than animals with rejected grafts ( vs. ng/ml; p= . ). two additional animals have healthy grafts (day +, +) without evidence of rejection or ptld, and have been converted to rapamycin after day . we have developed a preclinical model for facial cta transplantation that achieves prolonged graft survivals with tacrolimus monotherapy. the high incidence of ptld tumors of donor origin represents an outcome similar to bone marrow transplantation in contrast to its rarity in solid organ transplantation. our findings are a cautionary note regarding ctas that include vascularized bone elements. immunosuppressive protocol modifications have been made in an effort to decrease the incidence of these donor-derived ptlds. heterotopic heart transplantation: the united states experience. jama jahanyar, tarek a. sibai, matthias loebe, michael m. koerner, guillermo torre-amione, george p. noon. dept. of surgery, baylor college of medicine, houston, tx. heterotopic heart transplantation (hht) is utilized in patients (pts) who do not qualify for standard orthotopic heart transplantation (oht). specific indications include refractory pulmonary hypertension and a donor-recipient size mismatch. the objective of this study was to analyze the unos database and compare outcomes of hht to oht. the unos database with more than pts undergoing thoracic organ transplantation in the u.s. between and was reviewed (based on optn data as of may , ) . primary endpoint of this study was overall survival and subgroup survival [pts with transpulmonary gradient (tpg)> , ischemic (icm) and dilated cardiomyopathy (dcm)]. secondary endpoint was assessment of pretransplant criteria. exclusion criteria were retransplantation and missing transplant dates. of who underwent oht and who underwent hht, and respectively, were enrolled in this study. [ ] [ ] [ ] [ ] [ ] [ ] survival after oht is superior to hht. this survival benefit however, disappears in pts with a tpg> . overall the survival after hht is superior to the reported survival in pts who undergo lvad implantation as destination treatment (rematch-trial/ year survival of %). thus in selected pts, especially those with elevated tpgs, hht should be considered a viable option with overall good results. ventricular assist device as a bridge to heart transplantation in children: can we afford it? william t. mahle, glen ianucci, robert n. vincent, kirk r. kanter. sibley heart center cardiology, emory university school of medicine, atlanta, ga. ventricular assist devices (vads) allow children with severe heart failure to be bridged to successful heart transplantation (ht). vads are being used with increasing frequency in the pediatric population and newer devices allow even young infants to be supported. vad implantation and maintenance, however, is quite expensive and the cost-effectiveness of vad use in adults has been questioned. to date, an economic analysis of vad support in children has not been undertaken. methods: we used pediatric health information system (phis), an administrative database of the child health corporation of america (a consortium of children's hospitals in north america), to determine the costs related to vad use in children. data on subjects < yrs of age from - were reviewed. hospital charges were converted to costs based on hospital-specific cost-to-charge ratios. projected survival for subjects who were successfully bridged to ht was derived from published data. costutility was expressed as cost per quality-adjusted life years (qalys) saved, expressed in us dollars. all future costs and benefits were discounted at %. results: the median age at implantation from the phis database was . years, range days to yrs. the mean hospital cost per patient was $ , . estimated survival to heart transplantation was % and estimated successful explantation without transplantation was %. the calculated cost-utility for vad as a bridge to transplantation was $ , /qaly saved. if one assumes that the children who survived to vad explantation would otherwise have a high risk of hospital death ( %) without vad support, then the calculated cost-utility would be $ , / qaly saved. even if abstracts survival to transplantation exceeds %, vad implantation does not achieve a favorable cost-utility ratio. vad support in pediatric heart only becomes cost-effective if recovery and explantation can be achieved in over % of subjects. conclusions: vad supports serves as an effective bridge to heart transplantation in children. however, the cost-utility of this strategy is above the generally accepted threshold for cost-effectiveness ($ , /qaly). in a setting of limited healthcare resources vad as a bridge to transplantation may not be justified. purpose: heart transplantation (tx) in patients with hla sensitization presents challenges in organ allocation. virtual crossmatch (vxm), in which recipient hla antibodies, identified by labscreen pra beads, are compared to the prospective donor hla-type, could increase the use of allografts from distant donors (dd). accuracy of vxm and outcomes of this approach in heart tx are not known. methods and materials: to increase time-efficiency at the time of organ allocation, crossmatch testing is frequently initiated on pre-set trays which contain sera of multiple prospective sensitized recipients. we used results from these studies to determine expected accuracy of vxm. we assessed outcomes of allocation algorithm implemented in in sensitized patients. conventional prospective crossmatch was done when allografts were procured from local donors (ld), while vxm was utilized when allografts were offered from dd. there were direct t-cell ahg crossmatch tests done with sera of potential allograft recipients who had preformed hla-antibodies of known class i hla specificities. as shown in table , the positive and negative predictive values (ppv, npv) of vxm were % and %. table shows outcomes in sensitized patients who were eligible for vxm approach. received allografts from ld with negative prospective crossmatch while ( %) received allografts from dd with negative vxm. three dd patients had a positive retrospective crossmatch -npv of vxm was % in this cohort. vxm has high negative and positive predictive values, accurately predicting results of standard direct crossmatch in most patients. vxm allows use of allografts from dd and is likely to improve organ allocation in the disadvantaged group of sensitized patients. single center experience with new heart allocation system implemented by united network of organ sharing. biljana pavlovic-surjancev, nilamkumar patel, linda dusek, james sinacore, jennifer johnson, cassie bessert, alain heroux. heart failure/heart transplant program, loyola university medical center, maywood, il. purpose: in july , united network of organ sharing (unos) implemented a new allocation system for adult heart transplant (tx) candidates with the following sequence: local status a→local status b→zone a status a→zone a status b→local status . the purpose of this study is to evaluate the impact of new system on heart tx patients at a single center in region . methods: patients transplanted during year (y) prior to new system ( - - to - - , group , n= ) and y following new system ( - - to - - ,group , n= ) were compared for unos status at the time of transplant, waiting time, ischemia time, length of the hospital stay (los) before and after transplant, donor age, procurement-team travel distance and cost. results: new system significantly decreased median waiting time, but increased median ischemia time without affecting short-term survival: patient died in each group. number of transplants increased % in group mostly due to increased number of status a patients supported by iabp without change in number of status b and patients. median pre-transplant los increased -fold in group (p= . ), whereas mean pre-transplant los increased by days. in group , thirteen patients had donor heart procured in zone a and thirteen patients had donor heart procured locally, whereas in group , all donor hearts were procured locally. median procurement-team travel distance increased -fold and median travel cost -fold in group (p< . ). clinical outcomes associated with simultaneous heart-kidney transplantation. tariq shah, , , , suphamai bunnapradist, jagbir gill, steven k. takemoto. the figure below indicates recipients of shk transplants (open symbols) had lower rates of rejection when compared to heart (square) or kidney (diamond) recipients. survival rates were initially higher for kidney recipients with rates for shk similar to heart recipients. the hazard ratio (hr) for graft loss was higher for shk recipients compared to kidney, but lower when compared to heart recipients. the lower hazard for shk in heart allografts might be attributed to risk associated with pretransplant dialysis (hr= . , . - . , p< . ) . approximately % ( , ) of cardiac transplant recipients initiated dialysis prior to transplantation. the differing rates of shk rejection observed in the heart and kidney analytic files might be attributed to susceptibility or treatment of heart and kidney allografts, rejection monitoring or reporting. conclusion: retrospective examination of data provided to the optn indicates simultaneous heart-kidney transplantation seems to be effective for cardiac transplant candidates who require dialysis. abstract# objective: krp , a novel structural analog of fty , has been documented to display -fold greater selectivity of agonism for sphingosine- -phosphate (s p) type (s p ) receptor compared with s p receptor. clinical trial has shown that fty produced dose-limiting toxicity-bradycardia, due to its effect on s p receptor. we have tested the effect of krp on the survival of islet allografts either alone or combined with local delivery of cd + cd + foxp + t regulatory (treg) cells. previous studies using knockout mice have documented a key role for the integrin cd in promoting allograft rejection. these data are consistent with a critical role for cd expressing cells in this process. however, a direct test of this hypothesis has proven problematic due to the lack of mabs that efficiently deplete cd + cells in wild type hosts. to circumvent this problem, we conjugated the non-depleting anti-cd mab, m , to the toxin, saporin (sap), to produce an immunotoxin (m -sap) that selectively depletes cd -expressing cells in vivo. treatment of naive mice with m -sap selectively depleted cd + cd + cells and dramatically reduced the overall frequency of cd + lymphocytes in diverse compartment including intestinal intraepithelial lymphcyte,spleen and mesenteric lymph node. m -sap also depleted cd + dendritic cells (cd c + ) and t regulatory cells (tregs, cd + cd + ) in the above compartments. in the thymus, m -sap depleted cd -expressing cells in both cd -cd and cd -cd + subpopulations, both of which express cd , leading to a dramatic reduction in the number of thymocytes( . ± . × vs. . ± . × , p< . , in control vs. treated respectively). we next assessed the effect of m -sap in a fully allogeneic islet transplantation model (balb/c→c bl/ ). m -sap produced long-term (lt) graft survival (> d, n= ,vs. untreated median survival time d, n= ). unconjugated m or isotype control (igg-sap) did not significantly prolong islet allograft survival. graft histology showed little, if any, lymphocyte infiltration surrouding islet transplants in lt mice. in contrast, intense lymphocyte infiltration with disruption of islet morphology was observed in untreated mice. pretreatment of donor islets with m -sap did not significantly prolong allograft survival indicating that the immunosuppressive effect of m -sap resides at the level of host. interestingly, we found a - fold increase in both percentage and number of foxp + cd + cd + cells in the spleen and draining lymph node from lt mice, though it remains to be determined whether such cells account for graft acceptance in m -sap treated recipients. in summary, these data document that depletion of cd expressing cells promotes long-term islet allograft survival. these findings point to a novel strategy for therapeutic intervention in islet allograft rejection. pancreatic objective: to engineer pancreatic islets in a rapid and efficient manner with a novel form of fasl protein chimeric with core streptavidin and test the efficacy of engineered islets for long-term survival in allogeneic hosts. methods: balb/c pancreatic islets were engineered first by cell surface modification with biotin followed by the display of a chimeric form of fasl protein that consists of extracellular domain of fasl fused c-terminus with core streptavidin (sa-fasl). sa-fasl-engineered islets were transplanted into streptozotocin diabetic c bl/ mice under transient cover of rapamycin. unmodified islets or those engineered with streptavidin protein (sa) served as controls. results: all the islets showed effective engineering with sa-fasl, which persisted on the surface of islets for weeks in vitro as assessed by confocal microscopy. all the islets (n= ) engineered with sa-fasl survived over the observation period of - days without detectable signs of rejection. in marked contrast, all the unmodified (n= ) and sa-engineered (n= ) islets underwent acute rejection within days. the observed tolerance was localized to the engineered islets as unmodified second set of islets transplanted under contralateral kidney of long-term (> days) graft recipients were rejected in a normal tempo (mst= ± days) without any effect on the survival of primary islets. conclusions: engineering pancreatic islets with exogenous immunomodulatory molecules, such as sa-fasl, in a rapid (∼ hrs) and efficient ( % of targeted islets) manner represents a novel means of immunomodulation with considerable therapeutic potential for the treatment of type diabetes. supported in parts by nih (r dk , r ai , r ai , r hl ), jdrf ( - - ) the ability of embryonic stem (es) cells to form cells and tissues from all three germ layers can be exploited for the generation of cells that can be used to treat diseases. in particular, successful generation of hematopoietic cells from es cells could provide safer and less immunogenic cells than bone marrow cells, that require severe host preconditioning, when transplanted across mhc barriers. in the past, it has been difficult to derive hematopoietic cells from es cells. it has now become clear that this was due to the lack of self-renewal properties by these newly developed progenitor cells. here, we exploited the self-renewal properties of ectopically expressed hoxb , a homeobox transcription factor, to generate hematopoietic progenitor cells (hpcs) that successfully induce high level mixed chimerism and long-term engraftment in recipient mice. hoxb -transduced svj es cells (h b ) were allowed to form embryoid bodies. these were dismantled after days and the cells treated with a cocktail of hematopoietic cytokines. by day , es cells had formed hpcs. these newly generated hpcs were cd +, cd +, cd + but poorly expressed mhc class i molecules and no class ii. the hpcs fully restored splenic architecture in rag -/-γ c -/immunodeficient mice, abstracts comparable to bone marrow. additionally, hpc-derived newly generated t cells were able to mount a peptide-specific response to lymphocytic choriomeningitis virus (lcmv) and specifically secreted il- and ifn-γ upon cd stimulation. further, hpc-derived antigen presenting cells (apcs) in chimeric mice efficiently presented viral antigen to wild type (wt) t cells. in syngeneic recipient mice, hpcs engrafted and formed more robust t and b cell populations. the majority of the hpc-derived cells were however, gr- + , suggesting a bias towards myeloid cells by the hoxb . interestingly, these cells successfully engrafted in allogenic mrl (h k ) and balb/c (h d ) recipients without the need for immunosuyprresion. this ability to form mixed chimerism across mhc barriers is a consequence of their lack of mhc, cd and cd expression. our results demonstrate for the first time that leukocytes derived from es cells ectopically expressing hoxb are immunologically functional and escape immunological rejection when transplanted across mhc barriers allowing the induction of mixed chimerism. normalization the de is derived from the anterior segment of the primitive streak which corresponds to the early and mid-gastrula organizer during early embryo development, from which many of the major visceral organs, including the liver, pancreas, lung, thyroid and intestines are derived. es cells were cultured in a serum-free medium containing activin a and bfgf for - days, the differentiated cells developed into an epithelial monolayer yielding more than % of cxcr expressing cells. cxcr has been reported as a cell surface marker of the definitive endoderm. molecularly, the differentiated es cells express typical definitive endodermal genes in particular, foxa , sox- , gsc, and hnf α. the cxcr + definitive endodermal cells were further purified using immunomagnetic bead separation to more than % purity in order to eliminate teratoma-forming cells. to study their engraftment and regenerative capacity, these newly differentiated cells were intravenously infused into a mouse with carbon tetrachloride-induced liver injury. harvested livers from these animals showed large de-derived cells positive for albumin suggesting that they were de novo generated hepatocytes. a second cell type was ck- expressing, suggesting that the engrafted cells also differentiated into cholangiocytes. therefore, we further transplanted these de cells into a factor viii null mouse and asked whether these cells could correct factor viii activity. plasma factor viii activity (coamatic assay) fully normalized to that of wild type mice and has remained stable over days. these data suggest that es cell-derived de progenitor cells can restore factor viii activity in hemophilia a mouse model, presumably through protein production in de novo generated hepatocytes. more importantly, none of these animals developed teratomas. thus, es-cell derived cells can potentially be coaxed to form cellular transplants with curative capabilities. objective: we have established a novel approach, protex, to rapidly and efficiently engineer primary cells, tissues, or organs to display on their surface exogenous proteins of interest for immunomodulation. this approach involves generation of chimeric proteins with core streptavidin, biotinylation of cells, and the transient display of chimeric proteins on the cell surface. in this study, we displayed a chimeric form of fasl (sa-fasl) on the surface of bone marrow cells and tested the efficacy of these cells to establish mixed chimerism in allogeneic hosts under nonmyeloablative conditions. methods: balb/c bone marrow cells were engineered with sa-fasl and million of these cells were transplanted into c bl/ mice subjected to various doses of total body irradiation days earlier. a short course of rapamycin was used to enhance the tolerogenic effect of sa-fasl. bone marrow cell recipients were typed for multilineage chimerism at various times post-transplantation and tested for donor-specific tolerance using skin grafts. results: all the animals (n= ) treated with cgy total body irradiation and transplanted with sa-fasl-engineered donor cells showed significant levels of chimerism ( - %) on day post-transplantation that showed a steady increase overtime and reached to - % on day post-transplantation. in marked contrast, none of the control animals (n= ) receiving bone marrow cells and a short course of rapamycin showed detectable chimerism. chimerism was multilineage and associated with donor specific tolerance since chimeric animals accepted donor, but rejected third party skin grafts. conclusions: engineering bone marrow cells in a rapid (∼ hrs) and efficient ( % targeted cells) manner with exogenous proteins having immunoregulatory functions provides a new and effective means of immunomodulation to establish mixed allogeneic chimerism under nonmyeloablative conditions with significant potential in clinical bone marrow transplantation. funded in parts by nih (r dk , r ai , r ai , r hl ), jdrf ( - - ) , ada , and aha fellowship b. chronic allograft dysfunction is still a major clinical problem in organ transplantation. morphologically it is characterized by changes suggestive of an alloantibody mediated mechanism such as glomerulopathy and vasculopathy or by non-specific changes such as interstitial fibrosis and tubular atrophy. alloantigen dependent as well as -independent factors contribute to the pathogenesis of these changes. in this study we analysed allospecific t cells from the peripheral blood of kidney transplant patients under different immunosuppressive protocols with or without chronic allograft dysfunction. renal allograft recipients of our renal transplant clinic were screened at least six months after transplantation. all patients were on a calcineurin-based immunosuppressive protocol consisting of cyclosporine (csa)/mycophenolate mofetil (mmf)/steroid, tacrolimus (tac)/mmf/steroid, or csa/steroid. patients had to be mismatched for one or more of the five candidate hla-dr antigens for which synthetic peptides were available (dr , dr , dr , dr , and dr ). patients with biopsy proven chronic allograft nephropathy (can)with an elevated serum creatinine level of ≥ . mg/dl were compared with patients with stable allograft function (serum creatinine < . mg/dl). t cell lines were generated from peripheral blood lymphocytes of renal transplant recipients against donor-derived hla-dr peptides presented by self apc. t cell lines generated from patients with can produced significantly more ifn-γ, while those generated from stable patients produced il- associated with a low proliferation index in response to the donor-derived mismatched hla-dr allopeptide in vitro. moreover, significantly more cd +cd +foxp + t cells were found in stable patients on tac and mmf as compared to patients on csa and mmf. interestingly, a higher gene expression of cd , cd , ctla- , foxp , and il- was observed in those patients. taken together a th (ifn-γ) alloimmune response is deleterious and promotes chronic graft damage, while a th (il- ) response seems to be associated with a lower incidence of chronic allograft nephropathy. an immunosuppression based on tac and mmf seems to favour cd +cd +fosp + t cells and to allow long-term engraftment with stable renal function. cyclosporin induces epithelial to mesenchymal transition in renal grafts. the expression of epithelial to mesenchymal transition (emt) markers is a reliable predictor of the progression towards interstitial fibrosis and tubular atrophy of the renal grafts. in vitro experiments suggest that calcineurin inhibitors (cni) can induce emt of tubular epithelial cells. although no evidence was ever provided in vivo, this suggests that emt could be involved in the pathogenesis of renal fibrosis induced by cni. we have previously reported the results of a prospective randomized trial comparing the elimination at month of either cyclosporine (csa, n= ) or mycophenolate (mmf, n= ) from a triple drug regimen in de novo renal transplant patients. all of them had systematic graft biopsies at months and post engraftment. in the leftover material, we retrospectively detected in tubular cells and by immuno-histochemistry the expression of two validated markers of emt: the de novo expression of vimentin (vim) and the cytoplasmic translocation of b-catenin (cat). we were able to measure the emt score at both months and in a total of patients ( in each group). in the csa group, the vim and cat scores had progressed between and months from . calcineurin inhibitors (cni) are efficacious but nephrotoxic immunosuppressives. arteriolar hyalinosis is one of the characteristic histological correlates of this toxicity. yet, time course of this lesion, its reversibility, dose-dependency and the discrimination between drug-related effects, diabetic and hypertensive vasculopathy remain unclear. aim of this study was to evaluate the prevalence and time course of cni-related vascular changes after renal transplantation (tx) in protocol (pbx) as well as in indication biopsies (ibx) and to correlate this to the cni blood levels, blood pressure and diabetes. from patients, a total number of pbx, taken at weeks (n= ), (n= ) and months (n= ) after tx and ibx were classified according to banff-criteria. assessement of cni toxicity included: isometric vacuolisation of tubules (isovac), intimal arteriolar hyalinosis (iah) and nodular arteriolar hyalinosis (nah) and vacuolisation of small vessel smooth muscle cells (vsm). % of patients received either cyclosporine or tacrolimus. in pbx, isovac was present in %, % and % of patients at weeks, and months post-tx, respectively; iah in %, % and %; nah in %, % and %; vsm in %, % and %. in late ibx (> years post-tx) the prevalence of the analyzed parameters apart from isovac ( %) was markedly higher: % for iah, % for nah and % for vsm. in pbx, vsm, iah and nah were associated with each other but not significantly dependenct on blood pressure, rejection episodes or diabetes. through levels of cnis were not different between patients with and without vascular hyalinosis. in patients with vsm and iah in late ibx one third had these lesions already present in earlier biopsies. conclusion: the prevalence of presumed morphological signs for vascular cni-toxicity in pbx is low and constant and apparently, not associated with cni blood levels, hypertension or diabetes. in contrast, in ibx later than two years after transplantation, prevalence of vascular cni-toxicity signs is much higher. this emphasises that cni reduction protocols should be regarded within the first six months after transplantation, when vascular changes are still marginal. further elucidation of precursor lesions in pbx would help to find out patients at risk for cni-induced vascular changes. donor introduction: achieving donor specific tolerance has been the goal of the transplant community. success has been reported with donor stem cell transfusion in animal studies and prevention of chronic rejection in cardiac allograft recipients in the clinic. this report details the results of the initial phase of a study in humans. methods: a prospective phase i/ii fda approved pilot protocol was initiated to evaluate the effects of donor graft facilitating cell (fc)/stem cell infusion in kidney transplant recipients. conditioning was performed with cgy of total body irradiation. bone marrow processed to remove gvhd-producing cells but retain cd + /tcr -fc and stem cells was infused hours post-operatively. the dosage of stem cells was limited by the t cell dosage. the starting dose was x t cells. this was increased in steps of x per patient. as the study spans a -year period, the immunosuppression changed: patients received cyclosporine (cya), mmf and prednisone; were induced with basiliximab and maintained on cya( )/fk( ), cellcept and prednisone; and received alemtuzumab induction and maintenance with fk and mmf. all patients underwent tolerance testing and immunoprofiling studies. results: of the patients, received live donor kidney transplants. one graft was lost from arterial thrombosis on day . delayed graft function was seen in patients. good long-term graft function was seen in the other patients. acute rejection was noted only in and infectious complications (cmv- , histoplasma- ) in patients. two patients died with functioning grafts -one at years from lung cancer and another from complications from diabetes at years. six patients are alive with functioning grafts at mean follow-up of . years with a mean creatinine of . mg/dl. no gvhd was detected in any of the patients. macrochimerism was not detected in any of the patients at any point. notably, in spite of the fact that durable engraftment was not yet achieved, none of the patients were sensitized as a result nor did they experience immunologic sequelae. conclusions: in our patients there were no untoward sequelae related to either the conditioning regimen or marrow infusion. the incidence of acute rejection even on longterm follow up has been low. we currently propose to reduce the immunosuppression further in these patients. a pilot study was performed to evaluate whether immune cell depletion with alemtuzumab would permit post-transplant weaning of maintenance immunosuppression in well-matched renal transplant recipients. patients received alemtuzumab mg intravenously on the day of the transplant and the subsequent days while sirolimus and tacrolimus were started on day . tacrolimus was discontinued at day in all patients. extensive immune monitoring was performed at year. at current follow-up ( to months), all patients are alive with a functioning graft (median mdrd gfr= ml/ min). one patient experienced clinical and biopsy-proven rejection at months. all other patients remain on sirolimus monotherapy. four patients have been weaned to mg of sirolimus daily as their sole immunosuppressive agent, with resulting blood levels of - ng/ml. these patients have no evidence of donor-specific alloantibody, are unresponsive or hyporesponsive to donor cells by the cytokine kinetics test, and have a regulator phenotype to soluble donor antigens by trans-vivo dth. flow cytometry of peripheral blood demonstrated increased foxp expression in the cd +cd + population (p= . ). naive b cells (cd /cd neg) cells increased in of patients (p= . ) and memory b cells increased in all recipients (p= . ) when comparing pretransplant to year timepoints. other than the patient with rejection, -month protocol biopsies did not show any evidence of rejection, although of showed focal c d positivity and diffuse positivity. these patients also had evidence of alloantibody by luminex xmap testing. in conclusion, the cytokine kinetics test, alloantibody testing, and trans-vivo dth assay abstracts results correlated with clinical evolution of patients who successfully weaned both tacrolimus and sirolimus without rejection or alloantibody. the flow cytometry findings described occurred regardless of clinical evolution and may represent alterations of the immune system inherent in the treatment protocol independent of individual patient responses to the graft. however, the functional assays of cytokine kinetics assay and trans-vivo dth may be of potential use to correlate with the clinical immune status of the kidney transplant recipient. we have previously reported the short-term results of alemtuzumab (campath- h) pre-conditioning with tacrolimus monotherapy and subsequent spaced weaning in living donor kidney transplantation (ldkt). we report here our year experience. methods: we performed consecutive unselected ldkt (donor kidneys were removed laparoscopically) from / / to / / using mg ( . mg/kg) alemtuzumab and tacrolimus monotherapy. at months post-transplant and every to months interval, we used clinical data (including elisa antibody titers, cylex t-cell activation assay, and identification of donor specific antibodies) to wean tacrolimus when possible (bid-->qd-->qod-->tiw-->biw-->qwk). the recipients included hiv+, pediatric recipients, and re-transplants. the mean follow up was . + . days. results: actuarial recipient survivals at -, -, -years were . %, . %, and . %, respectively. graft survivals at -, -, -years were . %, . %, and . %, respectively. the mean creatinine (mg/dl) at -, -, -years were . + . , . + . , and . + . , respectively. the mean gfr (ml/min/ . m ) at -, -, -years were . + . , . + . , and . + . , respectively. the cumulative incidence of acute cellular rejection (acr) at -, -, -, -, -, -, -, and > conclusions: in the current era low risk patients infrequently have ar, and have excellent short and long term graft survival without the use of depleting antibodies. given the increased costs of these drugs, the indications for using depleting antibodies in low risk ktrs of scd kidneys should be further clarified. kidney transplantation prolongs survival in hepatitis c virus-positive (hcv+) patients with end-stage renal disease (esrd). however, the effects of induction therapy and chronic immunosuppression are unknown on the course of hcv infection and potential for cirrhosis in renal transplantation (rtx) recipients. we have retrospectively assessed parameters of liver function, child-pugh (cp) and meld scores in hcv+ esrd patients who received induction therapy with t-cell depletion (group : thymoglobulin, n= ) or an il- inhibitor (group : basiliximab, n= ). pre-rtx liver biopsies were similar in group and . patients were followed for a mean of days (range to days) following rtx and received tacrolimus, mycophenolate mofetil, and sometimes steroids post-transplant. overall graft survival was % in group and % in group (p > . ). data were analyzed pre-rtx, at and days and at time of last follow-up. serum ast, alt, platelets, inr, albumin and bilirubin did not change following rtx in either group. cp scores in group were not significantly changed after rtx ( . ± . to . ± . at last follow-up, p= . ). group patients on steroid-free protocols (n= ) demonstrated declining cp scores from . ± . to . ± . at last follow-up that were not statistically significant (p= . ). group patients on steroids showed opposite trends of cp: . ± . pre-rtx vs . ± . at last follow-up that similarly did not reach statistical significance (p= . ). group cp scores declined from . ± . to . ± . at last follow-up (p= . ). there was no difference between cp or meld scores at any point between the groups. as expected, meld scores improved significantly following rtx and remained low up until the final visit (p= . ); this was attributed to the drop in serum creatinine post-rtx. neither the use of thymoglobulin or basiliximab resulted in acute hepatitis resurgence or the development of cirrhosis post-transplant. we have not identified any association between choice of induction agent or maintenance immunosuppression regimens, including steroid withdrawal, with impaired hepatic function or progression to liver cirrhosis in hcv+ rtx patients. t cell depletion was well-tolerated by hcv+ rtx patients and resulted in good graft outcomes. interestingly, cp scores declined after renal transplantation in the basiliximab induction group. kidney: complications i prevalence background: a few years ago we observed an expansion of blood gd t cells following cytomegalovirus (cmv) infection in kidney transplant recipient (ktr). we recently demonstrated that these cells share a strong reactivity against cmv infected cells and tumor epithelial cells in vitro. an implication of gd t cells in the immune surveillance against cancer has been demonstrated in mouse and strongly suggested in human. we tested here the hypothesis of a protective role of cmv-induced gd t cells against neoplasia in ktr through: / a longitudinal case / control (ktr with cancer / ktr without cancer) study where gd t cell percentages were determined before and after cancer diagnostic (n= ), / a retrospective follow-up of ktr for . years looking for risk factors for malignancy. results:the median of gd t cell percentage in patients with malignancies was significantly lower when compared to control patients , and months before the diagnostic of the cancer (p< . ). using a conditional logistic model, we determined that patients with a gd t cell percentage above % were protected from cancer (p< . ). a significant association between increase of the vd neg gd t cell subset and lower cancer occurrence was only retrieved in the ktr who experienced pre-or post-graft cmv infection. finally, using univariate and multivariable analysis, absence of pre-or post-graft cmv infection in ktr was associated with a risk of cancer . times more elevated (p= . ). this study reveals an unexpected protective role of cmv against cancer in ktr most probably via the expansion of gd t cells cross-reactive against cmvinfected and tumor cells. background: viral infection (vi) is a morbidity factor in transplant recipients (tx pts). induction therapy (ind-rx) is a known risk factor for vi. although cam is thought to be a more potent ind-rx than zen, we have previously shown similar cmv infection rates in each. we have also shown that cmv-tc analyzed by cytokine flow cytometery (cfc) are consistently detectable in cmv sero(+), but not sero(-) individuals. cmv-tc(-) was associated with persistence of cmv infection in tx pts. here, we report on the effect of ind-rx on cmv-tc in kidney tx pts. methods: pre-tx samples from cmv-sero(+) pts and post-tx samples from pts were submitted for cmv tc-cfc. whole blood was incubated with a pooled overlapping peptide mixture consisting of peptides from cmv pp and brefeldin a at degrees for hours and room temperature overnight. ifnγ+cd + cells were enumerated by cfc and results were expressed as ifnγ+cd + cell%. results > . % were considered as (+ infection associated graft loss during the entire study period is shown in figure . infections contributing to renal allograft loss increased significantly from to . this may be due to increase use of both induction agents and potent maintenance regimens. this is an important cause for poor long-term graft outcome despite decreasing rejection rates and a balance has to be maintained between prevention of rejection and avoidence of infection. serum creatinine (scr) at procurement was ± µmol/l. the incidence of donor hypertension, diabetes, and death from cerebrovascular origin was %, %, and % respectively. multivariate analysis showed that the only clinical parameters associated with a low egfr were donor scr and donor hypertension. nyberg or pessione scores were not significantly associated with a low egfr. regarding d biopsies, univariate analysis showed that % of sclerotic glomeruli (sg, p= . ), arteriolar hyalinosis (p= . ), mean remuzzi score (p= . ) and mean cadi score (p= . ) were all significantly associated with a low egfr. a logistic regression showed that an integrated score including: i) donor scr (± µmol/l), ii) hypertension, and iii) sg (± %) had the highest performance in predicting a low egfr at yr compared to clinical or histological parameters alone. using this composite score, the adjusted or for the prediction of a low -yr egfr ranged from if none of the factors were present, to . (if sg > % was associated with one of the clinical factors), and to . (if the factors were present, p= . ). conclusion: this study highlights that d biopsies are useful to predict graft outcome particularly in md population, and may perform better than clinical scores alone. in this population, a simple and routinely applicable integrated scoring strongly predicts a poor graft outcome, which may allow an optimized allocation of marginal donors. prospective kidney transplantation from small pediatric donors is increasingly being utilized as a means to optimize the organ supply, however the single most common specified reason for the discard of pediatric kidneys is vascular damage, such as shortening of the suprarenal aorta or injury to the renal artery orifices, which often precludes en bloc transplantation (ebk). at our center, damaged kidneys were salvaged by transplantation as singles (sk background: in an effort to maximize the number of recipients transplanted per donor, transplant centers in our donor service area (dsa) voted to preferentially allocate local and imported en-bloc pediatric donor renal allografts to centers willing to transplant two individuals with single allografts. after year of implementing this policy into action, we report on our initial experience. methods: from july to june we reviewed our experience with adult single allograft recipients of pediatric donors less than months of age. there were no exclusions based on age or size with exclusion criteria consisting of donor age < months and single allograft size < cm. all but recipient received rabbit anti-thymocyte globulin induction, tacrolimus, mycophenolate mofetil, and rapid steroid withdrawal. results from this cohort were compared to consecutive recipients of adult single allografts from standard criteria donors with the same immunosuppression protocol used as historical controls. results: pediatric single allografts with median donor age of months (range - ) were transplanted into adults with median age years (range - ). showed that non-white race was associated with increased risk of death (p< . ). this effect of race was attenuated when ltx center was taken into account [b] . finally, with the addition of meld in the model, the effect of race on waitlist mortality all but disappeared [c] . conclusions: on the surface, minority patients may appear to have higher mortality on ltx waitlist compared to caucasian counterparts. however, this association is predominantly a result of minority patients having a higher meld score, although ltx center-specific mortality may contribute. these data suggest that waitlist outcome may be improved by optimizing referral of minority patients. background: in cirrhotic patients awaiting liver transplantation (lt), low serum sodium (na) predicts short term pre-lt mortality, independently of meld. incorporation of na into meld has been recommended to improve prognostic accuracy (meld-na; gastroenterology : gastroenterology : , ). however, short term interventions such as water restriction that improve na may have little effect on prognosis. hypothesis: the lowest level of serum sodium in the preceding (na ), (na ) or days (na ) may be better than the current serum sodium (nac) for predicting pre-lt cirrhotic mortality. methods: we reviewed electronic records of cirrhotic veterans referred for consideration of lt, / / - / / . date of most recent na at referral was chosen as time zero for determining nac, na , na , and na and for assessing subsequent survival. findings: within days, patients died pre-lt ( %) and underwent lt ( %). na at all time points was associated strongly (p<. ) with prelt death (censored at lt). areas under receiver operating characteristic curves (aurocs) for na , na and na as predictors of d prelt mortality (mean±se) were . ±. , . ±. and . ±. , respectively, compared to . ±. for nac (all p<. vs. nac). on multivariable logistic regression analysis, meld and na were independent predictors of d prelt mortality, with best discrimination given by the following model: meld-na = meld + ( -na )* . with value of na capped at . aurocs for meld-na , meld-na, and meld were . ±. , . ±. and . ±. , respectively. findings were similar when patients with hcc at referral (n= ) were excluded (aurocs . ±. , . ±. and . ±. , respectively), and when day survival endpoint was changed from "death censored at lt" to "death or lt" (auroc's . ±. , . ±. , and . ±. , respectively). conclusion: short term improvement in na may mask true prelt mortality risk. the lowest na in the preceding days is a better prognostic indicator than current sodium. substitution of meld-na for meld would permit more accurate "sickest first" organ allocation, while at the same time allowing prelt correction of na without loss of priority. prospective validation of meld-na , in comparison to meld-na and meld, is warranted. hyponatremia does not affect survival following liver transplantation. byung cheol yun, w. ray kim, y. s. lim, joanne t. benson, walter k. kremers, terry m. therneau. gastroenterology and hepatology, mayo clinic college of medicine, rochester, mn. background: hyponatremia is a common yet important complication of cirrhosis. serum sodium (na) has been found to be an important predictor of survival in patients with cirrhosis. models incorporating na have been proposed for liver allocation. concerns have been raised, however, that liver transplantation (ltx) in hyponatremic patients will adversely affect the outcome. in this work, we assessed the effect of pre-ltx na on the short term survival following ltx. methods: patient-level data on all waitlist registrants in the us for and were obtained from the organ procurement and transplantation network. demographic, clinical and laboratory data at the time of ltx and outcomes following ltx were extracted. the relationship between na pre-ltx and survival post-ltx was analyzed using multivariable regression analyses. results: there were primary transplants that met the inclusion criteria between and . the median na in meq/l at the time of ltx was (interquartile range, iqr: - ). there were patients who had a na ≤ meq/l. the mean meld score was . (sd . ). median follow up was (iqr: - ) days. the overall -and -day survival post-olt was % and %, respectively. in a multivariable logistic regression model, meld was associated with . -fold increase in -day mortality ( confidence interval: . - . ), while na did not have impact on survival (hr= . , % ci: . - . ). the figure represents the risk of -day mortality according to na after adjustment for meld, which clearly shows absence of mortality increase over a wide range of na. conclusions: hyponatremia at the time of ltx has no detrimental impact on short term patient survival following ltx. although these data do not address morbidity (e.g., central pontine myelinolysis), there is no evidence that incorporation of na in organ allocation will lead to diminished survival. objective. this study examined the relationship between meld at liver transplantation (lt) and post-lt quality of life (qol). methods. adult lt recipients (n = ) at two centers completed the sf- and transplant symptom frequency questionnaire (tsfq) -year post-lt. high sf- scores indicate better qol; high tsfq scores indicate more symptomatology. clinical (lab) meld at lt, demographic characteristics, presence of ascites, encephalopathy, and variceal bleeding pre-lt, current employment status, presence of co-morbid medical conditions, and bmi were collected from medical records. results. primary lt indication was viral hepatitis ( %), cholestatic liver disease ( %), or hepatocellular disease ( %), and % had ascites, % encephalopathy, and % gastroesophageal bleeding. mean meld at lt was ± . there was almost no correlation between meld and sf- physical (r = . ) and mental (r = . ) functioning. statistically significant yet weak correlations were found between meld and physical functioning (r = - . ) and role functioning -physical (r = - . ). meld was not significantly correlated with any other sf- scales (r's - . to - . ). meld was not significantly correlated with any tsfq domains: affective distress (r = . ), neurocognitive symptoms (r = . ), gastrointestinal distress (r = - . ), physical appearance changes (r = . ), appetite and weight changes (r = . ), and miscellaneous symptoms (r = . ). older age (ß = - . ), female sex (ß = - . ), viral hepatitis (ß = . ) or cholestatic disease (ß = . ), higher bmi (ß = - . ), and > medical co-morbidity (ß = . ) were significant predictors of lower qol as measured by the sf- (adj r = . , f = . , p < . ). older age (ß = . ), female sex (ß = . ), higher bmi (ß = . ), history of variceal bleeding (ß = . ), and > medical co-morbidity (ß = . ) were predictive of more symptoms on tsfq (adj r = . , f = . , p < . ). meld was not predictive of qol. conclusions. higher disease severity, as measured by meld, at lt does not portend a worse qol outcome for patients -yr after transplantation. other pre-lt indicators of decompensation also do not predict post-lt qol. post-lt qol is affected more by other variables, including age, sex, bmi, and medical co-morbidities. introduction: racial disparities in access to cadaveric renal allografts have been well described for renal transplantation. however, little is known about differences in orthotopic liver transplantation (olt) rates for patients of minority racial groups following listing. the purpose of the current study was to determine if there is difference in rate of transplantation among racial groups and to examine the potential reasons for the disparity. methods: the united network for organ sharing (unos) database was obtained. data was extracted for adult olts greater than years of age performed from / - / . transplants for which recipient race or model for end-stage liver disease (meld) score at listing were unknown and patients active on the list were excluded. rates of transplantation as well as differences in reasons for de-listing (transplantation, death/deterioration, and improvement) were examined. in an effort to examine only patients with chronic liver disease, further analysis was performed excluding patients with acute fulminant liver failure and retransplants. results: the database contained complete meld and race information on , olts. seventy-four percent of patients were caucasian, % hispanic, % african-american, and % were asian. as seen in table , laboratory meld score at removal differed between racial groups. examining pair-wise comparisons of the three minority groups to caucasians, only hispanics differed in reason for delisting (table ) . subgroup analysis excluding acute hepatic failure patients and retransplants showed similar results with hispanic patients being more likely to die/deteriorate as compared to other racial groups ( % deaths vs. % deaths for caucasians), and being less likely to receive a transplant ( % of hispanics vs. % of caucasians, p< . ). conclusion: hispanic patients, although listed with higher meld scores, are transplanted less often than caucasian patients and are more likely to die/deteriorate while awaiting olt. reasons for this discrepancy are unclear and merit further attention. background: since the implementation of the model for end-stage liver disease (meld) for liver allocation, an increasing number of candidates with renal insufficiency have undergone orthotopic liver transplantation (olt). since candidates with renal insufficiency have higher post-transplant morbidity and mortality, meld-based allocation may be shifting some waiting list mortality to the post-transplant period in these candidates. the objective of this study was to evaluate the survival benefit among candidates with renal insufficiency who underwent olt. methods: scientific registry of transplant recipients data for adult candidates age ≥ initially listed for olt between / / and / / (n= , ) were analyzed. the effect of serum creatinine on the survival benefit (contrast between waiting list and post-transplant mortality) was assessed by sequential stratification, an extension of cox regression. each recipient was matched with candidates active on the waiting list in the same organ procurement organization with the same meld score. results: for meld scores - , the survival benefit of olt significantly decreased as serum creatinine increased. among candidates transplanted at meld - , the % with serum creatinine > . mg/dl ( %) experienced no significant survival benefit ( figure) . candidates transplanted at meld ≥ experienced significant olt benefit irrespective of serum creatinine level. conclusions: comparing two patients with meld ≥ , the patient with higher creatinine experiences significantly less survival benefit from liver transplantation. almost onequarter of patients transplanted at meld - experienced no survival benefit from olt based on years of follow-up. therefore, more careful assessment of candidates is required in order to maximize the survival benefit gained by the wait-listed end-stage liver disease population as a whole. liver: living donors and parial grafts i assessment introduction: consideration of the risks and benefits of a procedure are critical in medical decision making. however, relatively little is known about risk tolerance amongst donors and transplant professionals in live-donor liver transplantation (ldlt). we conducted confidential semi-structured interviews in a convenience sample of donors, non-donors (individuals who had been assessed for donation but did not donate) and transplant team members. in addition to examining issues surrounding decision making for ldlt donation, we sought to assess the tolerance of participants, above which they would no longer contemplate donation, for a number of potential outcomes following ldlt. the outcomes that participants were asked to consider included their tolerance for risk of donor death, risk of serious donor complication, as well as risk of recipient death following transplantation. the interviews were conducted sequentially, data was coded quantitatively, and the study terminated once saturation was reached. (pre, weeks , , , and post-donation) . ambivalence detected by staff or described by donor was recorded. donor and recipient characteristics were examined and compared between ambivalent and non-ambivalent groups. results: staff identified and self identifed ambivalent donors were not equivalent. staff assessments indicated ambivalent donors ( male, female). donors self-identified as ambivalent ( male, female); donors were on both lists ( male, female). the combinations of brother to brothers and sons to fathers were the most common pairs among ambivalent donors and more common than in total donor cohort. recipient diagnosis of alcohol or hepatitis c related liver disease was more common in ambivalent donors. ambivalent donors were more likely to be college educated and to express significant religious affiliations than the total rhl donor group. all but ambivalent donor indicated that they would donate again on the year qol survey. conclusions: ambivalence about rhl donation is present in approximately % of candidates who complete donation. staff-identified and self-identified groups showed only % overlap; however, both groups showed similar characteristics. brother-tobrother and son-to-father pairings and recipients with perceived self-induced liver failure were more common in both groups compared to total donor cohort. ambivalent donors had more education and stronger religious or spiritual identification than the entire cohort. only donor indicated persistent doubt about donation. these results suggest that expressed or perceived donor candidate ambivalence may represent a process of careful consideration and should not be used sole basis for donor disqualification. the impact of donor age on recipient outcome for adult right-lobe living donor liver transplantation (rldlt) is unclear. aim: to analyze the effect of donor age on recipient outcome following rdldt. methods: since we have performed rldlt (mean donor age years, range - years), including donors age years or older. we analyzed the effects of donor age, as a continuous or categorical (< vs > years) variable, on recipient outcome. recipient outcome measures included biochemical markers of hepatocytes injury (ast, alt) and graft function (inr, bilirubin), postoperative infections, bleeding, biliary complications, acute cellular rejection, as well as patient and graft survival. analyses were carried out stratified for higher recipient meld scores (< vs. > ), recipient age (< vs. > years), and hepatitis c virus (hcv) infection (presence vs. absence). results: -year patient and graft survival after rldlt was % and %, respectively. donor age as a continuous variable was associated with increased ast (p= . ) and alt (p= . ) release after transplantation, while no effect was observed on inr or bilirubin. rldlt using donors above years of age resulted in an increased incidence of biliary strictures ( % vs. %, p= . ), postoperative cholangitis ( % vs. %, p= . ). no effect of donor age was found for the following recipient outcome measures: the number of bile ducts supplying the graft, type of biliary reconstruction required; rejection, hemorrhage, pulmonary or urinary tract infections, renal failure, or length of hospital stay. -year patient survival was identical for patients receiving grafts from donors below or above years of age ( % vs %, p= . ). similarly, -year graft survival was comparable for young and old grafts ( % vs %, p= . ). recipient age (< vs > years), recipient meld score (< vs > ), or hepatits c status of the recipient did not impact on the effect of age on patient or graft survival. conclusion: in this single center series of rldlt, the use of selected older donors did not impair graft and patient survival, but was associated with an increased rate of biliary strictures. background: biliary stricture rate after living donor liver transplant (ldlt) in adults remains relatively high in comparison to the stricture rate after adult cadaveric liver transplant or ldlt in pediatric patients. the etiology or risk factors for biliary stricture development at present time are uncertain. purpose: to determine the risk factors for biliary stricture after right lobe (rl) ldlt. methods: from / to / , ldlt procedures were performed in adult recipients. eleven patients were excluded from analysis due to < days follow up or need for retransplant. the following data was prospectively collected: . demographics, . acuity of illness, . number of bile ducts, . type of biliary reconstruction, . graft to recipient weight ratio, . hemodynamic parameters, . outcomes. these parameters were compared in patients with and without strictures. results: mean follow-up for patients is days (range: - ). of patients died during the follow-up range and required whole liver re-transplants. patients ( %) developed a biliary strictures during the follow-up period. comparison of risk factors in patients with and without strictures revealed the following results: mean meld > bile duct grwr* < . neither meld score, number of bile ducts or type of biliary reconstruction appear to be contributing factors to the development of bile duct stricture following rl ldlt. the biliary stricture rate was related to the volume of transplanted liver and post transplant graft recovery. therefore, the development of biliary strictures in some patients may represent yet another feature of small-for-size syndrome. background: ox and cd can be expressed by both foxp + tregs and activated t effector cells. however, the question as to how ox and cd function, individually or collectively, in regulating such functionally different t cell subsets in transplant models remains poorly understood. in some models, blocking cd costimulation is remarkably effective in prolonging graft survival, but targeting cd alone rarely creates tolerance. but the role of ox in regulating the cd blockade induced tolerance is completely unknown. in the present study we critically examined the role of ox in the activation of cd deficient t effector cells as well as in the regulatory function of foxp + tregs. we also examined the effect of ox on the induction of new foxp + tregs/th cells from activated cd deficient t effector cells. the impact of ox in the induction of allograft tolerance was examined using an islet transplant model. we found that cd deficient foxp + tregs constitutively expressed ox on the cell surface, but the cd deficient t effector cells did not. however, when the t effector cells were sorted and stimulated in vitro, ox expression could be abstracts readily induced on the t effector cells. to further examine how ox regulates such functionally different t cell subsets, we found that ox delivers potent costimulatory signals to t effector cells, which prevent the induction of new foxp + tregs from activated t effector cells but promote their differentiation to th cells but not th cells. surprisingly, ox costimulation to cd deficient foxp + tregs completely inhibited their regulatory functions. in an islet transplant model, we showed that cd deficient mice can reject the dba/ islet allografts, but blocking ox costimulation readily induced donor specific tolerance (mst> days), and this tolerant status was critically dependent on the induction of foxp + tregs. in contrast, treatment of cd deficient recipients with a agonist anti-ox mab precipitate rapid islet allograft rejection, suggesting that ox costimulation is critically important in the induction of transplant tolerance. conclusions: our data suggest that ox is a costimulatory molecule to t effector cells but a powerful negative regulator for foxp + tregs. thus, a key role for ox in the induction of transplant tolerance is the control of t cell mediated regulation. background: foxp is a winged-helix family transcription factor that is the master regulator for the development and function of regulatory t cells (treg). we investigated the molecular mechanisms important for regulation of foxp expression, and defined the structure of the active foxp promoter in cd + t cell lineages. methods: purified cd + cd -foxp -gfp -t cells (naïve) and cd + cd + foxp + gfp + treg were cultured with antigen presenting cells in the presence of il- , anti-cd ε mab, tgfβ or the dna methyltransferase inhibitor -aza- '-deoxycytidine (zdcyd). foxp promoter structure and activity were monitored with methylation-specific pcr, disulfite-sequencing, chromatin immunoprecipitation (chip) assays, electrophoretic mobility shift assay (emsa) and luciferase promoter assay. the foxp promoter has an upstream cpg island ∼ kb from the transcriptional start site. disulfite-sequencing and methylation-specific pcr analysis showed that this region is heavily methylated in naïve cd + t cells and tgfβ induced peripheral treg, but demethylated in thymic derived natural treg (ntreg). chip analysis showed that the methylated cpg island is bound specifically by the dna methyltransferases and b. zdcyd causes demethylation of the cpg island, and in combination with tgfβ, synergistically induces foxp expression. chip assays for acetylated histone and sp , both markers of gene activation, showed that the cpg island is acetylated and bound by sp in ntreg and zdcyd plus tgfβ induced treg, but not in activated cd + t cells or tgfβ induced treg. emsa likewise shows the cpg island binds sp . in contrast to the upstream promoter, the structure of the first intronic promoter differs markedly between ntreg and tgfβ induced treg, but is not affected by zdcyd. the upstream cpg island also possesses enhancer activity that is repressed by dna methyltransferases. zdcyd plus tgfβ induced treg have stable foxp expression and enhanced suppressive functions in vitro and in vivo. conclusion: these results demonstrate that ntreg and tgfβ induced treg are genetically distinguished from each other by the epigenetic structure of a unique upstream cpg island of the foxp promoter. the function of this region is regulated by dna methylation and histone acetylation. zdcyd demethylates the promoter, leading to enhanced and stable expression of foxp and suppressor activity, similar to ntreg. this has important implications for biology, and generating treg for tolerance. chemokine background: trafficking of lymphocytes through lymphatics to secondary lymphoid organs is crucial for immune responses. we previously showed that regulatory t cell (treg) function required trafficking from the inflammatory graft site to the local draining lymph node (dln). since the mechanisms that regulate migration through afferent lymphatics are poorly understood, we explored the role of chemokine receptors on treg for afferent lymphatic migration in an islet transplantation model. methods: islets were transplanted from balb/c mice into foxp gfp c bl/ mice. treg from wild type, ccr -/-, ccr -/-, ccr -/-, or ccr -/-c bl/ mice were isolated, labeled with red dye pkh , and transferred intravenously, or locally into the islet allograft. treg migration to islet grafts and dln was determined by flow cytometry and immunohistochemistry. endogenous foxp gfp+ treg and transferred pkh labeled treg were sorted from the islet grafts and the dln, and chemokine receptor and sphingosine -phosphate receptor (s p ) expression were determined by rt-pcr. islet allograft survival was determined by measurement of blood glucose. results: freshly isolated treg expressed s p and the chemokine receptors ccr , ccr , ccr , and ccr . endogenous treg, and both intravenously and locally transferred treg, that were recovered from islet allografts and dln expressed similar levels of ccr and ccr . ccr was expressed preferentially on islet migrating treg, while s p and ccr were expressed preferentially in dln migrating treg. locally transferred treg migrated to the dln, but ccr -/-treg were not able to migrate to the dln. ccr -/and ccr -/-treg were impaired in their ability to migrate to the dln. this suggested that these three chemokine receptors all regulated treg entry into afferent lymphatics and migration from the graft to the dln. in contrast, ccr -/-treg migrated normally from the islet to the dln. importantly, ccr -/-, ccr -/and ccr -/-, but not ccr -/-treg, were impaired in their ability to prolong islet allograft survival when transferred locally in the islet allograft. conclusion: treg migrate from the inflammatory site of the allograft to draining secondary lymphoid tissue through afferent lymphatics. this process depends on ccr , ccr , and ccr ; and is crucial for full treg function in vivo. these results demonstrate a novel role for sequential migration from the graft to the dln in treg function and suppression. epigenetic regulation of gene expression provides a major, and especially beyond oncology, largely unexplored means to regulate host immune cell functions. our ongoing analysis of histone deacetylase (hdac) expression by foxp + naturally occurring murine regulatory t (treg) cells showed tcr-activated tregs had - fold more hdac mrna than corresponding resting treg or non-treg cells. in various cell types, hdac deacetylates alpha-tubulin, cortactin, and hsp , abrogates formation of the aggresome, and blocks the unfolded protein response, though nothing is known regarding these pathways in tregs. we found that an hdac -specific inhibitor, tubacin (but not the control compound, niltubacin), increased treg suppressive function in vitro (p< . ), in association with increased expression of ctla, il- , gitr, pd- and other treg-associated genes (p< . ), and increased treg foxp protein (though not mrna) expression. tubacin enhanced the conversion of cd +cd -cells into cd + foxp + treg in vitro, and globally decreased cytokine production, with the exception of il- and il- mrna. comparable and dose-dependent effects were seen using the hsp inhibitor, geldanamycin, suggesting that the effects of hdac inhibition were mediated, at least in part, by blocking the chaperone effect of hsp . use of tubacin in vivo significantly decreased the severity of colitis in two murine inflammatory bowel disease models (p< . ), dextran sodium sulfate-induced colitis and the cd +cd lhigh adoptive transfer model of colitis, as assessed by standard clinical and histologic criteria. in addition, days combined use of tubacin and a subtherapeutic dosage of rapamycin led to significantly prolonged cardiac allograft survival (balb/c->c bl/ ) compared to use of either agent alone (p< . ). our data show that use of the first known small molecule inhibitor of one specific hdac has important therapeutic effects, including enhancing the production and suppressive function of tregs. while ongoing studies are directed towards unraveling the interactions of hdac -dependent pathways and treg functions, the current data indicate the importance of understanding the functions of hdacs to the development of entirely new ways to regulate host immune responses. dendritic cells supply paracrine il- for treg cell functional activity. regulatory cd +cd + t cells (tregs) are important for the maintenance of immune tolerance, and immunotherapy with tregs is being explored for organ and cell transplantation. treg development, expansion and function depend on il- . because tregs do not make il- , they must obtain il- from another cell. although cd + teffectors are a logical candidate, the identity of the paracrine source of il- for tregs is not substantiated. we explored whether dendritic cells (dcs) could serve as the paracrine source of il- for treg and rd , a cd +cd + regulatory hybridoma. using four dimensional live cell imaging we demonstrate that treg and rd cells establish tight contact with dcs, and cd is localized at these contacts. using the il- elispot and real-time rt-pcr we found that splenic dcs and the jawsii dc cell line constitutively make il- . lps and cpg increases dc production of il- . co-culture with jawsii dc cell line significantly upregulates cd expression on alloreactive do . tregs and rd cells, but not on do . cd + teffector cells. tregs and rd cells are functionally suppressive after activation by wild type but not il- knock-out allogeneic dcs, and anti-cd inhibits the function of treg and rd cells in a dose response fashion. in contrast, wild type and il- knock-out dcs are equally able to activate alloreactive cd +cd -cells. supplemental il- at high ( u/ml) but not low doses ( u/ml) restores the function of alloreactive tregs and rd that were activated by il- ko dcs. these data indicate that treg cells acquire il- from dendritic cells for their gain of function and validate dendritic cells as a paracrine source of il- for treg. introduction: previously, it has been demonstrated that foxp , a gene required for the development and function of regulatory t cells, was highly expressed in the graft during cardiac rejection, suggesting infiltration of regulatory t cells in the transplanted organ during an allogeneic response. in this study, we investigated whether graftinfiltrating t cells expanded from rejecting human cardiac allografts exhibit immune regulatory activities. methods: graft-infiltrating lymphocytes (gils) cultured from endomyocardial biopsies (emb; n= ) with histological signs of acute cellular rejection were expanded in the presence of donor-antigens in il- /il- -enriched medium for - weeks. flow cytometry was used to analyze the expression of cd , cd , cd and foxp . to analyze the immune regulatory function, we performed mlrs with peripheral blood mononuclear cells (pbmc) of the patients and irradiated donor or third party spleen cells in the absence and presence of gils (ratio : ). results: of the cd + gils, % (median; range: - %) stained positive for foxp . this foxp expression was detected in both cd + and cd + t-cell population (median: % and %, respectively). functional analysis demonstrated that gils suppressed the antidonor proliferation of responder t cells (range % inhibition: - %). interestingly, this suppression was predominantly achieved by cd + gils: depletion of cd + cells from the gils population diminished the inhibitory effect, whereas addition of solely cd + gils to the mlr abundantly suppressed the anti-donor response (range % inhibition: - %). in contrast, gils did not inhibit the proliferation of t cells stimulated with third-party antigens. the figure below depicts a representative example. graft-infiltrating lymphocytes expanded from rejecting cardiac allograft exhibit donor-specific immune suppressive activities. these results suggest that during acute cellular rejection, graft-infiltrating lymphocytes not only consist of graft-destructing effector t cells, but may also comprise immune regulatory cells of the cd + phenotype. the context: it has been previously suggested that a liver allograft is immunoprotective and able to decrease the rate of rejection of a donor-specific allograft of another organ. it has been recently proposed that allografts other than the liver may also be immunoprotective. objective: the aim of this analysis was to examine one year rejection rate and the incidence of rejection free survival of all combined transplants in the collective us experience to gain insight to any possible protective effect of one organ for another. methods: the united network of organ sharing (unos) provided de-identified patientlevel data. analysis included all recipients transplanted between january , and october , who were years or older (except intestinal transplants). rejection at one year was defined as treatment for one or more episodes of rejection. results: analysis included a total of , patients who received either one, or combined, simultaneous or sequential, organ transplants in all possible combinations. results are summarized in figure (one-year organ allograft rejection rate). the collected data demonstrate that the rejection rate of donor-specific organ allografts which accompanied primary liver, kidney, and heart transplants was significantly lower in combined transplants as compared to that of the primary allograft transplanted alone. this was not true, however, for intestinal and pancreatic allografts where protection for the accompanying organ was not observed. we further demonstrate that transplantation of two organs of the same type (double kidneys or double lungs), i.e. increase in antigen load, also leads to decreased rates of rejection of the allografted organs. conclusions: in combined simultaneous transplants, the heart, liver, and kidney allografts appear themselves to be protected, and to protect the other organ from rejection. increased antigenic load of identical antigens in case of double lung and double kidney transplants appears to also offer immunologic protection against rejection, perhaps by different mechanisms. background: a all ( -center adult-to-adult living donor liver transplantation cohort study) has identified risk factors for mortality after aaldlt, including center experience. the aim of this study was to determine if a all findings are reflected in the national experience. methods: aaldlt at a all (n= ) and non-a all centers (n= ) from / / to / / in the scientific registry of transplant recipients database were analyzed. cox regression models adjusted for recipient and donor characteristics were fitted to test associations with mortality risk after aaldlt, including center type (a all vs. non-a all) and case number (for each aaldlt at each center). results: aaldlt were performed at a all and non-a all centers. there was no significant difference in overall mortality risk between a all and non-a all centers. significant predictors of death (both groups combined) included donor age (hazard ratio (hr)= . per years, p= . ), recipient age (hr= . per years, p< . ), diagnosis of hcv (hr= . , p= . ) or hcc (hr= . , p< . ), and earlier center experience (aaldlt case number ≤ , hr= . , p< . ). there was no significant effect of transplant year after adjusting for experience. cold ischemia time > . hours was associated with higher mortality (hr= . , p= . ); this effect was similar in a all and non-a all centers. there were no significant interactions between center type and any predictor except center experience ( figure) . compared to later experience, earlier center experience was associated with significantly higher mortality risk in both a all (hr= . , p< . ) and non-a all centers (hr= . , p< . ). survival during early experience was significantly worse at a all vs. non-a all centers (hr= . , p= . ), but survival in later experience was similar. conclusions: after the first cases, aaldlt survival was similar at a all and non-a all centers, and similar significant mortality risk factors were identified, including center experience. these analyses support the generalization of findings from a all centers to others performing aaldlt. abstract# rejection with hemodynamic compromise (hc) and chronic allograft vasculopathy (cav) impact survival in pediatric heart transplantation (phtx). we showed that high pro-inflammatory / lower regulatory cytokine gene polymorphism (gp) profile increased the risk for acute rejection. in this analysis, we assessed the effect of genetic factors on hc and cav. methods: phtx with clinical and gp data for cytokines (tnf-α a- g; inf-γ t+ a; il- g- a, c- t, c- a ; il- c- t; il- t- c; il- g- c), growth factors (tgfβ- t+ c, c+ g; vegf a- c, c- t, g+ c), effector molecules (fas a- g; fasl c- t) and pharmacogenomics (abcb c t, g t/a) were analyzed regarding hc and cav. results: adjusting for recipient black race and age with cox regression models, we identified the following risk factors: il- high was associated with lower rates of hc. low th (inf-γ, tnf-α) with high th (il- , il- ) cytokine gp profiles were protective for hc in combination with il- high. carriers of fas high experienced higher rates for hc and cav and high fas-fasl combination doubled the relative risk for cav. abcb cc/ gg genotypes were also associated with lower rates of hc (table ) . conclusion: in this large multi-center study gps with higher regulatory profiles and increased drug transport were associated with a lower incidence of hc. a genetic proapoptotic profile might contribute to the pathogenesis of cav. sponsorship: this work was supported by p hl - from the national heart lung and blood institute, national institutes of health. it has recently been reported that cd d-restricted nkt cells that express invariant tcr (inkt cells) play an important role in the production of autoantibodies through the interaction with b- cells. this observation prompted us to investigate the possible role of inkt cells in the production of antibodies (abs) against transplant-related antigens, such as abo blood group carbohydrates and histocompatibility complex allopeptides, in a mouse model. we have previously demonstrated that b cells with receptors for blood group a carbohydrates were found exclusively in a cd b + cd + b- subpopulation of mice, resembling humans with blood group o or b. immunization with human blood group a red blood cells (a-rbcs) elicited the extensive production of anti-a igm and igg. furthermore, the number of b- cells with receptors for a carbohydrates increased in the peritoneal cavity. in cd d -/and vα -/-balb/c mice, which lack inkt cells, such elicited production of anti-a igm was not observed, even after immunization with human a-rbcs. however, class ii -/-balb/c mice, which lack cd + t cells but maintain normal levels of inkt cells, exhibited levels of anti-a igm production comparable to those in wild-type (wt) balb/c mice. moreover, anti-a igg production was absent in cd d -/-balb/c mice even after the immunization, indicating that although inkt cells crucially contribute to anti-a igm production and igg class switching, helper t cells do not. notably, the proportion of b- cells in the livers of cd d -/-balb/c mice was significantly reduced ( . ± . %, n = ) when compared to that in wt mice ( . ± . %, n = ). we next immunized cd d -/and wt balb/c mice twice with × allogeneic b mouse thymocytes, and thereafter detected the anti-b (allopeptides) abs by flow cytometry. in the cd d -/mice, anti-b igm production was comparable to that of wt mice, and igg class switching also occurred normally. these findings indicated that inkt cells play a pivotal role in the production of abs specific for blood group carbohydrate determinants that are believed to be t cell independent, but are not required in the production of abs for allopeptides that are believed to be t cell dependent. the depletion of inkt cells or the suppression of their function might constitute a novel approach for preventing antibody-mediated rejection in abo-incompatible transplantation, or in xenotransplantation, which involves similar carbohydrate antigens. background static cold storage (cs) is the most widely used organ preservation method for deceased donor kidney grafts. retrospective analyses have indicated that preservation by hypothermic machine perfusion (mp) may lead to improved outcome after renal transplantation. however, there is a lack of sufficiently powered prospective studies to test the presumed superiority of mp. in an international prospective randomized controlled trial we enrolled kidney pairs of consecutive deceased donors and randomly assigned one organ to mp and the contralateral kidney to cs preservation. follow-up was directed at all recipients of these grafts. the primary endpoint was delayed graft function (dgf). mp significantly reduced the risk of dgf (or . ; p= . ) and more than halved the incidence of primary non-function after transplantation, when compared to cs ( . vs. . %; p= . ). furthermore, mp significantly reduced the risk of graft failure in the first months post-transplant (hr . ; p= . ). in recipients who developed dgf, -month graft survival was better if their transplanted kidney was machine perfused ( vs. %; p= . ). hypothermic machine perfusion reduces the risk of delayed graft function, primary non-function, and graft failure in deceased donor kidney transplantation when compared to static cold storage. furthermore, mp alleviates the deleterious effect of dgf on graft survival. we investigated the trafficking of cells after skin and heart transplantation in a dynamic fashion through the use of in vivo microscopy. antigen presenting cells were followed using mhc-cl-ii-gfp and cd c-gfp transgenic mice. vascularized and non vascularized skin grafts as well as heart transplants were used in syngeneic as well as allogeneic settings. after syngeneic non-vascularized skin transplantation, we observed an early and massive cellular infiltration of host cells into the graft as early as hours post-transplant with a gradual accumulation in the dermis. the accumulation of host-derived cells was accelerated after graft vascularization at day / post transplantation. this graft infiltration by recipient cells was more pronounced with vascularized skin grafts, and to a higher degree in heart transplants. recipient cells similarly infiltrated allogeneic grafts early on and in larger numbers than for syngeneic grafts by day / post-transplantation. when visualizing mhc-cl-ii-gfp recipient cells in a syngeneic skin transplant, recipient dcs invaded the graft early on and, by weeks post transplant gradually replaced graft dcs in the dermis (dermal dcs) and the epidermis (langerhans cells). donor dcs could still be seen in the graft up to days post transplant. however, virtually all donor langerhans cells were eventually replaced by recipient ones in a concentric fashion suggesting that the new langerhans cells originate from the recipient skin adjacent to the graft and not from centrally-derived precursor cells. the vascular endothelium of a syngeneic transplant was partially replaced by recipient vascular endothelial cells in a centripetal fashion with more recipient-derived vascular endothelium present at the periphery of the graft and more donor-derived endothelium remaining in the center of the graft. therefore, the graft can be seen as a "chimera" of cells from donor and recipient origin. the presence of recipient endothelial vascular cells and dcs within the graft may be important for maintaining the indirect response thought to be responsible for chronic rejection. objective: maturation resistance and tolerogenicity can be conferred on dendritic cells (dc), -crucial regulators of t cells, by exposure to rapamycin (rapa), a tolerance-sparing immunosuppressant. the mechanisms underlying this acquired unresponsiveness, typified by diminished responses to toll-like receptor (tlr) or cd ligation, have not been identified. thus, our objective was to elucidate a molecular basis for rapa-induced dc maturation resistance. methods: rapa administration was used to condition splenic dc in vivo and bone-marrow derived dc in vitro. dc maturation was monitored by assessment of co-stimulatory molecule expression, cytokine production, and t cell allostimulatory capacity. to identify negative regulators of maturation, microarray analysis and quantitative rt-pcr was completed, and findings confirmed via western and flow cytometric analyses. results: in vitro or in vivo exposure of myeloid dc to rapa elicited de novo production of il- β by otherwise immature dc (cd lo ). interestingly, dc il- β production, acting in an autocrine/paracrine fashion, promoted dc overexpression of the il- receptor(r) family member, st l, and enhanced its surface expression. st l is the receptor for il- , an il- family member, and has also been implicated as a negative regulator of tlr signaling. consistent with this regulatory function, il- β-induced st l expression suppressed the responsiveness of rapa-conditioned dc to tlr or cd ligation. conclusion: rapa causes de novo production of il- β by immature dc, upregulating st l, and establishing a barrier to dc maturation following exposure to tlr or cd ligation. as such this work identifies a novel mechanism by which a clinically-important immunosuppressant impedes the capacity of dc to mature and consequently stimulate effector/adaptive t cell responses. these findings are particularly relevant to the potential use of rapa-conditioned dc as "negative" cellular vaccines to block alloag-specific responses, as exposure to endogenous and exogenous inflammatory stimuli can induce dc maturation and negate the tolerogenic properties of immature dc. exosomes are nanovesicles ( - nm) released to the extracellular milieu by different cell types. exosomes secreted by dendritic cells (dcs) and other apcs express mhc ag, adhesion molecules and costimulatory molecules oriented on the membrane surface with their binding domains facing outwards. thus, exosomes released by graft-infiltrating leukocytes (gils) could function as "ag-presenting vesicles" or as vehicles to transfer alloag between recipient's apcs during elicitation of t-cell allo-immunity. aims: to test if (i) gils activate anti-donor t-cells in secondary lymphoid organs by releasing exosomes with alloag into systemic circulation; or (ii) gils that traffic to the spleen as passenger leukocytes use exosomes as a local mechanism to transfer alloag to recipient's dcs. methods: exosomes were isolated from supernatants of bm-derived [c bl/ (b ), ia b ] dcs pulsed with the balb/c iea - allopeptide and purified by ultra-filtration and ultra-centrifugation on a %sucrose/d o gradient. we used pkh + exosomes and cd . congenic b mice for traffic studies, heart (heterotopic) and skin transplantation models (balb/c→b , thy . + ), and cfse-labeled h . tcrtg cd t-cells (thy . + ) specific for ia b (b ) loaded with iea - (balb/c). dcs were genetically engineered to release exosomes expressing green fluorescent protein (gfp). we have previously shown that blood-borne exosomes carrying balb/c alloag are reprocessed by different subsets of splenic dcs for presentation to indirect pathway h . cd t-cells. here, we demonstrated that although gils of cardiac and skin allografts release exosomes ex vivo, they did not secrete enough concentrations of exosomes with alloag into circulation to stimulate donor-reactive t-cells in lymphoid organs. instead, our findings indicate that migrating dcs (generated in vitro or isolated from gils), once homed in the spleen, they transfer exosomes expressing gfp and carrying allopeptides to spleen-resident dcs of the recipient, identified by the congenic marker cd . . conclusion: exchange of exosomes between dcs in lymphoid organs might be a mechanism by which passenger leukocytes transfer alloag to recipient's apcs in secondary lymphoid organs. t cell activation is critical in initiating adaptive immunity, and pkcθ, a novel member of the pkc family, mediates non-redundant functions in the t cell receptor; however, its role in the mediation of allograft rejection remains unclear. this study is aimed at investigating whether alloimmune response can be alleviated by a deficiency of the pkcθ molecule, and whether transgenic expression of anti-apoptotic bcl- methods. wild-type (wt) cardiac allografts were transplanted into pkcθ -/mice, with or without sub-therapeutic anti-cd mab. purified pkcθ -/or pkcθ -/-/ bcl-x l t cells were adoptively transferred into rag -/mice engrafted with cardiac allografts. lymphocyte proliferation assays were performed (cfse). nf-kb activation was assessed by bioluminescence imaging (bli) using luciferase transgenic mice under the control of a nf-kb promoter. results. the cardiac allografts were rejected in a delayed fashion in pkcθ -/mice with increased nf-kb activation; however, sub-therapeutic anti-cd mab (that normally delays rejection of cardiac allograft) induced long-term survival of cardiac allografts. the cardiac allografts were permanently accepted in rag -/mice with adoptive transfer of pkcθ -/-t cells, and the rejection can be elicited by transfer of pkcθ -/-/ bcl-x l t cells. in a lymphocyte proliferation assay, pkcθ -/-t cells displayed greatly reduced proliferation. in response to cd and cd stimulation, pkcθ -/-t cells underwent accelerated apoptosis and reduced th , th , and treg subsets compared to the wt t cells. bcl-x l restored the survival of the pkcθ -/-t cells. conclusions. the results suggest that pkcθ mediates the alloimmune response. bcl-x l transgene prevents pkcθ -/-t cell apoptosis and re-elicits allograft rejection. tolerogenic dendritic cells (dc) are immature, maturation-resistant(mr) or alternatively-activated dc that express mhc molecules and low levels or absent costimulatory signals. although mrdc administration has successfully prolonged allograft survival in murine models, the mechanism of action in vivo remains unknown. aim: to test in vivo if the down-regulation of the anti-donor response induced by donor-derived tolerogenic dc is due to: (i) direct interaction of the tolerogenic dc with donor-reactive t cells or (ii) by reprocessing of the tolerogenic dc into alloantigen (alloag) by recipient apc for interaction with indirect pathway t cells. methods: dc were generated in vitro by culturing balb/c bone marrow cells for - days in medium with gm-csf + il- supplemented with nm α, -( h) vitamin d (vd ). we used a model of heterotopic vascularized allogeneic heart transplantation [balb/c into c bl/ (b )] and cd t cells from h . tcrtg mice that recognize b ia b loaded with the balb/c allopeptide ieα - (indirect pathway) . results: we demonstrated that vd renders dc maturation resistant (vd -mrdc) as vd -mrdc fail to up-regulate co-stimulatory molecule expression, release il- p , or stimulate allo-responsive t cells after challenge with potent dc-maturation stimuli. adoptive transfer (i.v.) of balb/c vd -mrdc (day - ) significantly prolonged survival of balb/c heart grafts in b mice in the absence of immunosuppressive therapy. interestingly, we found that in vivo, balb/c vd -mrdc induced proliferation of indirect pathway h . cd t cells in the spleens of b recipient mice, indicating that reprocessing of the balb/c dc by host (b ) apc does occur. proliferation of h . cd t cells in response to balb/c vd -mrdc resulted in defective activation (cd l high , cd low ) of h . t cells, leading to their peripheral deletion and outgrowth of cd + foxp + treg cells. reprocessing of balb/c vd -mrdc was performed by recipient splenic cd c high cd α neg dc, and donor alloag continued to be presented through the indirect pathway for days after donor dc administration. conclusion: these results suggest that dc-based therapies downregulate t cell allo-immunity and prolong allograft survival, at least in part, through reprocessing of the tolerogenic dc into alloag by recipient apc. early introduction: alloreactive memory t cells are present in all transplant recipients due to prior direct sensitization or heterologous immunity. these cells are known to circumvent tolerance induction and/or prevent indefinite graft survival in several models, but mechanistic details of their function are unknown. the goal of this study was to test the hypothesis that cd memory t cells initiate alloreocognition and express effector functions within hours of reperfusion. methods: syngeneic or a/j (h- a ) hearts were transplanted into wt c bl/ (h- b ), cd -/-, cd -/-, or rag -/-recipients. rna and protein were prepared from total graft homogenates and analyzed by qrt-pcr and elisa. rag -/-mice received x wt or ifng-/- c cells and were used as recipients weeks after reconstitution. donor-specific cd memory cells were purified from wt spleens weeks after a/j skin grafting, and donor-specific effector cd cells were purified from spleens of cd . mice days after a/j heart transplantation. flow cytometry was used to quantify graft infiltrates. results: allografts contained elevated levels of ifng and cxcl mrna at , and hrs post-transplant vs. isografts. detectable cxcl protein was produced in allografts from wt and cd -/-recipients but not in isografts or allografts from cd -/-or rag -/recipients. treatment with ctla -ig and mr failed to reduce cxcl production. reconstitution of rag -/-mice with ifng sufficient or deficient c tcr transgenic cd cells indicated that early allospecific cxcl production absolutely requires ifng made by recipient cd cells. although donor-specific ifng production was undetectable in splenocytes until day - post transplant, graft-infiltrating cd hi cd l lo cd t cells were present as early as hrs post-transplant. in adoptive transfer studies, effector-memory cd t cells reconstituted early allospecific cxcl production in cd -/-mice. lastly, primed cd t cells adoptively transferred at day post-transplant readily infiltrated allografts in control but not cd depleted recipients. conclusions: cd memory t cells infiltrate allografts rapidly post-transplant, produce ifng, and propogate an inflammatory environment which optimizes recruitment of primed effector t cells. successful neutralization of this early allorecognition pathway should provide valuable adjunctive therapy to improve graft function and survival. background: allogeneic t cell stimulation requires not only antigen-specific signals but also costimulatory signals, most importantly between cd / on the antigen presenting cell (apc) and cd and ctla on the t cell. engagement of the t cell receptor without costimulation can lead to anergy and the induction of regulatory t cells (tregs). t cell activation is also controlled by expression of the tryptophan-catabolising enzyme indoleamine , -dioxygenase (ido). depletion of this essential amino acid, and/or the production of tryptophan metabolites inhibits t cell proliferation. methods: a genetic approach to confer tolerogenic properties on murine dendritic cells (dcs) has been explored using lentiviral vectors, based on the equine infectious anaemia virus. firstly, an intracellular method that prevents costimulation has been developed: a fusion protein consisting of ctla and kdel [an endoplasmic reticulum (er) retention signal] is expressed in dcs. the ctla -kdel binds to cd / in the er and prevents expression of these proteins on the dc surface. a second approach uses an elevated expression of the ido enzyme by transduced dcs. results: ctla -kdel-or ido-transduced dcs were unable to induce allogeneic t cell proliferation. however, using two-stage dc:t cell co-culture assays, it was shown that ctla -kdel-, but not ido-transduced dcs, can induce donor-specific t cell anergy in vitro and in vivo. tolerance to both the direct and indirect pathways was shown using ctla -kdel-transduced dcs. linked suppression was mediated by the generation of donor-specific tregs. ido-transduced dcs did not generate tregs. furthermore, it was shown separately that dcs expressing ido whilst lacking cd / expression for potential ligation by ctla (although ctla -cd / ligation upregulates ido, it downregulates t cell activation) failed to generate or even sustain foxp + treg populations. the ability of the transduced dcs to induce tolerance to allografts was assessed in a complete mismatch and cbk→cba (indirect pathway) corneal graft model. these results support a clinical strategy to induce treg-mediated, donorspecific transplantation tolerance using ctla -kdel-, rather than ido-expressing dcs. indirect cd t cells that recognise processed alloantigen on recipient apc can provide help to alloreactive cytotoxic cd t cells that recognise intact mhc i alloantigen on donor apc, but exactly how such 'un-linked' help is provided is not clear. the respective abilities of direct and indirect pathway cd t cells to provide help for cytotoxic cd alloimmunity were examined in a mouse model of heart graft rejection in which the recipients contain only monoclonal helper cd t cells, specific for self-restricted h-y antigen (female b mar/rag -/mice). mice were additionally reconstituted with b cd t cells, and then challenged with female balb/c (no cd t cell help), or male balb/c (indirect pathway help), or male b xbalb/c f hearts (direct pathway help) . un-reconstituted mar/rag -/mice lack effector b and cd t lymphocytes, and consequently all heart grafts survived indefinitely. in contrast, reconstituted mar/ rag -/mice rejected male f grafts rapidly (mst d), whereas female balb/c grafts survived indefinitely, confirming a cd -dependent effector role for the transferred cd t cells. cd t cell help through the indirect pathway, although sufficient to elicit graft rejection, was less efficient than direct pathway help, because male balb/c grafts were rejected more slowly than the f grafts (mst d, p< . ). we next considered whether indirect pathway cd t cells provide help through recognition of mhc ii complexes on the surface of alloreactive cd t cells, in analogous fashion to the cognate interaction between b and t lymphocytes. in support, reconstitution of mar/rag -/recipients with instead, mhc ii-deficient cd t cells, resulted in slower rejection of male balb/c hearts (mst d, p< . ), whereas male f grafts, that still permit provision of linked help, were rejected at the same tempo. most tellingly, mar/rag -/mice that received simultaneously a female balb/c heart and male b apc (to activate mar cd t cells) rejected their grafts rapidly when reconstituted with male cd t cells (mst d). in contrast, grafts survived indefinitely when female cd t cells were transferred. flow cytometric analysis of mitogenstimulated cd t cells revealed surface mhc ii expression. indirect allorecognition can provide help for generating cytotoxic alloimmunity, but not as effectively as through the direct pathway. indirect pathway help is potentiated by linkage through recognition of cd mhc ii. purpose: tolerogenic properties of dendritic cells (dc) are supported and preserved by conditioning with the immunosuppressant rapamycin (rapa). the ability of rapaconditioned, recipient-derived dc pulsed with alloantigen (alloag) to suppress both direct and indirect alloag-specific t cells in the absence of immunosuppression has been demonstrated in a murine allograft model. dc can acquire intact mhc from cells or cell lysates. however, the ability of alloag-pulsed rapa-dc to immunomodulate directly-reactive alloag-specific t cells has not been formally demonstrated. methods: dc were generated from c bl/ (b ; h b ) bone marrow cells in gm-csf and il- . rapa was added to indicated cultures (rapa-dc) beginning on day (d) . on d , cd c + bead-purified rapa-dc or non-treated control dc (ctr-dc) were incubated with balb/c (h d ) splenocyte lysates ("alloag pulsing"). following incubation, the dc were harvested and the level of donor and recipient mhc molecules on cd c + cells determined by flow cytometry and immunofluorescent imaging. surface levels of cd , b -h (programmed death ligand- ; pd-l ), and fas-l were compared. pulsed-dc were also incubated with cd + t cells from rag -/- c mice for d. c cd + cells express t cell receptors specific for h -l d , a mhc class i molecule of balb/c. following incubation, c cell proliferation and apoptosis were both assessed. results: ctr-and rapa-dc presented detectable levels of directly-transferred mhc class i and ii on their surface after incubation with allogeneic balb/c cell lysate. donor mhc presented by "pulsed" recipient dc stimulated directly-reactive, alloag-specific c t cell proliferation. however, only rapa-dc induced apoptosis in the overwhelming majority of these cells responding via the direct pathway. induction of apoptosis correlated with an increased level of surface fas-l on rapa-dc and their comparatively low level of cd relative to pd-l . conclusions: rapa-conditioned dc can present intact mhc molecules acquired from lysates of allogeneic splenocytes and concurrently induce apoptosis of directlyreactive alloag-specific cd + t cells. as such, we provide mechanistic insight into a mechanisms by which alloag-pulsed, recipient-derived rapa-dc may facilitate allograft tolerance. background: t regs actively regulate alloimmune responses and promote transplant tolerance. atg, a widely used induction therapy in organ transplantation, depletes peripheral t cells but may preferentially spare t regs . sirolimus is thought to expand natural t regs . b t cell costimulatory blockade inhibits effector t cell (t eff ) expansion and may promote regulation. we investigated the effect of combining mouse atg (matg), ctla ig and sirolimus on stringent skin allograft survival, and studied the mechanisms by determining t reg /t eff balance in vivo using a unique model (abm-tcrtg-foxp /gfp reporter mouse conclusion:this is the first report to establish that t cell depletion with matg combined with ctla ig and sirolimus synergize to prolong stringent fully allogeneic skin allograft survival by promoting regulation and tipping the t reg /t eff balance by both preserving t regs and facilitating generation of new t regs by a conversion mechanism. these results provide the rationale for translating such a novel therapeutic combination to promote regulation and tolerance in primates and human organ transplantation. expansion of cynomolgus cd +cd +foxp + regulatory t cells using low dose anti-thymocyte globulin. to test low dose atg in vivo, mg/kg ( % of depleting dose) was administered thrice (day , and ) to a naïve monkey and to a monkey that was treated concurrently with sirolimus (trough - ng/ml) after heart transplantation. in the naive monkey, lowdose atg led to expansion of cd +cd +foxp + tregs in peripheral blood (baseline . %, day = . %, day = . %) and in lymph nodes (baseline . %, day = . %, day = . %) without causing t cell depletion. similarly, in the transplanted monkey peripheral blood tregs expanded from . % at baseline to . % on day . low dose atg is not only able to expand tregs ex vivo by proliferation of natural cd +cd + cells, but can equally induce tregs in vivo without lymphodepletion. these findings provide the rationale for development of tolerance inducing strategies based on enhancing regulatory mechanisms in human transplant recipients. immunological background⁄aim: previously, we have shown that combination of human anti-cd mab, d and tactolimus exerts additive immunosuppressive effect and markedly prolongs renal allograft survival in cynomolgus monkeys. in this study, we further evaluated the immunological aspects among these transplant recipients. method: kidney transplantations were performed across mhc mismatched cynomolgus monkeys. transplant recipient was given either no-treatment, tacrolimus ( mg⁄kg⁄day, po), d ( mg⁄kg, iv) or tacrolimus+ d (n= ⁄group). peripheral lymphocyte population, mlr and serum anti-donor antibody levels and graft histology were assessed. results: mean graft survival for no-treatment, tacrolimus, d and tacrolimus+ d treatment groups was . ± . , . ± . , . ± . and . ± . days, respectively. peripheral cd + cells partially declined in both d alone and d + tacrolimus given animals at the early post-operation period, although the numbers recovered thereafter. cd + and cd + cells were unaffected. cd + effector memory population was reduced by addition of tacrolimus to d (fig. a ). mlr against donor and rd party antigens were suppressed in both d and tacrolimus+ d groups (fig. b) . addition of tacrolimus further reduced graft cd + , cd + and cd + cellular infiltration (fig. c ). anti-donor antibodies were detected in sera during the treatment course of d ; however, they did not develop under the tacrolimus+ d treatment. graft c d deposition correlated with serum anti-donor antibody levels. the d inhibits both cellular and humoral responses against donor antigens. addition of tacrolimus strengthens these immunosuppressive effects of d , leading to further prolongation of graft survival. objectives: allogeneic islet transplantation offers the potential for cure from diabetes. application of this therapy, however, is limited by immunologic mechanisms requiring medical therapy to prevent rejection of the islets. costimulatory blockade of the cd / cd /cd and the cd /cd pathways has shown promise in ameliorating the immune response to allow engraftment and function of islets. we have evaluated a new drug regimen consisting of induction therapy with a , a murine anti-cd antibody, and basiliximab and maintenance treatment with ctla ig and sirolimus in diabetic rhesus macaques which received allogeneic islets. methods: allogeneic rhesus macaque islets ( , ie/kg ± , ) were transplanted intraportally into diabetic rhesus macaques (n= ) under the following immunosuppressive regimen: short term administration of anti-il- receptor (basiliximab) and anti-cd ( a ), with maintenance immunosuppression using sirolimus for days and abatacept (ctla ig) for long term therapy. weekly peripheral blood flow cytometric and cmv viral load monitoring was performed. results: recipients treated with this immunosuppressive regimen had immediate return to normoglycemia following islet transplant. the graft survival in the first three animals was , and days. the fourth animal continues to exhibit good glycemic control at his current post-operative day . each of these animals had monthly intravenous glucose tolerance tests with monitoring of blood glucoses and c-peptides with further evidence of glycemic response and c-peptide generation. flow cytometry confirms cd blockade during the administration of a and return of cd after cessation of therapy. the treatment was well tolerated with minimal evidence of cmv reactivation and no evidence of thrombocytopenia or thromboembolism. conclusions: these preliminary results indicate that cd /cd costimulatory-based immunosuppressive regimens can protect allogeneic islets from rejection. furthermore, a appears to adequately block cd to facilitate this engraftment and function as demonstrated by flow cytometry. iwami, , qi zhang, osamu aramaki, nozomu shirasugi, katsuya nonomura, masanori niimi. surgery, teikyo university, tokyo, japan; renal and genitourinary surgery, hokkaido university, sapporo, japan. many studies have shown immunosuppressive effects of dietary intake of fish oil containing eicosapentaenoic acid (epa) in various models such as autoimmune diseases and transplantation. however, its mechanisms remain uncertain. furthermore, there have been no studies examining the effect of purified epa. here we determined the ability of purified epa to inhibit alloimmune response in mouse cardiac transplantation model. methods: cba recipients (h- k ) were given single injection of purified epa intraperitoneally on the same day as transplantation of a heart from c bl/ donors (h- b ). mixed leukocyte reaction (mlr) assay and enzyme linked immunosorbent assay (elisa) were also performed to evaluate the effect of purified epa on cell proliferation and cytokine production. to determine the presence of regulatory cells, adoptive transfer study was conducted. results: untreated cba recipients rejected c bl/ cardiac allografts with median survival time (mst), days. in contrast, cba recipients treated with purified epa ( . g/kg) had significant prolongation of allograft survival (mst, > days). cba recipients treated with . g/kg purified epa eventually rejected allografts (mst, days). in mlr assay, treatment with . g/kg purified epa suppressed alloproliferation of splenocytes in the recipients. the treatment also inhibited production of il- , il- and ifng by the splenocytes in the recipients. when splenocytes were harvested from the recipients treated with . g/kg purified epa days after cardiac allografting and were adoptively transferred into naïve secondary recipients, the adoptive transfer induced significant prolongation of cardiac allograft in nave secondary recipients (mst > days, compared to that in the recipients with adoptive transfer of naïve splenocytes, mst, days). conclusions: purified epa induced significantly prolonged survival of fully mismatched cardiac allografts, and generated regulatory cells. background: chronic allograft nephropathy (can), the most common cause of late kidney allograft failure, is not effectively prevented by the current regimens. activation of extracellular signal-regulated kinases / (erk / ) mediating intracellular signal transduction from various growth factor stimuli is required for tgf-β production, which plays a key role in the development of can. hence, the therapeutic potential of disruption of erk / signaling to prevent can was examined in an experimental model. methods: kidney donors from c bl/ j mice (h- b ) were transplanted to bilaterally nephrectomized balb/c recipient mice (h- d ). the recipients were treated with ci (mek-erk / inhibitor) or vehicle after days post-transplantation for days. can was evaluated with the banff working classification. results: all six allografts receiving ci treatment were survived, while two out of seven grafts were lost in vehicle-treated group. at the end of experiment, the function of grafts in ci treated recipients had been maintained, indicated by lower levels of serum creatinine and bun ( ± µm and ± mm, n= ) as compared to those ( ± µm and ± mm, n= ) in vehicle group (creatinine, p= . ; bun, p= . ). pathological evaluation indicated that ci reduced can, reflected by a lower can score in ci -treated group ( . , n= ) as compared to that ( . , n= ) in vehicle controls (p= . ). further examinations showed that ci treatment resulted in inhibition of phosphorylation of erk / and reduction of tgf-β levels in grafts. in vitro ci potently suppressed not only growth factors-stimulated erk / activation and tgf-β biosynthesis in renal tubular epithelial cells, but also attenuated alloantigenstimulated t cell proliferation. conclusion: our data suggest that interference of erk / signaling with pharmacological agent (i.e. ci ) has therapeutic potential to prevent can in kidney transplantation. objective: this is the first study to investigate the role of a novel jak and sykinhibitor, r , in the prevention of obliterative airway disease (oad), the major obstacle after lung transplantation. methods: trachea from brown-norway (bn) donors were heterotopically transplanted in the greater omentum of lewis (lew) rats. recipients were treated for days with r ( , , , or mg/kg), rapamycin ( . or mg/kg), or left untreated. allografts were recovered and processed for histological evaluation determining degree of luminal obliteration, percentage of respiratory epithelial coverage, and mononuclear cell infiltration. donor reactive (igg) antibodies from the recipient's serum were determined using flow cytometry. results: r at , , and mg/kg significantly inhibited luminal obliteration in a dose dependent manner ( ± %, ± %, ± %; p= . vs. no medication). rapamycin in both concentrations significantly inhibited luminal obliteration ( ± %, ± %; p< . vs. no medication) similarly to r at and mg/kg. r at and mg/kg significantly preserved respiratory epithelium compared to r at and mg/kg ( ± %, ± % vs. ± , ± %; p= . ) and was superior to rapamycin in epithelial preservation ( ± %, ± % vs. ± %, ± %; p= . ). all r and rapamycin-treated recipients expressed decreased numbers of peritracheal mononuclear cells in a dose dependent manner (p< . ). r , , and mg/ kg treated recipients had significantly reduced igg levels versus untreated recipients ( ± , ± , ± vs. ± ; p< . ). all r treated recipient thymus and spleen weights were significantly lower compared to the untreated group (p= . ). bun, cr, and cholesterol levels were unaffected in r treated recipients. conclusion: r potentially exhibits its inhibitory effect by preserving the respiratory epithelium, rather than by rapamycin's mechanism of reduced smooth muscle cell (smc) proliferation. r occupies a beneficial pharmacokinetic profile, lacks nephrotoxic and atherogenic properties, and provides a favorable alternative to rapamycin in the treatment of chronic rejection in lung transplant recipients. genz- is a novel, oral immune-modulatory agent identified in a high-throughput screen designed to find inhibitors of tnfα-induced apoptosis. the molecular target of the compound remains under investigation but is likely downstream of the tnfα cell surface receptor. in vitro studies have shown genz- to be an effective inhibitor of the tnfα-triggered caspase cascade but not anti-cd or fas-mediated apoptosis, and thus may act by inducing allograft resistance to immune attack rather than suppressing the alloimmune response per se. it has been shown to synergize with sirolimus in murine heterotopic cardiac allotransplant models. in order to test this promising new agent in a more clinically relevant model of solid organ transplantation, we studied genz- in a mismatched nhp (rhesus macaque) renal transplant model. genz- (n= ) was administered ( mg/kg, iv, days - ) with sirolimus ( mg/kg, po, days - ). five control animals received only sirolimus and vehicle ( mg/kg, po, days - ). all animals were followed serially by polychromatic flow cytometry to determine the relative and absolute number of cd + and cd + t cell subsets. time to allograft rejection, the primary end point, was determined by a significant rise in serum creatinine and bun, as identified with biweekly monitoring. after diagnosis of rejection, allografts were removed for histological and transcriptional studies, along with splenocytes for immune function assays. in this pilot study, prolongation of rejection-free survival was significantly improved with genz- and sirolimus combined vs. sirolimus alone ( . days vs. . days, respectively, p = . ). given these initial results, we have initiated a larger study (n= ) to optimize the dose and duration of genz- . five animals, transplanted within the past month remain alive and well in this study. further investigation of this agent will allow us to better understand the benefit of inhibiting tnfα-mediated apoptotic effects in both cellular alloimmune response and allograft injury in solid organ transplantation. targeting purpose: allospecific t memory cell responses are present in transplant recipients from exposure to cross-reacting antigens. we have previously reported that lfa- inhibition suppresses primary cd -dependent rejection responses which are not controlled by any conventional immunosuppressive strategy. these studies were conducted to analyze the efficacy of this anti-lfa- ab for control of cd -dependent responses in sensitized hosts. methods: fvb/n (h- q ) donor hepatocytes were transplanted into c bl/ (h- b ) or cd ko (h- b ) recipients. memory responses were analyzed by retransplantation with a second fvb/n allogeneic hepatocyte transplant. cohorts of mice were treated with anti-lfa- mab and observed for hepatocyte survival or magnitude of cd + t cell mediated allospecific cytolytic activity. results: the untreated secondary cd ko and c bl/ recipients rejected hepatocyte allografts with enhanced kinetics in comparison to the primary graft (mst= day vs day , and mst= day vs. day , respectively; p < . ). anti-lfa- mab treated cd ko recipients demonstrated delayed rejection (mst= day vs day ; p= . ) compared to secondary rejection in untreated cd ko hosts. anti-lfa- mab treatment did not delay rejection in sensitized c bl/ recipients (mst= day ) but did significantly reduce the in vivo allospecific cytotoxic effector function in c bl/ secondary recipients ( . ± . %; p= . ) as compared to untreated controls ( ± . %). the residual cytotoxicity observed in anti-lfa- mab treated c bl/ recipients is comparable to the in vivo cytotoxicity of cd -depleted c bl/ secondary recipients ( . ± . %) and is likely mediated by alloantibody. in fact, the level of allospecific cytotoxicity in anti-lfa- mab treated sensitized c bl/ recipients correlated with the amount of alloantibody present in recipient serum. conclusion: in conclusion, treatment with anti-lfa- mab delayed (cd -independent) cd -dependent rejection in sensitized recipients but did not delay rejection in sensitized cd -sufficient c bl/ recipients. despite the efficacy of treatment with anti-lfa- mab to significantly reduce the in vivo allospecific cytotoxic effector function in sensitized c bl/ mice this strategy did not delay rejection. this is likely due to alloantibody mediated rejection in sensitized c bl/ (but not cd ko recipients) which is not suppressed by treatment with anti-lfa- mab. abstract# cytomegalovirus (cmv) represents a major cause of infectious complications after transplantation. recently, chronic infections with lcmv, hiv or hcv were shown to be associated with functionally anergic t-cells characterized by high expression of the programmed death (pd)- molecule. this study was carried out to characterize functional exhaustion of cmv-specific cd t-cells as determinant of impaired cmv-control and to elucidate whether the pd- pathway may be operative in active cmv-infection after renal transplantation. cmv specific cd t cells from controls, hemodialysis patients, and renal transplant patients were quantified using flow cytometry and analysed for their expression of pd- and cytokines ifnγ and il . cmv specific proliferation was analysed by cfda-se dilution. in viremic transplant-recipients, a significantly higher proportion of cmv-specific cd t-cells were pd- positive (median . %) as compared to non-viremic transplant patients ( . %), dialysis-patients ( . %) or controls ( . %, p< . ). in line with functional impairment, pd- positive t-cells produced significantly less ifnγ per single cell as compared to pd- negative t-cells (mean fluorescence intensity . ± . versus . ± . , p< . ). moreover, unlike controls or non-viremic patients, the majority of cmv-specific t-cells from viremic patients showed a long-term loss of il- production. interestingly, functional anergy of pd- positive cmv-specific cd t-cells was reversible in that antibody-mediated blockade of pd- signaling with its ligands pd-l /-l led to a fold increase in cmvspecific proliferation. in conclusion, expression of pd- defines a reversible defect of cmv-specific cd t-cells, and blocking pd- signaling may provide a potential target for enhancing the function of exhausted t-cells in chronic cmv-infection. differential background: some patients with cmv disease may be simultaneously infected with multiple viral strains. it is unknown if different strains clear differently with the commencement of antiviral therapy. we assessed response to antiviral therapy in patients with simultaneous co-infection with multiple strains of cmv. methods: pcr-based strain typing of cmv was performed using the glycoprotein b gene of cmv (gb - ) in a cohort of organ transplant recipients with cmv disease. from this, patients were identified that had simultaneous infection with ≥ cmv strains. quantitative assessment of each of the strain types was performed at regular intervals after starting antiviral therapy. results: the different types of multi-strain infections were gb +gb ( / , %), gb +gb ( / , %), gb + gb ( / , %), gb +gb ( / , %), gb +gb ( / , %) and gb +gb ( / , %). / ( %) were simultaneously infected with or different genotypes. within individual patients, there was trend for gb cmv load ( . log genomes) to be lower than the other genotypes (p= . - . ) at the onset of disease. decay kinetics for all genotypes showed a bisphasic response with a st phase decline of ∼ . days and a nd phase of ∼ days. st phase delines were fastest for gb (p= . vs gb and ) while gb decline was slower than gb during the st phase. nd phase declines were similar between gb and ( days and . days) but were slower for gb and ( . days; p= . ). there was a significant correlation between st phase decline and log decline from baseline by day (r= . ; p= . ). relative fitness calculations revealed complex fitness dynamics between genotypes although gb was always less fit than gb , and , and gb and were always less fit than gb . conclusion: in patients with cmv disease who have simultaneous coinfection with multiple strains, the st and nd phase declines in gb are significantly slower than either gb or and have a lower log decline from baseline by day . these data indicate that either a significant fitness difference exists between cmv strains or that antiviral control of replication may be linked to cmv gb genotype and should aid our understanding of treatment success and failure. one introduction: parvovirus b (pvb ) is a single-stranded dna virus that was first reported to affect transplant (tx) recipients around years ago. in the kidney tx setting pvb has been reported to cause anemia and proteinuria. reported incidence in a general kidney transplant cohort has been reported to be between %- % and as high as % in an anemic kidney tx population. here we report our incidence of pvb infection over a year span. patients and methods: all records of kidney tx recipients from until were reviewed for the presence of pvb infection. there were kidney tx performed during this period. diagnosis of pvb infection was made either by detection of pvb via pcr in a blood/tissue sample or by detection of virus on renal tissue by immunostain. in patients found to have pvb infection; presence of anemia, proteinuria, concurrent infection and acute rejection rates were examined. response to treatment with ivig was also evaluated. results: incidence of infection was . % as patients were found to have evidence of infection. average time from tx to diagnosis of infection was . months (range days- months). average creatinine at diagnosis was . mg/dl. anemia was present in % of patients with an average hematocrit of . %. proteinuria was present in % of patients with evidence of pvb infection. co-infection was noted in patients ( cmv, ebv) and acute rejection was noted in % of individuals within months of diagnosis. collapsing glomerulopathy (cg) was present in patients and they all had subsequent graft loss at an average of months after diagnosis. of the patients with cg had proteinuria along with anemia and were caucasian. % ( / ) of all patients with evidence of pvb infection received ivig and cleared their infection. one of the remaining pts without ivig spontaneously cleared their virus. conclusion: although the incidence of pvb infection in our kidney tx cohort was very low, its presence portends an unfavorable outcome. the presence of cg associated with pvb is an especially devastating lesion with very poor outcomes. response to treatment with ivig and reduction of immunosuppression is variable. based on our data it seems reasonable to screen all tx patients with unexplained anemia and concurrent proteinuria as early detection of pvb may be crucial. background: prior to transplant, screening for latent tuberculosis (ltbi) by tuberculin skin test (tst) is recommended. the accuracy of tst in end stage renal disease however may be limited. the quantiferon®-tb gold assay (qft) detects interferon-δ produced by peripheral blood t-cells in response to tb specific antigens and may be more accurate for diagnosis of ltbi. methods: this prospective single center study compared the tst to qft for the diagnosis of ltbi in a cohort of adult patients listed or undergoing workup for renal transplantation. all patients had both tst and qft performed. additional data collected included demographics, tb risk history and chest x-ray results. based on demographic and radiographic findings, patients were classified as high or low risk for ltbi. a positive tst was defined as ≥ mm and positive qft as ≥ . iu/ml. results: a total of patients were enrolled. complete data was available for subjects ( did not return to have tst read). the mean age was . +/- . years with ( . %) males and ( . %) females. the most common etiologies of renal diseases were diabetes ( . %) and glomerulonephritis ( . %). most subjects ( of ) were on renal replacement therapy (hemodialysis in . % and peritoneal dialysis in . %). twenty ( . %) subjects had received bcg and ( . %) were born in or lived in a country in with tb prevalence rate > / population. fifteen ( . %) subjects were considered to be at high-risk for ltbi. overall ( . %) had a positive tst and ( . %) had a positive qft. the qft was indeterminate in subject due to a low mitogen response. agreement between the tests was % (k= . , p< . ). in low-risk subjects (n= ) the tst was negative in all and the qft was negative in and indeterminate in . in clinically high-risk subjects, ( %) had a positive tst and ( %) had a positive qft. the subjects with discordant results, both from tb endemic countries, had both completed treatment for ltbi years prior and remained tst positive, but were qft negative. in renal transplant candidates, the tst and qft are comparable for the diagnosis of ltbi. the qft has the advantage of being completed in a single visit and in our cohort indeterminate results were uncommon. optimal utilization of htlv i/ii positive organs -a nationwide survey. objective: we recently presented data from the unos database that demonstrated no significant difference in graft or patient survival between htlv i /ii (+) and (-) liver recipients. several organ procurement organizations (opo) including our own, do not offer htlv i /ii positive organs while many others find it difficult to place them. despite this, the number of htlv (+) organs is increasing with utilized in alone. this prompted us to evaluate the practical difficulties in placing these organs so as to improve utilization of these "high risk" life saving organs. medthod: a telephone/email survey of all the opos in usa was done over a month period from october to november . results: of the opos, responded. all screen patients for htlv i/ii with elisa. centers confirm with repeat elisa, confirm with western blot and centers do not pursue further. of the centers offer the htlv i/ii positive organs. there were a total of positive donors in the past years of which organs from donors ( . %) were placed. centers offer all the organs while offer one or more organs selectively based on accepting centers. none have been able to place the pancreas. only liver and kidney were commonly accepted. several centers noted a high false positive rate. based on the unos regional analysis data, % of the organs are utilized in ny state alone. many opos did not know which particular centers accept these organs and consequently spend a lot of time and effort in order to place them. a majority wanted to have a list of transplant centers that accept these organs. conclusions: htlv i/ii organs are being underutilized. moreover, our prior analysis of unos data shows that these life saving organs are shared more nationally than loco-regionally which is associated with a poorer outcome. increased knowledge of successful htlv (+) donation and the centers that are willing to utilize these organs in the appropriate setting will help expand the donor pool and decrease mortality on the waiting list. increasing traditional two-drug chronic immunosuppression (is) used in organ transplantation (tx) is associated with development of ebv-driven complications because of impairment of anti-viral cd + t cell surveillance. since the long-term impact of alemtuzumab preconditioning combined with tacrolimus monotherapy on ebv immunity after tx has not been studied, here we aim to analyze the frequency and function of peripheral blood ebv-specific cd + t cells. thirteen ebv + stable kidney transplant (ktx) recipients and ebv + healthy controls were recruited to this cross-sectional study. all patients received alemtuzumab preconditioning, followed by tacrolimus monotherapy. blood samples were collected at least year post-tx to allow immune reconstitution. the ebv-specific cd + t cell phenotype and function were screened by flow cytometry and ifng elispot assay. hla-a restricted ebv-lytic (bmlf ) and latent (lmp a) peptides were used to generate tetramer (tmr) probes, and for functional screening in elispot. circulating cd + t cells from ktx patients had recovered by year, and were comparable to those of healthy controls ( . %± . vs % ± . , p= . ). moreover, the memory distribution and the frequency of ebv-specific cd + t cells detected in patients and controls (bmlf -specific: . %± . vs . %± . , p= . , and lmp specific: . %± . vs . %± . p= . ) were similar. in contrast, the frequency of functional type- (ifn-g producing) ebv-specific cd + t cells was significantly lower in ktx patients than in healthy controls (bmlf : ± spots/ cd t cells vs ± p= . , and lmp : ± vs ± p= . ). accordingly, on average, only - % of circulating ebv-specific cd + t cells from ktx patients produced ifn-g, while - % of effector cells were functional in healthy controls. addition of il- ( iu/ml) during the elispot assay reversed the hypo-responsiveness of type- (ifn-g) ebv-specific cd + t in patients (range - fold increase), suggesting that these effector cells were anergic. these results support the notion that alemtuzumab-induced lymphocyte depletion followed by tacrolimus monotherapy renders ebv-specific cd + t cells anergic in vivo, a state that can be readily reversed by cytokines such as il- , which are commonly released during immune activation. background: the epidemiology of the transmission of cytomegalovirus (cmv) from organ donors to recipients is not completely understood. we studied donor to recipient transmission patterns by analyzing viral genomic variants through the use of cmv glycoprotein b (gb) genotyping by real-time pcr. polymorphisms in gb ul allow discrimination of distinct genomic variants (gb - ). methods: organ transplant recipient pairs or triplets were included in the study if: a) they had cmv infection, b) they received an organ from a cmv seropositive donor, and c) there was at least one other recipient from the same donor that also developed cmv infection. genotyping (gb - ) was performed by quantitative real-time pcr on stored blood samples. clinical charts were reviewed to evaluate the clinical characteristics and outcome of cmv infection. results: of the cmv seropositive donors screened, were multiple organ donors for which or more of their recipients developed cmv infection. the total number of recipients from these donors was (median of recipients per donor). of these recipients, ( %) had cmv infection ( recipient pairs and recipient triplets). the prevalence of genotypes was gb (n= ; %), gb (n= ; %), gb (n= ; %), gb (n= ). mixed infection with two concurrent genotypes was present in patients ( %). overall concordance between cmv gb genotype in recipient pairs was . % ( / ). if both recipients were cmv seronegative (d+/r-) the gb concordance in recipients was % ( / pairs). gb concordance was % ( / pairs) if one of the recipients was seronegative and the other seropositive. concordance was % ( / pair) if both recipients were seropositive. concordance between genotypes was seen in / ( %) recipients triplets. in seropositive recipients with cmv viremia, the origin of the cmv strain was thought to be donor derived in / ( %) and of reactivation of the recipients own virus in / ( %) of the cases. no difference in clinical outcome or organ tropism was seen between genotypes. based on an analysis of strain concordance within recipients from common donors, transmission patterns of cmv can be assessed. in d+/r+ transplant patients, donor strain superinfection accounts for the approximately two-thirds of cmv infection. backgroud: although map kinases have been implicated in the pathophysiology of liver iri, their functional significance in the mechanism of tlr mediated pro-inflammatory immune regulation, remains to be elucidated. methods: map kinase activation in a murine model of liver warm iri ( min. ischemia, h reperfusion) was determined by western blots. chemical inhibitors of erk (u , µm in vitro or mg/kg in vivo), jnk (sp , µm or mg/kg), and p (sb , µm, mg/ kg) map kinases were utilized in vitro in primary bm-derived macrophage cultures stimulated with lps ( ng/ml); or in vivo in liver pro-inflammatory immune responses induced by lps ( µg/mouse, i.p.) or iri. results: erk and jnk, but not p , map kinase activation were readily detected in liver iri. in primary macrophage cultures, lps induced pro-and anti-inflammatory genes, including tnf-α, il- β, il- , il- , inos and cxcl . erk inhibitor mainly suppressed il- β and il- ( % and % resp), whereas jnk inhibitor suppressed the majority of genes. in lps-induced liver inflammation, erk inhibitor suppressed il- , il- β, inos and il- by > %, but failed to affect tnf-α/cxcl . jnk inhibitor, on the other hand, preferentially inhibited pro-inflammatory genes, but marginaly affected il- (< %). and produced comparable suppression of pro-/anti-inflammatory genes (figure ). interestingly, tnf-α was the least responsive gene subjected to map kinase regulation. conclusion: erk and jnk map kinase activation: / are required for tlr activationinduced pro-inflammatory gene induction; / play critical role in the development of ir-mediated liver immune response/tissue injury. background: the jak/stat signaling is one of the major pathways for cytokine signal transduction. the signal transducer and activator of transcription (stat ) is mainly activated by ifn-α/ß/ifn-γ. the activation of stat by ifn-γ has been implicated in hepatic inflammation. we have shown that activation of toll-like receptor (tlr) complex initiates pro-inflammatory response leading to liver ischemia/reperfusion abstracts injury (iri). indeed, tlr signaling in vitro activates stat , which in turn triggers production of type- ifn-dependent cxcl (ip- ). this study was designed to analyze the cross-talk between stat and the map kinase (erk) downstream of jak/ stat signaling pathways. methods & results: we used a mouse liver model of partial warm ischemia ( min), followed by reperfusion ( h) . first, we employed stat ko (n= ) and control wt (n= ) mice. the hepatocellular damage, as measured by salt levels (iu/l), was significantly decreased in / stat ko mice (p< . ); the remaining / of stat ko showed salt levels comparable with wt. hence, we distinguished two groups of stat "protected" vs. "nonprotected" ko recipients. histology revealed minimal sinusoidal congestion without edema/vacuolization or necrosis in stat ko "protected" group. the induction of mrna coding for tnfα/ il- was higher in stat ko "nonprotected" livers. the expression of cxcl , the product of stat activation downstream of tlr in type i ifn pathway, was profoundly and selectively depressed in livers from stat ko "protected" mice, as compared to iri susceptible livers. similarly, western blot-assisted phospho-erk expression was up regulated selectively in the stat ko "protected" group. in the second series, c bl/ mice were treated h prior to liver ischemic insult with jak- inhibitor (tyrphostin ag ; mg/kg, i.p.; n= ), or vehicle (n= ). the hepatocellular damage, as measured by salt levels (iu/l), and histology was significantly decreased in ag group, as compared with controls (mean = vs. ; p< . ). the disruption of jak/stat signaling by inhibiting jak uniformly ameliorates the inflammatory immune response in liver iri. however, the blockage of stat alone is insufficient to reproducibly exert cytoprotection. as jak is upstream of stat as well as upstream of map kinase (erk), this study highlights the role of both signaling pathways in hepatic iri. purpose: tlr is required for maximal ischemic injury of the heart, liver, lung, and kidney. to better understand the mechanisms of tlr action, we investigated a murine model of ischemic kidney disease and examined endothelial tlr expression. methods: . animal ischemia reperfusion injury(iri): the right kidney of wildtype(wt) c bl/ , or tlr -deficient(ko) c bl/ scn mice was removed. the left pedicle was clamped for min, followed by hr reperfusion. sham animals were controls. . bone-marrow chimera: four groups of bm chimeras were created: wt→wt; ko→wt; wt→ko; ko→ko ( recipients/grp). wks later, chimerism was confirmed by tail and blood genotyping, and mice subjected to renal iri. . tlr mrna detected by dig-labeled antisense; tlr on endothelium by anti-tlr and anti-cd . . total genome mrna expression on ischemic vs. sham wt mice, ischemic vs. sham ko mice( mice/grp) determined using affymetrix mouse genome . genechips followed by genesifter analysis. quantitative real-time rt-pcr confirmed candidate genes. . ms endothelial cells were treated with h o ( um) for min, cultured for hr and then expression of tlr and endothelial genes determined. results: tlr -deficient mice had less renal injury as assessed by pathology and function. radiation chimeras showed that radioresistant parenchymal cells and radiosensitive leukocytes were both required for maximal injury. immunohistology and in situ hybridization identified endothelia in the outer medulla as a major tlr expressing cell type at hr post-reperfusion. genechip analysis revealed a panel of cytokine, chemokines, proinflammatory and cell-cycle related genes that were differentially expressed on iri versus sham kidneys. real-time rt-pcr confirmed that the following pro-inflammatory endothelial genes increased after ischemia in wildtype but not tlr ko mice: tlr , pentraxin related gene(ptx ), and endothelial cell-specific molecule (esm ). real-time rt-pcr showed that in vitro h o treatment of endothelial cells induced expression of tlr ( . -fold), ptx ( . -fold), and esm ( -fold). we found that endothelia in the outer medulla increase their expression of tlr after ischemia, and that the endothelial genes ptx and esm increase only in wt ischemic kidneys. we also found that h o , which mimics reactive oxygen species generated during iri, directly increases these same endothelial genes in vitro. nkg d is an activating receptor expressed on nk cells and cd + t cells. ligands for nkg d including rae- , mult- and h in mouse, may be upregulated by tissues in response to stress. a study in mouse macrophages described upregulation of rae- in response to stimulation through tlr by lps. we have shown that tlr mediates kidney ischemia reperfusion injury (iri) and also observed rae- upregulation in iri kidneys. we now determined whether: ) kidney iri could induce the expression of nkg d ligands: ) expression of nkg d ligands is tlr dependent; ). bone marrow (bm) derived cells or parenchymal kidney cells express nkg d ligands. methods. kidney-ischemia was induced in tlr -/-, myd -/and wt mice for min. blood and tissue were harvested at days , and . primary cultures of mouse tubular cells (tecs) were also subjected to ischaemia (mineral oil overlay for hr) or tlr activation (lps stimulation). bm chimeric mice were generated by transplanting bm into irradiated recipient mice before iri was induced. results. rae- mrna level in iri kidney was increased from day to day , peaking at day compared to sham operated kidney ( - fold increase, p < . ) measured by real time pcr. rae- protein was detected in renal tubular cells from ischemic kidney but not from shamoperated control by flow cytometry. mult- mrna expression was also increased from day to day ( - fold increase, p < . ). both rae- and mult- mrna levels were reduced in tlr -/and myd -/-iri kidneys ( - fold reduction) versus wt controls (p < . ). tlr -/and myd -/primary cultured tecs submitted to iri in vitro also showed less rae and mult- mrna expression than wt controls (p < . ). lps stimulated rae- and mult- expression in wt but not in tlr -/-tecs. tlr -/mice bearing wt hemopoietic cells had significantly lower kidney rae- and mult- mrna expression after iri versus wt mice with tlr -/-bm (p < . ). conclusion. kidney iri causes rae- and mult- expression and kidney parenchymal cells are the dominant source. tecs can be stimulated to express rae- and mult- by ischemia or lps via the tlr pathway in vitro and deficiencies in this pathway provide protection against iri and rae- and mult- expression in vitro and in vivo. thus, kidney iri causes upregulation of nkg d ligands by parenchymal kidney cells via tlr . background: intestinal ischemia/reperfusion injury (iri) is a major clinical problem. although toll-like receptor (tlr ) has been implicated as a potential link between the innate and adaptive immunity, little is known on its role in intestinal iri. our preliminary research in intestinal iri has shown that, compared to sham controls, wt mice had decreased survival, worse tissue injury/apoptosis, increased pmn infiltration, increased cd + cell infiltration, and increased production of tlr , chemokines, and adhesion molecules. here we used tlr ko mice to further investigate the role of tlr in intestinal iri and its effects on cytokine/chemokine programs and apoptotic signaling. methods: c bl wt and tlr ko mice underwent min of total jejunoileal warm iri by clamping of the sma. separate survival and analysis groups were performed. intestinal tissue was harvested at h and h. tissue analysis included histopathology, cd immunostaining, myeloperoxidase (mpo) activity, rt-pcr for chemokines/ cytokines, and western blots for apoptotic and ho- protein expression. results: tlr ko had superior survival compared to wt ( % vs. %, p< . ). on histopathology tlr ko had near normal-appearing villous architecture, while in contrast, wt showed mucosal erosions and villous congestion/hemorrhage. tlr ko had reduced cd + cell infiltration as compared to wt ( . ± . vs. . ± . per hpf at h, p< . ; and . ± . vs. . ± . per hpf at h, p< . ). early mpo activity was also reduced in tlr ko ( . ± . vs. . ± . u/g at h, p< . ). rt-pcr analysis demonstrated decreased production of mrna for ip- , mcp- , rantes, and ifn-γ and increased production of il- in tlr ko. there was decreased protein expression of caspase- and increased expression of bcl- and ho- in tlr ko mice. conclusion: the genetic absence of tlr exerts protection against intestinal iri, demonstrating for the first time that tlr is required for intestinal iri. the absence of tlr signaling reduces iri through reduced neutrophil and t cell chemotaxis, and up-regulation of protective molecules. these results support data that tlr is a mechanistic link between the innate and adaptive immunity, implicating tlr as a potential therapeutic target for the prevention of intestinal iri. it is well known that liver steatosis increases hepatic vulnerability to ischemia/ reperfusion (i/r) injury as part of the transplantation process. endotoxin (lps) is thought to be a major contributing factor to the pathogensis of i/r. during portal occlusion, lps is translocated across the mesenteric tissue barrier into the portal circulation, and is delivered as a large bolus to the liver at the point of reperfusion. at this time, lps is mainly recognized by toll-like receptor (tlr ). this leads to downstream signaling and the production of proinflammatory products that ultimately lead to cellular inflammation, necrosis, and apoptosis. it is well known that steatotic livers are highly sensitive to endotoxin as compared to their lean counterparts post-i/r, and we have previously seen that monoclonal antibody blockade of endotoxin dramatically improves animal survival after i/r. therefore, we propose the novel hypothesis that tlr signaling is a major contributor to cellular damage after steatotic hepatic i/r. to test this hypothesis, we subjected male -week-old c bl/ j (control) or c bl/ scn (tlr deficient, tlr ko) mice to a high-fat diet (hfd) for four weeks. then, we subjected the animals to minutes of total hepatic ischemia and or hours of reperfusion. there was a dramatic improvement in animal survival in the hfd tlr ko animals versus control hfd animals at hours ( % vs. % in control hfd animals, p< . ). there was significantly more liver necrosis (as measured by a grading scale from - ) in the control hfd animals as compared to the tlr ko hfd animals ( . ± . in control vs. . ± . in tlr ko, p< . ). in addition, we see significant increases in the message level of the proinflammatory cytokines il- , il- , and ifn-γ at one hour in the control hfd animals that is abrogated dramatically in the tlr ko hfd animals. we do not see these dramatic changes in the control animals fed a normal diet. despite the significant increases in inflammation in the control hfd animals versus the tlr ko hfd and normal diet control animals, we do not see changes in the tlr message level or endotoxin boluses, implying an increased sensitivity in the absence of an increased number of receptors. tlr is a critical molecule in the pathogenesis of steatotic liver ischemia/reperfusion, and represents a potential therapeutic target for expansion of the donor pool. the background: neutrophils are considered crucial effector cells in the pathophysiology of organ ischemia and reperfusion injury (iri). particularly, neutrophil elastase (ne) accounts for a substantial portion of the neutrophil function. this study was designed to explore the role of, and mechanism by which ne exerts its function in a mouse model of liver warm iri. methods: partial warm ischemia was produced in the left and middle hepatic lobes of c bl/ mice for min, followed by - h of reperfusion. mice were treated with ne inhibitor (nei; mg/kg p.o.; gw a; n= ) or control (n= ) at min prior to the ischemia insult. after h or h of reperfusion, sast/salt levels and intrahepatic neutrophil accumulation (myeloperoxidase [mpo] activity) were assessed. the pro-inflammatory cytokine (tnf-α, il- ), chemokine (cxcl- , cxcl- , ip- ) and toll-like receptor (tlr) gene expression profiles were screened by rt-pcr. liver samples were collected for histological grading, and detection of neutrophil infiltration by the naphtol as-d chloroacetate esterase stains. results: nei treatment significantly reduced sast/salt levels, as compared with controls ( ± vs ± ; p< . / ± vs ± ; p< . at h, and ± / ± vs ± / ± ; p< . at h). the expression of pro-inflammatory cytokines, and chemokines was significantly reduced in the nei treatment group (tnf-α in h; p< . , il- in h and h; p< . and p< . , cxcl- in h; p< . , cxcl- in h and h; p< . and p< . , ip- in h; p< . ). the mpo activity (u/g) was also significantly reduced following nei treatment ( . ± . vs . ± . ; p< . ). tlr expression was selectively diminished in nei pretreated livers ( h; p< . ). histological examination of liver sections has revealed that unlike in controls, nei treatment markedly reduced edema, diminished centrilobular ballooning/sinusoidal congestion, ameliorated hepatocellular necrosis, and decreased local neutrophil infiltration. conclusion: the inhibition of ne ameliorated hepatocellular damage, reduced local inflammatory responses, and neutrophil activity/infiltration in a stringent mouse liver model of warm iri. interestingly, it also downregulated the innate tlr signaling. this study documents the previously unrecognized ne -tlr cross talk, and implies neutrophil elastase in the signal transduction pathway instrumental for liver iri. lymphocyte lymphocytes are involved in the early pathogenesis of ischemia-reperfusion injury (iri) in kidney; however, their role during healing is unknown. this has direct clinical consequence since lymphocyte-targeting agents are currently administered to prevent rejection during recovery from iri in renal transplants. c bl/ mice underwent unilateral clamping of renal pedicle for min, followed by reperfusion, and were sacrificed at day . mice were treated with saline (c), methylprednisolone (pred) or mycophenolate mofetil (mmf) i.p. daily from day until sacrifice (n= /group). lymphocytes were isolated from the kidneys, counted and stained with monoclonal antibodies. kidney damage (% damaged tubules) and proliferation (ki assay) were assessed. flow cytometry analysis demonstrated increased numbers of tcrβ + cd + and tcrβ + cd + t and tcrβ -nk . + nk, but not cd + b cells at day in the ischemic (ir) kidneys compared to contralateral. regulatory t cells, tcrβ + cd + cd + foxp + , and t cell subsets tcrβ + cd + cd + and tcrβ + nk . + also increased. moderate tubular damage in cortex, severe injury in outer medulla and increased proliferation in both compartments characterized the repair phase. pred improved histological damage in ir kidneys, while mmf worsened it. proliferative index correlated with histology in outer medulla. pred reduced the total counts and activation of tcrβ + cd + and tcrβ + cd + t cells in ir kidneys, and increased the percentage of tcrβ + cd + cd + among total tcrβ + cd + t cells. mmf reduced all lymphocyte subsets, decreased the percentage of tcrβ + cd + cd + foxp + among total tcrβ + cd + t cells, and lowered il- tissue levels. il- and platelet derived growth factor-bb protein levels were also decreased in ir kidneys from mmf-treated mice. in conclusion, specific trafficking and phenotypic changes of kidney-infiltrating lymphocytes occur during recovery from renal iri, and lymphocyte-targeting agents, pred and mmf, alter tubular cell structure, proliferation, and inflammatory response in the repair phase. background: ho- plays an important cytoprotective role in a variety of organ injury models. we have shown that ho- exhibits potent cytoprotective effects against liver i/r injury. this study explores the function and mechanism of ho- in liver i/r injury by using sirna that suppress ho- expression both in vitro and in vivo. methods: using a partial liver warm ischemia model, c bl/ wide-type (wt) mice (n= /gr) were injected with ho- sirna/nonspecific control sirna ( mg/kg, i.v. at day - ) or ad-ho- /ad-β-gal ( . x pfu, i.v. at day - ). sham control wt underwent the same procedures, but without vascular occlusion. mice were sacrificed at h of reperfusion; liver tissue and blood samples were collected for future analysis. in in vitro studies, ypen- endothelium cells were transfected with ho- sirna ( nm) or ad-ho- / ad-β-gal. results: ho- sirna treated mice showed significantly increased sgot levels (iu/l), as compared with nonspecific control sirna or ad-ho- ( ± vs. ± and . ± , respectively; p< . ). these correlated with histologic suzuki's grading of liver i/r injury, with ho- sirna showing significant edema, sinusoidal congestion/cytoplasmic vacuolization, and severe hepatocellular necrosis; nonspecific control sirna showed moderate edema, sinusoidal congestion/cytoplasmic vacuolization. in contrast, ad-ho- revealed only minimal sinusoidal congestion without edema or necrosis. ho- sirna significantly increased local neutrophil accumulation and caspase- activity, and increased the frequency of apoptotic cells ( . ± . vs. . ± . and . ± . , respectively; p< . ), as compared with nonspecific control sirna or ad-ho- . both ypen- endothelium cells and wt mice treated with ho- sirna revealed markedly increased caspase- activity and reduced ho- expression. in contrast, ad-ho- significantly decreased caspase- activity and increased ho- and anti-apoptotic bcl- /bcl-xl expression. conclusion: this study provides evidence that ho- exerts cytoprotection against i/r injury by regulating liver apoptosis and inhibiting caspase- activation pathway. organ specific sirna is not only a powerful tool to study local gene function, but it may also provide novel therapeutic application in transplant recipients. islet cell transplantation has recently emerged as one the most promising therapeutic approaches for diabetic patients to improve glycometabolic control. one major problem of the procedure is the requirement of an immunosuppression protocol capable of counteract both auto and allo-immune response. recent data suggest that anti-thymoglobulin (atg) can halt efficiently the mounting of an alloresponse and the recurrence of autoimmunity in nod mice by expanding antigen specific t-regulatory cells. we retrospectively reviewed our casuistry type diabetic kidney-transplanted patients who underwent islet transplantation using an immunosuppressive protocol based on atg or daclizumab (as induction treatment) plus cyclosporine and mmf as maintenance therapy. patients underwent islet after kidney transplantation in our center. thirty-four patients received a time course of atg as induction ( mg per day for - days), (number of islet infused= , ± , ), and patients received daclizumab at induction ( mg/kg every weeks for weeks); (number of islets= , ± , ). no major adverse events were recorded in our center; no malignancies or infections outbreaks were evident. patients in the atg induction group showed a better islet survival rate compared to daclizumab (p= . ), according to c-peptide> ng/ml. a sustained and prolonged c-peptide secretion was evident in the atg group; while in the daclizumab group only patient was functioning at year. interestingly, in the atg, which reached a longer follow-up, we cannot observe a loss of beta cell mass according to our metabolic test, suggesting the preservation of islet mass. in conclusion, atg can provide a good protection towards both allo and auto immune response. the next step will be to use atg in a calcineurin free protocol, allowing a better expansion of t-regs. introduction: despite consistent achievement of insulin-independence, recent data indicate that the long term success of islets transplants using the edmonton protocol is < % at years. the cause of the nearly universal late islet allograft failure remains unknown but hypotheses include: allo or autoimmune injury, marginal mass exhaustion, hepatic site related dysfunction, and immunosuppression toxicity. we examined the series of islet transplants performed at our institution and noted marked differences in the outcome and complications in ia and iak groups. our results may provide insight as to the cause of chronic islet loss. methods: thirty-one islet infusions were administered to ia (n= ) and iak (n= ) type- diabetics between / - / . ia and iak had similar demographics and transplanted islet mass ( , vs , ieq/kg). ia received edmonton like immunosuppression with zenapax induction and cni/srl, whereas iak patients received zenapax and: cni/mmf/pred ( ), cni/mmf ( ), cni/srl ( )). results: insulin-independence was achieved in all but patients who completed therapy ( others withdrew). compared with ia, iak exhibited better glycemic control ( -month mean hba c . vs . , stimulated c-peptide . vs . ), and improved islet survival; all ia eventually failed and only / were insulin free for > -years, whereas only / iak grafts have failed with exhibiting continued robust function at > ,> ,> , and > months with / fully insulin independent. in addition, all ia patients demonstrated immune sensitization post graft failure versus / iak. all ia developed mouth ulcers versus only / iak. conclusions: ia and iak exhibit striking differences in outcome and complications. the absence of mouth ulcers and lack of sensitization in iak may relate to steroid use and continued immunosuppression for the kidney graft, respectively. the superior outcome of the iak cohort may be a result of differences between the two groups including the use of maintenance steroids, prior exposure to thymo or the chronically immunosuppressed state of the iak recipient. perhaps the most interesting correlation with outcome is the absence of the anti-proliferative agent sirolimus in the iak group. our results provide clues to the cause of chronic islet transplant failure and may lead to novel approaches to avoid it. islet background: although islet transplantation has become an option for treatment of type diabetes, all currently used immunosuppressive protocols have significant renal and islet toxicity. we describe a novel immunosuppressive protocol using sirolimus and the anti-lfa antibody efalizumab that permits prolonged islet allograft survival without the need for steroids or calcineurin inhibitors (ci). methods: between february and august , consecutive type diabetic patients with hypoglycemic unawareness and normal renal function received allogeneic pancreatic islet transplants. induction immunosuppression consisted of doses of thymoglobulin given on pre-transplant days - and - , efalizumab ( mg/kg sq/week starting on d - ), and sirolimus. maintenance immunosuppression consisted of sirolimus and efalizumab. results: all patients achieved insulin independence after single islet infusions (mean ieq/kg= , ). three of remain insulin independent or more months after transplant (table ) . patient resumed low dose insulin (approximately % of original dose) weeks after transplant and is awaiting a second islet infusion. her blood glucose control is markedly improved and she has not experienced any hypoglycemic episodes. all patients show persistent c-peptide secretion and have stable renal function. side effects due to efalizumab were limited to transient irritation at the injection site. conclusions: thymoglobulin induction followed by sirolimus and efalizumab maintenance is well tolerated and allows prolonged islet allograft survival. this protocol is the first ci/steroid free islet regimen resulting in insulin independence with a single donor islet infusion. by eliminating ci, this protocol minimizes renal and islet toxicity and may thus improve long-term islet survival and function. long . clinical and metabolic profiles were assessed every months for months. results: si-exn group was on this drug for median time of days pre-si. both groups were similar except for duration from post-completion to graft dysfunction ( ± vs ± in si-exn and si-c group respectively, p< . ) and duration of graft dysfunction before si ( ± vs ± , p= . ). si-c and si-exn groups received mean of ± and ± ieq/kg, respectively (ns). only / of si-c patients achieved insulin independence for , and > days after si. all subjects in si-exn group achieved insulin independence for more than , , , days. at months insulin independence was % in si-c and % in si-exn group. comparing pre and post-si, si-exn group had significantly lower a c at - months and lower auc glucagon at and months (p< . ). auc c-peptide in si-exn group was significantly higher than si-c at and months. intravenous glucose tolerance test showed significantly increased acute insulin responses to glucose at - months in si-exn and at and months in si-c group. si-exn group had more acute c-peptide response to glucose than si-c at and month (p< . ). acute exenatide administration during intravenous glucose tolerance test at month in si-exn revealed significantly increased acute insulin and c-peptide response to glucose which indicates improved first phase insulin release. conclusion: supplemental islet infusions under exenatide lead to insulin independence, restore first phase insulin secretion and result in long term insulin independence. exenatide this prospective phase / trial aimed to demonstrate safety and reproducibility of allogeneic islet transplantation (tx) in type diabetic (t dm) patients and implement a strategy to achieve and maintain insulin-independence with minimal islets. ten c-peptide negative t dm subjects with hypoglycemic unawareness received - intraportal allogeneic islet tx. four subjects (group ) received the edmonton immunosuppression regimen (daclizumab, sirolimus, tacrolimus). the next subjects (group ) received etanercept, exenatide and the edmonton regimen. we followed all subjects for months after the first tx. the primary efficacy end point was insulin independence. secondary endpoints were hba c, fructosamine, ogtt, mixed meal test, glucagon stimulation test, ivgtt and hypoglycemia. to study the effect of exenatide, we compared frequently sampled ivgtt, c-peptide, proinsulin, amylin and glucagon with and without exenatide. two self-limiting bleeds occurred in infusions. all subjects became insulin independent. group received a mean total number of islets (ein) of , , ± , in (n= ) or (n= ) tx, whereas group became insulin independent after tx ( , ± , ein, p= . ). all group subjects remained insulin free through the -month follow-up. two group subjects resumed insulin: one after immunosuppression reduction during an infectious complication, the other with severe gastroparesis and exenatide intolerance. hba c reached normal range in both groups ( . ± . at baseline to . ± . after - tx in group vs. . ± . to . ± . after tx in group ). baseline hba c was significantly higher in group than group (p= . ). pre-and post-tx hypo scores were . ± . and in group vs . ± . and . ± . in group . glucagon levels decreased significantly in all subjects. in group , the decrease in glucagon levels after challenge tests with and without exenatide was . fold more significant after exenatide in all subjects ( background istx has been investigated as treatment for type dm. however, the hope this approach would result in long-term freedom from exogenous insulin has failed in practice. techniques for isolating islets have advanced and with availability of new is agents, strategies can now be developed specifically for istx that will provide greater immunologic protection w/o diabetogenic side effects. rejection/ vascularization still remain major limitations for success of istx. we hypothesize that bm is an accessible, immunologic privileged space with natural well-developed vasculature and may be a suitable site for istx. method wistar rats were used as donors/ recipients. dm was induced by iv-streptozocin. rats who had morning glc levels > mg/dl on two separate occasions were used as recipients. ptx was performed as normal rodent standard. islets were isolated from pancreas by distending pancreatic duct with liberase. islets were separated on a discontinuous histopaque density gradient, further purified, counted, divided into aliquots transplanted into different sites (liver, bm). bw, glc and c-pep were measured in all groups before/after tx. background: in february , the islet community was notified of a possible bovine product contamination in the collagenase enzyme (liberase hi) used for human islet isolations. to eliminate the potential hazard of bovine spongiform encephalopathy, we successfully adapted our human islet processing procedure to utilize a different gmp collagenase and neutral protease (nordmark/serva). here we describe what we consider the most important factors for achieving reproducible and clinically useable islet isolations. methods/results: a standard isolation protocol involving controlled enzymatic digestion followed by density gradient purification was used. seventeen donor pancreata were processed and ten were ultimately used for clinical transplantation. eight of these successful isolations were performed using the nordmark/serva enzymes (table ) . the following factors were identified as being important for ensuring successful islet yields: ) donor age and size: male donors - years old who were tall (> cm) and heavy (> kg) conclusions: incorporation of several important modifications into our existing islet isolation protocol has allowed us to routinely obtain high quality islet isolations using an alternative, bovine product-free gmp enzyme. (n= )], and in pts immuno was cni-free. tac-treated pts were younger, more sensitized and more frequently re-kt. dgf was more frequent in pts receiving cni-free immuno. as a group, these pts were older, more frequently received a kt from a donor after cardiac death and less frequently from a living donor. acute cellular rejection (acr) was diagnosed in pts ( . %), occurred before day th (e-acr), and after this date (l-acr). c d-positive amr was diagnosed in pts ( . %), of which were early (e-amr) and were late episodes (l-amr rates of acute rejection (ar) and background: an increasing number of hs patients are being transplanted using desensitization protocols. these patients are considered high risk for ar, particularly antibody mediated rejection (amr). here we examined our ar rates and treatment outcomes for our hs kidney transplant (kt) recipients using our most current desensitization strategies. methods: between june (when rituximab was introduced to our desensitization and treatment protocols) to july , hs kt patients were transplanted using combinations of high-dose ivig, rituximab, and plasmapheresis (pp) for desensitization. we examined the overall ar, c d-cell-mediated (cmr), and c d+amr rates. amr episodes were treated with steroids, high-dose ivig, and rituximab. refractory and rapidly progressive amr was treated with pp. treatment outcomes and differences in ar rates between deceased (dd) and living donors (ld) was examined. recent reports suggest that treatment with the monoclonal anti-cd antibody, rituximab (rtx) may improve renal graft survival in antibody mediated rejection (amr); however optimal dosing for this indication is unknown. we examined the efficacy of a single low dose ( mg) of rtx for treatment of refractory amr in order to limit significant infective complications associated with conventional dosing regimens ( mg/m ). rtx was used in seven consecutive patients who had refractory amr as judged by ongoing biopsy evidence of amr after weeks of standard therapy consisting of pulse methylprednisolone and plasma exchange with low dose ivig ( mg/kg) (pe/ivig). all patients received tacrolimus and mycophenolate mofetil. amr was defined as ) characteristic histology on biopsy (banff criteria), ) graft dysfunction and ) presence of a donor specific anti-hla antibody (dsab). b-cell counts (cd ) and serum creatinine (scr) were monitored. pe/ivig was ceased in all cases after rtx dosing. the average follow-up since rtx dosing is . months (range . - . mths). all patients still have functioning grafts ( % month graft and patient survival), with current mean scr levels ( ± µmol/l) significantly lower than mean peak rejection levels ( ± µmol/l) p= . . cd counts fell to zero and remained < x /l for > months in all patients. dsabs remain detectable by luminex flow beads in all patients despite stabilization of scr. two of patients developed an infective complication post rtx dosing. one patient developed bacterial pneumonia requiring hospital admission whilst a second patient developed cmv viraemia and later bk nephropathy which has not led to significant graft dysfunction. hence, infectious complications are far less than those reported for multiple standard dose regimens in similar patient groups. large clinical trials are required to confirm the efficacy of rtx in treating amr as well as optimal dosing. standard dosing is based on oncology treatment regimens which are likely to be excessive for amr in patients already markedly immunosuppressed. our data suggests single low-dose rtx for refractory amr results in excellent patient and graft survival and leads to low rates of serious infective complications in the short-term. renal the demographic and clinical data were similar between +cxm and negative cxm groups. the rejection rate was significantly higher and the length of stay was significantly longer in +cxm group as shown in the table. the ra survival rates were %, % and % lower at , and years post transplant respectively among + cxm recipients. however, this did not reach significance mostly due to small sample size (p= . ). the inferior ra outcome is seen during the initial few years after transplantation that disappears after years. in clkt, pre-transplant +cxm can result in higher ra rejection rate and longer length of stay in hospital. la may not always confer immunological protection to ra in + cxm clkt and its true burden may be under recognized since cxm is not routinely performed in all clkt. study of antibody specificities or la volume to determine the effect of +cxm on ra outcome is essential. skpt in patients with positive cdc b-cell and/or flow cytometry crossmatch is associated with high amr rate despite low dose ivig and r-atg/alemtuzumab induction. pancreas graft survival is inferior in patients with positive crossmatch while kidney graft and patient survival are similar to that of negative crossmatch recipients. majority of amr can be reversed with treatment but further long-term follow-up is needed to determine the impact on graft survival. ten the first european phase iii trial with tacrolimus in the early ´s clearly showed advantages for tacrolimus in terms of acute rejection (ar) vs the original cyclosporin formulation. however, no advantages were seen in survival rates. the present investigator-initiated, observational follow-up study collected data on patients included in the original cohort of patients who participated in this large study and who were randomised to a triple immunosuppressive regimen consisting of tacrolimus, azathioprine and steroids (tac/aza/ster, n= ) or cyclosporine, aza and steroids (csa/aza/ster, n= ). efficacy and safety parameters assessed at follow-up included: acute rejection; patient and graft survival; renal function, vital signs, basic lab results and immunosuppressive regimen for the patients years after completion of the original study. results: currently, data are available from % of the patients. all assessments were conducted following the intent-to-treat principles. more patients in the tac than in the csa group remained on the randomised treatment. while kaplan-meier (k-m) estimates for patient survival at year show comparable ( % tac vs %csa) results, k-m estimates for graft survival demonstrate an advantage for the tacrolimus cohort ( % tac vs % csa). graft half-life estimates (gjertson and terasaki method) yielded overall results of . years (tac) and . years (cs). in both treatment groups, ar was associated with inferior long-term results. for patients with ar, half-life estimates were . and . years for tac and csa, respectively, while in patients without ar half-lives were . (tac) and . (cs) years. mean serum creatinine after years was significantly lower in the tac cohort vs the csa group ( . mg/dl tac vs . mg/ dl csa, p< . ). mean glomerular filtration rates (mdrd estimate) were . ml/ min in tac and . ml/min in cs. after ten years of follow-up, the mean (c- ) levels were . mg/ml (tac) and mg/ml (cs). conclusion: analysis of this long term follow-up of a large study confirms the benefits of a tacrolimus-based therapy. it also confirms the concept that freedom from early acute rejection is associated with superior long term results in renal fuction. therefore, long term renal allograft function is remarkably good in tac patients. cyclophosphamide a novel therapy for ivig/plex-resistant antibody-mediated rejection. (c)). moreover subgroup analyses within the different groups were made to identify potential differences. groups were analyzed for survival, graft rejection and graftvasculopathy (cad). kaplan-meier analysis was used and log-rank test was performed to detect differences. results: a total of transplants ( . %) were blood group compatible. the majority (n= ) were a transplants ( %) followed by b (n= ; %), aab (n= ; %), bab (n= ; %) and ab (n= ; %). overall survival comparison showed no significant difference in long-term survival ( -year) recent data has shown the utility of urinary biomarkers to predict delayed graft function early following renal transplantation, but their ability to predict longer-term allograft function is less clear. we evaluated whether urinary biomarkers measured in the early post-transplant period would predict allograft function at and months after renal transplantation. urinary biomarkers including n-acetyl-β-d-glucosaminidase (nag), kidney injury molecule- (kim- ) and matrix metalloproteinase- (mmp- ) were measured in patients at hours , , , and days and following renal transplantation. glomerular filtration rate (gfr) at and months were calculated using the mdrd equation. all patients had functional allografts at months and patients lost allografts after months. levels of individual biomarkers at different post-transplant time points were correlated with and month gfr using spearman's correlation (rho) and are shown in the urinary nag levels at post-transplant hours , , and days and showed significant negative correlation with -month gfr. nag levels at hour and days and maintained the significant negative correlation with -month gfr. urinary kim- levels at the hour point showed significant negative correlation with -month gfr and kim- levels at hour and day displayed significant negative correlation with -month gfr. urinary mmp- levels at no time points had significant correlation with either -month or -month gfr. urinary biomarkers particularly nag shows promise as a tool in the early prediction of longer-term allograft function following renal transplantation. in kidney disease chemokines are involved in the recruitment of leukocytes causing kidney damage and progression to endstage renal failure. similar mechanisms are proposed for chronic allograft failure in renal transplant recipients. the chemokine attracted leukocytes produce proinflammatory and profibrotic cytokines contributing to fibroblast proliferation, matrix production and tubular atrophy. the role of chemokines in the acute post-ischemic tubular necrosis early after renal transplantation and their impact on long term allograft outcome has not been investigated yet. methods patients ( m, f, mean age . yrs) with dgf (with a median number of . dialysis sessions) developed biopsy proven acute tubular necrosis during the first three weeks after transplantation. the biopsies were studied by immunostaining for ki , ccr , ccr , rantes, mcp- , cd and cd , respectively. the patients were followed for a mean time of . yrs. none of them developed a rejection episode in the follow up time. after follow up the mean serum creatinine was . mg/dl ( . - . the goal of a tx is for the recip to achieve long-term survival (surv.), with continued graft function, equivalent to the gen. population. we studied subsequent outcome in , -yr kidney tx survivors (tx - ) ; % living donor (ld); % st tx; % female; % type diabetes; mean age at tx (±se), ± yrs. actuarial -yr surv. is shown in table ; ld patient, graft, and death-censored graft surv. is signif. ↑vs. deceased donor (p<. ). mean creatinine (± se) at yrs was . ±. ; yrs, . ±. ; yrs, . ± ; yrs, . ± . the major causes of late graft loss (gl) were death with function (dwf) and chronic rejection (can). by multivariate analysis, risk factors for gl after yrs were age ≥ yrs at tx; type diabetes, retx, hla mm ≥ ; ≥ acute rejection episode, and pretx cardiac, peripheral vascular, or liver disease (p<. ). the most common cause of dwf was cardiovascular disease (cvd); however, > % deaths were due to malignancy. the use of kidneys from donors with a positive serology for hcv into hcv(+) recipients still remains controversial. in , our units adopted this policy, subsequently modified in , so these kidneys were limited to recipients with a positive rna hcv before transplantation. the aim of the present analysis was to review the long-term safety of our policy. since january to february , hcv(+) patients with a negative hbsag and not treated with interferon received a kidney transplant in our units. patients were transplanted from an hcv(-) donor(group ) and from an hcv(+) donor(group ). median follow-up time was (ir - ) months. remarkably, group showed a significantly higher donor age ( . ± . versus . ± . years;p< . ) and recipient age ( . ± . versus . ± . years;p< . ), as well as a worse hla compatibiliy than group . immunesuppressive therapy did not significantly differ between the two groups. group notably, only patients died because of a liver disease ( in group versus in group ) and only patients developed a hepatocarcinoma (both in group ). in summary, no significant differences were observed in hcv(+) recipients according to hcv serology of the donor, in terms of death censored graf survival, patient survival and evolution of liver disease. therefore, our experience clearly demonstrates that the use of kidneys from hcv(+) donors into hcv(+) recipients is a safe strategy in the long-term and a wise way of using these kidneys, that otherwise would be lost at a moment of shortage. introduction: deceased donor kidneys are allocated to adult candidates in the u.s. primarily by waiting time and hla similarity. we investigated two alternative allocation systems, lyft-scd and lyft-dy, that prioritize offers of kidneys to adults based in part on lyft. methods: based on characteristics of each candidate and donor, lyft was calculated as the difference between expected median years of life for the candidate with that kidney donor transplant (tx) versus without a kidney. years on dialysis were weighted at . of years with a functioning graft. the relative risk of graft failure for each donor was calculated from donor factors using a cox model and the donor profile index (dpi), the percentile score of that risk among kidneys used in ( %=greatest risk of graft failure). using actual candidates and deceased donors and acceptance patterns from , we modeled allocation with the kidney-pancreas simulated allocation model (kpsam). kpsam sequentially offers kidneys to candidates according to user-specified allocation rules, and models the probability for kidney placement and post-tx survival. the lyft-scd model allocated scd kidneys by lyft and ecd kidneys by dialysis years (dy). the lyft-dy model allocated organs according to the formula [. lyft( -dpi)]+[dy(. dpi+. )]+[ pra/ ] to adult kidney tx candidates. results: the table compares a year's worth of kidney-alone recipient characteristics, lifespan after tx and additional lifespan (v. dialysis) due to tx among all kidney (including spk) recipients, and the donor/recipient age correlation (r) under current national kidney allocation, allocation using lyft for scd, and allocation using lyft-dy within each donation service area. conclusions: allocation systems incorporating lyft have the potential to increase the number of years of life attainable from tx and are being considered for the allocation of kidneys within the u.s. introduction : organ shortage for transplantation has led to the use of marginal kidneys, which has been associated with poorer but still acceptable results. in our center, the transplantation of two very marginal kidneys into a single recipient was used as a strategy to increase the number of organs available. the present study reports renal function and survival of dual-kidney transplants (dkt) performed at our institution. methods : from october to june , transplants were performed at our center, from which were dkt. kidney selection for a dkt was based on refusal of the kidneys for single kidney transplantation (skt), donor's age ≥ years and ≥ % of glomerulosclerosis on pre-implantation biopsy. the calculated creatinine clearance (crcl, ml/min), graft and recipient survival from dkt were compared to those of skt from ecd (based on unos criteria, n= ) and ideal donors (id, aged to y, n= ) over a seven-year period. results : dkt donors were significantly older than the two other groups (dkt: year old, ecd: , id: ). dual transplants were offered to older recipients by design ( , , ). delayed graft function was more prevalent for dkt and ecd than with id ( %, %, %). twelve, and -month crcl were similar for dkt and ecd but lower than id (twelve months: , , ; months: , , ; months: , , , respectively). patient survival, actuarial graft survival and actuarial graft survival censored for death were similar between the groups. conclusion : to our knowledge, this study reports short and long-term outcome of the largest cohort of dkt performed at a single institution. it shows that dual-kidney transplantation is a more complex intervention with more risks of surgical and post-op complications (data not shown). however, with adequate surgical expertise, dkt patients can expect long-term results comparable or even better than ecd. in our center, the use of dkt has increased the number of transplantations by % for the period of study. it allowed older patients to receive a graft within shorter delays. moreover, it permitted a more judicious allocation of a resource that is still limited. an results: very few differences resulting from donornet were seen. for regionally exported kidneys, cold ischemia time (cit) was . h before donornet (bd) and . h after donornet (ad); . % of regionally exported kidneys had cit> h bd, as compared with . % ad. for nationally exported kidneys, cit was . h bd and . h ad; . % of nationally exported kidneys had cit> h bd, as compared with . % ad. the same hucs of exported kidneys bd were also hucs ad. of the top centers utilizing exported kidneys bd, only one was not within the top centers utilizing exported kidneys ad. when we looked at cit for kidneys exported to hucs, again there was little difference before or after donornet, with a trend to possibly longer cit for hucs. for kidneys regionally exported to hucs, cold ischemia time (cit) was . h before donornet (bd) and . h after donornet (ad); % of regionally exported kidneys had cit> h bd, as compared with . % ad. for kidneys nationally exported to hucs, cit was . h bd and . h ad; . % of nationally exported kidneys had cit> h bd, as compared with . % ad. conclusion: the first months of national implementation of donornet were not successful in decreasing cit for regionally or nationally exported kidneys. furthermore, the centers to which a high proportion of these kidneys were exported did not change as a result of donornet, and for these centers allocation efficiency is no better and might even be worse than before. machine cold machine preservation has been shown to improve outcome following transplantation of deceased heart-beating donor kidneys. to determine whether cold machine preservation also improves outcome of kidneys donated after cardiac death (dcd) we undertook a multicentre randomized controlled trial in the uk comparing machine perfusion with simple cold storage. one kidney from each dcd donor was randomized to machine perfusion (organ recovery systems lifeport device with kps- solution), the other to perfusion with uw (viaspan) solution followed by simple cold storage. the primary outcome measure was the need for dialysis in the first days (delayed graft function, dgf); secondary outcome measures included gfr at week (mdrd technique); and month graft and patient survival. at the time of writing, one week outcome data are available for all patients. a sequential design was used with the data inspected after transplants and then every . all recipients received basiliximab, mycophenolate sodium, tacrolimus and prednisolone. the significance of the initial results has been tested using paired t tests and mcnemar's exact tests. recruitment was stopped after donors when the unadjusted sequential analysis concluded that there was no difference in the incidence of dgf. of the kidneys were transplanted; one was not used for anatomical reasons. one kidney suffered primary non function; it had been machine preserved. the results shown below represent intention to treat. introduction: split liver transplantation has been adopted as an alternative to expand the organ donor pool. while the adult/child split liver (a/csl) in which an extended right graft (erg) is transplanted into an adult and a left lateral segment (lls), transplanted into a child, has gained a wide acceptance within the transplantation community, adult/ adult split liver (a/asl) in which the liver is split into a full right (fr) and full left (fl) is still performed very rarely. we analyzed the experience at our center with split liver grafts over a period of years. material and methods: between october and october we performed a total of liver transplants in recipients ( / children and / adults). among the ( children and adults) recipients of a primary isolated liver transplant, ( children and adult) were transplanted with a a/c or a/a sl. the recipients of a whole size graft ( adults and children) were used as a control. results: adults: patients received a split liver graft ( erg graft and fl/fr grafts) and a whole liver graft. overall the incidence of biliary complications using a split liver graft was % and with a whole liver graft % (p= , ).for the recipients of a split liver graft and years patient and graft survival was %/ % and %/ %. recipients of a whole liver graft had a and years patient / graft survival of %/ % and %/ % respectively. children: children received a split graft ( lls, erg and fl) and a whole size graft. biliary complications occurred in % of the recipients of a split liver graft and % of the recipients of a whole size graft (p < , ). among the recipients of a split graft and years patient / graft survival was %/ % and %/ % respectively. the recipient of a whole size graft had a and years patient / graft survival of %/ % and %/ %. conclusion: incidence of biliary complications is significantly higher using a split graft. at a high volume center, use of split liver grafts reached comparable and even better results of a whole liver graft in terms of patient and graft survival. thus, the use of split grafts should be strongly encouraged to expand the donor pool. a groups of primary ldlt and ddlt recipients were identified by matching diagnosis, meld score, and recipient age. cost data, acquired from the hospital financial database and inflation adjusted and clinical outcomes were compared between the groups. background: liver transplant recipients with (gw/rw) < . % are thought to have a higher incidence of post-operative complications, including small for size syndrome (sfss), and overall inferior outcomes. we analyzed a cohort of partial liver graft recipients and compared those with gw/rw < . % to those with gw/rw > . %. results: between and , adult patients underwent partial graft liver transplant. seventy-six grafts were from live donors (ldlt) and the remaining were from deceased donor split-liver transplants (slt). of these, patients had gw/ rw < . % ( ldlt, slt), and had gw/rw > . % ( ldlt, slt). median follow-up was . months and did not differ between the two groups. baseline demographics including donor and recipient age, and meld at the time of transplant also did not differ between groups (table) . three-month and -year graft survival for the two groups was comparable. three recipients with gw/rw < . % developed sfss ( . %); all three had inflow modification with splenic artery ligation (sal), and of the grafts was lost at one-year. eight recipients with gw/rw > . % developed sfss ( . %) (p = ns); six underwent sal and none had graft loss at one-year. there was a trend toward increased hepatic artery thrombosis with the smaller grafts that did not reach statistical significance (p = . ). the incidence of other surgical complications was similar between the two groups (table) . the diagnosis of rejection in post-transplant kidney disease depends largely on the assessment of biopsy pathology, which suffers from arbitrary scoring, subjectivity, and sampling variance. with microarray gene expression data from biopsies for cause, we used predictive analysis of microarrays (pam) to build a rejection classifier. because of the imperfect gold standard, the classifier cannot and should not have extremely high predictive accuracy. the goal was to see if microarrays could detect a robust rejection signature despite this uncertainty, and to identify the top genes distinguishing rejecting from non-rejecting biopsies. by examining discrepancies between pathology diagnoses and pam predictions, and using clinical follow-up information, we combine the strengths of each method to produce a more accurate diagnostic system. biopsies with rejection plus clinical episodes (fig. ) have higher positive predictive value than those lacking episodes. the majority of episodes occur in the top part of fig. , indicating that a valid rejection signature is being detected. of the exceptions, most had been treated with steroids before the biopsy, suppressing their gene expression patterns. samples called borderline rejection separated into two distinct high/low probability groups using pam, with all the cases classified as clinical rejection episodes occurring in the high probability group. of the genes chosen by the classifier, had previously been annotated in our studies of mouse kidney graft rejection. gzma, gzmb, and prf ranked th, nd, and th respectively. the top five genes were: cxcl , gbp , cxcl , indo, and cxcl , all previously annotated in rejecting mouse kidneys as interferon-γ induced genes. in summary, gene expression-based classifiers, combined with histopathology, promise more accurate diagnostic assessment of the state of kidney transplants at the time of biopsy. moreover our data driven classifier independently identifies the genes previously annotated in experimental studies. influence of donor background: renal-cell associated tlr activation was found to be important in mediating ischemia reperfusion injury to murine kidneys. we hypothesized that genetic variations within the tlr gene of the kidney donor affects the rate of delayed graft function (dgf). methods: we genotyped the functional tlr polymorphisms (snps) d g (rs ) and t i (rs ) in kidney donors from centers and correlated them with the occurrence of dgf. dgf was defined as the need of dialysis within days post-transplant or less than % drop in creatinine within the first hours after transplant. in a sample of patients from one center, we analysed intragraft hmgb- (high mobility group box protein- ) gene expression in pre-and post-implantation biopsies. statistical analyses were performed using the spss statistical package. results: both tlr snps were in hardy-weinberg equilibrium, and were combined for further analysis. recipients of a tlr mutated kidney showed a significant lower rate of dgf (p= . ), which was persistent after correction for known donor-derived risk factors (donor age, ecd vs. dcd-kidney, cold ischemia time, p= . , hr . , cl . - . ). additionally, we confirmed the presence of a possible tlr ligand, hmgb- , in pre-and post-implantation biopsies. we also confirmed the presence of a functional tlr receptor in human proximal tubular cells which expressed mcp- , il -β, il- and tnf-α after specific tlr agonist treatment. conclusion: human renal tubular epithelial cells express tlr and a functional tlr snp in donor kidney is associated with lower rate of delayed graft function. background: methylation of promoter cpg islands has been associated with gene silencing and demonstrated to lead to chromosomal instability. we postulate that differences in methylation patterns observed in tissues ranging from normal to cirrhosis to hcc may lead to the discovery of direct precipitating events that contribute to tumorigenesis in hcv-hcc patients. methods: dna from hcv-hcc tumors and corresponding non-tumor hcv cirrhotic tissues as well as independent hcv cirrhotic tissues and normal liver tissues were bisulfite treated and hybridized to the illumina goldengate methylation beadarray cancer panel i for interrogating cpg sites in the promoter regions of distinct genes. for each cpg site, a summary statistic representing "percent methylated" was estimated. for each cpg site, a jonckheere-terpstra test was applied to identify whether there was a significant monotonic trend in percent methylated across the independent normal, cirrhotic, and hcc tissues. in addition, the paired hcc and non-tumor cirrhotic tissues were analyzed using a paired t-test. the q-value method for estimating gene-wise false discovery rates (fdr) was used to adjust for multiple comparisons; cpg sites with an fdr< . were considered significant. to identify if serological responses to allogenic non-hla renal compartmentspecific antigens can be detected after renal transplantation (txp). methods: paired pre-and post-transplant (mean time months) serum samples from pediatric kidney allograft recipients were used for identification of de novo non-hla antibody formation assessed using invitrogen protoarray (v ), measuring signal post-pre. probes from the protoarray and cdna microarray platforms were re-annotated to current ncbi entrez gene identifiers using ailun. cdna arrays (gse: ) from normal kidney regions (inner and outer cortex, inner and outer medulla, papillary tips, renal pelvis and glomeruli; see table) were analyzed for compartment-specific genes by sam, and the highest-ranked genes in each compartment (ks two-sample test p < . ) and were ranked against each individual patient's numerical antibody response across the proteins on the protoarray. results: in % of patients ( / ), kidney-specific serological responses against the renal pelvis were the first to be detected, followed by responses against renal cortex. control gene expression data sets from other solid organs (gse: ; lung, heart, pancreas) did not demonstrate immune-response enrichment. the presence of these antibodies was not associated with donor specific hla class i or ii antibody levels. conclusion: we demonstrated de novo formation of circulating non-hla non-abo antibodies after txp, irrespective of hla antibodies, are detected against kidneyspecific protein targets. as these antibodies are not seen against other solid organs, the response is likely allogeneic. the renal pelvis and renal cortex have the highest immunogenic potential. we conclude that urinary cell mrna profiles that include levels of mrna encoding tubular proteins and mrna encoding proteins implicated in emt offers a noninvasive means ascertaining renal allograft status with respect to presence or absence of can. functional functional annotation of these genes identified cell cycle pathway and carboxylic acid metabolism pathway as potentially relevant for both datasets. altogether, these data suggest that as compared with recipients requiring on-going immunosuppression, operationally tolerant liver recipients exhibit traits of immunological quiescence and activation of natural killer related pathways. liver and kidney tolerant states appear to be fundamentally different biological processes, although some common pathways could be relevant to both settings. genetic introduction: both normal and fibrotic renal allografts develop a large number of persistent changes in pro-inflammatory gene transcripts early after transplantation ( ) . the aim of the current study was to determine if this "transplant effect" is attenuated by immunosuppression, fibrosis or hla-match. methods: we studied histologically normal implantation biopsies (t ) and m protocol biopsies (t ) from living donor kidney transplant recipients who had no identifiable post-transplant complication (no acute rejection, polyoma virus, etc). patients were stratified into distinct clinicopathologic groups. the first three groups had normal histology at both t and t and included: ) hla identical-tac treated (n= ); ) non-hla identical-tac (n= ); ) non-hla identical srl (tac-free, n= ). a fourth group was histologically normal at t but developed mild fibrosis by t (n= ). mrna expression from these biopsies was measured using the u plus . microarray and custom taqman low density arrays (tlda). data for each group was tested using a generalized linear model and changes common to each dataset identified (p< . ). results: in addition to transcript changes specific for each clinicopathologic condition, a large number of transcripts (n= ) were altered in all groups. % (n= ) had higher expression in all comparisons at t versus t , including fibronectin and collagen iv. % (n= ) of transcripts were considered down-regulated, including interleukin and β. gene ontology and signaling pathway analyses showed many of the transcripts to be involved in pro-inflammatory and immune response signaling pathways (ex. tlr, il- /- , etc). custom tldas were used to study several genes considered not detected by microarray. this included tgf-β , cd- e/- /- and vegf, all of which were significantly up-regulated in multiple comparisons. conclusions: persistent changes in pro-inflammatory transcripts occur in all renal transplants. this "transplant effect" cannot be explained by calcineurin-inhibitors (occurs in tac-free immunosuppression), increased alloreactivity (similar in hla identical/ non-identical) or fibrosis. a likely cause is persistent changes from ir injury. the role of the "transplant effect" in long-term allograft survival is unclear, but it likely interacts with other forms of graft injury. background: a critical gene-set for acute renal rejection (ar) diagnosis in peripheral blood has been previously identified by our group using cross-platform hybridization of unique peripherla blood samples with matched biopsy diagnosis, with ar (n= ) and without ar (sta; n= ), with cross-hybridization across human microarray platforms: k cdna lymphochip, k agilent and k affymetrix hu plus. in this study we proposed to verify and validate this gene-set for ar diagnosis and prediction by peripheral blood pcr-based analysis. method: / peripheral blood samples from the microarray gene-set were selected for -well format multiplex abi-taqman qpcrv validation of ar diagnosis across the gene-set. an independant set of new, time and immunosuppression matched, peripheral blood samples ( sta, ar) were used as a test-set for blinded prediction of ar diagnosis using qpcr across the most informative genes. sequential samples from ar patients (at ar, - months prior to, and after ar) were also examined by qpcr for these genes for blinded ar prediction, prior to biopsy proven ar. prediction models were generated using logistic regression analysis and p< . considered significant. result: in the validation set of samples, / genes were highly significant for confirming peripheral blood-ar diagnosis (p< . ). in the test group of samples, ar was predicted with a very high level of sensitivity and specificity (ppv and npv> %). in the group of ar patients with sequential samples pre-and post-ar, expression for these genes were significantly elevated in the pre-ar samples (vs. sta, p< . ) but were not different between pre-ar and ar values. conclusion: a highly specific and sensitive biomarker panel of genes has been derived and tested by cross-platform microarray analysis. thsi gene-set has now been validated and further verified by multiplex pcr, for ar diagnosis and prediction, even months prior to the rejection event. utility of this gene-set should be further validated in real-time by serial longitudinal peripheral blood testing, for more senstive and specific minimally invasive monitoring for graft rejection. tolerance/immune deviation ii background: our previous studies showed that regulatory t cells (treg) execute suppressive function in both the inflammatory site of the allograft and the draining lymph node (dln) to suppress allograft rejection. we explored how treg influenced the migration and function of antigen specific effector t cells and dendritic cells (dc) at these two sites in an islet transplant model. methods: treg were sorted from wild type or ccr -/-c bl/ mice, labeled with pkh , and transferred directly to islet allografts (balb/c into c bl/ ). effector cd t cells (te) from alloantigen specific t cell receptor transgenic mice were labeled with csfe and transferred intravenously. treg and te migration to islet grafts and dln were analyzed with flow cytometry and immunohistochemistry. chemokine expression was determined by rt-pcr. cx cr gfp mice, in which dc are internally labeled with gfp, served as islet donors, and donor dc migration was tracked with fluorescence microscopy. results: during priming and rejection, islet allografts expressed a panel of inflammatory chemokines shortly after transplantation that recruited te to the islets. te accumulated and proliferated in both the islet allograft and the dln. concomitantly, donor derived dc migrated from the islet to the dln as early as day after transplantation. local transfer of treg into the islet allograft inhibited islet chemokine expression, inhibited donor dc migration in an il- and tgfb dependent fashion, and reduced te migration to and proliferation in the graft. the transferred treg also migrated from the islet allograft to the dln, and directly inhibited te accumulation and proliferation in the dln, and migration of te to the islet. ccr -/-treg, which could not migrate to the dln but were retained within the graft, and were far less effective than wild type treg in inhibiting te migration and proliferation into both the islets and dln. conclusions: treg migrate to the islet and suppress parenchymal cell chemokine expression, dc migration, and te responses in the islet allograft. treg also migrate to the dln to suppress te proliferation and migration. treg trafficking from the allograft to the dln is crucial for suppressive function in order to target the separate effector mechanisms. these results demonstrate novel and important functions for migration in treg induced suppression and graft survival. tregs cd +foxp + regulatory t cells (tregs) play an important role in transplant tolerance, yet basic aspects of treg biology including the mechanisms involved in their induction remain unclear. α-cd rb is a potent tolerogenic agent that induces a x increase in number of tregs in wt mice, even in the absence of allo-antigen. here we use foxp red fluorescent protein reporter knock-in mice to study treg homeostasis and identify the mechanisms by which α-cd rb induces tregs. cfse-stained highly sort-abstracts purified foxp + or foxp -cells were adoptively transferred into fully replete naive wt congenic mice. whereas only - % of transferred foxp -cells undergo homeostatic proliferation (hp) over d, - % of foxp + cells proliferate -a surprisingly high rate of hp. moreover, treatment with α-cd rb markedly enhanced hp by transferred foxp + cells, resulting in a x increase in cell number. α-cd rb induced de novo foxp expression in - % of transferred foxp -cells (many of which subsequently underwent hp). thus, α-cd rb induces both conversion of foxp -to foxp + cells and promotes hp in foxp + cells in the absence of exogenous antigen. we then addressed the signals controlling basal hp of tregs and both hp and conversion mediated by α-cd rb. cfse-stained congenic cd + cells adoptively transferred into naive wt mice were untreated, or received csa, α-cd rb, or both and foxp + and foxp -cd cells were assessed on d . calcineurin inhibition greatly reduced basal hp of transferred foxp + cells compared to untreated mice. moreover, csa completely abrogated increased treg hp induced by α-cd rb, although conversion still occurred. next we assessed the role of tgfβ. we found that blocking tgfβ signaling with α-tgfβ shortened allograft survival, but had no effect on basal treg hp, or on treg hp or conversion by α-cd rb. finally, although exogenous antigen is not required, basal and α-cd rb-induced hp may still require recognition of self-ag bytregs. indeed, preliminary results reveal that when cfse-labeled cd + cells are transferred into mhcii ko mice, basal hp by tregs is reduced and not restored by α-cd rb. thus, α-cd rb alters normal controls regulating hp by treg. moreover, both basal and α-cd rb-mediated hp requires intact calcineurin activity and tcr signaling, but not tgfβ. understanding the signals controlling hp in treg may reveal new therapeutic targets for tolerance induction. we report the first demonstration of a tolerance-inducing strategy based on posttransplant administration of allo-ag-specific treg (aastreg) and rapamycin (rapa), in a fully allogeneic, unmanipulated mouse heart transplant model. enrichment of naturally-occurring aastreg represented the first step to counterbalance the high frequency of alloreactive t cells. selection was achieved by co-incubation of freshly-isolated cd + cd + t cells with donor bone marrow-derived dendritic cells (dc). the source of stimulatory factors necessary to sustain treg proliferation was the supernatant of cd + cd -t cells co-cultured with allogeneic dc (mlrsup). use of mature (cd high ) dc favored extensive expansion of foxp cells capable of il- production (t h ). co-culture of treg with immature dc in the presence of mlrsup rendered a t cell population with regulatory phenotype: foxp + , gitr + , ctla- + , ccr + , cd l -. these cells inhibited in vitro effector t cell proliferation at : and : treg:t cell ratios. the suppressive activity was ag-specific; no significant inhibition was evident when effector t cells were stimulated by third party dc. aastreg were then tested for their ability to induce transplant tolerance in a mouse heterotopic heart allograft model (balb/c to c bl/ ; unmanipulated). rapa was used: i) to inhibit effector t cell proliferation, while sparing treg activity and thus enhancing the in vivo treg:effector t cell ratio; ii) to promote resolution of the inflammatory state and preserve the susceptibility of conventional t cells to treg suppression. graft recipients received rapa ( mg/kg/d; d - ) and x aastreg i.v. on d . in comparison to the untreated group (median survival time, mst= d; n= ), rapa alone extended mst to d (n= ), with no long-term graft survival. under cover of rapa, aastreg exerted a profound tolerogenic effect: > % recipients exhibited longterm graft survival (mst> d; n= ). this effect was stronger than polyclonal treg administration: % long-term survivors (mst> d; n= ). moreover, the tolerogenic effect was ag-specific, as aastreg selected against third party dc (c h/hej) did not prolong graft survival in comparison to the rapa-only control group. these results indicate the feasibility and therapeutic potential of ag-specific tolerogenic cell therapy based on post-transplant administration of selected aastreg. direct intravenous immunoglobulins (ivig) is an effective treatment for t-cell mediated graft rejection and autoimmune diseases. ivig treatment is associated with rapid clinical improvements without the side effects of global immunosuppression. this prompted us to ask whether ivig might enhance directly the suppressive function cd +cd +foxp + regulatory t cells in vitro and in vivo. in vitro, mouse cba/ca (h k ) total cd + or cd + cd responder cells were stimulated with c bl/ (h b ) splenocytes, and human cd + or cd + cd cells were stimulated with allogeneic antigen presenting cells. in vivo, * total cd + or cd + cd -t cells of cba/ca mice were adoptively transferred into cba/rag -/mice, and one day later transplanted with a tail skingraft of c bl/ mice. ivig was administered i.v. on day , , , and . human serum albumin (hsa) was used as a control. binding of ivig and activation status of foxp + cd + t cells were determined. in vivo, only when total cd + t cells, but not cd -t cells, were adoptively transferred, ivig protected against t-cell mediated rejection of the fully mismatched skingraft (mst: ivig > vs hsa days, p< . ). ivig binds to ± % of foxp + t cells, while binding to foxp -t cells was minimal. this binding was partially fcγ receptor mediated. furthermore, ivig treatment resulted in activation of cd + t cells as detected by increased expression of phosphorylated zap /syk, which could be abrogated by specific tyrosine kinase inhibition. in vitro, ivig inhibited the alloproliferative response of murine cd + t cells by ± %, but after depletion of cd + t cells, this inhibition decreased to ± % (n= , p< . ). similar results were found in human mlr, where depletion of cd + t cells resulted in twofold reduction in ivig mediated suppression. significantly, incubation of human cd + cd + with ivig enhanced their ability to suppress allogeneic t-cell proliferation (ivig ± % vs hsa ± % of inhibition, n= , p< . ) . our results identify a novel pathway through which ivig treatment induces direct functional activation of both mouse and human regulatory t cells. immediate binding and activation of regulatory t cells is one of the mechanisms in the immunomodulatory repertoire of ivig, which allows rapid inhibition of allogeneic responses, and therefore can be a valuable tool after organ transplantation. generation foxp is a dna-binding protein that is necessary for regulatory t cell (treg) function, though recent data indicate that detection of foxp mrna or protein alone does not necessarily indicate whether the associated foxp + cell is functional or not. to that end, our analysis of foxp sequence showed the presence of an rxxr motif, conserved between mice and humans, that is located amino acids (aa) from the carboxy terminus of foxp and is a potential recognition sequence for cleavage by proprotein convertase enzymes. we found several proprotein convertases are expressed by naturally occurring tregs, with further upregulation upon tcr activation. we generated an antibody against the aa carboxyl peptide of foxp , and by western blotting detected a peptide of about . -kda, consistent with a -aa long carboxy-terminal foxp cleavage product. both cleaved and uncleaved forms of foxp were resolved by sds-page, and the cleaved form was found only in the dna-bound fraction. the requirement of proteolytic cleavage, at the intact tetrabasic rxxr motif ( rkkr ), for full treg function was shown by abolishing the motif through mutagenesis, followed by retroviral expression of mutants, and analysis of proteolytic cleavage by western blotting. assays of treg function by cells expressing either long-or short-foxp mutants showed short-foxp (missing the carboxy-terminal -aa) suppressed teff cell proliferation significantly more effectively than wt foxp or an engineered and cleavage-resistant mutant, termed long-foxp (p< . ). moreover, adoptive transfer of cells expressing short-foxp prevented experimental colitis more effectively than wt-foxp (p< . ), and both were more effective than cells expressing long-foxp . animals that received cells expressing short-foxp gained weight and were protected from disease. thus, function of foxp is regulated at a post-translational level by proteolytic cleavage and the short form of foxp represents the active form. our data shows proteolytic cleavage of foxp is key to the generation of functional tregs, with enzymes(s) of the proprotein convertase family likely playing an important role in this process and providing an extra and hitherto unrecognized important level of regulation for foxp . blocking since tgf-β is secreted in a latent form and active tgf-β is rapidly cleared from circulation. in order to make long-lasting active form of tgf-β, the mutant tgf-β was fused to a human igg fc component. the secreted human mutant tgf-β/fc (hmtgf β /fc) fusion protein stained with both anti-human tgf-β and anti-human igg antibodies, confirming the cytokine and isotype specificity of tgf-β moiety and fc domain. moreover, in vitro bioassay, hmtgf-β/fc inhibited il- dependent ht- cell proliferation in a dose dependent manner and had a circulating half-life of hours in mice. in vitro, anti-cd and anti-cd triggered cd + or cd + t cell proliferation, measured by h-thymidine uptake, could be synergistically inhibited by tgf-β and rapamycin. at the same time, the two reagents when added together could synergistically promote the induction of cd + foxp + t cells from peripheral naïve cd + foxp -t cells. in a pancreas islet transplantation model in which the fully mhc mismatched dba/ islets were transplanted into c bl/ mice rendered diabetic by streptozotocin, mean survival time of islet was days in control recipients (n= ). administration of muttgf-β/fc resulted in a delayed islet allograft rejection (mst; days, n= ). treatment with rapamycin prolonged islet grafts survival in % of recipients. in contrast, combined treatment with tgf-β/fc and rapamycin by four doses produced indefinite islet allograft survival in % cases. we have produced the long-lasting active hmtgf-β/fc fusion protein. the tgf-β/fc is synergistic with rapamycin to convert naïve cd +foxp -t cells into cd +foxp + tregs and promote long-term islet allograft engraftment. the the recognition of microbial motifs by the innate immune system leading to the stimulation of adaptive immune responses may explain the relationship between infections and susceptibility to graft rejection. a number of infectious agents have been reported to prevent the induction of allograft tolerance, however, none of these can reverse established tolerance, a situation that is highly relevant to clinical transpalntation. we here report that established allograft tolerance (induced with anti-cd + donorspecific transfusion) can be reversed in a cardiac transplantation mouse model following infection with listeria monocytogenes. this reversal of tolerance was dependent on the presence of both cd + and cd + cells, as well as of the tlr/il- /il- adaptor molecule, myd . we hypothesized that the reversal of tolerance requires that alloreactive conventional t cells (tconv) escape dominant regulation by pre-existing tregs. these alloreactive tconv can then proliferate resulting in an increased ratio of tconv:tregs favoring the reversal of established tolerance. indeed, we observed that tolerant grafts harbored low numbers of infiltrating cd + and cd + t cells ( - . x /heart), with - % of the infiltrating cd + cells co-expressing foxp (n= ). following the reversal of tolerance and allograft rejection, a - fold increase in cd + foxp and cd + foxp -tconv was observed in the graft, but no increase in the foxp + subset. in contrast, we observed no significant changes in the splenic t cell subsets, raising the possibility that the escape from tregs occurs locally within the graft. infection of tolerant il- -or ifnar -deficient recipients with listeria monocytogenes failed to reverse tolerance, consistent with a hypothesis that the initial escape of tconv from regulation may depend on il- , while their proliferation may be type i ifn-dependent. in summary, the conditions for the reversal of tolerance is more stringent than the prevention of tolerance, and requires myd -signalling and the presence of both cd + cells and cd + cells, as well as il- and type i ifn signaling. these studies point to the potential impact of bacterial infections on established tolerance, and to novel strategies to monitor and facilitate the maintenance of tolerance in the clinic. th our laboratory has identified kα tubulin, as an epithelial autoantigen to which immune response occurs following human ltx. further, we have shown a strong correlation between the presence of antibodies (abs) to kα tubulin and development of chronic rejection ie bronchiolitis obliterans syndrome (bos). goal of our study is to test the hypothesis that epithelial damage due to allo immunity results in remodeling exposes otherwise cryptic self antigens including kα tubulin and collagen type v (coll v) leading to cellular immune reactivity and ab production against these auto-antigens which may play a role in the pathogenesis of bos. patients who developed anti-hla ab and patients who had no detectable anti-donor hla abs post-ltx by luminex assay were analyzed for development of abs to kα tubulin and coll v using elisa method developed in our laboratory. the elisa for kα tubulin used recombinant protein ( µg/ml) purified on affinity resin. the elisa for collagen v uses commercially available human collagen v ( µg/ml). elispot assay for ifnγ and il- were performed for bos-and bos+ patient pbls (at the time of bos diagnosis), after stimulations with kα tubulin protein. the levels of anti-tubulin abs and anti-coll v abs were increased significantly in bos+ ltx recipients with anti-hla compared to those with no anti-hla, table (p< . ). . surprisingly, both cd and cd subsets induced long-term survival of secondary test grafts (> days). however, only the cd + t-reg prevented tvs (ni= + , + % of vessels), as compared to cd + t-reg (ni= + in + % of vessels). the cytokine profile indicated a dominant il- response. allo-antibody analysis showed up-regulation il- /il- dependent igg and igg c. conclusion: allochimeric protein-therapy and csa treatment generate t-reg that prolong graft survival, but only cd + t-reg generated from allochimeric protein-therapy prevent tvs. this cd + t-reg may be responsible for long-term graft maintenance through its unique ability to control anti-inflammatory and alloantibody responses. immunodominant h background: minor histocompatibility ags (mihas) are self peptides, derived from proteolytic processing of normal cellular proteins. miha incompatibility can induce t cell response to dominant mihas and facilitates expansion of ctls and graft rejection. however, the contribution of ctls recognizing these mihas in solid organ transplantation has not been fully evaluated. methods: balb.b (h- b ) donor hearts were transplanted heterotopically to c bl/ (h- b ) recipients. in vivo alloreactive cd t cells were monitored with peptide/mhc multimers. α-lfa- mab was given to recipients to prevent rejection. various numbers of h -specific cd t cells or cd t cells lacking h specificity were adoptively transferred into balb.b graft bearing b .scid recipients. results: % of transplantation recipients developed acute rejection and showed markedly increased numbers of h -specific cd t cells at day - in spleen. abundant cd infiltration was found and selective infiltration of h -specific cd t cells in the graft was confirmed with flow cytometry and in situ tetramer staining. α-lfa- mab treatment prevented acute rejection (mst> ) and allogeneic t cell expansion. it also profoundly attenuated neointimal hyperplasia ( graft-bearing b .scid mice. we found that the degree of acute rejection positively correlated with the number of h -specific cd t cells transferred. however, transferred h -specific cd t cells did not cause chronic rejection. interestingly, greater numbers of cd t cells with h immunodominance were found in spleen, blood and graft at days after adoptive transfer of cd lacking h specificity compared to h -specific cd t cell transfer. conclusion: h responses dominate other miha immune responses during acute rejection after balb.b to b cardiac allograft. we confirmed a role of immunodominant h specific cd t cells as pathological effector t cells in acute rejection but not in chronic rejection. maintaining a h response may be beneficial in allotolerance to suppress miha responses that could induce chronic rejection in long-term grafts. chronic lung allograft rejection, bronchiolitis obliterans syndrome (bos), affects up to % of transplant survivors years post-ltx. human neutrophil peptides (hnp - / α defensins), have been identified in the lavage fluids from patients with chronic rejection by proteomics. goals of our study were to determine the role of anti-hla abs and defensins in bos and to define the interactions between α- antitrypsin (aat), and defensins in regulating inflammation leading to epithelial cell proliferation and bos pathogenesis. bal and serum samples (post-ltx and pre bos) from bos+, bos-patients and normals were analyzed by elisa for α defensins (hnp - ), human β defensin (hbd ) and aat. small airway epithelial cells (saec) were treated with hnp or , with or without equimolar aat or with anti-hla abs and analyzed for levels of hbd production (elisa), cytokine and chemokine (luminex), and cell surface adhesion molecules (icam, vcam) by facs. bal and serum from bos+ patients had high levels of hnp - and hbd compared to bos-recipients or normal sera (p< . ) ( table ). there was also a significant decrease in aat levels in bos+ compared to bos-or normal serum (p= . ) ( table ) . saec produced human β defensins following anti-hla ab stimulation or by hnp treatment (table ) . there was increase in adhesion molecules (icam, vcam, folds) cytokines {il- , il- r α ( folds), il- β, il- ( folds)}, il- ( folds decrease), chemokines (il- , mcp , - folds increase) and growth factors (egf and vegf, . folds increase) in response to treatment with hnp or hnp compared to untreated saec, that was inhibited by aat. increased defensins and decreased aat levels were seen in lavage and serum of ltx recipients with bos. anti-hla abs further stimulate defensin production by saec. we conclude that chronic stimulation of epithelial cells both by defensins and anti-hla abs can lead to increased growth factor production contributing to the pathogenesis of bos. under tubular atrophy/interstitial fibrosis (ta/if) remains a major cause of late kidney allograft loss and epithelial mesenchymal transformation (emt) is now appreciated as a key feature in this process. we hypothesize that macrophages play a direct role in the development of ta/if by creating a profibrotic microenvironment and stimulating emt within the allograft. in human kidney allografts with ta/if (n= ), macrophage infiltration detected by immunostaining was significantly upregulated (mean score . ± . ) compared to biopsies without corresponding pathological changes from recipients with stable function (n= ; . ± . ; p< . ) and the extent of this staining also correlated to the magnitude of graft dysfunction (p< . ). rt-pcr in ta/if grafts also showed marked upregulation for emt markers αsma ( . ± . -fold; p< . ), s a ( . ± . -fold; p< . ), and vimentin ( . ± . -fold; p< . ), compared to stable function allografts. to explore the macrophage-emt relationship, we co-cultured freshly isolated human monocytes over a primary culture of human proximal tubular epithelial cells (ptecs) using culture inserts allowing media exchange but forbidding contact between the two cell populations. by rt-pcr, co-cultured epithelial cells showed significant downregulation of bmp ( . ± . -fold; p< . ), a negative regulator of emt, and epithelial marker e-cadherin ( . ± . -fold; p< . ), with marked upregulation of emt genes s a ( . ± . -fold; p< . ) and αsma ( . ± . -fold; p< . ) compared to ptecs cultured in media alone. investigating the mechanism of monocyte driven emt, we evaluated the effects of am , a synthetic retinoid that also inhibits il- and vegf signaling. am markedly reversed the transcriptional profile with reduction of emt markers s a ( . ± . -fold; p< . ), αsma ( . ± . -fold; p< . ) and vimentin ( . ± . -fold; p< . ), and a simultaneous increase in expression of bmp ( . ± . -fold; p< . ), thus reversing the pro-emt milieu. these results indicate that human monocytes induce transcription of emt related genes in ptecs, even in the absence of physical contact. moreover, this phenomenon appears to be mediated in part by il- , vegf, and other pathways mediated by the retinoic acid receptor. thus, in addition to their typical immune functions, macrophages support a milieu within allografts that promotes ta/ if in humans. further investigation into this novel pro-ta/if pathway could ameliorate chronic injury and improve graft survival. old donor kidneys are more likely to develop long-term graft failure, especially if they are exposed to stresses (e.g. rejection). this limited ability of old tissue to withstand stress may be due to its reduced capacity of replication and regeneration. telomere shortening determines lifespan and regenerative capacity. we showed that telomere shortening occurs in old human kidneys. late-generation terc ko mice with critically short telomeres have a reduced lifespan, show an accelerated aging phenotype and are an ideal model to resemble the situation in old human donors. this study addressed the question whether iri causes greater damage in kidneys from late-generation terc ko mice. we studied terc wildtype (wt), early-(g ) and late-generation (g ) terc ko mice day (wt:n= ; g :n= ; g :n= ), (wt:n= ; g :n= ; g :n= ), (wt:n= ; g :n= ; g :n= ) and days (wt:n= ; g :n= ; g :n= ) after iri. acute tubular necrosis was found mainly on days and and was significantly higher in terc ko g kidneys. tubular atrophy (ta) and intersitial fibrosis (if), reflecting chronic damage, were first detected at day and increased in all mice with a significantly higher extent of ta/if in terc ko g kidneys at day ( fig.) . the cell cycle inhibitor p , a downstream mediator of senescence induced by telomere shortening, was significantly upregulated in all groups after iri. p levels were highest in terc ko g kidneys at day ( fig.) . proliferative capacity, as measured by ki- immunostainings at day , was significantly lower in tubular, glomerular and interstitial cells of kidneys from terc ko g mice. we show that late-generation terc ko mice with critically short telomeres have a greater susceptibility towards acute injury and develop more chronic renal damage. this is likely due to the reduced capacity of these kidney to proliferate and thereby to regenerate. our data strongly suggest a pathogenetic role of telomere shortening, an important senescence mechanism, for the development of long-term graft failure. results: belatacept treatment had no effect on the number of peripheral blood treg cells and t cell suppression assays. the percentage of foxp cells was significantly elevated in rejecting kidney allografts in belatacept-treated patients compared to cnitreated patients. conclusions: following chronic belatacept therapy, the number and function of peripheral blood treg cells are maintained in kidney transplant patients. belatacept enhances the treg population in the allograft in patients with acute rejection. therefore, our data suggest that co-stimulation blockade with belatacept does not affect treg homeostasis. the increased number of treg cells in rejecting allografts in belatacepttreated patients may provide a novel mechanism whereby belatacept can mitigate the severity of acute rejection and improve graft survival. the steady-state auc of n-desmethyl-aeb was minor in comparison to aeb and similar between the patient groups: ± ng.h/ml in transplantation vs ± ng.h/ml in psoriasis (p= . ). demographic covariates: in the first week posttransplant with patients receiving fixed-dose aeb , intersubject variability for c was % and for auc was %. aucs were similar in men vs women ( ± vs ± , p= . ). age, which ranged from - years, did not influence auc based on regression analysis (r = . , p= . ). there was a borderline-significant negative correlation between weight (range, - kg) and auc (p = . ); however, its clinical relevance was low in that it could explain < % of the variability in auc (r = . ). there was a significant positive correlation between aeb c and auc (r = . , p< . ). conclusions: ( ) in the first week posttransplant, patients achieved aeb blood levels anticipated for this regimen. ( ) there was notable intersubject pharmacokinetic variability at this time but it was not attributable to standard demographic factors such as sex, age, or weight. ( ) a good correlation was noted between c and auc suggesting that c might serve as a marker for total drug exposure. a we studied which is protocol would be best after rapid discontinuation of p. between / and / , st and nd kidney tx recips were randomized: csa-mmf (n= ) vs. high tac-low srl (n= ) vs. low tac-hi srl (n= ) (for tac and srl levels, high = - , low = - ). all received thymoglobulin (tmg) doses, and p for days; tmg was continued in dgf. min f/u = yr; mean = ± mos. there was no diff between groups in recip age, gender, ethnicity, prim dis, donor source, % retx, pra; or in donor age, gender, ethnicity. there was no signif diff. between groups (intention to treat) in actuarial patient, graft, death-censored (dc) graft, acute rejection (ar), or biopsy-proven chronic rejection rates (cr), serum cr level or calculated (mdrd) gfr or in studied side effects. cr(sd) . (. ); . (. ); . ( . ); . ( ); . (. ) . (. ); . ( ); ( . ); . ( . ); . (. ) . (. ); . (. ); . (. ); . (. ); . (. ) mdrd gfr(sd) ( ), ( ), ( ), ( ), ( ) ( ), ( ), ( ), ( ), ( ) ( ) the most common cause of graft loss was death with function (csa %, high tac %, low tac %). the majority of recips in each group remained p-free (csa %, high tac %, low tac %) but a large % were not on the medications which they were randomized to (csa %, high tac %, low tac %). we found a signif ↑ of new onset diabetes (nodm) (p=. ) in the tac-srl groups: csa %, high tac %, low tac %. there was a trend towards more use of lipd lowering medications in the tac/srl groups. in summary, all is protocols were effective; with min f/u yr for each group, patient and graft survival and ar rates are similar. we found an increased nodm and possibly hyperlipidemia in the tac/srl groups. purpose: we present preliminary -year results from a worldwide trial comparing srl regimens with tac+mmf. methods: renal transplant recipients (n= ) were randomly assigned to the following treatment regimens: group : srl ( - ng/ml, then - ng/ml after week ) + tac ( - ng/ml) with elimination at weeks (n= ); group : srl ( - ng/ ml through week , - ng/ml thereafter) + mmf (up to gm/day) (n= ); or group : tac ( - ng/ml through week , - ng/ml thereafter) + mmf (up to gm/day) (n= ). all patients received corticosteroids and daclizumab. in june , group was terminated (after all patients were accrued) because of increased acute rejection (ar) rates. results: demographic characteristics were similar between groups except for more females in group . patient and graft survival were also similar among groups (see table) . biopsy-confirmed ar (bcar) was significantly greater in group compared with groups and , p< . , and most occurred in the first months posttransplant with preponderance during the first months. subtherapeutic srl trough concentrations were reported in a large number of rejectors in group . most of the rejections in group occurred within the first months before tac was eliminated. all ars were mild to moderate; grade ii ars were proportionally greater in group . mean nankivell gfr was numerically higher in group . preliminary results at years show excellent patient and graft survival and similar renal function among treatment groups, despite higher ar rates in group . early adequate exposure to sirolimus is mandatory to achieve desired (low bcar rates) results. the goal of rapid discontinuation of prednisone (rdp) after kidney transplantation is to minimize prednisone-related side effects without increasing acute rejection (ar) rates or decreasing long-term graft survival. to date, studies have shown that rdp is associated with decreased prednisone (p)-related sided effects, and randomized trials of rdp (vs. long-term p) have shown little or no ↑ in ar rates. however, concern remains that long-term graft survival will be worse with rdp protocols. we studied t½ (the time it takes for ½ of the grafts surviving at year to subsequently fail) for st tx recipients treated with rpd ( - ) (n = ) (antibody, cni, antimetabolite [mmf or srl] , and rdp) vs. st tx historical controls ( ) ( ) ( ) ( ) ( ) ( ) (n = ) treated with a protocol of antibody, cni, antimetabolite [mmf] , and long-term p. table shows characteristiscs of the groups. pra; rdp were more likely to get a living unrelated donor transplant. t ½ is shown separately for living (ld) and deceased (dd) donor transplants in table . there was no significant difference in t½ between groups. we conclude that, compared to historical controls, rapid discontinuation of prednisone can be done without any detrimental impact on long-term outcome. a prospective, randomized study to confirm this observation is necessary. successful a) . we enrolled patients (table ) with an average follow-up of . + . months. subjects - years old included primary and re-transplants, with primary endpoints of renal function and can. follow-up averaged . + . months in patients withdrawn from ci ( from group , from group ). we found no increased rejection after ci discontinuation and that both ratg induction dosing regimen and ci discontinuation significantly impacted renal function and the development of can. we successfully discontinued both calcineurin inhibitors and steroids with either single or divided-dose ratg induction, and single-dose ratg induction independently associated with improved renal function and reduced can. study demographics single-dose ratg ( mg/kg x ) divided-dose ratg ( . mg/kg x ) group (n = ) group (n = ) group (n = ) group (n = ) age . ± . . in subset analysis, we also find an enhanced negative impact of srl when combined with steroids (str) in patients without dgf. conclusion: this data supports previous findings that srl may be associated with a sustained survival disadvantage apparent early post transplant, and that this effect appears exacerbated when combined with dgf or str. several potential explanations for this effect may include srl-associated prolonged early graft dysfunction, hyperlipidemia or proteinuria. however, patients initiating srl after discharge may not evidence this survival disadvantage, and this question was not addressed here.these findings may be of particular importance to centers employing combined srl and str therapy, as well as to define the best mode of support during recovery from dgf. prospective randomized studies would be necessary to evaluate these. table shows cai in both groups from to years. in slr group the doses of cin were significantly lower from one through years (p= . ). cai due to interstitial fibrosis/ tubular atrophy was significantly lower in slr group at years. our data shows that year patient and graft survival, graft function, bpar and scar were comparable between mmf and slr groups despite lower prevelance of interstitial fibrosis/tubular atrophy in slr group. registry analyses suggest that tac/mpa immunosuppression is associated with superior kidney graft survival vs. tac/srl. large single-center experience may assist in clarifying these findings, by examining outcomes related to specific utilization practice. we retrospectively examined the outcomes of consecutive first renal transplants ( % deceased donor, % living donor) at a single center, treated with tac/srl or tac/mpa. graft and patient survival, acute rejection rates, and yr egfr were analyzed by era of transplant ( - vs. - ) . changes in tac/srl utilization between eras included elimination of the srl loading dose and a reduction in tac target trough concentrations. summary. compared to tac, srl+cya was associated with a % decreased risk of skin ca that was statistically significant. although srl+cya was associated with a % decreased risk of de novo solid ca, it did not reach statistical significance. this reduced risk may not reflect the unique aspects of srl itself, but may be a reflection of practice pattern, patient selection or center effect. the backgrounds: a number of studies have observed increase of malignancies following renal transplantation. however, the incidence and the site of malignancies were quite different by the follow-up times, the era and the region. methods: we reviewed the records of renal transplant recipients in our institute between and and recorded the incidence and types of de novo malignancies. they were divided into two groups by immunosuppressive era; azathioprine (aza) era ( . - . : n= ) and calcineurin inhibitor (cni) era ( . -: n= ) . results: a total of ( in aza era and in cni era) kidney recipients out of developed malignancies. the tumors included gi-tract cancers, liver cancers, skin cancers, tongue cancers, breast cancers, renal cell carcinomas, thyroid cancers, leukemia, lymphoma, one lung cancer, one uterus cancer and one kaposi's sarcoma (ks). the average interval between transplantation and development of malignancy was ± ( - ) months. mortality was high in liver cancer ( %) and leukemia ( %). cumulative incidence of malignancies of all recipients in , , , years were . %, . %, . % and . %, respectively. graft-loss censored cumulative incidence, which was calculated to see the incidence among graft survivors under continuing immunosuppression, of all recipients in , , , years were . %, . %, . % and . %. that of , and years in cni era was . %, . % and . %, while that in aza era was . %, . % and . %, showing early higher incidence in cni era outstripped by aza era by years. site of malignancy in cni era occurring within years, which was never observed in aza era, was focused on liver, leukemia (including atl), ks and ptld. discussions:our results demonstrated that recent potent immunosuppressive regimen shortened the interval between transplantation and viral-related malignancies. however, long-term incidence of whole malignancies has been decreasing by minimizing chronic immunosuppression in our institute. the impact of transplant center practice on the association between pulsatile perfusion and delayed graft function. jagbir gill, david gjertson, suphamai bunnapradist, michael cecka. ucla, la, ca. the use of pulsatile perfusion (pp) is increasing in the us, but practice varies widely among transplant (tx) centers. we describe the variability of pp use and its impact on post transplant outcomes. methods: we identified all cadaveric kidney tx from - using optn/unos data. the cohort was stratified by tx center pp use as follows: low pp centers ( - % pp use), med pp centers ( - % pp use), and high pp centers (> % pp use). donor characteristics and the incidence of dgf were compared between and within each strata. results: pp was used by % of centers, however most centers used pp < % of the time ( . %). compared to low and med pp use centers, kidneys pumped in high pp centers were from donors that were younger, had a lower mean terminal serum creatinine, and had a lower incidence of cva and hypertension. the overall incidence of dgf was lowest in the high pp centers ( . %), compared to the med ( . %) and low pp ( . %) centers. the rates of dgf within each strata (high, med, and low pp centers) for tx performed using pp versus cold storage (cs) are outlined in the table below . within each strata, the rate of dgf did not differ between tx performed with and without pp. in ecd transplants, pp was associated with lower rates of dgf across all center groups. however, the impact of pp on scd and dcd transplants was less significant and varied across centers by pp use. hla sensitized patients ( - %) in our dsa are now transplanted at a rate of %, which is significantly higher (p = . ) than the % rate when ua weren't entered into unet. furthermore, of kidneys imported into our dsa and allocated to the dsawide renal candidate list (since ua entry started), % ( / ) were transplanted into sensitized candidates ( % to %), each of whom had a negative flow or ahg t cell igg crossmatch. conclusion. the higher transplantation rate for hla sensitized patients in our dsa shows that virtual a, b, & c crossmatching yields a dsa-wide ranked list of sensitized candidates likely to have a negative final class i (t cell) crossmatch and be transplanted. the data also lend support to the notion that sharing kidneys across dsa boundaries for hla sensitized candidates, based on a negative virtual hla class i crossmatch, has merit. predicting introduction: predicting graft outcome after renal transplantation based on donor histological features has remained elusive and is subject to institutional variability. we propose a pre-transplant donor path scoring system that reliably predicts graft outcome regardless of recipient ® characteristics. methods: we retrospective analyzed imported cadaveric renal transplants which were initially rejected by other centers due to donor parameters between / - / . all kidneys were re-biopsied at our center prior to implantation. morphometric analysis performed consisted of measuring glomerular-size arterioles, interlobular, and arcuate/ interlobar arteries and wall to lumen ratio (wlr) was calculated; calculating % glomerulosclerosis (gs); the presence of arteriolar hyalinosis (ah), scar, periglomerular fibrosis (pfg), and acute tubular necrosis in the biopsies. the patients were followed for a mean of months. multivariate cox analysis was done to evaluate the predictive value of these path variables to graft outcome.results: ah, gs> %, wlr> . , pgf, and scar were found to independently predict graft outcome. the unos board of directors has approved the change from using panel reactive antibodies (pra) to calculated pra (cpra). the cpra is a formulated pra based upon the frequency of the specificities of hla antigens found in the donor pool and is expected to standardize the degree of patient sensitization. donor organs expressing unacceptable antigens will not be offered to a recipient with donor (hla) antigen specific antibodies (dsa). highly sensitive, single antigen bead and solid phase assays (flow pra and luminex) are used to identify these hla antibodies (abs). each transplant center can determine the criteria used for identifying an unacceptable antigen, for example, based upon dsa titer or the fluorescence intensity (fi) coming from the donor-specific single antigen bead. it is unclear whether abs identified by these techniques are clinically relevant for organ allocation. we retrospectively evaluated flow-pra, flow cytometry crossmatching (fcxm), hla ab specificities and titers of pre-transplant (tx) sera from transplant recipients of deceased renal allograft donors transplanted following a negative cytotoxic-anti-human globulin crossmatch. the two year graft survival of % for the recipients ( / , %) with low-titer (≤ : ) donor specific hla ab and a negative (-) fcxm was significantly better when compared to the % two year graft survival of the % ( / ) of recipients presenting with (+) dsa but a (+) fcxm (p< . ). recipients ( / , %) with non-donor abstracts specific hla abs (high or low titer) and a (-) fcxm also experienced a better two year graft survival of % compared to the % for the other % of recipients with (+) fcxms (p < . ). these data suggest that in the presence of donor-specific or non-donor-specific hla abs you can not predict the crossmatch outcome without actually performing the crossmatch which will then influence donor organ allocation and graft survival outcome. in the face of low-titer dsa and a (-) fcxm recipients experienced excellent graft outcome when compared to recipients with (+) fcxms. therefore, donor organ allocation based on cpra (ab specificity and unacceptable ags) utilizing highly sensitive single antigen bead and solid phase luminex assays may disadvantage recipients (no donor crossmatch) who could otherwise be successfully transplanted. aim: to assess vegfr expression in hcc and the adjacent benign cirrhotic parenchyma and its correlation with tumor differentiation, vascular invasion, and tumor morphologic parameters. background: hcc is a highly vascular tumor in which angiogenesis is mediated in part by vegf. vegf is highly expressed in hcc and mediates its effects through multiple receptors including vegfr . the tyrosine kinase inhibitor sorafenib inactivates the vegfr receptor and exhibits anti-tumor effects in hcc. clinical significance of vegfr expression with respect to tumor parameters has not been evaluated. patients and methods: immunohistochemical staining for vegfr was performed in hcc and corresponding adjacent cirrhotic liver from patients undergoing liver transplant. patients had hcc within mc. stains were scored by estimating the % of positive surface area in veins, arteries, and sinusoidal lining cells. data are presented as median [p , p ]; wilcoxon signed rank and wilcoxon rank sum tests were used. results: vegfr levels in hcc were significantly correlated to levels in adjacent non-tumorous liver. higher levels of vegfr in non-tumorous liver were associated with higher levels in hcc from the same patient. vegfr levels were significantly higher in hcc compared to adjacent areas (p< . ). vegfr levels in hcc were not significantly different between patients who fell within mc and those beyond mc. however, vegfr levels were significantly higher in the adjacent arteries of nontumorous liver ( . [ , ] vs. [ , ]; p= . ) in those patients with hcc beyond mc. subjects with moderate or poor differentiation had significantly higher levels of vegfr in sinusoids and veins of hcc and in the sinusoids of adjacent non-tumorous liver. there was no correlation with vascular invasion. conclusions: elevated vegfr in hcc correlates with elevated vegfr in adjacent cirrhosis, suggesting that high expressing hcc arise in a high vegfr expression, pro-angiogenic environment. moreover, higher vegfr expression in background cirrhosis correlates with advanced hcc (beyond mc), suggesting that anti-angiogenic agents may prevent tumor formation or progression in cirrhotic patients. this novel concept warrants further study. . we further attempted to find a subgroup of patients combining tumor size, number of nodules and various levels of afp which together would correlate strongly with pdiff tumors. however, the distribution was erratic and even in extreme outliers (> nodules, > cm in maximum size, with or without high afp), where transplantation is currently not indicated according to any current expanded tumor inclusion criteria, the incidence of pdiff did not exceed %. conclusions: pdiff is most highly associated with tumors that exceed the milan criteria and the expanded criteria currently used for liver transplantation. thus, tumor biopsy would not appear to be of benefit except perhaps in those patients with a high afp level. however, if tumor criteria are further extended in the future, tumor biopsy may be justified in those with higher tumor burdens. < cm) ), , ( . %) at ls=t ( tumor < cm or tumors ≤ cm), and ( . %) with ls> . results: overall survival at months was . %, with significant differences seen for listing stage (ls = . %, ls = . % ls> = . %, p= . ) and by histologic stage as determined by pathology (p<. ). survival for patients with histologic stage b hcc was only % at months, versus % for stage . patients with tumors greater than cm both by listing stage and by pathology fared poorly compared to those with smaller tumors (p= . . ). patients listed who received ablation treatment (at) preoperatively and who had their tumors "down-staged" had better results (p= . ). we observed no difference in at types (tace vs rfa). those with micro or macrovascular invasion had lower survival rates, at . % and . %, respectively (p <. ). afp > continues to be a significant predictor of lower post-transplant survival, with a survival rate of . % at -months (p<. ). conclusions: we conclude that listing and histologic tumor size, presence of micro/ macrovascular invasion, and high afp are associated with poorer lt results. at is emerging as potentially effective treatment for improving lt outcomes for hcc recipients. introduction: so far, milan criteria are used to select patients with hepatocellular carcinoma (hcc) for liver transplantation (lt). herein we compare prognostic markers in patients with pretreatment by transarterial chemoembolization (tace) to a second cohort transplanted without tace pretreatment. patients and methods: between september and october , patients with hcc underwent lt at our institution. eighty-two patients were pretreated by repeatedly performed tace whereas in patients none or other forms of pretreatment had been used (non-tace group). tace was performed using lipiodol and mitomycin. every weeks tace was repeated until transplantation. tumor response was assessed by ct scans ( -week intervals). results: sixty-seven percent of the patients transplanted after tace pretreatment exceeded the milan criteria compared to % in non-tace patients. the proportion of recurrence-free patients was comparable in the tace and non-tace group ( . % and . %, respectively). in the univariate analysis grading, angioinvasion and progress-free tace were significant predictors for recurrence after lt in patients with tace pretreatment. progress-free tace was the only significant predictor of recurrence in the multivariate analysis. in the non-tace group t classification, number of nodules, grading, angioinvasion, milan criteria and underlying disease (hcv versus all other diseases) were significant. after tace pretreatment freedom from recurrence was . % in patients with stable disease or regress but only . % in patients with progress during tace. conclusions: tace pretreatment is capable of selecting a biological entity of tumors which differs significantly from untreated tumors. this statement is deduced from the remarkable differences of predictors for tumor recurrence in patients with and without tace pretreatment. moreover, tace patients can be separated into two groups: those who experienced tumor progress during repeatedly performed tace and those who did not. stable disease during the continued tace before transplantation resulted in remarkably low tumor recurrence. liver with a median follow-up of months, there was no statistical difference in the year overall survival in the m ( %) and m+ ( %) groups (p= . ). the -year disease free survival was significantly higher in the m ( %) vs. m+ ( %) groups (p= . ). when stratifying for ucsf criteria tumors, the -year disease free survival was milan ( %) vs. ucsf ( %) vs. beyond ucsf ( %) groups (p= . ). univariate analysis demonstrated the following factors to be associated with disease recurrence: intermediate waiting time - months (p= . ), preoperative tace (p= . ) or resection (p= . ), more than tumors (p= . ), and max tumor size over cm (p= . ). multivariate analysis controlling for age, gender, and waiting time demonstrated that preoperative resection hr . ( %ci . - . ), more than tumors hr . ( %ci . - . ) and max tumor size greater than cm hr . ( %ci . - . ) were independently associated with disease recurrence. conclusions: the overall survival after liver transplantation is excellent in the m and m+ groups, far exceeding survival rates that can be obtained via any other modality. the current unos hcc algorithm should be reconsidered, to allow extra listing points for selected patients with hcc that exceed both the milan and ucsf criteria. postoperative use of intense insulin therapy in liver transplant recipients. lama m. hsaiky, iman e. bajjoka, dhaval patel, marwan s. abouljoud. transplant institute, henry ford hospital, detroit, mi. hyperglycemia and insulin resistance are common post liver transplant, even in patients with no history of diabetes. in the general surgical intensive care unit (sicu) population, the use of intensive control of blood glucose has recently been shown to reduce both morbidity and mortality. thus far, limited data exist in the liver transplant population. purpose: assess the impact of intensive insulin therapy to maintain blood glucose at or below mg/dl immediately post liver transplantation in the surgical intensive care unit (sicu). methods: a retrospective evaluation of liver transplant recipients who received two different insulin protocols in the sicu was performed. prior to january , patients were assigned to receive sliding scale insulin therapy (ssit) to maintain blood glucose (bg) less than mg/dl. the intensive insulin therapy (iit) was implemented in august with a goal bg level between - mg/dl. the following data was analyzed: bg ranges, need for mechanical ventilation, blood transfusions, infection rate in the sicu, rejection episodes and patient survival. results: a total of liver transplant patients were evaluated; of which patients were in the ssit group and the other in the iit group. demographic characteristics were comparable between the two groups. in the iit, % of the bg readings were maintained at < mg/dl versus % in the ssit. the incidence of hypoglycemia (bg < mg/dl) was less than % in both groups. the need for mechanical ventilation was . days vs. . days and the overall number of blood transfusion was on an average of . vs. units (p< . ) in the ssit vs. iit group, respectively. iit also reduced overall sicu infection rate by % (p= . ). the rate of acute cellular rejection at months post transplant was less in the iit, % vs. % in the ssit group (p= . ). moreover, mortality during hospital stay was reduced from % in the ssit to % in the iit group. conclusions: the use of intense insulin therapy immediately post liver transplantation has resulted in reducing infection rate and rejection episodes and a trend for reduced morbidity and mortality among post surgical liver transplant recipients without the adverse effects of hypoglycemia. medical epidemiology of patients surviving ten years after liver transplantation. kerri a. simo, stephanie e. sereika, david a. gerber. abdominal transplantation division, department of general surgery, university of north carolina, chapel hill, nc. background: as the population of long term survivors of liver transplantation (olt) grows, their medical epidemiology has become increasingly important. the goals of this study were to define a collective profile of liver transplant recipients ≥ years post olt and to compare their co-morbidities with those of the general population. in , the national health survey reported that % of the us population had hypertension, . % had diabetes/impaired fasting glucose, and . % had chronic kidney disease. methods: a retrospective review of a prospectively collected database of adult patients who underwent olt at a single transplant center from september , to october , was performed. inclusion criteria consisted of survival ≥ years post olt with > year follow up. results: seventy-one patients met inclusion criteria. ninety percent of patients had ≥ years follow up. the mean age at transplant was (range - ). the mean calculated meld score was (range - , median= ). indications for olt were hcv( %), alcohol( %), cryptogenic( %), autoimmune( %), hbv( %), psc( %), pbc( %), and other( %). seven patients required retransplant during the first years. an additional patients underwent other operations: arterial or biliary revisions, hernia repairs and non-transplant related ( abdominal). during analysis, the following medical co-morbidities were found: patients( %) had hypertension ( new onset), ( %) diabetes ( new onset), ( %) renal insufficiency and renal failure ( new onset), ( %) cardiovascular disease (all new onset). nine patients ( %) were diagnosed with de novo cancer. medications for chronic health problems included patients on diabetic medications, on antihypertensives and on lipid lowering agents. initial immunosuppression consisted of % on steroids, % on cyclosporine, % on tacrolimus, % on mycophenolate mofetil (mmf) and % on azathioprine. immunosuppression at years consisted of % on cyclosporine, % on tacrolimus, % on steroids, % on mmf, % on sirolimus, % on mycophenolate sodium, % on azathioprine. no patients were on triple therapy, were on dual therapy, and were on monotherapy. summary: patients alive years post olt have a significantly higher incidence of hypertension, diabetes, and renal disease than the general population. this study supports conscientious medical follow up to ensure continued meaningful survival. liver transplantation in the morbidly obese (bmi> ). c. quintini, l. kauzman, k. hashimoto, p. ding, t. doago uso', n. sopko, j. rosenblum, f. aucejo, c. winans, d. kelly, b. eghtesad, d. vogt, j. j. fung, c. miller. general surgery -liver transplant service, cleveland clinic oh. morbid obesity (mo) is a problem seen with increasing frequency among candidates for olt. mo is considered a contraindication for olt in some centers without clear evidence to support such a practice. our aim is to describe outcomes for olt in patients with a bmi> kg/m in a single center. methods. between / and / , olts were performed in patients. / patients with a bmi> were compared to all other olt patients with a bmi< . we analyzed patient and graft survival, operative time, blood transfusion requirements, and post operative events (icu and overall length of stay los, surgical complications and infections). we also analyzed the post transplant weight records of our study group at - and months. results. results are summarized in table . outcomes of olt in the morbidly obese are no worse than those of other patients undergoing olt. bmi is often artificially elevated in end-stage cirrhotic due to severe fluid retention. these patients exhibit rapid weight loss following transplantation that is likely due to extra-cellular fluid loss from the improved homeostatic milieu provided by the new liver and possible improvement in renal function. the presence of obstructive cad was not associated with increased peri-operative morbidity or mortality. these patients experienced similar patient and graft survival irrespective of the degree of cad. significant unmodified cad should not represent an absolute contraindication to liver transplantation. olt was also examined. we found that using a trj of . m/s as a cut-off created two age-matched groups with significantly different survival curves at one year (p = . ) with a relative risk of mortality of . for trj ≥ . m/s. this study underscores the importance of screening tte for the presence of pph in the evaluation of patients for olt, suggesting that clinically significant pph may be present at lower trj than typically prompt right heart catheterization. some of the limitations of the study are the variability of the time from pre-olt echo to transplant, and the assumption of rap = without assessment of ivc size. we are using these data as a framework for further prospective trials to better assess the clinical applications of the findings. hyperlipidemia has been shown to predict faster chronic kidney disease (ckd) progression over the long term in lung allograft recipients. it is unknown whether disordered lipid metabolism may also aggravate the early loss of renal function often seen in this patient population in the immediate post-operative period. we studied lung allograft recipients transplanted between january and december . pertinent demographic and clinical variables were recorded at baseline and one month post-transplant, including creatinine levels and fasting lipid panels. logistic regression models were created to investigate an independent association between lipid levels and change in renal function by one month post-transplant. mean +/-sd baseline creatinine was . +/- . mg/dl and low density lipoprotein (ldl) was +/- mg/dl, the latter remaining unchanged at one month. in contrast, by one month post-transplant the mean creatinine level of survivors increased significantly to . +/- . mg/dl (p < . ), with a overall mean increase of % above baseline. the highest quartile of patients that fared the worst experienced a rise in creatinine > % above baseline. on univariate analysis, there was a strong trend toward those with one month ldl values in the highest quartile (i.e., > mg/dl) having an increased odds of experiencing a rise in creatinine by one month > % above baseline (or . , p= . ). after controlling for age, gender, pre-transplant creatinine, bmi, and the presence of diabetes prior to transplant an ldl value in the highest quartile by one month post-transplant was the only variable independently predictive of a rise in creatinine > % above baseline at one month (or . , p= . ). in summary, hyperlipidemia occurring early post-lung transplant predicts faster loss of renal function soon after surgery. though speculative, given the known beneficial effects of lipid lowering agents such as statins on the rate of ckd progression, perhaps timely initiation of these medications after surgery may also attenuate the early decline in renal function often observed in this patient population. the risk for acute cellular rejection (acr) following lung transplantation (ltx) is still a problem despite heavy multidrug immunosuppression. induction therapy with potent t-cell depleting agents have facilitated the implementation of minimal post-transplant immunosuppression.the impact of this protocol on the activation of proinflammatory cytokines and effector molecules that affect the cellular rejection process is not well determined. in this study, we evaluated the relationship between upregulation of t-cell and macrophage-dependent inflammatory cytokines detected by molecular methods and the clinical status of ltx patients. we studied ltx patients who received anti-lymphocytic induction therapy(thymoglobulin n= or campath- h n= ) followed by maintenance immunosuppression with tacrolimus and low-dose steroids. we analyzed bronchoalveolar lavage (bal) mrna samples ( - per ltx patient) by real-time pcr for gzmb, ifn-γ, il- , mcp- , rantes, tnf-α, and gapdh (control). the abi prism sds and fast real-time pcr systems were used and data were analyzed by the dct and -ddct methods. we determined the relationship of categorical outcomes (rejection-no rejection) with continuous variables (number of cycles) by anova. early acr that occurred within the first days post-ltx was associated with an increase (> - fold) of macrophage-specific mrna (mcp- , rantes, tnf-α). / thymo-treated ltx patients experienced early acr while only / campath- h-treated patients had early acr (p< . ). in contrast, late acr that occurred greater than days post-ltx was associated with a significant upregulation ( - fold) of t-cell dependent mrna (gzmb and ifn-γ) in addition to increases of rantes and mcp- mrna. overall, ltx patients who experienced early or late acr (n= ) exhibited higher mrna levels for the above mediators compared to stable patients (n= ). our data indicated that in early post-t-cell depletion, the acr phenotype was characterized mainly by macrophage activation. in contrast, greater than months post-ltx with the recovery of cd + t-cells, the acr phenotype was associated with cytotoxic t-cell activation. furthermore, sensitive molecular methods may detect the activation of pro-inflammatory mediators within the allograft prior to the diagnosis of rejection by transbronchial biopsies and may impact optimal patient management. antibody-mediated rejection (amr) is defined by the presence of donor-specific alloantibodies, markers of complement activation and the clinical phenotype of organ dysfunction. compared to renal and cardiac allografts, very few amr cases are documented in lung transplantation (ltx). methods. we report here on seventeen ltx patients exhibiting: ) donor-specific hla antibodies (dsa); ) linear, continuous subendothelial c d deposition in lung allograft; ) lung allograft dysfunction. the presence and specificity of dsa were determined by elisa and/or luminex. c d deposition was assessed by immunohistochemistry in transbronchial biopsy paraffin blocks. allograft dysfunction was considered when either biopsy-proven acute cellular rejection (acr, ≥ ishlt a ) or bronchiolitis obliterans (bos) were diagnosed. the average detection of dsa occurred in the first year post-ltx, on ± postoperative day (pod), range to days. thirteen ( %) of amr patients were females. an anamnestic humoral response was encountered in cases (one pregnancyrelated and three re-transplant patients), while de novo dsa were detected in cases ( %). the percent-reactive antibody (pra) was lower in de novo cases ( %) when compared to memory response ( %, p< . ). anti-class i dsa were found in cases, anti-class ii in cases, while patients exhibited both class i and class ii dsa. specific vascular c d deposition was detected in ( %) patients. lung allograft dysfunction was considered in ( %) cases, while three patients with dsa and specific c d deposition fulfilled the criteria of sub-clinical amr. in patients where plasma-exchange/ ivig were applied, antibody titers dropped from : to : or : in two cases; in a third case, antibody titer remained high post-pheresis ( : ) and the graft failed. conclusions: both anti-class i and anti-class ii, low pra or high pra, pre-formed or de novo dsa can be detrimental for lung allograft. the presence of donor-specific alloantibodies, vascular c d deposition and allograft dysfunction shows that amr criteria can also be met in ltx. rationale: recently, inhaled cyclosporine has been shown to reduce mortality and bos. previously, we demonstrated that apically-dosed cyclosporine poorly transmigrated differentiated human airway epithelial cells in vitro (using a transwell system). only ∼ % of the apically deposited cyclosporine passed through the epithelial layer whereas most of the drug accumulated within the epithelium. thus inhaled cyclosporine may not be capable of inactivating airway allogeneic t cells since it may not reach the airway wall in high concentration. in this study, we hypothesized that inhaled cyclosporine alters airway epithelial signaling cascades that may ultimately result in reduced inflammatory cell recruitment to the lung. methods: human tracheobronchial epithelial (htbe) cells from healthy donors were grown in ali media to confluence at an air-liquid interface in millicells. differentiated htbes were treated on their apical surface with cyclosporine concentrations of and , ng/ml or vehicle for hr to mimic the effects of inhaled cycolsporine. the basilar and apical compartments (n= - for each) were then assayed for cytokine secretion (il , il , il , il- p , tnf, eotaxin, mcp- , gm-csf, rantes and egf) by luminex assays in pg/ml. results: , ng /ml of cyclosporine markedly blunted the basilar secretion of il- ( ± vs ± , p= . ), rantes ( ± vs ± , p= . ), gm-csf ( ± vs ± , p= . ) and mcp- ( ± vs ± , p= . ). il and eotaxin were unaffected; tnfα, il β and il p were undetectable. at ng/ml cyclosporine, cytokine secretion was decreased to a lesser extent. a similar pattern of diminished cytokine secretion was seen in the apical compartment of this system. last, apical, but not basal, egf secretion was augmented by cyclosporine ( ± vs ± pg/ml, p= . ). conclusion: cyclosporine decreased the secretion of critical cytokines and chemokines from human airway epithelial cells. these mediators are known to enhance mononuclear and t cell recruitment in a large variety of animal models of disease as well as in clinical studies. inhaled cyclosporine may work by reducing cell recruitment. this hypothesis will require in vivo testing. funded by: cf foundation. background: cytomegalovirus (cmv), human herpes virus - and - (hhv- and - ) are β-herpesviruses that commonly reactivate and have been proposed to trigger acute rejection and chronic allograft injury. the role of these viruses in the development of bos after lung transplantation remains unclear. we assessed the contribution of β-herpesvirus infection in the allograft by a prospective molecular assessment of serial broncho-alveolar lavage (bal) samples in lung transplant recipients. methods: quantitative real-time pcr of bal samples were performed for cmv, hhv- and hhv- in a prospective cohort of lung transplant recipients. a time-dependent cox regression analysis was used to correlate the risk of bos and acute rejection in patients with and without β-herpesviruses infection. results: patients were included in the study over a period of years. a total of samples from bal were obtained (median per patient). / patients ( %) had at least one positive result for one of the β-herpesviruses: patients ( %) for cmv, patients ( %) for hhv- , and patients ( %) for hhv- . median time to detection was days (range - ) for cmv, days (range - ) for hhv- , and days (range - ) for hhv- . median peak viral load was , copies/ml (range - , , ) for cmv, copies/ml (range - , ) for hhv- , and copies/ml (range - , ) for hhv- . acute rejection (≥ grade ) occurred in % and bos (≥ stage ) in %. in the time dependent cox regression model, the relative risk of bos or acute rejection was not increased in patients with cmv, hhv- , or hhv- reactivation. for example, the hazard ratio of cmv and bos was . ( % ci . - . , p= . ) and for cmv and acute rejection was . ( % ci . - . , p= . ). in many of the patients, β-herpesvirus reactivation occurred after the acute rejection episode likely reflecting augmented immunosuppression. abstract# mannose binding lectin in this large cohort of lung transplant recipients, local reactivation of cmv, hhv- and hhv- in the allograft was very common. however, despite high viral loads in many patients, infection was not significantly associated with the development of acute rejection or bos. introduction: the role of chemokine receptors in regulating donor-specific responses to allografts is poorly understood. cd + cd + t cells regulate alloreactive cd t cell responses and acute rejection of single class ii mhc-disparate cardiac allografts in c bl/ mice. ccr is expressed by a small proportion of cd + cd + t cells but the requirement for these cells in regulating alloreactive t cell responses remains poorly understood. the goal of this study was to investigate the role of ccr + t regulatory cells in acute rejection of single class ii mhc-disparate cardiac allografts. methods: wild-type c bl/ (h- b ) and b .ccr -/received heterotopically transplanted b .h- bm mice heart grafts. the presence of cd + foxp + t cells in the recipient spleen and in heart allografts was determined by flow cytometry. foxp mrna expression in the heart grafts was analyzed by qrt-pcr. donor-specific cd + t cells producing ifn-g or il- in allograft recipient spleens were enumerated by elispot assay. cell sorted naïve wild-type cd + cd + t cells and cd + cd -t cells were adoptively transferred to wild-type and ccr -/mice before the cardiac transplant. results: in wild-type recipients > % b .h- bm cardiac grafts survived more than days whereas ccr -/recipients rejected the allografts within days ( days mean survival) with intense cd + t cell infiltration in the graft. donor-reactive ifn-g and il- producing cd + t cell numbers were increased -fold in the spleens of ccr -/vs. wild-type recipients at day post-transplant and in contrast to wild-type recipients these numbers were sustained for at least more days. allograft infiltrating cd + cd + foxp + cells and intra-graft foxp mrna expression were clearly present in allografts from wild-type recipients and were virtually absent in allografts from ccr -/recipients. transfer of purified wild-type cd + cd + t cells to ccr -deficient mice resulted in the long-term survival of % of b .h- bm cardiac allografts. conclusion: ccr + regulatory t cells control the magnitude and function of the alloreactive t cell immune response to single class ii mhc-disparate cardiac allografts. profile that were distinct from those of cd +cd + tregs, naïve cd +cd -t-cells, and activated cd + t-cells. furthermore, the cd + converted dn t-cells were highly potent in suppressing antigen specific alloimmune responses in vitro. in this study, we further characterized and test the functional potential of the converted dn t-cells in vivo. we showed that the converted dn t-cells retained a stable phenotype after re-stimulation in vitro and in vivo. il- was capable of breaking the anergic status and reserving the suppressive function of dn t-cells. in an immunocompetent mhc completely mismatched islet transplant model, the transfer of x dn t-cells (converted from cd +cd -t-cells of naïve c bl/ mice by co-culture with mature dba/ dc plus ril- in mlr for days) resulted in a statistically significant prolongation of alloantigen specific dba/ strain, but not third party c h strain, islet allograft survival in c bl/ recipients in comparison with that of untreated control group. as il- was capable of breaking the anergic status and reserving the suppressive function of dn t-cells, we added il- /fc, a long-lasting form of il- , and low dose rapamycin with dn t-cells in a mhc mismatched skin allograft model. the single transfer of x dn t-cells plus days il- /fc and low dose rapamycin treatment significantly prolong dba/ skin allograft survival in c bl/ recipients in comparison with untreated group (mst days vs. days, p= . ) and il- /fc plus rapamycin treated group mst ( days vs. days, p= . ). the results of using ex vivo cd + t-cells converted dn t-cells in skin and islet transplantation models support the concept and the feasibility of potentially utilizing this novel cell-based therapeutic approach clinically for the prevention of allograft rejection. jessamyn bagley, jonathan g. godwin, joren madsen, john iacomini. introduction: it has been suggested that natural killer (nk) cells are critical mediators that connect the innate and adaptive immune response. cytokine production by nk cells contributes to the polarization of immune responses to t helper , and nk cells express co-stimulatory molecules that may affect t cell proliferation. recent work has shown that nk cells are involved in the chronic rejection of parental cardiac grafts by f recipients. we hypothesized that given the role of nk cells in t cell activation and proliferation, nk cells may play a role in the development and function of t regulatory cells (treg) which control alloreactive responses. methods: nk, cd + t cells and cd +cd + treg were purified from the spleens of c bl/ j mice using macs bead separation followed by fluorescence activated cell sorting. naïve cd +cd -t cells from c bl/ j mice (h- b) were placed in culture with tgf-beta in the presence or absence of nk cells, and the development of treg was monitored by assessing foxp expression by intracellular cytokine staining and flow cytometry. in addition, the effect of nk cells on the function of treg was measured by elispot assay. results: following days of culture with tgf-β and anti-cd antibody, cd +cd -t cells acquire foxp expression. the addition of activated nk cells to cultures with cd +cd -t cells and tgf-β prevented the acquisition of foxp expression by cd cells. tregs induced by stimulation of cd +cd -t cells with anti-cd in the presence of tgf-β are capable of suppressing the production of il- , ifn-γ and il- by cd t cells in response to fully allogeneic balb/c stimulators. however, in the presence of activated nk cells, induced tregs fail to function, and production of il- , ifn-γ and il- by cd t cells is restored. these experiments were repeated with natural cd +cd + tregs isolated directly from mice without induction, and found that the ability of natural treg to suppress a cd t cell response to alloantigen was impaired in the presence of activated nk cells. conclusions: the presence of activated nk cells in culture can prevent the development of induced treg. furthermore, the presence of activated nk cells interferes with the function of mature treg in culture and allows a productive cytokine response by cd effector cells in response to alloantigen. results: both the syngeneic b cells and allogeneic dba/ cells survived nicely in the rag-/-il- rg-/-mice. however, the allogeneic dba/ cells, but not the syngeneic b cells, were readily killed by the nk cells in the rag-/-mice. however, both rag-/-and rag-/-il- rg-/-mice accepted the dba/ skin allograft long term without any sign of rejection (> days). thus, nk cells by themselves, though cytolytic to dba/ cells, fail to reject the dba/ skin allografts. to test the hypothesis that the activation status of nk cells may dictate their alloreactive potential, we treated the rag-/-mice with il- /il- ra complex to maximally stimulate the nk cells in vivo. we found that il- is remarkably potent in stimulating nk cells in vivo; and nk cells stimulated by il- express an activated phenotype and are surprisingly potent in mediating acute skin allograft rejection in the absence of any adaptive immune cells, as il- treated rag-/-, but not the rag-/-il- rg-/-mice, readily rejected the dba/ skin allografts (mst= days). nk cell-mediated graft rejection doesn't show features of memory responses. and suggests that the fate of the allografts may depend on the activation status of nk cells and the availability of nk stimulating cytokines. background: t-bet is a transcription factor that promotes th development. both t-bet and the cytokines ifng and il- have been implicated as negative regulators of th . in contrast, il- promotes th development. il- production is associated with granulocytic pathologies in several disease states. hence, this study assessed the relationship between t-bet, ifng, il- and il- in th induction and granulocytic infiltration of cardiac allografts. (ifng-/-) mice were transplanted with balb/c cardiac allografts. recipients were left untreated, depleted of cd + or cd + cells, treated with anti-cd l mab, and/or treated with neutralizing anti-il- or anti-il- mab. graft histology was assessed and primed donor-reactive th responses were quantified by elispot. intragraft expression of il- and the th transcription factor rorgt were quantified by real-time rt-pcr. results: wt and t-bet-/-mice rejected their allografts at a similar tempo but with distinct pathologies: allografts in t-bet-/-recipients were heavily infiltrated with granulocytes while graft infiltrating cells in wt recipients were primarily mononuclear. while th and th responses were readily detectable in t-bet-/-recipients, th dominated the response in wt mice and th were not detectable. depletion of cd + cells prolonged graft survival in wt, but not in t-bet-/-recipients suggesting that cd + cells mediated rejection independent of cd + help in t-bet-/-mice. cd + cells were the source of il- in t-bet-/-recipients. anti-cd l therapy promoted long-term allograft survival in wt recipients, but not t-bet-/-mice unless cd + cells were depleted. additionally, anti-cd l therapy inhibited th responses in both wt and t-bet-/-recipients, but not the cd + th response in t-bet-/-mice. eliminating ifng and il- failed to induce il- production, while neutralizing il- reduced the th response in t-bet-/-mice. conclusions: while cd + th have been described in detail, cd + th have received less attention. in t-bet-/-allograft recipients, cd + th emerge independent of cd + help. cd + th are resistant to anti-cd l therapy and are associated with granulocyte infiltration of the graft. these data implicate t-bet, as opposed to ifng and il- , as a negative regulator of the th response while il- is required for cd + th induction. nan zhang, bernd schroppel, girdari lal, jordi c. ochando, jonathan s. bromberg. background: cd + cd + foxp + regulatory t cells (treg) are important in suppressing immunity to prolong allograft survival. treg migration and its effects on suppressive activity are poorly understood. we determined treg migration patterns and effector function in an islet allograft model. ccr -/-, ccr -/-, ccr -/-, ccr -/-, l-selectin (cd l) -/-, and fucosyltransferase (fuct) iv-vii -/-c bl/ mice were used to generate treg. treg were transferred intravenously, or locally to islet allografts, following islet transplantation (balb/c into c bl/ ). transferred treg were labeled with red dye pkh and migration to islet grafts, draining lns (dln), peripheral lns and spleen were tracked with fluorescence microscopy and flow cytometry. islet allograft survival was determined by measurement of blood glucose. results: treg expressed p-selectin ligand, cd l, and a panel of chemokine receptors similar to other t cell subsets. intravenously transferred wild type treg migrated to both islet grafts and dln, and prolonged allograft survival. cd l -/or ccr -/-treg, which migrated to islets but not dlns, prolonged allograft survival as potently as wild type treg. fuct iv-vii -/-treg, which lack e-selectin and p-selectin ligands, migrated to dln, but not islets, and did not prolong graft survival. similarly, ccr -/-, ccr -/-, and ccr -/-treg migrated to dln, but not islets, and did not prolong graft survival. when locally transferred to the islet graft, treg also migrated from the allograft to the dln, and prolonged graft survival even longer than after intravenous transfer. locally transferred ccr -/-, ccr -/-, or ccr -/-treg were not able to migrate from the islet to the dln, and were impaired in their ability to prolong islet survival. conclusion: treg migration to allografts is essential for their suppressive function; migration to lymphoid tissues alone is not sufficient to prolong graft survival. treg migration from the islet allografts to the dlns, via afferent lymphatics, is also required for optimal suppressive function and graft survival. the sequential migration from the site of inflammation and then to dlns is necessary for treg to execute fully their suppressive program. these results demonstrate a novel and important aspect of migration in treg suppression and tolerance. abstracts failure is unknown. methods: patients with iothalamate gfr < ml/min (n= ) or on dialysis (n= ) at the time of liver transplant evaluation had undergone a percutanous ct guided renal biopsy. prior to the biopsy an inr ≤ . and platelet count ≥ , / ml were achieved in the majority of cases. all patients were monitored overnight for complications. candidates were listed for slk if pathology showed ≥ % glomerulosclerosis (gs) or ≥ % interstitial fibrosis (if). results: patients were eligible for slk and for lta.creatinine was higher in slk candidates but not clinically different. background -it is well known that delayed graft function (dgf) is costly for those who received a renal transplant. however, the true cost of dgf is unknown. methods -we estimated the cost of dgf for adult cadaveric renal recipients in the usrds - who had medicare as their primary payer. those included were restricted to single organ recipients as well as those who had no previous transplants. cost was defined as the accumulated average cost per day for everyone with a functioning graft on that day. we examined the total cost of dgf, cost associated with dialysis, and non-dialysis cost for all patients combined and separately by donor type; standard criteria donors (scd), expanded criteria donors (ecd), and non-heart beating donors (dcd) as well as time to graft failure or no graft failure. background: based on adverse outcomes during the first year post-transplant, the optn membership and professional standards committee (mpsc) peer-review process flags transplant programs for further review using one of two methods. programs performing at least transplants during at . year cohort are flagged based on the comparison of observed to expected event counts (death or graft failure) and the corresponding p-value (< . ). programs performing or fewer transplants are flagged if they have any adverse events. this leads to different flagging rates for programs of different sizes. the p-value has low sensitivity to identify poorly performing programs with a "moderate" number of transplants ( to ) whereas flagging every event results in a high false positive rate for "small" centers with < transplants. during the july review, % of "small" centers and % of centers with + transplants were flagged for review (all organs). the scientific registry of transplant recipients (srtr) has developed alternative approaches for flagging centers with more consistent flagging rates. methods: the new method would allow for different choices of sensitivity (rr) and specificity (p-value) for different purposes and would flag program if either {p-value < . (a different value could be chosen)} or {observed / expected > rr}. the resulting false negative rate is less than % for centers with the given rr. this approach avoids an arbitrary definition of small versus large programs, and has sensitivity (or power) > % to flag programs with the selected rr, regardless of size. results: the following discussion: this approach gives a more balanced distribution of flagging across programs of different sizes and has sensitivity > % for transplant programs of all sizes. with the choice of rr= . , the overall number of centers flagged would be nearly unchanged from current methods. center performance ratings are of increasing importance to the transplant community with the introduction of the cms final rule. ongoing debate exists regarding how much center ratings are directly a reflection of quality of care or whether ratings can be substantially influenced by exogenous factors. the study examined data from the national srtr database from - . centers' semi-annual graft and patient survival were calculated along with a comparison with expected outcomes adjusted for covariates used by the srtr. centers meeting three criteria for poor performance were categorized within each cohort. patient characteristics at each center were compared with performance evaluations. overall, half of transplant centers met criteria for low performance in at least one of the semi-annual intervals. several center factors investigated were not significantly associated with the likelihood to meet low performance criteria including the proportion of older, obese and privately insured patients. in contrast, centers with higher levels of ecd transplants (most ecds= % vs least ecds= %), african american recipients (most aas= % vs least aas= %) and patients with low albumin level (lowest albumin = % vs highest albumin = %) were more likely to meet low performance criteria. approximately half the centers that initially met criteria for low performance no longer met criteria when excluding ecd transplants and african american recipients from the performance assessment. conclusions given the extreme implications of performance ratings for transplant centers including possible loss of funding to centers with low performance, it is critical that we recognize potential weaknesses and biases of performance ratings. our results are important towards understanding factors related to performance ratings and raising questions as to whether risk adjustment techniques are adequate for fair transplant center performance evaluations. rather than only risk adjustment, stratified evaluations may be a partial solution to remove disincentives to performing higher risk transplants. it is also important to recognize factors not associated with low performance such that centers do not unnecessarily limit access to groups based on perceived deleterious impact on ratings. model. olaf boenisch, takaya muramatsu, francesca d'addio, robert padera, hideo yagita, nader najafian. transplantation research center, brigham and woman's hospital and children's hospital, boston, ma; immunology, juntendo university of medicine, tokyo, japan. t cell immunoglobulin and mucin domain (tim)- , a molecule expressed on terminally differentiated th cells, is an important regulator of th autoimmunity and in induction of transplantation tolerance. its functions in alloimmune responses during acute and chronic rejection are unknown. tim - , a novel blocking antibody of tim- , was administered to recipients in various donor-recipient strain combinations on days ( ug), , , , and ( ug) after transplantation. the frequency of ifng-, il- -, and granzyme b-producing splenocytes was measured by elispot. these data establish the regulatory functions of tim- in alloimmune responses in solid organ transplantation models. the inhibitory actions may be secondary to modulation of effector or regulatory t cells and appear to dominate in conditions of low levels of t cell activation, due to a restricted degree of allogeneic mismatch or absence of cd costimulation. the i-r injury in transplanted kidney is a major cause of dgf, an event associated with an increased risk of acute rejection. adaptative immunity was suggested to play a role in the pathogenesis of renal i-r injury, although the influence of the th /th bias in this scenario is still debated. thus, the aim of the present study was to evaluate the features of t cell response during i-r injury at the peripheral and tissue level in renal graft recipients with dgf. the mrna levels of specific th (t-bet) and th (gata- ) transcription factors were evaluated in circulating lymphomonocyte of kidney transplant recipients with early graft function (egf) (n= ) and dgf (n= ), before (t ) and hours after transplantation (t ) by real time pcr. infiltrating lymphocytes were characterized in graft biopsies of patients with dgf (n= ) and in a control group of patients with tubular damage by acute cni toxicity (n= ) by immunohistochemistry. in addition, we evaluated the th /th bias at the renal level in a pig model of i-r injury. t-bet/gata- mrna ratio was similar in the groups of patients at t . at t the dgf group presented a significantly higher increase of t-bet/gata- ratio compared with the egf group ( ± vs ± % of t , p< . ). moving to the tissue level, dgf patients presented a number of interstitial cd + ( . ± . vs . ± . , p= . ) and cd + ( . ± . vs ± , p= . ) t cells significantly higher compared to the control group, while no significant differences were observed in cd + cells number between the two groups. also at the tissue level the ratio between t-bet + and gata- + cells was significantly higher in the dgf compared with the control group ( . ± . vs . ± . , respectively, p= . ). to confirm that these changes were due to i-r, we investigated the presence of t-bet + and gata- + cells in a pig model of i-r injury. interestingly, the ratio was significantly increased after hours of reperfusion (basal . ± . vs hours . ± . ; p= . ). in conclusion, our results suggest that kidney transplant recipients with dgf present a bias toward a th -driven immune response both at the peripheral and at the tissue level. this event, due to the i-r process, as suggested by the animal model, may represent a link between dgf and acute graft rejection. as expected a strong negative association between duration of dialysis and patient survival was seen in caucasian recipients. in contrast the relationship between patient survival and duration of dialysis was u shaped in minorities with the worst patient survivals seen among preemptive transplants and those patients with over months of dialysis. the difference in outcomes between caucasians and minorities could be related to the biologic differences in the effect of dialysis on subsequent transplantation or to a differential selection bias introduced by duration of dialysis in the two populations. anti-carbohydrate natural antibodies. lorenzo benatuil, jonathan g. godwin, shamik gosh, john iacomini. transplantation research center, boston, ma. background. we constructed immunoglobulin gene knock-in mice lacking expression of the αgal epitope that carry rearranged vh and vl genes encoding antibodies specific for the carbohydrate antigen galα - galβ - glcnac-r (αgal). here, we describe two novel populations of b cells in the spleen of these m vhvlgt mice and their role in the production of αgal specific antibodies. methods. m vhvlgt mice were sacrificed and single cell suspensions from spleen, bone marrow, peripheral lymph nodes and peritoneal cavity were prepared and stained with different antibodies and with fluorescently labeled αgal-bsa for flow cytometric analysis. using multiparameter cell sorting, we purified marginal (mz) and follicular (fo) zone b cells, in addition to two novel splenic b cell populations. cells were adoptively transferred into b cell deficient µmt/gt double knock-out mice. serum samples were collected, and production of αgal specific igm antibodies was assessed by elisa. to investigate these b cell tolerance mechanisms, we employed mice with naturally occurring antibodies (abs) against human blood group a carbohydrates in their sera and possessing b cells with receptors for blood group a determinants. b cells with receptors for a carbohydrates in mice belong to the cd + b- subset, with phenotypic properties similar to those of human b cells. when these cells were temporarily eliminated by injecting synthetic a carbohydrates, subsequent treatment with cyclosporin a or tacrolimus, which blocks b- cell differentiation, completely inhibited the reappearance of b cells with receptors for a carbohydrates in mice. it is probable that calcineurin inhibitors used for preventing t cell-mediated rejection simultaneously suppress b- cell differentiation. however, despite a very limited dose of calcineurin inhibitors, the b cell tolerance toward blood group a antigens was persistently maintained in the blood group a-to-o liver transplant recipient. b cell tolerance after abo-incompatible transplantation might be a consequence of presentation of blood group carbohydrate antigens by cells in the engrafted liver. immune fluorescence staining of the human liver reveals that blood group antigens are predominantly expressed on the liver sinusoidal endothelial cells (lsecs). we have previously proven that lsecs, which constitutively express fas-l and pdl- have the capacity to tolerize alloreactive t cells. taken together, we hypothesize that blood group antigen-reactive b cells are also tolerized through the interaction with the lsecs. in order to address this possibility, we used α- , galactosyltransferase-deficient mice. when the α-gal-expressing lsecs isolated from wild-type mice were adoptively transferred via the portal vein into the splenectomized congeneic α-gal-deficient mice, these mice lost the ability to produce anti-α-gal abs (n = ). this finding suggests that the lsecs expressing blood group carbohydrates play a pivotal role in the tolerization of newly developed b cells specific for the corresponding carbohydrate antigens after abo-incompatible liver transplantation. success in kidney transplantation has resulted from control of t-cell-mediated acute rejection. however, little has been done to improve the fate of patients who possess pretransplant donor-specific antibody (dsa), and no proven therapies exist to specifically prevent dsa formation post-transplant. while methods to detect and characterize dsas are clearly useful, the b-cell subsets that produce dsas or more importantly sustain their production are poorly characterized. this study set out to investigate the fundamental mechanisms determining the formation of donor-specific memory b cells and plasma cells in novel mouse models of dsa formation. we have developed two complementary and novel systems to track the phenotypic and functional properties of polyclonal donor-specific b-cells. the first system involves allosensitization between normal c bl/ and balb/c mice. we used advanced flow cytometric methods to track donor-specific b cells with h- k b or h- k d tetramers. tetramers are comprised of four identical h- molecules bound to a fluorescently labeled steptavidin molecule that is able to bind the donor-specific b-cell antigen receptor (surface immunoglobulin). in our second system, we use donor mice that constitutively express full-length membranebound chicken ovalbumin (mova) protein in all tissues. analogously, ova specific-b cells can be analyzed flow cytometrically with the use fluorescently-labeled ovalbumin. both systems allow us to identify donor-specific memory b cells ( aad -cd -cd -ova/ tetramer + igd -b + cd -) and plasma cells ( aad -cd -cd -ova/tetramer + igd -fb lo cd + ) during skin graft rejection (day post transplant). we were also able to track the development of a stable memory cell population in the bone marrow and spleen for > days cells.for the ova system quantitative elisa and elisot measurements for serum dsa and dsa-secreting cells, respectively, correlated with the development of donor-specific memory b cells. using these assays we will be evaluate polyclonal donor-specific b memory subsets under multiple conditions of immunity and tolerance and for the first time, characterize their functional properties and migration patterns. these experiments will provide new information on the basic biology of the memory b-cell response to allografts in mice and facilitate the development of these methods in sensitized patients that may lead to critical therapeutic opportunities for dsa production. in the tnf-related b-lymphocyte survival factor, blys/baff, is critical for primary follicular (fo) and marginal zone (mz) b-cell survival. in vivo neutralization of blys/ baff, using a newly developed monoclonal antibody, depletes the fo and mz b-cell compartments. here, we hypothesized that targeting b-lymphocytes, via the blys/baff pathway, could promote humoral tolerance to islet allografts. cohorts of stz-diabetic c bl/ mice were transplanted with isolated islets from balb/c donors. treatment with anti-blys/baff alone ( mcg/mse x doses+ mcg/wk/mse) did not protect islet allografts from acute rejection (mst= d; n= ) . on the other hand, a -day course of rapamycin ( mg/kg) prevented acute allograft rejection (mst= d; n= ). when rapamycin was combined with the anti-blys regimen, islet allograft survival was markedly prolonged (mst> d; n= ). importantly, islet allograft survival was coincident with the absence of detectable serum alloantibodies and blunted donor specific t-cell responses. following treatment with anti-blys, b-lymphocyte compartment reconstitution was detectable at days following treatment and was characterized by stringent selection at the transitional→fo b-cell tolerance checkpoint. overall, these data indicate that the blys/baff pathway may be a logical target of immunomotherapy for the achievement of humoral transplantation tolerance. reza tavana background: highly sensitized patients' ability to be transplanted is severely compromised because of high level of antibodies against various hla antigens. interleukin- is a type i cytokine that signals through a receptor composed of the il- r and the common cytokine receptor -chain ( c ). it is produced by t-cells and has been shown to be the contributing factor in terminal differentiation of memory b-cell to anti-body producing b-cell and plasma cells. objective: we evaluated the effect of il- co-stimulation on antibody production capacity of b-cells and also measured the expression of il- r on b lymphocytes of highly sensitized patients compared to non-sensitized patients on the kidney transplant list. methods: patients with a pra level > % (sensitized) were compared to non-sensitized patients from the transplant waiting list. after consent was obtained, peripheral blood was taken from patients before initiating hemodialysis. leukocytes were labelled with anti-cd , anti-il- antibodies and paraffin fixed after rbc lysis. il- r expression was measured by flow-cytometry over facscan machine on the same day. the expression of the il- r is significantly higher on b-lymphocytes of highly sensitized patients (hsp) compared with non sensitized patients (nsp) (fig .p< . ). in-vitro co-stimulation of isolated peripheral b-cell with il- and anti-cd results in higher igg production compared with anti-cd- or il- stimulation alone (fig ) . conclusions: il- is an important cytokine in b-lymphocyte stimulation and increases igg production. il- receptor on b-lymphocytes is up-regulated in sensitized kidney transplant recipients. il- to il- r interaction between t and b-lymphocytes may be an important pathway in antibody production in highly sensitized renal transplant recipients. we created mixed bone marrow chimeras in irradiated µmt (b cell-deficient) recipients by transplantation of syngeneic bone marrow from µmt, wildtype (wt) and mhcko (lack mhc i & ii expression on all cells) mice. µmt+mhcko chimeras lack expression of mhc i & ii on b cells but not other professional apcs such as dcs hence antigen presentation specifically by b cells is disrupted. allograft rejection and development of alloreactive memory t cells in µmt+mhcko chimeras was compared to µmt+wt chimeras that had intact antigen presentation by both b cells and apcs. skin allograft rejection was comparable between µmt+mhcko and µmt+ wt chimeras (mst = and days, respectively, p = . , n = /grp). however, heart allograft rejection was significantly delayed in the µmt+mhcko chimeras compared to µmt+ wt chimeras (mst = and days, respectively, p= . , n = / grp). development of alloreactive memory t cells was assessed in chimeras at weeks after skin allograft rejection by quantitation of antigen-specific ifnγ producing t cells. alloreactive cd and cd memory t cells were significantly fewer in µmt+ mhcko chimeras ( -fold fewer cd , p = . , and -fold fewer cd , p = . , n = /grp) than in µmt+ wt chimeras. these results show that the disruption of antigen presentation by b cells significantly delays heart but not skin allograft rejection. development of alloreactive cd and cd memory t cells is significantly impaired in the absence of antigen presentation by b cells. conclusions: antigen presentation by b cells accelerates heart allograft rejection and leads to development of alloreactive memory t cells. these findings emphasize antibodyindependent functions of b cells in promoting alloimmune responses and highlight the need for b-cell targeted therapies to improve long-term allograft survival. purpose: to test whether depletion of cd + b cells at the time of engraftment alters the prevalence of anti-donor alloantibody (ab)or severity of cav in the context of therapeutic immunosuppression with (csa) or high dose cd inhibition. methods: forty-five mlr-mismatched heterotopic cardiac cynomolgus allograft recipients were treated with high dose anti-cd monotherapy (αcd ; n= , with atg induction) or αcd with additional anti-cd therapy (rituximab mg/ kg q wk for weeks: αcd + αcd ; n= , with atg). thirteen other animals received therapeutic csa (target trough > ng/ml), five of which received additional αcd . graft survival was censored at days. ab was deemed (+) if present (by flow cytometry) around time of explant. results: animals died with beating grafts, mainly with atg-associated lung pathology or infectious etiologies and are excluded from this analysis. animals that had sustained αcd levels < µg/ml after protocol day were considered "subtherapeutic" for this reagent and also excluded from further consideration. graft survival with αcd + αcd (median > d) and proportion of grafts surviving to days ( / ) was significantly increased relative to αcd alone (median d, p= . ; / > d). graft survival with csa + αcd (median > d) and proportion of grafts surviving to days ( / ) was increased relative to csa alone (median d, / > d). with therapeutic αcd (trough level > µg/ml until graft explant), / ( %) developed ab vs. / with αcd + αcd ( %) (p= . ). average cav score for the αcd group was . ± . vs. . ± . in the αcd + αcd group (p= . using unpaired t test). preliminary cav scoring suggests that added αcd inhibited cav (scores ranging . - . ) relative to csa alone (median . ; range . - . ); ab analysis is in progress for these groups. conclusions: using αcd is associated with significant attenuation of cav when used with either "therapeutic" αcd or csa. our findings demonstrate for the first time that αcd reduces the severity of cav in conjunction with both conventional immunosuppression and costimulation pathway blockade. mechanisms include inhibition of ab production, and perhaps others that remain to be defined. subsaturating concentrations of anti-hla antibody ( sensitized recipients having donor specific anti-hla abs have been successfully transplanted following a conditioning regimen employing plasmapheresis with or without pooled human immunoglobulin. in vitro studies have shown that exposure of ecs to subsaturating concentrations (ssc) of anti-hla ab (priming) followed by subsequent exposure to high concentrations (hc) of anti-hla induces the expression of protective genes, bcl and ho- and confers protection to complement mediated lysis of ecs. however, the molecular events following priming with exposure to ssc of anti-hla ab still remains undefined. to determine the priming events and to define the kinetics of protective gene expression, we exposed human aortic ecs to ssc of anti-hla ab for hrs and re-exposed them to saturating concentrations of anti-hla abs. ecs were collected at , , and hrs after exposure to ssc as well as hrs after exposure to hc. expression profile of signaling intermediates (mapk, wnt, nf-kb, hedgehog, pi kinase, stress pathway, tnf family) in the ecs were analyzed by gene array. analysis of the bcl and ho- expression showed no significant increase in expression following exposure to ssc of w / (priming) or control ab alone at any of the time points ( background/aims: microcirculation disturbance, endothelial injury and cytokine overproduction are implicated in the pathophysiology of hepatic ischemia reperfusion injury (iri). thrombomodulin (tm) is a membrane-bound endothelial thrombin receptor that accelerates thrombin-catalyzed protein c activation, inhibits thrombin-induced fibrin formation, and also regulates inflammation. in the present study, we investigated the effects of recombinant human soluble tm (rhstm) on hepatic iri in the rat. methods: wister hannover rat was used for preparing ischemia/reperfusion model. hepatic iri was induced by subjecting % area of the rat liver to minutes of ischemia followed by h of reperfusion. the rats were randomly assigned to a group receiving an intravenous injection of rhstm ( mg/kg body weight) and to a group treated with saline minutes prior to the beginning of reperfusion. sinusoidal endothelial cells (secs) and kuppfer cells (kcs) were isolated using centrifugal elutriation. the plasma levels and the concentration in cultured cell supernatant of il- and tnfα were measured by specific enzyme immunoassays. results: the plasma alt, ast and hyaluronic acid levels were significantly decreased, and the histological damage of the liver was attenuated in rhstm-treated rats as compared to control rats. using laser doppler flow-meter we found that rhstm treatment improved hepatic microcirculation. the intrasinusoidal fibrin deposition, injury of secs and liver dysfunction during hepatic iri were weaker in rhstm-treated rats than in control rats. tm activity in secs was significantly recovered, and plasma il- and tnfα were significant decreased in rhstm-treated rats as compared to control rats. further, il- and tnfα production in isolated kcs was also significant decreased in rhstm-treated rats as compared to control rat . conclusion: the present results suggest that rhstm is useful for the prevention of secs damage and kcs activation induced by iri. our present study also suggests that disturbance of hepatic microcirculation is induced in part by intrasinusoidal microthrombus formation and by locally released inflammatory cytokines from kcs. protective effects of preservation solution including activated protein c in small-for-size liver transplantation in rats. background: small-for-size liver graft is a serious obstacle of partial orthotopic liver transplantation (olt). however, various therapeutic strategies including surgical innovations, pharmacological agents and gene therapies to protect small-for-size liver graft have not yet been developed. aims: activated protein c (apc) is known to have cell protective properties via its anti-inflammatory and anti-apoptotic activities. this study aimed to examine the cytoprotective effects of preservation solution containing apc on olt using smallfor-size rat liver graft ( % partial liver). methods: liver grafts were assigned to two groups: in the control group, the grafts were flushed and stored in histidine-tryptophan-ketoglutarare (htk) solution alone for h; in the apc group, in htk solution containing apc for h. results: the apc group significantly increased -day graft survival from % to %, decreased levels of transaminase, and improved histological features of hepatic iri compared to the control group. myeloperoxidase activity demonstrated that the apc group markedly suppressed the infiltrations of neutrophil. hepatic expressions of tumor necrosis factor-α and il- of the apc group were remarkably decreased. the apc group significantly reduced serum hyaluronic acid levels, indicating attenuated sinusoidal endothelial cell injury. moreover, the apc group markedly increased hepatic levels of nitric oxide caused by upregulated endothelial nitric oxide synthesis (nos) together with downregulated inducible nos, and decreased hepatic levels of endothelin- . finally, hepatocellular apoptosis of the apc group was remarkably suppressed by downregulated hepatic caspase- and caspase- activities. conclusions: preservation solution containing apc inhibited pro-inflammatory cytokine synthesis, which leads to hepatocellular apoptosis and liver injury. one of the cytoprotective effects of the apc treatment was to upregulate hepatic enos, followed by increased expression of hepatic no, and to decrease expression of hepatic et- , resulting in the prevention of microcirculatory disturbance. preservation solution containing apc is a potential novel and safe product for small-for-size liver transplantation to improve liver graft function and animal survival. deletion of cd on natural killer cells attenuates hepatic ischemia/ reperfusion injury. living donor liver transplantation (ldlt) has emerged as a solution to ease organ shortage in orthotopic liver transplantation. however, ldlt is often complicated by small-for-size liver graft that is highly susceptible to injury and shows decreased liver regeneration. suppression of liver regeneration in small-for-size grafts correlates with impaired priming as a result of limited nf-κb activation and decreased production of the priming cytokines tnf and il- . we have shown that the hepatoprotective protein a promotes liver regeneration, partly through blockade of the cyclin dependent kinase inhibitor p . however the impact of a expression in livers on il- production and/ or signaling were still unknown. in this study we demonstrate that secretion of il- (elisa) following treatment with lps or tnf was moderately lower in hepatocytes transduced with a recombinant a adenovirus (rad) as compared to non-transduced or rad.β-galactosidase transduced cells. this indicates that il- production in hepatocytes is not solely nf-κb dependent (not totally blocked by the nf-κb inhibitor a ). despite similar or lower il- levels, il- signaling as evaluated by phosphorylation of stat (western blot; wb) was enhanced in a expressing hepatocytes. this was confirmed in experiments showing that a increases stat- phosphorylation in response to exogenous human il- . accordingly, hepatocyte proliferation was significantly higher in rad.a transduced hepatocytes as opposed to controls. the pro-proliferative function of a mapped to the zn domain. since the balance of il- signaling in hepatocytes is finely regulated through a negative feed-back loop provided by the il- /stat- dependent induction of suppressor of cytokine signal- (socs ), we investigated whether a affects il- signaling by modulating socs expression. our results indicate that a indeed decreased il- mediated upregulation of socs (wb). this later result was confirmed in vivo. improved regeneration and survival in a treated livers correlated with a substantial decrease in socs levels before and hours following extended ( %) liver resection in mice. these results suggest that a enhances priming of hepatocytes by il- likely through down-regulation of socs . this added to the effect of a on p would further enhance its pro-proliferative function in hepatocytes to benefit survival and function of small-for-size liver grafts. background: we have previously demonstrated that silencing inflammatory, apoptosis and complement genes can prevent ischemia-reperfusion (i/r) injury occurring in heart transplantation. however, the method for efficiently delivering sirna into donor organ has not been established. this study was designed to develop a new method to induce gene silencing by coronal artery infusing with sirna solution for prevention i/r injury in heart transplantation. methods: multiple sirnas that specifically target tnfa, caspase , and c a receptor (c ar) genes were generated and selected. sirna protection of donor organs was evaluated in a rat heart transplantation model. heart grafts from lawis rats were infused with sirna solution via coronal artery and preserved in hkt solution at ° c for hrs, and subsequently transplanted into syngeneic lawis rats. cardiac functions were assessed by heart beating rate. gene expression at mrna level was determined by qpcr. the i/r injury was assessed by immunohistochemistry. results: after donor heart perfusion with sirna solution, sirna was found to enter the myocardial cells, indicated by the fluorescence emitted from the dye labeled sirna. the levels of tnfa, caspase and c ar genes were significantly up-regulated in the grafts after ex vivo preservation for hrs. these up-regulated tnfa, caspase , and c ar genes were significantly knocked down by sirna infusion. using a sirna infused organ as a donor, the graft survival was significantly prolonged in heart transplantation. while sirna solution-treated heart grafts retained strong heartbeat up to the end point of observation (> days), the control grafts lost function within days. in addition, an improved cardiac function was observed in the graft preserved in sirna solution. the protection of graft by sirna solution is associated with prevention of i/r injury. sirna solution-treated organs exhibited almost normal histological structures as well as less neutrophil and lymphocyte infiltration, compared with control solution-treated organs. conclusions: this study developed a novel ex vivo sirna delivery system using coronal artery infusion, which can effectively silencing genes in donor hearts and prevent cardiac i/r injury. background: ischemia/reperfusion (i/r) insult is a prime factor leading to liver dysfunction. apoptosis plays key role in the early graft loss following orthotopic liver transplantation (olt). bcl-xl has been showed to exert an anti-apoptotic function both in vitro and in vivo. this study was designed to evaluate potential cytoprotective effects and mechanisms for bcl-xl in liver i/r injury by ad-bcl-xl gene transfer. methods: a mouse model of partial min warm hepatic ischemia followed by h of reperfusion was used. balb/c wide-type (wt) mice (n= /gr) were injected with ad-bcl-xl or adβ-gal reporter gene ( . x pfu, i.p. at day - ). sham control wt mice underwent the same procedure, but without vascular occlusion. mice were sacrificed after h of reperfusion; liver tissue and blood samples were collected for future analysis. results: ad-bcl-xl treated mice showed significantly lower sgot levels (iu/l), as compared with ad-β-gal or wt controls ( ± vs. ± , and ± , respectively; p< . ). these correlated with histologic suzukis grading of hepatic i/r injury, with wt/ad-β-gal controls showing significant edema, sinusoidal congestion/cytoplasmic vacuolization, and severe hepatocellular necrosis. in contrast, wt mice treated with ad-bcl-xl revealed minimal sinusoidal congestion without edema/vacuolization or necrosis. ad-bcl-xl gene transfer significantly reduced local neutrophil accumulation and apoptosis ( . ± . of tunel+ cells in ad-bcl-xl vs. . ± . and . ± . of tunel+ cells in wt or ad-β-gal treated mice; p< . ). unlike in controls, intragraft expression of mrna coding for tnf-α, e-selectin/icam- , and ip- /mcp- remained depressed in the ad-bcl-xl group. ad-bcl-xl gene transfer markedly depressed the activation of nf-κb, caspase- , and increased ho- , a , and bcl- /bcl-xl expression, as compared with wt/ad-β-gal controls. conclusion: this study demonstrates that inhibition of nf-κb activation contributes to the cytoprtective effects after bcl-xl gene transfer in hepatic i/r injury. the induction of anti-oxidant ho- and anti-apoptotic a , bcl- by bcl-xl gene transfer exerts synergistic cytoprotective effect against antigen-independent hepatic inflammatory injury induced by i/r. hepatocyte background: primary graft non-function (pnf) affects survival and function of renal allografts. pnf, secondary to the ischemic and inflammatory injury in the peri-transplant period, leads to acute tubular necrosis and predisposes to acute rejection. defining new preconditioning regimens to reduce pnf are desirable. a is part of a negative antiinflammatory loop aimed at inhibiting nf-κb in renal proximal tubular epithelial cells (rptec). hepatocyte growth factor (hgf) is a pleiotropic growth factor upregulated in acute kidney injury and acute rejection likely to modulate inflammation and promote repair. in the present study we evaluated the effect of hgf on rptec and hypothesized that some of its protective functions may relate to the upregulation of a . methods and results: treatment of rptec with hgf ( ng/ml) led to a . ± . (n= ; p= . ) fold increase in a mrna (real time-pcr), which translated into a significant . ± . fold increase (n= ; p= . ) in a protein by h, as shown by western blot (wb). two lines of evidence suggested that upregulation of a by hgf was nf-κbindependent. hgf did not degrade iκbα in rptec (wb) nor upregulated the nf-κb dependent molecule icam- , as shown by flow cytometry analysis (facs). further, a was still upregulated in rptec expressing the nf-κb inhibitor iκbα, both at the mrna and protein levels. upregulation of a by hgf protected rptec from a subsequent inflammatory insult, here mimicked by the addition of tnf. pretreatment of rptec with hgf for hours blunted tnf-induced ( u and u/ml) upregulation of icam- , as analyzed by facs. conclusion: to our knowledge this is the first demonstration that a could be upregulated in rptec, in a non-nf-κb dependent manner. further studies are carried out to elucidate the transcription factors involved in hgf-induced upregulation of a . from a clinical standpoint, these results highlight the unique ability of hgf to protect rptec from inflammation by inducing the anti-inflammatory protein a , remarkably without triggering other pro-inflammatory signals. we propose that hgf-based therapies could serve in preconditioning regimens to prevent ischemia/reperfusion injury and reduce pnf and acute rejection in renal transplantation. background. liver ischemia reperfusion injury (iri) is one of the main causes of graft dysfunction and rejection in liver transplantation. it has been documented that iri is associated with inflammatory and complement pathway activation. this study was designed to investigate the efficacy of small interfering rna expression vector (shrna) targeting tnf-α and complement (c ) genes in the protection of mouse liver iri. methods. shrna expression vectors were constructed for tnf-α and c genes. mice received shrna by hydrodynamic injection prior to iri, which consisted of interrupting blood supply to the left lateral and median lobes of the liver for minutes followed by reperfusion. iri was evaluated using liver histopathology, as well as levels of serum alanine transferase (alt) and aspartate transaminase (ast). neutrophil accumulation was determined by a myeloperoxidase (mpo) assay. lipid peroxidation was assessed by malondialdehyde (mda) levels. realtime pcr was used to test gene silencing efficacy in vitro and in vivo. result. we demonstrated that iri is associated with an increase in tnf-α and c mrna levels in liver tissue hours after reperfusion. shrna-treatment effectively down-regulated tnf-α and c expression in iri livers. in comparison with vehicle control, the serum levels of alt ( . ± . u/l vs . ± . u/l) and ast ( . ± . u/l vs . ± . u/l), were significantly reduced in mice treated with tnf-α and c shrna. additionally, the neutrophil accumulation and lipid peroxidase-mediated tissue injury, detected by mpo and mda respectively, were improved after shrna treatment. tissue histopathology showed an overall reduction of injury area in shrna-treated mice. conclusion. this is the first demonstration that liver iri can be prevented through gene silencing of inflammatory genes and complement genes, showing potential for shrna-based clinical therapy. kidney -acute rejection: antibody-mediated rejection the ( ) in the first three days after transplantation, a temporary decrease in dsa was observed in all amr cases, and all of them quickly rebounded thereafter; ( ) c d can be detected very early (can be seen on day , % in day protocol biopsies, frequently in the absence graft dysfunction, and % in index biopsies); ( ) the pathologic changes observed in sequential biopsies were c d deposition followed by acute tubular injury, then interstitial inflammation and peritubular capillary margination seen in index biopsies; ( ) pure amr occurred early ( % at day ), usually evolving into mixed amr with accompanying cellular rejection ( % in index biopsies); ( ) most recipients ( %) had initial graft function before developing amr; ( ) background: antibody-mediated rejection (amr) has been recognized as a major problem in abo-incompatible (abo-i) renal transplantation (rtx). however, little is known about the long-term impact of amr in the abo-i renal transplant setting, especially after the introduction of a tacrolimus (fk)-based immunosuppressive regimen. the aim of this study was to assess the long-term impact of amr on the clinical and pathological outcomes in abo-i rtx. methods: fifty-eight patients who underwent abo-i rtx at our institution between march and december under an fk-based immunosuppressive regimen were enrolled in this study. protocol biopsies were performed regardless of renal function at one month and one year after rtx. fifty-six of the patients received the biopsy at one month and of patients underwent biopsy at one year posttransplant. amr was diagnosed by morphological features based on the banff ' update and other characteristic findings for amr previously reported, such as mesangiolysis, interstitial hemorrhage, and cortical infarction. we evaluated graft survival, incidence of chronic rejection characterized by transplant glomerulopathy (tgp) at one year posttransplant, and renal function using serum creatinine at three years posttransplant according to the incidence of amr at one month posttransplant. the overall graft survival rate at , , and years after rtx was %, %, and %, respectively. the incidence of amr at one month was % ( / ). the graft survival rate of the patients with amr was significantly lower than that of the patients without amr (p< . , years: % vs %, years: % vs %). the incidence of tgp in the patients with amr was significantly higher than that of the patients without amr (p< . , % vs %). the serum creatinine concentration at three years after rtx was significantly higher in the patients with amr than in those without amr (p< . , . mg/dl vs . mg/dl). in this study, we revealed that amr in abo-i rtx is associated with not only graft loss but also the progression of chronic renal impairment, functionally as well as pathologically, even after the introduction of an fk-based immunosuppressive regimen. further studies are needed to establish a more effective immunosuppressive regimen, such as rituximab induction therapy; against amr in abo-i rtx. conclusions: de novo dsa in ar is an independent predictor of graft loss and its degree of influence is comparable to other established risk factors (aa race, dgf, increased baseline creatinine). additional studies are warranted to: ) confirm the predictive ability of dsa and ) determine whether reduction/eliminattion of dsa will allow improvements in graft survival. was performed in all the recipients before and six months after lrkt. graft biopsies were performed as well within and after six months of the transplantation (tx). all the data of recipients were collected prospectively during the period of follow-up. humoral rejection rate, donor specificity, and time of appearance of the de novo abs were retrospectively studied. results among the lrkt recipients, ( %) showed negative/negative results, ( %) showed positive/positive results, ( %) showed positive/negative results, and ( %) showed negative/positive results (de novo abs) in the pre-/post-transplant flow-pra analysis. among the cases with de novo abs, ( %) had donorspecific abs (dsa) and the remaining ( %) had non-donor specific abs (ndsa) as determined by lab single antigen analysis. four of the five recipients ( %) with dsa showed evidence of both vascular and humoral rejection in the graft biopsies performed within months of the transplantation, while one of the eight recipients ( %) with ndsa showed evidence of cellular rejection during the same period. a -year graft survival rate of the recipients with de novo abs was %, compared with %, % and % in other groups without de novo abs (p= . ). conclusions lrkt recipients with developing de novo abs has much higher incidence of humoral rejection and worse prognosis, especially those with donor-specific de novo abs. cautious monitoring for the appearance of anti-hla antibodies should be adopted after transplantation, even in patients without anti-hla ab prior to the transplantation. despite significantly higher response than the males w/o amr (p< . ), the other females did not experience amr. conclusions: ) cfc is a novel assay to measure allo/ do cd -cell responses, assess the degree of sensitization, and predict amr in hs, ) allo/do cd -cell numbers are elevated in many hs, but not nc, ) hs w/ high(+) cfc are at increased risk for amr and may need additional pre-tx desensitization, ) allo/do reactivity are higher in hs females, which may explain their higher rate of amr, ) cfc cut off levels for amr prediction may be higher in females than males, ) monitoring hs using the cfc pre-and post-desensitization may help determine the efficacy of desensitization and risk for amr. were treated with plasmapheresis, ivig and rituximab, and pts with l-amr received ivig and rituximab. the -year gs post-amr in pts with e-amr and focal c d staining was % vs. % in pts with diffuse staining; while cases of l-amr with focal c d deposition had a gs of % vs. % in cases with l-amr and diffuse staining. the number of cases with focal staining was low, and the numerically evident differences were not statistically significant (log-rank p=ns). notably, when losses due to death with a functional graft were censored, post-amr gs was significantly lower in pts with e-amr and focal staining than in their counterparts with diffuse c d deposition ( % vs. %, log-rank p= . ). in this retrospective single center study, focally positive c d amr carries a worse prognosis than previously thought, and causes a significant reduction of gs. whether any degree of c d staining in the context of kt dysfunction should be treated as amr remains a pending question. association time of biopsy was . ± . mo after kt. however, cases were biopsied in the st year posttransplant. the extent of c d staining was graded as < % ( ), - % ( ), and ≥ % ( ) of ptc, and the intensity was graded as none ( ), light ( ), and strong ( ) staining. these findings demonstrate the significant discordance between detection of dsa and c d, which is a relatively specific histological evidence of ab-mediated injury. this factor should be taken into account when clinical decisions for treatment of patients with either c d or dsa positivity are made. the observed discrepancy could be partially due to the technique used for staining of the biopsy specimens, inability to detect anti-hla dsa with the available technology, or non-hla dsa. long term follow up data are needed to evaluate the impact of these markers on graft outcomes. introduction epithelial to mesenchymal transition (emt) is a potential mechanism of tissue fibrogenesis. in a previous study, we had reported that the early expression of emt markers was associated with the progression of renal grafts towards interstitial fibrosis and tubular atrophy (if/ta). here, we report the long-term follow-up of this cohort, paying a special attention to the evolution of graft function. patients and methods patients engrafted with a kidney from a cadaveric (n= ) or a living (n= ) donor, and in whom sequential protocol biopsies had been performed at and months, were included. the phenotype of epithelial cells was studied at three months according to the expression of vimentin (an intermediate filament normally expressed by fibroblast-like cells) and to the cellular localization of β-catenin. grafts in which these two markers were abnormally expressed by more than % of tubular cells were considered as emt+ grafts. serum creatinine and creatinine clearance (estimated abstracts by gault and cockcroft index) were collected from to months post-transplant and compared according to the emt status of the graft. results multivariate analysis demonstrated that the early expression of emt markers was an independent risk factor of the progression of graft fibrosis between and months. more importantly, these early phenotypic changes were associated with a progressive and sustained deterioration of the graft function : emt+ patients had a statistically higher serum creatinine from twelve months after transplantation, and a significantly lower creatinine clearance from months after transplantation (emt+ . ± . ml/min vs emt- . ± . ml/min, p= . ). the difference was persistent at months. conclusion the expression of emt markers by tubular epithelial cells at an early time point post-transplant (three months) is highly suggestive of an ongoing fibrogenic process, and has repercussions on the long-term graft function. therefore, these epithelial phenotypic changes are relevant and promising biomarkers for an early detection of if/ta. we recently reported that % of transplant glomerulopathy (tg) has evidence of alloantibody-mediated injury in biopsies for cause. we found that / of tg is c d+ab+ and / is c d-ab+ suggesting that c d staining is not sensitive enough to detect all biopsies with antibody-mediated injury. we aimed to develop a new laboratory test to detect biopsies with antibody-mediated rejection (abmr) which are missed by c d. using affymetrix microarrays, we analyzed gene expression in renal allograft biopsies for cause. we previously reported that both abmr and t cell-mediated rejection (tcmr) biopsies show increased expression of transcript sets associated with cytotoxic-t cells (cats) and gamma-interferon effects (grits) compared to biopsies without rejection (p< . ). however, abmr biopsies were discriminated by a selective increased expression of "endothelial cell-associated transcripts" (endats). these genes included established endothelial markers such as vwf, pecam , sele, cd , and cadherin , which are involved in endothelial-cell activation. hierarchical clustering of biopsies with ab+ using endats identified a group of c d-ab+ biopsies (n= ) clustered with c d+ ab+ biopsies (n= ). thus % of biopsies with antibody ( of ) had increased endat-scores despite being negative for c d. these c d-ab+ biopsies with high endats, had higher scores for cats and grits, increased incidence/severity of tg, tubular atrophy/interstitial fibrosis, and worse future graft function (p< . ), but similar incidence of tcmr or borderline lesions, in comparison to c d-ab+ biopsies with no increase in endats. the c d-ab+ cases with endothelial activation show extensive inflammation in the allograft, as measured by the gene sets, which is similar to c d+ abmr. there are a significant number of cases with alloantibody and no c d that show increased expression of endothelial genes. thus the transcriptomics detects deteriorating c d-allografts with ongoing alloantibody mediated injury. we conclude that increased expression of endothelial genes provides a new feature of abmr, and can be used as a new diagnostic test to detect and treat c d-abmr. probabilistic ( ) . the bayesian network model was analyzed and, interestingly, cd was critically related to tg, suggesting a b-cell mediated process. tg was also predicted by upregulation of ccl , ccl , ccl , cxcl , il- , il- , and icam gene expression. ten percent of the samples were excluded randomly from the initial model, and subsequently used for cross validation. in the validation analysis, the model effectively predicted tg (auc of . , % ppv) and sf (auc of . , % ppv). this study provides a compelling and clinically relevant example of the combination of quantitative gene expression with probabilistic bayesian modeling to predict renal allograft pathology. potentially important molecular pathways associated with transplant glomerulopathy were also identified. the application of this integrated approach has broad implications in the field of transplant diagnostics and interpretation of large data sets. , , , , , and months respectively. the daily dose and blood levels of tac were significantly lower in tac/slr group compared to tac/mmf group. renal function is shown. despite lower prevelance of cai in tac/slr group long-term graft function and patient and graft survival are comparable between tac/mmf and tac/slr groups. objective: the aim of this study was to determine if ethinicity impacts graft outcomes in kidney transplant patients converted to sirolimus (srl) and either maintained on calcineurin inhibitors (ci) or mycophenolate (mmf) with steroids. methods: this was a retrospective analysis of all kidney transplants converted to srl and transplanted from / to / . patients were divided into groups: group : aas converted to srl + continued on ci; group : non-aas converted to srl + continued on ci; group : aas converted to srl + continued on mmf; group : non-aas converted to srl + continued on mmf. pediatrics and multiorgan transplants were excluded. results: a total of patients were included ( % aa). demographics, baseline immunosuppression, and reason for srl conversion were similar between groups. table displays characteristics and outcomes. patients converted to srl+ci regimens had higher rates of acute rejection before srl conversion (p< . ), but equal rates after conversion. development of proteinuria was similar across groups. figure displays the graft survival rates for each group. aa patients converted to srl+mmf tended to have poorer outcomes compared to aa patients converted to srl+ci. non-aa patients converted to srl+mmf tended to have better graft outcomes compared to non-aa patients coverted to srl+ci, although this did not reach statistical significance(p= . ). conclusion: aas converted to srl may benefit from continued ci, while non-aas converted to srl appear to have better outcomes with mmf. further prospective studies are warranted to confirm these findings. aa srl+ci (n= ) there are no large registry studies evaluating the correlation of allograft failure for recipients of kidneys from the same deceased donor. we examined outcomes in such recipient pairs using data from the united states renal data system. methods: we studied the correlation of graft failure events within , pairs of same-donor recipients transplanted during through . analyses were limited to patients with functioning grafts months post-transplant (tx) and adjusted for known donor, recipient, and tx management factors. we estimated odds ratios to measure the increased risk for , , and -year graft failure and death-censored graft failure when the contralateral kidney had such an event. we also evaluated the effect of recipient pairs transplanted at the same center vs different centers. results: there is a strong correlation in outcomes for recipients with the same donor (table) . the correlation was stronger within pairs transplanted at the same center than for those transplanted at different centers. differences in the correlation of graft failures within pairs transplanted at the same versus separate centers diminished over and were absent by years post-tx. results for death-censored allograft failure were similar. conclusion: unmeasured donor factors contribute significantly to the correlated graft failure outcomes in paired recipients of deceased donor kidneys and need further study. kidney tx outcomes in the first year may be affected by differences in management between transplant centers, more so than in subsequent years post-tx. odds ratio of death-censored graft failure and graft failure in recipients of a donor pair, given that the outcome occurred in the recipient of the contralateral kidney, with both recipients being transplanted at the same (s) center or at different (d) centers. all odds ratios significant with p< . . the deterioration of kidney allograft function (dekaf) study is a nih-funded multicenter observational study of late allograft (ktx) loss. the study examines two cohorts: a "long-term cohort" (ltc) of prevalent ktx with scr < . mg/dl with deterioration of function ( % increase in scr or proteinuria) and a "prospective cohort" (pc) of incident ktx developing a persistent > % increase in scr. we examined the pathologic features of the first renal biopsy (bx) obtained for new onset deterioration in each cohort. all bx were read and scored centrally using a modified banff schema. on average, bx were obtained at (pc) and (ltc) months post-tx. mean scr was similar, but more patients (pts) in ltc had proteinuria. moderate to severe interstitial fibrosis and tubular atrophy (ta) were more prevalent in ltc than pc ( vs % ci score ≥ ; vs % for ta). the rate of vascular sclerosis > % was similar ( . % pc vs . % ltc); however, hyaline arteriolar sclerosis > % was more common in the ltc ( vs . %). interstitial inflammation (i) and tubulitis (t) scores were similar in both cohorts. however, more pts in ltc had peritubular capillary infiltrates (> cells) and evidence of tx glomerulopathy. while rates of interstitial inflammation and tubulitis sufficient to warrant diagnosis of acute rejection are similar in the prospective and long-term cohorts, long term cohort pts had more proteinuria, interstitial fibrosis, tubular atrophy, hyaline arteriolar sclerosis, and transplant glomerulopathy. analyses of histologic findings and renal outcome are ongoing. the term chronic allograft nephropathy (can) has been abolished by the last banff meeting report (am j transplant, ) and categories have been introduced for chronic changes: chronic active t cell-mediated rejection and chronic active humoral rejection (cahr). aim of the study was to review all cases of can diagnosed in the last years and to identify immunohistochemical markers of chronic rejection. a cohort of cad pts with biopsy-proven can was analyzed. each case was reviewed and assigned into groups according to banff criteria: chronic rejection (cr), chronic calcineurin toxicity (cnit) or chronic lesions not otherwise specified (nos). cd +, cd +, cd +, cd + cells and c d deposits were assessed by immunohistochemistry. twenty-eight pts were classified as cnit, as cr, of which were cahr, and as nos. serum creatinine and h proteinuria at renal biopsy, extent of interstitial fibrosis and glomerulosclerosis were not significantly different among groups (table ).the number of cd + cells was higher at ti level in cr compared to cnit (table ;*p=. ). cd + cells were higher at ti and g level in cr compared to cnit (table ;*p=. ). ti and g cd + cells were not different among the groups (table ). the number of g cd + cells was increased in cr compared to cni and nos (table ;*p=. ). no significant difference in cd , cd , cd , cd expression was found at ti and g level between c d + and c dcases of cr. cd , cd , cd but not cd expression at ti level correlated with ti fibrosis (r =. , . , . , respectively, p<. ) at the univariate analysis. only ti cd + cells independently correlated with fibrosis at multiple regression analysis. in conclusion, our data suggest that: morbid obesity limits access to kidney transplantation and predicts adverse transplant outcomes. there are limited data on the safety and efficacy of gastric bypass (gb) as a weight reduction therapy among transplant candidates and recipients. methods: we examined usrds registry data to identify medicare-insured kidney transplant candidates and recipients with billing claims for gb procedures. gb were categorized according to occurrence before listing, on the waitlist, or after transplant. we studied the clinical characteristics of gb-treated patients, and subsequent outcomes including progression from listing to transplant and -day mortality. usrds surveys bmi data at dialysis start, waitlist entry, transplant, and transplant anniversaries.we computed changes between most recently reported body mass index (bmi) values preceding and following gb, when available. results: we identified transplant candidates treated with gb before listing, who underwent gb on the waitlist, and gb cases after transplant. patients treated with gb were most commonly female, white race, and without diabetic or hypertensive renal failure (table) . -day mortality after gb, calculable for listed and transplanted patients, was . % and . %, respectively. transplant recipient experienced graft failure within days of gb. of patients treated with gb on the waitlist, proceeded to transplant. post-gb weight loss was detected for % with gb pre-listing, % with gb on the waitlist, and . % with gb after transplant. among patients listed for transplant in the same era and bmi > at first dialysis who were not treated with gb, % had lost weight between dialysis start and listing. conclusions: gb has been performed in small numbers of kidney transplant candidates and recipients, and is followed by weight-loss in the majority of cases. peri-operative mortality is comparable to reports in patients without kidney disease. gb warrants prospective study as a strategy for reducing complications of obesity in esrd. introduction: the present study investigated the incidence of posttransplant diabetes mellitus (ptdm) and calculated the risk of developing ptdm under a tacrolimus and mycophenolate mofetil (mmf)-based immunosuppression based on clinical characteristics, tacrolimus-pharmacokinetics, and genetic polymorphisms related to tacrolimus-pharmacokinetics, cytokines and diabetes mellitus. methods: seventy-one non-diabetic adult kidney recipients (male , female ) were studied. patients with continuous high plasma glucose levels, over . mg/dl of hemoglobin a c, or requiring insulin and/or oral anti-diabetic agents for more than months after transplantation at -year after transplantation were diagnosed as having ptdm. fifteen genomic polymorphisms were assessed. results: one year after transplantation, recipients ( . %) developed ptdm. positive risk factors were age (p= . ) and body mass index (p= . ). there were no significant differences in acute rejection rate, total steroid doses, tacrolimuspharmacokinetics or its related to genetic polymorphisms between the two groups. the frequencies of ptdm were significantly higher in patients with adiponectin t g tt genotype than in those with the g allele (p= . ), and in patients with glucocorticoid receptor (nr c ) bcl i cc genotype than in those with the g allele (p= . ). conclusions: the incidence of ptdm at -yr after transplantation was . % in our cohort. elder or obese patients were risky for the development of ptdm. the presence of the adiponectin t g tt or nr c bcl i cc genotype may also be risk factors for ptdm, suggesting that insulin and glucocorticoid sensitivity-related genes are associated with the development of ptdm. analysis of these genotypes is a possible method of predicting a patient's risk for developing ptdm and would be a valuable asset in selecting appropriate immunosuppressive regimens for individuals. pharmacokinetics persistent hyperparathyroidism (hpt) with hypercalcemia is common after renal transplantation. studies have shown that treatment with cinacalcet corrects hypercalcemia and lowers pth levels in these patients. so far cinacalcet's steadystate pharmacokinetics and their correlation with pharmacodynamics (pk/pd) have only been studied in hemodialysis patients, but not in renal transplant recipients with persistent hpt. to gain further insight into cinacalcet's effects on calcium-phosphate homeostasis, we determined its steady-state pharmacokinetics and pharmacodynamic effects in these patients. in a prospective, single center, open label study we examined the effect of a -week treatment with mg and subsequent -week treatment with mg cinacalcet daily on calcium-phosphate homeostasis over hours and determined the steady-state pharmacokinetics of cinacalcet in stable renal allograft recipients. the urinary calcium excretion was determined in timed urine samples. median auc - was . ng*h/ml and c max was . ng/ml for mg cinacalcet which is higher, and oral clearance (cl/f) was . l/h which is lower in renal transplant recipients compared to previously published data of hemodialysis patients ( mg cinacalcet auc - , c max . , cl/f ). we also observed a non-proportional increase of auc - after doubling of the cinacalcet dose. the once daily administration of cinacalcet dose-dependently reduced ipth and serum calcium. cinacalcet and parathyroid hormone (pth) concentrations showed an inverse correlation and were fitted to a simple emax model (e max = % reduction vs. baseline, ec = ng/ml). the -hour fractional urinary excretion of calcium was increased after mg cinacalcet (baseline . ± . %, mg . ± . %, mg . ± . %). renal function remained stable. cinacalcet's higher and non-proportional increase of auc - in transplant recipients compared to hemodialysis patients evokes the possibility of a pharmacokinetic interaction with concomitant cyclosporine treatment. cinacalcet effectively corrected the biochemical abnormalities of persistent hpt. the transient calciuria could potentially favor nephrocalcinosis and reduce bone mineral density, suggesting that higher doses of cinacalcet need to be used with caution in renal transplant recipients with severe persistent hyperparathyroidism. screening for proteinuria in the kidney transplant clinic. bryce a. kiberd, romuald panek. dalhousie university, halifax, ns, canada. proteinuria is a predictor of progression in kidney disease. it is not clear whether measuring albuminuria will have greater clinical utility over measurement by dipstick or total proteinuria in kidney transplant recipients. there has also been a trend away from using hour collections to using spot urine albumin/creatinine (ac) and protein/creatinine (pc) ratios. we compare the prevalence of proteinuria estimated by dipstick, ac and pc in prevalent patients (> months post transplant) in the kidney transplant clinic. significant albuminuria defined as ≥ mg/g was present in % ( / ). albuminuria was seen in % ( / ) with negative and % ( / ) with trace dipstick proteinuria. significant predictors of albuminuria in a mulitvariate logistic analysis were egfr (or . per ml/min/ . m , % ci . - . p= . ), diastolic bp (or . per mmhg, % ci . - . p= . ), and mmf use (or . , % ci . - . p= . ). macroalbuminuria (ac> mg/g) was seen in . % ( / ) and significant predictors in a mulivariate logistic analysis were lower egfr and higher systolic bp. sirolimus use was associated with more macroalbuminuria and mmf use with less macroalbuminuria. in a subset of patients followed for > years prior gfr loss was considerably greater (p= . ) in patients with albuminuria (- . ml/min/ . m /year) compared to those without (- . ml/min/ . m /year). however other measures of proteinuria were also significantly (p for trend) associated with prior gfr loss (ml/min/ . m /year) as shown in the < . (n= ) . - . (n= ) > . (n= ) ∆ egfr/year - . - . - . . * a pc cut point of . g/g had a sensitivity and specificity for albuminuria > mg/g of % and % respectively (c= . , % ci . - . ), and a pc cut point of . g/g had a sensitivity and specificity for macroalbuminuria > mg/g of % and % respectively (c= . , % ci . - . ). ac may be more sensitive and therefore have more clinical utility than other measures of proteinuria for progression. however prospective follow up of renal function change and cv outcomes is required. serum creatinine is a crude marker of gfr in renal transplant recipients and changes in gfr are frequently not accompanied by commensurate changes in serum creatinine concentration. serum cystatin c and estimates of gfr (egfr) based on cystatin c have been shown to be more accurate than serum creatinine and creatinine-based egfr in renal transplant recipients. the purpose of this study was to determine whether the filler, lebricon and rule cystatin c-based egfr equations were better able to detect changes in true gfr than the mdrd and cockcroft gault creatinine-based egfr equations. we performed two measures of m tc-dtpa gfr, serum creatinine and serum cystatin c on each of stable renal transplant recipients at least months apart. we calculated and compared the percent annual change in the measured gfr and the estimated gfr using the various gfr estimation equations. we also determined the sensitivity, specificity, positive predictive value and negative predictive value of each prediction equation for the detection of decline in measured gfr. results are presented below: the cystatin c and creatinine-based egfr equations all demonstrated poor sensitivity and diagnostic performance to detect a decline in gfr. novel equations derived and validated in the transplant population are needed to accurately assess kidney function over time. background: hypercalcemia, hypophosphatemia and renal phosphate wasting are common after kidney transplantation and are related to persistent hyperparathyroidism and hyperphosphatoninism. animal data suggest that these alterations in mineral metabolism may contribute to nephrocalcinosis and progressive graft dysfunction. supporting clinical data are limited. aim: to test the hypothesis that nephrocalcinosis is highly prevalent in the early posttransplant period and is related to a disturbed mineral metabolism. methods: biomarkers of mineral metabolism (including albumin-corrected serum calcium [ca c ], serum phosphorus [p], biointact pth, calcidiol, calcitriol and alkaline phosphatase) and renal calcium and phosphorus excretion parameters were prospectively assessed in renal transplant recipients ( % male, mean age ± yrs) at the time of their -month protocol biopsy. these protocol biopsies were screened for the presence of microcalcifications. intratubular, interstitial and/or cytoplasmatic microcalcifications were observed in . % of biopsies. calcifications were more prevalent in recipients of a living related donor as compared to cadaveric donor. high serum ca c levels, high serum pth levels, a high urinary ca×p product and high fractional excretion of p and low serum p levels were significantly associated with renal microcalcifications (see figure below). microcalcifications were not related to the fractional excretion of ca, use of diuretics, immunosuppressive regimen, serum alkaline phosphatase level and history of delayed graft function. the extent of microcalcifications correlated significantly with the severity of mineral metabolism disturbances. conclusion: our data demonstrate that nephrocalcinosis is highly prevalent in the early posttransplant period and suggest that a disordered mineral metabolism is implicated in its pathogenesis. polymorphism in abcb , the gene encoding for p-glycoprotein, predicts recovery of graft function early after kidney transplantation. the pharmacokinetics of cyclosporine (csa) is characterized by wide inter-individual variability. this might be particularly relevant in the early post-transplant period, due to the detrimental effects of the drug on the kidney. p-glycoprotein (p-gp), the product of the abcb gene, plays a key role in the distribution of csa at cellular level. single nucleotide polymorphisms (snps) of abcb might potentially influence the response of patients to csa. in particular, the snp in position of the exon , despite its silent nature, has been recently associated with altered specificity for its ligand, such as csa (kimchi-sarfaty et al, science , : ) . whether p-gp pharmacogenetics would help to guide csa treatment early post-transplant remains ill defined. we sought to evaluate the effects of the snps in the exon on the rate of recovery of graft function, as estimated gfr early postoperatively, in kidney transplant patients given csa as part of their immunosuppressive regimen. the frequency of dgf (as need for post-operative dialysis) among the different abcb genotypes was also estimated. of the kidney transplant recipients, % had the abcb wild type (c/c) genotype in exon , % were heterozygous (c/t) and % were homozygous (t/t) for the polymorphic variant in position . gfr values were significantly lower in patients carrying one of the two mutant alleles than in the wild type ( figure) . the frequency of dgf was %, % and % in patients with the cc, ct and tt genotypes, respectively. these findings demonstrate that in patients carrying the ct or tt mutant alleles in exon of the abcb gene and given csa, the recovery of graft function is less prompt, and the risk to develop dgf higher than in wild-type cc genotype. pre-transplant screening for abcb polymorphism would help to identify patients who may safely receive csa early post kidney transplantation. cigarette cigarette smoking has shown to reduce graft and patient survival in renal transplant patients. however, whether it could directly produce allograft disfunction has not been investigated. the aim of this study was to assess the smoking influence on renal graft function. we studied a cohort of adult renal transplant patients, transplanted from jan/ to dec/ and followed until dec/ . smoking habits were recordered at the time of transplant (never, former, current smoker). during summer of , a telephonical survey allowed us to obtain complete information about smoking habits in patients (aged . ± , % male): status (never, former, current), years of habit, years of quit, and number of cigarette smoked per day. number of "pack-years" was calculated. renal function was measure by inverse serum creatinine at rd month and then annually. time to decline a thirty percent in inverse serum creatinine was registered. patients were divided in two groups: those who always smoked during all transplant period (smokers, n= ) and those who did not (n= renal insufficiency occurs frequently after extrarenal transplantation as a result of acute tubular necrosis at transplantation, high blood pressure, and cni toxicity. we performed renal biopsies in patients after heart ( ), lung ( ) , liver ( ), bone marrow ( ), and cornea ( ) transplantation since . the time from transplantation to biopsy was ± months in general and was longest after liver ( ± months) and shortest after bone marrow transplantation ( ± months). the histologic changes were: tubular atrophy/interstitial fibrosis of ≥ % in % of biopsies (heart biopsies %, lung %, liver %, bone marrow %); acute tubular changes in % (heart %, lung %, liver %, bone marrow %); arteriolar hyalinosis in % (heart %, lung %, liver %, bone marrow %); arterionephrosclerosis in % (heart %, lung %, liver %, bone marrow %); glomerular sclerosis of ≥ % in % (heart %, lung %, liver %, bone marrow %); glomerulonephritis in % (heart %, liver %, bone marrow %; that means iga-nephropathy after heart and liver, immune complex nephritis twice after liver, mpgn after liver, and membranous glomerulonephritis and minimal changes after bone marrow transplantation); thrombotic microangiopathy in % (lung %, liver %, bone marrow %); finally one case of polyoma nephritis after lung transplantation. among heart and lung transplantations, patients needed kidney transplantation ( . %) after ± months; and among liver transplantations, needed kidney transplantation ( . %) after ± months (sign. later, p= ). conclusion: as expected, most histologic changes were those of cni toxicity and hypertension. surprising is the high number of glomerulonephritis under immunosuppression. thrombotic microangiopathy without the typical clinical signs were interpreted as cni-related toxicity and seems to occur more often after extrarenal than after renal transplantation. patients with heart and lung transplantation reach end-stage renal failure more often and earlier than patients with liver transplantation. the context: living kidney transplantation, a superior therapy to deceased donor kidney transplantation, is underutilized. states have enacted legislation and the federal government has launched initiatives to compensate living organ donors, but the effect of policy on improving living kidney donation rates in the united states is unknown. objective: to determine whether public policies are associated with changes in living kidney donation rates in the continental u.s. design, setting, and study subjects: series of cross-sectional analyses using records of state legislatures in continental states and living kidney donation rates from the united network for organ sharing. main outcome measures: living kidney donation rate during each year from - and change in donation rates before and after legislation enactment in each state and launch of federal initiatives. results: from january through december , states enacted legislation for living donors ( mandating paid leave, tax deductions, unpaid leave, encouraging paid leave). few states (n= ) enacted legislation prior to . there was a steady increase in the mean living kidney donation rate in the continental u.s during the study period (mean (standard deviation) annual increase in donations . ( . ) donations per , , population). in analyses accounting for length of time state legislation had been enacted, the types of legislation enacted, and the incidence and prevalence of esrd in each state, there was a slightly (but not statistically significantly) greater average annual increase in donations after compared to before state legislation enactment (annual increase in donations per , , population [ % confidence interval ( introduction: accurate and precise renal function assessment is essential in the evaluation of prospective kidney donors. while direct measurement of gfr is the "gold standard", it is not widely available. moreover, creatinine (scr)-based estimation equations are suboptimal to assess kidney function in this setting. ct scans are increasingly being used to study renovascular anatomy in donors and has replaced angiographic exams in many institutions. d imaging reconstruction allows for kidney volumes (kv) measurements which have been shown to highly correlate with measured gfr in this population. thus, the purpose of this study was to develop a model to estimate measured gfr that not only incorporates scr and demographic data but also kv as measured by d ct scans. methods: individuals who underwent donor evaluation were identified. an automated segmentation algorithm was used to measure renal parenchymal volume from preoperative abdominal cts. patient demographics and scr values were obtained from the medical records. gfr (normalized for bsa) was measured by i iothalamate renal clearances (igfr). an analysis of covariance model was created to correlate measured igfr with kv, patient age, sex, race, weight, height and scr. pearson's correlation coefficient was calculated for each variable. results: kv (p< . ), age (p< . ), scr (p< . ) and weight (p< . ) significantly correlated with igfr. sex ( . ), race ( . ) and height ( . ) were not statistically significant. the new fitted regression model is: kv-egfr (ml/min/ . m ) = . -( . *age) + ( . *weight) + ( . *volume) -( . *scr). we then compared the performance of the kv-egfr model to the re-expressed mdrd equation using calibrated scr assay. the r was . vs . , respectively; signed median % difference was + . % vs - . %, respectively (% difference b/w estimated gfr and igfr); and accuracy within % (% of estimated gfr values that fall within % of igfr) of . % vs . %, respectively. finally, the kv-egfr model was closer to igfr (in absolute values) than the mdrd eq. in / ( . %) cases vs / ( . %) cases, respectively. conclusions: kidney volumes highly correlate with igfr and the proposed gfr estimation model outperforms the mdrd equation in potential living kidney donors. the kv-egfr model could be used to estimate donor gfr in lieu of i iothalamate gfr which is less clinically available. for donor selection, current reports identify unsuspected renal pathology by time -biopsy. aim: to explore whether the findings at time -renal biopsy (bx) correlates with pre-donation clinical data including renal function. methods: kt databases from institutions were reviewed. time -renal bx are routinely performed from the upper pole during back-table and evaluated by nephropathologist for interstitial fibrosis (if), tubular atrophy (ta), arteriolar hyalinosis (ah), mesangial increase (mi), and glomerulosclerosis (gs). pre-donation data gathered from the donors were demography, body weight, bmi, systolic/diastolic bp, scr, proteinuria, and egfr by levey equation clinical data is summarized in the table. and gs showed no correlation. multivariate analysis failed to sustain the significant associations found on bivariate analysis, most likely due to a low event/parameter relation. conclusions: a significant correlation was observed between time -bx findings and clinical pre-donation parameters. whether these histological findings at the time of kidney donation represent a higher burden/risk for the remaining kidney ought to be evaluated during follow-up. in an era where living donation is increasing, we should advise a closer surveillance of these donors in order to modify risk factors that participate in kidney damage progression. predictors of poor early graft function following laparoscopic donor nephrectomy (ldn). matthew cooper, abdolreza haririan, stephen jacobs, michael phelan, benjamin philosophe, stephen bartlett, joseph nogueira. dept of surgery, urology, and medicine, university of maryland, baltimore, md. ldn has become the standard of care in many transplant centers. poor early graft function remains an important complication. we conducted a retrospective study to evaluate the risk factors for slow or delayed graft function following ldn methods: donor and recipient records from the first ldn were reviewed ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . results: slow graft function (sgf) was defined as cr> . mg/dl at pod and dgf as the need for dialysis within the first week following transplantation. donor variables examined included age, sex, race, bmi, egfr, and number of renal arteries. recipient variables included age, sex, race, bmi, prior tx, pre-tx dm, history of smoking and drug usage. additional variables evaluated included degree of relationship (lurt), hla mismatch, antilymphocyte induction, de novo cni usage, r v. l nephrectomy, wit, total or time, and performance of simultaneous deceased donor pancreas tx (splk). univariate analysis was performed with significance defined as p< . . significant variables were then included in the multivariate analysis. background: a kidney exchange program is the logistic solution for patients with positive cross match (x + ) or abo incompatible donors. a major problem in all kidney transplantation programs is the sensitized recipient. we analyzed the success rate for immunized recipients in the dutch kidney exchange program. methods: from january till december donor-recipient pairs were registered. there were couples in the x + group while pairs were abo incompatible. in the x + group the median pra was % ( - %). to create new combinations a match program was run times (every months) with a median of ( - ) participating couples. allocation criteria included bloodtype (first identical, then compatible), hla match probability within the actual exchange donor pool to ensure that highly sensitized recipients have the best chance to receive a kidney, and the waittime on dialysis. cross matches between new donor and recipient were performed centrally in our reference laboratory with cdc-tests. results: after match runs, we found matching couples for / ( %) x + pairs, for / ( %) abo incompatible pairs with o recipients and for / ( %) abo incompatible pairs with non-o recipients. median pra of the recipients in the x + group was % ( - %). after match runs chances for success became small. the overall success rate for abo incompatible and x + pairs in the dutch kidney exchange program after years is %. however, the success rate for immunized patients in the x + group is significantly higher ( %) as our match program gives priority to those recipients with the smallest chance of finding a compatible donor in each match run. thus our kidney exchange program is especially suited for immunized patients. although paired kidney donation (pkd) program is an established method to overcome incompatibilities between kidney donor-recipient pairs (drp), significant proportion of the incompatible drp participating in such program could remain unmatched. domino-kidney transplantation (kt) in which altruistic living non-directed donor kidney (lndk) is offered to a pool of incompatible drp, and is used to initiate a chain of pkd transplants, could provide more opportunities of kidney transplantation to drp in pkd program. we introduce our experience of multicenter domino kt for the last years sixteen hospitals participated in the domino-kidney transplantation between february, and july, . domino-kidney transplants were performed with domino-kt chains initiated by altruistic lndk. -pair chains were , -pair chains , -pair chains , -pair chains , and -pair chains . the development of a multi-regional kidney paired donation program. using an optimization matching algorithm the new england program for kidney exchange (nepke) efficiently matches incompatible donor/recipient pairs. in , the mid-atlantic paired exchange program (mapep) and other individual centers began sharing data with nepke. this is a report of the success of two regional programs working together to increase the probability of participants in both programs finding a compatible match. methods: incompatible pairs and non-directed donors (ndd) are referred to nepke through transplant centers. donor and recipient abo, hla and recipient hla antibody screening are entered into the computer database. utilizing the optimization program, searches for compatible matches are conducted every to days. the program identifies potential and -way matches, ndd chains, and list exchange chains. following the determination of compatibility nepke notifies transplant centers involved of the potential match and centers accept or decline the offer. transplant centers notify their pairs and preliminary crossmatches are performed. a conference call is scheduled to coordinate simultaneous donor nephrectomies and recipient transplants. surgeons speak prior to incision to ensure simultaneous donation. results: from july to december , pairs and ndds have entered nepke. during this time frame over one thousand possible matches were identified, with the majority of these matches involving the same pairs in multiple matches. after "optimizing" and eliminating multiple matches two-way exchanges; three-way exchanges; three-way list chain exchanges; and ndd chain matches were offered to transplant centers as possible matches. most common reason offers were declined include: positive crossmatch ( . %); donor factors ( %), and recipient inactive or transplanted ( %). four offers occurred in mapep alone pairs, in nepke, and offers were cross-regional. three matches are pending for additional transplants. one previous and one pending transplant are the result of cross-regional exchanges. five transplants performed and pending involve ndd chains. one pending match involves a list exchange chain. conclusion: using a computerized optimization algorithm to match and way exchanges, ndd and list exchange chains has lead to a substantial increase in the number of kpd matches and transplants performed. cross-regional coordination is feasible and expands the number of transplants performed beyond the ability of individual exchange programs. as living donors become an increasingly important source of life-saving organs, there is growing concern about the lack of comprehensive research on donor outcomes. in addition to possible long term consequences, there is a risk that donors will experience complications during or following surgery. of the , living kidney donors in - , none died during surgery, and . % (n= ) needed blood transfusions during surgery. in the six weeks following donation, . % (n= ) had at least one serious adverse event (sae): . % (n= ) needed readmission following initial discharge, . % (n= ) needed an interventional procedure, . % (n= ) needed re-operation, . % (n= ) had vascular complications, and . % (n= ) had other complications. when all saes were considered in combination, the rate was . %. because over % of ldr forms were submitted by transplant centers fewer than weeks post-donation, all complication rates should be considered minimum estimates. one donor was reported to have died from donation-related causes within weeks of donation. the number of living donor kidney transplants performed by a transplant center in - ranged from to transplants. additionally, the risk of donor complications is not equal across transplant centers. for example, there was a significant correlation between the number of living donor kidney transplants performed at a transplant center and the percentage of that center's patients who were readmitted within weeks of donation, with greater donor volume associated with a lower rate of readmission. living kidney donation is relatively safe, but prospective donors should be made aware that there is a non-trivial risk ( . %) of short-term complications post-donation. as with many other major surgical procedures, complication rates are lower, on average, at institutions that perform a larger number of these procedures. we sought to determine if intensive screening improves detection of polyomaviral reactivation in asymptomatic patients and pre-emptive stepwise modification can improve outcome of polyomaviral nephropathy (pvn). methods:this is a prospective single center study. we randomly assigned de novo kt (cluster randomization) to intensive screening (is:n= ) and routine care (rc: n= ) for the detection of decoy cells. is was initiated at week- of kt and rc at the time of increase in serum creatinine. this was complemented with urine and blood nucleic acid testing. all patients had biopsies performed for detection of polomya nephritis (pvn). both groups were treated with pre-specified stepwise modification of it based on cell cytology and viremia (step : decrease dose of cellcept by %, step : decrease dose of tacrolimus by %, or switch to sirolimus therapy, step : discontinue cellcept). primary outcome included persistence of decoy cells/viremia following each step in modification of it every three months and secondary outcomes included acute rejection, graft function and graft loss. results: polyomaviral reactivation developed in . % in is group and % had pvn without changes in serum creatinine. the estimated cumulative rate of primary outcome in the is versus rc groups, -months ( % vs. %) relative risk (rr), . ; %ci, . - . ;p= . ); -months ( %vs. %) (rr= . ; % ci, . - . ; p= . ); and -months ( %vs. %) (rr= . ; % ci, . - . ; p= . ). secondary outcomes: despite similar degrees of step-wise is modification, rate of acute rejection non-significant (p= . ), but % of patients in rc loss the graft vs no graft loss in is group. patients who continue to remain on tacrolimus vs. those who were switched to sirolimus therapy had persistent viremia (or= . ; %ci, . - . ; p= . ). conclusion: is for poloymaviral reactivation allows early detection of pvn in the presence of stable graft function. stepwise modification in it resulted in early resolution of decoy cells and viremia in both groups, albeit slowly in rc group, and it did not prevent the graft loss in rc group. background: dna sequencing of the bk viral (bkv) genome non-coding control region (nccr) from individual patient isolates demonstrate divergent sequence and alterations in the arrangement of modularly conserved sequence blocks (p-q-r-s) ranging in size from to base pairs. aim: primary aim to molecularly clone and analyze patient-derived bk virus nccr sequence variants. our secondary aim is to determine if reporter gene constructs of patient-derived nccr variants differ in their promoter activity upon transfection into a mammalian cell line (vero) and a human primary tubular epithelial cell line. methods: bkv dna was amplified and sequenced from blood and urine samples of renal transplant recipients. via sequence alignment, unique nccrs were determined. these sequences were pcr amplified and cloned into reporter plasmids containing the renilla luciferase gene. promoter activity was measured via luminometer hours after transfection into vero cells and human tubular epithelial cells. results: variation in naturally occurring bkv nccr promoter regions exist as single basepair insertions and deletions, and insertions or deletions of partial sequence blocks (p-q-r-s). single basepair substitutions were most commonly seen ( % of analyzed samples). promoter activity within vero cells ranged from % to % as compared to nccr activity of an archetypal strain (wwb). low promoter activity (< %) was seen in isolates with duplications of the p block and large deletions of the r block. conclusion: these sequence blocks are rich in regulatory elements and control the expression of both bkv structural and regulatory genes. variation in these cisacting eukaryotic transcriptional promoter binding sites corresponds to differential promoter activity in naturally occurring bkv isolates. current plans include repeating the promoter activity studies in human primary tubular epithelial cells. humoral and cellular immunity to polyomavirus bk large t and vp antigens after pediatric kidney transplantation. polyomavirus bk-associated nephropathy (bkvn) has emerged as a cause of graft failure after kidney transplantation (ktx). in a cohort of pediatric renal recipients undergoing prospective three-monthly monitoring for bk by blood and urine q-pcr, we evaluated antibody response, measured by enzyme immunoassay using bk vlp, and cellular immune response, reported as frequency of ifnγ-secreting cells in a elispot assay after -day stimulation with bkv large t (lt) and vp peptides. we could not observe any influence of recipient pre-transplant bkv-specific igg or t-cell levels, which were generally low, on bkv infection after allografting. after transplantation, both specific igg levels, and frequency of bkv-specific t cells increased according to the degree of viral exposure. in detail, bkv-seropositive patients who never reactivate the virus (group , n= ) did not show significant increase in igg levels (from a median od of . at month + to . at the end of follow-up), while patients with urinary shedding alone (group , n= ) or with viremia (group , n= ) increased from a median od of . to . (p= . ), and . to . (p> . ). in the case of cellular immunity, vp -specific t-cells increased in the three groups. conversely, lt-specific t-cells, which were high (median sfu/ cells) and remained unchanged throughout the follow-up period in group patients, had a significant increase in recipients belonging to both group and . interestingly, patients with urinary shedding who do not progress to viremia show a median -fold increase in lt-specific t-cell levels at peak viruria, compared to no increase observed in patients who develop viremia. the latter group mount a significant response to lt only after therapeutic reduction of immunosuppression. at peak viruria, viremic patients already show a -fold rise in specific igg compared to the . increase observed in group recipients. our data suggest that inability to reach protective levels of bkv lt-directed t cells, rather than specific igg, predispose ktx recipients to bkv replication. introduction:the antibody response to human bkv virus (bkv) is incompletely characterized. antibody responses to the vp- protein have been detected in kidney transplant patients, but it is not known if these have virus neutralizing activity. methods:recombinant bk, jc, and sv virus like particles were used to produce a panel of monoclonal antibodies. these antibodies were characterized for isotype and for ability to bind the respective antigens in elisa assays. to test neutralizing activity, bkv gardner strain (atcc# vr ) viral particles were incubated with the corresponding antibodies for hours at degrees c, and used to infect wi cells. bkv infection was monitored by quantitative real time pcr using primers directed against the vp- gene. neutralizing activity was defined as greater than % inhibition of viral yield. results:the monoclonal antibodies were of the igg a or igg b class with the exception of one igg and one igm antibody. all anti-bkv monoclonal antibodies bound to bkv capsids in-vitro in elisa assays. this binding affinity was species specific, as only antibody showed weak binding activity to jcv and sv capsids. neutralization of infectious bk virus was shown for / antibodies. denaturation of capsid proteins indicated that the monoclonal antibodies recognized primarily conformational epitopes, with only monoclonal antibody appearing to have a linear component. paucity of linear epitopes was further suggested by lack of reactivity of sera from bkv seropositive subjects in elisa assays based on genotype-specific short peptide sequences derived from the bkv vp- loop region. four monoclonal antibodies each generated from jcv capsids and sv capsids did not show any bkv neutralizing activity. conclusions: bkv vp- protein capsids contain species specific conformational epitopes which can elicit virus neutralizing and non-neutralizing antibody responses. measurement of these antibodies in renal transplant recipients may have diagnostic and prognostic applications. bkv specific monoclonal antibodies deserve further study as potential therapy of acute infections in the viremic phase. impact of immunosuppression reduction in bk viremic patients: year follow-up. s. kuppachi, a. guasch, c. p. larsen, k. e. kokko. transplant center, emory university, atlanta, ga. background: development of bk nephropathy is a risk factor for allograft loss. bk viremia (bkv) precedes the development of bk nephropathy. it has been reported with -year follow-up that reduction of immunosuppression leads to control of bkv. here, we report our -year follow-up experience of bkv patients that were identified by a prospective screening protocol and managed by sequential reduction of immunosuppression. methods: all kidney or kidney-pancreas transplant recipients at emory university between / - / were screened prospectively for bkv by real time pcr during follow-up visits ( - , , , , ) . patients with a bk viral load of greater than , copies/ml blood received a kidney biopsy to screen for bk virus nephropathy by immunohistochemistry. bkv without nephropathy resulted in reduced immunosuppression by a % reduction in mycophenolate dose. bkv with nephropathy resulted in discontinuation of mycophenolate. all identified bk patients were monitored every - weeks until viral load was below , copies/ml. immunosuppression was further reduced if viral loads failed to decrease. results: recipients were followed over a -month period. patients had received simultaneous kidney and pancreas, a liver and kidney and the rest kidney alone. of ( %) patients developed bkv within a year from time of transplantation. average time to diagnosis of bkv was . months. average dose of mycophenolate at years was . g/d in the bkv negative population as compared to . g/d in the bkv positive population. average hour trough blood level of tacrolimus at years was . ng/ml in the bkv negative population as compared to . ng/ml in the bkv positive population. survival rates for both patient and organ were comparable at years in bk viremic vs bk negative patients ( % vs %) and ( % vs %) respectively. while bk viremia is a historic risk factor for organ loss, prospective monitoring and reduction of immunosuppression is associated with comparable year patient and organ survival to patients that never develop bk viremia. background: there are currently no bk virus (bkv) specific therapies available for clinical use. this study evaluates viral large t antigen as a potential target for drug development, since (a) this is a key molecule that participates in several different stages of viral replication, (b) has no homologous human protein, and (c) offers multiple functional domains for chemical binding, particularly the atp binding site, the dna binding site, the hexamerization surfaces, and the hinge region. methods: virtual screening and protein modeling techniques were applied to bkv large t antigen using a model developed from the known crystal structure of sv large t antigen. two different structural states of large t antigen (monomer and dimer structure) in three different states (with the nucleotide pocket empty, with bound adp and bound atp), were evaluated for a total of large t antigen receptor conformations. results: a computational solvent mapping analysis of small molecular probes allowed identification of multiple functional sites, which represent potential drug binding pockets on the large t antigen molecule. it was possible to classify molecular conformations centered on the atp binding site, hexamerization surface and hinge region of the viral protein. we docked medium sized fragments (< da) to confirm the results obtained by computational solvent mapping, and further characterize chemical properties of the atp binding site. in another approach, known chemical structures of hsp and rho-kinase inhibitors were used to search compound databases and obtain a subset of compounds (mean size of da) capable of docking large t antigen. cross-referencing the top solutions obtained by energy ranking, we were able to identify compounds that bind large t antigen in all conformational states. a subset of compounds simultaneously binds the atp binding site, hexamerization surface and hinge region of bkv large t antigen. conclusions: virtual screening and three dimensional homology modeling technology has allowed us to identify compounds that can bind multiple sites on the large t antigen. these compounds are predicted to preferentially inhibit viral replication without the toxicity expected from simultaneous inhibition of host cell kinases. bk virus (bkv), a human polyomavirus, causes bkv nephritis, which often leads to graft loss after renal transplantation. currently, the only efficient therapy against bkv nephritis appears to be a reduction/change of immunosuppressive agents, and this may increase the inherent risk of rejection. since human renal proximal tubular epithelial cells (hrptec) represent a main natural target of bkv nephropathy, the analysis of bkv infection of hrptec is likely to provide necessary additional insight into bkv biology and contribute to the development of strategies for treatment of bkv nephritis. here we report the ability of -hydroxy- -methyl-glutaryl coenzyme a (hmg-coa) reductase inhibitor pravastatin, which is routinely used to treat hypercholesterolemia, to repress bk virus entry pathways in hrptec and, correspondently, prevent bkv infection. the percentage of hrptec infected with bkv was assessed by immunofluorescent analysis in the absence and presence of pravastatin. both, the percentage of bkv infected cells and the intensity of bkv infection, assessed by western blotting using antibodies against large t antigen, were significantly decreased in hrptec treated with pravastatin. it is likely, that pravastatin's inhibitory effect is explained by depletion of caveolin- , a critical element of caveolae. we demonstrate that bkv enters hrptec by caveolarmediated endocytosis and disruption of caveolin mrna and protein inhibits bkv infection of hrptec. we provide evidence that pravastatin dramatically decreased caveolin- expression in hrptec and interfered with internalization of labeled bkv particles. our data suggest that pravastatin, acting via depletion of caveolin- , prevented caveolar-dependent bkv internalization and repressed bkv infection of hrptec. our data represent the first report of inhibitory action of statins upon bkv infection. results: . % of patients were caucasian, . % hispanic, . % african-american and . % asian. overall -and -yr patient survivals were % and %. stratified by race, only african-american survivals differed from caucasian ( -year survivals of % vs. %; figure ). compared to caucasians, african-american patients were younger ( yrs ± . vs. yrs ± . ), were more likely to be status ( . % vs. . %), to have a serum creatinine ≥ . mg/dl ( % vs. %), to receive an multi-organ transplant ( % vs. %), to have fulminant hepatic failure ( % vs. %), to have a higher meld score ( . ± . vs. . ± . ) , to be in the icu ( % vs. %), and to be ventilated pre-transplant ( % vs. %); all p-values < . . after adjustment for each of these variables, race was still an independent predictor of mortality (p= . , hr: . , ci: . - . ). multivariate analysis of the african-american group (n= ) alone revealed that a bmi greater than (p= . , hr: . , ci: . - . ), a creatinine greater than . mg/dl (p= . , hr: . , ci: . - . ), and icu admission pretransplant (p= . , hr: . , ci: . - . ) are independent predictors of mortality in this subset of patients. conclusion: in the current meld era, race is still a predictor of worse outcomes, even after adjustment for multiple clinical variables. further work is necessary to elucidate why this disparity exists. the purpose of this study was to analyze the effects of successive pregnancies in female liver transplant recipients on newborn and maternal outcomes. data were collected from the national transplantation pregnancy registry via questionnaires, phone interviews and hospital records. analyses for linear trends (proportions and continuous variables) were done by chi square and least squares regression. there were outcomes of pregnancies, including twins. of the liver recipients who had a first pregnancy, had between one and four subsequent pregnancies. there were no significant differences in the variables analyzed as noted in the conclusions: successive pregnancies in liver transplant recipients are not associated with adverse fetal outcomes and/or increased maternal graft loss. female liver recipients with excellent allograft function without significant recurrent disease or chronic rejection who wish to have more than one pregnancy should not be discouraged to conceive. recorded and categorized in a blinded fashion. univariate, multivariate and survival analyses were performed. over a . -year period ( ) ( ) ( ) ( ) ( ) ( ) , olt recipients were randomized to receive a cca with biliary stent (n= ) or cca alone (n= ). patients with hepatic artery thrombosis (n= ; . %) were excluded. there was no significant difference in demographic or graft-related variables. the mean age at transplant was years, % were male, the mean meld was and % had hepatitis c. the mean donor age was years, % of donors were male, and the mean cold ischemia time was . hrs. the only complication related to the biliary stent was one occlusion. the rate of overall bc in the stented patients was . % vs. . % in non-stented patients, (p=ns). however, stented patients had significantly less bc in the first -days post-olt ( . % vs. . %, p< . ) and significantly less anastomotic leaks ( . % vs. . %, p< . ). over the year following olt, stented patients also required less biliary therapeutic interventions (mean . vs. . interventions/patient, p< . ) and fewer readmissions (mean . vs. . readmissions/patient, p< . ). we also observed improved late graft survival (> mo) in the stented group. intraoperative stenting of the cca at olt does not appear to reduce the long-term rate of bc but it decreases the incidence of biliary leaks and significantly improves many facets of early patient management. is background: long-term outcomes after retransplantation of the liver (re-olt) is inferior compared to primary olt. however, the survival benefit of re-olt based on model for end stage liver disease (meld) is not known. a single-center analysis of adult patients who underwent re-olt between february to february was performed. survival benefits, at a given meld score, were calculated by comparing re-olt survival at months to expected -month survival without retransplantation results: of pts, underwent re-olt, and received transplants. the figure shows re-olt survival benefit at any meld score with increased significance in patients with meld scores > . although meld scores - predicted the highest mortality after re-olt, they also demonstrated survival benefit. multivariate cox regression identified cold ischemia time > hrs (rr . , p . ), meld - (rr . , p . ), time from first olt ( days - year, rr . , p . ) and third transplant (rr . , p . ) as independent predictors for mortality following re-olt. conclusions: re-olt should be considered in all patients even with low meld scores. although patients with high meld scores ( - ) exhibit poor survival outcomes, a survival benefit is achieved. survival benefit that considers both probability of death without re-olt and expected survival with re-olt, should be used for selection of retransplantation candidates. this study analyzed posttransplant complications, meld score, and donor ages and their effect on length of stay (los). methods: this irb approved retrospective review of our prospectively maintained database included liver transplant recipients transplanted between - . los < days, - d, and > d were analyzed. primary analysis to look at los, meld, and donor age was performed using wilcoxon two-sample test. complication groups were analyzed using logistic regression and odds ratio estimates were determined. kaplan-meier for patient survival for the los groups was performed. univariate analysis: allograft dysfunction, vascular complication of liver allograft, intra-abdominal (other than liver), biliary, cardiac, pulmonary, neurologic, sepsis, renal, and endocrine were statistically significant (p< . ) using fisher exact test. multivariate analysis: using logistic regression, significant complications were analyzed to determine the complications linked with los > d and > d. analysis of liver transplants demonstrated increasing los with increasing meld in each donor age group ( - , - ) p< . . for donor age > , this relationship was not significant (p= . ). multivariate analysis using logistic regression determined odds ratio estimates for each complication resulting in los > days and > days. los > days and los > days were associated with different complications (as shown above). allograft dysfunction (including pnf) and renal complications were not significant factors in multivariate analysis. patient survival significantly decreased (p< . ) with increased los > days. introduction: some patients with primary biliary cirrhosis (pbc) may require longterm corticosteroid (cs) therapy following liver transplantation (olt) due to recurrent inflammation in the graft. our center has attempted to minimize cs use in all of our olt recipients. we reviewed our experience in this cohort of patients to determine ) patient outcome including recurrent disease and ) long-term requirement for cs use in pbc patients. methods: from to , , olts were performed in , adults at the university of colorado of which patients ( . %) with pbc received allografts. recurrence was defined by characteristic histologic changes on biopsy. bivariate and multivariate analyses were used to evaluate predictors of cs withdrawal. potential predictors of cs discontinuation were considered: age, gender, bmi, race, presence of inflammatory bowel disease (ibd), type of graft (cadaver or living donor (ld), recurrence of aih, warm ischemia time, follow up time (time since transplant), and immunosuppressant (is). results: overall survival at years was %. the , and year recurrence-free survival was , , and %, respectively. disease recurred in patients ( . %). of these patients, none received a second transplant because of recurrent disease. cs was withdrawn in % of patients at time of review. independent predictors of cs discontinuation are age (>median) (p = . ) and ld graft type (p= . ). conversely, cyclosporine (csa) (p= . ), female gender (p= . ), and bmi > (p= . ) were negatively associated with cs withdraw. interestingly, cs withdrawal did not influence pbc recurrence. conclusions: ) long-term outcomes in pbc patients are favorable and disease recurrence can be managed medically without abstracts re-transplantation. ) using an aggressive cs minimization approach, almost / of the patients were cs-free at the time of last follow-up. ) increasing age and ld grafts were associated with successful cs withdraw; while csa, female gender, and increasing bmi were associated with unsuccessful cs withdraw. incidence cholestatic disease (cd), either chronic rejection or recurrent primary sclerosing cholangitis (psc), post liver transplantation (lt) occurs in - % of psc grafts. the study objectives were to evaluate the incidence and long-term outcome of cd. from to , grafts in consecutive psc patients and grafts in concurrent alcoholic liver disease (ald) patients were compared. cd was diagnosed by biliary imaging and/or histology. median follow-up was months. the groups were similar including meld score and cold ischemic time; however, roux-en-y biliary anastomosis was more common in the psc group ( % vs. %, p< . ). the psc group had more cmv hepatitis ( % vs. %, p< . ) and acute rejection ( % vs. %, p< . ), and fewer biliary anastomotic strictures ( % vs. %, p< . ). cd occurred in psc grafts and ald grafts (p< . ). the incidence of cd was greater in the psc group (p= . , fig. ). no significant risk factors for cd were identified. in the psc group the graft survival was lower in the cd group (p= . , fig. ) ; however, patient survival at and years was not effected by cd: % and % vs % and % because the re-lt rate was greater in this group ( % vs. %, p< . ). at years, patient survival in the psc group was better than for ald ( % vs %, p< . ). long-term outcome post lt for psc is good and better than for ald; however, cd continues to develop beyond the first years with a prevalence of % at years. graft loss in patients with cd is high, but with re-tx, patient survival is similar to non-cd patients. further studies to distinguish chronic rejection vs. recurrent psc may provide insight into the prevention of cd following lt for psc. discussion: our analysis showed that patients with aih have a worse long term survival compared to pbc and psc after ddlt. this may be explained by possibly more advanced disease at the time of presentation or more septic complications due to pretransplant salvage therapy with immunosuppressants. also,pbc had the worst relative outcome after ldlt in this group-possibly explained by the older age of the recipients. overall, ldlt offered better outcomes than ddlt in terms of survival in patients with aih,pbc and psc. this study highlights an important and previously unvisited aspect of transplantation for autoimmune and cholestatic liver diseases. inflammatory bowel disease course in patients transplanted for primary sclerosing cholangitis. ariana wallack, joel s. levine, lisa forman. internal medicine, univ. of colorado hsc, aurora, co; gastroenterology and hepatology, univ. of colorado hsc, aurora, co. the natural history of ibd following liver transplant (lt) for psc is unknown. prior studies have not shown factors consistently associated with disease activity, but were limited by small sample sizes. the aim of the study is to describe our experience with ibd post-lt in patients with psc and determine factors predictive of disease activity. a survey was mailed to liver recipients transplanted for psc between and asking about medications, ibd activity and quality of life after lt. responses were linked to our lt database. results ( %) recipients responded. % were male with a median of ( - ) months since transplant. % were caucasian with a median transplant age of ( - ) years. % developed recurrent psc post-lt. % had a diagnosis of ibd ( % uc). immunosuppression included tacrolimus in % and cyclosporine in %. % experienced at least one episode of acute rejection. % rated their quality of health - on a scale of - . there was no significant difference in demographic variables between ibd and non-ibd cohorts. % of respondents had ibd pre-lt. of the patients without pre-existing ibd, developed ibd post-lt. of the de novo ibd cohort, % were male, median transplant age was years ( - ), and % were caucasian. ibd developed in % at more than years post-lt. there was no statistical difference between the de novo ibd cohort and those with pre-existing ibd except for ibd type ( % uc vs %, p= . ). significantly more patients were not on any ibd medications post-lt compared to pre-lt ( % vs %, p= . ). fewer post-lt patients were on aminosalicylates ( % vs %, p= . ) and prednisone ( % vs %, p= . ) compared to pre-lt. post-lt recipients developed fewer ibd flares requiring hospitalization ( % vs %, p= . ). % reported improvement in ibd activity post-l. % and % reported no change and worsening activity, respectively. there was no significant difference between reported disease activity and immunosuppression, cmv status, rejection rate, recurrent psc, transplant age, gender or race. background: symptomatic cmv continues to be a significant problem. the costs associated with its development remain high without an optimal method for prevention. the aim of this study was to measure the pharmacoeconomic impact of implementing an abbreviated pre-emptive monitoring strategy versus valganciclovir (vgc) prophylaxis in a large teaching hospital. methods: costs for this analysis were based on a societal perspective, including drug, personnel, hospital, outpatient infusion and monitoring costs related to resources needed to perform pre-emptive monitoring and treatment of cmv related events. time per hr costs were nurse/data coordinator $ , physician $ , and pharmd $ . cmv pcr cost was $ . vgc cost per mg was calculated for prophylaxis, treatment and days of consolidation as needed based on an awp ($ . per mg). estimated cost of cmv syndrome was based on cost of picc line placement, drug, personnel and supply costs based on days of therapy and was estimated to be $ , . . inpatient admission cost per day were $ . results: a total of patients were included in this analysis. baseline and transplant demographics were well matched. table displays the total direct and indirect costs accumulated for each group. cmv syndrome occurred in three patients for each group. there was no cmv disease in either group. % of patients in the pre-emptive group had dnaemia, but only patients required oral anti-viral therapy. provider time and lab monitoring costs were significantly higher in the preemptive group, while direct medication cost was significantly higher in the prophylactic group. conclusions: frequency of disease severity and outcomes were equal in each group. although the overall costs between strategies is equivocal, allocation of resources to provide pre-emptive monitoring places the burden of disease prevention on the health care system versus the patient necessitating further abbreviation of these strategies. we propose a non-simultaneous form of kidney paired donation that starts with a living, non-directed donor (lnd). a paired donation matching algorithm was developed to allow for lnds to start potentially never-ending altruistic donor (nead) chains in addition to closed loops of -, -and -way exchanges. results: in july , a lnd from michigan traveled miles to donate a kidney to a woman whom he had never met in arizona. the following week, the arizona recipient's husband donated one of his kidneys to a -year-old woman in ohio. the following month, the mother of this recipient traveled to a city hours away to donate her kidney to a patient whose incompatible donor simultaneosly gave a kidney to the fourth patient in the chain. the incompatible donor for this fourth recipient is now slated to give her kidney to a patient in maryland. over the past months, transplant programs have partnered to perform paired donation transplants. demonstrating the advantage of nead chains over classic paired donation, of transplants resulted from altruistic donor chains. conclusion: in order to fully realize the potential of the above approach, one must be willing to supplant two prevalent ideas: ) that kidneys from altruistic donors should be given to the top candidate on the deceased donor waiting list, and ) that paired exchanges must be done simultaneously. while there are certain pitfalls to using chains of donors as opposed to traditional "swaps" (i.e. the possibility that a donor could renege, or the accumulation of type ab donors who are not likely to be able to begin another chain), this proposed paradigm shift could result in a very significant increase in both the number and quality of paired donation kidney transplants. purpose: medical literature and national best practices correlate families' understanding of brain death with organ donation rates. analysis of hospital data demonstrated variability in family communication. although surgical residents frequently interact with family members of potential donors and play a critical role in the donation process, they receive no formal cst. we sought to determine if pre-training residents improved performances in cst involving explanation and notification of brain death to family members and aided efforts to achieve the national donation rate goal of %. methods: in collaboration with a regional organ procurement organization (opo), an educational model for end of life cst was developed. surgical residents were divided into groups. the first group (n= ) attended a -hour didactic session at the opo that included role-playing exercises explaining brain death to families. opo staff, trained to serve as family role-players and skills station coaches, debriefed residents after each simulation. the second group (n= ) received no specialized training. six weeks later both resident groups participated in formal videotaped family communication simulations. independent observers (hospital faculty and senior opo staff), blinded to training, evaluated residents' communication skills using a -parameter assessment tool. all residents reviewed their videotaped performances and evaluations, then repeated the simulations after six months. results: during the study period, the pre-trained resident group assessment scores increased by % (p= . ), while the untrained group increased by % (p<. ). while evidence of improvement existed in both groups, pre-trained residents consistently scored higher when compared to untrained ( % vs. %, p= . ). during this same time period, donation rates in the surgical intensive care unit (sicu) increased by %. conclusion: our educational model demonstrated effective training in communication skills during end of life discussions. although a direct relationship cannot be established, donation rates in the sicu increased after resident training. incorporation of this training program into resident education has the potential to improve donation rates and increase the number of organs available for transplantation. program. saverio mirarchi, graeme n. forrest, benjamin philosophe. medicine, university of maryland, baltimore, md; surgery, university of maryland, baltimore, md. objective: to improve the efficiency of care for solid organ transplant patients by having internists work in conjunction with transplant surgeons to manage transplant patients admitted to the hospital more than days post organ transplant. this includes patients who have undergone kidney, pancreas, and liver transplants which our center transplants over of these organs/year. in , the organ transplant program was divided into a surgical transplant service (sts) and medical transplant hospitalist service (mths). the mths consists of four full time physicians, one part time physician, and one nurse practictioner with daily rounds from a transplant surgeon on a weekly rotating schedule. methods: we analyzed our data from the past five years since the inception of the mths at a large university medical center. the length of stay (los) for the mths and sts were compared to data from the previous combined program as well as data from the university health consortium (uhc). in addition, we looked at the cost of care to determine if there were any savings related to reduced los and adjusted for the combined salary of the mths. results: in the review period, the total admissions for both the mths and sts averaged admissions/year. over the past five years the mths showed a major decrease in the los index, defined as the ratio between the observed los and the expected los based on uhc data. this index dropped from . to . for patients on the mths. there was also a parallel drop in the sts los index from . to . . this was associated with a significant cost savings for the hospital. on average, the program has realized an average savings of approximately $ , , per year. when accounting for the combined salary for the mths group which is , dollars/year, the total savings over the year period this amounts to $ . million. conclusion: the creation of a mths working within an organ transplant program at a large university center has been able to demonstrate a major decrease in los for transplant patients which has resulted in decreased costs and improved efficiency. this has also allowed more focused care for a complex medical population. we believe that our program can serve as a model for similar programs at other busy transplant sites. with increasing demand for kidney transplants(tx), more patients are opting to travel outside the us to obtain transplantation. we describe the characteristics and outcomes of kidney tx recipients followed at our center who traveled abroad for a kidney tx between and . methods: data were obtained via chart review. we compared demographics to all tx recipients at our center during the same period and compared post-tx outcomes to a cohort of patients transplanted at our center matched for age, race, tx year, dialysis time, prior tx, and donor type. median follow-up time was days (range - ). results: demographics are outlined in table. patients transplanted abroad were more likely to be asian and had shorter dialysis times. most patients were transplanted in china ( %) followed by iran ( %), the philippines ( %), and india ( %). living unrelated tx were most common. all patients were discharged on a calcineurin inhibitor, pred, and either mmf ( %), aza ( %), or rapamycin ( %). patients received induction. only patients received cmv prophylaxis. the median duration of hospitalization was days. the median time post-tx to initial visit at our center was days. patients required urgent admission to hospital, of whom lost their grafts. patients ( graft survival at -year was % for both "tourists" and matched recipients at our center. median time to graft loss was ( - ) days. mean scr and rejection -year post tx was not significantly different between recipients transplanted abroad and at our center. conclusion: compared to patients transplanted locally, patients transplanted abroad had similar graft survival and renal function post tx, but had a high incidence of infectious complications. [background] the primary benefits anticipated following successful induction of allograft tolerance are avoidance of the complications of long-term immunosuppression and prevention of chronic rejection. we have previously reported successful induction of renal allograft tolerance in recipients of hla mismatched combined kidney and bone marrow transplantation (ckbmt). no evidence of chronic rejection has been observed in these recipients after immunosuppression-free periods of to years. in the current study, we have evaluated the longer-term economic impact of this approach. [method] the conditioning regimen for ckbmt included cyclophosphamide, thymic irradiation, anti-cd mab, and a calcineurin inhibitor, which was discontinued after - months. stable renal transplant recipients receiving ongoing triple or double drug immunosuppressive therapy with compatible follow up times were compared with the four tolerant recipients. tolerant patients and stable patients on maintenance immunosuppression were also comparable with respect to their age, their original disease and donor-recipient histocompatibility. [results] the perioperative charges for ckbmt were approximately $ , higher than those for conventional living donor kidney transplantation. after - months, continuing medications in ckbmt recipients included only occasional over-thecounter analgesics. in contrast, the stable conventionally treated recipients were taking an average of pills daily. these included treatments required for de novo diabetes ( %), hypertension ( %), hyper lipidemia ( %) and gastro-intestinal symptoms/ prophylaxis ( %) in addition to their maintenance immunosuppression. these needs resulted in annual maintenance charges of over $ , /year/allograft recipient and do not include unmeasured costs related to issues such as quality of life or absences from employment. [conclusion] even with this admittedly expensive approach to tolerance induction, the overall medical costs for conventional kidney transplantation with ongoing immunosuppression and treatment for complications will exceed the cost of tolerance after approximately years. increasing african american donation rates in a midwest metropolitan community. susan gunderson, susan mau larson, david m. radosevich, clarence jones, bill tendle, tiffany scott. lifesource, st. paul, mn; transplant information services, university of minnesota, minneapolis, mn; southside community health services, minneapolis, mn. purpose: african americans are underrepresented in deceased organ donation in this + million community. historically minimal educational outreach had occurred and this study was designed to understand the community's disposition toward donation and to increase support for donation. methods: television, newspaper, and radio advertising aired over a month period beginning in using the nationally produced donate life-african american campaign as the primary intervention. other components included related faith-based and community outreach. the opo partnered with a minority focused community health clinic to survey african americans pre-and post-intervention. a mailed, selfadministered survey was sent to a sample drawn from organizational lists with a high likelihood of including african american households. for the evaluation, the sample was separated into ) community members and ) church members exposed to faithbased campaigns. results: african americans in this community have a sophisticated understanding of the importance of donation (average of knowledge questions scored correctly) in pre-intervention survey. in both community and church groups media exposure and donation knowledge increased after the media campaign (p< . and p= . respectively). similarly, donor designation rates for the entire population on the drivers licenses increased ( . % versus . %, p= . ). among all african americans the propensity to donate was, however, unchanged following the campaign. propensity to donate increased (p= . ) in the community sample whereas there was a reduced propensity to donation (p= . ) in the church sample. during the study time period the opo also experienced significant increases in donation authorization rates among african-americans, increasing from % to %. summary: a media based campaign combined with grassroots outreach is an effective tool to increase knowledge and awareness. partnership between the opo and community and faith based leadership was a significant positive byproduct of the project and should be included in future outreach efforts. background: it has been hypothesized that the clinical benefits of anti-thymocyte globulin (atg) induction therapy do not completely result from immunodepletion, but may also result from induction of immunoregulatory t-cells (treg). in this prospective, controlled study we investigated the effect of atg-induction therapy on the frequency and phenotype of peripheral cd + foxp + cd -/low t-cells in kidney transplant patients. methods: after transplantation, patients received atg-induction therapy (thymoglobulin ® ) and triple therapy consisting of tacrolimus, mmf and steroids. the control group (n= ) received triple therapy only. by flow cytometry, t-cells were analyzed for markers associated with immune regulation: cd , foxp and cd . within the foxp + t-cell population, the cd ro (memory) and ccr (homing receptor) markers were characterized. results: pre-transplant levels of cd + foxp + cd -/low t-cells in all patients were - % (median %) of cd + t-cells. one wk post atg induction therapy, no measurable numbers of treg were present. at wks post atg-induction therapy, a higher proportion of the first detectable t-cells expressed foxp compared to the control-group (atg vs. control-group; vs. %, median, respectively, p= . ) and then returned to pre-transplant levels at wks. this increased proportion of cd + foxp + cd -/ low t-cells resulted in a significantly higher foxp + /foxp neg ratio than in the controlgroup at wks; . vs. . , median, p= . ) . at wks, we found a decline in the proportion of naive foxp + treg (cd ro neg ccr + pre-transplant vs. post-transplant; vs. %, median, p= . ) which was associated with a rise in the proportion of memory foxp + treg (cd ro + pre-transplant vs. wks post-transplant; vs. %, p= . ). moreover, the proportion of memory t-cells exceeded that in the control-group at wks (atg vs. control-group; % vs. %, median, p= . ) which was mainly due to an increase in the proportion of effector memory foxp + treg (cd ro + ccr neg ). conclusion: after atg-induced immune cell depletion, a shift towards cd + foxp + cd -/low peripheral regulatory t-cells with the memory phenotype was measured in kidney transplant patients. this finding suggests that atg treatment triggers the generation of de novo peripheral regulatory t-cells by homeostatic proliferation. introduction in a prospective study, we investigated whether donor-specific regulatory cd + cd bright+ foxp + t cells develop in kidney transplant patients. methods we analyzed the percentage and function of peripheral regulatory cd + cd bright+ foxp + t cells of patients before, , and months after kidney transplantation. the immune regulatory capacities of cd + cd bright+ foxp + t cells were assessed by their depletion from pbmc and reconstitution to cd neg/dim responder t cells at a : ratio in the mlr. in the first year after transplantation, peripheral cd + cd bright+ foxp + t cells decreased from , % ± , pre-transplantation to , % ± , at months (p< . ). while mlr reactivity to rd party-ag ( rd p) significantly improved (p< . ), the reactivity against donor antigens remained low. functional analysis demonstrated potent donor-specific regulatory activities by cd + cd bright+ foxp + t cells after transplantation. depletion of cd + cd bright+ foxp + t cells from pbmc resulted into increased proliferation upon stimulation by donor antigens (p< . ). upon reconstitution, the capacity of cd + cd bright+ foxp + t cells to control the proliferation of anti-donor reactive cd neg/dim t cells increased over time: from % (median) pre-transplant to % post-transplant at month (p< . ). moreover, the anti-donor regulatory activities by the cd + cd bright+ foxp + t cells were significantly more vigorous than those controlling rd p-ag stimulated responder t cells ( %, p< . ). the generation of potent donor-specific regulatory cd + cd bright+ foxp + t cells in the periphery of kidney transplant patients prevents the development of adequate alloreactivity. conclusions: these results indicated that anti-donor responses could be detected even in a significant proportion of "stable" long-term hla identical kidney transplant recipients. speculatively this may be the cause of late graft failures in this group of patients. expression klotho is a gene almost exclusively expressed in renal distal tubules and loss of expression is associated with accelerated aging. in various models of acute and chronic renal injury, and with normal aging, renal klotho expression has been found to decrease. increased donor age is associated with poorer long term allograft function. we hypothesized that klotho mrna expression in renal implant biopsies would correlate with donor kidney quality, as determined by donor chronologic age and peri-transplant renal injury. our recent unsupervised microarray analysis of renal implant biopsies revealed a continuum of organ quality across all samples ranging from the best living donor (ld) kidneys at one end to the worst performing deceased donor (dd) kidneys at the other (am j transpl , nov ,epub). three predominant groups were identified of ld, dd kidneys with low risk ( . %) of delayed graft function (dgf) and dd kidneys with high risk ( %) of dgf (p < . ). analysis of klotho gene expression among these groups also revealed a spectrum of expression from highest levels in ld to lowest in dd kidneys, especially those who developed dgf. differences were highly significant among ld vs dd kidneys (p < . ), although donor age was not different between these groups. klotho transcript levels were significantly different among kidneys that developed dgf compared to those with immediate graft function (igf) (p < . ). in conclusion, reduced klotho gene expression is associated with grafts at risk of poorer function and appears to be independent of donor age. decreases in klotho expression likely reflect other factors impacting the renal tissue, which may impact potential for repair and ultimately allograft function. anti renal allograft rejection episodes produce a stereotypical response in the allograft characterized by infiltration by cytotoxic t lymphocytes (ctl), potent ifng response by donor and recipient cells, and decreased transcripts associated with the epithelium. we previously identified pathogenesis based transcript sets (pbts) that reflect the disturbance in rejecting allografts (qcats -ctl, grits -ifng response, kts -decreased function, ajt : , . we hypothesized that anti-rejection treatment would reverse the transcriptome changes of rejection more than histopathologic lesions. using microarray analysis we measured expression of these pbts in antibody mediated rejection (abmr)( untreated, treated) and t-cell mediated rejection (tcmr) ( untreated, treated) biopsies, normalized to nephrectomy samples. histopathology scoring of the primary rejection lesions were analyzed; interstitial inflammation(i), tubulitis(t), intimal arteritis(v), and glomerulitis(g) (fig a) . of these, only i and t differentiated between abmr and treated abmr (p< . ) yet none differentiated between tcmr and treated tcmr. pbts on the other hand differentiated treated from untreated for both abmr (p< . ) and tcmr (p< . ) with all pbts (fig b/c) . the changes in transcript expression in treated cases were dramatic. particularly impressive was the consistent correction of the disturbances in pbt expression despite the heterogeneous treatment following abmr episodes. unlike abmr treatment, tcmr treatment always included steroids which may contribute to the more pronounced changes compared to abmr. the time of treatment before the biopsy, which also varied within the groups, did not affect the changes in pbt expression since values in treated cases approached those of nephrectomy samples. thus, histologic rejection lesions persist following anti-rejection treatment whereas transcript disturbances of rejection are greatly reduced compared to untreated cases. this study suggests that assessment of anti-rejection treatment is more sensitively monitored by transcript expression than histopathology. blood deciphering the mechanisms of tolerance and chronic immune-mediated rejection remains a major goal in transplantation. data in rodents suggests that toll-like-receptors (tlr), regulators of innate immune responses, play a role in determining graft outcome. however, few studies have focused on tlr in human kidney transplant recipients. we addressed this issue by analyzing the peripheral blood (n = ) and graft biopsies (n = ) of renal transplant patients and healthy volunteers. we analyzed, for the first time, the expression of tlr in pbmc from kidney recipients with contrasted situations: operational tolerance and chronic immune-mediated rejection (banff ), compared to patients with normal histology and stable graft function, non transplant patients with renal failure and healthy volunteers. we found that myd and tlr were significantly contrasted in the pbmc, and in particular in monocytes, of patients with chronic immune-mediated rejection vs. operational tolerance. chronic rejection patients had significantly increased tlr and myd compared to operationally tolerant patients, who resembled healthy volunteers and non transplant patients with renal failure. interestingly, analysis of tlr transcripts in graft biopsies from patients with normal histology or chronic immune-mediated rejection reflected the blood findings, with a significant increase of tlr in chronic immune-mediated rejection. thus, we provide data to support a link between tlr expression and long-term graft outcome. the role of tlr and their endogenous ligands in mediating allograft rejection or acceptance therefore warrants further investigation and could give rise to new strategies of therapeutic intervention. our results suggest that peripheral blood tlr shows potential as a biomarker of chronic immune-mediated rejection and that measuring blood tlr levels may help to identify patients experiencing chronic rejection who require a biopsy. moreover, our data suggest that absence of tlr signaling may be a feature of operational tolerance to kidney grafts. identification of immune identification of immunological tolerance is an important prerequisite in order to establish an individually-tailored approach to the post-transplant management of allograft recipients. it will also provide new insight into the mechanism underlying the balance between tolerance and rejection. here we present data from a multi-centre study aimed at identifying tolerance to renal allografts. we have collected samples from five selected groups of renal transplant recipients: drug-free tolerant patients that were functionally stable despite remaining immunosuppression-free for more than one year; functionally stable patients on minimal immunosuppression (< mg/ day prednisone); stable patients maintained with calcineurin inhibitors (cni); stable patients maintained on cni-free immunosuppression regimen; and patients showing signs of chronic rejection. a group of age and sex matched healthy volunteers was also included as control. several biomarkers and bioassays, were combined to provide an immunological 'fingerprint' of the tolerant state. immunophenotype showed a selective expansion of peripheral blood b and nk lymphocytes in drug-free tolerant patients. this group of patients was also characterized by the absence of anti-donor specific antibodies. the differential expression of several immune relevant genes and a high ratio of foxp / α- , -mannosidase expression in these patients was observed. tcr landscape analysis highlighted differences between the vβ repertoires of drug-free tolerant recipients and chronic rejection patients. additionally, direct pathway donor-specific hyporesponsiveness by ifnγ elispot and lack of indirect pathway anti-donor responses assessed by trans-vivo dth were detected in drug-free patients. the diagnostic capabilities of the combined results of several of the above mentioned biomarkers and bioassays are as follows: specificity . , sensitivity of . and a positive predictive value of . %. these biomarkers could be used to inform drug weaning protocols of kidney transplant recipients. bile acid aspiration stimulates lung allograft immunity. bile acids detected in the broncho alveolar lavage (bal) as a marker of aspiration has been associated in a dose dependent fashion to earlier development of bronchiolitis obliterans syndrome. we sought to study the relationship between bile acids and active immune molecules as detected in the bal. methods: bal collected prospectively from lung transplant recipients at routine surveillance bronchoscopies were assayed for bile acids. samples were then assayed by luminex for cytokines , and by elisa for pulmonary collectins (sp-a, sp-d). results were analyzed according to levels of bile acids as per roc testing for accuracy for bronchiolitis obliterans syndrome diagnosis (high levels ≥ . µmol/l). results: we prospectively examined lung transplant recipients and a total of bal samples were collected. in no bile acids were detected, low levels were present in , and high levels were detected in samples. samples with high bile acids had significantly greater innate (tnf-a, il- b, il- , il- , il- ) and adaptive (ifn-g, il- ) cytokines as well as greater chemokines (mcp- , il- ) compared to the other samples. in contrast pulmonary collectins sp-a and sp-d were significantly reduced in samples with high bile acids. the figures shows the median and interquartile range for each molecule according to bile acid levels. conclusion: bile acids detected in the bal as markers of aspiration stimulate the lung allograft immunity in a dose dependent fashion. in particular high levels of bile acids are associated with an impaired lung specific innate defense system provided by the pulmonary collectins and with a broncho-alveolar district "cytokine storm". tolerance/immune deviation iii the results of using ex vivo cd + t-cells converted dn t-cells in nod mouse models support the concept and the feasibility of potentially utilizing this novel cell-based therapeutic approach clinically for the treatment of autoimmune type i diabetes. horng-ren yang, gouping jiang, john j. fung, shiguang qian, lina lu. immunology and general surgery, cleveland clinic, cleveland, oh. liver transplant tolerance was recognized by spontaneous acceptance of liver allograft in many species. the underlying mechanism remains unclear. interestingly, although liver allografts are accepted, hepatocyte transplants in the same combination are promptly rejected, indicating a crucial role of liver tissue cells in immune suppression. we have demonstrated a profound t cell inhibitory activity of hepatic stellate cells (hpsc), which are known to participating in repairing and fibrosis during liver injury. addition of activated (a) hpsc, but not quiescent hpsc, significantly inhibited allo-dc induced-t cell proliferative responses (mlr) in a dose dependent manner, which was associated with enhanced t cell apoptosis (tunel). neutralization of b -h by anti-b -h mab significantly reduced the hpsc-induced t cell apoptosis and reversed the inhibition of t cell proliferation, suggesting a key role of b -h . to evaluate this in vivo, balb/c islets ( ) were co-transplanted with x activated hpsc (b ) into stz-induced diabetic b recipients. co-transplant with hpsc effectively protects islet allografts from rejection. this was associated with reduction of graft infiltrating t cells and enhancement of apoptotic activity. co-transplant with hpsc from b -h -/livers markedly lost their islet graft protective capacity, associated with less apoptosis of infiltrating cells. to determine the subsets of apoptotic t cells, t cells were isolated from spleen, draining lymph nodes, and grafts for phenotype and function analyses. on pod , a marked reduction of graft infiltrating cd + ( . %) and cd + t cells ( . %) was seen in hpsc co-transplant group, as compared to islets alone, which was further progressed thereafter. cd t cells dropped ∼ folds on pod . cd + / cd + ratio was increased from . at the early pod to . in the long-term survival grafts. adoptive transfer of cfse-labeled des transgenic t cells was used to track the response and fate of antigen-specific cd + t cells. the results showed active division of des + cells within the allograft in both the islet only and hpsc co-transplantation groups. however, accumulation of these des + cells was significantly lesser in the hpsc co-transplantation group as compared to that in the islet only group ( . × vs. × cells per graft). these findings suggest that hpsc induce antigen-specific cd + t cell death, and may not inhibit their activation. donor-specific memory t cells are potent mediators of allograft rejection due to their ability to proliferate and give rise to cytotoxic and inflammatory cytokine-secreting effectors within hours of stimulation. furthermore, memory t cells have been shown to be relatively resistant to the effects of many tolerance-induction protocols, including blockade of the cd and cd pathways. while seminal studies have shown that donor-reactive memory cells, generated through pre-sensitization with donor tissue or infection with pathogens with cross-reactive epitopes, contribute to costimulation blockade-resistant rejection of fully mhc disparate allografts, the role of memory t cells specific for minor antigens in costimulation blockade-resistant rejection has not been well studied. we addressed the ability of memory t cells specific for a single donorderived class i epitope to mediate this process. tcr transgenic t cells (ot-i) specific for siinfekl/kb were adoptively transferred into naive b recipients, which were then infected with ovalbumin-(siinfekl) expressing listeria monocytogenes (lm-ova). at memory, mice received a skin graft expressing ovalbumin (mova), and therefore the siinfekl epitope. results showed that the transferred ot-i t cells proliferated in response to lm-ova, but not in response to a control infection with wild-type listeria (lm). at day , ot-i t cells comprised ∼ % of the total cd + t cell compartment. during memory, the siinfekl-specific cells comprised ∼ - % of the total cd + t cell compartment. engraftment of mova skin on lm-ova memory recipients resulted in rejection with accelerated kinetics relative to lm infected controls (mst= d vs d). following treatment with ctla- ig and anti-cd , / lm-ova infected recipients experienced costimulation blockade-resistant rejection, while lm-infected controls went onto long-term graft survival (p< . ). lm-ova-infected recipients also resisted the engraftment of mova-expressing donor bone marrow following a tolerance induction protocol containing busulfan, ctla- ig, and anti-cd . these results suggest that memory t cells specific for a single surrogate minor antigen are sufficient to induce costimulation blockade-resistant rejection, and support the feasibility of using this model to study the specific requirements for donor-reactive memory t cell activation and tolerance induction during transplantation. the during an immune response, cd helper t cells can be instructed by non-antigenspecific signals to differentiate into functionally distinct subsets with mutually exclusive patterns of cytokine production. we find that ikaros, a zinc finger transcription factor required for lymphocyte development, is crucial for the development of polarized t helper subsets. in the absence of ikaros dna binding activity, cd t cells induced to undergo th differentiation in vitro or in vivo produce high levels of il- , but fail to silence expression of ifn-gamma and il- , cytokines that contribute to inflammatory disease processes such as autoimmunity and organ transplant rejection. similarly, ikaros is required for repression of il- and il- expression by th cells, and inhibition of ifn-gamma and il- production by th cells. our results show that ikaros controls the expression of transcription factors such as gata- , c-maf, stat- , and runx , and in polarized th cells, ikaros inhibits ifn-gamma gene expression through direct repression of the t-bet locus. these studies place ikaros, a dna binding protein previously recognized only as a regulator of lymphocyte development, as a master regulator of peripheral t cell differentiation and function. introduction as the fastest growing subpopulation seeking organ transplantation is > yrs of age, it will be imperative to discern how aging impacts the acquisition of transplantation tolerance. prior work has demonstrated that viral infections induce the development of alloreactive t cells, which impede the induction of transplantation tolerance. in this study, we tested the hypothesis that aging alters host defense against viruses leading to the development of cross-reactive t cells, which impair transplantation tolerance induction. we first examined how aging modifies the function of plasmacytoid dcs (pdcs), as ifnα production by pdcs is essential for control of viral infections. using both in vitro and in vivo murine systems, we found that aged pdcs produced lower levels of ifnα in response to tlr activation with cpg sequences or herpes simplex (hsv)- virus (elisa). aged mice ( - mths) failed to the clear this virus as effectively as young ( - mths) mice. this was associated with increased liver inflammation, the release of systemic th -skewing cytokines, il- and il- , and augmented splenic il- levels in aged mice (elisa). prior to transplantation, unmanipulated aged mice (b or cba background) produced more donor-specific il- effector-memory t cells as compared to unmanipulated young mice (elispot). furthermore, mlr assays demonstrated that aged memory cd + t cells from unmanipulated mice produced significantly more il- in response to donor antigen compared to young t cells (elisa). to determine if aged recipients manifest an altered response to therapies that prolong allograft survival, aged and young b mice received balb/c skin allografts and perioperative anti-cd and anti-cd . we found that aged mice rejected their allografts significantly faster (median survival days) than young mice (mst, days, p < . ). similar results were noted when we employed perioperative treatment with anti-cd + dst and when we altered the donor-recipient (b to cba) strain combination. pre-treating aged mice with an anti-il- mab improved the efficacy of the graft-prolonging therapy compared to aged mice that received control mab (p = . ). conclusion our results suggest that impaired control of viral infections with aging leads to the generation of alloreactive il- producing t cells that impair therapies that may induce transplantation tolerance. prevention of type diabetes by thymus genetic modification with protective mhc class ii molecules. jesus r. paez-cortez, michela donnarumma, chaorui tian, john iacomini. transplantation research center, boston, ma. introduction. susceptibility to type diabetes is determined by multiple genetic factors, among the strongest of which is the inheritance of at-risk genes that lead to disease development. here we examined whether diabetes can be prevented by providing protective mhc class ii genes through directly infecting the thymus of diabetes prone nod mice. methods. after direct exposition of the thymus, lentiviruses encoding control (phage-cmv-dsred-ires-zsgreen-w) or protective mhc class ii iaβ d (phage-cmv-iaβ d -ires-zsgreen-w) genes were injected in a single thymic lobe of to week old female euglycemic nod mice. gene expression was determined by microscopic examination at different time points after injection and blood glucose levels were monitored weekly to examine whether this approach prevents the development of diabetes. the presence of diabetogenic cd + t cells were detected by flow cytometry via tetramer staining of splenocytes. pancreatic islet integrity and insulin production was assessed by immunohistochemistry. results. viral gene expression was observed exclusively in thymic epithelial cells beginning at days post-injection in both groups. nod mice injected with control lentivirus developed diabetes by weeks post injection, similar to non-treated animals ( - weeks). in contrast, phage-cmv-iaβ d -ires-zsgreen-w injected animals remained normoglycemic at months post-injection. diabetogenic cd + t cell population were not detected in splenocytes of iaβ d injected animals using mhc class i tetramers. islet integrity and insulin production was preserved in the treated group, in marked contrast to controls, which exhibited characteristic lymphocytic infiltration of islet cells and low insulin storage. conclusions. thymic genetic modification with protective a mhc class ii iaβ d molecule can be used to prevent diabetes in nod mice. central deletion of diabetogenic t cell populations may be involved in prevention of autoimmunity in these animals. role of invariant nkt cells in liver sinusoidal endothelial cell-induced immunosuppression of t cells with indirect allospecificity. masayuki shishida, hideki ohdan, yuka tanaka, masataka banshodani, yuka igarashi, toshimasa asahara. surgery, hiroshima university, hiroshima, japan. we have reported that liver sinusoidal endothelial cells (lsecs) endocytose portally injected allogeneic splenocytes and can negatively regulate t cells with indirect allospecificity via the fas/fasl pathway. as a result of in vitro transmigration across the lsecs from balb/c mice treated with a portal injection (pi) of b mhc class iideficient (c d) splenocytes, the naive balb/c cd + t cells lost their responsiveness to the stimulus of balb/c splenic antigen presenting cells (apcs) that endocytosed the donor-type alloantigens. however, they maintained a normal response to the stimulus of balb/c apcs that endocytosed third-party c h alloantigens. in the present study, we examined whether invariant nkt (inkt) cells influence the ability of lsecs to endocytose irradiated allogeneic cells. balb/c wild-type (wt) mice or balb/c cd d-deficient (cd d -/-) mice that lacked inkt cells were portally injected with × irradiated b c d splenocytes labeled with pkh- . only . ± . % lsecs endocytosed the labeled splenocytes in the balb/c cd d -/mice at h after pi, whereas . ± . % lsecs endocytosed the labeled splenocytes in the wt control mice (p < . , n = each). when balb/c wt mice intraperitoneally received µg α-galcer, before pi of b c d splenocytes, the expression of mhc class ii on lsecs and endocytic activity of lsecs were enhanced. thus, we found that the endocytic activity of lsecs was regulated by the inkt cells. intraportal adoptive transfer of lsecs isolated from balb/c wt mice, treated with a pi of b c d splenocytes, into balb/c mice significantly prolonged the survival of subsequently transplanted heart allografts (n = ) as compared to the adoptive transfer of lsecs isolated from balb/c cd d -/mice, treated similarly, into the balb/c mice (n = ). however, intraportal adoptive transfer of lsecs isolated from balb/c wt mice, which received µg α-galcer intraperitoneally prior to pi of b c d splenocytes, into balb/c mice did not result in a further prolonging of the effect (n = ). these findings indicate that inkt cells are required for such lsec-induced immunosuppression of t cells with indirect allospecificity; however, α-galcer-induced activation of inkt cells does not promote such suppressive effects on these t cells. in conclusion, naive inkt cells play a pivotal role in the lsec-induced immunosuppression of t cells with indirect allospecificity. notwithstanding the considerable amounts of in-vitro data supporting the nonimmunogenicity and immunomodulatory effects of mesenchymal stem cells (msc), scanty and conflicting data are available on their in-vivo immunomodulatory capacities. in this study we formally investigated whether msc had immunomodulatory properties in solid organ transplantation, using a semi-allogeneic heterotopic heart transplant mouse model, and studied the underlying mechanism(s). msc, isolated from bone marrow by adherence, were depleted from cd +cd b+ cells before injection. bone marrow-induced hematopoietic mixed chimerism is the most robust mechanism for the induction of transplantation tolerance. however, immunogenicity of bone marrow cells requires harsh immunosuppressive regimens that can lead to severe sideeffects including death. here, we examined whether embryonic stem (es) cells can be successfully coaxed to form hematopoietic progenitor cells (hpc) which potentially could be less immunogenic than bone marrow cells. here, we transduced es cells with hoxb , a hematopoietic transcription factor that confers self-renewal properties to hematopoietic cells and differentiated them into hematopoietic cells. transduced cells had a - fold greater proliferation capacity than controls. at the end of the differentiation procedure, most cultures were > % cd + . hpcs were purified using immunomagnetic bead separation. the separated cells were further characterized for leukocyte markers and showed a high percentage of cd , cd , cd and low class i, but no class ii expression. further, they poorly express co-stimulatory molecules such as cd and cd . when transplanted in rag -/γ c _/_ mice, hpcs fully reconstituted bone marrow, forming multi-lineage hematopoietic cells. to now determine whether these cells engraft in allogenic recipients, the cells were transplanted in syngeneic and allogenic mrl mice. all transplanted animals became chimeric (n> ), reaching - % after days. thereafter donor cells declined as a result of out-competition by resident bone marrow cells. this pattern was identical in both syngeneic and allogenic recipients. unexpectedly, allogenic chimeric mice became tolerant to donor-type cardiac allografts as monitored over days. grafts showed no mononuclear cell infiltration or signs of chronic rejection. interestingly, the t cells in tolerant animals showed responses to mrl alloantigen similar to that of controls, suggesting that our protocol was likely non-deletional, but could involve regulatory t cells. indeed, when stained for cd + foxp + cells, the allografts showed a high percentage of these cells, but not in controls, confirming our hypothesis. thus, these data show for the first time the potential of es-derived hpcs to regulate engraftment of allografts, providing an alternative approach for the induction of transplantation tolerance. we had previously shown that a is part of the regulatory atheroprotective response of endothelial (ec) and smooth muscle (smc) cells to injury. a is a nf-κb dependent gene with potent anti-inflammatory effects in ec and smc, through blockade of nf-κb. a also serves an anti-proliferative function in smc and opposite anti-apoptotic or pro-apoptotic functions in ec and neointimal smc. based on these functions, a would be a good candidate to prevent transplant arteriosclerosis (ta) and chronic rejection in vascularized organ grafts. this is supported by a expression in ec and smc correlating with the absence of ta in rat kidney allografts and long-term functioning human kidney allografts. fully mismatched c bl/ (h b ) and balb/c (h d ), were used as donors and recipients of an aortic to carotid allograft. in this combination, ta lesions start at weeks and become occlusive by weeks when left without immunosuppression. a expression in the graft was achieved by recombinant adenoviral (rad) mediated gene transfer prior to retrieval. control mice were infused with saline or control rad beta-galactosidase. the grafts were harvested at weeks and analyzed for ta lesions by measuring intima to media ratios (i/m) and for markers of inflammation and of the immune response by immunohistochemistry. a expressing vessels were significantly protected from intimal hyperplasia with i/m reaching . ± . as compared to saline ( . ± . ) and beta-gal ( . ± . ) treated vessels. this effect of a did not associate with a decrease in infiltrating cd , cd or cd t cells in a vessels as compared to controls. a possible modification of the phenotype of these t cells (t-regs vs. effector t cells) is being explored. rather, protection from ta correlated with increased expression of endothelial and inducible nitric oxide synthases (nos) in ec and smc of a expressing vessels, suggesting that this effect was, at least in part, related to increased in situ production of nitric oxide. in conclusion, we present the first direct evidence that expression in the vessel wall of the anti-inflammatory and atheroprotective protein a prevents transplant arteriosclerosis through a mechanism implicating increased expression of nos. carbon monoxide inhalation reverses established chronic allograft nephropathy through the no pathway. g. faleo, a. nakao, j. kohmoto, r. sugimoto, k. tomiyama, a. ikeda, m. a. nalesnik, d. b. stolz, n. murase. thomas e starzl transplantation institute, university of pittsburgh, pittsburgh, pa. chronic allograft nephropathy (can) is the most common cause of graft loss; however an established therapeutic strategy in preventing/treating can is not yet available. we have previously shown that carbon monoxide (co) effectively inhibits can development. here, we examine the mechanisms of co in overturning can through vascular endothelial cell protection. methods: orthotopic kidney transplantation (ktx) was performed in lewis to binephrectomized bn rats under brief tacrolimus ( . mg/kg, d - , im). by d after ktx, bn developed can with decreased creatinine clearance (ccr, . ± . ml/min), significant proteinuria ( . ± . mg/ h), and increased banff scores for intimal arteritis, interstitial fibrosis, and tubular atrophy. recipients were then treated with inhaled co ppm from d to d . results: inhaled co effectively reversed the severity of can and markedly improved renal function at d (table) and recipient survival (> d vs. d air control). co treatment resulted in reduced cytokine mrna levels (tnf-α, ifn-γ) and improved banff scores compared to untreated controls. in untreated allografts, cd expression on peritubular capillaries (ptc) was markedly diminished, while co-treated grafts showed normal cd expression, suggesting significant improvement in maintaining ptc integrity with co. interestingly, enos and inos protein expression was significantly upregulated in untreated grafts, while it was maintained at steady levels in co-treated grafts. immunohistochemistry revealed enos expression on vascular endothelial cells while inos on infiltrates. further, serum nitrate/nitrite levels were significantly higher in untreated than in co-treated recipients. elevated levels of mda, a marker for oxidative stress, in air control group were accordingly reduced in co-treated grafts. renal cortical blood flow data showed a better perfusion in co-treated group at d ( . chronic allograft vasculopathy (cav) is a component of chronic rejection and a major cause of graft loss. non-immunologic factors and indirect allorecognition participate in the pathogenesis of cav. new therapies with tolerogenic dendritic cells (dcs) are based on in situ-delivery of alloag to "quiescent" dcs of the recipient's lymphoid organs via apoptotic cells, vesicles or particles. we have shown that the ability of apoptotic cells to deliver alloag and an inhibitory signal to dcs down-regulates the indirect alloresponse and prolongs allograft survival in mice. aims: to test if targeting of recipient's dcs in situ with donor apoptotic cells ameliorates cav by down-regulating indirect pathway allo-immunity. methods: we performed functional aortic (abdominal) transplantation in mice [balb/c→c bl/ (b )]. b mice were injected i.v. with balb/c uvb-induced early apoptotic splenocytes (d- ). sixty days later, grafts were evaluated in sections with h&e, vangieson's (elastic fibers) and masson's (collagen) techniques. cfse-labeled h . tcrtg cd t-cells specific for ia b (b ) loaded with ieα - (balb/c) were used to evaluate the indirect pathway t-cell response. results: pkh + balb/c apoptotic cells injected (i.v.) in b mice were captured by splenic cd and cd α + dcs, but not plasmacytoid dcs. splenic dcs with apoptotic cells remained quiescent in vivo (mhc-i/ii lo , cd / lo , icosl + , pdl- / + ) and were unable to up-regulate mhc-ii and cd upon culture with gm-csf. injection of donor apoptotic cells induced defective activation and deletion of indirect pathway h . cd t-cells. therapy with donor apoptotic splenocytes reduced intimal thickness in aortic allografts ( ± vs. ± mm in controls; p< . ) and proliferation of α-smooth muscle cells and collagen deposition. the effect of apoptotic cells was allospecific, superior than that of cells alive, and depended on the physical properties of apoptotic cells, since necrotic cells did not achieve the effect. treatment with donor apoptotic cells decreased significantly the indirect pathway t-cell response (assessed by elispot for ifn-γ) and reduced the level of circulating alloab. conclusion: in situ-targeting of recipient's dcs with (early) apoptotic cells carrying donor alloag is a novel approach to prevent cav by down-regulating the indirect pathway alloresponse. the antifibrotic agent, pirfenidone, has direct inhibitory effects on t cell activation, proliferation, and cytokine and chemokine production, leading to suppression of host alloresponses. gary a. visner, fengzhi liu, hanzhong liu, liqing wang, wayne w. hancock. medicine, children's hospital boston, boston, ma; pathology, children's hospital of philadelphia, philadelphia, pa. there is an urgent need to develop new therapies effective against the fibrotic and other complications of chronic allograft rejection. while pirfenidone (pfd) is an established anti-fibrotic agent, we previously showed that pfd treatment reduced acute rejection in a rat lung transplant model suggesting that it might have direct immune modulating properties. accordingly, in this study, we tested the effects of pfd on t cell responses. we first evaluated whether pfd alters t cell proliferation and cytokine release in response to t cell receptor (tcr) activation in vitro. since pfd can inhibit tgf-β by mononuclear cell fractions, we also examined whether pfd affects the suppressive effects of regulatory t cells (cd +cd +). the effects of pfd on alloantigen-induced t cell proliferation in vivo were then assessed by adoptive transfer of cfse-labeled t cells across a parent->f mhc mismatch, as well as by using a murine heterotopic cardiac allograft model (balb/c->c bl/ ). pfd was found to significantly inhibit tcr-stimulated cd + t proliferation in vitro (p< . ), whereas cd + t cell proliferation was not significantly affected. while the beneficial effects of pfd were not associated with increased cd + t cell apoptosis, pfd use inhibited tcr-induced production of multiple cytokines and chemokines, including . interestingly, there was no change on tgf-β production by purified t cells, and pfd also had no effect on the suppressive properties of naturally occurring regulatory t cells. similar to the in vitro studies, pfd inhibited allo-antigen-induced t cell proliferation in vivo (parent->f model), and showed synergistic effects with low dose rapamycin in this model. lastly, though pfd alone did not affect the tempo of acute cardiac allograft rejection across a full mhc mismatch, use of pfd plus a subtherapeutic regimen of rapamycin significantly prolonged allograft survival (p< . ), decreased mononuclear cell infiltration and prevented development to chronic rejection, including arteriosclerosis and myocardial fibrosis. we conclude that pfd may be an important new agent in transplantation, with particular relevance to combating chronic rejection by inhibiting both fibroproliferative and alloimmune responses. we have previously reported studies in miniature swine showing that transplantation (tx) of prevascularized donor islets as part of composite islet-kidney (i-k) reversed diabetic hyperglycemia across fully allogeneic barriers, while free islets did not. in order to test the potential clinical applicability of this strategy, we have extended it to a fully allogeneic nonhuman primate model. methods: two diabetic baboons received composite iks and one diabetic baboon received free islets across fully allogeneic barriers. ( ) i-k preparation in donors: two i-ks were prepared by isolating islets from % partial pancreatectomies and injecting them under the autologous renal capsule, allowing for vascularization before allogeneic tx. these i-ks were harvested at days and for allogeneic ik tx. ( ) induction of insulin-dependent diabetes (iddm) and allogeneic i-k or free islet tx: all recipients received streptozotocin at mg/m x (body surface area). iddm was induced successfully in two animals, while one animal required total pancreatectomy to induce iddm. after confirming iddm by fasting blood sugar (fbs) > mg/dl for consecutive days, either i-ks or free islets were transplanted (single donor to each recipient) with atg (day - ) followed by mmf and low-dose tacrolimus. free islets were injected into the liver through the ileocolic vein. islet function was assessed by fbs and renal function was assessed by serum creatinine. immunologic status was examined by cml/mlr assays. results: all three recipients had strong ctl/mlr responses to donors pretx, indicative of a fully allogeneic combination. fbs decreased immediately after i-k tx and no insulin therapy was required throughout the experimental period (days and ). bs levels averaged . +/- . mg/dl in the first baboon and . +/- . mg/dl in the second. normal creatinine levels (< . mg/dl) were maintained by these life-supporting ik grafts. in contrast, the recipient of allogeneic free islets had unstable bs levels and required insulin from day (bs at day ) conclusions: life-supporting i-ks from single donors achieved glucose regulation without insulin therapy and maintained normal renal function. these results demonstrate the feasibility of composite i-k tx in a non-human primate allogeneic model, with possible clinical applicability for the cure of diabetic nephropathy. donor cell infusion without immunosuppression as a novel therapy for induction of donor-specific tolerance in islet cell transplantation. xunrong luo, kathryn pothoven, derrick mccarthy, matthew degutes, aaron martin, xiaomin zhang, guliang xia, dixon kaufman, stephen miller. medicine, northwestern university; microbiology and immunology, northwestern university; surgery, northwestern university, chicago, il. background in autoimmune models, peptide-pulsed splenic antigen presenting cells that are chemically fixed with ethylcarbodiimide (ecdi) have been used as a powerful and safe method to induce antigen specific t cell tolerance. ecdi fixed donor cells for allo-antigen specific transplant tolerance has not been well studied. material and methods c bl/ mice were rendered diabetic by stz. kidney subcapsular allogeneic islet transplant was performed days after diabetes stabilization (day ). x ecditreated donor splenocytes were injected i.v. either once (day - ) or twice (day - and day + ). animals were analyzed for graft outcome. results control mice receiving islet graft alone rejected the graft between day to day (mst = days, n= ). mice receiving one dose of ecdi-treated donor splenocytes (on day - ) showed similar graft survival as controls (mst = days, n= ). in contrast, mice receiving doses of ecdi-treated donor splenocytes (on day - and day + ) showed significant prolongation of graft survival with . % functional grafts at day (n= ), and some remained functional > days. this protection is donor-specific as mice receiving ecdi-treated sjl cells rejected balb/c islet grafts as controls (mst = days, n= ). immunohistochemistry of protected grafts showed positive insulin staining within well-defined islet architecture. peri-islet infiltrates were composed of cd +, cd +, and cd c+ cells, with occasional foxp + cells. anti-donor antibody production (igg ,g a,b, g ) was completely abolished in long-term graft survivers. this tolerance was undisturbed by anti-cd antibody treatment during maintenance stage, but could not be established if treatment was given around the time of the first donor cell infusion. in addition, lack of pd-l also impaired tolerance induction evidenced by using pd-l -/as recpients. conclusion . multiple infusions of ecdi-treated donor splenocytes significantly prolonged allo-graft survival in the islet transplant model. . the protective effect is donor-specific and is dependent on regulatory t cells as well as the pd-l signaling pathway. therapy with ecdi-treated donor cells may emerge to be a novel and potent agent for induction of donor-specific transplant tolerance. mice. rebecca stokes, k. cheng, c. scott, w. hawthorne, p. o'connell, j. e. gunton. garvan institute, darlinghurst, nsw, australia; nptu, westmead, nsw, australia. the aim was to investigate the effects of increasing hif- α protein in human islets upon islet-transplant outcomes. hif- α is a transcription factor which co-ordinates a program of cellular responses to stressors including hypoxia. in other cell-types hif- α improves survival following hypoxic-challenge. hif- α functions as a heterodimer with arnt which we have shown to be important for normal β-cell function ( ) . islet transplantation subjects islets to hypoxia. it is thought up to % of islets die within week of transplantation and this is at least partly due to hypoxia. the role of hif- α in β-cell function is unknown. we hypothesized that increasing levels of the protective factor hif- α in islets before transplantation would improve survival and engraftment and thus improve islet transplant outcomes. isolated human pancreatic islets from separate donors were cultured overnight in control media, or media supplemented with desferrioxamine (dfo), a small molecular stimulator of hif- α protein. islets were transplanted into diabetic scid mice. there were transplant groups, with mice receiving: .supra-physiological-mass transplant of control-cultured ieq (islet equivalents) .minimal-mass-transplant of control-cultured ieq, or .minimal-mass-transplant of ieq cultured with dfo. for each human donor, at least of each of the transplant groups was performed to avoid the confounder of inter-donor variability. recipients of control ieq cured in % of cases. minimal-mass-transplantation was ineffective: ieq cured % mice at -days. however, minimal-mass-transplant of dfo treated islets had % success (p< . vs group and p=ns vs -control-ieq). blood glucose levels were markedly improved in the dfo treated group compared to ieq control group (p< . ) and equivalent to control ieq transplants (p=ns). this data demonstrates increasing hif- α in human islets prior to transplantation markedly improves islet transplant outcomes. hif- α and dfo may have a therapeutic role in human islet transplantation. long-term disappearance of neovascularization of transplanted islets. eba hathout, nathaniel chan, annie tan, john chrisler, john hough, naoaki sakata, john mace, ricardo peverini, richard chinnock, lawrence sowers, andre obenaus. loma linda university, loma linda, ca. we recently reported an in vivo time-line for neovascularization of transplanted islets using dynamic contrast enhanced (dce) magnetic resonance imaging (mri) over a -day period. however, vascularization of transplanted islets must be maintained for extended periods to provide long-term function. in this dataset, we investigated whether vascularization was maintained in transplanted feridex-labeled syngeneic murine subcapsular islets ( ieq per kidney) using dce imaging on an . t mr scanner and subsequent immunohistochemistry over days. sub-capsular transplants could be visualized at post-transplant days and using t weighted imaging. however, the islets could not be seen on mri at post-transplant day . injection of the contrast agent gadolinium (gd)-dtpa for dce at , and days showed increased signal in the transplant area. at days, there was no change in signal intensity after contrast injection during dce. immunohistochemistry confirmed mri and dce findings. these results suggest that islet neovascularization occurs early after transplantation but is likely not maintained for the -day duration of our experiments. this work was supported by nih/niddk grant # r dk . a) t imaging at day clearly identifies iron-labeled islets (arrows) in the subcapsular region. no iron-labeled islets are observed at day (arrows). b) dce imaging for neovascularization of transplanted islets in the subcapsular region demonstrates a temporal decline in signal intensity. oleanolic acid, a natural triterpenoid, significantly improves islet survival and function following transplantation. n. angaswamy, d. saini, s. ramachandran, n. benshoff, w. liu, n. desai, w. chapman, t. mohanakumar. , surg, wusm; path & immunol, washington univ sch med, st. louis, mo. oleanolic acid (oa), a triterpenoid in medicinal herbs, is an integral part of normal human diet. oa has anti-oxidant, anti-inflammatory properties (inhibits inos & cox ) & lowers plasma glucose levels. we hypothesis that these properties of oa will prevent early islet cell loss following transplantation & also benefit long term function of allograft. c bl/ mice, made diabetic by streptozotocin ( mg/kg) were transplanted with balb/c islets (isolated by collagenase digestion) under kidney capsule. oa ( . mg/day) was administered i.p. in µl of pbs (with m dmso) or pbs-dmso as vehicle control daily from day - onwards. blood glucose was monitored daily. immunohistochemical analyses of grafts were performed for cd & cd markers. cellular immune responses to donor antigens & cytokines produced by cells and in sera were measured using elispot & luminex assays. effect of oa on function of transplant with suboptimal dose of islets ( - ) was also analyzed. optimal dose of islets ( ) transplanted into diabetic bl/ mice administered with oa significantly reduced time taken to reverse diabetes following transplantation (< ± vs ± days, p= . ). further, oa treatment reversed diabetes even with suboptimal dose ( ) of islets while untreated animals did not achieve normoglycemia. as expected, control diabetic mice rejected on ± days whereas, oa administration alone prolonged islet allograft survival to ± days (p< ). oa treatment resulted in > fold increase in serum kc, il- & vegf (p< . ) & fold decrease in mcp- , ip- & il- (p< . ) in luminex assay. stimulation of splenocytes from oa treated mice with donor balb/c cells resulted in significantly reduced ifng ( . fold), il- ( . ), il- ( . ) & il- ( ). in addition, proliferation in mlr was also reduced . fold. immunohistochemical analysis of grafts showed significant reduction in cellular infiltration in oa treated animals with reduction in both cd and cd t cells. daily administration of oa markedly improved islet engraftment & function with reversal of diabetes even when suboptimal dose of islet were transplanted. further, oa treatment allowed significant long term survival of allograft with no other immunosuppression. we demonstrate that prevention of inflammatory signaling cascades by oa resulted in marked reduction of cellular infiltration into graft allowing long term function of allograft. endoplasmic reticulum stress may be an important cause of cell loss after human islet isolation. soon hyang park, michel tremblay, steven paraskevas. surgery, mcgill university health center, montreal, qc, canada; mcgill cancer center, mcgill university, montreal, qc, canada. purpose: to evaluate the presence of endoplasmic reticulum (er) stress, induced by conditions to which islets are subjected during isolation (ischemia, nutrient deprivation, thermal stress and cytokine release) in human islets and to determine if this leads to the unfolded protein response (upr), which could alter cell survival. methods: human islets were purified from cadaveric pancreata by collagenase dissociation and continuous density gradient purification. islet preparations were cultured in serum-free medium and sampled at the end of isolation and daily thereafter. total mrna was purified and gene expression evaluated by rt-pcr. activity in upr signaling pathways was evaluated by immunoblot. apoptosis was measured by a caspase- activity assay. representative trends observed in > isolations are described. results: following isolation, a rapid increase in upr signaling was observed in the perk and ire- modules of the upr. these include the phosphorylation of perk target eif ? and splicing of mrna for the transcription factor xbp- . these changes occurred concurrently with a rapid spike in jnk activity and a rise in expression of the upr target gene chop. after these signals peaked, caspase- activity increased with time (apoptotic cells), as did expression of er chaperone bip (surviving cells). conclusion: we consistently observed upr activation in human islets. er stress and the upr may be one important and unrecognized cause of apoptosis in this context. current investigations focus on upr modification and determination of a causal relationship with apoptotic cell death. immunosuppression and the risk of renal transplant failure due to recurrent glomerulonephritis. atul mulay, carl van walraven, greg knoll. the ottawa hospital, ottawa, on, canada. glomerulonephritis (gn) is the most common cause of end-stage renal disease among those who undergo kidney transplantation. recurrent gn is a major cause of kidney transplant failure. immunosuppressive medication is used to treat gn in the native kidney prior to the development of end-stage renal disease but the impact of different immunosuppression on recurrent gn post-transplantation is unknown. we used the united states renal data system to determine the association of routine post-transplantation immunosuppressant use with time to renal allograft failure due to recurrent gn. immunosuppressants were treated as time-varying covariates. the study-cohort included patients with kidney failure due to gn who received first kidney transplant between and . the study cohort included , patients with a median follow-up of months. ten-year overall graft survival (including death as graft loss) and death-censored graft survival was . % and . % respectively. use of cyclosporine (hazard ratio . ; % ci . - . ), tacrolimus (hazard ratio . ; % ci . - . ), azathioprine (hazard ratio . ; % ci . - . ) or mycophenolate mofetil (hazard ratio . ; % ci . - . ) was not associated with risk of graft failure due to recurrent gn after adjusting for important covariates. there was no difference of recurrent gn causing graft failure between cyclosporine and tacrolimus (p= . ) or between azathioprine and mycophenolate mofetil (p= . ). however, change in any immunosuppressant during follow-up was independently associated with graft loss due to recurrence (hr . , % ci . - . , p= . ).when we restricted the analysis to patients who had no change in immunosuppression during follow-up we again found no association between any of the immunosuppressive medications and the risk of graft loss due to recurrent gn. despite the increased use of tacrolimus, cyclosporine and mycophenolate mofetil to treat gn in native kidney disease, the use of these medications following kidney transplantation had no impact on the risk of graft loss due to recurrent gn. glomerulosclerosis. junichiro sageshima, gaetano ciancio, alessia fornoni, linda chen, carolyn abitbol, jayanthi chandar, warren kupin, giselle guerra, david roth, sherry shariatmadar, gaston zilleruelo, george w. burke iii. university of miami miller school of medicine, miami, fl. background: disease recurrence is a major obstacle of kidney transplant for focal segmental glomerulosclerosis (fsgs). anti-cd antibody (rituximab) has been used for nephrotic syndrome of native kidney. the significant reduction of proteinuria in transplant recipients with fsgs recurrence was also reported after rituximab use for posttransplant lymphoma. we hypothesized that rituximab induction could alter the posttransplant course of fsgs recipients, particularly in those patients with rapid progression to end-stage renal disease who are higher risk of recurrence. methods: we compared the outcome of transplants for primary fsgs treated with and without rituximab. from jan. to dec. received renal allografts along with our "standard" immunosuppressive protocol, consisting of tacrolimus, mycophenolate, corticosteroids, antithymocyte globulin and/or daclizubab. from jan. to dec. received rituximab in addition to the "standard" immunosuppression. posttransplant proteinuria was treated with plasmapheresis (pp) and maintenance angiotensin blockade (ab). results: there was no adverse event related to rituximab infusion. the overall incidence of posttransplant proteinuria was significantly lower in recipients with rituximab induction (p < . ). four recipients treated with "standard" immunosuppression developed massive proteinuria (u-protein/creat. > ) immediately following transplantation; they responded poorly to pp and ab. four other recipients had moderate proteinuria. in contrast to this, of the patients induced with rituximab, only had massive proteinuria and had mild to moderate proteinuria which responded well to pp and ab. with a median follow-up of months, there was no significant difference of graft survival between groups ( -year survival: % without rituximab vs. % with rituximab). a half of the graft loss was related to non-compliance. conclusion: while the mechanism of action is unclear, our observation indicates that rituximab induction may decrease the incidence and severity of recurrence of fsgs following kidney transplantation. a larger-scale study is desirable to confirm this observation. mesangial chimerism in recurrent iga nephropathy. geoffrey talmon, dylan miller. department of pathology and laboratory medicine, mayo clinic, rochester, mn. background iga nephropathy (in) is the most common primary glomerulonephritis and nearly % of patients who undergo a renal transplant for in recur. data support that bone abstracts marrow-derived cells are capable differentiating into various mesenchymal cells within the kidney. the extent to which this phenomenon versus proliferation of resident mesenchymal cells is involved in populating mesangium is not well understood. the mesangial injury and/or hypercellularity seen in in provides a robust in vivo model for determining if this phenomenon is prevalent in human kidneys. design follow-up biopsies from male patients receiving female renal allografts for in that showed recurrent disease were selected. fluorescent in-situ hybridization and immunofluorescent staining was performed on unstained slides from the paraffinembedded tissue for smooth muscle actin, x, and y chromosome centromeres. cells within nonsclerotic glomeruli with triple positivity (y+) were assumed to be mesangial cells derived from the recipient. results four cases of recurrent in with nonsclerotic glomeruli were obtained, each displaying at least minimal mesangial proliferation by light microscopy (one "minimal", two "mild", one "moderate"). mesangial cells with y chromosome centromeric material were observed in each case ( %). between and mesangial cells were present in each glomerulus (mean . ) with no to three y+ cells seen (mean . ). these accounted for between % and % of mesangial cells in individual glomeruli. the ratio of y+ to total mesangial cells in each case ranged from : . . to : . (mean : . ). the case exhibiting minimal mesangial hypercellularity had a ratio of : . , those with mild had ratios of : . and . . , and that with moderate : . . conclusions recipient-derived mesangial cells make up a fraction of the population of glomerular cells in renal allografts affected by recurrent in. although the number of cases is small, the number of recipient-derived cells does not seem to be directly related to the degree of mesangial hypercellularity seen by light microscopy. the consistent presence of these "colonizing" cells in patients with recurrent in does, however, suggest that there may be a role for targeted therapy directed against circulating recipient cells. in the mid 's, patients developing esrd secondary to systemic lupus (sle) were deemed to be poor transplant candidates because of concern for early recurrent lupus nephritis (rln) leading to allograft loss. subsequently, rln was considered an unusual complication of kidney transplantation, occurring in < % of allografts. however, over the last decade, several reports have shown the frequency of rln to range from - %. we sought to determine the frequency of rln at our center and to identify any clinical variables associated with rln. between / between / - / allografts in patients with esrd due to sle functioned for more than days after engraftment. immunosuppression consisted of azathioprine (aza), or cyclosporine (csa) and aza, or mycophenolate (mmf) and csa, or tacrolimus and mmf depending on the date of transplant. all received steroids. proteinuria was defined as + on dipstick or urine protein/creatinine ratio > . . medical charts were reviewed. we found pathologic evidence of rln in ( %) of patients who underwent biopsy due to allograft dysfunction or proteinuria, comprising % of all patients transplanted for sle. characteristics of these patients are shown below: randomized studies have shown little or no increase in ar in kidney tx recips on p-free is; but concern remains about long-term outcome. we present -yr f/u of a protocol incorporating rapid (< days) discontinuation of p, with now over patients transplanted using this protocol. between / between / and / between / , adult tx recips were treated with thymoglobulin ( doses)(extended in dgf), p ( days), a cni, and either mmf or srl. of these, were ld ( lurd); dd. of the , % were female; % white; mean recipient age was ± years and mean donor age was . ± . years. diabetes was present in . % of the recipients and . % of the transplants were retransplants. the peak pra was > % in % of recipients; % had tx pra > %. table shows actuarial survival rates. graft survival rates were significantly better in ld vs dd transplants (p= . ) and and acute rejection rates lower (p= . ). compared to national data from srtr, overall outcomes were not significantly different. with mean follow-up of . years, a total of ( %) recipients have died -the most common cause being cerebrovascular accident ( %) followed by malignancy ( %). there were only ( . %) patient deaths due to cardiac causes. of ( . %) graft losses, ( %) were from dwf (death with function); ( %) from cr/can. renal function has been stable with mean serum cr of . mg/dl at and years posttransplant with cretinine clearance of and respectively. at years posttx, compared to ppretransplant values, recipients showed a . % increase in weight, a % decrease in serum cholesterol, and a . % decrease in serum lipid values. % of the kidney recips remain p-free; the most common reason for restarting p was acute rejection (ar). conclusion: short-term data suggests kidney tx recips do well with rapid discontinuation of p. our intermediate-term data suggests that patient and graft survival rates remain good and renal function remains stable. ongoing long-term follow-up is necessary. background. since / our program has employed a steroid-free, rapamycin and neoral maintenance immunosuppression regimen for kidney transplant recipients. prior to that time recipients were treated with prednisone, mmf and neoral. we noted a significant reduction in acute cellular rejection (acr) after implementing this regimen. this retrospective analysis was performed to examine the impact, if any, on the incidence, character, and outcomes of early ahr. results. this study includes consecutive kidney recipients transplanted between / and / . there were recipients in the prednisone, mmf, and neoral era (grp ) and in the steroid-free, rapamycin and neoral era (grp ). recipient age, gender, african-american race, ab and dr mismatch, and frequency of pra> % was not statistically significantly different between the groups. however, % of grp pts vs % of grp pts received a living donor kidney due to a more recent volume increase in this procedure (p< . ). there were a total kidney biopsies in pts performed in the first months post-transplant; in pts when excluding pre-perfusion biopsies. nineteen percent ( / ) of these showed > % peritubular capillary (ptc) c d deposition. comparison of grp to grp demonstrated the following: ) the incidence of clinical acute rejection in the first months was . % ( / ) in grp and . % ( / ) in grp (p< . ), ) the overall incidence of a c d+ biopsy was similar in the groups ( conclusions. despite a significant reduction in the incidence of acute rejection using our newer, steroid-free immunosuppression protocol, there has been no reduction in the incidence of early ( - months) ahr evidenced by c d+ kidney biopsy. however, the percentage of ahr unassociated with acr has significantly increased. the poor graft survival in pts with early ahr has not improved with our newer immunosuppression regimen. conclusions: four risk factors for ar were identified in the rdp study population: retx, aa race, age - (vs. > ) and pra > (vs. < ). four risk factors for gl were identified: pre-tx t dm, ar, dgf and dd tx (when ar and dgf omitted). these risk factors for ar and gl are the same as we observed in prednisone-containing protocols. additionally, many of these factors are not modifiable. identification of high risk groups allows for individualization of is. increasing lds and utilization of is protocols to decrease or minimize dgf and ar are goals for improving graft outcome. effect with the advent of more potent immunosuppression hla matching has been deemphasized in the allocation of deceased donor kidneys due to the limited impact on acute rejection and graft survival. an unforeseen consequence of poorer matching could be an increase in sensitization of patients in need for a repeat transplant. our study examined candidates listed in the us from - from the srtr database that were re-listed following loss of a primary kidney transplant (n= , ). the primary outcome of the analysis was change in pra from the listing prior to recipient's initial transplant to the subsequent listing. absolute change in peak and current pra levels were examined in general linear models as well as the proportion of patients with a rise in pra level in a logistic model. results hla(a,b,dr)-matching in the primary transplant was strongly associated with change in pra level (p<. , figure ). among recipients with -hla mm, over % had a rise in pra at re-listing as compared to % of -hla mm recipients. younger recipient and donor age, males, deceased donor transplants and african american recipients were also significantly associated with elevation in pra. in addition, the effect was apparent stratified by primary donor type. while there might be a limited impact of hla matching on graft survival, many patients might be negatively impacted from poor hla matching from their first transplant when needing a second transplant. as high pra is one of the strongest risk factors for not getting transplanted, this should be taken into account when evaluating the impact of hla matching in kidney transplantation. this might be particularly important in younger patients and in patients with a long life expectancy in general because of the high likelihood of needing a second transplant during their lifetime. the were about % less likely to die or lose an ecd kidney from a donor aged - and % more likely with kidneys from donors older than . a similar trend was seen with older recipients, but the risks seemed to be lower. logistic regression indicates recipients older than age were times more likely to have a donor older than age than recipients younger than , hypertension and creatinine > . were less likely in older donor kidneys. interestingly, the use of these kidneys relative to the total number of ecd kidneys has decreased since (odds ratio= . , . - . , p< . ). conclusion: an increase in the supply of kidneys might be achieved with increased utilization from deceased donors older than age . outcomes were similar to those from donors age - in recipients that were older than age . outcomes , but approximates non-dcd survival thereafter. dcd listing for retransplantation and graft failure progressed continuously over days versus days in non-dcd. when retransplanted, dcd recipients waited longer and received higher risk allografts (p= . ) more often from another region. more dcd recipients remain waiting for retransplantation with fewer removed for death, clinical deterioration, or improvement. conclusions: dcd utilization is impeded by early outcomes and a temporally different failure pattern that limits access to retransplantation. allocation policy that recognizes these limitations and increases access to retransplantaton is necessary for expansion of this donor population. orthotopic liver transplantation with allografts from dcd donors. roberto c. lopez-solis, background: in the current era of liver transplantation, organ shortage continues to be a significant problem. the use of extended criteria allografts from donation after cardiac death (dcd) donors to increase transplantation rates is widely practiced. this study is a review of one of the largest single center experiences utilizing dcd donors in the world with a follow-up of almost years. methods: from / / to / / , , liver transplants were performed at our institution, ( . %) of which were liver allografts from dcd donors. patient and donor demographics, recipient and graft survival, and the incidence of primary non function, hepatic artery thrombosis, retransplantation, and bile duct complications were analyzed for this subset of recipients. results: kaplan meier analysis showed a -and -year patient and graft survival of % and %, and % and %, respectively. the mean age of recipients was ± years with an average meld score of . ± . (range, to ), and there were male patients ( %). donor mean age was ± years and cold ischemia time was ± minutes. one hundred and three patients ( . %) are alive and ( . %) underwent retransplantation. the incidence of primary non-function was . % ( patients) and hepatic artery thrombosis was . % ( subjects the fda warns against using sirolimus (srl) in liver transplants, reporting increased hepatic artery thrombosis (hat), excess mortality and graft loss when srl is used as initial immunosuppression (is) with calcineurin inhibitors. we report the largest experience to date of patients with srl used as initial is, assessing hepatic artery complications and survival outcomes. materials and method all olt pts from - were reviewed. those using srl as initial is were identified, and the remaining olt pts from that time period were used as controls. ultrasound assessed graft vascular status and any issues were verified by angiogram. . there were no significant difference in demographics variables, lt indication or pre-lt meld score between the two gr. mean follow-up was . ± . months. all the enrolled pts were treated with abstracts an initial dose of cs of mg/kg/day, to target ng/ml for the first days. pts were randomized on day into one of the two following gr on a : basis. ev gr: initial dose of ev was mg/day, to reach blood level of ng/ml. the dose was increased on day , when cs was discontinued, in order to reach an ev blood level between and ng/ml. cs gr: after the th post-operative day the dose of cs was adjusted to a target level of ng/ml until day , then to ng/ml until the end of month . all pts received basiliximab induction on day and after lt. pts were weaned off prednisone by weeks. pt survival at and months was similar in the ev and cs gr ( . % and . % vs . % and . % respectively; p= ns). causes of death were sepsis ( ), hcv recurrence ( ), pulmonary embolism ( ) in the ev gr, and sepsis ( ), rupture of splenic artery aneurysm ( ) the overall incidence of infection episodes was comparable between two gr ( . % ev gr vs . % cs gr; p=ns). cholesterol but not triglycerides increased in the ev gr compared with the cs gr (p<. ); ev dose reduction decreased such parameters without the need for statin implementation. conclusion ev monotherapy in de novo lt showed similar patient survival and incidence of morbidity compared to a cs immunosuppressive protocol. the primary endpoint was achieved inasmuch as renal function was statistically better in the ev gr. background: sir is a potent immunosuppressive agent that inhibits t-cell activation and proliferation. in lt recipients, sir has primarily been used as a renal-sparing agent, but its toxicity and tolerability in this population has not been well defined. aims: to identify the adverse effects and predictors of discontinuation of sir in lt recipients. methods: records from adult lt recipients transplanted between / and / were reviewed. reasons for starting and discontinuing sir were captured, as were all significant adverse effects and laboratory abnormalities. factors predicting sir discontinuation in univariate analysis were further analyzed by multivariable logistic regression (mlr). results: mean age of the study group was ± years, and % were male. underlying liver disease was hcv ± alcohol in %, % had hepatocellular carcinoma, and % received living donor grafts. calcineurin inhibitors (cni) were started post-operatively in % ( % tacrolimus/ % cyclosporine), with or without mycophenolate and prednisone. patients ( %) started sir a median of days (iqr: - ) post-lt primarily for renal insufficiency ( %) or cni neurotoxicity ( %). sir was overlapped with tacrolimus and cyclosporine in % and %, respectively. prior to starting sir, total cholesterol was ± mg/dl, ldl-cholesterol ± , triglycerides ± . peak lipids after sir were ± , ± , and ± mg/dl, respectively, despite lipid-lowering therapy. serum creatinine was . ± . and . ± . mg/dl before and after sir, respectively. before sir, % of patients had no proteinuria, but only % had no proteinuria after sir. high range proteinuria (> mg/dl) was noted in % before and % after sir. finally, sir was discontinued in total of ( %) patients, for indications of cytopenias ( %), hyperlipidemia ( %), mouth ulcers ( %), sepsis ( . %), skin reactions ( . %), nephrotic syndrome ( %), gi intolerance ( %), pneumonitis/boop ( . %), myopathy ( . %), and combinations of above ( %). mlr failed to identify any pretreatment predictors of discontinuation. conclusions: immunosuppression with sir improves azotemia at the expense of considerable hematologic, metabolic, dermatologic, renal, pulmonary and muscle toxicity. considering the high incidence of proteinuria after sir treatment, the use of sir as a less nephrotoxic agent must be re-considered. and to identify the most effective protocol. peripheral blood was obtained from ebvseronegative and ebv-seropositive pediatric heart (h) tx patients. lcl vs dc-based methods were compared as follows: (i) lcl (ii) lcl + il- (iii) type- polarized dc (treated with il -b, tnf-a, il- and ifn-g) loaded with mhc class i-restricted ebv-peptide pool (dc/pep.) and (iv) dc/pep. + il- . the ebv-specific cd + t cell phenotype and function were screened using flow cytometry, ifng elispot and cytotoxicity assays. the yields and the functional activities of in vitro co-cultures differed based on the induction method employed, and on the ebv status of the patients tested. for the ebv-seropositive pediatric htx patients, all four methods resulted in the successful expansion of functional type- ebv-specific cd + t cells, suggesting that memory cd + t cell are readily reactivated in vitro. for the ebv-seronegative pediatric tx patients however, only the lcl + il- approach resulted in significant augmentation of type- ebv-specific ctls that were competent to secrete ifn-g ( ± / cells) and to kill ( ± lu/ cells) ebv + targets. we found that il- secreted by lcl (and not by dc) was critical in triggering expression of il- rb on naive cd + t cells, and rendering these cells responsive to il- p . further addition of exogenous il- p (which is generally not produced by lcl) proved to be essential for effective type- priming. however, blocking il- during ebv-priming has abolished il- rb expression and subsequent ifng production. these results demonstrate that the inducible expression of il- rb on naïve cd + t cells was dependent on il- , and support the critical early role of ebv infected b cells in the in vivo priming of naïve precursors into potent ebv type- cd + t cell in children. serial ebv load monitoring in pediatric heart transplant patients (phtx) has identified a group of asymptomatic children that exhibit persistently high ebv loads in peripheral blood (≥ , copies/ml on at least % samples over a period of at least months). these patients have a high rate of progression to late ptld. our goal is to characterize the deficiency of ebv-specific cd + t-cell immunity that allows this state to occur and be maintained. twenty-one stable ebv + phtx patients were categorized as follows: group (n= ) no detectable viral load; group (n= ) low viral load (≤ , copies/ ml); group (n= ) high viral load (≥ , copies/ml). twelve healthy subjects were recruited as controls. flow cytometric analysis with hla-a ebv-tetramer (tmr) probes in conjunction with mabs against memory/activation markers was performed on peripheral blood cd + t cells, and their ebv-specific ifn-γ production was measured by elispot. ebv-"latent" specific cd + t cells in g patients were mostly cd l + / cd ro + (central memory) and expressed heterogeneous levels of pd- and high cd (il- receptor α), the ebv-lytic-specific cd + t cells were more frequent, and biased toward cd l -/cd ro + (effector memory) and cd l -/cd ra + (stable effector memory), corresponding to terminally differentiated memory compartments. this cell population also expressed heterogeneous levels of pd- and down-regulated cd . in contrast, both ebv-lytic and -latent specific tmr + cd + t cells from g patients were homogeneously cd l + /cd ro + (effector memory), cd + and cd -, suggestive of "recently activated" phenotype. interestingly, although patients in groups g and g had high frequencies of ebv-specific tmr + cd + t cells (g . %± . , g . %± . , p= . ), only g patients exhibited a direct correlation between tmr + cd + t cells and ebv-specific ifn-γ production. these results demonstrate that different levels of chronic ebv-antigenic pressure trigger significant differences in the phenotypic and functional features of ebv-specific cd + t cells from phtx, suggesting that the immunologic characterization of high ebv load carrier state is a combined "activated" phenotype with "exhausted" function of ebv-specific cd + t cells. ebv-encoded lmp indirectly activates the jak/stat pathway through induction of ifnγ. abstracts evidence of ptld. children were enrolled at sites. mean age at transplant . years, mean time to ptld months . organs transplanted were lung , heart , kidney . all ptld were of b cell origin and expressed cd and all were ebv positive. histology was: polymorphic , monomorphic , hodgkins-like . patients received doses, patients doses and patient doses. treatment was associated with minimal side effects in , mild-moderate infusion related reactions in and moderate reaction in . no patient had treatment discontinued because of side effects. twelve patients ( %) showed complete response after - doses, had progressive disease and one had stable disease. at months, ( %) were alive with one graft loss (kidney) and none with residual disease. at latest follow-up (mean . months, - ), remain alive with further graft loss (lung) and no ptld. the deaths occurred between . and months and were associated with progressive disease ( ), chronic rejection ( ), and complications of elective surgery ( ) . conclusions: these findings support prior registry data and suggest that rituximab without chemotherapy is a successful second line treatment in approximately two-thirds of children with refractory ptld. cancer after organ transplantation in france. jean michel rebibou, fabienne pessione, francois aubin, bernard loty. agence de la biomedecine, france. cancer prevention appears as a major challenge in transplantation. estimating cancer frequency is a major step toward designing prevention policy. we report on patterns of cancer incidence among transplantations registered in the french data base. ). the risk of lung cancer is higher for recipients of a thoracic organ and the risk of kidney cancer appeared higher for kidney recipients. ten year cumulative incidence was . % for all cancer and transplantation types, . % for nhl. multivariate analysis demonstrated that cancer risk increased with recipient age (p< - ), year cumulative incidence was % for recipients older than year. it was higher in male (p< - ) and in thoracic organ recipients when compared with kidney recipients (p< - ). cancer incidence did not vary according to the transplantation period ( ( - ( vs ( - . p= . ) and nhl risk was significantly lower during the period - (rr= . , p= . ). this work does not report any increase in cancer incidence among transplant recipients while cancer incidence increased in the general population. the observed decrease of nhl risk is of particular interest. the both costimulatory and co-inhibitory signals are delivered by b ligands through the cd family of receptors on t lymphocytes determining the ultimate immune responses. although b -h , a recently discovered member of the b family, is known to negatively regulate t cell immunity in autoimmunity and cancer, its role in transplantation rejection and tolerance has not been established. to study its role in physiologic rejection processes, we first treated b wt recipients of balb/c hearts with a blocking mab against b -h or isotype igg control and found no difference in graft survival (mst days, n= vs. , n= ). however, b -h blockade resulted in accelerated allograft rejection in cd deficient b recipients (mst . vs. , n= , p= . ) , indicating that b -h signaling can mediate negative regulation in the absence of cd costimulation. we next studied b - /b - double deficient (dko) b recipients of balb/c heart allografts, as these mice are truly independent of cd /ctla- :b signals. while cardiac allografts were accepted in control dko recipients (mst> , n= ), blocking b -h precipitated rejection (mst , n= , p= . ) demonstrating non-redundant functions of these two negative pathways. based on these results, we next evaluated the role of b -h in acquired transplantation tolerance by blocking cd :b using ctla -ig. b -h blockade abrogated prolongation of allograft survival by ctla -ig ( µg on day ) in the fully mhc-mismatched cardiac allograft model (mst vs. . , n= , p= . ) . we conclude that the novel b -h molecule can regulate alloimmune responses independent of an intact cd /ctla- :b costimulatory pathway. the interplay between positive (stimulatory) and negative (regulatory) costimulatory signals is an important determinant of the outcome of the alloimmune response and could be exploited to induce tolerance. specific in a model of mhc-mismatched kidney allograft in the rat, treatment with anti-cd antibodies induced a form of tolerance independent of treg cells but associated with a two-fold accumulation of mdsc in the blood. to further characterize these cells, we analyzed their phenotype and mechanism of action by flow cytometry, western blotting and suppression assays. mdsc expressed cd and cd , nkrp- , cd a (sirpa), cd a, cd b, his and for a fraction of them cd but did not express mhc class ii molecules. mdsc dose-dependently suppressed the proliferation of t cells in mlr and after stimulation with anti-cd + anti-cd antibodies. although detected in blood, bone marrow, spleen and lymph nodes, mdsc were only suppressive in blood and bone marrow. this suppression was lost after physical separation from the responding t cells by semi-permeable membranes in transwell assays, as well as after addition of l-nmma, a selective inhibitor of inducible nitric oxide synthase (inos), suggesting a role for no in the suppression. western blot analyses revealed that inos was expressed only after contact between mdsc and activated cd + cd effector t cells and to a much lesser extent after contact with activated cd + cd high t reg cells. mdsc affected the viability of stimulated cfse-labeled effector t cells by blocking their proliferation but not their activation. in contrast, mdsc did not block the response of t reg cells stimulated by anti-cd + anti-cd antibodies. this selective suppression of effector but not of regulatory t cells was confirmed by cytokine profile analyses. in vivo, the expression of inos was higher in the blood of tolerant recipients, as well as in the graft, as compared with isografted recipients. in addition, the injection in stable tolerant animals of aminoguanidine, which inhibits inos, induced graft rejection within weeks. in conclusion, these results suggest that mdsc, accumulated in the blood of tolerant recipients of kidney allografts, release high levels of no after contact with activated effector t cells and specifically control their proliferative response. liver non-parenchymal components inhibit dendritic cell differentiation and maturation. ching-chun hsieh, horng-ren yang, guoping jiang, john j. fung, shigunag qian, lina lu. immunology and general surgery, cleveland clinic, cleveland, oh. the inherent tolerogenicity of liver allografts could be due to comparatively large numbers of potentially tolerogeneic antigen presenting cells, in particular dendritic cells (dc). it is not clear whether the unique antigen presenting function of liver dc is intrinsic, or is altered by the microenvironmental factors within the liver. in the present study, we investigated the effect of hepatic stallet cells (hpsc), a unique tissue cells in the liver which were actively expanded in the liver allografts, on generation and function of bone marrow derived dc (bm dc). we hypothesize that liver hpsc may modulate immune response via inhibition of liver dendritic cells (dc) which are known of bone marrow (bm) origin. in this study, dc were propagated from b bm cells with gm-csf for days. irradiated hpsc isolated from b mouse liver were added at the beginning into the culture at hpsc : bmdc progenitor ratio of : . the differentiation, maturation and function of propagated dc were determined by characterizing their surface molecule expression and functions of instructing t cell activation / differentiation. the results showed that addition of hpsc markedly blocked the differentiation of dc from bm precursors (most cells remained in cd b + cd cprecursors stages). the incidence of cd c + cells was % vs. . % in normal bm dc culture (without hpsc). the presence of hpsc also prevented maturation of cd c + dc, as evidenced by low expression of cd , cd and cd , but high of b -h . the inhibitory effect appeared to be mediated by soluble factor (s) produced by hpsc, since addition of the hpsc culture supernatant or transwell culture provided comparable inhibitory activity. culture of allogeneic cd + t cells with hpsc-dc elicited poor proliferative response in a d mlr assay, with low il- and ifn-γ production. three color staining of t cells stimulated by hpsc-dc showed that cd + foxp + t cells were preferentially expanded, suggesting that hpsc-dc were capable of inducting treg. in contrast, bm dc induced vigorous cd + t cells proliferation, most of activated cd + t cells were cd + foxp associated with high levels of ifnγ and il- in the culture, indicating induction of th cells. in conclusion, liver tissue cells, such as hpsc markedly inhibit dc differentiation and maturation, suggesting that the tolerogenic property of liver dc may not be intrinsic, but is altered by the microenvironmental factors in the liver. . allograft rejection was also significantly accelerated when bm hearts were transplanted into cd ko recipient (mst days). to investigate the mechanisms of these findings, lymphocytes harvested at day post-tx from spleens and regional lymph nodes were assessed by flow cytometry for phenotypic differentiation of the activation status, regulatory t cell markers and effector cell generation. the ratio of effector to regulatory cells was . : . : . in the wt, cd ko and b dko recipients, respectively. cytokine production was evaluated by elispot using donor specific antigen stimulation of recipient splenocytes. the mean ifn-γ production was spots per , splenocytes in wt, in cd ko and in b dko. this study for the first time demonstrates the paradoxical role of b -cd co-stimulation in fully allogeneic and class ii mismatched grafts and proposes a possible mechanism through the re-alignment of the effector to regulatory t cell ratio in favor of a highly alloreactive immune response. the major concern regarding kidney donation has been whether the occurrence of hyperfiltration, on the background of increasing prevalence of hypertension with aging and the decline in glomerular filtration rate (gfr) noted in some people as they get older, may put donors at a higher risk for progressive kidney disease. we have previously reported on donors > years after donation and found them to incur no excessive risk of hypertension or kidney disease. herein, we report on renal and non-renal outcomes on the world's largest experience of kidney donors to date (n= ) who donated more than years ago. methods: kidney donors were asked to fill out a survey detailing their medical history since donation and obtain a physical exam and laboratory testing by their local physician. results are expressed as mean±standard deviation (sd the graph below depicts the cross-sectional distribution of last serum creatinine available years or more after donation regardless whether the donor is presently alive or not though the majority is from currently alive donors. conclusion: in the longest follow-up of kidney donors to date, this data indicates that - decades of living with one kidney has no serious adverse renal effects and a prevalence of hypertension that is probably similar to the general population considering the age of these donors. centers ) . before and after adjustment for comorbidity, ( . %) and ( . %) centers, respectively, met all criteria for review, but only met criteria for review both before and after comorbidity adjustment. we conclude that failure to adjust for pre-existing recipient comorbidity results in grossly inaccurate estimation of expected gf per ktx center, more often resulting in expected gf that is too low. using data that are not adjusted for comorbidity to judge the quality of tx programs could encourage denial of access to high-risk patients. introduction: the purpose of our study was to examine temporal trends in the regionalization patterns and center volume-outcomes relationship for lung transplantation in the united states over the past decade. a retrospective analysis of all adult single-organ lung transplants included in the scientific registry of transplant recipients for three consecutive time periods between and was performed. for each time period, lung transplant centers were divided into three groups based on each center's annual volume of the procedure (low-volume group = - procedures per year, medium-volume group = - procedures per year, high-volume group = greater than procedures per year). oneyear observed-to-expected patient death ratios were then calculated and compared for each group in each time period. a temporal analysis of the percentage of transplants being performed relative to center volume was also performed. statistical comparisons were made using chi square testing. results: a total of , lung transplant procedures were included in the analysis. in period , there was not a significant difference in the one-year observed-to-expected patient death ratio of low-volume lung transplant centers when compared to high-volume centers (ratio . for low-volume centers vs. . for high-volume centers, p = . ). by period , however, a significant relationship between center volume and outcomes had emerged (ratio . for low-volume centers vs. . for high-volume centers, p = . ). over this same time period, the percentage of lung transplants within the united states that are performed at low-volume centers has decreased significantly (from . % of all lung transplants in period to . % in period , p < . ), while the percentage being performed at high-volume centers has increased significantly (from . % of all lung transplants in period to . % in period , p< . ). conclusions: a significant relationship between center volume and patient outcomes has emerged for lung transplantation over the past decade. at the same time, the percentage of these procedures being performed at high-volume centers has increased. these findings suggest that regionalization patterns for a given procedure may be influenced by the presence or absence of a volume-outcomes relationship for that procedure. liver transplantation (lt) has emerged as one of the few curative treatment modalities for patients with hepatocellular carcinoma (hcc). however, the increase in the incidence of hcc recurrence due to immunosuppressants administered after lt is a serious issue. we have recently proposed a novel strategy of adjuvant immunotherapy for preventing the recurrence of hcc after lt: intravenous administration of il- -stimulated natural killer (nk) cells extracted from donor liver graft to liver transplant recipients. since the immunosuppressive regimen currently used after lt reduces the adaptive immune components but well maintains the innate components of cellular immunity, the augmentation of nk cells response might be a promising immunotherapeutic approach. we confirmed that the il- -stimulated donor liver nk cells exhibited a significantly high level of trail and showed vigorous cytotoxicity against an hcc cell line without cytotoxicity against normal cells. after obtaining approval from the ethical committee of our institute, we successfully applied this therapy to cirrhotic patients with hcc from january . the average number of nk cells that had been administered to lt recipients at days after lt was . ± . × cells/body. the lt recipients were categorized as follows: ( ) based on the milan criteria, recipients met the criteria while did not, and ( ) based on the tnm stage, recipients were categorized as pathological tnm stage i; , stage ii; , stage iii; and , stage iv. in our institute, the -year recurrence-free survival rates of the lt recipients treated with and without this therapy were % and . %, respectively. kinetic studies revealed that in the early postoperative period, the peripheral blood obtained from the treated lt recipients exhibited a significant improvement in cytotoxicity against hcc cell line as compared to the untreated lt recipients (p < . ). furthermore, flow cytometric analyses revealed that the frequency of trail + nk cells increased remarkably in the peripheral blood of the treated lt recipients (p < . ). in conclusion, the administration of il- -stimulated donor liver nk cells contributes to the promotion of host anticancer activity and has the potential to regulate hcc recurrence after lt. abstract# vegf, a well-established angiogenesis factor, is expressed within allografts at high levels in association with acute and chronic rejection. in previous studies, we have reported that vegf possesses potent proinflammatory properties in part via its ability to mediate leukocyte trafficking into allografts. recently, we discovered that vegf mediates cd + and cd + t cell migration via interaction with its receptor kdr (also called vegfr ). blockade of t cell kdr significantly inhibits transendothelial migration. these observations suggest that kdr may be a novel t cell receptor for allogeneic lymphocyte recruitment. here, we first examined the expression of kdr on peripheral human cd + and cd + t cells by facs analysis. we found that ≤ % of circulating t cells express kdr, and its expression was at low levels on individual unactivated t cells. further, we found that the expression of kdr on t cells increased markedly following activation with mitogen and following interactions with activated allogeneic endothelial cells. induced expression of kdr on cd + and cd + t cells was at a similar level as that observed on endothelial cells. therefore, kdr appears to be selectively expressed on t cells, that traffick into allografts. to test the pathophysiological significance of these observations, we analyzed the expression of kdr in a total of cardiac, and renal, human allograft biopsies. we correlated the expression of kdr with cd + t cell infiltrates; and by double immunofluorescence staining, we determined co-expression of kdr on individual cd + t cell infiltrates. in cardiac allografts we found that kdr was expressed throughout the endomyocardium, and was most notable on endothelial cells in all biopsies examined. by grid counting of - areas of each biopsy, we found that the mean number of cd + t cell infiltrates ranged from to cells/hpf (x mag.). by double staining, we noted that kdr was expressed on ± % (mean±sem) of these cd + t cell infiltrates. similarly, we found that kdr was co-expressed on cd + t cells within renal allografts. while infiltrates were more focal, again ± % (mean±sem) of graft infiltrating t cells expressed kdr. collectively, these observations for the first time identify kdr as a novel receptor on allogeneic t cells. we suggest that intragraft vegf may interact with t cell kdr to facilitate homing and recruitment of allospecific lymphocytes into allografts. interaction of infiltrating cd + t cells and tissue cells in tolerant liver allografts: using tcr transgene approach. guoping jiang, qiwei zhang, horng-ren yang, kathleen brown, john j. fung, lina lu, shiguang qian. immunology and general surgery, cleveland clinic, cleveland, oh. the liver allografts are accepted without requirement of immunosuppression in mice. the underlying mechanisms are not completely understood. we hypothesized that it resulted from an abortive t cell response within the liver due to hyporesponsiveness or apoptosis. to test this, we examined the activation and fate of allo-ag specific cd + t cells following liver transplants (ltx) compared with heart transplants (htx) that were acutely rejected. following transplantation [b (h b )→c h (h k )], cfse labeled cd + t cells ( x ) from des tcr tg mice (h k b specific tcr) were adoptively transferred into recipients. animals were sacrificed two days following des t cell administration for analyses of t cells in the grafts or draining lymph nodes (d-ln). host cd + leukocytes were quickly infiltrated following ltx. among cd population ∼ % were cd + and ∼ % cd + . cd + t cells were further increased thereafter in grafts and d-ln, associated with high inf-g production. cd + t cells in the liver grafts rapidly reduced to % by pod , and to % by pod . however, the incidence of cd + t cells remained high. cfse dilution assay and elispot showed an active division of des + t cells in liver allografts either on pod or . these ag-specific cd + t cells functioned well evidenced by ifn-g production in response to allo-ag. however, compared to htx, the accumulation of des + cells in grafts was significantly lower in ltx [ . % ( x /heart), and . % ( . × /liver)] on pod , and further dropped to . % ( . × /liver) on pod . the expended cohorts of adoptively transferred cells followed by their elimination suggested elimination of ag-specific cd + cells. to examine the role of liver environment, graft cd non-parenchymal cells (npc) were isolated tested fro regulatory effect on des + t cell response. liver allografts showed significantly expansion of cd -npc, which were donor mhc class i + (h b + ), b -h + , trail + and low for cd and cd . these cells did not inhibit des + t cell proliferation in response to b spleen stimulation, but significantly enhanced their death, which was dependent on b -h /trail. this was confirmed by using cd -npc from b h -/or trail -/mice. in conclusion, activated t cells in liver grafts may stimulate tissue cells to express inhibitory and death inducing molecules, resulting in t cell death and graft acceptance. foxp + graft-infiltrating lymphocytes (gil) have been detected in the rejecting allografts of transplant patients. foxp is a marker for regulatory t cells (t reg ). published reports suggest that human foxp can be upregulated following tcr stimulation without induction of regulatory function. to investigate whether foxp + gil during acute rejection are t reg , we analyzed the phenotype of gil harvested from acutely-rejected non-human primate kidney allografts. methods: renal allografts with histologically-confirmed acute rejection were harvested at the time of necropsy from macaques that had undergone experimental transplantation. following digestion of kidney fragments using collagenase, gil were isolated using lymphocyte-separation media and cryopreserved. axillary lymph nodes (ax ln) were also isolated either at the time of necropsy or by biopsy. for seb-stimulated lymphocytes, ax ln cells were stimulated for days in the presence of ng/ml seb for - days. to perform intracellular interferon-gamma (ifng) analysis, cells were stimulated with pma and ionomycin in the presence of brefeldin a for - hours at °c. samples were prepared for flow cytometry by first staining for extracellular antigens. cells were then fixed and permablized (kit from ebiosciences) prior to intracellular staining for foxp , ki and ifng. results: the percentage of foxp + in cd + gil was similar to that found in ax ln ( table ). the majority of these cells were cd + . while % of the cd + /cd + /foxp + population of both ax ln and gil were cd + , a significantly higher frequency of cd + and ki + cells were found in gil (p < . ; student's t-test). simlar levels of cd and ki expression were found in seb stimulated lymphocytes. unlike the seb-stimulated lymphocytes, few ifng -producing cells were demonstrated following pma/ionomycin stimulation of gil. conclusion: our current data indicates that the majority of foxp + gil from acutely rejecting renal allografts are recently activated cd t cells that lack effector function. this suggests that foxp t cells within rejecting allografts may indeed be t reg . findings in mouse models of transplantation often fail to translate well in humans. three variables may account for the discrepancy: ( ) evolutionary divergence between mice and humans, ( ) influence of infection history on alloimmunity, and ( ) use of highly inbred strains of laboratory mice. here, we investigated whether the use of inbred mouse strains skews the rejection phenotypes and their response to treatment due to decreased genetic diversity and/or fixation of undesirable genetic loci, known as inbreeding depression. we examined heterotopic cardiac allograft survival in outbred and inbred mouse populations in the presence or absence of immunosuppression. in the absence of immunosuppression, heart transplantation within or between outbred stocks of mice (n = ) resulted in three distinct rejection phenotypes that resemble accelerated ( - days), acute ( - days), and chronic rejection (> days), respectively. in contrast, all fully allogeneic grafts transplanted between inbred mice (n = ) were rejected acutely ( - days) as were historical controls (n > ). the accelerated phenotype, present in % of outbred to outbred transplantations, was characterized by extensive hemorrhagic necrosis of the heart with thrombosis, neutrophil margination and neutrophilic arteritis, and did not correlate with donor:recipient mhc ii disparity. immunosuppression with t cell costimulation blockade did not prevent accelerated rejection (incidence = % in the treated group, n = ) but did convert the acute rejection phenotype into longterm allograft survival in all groups studied. the same accelerated phenotype was observed if transplantation was performed from outbred to inbred mice (incidence = %; n = ) but could not be duplicated if inbred to outbred transplantation was performed (n = ). finally, c depletion with cobra venom factor abrogated the accelerated rejection phenotype in outbred to outbred transplantations (n = ), suggesting a role for complement in the pathogenesis of this phenotype. in summary, our data ( ) indicate that the use of outbred mouse stocks may uncover clinically-relevant rejection phenotypes not observed in inbred mouse strains, and ( ) underscore the importance of the donor background in determining the phenotype of rejection. outbred mouse stocks may provide a platform to uncover mhc-unlinked genetic loci that play an important role in the outcome of solid organ transplantation. th are limited in their ability to reject allografts. elderly recipients represent the most rapidly growing segment of patients on the waiting list. however, little is known about age-dependent alterations of the immune response in organ transplantation. we examined age dependent t-cell functions in a transgenic mouse transplant model. effector t-cell phenotype, -function, cytokine production and regulatory t-cell function were analyzed in and mths old b mice. in an in vivo transplant model, bl/ nude mice were reconstituted with x young or old transgenic alloantigen-specific cd + tcells and engrafted with bm skin grafts. t-cell phenotype and cytokine secretion were sequentially analyzed in all lymphatic compartments. splenocytes of naïve old b mice contained significantly higher frequencies of t-cells with an effector/memory phenotype (cd + cd high cd l low and cd + cd h igh cd l low; p< . ). in vitro proliferation and ifnγ-production were significantly reduced in aged mice indicating an impaired t-cell response with increasing age as assessed by mlr (p< . ) and elispot (p< . ). in parallel, regulatory functions remained age-independent as alloantigen-specific cd + cd + foxp + t-cells isolated from sensitized old mice demonstrated a dose-dependent well preserved suppressor function. next, we tested the age-dependent alloantigen -specific cd + t-cell function in a transgenic skin transplant model: age did not significantly impact rejection kinetics (young vs. old: . vs. . days, n.s.) however, t-cell migration and activation were significantly different: fewer numbers of activated cd + cd + and effector/memory phenotype t-cells (cd + cd high cd l low ) were found in recipient spleens (p< . ) and draining lymph nodes (dln) (p< . ) after transfer of old t-cells. chemokine receptor staining revealed less cxcr + and ccr + t-cells in dln following the transfer of old t-cells (total cell numbers x : cxcr + : . ± . vs. . ± . , ccr + : . ± . vs. . ± . , p< . ). this was paralleled by reduced intragraft t-cell infiltration as observed by immunohistochemistry. in summary, native elderly mice showed an increased frequency of effector memory t-cells but an overall impaired t-cell response. regulatory -t-cell function remained preserved. in vivo allospecific cd + t-cell activation and migration was impaired in elderly transplant recipients. the background: the sensitized transplant recipients may undergo an "accelerated" form of rejection, which is mediated by t cell-dependent mechanisms. these patients often experience increased rate of early rejection episodes, which are difficult to control with currently used immunosuppressive agents. methods: in our model of cardiac graft rejection in sensitized recipients, b mice are first challenged with b/c skin, followed - days later by b/c heart transplant (htx). unlike in naive hosts, htx rejection and alloreactive cd activation in this model are cd blockade-resistant. we first performed systemic analysis at the intragraft transcriptional level by microarray to identify disparities in local immune responses in naive vs. sensitized hosts. aiming to improve the efficacy of costimulation blockade in the sensitization settings, we then determined the role of cd t cells in costimulation blockade-resistant alloimmune response by using cd depleting (gk . ) vs. cd blocking (yts ) ab, in conjunction with cd blockade (mr ). results: htx harvested from groups of naïve (day - ), sensitized (day - ), control ig or mr ab treated mice (n= /gr) were subjected to microarray analysis. mr treatment suppressed htx expression of proinflammatory genes (il- β, il- , tnf-α), and t cell-targeted chemokines (rantes, mig, cxcl ) early after htx in naïve, but not sensitized recipients. five groups of sensitized mice treated at the time of htx with: ( ) ). ctl activation was determined by facs phenotyping at day and . the simultaneous blockade of cd costimulation and cd help, but not a single blockade with mr ab or anti-cd ab, was required to inhibit peripheral alloreactive cd activation in sensitized mice. additionally, cd activation in the absence of cd help showed defective cytotoxic molecule profile, with suppressed perforin but upregulated granzyme b expression at the graft site. conclusion: cd blockade-resistant cd activation is critically dependent on cd t cells. this study provides novel immunological basis to study the potential synergy between adjunctive cd and cd targeted therapies to control accelerated graft rejection in sensitized hosts. mediators. g. einecke, l. g. hidalgo, p. f. halloran. department of medicine, university of alberta, edmonton, canada. the hallmark of t cell mediated rejection (tcmr) are interstitial inflammation and tubulitis. the mechanisms of tubulitis and epithelial deterioration during tcmr are unknown. we previously showed that tubulitis in mouse allografts is independent of cytotoxic molecules (gzma/b, prf) and is preceded by molecular changes with loss of epithelial genes, reflecting epithelial dedifferentiation. human tcmr is associated with loss of the same epithelial genes and re-expression of embryonic pathways (wnt, notch). we hypothesized that tcmr is mediated through soluble factors released by effector t cells or macrophages in the interstitium, and that supernatants of effector t cells would simulate these changes in epithelial cultures. we established an in vitro model in which cultured primary human renal epithelial cells are incubated with supernatants from effector t cell/monocyte co-cultures. the transcript changes in this model, analyzed by microarrays, closely simulated those in human and mouse tcmr (fig ), with loss of epithelial transcripts, activation of wnt/ notch pathways, and increased expression of ifng-inducible and injury-related transcripts previously defined in our mouse model. some of these changes were reproduced by incubation of epithelial cells with ifng or tgfb. the in vitro model identified additional epithelial transcript changes not previously identified in vivo (not affected by ifng or ischemic injury, not expressed in t cells, macrophages, b cells, or nk cells). expression of these transcripts (n = ) was highly altered in human tcmr compared to nonrejecting biopsies of human renal allograft biopsies and distinguished tcmr from antibody-mediated rejection in a hierarchical cluster analysis. thus we have established an in vitro model that closely simulates the epithelial events during human tcmr and confirms that these changes are independent of direct contact with inflammatory cells, supporting the hypothesis that interstitial effector t cells mediate allograft deterioration by soluble mediators. together with previous mouse and human data these results provide the first in vitro model of the epithelial consequences of tcmr. objective. c split product deposition to hla antigen-coated microparticles ([c d] flowpra) was previously shown to be a specific marker of c d-positive antibodymediated rejection (amr). the objective of this study was to assess the predictive value of [c d]flowpra reactivity in a cohort of non-biopsied patients with stable graft function during the first year. methods. a total of kidney transplant recipients were enrolled (inclusion criteria: functioning graft at months; prospective collection of sera taken before and at - , , and months after transplantation). included patients were serially screened for humoral panel reactivity applying [igg] and [c d]flowpra screening. results. fifty-four of the included recipients had stable graft function within the first year and were not subjected to diagnostic renal biopsy. in this particular patient group, detection of complement-fixing hla reactivity tended to be less frequent than in the patients with biopsied graft dysfunction (≥ % [c d]flowpra before transplantation: % vs. % of recipients, p= . ; ≥ % [c d]flowpra after transplantation: % vs %, p= . ). in line with our previous results, within the group of biopsied patients, pre-and/or post-tx [c d]flowpra reactivity was tightly associated with the immunohistochemical detection of peritubular capillary c d deposition (p= . ) reflecting ongoing amr. remarkably, in initially stable patients, detectable [c d] flowpra reactivity was not associated with inferior long-term outcomes. within this patient group, recipients with and without (pre-and/or post-transplant) c d-fixing anti-hla reactivity did not differ with respect to yr allograft survival (p= . ), yr serum creatinine levels ( . vs. . mg/dl; p= . ), and proteinuria at yrs ( . vs. . g/ h; p= . ). similar results were obtained for a comparison of [igg]flowpra positive vs. negative subjects. conclusion. our data suggest that a considerable number of patients with initially stable graft function may have excellent long-term graft function despite serologically detectable levels of (complement-fixing) alloreactivity. for these antibody-positive recipients, a potential role of graft accommodation can be speculated. the immunoproteasome subunit beta as a novel peripheral blood and intragraft biomarker of chronic antibody mediated allograft rejection in clinical transplantation. joanna ashton-chess, in an attempt to identify non-invasive biomarkers of specific histological scarring, we compared publicly available gene sets derived from microarray studies of human renal transplant biopsies published in the literature with our own microarray data derived from studies of rat heart allografts. in this way we identified an immunoproteasome subunit (proteasome subunit beta -psmb ) as a potentially interesting candidate. psmb is one of three members of the immunoproteasome that are induced by abstracts interferon gamma. messenger rna profiling in renal transplant biopsies (n = ) with normal histology, interstitial fibrosis and tubular atrophy, calcineurin inhibitor toxicity, transplant glomerulopathy or chronic antibody-mediated rejection (banff ) revealed psmb to be strongly and significantly increased in chronic antibody mediated rejection vs. the other three histological diagnoses. receiver operator characteristic (roc) curve analysis showed that psmb mrna could diagnose chronic antibody-mediated rejection with an auc of . , a sensitivity of . and a specificity of . . moreover, psmb mrna was significantly increased in the pbmc (n = ) of patients with chronic antibody-mediated rejection compared to those with normal histology. roc analyses revealed an impressive auc of . with all patients being correctly classified. similar results were also observed in a rat allograft model where psmb was significantly increased at day post transplantation in both the heart allograft and the pbmc of animals presenting chronic transplant vasculopathy vs. syngeneic grafts. moreover, inhibition of the proteasome by administration of velcade® at . mg/kg every other day for the first days post transplantation significantly and dose-dependently prolonged allograft survival (mst . days in velcade-treated vs. . days in untreated animals).together our data point towards psmb as a blood and intragraft biomarker of chronic antibody-mediated rejection as well as a potential therapeutic target. furthermore, our results suggest that using a threshold of psmb in the blood could help in guiding the decision to biopsy in the clinic. baff monitoring after b-cell depletion therapy for acute renal transplant rejection. valeriya zarkhin, snehal mohile, li li, jonathan martin, minnie sarwal. pediatrics, stanford university, stanford, ca. introduction: the objective of this study was to investigate the interaction between b-cell activation factor of the tnf family (baff) level and circulating b-cell repopulation in pediatric patients with acute kidney transplant rejection treated with the b-cell-depleting agent rituximab. methods: pediatric patients ( - yrs) with biopsy proven b-cell positive ar were treated with steroids and rituximab ( x mg/m /dose/week). all patients were followed up for months. peripheral blood cd cells and donor specific antibodies (dsa) were monitored monthly. serum level of baff was measured by elisa at ar, , , , and months post-ar treatment and correlated with clinical outcomes. results: complete depletion of circulating and intragraft b-cells was observed with rituximab, with improvement in ar grade in all patients. the median time of peripheral b-cells repopulation was months (range - months, fig. a) . no correlation was found between pre-treatment peripheral b-cell number and the b-cell repopulation time (r= . , p= . ). baff levels rose significantly with b-cell depletion with maximum values at months post-treatment ( . fold increase, p= . ) and returned to pre-treatment levels, with b-cell recovery, at months (fig. b) . serum baff levels correlated positively with b-cell depletion > months (r= . , p= . , fig b). a lack of depletion of dsa i, but not dsa ii correlated with higher baff levels (r= . , p= . ). the timing of b-cell repopulation and depletion of dsa i may be dependant on serum baff level. anti-baff treatment may be considered in addition to rituximab or standard immunosuppressive treatment protocols in patients with persistent and/or antibody mediated rejection. the background: the development of donor specific hla antibodies (dsa) post-transplant has been associated with graft failure. we have shown in a longitudinal study that increases in dsa may precede rejection by months. this retrospective analysis evaluates changes in maintenance immunosuppression (mi) and appearance of dsa in stable transplant recipients. methods: sera from stable renal transplant recipients were collected at - month intervals and tested for the presence of dsa. the types and doses of immunosuppression were correlated with the appearance of dsa. two hundred eighty stable renal transplant recipients who received either a deceased or a living donor kidney were monitored post-transplantation for the development of dsa. patients have been followed for to years and had a minimum of serum samples analyzed. all recipients received anti-lymphocyte induction therapy. maintenance immunosuppression (mi) consisted of a calcineurin inhibitor, prednisolone, and mycophenolic acid. hla single antigen beads analyzed in the luminex instrument were used to establish donor specificity of the antibodies. a chart review was undertaken to determine the doses of the mi posttransplantation. all mi was managed by the transplant team and changed according to clinical indications without regard to dsa. results: of the patients monitored developed dsa post-transplantation with a functioning graft. dsa was against hla-class ii antigens in of ( %); class i antigens in of ( %); and against both class i and ii antigens in of ( %). dsa against class ii was against dq in all except one case. in the majority of the recipients the appearance of dsa was preceded with dose reduction of the mi, either calcineurin inhibitor or mycophenolic acid or both. conclusions: our data show that dsa developed predominantly against hla-class ii antigens and that the appearance of dsa was often preceded with reduction of one or more of the mi. this data shows the importance of monitoring dsa with mi decreases in a stable allograft recipient. antibody production and antigen presentation are directly inhibited by mycophenolate mofetil. anat r. tambur, joe leventhal, nancy d. herrera, joshua miller. division of organ transplantation, northwestern university, chicago, il. immunosuppressive medications are primarily designed to target t cell proliferation. mycophenolate mofetil (mmf) exerts its effect by inhibiting de-novo synthesis of guanine, a dna building block. we, and others, have previously shown that mpa (active metabolite of mmf) affects the differentiation of monocytes into dendritic cells (dc). we further demonstrated that cell-surface receptors associated with antigen up-take and antigen-processing and presentation (cd and cd ) are down regulated when cells are matured in the presence of mpa. this phenotype translated into a decreased uptake of alloantigens and reduced stimulation of t cells. we concluded that mmf inhibits also cell functions requiring mrna synthesis. we now present data regarding the role of mpa in maturation and function of b-lineage cells. pbmcs from subjects were cultured in the presence of cpg, il- , il- and cd l for days to induce memory b and plasma cell maturation in-vitro. cultures were performed in the presence or absence of mpa ( ugr/ul) for the length of the incubation period. in-vitro stimulation of b cells increased the memory population (cd + cd +) from . +/- . % to +/- %. similarly, plasma cells were increased from . +/- . % to . +/- . %. the addition of mpa to the culture inhibited stimulation for both memory and plasma cells ( . +/- % p= . ; and . +/- . % p=ns, respectively). we have further analyzed the effects of mpa on antibody secretion using an elisa (measuring soluble antibodies) as well as a b-cell elispot assay (assessing the number of b cells that produce antibodies). while an expected increase in od values was observed for stimulated samples compared with non-stimulated samples, a significant decrease was observed when stimulation occurred in the presence of mpa. nonstimulated cells: . +/- . ; stimulated cells: . +/- . ; mpa treated stimulated cells: . +/- . ; p< . ). the number of antibody producing cells was also significantly lowered when cultures were done in the presence of mpa (a mean of cells were counted for the stimulated cells compared with - cells for non-stimulated and mpa-treated-stimulated cells). to our knowledge this is the first time where in-vitro experimental data document the inhibitory effect of mpa on b lineage cells and antibody secretion, although clinically known for some time. these results confirm our previous observations regarding the effects of mmf on non-proliferating immune cells. a non-allogeneic stimulus triggers the production of de novo hla and mica antibodies. luis e. morales-buenrostro, , lluvia a. marino-vazquez, anh nguyen, paul i. terasaki, josefina alberu. nephrology and transplantation., instituto nacional de ciencias medicas y nutricion salvador zubiran, mexico city, df, mexico; terasaki foundation laboratory, los angeles, ca; one lambda inc., canoga park, ca. background: in a previous study, we found that healthy people developed hla abs after immunization against hepatitis b virus. the aim of this prospective study was to establish if stimulation with influenza vaccine is capable of triggering the production of hla and mica abs. methods: we determined the presence of hla and mica abs (de novo and preformed abs) in groups of patients vaccinated against influenza: a) healthy adults, b) esrd patients, and c) tr. additionally, we followed healthy unvaccinated people without exposure to sensitizing factor: d) control group. sera samples were collected at baseline (pre influenza shot), at week, and monthly up months after immunization. hla abs were assessed with labscreen single antigen beads for luminex. all samples of each patient were tested simultaneously. a luminescence value higher than was considered positive only if it was times the baseline value. we analyzed the data using chi square, one way anova test, and logistic regression. results: the table shows the types of abs in each group. interestingly, we found preformed abs across all four groups, including the control group (which is free of any known sensitizing factors). the proportion of de novo abs was higher in the group b and c. multivariate analysis shows that the only independent factor associated with development of de novo abs was the presence of preformed abs. we observed a nonspecific immunologic response triggered by external stimulus and was not necessarily associated to the vaccine in people previously sensitized. a introduction. decisions about the minimization and ultimate withdrawal of immunosuppression (is) would be facilitated by the identification of biomarkers associated with operational tolerance (ot). methods. as part of an itn/nih supported study tolerant kidney transplant recipients (off all is for > yr with stable function, n= ) were compared to recipients with stable function on is (sis, n= ), recipients with chronic allograft nephropathy (can, n= ), and healthy volunteers (hv, n= ). pbmc, whole blood total rna, and urine samples from each group were examined using flow cytometry, microarrays, and rt-pcr respectively. results. analysis of microarrays revealed significantly higher expression of b cell differentiation genes in tolerant recipients compared to the sis and can groups. consistent with this finding, tolerant recipients also displayed higher numbers of naïve b cells in peripheral blood and increased expression of cd in urine relative to the sis and can groups. no differences in treg or genes associated with regulatory cells were observed in tolerant recipients relative to other groups. these analyses failed to demonstrate significant differences between tolerant recipients and hvs although support vector machine learning methods suggested potential differences in a number of genes including nfat and calcineurin. finally, relative to tolerant patients, those with can showed decreased numbers of t and nk cells and expressed lower levels of genes associated with immune cell activation in peripheral blood. conclusions. differences in b cell numbers may be useful in identifying tolerant renal transplant recipients or those predisposed to developing tolerance and could potentially provide insights into the mechanisms of tolerance. erythrocyte development of antibodies (abs) to mismatched donor hla antigens has been associated with acute and chronic rejection. complement activation, and c d deposition, has been correlated with humoral rejection of allografts. however, utility of c d staining in ltx has been controversial. a recent study (arthritis rheum. nov; ( ) : - ) shows a strong correlation between erythrocyte bound c d (e-c d) in diagnosis and monitoring of sle. goal of our study is to determine the utility of measuring e-c d in the diagnosis of humoral rejection following human ltx. ltx recipients were analyzed post-ltx for e-c d using facs of rbcs incubated with anti-c d (quidel) followed by fitc-goat anti-mouse. normals were also analyzed. the serum was analyzed for development of anti-hla abs by solid phase assays and for the presence of autoabs to kα tubulin and collagenv (elisa). biopsies from patients were stained immunohistochemically for c d deposition. summary of results are presented in table . infection= / ar= / % e-c d in normals- . %; mfi in normals- . ; mfi=mean fluorescence intensity; ar=acute rejection; dsa=donor specific abs out of patients show significant increase in the % bound e-c d (p< . ) as compared to controls. / had anti-hla and / had autoabs which were significantly different from those with low e-c d (p= . ). staining of the biopsies showed c d deposition in recipients with increased e-c d. all patients with acute humoral rejection had elevated e-c d. we conclude that there is a significant correlation between increase in % e-c d in ltx recipients and development of abs to either hla antigens or auto-antigens during the post-ltx period. biopsies from patients with increased e-c d showed deposition of c d in the allografts. preliminary data suggest that measurement of e-c d using a non-invasive method of flow cytometry may be of value in monitoring ltx patients for humoral rejection. innate immunity: chemokines, cytokines innate immunity is emerging as an important initiator and modulator of the adaptive immune response. in the setting of transplantation, ischemia-reperfusion injury and tissue trauma appear to potentiate the alloimmune response. one of the mechanisms through which the innate immune system modulates an adaptive immune response is dendritic cells (dc). in this study, we examined dc activation in a mouse model of skin transplantation by monitoring the expression of mhc ii and p chain of the proinflammatory cytokine il- . the p expression was detected in live cells using the yet reporter mouse, in which a transgene for yellow fluorescent protein (yfp) was placed downstream of the endogenous il- p gene, thus faithfully "reporting" p expression. skins from c bl/ or balb/c donors were grafted on the dorsal thorax of c bl/ .yet mice. draining and non-draining lymph nodes (ln) were harvested at hours and examined for yfp expression by fluorescent microscopy. a marked increase in the numbers of yfp-expressing dc was observed in draining ln in both syngeneic and allogeneic graft recipients. surprisingly, yfp-expressing dc also increased in nondraining ln when compared to non-transplanted controls. similarly, dc in draining and non-draining ln showed higher mhc ii expression than those in non-transplanted controls. upregulation of mhc ii was highest at hours and decreased significantly by - hours. to assess whether dc activation in non-draining ln was functionally significant, we monitored the activation of adoptively transferred ovalbumin-specific ot-ii tcr transgenic t cells in response to footpad antigen challenge in mice with or without a syngeneic skin transplant on the contralateral upper thorax. otii t cells in transplanted animals proliferated approximately -to -fold better and a higher percentage of the otii cells produced il- than those from non-transplanted animals. thus, local surgical trauma results in a widespread, time-limited, functional activation of dc that appears to act as a partial adjuvant for t cell responses. together, these data suggest that surgical trauma may incite a systemic barrier to transplantation via the activation of dc and therapeutic interventions that reduce the surgical trauma and dc activation may help to improve survival of transplanted grafts. tolerance of cardiac allografts: studies with cx cr -deficient mice. takaya murayama, katsunori tanaka, takuya ueno, mollie jurewics, guleria indira, fiorina paolo, paez jesus, smith n. rex, sayegh mohamed, reza abdi. transplantation research center, renal division, brigham and women's hospital, harvard medical school, boston, ma; department of pathology, massachusetts general hospital, harvard medical school, boston, ma. although donor/tissue dendritic cells (ddc) have long been known to play a key role in mounting alloimmune responses, however, their generation, trafficking and role in tolerance have not rigorously examined. we have used b .fvb-tg (itgax-dtr/ egfp) mice which has a gfp linked to the cd c promoter. using these mice as the donors of heart allograft transplantation provided us a unique model to study ddc posttransplantation. our trafficking data indicate there is a rapid migration of ddc into spleen ( hours post transplantation) but not lymph nodes and that ddc were unexpectedly detected in the spleen of the recipients long after rejection of heart allografts suggesting ddc could escape from the immunosurveillance of host immune system. our data also show that ddc proliferate in the lymphoid tissue of the recipients and co-express class ii molecule of the recipients. we then show that cx cr pathway regulates generation abstracts of heart tissue dc constitutively. as compared to wt hearts, cx cr -/hearts contain lower number of dc and transplanting cx cr -/donor hearts into wt balb/c mice led to significant prolongation of allograft survival without immunosuppression (mst of vs. days, respectively). increasing cx cr -/heart dc by implanting donors with flt -producing hybridoma cells has restored the time of rejection. unexpectedly, induction of long-term survival with anti-cd blockade (mr ) and ctla- ig (but not low dose rapamycine) was abrogated when cx cr -/hearts were used as donors, with concomitant lesser tregs in the cx cr -/heart allografts as compared to wt. furthermore, co-transplanting hearts from wt and cx cr -/into the same recipient treated with mr resulted in significant prolongation of cx cr -/heart allograft survival. depleting the ddc of heart donors prior to transplantation with diphtheria toxin also worsened markedly chronic rejection in the recipients at day post-transplantation. our data indicate that, in contrast to the widely accepted dogma, the presence of donor dc in graft tissue is not only central to allograft rejection but also is necessary for the induction and maintenance of peripheral tolerance. local c a interaction with c ar on dcs modulates dc function, subsequently up-regulating allospecific t cell responses. qi peng, ke li, steven h. sacks, wuding zhou. mrc centre for transplantation, department of nephrology and transplantation, king's college london, guy's campus, london, united kingdom. the innate system of immunity plays an important role in ischemia-reperfusion injury and allograft rejection. the early stages of inflammatory processes are accompanied by complement activation. one biological consequence of this activation is the release of potent inflammatory anaphylatoxins, c a and c a, which have been reported to regulate a range of inflammatory responses. we previously reported that dcs express c ar and c ar, and c a-c ar interaction has a positive impact on murine bm dcs, in terms of activation phenotype and capacity for ag uptake and allostimulation. however, the role of c a in modulating dc function remains unclear. the aim of this study is to investigate the role of local c ar signalling in modulating murine bm dc function and subsequent regulation of the allospecific t cell response. we first evaluated if c a-c ar interaction could result from local expression of factors. our results showed that c ar mrna was detected in wt dcs at different stage of dc culture by rt-pcr, and c a was detected by elisa in the culture supernatants from different stages of dc culture. we next determined if c a-c ar interaction modulates dc function in allospecific t cell stimulation in vitro and in vivo. we found that bm dcs cultured from c ar-/-mice or treated with c ar antagonist (c ara, w ) exhibited a less activated phenotype (producing significantly less il- and more il- , in response to lps stimulation); both c ar-/-and antagonist-treated dcs (lps stimulated) showed reduced capacity to stimulate naïve alloreactive t cells, as measured by ifn-γ production and thymidine uptake. as regards interaction in vivo, following i.p. administration of the c ara-treated dcs into allogeneic mice for days, ex vivo mixed lymphocyte reaction showed that cd + t cells from those recipients have reduced thymidine uptake, but increased il- production compared to that with untreated dcs. conversely, dcs treated with c ar agonist (c a) exhibited a more activated phenotype (producing more il- and less il- ) and were more potent in allospecific t cell stimulation. our findings demonstrate that murine bm dcs can express c ar and c a can be generated locally; c a-c ar interaction up-regulates murine bmdc activation and their allostimulatory capacity. thus, targeting c a-mediated signal may be able to prevent allograft injury. role of tnfα in early chemokine production and leukocyte infiltration into heart allografts. daisuke ishii, austin d. schenck, robert l. fairchild. immunology, glickman urological and kidney institute., cleveland clinic, cleveland, oh. objectives: the acute phase cytokines il- and tnfα are produced early during inflammatory processes, including wound healing and ischemia/reperfusion. the goal of this study was to investigate the role of these cytokines in the induction of early chemokine production and leukocyte infiltration into heart allografts. methods: c bl/ (h- b), balb/c (h- d), and balb/c.il- -/-mice received vascularized syngeneic or complete mhc mismatched, a/j (h- a), cardiac grafts. grafts were retrieved at different time points and total rna and tissue protein were prepared and analyzed by quantitative rt/pcr and elisa to test expression levels of tnf-α, il- , cxcl /kc, cxcl /mip- , and ccl /mcp- in the grafts. anti-tnfα mab ( ug) was given at the time of transplantation with or without anti-cd mab ( ug on days and ). infiltration of cd +, cd + t cells, neutrophils and macrophages was assessed by flow cytometry and immunohistochemistry. donor-reactive t cell priming to ifn-g producing cells in the recipient spleen was measured by elispot. results: expression of tnfα and il- mrna reached an initial peak at hrs post-transplant and a second peak at - hrs with equivalent levels in both iso-and allo-grafts. the neutrophil and macrophage chemoattractants cxcl /kc, cxcl / mip- and ccl /mcp- reached peak levels at hrs post-transplant in both sets of grafts and then declined to background levels. il- deficiency in the recipient or the cardiac allograft did not prolong allograft survival. in untreated mice, heart allografts were rejected at . ± . days after transplantation. anti-tnfα mab decreased neutrophil and macrophage chemoattractant levels % at hrs post-transplant and subsequent neutrophil, macrophage and cd + cell infiltration into the allografts as well as extended graft survival to . ± . days. anti-tnfα mab also decreased the number of donor-reactive ifn-g producing cd t cells almost % on day post-transplant. whereas anti-cd mab prolonged survival to day , administration of anti-tnfα and anti-cd mab delayed rejection to day and resulted in the long-term (> days) survival of % of the heart allografts. conclusions; these data indicate that anti-tnfα antibodies can delay donorreactive cd t cell priming and leukocyte infiltration into heart allografts rejection. as a conjunctive therapy, tnfa antibodies can promote long-term survival of the allografts. introduction recent evidence indicates that inflammation impairs immune regulation, yet the mechanisms behind this effect are not clear, in particular in regards to transplantation tolerance. in this study, we investigated the role of inflammatory cytokines, il- and tnfα, in transplantation tolerance induction. we first examined the impact of il- + tnfα on in vitro t cell alloimmune responses. t cells that were stimulated by allogeneic apcs in conditioned media harvested from lps-activated dcs proliferated more than apc-stimulated t cells that were cultured in conditioned media derived from non-lps-activated dcs. the ability of cd and cd t cells to respond to allogeneic apcs in the lps-activated conditioned media was significantly impaired by the addition of either anti-il- or anti-tnfα mabs. the addition of both mabs further diminshed t cell proliferation, indicating that il- and tnfα synergize to augment in vitro t cell allostimulation. in support of these findings, we noted reduced t cell proliferation during the mlr when t cells were cultured in conditioned media derived from either il- -/-or tnfα-/-lpsactivated dcs. furthermore, these diminished responses was restored by the addition of recombinant il- or tnfα, respectively. to examine the in vivo implications of these findings, we employed a murine skin allograft model, with recipients that were either b wild type, il- -/-or tnfα-/-. these groups were transplanted with a balb/c skin graft and treated with (or without) perioperative costimulatory blockade (ctla ig and anti-cd ). in the absence of immune modulation, all groups rejected balb/c skin allografts at a similar tempo (< days). in the presence of costimulatory blockade, il- -/-recipients (median survival time, mst = days, p = . ) rejected their allografts at a slower tempo compared to wt (mst = days) or tnfα-/-recipients (mst = days). however, this response in il- -/-recipients was further delayed by administering a tnfα inhibiting mab (mst = days), indicating that synergy between il- and tnfα occurs in vivo and prevents the ability of costimulatory blockade to delay the onset of allograft rejection. conclusions we conclude that synergy between il- and tnfα augments t cell alloimmune responses and impairs the effects of costimulatory blockade to delay allograft rejection. abstract# background: calcineurin inhibitors (cni) are involved in the development of post transplant diabetes mellitus (ptdm). changes in insulin secretion and sensitivity are central mechanisms involved in the development of ptdm. in addition alterations in endothelial function seem to be involved. the present study investigated the effect of cni's on these factors. methods: in a predefined sub-study of a previously published randomized trial it was aimed to compare the effect of cni treatment (n= ) with complete cni-avoidance (n= ) on insulin secretion and sensitivity as well as endothelial function. an oral glucose tolerance test and endothelial function investigation with laser doppler flowmetry was performed in patients, weeks and months following transplantation. results: insulin sensitivity differed already weeks posttransplant and was significantly better after months in patients never treated with cni drugs (p= . ). endothelial function was significantly correlated with insulin sensitivity (n= , r = . , p= . ) at weeks posttransplant, but not after months (p= . ). insulin secretion tended to be higher in cni treated patients both at week and month (p= . ). conclusions: findings in the present study indicate that long-term cni treatment reduce insulin sensitivity which was associated with impaired endothelial function. in response to this peripheral insulin resistance a tendency towards a compensatory increase in insulin secretion was seen. these effects combined may indicate a future risk for premature cardiovascular disease in cni treated renal transplant recipients, but this hypothesis needs further study. group(n) ktx ptx(kptx) ecd re-tx pra(> %) race(aa) low immunologic risk alem ( ) overall pt, ktx, and ptx survival are , , and % at months median follow-up. actuarial survival rates, initial length of stay, delayed graft function, steroid free rates, major infection, and incidence of ptld ( ratg pt) were similar for alem and ratg groups, but treated acute rejection (ar) occurred in ( %) alem pts compared to ( %) ratg pts (p= . ) and biopsy proven rejection (bpar) in ( %) alem pts compared to ( %) ratg pts (p= . ). only alem bpar has occurred after months. total daily mmf doses were similar for alem and ratg groups at months ( ± mg vs ± mg). neupogen use was greater in the alem group, ( %), than in the ratg group ( ( %), p= . ). excluding pak, chronic allograft nephropathy (can) was observed in ( %) alem pts and ( %) ratg pts. (p= . ). conclusions: alem and ratg induction both provide excellent and yr pt, ktx, and ptx survival. alem is associated with lower acute rejection rates and perhaps less can, but requires increased neupogen administration to help maintain mmf dosing. thymoglobulin dosing intensity and density: effects on induction efficacy ruth-ann m. lee, adele h. rike, background: alemtuzumab (campath h) has been used as induction therapy for kidney transplant recipients with acute rejection rates reported by us and others of to % at one year. the histologic type of rejection and the time frame for occurrence after treatment with alemtuzumab have not been well established. this study is a retrospective single center review of acute rejection episodes of kidney transplant recipients treated with alemtuzumab induction with respect to the kinetics and histologic patterns of acute allograft rejection. methods: from / / to / / , kidney transplants were done meeting the inclusion criteria for this review. all patients had negative t and b cell flow cytometric crossmatches and received induction therapy with alemtuzumab mg iv intra-operatively, methylprednisolone - mg during the first hours, and were then maintained on tacrolimus (target level - ) and mycophenolate mofetil without steroids. all episodes of biopsy-proven acute rejection (ar) were reviewed. patients in pre-transplant desensitization protocols or with documented non-adherence with medications were excluded from the analysis. results: a total of of patients ( . %) experienced ar during the study period, with a mean follow up of months (range - months). of the ar episodes, ( %) occurred within the first months post-transplant, ( %) occurred between - months, ( %) occurred between - months, ( %) occurred between - months, and ( %) occurred more than one year post-transplant. of the rejection episodes within the first months post-transplant, / occurred within the first days. histologic analysis showed that / rejection episodes ( %) within the first months included an antibody mediated component ( / within the first days.) in contrast, / rejection episodes ( %) which occurred greater than months post-transplant were antibody mediated. of the patients with antibody mediated rejection, only patients had panel reactive antibody (pra) levels > % at the time of transplant. conclusion: this large experience with alemtuzumab induction therapy with a steroidfree maintenance protocol, demonstrates that the majority of rejection episodes occur within the first months post-transplant, with the largest fraction in the first months. a significant number of early rejection episodes are antibody mediated and occur in unsensitized recipients. in a randomized, international, multicenter study, comparing the use of thymoglobulin (tmg) and basiliximab (bas) in recipients at high risk for delayed graft function (dgf) or rejection, tmg was associated with less acute rejection ( . % vs . %, p= . ) and a lower triple endpoint (rejection, death or graft loss, . % tmg vs . % bas, p= . ) but not a significantly lower quadruple endpoint including dgf. the purpose of this study was to compare the efficacy of tmg and bas for induction stratified by donor source: standard criteria donor (scd), extended criteria donor (ecd) or donor with hypertension (htn). methods: retrospective review of data collected in the original randomized trial. data-capture limitations necessitated defining ecd as donor age > or donor age between and with both a donor history of htn and donor renal insufficiency (history of atn or creatinine above . mg/dl during the hours prior to organ recovery/start of cold ischemia time). results: recipients received ecd kidneys [tmg n= ( . %), bas n= ( . %), p=ns]. outcomes are presented below. there were no differences in the rates of dgf between the groups examined. conclusion: standard and non-htn donor recipients had a tremendous benefit of tmg compared to bas with less acute rejection and death. contrary to the perceived niche of tmg in ecd recipients, tmg has its most beneficial effect in scd recipients and recipients of donors without htn at risk for acute rejection or dgf. evaluation we have changed our immnosuppressive protocol in abo-incompatible kidney transplantations and attempted to determine whether the changes in agents have resulted in better outcomes. we used tacrolimus(fk), mycophenolate mofetil(mmf) and methylprednisolone(mp) in immunologically high risk patients between and . moreover, we performed splenectomy at the time of the transplant surgery in patients (group ) with aboincompatibilities between ansd , and administered rituximab as an alternative to splenectomy in patients(group ) with abo-incompatibilities between and . in this study, we compared the graft survival rates as well as the incidence of acute rejection in these two treatment eras. the graft survival rate at one year was % in group and % in group (p=ns). the graft was lost in one case of the cases of group due to insufficient doses of the immunosuppressive drugs. the incidence rate of acute rejection was % ( / ) in group , and % ( / ) in group (p< . ). there were no significant differences in serum creatinine level one year after transplanatation between two groups( . ± . in group vs. . ± . mg/dl in group ). no serious adverse events associated with rituximab or splenectomty were encountered in either groups. in abo-incomaptible kidney transplantation, rituximab under fk/mmf combination as an alternative to splenectomy seems to yield an excellent result in terms of the incidence rate of acute rejection. introduction: the choice of immunosuppression in the elderly kidney transplant recipient remains unclear. the objective of this study was to compare outcomes with different t cell-depleting induction agents in the elderly. method: all solitary kidney transplant recipients over the age of years that received induction therapy with either alemtuzumab or thymoglobulin from to were included in this unos analysis. overall graft survival, the risk of graft loss, and the risk of rejection were compared using kaplan meier, cox proportional hazards, and logistic regression, respectively. results: patients receiving alemtuzumab had a significantly lower -year graft survival ( . %) than patients receiving thymoglobulin ( . %), p= . ) (figure) after adjusting for other risk factors, alemtuzumab had a higher risk of graft loss compared to patients given purpose. the aim of this prospective randomized study was the comparison of efficacy and incidence of adverse events in two induction therapy regimens (atg versus basiliximab) in patients receiving a dual immunosuppression. methods. recipients of first or second deceased donor kidney transplants were prospectively randomized to receive either atg (fresenius) or basiliximab (novartis) as induction therapy. dual immnosuppression consisted of tacrolimus (astellas) and methylprednisolone. cmv prophylaxis was not applied on a regular basis. statistical analysis was performed with fisher's exact or chi-squared test, anova or mann-whitney u test, kaplan meier curves and log-rank test. results. patient characteristics of populations treated with atg versus basiliximab were similar concerning average age ( years), gender and dialysis time prior to transplantation ( vs. months). average donor age and cold ischemia were also comparable ( vs. years and vs. minutes). the actuarial -year patient survival for the atg subpopulation is , % in comparison to % in the basiliximab group (n.s.). analyzing graft survival after years, rates of , % in atg patients compared to % in the basiliximab group can be observed (n.s.). the incidence of acute rejection episodes was similar in both groups (atg: n= vs. basiliximab: n= ). ( %) patients in the atg group and ( , %) in the basiliximab group showed a delayed graft function. serum creatinine was not significantly different at and years (atg: , ± , mg/dl and , ± , mg/dl vs. basiliximab: , ± , mg/dl and , ± , mg/dl). patients in the atg group had a higher rate of cmv infections (n= vs. n= ; p= , ), whereas patients treated with basiliximab had significantly more hematological complications like anaemia, leukopenia and thrombocytopenia. conclusion. comparing induction therapy with atg and basiliximab, our data shows similar patient and graft survival rates with slightly better results in the atg group. patients treated with atg had a higher rate of cmv infections but less hematological complications. predicting cardiovascular events (cvd) and the varied effects of immunosuppressive medication on cvd risk factors requires an understanding of how traditional and nontraditional risk factors impact cvd after kidney transplantation (ktx). single-center studies have generally lacked statistical power and generalizability. registry studies have lacked sufficient data on cvd risk factors. the port project is creating a multicenter international database of ktx recipients with the primary objective of developing risk prediction models for post-transplant cvd. as a preliminary data assessment, an analysis was done on , ktx from - from transplant centers representing european centers, north american centers, and centers from asia/oceania. all data were extracted from preexisting databases at each individual transplant center and processed into the consolidated port database. , major adverse cardiac events (mace) were identified, defined as non-fatal or fatal myocardial infarction, cardiac abstracts arrest, and sudden death. the mace-free survival curves by participating center are shown in the figure. in this preliminary analysis, the overall one-year cumulative incidence of mace was . %, ranging from . % to . % across centers; and the five-year cumulative incidence was . %, ranging from . % to . %. the prevalence of diabetes pre-transplant varied from % to % across centers. in cox proportional hazards models adjusted for age, gender, race, donor type, transplant center, and reported history of diabetes, hypertension (htn), and ami, patients with a reported history of ami had a % increased risk ( %- %, p< . ) for mace. for the final analysis, the definition of mace will be expanded to include major revascularization events. the final port database will be used to develop and validate an equation to predict mace and other health outcomes of interest, after accounting for differential cvd risk factors internationally. abstracts to center. the most commonly used bp medications were beta-blockers, followed by ccbs, and both were used with the same frequency at and months. in contrast, the percentage of patients on an acei or arb more than doubled between and months, suggesting reluctance to use these agents early after tx (a practice not necessarily evidence-based); however, more than % of subjects did not receive acei/arb therapy even at months. fewer than half of all patients received aspirin, including only % with dm and/or cvd. similarly, only half with dm and/or cvd received a statin at and months. these data indicate current management of ktx recipients fails to utilize optimal cvd risk reduction measures in a timely fashion, perhaps missing an opportunity to reduce long-term morbidity and mortality from cvd in this at-risk population. background: cardiovascular (cv) risk reduction has been a primary reason for pursuing early corticosteroid withdrawal (ecswd). to date, actual cardiovascular event data (cve) (rather than cv risk) has not been reported for ecswd. therefore, we analyzed and compared actual cv events (cve) and cv-related survival in ecswd (≤ days) and chronic corticosteroid (ccs) pts. methods: cve and heart failure (hf) data were prospectively collected. cve were defined as sudden death, myocardial infarction, angina, and cerebrovascular accident/ transient ischemic attack. hf events were defined as pulmonary edema or hf diagnosis. conclusions: rtx recipients receiving ecswd experienced: ) fewer cve and ) a trend toward overall better pt survival. these differences in cve and pt survival do not present until at least yrs ptx. and therefore require long term followup to become evident. abstracts immunohistochemistry was performed for cd + and cd + cells. results were compared with those of the patients on maintenance is (gr-is n= ) and the liver tissue from normal subjects (gr-normal n= ). results: the follow-up time in gr-tol was longer than that in gr-is.(gr-tol and gr-is: m and m, p< . ) in gr-tol, typical features of neither acute nor chronic rejection were observed following banff criteria. the extent of graft fibrosis in gr-tol, however, was greater, than those in gr-is and gr-normal (gr-tol, gr-is and gr-normal ; . , . and (ishak's modified staging )(gr-tol vs. gr-is, gr-is vs.gr-normal p< . ). each number of cd + and cd + cells in graft infiltrates was increased in gr-tol, compared with that in gr-normal, but equivalent with that in gr-is (cd + gr-tol, gr-is and gr-normal ; . , . and . cells/field, gr-tol vs.gr-normal p< . , gr-tol vs.gr-is ns / cd + gr-tol, gr-is and gr-normal; . , . and . cells/field gr-tol vs.gr-normal p< . , gr-tol vs.gr-is ns). conclusions+discussion : in tolerant graft after pediatric living-donor ltx, neither acute nor chronic rejection was observed, but fibrosis developed. because of the similar extents of cd + and cd + cells infiltrates and different follow up time between tolerant and immunosuppressed patients, it remains questionable whether fibrosis in tolerant graft is antigen-dependent. serial protocol biopsy before and after starting weaning is will detect fibrosis early, and observing whether reintroduction of maintenance is reverses fibrosis in that case will answer this question. operational tolerance may not always guarantee intact graft morphology. development of "operational tolerance" after pediatric liver background : in the setting of our pediatric living-donor liver transplantation (ltx), % of all the patients (significantly higher proportion, compared with those of other transplant centers) achieved complete withdrawal of immunosuppression (is), which is reffered to as "operational tolerance". nonetheless, some patients encountered rejection while they were undergoing weaning from is. it is,therefore,essential to identify and characterize the differences that will enable patients in these two distinct populations to be distinguished reliably. methods: the study groups consisted of group tolerance(gr-tol) in which patients are successfully weaned off from is, and group rejection (gr-rej) in which patients experienced clinically evident rejection during or after weaning process. the correlation between the clinical outcome (success or failure of weaning is) and following parameters was assessed ; donor/recipient age, donor/recipient gender, abo compatibility, hla mismatch, graft size, early (< month) rejection episode and initial immunosuppression.results: there was no difference between gr-tol and gr-rej with respect to donor/recipient age (gr-tol and gr-rej; y and y ns/ m and m ns), or donor/recipient gender (gr-tol and gr-rej (female); % and % ns/ % and % ns). abo compatibility did not differ between the two groups(gr-tol and gr-rej (i dentical:compatible:incompatible); %: %: %and %: %: % ns).the presence of hla-b mismatch was more frequent in gr-tol than that in gr-rej (gr-tol and gr-rej; % and % p< . ), while the presence of hla-a or dr mismatch did not affect success or failure of weaning is(hla-a gr-tol and gr-rej; % and % ns, hla-dr ; % and % ns). graft size did not differ between the two groups(gbwr gr-tol and gr-rej; . % and . % ns). the patients in gr-rej experienced early rejection more frequently than those in gr-tol(gr-tol and gr-rej; % and % p< . ). mean trough level of tacrolimus within days after ltx was compatible between the two groups (gr-tol and gr-rej; ng/ml and ng/ml ns). conclusions: development of operational tolerance after pediatric ltx was associated with the absence of early rejection and the presence of hla-b mismatch between donors and recipients. auxiliary partial orthotopic liver transplantation (apolt) in children with fulminant hepatic failure. patients with fulminant liver failure (fhf) who undergo auxiliary partial orthotopic liver transplantation (apolt) have a chance to come off immunosuprresion (isp) when the native liver regenerates. it may be most beneficial for children with fhf; however, the literature regarding its use in children has been limited. from the beginning of the pediatric liver transplant program at our institution, patients underwent liver transplantation for fhf. of those, received apolt and the remaining standard liver transplantation (olt). seven children (age months to years) who received apot (apolt group) were compared to matched control group of patients (olt group). since apolt was offered routinely at out instituting since , of apolt cases were done since . in apolt group, either left lateral segment or left lobe graft was used. recipients left lobe was removed in all cases. in olt group, received whole liver graft and received partial liver graft. all native livers showed submassive to massive necrosis at the time of transplant in pathology. all children ( %) in apolt group are currently alive with a median follow up of days (range - days) where ( %) patients are alive in olt group (median follow up days). six of children in apolt group ( %) showed native liver regeneration. first four apolt recipients ( %) are currently off isp with fully regenerated native liver. two of those patients developed complete atrophy of the graft liver, one underwent graft removal due to sepsis caused by severe rejection. one remaining patient who is off isp is displaying progressive atrophy of the transplant liver. incidence of acute rejection was % ( / ) in apolt group vs % ( / ) in olt group. other postoperative complications included hepatic artery thrombosis (hat) (n= ), bile leak (n= ), bilary structure (n= ) and bowel obstruction (n= ) in apolt group, hat (n= ), bile leak (n= ), bowel perforation (n= ), chylothorax (n= ) and aplastic anemia (n= ). median posttransplant length of stay was days in apolt and days in olt group. conclusions: apolt was safely performed in children with fhf. significant proportion of recipients displayed native liver regeneration and came off immunosuppression. natural killer cell dysfunction in pediatric acute liver failure. nada yazigi, greg tiao, alexandra filipovich, john bucuvalas. in pediatric patients, indeterminate acute liver failure (alf) accounts for ∼ % of all cases, and carries a particularly poor prognosis without transplantation. evidence exists to suggest that acute liver failure may reflect a disproportionate immune response to a common stimulus. nk cells comprise a central component of the innate immune system. we hypothesized that nk cell dysfunction (innate or secondary to an antigenic insult) plays a pathologic role in indeterminate alf. we reviewed peripheral nk cell function in a series of consecutive children cared for at cincinnati children's hospital, who met criteria for indeterminate alf as defined by the pediatric alf study group. peripheral blood testing was carried for nk cell number, cytolytic function and perforin and granzyme activity as part of our clinical alf protocol. seven of fifteen patients had nk cell dysfunction. only the severity of cholestasis was statistically higher in the nk cell dysfunction group. there was no statistical difference between the groups with respect to age, inr, or peripheral blood cell counts. of seven patients with nk cell dysfunction died in contrast to none of eight in the normal nk cell group. of the patients with nk cell dysfunction who eventually received a liver transplant, had severe early recurrence of chronic hepatitis in the graft at a year follow up. those outcomes are in sharp contrast to the group with no nk cell dysfunction where patients needed transplantation, but all had no complications both on short or long term follow up. we documented nk cell dysfunction at the time of alf diagnosis in / pediatric patients with indeterminate alf. this subgroup of patients was found to have higher: mortality, risk of infections, as well as recurrent disease in the graft. our findings suggest that nk cell dysfunction is involved in the pathogenesis of indeterminate alf. as such, it could therefore be a prime target for therapeutic intervention, with goals to rescue the patient from liver failure and /or to improve post-transplantation outcomes. background hrs is a reversible renal failure which occurs in pts with advanced liver disease and portal hypertension and is characterized by a marked decrease in gfr and rpf in absence of other identifiable causes. vasodilation theory is currently the most accepted hypothesis to explain the pathogenesis. in decompensated cirrhotics, probability of developing hrs is - %/yr and increases to % at yrs. ideal treatment is ltx. however, there is an urgent need for effective alternative tx to increase surv chances for pts until ltx can be performed. interventions that have shown some promise are vasoconstrictors in splanchnic circulation and tips. main objective was to compare efficacy of two different regimens (albumin/terlipressin resp hes/terlipressin both w/ wo midotrine) against tips whereas grf was considered as primary efficacy endpoint. pts/tx dx of hrs was based on criteria, as proposed by international ascites club. only pts with esld on the waiting list for ltx were eligible to be enrolled. pts were assigned to tx arms and randomized w/wo midotrine. volume/vasoconstrictor tx lasted for d, mitodrine was continued; follow up for d. results iia (albumin/terlipressin); iib (hes/terlipressin); iic (tips) discussion combination of volume expansion/vasoconstriction improved effectively gfr in pts with hrs. use of albumin shows no advantage compared to (cost effective) hes. although a marked improvement was observed during iv-treatment, renal fct deteriorated upon treatment withdrawal whereas pts with continued mitodrine showed superior long term outcome. we analyze our single institution experience to quantify the long-term incidence of renal failure based on month gfr compared to subsequent determinations. methods: this is an irb approved retrospective review of the prospectively maintained database of lt recipients. exclusion: patients on renal replacement therapy (rrt) at time of transplant, combined liver kidney, fulminant hepatic failure, and < -year follow-up. gfrs (i iothalamate glofil method) were measured at initial evaluation (ie), month (m ), year (y ), (y ), (y ), (y ), and (y ). patients were grouped by gfr > (g ), - (g ), and < (g ). ie and m gfr were used as starting points for longitudinal analyses. paired data analysis for ie, m , y and y was also performed. renal failure was defined as gfr < , received kidney transplant, on dialysis, or on kidney transplant list. results: liver transplant patients were reviewed between and . paired glofil data was available for the y and y analysis in patients. m gfr correlated more with long-term renal function (p< . ). g demonstrated largest reductions in gfr over time. g and g , when corrected for patients that got kidney transplantation and rrt, demonstrated progressive reduction in gfr. g , g , and g were statistically significant (p< . wilcoxon two-sample test). this study clearly demonstrates progressive decline in gfr continuing out to years after liver transplantation. m gfr correlates better with long-term renal function compared to ie gfr (not truly reflective of renal function at time of lt). if m gfr < , data showed a high rate of renal failure in our paired data analysis by y (p< . ). by correcting for patients with renal failure, the previously reported stability in gfr between y and y is not seen. analysis of grouping demonstrates that g patients at m have lower incidence of renal failure > years after lt. g and g patients will be at higher risk for renal failure each year after transplantation. introduction: calcineurin inhibitors have demonstrated efficacy in liver transplantation. however, they have a potential to impair renal function. delayed tacrolimus (tac) administration may reduce the risk of renal dysfunction. methods: a prospective study included liver transplant pts randomised to delayed introduction of tac (day ) + daclizumab (dac) (group a) or to immediate tac administration (group b). in both groups tac t was - ng/ml until week and - ng/ml thereafter. mmf was given at g/d for months, and corticosteroids (cs) at standard doses. pts with a serum creatinine (scr) > µmol/l at hours (h ) were excluded. the primary endpoint was the rate of pts with a mean scr > mmol/l at month . month results are presented. results: pts were randomised. baseline characteristics were similar. at month , mean tac t was . (group a) and . ng/ml (group b median follow-up post-tx was years ( - ). most frequent tx indications were alcoholic ( %) and hcv ( %) cirrhosis. amdrd glomerular filtration rate (gfr) was < ml/min/ , m in % (bt), % ( m), % ( y) and % ( y) of the patients. changes in gfr were then compared according to the immunosuppressive protocol: -group "cni+mmf" = a calcineurin inhibitor (cni) + mycophenolate mofetil (mmf). -group "cni" = a cni without mmf. in this group, some patients received only cni and some cni + azathioprine. there was no difference between those sub-groups, neither on rf nor on cni doses. all those patients were thus pooled. in both groups, gfr decreased from bt: - % in "cni+mmf" vs - % in "cni" at m (p= . ), - % vs - % at y (p= . ), and - % vs - % at y (p= . ). although their mean gfr bt was lower ( vs ml/min/ . m , p= . ), the decrease in rf in "cni+mmf" patients was less severe. nearly % of the patients had renal insufficiency in the years following liver tx. the reduction in the gfr is less pronounced in patients treated with mmf even if they were significantly more at risk bt. except at m, there was no difference in cni doses between the groups, suggesting that the sustained lower decrease in rf observed in "cni+mmf" may not be only explained by a cni dose reduction. acute rejection is a complex biologic process involving multiple cell types, cytokines and chemokines/chemokine receptors. we hypothesized that an mrna panel that included genes implicated in the anti-allograft response would distinguish allografts undergoing acute rejection from normal allografts with a high degree of accuracy. we tested this hypothesis by measuring levels of urinary cell mrna and peripheral blood cell mrna for cell surface proteins cd , cd , cd , cd , and ctla ; chemokines/ chemokine receptors ip , mig, cxcr ; cytotoxic attack molecules granzyme b(gb) and perforin, and immunoregulators foxp , tgf-beta and il- . gene specific primer pairs and probes were used in pre-amplification enhanced real time quantitative pcr assays to measure mrna and transcripts for s rrna. for each cell source, we used logistic regression to identify a linear function of up to log-transformed measures that would distinguish biopsies of ar patients from those of stable transplant patients. our study demonstrates that molecular signatures developed using urinary cell levels of just genes (signature , urinary cell levels of mrna for ctla , foxp , gb, cd , and mig), or a combination of urinary and blood cell levels (signature , urinary cell level of ctla mrna and peripheral blood cell levels of cd and ctla ) differentiate ar from stable biopsies with % sensitivity and % specificity. blood cell levels alone are also informative, but less so. we conclude that molecular signatures, developed from noninvasively ascertained mrna profiles of urinary cells/ peripheral blood cells, predict acute rejection with extraordinary accuracy. clinical trials to validate the predictive value of these signatures are worthy of pursuit. we have described the association of cd + b cell infiltrates in renal transplant (tx) biopsies (bxs) with acute cellular rejection (acr) and tx dysfunction (dysfx). we have also found metabolically active plasma cells (pcs) staining for s ribosomal protein (s rp) within these txs. herein, we report the significance of cd + pcs in rejection (rj) and evaluate the impact of cd , cd , and s rp on long term tx fx by calculated creatinine clearance (crcl). we studied tx bxs from pediatric (ped) patients (pts) who were bxed for suspicion of rj from nov to nov . pts were given daclizumab and maintained on prednisone, mycophenolate mofetil, tacrolimus or cyclosporine. immunohistochemical staining and quantification for cd , cd , s rp, and c d were performed under x light microscopy. bxs were classified by modified banff criteria. crcl was followed yr post-bx. cd + pcs were associated with c d-negative acr (p= . ) but not antibody mediated rj (amr, p= . ). roc analysis confirmed > cd + cells/hpf strongly associated with acr, yielding % sensitivity, % specificity, correctly classifying % and comprising total roc area . ( % ci . , ). higher cd counts at bx correlated with worse tx fx (fig ) . a univariate regression model showed that cd , cd , s rp and time were associated with a decline in tx fx at bx. multivariate model showed that cd , cd , and time had the main effects on crcl decline, with s rp dropping out. all patients regardless of rj status had a ml/min/ . m crcl decline exerted by time (p= . ). pts with cd had an additional sustained ml/min/ . m crcl decline seen yrs post-bx (p= . ). pts with cd also had ml/min/ . m crcl decline at bx (p= . ), but there was an interaction between time and cd that negated a sustained effect (p= . ). this study identifies a numerical threshold of > cd cells/hpf that is associated with acr and tx dysfx. infiltrating cd cells had the greatest, sustained effect on tx dysfx. we conclude that cells of the b lineage, particularly cd , play a key, but undefined, role in acr. intragraft there is now evidence that foxp + cells are not indicators of tolerance, since foxp is also increased during acute rejection. however, it is unknown whether foxp + cells are present during chronic antibody mediated rejection. moreover, the relative balance of regulatory, effector and cytotoxic pathways in chronic vs. acute injury has yet to be explored. here we addressed this issue. intragraft regulatory, effector and cytotoxic transcriptional profiles were analysed within renal transplant biopsies (n = ) classified (banff ) as displaying normal histology, chronic calcineurin inhibitor toxicity (cnitox), chronic antibody mediated rejection (camr) and acute cellular rejection (acr). granzyme b, tbet and foxp mrna were measured by quantitative pcr and foxp -positive cells were additionally quantified in graft biopsies by immunohistochemistry. distinguishing mrna profiles were analyzed in the peripheral blood (n = ). our data show that foxp mrna is increased not only in acr (p< . ) but also in camr (p< . ). expression of foxp mrna correlated tightly with the density of foxp protein-positive cells by immunohistochemistry (spearman r = . ; p < . ); foxp + cells were found in aggregates and within tubules. moreover, graft cytotoxic, effector and regulatory pathways were all found to be active in chronic as well as acute graft injury. significant increases in granzymze b, tbet and foxp mrna were observed in camr, cni-tox and acr compared to normal histology (p< . , p< . or p< . ). however, differences in the relative contribution of each pathway were evident, with significant accumulation of foxp mrna predominating in acr and granzyme b predominating in camr. thus, camr can be distinguished from both acr and cni-tox by an unfavorable intragraft granzyme b/foxp mrna ratio (p< . ). interestingly, this ratio was reversed in the blood, suggesting different migratory patterns for regulatory and cytotoxic cells between the blood and the graft.our data thus confirm that intragraft and peripheral blood foxp accumulation is also a feature of camr of kidney grafts. moreover, camr can be distinguished from other graft injury types based on its intragraft or blood cytoxicity/regulatory profile. survival of solid organ grafts depends on life long immunosuppression which results in increased rates of infection and malignancy. induction of tolerance to allograft would represent the optimal solution for controlling both chronic rejection and side effects of immunosuppression. we previously showed that operational tolerance after kidney transplantation could occur in some patient. here, the potential of high throughput microarray technology allowed us to study the peripheral blood gene expression profile associated to operational tolerance and chronic rejection in a cohort of human kidney graft recipients (n= ). microarrays were used to compare the gene expression profile of pbmc from patients with chronic rejection and drug-free operationally tolerant recipients. results have been treated using a classical statistical and a non-statistical analysis based on the identification of key leader genes associated respectively to chronic rejection and operational tolerance, either as those mostly changing their expression or having the strongest interconnections. differentially expressed genes were identified between operational tolerant patients and patients with chronic rejection. abstracts defined as missing > % of prescribed doses on mam and mems, and > sd among consecutive blood serum levels. results: participants were transplant patients (m = . + . years old, % male, . % caucasian). on the mam, . % of the patients acknowledged some non-adherence but minimized how many doses they missed. using mems technology, % had some non-adherence and specifically, . % of the participants missed doses and only % of their doses were taken within the allowable time frame. using > sd criteria for blood serum levels, % of the participants were considered non-adherent. non-adherence worsened with years since transplant. more missed (r = . , p = . ) and late doses (r = . , p = . ) on the mam and > sd among blood serum levels (r = . , p = . ) was associated with higher incidence of acute rejections. adherence data was examined for patients with documented acute rejections (n = ). sensitivity and specificity of each detection method was also examined. the mam and sd detection methods each identified non-adherence in % of the patients with acute rejections; mems did not identify any additional non-adherent patients. only % of the patients with acute rejections were identified consistently by all three adherence detection methods; all patients with acute rejections were identified by at least one method. discussion: non-adherence worsening with time since transplant and was associated with acute rejections. since no single method of detecting adherence identified all the patients with acute rejections, multi-method adherence assessments should be used to accurately capture patients who are non-adherent. non na is a leading cause of allograft loss and results from multiple factors. locus of control (loc) and beliefs regarding health have been associated with adherence in other populations. randomly chosen ktr's were interviewed using a confidential questionnaire administered by an outside investigator that included questions regarding loc, health beliefs and self-efficacy. the population was % female, % black, % hispanic, % deceased donor kidney, % diabetic, % greater than high school education, % employed, % married or cohabiting, % income < k per year, % insured by medicaid. mean age . ± . yrs, time on dialysis . ± mos, months since transplant . ± . , total meds . ± . . by pearson correlation, non-adherence (na), defined as "having missed doses of immunosuppression over the preceding months", was not correlated with race, gender, income, type of insurance, age, marital status, type of txp, mos on dialysis, time since transplant, or number of medications. na was correlated with higher education level (r= . , p= . ), current employment (r= . , p= . ), and knowledge of most recent creatinine value (r= . , p= . ). na was associated with concerns regarding prednisone (long term effects, dependency) r= . , p= . , feelings of greater personal control over illness (r= . , p= . ), and inversely correlated with powerful others loc (feeling that one's health is dependent on other people), r=- . , p= . and belief in the necessity of medication for maintenance of transplant health, r=- . , p= . . we conclude, in our population of inner-city patients: . na is not associated with standard demographic factors including income, race and gender. . contrary to findings in other populations, na is associated with higher education and current employment. . na is associated with knowledge about creatinine value, concern regarding long-term effects of prednisone and disbelief in the importance of transplant medications. . na is associated with feelings of personal control and feeling that powerful others (e.g. health care providers) are not of high importance in the outcome of illness. . education programs designed to address na in this population should be targeted towards altering negative beliefs regarding medications and stress the importance of partnering with the transplant team for optimal long-term outcome. purpose: the present study aimed to prospectively examine the relationships among nonadherence, health-related quality of life (hrqol), and family factors in adolescent kidney, liver, and heart transplant recipients. method: adolescent transplant recipients aged to years (m = . , sd = . ; % female; % kidney, % liver, % heart) and their parents participated. at baseline and -month follow-up assessments, adolescents and their parents independently completed phone interviews assessing self-/proxy-reported medication adherence, hrqol, and family cohesion and conflict. medical record reviews were conducted to obtain current medications, immunosuppressant drug assays, and clinical outcomes in the past year (i.e., rejection episodes, hospitalizations, graft loss). results: at baseline, adolescents classified as nonadherent based on self-report and tacrolimus standard deviation (sd) reported significantly lower general health perceptions (f( , ) = . , p < . ), self-esteem (f = . , p < . ), mental health (f = . , p < . ), and behavior hrqol (f = . , p < . ) compared to adolescents classified as adherent. similarly, parents of adolescents classified as nonadherent reported significantly lower physical functioning (f = . , p < . ), self-esteem (f = . , p < . ), and behavior hrqol (f = . , p < . ) for their adolescents. family conflict was correlated with adolescent report of behavior (r = -. , p < . ), physical functioning (r = -. , p < . ), self-esteem (r = -. , p < . ), and mental health hrqol (r = -. , p < . ). family conflict was correlated with parent report of behavior (r = -. , p < . ) and physical functioning (r = . , p < . ). improvement and deterioration in hrqol from baseline to -month follow-up is currently being examined. it is expected that increased family conflict and decreased medication adherence will be associated with deteriorations in hrqol. the interrelationships between medication adherence, family conflict, and hrqol domains such as self-esteem and mental health suggest that interventions targeting these domains may result in improvements in medication adherence behavior. the use of cam in general is associated with non-disclosure by patients to physicians. randomly chosen ktrs were interviewed using a confidential questionnaire administered by an outside investigator, including questions on cam usage, whether it was doctor-recommended, and whether the patient disclosed use. cam was defined as ingestion of herbal or other preparations, use of mind-body techniques or manipulation of the body for healing by someone not an allopathic medical provider. use of vitamins and spirituality were excluded. the population was % female, % black, % hispanic, % deceased donor kidney, % diabetic, % > high school education, % employed, % married or cohabiting, % income < k per year, % insured by medicaid. mean age . ± . yrs, time on dialysis . ± mos, months since transplant . ± . , total meds . ± . . % of patients (n= ) used cam. by pearson r, cam use was correlated with na to immunosuppressants, p= . , r= . , blood sugar-lowering medications, p= . , r= . , and cholesterol lowering medications, p= . , r= . , worries about long-term effects of medicines, p= . , r= . , belief that doctors place too much trust in medication, p= . , r= . , and that natural remedies are safer than medicines, p= . , r= . . cam use was inversely related to belief that health depends on allopathic medicines, p= . , r= - . , medicines protect from worsening disease, p= . , r= - . , and that following doctors orders is the best way to stay healthy, p= . , r= - . , and that having a kidney transplant makes them feel happy, p= . , r= - . . we conclude, in our population of inner-city patients: . use of cam is correlated with medication non-adherence. . patients who use cam are more worried about long term effects of medication, believe that natural remedies are safer than medications and that doctors place too much trust in medication. . patients who use cam do not believe that their health depends on allopathic medication, that medicines protect from worsening disease, or that following a doctor's orders is the best way to maintain optimal health. . patients who use cam are less happy with their kidney transplant. . disussing cam use and motivation for use is important in the transplant clinic and may alert the provider to possible risk for non-adherence. by multivariate cox analysis the risk of tg related to the presence of hla-iiab death censored graft loss occurred in . % of patients without tg and in . % of patients with tg (p< . ) hla-iiab are associated with higher risk of tg and reduced graft survival. furthermore, the risk of tg and its prognosis relate to the level of hla-iiab quantitated in a solid phase assay term survival of cardiac allografts in wild-type mice by alloantigen (alloag)-specific foxp + cd + cd + natural regulatory t (nt reg ) cells. guliang xia, jie he methods: fresh naive cd + cd + nt reg were isolated from congeneic b .pl mice via automacs and enriched for alloag specificity by in vitro culture with either anti-cd / cd -coated dynabeads (d - ), then donor bone marrow-derived dendritic cells % (d+ ) for dc/beads-expanded nt reg , while total fold of expansion of nt reg remained similar ( . ∼ . for beads/dc-or . ∼ . for dc/beads-expansion) regardless of the presence or absence of tgf-β. introducing ra ( nm) into bead/dc-based, tgf-β/ il- -conditioned culture resulted in marginal improvement with . % (d+ ) nt reg being foxp + . in mlr assays, nt reg expanded with tgf-β/il- exerted more potent suppression than cells conditioned with il- alone. in vivo, beads/dc-expanded, tgf-β/ il- -conditioned nt reg synergized with transient host t cell-depletion (anti-thy . mab i.p. µg at d- & µg on d+ ) in c bl/ mice to suppress balb/c heart allograft rejection with . % (n= ) and % (n= ) allografts surviving over days when x or x cells/mouse were injected immediately post-transplant, respectively. anti-thy . treatment alone led to only . % long-term survival. infused nt reg survived long-term ( . % circulating t cells ( x cell dose) or . % ( x cell dose) at d+ post-transplant) and expressed high level foxp ( ∼ %) in vivo. long-term surviving allografts showed characteristics of 'acquired immune privilege' with cellular infiltrates that were foxp + , tgf-β + , il- + and indoleamine , -dioxygenase (ido) + , although signs of mild to moderate chronic rejection were still evident conclusion: t-bet deficiency results in up-regulation of il- expression in addition to th associated cytokines resulting in acceleration of chronic rejection despite profound deficiency of ifn-γ. t-bet deficiency may contribute to the alloimmune responses independent of ifn-γ by in situ hybridization, tir mrna level was higher (p< . ) in cortical tubuli, glomeruli, perivascular and peritubular areas of kidney grafts at , and - d post-tx, than in naive kidneys. to assess how local expression of tir affects the outcome of kidney grafts, we transplanted tir -/-b x kidneys into dba/ mice. most ( %) recipients of tir -/-kidneys rejected their grafts with a median survival of . d (n= , p< . vs wt) and had more severe graft dysfunction (bun levels) at day , and - days post-tx, than recipients of a wt allograft (p< . ) opticept trial: efficacy and safety of monitored mmf in combination with cni in renal transplantation at months. r trough-based dose adjustments were made in the mmf cc arms. antibody induction and/or corticosteroids were administered according to center practice. primary endpoints were the proportion of patients with treatment failure (biopsy-proven acute rejection [bpar], graft loss, death), and mean percent change in calculated glomerular filtration rate (gfr; nankivell equation) at months. safety endpoints were incidences of adverse events (aes) and serious aes baseline characteristics did not differ among treatment groups with living donors accounting for approximately % of grafts. % received tacrolimus (tac) and % cyclosporine (cya): cni doses and levels were significantly lower in group a. mmf doses were greater in cya-treated subjects in all groups cya treated patients and in group a (p= . ); stability of renal function over time was greatest in group a. despite higher mmf doses in group a (p< . ) at most time points, significantly fewer mmf withdrawals occurred in group a vs. groups b and c. conclusions: a concentration-controlled mmf and reduced level cni regimen is not inferior to that of fixed-dose mmf and standard-dose cni as regards bpar and other end points. this regimen facilitated higher mmf dosing without an overall increase in adverse effects, and with a trend toward preservation of kidney function versus standard-dose cni regimens comparison at one year of interstitial fibrosis (if) by automatic quantification in renal transplant recipients with cyclosporine (csa) discontinuation and sirolimus (srl) introduction introduction: we previsouly reported the clinical results of a multicentric study showing that csa conversion to srl at week (w) is associated with a significant improvement in renal function. using routine renal biopsy (rb) performed at w during this study routine rb was performed at w . for each rb, a section was imaged using a colour video camera and analyzed by a program of colour segmentation which automatically extracts green colour areas characteristic of if. results were expressed as percentage of if and grade according to banff classification. results: male donor gender was associated with higher if ( ± % vs. ± %, p = . ). if was numericaly higher in patients who had experienced acute rejection ( ± %, n = vs. ± %, n= , p= . ) there was a positive correlation between renal function and the percentage of if on rb (p= . ). despite significant improvement of renal function at w in the srl group intent to treat (n= ) mean if (%) grade i (%) grade ii (%) grade iii (%) sirolimus (n= ) conclusion: despite significant improvement in renal function after csa to srl conversion at months, we found no difference of if on rb at w . the observed improvement of renal function may be due to a hemodynamic effect. a longer delay may be necessary to observe histological improvement. the higher if score than the one previously reported by others may be explained by the use of expanded criteria donors abstract# effects of cni or mmf withdrawal on carotid intima media thickness in renal transplant recipients methods: we included stable renal transplant patients on cni-based immunosuppression, including steroids ( mg/d) and mmf ( g/d), who were randomized to mmf-withdrawal (group a: csa-auc ng*h/ml) or cni-withdrawal (group b: auc-mpa µg*h/ml). patients were treated for traditional risk factors according to stringent predefined targets. ambulatory bloodpressure (abpm), lipids, estimated creatinine clearance (mdrd) and imt were measured at baseline and after months. results: groups were comparable with respect to demographic characteristics, immunological profile, renal function, systolic and diastolic bloodpressure and lipids. mean duration of follow-up was . ± . months. only patient ( . %) in group b and patients ( . %) in group c experienced acute rejection despite adequate exposure (p= . ). imt did not change final renal function outcomes from the spare-the-nephron (stn) trial: mycophenolate mofetil (mmf)/sirolimus (srl) maintenance therapy and cni withdrawal in renal transplant recipients purpose: to compare the effect on renal function of maintenance immunosuppression with mmf and srl to that of mmf and a cni in renal allograft recipients. methods: in a -year open-label, prospective, randomized, controlled, multicenter study, subjects maintained on mmf and a cni were randomized - days posttransplantation to either mmf ( - . g bid) plus srl ( - mg followed by ≥ mg/ day results: outcomes of the first subjects receiving mmf/srl and receiving mmf/cni (tac, n= ; csa, n= ) completing year of follow-up will be reported here. final outcomes of all subjects will be presented at the congress. mean time from transplant to randomization in both groups was days. groups were similar at baseline for all reported renal function endpoints after months of therapy, maintenance immunosuppression with mmf/ srl after cni withdrawal appears to preserve renal function when compared with a mmf/cni-containing regimen improved outcomes after de novo renal transplantation: -year results from the symphony study. h. ekberg, h. tedesco-silva frei, y. vanrenterghem, p. daloze, p. halloran at years, the rate of uncensored graft loss was lowest in patients receiving tacrolimus ( % vs - % in other groups; kaplan-meier estimates). gfr at the end of the core study was slightly better in the follow-up itt patients ( - ml/ min) than in the core study itt patients ( - ml/min), suggesting inclusion of betterperforming patients in the follow-up. renal function was generally stable over year . a slight improvement in gfr in the sirolimus group (+ . ml/min) was observed, whereas the tacrolimus group still had superior gfr ( vs - ml/min in other groups). conclusions: in follow-up patients, renal function was stable during the second year and gfr differences were less marked than at year a prospective randomized study of alemtuzumab vs rabbit anti-thymocyte globulin induction in kidney and pancreas transplantation gautreaux, s. iskandar, p. adams, r. stratta. surgery; medicine; pharmacy alemtuzumab (alem) and rabbit anti-thymocyte globulin (ratg) are the most commonly used t-cell depleting induction agents in kidney (k) and pancreas (p) transplantation (tx) expanded criteria donors (ecd) were included. results: between / / and / / pts enrolled and pts were transplanted. of pts, ( %) had ktx alone, ( %) kptx, and ( %) paktx. of ktx alone, ( %) were deceased donor, and ( %) were ecds. recipient age, race, re-tx abstract# purpose: to determine the impact of alginduction on long-term outcomes post-renal tx. methods: between / and / , consecutive adult pts received a deceased donor renal tx at a single institution results: the incidence of acute rejection was lower in gr. ( % vs. %, p< . ). the incidence of cmv infection was % in gr. and % in gr. (p=ns). the overall incidence of cancer was abstract# single-dose induction with rabbit anti-thymocyte globulin (ratg) safely improves renal allograft function and reduces chronic allograft nephropathy clifford miles, gerald groggel, lucile wrenshall. divisions of transplantation and nephrology we conducted a prospective, randomized trial in renal transplant recipients comparing two dosing protocols [single dose ( mg/kg) vs. divided doses ( . mg/kg for doses)] of rabbit anti-thymocyte globulin (ratg; thymoglobulin®). we present herein the results of the first patients throughout the first months post-transplantation, recipients of kidneys from non-marginal deceased donors derived the greatest benefit in renal function (egfr) from the single-dose regimen (p = . ). the incidence of chronic allograft nephropathy (can) was also lower in the single-dose group, in both clinically-indicated and protocol biopsies combined (p = . ) and in -month protocol biopsies alone high risk (race, pra) ( %) in multivariable regression, allograft failure strongly predicted increased risk of subsequent cve. among listed candidates, receipt of a transplant was associated with significant time adjusted for baseline factors, cve after transplant predicted increased risk of subsequent mortality: hr . (ci . - . ) after is microalbuminuria post-renal transplantation is related to inflammation and cardiovascular risk our objective was to define the relationship between microalbuminuria and these risk factors in stable rtr. methods: over one year, we identified stable rtr who were at least months post-transplant and provided successive urine albumin-to-creatinine ratio (acr) measurements, excluding those with recent illness and overt proteinuria. microalbuminuria was defined as averaged acr ≥ . in men and . in women (cda ). framingham-based traditional as well as novel cardiovascular risk factors associated with microalbuminuria were determined by univariate (p < . ), followed by stepwise backwards elimination (p > . ) multivariate logistic regression analysis microalbuminuria did not correlate with prior acute rejection, delayed graft function, or any specific antihypertensive or immunosuppressive agents. conclusions: post-transplant microalbuminuria is highly prevalent and is associated with elevated crp, elevated bp, and smoking. its relationship to these other factors suggests that it reflects an inflammatory state in otherwise stable patients and thus may indicate graft and patient health the first year after kidney transplantation (tx) is associated with increased mortality relative to dialysis. early post-tx deaths are often cardiovascular (cv) and frequently occur after the first week post-tx. ctnt is a sensitive and specific maker of myocardial injury. in this study we investigated whether ctnt relates to early post-tx survival. methods: patients received kidney tx from / to / , % from living donors. ctnt was measured during the pre-tx workup and periodically while on the tx waiting list. patients ( %) had a dobutamine stress echo (dse) and ( %) had a coronary angiogram. the combined end point of the study was death or major cardiac events. survival was censored for graft loss. results: mean age was + , % males. pre-tx ctnt level was elevated (> . ng/ ml) in % of patients other dse derived parameters did not relate significantly to survival. ctnt further stratified the risk associated with other variables. thus, among patients with ef< %, year survival was %, % and % (p= . ) in patients with ctnt < . , . - . and > . , respectively. similarly, these ctnt ranges stratified risk in patients with low albumin conclusion: an elevated pre-tx ctnt is a strong and independent predictor of reduced early post-tx survival. ctnt allows stratification of risk in patients who have other risk factors such as low ef, low serum albumin and dialysis> years. in all patients, independent of any other variables, a normal ctnt was an excellent predictor ( %) of survival abstract# validation of framingham risk assessment by actual cardiovascular event data in renal transplant recipients alloway, michael cardi, gautham mogilishetty, shazad safdar excellent outcome after liver transplantation in children with cystic fibrosis some studies have reported benefits of liver transplantation (lt) in cf patients, but large outcome studies are not available. we report the outcomes of a large cohort of cf patients undergoing lt. methods: pre and post-lt patient characteristics, post-lt morbidity and mortality, and patient and graft survival were patients age < yr) received a st isolated lt. cf patients were listed for st lt, neither waitlist deaths nor the probability of death from time of listing was different from non-cf. ( . %) cf patients underwent lt with an average followup of yrs ( - yrs) average peld: . ( . % had a peld < ), median age: . yrs ( . - . ) graft survival in cf patients was . %, . %, and . % at , , and yrs compared to . %, . %, and . %. rejection rates were not different ( . % cf vs . % non-cf @ yrs with % of these patients requiring dialysis. standardized height and weight scores showed no improvement over years followup in the cf patients (height z - . at tx to - . at yrs., weight z - . to - . ), but tended to improve in the non-cf group in addition, death rates from time of listing are not increased compared to non-cf patients. these data support lt as a treatment for cf liver disease, but studies investigating the lack of growth improvement and increased renal complications in these patients may further improve outcomes. abstracts full cni group. conclusion: compared to full cni, low cni/mmf a) allows renal function to recover in patients with impaired renal function at the time of ltx and b) preserves long term renal function. cni sparing in combination with mmf may become cellular islet autoimmunity influences clinical outcome of islet cell transplantation methods: twenty-one t d patients received cultured islet cell grafts prepared from multiple donors and transplanted under anti-thymocyte globulin (atg) induction and tacrolimus plus mycophenolate mofetil (mmf) maintenance immunosuppression. immunity against auto-and alloantigens was measured before and during one year after transplantation. cellular auto-and alloreactivity was assessed by lymphocyte stimulation tests against autoantigens and cytotoxic t lymphocyte precursor assays, respectively. humoral reactivity was measured by auto-and alloantibodies. clinical outcome parameters remained blinded until their correlation with immunological parameters. results: all patients showed significant improvement of metabolic control and out of became insulin-independent. multivariate analyses showed that presence of cellular autoimmunity before and after transplantation was associated with delayed insulinindependence (p= . and p= . , respectively) and lower circulating c-peptide levels during the first year after transplantation (p= . and p= . , respectively). / patients without pre-existent t-cell autoreactivity became insulin-independent, versus / patients reactive to both islet autoantigens gad and ia- before transplantation. autoantibody levels and cellular alloreactivity were not associated with outcome. conclusions: cellular islet-specific autoimmunity affects clinical outcome of islet cell transplantation under atg-tacrolimus-mmf immunosuppression bmp- is downregulated & tgfβ to bmp- ratio favors emt during acute rejection of human renal allografts allospecific cd + t-cells predict rejection risk and measure immunosuppressive effect after abdominal organ transplantation in recipients methods: allospecific cd +t-cells were measured in < hours with polychromatic flow cytometry to identify rejectors (who had experienced acute cellular rejection within days post-transplantation) in single mixed leukocyte responses (mlr) from cross-sectional recipients- children with liver or intestine allografts, and adults with renal allografts. where possible, results were correlated with proliferative alloresponses measured by cfse-dye dilution (n= ), allograft biopsies (n= ), and expression of ctla , a negative t-cell costimulator, which antagonizes cd -mediated effects (n= ). results: in the first children, logistic regression identified donor-specific, memory cd + t-cytotoxic cells (tc) as enhanced among rejectors, compared with non-rejectors ( ± vs ± per , cells, p= . ), relatively drug-resistant (r with drug levels =- . , p=ns), with greatest sensitivity/specificity (> %) for rejectors noninvasively developed molecular signatures accurately predict acute rejection of human renal allografts greater emotional well-being (sf- ) and felt that their transplant interfered significantly less with various aspects of their life (iirs). conclusions: findings highlight the potential utility of assessing attachment style in transplant populations cni sparing in de novo renal transplantation: -year results from the symphony study one background: single center non-randomized results with steroid avoidance have shown patient and graft benefits. methods: unsensitized, primary kidney recipients, - yrs of age, were enrolled from us transplant programs ( )( )( ), in a prospective : randomized multicenter study of steroid-free (sf) vs. steroid-based (sb) immunosuppression with matched demographics. . % of sf and . % of sb were african americans and . % of sf vs. . % of sb had esrd from fsgs. sf patients received extended ( mo) vs. standard ( mo) daclizumab induction in the sb group. patients in both arms received tacrolimus and mmf maintenance. protocol biopsies were performed at , , and mo, and for renal dysfunction. primary end-points were differences for standardized height scores and biopsy proven acute rejection (bpar) at year. results at year: sf and sb patients were enrolled; sf and sb were - yrs of age. patient survival was % in both arms. graft survival was similar ( . % in sf vs. . % in sb). intent to treat median delta height sds scores from baseline for different age groups were: . for sf and . for sb in the - yr old (p= . ); . for sf and . for sb in the - yr old (p= . protection of liver ischemia reperfusion injury by silencing of tnf-α and complement genes. roberto hernandez-alejandro, xusheng zhang, dong chen, xiufen zheng, hongtao sun, weihua liu, marianne beduhn, aminah shunnar, motohiko suzuki, norihiko kubo, bertha garcia, anthony jevnikar, , living kidney donation is rapidly increasing worldwide to offer a partial (?) solution for the numerous esrd wait-listed pts. in spite of properly followed guideline criteria conclusion: dcd donors are a viable source of liver allografts for transplantation. patients who receive dcd livers have outcomes comparable to subjects who receive grafts from brain dead donors. use of dcd livers from donors over years of age is accompanied by a higher incidence of retransplantation and biliary complications. background: hypothermic machine perfusion (hmp) is in its infancy in liver transplantation (ltx). potential benefits include diminished reperfusion injury and improved early function. methods: the study was designed as a phase trial of liver hmp. exclusion criteria included: multiple organ recipients, meld> , icu patients, and patients > years of age. donor livers > years, biopsy with > % macrosteatosis and dcd were also ineligible for hmp. seventeen patients were enrolled transplanted with livers that underwent hmp for - hours using dual centrifugal perfusion with vasosol solution at - °c. patient, operative and early outcome variables were recorded. we compared outcomes to matched cold stored (cs) controls from the same era. results: all hmp grafts functioned immediately by usual clinical criteria with intraoperative bile production. results are summarized in table . synergy between il- and tnfα promotes t cell alloreactivty and impairs the graft-prolonging effects of costimulatory blockade. hua shen, bethany m. tesar, wendy e. walker, daniel r. goldstein. internal medicine, yale university, new haven, ct. a novel role of th cells in allograft rejection and vasculopathy. francesca d'addio, jesus paez-cortez, m. javeed ansari, laurie glimcher, john iacomini, mohamed sayegh, xueli yuan. transplantation research center, renal division, brigham and women's hospital, boston, ma; harvard school of public health, boston, ma. introduction: transcription factor t-bet plays a crucial role in th /th development. here, we investigated the role of t-bet in th differentiation and function of th cytokines in allograft rejection using an mhc class ii mismatched model of cardiac allograft vasculopathy. methods/results: cardiac allografts from bm mice were transplanted into wild-type as well as t-bet and ifn-γ deficient c bl/ recipients. t-bet-/-mice showed significantly accelerated allograft rejection (mst= . ± . days). however, as previously reported, all ifn-γ-/-and majority of the c bl/ mice accepted grafts for greater than days. upon in vitro stimulation of recipient splenocytes by irradiated donor cells, t-bet-/-and inf-γ-/-lymphocytes produced significantly less inf-γ and more th cytokines. interestingly, production of the proinflammatory cytokines il- and il- was significantly higher in t-bet-/-( ± . and ± . pg/ml) than c bl/ ( . ± . , . ± . pg/ml, p= . and . compared to t-bet-/-) and inf-γ-/-( . ± . , . pg/ml, p= . and . compared to t-bet-/-) mice. in vivo administration of il- neutralizing antibody (mab ) significantly prolonged survival of bm hearts (mst> days, p< . compared to the . ± . days of the control igg group) in t-bet-/-mice. immunofluorescence staining of bm hearts harvested from t-bet-/-recipients indicated that both cd and cd infiltrating lymphocytes produced il- . however, t-bet-cd double knockout mice did not reject bm heart grafts, nor did the grafts exhibit chronic vasculopathy. in contrast, t-bet-cd double knockout mice rejected (mst: . ± . days). splenocytes from t-bet-cd knockouts produced significant lower il- ( . ± . ) and il- ( . ± . pg/ml) than observed in t-bet knockouts ( ± . and . ± . pg/ml) and t-bet-cd knockouts ( . ± . and . ± . pg/ml respectively) recipients when re-stimulated with donor cells, while there was no significant difference in inf-γ production. induction in the elderly transplant recipient: an analysis of the optn/ unos database. suphamai bunnapradist, steven takemoto, jagbir gill, tariq shah. medicine-nephrology, ucla, la, ca; medicine-nephrology, national institute of transplantation, la, ca.we examined the incidence and mortality implications of cerebrovascular events (cve) after kidney transplant. we also compared variations in risk on the transplant waitlist and after allograft failure. methods: we used registry data from the us renal data system to retrospectively investigate ischemic stroke (is), hemorrhagic stroke (hs) and transient ischemic attacks (tia) among , adults who received kidney transplants in - with medicare as primary payer. patients with prior indications of cve in the registry were excluded. we ascertained events from billing claims, and estimated incidence of first events by the product-limit method. at-risk time was censored at: loss of medicare, yr transplant anniversary, non-cve death or end of study ( / / ). cox regression was used to identify independent correlates of cve, and to examine cve events as time-dependent mortality predictors. we estimated cve incidence after graft failure among patients without cve diagnoses prior to graft loss (n= , ), and amongthe association between hyperuricemia at six months after kidney transplantation and the development of new cardiovascular disease, many studies have previously reported safe withdrawal of prednisone (pw) late after kidney transplantation (ktx). to determine the best immunosuppression regimen during the pw, we performed a prospective trial with stable ktx patients randomized to either csa or 's' based regimen. methods: all patients received antibody induction therapy at the time of rtx and maintained on csa, p and cellcept®. patients excluded if they had > acute rejection, > gm/d proteinuria or serum creatinine > . mg/dl. patients were enrolled and data presented for patients with > weeks follow-up (f/u) with mean f/u of . ± . weeks. no differences observed in baseline characteristics in both groups. all patients then randomized to either csa (n= ) or 's' (n= ) and cellcept® converted to equivalent dose of ms. csa dosed by c level ( -hour) with goal level of ng/ml. sirolimus target level was ng/ml. results: patients withdrew from study, patients on s returned to csa regimen because of side effects. patients in the csa group and patient in 's' group had ar ( of them due to drug non-compliance). death censored graft survival was %. mean csa drug level acheived was ± ng/ml and 's' drug level was . ± ng/ml. no significant differences noted in hematological values or bp measurements. csa ( purpose: the clinical significance of c d positiviity in patients with acute rejection is well defined but its significance in stable graft function is undetermined. this study was performed to evaluate the clinical outcome of protocol biopsy-proven c d positive renal transplants with stable graft function in the early posttransplantation period. methods: renal allograft biopsies were included. protocol biopsies (n= ) were performed from stable allografts on day posttransplantation, and indication biopsies (n= ) were performed from dysfunctioning allografts. incidence of c d positivity was compared between protocol and indication biopsies. clinical characteristics, biopsy findings, graft function, acute rejection episodes, and graft survival rates were compared between the c d-positive and c d-negative grafts in each group. results: c d deposition in protocol biopsies was detected in of biopsies ( . %), whereas . % ( of biopsies) in indication biopsies. the histological findings of c d-positive protocol biopsies were minimal inflammation of tubulointerstitium. on the other hand, those of c d-positive indication biopsies were various including acute humoral rejection, acute cellular rejection, acute tubular necrosis and calcineurin inhibitor toxicity. in the protocol biopsy group, graft function during year after biopsy, acute rejection rate, and cumulative graft survival did not differ between the c d-positive and c d-negative grafts. all c d-positive allografts maintained stable graft function without any antirejection therapy. in the indication biopsy group, graft function during year after biopsy and acute rejection rate did not differ between the c d-positive and c d-negative grafts. however the cumulative graft survival rate was worse in the c d-positive grafts than the c d-negative ones (p= . ). conclusion: c d positivity associated with allograft dysfunction indicates a poor graft outcome. however, c d-positive allografts with stable graft function in the early posttransplantation period take an indolent course. are methods: this was a retrospective single centre study reviewing all the adult patients who had a kidney transplant biopsy between april and october at guy's hospital. results: patients had diffuse (> %) c d staining out of who had kidney transplant biopsies in this time and had been followed up within the centre. of these patients, also had dsa prior or at the time of biopsy. the fall in egfr in this group a year post biopsy was greater than those with diffuse staining for c d but no dsa. the mean change in egfr from the day of biopsy at a year was - . ml/min/ . m (+/- . ) in those with dsa compared with + . ml/min/ . m (+/- . ) for those with c d but without dsa. the changes in egfr from the pre-biopsy baseline at one year showed a fall in egfr in both groups but this was greater in those with dsa (- . compared with - . ml/min/ . m ).of patients who never had diffuse or focal c d staining on biopsy, only had had dsa tested. of these only ( %) had a positive dsa result. from these eight, four had features of rejection and four did not. one person in each of these groups is dialysis dependant and one person in the rejection group has egfr < ml/min/ . m . although small numbers, this outcome appears to be worse than that of c d negative patients with no dsa but features of rejection who in fact showed an improvement in egfr from the day of biopsy by . m l/min/ . m or an improvement from their pre-biopsy baseline of . m l/min/ . m at one year. conclusion: dsa is of additional value in evaluating risk of graft failure. this appears to be of value in those with and without diffuse c d staining on biopsy. utility of post-transplantation flow cytometry crossmatching in predicting graft outcomes. michelle willicombe, graham shirling, ray fernando, henry stephens, paul sweny, peter j. dupont. department of renal medicine, royal free hospital, london, united kingdom; histocompatibility laboratories, anthony nolan trust, london, united kingdom. de novo development of donor-specific anti-hla antibodies after renal transplantation may be associated with increased rejection and decreased graft survival. flow-cytometry crossmatches (fcxm) have been suggested as method of screening for development of donor-specific hla antibodies post-transplantation, but interpretation of crossmatch results can be confounded by antibodies directed against antigens other than hla. we assessed the impact of developing a positive fcxm post-transplantation on clinical outcomes in a cohort of live donor renal allograft recipients. methods: patients were studied. / ( %) received tacrolimus-based and / ( %) ciclosporin-based immunosuppression. median follow-up was months. all patients had negative complement-dependent cytotoxic (cdc) t cell crossmatches pretransplantation. / ( %) in the group with a positive fcxm had an acute rejection episode in the first months compared with / ( %) in the group with a negative fcxm (p=ns). graft function at months was not different between the groups (positive fcxm -median creatinine mmol/l; negative fcxm -median creatinine mmol/l; p=ns). / grafts ( %) were lost within the first year in the positive fcxm group compared with / ( %) in the group with negative post-transplant fcxm (p=ns). the development of a positive fcxm post-transplantation alone is not predictive of adverse clinical outcomes. this may be explained by the poor correlation between a positive fcxm and the presence of antibody directed against mismatched donor hla antigens. surveillance for development of donor-specific anti-hla antibodies after transplantation may be best performed using high-resolution bead technologies rather than fcxm. use of the fcxm alone, without establishing antibody profiles, is of limited predictive value. based upon the amount of antibody (ab) measured by the titer of donor specific hla antibodies, dsa, or the fluorescence intensity (fi) of the donor specific single antigen bead. it is unclear whether abs indentified by sensitive single antigen bead and solid phase assays (flow pra and luminex) correlate with and are predictive of a clinically relevant end-point (a + fcxm). we evaluated the pra, dsa, bead specific ag fi and fcxm reactivity of pre-transplant (pre-tx) sera from recipients of a deceased donor renal allograft to determine whether amount of ab (measured by fi) predicts a (+) fcxm. patients with a (+) dsa, a (+) fcxm and pre-tx class i pra ≥ % (n = , mean pra of ± %) when compared to patients with pre-tx pra < % (n = , mean pra ± %) had comparable mean fis ( , ± , vs , ± , ) , fi ranges ( , - , vs , - , ) and median fis ( , vs , ). the class ii comparisons were of the same pattern. surprisingly, patients with a (+) dsa, a (-) fcxm and pre-tx class i pra ≥ % (n = , mean ± %) compared to patients with pre-tx pra < % (n = , mean pra ± %) had comparable mean fis ( , ± , vs , ± , ) , fi ranges ( , - , vs , - , ) we have recently showed that pre-treatment of the donor with epo causes a substantial reduction of the dysfunction and injury associated with the transplantation of kidneys recovered after cardiac death. -aminoisoquinolinone ( -aiq) a potent water soluble parp inhibitor has proven to reduce renal ischemia-reperfusion (i/r) injury. the aim of our study was to determine the effects in the graft and in the receptor of the pre-treatment of the donor with epo and treatment of the recipient with -aiq, in a porcine model of dcd kidney transplantation. material/methods: landrace pigs were killed by lethal injection; their kidneys were subjected to min of warm ischemic time (wit) and then transplanted after h of cold storage in celsior. in the pre-treated group, donors received a single dose of epo ( iu/kg) min before cardiac arrest. in the treated group, recipients received a continuous dose of -aiq ( mg/kg/h) minutes before reperfusion and maintained during minutes. blood, urine and renal tissue samples were collected at the end of the experiment for biochemical, histological and immunohistochemistry (pars, inos and cox- ) evaluation. data analysis performed with graph pad prism statistical package; p< . considered statistically significant. results:transplantation of kidneys from dcd resulted in: a significant rise of the levels of creatinine, n-acetil-b-d-glucosaminidase, glutathione-s-transferase, ast, ldh, alt, fractional excretion of na+, interleucin and , malondialdehyde levels and myeloperoxidase activity (p< . ); a significant reduction in urine flow and creatinine clearance, disturbances in the histological and imunohistochemistry pattern. administration of epo before ischemia and -aiq before reperfusion reduced significantly the biochemical (p< . ), histological and imunohistochemical evidence of glomerular dysfunction and tubular injury. they also reduced systemic injury, inflammatory response and oxidative stress. conclusions:pre-treatment of the donor with epo and treatment of the recipient with -aiq causes a substantial reduction of the dysfunction and injury associated with the transplantation of kidneys recovered after cardiac death. in the hmp group perfusate ast levels strongly correlated with recipient peak ast by linear regression (p< . ). conclusions: hmp of liver grafts provides safe and reliable preservation in our pilot series. perfusate ast may allow pretransplant prediction of reperfusion injury. a larger randomized trial will be necessary to demonstrate the magnitude of benefits of hmp over cs in ltx.purpose: liver discard rates have increased in a large, urban organ procurement organization from % to %. the reason is likely the result of increased transplant surgeon willingness to consider organs close to the margin of clinical acceptability. however, the costs associated with recovering these organs are high if the liver is discarded. we endeavored to determine whether a model based on pre-recovery data could predict liver discard introduction: we report our years experience with the use of campath- h (c h) in adult liver transplantation. from december until july we administered c h induction with low dose maintenance tacrolimus immunosuppression to adult recipients of a liver allograft. most common primary diseases were laennec (n= ), cryptogenic cirrhosis (n= ) and autoimmune: psc (n= ), pbc (n= ) and aih (n= ). the first dose of c h was administered immediately before (n= ) or after (n= ) the transplant procedure. follow up was until september, . results: five year patient and graft survival was % and % respectively. there were deaths due to stroke (n= ), chronic rejection (n= ), failure to thrive/pneumonia (n= ), sepsis (n= ), hepatic artery thrombosis, hcc, prostate cancer, graft lymphoma and non-compliance (one each). seven patients were retransplanted, for primary non function (n= ), portal vein thrombosis (n= ), hepatic artery thrombosis (n= ), hepatitis b (n= ) and chronic rejection (n= ). thirty six patients had biopsy proven rejection episodes: mild (n= ), moderate (n= ) or severe (n= ). the average tacrolimus hour trough levels were . , . ng/ml and . ng/ml for the rst, nd and th year post-transplantation, respectively. there was no significant difference in the outcome of the transplant so far, between patients that received c h before or after the transplant procedure. immunosuppression-related complications included a). opportunistic infections: most common were herpes zoster (n= ), cmv (n= ), and herpes simplex (n= ), b). neoplasms: skin cancer (n= ), kaposi sarcoma (n= ), lymphoma (n= ) and c). nephrotoxicity: five patients received a kidney graft for diabetic nephropathy (n= ), nephrotic syndrome (n= ) and calcineurin nephrotoxicity (n= ). conclusion: the use of c h induction with half the usual dose of tacrolimus is an effective regimen in adult liver transplantation. the timing of c h administration does not seem to affect the clinical outcome so far. a. david mayer, james m. neuberger. the liver unit, queen elizabeth hospital, birmingham, united kingdom. introduction: in the prospective respect study, primary liver transplant patients were randomised to of groups: a) standard-dose tacrolimus (target trough level > ng/ml) for the st month; b) g mycophenolate mofetil (mmf) iv until at least day , g po thereafter + reduced-dose tacrolimus (target trough level ≤ ng/ml); and c) mmf as in group b + reduced-dose tacrolimus introduced on day (target trough level ≤ ng/ml) + daclizumab on days and . steroids were given in all groups according to local centre protocol. results at year showed that g mmf + delayed and reduced tacrolimus + daclizumab is associated with significantly less impairment of renal function compared with standard treatment. here we present the results of the per protocol (pp) population. methods: the pp population, which was defined prior to the sub-group analysis, consisted of patients from the full analysis set who had no inclusion/exclusion criteria violation, had at least one creatinine clearance (crcl) value beyond months, were treated according to the protocol and did not receive any prohibited medication during the first days and for less than week at any time during the study. a composite endpoint comprising freedom from renal dysfunction (≥ % decrease from baseline in calculated crcl), acute rejection, graft loss or death was also investigated. results: the full analysis set included , and patients, whereas the pp population only included , and patients in groups a, b and c, respectively. the mean difference in calculated crcl from baseline to year was significantly smaller in group c compared with group a (- . ml/min vs - . ml/min, p = . ), but was not significantly different between groups a and b (- . ml/min). the incidences of death (n = , , ) and graft loss (n = , , ) were similar in all groups. the incidence of the composite endpoint at year was in both the full analysis set and the pp population significantly lower in group c compared with group a (pp population: % vs %, p < . ), but was not significantly different between groups a and b ( %). the pp analysis confirms the results from the full analysis set that g mmf + delayed and reduced tacrolimus + daclizumab is associated with less impairment of renal function compared with standard treatment with no negative effect on death and graft loss. aims: post transplant lymphoproliferative disorder (ptld) is a serious complication of solid organ transplantation that is closely associated with epstein barr virus (ebv) infection. ebv + ptld lymphomas express several latent viral genes including latent membrane protein (lmp ), a proven oncogene that is essential for human b cell transformation. lmp is able to activate erk, jnk, p , nfκb and pi k. the aim of this study is to determine whether lmp isolated from ptld tumors differs in signaling ability from lmp derived from the b. strain of ebv, originally isolated from a patient with infectious mononucleosis. methods: lmp variants isolated from a panel of ebv + ptld-associated b cell lines were cloned and sequenced. inducible chimeric constructs containing the lmp c-terminus and ngfr transmembrane domain were created for each tumor variant and expressed in the burkitts b lymphoma cell line bl . lmp signaling in bl clones was induced by crosslinking of ngfr. activation of p , erk, akt and jnk was assayed by western blotting (wb) with phospho-specific antibodies. nfκb activation was assayed by wb for iκb and cfos induction was analyzed by wb and the transam cfos binding assay. results: all three tumor variants of lmp , as well as the b. lmp isoform, were able to induce p activation within min of ngfr crosslinking while akt and jnk were activated within min. all variants showed similar ability to activate nfκb. however, tumor lmp variants induced prolonged erk activation (up to hrs) while the b. lmp variant induced a transient response. cfos is induced only during the sustained phase of erk activation. indeed, the tumor variants of lmp , but not b. lmp , were able to induce cfos protein. similarly, cfos binding to the ap consensus site was only observed in tumor lmp -induced nuclear lysates. two mutations in the c-terminus-aa (s vs g) and aa (t vs s) -are conserved in the tumor variants lmp compared to b. lmp . point mutation of either of these amino acids from the b. to tumor variant version allowed for sustained activation of erk and subsequent cfos induction and binding to the ap site. conclusion: tumor-derived lmp has enhanced ability to induce the cfos oncogene and this property can be localized to two amino acids in the c terminus. these findings suggest that these specific amino acid residues of lmp are important in determining whether ebv infection is benign or results in ptld. the absence of interferon regulatory factor- (irf- ) confers protection against the liver ischemia and reperfusion injury through an il- independent pathway. elizabeth r. benjamin, xiu-da shen, feng gao, yuan zhai, genhong cheng, ronald w. busuttil, jerzy w. kupiec-weglinski. surgery, dumont-ucla transplant center, los angeles, ca. toll-like receptor (tlr ) mediated liver reperfusion damage after warm ischemia requires signaling through the myd -independent, irf -dependent pathway with cxcl- (ip- ) playing a central role in the injury development. studies using cxcl- ko mice have shown that these mice are protected through an il- dependent mechanism. we chose to investigate irf , upstream of cxcl- , to further characterize its role in the injury progression, and to better understand the involvement of il- in this pathway. methods: we used irf ko mice and their wt counterparts in a model of partial hepatic warm ischemia with , , and h of tissue reperfusion (n= ko, wt at and h; n= ko, wt at h). wt bone marrow derived macrophages were generated and stimulated with lps to determine the kinetics of il- production. tissue was analyzed for histology and mrna levels were measured by qpcr. results: kinetic studies showed peak il- production at and h post-reperfusion (pr). on pathology, irf ko mouse livers were protected from ir injury both early pr, at and h, and at hrs pr when compared to wt. consistent with these data, il- mrna induction was decreased in irf ko, as compared with wt at , , and h. although il- induction was maintained in the cxcl- ko mice, the irf ko mice showed decreased levels of il- at h pr. by h, il- levels were normalized to wt. conclusion: irf ko mice are protected from liver ir injury with evidence of this protection as early as h pr. although cxcl- ko mice are protected from ir injury with maintained il- expression, the absence of the upstream molecule, irf , confers protection in an il- independent manner. these data suggest a novel mechanism of ir injury mediated by irf in the liver. background: bone marrow (bm) transplantation may induce donor-specific tolerance to prevent rejection of allogeneic solid organs while maintaining immunity against infections and tumors. currently allogeneic bm transplantation is limited by donor t cell mediated graft-versus-host disease (gvhd), as well as a variable requirement for recipient marrow ablation and high numbers of donor bm cells. furthermore, sustained macro-chimerism has not yet been easily or predictably achieved in partially ablated patients or large animals. while rejection of allografts is mediated primarily by recipient t cells, recent studies have demonstrated the capacity of nk cells to reject allogeneic bm and to prevent long-term mixed chimerism. thus, nk cells represent a barrier to long term bm engraftment even with t cell tolerance. we have previously identified a novel type of regulatory t (treg) cell with a "double negative" (dn) phenotype (tcrab + cd + cd -cd -). dn-treg cells can effectively suppress anti-donor t and b cell responses and prolong graft survival in allo-and xenotransplantation models. we therefore tested the capacity of dn-treg to alter nk cell function. methods: c bl/ bm cells were i.v. injected into sub-lethally-irradiated ( . gy) cb f (h- b/d) in a "parent to f " model, or into allo-disparate balb/c mice. bm cells were co-transplanted with various numbers of c bl/ dn-treg cells or cd + or cd + t cells as controls. recipient spleen cells were collected days after to detect donor progenitors in a colony-forming-unit (cfu) assay. mice then received cardiac (n= ) or skin transplants (n= ) to confirm tolerance. we found that donor-derived dn-treg cells suppress nk cell-mediated allogeneic bm graft rejection in both "parent-to-f " and fully mhcmismatched bm transplantation models. adoptive transfer of dn-treg cells with donor bm cells promoted the establishment of stable mixed chimerism and donor specific tolerance to bm donor cardiac and skin grafts (mst> days), without inducing gvhd in sub-lethally irradiated mice. perforin deficient dn-treg cells were unable to efficiently inhibit nk cell function, and donor bm did not engraft. these results demonstrate a potential approach to control innate immune responses and promote allogeneic bm engraftment and donor specific tolerance through the use of dn-treg cells.framingham risk score (frs) predicts cardiovascular (cv) risk in the general population, but may underestimate cv risk in kidney transplant (txp) patients (pts). frs has not previously been validated by prospective cardiovascular event (cve) data collection in kidney txp pts. the purpose of this study was to validate frs with actual observed cve data in kidney txp pts. methods: cve data was collected at routine intervals in our kidney txp pts and entered in a cardiovascular risk database. frs was calculated from baseline to yrs posttransplant (ptx) individual frs factors of age, sex, smoking, diabetes mellitus (dm), high-density lipoprotein (hdl), total cholesterol (tc), and blood pressure (bp) were evaluated for their ability to predict acutal cve occurring after kidney txp. pts with coronary artery disease (cad) were excluded from the frs analysis. cve were defined as sudden death, myocardial infarction, angina, and cerebrovascular accident/transient ischemic attack. frs factors were evaluated by cox proportional hazards in univariate (uva) and multivariate (mva) models. rho kinase (rok) modulates calcium sensitivity of vascular smooth muscle cells and contributes to the regulation of peripheral vascular tone in man. in essential hypertension increased rok-activity contributes to the generation of vascular resistance. arterial hypertension is a common complication in renal transplant recipients. in this study we were interested in the role of rok for systemic hemodynamics in hypertensive renal transplant recipients (tx). we tested the specific inhibitor of rok fasudil. tx and matched control subjects (c) received either fasudil ( g/min) or placebo over a period of minutes intravenously. peripheral blood pressure and heart rate were recorded every min over a total of minutes. measurements for pulse wave analysis (sphygmocor vt) were performed every minutes during this period. statistics by anova for repeated measurements.compared to placebo fasudil significantly reduced peripheral mean arterial pressure p< . ; figure ) and increased heart rate (+ . . bpm, p< . ) in tx but not in c. likewise, central systolic pressure(p= . ; (figure ), augmented pressure and augmentation index were decreased in tx only.we conclude that acute inhibition of rok by fasudil consistently and effectively lowers blood pressure in tx with a calcineurin inhibitor-based immunosuppression. interestingly, rok-inhibition also reduces central blood pressure and arterial stiffness in these patients. improvement of both these parameters has been linked to a reduction in cardiovascular morbidity and mortality in large trials. hence rok inhibition might prove beneficial for the treatment of hypertension in renal transplant recipients. use death with function causes half of late ktx failure, and cardiovascular disease (cvd) is the most common cause of death. chronic kidney disease (ckd) is a cvd risk equivalent, justifying aggressive risk reduction with blood pressure (bp) control, statins, aspirin, and use of angiotensin converting inhibitors (acei) and angiotensin receptor blockers (arb). dekaf is an nih-sponsored prospective observational study examining causes of ktx failure at transplant centers in the us and canada, with current enrollment of over subjects. we examined the use of cardioprotective medications among patients transplanted after / / with at least mos follow-up, focusing on subgroups with preexisting diabetes (dm) and/or cvd. we conducted a retrospective cohort study to asses the prevalence and the predictors for the development of hyperuricemia at months after kidney transplantation and the association between hyperuricemia and clinical outcomes including patient and graft survival, new cardiovascular events and chronic allograft nephropathy (can). adult patients who underwent kidney transplantation at mount sinai medical center between . . - . . were included. patients who died or lost the allograft within months after transplantation were excluded from analysis. of the patients with a functioning allograft at months after transplantation, patients ( %) had normal uric levels and patients ( %) had hyperuricemia. after age, race, sex adjustment, receiving a cadaveric kidney, having an egfr< ml/min, and taking diuretics and cyclosporine were associated with a higher odds ratio of hyperuricemia. over a mean of . years of follow-up, patients had one, or more, of the pooled outcomes; had new cardiovascular events, developed biopsy-proven can, patients died, and had graft failure. kaplan-meier survival curves demonstrated that the pooled outcomes of events occurred more frequently in hyperuricemic patients (figure, p < . ). due to association between low egfr and hyperuricemia, we analyzed the clinical outcomes in patients with low and normal egfr. while . % of hyperuricemic patients with an egfr< ml/min had one of the pooled outcomes, it was . % in patients with normal uric acid levels (p= . ). among patients with an egfr ≥ ml/min, . % of normouricemic and % of hyperuricemic patients had one of the events. these results suggests an important association between hyperuricemia at months after transplantation and the new cardiovascular events, biopsy-proven can, and graft loss in kidney transplant recipients with decreased allograft function. background: long-term survival after liver transplantation (lt) is now the rule rather than the exception. hence, assessment of outcomes for children after lt must consider not only the quantity, but also the quality, of life years survived and restored. aim: to examine key hrqol themes after pediatric lt raised by both recipients and their parent proxies, with evaluation by time ( - yrs, - yrs, - yrs, and > yrs) since lt. methods: semi-structured : item generation interviews were conducted in person with children (c) and parents (p) at time of ambulatory lt follow-up at pediatric lt programs in canada and uk. all interviews were audio-taped, transcribed verbatim, and subjected to content analysis utilizing qsr nvivo . software for hrqol related theme generation. the participants interviewed were part of a larger research program aimed at developing a disease-specific instrument to assess hrqol for children after lt. results: data representing ( % male) pediatric lt recipients was obtained from a total of ( c, p) item generation interviews. median recipient age at lt was . (range, . to ) yrs, for primary indications including biliary atresia ( %), fulminant liver failure ( . %), metabolic liver disease ( , %), malignancy ( . %) and others ( . %). median patient age at time of interview was . (range, . to . ) yrs. themes emerging at all time points post-lt included infection risks, limitations on physical activities, side effects from immunosuppression meds, educational supports, and ongoing bloodwork. themes identified within the medium ( - yrs) follow-up included worries about rejection episodes, need for future re-transplantation, school absenteeism, and altered sibling and family dynamics. the impact of living with a surgical scar was a more frequent theme with recipients > yrs from lt. as time from lt increased to > yrs, themes suggest a focus on normalization and health promoting behaviours, along with expressed desires to be like healthy peers. conclusions: unique hrqol themes emerged from item generation interviews not captured by currently available generic hrqol tools. hrqol themes identified after pediatric lt suggest the importance of considering time trajectories from lt, and a focus on elements of 'everyday life' apart from lt. the shortage of cadaveric donors has led many transplant centers to expand their criteria for accepting life-saving organs. utilization of donation after cardiac death (dcd) donors has been estimated to increase the number of cadaveric donors. we report our experience with a recently established dcd program at a pediatric hospital and the outcome with the transplanted grafts. methods: in a protocol for dcd was established at a free standing pediatric hospital. from to all patients undergoing withdrawal of care were evaluated for dcd. patients meeting criteria for dcd underwent withdrawal by the critical care team and organ retrieval was initiated if asystole was reached in less than minutes. in addition, one dcd liver was imported and was included in the liver results. results: during the year study period patients ( % of total donors) underwent dcd resulting in organs ( kidneys and livers) transplanted. the cases had a mean donor age of yrs (range - ), wit of min ( - ), time sbp < of min ( - ), and time from asystole to aortic flush of min ( ) ( ) ( ) ( ) ( ) ( ) ( ) . four kidneys were transplanted locally with cit - hrs, no dgf, and one month creat . - . . the remaining kidneys were exported for transplant. four livers were transplanted locally with donor age mth- yrs, wit - min, recipient age mth- yrs, cit - hrs, ast peak - , ast day - , inr peak . - . , inr day . - . , total bili one month . - . , and graft survival . - . yrs. there were no vascular or biliary complications. conclusions: a protocol for dcd at a pediatric hospital increased the number of pediatric donors by %. liver and kidney grafts from pediatric dcd donors demonstrated excellent graft function and survival. liver retransplantation in children. a year single centre experience. christophe bourdeaux, andrea brunati, magda janssen, jean-bernard otte, etienne sokal, raymond reding. pediatric liver transplant program, université catholique de louvain, saint-luc university clinics, brussels, belgium. when graft failure occurs in liver recipients, secondary transplantation represents the only chance of long-term survival. in such instance however, several surgical and immunological aspects should be carefully considered, with respect to their impact on final outcome.in the present study, the epidemiology and outcome of graft loss following primary pediatric liver transplantation (lt) were analysed, with the hypothesis that early retransplantation (relt) might be associated with lower immunologial risks when compared to late relt. between march and december , liver grafts were transplanted to children at saint-luc university hospital, brussels. among them, a total of children ( %) underwent relt, and were categorized into two groups (early relt, n= ; late relt, n= ), according to the interval between both transplant procedures (< or > days).ten-year patient survival rate was % in recipients with a single lt, versus % in recipients requiring relt (p= . ). ten-year patient survival rates were % and % for early and late relt, respectively (p= . ), the corresponding graft survival rates being % and % (p= . ). along the successive eras, the rate of relt decreased from % to %, whereas progressive improvement of outcome post-relt was observed. no recurrence of chronic rejection (cr) was observed after relt for cr ( / ). two children developed a positive cross-match at relt ( / , %), both retransplanted lately for cr secondary to immunosuppression withdrawal following a post-transplant lymphoproliferative disease.in summary, the current need for relt has been decreasing over years, with a parallel improvement of its outcome. the results presented could not evidence better results for early relt when compared to late relt. the latter did not seem to be associated with higher immunological risk, except for children with immunosuppression withdrawal following the first graft. the background: a serum conjugated bilirubin greater than umol/l (cb ), in neonates who receive parenteral nutrition (pn), has been demonstrated to be a predictor of end-stage liver disease requiring transplantation. given the recent interest in the role of omega- lipids in the development of parenteral nutrition associated liver disease (pnald), we sought to examine in a multiple variable model the role of days of maximal lipid (> . g/kg/day), in the development of this outcome. method: between and , data were collected prospectively on all neonates undergoing an abdominal surgical procedure. univariate logistic regression models for the prediction of cb were developed with the following predictors: gestational age, percentile weight, percent predicted small bowel and colonic length, resection of the ileocecal valve, presence of a stoma, post-operative enteral tolerance, number of septic episodes, days of pn amino acid > . g/kg/day, days of pn lipid > . g/kg/day, and total days of pn. univariate predictors significant at the . level were entered into a backward stepwise multiple variable logistic regression. results: infants received pn post-operatively, and developed cb . predictors that met criteria for consideration in the multiple variable model were: age (p= . ), weight (p= . ), small bowel length (p= . ), presence of a stoma (p= . ), proportion of enteral feeds post-operatively (p= . ), days of pn amino acid > . g/ kg/day (p= . ), days of lipid > . g/kg/day (p= . ), and total days of pn (p= . ).the final multiple variable model which had a negative predictive value of . % and positive predictive value of . % is presented in the table below. our model suggests a key role of pn lipids and intercurrent septic events in the development of cb from pnald. these data may provide targets, such as careful line care, reduction in maximal lipid dose, or the use of alternate lipids such as omega- fatty acids, to prevent cb an identified marker for the need of subsequent liver transplantation in infants with pnald. terminal renal failure occurs in more than % of liver transplant recipients after years. we have previously shown that, beside renal toxicity of calcineurin inhibitors, renal lesions may be related to diabetes, arterial hypertension, accumulation of hydroxyethylstarch (elhoes), and the etiology of the liver disease. we made the hypothesis that these lesions may be already present at the time of liver transplantation (lt), a finding that could lead to adapt the perioperative management. this work investigated prospectively whether renal histopathological lesions were present before lt by performing systematically a renal biopsy by endovenous route in candidates to lt with end-stage liver disease. these patients were ± years old, males ; / had a diabetes, and an arterial hypertension ; the liver disease was related to alcohol in cases, hcv in cases, hbv in cases, and to a cholestatic disease in cases. at the time of the pre-lt workup, the biochemical parameters were : child score ± , meld score ± , prothrombin rate ± , creatinin serum level ± umol/l, proteinuria . ± . g/ h. severe side effects related to the procedure were limited to cases of macroscopic hematuria, lasting less than hours. in cases, the material obtained during the procedure did not allow the histological analysis. among the samples available, were considered as normal ; in cases, lesions related to mesangial iga glomerulonephritis ( cases), diabetic glomerulosclerosis ( cases), elhoes accumulation ( cases), thrombotic microangiopathy ( case) were found, often associated ; in cases, the lesions were severe and lead to combined kidney/liver transplantation in cases. in conclusion, significant renal lesions are detectable in more than % of the candidates to lt. interestingly, histological findings often combined lesions related to the liver disease and to an associated cause (diabetes, previous treatment by elhoes or interferon). results of histological analysis could help to decide either to perform a combined renal/liver transplantation, to adapt the immunosuppressive regimen, or to abandon the lt project. . because serum creatinine is one of the components of meld, liver candidates with renal insufficiency have been transplanted in increasing numbers, with some candidates receiving a kidney along with the liver transplant. we aimed to compare the liver graft outcomes for liver alone (lta) transplants with those from combined liver-kidney transplants (clkt). a propensity score analysis was used to reduce the impact of selection bias in the comparison of outcomes in the two groups. methods. demographics, clinical factors and outcomes on lta and clkt recipients from / / to / / (n= , ) obtained from the optn database were used for the analysis. univariate post-transplant survival rates were estimated using kaplan-meier survival, and multivariable post-transplant outcomes were analyzed using a cox regression model with and without stratification by categories of the propensity score. the propensity score (probability of receiving a clkt) for each recipient was estimated using a logistic regression model. several donor and recipient factors were included in both the cox and logistic regression models. in this cohort, liver graft outcomes for clkt were significantly better than those for lta based on the multivariable analysis. the results were similar, although slightly less significant, when the model was adjusted for propensity. the superior outcomes of clkt may be due to unobserved differences between these groups of recipients, reflecting data not currently captured by the optn. effect of liver the tgfβ to bmp- ratio was higher in the ar group (median ratio: ) compared to recipients with stable graft function & normal biopsy (median ratio: , p= . ).our observations that bmp- is specifically down-regulated during an episode of ar and that the balance between tgfβ & bmp- is in favor of emt advance a mechanism for the deleterious impact of ar on the long-term outcome of human renal allografts. the non-statistical bioinformatic approach identified leader genes which define the highest interaction genes derived from the sam-gene list. an interaction map between the genes identified has been calculated. this network is formed around majors clusters: a network of interleukins and a network of signal transduction which allow us the identification of key genes such as bank , a negative modulator of cd mediated akt activation, thereby preventing hyperactive b cell response in blood from patients with operational tolerance and il r, a specific marker absent on potentially regulatory cd + cd +high t cells in blood from patients with chronic rejection. we have identified by a non-statistical analysis of the peripheral blood gene expression in human kidney recipients a cluster of genes which are strongly interconnected and which could be a starting point for further analysis of the molecular mechanisms of kidney graft operational tolerance and chronic rejection. fecal algorithm based on multiparameter mixed lymphocyte reaction assay for tailoring maintenance immunosuppressants after living donor liver transplantation. yuka tanaka, hideki ohdan, toshimasa asahara. department of surgery, hiroshima university, hiroshima, japan.background: no reliable immunological parameters exist for identifying liver allograft recipients in whom immunosuppressants can be safely withdrawn. for minimizing maintenance immunosuppressants, we established an algorithm determining anti-donor alloreactivity based on multiparameter mixed lymphocyte reaction (mlr) assay, wherein the number and phenotype of alloreactive precursorscan be quantified. we enrolled adults undergoing living donor liver transplantation (lt). the initial immunosuppressive regimen comprised tacrolimus/cyclosporine and methylprednisolone, which were gradually tapered off by months after lt. thereafter, therapeutic adjustments were determined by a policy of slow tapering off in the case of normal liver function. mlr assay was performed at month intervals to monitor immune status. in this assay, cfse-labeled pbmcs from recipients were used as responders. irradiated donor and third-party pbmcs were used as stimulators. after coculture, the responder cells were stained with cd or cd mabs along with cd mab, followed by fcm analyses. the proliferation and cd expression of cd + and cd + t cell subsets in response to anti-donor and anti-third-party stimuli were analyzed; the immune status of lt patients was categorized as hypo-response, norm-response, or hyper-response for cd + t cells and as hyper-response for cd + t cells. of the patients, had normal liver function at > months after lt. we examined the fluctuation of immunosuppressants at months after mlr in these patients. in patients whose immune status was categorized as hyper-response for cd + or cd + t cells (n= ), immunosuppressants had to be increased. in patients with norm-response immune status (n= ), immunosuppressant tapering was abandoned. immunosuppressant therapy was successfully tapered off in patients with hypo-response immune status (n= ). of patients with hypo-response immune status at > years after lt, immunosuppressants were completely discontinued in . in these "operational tolerance" patients, the precursor frequency of anti-donor cd + t cells (mean= . ± . %) was not reduced compared to that in non-tolerance patients, suggesting that donor-specific immune tolerance is maintained via inhibitory/ suppressive mechanisms rather than via clonal deletion. conclusion: multiparameter mlr assay can provide a clinically validated rule predicting the success of tailoring/weaning immunosuppression. psychological factors associated with non-adherence among adolescents before and after kidney transplant. nataliya zelikovsky. dept. of pediatrics, div. of nephrology, the children's hospital of philadelphia, philadelphia, pa.purpose: little is known about psychosocial risk factors for poor adherence among pediatric transplant patients. identification of variables that impact illness management can guide targeted interventions to improve adherence. methods: a longitudinal study was conducted to determine whether quality of life (pedsql), family functioning (fad), and parent adjustment (pip) would predict adherence in adolescent transplant patients. psychological questionnaires were administered prior to and months after the transplant. medical adherence measure (mam), a semi-structured interview was used to assess adherence. adherence was calculated as % missed and % late doses of those prescribed. results: patients (m = . years + . , % male, % caucasian) and their parents were evaluated at the time of listing for kidney transplant. the rate of non-adherence prior to transplant was high, with % of patients reporting some degree of nonadherence. of these patients, % missed and % took late > % of prescribed doses. on the quality of life measure, behavior issues were associated with missed (r=-. , p=. ) and late doses (r=-. , p<. ), and mental health issues were associated with late doses (r=-. , p<. ). adolescent reports of problems in affective responsiveness among family members was associated with missed (r=. , p=. ) and late (r=. , p=. ) doses. missed doses were also associated with mother reports of difficulties with overall family functioning (r=. , p<. ), communication (r=. , p<. ) and role definitions (r=. , p<. ) among family members. of the families were re-evaluated one year after the kidney transplant. % had been on dialysis prior to transplant and % received living-related transplants. % of the patients reported some degree non-adherence post-transplant, and using more stringent criteria, % of patients reported missing and % reported taking late > % of prescribed doses. worse quality of life such as limitations due to emotional problems (r=-. , p<. ), behavioral problems (r=-. , p<. ), and difficulties with family cohesion (r=-. , p<. ) was related to worse adherence. discussion: adolescent quality of life in behavioral and emotional domains, and family functioning play a significant role in adherence both before and after transplant. programs to improve adherence among transplant patients should incorporate psychosocial supports and behavioral interventions to improve adjustment of patients and families. kidney transplantation leads to marked improvements in health, yet transplant (tx) recipients often have difficulty with sexual functioning, which can affect quality of life. specific sexual concerns of tx recipients remain under investigated. the purposes of this study were to ) further establish the psychometric properties of the sexual concerns questionnaire (scq) including reliability and preliminary construct validity and ) identify the sexual concerns of kidney tx recipients. the scq was answered by kidney tx recipients who rated each item on a (not at all) to (extremely) scale. a cronbach's alpha correlation coefficient was calculated to determine the reliability of the scq. an alpha value of . was calculated for the questionnaire indicating it was reliable. exploratory factor analysis (efa) was performed to establish preliminary construct validity of the scq. as a result from the efa, items were dropped and a factor structure was accepted. examples of items and responses include question : "how difficult is it for your vagina to get or stay wet or moist?" (for women) and "how difficult is it for you to get or keep an erection?" (for men) and question "how comfortable are you talking about sexual concerns with your doctors and nurses?"participants were also asked to indicate how important their sexuality was to them on a (not at all) to (extremely) rating scale. twenty-six percent of participants rated their sexuality as quite a bit important, % rated their sexuality as very important, and % rated their sexuality as extremely important. the findings provide evidence of a reliable questionnaire with evidence for preliminary construct validity. they also indicate that sexuality is an important issue for a majority of kidney tx recipients. a cross-sectional study of fatigue before and after liver transplantation. james r. rodrigue, timothy antonellis, p= . # (none) to (extremely high); ♣ higher score = more fatigue, poorer sleep quality, or more mood disturbance; ¶ higher score = better qol one-third of pre-lt ( %) and post-lt ( %) patients reported severe fatigue. poor sleep quality was reported by % and % of pre-and post-lt patients, respectively. pre-lt fatigue was predicted by higher bmi (ß = . ) and meld (ß = . ), depression (ß = . ), and poor sleep quality (ß = . ), adj r = . , f = . , p < . . post-lt fatigue was predicted by older age (ß = . ), tension-anxiety (ß = . ), anger-hostility (ß = . ), and poor sleep quality (ß = . ), adj r = . , f = . , p < . . more fatigue was associated with lower sf- physical (r = - . ) and mental (r = - . ) qol. conclusions. fatigue and poor sleep quality are clinically significant problems for lt candidates and recipients. bmi, psychological functioning and sleep quality are modifiable variables that predict fatigue severity and should be targets of intervention when addressing fatigue symptoms. health literacy in kidney transplant recipients. elisa j. gordon, michael s. wolf. medicine, albany medical center, albany, ny; medicine, northwestern university. background: in order to successfully manage the transplant long-term, kidney recipients must have a basic understanding of key transplant-related concepts and terms indicative of their condition and treatment to properly communicate with health care providers and manage their health. kidney recipients must also possess numeracy skills to enable proper medication-taking and to monitor serum creatinine levels, bodily temperature, etc. the objective of this study was to examine health literacy levels among kidney transplant recipients. methods: we surveyed consecutive adult renal transplant recipients using the test of functional health literacy in adults (s-tofhla), and a modified version of the rapid estimate of adult literacy in medicine, called the "realm-transplant," which measured patients' knowledge of kidney transplant-related terms that patients are expected to have familiarity with. open-ended and multiple choice questions assessed numeracy related to kidney survival. results: most kidney recipients ( %) had adequate health literacy (s-tofhla), but % were unfamiliar with at least kidney transplant-related term (realm-t). patients who were less educated (p< . ), had lower income (p< . ), and were single or without a partner (p= . ) had significantly lower health literacy levels (s-tofhla). patients less familiar with transplant-related terms (realm-t) had less education (p< . ), lower income (p< . ), and were nonwhites (p= . ). the five least familiar terms were: sensitization ( %), urethra ( %), trough level ( %), blood urea nitrogen ( %), and toxicity ( %). sixteen percent wanted more information about their transplant. numeracy levels varied: % knew the likelihood of -year survival; % knew that half of kidney recipients have problems with the transplant in the first months; % knew the normal range of creatinine for kidney recipients; and % were aware of the risk of death within the first year of transplantation. conclusion: at this clinic, kidney transplant recipients generally had high levels of health literacy. however, most had difficulty recognizing frequently used transplantrelated terms, which could impede their understanding of health information and self-care management. greater efforts are needed to educate kidney recipients about transplant concepts, which may foster better self-care management, and ultimately transplant outcomes. abstracts by a single pathologist using the banff, cadi and cnit classifications. all indication biopsies with clinical acute rejection (ar; . % for sf and . % for sb) were excluded from this analysis. the histological and clinical parameters were assessed using multivariate generalized-estimating-equations statistical analysis. results: subclinical ar was present in . % sf vs. . % sb bx at mo and % sf vs % sb bx at mo (p=ns); borderline ar was seen in . % sf vs. . % sb bx at mo and % sf vs. % sb bx at mo (p=ns). despite the pristine condition of the kidneys at implantation, regardless of steroid exposure, there was a significant trend increase (p< . ) in chronic tubulo-interstitial damage; % of mo bx and % of mo bx demonstrated ifta; with moderate/severe changes (ifta grade - ) in . % and % of and mo bx respectively. the prevalence of biopsies with ischemic glomerular changes (p< . ), tubular microcalcifications (p= . ), vascular intimal thickening (p= . ) and the number of sclerosed glomeruli (p< . ) increased over the first year after transplantation, without any difference between the sb and sf group. a critical risk factor for ifta injury by multivariate analysis, independent of time after transplantation, was smaller recipient size. in this first ever serial histological analysis, embedded in a randomized multicenter pediatric study of steroid avoidance, we found significant progression of chronic graft injury in the first year post-transplantation in both study arms. small recipient size is the primary risk factor for tubulo-interstitial damage, likely related to vascular size discrepancies between recipient and the graft, resulting in chronic graft ischemia. in the -year symphony core study, a regimen with g mycophenolate mofetil (mmf) + low-dose tacrolimus ( - ng/ml) + daclizumab + steroids resulted in less acute rejections and better glomerular filtration rate (gfr) compared with g mmf + steroids and either standard-dose cyclosporine (csa), low-dose csa ( - ng/ml) + daclizumab or low-dose sirolimus ( - ng/ml) + daclizumab. methods: patients participated in an optional follow-up of years. gfr data from % of included patients ( % of the core itt population) were available at years.here we present results in the itt population. results: at inclusion into follow-up %, % and % of patients received csa, tacrolimus or sirolimus, and at years %, % and %, respectively. many follow-up patients had been switched to tacrolimus in the st year, including % of patients randomized to sirolimus. at years % of patients were on mmf and % on steroids.over the nd and rd year all arms had a low rate of biopsy-proven acute rejection (bpar; - %) and of graft loss ( - %). low-dose tacrolimus remained clearly superior in terms of bpar ( % vs. %- % in the other arms). uncensored -year graft survival was % with low-dose tacrolimus and low-dose csa, % with standarddose csa and % with low-dose sirolimus (p= . ). patient survival was between % and % (p= . ). in the four arms, the mean gfr change over the nd and rd year was between + and - ml/min and low-dose tacrolimus still had the highest gfr ( vs - ml/min, p= . ). observational follow-up results based on approximately half of the core symphony population indicate that during the nd and rd year renal function was stable, bpar and graft loss rates were low and many patients changed treatment regimen substantially. still, the itt arm with g mmf + low-dose tacrolimus + daclizumab + steroids was superior at years with respect to renal function and graft loss but differences were less marked and statistically not significant. discovering histological evaluation of time zero donor kidney biopsies has not conclusively predicted graft outcome. we hypothesize that gene expression analysis could provide additional information to determine graft outcome in the first year of transplantation. to this end, we evaluated all implantation biopsies obtained post reperfusion in deceased donors (dd) and living donors (ld) at our center. biopsies were evaluated and scored using banff criteria. low density real time pcr arrays were utilized to measure intragraft expression of genes associated with programmed cell death, fibrosis, innate and adaptive immunity, and oxidative stress signaling. results of expression were defined as folds compared to a pool of normal kidney biopsies. in dd, histological features of atn were more common ( %) than in ld grafts ( %; p< . ), whereas arteriosclerosis was infrequent in both groups ( % and %, respectively), as well as the extent of glomerular sclerosis ( % and %). there was no association between these histological features and renal function at year post transplant. not surprisingly, dd grafts displayed a pattern of gene expression remarkably different from ld, including an increased expression of complement protein c ( background: isa is a novel calcineurin inhibitor (cni), developed using a pharmacodynamic approach for use in autoimmune disease and solid organ transplantation. in moderate to severe plaque psoriasis, a canadian phase iii trial has demonstrated that isa is efficacious with minimal changes to renal function and a european trial is presently underway comparing isa to cyclosporine a (csa).in renal transplantation, a phase iia study comparing isa to csa in stable renal transplant recipients demonstrated isa to be efficacious and well tolerated. a phase iib study in de novo renal transplant patients comparing isa to tacrolimus is ongoing and final data will be available may . we hypothesize that isa is non-inferior to tacrolimus in terms of efficacy.methods: this is a month, randomized, multicenter, open-label, concentrationcontrolled study comparing three oral isa dosing groups ( . , . , or . mg/kg bid) to tacrolimus in north american transplant centres. all cni's were titrated to target trough concentrations. inclusion criteria included males and (non-pregnant) females between the ages of - who were receiving a first deceased or living donor renal transplant. cold ischemia times were to be ≤ hours, and peak panel reactive antibodies ≤ %. the primary efficacy parameter of the trial is non-inferiority (in at least one dose group) in biopsy proven acute rejection (bpar) at months as compared to tacrolimus. secondary objectives include: renal function; pk/pd relationships; patient and graft survival; and proportion of patients with hypertension, hyperlipidemia or new onset diabetes mellitus (nodm).results: interim data, as previously presented at the atc, demonstrated that isa had rejection rates similar to tacrolimus (isa . mg/kg bid %, isa . mg/kg bid %, isa . mg/kg bid %, tacrolimus %) and confirmed previous results indicating an improved safety profile. patients have now been enrolled between january and june , with an optional extension to months added to the trial. a recent approval by both fda and health canada has allowed continued use of isa in these patients until commercialization. the six month final results will be available for presentation at atc . key: cord- -v glur c authors: sheng, hui h; zhang, ge g; cheung, wing hoi wh; chan, chun wai cw; wang, yi xiang yx; lee, kwong man km; wang, hong fu hf; leung, kwok sui ks; qin, ling l title: elevated adipogenesis of marrow mesenchymal stem cells during early steroid-associated osteonecrosis development date: - - journal: j orthop surg doi: . / - x- - sha: doc_id: cord_uid: v glur c background: increased bone marrow lipid deposition in steroid-associated osteonecrosis (on) implies that abnormalities in fat metabolism play an important role in on development. the increase in lipid deposition might be explained by elevated adipogenesis of marrow mesenchymal stem cells (mscs). however, it remains unclear whether there is a close association between elevated adipogenesis and steroid-associated on development. objective: the present study was designed to test the hypothesis that there might be a close association between elevated adipogenesis and steroid-associated on development. methods: on rabbit model was induced based on our established protocol. dynamic-mri was employed for local intra-osseous perfusion evaluation in bilateral femora. two weeks after induction, bone marrow was harvested for evaluating the ability of adipogenic differentiation of marrow mscs at both cellular and mrna level involving adipogenesis-related gene peroxisome proliferator-activated receptor gamma (pparγ ). the bilateral femora were dissected for examining marrow lipid deposition by quantifying fat cell number, fat cell size, lipid deposition area and on lesions. for investigating association among adipogenesis, lipid deposition and perfusion function with regard to on occurrence, the rabbits were divided into on(+ )(with at least one on lesion) group and on(- )(without on lesion) group. for investigating association among adipogenesis, lipid deposition and perfusion function with regard to on extension, the on(+ )rabbits were further divided into sub-single-lesion group (son group: with one on lesion) and sub-multiple-lesion group (mon group: with more than one on lesion). results: local intra-osseous perfusion index was found lower in either on(+ )or mon group when compared to either on(- )or son group, whereas the marrow fat cells number and area were much larger in either on(+ )or mon group as compared with on(- )and son group. the adipogenic differentiation ability of mscs and pparγ expression in either on(+ )or mon group were elevated significantly as compared with either on(- )or son group. conclusion: these findings support our hypothesis that there is a close association between elevated adipogenesis and steroid-associated osteonecrosis development. steroids are indicated for many inflammatory and autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus and severe acute respiratory syndrome. one of the most serious complications for steroid administration is osteonecrosis (on), that most frequently presents in femoral heads and often advances to subchondral bone collapse and needs arthroplasty [ ] [ ] [ ] . however, there is a high failure rate in steroid-associated on patients [ ] . prevention of on is a very important strategy. however, the unclear pathogenesis of on is still the stumbling block for developing effective prevention modalities. there are many postulations about the pathogeneses of steroid-associated on. one of them is the theory of lipid deposition, i.e. the deposited marrow fat would compress on blood sinusoids to ischemia in compartmental bone: such as increased size of marrow fat cells, fat emboli and accumulation of lipid within the osteocytes [ , ] . however, the relationship between above observation and the increase in lipid deposition remains unexplained. one possibility is that marrow lipid was a consequence of the adipogenesis of marrow mesenchymal stem cells (mscs) [ ] . results of a previous study showed increased number of small size fat cells in the early steroid-associated on, that might be derived from the adipogenic differentiation of mscs [ ] . the in vitro studies also showed elevated adipogenic differentiation ability of mscs after steroid treatment [ , ] . however, the relationship between the adipogenesis of marrow mscs and steroid-associated on remains unclear. the present study was designed specifically to compare the adipogenesis of mscs between rabbits with on and rabbits without on, rabbits with single on lesion and rabbits with multiple on lesions using our established experimental model [ ] . twenty-five - -week old male mature new zealand white rabbits with body weight of . - . kg were used in this experiment. the on induction procedure was done based on our established protocol [ ] . briefly, the rabbits were intravenously injected with µg/kg body weight of lipopolysaccharide (lps) (escherichia coli :b , sigma-aldrich, inc. usa). hours later, three injections of mg/kg body weight of methyprednisolone (mps) (pharmacia & upjohn, usa) were given intramuscularly at a time interval of hours. the rabbits were kept in cage and received a standard laboratory diet and had free access to food and water ad libitum. all animal experiment procedures described below were reviewed and approved by the animal ethics committee in the chinese university of hong kong (ref no. / /mis). dynamic mri for bilateral proximal femora and distal femora was done before lps injection (week ), one week (week ) and two weeks (week ) after mps injection using a . t superconducting system (acs-nt intera; philips, the netherlands) based on our established protocol [ ] . briefly, rabbits were placed and fixed in supine position after anesthesia. preliminary sagittal and oblique axial images were obtained to define the local longitudinal axis. the contrast-enhanced dynamic mr pulse sequence used previously established ultrafast t weighted gradient-echo sequences (turbo-field echo; philips). a total of dynamic images were obtained in s. a bolus of dimeglumin gadopentetate (magnevist; schering, berlin, germany) ( . mmol/kg/body weight) was rapidly administered automatically via the right ear vein, immediately followed by normal saline flush. signal intensity (si) was then measured in the regions of interest (rois) over the target site beneath the joint space in the mid-coronal t -weighted images. the signal intensity values derived from the rois were plotted against time as time-intensity curve (tic) using the gyroview software system (philips). the baseline value (sibase) of the si in a tic was calculated as the mean si value in the first three images. the maximum si (simax) was defined as the peak enhancement value at a given time interval of s after contrast injection. perfusion parameter was calculated namely: "maximum enhancement". "maximum enhancement" was defined as the maximum percentage increase (simax-sibase) in si from baseline (sibase). the perfusion parameter was calculated according to the following equation: mscs harvest and culture after dynamic mri measurement at week , the bone marrow was harvested from proximal femur for mscs culture based on our established protocol [ ] . mscs were cultured in basal medium containing dulbecco's modified eagle's medium (dmem) with % fetal bovine serum, % mixture of penicillin, streptomycin and neomycin (invitrogen corporation, carlsbad, usa). the cells were cultured in an incubator at °c, % humidified co for two weeks. then the cells were harvested for the following evaluations: after plating cells to a -well plate ( /cm ), the cells grew to % confluence. the adipogenic differentiation ability was induced in adipogenic medium for days ( % normal horse serum and nm dexamethasone in basal dmem medium) [ ] . first, the density of oil red o positive cells were calculated using image pro plus software (media cybernetics inc., silver spring, md); second, the intracellular lipid droplets were extracted and quantified. the cells were fixed with % neutral buffered formalin followed by incubating with % propylene glycol, then incubated with a newly filtered oil red o staining solution. after staining, the cells were rinsed with distilled water, and ml of isopropyl alcohol was added to the stained dish. aliquots of the extracted oil red o were measured at nm with spectrophotometer (ultrospec , pharmacia biotech, usa) [ ] . the cells after adipogenic induction were collected for pparγ analysis. for rna extraction, total rna was isolated with trizol reagent (gibco, usa). single-stranded cdna was then prepared from the total rna extracted, using units of m-mlv reverse transcriptase per reaction with an oligo-dt primer (promega, madison, usa). for pcr reaction, ml of each cdna was subjected to pcr reaction using rabbit pparγ primers (pparγ forward 'ccaggggccgagaaggaga ' and reverse 'aagccagggatgtttttg '). the internal control housekeeping gene gapdh mrna was also amplified under the same conditions to normalize pparγ mrna expression (gapdh forward 'gcggagccaaaagggt catcat ' and reverse ' cagccc cagcatcgaaggta gagg '). pcr was performed in a dna thermal circler (biometra, germany). the pcr products were electrophoresed on a % agarose gel in the presence of ethidium bromide and absorbance measured by densitometer (bio-rad, model gs- , usa). the ratio of pparγ to gapdh was calculated for quantitative comparison. the rabbits were euthanized with overdose pentobarbital sodium after bone marrow aspiration in two weeks. bilateral femora were fixed for days with % buffered formalin (ph . ), then decalcified with % formic acid for weeks. all the decalcified samples were embedded in paraffin, cut into µm-thick sections along the coronal plane in the proximal one-third and axial plane for the distal part. sections were stained with routine hematoxylin and eosin. five sections from each animal were examined. five fields (magnification ×) within the proximal femur in each section were chosen. the first field was located at the approximate center of the femoral head at the ligamentum teres and the remaining four fields were located at the both sides of the first field. the mean of the five fields from each section was determined to represent that section. the mean of the five sections from each animal was taken as the value for that rabbit. the mean fat cells den-sity, mean fat cells size and fat cells area would be measured with imaging process software image-pro plus . (media cybernetics inc., silver spring, md). fat cells density = marrow fat cells number in selected field/(selected field area -trabecular bone area); fat cells diameter = the total diameter of fat cells in selected field/the number of fat cells in selected field; fat cells area = the area of all fat cells in selected field/(the selected field area -trabecular bone area) [ , ] . the entire areas of each dissected part of bilateral femoral samples, including epiphysis and metaphysis, were examined for the presence of on. diagnosis of on was blindly made by two pathologists based on the characteristic histopathological features with diffuse presence of empty lacunae or pyknotic nuclei of osteocytes in the bone trabeculae, accompanied by surrounding bone marrow necrosis [ ] . all rabbits that had at least one on lesion in the examined areas were considered to be on + , while those without on lesion were considered to be on -. the on + rabbits were further divided into sub-single-lesion group (son group: with one on lesion) and sub-multiple-lesion group (mon group: with more than one on lesion). the differences between on + and ongroup, mon and mon group were analyzed by nonparametric mann-whitney test using spss software . (spss inc., chicago, il, usa). the results are expressed as the mean value ± standard of deviation. statistical significance was set at p < . . no rabbits died during the entire experiment period. of the rabbits, were found on + ( %) and were on -( %). of the on + rabbits, rabbits had only one on lesion and were classified to son group, rabbits had more than one lesion and were classified into mon group. histologically, on lesion showed accumulation of marrow fat cells debris and bone trabeculae with many empty lacunae (figure ). for "maximum enhancement" in proximal femora, the rabbits in on + and mon group showed a continuous decrease with time. the on + group showed a . % decrease as compared with onrabbits (p < . ). the mon group showed a % decrease as compared with son group (p < . ) at week two ( figure ) ; similar pattern was found in distal femora (data not shown here). the fat cells density was ± /mm in on + group, increased by . % as compared with ongroup ( ± /mm ) (p < . ). it was ± /mm in mon group, much larger as compared with son group ( ± mm ) (p < . ). the mean fat cells diameter was . ± . mm in on + group, and . ± . mm in ongroup (p > . ). there were no significant difference found in fat cells size between son and mon group (p > . ). the fat cells area was . ± . % in on + group, which was . % larger than ongroup ( . ± . %) (p < . ); the fat cells area in mon group was . ± . %, which was % larger than son group ( . ± . %) (p < . ) (figure ). the cells accumulated triglycerides vesicles, that was small initially and increased in size with time. the number of adipocytes in on + group was % more as compared with ongroup, % more in mon group as compared with son group(p < . ). the optical density results showed % more triglycerides formation in on + group as compared with ongroup, and % more in mon group as compared with son group (p < . ) (figure ). figure blood perfusion assessed by dynamic mri for maximum enhancement and time-signal intensity. (a) maximum enhancement at the examined sites (both proximal femora and distal femora, the similar pattern was found, data not shown here for distal femora) showed a significant decrease from baseline in on + rabbits at week after steroid induction. there were significant decrease in maximum enhancement between on + and ongroup, mon and son group at week (p < . ). (b) representative time-signal intensity curves from contrast-enhanced dynamic mri on proximal femur. the time-signal intensity curve showed a significant decrease in enhancement slope in on + group as compared with ongroup at week . histopathological features of osteonecrosis in on+ group the pparγ mrna expression in on + group was % higher as compared with ongroup (p < . ), and % higher in mon group as compared with son group (p < . ) ( table ). the present study provides for the first time the evidence on a close association between the adipogenesis of mscs and steroid-associated on development during early stage. a close association between elevated adipogenesis of mscs and steroid-associated osteonecrosis occurrence. in the present study, the mscs showed elevated adipogenenic differentiation ability at cellular and molecular level in on + group as compared with ongroup. the histological evidence showed increased lipid deposition including larger fat cells number and fat deposition area in on + group as compared with ongroup. these suggested that the accumulation of marrow fatty tissue might come from the differentiation of mscs [ ] . at the same time, the local blood perfusion function in on + group was significant diminished at a time-dependent pattern. bone marrow lipid deposition would affect blood per- a b c fusion function even to ischemia [ , ] . these evidences showed the elevated adipogenesis of mscs was associated with steroid-associated on occurrence. a close association between elevated adipogenesis of mscs and steroid-associated osteonecrosis extension. in this study, the on + rabbits were further divided into son and mon group based on the on extension. the marrow mscs showed higher adipogenic differentiation ability in mon group as compared with son group. the histological evidence showed increased lipid deposition including larger fat cells number and fat deposition area in mon group as compared with son group. these showed that the ability of adipogenic differentiaon of mscs increased with larger on extension. at the same time, the intraosseous blood perfusion in mon group was significant decreased at a time-dependent pattern as compared with son group. these evidences showed the elevated adipogenesis of mscs was associated with steroid-associated on extension. there were few published works exploring the relationship between adipogenesis of mscs and steroid-associated on. lee studied the adipogenic ability of mscs from on patients was not able to find significant change. this difference between lee and our present study may be explained by the two reasons: first, the samples in the patients study were in a much advanced stage as compared with the on rabbit model histopatholocially, for they were receiving hip replacement surgery; second, the adipogenesis ability of mscs in osteoarthritis(oa) patients might have been elevated, this might blunt the difference between oa and on patients [ , ] . the adipogenesis of mscs, including the colony-forming unit of adipocytes was not compared between before and after steroid administration in this study. as clinical study showed core decompression would relieve on development, marrow aspiration before steroid administration might affect on development in the rabbit model. this is one of the limitations of this study. this study showed that there is a close association between elevated adipogenesis of mscs and steroid-associated on development. avascular necrosis and pulsed methylprednisolone in ra avascular necrosis of the hip in systemic lupus erythematosus: the role of magnetic resonance imaging steroidinduced osteonecrosis in severe acute respiratory syndrome: a retrospective analysis of biochemical markers of bone metabolism and corticosteroid therapy non-traumatic avascular necrosis of the femoral head fat-cell changes as a mechanism of avascular necrosis of the femoral head in cortisone-treated rabbits alcohol-induced adipogenesis in bone and marrow: a possible mechanism for osteonecrosis role of estrogens in adipocyte development and function the temporal change of bone marrow fat cells in the process of steroid-associated-osteonecrosis development pluripotential marrow cells produce adipocytes when transplanted into steroid-treated mice modulation of early human preadipocyte differentiation by glucocorticoids multiple bioimaging modalities in evaluation of an experimental osteonecrosis induced by a combination of lipopolysaccharide and methylprednisolone mesenchymal stem cells derived osteogenic cells is superior to bone marrow aspirate impregnated biomaterial complex in posterior spinal fusion maintenance of osteoblastic and adipocytic differentiation potential with age and osteoporosis in human marrow stromal cell cultures -isoprostane increases scavenger receptor a and matrix metalloproteinase activity in thp- macrophages, resulting in long-lived foam cells epimedium-derived phytoestrogen exert beneficial effect on preventing steroidassociated osteonecrosis in rabbits with inhibition of both thrombosis and lipid-deposition effects of pulse methylprednisolone on bone and marrow tissues: corticosteroidinduced osteonecrosis in rabbits bone marrow fat cell enlargement and a rise in intraosseous pressure in steroid-treated rabbits with osteonecrosis vertebral marrow fat content and diffusion and perfusion indexes in women with varying bone density: mr evaluation fatty marrow conversion of the proximal femoral metaphysis in osteonecrotic hips pathogenesis and natural history of osteonecrosis i would like to thank professor huang lin and miss winnie lee from the department of orthopedics and traumatology, the chinese university of hong kong, for their assistance in cells culture and related evaluation. this study was supported by rgc (cuhk / m) and itf (its/ / ) key: cord- -cc ph e authors: cree-green, melanie; carreau, anne-marie; davis, shanlee m; frohnert, brigitte i; kaar, jill l; ma, nina s; nokoff, natalie j; reusch, jane e b; simon, stacey l; nadeau, kristen j title: peer mentoring for professional and personal growth in academic medicine date: - - journal: j investig med doi: . /jim- - sha: doc_id: cord_uid: cc ph e mentorship is a critical component of career development, particularly in academic medicine. peer mentorship, which does not adhere to traditional hierarchies, is perhaps more accessible for underrepresented groups, including women and minorities. in this article, we review various models of peer mentorship, highlighting their respective advantages and disadvantages. structured peer mentorship groups exist in different settings, such as those created under the auspices of formal career development programs, part of training grant programs, or through professional societies. social media has further enabled the establishment of informal peer mentorship through participatory online groups, blogs, and forums that provide platforms for peer-to-peer advice and support. such groups can evolve rapidly to address changing conditions, as demonstrated by physician listserv and facebook groups related to the covid- pandemic. peer mentorship can also be found among colleagues brought together through a common location, interest, or goal, and typically these relationships are informal and fluid. finally, we highlight here our experience with intentional formation of a small peer mentoring group that provides structure and a safe space for professional and social–emotional growth and support. in order to maximize impact and functionality, this model of peer mentorship requires commitment among peers and a more formalized process than many other peer mentoring models, accounting for group dynamics and the unique needs of members. when done successfully, the depth of these mentoring relationships can produce myriad benefits for individuals with careers in academic medicine including, but not limited to, those from underrepresented backgrounds. mentorship can promote skill development, career advancement, and increased productivity. [ ] [ ] [ ] there is an inverse relationship between social or emotional support and burnout. the traditional mentorship structure of a senior mentor advising a less experienced mentee has long been a core component of academic medicine. however, the majority of faculty at us medical schools report mentoring to be infrequent or inadequate. of particular concern, underrepresented and/or subspecialized groups may lack access to appropriate mentorship that addresses their own specific needs and challenges. although best practices that address deficiencies in traditional mentorship models are not well defined, other mentorship structures and models have emerged. several formal mentorship programs with defined goals focus on underrepresented groups, and this can bolster engagement among these groups. [ ] [ ] [ ] [ ] peer mentorship among individuals of a similar rank with mutual interests or goals is another approach and may allow for more comprehensive and enduring support without hierarchical structure. this paper describes multiple types of peer mentorship programs and strategies for adapting existing formats to flexible peer mentorship models in academic medicine. there are many types of mentorship beyond the traditional hierarchical model. despite a substantial amount of literature on different mentoring models, effectiveness of peer mentorship for faculty members in academic institutions remains vastly understudied and underreported. historically, women have had more difficulty than men in finding mentors, which is troubling as mentorship influences personal and professional development and academic productivity. this may be related to lower rates of promotion for women. in a pilot study of female faculty in academic medicine, facilitated peer mentoring resulted in improvements in faculty members' perceived mastery of academic skills and numbers of peerreviewed publications, book chapters, abstracts, posters, and other academic activities. a similar program with both genders showed similar results, but with greater impact in women. in table and the following section, we share several more examples of peer mentoring groups, drawing from our own experiences and the scientific literature. the corporate world has employed formal leadership training as a strategy to optimize performance; this approach has more recently been adapted to academic medicine and includes components of peer mentorship. leadership training in academic medicine typically supports training in the skills needed for academic success. sponsors of these types of programs range from individual institutions to national organizations. the association of american medical colleges (aamc) offers careerspecific and general leadership skills programs for faculty in all stages of their careers, and categorize their offerings by career stage and skills to be gained (table ) . the aamc seminars foster peer mentoring by bringing participants together from across the country with similar career goals or demographic attributes, to encourage development of national academic peer networks. similarly, brandeis university offers a year-long program for mid-career academic medicine faculty where participants engage in facilitated peer group mentoring, with a goal of "energizing faculty for success, career advancement and leadership." this program is funded by the national institutes of health (nih, u gm ) to assess the efficacy of this peer mentoring model. in , the hedwig van ameringen executive leadership in academic medicine (elam) program was established to provide intensive -year leadership training with extensive coaching, networking, and traditional and peer mentoring opportunities tailored to the needs of women faculty. elam is aimed at expanding the national pool of qualified women candidates for leadership in academic medicine and the program achieves this goal. [ ] [ ] [ ] one of the key aspects of elam is the development of an individual institutional action plan in coordination with the dean of the elam participant's institution, as well as small-group regional peer learning communities facilitated by an elam graduate to allow support and interaction with female peers in the same geographical region during the year-long program and beyond. several institutions have developed and described their local formal peer mentorship programs, most often to aid junior faculty in the transition from trainee to faculty member. for example, the university of alabama at birmingham has a program where new internal medicine faculty can be matched with faculty who are within several years of their rank. similar programs have been described at the mayo clinic and emory university. benefits of these programs include local expertise and opportunities for frequent in-person interactions. after a -year formal peer mentorship program for women at the mayo clinic, participants reported a higher satisfaction with their job and increased abilities across multiple aspects of manuscript writing; at years, % were still working with their original peer mentor groups. programs within professional organizations expansion of a peer mentoring network to a regional and national level can also take place via engagement with national professional associations. in response to a critical need for increased representation of women and minorities in scientific and clinical leadership, multiple organizations such as the american academy of neurology, american gastroenterology association, american society of bone and mineral research, endocrine society, american diabetes association (ada), and american heart association each have formal women's leadership groups and/or diversity programs. these organizations can create a "home" for individuals across their career trajectory at larger national meetings, promote networking, recognize outstanding abstracts by women and/or minorities, and establish awards for mentorship. one of the high-impact functions of many of these groups is sponsorship: nomination of women for awards, leadership opportunities, scientific plenaries, reviews, and visiting professorships. professional organization-based groups often also share resources for formal career development training and mentoring. practically, for academic promotion, these organizations can also provide the opportunity for development of national recognition and academic relationships beyond one's home institution. many formal peer mentorship opportunities exist specifically for trainees through professional organizations, both online and/or in-person (table ) . in-person trainee meetings, such as those offered by the endocrine society, american thoracic society, american college of gastroenterology and ada, are often associated with scientific meetings, providing opportunities for attendees to meet and network with peers at similar career stages from different institutions. small group workshops allow attendees to discuss specific career issues with peers with unique perspectives, facilitated by more experienced mentors. programs such as that offered by the androgen excess and polycystic ovary syndrome trainee program have an in-person component at annual meetings and then a virtual component quarterly. online forums for trainees, such as the one offered by the american college of rheumatology, facilitate more expedient interactions for advice needed in real time, with a lower cost than in-person meetings. many training grants, both foundation-based and nihbased programs such as the k and kl programs, include peer-based training sessions and formal peer mentorship programs. the importance of these programs, in particular local kl programs, in developing lasting peer relationships was well described by dr. lovinsky-desir at columbia university. similarly, the building interdisciplinary research careers in women's health and women's reproductive health research k career development grant programs provide both opportunities for local and national peer mentorship. unique strengths of these programs are also their interdisciplinary nature and diverse faculty. the nih national institute of diabetes and digestive and kidney disease also has a multiple-day in-person meeting for k awardees. the doris duke foundation clinical scientist development award includes an annual multiple-day conference with ample opportunities for peer mentorship. the cross-disciplinary nature of grant-based peer mentorship can be particularly conducive to fostering collaborations and enriched networks for scientific innovation, promotion, and collaboration. social media has greatly changed how peer interactions occur. there are two main types of media-based interactions, those that are more interactive and those that are more informative, as listed in table . the benefits of membersonly interactive groups such as facebook-based physician mom's group (pmg) or groups on kevinmd include the opportunity to solicit and give specific advice. however, the value of this format becomes limited in larger, more heterogeneous groups. for example, pmg now boasts over , members but no longer meets the needs of some physicians who feel that it has become too large and impersonal. additional pmg subgroups based on geographic location, practice specialty, or secondary interests (eg, hobbies, member medical conditions such as autoimmune disease) allow for more focused discussions within smaller groups. many of these subgroups have extended online interactions to in-person or virtual meetings, which allow for further development of peer mentorship and the main pmg group now has annual in-person meetings. on-line platforms such as kevinmd, doximity, or online journals such as emergency medicine monthly provide timely essays on a wide range of topics on which readers can comment, though there is no formal engagement process. some of the most recent examples of peer mentorship in academic medicine evolved to share information during the covid- pandemic. topics discussed in these listservs (eg, emergency medicine physicians) and facebook healthcare provider groups have been wide-ranging, including practical advice (eg, setting up screening tents), tips for providing medical care, advocacy for governmental support, addressing the emotional burden on healthcare providers, coordinating research protocols, and assay development. groups with strict rules, such as banning political comments, are more focused. the use of social media forums may increase over time following a dramatic shift to even more virtual communication stimulated by the covid- pandemic. one of the most organic and personalized ways to form a professional support group is among colleagues that share a common environment, timeline, or professional interest. examples include trainees or faculty at a given institution and individuals who share a research or clinical interest. whether the organic mechanism uniting peer groups is geographical location or academic focus, these informal partnerships or small groups serve as an important resource to navigate personal or professional challenges and provide social support. while many will benefit from these ad hoc peer mentoring groups, their inherent lack of structure may leave some individuals with unmet expectations and exclude others altogether. this is, after all, the model of the "good ol' boys club" that leaves little space for those underrepresented in medicine. those who do not find themselves in one or more of these convenience groups may be forced to rely on other, often less personal, peer mentoring models. in the s, a small group of women decided to combat the stress and isolation commonly felt among women scientists by creating a platform for professional problem solving, outlined in the book, every other thursday. each member was encouraged to present a problem, professional or personal, that would benefit from the support and advice of peers. individuals benefited from group support by hearing others' opinions and learning lessons from their experiences. the group benefited from an inclusive culture, promoting the success and fulfillment of peers, and supporting each other during challenges. the every other thursday (eot) approach is still applicable to academic medicine today. when setting up such a group, the book outlines important recommendations (table ) , including limiting membership to eight individuals who can support others in a safe, confidential space where each individual can be present and focused on listening. the members do not need to share an academic discipline or research interest; however, they need to be committed to the group by attending consistently. these "rules" are important for the success of a group, as a satisfaction survey of a lessstructured approach to peer mentorship among women in emergency medicine identified that meetings with less defined structures could devolve into negativity. the eot small-group model has been replicated by many, with some groups publishing their structure and outcomes. female faculty at columbia university irving medical center created a group with similar themes: accountability and safe-space to promote, inspire, recharge, and empower (aspire). a mixedgender group at emory university, the internal medicine research group at emory (imerge), described that their peer mentorship group included meetings and also had a defined curricula, involved senior faculty advice events, and was coordinated formally through their department. the authors of this manuscript have also formed our own group, supporting women in the medical sciences (swims). similarities and differences between our group and eot are outlined in table . despite having diverse backgrounds, there are essential commonalities among swims members: ambitious women engaged in academic research, seeking to further career goals while integrating personal needs and commitments. members of the group have a variety of academic roles; however, an overlap in interests and professional career trajectory lend valuable insights into the systems, challenges, and opportunities we all encounter. the group includes individuals in varying stages of career development, relationships and family evolution, which brings a richness of life experience to the conversations. varying professional and personal strengths emerge in the types of advice and insights we gain from each other with examples listed in table . sometimes a consensus emerges from the group, and at other times a blended solution evolves from the mix of perspectives. a common theme in the experiences of swims members is the importance of this group as a "safe space" where there is freedom to set aside ego and self-consciousness. because the group has agreed to ground rules of confidentiality and support, a more open and accepting exchange of ideas and advice is possible. this culture of support has allowed the group to easily incorporate two new members over the past years and has maintained long-distance supportive ties to a member who moved to a new institution. swims members also note a particular benefit to having designated time for reflection and an opportunity to step back and identify areas of need where peer advice is beneficial. a summary of topics discussed, achievements, and reflections on our peer mentoring experience are in table . all members of the group have struggled from time to time with some element of "impostor syndrome." feedback from an intelligent, accomplished group of peers puts these doubts into a fresh light. our peers' perspectives are ample proof that these feelings are not consistent with the level of success we can so easily recognize in others, but sometimes struggle to honor in our own lives. much has changed in the five decades since the original eot group was formed. academic medicine has a greater percentage of women, minorities and individuals in dualprofessional relationships. junior and mid-level faculty members are also often members of the "sandwich generation," caring both for aging parents and young children. an eot group can provide much-needed support, balance, and advice. to facilitate ongoing support and advice-sharing between in-person meetings, swims has adopted a flexible, diversified, and multi-dimensional model of communication internal to our group that incorporates platforms such as group texting, a closed facebook group, and frequent email communication. the covid- pandemic began during our second swims anniversary celebration and we swiftly transitioned to virtual meetings to maintain momentum until in-person meetings could resume, underlining the utility of adjusting strategies as the situation demands. mentorship has been critical to advancement in academic medicine throughout history; however, the academic environment and its members have changed greatly since the time of socrates and aristotle. while there remains an important place for formalized, establishment-based hierarchical mentorship and support, peer mentorship is increasingly recognized as having unique strengths, particularly in fostering success of underrepresented groups. further, peer mentoring has evolved from solely in-person meetings to include electronic and social media platforms that transcend institutional, financial, and geographic barriers. here, we describe multiple types of peer mentorship available for those in academic medicine, each with different strengths and weaknesses. in an era of increasing technological connections, we advocate for the unique benefits of developing intentional small group peer mentorship in the eot model. these groups offer a customized, personal approach, allowing for discussion of confidential and sensitive topics in a supportive environment. this approach can be beneficial to anyone but are particularly advantageous to individuals underrepresented in academic medicine. we hope to have shed light on the benefits of a customized, purposeful, smaller peer mentorship group. we acknowledge that there is not a one-size-fits-all mentorship model, and perhaps it is a combination of a few different types over the course of one's career trajectory that will ultimately meet the needs of each individual. twitter melanie cree-green @cree_green contributors mc-g conceived, planned, wrote and reviewed the manuscript. all other authors planned, wrote and reviewed the manuscript. funding this study was funded by national heart, lung, and blood institute (grant no. k hl - ) competing interests none declared. patient consent for publication not required. provenance and peer review commissioned; internally peer reviewed. this article is made freely available for use in accordance with bmj's website terms and conditions for the duration of the covid- pandemic or until otherwise determined by bmj. you may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained. melanie cree-green http:// orcid. org/ - - - mentoring in academic medicine: a systematic review women mentoring women in academic medicine: pathways to success mentorship of women in academic medicine: a systematic review psychosocial and career outcomes of peer mentorship in medical resident education: a systematic review protocol medical student mentoring programs: current insights available: https://www. endocrine. org/ our-community/ career-and-professional-development/ futureleaders-in-endocrinology diversity related funding opportunity announcements mentoring programs for underrepresented minority faculty in academic medical centers: a systematic review of the literature a systematic review of qualitative research on the meaning and characteristics of mentoring in academic medicine academic advancement of women in medicine: do socialized gender differences have a role in mentoring? facilitated peer mentorship: a pilot program for academic advancement of female medical faculty long-term follow-up of a facilitated peer mentoring program a facilitated peer mentoring program for junior faculty to promote professional development and peer networking colleges aaom. aamc professional development national initiative of gender, culture and leadership in medicine: c-change evaluating a leadership program: a comparative, longitudinal study to assess the impact of the executive leadership in academic medicine (elam) program for women geographic mobility advances careers: study of the executive leadership in academic medicine (elam) program for women dental school deans' perceptions of the organizational culture and impact of the elam program on the culture and advancement of women faculty uab school of medicine early career peer mentoring group repaving the road to academic success: the imerge approach to peer mentoring the positive impact of a facilitated peer mentoring program on academic skills of women faculty the power of peer mentorship in medicine physician's mom's group com, social media's leading physican voice how the pmg became the mother of all physician support groups every other thursday: stories and strategies from successful women scientists women's night in emergency medicine mentorship program: a swot analysis key: cord- - vnaifi authors: chen, wenyu; yao, ming; fang, zhixian; lv, xiaodong; deng, min; wu, zhen title: a study on clinical effect of arbidol combined with adjuvant therapy on covid‐ date: - - journal: j med virol doi: . /jmv. sha: doc_id: cord_uid: vnaifi objectives: this study aims to explore the clinical effect of arbidol (arb) combined with adjuvant therapy on patients with coronavirus disease (covid‐ ). methods: the study included patients with covid‐ admitted to the first hospital of jiaxing from january to march, , and all patients were divided into the test group and the control group according to whether they received arb during hospitalization. various indexes in the two groups before and after treatment were observed and recorded, including fever, cough, hypodynamia, nasal obstruction, nasal discharge, diarrhea, c‐reactive protein (crp), procalcitonin (pct), blood routine indexes, blood biochemical indexes, time to achieve negative virus nucleic acid and so on. results: the fever and cough in the test group were relieved markedly faster than those in the control group (p< . ); there was no obvious difference between the two groups concerning the percentage of patients with abnormal crp, pct, blood routine indexes, aspartate aminotransferase and alanine aminotransferase (p> . ); the time for two consecutive negative nucleic acid tests in the test group were shorter than that in the control group; the hospitalization period of the patients in the test group and control group were ( . ± . ) d and ( . ± . ) d, respectively. conclusion: arb combined with adjuvant therapy might be able to relieve the fever of covid‐ sufferers faster and accelerate the cure time to some degree, hence it's recommended for further research clinically. this article is protected by copyright. all rights reserved. coronaviruses (covs) (order nidovirales, family coronaviridae, subfamily coronavirinae) are enveloped, positive single-stranded rna viruses, and they have the largest genomes for rna viruses as their genome sizes range from to kilobases (kb) in length . covs primarily infect birds and mammals, causing a variety of lethal diseases. they can also infect humans and cause diseases to varying degrees, from upper respiratory tract infections (urtis) resembling the common cold to lower respiratory tract infections (lrtis) such as bronchitis, pneumonia, and even severe acute respiratory syndrome (sars) [ ] [ ] [ ] . the virus is believed transmitted mainly via respiratory tract, fecal-oral transmission or contact . there are over types of covs that have been already known so far. historically, covs caused two serious infectious diseases including the sars in and the middle-east respiratory syndrome (mers) in , , with a fatality rate of approximately % ( / , ) and % ( / , ), respectively , . therefore, it is plain to see that covs pose a great threat to human life. since the outbreak of coronavirus disease in december in china, there were , confirmed cases by march , including , deaths. meanwhile, the disease spread overseas, with , confirmed cases and deaths. although the overall mortality rate of covid- is about . %, which is much lower than that of sars and mers, covid- is extremely contagious, contributing to a fairly large infection base, hence the death toll surpassed that of sars and mers. the most common clinical symptoms of covid- sufferers are fever, dry cough, hypodynamia, while some patients develop nasal obstruction, nasal discharge and diarrhea . the current therapeutic scheme has mainly focused on symptomatic treatment as no specific medicine has this article is protected by copyright. all rights reserved. been developed up to now. based on the therapeutic experience of sars and mers, we have strived to research the efficient drugs for covid- in order to improve patient's cure rate and survival quality. arbidol (arb) is a kind of hemagglutinin (ha) inhibitor with a high selectivity and is able to target ha fusion machinery and prevent covs from adsorbing cell surface and entering the cells . currently, arb has been authorized for years in china and was reported by researchers to be a broad-spectrum and multi-target antiviral drug, which plays an inhibitory effect on influenza virus, parainfluenza virus and coxsackievirus [ ] [ ] [ ] . therefore, the application of arb in sars was reported and the result indicated that arb could suppress sars-cov , which provides a new orientation for the treatment of covid- in our study. in this study, we used arb combined with adjuvant therapy for covid- sufferers and set up the control group to investigate the effect of arb on covid- patients. the study included patients with covid- admitted to the first hospital of jiaxing from january to march, , including females and males aged from to , with most patients ranging from to . all of them were confirmed cases of covid- by imaging examination and pathological examination upon admission. ground-glass opacity could be seen in imaging and virus nucleic acid (ncov-rna) testing was positive. we divided them into groups. the one who received arb combined with adjuvant therapy was classified into the test group (n= ), while the one who didn't was classified into the control group (n= ). all clinical data of patients, including gender, hypertension, diabetes, ct, temperature, oxygen saturation, hemoglobin (hb) concentration, c-reactive protein (crp) and so on, were listed in table test group: arb was additionally added on the basis of symptomatic treatment. patients started to take arb as soon as they were admitted to the this article is protected by copyright. all rights reserved. hospital. arbidol tablets (jiangsu wuzhong pharmaceutical group corporation) was given for adult: pills ( . g) by oral thrice a day. β receptor antagonists such as metoprolol and propranolol were not allowed to be used together. drug withdrawal was recommended when the heart rate (hr) was lower than beats/min. symptomatic treatment would be applied if digestive tract reaction appeared. patient's clinical symptoms, such as fever, dry cough, nasal obstruction, nasal discharge, sore throat, hypodynamia, diarrhea, and some laboratory indexes including blood routine indexes, crp, procalcitonin (pct), blood biochemical indexes as well as the virus nucleic acid testing were observed and recorded during the treatment. curative criteria: patient's quarantine couldn't be abolished until their temperature returned to normal for over days, with marked improvement in respiratory symptoms, significant absorption of inflammation showed by pulmonary imaging, and negative nucleic acid testing for consecutive times (sampling interval was at least day). all statistical analyses were performed using spss . . measurement data were expressed as x±s, and differences between the two groups were analyzed by student's t test. part of the enumeration data were represented as percentage (%). comparisons between the two groups were verified by means of chi-square test or fisher's test. p< . was considered statistically significant. this article is protected by copyright. all rights reserved. we recorded patient's temperature at the beginning of and during hospitalization as basically all of them had fever. the highest temperature of each patient was recorded every day. the results suggested that compared with the control group, the temperature in the test group dropped more significantly than that in the control group, and the time for back to normal was much shorter ( . ± . vs. . ± . , p= . , fig. ) . additionally, symptoms like dry cough of patients in the test group recovered faster than that of patients in the control group ( . ± . vs. . ± . , p= . ). while for other symptoms, such as nasal obstruction, nasal discharge, sore throat, hypodynamia and diarrhea, there was no marked difference in recovery time between the two groups (p> . ). the details were listed in table . in view of the fact that a number of patients had inflammation, we observed the changes of patient's blood routine indexes, crp, pct and biochemical indexes and recorded the indexes which were higher or lower than the normal range. the percentage of patients with abnormal crp and pct in the test group were lower than those in the control group, yet the percentage of patients who developed abnormal lymphocytes in the test group was increased than that in the control group. in addition, there was no significant difference between the groups with regard to the percentage of patients with abnormal blood routine indexes, including white blood cell (wbc), hb, platelet (plt) and so on (p> . ). as for blood biochemical indexes, we mainly recorded alanine aminotransferase (alt) and aspartate aminotransferase (ast) in order to observe whether the medication this article is protected by copyright. all rights reserved. would damage patient's liver. the result indicated that from admission to discharge, there was no significant difference between the groups concerning the percentage of patients with abnormal alt and ast (p> . ), which validated that adding arb to the therapeutic scheme would cause no new damage to patient's liver. the detailed results for above were seen in fig. - . patient's virus nucleic acid was tested every day starting from their admission. we recorded every patient's time to achieve negative nucleic acid testing (including the st , nd and rd time to achieve negative result, that is, the time for two consecutive negative nucleic acid tests was recorded) and their hospitalization period. the results revealed that compared with the control group, the time for patient's nucleic acid turning negative in the test group was shorter than that in the control group, especially the time to achieve nd and the rd negative result (fig. ) . the hospitalization period of the patients in the two groups were ( . ± . ) d (test group) and ( . ± . ) d (control group), respectively. relatively, the hospitalization period in the test group was shorter, but there was no marked difference between the groups in this aspect (p> . ). during the treatment, patient's principal adverse drug reactions in the groups included slowed hr (test group: n= , control group: n= ), nausea (test group: n= , control group: n= ), diarrhea (test group: n= , control group: n= ) and dizziness (test group: n= , control group: n= ). there was no significant difference between the groups regarding the number of patients with adverse drug reactions (p> . ), which demonstrated that the application of arb in covid- is safe and would cause no marked adverse drug reactions. this article is protected by copyright. all rights reserved. currently, antiviral, anti-infection and supportive treatment are mainly applied in covid- sufferers clinically. previously, a mers-related systematic review and meta-analysis unveiled that the application of antiviral treatment at an early stage and a low age was able to reduce the mortality rate of mers patients . conducting antiviral treatment has always been thought of as the key to curation of mers-cov infected sufferers. consistently, the key to the treatment of covid- patients also lies in antiviral treatment. in this study, we mainly found that arb combined with common systematic therapy could relieve patient's symptoms faster, including fever, cough, nasal obstruction, nasal discharge, hypodynamia, diarrhea and so on, and accelerate patient's cure time without producing new toxic reaction and side effect. subsequently, it was proved to demonstrate inhibitory activity against a number of dna/rna viruses and enveloped/nonenveloped viruses . arb plays its antiviral role mainly by suppressing virus-mediated fusion with the target membrane and consequently preventing virus from entering into target cells . it has been found that arb can interact with haemagglutinin (ha) to stabilize it against the low ph transition to its fusogenic state and therefore prevent ha-mediated membrane fusion during influenza virus infection . in the treatment of hepatitis c virus (hcv), arb interacts with hcv envelope protein and is capable of inhibiting membrane fusion to various extent , . besides, the immunoregulation effect of arb is able to interfere with macrophage activation . arb has become the this article is protected by copyright. all rights reserved. candidate drug for treatment of human virus infection due to its broad-spectrum antiviral activity. consistent with the prior researches, arb combined with systematic therapy in the treatment of covid- sufferers was able to relieve symptoms and shorten the course of many symptoms, and accelerate patient's nucleic acid turning negative. it could be seen that arb played a positive role in the treatment of covid- . however, the results of this study are likely to be affected by other drugs as covid- patients applied extensive and messy medications during treatment. consequently, more researches need to be done in the future so as to obtain more reliable results. in conclusion, the application of arb in the treatment of covid- sufferers is likely to shorten the course of the disease and is able to quicken patient's recovery. hence, it's recommended that more studies should be further done clinically. the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. coronavirus envelope protein: current knowledge progress and challenges toward the development of vaccines against avian infectious bronchitis human (non-severe acute respiratory syndrome) coronavirus infections in hospitalised children in france human respiratory coronavirus hku versus other coronavirus infections in italian hospitalised patients special expert group for control of the epidemic of novel coronavirus pneumonia of the chinese preventive medicine, a. [an update on the epidemiological characteristics of novel coronavirus pneumoniacovid- coronavirus as a possible cause of severe acute respiratory syndrome isolation of a novel coronavirus from a man with pneumonia in saudi arabia severe acute respiratory syndrome coronavirus as an agent of emerging and reemerging infection middle east respiratory syndrome coronavirus: risk factors and determinants of primary, household, and nosocomial transmission understanding of covid- based on current evidence arbidol as a broad-spectrum antiviral: an update antiviral activity of arbidol against influenza a virus, respiratory syncytial virus, rhinovirus, coxsackie virus and adenovirus in vitro and in vivo arbidol: a broad-spectrum antiviral that inhibits acute and chronic hcv infection antiviral activity of arbidol and its derivatives against the pathogen of severe acute respiratory syndrome in the cell cultures clinical outcomes of current medical approaches for middle east respiratory syndrome: a systematic review and meta-analysis arbidol: a broad-spectrum antiviral compound that blocks viral fusion the synthetic antiviral drug arbidol inhibits globally prevalent pathogenic viruses membranotropic effects of arbidol, a broad anti-viral molecule, on phospholipid model membranes characteristics of arbidol-resistant mutants of influenza virus: implications for the mechanism of anti-influenza action of arbidol the data and materials in the current study are available from the corresponding author on reasonable request. this study was conducted in accordance with helsinki declaration ii the and was approved by the institutional review boards of affiliated hospital of jiaxing university / the first hospital of jiaxing. wy and my conducted the literature search. zx and xd wrote the article. wy and my performed data analysis and drafted. zw revised the article. all authors gave final approval of the version to be published, and agreed to be accountable for all aspects of the work. the authors declare that they have no potential conflicts of interest. key: cord- -qobzttqa authors: rachwal, s.; katritzky, a. r. title: . , , -triazoles date: - - journal: nan doi: . /b - - . - sha: doc_id: cord_uid: qobzttqa rapid progress in the synthetic application of benzotriazole derivatives in the last years has resulted in over scientific papers on the subject. this fact is reflected in section . . , which involves almost a half of the volume of this chapter. the section is arranged according to hybridization of the c-α atom and atomic numbers of the atoms in positions β and γ to allow an easy access to the material of interest. recent discovery of copper catalysis in [ + ] cycloadditions of azides to acetylenes, the so-called ‘click chemistry’, which boosted application of the , , -triazole derivatives, especially in medicinal chemistry, is presented in section . . . from the point of view of practical applications, section . . is organized according to the number, position, and combination of the substituents at the aromatic rings. another novel feature that has no precedence in the previous editions of comprehensive heterocyclic chemistry is an addition of triazole and benzotriazole complexes with various transitions metals to section . . . . . . . n-substituted , , -triazoles . . . . c-substituted , , -triazoles . . . . , -disubstituted , , -triazoles . . . . , -disubstituted , , -triazoles . . . . , -disubstituted , , -triazoles . . . . , -disubstituted , , -triazoles . . . . tri-substituted , , -triazoles the present chapter is devoted to , , -triazole and benzotriazole and their various derivatives. triazolines ( , dihydro- h- , , -triazoles) are discussed in section . . . tautomeric forms of the parent molecules and atom numbering are given in figure . in chec( ) < chec( ) >, chapter . on 'triazoles and their benzo derivatives' ( pages) covered the literature through and was strongly aligned to the monocyclic , , -triazoles with the considerable emphasis on ring-reduced derivatives. in chec-ii( ) < chec-ii( ) >, the corresponding -page chapter covered the literature from - , when the position had already changed significantly with the realization of the utility of benzotriazole as a synthetic auxiliary. the present chapter is heavily biased toward benzotriazole as a consequence of numerous synthetic methods developed with the help of this molecule. it has been impossible to cover the field in a comprehensive manner in the pages available. we refer readers to the following reviews that have appeared during the last ten years: ( ) 'properties and synthetic utility of substituted benzotriazoles' < crv > -this review covers the literature in a comprehensive manner through ; ( ) 'benzotriazole-based reagents for efficient organic synthesis' < ald > -another review of some of the synthetic applications; experimental dipole moments and acidities of azoles, including , , -triazole, show linear correlations with their p-electron excess calculated by the semiempirical am method < che >. experimental dipole moments of azoles agree well with those calculated by the dft program allchem < pca >. calculated dipole moments m (in units of debye,d) of a few selected azoles are listed below: ab initio optimized geometries at b lyp/ - þg levels suggest that aromatic stabilization of h- , , -triazole is the highest of all azoles < t >. some values (in units of kcal mol À ) are given below for comparison: bond dissociation energies for several heterocyclic systems calculated by two ab initio methods, cbs-q, g and g b , show similar values < jpo >. the g b data for three selected azoles are as follows: potassium cation affinities of several azoles and other compounds in the gas phase were calculated by hybrid density functional theory [b -lyp with - þ g( df , p) basis set] < cej >. there is a striking difference in binding energies of h-and h- , , -triazoles. some of the collected data are as follows: monte carlo calculations of interactions of h-benzotriazole with water reveal significant electronic polarization of the heterocycle. the dipole moment is increased by . d for the ground state and . d for the excited state to the total values of . and . d, respectively. direct measurements of dipole moments in water are not possible, but these numerical results are supported by experimental solvatochromic blue shift of the p ! p * transition < ijq >. theoretical calculations at the b lyp/ - g * and b lyp/ - þþg ** levels concluded that -(hydroxymethyl)benzotriazole is slightly more stable than -(hydroxymethyl)benzotriazole . the energy difference of . kcal mol À suggests that both isomers should be almost equally abundant; however, in solid state and in solutions, only isomer is observed. one of the possible explanations of this phenomenon is formation of strong intermolecular hydrogen bonding between the oh group and n- in condensed phase of derivative . less basic nitrogen atoms in derivative do not provide such stabilization < jhc >. atomic charges of anions and have been evaluated at the hf/ - g * level using several partitioning schemes. the data obtained from the natural population analysis (npa) method are listed below. the electron-withdrawing power of the cn groups is clearly demonstrated by the total charge of the ring change from À . to À . < ssi >. x-ray crystallographic data for several basic derivatives of h- , , -triazole and benzotriazole are included in chec( ) and chec-ii( ) < chec( ) , chec-ii( ) >. hundreds of new h- , , -triazole structures have been analyzed since; some crystallographic data for representative examples (structures - ) are collected in table . table selected bond lengths (inÅ) for , , -triazole derivatives - as can be seen in table , for n- substituted triazoles (structures - ), the n( )-n( ) bonds ( . - . Å) are significantly longer than the n( )-n( ) bonds ( . - . Å), reflecting more single-and more double-bond character, respectively. an electron-withdrawing substituent at c- (compound vs. ) shortens slightly the n( )-n( ) bond and stretches the n( )-c bond indicating that such derivatives should dissociate more easily. in -substituted triazole , both n-n bonds are approximately equal. however, when two substituents of different electronic properties are attached, as in compound , the n-n bonds differ substantially, with that closer to an electron-withdrawing substituent being shortened and that closer to an electron donor being elongated. this observation can be rationalized by contribution of resonance forms involving the amino and carbonyl groups at c- and c- , respectively. for the same reason, the c( )-c( ) bond in derivative is the longest one in the series suggesting diminished aromatic character for this molecule. because substituents of the ring may have different effects on the individual bonds, it is informative to compare averages of the five ring bond lengths. in this aspect, the average bond of the triazole system in compound ( . Å) is the longest in the series - supporting the low aromatic character of this molecule. for comparison, the average bond length in molecule is . Å. triazole anion structure reveals relatively short bonds with an average bond length of . Å. the triazole ring in ruthenium complex , with average bond length of . Å, exhibits similar character to that of molecule due in part to its resonance involving the carbonyl group at c- . in the relatively simple and electronrich molecule , the average n-n bond ( . Å) and n-c bonds ( . Å) are the shortest in the whole series. table lists bond lengths for the heterocyclic ring of the benzotriazole systems in derivatives - . in comparison with , , -triazoles, n- substituted benzotriazoles have significantly longer n( )-n( ) bonds (average . Å vs. . Å) and somewhat longer n( )-n( ) bonds (average . Å vs. Å). in general, the c-n bonds and c-c bonds in the heterocyclic ring of benzotriazole derivatives are also slightly longer than the corresponding bonds in , , -triazoles. this causes the average heterocyclic ring bond in the whole series of benzotriazole derivatives - ( . Å) to be significantly longer than that in , , -triazole derivatives - ( . Å), reflecting the diminished aromatic character and therefore the higher reactivity of the benzotriazole system. a n( )-c. b n( )-n. c n( )-c'. , , -triazoles due to rapid proton exchange between forms , , and (scheme ), benzotriazole exhibits at room temperature just two c-h signals, each for two protons, in its h nmr spectra. however, when the temperature is lowered, the signals broaden and finally split into four separate resonances of the four individual c-h protons. the results of such study for an acetone solution of benzotriazole are given in table < t >. the situation is additionally complicated by formation of adducts and , which at À c contribute % and %, respectively, to the total molecular population. scheme to illustrate the h nmr assignment of benzotriazole derivatives, spectral data for three benzotriazol- -yl derivatives of tetrahydropyran, - , are presented in table < cjc >. chemical shifts (in ppm) for the ring protons as well as the a-hydrogen atoms of the attached substituents in triazole derivatives < tl >, < bmc >, < jco >, < t >, < sc >, < ol >, < ol >, < ja >, and < ja > are also shown below together with the structures. to illustrate signal assignments in c nmr spectra of the benzotriazol- -yl system, chemical shifts for five a-(benzotriazol- -yl)tetrahydrofurans (structures - ) < jpo > and three corresponding tetrahydropyrans (structures - ) < cjc > are listed in table . selected c nmr spectral data for triazolyl nucleoside analogs - < spl > are collected in table . in the previous issue of comprehensive heterocyclic chemistry < chec-ii( ) >, the nmr spectra of , , triazoles and benzotriazoles are extensively discussed, but , , -triazolines are only briefly mentioned. to clarify the picture, data for typical , -dihydro- h- , , -triazoles ( - ) < j(p ) > are collected in table . for the ring nitrogen atoms, the highest field resonance is always assigned to n- . to distinguish positions of n- and n- resonances, which sometimes come close to each other, isotopic labeling at n- and n- is used. the data presented indicate that change of a n- substituent from aliphatic to aromatic causes moderate downfield shifts of the n- and n- resonances and a strong upfield shift of the n- resonance. this feature can be explained by the resonance effect of the aromatic ring. electron-withdrawing substituents at c- shift strongly upfield the n- signals but do not significantly change the n- and n- resonances. substituents at c- shift significantly upfield the n- resonances. an sp c- atom shifts the n- resonance dramatically downfield, especially when a heteroatom is attached (structures - ). mixed malondiamide on reaction with benzenesulfonyl azide and sodium ethoxide in ethanol is converted into open-chain diazo-derivative , which readily cyclizes to triazoles and (scheme ). rapid equilibration in solution prevents separation of individual components of the reaction mixture. nmr studies of the equilibrium between products , , and , carried out in dmso-d are summarized in table . it is evident from the collected data that the equilibrium depends strongly on the substituent r. electron-withdrawing substituents on the phenyl ring destabilize structure but stabilize form . ortho-substituents on the aromatic ring, both electron-donating and electron-withdrawing, strongly destabilize triazoles , but they stabilize open-chain form . the benzyl derivative exists almost exclusively in the triazole form < che >. concentration of an ethanolic solution of dimethylglyoxime, cobalt(ii) chloride and benzotriazole results in deposition of crystalline complex . the product is stable at room temperature; however, it slowly decomposes upon heating. thermal analysis reveals that the compound releases first the chlorine atom and % of the benzotriazole content to form a new complex that is stable to c. probably in this new form, the benzotriazole moiety coordinates two cobalt ions simultaneously. further heating to c removes the benzotriazolyl moieties completely < jpy >. the first step of decomposition can be summarized as follows: ½coðdmghÞ ðbthÞcl ! ½coðdmghÞ ðbtÞ : where dmgh ¼ dimethylglyoxime anion, bth ¼ benzotriazole. a reaction of -(benzotriazol- -yl)pyridine with copper(ii) nitrate, carried out in methanol, provides complex . the product crystallizes in monoclinic space group p /n. the copper atom lies in the crystallographic center of inversion, and it is coordinated to two chelating ligands and two methanol molecules. in structures - discussed above, the benzotriazolyl n- atom is involved in bonding. by contrast, in structure , the benzotriazolyl n- atom is used to coordinate to the copper ion, with the bond length of . Å. the bond length of pyridyl-n-cu is . Å. in analogy to structure , the axial cu-o bonds in complex are elongated ( . Å) < jcd >. the ester derived from (benzotriazol- -yl)methanol and ferrocenecarboxylic acid reacts in dichloromethane with cobalt(ii) iodide to provide complex in quantitative yield, which recrystallizes from dichloromethane/hexane to give green air-stable crystals. the x-ray structure analysis reveals that the cobalt center is coordinated to two iodine atoms and the n- atoms of two benzotriazole ligands. the angles n-co-n, n-co-i, and i-co-i of . , . (average), and . , respectively, are close to the ideal tetrahedral angle. some deviation from the tetrahedral geometry is indicated by the relatively large i-co-i and relatively small n-co-n angles; this is presumably caused by strong repulsion between the iodide anions. the bond lengths, co-n . and . Å and co-i . and . Å, are typical for this type of complexes < jom( ) >. . . . di-, tri-, and polynuclear complexes (benzotriazol- -yl)methyl , -thiophenedicarboxylate reacts with [rhcl(co) ] in toluene at room temperature to give quantitatively rhodium(i) complex as an air-stable yellow solid. the dimeric nature of the molecule is clearly indicated by its esi molecular peak at m/z ¼ . complex catalyzes methyl iodide promoted carbonylation of methanol to give acetic acid and methyl acetate with much higher catalytic activities than the classical rhodium catalysts. treatment with carbon monoxide and methyl iodide converts compound into complex in high yield (equation ). in a single-crystal x-ray analysis, complex turns out to be a macrocycle containing two dinuclear iodo-bridged rh(iii) units. the four rhodium atoms have distorted octahedral geometries. the four rh-n bonds are almost equal in length ( . , . , . , and . Å). the rh-c bond lengths are . - . Å. the bond lengths for each of the rh i units ( . - . Å) are typical for that type of structures. in contrast to rh(i) macrocycle , rh(iii) complex does not catalyze the carbonylation of methanol < eji >. cisplatin is one of the most frequently used anticancer agents despite several drawbacks including acquired drug resistance and serious side effects. to overcome these problems, an intensive search is going on to find safer alternatives. in one such approach, dinuclear pt(ii) complex is obtained as dinitrate salt from a reaction of [cis-pt(nh ) (m-oh) ](no ) with -phenyl- , , -triazole. according to x-ray structure determination, the coordination of the pt atoms is square planar with the pt-n(ammine) distances slightly longer ( . - . Å) than the pt-n(triazole) distances ( . - , Å). the pt-o bond lengths are . and . Å. a weak intramolecular hydrogen bond is observed between one of the ammine groups as donor and the triazole n- atom as acceptor < ja >. compound and its simpler analog without any substituent on the triazole ring exhibit higher cytotoxicity to l murine leukemia cells than cisplatin. to explain the effect of its action on dna, a reaction of complex with -ethylguanine, as a model nucleobase, was studied using nmr. in the first step, the hydroxyl bridge is broken and -ethylguanine is attached to one of the platinum centers to give intermediate . in the following step, the freed diamminohydroxyplatinum group migrates to n- of the triazole ring to provide thermodynamically more stable intermediate . finally, a reaction with another molecule of -ethylguanine provides final adduct (scheme ) < ja >. reaction of ni(no ) ? h o with -hydroxybenzotriazole (btoh) and nh in dmf provides trinuclear complex [ni (bto) (nh ) ] . variation of the solvent and the btoh/ni(ii) ratio afford the same complex, in various solvated forms, as the only product isolated. according to the x-ray analysis, the central ni atom, ni- , in the trinuclear molecule is joined to each of the other two ni atoms, ni- and ni- , by three bridging bto À ligands. each bto À ion is coordinated to ni- via the n- atom of the benzotriazole ring and to one of the terminal ni atoms via n- . the ammonia ligands complete the six-coordination pattern at each of the terminal ni atoms. the metal centers have slightly distorted octahedral geometries. the molecule is almost linear, with the ni( )-ni( )-ni( ) bond angle of . . the ni-n(ammine) bond distances ( . - . Å) are very close to the ni-n(bt) bond lengths ( . - . Å) < tmc >. heating of a suspension of powdered manganese in a dmf solution of -hydroxybenzotriazole and ammonium thiocyanate in air results in formation of a polymeric complex of general formula [mn (bto) (ncs) (dmf) ] n . in this reaction zero-valent manganese is oxidized by oxygen from the air to mn(ii). composition of this complex does not depend on the reagent ratio indicating that complex is a thermodynamic product. according to x-ray analysis, complex consists of dinuclear subunits of two mn(ii) atoms bridged by two oxygen atoms from bto À ligands, forming a planar four-membered ring [-mn( )-o-mn( )-o-]. the octahedral coordination of each of these manganese atoms is completed by three oxygen atoms from dmf molecules and one nitrogen atom from the ncs À anion. the dinuclear subunits in polymer are connected via mononuclear subunits containing atoms mn( ) coordinated by n- atoms of two anions derived from -hydroxybenzotriazole. the octahedral coordination of the mn( ) atom is completed by two oxygen atoms from dmf molecules and two nitrogen atoms from ncs À anions. the mn( )-o(bto) bond lengths are . and . Å, which is a little more than the mn( )-o(dmf) bond lengths of . Å. the mn( )-n(bto) bonds ( , and . Å) are also longer than the mn( )-n(ncs) bonds ( . and . Å) < eji >. addition of a methanolic solution of -methylbenzotriazole (btme) to an aqueous solution of fe(ii)(clo ) ?xh o and sodium dicyanamide (nadca) results in slow deposition of crystalline complex [fe(btme) (dca) ]. x-ray analysis reveals that the obtained complex (structure ) consists of one-dimensional linear chains, in which the fe(ii) centers are bridged by the dicyanamide anions. the coordination sphere at each fe(ii) center is completed by two -methylbenzotriazole ligands occupying the axial positions. coordination geometry around the fe(ii) atom is distorted octahedral with the fe-n(dca) bond length of . Å and the fe-n(btme) bond length of . Å. similar linear polymeric complexes are obtained from mn(ii) and cu(ii) salts < pol >. a similar complex is also produced in a reaction of cobalt(ii) nitrate with potassium tricyanomethanide (ktcm) and benzotriazole (bth). according to the x-ray data for this complex, the con octahedron is only slightly distorted, having the n-co-n angles in the range of . - . . the equatorial co-n(tcm) distances ( . and . Å) are slightly shorter than the axial co-n(bt) bonds ( . Å). the polymeric one-dimensional chains are cross-linked by hydrogen bonding between the benzotriazole nh atoms and the uncoordinated cn groups of the bridging ligands in the adjacent chains < axc >. alkylation reactions of , , -triazole and benzotriazole are exhaustively discussed in chec( ) and chec-ii( ) . the electrophilic reagents, usually alkyl halides, sulfates or sulfonates, attack n- or n- atoms of the ring producing mixtures of the corresponding -alkyl-and -alkyl triazoles < chec( ) , chec-ii( ) >. some progress in this field provides finding of direct alkylation of benzotriazole with alcohols in the presence of triphenylphosphine and nbs < sc >. presumably, the first step is formation of a reactive intermediate that is attacked later by benzotriazole in the s n fashion to give derivative (scheme ). the reaction is regioselective and provides exclusively -alkyl-, -(arylmethyl)-, -( -alken- -yl)-, and -( -alkyn- -yl)benzotriazoles, respectively. secondary alcohols give the corresponding alkyl derivatives in low yields, while tertiary alcohols do not alkylate benzotriazole under these conditions. in aqueous micellar medium using cetyltrimethylammonium bromide as a surfactant, benzotriazole is alkylated regioselectively at n- with n-propyl and n-butyl bromides, but activated alkylating agents (benzyl chloride, allyl bromide, phenacyl chloride, etc.) produce mixtures of benzotrizol- -yl and - -yl isomers in ratios varying from : to : , respectively < bcj >. alkylation of benzotriazole with bis( -chloroethyl) ether under these conditions provides a mixture of derivatives - with isolated yields of %, % and %, respectively (equation ). use of ionic liquids as media for alkylation of benzotriazole provides generally higher regioselectivity; however, the trend is opposite to that under micellar conditions with phenacyl bromide and similar compounds providing exclusively benzotriazol- -yl derivatives and n-alkyl halides giving mixtures of benzotriazol- -yl and - -yl derivatives in a ratio of : < h( ) >. microwave irradiation can facilitate alkylation of benzotriazole. thus, compound is cleanly prepared in % yield upon irradiation of a solution of benzotriazole and the corresponding benzyl bromide in dmf for s < bml >. very often microwave-assisted alkylation of benzotriazole works best when no solvent is used; for example, derivative is prepared this way in % yield < t >. phase-transfer catalysis can also be used to increase the yield and improve regioselectivity of the alkylation process as it is illustrated by preparation of compound in % yield in the presence of a pyridinophane < s >. in another example, a reaction of benzotriazole with ethyl chloroacetate and k co in ethyl acetate is catalyzed by polyethylene glycol (peg ) to give a mixture of ethyl (benzotriazol- -yl)acetate ( %) and its benzotriazol- -yl isomer ( %) < sri >. adamantylation of benzotriazole represents a special case because direct substitution in adamantanyl halides by an s n mechanism is impossible, and an s n mechanism is improbable. in this case, reactive cation is generated by oxidative cleavage of the c-i bond in -iodoadamantane . benzotriazole added to the reaction mixture binds cations to afford a mixture of benzotriazol- -yl and - -yl derivatives in a ratio of : and the total yield of % (scheme ) < rjo >. alkylation of , , -triazole with n-( -bromoethyl)phthalimide in the presence of cs co followed by cleavage of the phthalyl moiety with hydrazine provides -( -aminoethyl)- , , -triazole in % yield < jme >. a reaction of -nitro- , , -triazole with propargyl bromide in the presence of koh gives a mixture of isomeric -propargyl- , , -triazoles and in the equimolar ratio < rjo >. however, in acidic media, when n- scheme and n- positions are protonated, -substituted derivatives of , , -triazole are formed regioselectively. thus, isopropyl alcohol reacts with , , -triazole in % sulfuric acid to provide -isopropyl- , , -triazole in % yield < jhc >. alkylation of benzotriazole with (chloromethyl)trimethoxysilane provides a mixture of its derivatives and in a ratio of : . in a reaction with tris-( -hydroxyethyl)amine, compound is converted to derivative in nearly quantitative yield. compound reacts with tris-( -hydroxyethyl)amine similarly (scheme ) < ark(xiii) , che >. when positive charge of the reaction center is stabilized by an adjacent atom, even the acetoxy anion can be a good leaving group. such a situation is typical in derivatives of sugars. thus, heating of an equimolar mixture of benzotriazole and tetraacetylribose at c for min results in formation of products ( %) and ( %) < nn >. due to strong electron-donating abilities of the ferrocene system, ferrocenyl methyl carbinol reacts eagerly with benzotriazole in the presence of % fluoroboric acid to give -(a-ferrocenylethyl)benzotriazole in % yield (scheme ) < jom( ) >. catalyzed by ytterbium triflate, (phenoxymethyl)oxirane reacts with benzotriazole to afford derivative in % yield < sc >. , -dioxaspiro[ , ]hexane with remarkably strained molecules reacts directly with benzotriazole without any catalyst to give oxetane derivative as the main product in % isolated yield. the preference for n- substitution in product seems to result from steric hindrance at the reaction center. however, under basic conditions, the same reagent gives product (isolated yield %) as a result of a regular s n attack on the oxirane methylene carbon atom < joc >. the anion derived from benzotriazole attacks electron-deficient aromatic rings of pyrylium salts in position para to oxygen to give h-pyrans in high yields. positions ortho in salts are blocked by aryl groups (r ¼ r ¼ ar) to avoid reactions there < jpr >. derivatives have been found to be very useful in the synthesis of corresponding -alkyl pyrylium salts , via -alkyl- -(benzotriazole- -yl)- h-pyrans (scheme ). benzo[b]pyrylium < joc , ejo > and xanthylium < joc > salts react similarly. derivatives similar to adducts were also obtained from nitrogen (n-methylacridinium) and sulfur (thioxanthylium) cationic heterocyclic systems < jhc >. when r ¼ r ¼ h, the anions derived from pyrans may also rearrange to , -diaryl- , -cyclopentadien- -ols < jpr >. upon microwave (mw) irradiation, benzotriazole and its derivatives react readily with -chloropyridine to afford products - in %, %, and % yield, respectively (scheme ). -chloroquinoline reacts similarly. -bromopyridine and -bromoquinoline give generally lower yields in these reactions < ol >. microwave-induced reaction of -acetamidobenzotriazole with -chloroquinoline gives a mixture of products ( %), ( %), and ( %) (equation ). interestingly, the product ratio does not depend on the solvent used (toluene, dmf, nmp) < t >. catalyzed by a copper-diamine complex, benzotriazole reacts well even with nonactivated aromatic iodides. the case is illustrated in scheme by formation of -phenylbenzotriazole in % yield. the acetyl group as an electron-withdrawing substituent in para position has surprisingly negative effect on the product yield as derivative is isolated in only % yield. potassium phosphate is used as a base. the reactions are highly regioselective with the benzotriazol- -yl to benzotriazol- -yl isomer ratio higher than : < joc >. nucleophilic substitution of a nitro group by benzotriazole or triazole in strongly electron-deficient aromatic systems can also be easily achieved. thus, heating of an equivalent mixture of , , -trinitrobenzene with benzotriazole and k co in nmp at c for h affords products and in a ratio of : with % total yield. a similar reaction of , , -trinitrobenzene with , , -triazole gives a mixture of derivatives and in a molar ratio of : . surprisingly, only n- substitution is observed when -( , -dinitrophenyl)benzotriazole is heated with benzotriazole and k co to give product in % yield. substitution of the last nitro group is also possible, but the reaction is much slower. insoluble in most common solvents, , , -tribenzotriazolylbenzene is isolated in analytically pure form in % yield. it can be concluded that electron-withdrawing abilities of benzotriazolyl substituents are comparable to those of a nitro group to activate aromatic rings for nucleophilic substitution (scheme ) < rcb >. scheme , , -triazoles under strongly acidic conditions ( % molar equivalent of tsoh), benzotriazole adds to unactivated alkenes to afford a mixture of -alkyl-and -alkylbenzotriazoles. because protonation of the double bond with formation of the corresponding carbocation is the first step in these additions, markovnikov's rule is followed, and derivatives with a benzotriazolyl substituent at the terminal carbon atom are not observed. three examples of such additions are depicted in scheme . thus, in a reaction with styrene, benzotriazol- -yl and - -yl are formed in a ratio of . : and total yield of %. in a reaction with -phenylbutene, derivatives and are obtained in a ratio of . : and total yield of %. normal terminal alkenes give the corresponding benzotriazol- -yl and benzotriazol- -yl derivatives as well, but the total yields are significantly lower ( % from -octene and % from -decene). increasing the amount of tsoh from to mol% improves slightly the overall yield, but it also results in more complex mixtures of the products due to rearrangements of the original carbocations. cyclohexene does not react with benzotriazole at c; however, at c, a mixture of derivatives and is obtained in a ratio of . : and total isolated yield of % < j(p ) >. scheme michael addition of benzotriazole to electron-deficient double bonds is described in chec-ii( ) < chec-ii( ) >. one of the innovations in this field is running the reaction of benzotriazole with chalcone in a micellar medium to afford a mixture of derivatives and in the molar ratio of : and total yield of % (scheme ) < cl >. even more important innovation is running such reactions enantioselectively with application of optically active bases as catalysts. thus, addition of benzotriazole to a,b-unsaturated ketones derived from acetone in the presence of catalyst b produces mixtures of products and in ratios varied from : to : with total yields in the range of - % and high enantioselectivity ( - % ¼ ee) < age >. addition of benzotriazole to -nitro- -alkenes proceeds enantioselectively in the presence of catalyst c to provide exclusively benzotriazol- -yl derivatives in the average yield of % and high ee ( - %) < ol >. when the electron-deficient alkene contains a good leaving group x at the double bond, addition of benzotriazole may be followed by elimination of x (or hx) with restoration of the double bond. the total effect is a nucleophilic substitution of group x by benzotriazolide anion. four examples of such reactions are gathered in scheme . thus, benzotriazolyl nitronyl nitroxide must result from addition of the benzotriazolide anion to c- of -bromo- , , , tetramethyl- , -dihydro- h-imidazole- -oxide- -oxyl followed by elimination of br À < t >. sometimes, the intermediate adducts are stable enough to be isolated and characterized. such is the case of adduct that is obtained from a low temperature reaction of benzotriazole with methyl -(trifluoroacetyl)vinyl sulfone. at slightly elevated temperature, adduct eliminates spontaneously methanesulfinic acid to give product < rcb >. addition of a benzotriazolide anion to carbon of (e)-( -phenylvinyl)phenyliodonium tetrafluoroborate results in unstable benzyl anion that rapidly eliminates iodobenzene to afford (e)- -( -phenylvinyl)benzotriazole < jcm >. heating a mixture of benzotriazole, -chloro- , , -trifluoroethane, koh and dmso at c for h leads to (e)- -( -chloro- -fluorovinyl)benzotriazole . the proposed mechanism for this reaction involves elimination of hf from the starting material and trapping of the evolved -chloro- , -difluoroethene by benzotriazolide anion to form intermediate anion that spontaneously eliminates f À to give product < t >. application of catalysts allows sometimes executing this addition/elimination process even with alkenes without any electron-deficient substituent attached. such case is illustrated by an example in scheme . in the presence of mercury-(ii) acetate and trifluoroacetic acid, , , -triazoles react with vinyl acetate at c to give vinyl derivatives in good yields ( - %) < rjo >. adducts are presumed to be intermediates in this process. in the presence of triphenylphosphine as a catalyst, benzotriazole adds readily to activated allenes. its reaction with ethyl , -butadienoate produces a mixture of adducts ( %) and ( %). both derivatives form exclusively as (e)-isomers < t >. in a reaction of benzotriazole with dibenzoylacetylene and scheme , , -triazoles triphenylphosphine (used in the equimolar amount), a mixture of compounds ( %) and ( %) is obtained (scheme ). neither open-chain benzotriazol- -yl analog of nor benzotriazol- -yl analog of furan derivative is detected < tl >. it seems to be the steric hindrance in reaction intermediates solely responsible for that distinction. to make the cyclization to a furan system possible, the molecule must first assume (e)-configuration, and than bring the carbonyl groups to close proximity. switching between (z)-and (e)-configurations in compound seems to be relatively easy by addition of another molecule of benzotriazole to the double bond followed by its elimination, but rotation of the a-benzoyl group would impose much strain on the molecule due to steric repulsion between its phenyl and the benzotriazolyl benzenoid ring. the less bulky benzotriazol- -yl substituent in the original adduct of benzotriazole to the triple bond allows for such transformations without high energetic barriers. -benzylbenzotriazole reacts rapidly with borane to form complex in quantitative yield. complex and its analogs derived from -alkylbenzotriazoles are inert to water and air at room temperature and easy to handle solids. treatment with bu n li followed by iodomethane converts complex into its a-methylated product . in the case of a sterically hindered and less acidic substituent (compound ), the corresponding complex with bh undergoes lithiation in position to afford compound . refluxing in ethanol removes the borane group from n- to restore the benzotriazole system (products and ) (scheme ) < opp >. oxidation of -alkylbenzotriazoles with dimethyldioxirane leads to the corresponding oxides , generally in high yield (equation ); however, in comparison with pyridine, the reaction is much slower < joc >. electron-deficient substituents r make the oxidation process more difficult and the yields of products are compromised (e.g., % for r ¼ cn). -benzoylbenzotriazole is not oxidized by this reagent. n-butyllithium lithiates oxides predominantly in position . refluxing in acetic anhydride converts oxides into starting -alkylbenzotriazoles. -alkylbenzotriazoles react differently with dimethyldioxirane; instead of the nitrogen, carbon atoms of the benzene ring are attacked to give dioxiranes (equation ). aza analogs of n-oxides, aminides, are reactive - -dipoles. in an example given in scheme , , , -triazolium- aminides undergo cycloaddition to esters of propiolic acid to give unstable adducts that under the reaction conditions, reflux in acetone, rearrange to fused pyrrolo[ , -d]- , , -triazolines (mesomeric forms and ). prolonged heating causes cleavage of the c-n bond (between c- a and n- ) in and rearrangement of the obtained betaines to more stable , -dihydro- , , -triazines . this relatively complex process produces triazines in moderate yields ( - %) < tl , joc >. benzyne generated in situ by diazotization of anthranilic acid adds readily to aminides to provide cycloadducts . introduction of a nitro group into para position of the phenyl ring on the nitrogen terminus of the , -dipole (x ¼ no ) stabilizes the system and results in higher yields of product ( % vs. % for x ¼ h). electrondeficient imines react also with aminides , but the yields of isolated adducts are relatively low ( - %) (scheme ) < ark(vii) >. scheme , , -triazoles . . . thermolysis of benzotriazole and triazole derivatives thermolysis of benzotriazole derivatives involves cleavage of the heterocyclic ring with extrusion of a molecule of nitrogen and formation of a diradical. if the substituent at n- of benzotriazole is suitable for trapping radicals, cyclization to a new heterocyclic system is usually the main route for quenching the diradical. thus, gas-phase thermolysis of -aryloxybenzotriazoles proceeds via diradical . the most favorable next step is formation of a bond between the carbonyl oxygen and the ortho carbon atom resulting in benzoxazole . in another route, a bond forms between the ortho carbon atoms from both rings to give phenanthradinone derivative (scheme ) < t >. distribution of the products is not affected much by substituents x supporting radical mechanism of the reactions. the picture can be generalized. if the substituent is attached to benzotriazolyl n- by an sp hybridized carbon atom, the produced diradical is relatively stable, and a product resulting from simple cyclization predominates, like in an example given in scheme . three additional examples of such reactions are shown in equations ( )-( ). thus, gas-phase thermolysis of hydrazones (r ¼ me or ph, ar ¼ ph or para substituted ph) produces benzimidazoles as the main products in - % yields. minor side products result mostly from cleavage of other bonds in the molecule not involving benzotriazole, and no products resulting from direct radical trapping by the carbonyl group are detected < t >. for a preparative purpose, it is more convenient to carry out pyrolysis of benzotriazole derivatives in high boiling solvents. this way, h-quino[ , , -kl ]acridine is obtained by refluxing a solution of -( h- , , -benzotriazol- -yl)acridine in diphenyl ether < jme , j(p ) >. similar thermal conversions of -( -substituted- , , -triazol- -yl)acridines generate corresponding h-pyrido[ , , -kl ]acridines < jcm , j(p ) >. base catalysis may help the thermolysis, as it is illustrated by conversion of -(benzotriazol- -yl)-spiro[cyclohexane- , - h-imidazo[ , -b]pyridine into the corresponding fused benzimidazole derivative occurring in refluxing toluene < jcm >. the presence of an electron-donating group adjacent to the benzotriazol- -yl system renders the triazole ring susceptible to opening at elevated temperatures. thus, upon heating to reflux in toluene, enamines undergo ring scission between the n- and n- atoms to form betaines . the consecutive loss of a molecule of nitrogen followed by cyclization and rearrangement leads to quinazolines (scheme ) < joc >. anions , derived from -(diarylmethyl)benzotriazoles , can be oxidized with mild oxidants to relatively stable triaryl radicals . one of the possible reactions of radicals is ring opening to give radicals . elimination of nitrogen from produces unstable species that undergo intramolecular cyclization to phenanthridines (scheme ) < jhc , joc >. when substituents x and y are identical, products scheme are obtained with average yield of %. when x and y are different but of similar electronic character, mixtures of two isomeric phenanthridines are formed. polycyclic phenanthridines are formed in these reactions when tricyclic analogs of derived from acridine, xanthene, or thioxanthene are used as starting materials < jhc >. another possible reaction of radicals is their dimerization resulting from combining one radical with another in position para of the aromatic ring (when x ¼ h) < joc >. . . . intramolecular electrophilic attack on n- treated with trifluoroacetic anhydride, sulfoxides undergo conversion to triazapentalenes with high yields. the process must involve acylation of the sulfoxide oxygen atom and generation of a carbocation that attacks the n- atom of benzotriazole. hydrogenation over raney nickel cleaves the c-s and one of the n-n bonds to generate ortho-substituted anilines (scheme ) < ejo >. addition of benzotriazole to -phenyl- -aroylacetylenes gives ,-unsaturated ketones in high yields. by treatment with dimethylsulfonium ylide, ketones are converted to epoxides , opening of the oxirane ring and electrophilic attack of the obtained tertiary carbocation on n- of the benzotriazole system leads to betaines that consecutively eliminate formaldehyde to give triazapentalenes (scheme ) < ark(iii) >. . . reactivity of nonconjugated rings . . . conversion of triazolines to triazoles . . . . retro diels-alder reaction a convenient synthetic method for , , -triazoles unsubstituted at c- and c- utilizes a reaction of azides with norbornadiene, for example, scheme < joc >. the process is performed in refluxing dioxane. in the first step, norbornadiene undergoes , -dipolar cycloaddition to glucose-derived azide to give triazoline . the following retro diels-alder reaction results in the elimination of cyclopentadiene to furnish triazole derivative in % yield. diethyl azidomethanephosphonate reacts with norbornadiene at room temperature to give triazoline in % yield. when heated at c, derivative decomposes with elimination of cyclopentadiene to provide ( , , triazol- -yl)methanephosphonate in % yield. however, when it is left at room temperature for an extended period of time, triazoline undergoes slow conversion to aziridine with elimination of nitrogen (scheme ) < h( ) >. . . . . elimination of amines , -dipolar cycloaddition of -morpholino- , -diene to azides provides triazolines (scheme ). triazolines a and b, derived from -(ethoxycarbonyl)-and -nitro-phenyl azides, respectively, are stable under the reaction conditions (benzene, c); they can be isolated in good yields and fully characterized. however, phenyl derivative c is less stable and spontaneously eliminates morpholine to give triazole c. to eliminate morpholine from triazolines a and b, they are heated to reflux in aqueous acetic acid. strong electron-withdrawing effect of the tosyl group in triazoline d promotes cleavage of the ring with elimination of diazomethane to furnish a,b-unsaturated carboximidamide . , -substitution of the triazole ring in derivatives is confirmed by nmr studies < hca >. less reactive (z)-ethyl -fluoroalkyl- -pyrrolidinoacrylates require prolonged heating with azides to afford triazoles in good yields ( - %). the reactions give the best results when mixtures of reagents are heated neat, without any solvent added. intermediate triazolines do not survive under such conditions and spontaneously eliminate pyrrolidine to form triazoles . the reactions are proved to be strictly regioselective with the ethoxycarbonyl group always located at c- of the triazole system (scheme ) < t >. scheme , , -triazoles scheme illustrates the difference in reactivity between triazolines obtained from cyclohexanone and cyclopentanone enamines. thus, the reactions of azidophosphonates with cyclohexanone enamines produce unstable aminotriazolines that cannot be isolated due to their spontaneous elimination of amines to provide triazoles . contrary to that, triazolines , derived from cyclopentanone enamines, are isolated in good yield ( - %) and cannot be converted to the corresponding triazoles even by thermolysis < h( ) >. probably, introduction of a double bond between two five-membered rings would involve too much molecular strain. scheme scheme . . . . elimination of alcohols or water -ethoxyvinyl trifluoromethyl ketone reacts slowly at elevated temperature with aryl and benzyl azides to provide triazoles in good yield ( - %). the reactions, carried out neat, are completed usually in - d(days). however, a longer reaction time ( d) is required for -methylphenyl azide due to its steric hindrance. -ethoxytriazolines , the expected intermediates in this process, readily eliminate ethanol under the reaction conditions and cannot be isolated (scheme ) < jfc( ) >. in reactions with azides, ketones are directly converted to -hydroxytriazolines. ketone enolate , generated by treatment of norbornanone with lda at c, adds readily to azides to provide hydroxytriazolines in - % yield. interestingly, -azido- -iodopropane subjected to the reaction with enolate gives tetracyclic triazoline derivative in % yield. the reaction starts from an electrophilic attack of the azide on the ketone a-carbon atom. the following nucleophilic attack on the carbonyl group in intermediate results in triazoline . the process is completed by nucleophilic substitution of the iodine atom to form the tetrahydrooxazine ring of product (scheme ) < joc >. in contrast to the triazolines from scheme , -hydroxytriazolines obtained from regular, unstrained ketones are unstable, eliminating rapidly water to furnish the corresponding triazoles. in an example given in scheme , azide reacts readily with cyclohexanone enolate to provide triazole in % yield. triazoline intermediate , formed in the first step of this reaction, is very unstable and cannot be isolated. the case of open-chain ketones is illustrated by a reaction of azide with diethyl ketone. again, intermediate -hydroxytriazoline decomposes rapidly to give, in part, triazole . however, a more complex process involving elimination of nitrogen and rearrangement to amide competes with the main reaction, making this synthesis less attractive < joc >. when a solution of phenacyl halide and excess tosyl hydrazide in methanol is heated to reflux, -(tosylamido)- aryltriazole is formed. the reaction proceeds presumably via dihydrazide derivative that subsequently undergoes intramolecular cyclocondensation to triazoline . in the following step, the triazoline must be oxidized to the final triazole product . mechanism of the oxidation is not quite clear, but the probable oxidant is the starting phenacyl halide, as a half of it is converted to the corresponding acetophenone tosylhydrazone that is isolated as the main side product of the reaction (scheme ) < h( ) >. cycloaddition reactions of dimethyl benzylidenemalonate with azides provide triazolines . all compounds , except one with r ¼ ph, are stable in xylene at c. the phenyl derivative eliminates molecular nitrogen to give dimethyl , -diphenylaziridine- , -dicarboxylate . at elevated temperature, the aziridine system is not acyl azides , derived from furan, thiophene and selenophene, add slowly at room temperature to the strained double bond of -methylenebicyclo[ . . ]hept- -ene. two regioisomeric triazolines, and , which form in the first step, are unstable and decompose with elimination of nitrogen to provide aziridine derivatives . products are isolated in good yield ( - %). it is worthy to note that not only the terminal, unstrained double bond in the starting material, -methylenebicyclo[ . . ]hept- -ene, is unaffected, but also the typical dipolarophiles like esters of crotonic, propiolic and byt- -ynoic acids do not react with azides under these conditions (scheme ) < j(p ) >. -(azidomethyl)benzotriazole reacts with n-methylmaleinimide in refluxing toluene to give, after h, exclusively triazoline derivative , together with the unreacted starting materials. prolonged heating of the starting materials results in formation of more triazoline ; however, products of its decomposition to derivatives and are also present. refluxing of a solution of triazoline in toluene for h leads to a mixture of aziridine and its opened isomer in : ratio (scheme ) < jhc >. triazolines are isolated in high yield ( - %) when the reactions of glucal with azides are carried out in refluxing trimethyl or triethyl orthoformate. in all other solvents, triazolines undergo immediate conversion to triazoles . it is believed that the orthoformates act as nonbasic acid-scavenging solvents. irradiated with uv light in acetone, triazolines are smoothly converted to aziridines . without isolation, aziridines are treated with nucleophiles in the presence of a lewis acid to provide aminoglycosides in high yield (scheme ) < ja >. fluoroalkanesulfonyl azides add readily to vinyl ethers to provide triazolines in good yield ( - %). at room temperature, slow decomposition of the products is observed with evolution of nitrogen and formation of piperazine derivatives . no other products are observed. formation of piperazines must involve cleavage of the triazoline ring with formation of zwitterionic intermediates (scheme ) < jfc( ) >. reactions of fluoroalkanesulfonyl azides with tetrahydropyran proceed fast in dichloromethane at room temperature. evolution of nitrogen is observed together with formation of n-(fluoroalkanesulfonyl)- -tetrahydropyranoimines . the reactions are believed to involve , -dipolar cycloaddition of tetrahydropyran to azides with formation of relatively unstable triazolines . opening of the triazoline ring results in zwitterionic structure that is losing molecular nitrogen and rearranges to final product by , -hydrogen shift < jfc( ) >. in a similar manner, reactions of azides with dihydropyridines lead to n-alkanesulfonylimines , via labile triazolines (scheme ) < jfc( ) >. tetrachlorobenzotriazole is readily prepared in % yield by heating a solution of benzotriazole in a mixture of hydrochloric and nitric acids < ja >. , -dibromobenzotriazole is prepared in % yield by treatment of benzotriazole with bromine and silver sulfate in concentrated sulfuric acid < bmc >. under more forcing conditions, when the reaction is run in refluxing nitric acid, , , , -tetrabromobenzotriazole is formed scheme scheme , , -triazoles (scheme ) < ja >. -ethylbenzotriazole < chec( ) , chec-ii( ) > is chlorinated by refluxing in a mixture of concentrated hydrochloric and nitric acids to give -ethyl- , , , -tetrachlorobenzotriazole in % yield < ja >. a reaction of derivative with bromine in refluxing concentrated nitric acid provides -ethyl- , , , -tetrabromobenzotriazole in % yield < ja >. coupling of -aminobenzotriazole with a diazonium salt derived from -methoxyaniline generates diazo derivative . conversion of the amino group into maleinimide produces dye (scheme ). diels-alder cycloadditions of dye to diene tagged nucleotides allows for their efficient labeling < cc >. benzotriazole and its -alkyl derivatives undergo [ þ ] cycloaddition to maleinimide when irradiated with uv light at > nm to give photoadducts (equation ). in all cases, only exo diastereomers are formed. since -alkylbenzotriazoles are completely unreactive under such conditions, unsubstituted benzotriazole must react as its -h tautomer. this remarkable difference in reactivity originates from a greater differentiation in bond lengths in the benzenoid ring of -substituted benzotriazoles in comparison with their benzotriazol- -yl analogs. bonds c( )-c( ) in derivatives are relatively short ( . Å); this renders them more double bond character and makes more susceptible to [ þ ] cycloadditions < ol >. < s >. organozinc intermediate is suitable for palladium coupling with aryl iodides to provide products in - % yield. apart of derivatives with phenyl substituents that listed in scheme , -aryltriazoles derived from pyridine, thiophene, and pyrazole are also prepared this way. scheme , , -triazoles . . . iodo derivatives -iodo- , , -triazoles are found to be versatile starting materials for derivatization of the triazole ring with sp and sp carbon substituents. in suzuki coupling with areneboronic acids, -aryltriazoles are obtained in - % yield. the reaction is catalyzed by palladium dichloride-triphenylphosphine complex and proceeds well in the presence of koh as a base. in reactions with alkeneboronic acids, -(alken- -yl)- , , -triazoles are generated in - % yield. in a heck reaction with methyl vinyl ketone, -iodotriazoles are converted to unsaturated ketones in - % yield. acrolein gives aldehyde (r ¼ h) in only % yield, but the yields of products obtained from a reaction of iodide with methyl acrylate (r ¼ ome) are much higher ( - %). acrylonitrile reacts well; however, mixtures of (e)-and (z)-isomers of nitriles are obtained. heck coupling of iodide with styrene is much slower, but product is obtained as a single (e)-isomer in % yield. in a sonogashira reaction, -iodotriazoles are coupled with alkynes to provide derivatives in - % yield (scheme ) < s >. esters of , , -triazolecarboxylic acids are the most common derivatives of triazole (section . . ); therefore, their conversions to other, more useful, functionalities are of great importance. in an example given in scheme , -triazolecarbocylic ester , obtained from a reaction of b-ketoester with -chloro- -nitrophenyl azide, is hydrolyzed to free acid ( % yield) by % koh. heated to reflux in dmf for h, acid undergoes decarboxylation to triazole derivative with % isolated yield < fa >. acid chloride , obtained in % yield by refluxing a solution of carboxylic acid in thionyl chloride, is converted to azide in % yield by treatment with sodium azide in pentane. reactions of azide with amines of low nucleophilicity in refluxing dmf provide ureas in - % yield via curtius rearrangement. in these reactions, -bromo-and -bromoaniline give also the corresponding amides, which are formed by simple substitution of the n group in azide with amines, as the side products. secondary amines and primary amines with more nucleophilic nh groups (e.g., p-anisidine and t-butylamine) provide exclusively the corresponding amides (scheme ) < jccs >. ester is hydrolyzed to acid by refluxing in % naoh. in a reaction with thionyl chloride, acid is converted to acid chloride , which is isolated as a solid in % yield and consecutively converted into amide in % yield. treatment of amide with lda extracts a proton from the methyl group. the generated anion is trapped by added benzonitrile. subsequent cyclocondensation of the obtained imine anion with the amide group provides derivative in % isolated yield (scheme ) < ejm >. in an example given in scheme , tricyclic system is generated by cyclocondensation between the ethoxycarbonyl group at c- of the triazole ring and the amino group of the substituent at n- . the process that starts from catalytic reduction of the nitro group in derivative does not stop at amine , but the subsequent spontaneous cyclocondensation leads directly to product that is isolated in % yield < ejm >. ethyl -chloromethyl- , , -triazole- -carboxylate , obtained by cyclocondensation of -amino- -azidofurazan with ethyl -chloroacetoacetate, is converted to pyrrolidine derivative in % yield. heating at reflux with n hcl deprotects the carboxylic group. the obtained acid is treated with carbonyldiimidazole followed by pyridine- -carboxylic acid amidrazone to provide product in % yield. compound is a potent inhibitor of glycogen synthase kinase- (gsk- ) (scheme ) < jme >. scheme , , -triazoles cyclocondensation of diazomalonaldehyde with -fluoroaniline carried out in methanol-acetic acid provides -( fluorophenyl)- , , -triazole- -carbaldehyde in % yield. oxidation with mno in the presence of sodium cyanide in methanol converts aldehyde into methyl ester with % yield. hydrazide ( % yield) is obtained in a reaction of ester with hydrazine. product reacts with various aromatic aldehydes to give hydrazones possessing interesting antiplatelet activity (scheme ) < bmc >. scheme scheme . . . amines , , -triazoles substituted with an amino group at c- are readily available from cycloaddition of nitriles to azides. they have become convenient intermediates in synthesis of biologically active compounds. in an example given in scheme , cycloaddition of anions derived from cyanoacetamides to benzyl azide provides -amino- , , triazole derivatives in - % yield. catalyzed by phosphorus oxychloride, amines undergo cyclocondensation with dmf under mild conditions ( c) to give amidines . at higher temperature ( c), cyclocondensation occurs with elimination of dimethylamine to form , , -triazolo[ , -d]pyrimidin- -ones , which are isolated in - % yield. however, lower yield ( %) is obtained for r ¼ -meoc h . for r ¼ h, simple heating of the corresponding amine with formamide at c provides derivative in good yield < rcb >. in a synthesis similar to that depicted in scheme , aminoesters dissolved in dmf are treated with pocl and heated at - c for h. the simple work-up procedure involves pouring into ice-water, neutralization with naoh and separation of the precipitate by filtration to afford amidines in - % yield (equation ). some of the obtained amidines exhibit selective antibacterial activity < sc >. scheme , , -triazoles , -dipolar cycloaddition of -cyanoacetamide to -azido- -(hydroxymethyl)-cyclopentanol , carried out in ethanol in the presence of sodium ethoxide, provides regioselectively -amino- , , -triazole derivative in % yield. in the following step, the hydroxy groups are protected by acetylation with acetic anhydride in pyridine to give diester in % yield. surprisingly, the amino group is not nucleophilic enough to be acetylated under such conditions. diazotization (isoamyl nitrite) and substitution with iodide (diiodomethane) converts amine into -iodo derivative that is isolated in % yield. by coupling with terminal alkynes under modified sonogashira conditions, iodide is converted to alkynes in - % yield. treated with % aqueous dimethylamine in ethanol at c in sealed tubes, amido groups in derivatives undergo intramolecular cycloaddition to alkynes resulting in formation of pyridine rings. in the same step, the hydroxy groups are deprotected to provide -substituted , , -triazolo[ , -c]pyridin- -ones in - % yield (scheme ) < t >. when a solution of azide and nitrile rch cn in ethanol is treated with sodium ethoxide, the anion derived from nitrile undergoes , -dipolar cycloaddition to azide . generated anion tautomerizes to more stable aromatic form . nucleophilic attack of the triazoloamine anion on the ethoxycarbonyl group in intermediate results in elimination of an ethoxy anion and ring closure to give pyrrolo[ , -e] , , -triazolo[ , -a]pyrimidin- -one in high yield. heating of compound (r ¼ ph) in dmso in the presence of traces of water results in its hydrolysis to aminoacid . under the reaction conditions, -aminotriazole system undergoes dimroth rearrangement to more stable derivative . spontaneous cyclocondensation between the carboxylic group and the triazole ring in leads to -methyl- , , -triphenyl- , -dihydro- h-pyrrolo[ , -d] , , -triazolo[ , -a]pyrimidin- one that is isolated in almost quantitative yield (scheme ) < jhc > . similar transformations are reported for ethyl -benzyl- -azido- -phenylpyrrolocarboxylate < t >. ethyl -azido- -methyl- h-indole- -carboxylate is prepared in % yield by diazotization of amine followed by substitution of the created diazonium group with sodium azide. in cycloadditions with nitrile anions, azide forms triazole intermediates . however, under the reaction conditions, cyclocondensation of the amino and ethoxycarbonyl groups in results in formation of an additional ring. this domino process provides efficiently h-indolo[ , -e] , , -triazolo[ , -a]pyrimidines in - % yield (scheme ) < tl >. scheme , , -triazoles in a similar tandem reaction, ethyl -azido- -methyl- h-indole -carboxylate is converted to indolo[ , -e] , , triazolo[ , -a]pyrimidin- -ones via triazole intermediates that are not separated (scheme ). products are obtained in - % yield as potential intercalates of dna < h( ) >. azide is prepared from -sec-butyl- -nitroaniline in % yield by its diazotization followed by treatment with sodium azide. in a , -dipolar cycloaddition with cyanoacetamide, azide is converted to triazole that without separation is directly subjected to dimroth rearrangement to give derivative in % yield. reduction of the nitro group provides ortho-phenylenediamine in % yield < ejm >. cyclocondensation of diamine with phosgene furnishes benzimidazol- -one in % yield, whereas its reaction with sodium nitrite in % hcl leads to benzotriazole derivative , which is isolated in % yield (scheme ). products and exhibit potassium channel activating ability < fa >. scheme amino groups on the benzenoid ring of benzotriazole behave similarly to those of typical aromatic amines. -aminobenzotriazole is readily diazotized to provide diazonium chloride . in couplings with phenols or aromatic amines, diazonium derivative is converted to the corresponding azo dyes. three examples of such reactions providing dyes ( %), ( %) and ( % yield) are shown in scheme < an >. dyes of this type are used for labeling of nucleotides < tl >. functional groups can be attached to the ring nitrogen atoms in position or of unsubstituted or symmetrically substituted aromatic rings of , , -triazoles and benzotriazoles giving rise to distinctive regioisomers and , respectively. in most cases, isomers form kinetically in predominant amounts. in some instances, there is a rapid equilibrium between isomers and in solution < chec-ii( ) >. for many reactions, there is no different outcome if pure isomers , or their mixtures are employed. for these reasons and clarity of the treatment, in the following paragraphs, only triazol- -yl and benzotriazol- -yl isomers are depicted in schemes, even if the corresponding triazol- -yl isomers are also present in the mixtures. if the chemistry of isomers and differs remarkably, they are treated separately. upon treatment with n-butyllithium at À c, -methylbenzotriazole is lithiated on the methyl group to give -(lithiomethyl)benzotriazole . rapid addition of a carboxylic ester to the solution provides a-(benzotriazol- yl)alkyl ketone in high yield (scheme ) < joc >. this easy access to ketones and their reactivity makes them valuable intermediates in several syntheses. their chemistry is discussed separately in section . . . . scheme , , -triazoles when treated with bu n li, -( -chlopropyl)benzotriazole , obtained from a reaction of benzotriazole with -bromo- -chloropropane and naoh, undergoes cyclization to -cyclopropylbenzotriazole < joc >. further lithiation followed by treatment with ketones provides alcohols (scheme ). upon heating at c with low valent titanium < joc >, alcohols are converted into interesting cyclopropylidene derivatives . -( -chloro- -methylpropyl)benzotriazole gives analogous products with a methyl group on the cyclopropane ring < joc >. perhaps due to oxidizing quinoid type electronic structure of benzotriazol- -yl derivatives, some of their properties are completely different from those of isomeric benzotriazol- -yl derivatives. thus, anions derived from -alkylbenzotriazoles are rapidly converted to appropriate radicals that undergo coupling to form dimers as mixtures of racemic and meso forms < la >. when the reaction mixture is kept for an extended period of time at À c, (z)- and (e)- alkenes are formed. when benzophenone is added to the reaction mixture, alcohols are obtained in good yields; however, benzaldehyde does not react under these conditions (scheme ). in a direct comparison of the reactivity of -alkyl-and -alkylbenzotriazoles, compound was lithiated in the presence of benzophenone with equiv of lda to give a mixture of alcohol and dimer (equation ) < la >. no reaction was detected at the carbon adjacent to the benzotriazol- -yl moiety. when benzaldehyde was used instead of benzophenone, only dimer was obtained. this suggests that a-benzotriazol- -yl carbon radical reactions are much faster than those of -benzotriazol- -yl) carbanions. easy synthesis of (benzotriazol- -yl)methylarenes and -heteroarenes, and their reactivity, makes them convenient starting materials for further transformations. benzotriazole assisted side-chain elaboration of alkylarenes can be illustrated by reactions carried out on -(benzotriazol- -yl)methyl- -methylthiophene (scheme ). starting material can be readily obtained by refluxing a solution of -(hydroxymethyl)benzotriazole, -methylthiophene and a catalytic amount of tsoh in dioxane. a-deprotonation of derivative with bu n li followed by treatment with an electrophile leads to product . phenyl isocyanate, phenyl isothiocyanate, benzaldehyde, alkyl iodides, benzyl bromide, and cyclohexanone have been used as electrophiles. upon treatment with nucleophiles, the benzotriazole moiety in compounds can be substituted to give products . to replace the benzotriazolyl group with hydrogen, derivatives are treated with zinc in refluxing acetic acid < joc >. similar benzotriazole-assisted side-chain transformations are reported for benzene < joc >, pyrrole < joc , tl >, and indole < joc , sc , joc >. an additional stabilization of the negative charge provided by the adjacent aryl group in aryllithiomethyl intermediates makes -(arylmethyl)benzotriazoles attractive starting materials for many syntheses. thus, reaction of anions with esters of carboxylic acids leads to a-(benzotriazole- -yl) ketones , which can be easily reduced to carbinols scheme , , -triazoles < joc >. in another approach, adducts are produced directly by addition of anions to carbonyl groups of aldehydes or ketones < joc , joc >. low valent titanium, generated by reduction of ticl with lithium or zn-cu couple metals, converts carbinols into olefins (scheme ). the reaction sequence depicted in scheme allows introduction of a variety of substituents r : for example, chiral allylamines are produced from aminoacids, or dienes are formed stereoselectively from a,b-unsaturated aldehydes or ketones. reaction of lithio derivatives with tosylhydrazones of aldehydes leads directly to (e)-stilbenes in a stereospecific manner < joc >. reaction of anions with chloromethyltrimethylsilane provides very useful intermediates < ja >. consecutive a-lithiation followed by addition to a carbonyl group of an aldehyde leads to alkoxide . during heating, anions undergo an intramolecular rearrangement with elimination of benzotriazole to produce silylated allyl alcohols (scheme ) < joc >. this approach provides a general method for the synthesis of allyl alcohols substituted with an aryl or heteroaryl group in the b position. scheme additions of lithiated silyl derivatives to a,b-unsaturated compounds bearing electron-withdrawing substituents x provide silyl derivatives with high , -regioselectivity. elimination of trimethylsilyl and benzotriazolyl groups facilitated by heating with csf leads to g,d-unsaturated ketones, nitriles, sulfones, nitroalkanes, or amides < joc >. formylation of intermediates produces masked acroleins that provide easy access to -substituted allyl alcohols . imines obtained from condensation of aldehydes with arylamines can be similarly converted to the corresponding allylamines < joc >. additions of anions to carbonyl groups of aldehydes or ketones produce anions that upon treatment with znbr eliminate benzotriazole at elevated temperature and rearrange to ketones (scheme ) < joc >. this insertion of carbons carrying aryl or heteroaryl substituents provides a convenient method for one-carbon chain extension or ring expansion for aldehydes and ketones. the reaction is characterized by significant regioselectivity; of two groups r and r , preferences for the migration are in the order: h > aryl > alkyl and tert-alkyl > sec-alkyl > n-alkyl. substitution of one of the a-hydrogens in -(arylmethyl)benzotriazole with an alkyl bearing an aromatic ring opens new frontiers. when the distance is right, an intramolecular electrophilic attack of a-carbon on an ortho atom of the aromatic ring is possible. examples of such annulation reactions are given in scheme . thus, treatment of derivative , obtained by alkylation of intermediate with ( -bromoethyl)benzene, with zinc bromide results in formation of indane . alternatively, intermediate can be first alkylated to product and then annulated to , -disubstituted indane . for effective annulation, the link between the aromatic ring and a-carbon must consist of two or three atoms. heteroatoms are also accepted, as exemplified by phenoxy derivatives - . heterocyclic aromatic rings can be used as well; for example, annulated products and are obtained from -( -chloropropyl)- -methylindole via intermediate or its methylated analog , respectively < joc >. similar annulation reactions involving thiophene are also described < joc >. two sequential lithiations and treatments with different bifunctional electrophiles make possible one-pot syntheses of relatively complex molecules. thus, in the [ þ þ ] annulation depicted in scheme , alkylation of -benzylbenzotriazole with -bromoacetaldehyde diethyl acetal to give intermediate is followed by alkylation with n-benzylideneaniline to produce derivative . following treatment with formic acid causes cyclization to ethoxypyrrolidine that subsequently eliminates ethanol and benzotriazole to give pyrrole < jhc >. anions derived from treatment of (diarylmethyl)benzotriazoles with bu n li are readily trapped by bromoacetophenone to produce ketones . increased acidity of the hydrogens in b-position, with respect to the benzotriazolyl moiety, renders derivatives susceptible to elimination of benzotriazole to give diarylvinyl ketones (scheme ). both benzotriazol- yl and - -yl derivatives, and their mixtures, can be employed in these reactions < joc >. treatment of (diarylmethyl)benzotriazoles with metallic lithium and electrophiles results in substitution of benzotriazole with formation of derivatives . the yields are generally good, and variety of electrophiles can be employed. some unusual outcome of these reactions can tentatively be explained by a single-electron transfer (set) from lithium to starting compounds to give radical anions which eliminate benzotriazole to form relatively stable radicals . following reduction with metallic lithium (another set) converts radicals into anions that are finally trapped by electrophiles to give products < joc >. is prevented by substitution of both para positions. contrary to the behavior of an analogous adduct obtained by dimerization of triphenylmethyl radicals < crv , tl >, adduct does not dissociate back to radicals , indicating different characters of these two species. treated with bases, adduct eliminates one benzotriazole to give highly conjugated system , red in color. acidic hydrolysis converts adduct into carbinol . radicals similar to can be also generated from -(diarylmethyl)benzotriazoles, but they are less stable undergoing easily ring opening with extrusion of nitrogen < joc >. . . . . ring n-c(sp )-ctc, nonaromatic n-allylbenzotriazoles ( and its benzotriazol- -yl analog) behave somewhat similarly to n-benzylbenzotriazoles. anions derived from compounds upon treatment with n-butyllithium undergo alkylation exclusively at the position a to the benzotriazole moiety to give products (scheme ). the lithiation and alkylation steps can be repeated to produce dialkylated derivatives , possibly with two different alkyl groups. although only benzotriazol- yl compounds are shown in scheme , in this case, both benzotriazol- -yl and benzotriazol- -yl derivatives have similar reactivity and their mixtures can be used effectively in the reactions next mentioned without separation < tl >. treatment of compounds and with metallic lithium in the presence of aldehydes or ketones cleaves the bonds with benzotriazole creating allylic anions that are trapped by the carbonyl groups to produce carbinols and , respectively, in high yields. in the presence of a palladium catalyst, the benzotriazole moiety in derivatives , (and also in compound ) can be substituted with amines to give allylamines (scheme ) < joc >. sulfonamides can also be n-allylated this way when triphenyl phosphite is used in place of triphenylphosphine as a complexing catalyst agent < joc >. palladium-catalyzed reactions of derivatives and with enamines lead to g,d-unsaturated ketones < joc >. lithiated allylbenzotriazoles and react with aldehydes and ketones to form alcohols < joc >. following treatment with amines and the catalyst converts alcohols into unsaturated aminoalcohols . the reaction of allylbenzotriazoles with amines can also be carried out intramolecularly. thus, alkylation of derivatives or with -bromo- -chloropropane gives chloropropyl derivative . subsequent substitution of the chlorine atom with an alkylamino group is easily accomplished by heating a solution of derivative and amine r nh in dmf. intramolecular substitution of the benzotriazole moiety by the amino group in amines occurs at room temperature in the presence of a palladium catalyst to furnish -vinylpyrrolidines (scheme ) < joc >. similarly, alkylation of derivatives and with -bromo- -chlorobutane and the following transformations lead to -vinylpiperidines < joc >. when an additional leaving group is present at the allylic system, conversion of n-allylbenzotriazoles to fivemembered heterocyclic rings is facilitated. thus, a-ethoxy derivative undergoes smooth rearrangement promoted by znbr to give (g-ethoxyallyl)benzotriazole . after lithiation, the obtained anion is trapped by a schiff base to give anion . catalyzed by znbr , intermediate undergoes cyclization with elimination of benzotriazole and ethanol to furnish , -diarylpyrrole (scheme ) < s >. alkylation of (g-ethoxyallyl)benzotriazole occurs exclusively at the carbon producing derivatives , which, in their lithiated forms, add readily to the carbonyl group of aldehydes. obtained anions are rapidly converted to , -disubstituted furans upon treatment with znbr < s >. treatment with znbr and water converts ethoxyallyl derivatives into a,b-unsaturated aldehydes . scheme the morpholin- -yl substituent in -position behaves similarly to the ethoxy group. compound is easily prepared by double addition of benzotriazole to acrolein followed by elimination of one of the benzotriazolyl moieties induced by treatment with nah. lithiation of derivative followed by addition to a schiff base results in formation of diarylpyrrole . lithiated product is alkylated exclusively at the carbon a, in relation to the benzotriazolyl substituent, giving intermediate . subsequent treatment with a grignard reagent leads to enamine (scheme ) < tl >. a phenyl substituent at the g-carbon atom is a much weaker electron donor in comparison with the discussed above ethoxy and morpholin- -yl groups. nevertheless, -(g-phenylallyl)benzotriazole is still lithiated exclusively at the carbon as it is evident from its reaction with aldehydes and ketones leading to dienes , resulting from scheme scheme , , -triazoles elimination of benzotriazole and water from intermediate carbinols < joc >. however, the strongly electron-withdrawing phenylsulfonyl group at the g-carbon shifts the equilibrium from form to form , which upon its alkylation gives sole product (scheme ) < jhc >. hydrazones are readily obtained from the corresponding ketones. upon treatment with molar equivalents of n-butyllithium, they are deprotonated to dianions which lose rapidly the tosyl moiety to form anions that further eliminate spontaneously n and benzotriazole to give alkynes (scheme ). in the special case, when r ¼ pho (compound ), organolithium reagents eliminate first the phenoxy group to give intermediates . addition of group r to followed by elimination of tosylate, nitrogen and benzotriazole provides alkynes . due to the stronger electron-donating influence of the phenylthio group in compound , the benzotriazolyl moiety is eliminated preferentially leading to unstable sulfide , which is converted by excess bu n li to acetylene < joc >. treated with only molar equivalents of bu n li, hydrazones behave differently. bond cleavage between n- and n- of the benzotriazole ring in the initial dianion leads to dianion . following ring closure produces benzotriazine system . the next step of the transformation sequence depends on substituent r . when r is an aryl, the structure is stable enough to survive work-up as dihydrobenzotriazine . when r is an alkyl, the whole hydrazone group is eliminated producing benzotriazine (scheme ) < sc >. when phenoxy derivative is subjected to such treatment, the dianion formed, analogous to , loses molecular nitrogen to give energetic dianion that quickly undergoes cyclization/elimination to furnish indole . treated with thionyl chloride, hydrazones (r ¼ h, r ¼ aryl) undergo cyclocondensation to thiadiazoles ; whereas from aliphatic derivatives (r ¼ h, r ¼ alkyl), mixtures of thiadiazoles and are formed < h( ) >. oximes can be converted to their tosylates , but use of a large excess of koh converts them directly into h-azirines (scheme ) < joc >. the benzotriazolyl moiety in azirines can be substituted by nucleophiles (organomagnesium reagents, potassium phthalimides, and sodium thiophenoxide) to give disubstituted azirines . there are several methods available that lead to a-benzotriazolyl ketones (scheme ). thus, the anions derived from n-alkylbenzotriazoles can be trapped by acid chlorides or esters < joc , h( ) >. alternatively, in reactions with aldehydes, n-alkylbenzotriazoles are converted to b-benzotriazolyl alcohols that are consecutively oxidized to ketones < la >. other approaches include substitution of halogens in a-haloketones by benzotriazole, < jhc , ark(iii) >, reactions of esters of a-benzotriazolylcarboxylic acids with grignard reagents < joc >, addition of benzotriazole to but- -ene- , -diones < pjc >, and reactions of n-chlorobenzotriazole with trimethylsilyl derivatives of the corresponding ketones < jcm >. in an interesting modification of the above methods, benzotriazoleacetic acid < la > is alkylated to produce carboxylic acids , which are then dilithiated and treated with acyl halides to give ketones , via unstable intermediates < ark(iii) >. removal of the benzotriazole moiety from ketones can be accomplished in several modes. thus, treatment of derivative with lithium naphthalenide followed by methyl iodide provides ketone in % yield (scheme ) < ark(iii) >. upon treatment with buthyllithium, anions derived from -(arylmethyl)-benzotriazoles can be trapped by esters of arylcarboxylic acids to give ketones which are readily oxidized with molecular oxygen under mild conditions to give diaryl , -diketones in good yields. this provides a convenient synthetic method for unsymmetrical , -diketones, especially valuable when ar and ar are heterocyclic systems < joc >. when trimethylsilyl derivatives are treated with tfa in dichlorometane, both the trimethylsilyl and benzotriazolyl groups are eliminated to provide , -diarylpropen- -ones in high yields < joc >. heating of ketones with csf in dmf yields also propenones , but usually a rearrangement occurs and the corresponding chalcones are the main products < j(p ) >. samarium iodide induced removal of benzotriazole from ketones works well with variety of groups r to provide ketones in high yield under mild reaction conditions < h( ) >. [ þ ] annulation reaction of (benzotriazol- -yl)acetone with chalcones provides an efficient route to , -diarylphenols . the reaction is catalyzed by naoh in ethanol. in the first step, michael addition of ketone to the ctc bond of a chalcone gives diketone . in the second step, condensation between the carbonyl scheme group at ar with the methyl group gives cyclohexenone . in the following steps, benzotriazole is eliminated, and the obtained cyclohexadienone rearranges to phenol (scheme ) < joc >. diketones , obtained by michael addition of (benzotriazol- -yl)acetophenones to chalcones, cannot undergo such cyclocondensation to form phenols, but they react readily with ammonium acetate to give pyridines < s >. some chemistry of propargylbenzotriazole and its applications in organic synthesis is already described in chec-ii( ) < chec-ii( ) >. further development in this field led to very useful oxirane derivatives < joc >. primary amines in refluxing isopropanol cause opening of the oxirane ring with addition of the amine to form aminoalcohols that undergo spontaneous intramolecular cyclocondensation to give pyrroles (scheme ). the benzotriazolyl moiety in can be directly substituted with nucleophiles or the molecule can be first lithiated at its a-carbon then treated with electrophiles and finally the benzotriazolyl group be removed to provide further classes of substituted pyrroles < joc >. -( -hydroxyethyl)pyrroles obtained from reactions of oxiranes with -aminoethanol are readily converted to , -dihydro- h-pyrrolo[ , -a]pyrroles < joc >. analogously, -( -hydroxypropyl)pyrroles give homologous , , , -tetrahydropyrrolo[ , -a]pyridines. easy manipulation with the benzotriazolyl moiety allows for convenient synthesis of a wide variety of fused [ , -a]pyrroles. a similar chemistry of indoles is also described < joc >. lithiated pyrrole derivative undergoes michael addition to a,b-unsaturated aldehydes or ketones, and the obtained adducts readily undergo cyclization to indoles in the presence of acids as catalysts < tl >. similarly, lithiated -[(benzotriazol- -yl)methyl]furans , obtained from oxiranes by their cyclization promoted by bu t ok, react with a,b-unsaturated aldehydes or ketones to provide benzofurans < joc >. , -dipolar cycloaddition of propargylbenzotriazole to nitrile oxides (r-cuc-nto) gives oxazoles in excellent yields < jhc >. addition of lithiated propargylbenzotriazole to aldehydes or ketones followed by methylation with iodomethane provides ethers . treatment with metallic lithium and the same or different aldehydes or ketones r r cto converts ethers into protected alkynediols < tl >. introduction of an alkoxy group to the a-carbon opens new possibilities regarding transformation and benzotriazole removal process from -propargylbenzotriazole. thus, ether < joc > can be coupled with vinyl triflates or bromides to give enynyl products . following alkylation at the carbon gives unstable derivatives that are readily hydrolyzed to enynyl ketones . in another approach, alkynes are coupled with aryl iodides, and the obtained ethers are alkylated and hydrolyzed to ketones (scheme ) < joc >. michael addition of (benzotriazol- -yl)acetonitrile to a,b-unsaturated ketones followed by heterocyclization provides new means for preparation of , , -trisubstituted pyridines. the reaction is catalyzed by bases. in the presence of secondary amines, a nucleophilic attack of amine on the cn group in adduct initiates the cyclization to tetrahydropyridine that subsequently eliminates water and benzotriazole to give pyridine . analogously, in the presence of naoh, pyridone forms, via intermediate (scheme ) < joc >. in solution, -(a-aminoalkyl)benzotriazoles are in equilibrium with iminium cation and hence with their benzotriazole- -yl isomers (scheme ). protonation or complexation of the benzotriazolyl moiety (e.g., mg, zn, b, al reagents) facilitates the transformation. intermediate iminium cations can be trapped by nucleophiles providing synthetic pathways to various amines. many such reactions are described in chec-ii( ) < chec-ii( ) >, and some newer results are compiled in reviews < t >. for clarity, in the following schemes of this subsection, the benzotriazol- -yl structures are often omitted when such derivatives are present in the reaction mixtures, and their chemistry is not different from that of the benzotriazol- -yl derivatives. when there is a clear distinction in chemistry, the benzotriazol- -yl isomers are treated separately. scheme . . . . substitution of benzotriazole with nucleophiles since the publication of chec-ii( ), the range of nucleophiles used for substitution of the benzotriazolyl moiety in derivatives and applied reaction conditions have been widely expanded. thus, treatment of benzotriazolyl amines with organozinc bromoacetate, provides conveniently amines (scheme ) < t . this extends the scope of this reaction to substituents bearing groups sensitive to organomagnesium reagents previously used for this purpose < chec-ii( ) >. reactions of intermediates with alkenylmagnesium and alkynylmagnesium reagents carried out in toluene lead to allylamines and propargylamines in excellent yield < s >. less stable perfluoroalkylmagnesium reagents give amines when the reactions are carried out at low temperature with additional activation of derivatives with trifluoroboron etherate < tl >. propargylamines can be also conveniently prepared in reactions of compound with dialkynyldiethylaluminates < joc >. treatment of benzotriazolyl derivatives activated by addition of znbr with sodium salts of amides allows preparation of acylaminals < s >. n-(a-aminoalkyl)benzotriazoles react smoothly with silyl enolates in the presence of lanthanide catalysts to provide aminoketones (r ¼ ph) or aminoesters (r ¼ alkoxy or phenoxy group) in practically quantitative yields < tl >. in the presence of aluminium chloride, the iminium cations derived from -[(dialkylamino)methyl]benzotriazoles (r ¼ h) add to the c- atom of allyltrimethylsilane, and the obtained adducts rearrange to aminosilanes via a , -hydride shift from group r to c- of the allyl system < om >. polymer-bound derivatives provide a convenient tool for combinatorial synthesis of compound libraries < jco >. scheme , , -triazoles addition of benzotriazole to enamines derived from cyclic or acyclic dialkyl ketones gives a-aminoalkylbenzotriazoles - , in which the benzotriazole moiety can be easily substituted by an alkyl, aryl, alkenyl, or alkynyl group in reactions with appropriate organomagnesium or organolithium reagents to form corresponding tertiary amines (scheme ). this approach extents the scope of tert-alkylation of secondary amines < joc >. condensation of succinaldehyde (obtained by hydrolysis of , -dimethoxyfuran) with benzotriazole and (s)- phenylglycinol provides ( s, r, ar)- -(benzotriazole- -yl)- -phenyl[ , -b]oxazolopyrrolidine (scheme ). oxazolopyrrolidine is a convenient synthon for asymmetric syntheses of -substituted and , -disubstituted pyrrolidines. thus, in a reaction with allyltrimethylsilane, the benzotriazolyl moiety is substituted with an allyl group to provide derivative . hydrogenation of product cleaves the chiral auxiliary to give ( r)- -propylpyrrolidine. alternatively, reactions of intermediate with grignard reagents lead to chiral , -disubstituted pyrrolidines < joc >. direct treatment with organomagnesium reagents converts oxazolopyrrolidine into mixtures of cis and trans , -disubstituted pyrrolidines that can easily be separated by chromatography scheme < tl >. again, hydrogenation removes readily the chiral auxiliary from the nitrogen atom in intermediates and . similar treatment of the piperidine analog of compound , obtained by condensation of glutaraldehyde with benzotriazole and (s)- -phenylglycinol leads to chiral , -disubstituted piperidines < joc >. chiral (pyrrolidin- -yl)-phosphonates are obtained from oxazolopyrrolidine (prepared by condensation of , -dimethoxytetrahydrofuran with benzotriazole and (r)-phenylglycinol) which reacts with triethyl phosphite to give intermediate that is alkylated to produce derivatives and finally deprotected by hydrogenation < tl >. condensation of ethyl glyoxylate with (s)- -phenylglycinol and formaldehyde gives n-[(benzotriazol- -yl)methyl]oxazolidine in which the benzotriazolyl moiety can be substituted with various nucleophiles in the presence of znbr to provide chiral n-substituted oxazolidines < jcm >. derivatives of optically active a-aminocarboxylic acids are also used successfully in reactions with aldehydes and benzotriazole. condensation of esters of a-aminocarboxylic acids with formaldehyde and benzotriazole gives derivatives in which the benzotriazolyl moiety can be substituted by nucleophiles to give various products (scheme ) < joc >. amides derived from a-aminocarboxylic acids undergo condensation with succinaldehyde and benzotriazole to give benzotriazolyl derivatives from which the benzotriazolyl group can be readily removed by treatment with sodium borohydride to furnish optically active tetrahydro- h-pyrrolo[ , -a]imidazol- -ones < joc >. analogous reactions with glutaraldehyde provide corresponding hexahydro[ , -a]pyridin- ( h)-ones < joc >. diamines obtained by reduction of amides with lithium aluminium hydride undergo condensation with benzotriazole and two molecules of formaldehyde to give derivatives in which the benzotriazolyl moiety is easily substituted by various nucleophiles to provide unsymmetrically substituted chiral imidazolidines < joc >. similarly to imidazolines , derivatives , obtained by condensation of monosubstituted , -propanediamines with formaldehyde and benzotriazole, react with organomagnesium reagents to give corresponding hexahydropyrimidines bearing two different substituents on the nitrogen atoms < joc >. analogously, condensation of scheme , , -triazoles -aminobenzylamine with formaldehyde and benzotriazole produces compound in which the benzotriazolyl groups can be substituted by treatment with organomagnesium reagents or other strong nucleophiles. the conversion can be carried out stepwise with two different grignard reagents, first substituting the more reactive benzotriazolyl group connected to the nitrogen atom in position < joc >. treatment of benzotriazolyl derivatives , originating from glycine, with sodium hydride in refluxing thf results in esters of trans- , -piperazinedicarboxylic acid , although formation of aziridine systems could be anticipated < hco >. the molecular structure of products is confirmed by nmr and x-ray crystallographic data, but the mechanism of their formation is not yet clear. the ylide obtained from (methyl)triphenylphosphonium bromide reacts with morpholine derivatives to give phosphonium salts which upon treatment with n-butyllithium are converted to new ylides . in a reaction with aldehydes, ylides form n-( , -disubstituted allyl)-morpholines (scheme ) < aq >. another less common nucleophile that can be used for substitution of the benzotriazolyl moiety in n-(a-aminoalkyl)benzotriazoles is an adduct of n-benzylthiazolium salt to an aldehyde which reacts with compounds to produce adducts . under the reaction conditions, refluxing in acetonitrile, salts decompose to liberate aminoketones < h( ) >. due to the high strain energy of a three-membered ring, an interesting case is represented by benzotriazolylaziridines. upon heating, the c-c bond of the aziridine ring in (benzotriazol- -yl)aziridines is cleaved to give azomethine ylides that can be trapped by diethyl acetylenedicarboxylate to form unstable pyrroline intermediates which consecutively eliminate benzotriazole to furnish pyrroles (scheme ). by contrast, in (benzotriazol- yl)aziridines , the c-n bond is cleaved, and the dipolar species undergo [ þ ] cycloaddition to acetylenedicarboxylate to form pyrrolines that aromatize to pyrroles by elimination of benzotriazole < joc >. -[a-(dialkylamino)benzyl]benzotriazoles , obtained by condensation of benzaldehydes with benzotriazole and dialkylamines, react with sodium phenoxides to produce -[a-(dialkylamino)benzyl]phenols (equation ). derivatives of heterocyclic aldehydes (ar ¼ pyridin- -yl, pyridin- -yl, or thiophen- -yl) react similarly < joc >. as a practical example of such approach may serve derivatization of , -diaza- -crown- -ether that is first condensed with benzotriazole and formaldehyde, and then the benzotriazolyl moiety is substituted with -hydroxycoumarin < joc >. examples in scheme show that the cyclization is not affected by even relatively complex substituents on the carbon of the phenethylamine system, and the stereochemistry can be carried from the starting amines ( , ) through the benzotriazolyl intermediates ( , ) to the final products ( , ) < ta , joc >. some of the nucleophiles used for substitution of benzotriazole in derivatives of type are listed in scheme , but many others can be successfully employed as well < s >. electron-rich heterocyclic rings are also used in such cyclocondensations. thus, -( -aminoethyl)pyrazole reacts with formaldehyde and benzotriazole to give bicyclic system < joc >, and an analogous reaction of -( -aminoethyl)- -methylindole leads to tricyclic system < joc >. seven-membered rings are also formed as a result of analogous [ þ ] cyclocondensations. compound was obtained from a reaction of -phenoxyethylamine with formaldehyde and benzotriazole, and compound was obtained from a similar reaction n-( -aminoethyl)-n-methylaniline < j(p ) >. in all of these derivatives, the remaining benzotriazolyl moiety can be easily substituted with various nucleophiles. reactions with dialdehydes allow the introduction of two additional rings in one step. thus, condensation of -( -aminoethyl)pyrrole with glutaraldehyde and benzotriazole gives tricyclic intermediate in which the benzotriazolyl moiety can be readily substituted with nucleophiles to give products (scheme ) < joc >. condensation of ethyl ester of l-tryptophan with , -dimethoxytetrahydrofuran and benzotriazole in acetic acid gives tetracyclic intermediate which upon treatment with nucleophiles (silyl derivatives) is converted to products < t >. scheme , , -triazoles cyclocondensations of n-(benzotriazolylmethyl)anilines with electron-rich unsaturated compounds of the type r chtchx lead to , , , -tetrahydroquinolines (scheme ). in the first step, an iminium cation generated by dissociation of derivative attacks the double bond of compound r chtchx to generate cation . in the second step, an intramolecular electrophilic attack of cation on the ortho atom of the aniline ring furnishes tetrahydroquinoline . depending on the reaction conditions and nature of the group x, benzotriazol- -yl (and benzotriazol- -yl) or group x remains as the substituent in position of tetrahydroquinoline . for compounds lacking good leaving group, like styrenes < jhc >, alkenes < jhc , jhc >, n-vinylamides < joc , jhc > and -vinylcarbazole < joc >, it is the group x that remains. in the case of enolizable aldehydes < joc > or vinyl ethers < joc >, the benzotriazolyl moiety is usually retained as a substituent at the c- atom of tetrahydroquinoline allowing further derivatization by substitution of benzotriazole with nucleophiles. comparison of this new synthetic method for , , , -tetrahydroquinolines with more classical ones has been reviewed < t >. derivatives of higher aldehydes ( , r ¼ h) allow introduction of an additional substituent into position of tetrahydroquinolines making variation of the tetrahydroquinoline system very versatile < joc >. in n,n-bis(benzotriazolylmethyl)anilines , both benzotriazolylmethyl groups may be involved in the cyclocondensation process producing julolidines < joc , joc >. when the nitrogen atom supporting the benzotriazolylalkyl group is already incorporated into a ring, like in structure , an additional ring is added to the heterocyclic ring system < s , jhc >. use of alkynes instead of alkenes in the reaction depicted in scheme results in formation of , -dihydroquinolines < jhc >. derivatives of aminoheterocycles, like compound < t > also undergo readily [ þ ] cyclocondensation with enol ethers and vinylamides. n,n-bis(benzotriazolylmethyl)amines derived from benzyl or phenethylamines undergo cyclocondensation with allylsilanes catalyzed by sncl to give -chloropiperidines (scheme ) < joc >. this [ þ ] cyclocondensation is assumed to proceed in two steps via intermediate . [ þ ] cyclocondensation of derivatives , originating from various aromatic and aliphatic amines, with dilithiated benzamides leads to , -benzodiazepin- -ones < joc >. scheme , , -triazoles < joc >. condensation of succinaldehyde with arylhydrazines and benzotriazole gives -aminopyrrolidines that upon treatment with organomagnesium reagents rearrange to , , , -tetrahydropyridazines < s >. treatment of n-(a-aminobenzyl)benzotriazoles with samarium diiodide generates radicals that undergo coupling to form vicinal diamines (scheme ) < tl >. formation of intermediate radicals at low temperature is confirmed by epr < ol >. short-living radicals are readily converted to more stable radicals by treatment with -methyl- -nitrosopropane. when one of the substituents on the amine nitrogen atom is ready to trap a radical formed by treatment of n-(a-aminoalkyl)benzotriazole with smi , cyclization may occur. such a situation is depicted in scheme . thus, ( -penten- -yl)amine derivative is reduced to radical that is then rapidly trapped by the alkenyl group and . . . . derivatives of amides, thioamides, sulfonamides, and related compounds benzotriazolylalkyl amides are easy to prepare by condensation of amides with aldehydes and benzotriazole. the chemistry of compounds is to some extent similar to that of the corresponding amines discussed above; however, increased stability of derivatives and higher stability of the products of their reactions bring additional synthetic possibilities. thus, the reaction with organozinc reagents, usually prepared in situ from zinc powder and alkyl bromides, leading to amides is analogous to the reaction of the corresponding amines (scheme ) < t , tl >. by contrast, the reaction with sodium alkoxides producing n-(a-alkoxyalkyl)amides is unique to derivatives < joc , joc >. similarly to the amine analogs, allylation with allyltrimethylsilane converts compounds to unsaturated amines < joc >, but the reaction with enamines leading to ketoamides < joc > has little precedent among the corresponding derivatives of amines. enol esters derived from ketones react as well, as it is illustrated by the example of acetone derivative < joc >. anions derived from t-butyl esters can also be used for substitution of benzotriazole to give b-amidoesters < joc >. enolizable aldehydes can be used for substitution of benzotriazole in derivatives as well. although the original product, , is unstable under the reaction conditions, in the case of r being a reactive aromatic ring, subsequent cyclocondensation leads to a stable n-acylated -aminoindene < joc >. condensation of , -dimethoxy- , -dihydrofuran with benzotriazole and an amine carried out in refluxing acetic acid produces -benzotriazolylpyrrolidin- -one in good yield and with strong prevalence of benzotriazol- -yl isomer < joc >. substitution of the benzotriazole moiety with nucleophiles gives -substituted -pyrrolidinones (scheme ). when a reactive aromatic ring is attached to the nitrogen atom of -pyrrolidinone by a two-or three-atom linker, the ortho carbon of the ring may serve as a nucleophile providing tricyclic systems < joc > or < joc >, respectively. n-(benzotriazol- -yl)methyl derivatives of boc-protected amines behave similarly to amides. thus, treatment of an anion derived from compound with methoxychalcone leads to -imidazolidinone with the substituents at c- and c- oriented trans. subsequent treatment with nucleophiles gives product stereoselectively (scheme ) < joc >. in the second reaction presented in scheme , alkylation of compound at the carbon gives derivative which upon treatment with tfa eliminates readily benzotriazole leading to -alkylidene- , -dihydro- h-isoindolo- -ones < tl >. scheme , , -triazoles the double anion, obtained from thioamide upon its treatment with lda or bu n li, reacts with alkylating agents to give a-alkyl derivatives (e ¼ alkyl) or with aldehydes to give a-( -hydroxyalkyl) derivatives [e ¼ rch(oh)] (scheme ) < t >. the following substitution of benzotriazole with nucleophiles results in thioamides . this simple process allows introduction of two different groups to the carbon atom attached to the thioamide nitrogen. use of only molar equivalent of the base makes possible selective methylation of the sulfur atom to give thioamidate . the anion derived from compound upon its treatment with sodium hydride adds readily to electron-poor double bonds to create unstable intermediate anion that spontaneously eliminates benzotriazole and thiomethoxide to generate pyrrole < t , joc >. in the presence of znbr , the benzotriazole moiety in dithiocarbamates can be readily substituted by mercaptans or phosphites providing new access to derivatives < ark(ix) >. cyclic analogs of , , thiazolidine- -thione and tetrahydro- h- , -thiazine- -thione, react similarly. substitution of the benzotriazolyl group in sulfonamide derivatives with cyanides occurs under mild conditions in dmso, alcohol or even water providing a good way for preparation of n-(a-cyanoalkyl)sulfonamides < sc >. in the presence of bu t ok, (benzotriazole- -yl)methyl isocyanide (betmic) undergoes alkylation on the methylene group to give isocyanide . the anion derived from , upon its treatment with bu t ok, adds to the electrondeficient double bonds of a,b-unsaturated ketones, esters or nitriles to produce pyrroles . a similar reaction of isocyanide with schiff bases provides imidazoles . in both cases, use of unsubstituted isonitriles in the reactions leads to heterocycles and with r ¼ h (scheme ) < h( ) >. the rich chemistry of parent iminophosphorane (r ¼ h), betmip, is described in chec-ii( ) < chec-ii( ) > and in a review article < jpr >. aza-wittig reactions of iminophosporanes with aldehydes provide imines . treated with an excess of allylmagnesium reagent, imines are converted into n,n-bis( -butenyl)amines , interesting intermediates for construction of heterocyclic systems (scheme ) < joc >. imines , particularly with r ¼ r ¼ aryl, can be also conveniently prepared by direct condensation of aldehydes with benzotriazole and ammonia < joc >. treatment of imine with n-butyllithium produces anion that adds readily to isothiocyanates to give intermediate anion . loss of a benzotriazole anion followed by tautomerization leads to aminothiazole . this way, -aminothiazoles bearing aryl or heteroaryl substituents at c- and c- can be easily prepared in good yields < joc >. reaction of n-[(benzotriazol- -yl)methyl]amide with pcl gives chloroimine , which upon treatment with bu t ok is converted to nitrile ylide . benzyl esters of a,b-unsaturated acids used as dipolarophiles trap species to generate pyrroles (scheme ) < jhc >. when no trapping agent is added, the n- atom of benzotriazole act as a nucleophile, and tricyclic system is formed < tl >. addition of benzyl bromide scheme scheme , , -triazoles to the reaction mixture causes formation of a new tricyclic system that, according to the x-ray diffraction analysis, has structure < joc >. a reasonable explanation of this phenomenon is as follows. benzylation of species creates cation that, affected by excess bu t ok, loses its acidic benzylic proton to form betaine . electron shift towards the positive charge causes breaking of the n-n bond. freed , , -triazolyl group in intermediate rotates to a more favorable position, and a bond between carbon atoms forms. finally, oxidation of newly formed betaine , probably by atmospheric oxygen during work-up, results in stable heterocyclic system . another possible mechanism, proposed by authors of the report < joc >, starts from formation of the c-c bond by direct benzylation of nitrile ylide that is followed by several rearrangements to produce final product . condensation of sulfoximine with an aldehyde and benzotriazole produces n-[a-(benzotriazol- -yl)alkyl]sulfoximine . treatment with allyl silanes in the presence of bf etherate or with organozinc reagents allows substitution of the benzotriazolyl moiety in compound to produce variety of substituted sulfoximines (scheme ) < ark(xv) >. scheme . . . . bis(heterocycle-n-yl)alkanes one of the simplest molecules belonging to this category is that of bis(benzotriazol- -yl)methane . treated with an excess of bu n li, molecule generates polyanion which, when subjected to reactions with various electrophiles, gives c-a and/or c- substituted derivatives ; an equimolar mixture of c-a, c-a, c- ( a) and c-, c- , c- ( b) trimethylated products forms in a reaction with iodomethane (scheme ). under these conditions, reaction of -methylbenzonitrile with gives enamine in % yield < t >. , -bis(benzotriazol- -yl)ethane treated with molar equivalents of buli undergoes lithiation at c-a and c- to give intermediate (scheme ). consecutive treatment of the reaction mixture with iodomethane leads to dimethylated product a in high yield. in a reaction with iodoethane, apart of diethylated product b, monoethylated derivative c is also formed. allyl iodide and benzyl bromide gives exclusively substitution at c-a ( d and e, respectively). reaction with benzylidene bromide leads to bromination at c- ( f). reaction with p-tolyl isocyanate gives diamide g, and that with diethyl oxalate produces triazoloquinolone < t >. scheme , , -triazoles condensation of benzaldehydes with benzotriazole in the presence of thionyl chloride readily gives a,a-bis(benzotriazol- -yl)toluenes that can be considered as , -gem-dicarbanion equivalents. thus, treatment of derivatives with ketones and lithium metal suspended in thf at À c generates substituted propylene glycols (equation ) < tl >. in the presence of koh, tris(benzotriazol- -yl)methane reacts with nitrobenzenes to produce p-[bis(benzotriazol- yl)methyl]nitrobenzenes (scheme ) < tl >. this vicarious nucleophilic substitution of hydrogen < s > can be considered as a convenient way to p-nitrobenzaldehydes . meta and para substituted nitrobenzenes do not react with compound under these conditions, probably due to steric reasons, but -nitronaphthalene reacts producing a naphthalene analog of derivative . n-[(benzotriazol- yl)methyl]azoles are dialkylated with , -dibromobutane to give , -disubstituted cyclopentanes . , -dibromopentane reacts similarly producing cyclohexanes (scheme ) < joc >. two alternative methods are used for elimination of benzotriazole: treatment with znbr or with koh. in some cases, acidic elimination works better, in others, basic elimination is preferred. both methods convert cyclopentane derivatives to -(cyclopenten- yl)azoles and their cyclohexane analogs to -(cyclohexen- -yl)azoles . -protons in pyridinium salts are acidic enough to be removed by weakly basic triethylamine. obtained ylides add to esters of -bromo- -alkenecarboxylic acids or analogous benzonitriles to give intermediate betaines . a nucleophilic attack of the anionic site on c- of the pyridinium system followed by elimination of hbr leads to indolizines (scheme ) < joc >. when esters of ordinary a,b-unsaturated acids (no br at c- ) are used in these reactions, indolizines are also formed but with much lower yields due to the oxidation required of the intermediate dihydro analogs of derivatives that form first. when treated with dbu at elevated temperature, -[(benzotriazol- -yl)methyl}- -aminopyridine salts eliminate rather the n-h proton than the c-h one. intermediates can be trapped with aromatic aldehydes to create betaines . the consecutive cyclocondensation and elimination of benzotriazole results in formation of imidazolo[ , -a]pyridines in good yields (scheme ) < joc >. aldehydes with enolizable a-protons fail to give bicyclic systems , producing corresponding enamines instead. substitution of the benzotriazole moiety in compounds with organomagnesium reagents has been discussed previously < chec-ii( ) >. newer applications of organometallic reagents to reactions with a-benzotriazolyl ethers are outlined in scheme . thus, reactions of benzotriazolyl ethers with sodium dialkynyldiethylaluminates provide propargylic ethers in high yields < joc >. -benzotriazolyl- , -dioxolane is a convenient equivalent of the formyl cation; its reactions with organozinc reagents lead to masked formylated products < joc >. in the presence of lewis acids, n-(diethoxymethyl)benzotriazole undergoes addition to enol ethers to produce -(benzotriazol- -yl)- , , -trialkoxypropanes . reactions with grignard reagents convert derivatives into -alkoxyalkanal acetals < joc >. a-protons in alkoxy derivatives are acidic enough to be pulled out by bu n li. nascent anions can be trapped with alkylating agents to give a-alkylated products . geminal benzotriazol- -yl and alkoxy substituents in compound behave as a protected carbonyl group; they can be removed by acidic hydrolysis to furnish ketones (scheme ). in this way, a conversion is made from aldehydes r chto (the precursor of ) to ketones r r cto. analogously, use of chlorosilanes as alkylating agents r x leads to acylsilanes (r ¼ aryl, r ¼ sime r) in good yields < om >. many other electrophiles can be used to trap anions ; four classes of such compounds are presented in scheme . thus, the reactions with aldehydes or ketones lead to a-hydroxyketones via intermediates . the reactions with acylating agents lead to vicinal diketones via intermediates . the reactions with imines give a-aminoketones via intermediates , and those with esters of a,b-unsaturated carboxylic acids give g-ketoacids via intermediates . examples of representative products - are collected in table . other electrophiles used in such reactions that are not shown in table include chlorotrimethylsilane < joc >, isocyanates < joc , joc >, isothiocyanates < joc >, diethyl carbonate < joc >, and ethyl chloroformate < joc >. benzotriazolyloxiranes can be prepared in practically quantitative yields by epoxidation of the corresponding alkenes with dimethyldioxirane, for example, conversion of alkene to oxirane (scheme ). at very low temperatures, substitution of the a-proton in oxirane is possible; just its treatment with lda at À c followed by benzyl bromide leads to a-benzyloxirane , via lithiated intermediate . at higher temperatures, rearrangement of lithiated oxirane to ketone is observed. stereochemistry of the molecule is preserved during these transformations. significant stabilization of the oxirane ring by the benzotriazolyl substituent makes its opening difficult; thus, heating in n sulfuric acid was required to convert oxirane into hydroxyketone < ark(v) >. addition of a silyl substituent into a-position of the a-(benzotriazol- -yl)alkyl ether brings additional possibilities. thus, lithiation of silyl ether followed by treatment with an aldehyde or ketone gives unstable b-hydroxy-a-silyla-(benzotriazol- -yl)alkyl ether that spontaneously eliminates silanol to give vinyl ether (scheme ). treatment with znbr followed by hydrolysis with a diluted acid removes both the benzotriazolyl and the methyl groups to furnish carboxylic acid . in this way, in a simple manner, aldehydes and ketones are converted to one-carbon homologated carboxylic acid < s >. scheme , , -triazoles scheme table n-(a-alkoxyalkyl)benzotriazoles and products of their hydrolysis scheme when crude reaction mixtures containing derivatives (scheme ) are treated with three-fold excess of znbr and heated to reflux, benzotriazole is eliminated and the products rearrange to a-alkoxyketones (scheme ). the proposed mechanism involves formation of oxiranes (in some cases isolated intermediates) which then open to betaines . subsequent migration of substituent r furnishes a-alkoxyketone . the conversion is characterized by remarkable regioselectivity with only one regioisomer formed from intermediates with r ¼ r with the order of migration: h > ar > alkyl (tert-alkyl > sec-alkyl > n-alkyl) < joc >. a similar rearrangement of derivatives is promoted by treatment with p-tsoh in acetic acid < tl >. treated with strong bases, a-(benzotriazol- -yl)alkyl ethers derived from benzyl alcohols undergo [ , ]-wittig rearrangement to ketones (scheme ). for the derivatives of aromatic aldehydes (r ¼ aryl), lda is a base strong enough to pull the benzylic proton from ether to give anion . the subsequent [ , ]-wittig rearrangement produces alkoxide which spontaneously expels benzotriazole anion to furnish ketone < ark(vii) >. in the case of formaldehyde derivatives (r ¼ h), a stronger base, bu n li, is required to do the job; however, it is difficult to stop the reaction sequence at the ketone stage, and alcohols are obtained as the major products < h( ) >. a-(benzotriazol- -yl)allyl ethyl ether can be readily alkylated to give tertiary ethers . grignard reagents attack ethers exclusively in g-position (s n reaction) producing enol ethers which are hydrolyzed during acidic work-up to ketones (scheme ). high regioselectivity of these reactions is rationalized by substitution of the a-carbon atom with bulky groups < joc >. scheme , , -triazoles treated with a suspension of metallic lithium at low temperatures, ethers are reduced to anions . addition of an aldehyde or ketone to the reaction mixture allows trapping these anions with formation of b-hydroxyethers and enol ethers (scheme ). for r ¼ h, in reactions with aliphatic aldehydes and ketones, the a-attack prevails to give hydroxyethers as the major products. in other cases, products resulting from the g-attack of anion on a carbonyl group become dominant. stereochemistry of products (cis : trans) also depends strongly on substituents r with the cis geometry prevailing ( : to : ) for r ¼ h or pr. when r ¼ ph, mostly trans isomers ( : ) are formed < tl >. condensation of benzotriazole with -carboxybenzaldehyde gives -(benzotriazol- -yl)phthalide (scheme ). the anion derived from phthalide adds to the b-carbon atom of a,b-unsaturated carbonyl compounds e to produce anion that by intramolecular nucleophilic attack on the phthalide carbonyl group is converted to anion . spontaneous expulsion of benzotriazole from molecules followed by aromatization leads to , -dihydroxynaphthalenes < sc >. two examples discussed above involve participation of an ortho substituent on the aromatic ring in the cyclization process; however without such a substituent, a-(benzotriazol- -yl)alkyl aryl ethers can also be employed as the starting materials for introduction of an additional ring. thus, lithiation of ether followed by treatment with an aldehyde generates b-hydroxyether (scheme ). treated with znbr and heated at c, derivatives eliminate benzotriazole and rearrange to a-aryloxyketones . when heating with znbr is continued at even higher temperature ( - c), cyclocondensation of ketones with involvement of the phenyl ortho carbon atom leads finally to benzofurans < j(p ) >. n-c(sp )-x (x ¼ heteroatom ¼ n or o) the preparation of a-(benzotriazol- -yl)alkyl thioethers and their reactions with nucleophiles have been discussed before < chec-ii( ) >. to some extent, a-(benzotriazol- -yl)alkyl thioethers react similarly to the related ethers. thus, thioether can be lithiated with bu n li then treated with an aldehyde or a ketone to give a sulfur analog of a-(benzotriazol- -yl)-b-hydroxyalkyl ether . similarly to ethers , their sulfur analogs can be hydrolyzed to a-hydroxyketones (scheme ) < joc , joc >. lithiated, then treated with an aldehyde or ketone followed by znbr , thioether is converted to the corresponding benzothiophene < j(p ) >, in analogy to conversion of ether to benzofuran . similarly to conversion of ethers to , -dihydrobenzofuran- -ones (scheme ), thioethers are converted to the corresponding , -dihydrobenzothiophen- -ones < ark(vi) >. in general, due to better stabilization of the adjacent carbocation than it is possible in ethers, properties of a-(benzotriazol- -yl)alkyl thioethers resemble in some aspects those of a-(benzotriazol- -yl)alkylamines. however, in other aspects, properties of thioethers are quite unique. -(mercaptomethyl)benzotriazole is conveniently prepared by treatment of -(chloromethyl)benzotriazole with sodium trithiocarbonate followed by hydrolysis of the obtained hemi ester with ammonium chloride (scheme ). in the presence of triethylamine, mercaptan reacts readily with arylmethyl halides to give sulfides in high yields. alkylation of mercaptan with chloromethyl methyl ether provides methoxymethyl thioether that can be substituted at the a-carbon atom by treatment with bu n li followed by an electrophile to scheme furnish thioethers . repeated treatment with bu n li and an electrophile (benzyl bromide) allows substitution of the remaining a-proton to get derivative . among other reactions performed on mercaptan are substitution of the chlorine atom in -chlorocyclohexanone to give product , addition to electron deficient vinyl groups (products ) and condensation/addition with , -cyclohexanedione and benzaldehyde to produce derivative < jhc >. the readily available benzotriazolyl derivative of dimethyl sulfide, compound , can be alkylated on a-carbon in a stepwise manner to provide (a,a-disubstituted)alkyl thioethers (scheme ). hydrolysis of these thioethers under mild conditions ( % h so at room temperature) furnishes ketones in high yields. the anion derived from mono substituted (benzotriazol- -yl)methyl thioether adds to butyl acrylate to give intermediate that can be hydrolyzed to g-ketoester . in another example of reactivity of a-(benzotriazol- -yl)alkyl thioethers, treatment of thioether with bu n li followed by phenyl isocyanate converts it into a-ketoanilide , via intermediate adduct < joc >. treated with znbr followed by enamines, phenyl thioethers derived from aryl aldehydes are converted to b-(phenylthio)alkyl ketones or aldehydes in moderate to good yields (equation ). enamines used in these syntheses are: ( ) morpholine enamine derived from diethyl ketone, ( ) diethylamine enamine of propiophenone, ( ) piperidine enamine derived from isovaleraldehyde, and ( ) pyrrolidine enamine of cyclohexanone < h( ) >. treatment of a-(benzotriazol- -yl)alkyl thioethers with znbr weakens the bond with benzotriazole, and the obtained complex may partially dissociate to thionium cation that can be trapped by even mild nucleophiles. thus, trimethylsilyl cyanide added to the reaction mixture causes substitution of the benzotriazole moiety by the cn group to give a-(phenylthio)carbonitrile . in a similar manner, treatment with allylsilane leads to g,d-unsaturated thioether . addition of species to the double bond of a trimethylsilyl a-arylvinyl ether followed by hydrolysis of the silyloxy group furnishes b-(phenylthio)alkyl aryl ketones (scheme ) < tl >. introduction of trimethylsilyl substituents attached directly to the a-carbon atom of a-(benzotriazol- -yl)alkyl thioethers provide new opportunities. thus, treatment of lithiated monosubstituted a-(benzotriazol- -yl)alkyl thioethers with chlorotrimethylsilane produces a-(trimethylsilyl)alkyl thioethers . in reactions with hexamethyldisilathiane and cobalt dichloride, thioethers are converted to thioacylsilanes that can be trapped in a diels-alder reaction with , -dimethylbutadiene to form -alkyl- , -dimethyl- -trimethylsilyl- , -dihydro- h-thiopyrans (scheme ) < joc >. all reactions of benzotriazole derivatives of the type bt-cr r -s discussed above are based on electrophilic or nucleophilic substitutions at the a-carbon, but radical reactions are also possible. thus, the first report on unsubstituted carbon-centered (benzotriazol- -yl)methyl radical involves derivatives of (benzotriazol- -yl)methyl mercaptan. s-(benzotriazol- -yl)methyl-o-ethyl xanthate is readily prepared in a reaction of -(chloromethyl)benzotriazole with commercially available potassium o-ethyl xanthate. upon treatment with radical initiators (lauroyl peroxide), the c-s bond is cleaved to generate radical that can be trapped by alkenes to generate new radicals . by taking the xanthate moiety from the starting material, radicals are converted to final products with regeneration of radicals allowing repetition of the process (scheme ). maleinimides are also satisfactorily used as radical traps in these reactions < h( ) >. . . . . -(chloromethyl)benzotriazole -(chloromethyl)benzotriazole is an important starting material for preparation of many derivatives of benzotriazole that are discussed in this section. all these reactions rely on the nucleophilic substitution of chlorine in with nucleophiles to give derivatives < chec-ii( ) >. however, it appears that compound can also be converted into its anion by treatment with lda at À c. the anions generated this way can be trapped by ketones to provide a convenient method for the synthesis of (benzotriazol- -yl)oxiranes (scheme ) < joc >. scheme . . . ring n-c(sp )tc . . . . alkenyl group not activated in the presence of a palladium catalyst, -vinylbenzotriazole reacts with iodoarenes to give derivatives (scheme ). exclusive addition to the b-carbon and (e) geometry of molecules are confirmed by nmr data < h( ) >. to introduce substituents on the a-carbon, -vinylbenzotiazole is lithiated first with molar equivalent of bu n li to give intermediate and then treated with electrophiles to furnish products < joc >. use of equiv of bu n li produces dilithiated intermediate giving rise to disubstituted products . when reagents with two electrophilic centers are used, like (phco) or (phco) ch , an additional ring is added to the heterocyclic system involving atoms c-and c- . initial addition of two isocyanate groups to c-and c- is followed by an intramolecular nucleophilic addition of the amide n-h to the vinyl bond resulting in products < joc >. -alkenylbenzotriazoles are readily prepared by isomerization of the corresponding allyl derivatives catalyzed by bu t ok. lithiated compounds are treated with electrophiles to provide a-substituted derivatives . epoxidation of the double bond with m-chloroperbenzoic acid converts intermediates into oxiranes that can be hydrolyzed to furnish a-hydroxyketones in good yields (scheme ) < sc >. compounds of this type with an electron-withdrawing substituent at c-a can be easily prepared by condensation of -(benzotriazol- -yl)acetophenone with aldehydes. exclusively (e) isomers of a,b-unsaturated ketones are formed. treatment with hydrazines converts derivatives into pyrazolines . elimination of benzotriazole from in the presence of mild bases furnishes pyrazoles . when in these reactions hydroxylamine is used instead of hydrazines, the corresponding isoxazoles are obtained (scheme ) < joc >. compound , as a representative of derivatives with an electron-withdrawing substituent at c-b of the vinyl group, is easily prepared by elimination of one benzotriazole from , -bis(benzotriazol- -yl)ethyl methyl ketone . the stereoselective elimination catalyzed by naoh gives exclusively the (e) isomer of derivative . addition of nucleophiles to the double bond of vinyl ketone followed by elimination of benzotriazole leads to a,bunsaturated ketones . amines used as nucleophiles do not need any catalysis, but reactions with carbon and sulfur nucleophiles require addition of a base. the total effect is nucleophilic substitution of the benzotriazolyl group at the b-carbon of a,b-unsaturated ketone (scheme ) < sc >. -(benzotriazol- -yl)enamines can be conveniently prepared in reactions of amides with benzotriazole and pocl . enamines are stable enough to be separated by column chromatography as pure stereoisomers; however, their long storage in a solution showed partial isomerization between benzotriazol- -yl and benzotriazol- -yl isomers. nucleophilic substitution of benzotriazole with organozinc reagents furnishes enamines (scheme ) < ark(v) >. triflate can be formally considered as an ester of the enol form of ketone . treatment with a base causes elimination of the triflate group to afford -(benzotriazol- -yl)alkynes (scheme ) < ol >. generated from the corresponding esters by addition of bu t ok, -imidoylbenzotriazoles give b-enaminoesters in - % yield. similarly, b-iminoamides are obtained in - % from reactions of compounds with amides deprotonated by bu n li. the anions generated from nitroethane, alkyl phenyl sulfones, or sulfoxides by action of bu t ok react with -imidoylbenzotriazoles to provide derivatives , , and , respectively, in generally good yields. all of these products can exist in equilibria between the enamine and imine forms; however, the nmr data indicate that the enamine forms are strongly predominant for derivatives , , and (scheme ) < ark(v) >. reactions of n-(a-aminoalkyl)benzotriazoles with isonitriles catalyzed by boron trifluoride etherate give n-(a-aminoalkylimidoyl)benzotriazoles in high yield. upon treatment with hydrochloric acid, derivatives are conveniently converted to a-aminoamides (scheme ) < jsc >. a reaction of benzotriazole with cyanogen bromide carried out in ethanol in the presence of naoh provides dibenzotriazolylmethanimine as a mixture of benzotriazol- -yl and -yl isomers < pol , joc >. to simplify the picture, only the benzotriazol- -yl isomer is shown in scheme . treatment with amines converts methanimine under mild conditions into carboxyimidamides as sole benzotriazol- -yl isomers. upon treatment with other amines at slightly elevated temperature, the second benzotriazolyl moiety can be replaced to provide guanidines bearing up to four different groups < joc >. acyl derivatives undergo cyclocondensation with alkyl or aryl hydrazines to give -amino- , , -triazoles in good yields scheme , , -triazoles < s >. cyclocondensation of derivative with ureas provides , , -triazin- -ones , whereas a similar reaction with thioureas gives , , -triazin- -thiones < joc >. hydrazides derived from aromatic carboxylic acids react with imine to give oxadiazoles almost quantitatively, whereas only % yield was achieved in an analogous reaction of acetyl hydrazide < ark(vi) >. cyclocondensation of imine with methylhydrazine produces , , -triazole ; however, in the case of arylhydrazines, a more complex process involving condensation of with two molecules of hydrazine, elimination of ammonia and oxidation with atmospheric oxygen leads to azo derivatives < ark(vi) >. ring n-c(sp )to . . . . ring n-(cto)-h considering benzotriazolyl moiety in compounds of the general structure r-(cto)-x (x ¼ benzotriazol- -yl or benzotriazol- -yl) as a synthetic equivalent of a halogen atom, the formyl derivative (r ¼ h) is of special interest due to unavailability of the halogen analogs. -formylbenzotriazole can be conveniently prepared in a reaction of benzotriazole with formic acid in the presence of dicyclohexylcarbodiimide < s >. some examples of c-acylation by -acylbenzotriazoles are collected in scheme . thus, acylation of aromatic rings involves reactions of derivatives with thiophene in the presence of znbr or ticl to give corresponding -acylthiophenes in high yield < cca >. furan reacts similarly. c- acylation of pyrroles and c- acylation of indoles under these conditions does not require n-protection < joc >. ketones are acylated in the presence of lda to give b-diketones < joc >; the reaction can also be carried out on a polymer support < jco >. acylation of aliphatic nitriles leads to the corresponding b-ketonitriles < joc > and that of sulfones to b-ketosulfones < joc >. imines delivered from methyl ketones are effectively acylated by derivatives on their methyl groups to give enaminones < s >. -picoline is readily acylated by to produce (pyridin- -yl)methyl ketones ; -picoline, -methylquinoline and the corresponding benzyl derivatives react similarly < ark(vi) >. in a reaction with thionyl chloride and methanol, l-aspartic acid is converted to its monoester, which is subsequently treated with ethyl trifluoroacetate to give n-protected aminoacid . upon treatment with benzotriazole and thionyl chloride, acid is converted to -acylbenzotriazole that can be used as an acylating agent for electronrich aromatics. thus, in its reaction with di-and trimethoxybenzene, the corresponding g-keto-b-aminocarboxylic acid esters are obtained in % and % yield, respectively. ketones are smoothly reduced with triethylsilane to b-aminoacid derivatives ( - % yield). higher yields of ketones ( - %) are obtained from reactions of acylating agent with reactive heteroaromatics like pyrrole, indole and their n-methyl derivatives. starting from glutamic acid, an analogous reaction sequence provides derivatives of the corresponding g-aminoacids (scheme ) < joc >. application of this methodology allows direct conversion of hydroxy carboxylic acids into their amides without any protection on the hydroxy group. thus, in reactions with amines, compound derived from -hydroxy- -phenylpropionic acid gives amides in - % yield < joc >. -acylbenzotriazole derived from salicylic acid reacts smoothly with amines to give salicylamides < joc > and with isocyanates to afford benzoxazine- , diones < ark(vi) >. many other hydroxy carboxylic acids, with various distances between the hydroxy and carboxylic groups, produce similarly good results < joc >. n-protected -(a-aminoacyl)benzotriazoles derived from chiral a-aminocarboxylic acids can be conveniently prepared by mixing molar equivalents of benzotriazole with equiv of thionyl chloride followed by addition of equiv of n-protected a-aminocarboxylic acid. acylbenzotriazoles react with chiral amines to give corresponding amides with retention of chirality < ark(viii) >. condensation of with unprotected a-aminocarboxylic acids in mecn/h o in the presence of triethylamine at room temperature gives readily chiral dipeptides < s , s , tl >. the methodology can be readily extended to tripeptides < s >. reactions of derivatives with amidoximes lead to -(a-aminoalkyl)- , , -oxadiazoles in high yields and with preservation of chirality < ark(vii) > (scheme ). reactions of aminoacylbenzotriazoles with pyrrole and n-methylpyrrole in the presence of alcl give chiral -(aminoacyl)pyrroles . analogous reactions with indoles lead to their -(aminoacyl) derivatives < joc >. despite the many simple methods for preparation of carboxylic esters and thioesters, in some instances, use of -acylbenzotriazoles as o and s acylating agents may be advantageous. for example, easy to prepare salicylic acid derivative reacts with cyclopentanol under microwave irradiation to give % yield of cyclopentyl salicylate in min < joc >. in another example, l-phenylalanine derivative reacts with benzyl mercaptan scheme , , -triazoles and triethylamine at c for h to produce the corresponding thioester in % yield < s >. -( -undecyloxybenzoyl)benzotriazole is conveniently used for acylation of a complex phenol in preparation of liquid crystals < ja >. esters are also formed with good yields in reactions of -acylbenzotriazoles with organozinc reagents in the presence of a palladium catalyst < ark(xi) >. the unusual course of these reactions must involve oxidation of the intermediates with atmospheric oxygen. carbonyl oxygen atoms of aldehydes can also be efficiently acylated by -acylbenzotriazoles in the presence of mild bases (k co , et n). the released benzotriazolide anions are consecutively attached to the aldehyde carbonyl carbon atoms to produce esters (equation ). aliphatic aldehydes react quickly at room temperature, but aromatic aldehydes require elevated temperatures. the yields are good to quantitative. the amounts of benzotriazol- -yl isomers of esters in the products mixtures is strongly dependent on the reaction conditions and the character of groups r and r , and it may vary from % to % < jhc >. similarly to the reaction depicted in equation ( ), acylation of the oxygen atom of aldehydes or ketones by pyrrole derivative produces intermediate cations . however, instead of being trapped by benzotriazole to give ester , the intramolecular electrophilic attack of the cation on the pyrrole nitrogen atom produces pyrrolo[ , -oxazol- one] . according to an alternative path, the adduct of pyrrole to the carbonyl group of aldehyde is formed first, and then its oxygen atom is intramolecularly acylated to give product . the reaction is catalyzed by dbu. the indole analog of reacts similarly with aldehydes and ketones to produce tricyclic systems (scheme ) < joc >. intramolecular acylation of oxygen atoms plays also an important role in reactions of carbanions derived from acylbenzotriazoles with aldehydes and ketones. thus, anion obtained in the first step undergoes intramolecular cyclocondensation to b-lactone (scheme ) < la >. a similar addition of anions derived from acylbenzotriazoles to cinnamaldehydes provide unstable b-lactones that undergo spontaneous ring opening and decarboxylation to dienes (a mixture of (e,e) and (e,z) isomers). however, in the case of chalcones, the nucleophilic attack goes on the b-carbon atom to yield , -dihydropyran- -ones , via intramolecular acylation of the oxygen atom in anionic intermediates < joc >. . . . . ring n-(cto)-r, elimination of benzotriazole treated with a base, -(arylacetyl)benzotriazoles eliminate benzotriazole to form ketenes . when no other reagent is added, ketene is acylated by another molecule of to produce a-ketoketene which upon addition of water and decarboxylation during the work-up is converted to symmetrical dibenzyl ketone scheme , , -triazoles (scheme ) < hac >. trapping of ketenes by arenesulfinates generates unstable adducts that consecutively undergo ring opening (intermediate ) and decarboxylation to aryl benzyl sulfoxides < sl >. upon heating at c, even simple acylbenzotriazoles (r ¼ alkyl) eliminate benzotriazole and generate corresponding ketenes that can be conveniently trapped by isocyanates < joc >. . . . . ring n-(cto)-x -chloroformylbenzotriazole is prepared in a reaction of benzotriazole with phosgene < sc , cca > or more conveniently with triphosgene < cca >. in reactions with alcohols in the presence of pyridine, the chlorine atom in derivative is substituted by an alkoxy group. obtained esters react with aminoacids to provide their n-protected forms (scheme ) < sc >. the reaction of compound with benzyloxyamine provides -(benzyloxycarbamoyl)benzotriazole . deprotection of the hydroxy group by hydrogenation gives acid that is treated then with phenethylamine to afford n-hydroxy-n -phenethylurea < cca >. scheme , -carbonyldibenzotriazole is conveniently prepared by stirring a thf solution of molar equivalents of benzotriazole and equiv of phosgene for d. successive treatment with two different amines provides an efficient synthetic method for asymmetrically substituted ureas via intermediate amidobenzotriazoles (scheme ) < joc >. the benzotriazole moiety in amides can be readily displaced by aryl and heteroaryl organomagnesium or organolithium reagents to provide benzamides (or heterocyclic amides) in moderate to good yields < jcm >. benzotriazole thioamides react with amines to produce thioamides under mild conditions (equation ). it is the preferred route to thioamides with reactive groups r and r where direct conversion of the corresponding amides to thioamides is not feasible < j(p ) >. more stable -nitrobenzotriazolyl analogs of are more convenient to use in some instances < ta , joc >. a significant drawback of this method is lengthy preparation of derivatives < j(p ) > or their -nitrobenzotriazolyl analogs < joc > involving several steps that start from the corresponding ortho-phenylenediamine and include formation of the triazole ring (see section . . ). ð Þ bis(benzotriazol- yl)methanethione is easily prepared from thiophosgene and -(trimethylsilyl)benzotriazole < joc >. in reactions with thiols and triethylamine, thiones are converted to derivatives in modest yields; the main side products result from nucleophilic attacks of the thiolate anions on the thione sulfur atom to produce disulfides < joc >. in reactions with amines, compounds are smoothly converted to -(thiocarbamoyl)benzotriazoles < joc >. substitution of one of the benzotriazolyl groups in by phenolate anions yields -(aryloxythioacyl)benzotriazoles (scheme ) < joc >. reactions of thiocarbamoyl benzotriazoles with organolithium or grignard reagents provide thioamides in moderate to good yields < joc >. substitution of the benzotriazolyl moiety in by alkoxide anions leads to thiocarbamates < joc >. in reactions with amines, substitution of the first benzotriazolyl group in scheme , , -triazoles bis(benzotriazol- yl)methanethione occurs readily at room temperature to give -(thiocarbamoyl)benzotriazoles . however, when the amines are used in : molar ratio, and the reaction mixtures in dichloromethane are heated at reflux, symmetrical thioureas (r ¼ r and r ¼ r ) are obtained. unsymmetrical thioureas are prepared in good yields by reactions of intermediates with different amines < joc , joc >. in the presence of triethylamine, -(thiocarbamoyl)benzotriazoles react with mercaptans to give dithiocarbamates < joc >. similarly to their amine analogs , the benzotriazolyl moiety in oxygen derivatives can be readily substituted with organometallic reagents to provide thionoesters , with amines to give thiocarbamates , with alkoxides to afford thiocarbonates and with mercaptans to yield dithiocarbonates (scheme ) < joc >. . . . ring n-c(sp) . . . . ring n-cc-r -formylbenzotriazole reacts with triphenylphosphine and ccl to provide -( , -dichloroethenyl)benzotriazole in % yield as a crystalline solid. treatment of derivative with molar equivalents of bu n li followed by alkylating agents leads to -alkynylbenzotriazoles in - % yield. alternatively, propargyl alcohols ( - % yield) are obtained in a reaction of with bu n li and aldehydes or ketones. p-toluenesulfonic acid adds readily to the triple bond of derivatives to give intermediates that are easily hydrolyzed to carboxylic acids . -(arylethynyl)benzotriazoles are prepared conveniently in a reaction of aryl (benzotriazol- -yl)methyl ketones with triflic anhydride in the presence of , -lutidine. nucleophilic attacks in derivatives occur on the c-a atoms; thus, their reactions with grignard reagents give alkynes in - % yield. lithiated heteroaromatics react similarly to give alkynes in - % yield (scheme ) < joc >. . . . . ring n-cun -cyanobenzotriazole is readily prepared in % yield by treatment of benzotriazole with sodium hydride followed by cyanogen bromide. solid and stable derivative is a convenient reagent for introduction of the nitrile functional group into activated methylene compounds r-ch -x, which are lithiated with lda prior to the reaction. less acidic materials such as ph-ch -ph and -pyridyl-ch -me are lithiated with bu n li. nitriles are obtained under mild conditions in average % yield (scheme ) < ark(iii) >. hydrolysis of -cyanobenzotriazole with % h o provides (benzotriazol- -yl)carboxylic acid amide( in % yield. substitution of the benzotriazolyl moiety in product by amines occurs readily at room temperature to furnish ureas in - % yield (scheme ) < ark(viii) >. scheme , , -triazoles . . . ring n-x (x ¼ heteroatom) . . . . ring n-o due to its wide application in peptide synthesis, -hydroxybenzotriazole is the most commonly used benzotriazole derivative with hundreds of references in chemical abstracts each year. utility of compound comes from its readiness to form esters with carboxylic acids in the presence of dehydrating agents (das). obtained esters react eagerly with amines to produce amides in high yields (scheme ). more details about this application are given in section . . . scheme shows application of this methodology for preparation of hydrazide . thus, the reaction of acid with -hydroxybenzotriazole and edc [ -( -dimethylaminopropyl)- -ethylcarbodiimide hydrochloride] gives ester that can be separated and characterized, but it rearranges slowly to isomeric form in solutions. however, both derivatives, and , are found to be equally reactive toward hydrazine and afford hydrazide in % isolated yield < joc >. scheme polymer-bound -hydroxybenzotriazole reacts with carboxylic acids in the presence of , -diisopropylcarbodiimide ( , -dic) and dmap to produce esters . treated with hydroxylamine, esters are converted to hydroxamic acids (scheme ) < obc >. starting -hydroxybenzotriazole is recycled in the process and can be used for other syntheses. this method is well suited for automated synthesis of a library of hydroxamic acids. in similar applications of polymer-supported -hydroxybenzotriazole , a wide variety of amides is synthesized < joc , jco >. although most common, application of esters is not limited to formation of c-n bonds. such esters are also effectively used for regioselective benzoylation of sugars < cej > and even for acylation of activated methylene groups < s >. biological activity of some esters of the -hydroxybenzotriazole against sars virus is attributed to their ability to acylate the cysteine sulfur atom in a key viral enzyme < cbo >. esters of -hydroxybenzotriazole with phosphoric acid are used for phosphorylation of nucleosides in a viral genome linked peptide < t >. . . . . ring n-s -sulfonylbenzotriazoles are readily available from reactions of benzotriazole with sulfonyl chlorides < joc > or reactions of -chlorobenzotriazole with sulfinic acids < joc >. condensation of with primary or secondary nitriles under basic conditions provides corresponding a-cyanoalkyl sulfones in good to excellent yields (scheme ). in a convenient manner, sulfonyl derivatives convert lithiated heterocycles into heterocyclic sulfones; for example, -ethylfuran is converted to sulfone . in similar reactions, alkylheterocycles give a-(sulfonylalkyl)heterocycles, enolizable carboxylic esters give a-sulfonylcarboxylic esters , and sulfones give a-sulfonylalkyl sulfones < joc >. cycloadditions of azides to alkynes and their derivatives < chec-ii( ) > continue to be the main synthetic route to , , -triazoles. some aspects of these reactions with focus on cycloadditions at low temperature are discussed in a review < h( ) >. recent advances in this area make the synthesis easy and high yielding to allow quick assembly of complex structures from relatively simple fragments. drug design, proteomics, and nanotechnology are the scientific fields of great contemporary interest in such synthesis. scheme esters of acetylenedicarboxylic acid are commercially readily available, are very reactive as dipolarophiles, and the carboxylic groups in products of their reactions can be easily converted to many other functionalities. therefore, they are often the first choice as substrates for , -dipolar cycloaddition to azides (huisgen reaction). the reactions are carried out at room or elevated temperature, and the yields of , , -triazoles are usually high to quantitative (equation ). several products obtained in this way are presented as structures - . some details about the reactions leading to these products are given in table . an example of application of the [ , ]-dipolar cycloaddition reactions between azides and esters of acetylenedicarboxylic acid in nanotechnology is given in scheme . in solutions, molecules of tris(crown ether) and tris(benzyl azide) , where r is a large template of c symmetry, are self-assembled into a bundle with benzyl azide groups poking through the crown-ether rings. when di(tert-butyl) acetylenedicarboxylate is added, the azide groups are converted to triazoles , that are too bulky to be pulled out of the crown-ether rings, and the assembly remains permanently mechanically interlocked < cej >. reactivity of azides towards acetylenedicarboxylates is very dependent on their electron density (energy homo). thus, strongly electron-deficient , -dicyano- , , -triazidopyridine reacts slowly with dimethyl acetylenedicarboxylate to give triazole derivative in % yield with most of the starting material recovered unchanged. under comparable conditions, less electron-deficient , -dichloro- , , -triazidopyridine reacts with dimethyl acetylenedicarboxylate to provide , -bis( , , -triazol- yl)pyridine derivative in % yield (scheme ) < che >. scheme an example of asymmetric synthesis involving cycloaddition of an azide to dimethyl acetylenedicarboxylate is depicted in scheme . thus, asymmetric auxiliary reacts with styrene and sodium azide to generate azide in % yield and % diastereomeric purity. the following reaction (scheme ) with dimethyl acetylenedicarboxylate converts azide into triazole in % yield. finally, the bond with selenium is cleaved by treatment with triphenyltin hydride and aibn to furnish triazole in % yield and preserved optical purity ( %) < age >. treatment of ruthenium azido complex with dimethyl acetylenedicarboxylate in ch cl at room temperature for h results in ruthenium triazole complex with % isolated yield. surprisingly, product forms also in reactions of complex with dimethyl fumarate and dimethyl maleate in comparable yields, but the reactions are slower and require one week for completion. presumably, the intermediate that forms in cycloaddition of azide to the double bond of fumarate undergoes consecutive dehydrogenation catalyzed by ruthenium. treatment with alkylating agents cleaves the ruthenium-nitrogen bond and releases n- alkylated triazoles (scheme ) < om >. use of unsubstituted acetylene as a substrate in , -dipolar cycloadditions with azides results in , -unsubstituted triazoles. the reactions have to be carried out under pressure. in an example given in equation ( ) showing synthesis of an antibacterial agent, a solution of azide in dimethoxyethane is transferred to a pressure bomb that is then charged with acetylene and heated at c for h to give triazole derivative in % yield < bmc >. scheme , , -triazoles ð Þ -butyn- , -diol is a common , -dipolarophile used in cycloadditions with azides; however, its reactivity is lower in comparison with esters of acetylenedicarboxylic acid, and the yields of its cycloaddition products are also lower. the advantage of using it in syntheses is direct introduction of two hydroxymethyl groups in positions and of the triazole system that may be useful as anchoring points for assembly of more complex structures. in the first example given in scheme , cycloaddition of alkyne to -azido- -aminofurazan is carried out in an ionic liquid at c to give triazole in % yield < mc >. in the second example, azide derived from acetylated glucose reacts with alkyne in refluxing toluene/ pyridine mixture to afford triazole derivative in % yield which is used as an intermediate in synthesis of anticancer agents < tl >. alternatively, the same final product is obtained when more reactive dimethyl acetylenedicarboxylate is used as the polarophile in cycloaddition with the glucose derived azide, and the carbomethoxy groups are consecutively reduced to hydroxymethyls. however, in the second approach, a different protection of the hydroxy groups in glucose is required adding a couple of additional steps to the process < tl >. in the third example, the reaction of alkyne with protected hydroxyethylazide is carried out by heating a neat mixture of the reagents at c to give triazole in % yield < t >. the same neat approach is used in synthesis of sugar derivative that is obtained in % yield from a reaction of alkyne with protected sugar azide < t >. due to molecular strain, cyclooctyne is a very reactive species. its reactions with azides proceed rapidly even at room temperature making it a convenient tool for probing structures of unstable azides. thus, the reaction of cyclooctyne with diazide carried out in ch cl at room temperature is accomplished within h and provides ditriazolyl derivative in % yield. a similar reaction of cyclooctyne with diazide leads to ditriazolyl derivative in % yield (scheme ) < t >. scheme represents the opposite situation, with stable phenyl azide used as a probe to trap very reactive and short living alkynes. thus, diazirine generates cyclohexyne that is too reactive to be isolated and characterized. however, when phenyl azide is added to the reaction mixture, it traps species in situ to give triazole in % yield. similarly, even more strained norbornyne , generated from diazirine , is trapped by phenyl azide to afford triazole in % yield < age >. after acetylenedicarboxylates, esters of propiolic acid are the second common group of reagents for , -dipolar cycloaddition with azides. they react fast, and the yields of products are high. however, because the reacting scheme scheme , , -triazoles partners can approach each other in two ways, two regioisomers are formed, with the -alkoxycarbonyl derivative usually strongly predominant. the results of an interesting study investigating influence of substituents in arylazides on a cycloaddition reaction with methyl propiolate are presented in equation ( ). the reactions are carried out in refluxing ccl , and the combined yields of products and are - %. to explain product distribution between the regioisomers, authors calculate chemical potential differences between the reactants and energies of their transition states < cej >. ð Þ some examples of the reactions between propiolates and azides leading to triazoles and (equation ) are collected in table . as can be seen (entries and ), water as a reaction medium can improve the product yield, but it does not improve the regioselectivity. microwave assisted synthesis (entry ) can reduce dramatically the reaction time, but the regioselectivity is poor. larger aliphatic groups in azides do not affect much the reactions (entries - ). an interesting novel approach to the problem of regioselectivity represents entry where cycloaddition between -aminophenyl azide and ethyl propiolate is carried out in polymer nanocavities imprinted by regioisomer used as a template. in comparison with a regular reaction carried out in a solvent (entry ), entry shows a great improvement. ð Þ in a new approach to the synthesis of , , -triazoles, polymer supported azide , based on monomethyl ether of polyethylene glycol with molecular weight of da, reacts with methyl propiolate in refluxing toluene to give a mixture of two regioisomeric triazoles and in % yield. however, the ratio of isomer to , : , is not improved and remains comparable to that observed in simple addition of alkyl azides to methyl propiolate. the advantage of this method is high yield of the products and easy separation by precipitation from a solution in diethyl ether. deprotection from the polymer is easily accomplished by treatment the mixture with formic acid. both regioisomers give the same monosubstituted product which is a rapidly equilibrating mixture of tautomers and (scheme ) < tl , t >. a simple procedure is developed for conversion of aliphatic bromides into methyl -alkyl- , , -triazole- -carboxylates . in the first step, alkyl bromide reacts with polymer-supported azide to provide a solution of azide in dma. the best results are obtained with merrifield resin. after the first step, the resin is simply filtered off, and the solution of azide is used directly in the next step for a reaction with methyl propiolate. in this way, the procedure is significantly simplified, and alkyl azides, that may be explosive in a concentrated form, do not require any additional work-up. as can be seen from the examples given in scheme , the yield and purity of products are high < tl >. regioselectivity in reactions of acetylenes with azides depends strongly on electronic and steric factors of both reagents. usually less electron-deficient and therefore less reactive acetylenes tend to be less regioselective. to compare reactivity of ethyl propiolate and phenylacetylene, reactions of both with tocopheryl azide are presented in scheme . the reactions are carried out in refluxing toluene for - d. from the reaction with ethyl propiolate, , -disubstituted triazole is obtained in % isolated yield and , -disubstituted derivative in % yield. for phenylacetylene, the regioselectivity is slightly higher in this reaction, although the isolated yields of products are lower: % for derivative and % for isomer . hydrolysis of derivative with % naoh in methanol cleaves the bond with tocopherol releasing -phenyl- , , -triazole < ejo >. not always , -regioisomers are predominant in , -cycloadditions of azides to alkynes. thus, in preparation of new building blocks for glycopeptides, ethynyl c-glucoside is subjected to a reaction with azide to give a mixture of triazole derivatives ( %) and ( %). for the ethynyl c-galactoside analog of , the ratio between the products is shifted even more towards the , -regioisomer (scheme ) < ol >. scheme , , -triazoles to facilitate parallel synthesis and purification of triazolyl derivatives of sugars, the products are tagged with an azulene chromophore. for this purpose, guajazulene, an inexpensive azulene, is converted to propargylic ester and reacted with mannose derivative to provide a mixture of regioisomers ( %) and ( %). separation of the products can be easily achieved by chromatography because they are visible on the column (scheme ) < ejo >. to facilitate dna sequencing, oligonucleotides are tagged with fluorophores. for this purpose, azido-labeled dna is subjected to a reaction with alkyne , derived from -carboxyfluorescein and propargylamine, to give derivative (together with its , -regioisomer) in % total isolated yield (equation ) < joc >. the fact that only reactions of terminal alkynes with azides are catalyzed by cu(i) suggests participation of cu acetylenides in the catalytic process. this conclusion is supported quantum-mechanical calculations of the transition state energies < ja >. brief outline of the reaction mechanism is given in scheme . thus, alkyne reacts with cu þ to give copper(i) acetylenide . in the key step, copper coordinates additionally a molecule of azide to form a complex . both entities brought to close proximity undergo facile cycloaddition to give triazole organocopper derivative . final exchange with proton generates neutral triazole and releases the copper catalyst. there are many studies comparing thermal and catalytic , -dipolar cycloadditions between alkynes and azides. in an example given in equation ( ), azide reacts with methyl propiolate in refluxing toluene to give a mixture of regioisomeric triazoles and in total yield of % and the ratio of : , respectively. the same reaction carried out in water at room temperature with mol% of a cui catalyst, added as a suspension, results in exclusive formation of regioisomer with % isolated yield (equation ) < ta >. in one approach to catalytic synthesis of , , -triazoles, copper(i) is introduced to the reaction mixture as cui. compounds - are obtained this way. as can be seen in table , a tertiary amine is often added as a base. the reaction conditions are mild and yields of the products are high. in some cases, the reaction can be carried out in water (compound ). for the synthesis of triazole , addition of cu powder is enough to generate catalytic amounts of cu(i). a separate preparation of azides is not always necessary. scheme illustrates a case where azides are generated in situ from the corresponding halides. the reactions are carried out in ionic liquid-water system. triazole is obtained in % yield from a reaction carried out at room temperature for h. butyl derivative is obtained in % yield under similar conditions < tl >. in another approach, cu(ii) salts which are more soluble and easier to handle are used together with reducing agents to generate catalytic amounts of cu(i) in reacting mixtures. in the first such example, presented in scheme , phenylazide reacts with -phenyl- -propargylpiperazine in isopropanol to give triazole in % yield < bml >. the reaction is catalyzed by the cucl -sodium ascorbate system. in the second example, borane complex with propargyl-diphenylphosphine reacts with phenyl azide in a mixture of tert-butanol and water. the reaction is catalyzed by cuso -sodium ascorbate and provides triazole derivative -borane complex in % yield. treatment of the product with dabco removes borane protection to give free triazole in % yield < ol >. in one more example of the reaction catalyzed by copper(ii)-ascorbic acid system, propargylamide , derived from protected glucoronic acid, reacts with , , , -tetra-o-acetyl-b-d-glucopyranosyl azide to give triazole derivative in % yield (equation ) < car >. to obtain n-unsubstituted triazoles by this method, readily available azidomethyl tert-butyrate or carbamates and are treated with alkynes to provide triazolyl derivatives , , or , respectively. the n-protecting groups can be easily removed by treatment with naoh to give monosubstituted triazoles . compound is very sensitive to bases and loses its protecting group after min treatment with . molar equivalents of naoh in methanol-water. deprotection of derivative is much slower under these conditions, and deprotection of requires heating at c. for base sensitive groups r, use of protection gives the best results. however, in other cases, more stable protections and provide better yield of products (scheme ) < sl >. (trimethylsilyl)acetylene is a versatile reagent in triazole synthesis. two ways of its application in synthesis of adenosine agonists are depicted in scheme < jme >. thus, iodide is first treated with sodium azide to be converted to azide . thermal cycloaddition of (trimethylsilyl)acetylene to azide gives c-silylated triazole (and possibly its regioisomer). regioselectivity in this reaction is not important because the trimethylsilyl group is subsequently removed by treatment with tetrabutylammonium fluoride to give triazol- -yl derivative without additional substituents on the ring. alternatively, iodide is treated with (trimethylsilyl)acetylene in the presence of cui and a palladium-phosphine complex as a catalyst to give (trimethylsilyl)ethynyl derivative . removal of the silyl protection by treatment with methanolic ammonia to give compound followed by regular cycloadditions with benzyl azides, catalyzed by cuso -sodium ascorbate, furnishes triazolyl derivatives in - % yield. . . . reverse regioselectivity , -disubstituted , , -triazoles are the minor products of thermal cycloaddition of terminal alkynes to azides, and they are completely absent when the reactions are catalyzed by cu(i). however, under strongly basic conditions, when magnesium or lithium acetylenides are used as the substrates, reverse regioselectivity is observed, and , disubstituted triazoles are separated as the only products. the proposed mechanism begins with a nucleophilic attack of the alkyne anion on the terminal nitrogen atom of azide . the resulting intermediate anion undergoes spontaneous cyclization to organomagnesium derivative . work-up with aqueous ammonium chloride furnishes , -disubstituted triazoles . when instead of work-up, the reaction mixture is treated with an electrophile, , , trisubstituted triazoles are obtained (scheme ) < ol >. the reactions are typically carried out in thf at room temperature. in the case of more reactive azides with electron-deficient groups r , the reactions are exothermic and can be accomplished in less then h. less reactive azides require longer, d, time to completion. the yields are high to quantitative < ol , ol , joc >. according to the recent finding < ja >, catalysis by ruthenium complexes used in mol% amounts leads also exclusively to , -disubstituted , , -triazoles. the reactions, carried out in benzene or dioxane, are relatively fast (typically - h) and high yielding ( - %). the method tolerates groups that may not be compatible with organomagnesium reagents. contrary to the copper(i) catalysis, this method works also well with disubstituted acetylenes to provide , , -trisubstituted , , -triazoles. the suggested mechanism < ja > is presented in scheme . simultaneous replacement of two ligands in ruthenium catalyst (e.g., triphenylphosphine) by the azide and alkyne molecules generates active transition state promoting bond formation between the terminal atoms of the new ligands to give a six-membered ruthenocycle . finally, formation of the second bond between the reacting partners releases a molecule of triazole and recycles the catalyst. treatment of -acetamido- -arylazo- , , -oxadiazole -oxides (furoxans) with aqueous naoh results in formation of -acetamido- -aryl- -nitro- h- , , -triazoles . according to the proposed mechanism, the anion derived from the acetamido group attacks n- of the furoxan system (form ) causing ring opening and formation of another oxadiazole ring (form ). rotation of the large substituent at c- in oxadiazole brings the arylazo group to proximity of the ring (form ). in the following step, which is reverse to that shown as form , an intramolecular attack of the arylazo group on oxadiazole causes ring opening with release of the acetamido group and formation of a new ring (form ). acidification with hydrochloric acid stabilizes the system as triazole derivative . this cascade rearrangement is fast ( min at room temperature) and provides triazoles in - % yield (scheme ) < mc >. reaction of amines with ethoxycarbonyl isocyanate, carried out in ethyl acetate at À c, provides -arylazo- -( -ethoxycarbonylureido)furoxans in - % yield. compounds are much less reactive than their acetamido analogs . to promote a cascade rearrangement similar to that depicted in scheme , furoxans have to be heated with potassium tert-butoxide in dmf. the probable reason for reduced reactivity of anion is the fact that it can exist in several tautomeric and resonance forms rendering the carbonyl oxygen atom less nucleophilic. however, at c, a nucleophilic attack of the oxygen atom on n- of the furoxan system results in its ring opening and formation of a new ring of oxadiazole . by rotation of the substituent at c- , the arylazo group comes to a suitable position for nucleophilic attack on n- resulting in opening of the oxadiazole ring and formation of triazole . during work-up, even under very mild conditions, the ureido group is hydrolyzed and -amino- -aryl- -nitro- h- , , -triazole is obtained. compounds are isolated in - % yield (scheme ) < rcb >. substitution of the -nitro group in , -dinitrofuroxan by ammonia occurs readily, even at low temperature. subsequent treatment of the obtained amine, product , with t-butylamine results in formation of -amino- -(t-butyl)- -nitro- , , -triazole -oxide . however, there must be some additional side products in the reaction mixture, as the isolated yield of compound is only %. upon treatment with trifluoroperacetic acid, the t-butyl group is removed. the obtained triazole system can exist in two tautomeric forms, and ; however, the -oxide form is strongly favored (scheme ) < che >. scheme , , -triazoles . . . , , - h-triazoles from , , -thiadiazoles in a reaction with ortho-phenylenediamine, carried out in dmf at room temperature, ethyl -bromo- , , thiadiazole- -carboxylate is converted to ethyl -[( -aminophenyl)amino]- , , -thiadiazole- -carboxylate with % yield. upon treatment with a mild base, amine undergoes dimroth rearrangement to -mercapto- , , -triazole (isolated in % yield). in a reaction with second molecule of bromide , mercaptan is converted to sulfide ( % yield). treatment of derivative with et n in refluxing ethanol leads to a nucleophilic attack of the amino group on the thiadiazole ring resulting in elimination of hydrogen sulfide and formation of the second benzotriazole ring. benzothiadiazepine obtained this way is isolated in % yield. hydrolysis of the carbethoxy groups in derivative followed by decarboxylation of the obtained acid furnishes di[ , , ]triazolo[ , -a: -d][ , , ]benzothiadiazepine (scheme ) < j(p ) >. scheme treatment of , , -thiadiazole derivative with pcl in refluxing benzene results in formation of the , , triazol- -yl disulfide . the reaction must proceed by dimroth rearrangement of the thiadiazole ring followed by oxidation of the obtained thiol, possibly with pcl . however, when the reaction is carried out in refluxing toluene, triazole derivative is obtained instead (isolated yield %). in this case, apart of dimroth rearrangement of the starting material, a reaction of pcl with the solvent generates benzyl chloride that benzylates the thiol group. hydrogen chloride released in this reaction converts the ethoxycarbonyl group into an acid chloride function in product . to prove the structure of derivative , it is converted to ester , which appears to be the same compound as the product obtained by regular dimroth rearrangement of thiadiazole catalyzed by among many tautomeric forms of species , there are structures with a single bond between the carbon atoms, which allow free rotation to bring the nh and n þ groups to close proximity. nucleophilic intramolecular attack of the amine n atom on the diazonium group leads to triazolyl derivative . in the aqueous hydrochloric acid reaction medium, is hydrolyzed to ( , , -triazol- -yl)amidine (scheme ) < pcj >. as shown in scheme , the -aminopyrimidine structure may be also incorporated into a more complex bicyclic system. thus, diazotization of -amino- -oxo- h-pyrimido[ , -b]pyridazines followed by treatment with % aqueous tetrafluoroboric acid results in precipitation of salts . when heated with alcohols, nucleophilic attack on the carbonyl group opens the pyrimidine ring. the obtained species assume conformation that is more suitable for bond formation between the opposite charged nitrogen atoms. alkyl -(pyridazin- -yl)- h- , , -triazole- -carboxylates are obtained in - % yield < ark(viii) >. reduction of benzo- , , , -tetrazine , -diones results in formation of benzotriazoles , which are isolated in high yield ( - %). common agents used for reduction of nitro groups, na s o , sncl , or fe/hcl, work well here; however, the required reaction conditions are milder allowing a nitro group survive untouched in product c. the proposed mechanism starts from a single electron transfer with generation of radical . reactions of salts of , , -triazole with electrophiles provide an easy access to , , -triazol-n-yl derivatives; although, usually mixtures of n- and n- substituted triazoles are obtained that have to be separated (see section . . ). another simple method for synthesis of such derivatives is addition of , , -triazole to carbon-carbon multiple bonds (section . . ). n- substituted , , -triazoles can be selectively prepared by , -dipolar cycloaddition of acetylene or (trimethylsilyl)acetylene to alkyl or aryl azides (section . . ). . . . . c-substituted , , -triazoles in the presence of copper and palladium catalysts, terminal alkynes react with trimethylsilyl azide and allyl methyl carbonate to provide , -disubstituted , , -triazoles in moderate to good yield. isomerization of the allyl substituent in the presence of a ruthenium catalyst gives -substituted -( -propen- -yl)- h- , , -triazoles . deprotection of n- by ozonolysis furnishes triazoles (scheme ) < ja >. finding that , -dipolar cycloaddition of alkynes to trimethylsilyl azide, carried out in dmf/meoh in the presence of cui as a catalyst, leads directly to products with much higher yields provides a significant progress to the synthesis of n-unsubstituted , , -triazoles < ejo >. scheme provides a methodology for the conversion of aryl bromides onto -aryl- , , -triazoles. in the given example, palladium-copper catalyzed substitution of the bromine atom in indole by trimethylsilylacetylene provides intermediate . hydrolysis of the trimethylsilyl protecting group releases terminal alkyne , isolated scheme scheme , , -triazoles in % yield (two steps). , -dipolar cycloaddition of alkyne to trimethylsilyl azide leads to a mixture of regioisomeric triazoles and , which is directly hydrolyzed by n naoh to give quantitatively triazole < jme >. in a quite different approach, shown in scheme , cycloaddition of nitrile to trimethylsilyldiazomethane provides silylated triazole , isolated in % yield. treatment with tetrabutylammonium fluoride removes the trimethylsilyl group and simultaneously the silyl protection of the carboxylic group to afford -substituted triazole derivative in % yield < pen >. . . . . , -disubstituted , , -triazoles , -disubstituted , , -triazoles are exclusive products of copper catalyzed , -dipolar cycloadditions of terminal alkynes to azides. a variety of substituents can be introduced in this way. many examples of such reactions are discussed in section . . . . . . . , -disubstituted , , -triazoles , -disubstituted , , -triazoles are formed in , -dipolar cycloaddition of alkynylmagnesium reagents to azides. this reverse regioselectivity is also achieved in ruthenium-catalyzed cycloadditions. examples of such reactions can be found in section . . . . . . . , -disubstituted , , -triazoles , -disubstituted , , -triazoles are usually minor components in the product mixtures obtained from reactions of triazole with electrophiles (see section . . ). the few regioselective syntheses of such compounds include a reaction of aminoacetophenones with hydrazines. the reaction with methylhydrazine proceeds well without any catalysis, but that with phenylhydrazine requires cupric chloride as a catalyst. it is assumed that hydrazone that forms in the first step is in a tautomeric equilibrium with its azo form . however, it is not clear how bond formation between the nitrogen atoms and oxidation to the triazole system occurs. -aryltriazoles are obtained in - % yield (scheme ) < sc >. scheme it appears that treatment of phenacyl bromides with methylhydrazine in refluxing acetic acid leads also to , -disubstituted triazoles . fivefold excess of methylhydrazine is used in these reactions. according to the proposed mechanism, structures - , methylhydrazine has a double role, as a condensing agent and an oxidant. in the final account, three molecules of methylhydrazine have to be used to produce one molecule of triazole , two molecules of methylamine and one molecule of ammonia. the basic triazole (x ¼ y ¼ h) is separated in % yield. the reactions go well with electron-donating substituents (for x ¼ oh, the yield is %), but electron-withdrawing substituents can lower the yield dramatically ( % for x ¼ no ) (scheme ) < jcm >. . . . . , -disubstituted , , -triazoles a simple procedure for the synthesis of , -disubstituted , , -triazoles involves stirring a mixture of nitroethene with trimethylsilyl azide and tetrabutylammonium fluoride at c for h. no solvent is needed. triazoline , which forms in the first step of the reaction, eliminates nitrous acid, and the trimethylsilyl group is cleaved off by the fluoride anion to afford triazole . various aryl and heteroaryl substituents r are used providing triazoles in - % yield (scheme ) < joc >. scheme , , -triazoles the synthesis of , -disubstituted triazoles shown in scheme , carried out on a polymer support with microwave assistance, is based on a similar principle. in the first step, sulfinate is converted to sulfone . condensation with aldehydes provides vinyl sulfones . cyclocondensation of sulfones with sodium azide generates corresponding triazoline intermediates that eliminate sulfinate to provide triazoles in moderate to good yield < ol >. azides obtained from propargyl halides or sulfonates undergo sigmatropic rearrangement to azidoallenes , which subsequently undergo cyclization to triazafulvenes . under the reaction conditions, species react with another molecule of sodium azide to furnish triazoles . products are isolated in - % yield (scheme ) < s >. . . . . tri-substituted , , -triazoles compounds of this type are the most common products obtained from thermal , -dipolar cycloaddition of disubstituted alkynes to azides. many examples of such reactions can be found in section . . . . . . derivatives of benzotriazole . . . . n-substituted benzotriazoles preparation of benzotriazolyl derivatives substituted at n- (or n- ) with variety of functional groups is described in detail in sections . . and . . . the basic strategy starts from a reaction of benzotriazole with an electrophile. in most cases, the reaction produces a mixture of benzotriazol- -yl and benzotriazol- -yl derivatives that is not difficult to separate. further modification of the substituent in subsequent steps leads to the desired product. scheme . . . . c-substituted benzotriazoles there are only few commercially available c-substituted benzotriazoles. in some situations, the substituents can be readily converted to more complex groups in the desired products. however, in many instances, it is more convenient to design first the right substituent and build the heterocyclic ring later. an example of such approach is shown in scheme . thus, in a reaction with , -dimethylpyrrole, followed by treatment with ddq, benzaldehyde is converted to product in % overall yield. deprotection of the amino group gives ortho-nitroaniline that is subsequently reduced to ortho-phenylenediamine with % yield. complexation of the dipyrrolyl moiety with boron trifluoride gives product ( % yield), which by treatment with sodium nitrite in n hcl is converted to desired triazole derivative in % yield < ja >. direct n-substitution of benzotriazole in its reactions with electrophiles is a common practice. however, that strategy usually does not work well when a c-substituted benzotriazole is used as the starting material. thus, in an example shown in scheme , reaction of -methylbenzotriazole with -bromopropionic acid provides a mixture of three products - with the n( )-substituted benzotriazole derivative being strongly predominant. thus, the use of this approach for the synthesis of desired compound , which appears to be the least abundant in the mixture, is very impractical. synthesis of the benzotriazole system starting from , -dinitrotoluene is a much better alternative. in the first step, heating of a solution of compound and sodium -aminopropionate in dmso allows for selective substitution of the nitro group in position meta to provide -nitroaniline . reduction of the remaining nitro group to give diamine followed by cyclocondensation with nitrous acid furnishes the desired product < fa >. a similar approach, synthesis of a selectively substituted benzotriazole from the corresponding ortho-nitroaniline, is depicted in scheme . the process starts from a microwave-assisted substitution of the fluorine atom in -fluoro- -nitrobenzonitrile by isopropylamine to give ortho-nitroaniline in % yield. reduction of the nitro group provides ortho-phenylenediamine that is directly converted to -cyano- -isopropylbenzotriazole , which is isolated in % yield < jme >. scheme , , -triazoles a series of para-substituted ortho-nitroanilines is converted in this way to benzotriazolyl derivatives , which are of interest as potassium channel activators. in the first step, nitroanilines are treated with salicylyl chloride to provide salicylamides in - % yield. the nitro group is catalytically reduced, and the obtained intermediates are subjected to a reaction with nitrous acid, generated in situ from nano , to afford -substituted -( -hydroxybenzoyl)- h-benzotriazoles in - % yield (scheme ) < fa >. . . . . c,c-disubstituted benzotriazoles c-derivatization of benzotriazole is rather difficult, and a benzotriazole system selectively substituted at the benzenoid ring is usually constructed from scratch. an illustration of this case is depicted in scheme . the process starts from a relatively simple molecule of -( -chloroethyl)nitrobenzene that is reduced to the corresponding aniline and acetylated to give acetanilide . chlorination with socl provides derivative in % yield that is subsequently nitrated to give product in % yield. deprotection of the amino group gives nitroaniline , in the following steps, the -chloroethyl substituent is converted into -(dipropylamino)-ethyl group (compound ), the nitro group is reduced, and the obtained ortho-phenylenediamine is subjected to cyclocondensation with nitrous acid to furnish benzotriazole with the last step yield of % < ap >. instead of sodium nitrite, isoamyl nitrite is sometimes used as a nitrosating agent in synthesis of the benzotriazole ring. with this reagent, the reaction conditions are very mild allowing survival of acid sensitive groups. in an example of such a reaction, methyl , -diamino- -methoxybenzoate is treated with isoamyl nitrite at room temperature. the reaction is fast and provides methyl -methoxybenzotriazole- -carboxylate in % yield, isolated by simple filtration off the precipitate (equation ) < jme >. scheme ð Þ scheme scheme , , -triazoles . . . . three or more substituents to get a complex set of substituents by direct derivatization of benzotriazole is not feasible. in such situations, it is better to have all the substituents in place first and later construct the heterocyclic ring. high reactivity of anilines and their well-developed chemistry makes them good stating materials. in an example shown in scheme , acetanilide is nitrated to afford nitro derivative in % yield. catalytic reduction of the nitro group provides methyl -acetylamino- -amino- -chloro- -methoxybenzoate in % yield. nitrosation of compound in diluted sulfuric acid leads to intermediate , which without separation is heated to be converted to -chloro- -methoxy- h-benzotriazole- -carboxylic acid , isolated in % yield < cpb >. preparation of , , , -tetrabromobenzotriazole and its tetrachloro analog by direct bromination or chlorination of benzotriazole is described in section . . . however, other tetra-substituted benzotriazoles have to be constructed from a suitably substituted benzene ring. thus, treatment of pentamethylbenzene with fuming nitric acid in concentrated sulfuric acid provides , , , -tetramethyl- , -dinitrobenzene in % yield. using routine procedures, derivative is reduced with sncl in aqueous hcl, and the obtained diamine is subsequently treated with nano (in aq. hcl) to provide , , , -tetramethyl- h-benzotriazole (scheme ) < bmc >. the last two decades have witnessed rapid development of organic synthetic methods based on benzotriazole derivatives. thus, introduction of benzotriazole moiety to organic molecules provides several practical advantages. among other benefits, a benzotriazolyl substituent activates the reaction center, stabilizes intermediates, increases regio-and stereoselectivity, and simplifies separation and purification of the products. after the desired molecular assembly is constructed, the bond with benzotriazole is cleaved off to provide the final product. a vast variety of scheme molecular structures is conveniently prepared in this way. the largest section of this chapter (section . . ) is devoted specifically to this topic. for this reason, benzotriazole itself and a hundred of its basic derivatives that are commercially available now have become important materials in organic synthesis. i-hydroxybenzotriazole (hobt) < chec-ii( ) > has become an everyday reagent in many chemistry labs, and the number of reports of its application in organic synthesis is boosted to hundreds per year. combined with a dehydrating agent and a tertiary amine, hobt is an excellent auxiliary in preparation of amides ( table ). the mechanism of its interaction with carboxylic acids is discussed in section . . . some of the dehydrating agents used in the process are also derivatives of hobt - . in some instances, these derivatives, hbtu very simple derivatives of benzotriazole with biological activity include , -dimethylbenzotriazole, a very effective agent against cysts of acanthamoeba castellanii < bmc >, tetrabromobenzotriazole, which provides selective inhibition of protein kinase ck < psc > and induces apoptosis of jurkat cells < bj >, -salicylyl- methylbenzotriazole, potassium channel activator < fa > and -isopropyl- h-benzotriazole- -carboxylic acid, a selective agonist of human orphan g-protein-coupled receptor gpr b < jme >. several , , -triazole derivatives have been designed to target g-protein-coupled receptors. among them are neurokine nk antagonists < jme , jep > and < bml >, selective a adenosine receptor agonist < jme > and highly selective a adrenoreceptor antagonists < jme >. other , , -triazole derivatives are of interest as inhibitors of some key enzymes: acetylcholinesterase < ja >, glycogen synthase kinase- < jme >, glycosidase < t >, galectin- < car , cc > and a- , -sialyltransferase < cc >. there are also , , -triazoles with antiviral < bml , jme >, antibacterial < bml , bmc >, antithrombotic < ap >, or antiplatelet < bmc > activities. some triazoles work as potassium channel activators < fa >, others as calcium signal transduction inhibitors < clc >. , -diaryl-Á - , , -triazolines are recognized anticonvulsant agents < cme , jlr >. among biologically active benzotriazoles are also inactivators of the severe acute respiratory syndrome cl protease < cbo >, trichostatin suppressors < cbo >, antagonists of the gonadotropin releasing hormone < bml >, and nonpeptide inhibitors of protein tyrosine phosphatase b < bml >. due to strong complexing affinities to copper and some other ions, benzotriazole and its derivatives have found wide application in anticorrosion formulations. hundreds of patents covering this subject are registered each year. one of the major applications of such formulations is in electronics that include thiol passivation of copper interconnects during semiconductor manufacturing, grinding composition for polishing of semiconductor devices, corrosion-preventing agents for etching of insulator films in manufacture of semiconductor devices, cleaning solutions for electrohydrodynamic cleaning of semiconductors, components of polymer coatings for silver-plated circuits, and in dispersants for preparation of nickel-coated copper powder for electricity-conducting inks. benzotriazole is also commonly used as an unticlogging agent in jet inks for forming high-quality images. anticorrosion abilities of benzotriazole and its derivatives are also widely utilized in fluids for all kind of machinery. they are important antifriction-antiwear additives for engine oils, components of antirusting grease for aircraft, biodegradable lubricants for turbines, brake liquids based on polyoxyalkylene synthetic oils, metal corrosion inhibitors in aqueous coolants containing acetic acid and propylene glycol, grease for gas compressors for fuel cell systems, emulsifiable oil for preparation of noncombustible oil-water hydraulic emulsions for coal mining, environmentprotecting lubricating oil for refrigerators, antifreeze composition for diesel engines, and lubricating oil compositions for hot rolling aluminium plates. benzotriazole derivatives can be also found in machine dishwashing detergents containing nonionic surfactants, corrosion inhibitors for thermoplastic polyurethanes in contact with metals, and in anticorrosion polymer coatings for guitar strings. due to strong uv absorption, benzotriazole derivatives have found application in cosmetic formulas for skin photoprotection, in cosmetic sunscreen compositions, in multifunctional eyeglass lenses with uv absorbers, in uv protecting films for radiation detectors in personal instant alert dosimeters, in polyester compositions reducing uv light penetration for production of bottles, in uv absorbers for decorative polyolefin sheets with improved weather resistance, in protective coatings containing uv absorbers for microporous sheets, in uv absorbers for plant protecting covers, in photographic emulsion of light-sensitive materials, and as uv absorber for a multilayer golf ball with a translucent cover. novel applications of benzotriazole methodology in organic synthesis include regiospecific preparation of , , trisubstituted pyrazoles < ark(i) >, efficient synthesis of , -disubstituted tetrazoles < sl >, , , -triazoles amidoalkylations of nitroalkanes, nitriles, alkynes, and esters < ark(xi) >, thioamidoalkylation of , -dicarbonyl compounds, enol silyl ethers, and enamines < s >, c-aminoimidoylation and c-thiocarbamoylation of esters, sulfones, and ketones < joc >, synthesis of cyano derivatives of n-alky and n-aryl piperazines < ejm >, and preparation of polyfunctional acyl azides < joc >. n-acyl derivatives of benzotriazole are used for efficient peptide coupling of sterically hindered aminoacids < joc > and -amino- -methyl- h-[ , , ]-triazole- -carboxylic acid < sc , expedient synthesis of n-z-pyroglutamyl-aminoacid derivatives < bml >, synthesis of (þ)-aphanorphine < h( ) >, and as mosher-bt reagents < joc >. chec-i( ) h. wamhoff; in 'comprehensive heterocyclic chemistry comprehensive heterocyclic chemistry ii his main research at that time was focused on chemistry of ferrocenophanes. during a sabbatical leave in , he joined professor alan r. katritzky at the university of florida to lay a foundation for application of benzotriazole in organic synthesis. he returned to the university of florida in , where, as a group leader, he pushed forward the research on derivatives of benzotriazole. his collaboration with professor katritzky till he was a founder fellow of churchill college, cambridge, and then founding of professor/dean of the school of chemical sciences at the university of east anglia before crossing the atlantic in to become kenan professor and director of the center for heterocyclic compounds at the university of florida. he has researched, published, lectured, and consulted widely in heterocyclic chemistry, synthetic methods, and qspr. he created the not-for-profit foundation arkat and since has been organizing the annual 'florida heterocyclic and synthetic conferences' (flohet) and publishes archive for organic chemistry (arkivoc) key: cord- -hea shy authors: pourali, fatemeh; afshari, mahdi; alizadeh-navaei, reza; javidnia, javad; moosazadeh, mahmood; hessami, amirhossein title: relationship between blood group and risk of infection and death in covid- : a live meta-analysis date: - - journal: new microbes new infect doi: . /j.nmni. . sha: doc_id: cord_uid: hea shy abstract introduction the relationship between abo blood group and the incidence of covid- infection and death has been investigated in several studies. the reported results were controversial, so the objective of the present study is to assess the relationship between different blood groups and the onset and mortality of covid- infection using meta-analysis method. methods we searched the databases using appropriate mesh terms. we screened articles on the basis of titles, abstracts, and full texts, and the articles that met the inclusion criteria were selected. quality assessment was done with the newcastle-ottawa scale checklist. the estimated frequency of covid- infection and death in terms of abo blood group and the overall estimate of the odd ratio between blood group with covid- infection and death was done with % confidence interval. results the pooled frequency of blood groups a, b, o, and ab among covid- infected individuals was estimated as . %, . %, . %, and . % respectively. the frequency of blood groups a, b, o, and ab among the dead cases due to covid- infection was estimated as %, %, %, and % respectively. the odd ratio of covid- infection for blood group a versus the other blood groups was estimated . (ci %: . - . ). the corresponding figures for blood groups o and ab versus other blood groups were estimated as . (ci %: . - . ) and . (ci %: . - . ) respectively. conclusion this meta-analysis showed that individuals with blood group a are at higher risk for covid- infection while those with blood group o are at lower risk. although the odds ratio of death for ab blood group was non-significant, it was considerable. coronaviridae is a family of enveloped, single-stranded, positive-sense rna viruses with the largest genome among rna viruses ( ) ( ) ( ) the club-shaped spike (s) proteins on their surface make them look like a crown. other structural proteins include the hemagglutinin esterase (he) (only found in some of them), small membrane (e), membrane (m), nucleocapsid (n), and internal (i) protein ( ) . they belong to the order of nidovirales, the suborder of cornivirineae and are divided into two subfamilies one of them is ortocoronavirinae which is divided into genera (alpha, beta, gamma, delta) ( ). six coronaviruses causes human infections ( ) including severe acute respiratory syndrome (sars), china, ( ) and middle eastern respiratory syndrome (mers), saudi arabia, ( ) . on late december , world health organization (who) have reported cases of pneumonia with unknown etiology in wuhan, china ( ) . further investigation of samples from patients with pneumonia isolated a novel coronavirus named -ncov ( ) . who has declared a pandemic on -ncov or covid- on march th , ( ) . there are more than million cases and half million deaths due to covid- worldwide according to worldmeter.info ( ). there were different risk factors for mortality in covid- patients including male gender, older age, diabetes, asthma, and other medical conditions ( ) . recently some studies found association between the abo blood group and covid- morbidity and mortality ( ) ( ) ( ) ( ) . abo blood group have been also reported to be related to different infectious diseases and syndromes. individuals with blood group o were reported to be more susceptible to norwalk virus, and also had a significantly higher prevalence of h pylori but less susceptible for sars ( ) ( ) ( ) . in another study blood group a was associated with an increased risk of acute respiratory distress syndrome (ards) in trauma and sepsis patients ( ) . a study by lebiush et al. on influenza a (h n ), has suggested higher seroconversion to a titer of more than in blood group a and b ( ) . b blood group was also reported as a risk factor for prostate and bladder cancer ( ) and non-o blood groups were reported to have a higher risk of gastric cancer ( ) . as mentioned, there are articles emphasizing the hypothesis of a relationship between abo blood group and covid- . in order to reach more reliable results, we have aimed to do a meta-analysis on this subject. meta-analysis is one of the study designs that combines the results of the preliminary studies and determine a valid estimate. therefore, our objective is to perform a rapid systematic review and metaanalysis to discover any association between abo blood group and covid- morbidity and mortality. note that there are limited primary evidence regarding the association between blood groups and covid infection, upcoming relevant studies will be added to the results of the present meta-analysis. . j o u r n a l p r e -p r o o f a systematic search was carried out in the available databases including pubmed, scopus, cochrane library, web of science, and also unpublished results in medrxiv. we used all mesh terms and relevant keywords (covid , sars-cov- infection, covid- virus disease, -ncov infection, abo blood group system, abo factor, blood groups, antigens, blood group). all casecontrol, cohort, and cross-sectional studies until st april were included. inclusion criteria: ) studies that reported a relationship between abo blood group and death due to covid- , ) studies that reported a relationship between abo blood group and covid- infection, ) studies that reported frequency of covid- among different abo blood groups and ) studies that reported death among covid- infected people. exclusion criteria: case-reports and letters to the editors were excluded. data extracted from the primary studies included first author's name, year of publication, place of the study conduction, type of the study, sampling method, number of participants, number of covid- infection, and death in each blood group, a, b, o, and ab. the required data was entered into excel spreadsheets. quality assessment was performed using the newcastle-ottawa scale (nos). this checklist has three parts: selection, comparability, and exposure. the checklist scores are between - . studies with a score lower than were excluded. the selection criteria for selection was in maximum, for comparability, and for exposure ( ) . quality assessment was performed by two authors independently. data analysis was performed using stata ver. . heterogeneity between studies was assessed using cochrane's q test and i-squared (i ) test. standard error was calculated to assess the frequency of covid- infection and death in each blood group. the overall estimate of the frequency of covid- infection and death with % confidence interval in each abo blood group was calculated, using random effect model. to assess the relationship between covid- infection and mortality with blood group, the required data was extracted in binary tables. using the metan command, the random effect model, and reverse variance, the point odd ratio and % confidence interval was illustrated on forest plots. in these plots, the size of the square shows the weight of each study and the lines beside it show the % confidence interval. in the cases that confidence interval didn't include number , the difference was considered statistically significant. by searching in databases, studies were found. after removing duplicates, checking the titles, abstracts and full texts of the remaining articles, irrelevant or duplicate papers were excluded. quality assessment scores for the four final selected studies in the meta-analysis were above . the eligible studies included two case-controls, one cohort and one cross sectional studies (figure ). studies included were conducted in china ( ) ( ) ( ) and united states ( ) . in total, data were found, j o u r n a l p r e -p r o o f from hospitals in wuhan, shenzhen, xi'an, beijing, and new york city. totally , participants were enrolled in these studies which included , controls. in evidence included in this meta-analysis, the frequency of blood group a among covid- infected people had been reported between . % and . %. combining these results using random effect model (i-square: . %, q: . , p-value: . ), the pooled frequency of blood group a among covid- infected people, was estimated as . % ( % ci: . , . ) (figure -a). the frequency of blood group b among covid- infected people had been reported in the seven evidence between . % and . %. combining these results with random effect model (isquared: . %, q: . , p-value< . ) the total frequency of blood group b among all covid- infected people, was estimated as . % ( % ci: . , . ) (figure -b). in evidence included in this meta-analysis, the frequency of blood group o among covid- infected people had been reported from . % to . %. combining these results with random effect model (i-squared: . %, q: . , p-value< . ), the pooled frequency of blood group o among covid- infected people, was estimated as . % ( % ci: . , . ) (figure -c). of the evidence included in this meta-analysis, five studies had reported the frequency of blood group ab among covid- infected people varied between . % and . %. combining the results with random effect model (i-squared: . %, q: . , p-value< . ), the frequency of blood group ab among covid- infected people, was estimated as . % ( % ci: . , . ) (figure -d). the odds for covid- infection among blood group a versus non-a blood groups was extracted from four evidence one of which was statistically significant. combining the primary odds ratios using random effect model (i-square= . %, q= . , p= . ), the pooled odd ratio for blood group a was estimated as . ( % ci: . - . ) ( figure -a) . the odds of covid- infection among blood group b versus non-b blood groups was extracted from four evidence. it was lower in b blood group than non-b blood groups in two studies, one of which was statistically significant. combining these results with random effect model (i-square= . %, q= . , p< . ), the odd ratio for blood group b was estimated as . ( % ci: . - . ) ( figure -b) . the odds of covid- infection among blood group o versus non-o blood groups had been reported in four evidence all of which reported lower odds of covid- infection among subjects with blood group o. three of these associations were statistically significant. by combining these results with random effect model (i-square= . %, q= . , p= . ), the odd ratio for blood group o was estimated as . ( % ci: . - . ) (figure -c). the odds of covid- infection among patients with and without blood group ab had been reported in four evidence just one of which was statistically significant. combining these results using random effect model (i-square= . %, q= . , p= . ), the odd ratio for having blood group ab was estimated as . ( % ci: . - . ) ( figure -d) . the odds for mortality among covid- infected people with blood group a versus non-a blood group had been reported by two evidence one of which reported higher chance of mortality among patients with blood group a compare to those without. however, it was not statistically significant. combining the results of this two evidence, applying random effect model (i-square= %, q= . , p= . ), the odd ratio for death among covid- infected people having blood group a was estimated as . ( % ci: . , . ). only two studies have compared patients with and without blood group b in term of the odds of covid- infection both of them showed lower odds of death among people with blood group b. but the results were not statistically significant. combining the results of these two evidence using random effect model (i-square= %, q= . , p= . ), the odd ratio for blood group b versus was estimated as . ( % ci: . , . ) the odds ratio for death of covid- infected people following blood group o had been reported by two studies which both have shown negative association. however, the results were not statistically significant. combining the results of these two evidence, applying random effect model (i-square= %, q= . , p= . ), the odd ratio for blood group o was estimated as . ( % ci: . , . ) the odds ratios for death among covid- infected people following blood group ab had been reported by two evidence. both of these studies reported more chance of developing death among patients with ab group. however, they were not statistically significant. combining the results of these two evidence, applying random effect model (i-square= . %, q= . , p= . ), the odds ratio for blood group ab was estimated as . ( % ci: . , . ) (table ). in three studies, the frequency of death among individuals with covid- infection was reported in terms of different blood groups. combining the results of these articles, the frequency of death due to covid- among patients with a, b, o and ab groups was estimated as % ( % ci - %), % ( % ci - %), o % ( % ci - %), and % ( % ci - %) respectively. meta-analysis of studies showed no significant association between mortality and different blood groups in covid- patients. however, prevalence of death due to covid- was significantly lower in blood group o in compare with other blood groups. in this study, we found that blood group a was a partial risk factor for covid- infection while blood group o was a protective factor. moreover, b and ab blood groups were not significantly associated with covid- infection. in a study investigating abo blood groups and susceptibility to sars in , hospital staff in contact with a patient without any protective clothes were checked. they were tested for sars-cov igg antibody ( ) . the results showed that individuals with blood group o, were less susceptible to sars infection however, the results were not statistically significant for blood group b and were undefined for blood group a and ab ( ) . in our included studies, cases were tested with molecular methods including rt-pcr or clinical diagnostic criteria including epidemic history or clinical symptoms and clinical characteristics ( ) ( ) ( ) ( ) . our results on the cases of sars-cov- infection were consistent with the mentioned study in the cases of sars-cov in blood group o. angiotensin converting enzyme (ace ) has been reported as the sars-cov receptor, and the receptor binding domain (rbd) is presented on the s proteins of the coronaviruses ( ) . guillon et al. ( ) have investigated if abo antibodies could stop interaction between sars-cov receptor and ace . they have indicated that s protein expressed by a-positive infected cells shares epitopes of a histo-blood group in vitro therefore, adhesion of s protein and ace can be inhibited by anti-a natural antibody. anti-a and anti-b natural antibodies being produced in individuals with blood group o could potentially block viral adhesion to cells which could explain lower risk of infection in them. as sars-cov and sars-cov- are from the same genus (betacoronavirus) ( ) and have similarities in the structure of rbd, ace has been also suggested as the receptor for sras-cov- ( ) . therefore, the same mechanism might explain the lower susceptibility of blood group o to sars-cov- as we have shown in our study. in explaining the higher risk for blood group a, lack of these antibodies can be expected, although it needs further studies to be confirmed ( ) . individuals with blood group o have a lower angiotensin converting enzyme (ace) level while blood group a has positive association within ace activity ( ) . ace is an enzyme that activates angiotensin, thus; the lower level of this enzyme can reduce the risk of hypertension ( ) which is a covid- risk factor ( ) this is another proposed mechanism for developing more severe covid- disease in blood group a and less severe in blood group o ( ) . although ace is the virus receptor, it can have some benefits. for example it can attenuate inflammatory response and redox stress and counter balance ace effect and in the case of lower ace level, it can work even more effectively ( , ) . as mentioned the primary receptor for sars-cov- is ace ( ) but like many pathogens that bind to specific terminal carbohydrates ( ), sars-cov- binds to the carbohydrates that determine the abo blood groups, which are extensively expressed in mucous membrane of respiratory tract ( , ) . therefore, the blood group ab has the most contact and blood group o has the least with the pathogen ( ) . in addition, a study by dai et al. ( ) hypothesized that blood group a was considered to have more attachment molecules on the vascular wall by protecting p-selectin and intercellular cell adhesion molecule (icam ) from cleavage which increases adhesion and inflammation and can cause more severe covid- disease ( ) . people with blood group o have also higher interleukin (il- ) levels ( ) which is a proinflammatory cytokine that can be produced by many cells and has an important role in cell defense in acute phase ( ) . however, studies showed that il- is associated with covid- severity as it can be part of cytokine storm ( ) ( ) ( ) . il- could have both protective role by involving in lung repair responses and also exacerbating roles in covid- infection ( ) . it should be noted that all of these mechanisms need to be more investigated. in our study, there was no statistically significant association between blood group a and covid- mortality but the prevalence of blood group a was significantly higher than blood groups b and ab in covid- patients. the prevalence of mortality in covid- patients was also significantly higher in blood group a than b and ab. menter et al. ( ) have suggested that blood group a might be associated with coagulopathies and pulmonary circulation disorder in covid- patients because they genetically has higher von willebrand factor (vwf) activity and consequently more susceptible to thrombosis. among covid- infected individuals and the mortality cases, blood groups a and ab had the highest and lowest prevalence, respectively. however, as blood group a is the most common blood group and ab has the lowest prevalence among other blood groups in china ( ) and united states ( ) , countries of included studies, it could have potentially affected the results of our study. no statistically significant association was also found between the blood group and mortality of covid- in our study. as there are many factors involving in covid- patients mortality including gender, age, diabetes, asthma and other medical conditions ( ) , blood group has no significant effect on the mortality outcome. limitations of our study includes primary studies entered into the present meta-analysis have not been peer-reviewed yet. confounding factors including diabetes, hypertension, cardiovascular diseases etc. was not adjusted in the study, because of incomplete data. more observational studies with large-scale samples and considering the confounding factors and blood groups distribution in society are being needed to conclude the association more robustly. studies are also needed to understand the mechanisms involving protective or deteriorating effect of blood groups on covid- infection. in this meta-analysis we have found that blood group a is a partial risk factor for covid- infection and blood group o is a protective factor. blood groups b and ab were not significantly associated with covid- infection. there were no significant association found between blood groups and covid- patients' mortality. further studies are being needed considering distribution of different blood groups in the society and other confounding factors concerning covid- patient outcome to reach more robust results. -analysis of odd ratios for covid -meta - figure properties of coronavirus and sars-cov- . the malaysian journal of pathology severe acute respiratory syndrome coronavirus- (sars-cov- ): an update advances in virus research epidemiology, genetic recombination, and pathogenesis of coronaviruses severe acute respiratory syndrome isolation of a novel coronavirus from a man with pneumonia in saudi arabia pneumonia of unknown cause-china', emergencies preparedness, response. disease outbreak news, world health organization (who) a novel coronavirus from patients with pneumonia in china who director-general's opening remarks at the media briefing on covid- - opensafely: factors associated with covid- death in million patients retrospective analysis of clinical features in death cases with covid- . medrxiv association between abo blood groups and clinical outcome of coronavirus disease : evidence from two cohorts. medrxiv relationship between the abo blood group and the covid- susceptibility. medrxiv testing the association between blood type and covid- infection, intubation, and death. medrxiv abo blood group and susceptibility to severe acute respiratory syndrome helicobacter pylori in gastric biopsies of taiwanese patients with gastroduodenal diseases human susceptibility and resistance to norwalk virus infection abo blood type a is associated with increased risk of acute respiratory distress syndrome in caucasians following both major trauma and severe sepsis the relationship between epidemic influenza a (h n ) and abo blood groups abo blood group polymorphism has an impact on prostate, kidney and bladder cancer in association with longevity mortality and cancer in relation to abo blood group phenotypes in the golestan cohort study critical evaluation of the newcastle-ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses inhibition of the interaction between the sars-cov spike protein and its cellular receptor by anti-histo-blood group antibodies diagnostic performance of covid- serology assays. the malaysian journal of pathology abo blood group predisposes to covid- severity and cardiovascular diseases angiotensinconverting enzyme inhibitors reduce mortality in hypertension: a meta-analysis of randomized clinical trials of renin-angiotensin-aldosterone system inhibitors involving patients cardiovascular diseases burden in covid- : systematic review and meta-analysis risk factors of critical & mortal covid- cases: a systematic literature review and meta-analysis how blood group a might be a risk and blood group o be protected from coronavirus (covid- ) infections (how the virus invades the human body via abo(h) blood group carbohydrates): figshare expression of abo or related antigenic carbohydrates on viral envelopes leads to neutralization in the presence of serum containing specific natural antibodies and complement genetic of the abo blood system and its link with the immune system a genome-wide association scan on the levels of markers of inflammation in sardinians reveals associations that underpin its complex regulation the cytokine release syndrome (crs) of severe covid- and interleukin- receptor (il- r) antagonist tocilizumab may be the key to reduce the mortality interleukin- as a potential biomarker of covid- progression detectable serum severe acute respiratory syndrome coronavirus viral load (rnaemia) is closely correlated with drastically elevated interleukin level in critically ill patients with coronavirus disease cytokine release syndrome in severe covid- : interleukin- receptor antagonist tocilizumab may be the key to reduce mortality the role of cytokines including interleukin- in covid- induced pneumonia and macrophage activation syndrome-like disease post-mortem examination of covid patients reveals diffuse alveolar damage with severe capillary congestion and variegated findings of lungs and other organs suggesting vascular dysfunction frequencies and ethnic distribution of abo and rhd blood groups in china: a population-based cross-sectional study abo and rh (d) phenotype frequencies of different racial/ethnic groups in the united states j o u r n a l p r e -p r o o f key: cord- -dyvhzvmm authors: mcguigan, michael title: pandemic modeling and the renormalization group equations: effect of contact matrices, fixed points and nonspecific vaccine waning date: - - journal: nan doi: nan sha: doc_id: cord_uid: dyvhzvmm in this paper we find common features between the equations that are used for pandemic or epidemic modeling and the renormalization group equations that are used in high energy physics. some of these features include the relation of contact matrices in pandemic modeling and operator mixing in the renormalization group equations. another common feature are the use of flow diagrams and the study of fixed points both in pandemic modeling and in evolution under renormalization group equations. we illustrate these relations through the study of some cases of interest to the current covid- pandemic. these include pandemic modeling with mixing between different age groups and also contact matrices associated with contact between countries. for the final example we study the effect on mortality of waning from nonspecific vaccines which are designed to combat different pathogens but nevertheless may lessen the severity and mortality of covid- infections. it is well known that in physics phenomena that are governed by the same type of equations can benefit from the sharing of techniques for the solution and visualization of the solutions to those equations. for example the simple harmonic oscillator and electronic circuits are described by similar equations and insight from one equation can be applied to the other. the first order nature of the differential equations used in compartment models for epidemic modeling draw a striking resemblance to the renormalization group equations used to describe high energy physics models. essentially each compartment or the number of class of individuals in the model correspond to a coupling constant in the high energy physics model. one can even go beyond this and draw a closer relation to scaling structure of virus spreading and evolution of a physics model under change in scale [ ] [ ] . in this paper we illustrate the relation between. the techniques used in high energy physics and apply these to cases of interest to pandemics with similar characteristics to the current covid- pandemic. this paper is organized as follows. in section one we give a basic introduction to our approach. in section two we give the basic equations that are used in pandemic and epidemic modeling based on classifying individuals in different compartments. in section three we give the basic renormalization group equations of high energy physics associated with coupling constants. we show how basic solution techniques and visualizations involving flow diagrams can also be applied to compartment models of pandemic modeling and how these can be used to identify fixed points of final state equilibrium in pandemic modeling. we also draw a parallel between the between pandemic contact matrices and operator mixing where a coefficient of an operator that may be zero at some scale nevertheless can become nonzero at a different scale through mixing with other operators in the theory. in section four we illustrate the above relations using contact matrices between different age groups using demographics and pandemic characteristics similar to the current covid- pandemic. in section five we further illustrate the techniques using contact matrices between different countries which encounter the virus through delayed interaction and visualizing the curves for infection and mortality during the pandemic. in section six we study the effect of nonspecific vaccines that do not prevent infection but may lessen the severity and mortality of the pandemic by studying the model with separate age groups both with and without the use of a nonspecific vaccine. finally in section seven we state the main conclusions of the paper and opportunities for further exploration of the common features of pandemic modeling and remormalization group equations. here s is the fraction of the population of susceptible individuals, i is the fraction of infected individuals and r is the fraction of recovered individuals. in these equations β and γ are constants associated with the epidemics that determine the likelihood of infection and the rate of recovery. another model that we will use is the sird model which is similar to the sir model but takes into account mortality associated with the infection. for the sird model the compartment equations are: with initial conditions here s is the fraction of the population of susceptible individuals, i is the fraction of infected individuals, r is the fraction of recovered individuals and d is the fraction of deceased individuals. in these equations β, γ and µ are constants associated with the epidemics that determine the likelihood of infection, the rate of recovery and the rate of dying from the infection. for small number of compartments these epidemic equations are not difficult to solve numerically using software such as mathematica or matlab [ ] . in figure we show the numerical solution for an epidemic described by an sir model for parameters (β = / , γ = / ) with initial conditions (s = . , i = . , r = ). in the compartmental models of epidemics one has different compartments associated with susceptible, infected , recovered and deceased individuals. in the renormalization group equations of high energy physics instead of compartments one has coupling constants that describe interactions in the high energy physics model. instead of evolving the system of equations in time as in the equations of epidemic modeling in the renomalization group equation one has evolution with respect to energy scale whose logarithm is denoted as t. perhaps the most important system of renormalization group equations of high energy physics is the equations governing the coupling constants of the standard model of high energy physics [ ] . these can be written as: with the right hand side give by the beta functions of the theory whose coefficients are computed using feynman diagrams and are given by: with initial conditions given by: in these equations λ is the coupling constant of the higgs boson, y t is the coupling constant of the top quark and (g , g , g ) are the coupling constants the electroweak and strong interactions. looking at the structure of the system of differential equations describing the renormalization group one can see that it describes a system of similar complexity to a five compartment epidemic model. in the following sections we will consider models with eight and twelve compartments of even greater complexity. one can study a simpler form of renoramlization group equations associated with the higgs boson coupled to the top quark in a model referred to as the yukawa model [ ] . for this model one has two coupling constants and the renormalization group equations are given by: now defining as in [ ] : we have: with β a λ = ( a λ + a y a λ − a y ) β ay = a y ( . ) in this form we see that the renormalization group equations of the yukawa theory have a strong resemblance to the system of differential equations used to describe the sir model. we may then expect that techniques and visualizations used in the renormalization group equations should be applicable to the equations used in epidemic modeling. below we illustrate this using the example of flow diagrams and mixing terms in the equations. the renormalization group flow diagrams illustrate fixed points in the renormalization flow where the coupling constants do not change in scale. thus they become fixed at whatever value make the beta functions vanish. in the pandemic context a similar phenomena happens when we reach a point in the pandemic when the number of susceptible, infected and recovered individuals are not changing in time. this can occur if the number of susceptible individuals dropped to a level that the pandemic is extinguished or it can also occur if the number of infected individuals reaches a constant level in the population and then the pandemic virus becomes endemic in the population. in such cases the fixed points of the flow diagram represent points of endemic equilibrium in (s, i, r) space [ ] [ ] . in figure we show the renormalization group flow for the yukawa theory considered in [ ] . it is clear from the diagram that the flow of coupling constant when the scale changes goes to a fixed point in coupling constant space where the flow is stationary and the beta functions or the right hand side of the renormalization group equations vanishes. in figure we show a similar flow diagram for the sir epidemic model. in this case we also see that the flow goes to a point where the compartments i and s become stationary when the epidemic has ended after the number of susceptible individuals drops to a level so that the epidemic can no longer be sustained. it will also be important to study flow visualizations over longer time scales where the virus can be come endemic and then recur at a later date. the contact matrix is a symmetric matrix that indicates the number of contacts between different groups. if the matrix is diagonal then the different groups do not mix. for example if two countries are island countries and have no boat or air travel between them then contact matrix will be diagonal. for the renormalization group one has an analogous concept of operator mixing. this occurs because loop graphs induce new operators that were not present in in initial renormalization group evolution. the matrix of coefficients that describe this operator mixing is the anomalous dimension matrix and is analogous to the contact matrix. for the renormalization group equation the effect of operator mixing is described by the anomalous dimension matrix γ i,j through the equation: where c i is the coefficient of an operator o i . these matrices have an important physical effect as operators which have vanishing coefficient at one scale but which develop a nonzero value at a different scale through the mixing with other operators in the theory. for the sir model the contact matrix plays a similar role. in this case a subset population may have a vanishing number of infections at one time but develop infections through the contact with another segment of the population at a later time. this contact matrix is proportional to the number of contacts between the different populations and is represented in the differential equations of the sird model in a similar manner to the anomalous dimension matrix in the renormalization group equations. for the sird model the effect contact matrix c ij is given by [ ] : in these equations β i is the contact coefficient between susceptible and infected individuals in group i, γ i is the infection rate in group i and µ i is the death rate in group i and c ij is the contact matrix between different groups. in the sird model s i is the number of susceptible individuals in group i, i i is the number of infected individulas in group i, r i is the number of recovered individuals in group i and d i is the number of individuals who died in group i. the sird model has been applied to pandemics including the ongoing covid- pandemic in [ ] [ ] [ ] . we will give two examples of the use of the sird model in grouping by age and also by country in the next two sections. the contact matrix between different age groups can be important especially if one age group is more susceptible or has a higher mortality rate than the other. for example the older population may be more inclined to severe outcomes if they have weakened immune systems or secondary health conditions. the other way around is possible too. older segments of the population may have been exposed earlier in life to a similar pathogen and still retain some immunity while the younger population would not been alive during this time and would be completely susceptible. still another scenario is that the younger population was vaccinated against a similar pathogen as part of routine child immunizations wheres the older population either never received them or the effect of the vaccines have waned leaving them vulnerable. the sird model among two age groups is given by an eight compartment model [ ] : the contact matrix between the two age groups is taken to be: other parameters we use are: where group is the age group - with a low mortality rate and group is the age group + with a substantially higher mortality rate. the initial population of group is taken to be , and for group the initial population taken to be , so that the total initial population of the two groups is , . the initial number of infected individuals in group was taken to be and in group it was taken to be . solving these equations with the parameters and initial condition we see that as the infections in group go down but once contact with group is initiated the infections in group increase and one obtains a second peak of infections in group with contributes substantially to the total number of deaths due to the high mortality in group . often during pandemics segments of the population are kept from the susceptible part of the population through stay at home orders. these segments may be added later to susceptible pool at a later stage in the pandemic when restrictions are eased. this can be modeled with nine groups from to + in ten year intervals as in figure or as two age groups one group under and the other over as in figure . in either case the population with a contact matrix which is diagonal initially and is non-diagonal at a later stage. the results from the sird model for the the two age group case is shown in figure and figure . we clearly see the second peak of infection in the older age group due to the the effects of the contact matrix and initial infection in the younger age group. because of the higher mortality rate in the older age group the model predicts that most of the deaths occur there. for the parameters that we chose in the sird simulation with a susceptible population of , in the younger age group and , in the older age group and we found that the number of deaths were in the younger age group and in the older age group for at total of deaths out of the , population. this is a dramatic illustration of the effect of the contact matrix between different age populations in pandemic modeling. it is important to note in the early phase of a pandemic such as from covid- the model parameters are not known accurately. these uncertainties can lead to a range of predictions that depend on these uncertainties. although there are several parameters in the models we simulate we found the parameter β that indicated the interaction between the susceptible and infected populations to be very important. for the simulation results shown figure increasing β by percent lead to a peak in infection in the younger group increasing from , to , and and an increase the peak in the older group from to . decreasing β by ten percent lead to a peak in infection in the younger group with a decrease from , to and and an decrease in the peak in the older group from to . for the simulation results in figure increasing β by percent lead to deaths in the younger group increasing from to and and an increase in deaths in the older group from to . decreasing β by ten percent lead to deaths in the younger to decrease from to and and an increase in deaths in the older group from to . figure : infections as a function of time for two age groups ( − ) and + where there is a nondiagonal contact matrix in the sird model describing the interaction between the two age groups during the pandemic. note the presence of two peaks corresponding to peak infections in both age groups. figure : deaths as a function of time for two age groups ( − ) and + where there is a nondiagonal contact matrix in the sird model describing the interaction between the two age groups during the pandemic. note the older age group leads to far more deaths than the younger age group due to the higher mortality rate in the older age group. in this section we consider a simple three compartment model involving three countries involved in virus spreading. in country the virus starts an exponential growth pattern. travel between country and country takes place, followed at a later date by travel from country to . the three country model can be described by the twelve compartment sird model: with contact matrix between the countries given by the three by three matrix which we take to be: other parameters we use in the simulation are: with these parameters and also multiplying the contact matrix with a smoothed out step function to model time delay in establishing contact between the countries we obtain the results for infections in figure and deaths figure . note that when the first country has contact with the second the infections in country have dropped substantially nevertheless there were enough cases to continue the pandemic into country . the same scenario then repeats itself after country 's infections go down and contact starts between country and country . the same step like effect can be seen in deaths in figure where deaths in country pick up after contact is initiated with the initial infection in country with the same scenario continuing between country and . note the three separate peaks in the number of infections which arise when travel restrictions are eased between countries and the stair like structure in the number of deaths as the pandemic moves between the countries. the number of deaths occurring assuming each country has a population of , is per country for a total deaths for the total population of the three countries of , . this is also a dramatic illustration of the effect of contact matrix in this case between countries in pandemic modeling. again it is important to note in the early phase of a pandemic such from covid- the model parameters are not known accurately. for the simulation results shown figure increasing β by percent lead to a peak in infection in the first country increasing from , to , , an increase the peak in the second country from , to , , and an increase the peak in the third country from , to , . decreasing β by ten percent lead to a peak in infection in the first country with a decrease from , to , , a decrease in the peak in the second country from , to , and a decrease in the peak in the third country from , to , as well. for the simulation results in figure increasing β by percent lead to deaths in the first country increasing from to , an increase in deaths in the second country from to , and an increase in the deaths in the third country from to . decreasing β by ten percent lead to deaths in the first country to decrease from to , deaths in the second country to decrease from to , and deaths in the third country to decrease from to as well. figure : infections as a function of time for three countries whose interactions are described by an nondiagonal contact matrix. note that although the contacts between country and country are zero country nevertheless becomes part of the pandemic because both countries and interact with country . figure : deaths as a function of time for three countries whose interactions are described by an nondiagonal contact matrix. note the stair like structure in the number of deaths as the pandemic moves from country to country and from country to country . there are two possible effects of vaccine waning in pandemic modeling. in the first case a vaccine is developed specifically targeting the virus. like the seasonal flu vaccine the effectiveness of this vaccine can effectively wane perhaps in short enough time scales so that people will lose immunity to the specific virus during the pandemic and will require a booster to regain immunity [ ] [ ] . in the second case one sees some efficacy from a vaccine which we call nonspecific to the pandemic virus but was developed for a different pathogen but nevertheless may have some positive effects that result in lower morbidity to the pandemic virus. in references [ ] [ ] [ ] nonspecific vaccines that are being studied including the mmr vaccine, the live attenuated polio vaccine and the bcg tuberculosis vaccine. the effects of this nonspecific vaccine could also wane over time. this can also lead to sporadic outbreaks of the original virus it was designed to protect against as for example has been seen in outbreaks of mumps. if the nonspecific vaccine has a positive effect against the pandemic then the effect of vaccine waning may also contribute to age dependence of pandemic morbidity as vaccine waning may reduce the effect of the nonspecific vaccine in older populations who have not received a booster and have a longer time period from inoculation. the waning involved in the nonspecific vaccine could be much longer than the time frame of the pandemic and the main effect would be a contribution to the age distribution of pandemic morbidity. here we study a set of two sird models to study this effect. in the first model we study a sird model with two age groups and no effect of the nonspecific vaccine. in the second model we consider a sird model including a possible effect reducing the morbidity with a greater effect on the younger age group due to possible waning of the nonspecific vaccine. the amount of waning by age group is given in figure and the effect on the death rate with or without the hypothetical nonspecific vaccine that we used in the simulation are shown in figure . the model we used for the second sird model is given by: then we compare the results of these two models to see the effect of the nonspecific vaccine and the pandemic. we see from figure with the same contact matrix c ij from ( . ). we see that there is an age related effect in pandemic modeling somewhat similar to what is seen in the covid- pandemic. it would be very interesting add more compartments and to represent comorbidities in the different age groups to more closely model the different age populations reaction to the disease. figure : (left) death rate for a population without a nonspecific vaccine for two age groups ( − ) and +. (right) deathrate for a population with a nonspecific vaccine taking into account vaccine waning for two age groups ( − ) and +. note the deathrate is reduced more for the younger age group as the nonspecific vaccine wanes less than the older age group. we also see from figure that the number of deaths in both age groups decrease with the hypothetical nonspecific vaccine. we chose parameters in the sird simulation from ( . ) with a susceptible population of , in the younger age group and , in the older age group. we found that the number of deaths decreased from to with the use of the hypothetical nonspecific vaccine in the younger age group. the number of deaths in the older age group decreased from to with the use of the hypothetical nonspecific vaccine. overall the number of deaths in the total population of , decreased from to due to the effect of the hypothetical nonspecific vaccine using the parameters figure : (left) deaths for a population without a hypothetical nonspecific vaccine for two age groups ( − ) and +. (right) deaths for a population with a hypothetical nonspecific vaccine taking into account vaccine waning for two age groups ( − ) and +. note the number of deaths is reduced more for the younger age group as the nonspecific vaccine wanes less than in the older age group. ( . ) of the sird model. the effect in the older age group is less because of the vaccine waning varying with the number of years from vaccination. the application of a booster of the nonspecific vaccine to the older age group could be expected to lower the mortality even further as more fatalities are recorded in the older age group where the mortality rate is higher. it will be interesting to examine the projections for pandemic modeling as more data becomes available on the effect of booster for nonspecific vaccines [ ] [ ] [ ] . this type of analysis could also be important for specific vaccines as more data becomes available from clinical trials and measurements are made as to the amount waning that occurs for vaccines designed specifically for the pandemic pathogen [ ] . finally the number of infections per day remain the same with or without the nonspecific vaccines in the sird model we considered. this is because the nonspecific vaccines reduce the severity of the illness and lower mortality but do not prevent infection with the pandemic pathogen as would happen with a specific vaccine targeted to the pandemic virus [ ] . for early stages of pandemics model parameters are not known accurately. to gauge the effects of parameter uncertainties in figure we vary the important parameter β to see its effects on the simulation. for figure (left) increasing β by percent increased the deaths in the simulation without the nonspecific vaccine from to for the younger age group and from to for the older age group. decreasing β by percent decreased the deaths in the simulation without the nonspecific vaccine in the younger group from to and from to in the older age group. for figure (right) increasing β by percent increased the deaths in the simulation with the nonspecific vaccine from to for the younger age group and from to for the older age group. decreasing β by percent decreased the deaths in the simulation without the nonspecific vaccine in the younger group from to and from to in the older age group. in this paper we have examined some similar concepts in the renormalization group equations of high energy physics and pandemic modeling based on differential equations. this include the nonlinear behavior of the differential equations, the dependence on the initial conditions and renormlalization group evolution, the similar nature of the contact matrix between compartment groups in epidemic modeling and the notion of operator mixing and fixed points in the renormalization group equations. we put these features together in models with mixing between different age groups, mixing with different countries and the effect of waning of nonspecific vaccines that were designed for different diseases but can lessen the severity of infection and mortality for a pathogen associated with a pandemic. in the future it would be interesting to extend these case studies using more data with respect to different regions, age demographics and age related mortality. it will also be interesting to extend the contact matrix study with different countries as travel is resumed between countries with lower rates of infection. finally we would like to update the model associated with waning of nonspecific vaccines as well as specific vaccines as more data becomes available from clinical trials about the effect of nonspecific and specific vaccines on the rate of mortality for the pandemic. nonperturbative renormalization group for the diffusive epidemic process renormalization group approach to pandemics: the covid- case a contribution to the mathematical theory of epidemics simple models for containment of a pandemic a model for influenza with vaccination and antiviral treatment the sir model and the foundation of public health influenza models with wolfram mathematica self-consistence of the standard model via the renormalization group analysis renormalization-group flows and fixed points in yukawa theories fixed point analysis of the kermack mckendrick sir model a fixed point theorem for a general epidemic model social contacts and mixing patterns relevant to the spread of infectious diseases estimating and simulating a sird model of covid- for many countries, states and cities studying the progress of covid- outbreak in india using the sird model analyzing covid- data using sird models stability analysis of an age structured seirs model with time delay waning immunity and mocrobial vaccines -workshop of the national institute of allergy and infectious diseases implications of vaccination and waning immunity vaccine waning and mumps re-emergence in the united states how long do vaccines last? the surprising answer may help protect people longer modelling the strategies for age specific vaccination scheduling during influenza pandemic outbreaks sir-based mathematical modeling of infectious diseases with vaccination and waning immunity modeling the effects of vaccination and treatment on pandemic influenza impact of a waning vaccine and altered behavior on the spread of influenza could an unrelated live attenuated vaccine serve as a preventive measure to dampen septic inflammation associated with covid- infection? can existing live vaccines prevent covid- ? bcg vaccine protection from severe coronavirus disease covid- safety and immunogenicity of the chadox ncov- vaccine against sars-cov- : a preliminary report of a phase / , single-blind, randomised controlled trial this manuscript has been authored by employees of brookhaven science associates, llc under contract no. de-sc with the u.s. department of energy. key: cord- -s qpiovr authors: ehrengut, w.; sarateanu, d. e. title: a two year serological surveillance of coronavirus infections in hamburg date: journal: infection doi: . /bf sha: doc_id: cord_uid: s qpiovr the occurrence of oc- coronavirus-like infections in the population of hamburg was determined by a monthly serological survey (hemagglutination inhibition test [hi]) undertaken between october and october . studies of , sera revealed a high incidence of hi antibodies ( . %). the frequency of seropositive reactions (= : ) and the geometric mean titer were higher in individuals to years old. treatment of positive sera (titer : – : ) with receptor destroying enzyme, kaolin and ethacridin for elimination of nonspecific inhibitors did not modify the hi-titer of the investigated sera. the serological seasonal pattern suggests that coronaviruses are circulating the whole year in the urban population with a prevalence in the fall-winter period. of the paired sera examined, . % presented a four- to eightfold rise in titer within eight weeks. various surveillance programmes undertaken in recent decades have provided evidence that viral infection is the major identifiable cause of upper and lower respiratory tract disease in man. as some cases did not appear to be linked with infections by known viruses, it was hoped that the human coronaviruses discovered relatively recently might account for a proportion of these unexplained illnesses. that coronaviruses are potential respiratory pathogens has been demonstrated in experimental studies ( , ) . however, data on the extent and significance of infections by these viruses in human illnesses are still limited. serological surveillance carried out at regular intervals on a large number of sera taken from representative groups reveals the total infection rates (apparent and non-apparent) and the level and distribution of the seroimmunity in the population. the following report of seroepidemiological studies of coronavirus infections is based upon observations made in the course of a surveillance programme in hamburg (carried out since october ) in various sections of the population in which all age groups were represented. population: a total of , blood samples was collected between october and september (minimum of sera monthly) from "normal" healthy individuals divided into four age-groups: group i ( to years old); group ii ( to years old); group iii ( to years old); group iv ( years old). we collected a second sample of blood two months later from girls, to years old. after inactivation for minutes at ° c, the sera were stored at - ° c until used. all paired sera were tested simultaneously. antigen: coronavirus strain oc- has been isolated by mclntosh et al. ( ) in human embryo trachea organ culture from an adult with a cold. the strain was subsequently adapted to suckling mouse brain. strain oc- antigen was prepared from infected suckling mouse brain according to the technique described by kaye and dowdle ( ) . serology: hemagglutination inhibition (hi) tests were performed according to the sever microtitre technique ( ), using chicken red blood cells ( ) . fifty positive sera (titre : - : ) were treated with receptor destroying enzyme (rde) ( ), kaolin ( ) or ethacridin ( ) for removal of nonspecific inhibitors. the incidence of seropositive reactions in the total population studied is presented in table . from the , sera investigated, , ( . %) showed hi antibody titres certain conclusions can be drawn from the data obtained during our two year surveillance period. infections with human coronaviruses are common in all four groups studied, especially in group ii ( to years old). the higher incidence of seropositive reactions in to year olds ( . % and . %, respectively) confirms our previous data ( , , ), those of henigst ( ) , monto and lira ( ) , and riski and estola ( ) who also found a higher percentage of seropositive reactions in the to year old group ( , ) and in individuals of to years ( ) . considering the results obtained in group i and ii, our data are in agreement with those of kaye and dowdle ( higher incidence of seropositive reactions found in group ii may be attributed to multiple infections and to a special susceptibility of the group. these data also indicate an increased spread of coronaviruses in this segment of the population. the percentage of seropositive reactions in group i ( to ) was smaller than that found in other groups. an explanation of this situation may be found in the data provided by mclntosh et al. ( ) : they suggested that in infants coronaviruses play a smaller role in the etiology of lower respiratory tract diseases. the lower rate of seropositive reactions could also mean that the virus is weakly antigenic in children. since preschool children are also included in group i, this may explain the rate of seropositive reactions. it is known that in preschool children infections with oc- and oc- coronaviruses are predominant whereas infections with strain e are prevalent in adults ( ) . the seasonal pattern suggests that coronaviruses are circulating the whole year in the urban population, with prevalence in the cold season, a decrease in the warm season and sporadic cases at other times of the year. other authors ( , , , ) also found coronavirus infections usual in the period january to april. in our study we observed peaks in november , october to november , and in september , followed by low infection rates in the spring-summer season. similar data were published by bradburne and somerset ( ) , and by mclntosh et al. ( ) . we may assume that in the peak periods hamburg witnessed a wave of infection caused by an oc- virus or a related virus. neither the number of human respiratory types nor the extent of their serological cross-reactivity are well known as far as coronaviruses are concerned. it is known however that several members cross-react in one or more types of serological tests and that heterotypic antibody rises occur ( ) . as we did not isolate coronaviruses in our patients and in view of the possibility of heterologous responses of the antibody titers that we have found, we cannot interpret them as being specifically due to the oc- virus alone. the antibody response found in this seroepidemiological survey may be an expression either of past or present infections or reinfections with an agent identical or closely related to the antigen used in the test. reinfections with coronaviruses are not a rare event considering that over % of the titer rises encountered in the paired sera occurred in individuals with prior antibodies. the high rates of seropositive reactions provide complete evidence that coronaviruses are circulating widely in the urban population of hamburg. effects of a "new" respiratory virus in volunteers cultivation of a novel type of common-cold virus in organ cultures recovery in tracheal organ cultures of novel viruses from patients with respiratory disease some characteristics of hemagglutination of certain strains of "ibv-like '" virus applications of a microtechnique to viral serological investigations department of health, education and welfare: advanced laboratory techniques for influenza diagnosis department of health, education and welfare: laboratory diagnosis by serologic methods darstellung noch nicht therapeutisch angewandter plasmaproteine. behring-werke mitteilungen incidence of coronavirus oc antibodies among the population of rumania serological study of coronavirus antibodies in hamburg jahreszeitliche schwankungen von koronavirusinfektionen in hamburg occurrence of antibody against coronavirus (oc ) in the healthy population and in patients with a disease of the respiratory tract the tecumseh study of respiratory illness. vi frequency of and relationship between outbreaks of coronavirus infection occurrence of antibodies to human coronavirus oc in finland. stand seroepidemiologic survey of coronavirus (strain oc ) related infections in a children's population seroepidemiologic studies of coronavirus infection in adults and children virologic studies of acute respiratory disease in young adults. v. coronavirus e infections during six years of surveillance coronavirus infections in working adults, eight-year study with e and oc isolation from man of "avian infectious bronchitis virus-like" viruses (coronaviruses) similar to e virus, with some epidemiological observations coronavirus antibody titres in sera of healthy and experimentally infected volunteers antigenic relationship amongst coronaviruses key: cord- - g to authors: haddad, kevin; potter, brian j.; matteau, alexis; gobeil, françois; mansour, samer title: covid- implications on stemi care date: - - journal: cardiovasc revasc med doi: . /j.carrev. . . sha: doc_id: cord_uid: g to background coronavirus disease (covid- ) has forced dramatic changes to the healthcare systems throughout the world. time-sensitive management of cardiovascular emergencies such as st-elevation myocardial infarction (stemi) has yet to be evaluated in the context of these new policies, particularly in so-called “hot spot” cities. methods we evaluated the early impact of the pandemic on stemi performance in the greater montreal area. a total of patients from different study periods were included. patients presenting in the lockdown period from mid-march to mid-may (group c, patients) were compared to those from mid-march to mid-may (group a, patients) and the pre-covid- period (group b, patients). results the number of stemi admissions was unaffected during the lockdown. however, significantly longer delays between symptom onset and first medical contact (fmc) were noted (group c . iqr [ . , . ] min vs. group a . iqr [ . , . ] min vs. group b . iqr [ . , . min], p= . ). in contrast, additional safety protocols do not appear to have significantly affected delays between fmc and first intracoronary device activation (group c iqr [ . , . ] min vs. group a iqr [ . , . ] min vs. group b . iqr [ . , . ] min, p= . ). patients that presented during the outbreak were more likely to be unstable with a higher incidence of killip classes ii-iv compared to groups a and b ( . % vs. . % vs. . % respectively, p= . ). worse in-hospital outcomes were also noted with a significantly higher rate of major adverse cardiac events (group a . % vs. group b . % vs. group c . %, p= . ). conclusion during the lockdown period, many patients appear to have been reluctant to present to hospitals. this was associated with more unstable stemi presentations and worse in-hospital course. importantly, the health care system appears able to ensure timely acute cardiac care while ensuring that covid- protocols are respected. coronavirus disease (covid- ), caused by severe acute respiratory syndrome coronavirus- (sars-cov- ), is the major global healthcare challenge of the st century and has exerted significant pressures on healthcare systems worldwide ( ) . geographic differences and temporal changes in rates and spread of infection have also been noted. in particular, there have been much-higher rates of diagnoses infection so-called "hot spot" regions, such as the greater montreal area, canada's covid- epicenter. while the direct impacts of covid- are increasingly understood typified by respiratory insufficiency, a pro-inflammatory and prothrombotic state leading to multi-organ dysfunction and an associated risk of mortality ( ) , data on the indirect costs of covid- are still lacking. in the context of a global lockdown, both new organizational barriers and patients' fear of acquiring covid- have led to major concerns of undue delays in seeking appropriate emergent care, in particular for st-elevation myocardial infarction (stemi) patients. to our knowledge, no study has yet analysed changes in the pattern of stemi presentations or related complications in the canadian epicenter of infection. the magnitude of the effect on stemi system performance metrics is also not known. as such, we report herein early results demonstrating the impact of the covid- outbreak on time-sensitive stemi care delivery in the greater montreal area; a hot-spot metropolitan region where the impact would be expected to be most pronounced. j o u r n a l p r e -p r o o f journal pre-proof this is a retrospective observational study of patients presenting with a diagnosis of stemi at either the centre hospitalier de l'université de montréal (chum) in montreal or the cité-de-la-santé hospital in laval, québec. data were collected for the lockdown period between mid-march and mid-may . data comparison was made with (a) the same period in and (b) the pre-lockdown period from january to mid-march . stemi was defined according to the fourth universal definition of myocardial infarction ( ) . the only exclusion criterion was the occurrence of in-hospital stemi. pre-hospital data was collected using the emergency medical service records (when applicable) and in-hospital records. time from symptom onset and fmc to first device activation were gathered for all patients. the killip classification was used to quantify severity of associate heart failure for all patients, and left ventricular ejection fraction (lvef) was available for most patients using a transthoracic ultrasound. major adverse cardiac events (mace) were defined as a composite of cardiac death, reinfarction, cardiogenic shock, target-vessel urgent revascularization, stroke, stent thrombosis, the occurrence of malignant arrhythmia, or mechanical complications of infarction (ventricular septal defect, papillary muscle rupture, or free wall rupture and pseudoaneurysm). patients were followed for the duration of the index hospitalization. j o u r n a l p r e -p r o o f journal pre-proof statistical analyses were performed using the statistical package for social sciences (spss, ibm, version ). continuous variables were all tested for normality using the shapiro-wilk test. data are presented as either means ± standard deviation (sd) or medians and interquartile ranges, when appropriate. categorical data are presented as counts and percentages of the total, and were analyzed using a χ test across groups. comparisons of continuous and normallydistributed variables were accomplished by a one-way anova test. a kruskal-wallis test was used for non-normal continuous data. a two-tailed alpha of . was used for all analyses. a total of patients with stemi were included in our analysis ( from the cité-de-la-santé killip class at time of hospital presentation was more advanced for patients with a stemi during the lockdown period compared to the pre-covid era, with significantly more cases categorized as a killip class > (group a . % vs. group b . % vs. group c . %, p= . ). the rate of anterior stemi was . j o u r n a l p r e -p r o o f journal pre-proof mace rates after the index procedure for patients admitted during the lockdown period were significantly higher than those observed in during the same period or the one recorded between january and mid-march ( . % vs. . % vs. . %, respectively, p= . ). in a post-hoc analysis, a composite endpoint of mechanical complications, shock, or death was significantly higher during the covid- lockdown period (group a . % vs. group b . % vs. group c . %, p= . ). rates of other cardiovascular events were also significantly higher from mid-march to mid-may compared to those observed in during the same period or those recorded in early : mechanical complications ( . % vs. . % vs. . %, respectively, p= . ), malignant arrhythmias ( . % vs. . % vs. . %, respectively, p= . ), target-vessel urgent revascularization ( . % vs. . % vs. . %, respectively, p= . ) and death ( . % vs. . % vs. . %, respectively, p= . ). see table this study represents the first canadian report of changes in the pattern and consequences of stemi presentation to specifically asses both ischemic time prior to and following contact with the medical system. our first important finding is that the rate of stemi did not decline during the pandemic. while it had been hypothesized that factors related to stemi onset might be reduced during a lockdown, this was either simply not the case or was otherwise offset by other aggravating factors, such as increased psychological stress. it, however, cannot be excluded that there was in fact an increased number of stemis during the period. although we appear to have captured all severe stemi patients, it is possible that patients with uncomplicated stemi may not have presented at all and therefore have yet to come to the attention of the medical system. also, we cannot exclude coagulation abnormalities in patients with a stemi and a concurrent covid- infection, as systematic screening for covid- infection was not done for all patients who presented to our hospitals. (the majority of patients were considered low risk based on absence of signs or symptoms of infection or a history of possible exposure or travel). some recent data suggest that stemi patients with covid- may present with a higher thrombus burden ( ) . whether this contributed to either the number or clinical severity of stemi admissions in our area remains a hypothesis in need of exploration. secondly, significantly longer delays between symptoms onset and fmc were recorded during the lockdown period, which is in line with recent reports from abroad ( ) . our data makes plain that public health and political leaders must actively communicate the message that patients with symptoms of a heart attack should not delay seeking medical help for fear of covid- . of note, there is no evidence in our cohort of patients contracting covid- by accessing emergency healthcare services. indeed, our study highlights that, during the lockdown period, delays in seeking care were associated with more advanced heart failure on presentation and significantly higher rates of inhospital mace. moreover, the increase in mace was primarily driven by the most serious complications, including a marked surge in mechanical complications, cardiogenic shock, and death. nearly in every patients during the lockdown period had a complicated stemi that included higher than historic rates of ventricular septal, free wall and papillary muscle rupture. importantly, the use of protective equipment during the pandemic and reorganization of prehospital and in-hospital care had no appreciable impact on fmc to device times. therefore, maintaining a safe working environment for both essential workers and patients in the context of covid- without sacrificing the expediency of quality of cardiac care is clearly feasible. this aligns with recent data from london showing that, despite the covid- outbreak, primary percutaneous coronary intervention (pci) could be delivered in a timely fashion with a short door-to-balloon time according to existing guidelines ( , ). it is important to note that this report may not be generalizable to non-urban settings or cities with a lower burden of covid- . moreover, as the organization of stemi services may well vary from a metropolitan area to metropolitan area, caution must be exercised in interpreting the results. however, as future public health and healthcare system policy decisions will need to be tailored to each regional setting, taking into account population density, the baseline organisation structure of local emergent healthcare delivery, and the local burden of covid- , providing granular data on a regional level of the impact of recent policy decisions on the provision and quality of care is essential. moreover, it appears likely that the local burden of disease would be j o u r n a l p r e -p r o o f journal pre-proof an important predictor of patients' attitudes regarding whether to delay seeking medical attention for an acute coronary syndrome. in conclusion, the rate of stemi in the greater montreal area appears unaffected so far by the covid- pandemic. however, patients have delayed, to their detriment, seeking emergent medical treatment. at the very least, clinical suspicion of stemi should remain high even in the context of the covid- pandemic or any future large-scale sanitary crisis. public health, political, and physician leaders must conduct awareness campaigns to ensure that patients with symptoms of a heart attack do not delay seeking care. moreover, such campaigns should stress that the system is able to provide prompt and effective care in a manner that is safe for both patients and healthcare workers. finally, front-line healthcare workers should remain vigilant for potential mechanical complications of stemi in patients with delayed presentation. none. there are no conflicts of interest to disclose. j o u r n a l p r e -p r o o f mace, % (n) . precautions and procedures for coronary and structural cardiac interventions during the covid- pandemic: guidance from canadian association of interventional cardiology implications for prevention, antithrombotic therapy, and follow-up: jacc state-of-the-art review high thrombus burden in patients with covid- presenting with st-elevation myocardial infarction letter by pilz et al regarding article covid- ) outbreak on st-segment-elevation myocardial infarction care in hong kong key: cord- - dd b di authors: rivera-benitez, josé francisco; de la luz-armendáriz, jazmín; saavedra-montañez, manuel; jasso-escutia, miguel Ángel; sánchez-betancourt, ivan; pérez-torres, armando; reyes-leyva, julio; hernández, jesús; martínez-lara, atalo; ramírez-mendoza, humberto title: co-infection of classic swine h n influenza virus in pigs persistently infected with porcine rubulavirus date: - - journal: vet microbiol doi: . /j.vetmic. . . sha: doc_id: cord_uid: dd b di porcine rubulavirus (porpv) and swine influenza virus infection causes respiratory disease in pigs. porpv persistent infection could facilitate the establishment of secondary infections. the aim of this study was to analyse the pathogenicity of classic swine h n influenza virus (swh n ) in growing pigs persistently infected with porcine rubulavirus. conventional six-week-old pigs were intranasally inoculated with porpv, swh n , or porpv/swh n . a mock-infected group was included. the co-infection with swh n was at days post-infection (dpi), right after clinical signs of porpv infection had stopped. the pigs of the co-infection group presented an increase of clinical signs compared to the simple infection groups. in all infected groups, the most recurrent lung lesion was hyperplasia of the bronchiolar-associated lymphoid tissue and interstitial pneumonia. by means of immunohistochemical evaluation it was possible to demonstrate the presence of the two viral agents infecting simultaneously the bronchiolar epithelium. viral excretion of porpv in nasal and oral fluid was recorded at and dpi, respectively. porpv persisted in several samples from respiratory tissues (rt), secondary lymphoid organs (slo), and bronchoalveolar lavage fluid (balf). for swh n , the viral excretion in nasal fluids was significantly higher in single-infected swh n pigs than in the co-infected group. however, the co-infection group exhibited an increase in the presence of swh n in rt, slo, and balf at two days after co-infection. in conclusion, the results obtained confirm an increase in the clinical signs of infection, and porpv was observed to impact the spread of swh n in analysed tissues in the early stage of co-infection, although viral shedding was not enhanced. in the present study, the interaction of swh n infection is demonstrated in pigs persistently infected with porpv. respiratory diseases in pigs are considered a primary health problem and are responsible for great economic losses in the worldwide swine industry (sørensen et al., ) . viruses that cause respiratory disease and pneumonia in growing pigs include the porcine reproductive and respiratory syndrome virus (prrsv), swine influenza virus (siv), pseudorabies virus (prv), porcine rubulavirus (porpv), porcine circovirus type- (pcv- ), and porcine respiratory coronavirus (prcv). all these viral agents can act individually or through interaction with each other, and associations with other infectious agents of bacterial origin can also occur (choi et al., ; deblanc et al., ; grau-roma and segales, ; kirkland and stephano, ; morin et al., ; rivera-benitez et al., a; segales et al., ) . porpv is the etiological agent of blue-eye disease (bed) in pigs. this disease remains endemic in mexico and has only been diagnosed in that country (escobar-lopez et al., ; stephano et al., ) . the virus genome is composed of single-stranded negative-sense rna. the virus belongs to the family paramyxoviridae (wang et al., ) . in growing pigs, the infection becomes established predominantly in the respiratory tract and the central nervous system. in lungs, interstitial pneumonia has been described, and an increase in respiratory signs was observed in experimental infection (reyes-leyva et al., ; reyes-leyva et al., ; rivera-benitez et al., a; stephano et al., ) . acute swine influenza virus infection causes interstitial pneumonia and bronchiolitis, with cough, dyspnea, fever, and lethargy as clinical manifestations, although recovery is usually rapid. the common subtypes circulating in swine have been characterised as h n , h n , and h n (brookes et al., ; olsen et al., ) . siv has been associated with porcine respiratory disease complex (prdc) in growing or fattening pigs ( - weeks of age), while interactions with mycoplasma hyopneumoniae, prrs, and pcv- (deblanc et al., ; van reeth et al., yazawa et al., have been widely studied. there are no previous studies of experimental or natural co-infection of porpv and siv. however, in the swine farms in the central and western-central regions of mexico, seropositivity (circulating antibodies specific against siv and porpv) in growing pigs is common. these regions are the most important swine production regions in mexico (avalos et al., ; bobadilla et al., ; escobar-lopez et al., ) . primary infection with porpv is common in pigs under field conditions, and it may become persistent (cuevas et al., ; wiman et al., ) . as a consequence, persistently infected pigs have greater susceptibility to secondary infections, and these infections may become exacerbated. the objective of this study was to analyse the pathogenicity of experimental co-infection with porcine rubulavirus and classic swine h n influenza virus in growing pigs. the porpv pac- strain was used (jalisco/ ; genbank access number: ef ) (ramirez-mendoza et al., ) . the viral stock was multiplied in the mdck cell line (madin-darby canine kidney). the pac- strain of porpv has been shown to cause respiratory disease and clinical presentations in experimentally infected growing pigs (rivera-benitez et al., a) . in this study, for coinfection, the a/swine/new jersey/ / (h n ) strain (swh n ) (genbank access number: k -m ) was used. the swh n viral stock was propagated in mdck cell cultures and in the allantoic cavity of -day-old embryonated chicken eggs. the a/swine/new jersey/ / h n strain was isolated from an outbreak of swine influenza in the united states and is considered the classic north american prototype that infects pigs (kendal et al., ) . in both cases, the viral stocks were titrated in cell cultures, and the reed and muench method was used to calculate the titre; the obtained titres were expressed as the % tissue culture infectious dose (tcid ). twenty-four -week-old crossbred conventional pigs were obtained from a porpv-and siv-free commercial farm. when the pigs arrived, their nasal swabs were subjected to real-time rt-pcr to confirm that the pigs were negative for porpv and siv infection. the pigs were housed in experimental isolation units at the departamento de medicina y zootecnia de cerdos of the facultad de medicina veterinaria y zootecnia at universidad nacional autónoma de méxico. all pigs were fed a commercial diet and had access to water ad libitum. after a -day adaptation period, pigs were randomly distributed into groups: porpv/mock (n = ), mock/ swh n (n = ), porpv/swh n (n = ) and mock/mock (n = ). the experimental design described above is summarised in table . all procedures and the experimental protocol were approved by the institutional experimental animal care sub-committee of the universidad nacional autónoma de méxico. the pigs were first evaluated clinically, and the observed clinical signs of respiratory disease were quantified using the loeffen et al. ( ) model. the categories evaluated were as follows: activity (value : active pigs in an alert state, : reduced activity, : apathy), breathing frequency (value : normal, : slightly elevated, : clearly elevated), abdominal breathing (value : normal, : slight abdominal breathing, : abdominal breathing, jerking), and coughing (value : absent; : present). the scores for each observation were recorded for each time point and then arranged on a scale from to (loeffen et al., ) . rectal temperature was measured, and samples were taken both pre-and post-infection. the samples collected were nasal and oral swabs (polyester swabs were placed in ml of antibiotic supplemented culture medium) and blood samples from the jugular vein. the samples (blood and swabs) were collected both pre-and post-infection on day - , , , , , , , , , , and . the pigs of all groups were euthanised at different points during the experiment: and dpi (three pigs in each group) (table ) . during necropsies, all macroscopic alterations of the respiratory tract were recorded, and a series of respiratory tissue (rt) and lymphoid tissue (slo) sections were collected (rt: nasal mucosa, anterior and bronchial trachea, and lung; slo: soft palate tonsil, mediastinal and tracheobronchial lymph nodes). bronchoalveolar lavage fluid (balf) was obtained from each pig using ml of phosphate-buffered saline. the balf samples were then centrifuged (  g/ min/ c), and the cell pellets were homogenised with ml of culture medium. all samples were preserved in liquid nitrogen until use. sections of the cranial lung lobe and mediastinal and tracheobronchial lymph nodes were fixed in % neutral buffered formalin for histopathological and immunohistochemical examination. the formalin-fixed lung samples were embedded in paraffin wax, sectioned, and stained with haematoxylin-eosin. these sections were evaluated by light microscopy for histopathological changes. for analysis, four specific changes were assessed: bronchiolar-associated lymphoid tissue hyperplasia, development of perivascular lymphoplasmacytic infiltration near to respiratory bronchioles, interstitial pneumonia, and increase of alveolar macrophages. lesion severity was scored as follows: , null; mild; , moderate; , marked; and , very marked. the pathological scores were averaged for each group analysed. for the immunohistochemical evaluation, two monoclonal antibodies were used, the first directed to the hn protein of porpv (kindly donated by dr. sandra cuevas-romero) and the second to the ha protein of the influenza virus (mab ; merck millipore, billerica, ma). the procedure was performed according to standardized protocols. immunoreactivity was evidenced using the immunodetector kit (biosb, santa babara, ca). the sera were inactivated and adsorbed to remove nonspecific inhibitors of the haemagglutination. hi was conducted following previously described protocols (oie, ; ramirez et al., ) . the serum samples were placed in a -well u-shaped plate, double serial dilutions were prepared in pbs, and eight haemagglutinating units of virus (porpv or siv) were added to each well. for porpv, the dilutions ranged from : to : , while for swh n , the range was : to : . hi titres ! ( log ) of porpv and ! ( . log ) for swh n were considered as positive. the titre of the haemagglutination-inhibiting antibodies was expressed as the maximum dilution in which the serum was capable of inhibiting the haemagglutinating activity of the virus analysed. the titres were transformed to log values. the fluids collected from the nasal and oral cavities were thawed and centrifuged (  g/ min/ c). the supernatants were inoculated in duplicates in mdck cells at % of confluence. a culture medium supplemented with mg/ml of trypsin-tpck (sigma-aldrich, st. louis, mo) was added, the inoculum were left to adsorb for min at c. afterwards, the inoculum was discarded, and culture medium with % foetal bovine serum was added. the cell cultures were incubated at c for h in a % co atmosphere. tissue samples (rt and slo) were analysed. approximately g of each tissue was homogenised in ml of culture medium, centrifuged and inoculated as described for the swab samples. after h, the cell culture plates were fixed with % paraformaldehyde to perform indirect immunofluorescence assays according to a previously described protocol (rivera-benitez et al., c). rna was extracted from the samples that contained cells (tissues and balf) and from the supernatants of the nasal and oral swabs using the rneasy tm mini kit and qiaamp viral rna tm mini kit (qiagen, dusseldorf, germany), respectively. all procedures were conducted in accordance with the manufacturer's protocol. initial extraction was performed in ml of supernatant from nasal and oral swabs and ml lysates of balf and unfiltered homogenised tissue (approximately mg); elution of total rna was performed in a volume of ml and ml, respectively. the total rna was quantified using spectrophotometry at a wavelength of nm (nanodrop, nd- , wilmington, de). rna integrity was determined by the ratio of the od /od reading, and the inclusion criterion was a ratio greater than . . the rna extracted from the samples was used in the quantification of the n gene of the porpv. real-time rt-pcr quantification was carried out following a previously described procedure (rivera-benitez et al., b) . for swh n , a previously described protocol was used that quantifies a fragment of the ha gene of swine influenza (richt et al., ) . this protocol was conducted in accordance with the established procedure, but with the following modifications: ml of total rna was used, and the amplification program was run for cycles. both taqman hydrolysis probes were marked on their ends with -fam ( -carboxyfluorescein) and on their ends with bhq (black hole quencher tm - ). briefly, a onestep, single-tube qrt-pcr assay was performed using the rna ultrasense tm one-step quantitative rt-pcr system (invitrogen, life technologies, carlsbad, ca). the -ml reaction mixture contained ml of  buffer, ml of enzyme mixture (reverse transcriptase and taq polymerase), . ml of nuclease-free water, nm of each primer, nm of probe, and ml (mean of ng) of total rna. thermal cycling was conducted in a smartcycler realtime pcr thermal cycler (cepheid, inc. usa). the cycling protocol involved an initial incubation at c for min, followed by a denaturation step at c for min, then cycles of c for s and c (for porpv) or c (for swh n ) for s (annealing step). the accumulated fluorescent signal was collected during the annealing step at each cycle. all assays were also performed with a no-template control (ntc), rna extracted from nasal and oral swabs and tissues taken from uninfected pigs. in both cases, tenfold serial dilutions ( À to À ) of the in vitro-transcribed rna were prepared in our laboratory and used to construct a standard curve. the detection limit of quantitative real-time rt-pcr assay was  viral copies/ml (the slope of the line was À . and À . . r was . and . for porpv and swh n , respectively). viral concentration was expressed as viral copy number per millilitre of total rna extracted from samples. spss v. was used for all statistical analyses. the microscopic lesion score was evaluated using a non-parametric test (kruskal-wallis). a student's t-test assuming unequal variance and a significance level of p . was used to compare rectal temperatures and the viral load of porpv and swh n in different samples (nasal and oral swabs, respiratory tissues and slo) between the single-infected groups to the co-infected group. in the porpv/mock and porpv/swh n groups, of the pigs in each group presented nasal secretions and conjunctivitis at dpi. in these same groups, pyrexia (> . c) was registred at and dpi in pigs (fig. a) . the clinical feature in the porpv/mock and porpv/swh n groups consisted of apathy and respiratory distress at dpi. no additional alterations in clinical signs were recorded on the remaining days in the porpv/mock group (except in the rectal temperature). in the co-infection group (porpv/swh n ), an increase of rectal temperatures above . c was observed at dpi of swh n in pigs, but later only one pig had a temperature of . c on dpi. this same pig was observed to have dyspnoea and nasal discharge. in the mock/swh n group, the rectal temperature was increased at dpi of siv inoculation. no significant differences in rectal temperatures were observed between the four groups at different times, and no clinical alterations or increases in rectal temperature manifested in the pigs of the mock/mock group. the clinical score for respiratory signs are shown fig. b. necropsies were performed at and dpi. macroscopic lesions were observed only in one pig in the mock/swh n group, who was found to have mild pneumonia localised in the cranial and diaphragmatic lobes ( dpi-swh n ). none of the other pigs from the analysed groups manifested macroscopic lesions. microscopic lesions were observed and scored (table ). in all infected groups, the most recurrent lesion was hyperplasia of the bronchiolarassociated lymphoid tissue (fig. ) . very marked interstitial pneumonia was observed only in one pig at dpi in the coinfected group (fig. b) . in the other groups, the severity of the interstitial pneumonia was found to be moderate (fig. c,d) . the presence of multinucleated cells in the lumen of the alveoli was a feature that was recurrently observed in / pigs of the porpv/ swh n group and in / pigs of the porpv/mock group (fig. e) . it was also possible to observe the formation of syncytia in the alveolar lumen in infected pigs with porpv (fig. f) . pigs of the mock/mock group presented no related lesions in the lungs (fig. a) . regarding immunohistochemical staining, positive reactivity to porpv was observed in / lung sections of pigs of the porpv/mock group (fig. i,j) . immunoreactivity to influenza was observed in / pigs of the mock/swh n group (fig. k, l) . as for the co-infection group, positive immunoreactivity to porpv was observed in / pigs and for influenza in / pigs. only one pig presented immunoreactivity to both viruses in the the bronchiolar epithelium (fig. g, h) . immunoreactivity to both viruses in mediastinal and tracheobronchial lymph nodes was seen only in two cases. the presence of haemagglutination-inhibiting antibodies against porpv was identified from dpi (porpv/mock group), and there was increased until maximum production was reached at dpi ( . log ). in the porpv/swh n co-infection group, the titre of antibodies remained unchanged at an average of log until the conclusion of the experiment. no antibodies against porpv were observed in the mock/swh n and mock/mock groups (table ) . with respect to the haemagglutination inhibition assay for swh n , antibodies were detected from the moment the pigs arrived in the porpv/swh n group. those antibodies corresponded to passive immunity because the sows are routinely vaccinated against swine influenza virus (subtype h n ). the titres of antibodies for both viruses are shown in the table . viral isolation for porpv and swh n was performed using the nasal and oral fluids and tissue samples. in the nasal swab samples, porpv was isolated at dpi ( / pigs) and up to dpi ( / pigs) in the porpv/swh n group. in the porpv/mock group, porpv was isolated at , and dpi in of pigs analysed. in the oral swabs, it was isolated from day ( / pigs) up to dpi ( / pigs) in the porpv/swh n group. in the porpv/mock group, porpv was isolated at , and dpi ( / pigs). in the mock/ swh n group, swh n -positive samples were detected only in the nasal fluids at ( / pigs) and ( / pigs) dpi. in the coinfection group, no positive samples for swh n were recorded. isolation of porpv and swh n was negative in all tissue samples of the evaluated groups. in the mock/mock group, no positive samples for porpv or swh n were recorded. in the nasal swabs, samples that tested positive for porpv were detected from h post-infection up to dpi (porpv/mock and porpv/swh n groups) (fig. a) , and there were no differences (p > . ) in the mean of viral loads at any time analysed for these two groups. in oral swabs, the excretion of porpv was more prolonged, and positive samples were detected from day up to dpi in the porpv/mock group. in the porpv/swh n group after co-infection with swh n , negative samples were recorded at dpi, and viral load was detected again at and dpi (fig. a) . with respect to balf, positive samples occurred in two pigs euthanised at dpi in porpv/mock group. after co-infection with swh n (in the porpv/swh n group), no positive samples were observed (table ). in slo samples, the assay detected % of positive samples. in samples from the tonsils and the mediastinal and tracheobronchial lymph nodes, the highest viral load was noted at dpi in the porpv/swh n group. in all cases, porpv persisted at % at dpi in the porpv/mock and porpv/ swh n groups (table ). in slo only at dpi were significant differences (p = . ) observed between the porpv/mock and porpv/swh n groups. with regard to tissues from the respiratory tract, positive samples were identified in all of the tissues analysed (i.e., nasal mucosa, anterior trachea, bronchial trachea, and lung), except in the trachea and bronchial trachea of the porpv/ swh n pigs at dpi. in the nasal mucosa, positive samples were detected from to dpi, with the highest viral load recorded on dpi ( . log ) (the porpv/swh n group). in the anterior trachea, the highest viral load was recorded at dpi, whereas positive samples were detected up to dpi (the porpv/ mock group). a similar distribution was observed in the bronchial trachea, with the highest viral load found at dpi. in both sections in the porpv/swh n group, we detected positive samples for swh n in nasal swabs on - dpi after co-infection with siv. in the mock/swh n group, positive tests were detected at and dpi after inoculation with swh n in significantly (p = . ) more pigs than in the co-infected group (fig. b) . for oral swabs, pigs were positive at dpi only in the mock/swh n group. in the balf samples, the highest viral load was recorded at dpi for the porpv/swh n group and dpi for the mock/swh n group (table ). in slo, the presence of swh n was negative in the tonsils of all the groups evaluated. the quantification of swh n was more frequent in the mediastinal and tracheobronchial lymph nodes in the porpv/swh n group. in the mock/ swh n group, only one positive sample was recorded in the tracheobronchial lymph node, at dpi. tissues from the respiratory tract were also analysed for the presence of swh n , but no positive samples were recorded from the nasal mucosa, except in one pig of mock/swh n group at dpi. in the anterior trachea, two samples with an average viral load of . log were detected at dpi (porpv/swh n group). in the mock/ swh n group, positive samples were detected at and dpi. in the bronchial trachea, positive samples were observed in the two groups analysed (porpv/swh n and mock/swh n ). in both tissue samples (anterior and bronchial trachea), the positivity observed at dpi in the co-infection group decreased at dpi, and negative samples were registered. in lung tissue, positive samples were detected more frequently in the co-infection group at and dpi, with viral loads of . and . log , respectively (table ) . no positive tests were recorded in any tissues from pigs from the porpv/mock and mock/mock groups. no significant differences in the viral load of slo and rt were observed between the four groups at two different times of necropsy. the objective of the present study was to evaluate the possible effect of swine influenza virus on growing pigs persistently infected with porcine rubulavirus. in swine farms in the westcentral region of mexico, blue-eye disease has become established as endemic, having reached a seroprevalence of % (escobar-lopez et al., ) . co-infection of porpv with other viral or bacterial agents increases the negative impact on production in this important swine-producing zone. the seroprevalence of siv in the west-central region has been identified at % for the h n swine subtype (avalos et al., ) . under field conditions, infection and co-infection with these two viral agents has been shown to be related to an increase in the number of pigs that experience respiratory disease. no experimental studies have been conducted that would allow us to assess the effects of a secondary infection of siv in pigs previously infected with porpv. in a previous study, we showed that porpv was able to induce a respiratory disease after experimental infection (rivera-benitez et al., a) . in this study, after infection with porpv, clinical observations included nasal secretion, conjunctivitis and decreased activity in the first week. after co-infection with swh n , only one pig presented with dyspnoea and nasal discharge. these results differ from those reported in other models of co-infection with influenza and m. hyopneumoniae (deblanc et al., ; thacker et al., ) and prrs with influenza (van reeth et al., . the findings from these previous studies included acute respiratory disease; these effects can be influenced by both the duration of the co-infection and the virulence of the strains used. the increase of the rectal temperature observed after porpv infection resulted in apathy and a reduction in activity. this increase in temperature lasted for a long period, and it could have been due to an unrelated infection however, this phenomenon was not analysed. in the co-infection group, an increase in rectal temperature was observed in / pigs. in the pigs infected only with swh n , an increase in rectal temperature was noted in / pigs at dpi. other studies of co-infection have reported fever after - dpi (m. hyo-influenza) (deblanc et al., ; thacker et al., ) or - dpi (prrs-influenza) (van reeth et al., ) and - dpi (prrs-influenza) (van reeth et al., ) . these findings indicated that the signs related to co-infection may occur at a subclinical level compared to other similar models. the scores for respiratory signs were low during the single infection phase with porpv. the highest score was recorded after co-infection with table detection of swh n and viral load rna in balf, secondary lymphoid organs (slo), and respiratory tissues (rt) in mock/swh n and porpv/swh n groups. number of positive and viral load of swh n swh n . loeffen et al. ( ) reported similar values in simple influenza infections during an earlier phase ( - dpi). the pigs in the mock/swh n group presented the lowest respiratory signs and rectal temperatures, with no pigs showing a difference in respiration or temperature after experimental infection, a finding that is in accordance with studies that used low-virulence swine influenza virus strains (busquets et al., ) . inspection of the lungs at necropsy revealed mild pneumonia in only one pig of the mock/swh n group. in other experimental infections with siv, marked pneumonia has been observed in the cranial lobes. this depends greatly on the virulence of the strain used (olsen et al., ) . histological evaluation of the lung samples indicated the presence of interstitial pneumonia and hyperplasia of the bronchiolar-associated lymphoid tissue in three infected groups. these results confirm that there is an increase in histological lung lesions after single-infection or co-infection. the increase in the presentation of histological lesions in the lungs has been reported in several experiments examining siv co-infection with other viral and bacterial pathogens (deblanc et al., ; loving et al., ; pol et al., ; thacker et al., yazawa et al., . persistent infection of porpv ( dpi) induces the formation of multinucleated cells and syncytia in the alveolar lumen. this has not been previously described in porpv infection, and this shows that persistent porpv infection generates a chronic disease that is indicated by the presence of microscopic lung lesions. the presence of immunopositivity to both viruses indicates a coinfection, at least in the lung and associated lymph nodes. the antibody response for porpv and swh n was not affected by single-infection or co-infection in all analysed groups. the serological response observed is equal to the normal dynamics previously reported in experimental infection (cuevas et al., ; rivera-benitez et al., a van reeth et al., . the presence of porpv in nasal swabs was detected using real-time rt-pcr from to dpi. a similar situation emerged in the first phase sampling with oral swabs, and later, positive samples were detected up to - dpi in the co-infected group. based on these results, it can be assumed that a reactivation occurred in the viral excretion of porpv, possibly influenced by immunostimulation generated by co-infection with swh n ; however, this is an event that will be studied later by means of immunohistochemical studies. viral isolation for porpv was more frequent in nasal and oral fluids in the first weeks post-infection. viral quantification for porpv was more frequent in oral swab samples. in cases of infection with the mumps virus in humans (a virus that is closely related to porpv), these are the samples chosen for viral quantification studies (boddicker et al., ; krause et al., ; uchida et al., ) . for siv, only samples that tested positive by real-time rt-pcr were recorded in nasal swabs, at and dpi in the two swh n -infected groups (and viral isolation in nasal fluid was only recorded for single-infected swh n group); however, differences in viral load between the mock/swh n group and the co-infection group were observed. in oral swab samples, no positive samples were detected in the porpv/swh n group. only positive samples were detected in oral fluid of pigs in the mock/swh n group. these results indicate that the primary infection with porpv does not cause greater excretion of swh n after co-infection. other models of infection with influenza and m. hyo did not produce increased excretion of siv in pigs previously infected with m. hyo (deblanc et al., ) . the balf samples were collected during the necropsies. in the porpv group, positive samples were detected at dpi. these observations had not been recorded previously at extended time points, and it is interesting to note that this type of sample may be useful for diagnosis of porpv. during the evaluation of swh n , two samples that were positive by real-time rt-pcr were recorded at and dpi in the single-infected and co-infected pigs, respectively. these results are in agreement with those obtained in other experimental infections that used the same influenza sub-type. busquets et al. ( ) reported the presence of influenza h n in bronchoalveolar lavage samples at dpi, and its continuation up to day . in that work, quantification was performed using samples of slo and rt. in the slo, samples that tested positive for porpv were detected on two sampling days. the viral load of porpv in lymphoid organs after co-infection was found to be greater than in the porpv/mock group. the tissue that presented the highest viral load was the soft palate tonsils. previous studies (cuevas et al., ; wiman et al., ) confirmed the persistence of porpv rna in lymphoid tissues from day to day post-infection in experimentally infected pigs. in the samples evaluated for swh n in this study, positive results were noted only in the lymph nodes. there were no positive samples from the tonsils. de vleeschauwer et al. ( ) reported the presence of swh n in tonsils from days to post-infection, and that study emphasised that the route of inoculation (intranasal vs. intratracheal) is an important factor for the distribution of the virus into diverse tissues. the positivity and viral load recorded for swh n in lymphoid organs was more frequent in the co-infected group, which presented with an increase in viral load even in the mediastinal lymph node. in rt, all samples were positive for porpv. in the analysed samples, no significant difference was observed in the viral load for porpv or swh n . in the nasal mucosa, positive samples for porpv were found from days - post-infection, and a higher viral load was observed in the co-infected group. in the case of swh n , only one sample was found to be positive in the mock/swh n group. however, the anterior and bronchial trachea was negative for porpv in the early stage of swh n co-infection. it is probable that after co-infection with swh n , the immune system was reactivated at this site and was able to clear the porpv in the trachea and bronchial trachea, at least in the early stage of infection with siv. with respect to swh n , viral load was found in samples from the trachea and the bronchial trachea on and dpi, predominantly in pigs of the mock/swh n group. previous studies obtained similar results by isolating swh n on days - post-infection (de vleeschauwer et al., ) , revealing a high tropism for this type of tissue. however, in the co-infection group, there was an increase in the presentation of swh n at the early stage of co-infection ( dpi). the increased viral load of swh n in the trachea and bronchial trachea coincides with the decrease in the viral load of porpv. in lung tissue, the distribution of porv was constant and persisted up to dpi. wiman et al. ( ) reported the presence of porv rna in lung tissue days after experimental infection. for swh n , viral rna was detected during the first two days in the co-infected group, and in the single-infected group, at dpi, which is similar to data from previous studies (de vleeschauwer et al., ; weingartl et al., ). an interesting effect was observed in balf and lung tissue: it appears that the pigs of the co-infected group were more susceptible to secondary infection because there was a greater number of a positive sample in this group compared with the single-infected group, thus demonstrating the association between primary porpv infection and subsequent swh n infection. in conclusion, the results obtained confirm infection, seroconversion, excretion, and distribution of porpv and swh n in growing pigs. the observations included an increase in the clinical signs in the co-infected group compared to simple infections. there were no significant differences in other measurements such as rectal temperature, macroand microscopic lesions, and viral loads of both viruses between the analysed groups. however, primary infection with porpv seems to have a positive impact on the spread and viral load of swh n in respiratory and lymphoid tissues in early stages of co-infection, although viral shedding in nasal and oral secretions was not enhanced. in the present study, the interaction of swh n with porpv is demonstrated in persistently infected porpv pigs. under field conditions, preventing porpv infection could also reduce the clinical effect of co-infections with viral or bacterial agents including, as in this case, siv. influenza porcina en méxico dinámica de la producción porcina en méxico de a real-time reverse transcription-pcr assay for detection of mumps virus rna in clinical specimens influenza a (h n ) infection in pigs experimental infection with h n european swine influenza virus protects pigs from an infection with the pandemic h n human influenza virus investigation of t-cell responses and viral mrna persistence in lymph nodes of pigs infected with porcine rubulavirus retrospective analysis of etiologic agents associated with respiratory diseases in pigs comparative pathogenesis of an avian h n and a swine h n influenza virus in pigs pre-infection of pigs with mycoplasma hyopneumoniae modifies outcomes of infection with european swine influenza virus of h n , but not h n , subtype identification of antigenic variants of the porcine rubulavirus in sera of field swine and their seroprevalence detection of porcine reproductive and respiratory syndrome virus, porcine circovirus type , swine influenza virus and aujeszky's disease virus in cases of porcine proliferative and necrotizing pneumonia (pnp) in spain identification and preliminary antigenic analysis of swine influenza-like viruses isolated during an influenza outbreak at fort dix, new jersey paramyxoviruses: rubulavirus, menangle, and nipah virus infections, diseases of swine real-time pcr for mumps diagnosis on clinical specimens-comparison with results of conventional methods of virus detection and nested pcr effect of maternally derived antibodies on the clinical signs and immune response in pigs after primary and secondary infection with an influenza h n virus influenza virus coinfection with bordetella bronchiseptica enhances bacterial colonization and host responses exacerbating pulmonary lesions severe proliferative and necrotizing pneumonia in pigs: a newly recognized disease manual of diagnostic tests and vaccines forterrestrial animals swine influenza, diseases of swine dual infections of prrsv/influenza or prrsv/actinobacillus pleuropneumoniae in the respiratory tract lesions in the reproductive tract of boars experimentally infected with porcine rubula virus hemoaglutinación e inhibición de la hemoaglutinación del paramixovirus porcino a través de la modificación de algunas variables que participan en la prueba detección de viremia en la infección experimental por rubulavirus porcino mecanismos moleculares de la patogenia viral: estudios con el rubulavirus porcino realtime reverse transcription-polymerase chain reaction assays for the detection and differentiation of north american swine influenza viruses respiratory disease in growing pigs after porcine rubulavirus experimental infection efficacy of quantitative rt-pcr for detection of the nucleoprotein gene from different porcine rubulavirus strains persistence of porcine rubulavirus in experimentally infected boars immunohistochemical demonstration of the spread of pneumotropic strain of aujeszky's disease virus in conventional pigs diseases of the respiratory system encephalomyelitis, reproductive failure and corneal opacity (blue eye) in pigs, associated with a paramyxovirus infection interaction between mycoplasma hyopneumoniae and swine influenza virus rapid and sensitive detection of mumps virus rna directly from clinical samples by real-time pcr dual infections of feeder pigs with porcine reproductive and respiratory syndrome virus followed by porcine respiratory coronavirus or swine influenza virus: a clinical and virological study clinical effects of experimental dual infections with porcine reproductive and respiratory syndrome virus followed by swine influenza virus in conventional and colostrum-deprived pigs virus taxonomy: classification and nomenclature of viruses. ninth report of the international committee on taxonomy of viruses experimental infection of pigs with the human pandemic influenza virus porcine rubulavirus lpmv rna persists in the central nervous system of pigs after recovery from acute infection experimental dual infection of pigs with an h n swine influenza virus (a/sw/ hok/ / ) and mycoplasma hyopneumoniae the authors thank alfredo díaz estrada (departamento de medicina y zootecnia de aves) and josé alfredo sánchez (departamento de patología) of fmvz-unam for their support in sampling and sample processing. this study was partially funded by the following projects: conacyt ac- ,papiit-in - and recursos fiscales inifap . j. f. rivera-benitez received a scholarship (no. ) awarded by the national system of scholarships for graduate studies through the consejo nacional de ciencia y tecnologia (conacyt). the authors affirm that no financial or personal relationships exist that could have inappropriately influenced the content of this manuscript or the opinions expressed. key: cord- -qfn dc q authors: wormser, gary p.; nunez, miguel; horn, david title: non-sexually transmitted infectious diseases of the oral, nasal, and vaginal mucosae date: - - journal: clinics in dermatology doi: . / - x( ) - sha: doc_id: cord_uid: qfn dc q abstract the skin and mucous membranes are the principal barriers to invasion of the body by microorganisms. besides functioning as a mechanical barrier, the mucosae are endowed with an array of still poorly characterized specific and nonspecific host defense capabilities. these include the production of mucus, secretory immunoglobulin (iga), lysozyme, lactoferrin, and alpha-antitrypsin, in conjunction with a low-grade exudation of leukocytes. in addition, the mucosal surfaces of the upper respiratory, gastrointestinal, and lower vaginal and urinary tracts support a large number of “nonpathogenic” microorganisms that comprise the so-called “normal flora.” this commensal flora plays an important and complex role in protecting the host from microbial invasion. mechanisms for this protection likely include the following: ( ) competition for the same nutrients (interference); ( ) competition for the same receptors on host cells (tropism); ( ) production of bacteriocins, that is, bacterial products that are toxic to other organisms, usually of the same species; and ( ) stimulation of crossprotective immune factors such as the “natural antibodies.” the “normal” flora is inconstant and may be altered by dietary factors, debilitation, hormonal events (such as menstruation, pregnancy, and possibly use of oral contraceptives), personal hygiene, medications, intercurrent infection, and probably many others. antibiotic therapy and menstruation can have a profound effect on the composition of this group of microorganisms. disturbance of the delicate host-commensal relationship may cause a clinically significant infection due to these “nonpathogens.” this may occur in response to the aforementioned factors (eg, pregnancy predisposing to vaginal candidiasis) or because of disruption of the anatomic barrier (eg, local mucosal infection at a site of trauma, or injury from cytotoxic drugs) or in association with exogenous infection (eg, rhinoviral infection leading to secondary bacterial otitis media). invasion by “normal flora” may result in serious systemic illness. a clear example of the latter is the development of infective endocarditis caused by viridans streptococci following a dental procedure. the skin and mucous membranes are the principal barriers to invasion of the body by microorganisms. besides functioning as a mechanical barrier, the mucosae are endowed with an array of still poorly characterized specific and nonspecific host defense capabilities. these include the production of mucus, secretory immunoglobulin (iga), lysozyme, lactoferrin, and alpha-antitrypsin, in conjunction with a low-grade exudation of leukocytes. in addition, the mucosal surfaces of the upper respiratory, gastrointestinal, and lower vaginal and urinary tracts support a large number of "nonpathogenic" microorganisms that comprise the so-called "normal flora." this commensal flora plays an important and complex role in protecting the host from microbial invasion. mechanisms for this protection likely include the following: ( ) competition for the same nutrients (interference): ( ) competition for the same receptors on host cells (tropism); ( ) production of bacteriocins, that is, bacterial products that are toxic to other organisms, usually of the same species; and ( ) stimulation of crossprotective immune factors such as the "natural antibodies."' the "normal" flora is inconstant and may be altered by dietary factors, debilitation, hormonal events (such as menstruation, pregnancy, and possibly use of oral contraceptives), personal hygiene, medications, intercurrent infection, and probably many others. antibiotic therapy and menstruation can have a profound effect on the composition of this group of microorganisms.* disturbance of the delicate host-commensal relationship may cause a clinically significant infection due to these "nonpathogens." this may occur in response to the aforementioned factors (eg, pregnancy predisposing to vaginal candidiasis) or because of disruption of the anatomic barrier (eg, local mucosal infection at a site of trauma, or injury from cytotoxic drugs) or in association with exogenous infection (eg, rhinoviral infection leading to secondary bacterial otitis media). invasion by "normal flora" may result in serious systemic illness. a clear example of the latter is the development of infective endocarditis caused by viridans streptococci following a dental procedure. the majority of all human pathogens enter the body through a mucosal surface, at which point they may or may not cause local disease. whether or not local mucosal infection is established on entry, the mucosae may still be affected secondarily as part of the systemic disease process. consequently, it is far too ambitious a task to describe in detail every infection known to involve the mucosae, even excluding the sexually transmitted ones. what must be considered an incomplete tabulation of those non-sexually transmitted infectious diseases with manifestations in the oral, nasal, or vaginal mucous membranes is given in tables and . -m instead, ihe focus of this chapter is to review the clinical features of an important and com-mon syndrome, pharyngitis, with particular reference to newer concepts regarding the relationship of this entity to that of the "normal flora." respiratory infections are the leading cause of acute illness in the united states, and sore throat is the third most common symptom seen in medical practice .=~ despite years of experience with this condition, its management is far from a settled or secure issue, and questions being raised today are not the same as those in prior years. the most important bacterial cause of sore throat is the group a streptococcus, also known streptococcal sore throat occurs most often in patients between the ages of and years, and in temperate climates the highest incidence of illness occurs in the colder months. transmission of disease is usually by person-toperson spread of respiratory droplets, although epidemics of streptococcal pharyngitis (both groups a and g) have been traced to contaminated food or water. the usual incubation period is - days with a range of l- days. illness typically begins abruptly, with fever, chills, headache, and sore throat. clinical manifestations, however, may vary greatly in severity from patient to patient. the most severe forms of tonsillopharyngitis are seen in epidemics occurring in closed institutional settings (eg, military barracks). abdominal pain, nausea, vomiting, and coryzal symptoms are more often present in non-sexuallv transmitted diseases children than adults. cough or hoarseness is prevent or attenuate acute glomerulonephritis, not typically seen in streptococcal pharyngitis a complication that occurs more frequently and suggests a viral etiology. after cutaneous streptococcal infection. about - % of asymptomatic school children carry group a streptococci in their throats in winter months, as do - % of asymptomatic family contacts of index cases. thus, the majority of individuals who harbor this organism have no complaints whatsoever. many of these individuals appear to be carriers; that is, this streptococal species behaves as a commensal, does not elicit an antibody response, and at least for a time blends into the "normal flora." studies in the past with intramuscular penicillin (benzathine penicillin g) had shown nearly uniform success in clearing s. pyogenes from the oral mucosa. slightly lower cure rates were reported for oral penicillin preparations, probably because of poor compliance with the full lo-day course of therapy. even a 'i-day treatment course with oral penicillin has been shown to be significantly less effective than the lo-day regimen. although many patients with streptococcal pharyngitis appear moderately ill, with tachycardia and fever of olf or greater, others look well and may be afebrile. erythema, edema, and lymphoid hyperplasia of the posterior pharynx will be present, and the uvula may be edematous. the tonsils are typically enlarged and may be covered with exudate. petechial stippling is sometimes seen on the soft palate. tender, anterior cervical node enlargement is common. infants tend to have less localization of their disease to the lymphoid tissue of the faucial and posterior pharyngeal areas. indeed, exudative pharyngitis in children less than years of age is rarely due to streptococci. the complications of streptococcal pharyngitis may be placed in two categories, suppurative and nonsuppurative. the suppurative ones include peritonsillar abscess, sinusitis, otitis media, retropharyngeal abscess, and, very rarely, brain abscess, meningitis, or septicemia. the nonsuppurative complications are acute rheumatic fever and glomerulonephritis. of concern, therefore, is the unfavorable bacteriologic response to penicillin therapy found in almost all recent studies. regardless of the penicillin preparation, - % of symptomatic patients have had positive post-treatment cultures.b"l furthermore, retreatment was unsuccessful in - % of patients. resistance of the organism did not appear to explain this outcome, since the streptococcal organisms were extremely sensitive to the inhibitory effects of penicillin. on occasion, apparent failures are actually reinfections from close personal contacts or possibly even from pets who may harbor the organism. however, this explanation was evaluated but considered unlikely in at least one study that involved a semiclosed population. o whether or not the use of antibiotics hastens clinical recovery, once a highly controversial issue, has now been resolved on the basis of several new studies as well as re-analysis of an older one. use of appropriate antibiotics shortens the duration of illness by - hours if begun early.=- in fact, it is so unlikely for fever to persist beyond the first hours of treatment that another diagnosis or a suppurative complication should be considered when this occurs. antibiotic therapy also prevents rheumatic fever, provided that the streptococcal organism can be eradicated from the pharynx. it is doubtful, however, that antibiotics a bacteriologic cure rate with penicillin of % or less is low in absolute terms. this figure is even more striking, however, when it is compared with the % spontaneous cure rate of streptococcal pharyngitis, observed in a study published in , of symptomatic children in chicago who were not treated with an antimicrobial.& itzhak brook has made an increasingly persuasive argument that the growing number of penicillin failures is due to the recent emergence of penicillin-resistant / -lactamase-producing microorganisms (ie, penicillin-destroying) in the "normal" mouth flora. l according clinics in dermatology to this theory, p-lactamase-producing organisms, by inactivating penicillin, protect group a streptococci from the antibiotic. in addition to staphylococcus aureus, the oropharyngeal cavity may normally harbor a number of other aerobic and anaerobic organisms that have the potential to produce p-lactamase. these organisms include various bacteroides and hemophilus species and branhamella catarrhalis. in studies of children with recurrent tonsillitis who underwent tonsillectomy, brook and yocum were able to correlate the presence of plactamase activity measured directly in tonsillar tissue with recovery of p-lactamase-producing flora from culture of the tonsils. in a subsequent clinical trial, children with acute group a streptococcal tonsillitis were treated with a lo-day course of an oral penicillin. sixty-three of the children were bacteriologically cured, and were considered treatment failures. prior to therapy, p-lactamaseproducing organisms were recovered from oral cultures of % of the children who were cured compared with % of the children for whom treatment failed. also p-lactamase producing organisms were present in significantly larger numbers in the nonresponders than in the responders. other data suggest that penicillin treatment itself promotes the emergence of a penicillin-destroying flora and that these resistant strains may be transferred to household contacts. further evidence to support the role of -lactamase-producing bacteria in streptococcal treatment failures comes from an experimental model in which a mixed subcutaneous abscess containing both a penicillin-susceptible group a streptococcus and a / -lactamase-positive strain of boxtertides species is produced in mice. in these studies, mice treated with either clindamycin (active in vitro against both isolates and not susceptible to plactamase) or penicillin in combination with a p-lactamase inhibitor (clavulanic acid) had a greater reduction in abscess size and in total number of streptococci recoverable on culture than did untreated control animals or those receiving penicillin alone. thus, it is reasonable to suggest that greater cure rates in patients with streptococcal pharyngitis might be achieved by one of several therapeutic strate-gies: . use of an antimicrobial (with or without penicillin) which is not susceptible to plactamase. use of combined therapy with penicillin and a second drug that either inhibits plactamase directly, such as clavulanic acid, or which inhibits the bacteria that are responsible for p-lactamase production. consistent with this hypothesis, in comparative studies using regimens similar to these such as clindamycin alone,@@ an oral cephalosporin alone, + dicloxacillin alone, or penicillin plus rifampin, +i cure rates were superior to those with penicillin alone. it is quite fortunate that despite documentation of increasing difficulties in eradicating streptococci, and little convincing evidence for a decrease in the frequency of streptococcal pharyngitis, that the incidence of rheumatic fever has not increased. on the contrary, rheumatic fever has all but vanished from suburban america. one county in california reported , cases of streptococcal illness over an -year interval but only three cases of rheumatic fever. similarly, the incidence of acute rheumatic fever among whites in suburban and rural parts of shelby county (tennessee) was only one case per , school children annually over the -year period from through . rheumatic fever rates are somewhat higher in inner city areas of major united states metropolitan centers and higher yet among large segments of the developing world in asia, africa, or south america. it is difficult to define precisely the contribution of penicillin to the downward trend in rheumatic fever incidence. considerable evidence exists, however, that antibiotic use may not be the primary factor and that the principal reason for the decline is actually a change in the "rheumatogenicity" of prevalent streptococcal strains. in fact, the decrease in incidence of rheumatic fever antedated the discovery of penicillin and began even before the causative relationship to group a streptococci was known. older studies, done when rheumatic fever was more common, indicate that about one third of patients with rheumatic fever do not recall a preceding respiratory tract infection and thus would not have received treatment for a streptococcal infection. if penicillin therapy were the only reason for the decline in incidence of rheumatic fever, one might anticipate that among newly diagnosed cases, the proportion who had an asymptomatic streptococcal pharyngitis and consequently did not receive penicillin would be higher. instead, land and bisnos recently reported that of patients with rheumatic fever diagnosed between and , . % denied a preceding upper respiratory infection or sore throat-a figure nearly identical to the % figure cited in a study published years ear ier.u how important then is the lessened efficacy of penicillin preparations for streptococcal pharyngitis noted in recent studies? clearly, inadequate bacteriologic responses have not been associated with a resurgence in rheumatic fever cases in this country, nor apparently with a rise in suppurative complications or a poorer clinical response during acute infection. vigilance for such changes, rather than abandonment of penicillin as first-line therapy, seems the appropriate course of action at present. another concern in the management of patients with possible streptococcal pharyngitis is when to begin antibiotic treatment. endemic cases cannot be diagnosed reliably on clinical grounds alone unless the characteristic rash of scarlet fever is present. a properly performed throat culture has been the diagnostic method of choice. in % of patients, a single negative throat culture will suffice to exclude the diagnosis. in % of cases, a second throat culture is necessary to detect the organism, which, under this circumstance, is usually present in low numbers and possibly not etiologic for the pharyngitis.@ the clinical dilemma has been whether or not to give antibiotics during the usual - hour period it takes to process throat cultures. withholding antibiotics may significantly delay clinical recovery in patients shown to have streptococcal sore throat, whereas routinely starting them will expose a great many patients with viral infections (that should not be treated) to potential drug toxicities, including an alteration in mouth flora. fortunately, recent technologic advances may help to adjudicate this dilemma. group a streptococcal antigen detection systems based on agglutination reactions with specific extracted group a cell-wall antigens are now offered as kits for practitioners. @ results can be available in as short a time as minutes. the specificity of these systems is excellent, often over %, whereas the sensitivity is somewhat lower, - %, when compared with standard culture. use of rayon throat swabs appears to give better results than do cotton ones. therefore, a practical approach to management is to base the decision to give or withhold treatment on the result of such an immediate diagnostic test, and to confirm the negative reactions by culture. members of the mouth flora, usually what appears to be a mixture of anaerobic bacteria and spirochetes, are an uncommon cause of acute pharyngitis (vincent's angina), sometimes complicated by tonsillar abscess formation. with this infection, a purulent exudate and a foul odor to the breath may be present. the lesion typically begins unilaterally but may spread to the other side of the pharynx or to the larynx. regional lymphadenopathy and leukocytosis are common. septicemia, specifically with the penicillin-sensitive anaerobe fusobacterium necrophorum, can be a disastrous complication of this condition (lemierre's disease), which may be associated with jugular vein septic thrombophlebitis and metastatic infection of the lung, joints, and other sites. peritonsillar abscess formation also occurs unilaterally and is associated with severe pain and dysphagia. in one retrospective review of patients who presented with peritonsillar abscess or cellulitis, throat cultures were negative for group a streptococci in ( %) prior to any treatment> cultures of the tonsillar pus obtained by needle aspiration also failed to grow group a streptococci in seven of eight patients, and the one patient with a positive culture had had a prior negative throat culture. thus, this unusual group of patients is liable to go un- wormser, nunez, and horn clinics in dermatology treated initially because of a negative throat culture. one can only speculate as to the number of such patients who may have been benefited inadvertently by the liberal and perhaps excessive use of penicillin for patients with exudative pharyngitis. the existence of such eases certainly argues against overly dogmatic recommendations on the "necessity" of withholding antibiotics, at least early on, in sick patients without streptococcal disease. more information is still needed on diagnosis and pathogenesis of this infection. a related infection known as acute necrotizing ulcerative gingivitis (vincent's disease, vincent's stomatitis, or trench mouth) is caused by the same or similar microorganisms indigenous to the oral cavity. the typical patient experiences the sudden onset of gingival pain and has tender, bleeding gums, fetid breath, and a bad taste. the gingival mucosa, especially the papillae between the teeth, becomes ulcerated and may be covered by a gray exudate, which is removable with gentle pressure. involvement of the gingivae is usually patchy but may be more extensive or spread to the posterior pharynx (vincent's angina-see above). if the ulceration is extensive, fever, cervical lymphadenopathy, and leukocytosis occur. most patients are young adults with poor oral hygiene. treatment includes local debridement and lavage with oxidizing agents, which usually brings prompt relief. antibiotic therapy with penicillin or metronidazole is highly effective.@j mycoplasma pwumoniae is another treatable cause of pharyngitis that has been incriminated etiologically in varying frequencies up to approximately % of cases the illness is relatively mild, although an exudate is sometimes seen. in the absence of concomitant myringitis or pneumonitis, however, it would likely go undiagnosed since mycoplasmal cultures are generally unavailable and routine antibody testing would be impractical. erythromycin or tetracycline, not penicillin, is the drug of choice. viruses cause the majority of cases of pharyngitis in which some pathogen is identified, and may well be responsible for most of the other approximately % of cases without a known cause. usually, the sore throat is mild and merely part of the overall symptom complex of the common cold. rhinoviruses are the most frequently isolated viruses, but several other viruses can cause an identical clinical picture (tables and ). j - sore throat is often a major complaint in patients with influenza but is rarely the only manifestation of the disease. the clinical presentation of pharyngitis due to adenovirus may be quite severe with pharyngeal erythema and exudate, more closely mimicking streptococcal infections. distinguishing features of adenoviral infections include their occurrence in the summer and the presence of conjunctivitis, which occurs in one third to one half of patients. conjunctivitis is unilateral in % of patients. pharyngitis associated with primary herpes simplex infection or that due to strains of coxsackievirus may be recognizable clinically. both are characterized by the presence of vesicles and shallow ulcers. primary herpes infection varies from asymptomatic to agonizingly severe. vesicles and ulcers are often numerous and may occur anywhere in the mouth, sometimes with a concomitant gingivitis. tender cervical adenopathy and fever are seen in the more ill patients. herpangina primarily affects children between the ages of and years, is usually caused by coxsackievirus a (types l- , , and ) and less commonly by coxsackievirus b (types l- ) or echoviruses (types , , , , , , and ) , and is characterized by two to six small vesicles typically confined to the posterior pharynx (soft palate, uvula, anterior tonsillar pillars). in some cases, the presence of anorexia and abdominal pain mimic acute appendicitis. gingivitis, prominent systemic toxicity, and cervical lymph node enlargement are not seen in herpangina. hand-footand-mouth disease is also caused by coxsackievirus (usually type a- and less commonly a- , a- , a- , a- , b- , and b- ). this illness occurs predominantly in children under years of age and is associated with vesicles in the oral cavity. unlike herpangina, however, in hand-foot-and-mouth disease, the oral lesions characteristically occur in the front of the mouth, especially on the inner aspects of the lip, the anterior buccal mucosa, and the tongue, and in most cases, lesions are also found on the extremities. the skin lesions are tender and consist of papules and clear vesicles with a surrounding zone of erythema. pharyngitis with tonsillar exudate persisting for or more days with a negative throat culture for group a streptococci, or occurring in association with diffuse lymphadenopathy, splenomegaly or with many atypical lymphocytes on blood smear suggests the possibility of infectious mononucleosis (im) (epstein-barr virus). pharyngeal involvement occurs in over % of patients with im, and tonsillar exudate and a palatal enanthem are each found in approximately one quarter of patientsz in most cases, the severity of the pharyngitis increases over several days, peaks around days, and then slowly improves. p@j inflammation of the pharynx may be severe and may pose one of the infrequent life-threatening complications of the disease. both pharyngeal and laryngeal edema can occur along with massive tonsillar enlargement (anginose mononucleosis, see fig. ). inspiratory stridor with significant airway obstruction secondary to lymphoid tissue hypertrophy is a medical emergency. in the past, concurrent streptococcal pharyngitis was reported to occur in % of patients with im. more recent studies, however, have failed to confirm this association. - prior studies also emphasized that the use of ampicillin is associated with the development of a macular-papular skin rash in up to % of patients with im. ~ the pathogenesis of this phenomenon is unknown, but evidence exists that discounts an allergic basis. interestingly, patients appear to tolerate penicillin normally. in a more recent study from three community hospitals of patients with im who received ampicillin, only ( %) developed a rash. the reason for the discrepancy between this and prior studies is unknown. diagnosis of im is established either by documentation of the presence of heterophile antibody, which is present in % of patients, or by demonstration of the characteristic antibody responses to specific epstein-barr viral antigens. management of patients with anginose mononucleosis is controversial. various therapies have been promoted only to be later discarded. these include neoarsphenamine, gamma globulins, bismuth, chloroquine, and metronidazole. differing opinions exist concerning the role of therapeutic or symptomatic intervention with corticosteroids. seven prospective controlled studies with a total of patients have been done to evaluate the effect of corticosteroids on the duration of sore throat and/or resolution of tonsillar enlargement."- findings are conflicting. further, anecdotal cases of patients with anginose im have been reported for whom tracheostomy, placement of a temporary airway or emergency tonsillectomy was required despite the use of corticosteroid therapy. therefore, the value of these medications in preventing airway obstruction in anginose im has not been established by objective data in the published literature. whether or not the immunosuppressive properties of corticosteroids may enhance the potential oncogenicity of the epstein-barr virus is unknown, but this consideration does warrant caution in their use. epstein-barr virus has been shown to be susceptible in witro to several antiviral agents including acyclovir,g+ adenine arabinoside,ss leukocyte interferona and phosphonacetic acid, and use of one or more of these drugs might seem a more logical and specific therapeutic approach. andersson and colleague@ randomized patients with im who had symptoms for or fewer days to treatment with intravenous acyclovir ( mg/kg per day) or placebo for days in a double-blind trial. acyclovir significantly inhibited oropharyngeal viral shedding compared with placebo (p < . ); in dermatology however, there was no significant improvement in rate of recovery of sore throat or tonsillar swelling, and one patient in the acyclovir group required tracheotomy because of respiratory obstruction due to tonsillar enlargement. therefore, to date, no therapy has been proved to be of clinical benefit to patients with anginose im. further studies are needed to determine if certain patients might benefit from the use of corticosteroids and/or specific antiviral drugs. recently, several investigators have reported a syndrome of prolonged atypical illness thought to be an epstein-barr-associated chronic mononucleosis syndrome. +l patients with this illness have had pharyngitis, chronic fatigue, low-grade fevers, lymphadenopathy, and other nonspecific symptoms in association with elevated antibody titers to certain epstein-barr viral antigens. the pathogenesis and treatment of this condition have not been elucidated. mucosal infections are common and extremely varied. as illustrated by the preceding discussion of non-sexually transmitted infections of the oral mucosa, it is clear that the pathogenesis of many of these infections is directly related to phenomena that affect the background ("normal") microbial flora. depending on conditions, this flora may assume divergent roles for the host, ranging from protector, to commensal, to pathogen. interactions between these organisms and those exogenous microbial species encountered by the host are undoubtedly complex but of immense interest to students of infectious diseases, and of potential practical importance in the day-to-day management of patients. emerging evidence has also suggested that the normal flora may influence the success of antibiotic therapy for streptococcal pharyngitis, adding still another dimension to the complicated interrelationship between these organisms and mucosal disease. general or non-specific host defense mechanisms je. principles and practice of infectious disease vaginal microbial flora: composition and influences of host physiology pharyngeal conjunctival fever two antigenic groups of human coronaviruses detected by using enzyme-linked immunosorbent assay herpangina: the etiologic spectrum report of an outbreak of febrile illness with pharyngeal lesions and exanthem hand-foot-and-mouth disease"in birmingham in acute respiratory disease of university students with special reference to the etiologic role of herpesvirus hominis a study of illness in a group of cleveland familes. xvii. the occurrence of asian influenza protective effect of antibody to parainfluenza type virus respiratorysyncytial virus infections within families rhinovirus infections in an industrial population. i. the occurrence of illness viral infections of humans: epidemiology and control fusobach-ium ilecrophowm septicemia following oropharyngeal infection the epidemic of diphtheria in san antonio infections caused by non-diphtheria corynebacteria a case of classical diphtheria, and other infections due to cwynebacferium tieram empyema due to betalactamase-producing h. inifluenzae type b complicating severe laryngopharyngitis and cervical cellulitis serologic evidence of chlamydial and mycoplasmal pharyngitis in adults number non-sexually transmitted diseases strategy for streptococcal pharyngitis. hospital medicine foodborne outbreak of group g streptococcal pharyngitis yersinia enterocolitiea pharyngitis the clinical manifestations of infectious mononucleosis, a report of two hundred cases brucellosis in children clinical and laboratory aspects of list&a numocytogenes infections syndromesof q fever the current burden of illness in the united states. occasional papers of the institute of medicine illness in the home: study of , illnesses in a group of cleveland families frequency of chlanqdia bachomatk as the cause of pharyngitis the group a streptococcal upper respiratory tract carrier state: an enigma effect of treatment on streptoeoccal pharyngitis: is the issue really settled? early treatment of streptococcal pharyngitis does penicillin make johnny's strep throat better? the effect of penicillin therapy on the symptoms and signs of streptococcal pharyngitis streptococcal pharyngitis. placebo-controlled double-blind evaluation of clinical response to penicillin therapy effect of antibiotic therapy on the clinical course of streptioccal pharyngitis penicillin v for group a streptococcal pharyngotonsillitis: a randomized trial of seven vsten days'therapy failure of penicillin to eradicate group a streptococci during an outbreak of pharyngitis the role of the carrier in treatment failures after antibiotic therapy for group a streptococci in the upper respiratory tract household pets as reservoirs of persistent or recurrent streptococcal sore throats in children controlled studies of streptococcal pharyngitis in a pediatric population: . factors related to the attack rate of rheumatic fever quantitative measurement of bets lactamase in tonsils of children with recurrent tonsillitis demonstration of penicillin inhibition by pharyngeal micro-flora in patients treated for streptococcal pharyngitis emergence of beta-lactamaseproducing aerobic and anaerobic bacteria in theoropharynx of children following penicillin in vitro protection of group a beta hemolytic streptococci by beta lactamase producing bacteroides species streptococcal pharyngitis. iii. streptococcal recurrence rates following therapy with penicillin or with clindamycin ( -chlorolincomycin) treatment of patients with recurrent tonsillitis due to group a beta hemolytic streptococci: prospective randomized study comparing penicillin, erythromycin, and clindamycin the role of beta lactamase producing bacteria in treatment failures of group a streptococcal pharyngitis abstract # comparison of cefuroxime axetil and penicillin v as therapy for group a beta-hemolytic streptococcal pharyngitis eradication by dicloxacillin of group a streptococci from penicillin treatment failures penicillin plus rifampin eradicates pharyngeal carriage of group a streptococci penicillin v and rifampin for the treatment of group a streptocoecal pharyngitis: a randomized trial of days of penicillin vs days penicillin with rifampin during the final days of therapy cost effectiveness of pharyngitis management and prevention of rheumatic fever acute rheumatic fever: avanishing clinics in dermatology disease in suburbia global changes in group a streptococ cal diseases and strategies for their prevention an evaluation of the maryland rheumatic fever registry streptococcal pharyngitis: optimal site for throat culture significance of quantitative salivary cultures for group a and non-group a b-hemolytic streptococci in patients with pharyngitis and in their family contacts rapid detection of beta haemolytic streptococci rapid diag nosis of streptococcal pharyngitis in two pediatric offices using a latex agglutination coopera tive study of latex agglutination to identify group a streptococcal antigen on throat swabs in patients with acute pharyngitis culturing of throat swabs: end of an era. ,i pediatr throat culture in impending peritonsillar abscess treatment of acute ulcerative gingivitis (vincent's type) principles and practiceof infectious disease syndromes of infectious mononucleosis infectious mononucleosis in incidence of beta hemolytic streptococcal pharyngitis in adolescents with infectious mononucleosis beta-hemolytic streptococcal pharyngitis: uncommon in infectious mononucleosis how frequent is bacterial superinfection of the pharynx in infectious mononucleo sis? hypersensitivity reactions to antibacterial drugs in infectious mononucleosis skin rash with infectious mononucleosis and ampicillin the ampicillin rash as a diagnostic and management problem: case reports and literature review infectious mononucleosis in the community hospital role of steroids in the treatment of infectious mononucleosis in the ambulatory college student acth, tetracycline, and tetracycline combined with cortisone in the treatmentof infectious mononucleosis infectious mononucleosis in university of wisconsin students corticotrouin in the treatment of infectious mononucleosis a double-blind study of eightytwo cases of infectious mononucleosis treated with corticosteroids theeffects of short-term corticosteroid therapy on the symptoms of infectious mononucleosis pharyngotonsillitis: a double-blind study hydroxyethoxymethyl) guanine] on epstein-barr virus dna replication drug therapy: treatment of herpesvirus infections effect of adenine arabinoside on epstein-barrvirus invitro the transformation of adult but not newborn human lymphocytes by epstein-barrvirusand phytohemagglutinin is inhibited by interferon: theearly suppression by t cells of epstein-barr infection is mediated by interferon transformation of human lymphocytes by epstein-barr virus is inhibited by phosphonoacetic acid effect of acyclovir on infectious mononucleosis: a double-blind, placebo-controlled study clinical evaluation of patients with infectious mononucleosis and development of antibodies to the r component of the epstein-barr virus-induced early antigen complex chronic epstein-barr virus disease: a workshop held by the national institute of allergy and infectious diseases persisting illness and fatigue in adults with evidence of epstein-barr virus infection key: cord- -gfy ytg authors: drent, marjolein; elfferich, marjon; breedveld, ellen; vries, jolanda de; strookappe, bert title: benefit of wearing an activity tracker in sarcoidosis date: - - journal: j pers med doi: . /jpm sha: doc_id: cord_uid: gfy ytg sarcoidosis causes many disabling symptoms, including fatigue and exercise limitations, which have been shown to improve by physical activity programs. the aim of this study was to estimate the effect of continuous activity monitoring using an electronic activity tracker (at) on exercise performance and fatigue of sarcoidosis patients, compared to controls (cohort study), and the effect of additional personal coaching (randomized trial) over a period of months. fifty-four sarcoidosis patients received an at (group ia: with coaching and group ib: without). a historical group of sarcoidosis patients (group ii; n = ) who did not follow a physical activity program served as controls. exercise performance of patients wearing an at (group i) improved compared with controls (group ii), including the mwd, % predicted (∆ . ± . versus ∆ . ± . , respectively), and fatigue levels decreased (∆− . ± . versus ∆− . ± . ). patients with coaching (group ia) showed greater improvement of exercise capacity over time than patients without coaching (group ib) as shown by the steep ramp test results (watts: ∆ . ± . versus ∆ . ± . ; and srt, vo( )max, % predicted: ∆ . ± . versus ∆ . ± . ). sarcoidosis patients wearing an at achieved improvement of exercise performance and reduction of fatigue. we therefore recommend encouraging sarcoidosis patients to wear an at to stimulate physical activity and reduce fatigue. the additional benefit of coaching needs to be explored in future studies. sarcoidosis patients often suffer not only from organ-related symptoms but also from disabling non-specific, non-organ-related symptoms, such as fatigue, reduced muscle strength, loss of physical condition, reduction of physical activity (pa) in daily life, and pain [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . fatigue is the most frequently reported symptom in sarcoidosis patients, regardless of the clinical presentation, varying from to % [ , , ] . this may persist after other signs of sarcoidosis activity have resolved and adversely impacts major life areas, including quality of life (qol) and work ability [ , , [ ] [ ] [ ] [ ] [ ] . so far, there is promising evidence for the benefits of physical training in sarcoidosis [ ] [ ] [ ] [ ] . interventions involving technology that is readily accessible on a daily basis to monitor activity levels can support care providers in encouraging patients to achieve behavioral changes [ ] . these interventions may be an effective strategy to provide pa coaching without increasing time demands on primary care providers [ , ] . moreover, they give patients an opportunity to keep up a more active lifestyle with direct feedback and monitor their physical performance over time. counseling, guidance and support using e-health technology has been found to be very helpful for patients who want to improve their pa [ , ] . the use of commercially available, technology-based wearable activity trackers (ats) is growing, for research and recreational purposes, both among healthy persons and among those with chronic illness. beneficial effects of at-based counseling have been demonstrated in patients with chronic diseases [ , ] . in a recent study by our group, we found that wearing an at stimulated patients to be more physically active [ ] . the aim of this study was to estimate ( ) the potential effect of continuous activity monitoring using an electronic at, compared with a historical control group in a cohort study and ( ) the effect of additional personal coaching of sarcoidosis patients in a randomized trial. the outcome measures were exercise performance and fatigue. patients were recruited from the ild center of excellence of the st. antonius hospital nieuwegein, the netherlands, from january until march . the diagnosis of sarcoidosis was confirmed by a multidisciplinary team in accordance with accepted guidelines [ ] . patients were eligible to participate if they ( ) were in a clinically stable condition without changes in complaints or changes in initiated medical management during the preceding three months and ( ) if they were between and years old, had sufficient command of the dutch language, and had internet access at home or a compatible smartphone/tablet. informed consent was obtained from all participants. patients who had participated in a training program during the months prior to inclusion were excluded. treatment allocation was done by one of the authors (eb), using minimization as randomization method. male and female patients were allocated to the groups in equal proportions (ia and ib) to ensure equal distribution. clinical trial id: nct . a historical control group of sarcoidosis patients included in an earlier retrospective observational study by strookappe et al. (n = ; evaluated by the ild care expertise team of gelderse vallei hospital, the netherlands), who did not follow a physical training program, was used as a control group in the present study (group ii) [ ] . our cohort study compared the participating patients (group i) with the historical control group of sarcoidosis patients (group ii). in addition, a prospective randomized clinical trial (clinical trial id: nct ) was performed within group i, comparing group ia (intervention by coaching) with group ib (without coaching), to estimate the effect of adding coaching to continuous activity monitoring with an electronic at. in both parts of the study, the outcome measures were exercise performance and fatigue. data were collected in both groups at baseline and after weeks. forced vital capacity (fvc) and forced expiratory volume in one second (fev ) were measured with a pneumotachograph. the diffusing capacity of the lung for carbon monoxide (dlco) was measured using the single-breath method (masterlab, jaeger, würzburg, germany). values were expressed as a percentage of the predicted value (i.e., fvc%, fev %, and dlco%, respectively). maximal oxygen uptake, and other commonly collected variables, were measured during a cardiopulmonary exercise test using the steep ramp test (srt) protocol on a cycle ergometer, as reported earlier [ ] . the -minute walk test ( mwt) was administered according to the american thoracic society guidelines [ ] . predicted mwd values were calculated according to gibbons and colleagues [ ] . to avoid gender as well as age bias, the outcome measures of physical performance were also expressed as percentage of predicted. this equation took age and sex into account. patients' daily activities were measured by an electronic at-fitbit charge hr by fitbit inc. (san francisco, ca, usa). the fitbit is a commercial tool, used to track physical activity, providing personalized data on step count, activity intensity and activity duration. the fitbit charge hr appeared to have good test-retest reliability for step count regarding slow, moderate and more vigorous walking speeds [ ] . we acknowledge that activity trackers are not medical devices and systematic errors have been reported [ ] . in our view, these limitations were acceptable with regard to the purpose of this study. number of steps, estimated distance, number of flights climbed, and activity minutes were visible for patients on their smartphone (ios and android app [mansystems nederland b.v., barneveld, the netherlands]) website. patients had access to their daily activity results and activity history. their physical therapist was able to monitor these parameters on a web-based client. fatigue was measured with the -item fatigue assessment scale (fas) [ ] . this questionnaire was filled out on a weekly basis. the fas has acceptable psychometric properties in sarcoidosis [ ] . moreover, the fas has shown good reliability and validity in a sarcoidosis population [ ] . all participants received a fitbit for free. they were encouraged to improve their physical fitness, which was assessed at baseline. the patients in the intervention group (group ia) engaged in a -month physical therapist-guided activity program. the guidance was based on the input from the at and the questionnaires. the weekly fas scores, fitbit-measured parameters and brief daily questions were combined in a web-based dashboard accessible to the assigned physical therapist. the information was used for goal setting, encouraging, and identifying barriers and facilitators for patients to become more active. the coaching procedure included weekly action planning and feedback, modeling of behaviors and problem solving, and individual decision making, by email and/or telephone. the coaching physical therapist acted as facilitator, and assisted participants in making choices and achieving success in terms of reaching self-selected goals. although the patients in group ib did not receive the guidance from a physical therapist, their daily activity was also computed with the fitbit charge hr, and patients were also able to use the fitbit and a monitoring app to monitor their performance, questionnaire results and progress. self-report feedback questionnaires at follow-up ( weeks) were used to determine participants' experience with data from the fitbit tracker itself and coaching, if applicable. descriptive statistics were used for baseline characteristics. differences between the two patient groups (groups ia and ib), and between group i and the controls (group ii), were examined using independent samples t-tests (mann-whitney u tests) or chi-square (or fisher's exact) tests on the baseline data, depending on the type of variable and the normality of the data. analyses of variance for repeated measures were performed between all groups to examine the effect of the training over time on fatigue (fas), submaximal exercise capacity ( mwd), and maximal exercise capacity (srt). the interaction with time would indicate whether both groups of patients differ or not concerning their scores across time. in our study, we first examined whether there was a difference between the two groups at baseline. since this was not the case, no adjustment was deemed necessary. a difference between the two groups at follow-up indicates a difference in time between the two groups. this difference between the groups at follow-up is a difference that occurred in time. to avoid gender as well as age bias, the outcome measures of physical performance were also expressed as percentage of predicted. this equation took age and sex into account.all statistical analyses were performed using spss statistical software (version . for windows) (spss inc., chicago, il, usa). sixty-three patients were enrolled in this study. nine patients were excluded because they did not have access to an appropriate smartphone. finally, patients were randomized by one of the authors (eb) to group ia or group ib in such a way as to ensure equal distribution of men and women in both groups. demographic and clinical baseline characteristics of the included patients (group i), the nine excluded patients, and the control patients (group ii; n = ; without monitoring or training) are summarized in table . none of the patients had cardiac involvement or any form of neurosarcoidosis. at baseline, the included patient groups did not differ from the control group regarding demographic and clinical variables, except for sex (p = . see also table ). no differences were demonstrated between groups ia, ib and ii with regard to fatigue and exercise capacity. fatigue scores (fas) did not correlate with the demographic and clinical variables of age, bmi, time since diagnosis, inflammatory markers, and lung function tests. exercise capacity ( mwd, srt) did not correlate with lung function tests, time since diagnosis, or baseline fatigue levels. sex, age and bmi were not significantly related to exercise performance; and baseline mwd, % of predicted, explained only % of the change in exercise performance, f = . , p = . . in contrast to the controls (group ii), the walking distance-both mwd distance and mwd, % of predicted-as well as the srt and vo max (ml/kg/min) increased significantly in the study sample wearing ats (group i), whereas fatigue decreased (p < . for all; see table ). however, an interaction effect for time with group was found for both mwd (f = . , p = . ) and mwd, % of predicted (f = . , p = . ). no interaction effect for time with group was found for fatigue (fas, f = . , p = . ) and for exercise capacity (srt and srt vo max ml/kg/min). the srt (watts) performance in group i improved between baseline and months, while the srt (watts) performance in group ii did not change. no interaction effect was found with regard to the srt (watts, f = . , p = . ). similar results were found with regard to srt vo max (ml/kg/min) (interaction effect: f = . , p = . ). the control group (group ii) included more female patients, but analyzing male and female patients separately did not change the results. patients wearing an at and receiving personal coaching (group ia) showed greater improvement of exercise capacity (srt, f = . , p = . and srt vo max ml/kg/min; f = . , p = . ) over time. fatigue levels decreased in group ia as well as in group ib. exercise capacity, assessed with the mwd and mwd, % of predicted, increased in both groups. no significant interaction effect was found for the outcome measures mwd and fas (see table ). at study completion, responses to feedback questionnaires from patients wearing an at were evaluated (see also table ). two participants had not completed these. most patients reported that they found the intervention helpful ( / : %), intended to continue tracking their activity ( / : %), and would participate in another pa study ( / : %). by contrast, most patients were not interested in participating in group activities ( / : %). they did report that the at had provided them with greater insight into what sarcoidosis does to them. forty-nine of the respondents ( %) indicated that exercise worked well for them. nearly half of the participants from group b (without coaching: / : %) indicated they liked the feedback from the fitbit, but would have preferred to get guidance and incentive from a physical therapist. to the best of our knowledge, this was the first cohort study assessing the effect on exercise performance and fatigue in sarcoidosis of encouraging pa by using a wearable at. in addition, our prospective randomized trial estimated the effect of additional coaching. the data from the cohort study were compared with those of sarcoidosis patients who did not participate in the at trial (historical control group). patients' symptoms, limitations of daily activities, physical fitness and personal goals were assessed at baseline and after weeks. half of the patients had contact with a personal physical therapist on a weekly basis and also had the opportunity to contact their coach for questions or advice (two-way contact opportunity; group ia). wearing an at improved exercise performance and reduced fatigue. it was especially patients who wore an at and received coaching (group ia) who showed improved exercise performance. our results were in line with previous studies that showed that a supervised physical training program improves fatigue, exercise capacity, and muscle strength [ , , ] . as reported before, the reason for reduced pa in sarcoidosis is multi-factorial, as there is no clear association with individual factors or sarcoidosis phenotypes [ , , ] . in line with cho et al., we found that functional exercise capacity ( mwd) was significantly reduced in sarcoidosis patients and was associated with reduced pa [ ] . they assessed pa by a validated triaxial accelerometer and found that daily step counts were significantly lower in participants with sarcoidosis compared to healthy controls. they also found that the -mwd had the strongest association with pa in patients with sarcoidosis. ats can provide unique information about the impact of disease on functioning that is not captured by existing clinical outcome measures for sarcoidosis and can potentially be used to assess response to therapy. in the present study, patients wearing an at and receiving coaching improved their exercise capacity ( mwd, mwd, % of predicted, and srt) and had reduced fatigue levels, in contrast to the patients not receiving this coaching. this is in line with gill et al., who demonstrated that healthesteps™ was effective in increasing pa (i.e., step counts per day) and decreasing weekdays sitting time [ ] . moor et al. evaluated patient experiences with a home monitoring program for sarcoidosis and assessed whether home monitoring is a feasible tool to enhance personalized treatment [ ] . all patients endorsed the usefulness of an at, as this stimulated them to be more active and provided good insights into their fatigue. the present study had similar findings. in particular, some of the quotes from the patients participating in their study were comparable with the findings of the present study. for instance, they mentioned that the activity levels corresponded better with their overall functioning than lung function alone [ ] . home monitoring may potentially enable timely recognition of, and response to, changes in symptoms and activity. it is particularly in a heterogeneous disease such as sarcoidosis that home monitoring may pave the way for better individually tailored treatment, enhanced self-management, and improved qol. a recent study by our group found that using ats encouraged patients to be more physically active and gave them a better understanding of their disease, thereby improving their self-management and behavior [ ] . however, only % of the dutch sarcoidosis sample we studied indicated to have ever used any kind of at. we should embrace the use of ats to meet the challenge of motivating and encouraging sarcoidosis patients to improve their physical activity level. an at is thus useful to stimulate and improve self-management. promotion of exercise and pa, as well as physical therapist-led physical training programs, are important and have many health benefits for patients with chronic illnesses, including sarcoidosis [ , ] . a randomized clinical trial studied the effect of counseling combined with the use of an accelerometer and a smartphone/web-based application on pa in patients with copd and diabetes mellitus [ ] . the group who received the intervention showed greater pa immediately after the intervention than the usual care group, and the effect was still present months after the intervention [ ] . another study about telerehabilitation in patients with pulmonary disease has been announced [ ] . in this study, participants will undertake an -week group-based pulmonary rehabilitation program, either in-person in a center-based pulmonary rehabilitation program, or remotely from their homes via the internet [ ] . for physicians it can be very helpful to be informed about the symptoms and activity levels of their patients over time in real life. a smartphone/web-based application with questionnaires can be very useful in several situations and may be preferable and more patient-tailored than standardized hospital visits every few months. monitoring in between visits can reduce the number of physician visits required, but what may be even more important is that this can be used to tailor the timing of the visits, thereby increasing the value of each visit and improving patient care [ ] [ ] [ ] [ ] . patients monitoring their symptoms and activity levels may improve their treatment compliance, also in sarcoidosis [ , ] . patients appreciated the use of an at. they mentioned that it encouraged them to improve their activity levels and try to achieve personalized goals. feedback and insights into their personal activity levels, in relation to the symptoms, was also one of the most frequently reported benefits for individual patients. the coaching part of the intervention was personalized and tailored, focusing on the personal needs of each individual participant. this was highly appreciated. almost half of the patients without coaching (group ib) reported that they would have preferred additional personal coaching. the covid- pandemic has made people reluctant about visiting hospitals, for fear of becoming infected with the coronavirus. these fears have only increased as health officials and governments have advised against visiting hospitals. hence, home monitoring and advice online or by phone has become an even more useful alternative to regular care. this study has several limitations. first, patients could not be blinded for the type of intervention (i.e., with or without coaching during the -months intervention period). also, the assessor at baseline and evaluation was not blinded. in trials involving different styles of patient management, like our at study (comparing a group receiving personal coaching with a group without coaching), full blinding is often impossible. we are aware of the risk of bias resulting from inadequate blinding, but bias associated with knowing the treatment is often subconscious. regarding our study, one could speculate that patients in the group without coaching were less satisfied with this situation and therefore achieved less. however, this was the case only for two of the endpoints we measured (see table ) [ ] . secondly, although it is known that short-term results of physical training or pulmonary rehabilitation may not be sustained in the time after the training period [ ] , no assessment of the long-term effect of the intervention was included. thus, it is unknown whether these benefits will sustain over a longer period of time. nevertheless, evaluation during outpatient clinic visits revealed that most of the patients were still using the application and continued their pa. another limitation is that the control group we used came from an earlier study by our group. however, their clinical presentation and treatment options did not differ from those of the sample used in the present study at baseline. patients' daily activity levels (number of steps, estimated distance, number of flights climbed, and activity minutes) were measured and accessible to patients and their physical therapists. unfortunately, pa data were not accessible to the researchers, and could therefore not be analyzed. it was thus not possible to report on patients' pa levels over time. wearing an at in general, even without personal coaching by a physical therapist, improved exercise capacity and reduced fatigue in sarcoidosis patients. therefore, we recommend encouraging sarcoidosis patients to wear an at, to help them improve their exercise performance and reduce fatigue. moreover, the patients wearing an at and receiving coaching improved their exercise capacity (srt and srt vo max ml/kg/min), in contrast to those not receiving this coaching. results from this study suggest that the use of wearable technology presents an opportunity to facilitate a more active lifestyle among sarcoidosis patients. whether or not such wearable technology-based interventions and additional coaching can create sustainable behavioral changes should be the subject of future research, which should include a cost-effectiveness analysis. data availability: the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. a video impression of this study can be found at: https://vimeo.com/ . the authors who took part in this study declare that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript. all authors read and approved the final manuscript. funding: this study was supported by a research grant from the ild care foundation: www.ildcare.nl. the study sponsor had no involvement in the study design; in the collection, analysis, and interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication. the burden of sarcoidosis symptoms from a patient perspective nonorgan manifestations of sarcoidosis exercise capacity, muscle strength and fatigue in sarcoidosis daily life physical activity in patients with chronic stage iv sarcoidosis: a multicenter cohort study sarcoidosis-associated fatigue fatigue and health-related quality of life in patients with pulmonary sarcoidosis treated by oral corticosteroids everyday cognitive failure and depressive symptoms predict fatigue in sarcoidosis: a prospective follow-up study sarcoidosis and work participation: the need to develop a disease-specific core set for assessment of work ability fatigue in sarcoidosis and exercise tolerance, dyspnea, and quality of life gender differences in sarcoidosis: symptoms, quality of life, and medical consumption does physical training reduce fatigue in sarcoidosis? benefits of physical training in patients with idiopathic or end-stage sarcoidosis-related pulmonary fibrosis: a pilot study benefits of physical training in sarcoidosis short-term effects of a multimodal -week inpatient pulmonary rehabilitation programme for patients with sarcoidosis: the prokasare study a systematic review of randomized controlled trials on the effectiveness of computer-tailored physical activity and dietary behavior promotion programs: an update maximizing the healthcare environment: a systematic review exploring the potential of computer technology to promote self-management of chronic illness in healthcare settings using electronic/computer interventions to promote physical activity the healthesteps lifestyle prescription program to improve physical activity and modifiable risk factors for chronic disease: a pragmatic randomized controlled trial systematic review of the validity and reliability of consumer-wearable activity trackers effect of 'activity monitor-based' counseling on physical activity and health-related outcomes in patients with chronic diseases: a systematic review and meta-analysis counting steps: a new way to monitor patients with pulmonary arterial hypertension experience with activity monitors of patients with copd, sarcoidosis and pulmonary fibrosis in the netherlands the european respiratory society (ers) and the world association of sarcoidosis and other granulomatous disorders (wasog) adopted by the ats board of directors and by the ers executive committee ats statement: guidelines for the six-minute walk test reference values for a multiple repetition -minute walk test in healthy adults older than years reliability and validity of ten consumer activity trackers depend on walking speed fitbit charge hr wireless heart rate monitor: validation study conducted under free-living conditions fatigue is associated with quality of life in sarcoidosis patients psychometric qualities of the fatigue assessment scale in croatian sarcoidosis patients physical activity and training in sarcoidosis: review and experience-based recommendations feasibility of a comprehensive home monitoring program for sarcoidosis it's life! mobile and web-based monitoring and feedback tool embedded in primary care increases physical activity: a cluster randomized controlled trial telerehabilitation versus traditional centre-based pulmonary rehabilitation for people with chronic respiratory disease: protocol for a randomised controlled trial improvements in illness self-management and psychological distress associated with telemonitoring support for adults with diabetes rethinking the frequency of between-visit monitoring for patients with diabetes effectiveness of home blood pressure monitoring, web communication, and pharmacist care on hypertension control: a randomized controlled trial web-based telemedicine for management of type diabetes through glucose uploads: a randomized controlled trial understanding patient compliance and persistence with osteoporosis therapy statistics notes: blinding in clinical trials and other studies short term and long term effects of pulmonary rehabilitation on physical activity in copd we kindly acknowledge mansystems nederland b.v., barneveld, the netherlands for developing the ios and android app and their technical support, and sysqa bv, it quality assurance consultancy, bunnik, the netherlands also for their technical support. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord- -l eisi authors: park, su-jin; yu, kwang-min; kim, young-il; kim, se-mi; kim, eun-ha; kim, seong-gyu; kim, eun ji; casel, mark anthony b.; rollon, rare; jang, seung-gyu; lee, min-hyeok; chang, jae-hyung; song, min-suk; jeong, hye won; choi, younho; chen, weiqiang; shin, woo-jin; jung, jae u.; choi, young ki title: antiviral efficacies of fda-approved drugs against sars-cov- infection in ferrets date: - - journal: mbio doi: . /mbio. - sha: doc_id: cord_uid: l eisi due to the urgent need of a therapeutic treatment for coronavirus (cov) disease (covid- ) patients, a number of fda-approved/repurposed drugs have been suggested as antiviral candidates at clinics, without sufficient information. furthermore, there have been extensive debates over antiviral candidates for their effectiveness and safety against severe acute respiratory syndrome cov (sars-cov- ), suggesting that rapid preclinical animal studies are required to identify potential antiviral candidates for human trials. to this end, the antiviral efficacies of lopinavir-ritonavir, hydroxychloroquine sulfate, and emtricitabine-tenofovir for sars-cov- infection were assessed in the ferret infection model. while the lopinavir-ritonavir-, hydroxychloroquine sulfate-, or emtricitabine-tenofovir-treated group exhibited lower overall clinical scores than the phosphate-buffered saline (pbs)-treated control group, the virus titers in nasal washes, stool specimens, and respiratory tissues were similar between all three antiviral-candidate-treated groups and the pbs-treated control group. only the emtricitabine-tenofovir-treated group showed lower virus titers in nasal washes at days postinfection (dpi) than the pbs-treated control group. to further explore the effect of immune suppression on viral infection and clinical outcome, ferrets were treated with azathioprine, an immunosuppressive drug. compared to the pbs-treated control group, azathioprine-immunosuppressed ferrets exhibited a longer period of clinical illness, higher virus titers in nasal turbinate, delayed virus clearance, and significantly lower serum neutralization (sn) antibody titers. taken together, all antiviral drugs tested marginally reduced the overall clinical scores of infected ferrets but did not significantly affect in vivo virus titers. despite the potential discrepancy of drug efficacies between animals and humans, these preclinical ferret data should be highly informative to future therapeutic treatment of covid- patients. low sn titers, resulting in a prolonged infection. as several fda-approved or repurposed drugs are being tested as antiviral candidates at clinics without sufficient information, rapid preclinical animal studies should proceed to identify therapeutic drug candidates with strong antiviral potential and high safety prior to a human efficacy trial. keywords covid- , severe acute respiratory syndrome coronavirus (sars-cov- ), antiviral therapeutics, immunosuppression, serum neutralization, ferrets i n december of , a novel coronavirus (cov) disease , identified in wuhan, hubei province, china, in patients with pneumonia, was found to be caused by a previously unknown betacoronavirus. the outbreak rapidly spread to other provinces in mainland china, and despite great efforts, the epidemic continued to spread from china to europe, north america, and other asian countries. the world health organization (who) announced that the severe acute respiratory syndrome cov (sars-cov- ) epidemic was a public health emergency of international concern on january , and on march , the who director general characterized covid- as a pandemic (http://www.euro.who.int/en/health-topics/health -emergencies/coronavirus-covid- /news/news/ / / -ncov-outbreak-is-an -emergency-of-international-concern; https://www.who.int/dg/speeches/detail/who -director-general-s-opening-remarks-at-the-media-briefing-on-covid- --- -march - ). currently, the number of people diagnosed with sars-cov- infection is increasing by approximately , cases a day. as of april , approximately , , cases had been diagnosed as covid- and , deaths had occurred ( ) . further, recent studies reported the detection of sars-cov- rna in various clinical specimens, suggesting other transmission routes for this virus besides respiratory secretions ( ) ( ) ( ) . unfortunately, to date, no vaccines or antiviral drugs have been approved for the treatment of sars-cov- infection by regulatory agencies. researchers are fervently working to develop vaccines specifically for this virus, as well as potential treatments for covid- . although many clinical trials are ongoing, there are no specific therapeutic agents approved for covid- . developing sars-cov- -specific antiviral drugs from scratch could take years; drugs that have already been approved by the u.s. food and drug administration (fda) have the potential to reach patients more quickly. during the sars outbreak in , screening of approved drugs identified lopinavir-ritonavir, a human immunodeficiency virus type (hiv- ) aspartate protease inhibitor, as effective against sars-cov replication ( ) . the antiviral activity of lopinavir-ritonavir against middle east respiratory syndrome coronavirus (mers-cov) both in vitro ( ) and in an animal model ( ) has been reported, and case reports suggest that the combination of lopinavir-ritonavir with ribavirin and interferon alpha results in virologic clearance and survival ( , ) . chloroquine (cq), a widely used antimalarial with immunomodulatory effects ( ), was found in a recent study to inhibit the growth of sars-cov- in vitro ( ) . however, this finding has not been strongly supported by clinical studies of approximately sars-cov- -infected patients ( , ) . a derivative of chloroquine, hydroxychloroquine (hcq) sulfate, was first synthesized in by adding a hydroxyl group to cq, resulting in a compound found to be much less toxic than cq in an animal study ( ) . in autoimmune diseases, hcq sulfate works by reducing inflammation ( ) . however, recent reports have also shown heart risk concerns with the use of cq and hcq sulfate for covid- treatment. emtricitabine-tenofovir (truvada) is a prescription medicine for hiv approved by the u.s. fda for preexposure prophylaxis to reduce the risk of hiv infection in adults and adolescents. as a nucleotide analogue, it is reported that the active triphosphate form of this tenofovir diphosphate inhibits activity for rna-dependent rna polymerase (rdrp) of hiv and hepatitis b virus (hbv) ( , ) . still, even these existing drugs will need rigorous testing for efficacy and safety and ultimately ramped-up production before they can be deployed widely against covid- . generally, immunocompromised patients are more susceptible to bacterial, fungal, viral, and parasitic infections than healthy persons due to their inability to mount successful immune responses. this can be caused by impairment or weakening of the immune system by a number of conditions, including diseases (e.g., diabetes or hiv infection), malnutrition, and the use of certain medications. it has become apparent that sars-cov- infection also affects immunocompromised individuals more severely. a majority of covid- patients who were clinically diagnosed are older than ϳ years and have underlying complications, including heart disease, diabetes, hypertension, or cancer, indicating that age and reduced immune activity are the critical risk factors or determinants for covid- morbidity and mortality. we have recently established a ferret model for sars-cov- infection and transmission that highly recapitulates aspects of the human infection ( ) . elevated body temperatures and virus replication were readily detected in sars-cov- -infected ferrets. sars-cov- -infected ferrets shed the virus through nasal washes and in saliva, urine, and fecal specimens. sars-cov- was transmitted readily to naive direct-contact ferrets but less efficiently to naive indirect-contact ferrets ( ) . further, acute bronchiolitis was observed in infected lungs. in this report, we evaluated the efficacy of oral administration of lopinavir-ritonavir, hcq sulfate, and emtricitabine-tenofovir for sars-cov- infection in ferret infection models. we also treated ferrets with azathioprine, an immunosuppressive drug, and evaluated the replication kinetics of sars-cov- . while most drug treatments reduced clinical symptoms (cs), none of them led to a significant reduction of in vivo virus titers in ferrets. thus, a drug candidate study in a robust preclinical animal model should greatly facilitate testing the efficacies and safety of therapeutic treatments for covid- patients. clinical features of sars-cov- -inoculated ferrets treated with antivirals. in order to determine the antiviral efficacies of lopinavir-ritonavir, hydroxychloroquine (hcq) sulfate, or emtricitabine-tenofovir for treatment of sars-cov- infection, sars-cov- antibody-free ferrets ( /group) were inoculated with . % tissue culture infective doses (tcid )/ml of an nmc-ncov strain through the intranasal (i.n.) route ( fig. ). at day postinfection (dpi) with sars-cov- , ferrets were administered lopinavir ( mg/kg of body weight)-ritonavir ( mg/kg), hydroxychloroquine sulfate ( . mg/kg), or emtricitabine ( mg/kg)-tenofovir ( mg/kg) daily via oral gavage for days (fig. ). in addition, to test the effect of immunosuppression on viral infection and clinical outcome, a group (n ϭ ) of ferrets was also treated with phosphatebuffered saline (pbs) (as a control) or azathioprine, an immunosuppressive drug ( mg/kg), for days prior to sars-cov- infection (fig. ) . while all groups of sars-cov- -infected ferrets showed elevated temperatures at to dpi, the lopinavirritonavir-or emtricitabine-tenofovir-treated group exhibited mild fever compared with the pbs-treated group ( fig. a) . as with the pbs-treated group, the hydroxychloroquine sulfate-or azathioprine-treated group showed ϳ % body weight loss at dpi, while the lopinavir-ritonavir-or emtricitabine-tenofovir-treated group showed a Ͻ % change in body weight on average (fig. b ). to compare clinical features of sars-cov- infection following treatment with each drug, we developed an arbitrary scoring method to generate clinical symptom values based on -min observations of cough, rhinorrhea, and reduced activity and compared these cs values among the ferret groups as described in table . the average cs value of pbs-treated control ferrets was . at dpi, remained relatively high (Ͼ ) for to dpi, and returned to normal (less than ) by dpi (table ). the lopinavir-ritonavir-treated ferrets showed the reduced overall cs values (less than ) that peaked at to dpi and resolved by dpi (table ) . the hcq sulfate-treated ferrets also showed reduced cs values at to dpi compared with those of the pbs-treated group, but overall clinical symptoms were similar to those of the pbs-treated control group (table ) . although the emtricitabine-tenofovir-treated ferrets initially demonstrated clinical symptoms similar to those of the pbstreated control group, their overall cs values were relatively low at to dpi, and clinical symptoms were ultimately resolved by dpi. finally, the azathioprine-treated immunosuppressed ferrets also showed cs values similar to those of the pbs-treated control group, but this group's clinical symptoms lasted slightly longer than those of the pbs-treated control group (table ) . these results collectively showed that the lopinavir-ritonavir-, hcq sulfate-, or emtricitabine-tenofovir-treated group exhibited lower overall clinical scores than the pbs-treated control group. the overall clinical symptoms of immunosuppressed ferrets were similar but persisted slightly longer than those of pbs-treated control ferrets. comparisons of virus titers and shedding periods in antiviral-drug-treated ferrets. to evaluate the antiviral activity of each drug against sars-cov- , we measured infectious virus titers in nasal washes from drug-treated ferrets (fig. c ). sars-cov- was isolated from all infected ferrets regardless of drug treatment from dpi to dpi, with similar virus titers ( . to . log tcid /ml). at dpi, the emtricitabinetenofovir-treated ferrets exhibited reduced virus titers compared with those of the pbs-treated control group. although infectious virus was not detected in ferrets of the pbs-or antiviral-drug-treated groups at dpi, three of four azathioprine-treated ferrets were positive for virus even at dpi (fig. c) , suggesting delayed virus clearance in the upper respiratory tracts of immunocompromised ferrets. because gastrointestinal involvement has been documented in coronavirus infections of animals and humans ( ) , we also collected fecal specimens and performed quantitative real-time pcr (qrt-pcr) to determine whether any of the drug treatments affected sars-cov- shedding in the gastrointestinal system (fig. d) . the results showed that the viral rna was present in fecal specimens of all groups from to dpi, with peak viral rna copy numbers observed at to dpi. however, there was no statistical difference in viral rna copy numbers among the groups during the experimental period. by dpi, viral rna copy numbers declined in all drug-treated ferrets. to further evaluate virus titers in tissues, three ferrets from each group were euthanized at and dpi, and virus titers were measured in nasal turbinate and lungs. at dpi, all groups of ferrets showed high virus titers of more than . log tcid /g in nasal turbinate tissues, and the virus was also isolated from their lung tissues (fig. ) . at dpi, while all nasal turbinate tissues were positive for virus, the azathioprinetreated group showed a much higher virus titer (ϳ . log tcid /g) than those of the other groups (fig. a) . at dpi, the azathioprine-treated group still had detectable virus titers in their lung tissues, whereas the rest of groups were negative for the virus (fig. b) . to compare the serum neutralization (sn) antibody titers among drug-treated groups, blood was collected from each group of ferrets at , , and dpi. at dpi, the pbs-treated control and drug-treated groups demonstrated sn titers greater than (fig. ) . the antiviral-treated groups showed sn titers similar to those of the pbs-treated control group until dpi, but they exhibited lower sn titers at dpi than the pbs-treated control group (fig. ) . it is noteworthy that the azathioprine-treated immunosuppression group showed geometric mean sn titers of . and . at and dpi, respectively, suggesting the continuously reduced sn antibody response of the immunosuppressed group. in this study, we evaluated the antiviral efficacies of three fda-approved drug candidates against sars-cov- infection using a ferret infection model which has previously proven to be highly susceptible to sars-cov- infection ( , ) . although several clinical trials continue to evaluate these drug candidates, most of the enrolled patient populations are considered heterogeneous with regard to the duration and severity of illness at enrollment. further, given the rapid spread of covid- around the efficacies of fda-approved drugs against sars-cov- ® world, there are relatively higher mortality rates in some regions and in certain age groups. therefore, the use of highly susceptible animal models and controlled experimental settings should be an effective approach prior to human clinical trials to evaluate the in vivo antiviral effects of potential therapeutics. ferrets treated with antivirals showed relatively reduced overall clinical scores compared with those of the pbs-treated control group, which displayed high overall clinical scores. of the three drugs, the emtricitabine-tenofovir-treated group showed a noticeable reduction in overall clinical scores (Յ ) and a shorter duration ( dpi) of clinical symptoms. although attenuation of the overall clinical scores was observed in lopinavir-ritonavir-and hcq-treated groups at some time points, their clinical durations were comparable with those of the pbs-treated control group. these results suggest that treatment with emtricitabine-tenofovir, a nucleotide analogue that inhibits rnadependent rna polymerase activity, may be the most likely candidate to reduce clinical symptoms, including the cough and morbidity of sars-cov- -infected hosts. while the lopinavir-ritonavir protease inhibitor and a cq/hcq sulfate autophagy inhibitor have been shown to be effective against sars-cov, mers-cov, or sars-cov- in in vitro culture ( ), several reports have already described no benefit for clinical improvement of covid- patients. furthermore, hqc has been reported to be associated with a number of side effects, including a heart rhythm problem, severely low blood pressure, and muscle or nerve damage. thus, these existing fda-approved drugs still need rigorous testing for efficacy and safety in an animal model prior to clinical trials of covid- patients. since the emergence of sars-cov- in china in december , the number of cases has rapidly increased as the disease has spread globally. the increase in the number of cases is alarming and specially compounded by the possibility of viral transmission from asymptomatic individuals. several studies indicate that asymptomatic patients can transmit the virus to persons in close contact ( , ) . therefore, although clinical symptoms were attenuated in ferret groups treated with antiviral candidates, we also evaluated virus titers in respiratory and gastrointestinal tracts using nasal washes and stool samples, respectively, from sars-cov- -infected ferrets. regardless of antiviral candidate treatment, sars-cov- was detected at more than log tcid /ml until dpi, and there was no statistical difference between the pbs-treated control group and the antiviral-drug-treated groups. however, the emtricitabine-tenofovir-treated group showed relatively low virus tiers and shortened periods of virus shedding in nasal wash specimens compared with those of the other groups. currently, the role of sn antibody in the pathogenesis and disease clearance of sars-cov- is unclear. wu et al. ( ) recently reported that the sn antibody levels in covid- patients were variable, depending on the immune status of the patient, and that about % of patients failed to develop high sn titers after sars-cov- infection, although the disease durations of these patients were comparable to those of others. this suggests that the sn antibody titer may be closely associated with immune activity rather than with the virus titer and disease duration in patients. interestingly, we found that the antiviral-treated groups showed lower sn antibody titers than the pbs-treated control group. it is possible that as the antiviral treatment reduced the overall clinical symptoms of sars-cov- -infected ferrets, it might evoke weak immune responses and thereby lead to reduced neutralizing antibody responses. nevertheless, further immunological studies are needed to understand the detailed mechanisms of the low sn antibody titers in antiviral-treated ferrets. efficacies of fda-approved drugs against sars-cov- ® while covid- is typically characterized by respiratory symptoms, gastrointestinal symptoms have been reported in some cases. moreover, there is evidence of viral rna in the stools of sars-cov- patients. emtricitabine-tenofovir has reportedly shown antiviral efficacy in the gastrointestinal tract as well as in the respiratory tract ( ) . however, qrt-pcr analysis of stools revealed no statistical difference in virus titers in stools among the pbs-treated control and the antiviral-treated groups, suggesting that none of the tested antiviral candidates significantly diminished gastrointestinal sars-cov- replication in infected ferrets. in conclusion, although there may be some discrepancies in drug efficacy between animals and humans, these results of a preclinical ferret infection study should aid in the selection of antiviral treatments of covid- patients. this also suggests that a robust preclinical animal model for sars-cov- infection is valuable in order to identify antiviral drugs for future human efficacy trials. a sars-cov- strain, nmc-ncov , was propagated in vero cells in dulbecco's modified eagle medium (dmem; gibco, grand island, ny) supplemented with % penicillin-streptomycin (gibco) and tpck (tosylsulfonyl phenylalanyl chloromethyl ketone)-treated trypsin ( . g/ml; worthington biochemical, lakewood, nj) in a °c incubator supplemented with % co for h. propagated virus was stored at Ϫ °c as the working virus stock for animal studies. the % tissue culture infective dose (tcid ) was determined through fixation and crystal violet staining. immunosuppression and antiviral-drug candidate treatments. ten ferrets were treated orally with azathioprine ( mg/kg) (celltrion) daily for days prior to sars-cov- infection, and treatment continued until days postinfection (dpi) to reduce the immune response. as a control, pbs in the same volume was administered to ferrets. to confirm the immunosuppressed status of ferrets, blood samples were collected from azathioprine-treated ferrets, and the percentage of lymphocytes was assessed at and days preinfection and at , , and dpi. the reduction in lymphocyte numbers in azathioprine-treated ferrets compared with lymphocyte numbers in the pbs control group was confirmed (see fig. s in the supplemental material). for treatment with candidate antiviral drugs, groups of ferrets ( /group) were administered lopinavir ( mg/kg)-ritonavir ( mg/kg) (abbott), hydroxychloroquine sulfate ( mg/kg) (elyson), or emtricitabine ( mg/kg)-tenofovir ( . mg/kg) (gilead) daily via oral gavage starting at dpi of sars-cov- infection and continuing until dpi. experimental infection of ferrets. groups of -to -month-old female ferrets ( /group), seronegative for sars-cov- and sars-cov- , were intranasally inoculated with . tcid /ml of nmc-ncov under anesthesia. the body weights and temperatures of infected ferrets were monitored every other day until dpi. nasal washes and stool specimens were collected every other day from the inoculated ferrets. blood was collected at , , and dpi to measure the serum neutralization titer. three ferrets per group were euthanized at and dpi, and nasal turbinate and lungs were collected to measure tissue virus titers and examine lung histopathology. virus titers in nasal washes and tissues were determined by % tcid assessment in vero cells, while the virus titers in stool specimens were measured with quantitative real-time pcr (qrt-pcr). briefly, total rna was extracted using trizol reagent (thermo fisher scientific) or an rneasy kit (qiagen), and cdnas were generated with a sars-cov- specific primer by reverse transcription using quantitect reverse transcription (qiagen). qrt-pcrs were performed using a sybr green supermix (bio-rad) and a cfx touch real-time pcr detection system (bio-rad) with a spike gene-based, sars-cov- -specific primer set as previously described ( ) , and virus rna copy numbers were calculated as a ratio with respect to the standard control. clinical scoring methods of sars-cov- -infected ferrets. the ferrets were monitored daily over a -day period for temperature change, weight loss, clinical symptom, and movement and activity change. briefly, the frequency of cough and rhinorrhea was assessed in each group of ferrets and scored on the basis of the following criteria: no evidence of cough (score, ), occasional cough (score, ), and frequent cough (score, ) and no nasal rattling or sneezing (score, ), moderate nasal discharge on external nares (score, ), and severe nasal discharge on external nares (score, ). a change in a ferret's activity was assessed and scored on the basis of the following criteria: normal movement and activity (score, ), mildly reduced movement and activity (score, ), and considerably reduced movement and activity (score, ) for at least min. neutralizing assay. sera were collected from each group of ferrets to detect the serum neutralization titer. heat-inactivated -fold-diluted serum samples were serially diluted by -fold. an equal volume of sars-cov- at tcid was added to all diluted samples. the mixture of serum and virus was incubated at °c for h and then added to vero cells in a -well tissue culture plate for min. the mixture of serum and virus was then removed, followed by two washes with cold pbs. fresh medium was added to infected cells, and cells were incubated at °c in % co for days. supernatants were removed, fixed with a % formalin solution, and stained with crystal violet to determine the titer. statistical analysis. to assess significant differences in values for weight loss, temperature, viral titers, and serum neutralization titers, statistical analyses were done. asterisks indicate the statistical significance between pbs-administered and treated ferrets determined by two-way analysis of variance (anova) and a subsequent dunnett test (*, p Ͻ . ; **, p Ͻ . ; and ***, p Ͻ . ). all statistical analyses were performed using graphpad prism version . for windows (graphpad software, la jolla, ca). park et al. who. . coronavirus disease (covid- ) situation report . who detection of sars-cov- in different types of clinical specimens viral load of sars-cov- in clinical samples temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by sars-cov- : an observational cohort study remdesivir, lopinavir, emetine, and homoharringtonine inhibit sars-cov- replication in vitro screening of an fda-approved compound library identifies four small-molecule inhibitors of middle east respiratory syndrome coronavirus replication in cell culture treatment with lopinavir/ritonavir or interferon-␤ b improves outcome of mers-cov infection in a nonhuman primate model of common marmoset combination therapy with lopinavir/ritonavir, ribavirin and interferon-␣ of middle east respiratory syndrome virological and serological analysis of a recent middle east respiratory syndrome coronavirus infection case on a triple combination antiviral regimen antimalarial drug chloroquine counteracts activation of indoleamine ( , )-dioxygenase activity in human pbmc hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting sars-cov- infection in vitro hydroxychloroquine for sars-cov- infection: how did we get here? connecticut hospitals using anti-malaria drug chloroquine 'out of desperation' to treat covid- animal toxicity and pharmacokinetics of hydroxychloroquine sulfate hydroxychloroquine for autoimmune diseases advances in nucleotide antiviral development from scientific discovery to clinical applications: tenofovir disoproxil fumarate for hepatitis b tenofovir alafenamide (taf) as the successor of tenofovir disoproxil fumarate (tdf) infection and rapid transmission of sars-cov- in ferrets enteric involvement of severe acute respiratory syndromeassociated coronavirus infection susceptibility of ferrets, cats, dogs, and other domesticated animals to sars-coronavirus transmission of efficacies of fda-approved drugs against sars-cov- ® -ncov infection from an asymptomatic contact in germany a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster neutralizing antibody responses to sars-cov- in a covid- recovered patient cohort and their implications drug-susceptible hiv- infection despite intermittent fixed-dose combination tenofovir/emtricitabine as prophylaxis is associated with low-level viremia, delayed seroconversion, and an attenuated clinical course all animal experiments were approved by the medical research institute, a member of the laboratory animal research center of chungbuk national university (larc) (approval number cbnur- - ), and were conducted in strict accordance with and adherence to relevant policies regarding animal handling as mandated under the guidelines for animal use and care of the korea centers for disease control (kcdc). the handling of virus was performed in an enhanced biosafety level (bsl ) containment laboratory as approved by the korea centers for disease control and prevention (protocol kcdc- - - ). supplemental material is available online only. key: cord- -srym kh authors: de rosa, nicoletta; giampaolino, pierluigi; lavitola, giada; morra, ilaria; formisano, carmen; nappi, carmine; bifulco, giuseppe title: effect of immunomodulatory supplements based on echinacea angustifolia and echinacea purpurea on the posttreatment relapse incidence of genital condylomatosis: a prospective randomized study date: - - journal: biomed res int doi: . / / sha: doc_id: cord_uid: srym kh introduction. hpv infection is a highly infectious disease; about % of partners of individuals with genital warts will develop genital condylomatosis. only in - % it regresses spontaneously and relapse rates range deeply ( - %). echinacea extracts possess antiviral and immunomodulator activities. the aim of this study was to evaluate the efficacy of the therapy, using a formulation based on hpvadl ® (on dry extracts of mg echinacea purpurea (ep) roots plus e. angustifolia (ea)), on the posttreatment relapse incidence of genital condylomatosis. materials and methods. it is a prospective single-arm study. patients with a satisfactory and positive vulvoscopy, colposcopy, or peniscopy for genital condylomatosis were divided into two random groups and subjected to destructive therapy with co laser. group a (n= ) immediately after the laser therapy started a -month treatment with oral hpvadl ®; group b (n= ) did not undergo any additional therapy. patients were subjected to a follow-up after , , and months. differences in relapse incidence between the two groups during follow-up controls were evaluated by χ -test; the groups were stratified by age, gender, and condylomatosis extension degree. results and discussion. gender, age, and condyloma lesions' extension degree showed no statistically significant differences between the two trial groups. the relapse incidence differs statistically between the two studied groups and progressively decreases during the months after treatment in both groups. statistically significant reduction of relapse rates has been shown in group a in patients over years old. this difference is significant for both men and women. the relapse incidence is superior in case of extended condylomatosis. conclusions. in conclusion, the presence of a latent infection causes condylomatosis relapse; in order to reduce the relapse risk an induction of a protective immune response seems to be essential to allow rapid viral clearance from genital areas surrounding lesion and treatment zones. echinacea promotes this process. ep and ea dry root extracts seem to be a valid adjuvant therapy in reducing relapse incidence of lesions in patients treated for genital condylomatosis. hpv infection is one of the most common sexually transmitted infections in the world. more than % of sexually active adults contract the infection during their life. in the two years after a sexual debut the sexual risk of infection varies from to % depending on the studied population and the hpv type [ ] . there is a similar incidence of genital condylomatosis in males and females ( - % and - %) [ ] [ ] [ ] . in men, compared to women, infections with multiple genotypes and low-oncogenic risk genotypes are more frequent [ ] . only - % of the genital condylomatosis regresses spontaneously. this is a highly infectious disease; about % of partners of individuals with genital warts will develop genital condylomatosis. the risk of infection and the risk of progression of hpv-associated lesions are related to several factors including number of sexual partners experienced during the life and early age of the first intercourse; tobacco smoking; and eating habits [ ] [ ] [ ] . it has long since known that the above-ground portion and the roots of echinacea angustifolia (ea) and of e. purpurea (ep) possess anti-inflammatory and immunostimulatory properties. numerous in vitro and in vivo studies have been recently conducted in an effort to validate some of the traditional uses of echinacea extracts [ ] . early studies have shown that only a few echinacea extracts possess significant antiviral activity. in particular, above-ground portions and roots of ep show a strong antiviral activity, as they have a virucidal effect against influenza virus, herpes simplex virus, and coronaviruses [ , ] . the ep appeared much less effective against intracellular viruses [ , ] , which could be resistant to the ep inhibitory effect; on the contrary, viral particles located in the extracellular fluids appeared to be vulnerable. therefore, ep can act during an initial contact with virus, that is, at the beginning of infection and also during the transmission of the virus from the infected cells. numerous viral and bacterial infections cause an increase of expression of proinflammatory cytokines, in particular, of il- and il- , which are therefore considered as markers of an inflammatory state [ , ] . any compound or herbal extract that inhibits or inverts the increase of il- / can be considered a potential anti-inflammatory agent. all the portions of the roots, leaves, stems, and flowers of ep show this effect [ ] . these studies make it evident that echinacea not exactly acts as an "immunostimulant" or "immune system booster," but more likely has an immunomodulatory action, rather than a generalized immunostimulatory effect [ ] [ ] [ ] [ ] . the aim of the present study was to evaluate the efficacy of the therapy, using a formulation based on mg of hpvadl (equal to mg polyphenols plus . mg of echinacosides), on the post-treatment relapse incidence of genital condylomatosis. between july and july , all patients with a genital condylomatosis diagnosis received in the colposcopy and cervical-vaginal pathology unit of university federico ii, naples, were invited to participate in a prospective randomized trial. patients were properly informed and provided their written consent to participate in the trial and to undergo ambulatory diagnostic examinations; afterwards, colposcopy or peniscopy was conducted and, if appropriate, biopsy examinations. all procedures performed in the study were in accordance with the ethical standards of the institutional and/or national research committee and with the helsinki declaration and its later amendments or comparable ethical standards. the criteria for participation in the trial were as follows: satisfactory and positive colposcopy / peniscopy for genital condylomatosis (cervix, vagina, perianal vulva, or perineum for females and penis, scrotum, or anal region for males) and / or histological examination for koilocytosis or condylomatosis in case of positive cervical biopsy. patients with h-sil cytological diagnosis, cin - histologic diagnosis, or invasive cervical carcinoma, pregnant women, immunosuppressed patients, and individuals infected with human immunodeficiency virus (hivpositive) were not enrolled in the trial. colposcopy and peniscopy were conducted after an application of % acetic acid. visible acetowhite lesions have been classified in accordance with the criteria of the international federation of cervical pathology and colposcopy [ ] . in case of genital condylomatosis, to standardize extension of the lesions, genitals were divided into genital areas for women, that is, cervix, left/right vaginal wall, left/right major labia, left/right minor labia, clitoris, pubis, perineum, and perianus and into genitals arear for men, that is, pubis, scrotum, glans, preputial balanus grooves, and penis. patients were classified into lesion degrees, according to the number of genital areas affected by condylomas and the number of the condylomas: ( ) from to condylomas on - genital areas (mild and localized condylomatosis) ( ) > condylomas on - genital areas (mild and diffuse condylomatosis) ( ) > condylomas on > genital areas (extended condylomatosis). patients with low grade (ztag ) or high grade (ztag ) cervical lesions were subjected to a targeted biopsy using a biopsy forceps (cfs chimo schumacher pliers) with - mm jaw in order to obtain - mm tissue specimens. two serial micron sections of the formalin-fixed and paraffin-embedded sample were stained with hematoxylin and eosin. the specimens were examined by optical microscope and classified as normal, cin , cin , and cin carcinoma in situ or microinvasive carcinoma according to the criteria of the world health organization. patients with low grade (cin ) or high grade (cin - ) preneoplastic lesions were excluded from the trial and carried on all the therapeutic and diagnostic procedures as recommended by national and international guidelines. patients with genital condylomatosis, diagnosed through colposcopy, vulvoscopy, peniscopy, and/or biopsy examinations, were included in the study. all enrolled individuals were divided into two random groups and subjected to destructive therapy with co laser. group a immediately after the laser therapy started a month treatment with oral immunomodulatory supplements based on hpvadl ; group b did not undergo any additional therapy (control group). the medical device administered to group a was composed of mg of hpvadl (equal to mg polyphenols plus . mg of echinacosides), mg vitamin c, mg of zinc, and . mg of copper. patients were subjected to a follow-up colposcopy after , , and months. in case the infection persisted and relapse condyloma lesions occurred, patients were again subjected to destructive therapy until the full lesion elimination. all colposcopy, peniscopy and biopsy examinations and therapies were performed by our team. statistical analysis of the data was executed by spss software . (spss inc., chicago, il, usa). data with p-values < . were considered statistically significant. demographic and clinical data of the two groups were compared by student's t-test for the data with parametric distribution (age) and by -test for ordinal variables (gender and condylomatosis extension degree). differences in relapse incidence between two groups during follow-up controls were evaluated by -test; the groups were stratified by age, gender, and condylomatosis extension degree. one hundred and forty women appeared to be suitable for destructive therapy with co laser and were divided into group a (n = ) and group b (n = ) at random. of these, patients did not undergo a required operation and patients did not undergo a programmed follow-up or interrupted the therapy before the -month period expired. one hundred and twenty-five patients, ( %) women and ( %) men, completed the diagnostic-therapeutic procedure as scheduled by the protocol and were therefore included in the analysis. of the studied population, women ( . %) underwent echinacea therapy after the treatment (group a) and ( . %) did not undergo any additional therapy (group b, control group). the mean age of female patients in group a is . ± . years, in group b . ± . years (p = n.s.); the mean age of male patients in group a is . ± . years, in group b . ± . years (p = ns). table shows epidemiological data and condyloma lesions' extension degree for groups a and b. there were no statistically significant differences in these data in the two trial groups. no severe side effects were recorded in group a. only ( . %) patients reported some digestive difficulties. the relapse incidence differs statistically between the two studied groups (table , figure ) and progressively decreases during the months after treatment in both groups. therapy does not seem to modify the relapse incidence in very young female patients under the age of . instead, statistically significant reduction of relapse rates has been shown in patients over years old. this difference is significant for both men and women. the relapse incidence is superior in case of extended condylomatosis (extension degree n. ) (table , figure ). clinical trials conducted on patients with genital condylomatosis show quite different relapse rates, depending on the studies and on the treatment and range from % to % [ ] [ ] [ ] [ ] . our data show a global relapse rate of about %. therapy with hpvadl is effective in reducing relapse incidence of lesions in patients treated for genital condylomatosis. our data prove, indeed, that the relapse incidence of lesion is greater in the control group compared to the treatment group at the first, second, and third follow-up controls. spontaneous remission of genital condylomatosis is possible, but not frequent; the percentage of spontaneously recovered patients varies considerably and ranges from % to % [ , ] . most commonly used therapy is cryotherapy or diathermocoagulation ( % and %); drug therapy is much less frequent ( %). approximately % of patients undergo a single treatment procedure; the number of patients that undergo more than one treatment procedures progressively decreases; % of patients undergo or more treatments [ ] . this pattern is similar for both sexes and is according to the anatomical site [ ] . in compliance with these data, the difference in relapse incidence between the two trial groups is statistically significant even when these are stratified by gender and extension degree of the lesion. on the other hand, age appears to be a determinant factor; in fact, in individuals under the age of , the therapy does not seem to influence significantly the relapse incidence of lesion. the small numbers of younger age groups, however, cannot induce us to generalize this data. based on these data, it follows that in very young individuals additional therapy with hpvadl could be superfluous. moreover, individuals under the age of show greater relapse incidence at the first follow-up. the relapse incidence decreases progressively in both groups as the time passes and is related to the extension degree; in fact, the extension degree of condylomatous lesions corresponds to a higher relapse incidence than degrees and . the presence of a latent infection causes lesion relapse; in order to reduce the relapse risk after the treatment of condyloma lesions, an induction of a protective immune response seems to be essential to allow rapid viral clearance from genital areas surrounding lesion and treatment zones. introduction of an immunostimulatory substance such as echinacea seems to promote this process. the hpv-induced immune response is both humoral and cell mediated. a humoral immune response to hpv capsid protein l is weak during natural infection. the humoral immune response to the viral capsid can be detected averagely starting from months after the infection, though - % of patients with persistent infection will never present a seroconversion [ ] . the seropositivity to the infectious genotype persists only in % of the cases, even when the initial lesion transformed to a cervical cancer [ ] . when viral dna has been eliminated, specific antibodies can be detected only in half of cases after years [ ] . hpv infection promotes a cellular immune response, especially in the active phase of the clearance of genital condylomatosis infection, when a cell infiltration of macrophages and t cells develops in correspondence to the lesion [ ] . in the blood, an immune response of cd + t cells against e , e , and e proteins is associated with hpv and hpv infection and occurs in particular in early disease phases and in case of regressing lesions, less when a persistent disease takes place. in individuals with a deficiency of cell-mediated immune response, hpv infection, genital condylomatosis, or precancerous lesions are destined to persist. therefore, this type of response seems to be essential for the viral clearance. the ep immunomodulatory effect has been widely demonstrated. ep extract was used for the preventive care and for the treatment of various viral infections [ ] . in vitro studies have shown that ep acts directly on a number of cell types, including natural killer cells [ ] , polymorphonuclear leukocytes [ ] , and macrophages [ ] . ep induces a proliferation of t cells. this has been conferred to the activation of macrophages that stimulates a production of ifn-and, consequently, a secondary activation of t lymphocytes [ ] . ifn-is one of the fundamental mediators for the latency prevention [ ] ; it has been proven that this mechanism is responsible for reducing the latency incidence of herpes virus simplex infection and, consequently, reducing the relapse risk of hsv lesions [ ] . it is possible that an analogous mechanism induces a cell-mediated response to hpv infection, which allows the reduction of the persistence of infection and, therefore, the lesion relapse. this study has some limitations: this is a single institution study with a small number of participants and it lacks placebo controls. on the other hand, the strengths of this study are as follows: the rigorous inclusions criteria, the evaluation of patients at colposcope (so not only grossly visible genital warts were evaluated and treated but also small lesions), and the treatment modality with laser co for all patients. in conclusion, hpvadl seems to be a valid adjuvant therapy in reducing relapse incidence of lesions in patients treated for genital condylomatosis. the data used to support the findings of this study are included within the article. the authors state that there are no conflicts of interest. meta-analysis of human papillomavirus infection concordance trends in genital warts and genital herpes diagnoses in the united kingdom anogenital warts incidence, medical management and costs in women consulting gynaecologists in france epidemiology and cost of treatment of genital warts in spain genital human papillomavirus (hpv) concordance in heterosexual couples risk of female human papillomavirus acquisition associated with first male sex partner highrisk human papillomavirus is sexually transmitted: evidence from a follow-up study of virgins starting sexual activity (intercourse) the role of high-risk hpv-dna testing in the male sexual partners of women with hpv-induced lesions echinacea plants as antioxidant and antibacterial agents: from traditional medicine to biotechnological applications characterization of antiviral activities in echinacea root preparations echinacea purpurea aerial parts contain multiple antiviral compounds antiviral properties and mode of action of standardized echinacea purpurea extract against highly pathogenic avian influenza virus (h n , h n ) and swine-origin h n (s-oiv) induction of multiple pro-inflammatory cytokines by respiratory viruses and reversal by standardized echinacea, a potent antiviral herbal extract the influence of traditional herbal formulas on cytokine activity anti-inflammatory compounds of plant origin. part ii. modulation of pro-inflammatory cytokines, chemokines and adhesion molecules antiinflammatory activities of echinacea extracts do not correlate with traditional marker components echinacea and anti-inflammatory cytokine responses: results of a gene and protein array analysis alkylamides from echinacea modulate induced immune responses in macrophages pharmacokinetics and immunomodulatory effects of phytotherapeutic lozenges (bonbons) with echinacea purpurea extract echinacea-induced macrophage activation colposcopic terminology of the international federation for cervical pathology and colposcopy the diagnosis and treatment of human papillomavirus-mediated genital lesions an evidence-based review of medical and surgical treatments of genital warts external genital warts: diagnosis, treatment, and prevention management of genital warts a retrospective analysis of the costs and management of genital warts in italy comparison of human papillomavirus types , , and capsid antibody responses following incident infection human papillomavirus and l serology compared across anogenital cancer sites determinants of human papillomavirus serological conversion and persistence in a population-based cohort of women in costa rica characterization of human antibody-reactive epitopes encoded by human papillomavirus types and treatment of the common cold with unrefined echinacea: a randomized, double-blind, placebocontrolled trial echinacea purpurea and melatonin augment natural-killer cells in leukemic mice and prolong life span the effect of aerial parts of echinacea on the circulating white cell levels and selected immune functions of the aging male sprague-dawley rat echinacea stimulates macrophage function in the lung and spleen of normal rats the current trend in genital herpes: progress in prevention cd t cell control of acute and latent murine gamma herpes virus infection requires ifn key: cord- -xms su w authors: rahmani, hamid; davoudi-monfared, effat; nourian, anahid; khalili, hossein; hajizadeh, nooshin; zarei jalalabadi, narjes; reza fazeli, mohammad; ghazaeian, monireh; saeed yekaninejad, mir title: interferon β- b in treatment of severe covid- : a randomized clinical trial date: - - journal: int immunopharmacol doi: . /j.intimp. . sha: doc_id: cord_uid: xms su w in this study, efficacy and safety of interferon (ifn) β- b in the treatment of patients with severe covid- were evaluated. among an open-label, randomized clinical trial, adult patients (≥ years old) with severe covid- were randomly assigned ( : ) to the ifn group or the control group. patients in the ifn group received ifn β- b ( mcg subcutaneously every other day for two consecutive weeks) along with the national protocol medications while in the control group, patients received only the national protocol medications (lopinavir/ritonavir or atazanavir/ritonavir plus hydroxychloroquine for - days). the primary outcome of the study was time to clinical improvement. secondary outcomes were in-hospital complications and -daymortality. between april and may , , patients were enrolled and finally patients in each group completed the study. time to clinical improvment in the ifn group was significantly shorter than the control group ([ ( - ) vs. ( - ) days respectively, p= . , hr= . ; % ci: . - . ]). at day , the percentage of discharged patients was . % and . % in the ifn and control groups respectively (or= . ; % ci: . - . , p= . ). icu admission rate in the control group was significantly higher than the ifn group ( . % vs. . %, p = . ). the duration of hospitalization and icu stay were not significantly different between the groups all-cause -day mortality was . % and . % in the ifn and control groups respectively (p = . ). ifn β- b was effective in shortening the time to clinical improvement without serious adverse events in patients with severe covid- . furthermore, admission in icu and need for invasive mechanical ventilation decreased following administration of ifn β- b. although -day mortality was lower in the ifn group, further randomized clinical trials with large sample size are needed for exact estimation of survival benefit of ifn β- b. coronavirus disease (covid- ) was reported from wuhan for the first time in late december . causing severe acute respiratory syndrome coronavirus (sars-cov- ) [ ] , it rapidly spread throughout the world to the extent that the world health organization (who) stated it as pandemic in march [ ] . until july , , more than million confirmed cases of covid- were reported worldwide. furthermore, more than . deaths were recorded [ ] . until now, there is no definite antiviral treatment for covid- and attempts continue for finding effective treatments worldwide. however, from the beginning of the pandemic, various treatments such as antiretrovirals, anti-malaria agents, favipiravir, remdesivir, and corticosteroids, immunoglobulin and cytokine blockers as adjunctive therapies were suggested for the treatment of covid- [ ] . except for the remdesivir which has had acceptable results, the efficacy of other drugs has not been significant on the outcomes of the patients with covid- [ ] [ ] [ ] [ ] [ ] . interferons (ifns) have a key role in defense against viral infections as a component of innate immune system [ ] . invitro activity of ifn β has been shown against severe acute respiratory syndrome coronavirus (sars-cov) and middle east respiratory syndrome coronavirus (mers-cov) [ ] [ ] [ ] [ ] . although ifn β was used less than ifn α for the treatment of sars-cov and mers-cov in human studies, it was effective in the treatment of mers-cov in retrospective studies and case series [ ] [ ] . the efficacy of ifn β- b is being assessed in the treatment of mers in a randomized clinical trial [ ] . according to the presence of this evidence, ifn β was considered as a promising option for the treatment of in this open-label, randomized clinical trial, efficacy and safety of ifn β- b in the treatment of patients with severe covid- were assessed. this open-label, randomized clinical trial was designed to evaluate the efficacy and safety of ifn β- b in the treatment of patients with covid- adult patients (≥ years old) with positive pcr and clinical symptoms/signs of pneumonia (including dyspnea, cough and fever), peripheral oxygen saturation (spo ) ≤ % in ambient air or arterial oxygen partial pressure to fractional inspired oxygen (pao /fio ) < or spo /fio < and lung involvement in chest imaging were included. these criteria indicated severe form of the disease [ ] . at baseline, patients with serious allergic reactions to ifn, history of suicide thoughts and attempts, alanine amino transferase (alt)> × the upper limit of the normal range, uncontrolled underlying diseases such as neuropsychiatric disorders, thyroid disorders, cardiovascular diseases and also pregnant and lactating women were not included. recruitment was considered during the first -hour of the hospital admission. during the study period, patients who received less than doses of ifn β- b were excluded. if patients were discharged before fulfilment of the treatment course, the treatment was applied at home. eligible patients were recruited in the ifn group or the control group according to the permuted block randomization. patients in the ifn group received ifn β- b along with the national protocol medications, while in the control group, patients received only the national protocol medications. ifn β- b (ziferon®, zist daru daneh co., iran) was administrated as mcg subcutaneously every other day for two consecutive weeks. the national protocol consisted lopinavir/ritonavir ( / mg bd) or atazanavir/ritonavir ( / mg daily) plus hydroxychloroquine ( mg bd in first day and then mg bd) for - days. other supportive cares such as fluid therapy, stress ulcer prophylaxis, deep vein thrombosis, treatment of electrolyte disorders and antibiotic therapy were considered according to the hospital protocols. the duration of the study was two weeks. a -week follow-up period was considered for all patients. patients' demographic data, baseline diseases, symptoms at the time of disease presentation, vital signs and laboratory data at the time of hospital admission were recorded. patients were daily monitored in terms of changes in the vital signs, hemodynamic parameters, oxygenation status, laboratory data and treatment strategies. clinical status of the patients was assessed by the six- category ordinal scale at days , , and of the randomization [ ] . need for supplemental oxygen therapy and also invasive or non-invasive respiratory supports were evaluated regularly. time to clinical improvement was considered as primary outcome of study. clinical improvement was defined as improvement of at least two points from the baseline status on the six-category ordinal scale [ ] . this scale contains the subsequent categories: ( ) death ( ) hospital admission requiring invasive mechanical ventilation ( ) hospital admission, requiring non-invasive positive pressure ventilation ( ) hospital admission, requiring oxygen ( ) hospital admission, not requiring oxygen ( ) discharge. secondary outcomes were clinical status of patients at day , and , icu admission and intubation rates, length of hospitalization and icu stay, and -day mortality. side effects related to ifn therapy and other adverse events during the study period were monitored and recorded as the safety outcomes. categorization of adverse events was done according to the common terminology criteria for adverse events (ctcae), national institutes of health and national cancer institute, . also serious complications during the hospitalization course such as acute respiratory distress syndrome (ards), nosocomial infections, septic shock, acute kidney injury (aki) and acute hepatic injury (ahi) were considered. continuous variables are demonstrated as median (interquartile range (iqr)) and categorical variables as frequencies and percentages. continuous variables were compared between the groups by mann-whitney u test. the fisher's exact test was applied for comparison of categorical variables. the hazard ratio (hr) and % ci for clinical improvement were estimated by cox proportional hazards regression analysis. the effect of ischemic heart disease, lymphocyte count, aspartate aminotransferase (ast) and c-reactive protein (crp) on the primary outcome was evaluated by the adjusted cox regression models as potential confounding factors. time to clinical improvement was estimated by kaplan-meier plot and compared with a log-rank test. all statistical analysis was done by spss software (version . ). time to clinical improvement was estimated to be approximately days and sample size was calculated by following equation: power= . according to the above equation, at least patients in each group were expected to make a difference of days in time to clinical improvement with power of %. patients were randomly recruited ( : ) to the ifn group or the control group. the method of randomization was the permuted block randomization ( patients per block). a biostatistician who was not involved in patients' care did this process. a total of patients were screened. of them, patients did not have the eligibility criteria of study and patients were referred from another hospital. three and four patients withdrew the consent during the study in the ifn group and control groups, respectively. four patients did not adhere to ifn injection after second or third dose. also three patients in the control group were enrolled in another trial. finally, patients in each group completed the study ( figure ). the median (iqr) age of patients was ( - ) years and . % of them were male. no significant difference in terms of the patients' demographic data was detected between the groups. the most common comorbidities were hypertension, diabetes mellitus and ischemic heart disease. dyspnea, fever and cough were the most frequent symptoms at the time of hospital admission. the median (iqr) time from onset of the symptoms to hospital admission was ( - ) and ( - ) days in the ifn group and control groups respectively. the time from onset of the symptoms to randomization was not statistically significant between the groups. all of patients required respiratory support at the time of randomization. oxygenation through facemask was required for more than percent of patients. none of the patients in both groups were intubated at baseline ( the ec values for remdesivir and lopinavir were determined as . and . µm respectively. the cc values of ifns, remdesivir and lopinavir were > . iu/ml, > µm and µm respectively. among ifns, the most reductive effects on viral load belonged to ifn β- a and ifn β- b. however, ifn β- b showed highest potency and selectivity index against sars-cov- [ ] . in a randomized clinical trial, and patients were recruited in the combination and control groups respectively. patients in the combination group received ifn β- b, lopinavir/ritonavir and ribavirin while those in the control group received only lopinavir/ritonavir. the primary outcome was defined as the time to reach a negative rt-pcr of respiratory secretions for sars-cov- . the time to resolution of the symptoms was considered as one of the secondary outcomes. the median time to achieving a negative rt-pcr was significantly shorter in the combination group compared to the control group ( vs. days). moreover, resolution of the symptoms occurred notably faster in the combination group than the control group ( vs. days) [ ] . similar with our study, ifn β- b was started in the viral phase of covid- i.e. within first days of onset of the symptoms. in our study median time from onset of the symptoms to randomization was days. in both studies, first dose of ifn β- b was administered within to hours of hospital admission. initiation of antiviral agents as soon as possible following onset of the symptoms is critical in control of viral replication and prevention of tissue viral invasion. the efficacy of antivirals significantly decreased after establishment of the cytokines release phase in covid- [ ] [ ] . due to resource limitations, evaluation of viral clearance was not possible in our study. and patients were assigned to the ifn and control groups respectively. in-hospital mortality was considered as the primary outcome of study. the mortality rate was statistically significant in the control group than the ifn group ( . % vs. . %) [ ] . retrospective design and lack of matching of the groups in terms of receiving other antivirals should be considered when interpreting the results. in a case series, characteristics and outcomes of five patients with severe covid- , who were treated with ifn β- b, lopinavir/ritonavir and hydroxychloroquine, were described. the antiviral regimen applied for these patients was similar to our study. treatment was successful in patients while clinical status of patients deteriorated during the treatment course. all patients received corticosteroids. furthermore, all patients were initially admitted in another hospital and later transferred to the referral hospital [ ] . . %). early administration of ifn β- a significantly reduced the mortality rate compared with late administration [ ] . absence of follow-up pcr and chest imaging along with the small sample size were the major limitations of the study. our study suffered from some limitations. follow up chest imaging or virological assessment was not possible due to resources limitations, therefore the effect of ifn β- b on viral clearance was not determined. small sample size did not allow accurate estimation of survival benefit of ifn β- b. in conclusion, ifn β- b was effective in shortening the time to clinical improvement without serious adverse events in patients with severe covid- . furthermore, icu admission rate and need for invasive mechanical ventilation significantly reduced by administration of ifn β- b. although compared with the control group, ifn β- b reduced duration of hospitalization, length of icu stay, intubation rate and -day mortality were not statistically different between the groups. further randomized clinical trials with enough sample size are needed to accurately estimate survival benefit of ifn β- b. in patients with severe covid- : -as add-on therapy, ifn β- b shortened the time to clinical improvement -ifn β- b significantly increased the discharge rate at day -ifn β- b reduced overall -day mortality -ifn β- b related adverse effects were mild and did not cause treatment interruptions review of the novel coronavirus (sars-cov- ) based on current evidence who declares covid- a pandemic johns hopkins coronavirus resource center home page pharmacologic treatments for coronavirus disease (covid- ): a review observational study of hydroxychloroquine in hospitalized patients with covid- a trial of lopinavir-ritonavir in adults hospitalized with severe covid- effectiveness and safety of glucocorticoids to treat covid- : a rapid review and meta-analysis clinical efficacy of intravenous immunoglobulin therapy in critical patients with covid- : a multicenter retrospective cohort study the antiviral effect of interferonbeta against sars-coronavirus is not mediated by mxa protein interferon-beta and interferon-gamma synergistically inhibit the replication of severe acute respiratory syndrome-associated coronavirus (sars-cov) interferon-beta a and sars coronavirus replication inhibitors of middle east respiratory syndrome coronavirus in cell-based assays ifn-α a or ifn-β a in combination with ribavirin to treat middle east respiratory syndrome coronavirus pneumonia: a retrospective study treatment outcomes for patients with middle eastern respiratory syndrome coronavirus (mers cov) infection at a coronavirus referral center in the kingdom of saudi arabia and the miracle trial group. treatment of middle east respiratory syndrome with a combination of lopinavirritonavir and interferon-β b (miracle trial): study protocol for a randomized controlled trial management and treatment of covid- : the chinese experience analysis of an ordinal endpoint for use in evaluating treatments for severe influenza requiring hospitalization type interferons as a potential treatment against covid- heightened innate immune responses in the respiratory tract of covid- patients imbalanced host response to sars-cov- drives development of covid- broad-spectrum host-based antivirals targeting the interferon and lipogenesis pathways as potential treatment options for the pandemic coronavirus disease (covid- ). viruses triple combination of interferon beta- b, lopinavir-ritonavir, and ribavirin in the treatment of patients admitted to hospital with covid- : an open-label, randomised, phase trial covid- : towards understanding of pathogenesis covid- infection: the perspectives on immune responses clinical evaluation of ifn beta b in covid- pneumonia: a retrospective study five severe covid- pneumonia patients treated with triple combination therapy with lopinavir/ritonavir, hydroxychloroquine, and interferon β- b interferon beta- a as a candidate for an open-label single-arm clinical trial subcutaneous administration of interferon beta- a for covid- : a non-controlled prospective trial efficacy and safety of interferon beta- a in treatment of severe covid- : a randomized clinical trial table -baseline characteristics of patients parameter; median (iqr) or n (%) we would like to thank the nurses and other staffs of imam khomeini hospital complex for their kind supports and also ms. ava khalili for english proofreading the manuscript. the authors did not receive any fund for this work. there is no conflict of interest for authors to declare. key: cord- -ut gczm authors: nan title: education day monday: plenary session monday: parallel sessions date: - - journal: vox sang doi: . /j. - . . .x sha: doc_id: cord_uid: ut gczm nan from the perspective of causal inference, there is a hierarchy of evidence, ranging from case-series to large randomized controlled trials (rcts). in addressing a particular clinical or policy problem, clinicians or policy-makers can base their decisions on the types of clinical reports that have been published, along with an assessment of the strengths and weaknesses of each study. rcts are controlled clinical experiments in which patients are randomly allocated by the investigators to receive a treatment under study. if randomization is used, all participants are equally likely to be allocated to either the treatment or the control arm of the study. rcts should be distinguished from observational studies in which investigators passively observe patients who happen to receive a treatment under study. because the allocation of subjects to the treatment and control arms of an rct is random, the play of chance should distribute all confounding factors equally between these two arms. thus, the treatment and control arms of an rct should be equivalent with respect to all confounding factors except for the treatment under study. randomization removes selection bias, because neither the investigator nor the participant knows what the treatment allocation will be before a patient enters a study. moreover, if an rct is double-blind, observation bias is also removed, because preconceived notions about benefit from the treatment cannot color the reporting of symptoms by a patient or the assessment of disease activity by an investigator. when the undertaking of rcts is deemed unlikely, meta-analyses of individual patient data, that is, of the data recorded previously on subjects enrolled in published, small rcts may allow investigators to address issues of possible biases ed- - standardizing blood components would allow better monitoring of the effectiveness of transfusion d davenport university of michigan, ann arbor, mi, usa in routine transfusion of red blood cells (rbc) or platelet concentrates (pc), we have only a very rough idea of the dose we administer. the minimum expected hemoglobin content of rbc should be g (fda criteria). however, actual measurements have found a mean hemoglobin content of . ± . g per unit, with variability between manufacturers. percent of units may contain less than . g of hemoglobin while percent may contain more than . g. the effect of storage senescence can magnify these differences. the resulting hematocrit increase, depending on size of recipient and age of a unit, may be . to percent. apheresis collection of rbc can help standardized unit contents, but this technology is relatively expensive and time consuming. knowledge of actual hemoglobin content can be used to optimize red cell transfusion. one trial, using a simple formula incorporating the desired hemoglobin and estimated blood volume, showed that nearly percent of transfusion orders could be met with one unit while achieving a mean target hemoglobin of . g/dl. for pc transfusion, about percent of transfusions achieve the targeted dose of - ¥ platelets in actual practice, with considerable variability between institutions. without knowledge of the actual content of pc, determination of refractoriness and response to matched pc is problematic. standardization and labeling of rbc and pc units for content will permit accurate dosage and quantification of transfusion practice. are transfusion guidelines evidence-based? jp aubuchon dartmouth-hitchcock medical center, lebanon, nh, usa application of the results of randomized, controlled clinical trials to similar clinical situations should increase the predictability of the outcomes of transfusions. unfortunately, too few such trials have been conducted to investigate all the potential situations where transfusion might be applied. however, the ones that have been reported indicate that, in general, transfusion is unlikely to provide substantial benefit in many of the situations where it is routinely used. in the intensive care setting, transfusing red cells at a trigger point of g/dl rather than g/dl not only did not lead to increased anemic morbidity but was actually associated with a reduction in overall mortality. subgroup analyses indicated transfusion at the higher trigger point did not decrease morbidity in patients with cardiac disease nor decrease the time until weaning from a ventilator. following cardiac surgery, a transfusion trigger of a hematocrit of % yielded the same outcomes as one of %. an observational study suggested that patients with peripheral vascular disease and a post-operative hematocrit below % were more likely to suffer a morbid cardiac event, but this group of patients had more evidence of anemia and cardiac ischemia preoperatively, illustrating the pitfalls of observational studies. most would agree that transfusion is necessary below a hb of g/dl and unlikely to be necessary at a hb above g/dl, but most patients fall between these limits, and there are insufficient data in the and residual confounding factors, and may permit them to make a judgment of a causal relationship. sackett proposed that the evidence generated from meta-analyses of individual patient data be regarded as being equivalent in strength to that generated from rcts. meta-analysis is the structured and systematic integration of information from different studies of a given problem. when the results of individual studies are discrepant, the purpose of an overview is to investigate reasons for disagreements among studies. when the results are concordant, the goal of meta-analysis is to derive, through application of a number of quantitative techniques, a measure of the effect of the intervention across combined investigations. this measure is referred to as the 'summary' effect of the treatment under study. meta-analysis differs from the traditional, narrative reviews of the literature, in that: ( ) all completed investigations of the efficacy of an intervention that meet specific, eligibility criteria are retrieved and included in the overview; ( ) the quality of retrieved studies is assessed systematically; ( ) the degree of agreement among studies is evaluated, both conceptually and based on statistical criteria, and the synthesis of the findings proceeds only if the variation in reported results is sufficiently modest to be attributed to chance; and ( ) quantitative methods are used to calculate the summary effect of the intervention and to test that effect for statistical significance. ed- - biology of stem cell mobilization th papayannopoulou university of washington, seattle, wa, usa at baseline hematopoiesis, the majority of developing hematopoietic cells (precursors, progenitors and stem cells) is actively retained in bone marrow (bm), whereas fully mature cells emigrate to peripheral circulation. a small number of stem/progenitor cells are also present in blood, serving presumed physiologic roles for the repopulation of remote damaged areas. however, in several hematopoietic perturbations, i.e. post irradiation, post chemotherapy or by using empiric treatments, a heightened emigration (mobilization) of progenitor/stem cells was noted over years ago. the introduction of g-csf as an efficient mobilizing agent not only had a major clinical impact, but has triggered a flurry of studies exploring the mechanisms of mobilization. from these studies, significant insight has been gained about the molecular pathways leading to mobilization, especially by studying the altered environment within bm post mobilization, and less so by studying cells mobilized in blood. several attractive scenarios have been proposed and their importance was further bolstered by studying genetic mouse models. a prominent role of the sdf- /cxcr pathway has been emphasized, either by down regulation of cxcr , changes in sdf- gradients, or by disruption of sdf- /cxcr signaling. whether this pathway is disrupted by a proteolytic mechanism prevailing within bm post g-csf or by other protease-independent mechanisms has not yet been settled. in addition to sdf- /cxcr , disruption of other pathways responsible for the retention of primitive cells in bm can lead to mobilization. for example, disengagement of the vla /vcam- pathway by anti-functional antibodies or its genetic deficiency in mice results in egress of stem/progenitor cells. mobilization is also seen following the use of other cytokines (i.e. kit-l, flt- l, il- ) or chemokines (i.e. il- , gro?), complement activation, etc., but the detailed mechanisms or the interdependence of these other pathways with the ones already proposed have not been worked out. finally, efforts to improve mobilization efficiency in man has led to the use of combination treatments with g-csf, either by adding another cytokine (i.e. growth hormone), agonistic sdf- molecules (i.e. ctce ), or cxcr antagonists (i.e. amd ) which have yielded synergistic increments, and these will be discussed. a full understanding of the principles of mobilization, as well as the bm homing characteristics of mobilized cells after their i.v. infusion in transplantation, should lead to targeted, more efficient experimental protocols in the future. the possibility of deriving all kinds of mature cell types from embryonic stem (es) cells for the purpose of cell replacement therapies will probably face a major obstacle; a limited supply of available hla types for an ever growing population in demand. one possible solution is to use adult sources of stem cells such as the haematopoietic stem cells (hsc) that can repopulate the entire haematopoietic system after transplantation in a myeloablated host. however cells with the repopulating ability of hscs are still elusive for tissues such as muscle, heart, cns and pancreas. it was therefore exciting news when it was shown that hscs could repopulate other non-haematopoietic tissues arguing for a general role of bmderived cells in tissue regeneration. the term plasticity was thus coined to describe the phenomenon whereby cells of one lineage could trans-differentiate into cells of another tissue. this in turn implied that a certain degree of developmental plasticity was still available in the adult hsc, or their derived progeny, that allowed them to present with novel phenotypes. how exactly this was accomplished was a matter of speculation. in order to address the mechanism we used an animal model of liver failure where bmt with normal (wild type, wt) hsc was shown to rescue the liver failure; the repopulating hepatocytes apparently differentiated from the sole source of wt cells, the bm compartment. by studying the genetic composition of the regenerating liver nodules we observed that both wt and mutant dna was present in the nodules, a finding that was consistent with bm-derived cells fusing with host hepatocytes. the mechanism of plasticity was therefore directly related to the exposure of the donor bm-derived wt nucleus to the transcriptional environment of the hepatocyte and the expression of hepatocyte-specific genes. this fusion mechanism was also shown to underlie perceived cases of haematopoietic cell transdifferentiation to purkinje cells in the cerebellum and to cardiomyocytes. however, there are carefully executed studies that strongly support the alternative transdifferentiation mechanism in tissues such as epithelia or the epidermis. what these observations may imply is that in tissues with high rates of cell turnover, there may be a potent stem cell niche that can reprogram incoming cells to follow relevant cell lineages. if this hypothesis is correct, then the major research effort should focus on what makes the niche and whether it can be recreated faithfully in vitro so as to educate hscs to diverse lineages opening the way for realistic cell replacement therapies. collection and distribution of blood and its products to meet the medical needs of industrialized countries are typically managed through large-scale national or nationally-supported blood programs. the development, maintenance, and ultimate success of such programs are all components of a process that involves the delicate balance of continuously competing pressures, e.g. social, economic, ethical, political, regulatory/legislative. as with all endeavors that directly affect human life, safety is a central, unifying theme of this process. because transactions of blood inherently involve risks at both donation and reception/transfusion ends, efforts to enhance and maintain an acceptable level of safety generally rely on a focused program of risk management (rm). rm involves three equally important elements: identification/evaluation of risk factors in a process, control of exposure to them, and continuous monitoring to assess the effectiveness of countermeasures and the emergence of new risk factors. specific approaches to rm and quality assurance in transfusion medicine will be presented. examples from blood programs currently in effect in selected countries will be discussed. rm efforts within the corresponding blood program in greece will then be examined. the lack of data to adequately assess the status of this program suggests that at least one of the elements of rm -monitoring -can still be improved. a preliminary research effort aims to survey blood donors, transfusion recipients, and physicians in order to build an understanding of the specific factors that drive the perception of risk in the greek population. the findings form important stepping points upon which specific recommendations can be made for the development and maintenance of a comprehensive, effective rm program in greece. ed- - the use of haemovigilance data to increase safety in transfusion medicine haemovigilance is a surveillance of all the procedures in the transfusion chain. the intension is to collect and assess information on unexpected or undesirable effects in bleeding of donors and transfusion of blood components. in europe haemovigilance was introduced as a concept in the middle of the nineties. the first national reports on haemovigilance appeared in the late nineties, and were only dealing with complications related to transfusion. later on other kind of events like 'near miss' events were added. nowadays national reports are dealing with all steps in the transfusion line, and to some extend also with complications in blood donors. the state of the art is haemovigilance with retrospective registration of unwanted events that has happened, but also a more active prospective part with an early warning in a rapid alert system about new threats in the transfusion world. the aim of the different national haemovigilance systems has been to improve safety in the transfusion line. after the first years with haemovigilance in the european countries, what has been the outcome of this big effort? data from national reports do not signify major improvements, but safety is suggested to have improved due to many minor changes of procedures and awareness of dangerous situations. however, in most countries nothing really effective has been done to avoid failures, the most important cause of serious complications in transfusion of patients. systems which can prevent most of the failures are on the market. the cost of these equals the cost of nat screening for virus introduced in the same period of time. the common perception of transfusion risks is still much more focused on the hypothetical risk of virus transmission than to the demonstrated magnitude of severe complications related to bleeding of donors and transfusion of patients. therefore, to increase safety in transfusion medicine the nature and occurrence of the risks should be revealed by haemovigilance and not less important the results should be published with the aim to get a realistic common perception of the transfusion risks. the role of diagnostic testing to identify congenital vs acquired disorders of hemostasis and to optimize the management of perioperative bleeding g despotis washington university school of medicine, st louis, mo, usa excessive bleeding with trauma or after surgery can result in hypoperfusion and anemia related end-organ dysfunction and mortality as well as transfusion-related complications. several large studies have demonstrated that if bleeding is excessive after cardiac surgery to the point that reexploration is required, that overall mortality increases by - fold. transfusion related complications include the following potentially lethal complications: disease transmission of pathogens, acute hemolytic reactions, allergic reactions, transfusion associated acute lung injury, allo-immunization related disease (e.g. post-transfusion purpura, platelet refractoriness, transfusion-associated graft-vs-host disease) and other potential complications (e.g. increased perioperative infection or multi-organ system failure) related to transfusion associated immune modulation. in addition, blood shortages related to increasing consumption (i.e. expanding geriatric population) and/or a shrinking supply (i.e. related to exclusion of donors related to donor exclusion criteria designed to prevent disease transmission) may limit our ability to adequately manage our anemic and bleeding patients. this highlights the relative importance of accurate diagnosis and optimal management of excessive bleeding to minimize bleeding related complications and conserve our blood supply. patients at risk for excessive bleeding include those with an established hereditary disorder (e.g. vwd, hemophilia, connective tissue disorders), end-stage hepatic or renal disease as well as patients with acquired defects of the hemostatic system. in specific, patients with platelet (i.e. platelet refractoriness) or coagulation factor inhibitors at increased risk, extracorporeal circulation related defects or as related to certain pharmacologic agents). patients who require longer periods of extracorporeal circulation for cardiac surgical procedures (e.g. repeat, combined procedures or use of deep hypothermic circulatory arrest) are at a greater risk of developing excessive bleeding (e.g. cpb-related abnormalities). in addition, patients receiving one or more longacting anti-thrombotic medications in the immediate preoperative period (e.g. plavix, reopro, low molecular weight heparin etc) are at increased risk for bleeding. clinicians in the past have resorted to empiric and 'shot gun' approaches when managing excessive bleeding due lack of immediate availability of results from laboratory-based coagulation tests. on this basis, the use of point-of-care (poc) tests of hemostatic function to facilitate the optimal management of excessive bleeding, help differentiate between microvascular vs surgical bleeding and reduce transfusion have been investigated. five of six recently published studies have demonstrated that implementation of a standardized approach to manage bleeding (e.g. algorithm) which when coupled with either point-ofcare or laboratory tests of hemostatic function can optimize the management of bleeding and reduce total donor exposures by %. ddavp has bee shown to be beneficial with uremia-induced platelet dysfunction and with type i von willbrand's disease. although previous studies have not been able to conclusively show that ddavp can reduce bleeding and transfusion when administered prophylactically, more recent evidence indicates that this agent may be useful in preventing excessive bleeding when a test (point-of-care) reveals platelet dysfunction. recombinant activated factor vii (rfviia) is licensed for use in bleeding episodes in hemophiliac patients with inhibitors. although, only anecdotal reports and results from small clinical studies have shown that this agent can reverse life-threatening bleeding after major surgery, other reports indicate that there is variability in the effectiveness of rfviia as well as highlight lifethreatening thrombotic complications in a subset of high risk patients (i.e. patients with congenital or acquired thrombotic disorders or systemic activation of the hemostatic system such as with dic or after cardiac surgery). therefore, large clinical trials evaluating the efficacy and safety of rfviia are needed before any widespread use can be recommended. in recent years, molecular methods of blood grouping have become routine diagnostic procedures in many laboratories throughout the world. they have proved especially valuable for the determination of fetal blood groups. the ability to detect rhd in pregnancies where the fetus is at risk from haemolytic disease of the newborn represents a significant advance in obstetric care. furthermore, the occurrence of fetal dna in the mothers' peripheral blood has allowed this diagnostic procedure to be carried out without the risks that accompany amniocentesis (lo ymd. ( ) ann med : - ). determination of the coding sequence of all the genes giving rise to antigens within the blood group systems currently recognised is virtually complete. by correlating the coding sequence of these genes with the phenotype of red cells from individuals with different blood groups it has been possible to infer the molecular bases of most of the antigens comprising each blood group system (daniels gl ( ) human blood groups, nd ed. blackwell science). the polymorphic antigens of most systems other than abo and rh, are defined by single nucleotide substitutions (snps) which effect a single amino acid sequence change in the gene product. numerous methods, both manual and automated, are available to determine snps and these have been applied to the determination of blood groups. useful applications of snps detection methods include, determination of the blood group phenotype of patients who have been transfused recently and still have donor blood in their circulation (rozman p, dove t, gassner c et al. ( ) transfusion : - ), and donor screening to find compatible units for patients with multiple blood group antibodies or for the management of patients with diseases like the haemoglobinopathies who are going to be transfusion-dependent over many years (castilho l, rios m, bianco c et al. ( ) transfusion : - ). other applications of molecular methods include zygosity determination for rhd, determination of the blood group phenotype of patients with a positive direct antiglobulin test, selection of donors with rare blood group phenotypes, and as aids to the solution of complex blood grouping problems in the reference laboratory. the molecular bases of abo and rh antigens are complex and cannot be determined reliably by a single snp. nevertheless, methodologies are available that allow the comprehensive sequence analysis of individual genes and could be applied to abo and rh typing. whether or not this will ever be a cost-effective procedure is a moot point. it is clear that molecular methods are a useful addition to the range of diagnostic procedures available to transfusion medicine practitioners but it is important to remember that methods based on dna analysis determine phenotype by inference and not by direct measurement. the results of molecular tests should be interpreted with this caveat in mind. ed- - the hla system g stavropoulos general hospital 'g. gennimatas', athens, greece since its discovery in the mouse in the major histocompatibility complex (mhc) has become one of the most important region in the vertebrate genome with respect to infection, autoimmunity and transplantation. mhc primary function is to provide protection against pathogens. this is achieved through sophisticated pathways in which mhc class i molecules present endogenous antiges to cd + t cells and class ii molecules present exogenous antigens to cd + t cells. an increasing number of other proteins are being found that support these two pathways; many of these proteins, together with the class iii complement proteins, also map to the mhc. the mhc molecules were originally studied for their ability to cxonfer tolerance (histocompatibility) following tissue grafts or later, organ transplants. nowadays, the success of unrelated hematopoetic cell transplantation is influenced by the degree of mhc compatibility between the donor and patient. thus, for patients who lack matched donors, the rules that govern permissibility of mhc mismatching still need to be identified. for patients with high risk disease who lack matched donors, use of donors with a single mhc mismatch may permit early treatment before disease progression. scientific evidence to fully answer the questions 'when are platelet components clinically effective' and 'what do we really know?' is limited. despite this limitation and the level of uncertainty it generates with regard to treatment options and policies, it is reassuring to note that current prophylactic platelet transfusion protocols -mostly derived from empirical observations collected during the 's and 's -protect oncology patients from clinically relevant bleeding in more than % of thrombocytopenic days spent in hospital or at home, even in aggressive conditions such as leukemia, lymphoma and other severe blood diseases. this evidence seems to justify the prevalent policy of transfusing platelets when the patient's platelet count falls below per microliter (or in 'unstable' patients). this policy is based on positive outcomes of prospective and retrospective studies performed during the 's including some hundred non-surgical patients and on the desire of balancing the will of reducing patient exposure to limited, expensive, potentially infectious and immunogenic blood products with the objective of preventing clinically relevant hemorrhage. several national and international organizations endorse the above policy. although the role of platelet support in surgery or in specific clinical situations requiring invasive procedures or in patients affected by multi-organ and system co-morbidity suffers from even more limited evidence, the latter has been carefully collected and summarized in the guidelines for platelet transfusion published in j clin oncol ; : - . additional data on lumbar puncture are reported in ann hematol ; : - . another important topic where there is room for improvement and need for further investigation is platelet refractoriness, a condition developed by a proportion of chronic platelet recipients, which causes high hemorrhage risk if compatible platelets are not provided and in which consensus on the diagnosis and treatment is lacking. with regard to the type of platelet product, it will be necessary to determine the clinical impact of buffy-coat derived platelets, consistently used in europe and current object of increased interest in canada, as compared to the platelet-rich plasma method traditionally used in the us, of viral inactivation procedures and of laboratory methods for detection of bacterial contamination of platelet concentrates. in addition, ongoing studies on the clinical impact of high versus low platelet doses will provide novel elements to determine the relative merits of apheresis versus whole-blood derived platelets. as far as the established procedure of white cell reduction by filtration, which shows high technical efficiency and has been implemented as a standard by a number of institutions, debate is still ongoing on its equivalence with serologic screening for the prevention of cmv transmission, whereas general consensus supports its pre-storage use to prevent febrile, non hemolytic transfusion reactions. finally, although the high cost of filters do not allow a generalized use of this technology in many settings, white cell reduced platelets have been unequivocally shown to reduce alloimmune refractoriness from about % to about % of patients. ed- - ffp: appraisal of the evidence for the clinical use of ffp although the indications for transfusion of plasma (fresh frozen plasma; ffp) are limited, the use of ffp continues to rise in the united kingdom and has risen by over % in the past few years. local uk audits continue to document that a significant proportion of ffp transfusions are not consistent with indications reported in guidelines. a systematic review of the evidence base for the effectiveness of ffp was therefore undertaken to identify, select and appraise all relevant randomised controlled trials, as the most robust form of study to assess effectiveness of ffp. in the systematic review of ffp, the criteria for inclusion of full-published studies were: there must have been at least two groups in the study; • allocation to the groups must have been either by formal randomisation or by a quasi random method e.g. alternation; • one of the arms of trial must include ffp or plasma as an intervention; results on the relevant clinical or laboratory outcome must be presented. the main analysis was qualitative, and differentiated between: . studies of interventions comparing ffp with no ffp; . studies of interventions comparing ffp with a non-blood product e.g. solutions of colloids and/or crystalloids; . studies of interventions comparing ffp with a different blood product; . studies comparing different formulations of ffp, e.g. solvent detergent and methodine blue treated. an evaluation of studies comparing ffp with no ffp would be expected to provide the clearest direct evidence for a positive effect of ffp. studies comparing ffp with colloids or crystalloids were separately appraised because these latter products may have variable effects on coagulation tests. studies comparing different formulations of ffp do not directly evaluate effectiveness of ffp but were included because there is now a uk national policy to use these products in younger patients and therefore these trials might identify negative outcomes. the search strategy identified a total publications. although it may appear that this number of randomised trials might provide a reasonable evidence base to help inform clinical policy and decision making, the review identified a number of important concerns about the published trials. few of the identified studies included details of the study methodology (method of randomisation, blinding of patients and study personnel). the sample size of many included studies was very small (range - patients per arm). few studies took adequate account of the extent to which adverse events might negate the clinical benefits of treatment with ffp. many of the identified trials in groups such as cardiac, neonatal, and other clinical conditions, evaluated a prophylactic transfusion strategy. however, when these trials evaluating prophylactic usage were assessed together as a single grouping in the review, it appeared there was no consistent support for a beneficial effect of prophylactic ffp, irrespective of clinical setting. there is a pressing need to develop new trials to determine the effectiveness of ffp, including for those clinical situations in which it has become an accepted part of current transfusion practice. a law decided upon by the riksdag (the swedish parliament) often sets the general standards as a framework and authorises the central government authority concerned to elaborate and decide upon the more detailed regulations. laws and regulations define the level of quality and safety that has to be reached and state what must be done, while establishments and their managers are kept responsible for fulfilling the requirements and how this is done. guidelines (non-binding) present detailed instructions on ways how to fulfil the requirements. making a law is complicated and time-consuming. the ministry draws up a legislative proposal, refers the proposal to relevant bodies for consideration and comments, and then drafts a bill which is referred to the council on legislation for consideration before it is submitted to the riksdag. a parliamentary committee deals with the bill before it is put to the chamber of the riksdag for approval. when adopted, the bill becomes law. regulations elaborated by central government authorities are handled in a principally similar way. however, regulations are more readily adjusted to scientific and technical progress, and when legislation need requirements for technical details, these are preferably presented in a regulation. the ministry of health and social affairs is responsible for elaborating the bill to be submitted to the riksdag on the blood safety law. two central government authorities, designated as competent authorities, are responsible for preparing the appropriate complimentary regulations as well as for inspecting and licensing the blood establishments: • the national board of health and welfare (nbhw), responsible for requirements related to blood components intended for transfusion, and • the medical product agency (mpa), responsible for requirements related to blood components intended for the manufacture of medicinal products. sweden became a member of the eu ten years ago. since then, experts in transfusion medicine have been appointed by the ministry, nbhw and mpa for advice on scientific and technical issues and for representing sweden at expert meetings arranged by the commission. some of these experts are also members of the handbook committee of the national society for transfusion medicine, preparing and revising the national guidelines. consequently, the requirements of the directives are readily implemented in the daily work of the blood establishments before (due to legal and technical reasons) the new blood safety law and the revised nbhw and mpa regulations can be promulgated. to a great extent, requirements of the blood directives are covered by existing swedish legislation. no major problems or obstacles seem to arise when implementing new requirements into law and regulations and into the blood establishments' daily service. a few detailed requirements have been found difficult to follow precisely in the routine work. these minor difficulties, however, will not compromise the high quality and safety of blood components prepared according to the standards set by the blood directives. the landscape for blood collection and distribution includes availability and safety. true international availability of blood has not been reached. the landscape of safety has been mountainous, if viewed by the degree of frustration among the transfusion specialists. the reasons for frustration have varied from serological problems to those of transmissible infections, to which no end is in sight. mistrust in the safety of blood taken by others is one reason for lack of international landscape in blood collection and distribution. increasing demands on safety, availability and economy force the health care providers to reorganise blood services. national systems are winning ground. this may make it easier to achieve international collaboration. the council of europe has pioneered in creation of international recommendations for blood collection and distribution. in a european agreement on the exchange of therapeutic substances of human origin, including human blood, was published. its purpose was to make blood available to other parties of the agreement in case of urgent need. many countries ratified the agreement rapidly, some did it first in the nineties. in practice little exchange of blood components has taken place. the council of europe recommendations lack legal power. the european union is different, and it has taken on its agenda activities aiming at improving confidence in the safety of the blood transfusion chain in the community (commission communication ) . the agenda is based on an agreement reached at a high level eu meeting in adare, ireland in . first in the commission agenda was a recommendation on donor selection criteria, given in . then came the european blood directive / /ec, the aim of which is to improve the safety of blood and blood components within the union so that enough mutual trust between member countries can be achieved to make the exchange of blood components possible. being a legally binding document the directive is undoubtedly helpful in reaching a harmonised standard in europe. hopefully the european commission has the resources to follow its implementation. there are concerns, however. the epidemiological differences among the eu member countries and frequent appearance of new infectious agents potentially transmitted by blood make it difficult to foresee that even effective viral inactivation of blood components could totally erase the national differences in donor approval. blood collection and preparation of components are already the same in eu member countries and the directive helps in their further standardisation. there has not been much distribution of blood components internationally, with the exception of export of red cell concentrates to the us from switzerland and the netherlands. the european legislation opens new horizons and widens the european landscape as its purpose is to simplify the crossing of borders between the member states, but before true movement of blood components is achieved more work is needed on the eu commission blood agenda. the eu directive implemented into the legal act for polish blood transfusion service blood transfusion service (bts) in poland is an integral part of the public polish health service. in the country of nearly million people, approximately one million units of blood and plasma are collected every year from voluntary, nonremunarated donors, which is statistically over donations per inhabitants. blood and plasma are collected in strictly appointed centers and no private collection sites are permitted. the legal basis for the activity of polish bts is polish blood transfusion act of nd august which came into force as of january st . this act was then updated in november according to eu directive / /ec and came into force as of january th . this act introduced the principles for organization, collection, processing, storage, transport and quality assurance in bts. it specified -among others -the system of accreditation, haemovigilence, as well as requirements for bts employees. according to this act the polish bts is obliged to monitor and supervise immunohematology testing and transfusion procedures in all hospitals where blood and blood products are transfused. polish bts consists of regional blood transfusion centers (rbtc), one military center and one ministry of internal affairs and administration center as well as the institute of hematology and blood transfusion (ihbt) which acts as supervisor. the rbtcs have a uniform organization structure, uniform quality assurance system and act according to uniform guidelines issued by ihbt. they have two financing sources -the central budget and hospital reimbursement for distributed blood and blood products. the polish blood transfusion act of nd august , in force since january st , has been supplemented by decrees: . procedures for external bts audits; . requirements for donor selection; . requirements and procedures for organization and safe management of blood transfusion in hospitals; . requirements for implementing of national and regional donor registers; . employment criteria for bts personnel; . training requirements for hospital personnel involved in blood and blood product administration; . national, uniform price list for blood and blood products; . organization requirements for setting up of a national committee for blood and blood transfusion. introduction: several technical aspects must be considered in pediatric apheresis due to the size of the patient. factors that must be evaluated are extracorporeal circuit volume, blood flow rates, type of anticoagulant and vascular access. adverse events are mainly related either to vascular access or to metabolic or hemodynamic changes. aim of the study: in this study we show our experience using fresenius hemocare com.tec for pbsc collection in children. methods: twelve pediatric patients (median age years, range - ; median weight kg, range . - . kg) with solid tumors at onset or on relapse underwent collections with the p y kit of the fresenius hemocare com.tec blood cell separator. our cd + cells target was ¥ e /kg. collections were started if a peak of at least . e /l cd + cells ( per microlitre) were reached in the peripheral blood. in all the patients, leukapheresis were performed through a central venous catheter and temporary peripheral venous access. acd ratio : - : was combined with heparin u/kg. in children with < kg the separator was initialized with a compatible filtered and irradiated red blood cell unit, suspended in % albumin, up to the patient's hematocrit, to avoid transient hypovolemia, due to the volume sequestered in the separator. results: twenty-five procedures were performed. a median blood volume of ml (range . - . ml) was processed in a separation time of min (range - min). the median product weight was g (range - g) and yield of cd + cells was . ¥ e /kg body weight (range . - . ¥ e /kg body weight). three poor mobilizing patients (peripheral blood cd + peak of - cells per microlitre) underwent more than two apheresis to collect the desired transplantation dose ( . and ). all collection procedures were well tolerated. children never required sedation to perform the leukapheresis. only mild hypocalcemia-related symptoms, promptly responding to small i.v. boluses of calcium gluconate, were reported. no circulatory side effects were observed. blood flow alarms occurred in every procedures but no collection had to be terminated due to insufficient flow. conclusion: in summary, leukapheresis in children can be safely and effectively performed with the fresenius hemocare com.tec separator with minimal technical difficulties even in patients under kg. m-pa- alternative methods for prevention of infection transmission (pathogen inactivation etc.), cost-benefit considerations of the procedure itself. however, one must also take the loss of plasma into consideration -and more difficult: calculate the effects of changes in product quality, as reduced content of factor viii, protein s and other labile proteins. for methods involving pooling, there are also concerns about the risks due to the pool sizes. the major benefit of the methods will be the potential reduction of infectious transmission, but also possible advantages as reduction of allergic transfusion reactions and trali must be evaluated. the study types involved in cost-benefit considerations are costeffectiveness analysis where the cost and effects of an intervention and an alternative are presented in a ratio of incremental cost to incremental effect and cost-utility analysis, where quality-adjusted life years (qaly) are used as the effectiveness endpoint. qualityadjusted life years is a method that assigns a preference weight to each health state and estimates life-expectancy as the sum of these products of each preference weight and time spent for each state. a complete glossary of terms is found at http://www.hsph.harvard.edu/cearegistry. in literature, there are several publications on cost-benefit considerations within the field of transfusion medicine. concerning plasma products, the costeffectiveness of solvent-detergent plasma has been the major focus. however, the conclusions of different authors have been conflicting. in , aubuchon and birkmeyer published a paper (jama ; ( ) : - ) where they concluded that the cost was usd per qaly, which is far above the 'acceptable limit' of usd . this estimate was adjusted to usd . mill. per qaly in a letter to jama (jackson, jama ). in , riedler et al. published (vox sang : - ) that the discounted cost/life year saved for sd-ffp use in the uk was gbp for neonates and gbp for patients aged . the main reason for the differences between the two papers (and others) was considered to be different calculation of non-infectious complications. the papers cited above underline the difficulties of the cost-benefit considerations. the age of the patient, the outcome of the treatment, the quality of life in an infected patient and the cost of side effects will differ. in addition, how much are we willing to pay for protection against emerging viruses? this paper will not provide the answers, but introduction: the photodynamic treatment of therapeutic plasma using methylene blue (mb) in combination with visible light is a well established procedure for the inactivation of blood borne viruses. aim of the study: evaluation of the quality and stability of mb/light-treated plasma (mb plasma) prepared under worst case conditions for routine processing. methods: single donor units (n = ) were treated using the macopharma theraflex mb-plasma system which includes plasma membrane filtration (plas ) and addition of mb prior to illumination followed by mb and photoproduct filtration (blueflex). samples were taken before treatment and from the final product. additionally mb-treated plasma was prepared from four different plasma pools and stored for up to months. treatment was done under worst case conditions for the preservation of coagulation factors: maximum mb concentration during illumination ( . mmol/l), maximum storage time of whole blood before separation ( °c, h), maximum storage time of mb plasma before freezing ( h). several plasma parameters and the concentration of mb and its photoproducts (azure a, azure b, azure c and thionine) were determined. results: mb/light treatment had a significant influence on thrombin time (+ . %), fibrinogen (clauss) (- . %), factor v (- . %), factor viii (- . %), factor xi (- . %) and protein c (- . %). no significant changes were detected for at iii, vwf : rco, vwf cleaving protease, plasmin inhibitor and alpha- -antitrypsin. the entire virus inactivation procedure including the filtration steps for leukocyte depletion and mb and photoproduct depletion had no significant effect on activation markers (prothrombin fragment + , thrombin-antithrombin-complex, d-dimers). no further essential loss of coagulation factor activity was observed during storage of the plasma at °c for months. mb and its photoproducts (azure a, azure b, azure c) were depleted to a final concentration of < . mmol/l. thionine was undetectable in all samples. conclusion: photodynamic treatment of fresh frozen plasma (ffp) using the theraflex mb-plasma system leads to only moderate decreases in the activities of different coagulation factors even under worst case conditions for routine production. mb and its photoproducts were effectively removed from the plasma by the blue-flex-filter integrated in the theraflex-system. the quality of mb plasma is well preserved during storage. pulmonary complications, particularly transfusion-related acute lung injury and circulatory overload, are the most common causes of transfusion-associated morbidity and mortality in the developed world. trali is a syndrome characterized by acute respiratory distress, hypoxemia, hypotension and pulmonary edema, occurring within hours (usually - hours) of transfusion of a plasmacontaining blood product. other signs, including hypertension, leucopenia and hypocomplementemia, are less frequent. all blood products, except for albumin and solvent/detergent plasma, have been associated with trali, but red blood cells, platelets and ffp are the most common. the incidence is unknown, but : plasma-containing transfusions is the most commonly cited figure. in % of patients, recovery is well underway within hours, and leads to complete resolution. death occurs in - %. the profile of the at-risk recipient has not been identified. recurrent cases have been infrequently described. there are two prevailing theories of pathogenesis: ( ) antibody-mediated and ( ) -hit hypothesis. evidence supports both concepts and neither is mutually exclusive. more than % of reported cases are associated with blood components containing either hla-specific (class i or ii) or hnaspecific antibodies. in % these antibodies correspond to at least one epitope in the recipient. most implicated components are donated by multiparous women. five percent of patients have hla or hna antibodies in their pre-transfusion serum. treatment requires prompt, assertive respiratory intervention, frequently necessitating mechanical ventilation. because trali has a much better prognosis than ards, it is an important diagnosis. some blood collectors are diverting plasma from multiparous donors away from ffp production or routinely screening for hla antibodies. the most effective method for identifying 'high risk' components has not been identified. introduction: trali is a life threatening adverse reaction of blood transfusion. it is characterized by noncardiogenic pulmonary edema developed soon after blood transfusion. in japan, we built hemovigilance system in and have been collecting the voluntary reports of severe adverse reactions of blood transfusion including trali cases since . since the diagnostic criteria of trali have not been established until recently and no specific diagnostic markers for trali have been discovered so far, it is very difficult to make proper diagnosis of trali in each reported case. we have been collecting the cases with respiratory distress and pulmonary edema developed after blood transfusion as suspected case of trali. we reevaluated each report whether it meet the recommended diagnostic criteria for trali published in transfusion journal in dec. . aim of the study: purpose of this study is to select trali cases which met internationally recognized criteria so that it will reveal the possible causes of trali with laboratory testing for anti-leukocyte antibodies in donors and recipients. methods: the cases with respiratory failure and pulmonary edema are selected for evaluation from the adverse reaction case reports voluntarily reported to japanese red cross. in order to make a proper diagnosis of trali, we have been utilizing the respiratory distress questionnaire which has recently revised. this helps us eliminate other adverse reactions such as circulatory overload, cardiac failure, anaphylaxis and bacterial contamination, which results in selecting out the internationally recognized trali cases properly. for laboratory testing, flowpra and labscreen for hla antibodies and gift-fcm for hna antibodies are performed. the cross-matching test is also performed if possible. results: during past years, cases of trali and cases of possible trali have been confirmed by critical review of each questionnaire. of cases of definite trali, donor specimens were obtained in cases. of cases, anti-leukocyte antibodies were detected in cases ( %) of donors' blood, which was significantly higher than the positive rate of anti-leukocyte antibodies in donors' blood of other adverse transfusion reactions (< %). of cases of antibody positive donors, anti hla antibodies were detected in cases, anti hna antibodies were detected in cases, and both were detected in cases. of cases of positive anti hla antibodies, class i antibodies were detected in cases, class ii antibodies were detected in cases, and both were detected in cases. on the other hand, the anti-leukocyte antibodies were detected in % of trali recipients, and this rate is almost the same with that of positive rate of other adverse reactions of blood transfusion ( %). these results indicate anti-leukocyte antibodies in the blood donors are one of the prerequisites for developing trali from the antibody-hypothesis-oriented point of view. other cases with no detectable antibodies should be investigated in more detail in the future. thus, reevaluating trali cases based on recommended trali criteria will allow us to reveal new information about trali. of adverse events analysed by the serious hazards of transfusion (shot) scheme ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , ( %) were haemolytic transfusion reactions (htrs). were due to incorrect blood component transfused (ibct): / were abo incompatible and / caused by other red cell antibodies. a further cases were reported as acute htrs (ahtrs; i.e. occurring within hours of transfusion) whilst were recognised more than hours after transfusion and reported as delayed htrs (dhtr). / ( %) patients died and suffered major morbidity. htrs associated with ibct result from clinical or laboratory errors and are all preventable. it has been assumed that other htrs are unavoidable. closer scrutiny reveals that this may not always be the case, though review is hampered by incomplete investigations. / ahtrs occurred in group a ( / ) or group b ( / ) patients given group o platelets. of the ahtrs related to red cell transfusion, were due to errors, were in patients with auto-antibodies, in only of whom alloantibodies had been adequately excluded/identified. at least / dhtrs were potentially avoidable; in cases the antibody was detectable retrospectively in the pre-transfusion sample; in cases the presence of a previous antibody was not communicated to the laboratory. two patient deaths related to dhtr might have been avoided by earlier diagnosis and clinical involvement. % htrs reported to shot would have been avoided by compliance with pretransfusion testing guidelines and provision of group a platelets for all group a recipients. htrs can be clinically overlooked and inadequately investigated. national guidelines are needed for the investigation and management of htr, with focus on the identification of underlying causes to guide the choice of future component therapy. reference laboratories can provide valuable support in elucidating complex serological problems. patients treated with high dose chemotherapy and autologous blood progenitor cell (bpc) support may get malignant cells reinfused together with stem cells. we analyzed bpc products collected from patients suffering from germ cell cancer measuring malignant contamination and followed these patients for up to months after transplantation also with the question if transplanted malignant cells influence survival. aliquots of stem cell apheresis products containing one million mononuclear cells were sedimented on glass slides and by immunocytochemistry quantitation of cytokeratin expressing cells was performed manually with light microscopy and by automated image analysis. in of patients ( %) cytokeratin expressing cells were detected in bpc apheresis products of patients treated for germ cell cancer. we followed the activity of the malignant disease of patients for more than eight years in median months after transplantation. no significant difference in survival was demonstrated for our two patient groups. background: the use of adequate number of peripheral blood stem cells (pbsc), collected by mnc apheresis is essential for effective treatment of hematological malignancies, solid tumors, and other disorders by transplantation. aims: the goals of this study were: (a) to obtain an effective apheretic protocol for mnc harvesting, and (b) to compare the hematopoietic reconstitution after hspc transplantations in different clinical settings. methods: in this study, pbsc transplantations - allogeneic from matched sibling healthy donors and autologous -were performed in the management of patients with severe aplastic anemia, leukemias (all, anll, cml), multiple myeloma, hodgkin's and non-hodgkin's lymphoma, breast and ovarial cancer, and extragonadal non-seminal germ cell tumor. pbsc mobilization was achieved with rhg-csf ( - g/kgbm/day). mnc-apheresis procedures (generally one and occasionally two) were performed using blood cell separator cobe-spectra. the first mnc-apheresis was accomplished when the leukocyte cont was - ¥ e /l (autologous setting) or on the th day - hour after the last rhg-csf administration (allogeneic setting). the processed blood volume during one mnc-apheresis was . - . l, and . l for one pbsc transplantation in average. results: using a minimal target dose of cd + cell count ( ¥ e /kgbm), performing one mnc-apheresis procedure for % recipients sufficient number of pbscs were obtained. the mnc yield was . ¥ e /kgbm in allogeneic and . ¥ e /kgbm in autologous setting in average. the mean cd + yields for allogeneic and autologous transplantations were . ¥ e /kgbm and . ¥ e /kgbm, respectively. hematopoietic reconstitution was achieved on the . th day for leukocytes and the . th day for platelets when pbsc transplantation was applied. summary/conclusion: improved mnc and cd + cell yield, as well as rapid hematopoietic reconstitution were observed when: (a) the intention of auditing any clinical practice is, ostensibly, to improve patient care. the term 'audit' implies comparison against a standard. although absolute indications for transfusion have not been defined by clinical trials applicable to most clinical situations, many institutions have established their own transfusion triggers based on their reading of the literature and common practice at that hospital. assuming these represent prudent guidelines, comparison of actual practice to them may allow physicians to re-assess their pattern of hemotherapy and bring it into conformance with the guideline. there are several common ways of performing transfusion audits. retrospective analysis of transfusions allows appreciation of the clinical situation (and its ultimate outcome) but reviews the event through a 'retrospectoscope' that assesses clinical information in a different manner than that available to the clinician making the decision to transfuse. furthermore, the time lapse between the decision to transfusion and feedback about that decision may render the feedback from the reviewing body (e.g., a transfusion committee or blood utilization review committee) of little practical import. to speed the provision of feedback and emphasize educational rather than any punitive outcomes of the audit, some facilities have abolished attempts at determining whether the decision to transfuse was supportable and have used electronic means to feed back to clinicians a non-judgmental informational message summarizing the literature regarding the indications for transfusion. this appears to be at least as effective as the traditional retrospective audit system. prospective review of requests for blood components have the potential to redirect practice in a manner that immediately helps patients. however, such interactions with clinicians may come at inopportune times, may require considerable (unscheduled) time, and are most likely to be fruitful if a knowledgeable transfusion medicine expert can serve as the intermediary. both approaches (or a combination) have been shown to be beneficial in altering practice, but efforts must be diligent and sustained. providing data comparing a physician's practice to colleagues in the same specialty may prompt additional introspection and practice change, particularly if physician leadership of the institution supports the effort as a quality improvement tool. extending the comparison to a group of physicians and contrasting their transfusion habits with benchmark data from other institutions may also be helpful, but one needs to be ready to counter arguments that differences in patient groups are the reason for the differences in practice (studies have shown that, in general, practice patterns are primarily related to training and habit rather than large differences in patient acuity). increased focus on the performance of hospitals as expressed in outcome data may soon extend to transfusion practices as well. the public or governmental institutions may ask to see data illustrating the transfusion practice of an institution and its improvement over time. carefully conducted, diligent, and ongoing transfusion audits are an integral part of an institution's quality improvement program. informed consent: the term informed consent, appeared for the first time in the late s but it was only in the s that it attracted attention with regard to health care. numerous discussions and publications have attempted to define the meaning and the justification of informed consent in recent years. initially it consisted in the obligation of the physician to disclose information to the patient, regarding the procedure he was to undergo, but more recently, ethicists have emphasized the need to ensure the patient's understanding and his autonomous decision to consent. current institutional rules of ethics demand that the physician must obtain the informed consent of a patient 'prior to any substantial intervention' . what is however the meaning of informed consent? is it a mutual decision making between physician and patient? in 'principles of biomedical ethics' beauchamp and childress claim that' it is critically important to distinguish informational exchanges through which patients elect medical interventions, from acts of approving and authorizing those interventions. the elements of consent include: disclosure, voluntariness, decision and authorization. when applying the concept of informed consent in transfusion medicine one can distinguish it into donors' and patients' consent. donor informed consent: information to blood donors constitutes a sensitive issue. it refers to their protection from side-effects of the donation, as well as to protection of the recipient. with regard to whole blood donors a detailed history and information as to side effects are necessary for first-time donors. for repeat donors one needs mainly an updated history. because of time-pressure, whole blood donors are usually given written information and are asked to answer written questions. donors however differ in literacy and even literate ones do not always understand medical terminilogy; so, during the interview one should probe the degree of understanding of each donor. with first time apheresis donors more time is needed in order to explain the procedure and potential side effects. since granulocyte and stem-cell donors require premedication with growth factors and or corticosteroids, the responsibility for detailed information is even greater. the fact that all donors sign the informed consent does not mean that they are all adequately informed! interviewers must be familiar with side effects, their frequency and sequelae and must pass on this information. misses and near-misses, (serious) adverse events and failures in medical practice seem to be not preventable. in medical interventions, preparing and prescribing of medication, assistance by doctors and nurses, medical treatment and follow-up, unwanted and unexpected events occur (http://www.mederrors.com.). these events happen also in transfusion medicine and focus on safety is not unique. haemovigilance which is defined in the eu blood directive as 'a set of organised surveillance procedures relating to serious adverse or unexpected events or reactions in donors or recipients, and the epidemiological follow-up of donors' (eu directive / /ec off. j. european union. . . :l / -l / ) is established to help in trying to identify and minimise the misses and (serious) adverse events in the chain from donor to recipient of blood components. the causes or reasons should be studied in order to prevent re-occurrence. adverse event reporting in blood transfusion and transfusion medicine is complex. it depends on the cooperation between blood establishments with clinicians and hospitals. it implies knowledge of blood banking, transfusion medicine and routine clinical care of all gender and ages, of potential hazards of transfusion, of immune-haematology, of microbiology, and of epidemiology. an adverse event may have its cause in every single part of the blood chain and reference may take place to a proven problem, a potential problem, or to a justified doubt. in almost all blood transfusion centres, a single donation will be processed into a number of different products, and these units might be divided or processed into more products. blood components are produced from whole blood or apheresis donations, and depending of the blood drawing and processing techniques, a high number of products with different specifications is prepared. the products' shelf life is not equal and therefore the moment in time of actual use of each unit prepared from the same donation may differ. in case the unit of platelets harms the recipient, a rapid alert can warn in order not to issue or to transfuse the unit of red cells or the unit of ffp prepared from the same donation because of the potential adverse reaction, which was detected during or after the transfusion of the first unit used. haemovigilance is not only important to blood establishments and to patients and prescribers, but it is also to clinical scientists, and to the public at large. it should provide a basis for minimising adverse reactions on blood components, and it should enable the therapeutic potential of new or established treatments with components to be maximised, since demonstrations of safety during widespread use may lead to extended usage, and wider availability. it is quite worrisome that underreporting is a general problem in medical care. it might be expected that in transfusion medicine the same rates of underreporting can be found, but also that the same mechanisms for improvement are applicable. although medical misses occur and do not seem to be preventable, the handling of these misses is often quite poor. many patients like to hear a detailed explanation, and the majority expects even apologies from the treating physician. it seems desirable to look for new routes in the prevention of unwanted events of transfusion medicine. for problem solving, analysis and improvement of working methods, where needed and possible, are often the most effective methods. attention should be focused on improvement and not on identification of the person who caused the problem ('bad apple'). lack of communication and insufficient insight in each other work are often the causes of problems and unwanted events. it should be recognised that advices given by the haemovigilance officer or the blood transfusion committee about prevention without the input and commitment of the direct responsible persons will lead in most cases to advices which are not effective or which will not be accepted. setting up a haemovigilance system or appointing of haemovigilance officers or installation of blood transfusion committees will not be sufficient. it will be necessary to develop ways of registration, data collection and analysis, but more importantly to support by giving advice and training to prevent reoccurrence of the adverse events or not optimal use of blood components. the confidentiality of the information should be guarded sufficiently. for a physician-patient relation, even after a medical failure, a 'blame-free culture' with a central role for openness and transparency is necessary. for blood establishments and hospitals, there is an important role in the right assistance and help of the physicians concerned both on a practical and on an emotional way. m-pa- years of shot data - : a view of transfusion safety in the uk and reactions. this will require investment in infrastructure, for which there must be a trade-off in improved transfusion safety. transfusion-transmitted infections and serious immunological reactions are rare; shot has highlighted the need for blood services to implement strategies to minimise bacterial contamination and transfusion related acute lung injury and will monitor their effectiveness. from the inception of shot it has been clear that the most frequent transfusion hazard is 'incorrect blood component transfused' i.e. a patient receiving a blood component intended for another person or not meeting appropriate requirements. only a minority of these events results in patient harm and is reportable under the terms of the directive. haemovigilance schemes such as shot, that analyse no-harm errors and near-misses, can reveal clues as to the root causes of 'wrong blood', which contributed to deaths and cases of major morbidity in the uk between and . analysis of such events shows that most errors occur in clinical areas, the most frequent being failure of the 'bedside check' . clinical audit data indicates that % of patients are transfused without a wristband or other form of identification, whilst anecdotal reports suggest that urgent clinical situations, massive transfusions and nocturnal transfusions are particularly error-prone. strategies aimed at reducing errors include structured education and competency testing, and methodologies, both high and low-tech, to ensure accurate patient identification in all circumstances. onethird of errors occurs in hospital laboratories; denominator data on laboratory workload shows that work done outside of 'core hours' accounts for % of all pre-transfusion testing but % of errors, suggesting that biomedical scientists 'on-call' or on shift work are working under pressure and beyond their competency. % of hospitals reported that they participated in shot in , but only % of eligible hospitals reported adverse events suggesting that transfusion hazards remain under-recognised and under-reported. however, benchmarking of 'wrong blood' incidents against transfusion activity shows that the number of observed incidents is roughly proportional to blood use. if haemovigilance data is to contribute to improved transfusion safety, clinicians must be encour-aged to report all events, thus contributing to an evidence base that can be used to effect change and facilitate learning. barriers to reporting include cumbersome systems, lack of time and resource, lack of feedback and fear of blame. transfusion practitioners have a vital role in the recognition and reporting of adverse events, education and clinical audit, but must be adequately resourced and supported by senior clinicians and managers through an active hospital transfusion committee. *provisional. m-pa- passing the borders: when, how and where d pirc-tiljak croatian institute of transfusion med., zagreb, croatia there may come that moment in professional life when you have to follow a strong professional and ethical need and confront your evidence-based statements with the leadership, passing the border of your own small society. in order to protect patient's health and respect human right to be informed about all possible consequences of irregular medical therapy, insisting on professional dignity and truth, you feel responsible and follow-up processing of your serious error report. once you pass the border, trying to warn authorities and find ethical resonance and critical confirmation of your professional fears, you are 'persona non grata' . methods/results: reality checking, personal experiences and observations studying the path of serious error report. although the qc system functions, yet omissions happen . . . the possible reasons could be: lack of knowledge, lack of experience, lack of independency, personal confront of interest, immature leadership, political influence, even corruption . . . how strict do the authorities manage a fault, bearing in mind the responsibility toward the patients under the risk. there is a need to create an available, effective international expert's board which will react and give professional counselling support-asylum for endangered professionals who found enough power to blow the whistle. who will hear it? transfusion transmitted infections (tti) are a major source of concern given the repercussions of hiv, hepatitis c, bacteria and vcjd transmission by blood components. large amounts of resource have been expended in making products safer and in maintaining public confidence in the blood supply. identifying emerging infections of concern is a major activity for many transfusion services. of the long list of emerging infections identified by disease control agencies around the world, identifying those responsible for tti requires, amongst other things, that: • the agent is identifiable. • it is present in blood • it causes a disease of concern. • it is transmitted by transfusion. • it is present at relatively low frequency. • if a test is available (nat, serology or immunoassay) what the infection window period is. once an agent has been identified various approaches are possible, including: • donor selection by testing, geography or lifestyle e.g. wnv; • product selection e.g. erythrovirus (b ) antibody or bacterial testing; • product treatment e.g. pathogen inactivation; • patient selection e.g. cmv matching, immune status. against this background where should our attentions focus? some agents of initial concern are now known to be ubiquitous and have minimal disease association (ttv, gbv) although transmitted by transfusion. for others (coronavirus -sars or the possible kawasaki disease agent, dengue, flavivirus encephalopathies, avian flu, etc.) this is less certain, with agents arising from species crossover being of particular concern (avian flu, vcjd, hiv). • enhancement of automation/computerisation; • process control to provide an 'error-free pathway'; • (national) surveillance and trend analysis of results, preferably based on national working standards; • significantly increased sensitivity, especially from development of antigen/antibody 'combi' assays (e.g. for hiv, and recently, for hcv); • awareness of hbsag vaccine-escape mutants and design of assays to cope with this; • extension of range of agents and markers tested for (varies in different countries); • increasing range of assays available for testing donors with a relevant history of exposure to malaria or chagas' disease infection (for retrieval of otherwise wasted blood); • european union's in vitro diagnostics directive: this has caused some problems and reduced flexibility. nucleic acid testing (nat): nat continues to increase in blood service usage world wide, although not (as yet) to replace serological methods. trends include: • reduction in sample pool size; • increased automation (and process control); • increased multiplexing to detect or more agents in the same assay; • increased number of agents being tested by nat (varies in different countries); • introduction of rapid and flexible nat to detect west nile virus, in north america. bacterial screening of platelet preparations: several countries have introduced (or will introduce) routine screening of platelet concentrates either with biomerieux, bactalert or pall ebds ( depletion assessment). other bacterial testing methods are under active assessment, some rapid enough for possible 'point of use' testing. m-pa- evaluation of in vivo red blood cell recovery after processing with a new filter designed to reduce prions e nelson*, h taylor † , p whitley † and t lieu* *pall medical, covina, ca, † american red cross and evms, norfolk, va, usa background: a filter, called the leukotrap affinity prion reduction filter (prf b filter, pall medical), has been developed to reduce the level of infectious prions, associated with several fatal neurodegenerative diseases including variant creuztfeldt-jakob disease (vcjd), from leukocyte-reduced red cell products. aim: the objective of this study was to evaluate the quality of leukocyte-reduced red cells (lr-rbc) processed through this filter and stored for days. red cell quality was determined by measuring the in vivo red blood cell recovery hours after re-infusion of the -day stored red cells. storage hemolysis and atp were also determined. methods: units of blood ( ml) were collected from normal volunteers into the leukotrap wb system containing cp d/as- anticoagulant/preservative solutions (pall medical). units were either processed to lr-rbc within hours at room temperature (rt units), or after hours at - °c (cold units). the prion filter set was sterilely connected to the units on day , and the units were filtered and stored for days. samples were taken pre-and post-prion filtration and post-storage for plasma hemoglobin and atp determinations. post-storage samples were taken for labeling with -cr radioisotope, re-infusion, and determination of the -hour in vivo rbc recovery. a donor sample was also labeled with m-tc to allow for red cell mass determination. thus, both single-and double-label -hour recovery values were calculated. results: twelve units were collected. in vitro testing was completed on all units. in vivo testing was completed on units. the mean single-label -hour recoveries were . % and . % for the rt and cold units, respectively. the mean double-label recoveries were . % and . % for the rt and cold units, respectively. the overall combined mean in vivo and in vitro results are shown in the table. conclusion: the -hour in vivo red cell recovery means are well above the fda and council of europe's requirement of achieving a mean post-transfusion survival of no less than % of the transfused red cells, and they are comparable to this center's previous results of red cells filtered using the licensed leukotrap rc system with cp d/as- (pall medical introduction: to reduce the risk of platelet transfusion-associated sepsis (tas), methods to routinely screen for bacterial contamination have been implemented. pathogen inactivation treatment of labile blood components provides an alternative means to prevent tas. the intercept blood system for platelets (baxter healthcare) has received the ce mark and has been introduced into clinical practice. aims: this study compared the efficacy of bacterial screening using a culture method (bact/alert system, biomerieux) with pathogen inactivation (intercept blood system) for prevention of transfusion of platelet components contaminated with bacteria. methods: seven strains of bacteria associated with tas, including gram-positive staphylococcus epidermidis, streptococcus agalactiae, and staphylococcus aureus, gram-negative escherichia coli, and klebsiella pneumoniae, and the anaerobes propionibacterium acnes and clostridium perfringens were studied. for each strain, three double-dose platelet concentrates (~ ¥ e platelets in ml of % plasma and % intersol) were collected using the amicus® cell separator. on day of collection, calibrated stocks of bacteria ( , , cfu) were added to the double units. each double unit was divided into two identical products containing , , or cfu of bacteria and stored overnight under conventional blood bank conditions. the control platelet concentrate was not treated. the test platelet concentrate was treated with the intercept process ( mm amotosalen + j/sq cm uva). both units were cultured using the bact/alert system at the time of bacterial inoculation and on days , and of storage. samples ( ml) were taken for both the aerobic and anaerobic cultures. a platelet sample was considered contaminated with bacteria if a positive signal was registered within hours of culture. results: for control platelet concentrates, cultures failed to detect low-dose inocula. the time to positive culture varied with the bacterial strain, contamination level, and time of sampling. at and cfu per product, strains (s. epidermidis, e. coli, c. perfringens, s. agalactiae) and strains (e. coli, c. perfringens) tested negative after days of platelet storage, respectively. k. pneumoniae tested positive after - hours of culture when sampled on day of platelet storage for both and cfu per product. at cfu per product, p. acnes tested negative in aerobic culture and c perfringens tested negative in anaerobic culture after days of platelet storage. the anaerobic cultures of p. acnes became positive after hours of culture when sampled on day of platelet storage. of the strains studied, only s. aureus consistently tested positive after - hours of culture. in contrast, all test platelet concentrates treated with intercept remained negative by bact/alert cultures throughout the entire -day observation period regardless of the strain and the contamination level. conclusions: bacterial detection using cultures may fail to detect low levels of bacteria typically associated with platelet contamination at time of collection and processing. failure to detect bacteria will result in the release of contaminated platelet products with 'test negative-to-date' status. in contrast, inactivation of bacteria is capable of preventing release of contaminated platelet components. background: since nat implementation for hiv- and hcv rna in france, the residual risk (rr) of transfusion-transmitted infections (tti) has dramatically decreased. the rr estimates, for a threeyear period from to showed a significant decrease from / and / before nat implementation to / and / after nat implementation for hiv and hcv respectively. as for hbv, the serological screening is only based on both hbsag and anti-hbc assays. for the same period, the rr estimate for hbv is / , five times higher than hiv one and times higher than hcv one. aims: as the overall rr of tti is mainly related to hbv, and given the availability of hbv nat assays, a study was conducted to determine whether hbv nat has the ability to further reduce the hbv rr and then should be implemented in blood donor screening in france. we have estimated the wp reduction by nat in comparison with one of the most sensitive hbsag screening assays, on commercial seroconversion panels (bioclinical partners, franklin, ma, usa). the nat test was the procleix ultrio assay (genprobe/chiron, san diego, usa). the hbs ag test was the prism hbsag (abbott, france). the comparison was performed on both neat samples and diluted samples / , / , and / , in order to simulate minipools of different sizes. then, we have calculated the yield of hbv-infected donations detected by nat relative to prism hbsag assay. results: on the basis of a window period (wp) of days, ultrio assay is projected to close the wp by an average of days on undiluted samples, days in minipools of samples, days in minipools of samples and only days in minipools of samples. the projected yield calculated on the basis of . million donations collected per year in france, would be . unit per year for minipool-nat and to units per year for individual donation nat. conclusion: introduction of minipool-nat will offer only a little added benefit to transfusion safety relative to current serological screening strategies based on both hbsag and anti-hbc assays. hbv minipool-nat is then unsuitable for hbv screening in french blood donors. single-sample nat or minipool-nat with smaller pool sizes and/or modified procedures (genome enrichment or test improvement) would be more relevant. automation when technologically and practically feasible is a prerequisite for single-donation nat. therefore, decision has been made not to implement hbv nat in the french transfusion network until fully automated systems will be available. however, as the prevalence of hbv infections is higher in the overseas territories than in continental france, and as nat is performed on individual donations in these sites, hbv-nat has been implemented since december in these territories. combined detection of hepatitis c virus core antigen and antibody as an alternative to nucleic acid testing in blood screening grating the capillary cytometer with a robotic workstation and a small footprint centrifuge. significantly, there was no decrement in system performance following automation: of clinical samples ( . %) typed identically with this system and cat, and of the discrepant results were eventually resolved in favor of the automated cytometry method. testing showed high-throughput capabilities (currently samples/day) and was inexpensive. to demonstrate the flexibility of this testing platform, we also developed a method to perform completely automated counting of residual wbcs (rwbc) following leukoreduction of blood components. there were no significant differences in accuracy and precision when rwbc in analytical controls and authentic clinical samples were quantitated by the automated capillary cytometry method or the leucocount method performed manually. given the flexibility of this system, it is very likely that additional blood bank assays could be modified for high performance automated testing on this platform. noninvasive prenatal genotyping on cell free fetal dna in maternal plasma ce van der schoot sanquin research, amsterdam, netherlands in lo et al. demonstrated that in the maternal circulation small amounts of cell free fetal dna are present, concentrations ranging from on average genome equivalents(geq)/ml early in pregnancy to about geq/ml at the end of pregnancy. most likely this dna is derived fom apoptotic syncitiorophoblasts. the human placenta is hemichorial, which means that the syncitiotrophoblast is in direct contact with the maternal blood flow, and apoptotic nuclei are directly released into the maternal circulation. the cell free dna is very rapidly cleared from the circulation, the t / being only minutes. in we have shown that this cell free fetal dna could be used for rhd genotyping. in the last years many groups have shown the successful application of different prenatal genotyping assays such as fetal sexing, thalassemia, achondroplasia, duchenne's disease, adrenogenital syndrome etc. on this source of dna. importantly, no false positive result have been described due to the presence of fetal dna from previous pregnancies, the main draw back of prenatal diagnostics on circulating fetal cells. at present prenatal rhd genotyping has been introduced in routine diagnostics in the united kingdom, france and the netherlands. in large scale high throughput studies it has been shown that the diagnostic accuracy of prenatal rhd genotyping is over %, and it is to be expected that in the netherlands this screening will soon be introduced to restrict the antenatal anti-d immunoprophylaxis to women carrying rhd-positive fetuses. in a large european project (safe, co-ordinator maj hulten, warwick uk) many researchers collaborate to further explore the possibilities of cell free fetal dna for future diagnostics. standard operating procedures for the isolation of plasma dna have been established. control pcrs for the presence of fetal dna have been developed. recent findings on differences in methylation status of placental genes in fetal dna opens new possibilities. the main technical problem that hampers wide application of prenatal genotyping is the impurity of the fetal dna, only - % of the cell free dna in plasma is from fetal origin. this makes diagnostic assays on numerical chromosomal abnormalities impossible. and also for many single nucleotide polymorphisms (snps) such as almost all blood group antigens, assays are hampered by aspecific amplification from maternal dna. our own preliminary results indicate that this latter problem can be solved by pna clamping. the addition of a pna probe specific for the k-allele partial d feature d antigen alteration, often identified as distinct 'partial' d epitope loss. the clinical impact of partial ds is due to the ability of their carriers to form anti-d antibodies upon confrontation with regular d after transfusion, or pregnancy. this leads to the -naively spoken -contradictory finding of an allo anti-d antibody in a d positive individual in connection with a negative autocontrol. the antibodies themselves include the same fatal clinical potential as anti-d antibodies of d negative individuals, but may be even more hazardous since unexpected in d positive individuals a priori. d categories (ii to vii) represent a nomenclatorily defined subgroup of partial ds. the molecular cause of partial d lies within single (caused by point mutation in the respective rhd gene sequence), or multiple amino acid exchanges (caused by gene conversion events leading to rhd-rhce-rhd hybrid genes) which determines a qualitative d antigen alteration, rendering them distinguishable from regular d by a partial d carriers immune system. nowadays, transfusion specialists and gynaecologists are more or less aware of these facts and are taking them into consideration in the clinical setting. most partial d exhibit decreased d antigen density, enabling principal recognition of them. however, routine serological methods may not properly recognise all partial ds and will identify their carriers after immunisation only, which represents a reactive diagnostic/therapeutic attitude second best to an actively prognostic one. this actively prognostic proceeding with respect to early detection of partial ds became widely feasible by rhd dna typing techniques. currently, routine rhd dna typing techniques offer an affordable, accurate and fast approach to an unambiguous identification of partial ds and their reliable discrimination from weak d types, not at risk for allo anti-d immunisation. a reasonable proactive proceeding could e.g. demand for (once in a lifetime) routine rhd dna typing of all weakly expressed ds as defined by serology, since most partial ds also meet this phenotype. rhd allele frequencies and their geographical and regional prevalence will certainly have an important impact on dna typing strategies and their (mandatory) specificities. fluorescence cytometry for completely automated immunohematology testing d roback*, b barclay † and d hillyer † *emory university school of medicine, atlanta, † transfusion & transplantation technologi, decatur, ga, usa we previously described a methodology for accurate immunohematology testing by fluorescence cytometry [roback, j.d. et al. ( ) transfusion ( ), ]. this system utilized low-speed centrifugation of -well filter plates for red cell staining, and a smallfootprint capillary cytometer for data acquisition. when authentic clinical samples from hospitalized patients were tested for abo group, the presence of d antigen, and red cell alloantibodies, the results were well-correlated with those obtained by commerciallyavailable column agglutination technology (cat). this system determined the correct abo group and d type for . % of samples, compared to . % for cat (p > . ). when samples were tested for unexpected alloantibodies, fc determined the correct result for . % of samples, as compared to . % for cat (p > . ). this novel method was better than cat at detecting weak anti-a (p < . ) and alloantibodies. based on these promising results, we sought to completely automate this method by inte-prevents the aspecific amplification of the k-allele, and makes it possible to detect the fetal k-allele in the presence of excess of maternal k-alleles. furthermore, it has been shown that fetal dna is in the plasma present in shorter fragments (< bp) than maternal dna. size separation of cell free fetal dna can therefore be used to increase the relative concentration of fetal dna, which will help the development of new genotyping assays. in conclusion, cell free fetal dna in maternal plasma is nowadays routinely used for prenatal rhd typing and fetal sexing. new technical developments will make it possible to extend these indications to other blood group antigens in the near future. more insight in the characteristics of fetal dna might finally lead to wider applications, including numerical chromosomal aberrations. furthermore, it might become possible to apply genomic dna microarrays for the screening on many different inherited diseases, including hemoglobinopathies. determination of the affinity of anti-d present in the serum of immunized subjects and in anti-d ig preparations by a method using unlabeled antibodies p lambin*, m debbia* and y brossard † *institut national de la transfusion, † chp hopital saint antoine, paris, france introduction: few data are available concerning the affinity of maternal anti-d responsible for the hemolytic disease of the fetus and the newborn (hdn), and the affinity of anti-d immunoglobulin used for the prophylaxis of that disease. we recently described a method to measure the affinity (ka) of untagged anti-d monoclonal antibodies. aims of the study: in this work, a similar method was applied to determine the affinity constant (ka) of polyclonal anti-d present in the serum from d-immunized mothers and donors and from anti-d ig preparations. methods: a constant amount of o r r rbcs was sensitized with increasing concentrations of anti-d present in the sera from immunized subjects, and in anti-d ig preparations. at equilibrium, the amount of anti-d bound to rbcs was measured by elisa. the scatchard equation (linear regression) and the langmuir equation (hyperbolic regression) were used to determine the ka of anti-d. the experimental data fitted well with the scatchard equation (mean r † = . ) but a better correlation was observed with the langmuir equation (mean r † = . ). in maternal sera, the mean ka of anti-d was . ¥ to the m- (from . to ¥ to the m- ). in the sera from immunized donors, the mean ka was . ¥ to the m- (from . to . ¥ to the m- ) and in lots of anti-d ig, the mean ka was . ¥ to the m- (from . to . ¥ to the m- ). the comparison of anti-d affinity measured in cases of hdn in which infants presented a fetal anemia and in cases of hdn in which infants presented only a postnatal anemia showed no significant difference. the mean value of ka in the cases of fetal anemia was . ¥ to the m- whereas in the cases of postnatal anemia the mean value of ka was . ¥ to the m- . conclusion: the method previously described for monoclonal anti-d was applied to polyclonal anti-d present in the serum of d-immunized subjects and in ig preparations. the experimental data fitted well with the langmuir equation, and the affinity of polyclonal of anti-d was measured with accuracy. in addition, no significant difference was observed (at least in the cases of this study) between the affinities of anti-d measured in the most severe cases of hdn (fetal anemia) and in the less severe cases of hdn (post-natal anemia). introduction: cryopreservation of platelets is widely used in platelet immunology to ensure the availability of well characterised panel cells for the detection of hpa antibodies. but recovered platelets do not express the hpa- alloantigens. aim of the study: here we describe a method for the successful preservation of platelets by lyophilization. we report the value of this new reagent for the detection of hpa alloantibodies and especially anti hpa- alloantibodies. methods: rehydrated lyophilised platelets (lyo p) were tested for their reactivity with monoclonal antibodies against gpiibiiia, gpibix, gpiaiia and cd by flow cytometry. the levels of reactivity were comparable with the ones obtained with fresh platelets. the rehydrated platelets were used in the maipa with a panel of hpa antibodies (anti-hpa- a, ; anti-hpa- b, ; anti-hpa- a, ; anti-hpa- a, ; anti-hpa- b, ; anti-hpa- a, and anti-hpa- b, ). results: all hpa antibodies showed the expected pattern of reactivity and in several cases absorbance reading were well above those obtained with fresh platelets. absorbance values produced by inert sera were comparable with those obtained with fresh platelets (ranges . - . ). interestingly, we used lyophilized platelet with a high expression of cd bearing the hpa- system and we have detected anti hpa antibodies among sera previously negative with fresh platelets. nineteen sera concerned patients suffering from hematological diseases and from pregnancy women. conclusion: lyophilized platelets are possibly an ideal reagent for the platelet immunologist to be used for the detection of hpa antibodies. moreover, this work bring new insights on the hpa- system in platelet transfusion. we are now pursuing more extensive validation studies with a larger number of samples representing all known hpa specificities and several diseases. the diagnosis and treatment of sick infants and children requires a broad knowledge of physiology, biochemistry, genetics and the application of sophisticated testing and treatment options. one of these options is transfusion of blood and blood products. transfusion of the infant, especially the premature infant, and sick child, especially those with major organ dysfunction, requires careful consideration of their unique metabolic, hepatic and renal clearance mechanisms. guidelines that direct the indications for transfusion differ from those in adults. non-invasive measures of oxygen delivery and oxygen offloading may assist in guidelines for red blood transfusion. metabolic complications from massive transfusion and/or the manipulation of blood products must also be considered. evidence from a high quality randomised controlled trial suggests that anaemia is also well tolerated by critically ill patients. a restrictive approach to rbc transfusion that maintained the hb concentration between and g/l was found to be as effective as and possibly superior to a more liberal strategy of maintaining the hb concentration between and g/l. there are concerns that some groups of critically ill patients, such as those with cardiovascular disease and patients who are difficult to wean from mechanical ventilation, may benefit from higher hb levels. rbcs also have a role in primary haemostasis and higher triggers may be appropriate in coagulopathic patients. it is important to realise that blood is not a uniform product and the clinical efficacy of rbc transfusion may vary. one factor that may have a considerable effect on the quality of the rbc product is the storage time. rbcs undergo marked changes during refrigerated storage. the implications of these changes on tissue oxygenation are not known but these concerns have led some clinicians to request 'fresh' blood for critically ill patients. there is insufficient evidence to support such practice. it is of great practical importance to determine if, or when, fresh rbcs could be superior to stored rbcs. background: with a decreasing blood donor base, fully tested, fresh unrefrigerated whole blood (fuwb) has been found to be a more efficient and effective use of a limited resource in place of, or as an adjunct to, traditional blood component therapy in surgical situations associated with massive blood loss. aims: to outline the use of fuwb in situations where there is potential for intractable bleeding associated with major surgery, and evaluate platelet function in fuwb versus platelet components. methods: outcomes of fuwb and traditional blood component use were examined for cases of cardiac bypass surgery. in addition, exclusive use of fuwb for burns debridement cases was analysed. an evaluation of platelet function in whole blood compared to platelet components was also performed by measuring platelet aggregation and activation parameters. results: there was a decreased requirement for blood components following administration of whole blood post cardiac surgery. whole blood usage for burns debridement surgery eliminated the requirement for additional blood components. platelet activation was markedly reduced in whole blood compared to component platelets, and this may be one reason for the increased efficacy of whole blood in these clinical settings. conclusion: fuwb appears to have a role in minimising blood product requirements and consequent donor exposure in situations associated with massive blood loss. m-pa- transfusion practice for coronary artery bypass surgery in greece s lakoumenta, m vassili, g hatzidimitriou, t asteri, p stratigi, s kanellas and g palatianos hellenic society of blood transfusion, athens, greece cardiac surgery is associated with a demand for allogenic blood and blood product availability as well as a considerable consumption. the impact of consensus guidelines for allogenic blood transfusion during coronary artery bypass graft surgery (cabg) in us attracted great attention . the present study is conducted in order to reveal the transfusion practice in greece on a similar population i.e. patients undergoing cabg operations. methods: five participating centers collected data concerning transfusion of allogenic blood and blood products in patients undergoing elective first time cabg procedures, as well as parameters that may influence blood loss, such as duration of the operation, cardiopulmonary bypass time (cpb) etc. the total estimated blood loss was calculated as the sum of red blood cell volume reduction [(body weight in kg ¥ ml/kg) ¥ (admission haematocrit-discharge haematocrit)]+(red blood cell volume transfused). results: results are shown in table : means, standard deviations, and p-values of the wilcoxon test comparisons between the hospitals. a preliminary analysis of data from centres ( patients) showed no difference in patient characteristics (age, body weight, male to female ratio). there is a statistically significant difference (p < . ) between the five centers in duration of the operation, cpb, estimated blood loss and volume of transfused plasma. red cell use showed also a variation which however did not reach statistical significance (p < . ). the center with the highest figure for blood loss has the lowest volume of allogeneic red cell transfusion because of the use of cell salvage. conclusions: although variations, as those observed in greek cardiac surgery centers, have been documented in other countries, the variation in the use of plasma is striking and we are in the process of trying to identify the reasons. our study is in progress and additional data are being collected and will be presented. introduction: premature infants and at term newborns have an higher circulating blood volume per kilogram than the adults ( ml/kg in premature; ml/kg in at term), for this reason, in case of neonatal thrombocytopenia, a specific hemocomponent, with a very high platelet concentration, needs for transfusion therapy. the laboratory criteria for platelet transfusion are the following: (a) a plt count < ¥ cells/l if bleeding is observed; (b) a plt count < ¥ cells/l without bleeding; (c) a plt count < ¥ cells/l in newborns showing critical clinical conditions. aim of this study: in this study, we have monitored the plt transfusion therapy in our neonatal intensive care unit (nicu) in the last four years. methods: effects of plt transfusions have been followed in children ( premature infants and at term newborns). the weight of premature infants ranged from - g and at term newborn from - g. gestation age of premature infants ranged from - weeks and of at term ones, of course, from - weeks. for every platelet transfusion in these newborns, the volume of platelet concentrate has been of - ml/kg, with a plt count < ¥ cells/l. results : in the study period, plt transfusions have been performed: children have been only transfused one time, while multiple plt transfusions (ranged - ) needed for children according to clinical conditions. the observed clinical indications for transfusions have been the sepsis with haemorrhagic syndrome ( cases) , haemorrhagic syndrome without sepsis ( cases) and neonatal alloimmune thrombocytopenia without haemorrhagic syndrome ( cases). after hours from transfusion therapy, the absolute plt count and the correct count increment have increased in all little patients. the highest increase in plt count was ¥ cells/l, while the lowest ¥ cells/l. no difference in the efficacy of therapy has been detected between premature group and at term group. % of children have been discharged from hospital in good general conditions without complications in following controls. in conclusion, we can affirm that plt transfusion in premature infants and in at term newborns is an efficient and safe treatment of severe haemorrhagic conditions. however a collaboration between nicu and transfusion center is necessary to choice the adequate platelet concentrate's volume for transfusion and the best plt donor for the newborn. developing transfusion strategies fusion society of turkey (bbtst) in with contribution of blood transfusion centers. according to these figures % of centers attended operates apheresis procedures. two centers informed us that apheresis in the hospital was carried out at blood bank. there was not enough information from one center, so it was excluded. of the blood banks performing apheresis, were university hospital blood banks. another blood banks were producing both productive and therapeutic, produce only productive and produce only therapeutic procedures. one center did not respond. all centers reported to prepare and separate erythrocyte and plasma. however only centers reported to prepare random platelets as well. each center had apheresis machines between - . a total of centers was carrying out around < procedures, around - , at centers about - , at a further centers around - procedures a year (one center was excluded). of the responders to the survey , all procedure were done at blood banks, whereas at of them all were carried out by the hematology clinics. at other centers, productive procedures were conducted by the blood bank, and therapeutics were performed by the hematology division. a total of blood banks stated that they have not kept the platelet suspensions produced and used them straightaway. productive apheresis center capacities were as shown: centers < , centers - , centers - and centers > units have donations a year. around % of all apheresis procedures were carried out by large well run blood banks. conclusion: as the use and production of random platelets increase, and settle of apheresis devices in big centers will eventually decrease the demand of apheresis procedures and keep the welltrained staff at big centers, decrease the cost thereafter. • planning of resources for the financing of the bts, adoption of a methodology for creating and adjusting the price list of products, adoption of the yearly plan of needs for blood/products and services of health institutions which use blood/products. • achieving recognition of real costs of products and services from the health insurance fund and ministry of health. • harmonization of low level of acclaimed costs and real costs of basic transfusion activities. results: acclaimed costs for activities in transfusion practice (collection, testing, processing, storage, distribution and transport) as a reflection on the price of the products are % lower than real costs. the prices of health services in the official price list are much lower than the proportion of costs of material resources needed for the realization of these services. this especially affects the management of independent blood establishments (bti's in serbia) with core blood transfusion activities as their basic field of work, in comparison with the hospital based transfusion services, which are financed within the budget of the whole hospital. the hospitals with hospital based transfusion services involved partly in core transfusion activities are completely financed by the health insurance fund, while independent blood establishments are financed through the price of products and services they provide. conclusion: in order to provide adequate quantities of safe blood/products for the end user -the patient, it is elementary to create stabile and equal financial management conditions for the whole blood transfusion service in serbia. this can be achieved only by continuous cooperation of the health insurance fund, ministry of health and independent blood establishments. sion centers (rbtc). the activities on promotion and organization of voluntary, nonremunerated blood donation, blood collection and patients' services are carried out in the rbtc and in departments of blood transfusion (dbt), part of the district hospitals. the collected units in dbt are transported by special cars to the ncht and the rbtc for processing, testing and control. the same transport is used for the requested by dbt blood components for storage and distribution to hospital departments. thus the issued components are with an equal quality and safety for all patients throughout the country. lbbdbt introduces hemovigilance as a mandatory system, covering the whole chain of the blood transfusion process. it includes as well the creation of registries at a national, regional and district level of blood donors, recipients of blood products and all activities of the blood transfusion service. . seventy hospitals are exclusively users of blood, blood products and services. the current organization of blood transfusion services faces the following problems: fragmented transfusion service, lack of a national blood policy, the blood program is not nationally coordinated, limited knowledge on quality management, inadequately distributed human resources, limited material resources, lack of it system, lack of planned, continuous skill upgrading. as a direct consequence we have: suboptimal blood collection activities, inadequate blood supplies significantly vary between seasons, high percentage of replacement donors, outdated methodologies, old, even obsolete equipment, the quality of blood products is not standard, there is a lack of traceability. aim of study: to reorganize blood collection activities in serbia to increase collection of safe blood up to % ( blood units). methods: division of responsibilities between blood establishments and hospital based transfusion services by: • optimizing organizational structure • implementing blood collection standards to enhance blood safety and donor care • gradually replacing family donors with a network of voluntary non-remunerated blood donors from low risk population groups • creating and implementing a training strategy. results: through the eu funded project support to a national blood transfusion service in serbia, we are in the effort of integrating the services and standardizing their work. the blood collection working group began by dividing serbia into blood collection regions: north, central, and south. each region is divided into sub regions covering approximately half a million population ( in the north, in the central and in the south region). each sub region will have one standard mobile blood collection team to collect blood units daily, i.e. annually. the blood units per teams provide the blood units ( %) to cover hospital needs in serbia. to this effect, the following has been achieved: • blood collection activities in serbia analyzed • performance analysis of bte and hbts mobile teams in place • two model standard mobile teams tested in the field • national blood collection sop's written • national donor questionnaire form prepared • national set of blood collection standards prepared • list of donor deferral criteria prepared • blood collection equipment renewed • regional reorganization plans in progress. the objectives and results can be achieved by the participation and mutual cooperation of all institutions involved in blood transfusion within an integrated, standardized system with clearly delegated responsibilities. p- years of the national blood transfusion institute in serbia n nedeljkovic national blood transfusion institute, belgrade, yugoslavia nbti was founded in . since and unpaid blood donation is mandatory, organized in cooperation with red cross. blood donation is regulated by the law in , / . codex of voluntary blood donation and health care staff has also been established; blood donors donates blood annually. in the past years, there was over million blood donations, performed in accordance with who regulations. over transfusion medicine specialists and technicians specially trained for the work in blood transfusion service (n = ), perform transfusion medicine doctrine of rational labile blood component and stable blood derivatives therapy, based on the selfsufficiency concept in fr yugoslavia with . million inhabitants in serbia, montenegro and kosovo. plastic blood containers and tests are imported or given as humanitarian aid gift and from . now, they have been regulated by tender. in , test to lues was introduced, to hbsag in , to a-hiv in and to a-hcv in . information system was introduced in . nbti includes: national haemovigilance coordinatoin center, center for medical care of haemophiliacs, tissue typing center, center for prenatal and perinatal protection of pregnant women and newborns. activities of nbti are organized through: center for planning, organization and development of blood transfusion service, center for blood collection, preparation and distribution, center for immunology and immunochemistry, plasma fractionation center for plasma in west balkan countries, center for diagnostics means, center for quality control of drugs and medical and diagnostic means, center for education and training and scientific research work. nbti is the third year of gmp, sop, yus iso implementation. in the current reform of transfusiology system we are aiming for percent of voluntary blood donation. nbti is the publisher of the national bulletin of transfusion medicine and it is included in the education system of the belgrade university medical faculty and the estm in belgarde . the problems of blood service in russia ea selivanov and t danilova russian inst. of hematol. & transfusiol., st. petersburg, russian federation background: the blood transfusion service (bts) development as a platform for providing the hospitals with blood and blood derivatives is an important national problem. aims: russian blood service assessment with international comparison. methods: a study was conducted on the base of the reports from all regions of russia followed by a computer statistical analysis. results: blood and blood components were collected in the russian federation in in stations of blood transfusion and in blood transfusion departments at big hospitals. amount of donors in was equal to , voluntary donors being . % of them. the average number of whole blood donations in relation to the general population is per inhabitants, and on average percent of the donor base consists of first time donors. the average number of blood collected in relation to the general population and health care system is . ml per inhabitant and ml per one bed. an average volume of one blood donation is ml. blood was collected into plastic bags containing domestic or foreign anticoagulants. about . % of collected blood is used for procurement of blood components and preparations, . % of banked blood is used for transfusions. amount of donors and the volume of whole blood have been significantly decreased for the last years. at present in russia all donations are tested for abo blood group, rh(d) type, anti-hiv- / , hbsag, anti-hcv and syphilis. the total percentage of blood discarded after testing for transfusion-transmissible infections is . %. % of plasma is obtained by plasmapheresis. blood components collected are as ffp, rbc, frozen rbc, eukocyte-and platelet-depleted rbc, rbc suspension, and preparations: % albumin, immunoglobulins, and cryoprecipitate. as to blood safety measures -implementation of blood components leucodepletion and ffp and rbc quarantine in process. the new national strategy of bts reorganization has been developed. it includes the following: increasing the visibility and resource commitment to blood issues at the national, regional and municipal levels; the national voluntary donor programme promoting; blood safety increasing; blood collection, testing and pro-cessing concentration in federal and regional bts establishments, appropriate blood and blood components usage. calculating the cost of blood in turkey n solaz, s kemahli and s cin ankara university, ankara, turkey background: like other fields of the medicine cost efficacy is gaining importance in blood banking and transfusion medicine since last few years. since last years even the most developed countries started to discuss about the cost of blood. in turkey ministry of health determines the cost of blood annually. aim: to establish a safe, cost effective and reliable prices for blood components. methods: turkish ministry of health (moh) started to determine the cost of blood components as 'all inclusive' principle. this means that cost of a unit of blood component will cover all conventional expenses such as; blood typing, infectious screening, labour, consumables, etc. this system has provided uniformity to blood component costs but if the system is not controlled and followed properly it will cause serious risks. there might be some blood banks which will not respect the safety regulations and may modify the test standards for decreasing the cost of tests. conclusion: current blood product pricing system looks generally reasonable and reliable but moh should establish close follow up systems for avoiding any abuse on the safety of blood. background: a positive direct antiglobulin test occasionally occurs in normal blood donors, and is often discovered when the donor's red cells are found incompatible in a compatibility test. the incidence of a positive dat was expected to increase since more sensitive techniques (gel test) were installed. the aim of our study was to examine whether dat positive otherwise healthy donors presented any clinical or laboratory abnormalities. methods: in the first . cross-matches last year (in months) were found incompatible due to dat positivity of blood donors' red cells ( . %). dat positive [( +)-( +)] samples were only igg positive in cases, only c d positive in and igm positive and c d positive in case. all blood donors were notified and thirty two of them responded to a request for a further sample. a complete blood count, a reticulocyte count, bilirubin (total, direct, indirect), transaminases, serologic immunological tests (ana, anti-dna, anti-ena, rf, anticardiolipin antibodies), quantitative assessment of immunoglobulins, aptt and lupus anticoagulant were performed, as well as serologic tests for markers of viral infections. dat and iat were performed by gel test (id-diamed) according to the manufacturer's instructions. dat were performed with polyvalent and monovalent reagents (anti-igg, -igm, -iga, -c c, -c d). the blood donors were also examined clinically. the donors who had positive immunological tests were referred to a rheumatologist for further investigation. results: among the thirty one blood donors eight had received medication the last hours before blood donation, two had been vaccinated for hepatitis b recently, four presented signs of a viral infection soon after blood donation, three had evidence of an allergic condition, five had positive tests for anticardiolipin antibodies and ana, two were positive for anticardiolipin antibodies only and two had a positive ana test only. in six blood donors we did not find any abnormality that might be interrelated to dat positivity. conclusions: all blood donors with positive dat should be requested to undergo further investigation. some of them are possibly candidates to long medical follow-up, especially those with other immunologic abnormalities such as positive ana and/ or anticardiolipin antibodies. the eligibility of such donors for future donation of whole blood, platelets or plasma needs to be elucidated. tions: usefulness, frequency and sincerity in answering questions. donors could choose one of the offered answers and elaborate in writing the answer they have chosen. results: of the donors that participated in the survey ( . %) answered the questionnaire, ( . %) men and ( . %) women. that the survey was useful thought % and % that it was not. opinions were elaborated by . %. that the questionnaire should be completed before each blood donation was the opinion of . %, % thought it should be filled out only the first time blood is donated and . % that the questionnaire should not be completed at all. the answers given were sincere in . % of blood donors, % were not and . % were given automaticallywithout comprehension. conclusion: most donors believe that completing the questionnaire before each blood donation is an effective way to increase safety by preventing potentially infected individuals from donating blood. they are also aware of the importance of answering questions truthfully because the end result is protecting the wellbeing of both blood donors and receivers. analysis of blood donor's deferral in national institute for transfusion medicine -skopje for the last five years ( ) ( ) ( ) ( ) ( ) p blagoevska*, i nikolovska † and r grubovik* *national institute for transfusion medic, skopje, † medical center, prilep, macedonia introduction: safety of blood and blood products depends on many different factors, starting with selection of blood donors. the aim of this study is to analyze the number of deferred blood donors and the reasons for their deferral, as well as the total number of blood donors in nitm and their correlation (voluntary/family donors). materials and methods: this is a retrospective, epidemiological study and data were taken from the blood donor's registry in nitm from . . till . . . statistical mass includes blood donors who came to nitm to donate blood in the mentioned period. results: there were total donors in nitm and ( . %) deferrals. . % of deferred ones are male, as well as in the group with donated blood (males are predominant). the most common reason for deferral is low hb level in ( . %) blood donors, use of drugs - ( . %), low blood pressure - ( . %), high blood pressure - ( . %), infections - ( . %), cardiovascular diseases - ( . %) and others. relation voluntary/family donors is almost equal ( . : . ). in the last two years the number of voluntary blood donors is increasing ( : ), which is good sign. conclusion: percentage of deferred blood donors in first three years is ~ %, which is result of insufficient data and it is increasing in the last two years (> %). reasons for deferral are predominantly from temporary character ( . %). permanent deferrals are only ( . %), which is probably due to good education of the population and self-deferral. we should establish the national registry for deferred donors, as well as for the donors with positive markers for tti. we should design a strategy for returning of temporary deferred donors. regruting blood donors in multiethnical environment p blagoevska*, r grubovik* and k elezi † *national institute for transfusion medic, skopje, † medical center, gostivar, macedonia introduction: population in r.macedonia consists of % macedonians, % albanians and % others (serbs, gypsies, turks). over % of blood donors are voluntary non-remunerated and ~ % are family donors. transfusion service and red cross should recognize the values and cultural differences of minors groups and recruiters should developed methods for reaching and motivating them to donate blood. the aim of the study is to present the ethnical structure of our donors and to develop strategy for their regrutation and retention. the study reviews the results from the blood donation actions among the high schools and university students in west part of the country (multiethnical environment) from till . results: there were blood donations for the mentioned period. predominant blood donors are employed and high school students in %. family blood donors are ~ %; between them % are from albanian population. the ratio between blood donors macedonians vs. albanians is : . woman blood donors are presented with %. first time blood donors are %, and regular donors arẽ %. conclusion: first step in planning the blood donation in multiethnic society is creation of special teams of important and devoted volunteers, such as religious leaders, teachers, doctors and businessman. for a successful campaign it is necessary to design special promotional material and address personally to the target population on their mother language. background: pursuit of pharmaceutical purity of the blood in the bag has led to a shrinking donor base and a significantly more expensive product. decisions regarding new infectious marker testing and donor deferrals have typically been made emphasizing decreasing one specific risk without considering the effect the intervention will have on the overall safety of blood transfusion. regulations have been formulated by governmental agencies with limited input from the medical community. the decision making process has lacked risk benefit analyses and has not had the robustness associated with spirited discussions. policies made in this manner may result in certain risks being decreased but can also have adverse unintended consequences. discussion: in the u.s., the fda's implementation of donor exclusions to prevent possible transfusion transmitted vcjd has reduced the donor base by more than %. given the demographics of the deferred donors, the impact on plateletpheresis donations has been even greater. to compensate for the loss of donors, blood services will have to persuade present donors to donate more frequently, to recruit new donors, or both. one study has indicated that two-thirds of donors have no intention of donating more frequently. new donors have higher rates of infectious disease markers with positivity for hiv and hcv twice as high as repeat donors. despite sensitive testing techniques, window periods still exist and not all potentially infectious donors will be excluded. another area of concern is the aggressive use of inducements to attract new donors. some blood services are offering lavish incentives such as enrolling donors into drawings to win automobiles. most donors entering the lottery will be low risk; however, it is reasonable to worry that such extreme tactics might also attract persons who should not be donat- conclusion: (a) blood donors who were patients' relatives were many more than volunteers as well as more were men than women. also people of young ages were more than those from older ages. (b) the frequency of the diseases for which the blood units were tested was found to be in low levels in the population of the area. specifically as concerns hcv, it seems that transmission frequency has been reduced after the obligatory testing of hcv in blood transfusion centres and stations. genotype b of hepatitis c virus is the most frequent in blood donors d, from a to f, from a to k, a and a. these are differently distributed in the world: types and are the most common in europe and in usa. aims: considering that, in our region, anti-hcv antibody positivity is variable from . to % of general population, aim of this study has been to evaluate the prevalence of hcv genotypes in blood donors. methods: in period from may to december , blood units were analyzed by nat for viral rna research. nat has been performed on single sample by tma technique. on rna-positive samples, the hcv genotype has been identified by reverse hybridisation with line probe assay. results: blood donors have resulted hcv-rna positive with identification of the following genotypes: a = cases ( . %); b = ( . %); a + b = ( . %); a/ c = ( . %); = ( . %); = ( . %); none was a or a. we have also analyzed the differences between the two sexes in hcv-genotypes distribution. hcv- a has showed a double prevalence in men ( cases, . %) respect in women ( cases, . %), while genotype b is more frequent in women ( cases, . %) than in men ( cases, . %), moreover genotypes and do not compare in women. although an accurate pre-donation selection, discharging all subjects with alt > iu, our results show that . : donors, apparently healthy and without risk factors, have resulted hcv-positive. analyzing our data, the genotype b has resulted the most frequent in blood donors' population, followed by type , while the others have showed a very low prevalence. the high frequency of genotype in blood donors is explained by the observation that hcv is usually associated with low alt levels, for this reason affected subjects may escape to donor's screening only based on dosage of alt. on the contrary subjects affected by other hcv types, associated with high alt levels, may be deferred increasing the hcv b relative prevalence. at the end, the different distribution of hcv genotypes between men and women and between age's classes probably reflects differences in the pathogenic characteristics of the virus, in the transmission way and in the risk factors. in fact, it has been demonstrated that genotype is principally linked to a not transfusion transmission way; genotype is linked to old age, to female sex and to post-transfusion transmission; genotypes and are associated to young age and to an history of drugs abuse, respectively with high and low viral load; genotypes and are still little known because extremely rare in europe. p- kell blood group system and rare blood donors v fakitsa*, p karyda*, s giannoulea † , c antoniou*, j flesiopoulou*, e haliou*, m papakonstantinou*, h dessilla † , e katsadorou*, g lyrakos* and k sofroniadou* *general hospital of nikea, pireas, † blood transfusion center, athens, greece background: the kell blood group system is a compound antigen system exclusively of red blood cells. some of the kell antigens are highly immunogenic. the commoner kell antibody is anti-kel . the kel (cellano) antigen is a high frequency antigen and the blood donors lacking this antigen are quite rare. the blood donors who have not factor cellano are classified in the rare blood donors. rare blood by its very nature is required rarely, but when needed that blood has to be ensured to specified patients. there are other blood donors in their family - ( . %) students, but the number of persons that donate blood from their neighborhood and close environment is much bigger - ( . %). motives for their donation are the following: their wish to help the ones that need blood - ( . %), concern that some day everyone can be a potential recipient of blood - ( . %), because of offered benefits - ( . %), for a friend or relative - ( . %), care for their health - ( . %), because of citizen duty - ( . %), because the others donate - ( . %), curiosity - ( . %). they want to be invited every months - (%) students, every months - ( . %), every months - ( . %) and ( the mean age of case group was / ± / and the mean weight of them was / ± / , / % was male and the mean number of blood donation was / ± / . the mean age of control group was / ± / and the mean weight of them was / ± / . / % of them was male and the mean number of blood donation was / ± / . the blood donors who were female, first time blood donor low wt the rate of vasovegal rx was higher in female, first time, low weight, younger blood donors (p < . ). the rate of vasovegal rx was higher in blood donor (p < . ) who were fatigue or first time blood donor, low wt blood donation, fatigue of them and starvation of them had higher absolute donation reaction than other donors. when each variable was adjusted for other variable by regression analysis. young age, first time blood donation, anxiety, fatigue, starvation were significant (p < . ) and the others were not. conclusion: donation -related vasovegal syncopal reactions are a multi factorial process. these reaction are more prevalent in blood donors who are young, first time donor, anxiety, fatigue, starvation. these reactions might be predicted vasovegal reaction and these some facth donors need more care. with better donation care, syncopal reaction may be decrease this would be improved donor safety, better donor retention, higher donor satisfaction, and reduce cost and increase regular blood donors. to avoid iron deficiency in blood donors, iron compensation is necessary in most females and males who donate more than - and - whole blood units per year, respectively. we present studies dealing with different dose and duration of iron compensation. in the first randomized placebo controlled study iron decreased continuously in males and females at donation intervals of two (males) and three months (females) without iron compensation. mg and mg daily combined with mg ascorbic acid over months (males) or months (females) compensated for iron loss or even overcompensated in females. in the second open study we reduced iron dose to mg daily over one month for both genders. this iron dose was sufficient for compensation of iron loss. a further reduction of iron dose to mg daily over half a month led to negative iron balance in the majority of donors. in all three studies donors with exhausted iron stores profit more from iron compensation, whereas donors with high ferritin values (> mg/ml) tend to loose storage iron. aim of the study: one of our campaign strategy how to increase blood donation among adolescents are periodical seminars and excursions for students of secondary schools (more than per year). the aim of this study is to analyze impact of our campaign educational system on adolescents in period - . methods: the donation of whole blood and aphaeresis platelets from donors of age from to (max. years for each class) were count for the period of five years ( ) ( ) ( ) ( ) ( ) . the percentage of the man´s donation was calculated for each target class ( ) ( ) ( ) ( ) ( ) . results please see tables and . in the tables there is shown observed data in relation to the total number of births in the czech republic in reviewed years. the study showed that number of donation from donors of age from to decreased during objected years. unfavourable state of total number of births in the czech republic ( birth in republic ( birth in , birth in ) and its decreasing tendency ( birth in !) is with high probability a major demographic factor affected number of young donors. despite energy invested in our campaign educational system our recruitment efforts should be intensified to decrease influence of demographic factors. we should find new ways and methods to attract new blood donors and keep the regular ones, too. the aim of the research was to investigate women's attitudes towards blood donation in cyprus. a statistical sample was selected using stratified sampling and consisted of women from the district of limassol (the second largest urban center of cyprus) between the ages of and . using linear logistic regression, the analysis of the data collected revealed that there is a greater probability for a woman to be a blood donor if she is of a higher educational level, a member of an organized group or association, or if she is acquainted with other blood donors. the percentage of female blood donors is higher in rural areas than in urban centers. % of women do not donate blood and attribute their reluctance to do so to health-related problems, while about % of those who have never donated blood claim to fear the blood donation procedure. in addition, more than half of the women who have stated they would never donate blood again have attributed their denial to healthrelated problems. the research revealed that there could be an increase of up to % of the percentage of female blood donors if they were given time off work for a few hours or one or two days afterwards. even though very few female blood donors expressed a preference for the blood donation to take place on a particular weekday, half of them prefer the donation to take place on the discussion: it is about small group of students. the impression is that the altruistic behaviour is present at most of the questioned students. the fact about free school days is not underestimated because it is one of the most important motives of blood donoring of the young population. families where the blood donoring is a tradition have a great influence for young children because the children in these families are better informed for blood donoring. conclusion: including the children in the process of education for young children is of particular importance because the altruistic behaviour as a higher feeling is from an early age of the child and it is under the influence of the environment (family and friends). active participation of the department for transfusion medicine in the educational process, especially in the education of young children, is a guarantee to achieve longlasted positive results. adverse reactions in blood donors taking betablocking antihypertensive medications l paesano*, m d'onofrio*, s misso † , g fratellanza* and e d'agostino* *university federico ii, naples, † hospital san sebastiano, caserta, italy one aim of blood donor's selection is to avoid an adverse reaction to phlebotomy (as vasovagal reaction, syncope and/or hypovolemic cardiac insufficiency). blood donation is surely contraindicated in various pharmacologic therapies, but not in all. in fact a certain degree of discretionarily exists about the assumption, or the period of suspension, relative to a numerous pharmaceutical products, as the antihypertensive agents. according to literature, the deferral of donors taking antihypertensive medication is not indicated when blood pressure is normal, symptoms are absent, and diuretics or similar agents are the only drugs used. on the contrary, it is a common opinion that an antihypertensive therapy by betablockers is not compatible with blood donation for its cardiac effects. nevertheless, in our daily activity, the observation of a blood donor taking beta-blocking drugs may occur for various causes. a possible error is a superficial pharmacological anamnesis, as it can occur in donations on autohemotheca, for a too fast medical visit (due to a large number of donors), or for the inexperience of the selector (often a not specialist of transfusion medicine young doctor). another possibility of observation is constitute by patients, undergoing to elective surgery, included in a program of autologous blood donation, suffering hypertension treated with betablockers. in fact, in this last case, the risk/benefit balance justify the blood letting procedure. in the last year we have just observed two severe post-donation reactions in donors suffering hypertension treated with atenolol. the reactions have been similar, in fact both donors showed lypotimia followed by convulsions about past half hour by the end of phlebotomy. no prodromic symptoms have been observer or referred. cardiac frequencies (cf) before donation were respectively and beat per minutes and blood pressures (bp) were both in the normal range ( / and / mmhg). after donation, during adverse reaction, cf showed no substantial variations, while bp have been decreased respectively to / and / mmhg. immediate treatment has consisted in putting the donors in the trendeleburg's position and in applying a dolorous stimulation. in the first case this treatment has been sufficient to report the bp to / mmhg (with disappearing of all symptoms) in only half hour time. in the second one, the marked hypotension showed a very slow remission, for this reason the subministration of a plasma expander needed, with the complete resolution of the symptoms after two hours. these two donors were not deferred from donation because they were periodic donors that had modified their antihypertensive therapy, without referring it neither in the questionnaire nor during anamnesis. our experience confirms that the blood donation don't must be permitted to subjects taking betablocking antihypertensive drugs. in fact these medications act on cardiac pump decreasing the cardiac rhythm and limiting the postdonation cardiac recover. this effect is very dangerous because it appears relatively in retard respect to the end of donation, when donor may have just leaved the transfusion center. introduction and aim of the study: in society under transition privatisation and marketisation probe all areas of life. transition to market economy is extremely important and sensitive issue in health and welfare services in general, and specifically in the case of blood transfusion service. the aim of the study was to analyze effects of confusing publicity which introduced possible ways of transforming blood transfusion service in serbia (ideas about privatization of some parts of national blood transfusion institute, buying blood from blood donors, selling blood from voluntary blood donors to private clinics, exporting blood from vbd, stories about tradition of paid blood donations in some european countries). publicity was restricted to a small number of sporadic outbreaks concerted in a limited period of time. table. conclusion: surveillance of adverse reactions and injuries or accidents during or after blood donation is essential for maintaining the well being of active blood donors, as well as for the safety and quality of the donated blood components. information on other activities and parameters affecting the quality of blood including materials, reagents and equipment should be collected and any serious deviations from standard operating procedures should be notified to the competent authority using haemovigilance infrastructures. skae has built up such procedures working along the lines of the european haemovigilance network. improvement of existing national haemovigilance systems is expected to follow from the implementation of the eu directive. although inevitable, blood donor deferrals lead to losses in donated blood supply and may affect donor-return rates and subsequent blood donations. to estimate the scope of blood donor deferrals and their causes, we analyzed the - data from regional blood centers using standardized criteria for temporary and permanent blood donor deferrals. within this period ( ) ( ) , . percent of persons who presented for donation were deferred; . % were temporary deferrals ( % due to laboratory test results, among others low hemoglobin, . % due to risk of acquiring a transfusiontransmissible infection) and . % were permanent ( % due to the infectious diseases markers, . % due to cardiovascular diseases). for regional blood centers the temporary deferral rates varied widely (see the table below ). in the case of individual regional centers, the differences as well as the most common causes were often difficult to explain. according to our analysis, some blood centers have a more restrictive approach to donor acceptance than others and this results in increased donated-blood loss. to some extent such losses could be avoided. further studies are recommended to elucidate the problem and eliminate unnecessary deferrals. caption : percentage of deferrals aims: from our experience in selecting blood donors, a certain number of issues have been noticed that remain obscure and need to clarification since those seem to 'haunt' the whole process of blood donation. methods: many first time blood donors and especially volunteers think that rejection reasons are permanent and they are completely incapable of donating blood their entire life. this is a 'tragic' misunderstanding since the doctor did not explain that the reason of the rejection is only temporary and in the future this man is capable of donating blood. those potential donors will never even approach again blood donation centre and when in the future they are asked why they do not donate blood, they repeat the cause of the past rejection. results: one of these rejection reasons is for example low blood pressure ( . % of total causes of rejection). as we all know blood pressure must be determined according to age, sex, weight and from other factors as sleep, emotional status, food and liquid intake. therefore blood pressure is very important but should be evaluated with all the above factors and must not be alone the only reason for rejection. even when one blood donor is rejected it should be made clear to him that this is only temporary and if in the future he is in better physical condition, he could donate blood. in fact - % of those donors rejected for hypotension are readmitted in blood donation after meeting the above mentioned criteria. another matter of equal importance is anemia ( . % of total causes of rejection), especially concerning young women. since most of those women tend to develop anemia due to depletion of iron stores, they should be advised to donate blood at longer periods than regular, to receive proper medication and diet according to their needs. the doctor must explain the donor the reasons for iron depletion, so blood donation should not be considered as the only cause for this situation from the donor. there are many factors contributing to anemia, menses, specific diets, overwhelming stress and exercise, not to mention other medical reasons. it is the duty of the doctor to correct those factors that resulted in iron depletion or anemia and readmits those donors in blood donation in the future ( - % of those rejected are readmitted in our centre). summary/conclusions: at our blood centre we have created a program of regular tests (blood tests-physical examination) for all our blood donors. our experienced and well taught personnel offers advice and provides useful information in every aspect of blood donation and more. we have created a friendly environment for all our volunteers with love, understanding and appreciation and believe that this is the only way to keep a constant 'flow' of blood in our region. introduction: an innovative perception for blood donation in a new and evolving environment must focus on specific matters and ideas and adopt in a certain level lifestyles and concerns of society. aims: the purpose of this study is to find methods and ideas that can help blood donation centers throughout our country to create new blood donors, give a motive and inspiration for blood donation by adopting new trends of society and finally accomplish national need. methods: by having a personal interview with many volunteers about their feelings for healthier life, their nutritional habits, daily physical activity, sports, vitamins, smoking, weight, cholesterol levels. we investigated whether they believe that blood donation has, if any role towards a more hygienic life. results: we divided blood donor volunteers according to their age, educational level, and number of blood donations per year. our results indicated that there is a tendency among young educated people to adopt a personal lifestyle that includes consuming healthier food, keeping their weight low close to the ideal, having some kind of personal activity, not smoking, watching cholesterol levels, following doctors advice and concerning seriously about their health. this dynamic group of blood donor volunteers considers blood donation as a contributing factor to well being and donates blood at specific intervals. besides the yearly run lab tests that are done by our blood centre they also seek advice and discuss any matter concerning their health with the blood centre doctor. it appears that they are extremely sensitive in those matters and they seem to appear well informed about issues concerning their health, they also believe that blood donation is part of the plan they have to keep fit and being well. in our blood centre we encourage this belief and we also provide information concerning this new trend towards healthier habits. summary/conclusions: this approach has already shown some positive results in our blood centre as many people especially young educated women have joined our blood donorship program and donate blood at scheduled intervals. in order to achieve our goal which is to raise the percentage of blood donors in the region we have to be flexible, innovative according to new habits and lifestyles. we have to move with society and modernize the way we attract various groups of people. blood donation against prejudice as saltamavros*, s dimitrakopoulos † , v zacharaki*, p giannaros*, s markou* and p tseliou* *st. andrews hospital patras greece, patras, † pyrgos general hospital, pyrgos, greece introduction: in order to achieve a greater population to be admitted in blood donation we have to provide information concerning any obscure issues that presents in selecting donors. to examine the accuracy of hb measurements obtained by the noninvasive clinical device, as compared to values detected by standard methods, (cell-dyn , abbott laboratories, usa), in a blood donor setting. methods: the nbm- device utilizes a finger base sensor using occlusion red/near-infrared spectroscopy (o-rnirs) to detect and analyze the hb/hct levels. the clinical trials were conducted at two blood donor centers (israel and usa). studies were carried out on a group of subjects ( females, males) aged - . subjects were healthy volunteers who had come to donate whole blood or aphaeresis components. after obtaining informed consent, hb/hct levels of all the study volunteer participants was tested non-invasively, using the nbm- device, followed by a venous blood sample. additionally, the usa center tested a capillary blood sample using the hematastat hct measurement device ( donors). hb levels were considered normal when readings were equal to or > . g/dl. results: venous hb measurements ranged from . - . g/dl. the mean nbm- hb level was . ± . g/dl, only . g/dl lower than the mean hb result obtained by venous sampling, which reached . ± . g/dl. the standard deviation of the difference between the invasive and noninvasive hb readings was found to be ± . g/dl. the mean absolute error (mae) of their difference was . g/dl. when checked against the cell-dyn in the usa center, where subjects had hb of . g/dl or lower, the nbm- and hematastat devices showed comparable sensitivity results. the nbm- using o-rnirs is a promising noninvasive technique for hb screening in blood donors. the device is easy to use and agreeable for both blood donors and personnel. the technique reduces the need for the invasive finger prick or venous blood sampling, thereby enhancing safety, reducing costs, and improving the experience of blood donation. the effect of short-term, temporary deferral on blood donor return rates and subsequent blood donations background: blood donors are deferred for numerous reasons. some deferrals like intravenous drug use, male homosexual contact or certain positive test results are permanent. the majority of donor deferrals, however, are short-term temporary deferrals (sttds) that are resolved in a matter of days, weeks or months, after which time the person is again an eligible blood donor. the effect of sttds on blood donor return rates and subsequent blood donations is studied. materials and methods: donors given sttds during the december to march were computer-matched with non deferred donors on the basis of age, sex, and donation date (case group: donors -control group: donors). computer records were evaluated during the next years ( march to march to determine donor return rates. significance for comparison between the two groups was based on chi-square analysis. results: the most common reasons sttds were elevated blood pressure ( %), deferred for medication ( %) and colds and/or sore throats ( . ). non deferred donors were a little more likely than donors with sttds to return over the next years ( . % vs. . % pv = . ) and non deferred donors donated more whole blood units. . according to ethnic structure, women -ethnic macedonians donate blood in largest numbers - ( %), while all other ethnic groups are present with only %. the most prevalent is the group of adults aged - ( - . %), with high school education - ( . %) and mostly those who donated blood - times ( - %). conclusion: having in mind that % of the population in macedonia is female, the obtained results reveal a significant, yet insufficient participation of women in blood donation with % in relation to the total number of blood donors surveyed in the period - . this is due to insufficient motivation and education of women from all ethnic groups especially those from the younger population and with elementary education. incorporating them in education and organization would contribute to their more extensive participating in blood donation. comparison of serum beta -microglobulin (b -mg) between hbsag positive donor and healthy control f tarabadi*, m shaeigan*, g babaee † , a talabiean* and m khadir* *iranian blood transfusion center, † tarbiat modarrs university, tehran, iran background: beta -microglobulin (b -mg) is a low molecular weight protein ( daltons) and found in all biological fluids it is light chain of histocompatibility class -human present on the most membranes of cells. in the hepatitis infection the viral antigen presentation on the hepatocyte in the presence of class -hla antigen plays a role in the elimination of the virus. method & samples: beta -micro globulin was measured in serum drawn from hbs ag positive blood donors include ( . %) female and ( . %) male in age between - years, and healthy ( %) female and ( %) male in the same age we detected serumic b -mg by enzyme immunoassay (ela). results: our studies showed b mg level increased in ( . %) hbs ag positive donor that was significant differences with healthy control (p = . ). conclusions: it seems that serum b mg is a good marker for hbs ag replication. the role of b mg in monitoring of response therapy needs to be more evaluated. and ( . %) were contributed by vd, rd and dd respectively. over the last / years, voluntary donations have shown a rising trend from . % to . %, where as rd ( . % to . %) and dd ( . % to . %) have shown a declining trend. the percentage of female donors was maximum in voluntary group as compared to rd and dd ( . % vs. . % vs. . %) respectively. the rates of all tti markers reactivity were significantly higher in rd as compared to others donors. the hbsag and anti hcv reactivity in vd and dd is comparable ( . % vs. . % and . % vs. . %). hiv antibodies was found more frequently in vd as compared to dd [ . % vs. . % (p < . )] whereas, vdrl reactivity was lower in formal as compared to latter [ . % vs. . % (p < . )]. conclusion: voluntary blood donation has shown a rising trend over a last few years, thus highlighting efficient donor motivational strategies. these strategies need to be strengthened to increase the female donor base. the safety of dd is equivalent to vd when the rates of tti are compared. thus, dd should be advised to donate blood regularly as voluntary blood donors. blood safety depends on a number of factors. the chain of safe blood starts with the donor. one of the procedures for obtaining safe blood for transfusion is the medical selection based on the completed questionnaire and the possibility of self-exclusion from the process of blood donation, the medical history of the potential donor and the medical examination. donor selection consists of two sets of information necessary for protection of the blood recipient as well as the donor himself. aim: to present the most frequent reasons for declining volunteer blood donors. material: the materials used for analysis were the questionnaires completed by all the potential blood donors at the transfusion department of the medical center in strumica as well as the record books of the blood donors which contain the results of the analysis we make for the potential donors. these donors donated blood in the period between and . results: during this period people volunteered to donate blood, out of which were allowed to donate blood, while were declined. out of the total number of blood donors were male and female donors. the reasons for declining potential donors were the following: . % had low levels of hb, . % were taking antibiotics, . % were ill, . % had low blood pressure, . % had high blood pressure, . % for other reasons. conclusion: donor selection and their care on one side and obtaining safe blood for transfusion on the other side entails obligatory organized medical control. the obligatory completion of questionnaires, the medical examination of the potential donor and their self-exclusion as a result of the feeling of personal responsibility as well as the obtained information are very important for the selection of quality blood donors and obtaining safe blood for transfusion. questionnaire on subjects-students, their knowledge and motivation on blood donation f vladareanu, a bugner and s sirian national institute of heamatology transf, bucharest, romania the research theme of this questionnaire is as follows: 'what is the level of knowledge and of motivation in the non-remunerated and voluntary blood donation at students?' we also tried to see the practical implications that this study will have and how it will influence the knowledge in this area. the purpose of this questionnaire was not dissimulated. the general theme of the knowledge and motivation on blood donation had been studied before through two big questionnaires applied in and , but the general population was their target. students had never been an investigated lot up to now. the hypothesis referring to this problem is as follows: students are not informed either on the act of donation, or on the crisis of blood. . the lack of information is a first cause of the indifference of the studied lot towards the idea of donation. . the lack of motivation of the studied lot is another cause. the questionnaire was applied on a lot of students from seven different cities: bucharest, iasi, constanta, cluj, sibiu, brasov, timisoara. the number of the questions was limited to , which we consider best for a questionnaire applied on the street or at college. as a conclusion, we can say that a passive-defensive attitude towards the blood donation was revealed after this questionnaire. not knowing the issue caused by their lack of information sometimes determines indifference at the statement of the subject. on a general dissolution environment of the responsibility of the youth, the donation problem is not in their aria of preoccupations, the general attitude being of non-involvement for the moment, at this idea which is not yet in every individual conscience and which is normally administrated at an institutional level. the donor data and the details of blood application of the north west transdanubian region of hungary k vÖrÖs*, c bercsÉnyi † , o petrÓ † , r jÁger † and e miskovits ‡ *hungarian national blood transfusion s., györ, † blood bank, tatabánya, ‡ headquarters hungarian n.b.s., budapest, hungary the ongoing fundamental reorganization of the blood service began on the . . in hungary. as the consequence of reorganization till . . , blood banks had been established instead of existing before, under direction of the hhnbts. the working profile of the regional blood centers and local blood banks will be changed step by step. virus screening, blood group serology and processing will be made in the regional centers. one of the regions is the 'north west transdanubian region' (nwtr, city györ as the center, with about inhabitants and hospital beds). local blood banks (tatabánya, sopron, and szombathely) are belonging to nwtr. the regional center and the local blood banks provide the labile blood products and high level clinical-transfusion service (cross-matching, antibody screening, outpatient immunhematology investigations, etc.) for the hospitals. annually donors donate blood in this region. this donation activity covers about the % of all inhabitants. the acceptance ratio of the donors is good ( - % of the donors were deferred). there are hospitals in our region. the regional demand on rbcc is - . u/year, on ffp is . - . u/year and on pc is - . u/year. the poster shows the donor data and the details of blood application of this region since . p- implementation of rbc collection using haemonetics mcs ® +: medical staff training, donor recruitment and acceptance g woimant, c fretz, d puydupin, e pÉlissier and jl beaumont efs ile de france, paris, france background: single donor rbc collection is an approved apheresis technique in france. aims: our goal was to evaluate the implementation of rbc collection in our center in terms of donor recruitment and acceptance, as well as medical staff training and adaptation. methods: donors were selected according to the french requirements for rbc collection (weight ≥ kg, height ≥ cm, hb ≥ . g/dl, ferritin ≥ ng/ml for repeat rbc donors). all personnel were trained on adequate communication with donors. eligible donors were contacted by mail, by phone or during pre-donation interview. among the recruited donors, all donors were male, % were regular whole blood donors, % were regular whole blood or apheresis donors and % were new donors. the medical staff was trained on rbc collection with the sdr protocol and disposable set ln pf on the mcs ® +. most of the medical staff was already used to autologous rbc donation with similar apheresis devices. blood samples were taken from donors pre-and post-donation, as well as to months later for those returning for a subsequent donation. donors were asked to fill out a post-donation survey for assessing donor comfort and information. results: donor profile and clinical follow-up are summarized in table . six percent of the donors had a ferritin level below ng/ml; these donors were regular whole blood donors. the collections were well tolerated and no changes in vital signs were noted. four reactions were reported: hematomas and citrate reactions. no reaction was observed post-donation and hemoglobin levels measured before next donation were back to normal. the technique was easily implemented by the medical staff and fitted well in the existing blood center processes. the medical staff as well as the donors found collection duration short (average of min). the results of the survey were very favorable as more than % of the donors considered their donation and the information they received as satisfying. most of them agreed to donate again and several actually donated twice during the evaluated period. conclusion: the implementation of rbc collection in our center, using haemonetics mcs ® +, was successful in terms of ease of use of the technique, as well as user and donor acceptance. we now plan to evaluate donor loyalty in the longer term. risk from first-time blood donors e zhiburt, s golosova and p reizman federal blood center, moscow, russian federation introduction: each third dose of whole blood in russia is donated by first-time blood donor. there are two reasons for attention to this kind of donors: ( ) possible risk of infectious disease in seronegative study; ( ) possible risk of donation for person with contraindication. aim of the study: we investigated role of regional deferred donors registry (rddr) in by first-time donor selection. methods: moscow rddr includes parts: hiv, viral hepatitis, syphilis, tuberculoses, malaria, drug users, psychiatry, days after blood donation. rddr was complete and our center began actively work with it since last year. each donor has to be registered in rddr and automatically checked for deferral reason. effectiveness of rddr was investigated. results: first-time donors donate less than % blood in our center. about a quarter of them are deferred before possible donation. part of donors deferred by rddr has been significantly increase in (c = . ; p < . ) at the expense of seropositive people. conclusion: rddr is effective for blood donor selection and decreases necessity in laboratory screening. first-time blood donors have to be examined before blood donation. if they have not contraindications, donation can be performed up to days before examination and screening. the double unite platelet production is important especially if the relatives of patient find the donors. we evaluated the effectiveness two apheresis machine for platelet collection. in our blood bank, one fenvall amicus and one cs + apparatus were used for platelet apheresis. apheresis were performed between / / and / / . including criteria of donors are that estimated process time is smaller than minute and estimated postapheresis platelet count is higher than ¥ /l. donors firstly was enrolled to amicus. if amicus was busy, then it was enrolled to cs. the properties of our donor populations were given in blood and plasma cell components are obtained either by traditional manual method from whole blood or by apheresis. modern medical treatment is based on transfusion of deficient components such as erythrocytes, leukocytes or plasma proteins. this involves new solutions to achieve higher yields and better quality of such components. the aim of our study was to estimate the efficacy of blood cell separator cobe trima in obtaining platelet concentrates (pcs) as compared to older-generation cobe spectra blood separator. apheresis procedures were performed on both these blood cell separators. the quality of platelet concentrates was tested during day storage period (see table below ). we have tested the effect of apheresis procedure on donors and estimated the operating comfort of both separators. the tolerance of both separators was satisfactory except for more frequent hypocalcemia when trima separator was used. most donors were more satisfied with trima procedure because of single venipuncture although it involved special donor selection (good vein access). in general we may say that trima is undoubtedly a more modern and more friendly separator. however, cobe spectra may continue to be used with success especially when a more versatile cell separator is necessary (leukocyte concentrates, peripheral blood stem cells or therapeutic apheresis). methods and results: tls ( procedures on patients) were used successfully in patients with acute or chronic leukemia with hyperleukocytosis (white cell count > ¥ e /l or blast count > ¥ e /l) when high cell count would promote leukostasis with vascular occlusion in the microcirculation. performed tl procedures were rapidly reduced both the white cell count and the whole blood viscosity. average fall in white cell count after treatment was . %. tp-treatments ( procedures on patients with symptomatic thrombocythemia and/or platelet count higher than ¥ e /l) were applied in order to prevent the development of 'thrombotic-hemorrhagic syndrome' . the tps performed resulted with rapid platelet counts reduction ( . % in average) and with clearly noted clinical improvements, subsequently. tes ( procedures on patients) were performed using manually technique in patients with 'cellular hyperviscosity syndrome' induced by high red blood cell count. it was shown that te procedures resulted to red blood cell number lowering and decreasing of blood hyperviscosity. average fall in hemoglobin and red blood cell concentrations after te treatments was from . % till . %. rbcx treatment ( procedures on five patients with malaria and two with severe aiha crysis) was performed on an urgent basis, particularly when clinical symptoms indicate life-threatening situations and resulted with rapid and significant reduction of concentration of unwanted pathogen affected rbcs and summary/conclusion: the effects of tcs depended on the nature and stage of the basic hds, of adequate selection of patients and of timely applied apheresis. rapid cytoreduction is obtained justly in patients with excessively high cell count, and this effect did not associated with bone marrow remission. thus, tc should be looked upon as adjunct to the standard treatment of different cithemias, but not as replacement therapy. the present study indicates that the best therapeutic effects were obtained by rbcx. were carried out with continuous flow blood cell separator cobe spectra and all patients underwent large volume leukapheresis (lvl). in all procedures, a blood warmer was connected to the return line and a continuous calcium infusion was administered preventively. six patients, who were under kg body weight, had the extracorporeal circuit primed with irradiated, filtered packed red cells diluted with % albumin solution. seven children had vital signs and ecg continuously monitored during the procedure. results: each patient underwent a median of collections (range - ). the inlet blood flow ranged between . and . ml/min (median . ml/min). the median blood volume processed was ml (range - ). leukapheresis lasted a median of min (range - ). the median total nucleated cell yield was . ¥ e /kg (range . - . ), mononuclear cell (mnc) yield was . ¥ e /kg (range . - . ) and cd + cell yield was . ¥ e /kg (range . - . ). the median of mnc collection efficiencies was . % (range . - . ). in ( . %) patients, in only one apheresis procedure more than ¥ e cd + cell/kg were collected. during ( . %) procedures patients had experienced apheresis-related side effects. the citrate-induced reactions were most commonly observed. the reactions were mild and cessation of collection was required only in one case, because of catheter related complication. mild sedation was required only in few very small children. post-donation platelet count was less than ¥ e /l in cases and these patients required platelet transfusion before subsequent procedure. our results show that lvl in pediatric patients is relatively safe procedure, well tolerated and with a very low risk of serious adverse events. close monitoring of blood counts, especially platelets, between pbsc collections is necessary. the cessation of procedure was required in only one case and no life threatening side effects occurred. neonatal alloimmune thrombocytopenia (natp) caused by fetomaternal mismatch for human platelet (plt) alloantigens (hpas) worsens approximately / pregnancies and can lead to a serious bleeding diathesis, intracranial hemorrhage (ich) and sometimes death of the fetus or newborns. we describe the successful management of a -year-old pregnant woman, alloimmunized to the hpa- a (p a , zwa) antigen, with a history of two previously children with severe thrombocytopenia and ich. the pregnant woman was at her terminal pregnancy and was suddenly admitted. to evaluate the risk of ich in the fetus, cordocente was performed to demonstrate fetal thrombocytopenia (plt . /mmc). to ensure a rapid provision of compatible negative-antigen platelets, we decide to collect platelets from the mother using apheresis. plateletapheresis was performed using com.tec separator, fresenius. blood processed was . ml in a short time procedure ( minutes). no significant adverse effects were observed in the mother and fetus, during and after the procedure. platelets collected ( . ¥ e ) were transferred to the preparation set and plasma was removed after centrifugation to resuspend the platelets in octaplas ab. then we separated the platelets into two units containing . ¥ e each. the day after the donation, the mother gave birth to a girl by caesarean section. after the transfusion, the plt account increased from . /mmc to . /mmc and after a week the child had plt . /mmc without hemorrhagic complication. according to the literature data and our observations of the patients, there are changes of the hemostasis system indexes in the most patients with the endogenous intoxication syndrome and immune disturbances. in the number of cases medicamentous therapy appears to be not enough to normalize the changes, but it is especially important for pregnant women and women in childbirth, because on the background of these disturbances different complications of pregnancy and postnatal period take place. the aim of our study was the substantiation of plasmapheresis using in complex therapy of purulent inflammatory complications in obstetrics and immunoincompatible pregnancy with hemostasiologic disturbances. patients with hemostasis system disturbances: one woman in childbirth with exacerbation of chronic pyelonephritis, who had in the first hours some signs of hypocoagulation on the background of permissible blood loss (prolonged coagulation time up to - minutes with episodes of its absence on the background of the normal indexes of general coagulogramm, quantity and function of thrombocytes and the dilute fibrin monomer complex level in times higher than the norm) and nine pregnant women with the perinatal losses in anamnesis severed by the pregnancy (threat of abortion, places of fetal egg detachment). these women were examined, the following was revealed: the high antibody titer to chorionic gonadotropin, parameters of partially activated thrombin time were higher than the norm ( - seconds), thrombin time ( - seconds), the dilute fibrin monomer complex ( - mg%), coagulation time ( - min). in all these cases the conservative methods of treatment (antibacterial, hemostatic, hormonal therapy) were effective for a short period of time and they didn't succeed to correct the given parameters of hemostasiogramm. the discrete centrifugation plasmapheresis was included in the complex of medical treatment. the woman in birth operations were done, in the programme of plasma replacement during the first two plasmapheresis procedures donor fresh-frozen plasma was included. six pregnant women on the given stage one course consisting of plasmapheresis procedures for plasma replacement with crystalloids was done, the volume of the removed plasma was - % of the circulating plasma volume. three pregnant women before delivery were required two courses of plasmapheresis more consisting of - procedures each. the system heparin was not used. in all patients already after the first procedure of plasmapheresis the normalization of hemostasis indexes was marked, that allowed to prolong pregnancy, to prevent the coagulopathy bleeding and the development of disseminated intravascular syndrome. four women are discharged from the hospital, the other patients are observed with progressive pregnancy. thus, the using of discrete centrifugation plasmapheresis is effective at the signs of hypocoagulation in patients with isoimmunisation with fetal antigens and infectious pathology, and is the reserve in prevention and treatment of obstetric complications. extracorporeal photochemotherapy: an alternative therapeutic approach to control graft versus host disease after allotransplant with reduced intensity conditioning regimen c del fante*, c perotti*, gl viarengo*, p bergamaschi*, p pedrazzoli † and l salvaneschi* *irccs policlinico s. matteo, pavia, † ospedale niguarda cà granda, milano, italy background: extracorporeal photochemotherapy (ecp) can be defined as an immunomodulatory therapy that demonstrated to be efficacious in treating patients affected with graft versus host disease (gvhd) after allotransplants for oncohematological diseases. reduced intensity conditioning regimen (ricr) for allotransplant is a relatively new practice in patients (pts) ineligible for a conventional myeloablative conditioning regimen. the use of immunosuppressive therapy (ist) to control gvhd is limited for the high risk of developing infections and disease relapse due to the strong reduction of graft versus tumor (gvt) effect. aims: to evaluate the effectiveness and safety of ecp in treating pts affected with gvhd post rcr and the possibility to taper, at the same time, the ist. methods: pts ( females, male), median age . years ( - ), affected with agvhd grade ii ( ) and extensive cgvhd ( ) gtx with median total granulocyte doses of ( - ) ¥ per gtx corresponding to . ¥ granulocytes/kg in children and . ¥ granulocytes/kg in adults. the wbc counts increased from baseline values of . ( - . ¥ ) g/l for both pediatric and adult patients to peak values of . ( . - . ) ¥ g/l (children) and . ( . - . ) ¥ g/l (adults) at one hour after gtx and to . ( . - . ) ¥ g/l (children) and . ( . - . ) ¥ g/l (adults) at hours after gtx. in out of patients ( %), the crp levels significantly declined ( ( - )%; p£ . ) during the granulocyte transfusion period; in almost all cases ( / ; %) after the initial or nd transfusion. thirty-eight patients ( %) were alive at day + after termination of neutropenia and gtx. patients without crp response to gtx ( / , %) and patients with severe viral infections / ( %) were not among the day + survivors. background: in recent years, the use of platelet concentrates obtained from single donors by automated apheresis has grown steadily. plateletpheresis donation is considered to be a safe procedure with modern instruments. so far, no studies have identified donor or procedure specific factors that may be associated with serious adverse events. aim: to evaluate the incidence of adverse events during plateletpheresis procedure, over a five-year period in our hospital. materials and methods: eight hundred single-needle plateletpheresis collections were performed by using two automated intermittent-flow cell separators: of them with mcs p and with mcsplus (haemonetics), according to automatic standard protocols a p and ldplp, respectively (with the collection of an additional plasma unit). acd-a was used as the anticoagulant in all apheresis procedures (acd-a: blood ratio was : ). most of the donors ( % men and % women) were patient´s relatives. half-hour before the initiation of the procedure, mg of calcium ( tablet cal-c-vita) were administered to each donor. the mean platelet yield was . e /unit. the overall rate of the donor related adverse events was . %. feeling faint was the most frequent event, which was occurred in . % of donations. hypotension and citrate related rates were . % and . %, respectively. all citrate related symptoms were only transient perioral paresthesias, which were relieved by slowing the i.v. rate, without additional administration of oral calcium. donor unconsciousness was the only observed severe event, the rate of which was . %. other adverse events were venipuncture related ( . %), machine related ( . %) and miscellaneous complications ( . %). ( ) plateletpheresis using the mcs p and the mcsplus automated cell separators is a safe procedure, with a low risk of serious adverse effects. ( ) with the used acd-a-to-blood ratio ( : ) satisfactory platelet concentrates were obtained with very low incidence of citrate-related events. ( ) the peros administration of calcium before the initiation of the procedure, probably lowers the rate and the severity of hypocalcemia symptoms. quality assessment of ffp collected as a byproduct of plateletpheresis . from the donors immediately with the initiation of the procedure (citrated whole blood) and . from the final platelet concentrates after one hour rest at room temperature without agitation. in vitro platelet response to the aggregation-inducing agonists adp, collagen, ristocetin and arachidonic acid was investigated by means of an aggregometer (pap- c, bio/data). results: there were no significant differences between the groups of donors with respect to age, sex, smoking habits, preapheresis wbc and plt counts and hemoglobin concentration, as well as in the harvesting time between the two cell separators. our findings are shown in the following table. mildly decreased response to all agonists was observed (mainly to adp and arachidonic acid) in the samples taken right after the initiation of the procedure, in both groups. platelets from the final component showed a further slight decrease in response to adp, which was more prominent in the mcs p device (p = . ). on the contrary, an increase in platelet response to the other three agonists was observed in both devices, which, however, was statistically significant upon collagen and ristocetin stimulation. conclusions: reduced response to aggregation stimuli is possibly caused immediately with the initiation of the apheresis process. literature reports regarding further platelet traumatisation due to the procedure, are rather conflicting. in our study, such traumatisation was observed only in the case of adp in the mcs p obtained collections and this could be correlated with the technological differences between the two devices. recovery of platelet aggregability, as it was expressed by the upregulation in platelet response in the other stimuli, could be attributed to the resting period and seems not to be affected by the timing of the leucodepletion procedure. background: lupus erythematosus often is accomplished with severe symptoms, such as polyarthritis, nephritis, pericarditis or dermal alterations. in pregnancy cytostatic therapy affects gestation. on the other hand the course of disease can be refractory to corticosteroid therapy. elimination of autoantibody and immuncomplexes by plasmapheresis could be an efficient way to amend the severity of symptoms. a year old pregnant woman in the th gestation week with systemic lupus erythematosus showed severe symptoms like polyarthritis, nephritis and pericarditis. treatment was initially mg/kg bw prednisolone for weeks and subsequently mg/kg bw for weeks. plasmapheresis was applied daily in the beginning and continued depending on the condition of the patient ( table ) . the eliminated plasma was substituted by fresh frozen plasma. the medium volume was . ml per apheresis. after day plasmapheresis treatment was suspended to avoid problems with coagulation and was followed by a cycle of immunoabsorptions to eliminate circulating immuncomplexes. results: prednisolone therapy alone brought no effect even after changing to high-dose treatment. a significant amelioration of all symptoms could be observed after the first plasmapheresis. good condition of the patient remained stable over the period of daily plasmapheresis for days. intermitting apheresis treatment for one day lead to a significant aggravation of symptoms. apheresis no. again lead to a recovery of the patient which held on until day . conclusions: treatment of systemic lupus erythematosus in pregnancy especially in combination with resistance to corticosteroid therapy, is an effective therapy to ease severe symptoms such as polyarthritis, pericarditis and nephritis. exposure to cytostatic drugs can be avoided and therefore the impairment of the fetus can be reduced. background: the collection of mnc represents the first step of photopheresis procedures and could be of critical importance in achieving a therapeutic goal. in this work we compare the cell yield of two collection programs on cobe spectra device: the mnc versus the autopbsc program using the ecp procedure modified by andreu. methods: procedures were carried out with mnc program and procedures with autopbsc on patients with cgvhd. both hemoglobin increased from . ± . to ± mg/tu, k+ from . ± . to . ± . mmol/l, level of glucose decreased from . ± . to . ± . to . ± . mmol/l, ldh from . ± . to . ± . ukat/, lactate from . ± . to . ± . mmol/l, ph from . ± . to . . . the volume of apheresis units was lower than wb-rbc, the leucocyte count was normal in all units. the rbc loss by filtration was . ± . ml/tu and was lower than at wb-rbc. in apheresis rbc there were the differences in hb and ht value between the day of storage and , in wb-rbc there were no differences. during the storage period we found no differences in k+ increasing value and no change in ph value between apheresis rbc and wb-rbc, the increasing of lactate was higher in wb -rbc, increasing of ldh correlated to hemolysis. the plasma hb value increase was higher at apheresis rbc in contradistinction to literature. hb and ht correlation in apheresis units according to predonate value in donors was lower than at wb -rbc. the method is a useful alternative to conventional whole blood donation, we get rbc units with high standard of quality and low correlation according to predonate hb and ht value in donors. acknowledgement: the study is supported by grant iga ministry of healthy cr n. nr/ - . background: in life-threatening exacerbations of sle a satisfying efficient therapy is lacking. despite intensive immunosuppressive therapy some patients are resistant or contraindicated to conventional treatment. in particular circulating antibodies and immune complexes play an important role in the pathogenesis of sle and mctd. an extracorporeal removal of these pathological substances may be effective in the treatment of active disease. methods: five patients with severe therapy-resistant sle/mctd underwent immunoadsorption onto protein a. blood was drawn from patients by using a jugular catheter or a peripheral intravenous catheter. anticoagulation was performed with acd-a and heparine or acd-a and r-hirudine. plasma was separated by centrifugation. the . to -fold total plasma volume was treated in every immunoadsorption. the columns were floated with a maximal plasma flow of ml/min. the procedure was carried out every second day. additionally supplementary intravenous immunglobulin therapy was given only once. results: remission of the disease was achieved in four patients. see table below . conclusion: pa-ia is highly effective regarding the elimination of autoantibodies and circulating immune complexes, might induce a remission in patients with sle/mctd. it is an acceptable alternative treatment option in patients when other therapies are ineffective or contraindicated. background: purification of bone marrow from erythrocytes is used to prevent early hemolysis in major abo incompatible allogeneic hemopoietic cell transplantations. erythrocyte depletion is strongly recommended to reduce product volume and stem cell purification before storing autologous and even allogeneic bone marrow in order to prevent early hemolysis and dmso toxicity that might develop after thawing. centrifugation, sedimentation with hes, and cell separating devices are methods for erythrocytes depletion. aim: in our center, we prefer to use cell separation device, since it is a reliable method and has a high-yield and risk of contamination with erythrocytes is low. success of the process is retrospectively analyzed for high and low volumes. method: erythrocytes depletion of bone marrow harvest was done in hemapharesis unit with cobe spectra device in the last five years in cases with bone marrow volume over ml, and cases with bone marrow volume under ml. fifteen of these cases were allogeneic, and were autologous procedures; a software uploaded with cobe pbsc coll vers . and (catalog no: - - ) set was used in the procedure, and at the same time, double bag system with intermediate connectors were used to prevent re-circulation (catalog no: - - ). results: the mean volume reduction was . % ( . - . ) for volumes over ml, and . % ( . - . ) for volumes less than ml. regarding the success of the procedure no statistically significant difference was found between procedures with high and low volumes. no complication developed related to the device or product, and waste bag never had to be re-used. in none of the patients early massive intravascular hemolysis was observed. conclusion: erythrocyte depletion and volume reducing with cell separation device is a reliable method. this process is successfully applied with high volumes (over ml); and in low volumes as well for reducing erythrocytes, and gain of mononuclear cells and cd + cells. platelet concentrates obtained by apheresis procedure-correlation between the initial count and the final concentration v srejic*, g bogdanovic*, z garic*, n vavic* and b balint † *national blood transfusion institute, † military medical academy, belgrade, serbia apheresis team of the national blood transfusion institute processed and classified data of donors who donated platelets by apheresis procedure from january till april . procedures were performed in accordance with the ldplp protocol, using haemonetics mcs+. initial donors' platelet count and the absolute platelet concentration in the final preparation were followed, as well as red blood cell and leukocyte contamination and the volume of the processed blood. donors' initial platelet count was not less than ¥ /l and the volume of the processed blood was not less than ml. according to histogram, the most frequent donors' initial platelet value ranged from ¥ /l to ¥ /l ( %). final concentration of the samples of tested donors ranged from . ¥ to . ¥ in the average volume of ml. regression analysis demonstrated that there was a correlation between the initial donors' platelet count and the obtained final concentrate. student's t test showed p < . . leukocyte contamination of the final concentrate prepared without the filter ranged from . ¥ /l to . ¥ /l. presence of red blood cells in the final concentrate ranged from . ¥ /l to . ¥ /l. p- therapeutic apheresis (ta) in croatian hospitalsadherence to respectable guidelines z zivkovic*, b jeren strujic*, s boras † , i bojanic † , b golubic cepulic † and z ivankovic † *clinical hospital dubrava, † clinical hospital center zagreb, zagreb, croatia introduction: besides considerable resources, ta requires high costs and risk for patients. therefore, indication for ta often considers interests of patient, hospital and requesting physician. the most respectable guidelines for the implementation of ta were defined by aabb and asfa, classifying total of diseases into categories (ctg), ranging from 'standard therapy' to 'lack of efficacy' . the objective of this study was to determine indications for ta performed in croatian hospitals in the period - , respecting aabb/asfa guidelines. results: during the observed period in croatia, ta was performed in patients suffering from various diseases. in ( %) patients ta was performed by membrane filtration, while in ( %) separation by centrifugation was used (table ) . according to the ctg, s of the aabb/asfa guidelines, ta was performed in ( %) diseases from ctg i, ( %) ctg ii, ( %) ctg iii, and ( %) ctg iv of patients. the most frequent indications included in ctg i were: myasthenia gravis ( %), collection of pbpcs ( %), sy. guillain-barré ( %), and plasmacytoma ( %). in ctg ii frequent indications were: poisonings ( %), systemic lupus erythematodes ( %), and rapidly progressing glomerulonephritis ( %), and in ctgs iii and iv: cytoreduction-polycythaemia ( %), thyroid storm ( %), gvhd ( %), and reumatoid arthritis ( %). ( ) the time spent for resolving h / , ( ) mtp / , ( ) discarded blood units / . iii group: wrong data input / , donor replacement / , marking errors / , error in determining blood group at the first blood taking / , errors in input medical consulting / and disregard of prohibitions / . the consequences are: ( ) the time spent for resolving h / , ( ) mtp . / . , ( ) discarded blood units / . conclusion: the analysis of errors has showed that the number of errors can be decreased by implementation of corrective/preventative action based on continual education of the staff, appropriate sop, effective organization, qmp for equipment. the conclusion of our study is that reducing the rate of work errors will decrease the waste of material and time, also that will decrease the number of discarded blood units. an iso standard for blood transfusion? background: in our search for an independent, objective assessment at western province blood transfusion service, we were unable to find one single model that met the specific requirements of blood transfusion. we therefore resorted to developing our own model but ask the question: why not have one international standard for blood transfusion? aims: our aim was to have a standardised system for the independent, objective assessment of our blood transfusion service with audits carried out by an internationally recognised body. we wanted a formalised, professional system of accreditation with inspection checklists, reports, certificates etc. methods: having moved away from accreditation by the american association of blood banks in mid 's, we evaluated various other options such as inspection by our government department of health or the world health organisation but neither organisation had trained inspectors or systems in place. we also investigated iso certification but, although this was acceptable on the quality management side, it did not cover the technical parameters relating to blood transfusion. results: we therefore developed our own model for accreditation that consists of three parts: • a quality management section incorporating iso principles; • a technical section incorporating specifications from the south african standards of practice (we also consulted the european, american, canadian and australian guides); • a laboratory section incorporating iso parameters (soon to be updated with iso ). we then chose to be accredited by the south african national accreditation system, sanas, an internationally recognised institution. once we had written a national accreditation checklist, sanas submitted this to two international accreditation bodies (iaf and ilac) for approval. the system has been in place for three years now during which time we have had four successful assessments. summary/conclusions: in developing our system, we reviewed what was being done elsewhere in the world and it became evident that, although there are great similarities between countries, there p- software for the management of the scansystem bacterial detection method the scansystem tm was developed for bacterial detection in blood products. to be implemented in blood banks, a specific software is now available in compliance with blood bank regulation in order to manage sample traceability and data file transfer. the software is divided in main levels: an administrator level to create an application configuration in compliance with customer needs (product bar code characteristics, frequency of the positive controls, manual or automatic data file transfer . . .), a technical level to manage the operators (password, id) and to validate some specific results, an operator level for routine testing. the software assess sample traceability when testing pools of samples from to more than . indeed, bacterial detection is performed for pools of to platelet samples and to red cell samples. each sample in the pool is traced through its barcode until the final result. the system is compatible with most of the barcode standard including isbt . in addition, the system checks each barcode protecting the sample against duplicate testing. the software assists and monitors the bacterial detection process from the sampling to the end of the test (final result), each step of the procedure is identified through its barcode and at each time, it is possible to know the test status for each sample. for a pool of samples, results can be obtained: 'negative' or 'on hold' for a positive result. for a 'negative' pool, each sample constituting the pool are determined as 'negative' . for an 'on hold' pool each sample constituting the pool must be tested as a single sample and the final result is 'negative' or 'positive' . data transfer may be manual or automatic. a final technical validation is necessary before the transfer through an active selection of results to download. final results are provided in a compliant format for an easy import into the blood bank database. all necessary information are displayed: 'machine id' 'product/sample barcode id' 'date' 'time of transfer' 'operator id' 'result' ('negative' or 'positive'). the main advantage of this software is a continuous check of each step reducing the risk of error in testing. it makes the scansystem tm test compatible with a routine use in blood banks according to the current regulations and quality assurance programs. is no overall consistency. we feel it would be of benefit to establish an international working group to investigate the feasibility of writing an iso standard for blood transfusion. the standard would harmonise quality management parameters based on iso principles and technical/laboratory parameters specific to blood transfusion. minimum technical specifications would need to be agreed upon based on the various standards and guidelines available around the world. this iso standard could then be used for the purposes of certification/accreditation or government inspections. this would ensure global standardisation of world-class best practices. first world countries would be able to achieve compliance and a subsequent step could be the establishment of an international forum to assist developing countries to work towards compliance in the longer term. residual leukocytes in leukoreduced cellular blood products -evaluation by flow cytometry web-based outcome review: do you know how productive your trima® can be? background: web-based outcome review is a new software tool developed by gambro bct for the management and the interpretation of data from the trima and trima accel tm automated blood collection systems. aim: does the interpretation of reports obtained through outcome review lead to an increase in the number of products per run and the overall productivity of the apheresis center? method: run data files (rdf) from trimaᮀ were collected and transferred onto the outcome review server. these rdf do not contain any donor related data that can lead to possible donor identification. the reports were generated on the outcome review website (gambro bct intranet), interpreted by a gambro bct employee and presented and discussed with the management of blood centers. results: a total of different reports can be generated on the website as a pdf file. for this study, reports were investigated. they are: doses per collection, doses per collection trend, platelet collection trend, platelet procedure performance, platelet procedure performance trend, product distribution, average procedure time, procedure time, machine productivity trend. the results obtained for a center can be compared to word-wide, national, regional or to other individual trima devices in the centre (benchmarks). this benchmarking allows the management of an apheresis center to compare the results, to draw the right conclusions and to develop and implement corrective actions. implementing successfully these corrective action plans will lead over time to productivity results that are more in line with the figures that are generally accepted to be the optimal production capabilities of trima. the reports also help to monitor the effects of the corrective action plan over time and to adjust this plan if the results are not in line with the expectations. reaching and maintaining the optimal production capabilities of trima will also increase the net revenue by procedure or decrease the cost by procedure for the blood centre. conclusion: web-based outcome review allows getting more products from the existing donor base by interpretation of the multiple reports and implementing the required corrective actions until optimal production capabilities of trima are reached and maintained. introduction: to examine the cell vitality of packed rbc's during storage several parameters like atp, free hb or , -dpg are used. less kits for the determination of atp are available and they need either a large sample volume and/or are time consuming. here we present the modification of a commercial testkit for a time-and cost saving detection of atp. methods: samples were analysed with (a) -phosphoglyceratekinase reaction according to bergmeyer, h. methods of enymatic analysis nd. edition. academic press, new york ; (b) detection via hplc and c) using a commercial testkit (r. greiner bio-chemica, germany). the atp-kit were minimized from ml to a total volume of ml and tests were performed in microtiterplates. results: samples were analysed in hplc and modificated commercial testkits, another samples have been examined in all tests. comparison of the results showed no discrepancies in the above mentioned methods. standard curves have been performed (range - mm atp) and statistical analysis demonstrated a given linearity (r = . ). variability has been calculated as . % (intraassay; n = ) and . % (inter-assay; n = ). the hand-on-time calculated for samples has been decreased from . hours to minutes. at least the costs of atp-determination have been reduced from € . to € . per sample. conclusion: performance of test kits in microtiter format is a fast and rapid method, reliable for high-throughput determination of atp in packed rbc's. background: in order to preserve both blood safety and availability it is mandatory that a minimal amount of blood units would be discarded due to defects in the materials and supplies used for blood collection, or to deviations in blood processing or storage. aims: ( ) to monitor the derangements of different materials and disposables used during blood collection and processing, and to study the suppliers' responses and corrective actions taken. ( ) to asses the relative contribution of different defective materials (dm) to the need to discard valuable blood components. materials and methods: about whole blood units were collected and processed by mda national blood services in [ ] [ ] [ ] . as part of the routine quality control activities, derangements of the dm used were recorded and analyzed. some different types of dm were defined. out of reports sent to the corresponding manufacturers for investigation, responses ( %) were received and analyzed. about % of dm were detected during blood collection. manufacturer defects of different materials were the reason for components discard in nearly % of cases. conclusion: defective materials are one of the major causes of the infringements of blood collection and blood component preparation processes. analysis and monitoring of the different defects and of the suppliers' responses and corrective actions are essential to improve products' safety and availability. establishment of a network for the exchange of information among international blood centers would enable the blood banking community to compare between different suppliers and to use the documented cases for training of personnel of both the blood services and the manufacturers. such a system may contribute to the improvement in quality of materials used and might lower the discard rate of valuable blood units. results: table analysis and characteristics of t ( ) comprehension of the blood bank's processes and the interaction between them and between the processes of the whole hospital. ( ) monitor, measure and analyze these processes, in order to improve their effectiveness continuously. ( ) implementation of internal and external quality controls for blood and blood products and implementation of appropriate statistical techniques for monitoring their results. ( ) identification of interested parties (doctors, donors, patients) satisfaction and taking up the necessary preventive or corrective actions to improve their satisfaction. the qms of our blood bank was certified by tuv rheinland in / / and the scope of the certification is: 'blood collection, testing of infections markers, production of blood components, compatibility screening for blood transfusion and other immunological tests and implementation of therapeutic schemes in thalassaemia patients' . the implementation of the qms based on iso : standards ensures the improvement of services provided by the blood bank and the increase in customer satisfaction, whether donors or patients are concerned. the former enjoy the respect and recognition of their social contribution, while the latter are assured of very high levels of service and health protection. finally, we shall not underestimate the positive impact of qms in the motivation of blood bank personnel. quality becomes integrated both in their professional and personal attitude and allows for achieving increased satisfaction from their work. equipment management in the national blood transfusion service in serbia introduction: new equipment was urgently needed in three blood transfusion establishments (bte) in serbia. equipment was mostly inadequate for core blood transfusion activities, placed in inappropriate facilities, very old without routine maintenance or calibration. also, technical documentation for most of the equipment did not exist, and procedures for equipment management and responsibilities were not defined. further more, coordination on equipment issues with the qa department was not recognized. service funded by the european agency for reconstruction, provided various equipment for the three blood transfusion establishments. the new equipment includes blood collection equipment, centrifuges, refrigerators, incubators, automated testing equipment, genetic analyzer and it equipment of . million euros value. before the new equipment is installed the bte's agreed to have the national procedures on installation, validation, calibration and preventative maintenance in place. this will ensure that the equipment can be properly installed and validated before use. the project has provided training on validation to the working group (wg) on quality. the wg has created national procedures related to the equipment, including quite new term validation. the same problems in implementation of procedures were present in all three bte's. significant efforts are made to explain to the staff how the equipment has an impact on quality, how to ensure that the equipment does what it is supposed to do, how to be confident that the results obtained are accurate and how important it is to generate records. qa managers played an important role in the preparation of facilities for equipment installation, making plans for equipment layouts, creating documents (master cards, instruction for use) and designing the validation protocols. the same procedures and records enable an exchange of results, comparability, sharing information on what works and what does not work between bte's. the qa managers also prepared an introduction of equipment requirements to the heads of departments, with special attention to the validation process so that they are able to fully understand what is required and why to validate their equipment. results: national standards in equipment management in serbia are set and are being implemented. qa managers carefully managed that the new, numerous equipment, delivered in the short period of months was correctly installed, validated, obtained with necessary documentation, followed by previously trained staff, so that equipment can be considered as controlled. the additional, positive effect is that validation is performed in one establishment for all bte in the country, allowing a more prompt response to problems and presenting of joint request to suppliers, as well as an easier way of monitoring equipment performance of the three bte's. organized equipment management has affect on every aspect of blood activities and finally to the quality of blood and blood components. background: the vista information system (vista tm ) is used in centers in europe as an apheresis management system. with vista tm it is possible to increase productivity, donor comfort and loyalty and therefore simultaneously improving the overall process in the center. aim: a calculation tool (microsoft excel) was developed to evaluate the added value of vista tm . three blood centers in different european countries completed a questionnaire using their local data. summarizing these figures gives us an idea about the impact of vista tm on the daily work and budget of a blood centre. method: the excel calculation tool that was used investigated major areas where vista tm could show added value: improvement of regulatory compliance, increase the efficiency in operations and improve productivity. results: regulatory compliance: the number of infringements decreased, causing a considerable direct financial gain because these events are very expensive to deal with. the time spent on regulatory reviews decreased with a mean value of %. operational efficiency: the number of reports is very site dependent: sometimes a report is made for every procedure together with the printout of a blood loss history form. because vista tm tracks all procedure related data, some sites decided to stop printing these types of reports and to go completely paperless. the percent time reduction in reporting is therefore very variable. however the % of errors related to these reports decreased considerably with a mean value of %. efficiency in operations was also obtained because of the number of reports that are available in vista tm . productivity, management and process reports allow verifying and correcting the daily operations of the blood center. increased productivity: depending on the center, also an increase in the number of platelet and plasma products collected was detected. the number of product discards caused by infiltration reduced with a mean value of %, mainly due to the possibility to have customized and more donor adapted trima settings. the percentage of whole blood donors targeted for conversion was very site dependent (min . %-max %). but because with vista any procedure brings between . and . products in general, the financial gain was considerable when donors could be converted from whole blood to apheresis. the use of vista allows the apheresis center to work with a reduced error rate and to increase the operational efficiency and the productivity. the financial impact of this has been estimated by the centers between € and € (mean value €) per procedure. establishment of national quality system in blood transfusion service in serbia introduction: the production of blood products is a semiautomated process in which the manual steps may be difficult to control and standardize. aim of the study: we introduced a specialised team for the blood production to test if this improved the control of the quality of the blood products. methods: the blood products tested for statistical process control were red cells in additive solution, buffy coat removed, and leukodepleted (ld) platelet pools prepared from buffy coats. the products were collected in t&b triple opti-pac from baxter and the platelet pools were ld using plx- filters from asahi and stored in platelet bags from baxter. using control charts, namely x-mrchart, exponentially weighted moving average ewma chart and for autocorrelated stationary data the ewmast chart, we examined if time series of quality control values were in statistical control. if not we examined if autocorrelation and/or differences between the technologists producing the blood products could explain the lack of control. data included approximately biweekly measurements of volume, haemoglobin (hb) concentration, hb/unit, haematocrit and log leukocyte count (wbc)/unit of units of red cells, measurements of volume, platelet concentration and platelet count/pool of ld platelet pools produced by a team of technologists and of ld platelet pools produced by a specially trained team of four technologists. results: log wbc/unit was out of statistical control due to systematic differences between technologists. apparent lack of control of volume, hb-concentration, hb/unit caused by autocorrelation disappeared when the ewmast chart was used. platelet concentration and volume of the platelet pools produced by the technologists were out of control. in that some technologists systematically produced low values. this could be explained by inappropriate handling of the platelet product between centrifugation and separation. systematic differences between the four specially trained technologists could not be demonstrated and they produced platelet pools with a significantly higher platelet count/pool. however, standard deviations of the four technologists differed significantly causing occasional outlying values. conclusion: training and routine in blood production or process automation, and also importantly, feed back to the technologists based on control chart quality control data, is recommended. background: one important principle of the use of blood and blood products is the ability to trace the units from donor to the recipient. this study set out to establish whether or not there was sufficient reporting on transfusions from the hospitals supplied by fort portal regional blood bank in western uganda as a means of establishing sound haemovigilance and look back systems. were reported with no unit number and could not be traced to the patients. there was sufficient reporting on the data requested by the blood bank. these results suggest that it is possible to establish effective 'look back' and haemovigilance systems. capture of data on outcomes and adverse effects will be necessary to fully establish the system. further efforts are required to educate those involved in transfusing blood about the need for adequate and accurate documentation. external quality assessment of blood grouping were misinterpreted as rhd-positive samples without the use of control reagent. rbc phenotyping was made correctly by . % of participants. the remaining . % of participants carried out the phenotyping incorrectly, while false-positive and false-negative results were derived in . % and . % of cases correspondingly. polyspecific human sera and monoclonal antibodies were used for abo, rh and antigens typing. the reason of errors in antigen detection was low quality of reagents. antibodies identification was carried out in six distributed exercises. % of participants detected anti-d-k-c alloantibody correctly. the rest of participants did not found alloantibodies or detected their specificity incorrectly. results of testing depended on quality of screening cells. thus, the participants using homemade pooled screening cells had a significant lower detection rate of antibodies comparing with those using diamed ag cell panel. consequently, the results of the first federal external quality assessment scheme show the necessity of improving the quality of red cell reagents produced in russia. in addition, the more appropriate training of staff is required. the importance of iso -quality system in increasing safety of blood transfusion introduction: hadassah hospital transfusion medicine department received on / iso -quality system accreditation. an essential element of this standard is the development of a reliable system to identify, document, analyze and correct actual and near miss events and assess the effectiveness of corrective and preventive actions. aim of the study: assessment of events and corrective actions following implementation of iso quality system. methods: events in the blood bank were identified by the staff, by internal or external audits and by complaints from the wards. all events were recorded and classified into two categories; quality system and technical. the latter were further classified into preanalytical (sample receipt), analytical (abo rh typing, antibody screen and identification, cross matching and phenotyping) and post-analytical (issue of components to wards). all events were graded into levels; -most severe, potentially harmful to patient. -severe, damage to process and result. -moderatly severe, damage to process only. -benign, no harm. events were corrected and effectiveness of corrective actions was assessed by monitoring recurrence of the event. results: during the years - , events were detected and recorded in the blood bank, they comprised . % of all tests performed ( ). most of the events were technical. all events were detected before causing harm to the patients. results are summarized in the table. *the percent analytical value is a summary of rates of events per test types included in this category. events detected in the quality system were mainly of severity level & , whereas technical events were mainly of severity levels & . analysis of event recurrence in the quality system revealed that % of events were resolved, whereas only %- % of technical problems were completely solved. the main source of event identification and documentation, in the quality system were audits whereas in the technical system, staff members revealed most events. the implementation of iso quality system provided a powerful means for recognition, analysis and study of patterns of near misses and actual events. understanding the root causes of events enables to choose the most effective corrective and preventive action to control event recurrence. evaluation of the frequency of events confined to the blood bank revealed a very low rate of . %. these results are in agreement with data in the literature. creating a non-punitive, non-stressing open environment, motivates personnel to identify and document events, which are regarded as opportunities for improvement and serve as important tools for upgrading transfusion safety. the explosive use of information technology and the speed with which it has spread into all life activities has created vulnerabilities for all organizations. those vulnerabilities are compounded by the complexity of information technology, limited time to market, development constraints, and constantly changing relationships between organizations and suppliers. growth in the sophistication of security threats makes it imperative that organizations remain equally competent in identifying vulnerabilities and mitigating security risks. aim: the goal of this document is to explain how isbt intends to provide guidance to the blood banking community on implementation of effective information security policy. when using information for critical activities, blood banks should consider information security as an important aspect of their management policies. evaluation of existing standards, such as iso and hipaa, allows us to establish a framework for information security without regard to the type of organization. it remains very difficult however, due to the complexities involved, to establish an information security policy without guidance. method: the isbt information task force was created to provide guidelines on information security for blood banking organizations of all sizes. the intent is to help them understand existing standards as well as provide tools for implementing information security policy. these guidelines are based on existing standards that are followed by most worldwide countries: iso and hipaa. results: information security can be defined as the 'protection of systems, information and services from accidental and deliberate threats to confidentiality, integrity and availability' . understanding existing information security standards was the first step for establishing a structure for the guidelines. the core is organized within an implementation framework and presented under the three following layers: . administrative for defining the it security organization, the information security policy, and information security awareness and training. . physical for providing solutions that relate to physical environment protection and access, equipment and it infrastructure security, and control for accessing computerized equipment. . technical for maintaining confidentiality of electronic information and ensuring that authorized access to information systems is maintained (technology relating to identification and authentication, logical access, operating system, network management, application access, etc.). strategy guidance is also included for senior managers in charge of establishing organization policy, including responsibilities and methods to successfully implement policy. further, the task force is addressing both risk analysis and management including identification of potential dangers to information systems (threat-source) and existing controls (risk description), as well as a plan to address identified vulnerabilities and mitigation of specific risks. conclusions: information security standards are prerequisite to understanding the issues involved when considering information vulnerability. international guidelines for information security, specifically directed to the blood banking community, are equally necessary if we are to identify, plan for, and mitigate risks associated with vulnerabilities to critical blood banking information. the isbt task force is committed to providing such guidelines. introduction: the important part of quality planning and quality assurance within production of blood components is measurement system analysis (msa). measurement system analysis was performed on microscopic counting of blood cells in our study. aim of the study: aim of this study is determination if microscopy counting of residual elements in whole blood plasma is suitable for quality control of blood components. methods: we practiced measurement system analysis in counting of residual elements (leukocytes and erythrocytes) in whole blood plasma. the counting performed two lab technicians in ten samples of plasma from whole blood. leukocytes and erythrocytes were measured in naggeotte counting chamber. we used the method of mean and range for the determination of reproducibility and repeatability (r&r) and analysis of variance for complex measurement system analysis. regulation diagrams were applied for the graphic statement. we determined the value of repeatability, reproducibility, coefficient r&r, variability among samples of plasma and total variability of measurement system. the important conclusion was to determinate if the microscopic counting of samples of blood components is sufficient with regard to quality parameters specified in guide to the preparation of blood components (erythrocytes: < . ¥ /l, leukocytes: < . ¥ /l). our results show that microscopy counting of residual elements in whole blood plasma is suitable for quality control of blood components. aim of the study: to provide transfusion services with a tool for proper qms implementation, an international collaborative study on qms applications, employing the 'process approach', has been undertaken by a group of transfusion services of varying sizes and structures with experience of qms, in collaboration with a university institute offering a master in qms implementation in health services, and an expert from a quality association. the 'process approach' serves as a tool to manage transfusion activities as a system based upon a network of processes and their interactions. guide-lines have been produced based upon this principle and will be published (volume and cd-rom) and distributed at no cost to all transfusion services of nations participating in the study. the main contents of the guide-lines' chapters are: through definition/analysis of single processes and the correlation network amongst these, the 'process approach' methodology renders the transfusion centre's functioning units completely interdependent, eliminates process interface barriers, provides personnel with a unified focus on the main transfusion objectives, and lays the basis for improvement of transfusion service quality, organization and performance through efficient control of processes' interactions. the blood screening system automated high-throughput nat system for simultaneous screening of hcv, hbv and hiv nucleic acids: full process surveillance e pfeifer*, b alessandri † , hr bachmann † , t barker † , y ohhashi*, c parkhouse*, j pinsl-ober ‡ , p wenzig ‡ and g ziegler ‡ *roche molecular systems, inc., pleasanton, usa, † roche instrument center ag, rotkreuz, switzerland, ‡ roche diagnostics gmbh, penzberg, germany introduction: the blood screening system combines on one deck both automation of dna/rna extraction from blood/plasma samples and multiplex pcr amplification and detection of nucleic acid targets. the system is designed for high-throughput single unit testing and pooled specimen processing. a data management system supervises and controls the complete process from initial sample pipetting through to result compilation and reporting. the objective of this project was to present the system assay and device built-in quality control measures that guarantee process safety and reliability. the study shows how internal control, external batch controls, pipetting sensors, validation & maintenance procedures, and a controlled development & manufacturing process yield an optimal test method and system stability. method: failure modes and effects criticality analysis (fmeca) was used to evaluate a mathematically derived safety metric for optimizing risk reduction. this method makes use of a system risk objective-function (srof), which provides a multivariate description of sample processing, amplification and detection steps. the method for analyzing system behaviour first employs product classification into risk domains, followed by ranking of process steps that are determined to be linked to known system hazards. this provides objective means for directing system design leading to risk minimization. the srof responses associated with redundant liquid sensing channels were shown to substantially reduce risk during sample or reagent transfer steps. the system liquid flow, airpressure-based (plld) and capacity-coupled liquid (clld) sensors detect aspiration and dispensing inaccuracies. sensor signal tolerance band widths studied for fluid classes representative of system reagents and for plasma samples from lipemic, icteric, and hemolized sample sources were shown to correlate with srof multivariate modelling. the impact of surveillance design elements on the srof response demonstrates that risk is functionally dependent on design elements. additional surveillance examples are presented that describes temperature sensing, robotic positioning and motion control. treatment of residual risk is addressed by introducing external controls that are configurable to specific workflow scenarios. the negative external control (nc) is used to check for contamination of reagents. five low concentration armored external controls, i.e. hiv- group m arna, hiv- group o arna, hiv- arna, hcv arna, and protected hbv dna are run at the beginning of a batch as a run-control measure. in addition to these roche controls the system supports running of user-defined external controls for co-validating the batch. the internal control (ic) is based on armored hiv- group m rna that is co-extracted and co-amplified with the external controls and the target nucleic acids potentially present in the sample. lastly, the system resource management monitors the status of samples, ready-to-use reagents and disposables via rack sensors and bar-coded bottles and tubes. the fmeca methodology provides a risk-minimized, comprehensive system design. redundant sensors with internal and external controls are evaluated through comparison of modelled versus actual run results. the system brings a new level of surveillance and throughput for automated pcr testing, and emphasizes roche's commitment to increasing the safety of the global blood supply. technical standards for safe storage and transport of blood components and blood samples objective: to implement standardization of technical specifications for safe storage, transport and distribution of blood samples and blood components intended for transfusion, as part of a quality system in blood transfusion medicine. methods: in the course of implementing a quality system in our blood establishment (distributing % of the national blood supply), we have developed standard operating procedures (sops) for temperature and hygienic conditions to maintain and control storage of blood components during their shelf life and to ensure their safe distribution to other blood services in the country and abroad, in compliance with eu directives / /ec and / /ec and the recommendations of the council of europe and who. procedures are validated and relevant records are kept. a statistical process control is also in place to monitor deviations from specified temperature and time range throughout the period of transportation. blood components collected and prepared for specific purposes (e.g. directed donations, irradiated units, hla-typed units, anti-cmv negative blood components and blood for neonates) are stored separately, and alarms and warning systems are in place. packing and transport conditions of red cells, platelets and ffp are submitted to the tests and criteria of adr (european agreement concerning the international carriage of dangerous goods by road). in greece, the adr legal framework has applied since . blood samples are classified according to adr in division . under un as diagnostic specimens, and the criteria for safe carriage include packaging, specific labelling and vehicle requirements as well as carrier obligations and personnel training. our blood establishment has a contract with biotrans, a private company accredited for packaging, storing and transporting blood, organs, tissues and cells as well as potentially infectious biologic substances and blood samples for diagnostic purposes. assurance system). the approach is specified in the form of requirements of art. . of the standard: the organization shall: (a) identify the process needed for the quality management system and their application throughout the organization, (b) determine the sequence and interactions of these processes, (c) determine criteria and methods needed to ensure that both the operation and control of these processes are effective. regional centre for transfusion medicine in biaĺystok was the first transfusion service in poland which was certified according to iso : standard. our expected profits from the implementation qms were: possibility to overview organization's pathways of operation and to inspire corrective and improvement actions, emphasis on the role of staff in the system, focus on self-control and responsibility for one's own work as a factor of staff's mentality creation/modification. our one year of experience with iso : standard proved the system to be handy tool of management for the organization collecting, processing, testing blood and releasing of blood products for the hospitals and to be well accepted by the staff. the implementation and certification of the internationally nor-malized quality management system simplify and shorten all accreditation and registration procedures required for legal activities of transfusion service as well as for any supplemental medical activities which may be performed by the centre. the implementation of qms facilitates the implementation of other quality systems and simplifies procedures required for the ce certification for the products. red blood cells stored in blood banks, normally undergo a series of chemical alterations, or storage lesions. the ultimate consequence of these lesions is a decrease in the viability of the red cells following transfusion. the chemical alterations are mainly changes in levels of na+, k+, cl-concentrations, ph and , dpg levels and they affect the electrical impedance of blood. the electrical impedance, cole-cole parameters, is determined mainly by the resistance of the red cell extracellular fluid (re), the resistance of the intracellular fluid (ri) and the capacitance of the cell membranes (cm). in this study we aimed to investigate the relation between blood parameters and electrical impedance changes, and their further clinical implication. all parameters were measured on erythrocyte suspension (es) samples during days of storage at oc on days , , , and . for whole blood (wb) samples during days of storage, same parameters were measured on days , , and . the measurement of the complex impedance of blood samples were performed in the frequency range from khz to mhz. by using the a hp lcr meter, the impedance z, and the phase angle a for each sample were read. these values were corrected according to the gain and phase characteristics of the amplifier; and the resistance r and the reactance x were calculated. each data was first fit to the cole-cole model; hence the cole-cole parameters, intracellular resistance ri, extracellular resistance re, characteristic frequency fc and phase angle a were obtained by using lms software. afterwards, cm was calculated by using ri, re, a and fc. whereas ri and cm decreased progressively with time on both wb and es, re changes showed some differences. the electrical impedance alterations were explained by measurements of na+, k+, clconcentrations, ph and , dpg by indicating days. storage of red cells resulted in a rise in extracellular k+ and a fall in extracellular na+, cl-, ph and , dpg. anova was used to evaluate differences in blood measures in relation to storage time. the results were presented as the mean ± sd. according to the regression analysis in spss, the intracellular resistance (ri) on both es and wb was affected more efficiently from all blood parameters among all other electrical parameters. although ri and re were correlated with na+, k+, cl-, ph and , dpg more significantly, cm measurements were failed to show correlations with blood parameters because of the intervening parameters, a and fc. the best relationship between the parameters mentioned above on both es and wb was ri and k+. ph changes were the same for ri and re both for es and wb. the correlation between parameters on es was better than those on wb, because whole blood consists of several particles that may affect our measurements. our study showed that , dpg has an effect on ri and re as efficiently as other blood parameters and therefore electrical impedance measurements may serve future implications. background: issue of quality blood products and donor safety are the main aims of blood transfusion services. a comprehensive quality system should be in place to fulfill these aims, which can be attained through strict adherence to the established standard operating procedures (sops). the drugs and cosmetics act of india, which controls the licensing of blood transfusion services, does not provide clear guidelines regarding plateletpheresis procedure. aim: we therefore established our own sop and operational flow chart for plateletpheresis that can be easily followed by other centers in india. methods: a total of plateletpheresis procedures performed using two cell separators (cs baxter, usa, mcs p, hemonetics, usa) were evaluated following our established sop. the mean platelet yield in cs was . ± . ¥ and in mcs p, it was . ± . ¥ per unit, however, only - % of sdps showed wbc levels < ¥ . six of donors complained of hypocalcemic symptoms. the operational flow chart designed in this study was found to be simple and easy to adapt by blood transfusion services in this country. the first advanced quality management training course for blood transfusion services in the western pacific region mk tan*, jp yu † and d teo* *health sciences authority, singapore, † who regional office for wpr, manila, singapore background: blood transfusion is a key part of modern medicine. a well-organised blood transfusion service (bts) is a prerequisite for the safe and effective use of blood and blood products. in , the world health organization (who) introduced a new initiative of quality management project (qmp) to achieve the goal of safe and adequate global supply of blood. through qmp, regional training centers were identified and quality management training (qmt) courses were established. in , centre for transfusion medicine (ctm) of health sciences authority singapore was appointed as a collaborating center for qmt in the western pacific region (wpr background: spectrophotometric method according to harboe was traditionally used at our institute for determination of free haemoglobin in supernatants of rbc blood components at the end of storage time. in the year hemocue plasma low hb system (hemocue, sweden) was introduced as a replacement method. aim: the aim of the study was to examine reliability and suitability of the hemocue method for measurement of free haemoglobin in supernatants of rccs. methods: hemocue plasma low hb method was validated and compared with harboe method. supernatants of rbc products were tested by two methods and results compared using regression analysis. additional testing was performed to investigate precision of hemocue method (within-run and between-day variation), trueness using reference material and to define optimal sample handling. results: regression analysis showed high correlation between two methods (r = . ), with higher values obtained with hemocue method. immediately after centrifugation one supernatant was measured times in order to determine within-run imprecision. coefficient of variation (cv) calculated from consecutive measurements was . %. to investigate between-day imprecision of the hemocue method one sample was divided in aliquots and frozen. one sample was thawed each day and measured. cv of five measurements was . %. during the period of validation measurements of reference material (low, medium and high) were performed. cv calculated for these measurements were . % (low), . % (medium) and . % (high). in order to investigate possibility of batch testing, supernatants of different rbc products were divided in aliquots and measured periodically during -month period. cvs calculated from measurements of each sample were in range . - . %. conclusion: hemocue plasma low hb method appears to be an excellent replacement for the harboe method. it is consistent, easy to use, measurements are performed in short time, and errors are minimized by eliminating dilutions and manual calculations. background: determination of haemolysis in red cell concentrates (rccs) at the end of storage time is routine method in quality control of blood components at our institute. for this purpose, haemoglobin concentration in supernatant of rccs is measured using hemocue plasma/low hb system (hemocue, sweden). according to manufacturer recommendation, visually turbid samples should be filtered before analysis with a . mm filter. because visual estimation of turbidity is highly subjective and unreliable, filtration of all supernatants before analysis using appropriate filters is possible solution for standardisation of the method. aim: the aim of the study was to investigate the effect of filtration of visually non-turbid samples on results of free haemoglobin measurement. methods: haemoglobin concentrations were measured in visually non-turbid supernatants before and after filtration using hemocue plasma/low hb photometer ( wb negative controls were used for each blood component. in all blood components tested bacterial contamination was detected using both types of bottles. in comparison with sa/sn bottles, nearly all enrolled microorganisms were detected faster in bpa/bpn bottles (see table ). all negative controls were negative (no false positive). the results of the study performed support the use of bact/alert bpa and bpn plastic bottles in quality control testing of different blood components. objective: management of returned blood products is important part of quality assurance activities in transfusion medicine. blood products are returned most frequently because of routine rotation of stock and because of nonconformities discovered after the product has been received. methods: qa data about returned blood products were retrospectively analysed for the -year period ( - ) . only blood products returned because of nonconformities were taken into consideration. data about the reasons for returns are presented and discussed. the top reasons for returns were positive dat, labelling errors, blood bag defects and visual appearance of blood units (see table ). in all cases positive dat was confirmed in our institute, and blood donors managed accordingly. nonconformities related to visual appearance of blood component and other nonconformities related to the quality of blood products were investigated and corrective actions conducted. in case of blood components returned because of damaged bag, significant problem is to investigate the cause of nonconformity (usually inappropriate transport conditions). conclusion: management of returned blood products is important tool in improving the quality of blood products. introduction: hemovigilance is the systematic monitoring of the blood transfusion chain for side effects and adverse incidents from the moment of blood collection until after administration of the unit to the recipient, and comprises all activities that can lead to a safer and more effective use of blood components. attempts to achieve a more safe and effective use of blood components constitute a huge task given the number of interventions and array of medical and not-medical personnel involved in the transfusion process. registration of the impact of all participants is a tremendous job as such. information management may enhance the chances for a successful hemovigilance. aim: the aim is, to establish a basis for all the information related to the chain, such as standard operating procedures, (inter)national guidelines, local transfusion protocols and forms, and procedures to direct the process. additional factors that contribute to the final results are the profile and role of employees, incidents, points of care, product information, prices, budget, contracts, etc. by clarifying and explaining the basis to all participants by means of an existing infra structure, everyone will gain access to identical, consistent and up-to-date information at all times. the primary activity is to create the basis by an outline of every individual link in the transfusion chain from donor to recipient. secondly, the resources, responsibilities, actions, and internal controls (what task, who is performing, why, which help, where, when) are documented. by creating distinct databases for these 'w's' in combination with a separate database for the hemovigilance process itself, it is possible to establish relations, hyperlinks, between the different databases. all the information collected in the foundation, complete with all the resources, responsibilities, actions, and internal controls is made available to target groups by means of the intranet in our hospital as well as in a printed handbook format. collecting and displaying the information on hemovigilance this way, creates a transparent and more easy-to-manage process. it establishes a basis, which incorporates all resources, responsibilities, actions, and internal controls to all participants and enables the organisation to operate both efficiently and effectively. it allows us to show auditors (both internal and external) which processes are related to which guidelines as well as the results in daily. in addition, it reveals which factors determine the genuine application of the guidelines in clinical practice. conclusion: by outlining the process, followed by defining, analysing, securing, on the 'w ' method, the hemovigilance process offers a stable basis and framework for all participants and may stimulate a more safe and effective use of blood components. background: transfusion medicine is a basic post-graduate specialty for medical doctors with a specific national curriculum in bulgaria. in order to improve the post-graduate training of medical doctors in transfusion medicine, a new curriculum was elaborated in . purpose of the new program: independent work of transfusion medicine specialists on all levels of the blood transfusion service (bts) -organization of bts, promotion of voluntary, nonremunerated blood donation, collection, processing, testing, storage and transport of blood and blood components, immunohematologic testing of patients, laboratory hematology, clinical experience, assistance and advice on diagnostic and therapeutic problems of patients, requiring treatment with blood products, teaching transfusion medicine to bts and clinical personnel. admittance and duration to training -medical doctors are admitted to post graduate specialization after a successful state examination. the overall duration of training is years, of which at least are obligatory for training in the national or regional blood transfusion centers. main sections of the curriculum: . organization of blood donation and blood transfusion, including promotion of voluntary, nonremunerated blood donation; organization, planning and information systems; organization of blood transfusion; quality management. . collection, processing, storage and transport of blood and blood components . laboratory hematology and specialized methods (general laboratory methods, immunology, immunohematology, transmissible infections, hemostaseology, nat techniques, flowcytometry) . clinical use of blood components and plasma products (treatment with blood products, adverse events and reactions, alternatives to blood transfusion). the new curriculum of transfusion medicine guarantees a better training of medical doctors, thus leading to safe and effective blood products their proper clinical use. introduction: transfusion medicine is integrated medical discipline based on clinical and laboratory practice. it is closely connected with molecular biology, genetics, as well as with apheresis, automatically techniques and transplantation. the aim of studies in transfusion medicine is proper education, skills, attitudes and knowledge of students at the medical faculty and of doctors on residency in transfusion medicine and other specialties about blood and its usage. material and methods: there will be presented how transfusion medicine is implemented in educational and health sector in r. results: there is -year specialization in transfusion medicine, established years ago (over specialists finished this specialization till now). we have postgraduate studies in tm started years ago. transfusiology, as subject at the medical faculty, is now included in new curricula of medical student, consists of theoretical and practical lectures. also, medical doctors on specialization in surgery, anesthesiology, obstetrics and gynecology, pediatrics, internal medicine, maxillo-facial surgery and others have obligatory -month education in tm. transfusion medicine is integral part in education of nurses and laboratory technicians; all personnel that work in transfusion field in our country finished -mounths course in tm and get certificate. conclusion: although we have already done so much in educational field, we will continue with our efforts to improve our collaboration with clinicians and to involve ourselves more in clinical disciplines. introduction: in hospitals of saint petersburg donor blood, its components and preparations, autoblood and its components, hemocorrectors are applied with the medical purpose at - % of hospital patients. the service of blood and the existing organization transfusion therapy in hospitals should provide maximal immunological and infectious safety and also its high medical efficiency. it demands special preparation for all doctors: general physicians on clinical transfusiology and doctors of blood service on all sections of the general, industrial and clinical transfusiology. clinical gemostasiology, pharmacology of hemotransfusion means and hemocorrectors, the organization of the blood service, the donor service; the organization, technique and technics of preparation of blood, its components and preparations, quality assurance, transfusion therapy programs, technique and technics of transfusion medicine, a problem of maintenance of immunological and infectious safety, preventive maintenance, diagnostics and treatment of posttransfusion complications, feature transfusion therapy in pediatrics and medicine of accidents). clinical physicians master all basic questions of clinical transfusiology, thus the special attention is given questions of clinical immunohematology and clinical gemostasiology, programs and a technique of transfusion therapy, the prevention of posttransfusion complications. employment are carried out in departments of city blood bank, hospitals blood departments. final examination under the test program and at interview shows sufficient mastering a theoretical and practical material (right answers of - %). the described system of postgraduate studies provides an opportunity of successful independent work of doctors on the workplaces both regular increase and qualifications not less often than time in - years. conclusion: the existing system of postgraduate education for doctors on transfusiology provides the blood services and hospital by the qualified staff. introduction: nowadays in hospitals of saint-petersburg more and more it is frequently applied the extracorporal hemacorrection (haemapheresis, haemasorbtion, plasmasorbtion, krhyoplasmasorbtion, ultrafiltration etc.) and photohemotherapy (optical radiation influence on blood) at various diseases and traumas. they are used at treatment almost % from the general number of patients of hospitals with positive results at % from them. for this purpose in hospitals there are specialized branches or cabinets with staff of the doctors -transfusiologists. therefore an actual problem is organization of postgraduate special education for them. because there is no specific blood banking and transfusion medicine training in either under or post graduate medical education those general practitioners have limited knowledge about this field. aim: to give basic knowledge and practice to those general practitioners moh has established a special training programme with the collaboration of medical schools for years. methods: this is a months programme which has basic components; theoretical education, laboratory and blood banking practice. the trainees are evaluated by a final examination. each group has limited cadets and the training is provided in selected blood banks with the collaboration of universities and moh training hospitals. conclusion: almost general practitioners are trained by this programme in the last years and those doctors helped to increase the quality of blood banking and transfusion service at their hospitals. background: even the history of public blood banking in turkey has dates back to , whole blood was comprising the majority of transfused units (more then %) in turkey until the last few years. aim: the main target was to decrease the whole blood use in a short time and establish countrywide effective blood transfusion practice. methods: there were no specific blood banking and transfusion education either at undergraduate and postgraduate medical education in turkey until the last few years. blood banks and transfusion society of turkey (bbtst) was established at with the main aim of education of the related people about blood banking and transfusion medicine. bbts has organized symposiums, national courses, national and international congresses since . due to increased knowledge about the blood components and improved infrastructure of blood banks whole blood consumption has decreased to national average to %. in most of the university hospitals and training hospitals this is around %. conclusion: like most of the public based behaviours dedicated efforts of civil initiative has changed the traditional habit of blood consumption in turkey by the direct affect of well organized educational activities. training of general practitioners in blood banking and transfusion medicine n solaz*, b keskinkilic † and c oruc † *ankara university, ankara, † ministry of health, ankara, turkey background: turkish ministry of health runs majority of the hospital blood banks in turkey. most of the moh hospital blood banks give service under the medical supervision of general practitioners. because there is no specific blood banking and transfusion medicine training in either under or post graduate medical education those general practitioners have limited knowledge about this field. aim: to give basic knowledge and practice to those general practitioners moh has established a special training programme with the collaboration of medical schools for years. methods: this is a months programme which has basic components; theoretical education, laboratory and blood banking practice. the trainees are evaluated by a final examination. each group has limited cadets and the training is provided in selected blood banks with the collaboration of universities and moh training hospitals. conclusion: almost general practitioners are trained by this programme in the last years and those doctors helped to increase the quality of blood banking and transfusion service at their hospitals. background: it has been accepted that during cardiac surgery the complement-system is activated which enhances ischemia-reperfusion injury, leading to postoperative complications as infections and organ failure. the lectin pathway is one of the mechanisms that can activate the complement-system, this pathway can be mediated by mannose-binding-lectin (mbl). the level of mbl in serum shows a wide variation. a low level of mbl can lead to more infections in some conditions and a high level to tissue damage after ischemiareperfusion injury. the effect of transfusions of erythrocyteconcentrates and plasma on the mbl levels and thereby on complications after cardiac surgery are not known. aim of the study: the role of pre-and postoperative mbl levels and the effect of transfusions on postoperative complications after cardiac surgery. in a randomized controlled trial cardiac surgery patients were included and blood samples were taken pre-and postoperatively. mbl measurements were performed by elisa assays. the data were linked with postoperative complications as mortality, infections and multiple-organ-dysfunction-syndrome-mods and with peri-operative erythrocyte and plasma transfusions. results: the mean pre-operative mbl-level was ± and postoperative ± mg/ml. there were no differences in preand post-operative mbl levels between patients with infections or mods compared with non-infected and non-mods patients. the difference in pre-operative mbl between non-survived ( ± ) and survived patients ( ± ) was not significant (p = . ). postoperative mbl levels between survived and non-survived patients was smaller. conclusions: pre-and postoperative mbl levels in cardiac surgery are not related to postoperative infections, mods and hospitalmortality. whether large amount of blood transfusions are affecting the mbl-levels and thereby the patients outcome is not known. introduction: patients undergoing cardiac surgery are receiving high amount of blood transfusions and are at risk for the development of infections and multiple-organ-dysfunction-syndrome (mods), these complications are influencing the survival of the patients. during cardiac surgery pro-and anti-inflammatory cytokines are released by different mechanisms. we found in a randomized trial in cardiac surgery a significant reduction in infections and mortality due to mods by transfusion of leukocytedepleted erythrocyte concentrates (ld) compared to leukocyte-containing, buffy-coat depleted erythrocytes (pc). aim of the study: the effect of ld on the concentration of proinflammatory cytokine il- and anti-inflammatory cytokine il- in relation to clinical outcome and complications after cardiac surgery. methods: in participating patients blood samples were taken before and after surgery. using elisa il- and il- were measured in these samples. the results were linked with the endpoints of the randomized trial: postoperative infections, mods and in-hospital mortality. results: all pre-operative concentrations of il- and il- were low. mean postoperative level for il- was ± and for il- ± . compared with patients without mods and without infections and survived patients only the il- was significant higher in patients who died and in patients with mods. there were no differences in mean levels related to ld and pc. the levels of il- were higher in patients receiving more then units blood transfusions compared to transfusions. conclusion: there is an association between mods and mortality and il- , not with il- . ld has no influence on mean levels of il- and il- . there is a correlation between transfusion of more then units and il- , not with il- . these cytokine-profiles are not associated with the beneficial effect of ld on the postoperative outcome in cardiac surgery patients. anemia and blood transfusion practice in critically ill patients e grouzi*, e tsigou*, p evagelopoulou † , g baltopoulos † and i spiliotopoulou* *kat general hospital, transfusion service, athens, † athens university school of nursing icu, athens, greece background: anemia is a common problem in critically ill patients admitted to intensive care unit (icu), but the consequences of anemia on mortality and morbidity in the critically ill is poorly defined. aim: to define the incidence of anemia and red blood cell (rbc) transfusion practice in critically ill patients in the icu) of our hospital, and to examine the relationship of anemia and rbc transfusion to clinical outcome. patients and methods: the period study was from july to december . patients were enrolled within h of icu admission. follow-up time was days, hospital discharge or death, whichever occurred first. results: a total of patients ( male, female, mean age . ± . years, range - ) were included in the study. the mean hemoglobin (hb) level at baseline was . ± . , which level was descending during the study. overall . % ( / ) of the patients received one or more rbc units while in the icu stay (mean . ± . units per patients). the mean pretransfusion hb was . ± . g/dl and the mean time to first icu transfusion was . ± . days. more rbc transfusions were given in the first week of the icu stay ( units vs , , units in the second, third and forth week respectively). the number of rbc units which a patient received during the study was positive associated with longer icu length of stay and an increase in mortality (r = . , p < . and r = . , p < . respectively). baseline hb level was significantly related to the number of rbc transfusion (r = . , p < . ), but was not an independent predictor risk factor of length of stay or mortality (r = . , p > . and r = . , p > . respectively). the mean baseline apache ii and saps scores were . ± . and . ± . respectively. furthermore both baseline apache ii and saps scores were significantly higher for patients with a baseline hb level of < g/dl ( . ± . vs . ± . and . ± . vs . ± . respectively), while the apache ii values were positive associated with a significantly increased likelihood of rbc transfusion (pearson correlation p < . ). conclusions: anemia is common in the critically ill patients, it appears early in the icu course and persists throughout the duration of the icu stay. rbc transfusion seems to be associated with worse clinical outcome. despite the intensive research for the transfusion practice, which taken place worldwide during recent years, data from our country is limited. the results of our study suggest that approaches to reduce rbc transfusion would be desirable. however, further well designed prospective studies with large number of patients are required to efficiently explore the risk of anemia, optimal transfusion hb threshold and the risk and benefit of rbc transfusion in the critically ill. consumption of blood products in a large, general hospital he heier*, j pillgram-larsen † , m hestnes ‡ , b gran*, a krog* and no skaga ‡ *ullevaal university hospital, oslo, † ullevaal university hospital, dept. of thoracic surgery, oslo, ‡ ullevaal university hospital, dept. of anestesiology, oslo, norway uuh is the largest general hospital in norway, and trauma referral centre for half of the norwegian population ( . mill) the trauma team performed initial assessment and resuscitation of patients, % males, during the first six months of . the aim of our study was to analyze transfusion practice at uuh with specific focus on trauma. materials and methods: blood consumption during this period was recorded. clinical data of trauma patients were collected from our trauma registry and anonymized before analysis. results: units of erythrocytes (er), of thrombocytes (thr) (buffy coat preparations from donors) and of s/d-treated whole plasma (op) (octaplasÒ) were transfused in uuh during this period. . % of er were given to surgical, . % to medical and . % to gynaecological and obstetric patients. % of er were given to patients above years. er units were given to patients (mean . units/patient; range - ). mean age of trauma patients was ± , median , range - years. for transfusion of this group local guidelines state that haemodynamically unstable patients should receive er if hgb < g/dl, irrespective of age and sex. eighty-eight patients ( . %) received er, of them as massive transfusion ( er units in < hours) ( . %), of these died ( %). altogether trauma patients received units of er ( . % of total uuh consumption), . thr ( . % of total) and units of op ( . % of total). massive transfusion consumed er ( %), . thr ( . %) and op ( . %) units. fourteen adult trauma patients ( . % of those transfused) received or er units only. lowest pre-transfusion hgb was . - . g/dl, median . , mean . ± ; highest post-transfusion hgb . - . g/dl, median . , mean . ± . five patients received er transfusion at higher pretransfusion hgb level than g/dl, but in er were given because of a hyperacute clinical situation. fifty-five% of issued er units had been stored for > days, while only % were issued before days of storage. discussion: life-saving effect of transfusion would seem evident in the massively transfused survivors, while in the other transfused patients documentation of clinical effect is inadequate. transfusion practice in trauma at uuh seems fairly well in accordance with internationally accepted guidelines. the trauma unit consumed a surprisingly small part of total uuh transfusion resources. trauma patients deviate from the general uuh patient population by sex and age; transfusion is otherwise mainly given to more elderly patients. further analysis is needed on transfusion indications and results to optimize the total use of blood products in uuh. special focus should be on transfusion to non-bleeding patients without haematological disease. it seems that only a small part of transfusion efforts results in the saving of life. in croatia national guidelines for the use of rhd gamma globulin were laid down in the year . in accordance with the guidelines, rhd gamma globulin is administered intramuscularly in doses of - mg and should be given to rhd negative women after delivery of rh positive children, after abortions, in week of their first pregnancy, as well as in cases pregnancies with an increased risk of fetomaternal hemorrhage. as to the latter, detection and measurement of fetomaternal hemorrhage are recommended. three years after the issuance of the guidelines a survey was conducted regarding the use of rhd gamma globulin that involved health institutions across the country. as many as deliveries and abortions were reported in . the institutions reported the usage of doses of mg rhd gamma globulin or doses/ deliveries + abortions. we compared our data with those obtained from similar surveys conducted in , i.e. before the issuance of the guidelines. in that year deliveries and abortions were reported, and doses of rhd gamma globulin or doses/ deliveries + abortions were administered. institutions were then divided into four categories: clinical hospitals, general hospitals with the capacity of - beds, general hospitals with the capacity of - beds, and institutions of rather limited capacity with gynaecology department. the range of the consumption of rhd gamma globulin/ deliveries + abortions in the first category was - with the median being ; in the second category there were - doses with the median being , in the third category - doses with the median being , while in the fourth category the range was - doses with the median of doses. the number of pregnancies which should have been protected with rhd immunization in year was obtained by the following formula: (frequency of rhd negative subjects) ¥ (frequency of the r gene) = . ¥ . = . . if a complete antenatal and postnatal preventive measures involving rhd immunization had been taken in , doses of rhd gamma globulin or mg/ deliveries + abortions should have been given. our research has shown that, despite of the national guidelines adopted in , the prevention of the rhd immunization in pregnant women is still not adequate in croatia. in fact, it has not improved since a year prior to the adoption of the guidelines. it has also been established that the category of the institution is a factor influencing the implementation of the protective measures. we consider that much more should be done on informing both women and gynaecologists about the importance of prophylaxis of the rhd immunization. consumption of plasma derivates in croatia g jaklin*, b golubic-cepulic † and m dondur* *general hospital, varazdin, † clinical hospital center zagreb, zagreb, croatia a increasing consumption of plasma derivates, their limited supply and insufficient national reserves are problems that croatia is faced with nowadays, as well as many other countries. in a study was carried out regarding the usage of plasma derivates. as many as health institutions took part having the capacity of acute beds out of a total of . the data regarding the use of plasma derivates were collected as follows: albumin, i.v. gamma globulin, and concentrate of coagulation factor viii in two periods of time. we divided institutions into three categories: clinical hospitals, general hospitals with the capacity of - beds and general hospitals with the capacity of - beds. institutional practice patterns regarding the use plasma derivates were compared among them. the parameters considered were the total consumption of plasma derivates, consumption per bed and consumption per inhabitant. data on the use of plasma derivates was obtained from hospital transfusion departments and pharmacies across the country. we compared our data with similar study carried out in . the consumption of albumin was . kg or kg/million inhabitants in and consumption per bed for the first category institutions was in range . - . kg with the median being . , for the second category the range was . - . kg with the median being . , while for the third category the range was . - . kg with the median being . . in in croatia the consumption of albumin was . kg or kg/million inhabitants. the consumption of i.v. gamma globulin was . kg or . kg/million inhabitants in and the consumption per bed for the first category institutions was in range . g- . g. with the median being . , for the second category was in range . - . g. with the median of . and for the third category was in range . - . with the median . g. in in croatia the consumption of i.v. gamma globulin was . kg or . /million inhabitants. the consumption of the concentrate of factor viii was . iu or . iu per inhabitant in . . iu, i.e. . %, was a recombinant factor viii. in the consumption of factor viii was . iu or . iu per inhabitant. discussion: the use of albumin showed stagnation. however, the use of i.v. gamma globulin increased . times and the use of the concentrate of factor viii increased . times if compared with the results in . self-sufficiency has not been reached in plasma derivates in croatia we needed l plasma for gamma globulin and l plasma for concentrate of factor viii for the level of usage of these plasma derivates in . significant differences in the level of usage among hospitals have been observed. these reflected a considerable difference in hospital policy regarding the use of these products in defined clinical settings. therefore, we would recommend that the national society sets out guidelines for the use of the products. background: blood bank good practice requires avoidance of rh alloimmunization. several studies report a probability of immunization of more than % following transfusion with rhd+ rbc's and as many as % in the case of platelets. aims: the purpose of this study was to investigate the development of anti-d and the causes of alloimmunization in a university hospital ( beds), reviewing our practice on the use of rhd+ blood components in rhd-recipients. method: a retrospective study was performed whereby . rhd-patients, from to , were evaluated for the development of anti-d analysing the data on the blood bank information system. results: from the . rhd-patients we found out identified anti-d, % ( ) detected before any transfusion in our hospital. of the left, nine were excluded because no information was available during some years. had history of pregnancy related to the immunization. patients were exposed to rhd+ blood components: were transfused only with rhd+ platelets (including two women of childbearing age); with rhd + rbc's. the remaining had been exposed exclusively to rhd -rbc's suggesting that some units could be mistyped. this idea was corroborated in three patients where there was a common donor (he was called for investigation). conclusions: transfusion services avoid as far as possible administration of rhd+ blood components to rhd-patients, although there are situations in which such transfusions are necessary. the retrospective review of records revealed the need for specific recommendations regarding the use of rh immunoglobulin to prevent anti-d immunization. the possibility of mistyping blood components also appeared in this review, emphasizing the role of these studies in the evaluation of methodologies used at blood banks. the purpose of the work: to present the usage of whole blood (wb) and blood products (bp) in the treatment of patients who are hospitalized in the internal disease department in gevgelija. material and methods: retrospective analysis is done according the data which were analysed in five years period ( ) ( ) ( ) ( ) ( ) . statistical methods which were taken from the history of the hospitalized patients in the internal department were used for analysis and the data of transfused wb units and units of bp were taken from the department of transfusion medicine. results: from the total hospitalized patients who have been analyzed, ( . %) received wb and bp, and there have been transfused units wb and bp. every patient, on an average, has been transfused with . units wb and bp. at the same time ( . %) units have been transfused as a wb, ( . %) have been transfused as red blood cells (rbcs) and ( . %) units have been transfused as a fresh frozen plasma (ffp). the data for every year particularly will be presented in our paper to the congress. the collaboration between doctors of transfusion medicine and health workers from the other medical branches is the most important thing in the medical practice. our aim is to raise the awareness among the health workers for the importance of blood safety and their role though adequate clinical usage of wb and rbcs, minimizing the non-useful transfusions, evaluation of reflexive information from undesirable reactions in the usage of blood and blood products, use the alternatives etc. the necessity of direct involvement of the doctors in transfusion medicine in the process of healthy workers' education from the other branches for regularly transfusion therapy via meetings and lectures is an imperative for regular function of the department of transfusion medicine. femoral neck fracture repair is one of the commonest orthopedic procedures. it mainly concerns intracapsular or intratrochanteric fractures and it may be considerably hemorrhagic, requiring blood transfusion perioperatively. the aim of our study was to investigate blood transfusion requirement in patients with femoral neck fractures repair at katerini general hospital during - and to compare them with other studies. one hundred sixty five ( ) unselected patients of whom ( %) were women and ( %) were men with a mean age of years (range - years) were studied retrospectively. seventy six ( %) patients had intracapsular fracture and ( %) intratrochanteric fracture. the mean hb concentration on admission was . g/dl (range . - g/dl) and the mean hb concentration at discharge was . g/dl (range . - . g/dl). a total of units of rbc were transfused (a mean of . units per patient). blood transfusion occurred in patients ( . %), ( - % in other studies) with a mean of . units per patient (range - units), ( . - . in other studies). patients with preoperative hb values < g/dl were transfused more often than those with hb values > g/dl ( % versus %) p: . . women were transfused more often men ( . % versus . %) p: . . patients aged > years were transfused more often than those aged < years ( % versus %) p: . . finally patients with intratrochanteric fractures were transfused more often than those with intracapsular fractures ( . % versus %) p: . . conclusions: in our study blood transfusion requirement for femoral neck fracture repair are similar with these reported in other studies. blood transfusion frequency is greater in patients with hb < g/dl, in patients older than years, in women and in intratrochanteric fractures repair. fresh frozen plasma guidelines and practices as saltamavros*, g talampouka*, c koumoundourou*, s dimitrakopoulos † and p tseliou* *st. andrews hospital patras greece, patras, † pyrgos general hospital, pyrgos, greece introduction: fresh frozen plasma transfusions should be done according to specific standards and guidelines. aims: we have reviewed the ffp transfusion practices followed in our hospital in an attempt to provide a set of guidelines and principles that will assist physicians and health care workers to make the right decisions for appropriate use of ffp transfusions. methods: retrospective review of ffp transfusions practices during the entire year of . we classified transfusion practices according to the diagnosis of the patient and also of the clinical depart-ment that demanded transfusion. then we analyzed our results by comparing the requests with the internationally approved guidelines for ffp transfusion and counted the percentage of ffp to rbc units. finally we discussed with our fellow physicians the proper use of ffp and informed them about the accepted guidelines. as we can see from the underneath table, diagnoses and departments with high consumption were: internal medicine %, plasmapheresis to patients suffering from guillain barre and ttp (thrombotic thrombopenic purpura) . % and trauma/surgery . %, cancer . %. summary/conclusions: the use of ffp corresponds to . % of the rbc units transfused in our hospital. plasma units should be used properly and according to internationally accepted standards. plasma use should be justified by the physician, in order to avoid unnecessary risks on behalf of the patient for effective treatment and care. to show gradual discontinuation of using whole blood and increased use of red blood cells (rbc) in the management of patients in the transfusion department of the clinical hospital 'zvezdara' . methods: data of wb and rbc use from to in our hospital. results: our data are presented in table . conclusion: after , wb usage rates systematically decreased from % to . %. however, in the period of - , the wb usage rates increased slightly, and we arrived at a generally very low rate of wb use, namely only in about % of the cases. education about transfusion medicine and rational use of blood in the medical curriculum was generally insufficient and very poor. therefore, we started an education program and we established a hospital transfusion committee (htc) with the task of medical control and monitoring the quality of clinical transfusion practice in our hospital. members of the htc are a specialist in transfusion medicine, an internal medicine specialist, an anesthesiologist, surgeon and gynecologist. we have been organizing courses for the medical staff, doctors and medical technicians since . background: platelet transfusions are given mainly to thrombocytopenic patients with malignant haematological diseases. currently the decision to give a prophylactic platelet transfusion is based almost exclusively on the number of circulating platelets in the patient although it is known that various clinical factors might influence the bleeding tendency. by free oscillating rheometry (for), using a reorox® instrument, it is possible to monitor the coagulation over time in whole blood and obtain information about clotting time and coagulum elasticity. aim of the study: the aim of this study was to find out if for using the reorox® instrument could be used to evaluate the hemostatic status of thrombocytopenic patients. methods: the change in elasticity over time in non-anticoagulated whole blood from leukaemia/lymphoma patients with thrombocytopenia was measured in the reorox® pre and post a platelet transfusion (n = ) and was compared with healthy controls (n = ). the effect of platelet concentration on coagulation was studied by diluting platelet rich plasma from healthy subjects with autologous plasma to various platelet counts whereafter the coagulation was monitored with for (n = ). the change in elasticity per minute (g'max slope) and maximum elasticity (g'max) were evaluated from the elasticity curves. results: the g'max, g'max slope and platelet count increased after transfusion for all patients. the thrombocytopenic patients had significantly lower g'max and g'max slope values both pre and post transfusion compared with healthy control subjects (p < . ). the measurement in platelet rich plasma showed that g'max and g'max slope increased with increasing platelet concentration. however patients with similar platelet count developed different clot elasticity. the reorox ® instrument responds to changes in haemostatic function in form of the clot elasticity. the fact that patients with similar platelet concentration developed different elasticity shows that clot elasticity is a function of not only platelet concentration but also of functional properties. the for method seems promising to evaluate platelet function. quality control of pre-storage leukodepleted red cell concentrates vu urlep salinovic, k perbil lazic and l lokar teaching hospital maribor, maribor, slovenia background: the system of quality assurance including quality control (qc) in transfusion medicine is most important for safe blood supply. the safety and quality of blood components are increased by pre-storage leukodepletion of whole blood (wb). aim: the qc of leukodepleted red cell concentrates (rcc), prepared from pre-storage filtration of wb (quadruple blood bag systems imuflex wb-rp terumo) is performed with the aim to be sure that the quality of leukodepleted rcc is in accordance with the guidelines of council of europe. in three years ( ) ( ) ( ) , units of wb were collected, among them ( . %) units were collected for pre-storage filtration and in ( . %) of these qc was done. within hours after collection, wb was filtered at room temperature. filtered wb was centrifuged at g for minutes and separated in rcc and plasma. the samples for qc were collected before and after filtration. for each unit, volume, hemoglobin, hematocrit, % of hemolysis and residual white blood cells (wbc) count were measured. the number of residual wbc after filtration was determined in the nageotte chambre. for all parameters the mean value and standard deviation were calculated. the results of qc for the following parameters were: volume ± . ml ( % corresponds with the guidelines of council of europe), hematocrit . ± . ( %), hemoglobin . ± . g/unit ( %), number of residual leukocytes . ± . ¥ ( %), hemolysis . ± . % ( %), the test of sterility was % negative. during filtration of wb, wbc were removed in approximately . %, the duration of filtration was ± minutes and the loss of hemoglobin was . ± . %. the pre-storage filtration of wb is highly efficient, . % of wbc were removed and the loss of hemoglobin was small. background: the patients of cardiosurgery use big amount of blood components. there is no uniform approach by treatment with blood components in these patients. the safest and the most rational use of blood is based on the individual treatment of a patient and the evaluation of the most clinical and laboratory factors. aim: the aim of our study is to analyse the use of blood components from , when the cardiosurgery department was founded in our hospital, to . the data about use of red cell concentrates (rcc), platelet concentrates (pc) and fresh frozen plasma (ffp) in the period from to were collected from information system datec. the average use of all three blood components per patient is presented. we were interested, if the average use per patient was diminished in the analysed period. results: the use of three blood components and average use of all blood components are presented in the table. the data from the table shows, that the number of patients increased more than three times, but the average use of blood components per patient was not essentially diminished. conclusion: during seven years period the use of blood components per patient in cardiosurgery was not diminished. for more rational use it is necessary to apply all methods of autologous blood transfusion because of the increasing number of cardiac operations and decreased number of voluntary blood donors. background: the presence of leucocytes in blood components is cause for appearance of various adverse posttransfusion reactions such as nhfptrs, urticary, anaphylactic shock, alloimunization and platelet refractorines, infection with bacteria and leucothropyc viruses (cmv, htlv). the removal of leucocytes from blood components through filtration is especially important in the treatment of patients with malignant diseases who need frequent transfusions of blood and blood components. this is because of their lowered immunologic status which is a result of the disease and received immunosuppressive chemotherapy and radiotherapy. aim: to show the prevention of posttransfusion reactions and the positive effect from transfusion of leucoreduced er. concentrates, produced with filtration in therapy of anaemia in patients with malignant diseases, treated in our daily transfusion hospital at medical center -stip. methods: patients with malignant diseases have been treated in our daily transfusion hospital in the last four years. most of these patients suffer from ca pulmonum, ca collonis, ca uteri, ca mammae. also, because of the secondary anaemia, the same patients were transfunded with at least two doses of leucoreduced er. concentrates. the blood donored by voluntary repeated blood donors was filtrated the same day after the donation, separation and the control of the same one. the blood was collected in baxter and terumo bags, and it was filtrated with baxter -sepacell rs - and pall -purecell rn filters. the analyses of leucoreduction were made for every filtrated and transfunded unit before and after filtration. the analyses samples were taken from the tubing system before and after the filter. haemathologic parameters were automatically made in the central clinic laboratory. results: er. concentrates poor with the leucocytes for about - . % were produced with the use od these filters, and platelets from - % with which side effects from frequent transfusions at these patients were prevented. with the routine monitoring of all patients none posttransfusion reactions were registered. the therapeutic effect is also important because of the fact that the number of er and the level of hg and hct remain almost unchanged. the aim of the blood banks is to help and to increase the safety of the blood components. the leucoreduction through of er. concentrates poor with leucocytes is a regular procedure in the therapy of malignant patients with remarkable clinical picture of anaemic syndrome and prevention the cancer recurrence end infection. the time of filtration is also very important which has to be shorter after collection of blood, because the leucocytes should be removed before they become disintegrated and relapse potentially dangerous substances end metabolites in the blood components. we have been applying so called ' prestorage filtration' because it has been proved that it is more efficient that bed -side filtration. background: the effect of leukocyte reduction of rbcs by filtration has been the topic of several rcts. these rcts investigated the effect of leukocyte reduction on mortality; post-operative infections and hospital stay in different patient populations. some rcts came up with answers that conflicted with the results of other rcts. aim of the study: with including the individual patient datasets of several rcts in one database, combined analyses are possible that may explain the differences in the reported results. using this technique, we may come up with answers (or questions) that cannot be obtained by performing standard meta-analyses of these rcts. methods: we coordinated several rcts comparing the perioperative use of buffy-coat depleted rbcs with the use of filtered rbcs. cardiac surgery patients were included in three rcts ( ¥ cabg and/or valve; ¥ re-cabg and/or valve; ¥ valve with or without cabg). oncologic surgery patients were also included in three rcts ( ¥ colorectal cancer; ¥ gi-oncology or vascular surgery; ¥ gi-oncology, vascular surgery or orthopedic surgery). the electronic data files of these rcts were uniformly recoded and entered in a single database. as different primary endpoints were investigated in the rcts, we focused on common endpoints, recorded in or more of the rcts. multivariate analyses were performed on: in-hospital mortality, -day mortality, hospital stay, stay on icu, postoperative infections, and mods. results: in the rcts, individual datasets from surgery patients were collected ( onco; cardiac; vascular; orthopedic, other). in the multivariate analyses, patients in the buffycoat depleted trial arm showed a higher mortality rate both in-hospital (p = . ) and at days post-surgery (p = . ). no association between randomization and stay in hospital (p = . ) or stay on icu (p = . ) was seen in the combined study population. also, no association of randomization with the incidence or duration of mods was seen. the analyses of post-operative infections in the total population showed the trial arm to be associated (p = . ), and 'hospital' to be far stronger associated (p < . ). however, when the oldest rct, that had not yet used our standard definition list for scoring post-operative infections, was excluded, the association with the hospital was lost (p = . ) and the trial arm became more strongly associated with infections (p = . ). in the analyses of surgery patients, the use of filtered rbcs, compared to the use of buffy-coat depleted rbcs, resulted in reduced mortality (both in-hospital and at days postsurgery) and a reduction in post-operative infections. the association of the variable 'hospital' with post-operative infections, as is frequently reported in literature, was initially confirmed in our analyses. however, when a standard definition for post-operative infections was used (excluding the datasets from one of six studies), this association was lost. background/aims: uk neqas for blood transfusion laboratory practice (btlp) operates an eqa service for uk laboratories (including eire) and participants throughout europe, including major groups in denmark (n = ) and portugal (n = ). in november a questionnaire was distributed to determine the criteria used for selecting phenotyped blood for different patient groups, including pre-menopausal women (pmfs). results were analysed by country to establish any variation in practice relating to the selection of k negative (k-) and rhc negative (c-) blood, since antibodies to these antigens are now the major cause of hdn. results: overall return rate was % (uk) and % (non-uk), although only centres treating pmfs were included in this analysis. k-blood was selected for pmfs by % in wales (n = ) and % in england (n = ), but only % in scotland (n = ), % in northern ireland (n = ) and % in eire (n = ). in mainland europe, variation was also observed: % in denmark (n = ), % in portugal (n = ) and % in other countries (n = from countries). fewer laboratories selected c-blood for pmfs: % in england and northern ireland, % in scotland and eire, rising to % in wales. mainland europe showed similar variation: % in denmark, % in portugal (all ccee matched) and % in other countries. there are no guidelines requiring selection of k-and c-blood for pmfs, but in the uk d negative blood is required for d negative females aged < years. trend analysis of questionnaire data in the uk, using theoretical clinical scenarios, shows a decrease in the number of laboratories that would select k + blood for a year old female (with pre-existing antibodies other than anti-k), from % ( ), % ( ) to % in . in this survey, k + blood was selected for a female aged (no antibodies) by %, whilst % selected a k + unit for a female aged (no antibodies), despite this patient being treated as a pmf for provision of d negative blood. a similar distinction was made between the and year old females in portugal and mainland europe. conclusions: variation in practice may at least in part be due to the availability of blood routinely labelled for rh and k. in the uk all donations are labelled, except for those from new donors, as are most units in portugal. uk questionnaire data ( ) suggested that > % laboratories would change to selecting k-blood for pmfs if all units were labelled. however, labelling alone does not account for the differences seen within the uk, and perhaps the trend towards providing k-(and to a lesser extent c-) blood for pmfs is influenced by advice from transfusion services. it would be of great interest to monitor and compare the incidence of hdn due to anti-k and anti-c in different countries to measure the outcome of differing practices for provision of blood to pmfs and to thereby inform future policy. there is no ultimate in ex-vivo assay described, which can predict the outcome of plt transfusion in vivo. current in ex-vivo assays and animal studies are rather very complicated to carry out, cost effective and time consuming. objective: we hypothesized that the quantitative measurement of gpib expression by facs can be used to predict the outcome of platelet survival post transfusion. in our previous studies we demonstrated that our phagocytosis assay can predict the plt survival sensitively (blood dec- ) . we isolated human washed plts by centrifugation and labelled with mepacrine and then incubated with pma-matured thp- cells ( °c). binding was measured by facs analysis of cd b/cd positive particles, and phagocytosis by counting mepacrine/cd positive particles. we measured gpib expression before and after plt-macrophages interaction by facs flowcytometry. results: gpib expression at surface of c fresh showed ± and after hours storage ± % expression. the gpib expression at surface of plt decreased and showed three populations with different densities high (gpib- ), low (gpib- ) and in-between (gpib- ). the binding and phagocytosis of plt showed an increase of ± % which implicates an indirect and negative relation to gpib- , and direct relation to gpib- expression. anti-human pselectin (cd p) delayed ± % the binding and annexing v ± % the phagocytosis of stored plts, after -hour storage. these results show that gpib expression is rather easy, reproducible test which can be standardised and be used as a very sensitive in vitroassay to predict platelet survival posttransfusion. transfusion and lung injury jd dodig*, d sovic † , m tomicic † and h sager* *university hospital 'sestre milosrdnice', zagreb, † institute for transfusion med, zagreb, croatia background: the respiratory tree has been viewed as an infrequent site of injury arising as serious complication of transfusion. in recent years, this view has changed as investigators have shown that two complications-circulatory overload and transfusion related acute lung injury-are relatively frequent events. case report: a -year-old men was admitted due to chronic macrohematuria. he had no history or current evidence of cardiac failure. the hb level was measured g/l. he received ml . % nacl and ml ringer solutions. after that, he was transfused with units of rbcs. during transfusion second unit he developed following symptoms: tachycardia, dyspnea, hypertension. massive pulmonary edema was noted. he was treated with mechanical ventilation, oxygen, diuretics, aminophillin, antihistaminic and corticosteroides. the patient recovered after being on ventilation for hours. two days after the patient was operated. after surgery he was transfused with units of rbcs. all transfusions were regularly performed. results: chest x-ray confirmed bilaterally pulmonary edema. the samples (patient and donors of first two units rbcs) tested were negative for the presence of hla specific and granulocyte antibodies. granulocyte agglutination and lymphocytotoxicity test were negative. tnf-a in recipient serum was slightly increased. conclusion: our patient is the first reported case suspected of trali, but all of the investigations didn't give us the answer. against neutrophils using flowcytometric detection of cell surface cd b expression and l-selectin shedding. methods: a hundred microl of volunteers' heparinized whole blood were incubated for minutes at °c with fmlp, lps or pma. monoclonal antibodies against hna a and hla-i, or patient serum were incubated with whole blood for min. surface cd b and l-selectin were detected using facscalibur. results: neutrophil activation was detected after fmlp, lps or pma stimulation. p map kinase inhibitor reduced activation induced by fmlp and lps. anti-hna a monoclonal antibodies induced neutrophil activation, which were also inhibited by p map kinase inhibitor. ten serum samples obtained from patients or donors who caused transfusion reactions were evaluated. five sera out of samples having anti-neutriphil and/or hla antibodies exhibited neutrophil activation, while two samples without leukocyte antibodies had no effect on any activation. conclusion: these findings indicate that neutrophils activation is regulated through mak kinase and detection of neutrophil activation may be useful to predict transfusion-related reactions. results: out of transfusion reactions were febrile, were anaphylactic, were due to circulatory overload, out of transfusion reactions concerned the transfusion of incorrect blood component. out of transfusion reactions concerned acute haemolytic reaction. post transfusion purpura or suspected trali was not seen. fatal complication was not seen. the reactions to plasma were predominately anaphylactic. we detected no case of bacterial contamination among the cultures of transfusion bags. conclusions: the incidence of reactions among patients malignancy was high, while among surgical patients was lower. the incidence of transfusion reactions during the months had no statistically significant difference. we suggest that the improvement in prevention of transfusion reactions require a continual vigilance system for rapid recognition and information regarding these complications. measurements of ige immunoglobulin in thalassemic patients, before and after blood transfusion background: many studies have reported the implications of proinflammatory cytokines including interleukin (il)- beta, il- and tumor necrosis factor alpha (tnf-alpha) in febrile nonhemolytic transfusion reactions. il- has been shown to accumulate in packed rbcs even after the procedure of filtration, which is explained by the release of il- from rbc receptors into the packed rbc super-natant. stress induced elevation in tnf-alpha levels was demonstrated in healthy individuals. aim: to assess the level of proinflammatory cytokines in peripheral blood of blood donors. material and methods: immediately upon blood collection, plasma was separated from postdonation blood samples obtained from blood donors and frozen at - °c. upon thawing, the level of the il- beta, il- and tnf-alpha cytokines was determined in plasma samples by elisa method using commercial kits for cytokine determination (roche molecular biochemicals). the level of il- beta was at the test detection limit in all donor plasma samples. in ( . %) bd, the level of il- was . pg/ml, exceeding the test sensitivity limit of . pg/ml. in ( . %) bd, the level of tnf-alpha was within the range of - pg/ml, with a test sensitivity limit of pg/ml. tnf-alpha levels > pg/ml were measured in plasma samples of ( . %) blood donors. the increased activity of blood donor's immune cells, indicated by elevated levels of the proinflammatory cytokines il- and tnf-alpha in peripheral circulation some blood donors, may lead to the occurrence of febrile nonhemolytic transfusion reactions in the recipients of the blood products manufactured from the blood of these blood donors. this hypothesis will be thoroughly investigated in our future studies. background: transfusion-related acute lung injury (trali) is a life-threatening complication of transfusion, under-recognized and underreported possibly lacking a consensus definition. aim: we report here a 'probable' case of trali syndrome in an elderly female patient. case presentation: an eighty-two year old female patient was transferred to the intensive care unit on the third postoperative day (pod) following the abrupt onset of acute pulmonary insufficiency (pao = mmhg, o saturation = %), hypotension (bp = / mmhg) and fever ( °c). this occurred ten minutes after initiation of an infusion of a unit of packed red blood cells (prc). the patient had no history of any cardiac or pulmonary disease. she was intubated and placed on mechanical respiration and supported hemodynamically. the cvp ( cm h o) ruled out fluid overload. the chest x-ray revealed bilateral pulmonary oedema, the echo cardiogram and blood cultures ruled out cardiac and infectious aetiology of the episode. after treatment for hours the patient improved significantly, was extubated and returned to the surgical unit on the th pod. reviewing the transfusion history we discovered that the patient did not receive any blood or blood component prior or during the correction of her ileum, but she was transfused a unit of ffp (fresh frozen plasma) five hours prior to the incident. the donor review revealed that the unit of ffp was from a -year old female with a history of multiple abortions whereas the prc unit was from a -year old male, a volunteer of several years who had no history of transfusions. there are some prerequisites for the implementation of a haemovigilance network and some of them have been met, so we can present the first results. methods: traceability of blood components is possible because there is unique information system in place in the whole country, identifying the donor, donation, each single blood component and identification of the recipient, but feed back information of the performed transfusion is still missing. cooperation between blood transfusion service and hospitals was established by introduction of hospital transfusion committees; the intensity and quality of their work is very different. homogeneity of reporting is achieved by the introduction of unique reporting form. a reporting route was defined: patients physician sends notification of atr to the local blood transfusion service. atr reporting form is prepared there and sent to the national blood transfusion service, where the data is collected for the centre for haemovigilance, which is going to be established very soon. data analysis will be responsibility of the centre for haemovigilance at the governmental level. type of adverse transfusion reactions and events is defined. education and information was passed to the health personnel by inclusion of haemovigilance in under and postgraduate programmes as well as seminars, scientific meetings and some publications. results: in the years - there were . blood components issued in slovenia and atrs were reported ( in blood components issued), in of them the severity grade was ( in . blood components issued). in the year there were considerable differences between the number of atr reports compared to the number of blood components issued among slovenian hospitals, ranging from in to atr in blood components issued. . % of all atr were not classified. conclusions: although the number of reported atrs was increased by % and % a year in and respectively, it can be assumed that the collected data is not complete. feed back reports, much more information and cooperation is needed, especially in some hospitals, which should contribute to a better registration of atrs and events in the future. the slovenian haemovigilance system still needs upgrading, but despite this, some important work has been done in building a national haemovigilance system. . considering the multiplicity groups in cattle and since there was no research on repeated blood transfusions reactions in iran's native cattle, we decided to consider crossmatching in different processes of repeated blood transfusion from a head of blood donor to five recipients and observe the clinical and hematological alterations. six healthy iran's native cow, . years old, with average weight of kg were used. the animals were dewormed by albendazole ( my/kg bw) and were kept for two weeks under uniform managemental condition. three days prior to blood transfusion, vital signs registration (temperature, heart rate and respiratory rate) blood collection via jugular vein was done to indicate the baseline of research parameters. after that, blood transfusions were performed from one donor cow to five recipients three times at one-week intervals. cross matching was done at each transfusion. after each transfusion the research parameters do determined. results indicated that one of the recipients cows experienced anaphylactic shock, in the first step of blood transfusion and another cows in the second step and finally in the third steps two other cows showed the serious shock. this is in the contrary of this opinion that the first transfusion can be given safely without crossmatching in cattle practice ( van der valt, et al. ( ) background and objectives: blood transfusion may lead to the manifestation of anti-hla and platelet-specific antibodies that may in turn bring about different problems like platelet refractoriness. it appears that the study of antibodies against hla-class i and platelet-specific antigens are useful for the selection and success of the appropriate treatment protocol. the aim of this study was to detect anti-hla and anti-platelet-specific antibodies by flowcytometry in patients with hematologic disorders (including acute leukemia, aplastic anemia) and patients with itp. in this descriptive study, anti-hla and platelet-specific antibodies were detected by flowcytometric technique, using sera drawn from patients with different haematological disorders who showed a poor response to platelet transfusion and from patients with itp. the results of anti-hla antibodies were then compared by panel reactive antibodies (pra). results: our results showed ( . %) out of ( . %) patients had anti-hla class-i antibodies in their sera. the frequency of each antibody isotype was found to be as follows: igm ( . %), igg ( . %) and iga ( . %). ( . %) out of patients had platelet specific antibodies and the frequency of each antibody isotype was found to be as follows: igm ( . %), igg ( . %) and iga ( . %). ( . %) out of patients had both antibodies. no difference was found between the two groups in platelet specific antibodies. despite significant correlation between flowcytometry and pra methods, pra can only detect antibodies which react with complement. conclusions: with increase in the number of platelet transfusion, immunization to hla antigens occurs; moreover, immunization against platelet specific antigens may also occur during autoimmunity. the presence of these antibodies may be one of the reasons of poor response to platelet transfusion and platelet refractoriness in patients under study. conducting similar studies with higher number of samples, platelet cross-match, and the use of hlamatched platelets for these patients are recommended. post transfusion purpura (ptp) is a rare, severe thrombocytopenia that results from alloimunization to platelet specific alloantigens, following blood transfusion. in this condition, the patient's own platelets are destroyed by the alloantibody even though they are not supposed to carry the 'guilty ' antigen. the disease is rare occurring mainly in multiparous women. the majority of reported cases involved antibodies against the platelet specific alloantigen hpa- a in a homozygous hpa- b patient. in a minority of cases the offending antibodies were directed against hpa- b, - a, - b, a, - a, - b. although self-limiting, the syndrome is characterized by severe bleeding with high morbidity and mortality; therefore prompt diagnosis and appropriate therapy is crucially important. ptp is a challenging diagnosis, because the patients are often critically ill or post-surgery, and have alternative explanations for thrombocytopenia such as infections or drugs. we present three patients with severe thrombocytopenia initially misdiagnosed. the first patient, a -year old women, had a past history of systemic lupus erythematosus and coombs positive autoimmune hemolytic anemia. at the present hospitalization, after antibiotic therapy for endocarditis, a severe hemolytic episode occurred and she need blood transfusion. when severe thrombocytopenia appeared, she was wrongly diagnosed as evans syndrome. the second patient, a -year old man, suffered from sepsis after vascular surgery and revealed clinical and laboratory picture of dic. the third patient, a -year old women, had end-stage renal failure and received heparin during hemodialysis, thus heparin-induced thrombocytopenia was first suspected. history of recent blood transfusion rose the suspicion of ptp in all this cases, and appropriate therapy with high dose iv immunoglobulin was started. adequate laboratory work-up confirmed the diagnosis. three different anti hpa-antibodies were identified: anti hpa- a, anti hpa- b and anti hpa- b, respectively. the platelets genotype of the first patient was hpa- b/ b, of the second hpa- a/ a and of the third patient, hpa- a/ a. the reported cases emphasized the importance of keeping in mind the possibility of ptp. incorrect diagnosis may lead to wrong treatment and fatal outcome. health sciences authority, singapore, singapore introduction: the haemovigilance programme in singapore was started by the centre for transfusion medicine (ctm) in . the system covers registration of collected, produced and transfused blood components, and monitors adverse transfusion reactions (atr). the programme runs on a voluntary, non-punitive and confidential basis. aims of the study: ( ) to gather and analyse reports of all adverse and untoward events occurring during transfusion of blood and components. ( ) to use the information acquired to determine the morbidity of transfusion. ( ) to provide guidance on corrective measures to prevent the recurrence of some accidents, and to improve transfusion safety. ( ) to improve public confidence by demonstrating to public, patients and professionals the safety of the existing transfusion system. methods: ( ) a common report form is used and made available to all participating hospitals. within the reporting system, the identification of the patient and staff involved are not required, to ensure confidentiality and protection of information belonging to the hospital. ( ) reportable events include immediate reactions during transfusion (haemolysis, non-haemolytic febrile transfusion reaction, urticaria, anaphylactic shock, bacterial contamination, trali), delayed untoward effects after transfusion (haemolysis, post-transfusion purpura, acute gvhd), transfusion-transmitted infections, incorrect components transfused, and near misses. ( ) within the hospitals, a responsible person ensures that all adverse events and untoward effects of transfusion are reported on the haemovigilance forms and provided to ctm for collation. within the ctm, the haemovigilance coordinator is designated to assist hospitals in investigating serious adverse events and advise on the reporting formats. results: ( ) the total number of reported cases has steadily increased since the introduction of the programme. ( ) the number of participating healthcare institutions has also increased to % (n = ). please refer to table entitled 'summary of the haemovigilance report - ' . ( ) the implementation of the haemovigilance programme in singapore is feasible with respect to the asian setting, and can significantly contribute to blood safety. ( ) there has been very good participation from the participating healthcare institutions, signifying greater awareness and willingness to partake in the programme. ( ) the results obtained from the programme have given rise to initiatives and recommendations aimed at reducing ( %) were rated for seriousness. of these, ( . %) were rated as grade (moderate to serious morbidity) or worse. ( . %) were rated for imputability to the blood transfusion. of these, a relationship to the transfusion was graded as 'certain' or 'probable' in ( . %) and as 'possible' in ( . %). overall relatively few errors were reported in comparison to other systems. a small number of reports concern (possibly) infected blood components, and imputability was deemed probable or certain only in a minority of these reports. autologous blood components gave rise to five reports (errors as well as mild transfusion reactions) which shows a relatively high risk associated with their use ( . per the rate of post transfusion hepatitis (pth) in israel in unknown. this information is important in order to learn about the residual infection risk in blood recipients. aim: to summarize the data on reported cases of pth. methods: suspected cases of pth are reported to mda blood services. the investigation procedure includes follow up testing of implicated donors and retesting of an archive sample of the transfused unit, if available. donors involved in suspected pth-b are tested for hbsag and anti-hbc. anti-hbc+ donors are tested for anti-hbs. hbv-dna testing is done if anti-hbs is less than miu/ml. donors involved in suspected pth-c, are tested for anti-hcv and alt. since hcv-ag or hcv-rna are performed, when appropriate. investigation is considered complete if all the involved donors are retested > months following the implicated unit. results: between between - suspected pth cases were reported: ( %) were pth-b, were pth-c ( %) and in patient both hbv and hcv infections were reported. investigation was completed in / ( %) cases, with % of the involved donors ( / ) being retested > months after the implicated donation. hbsag was not detected in any of the retested donors. anti-hbc was detected in donors involved in pth-b cases of which were also positive for anti-hbs. pcr for the detection of hbv-dna was performed on the 'anti-hbc+ only' donors, and none was found positive. only in / donors suspected to be involved in pt-hcv, anti-hcv antibodies were subsequently detected. this donation was collected and transfused before the introduction of anti-hcv testing in israel, which was implemented in . in another pth-c case, the implicated donor is still negative for anti-hcv, in follow up samples of up to months, but was found positive for hcv-ag and hcv-rna. pth investigation of all the donors involved was completed in % ( / ) of the cases where the patient received up to blood components. conclusion: in the past years an average of cases/year of suspected pth were reported to the israeli national blood services. investigation was completed in % of the reported cases. so far, there was no clear evidence of hbv transmission. in cases (out of . million blood units collected nationwide during - ) hcv seemed to be associated with blood transfusion: one caseprior to the implementation of anti-hcv testing and the otherprior to the implementation of hcv-ag testing in a donor that did not develop anti-hcv antibodies. these findings suggest that other modes of hbv and hcv transmission should be sought in blood recipients in israel. - . , p < . ). the seroprevalence for a-hiv in the bd population was . % (se: . ; ci: . - . ; p < . ) whereas in the a-hbc positive bd was . % (p < . ) and in the a-hbc negative bd was . %. from a-hiv positive donations, were also positive for a-hbc, that means that the sensitivity of the a-hbc in the detection of a donation a-hiv positive was . %. the relative prevalence (percentaje of positive donations for a-hiv in the a-hbc positive population divided the percentage of this marker in the donations a-hbc negative: rp) was . , which indicates that the number of bd a-hiv positive is . times higher in the a-hbc positive that in the a-hbc negative population of bd. as regards a-htlv, the seroprevalence in the bd population was . % (se: . ; ci: . - . , p < . ), in the a-hbc positive bd was . % (p < . ) and in the a-hbc negative bd was . %. from a-htlv positive donations, were also positive for a-hbc, that means that the sensitivity of the a-hbc in the detection of a donation a-htlv positive was . %. the rp for a-hbc as regards a-htlv was . , which indicates that the number of bd a-htlv positive is . times higher in the a-hbc positive that in the a-hbc negative population of bd. our results suggest that, in our bd population the screening with a-hbc would be useful to prevent other infections transmissible by blood transfusion, like retroviruses, because of the high sensitivity and the relative prevalence. . despite the high specificity of currently available elisas, the positive predictive value is lower in blood donors. therefore, immunoblot tests and polymerase chain reaction (pcr) have been adopted for routine testing in elisa +ve blood donors, by our service. . our data show that the real anti-hcv prevalence of our donor population is very low ( . %). . the selection and evaluation of appropriate assays of all donated blood for hcv infection ensure good laboratory practice and accurate post-notification counselling of infected donors. . given that donors who are elisa positive but persistently negative or indeterminate probably do not represent a risk for transmission, their deferral from donation increases the problem of availability of blood supply. . donor re-entry in the pool of donors is an issue for further discussion. . the introduction of nat technology may elicit more accurate responses and improve the screening process. background: the introduction of hcv antibody screening of all donor blood in represented a major step in the prevention of transfusion-associated hcv hepatitis and in identification of infected donors. the study of infected individuals provides a unique opportunity to define behavioral factors associated with infection. evaluating risk factors in hcv infected blood donors is essential for monitoring blood supply safety, donor screening effectiveness and developing appropriate prevention programs objectives: . to recognize the epidemiology of hepatitis c and how it differs geographically; . to investigate the risk factors for presence of anti-hcv antibody in blood donors; . to evaluate the effectiveness of our donor selection program in local level. methods: serological testing for hcv was performed according to standard procedures. initial screening was performed using secondgeneration eia and, after january , using third-generation eia. our study included a confirmation test (riba) a questionnaire was used to collect data concerning demographic, social and sexual behaviors, and number and type of donations of blood donors. the study also included testing of sexual partners and family members. changes in rates of hcv infections were evaluated by comparing yearly prevalence estimates. the overall prevalence of anti-hcv (eia) was . % out of blood donations. the average prevalence of hcv infection by riba was . %, which reaffirms the very low risk of transfusion-transmitted disease. the cumulative number of hcv infected donors was , with cases in males and cases in females. most infections were found among older persons ( % were aged - , and % aged - ). the seropositivity was higher in family/replacement donors ( %) than in volunteers ( %). the annual prevalence decreased throughout years. the relative importance of risk factors for hepatitis c was: transfusion %, hospitalization %, immigrants %, occupational %, sexual transmission %, injection drug use %, household contacts %, other %, tattooing %, unknown %. according to the criteria for blood donation, certain donors should have been excluded in the predonation interview but these donors had denied risky behaviour when questioned. the importance of sexual activity in the transmission of hcv has not been well-established as we tested sexual partners and family members and none of them was found positive. conclusions: our results suggest that major improvement in the safety and quality of our blood supply has been made in our area. introduction: apart from immuno-haematological complications, blood transfusion recipients are exposed to the risk of viral and bacterial contamination of donor blood. the latter infectious risks are generally associated with the number of donations that are needed in the production of blood products: the pooling effect. one measure recently being discussed is the generalisation of the use of trombocytapheresis for the production of trombocyte concentrates. normally, the trombocyte product is a concentration of trombocyte extractions from a pool of buffy coats: pooled platelet concentrates (ppc). in case of trombocytapheresis sufficient trombocytes for one transfusion can be collected from one single donor. aim of the study: in this presentation the effect of using % trombocytapheresis for the production of single donor platelets (sdp) instead of pooled platelet concentrates (ppc) on contamination risks will be assessed. these risks can be divided in ) the risk of bacterial contamination, ) the risk of viral contamination (e.g. hcv, hbv, hiv) resulting from window period donations, and ) the risk of contamination with tse or emerging infections for which no screening test exists. the contamination probability of sdp versus ppc is assessed on the basis of the production characteristics of both products, e.g. the presumption that the contamination risk per trombocyte product will be reduced by a factor equal to the number of pooled donations (five in our case). reduction of the bacterial contamination risk was estimated using the results of the bacterial testing of pooled and apheresis platelet products. as patients are likely to obtain multiple blood products during treatment, the contamination risk reduction through sdp is not only dependent on the reduction of risk in trombocyte products, but also will also dependent on the total number of blood products transfused and their associated contamination risks. the platelet recipient risk reduction was calculated on basis of the distribution of blood products received by the patient population of the university medical center utrecht (umcu) in the year . results: in the attached table the estimated risk reduction through % trombocytapheresis is shown for the general blood recipient patient and for the trombocyte recipient patients only. our analysis indicate that in platelet recipients, general application of sdp instead of ppc will reduce the risk for transfusion acquired tse infections by %, the risk of known viral infections by %, and transfusion acquired bacterial infections by %. the confidence intervals surrounding the results were obtained by bootstrapping. the large confidence intervals surrounding the reduction of bacterial infection risk is caused by the fact that only a limited set of apheresis trombocyte products were tested. conclusion: our analysis indicates that general application of sdp instead of ppc will not reduce the risk of transmitting infections to platelet recipients as linearly ( : ) as expected. whether it is a costeffective precautionary measure will have to be evaluated by a costbenefit analyses consideration clinical benefits and additional costs and risks of apheresis donations. introduction: hepatitis b is serious health problem world wide. its prevention, particularly in the population of blood donors is essential for providing good health care and protection. aim: the aim of this study is to present the distribution of hbsag(+) and hbsag(-) blood donors according to their profession. methods: specially designed questionnaires are used for interviewing the blood donors who has previously given signed consent for participation in this study. results: table shows the distribution of the blood donors in different professions. administrative clerks with ( . %) and the workers with ( . %) registered in the group of hbsag(+) blood donors, as well as workers with ( %) and administrative clerks with ( %) from the hbsag(-) group of blood donors are dominantly more frequent than the other categories of professions. health care professionals, housewives and farmers in both groups of blood donors are least frequent. taking in consideration the distribution of blood donors by the given professions in both groups, for u = and p > . there is no significant difference found. the analysis of the differences among the different frequencies, in distribution of blood donors according the profession, for d = . and p < . shows a significant difference, where the workers with ( . %) are the most dominantly represented. in relation to the issue of whether the type of profession of the blood donors is production or non production the results are presented on table . in the group of hbsag(+) blood donors the number of those who work in production profession- ( . %), is dominant over the number of those that has non-production profession- ( . %). in the group of hbsag(-) blood donors there is no significant difference between the types of professions. conclusion: having in consideration the professions of blood donors in both groups, for c = . and p < . there is a significant difference in the presented distribution. according to our study, which shows the horizontal transmission of hbv infection in the family in which there is an index case, the biggest number of participants in the study is workers, and the least number of participants are the farmers. introduction: blood donors, as part of the healthy population are tested for hbsag with each blood unit they give. therefore, they can be an epidemiological model for exploring the appearance of hbv infection in general population. aim: this study aims to show the distribution of hbv infection in blood donors in relation with their living conditions, space and facilities. the material needed for the study consists of the data obtained from confirmed hbsag(+) blood donors and confirmed hbsag(-) blood donors as control group. results: the table shows almost equal number of hbsag(+) blood donors that live in houses or flats. in the hbsag(-) group ( %) donors that live in a flat dominate compared to ( %) of those that live in a house. having in consideration the presented distribution (table ) for c = . and p < . there is a significant difference, that comes from the bigger number of blood donors ( ) that live in flat. as for the distribution of blood donors according the living space they use by member of the family (table ) , we can show that ( . %) of the hbsag(+) donors have less than m living space, in compared to ( %) from the hbsag(-) group. the bigger number of hbsag(+) blood donors with small living space gives bigger possibility for transmission of hbv infection in the family. the differences in the two groups for donors that have between and m , and between and m of living space per person, obviously are not very big. for u = and p > . there is no significant difference in the number of the donors in the two groups, when the available living space in m is discussed. introduction: when one of the sexual partners has hbv infection the other is also infected in from cases. aim: the aim of this study is to outline that the risk from transmission of hbv infection between sexual partners is smaller if they use condom as protection. methods: two groups of blood donors-hbsag(+) and hbsag(-) have been interviewed whether they are using condoms as protection, or not. results: table shows the distribution of blood donors concerning the use of condoms. table : in the group of hbsag(+) blood donors those who have not used condoms dominate with number of ( . %), in compared to those ( . %) who used condoms. these data are in favor of eventually possible sexual transmission of hbv infection in hbsag(+) blood donors. in the group of hbsag(-) blood donors dominate those who have used condom- ( %), compared to ( %) who have not. the given distribution of blood donors concerning the use of condoms for c = . and p < . , shows significant difference, which is due to the prevailing of the number of blood donors ( ), who have not used condom. of er -concentrates are leukodepleted. the choice of bacteriological control of empty bags for blood, bags with er -concentrates in additive solution, universal and iso group plasma, as well as the systems for taking of blood are taken on free choice. the control of the erytrocyte concentrates is performed on the first day after the preservation and dekanting, and again between the th- st day and th- th day after the preservation. the pulled plasma is controlled on the day of pouring (spreading), and the control of the iso group plasma on the day of deplasming. three months later the iso group and the universal plasma kept on the temperature of - °c is bacteriologically controlled again. bacteriological control is performed with standard procedures in the institute for health protection in stip. the transfusion transmitted infections are potentially dangerous complications of transfusion therapy in immunocompromised patients. the aim of this study was to determine the prevalence of transmissible infections in blood donor population in kashan, iran. a total of consecutive sera were tested for cmv-igm antibody, hbsag, hepatitis b core (hbc) antibody, hepatitis c (hcv) antibody, and hiv antibody with standard methods. of the sera tested, specimens ( . %) were cmv-igm positive. the frequency of seropositive revealed no significant differences between male and female donors. the frequency rates of cmv-igm seropositive tests tend to decline with increasing the age. there was no relation between the frequency rates of cmv-igm seropositive with the educational level, socioeconomic status, marital status, urban dweller and rural resident patients. the prevalence of hbv, hcv, and hiv antibody were . %, . %, and %, respectively. these findings implied important clinical applications because detection of cmv positive sera may reduce the risk for transmission of cmv in blood transfusion and thereby decrease the risk on cmv-induced complications. introduction: the worlds problem, aids, steel can't be said that is a problem in these three centers in r. macedonia, in which blood is collected, controlled, and distributed. found negative and of them were found positive for one of the three viruses (hiv- , hcv, hbv). with the elisa/axsym assay of the blood units which were negative by the procleix ultrio assay were positive for anti-hbcag and negative for anti-hbsag and hbsag. from those blood units units were given for transfusion following our blood centre protocol and the remaining units were discarded. the protocol consists of a good medical history, liver enzymes (ast, alt, ggt). we must take into consideration that from those that were found positive by the procleix ultrio assay was positive for anti-hcv and were positive for anti-hbsag. summary/conclusions: despite the fact of the short period of time we perform this method, the ability of the nat technique for rapid use, reliability and sensitivity in detecting three viruses simultaneously, indicates the need for immediate use in blood donation as a screening method. in spite of the high cost of the method, it is clear that this assay is a valuable tool in our blood centre to provide fast and safer blood. bacterial contamination of blood products is a persistent, but often overlooked, problem in transfusion medicine. in greece it is recommended that platelets (plt) must be used or discarded within five days post-collection. recent reports from europe have advocated the use of bacterial culturing of platelets on day or and, in case of negative result, prolongation of their storage time to days. aim of the study: to assess the prevalence of bacterial contamination of standard platelet units from whole blood, and to provide evidence that with the use of bacterial culturing it is feasible to extend the self life of platelets to days. materials and methods: eligible blood donors were bled according to standard operating procedures used in greece. plt were prepared from whole blood, solely for the purpose of the present study, by the platelet-rich plasma method. plts were stored for up to days at to °c with end-over-end agitation. other plts prepared from blood collected in triple-pack container system also provided with a predonation sampling device were also tested. plts were sampled in the bacteriology laboratory. plts were sampled on day , and . both aerobic and anaerobic culture bottles were inoculated with a -ml platelet sample. culture bottles were incubated at °c in an automated microbe -detection system (bact/alert system) until a positive reaction was detected or for days. all samples that were reactive were confirmed by routine culture. each reactive sample with bacteria growth on the routine culture was sub cultured for identification of the bacteria. results: a total of plt concentrates were cultured and bacterial contamination was assessed in each unit at day , and after collection. on of storage day two out of ( . %) plt units were found to be positive for bacterial growth. cases of unconfirmed positive results were noted at the beginning of the study. out of the other units which were negative on day and continued to be cultured for the next days, the assessment at day found no other positive. after further storage, at day , defined as the end of the prolonged incubation period, out of the plt concentrates ( . %) grew bacteria although testing of the same units on day and gave no signal. from the platelets units that were prepared from blood collected with a predonation sampling device, none of the plt concentrates gave a positive signal although pouches were found to be positive, and subculture showed bacterial growth of coagulase -negative staphylococcus. despite the relative small number of tested platelet concentrate units, our findings discourage specialists in attempting platelet storage time prolongation to days. bacterial contamination testing on day and a storage time of maximum days seems to be still the safest practice. bacterial screening of platelet concentrates using bact background: bacterial screening of blood components is a routine measure in the evaluation of blood product quality. at our institute bacterial screening is performed using bact/alert system. sampling and culturing of blood products is performed according to paul-erlich institute recommendations. methods: quality control data on the bacterial screening of platelet concentrates performed from - were retrospectively analysed. an initially positive (ip) and true positive (cp) rate, organisms isolated and time of detection are presented. results: a total of platelet products were tested during the year period. thirty ( . %) were found initially positive by bact/alert. the cultures screening positive were subjected to bac-terial identification to distinguish false positive from real positive signals. bacterial contamination was confirmed in ( . %) plt concentrates. positive cultures were confirmed and identified in an independent laboratory ( hbsag, anti-core, anti-hbs, anti-hcv, anti-hiv i/ii, anti-htlv i/ii, rpr. these patients were transfused with - units of concentrated red cells, depending on their problem. a total units were delivered from the beginning of their problem until december . the control were done using last generation enzyme-linked immunoassay (dade behring, ortho, biomeurieux), as also using automated enzyme-linked immunoassay (axgym). the same patients were checked by their physicians before the initiation of transfusions for the same diseases. results: we found: patients anti-hbc (+) and anti-hbs (+). patients anti-hbc (-) and Ánti-hbs (-) patients anti-hbc (-) and anti-hbs (+) patient anti-hbc (+) and anti-hbs (-) patient hbsag (+), anti-hbc (+) and anti-hbs (-). all patients were negative for hcv, hiv, htlv, and rpr. the same results were found also from patients' physicians. conclusions: we conclude that the blood supply for blood transfusion-transmitted diseases is % safe in our centre. these results are in accordance with current international literature. this is due to careful selection of blood donors, to high quality of corporation between departments as also to internal and external quality control. all these factors contribute to safety of transfusions, the quality of life of the patients and the protection of patient's environment. neither in the pipetor nor in the extractor runs was found contamination. no false positive were detected and all the positive samples confirmed. (see tables and ) . for hiv and hcv the specificity was . %. the validation criterion were met, so the system was implemented routinely in our laboratory. the purpose of our study was to analyse the applicability of the pall enhanced bacterial detection system (ebds) in the routine of our transfusion unit which is totally focused on apheresis platelet collection. methods: apheresis pcs, obtained by trima (cobe) and amicus (baxter) separators and re-suspended in % plasma and % ssp solution (macopharma), were submitted to microbiologic control using pall ebds system which uses oxygen percentage decrease as a surrogate marker of bacterial growth. the working steps were the following: - hour after donation, about ml of pc were sampled into the ebds collection pouch and then incubated at °c under continuous agitation (incubator helmer ) for hours. after this period, oxygen percentage was measured using an oxygen analyser (pall bdso ). the test is based on the 'pass/fail' principle. in case of 'fail' result the microbiology department has drawn up the procedure to follow in order to confirm the data and to allow the micro-organism to be identified. the incidence of post transfusion hepatitis has been reduced by blood donor screening for hbsag, but the hbv infection is still responsible for a certain cases of post-transfusion hepatitis in world-wide. in this study the hbsag negative blood units were evaluated for anti-hbc and hbv dna by pcr method. an extra sample was collected from hbsag, anti-hcv, anti-hiv and rpr-negative blood donors. all of samples were examined by approved anti-hbc assay. all of anti-hbc positive samples were tested by hbsab assay and evaluated for hbv dna (pcr). the sensitivity of the hbv dna (pcr) assay was estimated geq/ml according to vqc proficiency and run control panels. ( . %) out of samples were positive for anti-hbc. ( . %) out of anti-hbc positive samples were hbsab positive, and ( . %) were hbsab negative. all of samples were assayed for hbv dna (pcr) single and all of them were negative for hbv dna (pcr). further study for evaluation of anti-hbc test as a screening assay for blood unites in high hbv infection prevalence area strongly recommended. early detection of hepatitis b surface antigen: a comparison of ten assays hbsag detection is the corner stone of detection of hepatitis b virus infection in blood donors and patients with hbv infection. one of the most challenges is sensitivity of the technique and kit. in this study ten different assays evaluated by seroconversion and performance panels. some of them can not be used as screening assay due to low sensitivity. the sensitivity of ten hbsag assays from biorad, dade behring, biomeriux, diasorn, radim, diesse, thermo. biokit, gb and shanghai companies were evaluated by two or three seroconversion and two performance panels from boston biomedica ink. seroconversion panel is a series of samples that collected over a period of time from individual developing antibodies due to a primary infection. for evaluation of the assay sensitivity who and other notified body in the world-wide recommended the seroconversion and performance panels. the hbsag assays are two groups. group one with high sensitivity included six assays. they can detect ad and ay subtypes from . ng/ml bbi to . - . ng/ml bbi respectively. low sensitivity group included four assays and they can detect ad and ay subtypes more than . and . ng/ml bbi respectively. for blood safety, the high sensitivity hbsag assays recommended for blood screening and all assays should be evaluated by seroconversion and performance panels. diagnosis of chronic hdv infection is usually by antibody testing and hbv dna detected by pcr method. it is rare to find patients with two replicating hepatotropic viruses and if the accompanying hbv is replicating, prognosis will be very poor. to clarify the correlation between hepatitis delta virus infection and hepatitis b virus dna positivity, sensitive hbv dna (pcr) assay was used. the presence of hbv dna was investigated in patients referred during the aug. to dec. . all of them were hbsag positive. all samples were evaluated for hbv dna (pcr). the sensitivity of the hbv dna (pcr) assay was estimated geq/ml according to vqc proficiency panel and run control. anti-hdv was tested by commercial available enzyme immunosorbent assay. ( . %) were hbv dna positive and ( . %) were negative. ( . %) out of patients had evidence of delta infection and ( . %) samples of hbv dna (pcr) negative patients were positive for delta agent. the serum alanine aminotransferase (alt) levels in out of hbv dna (pcr) and anti-hdv positive patients were higher than reference interval, but only in out of hbv dna (pcr) negative and anti-hdv positive samples were higher than reference interval. the present data indicate that . % of patients with chronic hepatitis b have hepatitisdelta infection. patients with hbv dna (pcr) negativity had a significantly higher prevalence of delta marker ( . %) than those with hbv dna (pcr) positivity ( . %). delta rna testing in positive hbv dna and anti-hdv patients is recommended. introduction: reduction of the window period of hepatitis c virus (hcv) infection represents an important goal in the transfusional and diagnostic setting and nucleic acid technology-based tests have been introduced in some developed countries to reduce the potential risk of transfusion-associated infection. a prototype assay designed to simultaneously detect circulating hcv antigen and anti-hcv has been developed by biorad (biorad laboratories limited, marnes la coquette, france). aim of the present study: to define the cut-off (co) value of the assay and to evaluate the specificity and sensitivity of this new assay in the detection both of antibody and antigen comparing its efficacy with commercial assays. methods: in order to establish the co value and to evaluate the specificity of the assay, we tested sera samples from the general population and 'difficult' sera from haemodialysis patients (n conclusion: the new assay shows high sensitivity and specificity and could be a useful tool not only in the diagnostic setting, where procedures to reduce the window period, such as antigen or hcv-rna detection, are not currently recommended, but also in the screening of blood donations, when nucleic acid technologies is not feasible due to costs, organization, emergency and/or logistic difficulties. introduction: in recent years the concern with the blood safety regarding the transmission of blood-borne viruses has been improved. this safety has been achieved with the combining of different strategies, such as a careful selection of donors, the screening for relevant virological markers and the viral inactivation/ removal methods. more recently, the implementation of the nucleic acid amplification technologies for the detection of hiv- , hcv and hbv, has increase this aim by reducing the 'window period' of the infections. other viruses, such as parvovirus b (pb ) and hepatitis a virus (hav), can raise problems to the blood safety. these infections could provoke serious complications in some risk groups, like pregnant women, patients with haematological problems, children and patients with immunodeficiency. material and methods: an observational study was performed to determine the prevalence of pb and hav in portuguese blood donors. we gather, during four months, plasma donations and joined them into pools, with no more than donations each. [ ] [ ] [ ] [ ] [ ] in voluntary donors the anti-hcv prevalence ranged from . % to . %, in family replacement donors from . % to . %, autologous donors from % to . %. we observed that the anti-hcv prevalence has a decline tendency during years in blood donors. according to sex the anti-hcv prevalence in men is . % and women . % (p = . ). over the year periods the prevalence in men has a decline tendency ( . % to . %; p = . ) and increasing tendency in women ( . % to . %; p = . ). according to age group the anti-hcv is . % in - age group, . % in - age group, . % in - age group, . % in - age group (p = . ). the prevalence of anti-hcv is higher in fds than vds, but not statistical significant. [ ] [ ] [ ] [ ] [ ] . a total ftd and ad have been tested for hbsag. a sample was considered as hbsag positive when found repeatedly reactive by rd generation. immunoassay method (elisa). the chi-square test was used for statistical analysis. results: the -year overall hbsag prevalence among first time blood donors was . %. and ad . %. among autologous blood donors was observed a decreasing hbv prevalence from . % to . % in . according to age the prevalence was higher in - year group . %, while according to sex was higher in man ( . %) than female . % (p < . ). among ad, a decreased hbsag prevalence according to age was observed in men and women. the same trends by sex and age were observed in ftd. the prevalence of hbsag in ad was lower than in ftd. however, from - hbsag prevalence has decreased in the same proportion in both population. this decreased can explain by to main factor: the improvement hbsag screening method in blood donors and decreased the hbsag prevalence in general population. ( : ) . the hbv dna-emia in hbsag negative samples was . ¥ - . ¥ copies/ml. in two donors anti-hbc total was positive and in one anti-hbe was also detected. in one donor the glycin alanin mutation in the s region was identified. the frequency of hbv dna pos/hbsag neg donors in poland is high ( . %) therefore the decision to introduce routine hbv nat screening is justified. ( / ) with stored apheresis and whole blood derived platelet concentrates. of these failed results there were confirmed positives (presence of bacteria in both the ebds pouch and the platelet mother bag by culture) representing / . the bacteria detected were staphylococcus or streptococcus sp. of the fail results were false positives (no presence of bacteria in the ebds pouch and the platelet mother bag by culture) representing . % or / , and were not confirmed initial positives (no bacteria in the mother bag by culture, ebds pouch not tested) representing / . there was one reported case of a missed detection with confirmed presence of bacteria (staphylococcus epidermidis) in the mother bag by culture. subsequently, the bacteria strain was isolated and inoculated into platelet units in our laboratory at levels as low as cfu/ml. in all cases the pall ebds was able to detect. this supports the hypothesis that this missed detection was the result of a statistical sampling error rather than a system failure. the results from blood centers routinely using pall ebds demonstrated effective detection of bacteria in platelet products stored under routine conditions with a true positive rate of / , and with a low false positive rate (< . %). this is comparable to a recent survey result with other culture based systems. summary/conclusions: the minority group of pregnant women who come to labor without prenatal testing of hepatitis b and c revealed essentially similar prevalence of anti-hcv with healthy bd even if definitive confirmation is probably increased in this minority group. there is however markedly higher prevalence of hbv infection in the pw so that screening for hbv is essential for the prevention of vertical transmission. the systematic screening of bd with anti-hbc serves as further assurance for the prevention posttransfusion hepatitis eliminating only . % of the possibly infectious, a percentage which can be restored to the blood pool after proving their immunity. methods: blood samples were screened for the presence of hbsag, hcv and hiv antibodies using enzyme immune assay and for syphilis using the tpha test. the results were analysed retrospectively. all samples with results at or above the minimum positive value were considered reactive. the tests for hbsag, anti-hiv and anti-hcv were repeated in duplicate in all reactive donations. blood units that were reactive in the primary or secondary assays were discarded. hiv positivity was confirmed by western blot analysis using hiv blot . (genelab diagnostics) results: results from a total of screened donors were analysed. hepatitis b surface antigen rates was . %; anti-hcv seropositivity was . %; anti-hiv seropositivity was . % and tpha seropositivity was . %. one study calculated this risk to be one in for hbv, one in for hiv and one in for hcv. it is therefore important to take a careful history from blood donors to eliminate those at high risk of infection. in view of the high infectivity of hiv positive blood, it is important not only to screen donated blood but also to exclude donations from high-risk individuals, such as males who have engaged in homosexual activity and intravenous drug users. a careful history should identify those who should not give blood. in turkey, among blood donors the average hbsag prevalence in - was . %. but it had decreased to approximately . % in . anti-hcv positivity has been reported to be . % between and . but it was approximately . % in . rpr positivity in blood donors in turkey was reported to be < . % in and . % in . in , the rpr rates was . %. in our study these rates are . %, . %, . % and . % respectively. anti-hiv seropositivity was found around . introduction: the serological detection of specific antibodies to treponema pallidum (tp) is an effective means of diagnosing syphilis, and an automated chemiluminescent assay is ideally suited to testing large numbers of specimens for the laboratory diagnosis of the disease. aims of the study: to develop a qualitative syphilis assay for the detection of tp immunoglobulin m (igm) and g (igg) antibodies. the assay will be used for the serological diagnosis of syphilis using the architect platform, which has the capacity to test specimens/hour. the two-step assay is based on paramagnetic microparticle chemiluminescent technology, utilising microparticles coated with three recombinant tp antigens (tpn , tpn and tpn ) and acridinium labelled anti-human igg and igm monoclonal antibodies as conjugates. in the first step, specimens, microparticles and diluent are incubated together, prior to a wash step; in the second step, acridinium labelled antibodies are added and after washing, pre-trigger and trigger are added to produce chemiluminescence, which is measured as relative light units (rlu). specimens yielding rlus less than the cut-off are considered negative, while those yielding rlus greater than the cut-off are considered positive. the sensitivity of architect syphilis tp was determined to be %, after testing specimens that were previously screened as syphilis positive in fujirebio tppa; no prozoning was observed with high positive specimens (over titer by tppa). the specificity generated from testing hospitalised patients previously screened as tppa negative, was . %. testing a mixture of sera and plasma from random donor specimens, generated donor specificity figures of . %. the precision (cv%) with a positive control was . % ( % confidence interval: . - . %) by the standard -day nccls analysis (ep a ). in a study conducted at asahikawa medical college hospital, in which, positive and negative specimens were tested, concordance with fujirebio tppa was determined to be %. no significant interference to the assay was observed from bilirubin (conjugated type and free type), haemoglobin or lipid. the architect syphilis tp assay is an automated, specific and sensitive test for the detection of antibodies to t. pallidum. background: hcv exposure of blood donors is serologically determined by the detection of anti-hcv antibodies in serum or plasma. however a 'window' period of - days after exposure exists during which specific antibodies to hcv antigens cannot be detected. hcv rna detection and/or hcv core protein testing result in dramatic reductions in the preseroconversion window period. the new bio-rad test, based on the simultaneous detection of hcv core antigen and anti-hcv (core, ns , ns ) antibodies, improves the detection of hcv infection in the early phase. aims: the aim of this study is to assess the performance characteristics of this new screening microplate immunoassay, monolisa hcv ag-ab ultra, by using the bio-rad evolis automated microplate processor system. methods: this two-step elisa assay is based on the combination of an indirect test for the detection of antibodies (core, ns , ns ) and a sandwich test for core antigen detection. results are available within . hours, with sample addition monitoring and color coded reagents. no specimen pretreatment is required. evolis is a self-contained microplate processor designed for full automation of microplate-based eia techniques. the walkaway system can process four microplates at a time with continuous loading of samples and reagents. positive identification of samples, reagents and microplates, usage of disposable tips with clot detection, integrated quality control and complete traceability provide a high level of safety management. the monolisa hcv ag-ab ultra/evolis system performance is evaluated for clinical sensitivity on commercially available and well-documented seroconversion panels. the results are compared to viral rna detection and conventional hcv ab screening assays. specificity is evaluated by using random blood donor samples. results: among the seroconversion panels that begining with samples negative for hcv rna and anti-hcv antibodies, the monolisa hcv ag-ab ultra assay detects exposure to hcv an average of days earlier than the monolisa hcv plus v test. the mean delay of the monolisa hcv ag-ab assay in detecting hcv infection compared to hcv rna testing is around . days. the monolisa hcv ag-ab ultra/evolis system allows simultaneous detection of hcv core antigen and anti-hcv (core, ns , ns ) antibodies, thus significantly reducing the time gap between the initial detection of hcv rna and the first appearance of detectable anti-hcv antibodies. the fully automated system combines high degree of assay performance with optimization of laboratory workflow and safety management. operational evaluation of pall ebds bacterial detection system l larrea gonzalez, ma soler and rj roig centro de transfusion, valencia, spain introduction: regulatory bodies are increasingly mandating the use of bacterial detection systems for platelet products ( ed standards for blood banks and transfusion services). one system currently available is the pall ebds bacterial detection system which utilises percentage oxygen as a surrogate marker for bacterial growth. aims: to evaluate the pall ebds in routine use in our blood centre. in particular, to assess feasibility and adaptability to daily labour routines. the orbisac (gambro bct) system was used to produce leucocyte depleted buffy coat (bc) platelet pools ( bc/pool) stored in platelet additive solution (ssp macopharma). mean platelet count was . ¥ e /pool with mean leucocyte count . ¥ e /pool. ebds installation and training occurred over a day period. platelet pools were tested for bacterial contamination over the subsequent weeks. ebds pouches were sterile connected onto platelet pools hours after blood donation. platelet samples were taken into the pouches and then the pouches were incubated for hours on a shaking agitator at °c. after this time, percentage oxygen was measured. no positive results were found in this study. this was as expected due to the relatively low number of platelet pools tested and it also highlights the absence of false positive results. minimal training was required to use the ebds. the system was easy to use and did not require the use of a laminar flow cabinet to take samples. it was quick and simple to take samples and perform oxygen measurement. after pouch incubation, technician was able to make oxygen measurements in less than minutes. the data management system allowed full traceability of product and work flow. results were very easy to interpret. conclusion: the pall ebds was found to adapt perfectly to a routine blood centre environment. ( ) was . the percentage collected from volunteer blood donors was % (n = ) and the rest % (n = ) was given from patient-related donors. the age of donors ranged from to years old. the assay used for the detection of hbsag, hbeag, anti-hbc igg/total, anti-hbc igm, anti-hbe and anti-hbs was the automated microparticle enzyme immunoassay (axsym) of the abbot company. all the units were tested for hbsag, and anti-hbc igg. if the anti-hbc igg was detected, the specimens were automatically tested for anti-hbs. the units were wasted if the anti-hbs was negative, and the specimens were manually programmed for the testing of the anti-hbc igm, hbeag, and anti-hbe. from the total of tested units, of them were found to be positive to at least one marker of hbv infection, that means the . % of the health adult population was infected in the past by the hbv. the . % (n = ) was previously infected and now immunized with hbsag(-) and anti-core igg(+) and . % (n = ) were chronic carriers of the hbv with hbsag(+). the . % (n = ) of the positive donors were patient related donors and . % (n = ) were volunteer donors. in other words, of the not volunteers ( . %) and of the volunteers ( . %) were detected to be infectious. the combinations of the serologic markers for hbv are illustrated in the table attached. these results indicate that the incidence of hbv infection in the northeastern department of greece is equivalent to the incidence of hbv in other greek regions ( . %) as it is referred to the national haemovigilance data and moreover, the percentage of infectious donors is bigger among replacement donors, . % compared with the . % of voluntary donors. as a consequence, the best source for safe blood collection is the population of volunteers. earlier detection of human immunodeficiency type , hepatitis c and hepatitis b viruses using the procleix® ultrio tm assay on the procleix® system and the study objective was to assess the ability of the ultrio assay and associated discriminatory assays to reduce the detection windows for hiv- , hcv, and hbv. commercially available seroconversion panels were used for testing. methods: hiv- (n = ), hcv (n = ), and hbv (n = ) seroconversion panels were tested neat and diluted ( : and : ) in the ultrio assay. panels were tested neat in the appropriate discriminatory assay. times to detection of hiv- , hcv, and hbv nucleic acids in seroconversion panels were compared to the vendor's historical data on time to detection of antibody and/or antigen using licensed or validated serologic tests. p- effectiveness and limitations of methods for platelet bacteria screening -how to apply which screening method? the successful concept of virus safety in transfusion medicine is not suitable in bacterial contamination. bacteria can grow up in blood components to enormous amounts, whereas the initial number of contaminating bacteria is typically very low. therefore, sample drawing for bacteria screening must not be done immediately after blood donation. the established concept of relevance of clinical microbiology (pathogenic, non-pathogenic, facultative pathogenic species) is not valid for bacteria contaminating blood. here, the currently discussed criterion of clinical relevance is the ability of bacteria strains (not species!) to grow up in blood components. the paul ehrlich institute (pei) developed pei bacteria standards, which are characterized concerning their behavior in blood components. they contain a defined number of living bacteria, they are deep frozen, ready to use and shippable. there are two strategies to improve bacteria safety of blood: screening and pathogen reduction. neither of them is perfect, but screening methods are successfully established since several years in routine (belgium, the netherlands), and represent the current state of the art. further development and collecting of experience will produce the basis for assessments in the future. it is of high importance to apply the screening methods in dependence on their properties. methods implying an incubation/cultivation step ('early methods') have to be distinguished carefully from 'rapid methods' . for example, it is unreasonable to compare (or to advertise with) different sensitivities of methods not considering their detection principle or their informative value. both principles, cultivation methods as well as rapid methods, show advantages and disadvantages. selection of the method has to consider the respective conditions of the given blood service (including logistics up to time frame between issue and transfusion). results from the procleix hiv- /hcv and hiv- /hcv/hbv (procleix ultrio) assays for the detection of hiv- rna, hcv rna and hbv dna in blood donors of two blood transfusion centers of sw greece in discriminatory assay testing, out of ( % of the positive, . % of total) were reactive for hcv rna only and out of ( % of the positive, . % of total) were reactive for hiv- rna only. none were positive for both hiv- and hcv. the standard serological assays gave the same results for the above positive samples. two samples that tested positive by the standard serological assays tested negative in the procleix hiv- /hcv assay. of the samples tested by the ultrio assay, ( . %) tested reactive for hiv- /hcv/hbv. in discriminatory assay testing, out of ( . % of the positive, . % of total) was reactive for hiv- rna, out of ( % of the positive, . % of total) were reactive for hcv rna, and out of ( . % of the positive, . % of the total) were reactive for hbv dna. all were single positive i.e. none tested positive for more than virus. three out of positive samples for hbv dna tested negative by the standard serological tests. the opposite was not observed. the procleix ultrio assay is a definite improvement over the procleix assay in a region with a high incidence of hbv carriers. up until its use, it is obvious that hbv positive blood with very low antibody titers was transfused into patients. more results will show whether procleix ultrio can eventually replace the standard serological tests. the introduction: patients with hemophilia represent a high-risk group for post-transfusion hepatitis whose frequency is closely linked with the number and quantity of blood products used. in albania, the frequency of hepatitis is also linked with hbsag testing with elisa (introduced in ), and hcv testing (introduced in ). aim of the study: evaluation of the prevalence of the markers of hepatitis b, c, and d in patients with hemophilia. methods: our study included patients with hemophilia treated with cryoprecipitate and commercial clotting factors. blood testing for anti-hcv, anti-hdv, and hbsag was performed with elisa -gen. iii. results: of patients tested, cases ( %) were hbsag positive, cases ( %) were anti-hcv positive, and cases ( %) were anti-hdv positive. co-infection of hbsag and hcv was found in cases ( %), whereas co-infection of hcv, hdv, and hbv was found in persons ( %). the highest rates of infections and coinfections were found in patients above years of age. conclusion: mandatory blood testing has decreased the levels of post-transfusion hepatitis. in albania, hemophilia is also still treated with cryo-precipitation, thus patients are at a particularly high risk during the 'window period' . results: / ( . %) samples from rbd were anti hiv + nonreactive and rr for p ag both being nonreactive in the neutralization test, they were interpreted as false positives. / ( . %) sample from fbd was rr for p ag/anti hiv + nonreactive and it was confirmed positive by neutralization. this bd had been autoexcluded himself after blood donation. he showed seroconvertion days later: p ag nonreactive, anti hiv + reactive and western blot positive. the only bd p ag positive/anti hiv + nonreactive during the analized period, was an first time donor and the post donation autoexclusion was effective en this case. although a larger populations of bd is necessary to be studied and in spite of the low prevalence we have found, we consider p ag screening is an alternative up to implementation of nucleic acid testing and simultaneously we should increase the quantity of altruist repeat blood donors, undoubtedly, the best population to give blood. owing to the rather short interval between successive donations (~ days), this suggests that some - infectious units escape the screening annually. to these, one has to add the (now unknown) proportion of potentially hbsag negative + hbv dna positive ftbds. hcv: since the introduction of the screening in , the general incidence in rbd has dropped from . ‰ to . ‰, suggestive of a : escape rate. the prevalence in ftbd has stabilized at ± ‰. based on reasons similar to these employed for hbv, the residual incidence in rbd suggests that potentially infectious donation in rbd escapes the screening (= to a total of aprox. , annually). a limited investigation using hcv-antigen eia evidenced a ‰ escape rate in ftbds (= to a total of aprox. , annually table and are concerned to the fist two months of the implementation, where we had to adjust the volume of the eluate. conclusion: these system adjusts to the laboratory daily routine in the blood bank, with the pools released after first analysis in less than hours. background: the hbsag, anti-hcv, anti-hiv / , p antigen, alt and syphilis tests are performed for blood donations in czech republic. no nat tests are mandatory in czech republic. the aim of this pilot study was: . hcv rna pcr testing in anti-hcv negative blood donations; . correlation between hcv nat and anti-hcv testing results. methods: blood samples (anti-hcv serologically negative, alt not elevated) were pooled using the guardian plus spii into pools of samples. pools of ml were tested using the cobas ampliscreen hcv test v. . (roche). results: pools of samples from a-hcv serologically negative donations were tested from october to july . no one pool was initially reactive. invalid tests: ( . %) run failures were observed, due to: invalid internal controls ( . %) and invalid positive controls ( . %). invalid tests were repeated. in none of pools a positive hcv nat result was observed. conclusions: no discrepancy between hcv nat and a-hcv results was observed in our study. all of the nat tested donors in our study were regular voluntary whole blood or plasma donors who were repeatedly a-hcv serologically negative. the hcv incidence in the czech republic blood donor population is low but it is slightly growing up in general population. hcv nat testing could improve the safety of blood supply by reducing the window period for hcv. introduction: parvovirus b is the only parvovirus known to be a human pathogen. most commonly, it causes a mild childhood rash, erythema infectiosum, but in some cases more serious symptoms can be linked to b , such as acute or persistent arthropathies, critical failures of red cell production, hydrops fetalis, fetal loss, myocarditis or hepatitis. inactivation of the non-enveloped virus has proven difficult. as a consequence, manufacturers of blood products have implemented screening measures to reduce the load of parvovirus b in manufacturing plasma pools by the use of nucleic acid amplification techniques (nat). in our institute all blood donations were screened for human parvovirus b by nat since april . methods: over the last years . million donations were screened for b by nat. samples with a virus load over iu/ml were defined as positive, whereas samples with a virus load between the detection limit ( iu/ml) and iu/ml were defined as weak positive. weak positive products were released, whereas positive products were discarded. in addition infection markers of b positive donors (case group) were determined over a time period of one year. virus load and b antibody status was compared with b negative donors (randomised control group). b antibodies (igg vp , igm vp , ns ) were analysed by two commercial antibody tests. results: overall b nat-positive donors were identified with a virus load over iu/ml out of . million tested. there was a seasonal accumulation during spring and summer, whereas a large epidemic occurred throughout the last year. vp igg was detected in . % and % of the case and control group, respectively (p = . ). these data demonstrated statistically significance (p = . ). all donor samples which were b nat positive for more than three months developed neutralizing vp antibodies. in contrast, ns antibodies were observed in % of the case group and in % of the control group (p < . ). ns antibodies were detected more frequently in samples, which were b nat positive for more than six months. conclusion: b nat could be implemented in blood donor screening as release criterion without causing a shortage in blood supply. all b positive donors of the case group developed neutralizing antibodies within three months and virus load was dropped rapidly below iu/ml. these data support our testing algorithm all components of high positive donations (virus load over iu/ml) were discarded. donors with ns antibodies showed more often signs of a chronic disease with detectable levels of parvovirus b longer than six months. background: on recent years, the syphilis screening of blood donors has become increasingly important not only because of the transmission risk of this infection but also due to the risk behavior that this implies. on account of the importance of this screening the tests used are becoming more and more sensitive. aims: to evaluate an elisa screening test (the tmpa test recombinant is based on the sandwich principle, an immunoenzymatic technology in solid phase, for the measure of anti-treponema pallidum in serum or plasma). methods: in this study samples from blood donors were tested by the rotine 'cardiolipidic reagent for syphilis screening on microplates' -diagast laboratories as well as with 'hdtmpa recombinant' -hoslab diagnostics. positive samples were then confirmed with fta abs/tpha. results: using the mentioned tests we obtained the following results: . ( . %)cases turned out negative with both technologies; . ( . %) cases were positive in both methods; . cases were positive only using tmpa recombinant [of which ( . %) were confirmed positive by tpha/fta abs. as seen we found samples ( . %) that were only positives by tmpa recombinant test and that were confirmed by tpha/fta abs. we concluded that tmpa recombinant seems to be a suitable test for a quick and automated syphilis screening of blood donors and provides maximum safety for the recipients. background: in recent years, there has been substantial evidence indicating that typing and subtyping for hcv is clinically important in understanding hcv disease and its therapeutycal options. 'naive' viral load also seems to influence disease severity and responsiveness to therapy. therefore, viremia and genotype identification have been done routinely in molecular biology laboratory units. aims: the university hospital of coimbra studies and tests his own patients and patients from other hospitals in the central portugal. we also collect and test blood donor candidates from this region. we proposed to analyse the distribution of hcv genotypes in this region, among patients with cronic hcv infection. we have simultaneously analysed the viremia and correlated it with age and severity of liver disease. methods: nucleic acid extraction was done using the semiautomatic 'xstractor' from biomerieux laboratories (boom method). the genotyping used reverse hybridization and was performed using probes from the ¢ non-coding region (innulipa introduction: bacterial contamination of blood products remains a persistent problem. various techniques for the detection of bacteria in blood products exist but none of them has been widely accepted. bacterial detection systems could be divided into culture systems and rapid technologies. hemosystem has developed a rapid and sensitive technology for bacteria detection named scansystem tm . bacterial contamination of platelet concentrates is a rare event with an incidence between : to : per donation. therefore hemosystem developed a positive control in order to validate the scansystem tm platelet kit before use. aim of the study: the current study was designed to evaluate the performance of the scansystem tm positive control. the scansystem tm positive control is a capsule containing lyophilised lactobacillus casei subsp rhamnosus. the bacteria concentration per capsule is at least ¥ cfu. the positive control has to be stored at room temperature and is stable for years. after dilution in pbs, the preparation has to be used within hour. two capsules were tested for ten consecutive days with scansystem tm platelet kit as well as with optimised scansystem tm platelet kit. in an independent experiment three capsules were diluted in platelets stored in additive solution and were tested each with scansystem tm platelet kit and optimised scansystem tm platelet kit. results: microscopic fields were analysed for bacteria specific fluorescence for each sample. the ratio between bacteria specific fluorescence signals and analysed signals was . in all samples for both scansystem tm platelet kit and optimized scansystem tm platelet kit. therefore by definition all tested capsules were positive. the lyophilized positive control capsules enable the user to validate the scansystem tm platelet kit before use. because bacterial contamination of platelet products occurs rarely, the routine use of positive controls improves safety of the screening method. scansystem tm is currently the only method that provides this safety measure. introduction: whereas implementation of nat for blood donor screening reduced the risk for transfusion transmitted hiv and hcv infections currently below one per million transfusions, the risk for bacterial infections is estimated to be : to : . especially platelet products, which are stored at room temperature, are prone to bacterial contamination. aim of the study: several methods are currently developed to prevent the transfusion of bacterial contaminated platelet concentrates. the study investigates a new rapid bacterial detection method. material/methods: pool platelet concentrates were spiked with seven transfusion relevant bacteria strains under sterile conditions at concentrations of cfu/ml to cfu/ml. bacterial concentration was verified on blood agar plates immediately after spiking. five millilitres of spiked platelet concentrates were centrifuged, stained with thiazole orange dye and analysed directly by facs within five minutes after staining. aliquots of pool platelets spiked with concentration of cfu/ml and cfu/ml of each bacteria strain were incubated for two to eight hours in special bouillon at °c and were analysed by facs immediately after incubation. results: sensitivity of facs analysis differed between cfu/ml for e. coli and cfu/ml for klebsiella pneumoniae without preincubation and was enhanced to cfu/ml when a pre-incubation step of two to four hours was included. conclusion: bacteria detection by facs analysis combined with a short pre-incubation ( - h) at °c is a quick and simple method with sensitivity comparable to other commercially available detection systems. the advantage of this new method is the rapid analysis, easy handling, high sensitivity and less expensive price. introduction: detection of bacterial contamination of platelet concentrates represents a major challenge in transfusion medicine. for blood transfusion services the method must have a high sensitivity, an easy performance and a low price. aim of the study: in this spiking study we evaluated the new optimised scansystem tm platelet kit detection method for use in apheresis platelets. methods: apheresis platelet concentrates (apcs) were spiked with strains of ten different bacteria species. after different incubation periods, apcs spiked with cfu/ml were analysed by the optimised scansystem tm platelet kit. the number of bacteria was monitored by plating on blood agar. results: all bacteria strains were detected with the optimised scansystem tm platelet kit when the sample was collected h after spiking. identity of the spiked bacteria was confirmed by gram staining and dna fingerprints. conclusion: in summary, the optimised scansystem tm platelet kit was able to reliably detect ten transfusion relevant bacteria species in apheresis platelet concentrates within minutes when the sample was taken hours after spiking. background: since year our laboratory started routine screening of hcv-rna in plasma minipools for all plasma intended for fractionation. although nat testing is not yet mandatory all blood products are released depending upon nat results. aim: to test and compare two different methods of rna extraction in order to make all the necessary adjustments to the test procedures while preserving the availability of blood products. methods: plasma minipools of donations are prepared either on a tecan genesis robot or on a hamilton at plus. hcv-rna is isolated from ml plasma by using either the qiagen biorobot and qiamp virus biorobot kit or the manual extraction with cobas ampliscreen hcv pcr kit v . . results: between march and december a total of seronegative donations ( pools) were tested for the presence of hcv-rna. four pools were found to be positive for hcv-rna. of the four nat-positive pools with no eia-positive donor, four were confirmed as true positive by donor follow-up testing and/or testing of an independent sample from the index donation. all the positive donations were detected independently of the extraction method used (manual or automated). our experience shows that although the automated extraction method is 'off label' and it has to be validated, the use of biorobot does not pose a detectable contamination risk and it is possible to achieve a detection level for hcv less than iu/ml. the advantage of the manual method is that it has better recovery of nucleic acids than the qiagen extraction. concerning the time needed for the extraction process the automated method runs samples in hours where the manual method needs hours for samples, needing, prior to extraction, an extra centrifugation step for one hour. the automated extraction method results in an assay with a high sample throughput, fast time, sufficiently sensitive, that can be successfully introduced into routine use in laboratories which have more than samples/day while preserving the availability of blood products. anti-hcv similarly was high till ( . - . %), but in trend to decrease afterwards ( . %). anti-hiv reflected the low endemicity of the disease in public setting and was % through the mentioned years. rpr test for syphilis was around . %. directed donors were % of all and volunteer donors consisted nearly %. donors in our blood center are being informed about donation prior to giving their blood and donor questionnaire forms (dqf) are filled out by the donor candidates. using dqfs have been mandatory at all blood banks in turkey by law since . from that time infectious disease marker rates were dramatically reduced at all centers. donor information about the risks of transfusion and the importance of safe blood supply were detailed by the donation staff and physicians, consequently self-exclusion by the donor candidates who have risky behaviors was encouraged at our center. the interviewing staff was trained specifically for this topic. this steps were particularly emphasized in the last three years and the infectious screening results were displayed the outcome of this efforts. conclusion: education of the prospective donors, and recruit the voluntary, non-remunerated and regular donors will be the utmost goal of all blood banks. rigorous donor selection will contribute this ultimate success. we should spend more efforts to maximize enrolling voluntary donors to lower the serological marker results, consequently achieve safe blood. background: human t cell lymphotropic virus type i is endemic in japan, the caribbean, southeastern united states and parts of south america and africa. in non-endemic areas such as europe, htlv-i is less common and most infections are identified in immigrants. the epidemiology of htlv-ii is different, being predominantly found among indigenous american-indian populations and among ivdus, but the routes of transmission are the same. aim: our study's aim was to ascertain the prevalence of htlv i/ii in blood donors in order to understand the epidemiology of htlv in greece and initiate discussions of an acceptable level of risk and appropriate level of screening for rare transfusion-transmitted diseases. overall, anti-htlv seroprevalence levels among blood donors, are low. although the number of annual donations in this study is relatively small, the data for htlv indicate that rates of this infection are low and that infected donors will be seen infrequently. as all blood donations are screened for htlv i/ii during the last six years, a national survey is necessary in order to define the epidemiology of htlv in greece. introduction: toxoplasma gondii is the causative organism of toxoplasmosis. the disease transmitted by ingestion of either oocysts (in the feces of cats) or bradyzoites (in raw or undercooked meat). the parasite can also be acquired transplacentally by organ transplantation or from blood transfusion. the purpose of this study was survey of toxoplasma antibodies in some iranian blood donors at tehran blood center. blood samples were randomly collected for detecting of igg and igm antibodies (by elisa technique).the total numbers of donors was of (% ) were female and (% ) male in age ranged from to years. results: sera tested, ( %) were found to be positive for toxoplasma igg antibodies and ( . %) were igm antibodies positive and of them ( . %) were borderline for igm antibodies. among males the frequency of positivity was higher than woman but this different was not significant. the most frequency of seropositivity was found in age group to years. conclusions: diagnosis of toxoplasmosis can be aided by serologic or histocytologic examination. the acute infection in healthy individuals is generally asymptomatic and not associated with any morbidity but in an immunocompromised host, toxoplasmosis be a very serious disease, and this can occur if a person is infection with toxoplasmosis before or after his/her immunosystem is compromised. in spite of the progress in the development of diagnostic, therapeutic and prophylactic methods, virus hepatitis still presents a serious global health problem. the possibility of transmission of these infections through transfusion of blood and blood derivates implies obligatory control of the donated blood. post-transfusion hepatitis is an important health problem in everyday practice, especially in patients who have to receive transfusion of erythrocyte concentrates as the only possible treatment for many years. objective: to show the prevalence of hepatitis b (hbsag) and hepatitis c (anti hcv antibodies) in multitransfused thalassemic patients. in our region there are patients suffering from thalassemia major who are aged between and , and who have been receiving erythrocytic transfusion - times a month since the age of one or two. they receive washed red blood cells, and in certain periods filtered red blood cells, controlled for viral markers and they mostly receive blood from voluntary, periodic and regular donors. the patients are tested periodically for the presence of viral markers (hbsag, anti hcv antibodies), using tests for hbsag (abbott auxyme monoclonal eia) and for anti hcv (abbott hcv eia . ). the presence of markers for hepatitis b and hepatitis c has not been detected in any of these multitransfused thalassemic patients who receive at least transfusions a year. the tests in all patients were negative. the blood used for transfusion must be tested for viral markers, and for the patients who have to receive blood for their whole life, the blood should be from voluntary, regular and periodic donors who donate blood at least three times a year, because then the risk of transfusion transmissible infections is very small. introduction: we observe yearly the prevalence of transfusion transmitted diseases following instructions of skae (national coordination haemovigilance centre). aims: to investigate the prevalence of the most important blood borne infections in our blood transfusion centre in the state achaia during the last five years ( ) ( ) ( ) ( ) ( ) . materials and methods: the detection of hbsag, anti-hcv, anti-hiv / was made by automated microparticle enzyme immunoassay (axsym, abbott) and by enzyme-linked immunoassay methods (dade behring, ortho, biomerieux) syphilis tests were made by using rpr kits. confirmation for anti-hcv positive samples was made riba or inno-lia, while the confirmation of anti-hiv / positive samples was made by 'st. andrews' general hospital of patras reference centre. results: all the seropositive donors were first time donors. conclusion: ( ) we observe that there is a decrease in all four infections. ( ) the absence of anti-hiv seropositive donors is due to the high percentage of volunteer blood donation which approaches % in our centre during the last four years. methods: a prospective, one-year study has been set up in order to enrol at least out of the estimate of first-time donors, involving blood transfusion centres from of the italian regions. each centre was required to enrol all first-time donors born before december st, , and thus not included in the hbv mass vaccination campaign. the selected donors were tested for hbsag (mandatory by law) and for anti-hbc by commercial assays. all hbsag and/or anti-hbc positive specimens were stored frozen and sent to a reference laboratory for additional serological testing (anti-hbs, anti-hbe, anti-hbc/igm and anti-hbc avidity index by an experimental procedure) and for the determination of hbv-dna (both qualitative and quantitative) by real-time pcr. results: in the first months of the study the sites saw almost first-time donors, of whom . % belonged to the required age groups. among eligible donors, . % were both hbsag and anti-hbc positive, and . % were hbsag negative/anti-hbc positive. hbv positivity rates were higher in southern than in northern regions, although a high variability in hbv prevalence was observed between neighbouring areas in the north. hbsag positives were mostly males, % were positive for anti-hbe, % had raised alt and % were concurrently positive for anti-hbs. among hbsag negative/anti-hbc positive donors, % were negative and % were positive for anti-hbs. among anti-hbs positives, % showed values < miu/ml and % > miu/ml. the avidity index results suggested that approximately % of anti-hbc positive individuals were recently infected. conclusions: our preliminary data indicate that approximately % of the italian first-time donors are older than years of age and thus not belonging to the age groups who underwent to the mandatory vaccination against hbv, and that . % of them have serological markers of ongoing or past hbv infection. anti-hbc alone was detected in nearly % of the study population. hbv-dna testing is underway at the time of this writing. in our country mandatory tests for each blood donations are: hbsag, anti-hcv, anti-hiv / and tp ab. to c + ns + ns , ( . %) to c + ns , ( . %) to c + ns + ns , ( %) to ns + ns + ns , ( %) to c + ns + ns , ( %) to ns + ns . the use of the hcv core ag elisa test system may provide substantially earlier identification of hcv infection than it is possible with current serological assays. although all of six anti-hcv assays are very sensitive and specific screening assays, they didn't detect hcv infection in one patient. majority of anti-hcv positive patients ( . %) had anti-hcv ab for or more different epitopes of hcv. international comparison of performance of abbott prism assays used for blood donor screening background: the national serology reference laboratory, australia (nrl), coordinates a quality control (qc) programme for laboratories that screen for anti-hiv & , anti-hcv, hbsag and anti-htlv i/ii using the abbott prism assays. nineteen laboratories from australia, belgium, canada, ireland, israel, the netherlands, new zealand, norway, singapore, south africa and thailand have submitted data for this programme. aims: to determine the accuracy and precision of results from laboratories, individual prism instruments and different reagent lots by analysing data accumulated between october and january . the multi-marker qc sample 'pelispy s type ' (s ), produced by viral quality control (now acrometrix-viral quality control), was provided to participants. laboratories tested s in each calibration run, in addition to the manufacturer's controls, on each sub-channel of the instrument. pelispy was used as a 'go/nogo control' and results were required to be reactive (s/co > ) for a test run to be deemed valid. data were collected and analysed using the nrl's internet-based application edcnet (https://www.nrlqa.net). after submission, laboratories were able to compare their results with those submitted by other laboratories and investigate differences in results from reagent lots and instruments. data for five different s lots were exported from edcnet and analysed. results: nearly results were submitted: all results were reactive (s/co > ). fifty of these results ( . %) were excluded from analyses because they were reported from invalid test runs [due to pipetting, aspiration or sampling error (n = ) or due to unacceptable results (n = )]. a further results were excluded because data provided by laboratories were inconsistent or incorrect. a total of results, reported using different prism reagent lots ( for anti-hiv, for anti-hcv, for anti-htlv and for hbsag), were analysed. results from prism hbsag and anti-hiv showed the least variation with coefficient of variations (cv) of < % for all s lots. results from prism anti-hcv and anti-htlv produced cvs between . % and . % for all s lots. data reported for s lot ps (n = , range for anti-htlv to for hbsag) were analysed further to review performance of prism reagent lots. hbsag showed the least variability between prism reagent lots with < % bias for the prism hbsag reagent lots used (bias: the difference between the mean ratio for the reagent lot and the weighted mean ratio for all reagent lots, expressed as a percentage of the weighted mean ratio for all reagent lots). prism anti-htlv showed greater variability between reagent lots with a single reagent lot generating a + % bias. prism anti-hcv showed the greatest variability within reagent lot with results from of reagent lots showing a cv between % and %. conclusion: in results in a qc sample distributed to laboratories the abbott prism performance was found to be consistent over four assays. edcnet was robust in supporting laboratories' abilities to follow precision and accuracy of the assays in real time. introduction: since hcv rna testing of all blood donors started in finland in , the nat screening process has continuously been improved. investments in process automation have made the work more efficient and blood safety has further increased since hiv- rna screening of all blood donors started late . aim of the study: to implement hiv- rna testing in the nat screening program cost effectively, without increasing the throughput time of the samples and delay in the result reporting. to study if the sensitivity for both hiv- rna and hcv-rna will be sufficient when a single extraction is used and when the pool size of donations and the sample volume are kept unchanged. methods: the nucleic acids were isolated from plasma samples of ml with the magna pure lc instrument using the magna pure lc total nucleic acid isolation large volume kit. the internal controls from the cobas ampliscreen multiprep specimen preparation and control kit and the cobas amplicor hcv specimen preparation kit were added to the lysis/binding buffer ( ml/ml of each). from the final volume of the nucleic acid eluate ( ml) ml was used for the detection of hiv- rna (roche cobas ampliscreen) and ml for the detection of hcv rna (roche cobas amplicor). a run control containing both hiv- rna ( iu/ml) and hcv rna ( iu/ml) was included in all extraction runs. sensitivity of the both assays was assessed by testing dilution series of the who standards for hiv- rna and hcv rna. specificity was evaluated by testing fractionation plasmapool samples (n = ) and minipool samples (n = ). results: detection limits of the hiv- and hcv assays ( % hit rate) were calculated to be . iu/ml and . iu/ml respectively. specificity for both assays was % and during the validation phase also the robustness was good. the sensitivity of both assays with a pool size of was below the recommendations by the council of europe for blood donor screening (for hiv- rna iu/ml and for hcv iu/ml per individual donation). specificity of the assays was excellent, false reactive results were not observed. implementation of the hiv- nat assay in the screening program did not increase the throughput time of the donor samples when the pool size of donations, ml sample volume and a single extraction for two assays were used. the the very substantial increase in the number of industry-sponsored clinical trials has created challenges for medical schools, academic hospitals, faculty members of these institutions, and the journals that publish the results of these trials. in many cases, authors of reports of industry-sponsored clinical trials are paid consultants to the sponsor, have been paid by the sponsor to lecture on behalf of its products, or have equity in the sponsoring company. these ties to industry create a tension that actually is or can be perceived as • work internationally; • send young volunteers to international youth forums; • employ young people in your organisation; why use volunteers in blood donor recruitment? • they have networks to scout-groups, sports-organizations, tradeunions, rotary, staff of large companies etc. • they bring in fellow volunteers -with different prospects of society; • often paid recruiters are underpaid (!) and tend not to remain • you can not recruit by telephone! • out of donors are recruited by personal contact! • so you need direct personal contact = need many people (e.g. young ambassadors); • a large number of volunteer recruiters is a gift from heaven! paid donation gives the act of blood donation low status. the act of blood donation should be respected, and praised by role models, queens and presidents. efficient work and close cooperation of blood bank staff and volunteer organisations is the key to success in blood donor recruitment and retention! with such a prospect, it was important to evaluate the practices of blood donor selection in the eu. material and methods: a questionnaire was designed and sent in to the relevant institutions of the eu countries plus switzerland. the questionnaire included questions on the interviewing practices before homologous blood donations, regarding non-specific risks to donors and recipients, identified risks to donors, infectious, bacterial, viral, parasitic and prionic risks to recipients and non-infectious risks to recipients. the questionnaire also inquired about each country's exclusion period for each contraindication (ci) to donation. results: predonation interviews were prepared, in all countries, by circulating informative documents to blood donors. they were supported by written questionnaires in nearly all countries. in half of the countries, those interviews had to be led by physicians (nurses or technologists in the others). the - age limits for blood donation ( - for a first donation) were the rule in countries. in other countries the age limit could be brought forward to and extended to years old. the time interval between donations was identical for men and women in countries, and varied from to weeks according to country. the questions of the questionnaires were very similar as regards the identification of risks to donors and recipients, and very close to the requirements that appeared later in the / /ec directive. this particularly concerned how to meet the expectations of european donors, so that they come back to your blood center! know your donors: make regular donor surveys. age, gender, number of donations, number of first time donors, media consumption, education, job situation, income brackets. use local donor organisations let volunteers help! they work for free, but donor recruitment and -retention costs money. each blood center should have a local donor organisation, run by volunteers. the donor organisation should receive a payment for each bag collected. the reputation of the blood system tell the donors, what the blood is used for. that all blood is tested. and that blood provides safe medical treatment safety of the donor. insurance is a must good quality and efficiency in blood services decentralized blood collection no waste, and minimal outdating efficient service: • a friendly environment, • donor friendly opening hours, • pleasant rooms, beds and well equipped waiting rooms, • parking-spaces, transport, • beverages and food, • letters with correct data etc. donors expect to be serviced by trained, medical professionals and that the medical check-up is taken seriously. donors should be recognized continuously. use directed press-coverage to higher the self-esteem of the donors. donors should be well informed: • leaflets, posters and questionnaires should be % correct; • use e-mail and web-sites for quick up-date of donor information. be visible! • have an offensive and comprehensive media approach; • have a yearly national campaign june up to world blood donor day; • have an attractive home-page, constantly updated; • streamline your lay-out; • mail a donor magazine to all regular donors: • send newsletters regularly to volunteers and the press. • use recruitment cards. • easy phone-and fax numbers, e-mail addresses. directed campaign towards young people: • young ambassadors group; • special training sessions for young volunteers; • advertisements in media catering to young people; • poster competitions; • book and leaflets on blood addressed directly to young people; minimum bodyweight, blood pressure, pulse limits, questions involving viral risks, either sexually transmitted or linked to drug abuse, questions investigating risks of malaria transmission, questions aimed at identifying risk of prionic disease transmission. analyzing ineligibility times, on the other hand, revealed wide differences. for example, ineligibility for current multiple sexual partners, sexual relations with risk individuals, tattooing or body piercing, endoscopy, general anesthesia or invasive surgery, could vary from to months. previous transfusion history could not be a ci or could be one varying from months to indefinite ci (this point recently changed in several countries). the results of that survey have revealed some differences between countries in the questions asked and especially in the ineligibility times. however, the conditions under which donor selection interviews are conducted were similar in all countries. the enquiry tool used in this study proved to be well adapted to evaluate the donor selection practices throughout eu. a next step will be to use it to appreciate their evolutions and especially the impact of the /ec/ directive on these practices in the eu countries and furthermore to evaluate the results of this selection (rates and motives of deferral) which is a major factor of patients' transfusional safety. background: in europe on average whole-blood donations are performed per inhabitants and year. whole-blood donation comprises a puncture of a venous vessel and letting of blood (usually ml), which may be repeated several times a year. like other invasive procedures, blood donation has a range of effects on the individual who is subjected to it. aim: the aim of this paper is to review some aspects of the present state of knowledge on effects and complications of whole-blood donations. results: most studies of the effects of whole-blood donations on the donor have focused on negative or unpleasant events and on time in rather close association to the donation. complications related to percutaneous needle insertion (bruise assessed by inspection . % -bruise assessed using post-donation interview . %, sore arm - . %, nerve irritation . %, arterial puncture/pseudoaneurysm/arteriovenous fistula . - . % etc) are most commonly reported, while negative systemic reactions (vasovagal reactions . - . %, syncope . - . %) occurring in connection to blood donation are less frequent (newman bh: blood donor complications after whole-blood donation. curr opin hematol ; : - .) serious complications requiring hospitalization (myocardial infarction, stroke) are extremely rare ( . %). fatigue ( . %- . %) and diminished physical working capacity ( . %) are reported to occur during days after the donation. a recent study of a consecutive sample of swedish blood donors (nilsson sojka b, sojka p: the blood-donation experience: perceived physical, psychological and social impact of blood donation on the donor. vox sang ; : - .) (with a selfadministered questionnaire with an open-ended question: how does blood donation affect you? physically-bodily/psychologicallyspiritually/ethically-morally/socially during or after blood donation?) revealed that perceived negative effects (fatigue, diminished physical working capacity, vertigo/dizziness, susceptibility to infections etc) were less common ( % of the donors) than positive effects (feeling of satisfaction, being more alert, feeling generally better, less migraine, higher physical working capacity, respect from environment, feeling of relaxation etc; % of the donors). the duration of positive effects was regularly reported to be weeks, while negative effects lasted only days. investigations on the long-term effects of blood donation are scarce. yet, they may indicate that the donation of blood is associated with e.g. lower blood pressure and a reduced risk of myocardial infarction (nilsson sojka b, sojka p: the blood-donation experience: perceived physical, psychological and social impact of blood donation on the donor. vox sang ; : - ). conclusion: both the panorama and the frequency of occurrence of the different effects and complications of whole-blood donations vary as a function of how the information was gathered (openended questions, observations, interviews etc). serious reactions to whole-blood donations are extremely rare. more studies are needed in particular with respect to the long-term effects of regular wholeblood donations. t-pa- establishing a national adverse event reporting system for blood donors -a prospective study of . there was no national system and significant regional variation showed that the data was scientifically unsound. a coincidental initiative to remove the mandatory post donation rest period for regular donors further emphasised the lack of reliable, retrospective data to monitor and compare the impact of this new policy. aims: . to develop and implement a high quality, reliable national donor adverse events reporting (daer) system; . to define and categorise adverse events; . to record data systematically and prospectively using the existing computerised donor database. methods: from summer , a small project team of senior clinical and operational staff took months to agree a detailed policy for capturing and recording all donor adverse events, including precise definitions for grades of vasovagal reactions and bruising. detailed training material was written in may and the new protocol was validated in one region. from july to december a formal one day training programme was delivered to over staff working on mobile collection teams, static sites and blood centres. daer was fully implemented by january . adverse events are assessed by health care professionals on session and the relevant code entered onto the donor's computer record by clerical staff. information received after the session is entered by centre based doctors using the same system. the database is interrogated monthly for statistics. results: in the first months . million donors attended sessions throughout england and north wales. results were very consistent month on month. donors ( : ) had vasovagal symptoms but only % of these suffered syncope. % of all vasovagal reactions occurred in women. % occurred in donors aged - and a further % in donors aged - . (donors aged - represent only % of the total donor base.) donors ( : ) reported a delayed reaction, % of whom did lose consciousness. nerve injury, unrelated to haematoma, occurred in donors ( : ) and, more rarely, arterial puncture was diagnosed in donors ( : ). bruising was reported after the session by : donors. summary: a robust system has been developed and successfully implemented across a large, national blood service. based on the data already accumulated our next phase is to develop strategies to minimise adverse events, confident that any intervention will be effectively monitored. the community role in enhancement of voluntary, non-remunerated blood donation in the new millennium introduction: in the developing countries, about % of the blood supply comes from paid or replacement donors, where a high number of infected persons are in the donors population. only % of the global blood supply is donated as voluntary nonremunerated blood donors in countries with low and medium human development indices. and around % of the global blood population has access to only % of a safe blood supply. conclusion: blood is a national resource, it is the responsibility of governments through it's communities to ensure that the blood supply is safe and adequate to meet the needs of patients population and available to all who needs it. background: in response to a documented increase in the average age of donors, a survey was conducted to explore if young people had more unfavourable attitudes towards becoming blood donors. aim: to identify if the increasing difficulty in recruitment and retention of young people as donors, is linked to a low level of motivation for donating blood in this age group. methods: a national telephone-survey was conducted among a cross-sectional sample of the adult norwegian population ( participants). the survey was performed in november . results: five percent reported being active donors (had donated during the last months), % were passive donors (had not donated during the last months), % were non-donors with a positive attitude towards becoming donors, and % non-donors with no intentions ever to donate blood. in the youngest age group (age - ), % reported being active donors and % were passive donors. however, % of the young non-donors reported having intentions of becoming a blood donor. fifty-five percent of young non-donors had a negative attitude towards ever donating blood. all non-donors were asked why they did not donate. thirty-six percent of all non-donors reported health related reasons for not donating blood. thirty-one percent of all non-donors claimed that they did not donate because no one had requested them to do so personally, and % reported they did not care about blood donation. in comparison only % of young non-donors reported medical reasons for not donating. thirty-eight percent claimed lack of personal request, and % reported of lack of interest as the main reason for not donating. summary/conclusion: although the youngest age group was under-represented among active donors, we found that a great proportion ( %) of young non-donors had a positive attitude towards becoming blood donors. the most important reason why young people do not donate was the lack of a personal request. indifference regarding donation was not very widespread. a relatively high proportion of young people considered themselves as not medically disqualified to donate. in light of these findings, efforts to recruit young people as blood donors are strongly recommended. background: the ever-increasing demand for blood, coupled with emerging new threats to blood safety, motivate the strengthening of the blood banking infrastructure. aim: employing new technology as an instrument for building relationships of trust between blood bank and blood donors. material: . a new software module supporting the management of magnetic cards was added to e-aima blood bank management application. the magnetic card supports the following information: • front-side: donor's photograph, surname, name and blood group (including rhesus phenotype & kell) and sign of blood collection centre. • magnetic stripe where data concerning donor's serial number, medical history (risk factors), test results for infections and the number of donations is stored. . specific hardware allowing reading from and writing to magnetic cards is integrated to the software module: • magnetic card scanners were added to pcs serving to donation collection, including laptop for mobile team collection. • web cameras to capture the photograph of the donor to be printed on the card. • card printer was deemed necessary to produce magnetic cards for donors on a need basis. . consumables: blank plastic magnetic cards, ink cartridges for printer. methods: in order to evaluate the performance of magnetic cards compared to the paper-based system, a questionnaire was distributed to first-time and repeat blood donors, in order to be used as an indicant of donor's satisfaction. . first-time donors increased . % in the months of application. among them, . % were donors 'for relatives or friends' turned into volunteer donors and . % were first-time volunteer donors. the questionnaire analysis further revealed: • % were motivated by the use of magnetic card. • % appreciated the presence of their photo on the card and they confessed that they had used it as a spill for recruiting their friends as donors. • % were persuaded that employing new technology would result in safer and more trustworthy procedures combined with reduced waiting time. • % considered magnetic cards more practical compared to paper cards because of their compact size and improved durability. . the turnover of repeat donors also increased . % after replacing their plain old paper cards with new ones. further analysis revealed that: • % appreciated the quick cross-checking of donor's identity. • % were satisfied with the effectiveness and efficiency of magnetic cards in managing donor's data. conclusions: in , greek health policy provided the legal basis for establishing the electronic national health card. the introduction of the national donor's magnetic card is another step towards this direction, being aligned with the modern national health strategy. apart from the positive impact on the number of both firsttime and repeat blood donors, it should be also pointed out that the use of a unique donor serial number on country level results in less error-prone procedures due to the reduction of administrative process overhead and facilitates interoperability between national blood banks using compatible technological infrastructure. t-pa- emerging technologies in transfusion. dna based assays until the late s, mandatory blood screening for transmissible infectious agents depended entirely on antigen/antibody-based detection assays. recent emergence of nucleic acid technologies (nat) has revolutionized viral diagnosis by not only increasing the sensitivity level but also facilitating the detection of several viruses in parallel, by multiplexing specific primers. however, in more complex biological situations when a broad spectrum of pathogens must be screened, the limitations of these first generation technologies became apparent. high throughput systems such as dna arrays permit a conceptually new approach. these miniaturized microsystems allow the detection of hundreds of different targets simultaneously, inducing a dramatic decrease in reagent consumption, in additional confirmation tests and simplify data interpretation. however, the microsystems actually available require additional instrumentation and reagents for sample preparation and target-amplification prior to detection on the dna array. future technologies such as 'lab-on-a-chip' include channels, fluidics and thermal zones allowing extraction, amplification and detection. another major challenge in the area of dna detection is the development of methods that do not rely on target-amplification systems. almost all blood group antigens are bi-allelic and encoded by single nucleotide polymorphisms (snps). to facilitate the direct availability of typed red cells and platelets, we develop a high-throughput technique to genotype by dna microarray the whole donor cohort for all clinically relevant red cell and platelet antigens. methods: a multiplex pcr was developed to both amplify and fluorescently label gene fragments of red cell and platelet antigens in one reaction. each array contains spots of short ( - nt) allelespecific oligonucleotides to discriminate between the two alleles of an antigen system. results: two blinded panels encompassing donors were genotyped for hpa- through - and ; no discrepancies were found. currently, arrays are prepared for the red cell systems. the fya/fyb, fy-gata mutation, jka/jkb, k/k, kpa/kpb, m/n, rhc/c, rhe/e, rhdpseudogen, rhdvi negative, rs, doa/dob, genotypes can be determined. the set up of genotyping assays for rare genotypes is difficult because of lack or insufficient amount of dna. the latter can be overcome by phi dna polymerase-mediated isothermal genomic dna amplification, from minute amounts of dna present in stored red cell fractions or antiserum. the results show that the blood group typing dna microarray will provide a reliable and fast genotyping procedure. the method can be further improved to obtain the necessary automated throughput for typing of large donor cohorts. and , all other weak d types should be regarded as potential anti-d immunizers. for correct determination of weak d both serological typing (polyclonal and monoclonal), as rhd dna typing are mandatory. when serology indicates weak d, more anti-d antibodies are tested ( epitope model) to distinguish partial d from weak d. in addition, an rhd mpx pcr is performed to detect the presence of rhd exons , , , , and . in all known weak d types, all six rhd specific exons are amplified (except for weak d type which lacks rhd exons and ), whereas partial d phenotypes usually show aberrant patterns. aim: the aim of this study was to evaluate the diagnostic scheme for weak d typing. methods: between and , samples were investigated for weak d characteristics. four pcr-ssp assays were developed for identification of weak d types ( t > g), ( g > c), ( c > g) and ( c > a). weak d type was identified by the combination of serology and absence of exons and by rhd mpx pcr. rhd-specific exon sequencing was performed when serology and molecular typing were inconsistent. results: all samples were subjected to the rhd mpx pcr and sample showed absence of rhd exons and , indicative of a weak d type when combined with serology. the remaining samples were analyzed by the weak d pcr-ssps, resulting in weak d type samples, weak d type samples, weak d type samples and weak d type sample. two samples remained undetermined and were sequenced for all rhd exons and the rhd promotor region. one sample showed the mutations corresponding to the dau partial d phenotype ( g>a, g>a and c>t). the other sample had only one, not previously known mutation ( a>t), which is located intracellularly at the coohtail. extensive serology using the epitope model showed a pattern matching weak d. this new weak d variant was registered as weak d type . conclusions: based on these results it may be concluded that weak d phenotypes should be confirmed on molecular level to avoid misinterpretation of partial d that cannot be detected by rhd mpx pcr analyses. patients with weak d phenotypes, except for types , and should be regarded as being at risk for anti-d immunization after transfusion of rhd-positive blood products and should therefore be treated with rhd-negative bloodproducts. in this evaluation, out of patients carried such alleles. introduction: although kell antigens are expressed very early during erythropoiesis and a . % incidence of anti-kel is found in obstetric patients, this is a relatively rare cause of hdn. anemia is produced by immune destruction of fetal rbcs and suppression of erythropoiesis. maternal antibody titers or amniotic/cord blood bilirubin levels are not relevant indicators of the severity of the disease, and the measurement of the fetal haemoglobin by cordocentesis is a procedure with risks of miscarriage and sensitization. pcr techniques for the determination of blood groups using fetal dna isolated from maternal plasma, allows the application of noninvasive methods. clinical cases: we describe two cases of pregnancies in women with anti-kel acquired by transfusion/previous pregnancies: st case: in july , a -year-old woman (gravida , para ), rhdnegative, kel -negative was referred at weeks gestation. the father's phenotype was rhd-positive, kel -positive. a maternal antibody screen revealed d and kel alloantibodies. dna was extracted from amniotic liquid. the kel genotype was determined by pcr-rflp using the bsm i. pcr-ssp was used to studied intron and exon of the rhd gene. the results showed that the fetus was positive for rhd sequences and showed kel homozygosity; nd case: in august , a -year-old woman (gravida , para ) was referred at weeks gestation. she had a history of transfusion with rbcs units in -one of the donors was kel positive. the woman typed rhd-negative and her husband typed rhd-positive. rbcs from both were kel -negative. the maternal antibody screen revealed anti-kel . doubts existed about the putative father of this child. dna was extracted from maternal plasma using the magna pure lc (roche). real-time pcr was applied to analyse: sequences of intron , exons , , and pseudogene of the rhd gene and the sry gene by sybr green; and the alleles kel /kel by hybridization probes. all rhd sequences were detected (with the exception of the pseudogene) and the kel genotype gave a kel /kel result. in both cases the doctors choose not to use any invasive method to monitoring the fetuses regarding a hdn due to anti-kell antibodies, and the results of the molecular analysis were confirmed by testing the cord rbcs after birth. discussion: these cases illustrate the reliability of the molecular biology results, based on the collection of simple peripheral blood samples. a determination that the fetus lacks the relevant antigen obviates the need for expensive and invasive monitoring throughout the pregnancy. evidence-based medicine (ebm) is defined as: 'the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. the practice of ebm requires the integration of individual clinical expertise with the best available external clinical evidence from systematic research and our patient's unique values and circumstances. ' otherwise healthy individuals without cardiopulmonary dysfunction (cdf) tolerate acute reduction of haemoglobin concentration to about g/dl, provided that blood volume is kept normal by a volume expander. however, individuals experience physical fatigue, and there is faint reduction of perception as measured by neurophysiological tests. symptoms are reversed upon retransfusion of fresh, autologous erythrocytes. acute, normovolemic anemia seems to be progressively less tolerated with increasing age and cdf. controversy has existed on whether or not to correct hypoalbuminemia in asb or icp by infusion of albumin. recently a large trial showed no outcome differences between icp patients treated with albumin or saline. thus in general there is no indication for albumin in asb or icp. however, albumin may yet be advantageous in e.g. patients with head injuries. furthermore, fractionated albumin is not equivalent to native albumin, since fractionation stabilizers remain bound to the albumin molecule. thus more refined albumin preparations may carry advantages still to be investigated. erythrocytes are given to increase the total oxygen transportation capacity of the organism. the effect of blood bank stored erythrocytes may differ from that of fresh, autologous erythrocytes, since changes of presumably important erythrocyte properties occur during storage. in the only large trial available, a transfusion trigger of . g/dl was found to be favourable to one of g/dl in icp, except possibly in icp with unstable angina pectoris or heart infarction. however, the erythrocyte concentrates given were not leukocyte filtered, and side effects of infused leukocytes may have hampered the conclusion. on the other hand, a metanalysis showed transfusion as an independent indicator of unfavourable outcome in coronary bypass patients, but again, leukocyte filtered erythrocyte preparations were not applied. the effect on morbidity and mortality of 'top up' transfusions given e.g. to mobilize patients postoperatively has not been studied by trials, although this effect seems evident to many clinicians. grave anemia may reduce the haemostatic effect of thrombocytes because changes of blood rheology reduces the pressure forcing thrombocytes against the walls of small vessels. the transfusion trigger for thrombocytes in asb or icp remains to be established by clinical trials, however. the same applies for fresh frozen plasma, which is infused as a source of coagulation factors. on the other hand, the haemostatic effect of various fibrinolysis inhibitors is well established in asb and icp, but many clinicians appear hesitant to use them. another interesting haemostatic agent is recombinant fviia, the use of which to control asb in blunt trauma is supported by one well controlled clinical trial. evidence by systematic research is insufficient to decide what is optimal transfusion practice. the procurement of such evidence is one of the greatest current challenges to transfusion medicine research. . concerns about the transfusion-related complications, such as infections, tumour behaviour and immuno-modulatory effects, and the costs, necessitated a re-evaluation of the transfusion practice. aims: the goal of this study is to evaluate if a restrictive transfusion policy (hb transfusion trigger < . mmol/l) reduces the amount of red cell transfusion compared to a liberal transfusion trigger (hb < . mmol/l) without a decrease in hrqol. because of concerns about the feasibility of this study early results were analysed and are presented in this abstract. material and methods: after a run in period of months (hb transfusion trigger of hb < . mmol/l) patients are randomised for the restrictive or the liberal transfusion policy. patients are followed then months. hrqol is measured after inclusion, after randomisation, weeks, , , , and months after randomisation. also anaemia related complications and red cell antibodies are scored. hb values were blinded for the patients during the study period. results: from july till june patients were included ( ra, rars, rcmd, raeb, cmmol) in general hospitals and university hospital. two patients died in the run in period. eight patients were randomised for the restrictive transfusion policy and patients for the liberal transfusion policy. the mean follow up period in the liberal group was . months (inclusive run in period) and . months for the restrictive group. two patients in the liberal group died after randomisation. one patient received growth factors. in the restrictive group patients finished the study, received growth factors and patient withdrew informed consent. the mean hb level was lower in the restrictive group and after randomisation about % reduction in amount of transfused red cells was found ( . units per pt per month in the liberal group vs . in the restrictive group). no anaemia related complications were found, e.g. cardiac failure and cerebro vascular ischemia nor a decrease in activity performance. conclusion: there were some concerns after introduction of the restrictive transfusion policy. this preliminary results show, however, that a restrictive transfusion policy leads to a diminished use of red cell transfusion without an increase of cardiac complications or a decrease in activity performance. this study will be continued to compare hrqol scores in both groups. introduction: strong evidence supports the efficacy of blood conservation strategies such as autologous blood donation (abd) and erythropoietin (epo) for reducing exposure to allogeneic blood. however, use of these interventions is highly variable among institutions and frequently sub-optimal. the program to reduce orthopedic blood exposure (probe) evaluated a blood conservation program in patients undergoing total hip joint arthroplasty (thja) at ontario hospitals. aim of the study: the objective of probe was to determine whether a comprehensive blood conservation algorithm (bca) was more effective than usual care (uc) for reducing exposure to allogeneic blood in patients undergoing thja. methods: we randomized hospitals that perform high volume elective primary thja to implement either a bca or to continue with uc. the bca consisted of three components: physician and patient education, blood conservation interventions (use of abd or epo), and transfusion guidelines. t-pa- table) . mortality for non-transfused patients was significantly lower than for patients receiving either lr-or s-prbc at all time points (p < . ). t-pa- thalassaemia: the impact on blood transfusion services thalassaemia major is a genetically determined disease that causes severe chronic anaemia and further complications. it can be managed successfully in the vast majority of cases, so long as public health and other scientific and organizational infrastructures are adequate. although the progress achieved in the field of bone marrow transplantation and other disciplines promises cure of the genetic defect, regular blood transfusion from early childhood remains the cornerstone of treatment of patients with thalassaemia major. this presents national health authorities with the formidable task of assuring an adequate blood supply of high quality and safety for these patients and ensuring that it is transfused in the appropriate way. the basic principle in the modern management of thalassaemia patients is that of a global approach to care. within this approach, a standardized protocol for regular blood transfusions is a prerequisite for the patient's long survival and quality of life. if thalassaemia patients are not transfused effectively, the severe anaemia and over-expansion of bone marrow due to ineffective erythropoesis can lead to poor growth, bone deformities, organomegaly and impairment of normal physical activities. in countries or regions with large numbers of thalassaemic patients, the organizational and technical aspects of meeting their blood requirements represents a heavy additional workload for the blood transfusion services responsible for providing blood for this group of multi-transfused patients. the acquisition and preparation of blood, genotyping the patients' blood group (including at least rh, kell, kidd and duffy systems) preventing the transmission of infectious diseases and other transfusion associated complications, and assessing the patients' blood transfusion indices all have a tremendous impact on blood transfusion and treatment units. blood transfusion services are thus confronted with major challenges that can only be met if appropriate national transfusion policies are in place, both in the laboratory and the clinical setting of blood transfusion. the availability of safe blood is related to the effectiveness of donation programmes aimed at recruiting and retaining voluntary unpaid blood donors who are at low risk for the transmission of infectious diseases. sufficiency is further related to resources, organization and management of the blood transfusion service and continuous education of its staff. high technical standards for the transfused product and quality management systems are required to ensure that the product meets these requirements, as well as pre-transfusion, transfusion and haemovigilance systems and other more stringent quality measures in the whole chain of blood donation and transfusion. additional measures and continuous care are specifically required for the optimal transfusion therapy of the thalassaemic patient. the patients should be transfused with red cell concentrates, (rccs) preferably not more than one week's old and leucodepleted. other processes i.e washing of rccs, use of nutrient additive solutions, irradiation etc may be used to improve the quality and the safety of the transfused product, while other advances in red cell transfusion are expected to improve blood safety by preventing adverse reactions and reducing exposure of the patient to donor blood. should patients with thalassemia intermedia be regularly transfused? thalassemia major (tm) and thalassemia intermedia (ti) share mostly a common basic molecular mechanism, that is the reduced synthesis of the * globin chains. the consequences of the resulting chronic hemolytic anemia are also common and include growth retardation, bone marrow expansion, extramedular hematopoiesis, splenomegaly, increased intestinal iron absorption, susceptibility to infections and hypercoagulability. what differentiates the two forms of the disease is the severity of the clinical phenotype, which in turn depends on a particularly heterogeneous molecular background and imposes diverse therapeutic strategies. the consequences of the genetic defect as well as the effect of the applied therapy seem to be mainly responsible for the clinical course of the disease. in untreated tm cases, the aforementioned consequences occur fast and patients die early in life mainly due to high output heart failure. over the past decades, the gradual adoption of the current transfusion and iron chelation strategies and the patients' compliance with this therapy have resulted in a significant improvement of survival, that according to recent statistics reaches % at age . this rate is even better in well-treated patients, almost % of whom survive at age . regular therapy extends survival mainly by preventing early development of cardiac complications. in addition, a multi-organ improvement is accomplished while patients' physical appearance is almost indistinguishable from that of the general population, hence permitting a normal social behavior with a high overall quality of life. bone marrow expansion and extramedular hematopoiesis are prevented; hepatosplenomegaly is substantially restricted and usually there is no need for splenectomy, while thromboembolic complications are rare and pulmonary hypertension is practically absent. patients with ti remain as a rule without regular therapy until a number of severe complications arise. the consequences of chronic anemia develop slowly compared to untreated tm cases and dominate patients' clinical picture usually by the third decade of life. at this time, all patients have developed hepatosplenomegaly and most of them have been splenectomized. bone marrow expansion results to bone deformities and fractures often occur. extramedular hemaotpoietic masses and bone deformities may lead to various complications depending on their bulk and location, such as neurological symptoms from masses arising in the paraspinal area or dyspnea from lung restriction. hypercoagulability, resulting from defects of native erythrocyte membrane phospholipids, together with the coexistent thrombocytosis in splenectomized patients lead to a wide spectrum of thromboembolic events. pulmonary involvement with respiratory dysfunction and hypoxemia as well as pulmonary hypertension leading to congestive heart failure are well documented in ti patients. nowadays, the beneficial effects of regular transfusion and chelation therapy in tm are beyond any doubt. the occasional application of transfusions in ti has a transient effect and does not seem to inhibit the consequences of chronic hypoxia. intensive and regular transfusion and chelation therapy in ti has proved effective in ameliorating the established complications such as spinal cord compression, hypercoagulability and pulmonary hypertension, without however reversing them. given the -year experience on intensive therapy in tm and the first encouraging data in ti, the earlier application of such treatment seems to be crucial in ti. the timing however of therapeutic intervention in ti in order to prevent anemia-related complications still remains an open issue that needs to be properly addressed. the impact of prestorage leucodepletion on the immediate transfusion adverse events of patients with thalassaemia major backround: regular blood transfusion therapy in patients with bthalassaemia major decreases the complications of anemia but it is associated to many immediate and delayed side effects. febrile non haemolytic transfusion reactions (fnhtr) are common complications due to alloimmunization of recipients against hla and/or specific antigens on donor's wbcs or to the accumulation during storage of biologic response modifiers (bmrs) that are directly pyrogenic or indirectly by stimulating recipients' white cells to produce pyrogenic mediators. post storage leucoreduction (lr) has reduced the fnhtr in these patients from % to . % per unit. it is unknown whether introduction of prestorage leucodepletion (ld) has reduced the incidence of nhftr further. we analyzed the immediate transfusion reactions of adult patients with b-thalassaemia major transfused with a total of . rbc units from january to december . all units were fresh, stored less than days. . units were lr-rbc, . units were ld-rbc and . were washed lr-rbc. results: the incidence of fnhtr and allergic reactions in patients receiving lr-rbc was . % and . %/per unit respectively, in those receiving ld-rbc was . % and . %/per unit respectively, while in those receiving washed lr-rbcs was . % and . %/per unit respectively. the relative risk (rr) of fnhrt and allergic reactions following transfusion of ld-rbc and washed lr-rbc compared to lr-rbc is shown in table. conclusion: prestorage leucodepletion and washing of rbcs reduced the risk of fnhrt in regularly transfused b-thalassaemia patients . times compared to poststorage filtration. these findings show that fnhtr after rbc transfusions are due not only to alloimmunization but also to accumulation of bmrs even in patients transfused with fresh rbcs. washing is as effective as prestorage leucodepletion in reducing fnhtr. prestorage leucodepletion has no effect on allergic reactions or other immediate adverse events in these patients. t-pa- viral inactivation/elimination of plasma derived medicinal products the safety of medicinal plasma products (mpps) relies on a whole range of measures from the quality of the source material to the release of the products after manufacturing under cgmp conditions. viral safety relies on careful donor selection, viral testing of the source material and viral inactivation and/or elimination during the manufacturing process. mpp manufacturing processes must include viral safety steps capable of inactivating, and/or eliminating, a large range of viruses covering the known blood borne viruses as well as anticipating possible future pathogens. it is recognized that one single step is often not sufficient to satisfy this requirement and manufacturing processes very often include two or even three complementary viral safety steps. very efficient methods have been implemented by manufacturers, for two decades, for the inactivation of major blood borne enveloped viruses (hiv, hcv and hbv). additional safety steps have also been introduced to provide a second step for enveloped viruses and to extend the efficacy to nonenveloped viruses (hav and parvovirus b ). pasteurisation (liquid heat treatment at °c) which has been historically used for viral inactivation of albumin solutions has been applied to some other plasma products. solvent-detergent (sd) treatment which is specific to enveloped viruses is used primarily for coagulation factors. since the introduction of sd-treated products, no hiv, hcv or hbv transmission has been reported. viral inactivation of coagulation factors can also be achieved using various conditions of dry-heating. acidic treatment is also an efficient means of inactivating viruses in igg products. nanofiltration using filters of less than nm pore size was introduced in the early s. this technique for viral elimination is based on the size of the agent and is independent of their resistance to other treatments. this property could be helpful in cases of new emerging pathogenic agents. new inactivation tech-niques are currently under development such as uv treatment or gamma irradiation with efficacy reported on enveloped as well as non-enveloped viruses. these new techniques can complement existing methods after careful validation that they do not have harmful effects on proteins in the product. the efficacy of existing techniques is well documented in controlled clinical studies and pharmacovigilance records. their application to each product is extensively validated at laboratory scale, according to international regulations and then carefully evaluated by health authorities. in this context, a recent european guideline established a viral risk assessment model to quantitatively estimate the theoretical safety margins of mpps, by taking into account the different safety measures, such as viral testing of plasma and the efficacy of viral inactivation/elimination steps. whilst technical limitations and some lack of scientific data lead to very conservative estimates, this model gives an overall assessment of the efficacy of the measures in the manufacture of a given product. developments in viral inactivation/elimination methods, in plasma testing as well as in evaluation procedures have together given mpps an excellent level of safety never previously achieved. to date the important safety measures needed to ensure a high safety margin to pooled plasma products are well understood by the plasma fractionation industry. safety nets rely on carefully done: donor selection to exclude high-risk donors, serological and nat viral testing of single donations and, pooled plasma testing using sensitive validated methods, and most particularly, efficient viral reduction treatments that must be validated and implemented at a large-scale following good manufacturing practices. over the last years, successive key breakthrough in plasma product viral safety have included the use of solvent-detergent treatment to inactivate lipid-enveloped viruses, and nat testing of starting plasma pools and viral nanofiltration of products to reduce the risks associated to small non-enveloped viruses. the excellence of the system currently in place is illustrated by the demonstration that these safety barriers have virtually stopped the transmission of known viruses and avoided that of 'emerging' agents, such as west nile virus (wnv). however, multiple viral reduction treatments have generally decreased product recovery. in addition, although the implementation of viral reduction treatments have forced fractionators to introduce significant changes to product manufacturing methods, this period has been understandably followed by a period of relative conservatism of the plasma fractionation industry against further process changes. as time evolves and market dynamics changes struggle for improved economic balance of the plasma product industry is putting product recovery and diversified product portfolio at the forefront of r&d objectives. these developments in the plasma fractionation scene of the western world have been taking place in a context where many patients in the developing world are still treated with sub-standard, non-virally inactivated crude plasma fractions. in this specific area, one can expect that the developing world will bring innovative thoughts and take actions to find ways to improve the quality and safety of their own local plasma product supply. safety strategies adapted to the infrastructure and economy of less solvable countries may have to be considered. the intercept blood system for plasma uses a synthetic psoralen, amotosalen hcl, and long-wavelength ultraviolet light to photochemically inactivate a broad spectrum of bloodborne pathogens in plasma intended for transfusion (intercept plasma, i-ffp). phase clinical trials have shown that i-ffp retains proteins necessary for hemostasis in the treatment of acquired and inherited coagulopathies, and in support of therapeutic plasma exchange for ttp. a prototype plasma processing set was used for the clinical trials. for commercialization, a new processing set has been developed to improve productivity. the prototype set accommodated approximately ml of plasma, whereas the improved set accommodates up to ml of plasma, resulting in up to three i-ffp doses per treatment. aims: this study was designed to characterize pro-and anti-thrombotic proteins in i-ffp prepared using the improved processing set. proteins of interest included components of the intrinsic and extrinsic coagulation cascade, the fibrinolytic pathway, the contact factor pathway, and the complement system, the vonwillebrand complex, endogenous inhibitors, and markers of thrombin generation. methods: six fresh jumbo ( ml) apheresis plasma units, collected using the haemonetics pcs device (gambro), were photochemically treated. sodium citrate was used as the anticoagulant. plasma samples for analysis were collected before and after photochemical treatment, and were frozen below - °c until batch analysis. standardized clinical assays were used for all analyses. results: (results in the table below are expressed as the percent activity in i-ffp in proportion to the activity in plasma before treatment [mean ± sd]). retention of procoagulant factors in i-ffp plasma ranged from % to %. factor viii and vonwillebrand factor activity, antigen, cleaving protease activity (vwf : cp, adamts- ), and multimeric composition remained within normal ranges after treatment. endogenous inhibitors of coagulation were retained % to %. plasminogen and alpha -antiplasmin were retained % and %, respectively. retention of contact factors was variable; some factors were below the reference range prior to pct. with the exception of tat, all markers of coagulation activation were well within normal ranges. the tat level in one i-ffp unit was slightly above the normal range; all other units had tat levels that were well within the normal range. the significance of this is unclear. cept plasma is similar to conventional plasma. the improved processing set, intended for commercialization, allows up to doses of i-ffp to be produced from a single photochemical treatment. background: guidelines of the european directive / /ec require that fresh plasma prior to freezing contains < residual rbcs per litre. this rbcs content is below the sensitivity limit of the automated cell counters used in routine laboratories. aim of the study: it was therefore essential to make available an alternative method to detect and quantify rbcs in plasma. we implemented a method by flow cytometry using a pe conjugated anti-glycophorin a (gpa) monoclonal antibody that recognises rbcs and erythroid precursors. to quantify residual rbcs in fresh plasma, the method uses the same trucount test tubes (becton dickinson) as those used to quantify wbcs and that contain a known number of fluorescent beads. after addition of plasma and pe-gpa antibody, cell counting is performed on flow cytometer (bd facscalibur). validation of the method: assessment of accuracy, linearity, and reproducibility with different pe-gpa antibodies (immunotech and pharmingen) application of the method: quantification of rbcs in fresh plasmas divided into groups: group : plasmas from leucoreduced whole blood, group : plasmas from packed cells after removal of buffy coat and specific filtration, group : : apheresis plasmas. results: validation of the method: for both anti gpa antibodies, detection threshold is . ¥ residual rbcs/l; linearity study with concentrations of . , . , . , . , . , . , and . ¥ rbcs/l showed excellent correlation between observed and expected values (r > . ); reproducibility study showed c.v of respectively . % and %. for values > ¥ rbcs/l, it appeared necessary to introduce a correction factor of . for the anti gpa pharmingen. quantification of rbcs in plasma: group (plasma from leucoreduced whole blood): . ± . rbcs/l; group (plasma from packed cells after removal of buffy coat and filtration): < . °¥ rbcs/l in all the cases; group (apheresis plasma): < . °¥ rbcs/l in all the cases. conclusion: quantification of rbcs in plasma by flow cytometry is a precise, quick and reproducible test. in addition this study shows that even if there are differences in residual rbcs counts according to the origin of plasma, the obtained values are much lower than regulatory requirements. . improving basic transfusion knowledge amongst health workers; . improving pre-operative preparation for surgery . strategies such as cell salvage autotransfusion combined with a conservative transfusion strategy for the use of allogeneic blood. my presentation will outline the approach adopted to ensure that the use of cell salvage autotransfusion both improves the use of allogeneic blood and preserves allogeneic stores. well-organised training can both minimise the risk of using such advanced techniques and decrease the overall risk involved in undergoing surgery where blood loss may be a significant factor in increasing morbidity and mortality. the various training methods employed to improve knowledge in this area will be described. the increasing current perception that the safety of allogeneic blood transfusion has dramatically been improved during the last decade is challenging autologous haemotherapy methods. in addition, growing concern about the unfavourable cost-effectiveness of most autologous haemotherapy methods requires a refinement of the application of these measures to well defined circumstances. in contrast, newly emerging transfusion-transmissible infections or periods of blood shortage might revive interest in these blood sparing techniques. the first two cases of transfusion transmitted vcjd provide a paradigm for this scenario; not so much with respect to a public fear of infection but rather a waning donor population due to more rigorous recruitment criteria. preoperative autologous blood donation (pabd) still plays a significant role in settings with high individual benefit for the patient, high transfusion probabilities and when all opportunities of cost minimization can be applied. adjustment to the individual situation of the patient is the main aim of a medically reasonable and economic use of autologous haemotherapy. this implies consideration of the patient's haematocrit, blood volume, tolerable blood loss, expected blood loss, etc. in order to choose the optimal method in the individual case. in this respect, double red cell apheresis may play a significant role. with this approach, donation schedules assumed to enhance erythropoiesis can be adopted. moreover, inconveniencies caused by long distances between patient home and donation service can be facilitated by withdrawing two red cell units during one session in selected patients. in conclusion, red cell apheresis can be used to promote the proposed approach towards individualized autologous haemotherapy preoperative plasmapheresis is considered to be a sensible adjunct if intraoperative retransfusion of salvaged and washed red cells is planned. acute normovolaemic haemodilution is valuable when the patient's tolerability of the haemodilution and the expected blood loss are carefully examined beforehand. intraor postoperative salvage of wound blood can also be regarded as useful measures to prevent allogeneic transfusions as long as the specific advantages and disadvantages of the different methods are taken into account. finally, alternative and supplemental measures such as iron or erythropoietin administration should always be considered in order to optimize the efficacy and effectiveness of autologous haemotherapy methods. the goal of a 'bloodless medicine' might not be reached but is supposed to be approached closely with an integrated concept exploiting all measures available. however, in times of restricted health care resources, regular sound costeffectiveness analyses, taking the availability and the cur-rent safety profile of allogeneic blood products into account, are always warranted and needed. compensatory fluid replacement of surgical blood losses: the transfusion of allogeneic blood is expensive and -although safer than ever before -still associated with potential complications. to reduce both, costs and immanent risks, allogeneic transfusion should either be completely avoided or at least minimized during surgical procedures. as a consequence an intraoperative blood loss is initially not replaced by red blood cells, but by erythrocyte-free, i.e. cristalloidal or colloidal solutions. when normovolemia is maintained the resulting dilutional anemia is compensated by an increase of cardiac output and enhanced arterial o extraction. however, once the hb has dropped to values recommended as the lower intraoperative limit, or once compensatory mechanisms of acute anemia become exhausted, as a rule transfusion of red blood cells (rbc) is initiated to increase arterial oxygen content (cao ) and to preserve a margin of safety for tissue oxygenation and organ function. as an alternative to immediate rbc transfusion, ventilation with pure o (hyperoxic ventilation) can be employed to rapidly raise cao by increasing the amount of physically dissolved o in plasma (hyperoxia). however, molecular o causes vasoconstriction, mediated by products of the arachidonic acid metabolic pathway. as a consequence hyperoxia has been shown to increase systemic vascular resistance and to decrease cardiac output and o consumption in subjects with normal hemoglobin concentration ( properly scheduled, three women who did not reach the necessary hct level after the first donation and consequently they got out of the protocol, and one woman who had unexpected intraoperative bleeding and received homologous units in addition. the patients undergoing tkr and the patients undergoing removal of implants predeposited and units respectively, but finally and of them have been used. according to our patients data, the . % of unused autologous blood units belongs to patients with tkr and implant removal. therefore a better schedule is needed for these type of surgery. all the autologous donors were supported by oral iron supplementation throughout the predonation and month past surgery. fourteen of our cases were supported by erythropoietin s.c. in a dose of iu/kg every other day. the majority of these patients was female, only one was male with multiple alloantibodies and was scheduled to predonate autologous units. all of them underwent thr except one woman who also had a tkr months later. the autologous blood donation was well tolerated by all patients and only one woman had a reaction during predonation. furthermore a group of patients matched for age, sex and type of surgery, who did not predeposit blood, received a mean of . homologous units per patient, that is more than the patients on pabd program. our results show that autologous transfusion can be used in scheduled orthopedic surgical procedures and can reduce the need for homologous blood. however, every effort should be made to render the practice of pabd more efficient and to minimize its costs. colloid solutions and their establishment in clinical practice background: various situations like trauma, critical ill patients, sepsis, major surgical procedures and anaphylactic reactions are associated with disturbances in fluid homeostasis. this disturbance is related with reduced oxygen delivery, subsequent lactic acidosis and imbalance in oxidative status. the final result will most likely be an increased mortality and morbidity. aim: the important issue from clinical aspect is to define the optimal volume and type of fluid therapy. the debate for the ideal resuscitation solution lasts a couple of decades due to inconclusive and conflicting results. method: we searched the literature for clinical trials and major met analyses concerning patients undergoing scheduled surgical procedures, trauma patients and critical ill who received resuscitation fluids. results: dextrans reduce blood viscosity and von willebrand factor levels more, for the same degree of hemodilution, compared to other plasma expanders. in clinical setting they are effective in reducing the incidence of deep vein thrombosis and pulmonary embolism. after the initiation of dextran for prophylaxis against anaphylactic reactions, they are considered the safest plasma substitutes, except maybe during pregnancy. dextran % is the most like to cause the 'hyperoncotic acute renal failure' syndrome. gelatins also cause a decrease in circulating levels of vwf : ag, vwf r : co, thrombin-antithrombin complexes and f + . in clinical aspect however, there are contradicted results about the effect of gelatins in bleeding diathesis, although they appear to exert a greater effect on rbcs protection from mechanical stress. in respect to anaphylactoid reactions, they have the greatest relative risk. hes has the same effectiveness in volume expansion with albumin and has the advantage of remaining intravascular even if there is an increased capillary permeability. in addition, it may improve splanchnic blood flow and tissue oxygenation. hes / . subsides the inflammatory response in patients undergoing major surgery, compared to a crystalloid-based volume therapy, but has conflicting results about it's effects on neutrophil respiration burst. clinical trials have so far failed to have a unanimous conclusion about the bleeding diathesis after hes administration, especially. caution must be held when administering hes during renal transplantation. albumin became the scapegoat of transfusion strategy during the past years. resent met analysis have contradicted results about the safety of albumin infusion in variouw settings. a positive effect seems to have the early administration of hypertonic solutions in trauma patients, especially in combination with dextrans. conclusions: although some minor conclusions can be extracted, there is still a great lack of large scale multicentre randomized prospective clinical trials for extracting evidence based criteria. instead, we try to extract conclusions through met analysis. results show no evidence that resuscitation with colloids reduces the risk of death compared with crystalloids in patients with trauma, burns, major surgery or sepsis. also, there is lack of evidence that one colloid solution is safer -in clinical aspect -than any other. recombinant human erythropoietin therapy in critically ill patients -a dose response study* objective: the aim of our study was to assess the efficacy of two dosing schedules of recombinant human erythropoietin (rhuepo) in increasing hemoglobin (hb) level and reducing the exposure to red blood cells (rbc) transfusion in critically ill patients. design: a prospective, randomized, multicenter trial. patients: a total of patients who met eligibility criteria were enrolled. intervention: patients were randomly assigned to receive intravenous (i.v.) iron saccharate alone (control group), i.v. iron saccharate and subcutaneous rhuepo units once per week (group a) and i.v. iron saccharate and subcutaneous rhuepo units three times per week (group b). rhuepo was given for a minimum of weeks or until icu discharge or death. the maximum duration of therapy was weeks. the requirement for rbc transfusions was significantly higher in control group than that in group a and b. no significant difference was observed between group a and b. the mean increase in hematocrit (dhct) and hb (dhb) from baseline to final measurement were significantly higher in group b than these in control group. dhct was significantly higher in group b than that in group a. dhct in group a was significantly higher than that in controls, whereas dhb did not differ significantly between control and group a. conclusion: administration of rhuepo in critically ill patients significantly reduced the need for rbc transfusions. the magnitude of the reduction did not differ between the low and high dose of rhuepo, whereas there was a dose response of hct and hb to rhuepo in these patients. in transfusion medicine, antibodies to antigens in the platelet membrane have traditionally been regarded as less significant compared with antibodies towards red cell antigens. there is an increasing awareness of antibodies towards platelet antigens. detection of autoantibodies to platelets can be a diagnostic challenge, but is seldom a problem in transfusion medicine because patients with such antibodies rarely are candidates for platelet transfusions. also, severe foetal thrombocytopenia is seldom present in pregnancies with autoantibodies to platelet antigens. the real challenge in transfusion medicine is related to patients with severe thrombocytopenia who are refractory to platelet transfusion due to alloantibodies towards platelet antigens. in our department, flow cytometry is used for compatibility testing and the choice of compatible blood donor is done without knowledge of antibody specificity. if crossmatch negative random donors cannot be identified, antibody specificity testing is performed and donors are chosen based on the specificity of the antibodies determined by a modified maipa procedure and with hla class i beads (flowpra from one lambda, usa) in flow cytometry. in some cases both hla class i and human platelet antigen (hpa) specific antibodies are detected and hla class i, hpa matched donors are chosen for crossmatch. if the crossmatch is negative, there is > % chance of successful transfusions. in some cases drug induced anti-platelet antibodies are suspected and flow cytometry based antibody tests are performed in the presence and absence of the drug. in the case of suspected heparin induced antibodies, a beads assay is performed (diamed, switzerland). two percent of caucasian women have the platelet type hpa bb. ten percent of these women make anti-hpa a antibodies in their first hpa a incompatible pregnancy. in - new-born has thrombocytopenia due to maternal alloantibodies which have crossed the placenta (neonatal alloimmune thrombocytopenia, naitp). results from a screening study covering the outcome of pregnancies show that only babies were born with intracranial haemorrhage (ich) and there was no still-born babies in the study. pregnant women with a-hpa a antibodies were diagnosed, received careful clinical follow-up and the delivery was performed by caesarean section in week of the pregnancy with immediate transfusion of hpa compatible platelets if the new-born had platelet count < ¥ e /l. in previous studies, it is reported the ich appears in - % of the pregnancies where antibodies are present and that % of the babies with ich, die. our results are different from what is reported from other studies and this may reflect the prospective approach and the clinical interventions. naitp represent a challenge in transfusion medicine both diagnostically, but also related to compatible blood products for the thrombocytopenic new-born and the mother who may have high level of antibodies towards platelet antigens. methods: apheresis platelets ( ¥ e mean) from donors with same blood group were pooled and divided equally into two bags, po- and control (pl , baxter), which have and ml/m *day*atm of oxygen permeability, respectively. on days , , , , , and of storage, swirling, mean platelet volume, po , pco , ph, glucose, lactate, aggregation, and p-selectin expression were evaluated. six experiments were performed. results: the swirling pattern was preserved better for up to days in po- ( / ) than in control ( / ) bags. dropped ph less than . on day was observed / in po- whereas / in the control. aggressive drop of glucose ( mmol/l) with prominent lactate accumulation ( mg/l) was also observed on day in of control bags. the po level in the control dropped more significantly by % ( . mmhg) on day than in po- ( . mmhg) compared with the initial level ( . mmhg) (p < . ). these results suggest that aerobic metabolism of higher concentration platelets was maintained better in a container with higher oxygen permeability. and less lactate generation with slower glucose consumption is also suggested in po- bags than in control bags. the %hsr and aggregation decreased gradually in a similar manner in both bags until day , and became a detrimental defect in of control bags on day . p-selectin expression was higher in control bags than in po- on days and with no statistical difference. in two control bags p-selectin expression reached > % and was accompanied by a loss of swirling. these functional and biochemical characteristics of platelets at a higher concentration were kept better for - days when stored in a container with higher oxygen permeability than in the best of marketed containers. t-pa- background: maintenance of a neutral ph in the range of . - . is essential for preservation of platelet function and viability during storage. furthermore, studies have also indicated that the presence of glucose in the platelet suspending medium is important for maintenance of platelet quality. however, a platelet additive solution (pas) containing glucose having a ph of . - . cannot be manufactured by steam sterilization due to caramelization of glucose. in order to have optimal ph, the currently available pas such as t-sol does not contain any glucose. this study describes a novel twostep approach to provide a glucose containing additive solution (pas-g) by using an acid, glucose containing electrolyte solution (ph . ) for resuspension and processing of the pooled buffy coats (bc), followed by transfer of the processed platelet concentrate (pc) into a storage bag containing bicarbonate for ph neutralization and maintenance during extended storage. aim: compare the platelet quality of pooled bc pc stored in pas-g with pooled bc pc stored in t-sol. methods: a paired study design was used, where a pool of bcs obtained from standard day -old cpd-wb units, was divided into two equal parts: one part was resuspended and processed with a pall leukoreduction system (atsbc) using t-sol, the other part was processed in a similar manner with the acid part of pas-g. percentage plasma carryover ranged from - %. both processed pc products were transferred and stored in elx tm bags with the pas-g pc elx bag containing a bicarbonate tablet. ten replicate studies were performed. results: the yields ( . ± . vs. . ± . °¥ e ) were similar (pags vs t-sol). statistically significant (p < . with paired ttest) improved platelet quality at days , , and of storage was observed with platelets stored in pas-g as compared to t-sol. the table below shows results at and days of storage for ph, extent of shape change (esc) and hypotonic shock response (hsr). the results for t-sol stored platelets correlated highly with initial glucose (% plasma carry over) level (r = . for esc, and r = . for hsr at days storage), while no significant correlations were found for pas-g stored platelets. conclusion: this study demonstrated the practicality of using a two step procedure to store bc pc in a glucose containing additive solution with neutral ph during storage, and confirmed the importance of glucose in the storage medium as nutrient for optimal platelet storage quality. the effect of irradiation on white cell reduced platelet concentrates, stored for days background: the storage of white cell (wbc)-reduced platelet concentrates (pcs) can be extended from to days provided the quality has been validated and bacterial screening is performed. irradiation up to gray (gy) does not affect platelet quality, but the effect of pre storage irradiation with subsequent storage up to days is not known. method: two wbc reduced pcs, each made from buffy coats and a unit of plasma, were pooled and divided into control group 'a' and study group 'b' . pcs in group 'b' were irradiated immediately after preparation with gy. pcs in both groups 'a' and 'b' were then stored on a continuous flat bed shaker at - °c. swirl, ph and cd p expression were determined on day , and . twelve experiments were performed and compared with a paired t-test, p < . was considered significant. results: see table (day values; mean ± sd; n = ). pooling and dividing of the pcs was successful with respect to volume and platelet number. on day , the ph in group 'b' was slightly lower than in group 'a', but the difference is not significant. in group 'a', ph on day was < . in / pcs, versus / in group 'b' (not significant). the cd p expression in irradiated pcs is not significantly higher than in non-irradiated pcs. conclusion: irradiation had no significant effect on platelet quality when stored for up to days after blood collection. - b, - a, - b, pra %, donors. in patient -three transfu-sions were effective (two crossmatches neg by lct and pift, one pos lct, neg pift) but later on, when the patient was in severe clinical status (shortly before his death) two transfusions were ineffective in spite of neg crossmatches. it is very likely that for the same reason patient and were refractory to two and one hpa compatible platelet units respectively. in patient and compatible platelets were not transfused because they died before the whole procedure (diagnosis and finding a proper donor) was completed. conclusions: . the frequency of occurrence of anti-hpa antibodies in transfused patients was: - b, - b, - b, - a, - a; in three patients they were monospecific, in four polyspecific. . in patients who developed anti-hpa alone, transfusions of platelets without relevant hpa antigens were successful. .the effectiveness of compatible platelets in patients with both anti-hpa and -hla was more difficult to assess because of their severe clinical status, which might have been responsible for transfusion failure. in one of these patients, however, the transfusions of compatible platelets were successful when he was in relatively good clinical status, but shortly before death transfusions were ineffective. t-pa- the successful implementation of nucleic acid testing (nat) for hiv, hbv, hcv and further viruses as well as improved donor selection led to a dramatic risk reduction for viral transmission via blood transfusion over the last years. today, other risks get into the focus of haemovigilance. bacterial contamination of blood products can occur via the donor, suffering from a (clinically unapparent) bacterial infection, or via the donation process itself, storage and handling of the blood product. particularly platelet concentrates (pc) are vulnerable to bacterial growth due to their storage conditions. patients receiving such products have a potential risk of severe complications or even death. modern hygiene regimes, e.g. improved disinfection of the donors´ skin or preparation of blood products in fully closed systems as well as diversion, led to a significant reduction of bacterial contamination risk in the past. however, a small risk remains. therefore, two possible ways of further reducing the risk of bacterial contamination of blood products are feasible: (a) testing and/or (b) inactivation. testing for bacterial contamination is possible by different methods: direct detection methods for bacteria (microscopy, flow cytometry) have disadvantages regarding sample size and detection limit. bacteria might rapidly grow in a contaminated pc, so testing should be performed as close as possible to transfusion to the recipient. biochemical methods like oxygen consumption might not detect anaerobic germs. automated culture methods are still the most sensitive technique, but they have their downsides as well (e.g. time and size of aliquot drawn). novel molecular genetic test methods for detection of bacterial nucleic acid are in different states of development, but still have to proof their suitability for routine use. three different principles of pathogen inactivation can be distinguished: photodynamic reactions produce oxygen radicals which in turn inactivate bacterial structures by oxidation processes. examples for these chemicals are phenothiazines like methylene blue and thionin as well as vitamins like riboflavin (vitamin b ). photochemical reactants penetrate cell boundaries and irreversibly inhibit nucleic acid, thus blocking replication and proliferation of pathogens. chemicals of this group are psoralens like amotosalen as well as pen- or s- . the third method, the solvent detergent (sd) method, is used for pooled plasma only and consists of the combination of both solvents and detergents, which interact with membranes and destroy bacteria. methods for inactivation of bacterial contaminants have to proof, that they effectively inhibit bacterial growth while maintaining full functionality of the blood product at the same time. these two qualities have to be fulfilled up to the end of the storage period. toxic or mutagenic compounds must not remain in the final product. the technology must be easily integrated into the existing work cycle of a blood bank. finally, costs per product must be acceptable. in summary, both testing and inactivation have their advantages and disadvantages, which have to be weighed up against costs and benefits of both procedures. pros and cons of introduction of inactivation methods in a blood donor service producing blood components per year will be discussed. bacterial contamination of blood components, particularly platelets, is now recognized as a serious adverse reaction that is preventable. there are many studies that have documented that these reactions occur from platelets stored at room temperature, most commonly arising from a skin contaminant, but originating from donors with asymptomatic bacteremia in about / of cases. the problem is intensified for patients receiving pools of platelets compared to single donor platelets collected by apheresis. reactions are more commonly noted and more severe with platelets stored for greater lengths of time. previous studies at johns hopkins described a series of reactions in years with reactions more common in platelet pools ( : transfusions) than with single donor platelets ( : transfusions). these reactions caused fatalities in of cases. although our data suggests that these reactions are more common than other studies using hemovigilance systems, our case definition requiring culture of all transfusion reactions to platelets led to a more reliable estimate of the incidence of sepsis from platelets, many potential solutions have been proposed to prevent these reactions. improved skin antisepsis should always be sought but will never eliminate the / of reactions due to asymptomatic bacteremia. the same limitation applies to methods that divert potential skin plugs from the collection bag. antibiotics in the bag would lead to manufacturing concerns or problems for patients with drug allergies. although cold storage of platelets is currently being revisited, it is not yet a practical solution. pathogen eradication systems have been developed but they remain unapproved in most of the world and have led to concerns about toxicity of additives, damage to treated cells, and cost. as a result of increasing recognition of the problem, there has been increased interest in bacterial screening to prevent sepsis from platelets. in march , the aabb standards required testing of platelets for bacterial contamination. testing programs have been implemented in the us widely as a result of the aabb action. licensed systems based upon bacterial culture or growth characteristics are available for single donor platelets and have been commonly employed. although these systems have some difficulty with false positive reactions, the evolving national data suggest an incidence of : true positive reactions. these data suggest that a number of serious reactions have been averted, although some cases have persisted due to incomplete adoption, problems with slow growing bacteria, or the use of inferior testing methods with inadequate sensitivity. whole blood derived platelets have become a more difficult issue, since the approved testing methods are limited. the use of ph monitoring, gram stain, glucose measurements, and inspection for swirling have all been attempted. these methods are not sufficiently sensitive or specific to interdict many contaminated units, so that screening for bacteria in pooled platelets is less effective. it is anticipated that new methods may become available to make screening of whole blood derived platelets easier to perform in a reliable manner. it is also hoped that bacterial screening of platelets may form the basis to permit seven day storage and prestorage pooling in the us. results: twenty four hcv rna (+)/anti-hcv(-) repeat donors were previously tested in routine hcv rna in mini-pools and were negative. twenty available look back samples were individually tested for hcv rna and in one the virus was detected. to make sure that the failure of hcv rna detection in routine nat was not due to the pooling procedure, the hcv rna was tested in undiluted look back sample and dilutions of this sample by hcv negative plasma: / repeats of x dilution and / repeats of x dilution were hcv rna negative, whereas / repeat of x dilution and / repeats of undiluted sample were positive. the results of cobas amplicor monitor (sensitivity iu/ml) were negative, which means that viremia in hcv rna mini-pool negative donation was below iu/ml. in the recipient of red blood cell concentrate from this donation hepatitis c was diagnosed. however, the possibility of pretransfusion hcv infection cannot be excluded as no hcv marker tests were performed before transfusion. the patient and the donor were infected with genotype a. the low hcv viremia (below iu/ml) in the preseroconversion window period was responsible for no hcv rna detection in routine mini-pool hcv rna testing. introduction and aim of the study: bacterial contamination is a life threatening risk of blood transfusion, especially with platelet transfusions. bacterial culturing (bc) of platelets as well as pathogen reduction (pr) reduce the likelihood of such contamination. where the costs of bacterial contamination are far less than the costs of pathogen reduction, the latter will reduce not only the risk of bacterial contamination but also risks of other pathogens. therefore, the question arises whether this additional expenditure can be justified in the light of the additional effect achieved. this question we will answer by cost-effectiveness and sensitivity analyses. methods: the balance between costs and effects of preventing adverse events due to platelet transfusion is assessed using a mathematical model and assuming optimal effectiveness of pr. model parameters and valuations of health states were obtained from literature and information from dutch sanquin blood banks. . while the estimates in comparison to the situation without bc or pr are surrounded with large uncertainties, the conclusion that pr is not cost-effective in comparison to bc is very robust. the cost-effectiveness of bc and pr are very sensitive to the estimates concerning sepsis probability and associated complication rate, the cost-effectiveness of pr relative to bc is not. this conclusion is also insensitive to a wide range of assumptions regarding residual risks and costs associated with hiv, hcv and hbv. the estimates indicate that culturing in the netherlands is cost-effective, even with the deviation bag in place. the estimates however appear to be very sensitivity to the probability of sepsis. a decision to use pr will, after the introduction of bc and the use of a deviation bag, never meet cost-effectiveness criteria. even when assuming perfect protection, the conclusion that it is not cost-effective in comparison to bc is very robust and does not alter when varying underlying parameters within their margins of uncertainty. table) . of cb collection. two collections have been transplanted to date and this represents a . % take-up rate ( . % where a sibling is alive). this compares favourably with the numbers transplanted from unrelated cb banks. dcb collection is therefore at least as efficient a method as unrelated cb collection for transplantation albeit in the limited number of cases where a dcb collection is possible. dcb collection has the benefit of a possible immediate transplant combined with the availability of a sibling donor for future donation of both stem cells and lymphocytes. it is therefore a useful service to provide and complements the work of unrelated cord blood banks. increased yield of mature platelets in cultures of cd -enriched cord blood cells maintained at °c introduction: the future use in transplantation of ex vivo expanded hematopoietic stem (hsc) and progenitors cells will facilitate the transplantation of adult patients and speed up hematologic recovery. also ex vivo cultures of hscs may eventually permit to produce donor-free blood components such as platelets for transfusion. culture of animal cells is routinely done at °c. however there is previous clinical evidence suggesting that hematopoiesis may be more active in hyperthermic patients. we have therefore compared the effect of hyperthermia on the ex vivo expansion and differentiation of cord bloodderived hsc in megakaryocytes (mk) and mature platelets. the cord blood-derived cd cells were cultured continuously at °c or °c for days in cytokine conditions optimized for mk development and maturation. the cultures were regularly monitored for various parameters. results: compared to °c, the cultures maintained at °c produced significantly more total cells ( . fold) and total mks ( fold), and showed accelerated and enhanced mk maturation with increased yield of proplatelets and mature platelets ( . fold). accordingly, the cells cultured at °c contained an increased frequency of cfc-mk ( fold) at day . cultures done at °c and °c were also more efficient than at °c but less than at °c. platelets produced in °c cultures could be normally activated by thrombin. as expected, the cells cultured at °c contained an increased amount of the heat shock protein hsp . control experiments showed that the culture of several cell lines was inhibited or unaffected by the °c temperature. the unexpected resistance of hematopoietic cells to the deleterious effects of heat and the stimulatory effect of > °c temperatures on hsc proliferation and differentiation indicate that the routine culture of normal human cells at °c is a paradigm that needs to be revised. the responsible molecular mechanisms remain to be identified but the observation will facilitate the ex vivo expansion of the progenitors of the mk and possibly other lineages. the synchronous generation of a significant number of mature platelets in vitro will facilitate the study of the mechanisms of platelet formation and ageing and could eventually have important applications in transfusion medicine. it remains to be seen if the stimulatory effects of higher than °c temperatures represent a protective response against sustained body fever that is specific to the hematopoietic system. several countries have, in the past few years, included human tissue banking within a regulatory framework similar to that of blood. indeed, tissue safety has come to the forefront of the preoccupations of regulatory agencies after several well publicised morbidity and mortality cases have been reported in the press. tissue safety has many features similar if not identical to blood safety and a review of those common elements will be reported. as well, arguments in favor of integrating tissue banking within a blood system will be discussed, one of the more important aspect of which being the expertise of the blood centre staff with cgmps. the experience of a blood establishment (héma-québec) with the integration of tissue banking such as bone, skin, heart valves within its operations will be reported, emphasizing the medical as well as the management aspects of such an integration. finally, tissue banking is an activity which brings more expertise to a blood centre, expands its knowledge of its customers and gives more opportunities to its personnel. umbilical cord blood (cb) is an important source of stem cells for clinical transplantation and may cause less gvh disease than non-t-depleted bone marrow (bm). the relatively low numerical cell dose available from cb has usually restricted its use for transplantation in adults. only - % of patients have an hla matched sibling and for others an unrelated bm or a stored unrelated cb donation may also not be available. for some children the collection of cb following the birth of a sibling may be the only opportunity for a transplant. directed cb (dcb) donations from matched siblings have been shown to give better long-term overall results than matched unrelated cb or bm. dcb collection is however not as easy to control as cb for banking where dedicated hospitals and trained staff are used. here we review dcb banking in oxford over a . -year period. requests were received for deliveries from mothers and of these, collections were successful including pairs of twins. failed collection was most often due to a damaged cord at delivery. collections were made for siblings possibly requiring transplant (median age ) with for leukaemia, for erythroid disorders, for immune deficiency, for enzyme deficiency and others. the remaining collections were mostly requested where there was a family history of an inherited disorder (majority scid). three collections tested positive for anti-hcv antibody but negative for hcv by pcr. collections were not excluded on the basis of volume or cell number. mean volume was ml (range - , % exceeded mls) and mean tnc count was . ¥ (range . - . , % exceeded . ¥ ^ ). the mean cd +ve count was . ¥ (range . - . ). all collections were cryopreserved within hours using dmso/dextran/saline without volume reduction. the mean tnc viability prior to freezing was % (range - %) and the mean cd +ve viability post freezing was % (range - %). the reliance on the goodwill of midwives and the logistical difficulties that arise when organising collections from many different hospitals do not appear to reduce the success . rhd and rhce typing was performed by multiplex-pcr with fluorescent primer pairs. positive results were obtained for rhd-exons - , , and polymorphisms associated with antigens c, c, cw, e and e. sequencing of rhce-sequences, including exons to and intron/exon borders, were done by direct taq cyclesequencing using bigdye-terminators v. . in an abi (applied biosystems). background: a number of adverse immune reactions associated with blood transfusion result from contamination of blood products by donor white blood cells. among these reactions, transfusionassociated graft-versus-host disease (ta-gvhd) has a mortality of greater than %. mirasol ® pathogen reduction technology (prt) has been developed for the reduction of viruses, bacteria, parasites and white blood cells loads in blood products. the technology is based on light and riboflavin photochemistry. this study was performed in order to evaluate the effectiveness of the mirasol ® prt process for inactivation of human pbmncs. methods: human pbmncs were collected from trima platelet apheresis disposable sets, purified by ficoll-hypaque discontinuous gradient centrifugation and divided into test and control samples. the test cells were treated with mirasol ® prt in autologous plasma on day . both test and control samples (n = ) were tested on day for cellular immunophenotype, t-cell activation using flow cytometry, proliferation in response to mitogen or allogeneic stimulator cells, ability to stimulate the proliferation of allogeneic responder cells and cytokine synthesis in response to lps stimulation was measured using a cba assay kit. results: although mirasol ® prt treatment did not significantly change the distribution of cd +, cd +cd +, cd +cd +, cd + and cd +cd + human lymphocyte subpopulations there were significant functional change. the expression of the activation marker, cd , was observed in . % (sd = . %) of control t cells upon activation with pma, while only a . % (sd = . %) of the test t cells increased cd expression. proliferation assays showed that h-thymidine incorporation did not increase in the test cells in response to either pha or allogeneic stimulator pbmnc compared to the significant increase in thymidine incorporation levels observed with control cells. the test cells, when compared to the controls cells, demonstrated an inability to stimulate allogeneic responder pbmnc proliferation. the release of il- , il- , il- b and il- cytokines after -h incubation in culture media increased significantly to pg/ml (sd = ), > pg/ml, pg/ml (sd = ) and > pg/ml for control cells, respectively. under the same conditions, these cytokines in test samples remained at background levels of . pg/ml (sd = . ) for il- , . pg/ml (sd = . ) for il- , pg/ml (sd = ) for il- b and pg/ml (sd = ) for il- . addition of lps further stimulated the release of tnf-a, il- , il- , il- b and il- in the control samples, but not in the test cell samples. in vitro studies demonstrate that mirasol ® prt treatment does not change lymphocyte immunophenotype, inhibits tcell activation by pma, abolishes pbmnc proliferative activity, eliminates pbmnc stimulatory activity for responder cell proliferation and suppresses the production of cytokines by pbmnc in both the absence or presence of lps. introduction: it has been discovered that vaccination of dendritic cells (dcs) with tumor antigens is a potential strategy to induce tumor-specific immunity in tumor-bearing patients. aim of the study: the purpose of the study was to investigate whether human monocyte-derived dendritic cells (dcs) were able to present p bcr-abl protein and induce antigen-specific ctl responses in vitro after transfected with total rna of k cells (k -rna). methods: dcs were derived from human pbmncs, which were incubated for days in the presence of gm-csf and il- , and then were transfected with k -rna using electroporation or dotap lipofection. to verify the successful transfection of dcs with k -rna, bcr-abl fusion genes expression of dcs was detected by rt-pcr and western blot. the immune phenotypes of the dcs were analyzed by flow cytometry. the cytotoxicity of ctl was assayed by propidium iodide (pi) staining and flow cytometry. results: it was shown that the bcr-abl fusion gene was detected in the dcs immediately after the transfection, but disappeared hours later, while the cells were expressing p bcr-abl protein and expressing increased cd , cd , cd , hla-dr. moreover, the transfected dcs could significantly promote the t lymphocytes to kill the target k cells. conclusion: human dendritic cells transfected with total rna of k cells in vitro could induce effective p bcr-abl proteinspecific immune responses and be used to induce tumor-specific immunity, which implies potential application of immunotherapy to tumors. appear to be relevant to the clinical response. ivig has a remarkably good safety record for long term administration, however the following side effects have been observed: mild, infusion-rate related reactions such as headaches, myalgia or fever; moderate but inconsequential events, such as aseptic meningitis and skin rash; and severe, but rare, complications such as thromboembolic events and renal tubular necrosis. judicial use of ivig based on results from controlled studies is recommended. t-pl - donor-lymphocyte infusion: transfusion immunotherapy following allogeneic hematopoietic transplantation the notion that bone marrow containing immunocompetent cells is capable of mediating an antitumor effect was determined experimentally almost years ago. subsequently, pooled leukocytes from patients with cml were found to effect responses in patients with advanced leukemia. response correlated with cell dose and with severity of gvhd. in the 's, the graft-versus-leukemia (gvl) effect was defined in the transplant setting using a lethallyirradiated mouse model and splenocyte infusions. such studies suggested that gvl could be enhanced without causing severe gvhd. the era of adoptive immunotherapy in the transplant setting began in the 's with reports of donor lymphocyte infusions (dli) for relapsed acute and chronic leukemias after bone marrow transplant. it is now clear that chronic myelocytic leukemia (cml) in chronic phase is highly susceptible to gvl effects mediated by dli which induce durable remission in - % of relapsed patients. the success rate is % or less in patients with accelerated phase or blast crisis. since dli cell dose appears to be important in this setting, strategies of escalating dose infusions have been investigated to enhance gvl without exacerbating gvhd. unfortunately, the response to dli in relapsed acute leukemia and myeloma is less favorable (< %) and less durable. dli have been used successfully to treat viral infections and virus-associated malignancies following transplant. both unfractionated dli and ex vivo-generated tcell clones have suppressed reactivated cytomegalovirus and eradicated epstein-barr virus-induced lymphoproliferative disease, a polyclonal proliferation of donor-origin b cells that occurs after transplant. where tumor-specific antigens have been defined, efforts to target dli have been undertaken and donor and patient immunization has been investigated. acute or chronic gvhd develops in approximately % of patients receiving dli for relapsed hematologic malignancies and for related, but not unrelated transplants, correlates with the donor t-cell dose. dli-induced pancytopenia occurs in approximately % to % of patients, is generally mild, and transient, but in < % of patients, aplasia is severe and prolonged. complications of aplasia include infection, bleeding, increased transfusion requirements. efforts to limit the adverse effects of dli while retaining the therapeutic effects include insertion of 'suicide genes, ' selection of lymphocyte subpopulations, and targetting lineage-specific minor histocompatibility antigens. available clinical and experimental evidence suggests, that in addition to primary and secondary immune deficiencies, a wide spectrum of immune-mediated conditions could benefit from intravenous immunoglobulin (ivig), including acute and chronic/relapsing diseases, autoimmune diseases mediated by pathogenic autoantibodies or by autoaggressive t cells and inflammatory disorders e.g. an imbalance in cytokine networks. trimar-collected apheresis platelet concentrates (pcs) were exposed to . j/ml uv light in the presence of um riboflavin, followed by storage under blood bank conditions with various concentrations of -deoxyglucose from to mm for days. the control platelets were not stressed by uv light exposure and were stored under the same conditions without -dog presence. all test and control platelets were measured for in vitro cell quality including rates of glycolysis, morphology score and activation levels at days , , and . results: lactate production and glucose consumption increased from . mmol/ cells/h (sd = . ) and . mmol/ cells/h (sd = . ) for control samples to . (sd = . ) and . (sd = . ) for uv-treated platelets, respectively. uv treatment also caused a decrease in ph from . (sd = . ) for controls to . (sd = . ) for treated platelets at day , hsr from % (sd = . ) to % (sd = . ), esc from . % (sd = . ) to . % (sd = . ), swirl from . (sd = . ) to . (sd = . ), and increased p-selectin expression from . % (sd = . ) to . % (sd = . ). addition of -dog up to mm significantly reduced lactate production rate to . mmol/ cells/h (sd = . ) and glucose consumption rate to . mmol/ cells/h (sd = . ), and maintained ph above . (sd = . ) for days of storage. the effect of -dog exhibited a dose-dependent response. however, the addition of -dog had no effects on hsr ( . + . % at day ), esc ( . + . % at day ), swirl ( . + . at day ) and p-selectin expression ( . + . % at day ) during platelet storage. atp contents in both treated and control groups were maintained at a relatively constant level above % of the value seen in fresh platelets. furthermore, an exaggeration of uv-stressed platelet aggregation by addition of -dog was also observed. conclusions: increased glycolytic flux is not a direct cause for platelet morphology changes and spontaneous activation incurred during the development of the storage lesion. the results also suggest that a reduction in glucose utilization may foster an increase in platelet loss during storage. aim of the study: was to evaluate analytical sensitivity, sensitivity and inclusivity for subtypes and genotypes of hiv, hcv and hbv, the assay's effectiveness in closing the pre-seroconversion window period, clinical specificity as well as the effect of endogenous substances and microorganisms on the sensitivity and specificity of the assay. methods: secondary standard traceable to who international standard for hiv- ( / ), international standards for hcv ( / ) and hbv ( / ) were used to determine the analytical sensitivity. sensitivity and inclusivity for hiv- subtypes other than hiv- b, for hiv- and for hepatitis b and c genotypes as well as specificity was evaluated with > specimens. results: results from this study indicate that high analytical sensitivities ( iu/ml hiv- m, cp/ml hiv- o and . cp/ml hiv- , iu/ml hcv and iu/ml hbv) and a specificity of > . % are accomplishable for the mpx test. the % detection rate for hiv- m subtype isolates (a through h) was between to iu/ml, for hcv genotype isolates ( a through ) between to iu/ml and for hbv genotype isolates (a through g and precore mutant) between to iu/ml. investigating seroconversion panels, hiv- rna was detected an average of and days earlier than hiv- antigen with abbott hivag- monoclonal and coulter p antigen tests, respectively, hcv rna an average of or days earlier than hcv antibody with the abbott hcv eia . or ortho eia . tests, hbv dna an average of days earlier than hbsag with the abbott hbsag eia imx test. for all targets, no interference was detected with microorganisms tested as well as elevated levels of triglycerides, albumin, hemoglobin, human dna or bilirubin. conclusion: automated pooling, sample preparation, and real time pcr using the blood screening system taqscreen mpx test is an efficient and sensitive method to simultaneously screen for five important viruses in human plasma. the mpx test is another evolution step in the development of pcr automation by roche molecular diagnostics, and further represents roche's commitment to increasing the safety of the global blood supply. aim of the study: a prospective hemovigilance plan was set up in order to establish a registry for future reference, and to detect any unexpected side effect of ip that may occur with significant frequency in populations and indications that were not studied before and outside of a formal trial environment. methods: this plan is proposed to blood establishments and transfusion prescribers who have already decided to implement ip. this is an observational, non randomized, non controlled plan. no patient selection, inclusion or exclusion criteria are required. all ip transfusions are documented using an internet form, whether or not a reaction is observed. patient population data are collected anonymously, for epidemiological purposes. results: between october and september , apheresis ip units have been transfused in sites and registered in the database. ip platelets were considered leucocyte inactivated and were not irradiated, but were antigen matched as indicated ( . %). the population of patients receiving at least one transfusion (n = ) included . % of males, . % of females, the median age was (range - ). the most frequent broad diagnostic categories were hematology-oncology ( . %) and cardiovascular surgery ( . %). the patients received their transfusions either in regular hospital wards ( . %), intensive care units ( . %) or as outpatients ( . %). the number of transfusions by patient ranged from to (mean . ± . , median ). half of the patients ( . %) had previous transfusion experience and . % had previous history of transfusion reaction. transfusion reactions, defined as any deterioration of the patient's state of health observed following transfusion, were observed in . % (n = ) of the transfusions ( % ci . - . ), and . % of patients. only ( . %) were considered serious. after further causality analysis including biological and clinical investigations by the transfusion physician, . % ( % ci . - . ) of the transfusions were confirmed as having caused reactions in . % of patients, none of them serious. the most often reported symptoms were chills ( . %) and fever ( . %). itching, skin rash or urticaria was observed in . % of transfusions. of the serious reactions, one was hypotensive shock in a patient with liver cirrhosis and haemorrhage, and one was septic shock, in which the platelet unit bacterial culture was negative. none of the reactions occurred in cardiovascular surgery patients. patients were more likely to experience reactions if they had previous transfusion history (odd ratio . , p = . ). the active hemovigilance plan is a valid and feasible method to collect epidemiological data on transfusion safety. the risk profile of ip transfusions appears favorable. quality of theraflex mb-plasma during storage and treatment s reichenberg* and n mÜller † *maco pharma international gmbh, langen, † inst. for transfusion medicine, essen, germany background: although in the last decades thanks to the implementation of several methods like donor selection and testing procedures the risk of virus transmission from plasma has decreased, infection of patients still exists. additionally new viruses like west nile virus enter the transfusion chain. therefore, the treatment of therapeutic plasma with methylene blue (mb) is a technique used in several european countries for pathogen inactivation. macopharma has developed the proprietary theraflex mb-plasma bag system including a mb pill and a final mb filtration step. aims: aim of the study is to show the quality of the mb plasma during the preparation procedure and during storage using the theraflex system. methods: for the preparation process every single step was evaluated using single donor plasma units. for the evaluation of the plasma factors ml were drawn at different stages (before treatment, after plasma filtration with plas , after dissolution of the mb pill, after illumination, after treatment). because the sample volume for single sample measurements would be too low the samples were pooled after drawing and measured for the specified factors. six samples of each stage were pooled at three days. a whole panel of plasma factors was measured for the resulting three pools. global tests: quick, inr, aptt, thrombin time coagulation factors: fibrinogen, factor ii, factor v, factor viii:c, factor ix, factor x, factor xi inhibitors: at iii, protein c, protein s fibrinolysis: plasmin inhibitor, alpha -antitrypsin complement: ch activation: tat, factor xiia, d-dimer stability data were generated using three plasma pools. six plasmas were pooled and afterwards divided into six aliquots. each was treated as single unit and then each was divided into six storage samples. the same plasma factors as for the manufacturing process were evaluated. results: a moderate reduction for some coagulation factors during the preparation was found in the illumination step but not in the other preparation stages. this was mainly fibrinogen ( . %), factor viii ( . %), and factor x ( . %). despite this reduction the values were within the ranges found in non-treated plasma. all investigated plasma factors remained stable during the investigated storage time. summary/conclusions: the investigation showed that plasma treated with the theraflex procedure showed slight reduction during treatment and no reduction during storage. all plasma factors remained within the threshold values. the treatment of therapeutic plasma with mb is a valid technique of pathogen inactivation. validation of intercept treatment of pooled platelets g santos, c silva, f pereira and g sousa lisbon regional blood centre, lisbon, portugal background: intercept blood system for platelets uses amotosalen hcl and uva light to inactivate viruses, bacteria, protozoa and leucocytes that may contaminate platelet products. aims: the purpose of the study was to assess the feasibility of introducing this technology in the routine of lisbon regional blood center (crsl) and validate the procedure in our center. material and methods: whole blood units of ml were collected from volunteer blood donors in quadruple top and bottom blood bags (optipure rc soft t& b baxter), kept in n-butanodiol plates; buffy coats with a volume of ml were obtained in the opipress ii and kept overnight at room temperature before pooling. five buffy coats were pooled with ml intersol using the octopus system intercept buffy coat pooling set with an integrated filter. the pools were treated using the intercept. samples were taken before treatment, after cad remotion, on days , and . the following tests were performed: platelet count, mean platelet volume, ph, swirling. results: all pools met the intercept guardbands. platelet yield pre inactivation was . ¥ ( . - . ¥ ; sd- . ). platelet pool volume was . ml (sd- . ). plasma % was within . % and . %. all pools had leucocytes within council of europe specifications. after photoinactivation the platelet concentrates had . ¥ (± . ). the average platelet loss was . ¥ . the ph was within specifications during all the storage period. conclusions: intercept treatment of pooled buffy coat platelets is feasible in the routine of crsl and in vitro parameters do not show significant changes, allowing us to proceed to clinical use. shown ip and conventional platelets (cp), stored for up to days, exhibit comparable hemostatic efficacy and safety. extension of platelet storage duration to days has the potential to improve platelet availability and reduce outdating and inventory shortages. clinical efficacy and safety of ip stored for days were investigated. methods: a randomized, controlled, single-center, crossover, noninferiority design (pilot) study evaluated efficacy and safety of buffy coat ip vs buffy coat cp, each stored for days. patients were randomized to receive one -day ip transfusion and one -day cp transfusion in random order. after each study transfusion, the hour platelet count, ci, and cci; time to next transfusion; bleeding response; transfusion reactions; and serious adverse events (saes) were assessed. the primary endpoint, -hour cci, was analyzed by a one-sided non-inferiority test for the per protocol population (patients with both transfusions and no major protocol deviations interfering with efficacy evaluation). the per protocol population included patients, randomized to the ip-cp sequence and to the cp-ip sequence. more patients received allogeneic stem cell transplant in the cp-ip sequence than the ip-cp sequence ( % vs %; p = . ). mean platelet dose (¥ e ) was . for ip and . for cp (p = . ). there was a significant period by treatment interaction (p = . ) at the . significance level; therefore, the first period only was also analyzed for the primary endpoint. including both treatment periods, mean (±sd) -hour cci (¥ e ) was . ± . for ip vs . ± . for cp. the mean paired difference for both sequences was . ¥ e (p = . by non-inferiority test; upper bound of the % confidence interval = . ). for the first period only, mean -hour cci (¥ e ) was . ± . for ip vs . ± . for cp) the mean paired difference for the first period sequences was . ¥ e (p = . by non-inferiority test; upper bound of the % confidence interval = . ). the non-inferiority margin for the study was . ¥ e for mean treatment difference in cci (cp-ip). median time to next transfusion was h for ip vs h for cp following the first transfusion (p = . log-rank test; data censored at days after transfusion) and h ip vs h cp after the second transfusion (p = . ). bleeding pre-or post-transfusion was uncommon, usually mucocutaneous, and grade or lower, and responded similarly to ip and cp. no significant transfusion reactions or saes were reported. in this double-blinded, two-treatment crossover study the primary endpoint regarding -hour cci was not met. however, transfusion with -day-old platelets treated by the intercept blood system showed only a marginally and probably clinically insignificantly lower -hour cci compared to -day-old conventional platelets. methods: new zealand white rabbits were transfused with syngeneic blood ( ml/kg), across a major antigen (hgd) mismatch. high anti-s- ab titers (≥ : ) were induced after repeated immunization (days , , , , ) with klh-(s- ) hapten (klhhapten) in complete freund's adjuvant. ab titers against srbc were determined by gel card agglutination, or by facscan with fitc-goat_anti-rabbit_igg. survival of infused rbc ( ml/kg) treated with different methods was assessed by rbc biotinylation. blood samples were taken , , , , and days after transfusion, analyzed using streptavidin_pe and facscan to determine the proportion of circulating biotinylated rbc. results: groups (g) of rabbits were transfused with control rabbit rbc (crbc; n = , g ), or o-srbc (n = , g ). no ab against o-srbc developed after biweekly transfusions over weeks in g rabbits. high ab titers to o-srbc could however be induced by klh-hapten immunization in a different group of animals (n = ; g ). transfused rabbits (g & g ) exhibited no change in hematocrit or body weight and maintained good vital signs. high titer anti-s- abs were then induced by klh-hapten immunization in rabbits from g (n = ) and g (n = ), and in a group (n = , g ) of naïve rabbits. non-immunized rabbits (g , n = ), and (g , n = ) were maintained on the biweekly transfusion schedule of crbc and o-srbc, respectively. all rabbits treated with klh-hapten developed comparably high ab titers. klh-hapten immunization did not affect the viability of crbc in g rabbits. transfusion of o-srbc demonstrated reduced viability in hyper-immune g rabbits, but not any of the g rabbits. g rabbits exposed to o-srbc transfusions prior to hyper-immunization with klh-hapten, had viability of o-srbc comparable to crbc, suggesting induction of immune tolerance by repeated exposure to o-srbc. after depletion of labeled o-srbc from circulation, g and g were transfused with m-srbc. viability of m-srbc in all g rabbits (hyper-immune or not) and the hyperimmune g rabbits was equivalent to crbc circulation in g rabbits. in pre-immunized rabbits with high titer anti-s- ab, o-srbc are cleared faster than control. in contrast, m-srbc survive normally in rabbits with high anti-s- ab titers. repeated transfusion of o-srbc does not result in alloimmunization of naive rabbits. the modified s- rbc process offers the potential for pathogen inactivation with elimination of immunoreactivity and retention of rbc viability. introduction: the bombay phenotype is extremely rare and characterized by complete absence of abh activity both on erythrocytes and in secretions. those individuals can produce anti-h, which is active over a wide thermal range. method: using liss indirect antiglobulin technique, the patient's serum showed + reaction by panel of eleven cells at room temperature phase as well as indirect phase while the auto reaction is negative. a cold adsorption using rabbit erythrocyte stroma was done to remove the cold antibodies from the serum; + reaction of an antibody was detected in the patient serum after five folds of rabbit erythrocyte stroma adsorption. introduction: immunohematology reference laboratory in kuwait central blood bank receives samples from all hospitals in kuwait both governmental and private sector. the laboratory performs the tests according to international standards and it is monitored by internal and external quality assessments on periodic basis. material and method: a tube and gel cards are two methods in the reference laboratory for antibody identification. the laboratory can identify the most commonly encountered clinically significant antibodies and investigates causes of positive direct antiglobulin test that occur mostly in autoimmune hemolytic anemia. there are facilities to phenotype most of rare red blood cell antigens. results: records of all patients investigated in the laboratory since the year are kept in computerized system that has patient's records. central blood bank has the potential to identify rare phenotypes such as kpb-, jsb-, lan-, bombay, rzr , rzr , r¢r¢, r¢r≤, r≤r≤, ge- , , and rare red blood cell antibodies such as high frequency antibodies anti-k, anti-ge , anti-h, anti-lan, anti-kpb, anti-jsb, anti-wrb, anti-ena, anti-csa and low frequency antibodies anti-kpa-, anti-jsa-, anti-dia, anti-lua, anti-cob as well as hightiter-low-avidity antibodies such as anti-chido. samples of rare red blood cells and rare serums are kept frozen either by glycerol or liquid nitrogen technique to be used for pre-transfusion compatibility testing and continuing educational program. purpose of the work: to present the substitution of the blood groups o, a, b, ab in abo blood group system and rh (d) blood group in rh (d) blood group system in the population in the gevgelija-valandovo region. material and methods: a retrospective analysis was done on the data of following the blood groups o, a, b, ab and d in the blood group system abo and rh in the gevgelija-valandovo region. the asked population are voluntary blood donors, candidates for drivers, patients, pregnant women and newborn children. the period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) was analysed. the examinations were done with two standard methods (on the plate and in tube), to define blood groups from the most represented blood group systems abo and rh in the population. tests were done with different series of commercial anti serum tests from domestic and foreign origin. results: totally . examinees were typified. with o blood group were . ( . %); with blood group a were . ( . %); b blood group . ( . %) and ab blood group were . ( . %) examinees. totally . ( . %) were d positive and . ( . %) were d negative. discussion: the given results from our examinations for the frequency of o, a, b, ab and rh (d) blood groups from abo and rh (d) blood group systems in the region gevgelija-valandovo show that the most present is the blood group a from abo blood group system . ( . %) and d blood group in rh system with . ( . ) form examined population. the results are in correlation with data from the literature for other european nations. introduction: the policy of our center is to transfuse all heamatologic multitransfused patients with their own rhesus and kell phenotype. in addition, thalassemic and young leukemic patients are being transfused with compatible phenotype of the most clinical important duffy and kidd systems while all the other patients receive blood compatible only with abo and rhesus system. nevertheless, it is observed a significant positivity of the indirect antiglobulin test, due to alloimmunization. aim of the study: in this study we tried to evaluate the prevalence of alloimmunization in patients of our region. the most frequent detectable alloantibody remains the anti-d, with high prevalence . % of anti-d in females versus . % in males, due to alloimmunization during the pregnancy. as a consequence, the high incidence of anti-d is not transfusion related and anti-e is evidenced to be the most frequent transfusion related alloantibody, followed by anti-kell. care must be taken in order to transfuse as more patients as possible with their own phenotype regarding, at least the most immunogenic antigens, like anti-e and anti-kell. severe hemolytic reaction due to anti-j k background: red blood cell alloantibodies directed against antigens of the kidd system are notorious for causing delayed hemolytic transfusion reactions. the antibodies are formed because of pregnancy or transfusion. blood donors with the red blood cell (rbc) phenotype jk(a-b-) are extremely rare in the white population and exhibit a frequency of less than . %. however, the rare phenotype jk(a-b-) is more common in polynesians ( . %). individuals with jk(a-b-) phenotypes typically form anti-jk with inseparable anti-jka and anti-jkb activity. some jk(a-b-) patients' sera may show an additional distinct anti-jka or anti-jkb component when examined with adsorption studies. case report: a years-old caucasian female with a negative antibody screen, no prior history of transfusion, presented with gastrorrhagia. it is reported four pregnancies with no history of haemolytic disease of the newborn (hdn). on admission, her haemoglobin was . g/dl. she was given units of crossmatchcompatible rbc. on day her haemoglobin was . g/dl, with a total bilirubin of . mg/dl and lactate dehydrogenase of u/l. on th day an unexpected fall in hb ( . g/dl) occurred with an increase of bilirubin to . mg/dl and of lactate dehydrogenase to u/l. a new blood sample obtained for antibody screening and additional crossmatches showed a pan-agglutination and incompatible crossmatch. anti-jk antibody high titer was detected in the plasma by gel-test using liss/coombs cards (id-diamed). the dat was negative and the antibody reacted equally with jk(a-b+), and jk(a-b+) panel cells (jka: / and jkb: / ). other alloantibodies could not excluded, because jk(a-b-) cells are not available. she was started with erythropoietin-a (epo), folic acid, fe iv and high dose intravenous immunoglobulin (ivig). the epo was discontinued after four week of therapy when the haemoglobin was g/dl. two months later her haemoglobin was . g/dl and anti-jk was present in the same titer. a year later her blood cell count was normal and the anti-jk was detected in a lessened titer ( / ). no additional distinct anti-jka or anti-jkb component was shown after two adsorptions at °c using carefully selected phenotyped red cell compatible with patient's rh, fy, mnss, lu, le system and jka(+) and jkb(-), but two additional alloantibodies anti-c and anti-e of low titer ( / ) were revealed. the rare anti-jk alloantibody found in this case displayed the erratic nature of many kidd system antibodies. although anti-jk may cause mild hemolytic disease of newborn, she did not have a history of hdn. our patient was sensitized to a kidd antigen during pregnancy, but showed no serologically detectable antibody until challenged with a massive transfusion following a gastrorrhagia. the use of epo and high dose intravenous immunoglobulin succeeded to avoid transfusion with incompatible rbc unit. background: differential warm adsorption is used in the investigation of patients with red cell autoantibodies for searching of underlying alloantibodies, but it is also useful in the detection of clinically significant alloantibodies in patients with alloantibodies to high frequency antigens such as k, kpb, lub and inb. this technique is especially useful in cases when patients when patient's phenotype cannot be identified due to recent transfusion. purpose: differential warm adsorption is performing on cases presented with an antibody reacting with all red cells of the panel and having a negative auto control test. in these cases, even rare cells panels, which allow the identification of a pan antibody, are available, other more common clinical significant antibodies cannot be excluded. methods and result: case . a years-old caucasian female with preexisting myeloproliferative disorder (polycythemia) presented with pancytopenia. anti-k was detected in the plasma. it is reported two pregnancies and no history of transfusion. the dat was negative and the plasma did not react with one k-cell present on the red cell panel in use. the anti-k specificity was confirmed using additional k-cells. the patient's red cell were group a, d+, k+, k-, c-, e-, fy(a-), s-, le(a-), kp(a-), cw-. she was transfused with two units rbc k-. ten days after the first transfusion the dat became positive and the one k-cell present on the red cell panel reacted with her plasma. two adsorptions were carried out at °c using carefully selected phenotyped red cell (compatible with patient's rh, fy, jk, mnss, lu, le system and k positive). an anti-fya was identified in the presence of ant-k. . an antik (titer / ) was suspected. because k-red cell was not present in the panel in use, adsorptions were carried out at °c using carefully selected phenotyped red cell (compatible with patient's rh, fy, jk, mnss, lu, le system and k positive). after the anti-k antibody was totally removed, no additional alloantibodies were revealed. conclusion: differential adsorption in cases with alloantibodies to high frequency antigens represents a useful application of the technique and helps in the identification of clinical significant antibodies present, allowing a more accurate decision for transfusion. evaluation of validity of the expired enzymetreated . % red cells in antibody identification gel tests using nacl cards p chalkia, s intzepeli, v avgoloupi, a tsoukala, e ntinopoulou and p didoudi ahepa hospital, thssaloniki, greece background: expired red blood cells of required phenotypic profile is often used to identify antibody specificities in patients with multiple anti-erythrocytes antibodies. accurate results depend on the integrity of the antigens. purpose: to validate the expired enzyme-treated . % red cells for use in antibody identification gel tests using nacl cards. the serum of nineteen patients with common specificities antibodies in rhesus, kell, duffy, kidd, and mnss systems tested with commercially prepared . % enzyme treated cells rbc panel (id-diamed). gel tests were performed according to the manufacturer's instructions on in-date rbc and simultaneously on rbc month to months past expiration. reactivity of the expired antigen positive and antigen cells was compared to in-date cells. results: twenty antibodies detected with enzyme treated red cells in neutral gel cards [d( ), c( ), e( ), k( ), cw( )] and were tested with enzyme treated red cells in use and rbc to months post expiration. seventeen antibodies tested with enzyme treated cells gave acceptable results with antigen positive cells to months post-expiration, except anti-k antibodies (negative with k positive cells - months post expiration). conclusion: most rbc antigens studied were detectable months after rbcs expiration date. tests with . % cells were valid in gel test (nacl/enzyme) for at least months after manufacturer assigned expiration date and may be helpful for complex identification studies. studies for more antigens specificities are needed to testify the validity of the expired enzyme-treated . % red cells. background: wr(a) is a low-incidence blood group antigen ( : ) in the caucasian population. despite that anti-wr(a) is a common antibody type, it may cause severe transfusion reactions, haemolytic disease of the new-born. anti-wr(a) may occur as an autoantibody or arise without immune stimulus. we report a case of a naturally occurring anti-wr(a) antibody. case report, methods and results: -year-old non-transfused male patient with acute pancreatitis and severe anaemia had been transferred to surgery from a county hospital. the serological status identified by their blood bank was: b rhd positive, with anti-wr(a) antibody in the serum (cellbind card method). our results: the patient's cells were group b rhd positive (microplate method), dat negative (tube and gel test method). the antibody identification showed positive antibody reaction with all enzyme treated test cells but negative reactions in liss iat (tube test) and gel iat (scangel and diamed). discussion: our routine tests for antibody detection didn't detect any specific antibody in patient's serum. he was transfused several units of blood, that was wr(a) negative and showed negative crossmatch reactions. the patient had no transfusion reactions. days after the transfusion anti-wr(a) specificity was confirmed in the serum with cellbind test. only few test cell panels contain wr (a) positive cells, which are usually not present in commercial screening cells. in our case the cross-match was only performed for this patient because of the detected nonspecific antibody reaction in enzyme. the risk of transfusion reactions caused by rare antigens are particularly high in the type and screen cases. background: according to requirements of the french committee for accreditation (comité français pour l'accréditation cofrac, iso standards), it is essential to use validated and standardised methods in immunohematology. this imposes, among various requirements, the knowledge of metrological tolerances for all the techniques. aim: a multicentre study was carried out to define the maximal acceptable deviations concerning incubation temperature and time, volumes of patient plasma and of tests cells for antibody screening using indirect antiglobulin test (iat) in filtration technique. the antibody screenings were performed manually in blood centres using different filtration systems: id diamed, biovue ortho and scangel biorad, the same tests cells, a standard ng/ml anti rh (provided by cnrgs), a positive control anti kel and a negative control. all equipment used (oven, chronometer, pipettes) were calibrated according to cofrac standards. each antibody sample was tested under the following combined conditions ( tests/sample): results: all the tests of antibody screenings from the multiples combinations of the above parameters gave the same results with a + intensity agglutination for positive samples and the absence of agglutination for the negative control. conclusion: this study allowed us to define a range of tolerance for critical physical parameters involved in the antibody screening in iat using commercial filtration systems maryvonne. the authors present a retrospective study involving blood donors from the university hospital of coimbra during the year . the incidence of weak d and rh (d) phenotype was determined in individuals who were rh (d) negative. the ab and rh(d) blood grouping was performed using a column gel agglutination card (diamed). the rh (d) typing was done using a anti-d polyclonal and a anti-d monoclonal antibodies. all donors that gave negative or poor agglutination results were tested for weak d with an indirect antiglobulin test, with anti-igg (gel matrix card) plus anti-d serum (diamed). within our target group of blood donors the rh (d) negative represented . % of the total sample. we also describe ab , rh(d) phenotype (c, c, d, e, e) group frequencies and establish reliable estimates frequency for weak d and rhesus haplotypes. the background: in s and s several authors tried to assess the relationship between the number od igg molecules per rbc and in vivo haemolysis, but determinations usually concerned small groups of tested patients. some of the investigators suggested that the number of igg autoantibody molecules per rbc was a major determinant of the severity of the haemolysis, whereas others found aiha patients with severe haemolysis and undetectable autoantibodies. aim: presentation of our experience with the quantitative elat performed on a large group of aiha patients during long-term observation. material and methods: six hundred fifty eight blood samples from warm-type aiha patients were randomly tested for the number of igg molecules per rbc. eighty six of the patients were tested periodically from to times at one-month intervals. autoantibodies on rbcs were detected by the direct antiglobulin test (microcolumn technology) and measured by the enzyme-linked antiglobulin test (elat). results: in about / of tested samples the number of igg molecules per rbc was small (< ) and the laboratory signs of haemolysis were present in . % of them as well as in . % samples with moderately coated red cells ( - igg/rbc). the large number of igg molecules per rbc (> ) was significantly associated with high frequency ( . %) of severe haemolysis and it was also associated with presence of multiple igg subclasses on rbcs and c d. in % of patients tested periodically, the number of igg molecules per rbc decreased and it significantly correlated with improvement of haemolysis parameters. in % of aiha patients the number of igg fluctuated and it was a poor prognostic factor. conclusion: in aiha patients the dynamics of the changing number of igg autoantibody molecules per rbc is a more helpful diagnostic and prognostic parameter than the number of igg molecules per rbc evaluated in one test. -b+) , -h-negative (using the anti-h lectin). antibody work-up showed a positive antibody screen (liss and peg-tube methods) reacting + with o rbcs at all phases and + with a rbcs. the direct antiglobulin test (dat) was positive with polyspecific ahg as well as anti-c b,-c d (table ) . prewarming of test system did not change the reactivity ( + at antiglobulin phase). a treatment with dithiothreitol (dtt) was performed and abolished all reactivity of the serum ( table ). autoabsorption of the patient's plasma was performed. the absorbed plasma showed a decrease in reactivity from + to + when tested with o red cells, as well as a significant reduction in antibody titer from : to : tested at immediate spin (table ). the patient remained crossmatch incompatible with o and a rbcs, but was compatible with oh rbcs. summary: we report an unusually strong igm anti-h antibody in this patient, who may require oh phenotype units. the patient is not a para-bombay since her red cells type strongly as group a. the cause for the auto-anti-h remains unknown at this time. if a thermal amplitude test shows that the antibody appears to be clinically significant the patient should receive h-units if transfusion is required. introduction: fetomaternal haemorrhage may determine an alloimmunization, in fact the transplacental passage of antibodies may cause the haemolytic disease of newborn. for this reason, in pregnant women, a screening for irregular antibodies research is routinely performed. however the indirect antiglobulin test (iat) may result falsely positive or negative for various causes, as operative mistakes or low specificity/sensitivity of the used techniques. aim of the study. in this study we have retrospectively evaluated the real incidence of alloimmunizations occurred in women screened by private laboratories. methods: we have studied . women, - years old, resulted iat positive at the first screening and successively assisted by our two hospitals. all women were re-tested, using gel-agglutination technique, for both direct antiglobulin test and iat. results: a positive iat was confirmed only in cases; moreover a rbc autoimmunization was found in women. anti-d ( cases), e ( ), c ( ), k ( ), c ( ), s ( ), d + jka ( ), d + s + e ( ), d + c + k ( ), m ( ), c + e ( ), d + c + g ( ) were the identified alloantibody specificities. anti-s, -e, -k, -c and -jka were the specificities in autoimmunized women. conclusion: in conclusion, a real alloimmunization is occurred only in . % of screened women, while in the remaining cases iat resulted falsely positive: this observation forces us to affirm that, in order to minimize errors and alarmisms, the screening for antibody research in pregnant women must be performed only by immunohematology qualified center. background: one of the problems of the rbc transfusion is the alloimmunisation and the delayed haemolytic reactions (dhtr). besides rhesus and kell systems the antibodies against kidd antigens cause both dhtr and difficulties in their detection. aim and methods: the exact recording of all blood units according to abo rhesus kell and kidd systems. the abo-rh-kell systems are identified through automated microcolumn method (autovue, ortho), while kidd antigens are identified manually using microcolumn gel (diamed). results: the percentage of jka+ and jkb+ found in our department ( . %) and ( %) respectively is similar to that of the caucasian population. conclusions: given the fact that there is lack of available freezing rbc system in greece, detailed recording of all units to the above antigenic systems can be proved extremely useful under circumstances of incompatibility. in the latter case suitable donors can be called and cover the shortage. the identification of all antigentic systems of the donated rbc units is underway. background: in many countries transfusion recipients are currently typed and transfused d-positive, if their red cells are agglutinated by igm monoclonal anti-d that do not react with dvi. the transfusion strategy in weak d patients is not clear defined and it depends on the chosen monoclonal reagents and methods. patients who are carrying dw types , and were prone to develop anti-d. aim: the aim of this pilot study was to estimate capability of commercially available monoclonal anti-d reagents to recognize this weak d types as rhd positive. material and methods: edta anticoagulant blood samples were collected from blood donors, previously typed as weak d positive by indirect antiglobulin test. molecular genotyping of rhd gene and weak d alleles by cde-ssp and d weak-ssp kits (inno-train, germany) were performed. direct agglutination was tested in a tubes and microplates using the following antibodies: rum- , th- , ms- (bioscot/serologicals) and d e / - (immucor). results: out of samples molecular typing results were as follows: in samples dw were not determined, in samples, weak d type ; weak d type ; weak d type , weak d type ; weak d type and weak d type were determined. by all monoclonal reagents % weak d type , % weak d type , % weak d type and % weak d type negative results were given. by all monoclonal reagents weak d type and weak d type positive results were given. conclusion: according to weak d types, which were known to be at risk for anti-d immunization further advances may be brought by improved patient's monoclonal typing reagents with a low and donor's monoclonal typing reagents with high affinity for weak d type , type and type . such improved typing strategies with novel reagents would enhance the transfusion safety. background: vel is a high-incidence antigen found in > % of the population. anti-vel can be igm or igg and reacts optimally at iat, although it can also react at immediate spin and c. anti-vel may or may not cause severe hemolytic transfusion reactions and mild to severe hdn. autoanti-vel has also been reported. the aabb technical manual th edition states that the vel antigen is unaffected by protease and sulfhydryl treatment. we have reason to believe that sulfhydryl treatment may have an effect on the vel antigen as evidenced by a recently referred case. case report: a year-old caucasian female presented with symptoms of anemia and renal vascular hypotension. transfusion history indicated multiple red cell transfusions in . according to the patient, previous attempts to locate compatible units were unsuccessful. the case was referred to our laboratory. the patient's red cells (rbcs) typed as group o, d+ with a negative dat. the serological picture revealed an antibody reacting + - + s at c/liss, as well as at the antiglobulin phase. the antibody reacted with all rbcs tested and the autocontrol was negative. further characterization of the antibody showed similar reactivity using enzyme-treated rbcs ( . % ficin) and no reactivity using . m dithiothreitol-(dtt)treated rbcs. a high incidence negative red cell panel (untreated) was selected that lacked antigens reported to be destroyed by dtt. the antibody reacted with all rbcs tested. additional rbcs were tested that lacked high-incidence antigens, including vel. the antibody did not react with four vel-rbcs tested using liss and peg methods. the patient's rbcs typed as vel-negative. all other clinically significant antibodies were ruled out using vel-or dtt-treated rbcs. based on the unusual reactivity demonstrated by the anti-vel, we tested different examples of anti-vel (frozen in our rare sera inventory) against two sets of known vel+ and vel-rbcs. one rbc set was dtt-treated; the other set was tested neat. liss enhancement was used to test both sets. one of the antisera failed to react with the positive control and one reacted with the negative control. both were disqualified from the study. four of ten remaining antisera demonstrated a decrease in reactivity > grade, between the neat and the dtt-treated rbcs. the remaining six antisera showed no change in reactivity. conclusion: contrary to the statement in the aabb technical manual, we discovered that sulfhydryl treatment ( . m dtttreatment) can have an effect on the vel antigen. our experience has demonstrated that in some cases anti-vel may not react or may show reduced reactivity when tested with dtt-treated rbcs. therefore, the presence of anti-vel should not be ruled out if negative reactivity with dtt-treated rbcs is encountered. additionally, dtt treatment may be a useful tool obtaining rule-outs of other clinically significant antibodies in the presence of anti-vel. additional data is needed to confirm these findings. but with no identified specific antibodies were investigated by repeated screening/crossmatch, papainized panel identification, hla antibody screening by lymphocytotoxicity test (lct) and elisa in some cases. patients' age, sex, department, diagnosis, previous transfusions/pregnancies, techniques, reactions' strength, number of positive cells, urgency, subsequent antibody tests, identification and lct were noted. antibody tests were performed: at pretransfusion testing (pt) by liss-coombs (diamed) and at blood grouping (bg) by biovue polyspecific (ortho) microcolumns -manually in urgency and routinely by sampler iif (diamed) and mitis (ortho) systems. results: investigated reactivity was recorded in samples from patients; ( . %) patients had > episode. these findings comprised . % of unexpected results found at pt and bg. incidences were . % at routine and . % at urgent bg ( and bgs, respectively), and . % both at routine and urgent pt ( and pts, respectively). . % patients were female, . % over , but . % < years, coming mostly from surgery ( . %), internal medicine ( . %), hematology ( . %), ginecology ( . %), cardiac diseases ( . %) and cardiac surgery ( . % patients). frequent diagnosis were solid tumors ( . %), cardiac diseases ( . %), hematologic malignancies ( . %), uraemia ( . %), orthopedic surgery ( . %) and hepatic diseases ( . % patients). . % patients were previously transfused, with only . % patients proved as not transfused or pregnant. subsequently positive antibody test during the study had . % tested patients. at pt positive crossmatch was found in . %, antibody screening in . % and both tests in . % cases. majority of reactions were ' +' ( % at pt and . % at bg); reactions ' +' or ' +' were found in only . % cases at pt, compared to % at bg. one crossmatch only was positive in . % positive crossmatches, with / patients having > crossmatched unit. ahg identification was positive in . % tested patients; in % of them papainized panel was also positive. lymphocytotoxic antibodies were found in . % tested patients; . % ( %- %) of lymphocytes were reactive. finally, the cause of reactivity in antibody tests was determined as 'laboratory mistake' in . %, hla lymphocytotoxic antibodies in . %, 'igg antibodies of unknown specificity' in . % (hla noncytotoxic antibodies in / elisa tested samples!), contaminated sample in . %, anti-bga in . %, non-specific cold antibodies in . %, subsequently recognized specific antibodies in . % ( lua, m, kpa, yka), non-specific autoantibodies in . %, carry-over of dat-positive cells and antibody to reagent in . % cases each, while in . % cases antibody screening and in . % cases crossmatch was repeatedly positive without confirmation in panels. discussion: after introducing of sensitive microcolumns, positive antibody tests without detectable specific antibodies require significant laboratory activities, particularly in older patients with malignancies or surgery. such reactivity was frequently caused by laboratory mistake, but often hla and sometimes specific antibodies were later recognized, or reactivity continued without confirmation in panels. relationships that may be helpful are further discussed in abstract part ii. results: significant differences (p < . ) and relationships of interest were noted. sex. in female vs male patients frequent features were: crossmatch as only reactivity at pt ( . % vs . %), positive lct ( . % vs . %), lymphocytotoxic hla antibodies (lytxab) ( . % vs . %) and reactivity 'positive screening, negative panels' ( . % vs . %); in males non-specific cold antibodies ( . % vs . %) and antibodies to reagents ( . % vs ) were noted. age. in patients > vs < reactivity was often found at pt ( . % vs . %), caused by lytxab ( . % vs . %), anti-bga ( . % vs . %) or 'positive crossmatch, negative panels' ( . % vs ), but rarely by laboratory mistake ( . % vs . %) or later recognized antibody ( of patients). subsequent antibody tests: tests were subsequently positive more often if reactivity was found at pt ( . % vs . % at bg), as positive antibody screening ( . % vs . % if positive crossmatch), with positive panels ( . % vs . % if negative). subsequent tests were positive in only . % patients with lytxab, % with anti-bga, of with antibodies to reagent and in no case with 'positive crossmatch, negative panels' . techniques. lct was positive in % and . % tested samples found at urgent and routine pt (diamed), vs at bg. all cases due to lytxab, of anti-bga and of 'positive antibody screening, negative panels' were found by diamed. at bg (ortho) . % cold antibodies and . % laboratory mistakes were found. positive antibody test: identification was negative in . % screening-only cases; % of them were caused by laboratory mistake. lytxab were found in . % crossmatch-only cases; . % reactivities caused by lytxab were crossmatch-only. identification. ahg panel was positive in % cases with lytxab (in with papainized panel) and often due to 'igg antibodies of unknown specificity' ( . %), anti-bga ( . %), contaminated sample ( . %), but also to later recognized specific antibody ( . % cases). strength of reaction: laboratory mistake was noted in . % of 'w', . % of ' +', . % of ' +' and . % of ' + and +' antibody screenings (ns). diagnosis. in patients with solid and hematologic malignancy reactivity was often found at pt ( % and . % of patients, respectively), due to positive crossmatch ( % and %; and . % patients with liver and cardiac diseases) and caused by lytxab ( . % and . %) or 'crossmatch/screening positive, panels negative' ( . % patients with solid tumors). in patients with liver and cardiac diseases reactivity was often found at bg ( . % and . % of patients), due to laboratory mistake ( % and %) or cold antibodies ( . % and %), respectively. discussion: features of non-specific reactivity depended on sex, age, positive antibody test, diagnosis and, moreover, used techniques, sometimes in very distinctive manner. this analysis might be of considerable help in planning of laboratory tests, but also in quick analysis of unexpected results and choice of further testing, particularly in urgent situations. background: worldwide screen and type is a very usual method for pre-transfusional testing. the ultimate objective is to prevent not only the clinically expressed delayed hemolytic transfusion reactions but also the serologically revealed ones. aim: the aim of this study was to determine the frequency of red blood cell (rbc) alloantibodies in patients undergoing cardiac surgery or cardiac procedure, during the pre-transfusion screening. materials and methods: blood samples of patients ( male and female) were evaluated. the mean age of the patients was years. pre-transfusion samples were examined for clinically significant alloantibodies, using antibody screening with gel test (liss -enzyme). in case of a positive result, identification was performed (panel with autologous control). in addition, the serological testing included cold agglutinins´ detection (tube test), as well as titration (tube test) and identification (gel test) in case of a positive result. when the result was marginal ( / ) a new test was carried out after a seven days period. in the presence of a positive autologous control or an autoantibody, samples were examined with direct antiglobulin test (dat). results: alloantibodies were detected in patients with the incidence of . %. antibodies were registered more frequently in females ( / , . %) than in males ( / , . %). patients ( . %) developed single antibody with anti-kell being the most frequent. the incidence and the specificity of the detected antibodies are summarized in the following table (table ). in patients ( . %) multiple antibodies were detected, with most frequent the anti-d and anti-c combination. patients ( . %) were dat positive. autoantibodies were found in patients ( . %), all of which had specificity to rhesus system. cold agglutinins were positive in patients ( . %). no specificity could be assigned in patients ( . %), while in patients ( . %) non specific reactions in enzyme treated rbcs, were observed. one patient developed delayed haemolytic reaction days post-transfusion, due to anti-jka. the antibody, however, was not detected in the pretransfusion sample re-testing. the frequency of the pre-transfusion detection of red blood cell alloantibodies in our center, was . %. the most frequently identified were the anti-kell and anti-rh. the high rates of unidentifiable antibodies and non specific reactions in enzyme treated rbcs are probably attributed to the kind of medication that most of these patients receive, as well as to the degree of inflammatory process which usually accompanies such diseases. the high frequency of unidentifiable antibodies indicates that a larger and more complex erythrocyte panel would be useful for routine testing. the routine pre-transfusion screening for alloantibodies probably assures the prevention of dhtrs and provides sufficient time for blood selection for transfusion. introduction: in the united kingdom, about % of women form red cell allo-antibodies in pregnancy and . % of all pregnant women produce anti-c. before the introduction of prophylactic anti-d, it was reported that % of the total haemolytic disease of the newborn (hdn) cases were due to anti-c. currently, cases of hdn due to anti-c are half as frequent as anti-d and % of the uk population are rhc negative. we present two unusual cases of pregnant women who are d and c negative and have anti-c and anti-d detected in their serum. case studies and results: case : a -year-old asian woman had three previous uneventful pregnancies. in her th pregnancy she presented with miscarriage at weeks gestation. she was group b, d and c negative. her serum contained anti-c and anti-d. anti-d was detected by liss tube iat and anti-c was only detected by manual polybrene technique ( . iu/ml by quantification using r r cells). in a th pregnancy, no antibodies were detected until weeks gestation when this patient presented in early labour. anti-c was then detected by two-stage papain technique only as well as anti-d. case : a -year-old asian woman had a positive antibody screen post caesarean section in jan . no antibody had been detected during the pregnancy. standard prophylactic anti-d was given at and weeks gestation as this patient was d neg. anti-c and anti-d were confirmed in her serum. the anti-c level was . iu/ml using rr cells and the anti-d level was < . iu/ml using r r cells (prophylactic anti-d ig). she was phenotyped as o r¢r¢. at delivery the baby was found to have a negative dat and was phenotyped as r¢r. discussion: cde/cde (r¢r¢) is an uncommon phenotype in the uk population with a frequency of / . in routine antenatal testing, abo/d grouping is only performed for pregnant women at booking and weeks gestation according to bcsh guidelines. full rh phenotyping is not carried out unless the pregnant women has a positive antibody screen. in routine testing of the above cases, this extremely rare phenotype is missed. prophylactic anti-d was given to both patients and immunisation due to anti-d was prevented. there is currently no prophylactic regime developed to prevent anti-c allo-immunisation by the fetus in pregnancy. antenatal management of patients with anti-c and anti-d during pregnancy can be problematic: (i), problem in antibody identification; (ii) monitoring of antibody level (i.e. quantitation by auto analyser for anti-c and anti-d) with two different cells and ( ) provision of blood during pregnancy, at labour and post delivery for both mother and newborn. study on the frequency of red cell phenotypes (e.g. duffy, kidd and mns blood group system) in our local population l leou, yf wong, mbc koh and d teo health sciences authority, singapore, singapore background: the frequency of various red cell antigens in the caucasian population has been well studied. to date, the frequency of these antigens in the local population composed of a multi-racial mixture of chinese, malay, indian and others is still unclear, especially in the malays with paucity of data in the literature. aims: to investigate the frequency of clinically significant red cell antigens duffy, kidd and mns across the local ethnic groups. to investigate the occurrence of rare phenotypes. to be aware of these rare phenotypes so as to facilitate planning of blood inventories and supplies. typing for the duffy, kidd and ss antigen on blood donors was performed using monoclonal as well as polyclonal anti-sera by manual tube method. a total of blood donor samples were tested using specific anti-sera that will agglutinate red blood cells that have the corresponding antigen. agglutination is demonstrated by the indirect antiglobulin technique. result and discussion: table -a higher frequency of the fy(a+b-) phenotype is seen in chinese, malay and others in contrast to the indian and caucasian population. the clinically significant allo-antibody anti-fya is rarer in our local population. it occurs predominantly in malays and indians and usually in combination with other antibodies. it means that provision of antigen negative blood may be difficult. table -all groups show similarity of distribution of the kidd phenotype with the caucasians and distinct from the american blacks. the jk(a+b-) and jk(a+b+) phenotypes are relatively equal in frequency and there should be no problem looking for such a phenotype in the local population. table -the s-s+ phenotype is most common amongst all races. the indians are more similar to the caucasians with a relatively high frequency of s+s+ phenotype. the chinese and malay distribution are unique with > % being s+. conclusion: there is a unique distribution of red cell antigen groups in the races and the data on malays is especially useful. this data will allow the national blood service in its inventory planning and the potential difficulties of providing antigen negative products due to clinically significant allo-antibodies. miltenberger phenotypes among taiwanese table . conjointly, in order to obtain the frequency of mi.v phenotype, we screened samples among with anti-hil and four additional cases of mi.v were found. conclusion: in this study significant miltenberger polymorphism was seen among the taiwanese population. besides previously described mi.iii phenotype ( . %), there were also mi.i/ii phenotype ( . %), mi.v phenotype ( . %), mi.vi phenotype ( . %), mi.x phenotype ( . %), and most interestingly two miltenberger related not yet classified variants ( %). related variant a ( . %) was phenotypes as mia+, anek+ and hil+. related variant b ( . %) was phenotyped as mia+, anek+. interestingly, both variants were mur-(negative). the total estimated frequency of miltenberger variants in taiwanese population (including related variants a and b) is therefore . % (table ). the discovery of unclassified variants (most likely not yet described in the literature) is of great interest in the field of immunohaematology and warrant further molecular genetic study. introduction: the use of column technologies for the detection of rbc antibodies improved significantly the screen test sensitivity. each column-based method has its advantages and disadvantages. aim: to compare antibody detection by two column agglutination tests; the fully automated ortho auto vue tm method and the manual diamedᮀ id-micro typing system. material and methods: during the study period patient samples were screened, of the positive results were evaluated. blood samples with positive screen tests by the ortho auto vue tm method (av) performed with % cell suspension, and patient samples with antibodies identified by the diamedᮀ system (dm), were reciprocally re-screened, respectively. positive samples were tested by diamed panels for antibody identification. sera samples were divided into categories according to antibody specificity; . rh system antibodies (n = ), . clinically significant non rh system antibodies (n = ), . clinically non significant antibodies (n = ), . auto antibodies (n = ), . not identified (ni) antibodies (n = ), . negative screening results by the diamed technique (n = ). the categories were divided, according to the intensity of agglutination in the screen test, into those exhibiting stronger reactions by the auto vue (av > dm), those exhibiting equal strength reactions (av = dm) and those with weaker reactions by the auto vue (av < dm). statistical analysis was carried out using the wilcoxon signed ranks matched-pairs test. results: a total of samples were compared, . % of them gave stronger reactions by av, . % gave equal reaction strength and . % of them gave weaker reactions by av. positive screen tests by av only were detected in samples, no specific antibodies were identified. in contrast to that, positive screen tests by dm only were detected in samples, were rh system related, kell system related and not identified, results are summarized in the table. discussion and summary: the antibodies detected by dm only, are anti-d and antibodies directed to low frequency antigens. the failure of av to detect rh system antibodies is further sustained by the fact that statistically significant weaker reactions for this antibody system were obtained by av technique. recently ortho-clinical diagnostics modified the screening reagent red blood cells to . % suspension, in order to improve the sensitivity of the method (unpublished data). the possible explanation for the failure to detect low frequency antibodies is that ortho screen cells do not consistently carry the low frequency antigens cw and kpa. positive screen tests detected by av only, can be explained either by the fact that antibody identification was carried out on dm panels, or these are false positive reactions. in order to clarify this question we recently repeated these av only positive samples by the manual ortho bio vue technique. preliminary results indicate that no specific antibodies were detected. it can be assumed that these results are false positive. further study of this issue is required. aim of the study: we have detected blood donor with rohar variant which was mistaken as d-and his donations used for d-recipients. we tested these patients in order to evaluate possible anti-d or anti-lfa immunization. methods: rohar variant was tested serologically (commercial and workshop moabs) and on dna level (pcr-ssp). involved recipients were tested by diamed column agglutination (gliat with normal and enzyme treated rbcs) with commercial rbcs and with rh and rh rbcs. results: rohar variant was confirmed on phenotype and genotype levels. in four d-and two d+ recipients of rohar positive units no anti-d not anti-rh or -rh antibodies were detected. in one case anti-le(a) antibody was found. conclusion: in our cases massive exposition of recipients (whole transfusion unit) by rohar red cells did not lead to production of detectable anti-d or anti-lfa. the immunogenic potential of this variant seems to be low. unusual ab grouping discrepancy -inhibition of anti-b reagent by isolated increase of plasmatic b substance in a patient with group ab and pancreatic cancer m pisacka*, k petrtylova † , m kralova* and h flidrova* *uhkt, prague , † blood bank, faculty hospital m, prague , czech republic introduction: in rare pathological conditions excess amount of blood-group specific substances can be observed and can cause neutralization of grouping reagents. changes in abh and related histo-blood group antigens in malignant tissues were described but there are few information about similar changes in secreted bloodgroup specific substances. aim of the study: we describe a case of isolated increase of b group substance in plasma of a group ab patient with pancreatic cancer. methods: ab grouping was performed with registered immucor reagents (immuclone: anti-a birma , anti-b lb ) by slide and tube tests. neutralizing effect was quantified by (i) inhibition od anti-b reaction by titrated patient's serum; and (ii) inhibition of titrated anti-a and anti-b reagents by patient's serum, compared to ab serum of a healthy donor. results: slide test: unwashed rbcs: group a, washed rbcs: ab. tube test (washed rbcs): ab. titrated patient's serum when added in aliquot to anti-b reagent inhibited agglutination up to titre . titration of reagents /+ aliquot of serum added/: anti-a: titre (both patient's serum and control); anti-b + patient's serum: titre , anti-b + control: titre . conclusion: pancreas is known as rich source of blood group specific substances. malignant transformation is known to be associated with either loss or re-expression of cell-bound abh antigens. reported excessive increase of b substance in group ab patient could be either due to loss of a-transferase activity in malignant pancreas cells or isolated increase of b-transferase activity. further studies on larger groups of pancreatic cancer patients will help to understand this observation. weakened abh reactions of unwashed rbcs could be of diagnostic importance, because in other case this observation preceded several years the pancreatic cancer clinical manifestation. implementation of the autovue innova, an upgraded column agglutination technology (cat) for pre-transfusion testing in a large blood establishment c politis, k armyros, a antypas, v malamou and p katsea g. gennimatas general hospital, athens, greece objective: automated cat testing in a blood transfusion laboratory aims at standardization and savings in labour as well as reagents. a new technology is evaluated in comparison to standard methods. materials and methods: we used column agglutination technology with the innova autovue system, ortho, ratrian n.j. according to the manufacturers this system provides priority to the management of the stat samples while the random access feature of the system enhances the system throughput. it provides an extended test menu as well as automated antibody identification with the red cells panels. the autovue innova system supports the bi-directional communication with the lis interface for all the tests including the crossmatches and it provides a continuous traceability and notifying of the instrument's status concerning either the required and available resources or the proper function of the system's submodules. in this study we performed tests including forward and reverse abo group, rh type and phenotype and kell in randomly selected blood donors, as well tests in haematological patients for antibody screening using an untreated three-cell panel and autocontrol in the indirect antiglobulin test (iat). the results and the time performance (specimen handing, operation of testing and recording of results) were compared with those obtained by the semiautomatic id-diamed gel agglutination microtyping system and by standard manual methods. results: test results showed % agreement between all three methods. samples were tested per min with the autovue innova, compared to min required for the same number of tests performed with manual testing and min with the semi-automated method. the technical execution was easy with the autovue innova procedure and it appears that the consumption of testing reagents is smaller with the automated system comparing with the other methods. computerization of the test results with the autovue innova provides an important advantage in record keeping in the blood establishment. conclusion: standardization of sample collection and tests performance in pre-transfusion testing, as well as computerized records and time saving are advantages offered by the autovue innova, a new automated column agglutination technology, comparing with a semi-automated and the classical manual methods. a heavy workload is expected to significantly decrease time performance. clearance of senescent erythrocytes in young and old individuals al racca, a ensinck, c cotorruelo, s garcÍa borrÁs, l racca and cs biondi universidad nacional de rosario, rosario, argentina introduction: after a lifespan of days, human red blood cells (rbc) are captured and phagocytized by monocytes/macrophages. the accumulation of autologous igg on rbc membrane provides a direct mechanism for the removal of senescent (se) rbc. an alternative pathway, immunoglobulin-independent, with participation of sialic acid, has been proposed. the physiological elimination of serbc might be modified by individual's age. aim of the study: to investigate in young and old individuals, the interaction between monocytes and different erythrocytes suspensions: serbc, rbc stored with or without serum and desialinized rbc. methods: healthy individuals blood samples ( - years old, n = and > years old, n = ) were studied. different suspensions from each sample were obtained: (i) se and young (y) rbc by differential centrifugation; (ii) rbc stored with its own serum (rbcs) and without serum (rbcws); and (iii) rbc desialinized with neuraminidase (ne) and tripsine (t). the suspensions were subjected to the erythrophagocytosis assay: peripheral blood monocytes were incubated with the different erythrocyte suspensions for h at °c. two hundred cells were analyzed to determine the percentage of active monocytes (am) with phagocytosed and adherent red cells. non sensitized rbc (nrbc) and ex vivo sensitized rbc (srbc) were used as negative and positive controls respectively. results: the% of am obtained with old individuals were: serbc: . + . , yrbc: . + . , rbcs: . + . , rbcws: . + . , nerbc: . + . , trbc: . + . , nrbc: . + . ; srbc: . + . . the values of am obtained with young individuals were: serbc: . + . , yrbc: . + . , rbcs: . + . , rbcws: . + . , nerbc: . + . , trbc: . + . . nrbc: . + . ; srbc: . + . . conclusions: no differences in the% of am were found when compared to positive and negative controls, indicating that this assay would not detect variations in the phagocytic activity of monocytes from young and old donors. the values of am with serbc were higher (p < . ) than those obtained with yrbc in both populations analysed. the rate of erythrophagocytosis with serbc in old individuals was significantly higher (p < . ) than that obtained in young donors. the increase observed may be due to agedependent changes of rbc that occur with human ageing. the% of am with rbcs were higher (p < . ) in old individuals. no modifications were observed with rbcws. the significant increase in the rate of erythrophagocytosis with serbc and rbcs show the involvement of autologous igg in the selective removal of erythrocytes. these values were higher in old individuals indicating that this process would increase in aged donors. the tripsine activity was not enough to modify the% am. the values of am obtained with neuraminidase treated rbc were higher than those observed with yrbc (p < . ). however these values were similar between young and old individuals, suggesting that the desialylation would not participate in the increased removal of erythrocytes observed in old donors. cell-cell adhesion is a crucial phenomenon for the relationship between the cell and its environment. therefore, the development of experimental methods to obtain quantitative parameters of cellular adhesion is important. erythrocytes are widely available and their membrane properties are well known, so these cells are used as an ideal model for studying the cellular interaction mechanisms. the study of the formation and break-up of receptor-ligand bonds in sheared erythrocyte suspensions is a subject of considerable importance in the blood circulation, where formation and break-up of blood cell aggregates occur in a variety of physiological and pathological conditions. the main two objectives of this work were to study the cellular adhesion phenomenon using erythrocyte adhesion mediated by monoclonal anti-a antibody as a model and to achieve quantitative values of the parameters involved in the intercellular binding and its possible relationship with cellular deformability parameters. agglutinates of two a erythrocytes (doublets) induced by specific monoclonal antibodies anti-a were used. adhesion energy was indirectly quantified by the study of doublet dissociation under the effect of a given shear stress using a controlled flow chamber system. the chamber was installed on the stage of an optical inverted microscope (union optical, magnification ¥) in such a way that the cover glass was the floor of the microchannel. a ccd (charge coupled device) camera was placed in the ocular tube of the microscope and connected to a digital image processor (ipplus system) to digitize, record and analyze microscopic images. the doublets were initially immobilized inside the chamber, and then put under different shear stress values by a controlled laminar flow during a definite time. in this way, a shear stress parallel to the contact surface between both cells was applied, observing that the upper cell detached progressively with time and also with a gradual rise of the shear stress. the sequential microscopical images were registered and digitally processed, measuring the geometrical dimensions that the cells acquire during the deformation process, and the dissociation of the antigen-antibody bond. digital image processing allows the analysis and the quantification of the red blood cells doublets dissociation phenomenon. these results show that, while the shear stress applied is raised, the contact area between both cells diminishes. the obtained parameters give important information that lead to the estimation of the value of adhesion energy between two red blood cells agglutinated by monoclonal antibodies. as consequence, they will allow the characterization of the antibodies used, since it would evaluate their association capacity with cellular antigens. glycophorins (gp) a, b and c are abundant transmembrane integral proteins in red blood cell (rbc). their highly glycosylated nature and high sialic acid content account for the net negative charge of mature rbc membrane, which is physiologically important because it impedes any tendency to stick together in the circulation. in this study, we have tested anti-gp specific mouse monoclonal antibodies (moab) as primary antibody to directly agglutinate rbc. fret technique has been developed to characterize the hemoagglutination based on the interaction of fluorophores (alexa tm, dio and dii) located in the rbc membrane or combined to secondary antibody directed against the primary agglutining moab. combined intensity (spectral) and lifetime (flim) imaging was used to discriminate the fret signal of molecules on their different lifetimes whereas their emission spectra overlap (alexa tm or dio/dii) as independent phenomena of the fluorophore concentration and photobleaching. furthermore, gp-cytoskeleton interactions were analyzed by d-fluorescence microscopy after lipid extraction with triton x- in red cell. all the antibody used was found to directly agglutinate the human rbc. in view of the fluorescence properties depicted in rbc for the pair of fluorophore alexa- tm (donor) and dii (acceptor), it may be expected that upon agglutination of rbc, effective fret should be observed. flim in dynamic-state provides a discrimination of molecules in their fluorescence lifetime, which allows to evaluate the underlying mechanism of energy transfer process in the agglutinated erythrocytes. the results demonstrate that's upon excitation at nm the flim-fret from alexa tm to dii for the anti-gpb moabs only with a lifetime distribution in the picosecond range. similarly, effective fret was not observed for the anti-gpa moabs. the contrast in measured lifetime image is a reliable indicator for spatial variations in donor-acceptor association. d-fluorescence microscopy images showed interactions between gpc or gpb and cytoskeleton and did not show interactions between gpa and cytoskeleton. all together, these results only revealed by fret-flim and d-fluorescence microscopy strongly support the importance of the specific reactivity with glycophorin a or b of agglutining moab. introduction: the frequency of alloimmunization to red blood cell antigens in transfused sickle cell patients can range from to %, but the development of autoantibodies is much less recognized and descried. aim of the study: in order to evaluate the autoantibody formation and observe the blood transfusion association, we analyzed the direct antiglobulin test (dat) as well as the antibody screening results in transfused sickle cell patients. methods: all the patients included in the study had received at least unit of red blood cell concentrate, on the majority of the cases matched for the c, c, e, e, k antigens. the transfusion range was - units. the dat performed was a polyspecific gel test. in cases of positive dat, was performed the monospecific gel test (igg, iga, igm, c c, c d) . in almost all of cases an acid glicin elution was performed and the eluate was tested against a red cell panel (liss/coombs and papain). an antibody screening by gel test (liss/coombs and papain) was performed in all the patients. the dat was positive in ( %) of the patients. in cases ( %), the dat was igg type, in case ( %) igg + c d and in case ( %) igg + c c + c d. the acid elution was performed in cases. the eluate was positive in cases ( %). in ( %), of the cases, autoantibodies were pointed out whose specificity were specificity public, anti-e (rh ), anti-c (rh ), anti-ce (rh ). in cases ( %) we found alloantibodies whose specificity were anti-e(rh ), anti-k(k ), anti-c (rh ) and anti-jka (jk ). in the cases ( %) no antibody was identified on the eluate and the cause of positive dat is unclear. we could correlate the positive dat with a presence of autoantibodies in ( . %) of the patients. of these, ( %) had a blood transfusion association. the global frequency of red cell alloimmunization in this set of patients was %. seventeen patients ( %) of the patient who had autoantibodies had also alloantibodies associated. conclusion: the mechanism by which erythrocyte antibodies form in association with blood transfusion are not well understood, but even though the medical literature indicates strong association with blood transfusion as well erythrocyte alloantibody formation, we could not find support for this association. the loss of splenic to sickle cell patients could be important because experimental studies suggest that the spleen is involved in the regulation of autoantibody formation. forward and reverse blood grouping with lateral flow based assays p schwind*, i aebischer*, k loester † and p monod* *medion diagnostics gmbh, duedingen, switzerland, † prisma diagnostika gmbh, berlin, germany background: recently, a lateral flow assay for simultaneous typing of abod, rhesus subgroups and kell with stable end-point and without a centrifugation step was presented (loester k, fleischhauer s, schwind p: lateral flow assay for simultaneous typing of of abo, rhesus subgroups and kell. vox sang , (suppl. ), ). in many countries, the determination of isoagglutinins in addition to the red cell antigens is mandatory for abo grouping. aims: to develop a lateral flow test for reverse grouping, supplementing the lateral flow typing assay. a lateral flow device was constructed with a separation membrane equipped in a cassette housing having distinct incubation wells, application zones and detection areas. microliters of % suspensions of reagent red cells for reverse grouping (reverse-cyte a , a , b, , medion diagnostics, switzerland) are mixed in each incubation well with microliters of plasma. the resulting suspensions are incubated for min, followed by the transfer of microliters each to the application zones, where migration starts immediately. results can be read after min in the detection areas. a positive result is recognized as a distinct red dot, a negative result is monitored by the absence of a dot. results: the plasmas of donors, previously determined for the respective blood groups and isoagglutinins by the tube technique, have been tested with this method. the results for both methods were in full agreement. conclusions: a simple, rapid and flexible lateral flow method for reverse grouping is presented, allowing now for the determination of forward and reverse typing in similar formats. both methods give results after min with stable end-points without the need of a centrifugation step and are easily applicable to non-laboratory environments. the performance of the autovuetm system for red cell antibody screening of blood donors during background: in israel every donation is tested for the presence of red cell antibodies (rbc abs). screening is performed on the autovuetm system, using ortho screening rbc since the year . aim: (i) to summarize the performance of the autovuetm system for rbc abs, during years ( ) ( ) ( ) ( ) ( ) . (ii) to evaluate if an initial low positive result, with two negative repeats, could be considered a negative result. methods and results: rbc abs screening was performed using igg cassettes. positive results were confirmed by diamed gel cards, with screening rbc, followed by diamed panels for abs identification. results: summary of the results is presented in the table. (i) in . % of , blood donations that were screened, during - , using the autovuetm system, a positive initial result for rbc abs was detected, which was confirmed in . % ( . % of the donations). an increased percentage of confirmed tests is noted, since , probably due to an improvement in the manufacturing of the cassettes by ortho. (ii) during the validation, samples with low positive results (agglutination degree of . ) were retested twice on the autovuetm. / ( %) gave negative results in both repeats. only / was confirmed positive and anti-m was identified by diamed gel test. the remaining samples had at least one positive repeat. / ( . %) of those samples were confirmed positive. summary: autovuetm can be used as a competent method for rbc abs screening, in blood services which require high thoughput automated systems. samples with a low positive agglutination, which were negative in two repeats, can be considered negative. retesting these samples on the autovuetm, can reduce the number of tests sent for confirmation and allow early release of blood components. rk tagi-zadeh*, aa karimov*, ar hasanov † , ly novruzova* and si donskov ‡ *hematology and transfusiology, baku, † blood transfusion centre, ganja, azerbaijan, † centre for hematology, moscow, russian federation background: the main method of treatment of severe homozygous thalassemia forms at the moment is still an anemia control with regular rbc transfusions. the use of adequate transfusion regime for these patients not only prolongs their lives but also promotes normal physical development of the children and improves the quality of their lives. however, necessity to do multiple transfusions increases a risk of post-transfusion reactions and complications due to alloimmunization to rbc antigens. in order to prevent posttransfusion reactions it is essential to know the frequency of blood group distribution in the region and then implement organizational procedures to enhance the transfusion services for these patients. objective: examine the distribution of rbc antigens among thalassemic patients and blood donors. methods: blood samples of homozygous betta-thalassemia patients (who stayed at the daytime inpatient wards of scientific research institute of hematology and transfusiology baku, azerbaijan) and blood donors of azeri nationality were examined. patients' blood samples were typed on rbc rh (c, c, d, e, e) and kell (k, k) antigens. gel test bio-rad (france) was used to detect rbc antigens. results: phenotyping of the patients' rbc rh antigens (d, c, c, e, e, cw) revealed that frequency of occurrence of the antigens in general was higher than in the donors. studying of rh phenotype distribution showed that the patients' ccdee ( . %) •• ccdee ( . %) phenotypes were twice as much higher than the occurrence of those in the donors ( % and . % respectively). phenotype ccdee occurs more frequently in the donors ( %), whereas it is significantly rare in the patients ( . %). the similar picture was observed in relation to ccdee and ccdee phenotypes, which occurred more frequently among donors ( . % and . %) than in thalassemic patients ( . % and . %). additionally, the results demonstrated that k antigen of the kell system was not detected in the thalassemic patients whereas k antigen was detected in all the patients. the same picture was observed with two other antigens of this system. thus among the patients typed on rbc antigens kpa antigen was detected in just one case whereas kpb was detected in the rest the patients. the results of the analysis showed that for thalassemic patients with phenotypes ccdee and ccdee it is easier to find compatible blood than for patients with phenotypes ccdee, ccdee and ccdee. furthermore, it is known, that some congenital diseases are genetically connected with the specific group systems, for example, the mcleod syndrome is genetically associated with the sharp suppression of the kell alloantigen expression (absence of gene kx). the fact of the discovered absence of antigen k in homozygous bthalassemic patients makes it possible to assume, that this group of patients suffer from scarcity along the kell system, like the scarcity in mcleod syndrome. all the mentioned above make it possible for us to conclude, that prior to blood transfusion to thalassemic patients phenotyping of rbc rh and kell antigens must be carried out. hyperhaemolysis in sickle cell disease due to complement activation. tessa thorp rci national blood service manchester uk tm thorp national blood service, manchester, uk introduction: sickle haemoglobin is caused by a genetic mutation in codon of the beta globin gene, resulting in the conversion of glutamic acid to valine. when critical amounts of polymer accumulate within the sickled erythrocyte cellular injury results. clinically sickle cell disease is characterised by chronic haemolysis and intermittent vaso-occlusion. mold et al. demonstrated that deoxygenation and sickling of erythrocytes is related to membrane phospholipid changes and these changes result in the activation of the alternative complement pathway. aim: the objective of this study was to measure the amount of c c and c d bound in vivo to red cells of homozygous and heterozygous sickle cell patients. these levels were then compared to 'normal' sickle negative blood donors. haemoglobin levels and red cell morphology were also examined for signs of active haemolysis. the hypothesis was that an increase in red cell bound complement in vivo could provide an indication of hyperhaemolysis syndrome is sickle patients. method: flow cytometric analysis using rabbit anti-c c or anti-c d and fitc labelled goat anti-rabbit was developed using a beckman epics xlmcl flow cytometer. control samples were prepared using a fruitstone buffer technique of complement coating. results: a total of heterozygous sickle patients and homozygous patients were analysed. of the homozygous patients analysed only one was undergoing a sickle crisis. a positive result was indicated if the mean trait or homozygous sample was coated with complement to a greater degree that the mean normal donor plus two standard deviations. the results obtained in this research project indicate an increase in c c levels bound to red cells of homozygous sickle patients in vivo. statistical analysis of results obtained suggest that there was no increase in c d levels in either sickle trait or homozygous sickle patients. conclusion: these findings support research carried out by mold et al. ( ) and are present in more than % of caucasian population. it has been reported that anti-chido and anti-rogers don't cause hemolitic reaction but may be responsible for life-threatening anaphylactic reaction during transfusion of plasma proteins. case report: positive iat and dat were detected in a years old swedish woman, a rh negative, at th week of pregnancy. previous iat and dat determinations were negative. at time of detection dat wsa weakly positive and igg subclasses identified. antibody identification revealed the presence of high titre ( : ) anti-chido and anti-rogers antibodies. a slight decrease in platelet count (from . /ul to . /ul) was observed. this pattern showed no variation until the end of the pregnancy. at th week a healthy baby was delivered, dat negative. the mother dat and iat remained positive for four months after delivery. the platelets count raised again to . /ul. the same laboratory findings were detected in a previuos pregnancy in sweden. the patient reported the presence of antibodies at th week that disappeared few months after delivery. a healthy baby, dat negative was delivered in this case too. conclusions: this is the first report of the presence of chido and rogers as autoantibodies during the last months of pregnancy. the association with decrease in platelets count and the lack of evident clinical symptoms need further investigation. p- rbc alloantibody frequency and their prevalence within chinese, malay and indian community in singapore e widjaja, mbc koh and d teo health science authority, singapore, singapore background and aim: there is a recognised existence of different alloantibodies in different ethnic groups. while this has been studied in the caucasian population, their frequencies remain less well documented in the asian population. the frequency of different alloantibodies and their distribution in terms of age, sex in singapore population is studied, as were their prevalence within the chinese, malay and indian races in singapore. design and method: we conducted a retrospective study for the frequency of alloantibodies on blood samples over . these blood samples were largely sent by hospitals where preliminary antibody screening had been done and positive result obtained. they were sent to the centre for transfusion medicine for antibody identification. small number of these samples came from hospitals where preliminary antibody testing was not done. the antibody distribution across different ethnic groups (chinese, malays, indians) age and sex were studied. results: the most frequent alloantibodies in the population is mia ( . %), e ( %), le a ( . %), le b ( . %), p ( . %), m ( . %), d ( . %), c ( . %), jka ( . %) and c ( . %). within the chinese community, the most frequent alloantibodies were similar: mia ( . %), e ( . %), le a ( %), le b ( . %) and p ( . %). in the malays, the most frequent alloantibodies were le a ( %), le b ( . %), mia ( . %), e( . %) and p ( . %); while in the indians, these were mia ( . %), le b ( . %), le a ( . %), d ( . %), and e ( . %), with the anti-d reflecting the higher incidence of rh d negativity in the indians race. for the lower incidence antibodies, anti-c was more common in the malays and indians ( %) compared to chinese ( . %). anti jka tended to occur mainly in the malay race and anti-c was rare in all (< %) reflecting the high prevalence of c in the singapore population (r r phenotype). the ratio of alloimmunised male to female (m : f) is : . most alloantibodies demonstrated significant skewing towards to the female, although relatively less so for mia where m : f ratio is almost equal at : . . alloimmunisation increased with age for mia, e, k, p , jka and fyb while the frequency of alloimmunisation to lea, leb, d, m and c decresed with age. the prevalence of patients with multiple alloantibodies ( or more) within the alloimmunised subjects is . %. conclusion: anti mia is very common within the asian population especially in the chinese. anti d is common in the indians. most antibodies show increased frequency with age except for anti lea + b, d and m. the majority of alloimmunised patients are females. study aim: to identify the present antibodies in newborns, after a positive direct antiglobulin test (dat). material and method: during a years period, from / / - / / , we studied newborns and their mothers. each newborn was examined for abo group, rhesus with phenotype, kell and dat. each mother was also tested for abo group, rhesus with phenotype, kell and indirect antiglobulin test (iat). after each positive dat, the study was continued with the elution test, in order to identify the present antibody. dat test was performed with dc screening i-diamed sa, switzerland. for the laboratorial analysis of newborns the sample used was cord blood and in certain cases venous blood. results: the dat test was positive in ( %) of newborns and the antibodies found were igg type immunoglobulin. anti-a antibody was detected in ( . %) (newborns of group a with mothers of group o), anti-b antibody in ( %) (newborns of group b with mothers of group o), anti-d antibody in ( . %) (newborns d+ from d-mothers), anti-e in one case and anti-jka in another one. the eluate test was found negative in newborns and in the rest , no special antibody could be identified. the results are presented in the following table. conclusion: the majority of antibodies in newborns with a positive dat test, is due to abo incompatibility (the mother belongs to group o and the newborn to group a or b). anti-d ( ), anti-e ( ), anti-k ( ), anti-fya ( ), anti-s ( ), anti-jkb ( ), anti-n ( ), anti-kpb ( ). in two patients antibodies were identified, while in / ( . %) no antibody was identified (unspecific). it is remarkable that only in out of patients with both dat and iat positive, an irregular antibody was identified, while the rest patients had unspecific antibodies. in patients with only iat positive, had an irregular antibody and had unspecific antibodies. in out of patients with both dat and iat negative the cause of incompatibility was the positive dat in the corresponding sample of the blood donor, while in the rest patients the reasons were technical problems that include the inappropriate blood sample of the patient, patients under medication and errors during the crossmatching procedure. the results show that the incidence of red cell incompatibility in our hospital is . % and the most common antibodies are anti-k, anti-e, anti-fya, while anti-d is important for d negative patients. . % of the detected antibodies were unspecific and this is still a problem that possibly was due to the lack of additional panels of reagent red cells or antibodies to low-incidence antigens. finally, in some cases the reasons for incompatibility are due to factors affecting the blood donor or to technical problems in the crossmatching procedure. multiple isoforms excluding normal rhd mrna detected in rh blood group del phenotype with rhd a allele introduction: del phenotype is very common in rh-negative chinese. the rates in hans (more than % in china) were reported from % to %. moreover all del individuals in this population were found mainly carrying a same allele, rhd a, through genomic dna analysis. those individuals always possess one or two of this allele with ccee or ccee phenotypes. aim and the study: we focused on the mrna investigations of del individuals carrying rhd a alleles, in chinese, to expect it could be explained that why a silent mutation is associated with del phenotype. the full-length rhd mrna was analyzed in rh-positive donors with cde/cde and cde/cde genotypes, respectively, and del phenotype individuals carrying rhd a allele with cde/cde, cde/cde, cde/cde and cde/cde genotypes, respectively, through reversed-trancriptase pcrs and cdna direct or cloning sequencing. results: five transcripts and isoforms were detected in rh-positive and del, respectively. among them, isoforms have identical sequences, which are transcripts with exon , exons and , exons and , and exons to spliced out. the normal rhd mrna was only observed in rh-positive, but not in del individuals. in stead, two additional transcripts were found in del individuals. its exon or exons - were spliced out, but both possess a bp segment of sequence from intron of rhd. through additional reversedtrancriptase pcrs, which amplified exon to ¢-region and exon to ¢-region, the results showed that exon did not exist in del anyway. conclusion: (i) a normal rhd protein does not exist in a del individual with rhd a allele since the exon was always spliced out in all isoforms. all transcripts in del maintain a normal open reading frame and encode proteins with different numbers of amino acid residues and different c-terminals (genbank ay , ay , ay , ay , ay , ay ). among them, the sequence of del (isoform with exon spliced) transcript was the most similar as normal rhd mrna. this isoform was first described by chang et al. in taiwan in . it encodes amino acid residues and has amino acids more than normal rhd. it is different from rhd after codon . in normal rhd protein, the amino acids after ( residues) are mainly the trans-membrane and intracellular regions. therefore a further study on if a del red cell possesses all epitopes of normal d antigen may be significative. (ii) a normal rh-positive individual has also the transcript of del that was found in del. (iii) there is only one polymorphism in the region of bp segment between rhd intron and of the del transcripts, which indicated that other polymorphisms may exist in intron of rhd a allele compared rhd to explain that this situation was not happened in normal rh-positive individuals. total wbc were enumerated by flow cytometry and cell counting. wbc subsets were analyzed by flow cytometry with three-color fluorescence. in this study, the third generation bags and filters are used. results: before filtration, the total number of wbc, was significantly higher in fresh units compared with stored units, whereas in postfiltration samples the number of white cells was significantly lower in the fresh compared with the stored units. although absolute numbers were significantly reduced, filtration also induced significant changes in the proportions of subsets in hoth fresh and storod units, the percentage of t cells was decreased, whereas the percentage of b cells and monocytes was increased after filtration. in conclusion, both pre and post storage wbc filtration affect the proportions of wbc in the final product but pre storage wbc filtration of platelet concentrates is superior than post storage wbc filtration. the effect of pre-and post-storage filtration on platelet rich plasma: derived platelet concentrations background and objective: the white blood cells (wbc) within transfusion products are a major stimulus for a number of detrirmental biological reactions, including febrile nonhemolytic transfusion reactions, alloimmunization against hla antigens and cytomegalovirus transmission. in this work, our objective was to study the effect of storage time on the filtration of platelet concentrates (pcs). the total number of white blood cells as well as the distribution of wbc subsets, in units filtered before and after storage were compared. materials and methods: platelet rich plasma -derived pcs were filtered either fresh ( pooled we reported earlier that metabolic arrest followed by incubation at °c reduces the platelet storage lesion (badlou et al. transfusion ) . here we report that this treatment also reduces binding and phagocytosis by macrophages. metabolic suppressed platelets (msp) were prepared by incubation in glucose-free, antimycin a containing medium ( min, °c) followed by storage ( h, °c) and recovery with glucose ( h, °c). controls were (i) platelets in glucose-rich medium stored for h at °c and recovery with glucose (c ) and (ii) platelets stored for h at °c (c ) with rewarming. platelets were labelled with mepacrine and incubated with pma-matured thp- cells ( °c). binding was measured by facs analysis of cd b/cd positive particles, and phagocytosis by counting mepacrine/cd positive particles. binding of msp, c , c was ± , ± , ± % of total platelets. phagocytosis of msp, c and c was ± , ± , ± % of total macrophages (means ± sem, n = ). before recovery of msp, binding/phagocytosis was % higher than thereafter, revealing energy-dependent control of the mechanisms that trigger plateletmacrophage interaction. these data show that metabolic suppression prior to cold storage attenuates binding and phagocytosis by phagocytes and may help to develop means to improve platelet survival post-transfusion. platelet compatibility testing and alloimunization in multiply transfused hematologic patients purpose: multiply transfused patients with heamotological malignancy often become refractory to platelets due to alloimmunization. refractoriness is usually defined as an insufficient platelet increment after consecutive platelet transfusions. two major causes of a decreased platelet increment can be distinguished, immune and nonimmune factors. alloimmunization occurs most frequently against the hla, and rarely against the hpa system. nonimmune factors been identified are splenomegaly, fever, sepsis, and disseminated intravascular coagulation as well as the quality of the transfused platelet concentrates. we performed this study in order to investigate platelet crossmatching, compatibility, and antibody determination among thrombocytopenic patients multiply transfused. we performed crossmatchingcompatibility tests of single donor leucodepleted, abo compatible, platelet concentrates been transfused in patients with leukemia and lymphoma, males and females with mean age ± years old. we also obtained samples from the patients for platelet antibody detection. we evaluated the cci (corrected count increment) h after the transfusion. the solid phase rbc adherence assay (modified capture p system/immucor) was used for platelet compatibility and antibody detection. a total of compatibility tests were performed, of which were compatible. twenty five compatible platelet concentrates out of were clinically evaluated. twenty from compatible crossmatches ( %) were resulted in successful transfusion while only from ( %) in unsuccessful. the incompatible platelets been transfused was resulted in unsuccessful transfusion. we found statistically significant difference among patients successfully transfused with compatible and incompatible platelets (p~ . ). additionally patients out of ( . %) had been alloimmunized against multiple hla antibodies. three patients transfused with compatible platelets, during the study, developed alloantibodies. we found a large number of incompatible platelet concentrates that result in unsuccessful transfusion and clinical response. the platelet compatibility testing as well as alloantibody determination of multiply transfused patients is necessary for the identification and selection of compatible, with the patients, donors in order to result in succesful transfusion and clinical outcome. furthermore compatible platelet concentrates provide optimal support for refractory patients and it is known that they are acceptable as an alternative component. naitp is a rare clinical syndrome characterized by marked thrombocytopenia shortly after birth. it is caused by maternal immunization against paternally inherited antigens present on foetal platelets. screening and identification of antibodies in the maternal blood sample is the main support in the diagnosis and management of naitp. we have evaluated the frequency of maternal alloimmunization, the role of the antibodies involved (hpa and/or hla systems) and the pertinent risk of naitp in neonates using a fully automated system with a solid phase red cell adherence methodology (sprc-capture p) and paternal or random donors (indirect test). screening started in june and is still in course: in january , blood samples were examined. identification of antibodies in maternal serum was carried out using elisa methodologies: maipa and commercial kits (pak-plus and quick screen-gti). of the blood samples analysed, were reactive and the specificity of the antibodies were: anti hpa a: , anti hpa b: , anti hpa a + hla: , anti hpa b. , anti hla: , auto hpa- b: . specificity of hpa antibodies was confirmed by determination of parents' hpa genotype (hpa- , , , , , ) using pcr-ssp or pcr-rflp. the infants with hpa immunization suffered from severe (plt count - /ml) and symptomatic naitp (bleeding and petechiae were present), therefore they were treated with platelet transfusion and administration of high doses of intravenous immunoglobulin. we confirm that naitp due to hpa- and hla immunization is clinically less severe: all neonates had mild and self limiting thrombocytopenia at birth; no therapy was administered. it would be advisable to carry out pre-natal screening, at reasonable cost, using maternal serum versus paternal platelets and to proceed to the identification of antibodies only in presence of positive results. background: fetal or neonatal alloimmune thrombocytopenia (fmait) results from a maternal alloimmunization against fetal platelet antigens. it is the commonest cause of severe thrombocytopenia in the neonatal period. the diagnosis of fmait is made initially on clinical grounds, depending on exclusion of other causes of neonatal thrombocytopenia. in caucasians, hpa- a is the most frequently implicated antigen. other antigens such as hpa- a, or hpa- a are less often implicated. during the past few years fmait has been reported associated with rare or private antigens. the diagnosis is straightforward when a maternal alloantibody with a corresponding parental antigen incompatibility is present. however it could be equivocal in the absence of such an antibody or difficult when a private antigen is implicated. if the father is heterozygous for the considered antigen, the infant's platelet typing should be performed to confirm the diagnosis. due to the risk of hemorrhage, particularly intracranial hemorrhage (ich), during the course of severe thrombocytopenia, specific therapy is mandatory. because subsequent siblings may be more severely affected, accurate diagnosis will allow better management of subsequent pregnancies. study design and methods: since the first documented case of feto-maternal alloimmune thrombocytopenia (fmait) due to anti hpa- bw (maxa+), no additional cases have been reported. we present here a retrospective analysis of the cases referred to our laboratories in recent years. since we have screened for rare or private antigens in suspected cases of fmait when there is no incompatibility for the most frequently implicated antigens. the diagnosis was performed by genotyping and identification of the maternal alloantibody by the maipa technique. results: parental genotyping showed hpa- bw (maxa+) mismatch as the sole antigenic incompatibility in out of families. in the last one, incompatibility was found for hpa- without anti hpa- b maternal alloantibody. as the father was found to be hpa- bw (maxa+) heterozygous in all the cases, the infant or fetus was genotyped to ascertain the diagnosis. the maternal alloantibody was identified in the maipa technique. however, our data strongly suggest that recognition of the hpa- bw (maxa+) epitope is not uniform. the neonatal thrombocytopenia was severe in most cases with bleeding. the outcome was good in all the cases but one. conclusion: this analysis confirms that anti hpa- bw (maxa+) fmait is not uncommon and was found to be around % of our confirmed fmait cases with parental incompatibilities and presence of maternal alloantibodies. it is a clinically severe syndrome which requires prompt diagnosis, albeit difficult, and maternal platelet transfusion therapy. laboratory investigation of a suspected fmait case should be carried out in a specialist laboratory wellexperienced in optimal testing. therapy requires strict collaboration between clinicians and blood bank services. appropriate management and antenatal therapy should be considered for successive pregnancies to prevent fetal bleeding. introduction: the human platelet (plt) antigen (hpa) system is independent of the hla system. therefore, host-or donor derived alloimmune thrombocytopenia can develop after allogeneic haematopoietic stem cell transplantation (hsct) even in hlamatched donor-recipient pairs. we report the first case on a stem cell recipient developing thrombocytopenia due to host-derived hpa- a antibodies after non-myeloablative allogeneic hsct. a year-old male patient was diagnosed with multiple myeloma in / . treatment consisted of cycles vincristin, adriamycin and dexamethason followed by tandem autologous stem cell transplantation. because of progressive disease he received cycles of bortezomib, and after complete remission a stem cell allograft ( . ¥ /kgbw cd + cells) from his histocompatible (hla a,b,c,dr identical) brother after reduced intensity conditioning regimen with fludarabine ( ¥ mg/m ) and alkeran ( mg/m ). he had received only twice packed red blood cell concentrates and one plt concentrate before allogeneic hsct. stable bilinear engraftment occurred around d but was accompanied with a continuous decrease of plt counts. between d and d the patient received seven plt transfusions, containing a median of . ¥ plt/unit (range , - , ¥ plt/unit) from random donors. the corrected plt count increments at to h after these transfusions were < /ml. therefore, and because of even a further decline of platelet counts to /ml on d we investigated the presence of plt antibodies. methods: the patient's serum was tested by antigen capture elisa assays (pakplus® and pak ®, gti) and a solid phase assay (capture-p®, immucor). the maipa assay was used to confirm the results obtained by the above mentioned assays. in addition, we tested the patient's serum by the maspat kit (clb) against plt from the donor and against homozygous hpa- a plt obtained from our donor pool. stored recipient's dna from the time before hsct was used for genotyping. genotyping for hpa- , - , - and - of the donor and the recipient was performed by pcr-ssp (hpa, protrans). the patient's serum obtained on d after hsct reacted strongly with the donor's plt due to anti-hpa- a antibodies and antibodies against hla class i antigens. the patient's genotype before transplantation was hpa- bb, - aa, - ab, and - aa; the donor was hpa- ab, - aa, - aa, and - aa. thus, the antibodies were host derived and directed against the donor's plt. serum samples obtained on d , d and d after hsct contained antibodies against hla class i antigens but hpa- a antibodies were not anymore detectable. no hla antibodies were detectable on d after hsct. the severe thrombocytopenia was caused by hostderived hpa- a antibodies. fortunately, plt counts started to increase on d spontaneously and the patient could be discharged at d (plt . /ml) with a complete donor chimerism. the decrease of the serum antibodies parallel to the increase of the plt count strongly suggests a progressive elimination of residual host cells. we conclude that the hpa mismatch between recipient and host affected thrombopoietic engraftment and the success of plt transfusions. severe neonatal alloimmune thrombocytopenia with anti-hpa- b antibodies: case report p moncharmont, m vignal, y mÉrieux and d rigal efs rhone alpes site de lyon, lyon cedex , france usually, in case of feto-maternal incompatibility, the platelet (plt) specific anti-hpa- b antibodies (ab) induce only sometimes a mild neonatal alloimmune thrombocytopenia (nait). contrary to this observation here is reported the case of a severe nait. a -year old mother, gestation /partum , gave birth to a male neonate by caesarean section at weeks of gestation because of intra-uterine growth retardation (iugr) and anamniotic fetus. five years before, she had had a first pregnancy with iugr of the fetus but no nait. the second neonate weighted . g, was . cm tall and had a head circumference of . cm. the apgar score was , , , at , , and min respectively after birth. no bleeding, hepatomegaly, splenomegaly or infectious signs were noted. five hours after birth, a respiratory distress syndrome appeared and an oxygenotherapy was performed during h. the plt count which was . , . and . giga/l at day (d) , d and d respectively dropped dramatically at . giga/l at d . simultaneously, an intracranial hemorrhage grade ii was diagnosed on ultrasound scan. because of the clinical signs and of the decreasing plt count the mother's serum was tested for plt-specific ab by immunocapture and the ab identified by the monoclonal ab-specific immobilization of plt antigen (maipa) assay. a plt genotyping was performed in the neonate and his parents by sequence-specific primers polymerase chain reaction. the mother was hpa- a/a and anti-hpa- b ab were detected in her serum. the baby was heterozygous, hpa- a/b. plt were transfused to the baby and the plt count rose to . , . and . giga/l at d , and respectively. no further transfusion was needed and the development of the baby was satisfactory with a normal electroencephalogram. in conclusion, when a mild thrombocytopenia with iugr and hypoxia but without bleeding signs is present in a neonate immediately after birth, a maternal plt specific ab screening must be performed in case the thrombocytopenia became severe during the newborn monitoring. anti-hpa- b ab can be detected. partial results of the incidence of heparin induced thrombocytopenia type ii osc oliveira*, ra rached*, c cavalheiro-filho*, jc nicolau*, shgl pasqualucci*, daf chamone † and sp bydlowski † *heart institute, university of são paulo, † university of são paulo, são paulo, brazil heparin induced thrombocytopenia type ii (hit) is a severe side effect of heparin, associated with heparin-platelet factor antibodies. hit type ii occurs in up to % of patients who are exposed to unfractionated heparin (ufh). in our institution patients that are under heparin treatment are mostly cardiac patients. the purpose of this study is to determine the incidence of hit type ii in these patients. material and methods: patients from the intensive care unit and cardiac care unit treated with ufh or low molecular weight heparin (lmwh) for or more days were studied. known causes of thrombocytopenia were excluded. platelet count was monitored pre and post heparin therapy. all selected patients were tested for detection of anti heparin/pf antibody test (diamed id-card). results: from the studied patients, ( . %) developed thrombocytopenia (determined by a decrease in the platelet count below %, after the introduction of heparin therapy); ( . %) did not show decrease in the platelet count. six ( . %) out of thrombocytopenic patients were positive for anti-heparin/pf antibody. three ( . %) out of non thrombocytopenic patients were positive for anti-heparin/pf antibody. the results demonstrate that ( . %) patients were positive for anti-heparin/pf antibody and they were no different from those described in the literature regarding the frequency of heparin induced thrombocytopenia. moreover, a higher frequency of patients with heparin/pf antibody was noted without the presence of thrombocytopenia, indicating that other factors should be considered. introduction: neonatal alloimmune thrombocytopenia (natp) due to maternal immunization against fetal platelet antigens affects . - in live births. although it is usually a self-limiting condition, a major complication in cases of severe thrombocytopenia is the occurrence of intracranial haemorrhage leading to death (in up to % of reported cases). the commonest antibodies are anti-hpa- a. treatment consists of ivig, compatible donor platelet concentrates or washed maternal platelets. the administration of random donor platelet transfusions is controversial but has been used successfully in some urgent cases when compatible platelets were not available. case report: a baby born in week of gestation to a healthy mother after first uneventful pregnancy; birth weight g, apgar score . immediately after birth, severe thrombocytopenia ( ¥ /l) and signs of haemorrhagic diathesis (generalized petechiae and ich gr. ii-iii) were observed. coagulation tests were abnormal and k-vitamin, fresh frozen plasma and random donor platelet concentrate (retrospectively genotyped as hpa- a/a) were given. twenty-four hours later platelet count rose to ¥ /l and no new petechiae were observed. on third day of life the blood platelet count was ¥ /l and the newborn received ivig g/kg and corticosteroides. twenty-four hours later the platelet count rose to ¥ /l and further clinical course was uneventful. natp due to hpa- a was serologically confirmed. conclusion: optimal therapy for an infant with severe thrombocytopenia during the first h of life is the transfusion of platelets that will not be destroyed by the maternal alloantibody in the infant circulation. random donor platelet concentrates are controversial in a setting where optimal treatment is not available, however, in this case they led to a significant platelet count improvement in spite of hpa- a incompatibility. accordingly, random donor platelets may be considered appropriate in emergency situations. background: rhd is the most immunogenic blood group antigen, and its correct identification is essential in the blood bank and in the prevention of the haemolytic disease of the newborn. the weak d phenotype is the most common d variant, with a frequency of . % to % in caucasian individuals. there are several weak d types, with different frequencies in european countries, which may pose serologic problems and have the potential for alloimmunization. the objective of the study was to determine the frequency of the principal weak d types in portugal. study design and methods: lisbon regional centre of the portuguese blood institute and oporto são joão university hospital selected samples from blood donors and patients. rhd was tested by two (oporto) or three (lisbon) distinct anti-sera, in direct agglutination tests, at room temperature. when discrepant results were observed, the samples were tested with panels of monoclonal anti-d by liss-iat. samples that reacted weakly with igm anti-d but positive with igg anti-d were sent to the molecular biology centre. pcr with sequence-specific primers was performed using two commercially available kits (inno-train and bagene). real-time pcr, carried out on a light cycler, was applied when the interpretation was dubious. results: samples were referred after being characterized as weak d. in cases we obtained a positive result, with a preponderance of weak d type ( . %) over type ( . %), ( . %) and ( . %). two samples were not categorized. the high incidence of weak d type in our population is in marked contrast to studies performed in other european populations where weak d type was the most frequent. this might be due to our sample selection criteria or ethnic variation in the causes of weak d. there are advantages in genotyping serologically depressed d samples: to avoid the waste of d-negative rbc units and the use of immunoglobulin in pregnant women, who have no risk of alloimmunization. analysis of rhd zygosity in different rh phenotypes cal except for a -bp t insertion. the deletion of the rhd gene, found in most rhd-negative caucasians, was theoretically due to recombination of the upstream and downstream rhesus boxes resulting in the formation of a hybrid rhesus box. thus, the detection of a hybrid rhesus box in an rhd-positive individual denotes an rhd heterozygous status. aim of the study: to determine the rhd zygosity in different rh phenotypes. methods: blood samples from white trios (father, mother and child) were studied. the rh phenotype was performed by hemmaglutination and the rhd zygosity was inferred in each member of the family groups. the rhd deleted allele was determined by a pcr strategy using a forward primer complementary to ¢ end of the identity region of the upstream and hybrid rhesus boxes and a reverse primer complementary to the ¢ end of identity region of the downstream and hybrid rhesus boxes. these primers selectively amplify a -bp segment of the hybrid rhesus box in rhdnegative and rhd-positive heterozygous samples. serological and pcr inconsistencies were studied by a pcr-rflp method to detect another polymorphic site of the hybrid rhesus box. frequencies were obtained analysing only unrelated individuals (fathers and mothers, n = ). results: ( . %) rhd-positive and ( . %) rhd-negative samples were phenotyped. of the rhd-positive donors, ( . %) were rhd homozygous and ( . %) were rhd heterozygous according to pcr. pcr-rflp analysis confirmed the results of pcr in serological and molecular discrepancies. these results were coherent within each family group and did not differ from those published in the literature for caucasians based on the most probable genotype method. however, the homozygosity indexes were significantly higher in the dccee ( . % vs . %) and dccee ( . % vs . %) phenotypes due to an increase of the dce haplotype. in all samples with the dce haplotype the rhces allele, frequent in individuals of african descent, was investigated by pcr-ssp. this allele was found in . % of the dce haplotypes. . rhd and rhce typing was performed by multiplex-pcr with fluorescent primer pairs. positive results were obtained for rhd-exons - , , and polymorphisms associated with antigens c, c, cw, e and e. sequencing of rhce-sequences, including exons to and intron/exon borders, were done by direct taq cycle-sequencing using bigdye-terminators v. . in an abi (applied biosystems). results: see table . the substitutions of rhce-specific nucleotides in exons , and with their rhd-specific counterparts lead to different new rhc-antigens with weakened expression. since one amino acid change in allele lie in extracellular loop of the antigen suggested that this antigen may be involved in allo-immunization. inheritance of a rhd cat vi type ii in a twin pregnancy: a case report introduction: determination of hdn-relevant fetal blood groups in amniocentic fluid with pcr is a routinely used method. misinterpretation of test results -e.g. overlooking rhd category -decreases depending on the number of examinated rhd-specific exons. case report: a -year old mother (w.o.g. ) pregnant with twins was regularly tested for irregular antibodies and was shown to have an anti-d. after amniocentesis of both foetuses tests for the occurrence of rhd intron , exons and were performed in the hospital's lab. the sample of fetus i showed pcr-products for intron , exon and exon while sample of fetus ii lacked rhd-specific intron . therefore we investigated blood samples from the parents as well as amniocentic fluid of both foetuses. methods: total dna was amplified in a multiplex pcr with fluorogenic primers for rhd exons - , & ; polymorphisms for dweak type - , d-vii, d-hmi and rhce polymorphisms for c, c, cw, e, e. capillary electrophoresis for size fractionation and fluorigeneic analysis was done in an abi . rhd zygosity was determined by quantitative real-time pcr with co-amplification of rhdand rhce-specific exon and subsequent calculation of d ct value (ct rhce minus ct rhd). results: while maternal dna sample has been genotyped as rhdnegative, amplification of paternal dna for rhd-specific exons , , , and were possible and failed only in exon - . determination of rhd-zygosity revealed a homozygous constellation of the rhd-gen. investigation of amniocentic fluid from both foetuses resulted in a rhd-wildtyp for fetus i and a rhd cat. vi type ii for fetus ii which was the reason for missing amplification in rhd intron pcr. results: weak d type was not identified in our research population. weak d type was identified in cn, weak d type was identified in cn and weak d type was found in cn, bsa, be, bc and saa. conclusions: although weak d types to represent the majority of all weak d phenotypes in caucasian populations, none of these weak d alleles were found in black populations. since none of the frequent weak d types were identified in non-caucasians one might not expected to find type in all populations. however, regarding rhd phylogeny, the weak d type mutations ( c > g and t > g) form the basis of a cluster of aberrant alleles that are predominantly observed in blacks. therefore, it is not surprising that weak d type was identified in non-caucasians. based on these results it may be concluded that weak d phenotypes have evolved relatively recently since they are present in caucasian and asian methods: dna was extracted from a, b, ab subgroups, and provisional cis-ab after serological abo typing. allelespecific pcr, rflp, direct sequencing of exon and , and allele separation were performed on these samples. results: abo*a allele was observed in an aint subgroup. two new a alleles that showed g > a base change and c > t of intron and a polymorphism of c > t in a(pro) intron were discovered. o and o alleles were also observed. in b subgroups, a silent substitution c > t (leu leu) was observed as a new b allele. another new b allele which showed g > a was also found in b subgroups. conclusion: we discovered new abo alleles and polymorphisms in korean populations. many other polymorphisms and alleles already reported in japanese were also observed in koreans. evaluation of a multiplex snapshot-pcr method for red blood cell marker genotyping c jungbauer*, c hobel*, em dauber † , pk rabitsch*, dwm schwartz* and wr mayr* *austrian red cross, † medical university vienna, vienna, austria once conventional reagents for identification of rare red blood cell phenotypes are scarce, methods using current nucleic acid testing techniques to identify the patient's genotype and possibly to screen for donors would be desirable. the approach of multiplexgenotyping using pcr-ssp has apparently technical constraints so we are currently analyzing whether a modification using snapshot pcr-technique could provide a routine application for such purposes. compared to ssp-technique, the snapshot pcr only requires one single primer (labeling reaction) for the detection of two (or more) alleles instead of one pair of primers for every single allele. briefly, we perform snapshot pcr as follows: in a first step, dna segments covering the essential polymorphic regions for the abo, rhd, kel, jk and fy genes are amplified using a standard pcr step. after purification treatment of the pcr products (roche high pure pcr product purification kit or shrimp alkaline phosphatase (sap)/exo treatment according to the abi prism snapshot multiplex kit protocol) the labeling reaction is performed using the abi prism snapshot multiplex kit. after a second purification step the products are analyzed on a abi prism genetic analyser in fragment analysis mode. our preliminary results show the feasibility of this approach as reliable typing results can be obtained for all tested single nucleotide polymorphisms corresponding to alleles. generally a better signal quality from controls and samples is obtained compared to the ssp-technique with consecutive gel electrophoresis. we also consider the possibility of the automated interpretation of the results as an important improvement, especially when aiming for an application for a large number of samples (donors) or markers (patients). in contrast, the method involves more manual steps and higher costs. we may conclude that the implementation of snapshot-pcr techniques for red cell marker genotyping is a promising alternative to pcr-ssp. the obvious quality improvements compared to pcr-ssp might be critical for a routine application in blood banks (donor screening) or complex questions in clinical laboratories. quantification and quality control of monoclonal antibody using an optical sensor based on the laser reflectometry technique the monoclonal antibodies (moab) are biological reagents of homogeneous activity. they are generally used in the recognition and quantification of very small amounts of biological substances (hormones, enzymes) present in a solution, ag identification, blood group determination, oncology, organs transplant, etc. moab can be characterized by its specificity and affinity. affinity may be expressed as the equilibrium association constant (k). several techniques are available to determine the equilibrium constant of the ag-ab interaction. in this work, is shown an optical sensor for monoclonal antibody quantification by reflectometry technique. the laser reflectometry technique (null ellipsometry technique) can give information about the kinetic of the interactions, stoichiometry of molecular binding and the concentration of molecules in a solution, and also offers detailed and accurate determinations of real-time adsorption kinetics of protein without labeling. a silicon wafer was chosen as reflectant surface. once fixed the principal angle of incidence, an amount of anti-ab is added to the sample. the reflected laser intensity is registered in real time as the protein is being adsorbed onto the wafer. the mathematical analysis of the results verifies that the antibodies adsorption follows langmuir's kinetics. from the curve analysis, the parameters related to the anti-ab concentration are extracted. from them, the calibration curve is constructed. this curve allows the desired commercial monoclonal antibody quantification. the developed technique shows to be sensible and precise. the obtained graphics are very well approximated (r > . ) verifying that the monoclonal anti-ab associa- study aim: to prevent the sensitization to rh (d), to a d-patient who was transfused with d+ blood. material and method: on september , ( / / ), we admitted to our hospital through air-carriage, a female of years old, badly injured after a car-accident. the patient was on an olighemic shock (ht: %) due to retroperitoneal, paracolic and procystic hematomas, had multiple fractures on the left feet, the main important of which was an acetabulum one. she had a blood group: o, d-and her phenotype was ccdee with du-. after her arrival she was urgently admitted to the surgery room and our blood bank was asked for condensed red cells. initially she was transfused with blood of the same group (o, d-) but when we were short out of dblood, we were asked for more units. the necessity of blood was imperative, the patient was on a critical condition and the mechanism of blood transport, from another blood bank would take some time to be put in motion, and so it was decided that the patient would be provided with d+ blood. the indirect antiglobulin test (iat) and papaine were negative, so there would be no problem with the transfusion with d+ blood. the patient received finally units ( ml) of d+ condensed red cells, out of that were initially asked. before the h from the surgery had passed, it was decided that human anti-d immunoglobulin (rhesogamma p) should be provided, in order to prevent the sensitization of the patient to rh (d). the indicted dose was - iu/ ml of the transfused blood, provided piecemeal during a several days period. analyzed by real-time pcr amplification. based on a published report, we selected primer pairs targeting insertion/deletion polymorphisms which are located on different chromosomes, unrelated to each other and not associated with immunocompatibility. we optimized the amplification conditions for all primer pairs using our sybr green real-time quantitative pcr protocols, and investigated analytical sensitivity for each primer pair by performing spiking studies, in which a single copy of positive dna was added into copies of negative dna followed by allele-specific pcr amplification. we also created a theoretical panel of donor-recipient pairs (n = ) to evaluate the clinical sensitivity for detection of ta-mc using both hla-dr and indel panels. results: for the short-term samples, additional mc cases was identified in non-lr group using indel panel; and one additional mc case was detected in lr group (table ) . for the long-term follow-up samples, additional mc cases were found. when evaluating analytical sensitivity, we were able to detect a single copy of positive dna mixed with copies of negative dna in a single amplification tube for all primer pairs. we were also able to calculated the clinical sensitivity that using donor-recipient pairs. . % of donor-recipient had at least one informative allele for detection of ta-mc if we consider both hla-dr and indel panels. conclusion: using our new indel panel, we were able to detect more instances of mc in this cohort of patients. we conclude that the dr assay underestimates the presence of mc. moreover, the tandem use of both panels provides a powerful tool for the detection of mc with . % of recipients having at least one informative allele. background: we reported severe immunesuppression and longterm transfusion-associated microchimerism (ta-mc) in transfused trauma patients. we have also reported, in a murine transfusion model, that sensitivity to -chloro- - dinitrobenzene could be transferred, albeit transiently, by transfusion of fresh blood from a sensitized donor to a naïve immunecompetent recipient. in order to mimic the immunecompromised status of trauma patients and further investigate the mechanism underlying ta-mc, we established an animal model using immunedeficient knock-out mice. aim: our objective was to test virus-specific immune functionality of the chimeric donor leukocytes in a murine ta-mc model. material and methods: female rag- /common gamma double knock-out mice were transfused with fresh blood collected from male balb/c mice, which were either not infected (non-primed, np) or infected twice (primed, p) with million viral particles of murine cmv (mcmv). at different post-transfusion time-points ( h, weeks, weeks, weeks, weeks), different female recipients plus non-transfused female knock-out controls were challenged with million viral particles of mcmv intra-peritoneally, and then monitored weekly for the concentrations of male donor cells as well as mcmv viral load in recipient's circulation. each female knock-out received only one challenge of mcmv. if the subject died, we quantitated mcmv viral load in the brain, spleen, lung and liver. we used real-time quantitative pcr targeting murine y-chromosome, h k and mcmv to quantitate male donor cells, transfused recipient cell dna input, and mcmv vrial load, respectively. the number of recipient cell dna input served as a denominator to calculate the concentration of male donor cells and the mcmv viral load. results: results of overall mortality are summarized in the table. all female knock-out recipients transfused with primed donor blood, except for the post-transfusion weeks, are able to survive mcmv infection. all non-transfused control and recipients transfused with non-primed donor blood died after mcmv infection; these two groups also had higher mcmv viral load in blood than the recipients transfused with primed donor blood. when the subject died, we were able to detect mcmv in all four organs we analyzed, with liver having the highest mcmv viral load. there was no significant difference for the concentration of donor cells in recipients' blood between recipients transfused with non-primed donor blood and recipients with primed donor blood. the preliminary data of our study showed that chimeric primed donor cells, but not non-primed donor cells, are able to protect immune compromised knock-out recipients from murine cmv infection. the time-point of 'post-transfusion weeks' might represent a weak window for the functionality of chimeric donor cells, which requires further investigation and confirmation. aims: to compare the effectiveness and the cost of epoetin-a and darbepoetin in patients undergoing pabd. methods: seven adult patients scheduled for operations were administered aranesp ( mg sc once or q weeks if needed) for pabd (aranesp group) and they were compared with a historical epoetin-a group of seven age-matched adults (eprex iu/kg biweekly). the two groups were matched according to the ht, ferritin levels, number of the predonated units and type of the operation performed. cbc count and reticulocytes were measured weekly during the donation period, the day before, day and day after surgery while ferritin and biochemical indices were measured during the first visit. erythropoiesis-stimulating factor was administered when ht £ % during blood donations and blood donation was not performed if ht < %. results: there was no statistical significant difference in hematological parameters during the donation period, the pre-operation day and after surgery between the two groups. five of seven patients from both groups received one or two autologous blood units. both factors were well tolerated without any side effects. the cost per patient was . € in the aranesp group and . € in the epoetin group. conclusion: despite the small number of patients and the limitations of this preliminary retrospective trial we believe that subcutaneous darbepoetin-a is equally effective with epoetin-a in patients undergoing pabd. darbepoetin has the advantage of less frequent administration and it is possibly superior that epoetin-a in terms of patient compliance. however smaller doses should be examined in order to reduce the cost. larger prospective randomized trials are needed to estimate the cost-effectiveness of the use of darbepoetin-a in pabd. background: incompatibility with many blood units is a major problem in transfusion therapy. in selective operations, preoperative autologous blood donation could solve many problems, when of course the patient's condition and his haemoglobin levels are appropriate. we present here the experience of our blood transfusion centre from operations in patients with anti-erythroid antibodies. materials: three patients ( male and females), aged between - years old, had to undergo selective operations, total hip replacement surgery and aortic aneurysm. introduction: because of improvements in surgical techniques, preoperative autologous blood donation (pabd) in patients undergoing radical retropubic prostatectomy (rp) is contested. aim of the study: we wanted to develop and validate an algorithm to determine the patients who probably do not benefit from pabd. methods: we calculated the perioperative hb-loss of consecutive patients (group ) who donated two red cell units (rbc) of autologous blood and weeks before undergoing rp: hb-loss (g) = preop-hb ¥ bv + (n rbc ¥ ) -(postop-hb ¥ bv) (bv = blood volume (l) = body weight (kg) ¥ . ; postop-hb = hb ( - h after rp); n rbc = number of transfused autologous and allogeneic rbc). hb of rbc was taken as g. rbc requirement is probably if initial-hb -(hb-loss: bv) -trigger-hb (taken as g/l) < (initial-hb = hb at the first contact with the pabd-unit). this assumption was validated by the next patients who were also assigned for pabd (group ). pabd was refused if the probability of rbc requirement (prr) was < %. between - % one rbc was taken after considering the patient's individual risk of pabd. if prr exceeded % two donations were planned. results: both groups did not significantly differ in age or initial hb. preop-and postop-hb were significantly lower in group ( vs and vs g/l). % of autologous blood of group were discarded, / patients needed additional allogeneic rbc. hb-loss caused by rp was ± g. mean prr in group was . %. / patients donated one rbc, which was later discarded, and no patients donated two rbc. / of group needed allogeneic rbc. mean prr of these patients was % (range . - . ). conclusion: postop-hb were lower in rp-patients with pabd because of the lower preop-hb and the restrictive indication for transfusion of autologous blood. the individual calculation of prr, for which only body-weight and initial-hb of the patient are necessary, shows that pabd in patients undergoing rp is indicated only in rare cases. the algorithm also may be used in other major operations, if hb-loss is known. use of darbepoetin-alpha in preoperative autologous blood donation: preliminary results background: preoperative autologous blood donation (pabd) is an alternative practice to eliminate complications of allogeneic blood transfusion although its cost-effectiveness has been questioned. darbepoetin-a (aranesp, genesis pharma sa) is a novel erythropoiesis-stimulating factor that it has been shown to be equivalent to epoetin-a (eprex, janssen-cilag) in patients with chronic renal failure and cancer. darbepoetin-a has a longer serum half-life and higher relative potency than epoetin-a. this property leads to less frequent administration and may reduce drug cost. so far, no clinical trials with darbepoetin have been published in patients with surgical anemia. other ( . %) patients who required autologous and homologous blood, had average predonation hb level of (sd ± . ) g/l. we found a significant relationship between the need for postoperative transfusion and the predonation hb level (p = . ), predonation htc values (p = . ), weight (p = . ) and gender (p = . ): female patients and patients with lower predonation hb and htc, as well as patients with lower body weight more often needed additional homologous blood transfusion. no relationship was found between age of patients and the need for transfusion (p = . ). ( . %) patients with ptka were transfused with autologous blood only, and had average predonation hb level of (sd ± . ) g/l. other ( . %) patients transfused with autologous and homologous blood had average predonation hb level of (sd ± . ) g/l. the significant relationship was found between the need for postoperative transfusion and weight (p = . ): patients with lower body weight more often needed additional homologous blood transfusion. no relationships were found between predonation hb level (p = . ) predonation htc values (p = . ), gender (p = . ) and age (p = . ) of patients and the need for postoperative transfusion. conclusions: our results show that over % of patients needed only autologous blood. in our patients with ptha predonation hb was significant predictive factor for additional transfusion therapy, while in ptka it was not observed. in both groups of patients body weight was significant predictive factor, thus this feature seems important for planning of transfusion therapy in patients with ptha and ptka. aim: prevention results of loosen anastomoses on colon, with fibrin sealent (fs) application and influence on colagen production. materials and methods: investigations were done on rats, weight - g. in control group, after partial resection of left half of colons termino-terminal anastomosis was derivated. fs was applied in examined group. concentration of colagen was done indirectly, with quantitative l-hydroxyproline determination. place of anastomosis, cm proximal and cm distal of anastomosis, was analyzed iii, v, vii and xiii day postoperatively. results: analysis of hydroxyproline on the place of anastomosis showed higher hydroxyproline value in group with fs application. the highest approximate value of hydroxyproline was registered v day postoperatively. distal, cm of anastomosis, the quantity of hydroxyproline is higher iii day postoperatively in control group but v postoperative day value is intensively growing in group with fs application. electronic microscopical was done v postoperative day in control group at the place of anastomosis detected a defect with detritus and absence of larger colagen fibres. in group with fs application on the place on anastomosis, in the shape of bundle, colagen fibres were grouped and completely fills the place of anastomosis. conclusion: fs application accomplish higher concentration of colagen in all segments of isolated colon, that enables better healing of anastomosis. the study of the use of the safest blood (autologous blood transfusion) through preoperative blood donation (pbd) in surgery patients introduction: the use of the autologous blood is already under consideration in developed countries. thus, it is probable that autologous blood donation would be effective in one way or the other in reducing blood transfusion complications. in this study, pbd as the easiest method to use and the most cost-effective one was selected. aim of the study: it aims at improving blood safety and raising blood inventory. methods: in this study, patients, including males and females, intended to undergo elective surgery were selected as subjects to donate their autologous blood. the subjects with hematocrite level of about - percent as ordered by their physician donated their blood by this method. blood collection procedure was followed at - day intervals. the blood volume taken from patients in every collection differed from - ml according to their weight. results: this study showed that in all patients undergoing plastic, gynaecological, jaw, and ent surgeries autologous blood transfusion was used with no need for allogenic transfusion. in other surgeries, including orthopaedics, the need for allogenic transfusion was estimated to be at about percent of cases. to avoid the complications of allogenic blood transfusion, the safest way is the use of autologous blood which involves low cost and is easy to perform. the introduction: the purpose of this study is to describe a technique to perform labelling of autologous platelet-gel with in-oxine and to evaluate its usefulness, after in vivo graft implant, as a marker of bone osteoinduction by means of scintigraphy, in patients with jaws bone defects following the enucleation of cystic lesions and cystic lesion derived from extraction of deeply impacted lower third molar. methods: agp made. consent was obtained by patient to conduct hiv and hbv testing. briefly, cc to cc of blood is withdrawn from the patient. the blood was separated, by means of successive step of centrifugation, in to platelet-rich plasma (prp) , platelet-poor plasma (ppp), and red blood cells (rbc). the red blood cells were discarded. the prp [comprises of approximately % of the total blood volume withdrawn] had platelet counts of - /mm . the procedures of agp labelling were performed in laminar flow chamber. to seconds the solution will assume a gel-like consistency forming platelet gel. imaging: the scintigraphy was performed h after application of labelled agp (early scan) and at , , , h (delayed scan) by means of a gamma camera equipped with medium energy collimator. a later scan was performed at days after graft. the platelet uptake index (pui) was then calculated by dividing the cpm/pixel in the graft roi (recognized in and planar and trans-axial slice) for cpm/pixel in a mirror background roi. in vitro sampling: the radioactivity of the plasma samples collected at , h and at lapse time = h for days, were used for the plasma clearance determinations and for in vitro studies of the platelet loss from the gel. results: all patients presented early high concentration of in oxine agp, at site of the graft, that was easy recognized at scintigraphy performed as in anteroposterior and lateral planar projection of the jaw as in spet slices reconstructions. all labelled agp was well confined within area of original implant and no activity was seen in the surrounding tissues or in the distant organ. conclusion: all patients studied well tolerate the implant of agp; no adverse reactions were observed and follow up -performed months later -showed bone remodelling activity in the site of the graft. serial blood donations in a ko pregnant woman with the use of recombinant erythropoietin for intrauterine transfusions of severe hemolytic disease of the newborn due to anti-ku biweekly) were administered to the mother to ensure an adequate supply of compatible rbcs for intrauterine transfusions and possible perinatal haemorrhage as well. results: intrauterine transfusions were repeated every - weeks. by the th week of gestation the patient had donated four units of blood, her hematocrit was %, anti-ku titre was / and four intrauterine transfusions had been performed. cesarian section was decided and the apgar of the newborn were and at and min. the newborn was treated with phototherapy but without exchange transfusions and two weeks later he was discharged. by the th day of life rh-epo was administrated to him due to anemia. the maternal red cells completely disappeared from the child's blood by the day . the experience of the use of erythropoietin in pregnancy is minimal. as illustrated by this case treatment with rh-epo and iv fe has effectively increased mother's capacity to donate rbcs' for autologous use and intrauterine transfusions as well, with no adverse effects to the mother or the child. however, further research is necessary to evaluate if rh-epo crosses the placenta. introduction: blood components should be transported by a system which has been validated. the containers used for transport should be well insulated, some form of temperature indicator should be used to monitor the in-transit temperature. whole blood should be stored at different temperatures above °c. aim of the study: bags with whole blood collected in a collection site are transported in containers without active cooling. we tested temperature of blood in containers put into the extreme weather conditions (+ °c, - °c) during loading test for transport. methods: the container without active cooling was filled with the exact number of bags with blood and the exact number of passive cooling elements (frozen water cubes in plastic) placed in the exact positions without close contact with the blood bags. the bags with blood of the temperature + °c, + °c and + °c were used. temperature indicators were situated in the bottom, centre and top of the container. filled container was placed into thermostat (+ °c) or freezer (- °c). the temperature was observed in min intervals for three hours, first measurement was min after putting into freezer or termostat. results: (see table ) nt, non tested; tmp, temperature. in the table there are shown minimum and maximum temperature parametres observed during tested time including increasing or decreasing trend. conclusion: loading test for transport of the bags with collected whole blood helps us to optimize transporting system, especially number of cooling elements in relation to the season and its place in the container. in the light of presented data we corrected transporting system to maintain the recommended temperature during transport. background: since , we have produced pooled and filtered platelet concentrates out of four buffy coats in tsol platelet additive solution and have stored them in pall autostop clx bags made out of pvc/totm. the residual plasma content is between - %, the mean volume about ml and the mean platelet-content is . ¥ per unit. for pathogen inactivation or bacterial screening it is necessary to extent the storage time from to days. new foliage like polyolefin is supposed to maintain a good quality environment for prolonged storage of platelets. aims: storage bags made out of polyolefin (pall autostop elx) were tested to prove their suitability for prolonged storage of platelets. methods: twins made out of pools from buffy coats were produced with the standard method, one twin was stored in the conventional bag (cb) the other in the new foliage bag (nfb). the platelet pools were stored on flatbed shakers at °c, and sampled at day , day and day . ph, glucose, lactate, hypotonic shock response (hsr) and p-selectin expression were measured by standard in-house methods. results: mean ph on day with cb was . , with nfb . ; glucose with cb . mmol/l, with nfb . mmol/l; lactate with cb . mmol/l, and with nfb . mmol/l, hsr with cb %, with nfb %; p-selectin with cb % and with nfb %. the new platelet storage bag showed better results of in vitro quality markers, especially after day of storage. prolonging storage time will make it easier to introduce bacterial screening or pathogen inactivation techniques into platelet transfusion. the possibility to filter rbc either at °c or rt simplifies the preparation process. filtration at + °c enables to achieve a better leukoreduction performance. the nbs has successfully implemented this project which has the potential for improvement in patient safety and is predicated upon practical application and risk reduction rather than elimination. the impact of this work on the incidence of trali will require detailed, long term analysis of hemovigilance data using existing mechanisms. active communication, a team approach, perceived value of the initiative and the hard work of all staff involved were key success factors. quality assessment of buffy coat-derived platelets prepared from leucoreduced whole blood background: whole blood can be separated into; plasma, buffy coat and red-cell conc (rcc) by differential centrifugation and separation on a separation device. because of the high hematocrit of the rcc, % of the process time is needed for expression of the rcc. by increasing the internal diameter of the tubing at the bottom of a t&b system by . mm. a decrease of the process time is expected. methods: units of whole blood were collected with the new t 'wide boring' blood pack and separated on a routine base. quality control parameters were checked and the whole process time was monitored. free hemoglobine was measured up to days. results: process time of a 'wide boring' bag is significant shorter compared to a standard blood bag. average decrease: s. slightly increase in free hemoglobine is measured probably due to the increased express rate of the red cells. bloodproducts produced with the new t meet european guidelines. no significant increase of free hemoglobine due to the faster expression is measured. an significant decrease in process time is measured with the wide boring bloodpack. the new fresenius hemocare rcc in-line system: t can be used for routine production which will speed up the production process considerably. introduction: leukoreduction of blood components is required to prevent several transfusion-associated complications. aim: the aim of this study was the full process validation of the pall leukotrap wb system for the preparation of leukoreduced blood components. we collected whole blood units from donors suitable for donation using a quadruple blood-bag, which includes an wbf in-line filter (pall) for the removal of leukocytes and platelets. mixer balances (baxter) were used and donation occurred within min in all cases. after donation whole blood units were stored at room temperature for h. subsequently, whole blood filtration was performed by gravity at a standard height of cm using a blood leukoreduction cart (baby leuko cart, itl-corporation). filtered units were centrifuged at g ¥ min by an heraeus cryofuge i. an automatic extractor (bag press plus-bioelettronica) was used to prepare red cell concentrates in sag-m solution and fresh plasma units. air in the system was automatically expelled by the extractor. complete cell counts and hemoglobin concentration were evaluated in pre-filtration samples and at the end of the blood components preparation using an automated cell counter (pentra dx -abx). we enumerated residual leukocytes in red cell units by flow cytometry (becton dickinson-leucocount kit). results: pre-filtration data of whole blood and end-of-process data of red cell and plasma filtered units, are summarized in table . results are given as mean and standard deviation. whole blood filtration was completed within min in all cases. red cell units were transfused after a mean of days to patients affected from transfusion dependent ( %), post-surgery ( %), and post chemotherapy anemias ( %). no cases of transfusion reaction were observed. the pall leukotrap wb system was easily introduced in our setting. all blood components prepared by the system fulfilled the council of europe requirements with regards to hemoglobin content in red cell units and post-filtration residual leukocytes. future studies are needed to evaluate its cost-effectiveness in the setting of routine blood component preparation. background: during an evaluation of the compodock (fresenius hemocare) sterile connection device (scd), we observed irregularities on the inside of the tubing at the site of the weld. it was our aim to investigate the effect of these observations on the quality of blood products. methods: three leukoreduced red cell concentrates (rccs) were pooled and divided over bag systems: one without weld in the connecting tubing, one with a compodock-weld, and one with a weld made with the terumo scd. the rcc was transferred times over this tubing to have maximum result if the weld had deleterious effects. the rccs were stored in pvc containers, and sampled on day , , and , and free hemoglobin (hb) was measured. the same procedure was also performed using platelet concentrates (pcs), but these were stored in polyolefin containers, sampled on day , and , and cd expression was measured. ten experiments were performed per blood component. according to who standards processing of blood into labile components are considered an expression of quality of transfusion service. in our practice, modern transfusion principles are successfully applied. they cover blood collection, serological processing of blood units, technological preparation of blood products (gmp, sop) and rational utilization of blood components and blood derivatives. in the past four years ( , .) aberrations from these principles have taken place (self-sufficiency). nbti collected x = ( ) blood units into blood bags. in serbia x = ( ) blood units. retrospective analysis: ldpc-bc was administered x = % with the satisfactory haemostatic effect. increase of the cyta and plasmapheresis-manual procedures was also noted ( %). increase of the use of leukocyte poor red blood cells was also registered ( % introduction: according to the relevant recommendations of the council of europe, whole blood is a source material used for the preparation of blood components and blood products. basic concept of the therapeutic use of blood components is the compensation of the lacking or deficient blood component. in that way, a possibility of the infusion of unrequired or deleterious components of whole blood is eliminated. objective of this presentation is to analyze the reasons of non-utilization of certain blood units, the actual quantity and ratio. aim of the study: the purpose of our in vitro study is to compare storage of platelet concentrates at °c with platelets stored at °c, and to determine the in vitro-effects of pre-incubation at °c for h prior to analysis on the basis of the maintenance of platelet metabolic and cellular integrity. methods: platelets concentrates (pcs) were prepared from pooled buffy coats (bc) for paired studies to be stored into different conditions. (i) at - degree on a flat bed agitator; (ii) at - degree on a flat bed agitator and pre-incubated for h prior to analysis; (iii) at °c; and (iv) at °c and pre-incubated for h prior to analysis. this paired in vitro study (n = ) over days include volume, platelet counts, mpv, volume, ph, po , pco , bicarbonate, glucose, lactate, swirling, leucocytecount, hsr, esc, atp, ldh and release of a-granule content (rantes, ß-thromboglobulin and pf ). results: platelet count (day and ; p < . ), mpv (day ; p < . ), ph (day and ; p < . ), pco (day and ; p < . ), bicarbonate (day ; p < . ), glucose (day , , , and ; p < . ), atp (day and ; p < . ) was significantly higher in platelets stored at °c and platelets stored at °c with preincubation. ldh (day ; p < . ), bicarbonate (day and ; p < . ), lactate (day , , , and ; p < . ), ph (day and ; p < . ), esc (day , , , and ; p < . ), hsr (day , and ; p < . ) was significantly lower in platelets stored at °c and platelets stored at °c with pre-incubation. the concentration of rantes, ß-thromboglobulin and pf was significantly higher in platelets stored at °c than in platelets stored at °c (day , , , and ; p < . ). hsr (day and ; p < . ) and esc (day , , and ; p < . ) was significantly higher in preincubated platelets stored at °c compared with platelets stored at °c. conclusion: platelets stored at °c maintain metabolic and cellular characteristics to a great extent during days of storage. we confirm the loss of platelet discoid shape and have shown that loss of discoid shape in platelets stored at °c is associated with decreased metabolic rate and decreased release of a-granule content. aim: as reference centre of the swiss blood transfusion service for new materials and blood products we evaluated that system for routine use and official registration in switzerland. method: whole blood donations were collected in a whole blood filtration set with cpda- and stored at room temperature for h before filtration at room temperature. the leucodepleted whole blood was stored for days. following parameters were analysed on day , , : free haemoglobin in%, k. in addition leucocyte count was performed on day and a blood culture on day (see table) . blood cultures on day remained negative and all counts of residual leucocytes were below ¥ (exponential) /unit. summary and conclusion: as expected there was a clear increase in k and free haemoglobin after day . however the results were within the required specifications from the european and swiss guidelines up to day . we conclude that autologous leucodepleted whole blood can be stored in cpda- -for days without loss of stability of the red cells. we will introduce the system to the offi-cial material list of the swiss blood transfusion service and then implement the procedure to our daily routine. results of ffp production from whole blood, and of ffp and pc produced by use of cell separator over a -month period before and after the introduction of measures for trali prevention are presented. the following measures were undertaken: ( ) blood of female donors was not used for ffp production, and plasma was only used for fractionation ( ) plasma of female donors was not used for kt-bc pools ( ) platelets and plasma were produced on a cell separator only from the female donors without a history of pregnancy. female donors of whole blood: %*; %** ffp produced by plasmapheresis: %*; . %** female donor units on cell separator: . %*; . %** ffp from total plasma units: %*; %** plasma units used for bc-pc pools: %*; %** *period before and **after the introduction of measures for trali prevention the exclusion of female donors had no major impact on the production of ffp and bc-pc pools from whole blood because of the very low rate of female subjects in the croatian blood donor population. the amount of plasma and pc collected from female donors by use of cell separator was significantly lower (~ %), however, without any major impact on total ffp store because of the small rate of plasma and platelets obtained by apheresis. background: platelet concentrates (pcs) are currently stored for a maximum of days. extended storage to days would increase the supply and reduce the waste of pcs. transfusion-associated graftversus-host-disease (ta-gvhd) is a severe transfusion reaction caused by t-lymphocytes in the transfusion product. the risk of developing ta-gvhd can be prevented by gamma irradiation of the pcs. various in vitro tests can be used to study the quality of pcs such as inspection of the swirling phenomenon, hypotonic shock response (hsr), detection of platelet surface markers (e.g. cd p and cd b), metabolic parameters and blood gases. free oscillation rheometry (for) using the instrument reorox® can be used to monitor the coagulation over time in whole blood, pcs and plasma samples, and to obtain information about clotting time and coagulum elasticity. aim of the study: the purpose of this study was to evaluate the quality of pcs obtained by apheresis technique during storage for days and to study the effect of gamma irradiation by using several in vitro methods including for. methods: platelets were collected from healthy donors (n = ) using apheresis technique. the pc from each donor was divided in units, one served as control and the other was gamma irradiated with gy. the pcs were stored on a flatbed agitator at °c for days. samples were taken on day (= day of collection) for analysis of blood gases, metabolic parameters (glucose and lactate), platelet count and swirling. samples taken on day , and were also analysed for hrs, cd p (p-selectin) and cd b (gpib) expression utilising flow cytometry. evaluation of coagulation by for was performed on day , and . the maximum elasticity (g'max) and the time to g' were evaluated from the for elasticity curves. results: there was no difference between irradiated and nonirradiated pcs regarding any of the tested parameters during the storage period. swirling, hsr, platelet count and percentage of cd b expressing cells were well maintained for days of storage. glucose decreased and lactate increased significantly during the storage period, from . mmol/l to . mmol/l for lactate and from . mmol/l to . mmol/l for glucose. the percent cd p expressing cells increased significantly during storage from % on day to % on day . po was well maintained but ph increased and pco decreased significantly between day and whereafter ph decreased and pco continued to decrease. the for parameters g'max and time to g'max increased significantly between day and and the time to g'max continued to increase significantly between day and . the results indicate a well preserved platelet quality after storage for days. gamma irradiation did not affect the platelet quality. cytokine release during storage of buffy coat platelet concentrates produced manually and automatically background: transfusion reactions following platelet transfusion are still a problem even when leukoreduction is included in the production process. platelet derived cytokines released during storage upon activation or lysis, accumulate in the platelet products and have been suggested to be involved in transfusion reactions. rantes (regulated upon activation, normal t cell expressed and presumably secreted) is a chemokine playing an important role in the inflammatory immune response and causes degranulation of eosinophiles and release of histamines from basophiles, which again can cause allergic reactions. tgf-b (transforming growth factor b ) has been shown to be immunosuppressive, inhibits the proliferation of t-and b-lymphocytes and decreases the secretion of igg and igm from b-lymphocytes. aims: as part of our quality control program, we aimed to quantify the amounts of rantes and tgf-b released during storage in platelet concentrates produced from pooled buffy coats by our manual routine method (m-pcs) and by an automated method using the orbisac system (gambro) (a-pcs). methods: pcs were produced from buffy coats. following overnight storage at - °c, buffy coats were pooled with ml t-sol (baxter). forty-two pcs were produced either manually (n = ) using the imugard iii s-pl set (terumo) with integrated soft leuko-reduction filter or by the automated procedure (n = ) using the orbisac validation bc set (gambro) equipped with the lrp leuko-reduction filter (pall). swirling was scored visually, platelet count and mpv were measured on a cell counter (cobas argos, roche), and blood gas analyses, glucose as well as lactate were measured on an abl series analyser (radiometer). samples for testing of cytokines were centrifuged for min at g, °c; supernatants were harvested and frozen at - °c until analysis. cytokines were quantified using quantikine human rantes immunoassay (r&d systems) and human tgf-b elisa immunosorbent assay (bender medsystems gmbh). all analyses were performed on days , and . results: platelet concentrate volume (mean): m-pcs: ml, a-pcs: ml. platelet yield was found to be . ¥ for m-pcs and . ¥ for a-pcs (p < . ). in all pcs ph levels were between . - . . glucose consumption and lactate production from days - and days - did not differ significantly. rantes levels (pg pr plts) were significantly higher in a-pcs than in m-pcs (p = . , repeated measures analysis of variance), but no significant difference was found in tgf-b levels (pg pr plts). summary and conclusions: preparation of buffy coat platelet concentrates by the automated orbisac system improves platelet yield compared to our manual processing procedure, but the levels of the chemokine rantes were significantly highest in the automatically produced products. the clinical importance of these findings is still unclear, but may be related to the shear stress the platelets are subjected to during the automated production process. the quality of cryopreserved vs liquid stored platelets: a comparative study table . the mismatches can be divided into the two categories. the first of them is characterized by differences in allelic groups, i.e. at low-resolution level. allelic group differences were detected in the group with one mismatch, most of them in hla-c locus (this locus was not concluded in primary donor search). in the other category there are differences in alleles within the same group, i.e. at high-resolution level only. differences within the same group in all tested loci were detected in the group with one mismatch. the mismatches described above were heterogeneous and a correlation of specific mismatch with transplantation outcome was not possible in this group. conclusion: the use of high-resolution dna methods makes the identification of hla match/mismatch more accurate and can affect the outcome of unrelated hsct. this work was supported by the grant iga mz, no. nr/ - . pre-freezing and post-thawing quality controls in umbilical cord blood assigned for transplantation p bergamaschi, c perotti, g viarengo, c del fante, c parisi, a marchesi, l bellotti and l salvaneschi irccs policlinico 'san matteo', pavia, italy background and aims: nowadays umbilical cord blood (ucb) represents a well established source of haematopoietic stem cells for unrelated transplantation in children affected with haematological and inherited diseases. thanks to the large-scale banking of unrelated units and the preliminary encouraging results, ucb employ in adults is quickly growing up. in this context, total nucleated cells (tnc) count of the graft is considered the main predictor for clinical outcome; however, other indicators of the haematopoietic potential, such as cd + cell content and short-term culture clonogenic assay, are recommended in accordance to netcord-fact stan-dards. in order to guarantee the safety and the prompt availability of a ucb unit assigned to a matched recipient, a pattern of rigorous quality controls should be carried out not only at the time of cryopreservation but also before the release for transplant. we report the results of the quality controls performed on thawed cryovials referring to the units delivered by our ucb bank compared to the pre-freezing values. methods: every ucb unit stored in our bank is accompanied by satellite cryovials available for subsequent controls. for each unit issued for transplantation, one cryotube was thawed in °c water bath with gentle agitation without washing out dmso. tnc and mononucleated cells (mnc) were estimated by an automated cell counter; viability and cd + cell count were evaluated by flow cytometry with a no-wash, single-platform technique and aminoactinomycin d. cfu assay was performed using commercial reagents (methocult gf h , stemcell technologies) and colonies were counted after days. the same tests were performed before cryopreservation, taking a sample from each fresh unit. moreover, before the delivery for transplant, a second cryotube was thawed to investigate the bacterial contamination by direct microbial culture, whereas the sterility test before freezing was performed by inoculum into ml media (bact/alert®fa/fn, biomérieux inc). results: the ucb characteristics before freezing and after thawing are detailed in the tables , and . post-thawing tnc and mnc, as well as cd + cells, showed no significant difference in comparison to the pre-freezing values. despite of the expected decrease of the overall viability after thawing, we observed a highly satisfactory viability referred to the cd + cells. the colony forming units (cfu) growth after thawing was documented and was always lower as respect to the pre-freezing assay. finally, the results of microbial cultures were negative for all the units on both fresh and thawed specimens. conclusions: in our experience, well standardized evaluation of ucb content could be obtained with regard to tnc, mnc and cd + cell. concerning the results of short-term cultures, the presence of dmso as inhibiting factor may be advocated to explain the discrepancies between fresh and thawed samples. finally, rigorous quality controls documented that the procedures of manipulation and cryopreservation did not affect the quality of ucb to be infused for transplant and provided to the physician all the parameters necessary for a safe transplant in a close and appropriate time. bone marrow transplantation or bmt transplantation of progenitor blood cells to regenerate blood normal cells in patients with blood disorders. bone marrow has an organized and structured architecture in which close relationships exist between a regulatory microenvironment and primitive hematopoietic cells. in fact, normal hematopoietic cells depends on critical interactions that occur between stem cells and their microenvironment. this microenvironment is a complex meshwork composed of growth factors, stromal cells, and extracellular matrix. marrow injury can occur as a consequence of a variety of diseases. some diseases could be due to a microenvironment that fails to support hematopoiesis. a possibility is that aplasia and leukemia share a common etiology such as drug, chemical, radiation, virus or other environmental hazards. we can say that microenvironmental abnormalities in interactions between stromal cells and hematopoietic progenitors may be important in the pathogenesis and clinical expression of hematopoietic malignancies in humans. background: intrauterine growth retardation, with associated low birth weight, represents one of the most important cause of baby mortality and morbidity. understanding the genetic bases of this adverse event is still an open goal. there is evidence that motherchild hla compatibility and hla-drb foetal genotype are associated with a reduced placental growth and a low birth weight. the recent institution of cord blood banks, with their huge amount of hla types, offers an unique opportunity to look inside the molecular bases of normal birth weight. aims: we investigated whether the baby-linked immunogenetic profile, i.e. hla gene frequencies and homozygosity rate, affects the physiological variance of the size at birth. methods: cord blood units ( from males and from females) were hla typed with pcr-ssp and/or reverse pcr-sso techniques and recorded in the cord blood bank database of pavia-italy. all were defined at low resolution level for hla-a and b genes and at high resolution for hla-drb . blood units were also randomly typed for hla-dqa and dqb at high resolution. results: mean birth weight was g and mean relative birth weight (i.e. corrected for gestational age according to the gender) was . g. babies were < th centile ( g) and were > th centile ( g). comparing the hla allele distribution in these extreme bands we found that hla drb * was significantly associated with high relative birth weight: . % in th centile vs . % in th centile, p = . . on the contrary, hla-drb * and dqb * were associated with low relative birth weight: . % and . % respectively in th centile vs . % and . % in th centile p = . and p = . . all infants were analysed as to the effect of the above mentioned alleles. we confirmed the positive association of hla-drb * and higher relative birth weight (mean . vs . ; p = . ) as well as the association of hla-drb * with lower relative birth weight (mean . vs . , p = . ). no significant association was found as far as hla homozygosity was concerned. conclusions: the present findings confirm the role of foetal hla-drb gene in the intrauterine growth. about the specific involved alleles, one possible explanation comes from the studies of crystallography and amino acid sequencing of hla-dr binding groove. it has been demonstrated that hla-drb * and hla-drb * genes encode for different amino acid sequences in the pocket of the molecule (aa , , ). this implies distinct functional restriction patterns. the sequence motif of hla-dr is characteristic of some autoimmune conditions, such as hashimoto's thyroiditis, and preeclampsia which is associated with intrauterine growth retarda- which provides a high yield and excellent purity without lymphocyte and erythrocyte contamination. in a month period, we studied blood samples from bone marrow transplant patients and from normal subjects. the extraction of leukocyte polymorphonuclear was obtained with a %- % dextran solution in . % saline. after incubation at room temperature with lymphopre solution, the mixture was centrifuged. two clear and separate rings of mononuclear and pmn leukocytes were obtained. to eliminate any red blood cells, pmnl ring was separated and washed three times with cold ammonium chloride. after a short period of incubation °c, mixture was centrifuged and the pmnls were isolated. the purity and viability of total leukocyte population was counted and the percentage of pmnl obtained was established. the total blood samples studied were divided in two groups, i.e., bone marrow transplant patients and normal subjects. in both cases the pmns isolated were of high purity and viability. the overall percentage of pmnls obtained from both groups under study was % to % when stained with gimsa or wright staining method. the viability of isolated pmnls was also % too, which is excellent for numerous immunological or molecular studies. the pmnls isolated by this method were highly pure and viable in comparison with standard methods used to isolate human pmnls. generation a high amount of pmnls is another advantage of the suggested method. this method to separate pmnls is recommended for in vitro studies of different subjects. et al. .) the object of exchange transfusion (et) is to remove bilirubin already present in the plasma or remove alloantibody which can cause hemolytic disease (in order anti-d, anti-c and anti-k are easily the most important) or remove anti-d positive red cells. we have studied exchange transfusion in our hospital in neonatal intensive care unit, during to . at delivery cord samples were taken for determination blood group, rhesus, hb and ht have been counted. also direct antiglobulin test (dat) has been performed. in cases of positive dat, hb and bilirubin levels were monitored. newborn body-weight were weighted (ranged g to g). the blood for et was of group o, d negative and kell negative and was compatible with the serum of mothers; it was less than days old. the blood was screened for hbs and for anti-cmv as well as being submitted to all usual tests. the method has been determined by using the umbilical vein; the multi-way tap makes it possible to draw blood from the infant into the syringe, to discard the blood into a sterile empty vessel, then to draw blood from a donor unit into the syringe and inject this into the infant. results: exchange transfusions were carried out. four out of et due to abo incompatibility mother-newborn. five out of due to rhesus incompatibility mother-newborn and eight out of due to jaundice undetermined origin and immaturity. the last two years only three et were carried out due to immaturity. conclusions: phototherapy, when applied early enough and with sufficient intensity, can avoid the need for exchange transfusion in many infants. phototherapy alone or phototherapy plus high dose igg therapy has been used to minimize exchange transfusions in this population. detection abo blood group system antibodies of neonatal using fully automated column agglutination technology (auto-vue) background: the abo blood group system remains the most important in transfusion practice. this is because of the regular occurrence of the antibodies anti-a, anti-b and anti-a, b reactive at °c, in persons whose red cells lack the corresponding antigens. the regular presence of anti-a and anti-b is used in the routine determination of abo blood groups; in addition to testing red cells for a and b antigens, the group is checked, in serum or reverse grouping, by testing the serum against red cells of known abo groups. methods: samples were taken from newborns at first h of life for abo blood group typing during - . simultaneously the presence of anti-a and anti-b antibodies has been studied using fully automated column agglutination technology (auto vue ortho diagnostic systems) with bio-vue cassettes aborh/reverse. the column agglutination technology is based upon the ability of glass beads to form a physical barrier between agglutinated and unagglutinated red cells. to determine the abo serum group, test serum and abo reagent red cells were added to the top of column containing diluents. the abo grouping columns were centrifuged and examined for agglutination. the presence or absence of agglutination has been recorded. results: in out of newborns were found detected antibodies anti-a, anti-b. in out of newborns no antibodies were found. in out of were found antibodies maternal origin. the automated reader detected all positive reactions. positive results were recorded on a scale from + . to + . conclusions: the technical performance of device allows objectivity and precision to detect abo blood group antibodies of newborn. the origin and the type of antibodies and also factors that influence their presence are to be studied. introduction: diagnosis, management and prevention of red blood cell immunization have improved, so hemolytic disease of the newborn (hdn) has changed from a common to a rare pathology. aim of the study. in this study we have retrospectively evaluated the benefits of the immunohematological screening for the management of pregnancies with alloimmunization. methods: in the last years, we have performed an immunohematological screening on all pregnant women assisted by our hospitals. ab and rh typing, antibody screening and, eventually, identification and titration were performed on maternal specimens by microcolumn technique. results: not considering ab incompatibilities, we have discovered alloimmunized women with the following specificities: anti-d, anti-c, anti-c, anti-e, anti-jka, anti-d + anti-jka, anti-d + anti-s, anti-d + anti-c, anti-d + anti-c + anti-k, anti-s, anti-k, anti-m, anti-c + anti-e and anti-d + anti-c + anti-g. the most severe hdn were the d + c + g, the c + e and out of c newborns, with mean hemoglobin between and g/l, bilirubin = . g/l, reticulocyte count = %. in these exchange transfusion needed at the delivery. other newborns were only treated with phototherapy. conclusion. thanks to the immunohematological monitoring, the diagnosis of alloimmunization, the correct management of pregnancy and the adequate neonatal therapy were possible. in fact all newborns survived and showed no neurological lesions in the following controls. conclusion: in order to provide a highly specialized perinatal care, immunohematologist, obstetric and pediatric should provide a good antenatal and perinatal screening. this is an interesting case of rhd immunisation in rhd negative woman despite the application of rhd immunoprophylaxis. case report: a blood sample of pregnant woman, years of age, in th gestation week, was sent to our laboratory for serological analysis. her blood group was o, ccddee and she had an anti-d antibody reactive only with enzyme treated panel of test erythrocytes. her husband was a, ccdee, and two children were both a, ccddee. on the next visit, she gave the data of one arteficial and one missed abortion before the th gestation week covered with mg of rhd immunoprophylaxis, but without the measurement of fetomaternal haemorrhage (fmh). both of abortions were after the deliveries. until the end of the pregnancy, detailed serological analysis showed anti-d specificity of antibody in her sera which remained reactive only with enzyme treated red blood cells. the fetus was under permanent ultrasound control. she delivered a mature, rhd positive, ccdee male child, without any sign of haemolytic disease. the proper personal history, measurement of the size of fmh, distinguishing the anti-d and anti-g specificity of the antibody, administration of rhd immunoprophylaxis and cooperation between transfusion medicine specialists, gyneacologists and neonatologists still remain major principles of prenatal and perinatal care concerning haemolytic deisease of the fetus and newborn caused by anti-d antibody. anti d antibody, reactive only with enzyme treated red blood cells is usually harmless for fetus and the newborn. introduction: red blood cell (rbc) transfusion is widely used in neonatal intensive care units for acute or chronic pathological conditions. clinical indications for rbc transfusion are shock, sepsis and/or anemia with the following laboratory criteria: a) hematocrit (hct) < % or hemoglobin (hb) < g/dl and reticulocytes < %; b) hct < % or hb < g/dl in these conditions: o required < %, recurrent apnoea and bradicardia, cardiac rate > bpm and respiratory rate > bpm for more h; c) hct < % or hb < g/dl with severe respiratory distress. aim of the study. aim of this study has been to evaluate the effectiveness of rbc transfusion therapy in premature and at term newborns independently of initial pathological conditions. methods: our therapeutic objective has been to achieve an hct of % after the whole cycle of transfusion therapy. for each little patient, the volume of transfused rbc unit has been calculated, according to international guide lines, using the following criteria: weight (kg) ¥ blood volume ( ml per kg if premature or ml per kg if at term newborn) ¥ (hct desired -hct observed)/hct of unit transfused. particularly we have considered that premature infants (with a gestation age of - weeks) show a range of weight from to . g, while at term newborns from . to . g. in order to avoid a circulatory overload, the indicated hemocomponent has been always packed rbc with higher possible hematocrit. for the same reason, the rate of infusion has been always - ml/kg/hour. methods: this is a descriptive study. the name of the neonates who received transfusion was obtained from the blood bank of beheshti hospital. information concerning the type of blood product, frequency and indication of transfusion, sex, gestational age and weight of infants was recorded in questionnaire and analyzed. results: out of neonates admitted during one year, ( male, female) received blood components. fifty four percent received one, % two and % received three types of blood components. the frequency of transfusions were times. the most common used blood products were fresh frozen plasma ( %), red blood cell ( %), whole blood ( %) and platelets ( %). all the blood products except whole blood were used more common in premature and low birth weight infants. appropriateness of transfusion of red cells, fresh frozen plasma, platelets and whole blood were %, %, % and % respectively. (hdn) . in accordance to current regulations, this study is carried out in all pregnant women attending in our service. according to our protocol, when an alloantibody of any specificity is detected through the liss-coombs gel technique, the same determination is made using papain-treated screen cells to detect any association with other antibodies which could be of clinical relevance for a hdn. there are scientific evidences that the use of enzymatic techniques increase the test's sensitivity, though clinical relevance of 'enzyme only antibodies' may be questioned. aims: demonstrate the importance of a routine identification of irregular antibodies in pregnant by two methods (liss-coombs -enzymatic) and the prevalence of anti-d associated antibodies, only detected by using enzymatic technique. analyze the need to carry out a follow up of sensitized patients to determine if the associated antibodies only detected with in an enzymatic medium can be detected with a liss-coombs medium during pregnancy, thus acquiring clinical significance for hdn. materials and methods: between january and december we studied d-negative pregnant women. the studies performed were: abo grouping, d and weak d, rh phenotype, direct antiglobulin test and irregular antibody detection (iad) against commercial screen cells with liss-coombs (diamed) ® gel-medium technique, according to the manufacturer's specifications. when iad were positive, an antibody identification using two commercial cell panels with gel techniques (liss-coombs-enzymatic) was performed. along the pregnancy, periodic controls were carried out to determine the exact moment when antibodies, previously only identified in an enzymatic medium, could be detected in a liss-coombs medium (clinically significant antibodies). results: out of d-negative studied samples, ( . %) had a positive dai and it was only showed anti-d specificity in a liss-coombs medium. after analyzing this specificity against enzymetreated erythrocytes, it was possible to determine that patients ( . %) had in their serum other anti-d associated alloantibodies: anti-k ( . %), anti-c ( . %), anti-e ( . %) and anti-c + e ( . %). during the immunohematologic follow up, it was determined that in / patients some of the antibodies which were previously only detected in an enzymatic medium, could be identified in a liss-coombs medium and later they were identified in the red cell elution of the newborn. conclusions: these results confirm the relevance of a screening for irregular antibodies of clinical importance by means of a conven-tional technique and one of increased sensitivity in all pregnant women. the detection of an association of antibodies provides information for the undertaking of diagnostic and therapeutic measures, both by the obstetrician, as for any eventual transfusional requirements for hdn. it was also concluded that, although antibodies detected in an enzymatic medium are considered of low clinical significance, its investigation and follow up is suggested in pregnant women to determine the moment in which they can be detected in an antiglobulinic medium, thus revealing their clinical significance. background: fibrin glue is one of the most complex human plasma derivatives both in terms of composition and clinical applications. this product mimics the last step of coagulation cascade through activation of fibrinogen by thrombin, leading to the formation of a fibrin clot in the presence of factor xiii. in contrast to synthetic adhesives, the significant advantage of this plasma-derived sealant is its biocompatibility and biodegradability as well as the fact that it does not induce inflammation, foreign body reaction or extensive fibrosis. readsorption of the fibrin clot is achieved during wound healing within days/weeks following application, depending upon the type of surgery, the amount and type of product used or the proteolytic activity of the treated site. the risk of virus transmission by commercial fibrin glue products is still debated and investigators are looking for alternative fibrinogen sources. many of these studies rely on autologous on single donor cryoprecipitate as source of fibrinogen. aims: the aim of this study was to compare single and double methods of cryoprecipitation of fibrin glue. the influence of different plasma preparation methods and plasma storage temperatures (- °c and - °c) on the quality of fibrinogen concentrate was examined. methods: whole blood was collected by standard phlebotomy technique and centrifuged at ¥ g for min within h of collection. plasma was removed. four units of plasma were pooled into a ml bag, mixed, divided into parts (aprox. . ml) and immediately frozen. two of these units were stored at - °c and units of ffp at - °c. after one month the plasma was thawed at °c during - h. the fibrinogen concentrates ( - ml) were received by single and double cryoprecypitation. to compare single and double methods of cryoprecipitation, the levels of fibrinogen, fibronectin, plasminogen and factor xiii were determined. results and conclusion: the levels of fibrynogen were significantly higher in fibrynogen concentration obtained by double cryoprecypitation from plasma stored at - °c. there were no significant differences in the level of plasminogen in both tested groups. double cryoprecipitation of a single unit of plasma (stored - °c) is an efficient, simple and safe method of obtaining fibrin glue. background: talking about professional risk we generally consider the risk of acquiring some kind of infective disease through accidental injury. in this article i would like to point out another side of the problem-the risk of making preventable medical error. with all its consequences. aim: how blood transfusion errors are among the most serious types of medical errors, the final goal is to initiate nationwide, regular, mandatory error reporting. information obtained, distributed and openly discussed at professional meetings will contribute to improving the patient safety. at the same time it would contribute to avoidance of blaming and shaming of many health care providers. prevent what preventable could be! method: retrospective analyze was conducted at the middle size blood transfusion center ( donations per year and utilization of approximately of components). results: after clearly distinguishing adverse events due to underlying patient condition from preventable medical error we fined out that: -great majority of adverse events resulted from medical error -every part of blood transfusion center, from blood donation ward, through laboratory testing to component issuing has it' weak points' or vulnerable places -any educational level is equally liable to error there is no significant difference about occurrence time: -working day/holiday -emergency/routine request -routine h/out of routine h -main error cause were as follows: -donor sample misidentification -rhd typing error -abo typing error -incorrectly performed cross match -recipient misidentification -wrong component prepared -sample confusion during freezing preparation conclusion: the truth incidence of transfusion medical errors is underestimated. mandatory report of fatal or 'only' harmful errors to the referent institution and its periodical announcement is the step ahead in preventing errors. those reports should be discussed at professional meetings (not at the 'yellow pages') and served as educational tool. but, as the most of the errors are system related, the key to reduce them is to focus on improvement of the system and nil for plasma. wastage rate was highest for plasma components. the influence of local practices on such discarding and whether avoidable shall be discussed. audit for blood discarding and corrective actions to minimize discarding is essential for all transfusion services and blood centers. designed technical and economic support. options include importing finished products and/or procuring products made from locally collected plasma. one approach is to consider local fractionation of plasma by building and operating a plasma fractionation facility, which may produce, finished products, or may produce intermediate products that are further manufactured in another facility. an alternative approach is the implementation of a plasma fractionation program where local plasma is sent to an established fractionator, and the plasma is fractionated following preagreed terms. the end products are returned to the country of the plasma supplier. in the national center for the production of blood products was established, under the direction of elias politis and years later in begun the production of dried plasma from greek donors. by the year the center started the production of fibrinogen and by the year the production of antihaemophilc factor. in all the activities of the center settled down due to administrative aspects. at the beginning of s a contract fractionation program was instituted (under the direction of k. sofroniadou) concerning the fractionation of liquid plasma and production of albumin, which by the end of year stopped and was replaced with a new contract for the fractionation of source plasma and the production of albumin. the challenge of adapting to the new and more stringent regulations governing the manufacture of blood products was great and brought a lot of changes in the structure of our center. a new bar-coding system ensuring the traceability of blood donations was instituted together with complex software for packaging and preparation of plasma shipments to the fractionation center together with all necessary paper work. a close collaboration with the medicines regulatory authority in order to be able to fulfill all the requirements that regulate issues associated to the quality and safety of human derived medicinal products. collaboration with blood collection establishments was promoted in order to increase the amount of plasma produced. there is a continuous effort from all the implicated parts in order to follow defined quality assurance procedures as highlighted by international guidelines for the blood donor selection, collection procedures, testing methods, donation handling, storage and transportation of plasma. the plasma contract fractionation program may serve, as an initial step prior to switching production to a locally built facility. this lapse of time may be used to expand the plasma collection potential, and to permit appropriate design, qualification and validation of the facility as well as training of local personnel. background: fibrin glue became a reality in the early s, when techniques for the isolation and concentration of clotting factors were improved. in , matras et al. described successful application of fibrin glue for peripheral nerve repair. this encouraging report prompted the use of fibrin glue in wound closure, skin grafting and bone union of osteotomies. the fibrinogen component of fibrin glue is produced from single unit donations of fresh frozen plasma. such procedure helps to reduce the risk of transfusion transmitted infections encountered by exposure to pools from large numbers of donors or by use of fibrinogen prepared from autologous blood prior to surgery. the second component, a mixture of thrombin and cacl , is commercially available. thrombin is applied to the operation site simultaneously and in equal volume to the fibrinogen but from a separate syringe. there are many methods of fibrinogen concentrate preparation but none of them has been described in detail. aims: the aim of this study was to choose/select the most effective, simple and safe method of obtaining fibrinogen concentrate (basic component of fibrinogen glue) which would also be easy to prepare in blood transfusion centers. methods of precipitation of fibrinogen by polyethylene glycol (peg), ammonium sulphate, ethanol or cryoprecipitation were compared. methods: plasma was obtained after centrifugation ( ¥ g for min) of whole blood. four units of plasma were pooled into a ml bag, mixed, divided into parts and immediately frozen. one of them was stored at - °c and after one month the plasma was thawed at °c during - h. fibrinogen was obtained by cryprecipitation and each of the three remaining units was precipitated with ethanol, peg and ammonium sulphate. the levels of fibrinogen, fibronectin, plasminogen and factor xiii were determined in each fibrinogen concentrate. results and conclusion: the level of fibrynogen ratio in fibrinogen concentration, obtained by peg and ammonium sulphate was significantly higher. cryoprecipitation is a simple, economic and reproducible procedure with the advantage of being performed in a closed system. plasma fractionation program in greece: an unknown history the provision of safe and sufficient plasma derivatives to meet the needs of local population requires special consideration and a well- (light cycler, roche diagnostic systems, nj) was used for the identification of the c y, h d and the s c point mutations of the hemochromatosis gene, and were based on protocols developed, for c y by the unidad de medicina molecular (ingo, santiago de compostela, espanha), and for the other two mutations by bolhalder m et al. the primers and probes were designed by tib molbiol (berlin, germany). results: the analysis of the percentages of genotypes and allele frequencies of the hemochromatosis gene mutations are described in the table. no differences were found between the patients and the controls. when we compared subgroups of patients based on their hepatitis c genotypes, a higher value for the c y allele was obtained ( . %) in individuals with genotype , however without statistical significance. discussion: hereditary hemochromatosis is a common disorder and is associated, in some studies, with a worst prognosis in patients with viral hepatitis. follow-up studies are necessary in order to evaluate if the presence of these mutations can cause a more severe course of the illness (greater risk to develop fibrosis or cirrhosis) and a different outcome when treated with antiviral drugs. also, it will be important to evaluate if aggressive phlebotomies will modify their clinical evolution. introduction: portugal has a higher prevalence of viral hepatitis, with probably more than . patients chronic infected with hepatitis b and/or c. hereditary hemochromatosis (hfe) is one of the most common causes of known hereditary illnesses with hepatic repercussion. hfe mutations are also found in linkage desiquilibrium with particular hla haplotypes, conferring, eventually, a different response to viral agents and antiviral drugs. in this study we evaluated the prevalence of the main mutations c y, h d and s c for the hfe in a population with chronic hepatitis b and/or c and in a cohort control. background: haemolytic disease of the newborn (hdn) is the destruction of the red blood cells of the fetus and neonate by antibodies produced by the mother. although postpartum rhig prophylaxis reduced the incidence of alloimmunization from pregnancy from % to - %, the doubt subsists if it is appropriate to use it as routine antenatal prophylaxis. material and methods: a total of samples ( mothers and newborns), from / / and / / , were studied. all abo, rh typing, antibody tests and dat were carried out in column agglutination tests. results: from the cases studied it was found cases without incompatibility ( %). from the incompatibilities, . % were abo, . % were rhd, . % were other rh incompatibilities, and . % were due to auto-antibodies. % of the mothers were rhd+ and % rhd-. conclusion: of the pregnant women studied, only were rhd-. from this group ( %) delivered rhd-newborns, what revealed that the antenatal prophylaxis they were submitted was unnecessary. from the pregnant women rhd-, % had incompatibility abo, which decreases to near % the risk of development of rhd immunization. being anti-d immunoglobulin a product that has the potential risk of infection transmission, is it appropriate to use indiscriminately as a routine antenatal prophylaxis? the introduction of molecular methods to determine the fetal rhd genotype could rationalize the use of antenatal anti-d immunoglobulin prophylaxis. introduction: the frequency of hla a haplotype expression has been found about - % in caucasian and in greek population particularly, . %. because of the high frequency, it is used widely in anticancer immunization. the immune system plays an important role in the defense against neoplastic disease and immune response show temporal chances related to circadian variation of antibodies and total lymphocytes in the peripheral blood. aim: the probable difference in the frequency of hla a expression and their lymphocyte phenotype into a group of cancer patients and a group of healthy donors, during screening of immunization with hla-combined peptides. materials and methods: healthy donors who proceeded in the department of transfusion medicine, university hospital of heraklion crete were tested for the hla a expression. in of these donors the expression of cd , cd , cd , cd , cd , cd , hla dr, cd +cd +, cd +cd +, cd -cd +, cd +cd -cd +, cd -cd -cd +, cd -cd -cd + was examined. meanwhile, patients with metastatic cancer who were hospitalized in the department of medical oncology, university hospital of heraklion crete, were tested for their hla a expression, while in of them for their lymphocyte phenotype. the antigens expression was examined in flow cytometry. the hla a expression in healthy donors was . % and in cancer patients % (p > . ). in table the mean, standard error, t-test and p of the two groups are included. (see table ). the two groups (healthy donors and cancer patients) revealed no statistical significant difference on lymphocyte phenotype, except of the cd expression, which was higher in cancer patients. summary and conclusion: the expression of hla a in cancer patients and in healthy donors was comparable. also, the lymphocyte phenotype among the two groups has not statistical significant difference, except of the cd (total b-cells). the significance of this result has to be investigated. in the course of original documents research i found out that dr. kalic, head of the first organized blood transfusion institution in the balkan region (at beograd, serbia, in ), set himself a professional goal: blood should be awaiting all patients and transfusion should not be a privilege of large city inhabitants only. dr. kalic's idea was that blood transfusion should be administered according to clearly given instructions and using simple blood sets. encouraged by the conclusions of the congress held in paris in , dr. kalic started preparations for the transport of blood to the inland. he concluded bravely that citrated blood could be sent by regular mail, as an ordinary parcel, without particular protection from the outside temperature. he advised his colleagues to use blood as an intravenous injection. blood was taken from voluntary female donor in belgrade (capital), march . after keeping it for days at storage, blood was forwarded on a two-day journey to a small town, kilometres away from belgrade. there it was kept on a room temperature before its final use for a treatment of a patient suffering from secondary anaemia. the patient underwent the procedure without side effects and responded to the transfusion with blood sent in this manner much better in comparison to earlier methods of direct blood transfused. reminding ourselves of the courage of our ancestors to implement their professional knowledge and personal original ideas in a new way with the desire to help the patient as successfully as possible, we pay them the deserved respect and gratitude for inspiring and encouraging us in this way to try the same. conclusions: automation leads to increased standardization, faster specimen processing and reporting, elimination of manual specimen identification, uniform interpretation of serological reaction patterns and objective reading of haemagglutination endpoints. using auto-vue allowed the staff uninterrupted time to perform quality assurance duties, extended antibody identifications, preventative maintenance, inventory control. the instrument allowed us to leverage current staff to a more productive, less stressful level. introduction: exosomes are - nm secreted vesicles produced by antigen-presenting cells (apcs). the finding that exosomes from dc pulsed with tumor-derived peptides elicited potent antitumor tcell responses and tumor regression in mice has led to the proposal that human exosomes could be effective vectors for antigen delivery in the context of cancer immunotherapy. aim of the study: to establish the method of producing a new kind of tumor vaccine -exosomes secreted by dc, pulsed with tumor peptides. methods: exosomes used in this study were generated from monocyte-derived dc pulsed with peptides from k tumor cell lines. exosomes were purified by the methods of ultrafiltration and ultracentrifugation. the methods of dynal magnetic beads, flow cytometry and western-blotting were used to determine the surface molecules of the exosomes. the function of the exosomes was deter- objective: to develop an immunoheatological technique for the study of erythrocyte hyaluronic acid sodium salt (cd ) receptor expression in red blood cells (rbcs) from adults and newborns. materials and methods: samples of anticoagulated blood from adults (n = ) and umbilical cordon (n = ) were used. several dilutions oh hailuronic acid sodium salt solution % (sigma l- h ) were confronted with % erythrocyte suspension in phosphate saline buffer (pbs) ph . . the rbcs were previously treated with an enzymatic solution of % bromeline in pbs ph . (sigma l h ). agglutination readings' were been by slow sharking after of h incubation at °c. the results were expressed through the sensibility parameter which involves titer and score. this is defined by a mathematical expression a = à si. di- . - (i = , , . . .) where si represent the score and di- is dilution inverse. the adult' rbcs showed a = ± , while en the newborn the parameter was a = ± . our results showed significant differences between both groups. conclusions: in this work, we present a simple immunohematological technique for the hyaluronic acid sodium salt (cd ) receptor expression in red blood cells, which could be a useful tool to evaluate the alterations of the receptor's expression in rbc. a new technology for crossmatching tests adapted to a fully automated system l gaillard, v desvigne, a boulet, l fauconnier and jm pelosin diagast, loos, france we have developed a new automated technology for crossmatching (compatibility) test suitable for automation and high throughput. the method does not require centrifugation steps thanks to the use of magnetised red blood cells (rbc). all the steps described are performed on the fully automated qwalys system. this methodology requires washing steps under magnetic field and is based on the fixation of sensitised rbc on the surface of a well coated with monoclonal anti-human globulins. in a first step, the red blood cells from target blood bags were magnetised during min. then the patient plasma is distributed on a microplate and incubated with the previously magnetised rbc during min at °c. excess of unbound immunoglobulins is removed by washing steps. in a third step, sensitised magnetised rbc were transferred in the antiglobulins coated plate and placed min on a magnet plate. wells in which antigen-antibody interactions have occurred display a confluent layer of rbc (positive reaction). the negative reaction appeared as a pellet in the middle of the well. the test can be read by an automatic reader or by naked eye. the patterns in the well are stable for at least h at room temperature. the plasma samples are provided by the laboratory of haematology of the chru of lille. the red blood cells are collected from segment of tubing of blood bags coming from the laboratory of blood donors of the efs (french blood services) nord de france-lille. the results are obtained in min. comparative studies showed that our new technology, without any centrifugation steps, is reliable and sufficiently sensitive and specific enough to perform cross matching tests using a high throughput automated system. the mechanisms of p -dependent apoptosis involve a set of genes that possess the ability to modulate oxidative stress. one of them pig , is induced by p through a microsatellite in its promoter region. this microsatellite has been proposed to represent an evolutionary adaptation of tumor suppressor mechanisms. microsatellite instability and genetic constitution, comprising the presence of the low repetition allele ( tgycc repeats), at this locus have been hypothesized to provide an increased risk for cancer development. aim: in the present analysis we examined this polymorphism in blood samples from voluntary health donors and compared it with human lung cancer samples, employing two different ethnic groups, greek and british. results: analysis of this locus in both types of samples showed: (i) the homozygous presence of the repeats allele only in the samples from healthy blood donors; (ii) a very low frequency of microsatellite instability (< %) and no loss of heterozygosity in matched normal-tumor tissues; and (iii) a non-significant increase of the most frequent allele ( repeats) in the cancer groups as compared to samples from healthy blood donors. the last two observations were found in both greek and british populations. conclusion: taken together, these data do not support the notion that this pig polymorphism is associated with an increased risk for cancer susceptibility. background: blood group determinations are routinely performed by the sensitive technique 'gel test' for the last few years. many weak d and partial d phenotypes which react as d negative or weak d by slide test, are assigned the rh d + status by gel test. this is most desirable in the case of blood donors but creates concern in case of patients and antenatal women with a partial d phenotype. case report: we report a female patient (blood group o, c+, c+, e-, e+) whose red blood cells gave a positive reaction of different strength and speed with different anti-d antibodies in slide tests. we were asked to type the patient and provide the appropriate blood units. the patient's cells gave a +/ + reaction in the standard screening procedure for the rh d in gel test micro-typing system that contains a polyclonal reagent of human origin (which allows a direct detection of most weak ds), a + reaction in a test with monoclonal anti-d and a +/ + reaction in the gel test micro-typing system destined to detect du and which contains polyclonal anti-d of human origin. however, since the slide test gave a rather slow onset of agglutination with one commercial reagent (made up of a blend of polyclonal and monoclonal anti-d) we tested the patient's red cells against anti-d reagents in the id-partial d typing system. one of these (number ) gave negative reactions and the remaining five gave positive reactions (ranging from +/ + to +), indicative of a partial d category vii phenotype. the patient's red cells were also tested in the id-card 'diaclon abo/d' . this card provides the complete profile for abo/rh d in one single procedure step, including the confirmation of rh d. it contains two different anti-d reagents within the gel matrix in two consecutive microtubes. the first anti-d (polyclonal human) is expected to give a positive result with d+ red cells and partial d category vi, while the second (monoclonal rabbit) is expected to give a negative result with dvi+ red cells. our patient's cells gave a negative reaction with the first and a +/ + reaction with the second anti-d in this system, indicating a d variant other than dvi. finally the patient was assigned the partial d category vii phenotype (according to the pattern of the reactions obtained with the id-partial d typing set) and rhesus d negative blood units were issued. this case illustrates the diversity of reagents used for rhesus typing in different laboratories. failure to disclose some d variants is a disadvantage when typing patients. a combination of techniques is often needed to reveal the real rh d phenotype. the only single system that could have revealed a d variant in our patient from the beginning, is the id-card 'diaclon abo/d' with two different anti-d reagents in two consecutive microtubes as described above. a cost-benefit analysis should be undertaken to show whether it should replace other screening tests for abo and rh d when typing patients. who cares about the quality of life of the chronic patients treated with blood products? d ilcenco*, e hanganu-turtureanu † , c burcoveanu † , c vartolomei ‡ and d azoicai § *blood transfusion center, † hospital 'sfantul spiridon', ‡ institute of hygiene, § university of medicine, iasi, romania quality of life is one of the methods used to appreciate the quality of the health system. romania is going to join soon the european union, so there must be a concern regarding the improvement of the national health system. blood receiver's life quality never been researched before in romania. we have been chosen a batch of chronic ill patients who have been received blood transfusion with blood or blood components, and asked them to complete two types of questionnaires regarding their life. we used nottingham health profile and beck's depresion index. results shows that this kind of patients need special care, because they all (with one single exception) feel frustrated and feel like a burden to the other normal persons. evolution of the pain index, mobility index, energy index, emotions index, sleep index and social isolation index was in concordance with the depression index. in conclusion, this type of patients needs special attention and medical authorities should make more efforts to assure their life quality support. transfusion medicine practice in surgically treated urology patients: our experience il ilincic*, bm bozovic* and ts tadic † *clinical center dr dragisa misovic, † natio. blood transfusion inst., belgrade, serbia objective: multiple studies demonstrate that the use of blood/blood products in patients undergoing elective urology surgeries, as well as the actual needs assessment, present the issue of numerous debates. method: using the retrospective method, utilization of blood/blood products was analyzed, as well as the ratio of prepared/used blood units in urology patients in the surgical ward, in the intensive care unit (icu) and at the urology center within the cc dr dragisa conclusion: due to a rather liberal use of primarily ffp in certain cases (cystectomiae in the first place), and a discrepancy between the prepared and actually used blood units, hospital transfusion committees should be an imperative in order to solve current dilemmas regarding justified use and proper administration of blood and blood products. background: the safe collection, production, distribution and application of blood and blood products in a high quality needs logistic on a high level. since the seventies computers, special software and barcode are used in transfusion medicine and improved the safety of processing data. in the last years a new technology was developed for industrial use, the radio frequency identification (rfid). aim: the aim of our studies was to check whether rfid can use reasonable in transfusion medicine. methods: at first we developed a flow chart, where we can use the technology and where are the problems by introduction. so we tested in the red cross donation centre in saxony about passive rfid smart label under real conditions. in cooperation between the akh vienna and novatech research a new handheld pc software 'labelview' for all steps around the transfusion was developed, including the identification of the patient and the processing of the haemovigilance data, and tested in first time. results: passive and semiactive (with temperature control) rfid labels survives all hard steps during the working up of the whole blood (e.g. centrifugation by g, separation, etc.). as a result of the contactless identification they are help to make easier the documentation of all processing steps according good manufacturing practice. in clinical practice they are a good supplement to bed side transfusion software. conclusion: for all lot of problems by the logistic and the safe identification around the transfusion existing various single point solutions such as patient-wristband, bed-side test, double check of blood group typing and donor -donation registry in software, etc. the lecture will deal with new developments in logistics and data management, which can help to reduce the problems associated with documentation, safe identification and reporting of haemovigilance data. our experiences with the immunohaematological analyser olympus pk applied conventional and no conventional (hemolytic medium time) techniques in sera of patients with ascariasis. results: the ai and hk tests showed: b epithopes in ae from b patients and in ae from ab patients; a epithopes in ae from ab patient and in ae from a patients; p and p epithopes in ae and only p epithopes in ae. these patients had both epithopes in their erythrocytes. the hemolytic techniques showed: anti b immune antibodies in sera and anti a immune antibodies in sera. the presence of abo and p epithopes in ae and immune antibodies in patients with ascariasis show a relation about blood groups and ascariasis. the fact of to find the same abo and p antigens in a. umbricoides and in its hosts suggests that the parasite might absorb them during its life cycle. these epithopes would be involved in the molecular mimicry. the use of filters for leucocyte depletion in anemic patients on maintenance hemodialysis g poposki*, s kovaceski*, b krstanoski*, s mena* and n solaz † *institute of nephrology, struga, macedonia, † ankara university, faculty of medicine, ankara, turkey introduction: renal anemia is one of the major chronic complications in end stage renal disease. it is caused by reduced production of erythropoietin (epo) due to uremic toxin effects, reduced halflife of rbc, iron deficiency, aluminum intoxication, blood loss during hemodialysis, gastrointestinal hemorrhage, epistaxis, infections etc. allogenic blood transfusion is transplantation of certain or all cell types. however, allogenic blood transfusion can contribute to many immune system disturbances with clinical side effects. besides erythrocytes, mononuclear, t and b-lymphocytes, are also transfused, which cause immunomodulatory disturbances in immune system of recipient. leukocytes are responsible for frequent febrile non-hemolytic transfusion reactions, alloimmunization toward leukocytes and hla antigen and transmission of cmv. anti-le antibodies, forming of immune-complexes, complement activation with pirogenic c a and c a immunoinflamatoric citokines cause febrile reactions. commercial use of filters for leukocyte depletion with removal of leukocytes and degraded products of microagregates and cytokines, cause minimum harmful immunomodulatory effects and prevent transmission of cmv. aim: the aim of the study was to present the effects of transfusion of erythrocytes with residual number of leukocytes in anemic patients on chronic hemodialysis at institute of nephrology in struga. matherial and methods: during - period all anemic patients on hemodialysis were divided in groups. the first group pts with febrile non-hemolitic transfusion reaction. the second group- pts immunized toward leukocyte and hla antigen. the third group young candidates for kidney transplantation for prevention of hla immunization. the fourth group pts with sle (for immune-complexes and autoantibodies). total patients ( males and females) received units of rbc with residual number of leukocytes. commercial filters of baxterÔ (lekostop lds) and terumoÔ (imugard iii rc) of second and third generation with microagregate filter and synthetic polyurethane fibers, with - microns pores that remove leukocytes, platelets, microagregates and fibrin were used. erythrocyte concentrates are filtered until days of collection. result: aabb permits maximum < ¥ wbcs/unit for prevention of febrile non-hemolytic reaction. the filters we used reach residual leukocyte number of ¥ the le reduction of - . %. the number of rbc after filtration is minimum % - g hb per unit. in none of the patients who have received the leuco-filtered blood, no adverse post transfusion reactions were noticed. conclusion: the used filters for leucocyte depletion are characterized with superior biocompatibility, excellent elimination of all types of leucocytes and high 'recovery' of erythrocytes. the use of filters for le depletion reduces and minimizes the side effects of allogenic blood transfusion in patients on chronic hemodialysis who are alloimmunized, in patients with sle, and particularly in young patients candidates for kidney transplantation. background: fv leiden, prothrombin g a, mthfr c t are three most common and important prothrombotic inherited mutations. aims: the aim of the case-control study was to assess the prevalence of mutations and their single or combined effects as risk factors for thrombosis. methods: the study included thrombotic patients (venous thromboembolism, chronical venous diseases, different etiology) and asymptomatic healthy individuals as control group. extraction of genomic dna was followed with genotyping of fvl by pcr-ssp, prothrombin and mthfr mutation by pcr-rflp. results: a statistically significantly higher prevalence of fvl mutation was found in thrombotic patients ( . % heterozygous, . % homozygous) compared to controls ( . % heterozygous), p < . . the or for heterozygous carriers was . ( % ci . - . ), confirming the association of fvl mutation with the risk of thrombosis. there was no statistically significant difference in the prevalence of the prothrombin mutation in patients ( . %) and controls ( . %), or . ( % ci . - . ), p = . . although the group of thrombotic patients showed a higher prevalence of homozygous carriers of c t mthfr than the control group ( . % vs . %), or was not significant ( . , % ci . - . ), p = . . analysis of combined effects of mutations showed an additional thrombotic risk for carriers of fvl mutation and both mutated alleles of c t mthfr gene (tt and ct) (or . , % ci . - . ), p < . . conclusions: fv leiden mutation was detected as significant single risk factor for thrombosis in studied patients group. additional prothrombotic risk have carriers of fvl mutation and c t mthfr gene mutation. a female patient in a high fever due to urinary tract infection does not respond being given antibiotics. on the contrary, leukocytes rose (to ¥ /l), anaemia became even deeper, as well as thrombocytopenia. hemocultures were negative. hematologist decided to search for hematological disease. the first citology results of bone marrow aspirate suggested lymphoproliferative disease ( % atipical plasma cells). to treat heavy anaemia (hgb g/l) hematologist asked for red blood cell concentrate. pretransfusion testing revealed warm autoantibodies in the patient serum and on red blood cells. antibodies had no apparent specificity. biochemical parameters (bilirubin, ldh, haptoglobin) suggested mild hemolitic process. electroforesis revealed polyclonal hypergamaglobulinaemia. the th day of hospital treatment, the therapy with corticosteroids was introduced (solu-medrol mg per day). coagulation parameters were tested: pt . inr, aptt s, fibrinogen . g/l, trb ¥ /l, d-dimer mg/l, atiii %. dic was suspected. liver enzymes showed mild liver dysfunction (normal ast, alt, elevated ggt, low che). substitution therapy started with dose of cryoprecipitate, dose of fresh frozen plasma, iu atiii, doses of red blood cells and vitamin k mg. two days after the substitution therapy we saw pt . inr, aptt s, fibrinogen < . g/l, trb ¥ /l, atiii %. during the next few days erythrocytes and thrombocytes rose, but due only to corticosteroid therapy and not to substitution therapy. the patient had neither signs of con-sumptive coagulopathy, nor hypoproduction of coagulation factors, except for fibrinogen. till th day of therapy, fibrinogen was below . g/l. there was no hemorrhagic diathesis. after that, fibrinogen rose, and on the st day the patient was recovered, in both clinical and laboratory terms. the results of immunological tests, collected later, confirm the diagnosis of systemic lupus erythematosus. we did not have any specific test to confirm antibody mediated hypofibrinogenaemia, but in the setting of sle, without any specific treatment except corticosteroids, fibrinogen recovered. we assume it is quite enough for highly suspected immunological hypofibrinogenaemia. results: twenty-four-year-old male patient with severe hemophilia type a suffering from low incoercible digestive bleeding secondary to ischemic colitis caused by autoimmunity (vasculitis) without response to current management. treatment was initiated with mg/kg/dose of rfviia (*) for days, after which there was clinical and endoscopic recovery, and an inh decrease to . ub/ml (fviii dosage %) . he began to take meprednisone ( mg/kg/day) for days, after which the inh titre was . ub/ml. (table a ,b) the patient underwent surgery the following year (correction of equinus foot). he entered the operating room with an inh of . ub/ml and was treated with mg/kg/dose of rfviia (*) for days, obtaining an excellent hemostatic response. he had two autologous blood units, but it was not necessary to be administered. the inh titre decreased again (down to . ub/ml) during the intratreatment stage. thirty-five days after rfviia, the inh titre was . ub/ml. (table a ,b) the presence of high titre inh against fviii is a critical problem in cases of bleeding or surgery need due to the inefficacy of the available therapeutic options and the severity of the events. in this case, we have observed that, apart from inducing hemostasia through the activation of the coagulation extrinsic path, rfviia could reduce the inh titre in sequential dosages. we have introduced the case of a -year-old patient with hemophilia complicated by a high titre inh against fviii. in this case, we have observed that, apart from inducing an effective hemostasia through the activation of the coagulation extrinsic path, rfviia could reduce the inh titre in sequential dosages. there was also a decrease in the inh titre concomitantly with an increase of the plasma fviii level during its use. this phenomenon suggests that rfviia could produce a modulation in the immune response. evaluation of an automated blood collection system with standard ratio of anti-coagulation and integrated filter for whole blood leucodepletion l dadiotis, a kolokytha, m dimou, a perdiou, c alepi, p spyropoulou, e igoumenides, c velidou, v panagopoulou and s matsagos tzaneion general hospital, pireas, greece automated blood collection system (abc) is a device manufactured by macopharma which collects by gravity a preset volume of blood and mixes it with anticoagulant (ac) in standard ratio ( : ). this is managed by passing the ac, which is stored in a special bag, anti-erythrocyte antibodies are immunoglobulins that belong to the igg, igm and iga classes. their common characteristic is a specific reaction with antigens that are located on the erythrocyte surface. they can emerge as auto antibodies and alloantibodies. the blood transfusion in patients may induce a post-transfusion hemolytic reaction (pthr). in order to avoid or reduce the danger of the pthr it is necessary to examine whether there are irregular anti-erythrocyte antibodies in the patient's serum as well as in the serum of the voluntary blood donors. all the irregular anti-erythrocyte antibodies are not clinically relevant. the experience shows that the clinically significant antibodies most often belong to abo, rh, kell, kidd, duffy and ssu blood groups. in the period from april, to november, , we monitored and examined, at the institute for blood transfusion, clinically significant antibodies in the serum of the patients who are treated with blood transfusions as well as in the serum of the voluntary blood donors. we used the following tests for detecting irregular anti-erythrocyte antibodies: enzyme test, indirect coombs test, screening test by the commercial test erythrocytes and gel filtration method. the detected irregular antierythrocyte antibodies are identified by means of the commercial test erythrocytes for identification. our results are the following: voluntary blood donors: anti d, anti c + d and anti-leb antibodies. patients: anti-d, anti-k, anti-fya, anti-c and anti-e antibodies. in nine patients, anti-erythrocyte antibodies were discovered, namely, those that react at the temperature higher than °b ut whose specificity we could not discover with the existing techniques. improved predictive factors of response for myelodysplastic syndrome patients treated by the combination of erythropoietin and g-csf s park*, c kelaidi † , s grabar ‡ , v bardet ‡ , d vassilieff ‡ , f picard ‡ , m guesnu ‡ , mc quarre ‡ , p fenaux § and f dreyfus ‡ *service hématologie, hopital cochin, † hématologie, hopital avicenne, ‡ service hématologie, hopital cochin, § hématologie, hopital avicenne, paris, france it has previously been shown that serum epo level and number of previous red blood cell transfusions are predictive factors of response to epo + g-csf treatment of myelodysplastic syndromes (mds). in a subgroup of patients with mds having sepo < ui/l, known to be good responders to epo + g-cscf, the gfm group wanted to refine the model predicting the response to epo + g-csf, especially with cytology (who classification with dysplasia and percentage of erythroblasts and blasts). in a population of patients (ra, rars and raeb < % blasts) receiving epo ± gcsf between and and having serum epo < ui/l, the response rate at week (iwg criteria) was %. six variables were associated with response to epo ± g-csf for mds: age > years (p = . ), number of prior red blood cell transfusions < packs/months (p = . ), serum epo level < ui/l (p = . ), percentage of blasts < % (p = . ), percentage of erythroblasts > % (p = . ) and low ipss score (p = . ). we did not found any influence of dysplasia, type of rhepo (darbopoietin alfa or epoietin alfa) and karyotype on response rate. in multivariate analysis, age through a rotating pump. the abc can be used with all types of p- pan-european blood safety alliance the pan-european blood safety alliance is a unique alliance of patient organizations, formed to promote the highest level of blood safety for all in europe. it was formerly established on february , during the course of the first general meeting of the pbsa, which comprised of founding patient organizations. the objectives of the pbsa are: . to promote the fundamental right and duty to safety of all patients in need of blood transfusions and blood products. . to ensure the availability of sufficient amounts of safe blood, to meet all treatment need through: -the education of all staff handling blood components, to reduce human error. -the implementation of and access to, proactive blood safety technologies, for each patient across europe. -haemovigilance -the adequate access to blood transfusion services, which should be provided free of charge to the patient. other objectives are to raise awareness on a local and european level regarding blood safety, to promote eu legislation that improves safety standards of blood transfusion services, including stem cell preparation and storage across europe and to lobby for increased patient influence on eu health policy makers. very importantly, the alliance aims at providing a forum for patients, healthcare professionals, health policy makers and relevant industry, as well as acting as a point of reference to the national health authorities, the european commission and other european institutions, when seeking the opinions of patients on blood safety. cerns of insertional mutagenesis and the safety of some viral vectors that randomly insert genes through the genome have been recently resurfaced following the development of a haematological malignancy in a child treated with a retroviral vector. particularly questions also remain as to, whether gene therapy and the production of ectopic factor viii and ix will be a risk for inhibitor development or indeed whether it might promote tolerance in those patients with inhibitors. w-pl - gene therapy for thalassemia: will it become reality? university of washington, seattle, wa, usa experiments aimed to develop gene therapy approaches for the beta chain hemoglobinopathies, sickle cell disease and beta thalassemia started about years ago. in the beginning results were dismal because of the extremely low and variable expression of globin genes contained in the therapeutic vectors. a major development occurred in with the discovery of powerful regulatory elements that could guarantee high level of globin gene expression. these elements when incorporated into viral vectors allow expression of therapeutic levels of the transferred globin genes. a second major progress was achieved with the development of safe lentiviral vectors that can efficiently infect the human pluripotent repopulating hemopoietic stem cells. as a result of this progress, today beta thalassemia and sickle cell disease can be cured in murine models of these disorders. considerable effort is already being devoted into further improvement of lenti viral vectors with emphasis on incorporating elements which will decrease the probability of insertional mutagenesis and leukemogenesis. the major challenge for the clinical application of stem cell gene therapy of thalassemia is the need for genetic correction of large numbers of mutant stem cells. in vivo selection of corrected stem cells is being investigated but there are questions about its safety because of the possibilities of clonal expansion of stem cell lines carrying undesirable integrants. other major challenges have to do with logistics: production of therapeutic vectors, infrastructure required for stem cell gene therapy delivery, and sponsoring and funding of the clinical trials. gene therapy trials on limited number of patients are expected to be initiated relatively soon. if these trials are successful and cures of beta thalassemia ensue, the major challenge will be the delivery of this molecular therapy in the context of medical practice. w-pl - gene therapy for haemophilia haemophilia is an ideal target for gene therapy because only a small rise in factor levels to - u/dl would achieve the goals of prophylaxis without regular infusions of concentrate and deliver a substantial improvement in lifestyle for patients with severe haemophilia. gene therapy for haemophilia today relies upon addition of normal factor viii or ix genes. with present technology gene therapy can offer the prospect of a true 'cure' for haemophilia in animal models, although this may not be currently realizable in man. more than patients with haemophilia have now been treated in phase gene therapy protocols. all studies have failed to conclusively show that therapeutic levels of factor viii and ix can be reliably obtained. the first trial reported used im injection of a factor ix containing recombinant adeno associated virus (raav) in adult patients with severe haemophilia b. only very modest increases in factor ix level, < u/dl rise, in / patients enrolled were observed, although less factor ix concentrate was needed in / subjects. a similar study using the same raav vector via intrahepatic artery infusion has been conducted. this has been complicated by the observation of aav vector in the semen of subjects. in six patients enrolled, no durable levels of ix above u/dl were seen. further development of this raav vector is suspended. for haemophilia a, three systems are have been tried. the first study was an ex vivo addition of factor viii gene to autologous fibroblasts and then laparoscopic reimplantation. preclinical assessments demonstrated durable expression of factor viii (> % of normal) for > year in mice following a single treatment. in / patients treated repeated factor viii rises ( . - . u/dl) were seen, but no improvements lasted beyond months. the second protocol used a murine leukemia retrovirus containing factor viii, injected intravenouslya development of preclinical data in rabbits and haemophilic dogs. / patients enrolled sustained levels of factor viii > u/dl. the third study, using a modified, 'gutless', adenovirus containing factor viii gene has recruited one patient. this patient demonstrated transient liver toxicity and thrombocytopenia at doses lower than those that cause toxicity in primates. sustained levels of factor viii of ~ u/dl have been observed over a number of months. accrual to the study has been poor. haemophilia remains a prime target for gene therapy. however, haemophilia is no longer a life threatening disease with current therapy that is both safe and efficacious. a balance between the benefits and theoretical risks must be borne in mind when considering gene-based approaches to therapy. con- reference: petz ld, garratty g. immune hemolytic anemias. nd ed. philadelphia: churchill livingstone, , pp - . w-pa- autoimmune neutropenia introduction: autoimmune neutropenia (ain), a granulocytic disorder due to the presence of anti-neutrophil antibodies, may present as neutropenia of varying degree with or without recurrent infections un previously healthy individuals (primary or idiopathic ain) or in patients with a known underlying disease such as lupus erythematosus, lymphoid malignancies, etc (secondary ain). the condition affects more frequently infants of small ages while it is rare in adults [ ] [ ] [ ] [ ] [ ] [ ] [ ] . in some patients, diagnosis is established in occasion of a respiratory, urinary or cutaneous infection, but in many cases is simply a finding of cell blood counting performed for unrelated reasons [ ] . clinical and laboratory findings: in general, physical examination is negative. laboratory investigation reveals the existence of isolated neutropenia. association of the disorder with autoimmune hemolytic anemia or autoimmune thrombocytopenia is rarely seen [ ] . blood biochemistry is normal while serologic tests for bacterial, viral or other pathogens may be positive depending on the underlying infection. bone marrow is hypercellular without maturation arrest of granulocytic series. hemopoietic stem cell reserves and function are normal or increased, and stromal cell function is within the range of the normality [ ]. methods for the detection of granulocyte-specific antibodies: serology for the detection of granulocyte-specific antibodies has been marred, compared to erythrocyte serology, because the target cell here, the granulocyte, is short-lived, fragile and becomes easily activated. the former two of these difficulties require absolutely freshly (< h old) isolated neutrophils from a panel of donors to be used every day to run the tests with sera from patients, while the third difficulty is more important since spontaneous cell clumping in vitro is very common and nay mimic the specific aggregation caused by cross-linkage of surface bound antibodies in the granulocyte agglutination test (gat). in order to overcome these problems, the second international granulocyte serology workshop [ ] recommended a combination of two tests as the best screening procedure for the detection of granulocyte autoantibodies in patient sera, gat and granulocyte immunofluorescence test (gift). gat is mainly mediated by igm antibodies and is positive in about % of cases. gift detects igg antibodies and is positive in about % of cases. it is to be noted that flow-cytometry fluorescence may arise not only from the surface but also from the cytoplasm of neutrophils, necessitating assessment of membrane fuorescence by microscopy. a good direct anti-granulocyte test is not available today. this is due to the fact that too few neutrophils can be obtained from the blood of neutropenic patients, and also to the observation that neutrophils are often activated in vivo because if an underlying infection or other inflammatory process, thus expressing fcgrii and fcgriiib to which nonspecific binding of w-pa- practical approach to transfusion in autoimmune hemolytic anemia (aiha) g garratty american red cross blood services, pomona, ca, usa a major problem when transfusing patients with aiha is that often all units are incompatible. this may be due to autoantibodies (autoab) and/or alloantibodies (allo-ab). if the incompatibility is due to only auto-ab, then transfusion of incompatible blood will not usually result in a clinically significant reaction, but if due to alloab, the result may be similar to that seen in any other patient (i.e. a hemolytic transfusion reaction ranging from mild to severe). thus, it is essential (as in any other patient) to exclude the presence of allo-ab. it is wise to phenotype all patients, for as many antigens as possible, before the patient receives transfusion. there are two popular approaches to determine if allo-abs are present but being masked by 'warm' auto-ab activity. the preferred method is to remove the auto-ab by adsorbing the patient's serum with autologous rbcs treated with enzymes, or preferably, with zzap reagent. the latter reagent contains an enzyme leading to optimal adsorption of auto-ab, and dtt. these two chemicals will destroy significant antigens other than rh and kidd (e.g. mns, duffy, kell, lutheran, dombrock, cromer, lw, some yta and ge, inb, jmh, ch, rg, pr antigens), thus will not adsorb alloantibodies to these antigens. if autoadsorption is not possible (e.g. patient has been transfused recently or there are too few rbcs), one has to perform adsorption with enzymes or zzap-treated allogeneic rbcs. one does not have to be concerned with covering any antigens destroyed by zzap (e.g. kell and duffy systems). we use a rough guide relating the strength of the indirect antiglobulin test to the number of adsorptions needed to remove auto-ab ( + = adsorption; + = adsorptions; + = adsorptions; + = or more adsorptions). if there is no activity left after the adsorptions, then one can suspect that the incompatibility was due to auto-ab, but on rare occasions one can be wrong and an allo-ab to a high-frequency antigen has been removed. this is a major disadvantage of using allogeneic adsorptions, and is why adsorptions with autologous rbcs are preferred. if time ( - h) does not allow for adsorptions, one can dilute the patient's serum (e.g. in , or in ) and test the dilution against a panel to see if any alloantibody specificity becomes obvious. another approach is to select units matching the patient's phenotype as closely as possible. when dealing with cold agglutinin syndrome one can usually exclude allo-ab activity by testing strictly at c. this can be helped by performing adsorptions with enzyme-treated autologous rbcs at c, but it is difficult to adsorb all of the powerful cold autoagglutinin activity. it is reported that - % of aiha have allo-abs; the incidence is even higher in patients who have received multiple transfusions. thus, we feel that procedures such as those discussed above must be performed before transfusing incompatible blood if time allows. one should always negotiate with the attending physician regarding the time it will take to perform adsorptions. a decision may be made not to perform adsorptions if the patient has life-threatening hemolysis, and especially if the patient has never been transfused, or pregnant. serum igg may occur (naig). the presence of immune-comlexes in the serum, such as in patients with felty's syndrome, lupus erythematosus and other diseases, as well as the presence of immune aggregates formed in sera stored frozen for long time, may give false-positive tests given that they may bind to fcgriiib molecules expressed on the surface of neutrophils. elimination of immunecomplexes and immune aggregates can be easily obtained by ultracentrifugation [ ] . another cause of false-positive results may be the presence of anti-hla antibodies because of allo-immunization. these allo-antibodies react with hla molecules found not only on neutrophils but also on the surface of many other cells including lymphocytes. these allo-antibodies can be eliminated by platelet absorption. it seems that the best method in the search of true antigranulocyte antibodies is the monoclonal antibody-specific immobilization of granulocyte antigens (maiga) [ ] . with this method one can specify anti-granulocyte antibodies using a panel of known granulocyte antigenic specificity. finally, it is notable that the levels of serum antibodies to neutrophils may vary considerably over the time. one negative test does not exclude ain. usually, two to three tests have to be run over a period of months [ ] . antigenic specificity: human neutrophil antigens (hna) are classified according to an international granulocyte antigen working party [ ] . three glycoproteins have been found to be involved in the determination of antigenic specificity, fcgriiib, gpnb (cd ) and gp - . the respective antigens, frequencies and alleles are illustrated in table . antigenic specificity can also be studied by using methods applied in molecular biology. a promising approach is transfection of mammalian cells by cdna derived from granulocyte antigen specific mrna. cell lines have been established with cells expressing the respective human granulocyte antigen, making the detection of anti-granulocyte antibodies more easier. genotyping of hna antigens can also be stydied with the pcr technique [ ] . references are available from the author upon request. w-pa- a rare case of 'coombs negative' autoimmune haemolytic anaemia due to red cell autoantibodies of iga class warm autoimmune haemolytic anaemia (waiha) is usually associated with red cell auto-antibodies of the igg class, which can be detected by polyspecific direct antiglobulin test (dat). routine polyspecific direct antiglobulin tests contain anti-igg and anti-c d components, and are not standardized to react with iga-or igmsensitized red blood cells. haemolytic anaemia caused by warmreacting auto-antibodies solely of the iga class is exceedingly rare. those cases of autoimmune haemolytic anaemia can be difficult to diagnose because of the negative polyspecific coombs' test, which is a standard in investigation of possible causes of haemolysis. we present a case of severe warm autoimmune haemolytic anaemia caused by iga class autoantibodies. a -yr old male patient was admitted with anaemia, haemoglobinuria, and other signs of severe haemolytic disease. he received multiple transfusions but haemoglobin level did not rise above g/dl. the initial polyspecific direct antiglobulin test, containing an anti-igg and anti-c d antiserum, was negative. tests for cold agglutinins and other possible causes of haemolysis were negative. only by using a monospecific, anti-iga antiserum could we show that the warm iga auto-antibodies against red blood cells were present on patient's erythrocytes. we have not detected signs of complement activation by iga autoantibodies in this patient. the patient received corticosteroids with good initial effect. his haemoglobin level stabilized and he did not require more transfusions. anti-iga direct antiglobulin test became negative about to weeks after the therapy was initiated. however, in spite for the initial effect of steroid therapy haemolysis continued, and splenectomy was performed months after diagnosis was made. it has been shown that human lymphocytes, granulocytes and monocytes contain specific fc receptors for iga, and both monocyte-mediated phagocytosis and antibody-dependent cellular cytotoxicity due to iga auto-antibodies has been demonstrated. there is also increasing evidence that iga auto-antibodies can activate complement, both via the classical and the alternative pathway. a phenomenon of 'reactive haemolysis', which involves c -independent binding of c b complexes to 'bystander' red blood cells, has also been described. we emphasize the importance of performing additional testing in cases of apparent 'coombs' negative' haemolytic anaemia due to iga, igm or 'low affinity' igg autoantibodies, and serological aids that are available for that purpose. described. both siblings were born on term, in good general clinical status, free from any signs of infection, and with isolated severe neutropenia ( and neutrophils/ml). the diagnosis of annanti hna- a was made upon exclusion of other possible causes of neonatal neutropenia, and confirmed by serological testing of granulocyte antigens and antigranulocyte antibodies. in both cases, the course of the disease was mild, with bacterial omphalitis on day and , respectively. omphalitis was successfully treated with -day antibiotic therapy according to antibiotic sensitivity report. the first neonate received standard dosage of intravenous gammaglobulins for days without success. this was followed by an attempt at neutrophil count increase with -week corticosteroid therapy, also without response. the second neonate received no specific therapy for neutrophil count increase. the children were discharged for home care with clinical and laboratory control examinations at -week intervals. in spite of prolonged neutropenia ( and months, respectively), no other infections were recorded. discussion and conclusion: in our patients, the therapeutic approach to ann was individualized, based on standard antibiotic therapy, intravenous gammaglobulins, corticosteroids, available literature data, and our own clinical experience. although in the last few years rh-gcsf is successfully used in patients with neutropenia, we decided to postpone its use in case the neonatal sepsis developed. the reasons for such decision were: ( ) the fact that both neonates were in good general clinical status, with a mild course of the disease with only short-term umbilical infection successfully managed with antibiotic therapy; ( ) literature reports suggesting the unexpected failure to respond to rh-gcsf therapy in patients with neutropenia induced by anti hna- a immunization, and ( ) the unknown effect of rh-gcsf on developing tissues of the neonate. the choice and efficacy of specific therapy for neutrophil count increase in the management of alloimmune neonatal neutropenia have not yet been fully defined and require additional evaluation in the majority of cases. male donors for the production of fresh frozen plasma: a special issue for trali patients trali is a significant cause of transfusion associated morbidity and mortality, and has been reported as the third most common cause of fatal transfusion reactions. there is no good evidence on which to base transfusion support policy for patients who have experienced trali. the hypothesis that there may be patient associated factors that contribute to the risk of trali is generally accepted. for this reason it seems reasonable to try to avoid further transfusion during the period of illness. if this is unavoidable the next best solution to reduce the risk of recurrence seems to be the avoidance of using plasma containing blood components (especially ffp) as there is a high chance of positivity for leucocyte antibodies especially for those coming from female donors. as fresh frozen plasma transfusion accounts for up to half of all trali cases and as our center is the only in greece responsible for the testing and processing of blood from blood donors representing military recruits, the last two years we tried to set up a project in order to provide components from male donors on request. our donor base consists predominantly from males donors ( . %), aged between and years old, with a small chance of having a positive history for transfusion the difficulty of the project consisted on the fact that these donors are assigned to military camps throughout greece, which makes difficult the on time arrival of the units to our establishment in order to be processed for the production of ffp conform the european council quality requirements. this was the main reason why, till now, all plasma produced from these donations was regarded as plasma for fractionation. the first step for implementing the new project was to evaluate the number of donations that, by minor changes on the time of arrival, could be processed for ffp production. the next step was to re-schedule the shifts of the personnel for the on time production of ffp. during , % of donations were fulfilling the specifications for the production of ffp and with the flexibility of the schedule the % of them were successfully processed to ffp. during , % of the donations were fulfilling the specifications and . % of them were processed to ffp. so it is feasible to increase the proportion of male ffp by organizing better the transportation of blood from the donation sites to the blood establishment and by retaining available specialized personnel to cover the extra shifts. maximising the blood supply chain in times of shortage shortages in the blood supply chain may occur for a variety of reasons. they may be temporary e.g. due to a flu epidemic or prolonged e.g. due to the exclusion of a high proportion of donors due to new pre-donation tests or because of a lack of volunteer donors. increasing awareness of the possibility of blood shortages mainly related to increased precautions associated with the possible transmission of vcjd by transfusion has been the driver for the development of blood shortage contingency plans in the uk. in england and north wales, hospitals and the national blood service (nbs) have worked together to develop an integrated blood shortage plan (ibsp) designed to ensure that hospitals and the nbs work together within a consistent, integrated framework giving patients equal access to available blood on the basis of need. an essential element of the plan is the principle that shortages can, in most cases be avoided by reducing the current usage of blood through appropriate use programmes. the impetus for hospitals to implement these programmes was a government circular (hsc / ). hospitals have embraced the circular and have recruited specialist hospital transfusion practitioners, introduced lower hb triggers, cell salvage and hospital transfusion teams and are participating in the blood stocks management scheme (bsms). audits of compliance with the circular have taken place, and a web based tool kit is available. the demand for blood has declined for the last three years, with a decrease of about % during - , suggesting that the drive for improvement has been successful. the shortage plan introduced in england and north wales has two key aims: that the national pool of blood is available for all essential transfusions for all patients and that overall usage is reduced to ensure the most urgent cases receive blood. the plan is structured to provide actions for the nbs and hospitals in three phases, 'normal' circumstances, reduced availability and severe prolonged shortage. hospitals should have documented emergency blood management arrangements for each of the phases. the national plan is activated when the nbs red cell stock level falls to pre-defined levels, hospitals are informed by fax that they should reduce their normal stock holding levels according to guidance in the ibsp and comply with the daily hospital usage budget. the bsms has used its knowledge of hospital inventory levels and demand to provide guidance on appropriate inventory levels for normal and reduced status, it also provides the daily hospital budget. to monitor progress against the recommendations in hsc / hospitals will be benchmarked against a number of performance indicators. these include the presence of emergency blood management arrangements, median red cell usage for a number of surgical procedures and percentage wastage of blood. there have been no shortages within the nbs for more than six years, it is hoped that the implementation of the ibsp will help to ensure that in the unlikely event of reduced availability blood will be available to the maximum number of patients requiring a blood transfusion. w-pa- transfusion during disaster g klein nih, bethesda, md, usa publicity given to blood donation during wartime has created a powerful association between the need for blood and occurrence of a disaster. blood is rarely needed in excessive quantities at the moment a disaster occurs. the outpouring of blood donors, especially at the site of a disaster, often proves counterproductive. the terrorist attacks on the world trade center on september , , with almost deaths and more than injuries, provides an instructive model. more than a million potential donors contacted blood-collection centers. hundreds of thousands of prospective blood donors crowded collection facilities and many waited for hours, often to be turned away. qualified staff were in short supply and screening errors occurred as minimally qualified staff were recruited and as collection personnel fatigued. supplies and storage capabilities were pushed to their limit. some blood was inadequately processed and stored. resources were diverted from needed apheresis collections and component preparation to whole blood collection. in the aftermath of the disaster, blood outdated and volunteer donors became disillusioned as their 'gift of life' was refused or unused. similar responses have occurred numerous times over the -year period since blood-donor programs were introduced. in virtually every civilian disaster in the u.s. during the past century, all the blood that was needed was immediately available from blood inventory. in only four cases were more than units of blood used in the first to h. in in new york, the five hospitals closest to the disaster site admitted only disaster victims. the new york blood center, which supplies percent of blood for the city's hospitals, added units to routine inventory at hospitals. the center received telephone calls and collected more than units of blood in the first h. in the area of the pentagon, the chesapeake and potomac red cross blood center supplemented hospital blood inventories within h of the disaster. meanwhile, spurred by well-meaning media and federal officials, lines of blood donors were being processed at local hospitals, makeshift collection centers, the small research hospital at nih, and at a building next to the white house. in the week after september , america's blood centers collected more units of blood, and the american national red cross collected more units than in the same period the previous year. more than units were collected for the disaster victims, but only units were used. u.s. blood collectors and federal agencies have created a disaster plan that acknowledges the need for altruistic people to volunteer for blood donation in the time of disaster and speaks with a single voice to avoid needless collection activity while harnessing the good will of well-intentioned people to supplement the ongoing need for volunteer blood donation. rehabilitation of blood transfusion service in azerbaijan cd asadov, ga huseynov and ab hagiyev institute of hematology and transfusiolo, baku, azerbaijan at the end of th years of the last century in azerbaijan as well as in other republics of the former ussr began process of progressive deterioration of blood service parameters. in result there was an essential reduction of prepared blood and blood components quantity, manufacture of preparations from blood's plasma has completely stopped. it is connected by that our republic experiences a heavy transition period from scheduled to market economy. after reception by azerbaijan of the sovereignty on development of a national policy the big work has been lead to areas blood transfusion and development of national rules and the standards regulating functioning of establishments of blood service. in the law about ' the donorship of blood and its components in the azerbaijan republic' has been accepted, instructions on physical examination of donors and preparations of blood and its components are authorized, and also the new speciality transfusiology has been entered into the nomenclature of medical specialities. now the national program of blood service development is developed. at drawing up of the program social and economic conditions of the country, ethnic both cultural traditions and a mental potential of the nation are considered. within the framework of this program is planned to refuse gradually a paid blood donation during the certain period of time to reach %s' voluntary unpaid blood donorship. however in connection with limitation of resources, the state is not capable to allocate enough of means for its realization. the big work on attraction of the international organizations has been carried out. now the project of the united nations development program (undp) 'rehabilitation of blood transfusion service in azerbaijan' is carried out at sponsor's support of the norwegian government. realization of this project will lead to reorganization of blood transfusion service in our country according to practice of the european countries. within the framework of project realization it is planned to make changes and additions to a existing law about a blood and its components donorship to bring it into accord with recommendations of the europe council. updating of the russian law 'concerning the donation of blood and blood components' on june , , a law, 'concerning the donation of blood and blood components, ' was signed by the first russian president, boris eltsin. now, after more than ten years of market economy and democratic evolution in russia, this law was significantly changed on august , , as shown in the following sections: . the development of a voluntary blood donor system. . removal of the upper age limit for blood donors. . funding for blood donations. from january , , each level of the state power budgets for a blood donor service to supply blood products for federal, regional, or municipal hospitals. costs of these drugs and the need of prolonged growth factor treatment in these disorders. w-pa- can iron administration reduce peripartum blood transfusion c breymann university of zurich, zurich, switzerland the prevalence of iron-deficiency anemia in different regions of the world ranges from to %. the increased iron requirement in pregnancy and the puerperium carry with it an increased susceptibility to iron deficiency and iron-deficiency anemia and perioperative or peripartal blood transfusion. however, if ever possible administration of blood transfusion should be avoided for several reasons which will be pointed out in the talk. infections: it is well known that various pathogens such as bacteria and virus can be transmitted by administration of blood. around . % of are contaminated by bacteria such as yersinia or pseudomonas species but are not screened routinely for bacteria. in addition there is no donor screening for hepatitis a, herpes species (cmv, ebv, hhv , hhv ), parvovirus b , hepatitis g ( . %) and tt (transfusion transmitted) virus ( . %). numbers for positive testings for 'classic' virus such as hiv, hep. b and hep. c vary from country to country and lie around : to : depending on quality of donor screening programs, pcr sensitivity etc. recently there is increasing evidence that even prions which cause the jakob creutzfeld disease variation ('mad cow disease') might be transmitted by transfusions. therefore the fda has determined that blood donors from countries with high prevalence of prion positive persons are not permitted to give blood in the us (e.g. donors from uk). beside infections, other well known effects of transfusion are problems due to incorrect blood or components transfused, post transfusion purpura, acute and delayed lung injury, graft versus host disease and other acute and delayed allergic reactions. beside these negative effects it was also shown that patients who receive blood transfusion liberally after operations or in icu show higher morbidity and mortality compared to patients with restrictive transfusion policy. this might be due to negative effects on immune functions and inflammatory reactions and lack of stored blood to efficiently improve organ oxygenation. for example it is known that stored blood has worse capillary perfusion and worse viscosity properties compared to fresh blood. taken together there is increasing scientific evidence that blood transfusion is not the gold standard for anaemia management and alternatives such as endogenous blood pooling and efficient treatment of any anaemia must be enforced in the clinical settings. prevention and correction presuppose reliable laboratory parameters and a thorough understanding of the mechanisms of iron therapy. in order to correctly diagnose the type and degree of anaemia, a prerequisite for selection of the proper therapy, one must first of all correctly differentiate between the relative, i.e. the physiological anaemia of pregnancy due to the normal plasma volume increase during pregnancy, and 'real anaemias' with various different pathophysiological causes. when defining the hb cutoff value for anaemia in pregnancy, the extent of the plasma volume changes with respect to the gestational age must be taken into consideration. it has been found that haemoglobin values < . g/dl in the first and third trimesters, and < . g/dl in the second trimester may point to an anaemic situation which should be further clarified. the first important steps for diagnosing anaemia in a pregnant patient include a thorough check of her medical w-pa- impact of epo treatment on transfusion requirements in myelodysplasia c gardin and p fenaux hopital avicenne, aphp, university of paris , bobigny, france myelodysplastic syndromes (mds) are clonal disorders of hematopoeisis, associated with bone marrow failure and an increased risk of evolution to acute myeloid leukemia (aml). despite an normal or increased bone marrow cellularity in most cases, cytopenias worsen with time due to increased apoptosis and defective differentiation of blood lineage precursors. incidence of mds increases with age and reach / above years of age. bone marrow cytogenetics number of cytopenia and percentage of bone marrow blasts are strong predictors of survival and evolution to aml. a composite international prognosis scoring system (ipss) is used in everyday practice to guide the management of these diseases. these disorders are heterogeneous and include 'low risk' patients (less than % bone marrow blasts) with a prolonged evolution marked by chronic anemia, and 'high-risk' patients (excess of bone marrow blasts > %) evolving in a short timespan with severe cytopenias, and to aml in approximately % of cases. at diagnosis, % of mds patients are anemic, with an hemoglobin level less than g/l, and % of them will require chronic blood components transfusion, during the evolution of their disease. chronic anemia and multiple blood products transfusions are associated with an altered quality of life, clinical iron overload, and important health care costs. although transfusion practices and patient's transfusion need are variable, elderly mds patients require a mean of - units/year of follow-up, in recent surveys. therapies able to diminish or abolish the need for rbc transfusion have therefore a major role in the management of mds, as allogeneic bone marrow transplantation, the only curative therapy of these diseases, is limited to a small subset of mds patients. high-doses of recombinant erythropoetin (epo) ( - u/kg tiw, or a - u as single weekly dose) are typically used in low-risk mds. the response rate to epo is - %, including major responses (suppression of rbc dependency or rise of hemoglobin level of more than g/l). absent or low rbc transfusion needs and a serum epo level less than u/l are strongly predictive of response to epo, in patients with low-risk mds. the duration of response is variable ( - months) in most studies, with some long-term responders. the use of higher doses of epo or its prolonged administration may be associated with higher response rates, although no randomized studies are available combination of epo and low-dose granulocyte-colony stimulating factor (g-csf) increases the response rate to - %, including in patients not responding to several weeks of treatment with epo alone. two randomized trials published in , compared g-csf-epo to rbc transfusions and confirmed the efficacy of this combination, and a longer survival of epo-g-csf responding patients. studies are ongoing in mds, including with darbepoetin, a modified erythropoetin with longer half-life, administered once a week. two such studies have been recently reported, (darbepoetin or ug/week) with response rates varying from % to % in low-risk mds. in both studies, a response to darbepoetin was observed in some patients, who failed to respond to previous treatments with alpha or beta epoetin. further assessment of the optimal dosage, administration schedule of these drugs, and validation of their likely impact on qol are required, in order to epo and its derivatives to gain acceptance in mds, due the high history and a medical examination. this procedure often lays the basis for a correct diagnosis. the current gold standard to detect iron deficiency remains the serum ferritin value. to be reliable, this requires the ruling out of an infection (chronic or acute) as a cause of the anaemia. we recommend a complete laboratory test for the exact haematological status as well as the assessment of specific chemical laboratory parameters. these should the hb level alone is insufficient to guide management. a complete work-up (ferritin, transferrin saturation) is essential, preferably with haematological indices such as hypochromic and microcytic red cells and reticulocytes, classified by degree of maturity, in particular, before parenteral therapy is given. since ferritin acts as both an iron-storage and acute-phase protein, it cannot be used to evaluate iron status in the presence of inflammation. a high ferritin level thus requires the presence of an inflammatory process to be eliminated before it can be taken at face value. if the c-reactive protein level is also raised, the soluble tfr concentration can be used, since it is unaffected by inflammation. inadequate understanding of the complex chemistry of parenteral iron administration was previously responsible for serious side effects, such as toxic and allergic reactions, and even anaphylactic shock, in particular with dextran preparations. however, the current type ii iron complexes that release iron to the endogenous iron-binding proteins with a half-life of about h are not only effective but carry a minimal risk of allergic accident and overload, especially after a comprehensive pretreatment work-up. after correct diagnosis, major emphasis should be put on safe and effective treatment of anemia which again depends on severity of anemia, time for restoration and patients characteristics. today effective alternatives to oral iron only or blood transfusion such as parenteral iron sucrose complex and in selected cases also recombinant erythropoietin have been investigated and show promising results concerning effective treatment of anemia during pregnancy and postpartum. our departmental data collected over years and backed by postmarketing experience in countries indicate that iron sucrose complex therapy is a valid first-line option for the safe and rapid reversal of iron-deficiency anemia. w-pa- iron therapy in orthopaedic surgery surgery of the vertebral column, hip or knee is considered a bloody procedure (blood loss > l) and as a consequence represents the main indication for red blood cell transfusion in orthopaedics. because of the non-negligible residual risk of transmission of infectious agents by transfusion, but mainly because of immunologic complications induced by the administration of foreign proteins and cells, an alternative solution has been actively sought. studies have clearly shown that in patients undergoing such surgery, transfusion risk correlates inversely with pre-operative hemoglobin level. correction of even slight preoperative anemia is thus mandatory. in the elderly, iron and vitamin deficiency (b and/or folic acid) should be looked for as a matter of routine. we recommend the use of iron + epo whenever a rapid correction (< weeks) of the anemia is desirable in cases with transferrin saturation < % and ferritin levels < mg/l. with this regime it is possible to collect up to autologous blood units in cases of increased perioperative blood loss (e.g. double hip replacement). in the post-operative period, anemia worsens because of the existing inflammatory state. this inhibits iron absorption from the intestine and iron release from the macrophages while it affects epo function and production. there is increasing evidence that i.v. iron combined with epo induces a rapid correction of post-operative anemia. it is thus recommended to stimulate erythropoiesis by i.v. iron and epo starting on the first post-operative day and to avoid transfusions in asymptomatic patients even in cases with hb as low as g/l. background: hereditary hemochromatosis is one of the most common inherited disorders in which an excessive amount of iron is absorbed from the diet and then deposited in organs. the effective treatment is the regular whole blood removal which causes erythropoesis activation and leads to decrease of iron stores. red cell apheresis is an optional method for removing of higher amount of erytrocytes in one session. we performed red cell apheresis in patients with diagnosis of hereditary hemochromatosis ( ¥ c y homozygotes, ¥ c y + h d heterozygote) using haemonetics mcs p cell separator (protocol tae) in which red cells are removed from patients in - cycles; plasma and buffy-coat are reinfused. collection time, donor convenience, side effects and red cell yield were recorded and analysed. samples for hematology and iron studies in patients were drawn, analyzed and compared to baseline levels. background: the collection of units of red blood cells by apheresis (drbc) has been reported to be safe and effective in increasing the yield of rbc units from a donor population. however several reports demonstrated the risk of inducing iron depletion when the interval between a drbc donation and a subsequent rbc donation is shorter than days. aims: to evaluate the recovery from anaemisation and iron stores depletion after drbc donation. methods: donors who underwent drbc donation between december , and february , have been enrolled in a follow up program to monitor haemoglobin (hb), htc, serum iron and ferritin values. these parameters have been assessed on the day of donation and, thereafter and days after drbc procedure. donors suitable to drbc apheresis had to have: age between and years, weight > kg, hb > . g/dl and serum ferritin between and ng/ml. a written informed consent about the collection procedure and the follow-up program has been obtained from all the enrolled donors. drbc collection procedures have been performed by using a mcs + (haemonetics) cell separators. results: out of donors who donated drbc during the study period, only males completed the follow up program and have been analysed. baseline haematological values and iron metabolism parameters were: mean hb . ± . g/dl, ferritin ± ng/ml, serum iron ± microg/dl. on day mean hb was . ± . g/dl (p < . ). on day mean hb was . ± . g/dl (p < . ), ferritin ± ng/ml (p < . ), serum iron ± (p ns). only out of donors ( %) had a ferritin value > ng/ml. in the studied donors the collection of units of rbcs induced an expected reduction of about grams of hb, however only % of this reduction was recovered after days (p < . ). similarly, also iron stores have not been restored after months from donation, as shown by a % reduction in mean serum ferritin value. according to these data it appear that the amount of iron 'lost' with the donation of units of rbcs (approximately - mg of elemental iron) could not be completely compensated by iron absorption from the diet intake. further data are necessary to define the risk of iron depletion after the donation of a drbc, however, at least in areas where iron intake by diet is not very high, the opportunity to prolong the interval between a drbc and a subsequent rbcs donation beyond six months or to provide adequate iron supplementation therapy should be carefully considered. background: increased transferrin saturation and/or serum ferritin have been observed in italy in approximatively % of subjects at first blood donation and, in these subjects, hfe mutations prevalence was . for c y and . for h d (velati et al., ) . aims: the role of the c y mutation is well known in the patho-genesis of iron overload, whereas the role of the h d mutation remains uncertain. the aims of the present study were first to study the main hfe mutations prevalence in a random group of repeat blood donors and second to evaluate iron parameters and iron depletion in repeat blood donors heterozygous for the h d mutation in comparison to a population of blood donors wt/wt for the h d mutation. methods: a total of repeat blood donors were examined in italian transfusion centers ( in northern italy and in southern) for c y and h d mutations. out of those, blood donors heterozygous for the h d mutation and wt/wt for the same hfe mutation, both groups wt/wt for the c y, were enrolled to evaluate iron parameters and iron depletion. these two groups were similar for number of blood donations (expressed as iron loss) and for sex distribution. serum ferritin (sf) was the iron index recorded at first and second observation. results: table summarizes the allelic frequencies in the blood donors. table reports the haematological evaluation in the subjects heterozigous for h d mutation and the wt/wt for the same mutation. conclusions: these data suggest that subjects with h d mutation of the hfe gene have, at first observation, a higher ferritin levels than subjects wt/wt. this seems to be more evident in blood donors of southern italy than in northern. blood donation induces significant reduction of the iron stores both in h d heterozygous and in wt/wt subjects. although our observation is preliminary and restricted to a limited number of subjects, it seems worthwhile to extend the follow-up of blood donors h d heteroxygotes or even homozygotes when available, in order to get further insights on the h d role in iron metabolism. background: cd is a sialylated glycoprotein expressed on the surface of most hematopoietic cells and has been implicated in cell adhesion and signaling. consequently the levels of soluble cd as well as the expression on the cell surface is a marker of cell activation. furthermore, downregulation of this molecule has been correlated with increased susceptibility to infections. the myelodysplastic syndromes (mds) are a group of stem cell disorders characterized by ineffective hematopoiesis, refractory cytopenias and an increased risk of leukemic transformation. the mds patients are often introduced to transfusions for anemia improvement and present increased susceptibility to infections. aims: we studied cd expression in transfusion-dependent and non-transfused mds patient in an effort to investigate mechanisms of regulation of this molecule. we also studied other activationassociated antigens in the absence of manifest infection. material and methods: forty-two patients were included in the study suffering from refractory anaemia (ra). thirty-one were males and females aged to (median ). twenty of them had never been transfused (group a) and were regularly transfused (group b). nineteen age matched healthy individuals were used as controls (group c). cell surface antigens were detected by direct immuno-fluorescence evaluated by flow cytometer. the following mouse monoclonal antibodies were tested: anti-cd b, anti-cd , anti-cd , and anti-cd . leukocytes were gated according to cd . we used a sensitive sandwich enzyme linked immunoassay to measure the level of soluble vascular adhesion molecule as an indicator of endothelial cell activation. the r&d elisa kit was used according to the manufacturer's instructions. results: the cd was found down-regulated in the transfusiondependent mds patients compared with the non-transfused ones (p < . ) and controls (p = . ). this downregulation concerned the proportion of cd + cells, that was lower in the transfused patients than the non-transfused (p < . ) and controls (p = . ), and the rfi (relative fluorescence intensity) value that was also lower in the group a compared to the group b (p < . ) and group c (p = . ). negative correlation was observed between the cd expression and cd b (p = . ) and cd (p = . ). cd b was found up-regulated in the transfused patients. the rfi value was significantly elevated in the transfused patient compared with the non-transfused and controls (p = . and . respectively) while the percentage of cd b cells did not differ significantly between the various groups. increased expression of cd was also found in the group a compared to group b (p < . ) and c (p = . ). the proportion of cd + cells did not differ between the various groups. the levels of immuno-reactive svcam- as determined by elisa were found . + . in group a, . + in group b and . + . in the control group. conclusions: activated hemopoietic and endothelial cells are found in mds that may be associated to the vascular disorders found in these patients. cd downregulation may also be associated to increased susceptibility to infections in these patients. despite improved safety of the blood supply, allogeneic blood transfusion continues to be associated with risks that can be eliminated or reduced by autologous transfusion. preoperative autologous blood donation (pad) prevents transfusion-transmitted viral infection, red cell alloimmunization, and some adverse transfusions reactions. it may decrease the risk of postoperative wound infection because immunosuppression as a result of allogeneic blood transfusion is avoided. pad also supplements the blood supply, provides compatible blood for patients with alloantibodies and rare red cell phenotypes, accelerates erythropoiesis, and provides peace of mind to patients. as any medical intervention, pad has both advantages and disadvantages. with proper patient selection and dedicated attention to process control and quality assurance, the advantages outweigh. background: prestorage pooling of whole blood derived (wbd-pc's) buffy coat platelet concentrates (pc) is common practice in europe event-free survival was significantly better in patients who responded to epo + g-csf. we have reviewed data in centers and the gfm has the intention to extend the study to a larger population in at least centers in france blood components and preparations. the new law prohibits the mixing of different blood products, i.e. blood components and blood fractions. different methods are necessary for the quality control of blood components and blood preparations privileges for blood donors include: -a paid day off work on the day of blood donation and medical examination for blood donation additional paid day off work after blood donation an extra paid day off work if blood is given during vacation or on a holiday this award will be given to non-remunerated donors after blood donations or plasma donations. before , each 'honoured donor of russia' or 'honoured donor of the ussr' had three privileges: free use of public transportation, receipt of certain pharmaceuticals free of charge, and a discount on apartment utilities previously, municipalities also could have their own blood establishments. this resulted in more than blood establishments in the russian federation. from both administrative and financial points of view, many of these are too small to be costeffective, and should be discontinued. services, and wider implementation of modern technology for blood collection, testing, processing, storage, and distribution acknowledgements: we thank ksw microtec ag, dresden/ germany for sponsoring the rfid-labels and novatech research gmbh, vienna/austria for developing the clinic-software. background: the national preparation human immunoglobulin g % for intravenous use (ivig) that is produced at the serbian institute for blood transfusion is used in therapy of neurological, heartand haemolytic diseases and on patients that have undergone surgery. aims: it is our aim to prove the impact of this national medical preparation human immunoglobulin g % for intravenous use on patients that have been infected with sepsis as a consequence of surgery. material and methods: human immunoglobulin g % for intravenous use (ivig) has been used in the study. the preparation is liquid, % stabilised with glucose of a ph value of . ± . . it is used in those cases where sepsis developed after surgery. both an ivig group (n = ) and a control group (n = ) were viewed; the control group not being treated with ivig. the number of specimens with the ivig therapy cholecystitis is (n = ), and the control group (n = ); pancreatitis (n = ) control group (n = ); intestinal obstruction (n = ) control group (n = ); abdominal organ perforation (n = ) control group (n = ); abdominal perforate injuries (n = ) control group (n = ); serious abdominal interventions (n = ) control group (n = ). the period of hospitalisation of the patients in the ivig group was ± days while the period of hospitalisation in the control group was ± days. the mortality rate in the ivig group was % counter . % in the control group. summary: toxic gram -negative bacteria caused synergistic damage of human tissues and generalized inflammatory responsesepsis. by using human immunoglobulin g % for intravenous use, in cases of severe disease, the mortality rate is significantly lowered, depending of course on the anamnesis of the patient prior to surgery and the presence of other diseases such as diabetes mellitus, neoplasma, cardiac diseases etc. background: manual production pc from buffy coats (bc) is a procedure with some consecutive manipulations. the orbisac system (gambro bct) automates the steps and we assessed its performance. material and methods: pc were produced by this device and some parameters were studied. for the preparation of pc, bc were pooled using the orbisac set, with an integrated filter (pall lrp ). bc pool was resuspended in the additive solution t-sol in order to obtain a final ratio plasma/t-sol / . the pc was stored in a gambro elp bag. results: the average platelet count per unit was . ¥ e . the platelet recovery from pooled bc was . % (range . %- . %). all products of the tested pc containing < ¥ e wbc (by flow cytometry). the values of ph on day and of storage were . and . . the swirling phenomenon was good until day °. the average loss of haemoglobin per bc was . g.conclusions:the orbisac system is very suitable for routine pc preparation and it allows increased productivity and better standardization method for pc preparation. platelet concentrates met the requirements for leucodepleted product. increased production of plasma components from male donors background: we routinely separate whole blood (wb) after hard centrifugation into a red cell concentrate (rcc), a buffy coat (bc) and plasma (pl) by an automated expresser (compomat, fresenius). the bcs are subsequently processed into platelet concentrates (pcs) by soft centrifugation and an additional (manual) expression step. the atreus c system (gambro bct) eliminates several of those hand-on steps by combining them into one integrated process. a processing 'circular' bag is placed in the device and filled with the wb. while the bag is centrifuged, the system expresses pl, pc and rcc into separate containers. the rccs are subsequently leukoreduced (manually) with a filter (lr-rccs). this study was designed to evaluate the storage characteristics of the rccs obtained with a prototype of the atreus system in comparison to rccs obtained by routine procedure. methods: whole blood ( ml) was collected in top-and-bottom bags, and randomly selected to be processed by either ( ) current routine or ( ) atreus c. rccs were leukoreduced with the integrated inline filter: fresenius (routine group) or pall rc d (atreus). lr-rccs were stored at °c and sampled until day . various in vitro measurements were performed (n = per group).results: see table (mean ± sd). the lr-rccs contained significantly more leukocytes in the atreus group. despite the rbc loss in the bc, hemoglobin (hb) content was % lower in the atreus group, but met the requirements. in vitro storage characteristics for the rccs were similar in both groups. the atreus pcs contained ± ¥ platelets in ± ml. although plasma volume was higher in the routine group, subsequent preparation of pcs would have resulted in an additional loss of ml per unit in the control group. atreus plasma had extremely low levels of residual wbc and rbc. . ± . . ± . < < . aims: the aim of this study was to examine platelet quality of prestorage pooled prp-derived pc's for up to days storage. methods: pc's were manufactured from wbd-pc's using in-line filtration of prp on day . on day , either , , , or pc's were pooled into an elx® container using a sterile connecting device. studies were performed on days , and for the following measure of platelet quality. ph, morphology score (ms), extent of shape change (esc), hypotonic shock response (hsr), percent in surface expression of p-selectin (p-sel), phosphatidyl serine (ps), glycoprotein b (gp b) and by thromboelastography of the prp (maximum aplitude, ma). results: a total of pools were studied, each of , , and pc's. the mean platelet yield was . ¥ e with a range of . - . ¥ e . the five pc's had a mean yield of . ¥ e and all maintained a ph > . on day . all products had less than ¥ e residual wbc. platelet quality data is presented in the table. data are the mean ± sd, n = . conclusion: platelet pools manufactured from pc's produced by inline filtered prp and stored in elx® containers show good quality preservation to day over a range of platelet yields. introduction: the big progress in treatment of critically ill children significantly increases the need for blood and blood products. loss of blood (lowering of the total erythrocyte mass), as well as decreasing of oxygen capacity of blood that can influence cardiovascular function, is main indication for the erythrocyte transfusion. aim of the study: to present the number of erythrocyte concentrates (ek) that were issued to the pediatric clinic in skopje, as well as to point out how they were distributed. material and method: this is a retrospective study performed in nitm-skopje from january till may . the following criteria were followed: hemoglobin (hb), hematocrit (htc), as well the clinical evaluation, and then final decision for transfusion was made.results: there were blood units (ek) issued for the mentioned period to pediatric clinic for pediatric patients (~ , % units/per child). the biggest consumers are children at intensive care unit and at the hematology-oncology unit. one unit of leukodepleted erythrocytes (er) was split equally to - bags. for small and prematurely born children and for some other selected patients er unit was filtered and irradiated. the dosage was - ml er (depends on age and body weigh). ek was issued as washed concentrates, ek were filtered and ek were resuspended in ab plasma. distribution among abo system was the following: conclusion: gynecologic patients consumed rbc more than times than obstetric ones ( vs ) and the number of given transfusions is high. the a blood group is the most needed one. we should insist on using the who guidelines for the proper clinical use of blood and try to minimize the percentage of given transfusion. and z. cermakova university hospital, ostrava, czech republic background: fully automated system olympus pk is an immunohaematological analyser for detection of red blood cells antigens of ab , rh (d, c, c, e, e) and kell systems without centrifugation by mam (microplate agglutination method) on unique terraced microplate olympus. in the czech republic analyser pk is used only in blood center ostrava. aim: to evaluate the validity of results, sensitivity of microplate agglutinaton method, cause of abortive tests, requirements for analyst, capacity and reliability. methods: blood samples of donors were tested between july and january . all samples were analysed for ab blood group. samples were tested for rhd antigen and ones for rh (c, c, e, e) and k antigen. the validity of the results was evaluated for ab with parallel testing antigens and antibodies, while for rh (d, c, c, e, e) and k using two diagnostic serums. sensitivity of mam i.e. occurrence false negative or positive results were found out when results were confronted with previous ones in our data bank acquired testing classical manual tube or microplate methods. requirements for analyst were evaluated in according to demands for needful knowledge for new analyst, necessity of control pk during testing and maintenance. capacity were evaluated as a number of samples tested per day. reliability determine by occurrence disorders. results: ab , rh (d, c, c, e, e) and k were investigated truly by first testing at . % samples. two diagnostic serums anti-d olymp igm and totem differentiate directly rhd negative and rhd positive donors. false negative or positive results were not founded out due to mam or quality of diagnostic serums. about . % samples with abortive tests were analysed next time the same testing or manual technique. causes of abortive tests were microagglutination several samples except for anticoagulative edta, weak solution of red blood cells prepared by analyser, damage of microplate, hemolysis due to impurity of microplate. in one case analyser evaluated false ab blood group due to hemolysis. analyser has friendly software, simple maintenance and sound control during testing, capacity about samples per day and minimal occurrence of weighty disorders. conclusion: analyser olympus pk is an effective alternative full automation for medium serological laboratory and together with mam easy and truly proves blood groups of majority samples with minimal necessity repetition due to abortive tests. introduction and aim of the study: the purpose of this study is to establish nested-pcr for the detection of hepatitis b virus (hbv) in blood and blood products. methods: the primer pair set was designed to amplify bp in sregion of hbv genome in the first pcr and bp of first pcr amplicon with rubisco (internal control) in the second pcr. to assess the specificity of pcr results, all the samples were tested cross-reactivity or interference in the assay. results: in case of hbv spiked blood products such as immunoglobulin and coagulation factors, this method could detect hbv dna up to . iu/ml. nested-pcr was compared with pcr-elisa and hybrid capture ii (hc-ii), the pcr-elisa showed a sensitivity of % (hc-ii; %) and a specificity of % (hc-ii; %) (p < . ). the results of the study show that nested-pcr and pcr-elisa could be used equally in the management for hbv detection in blood and blood products. p- blood component therapy: slow improvement a mrdja health center subotica, subotica, serbia background: transfusion department at general hospital was founded in . since that time till now it has answered to all demands in blood and blood components. aim: the aim is to present development of the transfusiology department in the last years, so that we could see how much of scientific knowledge we have adopted and in which direction our department goes at the moment. method: retrospective analysis of blood/component utilization in period from . january to . december . results: in whole blood participated in the consumption with . %, packed red blood cells with (rbc) only . %, washed rbc were used in . % of the cases. in whole blood participated in the consumption with . %, packed rbc with . %, washed rbc with . % and rbc in additive solution with . %. as far as plasma preparations are concerned, there has been, since , a great consumption of plasma -witch was separated from whole blood in period up to five day in . % cases, and small consumption of fresh frozen plasma (ffp) only . %. since , there has completely been cancelled the production of five day old plasma, only ffp is being used. from to for the patients who needed platelets, platelet rich plasma (prp) was prepared and applied right after preparation. the consumption rate was from units to units per year. in , after the purchase of platelet shaker, began the production of platelet concentrates (pc) and consumption suddenly rose from units in to units in . conclusions: it is obvious from the analysis that irrational consumption of whole blood was reduced to more acceptable values and therefore the use of component therapy got increased. variation in blood consumption and its slight increase is obvious though application red blood cells was conducted according to strict indications. in the production of plasma old up to five days was cancelled and instead we produced only ffp. pc we prepared for patients only in agreement of treating physician. although very slow progress in development of transfusion therapy in our department can be seen in accepting scientific knowledge. transfusion specialist are active participants in patient treatment and by accepting scientific achievement are able to set standards and help our colleagues, clinics, in successful hemotherapy. introduction: blood groups may act as receptors of parasites, bacteria and viruses. there is evidence that they perform a function and play a biological role. objective: the aim was to detect abo and p epithopes in ascaris lumbricoides extracts (ae) and to study the presence of immune antibodies in patients with ascariasis. materials and methods: ae were prepared by refrigerated mechanical rupture of adult specimens. agglutination inhibition (ai) and haemogglutination kinetics (hk) tests were made with the ae. the patients´ abo and p blood groups were determined. we total febrile non haemolitic male transfusion reaction f e m a l e alloimunisation on le/hla male antigens f e m a l e kandidates of renal male transplantation female lupus nephritis male f e m a l e total female male introduction: irradiation of blood product has been in routine use to prevent graft-versus-host disease (gvhd) in certain recipients for many yeas. gamma irradiation can abrogate the ability of lymphocytes to proliferate in vitro, cgy of gamma radiation reduce lymphocyte response to mitogens by %.the aim of the study: . to estimate potassium level increment in stored irradiation blood units. . to compare the increment in potassium level between leucodepleted and non leucodepleted, irradiated stored blood units. . to evaluate the expiratory date of blood units post irradiation. the study included units of blood collected in cpd-adsol (as- ). in twenty units the blood collection bag was with inline leucodepletion, while the other units were non leucodepleted. all the units were irradiated using caesium as a source of irradiation, with a dose of - cgy. baseline samples from the bags were obtained for measuring of extra cellular potassium (k+). control samples included. results: there is statistically significant increment in potassium level in the irradiated samples compared to the non irradiated samples starting from st day post irradiation and continues to day post irradiation. comparing the group of irradiated leucodepleted, with irradiated non leuconondepleted, for potassium level estimation during the days of storage post irradiation. there is no statistically significant difference between the two groups during all the days of storage, starting from base line samples and other samples post irradiation until day , p value of more than . . . gamma irradiation of bloods units can cause cell damage that the use of such components needs to be modified. . there is a significant increment in the extra cellular potassium level in irradiated blood units that shows doubling value within h post irradiation. . there is no significant difference in extra cellular potassium level increment post irradiation when prestorage leucodepleted units are compared with non leucodepleted units. . an out date of days post collection (unless they expired before) for irradiated red blood units seems reasonable to ensure transfusion of irradiated units without serious complications, except in neonates and massive transfusion cases where irradiated blood units should be fresh and used within - h post irradiation. . the percentage of irradiated blood units requested by our physicians ( . %) is very less that reflects the needs of physicians awareness of the indications for requesting irradiated components that can prevent serious post transfusion complications. the use of whole blood and blood components in treatment of surgical patients in ten years period was analyzed in iran. in accordance with world trend of using blood component therapy, in medical centers throughout the country in ten years period, there are decreasing trend of using whole blood from % ( ) to . % ( ) and increasing trend of using packed red cells component therapy from . % ( ) to . % ( ) . there is also increasing trend of using fresh frozen plasma (ffp) from . % ( ) to . % ( ) . comparing and year, in use of blood therapy related to hospitalized patients at surgical department who received blood and patients who did not received blood; it appears that there is statistically significant difference between these two years. results: during year period, a total of units of blood and units of f.f.p were used. more specifically, the results can be shown in the following table . a high rate of f.f.p usage is observed both in surgery and pathology clinics. the main causes of its usage are: haemodynamic disorders -volume depletion, and coagulation disorders and low blood protein, for the two clinics respectively. conclusion: the only way for rational usage of f.f.p is the regular reminding of plasma transfusion indications to the clinical doctors, so that undesirable side-effects caused by plasma transfusion will be reduced and the percentage of plasma used for fractionation will increase. acquired factor v inhibitor is extremely rare and is associated with diverse clinical symptomatology that varies from asymptomatic forms of the disease to very severe hemorrhagic episodes with a potentially lethal outcome. it may occur spontaneously or as a result of various clinical conditions. a -year-old man was admitted to our hospital with a diagnosis of left-sided periscrotal abscess and scheduled for an incision procedure. during the routine preoperative procedure screening coagulation tests showed pathologic values: aptt s, pt %, fibrinogen . g/l, fv % (other factors were in normal range), platelet count ¥ /l. factor v inhibitor was detected by a modified bethesda assay. the assay showed a low level of inhibitor of about . bethesda units (bu). the patient's medical history showed no major morbidity except appendectomy performed years ago. the patient was prepared for operative procedure, with preventive preoperative administration of fresh frozen plasma (ffp) in a dose of mg/kg (~ ml). upon ffp transfusion, repeated determination of the factor v plasma was unchanged from the initial finding ( %), indicating a failure of therapeutic response. as the measured level of factor v activity was at the borderline hemostatic level, and the operative procedure was not associated with a high risk of hemorrhage, the patient underwent abscess incision. the procedure and postoperative course were uneventful and without major hemorrhage. laboratory testing for the possible systemic autoimmune disorder produced normal findings. control examination performed two years later revealed no major clinical or laboratory variation, while a low factor v level persisted ( %) along with the presence of factor v inhibitor at a level of . bu. we have evaluated two groups of rcc's, one we routinely use (quadruple leucoflex lcr t/t cpd/sagm) (macopharma) and one using an automated collection device which gives the ability to collect whole blood in cpd with a rate of : respectively during the whole donation. the mentioned system has been evaluated using the suitable, quadruple leu-coflex lcr t/t cpd/sagm (macopharma). whole blood ml in cpd was collected from random donors. in both groups the whole system was stored at scaled r.t. ± °c for to h. after component separation (beckman coulter j mi-optipress i-baxter), the red cell concentrates were filtered immediately at r.t. ± °c. sampling was done after filtration and wbc measurements were determinated using nageotte champer (bright line-detection limit . wbc/ml) with leucoplate solution (sobioda). the other parameters were measured with (celldyne abbott). conclusion: all products met the accordance of national and european norms for blood components quality. leucodepletion with leucoflex lcr and abc leucoflex lcr ( . and . ) is highly efficient. the use of abc leucoflex lcr showed better scaled donation in terms of collection (statistical analysis mann-whitney, minitab p-value = . < . ). additionally less hb-loss occurred, due to the filtration process, most probably due to the total absence of clots (analysis man-whitney, minitab, p-value = . < . ). this new generation of collection gives the ability in blood services to collect well calibrated donations, indoors or outdoors. smaller quantities of donations theoretically can be valid because of the stable : , rate of donation. the abc system gives the ability of fully traceability during donation. macopharma's blood collection bags, with or without integrated filters, provided they have this modified system of storing the ac. the device can keep records for many parameters and can transfer them to the data base server of the blood center. to evaluate the performance of the abc, we conducted a comparative study between abc leucoflex lst system and leucoflex lst system we currently use. the later is a well known macopharma's system for collection of whole blood with integrated whole blood filter and the final production of one unit of leucodepleted crcs and one unit of leucodepleted plasma. the abc was handled with the same system modified with the storage bag for the ac. issues of comparison were the accuracy in donation volume, the duration of filtration, the loss of blood in the filter and the residual wb cells after filtration. we performed donations with the lst system and donations with the abc lst system. all the donors were random male volunteers and they were meant to donate mls of whole blood. our results analysed by mann-whitney, minitab statistical analysis have as follows: . no significant difference was found between the two systems concerning the whole blood volume, but there was broader distribution of the values in the lst system compared to the abc lst system. . the duration of filtration has been found without statistically significant differences between the two systems. . the loss of volume in the filter of lst is higher than in the abc lst (p = . < . , which is statistically significant). . there was very good leucodepletion with the lst systems (median reduction of the wb cells . log) but there was a superiority of the abc lst over the lst concerning the leucodepletion per litter and per unit (p: . and p: . respectively). . the personnel after a very short period of training accepted fully the abc procedure.in conclusion abc is an easy to handle device which provides with high quality blood products in combination with leucoflex lst . evaluation of a post-storage filter for wbcs with an incorporated waste bag for washing rccs leucolab lcg is a system manufactured by macopharma for poststorage filtration of a rcc unit (with or without an incorporated waste bag for further washing of the filtered product). to evaluate the efficiency and reliability of the above system we conducted a study with twenty three random units of rccs stored in cpd/sag-m, aged - days, filtered and consecutively washed with ml of normal saline, span down in the regular way and the supernatant extracted in the waste bag. issues for evaluation were: . the duration of priming and filtering the rccs. . the loss of volume in the filter. . the efficiency of the filtration. . the acceptance of the personnel of a new (to them) filtration system.our results have as follows: . we counted the duration of priming and filtration. median time of priming was s (range - ) and of filtration was min (range - ). . the median volume lost in the filter (as calculated) was . ml (ranging from . to . ). this narrow range is apparently due to the non-flexible cell of the filter. . the efficiency of the leucodepletion was counted by flow cytometry. the median wbc counted per lt was . ¥ (range . - . ¥ ) and per unit was . ¥ (range . - . ¥ ). the median reduction of the wbc count was . log (range . - . ). . the personnel involved in the procedure found the system easy to handle, even without specific training. in conclusion the lcg is a reliable and easy to handle system, for leucodepleting (and washing) rccs, very efficient in removing wbcs with negligible loss of volume. objective: standardization of blood banks and establishing quality assurance are important landmarks in the new era of transfusion medicine. as the number of blood banks grows and the capacities of them changes, centralization need arises and trends to nationally coordinated blood services eventually appear. aim: to investigate the types and capacities of blood bank in the country and evaluate the statistics of them. material and method: blood banks and transfusion society of turkey conducted a nation-wide survey of a comprehensive questionnaire. this is a preliminary report of this investigation and illustrates the capacities of the most blood banks in turkey. it also guides the nationally planned renewing structure of blood banks. results: there are nearly blood banks and blood stations in whole country. the overall blood collected at those centers is about . . units. nearly one in third is being collected at government hospitals ( . %), nearly the same is collected at university hospital blood banks ( . %). the third major group is the red crescent society blood centers-rcsbc ( . %), followed by the social security hospitals ( . %). blood collecting capacities are not appearing in the same order. the major blood banks belong to the rcsbcs, whereas the small ones are mostly government hospitals. the only donor recruitment organization is run by the rcsbcs. yearly blood collecting capacity blood banks (%) > . . . - . . . - . . . - . . < . . conclusion: there are many steps for improving blood safety in a country, and the prior ones are structuring the blood transfusion system and donor organization on a national basis, and then establishing good manufacturing practices. these are only possible after centralization of all existing blood banks. in our country, we should first arrange all small capacity blood banks and standardize them. controversial clinical questions considered in a medical opinion forum by physicians for the advancement of transfusion medicine (patm) patm is a newly formed group of close to physicians drawn from pathology and hematology, transfusion services, hospital blood banks and blood centers. its mission is to address the concern that patient oriented medical opinion and influence has been diminished in transfusion medicine (tm). they believe that a patient oriented voice should be distinct from institutional, commercial or regulatory weight and have a common focus on patients and the therapeutics of transfusion and related therapies. therefore, their first objective is to create a new medical, patient oriented voice that weighs in on national policy pertaining to treatments related to tm. as such, patm held its first medical opinion forum where members of the group debated important questions pertaining to tm clinical practice. the forum was held just prior to the aabb annual meeting and attracted physicians. the questions debated were preselected by patm membership via an email survey. respondents were asked to select their top four preferences from among topics in five broad categories. the top two topics were selected for the forum from the completed surveys. the subjects selected and debated were (i) what are the medical considerations for reducing the rate of mistransfusion? and (ii) what are the medical considerations for managing a limited blood inventory? the participants were divided into four groups, with each topic assigned to two groups. all the groups were given two h to debate and arrive at consensus on their topic. each group then presented a summary of their discussions along with specific recommendations for addressing these clinical practice issues. there was remarkable consensus between the groups debating the same issue. the conclusions and recommendations on these two topics will be presented in detail. patm is a new organization that will add an important medical voice and opinion on current topics in tm. at its first meeting, two topics were successfully discussed and debated with broad consensus achieved on current issues confronting the field. key: cord- - adloi o authors: cunha, rafes d. s.; da silva junior, camilo l.; costa, camilla a.; de aguiar, hulliana m.; junqueira júnior, danilo g. title: comparison of immunity against canine distemper, adenovirus and parvovirus after vaccination with two multivalent canine vaccines date: - - journal: vet med sci doi: . /vms . sha: doc_id: cord_uid: adloi o background: viral diseases are a major cause of morbidity and mortality in puppies. there is a belief among veterinary practitioners and even educational institutions that the vaccines made in brazil against canine distemper virus (cdv), canine parvovirus (cpv) and canine adenovirus (cav) are ineffective or only partially effective. objectives: this study aimed at comparing the immunity of two multivalent vaccines in adult dogs in the city of uberlândia, minas gerais state, brazil. methods: the study was carried out at the animal protection association and a total of adult mongrel dogs were selected and divided into two groups. group a was immunized with two doses of elevencell(®) vaccine and group b received two doses of imported vaccine from the united states; each group was made up of females and males. results: in group a, the elevencell vaccine generated a protective antibody titre against cdv in out of subjects ( . %), cpv in out of subjects ( . %) and cav in out of subjects ( . %). in group b, the imported us vaccine generated a protective antibody titre against cdv in out of subjects ( . ), cpv in out of subjects ( %) and cav in out of subjects ( . %). there was no statistical difference between titres generated between vaccine types for any of the three diseases tested. conclusion: elevencell vaccine titres were not inferior to the imported us vaccine in conferring protective titres against cdv, cpv and cah, which confirms the efficacy of this product. viral diseases are a major cause of morbidity and mortality in puppies. in this canine population, there is a higher prevalence of canine distemper, parvovirosis and canine infectious hepatitis (vila nova et al., ) . these three diseases are aetiologically different, but they can be prevented by vaccination with recombinant or live-attenuated vaccines (day, horzinek, schultz, & squires, ) . canine distemper virus (cdv) induces several clinical signs, including fever, dyspnoea, diarrhoea and neurological disorders. these signs may vary according to the host immune status and virus strain. puppies are the most susceptible group to this infection and present the highest fatality rate (martella, elia, & buonavoglia, ) . parvoviruses is caused by canine parvovirus type (cpv- ), characterized by tropism through rapidly dividing cell lines and affecting dogs at different ages. this disease causes a severe enteric infection with bloody diarrhoea, immune suppression and also high fatality rates. the continuous incidence of enteritis is due to the ability of the virus to mutate, which gives rise to new, more resistant and virulent subspecies (goddard & leisewitz, ) . caused by canine adenovirus type (cav- ). this virus has tropism for hepatocytes and endothelial cells, which can cause hepatocellular necrosis and systemic bleeding. unvaccinated puppies are the most susceptible to this infection and present non-specific clinical signs, which requires differential diagnosis of other diseases such as canine distemper (decaro, martella, & buonavoglia, day et al., ) . therefore, to choose an appropriate vaccine and the right age for vaccination, it is crucial to seek veterinary advice. there is a belief among veterinary practitioners or even educational institutions that the vaccines made in brazil against cdv, cpv and cav are ineffective or only partially effective. however, there are no published scientific data to support this. a study carried out in viçosa, minas gerais (brazil), showed that the facility where vaccination is performed (veterinary clinics or agricultural stores) is not a determining factor for successful immunization, but rather adherence to the schedule recommended (monti, viana, dias, moraes, & salcedo, ) . the lack of research providing a better understanding of the effectiveness of vaccines made in brazil may influence the opinion of clinicians and pet owners when choosing the best immunogen. thus, this study aimed to compare two commercial vaccines, one made in brazil and another coming from abroad, for efficacy against three diseases, namely: canine distemper, parvovirosis and canine infectious hepatitis. this study consisted of a randomized double-blind comparative trial. all procedures were evaluated and approved by the ethics committee on the use of animals at the centro universitário do triângulo (unitri) under the protocol / - . the data that support the findings of this study are available on request from the corresponding author. the data are not publicly available due to ethical restrictions. this trial was performed at associação de proteção animal (animal protection association, apa in short) in uberlândia, minas gerais state, brazil. apa, an institution founded in ,which has a total of housing units divided into three sectors for dogs, as well as a nursery with housing units for cats and dogs plus two catteries, totalling dogs and about cats. these animals were rescued from the streets, where they had been abandoned, abused or injured. for this study, the criteria for inclusion were animals that had no clinical signs of distemper, parvoviruses and infectious hepatitis, they were dewormed, presented with a medical history inside the shelter (more than a sheltered year) and had negative results in the colorimetric test for the studied antigens. animals with a change in the physical examination, under the age of or over years, less than a year housed or had positive results in the colorimetric test were excluded. a total of dogs were selected (sampling error %), half of them males and half females. the animals studied were mongrel adult dogs aged between and years that received the same diet plus water (ad libitum) and were housed in the same housing unit. all animals underwent a thorough physical examination by a veterinarian in order to check for the presence of petechiae, ectoparasites, overt organomegaly and any other abnormalities that could be identified in the examination and interfere with the results. randomization was adopted first stratified by sex, by selecting males and females. then they were separated into blocks of two animals with two sequences of intervention. to guarantee the blinding of the study, the researchers had no contact with vaccines and animals until the moment of the vaccination. the vaccines were stored, prepared and coded by a guest veterinarian who was unaware of the purpose of the experiment. thus, both animals and researchers were blinded for the protocol used in the vaccination. at the end, each group was composed of males and females. group a was given v elevencell vac (made in brazil at labovet ® ) and group b received immunization with a vaccine imported from the united states (vangard ® plus, zoetis inc.). one of the vaccines used in this study, brand name v elevencell vac, contains live-attenuated virus antigens of distemper, canine parvovirus, infectious hepatitis, adenovirus type , canine parainfluenza virus, coronavirus-inactivated antigen and five leptospira serovars (l. samples were collected on two occasions: day (also known as d blood samples were collected from the cephalic or saphenous vein and refrigerated for clot retraction, followed by centrifugation and serum separation. serum was stored at a temperature of − °c until the tests were performed. all analyses were performed in a clinical laboratory at unitri. the pre-and post-vaccination responses were evaluated using the commercially available kit immunocomb ® (biogal galed labs) based on solid-phase 'dot'-elisa technology and designed for detecting seru-migg or igm levels, validated against gold standard tests: virus neutralization assay(vn) and haemagglutination inhibition assay (hi). in addition, this test kit is a qualitative and quantitative method that provides a diagnosis within min at room temperature (the best results are obtained at a temperature of - ºc) and consists of: (a)a developing plate with wells containing elisa test solutions; (b) an immunocomb card that is inserted in these wells and im- interpretation of the test results according to the manufacturer uses a colour scale from s to s . there are four levels of interpretation:s , negative; s - ,inappropriate immunity; ≥s ,positive; ≥s ,strongly positive. all dogs with a reading equal to or higher than s were regarded as immunized or protected. the same titre was used for all three diseases. the test presented the following values for specificity (sp) and sensitivity (se): cav, sp % and se %; cpv, sp % and se %; cdv, sp % and se % (biogal galed labs acs ltd., ). the cut-point s indicates a significant response of anti-cav antibodies ( : titre in vn), anti-cpv antibodies ( : titre in hi) and anti-cdv antibodies ( : titre in vn). the data for the animals were entered individually into excel spreadsheets (version ; microsoft corp.). as the procedure is a scale test with a non-normal distribution, the median post-vaccination titre response was obtained, as well as its comparison using the mann-whitney non-parametric test at a significance level of %. descriptive statistics were used to calculate the frequencies of animals immunized, and proportions were compared using the binomial test for two proportions at a significance level of %. all analyses were carried out using bioestat . software (ayres, ayres junior, ayres, & santos, ). of the animals selected and randomly distributed into two groups, only were analysed because three were adopted during the trial and one died as a result of trauma unrelated to enrolment in the study. thus, each group consisted of dogs. before immunization, both groups of animals presented results of ≤ on the colorimetric scale, which means that all of them were eligible to take part in the vaccination protocol. when analysing antibody titres against canine distemper, . % ( / ) of the animals of group a were protected (i.e. with a titre of ≥ )and . % ( / ) of group b were protected; thus, there was no significant difference between the groups (p = . ). both groups had a median response of . on the colorimetric scale and again there was no difference between the groups. a was shown to have a protective titre of ≥ in . % ( / ) and group b in % ( / ). there was no statistical difference between the groups (p = . ). both groups had a median response of on the colorimetric scale and again there was no difference between the groups. for analysis of antibody titres against adenovirus, group a was shown to have a protective titre of ≥ in . % ( / ) and group b in . % ( / ); thus, there was no statistical difference (p = . ). group a had a median response of . for colorimetric titration and group b showed a median response of . . however, these differences were not statistically significant. table shows the frequency of test results for both groups distributed according to the colorimetric scale of the immunocomb ® kit. randomized trials are a powerful tool for reducing bias. by distributing the animals randomly into groups, this ensures uniformity between them. coupled with a double-blind strategy, this helps to avoid any bias that could favour a particular treatment or control (oliveira & parente, ) . although no statistical difference between the two vaccines has been shown, a comparable proportion of animals was protected using vaccine v made in brazil, which reinforces the quality of the product in comparison to the vaccine imported from the united states. several different factors can affect vaccine induction of a protective titre and may account for the lack of an appropriate response in some animals: factors such as storage conditions, nutritional status of the animal, maternal antibody titres and vaccine immunogenicity (day et al., ; monti et al., ) . in relation to storage conditions, the vaccines used in this study were stored according to both manufacturers' guidelines and normative instructions (ima, ) at a temperature between °c and °c in a cold chamber, which ensures the quality of the products. another common cause of vaccination failure involves high levels of maternal antibodies, which can inhibit or neutralize the action of the vaccine (nandi, kumar, mohapatra, & ravishankar, ) . however, all animals immunized in this study were adults and therefore there was no correlation between vaccination failure and maternal antibody presence. ecto-and endoparasites can also influence the effect of the vaccine because these parasites extract nutrients from the host, causing weakness, anaemia, increased stress and secondary bacterial infections (bowman, lynn, eberhard, & alcarez, ) . thirty days before the beginning of vaccination, all animals were given fenbendazole, a broad-spectrum benzimidazole anthelmintic drug used against endoparasites, and also fipronil for the control of ectoparasites. additionally, when selecting the animals for this trial, those that presented with apathy, weight loss, pale mucous membranes, petechiae and ectoparasites were excluded from the study. every effort was made to control any variables that could interfere with the immune response of each animal individually. there were limitations to this study that can be addressed in the future. the absence of public and private funding for execution of the project limited the tests that could be carried out, such as complete blood count, imaging tests to evaluate the spleen and liver and also individual quantification of antibodies by spectrophotometry. both vaccines are effective in the protection of dogs and the v elevencell vac made in brazil has been shown to be an appropriate immunogen to induce a strong immune response in a highly challenging environment such as the apa shelter. on behalf of all authors, the corresponding author states that there is no conflict of interest. note: scale: - , inappropriate immunity; - , positive; - , strongly positive. all dogs with a reading equal to or higher than were regarded as immunized or protected. all dogs with a reading of or show the presence of some immune memory cells against the virus tested. manual of infectious hepatitis, parvovirus and distemper igg antibody test kit georgis' parasitology for veterinarians estratégias para vacinação de animais de companhia: cães e gatos wsava guidelines for the vaccination of dogs and cats canine adenoviruses and herpesvirus canine parvovirus. veterinary clinics of north america: small animal practice portaria n° de de outubro de canine distemper virus anticorpos contra o vírus da cinomose de cães vacinados em diferentes estabelecimentos emergence of canine parvovirus- variants and its impact on vaccination understanding randomized controlled trials evaluation of the humoral immune response induced by vaccination for canine distemper and parvovirus: a pilot study key: cord- -ww o kjr authors: al-anzi, bader s.; alenizi, mohammad; al dallal, jehad; abookleesh, frage lhadi; ullah, aman title: an overview of the world current and future assessment of novel covid- trajectory, impact, and potential preventive strategies at healthcare settings date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: ww o kjr this study is an overview of the current and future trajectory, as well as the impact of the novel coronavirus (covid- ) in the world and selected countries including the state of kuwait. the selected countries were divided into two groups: group a (china, switzerland, and ireland) and group b (usa, brazil, and india) based on their outbreak containment of this virus. then, the actual data for each country were fitted to a regression model utilizing the excel solver software to assess the current and future trajectory of novel covid- and its impact. in addition, the data were fitted using the susceptible–infected–recovered (sir) model. the group a trajectory showed an “s” shape trend that suited a logistic function with r( ) > . , which is an indication of the outbreak control. the sir models for the countries in this group showed that they passed the expected % end of pandemic dates. group b, however, exhibited a continuous increase of the total covid- new cases, that best suited an exponential growth model with r( ) > . , which meant that the outbreak is still uncontrolled. the sir models for the countries in this group showed that they are still relatively far away from reaching the expected % end of pandemic dates. the maximum death percentage varied from . % (india) to . % with usa recording the highest death percentage, which is virtually equal to the maximum death percentage of the world ( . %). the power of the exponential model determines the severity of the country’s trajectory that ranged from to with the usa and brazil having the highest values. the maximum impact of this covid- pandemic occurred during the uncontrolled stage ( ), which mainly depended on the deceptive stage ( ). further, some novel potential containment strategies are discussed. results from both models showed that the group a countries contained the outbreak, whereas the group b countries still have not reached this stage yet. early measures and containment strategies are imperative in suppressing the spread of covid- . today's world is changing rapidly at different levels during the current technological and medical renaissance due to research and development (r&d) that has resulted in innovative technologies and outcomes. sometimes such developments may lead to disastrous consequences causing adverse effects on the environment, which could be reflected on the health of living organisms at different levels such as global warming as a part of air pollution, water pollution, and even cancer. some of the advancements could be in the medical field, as well some new antibiotics and vaccines to fight new diseases and outbreaks. as a result, some microorganisms/pathogens have mutated to develop resistance to existing treatments causing many epidemics and outbreaks. disease and sickness have tormented humanity since the beginning of life on earth. human beings, along with plants and vegetables, have had to face challenges from microorganisms during their evolution. the mankind history has seen epidemics characterized by mortality and morbidity [ ] . however, the scale of these diseases has increased notably since the advent of globalization. with the rise in global trade, expansion of civilization, contact with populations across the globe, new opportunities for human interactions have become more common, resulting in the proliferation of such epidemics. the early years witnessed the onset of several diseases such as malaria, smallpox, tuberculosis, influenza, leprosy, whose cure has eventually been discovered [ ] . the scientific efforts made during the mid- th century has reduced the spread of epidemics in the world, mainly due to the advances in medical services, improvements in health care and the urban environment, and availability of vaccines and antibiotics [ , ] . however, the widespread outbreaks have again returned to the world in the st century, possibly due to pollution, overpopulation, global transportation network, and poverty in some parts of the world. hence, the recurrence and emergence of potential infectious diseases that may cause epidemics is most likely to continue [ ] . in fact, the world health organization (who) has claimed that approximately million deaths due to these infectious diseases takes place each year. in developing countries with the least economic resources, such diseases are the major causes of deaths. certain diseases such as tuberculosis and malaria, have reappeared due to the emergence of drug resistant microorganism strains. lastly, the perception of "deliberately emergent" pathogens (such as anthrax and smallpox), and the possibility of their use for bioterrorism in the contemporary world cannot be ruled out [ ] . recently, the world has gone through an intermittent communicable disease outbreak that led to unprecedented epidemics, which have significantly impacted humanity claiming many innocent lives and the economy. such epidemics are sever acute respiratory syndrome (sars), middle eastern respiratory syndrome (mers), and of course the current novel coronavirus that has been classified as a pandemic . table lists the historic and recent epidemics/pandemics [ , ] that have occurred in the world. no one can overlook what the world is going through these days as a result of the covid- pandemic that has already spread through the countries affecting , , people and, unfortunately, killing around , people over a short timeframe ( - months), still with an accelerated pace and notable upward trend [ ] . as aforementioned, this has affected the world economy, the humans' life, and has spread panic all around. on december , there was a cluster of pneumonia cases in wuhan, hubei province, china, whose investigation revealed that these cases were associated with the novel coronavirus or covid- , as it is called today [ ] . viruses are not from the plant or animal kingdom, and are neither bacteria, but are the typical parasites of the living kingdoms. viruses are not living organisms because they cannot live without a host cell. all viruses contain a core, made of a genetic material-nucleic acid, either dna or rna-and a protein shell, which encases the nucleic acid [ ] . coronaviruses are a large group of viruses [ ] surrounded by an envelope with protein spikes, which gives the appearance of a crown (or, in latin, corona) from where it derives its name. [ ] . there are different types of coronaviruses that cause respiratory and gastrointestinal problems [ ] . respiratory diseases can range from pneumonia and in most people the symptoms can generally cause a mild disease [ ] . however, there are some types of coronaviruses that can cause several diseases such as sars: the coronavirus sars-cov identified in table . historic and recent epidemics/pandemics [ , ] . the current novel coronavirus (covid- ) was first found through a group of chinese people who tested positive for pneumonia [ ] . this was at the end of year in wuhan city. the disease then spread to their family members and the surrounding people including their health care staff. the contagious nature of this disease resulted in its spread to other countries over few months [ ] . the coronaviruses circulate in a range of animals. this virus can "spill over" meaning they can jump from animal to human probably due to a range of factors such as mutation or increased contact between human and animals [ ] ; for example the mers-cov came from camels [ ] and the sars_cov from civet cats [ ] . the animal reservoir of coronavirus ( -ncov) is not known yet. in general, respiratory viruses are usually transmitted through droplets from an infected person's cough or sneeze or by touching a surface that has been contaminated with the virus [ ] . people at most risk of the coronavirus infection are those who work at an animal market, health care workers treating coronavirus patients, as well as family members caring for infected coronavirus members [ ] . the most common symptoms of this coronavirus ( -ncov) are fever, tiredness, respiratory symptoms such as cough, sore throat, and shortness of breath, and rare intestinal symptoms such as diarrhoea [ , ] . unluckily, this covid- virus has some features that contributed to its global spread at a relatively short time. the virus has spread all over asia and reached the united states (snohomish county, washington) on january [ ] and in germany on january [ ] through different routes from china. facts about this virus are still new, and what we know about this may change in the future. zhao et al. verified that the initial growth phase of the coronavirus in china was the exponential growth [ ] . they used the serial intervals (si) of infection caused by mers and sars as approximations for the si of the coronavirus and estimated the r [ ] . iwato et al. conducted simulations using the seir model to assess the impact of secondary outbreaks outside china, assuming that one infected patient travelled to an outside community [ ] . while applying the seir compartmental model, kuniya t. predicted the epidemic peak for the coronavirus in japan using real data from january to february [ ] . al qaness et al. developed a novel forecasting model that forecasted and estimated the covid- cases for the upcoming ten days using the adaptive neuro-fuzzy inference system (anfis), which uses the enhanced flower pollination algorithm (fpa) and the salp swarm algorithm (ssa) [ ] . roosa et al., in their study, generated forecasts based on two popular models used previously for forecasting infectious diseases outbreaks, i.e., richards growth model, and a sub-epidemic wave model [ ] . jung et al. modeled the epidemic growth using two methods, scenario- , from a single case recorded on december , and scenario- , using the growth rate fitted along with the other parameters based on data from exported cases reported by january [ ] . the current study aims to assess the trajectory of the recent pandemic due to the covid- outbreak utilizing a new splitting methodology of the selected countries into two groups and developing regression-based and sir-based statistical models and tools that depict the actual recorded data of covid- . different modeling techniques potentially provide different prediction results. we considered two modeling techniques that adopt two different prediction approaches to show that although the modeling techniques exhibit different detailed results, they lead to the same general conclusions. this study covers the entire world with emphasis on extreme cases based on the disease containment. such models will be useful in projecting the covid- trajectory to estimate the daily infection and death rates of the world and selected countries in advance. in addition, this study introduces new factors to be used directly to compare the countries' responses towards covid- . this will help the authorities take the necessary measures and proper action plans to minimize the covid- impact ahead of time. furthermore, the article also covers some novel potential strategies to contain the virus spread at healthcare settings. actual data (country wide population number, number of infected cases in a country, number of deaths in a country, number of new cases) for the entire world and a few selected countries were obtained from the worldometer website [ ] . according to the website, the data mentioned have been collected from the countries' health ministry, government institutions, or government authorities' social media accounts [ ] . the data were recorded daily where the day was reset after midnight gmt+ . all the countries recorded new cases for the current day while in progress except china who displayed the previous day cases. certain countries were chosen to conduct this study based on their outbreak containment and responses. then, a new splitting methodology was used in the current study to divide the selected countries into two groups (a) group a: that succeeded in containing the covid- outbreak, where its behavior was split into - subperiods and (b) group b: that failed and is still struggling in containing the outbreak, where its behavior was split into two subperiods. logistic and exponential growth statistical models were used to fit the actual model into regression equations utilizing the excel solver software. in addition, the susceptible-infected-recovered (sir) model [ ] was applied, which is a compartmental model that has been widely utilized in the literature to predict the spread of infectious diseases. in this model, the population (n) is categorized into three compartments including susceptible (s), infected (i), and recovered (r). the model assumes that the population and both infection and removal rates are constant during the whole epidemic period. in addition, it assumes that the population is well-mixed. during the epidemic period, susceptible cases become infected with a rate β and infected cases become recovered with a rate γ. the rate of change for the three compartments is estimated by the following three differential equations: this model is considered because it requires simple data that is available for the public. furthermore, its implementation is provided as an open source code. to obtain covid- prediction results for the selected countries, we applied an already existing matlab sir modeling tool [ , ] . the tool takes the daily new infection cases as an input and optimizes the model parameters by minimizing the difference between the actual and estimated number of cases and it considers the possibility of having multiple sub-waves. the number of daily new infection cases were collected from a publicly available repository [ ] on july . in this study, an assumption was made that all the data reported by the selected countries were accurate and up-to-date. it is important to note that the results of the prediction models might be inaccurate due to the fact that such models do not consider some affecting factors such as the containment strategies and other related governmental interventions. the considered pandemic prediction models assume that all such related factors remain the same. the prediction results are useful to assess whether more strict interventions must be applied to reduce the estimated number of infections and deaths and relieve the healthcare system. figure was generated to show the recorded daily total infected cases of the world over a certain timeframe ( january until present), which shows that the covid- disease started to increase slowly until about march and then accelerated at a faster speed afterwards. this means that the infected number of cases after march are significantly higher than the numbers before this date. to illustrate this further, the change in new infected cases for the first days (from january until march) is between to , cases, whereas the change for a similar period of time ( march until april)) varied between , to , , cases, which is a -fold increase in the new infected cases than that of the first interval. mathematically, this means that the change in the y over time (∆y/∆x) experienced a relatively drastic jump as opposed to the first interval. in other words, the slope of the second interval is steeper than the first interval ( figure ), which is also called the tangible line of the graph. this clearly means that the infection is spreading through the world in a faster change rate over a short timeframe. interventions. the considered pandemic prediction models assume that all such related factors remain the same. the prediction results are useful to assess whether more strict interventions must be applied to reduce the estimated number of infections and deaths and relieve the healthcare system. figure was generated to show the recorded daily total infected cases of the world over a certain timeframe ( january until present), which shows that the covid- disease started to increase slowly until about march and then accelerated at a faster speed afterwards. this means that the infected number of cases after march are significantly higher than the numbers before this date. to illustrate this further, the change in new infected cases for the first days (from january until march) is between to , cases, whereas the change for a similar period of time ( march until april)) varied between , to , , cases, which is a -fold increase in the new infected cases than that of the first interval. mathematically, this means that the change in the y over time (Δy/Δx) experienced a relatively drastic jump as opposed to the first interval. in other words, the slope of the second interval is steeper than the first interval ( figure ), which is also called the tangible line of the graph. this clearly means that the infection is spreading through the world in a faster change rate over a short timeframe. looking at the selected countries based on containment rates, the countries were classified into two groups: (a) countries that contained (had controlled) the covid- disease, and (b) those that failed to do so (uncontrolled), as follows ( table ) : china is taken as an example for group a where after the outbreak china managed to control the spread of the covid- virus, as shown in figure . china is the origin of covid- where the first cases were recorded in wuhan city on january . this virus started to spread in china with a short-term (interval in figure ) slow rate of infection for about days ( to january) followed looking at the selected countries based on containment rates, the countries were classified into two groups: (a) countries that contained (had controlled) the covid- disease, and (b) those that failed to do so (uncontrolled), as follows ( table ) : china is taken as an example for group a where after the outbreak china managed to control the spread of the covid- virus, as shown in figure . china is the origin of covid- where the first cases were recorded in wuhan city on january . this virus started to spread in china with a short-term (interval in figure ) slow rate of infection for about days ( to january) followed by a faster infection rate in the second interval that lasted for days ( january to february). then, the total infected cases continued to increase with a slow rate until it reached the maximum and levelled off thereafter (interval ). china went through three intervals where interval and represent the breakout stage, and interval the control stage. the slopes for intervals and increased from small to significant and then decreased until they became negligible in interval ( figure ). int. j. environ. res. public health , , x of by a faster infection rate in the second interval that lasted for days ( january to february). then, the total infected cases continued to increase with a slow rate until it reached the maximum and levelled off thereafter (interval ). china went through three intervals where interval and represent the breakout stage, and interval the control stage. the slopes for intervals and increased from small to significant and then decreased until they became negligible in interval ( figure ). an example of group b is brazil, where the covid- spreading rate went through two distinct intervals. interval where the slope of the curve was negligible indicating small increases in the new cases ( march to april) and interval represented by a sudden upward shift in the graph as a result of a massive increase in the newly infected cases each day from april onwards ( figure ). the daily increase rate for interval was from to new cases, whereas the same rate for interval was from to , , , which is significantly higher than that of interval with a notable upward trend. again, this is due to the drastic change in daily new cases as represented by the changing direction of the slope from a small slope to a steeper one. an example of group b is brazil, where the covid- spreading rate went through two distinct intervals. interval where the slope of the curve was negligible indicating small increases in the new cases ( march to april) and interval represented by a sudden upward shift in the graph as a result of a massive increase in the newly infected cases each day from april onwards ( figure ). the daily increase rate for interval was from to new cases, whereas the same rate for interval was from to , , , which is significantly higher than that of interval with a notable upward trend. again, this is due to the drastic change in daily new cases as represented by the changing direction of the slope from a small slope to a steeper one. by a faster infection rate in the second interval that lasted for days ( january to february). then, the total infected cases continued to increase with a slow rate until it reached the maximum and levelled off thereafter (interval ). china went through three intervals where interval and represent the breakout stage, and interval the control stage. the slopes for intervals and increased from small to significant and then decreased until they became negligible in interval ( figure ). an example of group b is brazil, where the covid- spreading rate went through two distinct intervals. interval where the slope of the curve was negligible indicating small increases in the new cases ( march to april) and interval represented by a sudden upward shift in the graph as a result of a massive increase in the newly infected cases each day from april onwards ( figure ). the daily increase rate for interval was from to new cases, whereas the same rate for interval was from to , , , which is significantly higher than that of interval with a notable upward trend. again, this is due to the drastic change in daily new cases as represented by the changing direction of the slope from a small slope to a steeper one. generally, the death rate is proportional to the infection rate but at a smaller scale that varies from country to country, depending on many factors such as population, awareness, health care system, hospital building capacity, demographics, and location. as shown in figures - , the death rates for the world and each selected country depict a similar trend as that of the infection rate. for example, figures and show the world and the usa death rates, respectively where they are still increasing continuously without reaching a maximum value. in switzerland, however, the death rate exhibited a similar trend as its infection rate behavior (figure ). generally, the death rate is proportional to the infection rate but at a smaller scale that varies from country to country, depending on many factors such as population, awareness, health care system, hospital building capacity, demographics, and location. as shown in figures - , the death rates for the world and each selected country depict a similar trend as that of the infection rate. for example, figures and show the world and the usa death rates, respectively where they are still increasing continuously without reaching a maximum value. in switzerland, however, the death rate exhibited a similar trend as its infection rate behavior (figure ) . figure is plotted to show the total deaths of the selected countries so far, which shows that usa recorded the highest total deaths due to the covid- infection. however, it would not be accurate to use such data to directly compare the death rates between the countries. therefore, the next section is dedicated to calculate the death percentage for the selected countries and the world. figure is plotted to show the total deaths of the selected countries so far, which shows that usa recorded the highest total deaths due to the covid- infection. however, it would not be accurate to use such data to directly compare the death rates between the countries. therefore, the next section is dedicated to calculate the death percentage for the selected countries and the world. figure is plotted to show the total deaths of the selected countries so far, which shows that usa recorded the highest total deaths due to the covid- infection. however, it would not be accurate to use such data to directly compare the death rates between the countries. therefore, the next section is dedicated to calculate the death percentage for the selected countries and the world. a simple equation ( ) is used to calculate the percentage of the deaths for each selected country for the sake of direct comparison. a simple equation ( ) is used to calculate the percentage of the deaths for each selected country for the sake of direct comparison. since population (p) is proportional to the number of infected cases (inf), then: where a is the infected cases per capita, which is the infection percentage of the population. similarly, another factor b that relates the total deaths (d) to the total infected cases is described below: although, china has the largest population in the world, it had the least infection percentage of population (a) compared to the other selected countries (figure ). furthermore, the death percentage (b) of the selected countries up to this date varies between . % (brazil) to . % (ireland). the world's death percentage of . % is within the foregoing values ( figure ). figure shows the accumulated daily death percentages of the foregoing countries in comparison with the world death percentage, which shows that the world experienced a sharp increase in the total death cases after march until it reached a maximum of . % on april and decreased afterwards until this moment with . %. group b showed a similar trend to that of the world with slightly less death percentages. this is due to the decline of the daily deaths in comparison figure shows the accumulated daily death percentages of the foregoing countries in comparison with the world death percentage, which shows that the world experienced a sharp increase in the total death cases after march until it reached a maximum of . % on april and decreased afterwards until this moment with . %. group b showed a similar trend to that of the world with slightly less death percentages. this is due to the decline of the daily deaths in comparison with the continuous daily increase in the infected cases. group a, on the other hand, exhibited a similar behavior at the beginning until it reached a maximum and then levelled off as an indication of containing the outbreak (negligible new infected cases with zero deaths). as stated in the previous sections, the trend of covid- outbreak varies between countries at different levels (e.g., death rates, total infected cases, and containment). this section focuses on fitting the actual data of the selected countries into regression-based equations/models that help in understanding the covid- trajectory for a better projection. once an accurate model is developed (r > . ) for each case, it was used to project the future behavior of covid- to provide potential statistics. this will help in developing proactive action plans and the necessary strategic measures to contain such pandemics in the future too. starting with group a, selected countries such as switzerland and ireland, a good regression fit for both countries was obtained from the logistic model with r > . ( figure ) to fit the "s" shaped trend. the fitted model of total covid- cases (tcov) for both countries is expressed by equation we have not carried out a sensitivity test in the current study to investigate the effect of each parameter of the logistic model (m and k) on the infection rate because it is not of our interest at this stage. given that, they are generally defined as follows, m is the amount after growth and k is the constant of proportionality (continuous growth). the values of the coefficients for each country are listed in table . as stated in the previous sections, the trend of covid- outbreak varies between countries at different levels (e.g., death rates, total infected cases, and containment). this section focuses on fitting the actual data of the selected countries into regression-based equations/models that help in understanding the covid- trajectory for a better projection. once an accurate model is developed (r > . ) for each case, it was used to project the future behavior of covid- to provide potential statistics. this will help in developing proactive action plans and the necessary strategic measures to contain such pandemics in the future too. starting with group a, selected countries such as switzerland and ireland, a good regression fit for both countries was obtained from the logistic model with r > . ( figure ) to fit the "s" shaped trend. the fitted model of total covid- cases (tcov) for both countries is expressed by equation ( ): we have not carried out a sensitivity test in the current study to investigate the effect of each parameter of the logistic model (m and k) on the infection rate because it is not of our interest at this stage. given that, they are generally defined as follows, m is the amount after growth and k is the constant of proportionality (continuous growth). the values of the coefficients for each country are listed in table . the trajectory projection of group a consistently suggests that the pandemic will continue to be contained for all of the group a countries. the group b countries' trajectory is different from the group a countries, and therefore a different model was sought to fit such trend. the regression fit that best described the group b behavior is an exponential growth model with r ≥ . as expressed below: = ( ) where the values of the coefficients for each country in this group are listed in table . generally, the exponential growth is deceptive because it starts off slowly and after a few days it jumps to enormous numbers. unfortunately, this is what exactly happened to some of the countries during the covid- pandemic. a set of graphs in figure shows the current and future trajectory of brazil and india in group b. over the same timeframe, all countries experienced a very slow increase on each day and continued to do so for a few days. this means that the change in y-axis was close to zero (slope of the curve). however, after a few doublings the total daily covid- infected cases was increasing with a sharp slope recording higher changes of new cases (Δy) until it reached enormous numbers. the group b countries' trajectory is different from the group a countries, and therefore a different model was sought to fit such trend. the regression fit that best described the group b behavior is an exponential growth model with r ≥ . as expressed below: where the values of the coefficients for each country in this group are listed in table . generally, the exponential growth is deceptive because it starts off slowly and after a few days it jumps to enormous numbers. unfortunately, this is what exactly happened to some of the countries during the covid- pandemic. a set of graphs in figure shows the current and future trajectory of brazil and india in group b. over the same timeframe, all countries experienced a very slow increase on each day and continued to do so for a few days. this means that the change in y-axis was close to zero (slope of the curve). however, after a few doublings the total daily covid- infected cases was increasing with a sharp slope recording higher changes of new cases (∆y) until it reached enormous numbers. if this is not controlled sooner, the total recorded new cases of covid- for these countries will further double claiming more precious lives. for example, the total predicted total covid- infected cases for brazil, india, and usa by august is expected to be around , , , , , , and , , with the number of deaths expected to be equal to , , , , and , , , respectively. despite the fact that the usa is leading the world in the total recorded infected cases, brazil will slightly pass the usa by august as predicted by the model. this is due to the fact that the coefficient of the exponential term for brazil is higher suggesting that the exponential growth stage of brazil is severer than that of usa. having said that, the total deaths in the usa will continue to be higher than the rest of the countries. actual observations proofed that the future actual statistics would be less than the predicted values due to the implementation of physical measures such as social distancing, wearing masks, lock-down, disinfection, and travel restrictions. currently, there are many countries exhibiting a similar trend to group b that caused the world trajectory to follow an exponential growth model ( figure ) with r = . . the world's total covid- infected cases trajectory was suited more for the exponential growth model (equation ( )) in the second interval (after march). if the pandemic is not contained, the model (tcovw) predicts that the world's total new infected cases would reach , , by august with total deaths equal to , , . if this is not controlled sooner, the total recorded new cases of covid- for these countries will further double claiming more precious lives. for example, the total predicted total covid- infected cases for brazil, india, and usa by august is expected to be around , , , , , , and , , with the number of deaths expected to be equal to , , , , and , , , respectively. despite the fact that the usa is leading the world in the total recorded infected cases, brazil will slightly pass the usa by august as predicted by the model. this is due to the fact that the coefficient of the exponential term for brazil is higher suggesting that the exponential growth stage of brazil is severer than that of usa. having said that, the total deaths in the usa will continue to be higher than the rest of the countries. actual observations proofed that the future actual statistics would be less than the predicted values due to the implementation of physical measures such as social distancing, wearing masks, lock-down, disinfection, and travel restrictions. currently, there are many countries exhibiting a similar trend to group b that caused the world trajectory to follow an exponential growth model ( figure ) with r = . . the world's total covid- infected cases trajectory was suited more for the exponential growth model (equation ( )) in the second interval (after march). if the pandemic is not contained, the model (tcov w ) predicts that the world's total new infected cases would reach , , by august with total deaths equal to , , . if this is not controlled sooner, the total recorded new cases of covid- for these countries will further double claiming more precious lives. for example, the total predicted total covid- infected cases for brazil, india, and usa by august is expected to be around , , , , , , and , , with the number of deaths expected to be equal to , , , , and , , , respectively. despite the fact that the usa is leading the world in the total recorded infected cases, brazil will slightly pass the usa by august as predicted by the model. this is due to the fact that the coefficient of the exponential term for brazil is higher suggesting that the exponential growth stage of brazil is severer than that of usa. having said that, the total deaths in the usa will continue to be higher than the rest of the countries. actual observations proofed that the future actual statistics would be less than the predicted values due to the implementation of physical measures such as social distancing, wearing masks, lock-down, disinfection, and travel restrictions. currently, there are many countries exhibiting a similar trend to group b that caused the world trajectory to follow an exponential growth model ( figure ) with r = . . the world's total covid- infected cases trajectory was suited more for the exponential growth model (equation ( )) in the second interval (after march). if the pandemic is not contained, the model (tcovw) predicts that the world's total new infected cases would reach , , by august with total deaths equal to , , . this section considers fitting the actual data for the infection cases of the selected countries using sir modeling and obtaining the prediction results in terms of total number of infection cases and end of pandemic dates. the results given in table and figures - show that the countries in group a are at the end state of the pandemic, which indicates an outbreak control. all these countries already passed the expected % end of pandemic dates. the prediction curves for the countries in group b show that they have just passed the inflection point of the curve and started the deacceleration phase. this indicates that the outbreak is still uncontrolled, and it is expected that these countries reach the outbreak control sometime in august. the prediction curve shows that some of the group b countries, especially usa, went through several sub-waves of the disease spread. this section considers fitting the actual data for the infection cases of the selected countries using sir modeling and obtaining the prediction results in terms of total number of infection cases and end of pandemic dates. the results given in table and figures - show that the countries in group a are at the end state of the pandemic, which indicates an outbreak control. all these countries already passed the expected % end of pandemic dates. the prediction curves for the countries in group b show that they have just passed the inflection point of the curve and started the deacceleration phase. this indicates that the outbreak is still uncontrolled, and it is expected that these countries reach the outbreak control sometime in august. the prediction curve shows that some of the group b countries, especially usa, went through several sub-waves of the disease spread. this section considers fitting the actual data for the infection cases of the selected countries using sir modeling and obtaining the prediction results in terms of total number of infection cases and end of pandemic dates. the results given in table and figures - show that the countries in group a are at the end state of the pandemic, which indicates an outbreak control. all these countries already passed the expected % end of pandemic dates. the prediction curves for the countries in group b show that they have just passed the inflection point of the curve and started the deacceleration phase. this indicates that the outbreak is still uncontrolled, and it is expected that these countries reach the outbreak control sometime in august. the prediction curve shows that some of the group b countries, especially usa, went through several sub-waves of the disease spread. applying the previous studies on local data for the state of kuwait resulted in the trajectory depicted in figure . the actual data was fitted to an exponential growth model with an r > . as expressed in equation ( ) . one can clearly visualize that the slope of the curve has changed since the end of april indicating the start of the exponential growth second stage/interval ( ) as those in group b and the world. this suggests that the state of kuwait has done a commendable job in reacting right away with this covid- outbreak and took all the necessary measures to control it, which resulted in delaying stage as much as possible. with the current trend, the model predicted that the total infected cases in the state of kuwait by august would be about , . applying the previous studies on local data for the state of kuwait resulted in the trajectory depicted in figure . the actual data was fitted to an exponential growth model with an r > . as expressed in equation ( ) . one can clearly visualize that the slope of the curve has changed since the end of april indicating the start of the exponential growth second stage/interval ( ) as those in group b and the world. this suggests that the state of kuwait has done a commendable job in reacting right away with this covid- outbreak and took all the necessary measures to control it, which resulted in delaying stage as much as possible. with the current trend, the model predicted that the total infected cases in the state of kuwait by august would be about , . as shown in figure , the results for sir-modeling for the infection cases in kuwait show that kuwait went through two main sub-waves of the disease spread and passed the inflection point of the second sub-wave by the beginning of july. the model predicts the pandemic to end % by july and % by august . the total infected cases are predicted to be , , which might be more realistic than the corresponding result of the regression model. as shown in figure , the results for sir-modeling for the infection cases in kuwait show that kuwait went through two main sub-waves of the disease spread and passed the inflection point of the second sub-wave by the beginning of july. the model predicts the pandemic to end % by july and % by august . the total infected cases are predicted to be , , which might be more realistic than the corresponding result of the regression model. applying the previous studies on local data for the state of kuwait resulted in the trajectory depicted in figure . the actual data was fitted to an exponential growth model with an r > . as expressed in equation ( ) . one can clearly visualize that the slope of the curve has changed since the end of april indicating the start of the exponential growth second stage/interval ( ) as those in group b and the world. this suggests that the state of kuwait has done a commendable job in reacting right away with this covid- outbreak and took all the necessary measures to control it, which resulted in delaying stage as much as possible. with the current trend, the model predicted that the total infected cases in the state of kuwait by august would be about , . as shown in figure , the results for sir-modeling for the infection cases in kuwait show that kuwait went through two main sub-waves of the disease spread and passed the inflection point of the second sub-wave by the beginning of july. the model predicts the pandemic to end % by july and % by august . the total infected cases are predicted to be , , which might be more realistic than the corresponding result of the regression model. the main pathways of covid- spread are through respiratory droplets either coughing, speaking or sneezing, body fluid contact, or touching contaminated surfaces [ ] . the prevention/containment of the virus at healthcare settings is more important because it will not only ensure the safety of healthcare workers but will prevent the transmission and spread of the virus. it has also been reported that conventional face masks and ordinary clothing do not provide % protection [ ] . therefore, development of new strategies to prevent virus transmission through common pathways is critical. below we describe current and potential strategies of prevention. the virus filtering capability of masks depends on the design and materials they are made up of and on the size of the particulates. the current masks have limited ability to protect against aerosol and smaller droplets with surgical and n masks having the best protection. therefore, development of masks with antiviral capabilities can substantially reduce transmission of the virus. furthermore, current masks from fossil fuel based polymeric materials do not degrade and will create a potential pollution threat to the environment. therefore, biodegradable antimicrobial masks could be a great potential option. the contaminated surfaces are another contributor to the spread and covid- is reported to remain present on surfaces for several hours to days [ ] . the current surface cleaning and disinfection methods are not highly effective where a single wiping of the surfaces becomes dry within min and recovery of the bacteria and viruses is reportedly high [ ] . therefore, efforts should be made to new preventive measures for surface decontaminations. one such method is nano-coating, which can enhance the effectiveness up to several folds compared to current technologies. the emerging self-cleaning nano-coatings have a great future potential to prevent surfaces against such microbial threats. other countries should learn from those who preceded them in the present covid- pandemic. in general, most of the developed countries went through a tough time in dealing with this outbreak. the trajectory of the covid- pandemic, for some countries, went through three critical stages depicting a logistic behavior, as shown in figure . the deceptive stage ( ) from the start of the outbreak that varied from one week (in china) to about a month (in usa). then, it was followed by an uncontrolled exponential increase stage that lasted in some countries for about days (in china, switzerland, and ireland) and the rest of the countries unfortunately still experiencing it (usa, brazil, spain, and india). the third stage (containment stage) applies to the countries in group a that controlled the outbreak. the maximum impact of this covid- pandemic occurred during the uncontrolled stage ( ), which mainly depended on the deceptive stage ( ). the shorter the deceptive stage, the shorter the controlling stage and hence the less damage occurred, and vice versa. that is why the countries performance of group a was better than that of group b because they took serious measures right from the beginning of the covid- infections (short deceptive stage ) that resulted in a shorter and less steep uncontrolled stage followed by a controlled stage. amongst the group b countries and based on regression modeling, brazil could potentially lead the world in the total infected cases in the next few weeks if the circumstances remain the same. however, the sir-modeling results predict that the usa will continue leading the world in terms of the total infected cases. the state of kuwait covid- trajectory is similar to that of group b (uncontrolled). both regression and sir-modeling results lead to the same general conclusion that countries in group a reached the controlling stage, whereas countries in group b are still far away from reaching this stage. the maximum impact of this covid- pandemic occurred during the uncontrolled stage ( ), which mainly depended on the deceptive stage ( ). the shorter the deceptive stage, the shorter the controlling stage and hence the less damage occurred, and vice versa. that is why the countries performance of group a was better than that of group b because they took serious measures right from the beginning of the covid- infections (short deceptive stage ) that resulted in a shorter and less steep uncontrolled stage followed by a controlled stage. amongst the group b countries and based on regression modeling, brazil could potentially lead the world in the total infected cases in the next few weeks if the circumstances remain the same. however, the sir-modeling results predict that the usa will continue leading the world in terms of the total infected cases. the state of kuwait covid- trajectory is similar to that of group b (uncontrolled). both regression and sir-modeling results lead to the same general conclusion that countries in group a reached the controlling stage, whereas countries in group b are still far away from reaching this stage. what needs to be done is to limit the spread of the disease as much as possible. this results in delaying the second stage, and the sharp increase would happen over a longer period instead of on a daily basis that results in reducing the slope of the curve to be less steep ( figure ). this will spread the new cases over a longer period enabling the health care system to accommodate the existing patients instead of having enormous new cases in a short timeframe. this can be achieved by taking the right measures at the government and individual levels, such as quarantine, personal hygiene, lock-down, curfew, etc. this is what is happening now in some of the countries. what needs to be done is to limit the spread of the disease as much as possible. this results in delaying the second stage, and the sharp increase would happen over a longer period instead of on a daily basis that results in reducing the slope of the curve to be less steep ( figure ). this will spread the new cases over a longer period enabling the health care system to accommodate the existing patients instead of having enormous new cases in a short timeframe. this can be achieved by taking the right measures at the government and individual levels, such as quarantine, personal hygiene, lock-down, curfew, etc. this is what is happening now in some of the countries. all the selected countries in both groups recorded lower death percentages than that of the world during the outbreak timeframe. the exponent value (b) of the exponential growth model determines the severity (slope) of the covid- trajectory. that is why the usa is leading the world in the total infected new cases now and brazil may surpass the usa in the next few weeks if the severity of the exponential remains the same. since the model did not consider effects such as containment strategies and other related governmental interventions taken by countries, this limitation could cause slight inaccuracies in the results of the prediction models. all the selected countries in both groups recorded lower death percentages than that of the world during the outbreak timeframe. the exponent value (b) of the exponential growth model determines the severity (slope) of the covid- trajectory. that is why the usa is leading the world in the total infected new cases now and brazil may surpass the usa in the next few weeks if the severity of the exponential remains the same. since the model did not consider effects such as containment strategies and other related governmental interventions taken by countries, this limitation could cause slight inaccuracies in the results of the prediction models. emerging and re-emerging viruses in the era of globalization visualizing the history of pandemics, visual capitalist epidemics: past, present and future-what are the risks? from pasteur to genomics: progress and challenges in infectious diseases as ebola death toll rises, remembering history's worst epidemics covid- . coronavirus outbreak. world meters. . available online biology of microorganisms-microbiology an overview of their replication and pathogenesis structure, function, and evolution of coronavirus spike proteins lung pathology of fatal severe acute respiratory syndrome characterization and complete genome sequence of a novel coronavirus, coronavirus hku , from patients with pneumonia who investigates china's fall in sars cases isolation of a novel coronavirus from a man with pneumonia in saudi arabia evaluation and treatment coronavirus transmission of influenza a in a student office based on realistic person-to-person contact and surface touch behaviour corona virus diseases (covid ) situation report clinical features of patients infected with novel coronavirus in wuhan early transmission dynamics in wuhan, china, of novel corona virus infected pneumonia first case of novel coronavirus in the united states transmission of -ncov infection from an asymptomatic contact in germany preliminary estimation of the basic reproduction number of novelcoronavirus ( -ncov) in china, from to : a data-driven analysis in the early phase of the outbreak a simulation on potential secondary spread of novel coronavirus in an exported country using a stochastic epidemic seir model prediction of the epidemic peak of coronavirus disease in japan optimization method for forecasting confirmed cases of covid- in china short-term forecasts of the covid- epidemic in guangdong and zhejiang real-time estimation of the risk of death from novel coronavirus (covid- ) infection: inference using exported cases the mathematics of infectious diseases matlab central file exchange estimation of the final size of the coronavirus epidemic by the sir model a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster protecting health-care workers from subclinical coronavirus infection aerosol and surface stability of sars-cov- as compared with sars-cov- residual viral and bacterial contamination of surfaces after cleaning and disinfection this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research received no external funding. the authors declare no conflict of interest. key: cord- - w kc c authors: ramiro, sofia; mostard, rémy l m; magro-checa, césar; van dongen, christel m p; dormans, tom; buijs, jacqueline; gronenschild, michiel; de kruif, martijn d; van haren, eric h j; van kraaij, tom; leers, mathie p g; peeters, ralph; wong, dennis r; landewé, robert b m title: historically controlled comparison of glucocorticoids with or without tocilizumab versus supportive care only in patients with covid- -associated cytokine storm syndrome: results of the chic study date: - - journal: ann rheum dis doi: . /annrheumdis- - sha: doc_id: cord_uid: w kc c objectives: to prospectively investigate in patients with severe covid- -associated cytokine storm syndrome (css) whether an intensive course of glucocorticoids with or without tocilizumab accelerates clinical improvement, reduces mortality and prevents invasive mechanical ventilation, in comparison with a historic control group of patients who received supportive care only. methods: from april , patients with covid- -associated css, defined as rapid respiratory deterioration plus at least two out of three biomarkers with important elevations (c-reactive protein > mg/l; ferritin > µg/l; d-dimer > µg/l), received high-dose intravenous methylprednisolone for consecutive days ( mg on day followed by mg on days – ). if the respiratory condition had not improved sufficiently (in %), the interleukin- receptor blocker tocilizumab ( mg/kg body weight, single infusion) was added on or after day . control patients with covid- -associated css (same definition) were retrospectively sampled from the pool of patients (n= ) admitted between march and march, and matched one to one to treated patients on sex and age. the primary outcome was ≥ stages of improvement on a -item who-endorsed scale for trials in patients with severe influenza pneumonia, or discharge from the hospital. secondary outcomes were hospital mortality and mechanical ventilation. results: at baseline all patients with covid- in the treatment group (n= ) and control group (n= ) had symptoms of css and faced acute respiratory failure. treated patients had % higher likelihood on reaching the primary outcome (hr: . ; % ci . to . ) ( days earlier), % less mortality (hr: . ; % ci . to . ) and % less invasive mechanical ventilation (hr: . ; % ci . to . ). treatment effects remained constant in confounding and sensitivity analyses. conclusions: a strategy involving a course of high-dose methylprednisolone, followed by tocilizumab if needed, may accelerate respiratory recovery, lower hospital mortality and reduce the likelihood of invasive mechanical ventilation in covid- -associated css. objectives to prospectively investigate in patients with severe covid- -associated cytokine storm syndrome (css) whether an intensive course of glucocorticoids with or without tocilizumab accelerates clinical improvement, reduces mortality and prevents invasive mechanical ventilation, in comparison with a historic control group of patients who received supportive care only. methods from april , patients with covid- associated css, defined as rapid respiratory deterioration plus at least two out of three biomarkers with important elevations (c-reactive protein > mg/l; ferritin > µg/l; d-dimer > µg/l), received high-dose intravenous methylprednisolone for consecutive days ( mg on day followed by mg on days [ ] [ ] [ ] [ ] . if the respiratory condition had not improved sufficiently (in %), the interleukin- receptor blocker tocilizumab ( mg/kg body weight, single infusion) was added on or after day . control patients with covid- -associated css (same definition) were retrospectively sampled from the pool of patients (n= ) admitted between march and march, and matched one to one to treated patients on sex and age. the primary outcome was ≥ stages of improvement on a -item who-endorsed scale for trials in patients with severe influenza pneumonia, or discharge from the hospital. secondary outcomes were hospital mortality and mechanical ventilation. results at baseline all patients with covid- in the treatment group (n= ) and control group (n= ) had symptoms of css and faced acute respiratory failure. treated patients had % higher likelihood on reaching the primary outcome (hr: . ; % ci . to . ) ( days earlier), % less mortality (hr: . ; % ci . to . ) and % less invasive mechanical ventilation (hr: . ; % ci . to . ). treatment effects remained constant in confounding and sensitivity analyses. conclusions a strategy involving a course of highdose methylprednisolone, followed by tocilizumab if needed, may accelerate respiratory recovery, lower hospital mortality and reduce the likelihood of invasive mechanical ventilation in covid- -associated css. cytokine storm syndrome (css), a state of systemic hyperinflammation, is a rare and potentially lethal complication of various infections, malignancies and autoimmune diseases such as systemic juvenile idiopathic arthritis. css is found in alarmingly high frequencies ( %- %) in patients with covid- pneumonia and may cause significant morbidity, including multiorgan failure, and mortality. css can be suspected if patients experience rapid respiratory deterioration, in combination with high fever and disproportionally high c-reactive protein (crp) and serum ferritin, among others. while a curative therapy for covid- is still lacking, intensive immunosuppressive treatment may ameliorate covid- -associated css and improve the outcome. to date, information about immunosuppressive treatment of covid- associated css is only anecdotal. [ ] [ ] [ ] [ ] key messages what is already known about this subject? ► covid- -associated cytokine storm syndrome (css) is an important complication of severe acute respiratory syndrome coronavirus infection in up to % of the patients, often responsible for a fatal outcome. what does this study add? ► a strategy involving a course of high-dose glucocorticoids, followed by tocilizumab if needed, has shown to accelerate respiratory recovery, lower hospital mortality and reduce the likelihood of invasive mechanical ventilation compared with supportive care only in covid- -associated css. how might this impact on clinical practice or future developments? ► css should be recognised and considered as a treatable complication of covid- and immunosuppressive treatment should be started timely. ► a treatment with high-dose glucocorticoids is a convenient choice since glucocorticoids are safe, widely available and inexpensive. the zuyderland medical center (zmc) is a large teaching hospital responsible for the care of . inhabitants in the south of the province of limburg. south limburg has an ageing population and a relatively poor health status and the covid- pandemic has hit the region hard. between march and march more than patients with severe covid- were admitted for hospital care. thirty per cent had symptoms of covid- -associated css, many of whom required intensive care treatment and over % died. by the end of march , zmc physicians agreed to start an experimental treatment protocol for covid- -associated css and follow these patients meticulously in a prospective observational study. rheumatologists were consulted because of their expertise in immunosuppressive treatment, as advised in recent european league against rheumatism recommendations. the protocol responded to the broadly felt need among physicians to do more than 'only' providing supportive care to them. the clinicians refuted the seemingly obvious choice for a randomised controlled trial (rct) with intensive immunosuppressive treatment versus supportive care alone in patients with css, with reference to the unacceptably high hospital mortality under supportive care only conditions, the reluctance to confront critically ill patients with an estimated % mortality and a one-to-one gamble of not receiving additional experimental treatment, and the overwhelming time pressure of the unprecedented pandemic. here we describe the results of patients with covidassociated css who have been treated according to the protocol (period ) in comparison to patients with covid-associated css who had received supportive care before the protocol was in effect (period ) (covid high-intensity immunosuppression in cytokine storm syndrome (chic) study). each patient in the treatment group was matched one to one to a control patient in order to create pseudorandomisation. in order to avoid exhaustion of the hospital care system, the zmc had agreed upfront with local general practitioners and nursing home physicians to not refer (suspected) patients with covid- to the hospital for diagnosis and supportive care if severe pre-existing clinical frailty was present, life expectancy was obviously limited or severe comorbidity in combination with covid- was expected to have a very unfavourable outcome. all patients admitted to zmc for covid- were registered in the zuyderland covid- registry (elvis) from which demographic data, clinical signs and symptoms at presentation could be retrieved. all patients in the elvis received written information about the registry as well as an opt-out form in case they did not want to participate. none of the patients included in the chic study objected to participation. treatment group (period ): patients eligible to the chic treatment protocol had to have a diagnosis of covid- and evidence for concomitant css. a diagnosis of covid- involved the presence of clinical signs and symptoms suggestive of covid- in combination with either a positive pcr test for severe acute respiratory syndrome coronavirus (sars-cov- ) or a chest ct result of covid- ct classification (co-rads) or . in order to meet the criteria for css in this study, patients had to have an oxygen saturation at rest ≤ % (ambient air) or tachypnoea (> /min). in addition, they had to meet at least two out of the following three biomarker criteria: high crp (> mg/l), high serum ferritin (> µg/l at one occasion, or a twofold increase of the level at admission within hours) and high d-dimer level (> µg/l). there were no pertinent exclusion criteria for the treatment protocol. every patient was fully informed about the off-label character of the treatment strategy and the potential side effects. informed consent was obtained before the start of the treatment strategy. if the patient was incapable of executing permission, informed consent was given by the closest relative. control group (period ): patients potentially eligible to the retrospectively assembled control group had to be admitted between march and march . their data were collected retrospectively for the presence of covid- pneumonia as described above. in addition, clinical data about daily respiratory status were retrieved, as well as crp, serum ferritin and serum d-dimer levels. missing laboratory tests were determined afterwards in stored serum samples, when available. the criterion for respiratory deterioration was checked as described above. css biomarker criteria were applied as described above. the eligibility of all control patients was independently checked in the patient's electronic file by two physicians (cd and cmc) and cases of disagreement were decided by consensus with a third physician (sr), without knowledge of the clinical course and outcome. the primary outcome was discharge from the hospital or improvement of at least two stages (compared with baseline; whatever came first) on a who-endorsed -point ordinal scale, originally developed for trials with patients with influenza pneumonia, and used in several trials with patients with covid- . - the stages are: ( ) non-hospitalised, able to resume normal activities; ( ) non-hospitalised, but unable to resume normal activities; ( ) hospitalised, not requiring oxygen therapy; ( ) hospitalised, requiring additional oxygen therapy; ( ) hospitalised, requiring high-flow nasal oxygen therapy, non-invasive mechanical ventilation or both; ( ) hospitalised, requiring extracorporeal membrane oxygenation, mechanical ventilation or both; and ( ) death. in our study we used the scale from to , as we could not (yet) collect information on whether discharged patients are able to resume normal activities. key secondary outcomes were hospital mortality and the need to start invasive mechanical ventilation. other secondary outcomes were improvement of one stage in the who score, who score at days and , independence from oxygen therapy, duration of mechanical ventilation in the survivors and duration of hospitalisation in the survivors. baseline and time points of primary and secondary outcomes, if met, were determined prospectively for all treated patients and in retrospect by chart review for all control patients. the treatment protocol included two steps: ( ) immediate treatment with methylprednisolone (mp) mg intravenously on day , followed by mp mg intravenously on days - , and an option for a -day extension if considered necessary and safe; ( ) escalation of immunosuppressive treatment with a monoclonal antibody directed against the interleukin- receptor, tocilizumab (tcz), between day and day (single-dose tcz, mg/kg body weight intravenous, max mg). criteria for escalation with tcz were lack of clinical improvement or worsening in respiratory status (assessed on the who scale). criteria for a -day extension of mp at day were clear clinical improvement in respiratory status (≥ stage improvement on the who scale) but a partial decrease of biomarkers (crp reduction less than %). close multidisciplinary monitoring was an integral part of the strategy and was assured by daily meetings (rlmm, rbml, cmc, sr, cmpd, rp, mg, ehjvh, jb) in which all patients in the protocol were discussed and treatment was optimised. discussions focused on immunosuppressive treatment decisions, treating secondary infections, thromboembolism and cardiac complications. glucose levels were assessed twice daily during treatment with mp. cointerventions: all patients received ceftriaxone ( g every hours for days) and up to may in the presence of oxygen saturation < % chloroquine mg every hours following a loading dose of mg unless the corrected qt interval on an ecg was prolonged (> ms). informed consent was obtained for this off-label therapy. complications during hospitalisation were closely monitored. complications of special interest were well-known adverse events related to short-term high-dose mp and tcz administration, and included bacterial or fungal infection, acute-onset congestive heart failure or aggravation of existing congestive heart failure, arrhythmia and gastrointestinal bleeding. matching procedure: after the first selection step, the two data files containing patients from the treatment group and patients from the control group were : matched on sex (m, f) and age (five age classes: < , - , - , - , ≥ years) using the match command in stata. the best matching result yielded two groups of patients each ( % of potentially available patients could be matched). comparability at baseline of treatment group and control group was analysed descriptively for a wide range of variables and common univariable statistical tests for between-group differences were applied to test if the null hypothesis of no difference had to be rejected. patients in the treatment group and control group were compared on a time-to-event basis, using proportional hazards regression analysis (cox). censoring of follow-up took place: ( ) when the patient died; ( ) when the patient was discharged; or ( ) at the end of follow-up on may (whatever came first). by convention, a patient who had died during the course of the study could not have improved ('zero improvement'). because of the relatively small sample in relation to the relatively high number of variables at baseline, a prespecified analysis for effect mediation and confounding preceded the final selection of variables for multivariable adjustment. this analysis involved a two-step procedure, in which effect modification was excluded first by testing per baseline variable the interaction of that variable with treatment group, under adjustment for the main effects. thereafter, confounding was checked per variable by investigating if the magnitude of the association between treatment group and outcome changed > % by adding the variable to the model. it was decided upfront that-apart from treatment group, age and sex (default variables)-only variables with a clinically relevant interaction and a p value < . were to be analysed in separate strata, and that only variables with true confounding potential that met the definition for confounding were to be included in the final multivariable models. the proportional hazards assumption was checked by graphical diagnostics and statistical testing using stata v. . kaplan-meier survival plots were constructed and the survival curves for treated and control groups were compared using a log-rank test. the effect size for treatment in the final multivariable models was challenged for robustness by several sensitivity analyses. the three sensitivity analyses were of the same type as the main analyses but on different patient selections: ( ) all patients minus those who were already on mechanical ventilation at baseline; ( ) all patients minus those who had received tcz; or ( ) all patients minus those in the lowest (< years) and highest (≥ years) age groups (trimming). at the start of the chic study there was only provisional information available about hospital mortality in patients with covid- -associated css under supportive care only conditions. we assumed % hospital mortality based on early experience. in order to declare an observed absolute difference of % or more statistically significant ( % mortality reduction, at alpha= . and beta= . (power: %)), at least patients per group were required. there was no funding source of this study. the corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication. after matching, patients ( per group) were available for analysis. all patients and controls were caucasians. mean age and sex distribution were similar. the age range was wide; younger and older patients were appropriately represented (online supplementary table s ). table shows a broad array of variables that describe the make-up of both groups. in general, the distribution of variables across groups was well balanced, but a few differences stood out. mean body mass index (bmi) was high in both groups, but almost units higher in the control group than in the treatment group. covid- pcr positivity was slightly higher in the control group, which was the consequence of an imminent shortage in test capacity over time, in combination with increasing confidence in the diagnostic value of chest ct under high a priori probability conditions (the co-rads scores were balanced across groups). differences in comorbidities at baseline were found in either direction. the control group contained more patients with diabetes (p< . ). the treatment group had more patients with cardiovascular disease (p= . ) and arrhythmias (p= . ). the charlson comorbidity index was low on average but slightly higher in the control group (p= . ). the mean who score at baseline was similar in both groups, with the notion that the distribution across stages is skewed towards more patients requiring mechanical ventilation in the control group, offset by more patients requiring high-flow oxygen in the treatment group. biomarkers of css showed very high mean levels for crp, serum ferritin and d-dimer in both groups, but serum ferritin (p= . ) and d-dimer (p= . ) levels were slightly higher in the control group. both ferritin and d-dimer had a non-normal distribution with outliers, and more than % of d-dimer levels in the control group were missing. all patients in both groups (except for one in the treatment group) received antibiotic treatment by protocol, and almost table shows the primary and secondary outcomes. as compared with patients in the control group, patients in the treatment group had a % higher likelihood of reaching the primary outcome of two-stage improvement in respiratory status (hr: . ; % ci . to . , table ) and they reached it on average days (median) earlier, all of them before discharge. their who scores at days and (table ) were consistently better (p< . ). the development of who clinical improvement per group is visualised in figure . curves start to separate from to days of follow-up. hospital mortality was % lower in the treatment group than in the control group (hr: . ; % ci . to . ; table , figure ). at hospital day , ten patients in the treatment group had deceased as compared with in the control group (p< . ) (table ). the likelihood to evolve to mechanical ventilation due to respiratory deterioration was % lower in the treatment group (hr: . ; % ci . to . ; table , online supplementary figure s ). among patients who were not mechanically ventilated at baseline (table ), the daily incidence of mechanical ventilation (new start) was . % vs . % (p= . ). once mechanically ventilated, the duration of mechanical ventilation was not different across groups. the analyses of effect modification and confounding revealed one clinically relevant interaction (treatment group vs serum ferritin level at baseline) and six relevant confounders (bmi, smoking status, hypertension, diabetes, cardiovascular disease and arrhythmia). the effect size of treatment was higher in patients with serum ferritin levels above the median the six relevant confounders were entered as covariates, together with age and sex, in the multivariable models for all outcomes (table ) . adjustment for confounding increased rather than decreased the estimated treatment effect for all seven analysed outcomes. all models were checked for not violating the proportional hazards assumption (online supplementary figure s ). all main effects remained constant and statistically significant in the three sensitivity analyses (table ) . of note, in the sensitivity analysis that excluded the % patients who had received tcz, the treatment effects for all outcomes increased and maintained statistical significance, suggesting that a clinically relevant treatment effect can be reached by high-dose gc alone (table , online supplementary table s ) . patients tolerated the short but intensive immunosuppressive therapy well. complications were balanced between groups (table ). bacterial infections were diagnosed during hospitalisation in patients ( in the treatment group vs in the control group). there was a trend towards more pulmonary embolism in the treatment group (p= . ). arrhythmias occurred in both groups, but slightly less frequently in the treatment group (p= . ). this historically controlled comparison of a strategy with intensive immunosuppression and close monitoring versus a strategy with supportive care only in patients with covid- -associated css suggests that clinically relevant improvement of respiratory status is % more likely, and can be accelerated by a median of days, that hospital mortality can be reduced by % and that the need for mechanical ventilation during admission can be reduced by %. these outcomes were robust and, especially if confirmed in randomised trials later on, highly relevant from a medical and societal perspective. it should be emphasised that this study cannot be read and interpreted as an rct. prognostic similarity at baseline cannot be assumed, in spite of several efforts to match the control patients as closely as possible to the treated patients. residual confounding by unmeasured variables is likely. while patients were almost perfectly matched for age and gender and efforts were made to assure that control patients were only sampled if they had evidence of css, certain baseline differences remained, although in both directions. diabetes and obesity were slightly more prevalent in the control patients and some biomarkers of css were slightly higher too. cardiovascular comorbidity and arrhythmias, on the other hand, were more prevalent in the treated patients. a rigorous confounding analysis revealed that none of these potential confounders had a reducing influence on the magnitude of the treatment effect, which importantly adds to the credibility of the univariable results. instead, hrs seemed to increase rather than decrease after adjusting for confounders, an observation that may point to statistical overfitting and therefore of limited relevance. however, a potential (time) period effect may have affected the results. such an effect is inherent to the design of the study and cannot be adjusted for. all control patients were admitted at least weeks earlier than the patients in the treatment group. these patients got sick in period , the initial phase of the pandemic, and it cannot be precluded that covid- -associated css was more severe in period than in period , that patients received less than optimal supportive care during the first hectic weeks of the pandemic or that infected patients of the first hour simply had worst health. this argument, however, can also be reversed. during period intensive care capacity still was relatively high and there was some consensus among experts to start lowthreshold mechanical ventilation, while patients in period had to 'compete with' those that already occupied high-care facilities and staff got exhausted. that more patients in the control group than in the treatment group already received mechanical ventilatory support at baseline is reflective of this situation. adjustment for this imbalance did not affect the treatment effect. the argument that covid- -associated css was more severe in period as compared with in period also lacks substantiation. the start of our protocol coincided with the peak in covid- admissions in the netherlands ( april) and preceded the peak in mortality by - days. the incidence density of admissions and mortality increased during period and decreased during period , but mortality as a fraction of number of hospital admissions in the netherlands was actually higher in period than in period . while this is an indirect argument, it argues against a better prognosis of patients with covid- -associated css in period . still, we are dealing with a new disease and the standard of care is rapidly evolving. changing policies with respect to the start of mechanical ventilation, diagnosing thrombosis and anticoagulation therapy occurred even within the time frame of our study. the trend of finding more pulmonary embolism in the treatment group, for instance, is a reflection of searching with more scrutiny for thrombosis over time. such developments have an impact on the external validity (generalisability) of our study and of others to be published, and may be responsible for treatment effects in daily practice that seem less dramatic than the contrasts found in this early study. several experts, including the who, warned against treating critically ill patients with a sars-cov- infection with gcs, an advice with potentially serious implications for many patients. the risk profile of such a short course of gc for treatment of css needs to be separated from pre-existing chronic use of gc for conditions like rheumatic and musculoskeletal diseases (rmd). they particularly feared impaired virus clearance and secondary bacterial infection. however, patients in the chic study tolerated the immunosuppressive therapy remarkably well and we did not find evidence for impaired viral clearance nor for bacterial superinfection. longer follow-up, however, is needed to give final resolution about the safety and efficacy of the strategy. speculating about which component of the strategy yields most benefit is tempting but risky. we think it is the combination of early intervention (the 'window of opportunity hypothesis'), the intensive immunosuppression and the close monitoring by a multidisciplinary team that best explains the favourable results. the results of the chic study also suggest that the timely administration of high-dose gcs alone may provide significant benefit in more than half of the patients and that tcz is only needed in those cases that had insufficient clinical improvement on mp alone. this is an important finding given the limited availability of tcz in many countries and tcz's high costs. it is not unthinkable that treatment with other compounds than gc and tcz that are often used by patients with rmds, such as tumour necrosis factor alpha inhibitors, or interleukin- receptor antagonists, may have similar beneficial effects. our choice for high-dose mp, broadly available and with a wellknown profile in severe systemic inflammatory diseases, and tcz, with an existing niche indication for a rare form of iatrogenic css, was to some extent serendipitous. future rcts may give resolution but will take time. our definition of css was rather pragmatic and arbitrary but sufficed to select the ~ patients with covid- and css from a total pool of approximately ( %). when untreated, mortality in this severe subgroup was more than %. in addition to the clinical criterion of rapid deterioration of respiratory status, we used commonly available biomarkers for css at cutoff levels based on our experience with the early patients with covid- . that the treatment benefit was highest in patients with serum ferritin levels above the median value of µg/l can be seen as an important endorsement for the hypothesis that covid- -associated css determines the immediate prognosis of covid- . fine-tuning these thresholds for css and introducing other biomarkers for diagnosing css may further improve the definition of css and optimise treatment effects. the choice for the who-endorsed classification of outcomes designed for patients with severe influenza pneumonia, next to hospital mortality, appeared rational and workable. the definition of an improvement of at least two stages or hospital discharge indeed reflected clinical improvement properly. in fact, all discharged patients also met the criterion of two-stage improvement. while we in principle advocate to further study strategies like ours in rcts, it is an interesting philosophical question whether rcts with 'supportive care only' in the control group will be justifiable in future. 'supportive care only' for covid- -associated css is ethically arguable in light of the biological plausibility of css complicating covid- and its high mortality, given the likely benefit of immunosuppressive therapy, such as reported here, even though formal evidence stemming epidemiology from rcts is lacking. while the magnitude of the treatment effects found in the chic study may be somewhat downplayed by formal methodological reasoning, it is unlikely that the entire contrast is only due to residual confounding. the evaluation of the treatment of covid- -associated css may have been caught up by the crisis itself. in conclusion, we have shown here that a strategy involving a course of high-dose mp, followed by tcz in case of insufficient improvement, may accelerate respiratory recovery, lower hospital mortality and reduce the likelihood of invasive mechanical ventilation in covid- -associated css. despite these promising results, further confirmation is still needed. familial and acquired hemophagocytic lymphohistiocytosis on the alert for cytokine storm: immunopathology in covid- cytokine release syndrome in severe covid- clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study covid- : consider cytokine storm syndromes and immunosuppression risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease pneumonia in wuhan, china interleukin- blockade with high-dose anakinra in patients with covid- , acute respiratory distress syndrome, and hyperinflammation: a retrospective cohort study anakinra for severe forms of covid- : a cohort study impact of corticosteroid therapy on outcomes of persons with sars-cov- , sars-cov, or mers-cov infection: a systematic review and metaanalysis een nadere analyse van de gezondheidsachterstand in stadsregio parkstad health atlas district health services zuid-limburg eular provisional recommendations for the management of rheumatic and musculoskeletal diseases in the context of sars-cov- co-rads -a categorical ct assessment scheme for patients with suspected covid- : definition and evaluation a trial of lopinavir-ritonavir in adults hospitalized with severe covid- remdesivir in adults with severe covid- : a randomised, double-blind, placebo-controlled, multicentre trial who r&d blueprint. novel coronavirus, outline of designs for experimental therapeutics understanding the effects of age, period, and cohort on incidence and mortality rates world health organization. clinical management of severe acute respiratory infection (sari) when covid- disease is suspected trials of anti-tumour necrosis factor therapy for covid- are urgently needed the authors extensively thank the healthcare professionals from zuyderland medical center who made this study possible, despite the pandemic situation, as well as the board of zmc for the trust in the study team and the support in the conduction of the study. additionally, the authors would like to thank the medical students (susan voncken, marlieke elsendoorn, jasper broerse, twan feron, mandy jongbloed and sophie laven) involved in data entry and employees from the research department (bureau wetenschappelijk onderzoek, bwo), namely anke linssen, esther bergman, christel jacquot, marijke lemmens and audrey merry. the authors also acknowledge professor d van der heijde for her critical reading of the manuscript.contributors sr, rlmm, cmc and rbml designed the study. all authors contributed to data collection. sr and rbml analysed the data. sr, rlmm and rbml critically interpreted the results and drafted the first version of the manuscript. all coauthors discussed the findings together, critically reviewed the manuscript and approved its final version. the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests sr reports personal fees from abbvie, personal fees from eli lilly, grants and personal fees from msd, personal fees from novartis, personal fees from ucb, personal fees from sanofi, outside the submitted work. rlmm reports personal fees from boehringer ingelheim, personal fees from roche, personal fees from galapagos, outside the submitted work. cmc is a clinical trial investigator for a study sponsored by lilly and was a subinvestigator for a study sponsored by gsk. cvd reports personal fees from novartis, personal fees from roche, outside the submitted work. td reports grants from adrenomed, grants from inotrem, grants from roche, grants from shionogi and co, other from castor, outside the submitted work. mg reports personal fees from roche, personal fees from msd, outside the submitted work. mdk reports personal fees from alk, personal fees from astrazeneca, personal fees from boehringer ingelheim, personal fees from sanofi genzyme, outside the submitted work. ml reports grants from astrazeneca, grants from pfizer, personal fees from roche, outside the submitted work. rp reports grants and personal fees from pfizer, grants and personal fees from abbvie, outside the submitted work. rl reports personal fees from abbvie, personal fees from bms, personal fees from galapagos, personal fees from gilead, personal fees from jansen, personal fees from novartis, personal fees from pfizer, personal fees from roche, personal fees from ucb, outside the submitted work; and owner and director of rheumatology consultancy, a company that provides consultancy and read services for clinical trials.patient and public involvement patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. ethics approval the medical ethics committee and the board of zmc approved the study protocol and the study started enrolling patients on april .provenance and peer review not commissioned; externally peer reviewed. data availability statement data may be obtained from a third party and are not publicly available.this article is made freely available for use in accordance with bmj's website terms and conditions for the duration of the covid- pandemic or until otherwise determined by bmj. you may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.orcid ids sofia ramiro http:// orcid. org/ - - - robert b m landewé http:// orcid. org/ - - - key: cord- -oasgagpc authors: bisno, alan l.; gerber, michael a.; jack m., gwaltney; kaplan, edward l.; schwartz, richard h. title: diagnosis and management of group a streptococcal pharyngitis: a practice guideline date: - - journal: clin infect dis doi: . / sha: doc_id: cord_uid: oasgagpc this is the second in a series of practice guidelines commissioned by the infectious diseases society of america through its practice guidelines committee. the purpose of these guidelines is to provide assistance to clinicians when making decisions on treating the conditions specified in each guideline. the targeted providers are pediatricians, family practitioners, and internists. the targeted patients and setting for the acute pharyngitis guideline are pediatric, adolescent, and adult outpatients with a complaint of sore throat. funding was provided by the idsa. panel members represented experts in adult and pediatric infectious diseases. the guidelines are evidence-based. a standard ranking system was used for the strength of the recommendations and the quality of the evidence cited in the literature reviewed. the document has been subjected to external review by peer reviewers as well as by the practice guidelines committee and was approved by the idsa council. an executive summary, algorithms, and tables highlight the major recommendations. indicators of quality will assist in guideline implementation. the guideline will be listed on the idsa home page at http://www.idsociety.org. outcomes -day course to achieve maximal pharyngeal eradication of group the desired outcomes are: ( ) prevention of acute rheumatic a streptococci, but the use of certain newer agents has been reported fever; ( ) prevention of suppurative complications (e.g., peritonsillar to achieve comparable bacteriologic and clinical cure rates among abscess, cervical lymphadenitis, or mastoiditis); ( ) abatement of patients with streptococcal pharyngitis when these agents are given clinical symptoms and signs; ( ) a rapid decrease in infectivity so for £ days. however, definitive results from comprehensive studas to reduce transmission of group a b-hemolytic streptococci to ies are not available; thus, final evaluation of these proposed shorter family members, classmates, and other close contacts and to allow courses of oral antibiotic therapy is not possible, and they cannot the rapid resumption of usual activities; ( ) minimization of potenbe recommended at this time. moreover, these antibiotics have tial adverse effects of inappropriate antimicrobial therapy. much broader spectrums than penicillin, and most, even when administered for short courses, are more expensive. except under special circumstances, neither repeated bacteri-evidence ologic testing (culture or radt) of patients who have success-we reviewed a large number of clinical trials of diagnostic fully completed a course of antimicrobial therapy nor routine and treatment strategies for group a streptococcal pharyngitis. testing of asymptomatic household contacts of patients with the reports were examined for indicators of quality. for examgroup a streptococcal pharyngitis is recommended. ple, studies of treatment were evaluated for randomization, a small percentage of patients will have recurrences of acute blinding, use of streptococcal typing to differentiate treatment pharyngitis that are associated with throat cultures (or radts) failures from new infections, duration and timing of follow-up positive for group a streptococci within a short period following examinations, and statistical power [ , ] . completion of a course of antimicrobial therapy. such episodes may be treated with one of the antimicrobial agents appropriate for treatment of the initial illness. if these episodes were previously values treated with oral agents and compliance is in question, retreatment in evaluating diagnostic options, we placed a high value with intramuscular benzathine penicillin g should be considered. on selecting the diagnostic test that was most accurate for when multiple episodes occur over the course of months or years, differentiating acute pharyngitis due to group a b-hemolytic it may be difficult to differentiate viral infections in a streptococcal streptococci from that due to other agents. for evaluation of carrier from true group a streptococcal infections. certain antimitreatment, particularly high values were assigned to proven crobial agents, such as clindamycin and amoxicillin/clavulanate, clinical and bacteriologic efficacy, safety, spectrum of antimimay be beneficial because they have been shown to yield high crobial activity, and relative cost. rates of pharyngeal eradication of streptococci under these particular circumstances. the group a b-hemolytic streptococcus is the most common definition bacterial cause of acute pharyngitis [ ] . accurate diagnosis, followed by appropriate antimicrobial therapy, is important for group a streptococcal pharyngitis (pharyngotonsillitis) is an acute infection of the oropharynx and/or nasopharynx with the reasons previously stated (see the section on outcomes). although acute pharyngitis is one of the most frequent illnesses streptococcus pyogenes. for which pediatricians and other primary care physicians are consulted, less than half of patients with this condition are infected by group a streptococci. moreover, the signs and objective symptoms of group a streptococcal and nonstreptococcal pharyngitis overlap so broadly that accurate diagnosis on clinical the objective of this practice guideline is to provide recommendations for the accurate diagnosis and optimal treatment grounds alone is usually impossible [ ] . with the exception of very rare infections by certain of the of group a streptococcal pharyngitis. other pharyngeal bacterial pathogens listed in table (e.g., corynebacterium diphtheriae and neisseria gonorrhoeae), antimicrobial therapy is of no proven benefit in the treatment of acute options pharyngitis due to bacteria other than the group a streptococcus. it is therefore extremely important for physicians to be able to physicians caring for patients with acute pharyngitis must formulate differential diagnoses and determine which, if any, exclude the diagnosis of group a streptococcal pharyngitis to prevent inappropriate administration of antimicrobials to large confirmatory tests should be performed. if clinical and laboratory evaluations result in a diagnosis of group a b-hemolytic numbers of patients with pharyngitis. the administration of such therapy unnecessarily exposes patients to the associated expense streptococcal pharyngitis, one of several antimicrobial agents and treatment schedules may be selected. and hazards, and it may also contribute to the emergence of / c $$se - - : : cidal uc: cid temperate climates, it usually occurs in the winter and early spring. patients with group a b-hemolytic streptococcal pharyngitis commonly present with sore throats (generally of sudantibiotic-resistant bacteria that is being reported with increasing den onset), pain on swallowing, and fever. headache, nausea, frequency in the united states and elsewhere. vomiting, and abdominal pain may also be present, especially if a diagnosis of group a streptococcal pharyngitis is conin children. physical examination reveals tonsillopharyngeal firmed, the clinician must select the most appropriate antimicroerythema with or without exudates and tender enlarged anterior bial agent known to be effective against the group a streptococcervical lymph nodes (lymphadenitis). other findings may incus. the cost of an effective course of antimicrobial therapy clude a beefy red swollen uvula, petechiae on the palate, excorimay vary as much as -fold, depending on the drug chosen. ated nares (especially in infants), and a scarlatiniform rash. the regimens recommended herein are judged to be optimal however, none of these findings is specific for group a bin regard to specificity, safety, and cost. hemolytic streptococcal pharyngitis, and they may occur with other upper respiratory infections. conversely, the absence of recommendations fever or the presence of clinical features such as conjunctivitis, cough, hoarseness, coryza, anterior stomatitis, discrete ulcera- tive lesions, viral exanthem, and diarrhea strongly suggests a viral rather than a streptococcal etiology. differential diagnosis. viruses are the most common nonbacterial causes of acute pharyngitis (table ) [ ] . respiratory viruses such as adenovirus, parainfluenza virus, rhinovirus, and who should be tested for group a b-hemolytic streptococcal respiratory syncytial virus frequently cause acute pharyngitis. other viral agents of acute pharyngitis include coxsackievirus and echo viruses as well as herpes simplex virus. epstein-when attempting to decide whether to perform a laboratory test for a patient who presents with acute pharyngitis, the clini-barr virus is a frequent cause of acute pharyngitis that is often accompanied by the other clinical features of infectious mono-cal and epidemiological findings mentioned above should be considered before the test is performed. a history of close nucleosis (e.g., generalized lymphadenopathy and splenomegaly). systemic infections with measles virus, cytomegalovirus, contact with a well-documented case of streptococcal pharyngi-/ c $$se - - : : cidal uc: cid tis is helpful, as is an awareness of a high prevalence of group a positive throat cultures that would not otherwise be identified. thus, while initial therapeutic decisions may be made on the b-hemolytic streptococcal infections in the community. testing usually need not be performed for patients with acute pharyngi-basis of the results of an overnight culture, it is advisable to reexamine plates at hours that are negative at hours [ ] tis whose clinical and epidemiological features do not suggest a group a streptococcal etiology. selective use of diagnostic (category a, grade ii). the clinical significance of the number of group a b-hemostudies for group a b-hemolytic streptococci will result in an increase in both the proportion of positive test results and the lytic streptococcal colonies present on the throat culture plate is problematic. while cultures are more likely to be strongly percentage of patients with positive tests who are truly infected rather than merely streptococcal carriers (category a, grade ii). positive for patients with true acute group a streptococcal pharyngitis than for patients who are streptococcus carriers, efforts have been made to incorporate clinical and epidemiological features of acute pharyngitis into scoring systems that there is so much overlap that the differentiation cannot be made accurately on the basis of the degree of positivity of the throat attempt to predict the probability that a particular illness is caused by group a b-hemolytic streptococci [ , ] . how-culture alone [ ] (category a, grade ii). the most widely used test for differentiating group a strepto-ever, at best these clinical scoring systems predict positive results of throat cultures or radts only £ % of the time. cocci from other b-hemolytic streptococci in physicians' offices is probably the bacitracin disk test. this test provides a therefore, unless the diagnosis of group a streptococcal pharyngitis can be confidently excluded on clinical and epidemio-presumptive identification based on the observation that ú % of group a streptococci show a zone of inhibition around a logic grounds (see clinical diagnosis above), bacteriologic studies should be performed (category a, grade ii). disk containing . units of bacitracin, while % - % of non-group a streptococci do not [ , ] . an alternative and highly specific method of identifying throat cultures streptococcal serogroups is the detection of the group-specific cell-wall carbohydrate antigen directly on isolated bacterial culture of a throat swab on a sheep blood agar plate remains the standard for the documentation of the presence of group a colonies. commercial kits containing group-specific antisera are available for this purpose. such tests are appropriate for streptococci in the upper respiratory tract and for the confirmation of the clinical diagnosis of acute streptococcal pharyngitis use by microbiology laboratory personnel, but most physicians who perform throat cultures would find it difficult to justify [ ] (category a, grade ii). a single throat swab cultured correctly on a blood agar plate has a sensitivity of % - % in the additional expense for the minimal improvement in accuracy that serogrouping with an antigen detection test would detecting the presence of group a b-hemolytic streptococci in the pharynx [ ] (category a, grade ii). provide [ ] . several variables impact on the accuracy of the throat culture results. for example, the manner in which the swab is obtained has an important impact on the yield of streptococci from the throat culture [ , ] . throat swab specimens should be ob-a disadvantage of culturing a throat swab on blood agar plates is the delay (overnight or longer) in obtaining the culture tained from the surface of both tonsils (or tonsillar fossae) and the posterior pharyngeal wall. other areas of the oropharynx results. radts have been developed for the identification of group a b-hemolytic streptococci directly from throat swabs. and mouth are not acceptable sites for sampling, and these sites should not be touched before or after the appropriate areas although these rapid tests are more expensive than blood agar cultures, the advantage they offer over the traditional procedure have been sampled. in addition, false-negative results may be obtained if the patient has received antibiotics shortly before is the speed with which they can provide results. rapid identification and treatment of patients with streptococcal pharyngitis or at the time the throat swab specimen is collected. it has also been reported that the use of anaerobic incubation can reduce the risk of the spread of group a b-hemolytic streptococci, allowing these patients to return to school or work and selective culture media may increase the proportion of positive cultures [ , ] . however, the data on the impact of sooner, and can reduce the acute morbidity associated with this illness [ , - ] (category a, grade ii). the use of radts the incubation atmosphere and the culture media are conflicting, and, in the absence of a definite benefit, the increased cost vs. throat cultures for certain populations (e.g., patients seen in emergency departments) has been shown to significantly and effort associated with anaerobic incubation and selective culture media are difficult to justify, particularly for physicians increase the number of patients appropriately treated for streptococcal pharyngitis [ ] . who process throat cultures in their own offices [ , , ] (category a, grade ii). most of the radts that are currently available have an excellent specificity ( § %) when compared with blood agar another variable that can impact on the yield of the throat culture is the duration of incubation. tomatic pharyngitis after the organism's presence in the throat the first radts were based on latex agglutination methodis confirmed by microbiological or immunologic means (figure ology, were relatively insensitive, and had unclear endpoints. ). when there is clinical or epidemiological evidence that newer tests based on eia techniques offer more sharply deresults in a high index of suspicion, antimicrobial therapy can fined endpoints as well as increased sensitivity. more recently, be initiated while laboratory confirmation is pending provided radts for which optical immunoassay and chemiluminescent such therapy is discontinued if the diagnosis of streptococcal dna probes are used have become available. data on these pharyngitis is not confirmed. early initiation of antimicrobial newer tests suggest that they may be more sensitive than other therapy results in faster resolution of the signs and symptoms radts and perhaps even as sensitive as standard throat cul- [ - ] (category a, grade i) of the infection, but two facts tures on sheep blood agar plates. however, in view of someshould be recalled. first, group a streptococcal pharyngitis is what conflicting data [ ] , additional corroborative information usually a self-limited disease; fever and constitutional sympis needed before these tests can be recommended for routine use toms disappear spontaneously within or days of onset, even without confirmatory throat cultures for negative test results. when antimicrobial therapy is not administered [ ] . second, titers of antibodies to streptococci reflect past and not presit has been shown that therapy can be safely postponed £ days ent immunologic events and are of no value in the diagnosis after the onset of symptoms and still prevent the occurrence of of acute pharyngitis. these titers are valuable for confirming the major nonsuppurative sequel, acute rheumatic fever [ ] prior streptococcal infections in patients suspected of having (category a, grade i). acute rheumatic fever or acute glomerulonephritis. they also these facts allow the clinician flexibility in initiating therapy are helpful in prospective epidemiological studies that are conduring the evaluation of an individual patient with presumed ducted to separate patients with acute infection from those who group a streptococcal pharyngitis. the results of the initial are carriers. therapeutic studies were reported nearly years ago; since guideline: the diagnosis of acute group a streptococcal then numerous antimicrobial agents have been examined in pharyngitis should be suspected on clinical and epidemiological grounds and then supported by the results of a laboratory test. either a positive throat culture or radt provides adequate confirmation of the presence of group a b-hemolytic streptococci in the pharynx, but a negative radt result should be confirmed with a throat culture (category a, grade ii). most asymptomatic patients with group a b-hemolytic streptococci present in the upper respiratory tract after a complete course of appropriate therapy are streptococcal carriers [ , ]. therefore, follow-up throat cultures are not routinely indicated for asymptomatic patients who have received a complete course of therapy for group a streptococcal pharyngitis (category a, grade ii). however, there are special situations when follow-up throat cultures should be performed for asymptomatic patients. throat cid clinical trials and have been shown to be capable of eradicating been shown to be resistant to erythromycin [ ] . sulfonamides and tetracyclines are not recommended for treatment of group group a streptococci from the upper respiratory tract. however, it must be recognized that the only antimicrobial actually exam-a streptococcal pharyngitis because of the higher rates of resistance to these agents among group a streptococci and the ined in controlled studies and shown to be capable of preventing initial attacks of rheumatic fever has been intramuscular reposi-frequent failure of these agents to eradicate even susceptible organisms from the pharynx. tory penicillin [ , ] (category a, grade i). these studies were performed with procaine penicillin g in oil containing antimicrobial therapy. when selecting an antimicrobial for treatment of group a streptococcal pharyngitis, important is-aluminum monostearate [ , ] , a preparation that has since been supplanted by benzathine penicillin g. (for this reason, sues include efficacy, safety, antimicrobial spectrum (narrow vs. broad), dosing schedules, compliance (or adherence), and no regimens listed in table have been assigned a grade of a .) there are data, although not definitive, indicating that cost. these factors influence the cost-effectiveness of antimicrobial therapy. benzathine penicillin g is effective in primary prevention of rheumatic fever (prevention of an initial attack of rheumatic a number of antibiotics have been shown to be effective for treating group a streptococcal pharyngitis. these agents in-fever following an episode of group a streptococcal pharyngitis) [ , ] . benzathine penicillin g has also been shown clude penicillin and its congeners (such as ampicillin and amoxicillin), as well as numerous cephalosporins, macrolides, and to decrease the occurrence of rheumatic fever cases during epidemics of streptococcal pharyngitis in military recruit camps clindamycin. however, penicillin remains the treatment of choice because of its proven efficacy, safety, narrow spectrum, [ ] . moreover, benzathine penicillin g has been proven effective for preventing rheumatic fever in patients who have had and low cost [ , , ] . erythromycin is a suitable alternative for patients who are allergic to penicillin. first-or second-a previous attack of the disease (secondary prophylaxis) [ ] (category a, grade i). other antimicrobials can effectively erad-generation cephalosporins are also acceptable for penicillinallergic patients who do not manifest immediate hypersensitiv-icate group a streptococci from the upper respiratory tract, and it is assumed that such eradication is an adequate measure of ity to b-lactam antibiotics. most oral antibiotics must be administered for days to effectiveness in the primary prevention of rheumatic fever. antimicrobial resistance has not been a significant issue in achieve maximal pharyngeal eradication of group a streptococci, but certain new agents have been administered in shorter the treatment of group a streptococcal pharyngitis in the united states. there has never been a clinical isolate of group a courses. it has been reported that azithromycin [ - ] , cefuroxime [ ] , cefixime [ ] , and cefpodoxine [ ] can be used to streptococcus documented to be resistant to penicillin anywhere in the world. although there have been geographic areas where achieve comparable bacteriologic and clinical cure rates among patients with streptococcal pharyngitis when these drugs are isolates have been highly resistant to macrolide antibiotics (specifically erythromycin), this has not been and currently is not given for £ days. however, definitive results from comprehensive studies are not available, and thus it is not possible to a clinically significant problem in north america. less than % of group a streptococci isolated in the united states have endorse these proposed shorter courses of oral antibiotic ther- * amoxicillin is often used in place of oral penicillin v in young children; the efficacy of amoxicillin appears to be equal to that of penicillin v, and this choice is primarily related to acceptance of the taste of the suspension. † see text. ‡ for patients weighing less than lbs ( kg). § two milliliters of c-r bicillin( / ) contains , units of benzathine penicillin g and , units of procaine penicillin g; this preparation thus contains less benzathine penicillin g than is conventionally used in the treatment of adolescents or adults. available data indicate that orally administered first-and second-generation cephalosporins also are effective in eradicating group a streptococci from the upper respiratory tract; these agents should not be used in patients with immediate hypersensitivity to b-lactam antibiotics. first-generation cephalosporin a ii second-generation cephalosporin a ii. # these are total daily doses (maximum daily dose, g per day). / c $$se - - : : cidal uc: cid apy at this time. moreover, the spectra of these antibiotics are special circumstances are present (see the section on repeated diagnostic testing). because routine retesting is no longer much broader than that of penicillin, and, even when they are administered for short courses, they are more expensive. advised, only those patients whose signs and symptoms of acute pharyngitis return within the succeeding few weeks will antimicrobials for group a streptococcal upper respiratory tract infections may be given either orally or parenterally. , noncompliance with the pre-group a streptococcal pharyngitis. intramuscular benzathine penicillin g is preferred for patients who are unlikely to com-scribed antimicrobial regimen [ ], or a new infection with a group a streptococcus acquired from family, classroom, or plete a full -day course of oral therapy. guideline: patients with acute streptococcal pharyngitis community contacts. a second episode of pharyngitis with the original infecting group a streptococcal strain (i.e., treatment should receive therapy with an antimicrobial agent in a dosage and for a duration that is likely to eradicate the infecting organ-failure) cannot be ruled out, but this occurs only rarely. streptococcal carriers do not ordinarily require further anti-ism from the pharynx. on the basis of penicillin's narrow spectrum of antimicrobial activity, the infrequency with which microbial therapy. these individuals have group a b-hemolytic streptococci present in their throats but have no evidence of it produces adverse reactions, and its modest cost, it is the drug of choice for nonallergic patients. an immunologic reaction to this organism [ ] . during the winter and spring in temperate climates, £ % of asymptom-management of close contacts and pharyngeal carriers. approximately % of individuals within the household of an index atic school-aged children may be streptococcus carriers. they may be colonized by group a b-hemolytic streptococci for patient may also harbor group a streptococci in their upper respiratory tracts. however, it is usually not necessary to perform several months, and during that period they may have episodes of intercurrent viral pharyngitis. when tested, these patients throat cultures for these contacts or treat them if they are asymptomatic. in those situations in which repeated testing is indicated are found to have group a b-hemolytic streptococci in their pharynges and appear to have acute streptococcal pharyngitis. (see the section on repeated diagnostic testing), performing cultures for asymptomatic family contacts and treating those who streptococcal carriers are unlikely to spread the organism to their close contacts and are at low risk, if any, for developing are positive are advisable. when a larger group (e.g., schools, day care centers, or domiciliary institutions) is involved in a suppurative complications or nonsuppurative complications (e.g., acute rheumatic fever) [ ] . documented outbreak of group a streptococcal upper respiratory infections or scarlet fever, throat cultures should be performed moreover, it is more difficult to eradicate group a streptococci from the upper respiratory tracts of streptococcal carriers for all patients; however, only those with positive throat cultures should be treated with antimicrobials. the administration of intra- [ ] . this has been shown to be true with penicillin therapy and also may be true with some other antimicrobials. in fact, muscular injections of benzathine penicillin g has been shown to be very effective in terminating such outbreaks. many of the published studies showing relatively high rates of failure to eradicate group a streptococci from the upper strains of group a streptococci that cause invasive infections may spread to close contacts of the index case. secondary cases respiratory tract with penicillin therapy were likely ''contaminated'' with carriers. of severe invasive infection have rarely occurred in family and institutional contacts and in health care workers [ - ] . data in practice it is difficult to differentiate a carrier with an intercurrent non-group a streptococcal infection from a patient are as yet too limited to assess with precision the risk of secondary illness or to make a firm recommendation regarding the with acute streptococcal pharyngitis. helpful clues include the patient's age, season of the year, local epidemiology (e.g., the advisability of routinely performing cultures and treating close contacts of patients with group a streptococcal infections such presence of influenza or enteroviral illnesses), and the precise nature of the presenting signs and symptoms (see the section as necrotizing fasciitis or the toxic shock -like syndrome. guideline: it is not necessary to perform throat cultures or on clinical diagnosis above). in many instances, however, the clinician may not be able provide treatment for household contacts of patients with group a streptococcal pharyngitis, except in specific situations in confidently to distinguish persistent carriage from acute infection and will elect to administer another course of antimicrobi-which there is increased risk of frequent infections or of nonsuppurative sequelae (category b, grade iii). als. for single episodes of symptomatic, culture-confirmed or radt-confirmed group a streptococcal pharyngitis that occur shortly after completion of a course of appropriate antimicro- bial therapy, any of the agents listed in table is appropriate. because patient compliance with oral antimicrobials often is b-hemolytic streptococci an issue, a regimen of intramuscular benzathine penicillin g should be considered. for these single repeated episodes, it is performing routine throat cultures (or rapid antigen testing) for asymptomatic patients after completion of antibiotic therapy not necessary to reculture the throat after the second course of therapy unless the patient remains or becomes symptomatic or for group a streptococcal pharyngitis is not necessary unless / c $$se - - : : cidal uc: cid unless special circumstances are present (see the section on there have been no definitive controlled studies of therapy for multiple, repeated symptomatic episodes of culture-positive repeated diagnostic testing above). an even more challenging clinical circumstance is a pa-acute pharyngitis in the same patient; however, the regimens listed in table have been reported to result in low bacteriologi-tient -usually a school-aged child or adolescent -who has multiple episodes of acute pharyngitis and cultures or radts cal failure rates [ - ]. guideline: a small percentage of patients will have recur-positive for group a streptococci within a period of months to years. it is likely that most patients in this category are rences of acute pharyngitis and throat cultures (or radts) positive for group a streptococci within a short period of time streptococcal carriers with nonstreptococcal infections. for patients who have frequent distinct episodes of infection, informa-following completion of a course of antimicrobial therapy. a single such episode may be retreated with the regimens listed tion regarding the clinical response to antibiotic therapy and the presence or absence of group a streptococci in throat cultures in table . when multiple episodes occur over the course of months or years, it may be difficult to differentiate viral infec-performed during asymptomatic intervals is helpful in distinguishing persistent carriage from repeated episodes of strepto-tions from true group a streptococcal infections in a streptococcal carrier. use of certain antimicrobial agents has been shown coccal pharyngitis. serotyping of repeated streptococcal isolates from an individual patient may also assist in arriving at to yield high rates of streptococcal eradication in the pharynx under these particular circumstances (category a, grade ii). this determination, but such studies can be done only in specialized research laboratories. suggested regimens with these agents are listed in table . when physicians suspect ping-pong spread to be associated with multiple repeated episodes of group a streptococcal infections in one family, performing simultaneous cultures for all d. indicators of quality family contacts and treating those whose cultures are positive may be helpful (category b, grade iii). there is no credible indicators of quality of care for patients with acute pharyngitis include: ( ) performance of throat cultures or radts for evidence that family pets are reservoirs for group a streptococci or that they contribute to familial spread. patients suspected of having group a streptococcal pharyngitis; ( ) performance of throat cultures for patients with negative continuous antimicrobial prophylaxis for group a streptococcal infection is not recommended because there is insuffi-radts; ( ) prescription of one of the antimicrobial regimens recommended in table for patients with acute pharyngitis cient evidence to show that it is effective, except for preventing recurrences of acute rheumatic fever. surgical removal of the and positive tests for group a streptococci; ( ) withholding or discontinuing antimicrobial therapy for patients with throat tonsils may be considered for the rare patient whose symptomatic episodes do not diminish in frequency over time and for cultures negative for group a streptococci; ( ) omission of routine follow-up cultures for patients who have received an whom no alternative explanation for the recurrent pharyngitis is evident. tonsillectomy may decrease recurrences of symp-adequate course of antimicrobial therapy; ( ) avoidance of routine throat cultures for asymptomatic family contacts of patients tomatic pharyngitis in selected patients, but only for a limited period of time [ ] (category a, grade i). with group a streptococcal pharyngitis; ( ) avoidance of con- † although shorter courses of some newer macrolides and cephalosporins have been reported to be effective for treating group a streptococcal upper respiratory tract infections, the evidence is not yet sufficient to recommend these agents for therapy at this time (this is also true for patients with repeated infections or for those in whom the organism is difficult to eradicate). ‡ maximum dose, mg of amoxicillin per day. § benzathine penicillin g is useful for patients whose compliance with previous courses of oral antimicrobials is questionable. limited data suggest that the addition of rifampin ( streptococcal pharyngitis: placebotinuous long-term antimicrobial prophylaxis for preventing recontrolled double-blind evaluation of clinical response to penicillin thercurrent episodes of acute pharyngitis. apy the effect of penicillin therapy on the symptoms and signs of streptococcal pharyngitis clinical evaluation of a latex aggluti-references nation test for streptococcal pharyngitis: performance and impact on treatment rates streptococcal pharyngitis: current therapy and criteria for evalua- antigen detection test for streptococcal pharyngitis: evaluation of purpose of quality standards sensitivity with respect to true infections immunoassay for rapid detection of group a b-hemolytic streptococci: ( pt )(suppl): - . should culture be replaced? perplexity and precision in the diagnosis of streptococ- do the b-hemolytic respiratory tract gerber ma. treatment failures and carriers: perception or problems? pedi- - . atr association of group c b-hemolytic streptococci with endemic pharyn- red book: report of the committee on infectious diseases. th gitis among college students clinical and microbiologi- - effect of streptococci community-wide outbreak tis and pharyngitis the role of the streptococcus diagnosis of pharyngitis: clinical and epidemiologic in the pathogenesis of rheumatic fever prevention of rheumatic fever. treatment of the preceding strep a simple scorecard for the tentative diagnosis of streptococcal tococcic infection streptococcal pharyngitis: evaluation of clinirheumatic fever by treatment of the preceding streptococcal infection with cal syndromes in diagnosis controlled studies of streptococinfections on clinical grounds comparison of throat cultures and rapid strep tests for diagnorate of rheumatic fever streptococcal pharyngitis: optimal site for throat culof rheumatic fever by treatment of previous streptococcal infections. i. ture cultures of streptococcus - . pyogenes from the oropharynx protection of a military population effect of atmosphere of incubation from rheumatic fever: routine administration of benzathine penicillin g on the isolation of group a streptococci from throat cultures. j lab clin to healthy individuals effect of atmosphere and duration of fever in children and adolescents. a long-term epidemiologic study of incubation on primary isolation of group a streptococci from throat subsequent prophylaxis, streptococcal infections, and clinical sequelae. cultures comparative effectiveness of three prophylaxis regimens in pre ann intern comparison of throat culture methods for the recovery of group a streptococci in a pediatric office setting in vitro susceptibility of recent north american diagnosis of pharyngitis: methodology of throat cultures suitability of throat culture procedures for detection of group streptococcal pharyngitis and prevention of rheumatic fever: a statement a streptococci and as reference standards for evaluation of streptococcal for health professionals. committee on rheumatic fever, endocarditis, antigen detection kits extraction method with pronase b for grouping beta-hemolytic strepto- . world health organization. rheumatic fever and rheumatic heart disease. cocci bacitracin differentiazation, . tion of presumptive identification of group a b-hemolytic streptococci: . hamill j. multicentre evaluation of azithromycin and penicillin v in the comparison of primary and purified plate testing effect of antibiotic . weippl g. multicentre comparison of azithromycin versus erythromycin therapy on the clinical course of streptococcal pharyngitis. j pediatr in the treatment of paediatric pharyngitis or tonsillitis caused by group a streptococci / c $$se a comparison of azithromycin and penicillin v for the treat- penicillin v for group a streptococcal pharyngoton comparative efficacy sillitis: a randomized trial of seven vs ten days' therapy. jama and safety of four-day cefuroxime axetil and ten-day penicillin treatment of group a beta-hemolytic streptococcal pharyngitis in children. pediatr . kaplan el. the group a streptococcal upper respiratory tract carrier state efficacy of tonsillectomy pharyngitis and/or tonsillitis: comparison with -day penicillin for recurrent throat infection in severely affected children: results of v therapy. cefixime study group course treatment of acute group a b-hemolytic streptococcal tonsil-clindamycin treatment of chronic pharyngeal carriage of group a streplopharyngitis: ten days of penicillin v vs days or days of tococci cefpodoxime therapy in children clusters of invasive group a scand streptococcal infections in family, hospital, and nursing home settings eradication of group a streptococci from the dinsa lin v treatment failure penicillin plus coccus among family members and health care workers. clin infect dis rifampin eradicates pharyngeal carriage of group a streptococci key: cord- -tj ye mx authors: nan title: abstract book date: - - journal: ann allergy asthma immunol doi: . /s - ( ) -x sha: doc_id: cord_uid: tj ye mx nan introduction: the effect of anti ige has been described as a function of complexing free ige to reduce mast cell implantation and consequent reduction of mast cell degranulation upon exposure to antigen. theoretically, as total free ige drops below ng/ml, improvement occurs as free and cell bound ige equilibrate and allergic reactions subside. initial observations ( togias a et al. j allergy clin immunol. ; :s )suggested that prick skin tests consistently reached their low point at days with significant reduction in size. laynadier (leynadier f, doudou o, gaouar h, le gros v, bourdeix i, guyomarch-cocco l, trunet p : effect of omalizumab in health care workers with occupational latex allergy.j allergy clin immunol ; : - ) noted some reduction in skin testing in sixty percent of patients treated over a six month period with monoclonal antiige. but clinicians since approval of the drug in have noted that even in the presence of good clinical response to asthma, skin test reactivity is still obvious, and in many cases unchanged. methods: following the suggestions for standard clinical follow up by lanier and marshall ( annals may ) , routine skin prick skin testing was completed after informed consent on patients at onset of anti-ige therapy, and repeated at - months. in all instances were skin tests done and photographed in a standard manner. in a few cases, skin tests were repeated on patients receiving anti ige for as long as five years. results: photographic evidence will be presented. in of patients on current therapy, prick skin testing remained at an almost identical photographic level to the baseline analysis, but there was a correlation between the patients with the lowest serum ige and the likelihood of apparent reduction. there was no correlation to reduction of skin testing and clinical response to anti ige since all patients had experience significant quality of life improvements. conclusion: anti ige has variable effects on reducing prick skin testing, with a greater likely hood associated with low or extremely low initial total ige levels. skin testing is more sensitive for detection of allergen-specific ige than is immunoassay for allergen-specific ige. for some assay methods, the qualitative cutoff of . ku/l is inappropriately high. this study was conducted in order to determine whether a particular assay system can be used to measure lower levels of allergen-specific ige. the pharmacia unicap system was studied. all reagents were purchased from the manufacturer, and the study was approved by a local human assurance committee. to determine background of the calibration curve, the fluorescent unit (fu) response of replicates of assay diluent measured with an anti-ige solid phase was determined. the background responses of arbitrarily selected allergen solid phases (oak, timothy and short ragweed pollen; cat; peanut; yellow jacket venom; penicillin g) were also measured. lower detection limits (lld) were calculated using the mean background measurement + standard deviations (sd). to examine linearity of a low-range calibration curve, : dilutions to extinction were made, starting with the . ku/l calibrator. the mean background of the anti-ige solid phase was . fu, sd . and coefficient of variation (cv) of %; the lld was . this lld corresponded to a level of approximately . ku/l of ige. the lld of the allergen solid phases ranged from . fu (yellow jacket venom) to . fu (short ragweed); this corresponded to about . ku/l ige. the low level dilution curve exhibited parallelism with a curve constructed using a zero (diluent) calibrator as a th point in the assay's reference curve. a low level method is capable of measuring specific ige levels lower than the manufacturer's . ku/l cutoff. this would seem to be particularly important in research applications, and in the analysis of certain highrisk allergens. the clinical significance of very low levels of specific ige in the serum warrants study. allergists/immunologists are often consulted on patients with rashes or recurrent infections. the differential diagnosis can comprise a variety of disorders, some of which are rare syndromes that require early diagnosis and specific management. a mo old wm developed persistent rash and worsening eczema. later, he had recurrent severe skin infections, skin abscesses, recurrent sinusitis, and chronic otitis media that required multiple placement of tympanostomy tubes, yet had a persistent tympanic membrane perforation. recurrent wheezing was noted from - yr of age. he had several episodes of pneumonia since yr of age affecting different lobes. he failed to shed the primary teeth and had history of periodontitis and oral thrush. he developed scoliosis and multiple fractures of the upper extremities and ribs. at yr he had staphylococcal bacteremia and osteomyelitis of the acetabulum. in spite of antibiotics prophylaxis, he continued to have recurrent skin infections and lymphadenitis. laboratory evaluation revealed eosinophilia (up to /mm ), normal levels of igg, iga, igm & igg subclasses, except for decreased igg ( mg/dl). he had protective levels of anti s. pneumoniae and h. influenzae, but low anti-tetanus and anti-diphtheria titers. at yr, total ige level was , iu/ml which supported the diagnosis of hyper ige (hie) syndrome; it decreased to iu/ml by yr. rast was positive to hd mite, cat, dog, egg, milk, and pollens. flow cytomerty, nbt and phagocytic index were normal; ch was low ( mg/dl). dexa scan showed osteopenia. chest x-ray showed bilateral infiltrate, atelectasis and scoliosis of the thoracic spine. during his hospitalization at yr, his skin was fair, lichenified with widespread maculopapular erythematous rash. the palms and fingers showed open cracks and pustules, but no weeping lesions. in addition to coarse facial features, his face was eczematous. conclusion: hie syndrome is an autosomal dominant disorder that mimics atopic dermatitis but has severe course, multiple infections, and several complications. although a markedly elevated total ige level introduction: mannose-binding lectin (mbl) is a serum protein in the lectin complement pathway. it is important in innate immunity, and is thought to be particularly relevant in young children during the development of adaptive immunity. deficiency in mbl has been reported in population-based studies as a risk factor in children for infection and hospitalization. additionally, age-dependent variability of mbl has been previously noted. this study evaluates the prevalence of mbl deficiency in children with established recurrent infection who were referred for evaluation of immunodeficiency. method: we prospectively evaluated mbl status of children referred for recurrent infection. serum was collected from october to september . children with known primary or secondary immunodeficiencies were excluded. mbl analysis was performed by standardized elisa using mbl oligomer assays. we performed chart and laboratory review for comorbid diagnoses, quantitative immunoglobulin levels and subclasses, and complement function with ch and ah . results: two-hundred thirty five children were evaluated. mean age was . years (range . - years). mean mbl was ng/ml (range - ng/ml). thirty-one of children ( . %) were mbl deficient, levels < , and among this group the mean mbl level was . ng/ml (range - ng/ml). mean age in this group was . years (range . - years). of the children with mbl deficiency, ( . %) children had levels < . the m:f ratio of children with abnormal mbl levels was . . linear regression analysis showed no correlation of mbl level with age. comorbid diagnoses were variable, including asthma, allergy, and atopic dermatitis. none of the children had symptoms compatible with connective tissue disease. no child with an abnormal mbl level was found to have significant deficiency of igg, iga, or igm. several children had low igg , which were within normal physiologic range. no other concomitant complement pathway disorders were detected. conclusions: our study did not reveal any correlation between mbl level and age. in children with recurrent infections, mbl deficiency was approximately twice the estimated rate of the general population. contrary to previous studies, no other significant immunologic disorders were identified. therefore, mbl deficiency alone is a risk factor for infection in children. t.b. fausnight * , hershey, pa. introduction: the incidence of perioperative anaphylaxis is estimated to be between in , and in , procedures. approximately % of cases of perioperative anaphylaxis are attributed to neuromuscular agents. very little information is reported in the literature regarding pediatric perioperative anaphylaxis. i describe a pediatric patient with suspected perioperative anaphylaxis to rocuronium. methods: a year-old girl with a history of sacral agenesis and neurogenic bladder was scheduled to have bladder augmentation surgery. the patient was taken to a latex-free operating room. during induction of general anesthesia, she was found to be difficult to ventilate. she also became hypotensive. examination of the patient revealed urticaria on her right arm. she was given epinephrine, diphenhydramine, and dexamethasone. the procedure was aborted. the reaction was believed to be from either rocuronium or propofol. results: because of the high incidence of anaphylaxis to neuromuscular agents, allergy skin testing was performed for rocuronium, vecuronium, and succinylcholine. the patient had negative percutaneous skin tests ( : ) for rocuronium, vecuronium, and succinylcholine. she had a negative intradermal skin test to rocuronium at the : dilution. she had a positive intradermal skin test to rocuronium at the : dilution. she had negative intradermal skin tests to both vecuronium and succinylcholine at the : , : , and : dilutions. she underwent surgery weeks after skin testing. she received a test dose of vecuronium and had no reaction. she received doses of vecuronium and multiple doses of morphine without any adverse reactions. propofol was avoided. the surgery was completed without difficulty conclusions: this case illustrates the usefulness of skin testing for neuromuscular agents in a pediatric patient. introduction: extrapulmonary pneumocystis jiroveci infection is rare in non-hiv infected individuals and, to our knowledge, it has not been reported before in a patient with good's syndrome. we report a case of extrapulmonary pneumocystis in a patient with good's syndrome. case report: a -year-old african american male patient with a history of good's syndrome presented with left flank pain of months duration. the pain was constant and associated with night sweats, fever, and chills. furthermore, the patient also reported a -pound weight loss. on exam, patient was found to have multiple hypopigmented areas over his abdomen and left lower extremity, bitemporal wasting, sunken eyeballs, and oral thrush. the patient was also found to have left costovertebral angle tenderness with a palpable solid fixed mass along the left mid axillary line overlying the splenic area. computedtomography (ct) scan of the chest and abdomen showed a . x . cm soft tissue mass at the left lateral aspect of the t vertebral body and . x . cm soft tissue parasplenic mass. the parasplenic mass involved the inferior anterior aspect of the left th and th ribs (see figure) . the giemsastained biopsy of the parasplenic mass revealed pneumocystis jiroveci and was confirmed using immunohistochemical stain with monoclonal antipnumocystis antibodies. the patient's symptoms of night sweats and loss of appetite improved within hours following initiation of trimethoprim-sulfamethoxazole therapy. a ct of the chest and abdomen, repeated six months post treatment, confirmed the resolution of both the paravertebral and the parasplenic masses. conclusion: to our knowledge, this is the first case of extrapulmonary pneumocystis presenting in a patient with good's syndrome. although it is rare, extrapulmonary pneumocystis should be considered in the differential diagnosis of patients with good's syndrome and chest or abdominal mass. introduction: t cells are regulated by cellular interactions with the environment during development. they play a critical role in the regulation and development of autoimmune diseases. we report inflammatory myositis in a -year-old caucasian female with primary t cell-deficiency since infancy. methods: at nine months of age, our patient developed lymphoid interstitial pneumonitis. immunologic evaluation revealed isolated t-cell deficiency. during the first years of life, she had failure to thrive, recurrent sinusitis, oral candidiasis, fungal skin infections, and pseudomonas pneumonia. at years, autoimmune conditions, characterized by a purpuric rash over the nose; face and exposure area of elbows; knees and fingers; raynaud's phenomenon; and nasal septum perforation, developed. inflammatory markers were persistently elevated and autoantibodies detected. by age , she developed proximal muscle weakness with distal joint contractures. dry gangrene of the fingers from a thrombotic incident occurred. results: serial immunologic evaluation revealed low cd - %, # - (normal - %, # - cell/mm ), low cd - %, # - (normal - %, # - cell/mm ) , decreased lymphocyte transformation to antigens but appropriate to mitogens. igg - (normal - mg/dl); iga - (normal - mg/dl), and igm - , (normal - mg/dl) with appropriate antibody responses to vaccine antigens. bone marrow and thymus biopsies were normal. further evaluation was not consistent with known primary or secondary immunodeficiencies. several skin biopsies revealed nonspecific dermatitis without vasculitis. mri of lower extremities showed abnormal signals involving bilateral muscles of thighs and calves. muscle biopsy revealed inflammatory myositis with plasma cell predominance, inconsistent with dermatomyositis or polymyositis. aldolase - iu/l (< ), crp - mg/dl (< . ), esr - (< ), rf : (< : ) and type ii collagen ab - ei/ml (< ) . ana, anca and ace were within normal range. antibodies for myositis and myositis related-antibodies were negative. diagnosis of nonspecific plasma-cell inflammatory myositis was made. a trial of monthly ivig gm/kg resulted in clinical improvement. conclusion: this novel plasma cell myositis occurring in a child with primary t cell deficiency underscores the role t cells play in the development of autoimmune diseases. introduction the incidence of hypersensitivity reactions (hr) is increased in patients treated with multiple courses of carboplatin. the purposes of this investigation were to evaluate the effectiveness of a -hour, -step desensitization protocol and to characterize the immune mechanism of carboplatin hr. methods we analyzed ten consecutive patients over a two year period with documented hr to carboplatin who required continued treatment with a platinum agent. the patients were treated with carboplatin using a -hour, -step desensitization protocol. skin tests were performed on five patients. results ten patients successfully completed planned courses of desensitizations to carboplatin, of which were without reactions. four patients had symptoms during their first (n= ) and third (n= ) desensitizations but tolerated the re-administration of infusions without further reactions. for subsequent courses, the protocol was modified for two patients who had extracutaneous symptoms during desensitization and was unchanged for the patient who had mild urticaria. these three patients tolerated subsequent courses of desensitizations without reactions. the fourth patient with symptoms during desensitization no longer required carboplatin. of the five patients who were skin tested to carboplatin, four had positive wheal and flare reactions. in one patient, the skin test response to carboplatin became negative after desensitization. conclusions the -hour, -step desensitization protocol is safe and effective for treating patients with carboplatin hr. positive skin tests to carboplatin suggest a mast cell/ige-mediated mechanism. conversion of the positive skin test to a negative response after desensitization supports antigen-specific mast cell desensitization. hypothesis: there is an association between food allergies and acid reflux in atopic adults study design: a retrospective chart review of patients was conducted. people who tested positive and people who tested negative for food allergy were included. the prevalence of gastroesophageal reflux disease (gerd) in the total group and each of the study arms was compared to population prevalence. methods: results of allergen specific ige tests (pharmacia immunocap, nj) run for food allergies were reviewed to help locate charts of atopic subjects, with positive, and with negative food allergy results. we reviewed charts for history of heartburn and acid regurgitation or the diagnosis of gerd, laryngopharyngeal reflux (lpr) or peptic ulcer disease (pud). population prevalence ( . %; ci . - . ) of acid reflux was estimated from a historical comparison that studied adults in a similar geographical location. results: in the food allergy positive group, . % of the subjects ( % ci . - . ) had either a history of heartburn and/or a diagnosis of gerd, lpr or pud. in the food allergy negative group, % ( % ci . - ) had acid related disorders. in the total study group of atopic subjects, the prevalence of heartburn, gerd, lpr or pud was . % ). on chi square analysis, the prevalence of acid reflux disorders was significantly higher in the total study group when compared with population prevalence (p= . ). the prevalence of acid reflux disorders between the food allergy study group and in the population shows no significant difference (p= . ). the prevalence of acid reflux disorders was significantly higher in the food allergy negative group when compared with the prevalence in the population (p= . ). there was no significant difference in the prevalence of acid reflux disorders between the two study groups with and without food allergy (p = . ). conclusions: the prevalence of acid reflux disorders was higher in people with food allergy when compared to the population, but missed statistical significance. patients without food allergy had a significantly higher prevalence of acid reflux disorders compared to the population. atopic individuals have a statistically significant higher prevalence of acid reflux disorders, but there is no statistically significant difference between atopics with and without food allergy. abstract background: analysis of dispensing patterns of injectable epinephrine offers a method to study the characteristics of school children with allergic or anaphylactic reactions. objective: to analyze the demographics of children prescribed injectable epinephrine in massachusetts school districts with diverse racial and ethnic enrollment patterns. methods: school nurses in schools (grades pk- ) enrolling , students recorded the characteristics of students prescribed injectable epinephrine including the number and racial mix of students in each school, student age, grade level, race, sex, and allergic disorder requiring epinephrine. surveyed school districts were two predominately white ( %) suburban districts enrolling students and one urban area with a minority population of % enrolling , students. the use of epinephrine for peanut allergy was analyzed in detail. results: a total of of , ( . %) students in three school systems were dispensed injectable epinephrine. males outnumbered females ( to ). whites outnumbered non-whites to . two thirds (n= ) of children dispensed epinephrine had peanut allergy. the second most common allergy was stinging insect allergy (n= ). the rate of dispensed epinephrine for peanut allergy was lowest in the urban school district ( . %) versus the two suburban districts, . % and . % respectively. whites with peanut allergy outnumbered nonwhites to . males outnumbered females to . the lowest rate of prescribed injectable epinephrine for peanut allergy in all three school districts was found in non-white school children- . %. eighty-nine of ( %) school children with peanut allergy were enrolled in grades pk through . there were twice as many white versus non-white ( to ) school children in the urban system with prescribed injectable epinephrine for peanut allergy. only eight (. %) of hispanic and asian students in the were dispensed injectable epinephrine for peanut allergy. conclusions: this is the first study to suggest that there may be a racial disparity in the prevalence of childhood peanut allergy. one possible explanation for this disparity is that varied feeding practices in minority infants and children may induce a state of tolerance and lead to a lower incidence of peanut allergy. f.i. hsu * , h.j. burstein, m.c. castells, boston, ma. introduction: trastuzumab is a humanized igg kappa monoclonal antibody specific for human epidermal growth factor receptor protein, her , used in the treatment of her /neu positive breast cancer. we present the first report of desensitization to trastuzumab in a patient with an ige-mediated reaction to trastuzumab and documented igg-anti-igg human antibodies. meth-ods: a year old woman with metastatic invasive ductal breast cancer (er/pr positive, her- strongly positive), unresponsive to conventional therapy, presented with an anaphylactic reaction to trastuzumab and was evaluated for rapid desensitization by skin testing and serum specific igg antibodies. the patient had previously received trastuzumab. results: the anaphylactic reaction to trastuzumab consisted of diffuse erythema, urticaria, respiratory distress and laryngeal edema. premedication with steroids, h and h blockade, and slow infusion did not prevent a subsequent reaction. skin prick testing with trastuzumab ( mg/ml) was positive with negative controls, confirming an ige-mediated mechanism. igg anti-human igg antibodies (haha) to trastuzumab were confirmed by elisa. the patient was desensitized to trastuzumab mg/kg with an intravenous protocol that started at . mcg/h, and increased in rate every minutes until a final rate of mg/h, for a total infusion time of to hours. premedication included diphenhydramine, prednisone, famotidine, and montelukast. desensitization was confirmed by negative skin prick and intradermal tests ( mg/ml and mg/ml), with positive histamine control. the patient tolerated a total of weekly doses of trastuzumab mg/kg. intradermal skin testing prior to her th and th courses showed reactivity, indicating resensitization. serum levels of tratuzumab were undetectable at week after desensitization. conclusion: allergic reactions to trastuzumab are rare but can include anaphylaxis. in patients with documented haha and/or ige-mediated reactions to trastuzumab and clinical symptoms of type i/mast cell mediator-related symptoms, desensitization can allow continued administration of this treatment by providing tolerance. the clinical effectiveness of desensitizations in patients with ige and haha antibodies remains to be defined. in contrast to reports in the medical literature, details of the medical aspects were limited. there were attacks on infants bringing the total to reported infant attacks to date. two of the infants suffered long term morbidity and died. like those reported in the medical literature, the majority of adults were in long term care facilities, although were in hospitals. overall, of the individuals stung died within one week of stings. no significant medical consequences of stings were reported in of of the newspaper reports as opposed to of reports in the medical literature. conclusion: our data suggest that increasing numbers of fire ant attacks are occurring in medical facilities, where chronically ill, frequently immobile patients come in contact with foraging ants. unattended infants in private homes in fire ant endemic areas also appear at risk. the factors that determine why individuals are stung and the severity of injury after attacks remain uncertain. the presence of fire ants inside health care facilities and homes is a harbinger for fire ant attacks of disabled or infant occupants. we hypothesize that morbidity is determined by the number of stings, the condition of the patient and the type of treatment administered. purpose: to determine if gender confers a risk for positive penicillin (pcn) skin test. method: rates of positive pcn skin tests, according to gender, were determined in patients with a history of pcn allergy undergoing an allergy pre-operative evaluation from june to june . during this period, , patients were seen in the pre-operative evaluation clinic in which had a history of pcn allergy and comprise our study population. a univariate logistic regression analysis was employed to calculate the odds ratio (or) and the % confidence interval (ci) for gender differences in the rates of positive pcn skin test and a multivariate logistic regression analysis was used to adjust for age and history of multiple drug allergies. p-value of . or less was considered statistically significant. results: of the patients, underwent skin testing for pcn, patients did not, and charts were not available for review. the mean age of the study group was years. sixtyfour ( . %) patients had a positive skin test to pcn. of these, ( %) were females and ( %) were males (or . , % ci . - . , p = . ). of those with a negative/equivocal pcn skin test, ( %) were females versus ( %) males. in a multivariate logistic regression analysis adjusted for age and history of multiple drug allergies, female gender again was more likely to have a positive pcn skin test (or . , % ci . - . p < . ). patients did not undergo pcn skin testing, ( %) were male and ( %) were female. conclusion: this is the first report showing that a greater risk for a positive skin test to pcn exists in association with female gender. age and a history of multiple drug allergies are unlikely to be confounding factors to the observed gender risk. further studies are needed to identify other possible confounding factors and/or mechanisms that can explain this risk. a. fiocchi * , p.a. restani , s. cucchiara , g. lombardi , g. magazzu' , g.l. marseglia , k. pittschieler , s. tripodi , r. troncone , a. vierucci , . milan, italy; . roma, italy; . pescara, italy; . messina, italy; . pavia, italy; . bolzano, italy; . napoli, italy; . firenze, italy. background: cow milk substitutes for children allergic to cow milk proteins (cmp) include soy-based formula and cow s milk hydrolysates. neither can rule out a sensitisation risk. objective: prospective assessment of clinical tolerance to a rice-based hydrolysate formula by children allergic to cow milk proteins (cmp) who consume rice openly. patients and methods: ninety-seven children aged to months with immediate reactions to cow milk confirmed during dbpcfc were assessed for clinical tolerance to cow milk by spt with whole milk, -lactalbumin (ala), -lactoglobulin (blg), -and -casein ( -cas, -cas) (sigma chemical, st. louis, mo). whole milk, ala, blg and cas specific ige determinations were performed using cap test (pharmacia, uppsala, sweden) . similarly, sensitisation to rice and hrf were investigated by spt and cap test. patients sera were investigated by immunoblotting for cmp, rice and hrf (heinz-plada, milan, italy). dbpcfc was carried our with g rhf powder masked in neocate tm (equivalent to ml reconstituted formula). results: spt: all patients were positive to cow s milk and/or cmp fractions (> mm wheal diameter). ige determinations gave positive results with cow milk and/or cmp fractions ( / patients tested), rice ( / ) and with hrf ( / ). immunoblots (n= ) were positive for -cas (n= ), -cas (n= ), ala (n= ), blg (n= ) and bovine serum albumin (n= ). similarly, although patients sera largely recognized rice ( / ), only one weakly reacted with rhf. challenge with rhf was negative in all cases. conclusions: we conclude that, despite their frequent sensitisation to rice, children with cma tolerate both rice and rhf clinically. hydrolyzed rice formulas may thus represent an alternative protein source for children with cma. r.c. cartwright * , w.k. dolen, augusta, ga. introduction: conventional treatment of human seminal fluid allergy includes abstinence, barrier protection, or subcutaneous immunotherapy with fractionated seminal fluid. treatment using local intravaginal desensitization with unfractionated seminal fluid has recently been described, but experience with this desensitization method is still limited and little has been reported as to its long-term results. methods: a -year-old woman with a history of allergic rhinitis and asthma experienced anaphylaxis following her first unprotected intercourse since the birth of her first child. ige-mediated sensitization was demonstrated through the use of specific ige testing (pharmacia cap system) and skin prick testing using undiluted seminal fluid obtained from the patient's husband. after approval from the human assurance committee, the patient underwent rush intravaginal desensitization with steadily increasing concentrations of seminal fluid, beginning with a : , v/v concen-tration. results: her specific ige level to human seminal fluid was . ku/l. skin prick testing was positive with a wheal of mm diameter with pseudopods and a flare of mm diameter. desensitization was successful and the patient tolerated local application of whole semen without significant reaction. following desensitization, the patient reported that she and her husband engaged in unprotected intercourse without local or systemic symptoms. over the last year since the desensitization, she has not experienced further anaphylaxis, but she has developed local symptoms if her exposure to seminal fluid was delayed past days. the longest time period between exposures has been weeks. she became pregnant months ago and has not had any pregnancy complications. conclusions: local intravaginal desensitization was a safe and effective treatment for human seminal fluid allergy in this patient. a delay in seminal fluid exposure greater than days was associated with the return of symptoms emphasizing the need for frequent seminal fluid exposure to maintain desensitization. l. terracciano, t. sarratud, a. fiocchi * , p. restani, s. guerci, milan, italy. background kiwifruit allergy in children has been seldom reported and the reactions observed are usually mild. anaphylaxis has not been described. we document the case of an infant who developed anaphylacic symptoms within minutes of his mother eating two kiwifruits and initiating breastfeeding. case history in his fourth month, the boy was admitted into an emergency department with dysphonia, breathing difficulties, generalised urticaria and angioedema of the lips and face. this episode was treated as an anaphylactic reaction with epinephrine, chlorpheniramine and hydrocortisone sodium succinate administered via a percutaneous catheter and symptomatic control was achieved within minutes. after days a second anaphylactic episode of similar severity occurred under the same circumstances. neither episode required critical care. the boy presented two months later for clinical evaluation in our paediatric allergy unit. skin prick tests (spt) were positive only with egg white and yolk while negative to cow s milk (and protein fractions), beef, chicken, pork, codfish, rice, wheat, soybean, maize, potato, carrot, tomato, bean, pea, celery, peanut, dermatophagoides pteronyssinus and d. farinae, grass and banana. spt with kiwifruit was specifically ordered because exquisite contact was suspected, and induced a positive wheal (> mm diameter). positive specific ige determinations (cap-feia from pharmacia, sweden) with kiwifruit ( . ku/l), cat dander ( . ku/l) and egg white ( . ku/l) were returned but determinations with other inhalant and food allergens were all below the cut-off point of . ku/l and total ige levels were ku/l. strict avoidance of kiwifruit by the breastfeeding mother proved effective and nothing untoward happened in the intervening year. currently aged . years, the boy is free from food-related symptoms. prick-byprick tests with native allergens and spt carried out with commercial extracts of allergens associated in the literature with kiwifruit allergy were all negative. comment there are no reports of immediate reactions to kiwifruit under two years. in this case, severe reactions via breastmilk in an infant monosensitised to kiwifruit indicate that nursing may represent a hidden source of exposure. in older children monosensitisation without prior sensitisation to pollen has been described as the major risk associated with severity of symptoms. m. sikora * , j.w. sleasman, n. tangsinmankong, st. petersburg, fl. introduction: treacher-collins syndrome (tcs) is an autosomal dominant disorder with an abnormality of craniofacial development during early embryogenesis. there is a known relationship between new bone formation and development of lymphocytes and cytokines. the association of tcs and humoral immunodeficiency has not yet been reported. we present a novel case of a year-old caucasian female patient with tcs and common variable immunodeficiency. methods: our patient presented with midface hypoplasia, micrognathia, microtia, conductive hearing loss and cleft palate with a history of recurrent upper and lower respiratory infections. patient had a -year history of chronic sinusitis, recurrent otitis media and pneumoniae which resulted in bronchiectasis. haemophilus influenza and staphylococcus aureus were persistently isolated from bronchial fluids. laboratory work-up for immunodeficiency was initiated. results: immunoglobulin analysis revealed low igg ( - mg/dl); low iga ( - mg/dl); igm ( - mg/dl); igg ( - mg/dl); low igg ( - mg/dl); igg ( - mg/dl); and low igg < . ( - mg/dl). patient had no detectable response to protein-derived vaccines (diphtheria and tetanus) and to polysaccharide-derived vaccines (pneumococcal) at baseline and at - weeks after immunization. t and b lymphocyte enumeration, ch , ah , and mannose-binding lectin were all within normal limits. laboratory findings were consistent with the diagnosis of common variable immunodeficiency. patient began receiving monthly doses of mg/kg/dose of intravenous immunoglobulin resulting in clinical improvement. our patient no longer requires antibiotic therapy for her respiratory infections; pulmonary function has improved and bronchiectasis resolved months after initiation of ivig. conclusion: our finding shows that tcs can be associated with common variable immunodeficiency which suggests a link between skeletal dysplasia and immunodeficiency. a.s. hartel * , j.w. sleasman, n. tangsinmankong, st. petersburg, fl. introduction: streptococcus pneumoniae is the most common cause of invasive bacterial infection in humans. however, incidence of s. pneumoniae infections in healthy adolescents is low ( / , per year). mannose-binding lectin (mbl) is a c-type lectin which plays a central role in the innate immune response by activating the classical complement pathway and acting as an opsonin by binding c q receptors. several studies have demonstrated an association between invasive bacterial infections, including s. pneumoniae and a homozygous mutation of the mbl gene. however, this association has not previously been described in patients with the heterozygous mutation. methods: a -year-old caucasian female presented with a second episode of meningitis over a -year span. streptococcus pneumoniae was isolated from peripheral blood cultures on both occasions. lumbar puncture revealed wbc , ; % bands; % pmns; glucose mg/dl, protein mg/dl; these results consistent with bacterial meningitis. extensive evaluation for predisposing causes revealed benign arnold-chiari type malformation. further immunological evaluation was initiated. results: evaluation revealed igg mg/dl (normal - ); iga ( - ); igm ( - ), and normal igg subclasses. antibody responses to diphtheria and tetanus vaccines were adequate. antibodies response to pneumococcal vaccine given years prior were protective to all common serotype tests (> . mcg/ml). lymphocyte subset analysis was within normal range. howell-jolly bodies were not detected from peripheral blood smear. evaluation for secondary immunodeficiency was negative, including hiv antibody by elisa. complement analysis showed ch u/ml ( - ); ah % ( - %), and markedly low mbl of ng/ml (> ). genetic analysis of her mbl revealed heterozygous mutation in codon and mutations in two promoter regions (homozygous mutation on h/l variants and heterozygous mutation on p/q variants). conclusion: heterozygous mutation of mbl codon when associated with mutation of promoter regions can result in severe impairment of mbl protein production, and may lead to increased susceptibility to invasive bacterial infections and meningitis. rationale: patients with similar symptoms may have allergic, non-allergic, or mixed rhinitis triggers and can differentially respond to distinct medications. we assessed st in our clinic patient population to characterize factors that influence appropriate diagnosis and treatment of rhinitis type. methods: we used a validated commercial questionnaire and chart review of patients seen in an academic allergy clinic, to assess the number of allergic vs. irritant st and demographic and historical factors (including pharmacotherapy) associated with differences in symptoms. results: the population (n= : female, male) consisted of individuals with a mixed rhinitis history. women had higher st scores than men, including: total scores [ . +/- . vs. . +/- . , p= . (unpaired t-test)]: allergen scores ( . +/- . vs. . +/- . , p= . ); and irritant scores ( . +/- . vs. . +/- . , p= . ). further, patients treated with both azelastine (az) and intranasal steroids (ins) had lower st scores than patients treated with either alone (total st: az . +/- . , ins . +/- . , both . +/- . , p= . ; allergen st: az . +/- . , ins . +/- . , both . +/- . , p= . ; irritant st: no significant difference). conclusions: female patients have significantly higher symptom scores; total, allergic and irritant. rhinitis monotherapy (ins or az) is minimally effective in reducing st but is more effective when used in combination. these data demonstrate rhinitis population heterogeneity and address differential responsiveness to similar medications. increased response to combined drug therapy support the heterogeneous pathophysiology of mixed rhinitis features and may relate to a combination of multiple aeroallergen and air pollution exposure in the houston area. introduction: interaction between eye & nose warrants attention with regard to the propagation and treatment of allergic reactions. the role of topical therapy for rhinitis and conjunctivitis is becoming more widely considered and questions of therapeutic route have been raised. purpose: to elucidate the anatomic and pharmacokinetic interactions of conjunctival & nasal mucosa leading to more rational selection of routes of medication administration. methods:our studies have investigated the effect of ocularly instilled allergen inducing signs and symptoms of rhinoconjunctivitis. study compared effects of allergen administered via conjunctival allergen challenge (cac) or nasal allergen challenge (nac) and analyzed tear & nasal secretions for ecp & tryptase. studies have also used the ability of the cac model to induce rhinitis signs & symptoms to evaluate the relative effects of medication routes: ) ocular v. nasal spray v. systemic; ) ocular + nasal spray v. systemic + nasal spray; ) ocular v. placebo. results: the nac/cac study revealed that, following cac (n= ), significant ocular and nasal signs & symptoms were noted; following nac (n= ), only nasal symptoms were clinically significant. nasal symptom scores between cac & nac differed significantly at timepoint, representing lag in allergen & mediator movement from eye to nose. measurable levels of ecp & tryptase were found in tears and nasal secretions for cac, but only in nasal secretions (with exception of subject) for nac. in cac studies: ) ocular therapy exhibited greater efficacy in ocular itching relief (n= ;p< . ) and was not significantly different from nasal or systemic therapy in nasal symptom relief. ) eyedrop+nasal spray combination exhibited significantly greater prevention of overall rhinoconjunctivitis signs and symptoms than nasal+systemic therapy (n= ). ) ocular therapy offered greater protection from nasal signs & symptoms compared to placebo (n= ;p< . ). conclusion: nac and cac results support the unidirectional flow from eye to nose, the ability of cac to yield nasal symptoms, and the efficacy of topical therapy. tearing, due to inflammation of the inferior turbinate would be the only ocular symptom resulting from nasal challenge. these results offer insight to the nature of the connection between ocular and nasal mucosa and the efficacy of varied medication administration routes for management of rhinoconjunctivitis symptoms. introduction: asthma disease management programs frequently target high utilizers because they are responsible for a large amount of asthma costs. once identified, such "frequent fliers" usually are offered interventions including case management. programs using this approach usually demonstrate reductions in utilization. though the interventions may cause this decline, it could also be due to regression to the mean (rtm) which is a tendency for outliers to become more like the mean over time. in this study we measured rtm in a medicaid hmo asthma population to determine whether targeted case management is effective independent of this phenomenon. we hypothesized that directed case management provides additional utilization reduction beyond rtm. methods: a weighted asthma utilization score was determined quarterly for members of an hmo with asthma from to . rtm was measured by determining how many patients were persistent high utilizers quarterly for year after baseline. to determine the effect of utilization-directed case management, the number of frequent fliers at baseline for each quarter also was determined. results: a total of asthma frequent fliers were identified on january , . by september , only of these individuals continued to be frequent fliers. similar decreases in utilization were seen for frequent fliers identified at the beginning of each quarter of . the mean decrease in the number of frequent fliers is shown in the table. this represents a substantial regression to the mean. the total number of high utilizers at baseline decreased by % after implementation of utilization-directed case management in independent of regression to the mean. this also represented a decrease from . % of health plan members with asthma to . % by the start of suggesting that the decline is not a result of diminishing health plan membership. the benefit appears to be the result of early intervention with members before they become frequent fliers. conclusions: utilization-directed case management can reduce overall asthma utilization by preventing members from becoming high utilizers at an early stage. programs that claim to intervene with plan members who already are high utilizers are likely to be taking advantage of regression to the mean. studies indicate a high incidence of asthma(as) among school-aged children. with the prevalence increasing, significant numbers remain unidentified. they experience morbidity, including school absenteeism, which may be preventable, in part, by adherence to national asthma guidelines. we implemented a pilot study to detect as, as control and initiation of appropriate health care among th grade students in a suburban population. the study was coordinated with the middle school staff and the local county health department. the screen parameters included: student questionnaires, peak flows, exercise with peak flow assessment (frast) , and spirometry as indicated. environmental tobacco smoke (ets) was recorded. results: students screened. no as history and negative screen (d). as history and negative screen (e). as history and positive screen (a). no as history with suggestive written screen and negative screen on exercise (b). no as history and positive screen (c). ets in groups a, b, c: %, %, %. ets in groups d, e: %, %. individual student results were mailed home with medical follow-up recommended for a positive screen. parents of the children who failed the questionnaire or exercise screen (groups a, b, c) were phoned at a - wk interval. no student in-group a or b had medical follow-up. ( %) students in group c had medical follow-up. conclusion: this as screen of th grade students identified ( %) as having significant, undetected as. ( %) with known as had uncontrolled as at the time of screen. ( . %) students with strong suspicion of as based on questionnaire had an acceptable exercise screen. only of the children with a screen suggestive of as or uncontrolled as had medical follow-up. ets was increased in the homes of students with a positive screen and remains a serious health issue. school screening for as has merit, but mail and phone follow-up was insufficient to intervene or initiate acceptable as treatment. references . redline s. et. al. development and validation of school-based asthma and allergy screening instruments for parents and students. ann allergy asthma immunol. ; : - . tsanakas.j.n., et al. free running asthma screening test. arch diseases in childhood. ; : - . american college of allergy, asthma, and clinical immunology screening test ages ( - ) acaai.org. introduction. some laboratory evidence suggests that desloratadine is effective in inhibiting of inflammatory mediators, which play an important role not only in allergic but also in virally induced inflammation. the purpose of this study was to assess its efficacy in acute bronchiolitis developed in young children suffering from concomitant atopic dermatitis (ad). meth-ods. participants were young boys and gilrs aged - who suffered from acute bronchiolitis as established by wheezing, rhinitis and fever. all patients also had concomitant ad as established by hanifin and rafka criteria. patients were allocated to receive syrup formulation of desloratadine (erius, schering plough) , mg/day for days (active group n= ) or no desloratadine treatment (control group n= ) using quota allocation system. we calculated physical global symptom score (combination of cough, wheezing, chest retractions, nasal flaring, blocked nose, runny nose, sore throat - - scale) and respiratory distress assessment instrument (rdai) to examine the patient at baseline and on day th after therapy was initiated, day of normalization of body temperature, respiratory rate, heart beat rate, and use of albuterol. results. both group of patients were comparable on age, gender, family history of asthma, time of onset of the acute respiratory illness, extent of medication taken prior to entering the study, global symptom score and rdai index. all children were evenly treated with oxygen, oral theophylline ( mg/kg/day) and adequately rehydrated. on day th global symptom score of patients receiving desloratadine was , ± , vs , ± , in control group (p= . ). on day th it was also significant difference between active and control groups on rdai index ( , ± , vs , ± , ; p= . ) especially for significant drop in wheezing score in active group. day when respiratory/heart rate normalized, temperature returned to normal, use of albuterol did not differ significantly in these groups. conclusions. our preliminary study is the first to show that desloratadine is an effective agent in viral lower respiratory tract infections of young children suffering from ad. it encourages further gcp trials to explore action of desloratadine in infantile bronchiolitis and concomitant ad. h.j. su * , w.t. lin, p.j. tsai, c.y. huang, p.c. wu, tainan, taiwan. increasing prevalence of childhood asthma has been observed across the world, and found to be associated with, partly, indoor pollution, including bioaerosol exposure. meanwhile, adequate ventilation is shown to be effective in diluting most indoor air pollutants, while only limited data are available addressing directly how the ventilation rate is implicated with childhood respiratory symptoms. this study aimed to examine the concentration distribution of selected indoor air pollutants, including bioaerosols, in domestic environment, and further to assess the effects of ventilation rate, characterized by a co trace gas concentration decay method, on concentration variations of the above-mentioned air pollutants. study subjects were chosen from a prior city-wide questionnaire survey based on positive response to inquiry for physician-diagnosed asthmatic status and wheezing symptoms in the past months. environmental assessments, including ventilation and air quality measurements, were conducted twice, in early winter and the other on early summer. respiratory health diary and pefr (peak expiratory flow rate) were recorded for week concurrent with the sampling activity. increasing ventilation rate is statistically associated with decreasing indoor concentrations of co and tvocs. after adjustment for sex, age, and selected housing characteristics, the or between tvocs concentrations and reporting cough of study children is . , and . between co and nasal congestion. the or between indoor bacterial concentration and the morning pefr less % is . in the similar multivariate logistic regression for data collected from winter study. in summer, the only significant relationship is between ventilation rate and the morning pefr less % of study children, or= . , in a multivariate logistic regression. this study has identified less reporting of childhood respiratory symptoms, especially for coughing and the morning pefr less % are associated with increasing ventilation rate, and higher levels of indoor air pollution appear to be present with greater frequency of the above symptoms. this study suggest quantitatively that proper management of ventilation efficiency may be beneficial for the control of childhood respiratory illnesses. *adjusted for: sex, age, environmental tobacco exposure, use of incense and air conditioner **:p< . ns:no statistical significance with whole model test background: moderate-to-severe allergic asthma can have a substantial impact on a patient's asthma-related quality of life (arql). in addition to asthma symptoms, allergic rhinitis, rhinosinusitis and other related comorbidities are often apparent in patients with more severe disease making it difficult to treat. despite guideline-consistent care, many patients still experience variability in asthma control signaling an unmet need within this population. omalizumab (xolair®) has recently demonstrated clinical efficacy and safety in treating asthma. objective: the aim of this paper is to summarize the arql outcomes associated with omalizumab therapy in moderate-to-severe allergic asthma. methods: we performed a systematic review of arql data from the clinical study reports and published clinical trials on omalizumab. arql was measured by the juniper-asthma quality of life questionnaire (aqlq). results: statistically significant results for arql endpoints consistently favored omalizumab over placebo. the magnitude of the changes in arql were consistently aligned with clinical endpoints. moderate to large effect sizes in the omalizumab groups were maintained throughout the -week clinical trial program and during the -week double-blind extension phase. however, the placebo groups also experienced within-group improvements and moderate effect sizes. a meta-analysis indicated a . to . fold increase in large (> . point) improvements in overall aqlq scores in the omalizumab-treated group compared with placebo during the stabilization and steroid-reduction phases of the clinical trials. conclusions: the consistently positive impact of omalizumab on arql outcomes during the clinical trial program provides evidence of its value as an adjunct therapy in patients with moderate-to-severe allergic asthma. significant differences and large effect sizes were observed despite the fact that the control group received active, guideline-consistent treatment producing a substantial placebo effect. improvements were observed in overall, symptom, activity, emotional and environmental dimensions of the aqlq indicating that omalizumab produced benefits in arql in patients with moderate-to-severe allergic asthma. background: omalizumab, a monoclonal anti-ige antibody, significantly improves asthma-related quality of life (arql) for patients with moderatesevere allergic asthma who express symptoms despite moderate-high inhaled corticosteroids (ics) doses. mean scores can mask underlying variability in arql outcomes. this investigation examined variability in outcomes to elucidate the specific impact of omalizumab treatment. methods: aqlq data (n= ) from two randomized, double-blind, placebo-controlled clinical trials were pooled to assess underlying variability in the mean scores and to identify key drivers of arql treatment-effect differences (juniper-asthma quality of life questionnaire (aqlq)) between omalizumab and placebo (active control) patients. results: correlations between aqlq and other clinical outcomes were low to moderate at best (r= . to r= . ). aqlq assessment captures patient benefit that supplements clinical outcome measures. across all component items of the aqlq patients receiving omalizumab improved more than patients receiving placebo (active control) (p< . ). omalizumab patients reported the greatest improvement for reducing waking with symptoms in the morning (symptoms domain: . vs. . ; p< . ), limitations in all activities done (activities domain: . vs. . ; p< . ), the fear of not having medication available (emotions domain: . vs. . ; p< . ), and symptoms from being exposed to dust (environment domain: . vs. . ; p< . ), compared to placebo (active control) patients. conclusion: arql assessment provides complementary and non-overlapping information on clinical benefit that is distinct from other clinical outcome measures. examination of underlying variability in aqlq mean scores and item-level response extend previously published results on omalizumab treatment effect by showing that aggregate arql improvements for omalizumab patients are strongly influenced by symptom and activity improvement. a. brimer , k. malhi, c. adams, c. dinakar, kansas city, mo. introduction: the desire to belong to a group is a very powerful motivator and is exceptionally strong in the adolescent population. asthma is a disease that makes people feel different. this perception may impinge on patient adherence with medication regimens. we hypothesize that belonging to a club where every member has asthma may encourage identification of the adolescent asthmatic with their peers, and mitigate the perception of being different. objectives: ( ) to investigate the factors that make the asthmatic adolescent feel different ( ) to explore the hypothesis that group activities, such as an asthma club, would help adolescent asthmatics feel less different. methods: as part of an ongoing survey, children with asthma between the ages of - years were offered an anonymous questionnaire in the primary care and adolescent clinics at our hospital. the questionnaire included both multiple-choice and open-ended questions designed to explore the feelings of the respondents. the responses were numerically tallied and reported as percentages. results: at the present time, surveys out of a proposed have been completed. one third of the youth with asthma answering the survey had negative feelings regarding their asthma. nearly forty percent of the respondents reported that their diagnosis made them feel different from their healthy peers. forty-five percent responded that they have felt restricted or excluded from school activities, athletics, and clubs due to their asthma. over one-third of them feel uncomfortable taking their inhaler in front of their friends. most respondents ( . %) indicated that they enjoy group activities. the majority of respondents ( . %) rated playing sports as their favorite group activity. conclusion: almost forty percent of asthmatic youth surveyed indicated that having asthma made them feel different and resulted in restriction/exclusion from school activities, athletics, and clubs. an overwhelming majority expressed a preference for participation in group activities, particularly recreational sports. this social preference towards group activities may be incorporated into an intervention, such as an asthma club, to help asthmatic youth adjust to the disease and its treatment regimen. introduction: airway hyperresponsiveness (ahr) is an exaggerated narrowing of the airways in response to stimuli, such as allergens, histamine, and cold air. ahr is a characteristic feature of asthma linked to chronic airway inflammation. phosphodiesterase (pde ) is an enzyme found in key inflammatory cells involved in the pathophysiology of asthma. inhibitors of pde prevent the breakdown of cyclic adenosine monophosphate, a natural modulator of inflammation. roflumilast is an investigational, oral, once-daily pde inhibitor, which has shown anti-inflammatory activity in vitro and in vivo. this study examined the effect of a single dose of roflumilast on changes in ahr following allergen-induced asthmatic reactions in patients with mild asthma. methods: this double-blind, randomized, crossover study consisted of treatment periods separated by a -to -week washout period. a total of patients (forced expiratory volume in one second [fev ] % predicted) who were hyperresponsive to histamine (provocative concentration causing a % drop in fev [pc fev ] mg/ml) were randomized to receive a single dose of oral roflumilast μg or placebo on day of each treatment period followed by an allergen challenge min after medication. histamine provocation was performed before and h after intake of study drug. results: there was no change in fev min after roflumilast administration, suggesting the absence of direct or acute bronchodilation. allergen challenge elicited early and late asthmatic reactions that were attenuated by a single dose of roflumilast μg. the histamine pc fev in patients treated with roflumilast decreased to a lesser extent than in those patients treated with placebo. the change in pc fev from baseline after challenge was . ± . mg/ml (mean ± sd) with placebo and . ± . mg/ml with roflumilast. the magnitude of the change in pc fev was statistically significantly different between the placebo and roflumilast treatment groups (p= . ). thus, roflumilast decreased the development of ahr by approximately . doubling-dilutions. conclusions: a single dose of oral roflumilast μg attenuated allergen-induced ahr. these data provide further evidence that roflumilast may provide anti-inflammatory activity in vivo and may be an effective treatment for patients with asthma. introduction for the past years we have been tracking pediatric asthma admissions and evaluations at the huntington memorial hospital. during the fall and winter months (oct-march) from to , we noted a . x increase in the number of asthma admissions and evaluations compared with the spring and summer (april -september; , patient encoun-annals of allergy, asthma & immunology ters in years). we have analyzed potential causes for this increase. diesel particulate was estimated in - , and a . -fold increase in the fall versus spring was found in burbank, a city adjacent to pasadena. pollutant particles from the combustion of fossil fuels may act as immuno-adjuvants to allergen exposure as has been demonstrated experimentally in mice and in human nasal exposure studies. methods computerized analysis of asthma admissions and evaluations were calculated according to established codes for acute and chronic reactive airways disease. infectious diseases in patients were analyzed by standard asthma questionnaire. also, pollen and mold counts, as well as diesel particulates and meteorological conditions were studied. results similar numbers of viral infections occurred in the fall of and spring of . among the most prevalent pollens and molds are chinese elm pollen (sept -oct) weed pollens (july -dec), and a newly recognized aureobasidium mold (nov -march). pollen grains can fragment and release respirablesized debris that are loaded with allergens (taylor et al (taylor et al , . the conidia of aureobasidium are also of respirable size and were identified by sequence analysis. fine particulate air pollution (pm . ), containing diesel particles, is increased in the fall and winter in southern california. con-clusions the incidence of asthma outbreaks may vary with air pollution levels in the immediate environment. pollen fragments and particles from fossil fuel combustion can deposit in similar regions of the lower airways. rainfall increases in the fall and winter and this coincides with increased molds and aureobasidium. aureobasidium was recently discovered in high concentrations in pasadena, is known to be allergenic and could be a factor in increased asthma. a mixture of pollens and molds and fine combustion particles may be relevant to this increased incidence of asthma in the fall and winter months in pasadena. background we have previously noted that tree and ragweed pollen grains can be airborne for most if not all daily periods during their respective seasons (aaaai, ) , (acaai, ) . because grass levels are lower than those of trees & weeds (aaaai / nab), we chose a longer daily interval to examine (six hours) that we had for trees (one hour) and ragweed (three hours). methods twenty-four hour microscope slide samples were collected using a burkard day air sampler from / / to / / . the slides were examined @ x along a single longitudinal traverse. the presence or absence of grass pollen was noted per six-hour segment (six successive fields). results the presence of airborne grass pollen during the daily segments was sparse the first two weeks of may. it gradually increased during the next days, and then was detected during most of the daily segments through to the end of june. # ammophila arenaria (aa) is a highly resilient grass with habitat in europe, north america, australia, new zealand, south africa and the mediterranean, used predominantly for dune stabilization. patients with atopic diseases including allergic reactions to pollen are transferred to coastal regions in order to minimize pollen exposure. in spite of the presence of aa pollens, patients experience allergy relief at the coast. our study examines the contradiction between the presence of strong grass allergens and the absence of allergic symptoms in atopic patients, and whether allergic cross-reactions among different types of grass pollen include aa pollen. adult patients presenting symptoms of grass pollen allergy underwent prick testing and rast testing to grass pollen mix and extracted aa pollen. subjects showed positive results in prick and rast testing to aa extracts and were subsequently tested via rhinomanometry for reactions to aa using prick test solutions. subjects showed positive reactions to prick tests for aa extract and grass pollen mix, but did not show specific antibodies. all other sera showed elevated specific ige levels, with specific reactions on protein bands of aa. in sera incubated with grass pollen extract, almost all specific bands previously detected with aa were now inhibited. patients with high levels of total and specific ige to aa showed weak bands after inhibition, demonstrating the allergenicity of aa. comparing data from coastal and mainland weather stations in june and july from to , coastal wind speeds average . to . m/s while inland wind speeds average only . to . m/s. high wind speeds likely dilute pollen concentrations. based on findings of an inverse relationship between wind speed and pollen concentration in the dispersion of ragweed pollen, we hypothesize that concentrations of aa pollens may be similarly influenced. no sensitized patient reported allergic symptoms in coastal areas inhabited by aa plants, indicating that under natural conditions, either the plant modifies its pollen allergenicity or that environmental conditions including salt aerosols, wind patterns, topography or light exposure cause the modification. as such patterns are likely to become more dramatic as the effects of global climate change transform the natural environment, these findings may also become relevant for other grass allergy types. asthma is the most common chronic inflammatory disorders of the airways with increased prevalence in the past decade. it is characterized by airway obstruction, airway inflammation and airway hyperresponsiveness (ahr) to non-specific stimuli. in this study, we examined the effect of a novel class of molecule, ocid , in inhibiting antigen-induced early and late allergic response (ear and lar), ahr, and airway eosinophilia in mouse and guinea pig models of asthma. pulmonary functions were measured in conscious unrestrained animals by whole-body plethysmography. animals were sensitized with ovalbumin (ova; mg, intraperitoneally) with mg alum followed by treatment with ocid ( mg/kg, i.p. twice daily for days). after the last dose, animals were challenged with ovalbumin. pulmonary functions were recorded for ear and lar and hrs later for ahr. this was followed by bronchoalveolar lavage, blood and lung tissue collection. treatment with ocid ( mg/kg) significantly attenuated lar in ova-sensitized and challenged mice or guinea pigs with no effect on ear. ahr to methacholine in mice and to histamine in guinea pigs were prevented by treatment with ocid . ocid attenuated the rise in total number of inflammatory cells in the lung and almost ablated the rise in bal eosinophilia in the lung due to antigen sensitization and challenge. effect of ocid on pulmonary functions and airway inflammation in ova-sensitized and challenged mice were comparable to that of dexamethasone in both models of asthma. these data suggest that ocid prevents the underlying pathophysiological changes in allergic airway inflammation and therefore could prove beneficial in the treatment of bronchial asthma. ma; . madison, wi; . portland, or; . milwaukee, wi; . normal, il; . denver, co; . los angeles, ca; . fremont, ca. introduction. daclizumab (zenapax®), a humanized monoclonal antibody directed against the il- receptor chain (cd ), is approved for prevention of renal allograft rejection and is under evaluation for treatment of asthma. daclizumab inhibits activation of human t lymphocytes by blocking il induced proliferation, and by reducing production of th -and th -associated cytokines. we recently reported that daclizumab improved pulmonary function in a phase ii trial of patients with moderate to severe chronic persistent asthma (jaci, , ( ):s ). we now report additional data from this trial on the possible role of daclizumab as an anti-inflammatory agent that affects asthma outcomes. methods. non-smoking asthmatics age - with baseline fev - % predicted despite use of mcg daily inhaled triamcinolone (taa) or equivalent were enrolled in a randomized, multi-center, double-blind, placebo-controlled trial. patients were randomized ( : ) to i.v. daclizumab ( mg/kg followed by mg/kg every weeks) or placebo added to stable dose taa. starting at week , patients underwent % reduction of taa every weeks while continuing study drug to week . results. patients on daclizumab demonstrated a prolonged time to exacerbation requiring systemic steroid rescue compared to placebo patients (p= . ). exacerbation rates were reduced in the daclizumab group compared to the placebo group for the -week steroid-stable and steroid-taper phases ( . % vs. . %, p= . ). patients on daclizumab demonstrated decreased peripheral eosinophil counts from baseline to week (- ± /mm vs. placebo + ± /mm , p= . ). daclizumab-treated patients with elevated baseline serum eosinophil cationic protein (secp) had a significant reduction in secp from baseline to day compared to placebo patients (p< . ). peripheral eosinophils decreased significantly in daclizumab patients who had no asthma exacerbations compared to an increase in daclizumab-treated patients with at least one exacerbation (p= . ). conclusions. daclizumab reduces time to and frequency of exacerbation in treated asthmatics. the mechanisms of this effect remain to be fully elucidated, but initial findings suggest that associated reductions in circulating eosinophil and eosinophil products may play a role in these therapeutic effects. hae is a genetic deficiency causing a decrease in c esterase inhibitor levels. it is a rare condition (approximate prevalence : to : individuals). it is manifest by acute attacks of swelling which can involve the larynx (a potentially life threatening condition), the gi tract (causing a syndrome similar to an acute abdominal catastrophe) or the skin and soft tissue of the patient including the limbs, face and external genitalia. there is no approved therapy for acute attacks in the usa. pathogenesis of this potentially fatal condition is thought due to excessive activity of plasma kallikrein. dx- is a specific and highly active (ki pm) recombinant inhibitor of human plasma kallikrein undergoing evaluation in hae and cardiopulmonary bypass. it is an animal free product. a double blind, randomised ( : drug to placebo) placebo controlled dose ascending study of dx- in acute attacks of hae was run in the usa and the european union. four dose groups of patients were to be included in the study. the doses were , , and mg/m . the primary outcome variables were proportion of patients achieving a significant clinical response within hours of administration of therapy, and safety. secondary endpoints included site response, dose response, and median time to significant response by site and dose group. dx- met its primary endpoint; % of dx- patients had a significant improvement within hours, (placebo response rate %, difference % p= . ). patients receiving dx- responded in a median time of minutes. there was no difference in proportions of cases that responded within hours between the three anatomical sites. time to significant response did not significantly differ between dose groups and anatomical sites. the safety profile was comparable for patients treated with dx- and placebo, in terms of saes and aes. in conclusion, dx- in this double blind study was shown to be statistically superior by % to placebo and to be at least as safe as placebo. the drug is effective at treating any hae site, including the larynx. dx- represents an important advance in the management of hae. ar is among the most common chronic childhood disorders, and is most effectively treated with intranasally inhaled glucocorticosteroids (ics). recent evidence suggests that intranasal ics therapy may suppress hpa axis function and decrease growth velocity. this study reports -year follow-up data on children ( female, african american), aged to years (mean . years) at entry, enrolled in a long-term growth trial of intranasal taa for treatment of ar. primary measures included height velocity, bone mineral density (bmd), serum osteocalcin and salivary cortisol levels. all subjects followed their expected age-appropriate growth velocities. average growth velocities were . and . cm/year for girls and boys aged < years, respectively, and . and . cm/year for girls and boys aged > years, respectively. mean (+ std) bmd was . + . and . + . gm/cm , mean serum osteocalcin levels were . + . and . + . ng/ml, and mean salivary cortisol levels were . + . and . + . nm/l at entry and -year follow-up, respectively. these results demonstrate no significant effect of one year of intranasal treatment with taa on growth velocity or hpa function in children with ar. patients males, females ranging in age from years to years, received (o) in doses ranging from to injections over to weeks. patients were evaluated with symptoms scores, pulmonary function (pft), blood eosinophil count (bec), medication use, and allergy skin test. st were initially performed by prick and if negative, by intradermal (id) ( / w/v) and if further negative by id ( / w/v). skin tests were performed immediately before and minutes after the administration of o. there was no change in pft or bec. however there were significant reductions in symptom scores, including nocturnal asthma (<. ), exercise tolerance (<. ), sense of well being(<. ). in addition, parenthetically there was a reduction in nasal symptoms (<. ). there were also significant declines in medication use especially for albuterol (<. ). st declined in all patients evaluated and dramatically in many. for several individual allergens st went from prick positive to id ( / w/v) negative. moreover st declined in all instances further, minutes after the administration of o except for patients. in addition to asthma one of the patients had allergic bronchopulmonary aspergillosis and another had allergic fungal sinusitis. three of the patients tested positive on prick test to mouse antigen and in each instance this became negative after administration of o with all patients tolerating o without problem. we conclude: ( .) administration of o is associated with an improvement in symptoms and decreased use of medications ( .) in addition there is a prominent decline in st which is more marked minutes after administration of o compared to immediately prior to administration the explanation of this finding is not apparent. ( .) o appears to be safe to administer to patients even if they demonstrate specific ige to mouse antigen by st a.p. baptist * , t.s. tang, j.l. baldwin, ann arbor, mi. introduction: academic medical institutions are under pressure to shorten or eliminate resident elective rotations due to federal work-hour restrictions. it is unknown if this will affect knowledge and referral patterns for resident and faculty physicians. the objective of this study was to examine the factors associated with resident and faculty perceived knowledge and referral patterns towards allergy/immunology (a/i). methods: a questionnaire was sent to primary care physicians at one academic center. it addressed past history of a/i referrals, referral intentions for conditions that may be seen by allergists, and perceived a/i knowledge. independent variables included history of an a/i rotation, gender, department, years in training/practice, and history of referral to an allergist. results: ( %) completed surveys were returned. using logistic regression with forward selection, we found in the resident physician cohort those with advanced years in training or history of an a/i rotation were more likely to have increased past history of referral to an allergist (or = . , or = . ), increased referral intention for chronic sinusitis to an allergist (or = . , or = . ), and increased perceived a/i knowledge (or = . . for the faculty physician cohort, those with a history of an a/i rotation were more likely to have an increased perceived knowledge about a/i (or = . - . ). in addition, pediatric faculty physicians were more likely to refer asthma (or = . ) and chronic eczema (or = . ) to an allergist than faculty from other departments. finally, faculty physicians with a past history of referral to an allergist were more likely to have refer asthma (or = . ) and allergic rhinitis (or = . ) to an allergist. conclusion: the factors associated with resident and faculty physician perceived knowledge, referral history, and referral intentions towards a/i differ. for residents, senior training level and a history of an a/i rotation appear most important. for faculty, history of an a/i rotation, pediatric department, and past history of referral to an allergist appear most important. given that a history of an a/i rotation may increase perceived knowledge and referral patterns towards a/i, eliminating a/i rotations in medical institutions may have important consequences for patients and the field of a/i. because recent anecdotal reports suggest that hbv may be an effective treatment for patients with multiple sclerosis (ms), there has been a movement of patients to zealous lay practitioners to receive multiple and repeated bee stings. since this practice has real risk of possible fatal allergic reactions as well as emotional and economic costs, properly conducted studies of safety and efficacy are needed. the purpose of the present phase i pilot study was to evaluate the safety of hbv extract in patients with pfms. a total of evaluable bee venom non-allergic patients with pfms ( - years) were enrolled and were randomly divided into groups, each receiving an increasing allergen dose immunization schedule for one year. hyperreactivity to hbv was evaluated by questionnaire, px and hematologic, metabolic and immunologic tests including skin tests. any possible beneficial responses to therapy were evaluated by questionnaire, functional neurologic tests (fnt) and changes in measurement of somatosensory-evoked potentials (seps) prior to and at the completion of the study. no serious adverse allergic reactions were observed in any of the subjects even at the highest doses of bee venom therapy. although of subjects had worsening of neurologic symptoms during the course of bee venom therapy, requiring termination, this response could not be ascribed to side effects of the hbv or to a spontaneous worsening of the neurologic disease independent of treatment since there was no correlation of these events with the bee venom injections. of the remaining , felt that the therapy was beneficial.there were no changes either in fnt or seps measured during the study. the present report represents the first controlled study evaluating the safety of hbv as a possible adjunctive treatment for multiple sclerosis. while this preliminary safety study suggests that administration of repeated injections of hbv in a step-up dosage regimen in appropriately selected non-hbv allergic patients with ms had no serious adverse allergic reactions, because of the small number of subjects studied, it does not permit conclusions regarding efficacy and therefore provides little evidence to support the use of hbv in the treatment of ms. much larger carefully conducted multi-center studies would be required to establish efficacy. i. finegold * , new york, ny. rush immunotherapy (rit) has benefits for inducing immunologic desensitization in shorter periods of time than conventional immunotherapy. however, there is an increased risk of systemic reactions utilizing accelerated schedules. in the past radiocontrast media reactions have been significantly reduced using a standardized protocol. a modification of this protocol was used prior to rit. the oral premedication consisted of mgm prednisone hours, hours and hour prior to rit, fexofenadine mgm at hours and again hour prior to the procedure, and ranitidine mgm, hours prior to rit. patients tolerated the premedications well. a signed consent was obtained prior to rit. patients were desensitized in an office setting with appropriate therapy for anaphylaxis available without an indwelling intravenous line. injections generally began with / dilution of the anticipated maintenance solu-tions and were doubled every - minutes for about - hours and then the patients were observed for hour or more prior to discharge. in this manner patients were desensitized in - half day sessions. the patient was injected again in week, weeks and then weeks. doses were increased if they were not at a full maintenance dose. if reactions occurred this process was appropriately decreased. utilizing this technique patients were treated. the average age was . years old ( - years of age) % were males. % of patients had allergic rhinitis, % asthma, % insect allergy. patients with complicated medical illnesses were excluded. nine patients had systemic reactions requiring an injection of epinephrine. among the symptoms experienced were wheezing, nasal congestion and flushing. no patient required a second injection of epinephrine, intravenous fluids, or hospitalization. the patient reaction rate was % of patients treated or in injections or % of all injections given during the rush protocol. these results are typical of the increased rate of reactions to rit. however, these systemics were mostly very mild and responded to therapy and in only one case was there a delayed hour reaction. thus premedication while not preventing systemic reactions seemed to modify them to make rit in an office setting a practical and effective therapy. we have previously shown that oligonucleotides consisting a novel '- 'linked structure and synthetic immunostimulatory motif cpr (r is a synthetic purine moiety), referred to as second-generation immunomodulatory oligonucleotides (imos), induce potent th immune responses and prevent ovainduced allergic asthma in mouse models. in the present study, we examined local and systemic immune responses of imos following intranasal (i.n.) administration to naive mice. these studies showed that imos produce higher levels of serum and local il- compared with il- . we next examined the ability of s.c. and i.n. administrated imos to reverse ova-induced th immune responses in a murine model of asthma. treatment of ova-sensitized and challenged mice with imos by either route of administration suppressed il- and il- levels with an increase in ifn-gamma secretion in spleen cell cultures and lung homogenates. imos decreased levels of serum ige and igg and induced higher levels of total and ova-specific igg a titers in serum and balf. while both routes of imo delivery showed similar efficacy on serum and balf immunoglobulin levels, s.c. delivery resulted in stronger systemic effects on the spleen cell cytokine production and the i.n. route of administration produced stronger local effects on the lung cytokines. imos also decreased eosinophils in balf and suppressed inflammatory cell infiltration and goblet cell hyperplasia in lungs. these effects in lung were superior with i.n. administration of imo than did with s.c. administration. further studies to understand the effect of low multiple doses against a single higher dose of i.n. administered imos in naive mice suggest that low multiple doses induce strong th responses locally while the single higher dose produces higher systemic responses. these findings suggest that second-generation imos containing cpr dinucleotides potently reverse ova-induced th immune responses with strong th type cytokine induction in ova-sensitized and challenged mice and i.n. delivery is superior to s.c. delivery in reversing ovainduced airway inflammation and mucosal secretion. showed ait was medically inappropriate, lacked documentation of necessity for initiation or continuation and/or had strong contraindications in / ( %) of the reviewed records. method: we audited a convenience sample of our own records for documentation of necessity for (continuing) ait, using a checklist based on the oig report which included the following criteria: an appropriate diagnosis; specific justification; exclusion of strong contraindications; signed, informed consent; a written physician order, and at least annual re-evaluation for continuing ait. results: the first charts in our alphabetized file of total ait charts were reviewed. the patients ( m, f) ranged in age from - yr (mean, yr). the mean duration of ait was . yr (range, . - yr). indications for ait included allergic rhinitis alone ( %) or with asthma ( %) or chronic sinusitis ( %), asthma alone ( %) and venom anaphylaxis ( %). all had initial documentation of necessity. seven charts ( %) had no written order to initiate ait. nine ( %) lacked a signed consent form. no strong contraindication was found. (peak flow documentation showed the asthma cases were well-controlled. three episodes of ait-induced anaphylaxis requiring epinephrine had occurred, but ait was subsequently resumed and well-tolerated.) seventeen ( %) charts had no documentation of re-evaluation during the preceding - months, including with no documented re-evaluation during the previous months or more, of ait. discontinuation of ait was "considered" for patients after . , , and yr of ait, respectively, but all were still receiving maintenance doses. the estimated time for completing this review was - min per chart. inter-pretation: an internal chart review for adherence to ait practice parameters using a checklist such as ours can quickly and easily assess documentation for medicare reimbursement and patient safety. objective(s): immunotherapy is an accepted mode of treatment for children suffering from allergic rhinitis and allergic asthma. this study demonstrates that rapid allergen vaccination (rav) can be as safe as conventional allergen vaccination (cav) in children. rav may also improve patient adherence. study design: pediatric patients, - years of age, diagnosed with allergic rhinitis and/or mild to severe asthma underwent rav over a / hour period in an office-based setting. all patients were premedicated with prednisone and h antagonists for days prior to the procedure. patients were monitored for reactions during the procedure and continued on a cav schedule. adherence was reviewed subsequently. results: a total of pediatric patients underwent rav utilizing a / hour protocol. of the patients, of them were male ( . %) and of them were female ( . %). ( . %) of the patients had allergic rhinitis, ( . %) had asthma, and ( . %) had chronic sinusitis. during the procedure, patients ( . %) experienced systemic reaction, and none experienced true anaphylaxis. seven of the eight patients who suffered a systemic reaction were patients with asthma on inhaled corticosteroids, three of the eight patients were male ( . %) and five of the eight were female ( . %). every systemic reaction occurred within minutes of the injection. treatment usually included one or a combination of the following: nebulized breathing treatment with albuterol, two sprays in each nostril of azelastine, and diphenydramine taken orally or intramuscularly. every patient that was treated was discharged within two hours, and no one required treatment with subcutaneous epinephrine, treatment for recurrent symptoms or hospitalization. all of the patients continued with a conventional allergen immunotherapy regimen following the rapid protocol to reach their maintenance dose. typically, months of build-up period was saved. patients reached efficacious dosages almost immediately. adherence rates were . %, . %, and . % at , , and months respectively. conclusions: effective doses of allergen vaccine can be safely reached using a / hour protocol annals of allergy, asthma & immunology for children. advantages of rav over cav include improved adherence with almost immediate clinical efficacy, and decreased costs. introduction: studies involving allergen immunotherapy (ait) have furthered our understanding of cat allergen, proteases, and dust mite allergen. the impact of these data has not been assessed. objective: to evaluate ait prescribing trends over years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) focusing on new prescriptions before and after published data regarding specific prescribing recommendations. methods: a retrospective review of , ait prescriptions from a centralized allergy and extract laboratory database was performed with respect to published literature on findings and recommendations regarding the ubiquitous nature of cat allergen, effective dosing of cat antigen, combining protease containing extracts with those susceptible to degradation, dust mite antigen dosing, and the use of house dust versus dust mite antigen. results: ) in , cat allergen was included in % of new allergy immunotherapy prescriptions reviewed; in , it was included in % of new prescriptions, a statistically significant increase (p< . ). ) over the past years, the mean quantity of cat antigen included in new prescriptions has been unchanged at ml/prescription. only % of new prescriptions were written at the manufacturer recommended maintenance dose of ml, significantly less than those written below this level (p < . ). ) there was no significant change in the percentage of extracts combining antigens with proteases with antigens susceptible to degradation. in , % of prescriptions containing alternaria and/or cockroach antigen were mixed with one or more antigens susceptible to degradation; in , % of these extracts were still being combined. ) the mean volume of dust mite mix contained in these prescriptions was between - . ml/ ml. ) prescriptions containing dust mite rose from % in to % in . the use of house dust was unchanged over the same period at . % of prescriptions. conclusions: although the percentage of cat containing extracts has increased significantly, dosing of cat allergen has remained unchanged despite published literature recommending higher volumes. protease-containing allergen prescribing patterns have not significantly changed from [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] young stage of life is a crucial period for aeroallergen sensitization, considering the immaturity of the neonatal immune system which may lead to t-cell anergy or a deviation towards th -type response in mice. the aim of this work was to evaluate the influence of oligodeoxynucleotides containing cpg motif (cpg-odn) on ovalbumin (ova) and blomia tropicalis (bt) immunization in early life compared to adult stage. three days old a/sn mice were immunized with ova in al(oh) and boosted on th and th day after immunization (dai) and bled on th dai. groups of mice received mg of cpg-odn or control-odn associated with ova on immunization and boost. some animals from the three groups (ova, ova+cpg, ova+co) were killed at days old and the spleen was collected and prepared to culture. eight to weeks old female a/sn mice were immunized with ova in al(oh) , boosted on th dai and bled on th dai. groups of mice received mg of cpg-odn or control-odn associated with ova on immunization. animals from the three groups were challenged months after immunization and bled days later. similar protocols were performed using blomia tropicalis (bt) extract in the place of ova. neonate and adult co-administration of cpg-odn with ova or bt were able to significantly decrease specific ige antibody levels and increase igg a production. moreover, cpg-odn decreased specific igg levels in the bt immunization. the co-administration of control-odn in neonates decreased anti-ova igg production. after ova-challenge months later of adult immunization, a similar response was detected in the group that received cpg-odn associated with ova, which showed a decreased anti-ova ige and igg and enhanced igg a levels. analysis of cell division of neonate lymphocytes by flow cytometry showed a decreased proliferation in ova+cpg mice group under ova stimulation. this effect was seen either in b cells and t cells. the results showed that immunization with both allergens, ova and bt, associated with cpg-odn decreased the type i hypersensitivity response. the pattern of antibody production suggests th -type response induced by cpg-odn, and the establishment of memory th response. this findings may imply that the use of cpg-odn in early life seems to be beneficial as an strategy to modulate or to prevent the development of allergic diseases. n. horne * , a. capetandes, m. frieri, east meadow, ny. introduction: it has been shown that dust mite allergens can affect the functioning of airway epithelial cells (winton et. al. br j pharm : , . previous experiments showed ca aggregate in the presence of dermatophagoides pteronyssinus (dp) (capetandes et. al. am j clin path, : , ) . it is hypothesized that epithelial damage is associated with airway remodeling characterized by fibroblast dysregulation. to evaluate the response of fibroblasts to damaged airway epithelial cells, the bioactivity of serum-free conditioned media from dp-treated ca cells (dpcm) was assayed with nhlf. methods: all experiments used insulin-transferrin-selenium supplemented dmem (its). dpcm (generated with ca treated with au/ml dp; alk-abello) was added to % confluent nhlf for hours at oc and % co . its from cultured ca without dp (its cm) was added to % confluent nhlf (control). cell morphology and density were evaluated by microscopy and mtt assay, respectively. data were analyzed by anova followed by student-neuman-keuls (snk) at p< . with power analysis. results: % confluent nhlf treated with dpcm showed decreased cell density (figure ) , and increased aggregation relative to its cm or its alone. nhlf in its alone or with direct addition of au/ml dp to its (dp its) showed no or weak aggregation. aggregated nhlf showed % viability and grew to confluence when subcultured to serum-supplemented media. conclusion: nhlf aggregation was greater, and cell density was lower with dpcm than with its, its cm, and dp its. this suggests that dp-treated ca cells release an unidentified factor or factors that contribute to nhlf aggregation and possible apoptosis. identification of these factors would increase the understanding of the fibroblast response to epithelial cell exposure to dp which may be involved in airway remodeling, a feature of chronic severe asthma. j.t. zimmermann * , y.c. huang, m. frieri, east meadow, ny. introduction: budesonide has been demonstrated to inhibit il- , tgf and gm-csf in ragweed and dust-mite (dm) stimulated human alveolar epithelial cells (j allergy clin immunol : a, ; ann allergy asthma immunology : p , ) . rantes production and expression in dm and il- -stimulated a cells has recently been shown to be inhibited by budesonide (allergy asthma proc, in press ). histamine is known to influence immune response by regulating cytokine synthesis (allergy : - ) . in this study we examined the effect of budesonide in the presence of histamine on il- production and expression by a cells. methods: a pulmonary epithelial cells were cultured in dmem for hours in % co in the presence of : of , au/ml dm, - m histamine and - m budesonide. il- production was measured by a sensitive elisa and il- mrna was measured by qualitative rt-pcr using standardized primers for il- with a gapdh control. results: a cells were stimulated by dm ( - pg/ml) (p< . ). budesonide alone decreased il- levels to pg/ml (p< . ), and in combination with histamine further decreased il- levels to pg/ml (p< . ). relative intensity of il- mrna expression was reduced -fold in dm-stimulated cells and -fold in control cells by budesonide. conclusion: budesonide in combination with histamine showed greater inhibition of il- production by a cells than budesonide alone possibly by increasing cell membrane permeability. c.r. oliveira * , a.e. fusaro, j.r. victor, e.a. futata, c.a. brito, a.j. duarte, m.n. sato, são paulo, brazil. antigen-driven bystander suppression induced by oral tolerance could be an interesting approach in the allergy field, considering the high incidence of new allergens sensitization in atopic individuals. to address the influence of non-related allergen exposure on the type i hypersensitivity response to the mite blomia tropicalis (bt) or ovalbumin (ova) in mice and to verify oral tolerance effect in the bt/ova co-immunization model. groups of mice were immunized with bt extract and two weeks later submitted to ova-immunization, or first immunized with ova or co-injected with bt and ova. ova feeding was performed five days prior co-immunization. ige abs were estimated by means of passive cutaneous anaphylaxis reaction and specific ab and cytokines secretion by elisa. mice sensitized with bt and then exposed to ova developed an enhanced ige response to itself and to ova, but such response has not been observed when ova-immunization was prior to btimmunization. co-injection of bt and ova led to a dominant ige response toward ova over bt and vice-versa for the igg response. ova feeding prior co-immunization decreased ige, igg and igg a ab levels against ova in parallel to a bystander suppression, which avoided the outcome of bt-sensitization. these mice showed increased ifn-?secretion levels induced by antigen-specific stimulus. furthermore, effectiveness of oral tolerance was also related with ova amounts employed in the co-immunization since ova feeding prior co-immunization with low amounts of ova led to inhibition of ige ab response to both allergens, whereas inhibition of specific and non-related antigen igg ab response was broken. the results evidenced that, depending on allergenic potential, new allergen exposure may exert an adjuvant effect on the primary sensitized allergen. the bystander effect to non-related allergen by oral tolerance should be an interesting mechanism to control new aller- rationale. cd + cd + regulatory t cells from patients with atopic asthma undergo apoptosis when stimulated by specific allergen. antihistamines are used to control allergic inflammatory diseases, but their influence on treg cells is currently unknown. the present study investigates the influence of desloratadine (d) on apoptosis of cd + cd + regulatory t cells in atopic patients having dust mite induced allergic disease, including allergic asthma. methods. patients (n= ) with positive skin prick tests to house dust mite allergens and a clinical history of allergic upper and/or lower respiratory symptoms were treated with d mg (schering-plough, usa) once daily for days. no patients used systemic corticosteroids, while theophylline and other medications were stopped at least hours before blood collection. blood was sampled before and after treatment with d. the control group was comprised of individuals without allergic respiratory symptoms and with negative skin prick-tests. peripheral blood mononuclear cells (pbmc) were isolated over a ficoll density gradient and stimulated by specific allergen (dermatophagoides farinae) and in a control series by phorbol myristate acetate (pma). pbmc were labeled with anti-cd , cd , cd , and bcl- monoclonal antibodies. the annex-inv-propidium iodide (anv-pi) test was done. lymphocyte subpopulations and apoptosis were analyzed by flow cytometry. results. after treatment with d, atopic patients had no significant differences in the number of cd + cd + cells. during co-culturing of pbmc from patients treated with d with specific allergen a significant increase in cd + cd + cells was observed. simultaneously, treatment with d led to a significant increase in expression of the antiapoptotic protein bcl- in cd + cells. this data paralleled the decrease of cd expression on cd + cells. there was also a decrease in treg cells in the late stages of apoptosis (anv + pi + cells) in d treated patients. conclusions. the antihistamine preparation desloratadine prevented allergen-specific apoptosis of cd + cd + t regulatory cells in patients with atopic asthma. the type histamine receptor may be involved in the regulation of apoptosis and/or survival of cd + cd + t cells. a.g. palma-carlos * , m.l. palma-carlos, lisboa, portugal. introduction: solar urticaria porphyrin corresponds to sun sensitivity to a a wavelengths and is due to disturbances of posphorin metabolism. photosensitivity can cause urticaria, erythema, polymorphic solar eruption and in more severe cases vesicles and bullae. photosensitivity was confirmed by light test. methods: protoporhyrin in rbc, uro and coproporphyrins in urines, copro and protoporhyrins in faeces and porphyrin precursors have been studied un all the cases of solar urticaria seen in the last few years. results: in patients, female, males, a diagnosis of porphyria has been confirmed by laboratory methods. clinically patients presented solar urticaria and solar erythema or polymorphic solar eruption. patients, female, males ( - ) presented also neuro visceral symptoms: abdominal pains ( ) vomiting ( ) asthenia ( ) constipation ( ) muscle pains and paresia ( ) depression ( ) anesthesic reactions ( ). in cases the symptoms were associated with anticonceptional drugs. the conjunction of clinical history with laboratory data has allowed to confirm the diagnosis of cases of protoporphyria erytheropoietica, one triggered by anticonceptionals, cases of coporporhyria hereditaria and cases of porphyria variegata. this group comprises one case of erythropoietic protoporphyria induced by estrogens not previously reported. conclusions: research of porphyrins must be done in all the patients with solar urticaria and erythema. the incidence of sun sensitivity in mixed hepatic porphyriaalso presenting neuro-visceral symptoms which can be drug dependent suggests that porphyria study must be mandatory in suspected cases. a.r. narayan * , j. kaplan , v. sirvan , a. chandrasekaran , c. goodwin , l. goodwin , l. guida , m. frieri , . east meadow, ny; . manhasset, ny; . bayshore, ny. rationale: our division has reported that nitric oxide (no) from tracheal epithelium can mediate induction of il- (american journal of respiratory critical care medicine : a, ) . increased levels of il- , ltb- , and no in mononuclear cells (mnc) from cystic fibrosis (cf) patients were noted.(pediatric asthma allergy immunology : - ) . no in mnc from cf was increased by stimulation with aspergillus fumigatus (asp) and rhdnase (j. clin allergy immunol : p ). tnf-is produced from bronchial epithelial cells (bec) in the presence of mnc of normal controls (nc). rantes, a chemokine that facilitates leukocyte migration, is associated with airway inflammation in cf, and asp sensitization in cf patients could amplify pro-inflammatory cytokines such as il- , tnf-, and rantes. methods: we studied the mrna and protein expression of tnf-, il- and rantes in a year-old cf patient and a nc. x mncs from the patient and nc were stimulated with μg/ml of asp with bec at x and μg/ml rhdnase. mrna expression was studied by real time pcr (taqman chemistry abi prism ) and protein levels by elisa. results: tnf-production in supernatants of mnc with bec from nc increased from pg/ml to pg/ml with rhdnase. whereas in cf patients the tnf-mrna expression was greatly enhanced over nc but declined in the presence of rhdnase (fold difference: . - . ). there was no difference in expression levels of nc (fold difference: . - . ) with rhdnase treatment. il- expression in mnc with bec of patients increased . fold compared to nc ( . fold). rhd-nase decreased asp stimulated levels to . fold in patients compared to nc ( . fold). mnc and bec rantes production in patients increased from to pg/ml and decreased to pg/ml with rhdnase, but increased from pg/ml to pg/ml in nc. in contrast, rantes mrna expression in all groups was higher in nc but decreased with rhdnase in both cf and nc ( - fold vs. - fold). conclusion: rhdnase can increase no and decrease pro-inflammatory tnf-and rantes in cf patients stimulated with asp. rhdnase could lead to augmented bactericidal activity and epithelial defense by enhancing no production and decreasing the expression and production of tnf-, il- and rantes. this is a case report of two steroid dependent atopic dermatitis patients who both responded to treatment with omalizumab. patient a is a year-old white male who presented with a history of severe atopic dermatitis for years along with concomitant mild persistent asthma and allergic rhinitis. he had previously received monthly triamcinolone injections, methotrexate and doxycycline with limited response. on presentation he had mild improvement on a regimen of alternate day prednisone mg, fexofenadine mg bid, and zafirlukast mg bid. however, attempts at weaning prednisone were unsuccessful. omalizumab was initiated at a dosage of mg every four weeks. the patient remains prednisone dependent yet free from atopic dermatitis. patient a's diagnostic work up determined a total ige of . ku/l. the patient's specific ige tests were positive for grass mix, weed mix, maple, white pine, peanut, strawberry, gluten, soybean, wheat, oat, and dog dander. specific ige tests were negative for cat dander, egg white, milk, goose feathers, chicken feathers, mold mix, dust mix, and fish mix. patient b is a year-old white male who presented with a history of severe full body atopic dermatitis along with mild persistent asthma and allergic rhinitis. he also was receiving triamcinolone injections with limited success. he responded to alternate day prednisone mg, desloratidine mg bid, and zileuton mg bid. attempts at weaning prednisone failed until initiation of omalizumab mg every two weeks. his atopic dermatitis is now under control with once daily desloratidine and omalizumab every two weeks. he was successfully weaned off of corticosteroid medication and has begun an immunotherapy regimen. patient b's diagnostic work up determined a total ige level of ku/l. patient b's specific ige tests were positive for weed mix, tree mix, maple, peanut, strawberry, dust mix, cat dander, dog dander, egg white, milk, oat, wheat, goose feathers, and chicken feathers. specific ige tests were negative for grass mix, white pine, mold mix, gluten, soybean, and fish mix. these two case reports reveal significant response to omalizumab in severe steroid dependent atopic dermatitis. further research is strongly indicated considering the quality of life issues with severe atopic dermatitis and potential side effects to long-term corticosteroid treatment. eosinophilic esophagitis (ee) has been described in children and is characterized by high levels of eosinophils (> - eosinophils/high powered field [hpf]) in the esophageal mucosa. a recent report indicates that the combined prevalence of the eosinophilic gastrointestinal disorders may be higher than that of inflammatory bowel diseases (ibd). the presenting symptoms of ee mimick those of gastroesophageal reflux disease (gerd), and patients of all ages may experience a delay in time from onset of symptoms to diagnosis of ee. there is a paucity of data in the literature regarding the delay in time from symptom onset to diagnosis of ee. we report the data on four children three years of age and under with ee who experienced a significant diagnostic delay. four young children were referred to the pediatric allergy clinic with a diagnosis of ee (table) . three of the patients were male and one was female. the patients were - months of age at the time of diagnosis, and the diagnostic delay was . - months (average delay . months). the most common presenting symptom was vomiting, and three of the four patients had a history of respiratory obstructive symptoms. all of the patients had received conventional treatment for reflux disease, and one had undergone a nissen fundoplication prior to diagnosis. in all four patients the esophageal biopsy revealed > eosinophils/hpf. three out of four patients had a family history of atopy, and two patients had a known history of a food allergy. skin tests to foods were positive in two patients and rast (radioallergoabsorbent) testing to foods was positive in one patient. recent data suggests that the diagnostic delay in ibd is decreasing as much as %. it is hypothesized that this may be due in part to an increased index of suspicion by health care providers. there is little data available regarding the diagnostic lag in children with ee. it is currently believed that chronic ee can lead to progressive esophageal scarring and dysfunction. stricture formation has also been described in children less than two years of age. given the reported increased incidence of this allergic gastrointestinal disease over the past decade, more data regarding the diagnostic delay of these conditions may be instrumental improving health care providers' awareness of this disorder. a. kohli-pamnani * , e. cooney, p. huynh, f. lobo, new haven, ct. introduction: cutaneous hypersensitivity reactions to amprenavir, an hiv- protease inhibitor, are reported in up to % of treated patients, of whom % have severe or life-threatening rashes, with treatment discontinuation required in % of cases. we report a case of successful desensitization to amprenavir, for recurrent maculopapular exanthem, in an hiv-infected patient with late stage disease and limited antiretroviral (arv) agent options. methods: the patient is a year-old caucasian female with late stage hiv disease (absolute cd count cells/mm , hiv rna , copies/ml) and multiple arv intolerances, who developed a severe generalized maculopapular eruption sparing mucous membranes six days following initiation of a regimen comprised of amprenavir, lopinavir/ritonavir, zidovudine, and lamivudine. a similar reaction occurred following re-challenge with amprenavir alone ( mg oral formulation bid via percutaneous endoscopic gastrostomy (peg) tube), despite concurrent administration of oral prednisone mg/day and loratidine mg/day. results: skin prick testing with amprenavir . mcg/ml was negative, whereas intradermal testing with . mcg/ml was positive with a mm wheal and mm flare. percutaneous and intradermal testing with normal saline was nonreactive. the positive histamine control (skin prick only) yielded a mm wheal and mm flare. subsequently, incremental doses of . mg, . mg, . mg, mg, . mg, . mg, mg, mg, mg, mg, mg, and mg of amprenavir oral solution were administered via peg tube at to minute intervals (table) . the patient successfully tol-erated amprenavir desensitization and has remained on therapy without recurrence of rash out to months of follow-up. conclusions: desensitization may permit continued use of amprenavir in patients with a history of amprenavirinduced maculopapular eruptions who have limited alternate treatment options. efforts aimed at characterizing the mechanism of amprenavir cutaneous hypersensitivity reactions seem warranted, given the frequency of reactions and the limited number of arv agents available for patients with late stage hiv disease. doses of oral solution were administered by peg tube at twenty to thirty minute intervals. introduction: beta-lactam (bl) allergy is the most common drug allergy. in most cases, ige antibodies are specific to the bl nucleus. however, sidechain-specific ige (scsige) to bl has been described. despite this, skin testing (st) to bl other than penicillin (pcn) is not commonly performed. we report a case of a year-old female with a selective allergy to pip, and describe the utility of st to this agent to confirm scsige. methods: st to prepen (pp) and pcn g was carried out with percutaneous (pc) testing followed by intradermal (id) testing. st was also carried out with ampicillin (amp; mg/ml), pip ( mg/ml at pc level; mg/ml at id level-a non-irritating concentration), and pip/tazobactam (tbm; mg/ml at pc level; mg/ml at id level) to exclude the possibility of selective allergy to tbm. case report: a year-old white female with crohn's disease was hospitalized for treatment of intra-abdominal abscesses. she had immediate flushing and urticaria during an infusion of pip/tbm approximately years prior. the allergy/immunology service was consulted for pcn st because her primary service preferred to empirically treat with pip/tbm. she had received imipenem approximately months prior without untoward reaction. st to pp and pcn g was performed with negative responses and adequate controls. she subsequently received pip/tbm, but developed flushing and urticaria during her initial infusion, consistent with an ige-mediated reaction. two months later, st to pp and pcn g was repeated. in addition, st to amp, pip, and pip/tbm was performed. she had positive responses to pip and pip/tbm with negative responses to pp, pcn g, and amp, implying selective ige-mediated potential to pip. she tolerated an oral challenge with pcn vk mg immediately following st without untoward reaction. conclusion: we have described a case in which st to pip was useful for diagnosing scsige in our patient, who had prior reactions consistent with ige-mediated pathogenesis. this information will be helpful in identifying antibiotics she can safely receive in the future. this case supports the utility of st to bl in addition to pcn, in evaluation and management of patients with a history of adverse reaction to bl that may reflect presence of scsige. a.r. vaishnav * , b.s. bochner, baltimore, md. we report the case of a -year-old caucasian male with a -year history of asthma, two episodes of eosinophilic pneumonia and chronic peripheral eosinophilia with baseline eosinophil counts around /μl who developed amnesia and elevated cardiac enzymes in february . another physician had added montelukast in january and because of a good response advair was decreased from / to / bid. in february his eosinophil count increased to /μl and soon he developed left arm numbness, diplopia as well as left arm and leg weakness. at his local hospital, he was found to have elevated troponins and cpks. cardiac catheterization showed normal coronary arteries and good left ventricular function. soon after discharge, he developed confusion and global amnesia. brain mri showed diffuse uptake consistent with global inflammation and/or vasculitis. upon hearing this story, we told him to take mg of prednisone and urgently come to our hospital for admission. within hours, his mental status and visual symptoms improved. physical examination was unremarkable except for subungual splinter hemorrhages. montelukast was stopped and gm/day solu-medrol iv was started. endomyocardial biopsy days later showed mild hypertrophy and fibrosis without eosinophils. repeat brain mri and mra were normal. chest ct showed multiple patchy infiltrates with a new central cavitary lesion in the right lobe. other labs included a negative anca, ana of : , normal complements and csf. our differential diagnosis included churg-strauss syndrome (css) versus hypereosinophilic syndrome (ihes) with myocardial, neurological and pulmonary involvement. serum tryptase was normal as was fluorescent in situ hybridization for the fip l -pdgfr fusion gene. based on this, along with the new pulmonary cavitary lesion on chest ct, the diagnosis of css was made. after days of iv steroids, he was switched to mg/day of prednisone. upon discharge his eosinophil count was /μl on mg of prednisone. after all procedures were completed, he was also started on aspirin mg daily to prevent thrombotic and thromboembolic complications. he was seen in follow-up in clinic and cytoxan mg daily was started. his prednisone is being tapered. he is tolerating the treatment well and so far has had an excellent clinical and laboratory response. introduction-c -esterase inhibitor (c -inh) deficiency is a rare disorder classified into acquired and hereditary forms. both entities are distinguished by recurrent angioedema without pruritus or urticaria. the upper airway, head, neck, extremities and gi tract are typically involved. the inherited form usually presents in the first or second decade accompanied by a family history. the acquired form more commonly presents after the fifth decade. in acquired c -inh deficiency, serological evaluation reveals low levels of c , c -inh, and c q and a normal c level. levels of c q are normal in the hereditary form. the acquired form may be associated with lymphoproliferative disorders and autoimmune disease. acquired c -inh deficiency is typically recognized before the underlying malignant condition is diagnosed. clinical regression has been reported in patients whose underlying disorder responds to treatment. methods-a case report of a -year old female who developed repeated episodes of facial angioedema requiring hospitalization preceded by one year of vague abdominal pain and cramping. data-laboratory investigation of this patient revealed c < mg/dl ( - mg/dl), c q< . mg/dl( . - . mg/dl), ch < u/ml( - u/ml), and c -inh at mg/dl( - mg/dl) with a % activity (> % normal). c was mg/dl( - mg/dl). other laboratory evaluation was notable for a normal cbc with diff, comprehensive metabolic panel, amylase, lipase and spep pattern. ige was elevated at ku/l. hematology was consulted. ct of chest, abdomen, and pelvis were nondiagnostic. peripheral blood flow cytometry revealed a small distinct pop-ulation consistent with a clonal b-cell lymphoproliferative disorder. a repeat test showed skewing towards lamba light chain expression. bone marrow biopsy and aspirate were essentially normal except for erythroid hyperplasia on danazol treatment. the physical examination was without any masses or lymphadenopathy. the patient remained asymptomatic after beginning danazol although elevations in rbc, hgb, hct and absolute lymphocyte count have developed. conclusion-acquired c -inh deficiency is rare cause of recurrent angioedema that has been reported in small cohorts and case presentations. we report another case report that reinforces the need for physicians to evaluate for concomitant lymphoproliferative disorders. chronic urticaria is a distressing condition usually associated with poor quality of life and poor response to symptomatic therapy. a wide variety of causes and mechanisms have been described and in some patients the cause remains unknown. rare cases have been associated with thyroid antibodies and some responded to thyroxin, even in the absence of overt thyroid disease. case report: a -yr-old obese white female presented with a history of persistent urticaria/angioedema for mo. urticaria involved various parts of the body and individual lesions usually lasted < hr. it was often accompanied by facial edema. oral diphenhydramine mg qid caused only little improvement. the patient could not suspect any offending factors. review of systems and past medical history were unremarkable, except for hyperthyroidism at age yr that was treated with "medication" for yr. on physical examination there were several urticarial lesions though she has been taking diphenhydramine. the thyroid appeared normal regarding size, shape and texture. various second generation antihistamines and doxepin were of little help. laboratory evaluation revealed total serum ige of iu/ml (normal < iu/ml) and ch of u/ml (normal - u/ml), but high tsh of . iu/ml (normal . - . iu/ml) and low free t of . ng/dl (normal . - . ng/dl). her antithyroglobulin titer was iu/ml (normal < iu/ml) but the antimicrosomal titer was highly elevated at iu/ml(normal < iu/ml) consistent with hashimoto's thyroiditis. thyroxin therapy was initiated at a dose of mcg/d which resulted in marked improvement within one week and the patient was able to discontinue doxepin and other antihistamines. because of marked drop in tsh to . iu/ml, the thyroxin dose was reduced to mcg/d. her thyroid function tests became normal within two months. she did not experience any recurrence of urticaria or angioedema during over mo of follow-up so far. conclusion: patients with chronic urticaria/angioedema, especially women, should be screened for thyroid autoantibodies and if positive, thyroxin therapy might bring impressive remission in urticaria. hypersensitivity pneumonitis (hp) results from an abnormal immunologically mediated response to an environmental antigenic trigger. typically patients with hp experience transient fever, hypoxemia, muscle and joint pain, difficulty breathing, fatigue, weight loss, and cough. there are two clinical presentations of hp differentiated by onset and resolution of symptoms. patients experiencing acute hp experience the onset of symptoms to hours following exposure to a particular antigen and resolve in to days without specific treatment. however, patients with chronic hp experience symptoms that persist for months to years when exposed to a recognized cause of hp. a year-old caucasian male was referred to our practice with acute bronchitis. his referral was secondary to a history of allergic rhinitis, chronic asthma, gastro-esophageal reflux disorder, and sinus surgery. this non-smoking male was a machine operator at a local factory. he was doing well until he began working in the presence of a heat induction machine and metal lubricating spray called multan ea (hinkle surface technologies), i.d. no.: . multan ea is a product containing naphthenic petroleum distillates, amine salts, amine soap, triethanolamine hexyl, hexylene glycol, ethanol, sodium petroleum sulfonate, and triazine. this lubricant is known to irritate the eyes, skin, and respiratory tract. recent studies indicate that thermal decomposition of triazine, which readily occurs during metalworking, results in the production of formaldehyde. formaldehyde is a known carcinogen, as well as respiratory, skin, eye and digestive tract irritant. the patient developed serious respiratory health problems resulting in work absence and eventually hospitalization. while hospitalized he received a high resolution ct scan which showed diffuse ground glass appearance, and multiple attenuation areas of the lung which are consistent with hypersensitivity pneumonitis. the patient was treated with corticosteroids, and antibiotics with eventual normalization of lung parenchyma by chest ct. this represents the first reported case of hypersensitivity pneumonitis resulting from exposure to the metalworking fluid and respiratory irritant multan ea . a.j. ham pong * , f. chan , s.l. bahna , . ottawa, canada; . shreveport, la. sexual intercourse has been known as the route for semen hypersensitivity reactions to the seminal fluid protein or to a contaminating drug or food. we report a case of anaphylaxis to cephalexin-containing semen by ingestion. history of present illness: a -year-old woman developed a systemic reaction after swallowing semen. since the couple frequently practiced fellatio without any reactions, her husband suspected cephalexin that he was taking over days ( mg qid). her reaction began in less than min and peaked over min; first as itchy oral mucosa followed by wheezing, flushing of the face and upper chest, and nausea. diphenhydramine mg was administered po at min and the reaction subsided over hr. past medical history: she had generalized urticaria to oral penicillin more than yr earlier and had positive penicillin skin test. she also had allergic rhinoconjunctivitis, mild intermittent asthma, and positive skin test to house dust mite, cat and dog epidermals, and pollens of grasses, trees, and ragweed. she also had oral allergy syndrome to certain fresh fruits and tree nuts; hazelnuts caused also diarrhea and colic. neither the patient nor her husband ate any nut-containing food on the days preceding the reaction. family his-tory: allergic rhinoconjunctivitis in the mother, sister and brother. eval-uation: the patient sought allergy evaluation about yr after the reaction. she and her husband gave a consent. her serum ige was iu/ml and skin test positive to penicilloyl polylysine x - mol id, but negative to cefazoline mg/ml for prick and mg/ml for id. she had negative prick test to her husband's seminal plasma both before and after his intake of cephalexin mg qid for days. using a cephalexin bioassay sensitive down to . mcg/ml, the medication level in the husband's urine at min post last dose was mcg/ml and in his serum at min was mcg/ml, but was undetectable in the semen collected at min. conclusion: this is probably the first case report of systemic reaction to ingested semen. the reaction occurred in an atopic, penicillin-sensitive woman and seems to be caused by cephalexin excreted in the semen or through urine contamination ( drop = mcg). in addition to her avoiding penicillin and cephalosporins, she was advised to avoid her husband's semen while him taking such drugs and for at least days afterwards. background:asthma causes serious morbidity & mortality all over yet most asthma educational evaluations and programs have an urban rather than rural focus.there is lack of data on rural north dakota(nd). this nd survey aimed to study knowledge & awareness of management strategies for asthma like use of metered dose inhalers, spacer devices and peak flow meters. methods:the qualitative survey addressed attitudes and beliefs on asthma & its triggers;knowledge of medication delivery routes & use of hospitals and provider visits.a simple questionnaire was self-administered at rural clinics in small towns in southeastern north dakota. questions explored asthma knowledge, extent of family history of asthma & factors aggravating asthma.it was voluntary & the population surveyed included patients, family, teachers, employees at nursing homes, the local hospital & clinics. results:of surveys completed % had no asthma in the family.of those with a family history( %), % had person with asthma, . % had & . % had or more.respondents were aged - years & . % were female.see table. discussion:our survey was rural & comparison with urban areas may help in planning for asthma education & resource allocation. % denied asthma in their family. similarly, nonurban alaskan natives have a lower incidence of asthma compared to nonnatives.our results show a lack of awareness in our area.grain dust exposure was perceived as an asthma trigger but without evidence, local research is needed.in our study smoking was considered a trigger by . % & this may be real.there was lack of awareness of peak flow meters & their role in asthma care.a study showed that compared to other areas even rural nurses used peak flow meters less often to assess and monitor asthma.this suggests a need for comprehensive asthma educational programs in rural areas that are based on national guidelines.we had only a moderate followup rate at %.in comparison, one study had % missed scheduled follow-ups. exercise induced asthma was known to only % of our group. conclusion:the need for better patient-provider communication has been highlighted by the lack of awareness of proven strategies to combat asthma.the use of a simple survey has revealed many unknown facts about asthma awareness in rural nd.further study to determine cost effective solutions to achieve national targets for asthma management are essential. aim: in most studies of asthma, the emphasis was on changes in large and middle airways. the aims of this study:( )to observe the morphologic changes in small airways and lung tissue(salt) in guinea pig asthma models(gpam); ( )investigate the role of vcam- , eotaxin, nf-b and ap- in the inflammation of asthma; ( )explore the functional variation of alveolar type cells in asthma; ( )evaluate the effects of inhaled glucocorticoids on the above annals of allergy, asthma & immunology parameters in salt of asthma models. methods: ( )the gpam were established by ovalbumin challenge. five groups were divided: control, asthma day and day , intraperitoneal dexamethasone, and budesonide inhalation group. ( )the expression of vcam- , eotaxin, nf-b and ap- was determined by immunohistochemical technology and rt-pcr; the dna binding activity of nf-b and ap- by electropharetic mobility shift assay. ( )the balf phospholipide concentration was measured by phosphorus detection. results: ( )significant inflammatiom with infiltration of eosinophils and lymphocytes in salt was observed in asthma groups. ( )the protein levels of vcam- , eotaxin, nf-b and ap- expressed in the salt were significantly elevated in asthma groups than those in control. ( )the mrna expression of vcam- and eotaxin of lung tissue homogenate was significantly increased in asthma group. ( )the dna binding activity of nf-b and ap- of lung homogenate was significantly increased in asthma group. ( )the balf surfactant represented by phospholipides was significantly decreased in asthma groups. ( )glucocorticoids in different ways of intake provided significant effects on the inflammatiom of salt. conclusion: ( )widespread and significant inflammation with eosinophilic infiltration existed in the salt in gpam, indicating asthma is a disease involving the whole airway and lung system. not only there were structural changes, but also impaired function of alveolar cells. the role of small airway inflammatiom may be of great importance. ( )eotaxin and vcam- actively mediated the process of inflammatiom, nf-b and ap- played important roles in the regulation of vcam- and eotaxin. the up-regulation of the above mediators in gpam was expressed in salt similar to that in central airways. we have recently reported that immunomodulatory oligonucleotides (imos) consisting of a novel structure and synthetic cpr or r'pg (r and r' are synthetic purine moieties) stimulatory motif effectively prevent ovainduced asthma in mouse models. in the present study we examined whether these novel imos (hyb and hyb ) can reverse established allergic airway inflammation in mice. balb/c mice sensitized and challenged with ovalbumin (ova) were evaluated for airway hyperresponsiveness (ahr) to methacholine. following ova-sensitization, mice were randomized and treated with placebo or mg or mg/dose of hyb or s.c. during the following days. two days after the final treatment, mice were rechallenged with ova and pulmonary functions were recorded. mice treated with either imo were significantly protected from both early (ear) and late (lar) allergic response, airway hypersensitivity and hyperreactivity to methacholine, bal and peribronchial eosinophilia, bal and serum il- , and total serum ige as compared to vehicle-treated ova-sensitized and challenged animals. there was a significant increase in immature lung dendritic cells (cd c+cd r+) together with increase in serum il- levels and significant decrease in lung dc type cells (cd c+ cd b+cd a-) as compared to vehicle-treated ovalbumin-sensitized animals in the lungs following treatment with either imo. these data suggest that both imos are effective and potent in attenuating key features of established allergic airway inflammation in bronchial asthma, and this effect could be mediated via decreasing lung dc cells and increasing immature dendritic cells. additionally, imos contain a novel '- '-attached structure that provides higher metabolic stability and may permit lower and/or less frequent dosing. hyb was evaluated for its safety and immunopharmacology in a phase clinical trial in healthy human volunteers. introduction -hemoglobinopathies are common in southern europe and mediterranean area the more frequent being thalassemia and sickle cell disease. aside of the major hematological diseases of homozygotic patients minor forms are frequent, thalassemia minor and sickle cell trait. in these cases mycrocytosis with decrease of red cell volume and mean corpuscular volume or abnormal erythrocytes are found and can lead to hemorheologic disturbances in bronchial circulation and bronchial hypereactivity. the rationale of this study is to evaluate the incidence of asthma in hemoglobinopatic patients allergic to house dust mites.methods-from patients seen in the last years in an out-patient allergy clinic cases of hemoglobinopathies have been confirmed by red cell count, hemoglobin electrophoresis, assays of hemoglobin a , f, and s, and sickle cell test.all these patients had allergic disease characterized by clinical history, skin prick test to aeroallergens total and specific ige (rast-cap-feia) and respiratory function evaluation. results -hemoglobinopathies: betathalassemia cases, betadelta thalassemia , sickle cell trait , hemoglobin c. . aside of cases of urticaria, all the patients presented respiratory allergy, rhinitis in cases of thalassemia and hemoglobin c, asthma with or without rhinitis in cases of thalassemia and cases of sickle cell trait. therefore asthma was present in , %. in a group of respiratory allergic patients without hemoglobinopathies, % had asthma and % only rhinitis. conclusions -the prevalence of asthma is higher in hemoglobinopathies.(p< square chi test). hemorheological changes probably greater rigidity of red blood cells and capillary bed can contribute to bronchial hypereactivity. detection of hemoglobinopathies must be done in asthmatic patients with slight anemia or mycrocytosis. we investigated the role of aspirin-exacerbated respiratory disease (aerd) as a risk factor for the development of airway remodeling. patients with aspirin intolerance develop hyperplastic sinusitis with fibrosis and nasal polyposis. we speculated that similar mechanisms could be acting in the lower airway and that these individuals would demonstrate more severe asthma and evidence for airway remodeling. the epidemiology and natural history of asthma: outcomes and treatment regimens (tenor) study is a multicenter observational study of subjects with severe or difficult-to-treat asthma. baseline data were compared between subjects years who reported asthma exacerbation following aspirin ingestion and those who did not. the primary measure of asthma remodeling was the maximally achieved post-bronchodilator spirometry. adult subjects with aerd (n= ) were compared with aspirin tolerant subjects (n= ). subjects with aspirin intolerance demonstrated evidence for airway remodeling as shown by lower post-bronchodilator predicted fev . in addition, they were more likely to have physician-assessed severe asthma, to have been intubated, and to have required high-dose inhaled corticosteroids or oral corticosteroids in the previous months. we conclude that aspirin intolerance is associated with remodeling of both the upper and lower airways. asthma is a complex and variable disease with two main components, airway inflammation and smooth muscle dysfunction. according to national and international asthma guidelines, subjects with persistent asthma can be classif ied into one of three categories (mild, moderate, or severe) based upon lung function, symptoms, nighttime awakenings, medications and exacerbations. though it is widely believed that there is a high degree of variability in both pediatric and adult subjects with asthma, few studies have compared variability between them. therefore, an analysis of previously conducted asthma studies was undertaken to evaluate pediatric subjects aged - years (n= ) and adult subjects (n= ) previously receiving short-acting beta -agoinsts alone in seven double-blind, randomized, -week trials. the analysis is limited to subjects who were randomized to placebo in these trials. during the study, subjects exhibited marked fluctuations in asthma severity. despite the fact that all subjects met criteria for moderate or severe asthma at baseline, %, %, % and % of weeks for pediatric subjects and %, %, %, and % of weeks for adults were spent in the intermittent, mild, moderate and severe categories, respectively. a summary of severity classification based upon symptoms and albuterol use is presented below. in addition, based upon pef % predicted, % and % of weeks were spent in the intermittent/mild category for pediatric and adult subjects, respectively. however, fluctuations in pef occurred frequently, with % of pediatric subjects and % of adult subjects experiencing changes in severity based on pef over weeks, indicating more variability in pediatric subjects. this analysis clearly demonstrates that asthma is a variable condition and that both pediatric and adult subjects frequently move between severity categories. furthermore, there are marked differences in severity classifications between pediatric and adult subjects. asthma severity, and consequent optimal therapy, cannot adequately be assessed by discrete, point-intime assessments of lung function, frequency of albuterol use, or asthma symptoms, especially in the pediatric age group. studies suggest that there may be an association between single nucleotide polymorphisms (snps) in the beta -adrenergic receptor gene (adrb ) and the response to beta -adrenergic bronchodilators. polymorphisms at codon have been at the center of this debate. therefore, a retrospective analysis of six large, randomized trials was conducted to evaluate clinical responses to salmeterol administered with fluticasone propionate (fsc) / mcg bid for weeks in patients ( yrs) with moderate or severe asthma and differing adrb polymorphisms at codon . baseline demographics were similar for all genotype subgroups. all measures of asthma improved over baseline and were similar across arg /gly subgroups at weeks. pairwise comparisons were conducted between genotypes and there were no differences other than fev as noted in the table. findings from this retrospective analysis show that regardless of arg /gly genotype, clinical response to salmeterol with an ics was similar during chronic dosing. although prospective studies are needed to fully understand the effect of adrb polymorphisms on response to therapy with a long-acting beta -agonist, this analysis suggests that therapy with salmeterol and an ics together is appropriate for caucasian patients with differing arg /gly genotypes. coronary artery disease(cad) and asthma commonly coexist in adults. iv dipyridamole thallium scintigraphy is considered a safe non-invasive technique in the evaluation of cad when patients can't exercise. dipyrdamole is a purine that blocks reuptake of extracellular adenosine increasing serum adenosine levels after iv administration.this results in a transient coronary vasodilation increasing the sensitivity of the thallium study. methylxanthines reverse the effects of endogenous adenosine by competitively antagonizing adenosine at local purinoreceptors. we report a case of a yr.old female with a year history of stable mild persistant asthma treated with daily salmeterol and low-dose fluticasone. she was referred to cardiology for atypical chest pain. within minutes of a standard iv dose of dipyridamole the patient reported chest tightness, cough, and wheezing. all these symptoms, typical of her past asthma flares, were abolished within minutes of an aminophylline infusion and before albuterol was administered.the stress test was completed and was normal. inhaled adenosine induces bronchconstriction and is used as a probe for bronchial hyper-responsiveness. commercial iv adenosine preparations used in treating supraventricular tachycardia are reported to induce bronchospasm in known asthmatics. since serum levels of adenosine are transiently increased following iv dipyridamole, bronchospastic symptoms during dipyridamole stress tests should not be unexpected. an earlier study found an increased incidence of wheezing in % of patients with known copd/asthma undergoing dipyridamole stress tests despite pretreatment with beta agonists. the marked decline of theophylline use for chronic asthma in recent years may actually be increasing the incidence of this risk. cardiologists performing thallium stress tests are familiar with the risk of asthma flares after dipyridamole. they use iv aminophylline frequently to reverse several types of clinical dipyridamole reactions, including bronchospasm. on the other hand, we are impressed that allergists are relatively unfamiliar with this association. allergists and asthma specialists as well as asthmatic patients should be aware of risk of acute dipyridamole induced bronchospasm during elective cardiac stress testing. it has been shown that adhesive molecules are involved in inflammatory diseases of the lungs such as bronchial asthma. the purpose of the study was to measure and establish possible difference in serum levels of soluble icam- in atopic patients (patients with allergic rhinitis and patients with bronchial asthma) in comparison with patients without atopy (patients with asthma without rhinitis); whether there is a difference in sicam- levels between groups of patients with allergic rhinitis and asthma in comparison with group of patients with allergic rhinitis only and also in comparison with healthy controls. results of the study have substantiated statistically significant difference in sicam- levels between all groups of patients in comparison to healthy control, but no statistically significant difference in sicam- levels between patients with and without atopy (z=- . ) or between patients with allergic rhinitis and bronchial asthma in comparison with group of patients with allergic rhinitis only (z= . ). conclusion: icam- is an important marker of inflammation in patients with allergic rhinitis as well as in those with bronchial asthma. atopic status does not influence differences in sicam- levels. although mean sicam- levels were higher in patients with allergic rhinitis and bronchial asthma ( . ng/ml) in comparison with mean sicam- levels in patients with allergic rhinitis only ( . ng/ml), no statistically significant difference was noted in sicam- levels between these groups of subjects, i.e. asthma itself did not contribute to statistically significant increase of sicam- levels. k. nadarajah * , g.r. green, m. naglak, abington, pa. objective: to study the various clinical outcomes of penicillin skin testing (pst) in a community-based hospital and to determine the percentage of patients who have an antibiotic modification and the choice of antibiotic used following the result of pst. method: this study is a retrospective chart review of all in-patients who were penicillin skin tested during a period of . years(jan to july ). information was collected on patients using a detailed data collection form. data was summarized using descriptive statistics including frequencies and percentages. results: of the patients penicillin skin tested, had a negative test, five had a positive test and in four patients the test was indeterminate(histamine controls were negative). eighty six percent of the patients had a history of penicillin allergy, . % had a history of cephalosporin allergy and . % had a history of both penicillin and cephalosporin allergies. the duration of antibiotic prior to pst ranged from zero to days. there was a . % ( / ) reduction in the use of vancomycin, a . % ( / ) reduction in the use of floroquinolones and a . % ( / ) reduction in the use of aminoglycosides following pst. aztreonam was used in . % ( / ) of patients before pst and in zero patients after pst. use of penicillin-based drugs was % ( / ) after pst and cephalosporin use increased from . % ( / (all third generation cephalosporins)) to . % ( / ( second and third generation cephalosporins)). i.e., % of patients with a negative pst received a penicillin or a cephalosporin. vancomycin usage was higher among pst positive patients. endocarditis was the diagnosis in % of all patients skin tested and staphylococcus aureus ( . %) and enterococcus ( %) were the most common organisms on culture. there were no serious adverse reactions to the use of penicillins or cephalosporins when used following a negative pst, and there were no adverse reactions to penicillin skin testing. conclusion: in the population studied, pst lowers the usage of vancomycin, floroquinolones and aminoglycosides and increases the use of penicillins. third generation cephalosporin usage was increased by pst in our study. overall, pst results in antibiotic modification that could lower the emergence of multi-drug resistant organisms and vancomycin resistant enterococcus. the aim of the study was to find a new marker which could be easily done to predict about possible allergy development in infants. preventive procedure is always economically better than treatment itself.food allergens are able to stimulate lymphocytes even in prenatal period. immunological maturity of newborns is still in the center of our interest because its dependence on many different factors. the question was if cd activity in cord blood and in -year-old children correlates with development or not of allergy? the examined group consists of newborns( , % of boys). breastfed were only children until -months-old and until they were -monthsold. total ige from cord blood and mothers' blood taken at delivery were measured using unicap. immunological detection was done using fluorocytometry(becton nad dako). additionally parents were questionaired( family atopy). our reaults show that positive family atopy history(group a) or elevated level of ige( group b) or symptoms of allergy in first months of life(group c) does not correlate with cd antigenicity. in all subgroups cd frequency was %. our findings show unfortunately that cd cannot be a predictive marker for allergy development. rationale: the etiology of eosinophilic esophagitis (ee) is unknown and the relationship to a type i allergic response is unclear. comparison of patients with positive and negative type i allergy testing may further clarify ee and determine what are the most common food allergens. methods: this is a retrospective chart review of medical records from january to january of children year of age with biopsy confirmed ee (n = ). ee was defined as having eosinophils per high power field on esophageal mucosal biopsy. patients were grouped according to positive (n = ) and negative (n = ) allergic responses on skin or radioallergosorbent testing (cap rast, pharmacia). skin testing with commercial extracts (hollister-stier laboratories and greer laboratories) was performed in an allergist's office. a wheal of mm greater than the negative control on skin testing or ige > . ku/l on rast was considered positive. we performed fisher exact analysis to determine if associations existed between a type i allergic response and factors such as age, symptoms, peripheral eosinophilia, and personal and family history of atopy (asthma, allergic rhinits, and atopic dermatitis). results: ee patients with a positive type i allergic response were significantly younger than those with a negative response (mean . yo, median . yo, range to . yo versus mean . yo, median . yo, range to yo; p = . ). vomiting as a presenting symptom was significantly increased in the allergic population ( %, %; p = . ) and abdominal pain as a chief complaint was significantly increased in the non-allergic population ( %, %; p = . ). personal and family history of atopy and peripheral eosinophilia were similar between groups. the most common allergens were cow s milk ( %), peanut ( %), egg ( %), soybean ( %), and wheat ( %). conclusion: patients diagnosed with ee who present at a young age or who present with symptoms of vomiting may have a type i allergic response contributing to the esophageal eosinophilic inflammation. consistent with food allergies in children, milk, peanut, egg, soybean, and wheat were the most common foods found with allergy testing. because the positive predictive accuracy of food annals of allergy, asthma & immunology testing is only about %, the challenge remains to develop a specific plan to confirm causative foods such as through oral challenges or elimination trials. rationale: the relationship between specific ige and igg levels in atopic individuals is unknown. increasing antigen exposure is expected to increase igg production, however, the influence on ige levels is unclear. to further clarify this relationship the following studies were conducted. methods: three hundred and sixty tandem determinations of specific ige and igg levels in individuals were collected using the immunocap instrument (pharmacia diagnostics) and commercially available reagents. only subjects who had ige levels > . ku/l and igg determinations > mg/l to the same specific allergenic species were included in the study. specific ige and igg determinations were to alternaria alternata, aspergillus fumigatus, penicillium notatum, cladosporium herbarium, felis domesticus, canis familaris, dermatophagoides farina, and periplaneta americana. correlation coefficients were calculated using excel (microsoft). results: the review of this data set yielded tandem determinations of specific ige and igg levels in atopic individuals. the most common ige sensitization was to alternaria. sixtyfour percent of individuals had specific ige directed against alternaria. the lowest ige response rate was for cat and roach. only % of individuals had an ige response to those specific species. correlation coefficients (cc) were calculated between specific ige and igg levels and were positive for all eight species tested. the highest cc was for dog (n = , cc = . ) followed by aspergillus (n = , cc = . ), penicillium (n = , cc = . ), alternaria (n = , cc = . ), cladosporium (n = , cc = . ), cat (n = , cc = . ), and roach (n = , cc = . ). the lowest correlation was for dermatophagoides farina (n = , cc = . ). conclusion: when individuals with measurable specific ige and igg levels are considered, there appears to be a positive correlation between specific ige and igg levels for many allergenic species. factors that influence the correlation are likely to be both genetic and environmental. identifying this link and a clinical application are our next challenge. recently, protein microarray tests are competing with traditional allergenspecific in vitro assays. while the advantages of microarrays in allergy testing are attractive, microarray analysis alone has not been very effective in reducing analysis time and automated microarray equipment typically is much larger than its benchtop counterparts. we have incorporated microarray technology into an automated microfluidic cartridge that provides rapid allergen testing using a compact, low-cost, desktop instrument. the injection molded microfluidic cartridge (fig. a) contains arrays of miniature pumps and valves that direct reagents independently to a solid phase reaction area. standard ige (nibsc) as well as allergens were immobilized within the cartridge to form a protein microarray. a small desktop analyzer actuated the pumps in the cartridge to automatically carry out a chemiluminescence-based elisa reaction. total ige quantitation was performed in a minute reaction. fig.b shows the resultant image of a dilution series of immobilized ige. concentrations ranged from . to iu/ml corresponding to . fg to ng ige per spot. the average cv value for ige quantitation was % showing good linearity (r = . ) and fg sensitivity. this quantitative ige curve is used to eliminate the effects of cartridge variability. specific ige detection was demonstrated using extracts, d. pteronyssinu(dp), a.fumigatus and b. verrucosa(bv). a -step, minute reaction elisa technique was employed. fig. c and d show the resultant images for bv and dp positive serum, respectively. the sensitivity of the dp specific ige test was further investigated using a positive class serum sample confirmed by mast. dilution of the class serum with negative control serum could then be detected on the cartridge down to an fold dilution, resulting in a limit of detection in the range of . - . iu/ml for dp specific ige. we have demonstrated total ige and allergen-specific ige detection with total analysis times less than minutes in a convenient, low cost system using a microfluidic-based microarray cartridge. such rapid diagnosis allows physicians to provide treatment while the patient is still in the office. background: accurate allergen skin tests (ast) are the basis of optimal care of the allergic patient. completing these tests on the first visit can expedite the diagnosis and treatment and offer patients(pts.) efficient use of their time and increase satisfaction. appropriate pre-visit preparation is necessary to reduce the variables that affect ast outcomes. both positive and negative skin test controls are necessary to assure the ast are reliable. methods: we conducted a retrospective chart review of , sequential pts. skin tested at an allergy practice, in order to examine the success of our pre-visit instructions and to identify other medications that may affect ast. pts. were given verbal and written instructions to discontinue antihistamines and other histamine- receptor antagonist medications (h- a) days before their visit. they then underwent ast only if adequate positive (histamine) and negative (saline/vehicle) controls were obtained. results: only ( . %) of the , pts. had inadequate histamine response (ihr). of these pts., ( . %) had used h- a within the prior days. ( . %) pts. had taken h- a in the recent past, but stopped them at least days prior to testing. ( . %) pts. had no exposure to h- a. the use of psychiatric medications in the pts. with an ihr was also examined. of the pts. who discontinued h- a for more than days, ( %) were also taking various medications drugs used in the treatment of psychiatric disorders (ssris, benzodiazepines, atypical antidepressants & antipsychotics) which are not usually associated with h- a. the group of of the pts. with no prior use of h- a included ( %) who were also on various psychiatric medications. the high prevalence of psychiatric medication use in these two groups is in contrast to the to pts. with recent use of h- a in whom % were on psychiatric medications. conclusion: pre-visit patient education about discontinuation of h- a can lead to successful first visit ast in the overwhelming majority of patients ( . %).failure to stop h- a at the appropriate time occurred in only . % of the pts. . % of pts. discontinued h- a for the recommended day interval, but still had ihr. another % of pts. had an ihr yet no obvious use of h- a. a few pts. taking psychiatric medications not normally associated with h- a had ihr. further investigation into this issue is warranted. a. blaziene * , a. chomiciene, l. jurgauskiene, n. ciaponiene, vilnius, lithuania. background: sublingual specific immunotherapy (sit) is accepted as an alternative treatment to subcutaneous sit of seasonal allergic rhinitis. the aim of this study was to evaluate changes in allergen-specific ige and basophil degranulation test (bdt) before and after year of sit with a grass pollen mix. methods: patients ( male and female, aged - years) having sensitization to grass pollen with seasonal allergic rhinitis were treated with standardized grass pollen extracts. the blood samples were collected before and after year of sit assessing allergen-specific ige using an elisa method and bdt using a direct immunofluorescent method employing monoclonal antibodies. results: the sit was well tolerated by all patients. an increase in total ige after sit was observed in all patients. specific ige concentration was increased in ( . %) patients, while the bdt result was greater in ( %) patients after year of sit. conclusions: allergen-specific ige and bdt may serve as markers to indicate the clinical efficacy of sit for seasonal allergic rhinitis patients. a.g. palma-carlos * , s.l. silva, m.l. palma-carlos, lisboa, portugal. introduction -the incidence of primary immunodeficiencies in patients attending an out-patient center for clinical allergy and immunology depends on the recruitment and on patients refered. methods -in the last years patients have been observed in lisbon clinical allergy center reporting allergic diseases or repeated infections or refered by specialists (ent, gynaecology, internal medicine, pediatrics, or gp.). screening for primary immunodeficiencies has been done by electrophoresis, assay of immunoglobulins and complement, igg subclasses and flux-cytometry for t, b and nk cells. results - cases ( , %) of primary immunodeficiencies have been diagnosed. humoral: deficits of iga ( , % of immunodeficiencies), of igg ( , %) of igg subclasses ( , %) of common variable immunodeficiency cvi-( , %), of igm ( , %). complement: cases of c esterase inhibitor deficiency ( , %) cellular: cases of mucocutaneous candidiasis ( , %) in fertile females, cases of cd deficiency ( , %). combined: cases of deficiency of the couple cd /c ligand with igg deficiency ( , %).conclusions -in the present series chronic mucocutaneous candidiasis is the prevalent primary immunodeficiency, due to the number of patients refered by gynaecologists. aside of this group where a decrease of nk cells was the more common immunologic pattern, humoral immunodeficiencies are frequent, mainly cvi, iga, igg and igg subclasses deficiencies. the search for immunodeficiencies must be done in all patients with repeated infections attending immuno-allergology departments. a case of atypical c complement deficiency. c.c. randolph * , waterbury, ct. introduction:c complemennt deficiency occurs in in , individuals .it results in decreased opsonization and chemotaxis with increased prevalence ofsle and other rheumatic disordersas well as enhanced vulnerability to pyogenic infection.there are two types of c complement deficiency :type ( %associated with sle)with no protein translation and type ii with absence of protein secretion.we present a year old white female otherwise healthy with recurrent urticaria and angioedema with c complement deficiency. method:case report:a y/o w/f athlete presented with a two month history of recurrent hives and angioedema which she associated with ingestion of halloween candy .one week before evaluation she had hives with coconut as well.her history was othewise unremarkable except for recurrent uti's, annual sinusitis, pneumonia in as well as migraines.she denied sexual activity.her physical exam was normal.results:an evaluation for autoimmune disease revealed normal esr, ana, dsdna, mono and hepatitis serology as well as lyme titers however her ch was low u/ml(normal - u/ml)and evaluation of complement revealed c mg/dl(normal - mg//dl)and c < . mg/dl(normal . - . mg/dl)with normal c , c -c .her father had nor-malc but c was . mg/dl (normal . - . mg/dl)her sister had c of . mg/dl and normal c and her mother had normal c and c .her workup included positive prick skin test to ragweed, ash and grass and she was started on rhinocort and clarinex seasonally.she has been followed for one year with resolution of hives and is asymptomatic.her diagnosis had been confirmed by a pediatric rheumatologist.conclusion;we present an atypical case of c complement deficiency in an currently asymptomatic individual. background: we diagnosed a month old male with cgd and aspergillus brain abscesses and pulmonary infiltrates. review of the literature suggests he is one of the youngest cases of cgd complicated by cerebral aspergillosis. case report: a ten month old male previously seen for unexplained persistent pulmonary infiltrates since month of age presented to our hospital with lethargy, fevers, and increased irritability. ct scan of the head revealed severe hydrocephalus. multiple brain abscesses were found on surgical exam and cultured for aspergillus fumigatus. he had a history of failure to thrive and hypotonia since birth. family history was significant for parents that were second cousins. there was no family history of recurrent infections or childhood deaths. physical examination was significant for a child with weight and height in the % and %, respectively with persistent fevers > . c, hypotonia, hepatosplenomegaly, and left lower lung field rales. initial immune workup was normal except for elevated total ige of ku/l. cd + ( /m ) and cd + ( /m ) t cells were initially low, but later increased to normal levels without intervention. neutrophil oxidase activity assessed by dihydrorotamine (dhr) oxidation was % of control. superoxide production assessed by cytochrome c reduction was zero. the patient was treated with interferon ? for presumed cgd. his aspergillus brain abscesses improved with intravenous voriconazole and caspofungun. the responsible organism for his recurrent pulmonary infections was not identified, but improved with antifungal therapy and broad spectrum antibiotics. the dhr test of both parents and siblings were normal. antibody testing showed a complete deficiency of the p protein with normal levels of gp , p , and p proteins. evaluation of the exons of the ncf- gene that encodes the p protein were normal. conclusion: mutations due to p protein deficiency are responsible for % of cases of cgd. there has been only one previously reported case of p deficiency without ncf- exon mutations in which a single point mutation in an intron of the ncf-ii gene was identified. fungal infections may complicate cgd, however cerebral aspergillosis is seldom encountered. this case annals of allergy, asthma & immunology reports a month old with cgd due to a p deficiency without exon mutations complicated by cerebral aspergillosis. introduction: lymphoid interstitial pneumonia is an uncommon condition which is considered both as a disease per se or as an inflammatory pulmonary reaction to various external stimuli or systemic diseases; however, at the present time most of the cases remain idiopathic. we present a case of an infant who developed a lymphoid interstitial pneumonia associated to a deficit of interferon-production. methods: we describe a clinical case and review the medical literature. results: we present the case of a five months old male with a history of cough, respiratory distress and four previous hospital admissions regarded as a 'pneumonic' events from two months of age and four siblings dead (two of them with 'abdominal disease' and one of them with candidiasis) during their first year of life. the parents referred no consanguinity. the physical examination showed a malnourished child with signs of bilateral lung consolidation. oxygen supplementation and intravenous antibiotics were started. our patient didn't have neonatal history related to the present compliant. the chest film revealed a diffuse bilateral interstitial pattern which was confirmed by pulmonary ct scan. sweat chloride test, hiv and epstein barr virus serology test were all negative. an initial immunologic evaluation reported slightly increased leukocytic count, hypergammaglobulinemia, lymphocityc flow citometry and nitro blue tetrazolium reduction test in normal parameters. the open lung biopsy showed a thicked pulmonar interstitium with moderate number of lymphocytes with not atypical pattern. our patient was discharged with clinical improvement, ambulatory oxygen supplementation and inhaled fluticasone-salmeterol. in an ambulatory follow-up we evaluated lymphocytic production of cytokines and we found no levels of interferon-. we started weekly administration of oral transfer factor. the patient showed an excellent clinical improvement evidenced by no more oxygen dependence, weight gaining and absence of further hospital admissions. con-clusions: our patient represent a new linkage between lymphoid interstitial pneumonia and primary immunodeficiency characterized by interferonproduction deficit, maybe with a non previously described molecular defect and a probably autosomic recessive inheritance pattern; also we confirmed the transfer factor usefulness to induce gamma interferon endogeous production. objective: marijuana is a schedule class psychoactive control substance more frequently used by the oriental societies( in the event of jubilation) causing altered state of conscience, euphoria, its prolonged use is followed by addiction and dependence.it contains more than chemical entities with over are of the cannabinoid i.e, cannabidiol (cbd), cannabinol (cbn), and delta- , tetrahydrocannabinol (thc) the later on use has been associated with craving for further use of narcotics just to enhance the euphorient effects .the active ingredients i.e, delta- -tetrahydrocannabinolthc) and other cannabinoids(thc) are liquid soluble at high concentrations which alters membrane function, resulting in alterations in immune cell response. cannabinoid has immunosuppressant properties causing impaired cell-mediated and humoral immune system activities, cytokine production, leukocyte migration and natural killer-cell(nk) activity resulting in reduction in the host resistance to bacterial and viral infection, (pms)with hiv infection are at higher risk of developing aids, infection by opportunistic bacteria, fungi, or viruses (pms), when compared to non marijuana smokers, have more respiratory ill-ness.cannabinoids also characteristically as being immunomodulators i.e, generally suppressing but occasionally enhance some immunological responses, some have suggested that the immunosuppressive effects of cannabinoids might be useful clinically; for example, in treating multiple sclerosis.as per clinical response cannabinoids had been found exacerbating existing allergies from antigenic complex (eliciting formation of specific antibodies/metabolites as a hapten, combining with a body proteins). methods .in the follow up studies including individuals(all males age - years) with(pms).of more than months having serum level of tch > um, there have been times reduction in the proliferation of t lymphocytes with a proportionate increase in the proliferation of b lymphocytes, reduction in the cytotoxic activity of t lymphocytes, reduction in macrophage activities i.e, phygocytosis rationale: patients with xla are subject to arthritis and cellulitis. these three relatives have had similar courses, suggesting infectious etiology. methods: two brothers and a cousin, from an african-american family known to carry xla, have been diagnosed with xla and chronically treated with ivig. all three have developed arthritis and cellulitis of a lower extremity. the eldest, now years old, had a -month waxing and waning arthritis and cellulitis that was refractory to the oral antibiotics attempted. his younger brother had not yet accomplished pubertal changes at the age of , and was below rd percentiles for weight and height. he also had several months waxing and waning arthritis and cellulitis refractory to oral antibiotics. he and his cousin have had esophogastroduodenoscopies that show gastritis and duodenitis with heavy growth of an organism visualized by specific staining for h. pylori. the cousin has also experienced more recent weight loss and arthritis/cellulitis. results: the younger brother had a blood culture that grew a curved gram-negative rod. a subsequent culture at the state lab grew a similar organism that was urease-negative. the two brothers are at or near completion of a six-month course of ertapenem and gentamicin; they have had resolution of their arthritis and cellulitis. the younger has gained . kg and experienced his pubertal changes at the age of years. con-clusions: there are prior reports of several different related organisms that can cause arthritis and cellulitis in patients with xla. these include helicobacter, campylobacter, and flexispira species. the urease-negative organism would not be flexispira, but may be a campylobactor species or helicobacter canis. the results from this family suggest that long-term combination iv antibiotics may be indicated for patients with this syndrome. slow virus infections have been reported to affect the central nervous system. parvovirus b , herpes and cmv are usually not included in the diagnosis of cns diseases nor has been associated with cns manifestation in an immuno-compromised patient. in this abstract, we report on a neurological manifestation that can be linked to ebstein-barr/herpes virus and parvovirus-b in an immune deficient patient. a year old female presented to our clinic with a history of chronic fatigue symptoms, daily arthralgias, frequent sinus infections and idiopathic tremors for the past years. the patients neurological evaluation, including mris was found to be within normal limit, despite worsening tremors of her head and arms. a full clinical and labora-tory evaluation was performed which revealed igg subclass, low t-cell numbers and functioning, low response to specific antibodies and positive igm for ebv, parvo and cmv. the patients common immune deficiency coupled with chronic viral infection and worsening tremors led us to try high dose ivig ( g/kg divided over days on cycles of every weeks). within three months of starting ivig, the patient had a large reduction in her tremors and negative igms for parvovirus, herpes and cmv. given our findings, we suggest that ivig may play a role as a neuro-immune modulator, as has been shown in other neuro-immune diseases. we further suggest that the interaction between parvovirus b- , herpes and cmv as part of the slow viruses, combined with underlying immune disorder may lead to neurological presentation and high dose of ivig can reverse the syndrome. purpose: to date, only two patients older than fifty years of age have been diagnosed with velocardiofacial syndrome (vcfs); this case represents the third such patient. methods: physical and laboratory findings of the patient are presented as a case report. results: we describe a sixty-six-year-old male, recently diagnosed with vcfs, confirmed by fluorescent in-situ hybridization (fish), was referred by his psychiatrist for comprehensive care. he had a history of cleft palate and learning disabilities as a child, with the onset of psychiatric illness in his late teens. although there was no history of cardiac disease, the patient had agenesis of the left renal artery as well as other vascular anomalies, including hypoplasia of the left a segement of the anterior cerebral artery. other findings included hypothyroidism, hypoparathyroidism, sensorineural hearing loss, and typical facies. he also suffered from chronic candidiasis. immunologic laboratory studies revealed over a : ratio of cd :cd t cells with a decreased cd percentage, markedly diminished b cell percentage, decreased t cell mitogen responses, and markedly decreased b cell mitogen responses. nevertheless, total serum igg and specific antibody responses remained normal, with a low serum igm. conclusions: this patient meets the criteria for the diagnosis of vcfs; only the third reported case diagnosed over the age of fifty. though his immunologic findings may be consistent with his diagnosis, they may be due in some part to immunologic senescence given his age. background: the classic presentation for patients with xla and mutations in the btk gene includes marked hypogammaglobulinemia, absent b cells, and significant sinopulmonary infections beginning at - months of age. typically, mds presents with anemia, leukopenia, monocytosis, and thrombocytopenia with recurrent infections, skin rash, and hepatosplenomegaly. many of these subjects demonstrate chromosomal abnormalities including monosomy . we describe a case of mds presenting with some features of both conditions. clinical history: we present a year old male with a suspected diagnosis of xla, chronic sinopulmonary disease beginning at mo, diffuse bronchiectasis, and agammaglobulinemia with absent b cells. he had wbc = cells/ul, with % monocytes and platelet count of , /ul. he had no anemia, hepatosplenomegaly, or skin rash. bone marrow biopsy showed mds with absent plasma cells and monosomy in % of his cells. btk expression and sequence analysis were normal. conclusion: while xla is the most likely primary immune deficiency that would present in a male with the clinical picture described above, this case illustrates the importance of maintaining an expanded differential diagnosis in patients with presumed primary immunodeficiency. j. wang * , l. mayer, c. cunningham-rundles, new york, ny. background: chronic granulomatous disease (cgd) usually results in acute or chronic infections with a defined spectrum of bacteria or fungi. other characteristics include inflammatory disorders, including genitourinary or mucosal inflammation resembling inflammatory bowel disease. gm-csf has been used in the treatment of mucosal inflammation in glycogen storage disease ib and crohn's disease with some success. objective: to explore the use of a novel therapy in the treatment of mucosal inflammation associated with cgd. methods: the patient was treated with daily gm-csf ( . mcg/kg/dose subcutaneous injection) along with parenteral antibiotics and total parenteral nutrition. after days on gm-csf, hydrocortisone enemas were added due to continued pain and swelling. results: rectal and abdominal pain significantly improved, blood streaked stools decreased; he tolerated a regular diet and was discharged home days after starting gm-csf. he now has no rectal or abdominal pain and no blood in the stool. conclusions: gm-csf may be a useful therapy for the management of mucosal inflammation in cgd patients. it appears safe and well tolerated and permits avoidance of immune suppressive alternatives. introduction: management of autoimmune cytopenias in patients with cellular immunodeficiency may be very challenging. treatment of these cytopenias with corticosteroids may potentiate the immune dysfunction leading to further infections. methods: we describe a month-old female with a cellular immunodeficiency and autoimmune thrombocytopenia / hemolytic anemia being treated with steroids and ivig without improvement. rituximab, a monoclonal antibody that binds to b-lymphocyte cd surface antigens, was initiated. results: this patient presented at months of age with failure to thrive, eczema and recurrent bacterial pneumonias. she was diagnosed with a t lymphocyte immunodeficiency with decreased absolute numbers of cd ( ), cd ( ), and cd ( ) lymphocytes. t cell function was markedly decreased as measured by pha, cona, and pwm. she developed chronic thrombocytopenia with platelets of less than , and coombs positive anemia with hemoglobin of g/dl. she was placed on mg/kg/day of prednisone with minimal improvement and continued to develop severe pneumonias. rituximab mg/m /week was initiated for doses. her cytopenias improved with an increase in both platelet count ( , ) and hemoglobin ( . g/dl). her absolute cd count fell from to . she was weaned off steroids permanently. she has also continued on ivig, prophylactic antibiotics, and as needed rituximab pending bone marrow transplant. conclusions: rituximab, a monoclonal anti-cd antibody, may be helpful in treating autoimmune cytopenias in patients with cellular immunodeficiency in which steroids need to be avoided. ivig antibody replacement substitutes for the subsequent humoral antibody depletion due to induced secondary b cell lymphopenia. introduction: the patient is a month old male born at full term. during his prenatal course he was noted to have a pulmonary abnormality in his left lower lobe at approximately weeks of age. serial ultrasounds and fetal mri were consistent with the diagnosis of congenital cystic adenomatoid malformation (ccam). histology from elective resection of the lesion performed at months of age revealed no evidence of ccam. silver stain revealed florid pneumocystis jiroveci (carinii) infection. the patient was completely asymptomatic. the differential diagnosis for this infection in the newborn period includes hiv infection, severe combined immunodeficiency, and x-linked hyper-igm syndrome. the infection has also occurred in newborns with apparently normal immune systems. methods: immunology evaluation was performed to evaluate the patient for the listed diagnoses. a complete blood count was performed. lymphocyte subsets were performed by flow cytometry. quantitative immunoglobulins g,a, m and e were measured by nephelometry. specific antibodies to tetanus and diptheria were determined by elisa. hiv status was ascertained by western blot and dna pcr. dichlorofluorescein assay was performed. fluorescenceactivated cell sorter technique was used to evaluate cd ligand. lymphocyte stimulation to mitogens and tetanus were performed. results: the patient had negative hiv / antibodies and a negative hiv dna pcr. the result of the complete blood count was normal with an absolute lymphocyte count of , . the patient had normal percentages and numbers of cd , cd , cd , cd , and natural killer cells. lymphocyte stimulation to mitogens and tetanus was normal. dcf assay was normal. facs revealed normal levels of cd ligand. at months of age he had protective titers to diptheria and tetanus titers of . iu/ml (protective > . iu/ml). at months igg, a, m and e were (normal - ), < , , and < respectively. conclusion: immunologic testing revealed no evidence of severe combined immunodeficiency, hiv infection or x-linked hyper-igm syndrome. the patient remains well clinically with normal growth and development with no subsequent infections. pneumocystis jiroveci pneumonia can be seen in infants with apparently normal immune systems. commercial preparations of igg produced for iv use (ivig), must fulfill regulatory requirements. the method of preparation, however, may produce alterations in the content or function of igg subclasses such as disturbed composition which can be reflected as a lowered clinical effectiveness of the product. we report patients with specific igg immunodeficiency, that, when changed to a new ivig preparation, had lessening of clinical effectiveness of the new product but who also experienced recovery after they were changed to a different ivig product. case . a y/o male with hx of cervical lymphadenopathy associated with recurrent uri, fatigue, cognitive alterations and hypercholesterolemia. he was dx in with a specific igg immunodeficiency for which he was started on ivig infusions mgxkg q/ w which brought his igg levels to normal values mg/dl, ( - mg/dl) with good clinical improvement. when he was changed to a different ivig product with lower iga content his initial symptoms returned with decrease of his igg to mg/dl ( - mg/dl) he was changed to a different ivig product with higher iga content with disappearance of all his previous symptoms. case . a y/o female with history of chronic yeast infection, fatigue, joint pain, asthma, ge reflux, depression, hypothyroidism and shunt for hydrocephaly. she was diagnosed with igg and igg immunodeficiency and started on ivig mg x kg x q/ w. when changed to another ivig with lower iga content she experienced worsening of her symptoms during the months that she was receiving it. she was changed to a different ivig product with a higher iga content with complete improvement of her symptoms. although the content of iga in product ( - ug/ml) was significantly lower than in prod-uct ( ug/ml), the total igg and igg subclass distribution (including igg ) were comparable therefore, the lack of clinical effectiveness of product would appear to be related to qualitative alterations in the product related to methodological preparation possibly in removal of the iga or other physicochemical alterations affecting biologic activity which contributed to a lessened clinical efficacy of the product. we present these cases to alert the allergist-immunologist to these observations when treating patients with igg or igg subclass deficiencies. background: development of atopy has been known to occur in nonatopic recipients of bone marrow transplants ( bmt) from atopic donors. the reverse condition, with atopic recipients losing evidence of specific ige after bmt from non-atopic donors is quite unique. case report: ph is a year old male referred for recurrent nasal congestion. as a teenager, the patient was treated for chronic allergic rhinitis and asthma, atopic dermatitis diagnosed as severe, and multiple food allergy. skin testing done as a teenager showed + reactions to multiple pollen, dog, cat, most seafood, cashew, walnut and pecan. at years of age, he underwent an allogeneic bmt from his non-atopic brother for acute myelogenous leukemia. asthma and atopic dermatitis were observed to clear almost completely and allergic rhinitis improve after the bmt. his blood type changed from + to -. skin testing done on his current visit showed unremarkable responses to all pollen, cat, dog, dust mites and foods with good histamine control. discussion: the negative skin test results suggests that his current nasal symptoms are vasomotor in nature. considering the past severity of his symptoms, it appears unlikely that he lost his specific-ige sensitivity spontaneously. transfer of atopy is known to occur in non-atopic recipients of bmt from atopic donors. in a study of patients undergoing allogeneic bmt for hematologic malignancies, nonatopic recipients developed positive skin tests with profiles similar to atopic donors. a possible mechanism is passive transfer of memory b-cells which initiate specific-ige production with a donor pattern. a reverse of this mechanism could occur with the recipient gaining lymphoid precursors with no atopic tendency leading to clearing of atopy. the literature yielded one report of asthma resolving after high-dose chemotherapy and autologous stem cell transplantation the authors suggested that chemotherapy could have resulted in immune system reconstitution, normalization of the t-cell repertoire and resolution of asthma. introduction: primary central nervous system (cns) lymphomas constitute only a small percentage of central nervous system tumors in adults and are seen more frequently in aids patients and immunodeficiency states. they are extremely rare in children, even those with primary immunodeficiency. we present a -year-old female with combined immunodeficiency who developed an eber+ (ebv-associated) large b-cell lymphoma that was confined to the cns. methods: the patient is a -year-old female that was being evaluated for combined immunodeficiency who presented to our institution with acute fever and seizure activity. results: the patient had a history of recurrent pneumonia, otitis media, sinusitis, and upper respiratory infections. she also exhibited failure to thrive, chronic diarrhea, and sen-sorineural deafness. she was found to have a combined immunodeficiency with severe neutropenia and lymphopenia, low iga, low igm, and poor specific antibody response to protein and polysaccharide antigens. she had no response to a candida delayed hypersensitivity skin test. hiv tests were negative. she was thought to have acute meningoencephalitis causing the fever and seizure activity, however bacterial, viral, and fungal studies were negative. she received multiple anitbacterial, antifungal, and antiviral agents. she died secondary to brainstem compression due to severe cerebral edema. autopsy revealed an eber+ large b-cell lymphoma that involved about % of her brain and spinal cord. no tumor cells were found elsewhere. con-clusions: this case represents a rare manifestation of combined immunodeficiency: the development of a primary cns lymphoma. the tumor cells were found to be eber+ (ebv-associated). ebv is known to be associated with lymphoma, especially in aids and immunocompromised patients. only . % of primary tumor sites in severe combined immune deficiency patients involved the cns in the immunodeficiency cancer registry that was instituted in the s. v. litvinova * , g. muzlaev, krasnodar, russian federation. introduction: glyoma is one of the most prevalent diseases among all brain tumors and more than % of them are malignant. in the previous investigations it has been shown the immune disorders in patients with glyoma tumor. at the same time it was suggested the possible anti-tumor activity of some proinflammatory cytokines (tnf, il , il ), which can penetrate via haematoencephalic barrier and induce the lysis of tumor cells. the aim of this investigation was to study the serum and spinal fluid concentrations of one of the key immunoregulatory cytokines -gamma ifn and il in patients with glyoma tumor. methods: the concentrations of the gamma ifn and il have been studied in serum and spinal fluid of patients with glyoma by eliza method. in control, the same parameters have been studied in patients with brain trauma. results: it has been shown that concentrations of gamma ifn and il in serum and spinal fluid was . - times higher than in trauma patients (p< . ). the serum levels of gamma ifn and il in glyoma patients were . and . pg/ml, accordingly. in trauma patients- . and . pg/ml. the concentration in spinal fluid of the studied cytokines was . time higher than in control patients. conclusion: proinflammatory cytokines gamma ifn and il may be involved in pathogenesis of glyoma and can participate as possible anti-tumor factors of immunity in glyoma patients. a. arrey-mensah * , r.u. sorensen, new orleans, la. rationale: immunodeficiencies need to be ruled out in infants that present with failure to thrive. patients with t-cell lymphopenia, hypogammaglobulinemia and pancytopenia may have a primary immunodeficiency such as scid, or a secondary immunodeficiency that may need to be managed differently. methods: evaluation of cellular and antibody-mediated immunity of a month old aaf admitted with failure to thrive and chronic diarrhea. ohistory of duodenal atresia corrected by creating a blind duodenal loop and anastomosis of the stomach to the jejunum at birth. o mass in hypogastrium. results: immunologic evaluation revealed: " lymphopenia ranging to cells/ul " anemia: hemoglobin . g/dl, retic . " ancs ranging to " thrombocytopenia l to l " cd +: " cd +: " cd /cd r: . " cd : " cd : " mitogen responses were normal: " pha , cpm " con-a, , cpm " pwm, , cpm immunoglobulins: igg mg/dl iga mg/dl igm mg/dl ige iu/ml total protein was . g/dl, albumin was . g/dl the immunoglobulin-g half-life study was days in our patient: metabolic imbalance: hypokalemia ( . mmol/l) hyponatremia ( mmol/l) hypocalcemia ( . mg/dl) blood, stool, urine cultures normal. stool ova, parasite, virus were negative. hiv-pcr (-) radiological evaluation: superior mesenteric vein thrombosis, chronic malrotation and volvulus, dilated duodenal blind loop with possible lymphatic obstruction. the patient improved clinically and all immunological markers normalized after surgical removal of adhesions and obstruction. conclusion: the patient had a secondary immunodeficiency due to lymphangiectasia. lymphangiectasia should be considered in the presence of a lymphopenia with normal lymphocyte function and hypogammaglobulinemia accompanied by hypoproteinemia and hypoalbuminemia. hypogammaglobulinemia and hypoproteinemia were secondary to gastrointestinal losses. the immunological component of q . deletion syndrome (also known as digeorge syndrome;dgs), hypoplasia of the thymus, is quite variable among patients and provides the opportunity to determine the relationship between thymic function and t cell receptor (tcr) repertoire diversity. using a novel measure of repertoire diversity based on cdr length polymorphism called hamming distance, tcrbv repertoire diversity in dgs was found to differ from control subjects by having an overall skewing of receptor expression. as expected from clinical outcomes, there was also great intra-individual variability in dgs tcr repertoires. the degree of repertoire diversity was directly correlated with thymic output as measured by t cell receptor excision circles (trecs), i.e. greater thymic output resulted in more diverse repertoires (see figure below). this result demonstrates a quantitative relationship between thymic function and repertoire diversity in humans and may reflect the balance between thymic output and peripheral expansion to maintain an adequate tcr repertoire. in addition, it may suggest a basis wherein limited repertoire diversity mediates both immune deficiency and autoimmunity. tcr repertoire diversity in dgs, as measured by hamming distance, correlates with thymic output, as measured by trecs (plotted on a logarithmic scale) a. sabra * , s. sabra , h.j. castro , j. malka-rais , j.i. mendez-inocencio , g. santos , j.a. bellanti , . rio de janeiro, brazil; . washington, dc. a major investigative effort of our laboratory has been directed to the study of non-ige mechanisms and their role in the immunopathogenesis of food allergy (fa). we have previously reported th and th cytokine alterations associated with several clinical entities that had overlapping disease manifestations affecting the mucosal-associated lymphoid tissues (malt), of the gi tract (galt), skin (salt), nasal (nalt) and bronchial tissues (balt). the objective of the present study was to evaluate specific immunologic alterations in a group of patients with non-ige fa. peripheral blood cd and cd lymphocyte subset analyses were performed in patients with fa documented by double-blind placebo-control food-challenge (dbpcfc). all patients were treated with an amino-acid based formula (aabf) and then received an open challenge using a panel of commonly offending allergenic food allergens in a normal diet.the clinical picture of all patients with fa were linked to malt-related manifestations; with galt symptoms of diarrhea, vomiting, abdominal pain and ftt, with balt symptoms of asthma, with salt symptoms of eczema, with nalt symptoms of rhinitis and with edema, ascites and anaphylaxis. all subjects had normal serum ige and eosinophil levels, negative ige food rast tests, normal cd (mean + ) and very low cd ( + ) levels in peripheral blood. abnormal cd /cd ratios > . were observed in all patients. age-and gender-matched controls revealed cd /cd ratios ranging from . to . . both patients with anaphylaxis had cd /cd ratios > . all patients responded well to aabf. open challenge to common offending foods from a regular diet (milk, soy, wheat, egg, nuts, beef and chicken), revealed multiple food allergies. after two years of follow-up on an aabf regimen, the patients remain well but allergic to multiple foods. very low cd levels remain as the unique immunological alteration in all patients.these studies suggest that abnormalities of very low cd distribution may play a pathogenetic role in non-ige mediated fa. since cd lymphocytes play a role in immunologic tolerance (it), it is tempting to speculate that the very low cd levels may signal the failure of development of it in our patients predisposing them to the development of allergies to multiple food components. background: mixed connective tissue disease (mctd) is a disease taht have caused controversy, while some authorities consider it a distinct rheumatic disease, others believe that it's an early stage of a fully defined autoimmune disease. the distinctive feature is the presence of the u small nuclear rnp autoantibodies. clinical features involve raynaud's is phenomenon, swollen hands, sclerodactyly, esophageal hypomotility, polyarthritis, and myositis, allof them can be present in others well deined rheumatic diseases. only aew cases have been described in the pediatric population. objetive: to determine the frecuency of mixed connective tissue disease in mexican.children in a tertiary level institution according to kasakawa's criteria, alarcon-segovia's criteria and sharp's criteria and establish if a diagnosis of a well defined autoimmune entity was made during the follow up. methods:medical charts were assessed with the diagnosis of mctd between and in our hospital. results: between and , , cases of autoinmune diseases were treated; with systemic lupus erythematosus(sle), with rheumatoid arthritis(ra), , with scleroderma and , with dermatomyositis. we found only four cases, of them did not complete the kasakawa's criteria but the diagnosis was probable according to alarcon-segovia and sharp's criteria. one of them developed sle after one year of follow up. the case that fulfilled the diagnosis criteria of mctd; raynaud's phenomenon, rnp antibody positive, arthritis, lymphadenopathy, restrictive pulmonary disease, sclerodactily and muscle weakness developed a full blown sle at years follow up. discussion: the disease is extremely rare in children. we conclude that at least in pediatric age the disease may not exist by it's own, but it's an early stage of a defined autoimmune disease, and the terminology "un differentiated connective tissue disease" is more appropriate to define this cases. a. baysan * , h.y. song, s. gupta, l. yel, irvine, ca. hereditary angioedema (hae) is an autosomal dominant disease characterized by episodic angioedema of the skin or mucosa of the respiratory and the gastrointestinal systems. hae is caused by a quantitative (type i) and/or functional (type ii) deficiency of plasma protein c inhibitor, an early component of the classical complement pathway. attacks of hae may be lifethreatening and even cause death when the airway is involved. here, we report a year-old female patient with hae type ii, who has seven affected family members, two of whom died of laryngeal angioedema. the patient had a history of recurrent swelling of the eyelids, lips, tongue and extremities, and respiratory distress since five years of age. she was hospitalized on several occasions one of which required intubation and assisted ventilation. laboratory studies, between the attacks, revealed normal serum ch and complement c levels. complement c level was decreased to mg/dl (n: - mg/dl). c esterase function was impaired, % (n: greater than %) in contrast to normal quantitative c esterase. the patient was on long-term danazol treatment for ten years and experienced side effects, most notably hirsutism. currently, there are limited efficacious and safe treatment options for hae. the treatment of choice for acute attacks and prophylaxis appears to be the c inhibitor concentrate, which is not yet licensed in the us. the present patient emphasizes the need to establish the correct diagnosis and an appropriate management plan in recurrent angioedema. j. hajsam * , l. ponomarjev, krasnodar, russian federation. background: the previous investigations indicate on the positive effects of ncir in different chronic inflammatory and infectious diseases. nevertheless, the mechanisms of the clinical efficacy of ncir remain still unknown. the aim of this investigation is the study of the immune disorders in patients with chronic tonsillitis and the immunomodulatory effects of the complex treatment in combination with ncir. methods: children with chronic tonsillitis in the age from to years old were under the observation. the t cell receptors (cd +, cd +, cd +, cd +, cd +, hla-dr+) have been studied using flow cytometry method. the cytokines (il , gamma ifn and il ) have been investigated by eliza method. the treatment include traditional methods in combination with ncir. control group (without tonsillitis) consists of children of the same age. results: it has been shown that in chronic tonsillitis was dcrease of the number of cd +, cd + and hla-dr+ cells. the decrease of cd + cells was mainly due to decrease of cd + cells. at the same time it has been shown the increase in number of cd + cells. in chronic tonsillitis have been determined the increase in serum proinflammatory cytokine il level in . times (p< . ). at the same time the levels of gamma ifn and il were lower than in control up to - times. the studied treatment method including ncir resulted in increase in the number of cd + and cd + cells. the level of il decreased from pg/ml to . pg/ml. at the same time the serum concentration of gamma ifn and il increased up to . and . times, accordingly. conclusion: in chronic tonsillitis it has been shown the immune disorders in t cell's subpopulations and cytokine production. the efficacy of ncir mainly depends on the normalisation in t cellular subpopulations and increase in the concentration of gamma ifn and il . introduction: viral hepatitis is characterized by suppression of cd +th cell function related to disease severity. the aim of our research was the determination of total ige concentration and anti-c q-autoantibodies levels in patients with viral hepatitis c (vhc) and mixed viral hepatitis (vhb+c) and the investigation of their correlation with t cell parameters. methods: patients with vhc and patients with vhb+c confirmed by pcr were examined. evaluation of serum total ige level was performed by elisa kits produced by "vector-best", russia. immunophenotyping of peripheral blood mononuclear cells (pbmc) was done by cytometry with monoclonal antibodies to cd , cd , cd , cd b, cd , cd , cd , cd and hla-dr-antigens. results: the level of serum total ige in patients with vhc and vhb+c was significantly increased in all groups studied, especially in acute hepatitis c ( . ± . mu/ml, p< . ) compared with the control group. analysis of pbmc subpopulations in patients with vhc and vhb+c was done related to the total ige level: group i - - mu/ml; and group ii -> mu/ml. in patients with viral hepatitis and high total ige level, the content of cd +t-lymphocytes, cd +t-cells and cd /cd ratio were significantly decreased compared with the control group (p< . ). more notable changes were found in patients with acute vhc and vhb+c. the increase in cd +-cell content was seen in groups with both low and high levels of total ige. the content of cd +-cells in patients with high levels of total ige was also increased (p< . ). conclusion: patients with vhc and vhb+c had significantly greater levels of total ige compared with the control group (p< . ). the increase in total ige levels in patients with viral hepatitis is associated with imbalances of t-lymphocyte subpopulations, including a decrease in cd +t-cells, and an increase in b-and nk-cells. title: occupational airway allergy among health care workers (hcw) with latex allergy. introduction: for the last years the frequency of latex allergy has increased. health care workers (hcw) is the risk group of this diseases. latex allergy symptoms occure in different organs -including skin, conjunctive, nose and bronchi. study aim:the aim of this study was to estimate the incidence of airway allergy in group of hcw with latex allergy. materials and methods: the investigations were carried out in a group of hcw, aged - (average age , ). there were two hundred and eight women and forty four men in the group. investigation consisted of questionaire examinations, skin prick tests (latex), patch tests (rubber additives), sige (latex) and spirometry. results: seventy eight ( %) hcw reported undesirable effects after the contact with latex products. fourty ( , %) hcw reported symptoms of airway (nose and bronchi). latex allergy (spt and/or sige and anamnesis positive) was diagnosed in ( , %) cases. the symptoms concerned with: skin, nose and conjunctive ( cases, %); skin and conjunctive ( cases, %); nose and conjunctive ( cases, %); nose and skin ( cases, %); bronchi, skin, nose, and conjunctive ( cases, %) and only skin in cases ( %). conclusions: the incidence of occupational airway allergy in group of health care workers with latex allergy is high ( % of all cases). latex allergy symptoms usually affect skin, but sometimes it includes also other organs -conjunctive, nose and seldom with bronchi. the incidence of anaphylaxis is increasing. the food allergy and anaphylaxis network wishes to expand the use of injected epinephrine by first responders to allergic emergencies. in indiana, there are , first responders, , basic emts, , advanced emts, and , paramedics. the use of injected epinephrine was only permitted by paramedics and advanced emts ( % of all responders). in a bill was introduced to expand the use of injected epinephrine by ems personnel in the event of an allergic emergency. it was sponsored by the indiana allergy asthma and immunology society and the emergency medical services commission of indiana. on july st senate bill no. took effect permitting all first responders to administer, without restrictions, injected epinephrine. once the legislation passed it became the responsibility of the medical director (md) of each ambulance service in the state to implement the change. in an attempt to assess the impact of this legislation we surveyed each of the mds in the state - months after the passage of the bill. mds were notified of the legislation by memo and public meetings. in addition each md received a copy of the legislation. of the mds, ( %) responded to the survey. results: . unaware of the legislation: ( %) . aware of legislation but no implementation: ( %) . aware of legislation with implementation restricted to basic emts: ( %) . aware of legislation and implementation at all levels: ( %) conclusions: twenty-five percent of mds were unaware of legislation. among those that implemented changes the majority ( %) permitted use by basic emts only. allergists, lay organizations, and ems commissioners need to assure implementation of legislation with all mds within the state. a. khadavi * , b. silverman , a. schneider , . great neck, ny; . brooklyn, ny. rabbit anaphylaxis is extremely rare, with one documented case upon inhalation only. we describe a patient with severe anaphylaxis upon consumption of a rabbit. a -year-old female with a -year history of asthma and allergic rhinitis was presented for evaluation. the patient complained of worsening asthma and rhinitis symptoms in the home and upon exposure to outdoor pollen. further history revealed the family had a rabbit as a pet. laboratory testing showed her total ige was ku/l, rast results were normal for tree, ragweed and molds (< . kiu/l). positive results were found for ragweed, dust, cockroach, cat, dog, mouse, peanut and rabbit epithelium ( . kiu/l, class iv). among other environmental control measures, the family was advised to eliminate the rabbit from the home environment, as it could be a potential trigger for their daughters allergy symptoms. two days later, the patient presented to the emergency room with wheezing, coughing and angioedema of the hands and face. she was treated with albuterol, diphenhydramine and oral steroids. the parents said they followed all of our instructions and did not know why anaphylaxis occurred. further questioning revealed that the family consumed the pet rabbit on the same night preceding the anaphylactic reaction. this was the first time the daughter ate rabbit. the parents assumed that only exposure to the live rabbit would worsen her allergy and asthma symptoms, never expecting an allergic reaction via ingestion. they were advised not to feed their daughter rabbit again and were given a prescription for self-injectable epinephrine. this demonstrates either complete identity, partial similarity or cross reactivity between inhaled and food allergens, as has been noted previously with certain other foods such as garlic and crustacean proteins. physicians need to advise food allergic patients that an allergic reaction can develop upon inhalation of the food, as seen with peanuts. but also respiratory sensitization to an allergen can lead to allergic symptoms upon its ingestion. t. nsouli * , j. scheiner , j. malka-rais , j.a. bellanti , . burke, va; . washington, dc. the safety of selective cyclooxygenase- (cox-ii) inhibitors in patients with known nsaid-induced allergic reactions has not been definitely established and is still open to debate. in the present report, we describe two patients with hypersensitivity reactions to naproxen, the first characterized by a systemic anaphylactic reaction and the second by localized urticaria following ingestion of the drug. the first case was a y/o wf with a history of osteoarthritis who, minutes after the ingestion of mg of naproxen, developed generalized pruritus, urticaria, laryngeal edema and hypotension. she was treated in the er with epinephrine, diphenhydramine and iv corticosteroids. epicutaneous and intradermal skin testing to celecoxib revealed negative results similar to a control. an oral challenge with celecoxib was well tolerated by the patient without any adverse responses. the second case was a y/o wf with a known history of chronic urticaria and osteoarthritis requiring regular use of naproxen. a complete allergic and immunologic workup was negative. upon discontinuation of the drug there was resolution of the urticaria. an oral challenge with celecoxib was well tolerated by the patient without adverse sequelae. these two case reports exemplify two extremes in the spectrum of adverse allergic reactions to naproxen, a non-selective cox-i and cox-ii inhibitor, one systemic, the second localized and suggest that the pathogenesis of these symptoms was most likely pseudo-allergic in nature and not immunologically-mediated. the dissimilar chemical structures of naproxen and celecoxib together with their differing mechanisms of action suggest that the absence of allergic reactions to challenge with celecoxib, a cox-ii inhibitor, may be related to a lack of cross-reactivity between the two drugs. although these findings suggest that oral celecoxib could be a possible safe alternative in patients with naproxen-induced drug reactions, it would be prudent to first conduct careful challenges with the drug in a well-equipped medical setting where clinical acceptability and tolerability could be safely assessed. introduction: most fixed and removable dentures are made from casting alloys. many orthodontic appliances are also fabricated from metallic biomaterials. it has been documented in vitro and in vivo, that metallic restorations release metal ions mainly due to corrosion. those metallic ions may be distributed systemically and locally and could pay a significant role in the induction of oral or/and systemic immunoinflammatory conditions. this study determines the frequency of sensitization to metal salts and clinical characteristics in the group of patients with complaints related to adverse effects of dental alloys. methods: patients ( women and men) aged - years with symptoms assumed to adverse effects of dental alloys were studied. all patients were studied with base metal salts, including cu + , co + , cr + , mg + , mn + , ni + , ti + , zn + using patch tests. all patch tests substances were % salts in petrolatum. the patch tests were conducted in accordance with recommendations of the icdrg. occlusion time was days, and patch tests were read when removing the patches (finn chambers on scanpor, epitest ltd oy, tulusa, finland) and to days later. the total number, percentage of irritant and allergic patch test reactions were calculated. results: in of patients ( %) sensitivity to base metals used in dental restorations was noted. symptoms included burning mouth ( %), metal taste ( %), electrical sensations ( %), dry mouth ( %), and taste irritation ( %), but / patients ( %) had no symptoms. local gingivitis ( . %), anomalies of the tongue ( %), stomatitis ( %) and lichenoid reactions ( %) were often seen. the most frequent patch test reactions were caused by ni ( %), cr ( %) and co ( %) . conclusion: this study demonstrated higher frequency of hypersensitivity reactions to ni, cr and co in this group of patients often having symptoms such as burning mouth, metallic taste, electrical sensation, local gingivitis, and anomalies of the tongue. w.y. mak * , s. kearney, b. silverman, a. schneider, brooklyn, ny. the process of intravenous drug desensitization often involves simple but tedious calculations. miscalculations may arise due to human error. for patients who are truly allergic to the drug in question, such errors can be life threatening, if not fatal. we propose the use of a spreadsheet to minimize such calculation errors. spreadsheets, such as microsoft excel, ibm lotus - - , and corel quattro pro, are used extensively in finance for tedious and repetitive calculations. this property of a spreadsheet makes it an ideal tool to assist with any drug desensitization protocol. we chose microsoft excel for its availability at our institution. a general template was initially created with equations in specific cells which were based on the protocols listed in patterson's allergic diseases, th edition and middleton's allergy: principles and practice, th edition. by inputting specific numbers, such as the amount of drug and volume of diluent into key cells of the spreadsheet, the program will automatically calculate the protocol for the given intravenous drug. an example of our pipericillin protocol is listed below. we find that the use of a spreadsheet not only minimizes calculation errors and hence reduces the likelihood of avoidable reactions; but also decreases our preparation time for the desen-sitization protocol. we recommend its use for all allergists performing drug desensitizations. states years ago, the infestation of homes across the northeast, southeast and midwestern states with these insects during the fall and winter months has become increasingly common. in the last years, several investigators have published case reports of patients with allergic rhinitis, conjunctivitis and asthma symptoms associated with suspected inhalational exposure to high levels of proteins from these beetles. we report a series of patients who presented with a spectrum of various allergy complaints ranging from symptoms of allergic rhinitis, asthma, urticaria, angioedema and acute anaphylaxis (with documented elevated serum tryptase) on exposure to high numbers of multi-colored asian ladybeetles(malb.) methods: we performed western blotting with the patients' serum and a whole-body ladybeetle extract made from confirmed h. axyridis obtained from one of the infested homes in that region. results: blots with the patients' serum revealed ige binding to different proteins with molecular weights approximately , and kd. the serum from two patients bound a kd protein possibly similar to the kd protein previously identified by yarbrough et al. jaci ; ; - . ige from four patients bound to an kd protein not previously reported. lastly, serum from two patients revealed ige binding to a kd protein possibly similar to the heavier proteins mentioned in an abstract by magnan et al. jaci ; ; . conclusion: we present five patients with specific ige to malb and allergic symptoms on exposure to high levels of malb. we conclude that malb are likely a significant source of several different allergenic proteins and that malb are increasingly becoming a significant cause of a wide variety of hypersensitivity reactions across the united states. as multiple exposed subjects and several entomologists report that these beetles bite humans, we speculate that a wide range of ige-mediated symptoms including urticaria, angioedema and anaphylaxis can occur by exposure to proteins by inhalation, direct contact and possibly by inoculation of these proteins into the skin by the bite or scratch of this beetle. a case report and literature review. c.s. taylor * , s. ramesh , . getzville, ny; . buffalo, ny. introduction: lentils belong to the legume family and are the staple ingredient of the ethnic indian diet. lentils have been shown to cause allergic reactions and even anaphylaxis. however, little research has been done to distinguish the types of lentils used commonly in the indian diet and their various hypersensitivities. some of these lentils include the black gram (phaseolus mungo), mung bean and split chick peas (bengal gram). case report: we report a -month-old indian boy who presented with severe atopic dermatitis since the age of four months. his dermatitis was exacerbated by the ingestion of peas and beans and resolved with the avoidance of such. at nine months of age, the child was introduced to boiled mung beans and subsequently developed lip swelling within a few minutes. a similar reaction occured with split chick peas. physical exam at consultation revealed severe eczema. skin tests using commercial extract revealed + response to peanut (he had never eaten peanuts), soybean, pea and egg. subsequent skin tests at the follow up visit to prepared reagents revealed much greater than + response to mung bean, chick pea, split chick peas, and black gram. the patient developed a systemic response during testing which required epinephrine. discussion: legume allergy (other than peanut, soy and peas) is rare in the unites states but has been reported in asia and the mediterranean area. it has been reported in one case series that patients with lentil allergy react to more than one lentil. there is a five percent cross reactivity between peanut and other legumes such as soy and peas. however, the extent of cross reactivity between peanut and the other legume sub-groups (ie. lentils) is not well documented. there also appears to confusion in the labeling of the various lentils used in ethnic diets. conclusion: this case has been presented to make allergists aware that there are many differnt types of lentils that can cause hypersenstivity reactions and the importance of considering ethnicity and dietary habits in evaulating for food allergy. background: epinephrine is the drug of choice for the treatment of anaphylaxis however it is frequently underutilized. one possible reason is the fear of adverse cardiac effects. the most common side effects of epinephrine are palpitations, tachycardia, sweating, nausea, vomiting, respiratory difficulty, pallor, dizziness, weakness, tremor, headache, nervousness, anxiety and arrhythmias. a previous study showed that administration of epinephrine, in a small number of healthy adults did not cause any significant cardiac adverse events and vitals sign changes were not clinically significant. the purpose of this retrospective analysis is to determine the safety profile of epinephrine in a large number of patients that were administered epinephrine for treatment of anaphylaxis that occurred in a physician's office. methods: all patients in an allergy office, that were administered epinephrine for acute anaphylaxis between - were selected for this retrospective analysis. a chart review for adverse events and vital was conducted. vital signs and side effects had been monitored every to minutes for minimum of to minutes after the administration of epinephrine. results: patients between the ages of yrs to yrs received injections of epinephrine. after an injections of epinephrine % of the patients had a pulse between - , % between - , and % between - . systolic blood pressure determined % of patients to be between - , with %, between - , and % between - , and % between - . concurrently, diastolic blood pressure was found to have % between - , % between - and % betweem - . the most common reported side effects were tremor, headache and pallor. any rise in blood pressure and heart rate after epinephrine was transient and returned to normal within minutes of observation. there were no serious side effects. all patients responded to the epinephrine and were able to go home. conclusions: this retrospective analysis revealed that the administra-tion of epinephrine is safe and effective for the treatment of acute anaphylaxis in an outpatient setting. the use of epinephrine for treatment of anaphylaxis is life-saving and its use to treat non-cardiac or elderly patients who have anaphylactic reactions should be encouraged. purpose: a clinical pathway was established to decrease the use of vancomycin in surgical patients with self-reported penicillin (pcn) allergy. methods: in , our institution developed a preoperative evaluation (poe) clinic for elective surgical patients. in june , on-site, same-day allergy consultation and penicillin skin testing was made available for preoperative patients with self-reported pcn allergy. we reviewed the antibiotic recommendations, the actual administration of vancomycin, and compliance by the surgeons with our recommendations from july , -september , . results: during this time, , patients were seen for their preoperative medical exam at the poe clinic, and were evaluated for pcn allergy. of these, patients met irb standards to participate in the study. the mean age of the patients was years. the top three surgical specialties represented in the poe clinic were orthopedic ( . %), urology ( %), and neurosurgery ( %). of the patients, underwent skin testing for pcn allergy. eighty-five percent ( %) or of these patients with a history of pcn allergy were recommended to use -lactams such as cefazolin, and ( %) were recommended to avoid -lactams. forty-three ( ) or % had one or more positive skin tests to pcn. of the patients, patients actually received pre-operative antibiotics. of these patients, ( %) of those received cefazolin, ( %) received clindamycin, ( %) received ciprofloxacin, ( %) received levofloxacin. some patients received more than one antibiotic for prophylaxis. only ( %) patients received vancomycin. conclusions: establishment of a clinical pathway in a preoperative clinic that includes allergy testing and consultation reduced vancomycin use to only % in surgical patients with a history of penicillin allergy. h. yarmohammadi * , a. nowak-wegrzyn, new york, ny. introduction: anticonvulsant hypersensitivity syndrome is a potentially fatal drug reaction with cutaneous and systemic reactions to the arene oxideproducing anticonvulsants. in most cases, the hallmark features of fever, rash, and lymphadenopathy are accompanied by multi organ-system abnormalities. fatal outcomes are most often associated with liver failure. recognition of the syndrome, which may have variable presentations, is the key to prompt discontinuation of the drug, close monitoring, and management. case : a y/o male received dilantin for seizure prophylaxis following craniopharyngioma resection. fourteen days later he was readmitted for fever and csf leak from surgical site. he was started on ceftriaxone and vancomycin empirically; an lp and pan culture was done. he continued to have low grade fever and, on the th day of admission, developed a maculopapular rash on trunk. on day th lfts increased and cbc showed eosinophilia. antibiotics were stopped but lfts continued to rise. on day , dilantin was stopped and lfts normalized in days, fever stopped and rash disappeared. case : a y/o girl was admitted to the hospital with generalized rash, facial edema and fever ( degrees c). she developed a pruritic maculopapular erythematous rash over her trunk and face weeks prior to admission. she then developed high fever. three months prior to this visit she had been started on phenytoin ( mg/kg) for control of grand mal seizure. physical exam revealed cervical and axillary lymphadenopathy. she had elevated wbc ( , ), eosinophilia ( %), and elevated lfts. phenytoin was stopped upon admission but hours later she continued to have fever, elevated lfts and devel-oped erythema in her mouth. treatment with ivig and prednisone was initiated and resolution of symptoms was seen within - days after therapy. conclusions: the timely recognition of anticonvulsant hypersensitivity syndrome is important, because accurate diagnosis prevents potentially fatal re-exposure and influences subsequent anticonvulsant treatment options. ivig and prednisone should be considered in situations where prompt improvement of the lfts or clinical symptoms is not observed. the recently published results of a telephone survey about the prevalence of seafood allergy in the us indicate that seafood allergy is a significant health concern. aim of the present study was to retrospectively review our data on the topic. we have interviewed subiects attending our allergy outpatients about any suspected food allergy. over % were years or older. any reaction to food was reported by % of the patients, more frequently by women. of these patients, reported reactions to seafood ( %) with an overall prevalence of seafood reactions of . %: to fish ( . %), to shellfish (including mollusks) ( . %) and to both ( . %). in the case of the reactions to fish it is quite possible that shellfish is also included, as the patients were often unable to tell the role of finfish from shellfish apart. this is most probably due to the fact that seafood dishes or a complete seafood meal in italy generally include both shell and finfish. in only less than half cases there was a convincing relationship between the ingestion of seafood and the reaction. the reactions reported were: gastrointestinal ( ), non life-threatening angioedema ( ), mild oral allergy syndrome ( ), acute urticaria ( ), asthma ( ), rhinoconjunctivitis ( ). the gastrointestinal reactions might not all be true (ige-mediated) allergic reactions, but also toxic. in conclusion, even in a selected population like that attending an allergy clinic and using a broad definition of adverse reaction, seafood allergy appears to be a rare phenomenon and of limited clinical impact, the prevalence of moderate to severe reactions (angioedema and asthma) in the whole selected population being . %. clopidogrel (plavix) is an antithrombotic agent currently used to prevent thrombotic cardiovascular events by inhibiting adenosine diphosphate (adp)dependent platelet activation. clinically, it has been used in patients with aspirin intolerance or who developed neutropenia from ticlopidine. there have been reported cases of clopidogrel causing rash and urticaria. often these patients are told they are allergic to clopidogrel and should not take it again, despite the fact that no workup was ever performed to elucidate whether the reaction was indeed immunologic in nature. a review of the literature revealed no reported attempts at desensitizing a patient to clopidogrel after a presumed immunologic drug reaction. we present the case of a year-old female who initially took clopidogrel ( mg. p.o. daily) for transient ischemic attacks. after tolerating the medicine for five days, it was replaced with an aspirin/warfarin combination, which she took for the next five days. reintroduction of clopidogrel a week later was uneventful, until she developed a pruritic, maculopapular rash on the th, through th days of restarting therapy. at that time, she was not taking any other medications, and had no cardiopulmonary or gastrointestinal complaints. she had discontinued the clopidogrel and was asymptomatic during our consultation. skin testing was done using clopidogrel prepared at concentrations of mg/ml and / mg/ml. at the same time, control skin testing on three non-atopic subjects was performed and produced no reaction to either epicutaneous or intradermal testing. by contrast, the patient had a positive skin reaction at both concentrations on intradermal testing. the patient was hospitalized for an oral desensitization where clopidogrel dilutions were prepared by the hospital pharmacy. the patient tolerated an initial dose of . mg. serial three-fold increases in concentration were given every minutes, until a total cumulative dose of mg. was reached. the patient tolerated the entire procedure and suffered no adverse reactions upon continuation of the treatment. this demonstrates the utility of oral desensitization to clopidogrel in patients with a positive skin test who require this medication. lamotrigine is a non-aromatic anticonvulsant with desirable pharmacological profile. the most common idiosyncratic reaction in children is rash ( - %). severe cutaneous adverse reactions and systemic hypersensitivity reactions are uncommonly reported. method: case presentation an -yearold caucasian female was prescribed lamotrigine in escalating dose for her first generalized seizure. a week later she developed a pink rash on her cheeks gradually progressing to her trunk, hands and feet. three days later she was seen in the er and treated for possible streptococcal-pharyngitis with fever and rash. oral penicillin-v treatment was initiated. the rash continued to spread all over her body with mild pruritis and sores on lips and mouth. few blisters were noted in left ear, hands and feet. later lamotrigine was discontinued. oral steroids were prescribed. she continued to develope new blisters, rash and hemorrhagic plaques and dysuria. she was later transferred to our institute. the physical examination was significant for afebrile girl without pallor and icterus. bilateral conjunctivitis without keratitis evident. tender cervical lymphadenopathy was palpable. multiple ulcers on lips and gingiva were seen. several targetoid lesions on trunk and extremity were noted along with few hemorrhagic plaques on extremities. superficial sloughing of distal fingers and toes was noted. nikolskys sign was not demonstrable. the systemic examination was unremarkable. laboratory tests: hemoglobin . g/dl, wbc-normal range without eosinophilia. normal pt/aptt and inr. liver function tests showed elevated sgpt- iu/ml and sgot- iu/ml with normal bilirubin. urine analysis was normal. serology for cmv, ebv, hsv and hepatitis a and b was negative. skin biopsy showed full thickness epidermal necrosis and sub epidermal clefts. aggressive supportive therapy was initiated. corticosteroids were continued for five more days. prior to being discharged from hospital the rash had dried and most lesions faded. the blisters and oral ulcers had healed. the liver enzymes had decreased. conclusions: we report an occurrence of stevens-johnson syndrome with lamotrigine in a young child. in the literature severe reactions are associated with higher doses or rapid escalation of the dose, and concomitant use of valproate. early recognition and withdrawal of medication is necessary to improve the outcome. introduction: in patients with a history of penicillin (pcn) allergy and negative pcn skin tests to major and minor determinants, - % of patients will tolerate pcn administration without risk of an immediate reaction. in fact, middletons allergy principle & practice reported that no life-threatening false-negative reactions have been reported when pcn was administered after a negative pcn skin test. we describe a case in which a patient with a history of pcn allergy and negative pcn skin tests to the major and minor determinants experienced life-threatening anaphylactic shock when administered piperacillin/tazobactam. case history: a -year-old woman with crohns disease was admitted for treatment of an enterocutaneous fistula. three months before admission, the patient reported a severe reaction to either piperacillin/tazobactam or intravenous (iv) lorazepam needing respiratory support in the intensive care unit. in order to delineate this problem, an allergy consultation was obtained. serum ige antibodies to pcn, measured by a commercial cap system radioallergosorbent test (rast) fluoroenzymeimmunoassay (feia; pharmacia and upjohn, uppsala, sweden), and pcn skin tests to major and minor determinants were negative. a skin test (prick and intradermal) to piperacillin/tazobactam at . mg/ml was also negative. five minutes into receiving . grams of piperacillin/tazobactam iv, the patient reported feeling lightheaded, flushed, nauseated, and diaphoretic. the blood pressure decreased to / from a baseline of / , heart rate /minute and appeared toxic. no wheezing or rash was noted on physical examination. patient was treated with iv epinephrine, diphenhydramine, and dexamethasone and recovered without sequela. serum tryptase, drawn hour after the beginning of the reaction, was elevated at . ng/ml but decreased to . ng/ml hours later. complement levels were normal. conclusion: despite a very high negative predictive value of a negative pcn skin test to the major and minor determinants and reports that no life-threatening false-negative reactions have been reported when pcn is administered after a negative pcn skin test, physicians need to be very cautious in administering piperacillin/tazobactam and other b-lactams in patients with a history of severe reactions such as anaphylaxis to past pcn administrations. a. majmundar * , d.a. khan, dallas, tx. introduction: a variety of adverse drug reactions have been reported after therapy with allopurinol. successful protocols for desensitization to allopurinol have been developed. we report a case of a patient who was successfully desensitized to allopurinol only to develop dress after four months of allopurinol therapy. methods: a year old man was referred to our department with a remote history of rash and fever resulting in hospitalization after initiation of allopurinol. due to severe gouty arthritis unresponsive to colchicine and requirement of chronic steroids, it was recommended to attempt allopurinol desensitization. based on the history of his prior reaction, a slow desensitization protocol was performed beginning with allopurinol μg and increasing the dose weekly to μg, μg, μg, μg, μg, mg, mg, mg, mg, mg, and mg. the patient tolerated the entire desensitization protocol without adverse reaction and was initiated on daily allopurinol at mg per day. results: four months after desensitization and daily allopurinol use, the patient developed fevers and an acute maculopapular eruption on his back and abdomen without mucosal involvement. laboratories demonstrated eosinophilia of cells/mm , elevated ast of , alt of , and ggt of u/l. he was treated with prednisone mg a day which was tapered weekly over weeks with successful resolution of his symptoms, eosinophilia and transaminitis. conclusion: while desensitization to allopurinol can be safely accomplished, allergists need to be cognizant of the potential for delayed serious drug reactions such as dress. wiskott aldrich syndrome is an immunodeficiency characterized by eczema, pyogen infections, and mixed immunodeficiency.we describe a male seven-month old, perinatals antecedents without importance who had an ulcer in site of application of bcg. non-blood relatives, healthy parents. at twomonths-old, he initiated with continuous fever, not quantified, treated with multiples antibiotics without resolution, he was hospitalized, plaquetopenia and anemia were diagnosed, he received a red globules and plateles transfusion, one week after he presented a disseminated dermatosis characterized by erythema and desquamation, at four-month-age presented right axillary adenomegaly, hepatoesplenomegaly and recurrent bilateral media otitis for what was hospitalized in our institute. he was malnutrition, bad general condition, febrile, with disseminated dermatosis affecting the head, trunk and extremities characterized by erythema and desquamation, in addition he had left ankle cellulitis, right axillary adenomegaly, hepatoespenomegaly. during his hospitalization he presented left hand cellulitis, hairy skin abscess, oral candidiasis, required surgical treatment by econdary compartimental syndrome because cellulitis of left ankle. persistent hemogram reported thrombocytopenia with normal platelet volume, blood cultives were positive for grampositive bacterias, isoaglutinines, were normal. immunoglobulines were elevated for the age range, he received antimicrobial and antifungic treatment. but he died. in the autopsy timic alymphoplasia was reported, cortical lymphoid depopulation in lymphatic ganglia and spleen, disease by disseminated cytomegalic inclusion, multifocal pulmonary pneumocystosis, bcgitis, disease graft versus guest. . with the previous features we concluded in a compatible mixed immunodeficiency with wiskott-aldrich syndrome with particular characteristics that make this case interesting. the patient course with cellular immune deficiencie with thrombocytopenia and eczema, even when he didn't have platelet sizing diminished, we consider that the patient had a severe of wiskott s aldrich syndrome and at the moment we are awaiting result of genetic study uasp gene. background : hypersensitivity to mosquito bites (hmb) is a disorder characterized by necrotic skin reaction and systemic generalized symptoms subsequent to mosquito bites. it has been suggested that hmb is associated with chronic epstein-barr virus (ebv) infection and natural killer cell leukemia/lymphoma. we describe here a korean child who had hmb associated with chronic ebv infection and natural killer cell lymphocytosis. case : a -year-old male was admitted with well-demarcated necrotic skin lesions and severe swelling on right ear lobe developed after mosquito bites. he had suffered several similar symptoms since last summer, which complicated as deep scars on skin. hepatosplenomegaly or peripheral lymphadenopathy was not detected. laboratory tests showed wbc , /mm (neutrophil %, lymphocyte %), total eosinophil count /mm , ige by prist above , iu/m. immunoglobulin levels were normal. specific ige for aedes communis by cap was negative. lymphocyte subset analysis demonstrated increased nk cells (cd +cd , %) and decreased cd and cd cells. igm for anti-nuclear antigen (ebna), igm for viral capsid antigen (vca) and igm for anti-early antigen (ea) dr to ebv were negative. but the levels of anti-vca igg (> u/ml), anti-ea dr igg (> u/ml) and anti-ebna igg ( u/ml) were increased. type a eb virus was demonstrated in blood mononuclear cells by dna pcr method, and eber in situ hybridization was negative in necrotic tissues. immunostaining with nk-cell marker (cd ) revealed many immunoreactive cells with the perivascular inflammatory infiltrates in tissue. skin patch tests for mosquito allergen (aedes togoi and culex pipiens) showed positive response to c. pipiens. introduction: scimitar syndrome is a congenital anomaly resulting in anomalous pulmonary venous return from the right lung to the inferior vena cava. recurrent respiratory infections have been associated with scimitar syndrome. methods: we report on a year-old adolescent female who presented to immunology clinic with recurrent pneumonias. results: the patient presented with numerous recurrent pneumonias, multiple er visits, and hospitalizations. she complained of intermittent chest pain, cough, fatigue and exercise intolerance. the patient had a large secundum atrial septal defect surgically corrected at years of age. a cardiac echo obtained at years of age revealed rvh, but was normal at years of age. she was a known atopic asthmatic. previous immunologic workup was normal with iga ( - ), igg ( - ) and igm . at presentation to our clinic pulmonary functions were fvc of % and fev of %. review of previous chest radiographs showed chronic changes with an opacity partially obscuring the right hemidiaphragm. a high resolution chest ct-scan showed a large irregular venous structure extending through the right chest joining the inferior vena cava above the liver consistent with scimitar syndrome. the patient was referred to pediatric cardiology who recommended surgical correction. conclusion: scimitar syndrome may present as recurrent pneumonias and chronic lung disease. a high resolution chest ct scan may be useful in delineating this disorder. background: laryngomalacia is the most common cause of stridor in infants but only rare reports exist of clinically relevant laryngomalacia in adults. objective: to present a case of laryngomalacia in an adult with significant respiratory symptoms initially attributed to asthma. methods: an year-old female with a history of allergic rhinitis and gastroesophageal reflux disease presented to the allergy clinic for further recommendations regarding a prior diagnosis of asthma poorly controlled on inhaled fluticasone, montelukast and albuterol. the patient was clinically diagnosed with asthma at age due exercise related symptoms. the symptoms progressed and intermittent trials of various inhaled steroids provided minimal relief. on evaluation, the patient described constant wheezing which occurred only on inhalation and originated from the throat. symptoms did not respond to albuterol use three to four times a day, rhinitis control and long-term, high-dose, antireflux therapy. baseline spirometry was normal. histamine bronchoprovacation and fiberoptic laryngoscopy were performed for further evaluation. results: histamine challenge was positive with a % decrease in fev with mg/ml histamine. however, laryngoscopy revealed redundant airway tissue most notable over the right arytenoid cartilage, consistent with laryngomalacia, which prolapsed into the laryngeal vestibule significantly obstructing the airway on inspiration only. the patient was referred to otolaryngology and surgical excision using a carbon dioxide laser was performed with subsequent improvement in symptoms and decreased asthma medication use. conclusions: we report an unusual case of laryngomalacia in an adult presenting as asthma, which was successfully treated with laser surgical excision. laryngoscopy of the patient revealing redundant airway tissue most notable over the right arytenoid. c. so * , s. kuhl , . davis, ca; . mather, ca. c. so, s. kuhl u.c. davis medical center, sacramento, ca & sacramento va hospital, mather, ca background: wheezing is an uncommon manifestation of phrenic nerve dysfunction. objective: we offer a description of wheezing attributable to phrenic nerve dysfunction to remind clinicians that dyspnea and wheezing can be caused by cor pulmonale which can be caused by phrenic nerve dysfunction. methods: a -year old male non-smoker presented with chronic dyspnea and occasional wheezing for the last decade. the patient had a remote history of pericardial stripping for presumed tuberculous pericarditis. he also had a non-productive cough and orthopnea. dyspnea was exacerbated by putting his hands over his head and bending over. he had been treated with inhaled corticosteroids and bronchodilators without relief. results: repeated chest x-rays showed a chronically elevated right hemidiaphragm. pulmonary function tests showed a restrictive pattern with: fev . ( %), fvc . ( %), tlc . ( %), dlco/va . ( %) and no bronchodilator response. left heart catheterization was normal while right heart catheterization showed elevated pulmonary artery pressures ( / ) and he was subsequently diagnosed with cor pulmonale. cardiopulmonary exercise testing showed an increase in minute ventilation which was achieved predominantly by an increase in respiratory rate rather than to an increase in tidal volume suggesting restrictive or interstitial lung disease. chest ct showed left ventricular enlargement and no evidence of interstitial lung disease. a fluoroscopic sniff test was performed and showed paradoxical movement of both diaphragms. he was diagnosed as having diaphragmatic dysfunction as a result of phrenic nerve injury from prior pericardial stripping. conclusions: wheezing and chronic dyspnea can be related to phrenic nerve dysfunction. a review and discussion of various causes of phrenic nerve dysfunction, including autoimmune causes, is offered. patients with a history of prior cardiothoracic surgery who present with recalcitrant dyspnea and wheezing may benefit from evaluation for phrenic nerve dysfunction. background: sudden sensorineural hearing loss (ssnhl) is defined by a loss of at least db in contiguous frequencies over a time course of hours or fewer. etiologies of ssnhl include viral infections, ototoxic drugs, autoimmune diseases, trauma, neoplasms, and vascular occlusion, but viral labyrinthitis is the most common cause. in cases of sudden hearing loss, herpes infections can be reported in approximately % of cases caused by viral infections. typically, sensorineural hearing loss is not recurrent. we report a case of recurrent ssnhl is which oral herpes lesion preceded the onset of symptoms on three consecutive episodes. case report: a -year-old male with a history of hypertension, hypothyroidism and chronic tinnitus of the left ear (since a gunshot wound years prior) presented to clinic with a complaint of recurrent episodes of sensorineural hearing loss. the first episode of bilateral hearing loss occurred months prior. an otolarnolgologist treated with a steroid taper and valacyclovir and the hearing loss resolved after one day of therapy. since the initial presentation, the patient reports three subsequent episodes of ssnhl, with two of the episodes responding to prednisone and valacyclovir and one episode responding to steroids alone. oral herpetic lesions preceded at least three of the episodes one day prior to the hearing loss. laboratory data was significant for an elevation of varicella-zoster igg, and of hsv igg. hsv igm was not performed. rpr was non-reactive and ana was negative. a mri of the head was normal. audiogram demonstrated db increase and speech discrimination improved from % to %. the rest of the laboratory data was unremarkable. the patient has been maintained on daily valacyclovir therapy and has had no further episodes of hearing loss. conclusion: our patient experienced hearing loss with concomitant evidence of hsv- stomatitis. this suggests a cause and effect relationship. we found that the antiviral therapy was effective for treatment of the ssnhl in this patient as demonstrated by the absence of further symptoms while on antiviral prophylaxis and conclude the most likely etiology of the recurrent hearing loss was secondary to the recurrent herpes simplex infections. abstract the illness was described for the first time in in the chinese literature by kimm, and szeto, the definitive histological description was published by kimura in , this illness is endemic in asia, but rare, about cases had been reported. kimura disease is extremely sporadic in the rest of the world. the etiology of this disease is ignored but it is believed that there is an aberrant immune reaction to an unknown antigenic stimulus, however epstein barr's virus, human herpes virus and candida albicans had been involved in certain cases. the mast cells had been implicated in its pathogenesis and a th cytokine pattern with the production of interleukin , and rantes which regulate the synthesis of ige and orchestrate the eosinophilic infiltration. on the other hand it is suggested that the eosinophils had undergone an accelerated apoptosis in this illness. case report. it is a year-old boy with a months evolution with the presence of bilateral subcutaneous nodules of x cm in parotid and submaxillary glands, presenting hypereosinophilia ( total eosinophils ) and high ige ( total ige), with normal renal function and negative mycotic and parasitic tests.the histopathologic findings revealed the presence of eosinophilic infiltrates with capillary proliferation and fibrosis. discussion. for the clinical characteristics of the nodules together with the hypereosinophilia, extremely high ige and the characteristic histological lesions the diagnosis is kimura disease. the usual clinical presentation consists on several indolent subcutaneous nodules that grow very slowly in volume, located in the neck and head, accompanied by satel-annals of allergy, asthma & immunology lites adenophaties, and with increment in the salivary glands, there is renal affectation in half of the patients, and the laboratory detects hypereosinophilia and elevation of the total ige. the histological lesions, shows hyperplastic lymphoid tissue with proliferative germinal centers, with infiltration of eosinophils in their interfollicular and perivascular zones sometimes forming an eosinophil abscess and proliferation of poscapillary venules. at the moment he have been treated with prednisone ( mgkdia), with great improvement in the clinical evolution. this is the first case reported in the literature in mexico. introduction: the incidence of cow's milk protein allergy (cmpa) is approximately - % and presents primarily during the first year of life. manifestations of cmpa in the neonatal period include gastroenteritis, colic, lethargy, metabolic acidosis, and hematochezia or melena and appear to be non-ige mediated. ige mediated reactions in the neonatal period, such as urticaria or angioedema, are unusual. case: a -day-old african-american male presented with a day history of rash, swelling, and erythema overlying multiple joints. there was no history of fever, diarrhea, or eczema. he had been on no medications prior to admission. besides mother with a history of childhood asthma, there was no family history of atopy or food allergy. he had been fed cow's milk-base formula (similac ® ) since birth exclusively. physical examination revealed a diffuse erythematous, raised, macular-papular rash, with areas of duskiness and exfoliation. there was angioedema overlying the joints and periorbital areas (figure ). laboratory evaluation included cbc with diff, hgb electrophoresis, lumbar puncture, urinalysis, c q (qualitative and quantitative), c , c , c , and cultures of the blood, csf, and urine which were within normal. percutaneous allergy skin testing for cow's milk allergy was performed revealing a + reaction to cow's milk extract (greer, lenoir, nc) with positive histamine and negative saline controls. rast testing showed . ku/l for -lactoglobulin and . ku/l for cow's milk. he was placed on an elemental formula. skin lesions and swelling resolved completely within hours. at week follow-up the patient was thriving without complaint. conclusion: early sensitization to cow's milk protein in the neonatal period may occur, resulting in ige mediated urticaria and angioedema. the rashes may be misdiagnosed as erythema multiforme or anaphylactoid purpura, since hemorrhagic lesions and cockade pattern are common. physicians should be aware that these reactions may occur so that early recognition and management may be initiated. neonate with periorbital angioedema and exfoliating, urticarial rash. rationale: two patients, presenting with invasive fungal cns infections, were found to have nk cell dysfunction and hypogammaglobulinemia. methods: case reports results: patient # : a year old caucasian male presented with headache, double vision, periorbital swelling, and bilateral sinus disease on ct scan. biopsies showed invasive rhinocerebral mucormycosis. he continued to deteriorate in spite of iv and intrathecal amphotericin b, hyperbaric oxygen, many debridement procedures, and a left orbital exenteration. immune evaluation revealed low igg, low igm and a barely detectable nk cell killing activity. neutrophil respiratory burst was normal. he continued to worsen despite ivig replacement. he had intolerable side effects to ifn-a. gm-csf ( mcg qod) was initiated, in order to boost nk cell activity. this resulted in stabilization of his infection. he was discharged on oral anti-fungal therapy (posaconazole), ivig, and gm-csf. sixteen months later, he continues to remain stable clinically and radiographically on ivig and gm-csf. patient # : a -year-old caucasian male presented with headache, mental status changes, and ataxia. a head ct scan showed a left mass effect and edema. he underwent surgical debridement for ventriculitis and zygomycetes (the same family as mucormycosis) was found. he was started on iv amphotericin b and oral posaconazole. his immune evaluation revealed low igg and igm and low nk cell activity. neutrophil respiratory burst was normal. he was started on ivig and gm-csf after which his nk cell function improved significantly. he remains clinically stable on ivig and gm-csf with persistent radiographic evidence of enlarged ventricles. conclusion: hypogammaglobulinemia is usually not associated with invasive cns fungal infections, suggesting that nk cell dysfunction was likely responsible for the clinical courses of these patients. nk cell deficiency has been reported to be associated with recurrent mucosal candidiasis, suggesting an important role for these cells in the control of some fungi. the spectrum of the clinical presentations of nk cell deficiency is not known since it is not normally included in immune system evaluations. these patients illustrate the importance of including functional nk cell assessment in any evaluation of immune function. introduction: to report a case of successful systemic hydrocortisone desensitization, since allergic reactions and systemic desensitization to corticosteroids have rarely been documented. method: we present a patient with multiple medical problems who has a history of both radiocontrast induced anaphylactoid reaction and corticosteroid allergy. this patient had to undergo cardiac catheterization and corticosteroid desensitization was performed prior to the procedure. results: skin testing to radiocontrast is not considered helpful, therefore patients with suspected reactions to radiocontrast are generally premedicated with corticosteroids and antihistamines to decrease the risk and severity of a reaction. , since this patient experienced an allergic reaction to a corticosteroid previously, she was skin tested to two different corticosteroids. the least reactive skin test revealed a + positive immediate reaction to hydrocortisone. cardiac catheterization with contrast was considered absolutely necessary in this case and corticosteroid desensitization was performed. the half-life of hydrocortisone is the shortest among the tested corticosteroids ( - minutes), so a protocol was developed with short intervals of escalating doses. each dose was diluted yielding a total volume of ml to avoid fluid overload because patient has renal failure. during desensitization, patient developed pruritus and erythema between the rd and th dose that resolved immediately with mg diphenhydramine. after desensitization, the patient continued to be on hydrocortisone mg intravenously every four hours. one hour prior to the procedure, the patient was premedicated with hydrocortisone and diphenhydramine and was administered radiocontrast without any adverse reactions. conclusion: we successfully desensitized our patient to a corticosteroid and premedicated her with hydrocortisone and diphenhydramine before administering radiocontrast. this case illustrates that intravenous desensitization may be a suitable approach to therapy in corticosteroid allergic patients who require systemic corticosteroids administration. autoimmune neutropenia is defined as a decrease in the absolute number of peripheral neutrophils caused by an immunologically-mediated mechanism. autoantibodies directed to neutrophils can lead to the peripheral destruction of neutrophils and/or inhibit myelopoesis in the bone marrow. although recurrent aphthous stomatitis is often the heralding sign of neutropenia, the diagnosis of ain requires the demonstration of specific antineutrophil antibody which acts by promoting the immune destruction and clearance of neutrophils by mononuclear phagocytes. the present case report describes the rare clinical association of ras in an adult. a yr-old black male presented with a year history of recurrent and repeated painful multiple oral ulcers. initially the oral ulcers occurred on a monthly basis then over time the ulcerations on the oral mucosa and tongue began to appear weekly and later continuously. past medical history revealed no drug allergies but a positive history of hypertension. physical exam revealed an otherwise healthy male with no lymphoadenopathy or splenomegaly. laboratory workup revealed : hiv negative, viral culture for h. simplex negative, mild increase in cd , cyroglobulins negative, anti dsdna negative anti-smith and rnp negative, wbc count /ml, neutrophils % (anc ), lymphocytes %, monocytes %, and platelets: , . bone marrow biopsy revealed a normal production of neutrophils. a direct neutrophil antibody assay: revealed an elevated value of , (n= < , ). although following initiation of prednisone ( mg) an immediate increase in anc was seen, the levels fell as the dosage was tapered. the figure below shows the time course and dose-response relationship of anc and prednisone dosage. this case report illustrates the importance of recognition of the relationship of ras and neutropenia, an association that can masquerade as other clinical entities. background: dyspnea, wheezing, and decreased fev are suggestive of asthma. it is essential for the clinician to consider a broad differential diag-nosis as the outcome could be catastrophic if the correct diagnosis is missed. case presentation: we present a case of a y.o. filipino female who was referred to our clinic for the evaluation of cough, shortness of breath, and wheezy respiration associated with changes in voice quality, nasal and palatal pruritus, and postnasal drainage. her initial evaluation revealed mold spore hypersensitivity by prick puncture testing and spirometry with an obstructive pattern with fvc- . l ( %) and fev - . l ( %) predicted and a % reversibility post nebulized albuterol. an initial diagnosis of allergic rhinitis with adult onset asthma was made and she was started on salmeterol, budesonide, montelukast, and pirbuterol. her symptoms persisted and rabeprazole was added to treat possible laryngopharyngeal reflux. repeat spirometry revealed fev - . l prompting treatment with systemic corticosteroids again with no improvement. fiberoptic laryngoscopy was within normal limits. a high resolution computed tomography was obtained and showed a mass in the left side of the trachea which was obstructing % of the airway. bronchoscopy revealed a tumor - cm below the vocal cords with the appearance of adenoid cystic carcinoma which was confirmed by pathology. the tumor was resected by removal of cm trachea with re-anastomosis, followed by a week course of radiation therapy. all medications were discontinued. her symptoms of wheezing, dyspnea, and cough completely resolved. repeat spirometry was within normal limits and she remained asymptomatic. surveillance bronchoscopies have been negative for any recurrence. discussion: adenoid cystic carcinoma (acc) is an uncommon form of malignant neoplasm that occurs within the salivary glands. tracheobronchial acc typically presents with symptoms of cough, dyspnea, and hoarseness. due to its slow growth, acc has a relatively indolent course. in a recent study of a cohort of acc patients, survival was % at years but only % at years. standard therapy is surgical resection often followed by radiotherapy. conclusion: in patients who fail conventional therapies for asthma it is important to entertain other diagnosis and have a systematic approach to establish the correct diagnosis. ipex is an extremely rare, hereditary condition characterized by immune dysfunction, polyendocrinopathy, enteropathy and x-linked recessive inheritance that leads to death without prompt diagnosis. patients usually present by months with severe diarrhea, failure to thrive, and early onset iddm. most children die by one year without a bone marrow transplant. immunologic evaluation is typically normal except for elevated ige, eosinophilia, and autoantibodies. we report a case of ipex in an infant who presented at birth and died at days of multi-organ system failure. this male infant was born at weeks due to chorioamnionitis and prom. at birth, copious green fluid appeared from his rectum and ng tube which evolved into a secretory diarrhea. workup for fistula was negative. at weeks, the patient developed ascites and explorative laparotomy revealed an inflamed appendix. after the laparotomy, the patient had no further stool output and never tolerated enteric feeds. he remained intubated and had problems with apnea and coagulapathy. pathology of the appendix showed an excess of lymphocytes. immune system investigation showed elevated ige ( ) and igg ( ). serum anti-enterocyte igg antibody was positive in the patient and negative in his mother. based on this data, ipex was suspected which autopsy seemed to confirm. autopsies are scarce in patients with ipex. the findings revealed many organs affected by fibrosis but lymphocyte infiltration of only the pancreas and gi tract. the pancreas revealed almost complete loss of the exocrine structure, with invasion of fibrosis and chronic inflammatory cells. the mucosa of the gi tract from the stomach to rectum showed columnar epithelium taken over by fibrosis, capillaries and chronic inflammation. these inflammatory cells were cd + lymphocytes and plasma cells on immunochemistry. the lymphoreticular system was consistent with lymphoid paucity in the thymus, lymph nodes and spleen. preliminary data suggests this patient has a splice mutation of the foxp gene. ipex is an extremely rare disease, often difficult to diagnose while a patient is alive. infants will present in early infancy with diarrhea and endocrinopathies. without prompt diagnosis, death is inevitable. as a result, one must be aware of atypical presentations and considered in patients with total villous atrophy and one other clinical feature such as iddm or autoimmunity. introduction: digeorge syndrome (dgs) is characterized by thymic hypoplasia, parathyroid hypoplasia, and conotruncal cardiac defects, but has a wide variety of clinical manifestations. there is also an increased risk for autoimmune phenomena in later life due to thymic hypoplasia. case report: a year-old aa girl with tetralogy of fallot (repair at age ), developmental delay, asthma, recurrent sinopulmonary infections/skin abscesses, gerd, arthralgias and seizure disorder (due to hypoxic encephalopathy during cardiac surgery) presented to allergy/immunology clinic for immune workup. there was no history of documented hypocalcemia. at age , she developed persistent annular patches on her left leg. a skin biopsy appeared consistent with sarcoid dermatitis. there was no other evidence of sarcoidosis except for slightly elevated ace level. given lack of systemic involvement, the skin lesions were not treated, but resolved spontaneously. at age , she developed swelling of the right mandible, and a bone biopsy revealed garre's osteomyelitis (sterile hyperproliferative osteomyelitis), likely triggered by dental caries, with elevated esr ( ) and polyclonal hypergammaglobulinemia (igg ), but normal crp. immune workup revealed a decrease in cd and cd cells (cd /cd ratio . ), slightly elevated b cells, high-normal range nk cells, normal range t cell cytokine production in response to mitogens and il- , but excessive production of proinflammatory cytokines in responses to lps. in conjunction with facial dysmorphism, dgs was suspected, and fish analysis revealed q . microdeletion. a repeat workup did not reveal evidence of systemic sarcoidosis, and autoantibody screening was negative including lupus anticoagulant. she was treated with a cox- inhibitor, secondary to gerd and mild thrombocytopenia, and her joint symptoms resolved with a concurrent decline in esr (to ) and igg level (to ) after months. conclusion: recurrent infections with fragmented care and resultant chronic inflammation (hence overstimulation of the immune system) may have led this dgs patient to develop atypical autoimmune phenomena and other unusual clinical manifestations. this case illustrates the importance of recognizing the phenotypic features of dgs early in life, and of providing close monitoring and coordinated care. rationale: we report a case of a patient with celiac disease who continues to have symptoms of fevers, nausea, vomiting, night sweats and fatigue despite being on a gluten free diet whose symptoms have been responsive to antihistamines. methods: case report. results: in , this year-old white male suffered from mononucleosis and episodes of prostatitis. he began suffering from fatigue and fevers and was followed at a chronic fatigue syndrome center in . in november , patient was placed on famvir alleviating his sore throat. he was later placed on interferon gamma which was discontinued due to increased fevers, nausea and vomiting. after stopping medication, symptoms abated for sometime. in , patient's father was diagnosed with celiac sprue. in april of , the patient developed a pruritic rash on his right arm. biopsy revealed subepidermal vesicles with pmn's at the tips of dermal papillae. in may of , he developed oral ulcers as well as joint pains. patient underwent endoscopy with biopsies revealing intraepithelial lymphocytosis in the duodenum. patient has been on a strict gluten free diet since october . he reports that some symptoms have improved: skin lesions, itchy eyes, and oral ulcers. however, he has begun to suffer from constipation and continues to intermittently have night sweats, fevers, nausea and vomiting. in february of , he had pruritus that was not alleviated by hydroxyzine. a regimen of benadryl and pepcid was started to aid with the pruritus. the patient reported in the improvement of his symptoms of pruritis, sweats, and emesis. conclusions: diagnosis: celiac disease(cd) patient with persistent nausea, vomiting, sporadic fevers, and fatigue despite maintaining a strict gluten free diet has shown improvement of symptoms with antihistamines. patient has history of chronic infections: prostatitis and chronic ebv. patient also reported alleviation of symptoms after interferon therapy suggesting some autoimmune component to his current illness. cd prevalence in the united states is much higher than once thought . - % of the u.s. celiac disease has been associated with increased risk of lymphoma and malabsorption leading to neurological diseases. this is a rare case of cd associated pruritus responding to antihistamines. rationale: eosinophilic cystitis is a relatively rare condition in children and adults with a varied course. it usually responds to short-term nsaid and steroid therapy. we report a man with a severe case who responded to prolonged oral steroids. case report: a year old caucasian man with a prior esophageal cancer s/p esophagectomy, diabetes, hypertension, allergic rhinitis and chronic obstructive pulmonary disease presented with suprapubic pain, urinary frequency, dysuria, and hematuria. urinalysis showed numerous red blood cells and bacteria but no malignant cells or eosinophils. he was treated with antibiotics with resolution of symptoms. several weeks later he experienced severe suprapubic pain and hematuria resulting in a symptomatic drop in his hemoglobin. he underwent a cystoscopy and biopsy that revealed a chronic cystitis with an inflammatory infiltrate containing numerous eosinophils. he was unresponsive to treatment with nsaid and intravesicular dmso and was then referred to our service. we started prednisone mg/day but the dysuria and hematuria persisted. prednisone was doubled plus a third generation quinolone was added. three weeks later the hematuria and dysuria resolved and he was asymptomatic. the antibiotic was stopped and prednisone was gradually tapered over several weeks. whenever his steroid dose dropped below mg/day he experienced an exacerbation of his symptoms. over the last three years this dose of prednisone has kept his symptoms abated and his renal function stable. conclusion: eosinophilic cystitis is an uncommon diagnosis of unknown etiology. we describe a patient with debilitating suprapubic pain and symptomatic anemia from the hematuria associated with eosinophilic cystitis. for over three years since we first saw him, continued therapy with mg of prednisone/day has prevented exacerbations. this case is unique in the severity of the hematuria experienced and the prolonged relatively low steroid dose needed to suppress exacerbations. we propose that in eosinophilic cystitis patients with severe hematuria who may otherwise be candidates for a cystectomy, a trial of prolonged oral prednisone may be beneficial. rationale: allergic reactions to insulin occurred more frequently in the past, with porcine and bovine preparations. in contrast, allergic reactions to human insulin preparations are now reported in < % of patients treated with insulin. insulin allergy may be manifested as an immediate-type ige-mediated reaction, delayed type hypersensitivity or as serum sickness, varying in severity from mild discomfort to life-threatening events. we present a case to illustrate that an insulin allergy may complicate hospitalization and often be misdiagnosed. methods: a y.o. diabetic female with a history of "insulin allergy" was evaluated. the patient is a long standing diabetic controlled on oral hypoglycemics but required insulin during acute illnesses and hospitalizations. the patient was unable to recall previous types of insulin she had received. during previous hospitalizations, the patient complained of vague symptoms of fatigue, parasthesia, sweating, anxiety, and palpitations. on one occasion the patient had a syncopal episode with hypotension and on another occasion the patient developed a rash and dyspnea after receiving sq insulin. the physcian intrepreted the findings may be due to hypoglycemic. an allergic reaction was not suspected and the patient never underwent any testing. during a recent hospitalization, the patient's history was reviewed and a formal allergy consult was obtained. she underwent epicutaneous and intradermal testing to human insulin preparations. insulin antibody levels were also obtained. results: the patient had negative epicutaneous testing to all human insulin preparations. however, on intradermal testing, the patient had positive reactions to lispro, nph, and lente and negative intradermal tests to insulin glargine and regular insulin. igg and ige insulin antibody test results were < . conclusion: hospitalized patients receiving multiple medications commonly experience pharmacologic, adverse and/or allergic reactions. it is necessary to obtain a thorough history and document all reactions that patients experience to determine what type of event occurred. with a suspicion of drug allergy, skin testing and/or rast assay may provide insight into possible ige mediated reactions. in this case we advised the patient that she may use regular insulin during hospitalizations and that insulin glargine can be used to help achieve optimal glycemic long term control. background: hereditary angioedema type iii (hae iii) is a recently described form of angioedema occurring exclusively in females and characterized by normal c , c inhibitor (c inh) protein and function. hae iii is thought to have an x-linked or autosomal dominant mode of inheritance. we evaluated a year old female with recurrent facial swelling, abdominal pain and laryngeal edema with a family history of similar symptoms in several female relatives. case report: a year old african american female presented with a two year history of recurrent lip, tongue and facial swelling. she also had abdominal pain, diarrhea and shortness of breath. episodes were not associated with hives. her symptoms predated menarche and did not correlate with her menstrual cycle. at the time of presentation she described an increase in frequency of her symptoms that did not respond to antihistamines (diphenhydramine, cetirizine) or prednisone. the patient had no other medical problems. family history was significant for recurrent episodes of facial, lip and tongue swelling in a maternal aunt, grandmother and great grandmother. the patient's great grandmother required tracheal intubation with ventilator support for upper airway compromise. the patient's physical exam was unremarkable. laboratory values drawn during an acute episode of swelling revealed: c inh function = > % (normal > %), c inh protein = mg/ml (normal - mg/ml), c = . mg/dl (normal - mg/dl). dna sequencing at exon to investigate the possibility of an unusual c inh mutation with normal c s binding but abnormal kallikrein inhibition was negative. other lab tests included a normal mast cell tryptase of . mcg/l, a negative rf and ana, a normal angiotensin converting enzyme of u/l (normal - u/l) and positive skin prick tests to a variety of foods which the patient tolerates. based on two case reports of treatment of hae iii with androgens, the patient was started on danazol mg daily with symptomatic improvement. conclusion: hae iii is a rare disease that affects females exclusively. clinically it is indistinguishable from c inh deficiency. the mechanism of inheritance remains to be elucidated. it is unclear why danazol appears to ameliorate symptoms even though there is no evidence for c annals of allergy, asthma & immunology inhibitor dysfunction in this disorder. we believe this to be the first kindred of hae iii reported in the united states. r. dworski * , m. peters, nashville, tn. a four-month-old female identical twin was evaluated for noisy breathing and recurrent cyanosis. she was delivered at weeks of an estimated gestational age after an uncomplicated pregnancy. at birth she was intubated for hours for respiratory distress but the remainder of her neonatal period was uneventful. at age weeks she developed a noisy breathing often associated with cyanosis, particularly in a supine position or while crying. treatments with inhaled albuterol and prednisolone were ineffective. she had no respiratory infections or symptoms of gastroesophageal reflux disease. her growth was normal. her twin sibling was well. the family history was negative for allergies or respiratory conditions. initially she was diagnosed with tracheomalacia. however, the history of cyanotic episodes prompted a search for a definitive diagnosis. she underwent bronchoscopy which showed tracheomalacia when breathing spontaneously and circumferential narrowing of lower trachea likely due to compression. echocardiogram revealed a double aortic arch. the finding was confirmed by computed tomography angiography which demonstrated the presence of a vascular ring composed of double patent aortic arches, each giving rise to the ipsilateral carotid and subclavian arteries. the airway was normal at the aortic inlet, but narrowed markedly at the level of the two arches. a surgical division of the ductus ligamentous and distal anterior vascular arch was performed. aortic arch abnormalities should be suspected in all infants with hoarse coughing or noisy breathing, especially during inspiration but sometimes also during expiration. the diagnosis should also be considered in older children with recurrent bronchitis or pneumonia. respiratory symptoms are more frequent than gastrointestinal manifestations. diagnosis usually occurs in the first year of life. a surgery is often the treatment of choice. postoperative complications are relatively rare. outcome of surgery should be judged after months, including at least one winter season. malacia can delay extubation and recovery following surgery. surgical cure occurs in approximately % of patients. surgery is probably less successful in children with double arches and malacia. a. thatayatikom * , a.j. white, st. louis, mo. background: common variable immunodeficiency (cvid) is the commonest symptomatic primary antibody deficiency syndrome in which b lymphocytes produce low levels of immunoglobulin, leading to recurrent bacterial infection. although hypogammaglobulinemia and susceptibility to the recurrent infection are seen in all patients, other associated conditions such as a non-infectious granulomatous disease have been well described in cvid. corticosteroid therapy has been used with improvement in a subset of cvid with granulomatous disease; however, its treatment remains problematic and a new therapeutic agent is needed. tumor necrosis factor (tnf ) has been demonstrated as a primary mediator in granuloma formation and maintenance. therefore, anti-tnf medications are potentially therapeutic agents of the granulomatous disease. case report: a -year-old caucasian male with cvid and severe granulomatous disease was treated successfully with infliximab, a chimeric anti-tnf monoclonal antibody. the patient initially presented with high fever, chills and abdominal pain; subsequently, he developed acute respiratory failure and adult respiratory distress syndrome. the patient was hospitalized and he required intensive care with ventilatory support. his diagnostic tests revealed elevated sedimentation rate and positive epstein-barr virus (ebv) capsid igm antibody. imaging studies demonstrated bilateral diffuse pulmonary infiltrates and hepatosplenomegaly. open lung and liver biop-sies revealed non-caseating granulomatous lesions without evidence of ebv or other infections. high dose corticosteroid therapy was given with partial improvement, then high dose infliximab ( mg/kg) was given weekly with remarkable improvement. the patient was able to wean off ventilator successfully within weeks and his prednisone dose was dramatically decreased. infliximab infusion ( mg/kg) every weeks and low dose prednisone were continued. a follow-up liver biopsy after months of the infliximab showed no granulomatous lesions. infliximab was discontinued after months of the treatment. there was no serious infection or complication during the period of treatment. conclusion: anti-tnf therapy may be a safe and effective treatment and may allow corticosteroid dose reduction. future clinical studies of anti-tnf therapy in cvid with granulomatous disease are warranted. background: chrug-strauss syndrome is a disorder characterized by hypereosinophilia and systemic vasculitis occurring in individuals with asthma. objetive: to present a pediatric case suffering from a systemic vasculitis. this case fulfilled the churg-strauss syndrome clinical criteria and the histophatology findings were compatible with the diagnosis. case: a year female came to our institution with the diagnosis of severe asthma, chronic sinusisits and polyps requiring high doses of steroids. there was no history of administration of antileukotriene receptor antagonists. months before her admission she presented weight loss, fatigue, cephalea and cough. on physical examination, pallor, respiratory difficulty and signs of bronchospasm were evident. tachycardia and hepatomegaly were also documented. the laboratory test showed anemia, eosinophilia /dl, anca+, sgot , stgop , ige elevated ui/ml. the chest-x ray showed patchy opacities in both lungs and cardiomegaly. pulmonary scintigraphy reported low perfusion in both lungs, predominantly in the left lung.echocardiography demonstrated signs of myocarditis and eyection fraction of %. an open lung biopsy was executed and vasculitis with fibrinoid changes affecting small and medium vessels was reported. treatment was started with oral prednisone mg/kg/d and cyclophosphamide pulses with a satisfactory evolution. discussion: to our knowledge this is the first pediatric case of css reported in mexico. she fulilled the following criteria. asthma, eosinophilia and systemic vasculitis involving the heart, liver and lungs. the disease is extremely rare, specially in mexico. aggressive treatment is necessary as in this case, with a favorable outcome. introduction "all that wheezes is not asthma" is a well-known aphorism among physicians. this same principle exists for patients that present with lip swelling in the allergist's office. we describe a patient who presented with fluctuating lip swelling who was ultimately found to have cheilitis granulomatosa. case history a -year-old male with a history of allergic rhinitis and asthma presented to the allergy clinic with lower lip swelling and occasional upper lip swelling. he was receiving allergen immunotherapy for dust mites and trees. the swelling had been waxing and waning for years, but became more persistent for the previous six months. he denied tongue/throat swelling, dysphagia, respiratory distress, or any triggers for the swelling. chapstick® and vaseline® were used topically on his lips. failed treatments included loratadine, ranitidine, cetirizine, fexofenadine, and montelukast. he was placed on a one-week course of prednisone, which decreased his lip swelling, but it recurred after completion of the treatment. physical exam was significant for diffuse, firm lower lip edema to - times the normal size. there were no oral lesions or tongue swelling. patch testing to a standard panel, preservatives, oral flavors, and dental acrylate was negative. punch biopsy revealed a noncaseating epithelioid granulomatous inflammation consistent with granulomatous cheilitis. he was placed on minocycline mg by mouth twice daily with little benefit. an -week course of oral prednisone resulted in improvement of the lip swelling. conclusion melkersson-rosenthal syndrome (mrs) is a rare syndrome that is characterized by a triad of recurrent facial paralysis, chronic edema of the face and lips, and hypertrophy and fissuring of the tongue. cheilitis granulomatosa is considered a monosymptomatic form of mrs and manifests as a chronic swelling of the lips caused by granulomatous inflammation. the swelling is typically not tender and may be either soft or firm. allergists are often consulted for lip swelling thought due to angioedema. however, as this case illustrates, not all lip swelling is angioedema and one must consider other diagnoses such as melkersson-rosenthal syndrome and cheilitis granulomatosa. progressive multifocal leukoencephalopathy (pml) is a disorder of the nervous system that affects individuals with immune suppression. it has been associated with hiv infection and is present in nearly % of patients with acquired immune deficiency syndrome. the jc virus, a common human polyomavirus, causes this demyelinating disorder. progressive symptoms reflect the multifocal distribution of brain lesions, and include mental deterioration, vision loss, speech disturbances, ataxia, paralysis, and, ultimately, coma. in rare cases, seizures may occur. there is no known treatment for pml. we report a year-old (y/o) male with months weight loss and a sudden onset of confusion, lethargy, and progressive loss of cognition requiring hospitalization. upon questioning he was found to have had recurrent upper respiratory tract infections since infancy successfully treated with antibiotics. as a child he had atopic dermatitis, exercise induced asthma, and myringotomy tubes placed twice. at y/o, he underwent a nasal polypectomy. in , at y/o, a squamous cell carcinoma was removed, and he developed benign cervical lymphadenopathy and common warts. a year later he developed hsv esophagitis. the remainder of his history was unremarkable with normal development and growth and no history of drug abuse, multiple sexual partners, or homosexual contacts. on physical examination, he was thin, ill appearing, with oral ulcers, generalized scanty lymphoadenopathy, multiple common warts on both feet, and occasional ronchi. a brain mri showed a demyelinating process consistent with pml. pcr for jc virus was positive, while hiv pcr was negative; total immunoglobulins and cd counts were low ( we are reporting a year old female with a year history of moderate persistent asthma, who was started on xolair mg sq q wks., and who then presented with a presumed allergic reaction. three hours after her second xolair injection, patient reported developing dizziness, shortness of breath, and felt like she was having an allergic reaction. she was evaluated and observed for two hours in an emergency department. the treating physician reported no wheezing and felt there was no need for treatment. to rule out psychogenic factors, she was given a placebo injection at the next scheduled visit. ten minutes later she reported developing throat tightness and shortness of breath. she had no changes in her peak flows and her lungs were clear. her "symptoms" resolved completely within minutes of receiving placebo epinephrine and nebulized normal saline. patient was informed she had reacted to a placebo injection, as well as placebo epinephrine and albuterol, and counseled. the patient returned to the office every week for the next three weeks to receive blinded injections. she subsequently did not react to either doses of placebo or xolair. she has since tolerated her monthly xolair injections without incident. this case illustrates the importance of ruling out psychologic causes of presumed allergic reactions. introduction :latex allergy, type i ige mediated hipersensitivity, occurs specially in high risk populations, like in patients that have undergone various surgeries. case: a year old boy with asthma and allergic rhinitis since , penicillin allergy and retrospectively, his mother refers lip edema with balloon inflating.at years of age ( ): left orchiorrhaphy because of cryptorchis. between - : surgeries because of sacral giant melanocitic naevus.during the fourth surgical intervention ( ct - ) to collocate a tissue expander, the patient presents perioral and fingertip cyanosis, generalized cutaneous rash and severe bronchospasm.ap: / mmhg, hr x/min. he was treated with iv fluids, steroids, antihistamines and inhaled racemic epinephrine.at the icu his final outcome is satisfactory. laboratory: total ige : . iu/l, skin prick test with glove extract, raw and natural latex extract and purified latex proteins(pseudoeveine, molecular hevein, hev b . and modified hevein)all positive +++. western blot with protein extract of latex positive and elisa with purified latex proteins ( same as above) positive. the last surgery to withdraw the tissue expander was performed with latex free surgical equipment without any problems. discussion: the patient's risk factors for latex allergy are atopy and repetitive exposure to latex articles because of surgery. he presents mild manifestations of latex allergy, till he finally develops full-blown anaphylaxis. diagnosis was made based on clinical history, skin prick test, western blot with protein extract and elisa with purified latex protein. he had a favorable outcome withdrawing latex during the last surgery. introduction: churg-strauss syndrome (css) is a form of primary vasculitis that is a rare diagnosis in an elderly patient. case report: a year old woman presented with a week history of fatigue, vomiting, diarrhea, abdom-inal pain, and right lower leg paresthesia. prior to admission she was being treated for left neck erythema and adenopathy presumed to be cellulitis. she was in good health with no history of atopy until the age of , when she developed both chronic sinusitis, requiring bilateral sinus surgery and polypectomy, * and new onset asthma, * that required systemic steroid control. prednisone was tapered month prior to admission. objective findings included coalescent non-blanching petechiae on her abdomen, peripheral eosinophilia of ( %), * normochromic normocytic anemia, rf= , esr= , ige= , igg= . ana, p and c-anca were negative. ct showed ascites and pleural effusions. egd revealed duodenitis with ulceration and eosinophilic infiltration on biopsy. echo showed pericardial effusion and septal motion abnormality. troponin of without cad was consistent with subepicardial myocarditis. emg confirmed right peroneal neuropathy.* skin biopsy revealed a dense superficial and mid-dermal perivascular and interstitial eosinophilic infiltrate. additional evaluation excluded malignancy, infection, and abpa. treatment with prednisone, mg/kg/day was initiated. a rapid clinical improvement ensued and has persisted. {*acr criteria for css}. discussion: churg-strauss syndrome is a rare form of vasculitis with mean age of onset within the third and fifth decades. it is an uncommon cause (< %) of systemic vasculitis in patients older than . the formes frustes of css is a variant in which early manifestations of the syndrome are hidden by oral and systemic steroids employed in the treatment of worsening asthma often associated with css. this variant makes expedient identification of css more challenging. delayed recognition contributes to a relentless progression of this entity resulting in a systemic vasculitis with multi-organ involvement. early diagnosis, especially in the prodromal and eosinophilic phases, is essential. untreated, css has a high rate of morbidity and mortality. therefore, css and the formes frustes variant must be an integral component in the differential diagnosis of patients presenting with adult onset asthma and/or recurrent sinusitis. common variable immunodeficiency (cvid) is the most prevalent of the primary immunodeficiency diseases. cvid is a heterogeneous group of immunologic disorders of unknown etiology, characterized by impaired antibody responses, hypogammaglobulinemia with normal b cells. the common immunologic defect in patients with cvid is defective antibody formation, and many different immune system defects have been reported in this group of patients. most patients, really, have no identified molecular diagnosis. cvid consists of several different genetics defect. the immunologic defect in cvid is a failure of b-lymphocyte differentiation into plasmacells. b lymphocytes from these patients failed to differentiate into ig-producing cells when stimulated with pokeweed mitogen in vitro, even when cocultured with normal t cells. an overwhelming body of literature suggests that most patients with cvid have intact b lymphocytes of immature phenotype. however the functional classification of cvid patients on the basis of in vitro ig production is time consuming. recently has been proposed a new classification based on the quantitative repartition of memory b cell according to the dual expression of igd and cd . we present a case of a yr old boy. he presented soon in his life frequent infections, of particular severity: pneumonia, meningoencefalitis, sepsis, bronchitis, otitis, linfoadenitis. he also had a -thalassemia intermedia. this clinical manifestations suggested an immunodeficiency. for this reason at years of age serum immunoglobulin and antibody detection showed a reduction in igg subclass and in cd + cells, with normal total igg, iga, igm, normal cd /cd ratio, normal cd , isohemagglutinins and in vitro t cell function. there was also a defective antibody production after tetanus, diphtheria, pertussis immunization. these laboratory findings did not allow, however, a sure diagnosis for cvid. a new immunological evaluation at the age of years old, after the onset of splenomegaly, and enlarged lymph nodes, demonstrated a b memory defect, with a severe deficit of t lymphocytes function in vitro. it was also possible to find a severe deficiency of cd + cells, meaning a defect in memory b cells: we can therfore label this condition as a cvid. in the past two decades there have been conflicting views regarding the clinical importance of igg subclass deficiencies in children. igg subclass plays a vital role in the immune response to polysaccharide antigen. isolated igg subclass deficiency may be widespread and often asymptomatic in children. however, in association with other subclasses and/or other immunoglobulin classes, there may be a significant, symptomatic outcome. the reported patient was diagnosed with familial dysautonomia (fd) at the age of five weeks, presenting with severe hypotonia and tachypnea. hindered by poor pulmonary function, he was hospitalized over fifteen times for recurrent pneumonias, including four lengthy intensive care admissions. daily inhaled-corticosteroids and brochodilator therapies were initiated, along with chest therapy via a high frequency chest wall oscillator. immunoglobulin levels were measured recently and point to low levels of igg , igg and total iga antibodies: igg mg/dl (n - ), igg mg/dl (n - ), igg . mg/dl (n . - . ), igg < . mg/dl (n . - . ), and total iga mg/dl (n - ). since receiving monthly ivig therapy he had no further recurrence of pulmonary infections and was slowly weaned off daily brochodilator therapy. the currently accepted theory is that low igg subclass levels may be associated with increased risk of bacterial infections only in selective groups. fd patients may be in a distinctively susceptible population in which igg levels are critical. the older brother, who was also diagnosed with fd, demonstrated igg , igg and iga levels that were slightly higher but nevertheless on the lower end of the normal range. he suffers from less invasive and less frequent bacterial infections. this may support a genetic association between the fd and hypogammaglobulinemia. alternatively, it may signal that fd patients may have a prolonged variant of transient hypogammaglobulinemia of infancy. follow-up immune profile studies, post-ivig trough levels and broader investigations of the fd population are necessary to determine the severity and prevalence of these findings. pulmonary failure is the dominant cause of death in patients with fd. prompt diagnosis and effective treatment of the associated immune deficiency may be proven essential in the effort to enhance and prolong their lives. s. hassan * , j.a. grant, galveston, tx. rationale: common variable immunodeficiency (cvid), a rare primary immunodeficiency presenting in young adults with repeated sinopulmonary infections as a result of profound hypogammaglobulinemia, was first described by suri et al. (ann acad. med. singapore, ) . we describe a young man with diagnosed but untreated cvid and its eventual course. case description: a -yr-old caucasian male hospitalized secondary to chronic pneumonia and respiratory failure was noted to have non-existent levels of immunoglobulins. history revealed ivig treatment at age , stopped after a year due to non-compliance. although untreated, he denied recurrent sinusitis, otitis media, or bronchitis for almost years but notes a recent inability in keeping up with baseball practice. he is the last of ten healthy siblings. patient started monthly ivig infusions but was noted to have hypertension ( / ), tachycardia ( - ), tachypnea ( - ) on the th month with o saturation of - % and po of % on room air. with a -day history of acute dyspnea, calf muscle and right abdominal pain, he was admitted to the hospital and pulmonary thromboembolism was ruled out. laboratory data: humoral functions (pneumococcal, tetanus toxoid, and hepvac) -undetectable t cell function (mumps, candida, ppd) -normal immunoglobulin (igg, iga, igm) -undetectable flow cytometry -b and nk cell markers normal, mild decrease in the cd /cd ratio high resolution ct thorax -bronchiectasis, bronchial wall thickening, and obstructive changes with airtrapping. minute walk -desaturation to % on l o by nc bnp - echocardiogramestimated ef - %; severe pulmonary hypertension. cardiac catheterization -normal coronary arteries, severe pulmonary hypertension (pa pressure / ). conclusion: cvid patients have a reasonably good prognosis on treatment. untreated cvid is associated with chronic lung infections, bronchiectasis, pulmonary hypertension and right heart failure. although, lung transplant became available during the early eighties (nejm ), this extremely invasive but life saving procedure was undertaken in a patient with cvid and end-stage pulmonary hypertension in (thorax ). lung transplant may be the only way of ensuring survival for this patient. introduction chronic eosinophilic pneumonia (cep) is a rare disorder of unknown etiology characterized as a chronic and relapsing interstitial lung disease with blood or tissue eosinophilia. cep occurs more often in women with preexisting atopic disease. patients with cep respond rapidly to systemic corticosteroids, but often relapse with short, low-dose courses of therapy. while uncommon, extrapulmonary involvement, such as arthralgia, cutaneous purpura, pericarditis, and hepatitis, have been reported. we present a case of a patient who has cep with pericardial effusion. case report the patient is a non-smoking -year-old woman with a past medical history significant for allergic rhinitis and asthma who initially presented with a four-month history of worsening shortness of breath, dyspnea on exertion, dry, non-productive cough, and weight loss (approximately five pounds). her symptoms were refractory to increased dosages of inhaled fluticasone. she then developed intermittent fever up to °c. chest x-ray revealed bilateral apical infiltrates. treatment with levofloxacin for seven days resulted in no improvement of symptoms or roentographic findings. thereafter, she presented with chest and abdominal pain, hypotension, and hypoxia. blood work revealed a white cell count of c/mm with a differential significant for % eosinophilia (absolute eosinophil count of c/mm ). chest ct showed dense consolidation predominantly along the peripheral aspect of the upper and superior segment of the lower lobes, and pericardial effusion. moderate pericardial effusion without evidence of tamponade was confirmed on echocardiogram. left upper lobe wedge biopsy findings included significant tissue eosinophilia, scattered foci of active organizing exudates, and no evidence of granulomatous or necrotizing vasculitis. the patient was treated for cep with a six-month course of prednisone, starting at mg daily, resulting in rapid improvement of her pulmonary and systemic symptoms. background: immunologists are consulted for evaluation of immunodeficiency in patients with recurrent skin infections. disorders of the phagocyte system may be associated with cutaneous infections. methods: case report case: a -month-old african american girl (twin a) presents with recurrent skin abscesses. at months of age, she had her first buttocks abscess, which required incision and drainage with oral antibiotics. a month later, she developed another abscess and was found to be neutropenic, with an absolute neutrophil count (anc) of /μl. cyclic neutropenia was considered and her pediatrician monitored cbcs, which all showed persistent neutropenia (ancs between and ). at months of age, she was hospitalized for fever with neutropenia. immunology was consulted for evaluation of neutropenia. the rest of the past medical history was unremarkable. she was healthy appearing and growth parameters were appropriate for age. her physical examination was unremarkable. immunoglobulins, b-and t-cell markers, nitroblue tetrazolium, complement assay, hemoglobin, platelets and the peripheral smear were normal. antibodies for hiv, cmv, ebv and parvovirus were undetectable. anti-neutrophil antibodies were positive, establishing the diagnosis of primary autoimmune neutropenia (ain). the abscess healed with oral antibiotics. severe neutropenia (anc - ) persisted for three subsequent months without further infections. twin (b) was also found to have persistent severe neutropenia without morbidities, suggestive of primary ain. primary ain is less known among physicians and is typically diagnosed after extensive investigations that exclude other causes of neutropenia. the exact incidence of ain is unknown. it is usually seen in children between and months of age, often with severe neutropenia and self-limiting bacterial infections. the clinical course and presence of antibodies to neutrophil antigens (na , na or cd b/ ) is diagnostic. familial occurrence of primary ain is not reported in the literature. conclusion: primary ain may remain under diagnosed due to lack of characteristic clinical features. although a benign clinical course is likely, severe infections, including pneumonia, sepsis and meningitis, have been reported. genetics may play a role in this disease, as we present primary ain in twins. background: atopic dermatitis (ad) is a chronic inflamatory disease of skin that affects % of the wordl population.the natural history of ad in some patients, evolve to the coexistence with other allergic diseases: allergic rhinitis, allergic conjunctivitis and asthma. the sublingual immunotherapy has demonstrated utility in some patients; however, semi-rush immunotherapy to pollens has only showed utility in one animal case published few years ago. case report: a -year-old infant was referred to us. he began one year before with skin lesions compatible with ad, six months later began perennial rinhorrea and nasal itching. multiple treatments with topic corticosteroids, moisturizing, antihistamines and topic/systemic antibiotics did not demonstrate utility. our evaluation revealed ad lessions that affected % of the total body surface and clinical features of allergic rhinitis (ar).the lab tests revealed eosinophylia ( cell/mm ) in blood cell count, normal levels of total ige but specific ige to dermatophagoides pteronissinus (dpt) was high. the skin prick test reveales the same results. we added environmental control, oral costicosteroids and transfer factor. despite our treatment no improvement was observed. we considered dpt as the principal factor in the maintenance of ad lessions and ar episodes. in the absence of sublingual immunotherapy in our hospital, we decided for semi-rush immunotherapy schedule. we began from . ml of : , w/v concentrations of dpt until , ml of : w/v concentrations in two months receiving three doses per week. no local or systemic adverse events was reported and the ad lesions and ar symptomatology disappeared in the first month of treatment. at this time, no exacerbations have been documented. conclusion: the semi-rush immunotherapy can be useful and safe for treatmente of ad in some patients in whom specific ige to aeroallergens has been demonstrated. introduction: eosinophilic gastrointestinal disorders are a rare group of disorders that can involve the entire gastrointestinal tract. presentations are varied but may include vomiting, dysphagia, abdominal pain, diarrhea and failure to thrive. the diagnosis is made by endoscopic biopsies which reveals eosinophil rich inflammation in the absence of known causes for eosinophilia. peripheral eosinophils and ige may be elevated but can be normal. we report a patient with eosinophilic gastroenteritis associated with an ampullary tubulovillous adnenoma. methods:a -year-old white male with allergic rhinitis and a family history of atopy was admitted for profuse watery diarrhea. he denied any new medications, eating raw foods or recent travels. eosinophils were elevated to . ( % of wbc) and ige was elevated to . multiple stool specimens were negative for ova & parasites and enteric pathogens. serology was negative for strongyloides, trichinella, e. histolytica and toxocara. ast, alt & bilirubin were elevated and a ct scan showed dilated billiary ducts with a possible ampullary mass. biopsy of the ampullary mass revealed a tubulovillous adenoma. biopsies of the duodenum, terminal ileum, colon and rectum were remarkable for focal eosinophilic cryptitis & chronic inflammation in the lamina propria consisting of eosinophils, scattered lymphocytes and histiocytes. all specimens were negative for parasitic infections including duodenal aspirates. he was empirically started on metronidazole and singulair with gradual improvement of symptoms, eosinophils and liver tests. two months after discharge, the patient remained diarrhea free with a normal eosinophil count. conclusion: we report a patient with eosinophilic gastroenteritis and an ampullary tubulovillous adenoma with obstruction of the biliary system. this unique presentation illustrates the diverse nature of gastrointestinal manifestations seen in eosinophilic gastroenteritis. background: zonisamide is an anti-seizure medication chemically classified as a sulfonamide and unrelated to other ant seizure agents. we report a case of hypersensitivity to this agent in a child. method: case report results: this patient is a -month-old girl who developed "peeling of her lips" three weeks after starting zonisamide. one week later she developed a rash that began on her face and generalized over several days to her neck, trunk and extremities. there was no respiratory distress, joint complaints and no angioedema associated with the episode, but fever to prompted referral to our hospital on day of the rash. the rash was macular-papular without discrete urticarial lesions. the rash coalesced with underlying erythema on face, chest and neck. the patient has a known history of seizure disorder, asthma, mild eczema, gastro esophageal reflux, development delay, lactose intolerance and failure to thrive. her other medications were, lansoprazole, topiramate, and albuterol. labs revealed a normal white cell count, an elevated sed rate ( ) and elevated lft's, i.e. sgot and sgpt . the only new medication was zonisamide that was discontinued. she was treated with iv steroids and hydroxyzine. the rash started fading by day and the patient's fever resolved by the third hospital day. liver enzymes returned to normal by day . conclusion: this relatively new anti-seizure agent can be associated with hypersensitivity reactions in children. introduction: kawasaki disease (kd) is an acute chilhood vasculitis. in addition to the diagnostic criteria a broad range of nonspecific clinical features may be observed including aseptic meningitis, vomiting, diarrhea, abdominal pain, sterile pyuria, arthralgia and arthrtis, pulmonary infiltration, pleural effusion and nonspecific paralytic ileum as manifestation of gastrointestinal vasculitis. we describe a child who developed all features of kawasaki disease included the most rarely reported. patient report: a year-old female presented days of high fever, nonsuppurative cervical lymphadenopathy, petequial rash in legs, swelling of feet, distended abdomen, vomiting, obnubilated and hypoactive, incongruent speech, fisured lips and distended abdomen. lab tests showed: anemia ( . g/dl), high wbc count ( , cells/mm ), thrombocytopenia ( , /mm ), hypoalbuminemia ( . g/dl), lactate dehydrogenase (ldh) mcg/l, glutamin transferase (ggt) . csf total proteins , glucose , cells , pm %, mn %, seric complement , cultures were negatives. she developed myocarditis, aneurysms in the right and left coronary arteries. on the th day presented cardiac failure, pleural effusion, paralytic ileum, hydrops vesicular, mechanic ventilatory assistance was required. the first dose of intravenous immunoglobulin (ivig) ( g/k) was infused, heparin and hydrocortisone. on day a second doses of ivig was infused, because of fever, and abdominal vasculitis. steroids ware discontinued, heparin was suspended and aspirin was added as antiaggregant. discussion: our patient presented an unusual and severe presentation of kd with pleural effusion, nonspecific ileum, cardiac failure secondary to myocarditis, aseptic meningitis and thrombocytopenia; all those manifestations had rarely been reported at the same time. she presented with a devastating evolution. complications were resolved. the lastest studies have shown that treatment with ivig plus corticosteroids significantly reduce serum concentrations of proinflamatory cytokines. in this case antiinflamatory doses of aspirin were contraindicated and steroids were used with satisfactory outcome. limited data is available for nonresponding patients to guide therapy. although multiple doses of ivig are sufficient in some patients, some of them remain refractory to therapy and they need corticosteroids to control the vasculitis process eosinophilia is defined by an absolute eosinophil count above . x and can be seen in association with a broad spectrum of disorders ranging from allergic to malignant. idiopathic hypereosinophilic syndrome (hes) should be considered in any patient with an eosinophil count above . x for more than months without commonly recognized causes of eosinophilia and with evidence for organ damage not otherwise explained in the clinical setting. it is potentially an aggressive disease with mean survival of less than a year without treatment. we present a year old male horse breeder, with eosinophilia lasting more than years. prior to coming to our institution, he underwent extensive medical evaluation including bone marrow and gi biopsies, multiple imaging studies with mri and ct scans of the chest and the head as well as detailed evaluation of his cardiac status. all these tests were normal and the patient was empirically started on treatment for possible hes including trials of prednisone, hydroxyurea, interferon alfa, and imatinib, all without lasting resolution of his eosinophilia and causing significant side effects with profound depression of his immune status. finally, in light of the patient's profession, a strongyloides enzyme immunoassay was done and found to be remarkably positive. duodenal drainage confirmed the infestation with this nematode. within a week of starting treatment with ivermectin, his eosinophil count came down by % and eventually normalized. we learn that one should be persistent in excluding all common causes of eosinophilia before considering hes. in case of parasite infestation, premature treatment with immunosuppressors can result in worsening of the infection with potential for poor and even fatal outcome. stool evaluation might not be sensitive enough for detection of parasites and it is therefore necessary to complete a diagnostic work up with appropriate serology. doxil is the pegylated liposomal form of doxorubicin and has been used successfully as a cancer chemotherapy agent in many types of tumors. a hypersensitivity reaction can occur, usually during the first infusion, and appears to be rate related. the symptoms include dyspnea, tachypnea, facial swelling, chills, hives, chest pain, and back pain. we report a case of a hypersensitivity reaction to doxil in a year-old woman with hodgkin's lymphoma. during her first outpatient doxil infusion at mg/min, she developed urticaria, chest tightness, dyspnea, and back pain. these reactions persisted despite being medicated with antihistamines and steroids and immediately resolved during pauses in the infusion. after mg of doxil, the infusion was discontinued. six days later, she was admitted to complete the other half of the dose. she had a negative intradermal skin test to a : dilution of doxil. she was then premedicated with diphenydramine, dexamethasone, acetaminophen, and famotidine. the doxil infusion was started at . mg/min and was soon stopped due to flushing of the hands and face. the infusion was decreased to . mg/min. she was able to tolerate this slow infusion with only mild and tolerable symptoms. when her symptoms worsened, the infusion was stopped for to minutes. she completed the mg infusion of doxil after hours. pre-infusion and post-infusion complement levels were drawn during this second administration of doxil. her pre-infusion c , c , c a, c , c , c a, and bb levels were all normal. her pre-infusion c a and sc b- levels were high, indicating that she might have had some residual or persistent complement activation caused by her first doxil infusion. her post-infusion c , c , c a, c , c , c a, and bb levels were all normal. however, her post-infusion sc b- levels significantly increased, suggesting complement was activated during the second doxil infusion. given her reaction during her first doxil infusion and a negative skin test to doxil, it is highly unlikely that her doxil hypersensitivity was an ige-mediated process. therefore, in patients with a similar doxil hypersensitivity, we suggest a slow rate of infusion of . - . mg/min, toleration of mild symptoms, to minute pauses during more severe symptoms, and continuation of premedication during the entire lengthy infusion. introduction eosiniphilic esophagitis (ee) is an isolated, severe esophageal eosinophilia. patients are usually young males presenting with vomiting, epigastric or chest pain, dysphagia and obstructive respiratory problems. they are often initially misdiagnosed with and treated for gastroesophageal reflux disease (gerd). distinction between the two diseases can be made with biopsies of the esophageal mucosa. while any eosinophils in the esophageal mucosa indicate pathology, gerd typically presents with up to eosinophils per high powered field (hpf, x) while ee most often presents with greater than - eosinophils per hpf. case report the patient is a and one half year old boy who has experienced severe symptoms of gerd from the age of months. he vomits after meals at least - times per day. he coughs when he lies down at night and regurgitates phlegm in the early morning. he has complained of discomfort in his lower chest after eating. his weight has remained at pounds for the last six months. the patient was diagnosed with asthma at age and a half; however, there is no family history of asthma or allergies. the patient initially experienced improvement on lansoprazole, but his symptoms recurred when the medication was discontinued and subsequent courses were ineffective. his physical exam was normal barring slightly edematous nasal turbinates. an endoscopic biopsy showed "numerous eosinphils" (later clarified to eosinophils per hpf) in his distal esophagus. the patient showed allergy to milk and wheat on radioallergosorbent (rast) testing. the patient was started on swallowed fluticasone puffs twice daily and advised to see a nutritionist regarding a wheat and milk elimination diet. conclusion ee is an important differential of gerd-like symptoms in childhood. to avoid misdiagnosis it is critical to evaluate the number of eosinophils present in a biopsy specimen to help differentiate between gerd and ee. children with ee are at increased risk of developing esophageal dysmotility and esophageal strictures. patients often have positive skin prick or rast tests to foods and aeroallergens. alternative treatments such as food elimination diets and glucocorticoids (systemic or topical) are effective in treating symptoms which may not respond to reflux medications. introduction in asherton introduced the term catastrophic antiphospholipid syndrome (caps) to describe patients sharing clinical evidence of multiple (three or more) organ involvement and/or histopathological evidence of multiple vessel occlusions. case report we present a year old female, with lumbar pain, arthralgias, weight loss, fever, malaise, raynaud phenomenom, alopecia, oral ulcers and hepatomegaly. on arrival, she was polypneic with tachycardia, basal hypoventilation, and hepatomegaly was evident. hb: . , leucocytes: . , total lymphocyctes: , , total neutrophyles: , , platelets , . coombs positive. urin exam: proteinuria, leucocyturia and erythrocyturia. creatinine . . diagnosed as sle with pericarditis, cardiac failure and acute pulmonary edema, urinary tract infection and pneumonia, requiring mechanical ventilation and inotropic support, intravenous gammaglobulin and hydrocortisone. acute renal failure and hemodialysis was begun with improvement. suddenly she presented seizures crisis, stuporous, livido reticularis skin and acrocyanosis, external opthamalplexia, bilateral facial diplexia, ocular fundus with arteriolar vasospasm. right facio-corporal hemiparesia, cortical and progressive medular annals of allergy, asthma & immunology segment changes. ct showed multiple left fronto-occipital parietal hypodensities suggestive of lacunar infarcts. diagnosed as neurolupus and caps. initially anti b glp and anti clp were negative with later positivization. urinary tract infection contraindicated high doses of steroids and, intravenous gamaglobulin and anticoagulation were started. with significant improvement. currently the patient is evolving in a satisfactory way. discussion the literature establishes that catastrophic aps is characterized by elevated mortality. in this patient damage was evident to the cns, pns, kidneys and the skin. with the presence of positive antiphospholipid antibodies with an energic antiinflamatory, immunoregulatory and immunosupressive therapy, the function of each affected organ completely recovered. this case exemplifies that the therapy of caps should be undertaken in a sufficient and early manner given the elevated mortality of this syndrome. patient, a -year-old white, male non-smoker physician on high-dose regimen of advair and singulair presents with an -day history of progressive chest tightness. pulmonary function tests showed normal (fev of %) lung function. in the past, whenever inhaled steroid dosages were lowered, patient experienced a reoccurrence of asthma symptoms, despite consistently normal lung function results. to rule out the possibility of a psychologically induced asthma exacerbation, the patient's fractional concentration of exhaled nitric oxide (feno) levels were measured. the patient's feno level was elevated at . ppb. values greater than ppb have been described as consistent with airway inflammation. with an increase in the patient's inhaled steroids, the patient had a remission of symptoms within a week. this case is illustrative of an increasingly common clinical picture where a symptomatic asthmatic may have normal spirometry but elevated feno. as devices for measuring feno become more available in the outpatient clinic setting, elevated feno may be an excellent diagnostic marker in assessing whether airway inflammation is being adequately treated in situations where spirometry values are within normal ranges. introduction the autoimmune thrombocytopenic purpura (atp) is characterized by thrombocytopenia and megakaryocytic hyperplasia. the first choice of treatment consists of intravenous gamma globulin (ivig), corticosteroids and anti-d antibodies and the second line measures are immunosuppressant drugs, splenectomy and danazol. case report a years old male presented in the first year of life ecchymosis in several parts of the body intermittently. in april he presented ephistaxis and lower gastrointestinal bleeding. complete blood count showed platelet count of , /ul. prednisone was started ( mg/kg) with no improvement. at that time, danazol, anti-d antibodies, and ivig ( g/kg) were added. subsequently, the platelet average count diminished to , . the patient was transferred to our hospital. at his admission he presented cushingoid habitus (figure ) and acanthosis nigricans. the immunological tests (aan, ch , c , c , immunoglobulins, anticardiolipins and b glycoprotein) showed no alterations. bone marrow aspirate demonstrated megakaryocytic hypercellurarity. prednisone dose was tampered when the patient presented secondary glaucoma. patient continued his treatment with danazol and ivig ( dosages of g/kg each), hydroxychloroquine and cyclophosphamide with no improvement. thus, months after the immunosuppressant treatment, splenectomy was performed, obtaining partial improvement. at that time ranitidine and hydroxychloroquine were suspended and cyclophosphamide was changed to azathioprine. last platelet count was , /ul. conclusion chronic atp in childhood as the present case account for approximately - % of the total atp patients. chronic atp that does not respond to conventional treatment is a therapeutic challenge. in this patient we used first choice and second choice drugs with no improvement, consequently a splenectomy was indicated, not obtaining the desired response at first. the use of immunosuppressant drugs is not common for this disease, but it could be a good alternative for atp resistant to conventional treatment. this are the most important laboratory test of our patient. background: budesonide is the only corticosteroid available for inhalation by jet nebulizer and is indicated for the treatment of asthma in children. objective: to evaluate the distribution and clinical efficacy of inhaled budesonide administered by nebulization with a modified commercial device. methods: a year old male with severe persistent asthma underwent a lefort procedure for multiple craniofacial abnormalities. the external device maintained his mouth open impeding the proper use of controller medications. as a result he developed an increase in his asthma symptoms. he was subsequently treated with nebulized budesonide delivered with a modified jet nebulizer through the end of a plastic tube in a flow-by manner. we then performed dynamic ventilation imaging after administering . mci of nebulized technetium m-dtpa diluted in two ml of normal saline. images were obtained for five minutes at three seconds per frame. spirometry monitoring was not possible given the obstructive nature of the facial device. results: the patient demonstrated improvement of his asthma symptoms. the ventilation scan showed that the patient breathed the technetium dtpa through the specialized device with delivery to his full lung volumes within seconds. conclusions: we report the successful treatment of a patient unable to use the commercially available methods for administration of inhaled steroids. rationale: hp is a non-ige mediated inflammatory response in the lungs due to a variety of organic antigens, including metal working fluids. the wideranging clinical features include acute, subacute, and chronic forms. elevated antineutrophilic cytoplasmic antibodies and platypnea, defined as dypsnea induced by the upright position and relieved with recumbency, have not been previously reported in patients with hp. case: -year-old white male tool and dye machinist presented with progressive cough, weakness, dyspnea on exertion, and platypnea. symptoms began weeks earlier with coryza and diffuse myalgias. he had lost % of his body weight since symptom onset. examination revealed a pulse of , respiratory rate , and right basilar crackles. resting pulse ox on room air was %, but dropped to % upon ambulation. pft's revealed severe obstruction (fev % predicted) with significant reversibility (fev + %), and a dlco of % (adjusted for va and hemoglobin). hemoglobin was . with a normal leukocyte count and differential. c-anca (anti-pr ) was . (< ), and p-anca (anti-mpo) was . (< ), both performed by elisa. echocardiogram showed an ef of - % with mild pulmonary hypertension; no shunt was present. chest roentogram was normal, but a chest ct revealed a diffuse ground-glass pattern with scattered centrilobular opacities. biopsy was consistent with hp. he was removed from his work exposure to metal working fluids with full recovery of lung function and resoulution of symptoms. conclusions: hp presents as a constellation of symptoms without a single, unique identifying pattern. platypnea and elevated anca's have been observed in a wide range of disorders, all of which were excluded in this patient. platypnea has been associated with hereditary hemorrhagic telangiectasia, pulmonary avm, hepatopulmonary syndrome, recurrent pulmonary emboli, and patent foramen ovale. elevated anca's has been associated with wegener's granulomatosis, goodpasture's syndrome, churg-strauss vasculitis, drug-induced vasculitis, inflammatory bowel disease, and others. elisa is a more specific modality for anca's than indirect immunofluorescence, but it is less sensitive. the possibility of hp should be considered in patients with either of these two abnormalities. rationale: heart disease is the leading cause of death in america and % of persons between and years of age have coronary athersclerosis at autopsy. the presentation in the elderly is commonly atypical. % of myocardial infarctions were silent or unrecognized in the framingham cohort. in patients and older, it is estimated that - % will present with dyspnea without any associated chest pain. we present a case of unstable angina presenting as exercise-induced asthma. case: an year-old white male with moderate persistent asthma, hypertension, dyslipidemia, and a long history of allergic rhinitis presented having had an abrupt increase in his usual exercise-induced asthma symptoms four weeks prior. asthma had been diagnosed at age with spiromety showing moderate obstruction and significant but incomplete reversibility. he had a remote history of pipe and cigar smoking, but had quit at age . he had been well-controlled since that time with his most recent regimen consisting of fluticasone mcg/salmeterol mcg diskus, one inhalation twice daily. his typical exercise-induced asthma symptoms included dyspnea on exertion and chest tightness without radiation, and were relieved with rest and albuterol. the amount of exertion needed to trigger his symptoms, however, was much less than he had previously experienced, and this remained constant during the four weeks prior to his presentation. one week prior he had a normal ecg evaluation by his primary care provider. six months prior he had a normal nuclear cardiac stress test. physical examination was unremarkale except for moderately decreased aeration and + pitting edema of his lower extremities. cardiology performed a nuclear stress test the next day which was abnormal. catheterization revealed % steonsis of his proximal lad. he succefully underwent cabg and is doing well on follow-up. conclusion: the elderly present many challenges to the diagnostician; these include multiple co-morbidities as well as atypical and often late disease presentations. the key to raising suspicion for cardiac involvement in this case was the recognition of the patient's cardiac risk factors in the setting of an abrupt onset of exercise symptoms while lacking other asthma symptoms such as nocturnal cough. cold urticaria is an uncommon form of physical urticaria. this case of a -year-old with cold urticaria and angioedema provides additional information regarding an unusual disorder in the pediatric population. an otherwise healthy -year-old female presented with a complaint of urticaria precipitated by cold exposure over the preceding weeks. she had no recent illnesses and a past medical history significant only for cat allergy. on multiple occasions the patient noted erythema and pruritus of her arms and face after walking through the freezer aisle of a grocery store. urticaria would then develop on regions where she scratched, spontaneously resolving in - hours. on one occasion, urticaria appeared diffusely while taking a shower after the patient had been swimming. the urticaria resolved within a few hours after the patient was given diphenhydramine by her mother. three days prior to presentation the patient experienced upper lip angioedema with erythema, globus sensation and difficulty swallowing after drinking a strawberry slushy. the patient denied any respiratory complaints at that time and her symptoms again annals of allergy, asthma & immunology resolved spontaneously. family history was significant for a maternal history of seasonal allergies. upon physical exam the patient was well appearing. she had - discrete urticaria on each calf. the patient's mother noted that recently these would appear on "cold and rainy" days, attributing them to the fact that the patient's pants left her lower legs exposed. the remainder of her exam was normal and dermatographism was absent. laboratory evaluation consisted of cryoglobulins and strawberry rast, both of which were negative. application of an ice cube to the patient's forearm for minutes resulted in a x centimeter wheal noted minutes after ice removal. a diagnosis of cold urticaria with associated angioedema was made. the patient's mother opted to use diphenhydramine as needed and an epinephrine autoinjector was dispensed. by months after symptom onset, the patient's only complaint was pruritus of her hands if they became too cold. no urticaria were noted. at month follow-up the patient denied any symptoms for the preceding months and had a negative ice cube test. cold urticaria in the pediatric population is a rare entity and not well understood. this case of a -year-old with cold urticaria and angioedema offers additional insight into this unusual disorder. a. khuntia * , m. mcmorris, ann arbor, mi. introduction: chronic granulomatous disease(cgd) is a heterogeneous group of disorders characterized by genetic defects in the ability of phagocytes to generate microbicidal reactive superoxide anions and its metabolites. it manifests early in life, primarily as recurrent infections, caused by catalase-producing bacteria such as staphylococcus aureus, burkholderia cepacia, and serratia marcescens and fungus such as aspergillus fumigatus. the disease may be inherited in an x-linked or autosomal recessive manner, with x-linked disease accounting for - % of cases. the us incidence of cgd is / , live births with an average age at presentation of years for xlinked and . years for autosomal recessive disease. case report: year old male with history of three separate episodes of pneumonia beginning at age . each episode resulted in a hospital admission and intravenous antibiotic therapy after failed oral antibiotic therapy. an extensive pulmonary evaluation was initiated after the third episode of pneumonia, including a chest ct, viral, bacterial and immunodeficiency studies. cbc, complement, immunoglobulins, flow cytometry, viral and bacterial studies were all normal. the ct scan revealed dense nodular opacities in the right upper lobe with surrounding ground-glass opacification and mild bronchiectasis. a subsequent bronchoscopy demonstrated necrotizing granulomatous inflammation. open lung biopsy grew burkholderia cepacia on tissue culture. the clinical history, tissue histopathology and atypical organism found on culture were all suggestive of an underlying immunodeficiency. a neutrophil oxidative burst assay was performed which demonstrated minimal neutrophil activity upon stimulation, suggestive of the diagnosis of cgd. a chemilluscence assay verified the diagnosis of cgd, with minimal fluorescence noted on flow cytometry after neutrophil stimulation. dna analysis demonstrated a p -phox deficiency, resulting in one of the autosomal recessive and less clinically severe forms of the disease. conclusions: this case of cgd is unusual because of the delayed presentation. it demonstrates the importance of a complete immunological evaluation including an evaluation for neutrophil disorders such as cgd in patients of all ages who present with recurrent and recalcitrant episodes of pneumonia, especially when atypical organisms such as burkholderia cepacia are found on culture. autoimmunity may play a role in the development of premature ovarian failure (pof), but the exact mechanism is not well understood. pof is mainly diagnosed after years of age and most women complain of secondary amenorrhea. pof has been reported in combination with presence of ana and autoimmune diseases, but rarely with jra. here we report two cases of pof and positive ana in pediatric patients, one with clinical features of jra. the first patient, an african american -year-old girl, height in th percentile, weight in th percentile, with tenosynovitis of wrists and arthritis of knees and elbows for the past two years, was referred for further evaluation and management. she did not have her menarche yet and laboratory investigation revealed positive ana. the second patient, an african american -year-old girl, th percentile for height and weight, was referred to the immunology clinic with chief complaint of primary amenorrhea and delayed development of secondary sexual characteristics and was found to have positive ana without clinical findings of jra. both patients were tanner stage for breasts and tanner stage - for pubic and axillary hair. both had elevated fsh and lh, karyotype xx and small uterus and small ovaries on pelvic ultrasound. antiovarian antibody was not detected in any of the two patients. the bone age was significantly delayed. pof in karyotypically normal women is frequently seen in combination with elevated serum ana. the clinical spectrum of rheumatoid disease associated with pof ranges from asymptomatic ana positivity to typical presentation of jra. women with pof should be monitored for the emergence of autoimmune disorders including jra, and women with jra should be followed for menstrual irregularities and signs of pof. introduction: many u. s. military personnel deployed to the middle east continue to develop infection with leishmaniasis, a parasite transmitted by the sand fly. pentavalent antimonials have been used as an effective treatment for leishmaniasis for many years. in the united states, sodium stibogluconate (pentostam) is the pentavalent antimonial of choice, and is currently being administered under an ind protocol. side effects of therapy include myalgias, arthralgias, rash, malaise, abdominal pain, pancreatitis, and hypersensitivity reactions. the true incidence of hypersensitivity reactions is not currently known. case reports: two u. s. soldiers receiving pentostam for the treatment of cutaneous leishmaniasis were evaluated in our clinic at walter reed army medical center after experiencing urticaria, angioedema, wheezing and dyspnea after medication infusion during the -day course of daily therapy. due to the concern of a potential ige-mediated reaction, skin testing was performed. after informed consent, skin testing included a prick test at full strength, followed by intradermal (id)testing. soldier # was a -year old male reporting lip swelling, throat tingling, dyspnea and chest pain - hours after treatment # / . skin testing to both lots used during the treatment course showed positive values of x mm and x mm respectively at id : . soldier # was a -year old male reporting diffuse pruritus, hives, dyspnea, and chest pain minutes after infusion # / . skin testing showed positive values of x mm and x mm respectively at id : . due to clinical symptoms and positive skin testing, therapy was discontinued in each case. one control individual showed negative testing to prick at full strength, id : , and id : . conclusion: skin testing with pentostam may provide an objective tool for accurate classification of adverse reactions as igemediated. reliance on skin prick testing alone may not be sufficient to detect pentostam skin test reactivity, as both of these patients reacted to id testing only. a prospective study including pre-and post-treatment skin testing should provide more information on the value of skin testing in providing objective evidence for an ige-mediated process and determining the incidence of hypersensitivity to pentostam. introduction: a -year-old girl with a history of multiple infections was hospitalized with respiratory distress and hypoxia. her past medical history was significant for hypothyroidism, psoriasis, asthma and multiple pneumonias. a cbc revealed an absence of lymphocytes. laboratory: t and b cell subsets showed no b-cells and very low t cells (< cells). inadequate lymphocytes were present for mitogen and antigen studies. serum immunoglobulins were normal and she had antibodies to streptococcus pneumoniae and tetanus. antibodies to rsv, influenza and mycoplasma were absent. chest x-ray revealed interstitial infiltrates bilaterally. a high resolution ct scan revealed septal thickening and confirmed interstitial infiltration. open lung biopsy was consistent with non-specific inflammation with extensive lymphocytic infiltration. bal fluids and biopsy were negative for bacteria, fungi and opportunistic pathogens. clinical course: the patient did not improve with antibiotics and steroids were started. the patient improved rapidly and was discharged to home. biochemical analysis demonstrated a deficiency of adenosine deaminase (ada), a form of severe combined immune deficiency (scid). the patient was started on replacement ada, adagen. a repeat high resolution ct scan showed some improvement. however, the patient continues to be steroid dependant to control her pulmonary symptoms. lymphocyte numbers remain low despite effective ada replacement and the absence of serum datp. she remains clinically stable and receives adagen injection twice weekly. discussion: ada deficiency is a condition, which leads to accumulation of the metabolite datp, which is toxic to lymphocytes. this disease most commonly presents in the first year of life as scid and is fatal unless treated. our case is unusual due to the late onset of severe disease, normal serum immunoglobulin and the presence of some protective antibodies. despite adequate replacement of ada the patient continues to be profoundly lymphopenic, most likely due to steroids. although we do not yet completely understand the underlying lung disease we suspect that the patient has an autoimmune process causing interstitial inflammation. background: atopic dermatitis has a broad range of differential diagnoses. human sarcoptic infestation is characterized by severely pruritic lesions of variable appearance and distribution and may masquerade as eczema. infestation may be difficult to confirm and eradicate. animal transmission has been reported as a source of human infection. objective: to report a case of persistent sarcoptic infestation masquerading as eczema and associated with delusional parasitosis. methods: a -year-old female was referred to allergy clinic for evaluation with a two year history of recurrent, pruritic rash thought to be refractory atopic dermatitis. previous ineffective treatments included topical steroid creams, lindane, topical anti-fungals and multiple otc antiitch preparations. at initial evaluation, she had widespread excoriated papules in various stages of healing over % of her body. she reputed her dog was diagnosed with recalcitrant mange, which necessitated giving him medicated baths twice daily. results: a clinical diagnosis of subacute sarcoptic infection was made and the patient was prescribed two courses of elimite followed by oral ivermectin. her rash quickly resolved except for post-inflammatory hyperpigmentation. three weeks after resolution of primary lesions, she again complained of pruritic eruptions occurring on easily accessible areas and began bringing in medicine bottles of skin debris and scabs for examination. scrapings, koh preparation and skin biopsy examined microscopically showed no evidence of sarcoptic re-infestation. a diagnosis of delusional parasitosis was made. conclusions: the animal to human transmission of sarcoptic infection seen in this patient is rare and responded quickly to appropriate treatment. despite eradication of the infection, she developed delusional parasitosis, a rare psychiatric disorder characterized by fixed, false belief of an infestation by insects or other creatures. she displayed the classic matchbox sign in which samples of skin, scabs and other detritus are brought in for examination. she is currently receiving psychiatric care. background: thimerosal is a mercury derivative that has been used since the s. it is a commonly used preservative in ophthalmic solutions, otic drops, and vaccines due to its bactericidal property. objective: to report the first case of a generalized reaction to thimerosal found in an influenza vaccine. methods: we present a patient who developed a generalized maculopapular eruption after receiving a thimerosal containing influenza vaccine. patch testing was performed to determine if there was an allergy to thimerosal. results: patch testing confirmed a type iv (t cell mediated) sensitivity to thimerosal, further supported by the prior history of a reaction to a thimerosal containing contact lens solution. the patient was asked to avoid thimerosalcontaining products, including vaccinations, unless the benefit clearly outweighed the potential risk of a reaction. conclusion: physicians need to be aware that thimerosal is found in many products including vaccinations. clinicians should also be aware that allergic reactions do occur with exposure to thimerosal even in vaccines. this is the first case report in the literature of a generalized reactions to thimerosal from an influenza vaccine angioedema is a rare condition that has been described in the literature and exists in both inherited and acquired forms. a defect of the innate immune system, more particularly the complement system, is the inciting culprit. the acquired form of c esterase inhibitor deficiency has been divided into two classes and is generally not commonly seen until after the forth decade of life. type acquired angioedema has been described in association with lymphoproliferative disorders, while type is related to excessive complement activation and consumption due to autoantibodies. our case is a -year old man referred from an outside physician for further management of idiopathic edema. he first experienced facial edema in april attributed to sweet myrrh root ingestion. subsequently, in november he developed diffuse swelling of his upper extremities and tongue without airway compromise. a minimal work-up at that time was inconclusive. he fortunately remained asymptomatic until january at which time he experienced two episodes of tongue swelling without etiology. he was seen in his local emergency department and treated with diphenhydramine, corticosteroids, and epinephrine on both occasions with gradual improvement of his symptoms. the patient was not on medications commonly associated with angioedema and did not report insect envenomation. subsequently, he was seen by his primary care physician who ordered a number of laboratory tests including a ch , which was significantly suppressed. in light of this finding, he was referred to our clinic for further evaluation. at the time of presentation to our office, the patient was symptom free. his physical exam was within normal limits. further laboratory evaluation was essentially unremarkable with the exception of comple-ment studies, which are listed in the table. our case demonstrates an elderly patient with evidence of idiopathic swelling. we arrived at our diagnosis of acquired angioedema based on clinical presentation and confirmatory serum complement levels. a low ch at time of presentation allowed us to further delineate the etiology of complement deficiency. the fact that our patient did not present with swelling until after age and the paucity of a family history of idiopathic angioedema makes the diagnosis of acquired angioedema probable. measure of serum c q level confirmed the diagnosis. introduction: certain diseases, widely believed to be of allergic etiology, including atopic dermatitis and episodes of wheezing might be the result of interplay of genetic and environmental factors, at least partially. we describe a child with a rare chromosomal disorder presenting with typical features of atopic dermatitis and recurrent mild wheeze. materials and methods: a new born african-american male was noted to have unusual facial features immediately after birth. the baby was born naturally, without antenatal and neonatal problems. on physical examination, the infant had unusual facial characteristics with tight and taut facial skin, relatively diminished facial pad of fat, pointed chin, and markedly hypertonic extremities. additionally, cardiac exam revealed mumur consistent with uncomplicated asd. frequent reassessments of the infant in the outpatient clinic were done. the child had repeated bouts of wheezing attacks, and facial rashes compatible with the diagnosis of atopic dermatitis. the wheezes were treated in the clinic with nebulaized bronchodilators, and the atopic dermatitis responded reasonably to topical steroid applications and moisturizers as needed. chromosomal analysis of the peripheral blood of the chid confirmed the diagnosis of deletion of long arm (q) of chromosome [ , xy, del ( )(q q )]. karyotypic analyses of the mother and father were normal. the child exhibited features of developmental delay, and seizure activities. anti-epileptic drugs (aed) were instituted. initial eeg was normal and the subsequent eeg showed findings of static encephalopathy. ct scan of the brain revealed absent corpus callosum. neurologic evaluations and physiotherapies were requested for improvement of fine motor skills. he did not seem to suffer from any serious infectious or immunodeficient illnesses. his cbc was normal. he continued to have fair gains in his weight, height, and head circumference. his atopic dermatitis and wheezing episodes remained under control. there were a few hospitalizations for break-through seizures and dehydration from gastroenteritis. a subsequent echocardiography confirmed closure of asd. con-clusion: a child with chromosomal anamoly, atopic dermatitis, and mild intermittent wheeze is reported. despite multiple congenital problems, the child continued to have a stable clinical course. etoposide is a chemotherapeutic agent used to treat many solid tumor malignancies. hypersensitivity reactions have been well described and there are a few reported deaths from anaphylaxis. some suggest that the hypersensitivity is an anaphylactoid type reaction as it may occur during the first dose. case reports of cutaneous complications include stevens-johnson syndrome, radiation recall and diffuse erythema. there are four cases in which diffuse erythematous papules developed after etoposide therapy. all rashes spontaneously resolved within three weeks and biopsies demonstrated keratinocytes in a starburst pattern. we report the first case of an immediate etoposide induced skin reaction that evolved into long lasting hyperpigmented plaques. pretreatement was able to prevent this immediate and late reaction on subsequent exposure to etoposide. a year old female with ovarian cancer was treated with bleomycin, etoposide and vinblastine. three hours after initiation of the third dose of etoposide, patient developed pruritic, erythematous macules on her chest, abdomen, face and extremities. the infusion was stopped and decadron administered. over forty-eight hours, the pruritic macules became hyperpigmented plaques on her chest, abdomen, extremities and face. pruritus resolved after a slow taper of prednisone. the darken plaques were treated with multiple topical preparations but persisted for about three months. biopsies demonstrated superficial perivascular infiltration of lymphocytes and a few eosinophils suggestive of a drug eruption. etoposide was considered essential for this patient so allergy was consulted. the literature supports cautious readministration of etoposide with pretreatment and slower infusion rate to prevent immediate hypersensitivity. we could not guarantee prevention of the late hyperpigmented reaction. the patient was pretreated with prednisone and cetirizine. etoposide was administered in an icu with a slower rate of infusion. etoposide was tolerated without immediate pruritus or erythematous reaction. the patient did not develop the delayed darkened plaques. cautious administration of etoposide after premedication and a slow rate of infusion prevented both the immediate and late reaction previously experienced by this patient. eosinophils normally comprise - % of peripheral white blood lymphocytes. peripheral blood eosinophilia is defined as an absolute eosinophil count > cells/mm and is most often caused by atopy, helminth infections, or collagen vascular diseases. less common causes include adrenal insufficiency and neoplastic processes. eosinophilia can be characterized as mild (< cells/mm ), moderate ( - cells/mm ) or severe (> cells/mm ). although severe eosinophilia has been reported in association with adult hiv infection, studies of hiv-infected children have not shown peripheral blood eosinophilia to be a feature of pediatric hiv infection. we report an unusual case of severe peripheral blood eosinophilia in an adolescent male who was subsequently found to be hiv-infected. a previously healthy -year-old male presented with week history of fever, diarrhea, cough, vomiting, abdominal pain, anorexia and a lb weight loss over the previous months. the patient had recently emigrated from guyana and denied sexual activity, intravenous drug abuse, or other hiv risk factors. there was no known maternal hiv infection. repeated stool specimens were negative for ova and parasites. serologies for e. histolytica, t. canis, and s. stercoralis were negative. an abdominal ultrasound, chest x-ray, serum electrolytes, and liver function tests were all within normal limits. total white blood cell was , with % eosinophils (absolute eosinophil count of , cells/mm ). elisa and western blot were positive for human immunodeficiency virus (hiv- ). cd + tlymphocyte count was cells/mm with an hiv- rna level of , copies/ml. the patients symptoms resolved over the next days without treatment. he was started on combination antiretroviral therapy (zidovudine, lamivudine, abacavir, and efavirenz). absolute eosinophil count continues to slowly decrease with the last count of , cells/mm three months following the introduction of antiretroviral therapy. severe peripheral blood eosinophilia may be a presenting feature of hiv infection in adolescents. hiv testing should be considered in cases where more common causes of eosinophilia such as atopy and parasitic infections are excluded. triad asthma is well described in adults but not in the pediatric literature. this case highlights the successful treatment of a severe pediatric asthmatic with nasal polyps and aspirin sensitivity. a year-old female presented with severe persistent asthma, eib, allergic rhinitis, chronic sinusitis, nasal polyps, and a history of pneumonia. her asthma symptoms were minimal from age until age . she then started flovent and required increasing amounts of inhaled and oral steroids. she required courses of oral steroids per year by age . in addition, she had snoring, fatigue, chronic nasal congestion, rhinorhea, and sneezing despite treatment withallegra and rhinocort. she had received immunotherapy from age to with no clinical improvement. since age she had recurrent sinusitis and had required polypectomies. she noted aspirin caused nasal stuffiness and mild wheezing and therefore avoided it. on exam she had allergic shiners, dennie lines, boggy turbinates, nasal polyps, and diffuse wheezing. on evaluation she had severe airway obstruction. her fev increased from % to % with albuterol. her chest ct had a mosaic pattern due to severe air trapping, and her no level was . a sleep study showed severe hypopneas, and she had pan-sinusitis on ct. she had multiple positive spts, an eosinophil count of and an ige of . she had a normal sweat chloride and ph probe.the differential diagnosis included churg-strauss, abpa, cystic fibrosis, bronchiolitis obliterans, and triad asthma. after a thorough evaluation, she was diagnosed with triad asthma. with weeks of treatment with oral prednisone, her fev improved from % to %. her inhaled controller therapy was increased and she was placed on xolair. she had a polypectomy and then underwent aspirin desensitization. one year after starting treatment her fev remains %. she requires albuterol x/month and has not required prednisone. her eib, allergic rhinitis and congestion are markedly improved. she has had no further episodes of sinusitis, and a repeat sleep study was normal. in conclusion, we treated a severe pediatric asthmatic with nasal polyps and aspirin sensitivity. this is not frequently reported in the pediatric population, and raises questions about the incidence, optimal long term treatment of triad asthma, and the differences from the adult onset of this disease. a.a. white * , r.a. simon, la jolla, ca. background: human disease from mold has traditionally been isolated to infection, allergic disease, or hypersensitivity pneumonitis. specific diseases or pathologic findings other than those listed above have not been well described. we report a case of acute eosinophilic pneumonia related to mold exposure. case presentation: a year old woman developed dry cough and shortness of breath after stachybotrys mold was discovered in her home. a chest radiograph showed bilateral upper lobe infiltrates which worsened two weeks later. treatment with macrolide and flouroquinolone antibiotics was ineffective. a white blood cell count was , /cumm with % eosinophils. an erythrocyte sedimentation rate was mm/hr. aspergillus ige was negative. treatment with prednisone led to complete resolution of the chest radiographic abnormalities and improvement in pulmonary function testing. this patient was given a diagnosis of acute eosinophilic pneumonia with mold as a likely causal factor. discussion: there is dispute amongst health care professionals regarding the significance of environmental mold contamination in the etiology of human disease. this case represents well characterized disease occurring in the setting of mold exposure. while a causal relationship cannot be established, the temporal relationship of mold contamination, symptom onset, and disease progression is compelling. interestingly, a recent report of mold contamination leading to nonspecific interstitial pneumonia/fibrosis has been described. we have observed a patient in our clinic with similar pathology on biopsy and temporal relationship to mold exposure. to our knowledge, acute eosinophilic pneumonia has not been reported in conjunction with mold exposure. conclusion: this case highlights a new condition in which mold may have a causal role. the mechanism is unknown, but likely is through a non-ige mediated immunologic pathway. public awareness of mold as a health concern is increasing. perhaps similar cases will emerge as a history of mold exposure is offered by patients at the time they are evaluated for lung disease. a stronger correlation may then emerge. scuba diving is a commonly practiced activity which normally carries only minimal risks. any severe allergic reaction such as anaphylaxis, however, occurring during this activity could be a particularly dangerous not only because the swimmer is submerged but also because of the lack of proximity to medical care. we report a case of anaphylaxis occurring during scuba diving resulting from an unsuspected hypersensitivity to a latex component of the scuba diving suit. a yr-old white male developed a severe generalized urticarial rash with angioedema of his lips and eyelids, and difficulty breathing within minutes of his applying the suit and entering the water. after being rescued, he was transported to a nearby emergency department where he received epinephrine, antihistamines, corticosteroids and iv fluids with gradual improvement over a hour period. the patient denied being stung by a marine aquatic organism and there was no prior history of allergy or medications usage prior to his reaction. since subsequent investigation revealed that the scuba diving suit contained latex (brazilian rubber), a specific ige rast was found to be strongly positive (class v) to latex. therefore, the patient was advised to use a suit made of neoprene synthetic rubber (polychloroprene) which is a nonlatex containing product. this case report illustrates the importance of a diligent search for hidden sources of latex products which can produce life-threatening allergic reactions in sensitized patients. there has been considerable debate concerning the safety of immunizing egg-allergic children with the combined mmr vaccine. this concern derives from the possibility of an anaphylactic reaction since the mmr vaccine is prepared from attenuated viruses grown on chick embryo fibroblast cell cultures. we have previously reported the safe administration of the mmr vaccine to severe egg-allergic children without development of an adverse reaction (nsouli, tm, et al. ann allergy asthma immunol. ; : ) , a finding consistent with the current report of the committee on infectious diseases, american academy of pediatrics, . the present case report describes an anaphylactic reaction in an egg allergic yr-old-white male consisting of generalized urticaria, angioedema, wheezing immediately following the administration of a second mmr vaccine. the history of hives following ingestion of eggs was confirmed by positive specific ige rast testing. the patient's anaphylactic reaction necessitated emergency treatment including epinephrine, diphenhydramine, and corticosteroids in addition to iv fluids. although the administration of mmr vaccine in egg-allergic children is not considered as an absolute contraindication, the present case report suggests that caution should be observed when administering the mmr vaccine in such patients and that careful medical observation be included together with the ready availability of emergency medical equipment. p. buddiga * , r. turbin, a. baisre, l. bielory, newark, nj. introduction: sarcoidosis is a chronic granulomatous disease of unknown etiology that may have a multi-organ system manifestation and is characterized by the histopathological evidence of nonnecrotizing granulomas. case report: a year old african american woman with a year history of type ii diabetes mellitus, hypertension and sinusitis recalcitrant to multiple courses of antibiotics over months was admitted to the hospital with complaints of right eye proptosis, diplopia, headache and right facial numbness.her exam was consistent with an ipsilateral mild optic neuropathy, complete sixth (vi)nerve palsy, trigeminal, ophthalmic and maxillary division numbness.ct and mri of the face, orbit and brain revealed an extensive process infiltrating ethmoid, maxillary and frontal sinuses;orbits and deep facial structures.chest ct revealed bilateral interstitial nodules and symmetric hilar adenopathy. differential diagnoses included sarcoidosis, lymphoma/tumor, wegener's granulomatosis or fungal infection.labs-purified protein derivative test=negative(neg), antineutrophil cytoplasmic autoantibodies=neg. angiotensin converting enzyme= [ - u/l], fungal & anaerobic and acidfast bacilli culture of sinus secretions=neg.ethmoid, adenoid and maxillary sinus biopsies=multiple nonnecrotizing granulomas. on the basis of compatible clinical and radiographic findings, histopathological evidence and exclusion of other diseases with similar findings, the diagnosis of sarcoidosis was established. she was started on parenteral methylprednisolone and subsequently tapered to oral prednisone after days.concomitantly she was started on methotrexate as a steroid sparing agent.most recent chest x-ray after months of treatment reveals near complete resolution of the hilar lymphadenopathy.at months her optic neuropathy and facial dysesthesia had resolved, and she was left with mild persistent vi nerve dysfunction. conclusion:sarcoidosis that manifests itself as sinusitis is an uncommon presentation and the mechanism involved is thought to be a consequence of the destruction of cilia and mucus producing glands by the granulomatous process.review of the literature indicates that this is the eighth case reported and illustrates that a high index of suspicion of other etiologies must be maintained when there is a refractory response to multiple courses of antibiotics in the treatment of sinusitis. j.b. hein * , p. patel, l. bielory, newark, nj. introduction: cid may result in opportunistic infections such as cryptococcal meningitis. we present an unusual case of cryptococcal meningitis in an hiv-negative patient with severe cd lymphocytopenia. case: a yearold male with a three year history of sarcoidosis presented with acute onset of right-sided body numbness. the patient had been on prednisone mg/day for months prior to presentation. ct and mri scanning showed no vascular defects, meningeal enhancement, hydrocephalus or mass lesions. gallium scanning revealed normal uptake in the liver and spleen, mild uptake in the lungs and nasopharyngeal region, and asymmetric uptake in bilateral kidneys. the patient's initial wbc was , cells/mm , composed of neutrophils/mm , eosinophils/mm , basophils/mm , lymphocytes/mm , and basophils/mm . repeat studies revealed the total lymphocyte count decreased at cells/mm with cd (pan b) cells decreased at cells/mm and cd (pan t) cells decreased at cells/mm . cd count was cells/mm and cd count cells/mm with a cd /cd ratio of . . igg levels were normal at mg/dl. elisa was negative for hiv, and hiv- rna by pcr was not detected. serum ace level was u/l and csf ace level was u/l. csf obtained by lumbar puncture stained positive with india ink and culture revealed cryptococcus neoformans. the patient responded to amphotericin b lipid complex mg/kg/day, and his neurological status eventually returned to baseline. conclusions: the severe lymphopenia in this patient caused predisposition to infection with cryptococcus neoformans. the etiology of the profound lymphopenia likely was multifactorial, including mild sarcoidosis activity (lung uptake on gallium scan) and chronic corticosteroid therapy. however, once cryptococcus became entrenched in the patient's csf, the infection itself likely depressed peripheral lymphocyte numbers even further. this case demonstrates the importance of exploring a broad differential diagnosis when faced with lymphocytopenia. background: isosulfan blue % is a common dye used in sentinel lymph node dissection. the usage of the procedure and dye has increased in numbers, and although rare, several cases of anaphylactic reaction have been reported. objective: we are reporting a patient who had an anaphylactic reaction to isosulfan blue while undergoing breast cancer excision with sentinel lymph node biopsy. methods: the patient is a year-old woman with breast cancer. she underwent breast mass excision with sentinel lymph node biopsy using the lymphazurin % blue dye (isosulfan blue). she has a history of penicillin induced hives but has no other drug allergy. as soon as the dye was injected, she became flushed, hypotensive, and tachycardic. hypotension was refractive to fluid challenge. she was then treated with epinephrine as well as intravenous steroids and cimetidine with relief of symptoms. subsequently, she was evaluated in allergy and skin tests with isosulfan blue % at : , : dilution, and undiluted were performed using histamine as positive control and saline as negative control. this procedure was also performed on two control subjects. results: the patient had a positive skin test (wheal and flare) to isosulfan blue % (undiluted) with the control being appropriately positive for histamine and negative for saline. control subjects had negative response to dye and saline and positive response to histamine. conclusions: isosulfan blue -% dye may cause anaphylactic reactions in patients undergoing sentinel lymph node dissection. . the positive skin test result to the dye plus the negative skin test responses in the controls suggests that the reaction may be immunoglobulin e (ig e) mediated. eosinophilic duodenitis (ed) and gluten-sensitive enteropathy (gse) or celiac disease (cd) are distinct clinical entities with well-defined clinical and laboratory parameters. ed is a rare condition of unknown etiology, which is manifest by eosinophilic infiltration of the gastrointestinal tract and peripheral eosinophilia. gse or cd is a form of non-ige food allergy caused by immune hypersensitivity to ingested gluten. the simultaneous occurrence of the two entities, however, is a rare event. the following presentation is a case report in which both entities were found in the same patient. an y/o white hispanic male presented with severe, chronic, colicky abdominal pain and headache of months duration. hematologic and immunologic studies were within normal limits. serum ige levels were iu/ml (n= < iu/ml), anti-endosomial ab (+), igg antigliadin: u/ml (n=: - u/ml), skin tests for food and inhalant allergens were weakly positive ( +). biopsy of the inferior third of esophagus revealed chronic moderate esophagitis; biopsy of gastric antrum revealed lymphatic hyperplasia; duodenal biopsy showed shortening of the villi with the presence of eosinophils. following treatment with esomeprazole mg bid, famotidine mg qd, montelukast md qd, lactobacillus, a diet free of gluten, rofecoxib mg qd and betamethasone for days, betamethasone the patient improved with partial resolution of symptoms. the presence of duodenal eosinophils persisted despite a gluten free diet, and continued to require repeated bursts of prednisone. since to our knowledge this is rare finding in which ed occurred in association with gse, a high index of suspicion for simultaneous occurrence of ed should be raised in any case of gse that fails to respond to a conventional gluten free regimen. we report the evaluation of a month old male presenting with a pustular rash and choking episodes from birth. by age weeks, he had experienced two pneumonias, one with fleeting infiltrates requiring intubation. persistent eosinophilia ( - /ml) and eosinophils on pustule biopsy were noted. persistence of these and subsequent rsv pneumonia and recurrent draining otitis media led to referral. physical examination showed a thriving male infant with multiple erythematous papules and pustules along the scalp, face, axilla, and trunk. eosinophilia was confirmed. quantitative immunoglobulins were abnormal for igg and ige iu/ml. peanut cap rast was kua/l. hib post-vaccination titer, t cell enumeration/stimulation, and nbt were normal. hiv testing, stool eosinophils, o&p, and hemoccult were negative. cxr, hrct, ekg, and echocardiogram were normal. pustule cultures for bacteria, virus, and fungus were negative. skin biopsy revealed numerous eosinophils in the pustule, dermis, epidermis, and perifollicular region. cd a+ and s- staining were negative for histiocytic infiltration. nemo defect/incontinentia pigmenti were considered but testing was negative and karyotype , xy. bone marrow biopsy revealed numerous eosinophils at different stages of maturation, and no myeloproliferative or neoplastic changes. bronchoscopy was remarkable for % eosinophils on balf. -hour ph probe and impedence evaluation was negative. egd with biopsy was normal except for mild eosinophilic infiltration of the proximal and distal esophagus. with the clinical picture of recurrent pruritic crops of sterile pustules and characteristic skin biopsy demonstrating eosinophil infiltration, the diagnosis of eosinophilic pustulosis (ep) of childhood was made. despite no longterm sequelae or other end-organ involvement in ep, the degree and duration of eosinophilia, and presence of eosinophils in the airways and esophagus, raises the concern for other eosinophilic syndromes. following cardiac, cns, pulmonary, and gi systems is warranted. the infants pneumonias were felt to be due to aspiration, and ear infections the result of humoral immunity nadir or draining pustules in the external auditory canals. immunoglobulin levels will be monitored. this case illustrates the heterogeneity of eosinophilic diseases and raises the question of what drives the mechanisms behind malignant and benign disease. introduction: behcet's disease is a chronic, relapsing vasculitic disease characterized by recurrent oral, genital, and gastrointestinal ulcerations, a wide variety of skin lesions, uveitis, and arthritis. pediatric cases of behcet's disease are uncommon with an estimated prevalence of in , children under the age of . although the disease in children shows similar characteristics as adults, the diagnosis of behcet's disease in the pediatric population remains a challenge. this report describes an year old girl referred to our pediatric immunology clinic for evaluation of recurrent painful oral ulcerations since the age of with no genital ulcerations. the oral ulcers would last for two weeks and heal spontaneously but would reappear to weeks later. the patient had a history of raynaud's phenomenon for the last to years and the recent onset of joint pain. physical examination revealed - white elliptoid lesions - mm in diameter on an erythematous base on the tongue and soft palate. skin examination was significant for hyperpigmented patches over the neck, abdomen, and back. there were erythematous, serpigenous lesions on the palms and punctuated necrotic lesions on the finger-tips. pathergy test was positive. laboratory investigation was unremarkable and cultures from the oral ulcers remained negative. the patient was diagnosed with juvenile behcet's disease. she was started on immunosuppressive therapy with low dose prednisone and responded. conclusion: behcet's disease is a difficult diagnosis to make in the pediatric population. this case demonstrates that in children, recurrent oral ulcerations may be the only initial manifestation of behcet, and an important clinical marker for the disease. rationale: relapsing polychondritis is an uncommon severe inflammatory condition with unknown etiology that can present in a variety of manners. we report a year old patient who initially presented with signs and symptoms of anaphylaxis to shellfish and was later diagnosed with relapsing polychondritis. case report: a year old african-american boy with a year history of asthma and fish and shrimp allergy presented to the pediatric intensive care unit on / / after an episode of severe shortness of breath. his symptoms started shortly after accidental exposure to shrimp. in the intensive care unit, he was noted to be wheezing and stridorous. an initial chest xray as well as subsequent fiber optic laryngoscopy showed sub-glottic stenosis. he was intubated and received mechanical ventilation for greater than a week. after extubation, he stated that he felt fine, but continued to demonstrate audible stridor. pulmonary function tests demonstrated extra-thoracic obstruction, laryngoscopy continued to show sub-glottic stenosis, and esophagogastroduodenoscopy showed erosive esophagitis consistent with reflux. initial lab tests demonstrated a normal eosinophil count, elevated ige ( iu/ml), and positive immunocaps testing to multiple foods. the patient was discharged home with minimal stridor and no wheezing. over the next nine months, the severity of his stridor waxed and waned, but in general it worsened in spite of a strict elimination diet and anti-reflux therapy. on / / he received an emergency tracheostomy. on / / , the patient was again admitted to the hospital. at this time he complained of bilateral knee pain as well as significant weight loss. physical exam demonstrated arthritis with effusions of both knees as well as unilateral auricular chondritis and bilateral episcleritis. antibodies against type ii collagen were positive ( . eu/ml). the diagnosis of relapsing polychondritis was suggested. conclusion: relapsing polychondritis is a rare inflammatory disorder of the cartilage and connective tissue with an unknown etiology. the wide array of presenting complaints as well as the relapsing nature of this disorder often causes significant delay in diagnosis and treatment. in our case there was a period of nine months between the initial presentation and the time when the diagnosis of polychondritis could be made. d.k. geller * , m. ballow, buffalo, ny. introduction: an yo male previously diagnosed with pandas presented to our immunology clinic for ivig. the patient was healthy until age when he developed facial motor tics associated with group a beta hemolytic strep pharyngitis. he was treated with antibiotics and the tics resolved completely. he has had multiple recurrences associated with strep and other viral infections. the tics improve or resolve completely when he is infection free. he has no history of vocal tics, attention deficit/hyperactivity disorder, or obsessional thinking or compulsive behaviors. laboratory: multiple throat cultures positive for group a beta hemolytic strep, positive antistreptolysin and antideoxyribonuclease b titers. discussion: pandas identifies a subgroup of children with an obsessive compulsive disorder and/or tic disorder whose symptoms seem to be triggered by streptococcal infections. the proposed pathophysiology is an immune-mediated mechanism in which antistreptococcal antibodies, antistreptolysin and antideoxyribonuclease b, cross react with the basal ganglia of genetically susceptible hosts. a few studies have looked at immunomodulatory therapies including ivig for neuropsychiatric symptoms including tic disorders secondary to post-streptococcal autoimmunity. we plan a trial of ivig for this patient given the recurrent nature of his tics and the relation to streptococcal and other viral infections. introduction: the chronic granulomatous disease (cgd) is an inheritable disorder of phagocyte cell respiratory burst that result in life-threatening infections. the pulmonary infection is the primary cause of death in greater that % of the cases and the role of surgery in management of this entity remains undefined. case report: a lobectomy was performed in a year-old male who presented a persistent opacity of the medial right lobe with fever, cough, malaise an rapid onset of respiratory failure; skin abcesses were concomitant. his familiar history was unremarkable. a chest tube was placed in a first instance in order to drain empyema, but no progress was observed. a ct scan showed necrotizing pneumonia of the right lung, mediastinal and retroperitoneal limphadenopathy and bronchopleural fistula. a second surgical intervention was undertaken to correct the fistula and pleural debridement was done. at this time, serratia marcenses was isolated from blood culture and lung; a primary immunodefiency was suspected. our evaluation showed nbt reduction on % and dyhidrorhodamine assay (dhra) didn't demonstrate and effective oxidative burst. the subsecuent management was based on specific antibiotic to serratia and prophylaxis with tmp-smz and itraconazole. transfer factor to improve the ifn levels was initiated. the patient's mother showed on dhra two granulocyte populations, with and without oxidative burst. a x linked cgd was consistent. medical progress was observed in the next days. conclusion: despite the poor utility showed by the surgical procedures in the complicated pneumonia in cgd patients in many series, attending to the unusual nature of the pulmonary infections and the high mortality and morbidity associated with thoracic surgery; the management of this case showed that an aggressive approach in the diagnosis combined with some procedures used in immunocompetent patients pneumonia may improve the clinical condition in cgd patients. background: takayasu arteritis is a large vessel vasculitis primarily affecting the aorta and its branches. it is most prevalent in women in the second and third decades of life. initial symptoms are systemic and often self-limited, but the disease may progress undetected over years until signs of vascular insufficiency develop. arteritis is commonly seen in the aortic arch and its branches, although the disease is a panarteritis and vascular compromise can occur in many organs. pathologically, involved vessels show intimal proliferation and fibrosis, and scarring of the elastic lamina. case report: we report the case of a year old southeast asian woman who presented with diplopia, ptosis, dizziness, and progressive dyspnea. past medical history was significant for rheumatic fever complicated by aortic valve insufficiency and hypertension. physical findings on admission included hypertension, asymmetric upper extremity blood pressure (left arm / mm hg, right arm / mm annals of allergy, asthma & immunology hg), wide pulse pressure and a harsh diastolic murmur. admission labs showed anemia (hemoglobin: g/dl, hematocrit %) and an elevated erythrocyte sedimentation rate of mm/hr. transesophageal echocardiography revealed severely dilated aortic root aneurysm with secondary severe chronic aortic valve insufficiency and calcified aortic leaflets not typical of rheumatic heart disease. resection of the aortic valve and aneurysm was performed. pathologic examination of the aortic aneurysm revealed intimal and adventitial fibrosis with focal chronic inflammation and partial loss and fibrosis of media, findings compatible with healed takayasu arteritis. the patient was started on prednisone mg by mouth daily for takayasu arteritis and discharged in stable condition. discussion: this is a case of takayasu arteritis masquerading as rheumatic heart disease. the episode of rheumatic fever was likely the initial presentation of takayasu arteritis, as the systemic symptoms of these diseases can overlap. takayasu arteritis is an insidious disease that often leads to a delayed diagnosis with considerable morbidity for the patient. since takayasu arteritis may go undiagnosed until ischemic symptoms develop, physicians should be alert to the possibility of this disease in young women to avert end organ damage and achieve early remission with drug therapy. we present a fifteen year old boy with disseminated papillomatosis and idiopathic cd + lymphocytopenia (icl). the warts have been present since he was one year old and have progressively worsened. there are more than fifty warts on each of his hands. his legs have multiple warts and about ten warts recently appeared on his lips and around his mouth. his past medical history is significant for no hospitalizations and no blood transfusions. he has never had problems with other infections, and he had a benign course of chicken pox that spontaneously resolved. he has been on cimetidine for six months without improvement. several topical therapies, including imiquimod, have failed. he has a total lymphocyte count of /ul (normal range, - /ul) and a cd + count of /ul (normal range, - /ul). the cd +, natural killer cells, and cd + cells were normal. his hiv test is negative. the serum immunoglobulins were normal as well. lymphoctye proliferation studies reveal an absent response to antigens (candida and tetanus) with a normal response to mitogens. further studies showed no other cause of cd + lymphocytopenia. this case shows that the diagnosis of idiopathic cd + lymphocytopenia should be considered in any patient with widespread viral infection whose hiv test is negative. appropriate evaluation of the cd + count should be pursued. j. ko * , a. nowak-wegrzyn, new york, ny. introduction: approximately % of children with moderate to severe atopic dermatitis (ad) have food allergies. complementary and alternative medicine (cam) is utilized by an estimated - % of patients with allergies. we present a case of a year-old boy with ad referred after receiving a diagnosis of food allergy by a cam practitioner. methods/case: a year-old boy was referred for evaluation of mild ad and possible food hypersensitivity. his ad started at year of age and was limited to the face. he was initially breast-fed and was switched to milk-based formula at months of age. solids were introduced at months of age without difficulty. he had no immediate reactions or noted worsening of ad due to foods. the patient presented to a naturopath for allergy evaluation. based on electrodermal skin testing results, he was reported to be allergic to milk, egg, peanut, rice, and beef (all of which he had tolerated previously). he was restricted from milk and egg for weeks without noticeable change in his ad, which was limited to the cheeks and controlled on topical pimecrolimus. results: his weight and height were both th percentile. physical exam was normal except for - cm dry, erythematous patches on both cheeks and mildly dry skin on flexor/extensor surfaces of both arms. skin prick testing revealed negative tests to milk, egg, peanut, and dust mite. serum ige testing was also negative. since he had no evidence of ige sensitization to commonly allergenic foods, he was recommended to continue an unrestricted diet and discontinue use of a "sippy" cup. his ad subsequently improved on a skin care regimen of postbathing moisturization and topical pimecrolimus prn. asthma and allergies are the # reason for cam use in the us. electrodermal skin testing is a method utilized by naturopathic doctors to detect allergen "sensitivity". however, in two double-blinded trials examining atopic and non-atopic patients, electrodermal testing did not correlate with skin prick testing results, regardless of inter-operator variability. conclusions: allergy patients are seeking cam treatment, and it is important for physicians to be aware of the safety and efficacy of alternative medical practices. the use of electrodermal skin testing has not been proven to detect allergen sensitivity and use of this modality should be discouraged. e.e. mcgintee * , k.e. sullivan, philadelphia, pa. introduction: hematopoietic stem-cell transplantation causes profound tcell immunodeficiency due to the rigorous conditioning involved. following transplant, the t-cell compartment is initially reconstituted through expansion of mature donor-derived t-cells. however, thymopoiesis is necessary to generate naive t-cells with a diverse repertoire. factors affecting thymic function impact the ability of the body to reconstitute the immune system. we report a case of severe t-cell immunodeficiency after two stem-cell transplants for neuroblastoma in a patient with a history of thymic hemorrhage secondary to mediastinal surgery. case: a -year-old female with a history of high-risk neuroblastoma was referred for immunologic evaluation due to a significant infectious history since completing her neuroblastoma therapy. she initially presented at months of age with a right atrial mass that was presumed to be an atrial myxoma. she underwent mediastinal surgery to resect the tumor, which was found to be neuroblastoma extending from her right adrenal gland along the vena cava. a ct scan following her surgery revealed an area of hemorrhage in her right thymus. she subsequently received high-dose chemotherapy and two autologous stem-cell transplants. her infection history was significant for multiple episodes of upper respiratory illnesses, sinusitis, and otitis media requiring myringotomy tube placement on two occasions. immunologic evaluation revealed a dramatically low absolute lymphocyte count with deficits primarily in the t-cell compartment, and reduced proliferation in response to mitogens. immunoglobulin levels were normal; she formed protective titers to diphtheria and tetanus but not to any of pneumococcal serotypes. conclusion: stem-cell transplantation often results in severe t-cell immunodeficiency. the thymus plays an important role in reconstituting the t-cell compartment with naive t-cells generated from hematopoietic stem-cells, which restores tcr diversity. as this case illustrates, damage to the thymus can significantly impair the ability to reconstitute the t-cell compartment. a.k. knight * , c. cunningham-rundles, new york, ny. rationale: this is the first case report of oxcarbazepine induced immunoglobulin deficiency. methods: a y/o white female was referred for further investigation of low serum immunoglobulin found as part of an evaluation for chronic bacterial vaginitis. she was taking oxcarbazepine for chronic pain. this was discontinued and immunoglobulin levels and b cell numbers were tested at intervals. specific antibody responses to pneumococcal vaccine were tested. results: at presentation, on oxcarbazepine, immunoglobulin levels were low [igg , iga < , and igm < mg/dl] and she had a b cell deficiency [ %, b cells (normal - %, - cells/cu mm)]. antibody response one month after pneumococcal vaccine was poor (protective antibody to / serotypes). ( %)] with protective antibody responses to / pneumococcal serotypes. she continued to have iga deficiency. conclusions: the patient's initial evaluation suggested the diagnosis of common variable immune deficiency with hypogammaglobulinemia and specific antibody deficiency. however, these defects reversed when oxcarbazepine was discontinued. it is unclear if persistent iga deficiency was a pre-existing condition, possibly predisposing her to this adverse reaction to oxacarbazepine, or induced by the oxacarbazepine. immunoglobulin deficiency is a known, though rare, reaction to carbazepine, the parent drug of oxacarbazepine; this adverse reaction can occur with its derivative oxcarbazepine as well. secondary hypogammaglobulinemia should be considered before diagnosing primary immunodefiencies such as cvid and committing the patients to lifelong immunoglobulin therapy. introduction: interferon and glatiramer acetate (copaxone) are indicated for the treatment of relapsing-remitting multiple sclerosis (ms). anaphylactic reaction has been reported as a rare complication of interferon and copaxone use. we report a case of interferon - a (rebif) and copaxone hypersensitivity associated with positive skin tests and desensitization to interferon - b (betaseron). case report: the patient is a year-old woman with asthma and allergic rhinitis who was diagnosed with ms in oct ' after an uncomplicated pregnancy and was subsequently placed on rebif. one month after starting therapy, patient developed wheezing and generalized urticaria after receiving a dose of rebif. the symptoms recurred the next day. her neurologist stopped the rebif and started her on copaxone. two months later she developed episodes of generalized urticaria. the patient was then evaluated in our center and underwent skin testing with interferon - a intramuscular (avonex), interferon - a subcutaneous (rebif), betaseron, and copaxone. she had a positive skin prick reaction to copaxone and positive intradermal skin tests to avonex ( : strength), rebif ( : ), and betaseron ( : ) after hrs. the intradermal reactions to all interferon formulations continued to progress upto hrs. her neurologist felt that she would benefit from betaseron therapy. the positive intradermal skin test to betaseron was sufficient to warrant desensitization to prevent immediate hypersensitivity reactions. she underwent subcutaneous desensitization as shown in the table. the desensitization was halted at minutes after the patient developed itching of the hands.* she returned in hrs and we restarted by administering . ml of : strength betaseron. increasing doses were given until the patient received a full therapeutic dose ( . mg in ml). she has since done well with daily doses of betaseron ( . mil units). conclusion: we report a ms patient who developed urticaria and asthma exacerbation in response to rebif and urticaria to copaxone. skin tests confirmed an ige-mediated allergic reaction. she underwent successful desensitization to betaseron. to our knowledge, this is the st report of desensitization to betaseron as well as extension to previous reported cases of systemic reaction to interferon and copaxone. pentoxifylline (ptx) is a phosphodiesterase inhibitor that has been used for ischemic vascular disease because of its effects on red blood cells and platelets. it has been used for systemic inflammatory diseases such as sarcoidosis because of its ability to inhibit production of cytokines such as tumor necrosis factor (tnf-a). we decided to offer a trial to a patient with chronic urticaria since agents that increase intracellular camp have been shown to inhibit mast cell degranulation. we report a case of a year-old female with a history of allergic rhinitis, hypothyroidism, and diabetes mellitus with recurrent episodes of chronic urticaria since adolescence. she had known allergies to various antibiotics but otherwise had an unremarkable history, family history and social history. she was being treated with fexofenadine mg qd, azelastine nasal spray, zafirlukast mg bid, hydroxychloroquine mg bid, levothyroxine mcg qd, doxepin mg qhs, metformin mg bid, and spironolactone mg qd at the time of her initial evaluation. her physical exam was notable only for scattered - cm urticarial skin lesions as well as areas of hypo and hyperpigmentation from previous excoriations. her nasal turbinates were mildly congested with dull membranes. a previous skin biopsy showed only urticaria with increased numbers of mast cells. her workup included normal cbc, urinalysis, spep and complete chemistry profile, as well as negative ana and anti-thyroid antibodies. pentoxifylline mg tid was added to the patient`s regimen. her urticaria resolved within - weeks and was no longer visible at months follow-up. pentoxifylline is a safe medication with few side effects that may benefit patients with chronic urticaria via several mechanisms, including the inhibition of mast cell degranulation and secretion of various cytokines and chemokines. the beneficial effects of pentoxifylline in the treatment of this patient`s urticaria have been seen in other patients. further study is indicated to determine which patients with urticaria are most likely to benefit from pentoxifylline, as well as elucidate the mechanisms of action by which pentoxifylline ameliorates symptoms of chronic urticaria. c.m. mjaanes * , m. boguniewicz, denver, co. we report the case of an -year-old male who since the age of years has suffered from recurrent episodes of left tongue swelling. onset of the swelling is usually abrupt, and generally occurs during the night, awakening him from sleep. he describes a sensation of pain in his tongue but denies any pruritus, throat, lip or eyelid swelling. he has no cough, dyspnea, wheezing, rash, or itchy/watery eyes. the episodes occur infrequently, approximately once every spring . they tend to resolve spontaneously within to hours, however, on occasions, the swelling has lasted for - days. the patient's current episode has been present for weeks and is progressing. today he reports more pain and increased swelling. the child reports no benefit from oral antihistamines. he was treated with dexamethasone during his initial episode and experienced gradual resolution of the swelling. he has never been treated with topical or systemic epinephrine, or additional courses of systemic steroids. there is no family history of angioedema. the child was referred for evaluation of an immunologic/allergic etiology of his unilateral tongue swelling. laboratory studies obtained early in the course of his current episode revealed the following: c level mg/dl; c level . mg/dl; c level . mug/ml; c d level . mug/ml; c esterase inhibitor function % of normal. c esterase inhibitor level . mg/dl; ch units/ml; ana : , negative; beta-tryptase < . ng/ml; total tryptase . ng/ml (all normal). initial evaluation revealed marked swelling along with erythematous and violaceous discoloration of the left lateral and anterior portions of the child's tongue. the remainder of his examination was normal. the patient was referred to the pediatric otolaryngology clinic with a presumptive diagnosis of a glossal hemangioma versus lymphangioma. he underwent a magnetic resonance imaging study which revealed a poorly defined, mass-like enlargement of the anterior and left aspect of the tongue. he was treated with a five day course of prednisolone. after initial regression of the lesion a planned surgical excision was carried out without any complications. in conclusion, this rare case illustrates the unique presentation of glossal hemangioma presenting as recurrent angioedema. highlighted are the differential diagnoses, laboratory studies and clinical features of oropharyngeal swelling. severe tongue swelling. rare skin conditions such as leprosy need to be considered in the differential diagnosis of apparent urticaria and angioedema that is atypical in appearance or response to therapy. a year old male originally from laos presented with chronic recurrent nonpruritic indurated plaques on his face and trunk, and was referred to allergy by his primary physician with a diagnosis of urticaria and angioedema to rule out an allergic reaction to foods. he was otherwise healthy and on no medication, and had a negative personal and family history of atopy. he had moved to the united states from southeast asia in , and visited for several weeks again in . he was treated with prednisone and hydroxyzine without benefit; skin testing to foods was negative, and cbc, differential, sedimentation rate, antinuclear antibody, and liver function testing was normal or negative. a skin punch biopsy from an indurated area on the back showed granulomas with clusters of acid-fast organisms on afb stain consistent with tuberculoid leprosy. as the patient was g pd deficient, he could not be treated with dapsone and was treated alternatively with minocycline mg, rifampin mg, and clofazimine mg daily. he was subsequently started on prednisone as he was determined to be having a reversal reaction; his lesions continue to improve. this patient had a rare condition, leprosy, which was confused with urticaria and angioedema. in patients presenting with atypical apparent urticaria or angioedema, especially if response to standard pharmacologic treatment is poor, a skin biopsy is indicated, and may be diagnostic as in this case. introduction: cutaneous flushing about the face of a toddler within minutes of eating specific foods prompts parents and clinicians alike to pursue food allergy testing. auriculotemporal syndrome, also known as frey syndrome, is an isolated and transient facial erythema about the distribution of the auriculotemporal nerve following mastication. we report a child who was referred for food allergy testing and was diagnosed with auriculotemporal syndrome. case history: a yo wf, prior full-term forceps-assisted delivery, has a history of facial flushing within minutes following ingestion of specific foods. the flushing can be induced by a variety of foods, specifically spaghetti, crackers, potato chips and hard candies, and typically resolves within minutes after eating. the child has no respiratory or gastrointestinal distress during the flushing episode. there is no angioedema, urticaria, or other rash elsewhere on her body. within ten minutes of eating a lollipop in clinic, an erythematous, warm macular eruption appeared in a band-like region anterior to her ear extending from her temporal bone to her mandible. this response occurred bilaterally, with a mildly greater intensity on the right side of her face. no sweating or other symptoms developed, and the flushing began to diminish after thirty minutes of observation. discussion: auriculotemporal syndrome is commonly seen in patients who have undergone facial surgery, specifically about the parotid gland. it is believed to be secondary to a disruption in the fibers of the auriculotemporal nerve. it is theorized that the nerve regeneration following an injury may join the parasympathetic fibers of the salivary gland with sympathetic fibers of eccrine sweat glands. mastication then could result in flushing and sweating over the cutaneous distribution of the auriculotemporal nerve that extends from the temporal region to the mandible, anterior to the ear. although rare in children, auriculotemporal syndrome has been associated with forceps delivery. therapy is seldom of benefit or needed, and the syndrome often resolves spontaneously over many years. conclusion: auriculotemporal syndrome leads to a cutaneous eruption temporally related to the ingestion of foods. allergists should maintain an awareness of this rare syndrome to minimize food allergy testing or eliminate unnecessary food provocation challenges or restrictive diets. m. al-ahmad * , s.s. mace, toronto, canada. introduction: ranitidine is a well-known h -receptor antagonist. anaphylactic reactions are seldom reported despite widespread use of the drug. we report a patient with anaphylactic reaction to ranitidine methods: we report a case of anaphylactic reaction with ranitidine. results: a -year-old female with a history of urticaria over one year period, presented with episodes of anaphylactic reactions of increasing severity over year, after ranitidine ingestion. the first two episodes, occurred one hour after ranitidine ingestion, began with a sensation of burning, and itching in the head followed by dizziness, hypotension and near loss of consciousness. the patient had no significant pulmonary or laryngeal symptoms. the fourth episode, occurred minutes after taking ranitidine tablet, was characterized by severe hypotension. two episodes were managed at the emergency department. a skin prick test with a crushed ranitidine tablet demonstrated a positive mm wheal response, which was negative in a control. investigations for carcinoid syndrome and systemic mastocytosis were negative. conclusion: an ige mediated allergy to ranitidine is possible. anaphylactoid reaction to ranitidine is a well recognized entity. however, to our knowledge, few cases of anaphylactic reaction to ranitidine have been described. hypersensitivity reaction to ranitidine should be considered in patients suspected of having drug-related allergy. introduction: severe combined immune deficiency(scid) and cystic fibrosis(cf) may both present in infancy with a history of failure to thrive, diarrhea, and recurrent respiratory infections. although cf is the most common genetic disease occurring in caucasians with an incidence of in births, scid is a rare condition estimated to occur between in , to in , births. we report a case of x-linked scid where the diagnosis of cf was originally entertained due to similar presentation and misleading laboratory results. case: -month-old caucasian male with month history of recurrent respiratory illnesses, fever, loose stools, thick nasal discharge and failure to thrive. this was his second admission for a respiratory infection. relevant lab results consisted of cultures which grew parainfluenza a virus on np wash and pseudomonas aeruginosa on deep throat culture, chest xray showed patchy infiltrates and a borderline sweat test of mmol/l. despite being treated with broad spectrum antibiotic coverage, albuterol and pulmozyme, his respiratory symptoms were not improving. physical exam revealed a thin infant with palpable though small lymph nodes cervical and groin, diffuse scattered rhonchi and liver edge palpable cm below the costal margin. quantative immunoglobulins were obtained and resulted as an igg of , iga of < , and igm of . review of his chest x-ray was significant for absent thymic shadow. lymphocyte count since admission ranged from - . flow cytometry revealed a cd /cd count of %, cd /cd count of %, cd of % and cd of % of all lymphocytes. t-cell stimulation tests were markedly diminished to both antigen and mitogen. a presumed diagnosis of x-linked scid was made and patient undrewent haploidentical bone marrow transplantation. subsequently, cf gene analysis resulted as negative. discussion: as outlined in the case it is essential to recognize the similarities between the presenting symptoms of cf, a relatively common genetic disease and scid, an uncommon one. although pseudomonas is seen in increased frequency in patients with cf, it is essential to recognize that it is also a leading pathogen affecting patients with antibody deficiency. review of the literature did not reveal any previous cases of individuals with scid reported as having an increased sweat chloride, nor any explanations of why this would occur. while immunodeficiency has previously been associated with some forms of dwarfism, we report the first described case of common variable immune deficiency in a patient with seckel syndrome (bird headed dwarfism). the diagnosis of seckel dwarfism, an autosomal recessive disorder, was made at months of age in this boy based on intrauterine growth retardation, proportional dwarfism, microcephaly, micrognathia, and narrow face with "bird-like" large eyes and beaking of the nose. hematologic abnormalities are reported in an estimated % of such patients, and this child developed thrombocytopenia at the age of years. by age , he had pancytopenia with hypocellular bone marrow. a low cd count ( /ul) was noted and both bactrim and neupogen were begun. his only significant infections, rotavirus and salmonella gastroenteritis, occurred at that time along with frequent otitis leading to pe tube placement at ages and but which subsequently resolved. he has never had opportunistic infections or thrush. by the age of years, he required monthly red cell transfusions for severe anemia. after several months of transfusions, the blood bank reported that he no longer had detectable blood group antibodies during crossmatch; this led to measurement of immunoglobulins. igm was undetectable with low iga ( mg/dl) and low igg ( mg/dl). he demonstrated no protective titers to any pneumococcal serotypes after either conjugated or unconjugated pneumococcal vaccines. response to diphtheria, tetanus, rubeola, and influenza vaccines was adequate. total hemolytic complement was normal. he remains lymphocytopenic (alc = /ul) with low cd ( /ul). after five doses of ivig at mg/kg monthly, platelets have remained between - k/ul and there has not been any improvement in the anemia. although the mechanism for the bone marrow failure in these patients is presumed to be chromosomal breakage, this has not been demonstrated in this child. his karyotype is xy with no chromosomal fragility or deletions detected to date. hypogammaglobulinemia should be investigated in any patient undergoing frequent transfusions who loses blood group antibodies, and suspicion of immune deficiency should remain particularly high in patients with severe growth retardation or dwarfism. n.l. rider * , t. craig, hershey, pa. the objective of this study was to assess the effectiveness of physicians at a university primary care clinic in diagnosing and managing adult patients with asthma. a retrospective chart review of adult patients from this clinic was performed. each chart was evaluated using a survey instrument developed from the national asthma education and prevention program (naepp), which consisted of queries. of the charts evaluated met our entry criteria. overall compliance with the naepp recommendations was %. adherences to the asthma guidelines in the following areas were: diagnosis ( %), treatment/disease control ( %), monitoring ( %), and education ( %). these data suggest that there is an opportunity to improve the care provided to patients with asthma, especially in the areas of asthma education and monitoring, even in a university outpatient facility. these data also suggest that naepp guidelines have not been effectively incorporated into primary care practices. b.m. wahlers * , l. sherwood, t. craig, hershey, pa. objective: our aim was to evaluate adherence to the national heart lung and blood institute (nhlbi), national asthma education and prevention program (naepp) diagnosis and management guidelines, regarding asthma admissions at a teaching hospital. methods: a retrospective chart review of patients over the age of years admitted to the hershey medical center between and with a primary diagnosis of asthma or asthma exacerbation was conducted using a -item questionnaire focused on key aspects of asthma care as outlined in the naepp guidelines. results: overall compliance to the guidelines was . %. maximal areas of compliance were noted in regards to pharmacologic treatments utilized ( %, %). much lower levels of compliance were noted in areas of patient education ( %), instruction in written action plan prior to discharge ( %), provision of peak flow meter for home use ( %), assessment of asthma symptoms and severity ( %), and inhaled steroid prescription on discharge ( %). conclusion: adequate care in terms of pharmacologic treatments is being given but sub-optimal cares in other areas of the guidelines exist. there continues to be room for improvement in regards to asthma management, most notably in the area of education, documentation of triggers, and preparation for discharge with adequate tools to monitor and control symptoms. background: asthma is one of the most common problems of childhood, responsible for a significant proportion of absence from school because of chronic illness. objective: this study was carried out among the school-aged children ( - years) in tehran schools during - , in order to determine the frequency of asthma. methods: according to the recommendation of who, a questionnaire was designed, containing standard questions, and the students were given necessary information to complete the questionnaires. the guidance and high school students completed the questionnaires but the parents of primary school students completed them by themselves. results: seven hundred and eight children out of children had asthma ( . %); this prevalence was higher in the boys ( . %), when compared to the girls ( . %). the prevalence of this disease has been estimated about . % in guidance schools, . % in high schools and . % in primary students. based on this survey, the most common clinical manifestations in asthma were included: prolonged cough lasting more than days ( . %), and exerciseinduced wheezing or dyspnea ( . %), followed by repeated dyspnea or wheezing ( . %). based on the drug responses after receiving solbutamol, the prevalence of asthma was evaluated in the range of . % in primary schools, . % in guidance schools and . % in high schools. conclusions: the prevalence of asthma is high among the students of tehran schools and it needs more careful screening programmes and either more information given to the patients and parents about the disease. in the us, asthma is the most common chronic disease of childhood and affects approximately million children. reasons for inadequate asthma control include: inappropriate therapy, incorrect inhaler technique, poor compliance with treatment, and exposure to environmental triggers. rates for asthma prevalence, hospitalization, and death are highest among children residing in inner cities, and important risk factors for asthma-related mortality include being poor and black. the communities of braddock, north braddock and rankin are among the poorest in allegheny county and are designated areas of greatest health risk. recent statistics have demonstrated an increase in the number of asthma hospitalizations in these communities: . children per , which is double the average for allegheny county and greater than seven-times the overall us rate of asthma hospitalizations. our goals were to assess asthmatic severity and appropriateness of treatment, provide asthma education, and to ensure access to healthcare for asthmatic children living in these medically underserved and predominantly african-american communities. twenty-seven asthmatic children were identified. of the children assessed % were under the age of years, % were aged - years, and % were - years of age. based on nhlbi guidelines the severity of each child's asthma was determined: % had mild-intermittent asthma, % had mildpersistent asthma, % had moderate-persistent asthma, and % had severepersistent asthma. the appropriateness of treatment based on severity was also determined. we found that % of the children with mild-intermittent asthma, % of children with mild-persistent asthma, % of children with moderate-persistent asthma and % of children with severe-persistent asthma were receiving inappropriate treatment. furthermore, of the inappropriately treated children % were undertreated. following the assessment, patients and parents were educated with regard to asthma triggers, pathophysiology, use of peak flow meters, inhaler technique and pharmacologic treatment. patients were also scheduled for outpatient follow-up care. these results demonstrate that inappropriate treatment, especially undertreatment, may be a significant cause of the increased asthma morbidity in this population and underscore the need for aggressive education and innovative methods of ensuring health care. w. li-ling * , t. keng-leong, f.c. stephanie, e. philip, singapore. background: asthma admission is an important indicator of asthma morbidity. little is known about the risk factors associated with asthma admission among high-risk asthmatics. purpose: ) to characterise the profile of high-risk asthmatics who had previous asthma hospitalization. ) to identify predictors and risk factors that are associated with asthma hospitalization. methods: data for consecutive high-risk asthmatics who were enrolled into our asthma program from october to may were retrieved from our prospective database. high-risk asthmatics were defined as patients who had a clinical diagnosis of asthma and who had at least one hospital admission for exacerbation of asthma in the preceding months or at least one severe exacerbation of asthma in the preceding months requiring unscheduled visit for beta -agonist nebulisation. a comparison was made among high-risk asthmatics who had at least one or more hospitalization for asthma in the past months prior to the asthma program enrolment with those who were not hospitalized. statistical analyses were performed using spss version . for windows. results: among high-risk asthmatics, ( . %) had at least one or more asthma hospitalization in the past months prior to the enrolment into the asthma program. hospitalization was significantly associated with female gender ( . % with asthma admission v . % without asthma admnission). a significantly higher proportion of asthmatics with no formal education ( . % v . %), primary education ( . % v . %) and secondary education ( . % v . %) were hospitalized for asthma as compared to the those who had tertiary education ( . % v . %). those admitted were predominantly in lower income group, had poor inhaler technique and have no ownership of an asthma action plan ( . % v . %). those hospitalized were also younger, median age years ( , ) v years ( , ) and had a lower first peak flow reading, l/min ( , ) v l/min ( , ) . conclusion: among high-risk asthmatics, certain population subgroups are at greater risk for hospitalization for asthma. intervention aimed to reduce asthma morbidity should take the above findings into consideration. introduction an association between asthma symptoms and air quality is well established, but controversy exists concerning the role of various air quality indicators. the association of san antonio air quality with emergency department (ed) visits for asthma at our military medical center has not been defined. the objective of this study is to determine the correlation of selected air quality indicators in san antonio with ed visits for asthma for both the general population and for the pediatric population. methods selected air quality indicators were the -hr air quality index (aqi) for ozone, -hr aqi for particulate matter < . μm, pollen counts, mold spore counts, and daily high temperature. the number of daily ed visits coded for asthma was obtained retrospectively. pediatric visits (patients < years-old) were evaluated as a subgroup. pearson correlation coefficients (r) were calculated for all data pairs. results during the days of the study period, there were visits for asthma. of these visits, were pediatric. the number of daily visits ranged from to for all visits and from to for the pediatric visits. r values for all visits were - . , - . , . , - . , and - . ; for pediatric visits, - . , - . , . , - . , and - . for the -hr aqi for ozone, -hr aqi for particulate matter < . μm, total pollen grains/m , mold spores/m , and daily high temperature, respectively. in addition to calculating r values for same-day air quality indicators and ed visits, r values were also calculated for a -day average of air quality indicators with the ed visits. for the -day averages, r values for all visits were - . , - . , . , - . , and - . ; for pediatric visits, - . , - . , . , . , and - . for the -day averages of the -hr aqi for ozone, -hr aqi for particulate matter < . μm, total pollen grains/m , mold spores/m , and daily high temperature, respectively. conclusion there was no significant correlation between the selected air quality indicators and ed visits for asthma, either for the general population or for pediatric visits. this study provides no evidence that air quality is linked to ed visits for asthma in san antonio but the degree to which air quality in san antonio affects asthma symptoms remains unclear. introduction: the aim of this study was to evaluate the level of no in the exhaled air of patients suffering from chronic cough. methods: the study was performed on young (mean age . +/- . years), nonsmoking patients with chronic cough referred to the allergy clinic for evaluation. bronchial provocation challenge with histamine was performed according to the method of ryan. exhaled no was measured on-line using a chemiluminescence analyzer (sievers, usa). all patients had resting spirometry within normal values. results: significant bronchoconstrictive response to histamine at a concentration equal to or lower than mg/ml (pc mg/ml) was found in patients ( . %). these patients had a significantly greater mean concentration of no in the exhaled air ( . +/- . ppb) than those with a pc > mg/ml ( . +/- . ppb; p< . ). receiver operating characteristic (roc) curve analysis revealed that it is possible to identify from among patients suffering chronic cough those who have significant bronchial hyperreactivity (pc mg/ml). using ppb as a cut-off value for the exhaled no concentration, the specificity for bronchial hyperreactivity was . % and sensitivity . %. conclusion: assessment of no concentration is helpful in the assessment of bronchial hyperreactivity in patients having chronic cough. l. abetz * , j. bousquet , e. juniper , e. bateman , h. boushey , w. busse , t. clark , r. pauwels , s. pedersen , . manchester, united kingdom; . montpelier, france; . ancaster, canada; . cape town, south africa; . san francisco, ca; . madison, wi; . london, united kingdom; . ghent, belgium; . kolding, denmark. introduction: the acq has been developed as a measure of asthma control for use in clinical practice or in clinical trials. the reliability, validity and responsiveness have previously been demonstrated for the original item acq, the item (minus fev question) and item (minus fev and short acting bronchodilator use questions) versions. data from the -year gaining optimal asthma control (goal) study was used to assess the predictive value of the acq s , , and item versions in determining asthma control status. method: receiver operating characteristic curves (roc curves), plotting true positive rates versus false positive rates for different acq cut-points, were used to determine optimum cut points for totally controlled and well-controlled asthma. scores for the , , and item versions of the acq were examined at . intervals. results: when predicting totally controlled asthma, the areas under the roc curves (arocc) were . / . / . for the , and item versions, respectively; and when predicting well-controlled asthma the arocc were . / . / . for the , and item versions. in both predictive models, the and item versions provided the best arocc. for the and item versions, the best cut-off point to predict totally controlled asthma was <= . , with arocc of . / . , and corresponding sensitivity of . / . and specificity of . / . , respectively. for the item version the best cut-off point was <= . , with arocc of . , sensitivity of . and specificity of . . the best cut-off points for predicting well-controlled asthma were <= . for the item version (arocc= . ; sensitivity= . ; specificity= . ), and <= point for the and item versions (arocc= . / . ; sensitivity= . / . ; specificity= . / . , respectively). conclusion: results indicate the sensitivity and specificity of the acq in predicting asthma control status. a yo black male with asthma and allergic rhinitis developed gradually worsening cough productive of clear to yellow sputum despite treatment with high dose fluticasone, salmeterol, monteleukast, and prn albuterol. asthma history was significant for an intubation at age and pneumonia at age . physical exam revealed pale turbinates and expiratory wheezes. pulmonary function test showed a severe obstructive lung defect with fev . ( %), improving by % after bronchodilator and fev /fvc ratio %. a chest ct revealed significant bronchiectasis in the right middle lobe, lingula and both lower lobes. evaluation for bronchiectasis showed normal quantitative immunoglobulins, subclasses, and humoral responses, rendering innate immunodeficiency less likely. the diagnosis of allergic bronchopulmonary aspergillosis was entertained, but ige was ku/l and aspergillus titers were negative. a sinus ct failed to show active disease, yet the patient reported chronic yellow nasal discharge despite courses of antibiotics. although he was sexu-ally active with several male partners, hiv testing was negative times, months apart. evaluation for cystic fibrosis (cf) showed no symptoms of malabsorption and a negative sweat test. other tests revealed normal - antitrypsin level, p-anca, esr, ace level, and negative sputum for afb and mycobacteria, helping to exclude other conditions such as -antitrypsin deficiency, vasculitis, sarcoidosis, and chronic infection. with no definitive answer, the diagnosis of cf was pursued, but genetic screening as well as mapping were negative. the diagnosis of primary ciliary dyskinesia was then entertained; however, a mucosal biopsy of the nose did not reveal any structural abnormalities. finally, a sperm analysis revealing azoospermia confirmed the diagnosis of young's syndrome, a rare disease with features similar to cf including bronchiectasis, chronic sinusitis and azoospermia. in young's syndrome however, there is an obstructive process rather than a lack of vas deferens resulting in azoospermia and normal sweat chloride, genetic, and pancreatic testing. this case demonstrates the importance of investigating a persistently productive cough in an asthmatic patient and the differential diagnosis as well as the appropriate work up for bronchiectasis. a final diagnosis is important since appropriate management in each situation may affect long term outcome. a.g. palma-carlos * , m.l. palma-carlos, lisboa, portugal. introduction: bronchial challenges are currently done in allergic asthma with allergen, histamine or metacholine.bronchial reactivity to allergens and histamine can probably be variable. purpose to evaluate if the dose of allergen and histamine triggering a significant bronchial obstruction are always correlated in asthmatic patients. methods: a vitalograph model compact has been used throughout the study. allergen challenge has been done with an acqueous solution of house dust mite. bronchial challenges with placebo (sodium chloride) histamine or allergens have been done in all patients. for the provocations with histamine or allergens the threshold dose, inducing a decrease in fev greater than % has been determined in all the cases, as well for histamine as for allergens. a second challenge has been done in all patients with a supra-threshold dose of histamine or allergen corresponding to the double of the threshold. results: provocations have been done in patients either with histamine or allergen. were allergic and non allergic. the threshold dose for histamine were between and ug. in allergic patients and and ug. in non allergic patients.in allergic patients after histamine threshold challenge mean decrease was for fev , % and for fev /vc , %. for supra-threshold dose fev decreases , % and fev /vc , %. after allergen challenge fev decreases , % and fev /vc , %. with supra threshold doses fev decreases , % and fev /vc , %. in non allergic patients there was no changes after allergen challenge. a good correlation in constriction induced by histamine or allergen either for threshold or supra threshold doses (p< . ) was observed but not between the threshold doses of histamine and allergen. conclusions: these results confirm that bronchial obstruction can be triggered by allergens and mediators that the sensitivity of fev and fev /vc for evaluation are roughly comparable after challenge and points to a better sensitivity of a supra threshold dose of allergen or mediators. allergen and histamine challenges don't give the same information. introduction: peak expiratory flow rate (pfr) and forced expiratory volume in the first second (fev ) are currently used in functional evaluation of asthmatic patients but his degree of correlation in obstructive, restrictive and mixed spirometric ventilatory patterns are not well known. the purpose of this study was to evaluate if the correlation between pfr and fev markers of global airways obstruction is comparable in asthmatic patients with obstruction restriction or both. methods: asthmatic patients, males, females have been studied by spirometry with a vitalograph compact in absence of bronchodilatory or anti-inflammatory therapy. patients have been classified in functional patterns according to vc, and fev /cv: normal : vc greater than % of expected value and fev /vc greater than %, obstructive:vc greater than % and fev /vc greater than % restrictive vc, less than % and fev /vc greater than % and mixed vc less than % and fev /vc less than % presenting a so called functional emphysema. results: according to these criteria patients were normal, restrictive, obstructive and mixed. in all the group the correlation between pfr and fev was statiscally significant (p< ) but the correlation coefficient variable. in functionally normal patients r =+ , in restrictive patients + , in obstructive + , in mixed + , and in the sub-group with functional emphysema + , . for this sub-group the correlation coefficient r allows to define fev = + , pfr. conclusions: the report between the two most usual assays of global bronchial obstruction depends on the balance between restriction, (either by interstial fibrosis or hyperinflation) and obstruction and is more close when a more marked obstruction coexist with a restrictive pattern (functional emphysema). in practice pfr has the same value that fev only in more severe cases of ventilatory failure. the dispersion of values and the standard error or regression do not allow to correlate both data in most patients. introduction: the tenor study longitudinally observes the natural history of subjects with severe or difficult-to-treat asthma. this analysis assessed the association between previous and future asthma exacerbations in tenor. methods: subjects eligible for this analysis were years of age at baseline and had at least one follow-up assessment in year and year . recent asthma exacerbations in the past months were defined as: asthma-related emergency room (er) visits, nights of hospitalization, unscheduled physician office contacts; or as a composite measure of at least one of the previous exacerbation events. relative risks (rrs) and % confidence limits ( %ci) were generated comparing exacerbations in year relative to year . exacerbation rates were defined as the number of events divided by total patient follow-up time. no adjustment was performed for baseline characteristics. results: subjects were eligible for this analysis. rrs in year vs. year were: . ( %ci: . - . ) for unscheduled office contacts, . ( %ci: . - . ) for the composite exacerbation measure, . ( %ci: . - . ) for er visits and . ( %ci: . - . ) for nights of hospitalization. over % of subjects with or more exacerbations (composite measure) in year had a similarly high rate in year compared to % of patients without an event in year who went on to have or more exacerbations in year (see table) . conclusion: tenor subjects who experienced an asthma exacerbation in year were at statistically significantly increased risk of subsequent exacerbations the following year compared to subjects not experiencing an exacerbation in year . this increased risk was consistent for all asthma exacerbation outcomes and most elevated for hospitalizations due to asthma. assessment of recent asthmarelated healthcare use is a critical component of the clinical evaluation of subjects with severe or difficult-to-treat asthma. funded by genentech inc. and novartis pharmaceuticals corp. background: preliminary studies investigating yoga and breathwork for asthma have been promising. several randomized controlled trials have shown a benefit from yoga postures and/or breathing versus control, but the control in these cases involved no intervention other than usual care. this study advances the field by providing an active control. methods: a randomized, controlled, double-blind clinical trial was conducted from october to march to determine the effectiveness and feasibility of a yoga and breathwork intervention for improving clinical indices and quality of life for adult patients with mild to moderate asthma. random assignment was made to either a -week yoga intervention that included both postures and breathwork, or a stretching control condition. outcome measures were assessed at , , and -weeks and included the mini asthma quality of life questionnaire (mini-aqlq), rescue inhaler use, spirometry, symptom diaries, and health care utilization. results: sixty-two participants were randomized into the intervention and control groups, and completed the final follow-up measures. intention-to-treat analysis was performed. significant within-group differences in post-bronchodilator fev and morning symptom score were apparent in both intervention and control groups at and weeks; however, no significant differences between groups were observed on any outcome measures.conclusions: iyengar yoga conferred no appreciable benefit in mild to moderate asthma. circumstances under which yoga is of benefit in asthma management, if any, remain to be determined. in order to investigate asthma mortality trends for the u. s. hispanic population, i have collected and graphed data from the national center for health statistics. mortality data for the hispanic population have been available for the entire united states only since and readily available for asthma only since . these data indicate decreases in deaths from asthma (j -j ) from in to in with decreases in the non-hispanic population from in to in . rates of death from asthma decreased for the hispanic population from . per , in to . in , while that for the non-hispanic population decreased from . to . . rates for non-hispanic whites decreased from . to . in . rates of death from asthma have been twice as high among hispanic women as men. rates of death from asthma for non-hispanic blacks have been more than twice as high as those for non-hispanic whites. (national center for health statistics data dictate racial terminology). data for people of hispanic origin include people of any race. these data are affected by both underreporting of hispanic origin on death certificates and undercoverage in the census and resultant population estimates for a net correction of . %. thus, rates of death from asthma have been lower and have been decreasing faster among hispanics than the rest of the population in the united states. allergic rhinitis and asthma are both highly prevalent diseases and often coexist in patients. rhinitis symptoms have been shown to impact the lower airway. as such, the impact of rhinitis on asthma control may be the greatest in patients with the most severe rhinitis symptoms. therefore, this analysis was performed to determine the impact of baseline rhinitis severity on asthma control in patients with both asthma and allergic rhinitis who received either fluticasone propionate aqueous nasal spray (fpans) or montelukast (mon) added to fluticasone propionate/salmeterol / mcg (fsc). a total of patients (> years) with persistent asthma and seasonal allergic rhinitis received fpans mcg qd, mon mg qd or placebo (pbo) in addition to fsc / mcg bid for weeks. at baseline, total nasal symptom scores (tnss) ranged from to . the analysis was restricted to patients whose pre-enrollment asthma therapy did not include fsc. regardless of baseline rhinitis severity, in patients with both asthma and allergic rhinitis, mon added to fsc resulted in no additional improvements in overall asthma control compared with fsc alone. these data suggest that optimal treatment of the individual conditions should be the goal of treatment for patients with coexistent allergic rhinitis and asthma. (sam ) introduction recent studies have demonstrated that parainfluenza and coronaviruses are as important triggers of asthma. parainfluenza viruses are one of the main triggers of virus-induced asthma at summer. parainfluenza viruses often cause severe low respiratory tract infections in immuncompromised patients and in patients with bone marrow transplantation. a retrospective study found that % of pediatric bmt patients with hpiv infection ( % of viral respiratory infections) developed pneumonia and % died. both viruses contributed to fatal asthma. materials and methods for amplification of these viruses, primers which anneal to specific regions of viral genomes: hn-gene for piv , piv and piv and spike glycoprotein gene for coronavirus oc and nucleocapsid glycoprotein gene for coronavirus e were used. pcrdiagnostics was performed on nasal and throat swabs taken from children with atopic asthma exacerbation. results from / to / a total of samples (including negative controls) were tested by pcr. positive for respiratory viruses samples noted in children having asthma exacerbations including . % of all tested samples. piv was detected in . % of all positive samples, piv in . %, and coronavirus oc in . %. piv and coronavirus e were not detected during this study. for negative controls samples were taken from children with atopic asthma in remission. all controls were found to be negative by viral pcr. conclusions respiratory viruses are an important factor in asthma exacerbations in children. piv was the most frequently detected among the positive samples. although hpiv- was less often positive than hpiv- and hpiv- infections in this study, the frequency of the detected coronaviruses may have been influenced by the seasonal activity of these viruses. introduction. in budapest all children come under the regular supervision of a specially trained paediatrician. each paediatrician is responsible for an average of children, often seen up to the age of years. methods. a questionnaire was sent to the district paediatricians of budapest in budapest in , budapest in and . the total number of children in their practice and the number of the asthmatics was assessed. the diagnosis of asthma in every case was established in a paediatric hospital, or a special allergy or pulmonology outpatient clinic. results. in , replies were received from paeditricians, who were responsible for the supervision of , children, of which . ± . % had been diagnosed as having asthma. in replies were sent by physicians, who had a total of , children under their care, including , asthmatics, a prevalence of . ± . %. at the end of , paediatricians having , children answered, noting , asthmatics, a . ± . % prevalence of asthma. conclusion. the current survey of prevalence of asthma in childhood is by far the largest that has been made. an increasing prevalence of the diagnosis of asthma based on clinical investigations was noted, the differences between the investigated years being highly significant. panel report guidelines for the diagnosis and management of asthma have been available since , to standardize and improve the quality of asthma care. however, asthma remains the leading cause of hospitalization for new york city children. implementation of the guidelines has not been fully embraced in the primary care setting. we attempted to increase primary care practitioners' compliance with the guidelines through extensive training. a hospital based pediatric clinic and school based health clinics in the brooklyn inner city, participated from april to march in the program as part of new york city's education and quality improvement project (equip). initially an asthma physician specialist and asthma educator trained the primary care physicians and nurse practitioners in the guidelines. the training was reinforced during monthly luncheon sessions. clinical exam rooms were also supplied with asthma education materials, peak flow meters, and asthma action plans. goals were to identify asthmatics, document asthma severity, give persistent asthmatics written management plans, and utilize appropriate controller medications. compliance was measured by tracking asthma visits with an asthma intake form. prior to this project no consistent attempt had been made in the clinics to regularly classify asthmatic severity, provide written asthma action plans or to place patients on controller medications. after onset of the project a total of asthma visits were evaluated; were from school based health centers and from hospital based pediatric clinic. severity was classified in %( / ) of asthma visits. patients classified as persistent received updated written management plan during %( / ) of asthma visits and %( / ) were placed on controller medications. this asthma management program demonstrated success in improving primary care practitioners' compliance with the naepp asthma guidelines. further studies are needed to determine if compliance with the guidelines persisted after cessation of the extensive training and if such compliance improves asthma outcomes. numerous studies have associated asthma and obesity. although obesity has been identified as a risk factor for asthma, there is limited information on the impact of obesity on childhood asthma. this study examines the effect of body composition on asthma severity and pulmonary function in children. we retrospectively reviewed charts from asthmatic children ages to years, referred to a community-based pediatric pulmonology practice between and . data were included if asthma was the the primary diagnosis and a baseline spirometry was available. asthma severity was classified and body mass index(bmi) was classified as normal, overweight and obese. spirometry results were reviewed. eighty-five patients were reviewed. thirtyone( . %) patients were normal weight; ( . %) were overweight and ( . %) were obese. baseline characteristics such as age, gender and race/ethnicity were similar. asthma severity classification did not differ between normal, overweight and obese children. overall, % were classified as intermittent, % as persistent mild asthma and % as persistent moderate-severe asthma. % of children with intermittent asthma were receiving controller therapy compared to . % with persistent mild and . % with moderate-severe asthma(p= . ). although healthcare utilization for asthma(emergency room visits/admissions) were significantly different between children with intermittent, persistent mild and moderate-severe asthma(p= . ), there was no difference when normal, overweight and obese children were compared. spirometry results showed comparable peak expiratory flow rates(pfr) in all groups; % of predicted in normal weight and % of predicted in both overweight and obese. mean forced vital capacity(fvc) was . %, . % and % and the mean forced expiratory volume in second(fev ) was . %, . % and . % respectively. there was no difference in fev /fvc; . %, . % and . % and forced expiratory flow in mid-lung volumes (fef - ); . %, % and . % of predicted. in this study we retrospectively reviewed asthmatic children and compared bmi, asthma severity and spirometry. we found no difference in asthma severity classification between normal and overweight/obese patients. regardless of the bmi, all indices of spirometry were similar. further studies are needed to examine the impact of obesity on different asthma related disease outcomes. our objective is to further investigate the effect of budesonide, formoterol, and levalbuterol, alone, and in combination, on tgf- production and expression in ragweed (ra) stimulated a cells. meth-ods: a cells were cultured in duplicate for hours at degrees celcius with % co in serum free dmem with or without the following: μg/ml of ra, . x - m of budesonide, . x - m formoterol, and . x - m levalbuterol. tgf- production and expression was measured by a sensitive elisa and mrna assay in cell supernatants and pellets. results: tgf- production and expression from a cells rose markedly in the presence of ra ( . - pg/ml) ( - amol/ml) with significant inhibition following the addition of budesonide, and the combinations of budesonide and formoterol, budesonide and levalbuterol, and budesonide, formoterol, and levalbuterol (p< . ). combined treatment with budesonide and levalbuterol versus budesonide alone reached significance for production and expression (p< . ). budesonide and formoterol compared with budesonide alone reached significance for tgf- production (p< . ). conclusion: combination therapy with budesonide and a long or short acting beta-agonist showed greater effect of tgf- inhibition compared with budesonide alone. this synergistic effect on the distal airways may prevent a subset of asthmatics from developing airway remodeling. g. tamura * , y. sano , k. hirata , s. ishioka , m. nakashima , t. miyamoto , . sendai, japan; . tokyo, japan; . osaka, japan; . hiroshima, japan; . hamamatsu, japan. tulobuterol tape is the world's first long-acting transdermal preparation of a beta -agonist designed to release tulobuterol in an optimal fashion. when it is applied once daily at bedtime, the blood concentration of tulobuterol peaks early in the morning and is kept at effective levels for hours. tulobuterol tape has milder and less frequent adverse events than conventional oral tulobuterol preparations, and when used at bedtime can prevent marked drop in peak expiratory flow (pef) early in the morning. consequently, tulobuterol tape has been commonly used in japan as a long-acting beta -agonist. in the present study, to evaluate its efficacy as a long-acting beta -agonist and to compare its effects at two different doses, we administered tulobuterol tape at doses of or mg/day to patients with persistent asthma already using inhaled corticosteroids. this study was a randomized, double-blind, double-dummy, parallel-group, multicenter trial of -week duration. mean pef in the and mg/day groups were significantly increased from the baseline value by . and . at week , . and . at week , . and . at week and . and . l/min at week , respectively. the increase in mean morning pef in the mg/day group was significantly higher than that in the mg/day group at every point of determination. the mean evening pef was significantly increased in both treatments groups compared with baseline values at every point of determination. although the increase in the mg/day group was greater than that in the mg/day group at each point of determination, the difference between groups was statistically significant only at week . the safety profiles of the two treatments were similar. in patients with persistent asthma who require inhaled short-acting beta -agonists while receiving inhaled corticosteroids, tulobuterol tape mg/day significantly improved pef compared with tulobuterol tape mg/day. introduction: on an average, % of the children admitted annually for asthma to children s hospital require admission to the pediatric intensive care unit (picu). these admissions are highest in the months of august, september and october. aeroallergens such as alternaria and ragweed predominate during this season, and allergies to these allergens may account for the increased number of picu admissions for asthma. objective: we hypothesized that the seasonal increase in the admission rate could be related to allergen sensitivity, particularly to alternaria and/or to ragweed that predominate during late summer and fall. method: data was collected from a retrospective chart review of all patients admitted to the picu for asthma exacerbation between and . skin prick testing (spt) within one year of picu admission was the criteria for inclusion in this study. results: there was a higher prevalence of admissions to the picu for asthma exacerbation during august, september and october ( out of admissions = % of all admissions, p< . ). sixty-one subjects met the one-year spt criteria for analysis. subjects admitted during august, september and october were categorized as group a, and all others were categorized as group b. sensitivity to a total of aeroallergens (tress, grasses, weeds, ragweed, outdoor molds, indoor molds, alternaria, cat, dog, roach and dust mites) was compared between the two groups. there was no statistical significance in aeroallergen sensitivity to alternaria or ragweed between subjects admitted to the picu in august, september and october (group a) and subjects admitted during the other months of the year (group b). conclusion: asthma exacerbation requiring picu admissions is more prevalent during the months of august, september and october. the increased rated of picu admissions did not correlate with the aeroallergen sensitivity to the prevalent allergens during august, september and october. therefore we suspect other factors such as, viral upper respiratory infections, in addition to aeroallergen sensitivity, which may contribute to severe asthma exacerbation during the late summer and fall months. k. kuzume * , shigenobu, ehime, japan. infantile wheezing may be the result of different phenotypes. the aim of this study was to evaluate the risk factors for allergies and the results of allergyrelated blood tests among infants with different types of allergy symptoms. infants were examined physically at birth and at , , , , and months of age, and questionnaires about number of siblings, the family history of allergy, and feeding methods were given. allergic diseases were diagnosed at months of age, and the subjects were divided into groups: infants with atopic dermatitis (ad) only (a group, n= ), infants with both ad and wheezing (a/w group, n= ), infants with wheezing only (w group, n= ), and infants without allergic symptoms (c group, n= ). risk factors were then evaluated. patients ( from the a group, from the a/w group, and from the w group) were given allergy-related blood tests, total serum ige levels, and rast with egg white, milk, and house dust mites at and months of age. the results of the blood tests in control subjects at months of age were compared to the other groups. as shown in table , there were more male infants in the a/w and a groups than in the c group (p< . , a/w vs. c; p< . , a vs. c). numbers of siblings were greater in the w and a/w group than in the a or c group (p< . , w vs. a and w vs. c; p< . , a/w vs. a; p< . , a/w vs. c). the rate of positive family history of allergic diseases was high in the a and a/w groups, compared to the w or c group (p< . , a vs. c and a/w vs. c; p< . , a/w vs. w). the rate of breastfeeding at months of age was high in the a group compared to the others (p< . , a vs. c). patients in the w group had lower levels of total serum ige at months of age, compared to patients in a or a/w (p< . , w vs. a/w and w vs. a). also patients in the w group had lower levels of rast with egg white at months of age, compared to patients a or a/w (p< . , w vs. a/w and w vs. a). the median of total serum ige levels at months of age was higher in a and a/w but not in w, compared to c (p< . , a/w vs. c and a vs. c). in conclusion, there were two different phenotypes of wheezing in infants before months of age. wheezing with ad might be "allergy-related", while wheezing without ad may be related to other factors. as compared to c group: a), p< . ; b), p< . ; c), p< . ; d), p< . as compared to a group: ), p< . ; ), p< . ; ), p< . ; ), p< . as compared to a/w group: f), p< . ; g), p< . ; h), p< . a group, infants with atopic dermatitis only; a/w group, infants with atopic dermatitis and wheezing; w group, infants with wheezing only; c group, infants without allergic symptoms. rast, radioallergosorbent test, n/a, data not available r. amelio * , c. capristo , a. capasso , m. miraglia del giudice , n. maiello , f. decimo , . naples, italy; . napoli, italy. forced oscillation technique (fot) is considered a sensible and specific method to estimate breathing functionality in asthmatic children aged to years, because it doesn't need special collaboration. the aim of our study was to value baseline respiratory resistances with the fot in preschool-aged children with asthma under high dose of budesonide and flunisolide treatment. at this purpose, asthmatic children aged to years were selected: at a first examination (t ) all the patients showed basal value fot at hz frequency (rr ) changes major or equal than % under mcg of salbutamol treatment. days before the study, children selected didn't take systemic and inhaled steroids, cromons, leukotrienes antagonists, teophylline or anti-histamines and they didn't present upper and lower airways infections; then, two weeks before run-in, all selected patients took beta- -agonists at least times per week. all the patients were divided in two groups: group i ( children) under inhalation of flunisolide mcg/kg/dose + salbutamol mcg b.i.d. for days and, for the following two weeks, under inhalation of flunisolide mcg/kg/dose + salbutamol mcg by pmdi+spacer prn.; group ii ( children) under inhalation of budesonide , mg b.i.d. + salbutamol mcg b.i.d. for days, and for the following two weeks, under inhalation of budesonide , mg b.i.d. + salbutamol mcg by pmdi+spacer prn. moreover, we gave diary-card with a simple symptoms score (at t and t ), to get the real perception of the symptoms in the course of study. however, during the treatment, children have ritired from the study. the results obtained were statistically analysed (t student's test). significant rr pre beta- -agonists and ? value reduction was obtained at t and t vs. t . group i had (at t ) such a quick action than group ii reducing airways resistances (p< , ). children treated with flunisolide had lower frequency of breathless and nocturnal cough at t and lower salbutamol use from t to t than budesonide group (p=n.s.). in conclusion, fot is actually a safety method to value efficacy of inhaled steroids in preschool-aged children with asthma. introduction: approximately . % of u.s. adults and . % of louisiana (la) adults have current asthma, and over % currently smoke cigarettes, according to the behavioral risk factor surveillance system (brfss). the purpose of this study is to compare asthmatic smokers vs. nonsmokers in la and the u.s. here we address whether asthmatic smokers utilize more medical care services in the er and outpatient clinics, and whether they were able to fully participate in activities of daily living compared to nonsmoker asthmatics. methods: brfss is a state-based, telephone survey of u.s. adults. the survey collects self-reported information about modifiable risk factors for chronic diseases. this study analyzed data from the brfss survey using sas software. data: out of the current asthmatics, % are cigarette smokers in the u.s. in louisiana, % of asthmatics are currently smoking, which is significantly higher than the national average (p< . ). within the past year, the average number of emergency room visits due to asthma was similar for both locations (la . , us . , p= . ) . nationally, smokers visited the er significantly more frequently than nonsmokers (s . , ns . , p< . ). in la, smokers visited the er twice as often as nonsmokers (s . , ns . , p< . ) the number of annual routine outpatient checkups for asthma was similar based on location (la . , us . , p= . ). smokers and nonsmokers had a similar number of checkups nationally (s . , ns . , p= . ) and in louisiana (s . , ns . , p= . ). the number of days where asthmatics were unable to perform their usual activities was significantly fewer in la than nationally (la . , us . , p< . ). smokers had a significantly higher number of missed days nationally (s . , ns . , p< . ). in la, there was not a significant difference in the number of missed days based on smoking status (s . , ns . , p= . ). conclusion: even though louisiana has a lower prevalence of asthmatics compared to the national average, significantly more of our asthmatics are smokers. asthmatic smokers in la and the u.s. utilized the er more than their nonsmoking counterparts. smokers and nonsmokers had similar numbers of routine outpatient visits. asthmatic smokers missed more days, but this was only significantly different at the national level. other research has shown that young age is highly associated with improper use in children using a mdi and holding chamber (arch pediatr adolesc med ; : ) . the objective of this study was to compare health outcomes achieved by children with asthma using inhaled corticosteroids (icss) delivered by a nebulizer compared with outcomes of children using icss delivered by non-nebulized device. methods: using a managed care organization database (pharmetrics integrated outcomes database), we identified children aged years with an asthma diagnosis and asthmarelated hospitalization/emergency department (ed) visit (july -june and with a prescription claim for an ics within days of discharge. we compared relative risk of hospitalization/ed recurrence from day - (cox proportional hazards regression, covariates=sex, age, current and prior asthma medications, prior oral corticosteroid and short-acting -adrenergic agonist use, initial type of index event) for patients receiving nebulized ics vs other ics by age groups ( - years and - years). results: of patients with claims for ics, received nebulized ics, of which were aged years; received non-nebulized ics, of which were aged years. postindex hospitalization/ed rates were . %. refill rate was higher for patients using nebulized ics. after model risk adjustment, patients using nebulized ics had a % risk reduction for hospitalization/ed recurrence vs those not using nebulized ics (hr: . , % ci: . , . ). in the -to -year age group, patients on nebulized ics had a % risk reduction compared with patients not using nebulized ics (hr: . , % ci: . , . ). in the -to -year age group, patients on nebulized ics had a % risk reduction (hr: . , % ci: . , . ). conclusion: in actual practice, treatment with nebulized ics after an asthma exacerbation is associated with a significant reduction of recurrent hospitalization/ed visits in young children, possibly due to improved technique and compliance. introduction: tenor is a -year, multi-center, cohort study of patients with severe or difficult-to-treat asthma. the objective of the tenor study is to better understand the natural history of patients with severe or difficult-totreat asthma. this analysis assessed the frequency of skin testing in this population and characterized the differences between the positive (st+) and negative (st ) subjects. methods: subjects were asked whether they had ever been skin tested and, if so, the test results. those who were st+ were compared to both st and those never tested (stnd) using clinical and other asthma-related characteristics. subjects years of age were included in this analysis. results: subjects were eligible for this analysis. . % were skin tested in the past, with stnd frequency of . % from allergist sites and % from pulmonologist/other sites. of those tested, . % were positive (allergist . %, pulmonologist/other . %). baseline ige for st+ subjects was . iu/ml vs. . iu/ml for st ; p< . (table) . as shown, the age at asthma onset, duration of asthma, rate of atopic disorders, and the rate at which asthma was triggered by aeroallergens differentiated the st+ from the st group. disease severity as evaluated by fev , healthcare utilization, and medication use, however, was similar between the two groups. in general, stnd were more likely to have values closer to the st+ group, suggesting that the majority of those not tested would have been st+, if administered a test. conclusions: the prevalence of st+ subjects from both allergy and pulmonary practices was high, demonstrating that the majority of these severe or difficult-to-treat patients have allergic asthma. st+ patients showed differences in clinical characteristics compared to st , including a greater likelihood of their asthma symptoms being triggered by aeroallergens. these data also show that the clinical profile of stnd patients may be similar to that of st+ patients, suggesting the utility of a more universal allergic evaluation in severe asthmatics. funded by genentech and novartis pharmaceuticals corp. background current national guidelines for the diagnosis and management of asthma such as the naepp epr , classify asthma severity based on frequency of asthma symptoms, medication use, and measurements of lung function by spirometry or peak expiratory flow variability. recently, the utility of spirometry measurements for assigning asthma severity has come into question. here we evaluate the correlation of spirometry measurements with asthma severity in school-aged children who are mostly naive to anti-inflammatory therapy. methods children were participants in a school-based lowincome asthma mobile van program, the breathmobile. recruitment was through referrals by school nurses and community public health clinics, parental response to flyers, and asthma screening questionnaires. spirometry was performed on all children greater than years of age as part of a comprehensive asthma evaluation. asthma severity was assigned based on symptoms only, according to the naepp epr . results from april to april of the children evaluated on the breathmobile, patients were diagnosed with asthma. classification of severity by symptom frequency according to naepp epr guidelines resulted in % as mild intermittent (mi), % as mild persistent (mip), % as moderate persistent (mop), and % as severe persistent (sp). the percentage of patients and their mean lung functions at baseline evaluation without bronchodilator challenge are shown in the table. there were statistically significant differences (p<. ) between severity groups which was most pronounced for the fef - % when comparing the severe persistent group and the intermittent group. however, mean values appear to be "normal" for all degrees of asthma given current accepted cut-off values, fvc %, fev %, fev /fvc %, and fef - %. conclusion in our study, airflow impairment did correlate with asthma severity, although it was "normal" (fev %) even in children with severe persistent asthma. therefore, a "normal" lung function measurement may be misleading as sole criteria for asthma severity classification. perhaps a higher cutoff point (fev < %) might be a better indicator of asthma severity in children. asthma is the most frequently chronic disease in childhood.our main was to know the prevalence of bronchial asthma in children ( - and - years) in the north zone of mexico city and to compare the prevalence obtained by the written questionnaire versus the video questionnaire in the group of to years, according to methodology proposed by isaac. material and methods: by means of a validated and standardized questionnaire (isaac) that was applied to children from to years and from to . the questionnaires of and years were filled out by their parents. the group from to years answered a questionnaire and a video questionnaire. according to isaac specification and based on a studied population, it was calculated by statcal program the size of the sample. it was choose a haz-ardous sample of children between - years and of the - group years, both sexes in elementary and high school. measures of central tendency and chi were used. results: the final sample size for both groups was children ( of - and adolescents), . % men and . % women. the prevalence of the asthma diagnosis for teenagers was of % (p< . ic . - . ) and it was . % in children (p< . ic . - . ), wheezing in the last months was . % (p< . ic . - . ) in children and of . % (p< . ic - . ) for - years. wheezing induced exercise appeared in . % (p< . ic - . ) in teenager and . % (p< . ic . - ) in the other group. the severity of asthma showed by nocturnal awakness was . % and . % (p< . ), number of crisis in the last year . % and . % for children and teenagers respectively (p< . ). in the video questionnaire of teenagers . % (ic . - . ) answered affirmative on have displayed a shaken breathing on the last year resting and only . % (ic - . ) in the last month. about exercise question . % confirmed have displayed symptoms, . %(ic - . ) in the last year and . % (ic . - . ) in the last month. wide-awake at night . % (ic . - . ) in the last year and . % ) in the last month. conclusions: the prevalence of asthma by diagnosis was higher in teenagers group than in children group. the prevalence of asthma was higher also in this group. rationale: we investigated the relationship of pet exposure and healthcare utilization (hcu) in a cohort of pediatric patients with severe or difficult-totreat asthma in the epidemiology and natural history of asthma: outcomes and treatment regimens (tenor) observational study. we hypothesized that pet exposure would increase hcu due to increased airway inflammation. methods: tenor is a -year multicenter cohort study of patients with severe or difficult-to-treat asthma. children ages - were interviewed at baseline regarding asthma-related hcu in the previous months. patients with pet exposure (ppe, n= ) were compared with patients with no pet exposure (pnpe, n= ). responses were analyzed using fisher's exact test. results: ppe were less likely to have severe asthma by physician assessment ( % vs. %; p= . ). in addition, ppe were less likely to have an emergency room (er) visit ( % vs. %; p= . ) or to have been hospitalized ( % vs. %; p= . ) in the previous months. more pnpe had an ige level > iu/ml ( % vs. %; p= . ). ppe and pnpe were similar with regard to presence of allergic rhinitis and skin test positivity. compared with pnpe, fewer ppe with two or more pets had er visits and hospitalizations (table) . among ppe, there were no differences in ige levels or in asthma severity related to the number of pets. conclusions: pet exposure was associated with reduced hcu in the tenor pediatric cohort, with the most pronounced effect seen in reduced er visits and hospitalizations needed by those with multiple pets. ppe had significantly lower ige levels compared to pnpe, regardless of the number of pets. these data support the hypothesis that exposure to pets may paradoxically protect individuals from the development of severe asthma. alternatively, these data may reflect a self-selection in patients with severe or allergic asthma who are likely to avoid having a pet. however, there may be other confounding factors in families with pets that confer a protective effect on asthma severity. introduction: in asthma and other chronic obstructive airway diseases, phosphodiesterase (pde ) is involved in the pathophysiology of the disease and is expressed abundantly in key inflammatory cells. inhibitors of pde are investigational, anti-inflammatory agents that prevent the breakdown of cyclic adenosine monophosphate, a natural modulator of inflammation. roflumilast is an investigational, oral, once-daily pde inhibitor with demonstrated in vitro and in vivo anti-inflammatory activity, which may translate into clinical efficacy in asthma therapy. this study examined the ability of roflumilast to exert direct or acute bronchodilatory activity in patients with mild to moderate asthma. methods: this was a double-blind, randomized, placebo-controlled, crossover study consisting of three treatment periods of one day each, separated by a -to -day washout period. during each treatment period, patients with a forced expiratory volume in one second (fev ) of % to % of predicted received either oral roflumilast μg, roflumilast μg, or placebo. the fev was measured twice prior to administration and periodically up to h following treatment. after h, patients inhaled μg salbutamol from a metered-dose inhaler; fev was measured min later. adverse events, vital signs, and electrocardiogram results were monitored throughout the study. results: median baseline fev was similar for the three treatment periods. both doses of roflumilast did not lead to statistically significant differences versus placebo in the time-averaged fev over the first or up to h after drug intake (p > . ). thus, there was no evidence of a direct or acute bronchodilatory effect with either single doses of roflumilast μg or μg. in contrast, inhalation of the short-acting bronchodilator salbutamol led to a distinct improvement in fev versus baseline in all treatments groups with median fev increases of %, %, and % in the roflumilast μg, roflumilast μg, and placebo groups, respectively. roflumilast was well tolerated. conclusions: oral, once-daily roflumilast exhibits no direct or acute bronchodilatory activity in patients with mild to moderate asthma as could be achieved with short-acting -agonists. these data support the proposed mechanism of action of roflumilast as an antiinflammatory agent. south africa; . guadalajara, spain; . munich, germany; . weinheim, germany; . budapest, hungary; . konstanz, germany. introduction: phosphodiesterase (pde ) is found in key inflammatory cells involved in the pathophysiology of chronic obstructive pulmonary disease and asthma. inhibitors of the pde enzyme are anti-inflammatory agents that prevent the breakdown of cyclic adenosine monophosphate, a natural modulator of inflammation. roflumilast is an investigational, oral, oncedaily pde inhibitor with demonstrated in vitro and in vivo anti-inflammatory activity. this study examined the dose-related efficacy of roflumilast in patients with asthma. methods: patients with stable asthma (forced expiratory volume in second [fev ] % to % of predicted) were enrolled in this randomized, double-blind, dose-range finding study. after a single-blind placebo run-in period of up to three weeks, patients received oral roflumilast μg, μg, or μg once daily (n = , , and , respectively) for weeks. efficacy was assessed by change from baseline in spirometric lung function fev and forced vital capacity (fvc), as well as morning and evening peak expiratory flow (pef) recorded in patient diaries. safety and tolerability parameters were monitored throughout the study. results: treatment with roflumilast led to dose-dependent and statistically significant increases in fev , fvc (both p < . ), and in morning pef (p < . ). at last visit, fev improved from baseline by ml ( %), ml ( %), and ml ( %) in patients treated with roflumilast μg, μg, and μg once daily, respectively. similarly, dose-dependent improvements of l/min, l/min, and l/min in morning pef from baseline were reached. roflumilast was well tolerated at all dose levels tested. the most frequent drug-related adverse events were headache followed by gastrointestinal disorders such as diarrhea and nausea. there were no clinically relevant changes in vital signs, electrocardiogram, or laboratory parameters. conclusions: oral, once-daily roflumilast was associated with dose-dependent, clinically relevant improvements of lung function in patients with stable asthma. roflumilast was well tolerated. j.l. izquierdo * , e.d. bateman , p. magyar , u. harnest , p. hofbauer , a. varga , c. schmid-wirlitsch , d. bredenbroeker , t.d. bethke , . guadalajara, spain; . cape town, south africa; . budapest, hungary; . munich, germany; . weinheim, germany; . tatabanya, hungary; . konstanz, germany. introduction: phosphodiesterase (pde ) inhibitors are a new class of anti-inflammatory agents for therapeutic use in inflammatory airway diseases. in several studies, the investigational, oral, once-daily pde inhibitor roflumilast has provided clinically meaningful improvements in patients with chronic obstructive pulmonary disease and asthma. this study examined the long-term safety and tolerability of roflumilast over weeks in patients with asthma. methods: patients with persistent, stable asthma (fev % to % of predicted at randomization) participated in a double-blind, randomized dose-range finding study and were treated with oral roflumilast μg, μg, or μg once daily for weeks. patients completing the -week study per-protocol, then continued treatment in this open-label -week extension study. all patients received oral roflumilast μg once daily during the extension period. adverse events (aes), clinical laboratory parameters, vital annals of allergy, asthma & immunology signs, and ecg were assessed throughout the extension period. results: a total of patients were enrolled in the -week extension study. overall, the most common aes were related to the respiratory system. only a small number of patients ( %) experienced aes that were assessed as at least likely related to study medication. the most frequent drug-related adverse events were headache, diarrhea, and nausea as reported by %, %, and % of patients, respectively. most aes were mild to moderate in intensity and transient in duration; % of patients discontinued the study due to aes. most ( %) of these aes leading to discontinuation were assessed as not related or unlikely related to study drug. out of patients, reported serious aes, which were all assessed as not related or unlikely related to roflumilast. no clinically relevant changes in clinical laboratory parameters, vital signs, ecg, or physical examination occurred. conclusions: oral, once-daily roflumilast μg administered for weeks was well tolerated in patients with persistent, stable asthma. this study provides evidence that roflumilast is associated with a low incidence of aes, which are mostly mild to moderate in intensity and transient in nature, thus, supporting the potential therapeutic use of roflumilast in asthma. paris, france; . madrid, spain; . guadalajara, spain; . harrow, united kingdom; . weinheim, germany; . augsburg, germany; . munich, germany; . kaufbeuren, germany; . konstanz, germany. introduction: in asthma, inhaled corticosteroids (ics) have been the mainstay of maintenance treatment. new therapeutic agents are needed that target key inflammatory processes in asthma as effectively as ics but overcome known limitations of ics. phosphodiesterase (pde ) inhibitors are anti-inflammatory agents that prevent the breakdown of cyclic adenosine monophosphate, a natural modulator of inflammation. roflumilast is an investigational, oral, once-daily pde inhibitor for potential use in anti-inflammatory asthma therapy. this study compared the standard corticosteroid treatment of twice-daily, inhaled beclomethasone dipropionate (bdp) with oral, once-daily roflumilast in patients with asthma. methods: in a randomized, double-blind, double-dummy study, patients (forced expiratory volume in one second [fev ], % to % of predicted) received either oral roflumilast μg once daily (n= ) or inhaled bdp μg twice daily ( μg/day; n= ) for weeks. mean change (lsmean and sem) in lung function parameters fev , forced vital capacity (fvc), and morning and evening peak expiratory flow (pef) from baseline was determined after weeks of treatment. further, symptom score and rescue medication use were assessed. results: both roflumilast μg and bdp μg improved fev from baseline to clinically meaningful levels ( ± ml and ± ml, respectively; both p< . ). similarly, roflumilast and bdp improved fvc ( ± ml and ± ml, respectively; both p< . ) as well as morning and evening pef (p . ). roflumilast μg was statistically non-inferior to bdp μg. roflumilast and bdp led to statistically significant and comparable improvements in asthma symptoms and use of rescue medication. adverse events were generally mild to moderate; the most common drugrelated adverse events reported in the roflumilast group were nausea, headache, and diarrhea. there were no clinically relevant changes in vital signs, ecg, or laboratory parameters. conclusions: roflumilast μg provided clinically meaningful improvement of lung function parameters, reduced asthma symptoms, and decreased the need for rescue medication. oral, once-daily roflumilast was as effective as inhaled, twice-daily bdp in the treatment of asthma. oral roflumilast μg was well tolerated. rationale: evaluation of medical claims from commercial health plans permits assessment of therapeutic interventions on resource utilization. this study investigated the impact of controller therapy in children starting asthma maintenance medications. the risk of obtaining prescriptions for oral corticosteroids (ocs), short-acting beta-agonists (saba) or adding another asthma therapy was evaluated. methods: this was a retrospective observational study utilizing medical and pharmacy claims from a large representative managed care plan from / / - / / . children aged - years old with an asthma diagnosis (icd- , .xx) and an initial pharmacy claim for one of the following regimens: fluticasone/salmeterol in a single inhaler, n= , (fsc), fluticasone propionate alone, n= , (fp), montelukast, n= , (mon), any inhaled corticosteroid plus montelukast, n= , (ics+mon), and an ics plus salmeterol from separate inhalers, n= (ics+sal) were included in the analysis. subjects were excluded if they had received any asthma controller medication in the months prior to the initiation of therapy. regression was used to estimate the incidence rate ratio (irr) for ocs and saba use (negative binomial) and the odds ratio (or) of adding a controller (add) and an ed or hospitalization (ip) event (logistic). all models controlled for demographics, pre-controller asthma-related medications and events, and baseline total health care costs. results: the ratios in the table with a confidence interval excluding unity indicate significantly increased use or likelihood of an event compared to the fsc cohort. controller naïve children started on fsc were less likely to add another controller than mon, fp or ics+sal, and had less use of ocs or saba than the cohorts when studied for months after the initiation of controller therapy. in addition, children treated with ics + mon had a significantly greater or of an ed/ip visit compared to fsc. conclusion: use of fp + sal (fsc) in a single inhaler assures that children are getting more optimal inhaled corticosteroid therapy as well as the benefits from the long acting bronchodilator while avoiding the potential for selective discontinuation of ics in the multiple controller cohorts. a.s. nayak * , r. nathan , j. williams , s. kundu , m. lloyd , d. banerji , . normal, il; . colorado springs, co; . bridgewater, nj. introduction: inhaled corticosteroids (ics) are recommended firstline therapy for severe, persistent asthma. systemic exposure to ics may suppress hypothalamic-pituitary-adrenal (hpa)-axis function, particularly at doses required to control severe asthma. ciclesonide (cic) hydrofluoroalkane (hfa) metered dose inhaler (mdi) is a novel and effective ics that is converted in the lungs to its active metabolite, desisobutyryl ciclesonide (des-cic). previously, in short-term studies, cic has been shown to have no effect on serum or urinary cortisol levels, which may be attributed to the low oral bioavailability, high serum protein binding and high clearance rate of cic and its active metabolite. this hpa axis analysis was part of a long-term study evaluating the safety of cic and beclomethasone dipropionate (bdp) hfa-mdi in patients with severe persistent asthma. methods: this was a multicenter, double-blind, parallel-group, -month extension of a -week double-blind trial of patients years with severe persistent asthma. patients were randomized in a : ratio (cic:bdp) to receive cic ( g bid) exactuator or bdp ( g bid) ex-actuator. after weeks, the doses of both medications could be titrated to g bid as needed for asthma control. hpa-axis function was assessed at selected centers in a subset of patients at baseline and end of study (at month or early termination) by measuring both peak serum cortisol induced by low dose ( -μg) cosyntropin and -hr urinary free cortisol corrected for creatinine. results: data were available for a small number of patients at centers evaluating hpa-axis (table) . mean baseline levels and change from baseline to end of study values in low-dose cosyntropin peak serum cortisol levels for cic and bdp were comparable. likewise, baseline levels and mean change from baseline to end of study values in -hr urinary free cortisol corrected for creatinine were comparable among the two treatment groups. conclusion: these findings demonstrate that cic to μg daily for months is safe and has no significant effect on hpa-axis function. a. long * , a. rahman , . boston, ma; . wilmington, de. introduction: little information is available regarding the relationships between asthma severity, disease control, and compliance with medications. methods: physicians' perceptions regarding these variables were determined by internet-based general asthma medication usage survey and patient-specific asthma medication usage surveys between december and , , for physicians ( pcps, pediatricians, allergists and immunologists, and pulmonologists). the patient-specific surveys were based on chart information of randomly chosen patients per physician on controller medication. results: of patients, %, %, %, and % were categorized by their physicians as having mild intermittent or mild, moderate, or severe persistent asthma, respectively. overall, % of patients were categorized as having "very controlled" asthma and % as being "very compliant" with their current regimen. worse asthma control, decreased compliance, and increased physician visits were all associated with increased asthma severity classification. physicians reported that only % of patients with severe persistent disease (n= ) had "very controlled" asthma in contrast to % of patients with mild intermittent asthma (n= ). patients with mild intermittent asthma, and mild, moderate, and severe persistent asthma, had a mean of . , . , . , and . physician visits for asthma, respectively, within the past year. physician perception of patient compliance varied less across the groups, with % of patients with severe persistent asthma and % of patients with mild intermittent asthma being rated as "very compliant." the incidence of allergic rhinitis was similar among all severity levels (range: %- %), but patients with severe persistent asthma were more likely to have comorbid conditions, including hypertension, chronic obstructive pulmonary disorder, chronic bronchitis, and osteoporosis, compared with patients in other asthma severity levels. conclusions: decreased asthma control and rates of com-pliance, as well as increased physician visits and comorbid medical conditions, may be associated with increased asthma severity classification. rationale: children with asthma frequently have co-morbid allergic conditions requiring medications. the purpose of this study was to assess whether the controller asthma medication selected would reduce the utilization of intranasal steroids (ins) and prescription nonsedating antihistamines (nsa) for children treated for co-morbid allergy. methods: this was an observational retrospective study that utilized the pharmetrics integrated outcomes database that contains administrative medical and pharmacy claims data from over managed care plans across the united states. children age - years old with a new diagnosis of asthma (icd- , .xx) were identified and observed for months after their initial diagnosis and treatment of asthma (post-index). four cohorts were established based on their controller medication dispensed: montelukast, n= (mon), fluticasone propionate, n= (fp), fp+mon n= , fp/salmeterol in a single inhaler, n= (fsc). results: baseline comorbid diagnosis of allergic rhinitis was observed in - % of the children. the patterns of use of ins and nsa were similar in the months before and the months after the initial asthma diagnosis and treatment. children with a diagnosis of allergic rhinitis were nearly twice as likely to receive a nsa or ins. all treatment cohorts used a similar amount of each allergy medication. the presence or absence of a diagnosis of allergic rhinitis did not alter the findings. the adjusted odds ratio ( %ci) of using a nsa or ins relative to the use of fsc in the post-index period was mon: . ( . , . ); fp: . ( . , . ); fp+mon: . ( . , , ). the table below shows the percent of children dispensed a nsa and/or an ins. the number of units of each allergy medication was also similar across all cohorts. conclusion: the use of mon, fp, fp+mon or fsc for asthma did not alter the rate or quantity of either intranasal corticosteroid or nonsedating antihistamines dispensed to children over the -month period. although allergic rhinitis is a common comorbidity of pediatric asthma, the selection of a regimen containing montelukast did not reduce the use of either nsa or ins compared to asthma treatments with fp or fsc. rationale: medication compliance is recognized as a significant challenge in pediatrics.the purpose of this study was to compare inhaled corticosteroid (ics) persistence in pediatric patients using a single inhaler, containing both an inhaled corticosteroid (fluticasone propionate, fp) and an inhaled long-acting beta-agonist (salmeterol, sal) (fsc), to patients receiving fp alone, fp + sal from separate inhalers, or ics + montelukast (mon). methods: retrospective -month pre-post database study utilizing medical and pharmacy claims. a total of subjects - years of age with a diagnosis of asthma (icd ) were grouped into cohorts: fsc [n= ]; fp only [n= ] ics+sal [n= ]; and ics+mon [n= ]. patients were controller naïve for months prior to the index event (the first prescription of the medication of interest). subjects were required to have continuous enrollment of months pre-and months postindex. subjects with cystic fibrosis, copd, bronchopulmonary dysplasia or respiratory distress syndrome were excluded. ics refill rates, as a measure of persistence, were compared between fsc and the ics components of the other cohorts over a -month follow-up period. results: mean refill rates over the -month follow-up period was significantly greater (p=< . ) for fsc ( . ) compared with the mean ics refill rate in the fp alone ( . ) cohort, the ics + sal ( . ) and the ics + mon ( . ) cohort. patients on fsc filled % more ics prescriptions than patients on fp alone, % more than ics+sal and % more than ics + mon. mean refills were generally higher than the median fills as a considerable number of children had only one fill: fsc ( . %), fp ( . %), ics ( . %) + sal ( . %), ics ( . %) + mon ( . %). conclusion: patients using fsc, are likely to fill their inhaled corticosteroids more often over -months compared with patients using ics + sal in separate inhalers, ics+mon, and fp as monotherapy. improved persistence with ics has been shown in other studies to decrease morbidity and mortality of asthma. use of fsc, a single inhaler, assures that children are getting more optimal inhaled corticosteroid therapy as well as the benefits from the long acting bronchodilator while avoiding selective discontinuation of ics that may occur when two medications are dispensed. the national health interview survey (nhis) estimates . million united states residents with asthma. noncompliance with treatment has been estimated as between and %. the consequences of noncompliance include absences from work or school, increased emergency room visits, more severe attacks, increased drug side effects, greater cost of care, and death. we questioned compliance in a yo man with severe, prednisone dependent eosinophilic asthma because he had persistent symptoms despite treatment with fluticasone propionate/salmeterol xinafoate / bid, prednisone mg to mg qd, and budesonide ( mcg/puff) puffs bid. after discontinuation of budesonide and prednisone and initiation of methylprednisolone mg bid for hours and then mg qd and beclomethasone dipropionate puffs ( mcg) hfa bid with a spacer, clinical improvement was unexpectedly abrupt. fev increased from % to % of predicted. sputum eosinophil counts decreased from % to %. because of the sudden improvement with the change to methylprednisolone, compliance to prednisone and fluticasone was questioned. to evaluate compliance, the patient's blood, urine, and sputum were tested for synthetic corticosteroids, without his knowledge, using mass spectrometry. the blood level of methylprednisolone was . mcg/dl and prednisolone was . mcg/dl, documenting use of methylprednisolone and the recently discontinued prednisone. the urine levels were mcg/dl of methylprednisolone, . mcg/dl of prednisolone and . mcg/dl of prednisone that further confirmed recent use of prednisone. the sputum testing revealed . mcg/dl beclomethasone, mcg/dl fluticasone and . mcg/dl methylprednisolone confirming compliance to inhaled fluticasone and beclomethasone at the time of the test. thus, contrary to our clinical suspicion, the patient was indeed compliant with his inhaled glucocorticoids and prednisone and subsequently with the methylprednisolone. to our knowledge, this is the first case report to document compliance to inhaled and oral corticosteroids by analysis of synthetic corticosteroid concentrations in blood, urine, as well as sputum. if compliance could be documented with certainty, it could potentially minimize the adverse effects of needless escalating steroid doses, reduce the cost of treatment, and minimize morbidity and mortality as well. rationale:the burden of pediatric asthma extends beyond those children with an asthma diagnosis. children with wheezing frequently have a delay in the diagnosis of asthma that may impede instituting appropriate therapy and reducing disease morbidity. this observational study was designed to assess the treatment patterns of children - years old receiving asthma medication(s) without a diagnosis of asthma compared with children diagnosed with asthma and children without claims for asthma. methods:this was a retrospective cross-sectional study that utilized the pharmetrics integrated outcomes database containing administrative medical and pharmacy claims data from over managed care plans across the united states. three cohorts were selected: children with an asthma diagnosis (icd- , .xx) (dx cohort), children with prescription claims for asthma controllers or rescue medications without an asthma diagnosis (rx cohort) and children with neither an asthma diagnosis nor prescription claims for asthma medications (control cohort). utilization of asthma medications, asthma specific costs and total costs of care were assessed. results: a total of , children were identified: . % in the dx cohort, . % in the rx cohort and . % in the control cohort. the potential asthma cohort was . %. total annual non-asthma related costs for the dx cohort was $ , for the rx cohort was $ , and for the control was $ . only % and % of the total healthcare charges in the dx and rx cohorts retrospectively were asthma related. non-asthma charges were significantly higher in both the dx and rx cohorts compared with the control cohort. in the rx cohort, the ratio of saba prescription claims to asthma controller claims were . -fold higher than in the dx cohort. conclusion: children treated with asthma medications without an asthma diagnosis consume greater health care resources resembling the pattern of health care utilization of children with an asthma diagnosis more closely than controls. further, children with treatment in the absence of an asthma diagnosis appear to be under-treated with controller therapy as recommended by national and international guidelines. background: a recent retrospective study assessed asthma variability in inner-city patients months before and months after enrollment into an naepp guidelines-directed clinical management and educational program. while guidelines-directed care improved asthma symptoms and outcomes, significant variability in disease indices were observed over the -month period. the present analysis evaluates resource utilization associated with this variability. method: economic end points, including hospital/emergency department (ed) visits, total unscheduled office visits, sick visits, and days lost from work or school, were collected from inner-city patients aged years ( % female, % minority, % treated by primary care physicians) enrolled in a guidelines-directed asthma clinical management and education program aimed at minimizing barriers to adherence. patients were stratified into groups: those with high variability in asthma (n= ) and those with low variability in asthma (n= ), with variability defined as number of fluctuations in naepp symptom class in the -month postintervention period (high variability = patients with fluctuations higher than the mean; low variability = patients with fluctuations lower than the mean). results: guidelines-directed therapy was associated with improvements in asthma during the -month treatment period for both groups. patients in the high-variability group had more ed visits, sick visits, total unscheduled visits, and office visits compared with patients in the low-variability group (see table) . conclusions: despite guidelines-directed therapy and overall improvement in asthma control, patients experienced variability in asthma, indicating that even when their disease is stable, their symptoms continue to fluctuate. as a result, asthma variability may contribute to increased resource utilization. introduction: inhaled corticosteroids (ics) are considered first-line therapy for patients with persistent asthma. ics can lead to oropharyngeal adverse events, which may affect treatment outcomes and adherence. the occurrence of these local adverse events is dependent upon several factors, including dosage and duration of ics treatment. ciclesonide (cic) hydrofluoroalkane (hfa)-metered dose inhaler (mdi) is a novel and effective ics, with relatively low oropharyngeal deposition. cic is converted in the lungs to its active metabolite, desisobutyryl-ciclesonide (des-cic). furthermore, cic undergoes limited conversion in the oropharynx, which may account for its improved safety profile. this oropharyngeal safety profile analysis was part of a long-term study evaluating the safety of cic hfa-mdi vs beclomethasone dipropionate (bdp) hfa-mdi in patients with severe persistent asthma. methods: this was a multicenter, double-blind, parallelgroup, -month extension of a -week double-blind study of patients years with severe persistent asthma. patients were randomized in a : ratio (cic:bdp) to receive cic ( g bid) or bdp ( g bid) (both ex-actuator). after weeks, the doses of both medications could be titrated to g bid as needed for asthma control.) oropharyngeal adverse events were monitored, and suspected oral fungal infections were verified by positive culture. results: the incidence of oral candidiasis was lower in subjects receiving cic ( . %), compared with those receiving bdp ( . %) ( table) . the incidence of pharyngitis and hoarseness was . % and . %, respectively, for the cic group, and . % and . %, respectively, for the bdp group. all local adverse events resolved without sequelae, and there were no withdrawals due to oropharyngeal treatment-emergent adverse events. conclusion: after -months of treatment with cic μg or μg twice-daily, the incidence of oropharyngeal adverse events was low. cic treatment resulted in a much lower incidence of oral candidiasis, compared with similar doses of bdp, reflecting a better local tolerance. objective: to determine the prevalence of asthma and asthma-related morbidity, treatment and asthma-risk factors in a selected population. method: a routine health screening, including tests for asthma, was conducted at the new orleans center for creative arts high school. participants ( ) identified their medications and asthma tools in addition to completing the isaac questionnaire. prevalence data included lifetime wheezing, month wheezing, and previous asthma diagnosis. asthma-related morbidity included sleep disturbance, wheezing with exercise, asthma attack rate and night awakening. results: " participants were aged - years ( . % african american, . % white) with . % male, . % female. " cumulative asthma prevalence was . %, lifetime wheezing ( %), -month wheezing . % with girls reporting . times more often ( % ci: . , . ), and wheezing more than times in months . %. " there was a significant association between race and wheezing in the last months (p < . ) with whites reporting . times more often ( % ci: . , . ). asthma morbidity was reported as follows: a. night cough - . % b. wheezing with exercise - . % " parents with a less education (high school or less) were . times more likely ( % ci: . , . ) to have children who developed wheezing in the past months. " higher body mass index (bmi = ) was associated with wheezing after exercise (p < . ) with a . -fold increase ( % ci: . , . ). " among those with current asthma ( / ), were not on any medication, were using bronchodilators, and were on anti-inflammatory medications. three reported using a spacer and reported using a peak flow meter. conclusion: asthma prevalence is higher in this school population than the national average. less parental education, female gender, and bmi = were associated with greater asthma morbidity. the majority of the participants with current asthma reported receiving episodic and inadequate treatment with inhaled corticosteroids. objectives: to determine the prevalence of asthma and asthma related symptoms; to assess its severity among new orleans school children. methods: seven elementary, middle, and high schools in new orleans participated in the screening of students, % female, % male, ages - in the fall, . the -item questionnaire was designed by the international study of asthma and allergies in childhood (isaac) to determine asthma prevalence and severity in children. the isaac questionnaire is a validated protocol used on over , children in countries. asthma is defined as cur-rent wheezing for the purposes of this study. data was entered using spss and sas software for analysis. results: table: presence of asthma symptoms by ethnicity conclusion: asthma prevalence is significantly higher in inner-city school children in new orleans when compared to the national prevalence ( . % to . % vs. . %). asthma prevalence and severity do not differ significantly between african-american and caucasian children in new orleans even after removing the effect of gender and age. video is an effective method of teaching pollen identification. projected digital images offer three-dimensional views of unique pollen detail similar to focusing a microscope. the national allergy bureau™(nab) currently provides pollen counts to the media. these reported levels are obtained by standardized counting methods rather than forecasts based on historical pollination predictions and weather patterns. the american college of allergy, asthma and immunology and the american academy of allergy, asthma and immunology have an interest in ensuring consistent counting and accurate reporting practices. both organizations offer pollen identification training in conjunction with their annual meetings and have used the video for initial training sessions and for experienced counters in advanced courses. there are certified pollen counting stations in the united states and canada with approximately currently active locations. the nab requires the demonstration of ability to count and accurately identify pollen on test slides. an updated recertification process using an interactive web site is currently being developed. ongoing pollen identification training is essential for the continued success of this aeroallergen network. most observers found that the video provided a quality emulation of microscopic viewing and enhanced the depth and detail of individual pollen characteristics. the video received the highest possible ratings by course attendees. in conclusion the video plays a positive role in pollen identification training and the continuing education of experienced counters. the diagnosis and treatment of mold allergies are complicated by the genetic diversity of individual fungal species and the influence of endogenous fungal proteases on extract compositions and potencies. studies examining the biochemical comparability of mold extracts from different sources and their compatibility with other allergens in immunotherapy mixtures are essential to the clinical effectiveness of these products. compositional comparisons of extracts prepared from alternaria, aspergillus and penicillium source materials by u.s. allergen manufacturers revealed variable sds-page protein banding patterns and noticeable differences in total protein and carbohydrate concentrations. alt a levels in alternaria extracts did not correlate closely with total protein levels or with ige-binding potencies measured by elisa inhibition. immunoblot profiles of fungal extracts were more closely related to one another compared to sds-page patterns, suggesting that similar allergenic or antigenic epitopes may be retained in molecules of varying size. parallel elisa inhibition dose-response curves provided statistical evidence that a repertoire of ige epitopes is conserved in many of these products. variations in the potencies of fungal extracts from different manufacturers may result from differences in source materials and/or conditions of extraction and storage. the stability and compatibility of allergen mixtures containing mold extracts were assessed after storage for up to months at - °c using specific immunoblot and elisa procedures. grass and mite allergens compromised by mixing with mold extracts were stabilized by glycerin. alternaria extracts from different sources produced similar effects on grass allergens when added at comparable strengths. degradative effects caused by aspergillus or penicillium products were more closely related to total fungal protein concentrations than to extraction ratios. structural epitopes on cat, ragweed and fungal allergens were stable after mixing with protease-containing mold extracts, indicating the presence of natural protease inhibitors or allergenic protein sequences distinct from those recognized by these enzymes. allergenic extracts labeled as weight/volume or by pnu have no regulatory requirement for determination of activity. alum-adsorbed allergenic extracts are labeled in pnu and are felt to be depot formulations. the purpose of this study was to develop methods to measure important allergen proteins and specific ige binding capability of these alum-adsorbed allergenic extracts and to begin to assess the potency of these non-standardized extracts. allergen proteins are adsorbed to alum particles making their measurement difficult. in this study allergens were released from center-al ® alum precipitated allergenic extracts using . m citrate buffer, ph . the major allergen contents of several lots of each product were measured using monoclonal antibody elisas for group grasses, cyn d bermuda, bet v birch, ole e olive, and pla l english plantain. these assays were developed and validated by alk-abello and optimized for the citrate releasing buffer. direct binding ige was performed by immobilizing serial dilutions of extract to microtiter plates and then adding specific atopic sera and enzyme labeled anti-ige. the methods used were able to measure in vitro allergen activity in the alum-adsorbed extracts. major allergen content was successfully measured in the extracts and the amount was related to the pnu content. as expected, the variability of the major allergens within a particular extract species was higher than in standardized extracts that are adjusted for potency. the extracts demonstrated specific ige binding ability in the binding assay. the ige binding capability at various dilutions was related to the major allergen content. in conclusion, methods were developed to release adsorbed allergen proteins from alum extracts. the extracts were then analyzed for major allergen pro-teins and the ability to bind ige. major allergen content is currently used to monitor the activity of aqueous and glycerinated extracts and this study demonstrates that implementing these testing procedures will improve the consistency and quality of alum-adsorbed extracts. introduction there are over species of smut and rust fungi. ustilago maydis, or corn smut, is a basidiomycete fungus that infects ears of corn. it is responsible for a percentage of grain loss in the united states but eaten as a delicacy in mexico. it grows into large tumor-like structures, called galls, dispersing soot-like spores responsible for the common name, "smut." it is readily airborne and believed to be a causal agent for allergic rhinoconjunctivitis. "corn smuts" was added to the standard screening panel for patients presenting for evaluation of rhinitis in the region of middle tennessee. methods using greer laboratories™ corn smut extract : w/v, patients were tested by prick/puncture method with the hollister-stier quintip™ device. if negative, intradermal testing was performed. positive and negative controls were assessed. based on current national recommendations, wheals mm greater than negative control were considered positive for prick/puncture testing and wheals mm greater than negative control were considered positive for intradermal testing. results patients were tested between november, and march, . / ( . %) met criteria for prick/puncture positivity. / ( . %) met criteria for intradermal positivity. patients prick positive to corn smut had the following prick positive tests: dust mites / ( . %); cat / ( . %); local grass mix / ( . %); local tree mix / ( . %); local weed mix / ( . %), mold mix / ( . %); cockroach / ( %); and dog / ( . %). discussion allergy testing for aeroallergens is available to a limited number of antigens, of which, only a few are standardized. as time passes, relevant antigens are discovered and their importance further elucidated. this assessment reveals a significant presence of corn smut ige largely accounted for by intradermal positivity which may or may not reflect clinical sensitivity. these numbers are provided so that other clinicians may compare to prevalence in their geographical area. further studies are needed to determine the association of corn smut ige with clinical symptoms. h antihistamines are the mainstay of therapy for allergic disorders, including skin diseases. the most common side-effect of marketed antihistamines is sedation, especially when the clinical symptoms require a higher dose than recommended, a condition commonly encountered in dermatological disorders. the present study describes the pharmacology of a new non-sedating h antihistamine, r (hivenyl™). r binds to the cloned human h receptor with a similar affinity (ki: nm) as the reference antihistamines cetirizine (ki: nm) and loratadine (ki: nm). in vivo, r protects rats and guinea pigs from lethal shock, induced by compound / and histamine, respectively (ed : . and . mg/kg respectively). the compound is at least as effective as cetirizine and loratadine. in rats, r inhibits the histamine-and allergen-induced cutaneous reactions (ed : . and . mg/kg) with a similar potency as cetirizine (ed : . and . mg/kg) and loratadine (ed : . and . mg/kg). even so, in guinea pigs the compound inhibits the histamine-and allergen-induced skin reactions (ed : . and . mg/kg) to a similar extent as loratadine and cetirizine. however, in dogs r is more potent in inhibiting the ascaris allergen-induced wheal reaction (ed : . mg/kg) than cetirizine (ed : . mg/kg) or loratadine (ed : . mg/kg). r fails to occupy central h receptors in the guinea pig cerebellum up to mg/kg, in contrast to loratadine (ed : . mg/kg). in vitro and in vivo cardiovascular safety experiments indicate that r lacks the intrinsic capacity to prolong the qt-interval, even at high doses. as such, r (hivenyl™) is characterized as a potent, non-sedating and cardiosafe h antihistamine. it has been selected for further clinical development, mainly in the field of dermatology. the compound will be a suitable tool to explore the activity of a selective h antihistamine in various indications, without the contamination of the sedative activity often observed with other marketed antihistamines when increasing the dose. ciu represents one of the most clinically perplexing disorders which the allergist-immunologist is faced with. we have previously reported the clinical efficacy of fxt (prozac), an ssri widely used for the treatment of depression, in the management of ciu (nsouli tm, et al. ann allergy asthma immunol ; : ) . in this presentation we report additional cases of ciu which responded dramatically following the use of fxt. a yr-old female and a yr-old male presented with ciu of and months duration, respectively, requiring oral corticosteroid (cs) therapy for control of their ciu after failure of high dose anti-h (hydroxyzine) and anti-h (ranitidine) agents (table) . testing for food and latex allergy, viral hepatitis, autoimmune thyroid disease and parasitic infection were all negative. a skin biopsy performed in subject # was consistent with an urticarial vasculitis. following one week of oral fxt ( mg qd [subject # ] mg qd [subject # ]) a striking and complete resolution of urticaria in each patient was observed within to days during which time it was possible to successfully taper the cs. both patients have been maintained on fxt therapy with complete control of their ciu. the very favorable response to fxt therapy in these patients in addition to our first case report suggests that this drug may have a new therapeutic application in the management of recalcitrant ciu. background: ipratropium bromide nasal spray (ib) is indicated for treatment of rhinorrhea caused by common cold (cc), seasonal and perennial allergic rhinitis (ar) in adults and children age and up. symptoms of rhinorrhea from cc or ar in children are similar to those in adults, yet there is little data on the use of ib in children under years of age. objective: evaluate the safety and efficacy of ib nasal spray . % in - year-old children with symptoms of rhinorrhea from cc or ar. methods: a total of children ( cc and ar) were treated in an open-label, multi-center study. the cc patients received ib nasal spray ( mcg per nostril) tid for days, the ar patients received ib nasal spray ( mcg per nostril) tid for days. effectiveness was measured using a global assessment questionnaire and daily symptom scores reported by the parent. results: from the global assessment questionnaire, % and % of the parents found ib either "very useful" or "somewhat useful" in the cc and ar groups respectively. regarding effectiveness, % (cc) and % (ar) of the parents reported that ib had either a "good effect" or "excellent effect" in treating rhinorrhea. moreover, % (cc) and % (ar) of parents found administration of a nasal spray either "extremely easy" or "very easy." eighty-one percent (cc) and % (ar) of the parents reported they would use ib again for their child's allergy symptoms. the daily symptom score ( = none to = unbearable) for rhinorrhea decreased from . to . (- %, p< . ) for cc and from . to . (- %, p< . ) from baseline compared to the average on-treatment score, with decreases also seen for stuffy nose and sneezing. the nasal spray was well tolerated with adverse events (ae) reported in % of cc and % of ar patients. the aes were mostly mild to moderate and no potentially systemic anticholinergic or serious aes were reported. conclusions: ib nasal spray . % administered at a dose of either or mcg per nostril tid is an easy to use, safe, and effective therapy for control of rhinorrhea in children to years of age with common cold or allergic rhinitis. chronic idiopathic urticaria (ciu) represents one of the most clinically perplexing disorders which the allergist-immunologist is faced with. the pathogenesis of the condition derives from the release of potent vasoactive substances including histamine, and products of arachidonic acid metabolism, e.g., prostaglandins and thromboxanes formed by the action of the enzymes cyclooxygenase (cox) of which cox- is responsible for pseudoallergic and other inflammatory responses. although a number of therapeutic options exist owing to the plethora of mediators produced, treatment has focused largely on the use of h antihistamines and, unsurprisingly, at times without complete resolution of symptoms. in this presentation we report the successful use of a cox- inhibitor for the treatment of chronic urticaria. a y/o white hispanic female presented with a month history of chronic urticaria predominantly on the soles of the feet, with unknown precipitating factors, and fail-ure to respond to prior treatment with: cetirizine, steroids, benadryl, ebastine and epinastine. the patient received a blood transfusion years ago and there was no prior history of allergies. skin testing revealed + reactions to dust mite, pollen, cockroach, shellfish, + reactions to corn, milk and ige = iu (nv < iu), aso = ui (nv < ui). after weeks of treatment with rofecoxib (vioxx) mg, and benadryl, the rash resolved. vioxx was continued for more weeks until complete resolution of symptomatology. this case illustrates that the addition of a selective cox- inhibitor (i.e., rofecoxib) with an h antihistamine may be a more effective regimen for patients with ciu who fail to respond adequately to conventional therapy. introduction: elderly asthmatic patients whose symptoms are controlled by inhaled corticosteroid (ics) therapy may still have breathlessness on exertion. we randomized elderly asthmatic patients stabilized by medium-dose ics therapy into two groups, treated one group with medium-dose ics therapy plus montelukast, a leukotriene receptor antagonist, and the other with increased-dose ics therapy, and compared the effects of the treatment regimens on exercise tolerance. methods:the subjects were patients with bronchial asthma ( males and females, . ± . years) stabilized by ics therapy (with fluticasone proprionate, fp; mg/day) for three months or more with low peak expiratory flow (pef) rates (< %predicted, variability< %). they were randomly divided into two groups ( patients each) to be treated with ics therapy plus montelukast ( mg/day fp + mg/day montelukast; m group) or with increased-dose ics therapy ( mg/day fp; f group). pulmonary function tests, a six-minute walking test, respiratory gas analysis during incremental ( w/min) cycle ergometer exercise were conducted, and exhaled nitric oxide (no) levels were measured before and after two weeks of the study treatment. results: pulmonary function tests showed significant increases in maximal mid-expiratory flow (mmf) and forced expiratory flow at % vital capacity (v ) in the m group (p< . ) but no significant changes in the f group. exhaled no levels decreased significantly in both groups ( . ± . to . ± . ppb in the m group and . ± . to . ± . ppb in the f group; p< . ). the six-minute walking distance extended from ± to ± m in the m group and from ± to ± m in the f group.the peak oxygen uptake (peakvo ) increased significantly in the m group (%peakvo /w from . ± . to . ± . %; p< . ) but not in the f group (%peak vo /w from . ± . to . ± . %). the peak exercise load also increased significantly in the m group ( . ± . to . ± . w; p< . ) but not in the f group ( . ± . to . ± . w). conclusions: the results indicate that concomitant administration of montelukast is more effective than dose escalation of ics on exercise tolerance in elderly asthmatic patients under medium-dose ics therapy. e. meltzer * , y. luo , l. shen , z. guo , c. schemm , y. huang , k. chen , p. king , r. nave , d. banerji , s. rohatagi , . san diego, ca; . bridgewater, nj; . konstanz, germany. introduction: inhaled corticosteroids (ics) are first-line treatment for persistent asthma. ciclesonide (cic) is a novel and effective ics under development. freely circulating, unbound ics is available to cause systemic adverse effects, such as hypothalamic-pituitary-adrenal (hpa) axis suppression. hence, it is important to determine the free fraction of ics in plasma. in separate studies, the protein binding of the active metabolite of cic, desisobutyryl-ciclesonide (des-cic), was evaluated, and the effects of inhaled cic on hpa axis function were determined. methods: human plasma protein bind-ing of des-cic ( . - ng/ml) was determined using equilibrium dialysis. dialyzed samples were analyzed by liquid chromatography with tandem mass spectroscopy to determine free and bound des-cic. in separate clinical studies, the effects of cic (hfa; - μg daily) and placebo (pbo), via metered-dose inhaler (ex-actuator doses), over days, or weeks, on basal hpa axis function ( -hour area-under-the-curve [auc - h] serum or urinary cortisol corrected for creatinine) or stimulated (low-dose [ μg] cosyntropin) serum cortisol were investigated in patients ( years) with persistent asthma. results: the mean % of human plasma protein binding for des-cic was %. in studies measuring serum cortisol auc - h, there was no difference between pbo and cic ( - μg). similar results were observed for -hr urinary cortisol corrected for creatinine. in the rd study measuring low-dose ( μg) cosyntropin-stimulated peak serum cortisol, after weeks of treatment, there was no significant difference in the mean change from baseline versus placebo for either cic (p= . ) or cic (p= . ). conclusions: the favorable pharmacokinetic profile of cic, in particular the high protein binding of des-cic, may explain the lack of hpa-axis suppression. this appears to result in greater systemic safety. purpose: unscheduled office and ed visits for urgent asthma care are an ongoing point of concern. determining preventive variables regarding these unscheduled visits could have a significant impact on asthma costs and quality of life. objective(s): this research addresses the following question: when stratifying by race, gender, age, metropolitan/rural place of residence and comorbidity, do adults with asthma have fewer ed or unscheduled office visits for urgent asthma care if they: a) have an identified primary care provider, or b) have health insurance? method(s): univariate and stratified bivariate contingency table analyses were performed on weighted behavioral risk factor surveillance survey (brfss) data. result(s): adults with asthma who had an identified primary care provider were more likely to have no unscheduled office visits (or= . ) or ed visits (or= . ) for urgent asthma care. this was also true for adults with asthma who had health insurance (or= . for no unscheduled office visits and or= . for no ed visits). these relationships held when stratifying by race, gender and age. the relationships also held for metropolitan residents. the analysis was inconclusive for rural residency and the existence of co-morbidities. conclusion(s): despite race, gender, age and metropolitan residency, having a primary care provider or having health insurance impact whether or not adults with asthma are more likely to have unscheduled office or ed visits for urgent asthma care. further investigations are needed to examine how these factors impact adults with asthma who are rural residents or who have co-morbidities. d. bukstein * , g.a. cherayil , . madison, wi; . brookfield, wi. introduction: costs for plans to process prior authorizations for non-formulary medications, has been estimated to be $ to $ per request. costs for physicians to process these requests has not been extensively studied. methods: dr.bukstein, board certified allergist, developed a data collection tool. the form was utilized by physicians and nurses to document time spent on processing prior authorizations. data collected included, class of medicines requiring the pa, nursing time spent on calling the patient, pharmacist, health plan, nursing time spent completing forms, nursing time clarifying the information for the pa, as well as physician time spent completing pa activities. results: data was collected over weeks in and requests were processed.the class of medicines most often processed was antihistamines, comprising % of requests. nursing calls were tracked and calls to and from patients were the most common call documented. they averaged . +/- . calls per day per nurse. the nurses spent an average of minutes per patient call. calls to health plans averaged . +/- . calls per nurse per day and time spent on these call was . +/- . minutes per call. physician calls documented included calls averaging . +/- . calls per physician per day. these calls averaged . +/- . minutes per call.often the results of the prior authorizations were not known on the day of the request. originally . % of requests were granted the same day. retrospective review revealed . % were approved the first time they were processed. salary and benefits were calculated for nurses and physicians. the hourly rate was defined as $ . per hour for nurses and $ per hour for physicians. the costs for the time spent on the prior authorizations were calculated. during the week study period, over hours was spent by nurses on calls and over hours was spent by physicians on calls during the same time period. the total nursing and physician cost in this specialty practice was $ . per prior authorization. conclusion: there are substantial costs with processing of prior authorization requests for non-formulary drugs on the physician office side of managed care as well as on the insurance side of the process. specialty physicians should have a different process for obtaining non-formulary medications since almost % of their requests are granted. introduction: diabetes mellitus can adversely impact the course and outcome of myocardial infarction (mi). one of the mechanisms underlying this phenomenon is alteration of the course of inflammation and the reparative process following myocardial necrosis. abnormal wound healing, tissue reparation and immune responses in diabetic patients have been intensively studied, but the cellular and the molecular mechanisms are still unclear. transforming growth factor-beta (tgf-beta) is a multifunctional cytokine which plays a critical role in coordination of the course of inflammation and reparation, acting as a potent depressor of inflammation and a stimulator of regeneration. this study investigates the dynamics of serum concentrations of the active form of tgf-beta during the period up to the th day after the onset of a mi in diabetic and non-diabetic patients. results: in non-diabetics a significant increase was observed in tgf-beta on day ( -fold greater than in controls; . ± . and . ± . pg/ml respectively) with further increases reaching a peak on day ( . ± . pg/ml). on day tgf-beta decreased to levels less than on day , but was still greater than in healthy controls ( . ± . pg/ml). in diabetics, concentrations of tgf-beta on days ( . ± . pg/ml) and ( . ± . pg/ml) after mi were similar to diabetics without mi ( . ± . pg/ml). only on day was tgf-beta increased to levels ( . ± . pg/ml) which were fold greater than in diabetics without an mi. thus, in diabetic patients serum concentrations of the active form of tgf-beta are much greater than in non-diabetics. mi in patients with diabetes mellitus is associated with a reduced and significantly delayed increase in tgf-beta . conclusion: tgf-beta deficiency may be a factor associated with low activity of tissue reparation after mi in diabetic patients. introduction helicobacter pylori (hp) is the most common gastrointestinal infection worldwide, but only - % of those infected develop chronic gastritis or peptic ulcer disease. the pathogenesis of ulceration, mechanisms of hp lifelong persistence in gastric mucosa and local immune disturbances induced by this infection are well known, but the mechanisms of resistance and elimination of this infection have not been extensively studied. most study is based only on phenomenological findings, such as absence or low hp colonization in subjects spontaneously producing high levels of il- . the aim of this investigation was the analysis of the efficacy of the recombinant interleukin (ril- ) roncoleukin (biotech, russia) in treatment of hp-associated gastric ulcer disease. methods patients were randomly divided into two groups. the first group of patients was treated with standard therapy including of two antibiotics (claritromycin and amoxicillin), proton pomp inhibitors and h receptor antagonists. patients of the second group were treated with the same therapy, but instead of antibiotics they received . mg roncoleukin into four to six areas submucously using a gastroscopic method and . mg roncoleukin dissolved in ml of . % nacl with ml % human albumin infused intravenously. this procedure was performed three times at an interval of hours. results immunological findings demonstrated that roncoleukin results in an increase of cd +, hla-dr+ and cd +cd + cell levels. there was an increase in the serum concentrations of il ( fold), il ( fold) and ifn (more than fold) while the level of tnf and il profoundly decreased. one month after the end of treatment, the group treated with ril- had hp eradication achieved in . % in comparison to . % of the control patients. in the ril- treated group, the ulcer epithelization period was . ± . days while in the normal treatment control group it was . ± . days (p< . ). conclusion immunotherapy with ril- is a more effective method of treatment of helicobacter pylori-associated gastric ulcer disease when compared with traditional methods of treatment employing only antibiotics. introduction the role of different cytokines and the growth factors is now appreciated in progression of essential hypertension. the participation of et- and tgf in pathogenesis of essential hypertension especially in the process of fibrosis, hypertrophia of vascular smooth muscular fibers, and cardiomyocytes, and the activation of renin-angiotensin system is now recognized, in addition to effects on myocyte cultures. the aim of the investigation was the study of serum et- and tgf levels in patients with essential hypertension. materials and methods patients with essential hypertension ( males and females) with average age . ± . years were studied. all patients suffered from left ventricle hypertrophy documented by echocardiography. the control group consisted of healthy volunteers similar to the investigated patients in sex and age. in all patients the serum concentrations of et- and tgf were determined using elisa (biomedica, biosource). results an increase in the serum concentrations both growth factors were noted in the studied group when compared with the control group. the average concentration of et- in patients with essential hypertension was . ( . - . ) pmol/l. the level of et- in the control group was . ( . - . ) pmol/l (p= . ). the concentration tgf in essential hypertension patients was . ( . - . ) pg/ml and in control group was . ( . - . ) pg/ml (p= . ). there was a positive correlation between the concentrations (spearmen's rank coefficient of correlation was . ; p= . ). con-clusion the increase of the serum concentration of growth factors et- and tgf and their co-influence in patients with essential hypertension, suggests a role of these growth factors in the pathogenesis of arterial hypertension. u. kaza * , c. lauter , . bloomfield hills, mi; . royal oak, mi. introduction: few studies have examined the referral patterns for allergy and immunology inpatient consultations in a community hospital. consequently, an invaluable part of physician and housestaff education is missing. our objective was to examine the number of inpatient allergy and immunology consultations, the reasons for consultations and the outcome of the patients in order to improve physician education. methods:we performed a retrospective chart review of all inpatient allergy and immunology consultations in the years - and in - to determine the reasons for consultation, the recommendations made and if they were followed and the outcomes of the patient. results:we reviewed a total of inpatient allergy and immunology consultations. in the - time period % of inpatient consults were for asthma, % for drug allergy, % for rash. in the - time period % of inpatient consults were for rash, % for drug allergy, % for asthma. the top three reasons for consultations remained the same although the order changed. consultations for immune deficiency, angioedema and rashes increased, whereas consultations for asthma and allergies decreased. there were a total of consultations in - and in - . the number of consultations remained the same despite an increase in overall number of hospital admissions from , in to , in . in greater than % of consultations, allergists' recommendations were followed. in both of the time periods studied, greater than % of patients improved, with less than % having no improvement, in the remainder of cases improvement was not applicable. conclusion:in conclusion, we believe that identifying the reasons for inpatient allergy and immunology consultations and examining the most common recommendations, as well as the outcomes of patients will be a valuable guide in the education of our physicians. by incorporating this information into grand rounds and resident conferences, physicians will benefit from learning about when an allergist can be helpful and how to manage some of the more common allergic and immunologic problems in patients that are hospitalized. the high percentage of providers who follow the advice of allergists indicate that allergists have a great deal of educational value to offer other physicians. while complementary and alternative medicine (cam) has generally experienced increased popularity, its utilization by allergy/asthma patients remains uncertain. our private allergy practice surveyed the use of cam in allergy/asthma patients in ( ). using a similar questionnaire, we assessed the current interest in cam with our allergy/asthma patients and compared the data to our survey. we analyzed completed questionnaires from sequential surveys administered. the results were compared to questionnaires reported in . they indicated that in both study periods ( & ) , the majority of patients wanted to discuss cam ( and % respectively). an equal number ( %) in each study period discussed cam with their primary care provider. sixteen percent ( %) of our respondents sought a cam practitioner for general medical needs in vs. % in . however, there was an increase from % to % of our patients seeing a cam practitioner for their allergies and/or asthma from to . sixty-two percent ( %) would like to consider pursuing cam through our allergy spe-cialty practice or other provider. when asked regarding preferred treatment, % stated combination traditional with cam, % preferred traditional only, % cam only, and % did not know/doctor s choice. more patients are now seeking chiropractic care ( % to %) compared to our results. acupuncture was the first choice cam modality at % in surpassing vitamin/mineral therapy in . currently, the second and third choices were vitamin/mineral therapy and deep tissue massage. while these numbers were small, we were impressed that currently % (two and a half times more since ) of patients in our practice were seeking cam allergy/asthma care from outside of our practice. these results demonstrated that more than half of our patients were interested in pursuing traditional with cam options within our office. given this trend, we have begun discussing the concept of integrative allergy, which to us means integrating evidenced-based cam modalities within our traditional allergy/asthma practice. ( ) introduction: clinical immunization knowledge is complex and demands ongoing training. nationally, basic immunization and vaccine safety education is limited within traditional medical, nursing, and provider education. project immune readiness (pir), a peer-reviewed, web-based, interactive course, was developed in response to this deficit and the need for standardized resources to provide initial and sustainment training for safe and effective immunization services. it is designed for medical personnel with diverse educational preparation. currently, pir offers course modules addressing hours of instruction on specific vaccines, their respective diseases, and general information on immunization healthcare and vaccination procedures. methods: users completed a pre-test (establishes baseline knowledge), an interactive module, followed by a post-test (to observe change from baseline) for each course in sequence. anonymous user and score data were collected as part of a quality assurance and course validation process. learning gain indices (lgi) were calculated based on average mean pre-test and post-test scores for each module lgi of all modules demonstrated substantial increases in user vaccination knowledge. comparing pre and post-testing is an effective method to assess learning gains. the findings support pir as a successful and valid distance-learning tool that establishes and documents core knowledge of medical personnel administering vaccinations. further research is needed to assess the effectiveness of knowledge acquisition and retention, in addition to variance in vaccine delivery after training. this approach to learning may have value as a resource that supports smallpox and influenza pandemic emergency preparedness plans for just in time training. introduction: variances from practice guidelines for the prescription of auto-injectable epinephrine are well documented among practicing physicians, families, and patients. effective patient education requires provider competency. the current study was designed to survey resident physician perceptions regarding auto-injectable epinephrine education, use, and patient education requirements. methods: residents from primary care disciplines at a tertiary care medical center were invited to complete a voluntary, anonymous questionnaire. a total of surveys were distributed and returned: emergency medicine, family practice, internal medicine, and pediatric residents completed the questionnaire. due to the small sample size, responses from physicians in various disciplines were reviewed as a whole. results: respondents ( %) reported that they had previously prescribed auto-injectable epinephrine for allergic emergencies. the majority ( %) of these prescribers reported that their training was inadequate. respondents ( %) reported no training, while respondents ( %) reported that their training was less than that needed to ensure proficiency. respondents ( %) reported that their training was adequate to ensure proficiency. none reported expertise. only of prescribers ( . %) reported that either they or their staff always demonstrated proper medication use to the patient. interestingly, of these providers reported they had not been trained on proper use. the table below summarizes resident training and patient education practices. additional physician knowledge deficits included the proper site of medication administration, the proper interval for replacing medication, and the proper place for medication storage. conclusions: of the residents surveyed, who have previously prescribed auto-injectable epinephrine, % identified training deficiencies. only . % of prescribers reported that the standard of care requirement to demonstrate proper medication use was always met. there is a clear need to improve auto-injectable epinephrine education in all residency training programs. r. bloebaum * , r.k. calabrese , m. . houston, tx; . new york, ny. introduction: pneumocystis carinii pneumonia (pcp) is a major cause of morbidity and mortality in patients with aids. adverse reactions occur frequently to the most effective medication for both the prevention and treatment of pcp, trimethoprim-sulfamethoxazole (tmp-smx). we looked at the immediate safety and efficacy of three protocols for desensitization in aids patients. methods: by retrospective chart review, we identified patients with aids who had experienced previous mild to moderate hypersensitivity reactions to tmp-smx and required desensitization. patients received one of three desensitization protocols based on illness severity or ward attending preference: a -hour intravenous (iv) desensitization, an -day oral desensitization, or a -day oral desensitization. results: of the patients that received desensitization, ( . %) completed successfully. of these, subjects had no reaction during the desensitization process; however, seven of these subjects were on steroids for treatment of other diseases. the remaining five successful patients had mild reactions which were treated symptomatically with acetaminophen, antihistamines or both. eleven patients failed to complete the desensitization: six stopped by the attending physician and four dropped out voluntarily. one patient expired during desensitization from extensive disease complications related to the admitting diagnosis. all protocols were equally successful when comparing the immediate success rates, / ( %) of the hour protocol, / ( %) of the -day protocol and / ( . %) of the day protocol. the -hour iv desensitization protocol was most frequently used in the intensive care unit on critically ill patients. two of these patients, counted as successfully desensitized, died and days post protocol completion secondary to extensive comorbid conditions unrelated to the desensitization. conclusion: given the insignificant differences between the success of the hour iv desensitization and the oral desensitization protocols, we believe that either may be used effectively. further, in patients with mild to moderate hypersensitivity reactions to tmp-smx, an oral desensitization protocol may be used safely in the outpatient setting if given appropriate lab follow up. a. morales * , e. gonzalez, a. contreras, d. lopez, g. lopez, mexico city, mexico. introduction in davis describes job syndrome in two women, in dr buckley reports two children, being known as hyper-ige syndrome (job's syndrome or buckley's syndrome). defined as a primary immunodeficiency, dominant autosomic, characterized by multi-systematic alterations (immunological, skeletal, dermal and dental). it's diagnostic criteria are levels of ige ui/ml, chronic dermatitis, recurring respiratory infections, cold abscesses, pneumatoceles, infections caused by candida, and finally craniofacial alterations. on another front, extraordinary high levels of ige have been reported in patients with allergic illnesses that increase the risk of anaphylaxis, but do not have the job's syndrome criteria. objetive to determine if allergic patients with ige levels higher than ui/ml have diagnostic of job's syndrome. material and methods a retrospective revision was realized from may to april in files of patients treated in allergy services at the instituto nacional de pediatria with a total ige greater than ui/ml, by means of a page with recollected dates. results nine women and men were included with an age range of to years, and an average age to years; ( . %) were diagnosed with allergies; of which . % rhinitis allergy, . % asthma, and . % topical dermatitis of which co-existed in patients. . % presented hereditary antecedents of atopic. the cutaneous tests were positive in ( . %) with a greater reactivity of dermatophagoids. one syndrome of hyper ige was detected. others diagnosed were found as not allergic were hunter's syndrome and toxocariasis. conclusion there are patients with allergies that have total levels of ige as elevated as , ui/ml without correspond to job's syndrome. by which a multi-allergic clinical entity is proposed with levels greater than ui/ml. introduction home monitoring of lung function in asthmatic patients is used extensively in both clinical and research settings, however, little attention is given to device quality control. objective the purpose of this study was to determine the accuracy, precision and usefulness of the airwatch system (enact health management systems, palo alto, ca, usa). methods the subjects included in this study were submitted to spirometry following american thoracic society guidelines (ats ), using collins gs g pft system. afterwards, peak expiratory flow rate (pef) and forced expiratory volume in one second (fev ) were determined using airwatch. fev and pef measures from both devices were compared, by using two sample t-test and pearson correlation coefficient. results a total of patients ( females) were enrolled, and their mean age was . years ( to years). fev measures ranged from . to . l (mean . l), and from . to . l (mean . l), in collins and airwatch, respectively. pef ranged from to l/min (mean l/min) in collins and from to l/min in airwatch (mean l/min). significant difference was noted for pef measures (p< . and pearson correlation r= . ) between the two devices; however, we did not observe this difference when fev measures were concerned. regarless the degree of obstruction (high or low flow rates), these results did not change. conclusion airwatch showed great utility for fev measures when compared to collins spirometer. although airwatch is able to assess lung function at home, on a daily basis, it is not reliable for pef measures. introduction: epidemiologic data show that poorly controlled asthma is a serious public health problem. the degree of implementation of the naepp guidelines in primary care practice remains to be defined. the objective of this survey was to determine if introduction of an assessment tool into primary care practices along with a specially designed program to implement the guidelines would improve diagnosis and therapy. methods: the asthma care network (acn), a program designed to assist healthcare providers in the assessment and management of their patients with asthma, employs a team of specially trained respiratory care associates (rcas), rns and rts, who visit primary care offices to inform staff about various components of the naepp guidelines and assist in their implementation. .a total of primary care providers in sites were recruited as part of the acn program. data from more than , patient visits were collected and analyzed between march and january . the program assessment tool surveyed asthma control and medication prescribing patterns. outcome measures included degree of symptom control, limitation of activity, sleep disruption, use of rescue medication and utilization of urgent care services. these data were collected on an office visit assessment form (ova) completed by both patient and physician. the rcas provided information, education, device training in the use of inhalers and spacers, and a ce course for the staff discussing pathophysiology, assessment and management of asthma. results: a total of , ova forms were completed. among all patient including adults (older than years of age) and children (< - years of age), % (range % to %) reported symptoms consistent with lack of asthma control. approximately % of the survey group had more than markers of uncontrolled asthma. as a result of this assessment, controller medication use increased by over %, % of which was an ics-containing medication. conclusion: the information provided to the primary care health care providers resulted in a considerable increase in prescription of controller therapy, and in particular, increased use of ics controller medication consistent with naepp guidelines. background: patients with allergic rhinitis (ar) demonstrate symptoms of allergy to fruits, vegetables and nuts in - % of cases. oral allergy syn-drome (oas), typical for hypersensitivity to plant food, is based on cross-reaction of pollen-allergen specific immunoglobulin e (ige) antibodies with homologous food proteins. the production of th and th cytokines in allergic rhinitis patients with or without sensitization to food (fruits and vegetables) allergens was assessed. methods: fifty five patients aged - years with allergic rhinitis were observed. group i - patients with ar; group ii - patients with ar and oas. sensitivity to pollen allergens was tested by skin prick tests. the allergic reaction to food in patients with oas was proved by a positive history of oral symptoms caused by eating fruits and vegetables and a positive skin prick test with respective food allergens. blood eosinophil counts and total ige levels were determined during the peak of allergic rhinitis symptoms. il- , il- and -interferon levels were measured by elisa. results: . % of patients were sensitized only to grass pollen, . % only to tree pollen and . % reacted to pollens of grasses, trees and weeds. in patients with oas, skin tests were more often positive to birch ( . %), alder ( . %), and mugwort ( . %). the most common food products implicated in oas were hazelnut ( . %), apple ( . %), carrot ( . %), and peanut ( . %). the allergy to fruits and vegetables was confirmed by positive prick test in . %. during the season blood eosinophil count and total ige levels were elevated in all patients. there was an increase in the production of il- to . ± . pcg/ml in group i and to . ± . pcg/ml in group ii (nor-mal= . ± . pcg/ml). the levels of il- increased to ± pcg/ml in group i and to ± pcg/ml in group ii (normal= . ± . pcg/ml); the level of -ifn decreased to . ± . pcg/ml in group i and to . ± . in group ii (normal= ± pcg/ml). after sit with pollen allergens the clinical manifestations of allergic rhinitis and oas decreased in . % of patients. conclusion: allergic rhinitis patients' sensitivity to food allergens may cause oas in these patients associated with increased functional activity of th responses. patient knowledge and improvement with aller-gen immunotherapy. c.c. randolph * , waterbury, ct. introduction: there is no consensus on objective parameters for improvement in immunotherapy. similarly little is known regarding patient knowledge of immunotherapy. utilizing two published questionnaires ( - ), we assessed clinical improvement based on symptom and medication scoring and knowledge of immunotherapy. methods: the charts of patients of an estimated ( %), ( %) with allergic rhinitis only and ( %) with concomitant asthma, were retrospectively or prospectively reviewed who had been on immunotherapy to inhalants for months to years, mean . years, age range y- y, mean y, male( %), female( %) with caucasian ( %), oriental ( %) and ( %) afroamericans .they completed symptom and medication survey ( ) every months with range of improvement using a decline in likert scale (+) to (-) , mean . ( %) indicated improvement in their symptoms and/or medication . ( %) completed ( ) a question survey of knowledge of immunotherapy. there were questions regarding the outcome of immunotherapy, the years to onset of immunity, the duration until onset of immunity, the danger of immunotherapy and the extract in the vial. the correct responses were recorded to / ( / = . %), ( . %) / , ( %) / , ( %) / , ( %) / . ( %) had a perfect response to all questions. ( %) had no correct responses. conclusion: the majority of immunotherapy patients improved ( %) by symptom and medication scoring over the mean of . years but only % had complete knowledge of the rationale for immunotherapy. further education and repeated surveying of patients on immunotherapy to assure comprehensive knowledge of immunotherapy and achieve better outcomes is recommended by this investigation. as is unique in this study symptom and medication scoring using the rhinitis /sinusitis questionnaire approved by the acaai and a comprehensive questionnaire assessing knowledge should be conducted periodically ie every months to provide objective parameters for improvement. references: .santilli j, nathan r, glassheim j .patient receiving immunotherapy report it is effective as assesses by rhinitis outcomes questionnaire(raq) in private ( )) is a protein involved in the parasite invasion of host erythrocytes and is a leading vaccine candidate for the erythrocyte stage of malaria infection. an increasing number of vaccine clinical trials are being undertaken using various formulations of msp- ( ). comparison of humoral responses among these trials has been limited by the lack of a universal reference standard for specific antibody. the purpose of this study was to develop a human reference standard for msp- ( ) antibody measured in absolute quantity units that could facilitate comparison of interstudy vaccine response. method: we formulated the reference standard by pooling human plasma samples known to contain high titers of msp- ( ) antibody. the specific antibody within the pooled plasma was captured by msp- ( ) adsorbed to nickel resin in a process of immobilized metal affinity chromatography (imac). the intact msp- ( ) antibody-antigen complexes were separated from the nickel resin and total igg in the complexes measured by enzyme-linked immunosorbent assay (elisa). results: our antibody quantitation method yielded a concentration of . mcg/ml of msp- ( ) antibody in the reference standard. conclusion: the reference standard characterized in this study may be useful as a quantitative working standard for msp- ( ) antibody response in future vaccine clinical trials involving msp- ( ). this standardization may facilitate the clinical development of msp- ( ) as a candidate vaccine for malaria infection. background. specific immunotherapy (sit) is currently one of the most effective and widely used treatment methods of allergic diseases including asthma. efficacy of sit depends on the correct choice of patients, severity of asthma and patient's condition when the sit is begun. according to who recommendations, sit is approved for use in patients with mild to moderate asthma. methods. sit with a saline extract of house dust allergen was administered to patients with mild persistent allergic asthma. injections were performed subcutaneously - per day. the course consisted of pnu of allergen and lasted - days. patients were repeatedly surveyed at , and months after sit was completed. dyspnea attacks occurring during daytime and at night were assessed, as was the influence of physical exertion on dyspnea and lung function, and also the number of utilizations of short-acting beta-agonists per day. pulmonary function measurements were performed as was assessment of concomitant allergic rhinitis. % of patients received treatment including cromones, and % utilized inhaled corticosteroids among whom . % had a dose of mcg per day and . % mcg per day. sit efficacy was assessed by clinical symptoms, pulmonary function measurements and amount of concomitant therapy received. results. the number of daytime dyspnea attacks reduced from . ± . per month to . ± . during the months following sit, and . % of patients reduced concomitant asthma therapy. at months, dyspnea attacks increased to . ± . per month, still significantly less then prior to sit. nocturnal symptoms followed the same pattern, occurring . ± . per month prior to sit, . ± . per month months after sit and . ± . per month at the end of the sixth month after sit. . % of patients had no symptoms of bronchial obstruction during the months after sit and their pulmonary function approached normal values, although . % of patients returned to asthma therapy. nasal congestion decreased from . ± . points to . ± . (p< . ), clinical improvement still present for months after sit, but recurring at months after sit. conclusion. sit may be an effective treatment method that improves both asthma and allergic rhinitis for more than months following a brief course, allowing a decrease in the amount of symptomatic treatment. a safe therapeutic vaccine that can alter the allergic response to peanuts would serve a serious unmet medical need. peanut allergy responses are largely associated with downstream events related to antigen specific ige crosslinking of ige receptors and subsequent degranulation of mast cells and basophils. our clinical studies with ragweed have shown that linking immunostimulatory dna (iss) to allergens can decrease ige recognition of the allergen and generate an immunogen that generates protective th responses and reduces harmful th responses. to test this approach to peanut immunotherapy, we focused on the clinically relevant allergen, ara h , as a proof of concept. iss oligonucleotides were linked to ara h at two different ratios: pic ( iss per protein) and hpic ( iss per protein). immunogenicity of pic and hpic was evaluated in c h/hej female mice immunized twice with ug of pic, hpic, or ara h . sera were analyzed for anti-ara h igg and igg a responses. spleens were harvested and ara h -specific ifng and il- responses were measured in vitro. mice were immunized with ara h elicited predominantly igg and il- responses, indicative of a th -type response. animals immunized with pic showed significantly enhanced igg a responses and strong ifng responses, indicative of th -type responses. hpic immunized mice elicited little antibody response, presumably due to iss blocking b cell epitopes, but did induce ifng responses. to assess allergenicity of pic and hpic, histamine release was measured in blood from peanut allergic donors treated in vitro with pic, hpic, and ara h . histamine release was detected at very low concentrations of ara h ( . ng/ml), -fold higher concentrations for pic ( . ng/ml) and was undetectable at concentrations up to fold higher for hpic ( ng/ml). an ige binding competition assay also confirmed reduction in allergenicity following the same trend for the iss-linked allergens. linking iss to ara h increases th responses to the allergen, blocking ige recognition of epitopes on ara h . thus, iss-linked ara h appears to be a promising candidate for a safe immunotherapy product for treating peanut allergic subjects. introduction: immunotherapy has been studied for its adverse effects in some sensitive patients as with worsening of therapeutic response in some amounting to withdrawal of the later. methods: in the allergy center therapeutic trials of immunotherapy(house dust, mixmite) had been undertaken since , in therapeutic dose of . pnu/ml, . pnu/ml, pnu/ml, pnu/ml, pnu/ml pnu/ml, pnu/ml(housedust), . au/ml, . au/ml, au/ml au/ml au/ml au/ml au/ml(mixmite).patients age - years, both sex after diagnostic scratch/prick tests with appropriate antigenic preparations reported for local/systemic adverse effects the details of which were as under, results: please see the attached table for details, in some cases worsening of the existing allergic status was noted, which on analysis revealed initially a slow rise in the allergen -specific ige to be later on fol-lowed by rise of igg & igg & gradual fall of ige.only / patient could not complete immunotherapy for fear of adverse effects. conclusions: with utmost care/follow-up, no incidence of mortality outcome was reported from to late the incidence of adverse effects were significantly lowered on pre-medication with anti-histamines significantly more with elderly than younger age. even with all these documented hazards the beneficial effects far exceeded the harmful effects. background: the prevalence of allergic disease in most human population is steadily increasing. seafood allergy is a serious food allergy, although hypersensitive reactions caused by seafood has long been know, biochemical and immunological studies on seafood allergies had only begun lately. shrimp and abalone are the most frequently reported causes early asthmatic response. objective: to investigate cross-reactivity of shrimp, abalone and derp . methods: shrimp and abalone extracts were prepare from raw seafood. sera from patients from hongkong were studied who had asthma after consumption of seafood. ige elisa analyses comfirmed the combined sensitization to shrimp, abalone and derp . specific-ige elisa assays were accomplished for shrimp and abalone extracts inhibited by derp and derp elisa and immunoblot assays inhibited by shrimp and abalone extracts. results: elisa inhibition showed that most ige antibodies against shrimp and abalone were cross-reactive with derp and the same time, derp elisa was inhibition by shrimp and abalone extract. the elisa inhibition percent (%)of shrimp extract (gm: . %) and abalone extract(gm: . %) by derp were significantly higher than derp by shrimp extract(gm: . %) and abalone extract (gm: . %). (p< . ). furthermore, and there was a significant correlation of elisa inhibition percent between shrimp extract, abalone extract and derp inhibited by each other; sds-page and immunoblot of shrimp and abalone is the and kd allergen respectively. conclusion: this indicates that derp was the sensitive agent. shrimp, abalone and derp demonstrate significant cross-reactivity. these findings confirm that the primary crossreactive allergen of shrimp and abalone is the and kd allergen respectively. b. sun * , a. wu , n. zhong , . guangzhou, china; . hong kong. background: the house dust mites (dermatophagoides farinae (derf) are a major source of aeroallergens implicated in the expression of atopic disorders, including asthma, allergic rhinitis, and atopic dermatitis . in particular, strong circumstantial evidence suggests that house dust mites antigens are important precipitating factors of asthma. many house duse mite allergens are proteases that can elicit airway inflammation by stimulating the release of cytokines in bronchial epithelial cells. objectives: we have investigated whether der f allergen proteases induced cytokine production from the epithelial cell line beas- b. methods: cells were exposed to four different concentrations with serial additions of der f ( . , . , , ug/ml) were incubated for h to h. and compare with those without incubation of allergen. cytokine in the supernatants were assayed by elisa, reverse transcription?pcr was also performed. results: cells treated with der f allergen showed serial changes in the cohesiveness of the monolayer. there was a significant increase in the level of cytokine production compared with the untreaed sample. statistically significantly increased with addition of der f caused the release of il- and il- in time and concentration-dependent manner (p< . , respectively). levels of il- and il- were elevated h and h after allergen exposure, increasing with time, continued increased levels to be present of il- and il- in the supernatants at h and h. at the same time show the concentration dependence of induction of il- and il- expression as well as an increase in the expression of il- and il- mrna. conclusion: hdm-induced airway inflammation may include der f-mediated release of inflammatory mediators, and the proteolytic activity of an allergen may stimulate the release of proinflammatory cytokines from human bronchial epithelium. suggesting that il- and il- production by bronchial epithelial cells may play a role in the pathogenesis of allergic asthma. the purpose of this study is to delineate the immune injury mechanisms that involved in the autoimmune inner ear disease by introducing plasmid dna encoding of th cytokines (inf-g) into the inner ear. b-tubulin is a microtubular protein which we found as an important autoantigenic in meniere's disease as well as other autoimmune hearing loss. hearing loss was induced in mice and guinea pigs when they are immunized with the tubulin molecules. autoimmune hearing loss could be the results of th cytokine responses from autoimmune injury. to test the hypothesis, guinea pigs were immunized with mg of tubulin in cfa and boosted once more. two weeks later, we introduced ug ( ul) of naked dna encoding inf-g was injected into the left side inner ear through round window. same volume of . m pbs was injected into right side as control. abr was recorded before and after the injection. weeks after the injection, the animals were sacrificed and temporal bones were examined with h-e and inf-g immunocytochemical staining. the ears injected with the plasmid dna-inf-g had an enhanced hearing loss ( db), and degeneration of the spiral ganglion was found in these ears. however, the injection of the naked dna encoding inf-g did not change the expression of the inf-g in the inner ears. these results suggest that autoimmune hearing loss could be the result of th responses to inner ear autoantigens. -tubulin is an important molecule in the hair cells supporting cells within the sensory epithelium of organ of corti and found to be an auto autoantigen in autoimmune hearing loss including mèniére's disease. the object of the study is to induce hearing loss in mice with varying doses of antigen and evaluate the pathogenesis of autoimmune hearing loss induced by -tubulin in mice. mice were immunized with , or μg of -tubulin and hearing was evaluated by auditory brainstem responses (abr) and distortion product of otoaccoustic emission (dpoae). all mice had hearing loss by abr and dpoae tests and morphological study of temporal bone showed spiral ganglion degeneration and tunel staining positive cells were noted in these immunized mice. thus this study showed that -tubulin is an autoantigen for hearing loss in animal model as in human autoimmune hearing loss patients including mèniére's disease. supported by nih r dc - introduction: oral polio vaccination (opv) in the united states is currently being replaced with inactivated polio vaccination (ipv) given parentrally. while past studies have looked into the relationship of vaccination and asthma prevalence, none have investigated this relationship with regards to vaccination route namely orally versus parentrally. this study investigates the relationship between vaccination rates for the live attenuated orally administered polio vaccine and parentrally administered vaccines(dtp, mmr)and two potentially dependent factors; asthma prevalence rate and asthma-caused death rate. methods: we looked at data from the national center for health statistics yearly publications of health, united states ( - and the morbidity and mortality weekly report surveillance summaries . two databases were compiled to cover the - age population in the united states since this is the primary period of childhood vaccination. one database contained information for asthma related deaths and vaccination rate (dtp, mmr, opv) covering the years - and the other database compiled information for self reported asthma prevalence and vaccination rates(dtp, measles, rubella, opv) covering the period - . a t-test was used for statistical analysis. results: statistically significant correlation was found between vaccination rates and asthma prevalence rates. data for dtp (p = . ), measles (p = . ), and rubella (p = . ) indicated a statistically significant positive correlation with asthma prevalence. the oral polio vaccine was the only one of the vaccines that failed to display a significant relationship with asthma prevalence rates (p = . ). statistical analysis proved that a correlation between vaccination rates of united states children ages - and asthma-caused deaths was insignificant (p > . ). conclusions: the opv, which is administered orally rather than parentrally, displayed no relationship with asthma prevalence. this could be due to the fact that live attenuated orally administrated polio vaccine may induce mucosal immunity, simulating a normal pathogen route of entry into the body. childhood vaccination had no relationship with asthma-caused death rates. a.s. alfrayh * , riyadh, saudi arabia. introduction: heredity plays a major role in asthma and other allergic diseases, mechanisms underlying the inheritance of these disorders are poorly understood. this study therefore analyzed the risk conferred by family history of asthma and atopy for having childhood asthma. methods : a total of children between - yrs selected randomly in three cities in saudi arabia ( hail, taif and gizan )in - . the questionnaire which is similar to the one used in the international study of allergy and asthma in childhood isaac. were self administerd under medical supervision.apart from the demogrphic details, the questionnaire included questions on symptoms and physician diagnosis of asthma, rhinitis, eczema and family history of these conditions. the family members were grouped as immediate family and relatives. asthma and atopy were defined as ever having had physician diagnosis of such conditions information was also available about exposure to cigarette somke at least one member was a smoker in the household and having pets. relative risk for developing asthma was estimated in terms of odds ratio by bivariate analyses using chi square test and p value was considered significant when less than . . results : history of asthma in the immediate family and relatives conferred a fold and fold risk for development of childhood asthma odd ratio ( or )= . , % confidence interval(ci)= . to . , p= . and or= . , %ci= . to . , p= . respectively. rhinitis in immediate family and the relatives was associated with folds increased risk for childhood asthma or = . , % ci = . to . , p= . respectively whereas history of eczema conferred over folds risk or= . , % ci = . to . , p= . for childhood asthma when present only in the immediate family. history of eczema in relatives was not associated with any risk. of the environmental factors, exposure to cigarette smoke conferred folds risk of developing childhood asthma or = . , % ci = . to . , p= . , whereas exposure to pets was not a significant risk foctor. conclusion : presence of asthma and atopy either in the biological parents or relatives constitute a significant risk for childhood asthma.paricularly in the presence of evironmental risk factors. the murine local lymph node assay (llna) has been developed as an alternative to guinea pig models for the assessment of the contact sensitization potential. however, there is a need to develop a non-radioisotopic endpoint for the llna, because of the radioisotopic method's requiring the use of special facilities. in this study, we investigated to evaluate the lymphocyte subpopulations in the lymph node cells following allergen and irritant treatment. female balb/c mice were treated by the topical application on the dorsum of both ears with sensitizers, , -dinitrochlorobenzene (dncb), toluene diisocyanate (tdi), and a-hexylcinnamaldehyde (hca), and an irritant, sodium lauryl sulfate (sls), once daily for three consecutive days. the lymph node (ln) cells were harvested h after the final treatment. phenotypic analysis of lymphocytes subsets was performed with a flow cytometry. the allergens dncb, tdi, and hca and an irritant, sls increased cell number compared to the vehicle. there was an increase in the percentage of b + cells in mice treated with dncb and tdi compared to the vehicle control, but not in those treated with sls. mice were treated with dncb, hca and tdi showed a preferential increase in the percentage of b +cd + cells compared with vehicle and irritant-treated mice. there was an increase in b +cd + cells of mice treated with dncb, tdi and hca, but no significant increases were observed in mice treated with sls. mice were treated with dncb, and tdi showed an increase in the percentage of b +cd + cells compared with vehicle and irritant-treated mice. these results suggest that analysis of b cell activation marker, cd on b cells may be useful in differentiating allergen and irritant responses in the draining lymph nodes of chemically treated mice. m. frieri * , y.c. huang, east meadow, ny. introduction: nitric oxide (no) is an important biomarker for inflammation in airway epithelial cells and in exhaled breath of asthmatic subjects. we have previously demonstrated no production in antigen-stimulated human bronchial epithelial cells and an effect of omalizumab (monoclonal anti-ige antibody) on no production in those cells [leyko bt et al. j allergy clin immunol ; (suppl ) :a ]. in this study, we investigated the potential role of ige and its receptors on a cells by characterizing the effect of omalizumab on antigen, egf, and il- stimulation of a cells in a medium containing atopic serum. methods: a human alveolar epithelial cells were stimulated with iu/ml of il- , μg/ml of ragweed (ra), au of dust mite (dm), and ng/ml of egf, and exposed to either - m budesonide or . μg/ml omalizumab for or hours. no production was measured in duplicate by a highly sensitive elisa. results: omalizumab but not budesonide inhibited no production at hours in a cells stimulated with il- ( - μm, p<. )and il- +dm ( - μm, p=. ), but not with ra alone. however, at hours omalizumab and budesonide each significantly inhibited no production stimulated by il- ( - μm; - μm), il- +dm ( - μm; - μm), and egf ( - μm; - μm) (p<. ). conclusion: no production is a marker for inflammation. omalizumab demonstrated a significant anti-inflammatory effect in distal alveolar cells by inhibiting no production stimulated by antigen, il- , and egf in a medium containing atopic serum. as persistent inflammation in asthma may play a role in airway remodeling, treatment with omalizumab may have a beneficial effect on chronic airway inflammation in patients with asthma. oral tolerance trigger regulatory mechanisms able to down-modulate antigen-specific t and b cell response. to address the lasting effect of several regimens of oral tolerance to ovalbumin, in naive or antigen primed mice, b-cell function has been focused. furthermore, we analyze specific antibody response up to eight months of post-immunization, proliferative response, b (cd /cd ) expression on b cells and t cell ctla- involvement in oral tolerance. a/sn mice were immunized by intraperitoneal route with μg of ova/ , mg-alum and boost days after priming (dap). ova feeding was done with mg at different days before or after antigen priming. in others protocols, mice were fed twice, before and after priming with a total of mg of ova. all groups were boosted at or or or dap. the results showed that only mice fed at naive status and those fed twice before and after immunization demonstrated a long lasting of ige ab response inhibition up to months of immunization. these mice showed a marked inhibition of antigen-specific proliferative response that was restored with anti-cd mab in vitro stimulation. evaluation by flow cytometry of spleen cells cultured for hours upon ova stimulation, showed an important decrease of b . expres-sion on b cells of naive fed mice, which remained inhibited until months of immunization. after addition of anti-ctla- mab an enhancement of b . expression was detected on b cells of naive fed mice. ctla- molecules expression on cd + t cells of naive fed mice remained unchanged following ova stimulation while a peak of expression was detected at h of ova stimulation in control group. this finding reinforce the t cell anergic status of naive fed mice, due to the less cell division and consequently a low rate of cd +/cd high activated cells. the results showed that antigen feeding before immunization induce a long lasting anergy mediated by an impaired t-b cell cooperation and ab production due to the decrease of costimulatory molecules expression on b cells and negative signaling effects by ctla- expression. introduction: vascular endothelial growth factor (vegf), basic fibroblast growth factor (bfgf) and fibronectin (fn) can promote angiogenesis, a putative component of airway remodeling. (s)-albuterol can exacerbate airway hyperresponsiveness, bronchospasm and release pro-inflammatory cytokines from small airway and smooth muscle cells. our study evaluated the effects of (s)-albuterol ((s))-and (r)-albuterol ((r)) on secretion of these factors on normal human lung fibroblasts (nhlf) and myofibroblasts (myonhlf) in the presence or absence of tgf , il- , or allergens. methods: nhlf were stimulated to differentiate to myonhlf with pg/ml tgf . dose-dependent effects of (s) and (r) [ - to - m] were evaluated for secretion of vegf, bfgf and fn by nhlf and myonhlf with and without au/ml d. pteronyssinus (dp), pnu/ml ragweed (ra), u/ml il- , or pg/ml tgf into serum-free media (its) at o c with % co collected at hr and assayed by elisa. results: in nhlf the following was observed: vegf secretion was -fold higher with - m (r) relative to (s), p< . ; bfgf secretion was increased %- % by - m (s) relative to (r), p< . . a lower concentration of (s) ( - m) in the presence of either dp or il- caused a -fold increase in secretion of bfgf relative to (r), p= . . in the presence of myonhlf the following was observed: - and - m (s) caused a %- % increase in secretion of fn relative to (r). at - m (s), this effect was further increased with the addition of il- , p= . ). conclusion: in a dose-dependent manner, (s)-albuterol stimulated the release of bfgf and fn by nhlf and myonhlf, respectively. this was enhanced by dust mite and/or il- , potentially contributing to the matrix remodeling observed in chronic asthma. vegf over-expression can have a protective effect against chronic hypoxia and can recruit immune cells to the alveoli. increased vegf by (r)-albuterol could contribute to such an effect in vivo in asthmatics. bfgf, in bal and sputum of asthmatics, and fn which contributes to subepithelial fibrosis, can promote angiogenesis. increased bfgf and fn by (s)-albuterol could be detrimental over time by enhancing matrix deposition and remodeling in a subset of asthmatics. o. ozdemir * , c. moore , y. ravindranath , s. savasan , . detroit, mi; . new orleans, la. background: mast cells (mc) have been shown to demonstrate natural cytotoxicity against mouse fibrosarcoma cell line in culture when incubated for - h. this effect has been postulated to be mediated through soluble and/or membranous tnf-. more recently; fasl, mc chymase and serine protease granzyme h with its chymase activity were proposed as mediators of mast cell-mediated cytotoxicity. thus, both 'granule-exocytosis' through chymase, granzyme h and soluble tnf-and 'death receptors' through membrane-bound tnf-and fasl pathways appear to be operative in this process. aims: following our earlier observations on long-term liquid culture-grown human bone marrow mast cell cytotoxicity against human leukemia cells in - h co-incubation experiments, we investigated mast cell-mediated cytotoxicity against natural killer/lymphokine-activated killer cell-sensitive cells in short term ( h) cultures without any stimulation for the first time. methods: human bone marrow mononuclear cells were cultured in methyl cellulose supported with il- , il- and scf. mast cell colonies that developed in six weeks were transferred to liquid medium and maintained for weeks before experiments. cytotoxicity was investigated against k , raji and daudi cells at , and hours of co-incubation by our established flow cytometric cell-mediated cytotoxicity assay. results: after h co-incubation, % ( % early apoptotic and % late apoptotic or necrotic death) and % ( % early apoptotic and % late apoptotic or necrotic death) target cell kill was demonstrated in daudi and raji cells, respectively. daudi cell killing has stayed stable at h ( %; % early apoptotic and % late apoptotic). despite a small numbers of experiments, daudi cell kill was statistically significant at h (p: . ) and h (p: . ) compared to control. however, k cell elimination ( %) has not occurred until h. mast cell-daudi cell conjugates were seen on the wright/giemsa slides (figure) . conclusion: our results demonstrate that human mc can cause cell-mediated cytotoxicity against certain cells in relatively short-term. this further suggests possible contribution of 'granule-exocytosis' pathway to mc natural cytotoxicity, indicating a faster mc response in immune surveillance. o. ozdemir * , m. buyukavci , y. ravindranath , s. savasan , . detroit, mi; . erzurum, turkey. background: the effect of melatonin (mlt) on cellular immunity has been controversial. recently, mlt has been demonstrated to activate t and nk cells through its membrane or nuclear high affinity receptors. it was also shown that pharmacological concentrations of mlt (>nm) could be cytotoxic against different human cancers. aims: our aim was to investigate the effect of mlt alone or in combination with il- on peripheral blood lymphocytes (pbl), lymphokine activated killer (lak) cell generation and its cytotoxicity. methods: pbl were cultured for days in the presence of mlt at different concentrations ( - , - , - m) with or without il- ( u/ml). cell viability was determined by trypan blue exclusion test. cell-mediated cytotoxicity of lymphocytes/lak cells against k- and daudi cells was studied using our established flow cytometric cell-mediated cytotoxicity assay. results: although - m concentration of mlt did not affect cell proliferation much on day , it significantly inhibited proliferation by day (p< . ) consistent with known anti-proliferative effect of mlt. - and - m concentration of mlt also mildly inhibited proliferation on day ; however there was a minimal rebound with - m concentration by day . consistent with the reported mlt-treated pbl's reduced response to mitogens, il- and mlt ( - m) combination suppressed proliferation on days and ; however, with - m mlt concentration pbl counts increased gradually from day to . although mlt treatment alone did not enhance cell-mediated cytotoxicity, il- and mlt combinational treatment at both concentrations ( - and - m) increased it significantly compared to baseline activity (figure) . conclusion: il- and mlt combination at - m concentration resulted in superior lymphocyte proliferation and lak cell-mediated leukemia cell kill. mlt-induced increase in il- r-expression of pbl shown earlier might be the mechanism for our observations. mlt can be considered in immunotherapy as an adjunct to il- treatment. a.e. fusaro * , j.r. victor, c.r. oliveira, c.a. brito, e.a. futata, m. maciel, a.j. duarte, m.n. sato, são paulo, brazil. the maternal exposure to allergens during pregnancy or even in postnatal period may influence the allergy onset to newborns, through antigen or antibody transmission. we sought to verify the effect of maternal antigen exposure before conception, during gestation or in the breastfeeding period on the offspring type i hypersensitivity response. female balb/c mice were immunized or not with ova extract/alum, boosted twice at th and th and mated with normal balb/c male on the th day after sensitization (das). others groups of immunized mothers also received oral administration with ova along pregnancy, or non-immunized mothers received ova only during breastfeeding. offspring from immunized or normal mice were immunized intraperitoneally with ova at do and boosted on the th das. the results showed a important decreased of tgf-levels in the amniotic fluid and milk from immunized mothers before mating in comparison to obtained from normal mothers. ova exposure during pregnancy of immunized mothers decrease significantly the transference of tgf-by breastfeeding, while both tgf-isoforms were founded at high levels in the amniotic fluid. similar levels of tgf-transference by placenta to the newborn was detected in both immunized mother groups. pups from mothers exposed with ag during pregnancy showed an increased spleen cell number, whereas did not produced il- , il- , il- e ifn-secretion induced by antigen neither altered responsiveness to anti-cd or mitogen. maternal ova-immunization induced a marked inhibition of spe-cific ige antibody response in the immunized pups, contrasting to the enhancement of ige responsiveness detected in the immunized pups from mothers which were exposed to ova only at postnatal period. these results showed that preconceptional immunization exert a protective effect on the offspring ige development and an exacerbation of ige responsiveness due to mother antigen exposure during breastfeeding. the findings suggest that rather than in utero antigen priming occurrence, postnatal period may contribute to offspring early life sensitization. financial support: fapesp and lim -fmusp introduction: the reasons for the increased incidence of allergic diseases in westernized countries are still unknown. mercury is an important pollution factor to which humans are increasingly exposed. prior studies on the effect of mercury on mitogen stimulated human lymphocytes indicated a th weighted immune response, but the results were inconsistent and difficult to reproduce. phorbol myristate acetate (pma) is a direct activator of protein kinase c, which has been shown to play a role in mercury induced il- production in animals. therefore we investigated the effect of mercury on pmaactivated human peripheral blood mononuclear cells (pbmc). methods: pbmc from individuals were cultured for days in culture medium containing pma and ionomycin in the presence or absence of mercuric chloride (hgcl ). il- and gamma-ifn concentrations were measured by elisa of culture supernatants. cell death and apoptosis were determined by -aad and annexin staining and fluorescence activated cell sorting (facs). cell-proliferation was assessed by h-thymidin-incorporation. results: after days of culture, pma/ionomycin-stimulated a small amount of il- compared to untreated pbmc ( . +/- . pg/ml versus . +/- . pg/ml). however, mercury induced a more than fold increase in il- production when added to pma-activated cells ( . +/- . pg/ml, p< . ). gamma ifn production was strongly increased in pbmc that were treated with pma/ionomycin (> pg/ml versus +/- pg/ml in unstimulated cells) but dropped markedly in cells treated with mercury plus pma/ionomycin. in addition, mercury induced increased cell death, apoptosis and reduced cell proliferation. conclusions: hgcl strongly stimulates il- production in pma/ionomycin treated pbmc while cell viability and gamma-ifn production drop significantly. these preliminary results suggest that human exposure to mercury may be playing a role in the observed increased incidence of allergic disease in the industrialized world background: mast cells (mc) have been shown to induce natural cellmediated cytotoxicity in long-term ( - hrs.) in vitro assay systems. the cytotoxicity is mediated by at least two pathways: secretory via exocytosis of mc granules containing serine proteases such as granzymes, chymase and soluble tnf-and nonsecretory (cell-to-cell contact) via membranous tnfand fasl. chymase induces apoptosis in neonatal rat cardiomyocytes and human vascular smooth muscle cells. the objective of this study was to investigate mc mediated cytotoxicity against nk/lak-sensitive cells in short term ( hrs.) unstimulated cultures. methods: human bone marrow mononuclear cells were cultured in methylcellulose supported with il- , il- , and stem cell factor. mast cell colonies developed at weeks and were transferred to liquid imdm and maintained for weeks. a flow cytometric cytotoxicity assay was used to determine cytotoxicity against daudi, raji, and k cell lines at hrs., hrs., and hours. the controls consisted of cell lines without mast cells at hrs., hrs., and hours. results: rationale: to establish the antibody response rate in children with recurrent infections and fully immunized with the pneumococcal -valent conjugate vaccine. methods: we have analyzed patients referred to our clinic with recurrent infections despite complete immunization with the pneumococcal -valent conjugate vaccine for age, according to acip guidelines. we assessed the patients by checking their immunization status and the antibody titers to all streptococcus pneumoniae serotypes included in the vaccine ( , b, v, , c, f, f) assessed by standardized elisa. the patients were assembled into groups, a non-immunized group with laboratory data prior to the vaccine, and an immunized group consisting of responders and nonresponders according to their antibody titer (< . or > . iu/ml respectively). the data were analyzed using epi info and spss. results: the mean age was . years for non-responders and . years for responders. there was no significant statistical difference between the groups regarding age, race and sex. ten patients were identified who failed to respond to all serotypes included in the pneumococcal -valent conjugate vaccine. there was no significant statistical difference between the non-immunized and the immunized nonresponders to all serotypes. conclusions: we have identified a special immunological phenotype of specific antibody deficiency (sad) patients with normal total immunoglobulins and normal responses to protein antigens, but who failed to respond to conjugate pneumococcal polysaccharides. a. yates * , r. deshazo , j. butler , g. howell , j. farley , h. liu , n. nanayakkura , g.b.yi , r. rockhold , . jackson, ms; . oxford, ms. introduction: venom from s. invicta consists of % disubstituted piperidine alkaloids and is toxic to insects, birds and farm animals. recent reports of morbidity and mortality in elderly patients after massive fire ant stings suggest the potential for systemic mammalian toxicity. we evaluated the toxic responses to systemic administration of two structurally verified, synthetic s. invicta venom alkaloids, solenopsin a (trans- -methyl- -n-undecylpiperidine) and its cis-isomer, isosolenopsin a, in rats. methods: sprague dawley rats were anesthetized with isoflurane, paralyzed with gallamine, artificially ventilated and instrumented to record arterial blood pressure (bp; mm hg), heart rate (hr; bpm) and % change in left ventricular contractility (lvc; p/ t). in addition, a group of rats was chronically instrumented to record bp and hr while the animals were conscious and freely-moving. results: solenopsin a at to mg/kg iv dose-dependently lowered bp, hr and lvc. at mg/kg iv, hypotension (- ± mmhg), bradycardia (- ± bpm) and decreased lvc (- ± p/ t) were marked. isosolenopsin a, mg/kg iv, produced responses similar to solenopsin a mg/kg iv. solenopsin a mg/kg iv elicited tonic-clonic convulsions and respiratory arrest in conscious, freely-moving rats. hematuria was seen with solenopsin a, but not isosolenopsin a. superfusion of a working, isolated, perfused rat heart with um of solenopsin a elicited a marked, reversible decrease in lvc, and cardiac arrest occurred with um of solenopsin a. conclusion: the results demonstrate that these alkaloids possess significant depressant activity on the cardiac and respiratory systems of rats. the neurologic and cardiorespiratory effects can account for lethality to small mammals in the wild, and may contribute to adverse cardiovascular effects noted in humans after massive fire ant stings. introduction: during asthma attacks, the ph of exhaled breath condensate (ebc) decreases two log orders (ph= . ), returning to normal levels after corticosteroid therapy (ph= . ). ion channels, once thought to participate only in the transport of ions, are now suspected of mediating airway inflammation in asthma as well. to determine whether allergen directly alters airway mucosal ph and ion function, we measured nasal ph and nasal potential difference (pd) before and after nasal allergen challenge (nac). methods: ten allergic rhinitic subjects (mean±sem age . years± . , females) underwent a crossover, single-blinded, placebo-controlled study, where they were challenged with allergen (dust mite, grass, cat) and control diluent in two different occasions in random order via nasal spray. nasal ph was measured on the surface of nasal mucosa with a ph probe. nasal mucosa pd was measured between nasal mucosa and forearm skin. subjects also filled out a nasal symptom scale. measurements were taken at baseline, hour, hours, and hours after nac. results: the nasal symptom score increased significantly immediately after allergen compared to control challenge ( . ± . vs. . ± . respectively, p= . ). there were no statistically significant differences in the nasal ph at h and h, but a significant decrease at h compared with baseline (- . ± . vs. + . ± . , p= . ). the change in ph from h to h correlated significantly and inversely with change in symptoms (r=- . , p= . ) and number of sneezes (r=- . , p= . ) after challenges. nasal pd did not change significantly after challenges. conclusion: allergen decreases nasal mucosal ph in the very late phase after challenge in allergic rhinitic subjects. decrease in airway mucosal ph during asthma exacerbations may be caused by aggravation of allergic inflammation. nasal potential difference does not change after allergen challenge. funding: niaid, acaai foundation introduction: uv induces differentiation of t-and b-lymphocytes, suppresses natural killer cells, renders a tolerogenic effect and induces apoptosis resulting in local and system immunosuppression. methods: lymphocytes were studied using indirect immunofluorescence methods employing monoclonal antibodies to cd-markers cd , cd , cd , cd , cd , hla-i, and hla-ii, from the blood of volunteers (aged - years) before uv exposure (control), after an exposure of blood in vitro to a dose . kj, and after hours of exposure of the medial surface of the elbow joint in vivo (s= cm ), to a dose of . kj. results: the direct exposure of blood results in a significant reduction in the number of lymphocytes, probably due to direct phototoxic effects. significant modifications both of the aggregate number of lymphocytes and amount of t-helpers after uv exposure of the skin were not seen. after uv the number of cells which express the marker cd is sig-nificantly increased. exposure to uv in vitro induces reduced number of cells bearing cd . however on in vivo exposure, a significant increase in number of cells which express cd was observed. uv exposure of blood reduced significantly the hla-i ( . ± . reduced to . ± . ) and hla-ii (dr) ( . ± . reduced to . ± . ) expression. uv exposure of skin increased significantly hla-i to . ± . , while hla-ii (dr) was insignificantly decreased to . ± . . cd expression increased from . ± . to . ± . due to blood uv exposure, while there were insignificant reductions in cd ( . ± . reduced to . ± . ) and cd ( . ± . reduced to . ± . ) expression. conclusion: uv starts a cascade-like response, including apoptosis, leading to changes in nk cell, helper and suppression lymphocyte numbers consistent with an immunomodulating effect of uv radiation. background: previous investigations have shown the involvement of histamine and histamine receptors (h , h , h , h ) in ige synthesis in atopic and lymphoproliferative diseases. ige responses may depend on the concentrations of histamine and histamine receptor antagonists and agonists. the goal of this investigation was to evaluate the role of the concentration of histamine and h /h antagonists along with the importance of pre-existing levels of ige in determining ige responses. methods: ige synthesis was studied in mnc cultures of patients ( - years old) having mild atopic asthma and rhinitis. all patients had high levels of total ige and specific ige to ragweed pollen, house dust mite, epidermal or mold allergens. patients were divided into two groups according to the serum ige and levels of spontaneous ige synthesis: group a -with low levels ( . ± . iu/ml) and group b -with high levels ( . ± . iu/ml). the serum level of total ige in group a was . ± . iu/ml and in group b was . ± . iu/ml. fub hydrogenmaleate was used as an h /h specific antagonist. results: histamine in high concentrations ( - m) suppressed and in low concentrations ( - m) stimulated spontaneous ige synthesis. the h /h antagonist fub activity depends on the pre-existing levels of ige. in high concentrations ( - m), the antagonist increased ige synthesis only in group a, but not in group b having high spontaneous levels of ige synthesis. the synthesis in group a increased . fold (p< . ), but h /h blockade cancelled the ige suppressive effect of high concentrations of histamine ( - m). the addition of histamine into the mnc culture stimulated ige synthesis . fold. fub had no effect on ige-stimulatory effects of low concentrations of histamine ( - m). in allergen (ragweed)-stimulated mnc culture, fub had a co-stimulatory effect on ige synthesis induced by histamine. conclusions: the ige stimulating response depends on the concentrations of histamine and the h /h antagonist as well as pre-existing levels of serum ige and ige spontaneous synthesis. introduction: preliminary data has shown that oral contraceptives can precipitate or worsen attacks of hereditary angioedema (hae). it is thought that estrogens affect the synthesis and degradation of bradykinin with resulting edema. objective: our objective is to determine if there is a difference among the various oral hormonal preparations, namely, combined monophasic, combined multiphasic, progesterone only, and hormone replacement therapy, in regards to their effect on frequency of hae exacerbations. methods: patients in this study consisted of women over the age of diagnosed with hae who receive their care at our institution and women meeting the same criteria who are active in the hae foundation and have access to this association's web page. all patients answered a sixteen item questionnaire about past or present birth control pill or hormone replacement therapy usage and its impact on the frequency of exacerbations. results: of the patients who completed the questionnaire, % had taken or were currently taking oral contraceptive pills or hormone replacement therapy. of the women whom had taken monophasic birth control pills, % worsened with increased number and severity of exacerbations. however, only % of the women that had used combined multiphasic birth control pills worsened. all of the women who had tried progesterone only birth control pills worsened. of those on isolated estrogen for hormone replacement, % had an increased number of exacerbations. when androgens were used concurrently with oral contraceptive pills or hormone replacement therapy, exacerbations decreased to %. conclusion: we are not able to demonstrate a statistical benefit of one oral contraceptive pill preparation over another because of our sample size. however, our preliminary data supports that the oral contraceptive pill which produces less exacerbations and less symptoms is a combined multiphasic pill with concurrent androgen treatment. introduction atopic dermatitis (ad) is associated with multiple immunological abnormalities including imbalances in the subsets of blood circulating lymphocytes forming cellular infiltrates in inflamed skin. many studies of the functional and phenotypic properties of lymphocytes in ad have been limited to either peripheral blood or skin-infiltrating lymphocytes. the purpose of our study was to evaluate and compare the content and phenotypic properties of cd + lymphocytes from blood and inflamed skin of ad patients. materials and methods adult (age - years) patients with chronic ad were selected by the criteria of hanifin. all patients gave written informed consent. the cd + lymphocytes of peripheral blood were phenotyped by flow cytometry. skin biopsies were obtained from eczematous areas, then cryosected and double immuno-histochemistry was performed. for phenotyping of lymphocytes in blood and skin a panel of monoclonal antibodies was used including cd , cd , cd , cd , hla-dr and cla. results immunophenotype analyses of the peripheral blood lymphocytes showed a predominance of cd +cd + cells ( %± . ). most cells were cd +hla-dr+ ( %± . ) and cd +cd + phenotype ( %± . ). double immunohistochemistry of the skin biopsies revealed in the epidermis rare but constant presence of cd +cd +cells ( . ± . cells/mm ) and cd +hla-dr+ cells ( . ± . cells/mm ). in the dermal inflammatory infiltrates the predominant cells were cd +cd + ( . ± . cells/mm ) and cd +hla-dr+ ( . ± . cells/mm ). the dominant inflammatory infiltrate consisted of cd +cla+ phenotype ( . ± . cells/mm ) cells. conclusion in ad skin inflammation is associated with the appearance in the circulation of cd + lymphocytes in activated form (cd +hla-dr+) and lymphocytes with regulatory properties (cd +cd +). these lymphocytes are recruited from the circulation, having the skin homing properties (cd +cla+), and form the main constituent of the dermal inflammatory infiltrate. contact dermatitis (cd) comprises a spectrum of inflammatory skin reactions usually caused by exposure to non-immunogenic low molecular weight substances (haptens). failure to diagnose the condition may result in a chronic and disabling condition with impaired quality of life. a yr-old white male presented with a severe, symmetrically distributed facial maculopapular rash with secondary excoriated lesions. prior to the appearance of the rash, the patient had been applying lubriderm as a skin moisturizer for dry skin. a standardized thin layer rapid use epicutaneous (true) test containing chemical agents suspended in a vehicle and attached to an adhesive backing was applied to the patient's back. at hrs, a positive reaction was observed at the skin site of the paraben mix application. the lubriderm preparation used by the patient contained paraben, in contrast to a newer preparation, advanced therapy lubriderm, which is paraben-free. complete resolution of the facial lesions occurred following discontinuation of the lubriderm and the use of oral and topical corticosteroid therapy. this case report illustrates how a commonly used moisturizer can contain a sensitizing agent that could be detected by standardized patch testing which should be a part of the diagnostic armamentarium of every allergist-immunologist. we report how a commonly used and effective moisturizer (lubriderm) can cause severe allergic cd and that the use of a standardized thin layer rapid use epicutaneous (true) patch test panel can be an effective diagnostic tool for the detection of the offending agent. rationale: this study aimed to establish the possible differences of cutaneous sensitization to common aeroallergens in children under years old. methods:the study was conducted between - and included infants from silesia/southern part of poland/.these infants were refered to our allergy unit due to respiratory symptoms like rhinitis, otitis, pharyngitis, cough, bronchitis recurring;eye's symptoms/ conjunctivitis/ and oral symptoms. the skin prick test/ spt/ to major aerollergens in our environment(hdii, birch, alternaria, cladosporium and trees)were done to -months-old and -yearold children. a spt of mm or larger was considered as positive. patients were classified into three groups: i:positive family atopy ii:smoking ciggarettemother/ or father iii:cat or dog at home iv: coexisting food allergy results: , % of examined children were boys. the prevalence of sensitisation found were as follows:latex , %, birch , %, dpii- , %, grass pollen , %, alternaria- , %. positive spts to latex were first seen in the -months-old group and this prevelance doubled until they finished year. conclusion: in our study, cutaneuos sensitisation start to appear in -months-old chlidren. background: propylene glycol (pg) may induce allergic contact dermatitis (acd) and skin irritant reactions. topical formulations frequently contain pg. it is present in low concentration ( %) in pimecrolimus cream %, a non-steroid inflammatory cytokine inhibitor. objectives: this study was designed to assess the incidence of cutaneous responses to pimecrolimus cream in patients allergic to pg and to determine their nature (acd or irritation) and severity. methods: in this double-blind, randomized, vehicle-controlled, withinpatient study, subjects allergic to pg underwent -hour patch-testing (pg and %, pimecrolimus cream and vehicle) followed by a -day repeated open application test (roat). application sites were assessed by the investigator using a scale ranging from (no reaction) to (spreading bullous reaction) at , , and hours after patch removal and at the completion of the roat. results: pg allergy was confirmed by patch-testing in patients. two patients showed a positive patch-test reaction with pimecrolimus cream and vehicle, indicating an acd. in contrast, no patient demonstrated signs of acd when pimecrolimus cream was applied under normal conditions, i.e. without occlusion (roat). the statistical analysis showed that there were significantly less reactions at pimecrolimus patch-test sites than at the pg patch-test sites (p< . for both pg concentrations, one-sided exact binomial test) and that the median severity was lower with pimecrolimus cream vs. pg (p= . and p< . for pg % and % respectively, wilcoxon signed-rank test). conclusions: this pilot study suggests that pimecrolimus cream %, when applied under normal conditions, can be used safely in patients with pg allergy. introduction: chronic idiopathic urticaria is not always responsive to antihistamine therapy. multiple alternative agents have been tried. we report two cases where tacrolimus has been successful in treating this condition. methods: this is a case report of two patients who have chronic idiopathic urticaria and have been treated with tacrolimus. patient # is a y/o wm who pre-sented with urticaria that had been going on several months. the duration of his urticarial lesions was < hours his urticaria was treated with several medications including: hydroxyzine, cyproheptadine, ceterizine, montelukast, colchicine, and dapsone. he was intolerant to hydroxychloroquine. montelukast seemed to provide some modest benefit but he continued to have daily urticaria with > lesions/day after two months of therapy. tacrolimus was added to montelukast at mg bid. patient # is a y/o wf with a history of biopsyproven urticaria. she had suffered from episodic urticaria since the age of six that was responsive to systemic steroids. after thirty years of having no urticaria, she developed recurrent urticaria at age . at this time, she was treated with hydroxyzine, doxepin, montelukast, loratadine, ceterizine, fexofenadine, colchicine, dapsone, and even prednisone with very little improvement in symptoms. she was then started on tacrolimus mg bid as monotherapy while she was having daily urticaria. results: after one month of treatment with tacrolimus mg bid, patient # had a decrease in the number of urticaria. his dose of tacrolimus was increased to mg/day, and after four weeks, his urticaria resolved. he remained on tacrolimus for a total of six months which was tapered and discontinued. he continues to be in remission from urticaria. patient # had complete resolution of her hives after just two doses of tacrolimus. after two months, she remains free of urticaria on tacrolimus mg bid. conclusion: for patients with severe chronic urticaria unresponsive to multiple therapies, tacrolimus, like cyclosporine, may be efficacious. tacrolimus may also be truly immunomodulatory and capable of inducing remission of urticaria. s.v. gerasimov * , lviv, ukraine. introduction. recent studies suggest that probiotics can be useful in prevention and treatment of atopic dermatitis (ad) in children. as clinical effect of probiotics varies greatly depending on the specific strain, we are currently conduct a search for the most promising probiotic to be used as complementary therapy in infants and young children with ad. methods. we studied infants aged - weeks ( ± ) with ad established using hanifin and rafka criteria. patients were evenly allocated among probiotic (n= ) and nonprobiotic (n= ) treatment groups using quota allocation system. severity of ad was defined using scorad index and infant`s quality of life was assessed using idqol index. patients were examined before and weeks after the treatment with/without probiotic powder formulation (b. infantis, l. acidophilus dds- , billion cfu/day, dds-junior, uas laboratories). we compared pre/posttreatment values of indices above and amount of mometasone furoate ( , %) used employing a paired or unpaired t-test. results. at baseline, infants in either groups were comparable on age, gender, duration of the disease, scorad and idqol indices, and medication taken for the previous weeks. before entering the study all patients were maintained on allergen elimination diet due to milk and egg white allergy. after the treatment with/without probiotics the mean scorad index decreased from , to , (p= , ) and from , to , (p= , ), respectively. however, the mean amount of mometasone furoate used in non-probiotic treatment group was significantly greater ( , g vs , g, p= , ), despite the same recommendation on the use of the drug was given. additionally, parents of children taking probiotics reported an improvement in infant`s quality of life as seen on the decrease of idqol index from , to , (p= , ). in non-probiotic group decrease in idqol was not significant ( , to , ; p= , ) . there were no adverse events in any of the treatment groups. conclusions. our preliminary results suggest that some probiotics may have a corticosteroid-sparing effect and improve quality of life of infants with ad. there is a clear trend towards reduction of scorad index, which did not change significantly, probably due to a limited number of patients involved. introduction : the aim of this study was to analyze the risk factors of severe atopic dermatitis(ad) in the first months of life. methods : the children aged less than months with ad were divided into two groups according to six area six sign in atopic dermatitis(sassad) score. children with score less than was classified as mild ad(n= ) and those with score above as severe ad(n= ). these patients were fed with breast milk or cow's milk formula, and no allergenic food was given except rice and some vegetables. we analyzed the gender, feeding patterns, family history of allergy, number of siblings, total ige and specific ige to common food allergens (egg white, cow's milk, wheat, soy) by cap-feia assay. total eosinophil count was ± /ul in severe ad and ± /ul in mild ad(p< . ). results : ) total ige was . ± . u/ml in severe ad and . ± . u/ml in mild ad(p= . ). specific ige to egg white, wheat and soy ( . ± . u/ml, . ± . u/ml, . ± . u/ml in severe ad; . ± . u/ml, . ± . u/ml, . ± . u/ml in mild ad; p< . ) were associated with severe ad, but cow milk( . ± . u/ml in severe ad, . ± . u/ml in mild ad) showed no difference. ) gender, feeding patterns, family history of allergy and the number of siblings were not significantly associated with severe ad. conclusion : severe ad is associated with sensitization to food allergens in the first months of life, although they are not fed with those foods. background: atopic dermatitis (ad), an inflammatory skin disease diagnosed primarily in children, has been shown to have a negative impact on quality of life (qol). pimecrolimus cream % is a non-steroid, topical calcineurin inhibitor with demonstrated efficacy in the acute treatment and longterm management of pediatric and adult ad. in a -week, double-blind, vehicle-controlled study, a secondary aim was to evaluate the impact on parent's quality of life of a pimecrolimus-based or corticosteroid (cs)-based treatment regimen of children with ad. methods: children aged months to years (mean years) with mild to severe ad were randomized : to receive treatment with pimecrolimus or vehicle cream. emollients for dry skin and pimecrolimus or vehicle bid were applied at the first signs of ad. for severe flares, a mid-potency topical cs (fluticasone or mometasone) indicated for once-daily use in ad replaced the evening study drug application for a maximum of weeks or until all ad resolved. parents completed the parent's index of quality of life-atopic dermatitis (piqol-ad), a -item validated questionnaire, which measures parent's needs-based qol, at baseline, week , and study completion. change in piqol-ad scores at baseline and week were compared between treatments. a negative change indicated improvement. results: parents of patients in both groups reported improvement in piqol-ad scores at week , with greater improvement for the pimecrolimus group. the mean change in piqol-ad score from baseline to week was - . in the pimecrolimus group vs. - . in the cs-based treatment group ( . % vs. . % improvement, respectively). ancova analysis, using treatment and center as main effects and baseline score as a covariate, compared the change in piqol-ad score in two treatment groups. pimecrolimus treatment demonstrated a more favorable change (- . ) which approached statistical significance [p= . ; %ci= (- . , . )]. conclusion: a treatment regimen utilizing pimecrolimus cream % had a beneficial effect on parent's quality of life compared to a corticosteroid-based regimen. this benefit was consistent with other measures of efficacy studied. introduction: atopic dermatitis is a chronic, inflammatory and recurrent skin disorder . its prevalence has increased in recent decades but little is known about it in mexico city. the aim of this study was to evaluate the prevalence and severity of atopic eczema in a pediatric population. methods: a cross-sectional questionnaire survey (isaac phase i questionnaire) was conducted on random samples of schoolchildren aged to years and to years from educational centers of four northern counties from mexico city. those children with a positive response to being questioned about the presence of an itchy relapsing skin rash in the last months were considered to have atopic dermatitis. children whose symptoms resulted in sleep disturbance for or more nights per week were considered to have severe atopic eczema. statistical analyses were done with spss . for windows, chi square . the size of the sample was determined folowing the isaac specifications and calculated with the statcal program. results: complete data was available for children aged to years in schools and children aged to years in high schools. . % males and . % females. response rates were high ( . % for those aged to years and % for those aged to years). the prevalence of symptoms of atopic dermatitis in the last months was . % at age to and % at age to years. medical diagnose of atopic eczema was % and . % for children aged to years and to years, respectively. reported eczema accounted for . % and . % at age to and to years, respectively. children with symptoms of severe atopic dermatitis accounted for % of all those with symptoms of atopic dermatitis. we also found that the majority of the children begun with skin manifestations of atopic dermatitis before the age of years old. conclusions: the prevalence of atopic eczema was very similar for both groups of ages. our results agree with those found in other two studies acomplished in other mexican cities (cuernavaca and chihuahua) and with those from other countries of latin america like brazil, chile and costa rica. although, we found lowest values than those from sweden, japan and australia. studies that include objective skin examination are required to confirm these findings. a. kaplan * , s. meeves , y. liao , s.t. varghese , g. georges , . charleston, sc; . bridgewater, nj. introduction: the symptoms of chronic idiopathic urticaria (ciu) can have a profound impact on patient health and quality of life. the safety and efficacy of fexofenadine (fex) bid for the treatment of ciu has been previously established in two multicenter, double-blind, randomized, placebo-controlled trials. this study evaluated the efficacy and safety of a qd dose of fex hcl mg, as this dosing schedule could offer advantages in terms of patient compliance and convenience. methods: this multicenter, randomized, double-blind, parallel-group, placebo-controlled study consisted of a single-blind placebo run-in period of - days, followed by a (± )-day treatment period. males and females aged years with a diagnosis of ciu and with active disease were enrolled. patients were randomized : to receive either fex hcl mg qd or placebo qd. the primary endpoints were change from baseline in mean daily number of wheals (mnw score) and mean daily severity of pruritus (measured on a -point scale) over the -day treatment period, as assessed reflectively by the patient. secondary efficacy measures included a modified total symptom score (motss), comprising sum of number, frequency, size and duration of lesions, and severity of pruritus. mnw and pruritus severity were also assessed instantaneously at trough drug levels (immediately prior to dosing). results: over the -day treatment period, patients treated with fex (n= ) experienced significantly greater improvements in mnw and pruritus scores compared with the placebo group (n= ) (p< . for both). similarly, over the treatment period, and at individual weekly timepoints, the mean reductions in am reflective, pm reflective and mean daily motss were significantly greater for patients in the fex group compared with those in the placebo group (p . for all comparisons). the mean reductions in instantaneous mnw and pruritus scores were greater with those who received fex than those who received placebo (mnw: p= . ; pruritus score: p= . ). there were no significant differences in the frequency of treatment emergent adverse events between the two treatment groups, and no clinically relevant changes were observed with respect to clinical laboratory data, vital signs or ecgs. conclusion: this study demonstrated that a qd dose of fex hcl mg offers effective and well-tolerated relief from the symptoms of ciu. introduction: the wheals and pruritus associated with chronic idiopathic urticaria (ciu) are often so debilitating that they have a profound impact on patient quality of life. specifically, ciu has been shown to negatively affect patient mobility, sleep, energy levels, social interaction and emotional wellbeing. the purpose of this study was to examine the impact of treatment with fexofenadine hcl (fex) mg on health-related quality of life (hrql) among patients with ciu. methods: as part of a multicenter, randomized, double-blind, parallel-group, placebo-controlled study, designed to evaluate the efficacy and safety of a once-daily dose of fex mg in ciu, the impact of treatment on hrql was also examined. patients were asked to complete the dermatology life quality index (dlqi) and the work productivity and activity impairment questionnaire (wpai) at baseline and at weeks and (final visit or early termination). the primary endpoint was mean change from baseline in dlqi total score, using the mean data of evaluations performed at weeks and as the post-baseline measure. secondary endpoints included change from baseline in individual dlqi domains and wpai scores. additional analyses were conducted to examine the reliability, validity and responsiveness of the hrql measures. results: a total of patients were included in the hrql population: n= fex, n= placebo. patients in the fex group experienced significantly greater improvements in the mean dlqi total score than those in the placebo group (p= . ). this pattern was repeated with respect to the individual domains of symptoms and feelings (p= . ), daily activities (p= . ), leisure (p= . ) and personal relationships (p= . ). both treatment groups reported improvements in productivity, as measured by change from baseline using the wpai. patients randomized to fex experienced significantly less impairment while working (p= . ) and performing activities (p= . ) than those who received placebo. the dlqi was demonstrated to be reliable (cronbach's alpha= . ); both the dlqi and wpai were found to be valid and responsive instruments in this ciu population. conclusion: this study demonstrated that a once-daily dose of fex mg improves the hrql of patients with ciu, as assessed by change in dlqi total score. t. algozzine * , a. lee , s. wong , l. anzisi , . manchester, nh; . centerport, ny; . syosset, ny; . mamaroneck, ny. symptoms of allergic and non-allergic rhinitis may significantly impact a patient's quality of life, by causing fatigue, headache, cognitive impairment and other systemic symptoms. appropriate management of allergic rhinitis is important in the effective management of coexisting or complicating respira-tory conditions (e.g. asthma, sinusitis, or otitis media). in addition, many commonly used over-the-counter (otc) antihistamines can cause performance impairment that may impact daily activities. we designed a brief ten-question allergy survey in an attempt to determine how patients were being treated for their allergies, evaluate a patient's self-assessed impact of their allergies on their daily activities, and identify any difference in treatment outcomes between primary care and allergist practices. patients were invited to complete the surveys anonymously. completed surveys were collected and entered into a microsoft access database for evaluation. minitab was utilized for statistical calculations. four hundred and thirty seven patients completed the survey. fifty-eight percent of survey respondents were women and % were adults (age > ). of those patients surveyed, % (n= ) were under the care of an allergist. compared to primary care, patients treated by allergists reported more allergies ( . vs. . , p < . ) and received more medications on average ( . vs. . , p< . ). pollen was the most common allergy type reported among all patients. while the majority of all patients ( %) received prescription medications, more primary care patients received no therapy or only otc treatment when compared to allergist patients ( % vs. %, p< . ). seventy-four percent of primary care patients reported their allergy symptoms were controlled compared to % of allergist patients (p< . ). patients receiving treatment from an allergist reported less impact of their allergies on daily activities (a lower score signified less impact) compared to patients seen in primary care ( . vs. . , p< . ). the results of our survey suggest that allergists treat more complex patients. these patients had multiple allergies, more uncontrolled symptoms, and utilized more prescription medications. despite these findings, patients treated by allergists reported less impact of allergies on their daily activities. introduction the patogenic mechanism of nasal polyps are unknow.they frecuently are associated with aspirin intolerance, intrinsic asthma, chronic sinusitis, young sindrome, cystic fibrosis, kartagener syndrome and churg-strauss syndrome.chemical mediators found in nasal polyps are as follows: histamine, serotonin, leukotrienes, norepinefrine and possibly pgd .recently, leukotrienes have been implicated in mediation of bronchoconstriction and inflammatory leukotriene levels have also been shown to be elevated in some patients with sinonasal polyposis (figure ) hypothesis antileukotrienes might play a significant role in controlling polyposis and symptoms secundary to sinonasal disease, and they might viable alternative to longterm, oral steroid therapy and repeat surgical debridement purpose this study was undertaken to evaluate the potential role of leukotriene receptor antagonist on recurrent polyposis associated with asthma and improvement of some factor implicated with them design of study:clinical assay, prospective, triple blind. materialsand methods:the study involved patients ( %) males and ( %) women, mean age . years, with a range - years selection criteria:inclusion criteria: nasal polyps associated with astha, allergic or non allergic.exclusion criteria: patients with any concurrent illness, use of sistemic or local corticosteroidsor any kind of antileukotriene within month prior to the beggining of the study.we made an alleatory selection patients recived montelukast ( mgs/day), and nasal steroids, beclometasone ( mgs/day) for months. patients recived loratadine plus pseu-doefedrin mgs/ mgs/day and nasal steroids, beclometasone, patints were operated of fees and transnasal endoscipic polypectomy plus montelukast and nasal steroids, beclometasone ige serum levels .skin prick test .sensitivity in vitro .ct scan . celullarity on nasal lavage (eosinophils and neutrophils) .proinflamatory cytokines (il -il -il ) on nasal lavege by elisa test. results ther was a tendency for more improvement of the group ( surgery-montelukast-local steroid) of symptoms and objective measurments, in second place of improvement the group montelukast-local steroid) and the worse on improvement subjective and objetive was group local steroid and loratadine-pseudoefedrine use as placebo introduction: sensory perceptions of intranasal corticosteroids (ins) vary among products and can be unpleasant and affect adherence to therapy. methods: we conducted a cross-sectional study of patients across allergy and immunology clinics in the united states. respondents were asked to choose between pairs of hypothetical ins that differed by sensory attribute composition. based on prior research, we measured salient sensory attributes: smell, taste, aftertaste, throat rundown, nose runout, and feel of spray in nose/throat. each attribute was described in intensity levels, such as "no taste" (low), "weak taste" (moderate), and "strong taste" (high) ( table) . other outcomes included an importance score for each sensory attribute and patients' willingness to adhere to an ins having the lowest levels of each sensory attribute compared to one with moderate levels. results: preferences decreased with increasing intensity level of each sensory attribute. the most important attribute was aftertaste in % of patients, taste in %, throat rundown in %, nose runout in %, smell in %, and feel of spray in %. only % had more than one attribute tied for most important. if instructed to take ins daily for months, % of patients stated that they would definitely be able to follow their doctor's advice (willing to adhere) if given an ins containing the lowest level of each sensory attribute compared with % for one having moderate levels (p< . ). conclusions: patients' preferences decrease with increasing intensity levels of each sensory attribute and affect patients' willingness to adhere. tailoring ins to patient preferences may lead to improved treatment satisfaction and adherence. introduction:a high prevalence of rhinitis and asthma comorbidity has been persistently noticed in epidemiological studies in last years. our objective was to evaluate the prevalence of rhinitis and asthma comorbidity in a portuguese population including both atopic and non-atopic patients. methods: a retrospective study was performed. clinical records from patients attending an immunoallergology outpatients'clinic during months (from january until june ) were reviewed. data were collected concerning clinical history of rhinitis and/or asthma, aeroallergens'skin prick tests and respiratory function evaluation. results: among the patients attending an appointment during the study period, ( . %) had rhinitis and/or asthma ( . % f; . % m;mean age +/- years). patients with respiratory disease included atopic ( . %) and non-atopic %). diagnosis of asthma, rhinitis or of both diseases was made in ( . %), ( . %) and ( . %), respectively, in atopic patients and in ( . %, ( . %) and ( . %), respectively, in non-atopic patients. rhinitis was diagnosed in . % of atopic asthmatic and in - % of non-atopic patients with asthma. in patients with rhinitis, asthma was also diagnosed in . % of atopic patients and . % on non-atopic patients. conclusions: in this study population rhinitis was frequently diagnosed in patients with asthma and vice-versa, thereby leading to a high prevalence of this comorbodity. this association was more frequent in atopic patients. our data are comparable to those we found in recent literature. these results suggest that clinical investigation of asthma should be mandatory in management of patients with rhinitis as well as asthmatic patients should be routinely submitted to clinical evaluation of rhinitis. introduction: cetirizine hcl (c) has been shown to be more effective than fexofenadine hcl (f) in controlling seasonal allergic rhinitis (sar) symptoms at - hr post-dose, however, the efficacy of c and f was comparable between - hr post-dose. response to treatment in the middle of the dosing interval needed to be addressed. methods: this randomized, double blind, placebo (p)-controlled study was designed to compare the efficacy and tolerability of a single dose of c mg, f mg, and p between - hr postdose in ragweed-sensitive sar subjects. subjects meeting entry criteria were exposed to pre-determined controlled levels of ragweed pollen in the eeu during priming and double blind treatment. subjects assessed rhinitis symptoms at half hr intervals during pollen exposure; at priming, at the qualifying period, at baseline, and from - hr post-dose. the primary efficacy endpoint was the change from baseline in total symptom severity complex (tssc) score at hr post-dose. tssc score was the sum of severity ratings ( =absent to =severe) for symptoms: runny nose, sneezing, itchy nose/palate/throat and itchy/watery eyes. results: a total of subjects (mean age . y; . % females) were randomized: c, ; f, ; p, . baseline characteristics were comparable among groups; tssc: c= . , f= . , p= . . c produced a % greater reduction in tssc score at hr (- . , p= . ) and a % greater reduction overall (i.e., average over the - hr post-dose period) (- . , p= . ) compared with f (- . , - . , respectively). both c and f reduced tssc score more than p ( hr, - . ; overall, - . , p< . ) including all individual symptoms (p< . ). c however, was more effective than f for runny nose and sneezing at hr and overall, itchy/watery eyes at hr, and itchy nose/throat/palate overall (p< . ). rates of discontinuation due to adverse events (aes) were low: c, . %; f, %; p, . %. the incidence of treatmentemergent aes was similar: c, . %; f, . %; p, . %. somnolence occurred in . % of subjects on c, and % on f or p. conclusion: c produced a greater improvement in rhinitis symptoms compared with f and p, at hr post dose and over the - hr post-dose period. all treatments were safe and well tolerated. background: medication utilization patterns of patients suffering from seasonal allergic rhinitis (sar) are not well documented, and although many anti-allergic medications are prescribed for daily use, actual usage is unknown, but recognized to be quite variable. methods: subjects with positive ragweed skin tests were mailed a survey during the third week of ragweed season, soliciting the nature and severity of sar symptoms, usage patterns and reasons for choice of anti-allergic medication. results: subjects completed the survey ( . %). the prevalence of symptoms were, in decreasing order: sneezing ( . %), runny nose ( . %), itchy/gritty eyes ( . %), stuffiness ( . %), itchy nose ( . %), watery eyes ( . %), itchy palate/throat ( . %), post-nasal drip ( . %), red/burning eyes ( . %), headache ( . %), itchy ears ( . %), cough ( . %), shortness of breath ( . %), and wheeze ( . %). sar patients used antihistamines most frequently ( . %), followed by decongestants ( . %), combination (antihistamine/decongestant) products ( . %), and intranasal corticosteroids ( . %). medications were mostly taken intermittently rather than daily (antihistamines . %; nasal corticosteroids . %), conclusion: a constellation of nasal symptoms were the most common seasonal allergic manifestations, followed by ocular, palatal and ear irritation. antihistamines were the most frequently used medication to treat symptoms, succeeded by decongestants (alone or in combination). a significant proportion of subjects took their allergy medication, including nasal corticosteroids, intermittently rather than regularly, underscoring the relevance of single-dose evaluations of drug efficacy. a.k. ellis * , e. rafeiro, j.d. ratz, j.h. day, kingston, canada. background: traditional assessment of seasonal allergic rhinitis (sar) medication efficacy utilizes randomized controlled trials over - weeks in season. an additional study method employs single-dose responses using controlled allergen challenge such as the environmental exposure unit (eeu). a comparison of allergic symptoms generated by controlled allergen challenge to those occurring in ragweed season symptoms has not been done. methods: subjects with known sar to ragweed were mailed a survey during the third week of ragweed season, soliciting the nature and severity of sar symptoms. subjects participating in a subsequent controlled allergen challenge study using the eeu, were again asked to complete a similar survey that documented symptoms generated in this model. those who completed both surveys comprised the primary analysis group. results: subjects completed the ragweed season survey, subjects completed the eeu survey, and completed both. symptoms generated by eeu exposure were similar to those elicited during ragweed season, with the exception of cough ( % vs. %, respectively, p < . ). subjects reported that symptoms were more severe in the eeu than those experienced on a typical ragweed season day, but less severe than those during peak ragweed season days. conclusion: allergic upper respiratory tract symptoms produced during controlled ragweed pollen exposure in the eeu were similar in nature and degree to those expe-rienced during ragweed season, supporting evidence that the eeu is a valid model for studying sar. r. nave , m.a. wingertzahn * , s. brookman , s. kaida , t. shah , . konstanz, germany; . florham park, nj; . princeton, nj; . tokyo, japan. rationale: ciclesonide (cic) is a new corticosteroid under development for treatment of allergic rhinitis (ar). cic is a pro-drug that is hydrolyzed to the active metabolite desisobutyryl-ciclesonide (des-cic) in the target tissue. cic has low oral bioavailability and is highly bound to plasma proteins; therefore cic administered as a nasal spray is expected to have minimal local and systemic effects. objective: the primary objective was to evaluate the safety and tolerability of repeated escalating doses of cic ( - mcg/day) given as a nasal spray for days to healthy and asymptomatic subjects with sar. secondary objectives were to determine pk of cic and des-cic and to evaluate the effect of cic on endogenous cortisol. methods: this was a single-center, randomized, placebo-controlled, double blind, modified sequential dose study. six cohorts were randomized. cohorts i-v consisted of healthy subjects given doses of cic up to mcg bid. cohort vi (asymptomatic sar subjects) received mcg bid. each cohort was comprised of subjects who received cic and subjects who received placebo. safety assessments were conducted by recording adverse events (aes), clinical laboratory, eye, and nasal examination findings. serum and urine samples were taken for evaluation of cortisol levels. cic and des-cic serum concentrations were determined by lc-ms/ms. results: no trend was observed for aes when comparing cic and placebo treatment. additionally, no subject experienced a serious ae or withdrew from the study due to an ae during the trial. cortisol levels showed no differences between the dose groups or between activetreated subjects and placebo-treated subjects. additionally, serum concentrations of cic and des-cic in the majority of serum samples were shown to be below the lower limit of quantification (lloq; pg/ml for cic and pg/ml for des-cic), therefore no descriptive statistics could be calculated. con-clusions: ciclesonide nasal spray, at the doses evaluated, was safe and well tolerated in healthy and asymptomatic sar subjects with no detectable effects of cic on serum or urinary free cortisol concentrations. additionally, no pk parameters could be calculated for cic nasal spray, as it was virtually undetectable in serum despite the use of a sensitive assay. the preferred treatment for allergies is avoidance. air filtration is logical but room air purifiers have been of limited efficacy. zephyr™ is a new device which creates an envelope of air % free of allergenic particles around the head of the sleeping person. allergic rhinitis frequently causes daytime somnolence. this is a pilot study of the effectiveness of zephyr on symptoms of seasonal allergic rhinitis (ragweed hay fever) and on daytime sleepiness. methods: subjects age to with ragweed hay fever were studied in the ragweed season using each subject as his/her own control. usual allergy medicines were not allowed, except loratadine for rescue. outcome measures were a symptom score, juniper rhinitis quality of life questionnaire, a tolerability rating, and epworth sleepiness scale. during the first week subjects qualified by symptom scores, then entered the one-week treatment period with zephyr. the third week was a post-treatment observation period. results: of participants, ( %) showed symptom improvement. the whole group averaged % reduction in morning symptoms and % reduction in evening symptoms. sleepiness scores improved %. rhinitis qol improved %. the zephyr system was well tolerated as evidenced by the response to several statements regarding zephyr use and tolerability: (scoring: = strongly disagree, = strongly agree) "the system did not bother me while i was sleeping." (mean score . ) "the noise level did not affect my ability to sleep." (mean score . ) "the temperature was just fine for me." (mean score . ) "the system did not get in my way during sleep." (mean score . ) conclusions: zephyr significantly reduced seasonal hay fever symptoms and daytime sleepiness, improved quality of life, and was well-tolerated by subjects. zephyr may provide maximal environmental control of bedroom allergen exposure irrespective of ambient airborne allergen levels in the room. nasal congestion is an important symptom that is associated with significant morbidity in the rhinitis sufferer. disrupted sleep leading to daytime fatigue, loss of concentration, and decreased productivity are potential results of this symptom. a study employing online interviews with rhinitis sufferers from harris interactive's online database was conducted in order to understand the symptoms they identify with most and to determine the impact nasal congestion had on their daily activities. respondents were at least years of age and experienced nasal congestion from seasonal allergic, perennial allergic, and/or perennial non-allergic rhinitis. the results showed that % of the respondents agreed nasal congestion is the most bothersome symptom of rhinitis; % experienced nasal congestion daily, while % experienced it several times per week. not surprisingly, sleep was the most important factor affected by nasal congestion. two-thirds ( %) of the respondents felt their sleep had been moderately or significantly impacted by nasal congestion, and more than half ( %) felt it was difficult to get a good night's rest because of congestion. sleep was interrupted or disturbed by nasal congestion approximately nights per week, on average. furthermore, sleep disruption from nasal congestion contributed to daytime fatigue; % of the respondents indicated that they were typically tired or fatigued during the day when they experience nasal congestion. in addition, % felt that activities requiring concentration, such as reading, were moderately or significantly impacted by nasal congestion. this study confirms that nasal congestion causes the rhinitis sufferer significant problems beyond that of just a stuffy nose. consequently, healthcare providers need to ensure that their rhinitis patients who have nasal congestion as their primary complaint are managed effectively. desloratadine (dl, clarinex ® ) is a non-sedating oral antihistamine that is metabolized to -oh dl. however, a phenotypic polymorphism has been observed in some patients that results in reduced formation of -oh dl. the prevalence and safety profiles of such poor metabolizers of dl were examined in pharmacokinetic and clinical trials. a poor metabolizer was defined as a subject having a -oh dl to dl auc ratio of < . , or a dl half-life of hours. in pediatric studies, where a sparse sampling approach was uti-lized to screen for poor metabolizers, a plasma concentration ratio of -oh dl to dl of < . at hours classified a subject as a poor metabolizer. a total of , adult and pediatric subjects ( - years old) were phenotyped with a single dose of dl or loratadine. the overall prevalence of the poor metabolizer phenotype was % ( / ). this prevalence was comparable for adult ( / , %) and pediatric subjects ( / , %), and greater in both populations among blacks ( % pediatric, % adult) than caucasians ( % pediatric, % adult). pharmacokinetic analysis found that exposure to dl was approximately -times higher in poor metabolizers than in normal metabolizers. there was no apparent difference in dl exposure among poor metabolizers in different age groups ( -months to < -years, -to < -years, -to < -years, and -years) when treated with age-appropriate doses. the multiple-dose ( - days) safety profile of dl was examined in pediatric poor metabolizers ( - years) in placebo-controlled trials, and in adult poor metabolizers ( - years) in pharmacokinetic trials. pooled ae rates were low and comparable between the poor metabolizer and placebo subjects, as shown in the table below with all aes that appeared in > % of subjects in any treatment group (or > % in adult poor metabolizers). there was no difference in cardiovascular safety profile or ecg results (including qtc interval) among these groups. in conclusion, ( ) expression of the dl poor metabolizer phenotype is independent of age, but higher in blacks than in caucasians, ( ) exposure to dl in poor metabolizers is independent of age when administered at age-appropriate doses, ( ) the safety profile of dl poor metabolizers is not different from that of placebo at all ages down to at least -years old. these results are consistent with the high therapeutic index of dl. desloratadine (dl, clarinex®) is extensively metabolized to -oh dl and subsequently glucuronidated. the enzyme responsible for the formation of this active metabolite is unknown. poor metabolizers of dl represent a subset of the population that has a reduced ability to form -oh dl. a poor metabolizer was defined as a subject having a -oh dl to dl exposure ratio of < %, or dl half-life of hr. pk parameters from adult and pediatric poor metabolizers following repetitive administration of dl were characterized in clinical pharmacology trials and are summarized in the table below. exposure to dl [auc( - hr)] in poor metabolizers was approximately -fold greater than the corresponding values in normal metabolizers; cmax was to -fold greater. the magnitude of the reduction in the formation of -oh dl and the concurrent increase in exposure to dl associated with the poor metabolizer phenotype was similar in pediatric and adult subjects at age-appropriate doses. despite the increased exposure to dl in poor metabolizers, there was no increase in adverse event frequency or changes in electrocardiographic parameters. a: dose normalized to mg. b: least squares mean ratio: anova of log-transformed data extracting sources of variation due to age group and metabolizer status. the ratio is a contrast of metabolizer status. c: lower and upper % confidence interval based on log-transformed data. introduction: many patients with seasonal allergic conjunctivitis (sac) complain of symptoms of dry eyes. we have previously reported that patients with sac experience discomfort from dry eyes anywhere between to days per week and that the overall severity of the dry eye symptoms tend to range from mild to severe. this preliminary cross over study evaluated the benefits of nedocromil sodium % ophthalmic solution used twice daily, compared with nedocromil sodium % ophthalmic solution used with refresh (ocular lubricant), for the treatment of dry eye symptoms in association with sac during weeks. methods: patients who had a minimum of two-year history of sac and dry eyes, a positive skin prick test towards grass pollen and between the ages of to were enrolled. patients were evaluated on four visits and completed a daily diary, which included scales for grading allergic conjunctivitis and dry eye symptoms. at each clinic visit they completed the osdi and the rqlq (rhinitis quality of life questionnaire). the osdi (ocular surface disease index) was developed to assess dry eye symptoms and the impact on vision related functioning. the rqlq evaluates quality of life in patients with allergic conjunctivitis. at the last visit, both the patient and the physician assessed the treatment and the effectiveness, if any, of the addition of refresh to nedocromil sodium % ophthalmic solution. daily grass pollen counts were preformed using a burkhard sampler. results: patients ( male and female) were enrolled and dropped out. patients experienced minimal symptoms at the start of the season due to low concentration of grass pollen. preliminary analysis carried out using a paired t-test was preformed on the ocular average scores for the two treatment periods. there was no significant difference between the treatment groups for redness, light sensitivity and tearing of the eyes. a reduction in dry eye symptoms was reported in all patients using refresh eye drops and the number of drops required varied between patients. during the treatment periods there was improvement in patients rqlq. conclusion: patients preferred the addition of refresh eyedrops in alleviating sac and dry eye symptoms. further studies need to be carried using refresh eye drops in larger number of patients with sac and dry eye symptoms. c. laforce * , raleigh, nc. introduction: the objective of this study was to determine the ability of azelastine nasal spray to improve rhinitis symptoms and quality of life parameters in seasonal allergic rhinitis patients remaining symptomatic after treatment with fexofenadine. methods: this placebo-controlled, double-blind study began with a -week, open-label lead-in period, during which patients received fexofenadine mg bid. after days, patients who improved less than % to % on fexofenadine were randomized to treatment for weeks with: ( ) azelastine nasal spray, ( ) azelastine nasal spray plus fexofenadine, or ( ) placebo. the primary efficacy variable was the change from baseline to day in thetotal nasal symptom score (tnss), which consisted of runny nose, sneezing, itchy nose, and nasal congestion scores recorded twice daily in patient diary cards. in addition, quality of life was assessed using the rhinitis quality of life questionnaire (rqlq). results: after weeks of treatment, azelastine nasal spray (p<. ) and azelastine nasal spray plus fexofenadine (p<. ) significantly improved thetnss compared to placebo. based on patients with complete tnss and rqlq data, the overall rqlq score also was significantly (p<. ) improved compared to placebo. conclusions: azelastine nasal spray was an effective treatment for patients with seasonal allergic rhinitis who did not respond well to fexofenadine and significantly improved quality of life parameters compared to placebo. the results of this study indicate that azelastine nasal spray is an important alternative to oral antihistamines and should be considered in the initial management of seasonal allergic rhinitis. w. berger * , mission viejo, ca. objective: to evaluate improvement over time with azelastine nasal spray in the treatment of patients with moderate-to-severe seasonal allergic rhinitis (sar) who remained symptomatic after treatment with loratadine or fexofenadine. methods: the studies were -week, multicenter, double-blind, placebo-controlled trials that began with a -week, open-label lead-in period in which patients received either loratadine mg qd (study no. ) or fexofenadine mg bid (study no. ). patients who improved < %- % with loratadine were randomized to treatment with: ( ) azelastine nasal spray sprays/nostril bid, ( ) azelastine nasal spray sprays/nostril bid plus loratadine mg qd, ( ) desloratadine mg qd, or ( ) placebo. patients who improved < %- % with fexofenadine were randomized to treatment with: ( ) azelastine nasal spray sprays/nostril bid, ( ) azelastine nasal spray sprays/nostril bid plus fexofenadine mg bid, or ( ) placebo. the primary efficacy variable was the change from baseline to day in the total nasal symptom score (tnss), consisting of runny nose, sneezing, itchy nose, and nasal congestion. symptom severity was recordedam and pm in diary cards on a -point scale ( =none; =mild; =moderate; =severe). results: in both studies, patients treated with azelastine nasal spray experienced increasing improvement intnss over days of treatment.the improvements were approximately -fold greater than placebo at each day of the study, and the differences from placebo were statistically significant (p<. ) at days , , , and overall. in study no. , % of patients treated with azelastine had > % improvement in tnss compared to % in the placebo group. in study no. , % of patients treated with azelastine had > % improvement in tnss compared to % in the placebo group. conclusions: azelastine nasal spray was effective in treating patients with moderate-to-severe sar who remained symptomatic after treatment with either loratadine or fexofenadine. azelastine demonstrated first-day effectiveness, and patients treated with azelastine experienced increasing improvements in rhinitis symptoms over the -day study periods.azelastine nasal spray is an effective treatment alternative to oral loratadine or fexofenadine and an appropriate first-line therapy in the management of sar. introduction: a large, open-label, azelastine (astelin) nasal spray patient experience trial was conducted in patients with sar, vmr, or mixed rhinitis (allergic rhinitis with nonallergic triggers). this analysis evaluated the effect of azelastine nasal spray in treating rhinitis symptoms in a subset of patients with a history of asthma or sinusitis. methods: patients were entered into an open-label protocol and treated for weeks with azelastine nasal spray at a dosage of sprays per nostril bid. after weeks, the patients completed a questionnaire that assessed onset of action, symptom improvement, satisfaction with therapy, and quality of life. results: from a total of rhinitis patients who received azelastine monotherapy during the -week study period, data were analyzed for patients with asthma (n= ) or sinusitis (n= ). a greater percentage of these patients had severe rhinitis compared to the overall population. nasal congestion and postnasal drip were reported as the most bothersome rhinitis symptoms. after weeks of treatment with azelastine nasal spray, > % of patients with asthma and > % of patients with sinusitis reported some or complete control of congestion and postnasal drip. in addition, > % of patients with asthma reported chest tightness, shortness of breath, and wheezing were somewhat or completely controlled, and > % of patients with sinusitis reported that headache and facial pain were somewhat or completely controlled during treatment with azelastine nasal spray. conclusion: azelastine nasal spray provided effective control of rhinitis symptoms, including nasal congestion and postnasal drip, in patients with a history of asthma or sinusitis. introduction: epinastine is an antihistamine with mast cell stabilization and anti-inflammatory properties. epinastine . % ophthalmic solution was evaluated for treatment of allergic signs and symptoms elicited by feline dander in a cat exposure room. methods: participants (n= ) were aged years, with a history of ocular allergy to cats, a positive skin prick reaction to cat dander, and an ocular itching score of (on a - scale) within minutes of entering the cat room. subjects wore a tb mask while in the cat room to reduce the effects of inhaled allergen. after minutes of exposure, drop of epinastine hcl . % was instilled in one eye, and olopatadine . % was instilled in the fellow eye. environmental exposure to cat dander continued for another minutes. prior to instillation, and at , , , and minutes after instillation, conjunctival hyperemia and chemosis (scales of - ), and ocular itching, tearing, ocular burning, nasal itching and rhinorrhea (scales - ) were assessed. results: instillation of a single drop of ophthalmic epinastine significantly reduced ocular itching from a mean pre-instillation score of . to a mean score of . at minutes after instillation (p<. ), despite continuous exposure to cat dander during the entire period. similarly, ocular burning, tearing, and hyperemia were significantly reduced by epinastine treatment (p<. ). chemosis was only weakly induced by cat room exposure, with a mean pre-instillation score of . ; however, epinastine treat-ment decreased that to (p=. ). instillation of epinastine also significantly reduced nasal itching and rhinorrhea scores (p<. ). results for olopatadine were not statistically different; however, the change from baseline in itching scores in the epinastine-treated eyes was greater than that seen in the olopatadine-treated eyes at the majority of timepoints. conclusion: ophthalmic epinastine is indicated for the prevention of itch associated with allergic conjunctivitis.this study shows that treatment of cat-sensitive subjects with ophthalmic epinastine following environmental exposure to cat dander significantly reduced ocular itching and other signs and symptoms of allergic conjunctivitis. objective: the objective of this study was to evaluate azelastine (astelin®) nasal spray, cetirizine (zyrtec®), fluticasone (flonase®), and placebo in the treatment of patients with symptomatic seasonal allergic rhinitis. methods: this was a double-blind placebo-controlled pilot trial in patients with seasonal allergic rhinitis. the study began with a -week, placebo lead-in period, followed by a -week blinded treatment period (day to day ). efficacy variables were: ( ) change from baseline to day in the total nasal symptom score (tnss; consisting of rhinorrhea, sneezing, itchy nose, and nasal congestion); ( ) onset of action based on tnss over the hours following initial administration of study drugs; and ( ) change from baseline to day ( -hour change) in tnss. tnss was scored twice daily (am and pm) on a -point rating scale ( =none, =mild, =moderate, =severe). patients recorded a minimum -hour tnss of on at least days during the lead-in period, and a congestion score of on at least days to qualify for entry. qualified patients were randomized to treatment with: ( ) azelastine nasal spray sprays per nostril bid plus placebo capsules qd; ( ) cetirizine -mg tablets qd plus placebo nasal spray; ( ) fluticasone sprays per nostril qd plus placebo capsules qd; or ( ) placebo nasal spray plus placebo capsules. results: azelastine significantly (p<. ) improved the tnss compared to cetirizine, fluticasone, and placebo beginning minutes after initial administration; cetirizine significantly improved tnss versus placebo at minutes; fluticasone showed no significant differences from placebo over the -hour evaluation period. azelastine significantly (p<. ) improved the tnss at day ( -hour change from baseline) compared to cetirizine, fluticasone, and placebo. conclusions: azelastine nasal spray improved the tnss in patients with moderate-to-severe seasonal allergic rhinitis. in addition, azelastine nasal spray demonstrated a -minute onset of action and significantly improved tnss versus cetirizine, fluticasone, and placebo hours after initial administration. introduction: epinastine, an antihistamine with mast cell stabilization and anti-inflammatory properties, has been developed for the treatment of allergic conjunctivitis. the efficacy and tolerability of epinastine was assessed and compared with levocabastine. methods: eligible patients for this randomized, double-masked, parallel-group, active-controlled environmental clinical trial were - years old with a recent diagnosis of seasonal allergic conjunctivitis. patients instilled drop epinastine hcl . % or levocabastine . % ophthalmic solution in each eye bid for weeks. patients and investigators assessed efficacy and tolerability at study visits on days (baseline), , , , and , and assessed overall efficacy and tolerability at study exit. adverse events were monitored. results: epinastine provided superior itch relief compared with levocabastine (p=. ; see figure) ; mean ocular itch scores over treatment visits were . for epinastine and . for levocabastine ( - scale; =worst; baseline scores were . for epinastine and . for levocabastine). the mean summed score (ocular itching, tearing, and foreign body sensation) over treatment visits was significantly better for epinastine than levocabastine (p=. ).at study exit, % of epinastine-treated patients rated overall efficacy "very good" (the highest possible rating), versus % of levocabastine-treated patients. at minutes postinstillation, % of epinastine-treated and % of levocabastine-treated patients rated tolerability "very good". at study exit, % of epinastine-treated and % of levocabastine-treated patients rated overall tolerability "very good", with investigator ratings being similar. treatment-related adverse events occurred in . % of epinastine-treated patients (most frequent: eye pain and skin itching, . % each) and . % of levocabastine-treated patients (most frequent: double vision, . %; influenza-like symptoms, . %); most aes were mild or moderate. conclusion: our results confirm the therapeutic potential for epinastine as an efficacious treatment suitable for long-term use throughout the allergy season. ophthalmic epinastine was superior to levocabastine for relief of ocular symptoms in patients with allergic conjunctivitis and was well-tolerated. since chronic inflammation is the histopathologic landmark of otitis media with effusion, clinical observations have led us to believe that the combination of a cysteinyl leukotriene receptor antagonist montelukast with an oral antibiotic may be more efficacious than monotherapy with an oral antibiotic in the treatment of serous otitis media. we studied twenty pediatric patients (age years to years) in a randomized open labeled -week trial to compare the efficacy of the combination montelukast ( mg or mg chewables tablets qd dosed according to patient's age) with an oral antibiotic amoxicillin/clavulanate potassium ( mg/kg/day in divided doses every hours) to a monotherapy with an oral antibiotic amoxicillin/clavulanate potassium for the treatment of otitis media with effusion. the efficacy of treatment options was assessed using pneumatic otoscopy, impedance tympanometry, and audiometry to monitor the clinical course of the middle ear effusion in both treatment groups. in the combination group montelukast and antibiotic a resolution of otitis media with effusion occured at the th day. in contrast in the group treated with monotherapy with the oral antibiotic the resolution of otitis media with effusion occured on the th day. in conclusion, the combination of montelukast plus an oral antibiotic is more effective than monotherapy with an oral antibiotic.the combination of montelukast plus an antibiotic may be a safer and shorter therapy given the safety issues with long term use of systemic antibiotics. introduction: a randomized, double-blind, placebo-controlled study was conducted in an environmental exposure chamber (eec) to compare the efficacy of three doses of olopatadine nasal spray, a topical anti-allergy treatment for seasonal allergic rhinitis (sar), versus placebo spray. methods: patients aged - years old with a history of sar were screened, consented, evaluated for a positive skin test to ragweed allergen, and enrolled in this irbapproved study. a total of "primed" patients were exposed to ragweed allergen in the eec and randomized to olopatadine . % (n= ), olopatadine . % (n= ), olopatadine . % (n= ), or placebo (vehicle) (n= ) spray, sprays/nostril once in the morning. symptoms were self-assessed using a point scale (total nasal symptom score, tnss, comprised of sneezing, runny, itchy and stuffy nose) via diaries at periodic intervals during the -hour study period. safety was also assessed. results: obvious trends indicated a dosedependent response to olopatadine . %, . % and . %, though concentrations were not statistically different from each other. all three concentrations of olopatadine were clearly more efficacious than placebo spray at the first time point, minutes, continuing to the end of the -hour session. olopatadine exhibited a safety profile comparable to placebo. conclusions: olopatadine nasal spray . %, . % and . % exhibited dose-dependent responses. onset of action for all three concentrations of olopatadine was apparent at the first post-dose timepoint, minutes, and efficacy was maintained throughout the next hours. olopatadine nasal spray was safe, well-tolerated, and effective for the treatment of sar in the eec chamber. c. slonim * , tampa, fl. objective: to assess patient subjective responses to the treatment of allergic conjunctivitis using azelastine hydrochloride ophthalmic solution. methods: participating physicians selected patients from their practice to receive azelastine hydrochloride . % ophthalmic solution drop per affected eye twice daily for days. patients on prior ocular allergy medications were allowed to participate. after days of treatment with azelastine hydrochloride, patients (n= , ) rated their experiences with azelastine hydrochloride via a self-administered survey. not all questions were answered by each patient. results: at baseline, % of patients reported that their ocular itching affected their work, school, and/or leisure activities at least "somewhat". after using azelastine hydrochloride, % of patients achieved either "moderate" or "complete" relief from ocular itching, including % who reported "complete" relief from itching. seventy-one percent ( %) of patients had been treated previously with a topical prescription anti-allergy medication for their ocular itching. seventy percent ( %) of patients (n= ) who had not been previously treated with a topical prescription anti-allergy medication treatment and % of previous medication users (n= , ) experienced at least "moderate" relief of itching when treated with azelastine hydrochloride. sixty-five percent ( %) of the previously-treated patients rated azelastine hydrochloride as "somewhat better" or "much better" than their previous medication. conclusions: results suggest that azelastine hydrochloride ophthalmic solution is an effective treatment for the ocular itching associated with allergic conjunctivitis as rated by the patient, regardless of whether they had been treated previously with a topical prescription anti-allergy medication. objective: to determine an association between food allergy and acid reflux in adults. method: we conducted a retrospective chart review of atopic adult patients in an academic otolaryngic allergy practice. adults who tested positive and adults who tested negative for food allergy were included in the study. charts were reviewed for a diagnosis of gastroesophageal reflux disorders (gerd). this included a history of laryngopharyngeal reflux (lpr) and peptic ulcer disease (pud). population prevalence ( . %; ci . - . ) of acid reflux was estimated from a historical study (locke gr et al. prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in olmstead county, minnesota. gastroenterology ; : - ) that had a similar subject population. the prevalence of gerd in each study arm, as well as in the total study group of atopic adults, was compared to the historical control. results: subjects testing positive for food allergy had a diagnosis of gerd in . % ( % ci . - . ) of cases. those subjects who did not demonstrate a food allergy were positive for gerd in % ( % ci . - ) of cases. in the total study group, the prevalence of gerd was . % ( % ci . - . ). on chi square analysis, the prevalence of gerd was significantly higher in the total study group when compared with the historical control (p= . ). those subjects who tested negative for food allergy had a statistically significant higher prevalence of gerd than the control population (p= . ). the prevalence of gerd between the group testing positive and the historical control did not show a significant difference (p= . ). when comparing the study arms to each other, there was no significant difference in the prevalence of gerd (p= . ). conclusions: the prevalence of acid reflux disorders was not higher in subjects with food allergy when compared to a historical control. although a statistical significance was noted between adults who tested negative for food allergy and the control population with regards to the prevalence of gerd, this may reflect the fact that individuals examined in an otolaryngologist's office are more likely to have acid reflux disorders than the general population. overall, the atopic subjects did have a higher incidence of acid reflux disorders, but there was no statistical significance between subjects with and without food allergy. a. suryadevara * , d.l. hamilos, boston, ma. introduction: recent studies suggest that crs without nasal polyposis (crssnp) and crs with nasal polyposis (crscnp) represent distinct pathologic entities. we wished to determine whether these conditions differed in their clinical presentation. methods: over a two-year period, new patients coming to a university based specialty clinic meeting criteria for crs were enrolled in an outcomes study. patients indicated which of four major (facial pain/pressure/headache, nasal obstruction, nasal purulence/discharge, and hyposmia/anosmia) and four minor (fever, halitosis, dental pain, cough) criteria for crs they were experiencing. rhinoscopy was performed to look for nasal polyps or polypoid tissue in any sinus area. the prevalence of each symptom was compared in the groups by chi square analysis. results: the population (n= ) had a mean age of +/- . and was % female, % caucasian, . % african-american, . % asian and . % hispanic. most patients ( %) were non-smokers. all had at least major criteria or major + minor criteria for crs at enrollment. forty-one patients ( . %) had crscnp. the mean number of major criteria was greater in the crscnp than crssnp ( . vs . , p= . ). nasal obstruction and hyposmia/anosmia were more prevalent in crscnp (p= . , . respectively). facial pain/pressure/headache was more prevalent in crssnp (p=). ). the most prevalent symptoms in crscnp were: nasal purulence/discharge ( . %)>hyposmia/anosmia ( . %)>facial pain/pressure/headache ( . %)>nasal obstruction ( %). in contrast, the most prevalent symptoms in crssnp were: facial pain/pressure/headache ( . %)>nasal purulence/discharge ( . %)>hyposmia/anosmia ( . %)>nasal obstruction ( . %). none of the symptoms were absolutely distinguishing of these conditions. no differences were found between the two groups for fever, halitosis, dental pain or cough. conclusion: we conclude that patients with crscnp have a greater burden of symptoms of crs and a much higher prevalence of hyposmia/anomsia. these findings are consistent with other studies showing that, in comparison to crssnp, crscnp tends to be more difficult to treat and have a higher rate of relapse after intensive medical therapy (subramanian et al, am j rhinology ; : ). l.e. mansfield * , e.e. philpot , c. posey , . el paso, tx; . research triangle park, nc. daytime sleepiness is a common complaint in sar. patients often complain of mental slowness, difficulty in concentrating, and thinking. the present study evaluated whether effective therapy of sar would decrease dss and improve an objective measure of cp. dss was measured using the epworth sleep scale (ess). objective cp was measured using the test of variables of attention (tova), a validated test. thirty two adults ( males, females with a year history of sar, a compatible physical exam, and corresponding positive allergy testing) volunteered for this week randomized double blind placebo controlled study. after a one week inf placebo (pl) baseline, the subjects received either active inf or continued pl. they maintained daily nasal symptom dairies and ess. the subjects took the tova test at the end of week and week . weekly nasal symptom scores significantly improved with the inf, but not the pl. w vs. w nasal congestion inf , p=. , pl , p=ns; runny nose inf . , . p=ns; pl . , . p=ns; sneezing inf . , p=. ; pl . , . p=ns. total weekly ess was abnormal and decreased significantly in the inf group, but not in pl group. w vs. w inf . , . p=. , pl . , . p=ns. response time of the tova testing, initially somewhat slow, significantly decreased in inf but not pl treatment. w vs. w inf msec, msec p=. ; pl msec, msec p=ns. these results demonstrate that sar is associated with dss and cp problems. the mechanism is likely to be sleeping disordered breathing associated with nasal congestion and obstruction. effective treatment of nasal congestion with inf led to decreased dss and improved cognitive performance. l.e. mansfield * , c. graham , . el paso, tx; . new york, ny. there is increasing recognition that sleep disturbance and daytime tiredness occur during active ar. the mechanism appears to be nasal congestion and obstruction leading to sleep disordered breathing and resultant poor quality of sleep. in our practice, as part of the initial history, questions regarding fatigue, snoring, sleep problems, and tiredness are addressed. sleep problems and tiredness are graded according to the following scale: effect on daily activity ; =not troubled; = a little trouble; =somewhat troubled ; = trou-bled a lot ; = total disruption. we reviewed consecutive charts of patients with allergic rhinitis documented by history, physical examination and allergy testing. there were females and males; age range y to y. ( %) of patients or parents recognized they commonly snored. ( %) stated they were chronically fatigued. the graded answers concerning sleep problems and tiredness were even more revealing of ar patient's perception of their problems see table in general, the higher sleep problem responses were associated with higher tiredness scores. national surveys of unselected populations suggest that about percent of adults consider themselves to have sleep problems. the high frequency of sleep related problems and tiredness in our sample has prompted us to add more detailed questions regarding sleep related events to our intake history. it is our opinion that questions specifically related to sleep and daytime tiredness should be included in all evaluations for allergic rhinitis. we conclude that sleep related problems and tiredness may be more common in patients with allergic rhinitis than previous reported. r.w. weber * , j. garcia , r. faruqi , d. banerji , g. georges , the study investigator group , . denver, co; . bridgewater, nj; nj. introduction: the intranasal glucocorticosteroid triamcinolone acetonide (taa) is a safe and effective treatment for persistent allergic rhinitis (par). a new hydrofluroalkane- a (hfa) propellant delivery system (taa-hfa) has recently been developed. this study primarily assessed the long-term safety of taa delivered via this new device, as well as its long-term efficacy. methods: patients aged - yrs (mean= ) with par enrolled in this -yr, open-label study at centers in the us. patients received taa-hfa μg once daily for a -week run-in period before adjusting the dose to μg or μg once daily based on symptom severity. doses were standardized to μg once daily across all patients at ~ months to ensure sufficient long-term safety data at the maximum dose. physical exams, including measurement of vital signs and laboratory measurements were taken at baseline, months and study end. independent patient and physician global symptom evaluations were performed at baseline, week and months - thereafter. patients recorded any adverse events (aes) on daily diary cards. results: of the patients included in the study, ( . %) reported aes. the incidence of aes was similar to that of other comparable allergic rhinitis long-term studies. the most frequently reported aes were pharyngitis, rhinitis, local reactions, headache, epistaxis and sinusitis (table ) . most aes were mild-to-moderate in intensity; patients withdrew from the study due to aes. there were no clinically relevant changes in physical exams, vital signs or laboratory measurements. a total of serious aes (saes) were reported; breast carcinoma (n= ), depression (n= ), post-operative spinal fluid leak (n= ) and staphylococcal infection (n= ). saes were thought to be not related to the study drug. at final visit, % of patients had either moderate or marked/complete relief of symptoms using global symptom scores. similarly, % of physicians rated their patients as having either moderate or marked/complete relief. conclusions: long-term administration of taa-hfa μg exhibited a good safety and tolerability profile, while providing moderate-to-complete symptom relief in more than % of patients treated for par. introduction: second-generation, 'non-sedating' antihistamines (ahs) have lower tendency to cross the blood-brain barrier and cause central nervous system side effects than first-generation agents. however, studies have suggested differences between second-generation ahs regarding cognitive function impairment. methods: a medline literature search was performed using the search terms 'antihistamine and impairment', 'antihistamine and psychomotor' and 'antihistamine and central effects', as well as with individual ah names (acrivastine, cetirizine, desloratadine, ebastine, fexofenadine, levocetirizine, loratadine, mequitazine and mizolastine). the findings for second-generation ahs were reviewed and well-designed, placebo-and positive-controlled studies in humans using objective measures of cognitive impairment were included. results: publications were identified as the inclusion criteria. all included objective assessments such as driving performance, critical flicker fusion and divided attention tasks. there was a large variation in the numbers of available well-designed studies; the most rigorously assessed agents were fexofenadine and cetirizine. a number of the ahs (ebastine, acrivastine, loratadine, mequitazine and mizolastine) were not impairing at recommended doses, but were at higher doses. in a small number of available studies, the newer ahs desloratadine and levocetirizine produced no impairment at recommended doses ( mg); however, higher doses were not investigated. cetirizine studies were variable; impairment at the recommended mg dose or higher was seen in a number of studies. in contrast, fexofenadine hcl, up to a dose of mg, was non-impairing in a large number of studies. only one study indicated impairment in one task (critical tracking) and this was only observed with the first doses of fexofenadine hcl ( and mg) and not subsequent doses; however, the authors concluded that doses up to mg/day should be safe for patients who drive. conclusion: while second-generation ahs are less impairing than the first-generation, some newer ahs produce impairment at or above the recommended dose. these differences become important to the patient when agents cause sedation or if patients over use beyond the recommended dose. in conclusion, fexofenadine was the only ah found to be non-impairing in all studies, even at double the recommended us dose. s. shaver , r.b. berkowitz * , c. lutz , p. jones , c. qiu , s. meeves , s.t. varghese , g. georges , . woodstock, ga; . bridgewater, nj. introduction: fexofenadine (fex) is a h -receptor antagonist, with proven efficacy in the treatment of allergic rhinitis (ar). to date, no live cat-room challenge studies have assessed the efficacy of fex in cat-allergen induced ar. this study assessed the efficacy of a single dose of fex hci mg in preventing and controlling cat-allergen induced ar using the cat-room challenge model. methods: this single-center, prospective, randomized, doubleblind, placebo-controlled, two-way crossover study consisted of a screening visit, one or two priming visits and two treatment periods, separated by a (± )-day wash-out. qualifying subjects were randomized to treatment sequence (placebo followed by fex) or (fex followed by placebo). baseline endpoints were obtained prior to study drug administration, and minutes before entering the cat challenge room for allergen challenge. allergen challenges were initiated . hours post-dose, for both treatment periods. the primary endpoint was the change from baseline in total symptom score (tss; sum of rhinorrhea, itchy nose/palate/throat, sneezing and itchy/watery/red eyes) after minutes of allergen exposure at hours post-dose, compared with placebo. other endpoints included changes in individual symptom scores, including nasal congestion. levels of airborne felis domesticus allergen (fel d ) were determined. results: of subjects screened, were randomized and completed the study; and in sequence and , respectively. mean change in tss from baseline was significantly less with fex compared with placebo at minutes after initiation of the cat allergen challenge (p= . ). significantly greater percentage reductions in the individual symptom scores for sneezing (p= . ) and nasal congestion (p= . ) were observed with fex compared with placebo, minutes after challenge. although levels of fel d varied widely, they were balanced between treatment groups. the overall incidence of treatment-emergent adverse events (aes) was low and comparable between groups; no serious aes occurred. conclusion: this study demonstrated that a single dose of fex hci mg is effective and well tolerated as a prophylactic agent for alleviating the ar symptoms induced by exposure to cat allergen. further large-scale clinical trials are warranted to confirm these findings. rationale: allergic rhinitis in children is thought to be associated with several co-morbid disorders. we conducted the following study to assess whether children with diagnosed hypertrophy of tonsils and/or adenoids evaluated by an allergist were more likely to demonstrate objective evidence of allergen sensitization than children similarly evaluated without evidence of these upper airway obstructions. methods: records from the past ten years were identified in the hospital database by presence of an allergy clinic visit and an icd- code for hypertrophy of adenoids and/or tonsils. we reviewed these records to confirm that the diagnosis was accurate. we included subjects if reliable skin prick or in vitro testing for specific ige to aeroallergens was performed. for comparison, we randomly obtained an age and testing-type similar sample. first group subjects were excluded from the second group. skin testing was performed with commercial allergen extracts applied with a dermapik©. in vitro testing was by unicap© feia. positive skin testing had at least a wheal mm or flare mm greater than the negative control. positive in vitro values were . ku/l or greater or a positive pollen mix. additionally, we performed a search in an insurance database to determine how many local children had a code for allergic rhinitis. results: of pediatric allergy patients with adenoid/tonsillar hypertrophy tested, . % ( % ci +/- . %) had at least one positive test. in without adenoid/tonsillar hypertrophy, . % ( % ci +/- . %) had at least one positive test. the observed difference was . % ( % ci +/- . %). the standard error of the difference in percentage was . ; the z score was . . the corresponding p value is . . the percentage of , children with an allergic rhinitis icd- was . % ( % ci +/- . %). conclusion: the number of allergist-referred children with adenoid and/or tonsillar hypertrophy testing positive for an aeroallergen is slightly less than the number of similar children without these diagnoses testing positive. it is not clear that adenoid/tonsillar hypertrophy is associated with a higher risk of allergic rhinitis. a prospective study with allergy testing of all children with adenoid and/or tonsillar hypertrophy might provide information that could alter referral patterns. w.e. berger * , w. storms , s. kimura , m. beck , s. galant , t. westbrook , . mission viejo, ca; . colorado springs, co; . pensacola, fl; . miami, fl; . orange, ca. background: patients having allergic rhinoconjunctivitis are often treated with nasal spray or systemic allergy therapy, forgoing therapy specifically targeting ocular symptoms. the rhinitis quality of life questionnaire (rqlq) and allergic conjunctivitis quality of life questionnaire (acqlq) instruments can be used to quantify the relative benefit of varying medication regimens. objective: to determine the extent of benefit gained in quality of life when an eye drop treatment for ocular allergy (olopatadine) was added to rhinitis patients' preexisting regimen of nasal or systemic allergic treatment. methods: this was a four week prospective, multi-center, open-label crossover, quality of life study occurring during allergy season. at visit , patients completed the rqlq and acqlq questionnaires to assess baseline quality of life. patients were randomized to receive ocular allergy therapy (olopatadine, patanol bid) concomitant with their systemic or nasal rhinitis treatment(s) for weeks between either visit and visit (group a) or between visit and visit (group b). at visit and visit , patients completed the rqlq and acqlq. results: a total of patients completed this study: in group a, in group b. of these, ( . %) experienced eye allergy symptoms at least day during the previous week as reported in the baseline acqlq. baseline scores of the rqlq and acqlq for both groups were comparable. clinically significant improvement from baseline in global rqlq and acqlq was seen following addition of ocular therapy for both groups (rqlq: - . , - . ; acqlq: - . , - . ). similar improvement was seen across all domains of both questionnaires. the acqlq correlated with the rqlq in the applicable domains. conclusion: many allergic rhinitis patients using nasal or systemic medication also suffer from ocular allergic symptoms. for these patients, quality of life improvement is not maximized; the addition of a topical antiallergy eye drop can result in beneficial effects on quality of life. in this study, the addition of olopatadine eye drops to these patients' medication regimens resulted in significant improvement in not only eye symptom related quality of life domains but in overall quality of life. h. milgrom * , r. lanier , f.c. hampel , b. kittner , . denver, co; . fort worth, tx; . new braunfels, tx; . bridgewater, nj. introduction: fexofenadine, a non-sedating, selective h -receptor antagonist, is currently indicated for use in children aged - years with seasonal allergic rhinitis in a number of countries, including the us, and has an excellent safety profile in this age group. this study was designed to assess the safety and tolerability of fexofenadine in children aged - years with allergic rhinitis (ar). methods: the study had a multicenter, double-blind, randomized, placebo-controlled, parallel-group design. children aged - years (n= ) with ar were randomized : to either placebo twice daily (bid; n= ) or fexofenadine hcl mg bid (n= ), for weeks. both treatments were given orally as granulated powders (capsule content) mixed with two teaspoons of apple sauce. treatment-emergent adverse events (teaes) were recorded for all subjects by parents/caregivers and assessed by investigators. clinical laboratory variables, physical examinations, vital signs and ecg evaluations were also assessed in a subgroup of children (placebo, n= ; fexofenadine, n= ). results: baseline demographics were similar in both treatment groups. while approximately % of children in both groups experienced at least one teae, no unusual or unexpected teaes were observed in the fexofenadine group. when the total group was analyzed for teaes by body system, or assessed separately by age groups of -, -, -and -year-olds, no clinically meaningful differences were observed between the two treatment groups. in both treatment groups, the majority of subjects overall and in each age group experienced teaes rated as mild or moderate in intensity. few subjects experienced teaes considered possibly related to study medication (placebo: . % [ / ]; fexofenadine: . % [ / ]). the percentage of discontinuations due to teaes was also comparable between treatment groups (placebo: . % [ / ]; fexofenadine: . % [ / ] ). in the subgroup assessment, no clinically relevant changes were seen from baseline for laboratory variables, vital signs, ecgs or physical examinations in either treatment group. introduction: the efficacy and safety of fexofenadine hcl mg bid has been proven in two large phase iii studies in pediatric subjects aged to years with seasonal allergic rhinitis. in addition, the safety of fexofenadine has been demonstrated in pediatric subjects to years of age with allergic rhinitis (ar). subsequently, two studies (t/ ; t/ ) have assessed the pharmacokinetics, safety and tolerability of fexofenadine and mg bid in pediatric subjects months to years of age. methods: both studies were of multicenter, randomized, double-blind, placebo-controlled, parallelgroup design and enrolled pediatric subjects aged months to < year weighing . kg and aged ± year to < years weighing > . kg. all subjects had a diagnosis of ar as assessed by previous medical history, pattern, or suggestive physical findings. subjects were randomized to receive fexofenadine hcl mg (t/ ), or mg (t/ ) granulation powder twice-daily, or placebo for a minimum of days. safety was evaluated based on adverse events (aes), vital signs, -lead electrocardiograms (ecgs), and physical examinations. results: a total of and subjects were randomized in studies t/ (fexofenadine hcl mg bid: n= , placebo: n= ) and t/ (fexofenadine hcl mg bid: n= , placebo: n= ), respectively. in t/ , . % ( / ) of children receiving fexofenadine and . % ( / ) receiving placebo experienced at least one treatment-emergent ae (teae). in t/ , the incidences of teaes were . % ( / ) and . % ( / ), respectively. in both studies, most of the teaes experienced were mild or moderate in intensity. the incidence of possibly-related teaes was also similar for both treatments in each study. no clinically relevant changes from baseline to study end were observed for vital signs, ecgs and physical examinations. conclusions: the findings of this study show that fexofenadine mg and mg bid are well tolerated and have a safety profile comparable to placebo in pediatric subjects aged months to years. for seasonal allergic rhinitis (sar) patients that remain symptomatic on an h -receptor antagonist, cetirizine, and a nasal glucocorticosteroid, mometasone furoate, the addition of omalizumab, a recombinant, humanized, chimeric, anti-ige monoclonal antibody, may provide additional efficacy in sub-optimally controlled seasonal allergic rhinitis patients. in this open labeled week trial, patients with symptomatic sar currently using cetirizine, mg qd, + mometasone furoate, mcg/nostril qd, were randomized to continue the existing therapy cetirizine + mometasone or to add-on omalizumab subcutaneously (every weeks to weeks) dosed according to patient's weight, and baseline ige levels to the existing therapy cetirizine + mometasone furoate. the endpoints of the trial include: rhinomanometry, nasal symptom score (composite score of nasal congestion, rhinorrhea, sneezing, post nasal drip and itching) and flexible rhinopharyngolaryngoscopy examination. mean efficacy measurements at the end of the -week trial revealed a significant improvements in all parameters examined in the treatment group receiving omalizumab (as add-on to the existing therapy), compared to the other group. in conclusion, the addition of omalizumab to the combination of cetirizine plus mometasone furoate, is more effective than the combination of cetirizine plus mometasone furoate, for the treament of seasonal allergic rhinitis patients. it appears that when omalizumab is added to the combination h receptor antagonist, cetirizine, and nasal corticosteroid, mometasone furoate, the primary end points (rhinomanometry and symptom scores) are significantly improved. background: based on the official statistic data, the prevalence of allergic diseases in russia has increased more than times during the past - years, but still the lowest of all european countries. in some studies done in some regions of russia based on isaac program, it has been shown that the prevalence allergies is significantly higher than indicated in official statistics of health departments. the goal of this investigation was to study the prevalence of allergic diseases, in children of south russian region. meth-ods: this study was done in two steps according to isaac program guidelines. in the first step a questionnaire was given to a total of school children, ages to (group a) and to years old (group b), from the two cities of krasnodar and novorossiysk in southern russia. in the second step a physical exam, skin prick tests with different allergens (pollens, molds, cat, dust mites, foods etc.), and pulmonary function tests were performed. results: wheezing was reported in . % of group a and . % of group b children within the past months. the severity of asthma reported was mild in % (group a)- % (group b); moderate in . % (group a)- . % (group b) and severe in . % (group a)- . % (group b) in studied children). majority of the cases of asthma was noted to be allergic asthma. in both groups of children there was a high incidence of allergies to perennial allergens such as dust mites, cats, molds and other indoor allergens, . % (group a) and . % (group b). the percentage of allergies to pollens was . % and . %, accordingly. allergic rhinitis symptoms were noted in . % (group a) and in , % (group b). atopic dermatitis symptoms with skin itching observed in . % ( - years old)and . % ( - years old). family history of atopy was noticed in . % of group a and . % of group b children. conclusions: the prevalence of allergic diseases in south russia is similar to the ones in most of the european countries. the prevalence of asthma has been associated with increased incidence of allergies, due to indoor and pollen allergens. the prevalence in rhinitis and atopic dermatitis in south russia is parallel to asthma. acknowledgement: we would like to thank hollister-stier lab., greer and antigen lab. for allergen samples. objective: to examine the cost and effectiveness of telithromcyin vs. azithromycin for treatment of mild acute sinusitis under current levels of antimicrobial resistance. methods: we considered an adult with mild acute sinusitis, and symptom duration of days. a decision analytic model was created to compare strategies of st-, nd-and rd-line therapies: azithromycin/amoxicillin-clavulanate/levofloxacin (azi/amc/lev), and telithromycin/amoxicillin-clavulanate/levofloxacin (tel/amc/lev). we considered outcomes: response to initial therapy, cost, and time to completion of all antibiotic therapy. clinical resolution was due to response to antibiotic, or to spontaneous resolution. we assumed bacteria that were resistant in vitro would only be resistant in vivo % of the time. resistance levels were based on the - us protekt surveillance study. model parameters, such as prevalence of bacterial infection, frequency of causative pathogens, and rates of spontaneous resolution, were based on the published literature. those failing to improve after days were switched to next line therapy. we analyzed claims data from managed care organizations to estimate non-drug charges for initial and follow-up care, and applied a % cost-to-charge ratio. drug costs were estimated using the wholesale acquisition cost plus $ for overhead and dispensing. all costs were adjusted to year $us. results: the model predicted the tel/amc/lev strategy would result in . % improving by days compared to . % for azi/amc/lev. the telithromycin strategy had lower mean cost, $ vs. $ . although telithromycin cost more than azithromycin, the tel/amc/lev strategy had slightly lower total drug costs ($ vs $ ) due to less need for additional antibiotic courses. mean time to completion of therapy was . days for tel/amc/lev and . days for azi/amc/lev. sensitivity analyses showed that tel/amc/lev had superior health outcomes even when only % of in vitro resistant organisms were also resistant in vivo. tel/amc/lev also had lower cost if at least % of cases were bacterial, or if in vitro resistant organisms were at least % resistant in vivo. conclusion: based on results obtained using this decision analytic model, initial treatment of mild acute rhinosinusitis with telithromycin may result in improved outcomes and lower cost than initial treatment with azithromycin. rationale: "delta crud" is the term used to describe rhinosinusitis syndromes in the mississippi delta region. local perception is that it is associated with chemical crop dusting, regional produce, especially cotton, or high rates of mold allergy. the climate is extreme with mild winters, hot humid summers, and large volume rain. thirty-five percent of inhabitants live below the poverty level, % are african american. patients from the agriculturally intensive delta suffer from asthma at almost twice the rate of those in the neighboring hills. rates of pesticide use are among the highest in the nation. there are no prevalence estimates for rhinosinusitis in this region. "delta crud" is chronic in many patients with exacerbations occurring in the summer and fall, especially during chemical spraying and defoliation. we conducted this cross-sectional questionnaire based pilot study to begin characterization of rhinosinusitis in this population. method: the sinusitis treatment outcome questionnaire, with two modifications, was given to consecutive patients presenting to the north sunflower regional hospital er and the sunflower outpatient clinic one month prior to the beginning of summer crop dusting. the question, "do you have delta crud?" was added. the survey was anonymous, allowing irb exemption. results: consecutive patients returned completed questionnaires. ( %) admitted to having "delta crud". patients who claimed to have delta crud had significantly more sinus headache, nasal pruritus, conjunctivitis, and chest symptoms (see table) . there was no significant difference in antibiotic prescriptions, er visits, and missed work. six patients with delta crud had been hospitalized for "allergy reasons" compared with three patients without delta crud. despite severe symptoms just patients received sinus ct scans. only / patients were prescribed intranasal corticosteroids. conclusion: in our pilot study, the prevalence of chronic rhinosinusitis symptoms (delta crud) is %, with severe sinus, pulmonary and ocular symptoms. evaluation and treatment may be suboptimal in this economically disadvantaged rural region. further characterization of "delta crud", pollen counts, ige mediated disease, environmental contributions and comparative studies of related regions are needed. introduction: patients with rhinitis commonly experience sinus pain and pressure (sp+p). many patients with recurrent acute bacterial sinusitis (rabs) base the presence of a recurrence on the severity of sp+p and other nasal symptoms. the ability of patients to differentiate between rhinitis and rabs was evaluated by reviewing the subject screening logs of previously reported clinical trials of flonase (fluticasone propionate) nasal spray, mcg (fp). methods: the efficacy of fp was studied in two trials in subjects with sp+p due to allergic rhinitis and in two trials of subjects receiving cefuroxime axetil to treat an acute episode of rabs. sp+p screening logs were examined to determine how many subjects who thought they had sp+p were excluded from the study for an upper respiratory or sinus infection. rabs screening logs were examined to determine how many subjects with symptoms of an acute episode of rabs were excluded from the study for a negative sinus x-ray or ct scan. rabs symptoms experienced at the screening visit by subjects who qualified for the study were also evaluated. results: of subjects screened in the sp+p studies, only ( . %) were excluded for evidence of sinus or upper respiratory tract infections, as clinically diagnosed by the investigator. out of subjects with screening log data in the rabs studies, ( . %) were excluded for a negative sinus x-ray or ct scan. of the subjects who qualified for the rabs study, the most prevalent symptoms included nasal congestion ( %), mucopurulent discharge ( %), facial pain or tenderness in the sinus area ( %), sinus headache ( %) and malaise ( %). only % of subjects had a fever. only one symptom, nasal congestion, was rated by clinicians as severe for greater than % of subjects in either study ( % and %). conclusions: while most subjects can determine when sp+p is due to allergic rhinitis, many cannot determine when symptoms progress to a sinus infection. symptoms experienced by subjects with rabs were consistent with inflammation, but did not include fever as may be expected with an untreated bacterial sinus infection. under appreciation by patients for the role of inflammation in sinus disease may result in over self-diagnosis of sinus infection and the demand for antibiotics. liposomes are small particles consisting of lipid bilayer membranes, which are used to deliver drugs including amphotericin b, more efficiently and with less toxicity. very few cases of allergy to liposomal amphotericin b (lab) have been reported to date. although there is a report on conventional amphotericin b (cab) desensitization, to our knowledge no case of lab desensitization has been described yet. a y/o patient with lymphoma was treated with lab for pulmonary aspergillosis. within minutes of infusion he developed urticaria, hypotension and tachycardia for which he was treated with the appropriate drugs for anaphylaxis. a second attempt to re administer lab resulted in a similar anaphylactic reaction. desensitization to lab was then successfully completed using a modified protocol based on desensitization to cab (jaci ; : - ) : . mg infusion over minutes . mg infusion over minutes . mg infusion over minutes . mg infusion over minutes mg infusion over minutes mg infusion over minutes mg infusion over minutes mg infusion over minutes conclusion: desensitization to lab, a lifesaving drug for invasive fungal diseases, can be performed successfully. adverse events (aes) were recorded throughout the study. therapeutic comparability was defined a priori as a clinical response within % for hfa vs cfc for the primary efficacy measures. results: baseline demographics were similar between treatments for the intent-to-treat population. mean -h baseline symptom scores for nasal stuffiness, nasal discharge and sneezing were . , . and . , respectively, out of a possible score of . all taa-cfc and taa-hfa doses significantly (p< . ) reduced -h, and am and pm -h reflective scores for nasal stuffiness, nasal discharge, sneezing and ni vs placebo (except cfc μg for sneezing). taa-hfa and taa-cfc were statistically comparable (within . and . for the one-sided % confidence interval) at doses of μg and μg for the primary variables of nasal discharge, sneezing and ni for the -h, as well as the am and pm -h reflective assessment, over the -wk period * , * agrawal p , p , , p , p , p , p , p * , p , p , p * p , p , p , p p * finegold, i. * fink p * * sienra monge * , , * so, c. p * soane * , p * staveren, a.m rates of cardiovascular mortality are higher during peak pollen times. (brunkreef, lancet ) . for this reason, mast cell stabilizing agents and leukotriene antagonists are under development for the treatment of myocardial infarction. conversely, ige mediated disease may be protective against sudden cardiac death.(szczeklik, coron art dis ) ar has not been studied in this context. we conducted a retrospective case control pilot study of va patients who were diagnosed with allergic rhinitis and had an acute myocardial infarction. methods:the electronic medical record of a large va hospital was queried for patients diagnosed with an acute myocardial infarction (ami) in the past six years. patients were divided into groups with and without ar. patients with chronic urticaria, asthma, and eczema were excluded from this study. primary outcome was all-cause mortality. secondary outcomes included lv systolic function and peak troponin levels. results: patients were diagnosed with ami, ( %) of which were also diagnosed with ar. patients with and without ar did not differ in terms of age, ethnicity, tobacco status, hypertension, diabetes, or lipid levels. / ( %) patients with ar died, compared to / ( %) control patients, (p-value: . ). ar patients had lower mean peak troponin values ( . vs. . ), but these were not significant. both groups had similar lv function. conclusion: this pilot study suggests an association between allergic rhinitis and a decrease in ami allcause mortality independent of other factors. atopic patients have been shown to have prolonged bleeding times, reduced platelet aggregation, and delayed thrombin generation which can result in delayed clot production. (szczeklik, thromb haem ) possibly, patients in our study diagnosed with allergic rhinitis were more likely to monitor their health symptoms or had physicians who carefully addressed multiple issues. rigorous prospective studies are needed to determine the role of ar in myocardial infarction. purpose and methods. a formulation of olopatadine hydrochloride ophthalmic solution (olopatadine . %) was evaluated in a randomized, placebocontrolled, double-masked, hybrid environmental study intended to determine efficacy and safety in subjects with histories of seasonal allergic conjunctivitis or rhinoconjunctivitis. in this -week trial, subjects regularly assessed their ocular signs and symptoms. additionally, subjects evaluated both the frequency and severity of their nasal symptoms. daily throughout the study, ragweed pollen counts were obtained from each investigative center. repeated measures analysis of variance was used to compare treatment differences in the slopes for nasal symptoms as a function of pollen counts. results. the nasal results are presented herein. specifically, relative to placebo, olopatadine . % significantly reduced the frequency of pollen effects on sneezing (p= . ) and itchy nose (p= . ), and reduced the severity of pollen effects on sneezing (p= . ), itchy nose (p= . ), and runny nose (p= . ). in this study, the most frequent ocular adverse event that was related to therapy with olopatadine . % was ocular dryness, occurring at an incidence of . %. no treatment-related, clinically relevant changes were observed for visual acuity, intraocular pressure, ocular signs, or fundus parameters. conclusion. olopatadine ophthalmic solution, . % is safe, well-tolerated, and effective in reducing some effects of pollen on the nasal symptoms associated with allergic rhinoconjunctivitis. author index key: cord- -jimw skv authors: fiumara, agata; lanzafame, giuseppina; arena, alessia; sapuppo, annamaria; raudino, federica; praticò, andrea; pavone, piero; barone, rita title: covid- pandemic outbreak and its psychological impact on patients with rare lysosomal diseases date: - - journal: j clin med doi: . /jcm sha: doc_id: cord_uid: jimw skv background: lysosomal storage disorders (lsds) are rare, chronic, progressive multisystem diseases implying severe medical issues and psychological burden. some of these disorders are susceptible to a treatment, which is administered weekly or every other week, in a hospital. during the covid- (corona virus disease ) pandemic lockdown, patients with lsds on enzyme replacement therapy (ert) missed their scheduled access to the day hospital to get their treatment. methods: based on the feeling that our patients were experiencing profound distress, we designed a structured telephone interview with the aim to evaluate how, and to which extent, the pandemic outbreak was changing their behavior and feelings about their chronic disease, the impact on therapies, and future expectations. the same interview was administered to an age-matched control group. results: all interviewed people experienced an increase of anxiety, worries, and uncertainty fostered by incessant media updates. moreover, a striking similarity emerged between the groups regarding forced home reclusion and the profound feeling to be excluded by normal life, well-known to those affected by a chronic rare disease. conclusions: although no statistically significant difference was found compared to controls, we felt that the reactions were qualitatively different, underlining the fragility and isolation of such patients. since march , the dramatic outbreak of corona virus disease in italy has changed our lifestyle as individuals, physicians, and patients. despite the evidence of minor involvement of children [ ] , pediatric units also had to deal with healthcare crises. as a referral centre for inborn errors of metabolism (iem), we had to face an unexpected restriction concerning daily normal activity with lowering of programmed admissions for diagnosis and follow-up visits. our concern was especially directed to those patients with lysosomal storage disorders (lsds), which are rare, chronic, progressive, multisystem diseases associated with serious medical issues, physical disability, and psychological burden [ ] . in the last decade, some of the lsds became treatable by pharmacological therapy, such as intravenous (iv) enzyme replacement therapy (ert) and oral substrate reduction therapy (srt), or chaperones. during the covid- alert, patients with lsds, under regular treatment with ert, failed their usual compliant behavior, missing scheduled infusions. based on the feeling that our patients were experiencing profound distress, we designed a structured interview [ , ] with the aim to evaluate how, and to which extent, the covid- pandemic was changing our patients' behavior and feelings about their chronic disease, the impact on therapies, and their future expectations. we emphasize the importance to investigate attitudes and behavior with respect to health treatment, especially among people with rare diseases, such as patients with lsd. they represent a group with increased vulnerabilities to covid- ; thus, we felt the need to attempt any possible solution that would let them maintain treatment protocols and minimize disease progression. at our regional referral centre for metabolic diseases, pediatric clinic, department of clinical and experimental medicine, patients with different types of iem are followed. at the time of the study, of them were affected by a treatable lsd and thus were regularly admitted to the day hospital with a personal schedule of ert (weekly or every other week) or followed-up every - months because of treatment at home. in this study, we included / patients who accepted to undergo our interview. there were females and males with age ranging from to years. seven of them were younger than years. ten ( %) had pompe disease (pd; early infantile type (eopd) and late-onset type (lopd)). the sample also included patients with mucopolysaccharidosis type iv (mps iv), pediatric patients with gaucher disease, and adult subject with fabry disease. all participants were receiving iv ert (alglucosidase alfa, elosulfase alfa, imiglucerase, or agalsidase beta, according to their disease). at the beginning of covid- emergency, study patients with gaucher disease or fabry disease were on home therapy. an ad hoc structured interview was developed and administered by phone and when possible by video calls (table ) during the third week of lockdown. the interview investigated personal feelings, familial relationship, degree of faith in others, and future perspectives and was inspired and developed in light of this extraordinary, life-threatening event. quantitative data were obtained from dichotomous questions (yes/no) used for a clear distinction of respondents' opinions. according to the age, we got direct information from subjects, while for pediatric patients, the parents were asked to respond to the interview. a psychologist (gl) from the centre contacted the patients or their caregivers to assess how the covid- emergency modified the daily life of patients and their family, which changes were due to the resulting government restrictions, how these were felt, and if any change had occurred with the personal therapy schedule. moreover, we gathered information about the mood of the patients, their families, and social relationships, the need for psychological support, and their expectations for the future. since we thought and developed the interview in light of this extraordinary event, the tool could not have been previously validated. to overcome this issue, a group of healthy volunteers was carefully selected for comparison. the control group included healthy subjects matching one-to-one with the patient and caregiver sample, in terms of age, social condition, instruction level, and family composition. data were presented as absolute frequencies and/or percentages for categorical variables. a comparison of proportions between groups was conducted by chi square test with yates' correction. differences with p ≤ . were considered to be significant. data were analyzed using the spss software, v. . (sps, bologna, italy) relations with family members appeared to be felt positively in % of patients stating that, being at home, they were closer and linked to each other in a co-working and beloved environment. on the contrary, before the lockdown, family members were less involved; moreover, the use of video calls and socials allowed contact with less frequently seen relatives and increased reciprocal affection and the feeling to be part of the same family. in the control group, a positive evaluation was found only in %, although they also stated to have rediscovered human values and lost values. a negative feeling was reported by % of our patients: they described intolerance, impatience, discomfort, distress, constriction, and impairment of contact with close relatives, if not by video calls. in contrast, % of the control group described a negative feeling of familial interrelationship because of isolation, uncertainty, fear, difficulties in handling children, and anxiety for older relatives with whom it was hard to communicate. a small percentage of investigated patients ( %) and % of the control group denied significant changes, stating that they were used to this aloneness and isolation. as a whole, no significant differences were observed in the rate of subjects experiencing positive, negative, or unchanged familial relationships between groups (x ( , n = ) = . , p = . ). patients revealed a strong inclination to feel "others" negatively ( %), as other people were considered to be disrespectful, self-oriented, or dangerous and were to be avoided. thus, relationships were commonly seen as characterized by lack of empathy, indifference, and detachment. in the control group, we also found a clear tendency to perceive other people negatively ( %). however, in the control group, the image of "others" was that of insecure, frightened, suspicious, avoidant, and elusive people, although considered only slightly inaccessible and deserving of being turned away. a small percentage ( %) of our patients, on the contrary, stressed the empathic attitude toward others who were then sharing the common fragility state. in the control group, % reported social relations positively stating how useful it was to protect each other by avoiding contact and discovering new ways of social interaction even with neighbors. only % of patients stated that they did not feel significant changes. the proportion of participants who experienced social relationships as dangerous or positive was not significantly different between groups (x ( , n = ) = . , p = . ). no significant differences between groups were observed in the rate of participants experiencing negative or positive reactions to modified daily activities (x ( , n = ) = . , p = . ). sixty percent of patients described boring moments, monotony, weakness, and stress for web lessons, limitation of normal activities, prohibitions in moving to familial places and seeing relatives, and the need for repetitive hand hygiene procedures. likewise, the majority of control subjects ( %) demonstrated a negative reaction regarding the monotony of daily life, which was felt as difficulty in commitment to following rules, in the need for space and temporal organization, and in the occurrence of sleep-awake rhythm problems. on the contrary, % of patients stated that they felt more relaxed and helped by the family dedicating more time to them. in addition, % of controls felt the changes positively, having more free time for themselves and for their domestic activities. among patients, % felt that there were no changes in their daily routine. mostly negative feelings were encountered in our patients' sample; % experienced fear, distress, anger, frustration, impotence, negative mood, and feeling of neglection; and % showed ambivalent emotions, with co-existence of astonishment, confusion, doubt, curiosity, and uncertainty alongside the need to protect their beloved ones. seventy percent of controls manifested aloneness, anxiety, concern, fear of the unknown, fear of contamination, sharing difficulties, pessimism, mood depression, sadness, and feeling of being in a surreal condition. on the contrary, % had a positive mood characterized by adaption, respect, positive dependence, and ability to find incitements and new energies; the remaining % showed ambivalent aspects with a hard and pessimistic approach, despite a feeling of well-being. in sum, the proportion of subjects suffering negative or positive feelings was not significantly different in the two groups (x ( , n = ) = . , p = . ). patients with lsds expressed their belief in state, regional, and hospital institutions in % of cases; % declared to be not confident; and % were uncertain because of discordant news and lack to timely assured protection devices. similar results were obtained in the control group with % manifesting faith, % manifesting diffidence and the feeling to be abandoned, and % showing an uncertainty to judge about the emergency-handling strategies (x ( , n = ) = . , p = . ). defense mechanisms adopted by patients and controls during the covid- emergency were analyzed: both groups tried to use mature psychological defenses ( % versus %, respectively) or denied any concern ( % of patients versus % of controls); annihilation was encountered in % of patients and % of controls; a tendency to discredit others was present in % of patients and % of controls; some of the patients ( %) activated distressing and pacifying actions; this was also seen in % of controls. a small percentage of patients ( %) showed a passive mood, demonstrating lack of affective interactions. almost half of the patients thought that, from this experience, they learnt something positive ( %) such as the real meaning of relationships, gratitude, and the ability to accept and respect others and to identify priorities. this feeling was even stronger in the control group ( %), stating that some positive aspects were coming from the actual situation as the discovery and enforcement of community spirit, sense of belonging to the same community and nation, values of life, solidarity, and the ability to face hard tasks and overcome limits gave a look inside themselves. twenty percent of patients stated that they were living this experience in a negative way, learning disillusion, frustration, and resignation to death; % of controls lived this dramatic situation as subverting daily routine and forcing to reschedule life; % of patients stated that there was nothing to learn by this situation, but to just wait for improvement; and % of controls were not able to cope with the actual moment. the proportion of subjects who reported to have learnt positively or negatively from this experience did not differ between the groups (x ( , n = ) = . , p = . ). almost half of the patients ( %) manifested negative anticipations, forecasting more preventive precautions, difficulties, limitations, and discomfort than those that had already suffered because of the disease, thus passing to resignation and unavoidable acceptance. such a negative future perception was present in % of the control group, forecasting a sad, stressing, and financially hard future, with consequences on work and relationships. nevertheless, % of patients had a positive vision of the future, including the opportunity to come back to normal life, due to a profound faith in scientific research. fifty percent of controls prefigured the return to normal daily life, although with unavoidable changes in physical relationship and environment. among the patients' group, % had a passive, static attitude without changes in future perspectives. no significant differences were observed between groups (x ( , n = ) = . , p = . ). most patients ( %) refused to regularly come to the hospital for their therapies because they feared that they would be infected. the remaining % respected their scheduled infusion in the hospital, although they expressed their fear to be infected and thus showed a strict adhesion to hygiene procedures. all patients asked to be treated at home, except for a child that was severely affected with pompe disease, whose parents felt safer coming to day hospital , but accurately checked the personnel health state. the fear of contamination was also observed in patients who had already been treated with home therapy as they were scared to allow people to come home. the italian government's emergency declaration on march, , drastically changed our lives. every action, behavior, or even gesture was filtered by the covid- alert. "stay at home" was mandatory for all people, except for medical doctors, all health operators, and patients needing urgent medical care (www.salute.gov.it). this study emerged from the observation of different reactions in patients with lysosomal disorders dealing with pandemic outbreak. lsds are genetic, multisystem diseases [ ] . to date, some of the rare lsds are susceptible to ert, which has been shown to at least delay progression, allowing a better quality of life in terms of disabilities. although, we offered a regular and covid -controlled service for these patients, who deserved to be regularly treated despite the emergency period, we observed that patients and their parents were extremely scared and worried about coming to the hospital, fearing a higher risk for covid contamination. thus far, most of them missed their scheduled ert. conversely, those patients who had already been treated with home therapy refused treatment by the dedicated team because they felt that this could represent a potential source of the infection. in this regard, sechi et al. ( ) analyzed data collected by a questionnaire from patients on ert therapy for lsds in italy [ ] . they found that almost % of patients who were receiving therapy at a hospital ( . %) had disruptions, especially for personal feelings (fear of infection). in the present study, we analyzed behavioral and emotional profiles of our patients with lsds during the pandemic, compared to healthy controls. for this reason, a structured interview was created and administered online by a trained psychologist, already known to all patients as working in the centre. since we thought and developed the interview in light of this extraordinary event, the tool could not have been previously validated. the interview was made during the first week of lockdown, when both patients and controls were experiencing the same uncertainty resulting from the special situation. this study certainly may have some limits due to the small sample size, but this is the rule dealing with patients with rare diseases who are referred to a single center. although no significant quantitative differences were observed in the type of response between clinical and control groups, there were some qualitative differences between the two groups in all investigated areas. in general, all people forced to stay at home and freeze their jobs and who were far from common relationships, but too close to the familial nucleus members, experienced an increase in anxiety, worries, and uncertainty fostered by incessant media updates on virus lethality and virulence, underlining its invisible presence in our environment and in our lives. nevertheless, peculiar differences emerged in social relations and perception of "others". the clinical group, always accustomed to dealing with diversity, exclusion, and unawareness of others with respect to their lives of illness, perceived "others" mostly in a negative way, as dangerous, disrespectful, and not empathetic and to be avoided. the control group, although having the same negative perception, experienced "others" as frightened, insecure, suspicious, and elusive. in the clinical group, daily routine was marked from the issues of illness and its treatment, while for the control group, main problems were related to difficulty in maintaining, according to an orderly sequence, rules, spaces, times, and sleep-wake rhythm. on the other hand, it is singular that, in the percentage of positive representation of the routine changes, subjects in the clinical group believed that the positive element was the opportunity of a better relationship with family members, while among controls, positive elements relied on the possibility of being alone and doing something for themselves. data about future perception evidenced that, while the control group directed its attention to a future focused on economic, social, and environmental issues, patients prefigured a future always oriented by their critical situation being aware of their limits, in terms of treatment opportunities and life expectation. we focused on the covid- pandemic effects on medical care and health status of patients with lsds. the real risk of contagion once again highlighted the vulnerability of patients with chronic rare diseases such as lsds, the difficulty of coping with his or her defenses, and the need to trust and rely on others. in this case, the subjects preferred to refuse treatment, the only chance to improve their condition. they gathered all their defenses and tried to put in place all the resources and strategies available, such as resist and wait, for example, for home treatment, rather than face unarmed an unknown, enigmatic, and dangerous "enemy". in our sample, a striking similarity emerged between the two groups, equally forced to stay at home and experience the same profound feeling to be excluded (isolation and inclusion, the lancet psychiatry ) [ ] by normal life. the pandemic, which represented a scary event, suddenly occurring in the daily life, destabilizing, and giving rise to uncertainty, had the same impact as a diagnosis of a chronic rare disease. the control group experienced the feeling to be involved in a mutual fight against a common enemy, thus enhancing brotherhood with others. the patients with lysosomal disorders and their families felt that covid- opened the curtains, revealing their human condition of chronic exclusion and impairing their liberty to go out, walk, meet others, love, and breath without fear of death as all the others normally do. especially the mothers of our patients reacted with strength and determination, feeling that other people can know understand their withdrawn lives to assist their sons. they could now teach others how to face isolation with dignity, aware of fragility, as they usually do: "i can't help from sadly smiling when my neighbors complain because their children are sad as they cannot go outside . . . don't say it to me, please, my child and i do not go out since he was born and he is years old. now we are all the same, all confined at home . . . you are not different from us, you also are vulnerable, now we all fear death". the outbreak of covid- evidenced the vulnerability of the patients with such rare diseases and their needs in terms of adhesion to the therapy schedule. thus far, a special license for home therapy was approved by aifa (agenzia italiana del farmaco (italian medicines agency), det. / ), including those drugs prescribed and dispensed only at hospitals. this determination allowed home treatment for most of our patients. the covid- emergency revealed lsd patients' strength in terms of improved relationships, such as adhesion to the patients' group, family members, and community and their observance of imposed rules and precepts, trust in authority and doctors, and hope for improvement. systematic review of covid- in children shows milder cases and a better prognosis than adults lysosomal storage diseases research in psychology: a practical guide to research methods and statistics qualitative interviewing: the art of hearing data impact of covid- related healthcare crisis on treatments for patients with lysosomal storage disorders, the first italian experience isolation and inclusion. lancet psychiatr. the authors wish to thank the patients, their families, battista mangani, and nefri basile for their collaboration. the family association "bacodirame" is deeply acknowledged for financing the university research grant for the psychologist. the authors declare no conflict of interest. key: cord- -phsr jp authors: nan title: abstracts tps date: - - journal: allergy doi: . /all. sha: doc_id: cord_uid: phsr jp nan (either in men or women) between metabolic syndrome and incident asthma. conclusion: this study confirmed the significance of obesity as a risk factor for incident asthma. moreover, obesity appeared to be a stronger risk factor than metabolic syndrome. | relationship between helminth infection, blood eosinophils and asthma symptoms in a rural community from the tropics peñaranda d; alvarez l; sierra n; lopez j; zakzuk j; caraballo l institute for immunological research. university of cartagena, cartagena, colombia background: immune response to helminths shares many features with the allergic response. in tropical regions where helminths are highly prevalent, asthma is still a major public health burden. large clinical cohorts suggest that high blood eosinophils (hbe=> cells/ mm ) are associated with asthma exacerbations. however, the association between hbe and asthma severity in rural communities with prevalent helminthic infections is unclear. method: patients with wheezing symptoms in the last year living in a rural tropical community (santa catalina, colombia) where helminths are highly prevalent, were recruited for this study. blood eosinophils were assessed by complete blood count. parasitic infection was evaluated with two serial coprological exams (kato-katz method) and skin prick tests were conducted to determine reactivity to ascaris. results: seventy-three patients (mean age: ; range: - years old) were recruited in this study. a. lumbricoides and t. trichuria active infection ( . % and . %, respectively) were not related to age or gender. a positive spt to ascaris extract, aba- and d. pteronyssinus was observed in %, . % and . %, respectively. mean eosinophil count was cells/mm ; . % had hbe. rate of patients with at least one emergency department visit was . % and hospitalization, . %. blood eosinophil counts (as a continuous variable) were inversely associated with age (p = . ) and higher in helminth infection (p = . ). in crude univariate analysis, exacerbations (er and/or hospitalization) were associated with age (or: . ; % ci: . - . , p < . ) and hbe (or: . ; %ci: . - . , p = . ), but not with helminth infection. for a better definition of asthma, multivariate analysis done in those > years old indicated that hbe, helminth infection and positive ascaris spt were not associated with asthma exacerbations. conclusion: uncontrolled asthma is common in rural places of the tropics. since helminth infection influences eosinophilia, the clinical value of hbe to predict exacerbations is limited in helminth-endemic populations. castro mc ; ferreira j ; sarmento d ; carvalho c ; matos a ; bicho m chln-immunoallergy; lisbon medical school-genetic department, lisboa, portugal; lisbon medical school-genetic department, lisboa, portugal background: the bioavailability of no and endothelial homeostasis depends on the functional polymorphism of -bp del/ins within intron- of dhfr (dihydrofolate reductase enzyme) (rs ) that could interfere in the regeneration of bh (tetrahydrobiopterin) from bh ( , -dihydrobiopterin) and contributes to endothelial dysfunction in asthma. method: asthmatics (n = ) compared with control group (n = ).the polymorphism was analyzed by pcr. control of asthma assessed by (acq and paqlq). statistical analysis with spss . establishing a significance level of p < . . results: there are women and males in asthmatics and women and males in controls (p = . ). in asthmatics: age ( x ± sd): . ± . ; and in control group: age ( x ± sd): . ± . . the genotype frequencies in asthmatics are: dd ( . %); id ( . %); ii ( . %); in control group: dd ( . %); id ( . %); ii ( . %); there is no statistical difference between groups (p = . ). the allelic frequencies in asthmatics are: allele d ( . %); allele i ( . %); in control group: allele d ( %); allele i ( %); there is no statistical difference between groups (p = . ). the genotype frequencies in the uncontrolled asthmatics are: dd ( . %); id ( . %); ii ( . %) ; in the controlled asthmatics are: dd ( . %); id ( . %); ii ( . %); there is statistical difference between groups (p = . ). genotypes id and ii are more frequent in the uncontrolled asthmatics. the allelic frequencies in the uncontrolled asthmatics are: allele d ( . %); allele i ( . %); in the controlled asthmatics are: allele d ( . %); allele i ( . %); there is a trend to have differences between groups (p = . ). allele i is more frequent among uncontrolled asthmatics. the uncontrolled asthmatics are older than the controlled asthmatics (p < . ). there is no differences in gender distribution (p = . ). the genotype ii confers a risk of being uncontrolled asthmatic of . times when compared with controlled asthmatics and adjusted for age: or b : . [ . - . ]; p = . . physiopathology and the emergence of evidence-based clinical guidelines. however, variation still exists among some diagnostic aspects of asthma in real life. it is unknown to what degree diagnosis is affected by the treating physician's medical specialty. results: a total of gps, pediatricians, allergists, pulmonologists and otolaryngologists (orls) replied. although for general application of diagnostic clinical criteria all physicians rated similarly, in general accordance with the mag suggestions, a third of non-pulmonologist practitioners don't recognize chest discomfort as one of the clue symptoms of asthma, but they erroneously believe crackles are (p = . ). we found agreement in almost half of all physicians to erroneously believe that viral illness' induced wheezing in non atopic children predisposes asthma. conversely, - % are aware that allergic sensitization predisposes to asthma. most specialists -except pulmonologists (p = . )-incorrectly listed fev as the best parameter to identify airflow obstruction (ao) and fev /fvc to assess ao severity. % of gps do not know peak expiratory flow (pef) measurements could be valuable, and % of all specialists are not aware that changes in pef can also be used to confirm ao reversibility. to classify asthma, only pulmonologists adequately considered the level of control in similar proportion than severity ( % and %, respectively), which is uniformly the preferred method by most other specialists. conclusion: although in general many clinical aspects of asthma diagnosis seem to be accurately assessed, there is a wide specialityspecific variation regarding some aspects of phenotyping and classification, diverging from mag's recommendations. as such, our results can help to detect knowledge-gaps and to guide the development of more focused specialty-specific learning tools to improve clinical impressions, process medical evidence, and apply it to patient care. | issues, continuous medical education on treatment of acute asthma, exercise induced asthma and asthma in pregnancy should include, per medical specialty background: to unify and improve the management of asthma, including asthma exacerbations, the mexican guideline on asthma ( . %) of employees who stated increased symptoms with flour exposure. among all workers ( . %) employees were diagnosed as asthma and ( . %) workers were diagnosed as ba. conclusion: wheat flour sensitivity is high among workers who are exposed to wheat flour, however the prevalence of ba is similar to the previous data in the literature. johnsen cr ; callesen kt ; jensen bm ; poulsen lk clinic of allergy, dept. of dermato-allergology, gentofte hospital, copenhagen, denmark; laboratory of allergy, gentofte hospital, copenhagen, denmark background: enzymes are well known as sensitizers and causes of occupational allergy primarily in the industries producing and using the products. we present a case of occupational contact urticaria, rhino-conjunctivitis and asthma in a year male chef who was using a transglutaminase enzyme powder obtained from fermentation of streptomyces mobaraense as meat glue in processing of fine culinary dishes. this transglutaminase has been used for protein food preparation in industrial settings since to improve the texture of protein rich foods such as surimi or ham. in this case it was used in small scale in a gastronomy restaurant kitchen spraying enzyme powder with a sieve over raw meat without any protective equipment in contrast to the producer's recommendation. the chef was also found allergic to dried, edible mushrooms also forming part of the meat dish prepared with the transglutaminase enzyme powder. in one occasion he experienced an oral reaction with itching and swelling of the mucosa in the mouth, stridor, angioedema of the face, and urticaria after ingestion of beef meat treated with transglutaminase and rolled in horn of plenty dried mushroom powder. no other symptoms of food allergy were reported but a known cat allergy was. background: formaldehyde and xylene are occupational skin and respiratory irritant and/or sensitizer, exposure to those may be associated with dermatitis, rhinitis and asthma. health care workers, as nurses, laboratory technicians, doctors could be exposed in different tasks in operating rooms, endoscopy and in pathology laboratory. we describe three cases of work-related rhinitis in technicians employed in the same unit of hospital pathology . first case: a woman of years old underwent medical examination in our occupational allergy unit because allergy respiratory symptoms. she has been working for years in pathology laboratory and was exposed to xylene and formaldehyde. she developed rhinitis, rhinosinusitis, hyposmia and cough with sputum after years started work. she had negative skin prick test for common aeroallergens. lung function was normal with a fev /fvc ratio of % of predict. blood cells count reveled % of eosinophils ( /mmc) with total leucocytes. second case: a woman of years old was affected by moderate persistent allergic rhinitis with positive skin prick tests to house dust mite, dog and cat. in the last year rhinitis symptoms worsened in relation to work and improved during vacation. when she was exposed mostly to formaldehyde during shift at the end of it she usually experienced face skin and conjunctival erythema. she developed work-related symptoms after years of exposure in the pathology unit. third case: a woman of years old, who has been working for years in the pathology unit and was exposed to formaldehyde and xylene, in the last year developed moderate-severe persistent rhinitis with hyposmia and chronic cough. she referred to otorhinolaryngologist and an irritant induced rhinitis was diagnosed. she had negative skin prick test for common allergens and normal lung function. results and conclusion: the workers experienced respiratory symptoms in relation to work exposure to formaldehyde and xylene. the suspected causal agents were monitored in the work environment and an exceeding of the recommended limit values was found. preventive measure were adopted with a reduction of exposure and symptoms improve only in the second and third case. challenge test with mannitol is considered to be more specific than test with methacholine. also, duration of procedure is shorter and safer. therefore the study aim was to compare the usefulness of these two tests in monitoring of sict. method: four bakery workers with suspicion of oa underwent single-blind, placebo-controlled sict with workplace allergens accompanied by evaluation of nsbhr with mannitol and methacholine before and after sict. clinical examination, spirometry, skin prick tests (spts) to common aeroallergens and occupational allergens, serum specific ige antibodies to occupational aeroallergens were also performed. results: positive spts results to occupational aeroallergens were found in all bakery workers, specific ige to flours were detected only in two subjects. three out of the four patients displayed positive sict reaction (in two cases early spirometric response). in all of these patients, airway response to methacholine increased significantly. in the first two patients also airway reaction to mannitol was significant, whereas in one subject with early reaction there was no increase in nsbr after mannitol inhalation. the patient with negative sict results did not reveal any changes in nsbr before and after the test, neither to methacholine nor mannitol. | rice-induced occupational anaphylaxis and socio-economic impact-case report method: in this prospective study, a total of students completed a self-administrated questionnaire that comprised different questions and gave information about the participants and their glove use, working habits, signs and symptoms related to these gloves, precautions taken to minimize it, etc. skin prick test is performed through commercial extract latex gloves (stallergenes), while patch test is prepared through latex gloves and adhesives. two types of gloves are used: gloves that contain latex and gloves without latex (vinyl gloves), which are used also as e negative control. results: questionnaire items and diagnostic tests revealed that one-fourth of subjects were suspicious for latex gloves hypersensitivity. their mean value for skin reactions like irritant or allergic dermatitis or contact urticaria was between % and %, while for other symptoms the mean value was under %. logistic regression analysis revealed an association between different questionnaire items and positive allergy tests among suspected cases and diagnosed cases of latex allergy. approximately % of people who work with laboratory animals experience some allergic symptoms and about % of animal technicians go on to develop serious symptoms of asthma. uk government guidelines state that employers must prevent or adequately control exposure of employees to animal allergens and should undertake monitoring to ensure that suitable controls remain effective. the most widely used monitoring method is personal iom filters. however, these need to be attached to a pump and carried by the technician which can be cumbersome and awkward. previous data has demonstrated that allergens from dust mite, cat, dog and pollen could be captured and quantified by a novel type of nasal filter. in this current study, we sought to assess the feasibility of using the nasal filters for the assessment of exposure to mouse allergen in a laboratory facility. method: technicians working in a laboratory animal facility were asked to wear the filters during normal routine work. for comparison, they were also asked to wear an iom filter for the same duration. allergen was extracted from nasal and iom filters by gentle rocking in pbs-tween for two hours. levels of the major mouse urinary protein (mus m ) were quantified using our multiplex array technology, which is highly sensitive and allows for quantification of mus m down to . ng/ml. results: significant levels of mus m were detected in the nasal filter extracts and these levels correlated with the type of activity that was being performed by the technician, as well as the housing environment of the mice. levels were compared to the suggested 'safe' limit of allergen exposure of ng/m . we also found that the technicians grew accustomed to the nasal filters quickly and found them far more practical for every day monitoring that wearing the iom filter and pump. conclusion: these data indicate that nasal filters may be considered a simple and easily wearable method for monitoring laboratory animal allergen exposure. future studies are planned to assess the feasibility of wearing the filters for analysing exposure to other laboratory animal allergens from rat and guinea pig. havana university lower co emission, water and feed consumption and limited waste production. insects are currently allowed both for human and animal feeding in some eu countries, including italy and the risk profile related to production and consumption of insects as food and feed, including risk of allergenicity, is currently under evaluation by efsa. both food and feed products derived from insects require multiple manipulations by the breeder and/or by the workers who transform the insect into the commercial products, thus the occupational exposure have to be considered too. the aim of this work is to evaluate the allergenicity of tenebrio molitor, one most used species for animal feeding. method: t. molitor proteins were extracted from intact dried larvae and from flour of dried larvae. the protein extracts were separated in one-dimensional electrophoresis conclusion: according to these results, the larva flour seems to be less immunoreactive than the intact counterpart, probably due to the processing that causes the degradation of protein bands over kda. working in gastronomy is associated with exposure to many factors with an irritating and allergic potential influencing respiratory system. food products and organic dust are the source of inhaled allergens which may cause sensitization during apprenticeship. the study aim is a prospective observation of incidence of sensitization to selected environmental and occupational allergens among culinary school apprentices and identification of work-related allergic diseases in this group. method: the cohort comprised apprentices. they were examined in the first and the second year of education. questionnaire and allergological tests [(skin prick test) spt to common and occupational allergens, ige level evaluation (total and specific for occupational allergens) and pulmonary tests] were performed]. results: the most frequent symptoms reported by examined apprentices were rhinitis ( . %), conjunctivitis ( %), skin symptoms ( . %), dyspnea ( . %) and cough ( . %). subjects developed nasal symptoms during the second year of education, while in cases the skin symptoms and in subjects conjunctivitis appeared. in cases the work-related symptoms were reported. the most frequent positive results of spts were obtained with dermatophagoides pteronyssinus . %, dermatophagoides farinae . %, grass pollens . %. positive spt to rye and barley flour were found in respectively . % and . % apprentices. . % of apprentices had specific ige to flours. the preliminary results indicate that work-related allergy symptoms and hypersensitivity to occupational allergens are rarely found among culinary school apprentices in the first years of education. the further observation will allow to evaluate the trends in incidence of allergy to occupational allergens, as well as the clinical presentation of allergy in that group. | how multifaceted the clinical presentation and etiology of allergic diseases could be? method: the study was done in children from west georgia randomly and on based of questionnaire of representative cohort. ( ) ( ) ( ) . the cohort was children, - years old, risk factors were studied by way of interviewing, clinical-laboratory dates. for assessing the risk factors, was used 'case control' method. the statistical processing of material was done with computer program sps/sv . inclusion criteria for enrolment were: collectors of dust, gender, existence of moisture and mold consuming of tabasco, atopic dermatitis and seasonality. results: the groups, which we have studied, prevalence of acute respiratory viral infection was %, bronchitis − . %, allergic rhinitis . %, atopic dermatitis . %, food allergy . %. the reliability was high (p < . ) in families with bronchial asthma compared with healthy population. bronchial asthma was detected in . % of population. the hereditary load of allergic diseases in patients with bronchial asthma was . % and in healthy cohort it was . % (p < . ). conclusion: based on the results, we can conclude that, ecological factors and genetic predisposition significantly influences on prevalence of sensibilisation of house dust mite, molds and formation of bronchial asthma. as the genetic and environmental factors that act on an immune system are better elucidated and their roles established, the implementation of more enduring preventive efforts will be developed. however, at present, the best approach to the child at high risk for the development of allergies is to institute dietary and environmental control measures early to decrease sensitization, and to recognize and appropriately treat the evolving signs and symptoms of allergic disease. background: plantation of road-side avenue trees has become a major part of the urbanization programme in kolkata metropolis of india for megacity beautification and environmental management. due to evergreen habits, gulmohor (delonix regia) and chhatim (alstonia scholaris) are frequently selected for plantation programme to generate green belts. however, an increasing incidence of seasonal pollinosis was observed among the inhabitants living in close vicinity to these trees suggesting a possible link between the airborne pollen load and the concomitant respiratory hazards. this prompted us to investigate the allergens in the pollen of these two dominant avenue trees. method: aerobiological surveys were conducted at multiple sites of kolkata for a period of two years using seven-day volumetric burkard sampler to record the pollen concentration in the outdoor ambient air. clinical data and residual blood of pollinosis patients were collected from a public hospital. allergens were detected in the pollen proteome fractionated in d gel by ige-serology. the major igereactive proteins were partially purified by ammonium sulphate fractionation followed by ion-exchange chromatography. the allergenic activity of the fractions was tested by histamine release assay. results: a clear correlation was observed between the pollinosis related morbidity and the aeropollen load especially during the peak flowering period of these two trees. about % and % of the patients displayed positive spt response and ige-reactivity using pollen extracts of gulmohor and chhatim respectively. immunoproteomic analyses revealed the presence of - ige-reactive components in the d pollen proteome of these species. hierarchical cluster analysis with patient immunoblot data identified a kda and a kda protein as major allergens of gulmohor and chhatim respectively. the purified fractions containing each of these two major allergens induced histamine release from granulocytes within a range between and %. method: immortalized human keratinocyte cell line (hacat) and primary normal human epidermal keratinocytes (nheks) were differentiated with calcium chloride for and days, respectively. following the differentiation, the cells were treated with il- ( ng/ml), il- ( ng/ml), and/or hcho ( × ^- %) for hours. the mrna expression of flg, ivl, lor, dsg , dsg , dsc , dsc , as well as tslp was analyzed using quantitative real-time pcr. results: hcho exposure decreased the mrna expressions of structural components (flg, ivl, and lor) and cell adhesion molecules (dsg , dsg , dsc , and dsc ) in a short-period time of exposure ( hours). we also found that hcho exposure significantly enhanced il- -and/or il- -induced tslp production in nheks as well as hacat. interestingly, exposure to hcho alone is enough to increase the tslp mrna expression in both cells. conclusion: our results suggest that hcho exposure might synergistically damage the skin barrier function with il- and il- by increasing tslp expression and decreasing structural components as well as cell adhesion molecules. | skin prick test reactivity to aeroallergens in adult allergy clinic in a tertiary hospital: a -year retrospective study results: five different human sera were screened for specific ige level against different allergen sources using test methods of three different suppliers. the sensitivity of the three different methods can be arranged in the ascending order manufacturer a < manufacturer c < manufacturer b. with the test of manufacturer a, % of the measurements were below the detection limit ( . ku/l), with the test of manufacturer c, % of the measurements were below the detection limit, whereas the test of manufacturer b leads to values below the detection limit in % of the cases. in terms of variation coefficient, the test system of manufacturer c had the best performance. test systems of manufacturers a and b exhibited comparable variation coefficients, which were considerably higher than that of manufacturer c. conclusion: based on these test results, only the test of supplier c is recommendable for determination of levels of specific ige for diagnostics of allergic patients. with the test of manufacturer a, elevated levels of specific ige antibodies for many allergens cannot be detected due to the poor sensitivity of the test system. the test system of supplier b exhibits a good sensitivity but the coefficient of variation is rather high for a diagnostic test. this drawback could be circumvented by multiple determination of one test parameter. although this is an advisable strategy in general, the routine in diagnostic laboratories is incompatible with this approach, since throughput would decrease while costs would increase. this study is another good example for the need of the implementation of a characterized standard material with known values of sige, as demanded by wojtalewicz et al. method: cd c and cd expression on basophils were monitored upon exposure of whole blood samples (< hours) to anti-ige and/or allergenic extracts. staining was conducted on exposed samples using dry room temperature stable antibody panels (dura innovations format) coated in well plates, eliminating all antibody pipetting steps from the workflow. red blood cells were lysed and data was acquired (without further wash steps) on a cytoflex flow cytometer (beckman coulter). staining and lysing were automated using a biomek (beckman coulter). results: the described no-wash preparation protocol, already established for manual preparation mode in tubes, could be trans- conclusion: the hr-test was significantly less likely to be positive, if a patient suffered from monosymptomatic ae than in ae patients with concomitant urticaria. this could signify a higher likelihood of treatment response to antihistamine and other anti-allergic medication in the latter group. background: pathogenetic mechanisms of allergy are polymorphic. they include ige-dependent and ige-independent, allergen-specific granulocyte-mediated and lymphocytic reactions, as well as nonspecific hypersensitivity, which are realized through a variety of mediators: histamine, tryptase, etc. allergen bucal challenge mimics the natural situation and is useful for understanding the mechanisms of allergic airway inflammation and airway hyperresponsiveness (ahr).saliva used as a non-invasive readily available bio-sample for diagnosis instead of blood. biomarkers in saliva are associated with the pathogenesis and clinical outcome of allergic diseases method: aim: to examine mediators for ahr with buccal(mucosal) challenge tests. we examined patients with allergic asthma(the history, positive skin prick test, serum specific ige) and healthy volunteers. saliva were collected. then, both groups were subjected to buccal(mucosal) allergen challenge by a water-salt solution of the mite allergen dermatophagoides pteronyssinus. saliva was recollected in minutes and hours after the provocation. the level of myeloperoxidase, elastase, tryptase in saliva were determined by the elisa. that provocative test did not cause clinical symptoms development or reduction in nasal bronchial patency in any patient. results: in patients with allergopathology, an initially increased level of myeloperoxidase and tryptase in minutes after the provocation, elastase increased in hours (table ) . tryptase in saliva after minutes increased till . ( . ; . ) (me, pg/ml (lq;uq)), p = . . increased tryptase is presence of increased cellular inflammation, e.g. mast cells. its ige-dependent hypersensitivity, because there was the correlation between the elevated level of tryptase and positive prick tests. elevated levels of myeloperoxidase and elastase in saliva may be the criteria for the neutrophil hypersensitivity and ige-independent reactions. in healthy volunteers this increase was not observed. the identification of tryptase, myeloperoxidase, elastase can be used for diagnosis of types of ahr. tryptase is a mediator of early (immediate) response to allergen. increased myeloperoxidase and elastase indicates the involvement of the eosinophils and neutrophils in the oral mucous membrane in the allergic process. these mediators have additional roles in the late phase response. elevated levels of myeloperoxidase and elastase in saliva may be the criteria for the neutrophil hypersensitivity. conclusion: safe and acute in vitro methods allow to conduct early etiological diagnosis of allergy, which contributes to the effectiveness of therapy; the detection of polyvalent sensitization dictates the need for molecular diagnostics to single allergens, which has a higher prognostic level and the clinical significance of predicting the appropriateness and effectiveness of allergen-specific therapy; laboratory diagnostics of the allergy allows to reveal sensitization at the ( , ) ( , ) ( , . ) *p = . ; **p = . ; ***p = . . subclinical level, which increases early diagnosis and identify persons with a predisposition to allergy; the establishment of causal aller- background: antibacterial chemicals like parabens and triclosan have been associated with allergic disease in children. parabens are also suspected to affect metabolic functions, possibly due to their weak endocrine disrupting properties. furthermore, a possible link has been suggested for eczema and adiposity, and thus, how body burden of chemical exposures affect both of these outcomes are of interest. we aimed to describe the association between exposure to parabens and eczema and body mass index (bmi) in an adult population in norway. method: urine biomarkers of butyl-, ethyl-, methyl-and propylparabens were quantified by mass-spectrometry in adult participants (median age= years) from the rhinessa study in bergen, norway. linear regression models adjusted for gender, age and bmi (for eczema outcomes) and with clustering for siblings, were applied to model possible association between specific gravity standardized urine biomarker concentrations of parabens with bmi and eczema. results: propyl-(ppb) and methyl-parabens (mpb) were detected in % of the urine samples; ethyl (epb) in % and butyl (bpb) in % of the samples. in women, epb and bpb were detectable in % and %, respectively. participants with current eczema ( %) had lower level of several parabens compared to those without eczema (bpb for both genders; epb in women only and sum of all parabens in men only). body burden of epb (geometric mean (gm)) was . μg/l in women with current eczema compared to . μg/l in women without eczema (p = . ). body burden of parabens (mpb and epb) were inversely associated with obesity (bmi> , ( . %) ), as compared to normal range bmi (bmi= . - ( . %)) in both men and women. the concentration of mpb for obese women was gm= μg/l compared to μg/l in women with normal range bmi. for men, the gm for mpb was . μg/l in obese compared to . μg/l in normal weight men (p = . ). conclusion: person with eczema or obesity had lower paraben levels in urine. we speculate that these chemicals might be stored in adipose tissue, and therefore excreted in urine in lower levels among the obese. eczema and obesity was not strongly associated in the current study. method: we retrospectively analysed medical records of patients who were patch-tested with our dental screening series of substances. adverse reactions to dental materials were suspected based on subjective complaints in the oral cavity and/or objective conditions of the oral mucosa. square plastic chambers on hypoallergenic tape were used. patch tests were applied to the upper back and removed by the patient after hours. readings were performed and days after application (d and d ). results were evaluated according to the international contact dermatitis research group guidelines. positive patch test reactions fulfilled the criteria of at least a one plus (+) reaction on d and/or d . the term »contact allergy« is usually used for such reactions. we prefer the term »contact sensitization«. clinical relevance of positive reactions to dental materials was not systematically assessed in this analysis. conclusion: we report a high frequency of positive reactions on d that were not seen on d . this finding demonstrates the importance of an additional late patch test reading in patients with suspected contact allergy to dental materials. background: psoriasis is a chronic inflammatory skin disease. its etiopathogenesis is not exactly known. it is believed that the disease occurs in people with genetic tendency with the effect of a triggering factor. in some studies it is observed that contact dermatitis in psoriasis is increased with respect to normal population. for this reason it is proposed that allergen materials could trigger psoriasis. in this study it is aimed to determine contact allergy frequency in psoriasis cases using patch test. results: of the cases were plaque, of them were guttate, of them were palmoplantar and of them were inverse type. more positivity rate is observed in psoriasis cases ( . %) than control ( %). the positively responsed materials with respect to decreasing number of patients are found as follows: nickel sulphate ( . %), thimerosal ( . %), peru balsam( %), p-phenylenediamine( . %), colophony( . %), n-isopropyl-n-fenil- -fenilendiamin( . %), mercaptobenzothiazole( . %), benzocaine( . %), most frequently plaque type and following guttate type positive responses are observed in evaluations with respect to clinical types. no statistical significance is found between patch test results and pasi values in psoriasis cases. conclusion: patients with psoriasis should be carefully evaluated. sometimes some materials may trigger psoriasis. the composition of the pigments that professional tattooists use are varied inorganic salts of metals or organic vegetable pigments. red tattoos, especially those that contain mercury, are the most common cause of late reactions. method: year-old male patient with no previous allergy history known, who gets a tattoo on his right leg and develops within months, cutaneous erythema and pruritus on the same location as the tattoo. true test ® for skin allergy patch epicutaneous testing is performed. results: and hours reading: showed positiveness for mercury ++, with no late positive reactions after that. conclusion: as allergists we should be familiar with the different types of tattoos available, and know the possible cutaneous complications that each of these decorative techniques can present. it is our responsibility to be able to diagnose any complications at an early stage, establish the most appropriate treatment and, if possible, prevent them by informing the possible users. background: within otorhinolaryngological pathology chronic eczematous otitis externa is one of the most common, usually treated with topical medication successfully; however, there are cases in which the poor response to treatment, or the recurrence thereof, may be due to causes secondary to the medication itself, as observed in cases of allergic contact dermatitis caused by these drugs. case report: we present a -year-old male patient without relevant pathological antecedents or known allergies, who consulted the otorhinolaryngology service of our center for otorrhea of days of evolution, bilateral external otitis is diagnosed and a topical otological combination is recommended (beclomethasone dipropionate . % and clioquinol %, excipient: macrogol) with improvement. however, during the following years the patient presents exacerbations and remissions of the condition, with negative or inconclusive microbiological studies. during all that time he was using the prior topical treatment and other combination treatments of topical antibiotics, corticosteroids and local antiseptics. more aggressive causes of external otitis such as malignant external otitis were ruled out. during the third year of follow-up, a clear relationship of exacerbations was observed with the use of the first combination of topical drugs, so it was decided to investigate allergic sensitization. material and methods: we perform patch tests using true test ® , standard spanish series (geidac -spanish group for investigation of contact allergy dermatitis), topical corticosteroid battery, antiseptic, as well as topical medications used by the patient. results: from the first reading on day two, positivity was observed for: mixture of quinolines ++ patient's otological combination ++ and chlorquinaldol ++; being confirmed in the reading at day four. eczematous external chronic otitis is diagnosed with allergic sensitization to quinolines (clioquinol, chlorquinaldol). we conclude that in the case of chronic external otitis, allergic contact dermatitis should also be investigated as a possible cause, and it is important to perform epicutaneous tests with the patient's own products to evaluate non-common or hidden allergens that may be relevant to their current pathology. most common causes of acd. it is important to distinguish local findings of infection from acd caused by topical antibiotic treatments. here we present a patient with acd with topical use of bacitracin and neomycin combination therapy due to recurrent blepharitis. an -year-old male patient presented with the complaints of itching, redness, swelling of the eyelids and facial edema. he had used various topical ophthalmic antibiotherapy and eye shampoo for years due to recurrent blepharitis. five days ago, due to the redness of the eyelids, burning sensation in the eye, itching of the eyes; he was examined by an ophthalmologist. the eyelids and eyelashes were scaly and dry. the patient was treated with warm water soaked cloth dressing, mechanical eyelash cleaning and topical antibiotherapy (neomycin-simple combination therapy). after the second day of treatment, the patient's topical ophthalmic antibiotherapy was discontinued due to an augmentation of the redness in the eye- | contact allergy after exposure to ivy (hedera helix l) potent steroid treatment associated with systemic antihistamines, but with no improvement. on dermatological examination a small, well delineated, eczema-like plaque was noticed on a digital finger, as a new finding striking with her old burn scars. she denied any symptoms and was in good health condition. a mm punch biopsy was performed and histological report established the diagnosis of squamous cell carcinoma. the patient was transferred to oncology department for further investigation and treatment. conclusion: early diagnosis and prompt surgical therapy are recommended to all patients with chronic wounds and scars who develop malignant transformation. *written informed consent for the publication of potentially identifiable personal details of patient (gender, age, illness, location) was obtained. **in relation to this presentation, i declare that there are no conflicts of interest. ertugrul a; hizli demirkale z; bostanci i dr sami ulus maternity and children training and research hospital, ankara, turkey introduction: the incidence of contact sensitization among adolescent has been increasing. nickel is one of the important causes of allergic contact dermatitis (acd) in this age group. increased exposure to nickel and deterioration of the skin barrier are among the important risk factors in children. the gold standard for diagnosis is skin patch test. we report here an adolescent patient who has allergic sensitization to nickel and cobalt. case: a -year-old female patient admitted in our clinic with a complaint of edema on her face. the patient had applied chickpea water to her face at least once a day for one week because of her acnes. her medical history revealed that she had experienced similar edema on her face after applications of clay mask one year ago. she was diagnosed with cellulitis and she had been treated with antibiotics for five days. on her physical examination, angioedema was observed on her face, especially on the glabellar region. eosinophilia was not found on her laboratory data. c-reactive protein (crp), c and c esterase inhibitor protein levels were also normal. the skin prick test was performed with aeroallergens, chickpea, lentil, bean and nuts, and no reaction had been observed. the patch test was performed with 'thin-layer-rapid-use-epicutaneous' (t.r.u.e) test and chickpea. the patient had positive reactions to nickel and cobalt. detailed questioning disclosed that the patient was preparing the chickpea water in a metal pot. result: chickpea water and clay mask contain varying amounts of nickel. it was thought that the edema of the patient is due to nickel allergic contact sensitization. an increased exposure to nickel and cobalt raises the frequency of sensitization. nickel allergy can cause different clinics ranging from localized lesions to systemic reactions. we want to emphasize that a detailed medical history and the patch test would enable clinicians to demonstrate hidden allergens and then make a correct diagnosis. case report: autoimmune progesterone dermatitis is a condition of hypersensitivity to progestogens. it is not an easy diagnosis given the variety of clinical presentations it may have, ranging from eczema, urticaria, erythema multiforme, folliculitis, to angioedema or even anaphylaxis. manifestations are cyclical, occurring when the levels of progesterone are higher, this is, at the luteal phase of the menstrual cycle, and disappear during menses, with the physiological decrease of the hormone. it can also be triggered by exposure to exogenous progestins. we report the case of a -year-old woman with a cyclical erythematous and violaceous rash related to the menstrual period. the symptoms typically began - days before the onset of menses and ended - days before. the diagnosis was based in the clinical history and intradermal skin tests: skin prick testing with levonorgestrel and medroxyprogesterone were negative, but the intradermal skin test with medroxyprogesterone was positive at a concentration of mg/ml. we performed intradermal testing with the same concentration in three other women with no symptoms to exclude an irritative reaction, which were negative. autoimmune progesterone dermatitis is, perhaps, not so rare, but rather poorly recognized and reported, and thus, underdiagnosed. clinicians should be aware and include always this condition in the differential diagnosis, especially in cases of atypical or intractable skin eruptions. case report: a year old male was referred to a community allergy clinic for assessment of chronic urticaria (cu). allergy assessments for foods, inhalant and inducible physical triggers revealed no association. an autoimmune workup followed, with treatment consisting of standard dose antihistamines (h and h ). blood work revealed a persistently low hemoglobin with low-normal ferritin. hematology consulted and followed attempted iron replacement to no avail. skin biopsy revealed neutrophilic rich urticaria with the presence of eosinophils. serum protein electrophoresis (spep) revealed a monoclonal gammopathy with elevated igm, felt to be of undetermined significance (mgus). c-reactive protein (crp) was consistently elevated ( , ) in conjunction with anemia. rheumatology consulted and cleared of any evidence of vasculitis. hematology considered the anemia to be of chronic disease linked to cu. the cu was resistant to treatment including high dose antihistami- background: isolated head and neck angioedema (ae) can be mediated by bradykinin (bk) or histamin (hi) . the objective of our study was to determine which etiology was most frequent in cases of death by asphyxiating ae in france. we sought all cases of death by isolated asphyxiating ae reported in france between and via death certificates and/or the national pharmacovigilance database. results: the overall mortality by asphyxiating ae for all causes was . / million inhabitants. the death rate of bkae per million inhabitants was . and lethality of . per thousand patients per year. the death rate of hiae per million inhabitants was . and lethality of . per thousand patients per year. we found a times higher risk of death in case of bkae than hiae. conclusion: consequently, particularly severe episodes must be initially considered as bradykinin mediated and quickly reassess any first-line treatment that is inappropriate. case report: we present the case of a -year-old man who suffered recurrent abdominal pain since age of eight, leading to unnecessary emergency surgical interventions and endoscopies before hereditary angioedema due to c inhibitor deficiency (c -inh-hae) was diagnosed at the age of . rare subcutaneous swellings were considered allergic reactions preventing proper diagnosis. family history, positive for recurrent abdominal pain and swellings was totally neglected until diagnosis of c -inh-hae type i was established through appearance of severe oro-facial symptoms in the propositus' grandson. the diagnosis was suggested by the boy's mother, directed by educational materials available in the international hae patients' association website (www.haei.org). this report highlights and emphasizes the importance of accurately evaluated personal and family history to suspect condition that are scarcely known to the majority of physicians. highlights: diagnostic delay in hae and iatrogenic procedures are an underestimated problem, hiding undefined consequences, possibly destructing an entire lifetime. correct, publically available information provided by patients' associations raise awareness about the disease and could put the milestone of establishing correct diagnosis. de luque v ; lara p ; guardia p ; jimenez ar virgen macarena hospital, seville, spain; hospital virgen macarena sevilla, seville, spain background: in the protocol for the study of patients who consult for recurrent acute angioedema with facial involvement, the contactant battery is included (epicutaneous test). we review the results in our patients with facial angioedema to evaluate the contactants to which these patients present sensitization, some of them coexisting with contact dermatitis clinic. we reviewed the patients referred to the clinic for recurrent acute angioedema with facial involvement and to whom a standard battery epicutaneous test was requested. in all these patients, other habitual triggers included in the diagnostic protocol (food, medications, autoimmune diseases, bradyinergic aea/complement deficit …) were ruled out. conclusion: it seems to be profitable to continue including in the diagnostic battery of patients who consult for aea with facial affectation, study of epicutaneous with standard battery. it is a small sample, but the data correlate with what has been published, being more frequent the sensitization to contactants in women and the contactant more frequently involved nickel sulphate. | ace inhibitor-related angioedema-the value of history taking background: angioedema is a well-recognized side effect of angiotensin-converting enzyme (ace) inhibitor therapy. although it occurs in < % of the patients who take these drugs, it seems to be responsible for % of the episodes of angioedema. this entity is underdiagnosed and failure to recognize it leads to recurrence of episodes, with an impact on morbidity and increased risk of serious reactions. our objective is to analyze the clinical, therapeutic and orientation approach of patients diagnosed with ace inhibitor-related angioedema, evaluated at the outpatient consultation (oa) of immunoallergology (ia). a -year retrospective study was performed by analyzing the clinical files of all patients diagnosed with angioedema observed in oa of ia. the following variables were analyzed: gender; age; clinical data; evaluation in emergency department (ed); therapy in the episode; evolution and orientation. the chi-square test was used to study the association between categorical variables: "established therapy"/"disease evolution" and "place of reference"/"withdrawal of ace inhibitor". results: review of cases of patients referred for angioedema. only in % the final diagnosis was "ace inhibitor-related angioedema". the mean age of the patients was . years and % were male. the location of angioedema occurred in the tongue in % and in the remaining sites (lip, hemiface, tongue and hemiface, tongue and lip) appeared in the same frequency, %. none of the patients had airway obstruction. during the episode of angioedema, % of patients were not referred to ed and the therapeutic approach was done with antihistamines in %. in patients who were referred to ed ( %), antihistamines and corticosteroids medications were administered in %. regarding the evolution, it was verified that the duration of the episode was independent of the established therapy (p > . ). regarding the place of reference, % of the patients were referred form hospital (ec or ed) and, in these, the ace inhibitor was suspended in %. in patients referred from general practitioners ( %), in none of them the ace inhibitor had been withdrawal. a causal association between the use of ace inhibitors and the episode of angioedema becomes crucial, since drug withdrawal is indicated. a reference for ai oa should be weighed. therapy with antihistamines and corticosteroids has no proven efficacy. hereditary angioedema (hae) seen by physicians belonging to the hae scientific committee of the aaaeic background: patients with c -inh-hae frequently suffer from anxiety and stress. the impact of prophylactic treatment on anxiety and stress in c -inh-hae patients is largely unknown. here, we analyzed data from the apex- study, a phase ii study that investigated the effects of the oral kallikrein inhibitor bcx . method: c -inh-hae patients with a history of at least hae attacks per month were randomized to receive four different doses ( , , , . mg) of bcx or placebo for days. the depression anxiety stress scale (dass) was administered at baseline and at day . the dass consists of three self-reported scales designed to measure the negative emotional states of anxiety and stress. subjects used a -point severity/frequency scale to rate the extent to which they have experienced each state. results: baseline dass total scores as well as anxiety and stress domain mean (sd) scores for the mg treatment arm (n = ) were . ( . ), . ( . ), and . ( . ) points respectively. placebo scores were generally similar or slightly lower at baseline than for the mg treatment arm. the dass questionnaire data showed statistically significant improvements in total score vs. placebo at day (− . method: a two-phase mixed methods approach was used to develop the hae-rt tool including: phase : delphi study [hae specialists (n = ) and national patient advocacy group members (n = )] was conducted to reach consensus ( % agreement) on predictor variables to include in the tool. phase : retrospective chart review was conducted to assess the predictive findings of the decided variables. a convenient patient sample presenting with angioedema (with and without hae) between january -january were included in the study. results: nine of invited experts ( %) participated in the delphi study. of hae-specific predictive variables, reached consensuses including: (i) recurrent angioedema; (ii) absence of urticaria; (iii) recurrent abdominal pain/swelling; (iv) lack of response to allergic therapy. the retrospective study included patients (n = with hae; n = non-hae; overall % female). hae patients were significantly more likely to have a family history of hae ( % vs %; p < . ); previous recurrent angioedema ( %; p < . ); present with no hives ( %; p < . ); previous recurrent abdominal pain ( %; p < . ); and % responded to allergy treatments (p < . ). a regression analysis categorized observed frequencies (actual patient outcomes from chart review) versus predicted (by model); plotted on a by table and calculated the sensitivity and specificity of the hae-rt which resulted in one hundred percent for both. conclusion: our study demonstrated that expert involvement led to the identification and prioritization of variables that when included an hae-rt tool, were associated with a high level of sensitivity and specificity when applied to known patients. the next step is to observe the effect of the hae-rt tool on patient care in the ed. method: evaluation of cardiovascular manifestation included morphology, serum level of troponin t, electrocardiography (ecg) and echocardiography. evaluation of pulmonary manifestation included spirometry, diffusing capacity of the lung for carbon monoxide (dlco) and evaluation for mastocytosis included bone marrow biopsy and serum total tryptase measurements. results: in the study there were patients - women and men between and years old (the average age was ). there were ( . %) patients with mpcm, ( . %) with bmm, ( . %) with ism and ( . %) with ssm. the average level of serum tryptase was . μg/l ( . - ) . troponin levels was within the normal range in all patients. one patient had lowered the ejection fraction (eflv= %). no one patient had restriction. the average value of a forced lung capacity was . l ( %) and a total here, we describe a case series of twelve mis patients seen at our department over a -year period and report how many of these patients have sm. common phenotypical manifestations of acute hae episodes in this region, to review therapeutic challenges in a rural setting in comparison with world standards, and lastly to evaluate the socio-economic burden inflicted by the disease. method: a sample of individuals from a total of . the exclusion criteria was the inability to attend booked appointments more than times in year ( ). the following methods were used: an interview to formulate a family tree identifying affected individuals in contiguous generations, and review of the acute presentations in the past year ( ) . a questionnaire to obtain the relevant hae associated socio-economic burdens. a chart review to identify the therapeutic strategies in this region. c inh levels, and complement c to confirm the diagnosis. results: polygamy as a local culture was found to be an important factor that perpetuated the genetic burden of the disease. c inh and c levels confirmed hae in all participants individually. clinical features during acute attacks included swelling of extremities ( %), facial swelling ( %), neck swelling ( %), and laryngeal swelling ( %). therapeutic strategies for acute attacks included fresh frozen plasma or fresh dried plasma. danazol was used for prophylaxis. hae has had a significant negative impact upon the socioeconomic status of the affected individuals. conclusion: hae is a newly identified disorder in the broad spectrum of allergy medicine in kwazulu-natal. the diagnosis is simple to confirm but requires an initial high index of suspicion, and therapeutic management still poses a challenge in this region due to lack of resources. genetic counselling is of paramount importance during intervention since polygamy forms part of most cultures in this region. a support strategy is highly recommended in order to help alleviate the socio-economic burden posed by the disease in this region. the socio-economic burden secondary to hae ( participants/ identical questions each) question ( - points) question ( - points) question ( - points) question ( - points) question ( - point) method: a total of medical faculty senior year students were included to study on a voluntary basis. students are divided into two groups. one group was given visual user guide that has not been modified, and a visual user guide on which we have modified to the other group ( figure ). then they were asked to show how to use the inhaler spacer. results: the mean age of the volunteers was . ± years and ( . %) were male. there were students in the group without modification of the visual user guide and students in the other group with modified the visual user guide. sixty-four per cent of the modified user guide group showed correct use of the inhaler spacer, while % of the unmodified group showed correct use (p = . ). the group that given modified visual user guide was more successful in all of the display steps of the inhaler spacer. conclusion: modification of the currently available visual user guide of inhaler spacer in our country will increase the correct usage rate. results: mean fev , fvc, fev /fvc z-score were . ( . - . ), . ( . - . ), . ( . - . ), respectively. restriction had ( . %) and obturation ( . %) patients. fev (p < . , r = . ) and fvc (p = . , r = . ) decreased with age (%pv and z-score). background: children who were treated for leukemia are known to have developed long term impairment of lung function. the reasons that complication are only partially known. the aim of this study was to asses pulmonary function in children treated the lower dlco is the most frequent abnormality in childhood leukemic survivors. hsct and pulmonary infection (in particular cmv pneumonia) is a strong risk factor for impairment of dlco in children. clinical manifestation of dlco impairment is poor exercise tolerance. a screening for respiratory abnormalities in survivors following treatment for childhood haematologic malignancies, seems to be of significant importance. | phenotyping allergic respiratory diseases: an unsupervised classification using latent class analysis allergen groups was significantly associated to uawi (aor[ % ci]: . [ . - . ] ), compared to uasi. results: . % of br and % of py were women, median age was years, % br and % py reported having more than four years of training. although they recognized the main symptoms of ar, % br and % py never asked whether the patient had a medical diagnosis of ar; . % br and . % py did not ask whether the symptoms occurred when close to animals or allergens; % br and % of py did not ask if the patient had a medical diagnosis of asthma; % br and % py did not ask if rhinitis worsens asthma symptoms and . % br and . % py did not ask whether symptoms of rhinitis interfere with their daily activities. results: there was a predominance of female (br: %, py . %, uy: %) median age years old, / worked in the community and / in the emergency departments, % of the br had more than years of education, % from py had between and years, and % from uy had been graduated for less than year. br/uy recognize the main symptoms of ar, however % of those from uy do not ask: if the patient has physician diagnosis of ar, % present shortness of breath, and % a medical diagnosis of asthma, % if rhinitis worsens asthma symptoms and % if symptoms of rhinitis interfere with the patient's daily activities. the prescribed treatment varied a lot, the intranasal corticosteroid use rate was: bd: %, pd: % and ud: %. % of doctors in py, . % in br and % of uy never refer the patient to the specialist. . % of pcd of br, % of py and . % of uy are aware of aria guideline. conclusion: although ar is largely attended by pcp, recognition of symptoms and their impact on asthma, as well as the knowledge about aria guide is low and treatment is not always prescribed according to best practice. allergy education programs, with an emphasis on ar and aria guide, need to be directed to pcp in la for the better assistance of ar patients. | assessing knowledge of allergic rhinitis among final year medical and pharmacy students in croatia-curriculum change necessity? the two factor structured questionnaire was formed by the authors regarding the topics mentioned. t-test was used for statistical analysis. the global results were formed as composites of ( ) ar general characteristics, ( ) ar treatment approach, and ( ) the participants' overall knowledge. of the respondents, ( . %) were female and ( . %) were male (p < . ). medical students had a median score of of correct answers on ( ), of on ( ), and of on ( ), whereas pharmacy students had median score of of correct answers on ( ), of on ( ), and of on ( ). there were no significant differences in knowledge between two student groups. the results indicate an inadequate level of knowledge of ar in both groups, especially regarding the therapy approach. since general practitioners and community pharmacists have a major role in providing treatment to patients suffering from ar, it is important to develop advanced knowledge on this topic during medical and pharmacy degree courses. despite a relatively small study population, it would be advisable to introduce change by improving the core curriculum regarding ar with more emphasis on treatment, but additional research on this topic is necessary. tan r ; cvetkovski b ; kritikos v ; price d ; yan k ; smith p ; bosnic-anticevich s woolcock institute of medical research; university of sydney, sydney, australia; observational pragmatic research institute pte ltd, singapore, singapore; royal prince alfred hospital, sydney, australia; clinical medicine, southport, australia; griffith university, sydney, australia background: people with allergic rhinitis symptoms frequently selfselect over-the-counter medications from community pharmacies without seeking advice from a health care professional. this increases the incidence of complications due to delayed diagnosis and suboptimal treatment. this study aims to (i) compare the demographics, clinical characteristics and medication selected, between pharmacy customers who choose to self-select and those who interacted with a pharmacist when purchasing medication for allergic rhinitis symptoms, and (ii) identify the key factors associated with allergic rhinitis patients' medication self-selection behaviour. a cross-sectional observational study was conducted in a convenience sample of community pharmacies from the sydney metropolitan area. data were collected using a researcher administered questionnaire that included: demographics, pattern of allergic rhinitis symptoms, their impact on quality of life, factors triggering allergic rhinitis symptoms and medication(s) selected. logistic regression was used to identify key factors associated with participants' medication self-selection behaviour. results: of the recruited participants, were identified with allergic rhinitis, of which . % were female, . % were aged more than years old, . % had a diagnosis of allergic rhinitis, and . % self-selected medication(s). significant differences were noted in allergic rhinitis symptoms, impact of allergic rhinitis on quality of life and medication(s) selected between participants who chose to self-select and those who interacted with a pharmacist. participants who experienced moderate-severe wheeze were times more likely to self-select allergic rhinitis medication(s), and those who had allergic rhinitis symptoms impacting on their quality of life were . times less likely to self-select allergic rhinitis medication(s). conclusion: there is a high incidence of self-selection of over-thecounter treatments for allergic rhinitis symptoms in community pharmacy, with the majority of allergic rhinitis sufferers failing to seek pharmacist advice. this research identified predictors of medication self-selection behaviour in community pharmacy among people with allergic rhinitis, which can inform the design of tools/strategies and targeted interventions, aimed at improving pharmacist engagement and future practice in optimising allergic rhinitis management. the weir family health clinic, cork, ireland; university college, cork, ireland background: allergic rhinitis is a common condition that is predominantly managed in primary care. the incidence of allergic rhinitis is increasing. it is frequently under diagnosed, misdiagnosed and mistreated. it has a significant impact on patients' health related quality of life and represents a huge cost both to healthcare systems and society. the aim of this study was to implement appropriate guidelines regarding the management of allergic rhinitis in primary care and evaluate the effect on patients' health related quality of life. method: patients with a history of allergic rhinitis were selected from three general practice bases in west cork, ireland and quality of life of patients was assessed initially in year one and followed up one year later in a general practice setting using the standardised rhinoconjunctivitis quality of life questionnaire (rqlq). allergic rhinitis and its impact on asthma (aria) guidelines and appropriate prescribing were implemented during this year and patient education and structured follow up was arranged in the intervention group. this was compared with the control group who received usual care. results: valid responses were received, from the control group and from the intervention group. the study demonstrated a statistically significant difference in quality of life in the intervention group. in the adult intervention group the quality of life score decreased between and representing an improvement in their quality of life, (t = . ; df= ; p < . ). the difference in the score between the control and intervention groups in was also statistically significant.(t = . ; df= ; p < . ). the numbers in the adolescent groups and paediatric group also demonstrated an improvement in quality of life but the sample size was too small to demonstrate a statistically significant difference. conclusion: as the majority of patients rely on their general practitioners for treatment and diagnosis of allergic rhinitis, primary care represents an important area to target in the management of allergic rhinitis to improve patients' quality of life. the implementation of guidelines has been shown to improve patients' quality of life. this study demonstrates this care can be delivered in a primary care setting with an improvement in patients quality of life but substantial investment in education and resources available to primary care physicians is needed. | the predictive value of allergy tests in the diagnosis of peanut allergy in adults rey-garcia h; gunawardana n; wheeler k; scadding g; durham s; skypala i royal brompton hospital, london, united kingdom background: adults presenting with either new-onset symptoms attributed to peanuts or with early-onset peanut allergy, often wish to know whether they should continue to avoid peanuts. clinical history and standard tests may be sufficient to provide an answer, but for many the tests are inconclusive and an oral food challenge is required. this review was undertaken to determine the most accurate tests. conclusion: these data suggests that peanut spt and ara h provide the most accurate prediction of the outcome of oral food challenge in adults. should components not be available, then spt would be the test of choice being more accurate in all aspects than sige. combining spt and sige improves the sensitivity and negative predictive value of spt alone. however, the best combination is spt and ara h , which increases the overall accuracy to %. further studies are needed before it can be determined whether peanut diagnostic tests can replace the oral food challenge in adult patients. method: retrospective chart review was carried out in a community allergy clinic. patients with rap, bloating and altered stools who underwent bt were characterized by age, gender and atopic status. a separate study to assess patients' outcome post-dietary counselling was carried out to determine impact on symptom management. results: thirty-four patients were assessed for fi from january to december . female gender predominated ( / , %) with an average age of years at presentation. results of fi were positive in / ( %), borderline in / ( %) and negative in / ( %). the average age of patients with a positive, borderline and negative tests were , and , respectively. of the patients who tested positive for fi, ( . %) had comorbid inhalant allergies alone, ( . %) had comorbid (unrelated) food allergies alone, ( . %) had inhalant and food (unrelated) allergies, and ( . %) were non-atopic. of the patients who tested negative for fi, ( . %) had comorbid inhalant allergies alone, ( %) had comorbid (unrelated) food allergies alone, ( . %) had inhalant and food (unrelated) allergies, and ( . %) were non-atopic. conclusion: patients investigated for carbohydrate intolerance with rap, bloating and altered stools were predominantly female ( %). fi was confirmed in half. atopic status did not help differentiate between the fi positive or negative groups. results of a fod-map elimination diet are separately reported. conclusion: post-bt, % of patients reported symptom improvement. patients who implemented fructose or fodmap avoidance reported symptom improvement. one patient who tested negative for fi reported symptom improvement with a low fodmap diet. patients suspected as being fructose intolerant may benefit from a fructose restriction or fodmap diet, while awaiting bt confirmation. this form of dietary intervention may assist and shorten the natural history of non-specific chronic gi symptoms. inappropriate referrals to a uk paediatric tertiary allergy clinic demonstrate lack of allergy education and knowledge in primary care marriage de bristol royal hospital for children, bristol, united kingdom background: up to % of children have a food allergy. allergy has become an explanation for all manner of nebulous symptoms and self-diagnosis is common. sham allergy tests are easily available giving incorrect results and resulting in unnecessary, potentially harmful abstracts | parentally-imposed dietary exclusions. there are million allergyrelated google searches per year. the rising prevalence of perceived allergic disease has led to an increase in health service utilisation, including increased referrals to secondary care. clinic waiting lists are long and children with severe food allergies have to wait longer than necessary to be seen method: uk paediatric tertiary allergy clinic referrals were prospectively reviewed over three months. five inappropriate referrals deemed most reflective of poor knowledge in primary care were selected as case summaries to highlight this gap in knowledge. results: : schoolchild referred for investigation of allergic cause for a red, watery eye after splashing juice in her eye whilst cutting a kiwi, despite having a co-existent dendritic ulcer. : schoolchild referred for peanut allergy testing after inhaling a peanut and developing wheeze, with all respiratory symptoms resolving following peanut removal. : young child referred for peanut allergy testing after developing a rash on leg following skin contact with faeces hours after ingestion of peanut butter. : teenage boy referred for investigation of likely peanut allergy despite eating peanut butter and tree nuts almost every day. the family were concerned he was allergic to peanut butter. : toddler referred for milk allergy investigation after developing urticaria lasting hours minutes after drinking a bottle of milk. the child had consumed cow's milk formula since birth, and continued to consume milk daily for a further five months following the episode of urticaria. conclusion: provision of allergy services in the uk is poor and lack of investment in allergy services has led to suboptimal recognition and management of food allergy in primary care. allergy education provision for primary care practitioners is inadequate and fails to empower healthcare professionals to discern between allergy requiring full investigation and management, parentally-diagnosed allergy or symptoms which clearly have no association with allergy. progress to improve primary care training for allergy needs to be optimised to prevent further unnecessary referrals and lengthening clinic waiting lists. background: in case of allergic reactions to food or insect venom, quick and adequate treatment, based on clear instruction for use of emergency medication and calling for help, is necessary. however, daily practice shows that patients do not use the prescribed emergency medication because they are afraid to use the epinephrine auto-injector or they do not know how to use it. information and instruction offered by a reliable app could be a useful aid. we aim to develop an app for adult patients and children older than years with allergy to food or insect venom, which offers a step-wise approach to support patients, their relatives or acquaintances in case of an allergic reaction. method: first, the content of the app, including a step-wise approach to treat the allergic reaction has been determined, based on literature, a survey about needs of patients and on consultations of healthcare professionals. subsequently, a web-based prototype has been developed with an adult profile and children profile. the content and flow of this prototype was tested by the project group, as well as by selected healthcare professionals and patients and improved according to the test results. next, the revised prototype was submitted to representatives of patient and professional organizations for final approval. currently the procedure for ce approval is ongoing. finally, the app will be built and offered to the market for ios and android. results: a web-based prototype of the allergy app is available with two profiles: adult and older children. the app is useful for patients with a doctor's diagnosed allergy to food or insect venom, who received emergency medication and instructions to use prescribed medication in case of an allergic reaction. based on severity of complaints, the user is informed about the steps to treat the allergic reaction. in case of a moderate to severe reaction, the patient is advised to use an epinephrine auto-injector, to call the emergency number and, if prescribed, to use medication such as antihistamines, prednisone or inhaler. besides that, the app provides links to websites of expertise centres and patient organisations and includes instructions how to use the epinephrine auto-injector. conclusion: the allergy app will help patients, their relatives or acquaintances to adequately treat an allergic reaction to food or insect venom. involving patients and professionals in the development of the app will contribute to its acceptability and usability. | electronic documentation of drug allergies in a tertiary hospital in singapore: are we relying too much on it? choo kjl; garuna murthee k; naing cs singapore general hospital, singapore, singapore background: singapore has hospitals shared between public and private healthcare system. its healthcare system, ranked # in the world by who in serves a multi-racial population of . million of which % are above years old. drug allergy alert cards (medik awas) were started in s by singapore medical association to improve patient safety. work on computerisation of drug allergy and medical alerts started in the s, a precursor to today's critical medical information system (cmis). cmis serves as a platform across all public hospitals in singapore. it promotes uniform reporting of drug allergy and notification of adverse drug events to the health science authority. yet, we found that there is a lack of awareness of one's own drug allergies. method: all patients admitted to ward (general medicine ward) at singapore general hospital from july to oct were screen for any previously documented drug allergies. consenting patients who had previously documented drug allergies on cmis were interviewed to document their demographics, education level, current medications, knowledge of their own drug allergies and possession of a drug medication alert card. the answers were then compared with their electronic documentation of drug allergies for accuracy. we interviewed patients aged - with documented drug allergies during the recruitment period. % had secondary school education or higher. the majority ( %) spoke english and ( . %) mandarin. almost half had medical problems and are on long term medications (mean . medications); hypertension and diabetes being the top two common diseases. % of the patients could accurately relay their drug allergies; antibiotics and analgesia being the most labelled. only % had a drug allergy alert card while the rest both rely on the hospital's electronic documentation and/or their caregivers to record and relay their allergies to future prescribers. about % received prescription from multiple healthcare sites in both the public and private healthcare system. we found patients' knowledge of their own drug allergies dismal. the cmis electronic documentation provided a false sense of security. unfortunately, the cmis platform is not available to all private hospitals, increasing the risk of mis-prescription due to the lack of information. unless this is made available nationally, patients with drug allergies should be given some written documentation, either a letter or medik awas. how frequent are they and how are they treated? method: for this cross-sectional study, participants were recruited in the waiting rooms of local doctors in the rural bavarian forest region of southern germany (q / ). a paper questionnaire was handed out to the participants, asking for allergies (pollen, animal hair, bee and wasp venom, drugs, food, house dust mites, contact allergies and other allergies) and how or rather by whom (e.g. general practitioner, specialist, self-treatment) these allergies are treated. results: participants with a mean age of . years (sd= . ) and % women were included in this study. . % indicated to have at least one allergy, including pollen allergy most frequently ( . %). women had significantly more often at least one allergy than men (rr= . ; ci [ . ; . ] ) and for almost all examined allergies a significant higher risk of disease. younger age groups indicated more often to have at least one allergy ( - [. ; . ]) seemed to be affected less. participants indicated most frequently that their allergy was treated by a general practitioner ( . %), except of the - -yearold young adults who indicated "no treatment" most frequently ( . %). conclusion: there is a high self-reported prevalence of allergies in the examined rural bavarian region, that increases with decreasing age and is significantly higher among women. moreover, the data on the absence of an appropriated treatment for allergies is alarming. therefore, medical care needs to be improved in rural regions to lower the burden of allergies. | the prevalence of the burnout syndrome among medical professionals involved in allergology education programmes astafieva n ; kobzev d ; gamova i ; perfilova i ; udovichenko e ; skuchaeva l ; michailova i ≥ ) and rpa (low ≥ - , subscales were calculated and analyzed. results: on average students demonstrated: moderate/high ee scores ( - ); moderate/high dp scores ( - ) and moderate rpa scores ( ); higher rpa scores were common ( . %) among junior students, which is also linked with their levels of engagement, and lower ( %) among senior students. junior specialist (starting specialization) had very low scores in all subscales and expressed a very high motivation in their course and new profession. clinical allergologists with significant experience demonstrated moderate / high ee scores ( - ); low dp ( ) ( ) ( ) ( ) ( ) and rpa (below ) scores. high ee scores associated with pressures of service were compensated by a substantial loyalty to their profession and positive assessment of the outcomes of their work. clinical academics demonstrated the highest level of ee scores ( + among + % of the group) with low to moderate dp and rpa scores, the latter being associated with a loyalty to their profession. it was also possible to identify a correlation between engagement in research activities and lower rpa scores. conclusion: burnout is a complex and multifaceted phenomena, which requires further investigation. however, this research identified that students and junior specialists involved in allergology and clinical immunology programmes with higher levels of engagement and motivation to acquire new specialist knowledge had lower levels of ee, while loyalty to the profession and positive assessment of the outcomes of clinical and research work allows to compensate high levels of ee among experienced practitioners and clinical academics and to reduce burnout effects overall. | appeal (allergy to peanuts impacting emotions and life): the first pan-european study to evaluate the psychosocial burden of living with peanut allergy deutscher allergie-und asthmabund (daab)/german allergy and asthma association, mönchengladbach, germany; food allergy italia, padua, italy; aepnaa asociación española de personas con alergia a alimentos y látex, madrid, spain; afpral association pour la prevention des allergies, paris, france; asthma-allergy denmark, roskilde, denmark; anaphylaxis campaign ireland, cork, ireland; brainsell ltd, london, united kingdom; aimmune therapeutics, london, united kingdom background: peanut allergy, one of the most common and rapidly growing food allergies, is most frequently a lifelong condition. current management is limited to avoidance and symptomatic treatment of allergic reactions when accidental exposures occur. peanut allergy can affect the quality of life (qol) of individuals and also that of parents/caregivers and family members. appeal was designed to assess the impact of peanut allergy on qol in peanut-allergic individuals and their parents/caregivers and families. method: the first, quantitative part of appeal is described here and consisted of a pan-european, cross-sectional online survey of approximately minutes in length. the study was conducted in the uk, republic of ireland, france, spain, germany, italy, the netherlands and denmark. over participants were recruited via patient advocacy groups or directly through a specialist survey recruitment panel. ethics committee approval was obtained and all participants provided their informed consent. eligible participants were: ( ) parents or caregivers of a child/adult with peanut allergy; ( ) parents or caregivers responding as a proxy for a child aged under ; ( ) adults. all allergic subjects had self-reported diagnosed peanut allergy. after several screening questions, eligible participants answered a set of clinical questions about their (or their child's) allergies and other conditions, details on the peanut allergy diagnosis, contact with healthcare professionals, worst allergic reaction to date and use of emergency medicine. depending on whether they were an allergic adult, a parent responding on behalf of the child, or a parent/caregiver recounting their own experience, they then answered specific questions on restrictions on life choices, coping strategies and the impact of peanut allergy on feelings and emotions of families, friends and other people. sociodemographic questions completed the questionnaire. the results of the survey are being summarized using descriptive statistics and the data are being analysed on a pan-european level, by country, and according to the participant's perspective (parent, caregiver or individual). conclusion: this comprehensive, pan-european online survey has been specifically designed to uncover the psychosocial burden and effect on qol of peanut allergy in terms of individuals' lives and those of their families. results: pediatric patients were included in the study. . % (n = ) were male. the median age of onset of symptoms (interquartile range) was months ( - ).the median age (interquartile range) of diagnosis was months ( - ). initial reactions associated with cmpa were observed in . % of patients before months old. patients' diagnoses were atopic dermatitis ( %), urticariaangioedema ( %), anaphylaxis ( . %), proctocolitis ( . %), atopic dermatitis and urticaria ( . %), food protein induced enterocolitis ( . %) and eosinophilic esophagitis ( . % method: the study involved patients, who are two years old (and above), diagnosed with cow milk allergy and are observed for at least six months in our hospital. socio-demographic features of the patients, their symptoms, symptom-start ages, age of diagnosis, clinical findings at diagnosis and during observation were recorded in data collection questionnaires. results: the samples were ( . %) boys. the average symptomstart age was observed to be months , average diagnosis age months ( - ) and average age of final check months . when symptoms at entry were observed, . % of the patients had dermal system, . % gastrointestinal system, respiratory system disorders, and % were detected to have developed anaphylaxis. among the patients diagnosed with cow milk allergy, . % showed food reaction to nutrients with lge agents, . % to mixed types, and % to nutrients with non-lge agents. it was also observed that, in the end of . ± . -month observations, sensitivity to cow milk was observed to continue in ( . %) of our patients. when tolerance improvement rates among the patients were compared, anaphylaxis (p < . ) during entry were observed to be influential in continued allergic state. ( . %) patients were able to consume yoghurt, ( . %) patients could consume dairy products and ( . %) patients could not consume dairy products. conclusion: in the end of our investigation, it was observed that ( . %) of the patients developed cow milk tolerance before the age of . when the factors enabling the continuation of sensitivity in cow milk allergy were investigated, anaphylaxis during entry, entry specific lge and pasteurized milk antigen as well as high skinprick test results were detected to be significant. | initial lower threshold was a risk factor of severe adverse reaction during oral immunotherapy for cow's milk anaphylaxis results: before oit, median age was . years old, median threshold to induce initial reaction was . ml, to induce anaphylaxis was . ml of cm and median milk specific ige was . ku/l. twentyseven subjects ( %) dropped out from the protocol, subjects | investigation of heat and matrix effect on milk proteins' allergenicity and the development of hypoallergenic food products reduce some milk proteins' allergenicity (ß-lactoglobulin) . in this project we aimed to investigate the effect of heat and matrix on different milk protein fractions through maillard reaction and eventually develop hypoallergenic food products that have milk protein with low reaction risk. method: milk cake matrix is prepared in different flour/sugar (f/s) ratio ( f/ s, f/ s, . f/ s) and baked minutes at °c. proteins that cake contains are separated using sds page and stained with coomassie blue to check total protein. in parallel specific proteins are detected by western blotting using pooled sera from patients with milk specific ige> ku/l for incubation results: in normal milk cake recipe ( f/ s) ß-lactoglobulin bands are disappeared but casein bands did not differ in size. in order to investigate the matrix effect f/s ratio is changed and it is found that when this ratio decreases, with the affect of heat and maillard reaction, milk casein bands' intensities also decrease in sds gel coomassie staining. in western blot experiments it is also shown that milk specific ige bound weakly to casein bands in low f/s ratio cake ( . f/ s) whereas in cakes that have high f/s ( f/ s) ratio it bound significantly higher. and ß-lactoglobulin proteins' structure and lower the milk specific ige bindings to milk proteins in low f/s ratio cake through maillard reaction. | extensively hydrolyzed formulas for the management of cow's milk protein allergy in infants: is extensive hydrolysis sufficient to guarantee success? method: to better understand the range of ehfs, we aimed to analyse samples of commercially available ehfs from countries and various manufacturers, with a focus on suitability for cmpa management. samples were de-identified and coded for the analyses. molecular weight (mw) distribution of hydrolysates and residual proteins and peptide profiling were assessed with sds-page gel and size exclusion-high-performance liquid chromatography (se-hplc), as they reflect both the design of the formula and the quality management applied during production. osmolarity, nitrogen fractions, lactose content, total and free amino acids, β-lactoglobulin, and casein content were quantified and β-lactoglobulin residual allergenicity was assessed. results: peptide mw distribution displayed significant variation, with the percentage of peptides with mw > . kda varying from % to %. mw distribution was shown to be positively correlated with β-lactoglobulin specific in vitro degranulation. twenty % of samples had non-measurable β-lactoglobulin content (smaller than or at the limit of quantification (loq): . mg/kg); however, % of samples had β-lactoglobulin content greater than the loq, with high variability from . to mg/kg. surprisingly, even in samples featuring a high degree of hydrolysis, significant levels of residual β-lactoglobulin were quantified. conclusion: lack of consensus over the definition of 'extensively hydrolysed' is reflected in the wide range of degree of hydrolysis in commercially available ehfs, and can result in products that are mislabelled as 'extensively hydrolysed' and may be high-risk or even unsuitable for the management of cmpa. results of these analyses also highlight that degree of hydrolysis alone is not sensitive enough to characterise ehfs, and that whilst a high degree of hydrolysis is desirable, further quality control measures are essential to ensure clinically safe and suitable products. actionable guidelines to better define hypoallergenic formulas based on extensively hydrolysed milk proteins are warranted. background: assessing the effect of baked milk products on accelerating unheated milk tolerance in patients with cow's milk allergy. method: a randomized clinical trial was done on patients ( months- years old) divided randomly to case and control groups matched for age and sex. baked milk in form of muffin for months followed by baked cheese in form of pizza for next months was given to the patients in case group. skin prick test and serum ige (sige) levels (immunocap) of milk, casein and betalactoglobulin were measured before and after the study. the ones having milk sige less than ku/l and being asymptomatic during the study underwent oral food challenge test for evaluating unheated milk tolerance. chualalongkorn university, bangkok, thailand; kk women's and children's hospital, singapore, singapore; university of the philippines, philippine general hospital, manila, philippines background: problems in recognising cow's milk allergy (cma) and lactose intolerance (li) in infancy may lead to a delayed or incorrect diagnosis, as well as inappropriate dietary interventions. method: between january and november , a survey was conducted online in china, india, singapore, thailand, mexico, kuwait, united kingdom, australia, and paper-based in the philippines. the survey consisted of multiple-choice questions on cma and li in infants aged under months, two case scenarios (non-ige cma and anaphylaxis) and questions on educational needs (likert scale [ ] [ ] [ ] [ ] [ ] . data on the type of medical practitioner and clinical setting were collected. responses were summarised as percentages and categorised by country. results: responses were received from general practitioners ( . %), paediatricians ( . %), paediatric allergists ( . %), paediatric gastroenterologists ( . %) and other specialities ( . %). there were significant misconceptions about the clinical importance of primary li in infancy. while primary li rarely manifests before years of age, . % of participants felt it was a significant clinical problem in the first year of life. regarding secondary li, % of respondents recommended lactose restriction for viral gastroenteritis, and % for cow's milk protein-induced enteropathy. while the management of ige cma was relatively well understood, there were greater knowledge gaps for non-ige cma. % of practitioners appropriately identified extensively hydrolysed formula (ehf) as first-line treatment of cma in formula-fed infants. however, the distinction between lactose-free and lactose-containing ehf appeared to be an area of uncertainty. in india, . % used soy-based formulas as first- results: patch tests were positive in ( . %) and negative in others. positivity to milk was seen in patients ( . %), to soy in ( . %), to egg white in / ( . %), to wheat in / ( %), to potatoes / ( . %), to corn (maize) in / ( . %), to rice in / , and to peanut in / ( . %). patients were requested to withdraw the suspected food(s) from their diets during a months period. preliminary follow-up data show the improvement of one or more symptom in / patients (gastroesophageal reflux in , appetite in , stool consistency in , respiratory symptoms in , pain in , eczema in ). conclusion: patch tests are informative, easy to use tools in order to identify potential causes of common lasting symptoms in children with negative or weak rast results and introduce beneficial changes in the daily diet. longer follow-up is necessary in order to refine and assess the benefit of such strategy. background: currently in the us, in children suffer from food allergies. at present, there is no cure and strict avoidance of the relevant foods is the only way to prevent allergic reactions. elimination diets put infants and children at risk for nutritional deficiencies and impaired growth. we examined the role of the registered dietitian (rd) in advising patients and families of food allergic children. method: a retrospective review of clinical notes was performed for the first consecutive children who required a dietetic consultation in a dedicated food allergy clinic. we examined common questions from parents that were addressed by the dietician during the consultation. results: patients were aged months - years (median: months) and were diagnosed with the following food allergies: cow's milk: . %, egg: %, tree nut: %, peanut: %, wheat: %, soy: %, fruit/vegetable: %, legume: %, fish: %, sesame: %. the most common questions for the dietitian included: ways to meet nutritional needs following a prescribed allergen-restricted diet ( %), meeting vitamin d and calcium requirements on a milk protein-free diet ( %), suitable oral supplements and recommended serving sizes ( %), appropriate order of solid foods introduction in food protein-induced enterocolitis syndrome (fpies) ( %), cautionary food ingredient statements ( %), baked milk protein introduction ( %), cross-reactivity risk of milk protein with soy ( %) and crossreactivity of nuts in retail bakeries ( %). conclusion: parents of children with food allergies have multiple questions with regards to nutrition. dietetic input in the food allergy clinic addresses important issues for children and families including successful avoidance of allergen-containing foods while ensuring optimal nutrition, decreased exposure to high-risk situations and avoidance of allergen cross-contamination. | multicenter prospective study of a stepwise single dose oral food challenge of egg background: oral food challenges (ofcs) are necessary for allergy management. we previously reported that a low-dose ofc can avoid complete elimination, even if patients react to higher doses of causative foods. nevertheless, this approach has only been validated in a retrospective single-center trial. we have previously reported that the median time for initial symptom onset is minutes for egg ofc using a single exposure. therefore, this study aimed to confirm the safety and effectiveness of a stepwise single-dose ofc in a multicenter, prospective study. who showed a positive reaction to low-dose ofc, only patient ( %) showed a severe reaction: barking cough immediately improved with adrenaline inhalation. among patients with a positive reaction to medium-dose ofc, none had a severe reaction. the median times to symptom onset were and minutes following low-dose and medium-dose ofc, respectively. patients in the three groups, divided according to threshold doses, differed significantly in sige levels against egg white and ovomucoid. conclusion: this multicenter prospective study confirmed that stepwise single-dose ofc to egg will help to clarify the severity of egg allergy, and will contribute to improved food allergy manage- method: the study design was a retrospective cohort study extracting data from the electronic chart of children older than years who visited our out-patient clinic for egg or milk allergy and who underwent an oral food challenge test (ofc) twice within months between november and december . the patients were divided into five groups according to their treatment schedule, which consisted of those who: a) started from / of the first ofc reaction threshold and maintained / till the end of oit; b) started from / of the threshold and maintained / ; c) started from / of the threshold and maintained / , d); conventional slow oit (started from just below the first ofc reaction and increased . - . times every few weeks); or e) continued elimination. we determined the presence or absence of an increase in threshold reacted to the allergen, any adverse events during oit, and food-specific ige reduction. results: the number of participants was and their median age was years. the number of patients in groups a, b, c, d, and e was , , , , and , respectively. the percentage of patients in groups a, b and c showing an increase in reaction threshold to the allergen was higher than that in group e (p < . ), and that in group b was higher than that in group d (p < . ). the number (percentage) for group a, b, c, d, and e was ( . %), ( . %), ( . %), ( . %), and ( . %), respectively. there was a significant difference in the frequency of adverse events during oit between group a-c and d, which was as follows: ( . %), ( . %), ( . %), and ( . %), for the respective groups (p < . ). there was no significant difference in the percentage of patients showing a decrease in food-specific ige in each group. conclusion: the regimen starting from / of the ofc reaction threshold and maintaining the dose at / was safer and more effective for increasing the threshold reacted to the allergen than the 'conventional slow oit' regimen. elimination continuation was not effective for increasing the threshold reacted to the allergen. legumes allergy was presented in different clinical features; urticaria and angioedema in ( %) patients, anaphylaxis in ( . %) patients, atopic dermatitis in ( . %) patients, eosinophilic esophagitis in ( . %) patients and as food-related enterocolitis in ( . %) patient. thirteen ( . %) of the patients had asthma, ( . %) had allergic rhinitis. fourteen ( . %) of the patients with single legume allergy showed improvement. the patients who developed tolerance, of these ( . %) had peanut allergy, ( . %) had lentil allergy and ( . %) had chickpea allergy. two of patients with multiple legumes allergies, it developed tolerance to all the legumes they are allergic. conclusion: peanut and lentils were the most frequent legumes that displayed allergic reactions in our study. in these patients the rate of allergy to non-legumes food is high. in patients who were allergic to single legumes, the symptoms were ameliorated in . %. conclusion: cashew nut is a potent allergen and can cause quite severe reactions. avoidance of pistachio nut and other related allergens should be advised to patients after allergologic investigation. in the majority of the patients, presence of atopic dermatitis with food allergy is noteworthy. therefore, it would be useful to investigate these patients for cashew and other tree nut allergy before they present with a serious clinical reaction. and jellyfish sting. serum allergen-specific ige test was negative; skin prick test was positive for natto and pork. we performed an oral food challenge with natto, pork, crustaceans, and wheat, and she developed a general itchy rash after hours of eating natto. h blocker was administered and she recovered soon. however, the general itchy rash relapsed after hours. hence, we intramuscularly injected epinephrine, h -blocker, and steroids; then, her symptoms did not relapse. based on these findings, we inferred that anaphylaxis caused by natto could be associated with a jellyfish sting. discussion: although association between japanese fermented soybeans (natto) allergy and jellyfish sting has been previously reported, its anaphylaxis is a rare event. in this case, we suggest that anaphylaxis was caused by natto allergy, which was perhaps related to jellyfish sting. hence, further investigation is essential to elucidate the association between fermented soybeans allergy and jellyfish sting. introduction: non-celiac gluten sensitivity (ncgs) is a syndrome characterized by intestinal and extra intestinal symptoms related to the ingestion of gluten-containing food, in subjects that are not affected by either celiac disease (cd) or wheat allergy (wa).once the gluten-containing foodstuff is removed from the diet, the patients will have relief of their symptoms. case: a -year-old girl was referred by his general practitioner with history of occasional constipation and abdominal pain (especially after main meals and defecation), short stature and low weight. the growth indices were proper for her age till she was . then after there was a stunting. she had short stature and low weight. despite different types of supplementation, there was no improvement in growth indices, so she was referred to a pediatric endocrinologist for gh therapy. primary investigations and anti-ttg, iga, anti-ema all were normal. after a consultation with a pediatric gastroenterologist, a genetic study of hladq and were done because of the highly suspicion of celiac disease. the results were also negative. at last she was referred to immunology-allergy clinic for evaluation of probable food allergy. ige level was checked and a prick test was performed which they were not indicative of any suggestive food allergy. because of the history of the abdominal pain and constipation which was more prominent after meals, negative results of genetic study, spt to wheat, and serologic markers, a gluten free diet was suggested for her with the suspicious of non celiac gluten sensitivity. a significant improvement in her symptoms was noticed within weeks of starting gluten free diet. she has kg of weight gain and height improved from cm to cm in months. she continued to improve on a gfd and when seen in the follow-up clinic months later reported complete resolution of symptoms and another cm and kg gain in her height and weight. conclusion: non-celiac gluten sensitivity syndrome is a diagnosis made by excluding celiac disease and wheat allergy. it should be taken into consideration especially in patients who have the suspicious symptoms of celiac without supporting lab data, and also negative spt to wheat. the young man in question along with his parents were keen to proceed, so with some hesitation we proceeded to a hazelnut oral provocation challenge, having very carefully explained the risks of undertaking such a challenge. he successfully completed the challenge and experienced no allergic symptoms and is now able to have hazelnuts in his everyday diet. discussion: this young man wanted to confirm if indeed he was allergic to hazelnuts. not being hazelnut allergic would mean that he would be no longer allergic to any nut and would not have to take precautions prior eating products. positive results to both cor a and cor a , hazelnut storage proteins are associated with the patient possibly experiencing systemic reactions, at a higher risk of experiencing anaphylaxis it they were to ingest hazelnut. these facts in conjunction with his specific ige to hazelnut would have prevented us from proceeding to challenge was it not for this young man's persistence that he wanted to proceed to challenge despite the risks. conclusion: appearances are deceptive, as this case demonstrates; allergen-specific ige and component testing can only predict the probability of an allergic reaction, the final test in the diagnostic process is the oral provocation challenge. the patient and his family were happy for me to share the above with other health care professionals. method: we present the case of a female of years old diagnosed of acu with poor control of the symptoms at maximum doses of antihistamines. we decided to associate omalizumab treatment. the patient had a good control of the symptoms with omalizumab at dose of mg/ weeks, but in the th month she presented an erythematous, raised and pruritic lesion in the area of injection together with localized abdominal edema at hours of the administration, with two weeks of evolution without symptomatic treatment. we decided to discontinue omalizumab alter a second episode with half doses. results: we performed a skin biopsy of the lesion and epicutaneous tests with the drug. immediate hypersensitivity tests were not taking due to the impossibility of stopping antihistamines. skin biopsy showed a perivascular lymphocytic inflammation of the superficial and deep dermis with frequent presence of perivascular and interstitial eosinophils, suggestive of a hypersensitivity reaction. results: nine months before presentation at our clinic, the patient had been hospitalized and treated with imipenem and tmp/smx for pulmonary nocardiosis. once discharged, she had been prescribed oral tmp/smx alone, according to antimicrobial susceptibility. at our first evaluation, the patient presented with fever, macular erythematous non-pruritic (vasculitic-like) skin lesions on the upper limbs, polyarthralgia and bilateral ankle arthritis. tmp/smx was transiently stopped. after four days, there was a dramatic improvement, with resolution of all signs and symptoms. she was tentatively diagnosed with a viral infection and thus tmp/smx was started again. however, after three days, the symptoms (fever, arthritis and skin lesions) recurred. laboratory investigations showed increased levels of inflammatory markers. complete blood count with differential, serum creatinine, urinary sediment, liver enzymes, rheumatoid factor, antinuclear antibody, c , c , immune complexes, serology for rickettsia, borrelia and coxiella were all negative. hence, tmp/smx was stopped again and cutaneous lesions, fever and arthritis resolved spontaneously in five days. conclusion: given the clinical course and the resolution after the withdrawal of tmp/smx, we diagnosed a sslr due to sulfonamides. to the best of our knowledge, this is the first case of sslr occurring after a nine-month therapy with tmp/smx and allergists/immunologists should be aware of the possibility of such a reaction even after months. case report: * we received written informed consent for publication of these clinical details and/or clinical images included in my abstract was obtained from the patient. drug rash with eosinophilia and systemic symptoms (dress) syndrome is a severe adverse cutaneous reaction that usually appears - weeks after treatment with the causative drug. this syndrome is characterized by severe dermal rash, fever, eosinophilia, and internal organ involvement, and clinically, diffuse maculopapular eruption, exfoliative dermatitis, and facial edema are often observed. we performed blood tests and laryngeal fiberscopy for the diagnosis of the patient. intradermal test with delayed reading and patch test were performed months after the end of treatment. a -year-old man had begun treatment with carbamazepine for epilepsy. after weeks of treatment, he observed skin rash with pruritus on both lower extremities, and after weeks, his skin lesions had begun to spread over his whole body, and he complained of several new symptoms, including hoarseness, dyspnea at rest, and dysphagia. an examination revealed maculopapular rash, facial edema, and bilateral cervical lymphadenopathy. laryngeal fiberscopy revealed both arytenoid and epiglottic swelling. laboratory studies revealed eosinophil counts of /μl and increase in alanine aminotransferase level to u/l. a diagnosis of dress syndrome was definite according to the regiscar group criteria. carbamazepine, the suspected culprit drug, was withdrawn, and systemic corticosteroid was initiated. the patient experienced rapid improvements in hoarseness, dyspnea, and dysphagia. after days of treatment, laryngeal fiberscopy revealed complete resolution of both arytenoid and epiglottic swelling. to the best of our knowledge, our case is the first reported case of dress syndrome to manifest with laryngeal edema. case report: bortezomib (velcade Ⓡ ), a targeted therapy works by blocking the action of proteasomes in side cells, is commonly used to treat newly diagnosed as well as relapsed/refractory myeloma. bortezomib has been reported to have gastrointestinal symptoms, peripheral neuropathy, neuropathic pain and thrombocytopenia as its most common side-effects. although several cases of skin lesion caused by bortezomib have been reported, severe cutaneous adverse reaction (scar) such as stevens-johnson syndrome (sjs) is very rare. we here report a case of bortezomib induced sjs. a -year-old female patient, who was diagnosed with multiple myeloma, received bortezomib and melphalan /dexamethasone therapy. after the th dose of bortezomib, she presented with fever and maculopapular skin rashes spreading from face to the trunk. erosive lesions in the oral mucosa and corneal ulceration with conjuntival injection were observed. she was diagnosed as sjs. the symptoms of sjs improved after bortezomib was discontinued and systemic steroids and intravenous immunoglobulin were administered. drug patch test was performed, the result was positive in bortezomib. this is the first case report of bortezomib induced sjs in this country, which was diagnosed by a patch test. although the scar by bortezomib is generally considered very rare, we suggest that clinicians be aware of potential adverse reactions, including sjs. case report: we report the case of a healthy -year-old woman with history of red erythematous macules in both hands, one hour after taking a fluconazole ( mg) tab for a vaginal candidiasis. it faded spontaneously. she didn't recall if she had ever taken that medicine, but denied known drug allergies. although fde is primarily a clinical diagnosis, we conducted an oral challenge test with fluconazole ( mg). two hours after intake of the drug the patient started complaints of pain and erythema in both hands and the challenge was stopped. two days after the challenge, she developed red painful erythematous macules on the same sites of the first episode. due to the specificity of the challenge, local patch testing was not performed. introduction: the classic form of a fixed drug eruption is one or more anular or oval erythematous patches as a result of systemic exposure to a drug. these skin lesions normally resolve with hyperpigmentation and may recur in the same location with re-exposure to the drug. other types of fixed drug eruptions have been described, being fixed drug urticaria a rare form of presentation. ( , ) case report: in the last years, a year old woman has developed more than episodes of a wheal in the right supraciliary region minutes after taking mg of oral ibuprofen. the symptoms resolved in less than hours without treatment and without leaving residual lesion. after the last episode, she refers good tolerance to g of oral paracetamol. she denies local traumas. she also refers mild spring rhinoconjunctivitis well controlled with antihistamine, and sneezing with house dust. a -year-old-m patient had psoriasis vulgaris for years, and had been using methotrexate at intervals of years. despite the addition of phototherapy, he underwent a new treatment with biological agent (antitumor-necrosis-factor; anti-tnf), since the disease control was insufficient. before anti-tnf, preventive treatment against latent tuberculosis (tb) activation was indicated with positivity in tuberculin skin test ( mm). he was given inh mg/day, and at the th day of treatment, desquamation, erythema, and subsequent exfoliation developed in his hands and foots dorsum. inh was withdrawn. in order to distinguish the lesions from psoriasis attack, skin biopsy was performed and reported as erythema multiforme-like dermatitis with no relation to psoriasis. the lesions were completely improved at weeks of topical steroids, and inh was re-initiated at the same dose. a week after the initiation of the drug, skin lesions similar to previous reoccurred with more severity and progression from distal to proximal extremities. cell counts, renal and hepatic function tests, and hepatitis markers in blood were in normal limits. skin lesions were retracted after weeks of topical steroids, and withdrawal of inh. there was positivity in skin patch test with inh at hours. finally, for tb prevention an alternative drug rifampicin ( mg/kg/day) was given, and the patient successfully completed with no adverse event. his psoriasis lesions were improved with anti-tnf which was started after month of tb prevention with rifampicin. in these days which the use of biologic agents is increasingly widespread, inh use will be more prevalent than the past. even tough, it is effective and safe in most of the patients, its adverse event dermatitis may be a reason to withdraw in patients with dermatological diseases. in this case, diagnostic drug allergy evaluation should be performed to optimize the second-line treatment of tb infection, in addition to early withdrawal of the culprit drugs. background: around % of cancer patients will receive radiotherapy (ionizing radiations) as a treatment, either as a single therapy or as an adjuvant to chemotherapy and surgery. several side effects have been described due to radiotherapy, of which we can mention erythema multiforme and stevens johnson syndrome, but in lower prevalence. erythema multiforme can be described as an acute skin condition and may be present within a wide spectrum of severity. erythema multiforme minor represents a localized eruption of the skin with minimal or no mucosal involvement. the papules evolve into pathognomonic target or iris lesions that appear within a -hour period and begin on the extremities (see the following image). lesions remain in a fixed location for at least days and then begin to heal. it is considered to be a type iv hypersensitivity reaction associated with certain infections, medications, and other various triggers precipitating factors and complex interactions may trigger the appearance of signs and symptoms. these include especially recurrent herpes simplex virus (hsv), epstein-barr virus (ebv), histoplasmosis, alcohol, systemic diseases and immunological factors. method: -year-old male diagnosed with prostate adenocarcinoma who underwent transurethral resection and was taking trinomia (ramipril, atorvastatin, acetyl-salicylic acid) after his th rte external radiotherapy session, he presented erythematous maculo-papular lesions in the suprapubic area with some vesicles. therefore, withdrawal of treatment was decided and the performance of a skin biopsy. days later, regarding the improvement of the lesions, rte was continued, presenting incipient exacerbations of the lesions but it allowed us to end the cycle of treatment. results: skin biopsy results (anatomical pathology): basal keratinocytes, which blur the dermoepidermal interface, with lymphocyte exocytosis at this level, associated with isolated images of spongiosis. the dermis shows a superficial perivascular lymphocytic inflammatory infiltrate of moderate intensity. compatible with erythema multiforme. conclusion: radiotherapy is a technique of increasing use, so it is important to recognize the associated cutaneous lesions that appear less frequently and are sometimes underdiagnosed. diagnosis is both clinic and pathological and is usually late in most cases so it is vital to take into account this skin disease complication in order to be properly managed. including chinese herbal medicine is usually considered to be without any allergic and adverse reaction. method: visits were made to pharmacies in hong kong and luoyang, china and a martial art monastery/temple in dengfeng, china. some cam were found to have ingredients with potential allergic and adverse reaction. results: three cam, one from hong kong ( ), one from shaolin martial art monastery/temple in dengfeng ( ) and one from luoyang ( ), china were found to contain chinese herbal medicine with potential allergic and adverse reaction. ( ) cordyceps ling-zhi complex ingredients: cordyceps sinensis "caterpillar fungus", tremella fuciformis "snow fungus", ganoderma lucidum (ling-zhi) "reishi mushroom" and others years old female patient who has ulcers in oral mucosa and purple, itchy lesions on her right hand palmar area, little finger, index finger, on her left hand palmar area, pollex finger. in her history, she has relapsing vaginal yeast and she hasn't any hypersensitivity reaction with fluconazole before month ago she started to take fluconazole because of vaginal candidiasis. after using fluconazole she started to itch from described areas and dark redpurple eruptions appeared. she was prescribed oral methylprednisolone and topical pomade which included corticosteroid for four days but she didn't aware of fluconazole related drug reaction. lastly four days ago she took fluconazole and metronidazole for severe vaginal yeast. hours later pruritus, same eruption appear on the same area, lip and tongue angioedema than she had dyspnea, dizziness, hypotension, arrhythmia and consciousness. she had admitted to the emergency department and performed adrenalin. after a day bullae and ulcers came into existence in her oral mucosa. in her blood analysis there was mild increase in white blood cell count ( . /mm ), eosinophil count was normal ( /mm ), biochemistry parameters were in normal limits, crp and sedimentation rate were in normal limits, total ige was iu/l. introduction: tuberculosis is a disease that most commonly affects the lungs, which is transmitted by the respiratory tract and drugs are the most important factor in the treatment. non-resistant tuberculosis infection is usually treated with hrze. in rare cases, a hypersensitivity reaction may develop against one or more of the drugs during treatment. case: a -year-old female patient was diagnosed with culturepositive pulmonary tuberculosis and hrez treatment was started by the related department. seven days later she referred to the policlinic with edema and itchy erythematous lesions which are common in her extremities, which developed after hours of taking her medication. liver and kidney function tests and eosinophil count were normal. drug eruption was considered with current physical examination findings. the treatment was interrupted, short time systemic corticosteroids and antihistamine treatment started. desensitization planned. there was no feature in the prick and patch tests with drugs. desensitization was performed with isoniazid, no reaction was observed during the procedure. six hours after the procedure, the patient applied to the emergency department with painful edema and pruritic erythematous lesions in the extremities. desensitization procedures with rifampicin, ethambutol, pyrazinamide were performed without any problems after the lesions were regressed. isoniazid was withdrawn from the treatment protocol. outcome: we would like to present on this case that drug eruption may develop in the form of maculopapular rash after desensitization. this study aims to compare ethmoid mucosa and nasal polyp regarding density of tissue eosinophil and its sensitivity, specificity, and correlation with clinical characteristics for diagnosing ecrs. method: patients with crs with polyps scheduled for endoscopic sinus surgery were enrolled. specimens were collected from polyp apex, polyp pedicle and ethmoid mucosa. tissue eosinophil from these three sites in the same patient were compared. using eosinophilic mucin as a reference, sensitivity, and specificity of each site for diagnosing ecrs was assessed. correlations between tissue eosinophilia (defined as greater than / hpf) and clinical characteristics of ecrs including asthma, serum eosinophilia, and eosinophilic mucin were analyzed using each site of specimens. results: thirty patients with crs with polyps were enrolled. polyp apex, polyp pedicle and ethmoid mucosa gave similar results regarding tissue eosinophilia in patients ( . %). eleven ( . %) patients were ecrs (having tissue eosinophilia at all sites) and five ( . %) were non ecrs (no tissue eosinophilia at any sites). median tissue eosinophil was significantly greater in polyp apex ( , and polyp pedicle ( , iqr: - ) than ethmoid mucosa ( , iqr: - ), p = . . sensitivity of polyp apex, polyp pedicle and ethmoid mucosa for diagnosing ecrs were %, % and % respectively. specificity were %, % and % respectively. correlations between tissue eosinophilia and asthma were significant when assessing ethmoid mucosa (p = . ), and polyp pedicle (p = . ) but not polyp apex (p = . ). correlations with serum eosinophilia, and eosinophilic mucin were not significant (p > . ) when assessing any specimens. gov/pubmed/) was performed using the following key words: "obstructive sleep apnea syndrome"; "allergy rhinitis"; "hypoxia"; "intermittent hypoxia"; "fluctuating hypoxia"; "cyclic hypoxia"; and "hif- α" results: osas may affect the prognosis of ar patients based on the following evidence: ) ar is thought to be a cause of osas. ) exposure to hypoxia could mediate immune activation in ar and affect the response to treatment. ) hif- α expression may be a risk factor for ar. ) intermittent hypoxia can induce robust expression of hif- α. conclusion: first, improvement of ventilation during sleep represents an efficient strategy for treating ar. therefore, continuous positive airway pressure or nasal surgery to resolve a nasal obstruction could be added to ar treatment. finally, medications that target hif- α, such as digoxin, can be tested as adjuvant therapy. method: forty patients diagnosed with allergic rhinitis and olfactory dysfunction were recruited in current study in the group and . patients of group were administered with no treatment and patients administered with the traditional chinese acupuncture therapy were incorporated into the group . before the treatment, all of them underwent t&t olfactory testing, nasal sinus computer tomography scanning and visual analog scale (vas; - ), and repeated the assessment after four-week treatment. results: improved total t&t olfactory testing scoring averages and vas scoring averages was observed in eleven patients treated with traditional chinese acupuncture compared with four patients in the observation group. no side effect was found. no significant differences in olfaction recovery were found according to age, gender, or duration of disease between the two groups. the observation group underwent nasal endoscopic sinus surgery and the control group underwent external approach surgery, and the therapeutic effect of the two groups were investigated. results: the total effective rate was % in observation group and % in control group, the total effective rate of observation group is significantly higher than control group (p < . ). the recurrence rate was % in observation group and % in control group, the recurrence rate of observation group is significantly lower than control group (p < . ). complication occurrence rate of observation group was % which is significantly lower than control group % (p < . ). the therapeutic effects of endoscopic sinus surgery on chronic sinusitis in geriatric patients are better than conventional external approach surgery which is worth clinical application. results: (descriptive). the equick app is user-friendly even for vkc patients with sub-optimal reading ability. home use between clinic appointments allows responsive temporal data gathering of qol, symptoms, medication scores and impact of medical interventions. equick may be used in future as a research tool in gathering outcome data following interventions for vkc. ectoine, a substance deriving from halophilic micro-organisms, is a strong water structure forming solute exerting cell protective antiinflammatory and antiallergic properties. method: purpose of our study was to assess the efficacy of the preventive administration of % ectoine eye-drops ( times a day for months) to shorten the duration of vkc relapses (which begin, in our country, very early in spring and usually end in october), or to mitigate the attacks, which are only controlled by topical corticosteroids or cyclosporine resulting in an important burden of side-effects. in this retrospective study, we included children of both sexes ( males and females), under the age of years (mean age . years), affected by vkc from more than years/seasons and treated for more than months during a year, with cyclosporine eye-drops. these patients underwent, from february to september , the additional-to-the-usual protocol treatment with % ectoine eyedrops. results: % of the included subjects astonishingly had no relapse of vkc, % needed topical cs or cyc treatment but it was started months later compared to previous years, % needed the topical drugs months later and % had a similar to previous years course (no ectoine efficacy). the treatment was well tolerated and only child had to stop it because of local allergy to the eye-drops. the preventive administration of % ectoine eyedrops was able to stabilize and to delay vkc attacks in more than % of the selected patients showing the importance of anti-inflammatory and anti-allergic properties of this product. following international criteria we considered normal levels of vitamin d the levels between nmol/l ( ng/ml) and nmol/l ( ng/ml), a potential deficiency between nmol/l and nmol/l and a severe deficiency less than nmol/l. results: . % ( children) of akc group patients presented vitamin d low levels, among them children showed a potential deficiency and a severe deficiency. . % ( subjects) of vkc patients suffered a deficiency in vitamin d which was mild in and severe in patients. . % ( children) of sac group showed a deficiency in vitamin d which was potential in and severe in subjects. conclusion: our study shows that in different forms of allergic conjunctivitis many children are suffering a vit. d deficiency and it can be supposed that a correlation between the severity of the allergic form and the level of vit. d deficiency exists. we recommend allergists and ophthalmologists to check vit. d levels in children suffering from allergic conjunctivitis because its deficiency is very common and many are unaware of it; in case of a vit. d insufficiency it is fundamental to give a vit. d suitable-to-the-case supplementation. method: children ( males and females, mean age . ± months) affected by vkc and allergic rhinitis from more than years were treated with mometasone furoate nasal spray spray bid × weeks in a month, for consecutive months as a co-seasonal treatment at the beginning of eye allergic symptoms. other systemic or topical treatments did not vary compared to the previous years. results: a quick questionnaire administered to children and their care-givers showed that nasal symptoms regressed after a mean period of . days from their beginning but, impressively, in more than % of them, these patients did not show a vkc typical relapse along the months of mometasone treatment, moreover the following summer period was milder in subjective ocular symptoms in more than % of the patients. our experience pointed out that incs adjunctive treatment was positively associated with a regression of eye and nose symptoms in children suffering from vkc, confirming previous literature data which concern milder forms (seasonal allergic conjunctivitis or allergic rhino-conjunctivitis) compared to the severe forms (like vkc) we analyzed in our work. one of the involved mechanisms of action can be the alleged effect on the reduction of substance p in tears; it is supposed to reflect the neuropeptides levels in ocular tissues. | patient response to mp-azeflu in an allergen exposure chamber onset of action (ooa) timing may impact treatment adherence. mp-azeflu, intranasal azelastine hydrochloride (aze) and fluticasone propionate (fp) in a single device, has proven to have greater efficacy and faster ooa than a combination of oral loratadine and intranasal fp (lora/infp), but the clinical relevance for patients is unclear. this single-center (ontario, canada), randomized, double-blind, double-dummy, three-period crossover trial examined by which extent mp-azeflu provides clinically relevant symptom improvements according to different efficacy parameters. method: ar symptoms were induced in asymptomatic, ragweedsensitive patients via ragweed pollen challenge in an environmental exposure chamber. patients received a single dose of mp-azeflu, lora/infp, or placebo and were monitored for hours. symptoms were assessed using total nasal symptom score (tnss) and total ocular symptom score. responder analyses included the number of patients to achieve relevant response (rr) to therapy ( % or % reduction in tnss), time to rr (ie, first time point at which rr was reached), and minimal clinically important difference (mcid) in ooa. background: nasal allergen provocation test (napt) is a standardized diagnostic tool indicated in the diagnosis of allergic rhinitis, to design and monitoring allergen immunotherapy, and to study the pathophysiology of airway allergy. unfortunately, until now very few studies have evaluated its reproducibility and safety. in this study we wanted to analyse the safety and reproducibility of napt in a large group of rhinitis patients and healthy controls. unit until december . a bilateral saline challenge followed by a bilateral napt were performed in symptoms-free individuals. the response was assessed by nasal-ocular symptoms and acoustic rhinometry. all subjects signed a written informed consent. the safety of napt was checked by the occurrence of extra-nasal/ ocular reactions (enor), severe adverse events (sae), and use of rescue medication (rm). enor was assessed by clinical symptoms, physical examination, cardiopulmonary auscultation, spirometry, and oxygen saturation. the reproducibility of napt was tested by comparison of the results in or more sessions with≥ -month interval. background: nasal hyperreactivity (nhr) is self-reported by a majority of patients with allergic rhinitis (ar) and is likely mediated by neural-immune interactions. the combination of fluticasone propionate (fp) and azelastine (aze) hydrochloride administered in a single spray (mp-azeflu) has been shown to be superior to fp or aze alone in patients with seasonal ar (sar). we hypothesize mp-aze-flu may reduce neuro-immune mediators in ar with nhr. in a post hoc analysis of three pivotal studies of mp-azeflu, we analyzed the efficacy of mp-azeflu, fp, and aze in patients with ar with and without nonallergic triggers. method: in three randomized, double-blind, controlled trials, patients with sar were randomized : : : to mp-azeflu, fp, aze, or placebo (pbo). patients self-reported sensitivity to nonallergic triggers. change from baseline in total nasal symptom score (tnss) and treatment differences between active agents and pbo were calculated. results: across patients in three studies, mean age was . years and mean age at ar symptom onset was . years. overall, % reported ≥ nonallergic trigger, which included sudden temperature/humidity change ( %), tobacco smoke ( %), perfumes/fragrances ( %), incense/candles ( %), and cleaning products ( %). change from baseline in tnss for patients with ar and nonallergic triggers was greater with mp-azeflu than with fp or aze (table) , and patients with nonallergic triggers improved slightly less than patients without nonallergic triggers in both the mp-azeflu and fp groups. background: in low-income countries (lics), assessment of phenotypes, prevalence and risk factors for allergy-related diseases (ards) using allergen-specific ige may be complicated by environmental exposures such as helminths. these exposures may also induce cross-reactive carbohydrate-specific ige profiles that could inhibit allergic effector responses. we sought to elucidate the molecular basis of ige sensitisation among individuals in uganda, using a component-resolved approach to ige measurement. we employed the isac ® allergen microarray to assess plasma ige reactivity to purified natural and recombinant allergen components in participants of three studies: a trial of intensive versus standard anthelminthic treatment in the rural helminth-endemic lake victoria islands (n = ), a parallel urban survey of allergy outcomes in a lower helminth exposure community (n = ) and a study on asthma risk factors in children from the urban setting and from nearby rural schools (n = ). data on sensitisation to crude allergen extracts were obtained by skin prick testing (spt) with cockroach and house dust mites (hdm), and by immunocap ige testing (cockroach, hdm, and peanut). results: the rural setting was characterised by high prevalence (≥ %) of sensitisation to crude extracts (immunocap ige> . ku/ l) but low sensitisation to the major, established, allergenic components on the microarray (≤ %, ige> . isu). however, sensitisation to cross-reactive carbohydrate determinant (ccd)-bearing components and venoms was more common in rural (up to %) versus urban (up to %) individuals, and was associated with helminth infection. urban individuals mounted higher responses to allergenic components of dust mites but responses to other components were similar between the two settings. sensitisation to allergenic components was higher among asthmatics and spt+ children but ccd sensitisation profiles were similar between asthmatics and nonasthmatics, and between spt+ and spt-school children. conclusion: we show that, in lics, ige to crude allergen extracts (detected in standard immunocap assays) reflects sensitisation to a myriad of environmental exposures (absent in more developed countries), such as ccds expressed by helminths, and may not accurately define ard phenotypes in this setting. however, our data does not seem to indicate that ccd-specific ige detected by isac ® microarray protects against ards. considered minor allergens. due to their sequence homology and conserved structure, they show a high cross-reactivity. the objectives were to study the ige/igg binding properties of polcalcin in relation to the calcium ions, and the ige cross-reactivity between purified polcalcin from olea europea (ole e ) and two recombinant polcalcins (rphl p and rbet v ). method: ole e was purified by immune-affinity chromatography using polyclonal antibodies anti-rche a . serum samples were obtained from patients allergic to grasses recruited at hospital de guadalajara (spain), all of them positive to phl p with sige values ranging from . to . ku/l. equal volumes of all sera were used to prepare a pool. calcium binding assay was performed either by addition or not, or depletion of ca + . ole e was incubated with . mm cacl or with mm egta ph . (ca + chelator agent) at the same time as the antibody in immunoblot or elisa assays with the pool of sera or with anti-che a polyclonal antibody. crossreactivity assay was performed by immunocap inhibition. aliquots of the pool of sera were previously incubated with amounts of ole e ranging from . to . ng. the same dilution of the pool of sera without ole e was used as a control. after hours of incubation, sige (ku/l) binding to rbet v or rphl p was determined. results: a kda protein was purified from the o. europea extract and identified by lc/ms-ms as ole e . in the calcium binding assay there were no differences between the samples with or without ca + . however, the addition of egta to the reaction completely inhibited the binding of the polyclonal antibody by immunoblot and also produced a . % reduction of ige binding by elisa. in the cross-reactivity assay, a % inhibition of ige binding was obtained with . ng of ole e for rbet v and . ng for rphl p . the maximum rate of achieved inhibition was . % for rbet v and . % for rphl p . conclusion: native purified ole e contains the ca + necessary to bind to the specific antibodies and the depletion of ca + inhibited this binding. high cross-reactivity of ole e with rphl p and rbet v was demonstrated. | effect of glutathione-s-transferase pi on the cysteine protease activity of the house dust mite allergen der p background: environmental proteases have been proposed to be involved in the pathogenesis of allergic disorders via different mechanisms, such as the disruption of epithelial tight junctions, the cleavage of surface proteins, the activation of damage and pathogen-associated molecular patterns receptors, and the alteration of redox status. der p from house dust mite is one of the most clinically relevant indoor allergens worldwide, which exhibits cysteine protease activity and has been linked to allergenic rhinitis and asthma. however, it is unknown whether the host microenvironment could regulate der p activity once it reaches the mucosal surface. glutathione-s-transferase pi (gstpi) is an anti-oxidant and detoxification enzyme. gstpi is the predominant gst in human lung epithelial cells, where it is expressed in high levels. polymorphic variants of gstpi have been associated to various inflammatory lung disorders such as allergic asthma. more recently, gstpi has been identified as a redox regulator through protein s-glutathionylation, a post-translational modification where glutathione (gsh) is conjugated to cysteine residues. method: this work aimed at determining if gstpi affects the cysteine-protease activity of der p , compared to gstmu -a different gst isoform-by using different in vitro approaches. results: we found that gstpi increased der p -activity, but not gstmu. our results suggested a potential role of gstpi in upregulating the protease activity of der p allergen. however, the clinical implications of these findings in allergic airway diseases needs for further investigations. | cari p , a novel polygalacturonase allergen from papaya acting as respiratory and food sensitizer biswas sarkar m; sircar g; ghosh n; das ak; jana k; dasgupta a; gupta bhattacharya s bose institute, kolkata, india background: papaya was globally reported to elicit ige-mediated hypersensitivity. certain papaya sensitive patients with food allergic symptoms were found to experience recurrent respiratory distresses at peak flowering period of papaya even after quitting the consumption of papaya fruits. the immunoreactive protein present both in pollen and fruit proteome was detected by ige-serology and identified by mass spectrometry. one such allergen, designated as cari p was cloned, and purified as recombinant protein. the ige-reactivity of rcari p was examined by immunoblot using patient sera. the allergenic activity of rcari p was evaluated by histamine release assay from ige-sensitized granulocytes. the aggregation and folding pattern of rcari p was assessed by size exclusion chromatography and circular dichroism spectroscopy respectively. the presence of cari p in papaya fruit was searched by igg-immunoblot using allergen-specific rabbit antisera. a mouse model of papaya allergy was established to study the role of rcari p in eliciting respiratory and food hypersensitivity. results: a kda ige reactive protein commonly present in pollen and fruit proteome of papaya was identified as endopolygalacturonase. recombinant cari p remained monomer and the cd-spectra revealed predominantly β-sheet characters. the melting curve of the allergen showed partial refolding from a fully denatured state indicating the possible presence of conformational ige-epitopes in addition to the linear ige-epitopes of food allergens. out of papaya allergic patients displayed ige reactivity to rcari p . rcari p at μg/ml, induced histamine release from challenged granulocytes within a range of % to % (i.e. ± . %; n = patients). expression of cari p was detected in the peel and pulp tissues of papaya fruits at two edible stages of fruit maturation. in mouse model, rcari p exhibited a comparable level of eosinophil infiltration and goblet cell hyperplasia in lung and duodenum histology. conclusion: cari p the first major allergen reported from papaya with a dual role in respiratory sensitization via pollen inhalation and sensitization of gut mucosa via fruit consumption. the recombinant allergen can be used as marker allergen for molecular diagnosis and immunotherapeutic management of papaya allergy. background: lipids can be potent stimulators of the immune system, and their role in allergy is highly investigated and debated. since many allergens bind lipids, one question that arises is the relative importance of the lipids versus the lipid-allergen complex in eliciting the immune response. also of interest is an evaluation of the importance of the allergen-lipid complex. in our characterization of the structure of the cockroach allergen bla g , we discovered that it could promiscuously bind a variety of lipids in a large central cavity. this suggested that bla g could be used as a prototypical allergen and lipid delivery vehicle to test in various models of sensitization. method: cd spectroscopy. nmr spectroscopy. molecular modeling. we have developed an hplc procedure to strip the phospholipids derived from the e. coli-based expression system, and reconstitute the allergen with a variety of lipids. using cd spectroscopy and nmr, we have verified that the protein conformation is highly similar in the presence and absence of lipids. temperature dependent cd spectroscopy revealed that unloaded bla g is the least stable, and the melting temperature increased with increasing fatty acid chain length up to c . similar cd melting experiments revealed that bla g could bind lipoteichoic acid (lta) from gram positive bacteria, but did not interact with lipopolysaccharide (lps) from gram negative bacteria. molecular modeling studies have suggested that the stoichiometry of phospholipid binding is likely phospholipids per bla g and give insight as to the different binding characteristics that would allow bla g to bind lta but exclude conclusion: these biophysical studies will allow the design of bla g -lipid systems to test a variety of sensitization models. | sal k , a new allergen from salsola kali sola jp; pedreño y; fernández j; cerezo a; peñalver m probelte pharma, murcia, spain background: the polcalcin from salsola kali was identified and sequenced (genbank kt ) and the recombinant protein was characterized as a minor allergen with a prevalence of % of patients with a spt positive to s. kali. the objective of this study was to purify the polcalcin from s. kali pollen and to include the allergen in the website for the systematic allergen nomenclature (www.allergen.org). method: the native polcalcin from s. kali (npsk) has been purified from pollen after a first step of protein extraction and then diverse chromatographic steps: a size exclusion chromatography to remove particles minor than kda, an ionic exchange chromatography, a hydrophobic interaction chromatography and a final step of size exclusion chromatography to obtain the purified sample of polcalcin. the purity of the npsk has been determined by sds-page and the binding capacity to a specific polcalcin antibody from rabbit serum was tested by immunoblot. the specific antibody had previously been obtained by immunization with the recombinant polcalcin from s. kali. the allergenicity of the npsk has been assayed by immunoblot with a pool of sera of patients sensitized to s. kali. the identity of the purified npsk has been analyzed by peptide footprint in hplc-ms/ms after digestion with trypsin. all the information about the polcalcin from s. kali was sent to who/iuis allergen nomenclature sub-committee. the npsk showed a high purity in sds-page with a molecular weight of approximately kda and this purified protein reacted with the specific polcalcin antibody from rabbit serum. the ige binding capacity of the npsk was confirmed by immunoblot using a pool of sera from patients sensitized to s. kali. the analysis of peptide footprint confirmed that the purified protein is a polcalcin. the who/iuis allergen nomenclature sub-committee included the polcalcin from s. kali in the website for the systematic allergen nomenclature as a new minor allergen named sal k . conclusion: the polcalcin from s. kali has been purified from pollen and tested for its ige binding. it is included in the website for the systematic allergen nomenclature as the new allergen sal k . background: alt a protein is the major allergen from the fungus alternaria alternata and responsible for chronic asthma, yet little is known about its physiological role and immunological activity. our main purpose was to investigate the mechanism through which alt a induces an allergic response in bronchial epithelium. method: although alt a has a unique topology, we studied the structural relationship by in silico procedures consisting of three distinct structural alignment methods in order to understand its nature. the immunological properties of the allergen were investigated by using monocyte cell line thp and human peripheral blood mononuclear cells. results: its crystal structure has been recently reported and claimed to be exclusively in fungi without equivalent in the protein data bank. data obtained in silico show that this allergen shows some structural relationships with a number of other β-barrel proteins such as human lipocalin (lcn ). besides, our experimental data demonstrate that alt a is also able to interact with lcn , human lipocalin. in this way, the results obtained from several immunological assays showed that alt a is able to produce a response of the immune system through different immune innate receptor pathway inducing the th cytokines. background: increasing evidence of cross reactivity syndromes between pollen grains and fruits, with immediate or delayed reactions, has been reported. while some syndromes such as the birch pollen/apple syndrome are well documented, some other such as the cypress pollen/peach syndrome remain to be understood. for the latter, significant progress has recently been made with the discovery of a new allergen family, the gibberellin regulated proteins (grps), which has been shown to be responsible for the observed cross reactivity i.e. pru p and bp ( , ) for the peach and the cypress pollen respectively. grps are small cationic proteins with anti-microbial properties and have been shown to be over produced in response to a stress. herein, the case of a patient, born and raised in the south of france but currently living in paris, has been studied. this patient has been suffering since childhood from allergic rhinoconjunctivitis to cypress pollen and from some oral symptoms to peach and other fruits (including pomegranate). method: in addition to the clinical exploration and cutaneous tests, a very thorough biological characterization of the patient samples has been performed through various specific ige quantitation techniques, western blotting after one and two-dimensional gel electrophoresis and flow cytometry based basophil activation testing (bat). results: specific iges to cypress pollen, birch pollen, peach, orange and apple have been found. pr allergenic proteins are recognized by iges but no ltps. the presence of specific iges to cypress pollen bp , peach peamaclein (pru p ) and a cationic kda protein from pomegranate has been shown through western blotting after gel electrophoresis separation of the protein extracts. the use of bat finally enabled to demonstrate that the basophils of this patient were, ex vivo, strongly activated with protein extracted from orange and cypress pollen and also with purified proteins such as bp and pru p . conclusion: these results unambiguously show that the cypress pollen grp, bp , is clinically relevant, similarly to its homologous protein in peach, pru p . it can be proposed that these two allergens are at the basis of the observed cross-reactivity syndrome. the search for new cross-reactive allergenic grps in pollen, fruits or vegetables may enable to better understand other pollen/food associated syndromes that still remain unexplained. background: nine allergens of phleum pratense have been described until now (iuis database) and classified into groups based on their function and cross-reactivity. group and allergens are considered the most immunodominant, due both to their greater ige-binding capacity and the number of patients ige-reactive to them. previously published studies have estimated that group is recognized by almost % of grass pollen-allergic patients, and group by %. however, until now a comparative of the ability of these allergens to provoke an immune response has not been performed. the objective was to study the immunogenicity of the major allergens phl p and phl p , by analyzing the ability of the recombinant forms (rphl p and rphl p a) to induce a humoral immune response. method: five mice were immunized with the same amount of each recombinant protein: rphl p and rphl p a (indoor biotechnologies) ( μg plus two boosters of μg). the specific igg antibodies produced by each mouse were tested against the recombinant proteins by direct elisa and the title of each of them was determined by optical density (o.d.). additionally, the recognition of both allergens in native and depigmented-polymerized (dpg-pol) extracts of p. pratense was studied by direct elisa using these generated antibodies. results: preimmune sera were negative. all mice produced antibodies against the corresponding recombinant protein. the immune response (sigg) was statistically significant higher in mice immunized with rphl p than in those immunized with rphl p ; it was needed times more rphl p serum than rphl p a serum to obtain the same o.d. values. the difference in responses was higher in the group of mice immunized with rphl p than with rphl p a. differences in the recognition of phl p and phl p in native and depigmented-polymerized extracts of phleum pratense was also observed. it was necessary times more rphl p serum to produce the same signal than rphl p a serum in native extract and it was necessary times more rphl p serum to produce the same signal than rphl p a serum in dpg-pol extract. conclusion: rphl p a is more immunogenic than rphl p , which was also probed with native and dpg-pol extracts. background: glioblastoma (gbm) is an incurable primary malignant brain tumour with a median life span of less than months despite multimodal treatments. therefore, there is a serious need for the development of innovative medications. several epidemiological studies underlined an inverse correlation between pre-existing igemediated allergy and gbm risk, where having such an allergy decreased the odds of developing gbm by to %. we aim to delineate the intrinsic immuno-biological and molecular mechanisms that can be responsible for these correlations, based on the hypothesis that allergies may promote a state of increased immuno-surveillance in the brain through the presence of immunological factors such as immunoglobulins, cytokines and cells involved in th -driven allergic reactions. we consider that as the major immune cell type of the brain, microglia should be implicated in this beneficial association and may favour the elimination of the nascent tumour in brain parenchyma in an allergic context. we implemented a long term allergic airway inflammation by repeated nasal instillation of house dust mite (hdm) extract in a syngeneic orthotropic mouse model of gbm. we followed animal survival and the tumour growth by mri. in addition, we purified microglia from allergic vs non-allergic mice in order to assess their cytotoxic function against the gbm cell line ex vivo and their secretory capacities. finally, we investigated immunoglobulin reactivity against gbm antigens in the context of allergic reactions by reverse phase protein array (rppa). we demonstrated an increase of the animal survival that was correlated with a delayed tumour engraftment and a reduced tumour growth. these phenotypes were associated with functional modification of microglia from sensitized mice. indeed, these microglia showed a rise in the production of il- and tnf-a as well as an increase in cytotoxic functions against a gbm cell line ex vivo. in parallel, we observed an increase in serum igg reactivity against gbm antigens in mice sensitized with hdm compared to control mice. results: in patients ( %) with cvid we recorded at least one temporary platelet count decrease below × /l compared to only patient ( %) with xla (p = . ). more importantly in patients ( %) with cvid this decrease was observed in a period longer than months compared to patient ( %) with xla (p = . ). in patients ( %) with cvid we recorded at least one temporary platelet count decrease below × /l and only in patients ( . %) with cvid this decrease was observed in a period longer than months. we did not record any platelet count decrease bellow × /l in patients with xla however the difference with cvid did not reach statistical significance. no thrombocyte count decrease bellow × /l was observed in either group. none of patients required immunosuppressive treatment for immune thrombocytopenia (itp). conclusion: although the statistical significance was documented only in temporary platelet count decrease below × /l it is obvious that numbers of thrombocytes commonly fluctuate in some patients with cvid. the mechanism leading to these temporary decreases is unclear. monitoring of complete blood count is a basic follow-up investigation in patients with cvid. introduction: wegener's granulomatosis (wg) is a systemic disease that may affect all organs, most frequently the ears, noses, throats, sinuses, lungs and kidneys. it is a rare autoimmune disease, also called granulomatosis with polyangiitis, and characterized by necrotizing granulomatous inflammation in small and medium sized blood vessels. anti-neutrophil cytoplasmic antibody against to proteinase (c-anca) is thought to be responsible for autoimmune inflammation. the coexistence of wg and common variable immunodeficiency (cvid) is extremely rare. in this report, we describe a patient with wg and cvid who was treated with immunosuppressive drugs and intravenous immunoglobin concomitantly. case report: a twenty-four-year-old male patient was referred to our clinic for immunological evaluation due to recurrent infections, fever of unknown origin and neutropenia. the patient had been diagnosed with wg and taking immunosuppressive therapy for three years. he had chronic renal failure due to wg and had also been on peritoneal dialysis for three years. serum igg, iga levels, peripheral blood cd + b cell percentage and absolute count of the patients were found to be low according to reference limits. he was diagnosed with cvid after excluding secondary reasons for hypogammaglobulinemia and he started to receive mg/kg intravenous immunoglobulin (ivig) therapy once in a month. also, the treatment that consists of mycophenolate mofetil (mmf) and glucocorticoids was continued to decrease c-anca levels in serum. he has been accepted as a candidate for kidney transplantation, and prepare for this purpose. discussion: the management of the patient with cvid and wg may be complicated. it is considerably difficult and needs competency and courage. moreover, the cases similar to ours, are extremely rare. therefore, the authors should share their own experiences on cvid and discuss them by comparing the data obtained from other cases. background: leukocyte adhesion deficiencies (lads) are a group of three genetic disorders leading to defective leukocyte adhesion to the endothelium and as a consequence decreased leukocyte recruitment and immune defense. lad-i is caused by mutations in the gene encoding the ß -integrin cd on chromosome .lad-iii is a rare primary immunodeficiency syndrome, characterized by homozygous mutations in the kindlin- gene (official symbol fermt ). we have aimed to evaluate our patients who were followed up with lad for the last years, retrospectively. method: all data of the cases were obtained from the file records of age at diagnosis. results: seven patients from separate families were included in the study. four patients were lad-iii and patients were lad-i. the female to male rate was / . the age of diagnosis is ranged from days to years. the median umbilical cord detachment was days ( - days groups: up to times ( people) and from to times ( people). healthy donors were examined as a control. flow cytofluorometry method was used to study peripheral blood and assess the parameters of innate and adaptive immunity results: it was found that at a frequency of edema up to times a year there are changes in the t-system of adaptive immunity, which are shown by a decrease in the expression of late activation markers (cd + hladr+ . ± . %, in control . ± . %), an increase in the number of cd + cd + cytotoxic lymphocytes ( . ± . x /l, in control . ± . x /l) and as an increase in their functional activity (cd + gr+ . ± . x /l, in control . ± . x /l). the nature of disorders of cellular factors of the innate immunity is manifested by decrease in the adaptive resources of neutrophils (kstnbt . ± . u.e., in control . ± . u.e.). patients with hae with a frequency of edema up to times a year, we observed the disorders of the humoral link of adaptive immunity, which consist in an increase in the number of circulating b lymphocytes ( . ± . x /l, in control . ± . x /l). in addition, with the strengthening of the hae clinic, changes in the system of innate immunity progressed very fast and consisted in increasing the amount (cd + . ± . x /l, in control . ± . x /l), and functional activity (cd + gr+ . ± . x /l, in control . ± . /l) of natural killer cells results: we included children, mostly males ( %), aged between month and years. . % of patients (n = / ) showed abnormal absolute results of lymphocyte count for age. we found more patients evaluated in the age group of to years ( . %), followed by - years ( . %), lymphopenia was found in . % of patients. b lymphocyte deficiency was the most common pattern ( %) followed, in decreasing order, by low cd , t cd , tcd and nk. many patients have more than one affected population ( . %) . some patients were affected in all three series ( . %). the cd / cd ratio decreased in . % of the patients. the majority of the children were males between the ages of month and years. . % of patients showed abnormal absolute lymphocyte count for age. b-cell deficiency was the most common pattern followed, in decreasing order, by low cd , t cd , tcd and nk. many patients have more than one affected population. | indicators of the humoral immunity in the mechanical jaundice of benign genesis the aim of the investigation was to study the indices of humoral immunity in patients with benign mj, depending on the level of bilirubin. method: patients with mj and practically healthy volunteers were examined. patients with a level of bilirubin less than μmol / l - , with a bilirubin level of - μmol / l - and with a bilirubin level of more than μmol / l - patients. the concentration of immunoglobulin classes a, m, e and g in serum was determined by enzyme immunoassay. the statistical significance of the differences was determined using the ranked mann-whitney test. the critical level of significance in checking statistical hypotheses was assumed to be p < . . results: of the contacted dermatologists, participated ( women, men; mean age . ± . ) which results in a response rate of . %. the guideline compliant prescription rate of biologicals in patients with csu was . %. the most prevalent barriers in the prescription were the high cost of the treatment ( . %), low reimbursement for doctors ( . %) and the fear of a recourse claim ( . %). however, a lack of evidence or an insufficient efficiency were not con- case report: eosinophil associated gastrointestinal disorders (egids) including eosinophilic colitis are commonly associated with atopy. aeroallergen sensitization may accompany food allergy in these patients. a case with eosinophilic colitis responsive to anti-ige monoclonal antibody (omalizumab) treatment is presented. an eleven-year-old boy had bloody diarrhea lasting nearly one month in autumn for last years. this year diarrhea lasted more than months. colonoscopic biopsy revealed lymphoplasmacytic inflammatory cells including eosinophils leading to a diagnosis of ulcerative colitis. corticosteroid and mesalazine treatment was started with a good clinical response. recurrence of diarrhea during corticosteroid dose reduction suggested corticosteroid dependent ulcerative colitis. eosinophilic/allergic colitis was an alternative diagnosis when seasonal recurrence, lack of weight loss, eosinophils in biopsy and high serum ige level were considered. colonoscopy done after cessation of therapy for one month, revealed exudative ulcerous lesions, lacerations, loss of haustration compatible with colitis (inflammatory/allergic?). presence of significant mucosa associated lymphoid tissue in biopsy supported any inflammatory, reactive process. he had recurrent bronchiolitis until age six and allergic rhinitis in spring for three years. total ige and mix aeroallergen specific ige were high ( iu/ml, . kua/l), absolute eosinophil count was normal ( /mm ). food skin prick and patch tests were negative. he had positive skin reactions with dermatophagoides, grass and olea pollens (induration diameter: , , mm, respectively). pulmonary function test was normal. he was considered as eosinophilic/allergic colitis and omalizumab was started according to manufacturer's dosing table ( mg/ weeks). rectal bleeding decreased after first dose and ceased after the second dose. early colonoscopy examination after rd month of therapy showed that exudations disappeared and haustrations became evident. microscopy revealed mild nonspecific colitis. few patients with eosinophilic colitis improved with omalizumab were reported before. ige-mediated processes are responsible from eosinophilic inflammation in egids, making anti-ige therapy as a promising treatment option. | design of liposomal carriers modified by glycoconjugates for liver cell delivery of nucleic acids used. the surface of liposomal nanoparticles can be modified to increase the selectivity of intracellular delivery. it is well known that asialoglycoprotein receptors of hepatocytes have a strong affinity to galactose carbohydrate. therefore, the aim of this study was to assess the effect of the modification of the liposome surface by glycoconjugates on the selectivity of intracellular transport of nucleic acids into the liver cells. method: liposomes based on ornornglu(c ) were chosen previously as the effective nucleic acid delivery system. we modified liposomes with novel lactose-based derivatives. every of four glycoconjugates was added to ornornglu(c ) in an amount of , and %. as a result, variants of modified liposomes were obtained. to determine the cytotoxicity, an mtt test was used. using luciferase test, the selectivity of penetration was evaluated on nonspecific t (human embryonic kidney) and specific hepg (human liver cells) cell lines. results: modified liposomal compositions ornornglu(c ) - + lacc ( %) and ornornglu(c ) - + lacggg ( %) had the lowest cytotoxicity similar to that for unmodified ornornglu(c ) . the ic , calculated based on the data of mtt test, was . and . , vs. . mg/ml, respectively. ornornglu(c ) - + lacggg ( %) showed a . -fold increase in transfection activity on the nonspecific t cells, compared to unmodified ornornglu(c ) , whereas the modification of ornornglu(c ) - + lacc ( %) resulted in a -fold decrease in transfection activity. however, the ability of these variants to penetrate the specific liver hepg cell was significantly higher by and times, respectively, than for unmodified ornornglu(c ) . results: the greatest inhibitory effect of sbfhd was observed in mdm infected with hiv- bal: % and % suppression of hiv replication was achieved at concentrations of . μg/ml and . μg/ ml, respectively. the activity in pbmc and dc was less pronounced (the respective ic values were . μg/ml and . μg/ml). studies in endometrial hec- a cells demonstrated that sbfhd suppressed cd -independent entry of hiv- ( tcid /ml) by %, %, and %, respectively, at , , and μg/ml. the effect was also observed after increasing the dose of the virus. at tcid /ml, sbfhd suppressed hiv infection by % ( μg/ml) and % ( μg/ml). the cytotoxicity of sbfhd in this system was low. similar results were obtained with colorectal caco- cells. sbfhd exhibited no spermicidal activity at concentrations of up to mg/ml. combining within a single microbicide two agents that target distinct steps of hiv life cycle will maximize its efficacy (via synergistic effects and/or interference with multiple stages of the transmission). we therefore explored the synergistic potential of combinations of sbfhd and azt, the classical nucleoside rt inhibitor. in these experiments, % suppression of hiv infection was reached at concentrations of sbfhd and azt, which were significantly lower than the respective ic values of each component (determined in parallel experiments). the synergistic effect was most pronounced for the combination of . μg/ml sbfhd (which is times less than the ic ) and . nm azt (which is times less than its ic ). cd expression was increased after the co-culture with reishi, shiitake and boletus mushrooms (c - . ( . - . )%; pma - . ( . - . )%; )%; shiitake - . ( . - . )%; boletus - . ( . - . )%). method: the study included men (mean age ± . years) before and immediately after staying in countries with a hot climate. results: the development of lymphopenia observed in the first week of observation. this was accompanied by a decrease in the number cd + lymphocytes expressing the markers of late activation (cd + hladr+ . ± . x /л и . ± . x /л). revealed significant decrease of cd + cd + foxp + regulatory cells in the first week after returning from the area of adverse climatic conditions, as well as a significant sustained decrease in the number cd + cd + hladr+(p < . ). change of the effector link of innate immunity was determined in significant reliable decrease in relative (cd + . ± % and . ± . %, respectively, p < . ) and absolute (cd + . ± . x /l and . ± . %, respectively, p < . ) in the number of a population of natural killer cells in the first week of observation. in the context of acute stress marked a significant increase in relative and absolute numbers of b lymphocytes ( ± . % ( . ± . × /l) before a trip to countries with a hot climate and ± . % ( . ± . × /l) in the first week after returning, p < . ). the activity is the production of antibodies was not changed. (ast) which is the intramuscular injection of patients own serum, is a promising therapy with a substantial efficiency on ciu patients. in this study we aim to assess the efficacy of ast on chronic urticaria patients by dlqi questionnaire. method: this was a single-blind randomized clinical trial which evaluated the efficacy of autologous serum therapy compared to oral antihistamines in patients with ciu. ciu patients received the ast. every session cc of each patient's blood was centrifuged at the speed of rpm for minutes and . cc of the serum was injected intramuscular into the patient's deltoid muscle weekly for weeks. the control group consisted of ciu patients took mg of cetirizine daily for weeks. patients answered the dlqi questionnaire at the first session of treatment as baseline and weeks after the last session(week ) as response to treatment. the mean baseline score of dlqi for ast group was conclusion: pharmacotherapeutic and inpatient costs for patients with prevalent ar and asthma were lower in those prescribed ait than in those not prescribed ait in all years, both with and without including the cost of ait itself. this indicates that treatment with ait is associated with lower cost burden for health services. background: immunotherapy with peptides rather than conventional whole allergens is being developed to improve the benefit/risk balance of subcutaneous immunotherapy (scit). lolium perenne peptides (lpp) demonstrated reduced allergenicity following ex-vivo analyses, allowing higher doses to be given over a shorter period to improve treatment adherence and compliance. such treatment resulted in significant reduction in symptoms and rescue medication intake during the grass pollen season. here we report the safety of lpp immunotherapy in adults. background: a new allergoid from alternaria alternata was characterized to determine its reduced allergenicity in vitro. the objective of this study was to determine the skin response to the allergoid and to evaluate the clinical tolerance of the immunotherapy with the allergoid product using a rush schedule. method: to assess the skin response (sr) two groups of patients were included: group with patients sensitized to a. alternata and with respiratory disease caused by this mold; group (control) with patients sensitized to others allergens and non-atopic patients. the sr was determined by spt using three concentrations of the allergoid: p (lowest concentration), p (four times higher than p ) and p (estimated to obtain a wheal area similar to histamine mg/ml). in spt was also used a native extract of a. alternata (n) and histamine mg/ml (h). all products were tested in duplicate in all patients and the sr was evaluated by comparing the median of the wheal area produced by different products. to evaluate the clinical tolerance to immunotherapy the patients of group were treated with the allergoid product using a rush schedule consisting in a dose of . + . ml the first day and . ml after one month (maintenance dose). the clinical tolerance was determined as the percentage of adverse reactions (ar) to the treatment and the classification of ar was established according to eaaci. the number of patients included to evaluate the sr was (group : ; group : , atopic and non-atopic) with an average age of . (range . the spt data from group were expressed as median and interquartile range of wheal area (mm ): h: . ( . - . ); n: . ( . - . ); p : . ( - . ); p : . ( - . ); p : . ( . - . ). it was determined that sr of allergoid was reduced in % respect to the native. the products n, p , p and p did not produce any response in patients of group . to evaluate clinical tolerance, patients of group were treated with the allergoid product with a rush schedule and only two ar were registered ( . % of doses). these were retarded local reactions with a wheal diameter higher than cm. no systemic reactions were registered and all patients continued the treatment. the allergoid from a. alternata produces a significant reduced response to spt due to its reduced allergenicity. the treatment with an allergoid product in a rush schedule is safety and clinically well tolerated. background: in our study we aim to determine the more effective, the total cost of years of patients using scit was tl per person whereas the total cost of years of patients using slit was tl per person. when we compare the total cost data of both groups, we found that they are close to each other. while the greatest portion of the cost data of patients with scit treatment was direct costs associated with the treatment itself ( %); the remaining part of the total cost was indirect ( %) with non-medical expenses such as transportation ( %). in the slit group, direct costs including drug expenditures have a larger percentage ( %) and it was significantly more costly compared to the direct costs of the scit group ( %). transportation costs were found to be more costly in the scit group ( %) when compared to the slit group ( %). similarly loss of parent work days in the scit group(% ) was found to be significantly more expensive compared with slit group ( %). our study results show that slit is a similar treatment for clinically and laboratorially and has a similar efficacy to scit to reduce the patients' complaints and to the need for medication. for cost-effectiveness however medicines for treatment of scit are less costly; when long term total treatment costs are calculated slit and scit treatment are economically close treatments. the protein content of the new acd was . μg/mg and the protein profile in sds-page and sec-hplc confirmed the presence of proteins with high molecular weight and the absence of smaller proteins. the content of free lysine in acd, involved in glutaraldehyde modification, was reduced in . % respect to ncd and it can be considered as the polymerization degree. regarding to the allergenic profile, through elisa inhibition was determined a reduction of times in the capacity to bind ige of the proteins in acd respect to ncd, whilst the igg binding capacity was maintained. in immunoblot there was no reaction of acd proteins to specific ige from sera. the analysis by peptide footprint determined the presence of fel d and others allergens in acd. the content of major allergen fel d in acd was determined as . μg/mg. the new developed and characterized allergoid from cat dander has an excellent safety profile and will allow a safer immunotherapy to treat the allergy to felis domesticus. results: the protein content of the new aaa was . μg/mg and the protein profile in sds-page and sec-hplc confirmed the presence of proteins with high molecular weight and the absence of smaller proteins. the content of free lysine in aaa, involved in glutaraldehyde modification, was reduced more than % respect to naa and it can be considered as the polymerization degree. regarding to the allergenic profile, in immunoblot there was no reaction of aaa proteins to specific ige from sera and by elisa inhibition was determined a reduction of % in the capacity to bind ige of the proteins in aaa respect to naa. the igg binding capacity in aaa was maintained. the analysis by peptide footprint determined the presence of alt a and others allergens in aaa. the content of major allergen alt a in aaa was determined as . μg/mg. a. alternata shows an excellent safety profile and allows a safer immunotherapy to treat the allergy to this mold. she was an otherwise healthy woman: she took no drugs and she did not have any remarkable concomitant diseases. the distribution and appearance of the remaining body hair was normal and the hormonal level profiles (lh, fsh, estrogens, progesterone and testosterone) did not show any significant alteration according to her age. a year old woman with allergic rhinitis underwent sq glutaraldehyde-modified ait to house dust mites (d pteronyssinus and g domesticus) without any incidences and complete tolerance to maintenance dose without local reactions during a year period. two years after ait discontinuation, patient first experienced a local urticarial reaction with multiple hives at previous sq ait injection sites minutes after mg of ibuprofen intake. these symptoms recurred at least in seven occasions when patient was exposed to ibuprofen (in five) and metamizol (in two). results: case : dermatologist diagnoses localized hypertrichosis. case : a single blind, placebo controlled oral challenge (sbpcoc) with ibuprofen mg was performed and elicited multiples hives in the circumscribed area in the arm where ait was conducted. subsequently, sbpcoc with aspirin was carried out showing the same reaction although a controlled challenge with celecoxib was negative. conclusion: local hypertrichosis is a very rare injection-disease associated with injected allergen vaccine treatment. we also firstly described a recall urticaria phenomenon after allergen immunotherapy which has been only elicited after different nsaids intake. results: there were included patients, in five spanish hospitals. following aria guidelines, . % of patients were diagnosed of persistent moderate/severe rhinitis. the mean age was . ± . years, being . % female. moreover, . % of the patients had concomitant mild/moderated asthma. the period between the diagnosis of rhino-conjunctivitis and the informed consent signing was . ± . years. according to international guidelines, eight systemic reactions were registered, representing . % of the administered doses: five reactions grade , (described as nonspecific ocular pruritus, nasal herpes, general discomfort, localized non-specific pruritus plus nausea and non-specific pruritus in throat), a grade i reaction described as rhinoconjunctivitis and two reactions grade ii, registered as generalized urticaria and asthma. all reactions were classified of mild or moderate intensity and only two required symptomatic treatment. there were five clinically significant delayed local reactions, which were higher than cm or involved modifications in next dose. regarding efficacy parameters, immunoglobulin titers between baseline and final visit according to specific igg and igg significantly increased. cutaneous reactivity also decreased significantly in the dose response skin prick test. results: patients were included, to accelerated and to polymerized cluster group schedules. according to aria criteria, . % of patients presented persistent moderate/severe rhinitis. the mean age was . ± . years, being . % male. moreover, . % had concomitant mild/moderated asthma. immunoglobulin titers method: the quantification of total proteins in the products was carried out by means of a colorimetric technique using the bradford reagent (sigma-aldrich™, us) in accordance with the manufacturer's instructions. the absorbances of each standard and samples were obtained in a scinco™ s- spectrophotometer (seoul, korea) at nm. all samples were analyzed in duplicate. the electrophoretic profile of the proteins in the tested allergens was obtained according to the procedure described by laemmli, under denaturing conditions in a polyacrylamide gel at . % concentration and stained in silver. in each lane approximately μg of total proteins were applied. commercial extracts of the main allergens marketed in mexico were obtained, rossel ® , alk ® , alerquin ® , alergomex ® , allerstan ® , ipi asac ® ; and they were assigned randomly with the numbers , , , , and . results: the following protein concentrations were found in the various extracts analyzed: see table conclusion: differences were found in the protein profiles ana- background: a new allergoid from cat dander was developed and characterized to determine its reduced allergenicity in a % and the maintenance of igg binding capacity. the objective of this study was to develop an immunogenicity assay in mice with the new allergoid and a native extract from cat dander. the study included female balb/c mice separated in three groups of mice each: group , immunized with a mold allergen extract (control); group , immunized with a native extract from cat dander with a fel d content of . μg per dose; group , immunized with the new allergoid from cat dander with a fel d content of . μg per dose. all mice were immunized four times by subcutaneous injections with a volume corresponding to / of the recommended human maintenance dose with an interval between injections of weeks. one week after the last injection the mice were sacrificed and the serum was obtained. to determine the specific antibody title indirect elisa were performed using a cat dander extract as antigen, sera from mice as primary antibody and antimouse igg or igg as secondary antibody. elisa assays were performed using serial dilutions of sera or a simple dilution by duplicate to determine the specific antibody title as arbitrary units/ml (au/ml). the data were analyzed by one-way anova and tukey hsd test to compare the averages of specific antibodies in each group. results: the immunization with both the native extract and the allergoid from cat dander produces specific igg and igg . regarding to igg, a higher title was observed in group respect to group in a curve obtained after elisa with serial dilutions of sera. the specific igg title obtained in terms of au/ml was . ± . in group , . ± . in group and . ± . in group . concerning to igg the au/ml obtained was . ± . in group , . ± . in group and . ± . in group . the increase of specific igg or igg in mice from group respect to mice from group and control group was statistically significant (p ˂ . ). the safety profile of the allergoid from cat dander allows a treatment with higher dose of allergens to produce a greater response to immunotherapy to induce formation of specific this was an open, multicenter clinical trial, in patients aged between to years with rhinoconjunctivitis with or without concomitant mild asthma sensitized to house dust mites (hdm). the aim was to evaluate the safety and tolerability of the vaccine. secondary endpoints included were: changes in immunoglobulin levels (specific ige, igg and igg ) versus d. pteronyssinus and d. farinae and changes in cutaneous reactivity. patients were under study treatment for weeks: five for the induction phase (weekly injections) and for the maintenance phase (monthly injections). results: patients were included. there were withdrawals from the trial; no one was related to treatment. the patients mean age was . years, being % female. . % were diagnosed of persistent moderate/severe rhinitis according to aria guidelines and . % presented concomitant mild asthma. regarding to safety results, systemic adverse reactions were registered which corresponded to . % from a total of administered doses. the most of systemic reactions were grade i, ( . %) described as rhinitis or urticaria, grade or nonspecific ( . %) and reaction ( . %), was grade ii. all of them were mild or moderate and only needed treatment. among local reactions, ( . %) were clinically relevant late local reactions, meaning a wheal at injection site > cm and /or requiring a dose readjustment in the next administration; ( . %) were clinically relevant immediate local reactions meaning a wheal > cm. concerning the efficacy parameters, cutaneous reactivity at the final visit versus baseline was, in average, significantly decreased, and specific titers of igg and igg against tested hdm increased significantly at final visit. patients completed the study. mean values in rqlq questionnaire (total score) decreased from . to . points ( . % score reduction) in final visit, reflecting a statistically significant improvement (p < . ). annual episodes of rhinoconjunctivitis decreased from . to . (p < . ). . % of patients improved from persistent to intermittent rhinoconjunctivitis (p < . ) and . % from moderate/severe to mild intensity (aria) (p < . ). moreover, . % of asthmatic patients at baseline, did not have any bronchial symptoms after -year treatment (p < . ). mean value of treatment satisfaction was . (sd= . ) and . (sd= . ) for patients and physicians respectively. | evaluation of safety and tolerability of "allergovac poliplus" in polysensitized patients with allergic rhinitis-rhinoconjunctivitis with or without asthma: an observational prospective study (apolo) background: the objetive of this study was the safety and tolerance assessment of "allergovac poliplus" scit treatment, with allergen combination-mixtures in polysensitized patients, as well as the evaluation of the clinical improvement and patients' satisfaction after treatment. method: this is a prospective observational clinical study. allergovac poliplus treatment is being administered in a " -day" or in an abbreviated schedule. polysensitized patients (to pollens or mites), with rhinitis or rhinoconjunctivitis, with or without asthma, and between - years have been included. all adverse events are being recorded. visual analog scales (vass) are being used to evaluate clinical improvement, tolerance and satisfaction after treatment ( months). results: a total of patients have been included, with an aver- results: in all groups prevailed severe forms of the disease and the phenotype of frequent exacerbations. groups were comparable in age composition and structure of severity. observations in the group of vaccinated pcv continue the dynamics of decreased dyspnea up to . ( . ; . ) results: of a total of pts under scait, were excluded due to data unavailability, and included (♀ ( %), mean age ± years (minutes: max md ), age range [ - ] being most prevalent ( %). the most frequent diagnosis was rhinitis/rhinosinusitis ( %), followed by asthma ( %), diagnosis coexisting in abstracts | pts ( %). other diagnosis such as conjunctivitis ( %), atopic eczema ( %) and food allergy ( %) were also found. mite sensitization occurred in patients ( %) of which ( %) were monosensitized. the pollen sensitization was verified in ( %) with monosensitized pts ( %). the double sensitization mitespollens was displayed in ( %). sensitization to epithelia and fungi occurred respectively in ( %) and pts ( %). it was found that pts ( %) presented sensitization to the groups of allergens (mites, pollens, fungi, dander). an average of ± pts started this treatment per year. prescription included laboratories with the following %: a- . ; b- . ; c- . ; d- . ; e- . ; f- . ; g- . ; h- . ; i- . ; j- . . option for extract of physical modification ( %), physical-chemical ( %) and chemical ( %). table shows the frequency of distribution of scait composition. conclusion: in this population sensitization to mites was predominant being the most prescribed scait followed thru sensitization to grasses with the respective scait. the majority of the population was polysensitized. however, in composition preference the choice of group of allergens prevailed and only % had more than one sort of pollen and % pollen+mites. polysensitization is a reality, nonetheless the choice of ait composition should be guided thru scientific criteria and not through the availability of mixtures encouraged by laboratories. background: allergen immunotherapy (ait) has been proven to be an effective treatment of allergic diseases in numerous studies. however, its use in seniors remains limited and questionable, due to common comorbidities and limited evidence of efficacy and safety of ait in aging population. the aim of presented study was to assess the safety of ait in patients over years of age undergoing subcutaneous immunotherapy (scit) and analyze the potential risk factors of adverse reactions in this population, compared to younger adults. we followed subcutaneous immunotherapy in a group of patients treated in the outpatient clinic of medical university of lodz, of whom were aged and older ( between the age of - , aged - and patients above the age of ). we recorded detailed information of each administration and corresponding adverse reactions over the period of years. we compiled results of our observations with patients' medical records to compile a database, which we then analyzed using statistical software. method: a total of cases with seasonal allergic rhinitis undergoing pre-seasonal immunotherapy and cases followed with conventional drug treatment were included in the study. immunotherapy and control groups were divided into monosensitized (only pollen) and polysensitized (at least additional allergen except pollens) patient groups according to skin prick test reactivity. all patients were followed between march-september with symptom and medication scores, and visual analogue scale (vas). the quality of life was assessed using the mini-rqlq questionnaire. phleum pratense (phl p) specific ige and specific igg (uni-cap , phadia) measurements were performed before and after weeks of immunotherapy in all patients. gramineae pollens were counted during the grass pollen seasons. results: mean age was . ± . and . ± years, female/ male ratio was / and / , the number of monosensitized/polysensitized patients were / and / in immunotherapy and control groups, respectively. in the immunotherapy group, june-july symptom scores, may-june-july-august vas scores and june combined symptom-medication scores were lower than the control group (p = . ). furthermore, improvements in activities-practical problems and other quality of life scores were significantly different between two groups (p < . ). in immunotherapy group, phl p specific ige and phl p specific igg levels measured after immunotherapy were significantly higher compared to those before immunotherapy (p < . , p < . , respectively). phl p specific igg levels measured after immunotherapy were also significantly higher in the immunotherapy group than in the control group (p < . ). there was no difference in terms of clinical and immunologic parameters in monosensitized and polysensitized patients (p > . ). conclusion: clinical improvement with pre-seasonal allergoid immunotherapy is accompanied by an important increase in specific igg blocking antibodies despite short-term injections. our findings show that pre-seasonal allergoid immunotherapy has similar clinical efficacy and b cell response in polysensitized subjects compared to monosensitized patients. | the safety trial of sequential sublingual immunotherapy with japanese cedar droplet and house dust mite tablet matsuoka t ; kuroda y ; igarashi s ; fukano c ; natsui k ; ohashi-doi k ; masuyama k university of yamanashi, yamanashi, yamanashi, japan; torii pharmaceutical co. ltd., tokyo, japan background: sublingual immunotherapy (slit) is recognized as the only treatment option with the potential to provide long-term posttreatment benefits. in japan, the prevalence of japanese cedar (jc) pollinosis is very high, about % of the population, of which the majority are co-sensitized to hdm. slit is now well established, safe and convenient treatment form for allergic disease, and recently, jc slit-droplet and hdm slit-tablet products were approved in japan for treatment of jc and hdm induced allergic rhinitis, respectively. however, the safety of sequential jc slit-droplet and hdm slittablet has not yet been investigated. therefore, we investigated the safety trial on slit combined with jc droplet and hdm tablet in allergic patients. method: eleven subjects with jc pollinosis and hdm rhinitis were enrolled. patients were treated once-daily with jc slit-drops for weeks, followed by weeks of sequential slit treatment where the jc slit-drops and the hdm slit-tablets were administered daily with a minute interval ( st: jc-slit drops, nd: hdm slit-tablet). the primary endpoint was the frequency and severity of adverse events (aes) during sequential slit by common terminology criteria for adverse events (ctcae) v . and slit grading system. serum antibodies were measured as the secondary endpoint. results: eleven patients were recruited. aes after jc slit-drops administration were found in patients out of cases ( %). aes after sequential slit were found in patients out of cases ( %). all aes were graded or . no severe aes were observed during the study period. the levels of jc-and hdm-specific ige and igg in serum were increased during treatment. conclusion: sequential-administration of jc slit-drops and hdm slit-tablets was well tolerated by patients suffering from both jc pollinosis and hdm rhinitis. background: according to the ema guideline on the clinical development of products for specific immunotherapy products should be tested in phase ii at different doses in several study-arms to establish a dose-response relationship for clinical efficacy before confirmatory trials can be initiated. allergen exposure in an aec may be used as primary endpoint. the study was a single-center, randomized, double blind, placebo-controlled, phase ii trial, treatment duration months. grass pollen allergic patients ( - years of age) with seasonal rhinitis/rhinoconjunctivitis (arc) with (mild, gina i) or without concomitant asthma were randomized to three different dosages of a liquid phase iii study is in preparation. as part of an effort to prepare the analysis plan using the csms as primary endpoint, the grass pollen data of the european aeroallergen network (ean) was used to identify the window within the grass pollen season (gps) with optimal correlation between the grass pollen counts and the csms. method: ean currently includes information from more than active and historical pollen-monitoring stations in europe including countries. the ean database used for analysis included grass pollen data collected during - . the daily allergy symptoms and medication were recorded spontaneously using an app questionnaire on the subject's smart phone. the csms was re-calculated using the ean database, using the recorded symptom scores with estimation of the medication score using similar methods as recently published. the correlation between the daily grass pollen count and the daily csms was analyzed with a mixed effects model accounting for patient-specific correlations and symptom levels. conclusion: these results confirm a statistically significant correlation between grass pollen counts and the csms. importantly, these findings suggest that the optimal window to observe treatment effects after immunotherapy may be a short interval after start of the gps and during the peak gps, due to generally higher csms values. this provides sufficient basis to consider additional sensitivity analyses to evaluate the treatment effect of grass mata mpl scit on the primary csms endpoint during a shortened window after the start of the gps and to consider excluding the overlapping period between the bps and gps from the primary analysis. | combo-vas as a tool to assess efficacy of allergen immunotherapy ciprandi g ; silvestri m ; olcese r ; tosca ma ospedale policlinico san martino, genoa, italy; istituto g. gaslini, genoa, italy background: allergen immunotherapy (ait) is at present the unique cure for respiratory and venom allergy. usually, ait lasts for some years, but its efficacy is longstanding. criteria for assessing ait efficacy are mainly based on symptom severity improvement and saving of symptomatic medications. in this regard, there are different score grading for both measuring symptom severity and drug use. visual analogue scale (vas) is a well-defined and validated method widely used in many diseases, including allergic disorders. vas is a psychometric tool measuring the patient's perception of symptoms, emotions, pain, drug use, etc. recently, it has been published an eaaci position paper concerning the recommendations for the standardization of clinical outcomes used in ait trials for allergic rhinoconjunctivitis, but it is complex. so we would propose a simpler way to measure ait efficacy by vas, in particular a combo-vas based on one vas for symptom and one for medications. results: globally patients were retrospectively evaluated. all of them were treated with a -year ait course: were defined as responders and as non-responders. in responders group the combo-vas mean value was (iqr - ) at baseline and (iqr - ) after ait treatment. in non-responders group combo-vas mean value was at baseline and (iqr - . ) at the end of ait. the difference was significant (p = . ). the d combo-vas was − . % in responder group and − % in non-responders group (p < . ). conclusion: combo-vas, i.e. the sum of vas for symptoms and medications, could be an easy and quick tool for assessing ait efficacy and reflects the patient's perception. therefore, it could be very fruitful in clinical practice. | rapid up-dosing in sublingual specific immunotherapy is safe, well-tolerated and effective in patients suffering from tree pollen allergic rhinitis background: an optimised up-dosing period of specific immunotherapy (sit) is desirable for better patient compliance because a long or complicated up-dosing scheme is sensitive to disruption. the aim of this study was to compare the safety, tolerability and effectiveness of an optimised up-dosing scheme with two preexisting schemes of sublingual sit (slit) in patients under standard medical care. method: this was a prospective, open, active controlled, multi-center non-interventional study in germany and austria to document the treatment of children and adults with allergic rhinoconjunctivitis and/or allergic asthma treated with a slit containing purified, aqueous extracts of birch, alder and hazel pollen. the investigators were free to select an up-dosing scheme for included patients: scheme a consisted of an up-dosing period of up to days at the patient's home using three different solution strengths to reach the maximum dose; ultra-rush scheme b performed only with the highest solution strength at the physician's office within hours, and the optimised scheme c which was initiated at the physician′s office and continued at home using exclusively the highest solution strength within (long-term) or (pre-seasonal) days. data on up-dosing and maintenance treatments were documented by physicians during patient visits and by patient diaries. the study was approved by ethic committees, and all patients or parents gave their informed consent. results: in total, patients aged - years were included into this study. scheme a was applied by patients, patients decided on regimen b, and patients on the optimised scheme c. conclusion: one-day ur-scit conducted in an outpatient clinic was safe and well-tolerated in patients with ad sensitized to hdm. ur-scit can be a safe and useful option to start a subcutaneous allergen immunotherapy for ad. | factors affecting on adherence to allergen specific immunotherapy results: among enrolled patients, ( . %) patients failed to complete at least years of ait, which were regarded to be nonadherent in this study. univariate analysis revealed that male, younger age group less than years, cluster and ultra-rush schedules, atopic dermatitis, the absence of associated diseases, and follow up of other department were found to be associated with nonadherence to ait. in multivariate analysis, younger age group less than years (or . , % ci . - . ), cluster ( . , . - . ) and ultra-rush schedules ( . , . - . ) , and absence of follow up of other department ( . , . - . ) were independently associated with non-adherence to ait. no association was found in gender, diagnosis of allergic diseases, kind of allergen extracts, and patients' distance from hospital. conclusion: various factors are related with ait non-adherence to interfere the effectiveness of immunotherapy. clinicians need to be aware of the factors associated with non-adherence to ait and consider them when choose to maximize ait adherence. | cost-effectiveness of allergen immunotherapy to grass in patients with allergic rhino-conjunctivitis and asthma background: allergen immunotherapy (ait) has been shown to reduce symptoms and medication use in subjects with rhino-conjunctivitis and asthma. however, long-term cost effectiveness of this therapy needs to be evaluated. our aim was to assess cost effective of ait, both subcutaneous immunotherapy (scit) and sublingual immunotherapy (slit), vs. pharmacotherapy alone in subjects with rhino-conjunctivitis, with or without allergic asthma, to grass pollens. method: a markov cohort state-transition model with a time horizon of years was used to assess the costs and effects of -year ait in adults. relative efficacy of the treatments expressed as standardized mean difference was estimated using an indirect comparison on symptom and medication score extracted from available meta-analyses. the rhinitis symptom utility index was used as a proxy to estimate utility values for symptom score. the societal perspective, through the human capital technique, was used to estimate indirect costs, to represent the scenario of a country with nationalized medicine. data on drug and other medical costs were derived from published sources as well as ait duration and asthma occurrence. additional sensitivity analyses were performed to test the robustness of our results. results: in the base case analysis, using italy clinical practice patients with moderate-to severe allergic rhino-conjunctivitis (ss ranging from to points) and a mean age at entry of years, both scit and slit were associated with increased cost but superior efficacy compared to pharmacotherapy alone. the results were most sensitive to variation in efficacy estimates and ait persistence rates. conclusion: this analysis suggests that ait is cost effective relative to pharmacotherapy alone. scit, despite significantly higher indirect cost burden, seems to be the most cost effective option. the results should be interpreted in the context of the data input and modelling assumption used. | ielisa as a tool to measure ige binding towards single modified peanut allergens background: immunotherapy has shown to be a potential treatment for food allergies but needs further research to improve safety. modification of peanut allergens to reduce their allergenicity is a promising approach to develop a safe and effective immunotherapy as shown by the successful completion of a first-in-human safety and tolerability study using hal-mpe in adult patients with peanut allergy (eudract - - ) . in order to assess the impact of modification on individual peanut allergens and to assess its impact on ige binding by individual patient sera, we have developed peanut allergen-specific inhibition elisas. with this methodology we are able to identify patients with residual ige binding to modified peanut allergens. method: ige inhibition elisas (ielisas) were developed and performed to test ige binding towards purified ara h and ara h and their reduced and alkylated (modified) versions, using the individual responses of single patient sera. results: ara h -specific ielisas showed that modification of ara h results in > % reduction in ige-binding for all individual sera tested. ara h -specific ielisas showed that modification of ara h also results in > % reduced ige-binding for most of the sera, but some sera were identified which showed residual, %- % ige binding to mara h . in some of the latter sera, the presence of ige binding to a linear hydroxyproline-containing peptide could be confirmed as a possible source for the residual ige binding to mara h . we have developed a methodology to assess residual ige binding to modified peanut allergens. the sensitivity of the allergen-specific ielisas allowed us to discriminate between patient sera in which ige binding to mara h and to mara h was virtually completely absent and sera in which - % residual ige binding to ara h was observed. the clinical importance of these observations is yet unknown. future clinical studies will need to reveal whether the patient-specific ige binding profiles to individual modified peanut allergens do correlate with the adverse events profile of immunotherapy with modified peanut extract. | design of a phase ii allergen immunotherapy study to determine the optimally effective and safe dose of subcutaneously administered tyrosine adsorbed modified grass allergen+mpl (mpl) adjuvants for the treatment of allergic rhinoconjunctivitis (arc) due to grass pollen. there is increasing evidence that the effectiveness of allergy immunotherapy to control arc symptoms is related to the cumulative allergen (or allergoid) dose administered. previously, two clinical studies have been conducted using a conjunctival provocation test (cpt) as primary efficacy measure for a similar scit mata mpl product for birch allergy [eudract - - and - - ] . these studies showed a . fold increase in cumulative dose to achieve~ % increase in efficacy, with a relative reduction in total symptom score (tss) of . % compared to placebo and no safety signals of concern. the shape of the dose response curve was curvilinear, where this high dose almost reached plateau. method: this is a multi-center (~ clinical study centers across europe), randomized, double-blind, placebo-controlled, parallel-group study in~ adult patients with moderate to severe seasonal arc with or without mild asthma. a positive cpt is to be achieved at screening and verified prior to randomization. the primary outcome is the post-treatment tss following cpt. a wide range of cumulative dose regimens is used ( , , and su) applied over weekly injections to establish the shape of the dose response to support dose selection for phase iii. the design of the current phase ii grass allergoid scit study will be discussed, including the rational of using cumulative dose regimens and placebo and the pre-selected shapes of the dose response curves. in addition, the number of patients screened and randomized will be presented by country, gender and/or age category and screen failures will be categorized. conclusion: this phase ii study was initiated to establish the dose response of a grass mata mpl scit product, using cpt to measure the effect of a wide range of cumulative dose regimens. the achievement of its aim will be an important milestone in the development of an efficacious and safe state-of-the-art grass scit. conclusion: we observed that the specific nasal challenge with house dust mite generates an inflammatory response within the first hours, but we did not demonstrate any correlation with the response to immunotherapy after six months. | tolerability of a two week rush updosing with modified allergens in pollen allergic subjects in the day-to-day practice background: in two phase iv studies the tolerability of a subcutaneous rush up-dosing, using three injections in two weeks, has been tested and proven to be save in adults. in the course of a non-interventional study (nis) now the tolerability of this treatment scheme was tested in the day-to-day practice. conclusion: over % of the patients could reach the highest dose of . ml. the overall tolerability is very good. the data from daily practice confirm the data that were previously obtained in two phase iv studies. siges from patients, evaluated during the st semester of at an outpatient clinic. all patients presented persistent moderatesevere allergic rhinitis, in pollen season and had not been submitted to it. all patients had positive spt for grasses (grass) and olive (olea). sige-tot for phleum pratense and olea europaea and some sige-crd (rphl p , rphl p , rphl p , rphl p , role and nole ) were determined. physicians were divided into groups (group if < years of practice and group if≥ years of practice) and were asked to choose which it to prescribe for each patient (none, only grass, only olive or both grass and olive), according to spt and sige results. results: fifteen physicians ( % with ≥ years of practice) participated in the survey. considering only the sige-tot results, the it choice (group / ) was: no vaccine in %/ %; grass vaccine %/ %; olive vaccine %/ % and both grass and olive vaccines in %/ % of the patients (p = . ), the intergroup agreement was % (kappa . ). according to the sige-crd results the physicians chose (group / ): no vaccine at %/ %; grass vaccine in %/ %; olive vaccine in %/ % and both vaccines in %/ % of patients however, data on control of allergic rhinitis (ar) after discontinuation of therapy are insufficient. the aim of our study was to assess sustained control of ar in three consecutive years after grass-pollen slit discontinuation. method: a total number of patients [ ( . %) males; mean age years, age range - ] well-controlled after a three-year course of slit with grass pollen extract were prospectively evaluated in three consecutive years after discontinuation of therapy. conclusion: a three-year course of grass-pollen slit seemed to have a long-term effect on control of symptoms in patients with ar. the authors declare no conflict of interest. results: all patients showed a positive sensitization profile by skin prick test to either betula and/or alnus. in % of patients this profile was furtherly confirmed with serum specific ige levels to betv , (mean . ku/l). allergic symptoms in patients with birch/alnus pollen allergy after ingestion of certain food can result from crossreactivity of bet-v -specific ige to homologous pathogenesis-related proteins, particularly the pr- protein. conclusion: within the allergy history we emphasize on focusing on sao symptoms as many patients under-recognize them. among the sensitization profile of these patients it is quite important to highlight cross reactivity between bet v and alnus. the other patient suffered from anaphylaxis(grade ii) induced by minimum amount of lettuce consumption without co-factors. both patients suffered from oral allergy syndrome to peach and allergic rhinitis. spts to foods and pollens were performed with commercial extracts, prick-through-prick with fresh plant foods, while specific ige was determined accordingly. ltp syndrome was defined as a sensitization to pru p and symptoms elicited by at least unrelated plant foods. co-factors were also investigated. results: the first patient was sensitized to lettuce, peanut, hazelnut, sunflower's seed, peach and banana, and plane tree, olive tree, grasses, parietaria and mugwort. sige to lettuce was . kua/l, to pru p was . kua/l and total ige was . u/ml. co-factors, such as exercise, were involved. the second patient was sensitized to peanut, walnut, hazelnut, almond, sunflower's seed, cashew, lettuce and peach, and, plane tree, olive tree, grasses, parietaria, mugwort and willow. sige to lettuce was . kua/l, to pru p was and total ige was . ku/l. no co-factors were identified. background: garlic (allium sativum) is a vegetable that belongs to amaryllidaceae's family. hypersensitivity to garlic is not very common. it has been mainly reported in occupational allergy but it also may cause contact dermatitis, rhinoconjunctivitis, asthma, urticaria, gastrointestinal symptoms and anaphylaxis after its ingestion. some studies have identified alliin lyase, a kda protein, as a major garlic allergen and it seems to be a heat-sensitive allergen. we report on a -month-old infant who presented, minutes after an accidental ingestion of garlic sauce, generalized erythema and cough. she was still breastfeeding and she had never abstracts | eaten garlic before (although the mother usually consumed garlic). the patient had never tasted other vegetables belonging to amarylidaceae's family either but zucchini, with good tolerance. we performed skin tests and specific ige (sige) to different vegetables. a raw garlic extract was also carried out and analysed in the patient by sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page). results: prick by prick with garlic was positive ( mm) and negative to onion, leek, asparagus, zucchini and saffron. skin prick tests to commercial extracts of mugwort, grass pollen, peach ltp and profilin were negative as well. specific ige to garlic was . ku/l (out from a total ige ku/l) and ku/l to onion and asparagus. sds-page immunoblotting assay with patient′s serum revealed ige reactivity with proteins of kda and kda. conclusion: we report a garlic ige-mediated anaphylaxis case in an infant with proteins of and kda as the relevant allergens. the mechanism of sensitization in the present case remains unclear. the authors hypothesized that breastfeeding, cutaneous contact or inhalation might be possible mechanisms involved. chong kw ; saffari se ; chan n ; seah r ; tan ch ; goh sh ; goh a ; loh w allergy service, department of paediatric medicine, kk women's and children's hospital, singapore, singapore; centre for quantitative medicine, office of clinical sciences, duke-nus medical school, singapore, singapore; yong loo lin school of medicine, national university of singapore, singapore, singapore background: the predictive decision points for both peanut skin prick test (spt) wheal size and serum ige concentrations, in peanutsensitized children, have not been evaluated in singapore. we aim to assess these for purposes of risk stratification and prediction of oral food challenge (ofc)s' outcomes by means of a retrospective chart review. results: the number of patients evaluated was , of which had clinical diagnosis of peanut allergy based on recent immediate reaction to peanut (pa group) and were tolerating peanuts regularly (pt group). the mean age of both groups were similar, . ± . and . ± . years in pa and pt groups respectively. there was a high prevalence of atopic diseases in both groups, with atopic dermatitis ( . % in pa, . % in pt), and other food allergies ( . % in pa, . % in pt). presence of rhinitis was statistically higher in the pa group compared to the pt group, with odds ratio of . ( % ci: . - . ) . a wheal size of ≥ mm and a peanutspecific ige of ≥ ku/l provided for a % positive predictive value. the larger the wheal size on spt, the higher the probability of a clinical reaction to peanuts. the results will help us in deriving preliminary cut-off values when conducting future prospective studies with ofcs in our peanut-sensitized cohort (whom had no prior peanut exposure), and to eventually reduce the need for expensive and potentially risky food challenges. | ginger: flavory, spicy …allergenic? a report of four patients with allergy to ginger background: ginger (zingiber officinale) belongs to the family zingiberoidae, along with cardamom and turmeric. the edible portion is the horizontal rhizome, and it is very appreciated for its aroma and spicy flavor. it also presents great interest for its therapeutic and culinary use. hypersensitivity to ginger is rare and has been scarcely reported. we report cases (p , p , p , p ) of adverse reactions to ginger after its ingestion and with good tolerance to cardamom and turmeric. method: skin prick tests (spt) to environmental allergens and prick-by-prick with ginger were carried out. total ige, and specific ige to ginger were also determined. a raw ginger extract was prepared. this extract was analyzed in all the patients by sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page). background: food allergy is divided into groups according to pathophysiology: ige-mediated, ige-and non-ige (mixed type), and non-ige (cellular type). however, in clinical practice, patients who fall under more than one group may be observed. method: patients who were diagnosed with food allergy at our clinic from january to december were included in the study. the medical files of patients were retrospectively evaluated, their symptoms and findings after consumption of foods were recorded, and they were categorized into groups (ige-mediated type, non-ige type, and mixed type) according to their symptoms and findings. results: a total of patients ( . % male) with food allergies were included in the study. according to categorization via symptoms and findings, the distribution of patients was as follows: ( . %) ige-mediated type, ( . %) non-ige type, ( . %) mixed type. the remaining ( %) patients were found to show various combinations of symptoms and findings that fit more than one group. in this study, we observed that food allergy symptoms and findings were distributed in a broad range which caused difficulties in the categorization of more than one-third of our patients. background: fish allergic patients suffer a lifetime of strict dietary restrictions. crocodile meat is a nutritious alternative choice in many countries around the world; however, it has recently been reported to also trigger severe allergic reactions. in these two case reports from pediatric patients were sensitised to the major fish allergen parvalbumin (pv), a potential cross-allergen. bony fish contain predominantly pvs of the β-lineage, which are the most common trigger of allergic reactions in fish allergic patients. in most other vertebrates, pvs of the α-lineage are most abundant, which have been reported as a causal allergen in frog, cartilaginous fish, and chicken allergies. we aimed to evaluate the allergenicity of crocodile meat in fish allergic children, with focus on pv. method: over children with clinical history of ige-mediated fish allergy were identified, skin tested to commonly consumed fish species using commercial and in-house preparations, and serum samples were collected. a sub-cohort was skin tested to crocodile using heat-treated tail muscle tissue from saltwater crocodile (crocodylus porosus). extracted proteins and purified pvs were analysed by sds-page, immunoblotting, and mass spectrometry. serum from all fish allergic children was analysed for ige reactivity to the crocodile pv. this reactivity was compared to those of raw and heated crocodile protein extracts as well as protein extracts and purified pvs from frequently consumed fish species. results: more than fish allergic children were positive on skin testing to crocodile (wheal size> mm), demonstrating its clinical reactivity. in vitro analyses revealed ige reactivity to crocodile pv in serum from more than half of all patients. two βand one α-crocodile-pv isoforms were identified. pvs constituted approximately % of total proteins in heated crocodile extracts, with β-pv ( kda) being times less abundant, but up to times more ige-reactive than α-pv ( kda). αand β-pvs from crocodilians, including alligators and crocodiles, share more than % and % of their amino acid sequence, respectively. conclusion: crocodile pv is a new allergen as per the iuis guidelines. fish allergic patients may be at risk of severe allergic reactions upon ingestion of crocodile meat due to strong ige cross-reactivity of β-pvs. this study suggests that fish allergic individuals and health professionals need to be aware of potential allergic reactions to meat from crocodilians, termed 'fish-crocodile syndrome'. background: we present a -year-old nonatopic woman that in december after eating a seafood paella with green pepper presented asthenia, nasal obstruction, incoercible vomiting and diarrhea. later she ate a grilled loin sandwich in a bar and she had the same symptoms (she asked the waiter at the bar and the chef had cooked her sandwich in the same pan where he had cooked green pepper just before). after that, she suffered from abdominal pain, nausea, abdominal distension without diarrhea two hours after she ate an omelet sandwich with certain flavor of green pepper. at present even the casual smell of pepper causes her nausea. the woman eats everything including spices and just avoids pepper. method: skin prick tests were performed using extracts from food (nuts, fish, mollusk, fruits, vegetables, legumes), aeroallergens (mites, abstracts | pollens and epithelia) and purified proteins (pru p , profilin, polcalcin, alfalactoalbumin, betalactoglobuline, casein). we also performed prick by prick to raw and cooked green pepper. sds-page immunoblotting according to laemli under reducing conditions (with -mercaptoethanol) was performed to study the molecular mass of the ige-reactive proteins. extracts from green pepper and green pepper seed were used. the prick tests were all negative and the prick by prick test to raw and cooked green pepper was positive in both cases. blond was taken from all patients to specify the levels of allergenspecific ige against allergen components of immunocap isac test, the result≥ . isu-e was assumed as positive. results: in the study group, in patients ( %) specific antibodies against ltp were detected, the isu-e level range . - average . isu-e on average, in patients with detected ltp ige was detected for . components belonging to the ltp, however the highest number % patients were detected ige only for ltp. in subjects ( % of respondents with detected ltp), ige was detected against art v and this is the only ltp component whose occurrence was statistically significant (p = . ). in patients ige was detected against pru p , jug r , pla a ,; patients ige to ara h ; patients cor a ; patients ole e , patients tri a , and in person para j . background: the birch pollen-associated oral allergy syndrome (oas), an ige-mediated local allergic reaction, is the most common manifestation of pollen-associated food allergies. its origin is explained by cross-reactions between birch pollen-and food-allergens belonging to the pathogenesis-related protein subfamily (pr- ). [ ] so far, there is no marker available for its detection and no standardized test established to evaluate objectively the subjective feelings experienced by oas. the diagnosis is based on a characteristic history and on detecting the sensitization to triggering allergens in skin prick test (spt) and laboratory examination. method: the aim of this study was to evaluate whether the food skin prick test could be a helpful marker in the diagnosis of a birch pollen-associated oas. for this exploratory study, data from - was collected retrospectively at the dermatological outpatient department of the ordensklinikum linz elisabethinen. patients with positive spt results for birch pollen were included. the variables age, gender, tree pollen-(birch, alder, hazel) and food-spt, laboratory tests (ige, bet v , bet v , gly m ) and symptoms (oas, rhinoconjunctivitis allergica, atopic dermatitis, anaphylaxis) for statistical analysis. results: there was an association between food-spt and oas but also between the negative oas patients and food-spt (p = . - . ). all of the bet v sensitized patients with positive gly m results had also a positive food-spt result. conclusion: there was no evidence for a possible role of food-spt as helpful markers in the diagnosis of birch pollen associated oas. maybe gly m could be a helpful marker, but more data are needed. bet v seems to be the cause of birch-pollen associated oas, due to the dominant sensitization pattern to major allergens in austria. background: eggs are among the foods most frequently causing allergy. the most common one is hen egg, although we may consume other bird's eggs such as duck's, those of goose, quails and seagulls. clinical and serological crossreactivity between hen egg proteins and those of other birds eggs have been described. allergy to other species eggs are less frequent and are usually described in patients allergic to hen eggs. we report a case of food allergy after ingestion of duck egg in an adult patient without hen egg allergy. the patient was a year-old man who had symptoms of generalized itching, swelling uvula, erythema neck and deglutition difficulty immediately after he ate eggs from duck and hen. he claimed to have eaten hen eggs almost daily without clinical symptoms and he had not previously ingested duck egg. he denied allergic reactions to any other food but did complain of seasonal allergic rhinoconjunctivitis in the spring. we performed skin prick test with extracts of egg and feathers, prick by prick test with cooked and fresh yolk and white from duck and hen egg and oral challenge with hen eggs. specific serum ige was measured to hen proteins and we carried out a western blot with the proteins of allergenic extracts from different eggs (white and yolk of quail, chicken, goose and duck) and an inhibition of western blot with ovalbumin as inhibitor allergen. results: skin test with extracts of eggs and feathers, cooked and fresh hen and duck eggs were positive. total serum ige was . ku/l. specific ige to hen's egg was class two for hen egg white, ovoalbumin and class one for yolk and ovomucoid. oral challenge with heated egg yolk negative and with egg white was positive. the patient's serum recognized mainly and intensely several proteins of white and egg yolk of quail and duck with a molecular mass around to kda respectively. on the other hand a protein around and - kda was unique recognized in white eggs of hen and goose. the western blot inhibition revealed ovalbumin inhibited the protein recognized in the egg white but not egg yolk involved in. background: management of tree nut allergy is usually based on the avoidance of the suspected tree nut (tn), as well as peanuts and seeds, either because of the risk of cross-reactivity and/or contamination, or due to the clinical severity. objective: to assess the sensitization pattern and clinical reactivity patterns to different tn, peanut and sesame seeds (ss) in patients with a history of reaction to at least one of these foods. results: a total of patients with confirmed nut allergy were included; % female, median age [interquartile range] of years; % were atopic. the most frequently involved foods were walnuts ( %), hazelnuts ( %), almonds ( %) and peanuts ( %). anaphylaxis was the clinical presentation in % of the patients. in those with a history of reaction to only one nut ( ), the most prevalent was peanut ( %). in the patients that reacted to more than one nut, the most frequent combinations were walnut/hazelnut ( ), walnut/almond ( ) and almond/ hazelnut ( ). of these patients, tolerated other nuts. two had sesame seed allergy, one reacted only to ss. nine patients ( %) were sensitized to foods that they tolerated. fourteen ( %) patients were sensitized to ltp and of them reacted to more than one nut. conclusion: these data concur with the existence of different sensitization profiles (primary, concomitant or cross-reactive), which may predict different clinical reactivity patterns and therefore, influence dietary recommendations. background: buckwheat (fagopyrum esculentum) is a polygonaceae weed, not a cereal, which is increasingly been consumed and used as an alternative food in the diet of celiac patients. despite its wide use, allergy to buckwheat has unfrequently been reported in our setting. method: two female patients, aged and , suffered an immediate severe allergic reaction after eating a bread and a pancake containing buckwheat among its ingredients. the first patient presented generalized urticaria, palpebral angioedema and pharyngeal occupation. the second one showed those same symptoms, as well as abdominal pain, nausea, dyspnea, dizziness, hypotension and loss of consciousness. skin tests and specific ige determination to aeroallergens and food allergens were carried out, including prick-prick test with buckwheat and all other components contained in the food involved. buckwheat allergens were studied by sds-page and ige-immunoblotting of one of the patients. results: prick-prick tests yielded strongly positive results to the food itself and buckwheat, and negative to the remaining food components in both cases. cap was positive to buckwheat ( . ku/l and > ku/l, respectively). basal serum tryptase levels were normal. both patients were not sensitized to cereals, ltps, profilins or pr- proteins. for the first patient, the skin tests were negative for other foods, seeds and nuts. the cap was negative for ltps, profilins and storage proteins of peanut and other nuts. the second patient who had the most severe reaction, was also sensitized to hazelnut(cap . ku/l), pistachio ( . ku/l), almond( . ku/l), walnut( . ku/l) and sesame( . ku/l), which were not included in the pancake. the buckwheat immunoblot of the first case, under non-denaturing conditions, revealed a ige-binding protein of -kda. ige-immunoblotting under reducing condition showed protein bands of , , and kda in the buckwheat extract. conclusion: two cases of anaphylaxis by buckwheat flour contained in two frequently consumed foods are presented. the absence of sensitization to ltps, together with the pattern of specific ige binding in the immunoblot in one of the cases suggests that the responsible allergen could correspond to a storage protein of buckwheat, without cross-reactivity with other seed and nut allergens. buckwheat must be taken into account as an unsuspected food allergen capable of causing severe allergic reactions. background: allergy to linseed (linum usitatissimum) has infrequently been reported despite of its wide use in bread and in a range of "health food" products. linseed contains potent allergens which have not yet been characterized. we studied three patients who presented allergic reaction after eating different foods which contain linseed. two of them (patient p and patient p ) had anaphylaxis and the third one (patient p ) had oral syndrome, abdominal pain and diarrhoea. p was also allergic to mustard and p to sesame seed. all of them tolerated the remaining seeds, nuts and food. baseline tryptase levels were in normal range in all patients. skin tests and specific ige determination to inhalants and food allergens were carried out. linseed allergens were studied by sds-page and ige-immunoblotting. skin tests: patient : prick tests were positive to pollens and linseed, and negative to ltp, profilin, nuts, seed and the remaining food; patient : prick tests were positive to linseed and mustard and negative to other food and inhalants; patient : prick tests were positive to linseed, pollens, sesame and nuts (peanut, hazelnut, almond, pistachio). we present three cases of severe allergic reactions to linseed. the pattern of specific ige binding in the immunoblot seems to lead to storage proteins as the responsible allergens. | pr- sensitization-looking it up in food allergy background: pr- protein group sensitization is found in patients with respiratory allergy, mainly in areas inhabited by trees of the betulacea or fagacea families. its role in food allergy is, however, more frequently described in the context of cross reactivity. our aim was to characterize the pattern of molecular sensitization of food allergic patients sensitized to pr- protein group with immu-nocap isac ® (isac). the remaining patients, with more severe reactions, were all co-sensitized to either ltp and/or storage proteins (sp). only of the patients without pfa were co-sensitized to ltp or sp versus of with pfa (p < . ). conclusion: pr- sensitization is rare in our population. approximately half of the patients had allergy to plant foods, but the majority were co-sensitized to ltp and/or sp. the few patients only sensitized to pr- had minor reactions. among the patients without plant food allergy, co-sensitization to ltp and sp was significantly less common. according to these results, in our population, pr- seems to be less relevant to food allergy, when compared to reported results from other european countries. gür Çetinkaya p; uysal soyer Ö; esenboga s; sahiner Üm; sekerel be hacettepe medical school, ankara, turkey background: pistachio is a tree nut belonging to "anacardiacea" family, and constitutes % of tree nut allergies. this nut most often abstracts | cross-reacts up to % with cashew which is located in the same family. pistachio allergy is mostly seen in iran, turkey, the united states, and china where this tree nut is frequently consumed. in this study, we analyzed age and cut-off values for development of tolerance to pistachio. method: children who had reported allergic reactions with pistachio, and who have not consumed pistachio, but had positive spt and/or specific ige levels were enrolled into the study. spt and specific ige levels were measured in all patients. oral provocation(op) tests with pistachio were performed by patients, and of them had positive test result. the median age of tolerance development was months (iqr: . - . months). the most commonly involved systems during op tests were skin ( %, n = ), gastrointestinal system ( %, n = ), and lower respiratory tract ( %, n = ). concomitant allergic diseases were atopic dermatitis ( %), asthma ( %) and allergic rhinitis ( %). there was a positive correlation between skin prick test diameter (spt) and specific ige levels (spige) (r = . , p = . ). spt of≥ . mm to pistachio nut was found as highly predictive of clinical allergy (auc: . , %ci: . - . , p < . ). any relation was not determined between eosinophil, basophil counts, triptase levels, and op test positivity. conclusion: pistachio allergy is one of the frequently seen nut allergies in turkey which may cause serious allergic reactions including anaphylaxis. op test showed that tolerance was achieved by the median age of months, and a cut-off level of . mm was best predictor for positive reaction. in an oral challenge test, the patient responded with generalized urticaria, swelling of the lips and difficulty breathing at a cumulative dose of . g peanut protein, however, without blood pressure drop. (grade , moderate symptoms). the patient was treated with anti-ige for months (with mg every weeks sc). oral desensitization began with ingestion of μg peanut, escalating to mg, on the first day and escalating weekly doses of peanut from mg to mg ( peanuts). then anti-ige was discontinued while the patient ingested peanuts every day. we have followed the patient's sensitivity to peanuts from before anti-ige treatment to after anti-ige washout with basophil testing. results: the patient completed desensitization without side effects, and continues to ingest peanuts a day. basophil sensitivity was reduced -fold by anti-ige treatment, but returned to baseline levels after anti-ige washout. conclusion: anti-ige allows rapid desensitisation of peanut allergic subjects with peanut oral immunotherapy. in the majority of subjects, this desensitization is sustained after anti-ige is discontinued. additional studies will help clarify which patients would benefit most from this approach. the return of basophil response to pre-treatment levels suggests that the patient is desensitised, and depends on the daily ingestion of allergen. what do we (not) know? background: the use of biologic prosthesis is a well-established surgical procedure. acute and delayed complications may occur, but accurate epidemiologic data about allergic reaction to graft tissue is lacking. methods: a years old boy referred to our unit for urticaria and gastrointestinal symptoms which developed a few years before. he received a biologic porcine vascular duct during a cardiovascular surgery at days of life. at the age of urticarial episodes occurred, and a diagnosis of beef allergy was made. after the exclusion of beef meat from the diet, most symptoms resolved, but the child began to complain about occasional episodes of vomit and diarrhoea. results: skin prick tests confirmed the beef meat sensitization and prick-prick test resulted positive against raw pork meat but not against cooked pork meat. in vitro tests demonstrated the presence of pork meat specific iges ( . kua/l). component-resolved diagnostic tests revealed allergy sensitization toward bos d (bovine serum albumin, bsa; porcine serum albumin was not tested due to lack of a specific test). after accurate exclusion of pork meat from diet, a complete remission was achieved, and the diagnosis of pork meat allergy was confirmed. conclusion: bsa is a major beef allergen, responsible for the raw beef-cow milk cross-reactivity but with a scarce importance in milk allergy. it is highly homologous with human serum albumin and other mammalian serum albumins, including porcine albumin. porcine albumin is also highly homologous with cat serum albumin and therefore responsible for cross-reactivity in patients affected by cat-pork syndrome. we hypothesize that the implanted porcine tissue was the trigger for pork meat allergy in our patient, as this condition is exceptional in childhood and that our patient never owned a cat. few cases of pork allergy due to porcine tissue implantation have been reported so far. of interest, pig sensitization was recognized as a rare but possible cause of blood-culture negative endocarditis in patients with porcine bioprosthesis according with anamnesis, increased ige level against pork, tissue eosinophilia during autopsy. background: desensitization to foods is assuming a new paradigm in food allergy. this technique is becoming widespread especially for patients with egg and milk allergy, but the effect of desensitization on the consumption of similar but not identical foods is still uncertain. material and methods: we describe the case of a -year-old patient, with a history of chicken egg allergy, who had been successfully desensitized tolerating cooked and raw chicken eggs for a year. the patient came to the office after presenting an episode of anaphylaxis immediately after eating fried quail eggs. an immunological study was carried out. we performed skin prick test with chicken egg′s proteins (white, yolk, ovoalbumin and ovomucoid). an immunoblotting to detect specific ige to egg proteins was also performed. for this purpose, the following extracts were used: chicken egg white and yolk (commercial extract form alk) and quail egg white and yolk prepared following a similar procedure (extracted in % phosphate buffer (w/v)). conclusion: we present the case of a patient with specific allergy to quail egg white and yolk, probably through ovotransferin, but not to chicken egg. the desensitization against chicken eggs does not allow the consumption of eggs of other species of birds, such as quail eggs, and this indication must be made specifically to patients after a protocol of desensitization against chicken′s eggs. case report: seven years ago we presented the case of a year-old male, who suffered two acute episodes of oral pruritus, lip angioedema, epigastric pain, generalized urticaria and dizziness after ingesting lettuce. he previously tolerated salads (including lettuce). he was later diagnosed with non-ltp-dependent lettuce anaphylaxis and an aspartyl protease was identified as a new lettuce allergen with cross-reactivity with other members of the compositae family. since the diagnosis he has avoided lettuce and all the other compositae. we present the patient's curious outcome after years of follow up. methods: total ige, basal tryptase, specific ige to lettuce by immu-nocap, prick-prick and oral challenge tests with lettuce and other compositae. sds-page, immunoblotting and molecular characterization of ige binding bands by mass spectrometry. skin prick tests and specific ige to lettuce were repeated on several occasions in the following years. after years an oral challenge test with lettuce was carried out. results: prick-prick test was positive to fresh lettuce ( × mm) and to other compositae (raw endive, chicory, thistle, artichoke and chamomile). prick-prick test was negative with these boiled compositae. basal tryptase was . μg/l. total ige in serum was ul/ml. specific ige by immunocap was positive to lettuce ( . ku/l) and negative to profilin, ltps and thaumatin. oral challenge test with endive was positive and negative with cooked compositae (artichokes and thistle). sds-page and immunoblotting detected an intensely binding ige band about kda, common for endive and chicory, which was identified by mass spectrometry as an aspartyl protease. no bands were detected at ltp ( kda) and profilin ( kda) . in the first two years after the diagnosis, prick-prick test and specific ige to lettuce remained positive (cap . ku/l and . ku/l, respectively). after years, prick-prick test and specific ige to lettuce became negative (cap . ku/l). with this findings a new oral challenge test with lettuce was carried out which result turned out negative. we report the first case of spontaneous tolerance to lettuce in a patient who previously presented lettuce anaphylaxis and identify an aspartyl protease as the causative allergen. introduction: eosinophilic esophagitis (eoe) is an emergent allergic inflammatory disease that is triggered by food allergens and characterized by progressive esophageal dysfunction. recently, it has been seen that eoe develops in up to . % of patients with ige-mediated food allergy undergoing oral immunotherapy (oit). ingestion of baked milk and egg was associated with increased development of tolerance to regular milk and immunologic changes have been reported in subjects ingesting baked milk and egg, similar to those seen in food oral immunotherapy studies. case description: we present the case of a -year-old girl, with history of ige mediated cow′s milk allergy and rhino conjunctival and bronchial asthma symptoms. prick test against milk proteins showed: milk mm, alpha-lactalbumin mm, casein mm and to beta-lactoglobulin: negative. total ige: ku/l. specific ige to milk: , alpha-lactalbumin: , ku/l; casein: ku/l and beta-lactoglobulin: . ku/l. we performed an oral food challenge with baked milk which was well tolerated. then, we performed an oral food challenge with fresh milk and she presented facial urticaria and pharyngeal pruritus. after months eating baked milk every day, she had symptoms of dysphagia and esophageal food impaction. for this reason, we performed an esophagogastroduodenoscopy (egd) and biopsies which showed white exudates and vertical furrows. the histological study showed eosinophil count> per high-power field. eosinophilic esophagitis was diagnosed and she started treatment with esomeprazole mg. the egd was repeated weeks later with similar results in the biopsy. she was treated with a comprehensive diet free of cow′s milk proteins. after weeks she was asymptomatic and endoscopy and biopsy findings were normal. we report the case of a cow′s milk allergic patient who developed eoe after introduction baked cow′s milk which apparently was tolerated in her diet. the avoidance proved efficacy in inducing the remission of eoe. method: we examined bottle-feeding infants with food allergy aged from to months. serum vitamin levels were measured by immunoassay methods (retinol binding protein (rbp), vitamin b , hydroxy vitamin d), biochemistry methods (vitamin c, vitamin e) and microbiology methods (vitamin b , vitamin b ). as criteria for complete sufficiency standards adopted in the russian federation were used (the lower limit of normal levels: rbp - . μmol/l; b - ng/ml; -hydroxy vitamin d- ng/ml; vitamin c - . mg/dl, vitamin e - . mg/dl; vitamin b - μg/ml; vitamin b - ng/ ml). results: complete sufficiency were observed in infants ( . % cases), one vitamin deficiency in infants ( . %), two vitamins deficiency in infants ( . %), three and more vitamins deficiency in infants ( . %). should be used after vitamin status asses, mainly using monovitamin medication. results: patients were followed with the diagnoses of cma and asthma. age at the beginning of symptoms and start of oit were in the range of - months and - years, respectively. they had high total ige ( - iu/ml), milk spige ( . - kua/l), casein spige background: food allergies may affect up to % of school-aged children. it has been shown that approximately % of all anaphylactic reactions caused by food allergy are firstly presented at (pre) school. therefore, it is of high importance that (pre)schools have a policy on food allergy management and the use of an epinephrine auto-injector (eai). to our knowledge, limited is known on the policies of food allergy management at (pre)schools. the aim of this study was to investigate the policy on food allergy management in preschools and primary schools in the northern part of the netherlands. results: we included preschools and primary schools in this study. we showed that . % of the preschools and . % of the primary schools had a child(ren) with food allergy. only . % of the participating preschools and . % of the primary schools had a policy on allergen avoidance and only . % of the preschools and . % of the primary schools had a policy for the use of an eai. the majority of the pre-and primary schools in the northern part of the netherlands have children with food allergy. however, only a limited number of (pre)schools do have written guidelines for food allergy management in (pre)schools. additionally, there is limited experience how to use an eai at (pre)schools. therefore, an evidence-based policy on food allergy management in (pre) schools is needed. background: food allergies are the most common cause of anaphylaxis in childhood. here we present cases had anaphylaxis due to cow 's milk allergy, and treated with specific oral tolerance induction (sotİ) to cow' s milk. method: soti protocol was administered according to previously published by longo et al. skin prick test were performed according to standard methods with allergens. cow's milk specific ige was investigated with immunocap system. in all cases, the wheal size of the cow's milk in skin prick tests or the specific ige levels was higher than level of positive predictive value of %. results: case : a years old male patient who had anaphylaxis after milk consumption. soti treatment was started one year ago. there was no complications during the dose increasing phase. however, he had two episodes of anaphylaxis during the maintenance phase. in the final visit, we observed that he could drink ml milk and could consume dairy products. case : eight-year-old male patient has an intensive care-of-hospitalization story due to anaphylaxis three times after milk consumption. his accordance to strict diet was bad, and had frequent asthma attack. anaphylaxis developed times during the dose increasing phase in soti protocol. after soti treatment, he could consume ml cow's milk and dairy products without problems. case : a -year-old male patient followed-up for asthma and cow's milk allergy. it was learned that anaphylaxis developed times after milk consumption. he was fed in accordance with the milk-free diet. he has used fluticasone nebules, montelukast, mometasone nasal spray, and cetirizine. anaphylaxis developed times during the dose increase phase of soti administration. there were many mild to moderate anaphylactic episodes during the maintaining phase. after the soti treatment, he could consume ml milk and dairy products. background: cow's milk protein allergy (cmpa) is one of the most common food allergies in early childhood. small dietetic group sessions for parents of infant with non-ige mediated cmpa were held to meet increasing demands and reduce waiting times. parents were given information on cmpa, advice on weaning and milk reintroduction using a locally designed milk ladder. parents were also advised to contact the dietitians via telephone if they had further questions. we aim to evaluate the sustained effectiveness and patient satisfaction of the group sessions. method: parents and carers who attended the group dietetic sessions held between november and july were included in the survey. feedback were obtained via a self-designed questionnaire using a likert-type scale, rating several questions from (least satisfied) to (most satisfied). initial feedback was obtained directly after the session. we followed these patients up a year after the initial session via telephone and postal questionnaire. results: overall attendance rate of the group sessions held was % (n = ). during the initial survey, participants found the group session useful (mean score . out of ) and felt more confident in managing cmpa (mean score . ). we successfully obtained follow up feedback from participants. majority agreed that the group sessions have been informative (mean score . ). they also said they felt confident weaning their child on milk-free diet (mean score . ), and in reintroduction of cow's milk in diet (mean score . ). % (n = ) said that they would have preferred an individual session. % (n = ) have contacted the dieticians via telephone after the initial session, and % (n = ) had requested individual consultations. % (n = ) have attempted reintroduction of cow's milk in their child's diet using our local milk reintroduction guide. the mean age at first challenge was months (age range to months), with average of two attempts. % (n = ) have been successfully challenged and are managing well on a normal diet. we recognised the limitation in obtaining feedback via telephone and postal questionnaire, which resulted in the poor follow-up response rate. overall, parents felt more confident in managing cmpa and the positive responses were sustained a year on, highlighting the success of these group sessions. follow up opt-in sessions could be offered to provide additional support and allay parental anxiety in challenging their child with cow's milk at an appropriate age. results: goats and rabbits were immunized with specific allergoids, the allergoid-specific igg titer determined and sera pools produced. the allergoid reference material was comprehensively characterized. while ige reactivity of the allergoids was not detectable anymore, igg reactivity was maintained. allergoid-specific assay parameters as serum dilution, reference dilution and sample dilution factor to obtain at least six data points within the pseudo-linear range of the inhibition curve were determined. with these set parameters the evaluation of the analytical method was performed. the assay showed very good results in terms of linearity, accuracy, precision, reproducibility and robustness for all investigated allergoids as well as aluminum-adsorbed allergoid-preparations. conclusion: with the developed immunological inhibition assay, it is possible to determine the specific igg reactivity of allergoids in different preparations. the performance of the analytical method met all pre-defined acceptance criteria, which will be confirmed in the next step by a validation procedure according to ich-guidelines. case report: we present the case of a -year-old patient, diagnosed with rhinitis and asthma due to sensitization to pollens, as well as dyshidrosis and allergic contact dermatitis to cobalt. the patient presented a cutaneous pattern consisting of erythematous papules, some scaly, very pruritic, of initial appearance in the upper limbs - days after initiation of administration of specific immunotherapy extract (depigoid forte grasses, leti ® ). subsequently generalize lower limbs and neck. she presented them repeatedly and late after - days of the first doses administered. she referred partial control of pruritus with oral antihistamines, without total resolution of lesions for weeks. immunotherapy was suspended persisting the skin lesions for more weeks. according to the personal history of sensitization to metals, and the clinic presented in a temporal relationship with the use of an extract of immunotherapy with aluminum hydroxide, a study was requested with epicutaneous tests with aluminum hydroxide as well as with epicutaneous tests with immunotherapy extract. aluminium hydroxide and depìgoid forte grasses extract epicutaneous test were negative. in subsequent visits the patient reported that coinciding with the start of immunotherapy, presented at home and mainly in her bedroom a plague of cimex lectularius, popularly known as bedbugs, proving that they had been the cause of bites on their skin, and later skin reaction. patient reported that with the elimination of said pest the skin lesions disappeared. the administration of its immunotherapy extract was tolerated. cimex lectularius, commonly known as bed bugs, is a hemiptera insect of the family cimicidae. the clinical picture usually corresponds to multiple pruriginous lesions from the prurigo type, to multiple erythematous plaques, some infiltrated and others with a urticarial appearance, or even bullous. the lesions last for to weeks without treatment, and while the older ones heal, new ones may appear. in our patient it was not considered as an initial diagnosis, having considered immunotherapy as an etiological factor, but we must not forget that although in our country it is not a reason for frequent consultation, either due to underdiagnosis, because of the transitory nature of the pathology or because of scarce number of causative agents, it is important to consider insect bites in the differential diagnosis of dermatosis. di cara g; salvatori c; testa i; pacitto a; bizzarri i; isidori c; tarsia m; esposito s università degli studi di perugia-dipartimento di scienze chirurgiche e biomediche, perugia, italy background: house dust mites (hdm) are one of the most important allergens involved in childhood respiratory diseases, and the most frequently prescribed extract for sublingual immunotherapy in children (slit). despite the improvement of standardization methods for the production of slit, the differences in cultivation and purification processes used to produce raw materials for specific immunotherapy extracts may still impact on the final composition of mite allergen extracts. our study investigated the total protein and main allergen content of five commercial hdm sublingual immunotherapy extracts using sds-page and immunoblotting. recombinant allergens of group and group major allergens were used to test the immunogenicity of such extracts. method: hdm slit extracts were purchased from five italian suppliers (alk-abellò, allergy therapeutics, anallergo, lofarma, stallergenes). the protein composition of extracts was evaluated analysing equal volumes ( ml/lane) by sds-page ( % separating gel) and subsequent immunoblotting. for identification of allergens in the extracts, western blot analyses were performed with rabbit monoclonal antibodies (raybiotech) against der p and der p . the total protein content in the five tested commercial extracts showed a relevant variability. the protein contents ranged from . to . μg/mg for what concerns der p , while der p showed a greater variability, ranging from . to . μg/mg. sds-page showed a similar pattern of distribution in of the tested extracts, which showed protein bands of comparable intensity, while extracts showed a lower total protein count. extract showed a higher intensity band corresponding to the molecular weight of tropomyosin. western-blotting showed a similar concentration of der p in most extracts, while der p was more variable. conclusion: our analysis of five commercial extracts commonly used for sublingual specific immunotherapy against hdm showed important variations in term of total protein content. a less evident but still relevant difference was also evidenced when testing the major allergen content, with up to % variation in der p and up to a -fold variation in der p concentration. this differences, likely related to the different production and extraction methods, could still be responsible of a different immunological response in children who underwent slit. method: we evaluated children who had completed their immunotherapy treatment. along with demographic data we were able to record skin prick test (spt) results and mrqlq at start and end of treatment. we only included patients who had completed pre and post treatment questionnaires in the study to allow a comparison. the scores were evaluated using a student t test. results: patients' starting age ranged from to years (mean years). of the children had completed pre and post treatment questionnaires. all had grass pollen allergy confirmed on spt at the start of treatment. patients ( %) had isolated grass pollen allergy on spt and ( %) had multiple allergies. mean start treatment score for all patients was on mrqlq. mean score at end of treatment was , indicating a % reduction in total mrqlq score (p value < . ). for those with multiple allergies the mean total mrqlq scores were at start of treatment and at end of treatment, indicating a % reduction (p value . ). for those with isolated grass pollen allergy scores were at start of treatment and at end of treatment indicating a % reduction (p value < . ). conclusion: for children with uncontrolled symptoms of allergic rhinoconjunctivitis, grass pollen immunotherapy is associated with statistically significant improvement in quality of life. this improvement is most beneficial for patients with isolated grass-pollen sensitivity on spt. those with multiple aeroallergen sensitivities on spt did show an improvement (not statistically significant) post-treatment. grass-pollen immunotherapy is an effective treatment for rhinoconjunctivitis to offer patients in a rural dgh setting. background: allergic asthma is a common clinical refractory disease, most patients with asthma are accompanied by varying degrees of allergy. in clinical practice, treatment of this disease using specific immunotherapy has proven effective. in the current study, we examined the effectiveness of specific immunotherapy in a total of patients admitted to our hospital from to . method: to investigate the clinical efficacy of allergic asthma-specific immunotherapy. patients were selected, of which were males, aged to years, females, aged between to years old, all patients were clinically diagnosed only as allergic asthma. the patients were randomly divided into two groups, including the observation group containing cases, the control group of cases. all patients were first treated with conventional basic treatment. the observation group was subsequently treated with specific immunotherapy. both groups were followed-up and the treatment efficiency were analyzed. results: after treatment, both two groups of patients showed improvement, in the observation group, the effective rate was %, while for the control group, the effective rate was %. observation group showed significantly better outcomes than the control group. conclusion: in allergic asthma treatment, adding specific immunotherapy on the basis of routine treatment is beneficial and could be widely used in clinic. case report: atopic dermatitis(ad)is the most common itchy dermatosis that affects millions of children and adults. during recent years, diagnosis and treatment based on component resolved diagnostics (crd)is recommended. we report a -year-old boy with severe atopic dermatitis. he had positive family history of atopy. the atopic dermatitis was developed since infancy. he was referred to our clinic when he was years old. he had generalized xerosis with ulcerative eczematous lesions on his neck, popliteal and antecubital areas. he had mild eosinophilia and his serum total ige level was iu/ml. daily bleach bath, moisturizing agents, topical steroids and systemic antibiotics in addition to antihistamine were prescribed. he had multiple food and aeroallergen sensitization in skin prick test (spt). he started to eliminate some foods according to the spt results. he was suffering from recurrent relapse even after strict food avoidance; so treatment with cyclosporine was initiated for him, with partial response. crd showed sensitization to alternaria alternata (alt a specific ige: . ku/l). allergen immunotherapy by alternaria alternata was started. after accomplishment of buildup phase, he had significant improvement and we were successful to taper and finally discontinue cyclosporine. now he is on maintenance phase of immunotherapy, his skin is in optimal condition only by hydration and moisturization. result: a -year-old thai girl is a known case of severe asthma since one year old. her asthma was uncontrolled asthma even treatment with high dose combination of inhaled corticosteroid and long acting beta agonist (ics/laba), montelukast and omalizumab. spirometry revealed the force expiratory volume in one second (fev ): % predicted, fev /forced vital capacity (fvc): % predicted and % improvement of fev after salbutamol ug inhalation. allergic sensitization showed specific ige to cat: . kua/l. slit with cat allergen started at the dose of au per month and increased to au per month (scit dose is au per month) for three-year-and-six-month course. after slit, her asthma symptom improved significantly. she can exercise without exacerbation and plays sport at school. her last episode of asthma exacerbation was . year ago. her fev (% predicted) was improved from % predicted to % and the fev bronchodilator response decreased from % to %. conclusion: an improvement of pulmonary function and asthmatic symptoms of the presenting case would support the efficacy of slit of cat allergen in a patient with severe asthma. ra developed during pollen scit in this case might be related with immunomodulation effect of immunotherapy. background: we report a case of -year-old woman with allergic rhinoconjunctivitis and mild persistent asthma due to sensitisation to seasonal pollens and molds with bad clinical evolution and not response to conventional drug therapy. we decided to start subcutaneous allergen specific immunotherapy with alternaria extract in our immunotherapy unit in accordance with the guidelines of the european academy of allergology and clinical immunology (eaaci) and we used a cluster regimen. the immunotherapy was not well tolerated: the patient had two grade systemic reactions with the first dose in two attempts. method: sensitisation was diagnosed through skin prick test with aeroallergens standard panel and serum specific ige by elisa. due to the bad tolerance to immunotherapy, molds molecular diagnosis by immunocap, study of the molecular weight to specific ige binding proteins by sds-page ige immunoblotting, and cross-reactivity study by means of immunoblotting-inhibition assay were performed. a. fumigatus extract was able to produce a total ige binding inhibition on the kda band of a. alternata extract when ige immunoblotting assay was performed. conclusion: respiratory allergic disease due to alternaria is difficult to control, the use of subcutaneous specific immunotherapy could be of significant benefit. most of the allergic patients to a. alternata are sensitized to alt a , major allergen from a. alternata. however, our patient is sensitized to a kda alternaria protein due to cross-reactivity with a. fumigatus allergens, this sensitization could explain the bad tolerance to the alternaria immunotherapy. background: the association between natural pollen exposure, clinical symptoms as well as allergen-specific immune responses has not been investigated at a molecular level. our aim was to monitor the effect of seasonal birch and grass pollen exposure on clinical symptoms as well as specific b cell and t cell responses to defined allergen molecules in sensitized subjects during two consecutive years. method: grass pollen sensitized (n = ) and birch pollen sensitized (n = ) subjects were included in this study and were followed for two consecutive years ( ) ( ) . subjects were taking part in a clinical trial for the recombinant grass pollen vaccine (bm ) but did not receive immunotherapy for the allergen they were sensitized to. before, during and after the respective seasons ige and igg levels as well as t cell responses to the major birch pollen allergen bet v and the major grass pollen allergens phl p , , and were measured. pollen counts were recorded throughout the year and patients kept a daily diary including symptom medication score (sms) and visual analogue scale (vas). results: we noted that ige levels specific for bet v and the grass pollen allergens increased most in the seasons in which patients experienced the highest peak symptoms according to vas and sms but not depending on cumulative pollen counts. increases in allergen-specific t cell responses were observed in the pollen seasons as compared to shortly before the pollen seasons in the grass pollenallergic patients also in association with vas and sms but not in the birch pollen allergic subjects. no relevant changes of allergen-specific igg levels were observed during the two years observation in grass and birch pollen allergic patients. we found an association of increases of allergen-specific ige increases shortly after the pollen season with clinical symptoms in the pollen season as reflected by vas and sms which was not necessarily reflected by cumulative pollen counts in the season. these results may be important for the analysis of allergen-specific immunotherapy trials. background: the morbidity and mortality of severe asthma is much higher than that of mild to moderate asthma. this study was performed to understand the clinical characteristics of severe asthma in korea. results: data from the questionnaire showed that bronchial asthma was diagnosed before pregnancy only in women ( . %). patients ( . %) were diagnosed with chronic bronchitis at the pregestation stage. asthma attacks were experienced repeatedly during a lifetime in . % of patients, . % of patients noted long periods of dry cough at night, among them . % had wheezing. the cold did not precede the wheezing breathing in . % of patients. difficulty in breathing on waking was noted in . % of patients, at night- . %. after examination, the diagnosis of asthma was confirmed in . % of the respondents ( people). symptoms of rhinitis are noted in % of women surveyed, % of rhinitis was allergic. before examination, the diagnosis of ar was only in . % of patients. the incidence of symptoms of asthma and ar in pregnant women is significantly higher than the reported cases of these diseases, which leads to untimely initiation of treatment. method: a total of nonsmoker asthmatic patients without concomitant pulmonary pathology are recruited to our study. all patients underwent spirometry tests, measurement of fraction of exhaled nitric oxide and sputum induction to asses sputum cell counts, demographic features and current medications were recorded. using the variables of age at onset, bmi, allergy status, fev %, fev /fvc, asthma severity and induced sputum cytology cluster analysis is performed. results: clusters are identified. cluster : (n = ) early onset atopic asthma, consists of mild asthmatics with a good asthma control and lower bmi. cluster : (n = ) severe atopic asthma, consists of lowest spirometry measurements with a least act scores. induced sputum cytology shows a neutrophilic character, while having also the highest percentage of eosinophils. cluster (n = ) late onset obese asthma, nonatopic asthmatics having high spirometry measurements, with a lower act scores. cluster (n = ) nonatopic mild asthma, consists of patients with the best respiratory functions and least inflammation in means of lowest total ige, feno, sputum cell counts. conclusion: identification of asthma phenotypes in different countries will improve our understanding on the heterogeneity of the disease among the different geographies. results: results and discussion. in the course of analysis, obesity was more common in children with bronchial asthma − % than in the comparison group-in . %. obesity of the st degree was diagnosed in patients of the main group, ii degree-in , and iii degree- and iv degree-in patients e diagnosis of obesity, the sds indices of body mass index (bmi) were determined. obesitymore than + . (i degree: sds bmi . - . , ii degree: sds bmi . - . , iii degree: sds bmi . - . , iv degree: sds bmi ≥ . ). conclusion: thus, the results obtained indicate a high prevalence of constitutional-exogenous obesity in children with bronchial asthma and precedes the formation of the underlying disease e diagnosis of obesity, the sds indices of body mass index (bmi) were determined. obesity-more than + . (i degree: sds bmi . - . , ii degree: sds bmi . - . , iii degree: sds bmi . - . , iv degree: method: postal questionnaires were distributed to an unselected group of asthma patients (n = ). healthy non-asthmatic volunteers were recruited amongst university and hospital co-workers (n = ). the presence of self-reported nhr, the type of triggers evoking nasal symptoms, asthma phenotype, medication use and environmental factors were evaluated. results: patients and controls completed the questionnaire (responder rate of % and % respectively). nhr was reported in % of asthma patients and % in non-asthmatic controls (p < . ), with changes in temperature being the most important inducer of nasal symptoms ( % of asthmatics), followed by strong odours ( %) and cigarette smoke ( %). interestingly, nhr was more prevalent in patients with severe ( %) compared to mild ( %) asthma symptoms (p = . ), and more prevalent in atopic ( %) compared to non-atopic ( %) asthmatics (p = . ). most asthma patients reported more than one trigger evoking nasal symptoms, with % of patients reporting or more triggers evoking nasal symptoms. results: the mean score of cbcl questionnaire in case group with . ± . was significantly higher than in comparison with a control group with . ± . (p = . ). the mean scores of the subscales of social isolation (the case group: . vs control: . , p = . ), anxiety-depression ( . vs , p = . ), intellectual problems ( . vs . , p = . ), and aggressive behaviors ( . vs . , p = . ) were significantly higher in children with asthma than in healthy children. the study showed a significant correlation between the mean duration of asthma and a general score of cbcl (p = . , cc= . ). moreover, there was also a significant correlation between asthma severity and cbcl scoring (p = / , cc= . ). conclusion: behavioral disorders in children with asthma are significantly more than healthy children. the duration of asthma and the severity of asthma, are related to and can predict behavioral disorders in children with asthma. background: assessment of asthma control is an integral part of the management of asthma. whilst asthma control test (act) is a commonly used questionnaire to assess symptom control, its utility in predicting long term risk of exacerbation has not been well studied. aim: to analyze the factors associated with uncontrolled asthma symptoms using act and its impact on predicting future exacerbation. method: severe asthma patients on at least step background: most of the asthma-scoring tools detect the asthma severity from patients' symptoms but there is no scoring tool using parameters to define risk of asthma exacerbation. thus, this study use factor analysis to evaluate the relationship of parameters in childhood asthma. method: the descriptive study using factor analysis in asthmatic children aged less than years old, who attended thammasat university, the center of excellence for allergy, asthma and pulmonary diseases, thailand. the participants or caregivers were inter- the factors which have the major impact on asthma control are changing bed sheets less than once per month and using dust mite-proof bed sheets. this study is supporting non-pharmacological strategies but further studies are needed to create a more efficient asthmatic symptom checker. were not different between the controlled and uncontrolled group. the act score in the controlled group was significantly higher than the uncontrolled group (p < . ). the study showed that cigarette smoke is one of the significant factors that can trigger asthma exacerbation (p < . ) and mosquito repellent coil smoke is also significantly associated with asthma exacerbation (p < . background: experimental studies have demonstrated that tumor necrosis factor family member (tnfsf /light) plays an important role in airway remodeling. there is little data available concerning in vivo regulation of tnfsf /light expression in humans. the aim of this study was to evaluate serum concentration of tnfsf / light in different subsets of asthmatic patients. the study was performed on nonsmoking asthmatic patients (a), including mild-moderate-severe asthmatics controlled on inhaled corticosteroids (aics) and asthmatics evaluated twice during asthma exacerbation (aex) and during subsequent remission (arem). in addition age and sex matched nonsmoking healthy controls were included (hc). serum tnfsf /light concentration was evaluated using elisa method. in asthmatic patients lung function tests, exhaled nitric oxide concentration (feno), serum total ige concentration (t-ige), allergen-specific ige concentration (s-ige) and peripheral blood eosinophilia were evaluated. ( + /- pg/ml) was significantly greater than that in hc ( + / - pg/ml; p < . ). among all asthmatic patients studied the greatest tnfsf /light serum concentration was demonstrated in aex ( + /- pg/ml), which was significantly greater than that in aics ( + /- pg/ml p < . ). during resolution of asthma exacerbation a significant decrease in serum tnfsf /light concentration ( + /- pg/ml; p < . ) was demonstrated. in arem the mean serum tnfsf /light concentration was comparable to that seen in aics (p = . ) but was still significantly greater than in hc (p < . ). no significant correlation could be demonstrated between serum tnfsf /light concentration and baseline lung function parameters, exhaled nitric oxide concentration, serum t-ige or s-ige concentration or peripheral blood eosinophilia. conclusion: enhanced production of tnfsf /light seen in asthmatic patients, which is further upregulated during asthma exacerbations may play an important role in asthma pathogenesis. method: two models of aspergillus fumigatus-induced allergic airway inflammation were used in the study: long terms ( weeks) and short terms ( weeks background: chalcone is identified as an inhibitor of the interaction between cxcr or cxcr and their ligand cxcl . therefore it is called a neutraligand. the chemokine cxcl , interacting with the cxc-receptor (cxcr ) can play a role in the progression and development of bronchial asthma. asthma is defined as a chronic disease characterized by episodes of obstructive events which affects about million people over the world. the aim of this study is to approach the mechanism of the anti-inflammatory effect of the cxcl neutraligand chalcone and also to assess its impact on the migration of dendritic cells in a murine model of allergic airway inflammation. method: chalcone is administered intranasally to balb/c ovalbumin (ova) asthma mice and control groups as well. our results indicate that the cxcl neutraligand chalcone can modify the inflammatory reaction in an airway allergic hypereosinophilia model. furthermore, found out that cxcl neutraligand chalcone prevents dc migration to the airways and airway jnc ganglia during allergic airway inflammation. the detection of the cxcr -cxcl pathway and its role in the pathophysiological actions of asthma offers a promising target for allergic diseases treatments. method: four groups of balb/c mice were defined: control and asthmatic, with and without treatment. asthmatic groups were sensi- overexpression of ptgdr in pulmonary cells associated to a generalized increase of cytokine expression. conclusion: in a mouse model we confirmed the involvement of ptgdr in allergic asthma by the increase of its expression levels after ovalbumin sensitization. we also identified a reduction of ptgdr levels in response to dexamethasone treatment. the in vitro model suggests that ptgdr induces an inflammatory response, increasing the cytokines levels. | immune imbalance between transcription factor t-bet/gata and allergic asthma results: t-bet mrna expression of peripheral blood lymphocytes in patients with allergic asthma was lower than that of the normal control group, and the expression level of gata- mrna was higher than that of the normal control group (p < . ). the th percentage of peripheral blood lymphocyte subsets was lower than that of the normal control group (p < . ), the percentage of th cells was significantly higher than that of the normal control group (p < . ), and the changes in t-bet/gata expression and th /th ratio was highly correlated. our objectives were to assess the changes of bmp and bmp serum levels in the response to allergen and methacholine challenge tests and the correlation between bmp and bmp serum levels and fev before and after allergen and methacholine challenge tests. method: study group consisted of patients with asthma and healthy volunteers. spirometry, skin prick tests, allergen and methacholine challenge tests were performed in compliance with eaaci, ers and ats guidelines. personalized clinic surveys including act ™ were performed. venous blood was collected before and after hour, and hours afterwards the provocation to edta-ke-filled test tubes. evaluation of bmp and bmp serum protein levels was performed using specific elisa immunoassay kits according to the manufacturer's protocol. results: the increase in bmp and bmp serum level hours after provocation test correlates significantly with the concentration methacholine during provocation time (p < . ). bmp serum level before the provocation, hour and hours after provocation, correlates negatively with fev change (p < . ). the median bmp level hours after provocation was significantly lower in patients with negative methacholine challenge test compared to the control group (p = . ). the median bmp level hours after provocation was higher in patients with positive allergen provocation test than in patients with negative test results (p = . ). the bmp serum level hours after positive methacholine test is lower and correlates inversely with fev change in every time point, which could indicate that serum level of bmp is a predictive factor of fev change. the higher bmp serum level, the lower fev change was observed. this could suggest the protective influence of bmp in patients with obstructive pulmonary disease, i.e. asthma. the higher bmp serum level hours after positive allergen provocation test result shows that the bmp could be an indicator of the response to a specific trigger. background: inflammation and coagulation are closely linked events. thrombin is the key enzyme in coagulation system. besides its well-known functions in hemostasis, thrombin plays a role in inflammation. the aim of our study was to evaluate thrombin generation in children with mild asthma and demonstrate associations between thrombin levels and control of asthma. method: forty-two children with mild asthma and forty-nine healthy children included in the study. asthmatic children had no asthma exacerbation during the last months. patients (n = ) who had mild persistent asthma, were using either inhaled steroid or montelukast. all patients performed spirometry. thrombin levels were measured by thrombin generation test. thrombin peak levels, endogenous thrombin potential, thrombin lag time, time to thrombin peak and thrombin tail time were recorded. results: thrombin lag time was significantly longer in children with asthma ( . ± . ) compared to those in control group ( . ± . ) (p < . ). children with asthma also had longer thrombin tail time compared to control group ( . ± . vs . ± . , p = . ). thrombin peak was inversely correlated with fef - (- . , p < . ). thrombin lag time was inversely correlated with fef - (- . , p < . ). thrombin generation parameters did not show difference according to asthma control treatment, asthma control scores and having atopy. conclusion: coagulation/anticoagulation balance is disturbed in mild asthma but this disturbance may not be as strong as to increase thrombin levels. factors increasing inflammation may cause an increase in lag time, and increase in inflammation and excessive fibrin deposition may contribute to airway narrowing. background: cytokines represent key mediators in the onset and persistence of inflammatory process, in both asthma and copd. il- , which belongs to il- family, it might act in a similar way with il- at the beginning of the inflammatory process. its role in atopic skin diseases has already been demonstrated, but there are conflicting results related to its role in respiratory allergic diseases. the aim of the study was the evaluation of il- plasmatic level in patients with asthma and copd and the its correlation with clinical and lung function parameters. method: fifty consecutive patients with bronchoobstructive diseases were included in the study. thirty-two patients presented asthma and patients had copd. the evaluation included: number of exacerbation in the last year, disease's severity, spirometry. plasmatic levels of il- and il- were determined in all patients. results: the mean age was higher in patients with copd dermatophagoides pteronyssinus [house duste mite (hdm), ug/ mouse] were administered oro-tracheally on days , , , , , , and . at was performed in a treadmill during weeks in moderate intensity, from day until day . results: at inhibited hdm-induced total cells (p < . ), eosinophils (p < . ), neutrophils (p < . ) and lymphocytes (p < . ) in bronchoalveolar lavage (bal), and eosinophils (p < . ), neutrophils (p < . ) and lymphocytes (p < . ) in peribronchial space. at also reduced bal levels of il- (p < . ), il- (p < . ), il- (p < . ), cxcl (p < . ), il- (p < . ), il- (p < . ), il- (p < . ), while increased il- (p < . ). airway collagen fibers (p < . ), elastic fibers p < . ) and mucin (p < . ) were also reduced by at. at also inhibited hdm-induced airway hyperresponsiveness (ahr) to methacholine . mg/ml (p < . ), . mg/ml (p < . ), mg/ml (p < . ) and mg/ml (p < . ). mechanistically, at reduced the expression of stat (p < . ), stat (p < . ), stat (p < . ) and jak (p < . ), similarly by peribronchial leukocytes and by airway epithelial cells. socs expression (p < . ) was upregulated in leukocytes and in airway epithelial cells, socs (p < . ) was upregulated in leukocytes and socs down-regulated in leukocytes (p < . ) and in airway epithelial cells (p < . ). conclusion: at reduces asthma phenotype which is followed by positive modulation of socs-jak-stat signaling in peribronchial leukocytes and in airway epithelial cells. rodolfo a ; paciência i ; rama t ; leão l ; silva d ; rufo j ; mendes f ; padrão p ; oliveira fernandes e ; moreira p ; delgado l ; moreira a porto, portugal; potentially irritating chemicals that may have a cutaneous drying side effect. this study aimed to evaluate if skin barrier function, as measured by transepidermal water loss (tewl), is affected by a training session in swimmers compared with football players. environment impact on the human respiratory health (clinicaltrials.gov identifier: nct ) and football players were invited to participate. due to the lack of prior information no sample size calculation was possible and all athletes that provided informed consent were included in the analysis (n = , females, aged to years). tewl was measured using the tewameter ® tm before, immediately after, and minutes after a hours training session. the probe was held on the dorsum of hand, the volar forearm and the antecubital flexure for s. the average of two consecutive measurements was recorded. non-parametric statistic was used were appropriate. ethical approval was obtained from the university clinical research ethics committee and informed consent provided. results: mann-whitney u test showed significantly higher baseline median tewl level on football players hand's dorsum compared with swimmers, median (p -p ) respectively . ( . to . ) and . ( . to . ); p = . . friedman test revealed a significant effect of swimming on tewl on the hand's dorsum, volar forearm and antecubital flexure (p < . ) while football training affected only the hand's dorsum (p = . ). differences in changes after swimming and football training were significant only for tewl in volar forearm (p = . ). in conclusion, our exploratory findings do not provide support for a specific deleterious effect of swimming, compared with football training, on the training induced changes in tewl. background: exercise-induced bronchoconstriction (eib) is defined as transient, reversible airway narrowing occurring during or after exercise, is common among elite athletes and associated with epithelial damage. however, little is known about the existence of eib in young athletes. the goal of this study is to investigate the presence and to evaluate potential (bio)markers of eib in young high-school elite athletes in different sport disciplines versus age-matched control subjects. method: high-school selected elite athletes ( - years) from different sport disciplines: basketball (n = ), football (n = ) and swimming (n = ) performing at least hours of sport per week (median= h) and control subjects (performing less than hours of sport per week) were recruited. the eucapnic voluntary hyperventilation (evh) test was performed according to ats guidelines and adapted for this age group. lung function was measured before, immediately after and , , minutes after the evh test. the test was considered positive if a maximal fall in fev of % was measured on at least one time point and exhaustion was excluded. a blood sample was obtained at baseline. sputum induction and skin prick test for the most common allergens were performed after the evh test. results: fifteen swimmers had a positive evh test ( . %), which is higher than in basketball players ( . %), football players ( . %) and controls ( . %). . % of the swimmers were atopic which is also higher than in basketball players ( . %), football players ( . %) and controls ( . %). serum clara cell secretory protein (cc ) levels are significantly higher in swimmers ( . ± . ng/ml) compared to indoor athletes ( . ± . ng/ml) and controls ( . ± . ng/ml). a significant positive correlation was found between the magnitude of maximal fall in conclusion: young elite swimmers have a higher prevalence of eib compared to basketball and football players. atopy and/or chlorine is a risk factor for the development of eib in young elite athletes. cc levels and sputum uric acid levels are increased in athletes compared to control subjects suggesting the presence of epithelial damage already at young age. this is especially observed in young elite swimmers, pointing to a probable role of exposure to chlorineby-products in combination with intensive exercise. results: data from subjects ( females, . %) were analyzed. frast was positive in ( . %) patients ( females, median age of years (iqr - )). in this group, ( . %) had a previous diagnosis of asthma, ( . %) practiced federated sports, ( . %) had smoke cigarette exposition and ( . %) had a bmi > kg/m . . % of patients showed a Δfev % > % in the first minutes after finishing the challenge. median fev reduction was . % ) and ml . frast was more frequently positive in patients with previous diagnosis of asthma (p < . ). there were no differences related to conclusion: frast is an important tool to diagnose exerciseinduced bronchospasm without asthma (eib wa ), as well as to diagnose asthma. in our study, frast was fundamental to access eib wa in % of patients with rsee, and confirmed asthma diagnosis in % of cases with previous asthma diagnosis and negative sbt. there was no difference in the prevalence of atopy between patients with positive and negative frast. patients older than years-old presented higher Δfev % compared to younger patients (p = . ). higher levels of feno were observed in patients with positive frast (p = . , p = . ), both in patients with and without previous diagnosis of asthma. a positive correlation was observed between feno levels and Δfev % in the whole sample (r = , p = . ); when these data were analyzed considering a previous diagnosis of asthma, only patients with this condition showed a positive correlation of feno and Δfev % (r = . , p = . ). conclusion: our results evidenced that higher feno was associated with atopy and a positive frast, both in patients with and without previous diagnosis of asthma. higher feno seems to correlate with Δfev % in patients with previous diagnosis of asthma. background: specific immunotherapy is the casual treatment for allergic rhinitis. a year old professional footballer suffer from severe allergic rhinitis since two years. during may, june and july his level of playing, concentration and durability decreased about %. patient was complaining of runny nose, nasal blockage, each eyes, sneezing, tearing. method: we did skin prick tests -which showed greatest allergy to grass pollen. we confirmed the allergy by specific ige and nasal provocation tests. spirometry was done-fev %. the patient was qualified to undergo specific immunotherapy. however, because of his profession, it was hard to find a day without trainings to get the vaccine. after long discussion, patient decided to start specific immunotherapy-scit. results: the patient start the immunotherapy. he was attuning very irregularly, because of matches, injuries, trips, trainings, and lack of time. several times we had to call the patient to remind him about the immunotherapy. after one year of scit the patient felt big improvement. during grass pollen season he suffered from mild allergic symptoms, and just for few days. after next year of immunotherapy, the patient had no symptoms of allergic rhinitis during the grass pollen season. however, it was the reason for him, to stop sit, before rd year of immunotherapy. conclusion: such a treatment-specific immunotherapy-is a burdensome method for both, for professional athletes and doctors. such a patients need to be on special observation, and cooperation with trainers must be obtained, if we want to see results. to improve compliance we have to keep in touch with patients, to remind them about next visit. gherasim a ; choual i ; radu c ; khayath n ; beck n ; jacob a ; schoettel f ; domis n ; de blay f alyatec, strasbourg, france; hôpitaux universitaires de strasbourg, strasbourg, france background: late allergic response (lar) is a good asthma model. it has been shown, in individual challenge tests that mite allergen induces more frequently late allergic responses (lar) than cat allergen. the aim of this study is to compare the frequency of lar in asthmatic subjects allergic to mite with asthmatic subjects allergic to cat. method: asthmatic subjects allergic to mite were compared to subjects allergic to cat (gina or ). the subjects had prick tests≥ mm compared to the negative controls and specific ige ≥ . ku/l. the dose selected for the mite and cat allergen was the airborne allergen concentration inducing the most frequently early asthmatic response (ear) (a % drop in fev ) and lar (a % drop in fev ). results: the frequency of lar with mite allergens was . % and % with cat allergens (p = . ). the frequency of ear for mites was . %; of . % for ear or lar, and % for ear and lar. in contrast, with cat allergens, % of patients had an ear, % had ear or lar and % had an ear and lar. no significant differences was observed between cat and mite allergen regarding the severity and the time necessary to obtain an ear and lar. no significant differences was observed between cat and mite allergen regarding the severity and the time necessary to obtain an ear and lar. the frequency of lar in asthmatic subjects allergic to dust mite exposed in alyatec ® eec was higher than in asthmatics sensitized to cats. our results confirmed previous results with individual bronchial challenge. therefore, it appears that the mite model is more interesting in the study of asthma. exposure chamber in strasbourg (alyatec ® ) in asthmatic patients allergic to cat allergens gherasim a ; choual i ; radu c ; khayath n ; beck n ; jacob a ; schoettel f ; domis n ; de blay f alyatec, strasbourg, france; hôpitaux universitaires de strasbourg, strasbourg, france background: as recommended by the task force on environmental exposure chamber (eec), allergenic and non-allergenic exposure must be better controlled in eec. it is the aim of alyatec's eec. the aim of the study is to validate alyatec's eec by determining the concentration of fel d inducing % of early asthmatic response (ear) and/or late phase asthmatic response (lar) in subjects sensitized to cat. method: it was a randomized, double blind, cross-over study including group a: asthmatic subjects allergic to cat and group b: asthmatic subjects allergic to another allergen. all subjects were first exposed to placebo. group a was exposed to fel d concentrations. the number and size of particles were recorded online during the exposure. group b was exposed to the concentration of fel d which fulfills the objective of the study. the mean age of subjects was years (± ). for the concentrations of fel d , we obtained more than % ear and/or lar. the mean time necessary to obtain an ear was: . ± minutes and . ± minutes for the lar. the mean fall in fev during ear and lar was − . % and − . % respectively. we didn't observe any severe reaction. no subjects in group b experienced any symptoms during exposure. we have validated alyatec's eec in asthmatic subjects allergic to cat allergens. we also demonstrated its specificity. background: the best test and strategy for diagnosing asthma especially in those patients with negative bronchodilator reversibility tests still remains unclear. in this study we aimed to investigate the diagnostic yield of peak expiratory flow (pef) variability for the patients with symptoms suggesting asthma but negative bronchodilator reversibility tests. method: subjects referred to our outpatient clinic with suspicion of asthma were enrolled in this study. demographics and referral symptoms were recorded, asthma control test (act) scores and health related quality-of-life scores (aqlq, sf ) were calculated. monitoring of pef variability during -weeks and bronchial challenge test with methacholine (bpt) were analyzed. asthma was diagnosed by having pef variability ≥ % and/or positive bpt. results: thirty out of enrolled patients were diagnosed as having asthma. when we compare asthmatic patients with nonspecific respiratory symptomatic subjects there were statistically-significant differences regarding to wheezing (p = . ), activity limitation (p = . ), total symptom score (p = . ) and basal fef (p = . ) in the favor of asthma cases. multiple logistic regression analysis revealed that lower basal fef - was an independent predictive factor of asthma diagnosis (p = . ). when the bpt positivity was assessed as gold standard for the diagnosis of asthma, the sensitivity and specificity of pef variability for different cut-offvalues (≥ %, > % and >% ) were . - . %, . - . % ve - . %, respectively. conclusion: fef - is an important diagnostic parameter for asthma. although current guidelines recommend pef variability of % for the diagnosis of asthma in general, this cut off level may not be appropriate for this defined group of subjects. our results suggest to use a cutoff level of > % while excluding asthma and ≥ % while confirming the diagnosis of asthma for patients with asthma suspicion but without shown reversibility. de barayazarra s background: in recent years obesity has been considered as a factor that contributes to the development of asthma, increases exacerbations and leads to poor control of it due to resistance to drugs to control this pathology. it is known that obesity produces chronic systemic inflammation; one of the markers that are affected is the levels of c-reactive protein (crp), which are increased. objective: evaluate, lung function, the use of medications to control asthma and systemic inflammation, after bariatric surgery. results: obese asthmatic patients with surgery, non-asthmatic obese patients with surgery, obese asthmatic patients without surgery. a significant difference was found between the severity of obesity and forced expiratory volume in patients with asthma and without asthma of second (fev ) before surgery with an average of . % at the beginning of the study and . % at months (p: . ). in the non-operated group, fev at the beginning was % and . % at months (p: . ). the crp, before surgery in all operated patients had crp: , at months after surgery they became negative, crp: (p: . ). in obese asthmatics with surgery at the beginning, % used medication, and at months only % in obese asthmatic patients without surgery, . % used the medication at the beginning, at months . % (p: . ). method: patients with asthma aged to and a predetermined positive methacholine pc were recruited and underwent a single challenge to cause bronchoconstriction of~ % comparing the outcome of the device with spirometry. the subjects were monitored at baseline, after a~ % fall in fev and after bronchodilation back to baseline. the study protocol allowed for an interim analysis of the initial subjects at which point the sensor was calibrated to optimise sensitivity. a further subjects were studied using the optimised sensor. results: all subjects successfully completed the study. the device was found to be straightforward to use by both operator and subject with no concerns regarding safety. the initial sensitivity of the device was found to be suboptimal in the first eight patients to reliably detect changes in lung function. after adjustment to the device the tests results of the remaining subjects were analysed. . % of subjects were female. the mean age of all subjects was . years. an average baseline fev value of . (s.d. . ) was observed. changes in lung function were detected in % of subjects. a baseline value, drop in lung function and reversal were measured in % of subjects. the mean percentage drop observed in % of subjects using the investigational device was . %. the mean percentage increase observed using the investigational from drop to reversal was . %. the device (using ebc ) was able to detect changes in lung function tracked using fev . this provided proof of concept that the device could potentially be used to monitor lung function more effectively in the home than peak flow and supports further development to optimise the device and demonstrate functionality in clinical asthma. method: ninety four patients under years of age seen in the allergy department due to common asthma symptoms (wheezing, dyspnea, cough, chest tightness) with normal spirometry and negative bronchodilator response, underwent mct during and . the variables studied were: sex, age, body mass index (bmi), asthma symptoms, exercise symptoms, rhinoconjunctivitis, family history of atopy, sensitization to respiratory allergens, spirometric data and fractional exhaled nitric oxide (feno). results: of the total sample, half were women ( . %) and the other half were males ( . %). mean age was . years. bmi was normal in most of them (with an average of . kg/m ). the most common symptom among the patients with positive mct was cough ( . %), followed by dyspnea ( . %), wheezing ( %) and chest tightness ( . %). . % had symptoms of asthma with exercise and . % had rhinoconjunctivitis. . % had a family history of atopy. . % were sensitized to aeroallergens, mainly to pollens (grass and olive tree). . % of the mct′s were positives, with a mean pc of . mg/ml. . % had a moderate-severe result (pc ≤ mg/ml), . % mild (pc - mg/ml) and . % bordering (pc - mg/ml). the mean feno was . ppb. conclusion: in our series, the completion of a test of hrb was decisive to confirm the diagnosis of asthma in most patients of a pediatric population with symptoms of suspicion (cough, mainly), normal spirometry and negative bronchodilator response (with normal feno in most of them). therefore, we consider it important to include in the routine clinical practice hrb tests in the pediatric population with suggestive symptoms of asthma, despite normal functional and/or inflammation tests. | cut-points of the ′control of allergic rhinitis and asthma test′ (carat) asthma subscale based on an international survey patients with asthma) in kashan, iran. the data collection tool was a questionnaire with questions, designed to gather information on demographic asthma patients, the current use of mobile functionalities, and the willingness to use these functionalities to receive selfmanagement services, which was distributed among patients with informed consent. the collected data were analyzed by descriptive statistics method using spss software. results: the most use of patients from mobile phone functionalities was to receive information about asthma symptoms and allergens and irritants via mobile internet ( . %). patients were most likely to use social networking ( . %) in comparison with other mobile phone functionalities, to receive reminders about appointments and medication. the respondents were most likely to use social networks through mobile phone functionalities, to receive asthma self-management information ( . %), to communicate with other patients ( . %), to receive reminders about medication use, and to perform a peak flow meter test ( . %) and to get an alert when the asthma is not controlled ( . %). the findings show that asthma patients are currently using the internet search for educational information and they have a tendency to use social networks to receive asthma-related services. patients believe that mobile health is an appropriate intervention for providing educational information, reminders, and alerts and communication with other patients. | concordance between the determination of asthma control through the gina guidelines and the act questionnaire-results of the efimera study background: the exacerbation of asthma, progressive worsening of acute episodes, is one of the most frequent attending reasons at hospital emergency unit . several factors causing poor control of asthma, such as inadequate therapy, have been described. in the present study, estimations of asthma severity by researchers were assessed by comparing the concordance between the assessment of asthma control through the gina guidelines and the act questionnaire method: cross-sectional observational study on the evaluation of factors related to treatment that influence the poor control of asthma was assessed through the gina guidelines and the act questionnaire. patients referred to a pneumologist or allergist by a primary care for the first time were evaluated. two variables were collected for the assessment of asthma control: one derived from the gina guidelines and another derived from the act questionnaire. regarding the gina assessment, researchers' evaluations guidelines were compared with the scoring calculated from the variables registered in the crd. both measures were compared in terms of sensitivity-specificity to determine their ability to classify patients. the patients included in this study (n = ) had a mean age of ± years, with a % of women and an average disease evolution of . ± . . the control of asthma according to "gina results: pts were reasonably representative of those in sls asthma (at sls baseline: . % male; mean age . yrs; mean asthma control test [act] score . ) . the most frequently reported symptoms during sls asthma for these pts were cough/ breathlessness, followed by wheeze, phlegm and chest tightness; breathlessness and wheeze were perceived as the biggest impactors on pts' lives. the aspects of daily life most impacted by asthma were reported as walking at a hurried pace, strenuous physical activity, and asthma-related frustration. since sls began, % of pts in this subset reported improvements in overall asthma ( % no change; % worsening). perceived changes in symptoms are shown (table) . most pts ( . %) reported avoiding places with dust, smoke or fumes. most pts ( . %) perceived no change in overall qol; . % reported improvement. being an act responder during sls (total act score ≥ or ≥ change at end of sls) was associated with reported improvements in overall asthma symptoms, lower impact of asthma on qol, and higher perceived confidence/control in managing asthma. more pts ( . %) in the ff/vi arm reported an overall improvement in asthma vs uc ( . %); the most evident differences between treatment groups were for breathlessness, wheezing and chest tightness. improvements in confidence/control in managing asthma were reported by . %/ . % of pts (ff/vi) vs . %/ . % (uc). conclusion: breathlessness and wheezing were key symptoms in sls asthma and had the biggest impact on pts' daily lives. this patient-centred study enriches the findings of sls asthma. funding: gsk (study ) | asthma and copd treatment adherence and breach using tai questionnaire suarez-vergara m; fuentes-soltero f; garcia-nunez i; ignacio-garcia j background: adherence is defined as medication (inhalator) intake following the dosage and schedule prescribed. adherence mistakes are a public healthy problem according to the big morbi-mortality presented in patients with an incorrect intake. our aim is to evaluate the adherence level and fulfillment in patients with asthma or copd using tai (inhalators adherence test) questionnaire. method: patients with a diagnosis of persistent asthma or copd were selected. we used to size adherence and breach type the tai questionnaire. adherence is defined as good when patient′s test reaches points, medium ( - points) and bad (less than points). breach type is defined as erratic when points between questions to are less than , deliberate when questions to are less than , and unconscious when questions and are less than points. a correct fulfillment is defined when questionnaire reaches points plus points of conscious fulfillment. results: fifty-five patients more than years old (mean age . years and . % males) were selected. a . % of them were asthmatics, . % copd and . % a mix phenotype. a . % presented a correct fulfillment with conscious fulfillment, and the other . % presented good, medium or bad adherence with a breach type. according to adherence level, a medium adherence was defined in patients ( . %), with an erratic mistake in patients ( %). bad adherence was seen in patients ( . %) , with the three breach types in patients ( %). good adherence with unconscious breach type was defined in patients ( . %). conclusion: tai questionnaire confirms a good adherence and fulfillment in less than % patients. an erratic mistake is the most frequent breach type defined in our patients. educational protocols should be applied to improve adherence and fulfillment. | what is adhesion to treatment of asthmatic patients like in argentina according to the tai questionnaire? background: asthma is a chronic inflammatory disease of the airways, which requires an adequate treatment and control. the adhesion of a patient to an asthma treatment is a critical factor in order to achieve and maintain control. this adherence arises from a consensual agreement of the doctor-patient relationship; it is a complex multifactorial variable in which the variability in human behaviour in relation to its environment influences. background: the association between ambient pollen and asthma has been studied intensively with inconsistent results, attributed to differences in study population, geographic factors (geoclimatic features), data sources, measurement of pollen (different types of traps), and different outcome occurrence (hospitalizations or emergency department visits). we investigated the associations between daily sales of short-acting β -agonists (saba) and outdoor pollen concentrations in the central france area. the relationship between daily changes in pollen concentrations and daily saba sales obtained from the social security database was analysed with generalized additive models, taking into account confounding factors such as air pollution, weather conditions, and day of the week. results: the daily saba sales (mean, sd) rose from . ( . ) conclusion: this study indicates that outdoor pollens contribute to asthma morbidity in the general population. it confirms the highly allergenic role of fraxinus, betula and quercus pollens, but also shows a relatively unknown association between treated asthma and carpinus and platanus pollens, despite their counts being less than % of overall pollen concentration. results: of asthma patients (mean age . years, female . %), regular ocs use was identified for patients ( . %), periodic ocs use for patients ( . %), and no ocs use for patients ( . %) -year post-index. regular ocs users had a greater mean age, were more often male, and had greater eosinophil counts, lower lung function, and greater prevalence of comorbidities than did the periodic and no ocs users (p < . ). total yearly cost was greatest for the regular ocs users (€ ), followed by periodic ocs users (€ ) and no ocs users (€ ) (p < . ). among regular ocs users, hospital admissions were the main cost driver ( . % of total cost), while gp consultations were driving the total cost in periodic and no ocs users ( . % and . % of total cost, respectively). conclusion: in this sample of patients with asthma in sweden, the total yearly cost of health care resource utilization for a regular ocs user is twice as high as for a patient with no ocs use, demonstrating substantial economic and clinical burden in asthma patients on regular oral steroid treatment. method: children with physician-diagnosed asthma who attended to an outpatient pediatric allergy and asthma center were enrolled in the study along with control subjects. asthma severity and control status of the patients were evaluated according to recent gina guidelines. laboratory investigations including skin prick tests, complete blood counts with differential, total ige levels, serum periostin levels and pulmonary function tests were performed. results: a total of children ( with asthma and age and sex-matched control subjects) with a median age of . years (range . - . ) were enrolled. asthma severity was mild in ( . %), moderate in ( . %) and severe in ( . %) children. children with asthma had significantly higher periostin levels than controls ( . ± . vs . ± . ng/ml; p < . ). the mean serum periostin levels of children with severe asthma ( . ± . ) were significantly higher than in children with moderate asthma ( . ± . ) and mild asthma ( . ± . ) (p < . ). serum periostin levels were found to be significantly correlated with asthma severity (spearman's rho [r]=. , p < . ). analysis using roc curves identified the role of periostin levels in determining children with severe asthma (auc: . , % ci: . - . , p < . ]. conclusion: serum levels of periostin, a novel asthma biomarker, were higher in asthmatic children, and were associated with asthma severity. adam i ; selevestru r ; rogut v ; sciuca s background: nowadays, data from several epidemiological studies confirm the important role of fungi in respiratory disease in the indoor as well as in the outdoor environment. in general, exposure to fungi occurs via inhalation, skin contact, or ingestion. alternaria alternata is one of the most common fungi associated with presence asthma and persistence and severity of asthma. although exposure to a. alternata is also may represent a risk factor for development of asthma. in ukraine has been an increase in the number of the mold sensitized children for the last few years. at the same time we can see increasing frequency ba at the children of pre-school age. method: thirty five children aged - years with allergic rhinitis and high level of asthma predictive index (api) sensitized to a. alternata were included in a -year cohort study of the efficacy and safety of slit (diater laboratories, spain) using standardized sublingual extracts containing molds (alternaria alternata). treatment efficacy was analyzed using the score of symptoms such as difficulty in nasal breathing, rhinorrhea, sneezing, itching of the nasal mucosa (upper palate) and discharge from the nose and recurring wheezing. we also have analyzed the level api during the period investigation. symptoms were measured before starting treatment, and at , and months after starting immunotherapy. results: slit significantly reduced both symptoms and medication score: nasal symptoms ( % vs. control group) and the use of rescue medications ( % vs. control group), and improved fev (in children aged≥ years). in the slit group, api decreased by % for the first year, by % for the second year. no patient had a systemic reaction during therapy. our results have shown that slit is an effective treatment in pediatric patients suffering from allergic rhinitis and high api with significantly improved clinical outcomes (less symptoms and less medication intake) in comparison with children treated with symptomatic drugs only. in this study, large and statistically significant differences in symptom and medication scores were demonstrated in patients receiving slit compared to control group. sublingual immunotherapy is effective for allergic rhinitis in children especially early age and is generally advantageous because of the convenient administration and safety profile and ensure prevention of developed ba. bednarek a background: the classification of asthma based on the severity of its clinical course has been recommended by gina since . this division is useful for the patient's initial assessment when asthma is being diagnosed and essential decisions concerning an appropriate therapy are made. the objective of the work is to evaluate the influence of a clinical form of asthma on vaccine immunity in preschoolers following three years after the programme of mandatory vaccination has been realised. the study encompassed preschool children (mean age of . ± . years old) with asthma being newly diagnosed, including patients with mild asthma and ones with moderate asthma, whose vaccine immunity (igg specific antibody titer) was assessed after the mandatory early childhood vaccines had been administered. monovalent vaccines (hbv+ipv+hib) along with a three-component combined vaccine (dtwp) were given to children while a six-component vaccine (dtap+ipv+hib+hbv) was given to the remaining children. the vaccine doses were consistent with the polish immunisation programme and manufacturers' recommendations. the elisa immunoenzymatic method was applied to assess titer of specific antibodies to diphtheria, tetanus, pertussis, poliomyelitis and h. influenza type b. the level of hbv antibodies was measured chemiluminescently. the immunity class for particular vaccinations was assessed according to the test manufacturers' instructions. results: children suffering from mild asthma had considerably more frequently vaccinations on time (p < . ) and the type of vaccines (monovalent, highly-combined) administered to them did not have a significant influence on a clinical form of asthma in the children examined (p > . ). apart from the vaccines against hepatitis b and rubella where considerably more frequently a high antibody titer occurred in children with mild asthma, the titers of antibodies to other vaccines, namely diphtheria, tetanus, pertussis, hib and mumps, were not associated with a clinical form of asthma. the protective antibody titers in the children with asthma were found in % after vaccinating them against poliomyelitis (≥ u/ ml) and measles (≥ ml u/ml). significantly higher current weight was solely found in the children with mild asthma (m = . , sd= . ; p < . ). conclusion: there are some clinical and cultural differences among the four southern chinese cities within the canton province. this study identifies potentially modifiable environmental and treatment factors associated with poor asthma control and qol for healthcare interventions. having a smoker in the family is independently associated with poor asthma control and qol. were classified into two groups (levocetirizine group (l) and montelukast group (m)) and we treated each group for another week. to evaluate the therapeutic effectiveness, we used symptom score (ss) and ebc leukotriene e (lte ). ebc samples were collected with rtube. each parameter was checked at , , week therapeutic period. results: most ar patient showed clinically improvement with and week fluticasone therapy ( wk ss= . , wk ss= . , wk ss= . p < . in l group; wk ss= . , wk ss= . , wk ss= . p < . in m group). lte levels of ar were higher than control ( wk vs. pg/ml), and were reduced after week fluti- mic were: md allergic rhinitis, wheezing apart from colds, eosinophilia ≥ %. outcome was defined as md asthma and at least episode of asthma during the previous year or more than episodes of wheezing during the months regardless of asthma diagnosis. results: from a total of of parents approached, ( %) agreed to participate in a phone interview. ( %) children were diagnosed with asthma. the age at the time of admission (mean, abstracts | (sd)) was . ( . ), at the time of phone survey . ( . ) months, respectively. positive loose api at - years of age had sensitivity of . %, specificity %, positive predictive value (ppv) . %, negative predictive value (npv) . %. positive stringent api at - years of age had sensitivity of %, specificity %, ppv . %, npv %. background: asthma is the most common chronic airway disease in childhood, with a high unmet need for new treatments due to insufficient symptom control in a relevant percentage of patients. ethics and resource factors limit the feasibility of large, long pediatric trials required to assess outcomes such as exacerbations and symptoms. for diseases like asthma, where the disease process is largely similar in children and adults, with the same expected therapy outcome, the international council for harmonisation advise extrapolating adult data to those of a younger age, reducing unnecessary pediatric trials. here we assess the partial extrapolation used in the clinical development of tiotropium. phase trials in adults (aged - ), adolescents (aged - ) and children (aged - ) with symptomatic severe (primotina-/pensie-tina-/vivatina-asthma) or moderate asthma (mezzotina-/rubatina-/ canotina-asthma), respectively. trials lasted - weeks, all with tiotropium respimat μg add-on vs placebo as two puffs once daily. results: in adult trials, lung function, symptoms and exacerbation endpoints were evaluated in a confirmatory manner: tiotropium significantly improves lung function and asthma control, and reduces risk of exacerbation, vs placebo ( conclusion: based on similarities in disease profile and magnitude of treatment responses between age groups, it is reasonable to expect tiotropium add-on to produce clinically meaningful improvements in exacerbation and symptom endpoints in children and adolescents, as in adults. the robust tiotropium clinical program supports using a partial extrapolation to avoid overly long and large trials in pediatrics. | clinical state of treatment and examination during last years before remission about asthmatic children in long-term remission cases method: remission cases (no symptom and no therapy) for years of asthmatic children were studied. clinical background and treatment (drugs) was studied during last years before remission annually. acetylcholine inhalation test by standard method was performed, and respiratory threshold of acetylcholine (rt-ach) was obtained. fev %, and serum ige also examined. these data were compared before remission with years after remission. results: mean age of cases at year before remission was . years old. male to female ratio was . . severity of asthma was all mild type, and number of attack was to times in a year. there was no admitted case during this study. the long-term therapeutic drugs were leukotriene receptor antagonist (anti lt) in cases, and/or inhaled corticosteroids (ics) in cases, but cases had no treatment for the control. geometric mean of rt-ach (after then: years before and after remission) was μg/ml and μg/ml. the mean fev % was % and %. geometric mean of serum ige level was iu/l and iu/l. complicated cases of atopic dermatitis decreased after remission, but the incidence of allergic rhinitis increased slightly. conclusion: characteristics of asthmatic children during last years before remission were mild type, had several times of attack in a year, and the treatment was mainly anti lt and/or ics. fev % was within normal range, and serum ige level was not changed after remission. rt-ach had the tendency to improve during years before and after remission. these data is supposed that airway hyperresponsiveness is one of the indicators for quitting treatment. | clinical aspects of polyvalent mechanic bacterial lysate (pmbl) treatment in children with uncontrolled asthma our results indicate that long-term treatment with omalizumab in children can help to achieve better asthma control and reduce the amount doses of basic therapy. method: allergic rhinitis (ar) and allergic rhinoconjunctivitis (arc) diagnosed-patients' demographic information, accompanying-asthma, the allergic history of the family, the onset of symptoms, types of aeroallergens sensitivity were noted from patients' files in our hospital's pediatric allergy clinic. results: in this study, patients were evaluated. the mean age of the patients were . ± . years and % (n = ) were male. ( %) patients had ar and ( %) patients had arc. background: allergic rhinitis (ar) is a disease characterized by symptoms of nasal discharge/congestion, sneezing, and pruritus, and is caused by an ige-mediated immunological response to inhaled allergens. we aimed to evaluate pollen season and out of pollen season pulmonary function tests (sft) of patients with ar in our study. method: in our study, the demographic characteristics and aeroallergens were recorded from patients' files with ar diagnosed. in addition, pollen season and out of pollen season sfts were evaluated and compared. conclusion: in patients with ar, fev and fvc values are seen to be lower during the season even though there is no lower respiratory symptom. therefore, sfts of patients with ar should be evaluated during pollen season. results: among the clinical manifestations, the most common combination of allergic rhinitis (ar) and conjunctivitis (ac) is noted in . % of adults and . % of children, but in children aged - , the combination of ar and ac is observed only in . %, among - years old- . %, while in the remaining age groups it is encountered in more than %. higher percentage of isolated ar is also observed among young children- . %, and those of the results: allergic rhinitis was a main symptom in . % of children with pollen-food sensitization. in all of them concomitant allergic disorders were noticed: bronchial asthma ( . %), atopic dermatitis ( . %). only in . % temporal association between ingestion of pollen-related foods and nasal symptoms was observed (mainly apple and peanuts); occurring also outside the pollen period. the simultaneously sensitization to animal origin food allergens was stated in . % of children with sar, but only in two of them milk and white egg proteins were an additional exacerbation factor of nasal symptoms. in . % anaphylactic reactions to food allergens were registered. . % of children were asymptomatic despite pollen-food sensitization. the statistically significant differences were noticed in comparison to the control group. conclusion: . allergic rhinitis in children, similar to adults, is a common manifestation of pollen-food syndrome and this type of sensitization should be taken into account regardless to age. . children with pollen-related food allergy have the predisposition to multiorgan clinical manifestation. . the lack of association of symptoms with plant-origin foods in the majority of cases and the asymptomatic course of food sensitization in more than one third of patients indicate the need for follow-up. | clinical benefit of the screening of suspected food allergen using multiple allergen simultaneous test in the patient with pollen-food allergy syndrome (pfas) background: the quantitative fluoresce enzyme immunoassay immunocap (ic) system has been widely used for detection of allergen-specific ige for the diagnosis of allergy. however, the system can only detect ige against a single allergen, the multiple antigen simultaneous tests has been developed such as the fluorescence enzyme immunoassay view allergy (va) or chemiluminescent enzyme assay mast iv (ma) and both assay detect more than allergen-specific ige. in this study we examined the diagnostic capability of these two systems for screening test in the patient with pfas. method: total number of participants are (male/female: / ), aged . ± . (range ~ ) years old. all the patients showed oral allergy syndrome (oas) to rosaceae family plants (apple, peach) and/ or kiwi and/or banana, also showed tree pollen allergy. specific ige assay were performed using ic, ma or va. results of greater than class were to be regarded as positive, and the concordance rates between the assays were assessed. results: the correlation of sensitivity between pr- (rbet v , rmal d , rpru p , measured by ic) and specific ige to apple (measured by va), specific ige to peach (measured by ma) in oas patients to rosaceae family plants were assessed. rbet v , rmal d , rpru p were found to be . %, . %, . % positive measured by ic while the specific ige to apple (supposed to be including pr- ) were found to be % positive measured by va. on the other hand, the specific ige to peach (supposed to be including pr- ) were found to be only . % positive measured by ma, this detection rate was lower than that of va (p < . ). also, the correlation of sensitivity between pr- (ract d , measured by ic) and specific ige to kiwi in patients with oas to kiwi were assessed. ract d were found to be . % positive measured by ic while the specific ige to kiwi (supposed to be including pr- ) were found to be . % and . % measured by va and ma, respectively (p < . ). additionally, all the oas patients to banana found to be positive for the specific ige to banana measured by va, but only patient was detected as positive measured by ma. conclusion: in this study, we found that va showed better agreement of sensitivity and specificity with ic compared to ma in the oas patients to rosaceae family plants, kiwi, or banana. therefore, it may be clinically useful for screening of allergen specific background: the hygiene hypothesis for autoimmune and allergic diseases, which exists nowadays, shows that human immune system is dependent on various environment factors. we consider the effects of humic substances (hs) to be important in understanding the hygiene hypothesis. due to urbanization, the amount of human interaction with hs found in soil has significantly dropped. the goal of our work was to study allergenic potential and antimicrobial activ- conclusion: hs appear to be exogenous immunocorrectors, and also to have an ability of suppressing propagation of allergic reactions and sensibilization, which leads to conclusion that they seem to play a major role in hygiene hypothesis. moreover, hs selectively interact with bacterial cell wall, and this effect could be used in order to create antimicrobial drugs based on hs. background: peach tree pollen has been identified as having relevant allergens (the third most prevalent after olive tree and grass pollen) in areas of high cultivars (murcia, east-spain). when analyzing molecular components in sensitized patients, along with pru p , we have identified other relevant inhalant allergens one of which was named pru p x. because pollen of different species share allergens and with plantderived food, we have also studied peach tree pollen sensitization in a non-exposed population (madrid, central-spain). the aim was to study the association between peach tree pollen and several panallergens, as well as the relevance of pru p x in our area (madrid). method: a total of patients who came to our allergy unit in those patients with positive spt to at least one pollen we also performed peach tree pollen spt. if positive, we tested pru p , pho d , pho d and pru p x. to study the clinical relevance of these findings, we also performed nasal provocation test (npt) with peach tree pollen and pru p x. results: a total of patients were sensitized to peach tree pollen. from these, % had also positive spt to pru p and none of them to pru p x. positive spt to polcalcin were found in the % of the cases and to profilin in the %. in patients sensitized to peach tree pollen npt was performed being cases positive to peach tree pollen and none to pru p x. conclusion: peach tree pollen sensitization in non-exposed patients with allergy to other pollens is high although primary sensitization is unlikely. these patients present clinical response when exposed to that pollen that needs further evaluation. in our study, one third of the patients were also sensitized to polcalcin and pru p and none to pru p x. we have not found clinical response to this new inhalant allergen identified in highly exposed peach tree pollen population. results: the bet v elisa . -ep complete kit format (including pre-coated plates and all buffers and reagents) allowed for the consistent measurement of bet v in birch pollen extracts within the same lab (intralab cv= . %) and between different labs (interlab cv= . %). the average recovery from matrix spiked samples (crs in birch pollen extracts) ranged from - %, with an average recovery of % (n = ). assay time was reduced from several days to two hours compared to the original method. the performance of the bet v elisa . -ep kit was comparable to that of the stallergenes greer candidate standard method and has been successfully cross-validated. this will enable allergen manufacturers and regulatory authorities to adopt a standard method for bet v determination, which, ultimately, may be included in the european pharmacopoeia. the development of a certified elisa represents a major step forward in the standardization and quality control of allergen products. | an isoform of the ole e allergen assembled by proteomics could explain the cross-reactivity with pollen and food nsltps results: a total of peptides were obtained by de novo sequencing. ten of them allowed the completion of the full-length amino acid sequence of the allergen. after purification, role e was obtained with a yield of . mg/l of cell culture. immunological assays confirmed that the recombinant isoform of ole e shared most of the allergenic and antigenic properties of the natural allergen. moreover, we observed its implication in cross-reactivity with pollen extracts, and plant-derived food extracts. conclusion: these results suggest that the presence of this isoform in the olive pollen could explain the co-sensitization observed in some allergic patients between ole e and nsltps from foodderived extracts and might be used for a more effective clinical diagnosis of olive pollen sensitized patients. background: penicillium oxalicum, one of the prevalent airborne fungi in india, was selected to detect its spores as potential source of allergens and also to identify and characterise its major ige-reactive component. the airborne spores of penicillium oxalicum was detected by andersen -stage air sampler at different parts of west bengal. the allergenic potency of p.oxalicum was tested by spt, elisa and immunoblotting. total protein was resolved in -d and -d gel electrophoresis and allergens were identified by -d and -d immunoblots. identification of major ige-reactive protein spots was made by mass spectrometry based maldi-tof-tof. major allergen was partially purified by ion exchange chromatography. results: aerobiological investigation clearly indicated the predominance of p. oxalicum spores ( cfu m − ) in the air of west bengal, india. sensitivity of patients to spore antigens was highly correlated with rhinitis. in sds-page, bands were detected with molecular weight range of - kda. the allergenic potency of spores was confirmed by skin-prick test, elisa and dot-blotting. eleven ige-reactive proteins were detected as allergens by -d and -d immunoblots, of which % patients were sensitized to kda allergen. this kda protein was found to be the major allergen which was further characterized by mass spectrometry based maldi-tof-tof. this major allergen (pi . ) was partially purified by ion exchange chromatography. the eleven allergens were identified from spore of penicillium oxalicum fungi for the first time from india. immuno-proteomic identification of major ige-reactive protein ( kda background: airway epithelium (ae) is one of the largest cellular surfaces exposed to the environment. ae constitutes a physical barrier due to the presence of intercellular apical junctional complexes between neighboring cells. in the past years evidence indicates an association between epithelial airway dysfunctionality and allergic asthma. it is still unclear if an impaired epithelial barrier could be the cause of allergy development as opposed to the consequence. one of the most common comorbidities of asthma is house dust mite (hdm) allergy. it has been shown that hdm allergen der p can disrupt the epithelial airway due to its protease action against cellular apical junction complexes damaging the epithelial monolayer. in the last decade, metabolomics has been successfully employed as a new approach to describe metabolic changes in biological systems. metabolomics focuses on describing and identifying small molecules to explain complex biological processes. we theorized that metabolomics could be used as a new tool to detect damage of epithelial barrier in vitro after der p exposure. method: human cell line calu- cultured at air-liquid interphase (ali) was used as an in vitro model of bronchial epithelium. ali culture system allows establishing different compartments, mimicking the conditions found in the human airways: a basolateral compartment in which basolateral surface of the cells is in contact with the culture medium, and an apical compartment where the apical cellsurface is exposed to air. after days in ali, the cells were exposed to either der p or pbs as a control in the apical side for hours. then, apical and basolateral media were collected and processed for metabolomics analyses. results: metabolic profiles from samples were obtained, these were composed by and features for apical and basolateral media, respectively. of these, using mann-whitney unpaired test as statistical analysis, and features were found changed within the apical and basolateral compartments, respectively. specifically, in the apical compartment there were signals significantly increased and decreased after der p exposure; whereas for the basolateral compartment, signals were found to be significantly decreased and increased after exposure. background: mites are one of the major causes of allergies. it is known that allergen concentration varies depending on the species of mites and the degree of allergy induction is different, but the difference in microbiota according to mite species is not known. in addition to allergen, endotoxin or bacterial dna, adjuvants of allergen derived from the microbiota in the mites, are also present in the feces. bacterial endotoxin is found in gram-negative bacteria, acting on tlr and acting as an adjuvant to allergies. method: three species of mites (d. farinae, d. pteronyssinus, and t. putrescentiae), known to cause allergies, are cultured in same condition(autoclaved media, %rh, °c)and analyzed for microbiota of each species. using the next generation sequencing that complements the existing sanger sequencing, we analyze the difference of microbiome according to the dust mite species and measure the level of endotoxin. method: six hundred and thirty five patients ( . % males and . % females, mean age . years old, range to years old) were included. all of them referred respiratory symptoms (rhinitis, conjunctivitis or bronchial asthma) and had skin prick tests positive with any pollen. patients were skin prick tested with a battery of common pollens in our area, including three species of chenopodiaceae: chenopodium album, salsola kali and salsola oppositifolia. results: three hundred and forty tree ( %) patients were sensitised to pollen of any chenopidaceae species: ( . %) to chenopodium album, ( . %) to salsola kali and ( . %) to salsola oppositifolia. the prevalence of skin sensitisation to pollen of salsola oppositifolia was . % in the population studied and . % in patients sensi- results: in patients aged - years of age in . % of the cases ige reactivity was at least to one allergen tested. the majority of patients (more than / ) had a complex sensitization profile and reacted on average to more than allergens. the highest frequency of sensitization in ukraine among patients who turned to the clinic among adults was found phl p ( . %), amb a ( . %), fel d ( . %), bet v ( . %) and children ( . %, . %, . %, . %), respectively. when analyzing the results of tests for the source of the allergen, most often among house dust mites (hdm) allergens in adults and children is sensitization to fel d ( . %), as well as to hdm: in adults (der f - . % der p − . %, der f - . %, der p - . %) and in children ( . %, . %, . %, . %), respectively. among fungal allergens the most common is sensitization to alt a and varies from . % in adults to . % in children. among pollen allergens in adults is sensitization to phl p ( . %), amb a ( . %), bet v ( . %), cynd ( . %), art v ( . %), bet v ( . %) and in children ( . %, . %, . %, . %, . %, . %), respectively. tests for food allergens in adults and children are more common on pr- proteins. in children, sensitization to milk and egg proteins is more common than in adults. conclusion: most patients who came to the clinic have a complex ige reactivity profile in which pollen sensitization predominates. among hdm allergens, more than / of the examined have sensitization to the cat's proteins. sensitization to mold alternaria alternata in children occurs times more often than in adults. results: total children were examined, aged - years (median years). % children were sensible to two and more components . %to and more components. the frequency of sensitization to inhalation components was . %, to food abstracts | components- . %. among the most frequent inhalation components were feld - %, betv - %, amba - %, phlp - %, alta - %, the sensitization to house dust mites (hdm) was most often observed to der p - %. however, the analysis of these protein by the level of isu showed that the highest levels were for der f median (iqr . - . ), whereas for fel d - . (iqr . - . ). among food allergens, sensitization was most commonly observed to pr- proteins - %. children sensitized to pr- proteins were in most cases sensitized to -mal d ( %), cor a . ( %), pru p ( %).this co-sensitization was accompanied by a high correlation of isu levels among these components. sensitization to celery and kiwi was less common, the level of these proteins was also low. the frequency of sensitization to storage proteins was %, among which the highest level of isu was in ara h median . sensitization to ltp proteins was detected in % of children, among which the most commonly detected pru p protein was . %. the sensitization to profilins, which was evaluated at the level of bet v , was found in % of children, but the levels of these proteins were not high. among the food products of animal origin, the most frequent was sensitization to egg component gal d − . %, however, isu levels were the highest to milk component bos d − . (iqr . - . ). the most frequent causative inhalation allergens were epidermal allergens and weed pollen, however, the highest level of isu was to hdm and mould. among food allergens, the most commonly observed sensitization was to pr- proteins. hypereosinophilia of peripheral blood was observed in children under study, which was % ( . %). as a result of testing patients with a wide panel of allergens, % of the patients had diagnostic levels of antibodies to allergens siged , . %to allergens siged . in % of cases, a significant level of antibodies to plantain allergens sige w was detected, . % to dandelion allergens sige w , . % to evergreen trees sige t , to maple sige t to . %, to allergens of olive tree sige t - %, to the banana allergens sige f - . %, to the egg protein sige f in . %, in % to the milk allergens sige f , to the food mixture sige f x - . %, to allergens of mold fungi mx − . %. among the leading household allergens were registered in the st group and in the nd group of the investigated children -d pteronyssinus ( . %, . %), and d. farinae results: the prevalence results are expressed in the table . we have not observed any significant association in allergic rhinitis patients group with any ltp or pr- molecules. for atopic dermatitis only rara h (or with % ci - . ( . - . ) and njug r (or with % ci - . ( . - . )) were associated significantly. for asthma, the most important molecules were rbet v , raln g , rcor a . , rcor a . , rmal d , rpru p and rapi g (p-values for or less than . ). conclusion: future studies focusing on the evaluation the association of cross-reactive molecules with allergy phenotype should be done. background: the fuzzy/green kiwifruit (actinidia deliciosa), widely grown commercially, contains various pulp allergenic molecules, including the major allergen cysteine protease actinidin. methods. this case report is about a -year-old male patient with house dust mite allergic persistent rhinitis and intermittent asthma, presenting a convincing history of anaphylaxis immediately after eating a kiwifruit on empty stomach, followed, a few months later, by a severe oral allergy syndrome after licking a slice of raw kiwi. previously, the patient ate kiwi without any problems and had no manifestations of pollen or latex allergy. skin prick testing was done with commercial allergen extracts, while prick-prick testing was performed with raw kiwifruit, avocado and banana. molecular approach consisted in assessment of serum specific ige to native extracts and molecular allergen components using patient-friendly allergen nanobead array multiplex test and singleplex capsule-enclosed activated cellulose solid phase fluorescence enzyme immunoassay. results. regarding kiwifruit allergy, the patient presented positive prick-prick tests with raw edible kiwifruit components: outer pericarp and inner pericarp (each mm wheal) and columella/core ( mm wheal) and negative with kiwifruit whole seeds, avocado and banana, and pollen extracts. serum specific ige to kiwifruit were detected ( . ku/l), but specific ige values were negative (≤ . fiu/ml) for actinidin act d , thaumatin act d , kiwellin act d , nsltp type act d , bet v -like major latex/ripening-related protein act c , act c chitinase_iv, act d cross-reactive profilins bet v (birch pollen profilin) and hev b (latex profilin), and also negative (< . ku/ l) for pr- ract d . moreover, specific ige to avocado were nor found (≤ , fiu/ml). although ige against seed proteins cupin/ s globulin act d and s albumin act d were not determined, this was not considered of great importance since allergic symptoms were also induced by licking kiwi pulp, in which abundantly expressed actinidin enzymatically degrades seed storage proteins, and prick-prick test was negative to kiwifruit seeds. conclusion: in a patient with anaphylaxis to kiwifruit, positive skin tests to its pulp and detectable serum specific ige to actinidia deliciosa, a detailed molecular allergy diagnosis is necessary, including assessment for act d glycoallergen or other molecules, not performed in this patient. | is pr- sensitization a portuguese phenomenon as well? background: bet v , a major allergen found in birch pollen, belongs to the pr- protein group. in our practice, some bet v sensitized patients have been identified, residing in areas without this tree genus in its flora. our aim was to characterize a portuguese patient population with pr sensitization. method: a group of patients in whom immunocap isac ® (isac) study was performed, between january and june , were analyzed. all subjects with one or more pr- sensitizations were selected, and their clinical records reviewed. a sequential sample of the last subjects (n = ) who underwent isac study, was then used for comparison. results: out of isac studies performed, only were positive for pr- protein group. median age was . years, % (n = ) were male. pr- sensitized individuals were more likely to live in portalegre district compared to the control group ( / vs / ; p < . ). patients were positive for pr- family pollens ( . %), frequently bet v (n = ), followed by aln g (n = ) and cor a (n = ). out of the patients were sensitized to pr- foods, mostly cor a . (n = ) and mal d (n = ). skin prick tests revealed birch as the main sensitizing pollen as well ( / ). moreover, only four patients were skin prick tested for fagaceae trees which were positive for oak ( ), chestnut tree ( ) and cork tree ( ) . all patients were co-sensitized to other pollens, namely grass and all had respiratory allergy. nine patients were food allergic, although seven of them were co-sensitized to other cross reactive (ltp/profilin) or species specific proteins. conclusion: although pr- sensitization is known to be rare in our population, mostly alto alentejo inhabitants showed sensitization to this protein family in our sample, either by in vitro and/or in vivo methods. this phenomenon is consistent with the native plant species of this region, which should be taken into account when studying the allergic profile of these patients. in our sample, all pr- sensitized patients had respiratory allergy while this protein didn't seem to be relevant when it comes to food allergy. further studies are needed to characterize which plant species belonging to this protein family are more significant for our country's aerobiology context and to determine its clinical relevance. included. allergic asthma, rhinitis, conjunctivitis and eczema allergic symptoms were diagnosed. all patients were tested by immunocap with mugwort pollen extract and the natural components nart v , nart ar , nart v , and nart an . results: the positive frequency and sige levels of the four components in the artemisia allergic patients from southwestern china were significantly lower than that from the north. art v and art an were the highest recognized allergens, followed by art v and art ar . patients from northern china were more likely to have abstracts | asthma ( %) than patients from southwestern china ( %), and being sensitized to more than two allergens increased the risk of asthma. sensitization to art v , art v and art an played a significant role in the development of asthma. artemisia pollen allergic patients is helpful to assess the potential risk of asthma. conclusion: a small but significant part of the population react to ragweed pollen extract and are not identified as disease-positive by standard sige tests. there is a need for targeted tests towards a larger spectrum of allergen molecules. in ragweed allergic individuals, this allergy can be the main cause of overall sige levels and also of in vivo reactions (tested by spt). | molecular profile of pollen sensitization of tashkent residents with respiratory allergy background: in paediatric cohorts, a correlation between specific ige (sige) levels to house dust mite extract or allergen components and the occurrence of asthma has been shown. higher levels of sige to mite extract were associated with a higher risk of wheezing. moreover, asthmatic children recognized more allergens and had higher sige levels to nder p as well as rder p , and . we sought to investigate potential differences in sige levels or sensitization patterns between asthmatic and non-asthmatic patients in a mixed paediatric and adult house dust mite allergic cohort. method: total ige and specific ige against house dust mite extracts (dermatophagoides pteronyssinus and farinae) and allergen components (rder p , , , and ) were determined in house dust mite allergic patients. patients had diagnosed asthma ("asthmatic", % females, mean age ± years, % younger than years), whereas had rhinitis (and conjunctivitis) without respiratory symptoms ("non-asthmatic", % females, mean age ± years, % younger than years). results: total ige levels were markedly higher in asthmatic compared to non-asthmatic patients ( vs. ku/l, p = . ). positivity to rder p ( vs. %, p = . ) as well as rder p ( vs. %, p = . ) differed between both groups. specific ige levels to house dust mite extracts and allergen components (rder p , , , and ) and positivity to rder p and did not differ between both groups. conclusion: in contrast to previously published data, sige levels to house dust mite extracts or allergen components were not statistically different between asthmatic and non-asthmatic patients in our mixed paediatric and adult house dust mite allergic cohort. only higher total ige levels and a higher reactivity to rder p and were found in asthmatic patients. however, larger studies are needed to confirm clinical relevance of these findings. results: prior treatments reported at baseline (bsl) included: . % of pts were receiving or more second-generation h -ah at approved dose (recommended first-line), . % were receiving them at increased dose (second-line); . % were receiving omalizumab (third-line); . % had no treatment. the majority of pts ( . %) had uncontrolled csu (uct< ) at bsl (table) . treatment changes were most evident at the bsl visit, with an increase in pts receiving omalizumab ( . %) and a decrease in those receiving no treatment ( . %) vs. prior therapy. these changes were associated with improvements in rates of hives and/or angioedema, uct and qol scores at month , but only modest improvements thereafter (table) . a sub-analysis of pts with uct< and who were receiving the approved ( . %) or increased dose h -ah ( . %), revealed that few pts had recommended escalation from the approved to increased dose h -ah ( . - . %) or from increased dose h -ah to omalizumab ( . - . %) (table) . conclusion: poor physician adherence to guidelines was evident throughout aware. initial improvements in disease activity and qol plateaued after month , possibly owing to fewer changes to recommended therapies. greater physician adherence to guidelines is needed for better symptom control in pts with uncontrolled csu. results: we revealed that in russians urticaria is associated with rs *arg/gln genotype of the il gene (p = . ) and rs *cc genotype of tlr (p = . ) gene polymorphism. in tatars the association with disease development was shown for rs *tt genotype of tlr gene snp (p = . ). the rs *c allele of tlr gene polymorphism is associated with acute and chronic forms of urticaria (p = . and p = . , respectively) and rs *c allele of il gene polymorphismwith acute urticaria (p = . ). method: csu patients from the urtica cohort (clinicalttrials.gov number: nct ) participated in the study. a questionnaire was carried out evaluating the triggers identified by the patients, the comorbidities and the treatments received. patients with a self-report of skin exacerbation by foods, nonsteroidal antiinflammatory drug (nsaid) or physical triggers were subjected to a controlled provocation test with the suspect food, medication or physical stimuli report by the patient. the levels of anti-tpo ige were measured during a period of clinical control and during two exacerbations in all patients. results: % of the patients had at less one inducible urticaria demonstrated by provocation tests ( % dermographism, % cold, % pressure). self-reported exacerbation for a food ( %) or medication ( %) were high, but positive provocation tests were low ( % and % respectively). patients had (+) anti-tpo ige during the baseline period. among them, % presented a significant elevation of anti-tpo ige during at less one of the two exacerbations. . % of patients (n = ) with (−) anti-tpo ige, presented elevation of anti-tpo ige one of the two exacerbations. conclusion: foods, drugs and physical triggers must be verified by challenge tests to avoid unnecessary lifestyle restrictions in patients with csu, nevertheless self-report is usually greater than positive provocation tests. increase concentrations of anti-tpo ige seems to be implicated in urticaria exacerbations in some patients with csu. brzoza z ; adamczyk k ; wcislo-dziadecka d ; zbiciak-nylec m ; brzezinska-wcislo l adipokines. the aim of the study was to evaluate the possible contribution of leptin to chronic spontaneous urticaria pathophysiology. the study included chronic spontaneous urticaria patients and healthy subjects. the leptin level in both examined groups was measured. results: no statistically significant difference in leptin level was determined between the studied subgroups. we are among the first to present the effects of exploration aimed at assessment of the possible role of adipokines in chronic spontaneous urticaria pathogenesis. in this study we did not prove any difference in leptin level. in our opinion it is valuable to perform further studies in this area. the microorganisms were inactivated with phenol, and the concentration was adjusted to microbial cells/ml (labeled as a / ). dilutions / and / were made from the product labeled / . the dot blot technique was used to detect the presence of specific ige to the different microbial antigens and controls (anti ige / and fold dilution ½ and ¼). the dot blot images were processed with a documentation system (gel doc ez, bio-rad), and the different microbial antigens in different dilutions were compared with the positive anti-ige controls. results: all patients have specific anti ige to microbial antigens (see table below). the presence of microorganism-specific ige could explain, the relationship between the infections and / or microorganisms in ciu, as well, the urticaria control by omalizumab, even when it has not been detected ige sensitizations to common allergens. finally, these findings, showed that the bacterial allergy could be one line of research to understand the unresolved etiology of urticaria. background: dermographism is the most common form of inducible urticaria. it shows itself as hives made by scratching or rubbing on the surface where it has been produced and with the same morphology. the pathogenesis has not been clarified nor has it been associated until now with the sensitization to allergens. we have studied the relationship between the presence of dermographism and domestic mites sensitization. we have selected patients older than years old. all of them had symptoms compatible with dermographism at the moment of medical evaluation. at least one third of patients additionally showed rhinitis and/or asthma symptoms. we performed:: -skin prick tests with our basic neumoalergens (mites d. pteronyssinus y lepidoglyphus destructor, pollen, molds, dog, cat and horse dander, latex and anisakis simplex). -determination of specific ige levels for dermatophagoides pteronyssinus, lepidoglyphus destructor, and anisakis were measured in serum by using the immunocap (thermo fisher scientific). -blood count, serum immunoglobulins, antithyroid antibodies, serine tryptase and proteinogram. results: blood count, serum immunoglobulins, antithyroid antibodies, serine tryptase and proteinogram were normal. we divided patient in different groups. background: urticaria results from the appearance of pruritic papules and/or erythematous plaques caused by substances from mastocytes present in the skin, notably histamine. chronic urticaria is defined as flare-ups that occur at least two or three days per week over a six-week period. in addition, affected subjects are often prone to an atopic or auto-immune profile that promotes urticaria [ ] . the association of polyphenols (ambora, green tea) and the soothing active ingredients slow down the itching biological process from the outset by reducing the release of pruritic mediators (e.g. histamine, cytokines, etc.) of immune cells such as mastocytes and lymphocytes, involved in urticaria. in this context, the purpose of the study was to evaluate the efficacy and the tolerance of an anti-pruritic spray containing the polyphenols and the soothing ingredient. the tested product aims to quickly calm the itching in subjects with chronic urticaria. results: on average, the product was applied . times per day with a significant decrease of d-pruritus scale (- %) and sensations of itching (- %) between d and d . in terms of quality of life, a significant decrease of the skindex score was observed (- %). the product soothed the pruritus within seconds for all subjects and the anti-pruritic effect lasts at least hours for % of subjects. the product also showed very good cosmetic properties and was well tolerated; no intolerance case was reported. showed near complete remission. in the week before omalizumab and for a few days after, her urticaria flared but on of weeks she was largely asymptomatic (uas - ). after years of successful treatment she reported an increase in csu activity. no trigger factors could be identified. add-on treatment with cyclosporine was refused, montelukast showed no, and prednisolone only transient benefit. over a period of months wheals occurred almost daily and a maximal score of was achieved on uas . we replaced omalizumab with cyclosporine but this was subsequently discontinued due to side effects. months later the patients' csu remained poorly controlled with up to wheals occurring almost daily despite rupatadine mg/d. due to the good initial response to omalizumab and lack of good treatment alternatives, a trial of re-treatment was considered. results: within week of re-commencing omalizumab she once again achieved near complete remission of csu with uas ≤ on of weeks. the mechanism of action of omalizumab and the development of resistance to it in csu, are incompletely understood. our case shows that some csu patients developing resistance to omalizumab may benefit from a subsequent trial of re-treatment, particularly if treatment alternatives are poorly tolerated. manipulate and store data by electronic means. this includes e-mail, sms text messaging, video chat and online social media as well as all the different computing devices that perform a wide range of communication and information functions. a rapid increase in the use icts in recent decades is an enormous contributing factor in the development of a number of novel clinical and public health intervention strategies. the aim of the present study is to assess the level of ict use and to examine patterns of preferences among patients with chronic urticaria (cu). method: we will conduct an anonymous multicentre cross-sectional study, starting from january , to investigate the use of icts in patients with cu, using a questionnaire as a survey method. this questionnaire will assess the frequency of use of social media and icts in patients, and their preferences for receiving and asking disease-related information. the survey will consist of items, evaluating demographical information, time with disease, medication currently used, and additional aspects of social network use. results: we will use a chi-squared test to assess the association between internet access or owning a cell or smartphone, and age, gender, type of urticaria, educational level and number of years since diagnosis. we will employ the same test to assess the association between the independent variables previously introduced and the frequency of use of each ict type (short messaging service [sms], facebook, twitter, youtube, email, internet, linkedin and skype) as well as agreement in receiving and seeking information (i.e. asking questions to the practitioner) through such icts. we will perform adjusted regression analyses between categories of age, gender, educational level, type of urticaria, years since diagnosis and the use and level of interest shown in communicating through icts. our aim is to report on remarkable findings from a registry of a large sample of patients, potentially providing clues for its approach and results: patients with a median length of months suffering from urticaria were registered, being % women; mean age . years. in % of patients no causal agent was identified. parasites were found in . % and thyroid peroxidase antibodies in . %, while autologous serum skin test was positive in % and igg to mycoplasma in % of evaluations. two thirds of patients reported wheals on uas , with just / having concomitant angioedema. almost / reported significant affection on quality of life because of itch by cu-q ol. just % of patients achieved total control on first anti-histamines provided, and less than half had good control of urticaria. cetirizine was the first choice in %, followed by fexofenadine ( %) and first generation anti-histamines ( %). method: cases at - years of age which were being followedup in our clinic with diagnosis of chronic urticaria and were not receiving any antihistaminic medication for last one month were included in the study. cu-q ol, uas- , psqi and psg results of the patients were evaluated. correlation of data with each other in regard to sleep disturbances was evaluated. results: patients were included in the study. patients' mean total score in cu-q ol was . ± . . patients' mean uas- value was . ± . . mean total psqi was . ± . , the ratio of total scores ≥ and those with poor quality of sleep was . %. mean epworth sleepiness scale (ess) score was . ± . , with total score ≥ in . %. in psg, mean apnea-hypopnea index (ahi) was . ± . , with . % of the patients having ahi ≥ . when patients having ahi< were compared with patients having ahi ≥ , no significant difference was determined in regard to total cu-q ol score, mean score for questions concerning status of sleep, uas- and psqi. when correlation analysis was performed between cu-q ol and total score for questions concerning status of sleep, a positive correlation was determined with psqi (p = . ). conclusion: it was demonstrated in our study that patients with chronic urticaria had poor quality of sleep and this disturbance was independent from ahi. omalizumab was discontinued due to absence of improvement in csu symptoms after three consecutive doses. the plasmapheresis without intravenous immunoglobulin replacement was initiated. results: the symptoms were relieved during the first procedure and the disease improved shortly thereafter. the following weeks the symptoms still occurred but with lower intensity and severity. (angioedema was gone). the second attempt with omalizumab was successful after this course ( procedures of plasmapheresis). case report: rosacea is a chronic skin disorder associated with flushing, erythema, dryness, burning and stinging, and inflammatory papules and pustules. new treatments available or in development target the inflammatory and erythematous components of the disease. these agents include the selective alpha- receptor agonist brimonidine. allergic contact dermatitis to brimonidine is an unusual condition. in addition to this, urticarias due to brimonidine are rarely reported. we report on a -year-old woman who, immediately after apply a thin layer of brimonidine gel as preparation for a rosacea treatment on her face developed facial urticaria, which reverted in approximately four hours with systemic steroids. she had previously tolerated this product without any problems, but has not use it again ever since. skin prick-tests with brimonidine ( . mg/ml) and latex were realized in the patient. skin prick-tests with brimonidine were realized in eleven healthy control subjects. results: skin prick-tests with latex was negative in the patient. skin prick-tests with brimonidine were positive in the patient ( x mm). the prick-test with brimonidine was negative in teen healthy control subjects. we report on a case of immediate urticaria due to brimonidine and triggered by an immediate, probably ige-mediated, hypersensitivity mechanism. we highlight this case because it is the only case described in the literature with a positive prick-test. method: the study was in accordance with the helsinki declaration and was previously approved by the national comity of ethics. this was a one dose study conducted on fasting young healthy volunteers, of which were females and five males. the mean age was ± years old and the body weight . + . background: cetirizine is a potent h -receptor antagonist indicated in the treatment of allergic rhinitis and urticaria. cetirizine is widely used due to its potent antihistaminic effects in yielding strong and fast relief of itchy sensation, sneezy and rhinorrhea and its unlikely probability to manifest anticholinergic side effects in therapeutic doses. histamine flare and wheal inhibition by anti-h are widely used as a standard to test and compare the effect intensity and duration. our study aimed to test these effects of cetirizine in young healthy adults. method: this was a double-blind, single dose study in healthy young adults, previously approved by the national comity of ethics. eleven females and five males with a mean age ± years participated in this study. histamine skin pricks were tested before and after they received a tablet of mg cetirizine as previously scheduled. twenty minutes after each test flare and wheal were drawn in a transparent paper which was then scanned and measured with a software. wilcoxon signed ranks test two-sided with significance at % level was used to analyze the differences. claims that the preparation relieves itch within seconds of its application. we performed a simple study to verify this claim. we used irp in consecutive subjects, males, median age , range - years, whose workup implied ast. their preliminary diagnoses were "asthma" ( subjects), "allergic rhinitis" ( subjects), "atopic dermatitis" ( subjects) and "food allergy" ( subjects). all of them had refrained from systemic antihistamines for at least one week. standard skin prick tests (spt) were applied as appropriate, including histamine controls to assess the level of their skin sensitivity. subjects were asked to mark their sense of itch in the area of the skin to be tested on mm visual-analogue scales (vas) starting from " "-"no itch" to " "-"unbearable itch". vas assessments were repeated minutes after ast was done; then irp was applied according to the manufacturer's instructions, and the vas assessments were repeated after seconds and minutes. results: there vas assessments are shown in table format: table irp did not affect the wheal and flare of the histamine control, nor did it abolish positive spt. no differences were outlined between subjects with different diagnoses. the commercially available itch relieving preparation not containing defined pharmacological antihistamine is effecting in relieving itch associated with allergen skin testing. before ast ( ) . ± . vs ( ) p < . represent the first-line treatment for osteoporosis-related mastocytosis. we report a case of sm with bone pain and with an area of osteolysis in the femur as first sign and symptom. we had to consider the risk of adverse reaction when we decided to treat the patient with bp, but the patient was under antihistaminic treatment and also we made a premedication to reduce the risk. the pk/pd model available was informed by data from clinical trials. the pd endpoint data was available from two studies and used to characterize the effect of bilastine on wheal and flare. moreover, food effect had been characterized in pk studies and the data was used to model the effect of food in the pk of bilastine. the pk parameters relative to the fed state were then used to simulate the temporal evolution of the wheal effect using the pk/ pd model. all analyses were conducted by nonlinear mixed effect modeling (nonmem v . ). using the pk model developed (food effect model) and the pk/pd model already available, monte-carlo simulations for plasma concentrations and pd over time were performed for both the fed and the fasting states. results: . a reduced bioavailability (f) and a slow absorption constant characterized the pk of bilastine when administered concomitantly with food (f = % relative to the fasting state and ka = . hour − , a -fold reduction compared to fasting conditions). the rest of the pk parameters remained unchanged. onset of action was hour for bilastine both in fed and fasted conditions. maximum wheal inhibition occurred at . hours (fasted % and fed %). from to hours, the percentage reduction with bilastine for both fasted and fed was between % and % after the third day of treatment. a % inhibition in wheal effect was maintained during hours for both conditions after the third day. the results of the simulations show that even if the pk is altered with food, the pd is maintained unchanged. conclusion: even if a significant food effect was described for bilastine at a pk level, the difference is not translated directly into the pd. therefore, the antihistaminic effect of bilastine remains unaffected by the concomitant administration with food. the results of these simulations will be further confirmed in a dedicated clinical trial. results: we also found no correlation between the different tgt parameters and other clinical and analytical parameters associated with uc (table ) results: both cetirizine products have no differences in respect to the pharmacodynamic and pharmacokinetic parameters analyzed. the % confidence interval of the mean ratios of the auc - , auc -inf , cmax, auce - , and e max , between the test and the reference, were within the bioequivalence ranges ( %- %) in both cases. no statistical difference was revealed when comparing the respective t max and te max too. the two cetirizine products tested were bioequivalent. the bioequivalence was evident even when tested with the pharmacodynamic parameters. there is strong evidence that supports the use of histamine skin prick test for the bioequivalence evaluation of different cetirizine products. | bradykinin-mediated angioedema associated with combination of angiotensinconverting enzyme and dipeptidyl peptidase iv inhibitors: a disproportionality analysis from the who database method: we performed a disproportionality analysis using data from the who pharmacovigilance database by a case-noncase study, until the / / . we extracted all individual cases safety reports (icsrs) included in the high level term "angioedemas", according to the medical dictionary for regulatory activities classification. given the absence of term "bma", we selected only the icsrs of angioedema without associated symptoms evoking another underlying mechanism, such as histamine angioedema (e.g. pruritus, urticaria, rash, etc.). drug class exposure was "acei" and "dpp i", considered suspect or concomitant, using the atc classification. we results: there was no correlation between mother's disorders such as periodontitis, rhinitis, diabetes etc. and the onset of ar (p > . ). a multivariate analysis showed, neonatal jaundice (p < . ), respiratory system infection (p < . ), diarrhea (p < . ), eczema (p < . ) in the first months of life and home environmental factors (house decoration (p < . ), mold environment (p < . ), keeping flowers (p < . ), passive smoking (p < . )) increased the risk of ar. besides, there was no significant difference in current height and birth weight of the participants between ar and control group. however, ar group had significantly lower current weight (p = . ) and age (p < . ) compared with the control group. paternal age and maternal age in the ar group were significantly higher than the control group (p < . ). conclusion: diseases in the first months of life and home environmental factors increased the risk of sequential ar. the older parents increased the possibility of ar in the offspring. the data of general characteristics of participants were statistic analysis by z text analysis. *significance at p < . . results: anosmia was more frequent in crs than in rhinitis ( . % vs . %, p < . ) and in crswnp than in crssnp ( . % vs . %, p < . ). lms was higher in crs than in rhinitis ( [ - ] vs [ - ], p < . ) and in crswnp than in crssnp ( [ - ] vs [ ] [ ] [ ] [ ] [ ] [ ] [ ] , p < . ). in addition, lms was associated with loss of smell in patients with hyposmia (or = . [ . , . clinics. patients were submitted to confirmatory exams including oral provocation test with aspirin. nasal polyps were removed by functional endoscopic sinus surgery and eosinophils in this tissue were quantitated. eosinophil counts in peripheral blood was obtained. serum periostin was measured by elisa and total ige was determined using immunocap. as control groups, ( f/ m) patients with par and healthy subjects ( f/ m) were selected. samples of nasal tissue and blood were collected from these subjects during elective surgery for correction of anatomical variations, and compared with the patients with aerd. results: ar symptoms were significantly improved in the treatment group compared with the control group ( . % ( / ) vs . % ( / ); p < . ). furthermore, the mean total vas score for patients in the treatment group was reduced from . ± . before treatment to . ± . after treatment (p < . ). moreover, the reduction in free ige levels was greater in the treatment group than in the control group. the results of this study suggest that the chinese herbal medicine ber may be effective for improving the symptoms of ar. a multicenter clinical trial is needed to confirm this finding. results: in patients with "eosinophilic" polypoid rhinosinusitis, mucociliary transport was . ± . minutes, ph . ± . , suction- . ± . minutes, excretory- . ± . mlg and in patients with "neutrophilic" polypous rhinosinusitis, mucociliary transport was . ± . minutes, ph . ± . , suction- . ± . minutes, excretory- . ± . ml. the study showed that disruption of the transport function, changing the concentration of hydrogen ions method: this prospective controlled study was carried out on crs patients underwent ess. patients participating in the study were divided into two groups-group : partial middle turbinectomy (n = ) and group : partial middle turbinectomy and middle turbinate fenestration (n = ). objective assessment of olfactory function using the university of pennsylvania smell identification test (upsit) and subjective assessment of symptom using visual analogue score (vas) were performed before and months after surgery. results: there were significant improvement comparing postoperative and preoperative upsit in both group ( . ± . vs . ± . , p = . ) and group ( . ± . vs . ± . , p = . ). the vas were also significantly improved postoperatively compared to preoperatively in both group ( . ± . vs . ± . , p = . ) and group ( . ± . vs . ± . , p = . ). patients undergoing partial middle turbinectomy and middle turbinate fenestration were more likely to show improvements in upsit ( . ± . vs . ± . , p = . ) and vas ( . ± . vs . ± . , p = . ) compared to those with only partial middle turbinectomy. conclusion: partial middle turbinectomy and middle turbinate fenestration during ess is an effective method for improving postoperative olfactory function. | nasal irrigation for the alleviation of nasal symptoms in pregnant women with allergic rhinitis we sought to determine specific ige responses to bacterial pathogens in sera from cystic fibrosis patients and analyze their kinetic during disease course. genes, respectively. in contrast, most of healthy donors had normal homozygous genotype with tt- . ± . %(n = ) and cc- . ± . %(n = ) with low frequency of mutations; gg- . ± . %(n = ) and tt- . ± . %(n = ) and heterozygous genotype tg- . ± . %(n = ) and ct- . ± . %(n = ) for il- and il- genes, respectively. following a month treatment, there was a significant reduction of cytokine levels in the il - . ± . and increased in the il - . ± . , when compared to the beginning of therapy and after months (p < . ) results: at baseline the st group had serum levels of il- ( . ± . ) pg/l; il- ( . ± . ) pg/l and ifn-γ ( . ± . ) pg/ l; nd group had il- ( . ± . ) pg/l; il- ( . ± . ) pg/l and ifn-γ ( . ± . ) pg/l vs il- ( . ± . ) pg/l; il- ( . ± . ) pg/l; ifn-γ ( . ± . ) pg/l in the control group. after months, there was a significant decrease in pro-inflammatory cytokine levels in the st (il- : ± . ; ifn-γ: . ± . ) pg/l and nd group (il- : . ± . ; ifn-γ: . ± ) pg/l, respectively. conversely, il- increased in st and nd groups to . ± . pg/l and . ± . pg/l (p < . ). conclusion: prior to the study initiation patients with tuberculosis had higher il- , ifn-γ and lower il- content than healthy controls. two-month chemotherapy produced significant reduction in proinflammatory cytokines and increase in anti-inflammatory il- , with levels approaching those of healthy controls. thus, tuberculosis drugs appear to have the anti-inflammatory effect in tuberculosis patients, which was predictive of positive clinical outcome. | antibiotic resistance: ligands of innate immunity take the challenge in this work, we aimed to perform an ex vivo hrsv infection in precision-cut lung slices (pcls) from human, rhesus, and cynomolgus macaques, comparing whenever possible the response with the viral surrogate poly i:c. method: pcls containing airways were prepared from lung sections of human, rhesus, and cynomolgus macaques. the slices were inoculated with hrsv-a iu/ml, uv-inactivated hrsv, or vehicle control for hours. macaque slices were also incubated with poly i:c μg/ml with and without the immunosuppressive dexamethasone μg/ml. viral replication, tissue viability, and immune response assays were assessed in supernatants, lysates, or slices. the inoculum infectivity of iu/ml as well the uv-inactivation were confirmed by plaque-assay on hep- cells. immunofluorescence staining using a fitc-labeled anti-rsv showed the presence of infected macrophages in pcls, but not in mock infected samples. hrsv stimulation slightly decreased tissue viability, as seen by live/dead staining and ldh assay. the viral infection increased ip- production in pcls of human, rhesus, and cynomolgus macaques, reaching respectively . , . , and . fold-increase in comparison to the vehicle controls. poly i:c stimulation caused ip- response comparable to hrsv in rhesus and cynomolgus pcls. the ip- production ratio comparing hrsv/poly i:c was . in rhesus and . in cynomolgus pcls. conclusion: hrsv infects ex vivo pcls of human and non-human primates, inducing the release of the pro-inflammatory chemokine ip- . this response is comparable to the viral surrogate poly i:c. in the future, these systems can be used to further investigate host response to hrsv, especially in the context of asthma development. however, a relatively small number of reports are related to the association of ebv with allergic diseases, in particular atopic ones. we found that among patients with activated ebv infection, polysensitization was found to be . times more frequent, chest syndrome was . times more common and hyper-ige syndrome occurred . times more frequently. in most of these patients, atopy was not detected in medical history. method: we evaluated the laboratory test results of five boys ( . %) and six girls ( . %), children ( with hbov and with cov). their average age at the study time was . ± months. nasal swab specimens were taken from these patients who admitted to our hospital with respiratory symptoms between - . patients are recalled after an average of ± . months. isaac questionnaire and skin prick test to common inhalated allergens were performed. results: only one patient had family history of atopy. forty percent of the patients with cov and % of the patients with hbov developed rhinitis. one patient with cov and one patient with hbov developed recurrent wheezing. one patient with cov developed atopic dermatitis. all skin prick tests were negative. it was noteworthy that . % of the patients were passive smokers. conclusion: hbov and cov may be associated with rhinitis but there is a need for more patient groups for a clear result. rna_lig (ccg-agg-aug-cga-ggc-uug-uu) . to study chemotaxis in vitro, a boyden chamber was used -wellfiltrationplatemultiscreentm -mic with a pore size of μm (millipore, usa). chemotaxis was studied in dynamics after , minutes and a day using the above ligands. as control, rpmi- medium without glutamine was used (paneco, russia). the statistical analysis was carried out using the computer statistical program biostat conclusion: with all the data provided, a drug induced hypersensitivity was diagnosed. we present a case of immediate allergic reaction with eosinophilia due to carbapenems, with tolerance to other beta-lactams antibiotics. written informed consent of patient has been obtained in the two cases. discussion: the first case shows cutaneous immediate hypersensitivity response to infbeta a. literature reports a few cases of urticaria and anaphylaxis but this is the first for the pegylated formulation. polyethylene glycol (peg) confers to a drug modified pharmacokinetics, solubility and immunogenicity. immediate reaction to peg (macrogol) have been described when combinated in vaccines or drug pils. dmf is a known cause of contact dermatitis related to footwear, wallets and furniture. flushig is a reported side effect of dms in ms managed with dose reduction. this case shows the possibility to immediate sensitization to dmf. as the armamentarium to treat ms now combines immunomodulatory and biologic drugs, the avaliability of diagnostic and desensitization protocols for hypersensitivity reactions must be keeped in mind. case report: drug rash with eosinophilia and systemic symptoms (dress) syndrome is an uncommon but serious hypersensitivity drug reaction, manifested with rash, fever, lymphadenopathy and visceral organ involvement. table) . drug withdrawal and prednisolone treatment leaded to attenuating of mentioned skin symptoms within days, associated by occurrence of a exfoliative dermatitis. one week after admission, the patient developed fever that lasted for days with enlarged lymph nodes on submandibular, paracervical, axillar and inguinal regions. a preventive antibiotic therapy is started and weeks later, the lymph nodes were not palpable and the skin got the normal appearance. corticoid therapy is reduced gradually according to symptoms resolvement. case : a -year old woman presented to our department with a -day history of pruritic, macular rash, periorbital swelling, cheilitis and fever. she had started some weeks ago the allopurinol for asymptomatic hyperuricemia, had longer history for treatment of arterial hypertension and type- diabetes mellitus (olmersartan, nitrendipine, methyldopa, furosemide, regular and glargine insulin), and experienced nephrectomy and cholecystectomy. the patient was febrile, while blood tests revealed eosinophilia, increased seric creatinine/urea levels (due to nefrectomy), and severely-altered liver parameters (see table) . the allopurinol withdrawal, topical and systemic corticoid therapy, and the liver protectors attenuated serologic transaminases levels and patient's skin lesions within few days, followed by substantial improvement of laboratory findings one week after therapy start. the treatment dosage was gradually tapered and finally stopped within a period of months in accordance with attenuating and complete resolvement of the clinical and laboratory abnormalities. our case demonstrated that dress syndrome is a severe drug reaction, but the immediate introduction of treatment and supportive measures can improve disease's outcome even after a temporary exacerbation or severe affection of internal organs. case report: a -years-old woman, diagnosed of ischemic cardiopathy, developed an anaphylactic shock minutes after the administration of ml sulphur hexafluoride intravenous during an echocardiogram. she was treated in emergency room with a total recovery. months earlier, she had developed an extensive erythematous-maculopapular rash converging in plaques in relation with adhesive dressings which had been placed during a hospitalization due to thoracic pain. an allergic contact dermatitis was suspected and recommendations thereon were given. interestingly, an arteriogram with iodixanol (icm) was carried out one week before skin reaction with good immediate tolerance. methods: blood test: blood count and serum chemistry were done during both reactions to contrast media. serum tryptase level was not measured during the anaphylaxis, but its baseline level was quantified later. conclusions: we present a patient with a double sensitization to parenteral contrast media: an anaphylactic shock due to sulphur hexafluoride and an atypical delayed exanthema related to iodixanol, and diagnose was obtained with st in both cases. this is the first documented case with a positive immediate st to sulphur hexafluoride. with the culprit drugs mixed with % and % petrolatum resulted negative. patient was suspected to have behcet's disease, and consulted to rheumatology department. oral colchicum dispert twice a day was prescribed. afterwards, patient achieved to take oral amoxicillin-clavulanate for a week without any hypersensitivity; and has been following by oral colchicum dispert maintenance therapy since then. the reported patient had one anaphylactic perioperative reaction to morphine and another anaphylactic reaction to tramadol during her diagnostic investigation. remain the question if this patient had two allergic anaphylactic reactions with cross-reaction between morphine and tramadol, or two non-allergic anaphylaxis due to "hypersensitive" mast cells. case presentation: a -year-old female was diagnosed with rectal adenocarcinoma. one year after radical surgery, progression with pulmonary metastasis was shown. in first line of systemic therapy she received premedication with pantoprazole, metoclopramide, clemastine and dexamethasone, followed by cetuximab infusion. during first minutes of infusion, grade anaphylactic reaction occurred. a reaction started with generalized pruritus, urticaria, rhinitis, followed by hypotension, bradycardia and loss of consciousness. she was treated with fluids, clemastine and methylprednisolone. next day she received same premedication followed by panitumumab. during first minutes she had grade reaction with generalized urticaria. the third day she had generalized urticaria minutes after metoclopramide application. skin prick tests with cetuximab ( mg/ml) were negative, but intradermal test were posi- bat response was highly positive for both cetuximab and alpha-gal, with comparable values and dose response curves. thus, we showed %, %, %, % and % of cd positive basophils for stimulation with cetuximab ( - . μg/ml), and %, %, %, and % for stimulation with alpha-gal ( . - . ng/ml). bat response to panitumumab was negative (< %; - . μg/ml). drug provocation with panitumumab was negative and patient received treatment with panitumumab. in the operating theatre, the skin is disinfected using povidoneiodine and pupil dilation is carried out with tropicamide (showing no immediate reaction in the surgery). method: as we are dealing with a late cutaneous reaction, the study of the medicine involved is carried out by means of epicutaneous medicine testing. in order to do the study of aflibercept, we wore gowns, two sets of gloves, a mask, eye protection and in a containment hood in the outpatients hospital. the patient diagnosed himself with dermatitis when in contact with povidone-iodine and despite the fact that the cutaneous provocation was negative, it is known that when there is surgery involved, there needs to be moistness and occlusion for it to show up clinically. the application of this antiseptic seems to lose its irritation and allergic properties when it dries on the skin and therefore tends to give a negative result in these patients, but this does not mean that they are not allergic to this antiseptic. we report the case of a year old man who experienced erythema and pruritus immediately after an intravenous injection of ranitidine and hyoscine butylbromide given for gastric pain treatment. results: spt and idt were performed for ranitidine ( mg/ml and . mg/ml respectively) and hyoscine butylbromide ( . mg/ml and . mg/ml respectively) being exclusively positive for ranitidine at idt dose with a × mm papule (histamine control × mm). oral provocation test for hyoscine butylbromide was negative. bat for ranitidine and famotidine were carried out, being negative for both drugs. conclusion: skin tests for h ra are the best option when studying a suspected reaction to h ra and are also useful for assessing cross-reactivity between other h ra. the sensitivity for bat in diagnosis of drug allergy is about %, and the specificity up to %, although these percentages make reference to the common drugs studied (beta-lactams, quinolones, pyrazolones, etc). specific studies for h ra are still to be done. in our case we had a negative result for the bat test, although we proved ranitidine was responsible for the reaction. conclusion: gentamicin is an aminoglycoside antibiotic used systemically for septicemia and as prophylaxis during surgery. immediate type allergy (type i) to gentamicin is rarely reported. since , approximately only five cases have been reported in literature. in our case, initial theories were pointed towards cefazolin as beta-lactams report a higher rate of allergic reactions. after an exhaustive allergological study, results disproved our initial theory indicating gentamicin as the responsible drug. giangrande n ; bobadilla-gonzález p ; garcía-menaya jm ; cámara-hijón c allergy department, infanta cristina university hospital, badajoz, spain; clinical immunology department, san pedro de alcántara hospital, cáceres, spain background: polyethylene glycol (otherwise known as macrogol or peg) is a polymer with a wide application as an excipient, solvent and dispersing agent in food, cosmetic and pharmaceutical industry. it presents distinct length polymer chains with a molecular weight from to g/mol conferring them specific properties. macroglol with a molecular mass between and g/mol is commonly used as osmotic laxative previously to colon endoscopy and radiologic examinations. after the introduction, anaphylactic reactions to macroglol are rarely reported, considering it safe and well tolerated. we report on a -year-old man who, immediately after of the topical application of benzindamine in left inferior limb developed acute urticaria in this limb, which reverted in approximately hours with systemic steroids. she had previously tolerated this product without any problems. skin prick-tests with benzindamine ( . mg/ml) and latex were realized in the patient. skin prick-tests with benzindamine were realized in eleven healthy control subjects. results: skin prick-test with latex was negative in the patient. skin prick-test with benzindamine was positive in the patient ( × mm). the prick-tests with benzindamine were negative in eleven healthy control subjects. we report on a case of contact urticaria due to benzindamine and triggered by an immediate, probably ige-mediated, hypersensitivity mechanism. some of the drug used in daily clinical practice can cause allergic contact urticaria and should therefore be borne in mind. background: the use of new oral anticoagulants which act as direct inhibitors of activated factor x is constantly increasing, due to lower rates of serious and fatal bleeding events than warfarin/acenocoumarol. rivaroxaban, the first commercialized drug in this group, is the most used for prevention of thromboembolic events. however, < cases of hypersensitivity reactions have been described so far, most of them delayed and severe. to present a case of delayed hypersensitivity to rivaroxaban, diagnosed by a positive ltt (lymphoblastic transformation test). a year old woman with hypertension and chronic atrial fibrillation (af) was referred to our clinic for suspected drug allergy. she reported that months before, for af she was started on oral amiodarone and rivaroxaban, presenting on the seventh day with both of them generalized erythema, pruritus, micropapular rash and facial angioedema. no oral or other mucosal were observed, neither pustules, vesicles or blisters. blood eosinophilia, enlarged lymph nodes, renal and hepatic injury were discarded in emergency, where the new drugs were discontinued and replaced by acenocoumarol. the rash subsided one week later, with oral antihistamines. before and after the episode the patient also has been taking losartan and hydrosalurethyl, with good tolerance. she denied other adverse reactions. in allergy department we performed skin prick tests and intradermal tests with amiodarone ( . mg/ml and . mg/ml) and rivaroxaban ( . mg/ml and mg/ml), and a ltt with both drugs, months after the reaction. background: patients with history of beta lactam allergy, often self-reported, are commonly encountered in the hospital setting. this frequently leads to increase use of broad spectrum and more expensive antibiotics that may be unnecessary or even less efficacious at times due to fear and concerns about potential disastrous outcomes. nonetheless, with increasing awareness, many patients are now being referred to allergy service for formal evaluation. we aim to look at patients who underwent evaluation for beta-lactam hypersensitivity and determine the number of patients that were successfully de-labelled. method: a retrospective analysis was conducted with patients referred for evaluation of questionable beta-lactam allergy to the allergy service in our institution from the years - . initial evaluation process included a thorough history to determine the type of hypersensitivity reaction and suitability for further testing. patients underwent skin prick test (spt) and intradermal (idt) with either (a) both major and minor determinants of penicillin, benzyl penicillin, amoxicillin and ampicillin, and/or (b) the culprit drug itself. if skin testing was negative, oral or intravenous (iv) drug challenge was then performed after informed consent. clinical details and reactions were documented. patients were also contacted post challenge to ensure no delayed reaction had occurred. results: a total of patients were evaluated for beta-lactam allergy in the year period, of these were females and were males. of the referred patients had presumed penicillin group allergy and had cephalosporin group allergy ( patients had both penicillin group+cephalosporin allergy). cases ( %) were successfully de-labelled. beta-lactam allergy was confirmed in patients ( %); identified by positive spt in two patients, positive idt in six patients and positive drug challenge in patients ( patients developed rash/urticaria, had respiratory symptom and patients developed anaphylaxis). patients were referred before any drug allergy labelling was done, out of which were confirmed not to have beta-lactam allergy. conclusion: in our study, % of patients were confirmed not to have true beta-lactam allergy. we were able to successfully remove beta-lactam allergy label from the electronic record for % of the patients. results: a total of % referred amoxicillin-clavulanic acid (ax-clv) as trigger for the hypersensitivity reactions (hrs), followed by ax ( %), penicillin ( %) and cephalosporins ( %). almost % of hrs were immediate (< minutes). positivity of skin tests was observed in % subjects, of bat in % and of rast in %. in conclusion: the label of penicillin allergy is quite often erroneous. this involves using of more expensive and less effective therapeutic alternatives, which also facilitate the emergence of multi-resistant micro-organisms. hence the importance of confirming the diagnosis of allergy. finally, we did not find differences in the study of penicillin allergy in patients older than years compared with the general population. background: severe cutaneous delayed drug reactions (toxic epidermal necrolysis -ten-, stevens-johnson syndrome -sjs-, acute generalized exanthematous pustulosis -agepand drug reaction with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome -dress/dihs-) among others, are a rare but potentially fatal complications of drug treatment. although its epidemiology has been described in different latitudes, it is unknown in latin america. our aim was to describe the epidemiological characteristics of severe cutaneous reactions to drugs in countries of latin america. method: an online questionnaire was designed to report new and old cases (since ). it was a modified and adapted version of enda questionnaire for drug allergy interesting group. sociodemographic data, type of reaction (ten, sjs, dress-dihs, agep), culprit drug (s), treatment, complications, mortality and sequelae, were described. three centers from colombia, one from argentina, one from brazil and one from paraguay were included. an excel database was created, in which cases were recorded and analyzed. results: thirty seven cases were reported. ( %) were women. the median age was years. ( %) had dress/dihs, ( %) ten, ( %) sjs, ( %) agep, ( %) other not classified scars, and ( . %) overlapping ten/sjs. the main culprit drugs were aromatic anticonvulsants in cases ( %), beta lactam antibiotics in ( %), non-beta lactam antibiotics in ( %) and allopurinol in ( . %). in % of the patients the suspect drug was withdrawn. thirty one patients ( . %) received systemic corticosteroids. complications occurred in cases ( %) and death in one patient ( . %). seven patients ( %) had some type of sequelae. countries, dress/dihs was the most frequently reported clinical entity, and the anticonvulsants were the main triggers. complications were frequent, but mortality was low. | drug-induced cough: analysis of nationwide spontaneous reports in korea over ten years using who-adverse reaction terminology (who-art) indicative of cough. results: from cases of spontaneously reported adverse drug event cases, a total of cases ( . %) were identified as drug-induced cough. most cases occurred in adults ( . % of the subjects) and females were more common than males ( . % vs . %). regarding severity, only cases ( . %) were classified as serious based on who criteria. the most common causative drug category was antineoplastic and immunomodulating agents ( . %), followed by cardiovascular drugs ( . %). the most common causative drugs were ace inhibitors including perindopril and ramipril. conclusion: in the nationwide spontaneous reports of adverse drug events, many cases of drug-induced cough have been reported so far. much attention is needed to find new causative drugs of cough in the future. background: allergological assessment to determine the mechanism of the perioperative reaction and to identify the agent responsible and recommendation of a range of drugs or agents likely for future surgery is essential, but it often poses a significant challenge. in this study, we analyze our experience in the investigation of adverse reactions during anesthesia in the last years. method: a total of patients who attended our allergy unit with suspected perioperative reactions between january and december were reviewed retrospectively. the severity of the perioperative allergic reactions was graded according to ring and messmer system. results: grade iii, ii and i reactions were observed in , and patients, respectively. in patient we didn't know the reaction suffered. tryptase measurements were available for patients. of those, and patients had elevated and normal levels respectively and suffered grade reaction. ige mediated reactions was diagnosed in patients ( %): for ßlactam antibiotics ( . %), for patent blue ( . %), for neuromuscular blocking agents-nmbas ( . %), for latex ( . %), for colloids ( . %) and for ranitidine ( . %) . cefazolin was the ß-lactam antibiotics causing the largest number of reactions. non-ige-mediated reactions was diagnosed in patients ( %). the allergy tests were negative and tryptase levels were normal. conclusion: in our series, among the patients who suffered allergy reactions during anaesthesia and the cause was subsequently identified, ß-lactam antibiotics were the most common causative agent ( . %), followed by patent blue ( . %), nmbas, latex, colloids and ranitidine ( . % each agent). in contrast, data from other authors indicated that nmbas were the most common cause of anaphylaxis, followed by latex, hypnotics, antibiotics, plasma substitutes and opioids. these differences might be due to the small size of our study, which was limited to our centre over the last years and thus may not be representative. diagnostic evaluation. all patients signed an informed consent. we made a retrospective analysis of their clinical records and excluded patients whose records were missing or incomplete. it was analyzed each patient's medical history (focusing allergic disease) and clinical reaction to the suspect drugs. signals/symptoms at pcc were characterized. we also studied the variation of the dpt's results when it was performed after a pcc. aim: to define and quantify the ongoing pharmacy needs in sustaining a large drug allergy assessment program. method: a retrospective review of pharmacy files was used to identify and quantify the drugs and dosages most frequently used and to determine prescription trends within the allergy testing program over the last years. results: initially, this reaction was thought to be a result of a drug allergy, but upon further review and the onset of fever, we determined that it met the diagnostic criteria of jhr. his twin brother was diagnosed with penicillin and betalactamic allergy. neutrophilia % was to be underlined in the blood test. after this, drug oral challenge with penicillin was performed, ruling out penicillin allergy. conclusion: it is not uncommon to confuse drug allergy with jhr. jhr should be an anticipated reaction to early doses of antibiotic treatment for treponemal diseases, such as syphilis. antibiotic treatment should be continued; it is not a warrant to stop treatment. clinicians should be aware and anticipate jhr as a potential complication to early doses of antibiotic for spirochetal diseases such as syphilis or lyme, leptospirosis. the patient was unresponsive in oral drug provocation tests with amoxicillin-clavulanic acid, clarithromycin and trimethoprim sulfamethoxazole for months. the patient could use these drugs. results: chronic abacterial inflammation of the prostate gland was accompanied by a significant increase in concentration of slpi, il- , tnf-α, il- in the seminal plasma and serum concentration, and a decrease in the concentration of il- and tgf-β compared to healthy men (p < . ). there was no statistically significant difference between slpi, il- , tnf-α, il- , il- , and tgf-β in the ejaculate of patients with inflammatory and non-inflammatory forms of cap (p < . ). the concentration of il- in ejaculate of patients with inflammatory forms of cap was significantly greater than in patients with non-inflammatory form of cap (p = . ). the inflammatory and non-inflammatory forms of cap are pathologically similar with changes in the concentration of the studied cytokines except for il- in both forms with signs of inflammation. the terms "leukocytic" vs "non-leukocytic" chronic abacterial prostatitis are more correct than "inflammatory" and "non-inflammatory" when describing chronic abacterial prostatitis. results: the status of all patients after dc immunotherapy was evaluated as satisfactory. heart rate, blood pressure in patients remained within the age norm. skin had normal color without rash or peripheral edema. there were no local or systemic allergic reactions. the body temperature after the injection did not exceed °c. conclusion: these results show, for the first time, that among mastocytosis patients, besides the already known periodontal disease risk factors that include diabetes, age, osteoporosis and alcohol consumption, the bone marrow mast cell burden is also associated with increased periodontal disease severity. results: metformin at relatively low doses ( - μm) was shown to mildly suppress ige-mediated responses, including degranulation ( % reduction, p = . ), tnf-α ( % reduction, p = . ) and il- ( % reduction, p = . ) secretions in bmmcs. importantly, metformin at the same doses potently inhibited mast cell responses in all parameters ( % reduction, p < . for degranulation; % reduction, p < . for tnf-α; % reduction, p < . for il- ) in mast cells treated with an ahr ligand, , -dihydroindolo[ , -b]carbazole- -carbaldehyde (ficz). mechanistically, its inhibitory effect was mediated through the suppression of ficz-induced mapk activation, intracellular calcium release and ros generation. metformin also blocked ahr-mediated pca in vivo ( % reduction, p < . ). conclusion: metformin, a common anti-diabetic agent, was shown to exert inhibitory effect on ahr-mediated mast cell activation in vitro and in vivo, suggesting its potential utility as a newer form of therapy for asthma and allergic diseases; this is particularly relevant when considering the adverse effect of the exposure to environmental polycyclic aromatic hydrocarbons. gasser p ; brigger d ; zbären n ; jardetzky t ; pennington l ; eggel a results: in one of affected family members, we were able to identify the c. a>g mutation in the plasminogen (plg) gene that was recently described to be associated with hereditary angioedema. this mutation leads to a missense mutation with an amino acid exchange p.lys glu in the rd kringle domain of plasminogen. there is no direct relationship between the earlier described cases with this mutation and the family we report here. in all affected members of the family, the symptoms manifested in early adulthood, with swelling of the face, the tongue and the larynx. the frequency of attacks was variable, between once in a year to once in a month. in one of the three family members, we found a slightly decreased level of coagulation factor xii and of plasminogen. icatibant proved to be very effective for the treatment of acute attacks in the affected family. the occurrence of the same c. a>g (p.lys glu) mutation in the plg gene in many families with no or only unknown distant relationship suggests that the disease might have been inherited through the generations without being purged from the population. the mutated amino acid exchange appears to be significant for the function of plasmin or plasminogen. we found a decrease in plasma levels of coagulation factor xii and plasminogen, which may be beneficial markers for diagnosis and monitoring of this disease. several biomarkers are useful in the diagnosis (fibrin degradation products (fdps), d dimer (dd), and fragments of prothrombin + ). also, a correlation between the levels of biomarkers and activity phases of the disease has been detected. alterations in coagulation parameters have an etiopathogenic role in the ae attack, but have not been considered as biomarkers of activity phases. tgt is a global coagulation test which quantifies in vitro the ability of plasma to generate thrombin and estimates alterations in coagulation parameters. the objective is to assess the usefulness of the thrombin generation test (tgt) to characterize patients with hereditary angioedema (hae). method: seventeen hae patients from hospital la fe were recruited to obtain blood samples in remission and during ae attacks. none of them experienced thromboembolic events. plasma was collected in citrate tubes to obtain platelet rich plasma. hemostatic parameters were analyzed:. tgt was conducted using a calibrated automated thrombogram (cat) method and a fluoroskan ascent as a reader. results were analyzed via thrombinoscope v . citrated plasma was incubated with calcium, tissue factor, phospholipids and a fluorogenic substrate. a thrombin generation curve is generated, obtaining parameters: latency time (lagtime), thrombin generation maximum speed (vo), maximum peak of thrombin generated (peak), time to generate the maximum peak of thrombin (ttpeak), total quantity of generated thrombin (etp), and the end time of thrombin generation (starttail). tgt parameters from healthy donors were used as controls. results: thirty-eight samples were collected from seventeen hae patients ( . % female). fifteen ( . %) samples were collected during ae attacks. tgt parameters and fdps were significantly higher in hae patients compared with controls (p < . ), although no significant differences were found in tgt between acute attacks and remission. a decrease trend in tgt is observed in ae attacks. fdps were increased during ae attacks, but normalized at remission periods. these results support the involvement of coagulation in the pathophysiology of hae, although no increase in prevalence of thrombosis is observed during acute attacks. method: the repeated measures design study included patients in two groups: the slit group, patients- follow-ups per allergen (p), and the vit group, patients- p. the slit group had patients treated for hdm ( p), and patients on pre-coseasonal pollen ait (grass p, ragweed p, birch p). the vit group had patients on rush protocol ( for bee and for wasp) and patients on conventional protocol ( bee, wasp, and for both). the ige and igg levels were measured by the immunocap method. the friedman test was used to compare data. results: when compared to placebo group, slit+vitamin d group therapy was more effective in the reduction of nasal symptoms (p = . ), asthma symptoms (p = . ) and combined symptommedication score (p = . ); there was no significant difference between groups in medication and ocular scores. we observed a significant improvement of fev (vitamin d group p = . , placebo group p = . ) and fev %vc levels (vitamin d group p = . , placebo group p < . ), within both groups, between visits. feno results did not differentiate statistically significantly the study participants in terms of receiving slit along with vitamin d or placebo. significant increase in the percentage of cd + cd + foxp + and in tlr positive cells in children receiving slit+ vitamin d was observed compared to placebo group. increase in cd + cd + fox-p + induction, and in tlr positive cells recruitment were independently associated with better clinical effect of slit in children. conclusion: overall, ait with a high-polymerized ash pollen extract was well tolerated. as ash pollen are supposed to be an important allergen during spring time, it is recommended to include spt and npt with ash pollen in the test panel for allergological diagnostic. additionally, determination of ash pollen specific ige could be applied. furthermore, appropriate ait should be considered for ash pollen allergic patients. a | impact of sublingual immunotherapy with a five-grass pollen tablet on grass pollen allergic rhinitis and asthma: a real-life, long-term analysis in france background: data on the fulfilment of prescriptions of symptomatic medications in patients with grass pollen allergy were analysed to evaluate the long-term effectiveness of sublingual immunotherapy (slit) on allergic rhinitis (ar) and asthma. method: by using data in the lifelink ™ treatment dynamics database (iqvia, paris, france), we compared two cohorts of patients with ar: a group treated with oralair® (stallergenes greer, antony, france) slit tablets (n = ), and a matched control group having received symptomatic medications only (n = ). oralair®'s effectiveness was assessed as the change in symptomatic medication fulfilments between the pre-index period (before the initiation of slit) and the follow-up period (after slit), and as the onset of asthma or the progression of pre-existing asthma (based on fulfilments of prescriptions for asthma medication). the number of fulfilments per year was calculated for each patient and each period. results: in line with prescribing guidelines, the mean duration of treatment with oralair® was . months per season for either seasons or seasons. the mean number of symptomatic medications for ar fulfilled per patient and per year in the pre-index period was . ± . in the slit tablet group and . ± . in the control group. in the follow-up period, this value fell for the slit tablet group (to . ± . ) but did not change significantly in the control group ( . ± . ). when considering individuals not taking any asthma medications in the pre-index period, asthma onset during the treatment period was observed in . % of those in the slit tablet group and in . % of those in the control group. the corresponding values for the follow-up period were . % in the slit tablet group and . % in the control group. when considering individuals already taking asthma medications in the pre-index period, the mean ± sd number of asthma medication fulfilments in the pre-index period was lower in the slit tablet group ( . ± . ) than in the control group ( . ± . ). the corresponding values for the treatment period were . ± . and . ± . , respectively. in the follow-up period, the number of asthma medication fulfilments fell more in the slit tablet group (to . ± . ) than in the control group ( . ± . ). oralair® tablets have long-term effectiveness by relieving allergic rhinitis and slowing a progression to asthma. b | a real-life, retrospective analysis evidencing slower long-term progression of asthma in grass pollen allergy patients treated with sublingual immunotherapy tablets | an examination of the reasons for treatment discontinuation and non-compliance to allergen immunotherapy background: allergic rhinitis (ar) patients treated with subcutaneous immunotherapy (scit) and sublingual immunotherapy (slit) may be non-compliant or discontinue treatment too early, which can negatively impact efficacy. therefore, understanding the reasons for non-compliance and treatment discontinuation is vital to help improve compliance, persistence and thus outcomes. this study reported reasons for treatment discontinuation to scit and slit and non-compliance to slit in patients with ar in published real-world studies. method: a literature review was conducted in embase, medline, ebm reviews, psycinfo and econlit ( - ) using key search terms for allergic rhinitis, scit, slit, non-compliance and non-persistence. across all studies,~ % of patients were non-compliant, and -year drop-out rates ranged from % to %. reasons for noncompliance and treatment discontinuation in this subset of patients were stratified according to the who dimensions for adherence (patient-related, treatment-related, or socio-economic). results: from the publications identified, six studies reported reasons for non-compliance to slit (n = ) or treatment discontinuation (n = ) to scit or slit, and the results were grouped for analysis. the majority of patients cited treatment-related factors as the primary reason for discontinuation ( % for slit, % for scit). common reasons were a length of treatment for slit and frequency of injections for scit. % of patients discontinued scit due to patient-related factors such as travel to doctors and waiting time for administration. only % of slit patients discontinued due to patient-related factors. socio-economic reasons for discontinuation were low for both therapies ( % slit and % scit). conversely, for non-compliance to slit, socio-economic factors were the most frequently cited reasons ( %), and included taking time off work and financial concerns. conclusion: of patients who discontinued therapy, treatmentrelated factors were the most cited reasons for scit and slit, reflecting concerns with administration and treatment length. noncompliant slit patients cited socio-economic factors as common reasons for non-compliance, suggesting financial concerns over a long treatment course. differences in reasons for non-compliance and treatment discontinuation may be due to patients assigning differing importance for compliance (a day-to-day decision) compared to the long-term decision to discontinue treatment. results: % of patients had monosensitization to rbet v component. the rest % had combinations ige to rbet v and ige to one, two or even three minor allergens ( %, %, % accordingly). after courses of slit by standardized pollen extracts symptoms of arc and pfas decreased in % and % patients accordingly. in group patients with monosensitization to rbet v : patients had a reduction of arc ( % had - degree by ado); patients had reduction of pfas. patients hadn't finished treatment due to allergic reactions. among patients with sensitization to rbet v /v : patients had a reduction of arc ( % - to degree by ado); had reduction of pfas. patient hadn't finished treatment due to allergic reactions. in patients with sensitization to rbet v /v : patients had a reduction of arc ( % - to degree by ado); had reduction of pfas. patients with sensitization to rbet v /v /v showed the similar results: patients had a reduction of arc ( % - to degree by ado); had reduction of pfas. patients had sensitization to all cra, and only patient who also received slit with grass allergens had reduction of arc only ( degree by ado). as the result of the study it was identified that beneficial effect of slit is highest in patients with monosensitization to rbet v . the increase of sige sensitization profiles to minor birch allergens caused less efficacy of slit treatment. dermatophagoides pteronyssinus immunotherapy is independent of sensitization to blomia tropicalis among children with allergic rhinitis and asthma method: children ( - years old) with allergic rhinitis and asthma sensitised to both dp and bt received years dp-scit. clinical symptom and medication scores, serum specific ige and specific igg were evaluated during dp-scit. in order to investigate whether the treatment outcome was dependent on the sensitisation pattern between dp and bt, patients were further grouped into dp and bt co-sensitisation and cross-reaction, according to positive or negative ige against bt major allergen (btma) blo t and blo t . btma+ group, with specific ige to either blo t or blo t , was defined as the co-sensitized group; btma-group, with no detectable ige to both blo t and blo t , was defined as the cross-reactive group in this study. results: all the recruited patients completed year of dp-scit, ( %) patients completed years of treatment. after years of dp-scit, compared to baseline, all patients had significant reduction in symptom and medication scores. lung function (fev ) was significantly improved as well. % of the patients were free of medication use and asthma symptoms, % of them were free of rhinitis symptom, and the fev % in all patients were higher than % of predicted. dp-scit induced significant increases in dp and bt specific igg . in % of patients, dp specific igg increased more than fold and bt specific igg increased more than . fold. further investigation in btma groups showed moderate correlation (spearman r = . , p = . ) between specific ige against dp and bt in the btma-group (n = ), indicating specific ige cross-reactivity. no specific ige correlation (spearman r = . , p = . ) was found in the btma+ group (n = ) indicating co-sensitisation to both dp and bt. the two groups showed almost identical change in clinical responses. dp and bt specific igg significantly increased during dp-scit, no difference was found between the two btma groups. conclusion: dp-scit can induce specific igg cross-reacting with bt allergens. patients with specific ige sensitisations to both dp and bt may have clinical benefit from dp-scit treatment. moreover, the clinical benefit of scit was independent of ige cross-reactivity or co-sensitisation to dp and bt. method: we investigated allergic rhinitis children who were basically sensitized to house dust mite and received house dust mite slit for year and months. among patients, patients were mono-sensitized to house dust mite (group ) and patients were poly-sensitized aside from house dust mite (group ). we also assigned another allergic rhinitis children who were only treated by medication as control group. nasal symptoms (rhinorrhea, sneezing, nasal obstruction, nasal itching, sleep disturbance) and anti-allergic medications use were assessed at every -month visit. results: the symptoms of allergic rhinitis started to improve after months of slit and significantly improved after a year and a half in group and group compared with control group. there was no significant difference between group and group . anti-allergic medication use in group and group significantly decreased after a year and a half compared with control group and there was no significant difference between group and group . conclusion: house dust mite slit was more effective than treatment only by medication. the effect of house dust mite slit was similar between mono-sensitized and poly-sensitized allergic rhinitis children. house dust mite slit could also be recommended to polysensitized allergic rhinitis children. method: a prospective, randomized, double-blind, controlled, multicenter phase ii study was conducted with four different concentrations of cluster allergoid clustoid wiesenlieschgras (group : tu/ml; group : tu/ml; group : tu/ml; group : tu/ml). out of patients screened, grass pollen allergic patients ( - years) were randomized. the cluster build-up phase was followed by four monthly maintenance injections of . ml. the efficacy was evaluated by the change of the threshold concentration step needed to induce a positive reaction in a titrated nasal provocation test (tnpt) before start and after end of the study (pre-post analysis). the safety profile was assessed for each treatment group by analyzing treatment-related adverse events. background: allergen immunotherapy relies on the consistent administration of allergen extract, therefore compliance to these treatments (subcutaneous immunotherapy (scit) and sublingual immunotherapy (slit) tablets and drops) is vital for efficacy. as scit is administered as an injection by a healthcare professional, and slit is self-administered, compliance to scit may be perceived as superior. therefore, a review of real-world studies investigating compliance to scit, slit-tablets or slit-drops was conducted. real-world studies, instead of clinical trials, were included in this review as they are more likely to reflect actual clinical practice and patient compliance. method: a literature review was conducted in embase, medline, ebm reviews, psycinfo and econlit ( - ) using key search terms for ar, scit, slit-tablets and slit-drops, and real-world compliance. compliance was reported according to ispor medication compliance and persistence work group definitions. results: from the publications identified, eight studies (seven slit [one slit-tablets, two slit-drops, four unspecified], one both scit+slit-tablets) reported compliance rates and were included in the analysis. real-world compliance rates ranged from % to % for slit administration and % for scit administration. only one study compared compliance of slit to scit, with similar rates reported over three years ( % and % respectively). three studies reported "good" compliance (physician-reported or patients consuming > % of allergen extract) to slit-drops or slit-tablets. the good compliance rates were higher for slit-drops ( %- %) compared to slit-tablets ( %- %). observed compliance to slit-drops or slittablets did not vary by country or geographical region. the percentage of patients defined as having "good" compliance to slit-tablets or slit-drops did not vary by study length or patient population. conclusion: whilst compliance to scit may be perceived as superior to slit-tablets and slit-drops, comparable compliance rates between scit, slit-tables and slit-drops were identified across real-world studies. differences between perception and real-world results may be explained by a lack of direct comparisons between scit and slit administration. limitations included discrepancies in definitions of compliance, as well as methodology between studies. however, these are common to reviews analysing compliance, regardless of therapy area. conclusion: in the allergic rhinitis patients, successful compliance for -year slit compared with control was approximately %. method: igg inhibition elisa: rabbit igg antibodies specific for grass allergen allergoids are pre-incubated with different concentrations of alum-adsorbed grass pollen allergoid. the mix is added to an allergoid coated microtiter plate. unbound igg will bind to the allergoid coat and is subsequently incubated with anti-igg hrp labeled conjugate and stained with tmb. results are expressed as percentage inhibition relative to the uninhibited value. the concentration of alum-adsorbed allergoid that is required to inhibit % igg is used as read-out. circular dichroism: far-uv cd spectra ( - nm) were recorded on a j- spectropolarimeter. a cuvette with a stirring compartment was used to keep the suspension homogeneous during measurement. results: the igg inhibition elisa assay is specific for grass pollen allergoids (not for other allergen allergoids), has a good inter-and intra-assay precision and is robust for assay variation. thermally stressed alum-adsorbed grass pollen allergoids were used to show that the igg inhibition assay can be used as a stability indicating method. severe thermal stressing resulted in a higher % inhibition value, indicating a loss of igg epitopes. furthermore, far-uv cd analyses showed that there is a close relation between the decreasing igg binding capacity ( % inhibition values) and the loss secondary protein structures by unfolding (cd-ratio / nm values). the igg inhibition assay was demonstrated to be a valuable method to determine the stability of alum-adsorbed grass pollen allergoid preparations. in addition, a relation was shown between the igg binding capacity and the change in secondary protein structures. | design of a pivotal phase iii trial of allergen specific immunotherapy (ait) using a high-dose house dust mite (hdm) allergoid in patients with allergic bronchial asthma method: male and female outpatients (age - years) asthmatics allergic to hdm are enrolled. during the baseline phase, the patient's minimal dose of ics required to achieve asthma control will be assessed. after the baseline period, approx. patients will receive double-blind placebo-controlled treatment for approx. months, followed by a nd period of weeks to assess the minimal ics dose and further months of observation for the assessment of asthma exacerbation. based on the results of the dose finding study regarding the efficacy endpoints and the safety profile, the optimal allergoid dose is considered to be pnu. results: competent authorities and ethic committees in all participating eu countries, serbia, russia and ukraine approved the study design. the primary endpoint of the trial is the change in predefined dose steps of the minimal daily ics dose required to achieve asthma control after approximately months of subcutaneous ait. all efficacy data will be determined using daily questionnaires and the acq by e-diary for months from october to january. the aim of this clinical trial is to demonstrate efficacy and to evaluate safety of ait with an allergoid preparation of major allergens of dermatophagoides pteronyssinus in patients suffering from allergic bronchial asthma caused by house dust mites. asthma increases the burden of allergic disease and health care costs, especially when uncontrolled. with the development of a high-dose preparation we intend to treat asthmatic patients highly efficiently. romantowski j; jassem e; lata j; wasilewska e; chelminska m; specjalski k; niedoszytko m background: specific immunotherapy (sit) is the only causal treatment in patients allergic to airborne allergens. it has been proven to be widely effective in allergic populations, but individual patients vary in terms of response to the therapy. the aim of the study was to assess the factors that might affect the efficacy of sit. method: patients treated with sit for grass pollen or house dust mites were included. the efficacy of sit was assessed with the use of allergy control score (acs), performed before and at least after one year of sit. the following variables were assessed as potential risk factors for a poorer response to sit: age, gender, type of allergy, type of allergen, type of vaccine, type of sit and smoking history. background: specific immunotherapy (sit) is a suitable treatment option for asthma and allergic rhinitis (ar), but it is not commonly used in korea. in the achievement of the treatment, it is important that immunotherapy is applied with ideal dose and regular intervals and it is essential for the patient compliance. the aim of this study is to investigate evaluate compliance with immunotherapy protocols of patients who were treated with sit in clinic and their satisfaction of the treatment. we performed a multicenter, cross-sectional survey using a specially designed questionnaire that was given to allergy specialists and patient in korea. a member of the trained research group conducted face-to-face questionnaire interviews with each respondent. conclusion: this study shows that most patients are ar with asthma. in our study sit compliance and satisfy are found to be high in both groups. aim: to identify the frequency of regress claims in a dermatological setting and to assess its impact on general prescription behaviour and immunotherapy. method: all physicians of the psoriasis-praxisnetz süd-west e.v. (n = ) were invited to participate in a web based questionnaire study on the topics of dermatology and medical law. the survey was separated into two sub-polls which were carried out after a first poll deciding whether the topic of medical law is of any interest for the dermatological practice. the topic of interest was located in the second poll. results: overall, dermatologists participated in this study. most participants were form bavaria, baden-wuerttemberg or rhineland-palatinate and had more than years of experience as a dermatologist. out of the participating physicians . % (n = ) already experienced a previous regress claim. of these, . % (n = ) stated, that the experienced regress claim changed their prescription behaviour. half of these participants (n = ) further stated, that the fear of a possible recourse affects their prescription behaviour, whereas only out of the other participants declared a possible influence. missing values excluded, this leads to a substantial hesitation in physicians who experienced a prior recourse ( . % vs . %). nevertheless, this seems not to affect the usage of allergen immunotherapy, as all physicians who already experienced a regress claim, stated to use allergen immunotherapy. the fear of a possible regress can change physicians' prescription behaviour but does not seem to have an effect on the prescription of allergen immunotherapy. therefore, the topic should be addressed from another perspective such as providing trainings on relevant regulations for physicians who experienced a prior recourse claim. this approach could also improve patient centred care related to modern treatments. results: the sds were significantly reduced in patients subjected to slit (p < . ) year after the onset it. vas also was significantly reduced (p < . ) with satisfied control of sar and the same time with translation from moderate-severe to mild-moderate sar, after slit. nbh was also significantly reduced (p < . ) year after the onset slit. in patients receiving pht only, sds, vas and severity of sar did not change and significantly higher (p < . ) from the value obtained in the experimental group. nbh also remained unchanged and significantly higher (p < . ) then in experimental group. precoseasonal slit added to pht shows short-term beneficial clinical effects in polysensitized patients with sar and scuad phenotype. results: ten studies ( children, adults; median sample size, ) met the inclusion criteria. the risk of bias was moderate to high in all but one studies. low strength evidence supports the assumption that ait is effective in reducing symptoms and medication use, with only out of studies reporting higher benefit in the ait group vs comparator group. subgroup analyses of studies sharing similar characteristics did not explain inconsistency. safety does not appear was not major concern for alternaria ait. conclusion: this is not enough strength of evidence to suggest that mold ait is efficacious for the treatment of respiratory allergies. high-quality studies with an adequate sample size are needed. abstracts | | tolerability of a two week rush updosing with modified trees, modified grasses or modified grasses/trees mixture in pollen allergic subjects in the day-to-day practice table) severe systemic reactions (grade iii and iv) did not occur. conclusion: rush immunotherapy is an effective therapeutic method for patients with allergic rhinitis. it seems that in cases requiring faster response to treatment, this immunotherapy can be considered as a substitute for conventional immunotherapy. | design of a pivotal phase iii allergen immunotherapy study to assess the efficacy and safety of subcutaneously administered tyrosine adsorbed modified birch allergen+mpl results: the design of this study, including sample size and primary and secondary endpoints, will be discussed based on prior experience gained in two dose finding studies. in addition, the number of patients screened and randomized will be presented by country, gender and/or age and screen failures will be categorized. results: the primary analysis showed an absolute difference in tcs between placebo and du of . ( %, p < . ). the odds of experiencing a severe day during the bps were approximately doubled in the placebo group compared to the du group (or = . , p < . ) and the odds of experiencing a mild day were halved (or = . , p < . ). similar results were seen for the tree pollen season (tps), covering both alder, hazel and birch pollen seasons. the total rqlq score was improved for du compared to placebo during the bps and tps (p < . , except for the last week of the tps), with the most pronounced effects during week - of the bps (absolute difference: . - . , p < . ). treatment was well tolerated. the most frequent adverse reactions were mild or moderate local reactions related to the sublingual administration. no deaths were reported and no serious adverse events were assessed as related to the sq tree slit-tablet. conclusion: treatment with the sq tree slit-tablet improved arc symptoms and need for symptomatic treatment. the du group had less "severe days" and more "mild days" during the pollen seasons. the quality of life was similarly improved. these findings substantiate the clinical relevance of the sq tree slit-tablet for patients with arc induced by pollen from the birch homologous group. nagaraju k ; nagaraju k ; katare s ; kapatkar v ; shah a ; rathod r results: total n = subjects (mean age . ± . years, . % males) completed entire study. the mean incidence of artis reduced from . ± . episodes at baseline to . ± . (p < . ), with . % subjects not suffering from any episode. the mean duration of episodes reduced from . ± . to . ± . days (p < . ). % of episodes (vs % at baseline, p < . ) required antibiotics for mean duration of . ± . days (vs. . ± . days, p < . ). none of arti episodes in follow-up period required hospitalization as against . % episodes, (mean duration ± . days; p < . ) before pidotimod therapy. the number of school days lost & work days lost showed reduction of . ± . days(p < . ) & . ± . days(p = . ) respectively. the average expenses incurred in treatment of artis shows significant reduction of rs. ± (p < . ). adverse events were reported in ( %) subjects, which were mild in nature. a statistically significant increase in absolute counts of t-& nk cells was seen in explorative assessment of immune markers. the study shows pidotimod to be well-tolerated effective therapy in reducing the incidence and severity of recurrent artis, thereby providing additional benefit of reduction in discomfort & healthcare cost due to recurrent artis. thus, pidotimod can be considered as potential therapeutic option for treatment of recurrent artis in children. martignago i ; ridolo e ; incorvaia c department of medicine and surgery, university of parma, parma, italy; cardiac/pulmonary rehabilitation, asst pini/cto, milan, italy background: two registered sublingual immunotherapy (slit) products are available to treat grass-pollen induced rhinoconjunctivitis, consisting of the -grass (phleum pratense) and the -grass pollen tablets. no study of direct comparison of the efficacy of the two products was performed. we report the case of a patient who was treated in different years with the -grass or the -grass tablets with contrasting efficacy. the patient was a -year old woman suffering from years of grass pollen induced rhinoconjunctivitis. in slit was started with the -grass pollen tablets, but in , due to unavailability of the product, slit was performed by the -grass pollen tablets. in the third year of treatment slit with the -grass pollen tablets was resumed. for the -grass tablets slit was initiated before the pollen season and stopped after months of treatment, while for the -grass tablets the treated was prescribed to be continuous. the efficacy of slit was evaluated by symptom-medication scores as reported in diary cards by the patient during the month of may, when the grass pollen usually reach the higher concentration in the atmosphere in lombardy, where the patient lives. results: the mean symptom-medication score in the first year of treatment ( -grass tablets) was . , compared with a mean score of . in the second year ( -grass tablets). the patient was unsatisfied of the symptoms control and asked to resume for the last year of slit the -grass tablets. the mean symptom-medication score in such year was . . no clinically relevant adverse event was reported with any slit product. conclusion: based on the momentary unavailability of the -grass pollen tablet, it was possible to assess in a same patient the clinical outcome associated to either of the two registered slit products. a significantly different efficacy of slit with the -grass tablets compared with the -grass tablets was observed. | fusion proteins consisting of bet v and phl p form ige-reactive aggregates with reduced allergenic activity najafi n ; hofer g ; gattinger p ; smiljkovic d ; blatt k ; selb r ; stoecklinger a ; keller w ; valent p ; niederberger v ; thalhamer j ; valenta r ; flicker s background: bet v and phl p representing major allergens in birch and grass pollen, occur as monomeric proteins with high allergenic activity as assessed by clinical provocation testing in patients. she did not suffer more hymenoptera stings after the last reaction. one bee sting several years before bst resulted in no reaction. she has no symptoms with honey, vegetable or other food ingestion. methods: total ige and specific ige were determined using inmu-nocap system (thermofisher, scientific inc). apis, vespula and polistes (hørsholm, denmark) were also performed. prick tests showed negative results for all extracts tested. intradermal skin tests were positive for apis at μg/ml, but negative for vespula and polistes. our patient was diagnosed of anaphylaxis due to apis venom, thus bst was contraindicated and an epinephrine autoinjector was prescribed. she rejected hymenoptera venom immunotherapy. conclusion: to our knowledge, this is the first case of anaphylactic reaction after bee sting therapy. bee sting therapy should be considered a risk factor for anaphylaxis. patient reported good control of their disease, improved their quality of life, tolerating contact and exposure to numerous horses as well as contact with clothes of people who had been exposed. although ita is absolute contraindication on uncontrolled asthma with a degree of evidence ia, our case had only "transitory" con- and immunocap among wasp allergen components-i , i , i were %; . , %; . and %; . respectively and honey bee allergen components-i , i , i were %; . , %; . and %; . respectively. agreement between polycheck and immuno-cap i and i allergen components were %; . and %; . respectively. agreement between polycheck and euroline i and i allergen component were %; . and %; . respectively. based on wasp and bee components in all three systems, sensitization pattern was analyzed. similar test results were found between euroline and immunocap systems. the comparative studies carried out showed a markedly higher compliance of results with the euroline tests compared to polycheck with the immunocap system. percent agreement was extremely high and kappa value was substantial or almost perfect in the case of bee venom allergy between euroline results: a total of patients were included; ( %) males, with a mean age of (± ) years; ( %) beekeepers, ( %) were atopic, ( %) had asthma, ( %) rhinitis and ( %) cardiovascular disease, and of these patients were on ace/beta blockers. vit with honeybee was proposed in ( %), wasp ( %) and polistes ( %). the mean duration of vit was (± ) months. however, completed less than months. of the total, patients ( %) were not treated with vit. eighty-eight patients ( %) participated in the telephone interview: completed vit ( %), were still on vit ( %) and did not undergo vit ( %). of those who completed vit, ( %) were restung and went to the emergency department (er). twenty-four patients ( %) were stung while still on vit. of those never on vit, ( %) were re-stung and went to er. the severity of the reactions according to mueller of the patients who completed vit (mean follow-up time was months ( - months)) and were stung again was: local reaction in ( %), grade i in ( %); grade iii in ( %). one had a toxic reaction after multiple stings. in those who were stung during vit, ( %) had local reactions, ( %) grade i and ( %) grade iii. of those who were not treated and were re-stung: ( %) had grade i, ( %) grade iii and ( %) grade iv. in this series, the patients who did not undergo vit presented a greater number of systemic reactions when re-stung as well as more severe reactions (p < . ). conclusion: in this group with indication for vit, the reactions of the re-stings were less severe in the patients who had completed or who were on venom immunotherapy, as expected. three quarters of those who did not undergo treatment had severe anaphylactic reactions when they were stung again. this study reinforces the importance and the efficacy of immunotherapy in the treatment of hymenoptera venom allergy. method: this is a retrospective, descriptive study of cases diag- method: data were issued from the reference centre in mastocytosis of toulouse university hospital. ms diagnosis was determined using world health organization diagnostic criteria. hymenoptera venom immunotherapy was performed with an ultra-rush protocol (table) . results: seven patients were included ( women, men), median age years old. during the anaphylactic reaction, cutaneous signs missed in all cases. the reaction was most often severe: grade (n = ), grade (n = ), grade (n = ). three patients suffered from digestive symptoms and one from respiratory manifestations. basal tryptase in serum reached . - . μg/l. hymenoptera venom specific ige were low ( . - . kui/l) except for one patient ( . kui/l). ait was initiated with vespula venom in patients, polistis in patient, apis mellifera and vespula in patient, vespula and polistis in patients. no reaction was observed during ait. four restringing accidents led to increase the cumulative dose to μg and μg in patients. in these patients, the diagnosis of mastocytosis was made due to the resting. conclusion: hymenoptera venom ait using ultra-rush protocol seems well tolerated in patients with systemic mastocytosis. specific studies are necessary to determine the real tolerance profile of this protocol. collaboration with reference centres for mastocytosis should be considered for all patients with mastocytosis associated to hymenoptera venom allergy. dose (μg/ml) results: see table. conclusion: there is a shift or immunomodulation in terms of sige to vespids. even in patients double sensitised who were receiving venom of only one of the vespids. albanesi m background: slit has been suggested as an alternative route for allergen-specific immunotherapy. aim of this study was to investigate allergen-specific antibody responses in birch pollen allergic children who had received slit for two years using recombinant allergens. method: children (n = ; - y o) with respiratory symptoms of birch pollen and oral allergic syndromes (oas) were studied. ten children received slit with staloral, were treated by slit with microgen, and children received only symptomatic therapy (control group). sige and sigg levels to rbet v , rbet v , rbet v were measured twice (before therapy started and after two years) using quantitative immunocap and a panel of more than microarrayed allergens using immunocap isac technology. clinical efficacy of slit was evaluated by recording symptoms upon allergen contact and need of rescue medication. results: all children were sensitized to the major birch pollen allergen, bet v and one patient from each of the groups showed to bet v , no patient had sige to bet v . after two years of slit clinical improvement was observed in the slit patients. in the staloral group there were no respiratory symptoms in patients and a decrease of symptom severity in the other cases as well as a partial or complete tolerance to pr allergen-containing food in the patients. microgen treatment had no influence on oas symptoms but decreased of pollinosis severity in children. however, there were no statistically significant differences of bet v -specific levels measured before and after treatment in the slit and control groups (mann-whitney, p > . ). in this real-life study we found that birch allergic children who had been treated with slit showed a reduction of clinical symptoms but we did not find a significant induction of allergen-specific igg levels in the slit-treated group when compared with children who had only symptomatic treatment. conclusion: our study confirms the scarcity of food additives allergy. it also suggests that even when the diagnostic of allergy was excluded with a negative oral food challenge, families remain suspicious about industrials feeding products containing food additives. these results should reassure health professionals and parents who incriminate too frequently food dyes and conservators when a manifestation which mimics allergic reactions occurs. background: autumn/winter birth has been reported to be a risk factor of food allergy (fa) development. a putative mechanism is that dry/cold weather causes and exacerbates infant atopic dermatitis (ad), which is a major risk factor for food sensitization through inflamed/damaged skin. we investigated prevalence of fa among infants under well skin care in relation with seasons of birth (sob). we recruited full-term newborn infants without perinatal diseases at an obstetric/pediatric clinic. participants were followed up for skin status and food allergy symptoms until months of age. sob were defined as spring (march-may), summer (june-august), autumn (september-november) and winter (december-february). ad was diagnosed based on the united kingdom working party's criteria. use of moisturizer (mo) and topical corticosteroids (tcs) was recorded. primary outcome was fa based on apparent immediate allergic reaction after ingestion of causative food. we classified infants who avoided any food because of sensitization or mother's anxiety as suspected fa. results: six hundred and thirty-one infants were screened for month-period and infants were enrolled in this study. of them, infants were born in spring-summer (s-born) and infants were born in autumn-winter (w-born). fa developed in ( . %) infants and ( . %) infants had suspected fa. there was no difference (p = . ) in prevalence of fa and suspected fa between s-born and w-born. multivariate analysis revealed ad at and months of age was a significant risk factor for fa with or= . ( %: . - . ) and or= . ( % ci: . - . ), respectively. prevalence of ad at months of age was higher in w-born than s-born but prevalence promptly decreased thereafter and stayed low with early use of mo and tcs. prevalence of ad was rather higher at months in s-born than w-born. results: cases and controls were included. the median age was years, (q -q - ). men and women were almost equally represented ( . % males). alcohol consumption associated with the intake of mammalian meat or innards as the trigger factor. the overall prevalence of a positive result of sige to α-gal was abstracts | . % ic % ( . , . ); cases _ . % ic % ( . , . ) controls _ . % ic % ( . , . )_. among cases sige anti α-gal positivity rate ranged from . % (rural), to . % (half-urban) and . % (urban). the rates of positivity were . %, (northern) . % (center) and % (mediterranean). a positive result of sige to α-gal was more frequently observed among men ( . %) than women ( . %) and associated with history of tick bites, practice of outdoor activities, pet's ownership and the antecedent of having eaten mammalian meats or innards previously to the development of symptoms background: a special challenge in the st century for allergists is allergy to food, which is considered "the second wave" of epidemics of allergic diseases. panallergens occur in unrelated organisms and perform a similar function in them. in their structure, they have highly conserved amino acid sequence regions and a similar three-dimensional structure, and thus meet the requirements for cross-recognition by ige. results: in patients ( %) isac test has been shown to have specific ige for panallergen components. mostly, the presence of ige for pr- proteins has been shown in patients. in patients ige to ltp; patients ige to ccd; patients to profilin; patients to tropomyosin; patients to serum albumin, person to tlp. an important aspect is undoubtedly the occurrence of simultaneous sensitization to several panallergens. analysis of data from the study group showed that isolated sensitization to one panallergen concerned only pr proteins ( patients), tropomyosin ( patients) and profilin ( patient). in the remaining patients, the analysis of the isac test results showed that two or more panallergens were allergic. in the study group, asige for the component responsible for the occurrence of real food allergy was detected in ( %) patients. mostly, the presence of ige for jug r has been shown in patients. in the study group, panallergens were more likely to be responsible for food intolerance than specific food allergens. results: of children, children had peanut allergy only, children had tree nut allergy only, and children had both. the mean age was . ± . years in peanut allergy, . ± . years in tree nut allergy, and . ± . years in both. male to female ratio was significantly higher in tree nut allergy ( . %) than peanut allergy ( . %). among tree nut allergens identified, walnut ( . %) was most frequent, followed by almond ( . %), hazelnut ( . %), pine nut ( . %), chestnut ( . %), cashew ( . %), pistachio ( . %), and macadamia ( . %). mean serum total ige level was kua/l in tree nut allergy and kua/l in peanut allergy. mean serum specific ige level to peanut, walnut, almond, hazelnut, and pine nut was . , . , . , . , . , and . kua/l, respectively. children with peanut allergy had higher rate of co-sensitization with soybean and higher soybean-specific ige levels than children with tree nut allergy. however, there was no difference in co-sensitization rate with tree pollen between peanut and tree nut allergy. children with peanut allergy showed significantly increased co-sensitization rate with egg white and wheat compared to children with tree nut allergy. a . % of the children with peanut allergy and . % of tree nut allergy showed co-sensitization with aeroallergens. a total of % of the children with peanut allergy showed decreased specific ige levels within - years. conclusion: prevalence of peanut and tree nut allergy is similar. tree nut allergy develops later than peanut allergy and more common in male. children with peanut allergy showed higher co-sensitization rate with soybean, egg white and wheat compared to children with tree nut allergy. | natural history of egg allergy in a large cohort of infants with food allergy shows its high prevalence but also its transient nature in a months of follow-up background: the cohort of infants ( boys, girls, - months) with the food allergy has been followed for months. as more than % of infants manifested atopic dermatitis (ad), a condition closely linked to egg sensitisation, we focused our attention on egg allergy, following its natural history as well as a development of atopic march. method: the diagnosis of food allergy was based on a personal history, clinical examination, skin prick tests and/or atopy patch tests with native foods. laboratory tests were performed within year of age the latest. the specific ige levels against food allergens were measured using immunocap or immulite. patients with ad were scored according to scorad system. the oral food challenges (ofcs) with cooked/baked egg were done in children at the age of months except for children at risk of anaphylaxis. results: within the whole cohort the allergy to cow milk proteins was confirmed in pts ( . %), to egg in pts ( . %), to wheat in pts( %), to lentil in pts ( . %) to banana in pts ( . %), to soya in pts ( . %) and to potatoes in pt ( . %). in a cohort of egg allergy patients we found out that: % of pts presented the early onset of allergy-up to months of age, % of pts presented severe ad (scorad > ), % of pts showed cosensitisation to peanuts, % of pts had early sensitisation to inhaled allergens, and majority % of pts presented with early onset allergic rhinitis and/or asthma. we proved that egg allergy is closely linked with the early onset of allergy symptoms, with severe forms of ad, co-sensitization to peanuts, early sensitisation to inhaled allergens and an early onset of allergic rhinitis and/or asthma. we also proved that the egg allergy in infancy is transient. the tolerance to baked/cooked egg was achieved in about % of pts at the age of years, unlike previously published results claiming the reach of tolerance in % of pts at the age of years. in these patients we studied: sex, personal history, type of reaction they presented, time of onset of symptoms and food involved. results: out of a total of patients over years of age (from to years old) who have been attended the consultation for the first time during these period, patients ( . %) ask about possible allergic food allergies. of these patients who came for possible allergic pathology, patients ( %) presented positive results. these are the other item we have studied: . sex of patients: % of the patients are women. these patients because of that, it is important to remember that food allergy can also appear in old people. the food that is mainly involved in our population is fish and seafood. a much higher percentage than in other populations, probably due to the mediterranean diet of spain. the symptoms mainly involved are itching and skin lesion, which is the characteristic symptom of a mild allergic reaction. in our population, there was patients with a anaphylactic shock, a much higher percentage than in other studies. the experience with this group of patients is still limited. more studies are needed to know better this patient profile. background: cow's milk allergy (cma) is the first atopic disease in children. diagnosis suspicion in the emergency room (er) is increasingly frequent, however, further assessment by an allergist is often difficult to schedule. therefore, screening for cma through a blood test (specific ige) while the infant is still in the er has gained momentum in recent years. we set out to analyse (a) symptoms which had led the emergency physician to prescribe specific ige, (b) the prevalence of confirmed cma among infants screened in the er, and (c) the long-term outcome of the screened infants. method: a retrospective study of medical records and laboratory results was performed. patients were infants under months, without a previous diagnosis of cma, attending one of the two pediatric er of the university hospitals of marseille, france. allergy blood tests were specific ige to cow's milk extract (immuno-cap, thermofisher, sweden). in infants with specific ige to cow's milk extract of . kua/l or higher, ige directed to the main three individual proteins (casein, alpha lactalbumin et beta lactoglobulin) were also measured. results: infants were included from december to june . the sex ratio was . . % of infants were atopic et % were currently or had been breastfed. the most prevalent symptoms were vomiting and reflux. one third of infants were hospitalized after the er visit. following the er visit, % of infants attended a specialized consultation with an allergist. % of infants with a follow-up visit were diagnosed with an ige mediated cma. infants with cma developed further food allergies (egg, nuts, cashew…). it is difficult to diagnose it. the emergency pediatrician are increasingly confronted to infant with symptoms evoking cma. thus they prescribe sige and extensively hydrolysed proteins because they know that ige-positive infants can be ige-negative during the interval between the er visit and the follow-up one. after bad results interpretation of blood assay after er visit, cma was probably over diagnosed without prick test for ige positive allergy and no eviction/ reintroduction test for non ige. the lack of allergist is probably leading to over prescription of blood assay in er to diagnose cma and prolonged eviction of milk. results: a total of patients were included ( % female) aged from to yo with an average . ± years. % of patients had history of atopic disease: % rhinitis, % asthma, % prior food allergy, % eczema, % drug allergy, % eosinophilic esophagitis (ee) and % chronic urticaria. mean serum total ige was . ui/ml. sensitization to aeroallergens was present in % of patients, the most common were dust mites ( . %), pollen ( . %) or both ( %). in ( %) patients, first symptoms of fa appeared ≥ yo, with an average age of ± . yo. in this group, were diagnosed with ee, with eosinophilic colitis and with eosinophilic gastritis. from the remaining patients, had history of reaction with more than food group (fg). cutaneous reactions were referred in % of patients followed by anaphylaxis ( %) and gastrointestinal symptoms ( %). the fg most commonly implied were: fresh fruits (n = ), seafood (n = ) and tree nuts (n = ). fa diagnosis was confirmed in % of patients, the remaining had negative ofc. in ( %) patients, their symptoms started under yo, with an average age of . ± yo. from this group, ( %) were diagnosed ee. from the remaining patients, cutaneous complaints were the most frequent ( %) followed by gastrointestinal ( %) and respiratory symptoms ( %). the most common fg implied were: fresh fruits(n = ), seafood(n = ) and tree nuts(n = ). only one anaphylaxis was referred. fa was confirmed in %, the remaining had negative ofc. in patients with history of anaphylaxis of had positive st and/ or sige; one had negative sp and sige, with ofc positive. the blood donors were classified based on their clinical symptoms related to possible as contact via fish intake: allergic to as ( %), chronic urticaria ( . %), unspecific dyspepsia ( . %) and asymptomatic ( . %). the prevalence of sensitization (anti-as ige > . kua/l) were . % (ic: . - . %; mean . kua/l; median . kua/l) with a maximum value of . kua/l. raw fish consumption was the only variable associated with statistical significance (p < . ) to as sensitization ( . % vs . %, respectively). albacore and codfish were the most consumed species associated to seropositive results ( %), followed by hake ( %). coastal population ( . % vs . %), non-previously frozen fish consumption ( . % vs . %) and > times per week fish consumption ( . %) were other seropositive associated factors. background: oral allergy syndrome (oas) is an ige-mediated allergy caused by raw fruits and vegetables in patients with pollen allergy, which is known as the most common food allergy in adults. however, there has been no nation-wide study on oral allergy syndrome in korea. the aim of this study is to investigate the prevalence and clinical manifestations of oas in korea. method: twenty two investigators from hospitals and private clinics participated in this study. the patients with allergic rhinoconjunctivitis and/or bronchial asthma with pollen allergy were enrolled to the survey. the questionnaires include demographics, a list of fruits and vegetables, and clinical manifestations of food allergy. pollen allergies were diagnosed by positive results of one or more pollen allergens including birch, alder, hazel, beech, oak, willow, poplar, bermuda, meadow, orchard, rye, timothy, mugwort, ragweed, hop japanese on allergy skin prick tests (allergen/histamine ratio ≥ +) and/or serum specific ige levels using multiple allergen simultaneous tests (mast ≥ +) or immunocap (≥ . ku/l). conclusion: this is the first nation-wide study for oas in korea. the prevalence of oas in korea was . %, in which substantial proportion had anaphylaxis. these results will provide useful information for clinicians to apply in clinical practice. we conducted a self-administered, questionnaire-based survey in - during the -month checkup. children were considered to have food allergies if they were diagnosed by a physician or if they had been instructed to avoid a causative food after medical examination by interview. we divided the year into three periods. the months of march-june were considered spring, july-october as summer/fall, and november-february as winter. while the season of onset for the boys occurred in . %, . %, and . % in spring, summer/fall, and winter, respectively, it was . %, . %, and . %, respectively, for the girls. thus, the onset rate was the highest in winter for both genders. in boys whose mothers did not consume folic acid (fol − ), the food allergy onset rate was significantly higher for boys whose mothers ate no eggs and for boys whose mothers ate - eggs per week than for those whose mothers ate eggs daily according to the dunnet multiple comparison test. however, no relationship was observed with egg intake if the mother had consumed folic acid (fol + ). on the basis of seasons, fol − and egg intake by mothers affected only children born in winter, with a significant difference in the dunnet multiple comparison. among mothers who did not eat eggs, fol + was . % and fol − was . %; for mothers who ate - eggs per week, fol + was . % and fol − was . %; and for mothers who ate eggs every day, fol + was . % and folwas . %. thus, consumption of folic acid seemingly annulated the effects of eating eggs. however, for girls, neither folic acid nor eating eggs had any effect on the onset rate. conclusion: since this effect varied according to the birth season, consumption of folic acid, a methyl group donor, appeared to affect the allergy onset in children. results: skin prick test with commercial extracts of tuna ( mm), cod ( mm), rooster ( mm), hake ( mm), salmon ( mm), trout ( mm) and anisakis ( mm ige to shrimp, lobster, crab and mixed seafood were all undetectable. dermatophagoides pteronyssinus , to assess for tropomyosins was negative. outcome: the patient continues to react to both hdm and shrimp, despite undetectable ige levels to tropomyosin associated components. this is the only testing available in south africa currently and hence we are unable to look at other proteins. the relationship between tropomyosins in shellfish allergy and mite allergy has been well documented and investigated, but other allergens are now also being implicated in cross-reactions. we also established the level of ige specific to allergen components using the immunocap isac method. allergen-specific ige was not elevated to any shrimp allergens available in immunocap isac: n pen m (tropomyosin), n pen m (arginine kinase) and n pen m (calcium binding sarcoplasmic protein). the patient was diagnosed with a shrimp allergy. the molecular diagnostics used did not explain which allergen component is the patient allergic to. it is possible that the patient is allergic to hemocyanin, which can also cross-react with house dust mite allergens, but confirmation of this diagnosis requires further investi- results: the groups were identical in terms of the age and sex (table ) . ara h ige correlated (spearman test) with the cumulative protein dose (threshold dose) r = − . (p = . ) but not with reaction severity r = . (p = . ), or the use of adrenaline r = . (p = . ). patients with ara h ige < ku/l had higher threshold doses ( vs mg) than children whose ara h ige was ≥ ku/l (p = . ). there were no significant differences in severity of the reaction or in use of adrenaline (table ) . the level of ara h ige is relevant in predicting the threshold dose at peanut exposure. a low reaction threshold dose increases the risk of reaction at an accidental exposure leading potentially to a severe reaction. flaxseed allergy is uncommon and most of the cases reported involved anaphylaxis. cross reactivity has been described with other seeds. case report: a -year-old atopic girl diagnosed with egg allergy and rhinoconjunctivitis and asthma due to pollens. when she was eight, she presented two reactions consisting of conjunctival, periorbicular, malar erythema and abdominal pain after eating egg free french toasts cooked with flaxseed. she was treated with oral antihistamines. the allergic workup included prick-by-prick test with flaxseed which was positive and skin prick tests with mites, molds, cockroach, cat, dog, profilin, ltp and pollens with positive results for olive and grass pollens. the serum total immunoglobulin (ig) e was u/l, and specific ige to flaxseed was . kua/l. the flaxseed extract was resolved with sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page) and an ige immunoblotting was performed under nonreducing conditions. the patient's serum showed specific recognition of a -kda band in the immunoblot. proteins were identified using mass spectrometry (maldi-tof) that showed results highly consistent with conlinin, a s storage protein of flaxseed. we described for the first time a patient with allergy to flaxseed due to conlinin, a s storage protein of flaxseed. background: cyperus esculentus is an herbaceous plant that has edible tubers called tiger nuts. in spain, they are used mainly in the elaboration of the well-known "horchata" or tiger nut milk, which is obtained by macerating tiger nuts with water and sugar. tiger nut allergy has rarely been reported, despite of its widespread consumption. case report: we present the case of a -year-old male with a history of oral syndrome allergy with several fruits (peach, melon, banana, kiwi, apple, pear and plum) and seasonal allergic rhinoconjunctivitis due to grass pollen. he reported oral pruritus, vomiting and cutaneous itching in both arms and hands immediately after drinking tiger nut milk. he became asymptomatic without treatment after - hours. the allergic workup included skin prick tests with profilin, ltp, latex and fruits that were positive to melon and watermelon and negative to profilin, ltp, latex and the rest of the fruits. prick-by-prick tests with melon, banana, kiwi, apple, pear, tiger nut and tiger nut milk were positive. the serum total immunoglobulin (ig) e was . μg/l, and specific ige was negative to profilin, ltp, bet v and all the tested fruits. background: specific blood ige tests for food allergens are mainly used to confirm a suspect food allergy than to diagnose such an allergy. this is due to the low positive predictive value and the high negative predictive value they have. nevertheless, they are very helpful when they are interpreted in the context of medical history by an experienced allergist. we analyzed the prevalence of sige in children with suspected food allergies. we retrospectively analyzed the all the consecutive laboratory tests of sige for food allergens during the two-year period ( ) ( ) ( ) . tests were of children diagnosed or suspected to have food allergies. a quantitative immunoblot assay was used to measure the circulated different sige. t-test, wilcoxon signed rank test, and chi-square were used to make comparisons. results: fifty-six ( . %) men and ( . %) females, . + . years old with a maximum of years and a minimum of months old were part of children whose tests were analyzed. one-third of the tests ( . %) reveals more than one sige present and . % of the tests resulted negative for the sige for the allergens tested (table) . only ( . %) children have very high concentrations (> iu/ml) of egg whites sige, and ( . %) have egg yolk sige. concentrations of . % of sige positive cases were . - . iu/ml. in our study more than half of the children suspected of food allergies resulted negative for sige for most common food allergens. seventy-nine percent of the positive cases had relatively low sige. only a few positive cases have higher sige than iu/ml. our data support the recommendation that sige couldn't be decisive in food allergic diagnosis, but they may help if they are interpreted cautiously. method: seven patients with a mean age of . years and female to male ratio of: : , with a background history of hypertension treated with an acei presented with oro-pharyngeal irritation (itch, tingling), face and tongue angioedema and laryngeal constriction, on ingesting fresh fruits (cherries, apples, plums, peaches, apricots, strawberries, grapes), vegetables (parsnips) and/or nuts (peanuts, hazelnuts). two patients required admission to emergency department and three received adrenaline auto-injector. six out of seven patients underwent skin prick testing to common aeroallergens and the index foods. in five cases, immunocap/isac testing was undertaken. in one case the diagnosis was based on the history and in one other case it was based on history and skin prick tests. results: a diagnosis of pfas was confirmed in all patients through the clinical history, spt and/or specific ige serology to the offending food confirming predominant sensitisation pr- allergens. primary food allergy and spontaneous angioedema was excluded in all patients. in the cohort studied, the pfas symptoms were unusually severe. we therefore postulate that this was secondary to concurrent use of acei. the management of these patients to sensitization to a β-casein with high homology between only the first milks. more precisely, the allergen candidate could be γcasein, which is derived from β-casein by proteolysis, whose abundance increases during cheese production from fresh milk, and which is absent in cow's milk. a lactoglobulin specific to buffalo's milk may also be responsible. in case of ewe's and goat's milk allergy without cow's milk allergy, sensitization to buffalo's milk should systemically be seeked out. we recommend inclusion of all mammalian milks in the list of the mandatory allergens for declaration on food products. method: prick tests with fruit battery, ltp and profilin was made. analytical with blood count, immunoglobulins, triptasa, total ige and specific ige to banana, apple and orange. finally, open oral provocation with fruits was performed. the diagnostic key was given by the mother of the patient who attended consultations because the infant had erythema in the temporary zone after drinking sea water on the beach. associated with salivation, the patient presented erythema in the malar area lasting a few seconds many times. the prick tests with fruits, ltp and profilin were negative. hemogram: eosinophils/μl, total ig e: . iu/ml, specific ige to fruits were negative. triptase: . μg/l. method: here we describe a variety of cases of nsltp allergy presenting to a tertiary allergy centre in the north west of england. results: nsltps have been found to be major allergens in various foods and they are likely to produce severe and systemic allergic reactions. this is reflected in the cases we present here. these proteins are highly cross-reactive due to extensive sequence homology and are panallergens. nsltps are remarkably heat stable and retains its allergenicity in processed foods. it is assumed that nsltps may sensitise both by inhalation and ingestion. an intriguing aspect in nsltp hypersensitivity is the extreme variability of its clinical expression. co-factors are often needed for the clinical expression of nsltp hypersensitivity. conclusion: patients regardless of where they are from, presenting with multiple severe/systemic food allergies need to be investigated for nsltp allergy. these patients require specific dietary advice on foods to avoid and a tailored management plan on how to deal with their allergic reactions. cow's milk as well as cow's milk products are tolerated. material and methods: skin prick tests with different sorts of milk, cheese and milk proteins were performed, specific ige antibodies were measured, a basophil activation test with cow's and goat's milk was performed and an oral provocation test (opt) with cow's milk, cow's milk cheese, raw milk and raw milk cheese was conducted. results: skin prick tests were positive for sheep's milk, goat's milk, goat's milk casein, feta, pecorino and parmesan cheese. elevated specific ige against goat's milk ( . ku/l) and sheep's milk ( . ku/ l) were detected. activation of basophil granulocytes after incubation of the patient's blood with cow's milk and goat's milk was measurable but also in the non-incubated control blood. all cow's milk products were tolerated in the opt. conclusion: despite consistent homologies between whey and casein proteins of mammals and high cross-reactivity between cow's, goat's and sheep's milk an isolated goat's and sheep's milk allergy with tolerance of cow's milk is possible. skin testing and specific ige help to distinguish from allergy against cow's milk proteins. diet counseling is possible after opt. introduction: salmon roe's allergy, without concomitant fish allergy, is rarely described in western countries. there are few studies on its allergenicity. objective: to report of a case of salmon roe allergy without concomitant fish allergy in a western country. case report: a -year-old male with house dust mite allergic rhinitis and asthma, describes for the st time, in , an acute episode of dyspnoea, rhinorrhoea, ocular pruritus, epigastric pain and nausea, a few minutes after the ingestion of a sushi meal with rice, salmon, salmon roe, wasabi, soy and ginger. these complaints motivated observation in the emergency room, where it was still documented uvular oedema. he was prescribed intramuscular adrenaline, intravenous steroids and anti-histamines with complete symptoms resolution. the patient declares not had eaten other foods, taken any drugs including nsaid, been infected or practised exercise. skin prick tests with food extracts (salmon and other fish, shellfish, soy, rice, egg total, egg white, egg yolk, ovalbumin and ovomucoid) were negative. skin prick-prick tests were positive for salmon roe ( × mm) and negative for egg (white and yolk), ginger, salmon, flying fish roe (tobiko), sturgeon roe (caviar) and black scabbard fish roe. specific-ige (sige) to salmon roe extract was . kua/l (immu-nocap-phadia) and negative against extracts from salmon fish and other fish (< . kua/l). sds-page immunoblotting with salmon roes extract showed a kda-ige binding band, that may correspond to a lipovitelin. after the allergic reaction the patient have tolerated abstracts | salmon fish and other fish roes (tobiko, caviar and black scabbard fish). no oral provocation test with salmon roes was performed given the severity of the reaction. conclusion: this report is an example of a severe allergic reaction to salmon roe without concomitant fish allergy, where the clinical history and the in vivo and in vitro tests were important to an accurate diagnosis. the authors believe this is the first report of a salmon roe anaphylaxis in our country and highlight the importance of this allergen in the western countries, given the increase of sushi consumption in these countries. case report: the prevalence of food allergy is increasing worldwide and consumer habits are changing. pomegranate (punica granatum) was commonly consumed in the mediterranean area but in the last few years became also popular in the different parts of europe. a -year-old boy was admitted to our emergency department suffering from allergic reaction within minutes after consumption of pomegranate. he presented with skin pruritus, generalized urticaria and eyelid edema. symptoms resolved within an hour after oral intake of cetirizine. prick-to-prick test with pomegranate was positive (wheal diameter × mm). he had a history of anaphylaxis with egg (urticaria and wheezing) at the age of month, meanwhile consumption of egg is well tolerated. an episode of anaphylaxis with unknown origin appeared at the age of years (urticaria, wheezing and abdominal pain). skin prick tests with aeroallergens revealed birch pollen allergy and he was diagnosed with allergic rhinoconjunctivitis. dietary elimination of pomegranate was suggested and adrenaline auto-injector was provided. we have analyzed omalizumab effectiveness and safety in patients with csu from our database. clinical response was categorized as: no response, partial or complete response by using the urticaria activity score (uas ). furthermore, the dosage, administration frequency and any side effects were recorded. results: effectiveness: out of patients ( %) achieved complete response. ( . %) after a single dose of mg ( patients) or mg ( ); patients ( . %) after two doses of mg ( patients) or mg ( ) results: multi-ethnic adolescents accounted for approximately . % of the total sample of adolescents. prevalence of asthma was significantly higher in multi-ethnic group than non multi-ethnic group. we examined if maternal or paternal foreign born status had a differential effect: in multi-ethnic family with foreign-born father, prevalence of asthma was significantly higher. parental region of country at birth had a significant influence on the prevalence of asthma. adjusted logistic regression analysis was used to determine risk factors for occurrence of allergic disease. residential area, perceived household economic status, parental region of country at birth, and body mass index (bmi) had a significant effect on prevalence of asthma. conclusion: population admixing appears to have significant effect on the prevalence of asthma. further study will be needed to clarify the effect of population admixing on prevalence of allergic disease. several studies have aimed to explore the possibility of mirs as biomarkers for various diseases. in our study we examined six different mirs, previously shown to be involved in eosinophil development and other immune responses, in serum from non-allergic and allergic asthmatics and healthy control subjects in order to determine their potential ability to be used as biomarkers for varying forms of asthma. method: serum from healthy individuals as well as age matched non-allergic asthmatics (naa) and allergic asthmatics (aa) were utilized. additionally, the naas and aas subjects had high eosinophila (≥ . × cells/l) compared to healthy controls (≤ . × cells/l) and eosinophil cationic protein (ecp) in serum was measured. asthmatic subjects were included irrespective of inhaled corticosteroid usage. rna was extracted from serum, reverse transcribed and subjected to qpcr analysis. expression changes in six candidate mirs, mir- , - , - a, - , - , and - , were investigated. results: two mirnas, mir- and mir- a, were significantly upregulated in aas as compared to naa or healthy subjects. additionally, mir- was upregulated in naa, but not aa or healthy subjects. furthermore, the expression change observed in the aa mirs appeared to correlate with the use of inhaled corticosteroids, but not in the naa mirs. finally, mir- and mir- expression levels were altered based on the number of eosinophils, which correlated to ecp levels, in naa subjects. conclusion: using six mirs found in the literature to be involved in eosinophila or immune responses, we were able to detect expression changes in the serum of healthy and asthmatic individuals. moreover, were able to distinguish between healthy individuals, aas, and naas on inhaled corticosteroids or with differing eosinophil levels, leading to the possibility that these mirs may be valuable future biomarkers for asthma. background: some studies report that certain sensitization profiles may increase the risk of a more serious allergic respiratory disease. the aim of this study was to describe the sensitization patterns to major allergens of dust mites in our area and investigate the association of these patterns with a specific clinical picture. method: multicenter study performed in hospitals for months. we recruited patients older than years with rhinitis and/or bronchial asthma, with a history of allergy to dust mites and both skin test and specific ige to d. pteronyssinus, d. farinae or l. destructor positive. der p and der p were determined to all of them. we analyzed patients with an average age of . years, . % women, . % smokers, . % rhinitis and asthma, . % only rhinitis and . % only asthma. % of patients presented sensitization to d. pteronyssinus, . % to d. farinae and . % to l. destructor. the detected sensitization patterns were: both der p /der p positive . %; der p positive . %, der p positive . % and both der p /der p negative . %. it was observed that patients with higher specific ige levels had more severe forms of respiratory disease, with isolated asthma or associated with rhinitis. for d. pteronyssinus, d. farinae, der p and der p > ku/l there is a greater number of cases of asthma associated with rhinitis, while for l. destructor > . ku/l greater number of cases of asthma. no relationship was observed between a specific sensitization pattern and an increased risk of asthma. conclusion: . specific ige values greater than ku/l for d. pteronyssinus, d. farinae, der p and der p , were significantly associated with a higher probability of asthma and this association was significant for l. destructor> . ku/l (class ). . there are four well-defined sensitization patterns in our population that are influenced by geographic location, being the double sensitization to der p and der p the most prevalent and allowing the correct characterization of % of the cases. none of them increased the risk of asthma. kobori t ; nagao m ; ekenkrantz t ; borres m ; sjölander a ; fujisawa t national mie hospital, tsu-city, japan; thermo fisher scientific, uppsala, sweden background: reliable biomarkers for diagnosis and management of asthma in young children are needed since pulmonary function test and exhaled no measurement, good biomarkers for asthma in older children and adults, are difficult to perform in young age. we have developed a sensitive and stable assay system to measure eosinophil-derived neurotoxin (edn), an eosinophil granule protein, that is released upon activation, and that may serve as a marker for eosinophilic inflammation also in young children. method: volunteer children from - years old were recruited and an isaac-based questionnaire was filled out by their caregivers. venous blood was obtained to measure serum and plasma edn and eosinophil count. edn was measured with a research assay developed on the immunocap ® platform. conclusion: blood edn may be a reliable biomarker for diagnosis of asthma in preschool children. conclusion: feno measurement as an add-on option in asthma management to identify asthma patients with th driven airway inflammation is less costly than the use of standard diagnostic methods. new biologics may have an additional impact on overall asthma treatment costs. our model demonstrates that incorporating feno measurement may help to optimize asthma medication and reduction in physician visits as well hospitalizations due to severe exacerbations. | peripheral airway inflammation assessed by fractional measurement of the exhaled breath temperature is a leading feature of asthma background: airway inflammation is considered to be a hallmark of asthma. the potential clinical benefits of assessing it non-invasively has led us to develop a method and device for measuring the temperature of the exhaled breath (ebt=exhaled breath temperature) reflecting the thermal state of the airway mucosa. studies have demonstrated that ebt is increased in asthma, proportionately to the level of control of the disease. in an attempt to further increase the usefulness of this approach, we have further developed a device to allow the assessment of the relative contribution of the central and peripheral airways (caw and paw). now we present the frebt data gathered from patients with suboptimal control of their asthma and from healthy subjects. method: in this cross-sectional study we included volunteers: patients with suboptimally controlled asthma of mild to moderate severity (median age , range - years, men) and nonsmoking subjects without respiratory disease (median age , range - years, men). we measured the fractions corresponding to caw and paw sampled with a fast reacting inflatable balloon valve system operated by a computer during a single breathing cycle. it allows steering of the expired airflow through channels with sensitive temperature sensors. during an initial deep inhalation, the inspired volume is measured and the sequence of valve openings is adjusted so as to yield volumes of air characteristic of caw or paw during expiration. the ratios between [pawebt-cawebt] over the total ebt [%] measured during the same manoeuvre (fractional ebt, frebt) were calculated and compared between asthmatics and controls. results: there was high statistically significant difference between the frebt ratios of asthmatics and controls: . ± . (mean ± sem) vs . ± . , p < . . as the magnitude of the ratio depends on the difference between pawebt and cawebt, higher values of the frebt ratio point to bigger contribution of the peripheral lung tissues, presumably indicative of peripheral inflammation. multiple regression analysis with frebt ratio as dependent variable identified only asthma diagnosis as significant predictor (p < . ) and excluded all other anthropometric indices. conclusion: peripheral airway inflammation assessed by frebt measurement appears to be a leading characteristic in asthmatics compared to healthy subjects. method: we examined outpatients ( % male, aged - year, mean age . years) with severe asthma according to ers/ ats ( ) definition treated with high dose of ics/laba± tiotropium, antileukotrienes and omalizumab. some patients (n = ) had orally steroid-dependent asthma. they referred to our secondary care center by gps. pulmonary function tests were measured by dry spirometer ( , vitalograph ltd., uk). skin prick tests or serum specific ige to common inhalant allergens (house dust mite, animal dander, pollen) were used to assess atopic status. results: seventy five percent (n = ) of patients with severe asthma had fao in % of those was diagnosed concomitant copd. duration of asthma was . years in patient with reversible airway obstruction (rao) and . years in those with iao (p > . ). early (before age years) onset of asthma was established in % of patients with rao and in % of patients with fao (p > . ). prevalence of atopy did not differ between both groups ( % vs %, p > . ) but total ige level in serum was higher in severe asthmatics with rao than fao ( me/ml vs me/ml respectively, p < . ). most of atopic patients with severe asthma both with fao ( %) and roa ( %, p > . ) were sensitized to house dust mites (d. pteronyssinus and d. farinae). hypersensitivity to pollen was diagnosed in % patients with foa and in % with rao (p > . ), to cat and dog dander in % and % respectively (p < . ). the majority ( %) of patients with severe asthma had fao. hypersensitivity to house dust mites was most common in severe atopic asthmatics with foa and roa where as sensitization to animal danger was associated with presence of foa. | loss of smell as a clinical marker of severe asthma and its association with upper airway inflammatory diseases background: asthma is frequently associated with rhinitis and chronic rhinosinusitis (crs) while severe asthma is more associated with crs with (crswnp) than without (crssnp) nasal polyps. loss of smell (los) is associated with crs, mainly with crswnp. we aimed to assess loss of smell as a clinical marker to discriminate crs from rhinitis and severe from non-severe asthma. method: in a cross-sectional multicentric study, asthmatic patients (n = ) were evaluated by pulmonologists and ent specialists using gina, aria, and epos definitions. los was evaluated by severity [vas scale, - mm, median (iqr,inter-quartil range)] and by prevalence of anosmia (hyposmia vas > - mm, anosmia vas> mm). results: los was present in . % of asthmatics (hyposmia . %, anosmia . %). los was more severe [ mm ( - ), p < . ] and anosmia more frequent ( . %, p < . ) in severe persistent asthma than in moderate [ mm ( - ); . %] mild [ mm ( - ); . %], or intermittent [ mm ( - ); . %] asthma. in addition, los was more severe [ mm ( - ) vs mm ( - ), p < . ] and anosmia more frequent [ . % vs . %, p < . ] in crs than in rhinitis patients. in those asthmatic patients with crs, los was even more severe [ mm vs mm ( - ) p < . ] and anosmia more frequent ( . % vs . %, p < . ) in crswnp than in crssnp. conclusion: loss of smell and specially anosmia may clearly discriminate severe from non-severe asthma and crs (specially with np) from rhinitis alone in asthma patients. thus, los may be considered a significant clinical marker of severe asthma and its association with upper airway inflammatory diseases. | last station in the eosinophilic asthma with chronic rhinosinusitis and/or nasal polyposis march: eosinophilic asthma with radiological findings associated with blood eosinophilia yilmaz i ; nazik bahçecioglu s ; türk m ; tutar n ; oymak fs ; gülmez i erciyes university school of medicine, kayseri, turkey; department of chest diseases, kayseri, turkey; division of immunology and allergy, kayseri, turkey background: eosinophilic asthma with chronic rhinosinusitis and/or nasal polyposis (eacrs/np) is a subphenotype of adult-onset eosinophilic asthma. blood eosinophil levels are shown to be highly elevated in patients with ea-crs/np and have potential for tissue infiltration. we aimed to demonstrate the clinical features of the patients who have a blood eosinophil level above % and have thorax computed tomography findings due to blood eosinophilia. results: we identified patients who met the above criteria. we defined this group as "eosinophilic asthma with chronic rhinosinusitis and/or nasal polyposis with radiological findings related to blood eosinophilia" (earr). the mean age was . ± years and % was female. nasal polyps, aspirin exacerbated respiratory disease and atopy was present in %, % and % of the patients, abstracts | respectively. the mean blood eosinophil count was . cells/mm ( %). the majority of earr patients had upper lobe dominant ground-glass opacities. the mean follow-up period was . ± . years. earr patients did not evolve into eosinophilic granulomatous polyangiitis in the follow-up. method: we aimed to identify features more probably associated with asthma in a unselected group of patients with diagnostic criteria for aco. we consecutively selected the first consecutive patients with diagnostic criteria for aco. all patients were evaluated by accurate clinical history interview, assessment of asthma control test (act) and copd activity test (cat), lung function and exhaled nitric oxide (fe no ) measurements, sputum cytology, blood eosinophil count, serum total ige and periostin levels, methacholine and adenosine-mono-phosphate (amp) bronchial challenges. all these measures were repeated after an oral corticosteroid (ocs) trial of methylprednisolone mg/day for days. we defined parameters that we expected improved after the ocs trial, and therefore considerable as markers of asthma: fev , fef - , fev /fvc, fe no , act, sputum and blood eosinophilia, methacholine and amp challenges. patients with improvement of at least of these parameters after ocs trials were defined as "responders" to the treatment, and therefore more likely to be asthmatic than copd or aco. results: five ( %) patients were classified as responders and they were characterized by having basal higher fe no values ( . ± . vs . ± . ppb, p = . ), greater bronchial reversibility basal values of serum periostin and total ige, and blood eosinophils were higher in responders but without reaching the statistical significance. conclusion: fe no and the degree of bronchial reversibility (and possibly also the degree of response to an amp challenge) are reliable biomarkers to distinguish asthmatics among those with suspect aco. method: the preliminary case-control study included obese persons with asthma who were matched for age and sex and nonobese asthma subjects. non fasting serum levels of adiponectin, and leptin were measured by commercially available immune assay kits, and routine biochemical parameters were analyzed in both the study groups. the results show statistically significant lower levels of serum adiponectin and higher serum leptin levels in obese asthma subjects with respect to non-obese asthma patients (p < . ). moreover, an inverse correlation was also observed between serum adiponectin and serum leptin in obese asthma subjects (p < . ). our results indicate the association of these hormones might act as a significant predictor in the progression of asthma. moreover, the role of serum adipokines is promising and might potentially act as a meaningful drug target in the pathogenesis of asthma. background: overweight/obesity is known to be a possible factor for poor asthma control. the aim of the study is to determine the serum concentrations of leptin in atopic asthmatic patients and its relationship with body mass index (bmi), asthma severity defined by medical treatment and asthma control defined by the asthma control test (act). method: we randomly selected adult patients previously diagnosed with allergic asthma based on gina (global initiative for asthma) guidelines, returning for follow-up to an outpatient allergy/ immunology clinic during november . following an informed consent, the patients were asked to fill act, their bmi was recorded, and elisa blood assays for leptin were drawn. exploratory data analysis, spearman's correlation ( % ci by bootstrapping), and partial correlations were performed. results: female/male ratio was / , mean bmi was . ± . conclusion: leptin was significantly associated with overweight/ obesity in asthmatic subjects, and showed higher values for women. leptin inverse correlation with act did not reach statistical significance, likely owing to underpowered estimates, in a small sample characterized by an elevated mean bmi and severe allergic asthma. background: immunoglobulin lowering may be associated with recurrent wheezing symptoms and clinic by increasing the tendency to viral respiratory tract infections. in this study, it was aimed to investigate the frequency of immunoglobulinemia in preschoolers with wheezing. the study was conducted between . . and . . between. university of health sciences, ankara child hospital, the children allergy and immunology clinic included patients who had been followed up and treated for at least one year with recurrent wheezing attacks within younger than months. the immunoglobulin (g, a, m) values of the patients were retrospectively analyzed. immunoglobulin levels were determined to be normal and low according to age limits. the study included patients ( . % male, . % female) under the age of years with a mean age of . months. the mean follow-up period of the patients is . years. in . % of these patients, at least one immunoglobulin was found to be low. none of these patients had any signs or symptoms of immunodeficiency. immunoglobulin a was low in % of the patients, immunoglobulin g in %, and immunoglobulin m in . % of all patients. conclusion: immunoglobulin was found to be low in these patients when there was no immunodeficiency and preschool wheeze was diagnosed. this should be etiologically investigated as to whether if this is a special group in preschoolers with recurrent wheezing and hypogammaglobulinemia combination. method: asthma severe unit is formed by allergists, pneumologists, pediatricians and otorhinolaryngologists. hematologists and immunologists make specific collaborations. we present the partial results of our data collection, which include patients with severe asthma according to ers/ats task force, selected by peripheral eosinophils > according to wagener et al. we followed them up to assess control for year. we obtained cellularity in sputum using induced sputum technique. values of il of th , th , th pathway, periostin and ilc were not yet available. results: median age was ± , feno ± , exacerbations previous year . ± . , act . ± , fev % ± and dose of inhaled corticoids (budesonide equivalent) ug ± . most of the patients were sensitized ( %) and . % were polysensitized. the most frequent sensitization was dust mites ( %). % had received immunotherapy of whom . % with lack of response. not sensitized patients were older. sputum cell analysis of patients was performed, % had sputum eosinophils> %, mean sputum eosinophil value was . ± . and peripherally ± . correlation among sputum and peripheral eosinophilia was . (p = . ). the peripherally eosinophil value > had a sensitivity of % and a specificity of % for the detection of sputum eosinophils > %. no differences were observed in sputum cell count depending on allergic sensitization. % had an uncontrolled asthma. presence of polysensitization, rhinitis or polyposis were not statistically related with the control. different patterns were observed in function of cause of poor control: patients with obstructive pattern (fev < %) were older and received more inhaled treatment. patients with high rate of exacerbations had more sputum eosinophilia and neutrophilia. both groups had worse act and received more oral steroids. patients who received oral steroids were more often sensitized to fungi in some follow-up visits. not significant differences were observed in control according to the act. asthma had more sputum neutrophilia, were older, received higher inhaled steroids dose and had adult onset asthma. the only control variable related with sputum eosinophilia was exacerbation. fungi sensitization was more frequent among patients with oral steroids. method: a randomized, double blind, placebo controlled study with patients from the de la salle university medical center with a mean age of with partly or uncontrolled asthma. they were assigned to either cm glucan or placebo group for two months. act score and %fev postbronchodilator were assessed at the st visit, th week follow up, and th week follow up visits. an independent and paired t-test were used to determine mean changes in act scores and %fev between the groups. results: in the two treatment groups, those in the cm glucan group had a greater % fev mean change of − . compared to placebo which had only − . , a mean difference of − . , and a trend toward significance with a t-test p value of . . in terms of changes in act score, those in the cm glucan group had a mean change of . and . for placebo, a mean difference of . and was not significant at t test p value of . . the result of the emanuel trial showed a trend of improvement among patients on both groups in terms of act score and %fev postbronchodilator. however, it was not statistically significant. | lung function improvements with tiotropium in patients across all ages: impact of episodes of asthma worsening during phase trials vogelberg c ; casale tb ; bleecker er ; goldstein s ; szefler s ; engel m ; el azzi g ; dewberry h ; hamelmann e method: post hoc analyses involved phase iii, randomized, double-blind, placebo-controlled trials: in patients aged - years (rubatina-/canotina-/vivatina-/pensietina-asthma) who received tiotropium ( or . μg) or placebo, as two puffs once-daily via the respimat, as add-on to ics ± other controllers; and in adults (pri-motina-asthma replicate trials) who received once-daily tiotropium μg or placebo, as add-on to ics/laba ± other controllers. we analyzed change from baseline for peak fev ( - h) and trough fev at week in vivatina-and pensietina-asthma, and week in pri-motina-/rubatina-/canotina-asthma, comparing patients with and without episodes of asthma worsening during the trials. asthma worsening was defined as an episode of progressive increase in dayto-day asthma symptoms (recorded by patients and confirmed by the investigator) or a decrease of patient's best morning pef ≥ % from mean for ≥ consecutive days. as a post hoc analysis, p values are nominal. results: there were no differences in baseline disease characteristics between those who experienced episodes of asthma worsening and those who did not, within specified age and asthma severity groups. placebo-adjusted lung function improvements were observed with tiotropium μg in patients who experienced episodes of asthma worsening and those who did not during the trials (table ) . there was some variability in subgroups with low numbers of patients. conclusion: once-daily tiotropium add-on had a similar efficacy in adult and pediatric patients with symptomatic asthma, irrespective of whether they experienced episodes of asthma worsening or not during the trials. these data support the broad efficacy of tiotropium and show largely consistent improvements in lung function even in patients who experience episodes of disease worsening. | cochrane review of the use of antibiotics for acute exacerbations of asthma method: we searched the cochrane airways trials register, trial registries and reference lists of primary studies. we extracted outcome data and assessed risk of bias in duplicate and used current cochrane methodology throughout. our primary outcomes were intensive care unit (itu) admission, duration of symptoms/exacerbation and adverse events. we included six studies, including a total of adults and children. trials were of varied methodological quality and we were able to perform only limited meta-analysis. one study reported a single itu admission but no other studies reported admissions to itu. two studies investigating macrolides reported diary card symptom score and showed antibiotics improved symptoms (md − . , % ci − . to − . ). one study including participants reported more symptom-free days in the macrolide group than usual care. one study of a penicillin including participants reported asthma symptoms at hospital discharge; the between group difference was reported as non-significant. serious adverse events were rare; events were reported across the three trials (n = ). the pooled effect estimate for all adverse events from three studies was imprecise (or . , % ci . - . ). no deaths were reported. conclusion: our results confirmed that omalizumab significantly improves disease control and is a safe add-on therapy. also in appropriate patients with controlled disease over time, efforts to stepdown other asthma medications will be appropriate. ( ) aerd: aspirin exacerbated respiratory disease; sd: standard deviation. data are n (%), mean ± sd or n/n (%). c-act: asthma control test for children, fev : forced expiratory volume in one second; fev /fvc: the ratio of forced expiratory volume in one second to forced vital capacity, pef: peak expiratory flow; feno: fractional exhaled nitric oxide, vas: visual analogue scale *these included allergic rhinitis, asthma, eczema, atopic dermatitis, food allergy, etc. **there were , and missing data in treatment a, b, and c, respectively. this study examines the potential treatment effects of sq ® hdm slit-tablet on qol measured by sf- v in people with aa and ar. the analyses are based on data from the mt- trial (eudract no. - - ) and utilize data from the sq-hdm treatment group ( subjects) and the placebo group ( subjects). throughout the trial, qol was measured at each of visit - via sf- v . this yielded psychometrically-based physical and mental health summary measures, as well as a sf- v total score. according to trial design, the use of inhaled corticosteroid (ics) was reduced by % for a three months period (visit and ) and completely withdrawn for the last three months of the trial (visit and ). results: by estimating a simple regression on differences in sf- v total score from baseline measurements (visit ), a positive and statistically significant treatment effect on the overall qol of the sq-hdm treatment compared to the placebo group in visit and was found. further analyses show that the qol improvements are mainly driven by increases in the general mental health score, which are carried through to visit . in particular, the mental health and role emotional domains show statistically significant improvements. the results show that the sq ® hdm slit-tablet improves qol measured by sf- v in patients with hdm induced aa and that this effect is driven by improvements in the mental health domains. | impact of treatment prescription, adherence to treatment and use of inhalers in asthma control-results of the efimera study method: cross-sectional multicenter observational study conducted with patients who use any type of medication with inhaler devices. patients referred from primary care and seen by a pneumologist or allergist for the first time were evaluated. the following data was collected in a single visit: adequate prescription according to gina guidelines (gina); specific and general treatment adherence using morisky-green questionnaire (mg) and inhaler adherence test (tai); disease control with asthma control test (act) and assessment of inhaler use technique were measured with the extended tai. results: patients included in this study (n = ) had a mean age of ± years, an average disease evolution of . ± . years, % of which were women. according to gina recommendations, . % of patients have insufficient or inadequate prescription. when measured by the mg test the . % of patients showed bad adherence, meanwhile measured by the tai test adherence was . % measurements of inhaler use technique resulted in % of patients having one or more mistakes regardless of whether the device was a mdi or dpi. several factors showed to be related with bad asthma control: inadequate prescription (or: . [ . - . background: it is well known that the constant and prolonged tobacco smoking affects the natural history of asthma. vaping is the act of inhaling and exhaling the vapor produced by an electronic device called e-cigarette (e-cig), whose basic structure includes a power source and an atomizer. two types of vaping are the most popular ("mtl" and "cloud chasing"). we have created a web-survey with questions concerning epidemiological data, quality of life and symptoms worsening in asthmatic vapers. the survey has been advertised through various social networks and local press. people responded, including asthmatics ( %). the asthmatics were: males %, under %, - years %, - years %, - years % and over %. % used ecig-only, % smoked and vaped together, %. those who preferred mtl-type of vape were % and "cloud chasing" were %. results: to the question: "has vaping ever worsened asthma symptoms?" % answered no, % yes. to the question: "as asthmatic, would you suggest to an asthmatic smoker to start vaping instead of smoking?" . % answered no, . % yes. to the question: "how much nicotine do your vaping liquids have?" % answered mg/ml, % . mg/ml, % mg/ml, % mg/ ml, % mg/ml, % mg/ml and % mg/ml. to the question: "do you take medications for your asthma?" % declared to use a drug as needed, % used a single drug daily, % used more than one drug daily and % declared "i don't take any asthma medication". we related (χ test) the worsening of asthma symptoms with the nicotine content (p = . ), the type of vaping (p = . ), the current therapy (p = . ) and we did not find a statistically significant correlation. vaping has undoubtedly shown an advantage in terms of improvement of symptoms compared to cigarette smoking (p = . ), in particular . % subjects who smoke and vape did not have a worsening of symptoms, while . % of them had a worsening. the vaper-only users who never worsened were ( . %) and ( . %) had a worsening. conclusion: despite the limits related to the online survey as a data source, e-cigs seem to be a useful tool in the pathway to quit smoking. in fact, % of the asthmatics who smoked traditional cigarettes would recommend switching to e-cig and % did not worse their asthma symptoms. background: despite the success of pharmacotherapy, more than half of patients with persistent bronchial asthma (ba) do not achieve disease control. in recent years, the issue of approaches to treatment based on the identification of phenotypes of the disease has been increasingly discussed. this approach becomes the key to optimizing therapy for asthma, allowing the personification of treatment. anti-ige-therapy using omalizumab is one of the most researched variants of phenotype-specific treatment. method: aim of our study was to investigate of the causes of uncontrolled predominantly atopic asthma, the frequency and effectiveness of the personalized therapy in real clinical practice. patients with uncontrolled severe atopic asthma were examined in outpatient department of the city hospital during . all patients underwent physical examination, pulmonary function testing, and total serum ige evaluation. results: % of patients had uncontrolled asthma due to inadequate basic therapy of the disease. the change in therapy allowed them to achieve control of the disease. obstructive sleep apnea syndrome (osas) was revealed in . % of patients. these patients underwent cpap (continuous positive airway pressure) therapy. % of patients had gastroesophageal reflux disease (gerd). % of patients had an elevated level of serum ige level and needed anti-ige therapy. in . % of cases, the initial serum ige level was more than iu/ml which was a contraindication to therapy of omalizumab. patients received omalizumab therapy. this therapy led to relief of symptoms and decreased frequency of asthma exacerbations. results: it was found that the prevalence of obesity among the patients with asthma and being treated in inpatient conditions in - was . % of patients, which is comparable to the prevalence of obesity among the population in general. the data of the patients suffering from asthma and obesity treated both in inpatient and outpatient conditions, was analyzed and it is set that obesity does not affect the severity of the clinical course of asthma. it is shown that obesity does not affect the control of symptoms of asthma. thus, the control of asthma symptoms depends on timeliness of diagnosis, the adequacy and terms of appointment of basic asthma therapy, the presence, severity and adequate treatment of concomitant diseases, psychoemotional background of patients, their compliance and adherence to therapy. results: the causes of smoking in asthmatics were not significantly different from the control (p > . ). patients most often used smoking as "support for emotional stability". the motivation to smoking cessation was higher in the asthmatics group ( %) than in the control group. the main reason for smoking cessation was a deterioration in health - %. the majority of smokers - %, performed attempts for smoking cessation. low level of br was revealed in % asthmatics ( % non-smoking asthma patients and . % of cases in the control group, p < . ), cf had low values and was lower in asthmatics group in compare to the control group (p < . ). the pac values correlated with the level of br: a low level was determined in % in smoking asthmatics, in % in nonsmokers with asthma and . % in smokers of the control group obstructive sleep apnea (osa). all of the patients were on regular treatment with low dose inhaled corticosteroids for at months and start treatment with continuous positive airway pressure (cpap) .to assess quality of life, we used asthma symptom control tools (asthma control test) .patients performed daily peak flow meter and spirometry (once a week) during period of weeks after start using cpap. results: during the study, of the followed patients had no exacerbation of asthma. four of patients during this period had exacerbation, due to upper airway infection so they were excluded from study. results of following showed that there was improvement in quality of life in all patients included in study but there no statistically significant improvement in pulmonary function tests fpt. huang y ; yao t ; huang y ; chiu c ; tsai z ; kao p ; lu k ; fang h ; lin c ; gau c ; lee w ; tsai h results: the rate of preterm birth among the study subjects was . %. the prevalence of physician-diagnosed rhinitis was . %. there was no significant association between preterm birth and physician-diagnosed rhinitis (p = . ). when stratifying by atopy status, we found that preterm birth was associated with physiciandiagnosed rhinitis among children without atopy (adjusted or [aor] = . , % ci = . - . , p = . ), but not among children with atopy (p = . ). when further classifying by gender, greater protective effect of preterm birth on rhinitis was only found in boys without atopy (aor = . , % ci = . - . , p = . ). the results suggest that preterm birth may have a protective effect against the development of childhood rhinitis in our study population. the protective effect is only observed in boys without atopy. further investigations will be merited to confirm these findings and to investigate underlying mechanisms. background: folic acid supplementation (fas) during pregnancy has been suggested due to its protective effect against neural tube defects. at present the effect of fas during pregnancy on childhood rhinitis has remained unclear. we aimed to investigate the relationship between fas during pregnancy and childhood rhinitis. logistic regression analysis with covariate adjustment was performed. adjusted covariates included sex, age, number of older siblings, breast feeding duration, maternal smoking during pregnancy, maternal allergy, maternal education level, maternal age and socioeconomic status results: the prevalence of physician-diagnosed rhinitis was . %. there is a significant association between fas and physician-diagnosed rhinitis (adjusted odds ratio [aor] = . ; % confidence interval [ci] = . - . for fas ≥ months) compared to the group of never use. in the stratified analysis by atopy status, maternal fas during pregnancy was significantly associated with physician-diagnosed rhinitis in the atopic group (aor = . , % ci = . - . for fas < months; and aor = . , % ci = . - . for fas ≥ months), but not in the non-atopic group. when further stratified by gender, significant association between maternal fas during pregnancy and physician-diagnosed rhinitis was only found in boys with atopy (aor = . , % ci = . - . for fas < months; and aor = . , % ci = . - . for fas ≥ months). the results demonstrate that maternal folic acid supplementation during pregnancy might increase the risk of childhood rhinitis, especially among boys with atopy. further investigation will be needed to validate our findings and to understand potential underlying mechanisms. according to sequence data from detected adv (in all groups of patients) belongs to species f type and samples to species c type (rei group). bv type was identified in strongly positive (ct ≤ ) swab samples in ari group. conclusion: simultaneous testing of respiratory and stool samples together shown that at least . %/ . % of study subjects had dual/mixed infections, respectively, including %/ . % of respiratory disease patients, . %/ % of gastroenteritis patients and . %/ . % of patients with combined respiratory/enteric infections. we found no virus combination specific for different groups of patients. | neonatal respiratory supports and future asthma-like presentation in prematurity with bronchopulmonary dysplasia results: of all the tests analyzed . % were males and . % females with a mean age . ± . years old. half of the tests ( . %) reveals positive specific-ige to more than one allergen and . % ( ) have no serum specific-ige for the tested allergens (table ) . sixteen patients ( . %) have very high concentrations (> iu/ml) of derm. pteronyssinus specific ige, ( . %) of derm. farina, ( . %) of rey pollen and ( . %) of oak and timothy grass pollen. further studies are needed in order to elucidate the effect of these cytokines on allergy development and protection. shinohara m ; matsumoto k department of pediatrics, ehime university hospital, toon, japan; department of allergy and clinical immunology, national research institute for child health and development, tokyo, japan background: probiotics consumption during perinatal and postnatal periods reportedly reduces the risk of atopic dermatitis in the offspring, whereas such probiotics consumption did not affect ige levels or the risks of other allergic diseases; the precise mechanism how probiotics consumption reduces the risk of atopic dermatitis remains unknown. we hypothesized that probiotics consumption may reduce skin hypersensitivity to histamine. to test this hypothesis, we investigated whether perinatal/postnatal consumption of yogurt associates with skin hypersensitivity to histamine or not. method: this was a cross-sectional study enrolled motherinfant (≥ -months-old) pairs. physician-diagnosed allergic diseases and food consumption, such as milk, fermented drinks, and yogurt, by mothers during the third trimester of pregnancy and by infants during the first months of life were assessed using self-questionnaires. skin prick tests (spts) to saline and mg/ml histamine were performed using bifurcated needles, and wheal sizes were measured minutes after the puncture. the spt wheal sizes in infants with eczema/atopic dermatitis (n = ) were significantly larger than those in infants without eczema/atopic dermatitis (n = ; . ± . mm vs . ± . mm, respectively, p = . ), and thus these infants were excluded from the further analyses. the spt wheal sizes to histamine in infants with daily yogurt consumption during the first the aim of this study was to evaluate the prevalence and clinical relevance of sensitization to profilins in atopic patients with food allergy. the study was performed on a group of children age - years with sensitization to at least one plant-derived food allergen (ige > . ku/l). the included patients had never been treated with allergen immunotherapy before the study. the presence of ige to recombinant (r) rbet v , rart v and ramb a in serum was evaluated using elisa method as previously described (jbc ; : ) . in addition serum level of igg to rbet v , rart v and ramb a was also evaluated. results: sensitization to profilins was found in out of ( . %) patients (p+). sensitization to all studied profilins was demonstrated in each p+ patient. the remaining children, with pollenfood sensitization, were not sensitized to any of the studied profilins and they served as a comparator group (p−). analysis of the clinical status revealed that asymptomatic patients in regard to plant-derived food hypersensitivity were found more frequently among p+ ( %) than p− ( . ; p < . ) patients. sensitization to profilin was associated with positive ige to the same food allergens as in the control group. clinical manifestation of pollen-food sensitization expressed as allergic rhinitis, bronchial asthma and atopic dermatitis was comparable between groups, except of oral allergy syndrome, which was not seen among p+ children. similarly, history of anaphylaxis to plant-derived foods was registered only among p− ( . %) patients. interestingly, all patients with sensitization to profilins had also elevated level of serum igg against rbet v , rart v and ramb a . results: no significant difference of physician-diagnosed eczema (p = . ) or current eczema (p = . ) was observed between children born full-term and preterm. after stratifying by atopy status, we found that children born preterm had a more than three-fold higher risk of having physician-diagnosed eczema (adjusted or (aor) = . ; % ci = . - . ; p = . ) and current eczema (aor = . ; % ci = . - . , p = . ) than their counterpart in the non-atopic group. no statistical significance was observed for the association between preterm birth and eczema in the atopic group. no association between preterm birth and eczema was found when stratifying by gender. our results reveal that non-atopic children born preterm have a higher risk of developing eczema. the results suggest potential modifiable effect of atopy on the association between preterm birth and eczema. further studies with a larger sample size are needed to validate the findings in this study. background: there is a need for more knowledge about factors of importance for a successful transition from childhood to adulthood among adolescents with allergic disease and especially those with severe allergy. therefore the aim of this study was to describe experiences of living with severe allergy from the adolescents and their parent's perspective and thereby identify factors of importance for transition from pediatric to adult care. method: a qualitative study was performed based on six focus groups interviews, two with adolescents and four with their parents. in total adolescents (age - years old) and parents participated. the interview guide contained questions about experiences of living with severe allergy. the transcribed data was analysed using systematic text condensation. results: in total four themes were presented, two themes occurred in both the adolescent and the parent's focus groups, to be special and to be prepared. for two themes there was a difference between the adolescents and their parents. the theme, the importance of the parents, only occurred in data from the adolescents and the theme the meetings with health care only occurred in the parent's data. the adolescents felt that they had low priority in the class and several stated they were teased at school and their parents felt that focus on their child often was in a negative way. the adolescents described that they took responsibility for their diseases while their parents expressed a need to protect. the adolescents stated that one of the parents were always present or had been during the years, the reason being safety and security. only the parents mentioned experiences from healthcare. parents who described that they had continuity in healthcare meetings and where met by high competence and with a professional approach were more satisfied with the support from the health care. one factor that was felt to be important was whether the doctor involved the youth in the conversation or not. the teenagers in this study relied on their parents while also taking responsibility for their illness at the same time. parents, on the other hand, showed a tendency to overprotect their adolescents. for healthcare professionals it is important to involve the adolescents in the care to facilitate the transition. results: . % of the children used antibiotics currently and . % out of them used antibiotics ≥ times yearly. current wheeze (w) was established in . %, sleep-disturbing w in . %, exerciseinduced w in . %, dry night cough apart from a cold in . %, and asthma in . %. current antibiotics use ≥ times yearly was positively associated with current w (aor: . ; . - . ; p < . ), sleep-disturbing w (aor: . ; . - . ; p < . ), exercise-induced w (aor: . ; . - . ; p = . ), dry night cough (aor: . ; . - . ; p < . ), and diagnosed asthma (aor: . ; . - . ; p = . ) while antibiotics use < times yearly was positively associated only with current w (p = . ) and dry night cough (p = . ). the results suggest an aggravating role of antibiotics use on asthma in school age thus further supporting the recommended restriction of antibiotics exposure. results: after questioning . % % ci, . - . were suffering from respiratory diseases, having symptoms of chronic disease: cough- . %, wheezing- . %, tightness in the chest- . %. the risk factors (passive smoking, open fire house warming and no air conditioning) were commonly met in major cases at ill children rather than healthy ones ( . % % ci, . - . ). as a result of studies made of the equal to . ± . , comparative the end of lessons equal . ± . (p ≤ . ); air relative humidity varies during lessons equal with . ± . (norma toilet %- %); co concentration exceeds allowable limits − . ± . (mac − . %). conclusion: respiratory morbidity in high school examined has a tendency to increase. we noticed deviations from the hygienic norms: the indoor temperature and relative humidity was lower and the co level was twice higher than the normal one. the "asthma ever" outcome was reported in cohorts. cohorts defined this as parental reported asthma (with or without specifying that it was doctor-diagnosed), cohorts used gp records as the only source of diagnosis, and used parental report or gp records. the "current asthma" outcome was reported in cohorts. there was little consistency with how current asthma was defined or worded, with different definitions used. the most common definition of current asthma, reported times, was "asthma ever and either asthma symptoms in the last months or asthma medication in the last months". other criteria included in asthma definitions were bronchial hyper-responsiveness, reversible airway obstruction, positive exercise test, and asthma symptoms reported at a previous questionnaire. only one "current asthma" definition was based exclusively on prescription data: "dispensed two asthma medication during the past year". nine cohorts reported asthma outcomes without specifying how it was defined, and were categorized as "asthma unspecified". conclusion: "asthma ever" and "current asthma" are two main asthma outcomes used to define asthma in child cohort studies. definitions of asthma vary substantially across cohorts. case report: thereby we present two case reports of two children with impairment verbal communication as part of asd and allergic diseases. the first patient was a year old boy with sneezing, rhinorrhea night cough and eye redness. he had been suffering for almost years from the above mentioned symptoms. he had family history for atopic diseases and was for month breastfed. specific ige revealed sensitization to birch, alder, hazel, oak, mugwort pollen and dog epithelia and dermatophagoides farinae. specific ige resulted positive for nuts and rye flour. the second patient was almost year of age in the tame that he presented in our hospital. he cried and screamed all the time because of severe atopic dermatitis and typical symptoms such as itching all over the body and his impairment of verbal communication. specific sensitization showed sensibilization to egg white and egg yolk, to nuts, rye and wheat flour. the food specific ige leaded to positive results to alder, birch, hazel and oak pollen, but also to grasses, ragweed and mugwort. prick by prick test showed positivity to egg white and egg yolk. atopy patch test to pollens resulted negative. results: the first patient symptoms were well controlled after treatment with antileukotrienes. his verbal communication was also improved after a year or more. the second three year old patient after required a combination of specific treatment with antihistamines, corticosteroids, immunosuppressive drugs and diet recommendation. afterwards he had a reduced level of itching and anxiety but compared to other children he had a severe eczema. erythema multiforme (em) is an acute, immune-mediated, mucocutaneous condition that is most commonly caused by infection and drugs. it is characterized by targetoid lesions, sometimes accompanied by oral, genital or ocular mucosal erosions. there was no pediatric patient that had previously been reported in the literature with development of type reaction after omalizumab treatment. we presented a case who developed em to omalizumab therapy. an year-old female patient was admitted to pediatric allergy clinic with complaints of fever and rash. she had been diagnosed with chronic spontaneous urticaria (csu) years ago and she was planned to treat with omalizumab ( mg, subcutaneously every week) because of the inadequate response of antihistamines at a medical center. her complete blood counts, liver, renal, thyroid function tests and serum c ,c ,c esterase inhibitor protein levels introduction: celiac disease is an autoimmune disease triggered by exposure to gluten in genetically predisposed individuals and characterized by chronic inflammation of the small intestine. chronic urticaria is a skin disease, characterized by the appearance of pruritic wheals with or without angioedema, whose underlying mechanism cannot be identified. objective: to report a sporadic case of an -year-old boy with chronic urticaria associated with celiac disease. methods: an -year-old boy(weight kg, rd- th percentiles) was admitted to our clinic with a -year history of chronic urticaria. during the first three years, he was under antihistamine treatment(of incremental doses)and occasionally received preparations of cortisone according to the eaaci guidelines. he was asymptomatic for years until treatment was discontinued. eight months earlier, after a viral infection, a recurrence of urticaria, involving the trunk and extremities without angioedema was noted. subsequently, he was under antihistamine treatment with cetirizine but had an uas- score of . total laboratory investigations were performed. results: laboratory control was negative except for positive antibodies to celiac disease(anti-transglutaminase > u/ml, anti-endomysial, gliadin antibodies).further control with colonoscopy and biopsies (from duodenum and stomach) were obtained. the histopathological findings along with the clinical findings indicate celiac disease, type b marsch-oberhuber and grade b corazza-villanacci. in the past, similar cases have been reported. efforts have been made to associate chronic urticaria with celiac disease, although the mechanism remains unclarified. evidence suggests that the duration of gluten exposure, among otherwise asymptomatic patients with celiac disease, is related to the development of other autoimmune mechanisms. this can be explained by resolution of urticaria manifestations after the onset of gluten-free diet. in our case, three months after gluten-free diet, an improvement of urticaria with decreased uas- score of was observed. conclusion: he specific case of subclinical diagnosis of celiac disease in a child with chronic resistant urticaria further reinforces the suggestion that screening for celiac disease should be included in the diagnostic approach of chronic urticaria. | allergy to gingival balm in an infant with cow's milk protein allergy we report a case of an infant with a diagnosis of cmpa with an allergic reaction to a gingival balm caused by the presence of cmp in its constitution. furthermore, it is important to reinforce that milk proteins were labeled in an unusual form which might increase the risk of misunderstanding. these findings illustrate the difficulty in implementing total avoidance of common food allergens as well as the need to improve their labeling, particularly in non-food products. bakiri ah results: after specific treatment with corticosteroids, antihistamines, emollient creams, disinfectants and antileukotriens he was feeling better, he was smiling again and wished to have the chance to play with his classmates again. conclusion: this case report shows an association between level of stress and risk for atopic dermatitis. as previously showed children with low educational level parents and boys with higher stress have increased risk of having severe atopic dermatitis as compared to "no stress" boys. so early treatment and diagnoses are key important factors improving the children`s social life. results: the data cover immigrants (mean age . , range - ) and locals (mean age . , range - ). a slight difference in male prevalence ( . % vs %, p = . ), and pet possession ( . % vs . %, p = . ) were found between immigrants and locals, respectively. no differences were find in term of age and symptoms at presentation. the pattern of sensitization to the different allergens showed no statistically significant differences between migrants and controls. the rate of monosensitization resulted slightly higher in migrants ( . %) than controls ( . %). pollen-only sensitization was statistically higher among migrants than control ( . % vs . %, p < . ). monosensitization was more frequent among patients who have been living in italy for less than years ( . % vs %, p = . ). the opposite phenomena can be seen among polysensitized patients. conclusion: migrants are more frequently monosensitized than locals and tends to cluster towards either a pollen or dust mite sensitization. sensitization to house dust mite tends to appear early (< years of stay). pollen or mixed sensitization is more frequent the longer the residence time. | allergenonline.org: update of comprehensive allergen and celiac protein searchable databases for risk assessment of novel food proteins goodman re ; baumert jl ; taylor sl ; ebisawa m ; ferreira f ; bohle b ; van ree r ; kleine-tebbe j ; abdelmoteleb m ; koning f ; amnuaycheewa p conclusion: allergen and cd databases have been updated following a described review process. they can be used to identify proteins that might represent risks of food allergy or cd for affected consumers. han dh ; lee jw ; yim hj ; ko yk ; kim d ; rhee c seoul national university hospital, seoul, south korea; seoul national university bundang hospital, seoul, south korea background: stress can change the immune response and aggravate various allergic diseases. we already demonstrated in previous allergic rhinitis cohort (arco) kids study that stress might be a risk factor for pediatric allergic rhinitis (ar). the aim of this arco study is to investigate relationship between stress intensity, symptoms severity and quality of life as well as allergic markers in adult ar patients. results: as stress intensity increased, the proportion of moderatesevere ar patients was significantly increased. ar patients in high stress group was likely to belong to moderate-severe group (or, . ; % ci, . - . ). global vas of ar symptom was . ± . in high stress group and . ± . in low stress group, respectively. the each rqlq domain score was significantly higher in high stress group than in low stress group. total rqlq scores were . ± . in high stress group and . ± . in low stress group, respectively. however, as the level of stress increased, there were no significant changes in serum levels of allergic markers. our results suggest that stress may affect ar symptom severity and quality of life in ar patients. | skincare and synbiotics for the prevention of atopic dermatitis or food allergy in newborn infants: a × factorial randomized non-treatment controlled trial dissanayake e ; tani y ; sahara m ; mitsuishi c ; nagai k ; sato y ; suzuki y ; nakano t ; yamaide f ; shimojo n (n = ). the skin care group was advised to apply an emollient - times/day especially on cheeks and peri-oral area. the synbiotics group consumed a mixture of fos ( g) and bifidobacterium bifidu-mol ( × )/day. the last group received both. emollient application was not prohibited in the no-intervention group. interventions were carried out from birth to months of age. the development of ad was assessed at month, months and months by a pediatrician and at year by a questionnaire. ad was diagnosed using guidelines of the japanese society of dermatology. sensitization to food allergens was assessed by allergen-specific ige levels at months of age. results: skin care and synbiotics, alone or in combination, did not prevent the development of ad at year of age or the sensitization to food allergens at months of age. conclusion: our data suggest that skin barrier protection using emollients may be insufficient to prevent the development of ad as other factors affecting skin barrier integrity and trans-epidermal water loss such as the method of skin washing may have an additional effect. the probiotic bacterial species used may also affect the outcome as lactobacilli have been shown to be more beneficial. more studies are required to confirm the effects of skin care and synbiotics on ad. results: in the population number of girls exceeded the one of boys (p < . ), especially within the age group from to years. questioning, for months, symptoms of allergic rhinitis (rhinorrhea, sneezing, nose itch, nasal obstruction and eyes' itch) were identified in . (p < . ); symptoms of bronchial asthma (wheezing ( %), episodes of cough at night ( . %), intolerance to physical load ( . %), indoor and outdoor ( . %), coughing and rales in response to stimulus ( . %)) in . % of the population; atopic dermatitis (dermatitis, itch, revelation in early age, involvement of large areas in early age, damage of extremities bending and stretching surfaces in adults)- . % (p < . ); food allergy- . % (p < . ) etc. at the second stage of clinical studies, on the basis of prick-testing, average ige, in our case, was - times greater than normal level. results of study of allergens showed sensibilization to domestic dust (d.f. and d.p.) ( , %) (p < . ). in . % of cases there was stated sensibilization conditioned by cat and dog epidermal allergens results: among the women with available serum, . % were sensitized of whom . % were monosensitised, and . % polysensitised (to two or more allergens). sensitisation to inhalant allergens dominated ( . %), with grass being most common ( . %). only . % were sensitized to food allergens, most often to peanuts ( . %), while among the . % who reported ddfa, ige reactivity to foods were identified in . %. compared to women with no asthma, women with dda ( . %) were in a significantly higher background: regular exercise has been known as beneficial that it reduces the risk of chronic diseases including allergic diseases. however, little has known regarding the relationship between exercise and allergic diseases in korean adolescents. we analyzed the national data whether exercise is related to the prevalence of allergic diseases in the population of korean adolescents method: data from sixth korean national health and nutrition examination survey ( - ) that included adolescents from to years old was analyzed. we defined regular exercise according to physical activity guidelines for americans. multivariate regression analysis was performed to find whether lack of exercise could be a risk factor for allergic diseases. results: the prevalence of asthma, allergic rhinitis (ar) and atopic dermatitis (ad) were . %, . % and . % in korean adolescents, respectively. after adjusting for factors, lack of exercise was not associated with asthma and ar, but was significantly related to ad in korean adolescents (adjusted odd ratio . , . - . , results: it was found that over % of ch up to y.o. having the ad within allergic disease (ads). the most significant symptom was a long-lasting itchy rash lasting for month in . ± . % of g and . ± . % of g. the first morbidity of ad was noticed at the age of up to y.o. among . ± . %. at the age of ch - y.o. and older than y.o. the skin ads onset was noticed for . ± . % and . ± . % accordingly. the ad sl was determined as follows: %moderate (mo), %severity (s), % were ± kua/l, ± iu/l respectively. skin prick tests were positive in . % of the patients ( . % multiple allergens). grass pollens ( %) and dermatophagoides ( . %) were the most common allergens. average vitamin a and d levels were . ± μg/l ( - ), . ± . ( - ) respectively. thirty percent of the patients vitamin d levels were mildly low, . percent was low. in control group % was mildly low, vitamin a levels was low in . % of the patients. none of the children in control group had low vitamin a levels. we didn't find any statistical significant difference for both vitamin levels between patient and control groups. vitamin a deficiency was mostly found in asthma patients whereas vitamin d deficiency was mostly in allergic rhinitis and asthma groups. passive smoking and vitamin d deficiency was significantly related (p = . ). there wasn't any relation between asthma attacks and vitamin levels. conclusion: in conclusion vitamin a and d levels weren't found significantly related with allergic diseases but was found lower than control group. patients having chronic diseases are one of the population groups that are chronically exposed to drugs. this study aims at evaluate the impact of this factors in developing drug allergies in the medical staff. method: this was a cross-sectional study that included nurses from the uhc "mother theresa" of tirana. they were asked to fill up a questionnaire where questions about chronic diseases and drug allergies were included. . % were females and the mean age was . (+ . ) years old. relative risks with % ci were calculated for different groups. results: . % ( ) nurses reported to have at least a chronic disease. the most common non-atopic disease was hta followed by the groups of autoimmune and thyroid diseases. nurses who had one chronic disease have a rr of . ( % ci = . - . , p < . ) to develop a drug disease higher than those who didn't had any chronic disease, and those who have more than one chronic disease have a rr of , p < . ) to develop a drug disease. the presence of chronic diseases can be a risk factor to develop a drug allergy probably through the increased risk to drug exposure. these patients may be exposed to drugs not only through therapy but also through hospitalizations and other forms of health care. lapeere h ; oosterlinck p ; vermeir p ; vermeire i ; coppens m ; gevaert p ghent university hospital/ghent university, ghent, belgium; ghent university hospital, ghent, belgium; ghent university hospital/ghent university, ghent, belgium background: the key to managing latex allergies in healthcare professionals and patients lies in correct recognition and appropriate action. . million people are employed in the health care sector. while there are no overall statistics on the prevalence of latex allergy in that work force, studies do indicate that %- % of health care workers regularly exposed are sensitized, compared with %- % of the general population. latex allergy is defined as an immune mediated reaction to latex products (e.g. balloons, contact dermatitis for gloves, condoms, surgical catheters); these encompass immediate and delayed hypersensitivity reactions. method: based on the experience of the belgian dutch pathway network, a -phase method to develop, implement, evaluate and continuously follow up a care pathway for latex allergy was designed and implemented. the purpose of the study was to develop and implementation of latex allergy clinical care pathways to provide all staff at ghent university hospital with appropriate knowledge and skills to identify and manage patients who have a known latex allergy or those at risk of developing latex allergy. results: care pathways, also known as clinical pathways, are used all over the world to implement and monitor patient-centered care processes in a transparent way. care pathways are defined as a complex intervention. -phase method consists of: ) screening phase; ) project management phase; ) diagnostic-and objectification phase; ) development phase; ) implementation phase; ) evaluation phase and ) continuous follow-up phase. this phased approach is based on the deming cycle, better known as the "plando-study-act" (pdsa)-cycle. conclusion: this method can offer support to multidisciplinary teams (re)designing and implementing safe, efficient, effective, person-centered, timely, equitable, continuous and integrated care processes. however, the method is no guarantee to success. the key to success is the collaboration and critical attitude of the entire multidisciplinary team when implementing pathways. background: cord blood ige (cb-ige) were considered to be a useful predictive tool for allergic symptoms especially in early childhood. there is only sparse knowledge about their importance for health in later life. the aim of our work was to determine the importance of cb-ige for allergic symptoms in young adults. we also studied the possible modifying factors for cb-ige concentration. results: resutls shown as daily mean, pollen grains/m³: table . the daily means of pollen concentrations of cupressus arizonica, platanus acerifolia and plantago lanceolata in our area differs from other sites in madrid city. although cupressus arizonica and platanus acerifolia counting were lower, plantago lanceolata counts were higher, representing a relevant pollen in our area. the clinical relevance of these findings is under evaluation by our group. method: grass pollen counts were performed since - using a burkard days spore trap located in our allergy center in madrid. the beginning of the algid period of pollination was considered the first of three consecutive days with more than grains/m and the end, the last day of three consecutive days with more than grains/m . madrid, barajas meteorological station data, was used. skin prick tests (pt) to grass pollen was also studied in comparison conclusion: total grass pollen concentration did not suffer any increase or decrease in its counts despite the dramatic increase of the temperature. an advance at the beginning and the end of the season was seen. these changes significantly correlate with the temperature increase during may and july. discrete decrease in the sensitization prevalence. since several years, the reference method to monitor the biological particles concentrations has been the hirst method: a volumetric pollen trap, located on the roof of building for background measurements, sucks continuously l of air per minute, particles depositing by impaction on a coated tape. the tape is then analyzed by optical microscopy. the hirst method produces accurate but past data. nowadays, many researches are focused on the development on new devices to get real time information. method: rapid-e from plair sa is a device using red laser beam to determine the size and the shape of sucked particles and an ultraviolet ray to measure the fluorescence of these particles. the results: the correlation coefficients got between rapid-e and hirst trap are higher than % for most of calibrated pollens, this correlation reaching % for all pollen taxa: • plane % • pine % • birch % • oak % • plantain % • dactylus % • urticaceae % conclusion: new calibrations are planned for and a real time information will be set up. results: the quinquennial media concentrations since - were . ; . ; . ; . ; . ; . ; . and . grains/m . the quinquennial media temperatures were . ; . ; . ; . ; . ; . ; . and . °c. increase of . °c (r s = . p < . ). the beginning and the end of the actual season advanced days respectively in regard to the period from to . the annual prevalence of positive pt to platanus in was % an % in . the quinquennial media from to was , , and %. conclusion: platanus pollen counts had a dramatic increase that meaningfully correlates with the dramatic increase of the temperature. a discreet advance at the beginning and the end of the season was seen. these changes did not influence in a longer duration of the season. we observed a significant increase in platanus pollen sensitization prevalence whiting madrid pollinosis patients. results: the quinquennial media concentrations since - were , , , , , , and grains/m . the quinquennial media temperatures were . ; . ; . ; . ; . ; . ; . and . °c. increase of . °c (r s = . p < . ). the actual season beginning advanced in days and the end has results: over % of house dust samples collected between april and may from central european countries were found to contain bet v allergen at levels well above the limit of detection of . μg/g for elisa . ep kit and . μg/g on maria. samples were found to have much higher levels of bet v allergen from midto-late april, particularly those that were collected in germany, belgium and hungary. samples taken from outside of the pollination season were tested and found to be negative for bet v . in conclusion, we found that bet v allergen can be detected and quantified in house dust samples. these data suggest that household dust is a source of pollen allergen and could therefore be contributing to asthma and allergic rhinitis symptoms in individuals affected by pollen allergy. household dust may also be considered as a source of bet v allergen which could contribute to allergic sensitization. | cupressaceae pollen in the atmosphere of alentejo: disruption of pollen grain during air transport spring, depending on the temperature. despite being considered moderately allergenic, it might be responsible for winter allergic outbreaks. as ornamental trees, they are found scattered throughout the territory but are more abundant in pockets of wild forest, outside alentejo. despite being more common in mountain, this pollen type is captured in considerable amounts in alentejo, portugal, where its aerobiological features and allergenic impacts are poorly characterized. the aim of this work is to characterize the aerobiology of cupressaceae pollen, to evaluate the effect the meteorological conditions and the source of this allergenic pollen type in the atmosphere of evora, alentejo. method: pollen were collected using a hirst type -day pollen trap and pollen was identified following standard methodology. background: allergic rhinitis caused by pollen is one of the most common allergic diseases. the presence of pollen in the air is currently centrally monitored at roof top levels, and not in the direct living environment of sensitized subjects. in the current project we aimed to develop a handheld pollen sampler, called pollensniffer, that can collect pollen in the living environment of the allergic subjects. as a first step this device was validated against the standard burkard pollen sampler and used to monitor local pollen concentrations at street level in the city of leiden. method: rooftop level pollen were monitored routinely by a hirst type pollen sampler (burkard, uk). the pollensniffer ( | does the allergy risk due to pollen exposure information is useful for the allergy sufferers? sindt c; oliver g; thibaudon m background: in france the information for the allergy sufferers is not made with pollen counts, which have not a real signification, but with the allergy risk due to pollen exposure. method: since more than years, rnsa (réseau national de surveillance aérobiologique), the french aerobiology network, has measured the pollen exposure in the main cities of france, using background: the effect of environmental factors on allergic sensitizations is still unclear. rural areas vs cities have different exposure levels to pollutants and aeroallergens. these differences could give clues on the causes of higher allergic sensitization rates in children exposed to city air. method: two studies with children aged years old were initialized to analyse the airborne drives of allergic sensitization: seal (günzburg, children) and ae r kids (munich, children). capillary blood was collected and the parents filled in a questionary. sensitization rates were quantified using the immunocap ® isac sige array. pollen data were measured at both locations. results: in günzburg more children were sensitized to aeroallergens, however munich children showed significant higher sensitization to phl p (p < . ), despite the lower concentration of pollen. in günzburg % children had no sensitization at all compared to % in munich. % of the children in munich spend at least hour per day outside and % of the total have no animals at home. % felt symptoms of hay fever in the last months, the majority between march and june, which correlated with the pollen flight. results: the total rate of atopy in crd patients was . %, and asthma patients was the highest ( . %). the positive rate of phadiatop in urban asthma patients ( . %) was significantly higher than that in rural areas ( . %, p < . ) and the phadiatop positive rate of office staff ( . %) was significantly higher than that of outdoor workers ( . %, p < . ). the total rate of atopy in copd patients was . %, and in patients with acute exacerbation was . %. beside, atopy is a risk factor for dyspnea (or = . , p < . ), and the fvc levels in copd patients with atopy were significantly lower than those without ( . l vs . l, p < . ). optimal scaling analysis show that, there were a correlation between the tige and smoking coefficient (cronbach's alpha = . %). in addition, the correlation between the level of tige and phadiatop sige was so strong in the patients with mild to moderate asthma (r s = . , p < . ), but it was weak in severe asthma patients (r s = . , p < . ), and up to . % of the gold iii iv patients with low phadiatop level (≤ ku/l) had a high level of tige (≥ ku/l) compared gold i ii ( . %). conclusion: the rate of atopy in patients with crd is high, and atopy is an important factor affecting the process of crd. the patients with severe copd or asthma is likely to has high serum tige level but the level of common allergen sige is low, so the allergy screening strategy should be adjusted and we should pay attention to those patients, therefore, it is necessary to screen the sensitization situation of crd patients at first, and the results can guide the treatment, management and prevention of crd. background: due to a limited amount of epidemiological data [ ] it has been thought that many severe allergic asthmatics in germany remain unidentified and are therefore not adequately treated. a pilot project demonstrated that more than % of patients, having been mean total ige (sd) was . ( . ) ku/l. . % of the patients had no sensitization towards any of the specific iges tested, whereas % were positively tested on - allergens and further . % showed sensitizations towards > allergens. conclusion: approximately % of online recruited (severe) asthmatics had a total ige level of > ku/l and ≥ sensitization (allergen-specific ige) towards atopic allergens. this further supports the high prevalence of atopy in asthma. results: patients (mean age: ± . years, range - years, m/f ratio: . ) who suffered from allergic rhinitis or allergic rhinoconjunctivitis enrolled in this study. highest rate of skin sensitivity was for weeds/grasses pollen including salsola kali, amaranthus retroflexus, chenopodium album and compositae family ( . %, . %, . % and . % respectively). among tree's pollen; ash ( %), walnut ( . %) and mesquite ( . %) were the most common. less than % of patients showed skin reactivity to indoor allergens and storage mites, mix of cockroaches and house dust were the most common ( . %, . % and . % respectively). the results of current study confirmed the importance of weed/grass and trees pollen as the major source of allergic sensitization in our area. interestingly the rate of sensitization to indoor allergens was low which can be explained by geo-climatic situation. background: there are few studies of cutaneous sensitivity to gramineae in our region. mostly of them use allergens of foreign species. the study aims to estimate the prevalence of skin sensitivity to widespread grasses in our region. method: this is a retrospective observational study of patients with seasonal allergic rhinitis. patients were studied using skin tests with pollens extracts from pooideae, chloridoideae and panicoideae grass species. results: the prevalence of positive reaction to pollen from pooideae subfamily was . % (ic: . %- . %). in turn, prevalence of allergy to panicoideae subfamily pollens was . % (ic: . %- . %) and positive reaction to chloridoideae subfamily reach . % (ic: . %- . %). cochran test suggests that prevalence in those three groups is different (χ = . , p < . ). when comparing just the groups of allergens from pooideae and panicoideae differences are also significant (χ = . , p < . ). in particular, . % (ic: . %- . %) of patients were allergic to paspalum notatum. regarding cross-reactivity between subfamilies, we find a no crosscorrelation between pooideae and panicoideae (χ = . , p = . ). conclusion: in bahia blanca, patients with seasonal rhinitis are sensitive to pooideae, chloridoideae and panicoideae. paspalum notatum, belonging to panicoideae, has a significant prevalence, high reactivity and low cross-reactivity within the group of species studied. this last species is relevant because it is a native grass from the northwest region of our country, paraguay and the south of brazil. prevalence of grass positive skin tests in patients with seasonal rhinitis by species. allergen frequency percentage % ci results: correlation analyzes were performed between sige and spt and area results. the concentration with the highest correlation by diameter and area for blo t was μg/ml and for der f of μg/ml. in the case of der p the concentration with the highest correlation for the diameter was μg/ml and for the area of μg/ml. when evaluating the reproducibility of the results according to the area and the greater diameter of the spt, a strong agreement was observed for blo t in the concentrations of μg/ml and . μg/ml. results: among the patients, the majority of allergens-positive was t , accounting for . %, followed by f ( . %), f ( . %), ds ( . %) and ccd ( . %). the prevalence of plant-related allergens (t , w , f , f , w and u ) in ccd-positive patients were significantly higher than those in ccd-negative patients (all results: with our new point-of-care methods using a selected recombinant protein e other markers, we were able to detect the disease early as days post-infection and more than % of positive cases from chronic and low endemicity areas (which are characterized by hard to detect patients with extremely low parasite load, < eggs per gram of feces) were obtained. plus, chromatography poc-cca ® test was improved by our group with a urine concentration step that turned its sensibility from % to %. conclusion: monoclonal antibody and recombinant protein technologies allowed superior detection methods when comparing it to the conventional ones. in conclusion, data showed % of sensitivity of chronic patients and % of acute patients. marton c county hospital, oradea, romania background: allergic rhinitis is a disease that affects about a quarter of the population, a disease with an important negative impact on daily activities, both on learning and working ability, as well as spending leisure time or sleeping. in the western part of romania, the most popular and blamed allergen is ambrosia, in the late summer months. it is a plant of the compositae/asteraceae family, along with goldenrod, sunflower, dandelion, cocklebur, chamomile, wormwood, daisy, etc. allergen identification is important for applying prophylactic measures, but especially for determining the allergen to be desensitized. considering the possible cross-reactivity within the compositae plant family, as well as the possibility of co-sensitization, as well as the number of patients sensitized to these pollens, which is steadily increasing, i considered is necessary a broad screening for a more precise identification of the allergen and increase chances for a successful desensitization. method: the observational study includes patients who presented on october for testing with standardized allergen extracts, as recommended. criteria for inclusion: patients with specific symptoms of rhinoconjunctivitis in august and september, with or without asthma symptoms, who returned for allergic prick test after the end of treatment. criteria for exclusion: patients who disagreed with cutaneous testing, who did not discontinue antihistamine treatment or who had been treated for other diseases with drugs that influence skin testing. background: in recent years, cationic liposomes are thought to be the most effective and non-toxical nucleic acids`transport system, so most of gene therapy drugs are developed on their base. however, lipoplexes are quickly captured by reticuloendothelial system cells after the injection and taken out of a blood stream. there are many modification methods of liposomal surface for liposomes with prolonged pharmacokinetic properties production. addition of hydrophilic polymers (peg) is seemed to be the most promising approach, that is able not only to create steric barrier on the particle`s surface and prevent the interaction with blood plasma lipoproteins, but also inhibits the protein adsorption, opsonisation and subsequent degradation in human body. the aim of this study is the evaluation of liposomal surface modification by hydrophilic polymers influence on nucleic acids`lipoplexes conjugation and on their physico-chemical and biological properties. method: liposomes preparation (including peg-modified liposomes), size determination by photon-correlation spectroscopy, examination of transfection efficacy by luciferase assay. (c h ) ) were obtained. also the modified liposomes were produced by addition of % of peg (by mass) during thin lipid layer preparation step. the size distribution was analysed by photon-correlation spectroscopy. it was shown that peg addition does not increase the par- conclusion: it can be noted that addition of peg can change the lipoplex formation but the cationic liposomes still remain an effective rna delivery system. and peg modification will be able to impart prolonged properties for the vehicle in bloodstream. foundation (grant № - - ). ory c may cause a cross reaction with fel d (cat), can f (dog), equ c (horse), mus m (mouse) and rat n (rat). february eight patients that were treated at our institution were diagnosed with rabbit allergy. results: all eight patients with the diagnosis of rabbit allergy presented with signs of upper respiratory involvement. two patients had itching teary eyes, watery nasal discharge and sneezing while feeding farm rabbits. one of those also presented with dyspnea. four patients developed problems whenever in contact with domestic rabbits. one patient developed allergic rhinoconjunctivitis whenever she was home-her parents own a rabbit, but while away in her college room she had no problems. another patient had dyspnea whenever visiting his girlfriend's house. she owned a rabbit. two patients developed asthma-like symptoms, one also presented with angioedema. the other two had developed allergic rhinoconjunctivitis. two patients have problems in contact with cats, one of them also with cows, however skin prick tests were also positive to rabbit. three out of eight patients developed allergic asthma with a positive methacholine test. six patients had a positive house dust mite prick test. all patients were diagnosed with a positive prick tests to rabbit allergens. all were treated with a nasal steroid and antihistaminesic. they were also advised to avoid contact with the animal. conclusion: domestic rabbit-induced asthma and/or allergic rhinoconjunctivitis is possible, however it is still rare in our environment. it is very important to always ask the patient about their pets in general, not just focusing on cats or dogs. only with a thorough examination and history we can find the true cause of the patient's allergy where pets play an important role. korea. changes of protein and major allergen concentration were measured over one year by bradford assay, two-site elsia, and sds-page after reconstitution of the lyophilized allergen extracts in various buffer (normal saline, . % phenol saline, and or % glycerol with saline) and stored at room temperature (rt, ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) or refrigerated ( °c). results: more than % of the initial protein concentration in all four extracts examined was detected over one year when % glycerol was added and refrigerated, whereas . %- . % remained in the extracts at rt. the addition of % glycerol to the storage buffer was found to prevent protein degradation at rt. all four extracts were found to be stable when reconstituted in % glycerol. amb a , a major allergen of ragweed, was almost completely degraded in weeks at rt when reconstituted in a buffer without % glycerol. however, . %- . % of amb a content was detected after one year of incubation at °c in all buffer conditions except . % phenol. conclusion: addition of % glycerol as well as refrigeration was found to be the important to increase the shelf-life of allergen extracts from pollens of allergenic importance. results: this is the first genetic study of the bulgarian hae patients. genetic defects were identified in hae families are: nonsense, splice-site defects, frameshift mutations, indel non frameshift, missense, and large deletion of exon . novel mutations, not previously reported in human gene mutation databases were discovered, and were predicted to be deleterious due to the expected effect on dna transcript and protein. descriptive statistics were used to summarize the eq- d-y descriptive system responses and vas scores by treatment and visit. results: twelve patients with hae type i and a median (range) age of . ( ) ( ) ( ) ( ) ( ) years were enrolled, ( . %) of whom were female. during bop, treatment with u c inh, and u c -inh, ≤ . %, ≤ . %, and none of the patients, respectively, reported having problems with mobility, self-care, doing usual activities, pain or discomfort, and feeling worried, sad or unhappy. the mean [sd] eq- d vas scores increased from . ( . results: overall, the model-derived median exposure and peak concentration across all weight ranges in paediatric patients is predicted to be higher with wb vs weight-based dosing (table) . the effect was most pronounced in patients aged - years, where the wb dosing achieved approximately % higher values than weight-based dosing for median auc - ( ng hour/ml vs ng hour/ml, respectively) and c max values ( ng/ml vs ng/ml, respectively). the wb levels are closer to those in adults receiving mg icatibant (median auc - ng hour/ml; median c max ng/ ml) but never exceed them. results: samples from patients were analysed. lanadelumab concentrations in plasma increased with higher doses and dosing frequencies. steady state was reached around week (range week to week as evaluated by predose concentrations). at baseline, mean (sd) chmwk levels were . % ( . ), . % ( . ), . % ( . ) and . % ( . ) for patients in the placebo and lanadelumab mg q wks, mg q wks and mg q wks treatment arms, respectively. by week , mean (sd) chmwk levels decreased to . % ( . ), . % ( . ), and . % ( . ) following treatment with lanadelumab mg q wks, mg q wks, and mg q wks, respectively, and remained reduced throughout the treatment period. conversely, chmwk levels remained elevated at . % ( . ) at week in patients who received placebo. patients in the placebo group had the highest attack rates over the -week treatment period (mean . attacks/month), whereas the rates were markedly lower in patients treated with lanadelumab mg q wks ( . attacks/month), mg q wks ( . attacks/month) and mg q wks ( . attacks/month). dose-and frequency-dependent manner. exposure to lanadelumab was associated with decreased chmwk levels (indicating inhibition of plasma kallikrein activity) and lower hae attack rates, corroborating the efficacy findings and utility of chmwk as a bioactivity marker in the help study. with cyklokapron (tranexamic acid) since she was years old and took the medication very irregularly due to lack of efficacy. one year before presentation at our clinic, she married and moved to vienna. we started a treatment with the bradykinin- receptorantagonist icatibant sc at the beginning of the menses and if needed a second time at the time of ovulation. she responded well until she got pregnant. during pregnancy, she developed weekly attacks with increasing severity. therefore, a weekly treatment with humanplasma-derived, pasteurized, nanofiltered c -inhibitor (inh)-concentrate, units iv once a week was started and had to be increased to twice per week after one month of therapy due to increasing number and severity of attacks. results: with this treatment attack frequency and severity attenuated. in january she had a normal delivery at term and gave birth to an otherwise healthy son. treatment had to be continued during year of lactation period and also thereafter due to persistent attack severity. conclusion: there are only limited data for the use of humanplasma-derived, pasteurized, nanofiltered c -inh concentrate during pregnancy and lactation period. this case confirms the safety and efficacy of the named drug during these periods. wheals are yet classified. the best characterized stem from hereditary or acquired c inhibitor deficiency (c -inh-hae and c -inh-aae) . last year, the french angioedema network (creak) joined the registry of angioedema without wheals (cloud-r hae). here we present the contribution of the grenoble alpes university hospital (chuga) to this disease registry. the study population is composed of patients with a proved diagnosis of c -inh-hae/aae. the following items are collected: patients' personal-demographic data, clinical/laboratory/genetic characteristics, major comorbidities, treatments (prophylaxis/acute attacks). data from existing registries at chuga are merged into cloud-r hae and missing data obtained at follow-up visits. as from cloud-r hae structure, patients can directly provide information on angioedema attacks and their treatment through a dedicated electronic app, web connection or paper support, which is then transferred into the registry at chuga. method: in a retrospective study, we included a total number of patients, suffering from a chronic skin disease, whose lesions did not improve or even worsened under immunosuppressive treatment ( chronic ulcers/pyoderma gangrenosum, bullous autoimmune diseases, skin lymphomas). ffpe tissue was examined for the presence of cmv dna by pcr. next, within the framework of a small prospective study (n = ) we analyzed the seroprevalence of cmv as well as the presence of cmv dna in lesional skin in patients that had been diagnosed with a chronic skin disease and in whom longterm immunosuppressive therapy had been initiated. results: in the retrospective study cmv dna could only be detected in / chronic ulcers/pyoderma gangrenosum ( . %), but not in bullous autoimmune diseases and skin lymphomas. / patients ( . %) of the prospective study group were seropositive for anti-cmv-igg, as compared to / patients ( . %) in an ageand sex-matched control group. anti-cmv-igm could be detected in method: in this study, we aimed at testing the diagnostic potential of skin function measurements in ss. sixteen patients with conformed diagnosis ss were enrolled in the study. skin fibrosis was assessed by conventional rss and involvement of inner organs and serum inflammation parameters were determined. four objective criteria, namely transepidermal water loss (tewl), corneometry, ph and elasticity, were assessed at nine predefined sites of the body. results were compared to patients with atopic dermatitis (n = ) and acne vulgaris (n = ). method: a multicenter prospective observational study was conducted to investigate the clinical significance of serum scca in children as a biomarker for ad. patients with ad younger than years old and age-matched healthy children without any allergic disease were enrolled in this study. the severity of ad was evaluated using the objective scorad (o-scorad). the serum levels of scca , tarc and total ige were also measured. results: in total, patients with ad and non-allergic healthy children were recruited. the serum levels of scca had the strongest significant correlation with o-scorad, compared with tarc and ige (r = . , and . , respectively). after standard treatment with topical steroids and emollients resulting in an improvement of symptoms, the serum levels of scca and tarc decreased significantly. the area under the curve (auc) for the roc curve was higher for scca ( . ) than for tarc ( . ) or ige ( . ). the difference in aucs between a single cut-off value and age-dependent cut-off values was not significant for scca , compared with that for tarc ( . and . , respectively). conclusion: scca is a more reliable biomarker than tarc for the diagnosis of ad and for determining the clinical severity of ad in children. challenges in predicting severity of atopic eczema patients results: before modeling, we checked for significant differences between patients and controls. these were detected for the levels of ccl , ccl , cxcl , ige and ldh. next, we assessed whether single serum proteins already explain disease severity by calculating correlations. twelve of the proteins, namely gcsf, il- , il- , il- , ccl , il- ra, cxcl , ifng, ccl , il- ß, ccl , and il- , significantly correlate with severity (r range: . - . ). finally, we built a model for the severity of ae based on all measured serum proteins. ten of the proteins are included in the best-fit model (adjusted r = . ). the overall correlation between original and predicted severity scores is high (r = . ) nevertheless the cross validation prediction error is substantial with %. conclusion: applied in daily practice, a prediction error of % translates to a possible miscalculation of scorad points in both directions and therefore the model is of no practical use. aside from using model-based quality measures like cross validation prediction errors to infer the usefulness of predictive models, testing them in independent cohorts could validate these models. collaborations among scientists working on similar approaches would lead to an increase in statistical power and ideally to more robust models. only robust and validated models are going to have the chance to take the step forward from being a result of computational modeling to being applied in the clinical practice of assessing disease severity in patients. jargosch m ; lauffer f ; pätzold k ; krause l ; garzorz-stark n ; schmidt-weber c ; eyerich s ; eyerich k preclinical studies in cell cultures, mice, guinea pigs and rabbits, comprising sterility, cytotoxicity, systemic toxicity, skin irritation, delay contact sensitization and phototoxicity tests, demonstrated safety of this therapeutic agent. we next conducted a single-blinded, intra-individually controlled, phased clinical trial on patients with keloids. the aim was to determine the effects of -month therapy on keloid volume and symptoms of pain and itch. two similar keloids on each subject were selectedone was treated with once-daily, self-administered application of triamcinolone-loaded ( . mg/patch) microneedles for weeks, while the other served as control with no intervention. outcome measures were (a) keloid volume using a -dimensional high-resolution ( . mm) scanner and (b) pain and itch scores on - numerical rating scales. evaluations were performed at baseline, and weeks. in phase of the trial, the whole process was repeated using microneedles loaded with a higher dose of triamcinolone ( . mg/patch). case report: a -year-old girl was admitted to our department with a single round-shaped lesion in the popliteal fossa which spread to extremities, trunk and face and persisted for several weeks and then faded slowly to residual hyperpigmented patches. courses of antihistamines, antibiotics, cyclosporine a, fluconazole, hydroxychloroquine, prednisolone and topical steroids were ineffective. also patient has had history of itchy urticarial rash and angioedema since -year-old, suffered from the flares triggered by physical exertion, stress, cold air and water, spicy food, which resolved within - hours. the patient's father and -year-old brother also had chronic urticaria induced by the same stimuli. the physical examination revealed multiple pink-to-red non-scaly, non-pruritic papules coalescing into annular, arcuate, polycyclic plaques ( - cm) with central clearing, centrifugal spread, indu- | the role of humoral immunity in the pathogenesis of psoriasis results: we found significantly increased levels of iga in the serum of treatment-naïve psoriasis patients correlating with disease score. however, iga was only observed in dermal vessels of skin sections. we next performed in-depth analysis of peripheral b cell subsets using flow cytometry. among all investigated subsets, we only found a moderate positive correlation of cd + plasma cells with iga levels and disease score in untreated psoriasis patients. however, in the group of treated psoriasis patients, neither did iga levels drop nor did plasma cells correlate with iga levels and disease score, rather hinting at an epiphenomenal finding. confirming our hypothesis that psoriasis can develop in the absence of proper humoral immunity, we present a patient who suffered concomitantly from both psoriasis and a hereditary common variable immune defect (cvid). conclusion: here, we provide new insights in the immunology of psoriasis, demonstrating the clear dominance of t cells over shifts in b cell subsets. conclusion: allergic diseases show an increasing incidence in geriatric age. this is partly due to the growing emphasis on a more accurate and careful diagnosis of the aging population. we must also take into consideration the influence of other factors, besides comorbidities and therapeutic regimens in elderly that might affects the immune response, such as environmental pollution as well as food contamination and changing dietary habits of elderly such as easy access to exotic food. one of the challenges in the decades to come is recognizing and fulfilling the need for accurate and timely diagnostics of allergic manifestations in elderly patients, as important part of achieving the best possible quality of life for this growing age group. method: sixty-eight patients with various forms of psoriasis and healthy subjects (healthy control group) were assessed after informed consent was obtained. all subjects were asked to complete a questionnaire including age, gender, duration of psoriasis, concomitant diseases and medications. in the group of patients psoriasis was with only skin involvement with skin plus joints involvement ranging from moderate to severe. psoriaticplaques were evaluated by a specialized medical team using the psoriasis area and severity index (pasi). all patients were seen by a dermatologist and clinical immunologist, who collected data considering the demographic, health status and any other relevant details. blood samples included serum levels of -hydroxycholecalciferol and tnf-α using an elisa kit (germany). method: % ethanolic extract of sp (sp etoh ) and its five major chemical constituents are prepared. to elucidate whether human orai modulated by sp etoh and its chemical constituents, conventional whole-cell patch clamp performed in horai -overexpressing hek t cell. we also assessed whether sp etoh and its constituents could inhibit mast cell degranulation and t cell activation. results: in jurkat t lymphocytes, we found that mg/ml sp etoh inhibited orai current (i orai ) by . ± . %, while one of its constituents (compound v (com v ); μm) inhibited i oria by . ± . %. investigation of human primary t cell proliferation induced by co-stimulation with antibodies to cluster of differentiation and , and of rbl- h mast cell degranulation following ige-antigen complex stimulation, revealed that μm com v inhibited both t cell proliferation (by . ± . %) and mast cell degranulation (by . ± . %); these effects were concentrationdependent, and no cytotoxicity was observed. conclusion: considering that most regional plants have not been investigated chemically or pharmaceutically, they remain as untapped potential sources of topical agents for drugs and other application. our findings suggest that com v , which derived from sp etoh , represents a promising candidate compound for the development of therapeutic agents for the prevention and treatment of allergic diseases. results: the cohort consists of caucasian patients. eight of them ( %) are women. the mean age (and range) at the clinical presentation of disease was years ( - years). the mean age at diagnosis for men was years and years for women. all patients have a positive history of recurrent and/or persistent lip swelling, of them ( %) report oral ulceration, cases ( %) have history of previous or current facial palsy and patients ( %) present tongue fissuring. concurrent cd has been diagnosed in one patient. biopsy reports were available for patients ( %); in cases ( %) non-caseating granulomas were seen. various therapeutic approaches have been described: intralesional corticosteroids had a good response in patients, infliximab was partially effective in cases; oral corticosteroids and/or methotrexate seem to cause a partial symptoms improvement. conclusion: this is the first attempt, in our knowledge, to (a) centralize all data of patients with ofg in a national registry with the aim of carrying out epidemiological data and (b) develop italian guidelines including a diagnostic-therapeutic flow chart, shared by the participating centers. the registry will guide the clinicians in the identification and management of the ofg patients, reducing the diagnostic delay and hopefully improving quality of life. case report: a -year-old girl without personal history of atopy, got a temporary tattoo with henna. after three days, she developed a local exudative, erythematous eruption with painful blisters lesions that followed the contours of the tattoo. she had neither fever nor other lesions. she was treated with topic methylprednisolone-gentamicin showing an important improvement days after. as a liquenoid scar remained in tattoo area, trofolastin ® (centella asiatica, αtocopherol, hydrolysed collagen, elastin) patch was prescribed to be placed on the scar. forty-eight hours later, the patch was removed and was newly observed an exudative, erythematous and painful wound that required oral treatment with amoxicillin-clavulanic. after three days, the girl developed on a maculopapular, generalized and itching rash. she was treated with dexchlorpheniramine and methylprednisolone with a complete resolution in days and she was referred to our allergy unit to be studied because of a suspicion of drug allergy to amoxicillin-clavulanic acid. an allergy workup was performed after obtaining an informed consent. case report: it may be sometimes difficult to find the causing allergen in allergic contact dermatitis. face is a region on which various materials contact. in this manuscript a woman case is presented who shows patch test positivity to her husband's shaving product. a years old woman applied because of allergic contact dermatitis on her face. it is learnt that lesions have been continuing for a long time, occasionally getting well with corticosteroid creams; but continuing again. patch test was performed with european standard series and cosmetic products she was using. negative result was observed. following, patch test was performed for the products her husband was using. positive results were obtained for the shaving cream of her husband was using. in detailed anamnesis, it is learnt that the lesions developed approximately month after her husband started to use this cream. it is advised not to use this product to her husband. the disease did not repeat again. it should not be forgotten that cases with allergic contact dermatitis could get in touch with allergenic materials via individuals in close contact. gül Ü akdeniz university faculty of medicine, department of dermatology, antalya, turkey case report: tnf-alpha plays role in etiopathogenesis of allergic contact dermatitis (acd). in mice which lack tnf-alpha, the response of late type hypersensitivity is spoiled. in addition, tnfalpha blocker are also used in some cases with acd. in this poster the results of european standard patch test is given in which acd is observed and tnf-alpha blocker are used without dermatological indication. cases who use tnf-alpha blocker applied because of acd: there was lesion in one case on face, in other case on face and hand, and in the last case only on hand. european standard patch test was performed to patients who were continuing to use tnf-alpha blocker. in one case no positive response was observed, while in two cases positive response to more than one allergen were obtained. in conclusion, tnf-alpha blockages cannot suppress the response of delayed type hypersensitivity. | case of allergy to nickel on the background of its intake in food peredelskaya m case report: nickel is one of the most commonly used metals; it is used for the manufacture of jewelry, plates and dishes, and medical products. a patient n, years old, female, complains of pruritic rash on the body skin with the itch intensity up to - points and the number of lesions more than . allergic background: for quite some time now the patient noted occasional eruptions on her skin after a contact with jewelry made of non-precious metals. previously patch skin tests with nickel showed a positive reaction. the patient sought emergency medical care with complaints of a number of itchy lesions erupted on her whole body during the last hours. on admittance: state of moderate severity, the patient was emotionally labile, focused on her body sensations, tearful. on the skin of face, upper and lower extremities and torso a punctuate purpura with lesions up to . cm diameter, prone to confluent. a physical status was within normal limits. in order to control the itching, as well as to sedate the patient, antihistamines of the first generation were administrated parenterally; but the eruptions kept to progress and to intensify; lesions were spread throughout the whole body, merged in gigantic areas. system glucocorticosteroids therapy was administrated, with mg of prednisolone, but then new lesions kept appearing in a large number, including after-meal rash. water, tea, bakery products, thin yoghurts did not impact the skin condition, whereas the intake of pasta, cereals, and similar products provoked intensifying of eruptions. the patient observation revealed a sharp increase in the rash after such manipulations as intravenous injections or blood sampling from the vein, the process spreading from the injection site to the entire arm. a detailed anamnesis of the disease: on the eve of the start of hives, the patient purchased a coffee machine (with metal nickel-plated parts) and started to use it. diagnosis: a systemic contact dermatitis. an allergy to nickel. the injection treatment was discontinued and a therapy with per oral gcs and antihistamines of the second generation was administrated. a recommendation was given to cook and to eat food using ceramic or wooden utensils. three days later marked positive dynamics of the skin process has been noted. the episode of systemic contact dermatitis has developed due to exposure to nickel from ingestion in food, as well as during the parenteral treatment. background: anaphylaxis reactions during anesthesia can have a mortality of %- %. / of the anaphylaxis in the operating room are due to the use of neuromuscular blockers. rocuronium is frequently involved because is oftenly used. we present a case of a years old man with an anaphylaxis shock due to the administration of rocuronium. method: years old man with no personal history of interest that is going to undergo vertebral surgery. minutes after anesthetic induction with fentanyl, propofol and rocuronium he started with lowering of oxygen saturation. orotracheal intubation is performed and, with the suspicion of anaphylaxis shock, adrenaline, antihistamines and corticoids were administered. after minutes without improvement, mg of sugammadex was administered, given the possibility that the condition was secondary to the use of rocuronium. tryptasa level was . results: skin test to fentanyl, propofol, látex and rocuronium were done weeks after and only rocuronium test was positive. conclusion: in summary, the occurrence of anaphylactic shock after neuromuscular blockers is widely described in medical literature. there are conflicting data about the use of sugammadex as coadjutant treatment in case of anaphylaxis due to the use of rocuronium. we believe is a good option when conventional treatment is not useful. case report: a -year-old woman with past history of allergic rhinitis and hypertension was admitted to the obstetrics service in labor of first child in april . epidural anesthesia with ropivacain and sufentanil was administered. as there was no labor progression, eighteen hours later she was admitted to undergo cesarean section and epidural anesthesia was re-administered. metoclopramide, ampicilin and ranitidine were given intravenously. during ranitidine perfusion, the patient presented general cutaneous erythema and pruritus, tongue, lips and eyelids angioedema and dyspnea. perfusion was suspended and hydrocortisone and supplementary oxygen administered. she denied any type of previous adverse reaction to drugs and any symptoms with use of latex-containing material. allergic evaluation revealed negative latex skin prick test (spt) and negative penicillin, amoxicillin and ampicillin specific ige assay. skin prick and intradermal tests with sufentanil, ppl, mdm, amoxicillin and ampicilin were negative. oral amoxicilin and metoclopramide provocation challenge were negative. spt and subcutaneous provocation challenge with ropivacain were negative. spt with ranitidine was negative but skin intradermal test proved to be positive. the patient was taught to avoid histamine h receptor antagonists and use as a safe alternative proton pump inhibitors. conclusion: anaphylaxis during anesthesia is an unpredictable, severe, and rare reaction. the identification of responsible drugs is a complex task. we report a case in which a commonly used and generally safe drug caused a severe reaction, which demonstrated that even the least obvious culprit should not be disregarded. epidemiologic data suggest that the number of cases of chx allergy appears to be increasing. background: chlorhexidine is a synthetic chemical with excellent antiseptic and disinfectant quality frequently used in everyday products and medical devices. the prevalence of allergic reactions towards chlorhexidine is rare, though there is increasing evidence for its allergenic potential. in this case we report about a patient with serious perioperative anaphylaxis. next to multiple potential allergens that he was exposed to, a chlorhexidine containing lubrication gel has been used for urinary catheterisation. within minutes post-exposure, the patient developed generalized urticaria, bronchospasm, tachycardia and hypotension. material and methods: we performed skin prick tests and intradermal tests with all substances documented in the anaesthesia chart, further we analysed specific immunoglobulin e (sige) antibodies and performed oral provocation challenges for exclusion. results: in the skin tests all substances except for chlorhexidine (spt: mm wheal diameter/ mm erythema) were negative. a sensitization for chlorhexidine was further corroborated by chlorhexidine-specific ige antibody ( . ku/l) in the patient's serum. in addition, the challenges for the drugs without sensitization (cefuroxime, lidocaine) were tolerated. considering all potentially relevant allergens that the patient was exposed to and the proof of specific sensitization, we diagnosed an immediate-type allergy towards chlorhexidine. conclusion: with the ubiquitous use of chlorhexidine an increase in hypersensitivity reactions including immediate-type allergic reactions is observed. anaphylactic reactions are rare, but potentially life-threatening, the diagnosis is crucial. as a warning declaration in medical devices is missing, the diagnosis of chlorhexidine allergy might be easily under-recognized or misdiagnosed. unfortunately, until now validated provocation tests are not existent, but the evaluation of combined skin tests and sige is sensitive and specific. | an approach to incidence of death due to anaphylaxis in spain ( spain ( - background: reports about death due to anaphylaxis are still scarce because of its rarity and limited information to few countries. also, data source analysis is usually not included. we report incidence of death due to anaphylaxis in spain using two databases. method: we used a hospital series of anaphylaxis deaths from the spanish hospital system and a series from the national institute of toxicology and forensic sciences (intcf) predominantly formed by extra-hospital deaths. deaths from the spanish hospital system were extracted using codes from icd- -cm, related to anaphylaxis among all deaths occured in the - period. for extracting deaths due to anaphylaxis at the intcf in the same period, two allergist researchers identified these deaths among cases with suspicion of anaphylaxis cause. a regression logistic was run to discriminate the probability of anaphylaxis death belonging to each database. incidence rates were calculated for the different groups (age, sex) using the spanish population as the denominator. temporal trends were calculated from the hospital database using poisson regression models with the number of cases of anaphylaxis detected each year as the dependent variable, and age and sex as covariates. results: there were four positive predictors of fatal anaphylaxis after the logistic model (usual allergen, positive specific ige, suggestive symptoms and previous reaction to the same allergen case report: we were informed that a girl was admitted to the pediatric endocrinology department due to early breast development. she had been diagnosed as central precocious puberty (pp). later, triptorelin acetate (ta) therapy had been started monthly. within minutes after first sc injection of ta at home, she had developed shortness of breath, decreased air entry, and coughing for ten minutes and lastly she had developed vomiting for minutes. her symptoms were accompanied by a pruritic blanchable maculopapular rash on her ears, cheeks, lips, and eyelids approximately for two hours. although they had applied emergency department of the local hospital. based on the diagnosis of anaphylaxis she was immediately treated with adrenalin. she was subsequently hospitalized for possible recurrence and discharged next day without any further events. treatment with another preparation, leuprolide aseptate(la-lucrin), as an alternative treatment was started with premedication against anaphylaxis risk only at first time and the patient did not develop any reactions. the patient is still on this treatment with no complications. anaphylaxis is diagnosed in the presence of a detectable allergen accompanied by symptoms of two systems. our patient had symptoms of the three systems as described above, that is, dyspnea with coughing, hives, nausea, and vomiting. main treatment of anaphylaxis is the epinephrine use. early usage maximizes the likelihood of survival. diagnostic tests with culprit drug were not performed in our hospital if the patient had the anaphylactic drug reaction and grouped as "physician diagnosed anaphylaxis". there has been only one report regarding anaphylaxis to ta treatment in cpp in turkey. in the literature, anaphylactic reactions against ta have been reported only in few pediatric cases. gnrh analogues are important to ensure the physiological growth in precocious puberty. because anaphylaxis can be lethal, and gnrh analogues are similar structure; the present case suggests that one should bear in mind the possibility of anaphylaxis in all patients who receive gonadotropin-releasing hormone and anologs and monitor such patients carefully as needed. furthermore, we must provide sufficient information of adverse reactions, including anaphylaxis, to patients. hence, managements against anaphylactic shocks should be recognized and treatment should be given immediately. | an anaphylactic shock induced by the rocuronium anesthesia: a case report cabrera v; barrios j; callero a; gonzález ce; pérez e; martínez ja hospital universitario nuestra sra de la candelaria, santa cruz, spain background: the anesthetic act is a unique pharmacological situation, where the patient is exposed to a multitude of substances.among them, neuromuscular blocking agents are the leading cause of preanesthetic anaphylaxis, with a frequency of between %- %.followed by latex in second place and antibiotics in third place. among the neuromuscular relaxants, most reactions are due to suxamethonium or succinyl-choline in . %, followed by atracurium, rocuronium and verocuronium.the one that produces the least reactions is cisatracurium. method: a -year-old woman presented a type iii anaphylaxis of the brown classification during the anesthetic induction in a surgery scheduled for laparoscopic cholecystectomy. for which adrenaline, dexchlorpheniramine, hydrocortisone, ranitidine and sugammadex was administered and was transferred with orotracheal intubation to the anesthetic resuscitation room. due to good evolution of the patient, she was extubated within three hours. the drugs involved in the reaction were: rocuronium, amoxicillin-clavulanic, fentanyl, propofol, midazolam, lidocaine and atropine. there was a high suspicion by the anesthesiology and resuscitation service that the abstracts reaction could have been due to the neuromuscular relaxant used, in this case rocuronium, since the reaction was reversed with sugammadex. the patient had undergone surgeries under general anesthesia previously without incidents. a specific allergy study was performed with laboratory tests with tryptase, skin tests with drugs and basophil activation test for rocuronium, sugammadex-rocuronium mixture and cisatracurium. • serial measurement of serum tryptase: . u/l, . u/l y . u/l there is no activation of basophils for sugammadex-rocuronium mixture and cisatracurium. the patient is diagnosed with rocuronium allergy. sugammadex not only acts as an antidote to reverse the neuromuscular block against rocuronium, but also has antiallergic properties by inhibiting mast cells. as an alternative for future interventions, the patient can use cisatracurium, as the skin tests and the basophil activation test are negative. unal d yedikule chest disease, istanbul, turkey case report: tetracycline hydrochloride may rarely cause hypersensitivity reactions. (hrs). immediate type reactions are at the level of case presentations and anaphylaxis is reported. we report a patient with late onset anaphylaxis caused by tetracycline. a -year-old woman referred to our allergy outpatient clinic because of urticaria due to an antibiotic that she does not remember the name of. the patient reported that many years before she had presented urticaria on her arms and legs one hour after taking the drug. to confirm drug allergy invivo and invitro testing have to performed. for many drugs there was no validated skin test. for all that invitro tests are often less sensitive and more expensive. therefore single blind placebo controlled drug provocation tests (sbpcdpt) is the gold standard in the diagnosis of drug hypersensitivity reactions. we did not know which group of antibiotics were allergy to the patient. because the patient had history of asthma and atypical pneumonia we were performed the allergy tests with clarithromycin and she had tolerated. it was necessary to use tetracycline because of patient had vaginal infection. skin tests have not yet been validated for tetracyclines. for skin prick tests of tetracycline that is only available as tablet, not in a soluble form. therefore, the tablet was smashed and diluted with . % nacl. it was also tested. healthy controls to exclude irritation. because of skin prick tests with tetracycline negative. sbpcdpt was planned. sbpcdpt was performed by progressively increasing four divided doses at minute intervals. two hours after last dose the patient experienced dyspnea, palpitations, and hypotension. as the reaction was considered to be anaphylaxis, she was given . mg of intramuscular epinephrine, intravenous mg of pheniramine, and mg of methylprednisolone. the reaction resolved within hours. blood tryptase level was . ug/l taken at the nd hour of the reaction approximately months after the anaphylaxis, serum tryptase level was . ug/l the serum tryptase level and the patient's clinic confirmed anaphylaxis due to tetracycline. we had proved late onset anaphylaxis due to tetracycline with the patient's clinic and serum tryptase level. anaphylaxis due to tetracycline is limited to case reports and small series but to our knowledge, there is no previous report of late onset tetracycline anaphylaxis. | case series of ige mediated anaphylactic shock due to polysorbate case : an -year-old male patient with hypertension, hypothyroidism and episodes of sustained monomorphic ventricular tachycardia (smvt), developed an anaphylactic shock after the administration of injectable amiodarone due to smvt. serum tryptase levels reached . μg/l during the reaction (baseline . μg/ l). skin tests were positive to injectable amiodarone (prick mg/ ml, intradermal . mg/ml) and polysorbate and (prick-prick). skin prick-prick to amiodarone and dronedarone tablets were negative. the patient tolerated oral amiodarone. we report an anaphylactic reaction during the first intravenous administration of amiodarone in a female patient being treated for supraventricular tachycardia. bat was positive, suggesting a direct effect on basophil activation, as the patient was not previously exposed to the drug. | anaphylaxis during labor: don't forget to think of an amniotic fluid embolism case report: a -year old primigravida ( weeks of gestational age) was admitted with signs of pre-eclampsia and labor was induced. benzylpenicillin and ropivacaine (epidural anesthesia) was administered > hours before the event. eighteen minutes after starting an infusion with oxytocin ( ml/h) and a vaginal toucher, the patient developed a decreased level of consciousness, generalized edema/erythema and thoracic pain, followed within minutes by fetal bradycardia and maternal collapse. after resuscitation, an urgent sectio was performed, and a baby girl was born. patient was extubated the same day. serum tryptase, hours after the event, was . μg/l (basal tryptase level . μg/l). allergy workup demonstrated negative specific ige and skin tests for latex and chlorhexidine, negative skin and provocation testing for ropivacain. however, skin testing was hampered by dermographism: intradermal (idr) testing of benzylpenicillin ( iu/ml, / - / ) and oxytocin ( ie/ml, / - / ) showed extensive erythema. idr testing of oxytocin in healthy volunteers showed pallor around the injection site (n = ). intravenous provocation with benzylpenicillin was uneventful. a basophil activation test with oxytocin (patient and control) was negative. an additional bone marrow evaluation showed no evidence for mastocytosis. although clinical criteria for anaphylaxis were fulfilled, a diagnosis of an amniotic fluid embolism (afe) was concluded. no drugs were prohibited. patient gave consent for publication. conclusions: afe is one of the most devastating conditions in obstetrics, occurring typically during labor and delivery or immediately postpartum. the pathogenesis remains incompletely understood, however, it has been suggested that afe involves an anaphylactic reaction to fetal tissue exposure associated with breaches of the maternal-fetal physiological barrier, supported by transiently increased serum tryptase levels. the diagnosis is primarily clinical, and generally one of exclusion. no specific antemortem diagnostic tests are available to confirm afe. postmortem identification of fetal squames in the maternal pulmonary circulation gives final diagnosis. differential diagnosis includes drug-induced anaphylaxis or mastocytosis, which were ruled out in our case. method: the patient presented after hymenoptera stings dyspnoea, generalized erythema with pruritus, edema of the face that required emergency therapy in episodes. results: an angio-ct was performed at the inferior limbs with optiray and minutes after the end of the investigation, the patient presented an anaphylactic shock requiring admission to the icu for days. conclusion: the patient's progression was slowly favorable. results: thirty seven cases were reported. ( %) were women. the median age was years. ( %) had dress/dihs, ( %) ten, ( %) sjs, ( %) agep, ( %) other not classified scars, and ( . %) overlapping ten/sjs. in % of the patients the suspect drug was withdrawn. thirty one patients ( %) received systemic anti-inflammatory treatment. twenty six patients ( %) received intravenous (iv) corticosteroids alone, ( %) iv corticosteroids plus ivig, ( . %) iv corticosteroids plus ivig, infliximab and colchicine, and ( . %) iv corticosteroids plus infliximab and cyclosporin. there were complications in cases ( %), and death occurred in the patient with overlapping ten/sjs who had received corticosteroids plus immunoglobulin. in this study, our aim was to evaluate severe ihr to icm. method: we retrospectively analysed patient who consulted to our allergy unit between july and july reporting symptoms within hour after icm administration. from a total of patients, we selected eight that had suffered an anaphylactic reaction. a written informed consent had been obtained for diagnostic procedures. introduction: immediate type hypersensitivity reactions to pemetrexed have been reported as very rare case reports. as limited availability of alternative therapies in chemotherapeutic allergy, desensitization plays an important role in ensuring reuse of the culprit drug. we report a case of pemetrexed anaphylaxis and successful desensitization. case: years old female patient with lung adenocarcinoma had been treated with cisplatin-pemetrexed as second-line therapy. during the th cycle within minutes after the end of pemetrexed infusion she had chest pain, shortness of breath, cough, swallowing difficulty, erythema on face and body, nausea and vomiting. she was diagnosed as anaphylaxis and adrenaline was administered besides antihistamine and methylprednisolone. symptoms and findings of the patient were improved within minutes. oncologists decelerated no suitable alternative therapy for the patient. although skin tests (prick test with / concentration, intradermal test with / - / concentration) were negative with pemetrexed, taking into account the severity of the reaction, pemetrexed desensitization was applied with the consent of the patient. no reaction was observed during the procedure result: desensitization is a successful and safe method of reusing the culprit drug. successful desensitization of pemetrexed with immediate type hypersensitivity reaction is described. the years old man was admitted emergency department with fever, rash (maculo-papular) and pain in joints. it was the th day of taking of amoxicillin. the hematological abnormalities were revealed -eosinophilia, increased erythrocytes sedimentation rate. the level of serum ecp was μg/l. the liver functional tests were increased too. hepatomegaly and cervical lymphadenopathy were observed. the patient was treated as a dress syndrome (infusion therapy, systemic steroids) and discharged after weeks with improvement. all hematologic parameters were in normal limits. lymphadenopathies were resolved. the level of ecp was retaken - μg/l. patient was prescribed oral steroids till normalization of limits of ecp. it lasted weeks after discharging. the serum level of ecp can play key role in the management of dress syndrome and in the making of diagnostic processes. until now, allergic or anaphylactic reactions to peg have been rarely reported. although patient with hypersensitivity to peg should avoid peg-containing drugs or products, patient who needs colonoscopy has few alternative bowel cleansing methods. no successful desensitization to peg has been reported to date. we report a case of successful desensitization and subsequent safe colonoscopic examination in patient with allergic reaction to peg. method: a -year-old woman developed generalized urticaria, pruritus, throat swelling, and shortness of breath immediately after taking a bowel preparation solution for colonoscopy. she had the first symptoms years ago, and has had more experiences so far. the symptoms appeared within - minutes of taking cleansing solution, and the endoscopy was no longer possible. seven years ago, she underwent endoscopy with no specific symptom. when the last symptom occurred a year ago, she was treated at emergency room because of severe dyspnea and dizziness. the patient came to our clinic for the proper diagnosis of allergy reaction and possible colonoscopic evaluation. objectives: to describe a successful desensitization to vedolizumab in one patient diagnosed with ulcerative colitis, refractory to infliximab and intolerant to azathioprine and sulfasalazine. methods: our patient was a year old woman receiving treatment with intravenous vedolizumab ( mg/cycle). cycles and were well tolerated, but in cycles , and she experienced hypotension and dyspnea, in spite of premedication with oral dexamethasone and metoclopramide. during cycle , she also showed facial angioedema, systemic urticarial reaction and oropharyngeal pruritus treated with methylprednisolone and ebastine. the results of prick (vedolizumab concentration mg/ml) and intradermal skin tests ( : and : ) with vedolizumab were negative in our patient and in ten healthy controls. total ige level was . ui/ml and specific ige against dermatophagoides were positive, being negative for hamster epithelium and latex. since vedolizumab was the only therapeutic alternative, the patient was planned to undergo vedolizumab desensitization according to an -step protocol. patient informed consent was obtained previously. premedication consisting of ebastine, acetylsalicylic acid, montelukast and methylprednisolone one hour before desensitization was administered. desensitization protocol was performed with a total duration of hours and minutes and a total dose of mg. dose steps were . , . , . , . , . , , and . mg. conclusions: our -step protocol desensitization to vedolizumab resulted safe and effective in our patient and it has allowed the continuation of treatment with vedolizumab for her ulcerative colitis. montelukast, anti h and h blockers were used for the pretreatment of desensitization. all procedures (skin and blood tests, desensitization) were carried out with the informed consent of the patient. we present an exceptional, non-immediate case of fever after cisplatin and etoposide infusion with positive skin test. case report: a -year-old man, recently diagnostic of lung cancer stadium iv, in first line of treatment with cisplatin and etoposide, started hours after finishing the nd infusion: facial erythema that becomes generalized after - hours from infusion. twelve hours later, developed warmth sensation, shivering and fever ( °c) that persisted despite the use of several oral antipyretics treatment. infectious disease was discarded, so he was referred to our department in order to assess further administration of cisplatin and etoposide. methodology: skin testing was performed days after the last reaction to minimize false-negative results, as follows (a) cisplatin prick test ( mg/ml) and intradermal tests ( . mg/ml); (b) etoposide prick test ( mg/ml) and intradermal tests ( mg/ml); with histamine as the positive control and nacl-diluent as the negative control. the results of skin test were negative for immediate reading. but two hours later, intradermal test for cisplatin turned into red and itchy and hours later, still associated a wheal. the patient was classified as high-risk (lung diseases, forced expiratory volume in second < l) and underwent programmed inpatient desensitization according to the standardized birmingham women's hospital protocol. desensitization was performed in the medical intensive care unit. the patient received only standard oncology premedication. he tolerated the final dose of cisplatin with no breakthrough reactions followed by etoposide standard infusion. two additional desensitization procedures were performed, with no breakthrough reactions. therapy ended when the disease worsened. the importance of this case, lies in the fact that fever has not been described as a clinical hypersensitivity reaction for cisplatin but for oxaliplatin. although a non-immediate reaction at the nd infusion of cisplatin could scarcely suggest a hypersensitivity reaction, the positive skin test and successful desensitization with this drug, could suggest it. introduction: propylthiouracil is commonly used as the first treatment option in patients with hyperthyroidism. although it is generally a well-tolerated drug, it may lead to some side effects including liver damage, leucopenia and skin rash. among skin rash findings, urticaria is considerably common. nevertheless, in cases that developed urticaria, a rapid desensitization protocol specific to propylthiouracil has not been encountered. we represented a case in which we applied successful oral desensitization via a scheme in accordance with general desensitization principles in a case that developed propylthiouracil-induced urticaria. case report: propylthiouracil at a dose of mg/day was initiated for a year-old female patient with diagnosis of hyperthyroidism in internal diseases clinic. the patient developed widespread itching and swelling in the body - hours after she took the first dose of the drug. she had experienced a similar reaction with use of propylthiouracil in . the patient who was breastfeeding a baby and did not have any treatment option other than propylthiouracil was referred to us with pre-diagnosis of drug allergy. the patient was thought to have propylthiouracil-induced hypersensitivity reaction and desensitization was planned. we prepared a desensitization scheme in accordance with general desensitization principles (table ). in accordance with this prepared scheme, we successfully applied the desensitization protocol with propylthiouracil for the patient. the patient gave informed consent before testing and desensitization. results: spt was negative, but idt reaction was positive at : method: we present a desensitization protocol to intravenous etoposide used in a -year-old male for non-hodgkin's lymphoma who was referred to the department of allergy at sotiria general hospital of athens. within minutes after receiving the first dose of the drug, the patient complained for flushing, retrosternal pain, difficulty in breathing and weakness. the infusion was ceased immediately and the patient received proper treatment with gradual recovery of the symptoms. the next day, skin prick test (spt) and intradermal test (id) were performed with etoposide at dilution : ( mg/ml). both of the tests, spt and id, were negative. histamine and nacl . % were also used as positive and negative controls, respectively. a desensitization protocol of three-day cycle with intravenous etoposide was conducted. premedication for days was administered including methylprednisolone, cetirizine, ranitidine, paracetamol and montelukast. results: the desensitization protocol of the first day consisted of steps of rapid pulses administered at increasing infusion rates every minutes, and step of drip infusion at a final rate of ml/hour ( mg/ . ml) until completion of the infusion. the following days, the patient received a modified rapid protocol consisting of the administration of the calculated dose of mg in only one step of infusion rate of ml/hour completing in only hours and minutes. the same protocol was applied in another three-day cycle with no adverse reactions. conclusions: hsrs to etoposide are rarely described in the literature. we propose a three-day modified rapid desensitization protocol to intravenous etoposide that could be particularly useful compared to other time-consuming desensitization protocols. case report: imatinib, a tyrosine kinase inhibitor, sometimes causes cutaneous reactions that can be of various severity. we present a case of a patient who was started on imatinib mg daily and after months developed diffuse mildly pruritic rash with some desquamation of palms of the hands. the dose of imatinib was reduced to mg daily and therapy with prednisone mg was started. after resolution of rash, the dose of prednisone was tapered to mg daily, but the rash reappeared, although milder in intensity. the dose of prednisone was increased and levocetirizine added and rash resolved. prednisone was slowly discontinued and rash did not appear. in the case of reactions to imatinib the dose of drug can be reduced and short course of oral corticosteroid given. milder reactions can be treated with antihistamine or topical corticosteroid. therefore, when adverse skin reaction to imatinib occurs, induction of tolerance to this important drug should be attempted. method: the exosomes were collected from in vitro primary human sinonasal epithelia cell, which derived from three different groups (normal control, chronic rhinosinusitis and chronic rhinosinusitis with asthma). generation of exosomes in epithelia was confirmed by nanosight, tem and western blot. the proteins of exosomes were identified by proteomics analysis. the cellular proliferation and ciliogenesis were analyzed by cck and qpcr.the ciliary beat frequency was detected by sava system. we found that epithelial cellular exosomes from chronic rhinosinusitis and chronic rhinosinusitis with asthma could reduce the multiplication rate of normal epithelial cell at a certain concentration (≥ μg/ml).we found that exosomes from chronic rhinosinusitis with or without asthma could interrupt the cellular ciliogenesis and ciliary beat frequency. using mass spectrometric analysis we demonstrated that the epithelial exosomes contained different proteins in different disease states. conclusion: our findings first identified that exosomes could be secreted by nasal epithelial cells. we also demonstrated exosomes from chronic rhinosinusitis with or without asthma could be a pathogenic factor in the remodeling of sinonasal mucosa. it could be considered as a significant biomarker for detecting the progress of chronic rhinosinusitis and a alternative therapy target. background: mucociliary transport (mct) is a major respiratory tract host defense mechanism and chronic exposure to allergen can deteriorate the these defense mechanism. the aim of this study was to investigate the effects common allergen (dp/df) on human nasal mucociliary transport in allergic rhinitis patients, and to determine the pathophysiology of ciliary beat frequency (cbf) during allergeninduced change method: allergic nasal mucosa cells of allergic rhinitis patients were exposed to common allergen (dp/df), and cbf was analyzed using an optical flow technique with the peak detection method results: the allergen(dp/df) exposed group showed a decreased cbf when compared to the control group. in the cytotoxicity assay, difference in survival rates was not found between the two groups. in the allergen(df/df)-exposed group, protein kinase c (pkc) activity was increased during a pkc activity assay. the broad pkc inhibitor, calphostin c abolished the allergen(dp/df)-induced decrease of cbf. the allergen-induced decrease of cbf was abolished by gf x, a novel pkc (npkc) isoform inhibitor, whereas the decrease was not attenuated by g€o- , a specific inhibitor of conventional pkc (cpkc) isoform. conclusion: allergen may inhibit cbf via an npkc-dependent mechanism. therefore, we have confirmed that chronic exposure to allergen could decrease cbf by increasing pkc activity. method: ova-alum allergic rhinitis mouse model (ar model) and poly(i:c) induced il- dominant mouse model (neutrophil dominant model) were used. both mouse models were exposed to tio particles for hours twice daily for days, while the controls (n = ) were not. sirius red staining for eosinophil infiltration, immunohistochemistry for neutrophil and il- a, serum immunoglobulin (ig) g and e were assayed by using enzyme-linked immunosorbent assay. in addition, the expression of interleukin (il)- , il- , and interferon (ifn)-γ in the nasal mucosa and cervical lymph nodes was measured by immunohistochemistry, and real-time reverse transcription-polymerase chain reaction (rt-pcr), il- monoclonal antibody (secukinumab) was administered in vivo to evaluate il- a dependency. results: tio exposure did not influence eosinophil infiltration in both ar and neutrophil dominant model. however, tio exposure increased neutrophil infiltration in both models and neutrophil infiltration was correlated with il- expression in the nasal mucosa. serum igg and ige levels were changed significantly in the tio exposed group. th cytokines (il- , il- ) and th cytokine, ifn-γ were not changed significantly in both models after tio exposure, however, il- were increased in tio exposure group. and these increased type pathway and neutrophil infiltration were reversed after il- monoclonal antibody administration. conclusion: exposure to airborne tio induced neutrophil infiltration in the nasal mucosa. the type response seems to play a dominant role in the nasal immune response following airborne tio exposure. | toll-like receptor ligands increase type i interferon induced b-cell activating factor expression in chronic rhinosinusitis with nasal polyposis results: first: paf-r mrna expression was very low in fibroblasts from nm and np (data not shown). paf-r mrna expression was detected in whole sinonasal tissue, submerged and ali epithelial cell cultures from both controls nm and np. paf-r mrna was also detected in peripheral blood eosinophils. although no differences were found between nm and np tissues and cultures, paf-r mrna expression was significantly higher (p < . ) in eosinophils than in upper airway tissues and cells. second: protein paf-r was found expressed in whole tissue (predominantly in the epithelium and submucosal glands), submerged and ali epithelial cell cultures from both nm and np. peripheral blood eosinophils also showed paf-r protein expression. conclusion: both paf-r mrna and protein expression was found in sinonasal nm and np tissues (epithelium and submucosal glands) and in peripheral blood eosinophils. these findings suggest the paf/ paf-r system could play a pathophysiological role in crswnp through the modulation of structural and inflammatory cell functions. "this study was funded with a research grant from uriach group". background: allergic rhinitis (ar) is an increasingly more common nasal inflammatory disease in which an antigen such as pollen or dust mites triggers symptoms such as itching, sneezing, and rhinorrhea, which can lead to nasal obstruction. ar is mediated by thelper type cells together with mast cells, eosinophils, and several inflammatory cytokines and chemokines. for example, recent abstracts | research indicates that hypoxia-inducible factor α (hif- α) is involved in the mechanism of ar development. the anti-heart failure drug digoxin has a specific inhibitory effect on hif- α, and thus, the aim of the present research was to explore the anti-hypertensive effect and mechanism of digoxin in ar. method: an animal model of ovalbumin-induced ar was established in guinea pigs. the experimental group was treated with digoxin through the tail vein. for the comparison of symptoms between the experimental and control groups, the incidence of sneezing was recorded, and the eosinophilic interleukin il- and il- levels in nasal secretions were measured by enzyme-linked immunosorbent assays. western blotting and reverse transcription polymerase chain reaction analyses were conducted to evaluated hif- α expression in guinea pig nasal mucosa. results: the ar symptoms of guinea pigs in the experimental group were significantly improved after administration of digoxin. specifically, the experimental group exhibited a significantly lower numbers of sneezing times(average . ± . vs . ± . , p < . ) and lower il- and il- secretion levels (p < . ) compared with the control group. moreover, guinea pigs of the experimental group showed less severe nasal mucosa edema, lower hif- α production, and reduced eosinophil infiltration in nasal mucosa compared with the control group. conclusion: the anti-heart failure drug digoxin may ameliorate the symptoms of ar by inhibiting hif- α production. campo p ; eguiluz i ; bogas g ; gomez f ; ariza a ; espino t ; torres mj ; rondon c allergy unit-regional hospital of malaga-ibima, malaga, spain; allergy laboratory_regional hospital of malaga-ibima, malaga, spain background: similarly to what has been described in allergic rhinitis, there is an important association of local allergic rhinitis (lar) with lower airway symptoms suggestive of asthma, being selfreported in . % of lar patients after five years of follow-up, and increasing to . % after years. however, clinical suspicion alone it is not enough for asthma diagnosis and could overstate its real prevalence. the aim was to evaluate the real prevalence of asthma in lar patients based on validated objective methods. method: seventy-five patients ( with lar, with non-allergic rhinitis (nar), with allergic rhinitis (ar)), and healthy controls (hc) were included. all patients had perennial history of rhinitis and bronchial symptoms suggestive of mild-moderate asthma for at least two years. non-specific airways hyperresponsiveness (methacholine challenge test, using tidal breath method following ats guidelines) was performed in all subjects. results: subjects were mostly young females, non-smokers. median μg/day of inhaled corticosteroids (budesonide/equivalent dose) was similar in all groups. median fev % in ar group ( . %) was significantly lower compared to lar ( %, p = . ), nar ( %, p = . ) and hc ( %, p = . ). in the lar group, / ( . %) had a positive methacholine, / ( %) in the nar, / ( . %) in ar group and / ( %) in hc. patients with lar had a significant lower percentage of confirmed asthma than ar (p = . ) and similar to nar (p = . ). no differences were detected between ar vs nar (p = . ). conclusion: presence of objectively demonstrated asthma was lower in lar compared to ar, and with better lung function. conclusion: ambient air pollution influenced the hospital visit of patients with rhinitis, even, the level of pollutants, below the national standard. so , o , no , and pm could increase an incidence of rhinitis and/or induce an aggravation of rhinitis symptoms. health care provider might expect upraising patients with rhinitis in the clinic with increase of air pollutants, even under the standard levels. results: during relapse of erosive oral lichen planus mononuclear cells obtained from peripheral blood of patients showed increased number of nk-cells cd + cd + in acute ( . ± . %) and chronic ( . ± . %) disease periods, and cd + grb cells in acute ( . ± . %) and chronic ( . ± . %) disease periods, p < . . in patients with the non-erosive forms of olp there were cd + cd + and cd + grb cells in acute ( . ± . %) and ( . ± . %) and chronic disease ( . ± . %) and ( . ± . %), p < . . the number of cd + cd + and cd + grb cells in the controls were ( . ± . %) and ( . ± . %), p < . . conclusion: acute relapse of erosive oral lichen planus, unlike nonerosive forms, is characterized by increases in the number of cd + cd + and cd + grb cells. chronic disease in patients with erosive oral lichen planus showed a steady increase in the number of cd + cd + killer cells and cd grb lymphocytes. bite", were observed in patients ( %). typical hyper-and hypopigmentation were observed in six patients mainly on the fingers and the cheekbones. fibrosis of the skin of the fingers often leads to flexion contractions, which we observed in patients. we were watching two-sided swelling of the fingers, but it was very pronounced in patients ( %). % of our patients have impaired motility of the esophagus. accelerated esr and c-reactive protein were found in patients as follows- intensively accelerated and moderate. in our patients with positive ana, we observed patients -at low titer : at and titration : in patients. the spectrum of ana found by us in raynaud's syndrome patients is closer to scleroderma than to lupus. we underline the importance of ana ( %) and anti-cc antibodies ( %) for the early diagnosis of raynaud's syndrome and scleroderma, which is also seen in our patients. anti-scl- antibodies were observed in patients coinciding with other publications describing about % of the patients. low levels of complement were observed in patients. low hemoglobin levels were observed in patient, with no iron deficiency. conclusion: . we observed a typical fibrinoid necrosis and polymorphonuclear infiltration, and collagen accumulation in the walls of small and medium-sized blood vessels. results: statistically significant increase of il level ( . pg/ml [ . ; . ]; . pg/ml [ . ; . ] respectively) was determined in patients with uc both in acute stage and remission compared to controls ( . pg/ml [ . ; . ] , (p = . ; . respectively). statistically significant increase of il a level ( pg/ml [ . ; . ] ); . pg/ml [ . ; . ] respectively) was also observed in patients both in acute stage and remission compared to controls ( . pg/ml [ . ; . ], p = . , p = . respectively). besides statistically significant increase of ifnγ both in acute stage ( . pg/ml [ . ; . ] ) and remission ( . pg/ml [ . ; . ]) compared to controls ( . pg/ml [ . ; . ], p = . ; . respectively) was revealed. background: the presence of antinuclear antibodies (ana) is commonly associated with a broad spectrum of connective tissue diseases. low titres might be detected rarely also in healthy individuals, especially in higher age. an indirect immunofluorescence (iif) detection of ana antibodies on hep- cells is the most frequently used laboratory method in this respect. the method is quite reliable regarding sensitivity, however the specificity of this test is lower. we would appreciate a biomarker for clinical discrimination of ana- other autoantibodies were tested in relation to basic diagnosis. results: a cohort of patients was divided into groups according to main diagnosis: immunodeficiency, connective tissue diseases, bronchial asthma and allergic rhinitis, recurrent infectious diseases, gastrointestinal diseases, endocrinopathy and others and the last group was generated from healthy subjects. the presence of anti dfs antibodies was highest in the group of recurrent infections, mostly in females. in these subjects homogenous pattern of ana antibodies by iif was also detected quite often, probably induced by non-specific activation of immune system. on the other hand, in a group of connective tissue diseases, we have not found any anti dfs positive patient. the clinical impact of anti-dfs antibodies is not yet finally confirmed, but their low frequency in connective tissue diseases and presence in %- % of healthy subject suggests their potential role as a new biomarker to be used as a negative predictive factor in non aard. confirmation of presence or absence of anti-dfs antibodies seems to be helpful to exclude potential diagnostic errors in iif ana positive patients. background: multiple sclerosis is a debilitating autoimmune and degenerative condition of the central nervous system, that predominantly affects young adults. both genetic and environmental factors are associated with increased risk for this disease. we propose that the effect of environmental factors, particularly latitude of childhood, is mediated through epigenetic mechanisms. specifically, we propose that unfavourable gene methylation predisposes individuals to multiple sclerosis, that this is set in childhood and adolescence, and transmitted from haematopoietic stem cells to progeny. method: cd + , cd + and cd + cell subsets were isolated from peripheral blood of healthy controls. libraries enriched for cpg islands and promoter regions were generated using modified reduced representation bisulfite sequencing and subjected to next generation sequencing. site specific methylation profiling of genome wide cpg islands, including ms susceptibility genes was conducted using methpipe software. results: genomic coverage was consistent with other published methylomes using modified reduced representation bisulfite sequencing. the methylation signature of peripheral blood derived subsets showed greater differences in methylation compared to buccal cells than with each other. individuals displayed differences in cd + methylomes, and these were recapitulated in the progeny cd + and cd + cells for those individuals. methylation of specific genes regions (e.g. prf ), were consistent with the known biological function of these genes and their potential contribution to ms risk. the vast majority of cpg islands interrogated show recapitulation of their methylation signature from cd + to progeny. however, individual differences and cell subset differences identified, likely reflect the known biological function of these genes in progeny cells. our preliminary results are consistent with the hypothesis that the epigenetic signature (that predisposes to ms risk) is set in childhood and adolescence. the physiological basis underlying the setting of this epigenetic signature is still to be elucidated, but may involve uv light and/or vitamin d, and may provide novel therapeutic targets, especially at a personalised level, for treatment of ms. background: auto-inflammatory diseases are rare disorders characterized by recurrent episodes of fever/inflammation affecting serosal surfaces, joints, eyes and skin without autoantibody production or an underlying infection. innate immunity is implicated in their pathogenesis and the underlying genetic defect has been identified in a fraction of the syndromes. during last years, the increased knowledge about auto-inflammatory diseases and the difficulty in their characterization aroused great interest to better understand these pathologies. the acidic soluble fraction of salivary proteome of patients and controls (hc) were analyzed by rp-hplc-esi-ms. known salivary proteins (salivary acidic proline-rich phosphoproteins (aprps), histatins (hst), salivary cystatins s, sn and sa, statherin, p-b peptide, α-defensins - , cystatins b, c, thymosin β- , s a , s a , s a , and s a proteins) and several derivatives (acetylated, glutathionylated, phosphorylated, and oxidized forms) were searched in the chromatographic profiles by xic (extracted ion current) procedure. adult patients (mean age ± sd: . ± . ; f, m) were enrolled and compared with sex/age matched healthy controls (mean age ± sd: . ± . ; f, m). patients are classified on the base of clinical manifestations as follows: patients with fmf (mean age ± sd: ± . ; f, m), and with unclassified fever syndrome (uc) (mean age ± sd: . ± . ; f, m). results: fmf patients showed low levels of α-defensins , and , this last was absent, with respect hc, and high levels of the glutathionylated proteoforms of cystatin b, and s a , and of antileukoproteinase (slpi). similar results were obtained on saliva of unclassified patients, which showed also levels of cystatin c higher than controls. interestingly, proteins and peptides typically secreted by salivary glands (cystatin c, histatins, statherin, aprps) were found more abundant in uc patients than in controls, and in some cases also than fmf patients (see table) . an evaluation of relative abundance of phosphorylation of phosphorylated proteins/peptides highlighted a significant hypophosphorylation of hst- , prp- and prp- in uc patients with respect to controls, probably due to a less active fam c kinase responsible for their phosphorylation conclusion: we show by a top-down proteomics approach a wide salivary modification, highlighting dysregulation in neutrophil-derived proteins and significant differences between fmm and uc patients. the control group consisted of healthy donors aged - years. immunological methods of investigation included determination of membrane antigens b cells: cd − cd + cd + , cd + cd + cd + , cd + cd + cd , cd + cd + cd + , cd + cd + cd + , cd + cd + cd + , cd + cd + cd l + cd + , cd + cd ra + cd + cd + , by flow cytometry. results: in the study subpopulation composition of lymphocytes in seropositive variant form of ra visceral a statistically significant increase in relative amount as b -cells with immunophenotype cd + cd + cd + ( . ± . % . ± . %) and b lymphocytes with the phenotype cd + cd − cd − cd + ( . ± . % and . ± . %). in the analysis of the processes of maturation and differentiation of b cells detected statistically reliable increase of the relative number of mature cd + cd − cd + naïve b cells cd + cd ra + cd number of mature cd + cd − cd + naïve b cells cd + cd ra + cd − cd + ( . ± . % and . ± . %) compared to the control group. in the study of surface markers b lymphocytes revealed an increase of expression of costimulatory cd + cd + ( ± . % and . ± . %) molecules and increasing the relative amount of cd l . ± . % ( . ± . %) ligand on cd + cd + cd + subpopulation of t-lymphocytes. analysis of surface antigenic receptor b cells in the visceral form of ra showed an increased expression of early markers of cd + cd + cd + ( . ± . % and . ± . %), cd + cd + cd + ( . ± . % . ± . %) activation in comparison with the control group. case: a year-old male patient who works as a dental technician with a history of lung silicosis and recurrent sinusitis applied to an orthopedics clinic for left hip pain and difficulty in walking. he has a history of keeping a dog during childhood. hip mri revealed a × cm sized mass on left iliac wing extended to gluteus muscle and subcutaneous tissue. incisional biopsy was reported as chronic granulomatous osteomyelitis. the lesion was considered as tuberculous abscess. despite anti-tuberculous (fourdrug regimen) treatment for one year, the lesion showed no regression. excisional biopsy was carried out by the same orthopedics clinic. chronic inflammatory reaction and fibrosis was considered to be due to cyst hydatid in the detailed evaluation. antiechinococcus igg and igm was performed with elisa and found positive. no other lesion was detected in lungs and liver. albendazole mg twice a day was initiated and substantial regression observed after three months. atypical and sustained infections made us think of primary immunodeficiency disorders. immunoglobulin subgroups were as follows: iga: < mg/dl ( - case description: year-old male was firstly admitted to gastroenterologist due to intermittent diarrhea, abdominal pain and reactive lymphadenopathy. celiac disease was suspected as genetic test showed hla dq (hla-dqa * and hla-dqb * ), histological evaluation of duodenum biopsy provided picture of lymphoid hyperplasia and marsh iiia variant. however, laboratory testing for celiac disease showed very low amount of antibodies against transglutaminase. gluten free diet for almost one year was ineffective as patient had a continuous problem of gaining weight due to chronic diarrhea. additional questioning revealed recurrent respiratory tract infections with a need of antibiotics more than two times/year during last decade. lymphocyte phenotyping by flow cytometry showed that cd , cd , cd , cd are in normal ranges, but amounts of all immunoglobulins are low: igm < . g/l, igg . g/l and iga . g/l. based on clinical symptoms and immunological evaluation diagnosis of cvid was confirmed, and replacement therapy with subcutaneous immunoglobulin ( mg/kg/month) was initiated. after six months of treatment patient affirmed reduction of gastrointestinal symptoms; he gained kg of weight, has no more infections and stable sufficient level of igg ( . g/l). conclusions: this clinical case shows the importance of immune testing for primary immunodeficiency in all subjects (despite age) with unusual symptoms of autoimmune and/or infectious disorders. cvid may have manifestation of various symptoms, which can lead to misdiagnosis, as well as inadequate treatment. results: in our sample, all patients who progressed to hypogammaglobulinemia were receiving lymphomas. there is no immunoglobulin dosage record prior to treatment. of the cases, mean age was years ( men and women), lost follow-up, and of them also presented neutropenia. seventeen patients who continued in followup required ivig replacement, due to infectious exacerbations, mainly pneumonia and sinusitis. the mean serum igg dosage at the time of onset of ivig replacement was g/dl. the mean time between the first dose of rtm and the need for ivig replacement ranged from to years, with an average of years. the iga dosage was used as a parameter for the recovery of hypogammaglobulinemia, and it was observed that only of the patients presented recovery of the condition up to the moment. conclusion: given the data, we considered the immunoglobulin dosage to be important before initiating rtm treatment and periodically, in order to indicate the replacement of ivig or igsc in a timely manner avoiding complications such as potentially serious infections. background: steinert's disease, also known as type myotonic dystrophy (md ), is the most common dystrophy of the adult. it is inherited with an autosomal dominant mechanism. it causes myotonia, progressive muscles atrophy, muscular weakness, and problems at the heart's conduction tissue and at the respiratory muscles. in patients with myotonic dystrophy, hypogammaglobulinemia is frequently described. the associations and the pathogenesis between those affections are not totally clear, but it is recognized an increased catabolism of the immunoglobulin in these patients. in most of the cases, hypogammaglobulinemia affects only the igg class and does not become clinically manifest. however, replacement treatment is not always successful in these patients. we report the case of a patient with myotonic dystrophy and hypogammaglobulinemia. case report: a -years-old man with md came to our attention for a history of recurrent infections of the upper respiratory tract and persistent infection by helicobacter pylori. at the laboratory tests, we documented low serum igg levels ( mg/dl), normal igm and iga levels and protective antibodies against tetanus consisting with the diagnosis of hypogammaglobulinemia. due to the recurrent infections, he started replacement therapy with ivig ( . g/kg/ months), switched one year ago to facilitated subcutaneous ig (fscig) with achievement of protective serum igg levels (> mg/dl) and significantly reduction of infectious episodes. conclusion: hypogammaglobulinemia is frequently reported in patients with md . in literature most of the cases described does not become clinically manifest, but in our case, the patient was symptomatic with recurrent infections. the replacement therapy with fscig showed both clinical effectiveness and safety. | real-world experience of a novel, highly purified % liquid iv human immunoglobulin for the treatment of antibody deficiencies guidelines for immunoglobulin use (july ). a highly purified % liquid iv human immunoglobulin (ig), with low levels of iga, anti-a and anti-b haemagglutinins, factors xia, xiia, kallikrein and aggregates (i e) was recently approved for use in the uk. here i report our centre's experience in using this novel % i e in three patients with antibody deficiencies. case presentations: a patient who presented in clinic with a first diagnosis of pid, was initiated on % i e at g infused every four weeks. after starting i e, they experienced a decrease in the rate and frequency of infections, in line with expectations for igrt. a young patient on home therapy with a % subcutaneous ig for pid presented in clinic with low trough igg levels. non-compliance was identified as the cause of these low trough levels and therapy was switched to % i e at g infused every four weeks in a clinical setting. both the rate and severity of infections reduced and trough igg levels normalised. an older patient on igrt for sad was reviewed in clinic due to discontinuation of their current igrt product. they were switched to % i e at g infused every four weeks. the efficacy and tolerability of i e was comparable to their previous therapy. a detailed analysis of patient, clinical and safety parameters associated with the initiation of % i e will be presented, including infection rates, white cell counts, c-reactive protein levels, tolerability and infusion-related adverse events. conclusion: these cases highlight the real-world use of % i e in two patients with pid and one patient with sad. they show that i e was well-tolerated and efficacious in one treatment-naïve, and two previously-treated patients. method: prospective study of families with one or more members with c -inh-hae followed in hospitals in the northern area of spain. a cohort of patients from families with c -inh-hae was evaluated for familiar diagnosis of c -inh-hae one or several patients from the same family were chosen and were given a questionnaire to identify the total family members from the family branch affected by c -inh-hae that had been already studied (members with diagnosis of c -inh-hae and healthy members) and those that had not been previously studied. we also register the difficulties for obtaining these data. family members not previously studied and that consent to be contacted were asked for study of c -inh-hae. for c -inh-hae screening we use c blood levels results: we have studied families with c -inh-hae, ( %) type and ( %) type ii; families had all their known members already studied for c -inh-hae ( %): families have all their members studied ( . %), families have % or their known members studied ( . %) and families had less than % of their total known members studied. we have identified members from unrelated families that had not been previously studied for hae, healthy, had low c levels and had presented symptoms of hae; had not presented symptoms of angioedema, had normal c levels, and low antigenic and functional c -inh levels. difficulties for a complete family testing study have been: family dispersion, scarce or no family relationship, do not wish to know their possible pathology conclusion: it is crucial to insist on the study of the relatives of patients with hae. we propose to include a questionnaire to identify all patient's relatives at medical reviews of hae patients. case: a- year old boy was admitted to our clinic with the history of recurrent respiratory tract infections. his all immunoglobulins were low (igg < mg/dl, iga < . mg/dl, igm < . mg/dl) associated with the absence of b cells. his aunt cousin also had xlaa missense point mutation, c c>t in exon of the btk gene was identified in both affected cousins. the patient was commenced on regular ivig treatment every weeks. at the age of , he suffered from intermittent fever attacks, abdominal pain and weight loss. tests for giardia lamblia, clostridium difficile and cryptosporidium, noro virus or parasites were negative. mr-enterography revealed intra-abdominal fluid and thickened walls of his jejunum and cecum. histopathological examination of the biopsy material obtained from terminal ileum, colon and cecum showed crohn disease. initially, he was treated with prednisolone and infliximab. because of the lack of response, infliximab treatment was switched to adalimumab. terminal ileum was resected to relieve obstruction complication. although he had been treated with adalimumab for year, a significant improvement was not observed. vedolizumab (entyvio ™ ), is a humanized monoclonal antibody α β integrin-receptor antagonist, was commenced. induction dosing was mg infusions at , , and weeks followed by a maintenance phase at week intervals. at the month of the treatment, fever and abdominal pain attacks reduced, while his weight and oral intake increased. no side effects were observed. discussion: vedolizumab is effective for inducing and maintaining remission in adults with inflammatory bowel disease (ibd); however, there is limited pediatric data. this is the first immunocompromised child treated with vedolizumab. the symptoms of the patient receded and no side effect observed during months of the treatment. results: louis-bar syndrome is a multisystem progressive disease with polymorphic manifestations which varies by age. the locomotor disability of these children is determined by neurological disorders, the exitus being caused by respiratory infectious and malignancies. the children involved in the study, had frequent episodes of respiratory infectious (bronchitis, pneumonia, atelectasis, empyema, lung abscess), ent infections (otitis, mastoiditis, sinusitis), chronic pulmonary disease (pulmonary fibrosis, bronchiectasis). index of death in this group is high ( . %). in one of the boy, the pulmonary ct showed lymphadenopathy, later was confirmed non-hodgkin lymphoma, with subsequent death. another child died from pulmonary and systemic infectious complications. results: in this paper we present the clinical and morphological analysis of children with nezelof syndrome diagnosed post-mortem. clinically were predominantly the generalized intrauterine infections or their development in the postnatal period. at macroscopic examination all patients had thymic hypoplasia. later on the microscopic study of the thymus specimens determined dysplastic changes, defined by the presence of concentrically arranged epithelial cells. in all patients, was determined the total lack of hassall corpuscles and its predecessors. besides the above-mentioned modifications in all specimens, there was no cortico-medullary segregation. thymic parenchyma outside pseudorrhagia was made up of a reticular stroma with total lymphocyte depletion. conclusion: nezelof syndrome is a severe primary immunodeficiency associated with thymic dysplasia and alymphocytosis, which is manifested early with generalized infections and major risk of death in neonatal and infant. background: the study was aimed to evaluate the cytokine profile in nasal secretion and blood serum in patients with seasonal (sar) and perennial allergic rhinitis (par) with a potential for additional sensitization with microbial allergens. method: the inclusion criteria for ar were as follows: a diagnosis of ar for more than years, the absence of nonallergic disorders of the nasopharynx, age of patients from years to years.control group: healthy volunteers at the age of - years without any allergic disorders at examination.in order to evaluate the innate and adaptive immunity, the cytokine profile of blood serum (il- , il- , and tgf-β) and nasal secretion (tslp, il- β, tnf-α, and gm-csf) was determined. to determine tslp, tgf-β, il- , and gm-csf concentrations, enzyme-linked immunosorbent assay kits were used (ebioscience, bender medsystems, r&d systems, mn, usa). we have noticed a significant correlation (r = , p = ) between the tslp concentration in nasal secretion and as-ige level to staphilococcus aureus enterotoxin (allergen component m ) in patients with par. there was a significant correlation conclusion: staphylococcal superantigens might be one of the stimuli of local tslp hyperproduction by the epithelium. there was a significant correlation between gm-csf concentrations in nasal secretion and the intensity of sensitization to a staphylococcal enterotoxin (seb) in the patients with ar. seb is one of the polyclonal t cells activators, which may account for increased concentrations of cytokines such as gm-csf locally within the system of mucosal immunity. the patients with ar and additional high sensitization to ses demonstrated a higher tnf-α production profile due to macrophage and tcell activation by these toxins. | evaluation of circulating osteopontin level as potential biomarker of allergic asthma in patients with caucasian and south-east asian ethnicity background: osteopontin (opn) is a pleomorphic cytokine known to influence a wide range of immune cells; allergic asthma was previously associated with high circulating opn levels. in the present study, we aimed to verify if opn may qualify as biomarker of activated immune response in allergic patients belonging to two different ethnic groups: caucasians and south-east asians. method: serum opn levels were measured by elisa test (human osteopontin duoset, r&d systems) in a series of italian adult patients affected by extrinsic asthma, allergic rhinitis, hymenoptera venom allergy, food allergy, allergic contact dermatitis and ige mediated hypersensitivity to beta lactams. healthy subjects served as controls. ethnic chinese subjects were recruited at the national university of singapore (nus) as cross-sectional cohort of an ongoing epidemiological study on the national prevalence of allergic diseases, and opn levels were detected by luminex (milliplex map, merck) and elisa assays (r&d systems). results: in the italian cohort, opn levels were significantly higher in cases compared to controls (p = . by the mann-whitney test). statistically higher opn levels were found in asthma (p = . ) and food allergy (p = . ) groups in comparison to controls. no significant differences were found (p = . ) between singaporeans with lifetime asthma and healthy controls, only the highest opn levels were heterogeneously found to correlate with asthma. however, a strong gender effect was shown, in both cases (p < . ) and controls (p < . ), with males presenting higher opn levels in comparison to females. consequently, we checked the mrna expression levels of opn gene (spp ) with illumina chips in whole blood of males and females, and no difference was found (p < . ). several experiments with western blots and different gel types were performed to verify if possible post-transcriptional/posttranslational modifications of opn could explain these findings. conclusion: opn seems to be a promising biomarker for current, active allergic asthma in caucasians even though technical difficulties, due to opn intrinsically disordered structure, the complex enzymatic metabolism, and the low circulating levels, significantly affect the experiments. further studies are needed to confirm these data. | mortality, intubation, and healthcare cost in patients with allergic bronchopulmonary aspergillosis in a hospital setting: a nationwide study fan x; luo y; yue b background: abpa is a complex hypersensitivity reaction to aspergillus fumigatus that colonize in airways, it is almost exclusively seen in patients with asthma or cystic fibrosis(cf). this study is to estimate hospitalization outcomes and healthcare cost of hospitalized patients with abpa. method: we conducted the study using data from national inpatient sample(nis) from to . diagnosis were identified using icd- -cm codes. hospitalization with a primary diagnosis of abpa and hospitalization with a primary diagnosis of acute respiratory failure/acute and chronic respiratory failure/respiratory distress/ asthma/cf and a secondary diagnosis of abpa were included. the study population was divided into groups including abpa with asthma, and abpa with cf. mortality and intubation rate were the primary outcomes; length of stay and total hospitalization cost(adjusted to cost in based on medical care cpi) were secondary outcomes. student t-test and chi-square were used for univariable analysis, linear and logistic regression were used for multivariable analysis. results: a total of hospitalizations with abpa were included, with hospitalizations with abpa and asthma, and hospitalizations with abpa and cf. the overall mortality rate was . % ( % ci: . %- . %), the mortality for abpa with asthma was . % ( % ci: . %- . %) and for abpa with cf was . % ( % ci: . %- . %). the overall intubation rate was . % ( % ci: . %- . %); the intubation rate for abpa with asthma was . % ( % ci: . %- . %) and . % were early intubation (< days); the intubation rate for abpa with cf was . % ( % ci: . %- . %) and . % were early intubation. the overall mean length of stay(los) was . ( % ci: . - . ) days, while the los for abpa with asthma was . ( % ci: . - . ) days and the los for abpa with cf was . ( % ci: . - . ) days. the overall total cost was million usd, the total cost for abpa with asthma was . million usd with a mean of , while the total cost for abpa with cf was million usd with a mean of . conclusion: mortality among hospitalized patients with abpa is low< %. intubation rate is relatively low, intubation, especially early intubation (< days), is more common in patients with asthma. although abpa is not a common disease in inpatient population, it does have a high health care cost and despite lower intubation rate, patients with abpa and cf generally have a longer hospital stay with a higher hospitalization cost. | frequent exacerbations of bronchitis with wheezing in adults: is it possible to predict and prevent asthma? case report: frequent episodes of bronchitis, accompanied by wheezing and dry with a prolonged duration in adults, the clinical course may be similar to bronchial asthma. the aim is to assess the risk of asthma in adult patients with or more episodes of acute bronchitis per year, had a prolonged duration and accompanied by a dry wheezing. for years in two regional clinical pulmonology centers were observed in patients ( men and women) with average age ± . years. each had at least episodes of acute bronchitis per year, which was accompanied by prolonged cough and presence of wheezes. average number of acute episodes per year was . ± . . in the course of the observation the patients were divided into equal groups. the first group consisted of persons treated in acute episodes of the disease symptomatic therapy, including inhaled β -agonists short-acting short course. in the second group to the corresponding treatment added montelukast mg per day lasting for month. in all cases of exacerbation had a viral nature. held in the period of remission of allergic sensitization, the survey revealed. starting from the first year of follow-up all patients were vaccinated against influenza annually. by the end of the fifth year of observation in the first group in cases was diagnosed of bronchial asthma- cases easy persistent asthma and case moderate. the diagnosis was exhibited in accordance with the gina criteria. in the second group, the diagnosis of bronchial asthma were exposed to patient (hazard ratio of . ). prospective observation suggests that the use of anti-inflammatory potential antileukotriene medicines in complex therapy of recurrent acute episodes of bronchitis accompanied by a dry wheezing in adults may be a factor preventing the development of asthma. for more conclusive results require more extensive research. background: chemokine receptors play an important role in regulating the migration of t lymphocytes, monocytes and neutrophils from the peripheral blood into inflamed tissue, such as lung. however, little is known about their expression on natural killer (nk) and natural killer t (nkt) cells in patients with chronic obstructive pulmonary disease (copd). therefore the aim of the study was to determine the chemokine receptor profile of peripheral blood nk and nkt cells of copd patients. method: for analysis of lymphocytes subtypes the flow cytometry method was used. the study population consisted of smokers with copd, healthy smokers and healthy non-smokers. results: we observed an increase in blood nk cells expressing cxcr receptors in smokers with copd compared to healthy smokers (p = . ) and healthy non-smokers (p < . ). the percentage of nkt cells containing cxcr receptors was also significantly higher in blood of smokers with copd compared to healthy smokers (p = . ) and healthy non-smokers (p < . ). copd smokers had significantly higher proportion of ccr + nk cells than smokers without copd (p = . ) and healthy non-smokers (p < . ). increased proportion of blood nkt cells expressing ccr on their surface was observed in smoking copd patients compared to healthy smokers (p = . ) and healthy non-smokers (p < . ). there were no significant changes in the percentage of cxcr + and ccr + nk and nkt cells between healthy smokers and non-smokers. in addition, no differences were seen in the proportion of nk and nkt cells expressing cxcr , cxcr , ccr and ccr among all studied groups. method: patients with copd in stable condition (gold stage ) aged - years old, smoking history of ≥ pack-years, were studied. bmi of patients were divided into groups: obese (n = ) (bmi- . - . kg/m ) and non-obese (n = ) (bmi- . - . kg/ m ). ten subjects with normal lung function and bmi were the control group. the level of il- assessed in induced sputum (pg/ml) was measured using an elisa (raybiotech ® ). serum levels of crp were measured using the "vector-best" (russia federation). spirometry was performed according to american thoracic society and the european respiratory society (ats/ers) guidelines. results: obese copd patients had significantly increased concentrations of il- compared with healthy subjects and non-obese copd patients by . fold ( . ± . pg/ml vs . ± . pg/ ml) (p < . ) and . fold, ( . ± . pg/ml vs . ± . pg/ml)(p < . ), respectively. non-obese copd patients had higher levels of il- by . fold compared with healthy subjects ( . ± . pg/ml vs . ± . pg/ml) (p < . ). results: among these three groups, the level of cer in lung cancer patients ( . ± . g/l) was significantly higher than that in ild patients ( . ± . g/l) and healthy individuals ( . ± . g/l) (p < . ). meanwhile, the levels of c and c in healthy individuals, which are . ± . g/l and . ± . g/l respectively, were both significantly higher than that in lung cancer patients (c : . ± . g/l, c : . ± . g/l) and ild patients (c : . ± . g/l, c : . ± . g/l), (c : p < . , c : p < . ). results from optimal scaling demonstrated that lung cancer was closely associated with immune factors including crp, cer, c and c (cronbach's alpha = . %). conclusion: for ild patients, when the level of crp and cer is increased and the level of c and c is decreased simultaneously, the risk of the development of lung cancer should be considered for these patients. results: among pbmc subpopulations, endurance exercises impacted the number of nkt and activated t cells with nkt cell numbers greater in male bobsledders vs bullet shooting and biathlon ( . % and . %, respectively). the number of activated t cells (cd + ) was greater in bullet shooting and bobsleigh athletes vs the biathlon group ( . % and . %, respectively). in female athletes the number of cd + cells in the shooting and bobsled groups was greater by . % and . %, respectively vs the biathlon group (p < . ). increased il- occurred in bobsleds in comparison to bullet shooting and biathlon: % and % in male and . % and % in female, respectively (p < . ). the concentration of il- in male bobsledders and biathlon was % and % greater, respectively, compared with bullet shooting (p < . ). serum concentrations of ifnγ in male as well as female athletes showed an increase of . % and . %, respectively vs biathletes (p < . ). increased il- occurred in the male biathlon group by . % and %, respectively, vs the bullet shooting and bobsleigh athletes (p < . ). il- was increased in the male biathlon group, compared to bullet shooting and bobsledders by . % and . %, respectively (p < . ). conclusion: prolonged endurance exercises impacts secretion of pro-and anti-inflammatory cytokines in athletes of different sport specializations. concentrations of studied cytokines did not exceed reference values perhaps due to specialized sport nutrition, which may restore immune function during endurance exercises. background: oral immunotherapy (oit) is a promising therapeutic approach to treat food allergic patients. recently, we have shown that the use of a mixture of short-chain-and long-chain fructo-oligosaccharides (scfos/lcfos) improves the efficacy of oit in cow's milk and peanut allergic mice. however, concerns with regard to safety and long-term efficacy of oit remain and there is a need to identify novel biomarkers (panels) that predict, monitor and/or evaluate the effects of oit. here we present a method for the selection of candidate biomarkers by using the computational approaches bayesian networks (bn) and topological data analysis (tda). method: data were used from scfos/lcfos diet-supported oit studies performed in independent cow's milk allergy (cma) and independent peanut allergy (pna) experiments in mice. first, a subset of the data was used for learning the data structure and their interactions in terms of a bn. this bn was used to compare the key parameters in both experimental food allergy models. finally, the relations within the dataset in combination with the bn were explored to identify and rank candidate biomarkers for the effect of oit by applying tda. the bn was able to predict the efficacy of oit in the cma and in the pna model with % and % accuracy respectively, thereby identifying a set of parameters (allergen-specific ige and igg , body temperature, mmcp- , earswelling) being key in the mechanisms involved in both scfos/lcfos-aided oit food allergy models. the tda zoomed in on the full set of previously analyzed parameters and identified clusters of biomarkers closely linked to biologically relevant clinical symptoms but also unrelated and redundant parameters within the network. taken together, this enables the prioritization of candidate biomarkers. moreover, the tda indicated differences between pna and cma models in how the data are related to each other. here we provide promising bioinformatics methods to compare mechanistic features between two different food allergies and to determine the biological relevance of biomarker (panels) of oit for food allergy. we have shown that the key drivers that influence pna and cma are similar, but that these phenotypically similar diseases show mechanistic differences in their subnetworks. these new insights provide excellent starting points to generate new hypotheses to explain why cma has a different disease pattern than pna and to select biomarkers that are useful in future clinical studies. | functional and immunoreactive levels of igg correlate with clinical responses during the maintenance phase of house dust mite immunotherapy basophils were identified as ssc low cd high , and cd was used as an activation marker. reactivity was confirmed by anti-ige as a positive control. results: in patients, basophil reactivity and sensitivity was comparable for grass pollen extract and recombinant phl p , while phl p only caused a lower basophil activation. in one patient, recombinant phl p did not cause any basophil activation, while phl p elicited an even higher sensitivity and reactivity than grass pollen extract. conclusion: in patients, basophil reactivity was comparable for grass pollen extract and recombinant phl p , while phl p only caused a minor basophil activation. in one patient, recombinant phl p did not cause any basophil activation, while phl p elicited an even higher sensitivity and reactivity than grass pollen extract. reactivity of extract and the main sensitizing components correlated, while sensitivity did not. | in vitro assessment of hypersensitivity to allergen before and after allergen immunotherapy with whole blood basophil histamine release assay wbbhr assay in these patients was performed - days before and - days after ait. heparinized whole blood samples ( ml) of each patient after substitution of plasma with pipes buffer were incubated one hour at °c with different concentrations of birch pollen extract (t ) in u-shape -well micro-titer plates. after incubation plates were centrifuged and supernatants from each well of the plate were directly analyzed for histamine content by reversedphase high performance liquid chromatography with electro-spray ionization mass-spectrometry (rp-hplc-esi-ms). results were expressed as ng/ml released histamine. sensitivity (limit of quantification) was - ng/ml. to compare results of histamine release in patients before and after ait data were calculated as area under the curve (auc) values. results: in contrast to pre-immunotherapy activity of blood basophils there were significant decreases in hr induced by t extract after ait. according to auc values all patients demonstrated decrease in hr after ait in compare to hr before ait in a range of %- % demonstrating a decrease of hypersensitivity to birch allergens. analysis of basophil hr in patients received s.c. or s.l. the asthma and rhinoconjunctivitis symptom scores during and after pollination season decreased significantly and showed correlation with histamine release by t . | immunotherapy with the recombinant b cell epitope-based grass pollen allergy vaccine bm induces a biphasic allergen-specific igg and igg response background: immunotherapy with the recombinant b cell epitopebased grass pollen allergy vaccine has been shown to reduce symptoms of grass pollen allergy in a multicenter, double-blind, placebocontrolled study. aim of this study was to investigate the levels and kinetics allergen-specific igg responses in a double-blind, placebocontrolled phase iib combined field and exposure chamber trial studying the effects of three, four and five pre-seasonal injections of bm as compared to placebo. method: a quantitative elisa assay based on purified human monoclonal allergen-specific igg as well as igg antibodies as standards was developed to measure allergen-specific igg and igg concentrations induced by ait with bm . results: we found rises in levels of both tested allergen-specific igg subclasses in the actively but not placebo-treated patients. phl p -and phl p -specific igg levels up to μg/ml and μg/ml, respectively and phl p -and phl p -specific igg levels of up to μg/ml and μg/ml, respectively were measured in bm treated patients. five pre-seasonal injections induced the highest allergen-specific igg levels. interestingly, allergen-specific igg and igg antibodies showed a biphasic response with early rises of allergen-specific igg which declined quickly after the pollen season and a delayed but very sustained allergen-specific igg response. conclusion: treatment with bm induces a biphasic allergen-specific igg response consisting of an early igg and a sustained allergen-specific igg response which may be responsible for early and sustained protection against allergic symptoms. | t reg cd + cd high in peripheral blood in patient with grass pollen allergy during sublingual specific immunotherapy slit the aim of this study was to evaluate t reg cd + cd high in peripheral blood in patients with grass pollen allergy during sublingual immunotherapy slit. method: we examined adult patients, aged - , female and male. patients were qualified to slit after confirmation of allergy-by skin prick tests, specific ige and nasal provocation tests. we determined t reg cd + cd high from blood sampling of those patients (by flow cytometry method), before the slit, after reaching the maintenance dose, before the grass pollen season, during the grass pollen season, and after one year of slit. results: during slit the percentage of t reg cd + cd high increase after reaching the maintenance dose, then it decreased before and during the grass pollen season, and again increase after one year os slit. we observed, that in the group with significant improvement of symptoms, t regcd + cd high decreased during grass pollen season, comparing to group without clinical improvement. conclusion: slit as a method of immunotherapy influence on levels of t reg cd + cd high cells. the observed decreased levels of these cells during the grass pollen season might be consider as a prognosing marker of clinical improvement. | t reg cd + cd high from peripheral blood during subcutaneous specific immunotherapy (scit) for grass pollen hofman a; hofman j; hofman t centrum alergologii, poznan, poland background: specific immunotherapy is the only causal method for grass pollen allergic rhinitis. however, we don't observe in every patients satisfying clinical effects. because the treatment of allergic rhinitis takes - years, and is quite expensive, everyone is constantly looking for a perfect parameter, which may prognose the effectiveness of specific immunotherapy (sit). the aim of this study was to evaluate t reg cd + cd high lymphocytes from peripheral blood in patients during subcutaneous specific immunotherapy (scit) for grass pollen . method: we examined adult patients ( female, male), age - , who undergo scit for grass pollen allergy. we have done skin prick tests and specific ige in those patients. additionally, we confirmed the allergy by nasal provocation tests. we have determined lymphocytes t reg cd + cd high from blood sampling from those patients, with flow cytometry method: before immunotherapy, after reaching the maintenance dose of scit, before and during the grass pollen season, and after one year of scit. our control group was represented by adult healthy volunteers. after one year of scit we divided patients into two groups-with and without clinical improvement. results: in allergic patients we have observed decreased levels of t reg cd + cd high compared to control group before the start for scit. during immunotherapy, the percentage of t reg cd + cd high increased after reaching the maintenance dose, however it did not reached the level of healthy volunteers. again, levels of t reg cd + cd high decreased before and during the grass pollen season, and increased after one year of scit. we compared also patient with significant improvement of clinical symptoms, and without. and we observed that the level of t regs cd + cd high decreased during pollen season in improved group, and increased in the group without clinical improvement. conclusion: in patients with grass pollen allergy, during the grass pollen season, decrease of t reg cd + cd high cells might be con- results: in the group of patients treated with sit gene expression analysis revealed significant change in ifng expression (p = . ) (comparison between sample a and b). comparison between samples a and c showed significantly different expression in genes: afap l (p = . ), commd (p = . ), pik cd (p = . ), and twist (p = . ). duncan's multiple range test confirmed difference between sample a and c for commd (p = . ) and also revealed new significant difference in tbx in samples a and b (p = . ; in wilcoxon's test p = . ). k nearest neighbors algorithm was built based on ifng, pik cd, commd expression. the results of the study indicate, that there is a significant change in the expression of a few genes during the build-up phase of sit. it may be suspected, that this change contribute to the mechanisms involved in the building tolerance to allergen. k nearest neighbors algorithm may be useful for sit efficacy prediction. | regulation of cytokine thymic stromal lymphopoietin (tslp) in modulating tgf-ß induced interstitial inflammation and cellular fibrosis background: thymic stromal lymphopoietin (tslp) has previously been linked to allergic inflammatory diseases, tissue fibrosis and organ dysfunction. it remains unclear, however, whether tslp plays any role in the occurrence of renal fibrosis, so this study investigated that underlying mechanism. method: an in vitro fibrosis model was established by treating normal rat kidney fibroblast (nrk- f) cells with transforming growth factor-β (tgf-β ), after which the levels of various fibrogenic markers (e.g., fibronectin) and downstream fibrogenic signal proteins (e.g., smad ) were investigated. also, tslp shrna was used to silence the effects of tslp, while an elisa was conducted to evaluate the fibronectin secretions. results: the level of fibronectin in the nrk- f cells was doseand time-dependently increased by the administration of exogenous tslp (p < . ). tslp also significantly increased the level of fibrosis signaling, in addition to inducing a marked decrease in the down-regulation of smad . interestingly, the application of tslp shrna caused a dramatic reversal of the tgf-β -induced cellular fibrosis while simultaneously leading to the suppression of fibronectin and fibrogenic signal proteins. conclusion: taken together, these observations provide insights into how extracellular matrices develop and could lead to potential therapeutic interventions for the suppression of renal inflammation and fibrosis. abstracts | | effects of two years treatment with the recombinant b cell epitope-based grass pollen allergy vaccine bm on allergen-specific b and t cell responses background: bm contains recombinant fusion proteins of nonallergenic peptides from ige-binding sites of the four major timothy grass pollen allergens phl p , , and and pres protein from the hepatitis b virus as a carrier. in a multicentre, double-blind, placebocontrolled trial, grass pollen allergic subjects were treated for two years either with bm or placebo. here we investigated in detail the effect of immunization with bm on allergen-specific t and b cell responses. during the study from subjects treated in the vienna centre (bm : n = , placebo: n = ) were investigated regarding proliferation using h thymidine incorporation and cytokine production in response to various recombinant allergens at different time points. grass pollen allergen-specific ige, igg and igg levels were determined by immunocap and elisa. results: a significant increase of allergen-specific igg and igg levels was found in the bm -but not in the placebo group in both years (year > year ) after treatment. there was no difference regarding t cell proliferation in response to phl p and phl p after first grass pollen season between actively and placebo-treated patients whereas proliferation in particular of phl p -specific responses seemed to be blunted in the active group in the second year. no significant differences regarding allergen-specific th , th and tolerogenic (i.e., il- ) cytokines were observed between bm and placebo-treated patients. the findings indicate that the bm induces high levels of allergen-specific blocking antibodies which may reduce allergen-specific t cell proliferation but does not induce significant increases of regulatory cytokines in t cells. this study was supported by grants f , f and dk -b of the austrian science fund (fwf). hospital universitario ramón y cajal, madrid, spain; department of immunology iis-fundación jiménez díaz, uam, madrid, spain background: shiitake mushroom (sm) (lentula edodes) is an edible fungi native to east asia. it is traditionally cultivated and used in many asian countries and its consumption is increasing worldwide. direct skin exposure to sm can cause cutaneous reactions, including allergic contact dermatitis and urticaria, while its oral intake may prompt "shiitake flagellate dermatitis" (sfd), which is a distinctive itching linear erythematous eruption. sfd is usually considered a toxic reaction to lentinan, a thermolabile polysaccharide that increases interleukin- . we report cases (p , p , p ) of shiitake flagellate dermatitis studied in our centre. method: skin prick tests (spt) to environmental allergens-including moulds -, prick-by-prick and patch test with raw and cooked sm were carried out. total ige and specific ige to mushroom, white mushroom and environmental moulds were also determined. a raw and cooked shittake mushroom extracts were prepared. both extracts were analyzed in all the patients by sodium dodecyl sulfate polyacrylamide gel electrophoresis (sds-page). results: skin prick tests, prick-by-prick, patch tests and specific ige were all negative except for p , who had positive prick-by-prick to raw shiitake mushroom. sds-page ige immunoblotting assays with the patient's sera revealed ige-reactivity with proteins ranging from kda to kda for p , p and p . we report cases of shiitake flagellate dermatitis with demonstrated ige-sensitization. physicians should take into account that some cutaneous reactions considered as toxic might be allergic reactions. vorozhko i ; sokolnikov a ; sentsova t ; donnikov a ; ilyenko l ; denisova s background: allergic diseases such as asthma, rhinitis and food allergy have increased in recent decades in tropical countries. the tropics has climatic, environmental and ecological peculiarities that allow us to emit several hypotheses that could explain this phenomenon. in one of them, it is postulated that the increase of the sensitization to food, is due to the presence of lower serum levels of vitamin d, product of the adoption of a western lifestyle, with lower sun exposure, which in its turn diminishes the immunomodulatory action of this vitamin at intestinal level, favoring the sensitization against food antigens. we evaluate differences between the titers of serum antibodies against food antigens between two populations with african ancestry but different environment (rural vs urban) and investigate the influence of vitamin d levels. method: an observational, cross-sectional and descriptive study was carried out on afro-descendant children living in san basilio de palenque (rural) or in the city of cartagena, bolivar (urban). the sensitization was determined by a positive skin prick test to allergen extracts, including foods, and, specific ige, iga and igg to egg, milk and peanut extract, as well vitamin d, were measured by elisa. antibody and vitamin d titers were correlated by spearman's test and comparisons between groups were done using the wilcoxon rank sum test. a p < . was considered significant. results: atopy was more prevalent in the urban population ( % vs %, p < . ). however, none participant tested was positive for food allergens. regarding vitamin d levels, these were found to be higher in the rural population compared to the urban group (p < . ). among the antibodies analyzed, only ige against peanut showed differences, which were higher in rural population (p < . ) as well as those of iga to peanut, which were higher in the urban population (p < . ). we observed only a significant correlation between peanut specific ige (rho . , p < . ) and iga (rho - . , p < . ) response and vitamin d. conclusion: in our study, we found differences between the peanut specific ige and iga response in urban and rural populations. the correlation between the levels of specific ige and iga to peanut and vitamin d, suggest that this vitamin may influence peanut sensitization in this population, besides other components like diet and genetic and environmental factors. | evaluation of inhaled allergen sensitivity in patients with food allergies younger than two years of age kulhas celik i ; aldemir es ; buyuktiryaki b ; ginis t ; toyran m ; dibek misirlioglu e ; kocabas cn ; civelek e carbohydrates and pyruvate was observed in the severe group compared to the rest of allergic groups. in addition, an increment in lactate was noticed. these metabolites were closely associated with the energy metabolism. other metabolic changes included increased levels of fatty acids such as myristate, palmitate and laureate. these fatty acids might be precursors of arachidonic acid, a key molecule in inflammation. finally, alterations in some amino acids and adenosine were found method: to evaluate these critical processes, five-week old germ-free c h/hen mice were split into two groups; were intraperitoneally sensitized to the peanut allergen ara h and remained ns. upon reaching weeks of age, mice were intragastrically challenged with purified ara h . mice were harvested in two groups: -minutes and -minutes post-gavage. upon harvest, the left lobe of the liver was collected and sera were removed. sera and livers were evaluated for drp-ara h using an in-house quantitative sandwich enzyme-linked immunosorbent assay (elisa). a sample of the proximal small intestine was monitored for drp-ara h using immunohistochemistry (ihc) and for mast cell degranulation using toluidine blue stain. results: sensitization does not have a large effect on the concentration of allergen present in the sera or liver. however, s mice allowed to digest ara h for -minutes were more likely to display tissues positive for detection of drp-ara h than ns mice at the same time point. conclusion: there is drastic biological variation among mice in their capacity to absorb and transport allergens. the elisa used in these analyses proved effective in the quantitative detection of drp-ara h in both liver and sera samples, while ihc provided inconsistent results for the detection of drp-ara h in tissues. however, in positive ihc samples, staining was indicative of paracellular transport across the epithelial barrier. | eczema induces a high ovalbuminspecific ige/igg ratio and affinity maturation during the lactation period irahara m; kido h; shinahara w inst. for enz. res., tokushima university, tokyo, japan background: recent articles have revealed that ingestion of foods induces oral tolerance and cutaneous sensitization induces food allergy. relationships with levels of immunoglobulin subclasses, affinity of allergen-specific ige, and development of food allergy have also been indicated. however, relationships with levels and affinity of specific immunoglobulins and eczema during early infancy remain poorly understood. therefore, the present study aimed to elucidate these relationships. method: this study enrolled women who visited naruto hospital (tokushima prefecture, japan) in late pregnancy and their children. blood samples and information on skin condition were taken every months from neonate to months old. egg white and milk allergen-specific immunoglobulin subclasses and affinity of ovalbumin (ova)-specific ige levels were measured using the densely carboxylated protein (dcp) microarray with μl of serum. results: this study included infants whose parents agreed to join this study. of these, infants ( %) were diagnosed with eczema by months old. egg white (ew) and milk-specific igg were detected in a few subjects at months old. however, these specific ige and igg were detected in some subjects at that time ew-and ova-specific ige levels and ige/igg ratios were significantly higher in participants with eczema than in those without eczema at months old. moreover, subjects with high ova-specific ige/igg ratios showed higher affinity ova-specific ige antibodies than subjects with low ova-specific ige/igg ratios. these results were not reflected in milk-specific ige levels. the milk-specific ige level differed between breast feeding and formula-fed infants, with no difference in the ige/igg ratio. conclusion: eczema contributed to high ew-and ova-specific ige levels and ige/igg ratios. high ova-specific ige/igg ratios involved high affinity ova-specific ige antibodies. however, the milk source during early infancy had no effect on the specific ige/igg ratio with eczema. these results suggest different sensitization routes provoke different results in levels and affinity of immunoglobulins. | purification and characterization of naturally occurring post-translationally cleaved ara h , an allergen that contributes substantially to the peanut allergome background: the s albumin ara h is one of the most important peanut allergens. a post-translationally cleaved ara h isoform has been described in the past but had not been characterized in detail, nor had its relevance for peanut allergy been investigated. method: post-translationally cleaved ara h (para h ) and intact ara h (intact ara h ) were purified from virginia type peanuts and the cleavage site was mapped using high-resolution mass spectrometry. biochemical characteristics were determined by sds-page, uv absorbance spectroscopy, far uv cd spectroscopy, and immunochemical reactivity of both forms of ara h was compared by igg immunoblotting and ige-elisa using sera from individuals sensitized to peanut. reversed-phase liquid chromatography was applied to study the occurrence and abundance of para h in various peanut types. results: compared to intact ara h , para h lacks a -amino acid stretch, resembling amino acids - (uniprot accession number q g ) in the non-structured loop. consequently, para h consists of chains; a n-terminal chain of approximately kda, and a c-terminal chain of approximately kda, held together by disulfide bonds. intermediate post-translationally cleaved products, in which this stretch is cleaved but not removed, are also present. the secondary structure and ige-binding of para h resembles that of intact ara h , indicating that the loss of the non-structured loop is not critical for maintaining conformational ige-epitopes. both forms of ara h were reactive with several commercially available igg antibodies. the peanut cultivars runner, virginia, valencia, and spanish contained para h at equivalent levels, suggesting para h is a consistent and important constituent of the peanut proteome. conclusion: a post-translationally cleaved form of ara h is abundant in the main peanut market types, and has ige-binding comparable to intact ara h . this should be taken into account when ara h is investigated in peanut-containing products. | release of major peanut allergens from their matrix at various ph and at saliva conditions; ara h and ara h are quickly bioaccessible background: the oral mucosa is the first immune organ that encounters allergens upon ingestion of food. peanut is often consumed in solid form, and it is not known if peanut allergens are released from the food already in the mouth. we set out to investigate the solubility of individual peanut allergens at conditions that mimic the first exposure site, i.e. the mouth. method: light roast peanut flour was suspended in buffers of various ph mimicking saliva. protein concentration was measured in supernatant, and release of major allergens ara h , ara h , ara h , and ara h was assessed by sds-page. also, the allergen profile of un-dissolved material was assessed. results: peanut protein solubility is poor in the ph range - , while at low ph ( . ) and at moderately high ph (> ), the solubility is higher. at all conditions tested, there was a substantial amount of un-dissolved protein. this indicates that the ph range of saliva, between . and . in healthy individuals, may be critical for the release of peanut protein from its matrix. in this ph range from . to . , ara h and ara h are readily released, while ara h and ara h are poorly released. increasing the ph from . to . slightly increased the release of ara h and ara h , but still the recovery was low (approximately % for both ara h and ara h ) compared to that of ara h and ara h (approximately % and %, respectively). this remarkable difference in extraction kinetics suggests that ara h and ara h are the first allergens an individual is exposed to upon ingestion of peanut-containing food. conclusion: based on our observations, we conclude that the peanut allergens ara h and ara h are quickly bio-accessible in the mouth upon ingestion of peanut. this new insight may contribute to the understanding of the extraordinary allergenicity of ara h and ara h compared to other peanut allergens. background: in proven cases of non-ige mediated cow's milk allergy clinical response can be partial even when treated with amino acid formulae e.g pain in infants. residual intestinal symptoms can be related to ongoing nerve hypersensitivity, changes in microbiome or motility disturbance. mast cells are thought to play crucial role in non-ige mediated food allergy. ketotifen is a first generation h antihistamine which has mast cell stabilising properties with pain blocking and anti tnf-a effect. hence ketotifen could have important role in symptom resolution where diet elimination has not been successful. we aim to find out effectiveness of ketotifen to unresponsive/partially responsive symptoms such as pain in non-ige mediated cow's milk allergy infants. method: children who presented to single specialist centre over years had their case notes reviewed retrospectively. inclusion criteria were those children with confirmed non-ige mediated cow's milk allergy by elimination of cow's milk with improvement of symptoms and worsening of symptoms on reintroduction of dairy. where symptoms partially responded e.g pain, ketotifen was used at . - mg once at night for weeks and symptoms were reassessed. statistical analysis was performed using r v . . with significance was set at p = . . results: patients were identified with patients excluded due to unconfirmed non-ige mediated allergy. of the case ( males, age - months), atopic co-morbidities were found in % children. common symptoms were abdominal pain ( %), vomiting ( %), back arching ( %), constipation ( %), bloating ( %), food aversion ( %) and diarrhoea ( %). we compared the children who had symptom improvement on ketotifen and cow's milk elimination against children who improved on cow's milk elimination alone. significant difference of symptom improvement was found with abdominal pain; % using ketotifen compared to % who did not use results: a total of analysis for ttgiga have been performed for a total of patients during the study period ( , , , ) . patients showed at least once a positive ttgiga. among these, had a negative result at first testing, and were positive at the second (n = ) or third testing (n = ). despite an increasing number of ttgiga requests, the number of positive results decreased. wige were rarely requested but were positive in about % of tested sera (table a and b). the amount of laboratory requests for ttgiga has increased, while those for wige remains stable and is rare. wheat allergy seems to be rarely investigated in our center and may deserve more attention. case report: eosinophil-associated gastrointestinal disorders (egids), including eosinophilic gastroenteritis (eog), are a inflammatory diseases, characterized by gastrointestinal symptoms and eosinophilic infiltration. patients with eoe have an increased incidence of allergy, with increased ige mediated food and inhalant sensitivities. use of either a targeted food allergen avoidance approach (based on allergy testing) or untargeted approach (based on food allergen avoidance) results in the resolution of eosinophilia in the gastrointestinal tract of %- % of adult. we describe a case of a -year-old patient diagnosed with eosinophilic enteritis, associated to protein-losing enteropathy. the patient experienced severe diarrhea, nausea, vomiting and weight loss, that caused a severe dysproteinaemia and electrolytes abnormalities. an upper and lower endoscopy was performed, showing an ulcerative ileitis. the histological pattern was characterized by eosinophilic infiltration of ileum and duodenum> hpf. she presented also high levels of total ige ( k/ui), high serum tryptase ( μg/l, n.v. ≤ . ) and sensitization to the lipid transfer protein (ltp) of peach. the patient was prescribed to a six-food elimination diet (sfed) and underwent high doses of oral and intravenously corticosteroids, but a satisfactory therapeutic response was not achieved. we hypothesized that ige has a role in the mechanism of aeg and that blocking ige would have improved disease symptoms and reduced allergic inflammation, as measured by a decrease in intestinal tissue eosinophilia. we started off-label administration of omalizumab mg/month subcutaneously, the same dosage schedule used in allergic asthma and, by other authors, in eosinophilic gastrointestinal disease after achieving informed consent by patient. except for an exacerbation of symptoms occurred months after starting the therapy, when a further endoscopy, showing a gastrointestinal eosinophilic infiltration> hpf, was performed, a significant improvement of both gastrointestinal and cutaneous symptoms was observed during therapy, together with a normalization of laboratory parameters. after months a clinical remission of disease was obtained and administration was stopped. although a histological remission during the first few months of treatment was not obtained, in a subset of aeg patients, ige plays a role in the pathophysiology of the disease and that anti-ige therapy with omalizumab may result in disease remission. | fullerene c reduces the allergic inflammation in food allergy mouse model background: a food allergy (fa) is an abnormal immune response to food. the signs and symptoms may range from mild to severe. they may include itchiness, swelling of the tongue, vomiting, diarrhea, hives, trouble breathing, or low blood pressure. food allergy is becoming increasingly common. fullerene c has the unique electronic properties making it an attractive candidate for allergic diseases therapy. the main purpose of our research was to assess therapeutic effect of fullerene c in a mouse model of fa. method: new efficient method for producing a water-soluble fullerene c has been developed. fa experimental model was induced in balb/c mice by the intragastrical (ig) ova administration after subcutaneous (sc) sensitization. fullerene c was administrated ig once a week, or twice a week, or daily. ova-specific antibodies were assessed by elisa. splenocytes cytokine production upon ova in vitro stimulation was detected by elisa. samples of jejunum of the small intestine were removed for histological examination immediately after the last ig allergen administration. results: it was shown that ova-specific ige and il- level were significant decreased in groups treated with water-soluble fullerene c . the greatest effect was observed in mice receiving fullerene c daily. the ifn-gamma level was significantly higher in ig c treated groups. the histologic analysis of jejunum of the small intestine samples showed that c -therapy improved the histologic picture. the greatest effect was observed in mice receiving fullerene c daily too. conclusion: taken together, these results demonstrate that the water-soluble fullerene c exhibits a significant anti-inflammatory effect in a mouse model of fa, and possesses a high therapeutic potential. background: a -year-old male reported eight episodes of anaphylaxis after exercise. all the ingested food eight hours before each episode was analyzed. before each episode, he had always eaten chicken or turkey meat, and he tolerated these foods without exercising. in one of the episodes the patient had taken a tablet of dexketoprofen a few hours before. since several years, he referred chest tightness after eating some fish (emperor, salmon and whiff), however he tolerated others. the patient denied having eaten fish before any of the episodes of anaphylaxis. method: commercial skin prick tests (spts) and prick by prick tests (pp) with all food ingested and fishes were performed. tryptase, total serum ige (ige) and specific ige (sige) (immunocap. thermo-fisher scientific, uppsala, sweden) to the foods involved were determined. a controlled oral provocation test (opt) with dexketoprofen was performed. results: spt was positive to tuna extract ( mm) and negative ( mm) for the rest of fish extracts. it was also negative for chicken meat extract and other foods tested. pps were positive for raw and cooked turkey meat ( mm), raw and cooked tuna ( and mm), raw emperor ( mm), raw and cooked whiff ( and mm) and raw hake ( mm). pps were negative to raw and cooked chicken meat. ige was ui/ml and tryptase . ng/l. sige was slightly positive to hake, cod and chicken meat. dexketoprofen opt was negative. at that moment, we recommended the patient to avoid chicken and turkey, as well as the fishes which he had symptoms with. since then, he has not suffered any new episode of anaphylaxis despite exercising daily. protein extracts from turkey meat, tuna, emperor, salmon, hake and whiff were prepared and analyzed by sds-page. conclusion: recently, triosephosphate-isomerase ( kda) has been identified as a new chicken meat allergen. this allergen could be responsible for the cross-reactivity between bird and fish meat and the episodes of anaphylaxis after exercise in our patient. the triosephosphate-isomerase has not been implicated previously as a cross-reactive allergen involved in the fish-chicken syndrome. results: twenty-three patients were included, % male, median age years (iqr . ), % atopic, % asthmatic. non-specific lipid transfer proteins (nsltp) were implicated in % (n = ) and ω- -gliadin in % (n = ). eighteen ( %) patients referred anaphylaxis in the reaction with co-factor, ( %) urticaria/angioedema, had both depending on the co-factor. all patients in which ω- -gliadin was the allergen involved had anaphylaxis in the presence of co-factor, with tolerance to wheat without it. in patients in which nsltp was the allergen involved, ( %) had anaphylaxis in the presence of co-factor. reaction with co-factor was more severe than without in ( %) patients; patients had no previous history of reaction and subsequently tolerated the culprit food. only patient had anaphylaxis in the absence of co-factor; the remaining presented oral allergy syndrome and/or urticaria. exercise was the main co-factor, present in patients. nonsteroidal anti-inflammatory drugs (nsaids) were the only co-factor in patients; all of them had anaphylaxis, with allergy to ω- -gliadin, to nsltps. all subsequently tolerated the nsaids involved. conclusion: nsltps and ω- -gliadin were the most frequently involved allergens in cefa, with exercise being the most frequent co-factor. nsaids were relevant co-factors, even when ω- -gliadin was the allergen involved. several patients subsequently tolerated culprit foods and nsaids, difficulting the diagnosis and further emphasizing the importance of a correct cofactor evaluation. molecular allergens had an important role in the diagnosis, avoiding unnecessary ofc. information about co-factors must be included in all patients with allergy to nsltps and ω- -gliadin. | allergy to wheat-dependent exerciseinduced anaphylaxis (wdeia) proteins, without? -gliadins as responsible ferreira a ; castillo m ; martins s ; pineda f unidade de imunoalergologia hospital das forças armadas., lisbon, portugal; departamento de aplicaciones. diater laboratorios, madrid, spain background: the second well-characterized form of allergy to wheat proteins is wheat-dependent exercise-induced anaphylaxis (wdeia), with the ω -gliadins (part of the gluten protein fraction) being the major group of proteins which are responsible, but other forms of food allergy have also been reported, with the proteins responsible including gluten proteins, cm proteins and non-specific lipid transfer proteins. the patient was a -year-old man who visited the hospital with acute urticaria just eat bread before run ( minutes). according the components of bread. it was formed by a mixture of wheat, rye and barley. with a history (for several years) of episodes of severe urticaria after intake a mixture of cereals and/or different kinds of beer. results: prick test and specific ige with wheat, rye and barley were negative and the proteins from allergenic extract from these cereals, and also the gliadins and glutenins fractions were transferred onto a pvdf membrane to carried out a western blot technique with the patient's serum. the patient's serum recognized several proteins from wheat and millet gliadins not compatible in molecular mass with a ω -gliadins. the association of w gliadin as responsible for the symptoms produced after the intake of products containing wheat and exercise is well referenced but in the case of this patient could have other proteins involved as triggers of their symptoms. suksawat y phramongkutklao hospital, bangkok, thailand background: food-dependent, exercise induced anaphylaxis (fdeia) is an anaphylactic condition that develops in patients who ingest specific food followed by exercise. a variety of foods have been described to be the cause including shellfish, wheat and vegetables. the mechanisms of fdeia is believed that exercise increases allergen absorption or decreases threshold of mast cell. the investigations such as skin prick test or specific ige for food are useful because food sensitization is demonstrated. however, a challenge test including ingestion of suspected food followed by exercise is the only method to diagnose this disease. we report a case of fdeia in a -year-old adolescent male. result: he presented with generalized urticaria and hypotension after eating a barbecue buffet which was one hour followed by playing taekwondo. after treatment with intramuscular adrenaline, antihistamine and systemic steroid, his condition was improved. the barbecue buffet consists of many kinds of food including shrimp, squid, salmon and pork meat which were previously tolerated. he had no past history of anaphylaxis or drug allergy. he was referred to our allergy unit for investigation. we performed skin prick test with food allergens and many kinds of fresh foods that he ate on that day and the result was positive to shrimp ( mm. in diameter). three-day challenge protocol was set up a month after recovery and we used aspirin as a cofactor. on the first day, open challenge for gram of shrimp was administered and the result was negative. on the second day, exercise challenge test based on the american thoracic society guideline was also negative. however, on the last day, he developed generalized urticaria five minutes after the same exercise challenge test which was hour preceded by aspirin intake and gram of shrimp ingestion. but his vital signs appeared to be stable. the patient was administered intramuscular adrenaline and antihistamine with full recovery. he was strongly advised to avoid shrimp for - hours before exercise and carry an adrenaline autoinjector. the-three day challenge protocol is a definite tool to confirm the diagnosis of fdeia. a correct diagnosis is important to avoid unnecessary restricted diet. | food dependent exercise induced anaphylaxis in peach allergic patient-case report consumption of different types of food (pancakes with cream cheese and fruit, peach, chinese dish, sandwiches-all eaten on other occasions without symptoms) and co-occurring physical exercise (dancing, shopping, walking). during diagnosis we performed spt with inhaled and food allergens (allergopharma), prick by prick tests with peach, banana, apple, pear and bread. we established the concentration of allergen specific ige (peach, wheat flour, peanuts, hazelnuts) and the level of ige specific to allergen components (immunocap isac). we performed exercise provocation test and open food challenge with peach. results: spt were negative with all tested food and inhaled allergens (inc.egg; milk; cocoa; tomato; carp; apple; banana; strawberry; rye flour; wheat flour; peanuts; hazelnut; citrus, d. farinae; d. pteronyssinus; grass; weeds; clad. herbarium; alt. tenuis; dog; cat; poplar; hazel; alder; birch; mugwort). prick by prick tests were positive with fresh peach. concentration of peach specific ige was . ku/l. in immunocap isac we found elevated levels of ige specific to ltps from different allergen sources (jug r - . ; pru p - . ; pla a - . ; tri a - . [isu-e]). open food challenge with a medium size peach was negative. exercise provocation test without allergen exposition was negative. exercise provocation test after eating a medium size peach concluded with severe lip and eyelids edema, followed by whizzing, dyspnea and urticarial. patient received adrenaline . mg im, steroids and antihistamines with good clinical effect. conclusion: patient was diagnosed with food dependent exercise induced anaphylaxis (fdeia) due to ltp allergy. she was advised to eat peeled fruit and vegetables, avoid cofactors of allergic diseases and carry rescue set (adrenaline, steroids and antihistamines). cases reports: we report case of fdeia and cases of wdeia. case : -year-old woman with intermittent severe allergic rhinitis and food allergies since childhood. in the last years she registered weekly episodes of fdeia (urticaria, angioedema, wheeze, drop of bp) especially when during effort and after alcohol intake. prick tests were positive for grass pollen, mugworth, ragweed, dust mites, celery, soy, sesame, pistachio, mango, honey and shellfish. she followed years of subcutaneous immunotherapy for grasses pollen. the fdeia episodes frequency and severity diminished during it. provocation test for celery and mango were positive, for alcohol, soy, sesame, pistachio, honey and shellfish were negative. case : -year old man with a -year history of acute gluten induced urticaria, recently developed episodes of wdeia (flushing, severe urticaria and angioedema, wheeze) when he went for gym. skin test was highly positive for wheat flour and dust mites, in vitro tests for omega gliadin and wheat-specific ige were positive. food challenge for wheat was positive. he followed oral immunotherapy for wheat. the wdeia episodes were rare and mild. case : -years old female with mild allergic rhinitis and controlled asthma, with wdeia (urticaria, angioedema, wheeze, drop of bp) in the last years. skin tests showed positive results for wheat flour, dust mites and dog hair. omega- gliadin and wheat specific ige were high, but the provocation test for wheat was negative meanwhile combined wheat and effort provocation test was positive. -year-old female athlete, otherwise healthy, experienced three episodes of fdeia following running sessions. two reactions were preceded by intake of salad containing lettuce, tomato and sunflower seeds and the third one occurred after eating celery salad. the patient denied occurrence of any symptoms with physical exertion or food ingestion alone. physical examination and blood testing did not reveal any abnormalities. the differential diagnosis was performed. in skin prick test and specific serum ige antibodies sensitization to house dust mite, grass and mugwort were found. the spt and specific ige assay to culprit and most common food allergens were negative. the molecular diagnostic has been applied (faber, caam, rome, italy). the test scored positive for art v, blo t, der f, der p, eur m, lol p, phl p. no positive results for available food molecules including celery, tomato, sunflower seeds and lettuce were found. the detection of culprit food in fdeia is of crucial meaning as the syndrome can be life-threatening. the molecular diagnostic has been applied already in diagnosis of wheat-dependent exercise-induced anaphylaxis (wdeia) proving ω- -gliadin sensitization in the majority of the cases. as the presented case did not reveal sensitization to culprit food in traditional allergy tests the molecular diagnostic was performed. this test did not show sensitization to culprit food either. however, not all of the molecules are available in molecular assays yet. cross-reactivity reaction to mugwort and grass has to be considered. the pathophysiological components of physical exertion has to be taken into consideration as well. this could contribute to the assessment of reasonability of molecular approach in diagnostic work-up for fdeia and to the establishment of standardized protocols for diagnosis and management of that syndrome. case report: food allergy to wheat is rare in adults, often reported in exercise-induced anaphylaxis. food-dependent exercise-induced anaphylaxis (fdeia) is a form of food allergy induced by exercise. fdeia symptoms can include urticaria/angioedema, respiratory and gastrointestinal manifestations and hypotension/shock. a -year-old male patient presented to the emergency department, was admitted after an episode of hives, hypotension and loss of consciousness. his consciousness was restored after treatment with epinephrine, glucocorticoids as well as fluids, and thereafter, the patient reported that the anaphylactic episode occurred when he started rapidly walking hour after eating a slice of pizza. he mentioned that the offended food was tolerated always when it was not followed by a physical exercise. review of his past medical history and family one were non-contributory with respect to this episode. the allergy skin prick testing for common foods revealed a positive response only to wheat, while and other laboratory test values were within normal ranges. the patient is discharged after instructions on the use of epinephrine auto-injector. he was also advised to avoid wheat containing products up to hours prior to physical exercise. our case demonstrated that fdeia can be characterized by the onset of anaphylaxis soon after physical exercise, when preceded by the ingestion of the responsible food. avoidance of the combination of the exposure to respective allergen and exercise is the most efficient precautive measure toward subsequent fdeia episodes. | residual exercise-induced allergic reactions after successful rush oral immunotherapies for milk and wheat method: we conducted roit for children (median . years old) with milk allergy and children (median . years old) with wheat allergy during - . after - days of the rush phase in the hospital and a slow-increasing phase at home, patients consumed the maintenance dose ( . g milk protein or g wheat protein). after at least three months of the maintenance phase without allergic symptoms, we conducted an exercise provocation test (ept) after eating the target food. if the ept was positive, we repeated it after a couple of years to check for remission. the presence or absence of eiars was based primarily on the results of epts but also on the clinical history in some cases. results: as of december , milk-and wheat-allergic patients were able to continue ingesting the maintenance dose (desensitization). in these patients, milk-and wheat-allergic patients underwent the first ept at a median of ( - ) days after roit, and the result was positive in ( . %) and ( . %) patients, respectively. among these ept-positive patients, milk-and wheat-allergic patients conducted a second ept at a median of ( - ) days after the first ept. the result of the second ept was positive in milk-and wheat-allergic patients. in addition, clinical histories of eiars were subsequently observed in milk-and wheat-allergic patients after negative results on an ept. altogether, ( . %) milk-and ( . %) wheat-allergic patients still had eiars even after getting desensitization as of december conclusion: patients with persistent milk and wheat allergy often have residual eairs even after three to five years of desensitization due to the administration of successful roit. abstracts | | anaphylaxis caused by omega- -gliadin initially diagnosed as idiopathic anaphylaxis: a case report tziotou m ; syrigos k ; syrigou e ; sinaniotis a department of allergy,, athens, greece; gpp,, athens, greece case report: we report the case of a -year-old man who experienced two episodes of wheat dependent exercise induced anaphylaxis, initially diagnosed as idiopathic anaphylaxis. first episode: the patient woke up in the morning and drove to his resort. while driving, he ate a piece of cheese and ham pie. when he arrived, he walked some meters to the garden and started feeling pruritus and dizziness. he lost consciousness and recovered by himself. he was carried to hospital where his vital signs were normal. the patient has a history of atrial fibrillation and has been on flecainide bid and aspirin at noon for the last four years. a month after the first episode he visited an allergist. skin prick tests to aeroallergens and prick to prick tests to the ingredients of the pie were negative. tryptase levels were within normal limits and skin biopsy was negative for mastocytosis. an endocrinology workup was also negative. the patient was prescribed an epinephrine autoinjector and was asymptomatic for eight months. second episode: that morning he had a cup of milk and two slices of toast for breakfast and started working in the garden. two hours later he experienced pruritus and urticaria and fell unconscious. his wife had to administer two epinephrine autoinjectors before he regained consciousness. after the second episode it was decided to start treatment with omalizumab. two months later he experienced an episode of urticaria while working in the garden. he could not recall what he had eaten before. based on history, we thought that a cofactor might contribute to the occurrence of anaphylaxis. we performed skin prick tests with peach (ltp) and gliadin, allergens associated with food dependent exercise induced anaphylaxis in our region. the test to gliadin was positive. specific ige in serum to omega- -gliadin was also positive, while specific iges to all ltps tested were negative. the patient was advised to avoid wheat and has been asymptomatic ever since. cases diagnosed with idiopathic anaphylaxis may actually be cases in which the culprit allergen has not been identified. detailed history and extensive workup may contribute to the successful management of these patients. written informed consent has been obtained from the patient. | wheat-dependent exercise-induced anaphylaxis (wdeia) and nsaids: clinical history is crucial conclusions :we present a case clinically compatible with wdeia with nsaids intake as augmenting factor. this case emphasizes that a carefully and thoroughly taken medical history is of crucial importance, otherwise wdeia can easily be unrecognized. as a result, non-allergic hyperreactivity to nsaids could be excluded and the diagnose of selective allergy to arylpropionic acids was made. exercise challenge test could not be performed in our case. case report: kounis syndrome (ks) has been defined as an acute coronary syndrome that manifests as unstable vasospastic or non-vasospastic angina, and even as acute myocardial infarction. it is triggered by the release of inflammatory mediators following an allergic insult. a -year-old woman with type ii diabetes and hypertension, and unstable angina pectoris as cardiovascular risk factors, has consumed chamomile tea. thirty minutes later, she developed generalized itching, skin rash, swelling of the face and the throat, chest tightness, dyspnea and syncope. the patient was transferred immediately to the emergency department, and sodium chloride, mg prednisolone, mg dexamethasone, mg methylprednisolone, ui heparin, mg voltaren were intravenously administered along the subsequent minutes under simultaneous treatment with oxygen therapy. an ekg examination is performed based on the patient disease's history, showing a . - mm st-depression on d -d leads, mm on v , and . mm on the v -v ones. in addition, . mm st-elevation on the avr and mm on the v derivation was observed, associated by a negative t-wave on the v , v , and avr leads. blood tests revealed a normal troponin i level (of . ng/ml). five hours later in the ekg was noticed: isolined st-segments, and negative t waves on the d , avr, and v leads. ultrasound examination revealed normal heart kinetics and function. following the heart changes, the patient was administered sol. heparin ui twice i.v., nebivolol mg, plavix mg, atorvastatin mg, abstracts | monocinque mg, ordinary insulin ui s.c., glargine insulin ui s.c., and sol. furosemide mg i.v. the patient progressed favorably, and four days after the anaphylactic episode the ekg revealed a . mm st-depression on leads v , and v , negative t-wave on avl lead, and normalized one on the v one. this case emphasizes the role of serious allergic reactions as cause of acute coronary syndrome in patients with altered coronary arteries and food intake as cause of kounis syndrome. | recall urticaria in two young patients with alpha-gal-syndrome after tick bites case report: patient a (m, age ) had suffered from - anaphylactic reactions (hives, nausea, dyspnea and dizziness) within the past months. all episodes occurred - hours after ingestion of red meat, once with alcohol as a co-factor. all episodes started with a wheal measuring about . cm in exact the same spot where he had been bitten by a tick one year before. specific ige to galactose-alpha- , -galactose (alpha-gal) was positive ( . ku/l). skin prick testing using raw pork kidney suspension and intradermal testing with gelafundin ® % diluted : also showed positive reactions. we performed an oral challenge with cooked pork kidney under careful monitoring being able to reproduce the recall urticaria as described above with a cumulative dose of g pork kidney. we stopped the challenge and treated the patient with antihistamines and corticosteroids. patient b (m, age ) reported on several anaphylactic reactions within the past years with symptoms including abdominal pain, diarrhea, as well as dyspnea and loss of consciousness in one of the episodes. all episodes occurred several hours after ingesting food. furthermore the patient remembered a tick bite about years before the first anaphylactic reaction, which repeatedly became inflamed and only healed completely over months. every episode started with pruritus and a wheal in the area of the former tick bite (in loco). specific ige to galactose-alpha- , -galactose was positive ( . ku/l) as well as the skin prick testing with cooked pork kidney and intradermal testing with gelafundin ® % diluted : . this patient refused performance of oral challenge tests. an elimination diet of red meat for months resulted in the absence of the symptoms as described. the diagnosis of alpha-gal-syndrome with recall urticaria in loco was made in both cases. this symptom may also be useful in evaluating results of oral challenge tests as well as an important clinical sign in medical history. pali-schöll i ; meinlschmidt p ; purschke b ; hofstetter g ; einhorn l ; mothes-luksch n ; jensen-jarolim e ; jäger h background: insects have gained interest as alternative nutrient source for humans and animals. however, being a "novel food" in the industrialized part of the world, several safety aspects, like allergenicity, need to be thoroughly addressed. in the present work we evaluated the cross-recognition of ige from patients allergic to crustaceans, house dust mite or stable flies, using house cricket acheta domesticus (ad), desert locust schistocerca gregaria (sg) and mealworm tenebrio molitor (tm). we further investigated changes of immune-recognition in terms of ige-binding in differently processed insect extracts. method: migratory locust locusta migratoria (lm) was subjected to different extraction methods, enzymatic hydrolysis or thermal processing, whereas tm larvae (tml) were evaluated after different centrifugation modes and ph levels. results: we revealed that ige from patients with crustacean allergy shows cross-recognition of acheta domesticus, schistocerca gregaria and stable flies. ige from house dust mite allergic individuals binds to acheta domesticus and schistocerca gregaria. importantly, the cross-reactivity to lm can be deleted by enzymatic hydrolysis with different enzymes or heat treatment (cooking, autoclaving), but not by different extraction methods. changes of ph and varying centrifugation steps are not sufficient to reduce ige-binding to tml. our results show that patients allergic to crustaceans, house dust mite or stable flies-allergic patients cross-recognize desert locust and house cricket proteins, and crustacean-allergic patients also flies proteins. furthermore, we confirm that the appropriate food processing method of insect proteins can reduce the risk of cross-reactivity for crustaceans-and house dust mite-allergic patients. the study was supported by the austrian science fund fwf (grant sfb f -b to ejj). results: the mean age at diagnosis was years in children and years in adults, more frequent in males ( : ). in the pediatric group, three had first-degree relatives with eoe and three had celiac disease. two children had performed milk oral immunotherapy and five adults aeroallergens subcutaneous immunotherapy. most of them were atopics with sensitization to aeroallergens ( . % of children and . % of adults) and food allergens ( % of children and . % of adults), without statistically significant differences. the most frequent foods were fruits and nuts in both groups. we found significant statistical differences in fruits ( % of children abstracts | and . % of adults; p = . ) and cereals sensitization ( % of children and . % of adults; p < . ). in the clinical presentation we observed significant statistical differences in impaction ( . % of children and . % of adults; p < . ), dysphagia ( . % of children and . % of adults; p < . ) and abdominal pain ( % of children and . % of adults; p = . ). in the endoscopic findings children had more frequently exudates ( . %; p < . ) and adults had esophageal trachealization ( %; p < . ). significant statistical differences were found in the treatment with topical corticosteroids ( % of children and . % of adults; p < . ) obtaining a variable positive response. . % of patients in both groups received food elimination diet, % with four or more foods. conclusion: eoe presents differences in the sensitization profile, clinical manifestations and endoscopic findings according to the age of presentation. the response to pharmacological treatment is variable and a high percentage of patients receive food elimination diets. it is a pathology difficult to control, therefore new non-invasive techniques would be useful in order to facilitate its management. | modulation of gut microbiota in patients with nickel allergy and ibs after diet and probiotics supplementation mb ; garcía-figueroa be department of allergy department of allergy fang l united states | bcx improves health-related quality of life in hereditary angioedema with c -inhibitor deficiency bygum a fang l former yugoslav republic of; division of clinical immunology huissoon a bygum a ; panovska vg united states callejas fdb alobid i ; muñoz-cano r izquierdo i icahn school of medicine at mount sinai method: the case report form was developed by experienced allergists, and the web-based registry was established in cooperation with a professional medical software team. twenty-two departments from hospitals took part during the first year %), whereas in adults, drugs ( . %) were more common than foods ( . %). the most common food triggers were eggs ( . %), milk ( . %), and walnut ( . %) in children, and shrimps ( . %), wheat ( . %), and crab ( . %) in adults. among drug triggers in adults, antibiotics ( . %) were the most common cause followed by nsaids ( . %), and h -blockers ( . %). the onset time was≤ minutes in . %. in children, home was the place of occurrence in more than half of the cases, whereas adults experienced anaphylaxis in out-of-home settings more often than children. cofactors were present in %. among the cases registered via the emergency department of participating hospitals, epinephrine was administered in . % ( . % in adults, . % in children) and the route of administration was im in . %, iv in . %, both im and iv in . %, and subcutaneous in . %. the number of epinephrine administration was single in % conclusion: this multicenter prospective registry would provide a better understanding of anaphylaxis, and provide visionary modalities to improve the management and prevention of anaphylaxis in future a case of kounis syndrome after chamomile tea consumption characterized by symptoms related to esophageal dysfunction and esophageal mucosal infiltration by eosinophils objective: characterize patients (pts) with eoe diagnosis and analyze the differences between pts with diagnosis at pediatric (ch, < years old) and adult age epicutaneous tests(epict)], serum total ige and eos, findings in upper digestive endoscopy (ude) and biopsies. the correlation between food sensitization, clinical severity (visits to er services or hospitalization due to complications of eoe, sclin) or severe histology results: pts ( % male, average age ± years) ad and , respectively. % ch and % ad were atopics. the most frequent symptoms of eoe were dysphagia ( %) and gastroesophageal reflux( %) in ch; impaction( %) and dysphagia( %) in ad. % ch and % ad had aeroallergens sensitization. % ch and % ad had food sensitization. the most frequent positive tests were for ch: spt to milk( %) and shellfish( %), epict to shellfish( %) and meat( %); for ad: spt to milk( %), fresh fruits and nuts both %), epict to shellfish( %) and meat( %). ude showed: % striation and white plaques in % ch shist ( %) was associated with sclin ( %), p = . in ch; but this was not observed in ad group there was no correlation between food sensitization and sclin or shist in both groups(p > . ). the average values of serum total ige (kua/l) were in ch and in ad; eos were and , respectively in ch and ad allergy unit-fondazione policlinico universitario a. gemelli, università cattolica del sacro cuore conclusion: ltp with a fixed dose ( iu in ml) of ready-touse shp led to fewer severe attacks, a higher proportion of attack-free patients, and a clinically meaningful and statistically significant reduction in cumulative attack severity and daily severity in hae patients relative to placebo. background: c -inh-hae is a rare, potentially life-threatening disease characterized by episodes of subcutaneous and/or submucosal swelling. apex- was a phase , double-blind, placebo-controlled study to evaluate the prevention of attacks with bcx , a once daily oral kallikrein inhibitor, in patients with c -inh-hae.method: patients with c -inh-hae with a history of at least hae attacks per month were randomized to receive four different doses of bcx ( mg, mg, mg, . mg) or placebo for days. blood samples for bcx concentrations and kallikrein inhibition were obtained from patients before dosing and for hours post-dose on day . pk analyses and pk-pd modeling were done in phoenix winnonlin v . and sas v . . the pk population included , , , and subjects in the mg, mg, mg, and . mg groups respectively.after daily dosing achieved steady state, c max was reached at a median of - hours after dosing. there was a greater than dose proportional increase in exposure (auc tau and c max ) over the . -mg to -mg dose range, with an approximate -fold increase in exposure with a . -fold increase in dose. at doses ≥ mg, which showed statistically significant and clinically meaningful reductions in hae attack rates, geometric mean plasma trough concentrations (c tau ) were maintained at or above the minimum target concentration ( -fold ec ) estimated to be required for adequate plasma kallikrein inhibition. percentages of study subjects at steady-state with bcx plasma concentrations> -fold ec were %, %, % and % in the . , , , and mg dose groups, respectively. a -mg dose provided a mean c tau of slightly above . fold ec , with a corresponding reduction in hae attack rate of % (p < . ) compared with placebo. consistent with the exposure data, a dose dependent inhibition of kallikrein was observed with bcx treatment over the dose range. the drug effect on kallikrein inhibition was highly correlated with exposure (r = . ). in patients with c -inh-hae, bcx treatment at doses ≥ mg resulted in clinically meaningful reductions in the mean weekly hae attack rate. concentrations of bcx at doses ≥ mg were maintained at or above a c tau of -fold the kallikrein inhibition ec in most patients, and kallikrein inhibition was highly correlated with bcx plasma concentrations.background: c -inh-hae is a rare, life-threatening disease characterized by recurrent episodes of subcutaneous and/or submucosal swelling that lead to considerable morbidity and a poor quality of life (qol). apex- was a phase , double-blind, placebo-controlled study to evaluate the prevention of attacks with bcx , a once daily oral kallikrein inhibitor, in patients with c -inh-hae.method: patients with c -inh-hae with at least hae attacks per month were randomized to four different bcx doses ( mg, mg, mg, . mg) or placebo. subject-reported qol assessments were conducted at the start and end of treatment using the disease specific angioedema quality of life (ae-qol) questionnaire that measures domains (function, fatigue, nutrition, fear/ shame) and has minimal clinically important difference (mcid) of points. the changes from baseline in total and domain scores was compared between the treatment and placebo groups. modified angioedema activity score (aas) values across domains (daily activities, appearance, physical discomfort, overall severity) were calculated for each attack and a total score was derived for each subject by summing scores from each attack. total scores were compared to placebo using an ancova model with adjustment for qualifying attack rate. reduction of attacks was statistically significant for all top doses and there was a dose related increase in adverse events.results: in the mg dose group, qol assessed by ae-qol was significantly improved after weeks of treatment compared to placebo for ae-qol total score (- . , p < . ) as well as across all domains (function: - . , p = . ; fatigue: - . , p = . ; fears/shame: - . , p < . ; nutrition: - . , p = . ). all other treatment groups showed a trend towards improvement. qol improved the most in the mg group, and % of subjects in the mg group showed ae-qol reduction of more than points. disease activity as assessed by the aas was significantly reduced in the mg, mg and mg dose groups as compared to placebo, whereas there was no significant reduction in the . mg dose group. results: there were no marked differences in the age, sex, total ige titer, comorbidity of bronchial asthma and atopic dermatitis or the starting dose of rush oit among the groups. all patients in the low-bmfi group achieved ≥ % of the target dose, whereas . % of the middle-bmfi group and % of the high-bmfi group failed to achieve the target dose (p < . ). results: a total of infants were diagnosed with food allergy (ige-mediated and mixed type) at our center during the study period, of these patients underwent prick test for inhalant sensitivity, and ( . % male) of these were younger than years of age. conclusion: sensitivity to inhaled allergen were found in of ( . %) patients with food allergy. therefore, we believe that inhalant sensitivity should be evaluated in these patients. there is also a requirement for further studies to identify the influence of inhaled antigens on the disease activity of patients with allergic conditions. method: in this study, we aimed to perform the metabolic profiling of severe profilin mediated food allergic patients looking for biomarkers that might both, predict the prognosis of the disease and understand the molecular mechanisms of inflammation underneath. other allergic patients (mild and moderate) and non-allergic were recruited in the study as comparative groups. the allergic patients class was predicted using a mathematical algorithm from non-allergic vs severe model results: plasma samples from non-allergic subjects, mild, moderate and severe allergic patients were measured using gas chromatography coupled to mass spectrometry (gc-ms). the samples were from different hospitals in spain covering the areas with the highest pollen exposure. the metabolic profile was composed of metabolites for each sample. results after the statistical analysis showed differences between the groups. firstly, a clear reduction of several abstracts conclusion: we found, as expected, a predominance of males with eoe diagnosis. ch were more frequently atopic and had aeroallergen and food sensitization. impaction and esophageal stenosis were more frequent in ad than ch. shist was associated with sclin only in ch. method: three children with ee, boys aged . - years, were assessed over months to years. results: cases developed in infancy. one had dyspepsia and low weight gain in infancy soon after feeding began. another had symptoms in infancy but not diagnosed until age with dysphagia and esophageal stricture.. the third case was diagnosed at years old after episodes of food impaction in the esophagus beginning at age . all cases had allergic comorbid diseases including atopic dermatitis in all and allergic rhinitis in . skin prick tests were positive to several food allergens (cow's milk, egg protein) in , to dust mite in and to pollens in . serum total ige levels ranged from to iu/ml. eosinophils in peripheral blood were elevated in all , reaching %- %. treatment included restricted diet and topical budesonide - mg daily depending with periodic endoscopic biopsy.in all cases clinical improvement occurred by one month of treatment, with endoscopic confirmation. morphological improvement fol- the study aimed to evaluate the effects of probiotic supplementation, in addition to diet, in ibs and snas patients, in terms of modulation of faecal microbiota population, reduction of gi and cutaneous symptoms, increase of patient's quality of life and modification of gut dysbiosis.method: forty patients aged between and years, affected by ibs, ni sensitization and ltp sensitization were enrolled to evaluate gut dysbiosis. dna extraction method (next generation sequencing) with commercial kit (microbiopassport ® ) was performed on stool samples. ibs patients were divided in two groups, according a gluten free diet prescription or a low fodmaps diet prescription for three months. similarly, (suspected) snas patients (confirmed by % ni sulfate in petrolatum patch test) were prescribed a low ni diet ( μg/kg nickel content during the first four weeks and then up to μg/kg up to three months). two ltp (lipid transfer protein) sensitized patients underwent a ltp free diet.gut dysbiosis was re-assessed after a fixed probiotic supplementation. a sex-age matched group of individuals without history of ibs, snas or any gastrointestinal disease was considered as control.gastrointestinal symptoms were evaluated using the visual analogue scale before and after treatment. conclusion: our preliminary findings suggest that probiotic implementation could be useful in patients with snas on a low-ni diet to increase population diversity, which could contribute to restore the intestinal homoeostatic conditions. key: cord- -tqceazdp authors: n. nuñez, luis fabian; santander-parra, silvana h.; de la torre, david i.; de sá, lilian r. m.; buim, marcos r.; astolfi-ferreira, claudete s.; piantino ferreira, antonio j. title: molecular characterization and pathogenicity of chicken parvovirus (chpv) in specific pathogen-free chicks infected experimentally date: - - journal: pathogens doi: . /pathogens sha: doc_id: cord_uid: tqceazdp chicken parvovirus (chpv) is an agent frequently associated with runting stunting syndrome (rss). this syndrome has been reported in association with chpv in many countries, including brazil; however, studies characterizing the virus on a molecular level are scarce, and chpv pathogenicity in day-old chicks remains unclear. the aim of the present work was to establish the molecular characteristics of chpv, determine the pathogenicity of chpv in spf chicks and detect and quantify chpv by qpcr in several tissues and chicks of different ages. the experimental challenge was performed at one day of age, and daily and weekly observations were performed and five birds from each experimental group (mock and infected birds) were euthanized to perform the different analysis. chpv genome copies were detected and quantified by qpcr in gut, spleen, thymus, kidney, pancreas, proventriculus and bursa. clinically, the infected group presented with diarrhea h post-infection, which persisted until days of age. the small intestine was distended, and its contents were aqueous and foamy. enteritis and dilated crypts with cyst shapes were observed in intestinal segments. acute pancreatitis associated with lymphocytic nodules, infiltrating lymphocytes and plasma cells between the pancreatic acinus was observed. koch’s postulate was demonstrated and the genetic characterization of the vp gene showed that the brazilian chpv isolate belongs to the chpv ii group. enteric disorders are considered the most important concern to poultry gut health due to their compromising effect on poultry growth. enteric disorders have a multifactorial etiology and are associated with bacteria, fungi, protozoa and viruses [ ] [ ] [ ] [ ] [ ] [ ] . runting-stunting syndrome (rss) is commonly reported in poultry production and is associated with several viruses, such as astrovirus, rotavirus, reovirus, coronavirus and parvovirus, and bacteria, including coccidia [ ] [ ] [ ] [ ] [ ] [ ] . the clinical manifestation of rss is characterized by ruffled feathers, diarrhea, cloacal pasting, apathy, depression, the sequences obtained in this work from the vp gene of chpv generated a sequence of bp, accession number mk . , which corresponds to the complete gene sequence of vp . the obtained vp nucleotide sequence was aligned and compared with previously published sequences of chpv. the analysis of complete vp nucleotide sequences showed high similarity of nucleotides (nt) and amino acids (aa) between the analyzed sequences ( table ). the sequence of the isolated chpv showed - . % nt and - . % aa similarity to sequences from korea; . - % nt and . - . % aa similarity to sequences from the united states; . % nt and . % aa similarity to sequences from china and . % nt and % aa similarity to reference sequences from hungary. compared to tupv sequences, the obtained sequence showed low nt ( . - . %) and aa ( . - . %) similarity, as shown in table . phylogenetic analyses showed two well-defined groups, a chpv group ( % bootstrap) and a tupv group ( % bootstrap). the sequence of the chpv isolate used in the present work clustered with a usa isolate (km . ) (bootstrap %) belonging to chpv group ii; the chpv reference sequence was grouped in a separate branch ( % of bootstrap) with the usa sequence (km . ; figure ). in the experimental infection, depression, lethargy, somnolence, ruffled feathers and diarrhea were observed h post-inoculation. after h of infection, the animals presented with cloacal pasting, dirty and wet feathers at the cloacal region caused by watery feces and ruffled feathers ( figure ). somnolence and lethargy increased, resulting in birds that moved less and had more apathy, in addition to an increase in diarrhea. the clinical signs of enteric disease, mainly diarrhea, were observed throughout the experiment ( table ). the infected animals also showed differing characteristics of the feathers on their wings, namely, the wings were found folded in the outer direction. ten days after infection, animals in the two groups were observed to have different sizes, with the infected animals appearing smaller and stunted compared with animals from the mock group. the mock group did not show any clinical signs and exhibited normal movement and healthy appearance, as described above. outer direction. ten days after infection, animals in the two groups were observed to have different sizes, with the infected animals appearing smaller and stunted compared with animals from the mock group. the mock group did not show any clinical signs and exhibited normal movement and healthy appearance, as described above. the birds of the mock group did not show any macroscopic lesions in the organs at any age examined. the postmortem examination of the challenged birds showed distended coelomic cavity intestinal loops filled with aqueous and foamy content. the intestinal loops exhibited segmentations along the small intestine; there were dilated stretches as well as narrow ones, and the contents were liquid, containing foamy and undigested feed along the length of the intestine. the birds in all age groups presented with intestinal volvulus, in which there was rotation of the duodenal loop segment in the mesenteric axis that resembled a corkscrew ("j" appearance). the mesentery presented opacification in this segment, and there was atrophy of the pancreas. the birds showed persistence of the yolk sac. the rest of the organs did not show any macroscopic alteration (table ; figure ). pathogens , , x for peer review the birds of the mock group did not show any macroscopic lesions in the organs at any age examined. the postmortem examination of the challenged birds showed distended coelomic cavity intestinal loops filled with aqueous and foamy content. the intestinal loops exhibited segmentations along the small intestine; there were dilated stretches as well as narrow ones, and the contents were liquid, containing foamy and undigested feed along the length of the intestine. the birds in all age groups presented with intestinal volvulus, in which there was rotation of the duodenal loop segment in the mesenteric axis that resembled a corkscrew ("j" appearance). the mesentery presented opacification in this segment, and there was atrophy of the pancreas. the birds showed persistence of the yolk sac. the rest of the organs did not show any macroscopic alteration (table ; figure ). the birds infected with chpv showed preserved villous:crypt ratios and mild to moderate hyperplasia of crypts with the presence of crypt bifurcations, which were dilated, elongated and tortuous in different evaluation periods. from the th to nd day after inoculation, the crypts of lieberkühn were lined by a squamous epithelium containing cellular debris and degenerated inflammatory cells that formed structures with a cyst shape; these structures were observed in the table . clinical signs and macroscopic findings at postmortem examination of chickens from chpv infected group. the birds infected with chpv showed preserved villous:crypt ratios and mild to moderate hyperplasia of crypts with the presence of crypt bifurcations, which were dilated, elongated and tortuous in different evaluation periods. from the th to nd day after inoculation, the crypts of lieberkühn were lined by a squamous epithelium containing cellular debris and degenerated inflammatory cells that formed structures with a cyst shape; these structures were observed in the duodenum, jejunum and ileum (figure ) . table shows the distribution of histopathological parameters of the digestive system in both groups. between the th day and th day post-infection, necrosis of crypt cells was observed in all segments of the small intestine (p < . ). furthermore, there was an increased number of mitotic cells in segments of the duodenum and an increased number of intraepithelial lymphocytes from the th to nd day (p < . ). the density of lymphocytes and plasma cells found in the lamina propria of the duodenum was significant (p = . ) from the th to the st day after inoculation, that of the jejunum was significant from the th to st day (p < . ) after infection, and that of the ileum was significant from the st to th day after infection (p < . ). the pancreas showed a loss of zymogene granules; lymphocytic nodules that contained an infiltrate of lymphocytes and plasma cells between the pancreatic acinus were also present, indicating acute pancreatitis. lymphoplasmacytic mesenteritis was observed in the mesentery of the duodenal loop and the peripancreatic area, which is associated with pancreatitis. the birds of the mock group showed segments of the duodenum, jejunum and ileum within the standard of normal histology (table ; figure ). the qpcr assay for the detection and quantification of chpv showed that all analyzed animals were positive for chpv in all collected organs from the first day post-infection. peak titers of chpv was observed in the intestines, for the ileum, followed by the jejunum and duodenum. however, it was very interesting to note that replication of the virus seemed to commence at - days post-infection for the ileum followed by the jejunum and then the duodenum. interestingly, in this study, replication in the pancreas and an elevated number of genome copies were not observed. the gastrointestinal tract (duodenum, jejunum and ileum) showed the highest level of genome copies of chpv at day fourteen post-infection, and the viral concentration decreased through day . the pancreas, thymus, liver, proventriculus and kidney showed basal virus genome titer from the first day until the end of the experiment at days old. the spleen had the highest viral concentration at day , after which the concentration decreased (table ; figure ). figure . the figure compares the viral distribution in the days after infection with the chpv strain according to each organ/tissue. note that peak titer of chpv is greatest in the intestines. however, it is interesting to note that replication of the virus seems to commence at - days post-infection for the ileum followed by the jejunum and then the duodenum. interestingly, multiplication in the pancreas was not observed. in the present work, the pathogenicity, viral tissue distribution and molecular characterization of chpv in chicks from a strain isolated in brazil were determined with a demonstration of koch's postulates according to our previous description [ ] . there are few complete genomes of chpv available, and the complete genome refers to the chpv reference strain abu-p , which was followed figure . the figure compares the viral distribution in the days after infection with the chpv strain according to each organ/tissue. note that peak titer of chpv is greatest in the intestines. however, it is interesting to note that replication of the virus seems to commence at - days post-infection for the ileum followed by the jejunum and then the duodenum. interestingly, multiplication in the pancreas was not observed. in the present work, the pathogenicity, viral tissue distribution and molecular characterization of chpv in chicks from a strain isolated in brazil were determined with a demonstration of koch's postulates according to our previous description [ ] . there are few complete genomes of chpv available, and the complete genome refers to the chpv reference strain abu-p , which was followed by viral genomes from korea [ ] , the united states [ ] and china [ ] . thus, these genomes possess the classical conformation of parvovirus and contain structural and nonstructural proteins; based on their vp gene sequences, three groups of chpv can be identified [ ] . the lack of chpv vp gene sequences could likely be related to the difficulty in chpv dna isolation for whole vp gene sequencing; however, the majority of published works have included a molecular characterization of the ns gene sequence [ , ] . nevertheless, genetic information based on ns gene sequences is not sufficient for discriminatory genotyping because there are few differences among strains [ ] . hence, we report the first molecular characterization of chpv in brazil based on complete vp gene sequence analyses, confirming that the chpv used in the experimental infection belongs to the chpv ii group. around the world, chpv has been reported and detected in healthy and sick chickens, but it has mainly been identified in chickens showing enteric disorders. this virus has the particularity that it is detected relatively more in chicks and young animals [ ] [ ] [ ] [ ] . chpv causes severe enteric problems that are characterized by the presence of diarrhea, high morbidity and mortality [ , ] . in the field, outbreaks that affected chickens showed many pathological alterations in the intestine upon postmortem examination, showing mainly distended intestines filled with aqueous feces and foamy and undigested feed. moreover, the challenge with outbreaks in the field is the association of chpv with other enteric viruses or bacteria, which could decrease the quality of the gut integrity [ , , , , ] . experimental infections with isolated chpv (abu-p ) have demonstrated that the virus causes enteric diseases, resulting mainly in chickens with diarrhea, cloacal pasting, impaired growth, runting and stunting [ ] . as reported in the present investigation, the principal clinical signs present in the infected animals were also diarrhea, cloacal pasting, somnolence, apathy, ruffled feathers, impaired growth, runting and stunting. however, the chpv strain abu-p does not cause any macroscopic lesions in enteric tissues [ , ] . interestingly, this investigation revealed the presence of intestinal volvulus characterized by the rotation of the duodenal loop segment in the mesenteric axis; thus, the duodenal loop was rolled, resembling a corkscrew and pancreatic atrophy was also observed. lesions were previously described in commercial chicken flocks affected with rss and reported by our own group [ ] ; the duodenal loop presented the same features, demonstrating koch's postulates in relation to chpv and experimentally infected chickens. the enteric diseases caused by bacteria or viruses (rss) have the particularity of presenting alterations at the ciliated columnar epithelium, lieberkühn crypts, and in intestinal villi, which show atrophy and fusion or expansion of the lamina propria as a result of inflammatory infiltrates [ , , ] . nevertheless, experimental infections with chpv (abu-p ) have reproduced rss, but microscopic alterations were not found in the intestines or in any other organ [ ] . in the present investigation, we demonstrated the presence of crypt alterations, which were characterized principally by dilated crypts lined by a squamous epithelium that contained cellular debris and degenerate inflammatory cells, a cyst shape and crypt cell necrosis, all of which are present in the segment of the rolled duodenal loop and in other segments of the intestine; thus, these findings microscopically characterize the chpv strain isolated in brazil. chpv was detected initially in the intestinal content or in the intestinal wall [ , , , ] , because the intestine is considered the primary target for enteric virus infection; however, other studies showed the presence of the virus in the spleen and pancreas [ ] , suggesting another tropism of enteric viruses. these results were supported by qpcr targeting the chpv strain usp- - [ ] . furthermore, the presence of chpv was quantified and detected in the three segments of the small intestine (duodenum, jejunum and ileum) and increased after third day post-infection (p.i.) for ileum; after the sixth day for jejunum and after the seventh day for duodenum with high concentrations of genome copies per mg of tissue, however, in the thymus, liver, kidneys, pancreas, proventriculus and bursa, an increase in virus in the tissue was not detected. nevertheless, the peak of the genomic titer was observed between the first-and fourth-weeks post-infection. the presence of chpv in many organs until day showed that the virus could persist for a long time, explaining the continuous reinfections through the presence of chpv in poultry litters [ ] . the total weight of the infected animals showed a significant decrease compared to the mock group, which agreed with previously reported data from experimental infection with abu-p [ ] and showed that the chpv strain isolated in brazil is an important virus causing enteric diseases. other studies should be performed to understand the interaction of chpv with the lymphopoietic organs (bursa of fabricius, spleen and thymus), the exocrine function of digestive organs and certainly the interaction of chpv with chicken immune system cells. a strain of chpv was isolated in spf chicken embryos as described previously and was designated usp - [ ] . an aliquot of a macerated embryo from which the virus was isolated was transferred to a ml microtube containing ml of . m pbs at ph . . the suspension was subjected to three freeze thaw cycles consisting of freezing at − • c for min and thawing at • c for one min; each cycle was followed by homogenization. the sample was centrifuged at , × g for min at • c. the viral dna was extracted from µl of the supernatant of the viral suspension using trizol (thermo fisher scientific, carlsbad, ca, usa) reagent according to the manufacturer's instructions. for molecular characterization of chpv, pcr was carried out in triplicate as described previously [ ] , with some modifications. the amplified products were purified using gfxpcr dna and gel band purification kit (ge healthcare, piscataway, nj, usa) following the manufacturer's instructions. the purified dna was then ligated into the pcr™ . -topo cloning vector (thermo fisher scientific, carlsbad, ca, usa), and the vector was transformed into e. coli top competent cells according to the manufacturer's instructions. the bacteria were cultured on luria bertani (lb) agar containing ampicillin µg/ml. three colonies were cultured in ml of lb broth and shaken at rpm for h. plasmid dna was extracted from the lb broth bacterial suspensions using the qiaprep spin miniprep kit (qiagen, hilden, germany). the plasmid dna was then sequenced in the forward and reverse directions using a bigdye ® terminator v . cycle sequencing kit (thermo fisher scientific, carlsbad, ca, usa) with m primers. sequencing reactions were performed with an abi dna analyzer (thermo fisher scientific, carlsbad, ca, usa). the obtained electropherograms were analyzed using geneious . . software using de novo assembly. the consensus sequences were aligned and compared with other sequences of chpv available in genbank using the clustal w method in clustalx . . software (european bioinformatics institute, saffron walden, uk). the similarity of nucleotides (nt) and amino acids (aa) was determined using bioedit . . . the phylogenetic tree was built using the neighbor-joining statistical method and p-distance substitution model with bootstraps of replications in the mega software package [ ] . eighty (n = ) day-old spf chicks, supplied by ceva (ceva animal health, campinas, brazil), were divided into two groups of forty (n = ) birds: group i was infected with × genome copies (gc) of chpv in µl of pbs, as previously determined through qpcr [ ] , and group ii was mock infected with µl of sterile . m pbs ph . . all chicks were challenged by gavage. both groups were maintained for days in separate isolators under positive air pressure (alesco, campinas, sp, brazil), with water and food supplied ad libitum. the birds were maintained and used in accordance with the guidelines and the approval of the committee on the care and use of laboratory animal resources of the school of veterinary medicine, university of são paulo, brazil, under protocol number # / . the birds were observed daily and scored for clinical signs and mortality. the experimental challenge was performed at one day of age, and daily and weekly observations were performed (day pre-inoculation; daily , , , , , and days post-inoculation; and weekly , , , and days post-inoculation). five birds ( ) at each experimental phase/step were euthanized and subjected to necropsy examination. hereafter, each organ sample was collected separately, and selected organs included the duodenum, jejunum, ileum, proventriculus, pancreas, liver, spleen, bursa, thymus and kidney. the samples for qpcr were initially stored in liquid nitrogen and then stored at − • c until processing. a fragment of each organ listed above from the th to nd day was fixed in neutral-buffered % formalin and embedded in paraffin. sections of µm thicknesses were prepared and stained with hematoxylin-eosin (h&e). the slides were examined by light microscopy. the intestinal segments were examined by observing the villous:crypt ratio, lieberkühn crypt morphology, intensity of mononuclear and polymorphonuclear infiltrate in the lamina propria, presence and distribution of lymphoid follicles, number of intraepithelial lymphocytes present in one hundred enterocytes, and the number of cells in mitosis observed in the crypts in three fields at ×. the microscopic examination of fragments of intestine was semiquantitative according to the parameters described in table . the organs, including the proventriculus, pancreas, spleen, bursa, liver, thymus and kidney, were examined for the presence of inflammatory infiltrate, cell degeneration and other microscopic lesions. three randomly selected birds were necropsied from both the infected and mock groups, as described above, and dna was extracted from mg of tissue from each collected organ. chpv was detected and quantified using qpcr as described by nuñez et al. [ ] . each organ was tested in duplicate, and absolute quantification of the chpv genome copies was performed. the weight, number of cells in mitosis and number of intraepithelial lymphocytes were evaluated using the mann-whitney u test. semiquantitative evaluations of the variables, namely, the presence of polymorphonuclear and mononuclear cells in the lamina propria and changes in crypt morphology, were evaluated using a chi-square test. the genetic characterization of the vp gene showed that the brazilian chpv isolate belongs to the chpv ii group. koch's postulate was demonstrated because rss was reproduced through detection of the "j" appearance in the duodenum of the infected group, as observed in field conditions. molecular characterization and typing of chicken and turkey astroviruses circulating in the united states: implications for diagnostics partial genome sequence analysis of parvoviruses associated with enteric disease in poultry molecular characterization of avian astroviruses host specificity and phylogenetic relationships of chicken and turkey parvoviruses enteric virus diversity examined by molecular methods in brazilian poultry flocks development of a sensitive real-time fast-qpcr based on sybr ® green for detection and quantification of chicken parvovirus (chpv) detection of rotaviruses and intestinal lesions in broiler chicks from flocks with runting and stunting syndrome (rss) detection of chicken astrovirus by reverse transcriptase-polymerase chain reaction development and evaluation of real-time taqman ® rt-pcr assays for the detection of avian nephritis virus and chicken astrovirus in chickens emergence of enteric viruses in production chickens is a concern for avian health capsid protein sequence diversity of avian nephritis virus chicken astrovirus as an aetiological agent of runting-stunting syndrome in broiler chickens presence of parvoviruses in the intestine of chickens showing stunting syndrome experimental infection of chicken embryos and day-old chickens with parvovirus of chicken origin high prevalence of turkey parvovirus in turkey flocks from hungary experiencing enteric disease syndromes samorek-salamonowicz, e. occurrence of chicken parvovirus infection in poland parvovirus host range, cell tropism and evolution recent progress in the characterization of avian enteric viruses determination and analysis of the full-length chicken parvovirus genome identification and phylogenetic diversity of parvovirus circulating in commercial chicken and turkey flocks in croatia molecular detection of chicken parvovirus in broilers with enteric disorders presenting curving of duodenal loop, pancreatic atrophy, and mesenteritis chicken parvovirus-induced runting-stunting syndrome in young broilers genetic characterization of three novel chicken parvovirus strains based on analysis of their coding sequences development of an enzyme-linked immunosorbent assay to detect chicken parvovirus-specific antibodies development of a polymerase chain reaction procedure for detection of chicken and turkey parvoviruses a novel tool for specific detection and quantification of chicken/turkey parvoviruses to trace poultry fecal contamination in the environment chicken parvovirus viral loads in cloacal swabs from malabsorption syndrome-affected and healthy broilers avian parvovirus: classification, phylogeny, pathogenesis and diagnosis genetic characterization of parvoviruses circulating in turkey and chicken flocks in poland naturally occurring parvoviral infection in hungarian broiler flocks investigation into the aetiology of runting and stunting syndrome in chickens periodic monitoring of commercial turkeys for enteric viruses indicates continuous presence of astrovirus and rotavirus on the farms phylogenetic diversity of avian nephritis virus in hungarian chicken flocks detection of enteric viruses in pancreas and spleen of broilers with runting-stunting syndrome (rss) isolation and molecular characterisation of chicken parvovirus from brazilian flocks with enteric disorders mega : molecular evolutionary genetics analysis version . for bigger datasets this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare that there is no conflict of interest in this manuscript. key: cord- - iwo tlb authors: vieira, tiago title: the lose-lose dilemmas of barcelona’s platform delivery workers in the age of covid- date: - - journal: social sciences & humanities open doi: . /j.ssaho. . sha: doc_id: cord_uid: iwo tlb the abrupt lockdown experienced by a big part of the world population due to the covid- pandemic has bestowed upon home delivery services an unexpected importance. officially considered amongst “essential services”, their workers circulate freely while most people are advised (when not forced) to stay in their homes. the present paper explores how this context helps to shed light on the precarious situation of the majority of the platform delivery workers (pdw). this is done through in-depth, semi-structured interviews and digital ethnography of the interactions within a whatsapp group. the main finding is that the covid- context deepened the precarization of the pdw confronting them with four dilemmas from which there is no way out. the uncontrolled spread of the covid- in spain led the government to enforce a nation-wide lockdown on march . amidst critics from autonomous communities' leaders, opposition parties and even members of the government itself, the enforcement of the lockdown dictated a staggering breakdown of the everyday routines of the spanish people(s). as has been the case almost everywhere else, the main aim of the lockdown was to prevent the proliferation of the virus, through the refraining of human contact. in order to achieve such a goal, all activities considered less than essential for facing this unprecedentedly critical moment were first advised and, later on, forced to come to a stop. on top of this, the very ways in which people interacted became the subject of scrutiny from the authorities: any form of not strictly functional social engagement was deemed unwelcomed -even the once overcrowded supermarkets were now vast empty corridors, as people queued by the door in long, -m-of-distance-between-each-person-please lines. as millions of other people in the city of barcelona followed the protocols, i also did my best to follow the rules, only leaving my thirty square meter flat every other day, and only to buy bread and some groceries. thirty minutes of freedom and, if lucky, some sunlight. while i briefly strolled the never-to-be-seen-so-empty-streets of the up-untilrecently bustling streets of raval, the only few other freedom companions i'd get would be: police officers (dozens of!), dog walkers, fellow groceries' purchasers, and bike riders floating around with huge, fully colored backpacks on their backs. all the three former categories were expected, they all had a reason to be where they were. however, the latter posed me an intriguing puzzle: in a moment where the majority of the population was notably (and perhaps justifiably) afraid of contagious contacts with other human beings, why and under which circumstances (incentives, if you will) would these workers, who are formally free to choose the extent of their availability to work, expose themselves to the possibility of hitting the covid- infected list? in the present paper, i explore the situation of the platform delivery workers (hereafter, pdw) in the peak of the covid- crisis in spain. the pdw form part of broader group of workers whose activities are performed directly and/or mediated by a digital platform, commonly known as platform workers. in the case of the pdw, the platform ensures the liaison between the users/clients, the sellers (restaurants, retailers, etc.) and the pdw who receives the task of having the delivery made. in very simple terms, they are the pizza delivery boy/girl of the smartphone era. the present research is done through the combination of a digital ethnographical approach to a whatsapp group of pdw of barcelona and the conduction of semi-structured interviews to some members of the group. informed by the existing literature on precarity, my qualitative approach aims at unveiling to what extent the workers of this very specific activity are faced with a series of dilemmas from which there is no good way out -essentially they are trapped by their extremely precarious position. the interactions described in the following sections of this paper intentionally overlook any aspects that do not fall under the scope of the purpose of this research: grasping the relation between precarity and exposure to hazardous situations by pdw. other results notwithstanding, my expectation by doing this paper is that those whose voice is so scarcely heard, might have attention drawn to their situation, for unlike the gurus of one of most prominent companies of the platform economy (airbnb), i don't see "people as businesses" (kaplan & nadler, ) , but rather people as people. the deep changes brought about by the hegemony of neoliberalism as a global mantra (harvey, ) produced effects on the life of all human beings on the planet, rendering the organization of societies a process in which stability and predictability were gradually, more and more, nothing but fading memories of a not-so-distant, yet apparently very far away time. while addressing this matter, bourdieu (bourdieu, ) played a decisive role unveiling the "insecurity-inducing strategies" promoted by employers to render the working class more dependent and less demanding -which is synthetized by the word precarit e (precarity ). contributions following bourdieu's notwithstanding, standing's precariat (standing, ) stood out as a particularly important expansion for the research on the topic of precarity. the author developed a seven-axis framework of analysis of labor security, which absence (individually considered or as a whole) led to precarity. his findings seconded those of bourdieu, as he observed that in the post-fordist era workers are increasingly exposed to circumstances making them precarious. since then, namely throughout the last decades, the fact is that this phenomenon has been greatly expanding. not only is it evolving into an increasing share of the labor force, precarity is impacting the lives of workers in increasingly diversified ways (armano et al., ) . bauman's (bauman, ) "liquid modernity" is rapidly turning into a very "age of precarity" (lazar & sanchez, ) . in fact, the changes occurring in the labor market are deeply intertwined with further changes taking place in societal discourses and perceptions (gilbert, ; valas & prener, ) . this "structural precarity" (antunes, ) stems from the multidimensional nature of insecurity and vulnerability (herrmann & kalaycioglu, ) , both cause and consequence of increasing levels of inequality (piketty, ) . unsurprisingly, the substantial technological developments of the last decade -mainly owned by the biggest capitalist corporations -have only further enhanced the critical precarization of labor relations. "labour power comes to be transformed into a commodity in a context where the encounter between supply and demand of work is mediated by a digital platform, and where feedback, ranking and rating systems serve purposes of managerialization and monitoring of workers." (gandini, ) . insofar as this topic seems to be currently very trendy, which has led to rapid expansion of the existing scholarship, the in-depth descriptions provided by srnicek (srnicek, ) and scholz (scholz, ) on how these new labor forms are shaped still stand as seminal works. they shed light on how "the emergence of labor flexible forms has produced a new type of self-employed worker, one that even if autonomous in many aspects as his predecessor (schedule, low social protection) is, indeed, much closer to the temporary worker: precarious, involuntary, dependent." (jansen, ) . building upon this legacy, de groen et al. (de groen et al., ) provide an insightful -to the best of my knowledge, the most developed to this day -account on how "platform workers" are exposed to intense and highly sophisticated forms of precarity. by scrutinizing the work and employment conditions through the lens of a four dimensional scale -the "adjusted wes" -which, in turn, unfolds into different indicators, this paper stands as a landmark for a comprehensive understanding of the challenges faced by the workforce forming part of this emerging, apparently unstoppable new shape of labor relations. all the angles from which labor relations of platform workers and their employer counterparts are looked at by the existing literature notwithstanding, the ways in which precarity penetrates platform work is far from exhausted. among eventually others, one issue that stands outmost notably amidst the pdw -is that of platform workers renting their accounts, thereby emerging rather as subcontractors than as wageearners. the ways in which this unfolds -to be briefly explained in following sections of this paper -has been vastly documented by the media (e.g. (bbc, ; crispino, ; ponte & moya, ) ,), however, surprisingly, it has been overlooked by the scholarship produced by academic researchers. as hereafter observed, the workers hired by this sort of platform's "subcontractors" are served the worst of two worlds: on the one-hand, they operate as illegal, undeclared workers, who not only are deprived any form of social protection, as also, if caught working illegally, are likely to face legal consequences; on the other hand, they are forced to pay all the taxes their sub-contractor has to pay to public institutions, and still need to comply with the control mechanisms entailed in the so-called "application-based management" (ivanova et al., ) . it stands out that this specific issue can hardly be disentangled from the vast precarity web where workers of platforms often find themselves trapped. indeed, it should be seen more as an additional thread of the web than a stand-alone matter -more often than not, although not exclusively, closely related with situations of undocumented immigration. this intertwined thread stands as the central axis of this paper, in which the exposure of both "regular" and "sub-hired" platform workers to the covid- pandemic and subsequent societal context of unexpected and unprecedented measures of confinement is analyzed. the constraints provided by the lockdown made it particularly challenging for any research to be conducted beyond the limits of my desk. while attempting to successfully attain the goals of myself set endeavor, i played to my advantage the increasing "ubiquitous computing" (elwell, ) of human existence as an undisputed advantage. in fact, acknowledging that the "materiality of the digital (…) should be at the forefront of theories attempting to understand contemporary practices" (duggan, ) can only play to this research agenda's advantage, more so if taking for granted the quasi teleological proneness of the pdw for digital engagements (leonardi et al., ) . all this rendered digital ethnography an indisputably valuable methodological approach. provided the term can lead to different interpretations (dicks et al., ) , this is precisely what was done: while analyzing the content of the interactions of a whatsapp group of pdw, i stood as non-participant observer of the life dynamics of this group, grasping as much as possible given the existing limitations their perceptions, concerns, attitudes and praxis. this process was implemented from march to april , (the first four weeks of an unprecedented lockdown for most the people to be fair, the actual translation would be "precariousness". for how, to describe precarit e at labor level, one has evolved from precariousness to precarity see the cambridge encyclopedia of anthropology (cambridge encyclopedia of, ). social sciences & humanities open ( ) walking the earth), in a group to which access is publicly advertised on one of the several existing facebook pages of pdw, and to which no prior conditions of admission are established, so there was no need for a formal introduction to the group or its moderator from my side to ensure access. however, i ended up doing it somehow, given that a big percentage of my interviewees were assembled by individually approaching each one of the group members -to whom i introduced myself as a researcher, explaining i had joined the group looking for interviewees for a research project related to the life of the pdw. this strategy also allowed me to ensure that all group members knew that there was one among them that was not a pdw, but rather a social researcher, thereby ensuring there were no ethical obstacles to my research. this was perceived as unproblematic by group members, since most of them simply ignored me, and those who actually answered (even if not made available to be interviewed) shared words of encouragement. as for the actual analysis, as an initial step, i coded each of the entries according to the topic they referred to -a proof of how active the group, was with a daily average of messages exchanged. each category would receive one point for each entry that fell under its topic. in the not so common case that one entry would cover two different topics (e.g., requests for information on labor rhythm and police controls), both categories received a point (results are presented in the next section). the code construction was inductive, i.e., i developed it after a global content analysis of the interactions, as this allowed to a have a better look at what was going at the level of interactions -the results of this process are presented as part of the findings' section. although the literature review had drawn my attention to the main trademarks of precarity, such as matters of income and managerial control techniques implemented in the framework of "platform work", the general overview of interactions made it clear that more dimensions of analysis had to be explored. in line with that, it was thus necessary to address how labor precarity was closely related to other forms of broader insecurity, namely the exposure to dangers arising from either their legal status or the impossibility to control the content of the packages delivered. sequentially, valuable as the interactions on the whatsapp group were, making sense of them and having more in-depth information on daily routines was only truly possible when the interviews were accomplished and successful analyzed. in other words, my rapport towards the group interactions was only built a posteriori, for it was in the interviews that the most pressing issues of the pdw lives became clear to me. this was particularly important for me as a researcher, given that i have never had the professional experience of working as a pdw, on the one hand, and that all i knew about these workers until now was essentially based on media reports describing their often precarious work and employment conditions. in total, interviews were done, all under anonymity. they were all done by videocall and, in average, lasted for min. they were all conducted in spanish, which i speak fluently as second language, and which allowed all interviewees to express themselves in their mother tongue. all interviews were recorded having the informed consent of the interviewees that the disclosure of the information retrieved would be anonymized. the flexible nature of the interviews made them the most relevant part of this research. as hereafter observed, the information collected confirmed the validity of this technique as a means to have a wider perspective of the existing constellation of visions of the same phenomenon (mason, ) . following kvale's (kvale, ) approach, the interviews were a mix of an unpreoccupied conversation among two acquaintances and an investigation. the script underlying these semi-structured interviews was thus quite loose, aiming mostly at having the interviewees relating their broader experience as pdw with the one of the present moment -even for cases in which they have decided to stop working, in order to protect their health. i dedicated a substantial amount of the interviews' time to understand how the work and employment conditions unfolded for the pdw, and how -in these particular circumstances -this was lived by each one of them. i focused on elements that could present themselves as hazardous, such as excessive work rhythm, overwork, absence of or difficult access to individual protection equipment, lack of alternatives in face of infection, and access to social welfare mechanisms. in both cases -those who continued to work and those who decided to stop -the interviewees' discourses shed light on the adaptations and justifications adopted by the subjects to navigate the current broader cultural framework -that of precarity. all this said, one should not understimate the limits posed by a context in which this research process unfolded. the very strict lockdown imposed by the spanish authorities made it completely impossible to grasp important information and its inclusion in the findings sequentially presented. this fact surely doesn't undermine the results altogether, but it has certainly prevented me from having access to broader dimensions of the precarious lives of the pdw. those which i consider future research would benefit from grasping are: physical living conditions; social capital; mental and physical strategies to cope with the workers' immensly precarious situation. undoubtedly, the conduction of presential (rather than merely digital) ethnography and of focus group interviews, would have made the results of the present research even deeper. the current section presents the main findings retrieved from the combined information of the interactions in the whatsapp group and the interviews. an insightful presentation deems useful the splitting of the information by topic, disregard their intertwined nature. a general overview of the trends of the interactions of the whatsapp group is followed by a specific approach of the topics. the whatsapp group hereafter analyzed was created on january , . it was composed of members when i joined it (march ) and kept on growing steadily until the last day of my research (april ), when it counted with participants -however not all participants were active, many of them stood as mere "observers". the group founder and moderator, himself also a pdw (assuming his profile photo is actually of himself), was one of such silent members -not even once has he interacted publicly within the group. the participants were mainly pdw who worked in barcelona, although there were a very small number of exceptions -people from other spanish cities looking for info or technical information. although most of the interactions referred to glovo, there were pdw who worked for other companies such as deliveroo, uber eats and stuart. some pdw had accounts open in more than one platform. elements like age and country of origin are impossible to account for. however, admitting that the photo provide by the profile picture is, most of the times, from the owner of the whatsapp identity, it was from the beginning clear that this group where young adults are the overwhelming majority (something that was later confirmed by the pool of interviewees, whose age ranged from to ). the same rationale applies for gender. based on the whatsapp profile photos and on the usernames -admitting they were reliable -i could only count seven women. notably, one was a fellow social researcher performing digital ethnography as i was doing, another was the wife of a pdw (it was unclear whether she, herself, was also a pdw) -the remaining others were actual pdw. this does not mean that all other members of the group were men: in the case of at least members, neither their usernames, nor their photos allowed to make a solid prediction on their gender. be as it may, during the two female interviewees confirmed that women were extremely rare in the pdw world. as for the content of the interactions, after a global reading, i deemed to code the information retrieved from the group in the following manner: company -dealing with aspects of the relation with the companies (mainly doubts and complaints shared among peers, before/instead of addressing the company itself); labor rhythm -related to the ongoing movement of demands made by clients (usually to assess if low levels of requests were an individual situation or a broader issue); police/security -shared information about (past or present) police controls and other aspects that could jeopardize the security of pdw, such as requests for delivery of illicit substances; rented accounts -information on accounts to be rented (essentially from people procuring them, but also some advertising and some doubts' clarification); state -discussion all aspects related to the relation of pdw with the state, mainly: the decision of the state of emergency, its renewal and its implications, and clarification of doubts on issues related with taxes and social security; covid -information and debate of news and concerns directly related to covid- (the evolution of numbers, who is to blame, what measures to take to reduce of the possibility of being infected); services -advertisement, sharing or procurement of services, disregard how work-related they are: second-hand backpacks, bikes' workshops, flats for rent, cigarettes, fuel, videogames or even direct requests to workers seeking to avoid the fees charged by the apps; other -jokes, memes, motivational messages of various sorts. as shown by fig. , throughout this period, the main concern of the dpw was related with the action of the police and other aspects related to security, taking up almost one third of all the interactions. most notably, concerns with covid- itself were extremely rare ( %). in fact, direct work-related worries were by far the most pressing, adding up to an aggregated result of % of the interactions. even if the services category is not considered as necessarily work-related -although a large number of the interactions that form part of it indeed are -, one would still observe that % of interactions refer to the need to deal with aspects that are connected to work. the "others'" category -which altogether added up to % of the interactions -was the locus of empathy among the pdw par excellence. inasmuch as these were not directly work-related contents, it was clear that group members found in this type of message a way to mutually motivate one another, expressing individual and collective resilience before such complex context as that of the covid- . undoubtedly, most messages were or religious (or related to them), even if, seldom, some jokes, memes and gifs would be posted, particularly as reaction to some previous message, as a way to provide feedback. the rest of this section is highly informative to why this is and how each of the different dimensions is, one way or another, related to the specific circumstances brought up by the covid- pandemic. if there is one thing that seems consensual among the interviewees is that working as pdw provides a low monthly income. most have noted that work is exhausting, allowing to obtain an amount with which one can "pay your food, your rent, and not more" (juan). of those interviewed the declared net income ranged from to euro per fortnight, all highlighting that reaching these amounts deemed necessary a very intense work rhythm, with no more than one day per week to rest. an important element of instability stems also from the inexistence of a minimum guaranteed wage, rendering it pure luck that there will be enough movement to allow one to earn enough to pay their bills. this is arguably why almost % of the interactions group are dedicated to understanding how rhythm of demands is at each day. the randomness of this possibility to make money is well expressed by the following statement of a member of the whatsapp group: april : wg# "one has to be patient, that i learnt from [name of company] … one just has to get out soon and have faith in god that a request drops." furthermore, the situation of the pdw is of people who live on the edge, renting rooms by the day, with no security at all, exposed to the arbitrariness of those with more power -something that became even more critical during the pandemic, leading one to believe that the covid- crisis may just be the tip of the iceberg of much deeper crisis, where job, food, shelter and medicines' scarcity may lead up to a not so distant perfect storm. take as examples: although the jokes and gags could, altogether, be a strand of this research on its own -following the steps of, among others, 't hart (t hart, ) -their scarcity and discontinuity rendered this possibility unattainable. march : wg# "i could not go out to work because the person who is renting me [a room], told me to look for another place to live, that they did not want to expose to the possibility of me taking the virus to the flat …" march : wg# "if you know of any bicycle account recommend it friends, maybe having some money it is easier to find a place to sleep, this night one good person let spend the night so i don't get frozen with the cold of the last days. i have a bike to work. if you know of any account please i'm very unsettled" beyond income, a decisive element to understand the whole context lived by most pdw is the way the apps are run, commonly known as application-based management. although each platform (which tangible expression is the application) has its specific features, the outline is similar for all. in a nutshell, the odds of a pdw having possibility to work (and, necessarily, obtaining income) is directly related to a mathematical combination of factors, such as: the availability to work in the hours deemed necessary by the platform (most notably in the evenings and weekends), the speed of delivery, the review the given by the customer who gets the order (and, in case it is food, also from the restaurant producing the food). when accomplished within the goals set by the platform, the pdw obtain points. when that is not the case -no matter whose fault it is -the pdw loses points. this extremely important since it is the amount of points one has that determine one's ability to "catch" hours of work. the more points one has, the more hours one will be able to reserve -hence, the more money one can make. diego pointed out how the lockdown was a special period, since "in this period they let you choose the hours you want, something that never happened", which stems from the huge demands received in these days, particularly for food orders. juan reported that the company he delivers for was now increasing the income rate to attract workers to work for more hours, something that had been done in the past only in rainy days or special holidays. be as it may, there still are the "hours of high demand" (defined by the platform and the restaurants), in which "if you don't work, your score will be lowered" (juan). in a context like that emerging from the covid- pandemic, it should come as no surprise that many people have tried to desperately find solutions to economically survive. in the month of march alone, more than thousands of workers were affected either by unemployment or by their companies making use of lay-off mechanisms (gomez, ) . one way or another, the financial stability of hundreds of thousands of families was directly affected, rendering them more prone to searching solutions where there might be potential for fresh and fast income. if one goes back to fig. , the fact that more than in every interactions are related to this topic provides evidence of its relevance. however, to fully grasp the meaning of this number it is important to keep in mind that these are interactions about performing an illegal action held in an open forum, in which everyone can be easily traced by their mobile number. this renders highly likely that many more interactions take place in non-public spaces. from the reports in the media and the interviews had, it is relatively easy to understand how this unfolds. in a nutshell: individual a signs-up for working in one platform, providing the required paperwork to be granted a license; once that is obtained, individual a procures someone who is willing to work but cannot/is not willing to sign-up for working in the platform; once that person is found (hereafter individual b), an oral agreement is celebrated: individual a grants access to his/her account to individual b, provided that the latter concedes the former a percentage of the income earned by working to the platform, plus all taxes. in all cases, individual a is in control at all times: the bank account where the money is deposited by the platform is his/hers; the mechanisms for password change are in his/her hand. the situation reported by jos e speaks for itself in terms of the vulnerability to which people renting accounts are exposed: "in of those payments he decided not to give me a thing, not to pay me … making excuses, that he wasn't making any money with that account and i don't know what else … and he stole that fortnight from me. that was a great problem, i had to pay the rent, and to eat also and, well, that time we even had to put up with hunger, because we lived very poorly …" a side, but important note to take here is: traditionally, this is a situation in which undocumented migrants are more likely to be found both the existing literature and the interviews made confirm it. however, in the pandemic context, it is likely that spanish nationals and documented migrants are drawn by the perks of renting an account: skip all the (although light, time consuming) bureaucracies to become a legal pdw and start making money "right away". while some companies only deal with distribution of food, there are others who provide delivery of packages of any sort (as long as they fit in the backpacks of the workers), including items between two addresses of two private individuals. the second half of this paper's research period was marked by the emergence of cases related to drug traffickers making use of these platforms' services to have their products distributed around the city -thus avoiding having themselves or their customers exposed by walking around the highly patrolled streets of barcelona. an example: april : wg # "well not long ago, a super beautiful blondie asked me to take a box of chocolates … and when she passed it onto my hands … and weighted nothing … that made me curious … and when was coming in the lift i found it suspicious and i felt like smelling it, and it was pure marijuana in the box of chocolates …" unsurprisingly, the lockdown was enforced by the action of police. practically empty, the streets and avenues of barcelona became constantly patrolled by police officers enquiring the purposes of people going around, no matter if they were on foot, riding their bikes or cars. allowed by the governmental decision on "essential activities" to keep on working, the pdw were not unexposed to trouble with the authorities -reason for which % of the interactions on the whatsapp group was about the police controls. as expected, the topic also came up in which case the account owner has an additional power over the individual renting it: that of, at any moment, denouncing him/her to the authorities. those renting an account for this purpose will not be caring for the last, but not least problem stemming from running a rented account: the absence of any form of social protection or benefit. this became outstandingly important when the spanish government announced a series of measures to support the selfemployed workers (which, in theory, is the legal category of the pdw) and those running rented accounts could not enroll for having access to such mechanisms. this was, by far, what occupied the % of the interactions above categorized as "state". in the first two weeks alone, there were more than . detentions and . fines for unjustified violation of the lockdown in the whole of spain. notably, from that the day on it is not possible to find overall data. in most of the interviews, although not with such relevance. indeed, the three reasons behind the concerns with the police controls are deeply intertwined with the previous four dimensions of precarity. even if, in most cases, an overlapping of issues is observed, they are hereafter split for a more comprehensive description. the systematic disrespect for traffic rules has very few (if anything) to do with the covid- context, however the huge reduction in traffic and having "police coming out of every corner" (march , wg # ) made the situation more hazardous. as noted by some, even when not fined, a pdw will necessarily be doubly harmed by a police control: the time spent while having his backpack and documentation checked will necessarily lose him precious hours of work and, simultaneously, impact the evaluation given by the client who will receive his package later than expected -something particularly critical in the case of food coming from restaurants. the words of jos e provide a clear picture of why pdw are so eager to avoid the police: "i cross a lot of red lights. and why do i do it? one is working with the hours given by [name of company], so one has to do what is possible to answer more requests in that hour, and so one goes as fast as possible to work more. sometimes i am afraid, because as much as one is careful, there is always risk" b) rented accounts although they are paying taxes to the account owner (rendering this slightly different from other forms of undeclared work), renting an account is an illegal action and, as noted above, it is often performed by undocumented immigrants. this deems police controls particularly unwelcome for many pdw, with consequences ranging from fines to severe legal complications. this widespread shared concern informs much of the interactions in the whatsapp group, as well as it emerges in several interviews. it is an undisputed source of anxiety: juan: "now they are also asking for documentation, and i will present the documents of my country and they will see that the account is someone else's … and things get complicated …" march : wg # "if one has a rented account, and besides it one doesn't have a passport, then you will have to take a lot of precaution, take latex gloves if possible, mask, lights on the bike, that way we avoid drawing attention." c) transport of illicit substances. it goes without saying that no one will want to be found by the police carrying illicit substances. scrutinizing the information retrieved from the whatsapp group (by the times the interviews took place this wasn't yet an issue), it stands clear that the pdw faced an unprecedented situation, which rendered many of them anxious. the discussion floated around how to avoid being used by drug dealers as carriers, and simultaneously, how to act in order to ensure the police would believe that -when they did carry drugs -they belonged to the client, and the pdw was unaware of what was being carried: april : wg# "guys, the best is not to take packages, there are already many cases of these, i know we are here to earn money but we can't risk, so even if we take a thousand photos, if the police will stop us, it is enough that it is in our package to have us being the harmed ones" against all odds, the issue of the covid- deserved very scarce attention from the pdw, particularly in the whatsapp group (only % of the interactions were directly related with it!). in fact, most of the references to it were purely instrumental and referred to how it connected with other dimensions of the pdw life, namely whether the state of emergency would interfere with their possibility to keep working. this statement should not, however, overlook the direct impact that covid- had on the life of several pdw. for instance, afraid of becoming sick jos e and maria reported having stopped working, while juan spoke of being extra careful -not afraid of the disease itself, but rather of, by becoming sick, not being able to work and, therefore, having no means of survival. despite different approaches to the topic, one aspect seemed to be consensual: the answer of the corporations that own the platforms was seem as scarce and perceived with disbelief by the pdw: march : wg # "they don't give you even a glass of water, let alone a mask. i came from there. and they don't even thank you" wg # "i saw some guy asking for it and they give them [masks], as well as gloves. obviously, when they run out, they won't give you … and you have to ask for it, it's not like they will be announcing it … their obligation would be to even notify us through the app, but we already know how it is …" to a large extent, the pandemic brought up the already existing precarious situation of the pdw. although the pool of interviewees does not stand as a representative sample -nor was that ever the intention -, it is clear that the pdw are mass of people who could not make their way into the world of standardized wage-earning decent jobs. either due to their situation of undocumented migrant, or simply because youth unemployment is massive in spain, working as a pdw forms part of the "precarity trap" in which millions of workers increasingly find themselves (fumagalli, ) . having this in mind, it is of the essence to the latter understanding of the emergence of a set of dilemas that, in a different context, could have assumed substantial different shapes, or not have surfaced at all. as aforementioned, the interviewees and the interactions in the whatsapp group made clear that there were different levels of concern regarding the possibility of being infected (and possibly killed) by the covid- . nonetheless, it stood crystal clear that, even for those exhibiting less fear, the decisive driver of their decision to work (in the case of those who did) was their impossibility to have reach out to any sort of alternative whatsoever. as per the definition of the merriam-webster dictionary ("dilemma." merriam-webste, ) a dilemma is "a usually undesirable or unpleasant choice". provided the above-mentioned circumstances in which pdw find themselves, i consider that, in the present context, they face critical dilemmas -which are hereafter systematically exposed: by far the most critical of all, the survival dilemma stands as a trademark of this particular time. on the one hand, by working and contacting dozens of other people (restaurant workers, clients, police officers, random people on the street), pdw are highly exposed to the highly contagious covid- . on the other hand, the absence of mechanisms of social support (such as unemployment or health benefits) and the possibility of having their account renting agreement unilaterally cancelled (for not being as productive as the original owners of the accounts expect/demand), impels them to continue work. over the period of research, i found two highly informative accounts, which i believe to efficiently summarize this dilemma: pablo: "of course there is a widespread fear … but even more fearsome is not to eat or having to stay on the street. you may get the virus and heal when it's over, but if you don't have anything to eat, you or your family, the death is of starvation. so, the fear is from hunger and that's it. i mean, the delivery workers, we are not fighting against one virus, we are fighting against several." march : wg # "i understand all that, but i have my daughter and the rent won't be forgiven. and my fear is to bring the virus to my house, to my wife and daughter. it is being between the sword and the wall. i'm desperate." . . the cost minimization dilemma: fines versus absence of income particularly for those not having an account under their name, the existence of a higher level of police control in the streets raises yet another dilemma. while going out is decisive to earn income to pay for their basic expenses, pdw caught using other people's accounts without documentation risks being severely fined -which would, of course, render completely useless all the efforts for gathering money. jos e: "i decided not to go out because this is a serious problem. what's more, i heard that the police was in the streets asking the delivery workers to show their working license and the social security documentation. from my side, i have no way to deliver that because my account is rented, so there is a risk i'm fined, and i've been told it can go up to euro. this fortnight i haven't earned a single euro." april : wg # "partners i have a rented account and i am about to run out of euros, what do you recommend, get out or can i get even more screwed with a fine?" wg # "with the fine or with virus, any of the two." wg # "of course you can get more screwed but you have to work. get out from to . whatever you do then is good. i go out everyday and i'm like that" . . the algorithmic dilemma: red signs versus police attention the third dilemma is not specific to this period, however the ubiquitous presence of the police in the streets makes it rather more pressing than in the recent past. the quotes provided in previous sections stand as the most significant to shed light on this issue, reason for which no new quotes are provided here. nonetheless, this dilemma's underlying rationale is the following: on the one hand, the only way to "please the algorithm" which lies at the foundation of the app is to work with high pace, since that will improve the odds of having good reviews, which, in turn, will allow the pdw to have more hours available to work and, thus, earn more income. even if the results of a high rhythm of deliveries doesn't have immediate algorithmic impact -although far from only long term, since the score of each pdw is updated on a daily basis -, as noted by some of the interviewees, the fact that the pdw get one delivery done, allow them to move on to the next one within the available hours. this will be particularly critical to those start to work as pdw, since they will have both fewer hours available and, within those, fewer odds of having a delivery requested to them. notably, this seems to confirm that technology is not, on its own, a form of control or exploitation: the ways in which it is designed and implemented rather mirrors the social relations it embodies (moore et al., ) in the case of the pdw, the absence of human (visible) interference in the decision-making process, allows managerial control to be perceived as computational and, thus, non-biased towards the boss or the employee (gillespie, ) , thus impelling workers to incur in hazardous behaviors, although keeping the appearance (in some cases some sort of fetishicized illusion) that it was their choice all alongand not the companies' perverse algorithmic design inducing them to adopt such praxis (veen et al., ) . on the other hand, to ensure that this very high rhythm is accomplished demands to not always act according to the laws, particularly traffic rules. such an attitude may, however, entail a series of negative consequences, all of them steaming from having the police attention drawn to oneself. the first, and most obvious, is that being stopped by the police will mean losing time, thus rendering the risks and the efforts to make a fast delivery useless. the second, almost as likely in case is not respecting traffic rules, is that one may be fined, which will obviously impact on the available income as soon as the fine is paid. third and most seriously, particularly for those using rented accounts, having the police checking their situation will probably lead to even heavier sanctions, ranging from bigger fines to serious legal complications (particularly for undocumented immigrants, which, as above mentioned, is many times the case). ironically enough, given the more precarious one's situation isspecifically in the case of account renters -, the more one will feel compelled to violate the laws, given that the net income retrieved from working as pdw will be even lower. as noted in the previous section, a problem that has been emerging for the pdw is that there seems to be a sudden increase in cases of drug traffickers making use of them to ensure the distribution of their product. such fact poses a series of problems that dialogue directly with several critical features of the pdw activity and the way it is designed. on the one hand, pdw afraid and/or suspicious of being used as involuntary carriers of drugs may choose to take one of three different actions, all of which may have important consequences: (i) refusing the request for deliver packages from private senders: the immediate consequence is that the earnings that would be obtained from that service will be missed, without the pdw knowing when will he/she be able to have another service; beside that, rejecting services is very likely to have negative impact on one's score, thus affecting his/hers possibility to earn money in the future. (ii) requesting the sender to open the package to ensure it's drugsfree: by asking something that does not comply with any recommendation of the platforms and is, most likely, illegal, pdw risk being sanctioned, either by having a bad review and/or if denounced by the sender to the main company; furthermore, even if this is not at all negatively interpreted by the sender, the fact that the pdw is losing time will already stand as an indirect sanction, for as noted in the previous dilemma it will likely harm the total income earned. (iii) voluntarily asking the police to check a package: particularly under the ongoing circumstances, the police has the authority to open a package and provide a legal document that the pdw may attach to it, thus defending him/herself from any accusation of violation of privacy, thus rendering this the safest option; however, this option will make the pdw lose time of eventually scarce available hours to work, which will have the impacts described above; furthermore, for an account renter (let alone an undocumented migrant!), voluntarily stop at a police control will most probably mean having documentation checked, which, for what has been exposed previously, will hardly stand as a true option on the other hand, not taking any of these three actions poses a serious risk of being stopped by the police anyway, except in this scenario, beyond any other eventual illegalities performed, carrying drugs (or even throwing it away, as some proposed in the whatsapp group). while the pdw may argue that this was being done as part of the job, proving it may be far more complicated -notably, this will be particularly more complex for undocumented immigrants. a relevant excerpt would be: april : wg # "how heavy it is with this thing of the deliveries. even if you reject it because you know its drugs and report it, you lose points …" wg # "my husband asked the client to open the boxes in front of him and the man didn't want to. he obviously didn't take it. and told him all sorts of things but his security is first, since he is already risking by going out because he rents an account. of course that for the police you are an accomplice and that's it." all things considered, exceptions notwithstanding, the pdw options are everything but true choices. the insecurity to which they are exposed deems necessary to incur in ever-growing risks (inter alia, exposure to disease and security risks, high degree of probability of being fined by of the police, or even worse) -which renders these as practically false dilemmas: at the end of the day, there is no choice but to comply with the companies' rules and go to work. as i write the last lines of this paper the developments of the covid- are still very much unpredictable. be that as it may, out of the many conclusions that can already be extracted from this health crisis -and which may prove of the essence for the more than likely upcoming economic crisis -, one is surely that there is no such thing as everyone being on the same boat. if anything, the covid- crisis has exposed the multiple-fold consequences of precarity. not that the immunity of some human beings is stronger than others just because of their job and/or economic security, however, the exposure to health and other risks, the way one cope's with temporary economic scarcity, the very ways in which one goes by a period such as this (for now) one month of quarantine, are not the same for everybody. as part of his precariat, guy standing (standing, ) drew attention to how the expansion of precarity has meant the reemergence of the ancient denizenry, i.e. a mass of people whose absence of many rights denied them the entitlement to a full citizenship. while this has always been the case of vulnerable layers of society, such as the undocumented migrants, as this paper has confirmed, these are far from the only ones falling onto this dark category. inasmuch as the existing constraints to circulation and the rapid unfold of events posed some limitations to the elaboration of this papernamely the possibility to have a larger pool of interviewees -, it still stands as a contribution for a broader understanding that the modernization of the labor process does not necessarily entail progress or social justice. nonetheless, still further research on how the covid- crisis impacted the life of precarious layers of societies is needed. among others, two critical aspects stand out as not possible to have been fully grasped by the research hereby entailed: i) to what extent the pdw were exposed to health risks to ensure they would fulfill their mission, and what did the corporations they work for do to actually tackle those risks. ii) disregard the public discourses surrounding the pdw's importance, in a moment when many people are forced (by law and/or by risk) to not to leave their homes, at least one of the companies -most notably the biggest in spain -has decided to lower the retribution per delivery ("dilemma." merriam-webste, ); beyond the outstanding contradiction, both the justifications and consequences of this decision remain unpredictable, but of the utmost interest from a sociological standpoint. as a final word, the present paper seems to underline that unless policies are designed to reconcile the development of technology, justice and human development altogether, the odds are that groundbreaking innovations are appropriated by those already concentrating wealthusing them to their advantage to further improve their already privileged situation -even if that means voting those around them to indecent living conditions. if ever there were any doubts this is the way unregulated capitalism works, the situation of the pdw in the age of covid- leaves very few room for doubts any sort. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. credit authorship contribution statement tiago vieira: conceptualization, methodology, software, data curation, writing -original draft, visualization, investigation, validation, supervision, writing -review & editing. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. humour and social protest: an introduction o privil egio da servidão introduction vida líquida o mercado ilegal das contas de app de entrega alugadas por brasileiros em londres acts of resistance: against the new myths of our time caporalato digitale tra rider, account italiani venduti a migranti irregolari: «dammi il % e ti cedo l'account study to gather evidence on the working conditions of platform workers qualitative research and hypermedia: ethnography for the digital age questioning "digital ethnography the transmediated self: life between the digital and the analog cognitive biocapitalism, the precarity trap, and basic income: postcrisis perspectives labour process theory and the gig economy common ground the relevance of algorithms la crisis del coronavirus provoca la p erdida de . empleos desde el inicio del estado de alarma. el país a brief history of neoliberalism precarity -more than a challenge of social security or: cynicism of eu's concept of economic freedom the app as a boss? control and autonomy in application-based management. arbeit | grenze | fluss -work in progress self-employment as atypical or autonomous work: diverging effects on political orientations airbnb: case study in occupancy regulation and taxation det kvalitative forskningsintervju understanding labour politics in an age of precarity the ambivalence of logistical connectivity: a co-research with foodora riders. work organisation qualitative researching humans and machines at work. monitoring, surveillance and automation in contemporary capitalism capital in the twenty-first century el mercado negro de los «riders» de glovo en madrid: alquilan sus licencias a «sin papeles uberworked and underpaid: how workers are disrupting the digital economy platform capitalism dualism, job polarization, and the social construction of precarious work platform capital's 'app-etite' for control: a labour process analysis of food-delivery work in australia this paper would not have been possible with the insights and incentive of mireia bolíbar, without the comments of daniel romero-portillo and adam tash, and without the contributions and companionship of my quarantine and life partner, ana oliveira. all of them deserve may utmost gratitude. key: cord- - dp u authors: tan, zhen; dong, wanting; ding, yaqun; ding, xiangdong; zhang, qin; jiang, li title: porcine epidemic diarrhea altered colonic microbiota communities in suckling piglets date: - - journal: genes (basel) doi: . /genes sha: doc_id: cord_uid: dp u porcine epidemic diarrhea (ped) is a major gastrointestinal disease afflicting suckling pigs that causes huge industrial economic losses. in this study, we investigated microbiota from the colonic mucosa and content in healthy and ped piglets. high-throughput s rrna gene sequencing was performed to identify inter-group differences. firmicutes, fusobacteria, proteobacteria, and bacteroidetes were the top four affected phyla. the proportion of proteobacteria was higher in infected than in healthy piglets, and the opposite was observed for bacteroidetes (more than four-fold higher in the healthy group). in the infected group, fusobacterium accounted for . % and . % in the colonic mucosa and contents, respectively, while in the healthy group, they comprised . % and . %, respectively. the percentage of lactobacillus in healthy colons ( . %) was considerably higher than that in the disease group (< %). in both the colonic mucosa and contents, functional enrichment differed significantly between healthy and diseased groups. overall, infection with the ped virus increased the proportion of harmful bacteria and decreased the proportion of beneficial bacteria in the colons of piglets. targeting intestinal microbiota could be a promising method for ped prevention, thus opening new avenues for future research. to minimize the effects of random sequencing errors, raw fastq files were demultiplexed, quality-filtered using trimmomatic version . , and merged using flash version . . [ , ] . to obtain high-quality tag sequences, initial base sites with phred score < were truncated, tags were filtered out if their continuous high-quality base length was less than three-quarters of the whole sequence, and chimeric sequences were removed in uchime version . [ ] . sequences with ≥ % similarity were assigned to the same operational taxonomic units (otus) using usearch version . [ ] . a representative sequence for each otu was screened and taxonomically analyzed against the s rrna database silva, using ribosomal database project classifier version . [ ] . representative sequences were subjected to multiple sequence alignment and a phylogenetic tree was constructed. next, the composition of each sample community was determined at the phylum, class, order, family, genus, and species level. the alpha diversity indices were evaluated using mothur version . [ ] and compared with student's t-test. the beta diversity per group was calculated using principal coordinate analysis (pcoa) based on weighted unifrac distances [ , ] in qiime version . . [ ] . between-sample differences in evolutionary information were determined using the unweighted pair-group method with arithmetic mean (upgma) [ ] . images were drawn and statistical analyses were performed using r software. linear discriminant analysis (lda) effect size (lefse) was used to identify biomarkers that differed significantly between groups. analysis of variance (anova) was used to determine between-group differences in gut microbiota. statistical significance level was set at p < . . functional predictions for all otus were performed using the kyoto encyclopedia of genes and genomes (kegg) and clusters of orthologous groups (cog) databases, based on the picrust-established structure of gastrointestinal microbiota [ ] . we collected , , quality-filtered and chimera-checked sequences with an average length of . bp. the mean number of reads per sample was , , ranging from , to , reads. a good coverage of more than . % was obtained for all samples, indicating reliable sequencing accuracy. we obtained a total of otus, and of these were observed in all four groups (supplementary figure s ) . the chao index was the highest in comh, while the shannon index was higher in coch and comh than in cocd and comd (p < . ) (figure ). dynamic changes in gut microbial alpha diversity (a, chao index; b, shannon index) of pedv-infected piglets. different letters denote significant differences in alpha diversity indices between groups based on the student's t-test and adjusted for false discovery rate (fdr) (* p < . , ** p < . ). taxonomic analysis indicated that firmicutes, fusobacteria, proteobacteria, and bacteroidetes were the top four phyla in all groups, representing approximately % of the sequences (figure a ). microorganism structure differed more between healthy and infected groups than between colonic content and mucosa. the proportions of firmicutes in colonic mucosa and content in the healthy piglets were . % and . %, respectively; while they were . % and . %, respectively, in the infected piglets. the proportions of fusobacteria in colonic mucosa and content in the infected piglets were . % and . %, respectively; and . % and . %, respectively, in the healthy piglets. the proportions of proteobacteria were higher in the infected colonic mucosa and content ( . % and . %, respectively) than that in the healthy groups ( . % and . %, respectively). in contrast to this general trend, the proportions of bacteroidetes were more than four-fold greater in healthy groups ( . % in coch and . % in comh) than in the infected groups ( . % in cocd and . % in comd). taxonomic analysis indicated that firmicutes, fusobacteria, proteobacteria, and bacteroidetes were the top four phyla in all groups, representing approximately % of the sequences (figure a ). microorganism structure differed more between healthy and infected groups than between colonic content and mucosa. the proportions of firmicutes in colonic mucosa and content in the healthy piglets were . % and . %, respectively; while they were . % and . %, respectively, in the infected piglets. the proportions of fusobacteria in colonic mucosa and content in the infected piglets were . % and . %, respectively; and . % and . %, respectively, in the healthy piglets. the proportions of proteobacteria were higher in the infected colonic mucosa and content ( . % and . %, respectively) than that in the healthy groups ( . % and . %, respectively). in contrast to this general trend, the proportions of bacteroidetes were more than four-fold greater in healthy groups ( . % in coch and . % in comh) than in the infected groups ( . % in cocd and . % in comd). taxonomic analysis indicated that firmicutes, fusobacteria, proteobacteria, and bacteroidetes were the top four phyla in all groups, representing approximately % of the sequences (figure a ). microorganism structure differed more between healthy and infected groups than between colonic content and mucosa. the proportions of firmicutes in colonic mucosa and content in the healthy piglets were . % and . %, respectively; while they were . % and . %, respectively, in the infected piglets. the proportions of fusobacteria in colonic mucosa and content in the infected piglets were . % and . %, respectively; and . % and . %, respectively, in the healthy piglets. the proportions of proteobacteria were higher in the infected colonic mucosa and content ( . % and . %, respectively) than that in the healthy groups ( . % and . %, respectively). in contrast to this general trend, the proportions of bacteroidetes were more than four-fold greater in healthy groups ( . % in coch and . % in comh) than in the infected groups ( . % in cocd and . % in comd). ten bacterial genera accounted for % of the total reads in all groups except coch ( figure b ). among healthy piglets, fusobacterium, bacteroides, and lactobacillus were dominant, while in the infected piglets, fusobacterium, actinobacillus, and escheria-shigella showed higher relative abundances. the proportions of fusobacterium in the infected groups were . % (comd) and . % (cocd), whereas in the healthy groups they were . % (comh) and . % (coch). the bacteroides percentages in the healthy piglets were . % (comh) and . % (coch), but only . % (comd) and . % (cocd) in the infected piglets. the lactobacillus proportion in coch ( . ) was considerably higher than that in the other groups. actinobacillus, however, showed noticeably higher abundance in the infected piglets ( . % in cocd; . % in comd) than in the healthy piglets ( . % in coch; . % in comh). the escherichia-shigella proportions were also higher in the infected groups ( . % in cocd; . % in comd) than in the healthy groups ( . % in coch; . % in comh). at each taxonomic level, we selected the most abundant otu sequence as representative and performed multiple sequence alignment. we then constructed a phylogenetic tree from these data ( figure ). our analysis revealed that firmicutes was the most well-represented phylum (by number of genera), followed by proteobacteria and bacteroidetes. genes , , x for peer review of ten bacterial genera accounted for % of the total reads in all groups except coch ( figure b ). among healthy piglets, fusobacterium, bacteroides, and lactobacillus were dominant, while in the infected piglets, fusobacterium, actinobacillus, and escheria-shigella showed higher relative abundances. the proportions of fusobacterium in the infected groups were . % (comd) and . % (cocd), whereas in the healthy groups they were . % (comh) and . % (coch). the bacteroides percentages in the healthy piglets were . % (comh) and . % (coch), but only . % (comd) and . % (cocd) in the infected piglets. the lactobacillus proportion in coch ( . ) was considerably higher than that in the other groups. actinobacillus, however, showed noticeably higher abundance in the infected piglets ( . % in cocd; . % in comd) than in the healthy piglets ( . % in coch; . % in comh). the escherichia-shigella proportions were also higher in the infected groups ( . % in cocd; . % in comd) than in the healthy groups ( . % in coch; . % in comh). at each taxonomic level, we selected the most abundant otu sequence as representative and performed multiple sequence alignment. we then constructed a phylogenetic tree from these data ( figure ). our analysis revealed that firmicutes was the most well-represented phylum (by number of genera), followed by proteobacteria and bacteroidetes. pcoa revealed variations between the microbiome profiles within each group based upon bray curtis dissimilarity ( figure a ). coordinate ( . % of variation) was associated with disease status (healthy or infected) and sample location (colonic content or mucosa). samples from healthy and pcoa revealed variations between the microbiome profiles within each group based upon bray curtis dissimilarity ( figure a ). coordinate ( . % of variation) was associated with disease status (healthy or infected) and sample location (colonic content or mucosa). samples from healthy and pedv infected pigs showed more distant separation, while samples from the same group were more similar. based on bray curtis distances, upgma showed that the microbes in healthy piglets were grouped in one cluster, while microbes in infected piglets were grouped in another in both colonic contents and mucosa samples ( figure b ). thus, the healthy samples were clearly distinguishable from the infected samples in the clustering tree, likely due to variations in their microbial compositions. genes , , x for peer review of pedv infected pigs showed more distant separation, while samples from the same group were more similar. based on bray curtis distances, upgma showed that the microbes in healthy piglets were grouped in one cluster, while microbes in infected piglets were grouped in another in both colonic contents and mucosa samples ( figure b ). thus, the healthy samples were clearly distinguishable from the infected samples in the clustering tree, likely due to variations in their microbial compositions. next, the lefse-identified biomarkers ( figure a ) were found to be different between the four groups, as shown in the microbial cladogram ( figure b) . we identified different taxonomic groups ( in comh, in comd, in coch, and in cocd) that could be used as biomarkers. more biomarkers were present in healthy groups than in infected groups. microorganisms that differed between groups mainly included firmicutes and bacteroidetes in the coch and comh groups, proteobacteria in the comd group, and class gammaproteobacteria in the cocd group. eight phyla were shared between the four groups, and four phyla differed significantly between groups (p < . , wilcoxon rank-sum test; supplementary figure ). the proportion of proteobacteria was . fold higher in the infected groups than that in the healthy groups, while the proportion of bacteroidetes was . fold higher in the healthy groups than in the infected groups. next, the lefse-identified biomarkers ( figure a ) were found to be different between the four groups, as shown in the microbial cladogram ( figure b) . we identified different taxonomic groups ( in comh, in comd, in coch, and in cocd) that could be used as biomarkers. more biomarkers were present in healthy groups than in infected groups. microorganisms that differed between groups mainly included firmicutes and bacteroidetes in the coch and comh groups, proteobacteria in the comd group, and class gammaproteobacteria in the cocd group. eight phyla were shared between the four groups, and four phyla differed significantly between groups (p < . , wilcoxon rank-sum test; supplementary figure s ). the proportion of proteobacteria was . fold higher in the infected groups than that in the healthy groups, while the proportion of bacteroidetes was . fold higher in the healthy groups than in the infected groups. a total of second-level kegg pathways were verified. carbohydrate metabolism, global and overview maps, and amino acid metabolism were the top three functional annotations in all four groups, followed with energy metabolism, and metabolism of cofactors and vitamins. pathways were identified for the colonic content ( figure a ) and were identified for the colonic mucosa ( figure b ) between the healthy and pedv-infected groups. among them, pathways were identified for both tissues. additionally, membrane transport and transcription were more enriched in the disease groups than in the healthy groups. a total of second-level kegg pathways were verified. carbohydrate metabolism, global and overview maps, and amino acid metabolism were the top three functional annotations in all four groups, followed with energy metabolism, and metabolism of cofactors and vitamins. pathways were identified for the colonic content ( figure a ) and were identified for the colonic mucosa ( figure b ) between the healthy and pedv-infected groups. among them, pathways were identified for both tissues. additionally, membrane transport and transcription were more enriched in the disease groups than in the healthy groups. through cog analysis, we obtained second-level classifications across the four groups; the top annotations were general function prediction only, carbohydrate transport and metabolism, amino acid transport and metabolism, and transcription. six annotations differed between the cocd and coch groups ( figure a ), while five differed between the comd and comh groups ( figure b ). in both colonic content and mucosa, amino acid transport and metabolism and cell wall/membrane/envelope biogenesis enrichment differed between the healthy and diseased groups. genes , , x for peer review of through cog analysis, we obtained second-level classifications across the four groups; the top annotations were general function prediction only, carbohydrate transport and metabolism, amino acid transport and metabolism, and transcription. six annotations differed between the cocd and coch groups ( figure a ), while five differed between the comd and comh groups ( figure b ). in both colonic content and mucosa, amino acid transport and metabolism and cell wall/membrane/envelope biogenesis enrichment differed between the healthy and diseased groups. through cog analysis, we obtained second-level classifications across the four groups; the top annotations were general function prediction only, carbohydrate transport and metabolism, amino acid transport and metabolism, and transcription. six annotations differed between the cocd and coch groups ( figure a ), while five differed between the comd and comh groups ( figure b ). in both colonic content and mucosa, amino acid transport and metabolism and cell wall/membrane/envelope biogenesis enrichment differed between the healthy and diseased groups. several microorganisms, including rotavirus, coronavirus, escherichia coli, clostridium perfringens, c. difficile, cryptosporidium spp., giardia spp., cystoisospora suis, and strongyloides ransomi, have been linked to enteritis and diarrhea in suckling pigs. in this study, we successfully demonstrated that the microbial community structure of colonic mucosa and content differed significantly between healthy and pedv-infected piglets. likewise, previous research has shown that the proportions of escherichia-shigella, enterococcus, fusobacterium, and veillonella increased significantly in pedv-infected piglets, while those of short-chain fatty acid (scfa)-producing bacteria (e.g., rikenellaceae_rc _gut_group, butyricimonas, and alistipes) underwent a decrease [ ] . moreover, the gut microbiota of pedv-infected piglets was shown to exhibit significant changes at the genus and phylum levels [ ] that are likely to disrupt microecological homeostasis. the intestinal microbial ecosystem of suckling piglets is unstable and sensitive to different external and internal factors in first week of birth. this sensitivity may generate individual differences in microorganisms, even in piglets from the same cohort [ ] . here, we found that pedv infection significantly altered the gut microbiota in piglets, an outcome that was confirmed in several other studies [ ] [ ] [ ] [ ] . although the small intestine is the main site of pedv infection, the large intestines are the main metabolic and absorption sites for microbial fermentation, and contain considerably greater microbial abundance than the small intestines. therefore, studying the cecum and colon is necessary to obtain useful information for understanding the overall gut responses to pedv infection. microorganisms in the cecum and colon produce scfas that are beneficial to host health [ ] . in our previous study, we compared the cecal microbial diversity between the healthy and pedv-infected piglets and found that the diseases associated bacteria were increased along with a decrease of beneficial bacteria in the pedv-infected piglets [ ] . similar results were observed for the colonic microbial diversity. according to the analysis of lefse, more bacteria were significantly enriched in cecal mucosa and cecal contents in the infected group than in the healthy group, while it was the opposite in the colon. in addition, differences existed in the distribution of some bacteria in the cecum and colon of the infected piglets. for example, the fusobacteria was enriched in the colonic mucosa of the infected group in colonic position, while in cecum, this bacteria was higher in the cecal contents of the infected group than other three groups. we observed a clear increase in the relative abundance of proteobacteria and fusobacteria in pedv-infected suckling pigs. fusobacteria increases have previously been observed in the feces of pedv-infected suckling pigs [ , , ] . furthermore, many studies suggested that this phylum is associated with various clinical anaerobic infections (including in the mouth, teeth, gut, and brain) in humans, and is positively correlated with catarrhal appendicitis on the mucosal surface [ , ] . within this phylum, the genus fusobacterium plays a key role in promoting human colorectal cancer and various diseases in animals [ , ] . fusobacterium nucleatum is important for the pathogenesis of various gut diseases, including intestinal inflammation and colon cancer [ ] . a previous report showed that the abundance of fusobacterium decreases sharply as the porcine gut microbiota matures from suckling to weaning [ ] . the elevated fusobacterium proportions in pedv-infected piglets is likely correlated to colon inflammation. the proportion of bacteroides decreased in the colonic microbiota of pedv-infected piglets. bacteroides are important for carbohydrate fermentation and polysaccharide catabolism, as well as amino acid and protein utilization [ ] . several genera, including bacteroides, prevotella, and parabacteroides, are important producers of scfas and are dominant in healthy piglet intestines [ , ] . scfas are rapidly absorbed by colonic epithelial cells [ ] , protect the host against colonic diseases, exhibit anti-inflammatory effects, and promote energy intake by intestinal fibers [ , ] . thus, scfa-producing bacteria contribute to carbohydrate fermentation, mucosal defense mechanisms, adipogenesis, and lipid oxidation [ , ] . decreased bacteroides abundance can result in reduced scfa concentrations among pedv-infected piglets, a link that could compromise intestinal and immune homeostasis. here, lefse showed that each experimental group differed significantly in terms of microbial enrichment, suggesting that microbial profiles are useful as specific biomarkers for distinguishing between healthy and infected piglets ( figure ) . a number of the microbes identified as biomarkers are associated with intestinal diseases and piglet health. the relevant microbes mainly belonged to firmicutes, bacteroidetes, proteobacteria, fusobacteria, verrucomicrobia, and epsilonbacteraeota. some bacteria from firmicutes and bacteroidetes were enriched in healthy piglets, while some from proteobacteria and fusobacteria were more abundant in pedv-infected groups. we observed similar outcomes when comparing cecal microbial diversity between healthy and pedv-infected piglets. the abundance of butyrate-producing clostridium butyricum was greater in the comh group than in the other groups. another study found that butyricimonas was present in all healthy piglets, but not in pedv-infected piglets [ ] . a reduction in this genus is linked to numerous autoimmune and inflammatory diseases, including inflammatory bowel disease, rheumatoid arthritis, and type diabetes. overall, these changes in biomarker bacteria compositions partly explained the low relative abundance of microflora related to energy metabolism, secondary metabolite synthesis, and amino acid metabolism in the intestines of pedv-infected piglets. collectively, our findings suggest that providing supplements to suckling piglets based on deficiencies of individual beneficial bacteria may prevent or alleviate pedv-induced diarrhea. colonic microorganisms that differ in abundance between healthy and diseased groups are mainly involved in transport and energy metabolism. therefore, pedv likely causes negative effects by disrupting microecosystem homeostasis in porcine intestines. the timely treatment of pedv-induced diarrhea and vomiting can effectively reduce mortality in newborn piglets [ ] . many previous researches [ , [ ] [ ] [ ] linking specific bacteria to healthy versus infected piglets suggests that regulating intestinal microbiota is a promising method for ped treatment. indeed, gut microbiota have been successfully used to prevent diarrhea [ ] . however, we noted that all infected samples in this study were pedv-positive, so we could not determine the clinical importance of other detected viruses. to better characterize the intestinal microbiomes of healthy versus pedv-infected piglets, we recommend that future studies fully examine virome diversity using a larger sample size and metagenomic de novo sequencing of the gut microbial genome. our study revealed the dysbiosis of colonic microbiota in pedv-infected piglets. infection increased the abundance of bacteria associated with diarrhea and other conditions, while decreased the abundance of beneficial scfa-producing bacteria. our results suggest that the gut microbiota is crucial for ped pathology and physiology. overall, our findings greatly enhance the current understanding of pedv-associated gut microbiota. supplementary materials: the following are available online at http://www.mdpi.com/ - / / / /s , figure s : detection of pedv in healthy groups and diarrhea groups using qpcr, figure s : shared otu analysis of the different piglet groups using venn diagrams, figure s : significant differences in microbe compositions between piglet groups, (* p < . , ** p < . ). author contributions: l.j., q.z. and x.d. planned the project and designed the experiments. z.t. and w.d. conducted the experiments and carried out the data analysis with help from y.d. and l.j., z.t., w.d. and l.j. contributed reagents preparation and samples collection. z.t. wrote the manuscript, which was critically reviewed by z.t. and l.j. all authors have read and agreed to the published version of the manuscript. changes in the swine gut microbiota in response to porcine epidemic diarrhea infection. microbes environ porcine epidemic diarrhea virus infection: etiology, epidemiology, pathogenesis and immunoprophylaxis emergence of porcine epidemic diarrhea virus in the united states: clinical signs, lesions, and viral genomic sequences evidence of porcine epidemic diarrhea virus (pedv) shedding in semen from infected specific pathogen-free boars animal disease deadly pig virus slips through us borders porcine epidemic diarrhoea virus: a comprehensive review of molecular epidemiology, diagnosis, and vaccines re-emergence of porcine epidemic diarrhea virus in the global pig population porcine epidemic diarrhea: a review of current epidemiology and available vaccines outbreak of porcine epidemic diarrhea in suckling piglets origin, evolution, and genotyping of emergent porcine epidemic diarrhea virus strains in the united states new variant of porcine epidemic diarrhea virus role of the intestinal microbiota and fecal transplantation in inflammatory bowel diseases immune evasion of porcine enteric coronaviruses and viral modulation of antiviral innate signaling characterization of the fecal microbiome in different swine groups by high-throughput sequencing the maturing development of gut microbiota in commercial piglets during the weaning transition probiotic properties of human lactobacilli strains to be used in the gastrointestinal tract interaction of probiotic lactobacillus and bifidobacterium strains with human intestinal epithelial cells: adhesion properties, competition against enteropathogens and modulation of il- production microbial exposure during early life has persistent effects on natural killer t cell function commensal host-bacterial relationships in the gut porcine epidemic diarrhea virus infection induced the unbalance of gut microbiota in piglets altered gut microbiota profiles in sows and neonatal piglets associated with porcine epidemic diarrhea virus infection differences in the intestinal microbiota between uninfected piglets and piglets infected with porcine epidemic diarrhea virus dynamic change of gut microbiota during porcine epidemic diarrhea virus infection in suckling piglets comparison and evaluation of conventional rt-pcr, sybr green i and taqman real-time rt-pcr assays for the detection of porcine epidemic diarrhea virus qiime allows analysis of high-throughput community sequencing data flash: fast length adjustment of short reads to improve genome assemblies uchime improves sensitivity and speed of chimera detection uparse: highly accurate otu sequences from microbial amplicon reads the silva ribosomal rna gene database project: improved data processing and web-based tools introducing mothur: open-source, platform-independent, community-supported software for describing and comparing microbial communities unifrac: an effective distance metric for microbial community comparison metagenomic biomarker discovery and explanation in-feed antibiotic effects on the swine intestinal microbiome predictive functional profiling of microbial communities using s rrna marker gene sequences differences in the development of the small intestine between gnotobiotic and conventionally bred piglets the effect of dietary protein and fermentable carbohydrates levels on growth performance and intestinal characteristics in newly weaned piglets changes in cecal microbiota community of suckling piglets infected with porcine epidemic diarrhea virus acute appendicitis is characterised by local invasion with fusobacterium nucleatum/necrophorum ubiquitous sialometabolism present among oral fusobacteria detection, isolation and characterization of fusobacterium gastrosuis sp tlr /tlr activation induces tregs and suppresses intestinal inflammation caused by fusobacterium nucleatum in vivo fusobacterium nucleatum increases proliferation of colorectal cancer cells and tumor development in mice by activating toll-like receptor signaling to nuclear factor-kappa b, and up-regulating expression of microrna- how host-microbial interactions shape the nutrient environment of the mammalian intestine gut microbiome, short-chain fatty acids, and mucosa injury in young adults with human immunodeficiency virus infection regulation of inflammatory responses by gut microbiota and chemoattractant receptor gpr bifidobacteria can protect from enteropathogenic infection through production of acetate immune responses to the microbiota at the intestinal mucosal surface this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we are grateful to the reviewers of this manuscript for their constructive suggestions. the authors are also indebted to the molecular quantitative genetics team at the china agricultural university for their expertise. the authors declare no conflict of interest.data availability: data were deposited in the ncbi short read archive (accession no. srp ). key: cord- - dk authors: gulla, krishna mohan; balaji, arvind; mukherjee, aparna; jat, kana ram; sankar, jhuma; lodha, rakesh; kabra, sushil k title: course of illness after viral infection in indian children with cystic fibrosis date: - - journal: j trop pediatr doi: . /tropej/fmy sha: doc_id: cord_uid: dk objective: to study the clinical impact of respiratory viral infection in children with cystic fibrosis (cf). design: retrospective cohort study. setting: tertiary care referral centre for cf in india. participants/patients: children with cf attending a pediatric chest clinic. methods: case records of the children with cf who had a pulmonary exacerbation with documented acute respiratory viral infection between october and december (group i) and an equal number of controls (group ii) with pulmonary exacerbation in absence of acute respiratory viral infection were reviewed. outcome measures: the two groups were compared for the following outcomes over a period of – months: bacterial colonization, antibiotics usage, pulmonary exacerbations, numbers of outpatient visits, hospitalization and oxygen therapy and spirometric parameters. results: in total, children [ each with viral infection (group i) and without viral infection (group ii)] of age – months were enrolled; baseline clinical status and pulmonary function tests were comparable. mean (sd) follow-up duration in those who had viral infection and who had no viral infection was . ( . ) and . ( . ) months, respectively. on follow-up, children with viral infection (group i) had adverse outcome in form of greater worsening of shwachman clinical scores, number of pulmonary exacerbations requiring antibiotic usage [ ( . %)] and [ . ( . %)], need for intravenous antibiotics . % vs. . %, hospitalization rates . % vs. . % and mortality . % vs. . %, respectively. conclusion: acute viral infection in children with cf affected course of illness on follow-up, including frequent and severe pulmonary exacerbations requiring hospitalization, intravenous antibiotics, decline in cf scores and increased mortality over next – months. respiratory failure is the major cause of morbidity and mortality in patients with cystic fibrosis (cf); bacterial infections are generally thought to be the major cause of clinical deterioration [ ] . however, literature suggests that respiratory viruses do play an important role in pulmonary exacerbations, disease progression and an increase in bacterial adherence to the cf airways [ ] . even with appropriate use of antibiotic therapy, chronic obstructive airway disease continues to develop in patients with cf and is the major cause of morbidity and mortality. in children with cf, approximately half of the pulmonary exacerbations are associated with viral infections and are associated with worsening of spirometric parameters over time, especially in young children [ ] [ ] [ ] [ ] [ ] . if respiratory virus infections do lead to secondary bacterial infection in cf, there may be implications for the management of cf. hence, we conducted a retrospective cohort study to compare the effects of viral infection on the clinical course of children with cf over a period of months. in this retrospective cohort study, data were collected from the case records of cf patients attending the pediatric chest clinic of an indian tertiary care centre. cf was diagnosed based on typical clinical characteristics and two elevated sweat chloride levels on different occasions. nasopharyngeal aspirates/ nasal swabs of children with cf who presented with pulmonary exacerbations during october to december had been tested for viral pathogen using real-time polymerase chain reaction, pcr (fast-track diagnostics, luxembourg) as a part of another study done at the same institute [b. arvind, unpublished dissertation]. this pcr test could detect rhino, human corona, influenza a and b, parainfluenza, adeno, respiratory syncytial, human metapneumo and echo viruses. children with cf were routinely followed up in the pediatric chest clinic every months or earlier if indicated. the clinical information is recorded using a predesigned performa. children with cf whose nasopharyngeal aspirates/nasal swabs were tested and found positive for viral infection during an exacerbation were included as group i. children with cf and pulmonary exacerbation, whose throat swabs tested negative for viral pathogens were enrolled as controls after matching for age and sex (group ii). the children had been followed up every months or earlier, if needed. details of the follow-up visits during the months after throat swab collection were collected in a predesigned performa, which included the following: age; gender; weight; height at time of throat swab collection and during follow-up; bacterial colonization; intravenous and oral antibiotics usage; episodes of outpatient visits; hospitalization; percentage of predicted fev (forced expiratory volume in s), fvc (forced vital capacity), mmef (maximum mid-expiratory flow) and fev /fvc for the age and height; and clinical cf score. clinical cf score designed by shwachman and kulczycki [ ] was used to assess the clinical status of the children in follow-up. assessment of pancreatic insufficiency was done with history of frequent, foul-smelling and oily stools. written informed consent had been taken from parent/guardian before collecting respiratory specimen for viral detection in the earlier study [b. arvind, unpublished dissertation]. ethical clearance had been obtained from the institutional ethics committee for the current study. as we collected data from case record forms of children with cf who are routinely followed up in the pediatric chest clinic of the institute, consent for this retrospective study was not obtained from parent/guardian. data were analysed using stata ver. (college station, tx, us) and significance of difference of various parameters between groups i and ii were examined using student's t-test and mann-whitney test, according to the distribution of the parameter. weight for age and height for age z-score were calculated using the anthroplus software (who, geneva). the visit where throat swab for viral detection was collected was considered as the baseline visit for this study. multivariate analysis was performed using performing logistic regression model. twenty-three children with cf were included in each group. the baseline characteristics of the study children were comparable in both the groups and are presented in table . the distribution of viruses detected in the respiratory specimen in the enrolled children is shown in intravenous antibiotic usage and episodes of hospitalizations were significantly more in children who had a viral infection as compared with the others. mortality was also significantly higher in children in whom virus had been detected ( ; . %) as compared with those in whom no virus could be detected in respiratory specimen ( ; . %), p ¼ . (table ). in total, children in group and children in group could perform spirometry and parameters were shown in table . of the seven children who died in group i, rhinovirus had been detected in five, adenovirus in one and coronavirus in one during the pulmonary exacerbation evaluated for viral infections. the course of illness of children infected with rhinovirus was compared with those who were infected with other viruses (table ). in group i, three patients were newly colonized with pseudomonas aeruginosa and one patient was colonized with beta-haemolytic streptococcus. whereas in group ii, three patients were colonized with pseudomonas and two patients were colonized with staphylococcus aureus after virus isolation. allergic bronchopulmonary aspergillosis (abpa) was present in three children in group i and five children in group ii. one patient was home oxygen-dependent this retrospective cohort study demonstrated that cf children who had suffered a viral respiratory infection had worse outcome in follow-up in the form of lower cf scores, higher use of intravenous antibiotics, higher rate of hospitalization and higher mortality as compared with matched controls who did not have viral respiratory infection. respiratory viruses associated with the respiratory exacerbations of cf include influenza a and b, respiratory syncytial virus (rsv), parainfluenza virus (piv) types - , rhinovirus, human metapneumovirus, coronavirus and adenovirus. viral infections predispose the respiratory epithelium to secondary bacterial infections by multiple mechanisms resulting in frequent pulmonary exacerbations [ , ] . rhinovirus has been reported as major viral pathogen in cf with detection rates reaching up to % from samples collected both during exacerbations and routine visits [ ] . in our cohort too, rhinovirus was the most commonly detected ( . %) virus. in a prospective multi-birth cohort study by armstrong et al. [ ] on viral infection in infants with cf during infancy, children of ( %) were hospitalized for respiratory distress and of them had viral infection, and they concluded that viral infections are important cause of hospitalization in children with cf. abman et al. [ ] followed infants with cf over a period of . months (range - months); ( %) infants had been hospitalized times for respiratory distress. among these children, rsv was detected in infants. reports from earlier research on cf children have documented that patients with virus-associated infections had higher use of antibiotics at the longterm follow-up, compared with those without virusassociated respiratory tract infections [ , ] . in our cohort, usage of oral antibiotic was similar in both groups. but the requirement of intravenous antibiotics was significantly higher during follow-up of cf patients with viral respiratory infection compared with those who did not have any virus detected in the respiratory specimen ( . % vs. . %, p ¼ . ). in our cf patients with viral infection, of ( %) children required hospitalization for pulmonary exacerbation during their follow-up period, whereas only patient of ( . %) from the other group required hospital admission. hospitalization was higher in cf children in whom rhinovirus was detected as compared with other virus. over few decades, it has been presumed that viruses may be the harbinger of infection with typical bacterial cf pathogens. a temporal link was proposed between viral infections and new pseudomonas infection [ ] [ ] [ ] . there are currently limited data available to determine the effects of viral infection on the cf lung microbiota. in vitro studies have shown that rsv and influenza virus increase the adherence of pseudomonas to human airway [ , ] . it was also shown that rsv promotes growth of pseudomonas biofilms through modulation of the immune response and pathogen iron metabolism [ ] , while rhinovirus promotes the free movement of pseudomonas from biofilms [ ] . in contrast to what was believed, a recent study on dynamic interaction between respiratory viruses and the lung microbiota in children recently reported that viral infection had no impact on bacterial diversity [ ] . in our cohort, three children in each group were found to have new pseudomonas infection in follow-up, which suggests that viral infection may not be the only factor involved in colonization of pseudomonas in airway epithelium of cf children. viral infections in cf patients are associated with decline in pulmonary function. the majority of studies had shown declining trend of fev and fvc in long-term follow-up in those cf patients who had virus-associated lower respiratory tract infection [ , , ] . some studies like that by ramsey et al. [ ] showed no effect on pulmonary function tests (vital capacity (vc) or residual volume (rv)/total lung capacity (tlc)) in the follow-up of children with cf after viral infection. a recent review on clinical impact of respiratory viruses in cf suggests that high burden of viral respiratory infection in children with cf is likely to be linked with progression of cf lung disease [ ] . in our cohort, both the groups had shown decrement of lung function tests over the follow-up period with more decrement in group , though statistically not significant. it suggests that lung disease progresses over the period of time in these patients irrespective of viral infection. disease progression in cf is assessed through clinical data, chest radiography and tomography and pulmonary function tests. shwachman-kulczycki (sk) [ ] score is the most commonly used score to follow the progression of disease activity in cf children. we reviewed clinical data on general activity, physical examination and nutrition in our cohort. at the baseline, both the groups were comparable in above said three domains. however, at the last visit, children in group i had poorer scores in the domains of general activity, physical examination and nutrition as compared with group ii suggesting that viral infection may play a role in worsening of clinical status in children with cf. nevertheless, the subjectivity in the score needs to be kept in mind. apart from morbidity of cf caused by pulmonary exacerbations, the annual number of exacerbations has a considerable impact on survival also. in our cohort, . % of mortality was constituted by group i who had viral infection. this can be attributed to the severe pulmonary exacerbations requiring hospitalization in this group of children. in total, of ( . %) children who required hospitalization in group i (cf with viral respiratory infection) died by the end of follow-up period. in a predictive model, cf patients who required hospitalization more than twice a year were . times more likely to die within years [ ] . in a similar survival prediction model comprising data from cf patients selected from cystic fibrosis foundation patient registry, each acute pulmonary exacerbation within the first year of follow-up increased the risk of death by . times in the following years [ ] . in a prospective cohort study conducted on adult cf patients, more than two exacerbations per year had a greater risk of lung transplant or death during the study than those with less than one exacerbation per year (adjusted hazard ratio, . ) [ ] . all of our patients had at least moderate pancreatic insufficiency as suggested by presence of history of frequent, foul-smelling and oily stools. we also note that our patients were malnourished at baseline in both the groups along with low fev , which might have contributed to the high mortality in part. supportive care apart from antibiotics during pulmonary exacerbation plays an important role in the care of cf patients. in our clinic, we do advise and demonstrate regarding chest physiotherapy, inhalation therapy such as hypertonic saline ( % saline) and daily enzyme replacement therapy. however, we do not routinely use dnase, potentiators or correctors because of cost constraints. we also want to highlight the fact that all of our patients were pancreatic insufficient because patient with milder diseases were not suspected to have cf because of lack of awareness and belief that cf does not occur in indian children. strengths of the study include the use of highly sensitive assay for detection of virus and long-term follow-up of months in indian children with cf. the major limitation of the study is its retrospective design. the determination of viral aetiology of pulmonary exacerbation was done only at enrolment; subsequent exacerbations were not investigated for viral etiology. c o n c l u s i o n following the viral respiratory infections in children with cf who were already nutritionally compromised, there were frequent and severe pulmonary exacerbations requiring hospitalization, intravenous antibiotics, decline in cf scores and increased mortality over next - months. the seattle virus watch. ii. objectives, study population and its observation, data processing and summary of illnesses community study of role of viral infections in exacerbations of asthma in - year old children detection of viral, chlamydia pneumoniae and mycoplasma pneumoniae infections in exacerbations of asthma in children the role of respiratory viruses in cystic fibrosis the art and science of the use of antibiotics in cystic fibrosis severe viral respiratory infections in infantswith cystic fibrosis effects of upper respiratory tract infections in patients with cystic fibrosis the effect of respiratory viral infections on patients with cystic fibrosis respiratory viral infection predisposing for bacterial disease: a concise review rsv mediates pseudomonas aeruginosa binding to cystic fibrosis and normal epithelial cells long-term study of one hundred five patients with cystic fibrosis; studies made over a five-to fourteen-year period viral and atypical bacterial infections in the outpatient pediatric cystic fibrosis clinic role of respiratory syncytial virus in early hospitalizations for respiratory distress of young infants with cystic fibrosis prevalence and impact of respiratory viral infections in young children with cystic fibrosis: prospective cohort study respiratory infections in cystic fibrosis patients caused by virus, chlamydia and mycoplasma-possible synergism with pseudomonas aeruginosa seasonal onset of initial colonisation and chronic infection with pseudomonas aeruginosa in patients with cystic fibrosis in denmark adherence of pseudomonas aeruginosa to tracheal cells injured by influenza infection or by endotracheal intubation respiratory syncytial virus infection enhances pseudomonas aeruginosa biofilm growth through dysregulation of nutritional immunity rhinovirus infection liberates planktonic bacteria from biofilm and increases chemokine responses in cystic fibrosis airway epithelial cells insights into the respiratory tract microbiota of patients with cystic fibrosis during early pseudomonas aeruginosa colonization infective respiratory exacerbations in young adults with cystic fibrosis: role of viruses and atypical microorganisms association of respiratory viral infections with pulmonary deterioration in patients with cystic fibrosis the diagnosis and management of respiratory viral infections in cystic fibrosis developing cystic fibrosis lung transplant referral criteria using predictors of -year mortality predictive -year survivorship model of cystic fibrosis exacerbation frequency and clinical outcomes in adult patients with cystic fibrosis key: cord- -c y m do authors: guo, baoqing; lager, kelly m.; henningson, jamie n.; miller, laura c.; schlink, sarah n.; kappes, matthew a.; kehrli, marcus e.; brockmeier, susan l.; nicholson, tracy l.; yang, han-chun; faaberg, kay s. title: experimental infection of united states swine with a chinese highly pathogenic strain of porcine reproductive and respiratory syndrome virus date: - - journal: virology doi: . /j.virol. . . sha: doc_id: cord_uid: c y m do the pathogenesis of type highly pathogenic porcine reproductive and respiratory syndrome virus (hp-prrsv) in -week old swine in the united states was investigated. rjxwn , rescued from an infectious clone of chinese hp-prrsv, replicated in swine with at least -fold increased kinetics over u.s. strain vr- . rjxwn caused significant weight loss, exacerbated disease due to bacterial sepsis and more severe histopathological lung lesions in pigs exposed to hp-prrsv than to those infected with vr- . novel findings include identification of bacterial species present, the degree of thymic atrophy seen, and the inclusion of contact animals that highlighted the ability of hp-prrsv to rapidly transmit between animals. furthermore, comprehensive detailed cytokine analysis of serum, bronchoalveolar lavage fluid, and tracheobronchial lymph node tissue homogenate revealed a striking elevation in levels of cytokines associated with both innate and adaptive immunity in hp-prrsv infected swine, and showed that contact swine differed in the degree of cytokine response. in , investigators from several chinese provinces reported a unique syndrome in growing swine that was highlighted by the predominant clinical signs of high fever, anorexia, listlessness, red discoloration of skin, respiratory distress and very high morbidity and mortality rates (li et al., ; tian et al., ; tong et al., ; wu et al., ; zhou et al., ) . originally known as porcine high fever disease (phfd), this syndrome spread to vietnam in and to cambodia, laos, the philippines, bhutan, myanmar, thailand, south korea and russia in later years feng et al., ) . although there was concern that this syndrome may have been caused by a new disease agent, extensive diagnostic testing revealed only known pathogens. one consistent finding was the detection of porcine reproductive and respiratory syndrome virus (prrsv) with two discontinuous deletions in the replicase polyprotein known as nonstructural protein (nsp ), and two single nucleotide deletions in the and untranslated regions (utrs) (zhou and yang, ) . experimental infection of chinese swine with the initial novel prrsv field isolates reproduced the clinical disease (li et al., ; tian et al., ; tong et al., ; wu et al., ; zhou et al., ) , providing strong evidence for its role as the causal agent of phfd. since the severity of the clinical disease was greater than expected for a typical prrsv infection, there remained the chance that an unknown agent in the prrsv isolates exacerbated the disease symptoms. this question was resolved when phfd was reproduced in chinese swine with virus derived from an infectious clone of the jx prrsv isolate (lv et al., ) . the prior studies demonstrated that prrsv isolates with a common genetic pattern had a causal role in phfd, leading to the new designation of this viral lineage as highly pathogenic prrsv (hp-prrsv). the presence of the unique nsp deletion motif was initially thought to contribute to the severity of disease (tian et al., ) . however, studies showed that the nsp region of hp-prrsv strain rjxwn containing the novel deletion could be replaced with amino acids from low virulence strain hb- / . to result in a chimeric virus with only a minor delay in mortality (zhou et al., ) . there was also concern that there may be some unique aspect that may predispose asian pigs to a severe outcome, e.g., husbandry practices, endemic infections with other pathogens, climate, or host genetics. although a number of experiments have associated genetic changes in prrsv with an attenuation phenotype using point mutations (grebennikova et al., ; nielsen et al., ; storgaard et al., ) or by the construction of chimeric viruses (ellingson et al., ; kwon et al., ; wang et al., ; zhou et al., ), there appears to be no single locus for which mutations confer a predictable change in virulence. collectively, this area of study suggests the factors that contribute to prrsv pathogenicity are complex and viral strain-specific . as part of the single-strand positive-sense rna virus order nidovirales, family arteriviridae, prrsv genomes can vary between kb to . kb, consist of at least open reading frames (orfs) and replicate through a nested set of subgenomic rnas (van hemert and snijder, ) . members of this highly variable virus have been grouped into two genotypes, type (european-like, prototype strain lelystad) or type (north american, prototype strain vr- ), which differ in nucleotide similarity by approximately % (nelsen et al., ) . both genotypes have representatives of varying pathogenicity, and intragenic nucleotide sequence variation in each can be as much as % (shi et al., ) . for this study, we imported a plasmid containing the cdna copy of the hp-prrsv strain rjxwn genome, a type prrsv genome that is , bases in length and has % pairwise nucleotide identity to the prototype genome of vr- (zhou et al., ) . to investigate the pathogenesis of hp-prrsv infection and the potential contribution of climate, host genetics, commensal bacteria, other environmental conditions and husbandry practices to the pathogenicity of hp-prrsv in u.s. swine, we compared and contrasted the pathogenicity of rescued jxwn (rjxwn ) virus to that of vr- in -week old swine. we found that this hp-prrsv strain caused extreme morbidity, as was seen in asia, but novel to this study, resulted in up to x higher abundance of circulating virus when compared to vr- , caused extremely exacerbated thymic atrophy such that the thymus was often difficult to discern, and the host response was assessed in comparison to animals infected with strain vr- for the first time by a swine protein array including innate and adaptive cytokines in serum, bronchoalveolar lavage fluid and lymph nodes. moreover, we completed bacterial speciation and loads after necropsy and specified the degree of weight loss seen. lastly, we showed that hp-prrsv readily transmitted to contact swine causing a different pattern of cytokine responses. as a result of our study, the remaining plausible contributing factors to the high virulence seen in asia were discredited, and thus hp-prrsv strains pose a serious threat to the u.s. swine industry. pigs challenged with chinese hp-prrsv strain rjxwn (group ) began exhibiting clinical signs of disease within - days post exposure (dpe). as a group, the pigs developed fevers, became listless, anorexic, and began shivering and huddling together in a pile. clinical signs became more severe over the next few days, with pigs rapidly losing body weight (fig. ) , becoming dehydrated and weak. respiratory distress, characterized by dyspnea, tachypnea and coughing was common in all pigs. erythema of the skin was present in most of the pigs, and several developed cutaneous hemorrhages and cyanotic extremities (blue ears) (fig. ). on dpe, one pig from group was found dead. two others were euthanized due to severe weakness and moribund condition on dpe and , and one was found dead on dpe . on and dpe, clinical signs of disease in some of the hp-prrsv challenged group began to decrease in severity. while pigs remained huddled in a pile with respiratory signs, approximately half of them were subjectively less listless, would move away when approached and began showing an interest in feed again. during the study, contact pigs displayed similar clinical signs as those challenged with hp-prrsv . pigs challenged with vr- (group ) were clinically normal until dpe , when they began to exhibit slightly increased respiratory rates and became a little less active than the control group. one pig from the vr- group was found dead on dpe ; however, the cause of death was attributed to gastric dilatation and volvulus, rather than to clinical disease typical of prrsv strain vr- . control pigs (group ) remained clinically normal for the duration of the study. postmortem examination revealed severe lesions in the hp-prrsv challenged pigs including: marked interstitial pneumonia, lymphadenopathy and thymic atrophy. necropsy findings in this group include: pulmonary edema, pleuritis, peritoneal and pericardial effusions, renal petechia, and fibrinous peritonitis that are delineated in table . lungs and representative lesions are shown in fig. . no pathologic lesions were identified in control pigs (group ). pigs in the vr- challenge group (group ) had diffuse interstitial pneumonia, characteristic of an uncomplicated prrsv infection. although lung lesions were subjectively more severe in the hp-prrsv and contact groups, a statistically significant difference in lung scores was only found between the rjxwn contact group and the group inoculated with vr- (groups and , po . ) (fig. a) . lymphadenopathy was present in all infected pigs (groups - ), with no statistically significant difference between hp-prrsv and vr- infected groups (fig. a ). thymic atrophy was also a common finding in infected pigs and was significantly more severe in hp-prrsv infected and contact pigs compared to vr- infected pigs (p ¼ . and po . ; fig. b ). table summarizes aspects of the clinical disease seen in this study. shown are adwg and associated standard errors for each of the four groups for days À - and days - . sham inoculated control swine (group ) and those challenged with vr- (group ) gained weight at an expected rate for their age group. group swine challenged with hp-prrsv strain rjxwn and their contacts (group ) lost body weight during the last week of the experiment. the adwg for group on days À - includes only pigs, and on days - includes only pigs. the body weights for the contact animals were taken on the same day as pigs in the other groups. significance values are shown. microscopic lung lesions consisted of histiocytic interstitial pneumonia with increased numbers of macrophages in alveolar septa and lumina (fig. a , c). type ii pneumocyte hyperplasia was also present. these lesions were seen in the hp-prrsv challenge group (group ), the hp-prrsv contact pigs (group ) and the vr- challenge group (group ). mean interstitial pneumonia lesions were . , . , and . for chinese prrsv challenge group (group ), contact chinese prrsv pigs (group ) and vr- challenge (group ), respectively (fig. b ). lesions were significantly (p¼ . ) more severe in the chinese prrsv challenge group (group ) and contact chinese prrsv pigs (group ) as compared to the vr- challenge (group ). two sham inoculated control pigs had mild lesions with a score of , while the remaining pigs had no lesions. immunohistochemistry labeling for prrsv nucleocapsid was positive in % of chinese prrsv challenge and contact pigs (groups and ) and % of vr- challenge pigs (group ), with mean ihc labeling scores of . , . , and . , respectively (fig. ) . positive labeling was present in alveolar macrophages and interstitial macrophages for all infected groups ( fig. b and c). no significant difference was present in the amount of prrsv labeling in the lung among the three treatment groups. immunohistochemistry labeling for prrsv in lung tissue was negative in all sham inoculated control pigs. sera collected at À , , and dpe were tested for prrsv antibody. most swine infected with rjxwn (group ) had seroconverted by dpe (mean s/p ¼ . , sd¼ . ), and all had seroconverted by dpe (mean s/p ¼ . , sd ¼ . ); however, the rjxwn contact animals (group ) had not yet seroconverted by dpe (mean s/p ¼ . , sd ¼ . ) but did by dpe (mean s/p¼ . , sd¼ . ). vr- infected pigs (group ) were seronegative at dpe (mean s/p ¼ . , sd ¼ . ); but positive by dpe (mean s/p¼ . , sd ¼ . ). the sham inoculated control animals (group ) remained negative for prrsv nucleocapsid antibody throughout the study. all serum and balf samples were screened on marc- cells for infectious virus, and vi positive samples were then titered. a significant increase in virus load ( - fold) for the rjxwn challenge and rjxwn contact pigs was found in the serum when compared to the vr- challenge group (fig. a ). no significant differences were found in serum virus titer between the rjxwn challenge and rjxwn contact groups at any time points even though the contact pigs were exposed to rjxwn infected pigs at dpe. at necropsy, no significant differences in balf titers were found among the rjxwn challenge, rjxwn contact, or vr- challenge groups (fig. b ). control serum and balf samples were vi negative throughout the experiment ( fig. a and b) . to examine the levels of prrsv rna and to strengthen the case for the apparent difference in viral loads between the hp-prrsv and vr- inoculated animals seen above, qrt-pcr was completed on all serum samples as well as balf and lymph node tissue (fig. ) . the level of viral rna detected in serum samples mirrors the results obtained by virus isolation on marc- cells (fig. a, pr . at all dpe). the qrt-pcr results from balf showed little or no significant difference between the infected lymph node weight (lnw) to body weight (bw) ratios showed pronounced lymphadenopathy in all infected animals (groups - ) as compared to control animals (group )(p¼ . or higher significance), but no statistical significance between prrsv infected swine. (b) thymus weight (tw) to bw ratios showed thymic atrophy in all infected animals (groups - ) as compared to control animals (p o . ), and statistically significant differences between hp-prrsv inoculated (po . ) and naturally infected (p ¼ . ) animals compared to vr- inoculated swine. groups (fig. b ). tbln samples suggested that swine inoculated with vr- had significantly less viral rna present than those inoculated (p¼ . ) or infected (p¼ . ) with hp-prrsv (fig. c ). sham inoculated control serum, balf, and tbln tissue samples were viral rna negative throughout the experiment ( fig. a -c ). bacteria were isolated from the balf of of the rjxwn inoculated pigs (group ) and of the rjxwn contact pigs (group ) but from only of pigs in each of the sham inoculated control (group ) and vr- inoculated (group ) groups. in the rjxwn challenge group pasteurella multocida was isolated from four pigs (ranging from to cfu/ ml), p. multocida ( cfu/ ml) and actinobacillus suis ( cfu/ ml) were isolated from two pigs, p. multocida, a. suis and streptococcus suis (approximately , , and cfu/ ml, respectively) from one pig, and staphylococcus aureus and klebsiella pneumoniae (approximately and cfu/ ml, respectively) were isolated from one pig. in the contact group, p. multocida and a. suis were isolated from one pig ( cfu/ ml each) and p. multocida, a. suis, and arcanobacterium pyogenes (approximately , , and cfu/ ml, respectively) were isolated from a second pig. s. aureus and escherichia coli ( cfu/ ml each) were isolated from vr- inoculated pig, and bordetella bronchiseptica ( cfu/ ml) was isolated from sham inoculated control pig. results on cytokines measured in serum, balf and tbln homogenates are presented in figs. and and the changes in cytokine levels relative to sham-inoculated controls are listed in table . pigs directly inoculated with rjxwn (group ) had significantly elevated average serum levels of ifna, il- b, il- , il- and ifng, ranging from to times the levels detected in sera of sham inoculated controls (group ). in pigs inoculated with rjxwn , serum ifna levels were significantly elevated at dpe in comparison to both controls and vr- exposed pigs (po . ) and remained significantly elevated at dpe versus both groups. serum levels of il- were elevated by dpe, with il- , il- , il- and ifng all signficantly elevated at dpe compared to both controls and vr- exposed pigs (po . ). compared with sham inoculated controls, contact pigs exposed to rjxwn (group ) developed significant serum level elevations ( to times greater) in out of innate immunity cytokines measured (ifna, tnfa and il- b) and elevated levels ( to times greater) for all cytokines measured associated with adaptive immunity (il- , il- , il- , il- and ifng). in pigs exposed to rjxwn by contact transmission, serum ifna levels were signifcantly elevated at , and dpe in comparison to controls (po . ). in addition, contact pigs had significant elevations in il- b at and dpe (po . ). contact pigs also had significantly elevated levels of all adaptive immunity cytokines at and dpe (p o . ) with il- also significantly elevated at dpe. in contrast, none of the cytokines measured had significant elevations in serum levels detected in pigs inoculated with the north american prototype strain vr- (group ) when compared with sham inoculated controls. similarly, when compared to sham inoculated controls, balf of swine inoculated with rjxwn (group ) had significantly elevated ( to times greater) levels of out of innate immunity cytokines measured (tnfa, il- b and il- ) and elevated levels ( to times greater) for all cytokines measured associated with adaptive immunity (il- , il- , il- , il- and ifng). compared with sham inoculated controls, contact swine exposed to rjxwn (group ) had significantly elevated balf cytokine levels ( to times greater) in out of innate immunity cytokines measured (ifna, tnfa and il- ) and elevated levels ( to times greater) for all cytokines measured associated with adaptive immunity (il- , il- , il- , il- and ifng). in contrast, swine inoculated with vr- (group ) had significantly elevated balf cytokine levels ( times greater) for only out of innate immunity cytokines measured (il- b and il- ) and elevated levels ( to times greater) for of cytokines measured associated with adaptive immunity (il- and ifng). in this study, we compared the pathogenicity of chinese hp-prrsv strain rjxwn to north american prototype vr- in u.s. high health swine under controlled conditions. the clinical disease induced in this study by the hp-prrsv virus was similar to what has been reported in asia for phfd and for experimental infections with the wild-type or rescued virus ( zhou et al., ; zhou et al., ) . likewise, the clinical disease induced by the vr- virus was similar to that observed in previous reports (faaberg et al., ; rossow et al., ) . clinical disease and pathology were much more severe in the rjxwn group and their contacts than in the vr- group. overall, gross pathology lesions in the rjxwn challenged and contact groups were much more extensive and not restricted solely to the respiratory tract and lymph nodes as was the case with the vr- challenged pigs. the high occurrence of bacterial co-infections in the rjxwn challenge and contact swine likely played a prominent role in the difference in pathology and clinical disease between groups. bacterial co-infections in pigs naturally infected with prrsv have been documented, with susceptibility attributed to factors including prrsv strain differences, host genetics, management practices and environmental factors (rossow, ) . in this study, we used swine of high health status in a controlled research environment that were from -and -way crosses of commercial genetic lines. we believe the incidence and magnitude of bacteria isolated from the rjxwn challenge and contact groups when compared to the vr- and control groups suggest the differences in secondary bacterial infection susceptibility are specific to viral strain. in this study, we observed a % mortality rate in rjxwn infected pigs by dpe, which is less mortality than the original report (zhou et al., ) , but similar to other hp-prrsv strains used (li et al., ; lv et al., ; zhou et al., ) . possible explanations for differences may be the route and dose of inoculation, the age of pigs, the hp-prrsv strain utilized, and the time course of study. in addition, since the hp-prrsv lineage may exacerbate subclinical bacterial infections, it is possible different endemic bacterial infections played a role in apparent different mortality rates. in natural infections with chinese hp-prrsv, pulmonary interstitial hyperplasia with hemorrhage and edema is described, which suggests an acute septicemic process due to a secondary bacterial pathogen (tian et al., ; zhou and yang, ) . upon histopathologic examination of tissues from this study, north american pigs directly inoculated with rjxwn , as well as contact pigs, had an interstitial pneumonia that was significantly more severe than the vr- inoculated group, which is consistent with the severity of disease reported in china. although pulmonary lesions were more severe in the rjxwn challenge and contact pigs, the amount of antigen labeling was not significantly different from the vr- inoculated swine. since levels of proinflammatory cytokines, including tnfa, il- b and il- , were significantly increased in the balf of rjxwn -inoculated and contact pigs, the host response to hp-prrsv may play a role in the augmented lung pathology seen. in addition, the increased incidence of secondary bacterial infections in rjxwn challenge and contact pigs may have contributed to increased cytokine production and resultant immunopathology. there are numerous reports about the interplay of prrsv with the swine immune system that describe variable responses to infection at the cellular and cytokine level (miguel et al., ; thanawongnuwech et al., ; thanawongnuwech and thacker, ; wang et al., ) . although a large part of this variability may result from differing methods, challenge viruses, outbred pigs, and experimental designs, there are consistent findings emerging among the studies of increases in levels of selected cytokines associated with both innate and adaptive immunity. here we report a comprehensive assessment of the effects of prrsv infection on levels of cytokines critical to innate (ifna/b, tnfa, il- b, il and il- ) and adaptive (il- , il- , il- , il- and ifng) immune systems in serum, balf and tbln homogenates. it was demonstrated that infection with a highly pathogenic strain of prrsv elicited a significant elevation of all adaptive immunity cytokines measured in balf, as well as a majority of these cytokines in serum and tbln homogenates of the same groups of pigs. this observation is consistent with previous reports of table changes in cytokine levels in sampled tissues relative to non-challenged control pigs (p-values in comparison to non-challenged controls). serum values are an area under the curve overall average level measured in samples collected after exposure to virus. geometric means back-calculated from log means were used to determine relative changes in tbln and balf cytokine levels compared to sham-inoculated controls. (sun et al., ) ]. in contrast, in pigs infected in this study with rjxwn , we observed significant elevations of serum ifna as the first cytokine to peak following exposure to rjxwn in either the directly challenged or contact pigs, with the zenith occurring and dpe, respectively. however, consistent with a previous study (gomez-laguna et al., ), elevated serum ifna had little to no apparent effect on virus clearance as the viremia peaked in the rjxwn challenge and contact pigs on dpe and , respectively, and remained above the serum virus levels of vr- pigs until the end of the study ( and dpe). it is well documented that prrsv infection will increase the susceptibility of swine to co-infection with various bacteria (brockmeier et al., ; thanawongnuwech et al., ; thanawongnuwech and thacker, ; thanawongnuwech et al., ; thanawongnuwech et al., ; xu et al., ) , and based on previous findings with other hp-prrsv strains (xu et al., ) and our current rjxwn findings, it is clear that exposure to hp-prrsv greatly increases the likelihood of secondary bacterial infection due to commensal or pathogenic organisms typically found in the swine upper respiratory tract. whether the significant elevations of multiple cytokines that were measured in serum, balf and tbln following exposure to rjxwn were a direct result of the virus, an indirect effect mediated by the secondary bacterial infections, from extensive host tissue damage, or a combination of all of these events cannot be determined from our experiments. however, the pattern of multiple cytokines being elevated nearly simultaneously in serum ( of cytokines in rjxwn contact pigs and of cytokines in direct inoculated pigs) has not previously been reported and was not detected in vr- infected swine. cytokines are a diverse collection of peptides that elicit a wide range of biological responses and are characteristically understood in the context of an immune response wherein inflammation and immunity are carefully orchestrated by sequential secretion of cytokines that coordinate innate and adaptive immune responses. macrophages and stressed or damaged cells typically initiate a cytokine cascade through secretion of chemokines and proinflammatory cytokines in order to initiate the innate immune response at sites of acute infection or damage. generally, they act locally at nano-to picogram levels with short half-lives and transient activity. however, inflammatory cytokine cascades classically comprise a sequential appearance and disappearance of proinflammatory cytokines (e.g., tnfa, il- and il- ) intended to activate immune cells and their recruitment to generate additional cytokines and chemokines. this initial wave of cytokine production is usually followed by anti-inflammatory cytokine production (mainly the il- family) to moderate or down regulate the pro-inflammatory cytokines. cytokine cascades are therefore usually sequential with transiently detectable levels in peripheral blood; any dysregulation of these cascades can lead to adverse immunopathological responses. while significant elevations of several cytokine levels in tissues such as balf and tbln were expected, near simultaneous elevation of several cytokines in serum was not entirely expected as part of a normal host immune response. moreover, the levels of cytokines detected were in several instances significantly elevated (usually several times more) over levels detected with the low virulence north american prototype prrsv strain, vr- . prolonged elevations of serum ifng levels have been reported in swine infected with prrsv, a finding in contrast to serum ifng in pigs infected with influenza or respiratory coronavirus, where minimal transient detectable levels are observed (wesley et al., ) . in swine infected with rjxwn , it appears the normal sequence of cytokine production (e.g., ifng, tnfa, and il- often being the first cytokines produced in response to a viral infection, followed by il- and il- ) leading to effective virus clearance and a normal immune response was dysregulated given that significant elevations of several serum cytokines levels were still evident at to dpe. two recent studies have reported hp-prrsv infection in swine results in down regulation of a key toll-like receptor adapter gene, sarm (sterile aand armadillomotif-containing protein) (zhou et al., ; zhou et al., ) . sarm normally dampens the proinflammatory immune response by attenuating nf-kb activation and decreasing expression of il , il- and tnfa (carty et al., ) . previous studies in pigs infected with strains of hp-prrsv were reported to have swollen livers and petechial hemorrhages on the kidneys as well as immunohistochemical staining evidence of viral antigen in the liver and kidneys (among other tissues) (li et al., ; tian et al., ) . impaired hepatic and renal function as a consequence of viral or secondary bacterial disease could have a significant effect on clearance of the cytokines detected in serum, and contribute to an apparent severe cytokine release syndrome. whether our findings represent a parallel condition in swine to severe cytokine release syndromes or cytokine storms reported in humans that have been attributed to various causes cannot be proven with our data (descotes and gouraud, ; tarrant, ) . however, given prrsv causes polyclonal b cell activation, autoimmunity, lymphoid hyperplasia and hypergammaglobulinemia in pigs (lemke et al., ) , and it modulates multiple intracellular signaling pathways [reviewed in (sun et al., ) ], it is not surprising to find an exaggerated immune stimulation in swine infected with a particularly virulent strain of prrsv. early studies with cytokine administration to livestock species identified potential toxicities associated with systemic cytokine administration. interferon-g was found to have beneficial activity on immune function but was too toxic for practical usage due to febrile responses observed within h of a single dose of . mg/ kg of body weight (roth and frank, ) . similarly, administration of ng of bovine il- b/kg of body weight every h for days caused transient fever, inappetence, increased pulse and respiratory rate, and diuresis (goff et al., ) . blood cytokines have been proposed as biomarkers of in vivo toxicity associated with new drug development (tarrant, ) . under most disease scenarios where there is rapid resolution of the infection by the host immune response, much of the biological activity of cytokines will occur in the locally infected tissues and elevated levels of the cytokines may not be detected in serum. we cannot definitively state whether the elevated cytokine syndrome reported here contributes to the pathophysiology of the disease caused by this highly pathogenic prrsv isolate. however, the association between the elevated levels of multiple cytokines and the severe morbidity and high mortality reported is consistent with a multiple cytokine toxicity syndrome in humans associated with various therapeutics (tarrant, ) . adverse reactions ranging from mild-to-moderate flu-like reactions to severe cytokine release syndromes have been observed with many therapeutic proteins in current use in human medicine, and some result in severe and even potentially life-threatening syndromes (reviewed in (tarrant, ) ). macrophage activation syndrome and cytokine storm are different names for two syndromes that share many features including a massive inflammatory response, elevated serum cytokine levels, multiorgan system disease and often death (behrens et al., ) . although these syndromes may be clinically indistinguishable, the cytokines that predominate in each may differ with tnfa being dominant in bacterial sepsis and ifng predominate in the macrophage activation syndrome (behrens et al., ) . the exact pathophysiology of the systemic toxicity in these syndromes is not fully defined. in pigs infected by natural contact with rjxwn inoculated pigs, we detected significant serum elevations in ifna, tnfa, il- b, il- , il- , il- , il- and ifng. however, given that prrsv infects the macrophage cell line in pigs, the elevated serum cytokine levels in pigs infected with hp-prrsv may represent both conditions (macrophage activation syndrome and cytokine storm) and contribute to the multiorgan damage and high mortality reported here. marc- cells were cultured in minimum essential medium (mem, safc c) with % fetal bovine serum at c, % co . wild-type (wt) type prrsv strain vr- (genbank u ), passage on marc- cells, was titrated, and used for the swine study. virus (rescued rjxwn ; rjxwn ) was rescued from a cloned cdna of chinese highly pathogenic type prrsv strain jxwn in marc- cells [pwsk-jxwn; genbank ef , (zhou et al., ) ] and passaged times on marc- cells for use in the swine study. the in vivo swine study described here was performed at the national animal disease center under approval from its animal care and use committee. thirty-two -week-old cross-bred pigs were obtained from a u.s. high-health status herd and were found to be free of prrsv antibodies by herdchek elisa, influenza virus antibodies by np elisa, and negative for porcine circovirus type by quantitative real-time pcr (data not shown). one day prior to inoculation, pigs were bled, weighed and randomly assigned to one of four groups. group (n ¼ ) consisted of sham inoculated control pigs, which received an intranasal ml sham inoculum of mem on day . group pigs (n ¼ ) were challenged intranasally with ml of  % tissue culture infective dose (tcid )/ml of chinese prrsv strain rjxwn in animal biosafety level -agriculture (bsl -ag) housing, where they remained for the duration of the experiment. group consisted of naïve pigs (n ¼ ) that were placed in contact with group two days after group was inoculated (dpe). group pigs (n ¼ ) were challenged intranasally on day dpe with ml of  tcid /ml of type prototype strain vr- . groups and were housed in separate isolation rooms in an absl facility. clinical monitoring of pigs was performed daily throughout the study. specifically, observations were made regarding the pig's mental alertness, body condition, appetite, activity level, and clinical signs of respiratory or systemic disease. serum was collected on À , , , , and dpe (sera from group pigs was collected on À , , , and dpe), and pigs were weighed on À , and dpe (group were weighed on À , and dpe). necropsy was scheduled on dpe (dpe for group ), or sooner if pigs died or were euthanized due to severe disease. at necropsy, a thorough post-mortem examination was performed, and a complete set of samples was collected for evaluating disease severity. tracheobronchial lymph nodes (tbln) and thymic tissue were weighed (lnw and tw, respectively) and compared to respective body weights (bw) to derive a tissue mass index (lnw/bw, tw/bw) measuring the effect of prrsv infection on organ weight (mengeling et al., ) . upon removal, lungs were examined and extent of macroscopic lung lesions was estimated, as previously described, and reported as a percentage of lungs affected (halbur et al., ) . sections of tissues (lung, tracheobronchial lymph node, trachea, thymus, heart, tonsil, spleen, iliac lymph node, mesenteric lymph nodes, ileum, bone marrow, kidneys, liver, inguinal lymph node, cerebrum, brainstem, cerebellum and ventral midbrain) were collected into % neutral-buffered formalin for histopathology and immunohistochemistry. tbln were collected for rna extraction and cytokine protein assays. bronchoalveolar lavage fluid (balf) was collected after removing whole lungs from pigs and aseptically lavaging with ml antibiotic-free mem. tissues were processed by routine histopathologic procedures and slides were stained with hematoxylin and eosin. a boardcertified veterinary pathologist blinded to treatment groups evaluated microscopic lesions. lung sections were scored on a -point scale that accounted for distribution and severity of interstitial pneumonia: -no lesions, -mild, focal to multifocal interstitial pneumonia (o % of lung section affected), -moderate, multifocal to coalescing ( - % of lung section affected), -severe, patchy to coalescing and extensive ( - % of lung section affected), and -severe and diffuse ( % of lung section affected). immunohistochemistry prrsv-specific antigen was detected in lung tissues using a previously described immunohistochemical (ihc) method with minor modifications (halbur et al., ) . briefly, tissue sections were deparaffinized and hydrated in distilled water. slides were quenched in % hydrogen peroxide for min, rinsed three times in distilled water and treated in . % protease for min. slides were then rinsed three times in distilled water. a primary monoclonal antibody (mab) cocktail of one part : prrsv sdow (rti, brookings, sd) and one part : prrsv sr (rti, brookings, sd) was applied to the slides and were incubated at room temperature for h. bound mabs were stained with peroxidase-labeled anti-mouse igg followed by chromogen using the dako lsab -hrp detection system (dako, carpinteria, ca) according to the manufacturer's instructions. , -diaminobenzidine (dab; vector laboratories, burlingame, ca) was applied to the slides for min. the slides were rinsed in deionized water and counterstained with gill's hematoxylin. prrsv labeling was graded on a point scale of : none, : mild scattered signals ( to cells in entire section), : moderate scattered signals (less than or equal to % of high power fields (hpf) containing immunolabeling) and : abundant scattered signals (greater than % of hpf contain labeling and/or there are at least - groups of cells or more with staining). virus isolation was attempted on all serum and balf samples as described previously (faaberg et al., ) . those samples that were positive by virus isolation were then titered by serial dilution on marc- cells to determine the quantity of virus present to produce a cytopathic effect in % of inoculated tissue culture cells (tcid ). quantitative rt-pcr (qrt-pcr), as previously described (faaberg et al., ) , was used to determine the amount of viral rna per ml of serum and balf, and per gram of tbln homogenized tissue prepared as described below. serum samples were tested on study days À , and for evidence of seroconversion with the prrs xr enzyme-linked immunosorbent assay (herdchek elisa; idexx laboratories). a sample was considered positive for antibodies to prrsv nucleocapsid protein if the sample-to-positive (s/p) ratio was equal to or greater than . . levels of tnfa, il- b, il- , il- , il- , il- , il- , il- p and ifng cytokine levels (pg/ml) were measured in serum, balf and tbln samples diluted : with dilution buffer supplied by the manufacturer using a searchlight (aushon biosystems, woburn, ma, usa) customized multiplex immunoassay (m-elisa) following the manufacturer's protocol. m-elisa samples were assayed in duplicate. the elisa limits of detection for tnfa, il- b, il- , il- , il- , il- , il- , il- p and ifng were . , . , . , . , . , . , . , . , and . pg/ml respectively. approximately g of tbln was homogenized in ml of lysis buffer containing . % triton x- , mm nacl, mm tris, mm cacl , and mm mgcl , ph . , using a tissue homogenizer (biospec products, bartlesville, ok) (greenberger et al., ) . homogenates were incubated on ice for min, then centrifuged at x g for min. supernatants were collected, passed through a . micron filter (gelman sciences, ann arbor, mi), then stored at À c prior to assessment of cytokine levels. ifna protein was measured with a porcine ifna specific elisa by using f monoclonal antibody (mab) and k mab (r&d systems inc.) as previously described (miller et al., ) . mab k was conjugated with horseradish peroxidase (hrp) using a peroxidase labeling kit (roche molecular biochemical, indianapolis, in). immulux hb flat-bottomed -well plates (dynex technology, chantilly, va) were coated overnight at c with f at a concentration of mg/plate in coating buffer ( mm carbonate buffer, ph . , sigma inc., st. louis, mo). after blocking with % non-fat dried milk, . % tween in phosphate buffered saline (pbs) for h at c, the plates were washed three times with . % tween in pbs. samples ( ml) were added into each well containing ml of % non-fat dried milk, . % tween in pbs and incubated for h at c. following three washes, ml of peroxidase conjugated k was added to each well. after h incubation, at c, and three washes, ml of substrate solution, tetramethylbenzidine (kpl inc., gaithersburg, md), was added to each well. after min, the reaction was stopped with tetramethylbenzidine stop solution (kpl inc., gaithersburg, md) and the optical density was measured at nm by an elisa plate reader. quantified recombinant porcine ifna (rifna, r&d systems inc., minneapolis, mn) was used as a standard, and ifna concentrations were calculated based upon a standard curve. one unit/ml of rifna is equivalent to pg/ml. bacterial culture was performed by plating ml of balf both on a casman's agar plate supplemented with . % nicotinamide adenine dinucleotide (nad) and % horse serum, and on a % sheep's blood agar plate. both agar plates were incubated for h at c. bacterial identification was performed by s rrnaspecific pcr and dna sequencing. s rrna-specific pcr and dna sequencing whole-cell bacterial lysates, used as templates, were prepared by suspending a colony, $ mm in diameter or the equivalent, in ml of sterile water. the mixture was boiled for min, placed on ice until chilled, and centrifuged at ,  g for min to pellet cell debris and stored at À c. supernatant ( ml) was used as the template in each pcr. the forward primer ( -agagtttgatcctggctcag- ), designated univ s- , is homologous to a highly conserved sequence from the end of the s rrna gene and the reverse primer ( -gcggctgctggcacg- ), designated univ s- , is homologous to a highly conserved sequence between the third and fourth variable regions of the s rrna gene. this previously described primer set generates an amplicon of approximately bp (register and yersin, ) . reactions were carried out in a volume of ml and contained u amplitaq polymerase (applied biosystems, foster city, ca), ml x buffer ii ( mm tris-hcl , ph . , mm kcl), ml dimethyl sulfoxide, . mm mgcl , . mm primers, and mm deoxynucleoside triphosphates. an initial denaturation step of min at c was followed by cycles of s at c, s at c, and min at c, with a final extension step of min at c. ml of each pcr was analyzed by agarose gel electrophoresis and pcr products were purified with spin columns (promega, madison, wi) and sequenced directly by fluorescence-based cycle sequencing with amplitaq and bigdye terminators on an abi sequencer at the national animal disease center genomics unit. sequences were analyzed using geneious . software (biomatters ltd, auckland, new zealand). quantitative virus copy numbers and serum cytokine levels were analyzed using a mixed linear model for repeated measures (proc mixed, sas . for windows, sas institute, cary, nc, usa). linear combinations of the least squares means estimates for each variable were used in a priori contrasts after testing for either a significant (po . ) effect of prrsv challenge strain (vr- , rjxwn , rjxwn contacts or sham inoculated controls). comparisons were made between groups at each time-point using a % level of significance (po . ) to assess statistical differences. log transformed virus copy numbers and cytokine levels in balf and tbln homogenates were analyzed by analysis of variance using a general linear model for unbalanced data (proc glm, sas . for windows, sas institute, cary, nc, usa). a % level of significance (po . ) was used to assess statistical differences. geometric mean back transformations were made for final data presentation in figures and tables. mention of trade names or commercial products in this article is solely for the purpose of providing specific information and does not imply recommendation or endorsement by the u.s. department of agriculture. usda is an equal opportunity provider and employer. highly pathogenic porcine reproductive and respiratory syndrome virus repeated tlr stimulation results in macrophage activation syndrome-like disease in mice effects of intranasal inoculation with bordetella bronchiseptica, porcine reproductive and respiratory syndrome virus, or a combination of both organisms on subsequent infection with pasteurella multocida in pigs the human adaptor sarm negatively regulates adaptor protein trif-dependent toll-like receptor signaling clinical immunotoxicity of therapeutic proteins immune responses of pigs after experimental infection with a european strain of porcine reproductive and respiratory syndrome virus vaccine efficacy of porcine reproductive and respiratory syndrome virus chimeras in vivo growth of porcine reproductive and respiratory syndrome virus engineered nsp deletion mutants porcine respiratory and reproductive syndrome virus variants, vietnam and china physiological effects of exogenous administration of interleukin- b in cows cytokine expression by macrophages in the lung of pigs infected with the porcine reproductive and respiratory syndrome virus changes in lymphocyte subsets and cytokines during european porcine reproductive and respiratory syndrome: increased expression of il- and il- and proliferation of cd ( À )cd (high) acute phase response in porcine reproductive and respiratory syndrome virus infection genomic characterization of virulent, attenuated, and revertant passages of a north american porcine reproductive and respiratory syndrome virus strain neutralization of il- increases survival in a murine model of klebsiella pneumonia immunohistochemical identification of porcine reproductive and respiratory syndrome virus (prrsv) antigen in the heart and lymphoid system of three-week-old colostrum-deprived pigs comparative pathogenicity of nine us porcine reproductive and respiratory syndrome virus (prrsv) isolates in a five-week-old cesarean-derived, colostrum-deprived pig model identification of virulence determinants of porcine reproductive and respiratory syndrome virus through construction of chimeric clones lymphoid hyperplasia resulting in immune dysregulation is caused by porcine reproductive and respiratory syndrome virus infection in neonatal pigs emergence of a highly pathogenic porcine reproductive and respiratory syndrome virus in the mid-eastern region of china an infectious cdna clone of a highly pathogenic porcine reproductive and respiratory syndrome virus variant associated with porcine high fever syndrome strain specificity of the immune response of pigs following vaccination with various strains of porcine reproductive and respiratory syndrome virus expression of inflammatory cytokines and toll-like receptors in the brain and respiratory tract of pigs infected with porcine reproductive and respiratory syndrome virus role of toll-like receptors in activation of porcine alveolar macrophages by porcine reproductive and respiratory syndrome virus porcine reproductive and respiratory syndrome virus comparison: divergent evolution on two continents reversion of a live porcine reproductive and respiratory syndrome virus vaccine investigated by parallel mutations analytical verification of a pcr assay for identification of bordetella avium porcine reproductive and respiratory syndrome experimental porcine reproductive and respiratory syndrome virus infection in one-, four-, and -week-old pigs recombinant bovine interferon-g as an immunomodulator in dexamethasone-treated and nontreated cattle molecular epidemiology of prrsv: a phylogenetic perspective examination of the selective pressures on a live prrs vaccine virus interplay between interferon-mediated innate immunity and porcine reproductive and respiratory syndrome virus blood cytokines as biomarkers of in vivo toxicity in preclinical safety assessment: considerations for their use increased production of proinflammatory cytokines following infection with porcine reproductive and respiratory syndrome virus and mycoplasma hyopneumoniae interleukin- , interleukin- , and interferon-gamma levels in the respiratory tract following mycoplasma hyopneumoniae and prrsv infection in pigs effect of porcine reproductive and respiratory syndrome virus (prrsv) (isolate atcc vr- ) infection on bactericidal activity of porcine pulmonary intravascular macrophages (pims): in vitro comparisons with pulmonary alveolar macrophages (pams) differential production of proinflammatory cytokines: in vitro prrsv and mycoplasma hyopneumoniae co-infection model emergence of fatal prrsv variants: unparalleled outbreaks of atypical prrs in china and molecular dissection of the unique hallmark highly pathogenic porcine reproductive and respiratory syndrome the arterivirus replicase immune responses in piglets infected with highly pathogenic porcine reproductive and respiratory syndrome virus attenuation of porcine reproductive and respiratory syndrome virus strain mn using chimeric construction with vaccine sequence infection with porcine reproductive and respiratory syndrome virus stimulates an early gamma interferon response in the serum of pigs genetic variation and pathogenicity of highly virulent porcine reproductive and respiratory syndrome virus emerging in china secondary infection with streptococcus suis serotype increases the virulence of highly pathogenic porcine reproductive and respiratory syndrome virus in pigs porcine reproductive and respiratory syndrome in china the -amino-acid deletion in the nsp of highly pathogenic porcine reproductive and respiratory syndrome virus emerging in china is not related to its virulence molecular characterization of transcriptome-wide interactions between highly pathogenic porcine reproductive and respiratory syndrome virus and porcine alveolar macrophages in vivo molecular characterization of porcine sarm and its role in regulating tlrs signaling during highly pathogenic porcine reproductive and respiratory syndrome virus infection in vivo highly virulent porcine reproductive and respiratory syndrome virus emerged in china the authors would like to recognize ann vorwald, sarah anderson, deb adolphson and amanda burow for their excellent technical assistance, and jason huegel, brian pottebaum, and jason crabtree for their exceptional animal care. we also appreciate the suggestions on manuscript layout and data organization made by crystal loving. key: cord- - ikx x authors: gÖker, hakan; aladaĞ-karakulak, elifcan; demİroĞlu, haluk; ayaz, cağlayan merve; bÜyÜkaŞik, yahya; İnkaya, ahmet cağkan; aksu, salih; sayinalp, nilgün; c. haznedaroĞlu, İbrahim; uzun, Ömrüm; akova, murat; Özcebe, osman; Ünal, serhat title: the effects of blood group types on the risk of covid- infection and its clinical outcome date: - - journal: turk j med sci doi: . /sag- - sha: doc_id: cord_uid: ikx x background/aim: covid- (coronavirus disease of ) is an infectious disease outbreak later on declared as a pandemic, caused by the sars-cov- (severe acute respiratory syndrome coronavirus- ). it spreads very rapidly and can result in severe acute respiratory failure. the clinical studies have shown that advanced age and chronic diseases increase the risk of infection. however, influence of the blood groups on covid- infection and its outcome remains to be confirmed. the aim of this study is to investigate whether there exists a relationship between the blood groups of the patients and risk of sars-cov- infection and the clinical outcomes in covid- patients. material and method: patients with pcr confirmed diagnosis of covid- were included in this study. age, sex, blood groups, comorbidities, need for intubation and intensive care unit follow up and mortalities of the patients were analyzed retrospectively. healthy individuals, who presented to the hacettepe university blood bank served as the controls. results: the most frequently detected blood group was blood group a ( %) amongst the covid- patients. this was followed by blood group o ( . %). the blood group types did not affect the clinical outcomes. the blood group a was statistically significantly more frequent among those infected with covid- compared to controls ( % vs. %, p < . ; or: . ). on the other hand, the frequency of blood group o was significantly lower in the covid- patients, compared to the control group ( . % vs. . %, p: . ; or: . ). conclusions: the results of the present study suggest that while the blood group a might have a role in increased susceptibility to the covid- infection, the blood group o might be somewhat protective. however, once infected, blood group type does not seem to influence clinical outcome. covid- was first described as a serious infection leading to significant morbidity and mortality in wuhan, china in january [ ] . world health organization (who) declared covid- infection caused by sars-cov- virus as a pandemic on march . sars-cov- is beta coronavirus that is closely related to sars-cov, both viruses use the angiotensin-converting enzyme-related carboxypeptidase (ace ) in order to enter the cell [ , ] . covid- disease has been observed over , million people worldwide as of may , ; and it has caused the death over , of these patients. many studies have shown that advanced age, male sex, and comorbidities of the person increase the risk and severity of the infection [ ] . to date, there is no specific biological marker that has been demonstrated to predict the disease. many previous studies indicated that the connection between hepatitis b and the norwalk virus infection with the blood groups [ , ] . few studies on sars-cov- demonstrated that there exists a relationship between infection risk and the blood types and that the blood group o was somewhat protective against the sars-cov- [ , ] . there are only few clinical studies examining the relationship between sars-cov- and the blood groups. in these studies, it was demonstrated that the blood group o had a negative predictive effect and the blood group a was more frequent in patients who presented with severe pulmonary damage [ ] [ ] [ ] . the aim of this study is to investigate the distribution and relationship between the blood groups amongst the covid- patients and their clinical outcomes at a referral university hospital. the present study included patients who were followed at hacettepe university school of medicine hospitals between / / and / / with the covid- infection who were positive for the sars-cov- rna test through pcr from the nasopharyngeal swab, and who were approached in accordance with the treatment guidelines of the turkish ministry of health. the medical records of patients were retrospectively analysed. the patients, whose blood group analysis that were not done at our hospital, were later on contacted, and their blood groups were also obtained. a total of patients were evaluable for the final statistical analysis. the remaining patients were excluded from the study because their blood group information was not reliable or the patients could not be reached. clinical data including age, sex, comorbidies, intubation needs, intensive care admissions and outcome of the patients were obtained from medical records. due to the existing protocols of the hospitals of hacettepe university faculty of medicine, all of the ethical considerations were strictly followed. as a standard care/action of the hospitals of the hacettepe university faculty of medicine, it has been recognized from the patient records that all of the studied patients gave informed consent at the time of admission to the hospital for diagnostic/therapeutic procedures as standards of care. local ethical committee approval was obtained from hacettepe university numbered go / and additionally, turkish health ministry approval was also obtained on may th, for this study as required. as for the comorbidities, histories of cardiovascular disease, respiratory disease, obesity, diabetes mellitus, and malignancy were screened. hypertension, coronary artery disease, congestive heart failure, and arrhythmias were classified as cardiovascular diseases; copd and asthma were classified as respiratory diseases. clinical outcomes were determined as the need for intubation, the need for icu, and death. in order to determine the normal distribution of the blood groups, healthy individuals, who applied to the hacettepe university blood bank affiliated with our center between / / and / / , were included as the control group. the blood group distributions, age and sex of these patients were recorded. analyses were made using spss version . (ibm corp., armonk, ny, usa). the distribution between the blood groups of the patient and control groups was evaluated using chi-square and fisher exact tests. the impacts of blood groups and comorbidities on the clinical outcomes were evaluated using logistic regression analysis. hosmer-lemeshow test was used for goodness-of-fit. the cases with the p-value below . were accepted as statistically significant. the clinical characteristics and outcomes of patients included in the study according to their blood groups are presented in tables and . the median age of patients was ( - ) and the percentage of female patients was . %. the most frequently detected blood group was blood group a with % amongst the covid- patients. this was followed by blood group o with . %. there was a history the distribution of the patient and control groups according to their blood groups is presented in table . when the healthy control group was compared to the covid- patient group, it was observed that the covid- infection rate was statistically significantly higher in those with blood group a ( % vs. %, p < . ; or: . ). though, covid- was significantly more seen with the blood group a, on the other hand, rh factor did not make any significant difference (p > . ) it was observed that the blood group o was significantly lower in the covid- patient group in comparison to the controls ( . % vs. . %, p: . ; or: . ). there was no difference between blood groups of b and ab. the effect of blood groups on clinical outcomes of covid- patients are presented in table . no significant effect of abo and rh systems were demonstrated on the clinical outcomes. a total of covid- patients, who were followed at the hacettepe university, were included in the present study. it was observed that blood group a was more frequent and the blood group o was less frequent in covid- patients compared to the control group. the blood group a was significantly more frequent and the blood group o was less frequent amongst the covid- patients when compared to the controls (p < . and p: . , respectively) when we looked at the effect of blood groups and rh type on the clinical outcomes, it was demonstrated that the blood groups did not have significant predictive effects on the need for intubation, need for icu hospitalization and mortality; and that the most significant factors affecting the few studies evaluated were evaluated in blood groups in terms of the needs for intubation, icu hospitalization and clinical outcomes [ , ] . there have been studies indicating the predictive effect of abo blood groups on the helicobacter pylori, norwalk virus, and sars-cov [ ] . in a previous study, conducted with healthcare professionals in hong kong during the sars epidemic period, it was presented that those with blood group o had a lower incidence of sars-cov infection than the non-o (or, . ; % confidence interval, . - . ). the patients with blood group b also demonstrated a tendency to the disease; however, there was no statistical significance (or: . ) [ ] . in an animal model, which was carried out to present the mechanism of this result, it was found that the anti-a antibodies found in individuals with blood group o inhibited the interaction of sars-cov- virus s spike protein and the ace- receptor [ ] . a number of studies have been carried out on this subject since the beginning of the sars-cov- pandemic. first of all, in a study on covid- patients, it was presented that the blood group o was less frequent in severe covid - patients who required long hospitalization (p < . ), and the blood group a was more frequent in patients with severe covid- infections compared to the normal population ( . ) [ ] . two different studies have also demonstrated the possible protective effect of the blood group o [ , ,] . the relationship between abo blood groups and cardiovascular diseases was well established previously [ ] . it is known that thrombotic risks decrease significantly in blood group o compared to the non-o [ , ] . studies have shown that the micro thrombosis developing in the covid- infection in pulmonary vascular bed lead to a serious contribution in the acute respiratory syndrome; therefore, the use of prophylactic anticoagulants was included in the guidelines, as well [ , ] . there are opinions arguing that the protective effect demonstrated in blood group o is based on this phenomenon [ ] . the present study, there was no significant relationship between the clinical outcomes and the blood groups. however, this is an important study amongst turkish covid- patients that demonstrate the blood group a might be susceptible to covid- infection and the blood group o might be somewhat protective which should be better elucidated in prospective much larger studies, as well. the limitation of this study is the somewhat small number of patients with the clinical outcomes may have caused the failure in demonstrating the effect of blood groups on clinical outcomes in statistical terms. in conclusion, the present study demonstrate that the blood group o might be protective while the blood group a might have increased susceptibility to the disease, and guidelines set forth by the centers for disease control and prevention (cdc), who and healthy authorities, such as social distancing, hand hygiene, mask use strictly should be followed. one might conclude that stronger, stringent measures should be taken when taking care of individuals with the blood group a for possible covid- , i.e. sars-cov- infection susceptibility. there is a need for further molecular studies to elucidate the relationship between the blood groups and the disease. prospective larger multicentre studies may be needed in order to further elucidate the role of possible somewhat protective role of the blood group o. a pneumonia outbreak associated with a new coronavirus of probable bat origin clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study human susceptibility and resistance to norwalk virus infection abo blood groups and hepatitis b virus infection: a systematic review and meta-analysis abo blood group and susceptibility to severe acute respiratory syndrome blood groups in infection and host susceptibility relationship between the abo blood group and the covid- susceptibility association between abo blood groups and risk of sars-cov- pneumonia testing the association between blood type and covid- infection, intubation, and death inhibition of the interaction between the sars-cov spike protein and its cellular receptor by anti-histo-blood group antibodies abo(h) blood groups and vascular disease: a systematic review and metaanalysis abo blood group determines plasma von willebrand factor levels: a biologic function after all? abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia immune mechanisms of pulmonary intravascular coagulopathy in covid- pneumonia more on "association between abo blood groups and risk of sars-cov- pneumonia key: cord- -fr uod authors: nan title: saem abstracts, plenary session date: - - journal: acad emerg med doi: . /j. - . . .x sha: doc_id: cord_uid: fr uod nan objectives: we sought to determine if the ocp policy resulted in a meaningful and sustained improvement in ed throughput and output metrics. methods: a prospective pre-post experimental study was conducted using administrative data from community and tertiary centers across the province. the study phases consisted of the months from february to september compared against the same months in . operational data for all centres were collected through the edis tracking systems used in the province. the ocp included main triggers: ed bed occupancy > %, at least % of ed stretchers blocked by patients awaiting inpatient bed or disposition decision, and no stretcher available for high acuity patients. when all criteria were met, selected boarded patients were moved to an inpatient unit (non-traditional care space if no bed available). the primary outcome was ed length of stay (los) for admitted patients. the ed load of boarded patients from - am was reported the editors of academic emergency medicine (aem) are honored to present these abstracts accepted for presentation at the annual meeting of the society for academic emergency medicine (saem), may to in chicago, illinois. these abstracts represent countless hours of labor, exciting intellectual discovery, and unending dedication by our specialty's academicians. we are grateful for their consistent enthusiasm, and are privileged to publish these brief summaries of their research. this year, saem received abstracts for consideration, and accepted . each abstract was independently reviewed by up to six dedicated topic experts blinded to the identity of the authors. final determinations for scientific presentation were made by the saem program scientific subcommittee co-chaired by ali s. raja, md, mba, mph and steven b. bird, md, and the saem program committee, chaired by michael l. hochberg, md. their decisions were based on the final review scores and the time and space available at the annual meeting for oral and poster presentations. there were also innovation in emergency medicine education (ieme) abstracts submitted, of which were accepted. the ieme subcommittee was co-chaired by joanna leuck, md and laurie thibodeau, md. we present these abstracts as they were received, with minimal proofreading and copy editing. any questions related to the content of the abstracts should be directed to the authors. presentation numbers precede the abstract titles; these match the listings for the various oral and poster sessions at the annual meeting in chicago, as well as the abstract numbers (not page numbers) shown in the key word and author indexes at the end of this supplement. all authors attested to institutional review board or animal care and use committee approval at the time of abstract submission, when relevant. abstracts marked as ''late-breakers'' are prospective research projects that were still in the process of data collection at the time of the december abstract deadline, but were deemed by the scientific subcommittee to be of exceptional interest. these projects will be completed by the time of the annual meeting; data shown here may be preliminary or interim. on behalf of the editors of aem, the membership of saem, and the leadership of our specialty, we sincerely thank our research colleagues for these contributions, and their continuing efforts to expand our knowledge base and allow us to better treat our patients. david background: two to ten percent of patients evaluated in the emergency departments (ed) present with altered mental status (ams). the prevalence of non-convulsive seizure (ncs) and other electroencephalographic (eeg) abnormalities in this population is not known. this information is needed to make recommendations regarding the routine use of emergent eeg in ams patients. objectives: to identify the prevalence of ncs and other eeg abnormalities in ed patients with ams. methods: an ongoing prospective study at two academic urban ed. inclusion: patients ‡ years old with ams. exclusion: an easily correctable cause of ams (e.g. hypoglycemia, opioid overdose). a -minute eeg with the standard electrodes was performed on each subject as soon as possible after presentation (usually within hour). outcome: the rate of eeg abnormalities based on blinded review of all eegs by two boardcertified epileptologists. descriptive statistics are used to report eeg findings. frequencies are reported as percentages with % confidence intervals (ci), and inter-rater variability is reported with kappa. results: the interim analysis was performed on consecutive patients (target sample size: ) enrolled from may to october (median age: , range - , % male). eegs for patients were reported uninterpretable by at least one rater ( by both raters). of the remaining , only ( %, %ci - %) were normal according to either rater (n = by both). the most common abnormality was background slowing (n = , %, %ci - %) by either rater (n = by both), indicating underlying encephalopathy. ncs was diagnosed in patients ( %, %ci, - %) by at least one rater (n = by both), including ( %, %ci - %) patients in non-convulsive status epilepticus (ncse). patients ( %, %ci - %) had interictal epileptiform discharges read by at least one rater (n = by both) indicating cortical irritability and an increased risk of spontaneous seizure. inter-rater reliability for eeg interpretations was modest (kappa: . , %ci . - . ). objectives: to define diagnostic sbi and non-bacterial (non-sbi) biosignatures using rna microarrays in febrile infants presenting to emergency departments (eds). methods: we prospectively collected blood for rna microarray analysis in addition to routine screening tests including white blood cell (wbc) counts, urinalyses, cultures of blood, urine, and cerebrospinal fluid, and viral studies in febrile infants days of age in eds . we defined sbi as bacteremia, urinary tract infection (uti), or bacterial meningitis. we used class comparisons (mann-whitney p < . , benjamini for mtc and . fold change filter), modular gene analysis, and k-nn algorithms to define and validate sbi and non-sbi biosignatures in a subset of samples. results: % ( / ) of febrile infants were evaluated for sbi. . % ( / ) had sbi ( ( . %) bac-teremia, ( . %) utis, and ( . %) bacterial meningitis). infants with sbis had higher mean temperatures, and higher wbc, neutrophil, and band counts. we analyzed rna biosignatures on febrile infants: sbis ( meningitis, bacteremia, uti), non-sbis ( influenza, enterovirus, undefined viral infections), and healthy controls. class comparisons identified , differentially expressed genes between sbis and non-sbis. modular analysis revealed overexpression of interferon related genes in non-sbis and inflammation related genes in sbis. genes were differently expressed (p < . ) in each of the three non-sbi groups vs sbi group. unsupervised cluster analysis of these genes correctly clustered % ( / ) of non-sbis and sbis. k-nn algorithm identified discriminatory genes in training set ( non-sbis vs sbis) which classified an independent test ( non-sbis vs sbis) with % accuracy. four misclassified sbis had over-expression of interferon-related genes, suggesting viral-bacterial co-infections, which was confirmed in one patient. background: improving maternal, newborn, and child health (mnch) is a leading priority worldwide. however, limited frontline health care capacity is a major barrier to improving mnch in developing countries. objectives: we sought to develop, implement, and evaluate an evidence-based maternal, newborn, and child survival (mncs) package for frontline health workers (fhws). we hypothesized that fhws could be trained and equipped to manage and refer the leading mnch emergencies. methods: setting -south sudan, which suffers from some of the world's worst mnch indices. assessment/intervention -a multi-modal needs assessment was conducted to develop a best-evidence package comprised of targeted trainings, pictorial checklists, and reusable equipment and commodities ( figure ). program implementation utilized a trainingof-trainers model. evalution - ) pre/post knowledge assessments, ) pre/post objective structured clinical examinations (osces), ) focus group discussions, and ) closed-response questionnaires. results: between nov to oct , local trainers and fhws were trained in of the states in south sudan. knowledge assessments among trainers (n = ) improved significantly from . % (sd . ) to . % (sd . ) (p < . ). mean scores a maternal osce and a newborn osce pre-training, immediately post-training, and upon - month follow-up are shown in the table. closed-response questionnaires with fhws revealed high levels of satisfaction, use, and confidence with mncs materials. participants reported an average of . referrals (range - ) to a higher level of care in the - months since training. furthermore, . % of fhws were more likely to refer patients as a result of the training program. during seven focus group discussions with trained fhws, respondents (n = ) reported high satisfaction with mncs trainings, commodities, and checklists, with few barriers to implementation or use. conclusion: these findings suggest mncs has led to improvements in south sudanese fhws' knowledge, skills, and referral practices with respect to appropriate management of mnch emergencies. no study has compared various lactate measurements to determine the optimal parameter to target. objectives: to compare the association of blood lactate kinetics with survival in patients with septic shock undergoing early quantitative resuscitation. methods: preplanned analysis of a multicenter edbased rct of early sepsis resuscitation targeting three physiological variables: cvp, map, and either central venous oxygen saturation or lactate clearance. inclusion criteria: suspected infection, two or more sirs criteria, and either sbp < mmhg after a fluid bolus or lactate > mmol/l. all patients had an initial lactate measured with repeat at two hours. normalization of lactate was defined a lactate decline to < . mmol/l in a patient with an intial lactate ‡ . . absolute lactate clearance (initial -delayed value), and relative ((absolute clearance)/(initial value)* ) were calculated if the initial lactate was ‡ . . the outcome was in-hospital survival. receiver operating characteristic curves were constructed and areas under the curve (auc) were calculated. difference in proportions of survival between the two groups at different lactate cutoffs were analyzed using % ci and fisher exact tests. results: of included patients, the median initial lactate was . mmol/l (iqr . , . ), and the median absolute and relative lactate clearance were mmol/l (iqr . , . ) and % (iqr , ). an initial lactate > . mmol/l was seen in / ( %), and / ( %) patients normalized their lactate. overall sutures on trunk and extremity lacerations that present in the ed. the use of absorbable sutures in the ed setting confers several advantages: patients do not need to return for suture removal which results in a reduction in ed crowding, ed wait times, missed work or school days, and stressful procedures (suture removal) for children. objectives: the primary objective of this study is to compare the cosmetic outcome of trunk and extremity lacerations repaired using absorbable versus nonabsorbable sutures in children and adults. a secondary objective is to compare complication rates between the two groups. methods: eligible patients with lacerations were randomly allocated to have their wounds repaired with vicryl rapide (absorbable) or prolene (nonabsorbable) sutures. at a day follow-up visit the wounds were evaluated for infection and dehiscence. after months, patients were asked to return to have a photograph of the wound taken. two blinded plastic surgeons using a previously validated mm visual analogue scale (vas) rated the cosmetic outcome of each wound. a vas score of mm or greater was considered to be a clinically significant difference. results: of the patients enrolled, have currently completed the study including in the vicryl rapide group and in the prolene group. there were no significant differences in the age, race, sex, length of wound, number of sutures, or layers of repair in the two groups. the observer's mean vas for the vicryl rapide group was . mm ) and that for the prolene group was . mm ( %ci . - . ), resulting in a mean difference of . mm ( %ci- . to . , p = . ). there were no significant differences in the rates of infection, dehiscence, or keloid formation between the two groups. conclusion: the use of vicryl rapide instead of nonabsorbable sutures for the repair of lacerations on the trunk and extremities should be considered by emergency physicians as it is an alternative that provides a similar cosmetic outcome. objectives: to determine the relationship between infection and time from injury to closure, and the characteristics of lacerations closed before and after hours of injury. methods: over an month period, a prospective multi-center cohort study was conducted at a teaching hospital, trauma center and community hospital. emergency physicians completed a structured data form when treating patients with lacerations. patients were followed to determine whether they had suffered a wound infection requiring treatment and to determine a cosmetic outcome rating. we compared infection rates and clinical characteristics of lacerations with chisquare and t-tests as appropriate. results: there were patients with lacerations; had documented times from injury to closure. the mean times from injury to repair for infected and noninfected wounds were . vs. . hrs (p = . ) with % of lacerations treated within hours and % ( ) treated hours after injury. there were no differences in the infection rates for lacerations closed before ( . %, %ci . - . ) or after ( . %, %ci . - . ) hours and before ( . %, % ci . %- . %) or after ( . %, % ci . %- . %) hours. the patients treated hours after injury tended to be older ( vs. yrs p = . ) and fewer were treated with primary closure ( % vs. % p < . ). comparing wounds or more hours after injury with more recent wounds, there was no effect of location on decision to close. wounds closed after hours did not differ from wounds closed before hours with respect to use of prophylactic antibiotics, type of repair, length of laceration, or cosmetic outcome. conclusion: closing older lacerations, even those greater than hours after injury, does not appear to be associated with any increased risk of infection or adverse outcomes. excellent irrigation and decontamination over the last years may have led to this change in outcome. background: deep burns may result in significant scarring leading to aesthetic disfigurement and functional disability. tgf-b is a growth factor that plays a significant role in wound healing and scar formation. objectives: the current study was designed to test the hypothesis that a novel tgf-b antagonist would reduce scar contracture compared with its vehicle in a porcine partial thickness burn model. methods: ninety-six mid-dermal contact burns were created on the backs and flanks of four anesthetized young swine using a gm aluminum bar preheated to °celsius for seconds. the burns were randomized to treatment with topical tgf-b antagonist at one of three concentrations ( , , and ll) in replicates of in each pig. dressing changes and reapplication of the topical therapy were performed every days for weeks then twice weekly for an additional weeks. burns were photographed and full thickness biopsies were obtained at , , , , and days to determine reepithelialization and scar formation grossly and microscopically. a sample of burns in each group had % power to detect a % difference in percentage scar contracture. results: a total of burns were created in each of the three study groups. burns treated with the high dose tgf-b antagonist healed with less scar contracture than those treated with the low dose and control ( ± %, ± %, and ± %; anova p = . ). additionally, burns treated with the higher, but not the lower dose of tgf-b antagonist healed with significantly fewer full thickness scars than controls ( . % vs. % vs. . % respectively; p < . ). there were no infections and no differences in the percentage wound reepithelialization among all study groups at any of the time points. conclusion: treatment of mid-dermal porcine contact burns with the higher dose tgf-b antagonist reduced scar contracture and rate of deep scars compared with the low dose and controls. background: diabetic ketoacidosis (dka) is a common and lethal complication of diabetes. the american diabetes association recommends treating adult patients with a bolus dose of regular insulin followed by a continuous insulin infusion. the ada also suggests a glucose correction rate of - mg/dl/hr to minimize complications. objectives: compare the effect of bolus dose insulin therapy with insulin infusion to insulin infusion alone on serum glucose, bicarbonate, and ph in the initial treatment of dka. methods: consecutive dka patients were screened in the ed between march ' and june ' . inclusion criteria were: age > years, glucose > mg/dl, serum bicarbonate or ketonemia or ketonuria. exclusion criteria were: congestive heart failure, current hemodialysis, pregnancy, or inability to consent. no patient was enrolled more than once. patients were randomized to receive either regular insulin . units/kg or the same volume of normal saline. patients, medical and research staff were blinded. baseline glucose, electrolytes, and venous blood gases were collected on arrival. bolus insulin or placebo was then administered and all enrolled patients received regular insulin at rate of . unit/kg/hr, as well as fluid and potassium repletion per the research protocol. glucose, electrolytes, and venous blood gases were drawn hourly for hours. data between two groups were compared using unpaired t-test. results: patients were enrolled, with being excluded. patients received bolus insulin; received placebo. no significant differences were noted in initial glucose, ph, bicarbonate, age, or weight between the two groups. after the first hour, glucose levels in the insulin group decreased by mg/dl compared to mg/dl in the placebo group (p = . , % ci . to . ). changes in mean glucose levels, ph, bicarbonate level, and ag were not statistically different between the two groups for the remainder of the hour study period. there was no difference in the incidence of hypoglycemia in the two groups. conclusion: administering a bolus dose of regular insulin decreased mean glucose levels more than placebo, although only for the first hour. there was no difference in the change in ph, serum bicarbonate or anion gap at any interval. this suggests that bolus dose insulin may not add significant benefit in the emergency management of dka. ihca; . return of spontaneous circulation (rsoc). traumatic cardiac arrests were excluded. we recorded baseline demographics, arrest event characteristics, follow-up vitals and laboratory data, and in-hospital mortality. apache ii scores were calculated at the time of rosc, and at hrs, hrs, and hrs. we used simple descriptive statistics to describe the study population. univariate logistic regression was used to predict mortality with apache ii as a continuous predictor variable. discrimination of apache ii scores was assessed using the area under the curve (auc) of the receiver operator characteristic (roc) curve. results: a total of patients were analyzed. the median age was years (iqr: - ) and % were female. apache ii score was a significant predictor of mortality for both ohca and ihca at baseline and at all follow-up time points (all p < . ). discrimination of the score increased over time and achieved very good discrimination after hrs (table, figure) . conclusion: the ability of apache ii score to predict mortality improves over time in the hours following cardiac arrest. these data suggest that after hours, apache ii scoring is a useful severity of illness score in all post-cardiac arrest patients. background: admission hyperglycemia has been described as a mortality risk factor for septic non-diabetics, but the known association of hyperglycemia with hyperlactatemia (a validated mortality risk factor in sepsis) has not previously been accounted for. objectives: to determine whether the association of hyperglycemia with mortality remains significant when adjusted for concurrent hyperlactatemia. methods: this was a post-hoc, nested analysis of a single-center cohort study. providers identified study subjects during their ed encounters; all data were collected from the electronic medical record. patients: nondiabetic adult ed patients with a provider-suspected infection, two or more systemic inflammatory response syndrome criteria, and concurrent lactate and glucose testing in the ed. setting: the ed of an urban teaching hospital; to . analysis: to evaluate the association of hyperglycemia (glucose > mg/dl) with hyperlactatemia (lactate ‡ . mmol/l), a logistic regression model was created; outcome-hyperlactatemia; primary variable of interest-hyperglycemia. a second model was created to determine if concurrent hyperlactatemia affects hyperglycemia's association with mortality; outcome- -day mortality; primary risk variablehyperglycemia with an interaction term for concurrent hyperlactatemia. both models were adjusted for demographics, comorbidities, presenting infectious syndrome, and objective evidence of renal, respiratory, hematologic, or cardiovascular dysfunction. results: ed patients were included; mean age ± years. ( %) subjects were hyperglycemic, ( %) hyperlactatemic, and ( %) died within days of the initial ed visit. after adjustment, hyperglycemia was significantly associated with simultaneous hyperlactatemia (or . , %ci . , . ). hyperglycemia with concurrent hyperlactatemia was associated with increased mortality risk (or . , %ci . , . ) , but hyperglycemia in the absence of simultaneous hyperlactatemia was not (or . , %ci . , . ) . conclusion: in this cohort of septic adult non-diabetic patients, mortality risk did not increase with hyperglycemia unless associated with simultaneous hyperlactatemia. the previously reported association of hyperglycemia with mortality in this population may be due to the association of hyperglycemia with hyperlactatemia. the background: near infrared spectroscopy (sto ) represents a measure of perfusion that provides the treating physician with an assessment of a patient's shock state and response to therapy. it has been shown to correlate with lactate and acid/base status. it is not known if using information from this monitor to guide resuscitation will result in improved patient outcomes. objectives: to compare the resuscitation of patients in shock when the sto monitor is or is not being used to guide resuscitation. methods: this was a prospective study of patients undergoing resuscitation in the ed for shock from any cause. during alternating day periods, physicians were blinded to the data from the monitor followed by days in which physicians were able to see the information from the sto monitor and were instructed to resuscitate patients to a target sto value of . adult patients (age> ) with a shock index (si) of > . (si = heart rate/systolic blood pressure) or a blood pressure < mmhg systolic who underwent resuscitation were enrolled. patients had a sto monitor placed on the thenar eminence of their least-injured hand. data from the sto monitor were recorded continuously and noted every minute along with blood pressure, heart rate, and oxygen saturation. all treatments were recorded. patients' charts were reviewed to determine the diagnosis, icu-free days in the days after enrollment, inpatient los, and -day mortality. data were compared using wilcoxon rank sum and chi-square tests. results: patients were enrolled, during blinded periods and during unblinded periods. the median presenting shock index was . (range . to . ) for the blinded group and . ( . - . ) for the unblinded group (p = . ). the median time in department was minutes (range - ) for the blinded and minutes (range - ) for the unblinded groups (p = . ). the median hospital los was day (range - ) for the blinded group, and days (range - ) in the unblinded group (p = . ). the mean icu-free days was ± for the blinded group and ± for the unblinded group (p = . ). among patients where the physician indicated using the sto monitor data to guide patient care, the icu-free days were . ± for the blinded group and . ± for the blinded group (p = . ). background: inducing therapeutic hypothermia (th) using °c iv fluids in resuscitated cardiac arrest patients has been shown to be feasible and effective. limited research exists assessing the efficiency of this cooling method. objectives: the objective was to determine an efficient infusion method for keeping fluid close to °c upon exiting an iv. it was hypothesized that colder temperatures would be associated with both higher flow rate and insulation of the fluid bag. methods: efficiency was studied by assessing change in fluid temperature ( c) during the infusion, under three laboratory conditions. each condition was performed four times using liter bags of normal saline. fluid was infused into a ml beaker through gtts tubing. flow rate was controlled using a tubing clamp and in-line transducer with a flowmeter, while temperature was continuously monitored in a side port at the terminal end of the iv tubing using a digital thermometer. the three conditions included infusing chilled fluid at a rate of ml/min, which is equivalent to ml/kg/hr for an kg patient, ml/min, and ml/min using a chilled and insulated pressure bag. descriptive statistics and analysis of variance was performed to assess changes in fluid temperature. results: the average fluid temperatures at time were . ( % ci . - . ) ( ml/min), . ( % ci . - . ) ( ml/min), and . ( % ci . - . ) ( ml/min + insulation). there was no significant difference in starting temperature between groups (p = . ). the average fluid temperatures after ml had been infused were . ( % ci . - . ) ( ml/min), . ( % ci . - . ) ( ml/min), and . ( % ci . - . ) ( ml/min + insulation). the higher flow rate groups had significantly lower temperature than the lower flow rate after ml of fluid had been infused (p < . ). the average fluid temperatures after ml had been infused were . ( % ci . - . ) ( ml/min), . ( % ci . - . ) ( ml/min), and . ( % ci . - . ) ( ml/min + insulation). there was a significant difference in temperature between all three groups after ml of fluid had been infused (p < . ). conclusion: in a laboratory setting, the most efficient method of infusing cold fluid appears to be a method that both keeps the bag of fluid insulated and is infused at a faster rate. fluid bolus. patients were categorized by presence of vasoplegic or tissue dysoxic shock. demographics and sequential organ failure assessment (sofa) scores were evaluated between the groups. the primary outcome was in-hospital mortality. data were analyzed using t-tests, chi-squared test, and proportion differences with % confidence intervals as appropriate. results: a total of patients were included: patients with vasoplegic shock and with tissue dysoxic shock. there were no significant differences in age ( vs. years), caucasian race ( % vs. %), or male sex ( % vs. %) between the dysoxic shock and vasoplegic shock groups, respectively. the group with vasoplegic shock had a lower initial sofa score than did the group with tissue dysoxic shock ( . vs. . points, p = . ). the primary outcome of in-hospital mortality occurred in / ( %) of patients with vasoplegic shock compared to / ( %) in the group with tissue dysoxic shock (proportion difference %, % ci - %, p < . ). conclusion: in this analysis of patients with septic shock, we found a significant difference in in-hospital mortality between patients with vasoplegic versus tissue dysoxic septic shock. these findings suggest a need to consider these differences when designing future studies of septic shock therapies. background: the pre-shock population, ed sepsis patients with tissue hypoperfusion (lactate of . - . mm), commonly deteriorates after admission and requires transfer to critical care. objectives: to determine the physiologic parameters and disease severity indices in the ed pre-shock sepsis population that predict clinical deterioration. we hypothesized that neither initial physiologic parameters nor organ function scores will be predictive. methods: design: retrospective analysis of a prospectively maintained registry of sepsis patients with lactate measurements. setting: an urban, academic medical center. participants: the pre-shock population, defined as adult ed sepsis patients with either elevated lactate ( . - . mm) or transient hypotension (any sbp < mmhg) receiving iv antibiotics and admitted to a medical floor. consecutive patients meeting pre-shock criteria were enrolled over a -year period. patients with overt shock in the ed, pregnancy, or acute trauma were excluded. outcome: primary patientcentered outcome of increased organ failure (sequential organ failure assessment [sofa] score increase > point, mechanical ventilation, or vasopressor utilization) within hours of admission or in-hospital mortality. results: we identified pre-shock patients from screened. the primary outcome was met in % of the cohort and % were transferred to the icu from a medical floor. patients meeting the outcome of increased organ failure had a greater shock index ( . vs . , p = . ) and heart rate ( vs , p < . ) with no difference in initial lactate, age, map, or exposure to hypotension (sbp < mmhg). there was no difference in the predisposition, infection, response, and organ dysfunction (piro) score between groups ( . vs . , p = . ). outcome patients had similar initial levels of organ dysfunction but had higher sofa scores at , , and hours, a higher icu transfer rate ( vs %, p < . ), and increased icu and hospital lengths of stay. conclusion: the pre-shock sepsis population has a high incidence of clinical deterioration, progressive organ failure, and icu transfer. physiologic data in the ed were unable to differentiate the pre-shock sepsis patients who developed increased organ failure. this study supports the need for an objective organ failure assessment in the emergency department to supplement clinical decision-making. background: lipopolysaccharide (lps) has long been recognized to initiate the host inflammatory response to infection with gram negative bacteria (gnb). large clinical trials of potentially very expensive therapies continue to have the objective of reducing circulating lps. previous studies have found varying prevalence of lps in blood of patients with severe sepsis. compared with sepsis trials conducted years ago, the frequency of gnb in culture specimens from emergency department (ed) patients enrolled in clinical trials of severe sepsis has decreased. objectives: test the hypothesis that prior to antibiotic administration, circulating lps can be detected in the plasma of fewer than % of ed patients with severe sepsis. methods: secondary analysis of a prospective edbased rct of early quantitative resuscitation for severe sepsis. blood specimens were drawn at the time severe sepsis was recognized, defined as two or more systemic inflammatory criteria and a serum lactate > mm or spb< mmhg after fluid challenge. blood was drawn in edta prior to antibiotic administration or within the first several hours, immediately centrifuged, and plasma frozen at ) °c. plasma lps was quantified using the limulus amebocyte lysate assay (lal) by a technician blinded to all clinical data. results: patients were enrolled with plasma samples available for testing. median age was ± years, % female, with overall mortality of %. forty of patients ( %) had any culture specimen positive for gnb including ( %) with blood cultures positive. only five specimens had detectable lps, including two with a gnb-positive culture specimen, and three were lps-positive without gnb in any culture. prevalence of detectable lps was . % (ci: . %- . %). the frequency of detectable lps in antibiotic-naive plasma is too low to serve as a useful diagnostic test or therapeutic target in ed patients with severe sepsis. the data raise the question of whether post-antibiotic plasma may have a higher frequency of detectable lps. background: egdt is known to reduce mortality in septic patients. there is no evidence to date that delineates the role of using a risk stratification tool, such as the mortality in emergency department sepsis (meds) score, to determine which subgroups of patients may have a greater benefit with egdt. objectives: our objective was to determine if our egdt protocol differentially affects mortality based on the severity of illness using meds score. methods: this study is a retrospective chart review of patients, conducted at an urban tertiary care center, after implementing an egdt protocol on july , (figure) . this study compares in-hospital mortality, length of stay (los) in icu, and los in ed between the control group ( patients from / / - / / ) and the postimplementation group ( patients from / / - / / ), using meds score as a risk stratification tool. inclusion criteria: patients who presented to our ed with a suspected infection, and two or more sirs criteria, a map< mmhg, a sbp< mmol/l. exclusion criteria: age< , death on arrival to ed, dnr or dni, emergent surgical intervention, or those with an acute myocardial infarction or chf exacerbation. a two-sample t-test was used to show that the mean age and number of comorbidities was similar between the control and study groups (p = . and . respectively). mortality was compared and adjusted for meds score using logistic regression. the odds ratios and predicted probabilities of death are generated using the fitted logistic regression model. ed and icu los were compared using mood's median test. results: when controlling for illness severity using meds score, the relative risk (rr) of death with egdt is about half that of the control group (rr = . , % ci [ . - . ], p= . ). also, by applying meds score to risk stratify patients into various groups of illness severity, we found no specific groups where egdt is more efficacious at reducing the predicted probability of death (table ) . without controlling for meds score, there is a trend in reduction of absolute mortality by . % when egdt is used (control = . %, study = . %, p = . ). egdt leads to a . % reduction in the median los in icu (control = hours, study = hours, p = . ), without increasing los in ed (control = hours, study = hours, p = . ). conclusion: egdt is beneficial in patients with severe sepsis or septic shock, regardless of their meds score. background: in patients experiencing acute coronary syndrome (acs), prompt diagnosis is critical in achieving the best health outcome. while ecg analysis is usually sufficient to diagnose acs in cases of st elevation, acs without st elevation is reliably diagnosed through serial testing of cardiac troponin i (ctni). pointof-care testing (poct) for ctni by venipuncture has been proven a more rapid means to diagnosis than central laboratory testing. implementing fingerstick testing for ctni in place of standard venipuncture methods would allow for faster and easier procurement of patients' ctni levels, as well as increase the likelihood of starting a rapid test for ctni in the prehospital setting, which could allow for even earlier diagnosis of acs. objectives: to determine if fingerstick blood samples yield accurate and reliable troponin measurements compared to conventional venous blood draws using the i-stat poc device. methods: this experimental study was performed in the ed of a quaternary care suburban medical center between june-august . fingerstick blood samples were obtained from adult ed patients for whom standard (venipuncture) poc troponin testing was ordered. the time between fingerstick and standard draws was kept as narrow as possible. ctni assays were performed at the bedside using the i-stat (abbott point of care). results: samples from patients were analyzed by both fingerstick and standard ed poct methods (see table) . four resulted in cartridge error. compared to ''gold standard'' ed poct, fingerstick testing has a positive predictive value of %, negative predictive value of %, sensitivity of %, and specificity of %. no significant difference in ctni level was found between the two methods, with a nonparametric intraclass correlation coefficient of . ( % ci . - . , p-value < . ). conclusion: whole blood fingerstick ctni testing using the i-stat device is suitable for rapid evaluation of ctni level in prehospital and ed settings. however, results must be interpreted with caution if they are within a narrow territory of the cutoff for normal vs. elevated levels. additional testing on a larger sample would be beneficial. the practicality and clinical benefit of using fingerstick ctni testing in the ems setting must still be assessed. background: adjudication of diagnosis of acute myocardial infarction (ami) in clinical studies typically occurs at each site of subject enrollment (local) or by experts at an independent site (central). from from - , the troponin (ctn) element of the diagnosis was predicated on the local laboratories, using a mix of the th percentile reference ctn and roc-determined cutpoints. in , the universal definition of ami (ud-ami) defined it by the th percentile reference alone. objectives: to compare the diagnosis rates of ami as determined by local adjudication vs. central adjudication using udami criteria. methods: retrospective analysis of data from the myeloperoxidase in the diagnosis of acute coronary syndromes (acs) study (midas), an -center prospective study with enrollment from / / to / / of patients with suspected acs presenting to the ed < hours after symptom onset and in whom serial ctn and objective cardiac perfusion testing was planned. adjudication of acs was done by single local principal investigators using clinical data and local ctn cutpoints from different ctn assays, and applying the definition. central adjudication was done after completion of the midas primary analysis using the same data and local ctn assay, but by experts at three different institutions, using the udami and the manufacturer's th percentile ctn cutpoint, and not blinded to local adjudications. discrepant dignoses were resolved by consensus. local vs. central ctn cutpoints differed for six assays, with central cutpoints lower in all. statistics were by chi-square and kappa. results: excluding cases deemed indeterminate by central adjudication, cases were successfully adjudicated. local adjudication resulted in ami ( . % of total) and non-ami; central adjudication resulted in ( . %) ami and non-ami. overall, local diagnoses ( %) were either changed from non-ami to ami or ami to non-ami (p < . ). interrater reliability across both methods was found to be kappa = . (p < . ). for acs diagnosis, local adjudication identified acs cases ( %) and non-acs, while central adjudication identified acs ( %) and non-acs. overall, local diagnoses ( %) were either changed from non-acs to acs or acs to non-acs (p < . ). interrater reliability found kappa = . (p < . ). conclusion: central and local adjudication resulted in significantly different rates of ami and acs diagnosis. however, overall agreement of the two methods across these two diagnoses was acceptable. occur four times more often in cocaine users. biomarkers myeloperoxidase (mpo) and c-reactive protein (crp) have potential in the diagnosis of acs. objectives: to evaluate the utility of mpo and crp in the diagnosis of acs in patients presenting to the ed with cocaine-associated chest pain and compare the predictive value to nonusers. we hypothesized that these markers may be more sensitive for acs in nonusers given the underlying pathophysiology of enhanced plaque inflammation. methods: a secondary analysis of a cohort study of enrolled ed patients who received evaluation for acs at an urban, tertiary care hospital. structured data collection at presentation included demographics, chest pain history, lab, and ecg data. subjects included those with self-reported or lab-confirmed cocaine use and chest pain. they were matched to controls based on age, sex, and race. our main outcome was diagnosis of acs at index visit. we determined median mpo and crp values, calculated maximal auc for roc curves, and found cut-points to maximize sensitivity and specificity. data are presented with % ci. results: overall, patients in the cocaine positivegroup and patients in the nonusers group had mpo and crp levels measured. patients had a median age of (iqr, ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , % black or african american, and % male (p > . between groups). fifteen patients were diagnosed with acs: patients in the cocaine group and in the nonusers group. comparing cocaine users to nonusers, there was no difference in mpo (median [iqr, ] v ng/ml; p = . ) or crp ( [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] v [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] mg/l; p = . ). the auc for mpo was . ( % ci . - . ) v . ( % ci . - . ). the optimal cut-point to maximize sensitivity and specificity was ng/ml which gave a sensitivity of . and specificity of . . using this cutpoint, % v % of acs in cocaine users vs the nonusers would be identified. the auc for crp was . ( % ci . - . ) in cocaine users vs . ( % ci . - . ) in nonusers. the optimal cut point was . mg/l with a sensitivity of . and specificity of . . using this cutpoint, % v % of acs in cocaine users and nonusers would have been identified. conclusion: the diagnostic accuracy of mpo and crp is not different in cocaine users than nonusers and does not appear to have sufficient discriminatory ability in either cohort. results: hrs of moderate pe caused a significant decrease in rv heart function in rats treated with the solvent for bay - : peak systolic pressure (psp) decreased from ± . mmhg, control to ± . , pe, +dp/dt decreased from ± mmhg/sec to ± , -dp/dt decreased from ) ± mmhg/sec to ) ± . treatment of rats with bay - significantly improved all three indices of rv heart function (psp ± . , +dp/dt ± , -dp/dt ) ± ). hrs of severe pe also caused significant rv dysfunction (psp ± , -dp/dt ) ± ) and treatment with bay - produced protection of rv heart function (psp ± , -dp/dt ) ± ) similar to the hr moderate pe model. conclusion: experimental pe produced significant rv dysfunction, which was ameliorated by treatment of the animals with the soluble guanylate cyclase stimulator, bay - . hospital of the university of pennsylvania, philadelphia, pa; cooper university hospital, camden, nj background: patients who present to the ed with symptoms of potential acute coronary syndrome (acs) can be safely discharged home after a negative coronary computerized tomographic angiography (cta). however, the duration of time for which a negative coronary cta can be used to inform decision making when patients have recurrent symptoms is unknown. objectives: we examined patients who received more than one coronary cta for evaluation of acs to determine whether they had disease progression, as defined by crossing the threshold from noncritical (< % maximal stenosis) to potentially critical disease. methods: we performed a structured comprehensive record search of all coronary ctas performed from to at a tertiary care health system. low-tointermediate risk ed patients who received two or more coronary ctas, at least one from an ed evaluation for potential acs, were identified. patients who were revascularized between scans were excluded. we collected demographic data, clinical course, time between scans, and number of ed visits between scans. record review was structured and done by trained abstractors. our main outcome was progression of coronary stenosis between scans, specifically crossing the threshold from noncritical to potentially critical disease. results: overall, patients met study criteria (median age , interquartile range [iqr] ( . - ); % female; % black). the median time between studies was . months (iqr, . patients did not have stenosis in any vessel on either coronary cta, two studies showed increasing stenosis of < %, and the rest showed ''improvement,'' most due to better imaging quality. no patient initially below the % threshold subsequently exceeded it ( %; % ci, - . %). patients also had varying numbers of ed visits (median number of visits , range - ), and numbers of ed visits for potentially cardiac complaints (median , range - ); were re-admitted for potentially cardiac complaints (for example, chest pain or shortness of breath), and received further provocative cardiac testing, all of which had negative results. conclusion: we did not find clinically significant disease progression within a year time frame in patients who had a negative coronary cta, despite a high number of repeat visits. this suggests that prior negative coronary cta may be able to be used to inform decision making within this time period. . - . ) compared to non tro ct patients. there was no significant difference in image quality between tro ct images and those of dedicated ct scans in any studies performing this comparison. similarly, there was no significant difference between tro ct and other diagnostic modalities in regards to length of stay or admission rate. when compared to conventional coronary angiography as the gold standard for evaluation of cad, tro ct had the following pooled diagnostic accuracy estimates: sensitivity . conclusion: tro chest ct is comparable to dedicated pe, coronary, or ad ct in regard to image quality, length of stay, and admission rate and is highly accurate for detecting cad. the utility of tro ct depends on the relative pre-test probabilities of the conditions being assessed and its role is yet to be clearly defined. tro ct, however, involves increased radiation exposure and contrast volume and for this reason clinicians should be selective in its use. background: coronary computed tomographic angiography (ccta) has high sensitivity, specificity, accuracy, and prognostic value for coronary artery disease (cad) and acs. however, how a ccta informs subsequent use of prescription medication is unclear. objectives: to determine if detection of critical or noncritical cad on ccta is associated with initiation of aspirin and statins for patients who presented to the ed with chest pain. we hypothesized that aspirin and statins would be more likely to be prescribed to patients with noncritical disease relative to those without any cad. methods: prospective cohort study of patients who received ccta as part of evaluation of chest pain in the ed or observation unit. patients were contacted and medical records were reviewed to obtain clinical follow-up for up to the year after ccta. the main outcome was new prescription of aspirin or statin. cad severity on ccta was graded as absent, mild ( % to %), moderate ( % to %), or severe ( ‡ %) stenosis. logistic regression was used to assess the association of stenosis severity to new medication prescription; covariates were determined a priori. results: patients who had ccta performed consented to participate in this study or met waiver of consent for record review only (median age, , % female, % black). median follow-up time was days, iqr - days. at baseline, % of the total cohort was already prescribed aspirin and % on statin medication. two hundred seventy nine ( %) patients were found to have stenosis in at least one vessel. in patients with absent, mild, moderate, and severe cad on ccta, aspirin was initiated in %, %, %, and %; statins were initiated in %, %, %, and % of patients. after adjustment for age, race, sex, hypertension, diabetes, cholesterol, tobacco use, and admission to the hospital after ccta, higher grades of cad severity were independently associated with greater post-ccta use of aspirin (or . per grade, % ci . - . , p < . ) and statins (or . , % ci . - . , p < . ). conclusion: greater cad severity on ccta is associated with increased medication prescription for cad. patients with noncritical disease are more likely than patients without any disease to receive aspirin and statins. future studies should examine whether these changes lead to decreased hospitalizations and improved cardiovascular health. background: hess et al. developed a clinical decision rule for patients with acute chest pain consisting of the absence of five predictors: ischemic ecg changes not known to be old, elevated initial or -hour troponin level, known coronary disease, ''typical'' pain, and age over . patients less than required only a single troponin evaluation. objectives: to test the hypothesis that patients less than years old without these criteria are at < % risk for major adverse cardiovascular events (mace) including death, ami, pci, and cabg. methods: we performed a secondary analysis of several combined prospective cohort studies that enrolled ed patients who received an evaluation for acs in an urban ed from to . cocaine users and stemi patients were excluded. structured data collection at presentation included demographics, pain description, history, lab, and ecg data for all studies. hospital course was followed daily. thirty-day follow up was done by telephone. our main outcome was -day mace using objective criteria. the secondary outcome was potential change in ed disposition due to application of the rule. descriptive statistics and % cis were used. results: of visits for potential acs, patients had a mean age of . ± . yrs; % were black and % female. there were patients ( . %) with -day cv events ( dead, ami, pci). sequential removal of patients in order to meet the final rule for patients less than excluded patients based upon: ischemic ecg changes not old (n = , % mace rate), elevated initial troponin level (n = , % mace), known coronary disease (n = , % mace), ''typical'' pain (n = , % mace), and age over (n = , . % mace) leaving patients less than with . % mace [ % ci, . - . %]. of this cohort, % were discharged home from the ed by the treating physician without application of this rule. adding a second negative troponin in patients - years old identified a group of patients with a . % rate of mace [ . - . ] and a % discharge rate. the hess rule appears to identify a cohort of patients at approximately % risk of -day mace, and may enhance discharge of young patients. however, even without application of this rule, the % of young patients at low risk are already being discharged home based upon clinical judgment. background: a clinical decision support system (cdss) incorporates evidence-based medicine into clinical practice, but this technology is underutilized in the ed. a cdss can be integrated directly into an electronic medical record (emr) to improve physician efficiency and ease of use. the christopher study investigators validated a clinical decision rule for patients with suspected pulmonary embolism (pe). the rule stratifies patients using wells' criteria to undergo either d-dimer testing or a ct angiogram (ct). the effect of this decision rule, integrated as a cdss into the emr, on ordering cts has not been studied. objectives: to assess the effect of a mandatory cdss on the ordering of d-dimers and cts for patients with suspected pe. methods: we assessed the number of cts ordered for patients with suspected pe before and after integrating a mandatory cdss in an urban community ed. physicians were educated regarding cdss use prior to implementation. the cdss advised physicians as to whether a negative d-dimer alone excluded pe or if a ct was required based on wells' criteria. the emr required physicians to complete the cdss prior to ordering the ct. however, physicians maintained the ability to order a ct regardless of the cdss recommendation. patients ‡ years of age presenting to the ed with a chief complaint of chest pain, dyspnea, syncope, or palpitations were included in the data analysis. we compared the proportion of d-dimers and cts ordered during the -month periods immediately before and after implementing the cdss. all physicians who worked in the ed during both time periods were included in the analysis. patients with an allergy to intravenous contrast agents, renal insufficiency, or pregnancy were excluded. results were analyzed using a chi-square test. results: a total of , patients were included in the data analysis ( pre-and post-implementation). cts were ordered for patients ( . %) in the pre-implementation group and patients ( . %) in the post-implementation group; p = . . a d-dimer was ordered for patients ( . %) in the pre-implementation group and patients ( . %) in the post-implementation group; p = . . in this single-center study, emr integration of a mandatory cdss for evaluation of pe did not significantly alter ordering patterns of cts and d-dimers. identification of patients with low-risk pulmonary emboli suitable for discharge from the emergency department mike zimmer, keith e. kocher university of michigan, ann arbor, mi background: recent data, including a large, multicenter randomized controlled trial, suggest that a low-risk cohort of patients diagnosed with pulmonary embolism (pe) exists who can be safely discharged from the ed for outpatient treatment. objectives: to determine if there is a similar cohort at our institution who have a low rate of complications from pe suitable for outpatient treatment. methods: this was a retrospective chart review at a single academic tertiary referral center with an annual ed volume of , patients. all adult ed patients who were diagnosed with pe during a -month period from / / through / / were identified. the pulmonary embolism severity index (pesi) score, a previously validated clinical decision rule to risk stratify patients with pe, was calculated. patients with high pesi (> ) were excluded. additional exclusion criteria included patients who were at high risk of complications from initiation of therapeutic anticoagulation and those patients with other clear indications for admission to the hospital. the remaining cohort of patients with low risk pe (pesi £ ) was included in the final analysis. outcomes were measured at and days after pe diagnosis and included death, major bleeding, and objectively confirmed recurrent venous thromboembolism (vte). results: during the study period, total patients were diagnosed with pe. there were ( %) patients categorized as ''low risk'' (pesi £ ), with removed because of various pre-defined exclusion criteria. of the remaining ( %) patients suitable for outpatient treatment, patients ( . %; % ci, . % - . %) had one or more negative outcomes by days. this included ( . %; % ci, % - . %) major bleeding events, ( . %; % ci, % - . %) recurrent vte, and ( . %; % ci, % - . %) deaths. none of the deaths were attributable to pe or anticoagulation. one patient suffered both a recurrent vte and died within days. both patients who died within days were transitioned to hospice care because of worsening metastatic burden. at days, there was bleeding event ( . %; % ci, % - . %), no recurrent vte, and no deaths. the average hospital length of stay for these patients was . days (sd ± . ). conclusion: over % of our patients diagnosed with pe in the ed may have been suitable for outpatient treatment, with % suffering a negative outcome within days and . % suffering a negative outcome within days. in addition, the average hospital length of stay for these patients was . days, which may represent a potential cost savings if these patients had been managed as outpatients. our experience supports previous studies that suggest the safety of outpatient treatment of patients diagnosed with pe in the ed. given the potential savings related to a decreased need for hospitalization, these results have health policy implications and support the feasibility of creating protocols to facilitate this clinical practice change. background: chest x-rays (cxrs) are commonly obtained on ed chest pain patients presenting with suspected acute coronary syndrome (acs). a recently derived clinical decision rule (cdr) determined that patients who have no history of congestive heart failure, have never smoked, and have a normal lung examination do not require a cxr in the ed. objectives: to validate the diagnostic accuracy of the hess cxr cdr for ed chest pain patients with suspected acs. methods: this was a prospective observational study of a convenience sample of chest pain patients over years old with suspected acs who presented to a single urban academic ed. the primary outcome was the ability of the cdr to identify patients with abnormalities on cxr requiring acute ed intervention. data were collected by research associates using the chart and physician interviews. abnormalities on cxr and specific interventions were predetermined, with a positive cxr defined as one with abnormality requiring ed intervention, and a negative cxr defined as either normal or abnormal but not requiring ed intervention. the final radiologist report was used as a reference standard for cxr interpretation. a second radiologist, blinded to the initial radiologist's report, reviewed the cxrs of patients meeting the cdr criteria to calculate inter-observer agreement. patients were followed up by chart review and telephone interview days after presentation. results: between january and august , patients were enrolled, of whom ( %) were excluded and ( . %) did not receive cxrs in the ed. of the remaining patients, ( %) met the cdr. the cdr identified all patients with a positive cxr (sensitivity = %, %ci - %). the cdr identified of the patients with a negative cxr (specificity = %, %ci - %). the positive likelihood ratio was . ( %ci . - . ). inter-observer agreement between radiologists was substantial (kappa = . , %ci . - . ). telephone contact was made with % of patients and all patient charts were reviewed at days. none had any adverse events related to a background: increasing the threshold to define a positive d-dimer in low-risk patients could reduce unnecessary computed tomographic pulmonary angiography (ctpa) for suspected pe. this strategy might increase rates of missed pe and missed pneumonia, the most common non-thromboembolic finding on ctpa that might not otherwise be diagnosed. objectives: measure the effect of doubling the standard d-dimer threshold for ' 'pe unlikely'' revised geneva (rgs) or wells' scores on the exclusion rate, frequency, and size of missed pe and missed pneumonia. methods: prospective enrollment at four academic us hospitals. inclusion criteria required patients to have at least one symptom or sign and one risk factor for pe, and have -channel ctpa completed. pretest probability data were collected in real time and the d-dimer was measured in a central laboratory. criterion standard for pe or pneumonia consisted of cpta interpretation by two independent radiologists combined with necessary treatment plan. subsegmental pe was defined as total vascular obstruction < %. patients were followed for outcome at days. proportions were compared with % cis. results: of patients enrolled, ( %) were pe+ and ( %) had pneumonia. with rgs£ and standard threshold (< ng/ml), d-dimer was negative in / ( %, % ci: - %), and / were pe+ (posterior probability . %, % ci: - . %). with rgs£ and a threshold < ng/ml, d-dimer was negative in / ( %, - %) and / ( . %, . - . %) were pe+, but / missed pes were subsegmental, and none had concomitant dvt. the posterior probability for pneumonia among patients with rgs&# ; and d-dimer< was / ( . %, - %) which compares favorably to the posterior probability of / ( . %, - %) observed with rgs& # ; and d-dimer< ng/ml. of the ( %) patients who also had plain film cxr, radiologists found an infiltrate in only . use of wells£ produced similar results as the rgs&# ; for exclusion rate and posterior probability of both pe and pneumonia. conclusion: doubling the threshold for a positive d-dimer with a pe unlikely pretest probability can significantly reduce ctpa scanning with a slightly increased risk of missed isolated subsegmental pe, and no increase in rate of missed pneumonia. background: the limitations of developing world medical infrastructure require that patients are transferred from health clinics only when the patient care needs exceed the level of care at the clinic and the receiving hospital can provide definitive therapy. to determine what type of definitive care service was sought when patients were transferred from a general outpatient clinic operating monday through friday from : am to : pm in rural haiti to urban hospitals in port-au-prince. methods: design -prospective observational review of all patients for whom transfer to a hospital was requested or for whom a clinic ambulance was requested to an off-site location to assist with patient care. setting -weekday, daytime only clinic in titanyen, haiti. participants/subjects -consecutive series of all patients for whom transfer to another health care facility or for whom an ambulance was requested during the time period of / / - / / and / / - / / . results: between / / - / / and / / - / / patients were identified who needed to be transferred to a higher level of care. sixteen patients ( . %) presented with medical complaints, ( . %) were trauma patients, ( . %) were surgical, and ( . %) were in the obstetric category. within these categories, patients were pediatric and non-trauma patients required blood transfusion. conclusion: while trauma services are often focused on in rural developing world medicine, the need for obstetric care and blood transfusion constituted six ( . %) cases in our sample. these patients raise important public health, planning, and policy questions relating to access to prenatal care and the need to better understand transfusion medicine utilization among rural haitian patients with non-trauma related transfusion needs. the data set is limited by sample size and single location of collection. another limitation of understanding the needs is that many patients may not present to the clinic for their health care needs in certain situations if they have knowledge that the resources to provide definitive care are unavailable. background: the practice of emergency medicine in japan has been unique in that emergency physicians are mostly engaged in critical care and trauma with a multi-specialty model. for the last decade with progress in medicine, an aging population with complicated problems, and institution of postgraduate general clinical training, the us model emergency medicine with single-specialty model has been emerging throughout japan. however, the current status is unknown. objectives: the objective of this study was to investigate the current status of implementation of the us model emergency medicine at emergency medicine training institutions accredited by the japanese association for acute medicine (jaam). methods: the er committee of the jaam, the most prestigious professional organization in japanese emergency medicine, conducted the survey by sending questionnaires to accredited emergency medicine training institutions. results: valid responses obtained from facilities were analyzed. us model em was provided in facilities ( % of facilities), either in full time ( hours a day, seven days a week; facilities) or in part time (less than hours a day; facilities). among these us model facilities, % have a number of beds between - . the annual number of ed visits was less than , in %, and % have ambulance transfers between , - , per year. the number of emergency physicians was less than in % of the facilities. postgraduate general clinical training was offered at us model ed in facilities, and ninety hospitals adopted us model em after , when a -year period of postgraduate general clinical training became mandatory for all medical graduates. sixty-four facilities provided a residency program to be a us model emergency physician, and another institutions were planning to establish it. conclusion: us model em has emerged and become commonplace in japan. the background including advance in medicine, aging population, and mandatory postgraduate general clinical training system are considered to be contributing factors. erkan gunay, ersin aksay, ozge duman atilla, nilay zorbalar, savas sezik tepecik research and training hospital, izmir, turkey background: workplace safety and occupational health problems are increasing issues especially in developing countries as a result of the industrial automatisation and technologic improvements. occupational injuries are preventable but they can occasionally cause morbidity and mortality resulting in work day loss and financial problems. hand injuries are one-third of all traumatic injuries and are the most injured parts after occupational accidents. objectives: we aim to evaluate patients with occupational upper extremity injuries for demographic characteristics, injury types, and work day loss. methods: trauma patients over years old admitted to our emergency department with an occupational upper extremity injury were prospectively evaluated from . . to . . . patients with one or more of digit, hand, forearm, elbow, humerus, and shoulder injuries were included. exclusion criteria were multitrauma, patient refusal to participate, and insufficient data. patients were followed up from the hospital information system and by phone for work day loss and final diagnosis. results: during the study period there were patients with an occupational upper extremity injury. total of ( . %) patients were included. patients were . % male, . % between the age to , and mean age was calculated . ± . years. . % of the patients were from the metal and machinery sector, and primary education was the highest education level for the . % of the patients. most injured parts were fingers with the highest rate for index finger and thumb. crush injury was the most common injury type. . % (n = ) of the patients were discharged after treatment in the emergency department. tendon injuries, open fractures, and high degree burns were the reasons for admission to clinics. mean work day loss was . ± . days and this increases for the patients with laboratory or radiologic studies, consultant evaluation, or admission. the - age group had a significantly lower work day loss average. conclusion: evaluating occupational injury characteristics and risks is essential for identifying preventive measures and actions. with the guidance of this study preventive actions focusing on high-risk sectors and patients may be the key factor for avoiding occupational injuries and creating safer workplace environments in order to reduce financial and public health problems. background: as emergency medicine (em) gains increased recognition and interest in the international arena, a growing number of training programs for emergency health care workers have been implemented in the developing world through international partnerships. objectives: to evaluate the quality and appropriateness of an internationally implemented emergency physician training program in india. methods: physicians participating in an internationally implemented em training program in india were recruited to participate in a program evaluation. a mixed methods design was used including an online anonymous survey and semi-structured focus groups. the survey assessed the research, clinical, and didactic training provided by the program. demographics and information on past and future career paths were also collected. the focus group discussions centered around program successes and challenges. results: fifty of eligible trainees ( %) participated in the survey. of the respondents, the vast majority were indian; % were female, and all were between the ages of and years (mean age years). all but two trainees ( %) intend to practice em as a career. one-third listed a high-income country first for preferred practice location and half listed india first. respondents directly endorsed the program structure and content, and they demonstrated gains in self-rated knowledge and clinical confidence over their years of training. active challenges identified include: ( ) insufficient quantity and inconsistent quality of indian faculty, ( ) administrative barriers to academic priorities, and ( ) persistent threat of brain drain if local opportunities are inadequate. conclusion: implementing an international emergency physician training program with limited existing local capacity is a challenging endeavor. overall, this evaluation supports the appropriateness and quality of this partnership model for em training. one critical challenge is achieving a robust local faculty. early negotiations are recommended to set educational priorities, which includes assuring access to em journals. attrition of graduated trainees to high-income countries due to better compensation or limited in-country opportunities continues to be a threat to long-term local capacity building. background: with an increasing frequency and intensity of manmade and natural disasters, and a corresponding surge in interest in international emergency medicine (iem) and global health (gh), the number of iem and gh fellowships is constantly growing. there are currently iem and gh fellowships, each with a different curriculum. several articles have proposed the establishment of core curriculum elements for fellowship training. to the best of our knowledge, no study has examined whether iem and gh fellows are actually fulfilling these criteria. objectives: this study sought to examine whether current iem and gh fellowships are consistently meeting these core curricula. methods: an electronic survey was administered to current iem and gh fellowship directors, current fellows, and recent graduates of a total of programs. survey respondents stated their amount of exposure to previously published core curriculum components: em system development, humanitarian assistance, disaster response, and public health. a pooled analysis comparing overall responses of fellows to those of program directors was performed using two-sampled t-test. results: response rates were % (n = ) for program directors and % (n = ) for current and recent fellows. programs varied significantly in terms of their emphasis on and exposure to six proposed core curriculum areas: em system development, em education development, humanitarian aid, public health, ems, and disaster management. only % of programs reported having exposure to all four core areas. as many as % of fellows reported knowing their curriculum only somewhat or not at all prior to starting the program. conclusion: many fellows enter iem and gh fellowships without a clear sense of what they will get from their training. as each fellowship program has different areas of curriculum emphasis, we propose not to enforce any single core curriculum. rather, we suggest the development of a mechanism to allow each fellowship program to present its curriculum in a more transparent manner. this will allow prospective applicants to have a better understanding of the various programs' curricula and areas of emphasis. background: advance warning of probable intensive care unit (icu) admissions could allow the bed placement process to start earlier, decreasing ed length of stay and relieving overcrowding conditions. however, physicians and nurses poorly predict a patient's ultimate disposition from the emergency department at triage. a computerized algorithm can use commonly collected data at triage to accurately identify those who likely will need icu admission. objectives: to evaluate an automated computer algorithm at triage to predict icu admission and -day in-hospital mortality. methods: retrospective cohort study at a , visit/ year level i trauma center/tertiary academic teaching hospital. all patients presenting to the ed between / / and / / were included in the study. the primary outcome measure was icu admission from the emergency department. the secondary outcome measure was -day all-cause in-hospital mortality. patients discharged or transferred before days were considered to be alive at days. triage data includes age, sex, acuity (emergency severity index), blood pressure, heart rate, pain scale, respiratory rate, oxygen saturation, temperature, and a nurse's free text assessment. a latent dirichlet allocation algorithm was used to cluster words in triage nurses' free text assessments into topics. the triage assessment for each patient is then represented as a probability distribution over these topics. logistic regression was then used to determine the prediction function. results: a total of , patients were included in the study. . % were admitted to the icu and . % died within days. these patients were then randomly allocated to train (n = , ; %) and test (n = , ; %) data sets. the area under the receiver operating characteristic curve (auc) when predicting icu background: at the saem annual meeting, we presented the derivation of two hospital admission prediction models adding coded chief complaint (ccc) data from a published algorithm (thompson et al. acad emerg med ; : - ) to demographic, ed operational, and acuity (emergency severity index (esi)) data. objectives: we hypothesized that these models would be validated when applied to a separate retrospective cohort, justifying prospective evaluation. methods: we conducted a retrospective, observational validation cohort study of all adult ed visits to a single tertiary care center (census: , /yr) ( / / - / / ). we downloaded from the center's clinical tracking system demographic (age, sex, race), ed operational (time and day of arrival), esi, and chief complaint data on each visit. we applied the derived ccc hospital admission prediction models (all identified ccc categories and ccc categories with significant odds of admission from multivariable logistic regression in the derivation cohort) to the validation cohort to predict odds of admission and compared to prediction models that consisted of demographic, ed operational, and esi data, adding each category to subsequent models in a stepwise manner. model performance is reported by areaunder-the-curve (auc) data and %ci. signs, pain level, triage level, -hour return, number of past visits in the previous year, injury, and one of chief complaint codes (representing % of all visits in the database). outputs for training included ordering of a complete blood count, basic chemistry (electrolytes, blood urea nitrogen, creatinine), cardiac enzymes, liver function panel, urinalysis, electrocardiogram, x-ray, computed tomography, or ultrasound. once trained, it was used on the nhamcs-ed database, and predictions were generated. predictions were compared with documented physician orders. outcomes included the percent of total patients who were correctly pre-ordered, sensitivity (the percent of patients who had an order that were correctly predicted), and the percent over-ordered. waiting time for correctly pre-ordered patients was highlighted, to represent a potential reduction in length of stay achieved by preordering. los for patients overordered was highlighted to see if over-ordering may cause an increase in los for those patients. unit cost of the test was also highlighted, as taken from the medicare fee schedule. physician times. however, during peak ed census times, many patients with completed tests and treatment initiated by triage await discharge by the next assigned physician. objectives: determine if a physician-led discharge disposition (dd) team can reduce the ed length of stay (los) for patients of similar acuity who are ultimately discharged compared to standard physician team assignment. methods: this prospective observational study was performed from / to / at an urban tertiary referral academic hospital with an annual ed volume of , visits. only emergency severity index level patients were evaluated. the dd team was scheduled weekdays from : until : . several ed beds were allocated to this team. the team was comprised of one attending physician and either one nurse and a tech or two nurses. comparisons were made between los for discharged patients originally triaged to the main ed side who were seen by the dd team versus the main side teams. time from triage physician to team physician, team physician to discharge decision time, and patient age were compared by unpaired t-test. differences were studied for number of patients receiving x-rays, ct scan, labs, and medications. results: dd team mean los in hours for discharged patients was shorter at . ( % ci: . - . , n = ) compared to . ( % ci: . - . , n = ) on the main side, p < . . the mean time from triage physician to dd team physician was . hours ( % ci: . - . , n = ) versus to . hours ( % ci: . - . , n = ) to main side physician, p < . . the dd team physician mean time to discharge decision was . hour ( % ci: . - . , n = ) compared to . hours ( % ci: . - . , n = ) for main side physician, p < . . the dd team patients' mean age was . years ( % ci: . - . , n = ) compared to main side patients' mean age of . years ( % ci: . - . , n = .) the dd team patients (n = ) received fewer x-rays ( % vs. %), ct scans ( % vs. %), labs ( % vs. %), and medications ( % vs. %) than main side patients (n = ), p < . for all compared. conclusion: the dd team complements the advanced triage process to further reduce los for patients who do not require extended ed treatment or observation. the dd team was able to work more efficiently because its patients tended to be younger and had fewer lab and imaging tests ordered by the triage physician compared to patients who were later seen on the ed main side. ed objectives: to evaluate the association between ed boarding time and the risk of developing hapu. methods: we conducted a retrospective cohort study using administrative data from an academic medical center with an adult ed with , annual patient visits. all patients admitted into the hospital through the ed / / - / / were included. development of hapu was determined using the standardized, national protocol for cms reporting of hapu. ed boarding time was defined as the time between an order for inpatient admission and transport of the patient out of the ed to an in-patient unit. we used a multivariate logistic regression model with development of a hapu as the outcome variable, ed boarding time as the exposure variable, and the following variables as covariates: age, sex, initial braden score, and admission to an intensive care unit (icu) from the ed. the braden score is a scale used to determine a patient's risk for developing a hapu based on known risk factors. a braden score is calculated for each hospitalized patient at the time of admission. we included braden score as a covariate in our model to determine if ed boarding time was a predictor of hapu independent of braden score. results: of , patients admitted to the hospital through the ed during the study period, developed a hapu during their hospitalization. clinical characteristics are presented in the table. per hour of ed boarding time, the adjusted or of developing a hapu was . ( % ci . - . , p = . ). a median of patients per day were admitted through the ed, accumulating hours of ed boarding time per day, with each hour of boarding time increasing the risk of developing a hapu by %. conclusion: in this single-center, retrospective study, longer ed boarding time was associated with increased risk of developing a hapu. queried ed and inpatient nurses and compared their opinions toward inpatient boarding. it also assessed their preferred boarding location if they were patients. objectives: this study queried ed and inpatient nurses and compared their opinions toward inpatient boarding. methods: a survey was administered to a convenience sample of ed and ward nurses. it was performed in a -bed academic medical center ( , admissions/yr) with a -bed ed ( , visits/yr). nurses were identified as ed or ward and whether they had previously worked in the ed. the nurses were asked if there were any circumstances where admitted patients should be boarded in the ed or inpatient hallways. they were also asked their preferred location if they were admitted as a patient. six clinical scenarios were then presented and their opinions on boarding queried. results: ninety nurses completed the survey; ( %) were current ed nurses (ced), ( %) had previously worked in the ed (ped). for the entire group ( %) believed admitted patients should board in the ed. overall, ( %) were opposed to inpatient boarding, with % of ced versus % of current ward (cw) nurses (p < . ) and % of ped versus % of nurses never having worked in the ed (ned) opposed (p < . ). if admitted as patients themselves, overall ( %) preferred inpatient boarding, with % of ced versus % of cw nurses (p < . ) and % of ped versus % ned nurses (p = . ) preferring inpatient boarding. for the six clinical scenarios, significant differences in opinion regarding inpatient boarding existed in all but two cases: a patient with stable copd but requiring oxygen and an intubated, unstable sepsis patient. conclusion: ward nurses and those who have never worked in the ed are more opposed to inpatient boarding than ed nurses and nurses who have worked previously in the ed. nurses admitted as patients seemed to prefer not being boarded where they work. ed and ward nurses seemed to agree that unstable or potentially unstable patients should remain in the ed. weeks. staff satisfaction was evaluated through pre/ post-shift and study surveys; administrative data (physician initial assessment (pia), length of stay (los), patients leaving without being seen (lwbs) and against medical advice [lama] ) were collected from an electronic, real-time ed information system. data are presented as proportions and medians with interquartile ranges (iqr); bivariable analyses were performed. results: ed physicians and nurses expected the intervention to reduce the los of discharged patients only. pia decreased during the intervention period ( vs minutes; p < . ). no statistically/clinically significant differences were observed in the los; however, there was a significant reduction in the lwbs ( . % to . % p = . ) and lama ( . % to . % p = . ) rates. while there was a reduction of approximately patients seen per physician in the affected ed area, the total number of patients seen on that unit increased by approximately patients/day. overall, compared to days when there was no extra shift, % of emergency physicians stated their workload decreased and % felt their stress level at work decreased. conclusion: while this study didn't demonstrate a reduction in the overall los, it did reduce pia times and the proportion of lwbs/lama patients. while physicians saw fewer patients during the intervention study period, the overall patient volume increased and satisfaction among ed physicians was rated higher. provider-and hospital-level variation in admission rates and -hour return admission rates jameel abualenain , william frohna , robert shesser , ru ding , mark smith , jesse m. pines the george washington university, washington, dc; washington hospital center, washington, dc background: decisions for inpatient versus outpatient management of ed patients are the most important and costliest decision made by emergency physicians, but there is little published on the variation in the decision to admit among providers or whether there is a relationship between a provider's admission rate and the proportion of their patients who return within hours of the initial visit and are subsequently admitted ( h-ra). objectives: we explored the variation in provider-level admission rates and h-ra rates, and the relationship between the two. methods: a retrospective study using data from three eds with the same information system over varying time periods: washington hospital center (whc) ( - ), franklin square hospital center (fshc) , and union memorial hospital (umh) . patients were excluded if left without being seen, left against medical advice, fast-track, psychiatric patients, and aged < years. physicians with < ed encounters or an admission rate < % were excluded. logistic regression was used to assess the relationship between physician-level h-ra and admission rates, adjusting for patient age, sex, race, and hospital. results: , ed encounters were treated by physicians. mean patient age was years sd , % male, and % black. admission rates differed between hospitals (whc = %, umh = %, and fshc = %), as did the h-ra (whc = . %, umh = . %, and fshc = . %). across all hospitals, there was great variation in individual physician admission rates ( . %- . %). the h-ra rates were quite low, but demonstrated a similar magnitude of individual variation ( . %- . %). physicians with the highest admission rate quintile had lower odds of h-ra (or . % ci . - . ) compared to the lowest admission rate quintile, after adjusting for other factors. no intermediate admission rate quintiles ( nd, rd, or th) were significantly different from the lowest admission rate quintile with regard to h-ra. conclusion: there is more than three-fold variation in individual physician admission rates indicating great variation among physicians in hospital admission rates and h-ra. the highest admitters have the lowest h-ra; however, evaluating the causes and consequences of such significant variation needs further exploration, particularly in the context of health reform efforts aimed at reducing costs. background: ed scribes have become an effective means to assist emergency physicians (eps) with clinical documentation and improve physician productivity. scribes have been most often utilized in busy community eds and their utility and functional integration into an academic medical center with resident physicians is unknown. objectives: to evaluate resident perceptions of attending physician teaching and interaction after introduction of scribes at an em residency training program, measured through an online survey. residents in this study were not working with the scribes directly, but were interacting indirectly through attending physician use of scribes during ed shifts. methods: an online ten question survey was administered to residents of a midwest academic emergency medicine residency program (pgy -pgy program, annual residents), months after the introduction of scribes into the ed. scribes were introduced as emr documentation support (epic , epic systems inc.) for attending eps while evaluating primary patients and supervising resident physicians. questions investigated em resident demographics and perceptions of scribes (attending physician interaction and teaching, effect on resident learning, willingness to use scribes in the future), using likert scale responses ( minimal, maximum) and a graduated percentage scale used to quantify relative values, where applicable. data were analyzed using kruskal-wallis and mann-whitney u tests. results: twenty-one of em residents ( %) completed the survey ( % male; % pgy , % pgy , % pgy ). four residents had prior experience with scribes. scribes were felt to have no effect on attending eps direct resident interaction time (mean score . , sd . ), time spent bedside teaching ( . , sd . ), or quality of teaching ( . , sd . ), as well as no effect on residents' overall learning process ( . , sd . ). however, residents felt positive about utilizing scribes at their future occupation site ( . , sd . ). no response differences were noted for prior experience, training level, or sex. conclusion: when scribes are introduced at an em residency training site, residents of all training levels perceive it as a neutral interaction, when measured in terms of perceived time with attending eps and quality of the teaching when scribes are present. the effect of introduction of an electronic medical record on resident productivity in an academic emergency department shawn london, christopher sala university of connecticut school of medicine, farmington, ct background: there are little available data which describe the effect of implementation of an electronic medical record (emr) on provider productivity in the emergency department, and no studies which, to our knowledge, address this issue pertaining to housestaff in particular. objectives: we seek to quantify the changes in provider productivity pre-and post-emr implementation to support our hypothesis that resident clinical productivity based on patients seen per hour will be negatively affected by emr implementation. methods: the academic emergency department at hartford hospital, the principle clinical site in the university of connecticut emergency medicine residency, sees over , patients on an annual basis. this environment is unique in that pre-emr, patient tracking and orders were performed electronically using the sunrise system (eclipsys corp) for over years prior to conversion to the allscripts ed emr in october, for all aspects of ed care. the investigators completed a random sample of days/evening/night/weekend shift productivity to obtain monthly aggregate productivity data (patients seen per hour) by year of training. results: there was an initial . % decrease of in productivity for pgy- residents on average from . patients per hour on average in the three blocks preceding activation of the emr to . patients seen per hour compared in the subsequent three prior blocks. pgy performance returned to baseline in the subsequent three months to . patients per hour. there was no change noted in patients seen per hour of pgy- and pgy- residents. conclusion: while many physicians tend to assume that emrs pose a significant barrier to productivity in the ed, in our academic emergency department, there was no lasting change on resident productivity based on the patients seen per hour metric. the minor decrease which did occur in pgy- residents was transient and was not apparent months after the emr was implemented. our experience suggests that decrease in the rate of patients seen per hour in the resident population should not be considered justification to delay or avoid implementation of an emr in the emergency department. emory university, atlanta, ga; children's healthcare of atlanta, atlanta, ga background: variation in physician practice is widely prevalent and highlights an opportunity for quality improvement and cost containment. monitoring resources used in the management of common pediatric emergency department (ed) conditions has been suggested as an ed quality metric. objectives: to determine if providing ed physicians with severity-adjusted data on resource use and outcomes, relative to their peers, can influence practice patterns. methods: data on resource use by physicians were extracted from electronic medical records at a tertiary pediatric ed for four common conditions in mid-acuity (emergency severity index level ): fever, head injury, respiratory illness, and gastroenteritis. condition-relevant resource use was tracked for lab tests (blood count, chemistry, crp), imaging (chest x-ray, abdominal x-ray, head ct scan, abdominal ct scan), intravenous fluids, parenteral antibiotics, and intravenous ondansetron. outcome measures included admission to hospital and ed length of stay (los); -hr return to ed (rr) was used as a balancing measure. scorecards were constructed using box plots to show physicians their practice patterns relative to peers (the figure shows an example of the scorecard for gatroenteritis for one physician, showing resources use rates for iv fluids and labs). blinded scorecards were distributed quarterly for five quarters using rolling-year averages. a pre/post-intervention analysis was performed with sep , as the intervention date. fisher's exact and wilcoxon rank sum tests were used for analysis. results: we analyzed , patient visits across two hospitals ( , pre-and , post-intervention), comprising . % of the total ed volume during the study period. patients were seen by physicians (mean patients/physician). the table shows overall physician practice in the pre-and post-intervention periods. significant reduction in resource use was seen for abdominal/pelvic ct scans, head ct scan, chest x-rays, iv ondansetron, and admission to hospital. ed los decreased from min to min (p = . ). there was no significant change in -hr return rate during the study period ( . % pre-, . % post-intervention). conclusion: feedback on comprehensive practice patterns including resource use and quality metrics can influence physician practice on commonly used resources in the ed. billboards, via iphone application, twitter, and text messaging. there is a paucity of data describing the accuracy of publically posted ed wait times. objectives: to examine the accuracy of publicly posted wait times of four emergency departments within one hospital system. methods: a prospective analysis of four ed-posted wait times in comparison to the wait times for actual patients. the main hospital system calculated and posted ed wait times every twenty minutes for all four system eds. a consecutive sample of all patients who arrived / over a -week period during july and august was included. an electronic tracking system identified patient arrival date and the actual incurred wait time. data consisted of the arrival time, actual wait time, hospital census, budgeted hospital census, and the posted ed wait time. for each ed the difference was calculated between the publicly posted ed wait time at the time of patient's arrival and the patient's actual ed wait time. the average wait times and average wait time error between the ed sites were compared using a two-tailed student's t-test. the correlation coefficient between the differences in predicted/ actual wait times was also calculated for each ed. results: there were wait times within the four eds included in the analysis. the average wait time (in minutes) at each facility was: . (± . ) for the main ed, . (± . ) for freestanding ed (fed) # , . (± . ) for fed # , and . (± . ) for the small community ed. the average wait time error (in minutes) for each facility was (± . ) for the main ed, (± . ) for fed # , (± . ) for fed # , and (± . ) for the community hospital ed. the results from each ed were statistically significant for both average wait time and average wait time error (p < . ). there was a positive correlation between the average wait time and average wait time error, with r-values of . , . , . , and . for the main ed, fed # , fed # , and the small community hospital ed, respectively. each correlation was statistically significant; however, no correlation was found between the number of beds available (budgeted-actual census) and average wait times. conclusion: publically posted ed wait times are accurate for facilities with less than ed visits per month. they are not accurate for eds with greater than visits per month. reduction of pre-analytic laboratory errors in the emergency department using an incentive-based system benjamin katz, daniel pauze, karen moldveen albany medical center, albany, ny background: over the last decade, there has been an increased effort to reduce medical errors of all kinds. laboratory errors have a significant effect on patient care, yet they are usually avoidable. several studies suggest that up to % of laboratory errors occur during the pre-or post-analytic phase. in other words, errors occur during specimen collection and transport or reporting of results, rather than during laboratory analysis itself. objectives: in an effort to reduce pre-analytic laboratory errors, the ed instituted an incentive-based program for the clerical staff to recognize and prevent specimen labeling errors from reaching the patient. this study sought to demonstrate the benefit of this incentive-based program. methods: this study examined a prospective cohort of ed patients over a three year period in a tertiary care academic ed with annual census of , . as part of a continuing quality improvement process, laboratory specimen labeling errors are screened by clerical staff by reconciling laboratory specimen label with laboratory requisition labels. the number of ''near-misses'' or mismatched specimens captured by each clerk was then blinded to all patient identifiers and was collated by monthly intervals. due to poor performance in , an incentive program was introduced in early by which the clerk who captured the most mismatched specimens would be awarded a $ gift card on a quarterly basis. the total number of missed laboratory errors was then recorded on a monthly basis. investigational data were analyzed using bivariate statistics. background: most studies on operational research have been focused in academic medical centers, which typically have larger volumes of patients and are located in urban metropolitan areas. as cms core measures in begin to compare emergency departments (eds) on treatment time intervals, especially length of stay (los), it is important to explore if any differences exist inherent to patient volume. objectives: the objective of this study is to look at differences in operational metrics based on annual patient census. the hypothesis is that treatment time intervals and operational metrics differ amongst these different categories. methods: the ed benchmarking alliance has collected yearly operational metrics since . as of , there are eds providing data across the united states. eds are stratified by annual volume for comparison in the following categories: < k, - k, - k, and over k. in this study, metrics for eds with < k visits per year were compared to those of different volumes, averaged from - . mean values were compared to < k visits as a reference point for statistical difference using t-tests to compare means with a p-value < . considered significant. results: as seen in the table, a greater percentage of high acuity of patients was seen in higher volume eds than in < k eds. the percentage of patients transferred to another hospital was higher in < k eds. a higher percentage arrived by ems and a higher percentage were admitted in higher volume eds when compared to < k visits. in addition, the median los for both discharged and admitted patients and percentage who left before treatment was complete (lbtc) were higher in the higher volume eds. conclusion: lower volume eds have lower acuity when compared to higher volume eds. lower volume eds have shorter median los and left before treatment complete percentages. as cms core measures require hospitals to report these metrics, it will be important to compare them based on volume and not in aggregate. does the addition of a hands-free communication device improve ed interruption times? amy ernst, steven j. weiss, jeffrey a. reitsema university of new mexico, albuquerque, nm background: ed interruptions occur frequently. recently a hands-free communication device (vocera) was added to a cell phone and a pager in our ed. objectives: the purpose of the present study was to determine whether this addition improved interruption times. our hypothesis was that the device would significantly decrease length of time of interruptions. methods: this study was a prospective cohort study of attending ed physician calls and interruptions in a level i trauma center with em residency. interruptions included phone calls, ekg interpretations, pages to resuscitation, and other miscellaneous interruptions (including nursing issues, laboratory, ems, and radiology). we studied a convenience sampling intended to include mostly evening shifts, the busiest ed times. length of time the interruption lasted was recorded. data were collected for a comparison group pre-vocera. three investigators collected data including seven different addendings' interruptions. data were collected on a form, then entered into an excel file. data collectors' agreement was determined during two additional four hour shifts to calculate a kappa statistic. spss was used for data entry and statistical analysis. descriptive statistics were used for univariate data. chi-square and mann whitney u nonparametric test were used for comparisons. results: of the total interruptions, % were phone calls, % were ekgs to be read, % were pages to resuscitation, and % miscellaneous. there were no significant differences in types of interruptions pre-vs. post-vocera. pre-vocera we collected hours of data with interruptions with a mean . per hour. post-vocera, hours of data were collected with interruptions with a mean . per hour. there was a significant difference in length of time of interruptions with an average of minutes pre-vocera vs. minutes post-vocera (p = . , diff . , % ci . - . ). vocera calls were significantly shorter than non-vocera calls ( vs minutes, p < . ). comparing data collectors for type of interruption during the same -hour shift resulted in a kappa (agreement) of . . conclusion: the addition of a hands-free communication device may improve interruptions by shortening call length. '' talk background: analyses of patient flow through the ed typically focus on metrics such as wait time, total length of stay (los), or boarding time. however, little is known about how much interaction a patient has with clinicians after being placed in a room, or what proportion of the in-room visit is also spent ''waiting,'' rather than directly interacting with care providers. objectives: the objective was to assess the proportion of time, relative to the time in a patient care area, that a patient spends actively interacting with providers during an ed visit. methods: a secondary analysis of audiotaped encounters of patients with one of four diagnoses (ankle sprain, back pain, head injury, laceration) was performed. the setting was an urban, academic ed. ed visits of adult patients were recorded from the time of room placement to discharge. audiotapes were edited to remove all downtime and non-patient-provider conversations. los and door-to-doctor times were abstracted from the medical record. the proportion of time the patient spent in direct conversation with providers (''talk-time'') was calculated as the ratio of the edited audio recording time to the time spent in a patient care area (talk-time = [edited audio time/(los -door-to-doctor)]). multiple linear regression controlling for time spent in patient care area, age, and sex was performed. results: the sample was % male with a mean age of years. median los: minutes (iqr: - ), median door-to-doctor: minutes (iqr: - ), median time spent in patient care area: minutes (iqr: - ). median time spent in direct conversation with providers was minutes (iqr: - ), corresponding to a talk-time percentage of . % (iqr: . - . %). there were no significant differences based on diagnosis. regression analysis showed that those spending a longer time in a patient care area had a lower percentage of talk time (b = ) . , p = . ). conclusion: although limited by sample size, these results indicate that approximately % of a patients' time in a care area is spent not interacting with providers. while some of the time spent waiting is out of the providers' control (e.g. awaiting imaging studies), this significant ''downtime'' represents an opportunity for both process improvement efforts to decrease downtime as well as the development of innovative patient education efforts to make the best use of the remaining downtime. degradation of emergency department operational data quality during electronic health record implementation michael j. ward, craig froehle, christopher j. lindsell university of cincinnati, cincinnati, oh background: process improvement initiatives targeted at operational efficiency frequently use electronic timestamps to estimate task and process durations. errors in timestamps hamper the use of electronic data to improve a system and may result in inappropriate conclusions about performance. despite the fact that the number of electronic health record (ehr) implementations is expected to increase in the u.s., the magnitude of this ehr-induced error is not well established. objectives: to estimate the change in the magnitude of error in ed electronic timestamps before and after a hospital-wide ehr implementation. methods: time-and-motion observations were conducted in a suburban ed, annual census , , after receiving irb approval. observation was conducted weeks pre-and weeks post-ehr implementation. patients were identified on entering the ed and tracked until exiting. times were recorded to the nearest second using a calibrated stopwatch, and are reported in minutes. electronic data were extracted from the patient-tracking system in use pre-implementation, and from the ehr post-implementation. for comparison of means, independent t-tests were used. chi-square and fisher's t-tests were used for proportions, as appropriate. results: there were observations; before and after implementation. the differences between observed times and timestamps were computed and found to be normally distributed. post-implementation, mean physician seen times along with arrival to bed, bed to physician, and physician to disposition intervals occurred before observation. physician seen timestamps were frequently incorrect and did not improve postimplementation. significant discrepancies (ten minutes or greater) from observed values were identified in timestamps involving disposition decision and exit from the ed. calculating service time intervals resulted in every service interval (except arrival to bed) having at least % of the times with significant discrepancies. it is notable that missing values were more frequent post-ehr implementation. conclusion: ehr implementation results in reduced variability of timestamps but reduced accuracy and an increase in missing timestamps. using electronic timestamps for operational efficiency assessment should recognize the magnitude of error, and the compounding of error, when computing service times. background: procedural sedation and analgesia is used in the ed in order to efficiently and humanely perform necessary painful procedures. the opposing physiological effects of ketamine and propofol suggest the potential for synergy, and this has led to interest in their combined use, commonly termed ''ketofol'', to facilitate ed procedural sedation. objectives: to determine if a : mixture of ketamine and propofol (ketofol) for ed procedural sedation results in a % or more absolute reduction in adverse respiratory events compared to propofol alone. methods: participants were randomized to receive either ketofol or propofol in a double-blind fashion according to a weight-based dosing protocol. inclusion criteria were age years or greater, and asa class - status. the primary outcome was the number and proportion of patients experiencing an adverse respiratory event according to pre-defined criteria (the ''quebec criteria''). secondary outcomes were sedation consistency, sedation efficacy, induction time, sedation time, procedure time, and adverse events. results: a total of patients were enrolled, per group. forty-three ( %) patients experienced an adverse respiratory event in the ketofol group compared to ( %) in the propofol group (difference %; % ci ) % to %; p = . ). thirty-eight ( %) patients receiving ketofol and ( %) receiving propofol developed hypoxia, of whom three ( %) ketofol patients and ( %) propofol patient received bag-valve-mask ventilation. sixty-five ( %) patients receiving ketofol and ( %) receiving propofol required repeat medication dosing or lightened to a ramsay sedation score of or less during their procedure (difference %; % ci % to %; p = . ). procedural agitation occurred in patients ( . %) receiving ketofol compared to ( %) receiving propofol (difference . %, % ci % to %). recovery agitation requiring treatment occurred in six patients ( %, % ci . % to . %) receiving ketofol. other secondary outcomes were similar between the groups. patients and staff were highly satisfied with both agents. conclusion: ketofol for ed procedural sedation does not result in a reduced incidence of adverse respiratory events compared to propofol alone. induction time, efficacy, and sedation time were similar; however, sedation depth appeared to be more consistent with ketofol. with propofol and its safety is well established. however, in cms enacted guidelines defining propofol as deep sedation and requiring administration by a physician. common edps practice had been one physician performing both the sedation and procedure. edps has proven safe under this one-physician practice. however, the guidelines mandated separate physicians perform each. objectives: the study hypothesis was that one-physician propofol sedation complication rates are similar to two-physician. methods: before and after, observational study of patients > years of age consenting to edps with propofol. edps completed with one physician were compared to those completed with two (separate physicians performing the sedation and the procedure). all data were prospectively collected. the study was completed at an urban level i trauma center. standard monitoring and procedures for edps were followed with physicians blinded to the objectives of this research. the frequency and incremental dosing of medication was left to the discretion of the treating physicians. the study protocol required an ed nurse trained in data collection to be present to record vital signs and assess for any prospectively defined complications. we used chi-square tests to compare the binary outcomes and asa scores across the time periods, and two-sample t-tests to test for differences in age between the two time periods. results: during the -year study period we enrolled patients: one-physician edps sedations and (- to ) also received bag-valve-mask ( ) [ . to ) ( ) [ . to ] (- to ) two-physician. all patients meeting inclusion criteria were included in the study. total adverse event rates were . % and . %, respectively (p = . ). the most common complications were hypotension and oxygen desaturation, and they respectively showed one-physcian rates of . % and . % and two-physician rates of . % and . % (p = . and . .) the unsuccessful procedure rates were . % vs . % (p = . ). conclusion: this study demonstrated no significant difference in complication rates for propofol edps completed by one physician as compared to two. background: overdose patients are often monitored using pulse oximetry, which may not detect changes in patients on high-flow oxygen. objectives: to determine whether changes in end-tidal carbon dioxide (etco ) detected by capnographic monitoring are associated with clinical interventions due to respiratory depression (crd) in patients undergoing evaluation for a decreased level of consciousness after a presumed drug overdose. methods: this was a prospective, observational study of adult patients undergoing evaluation for a drug overdose in an urban county ed. all patients received supplemental oxygen. patients were continuously monitored by trained research associates. the level of consciousness was recorded using the observer's assessment of alertness/sedation scale (oaa/s). vital signs, pulse oximetry, and oaa/s were monitored and recorded every minutes and at the time of occurrence of any crd. respiratory rate and etco were measured at five second intervals using a capno-stream monitor. crd included an increase in supplemental oxygen, the use of bag-valve-mask ventilations, repositioning to improve ventilation, and physical or verbal stimulus to induce respiration, and were performed at the discretion of the treating physicians and nurses. changes from baseline in etco values and waveforms among patients who did or did have a clinical intervention were compared using wilcoxon rank sum tests. results: patients were enrolled in the study (age , range to , % male, median oaas , range to ). suspected overdoses were due to opioids in , benzodiazepines in , an antipsychotic in , and others in . the median time of evaluation was minutes (range to ). crd occurred in % of patients, including an increase in o in %, repositioning in %, and stimulation to induce respiration in %. % had an o saturation of < % (median , range to ) and % had a loss of etco waveform at some time, all of whom had a crd. the median change in etco from baseline was mmhg, range to . among patients with crd it was mmhg, range to , and among patients with no crd it was mmhg, range to (p = . ). conclusion: the change in etco from baseline was larger in patients who required clinical interventions than in those who did not. in patients on high-flow oxygen, capnographic monitoring may be sensitive to the need for airway support. how reliable are health care providers in reporting changes in etco waveform anas sawas , scott youngquist , troy madsen , matthew ahern , camille broadwater-hollifield , andrew syndergaard , jared phelps , bryson garbett , virgil davis university of utah, salt lake city, ut; midwestern university, glendale, az background: etco changes have been used in procedural sedation analgesia (psa) research to evaluate subclinical respiratory depression associated with sedation regiments. objectives: to evaluate the accuracy of bedside clinician reporting of changes in etco . methods: this was a prospective, randomized, singleblind study conducted in ed setting from june until the present time. this study took place at an academic adult ed of a -bed ( in the ed) and a level i trauma center. subjects were randomized to receive either ketamine-propofol or propofol according to a standardized protocol. loss of etco waveforms for ‡ sec were recorded. following sedation, questionnaires were completed by the sedating physicians. digitally recorded etco waveforms were also reviewed by an independent physician and a trained research assistant (ra). to ensure the reliability of trained research assistants, we compared their analyses with the analyses of an independent physician for the first recordings. the target enrollment was patients in each group (n = total). statistics were calculated using sas statistical software. results: patients were enrolled; ( . %) are males and ( . %) are females. mean age was . ± . years. most participants did not have major risk factors for apnea or for further complications ( . % were asa class or ). etco waveforms were reviewed by ( . %) sedating physicians and ( . %) nurses at the bedside. there were ( . %) etco waveforms recordings, ( . %) were reviewed by an independent physician and ( %) were reviewed by an ra. a kappa test for agreement between independent physicians and ras was conducted on recordings and there were no discordant pairs (kappa = ). compared to sedating physicians, the independent physician was more likely to report etco wave losses (or . , % ci . - . ). compared to sedating physicians, ras were more likely to report etco wave losses (or . , % ci . - . ). conclusion: compared to sedating physicians at the bedside, independent physicians and ras were more likely to note etco waveform losses. an independent review of recorded etco waveform changes will be more reliable for future sedation research. background: comprehensive studies evaluating current practices of ed airway management in japan are lacking. many emergency physicians in japan still experience resistance regarding rapid sequence intubation (rsi). objectives: we sought to describe the success and complication rate of rsi with non-rsi. methods: design and setting: we conducted a multicenter prospective observational study using the jean registry of eds at academic and community hospitals in japan during between and . data fields include ed characteristics, patient and operator demographics, method of airway management, number of attempts, and adverse events. we defined non-rsi as intubation with sedation only, neuromuscular blockade only, and without medication. participants: all patients undergoing emergency intubation in ed were eligible for inclusion. cardiac arrest encounters were excluded from the analysis. primary analysis: we described rsi with non-rsi in terms of success rate on first attempt, within three attempts, and complication rate. we present descriptive data as proportions with % confidence intervals (cis). we report odds ratios (or) with % ci via chi-square testing. results: the database recorded intubations (capture rate %) and met the inclusion criteria. rsi was the initial method chosen in ( %) and non-rsi in ( %). use of rsi varied among institutes from % to %. success cases of rsi on first and within three attempts are intubations ( %, %ci %- %) and intubations ( %, %ci %- %), respectively. the success cases of non-rsi on first and within three attempts are intubations ( %, %ci %- %) and intubations ( %, %ci %- %). success rates of rsi on first and within three attempts are higher than non-rsi (or . , %ci . - . and or . , % ci . - . , respectively). we recorded complications in rsi ( %) and in non-rsi ( %). there is no significant difference of complication rate between rsi and non-rsi (or . , % ci . - . ). conclusion: in this multi-center prospective study in japan, we demonstrated a high degree of variation in use of rsi for ed intubation. additionally we found that success rate of rsi on first and within three attempts were both higher than non-rsi. this study has the limitation of reporting bias and confounding by indication. (originally submitted as a ''late-breaker.'') methods: this was a prospective, randomized, singleblind study conducted in the ed setting from june until the present time. this study took place at an academic adult ed of a -bed ( in the ed) and a level i trauma center. subjects were randomized to receive either ketamine-propofol or propofol according to a standardized protocol. etco waveforms were digitally recorded. etco changes were evaluated by the sedating physicians at the bedside. recorded waveforms were reviewed by an independent physician and a trained research assistant (ra). to ensure the reliability of trained ras, we computed a kappa test for agreement between the analysis of independent physicians and ras for the first recordings. a post-hoc analysis of the association between any loss, the number of losses, and total duration of loss of etco waveform and crp was performed. on review we recorded the absence or presence of loss of etco and the total duration in seconds of all lost etco episodes ‡ seconds. ors were calculated using sas statistical software. results: patients were enrolled; ( . %) are males and are ( . %) females. . % participants were asa class or . waveforms were reviewed by ( . %) sedating physicians. there were ( . %) waveforms recordings, ( . %) were reviewed by an independent physician and ( %) were reviewed by ras, where there were no discordant pairs (kappa = ). there were ( . %) crp events. any loss of etco was associated with a non-significant or of . ( % ci . - . ) for crp. however, the duration of etco loss was significantly associated with crp with an or of . ( % ci . - . ) for each second interval of lost etco . the number of losses was significantly associated with the outcome (or . , % ci . - . ). conclusion: defining subclinical respiratory depression as present or absent may be less useful than quantitative measurements. this suggests that risk is cumulative over periods of loss of etco , and the duration of loss may be a better marker of sedation depth and risk of complications than classification of any loss. background: ed visits present an opportunity to deliver brief interventions (bis) to reduce violence and alcohol misuse among urban adolescents at risk for future injury. previous analyses demonstrated that a brief intervention resulted in reductions in violence and alcohol consequences up to months. objectives: this paper describes findings examining the efficacy of bis on peer violence and alcohol misuse at months. methods: patients ( - yrs) at an ed reporting past year alcohol use and aggression were enrolled in the rct, which included computerized assessment, and randomization to control group or bi delivered by a computer (cbi) or therapist assisted by a computer (tbi). baseline and months included violence (peer aggression, peer victimization, violence related consequences) and alcohol (alcohol misuse, binge drinking, alcohol-related consequences). results: adolescents were screened ( % participation). of those, screened positive for violence and alcohol use and were randomized; % completed -month follow-up. as compared to the control group, the tbi group showed significant reductions in peer aggression (p < . ) and peer victimization (p < . ) at months. bi and control groups did not differ on alcohol-related variables at months. conclusion: evaluation of the saferteens intervention one year following an ed visit provides support for the efficacy of computer-assisted therapist brief intervention for reducing peer violence. violence against ed health care workers: a -month experience terry kowalenko , donna gates , gordon gillespie , paul succop university of michigan, ann arbor, mi; university of cincinnati, cincinnati, oh background: health care (hc) support occupations have an injury rate nearly times that of the general sector due to assaults, with doctors and nurses nearly times greater. studies have shown that the ed is at greatest risk of such events compared to other hc settings. objectives: to describe the incidence of violence in ed hc workers over months. specific aims were to ) identify demographic, occupational, and perpetrator factors related to violent events; ) identify the predictors of acute stress response in victims; and ) identify predictors of loss of productivity after the event. methods: longitudinal, repeated methods design was used to collect monthly survey data from ed hc workers (w) at six hospitals in two states. surveys assessed the number and type of violent events, and feelings of safety and confidence. victims also completed specific violent event surveys. descriptive statistics and a repeated measure linear regression model were used. results: ed hcws completed monthly surveys, and violent events were reported. the average per person violent event rate per months was . . events were physical threats ( . per person in months). events were assaults ( . per person in months). violent event surveys were completed, describing physical threats and assaults with % resulting in injuries. % of the physical threats and % of the assaults were perpetrated by men. comparing occupational groups revealed significant differences between nurses and physicians for all reported events (p = . ), with the greatest difference in physical threats (p = . ). nurses felt less safe than physicians (p = . ). physicians felt more confident than nurses in dealing with the violent patient (p = . ). nurses were more likely to experience acute stress than physicians (p < . ). acute stress significantly reduced productivity in general (p < . ), with a significant negative effect on ''ability to handle/ manage workload'' (p < . ) and ''ability to handle/ manage cognitive demands'' (p < . ). conclusion: ed hcws are frequent victims of violence perpetrated by visitors and patients. this violence results in injuries, acute stress, and loss of productivity. acute stress has negative consequences on the workers' ability to perform their duties. this has serious potential consequences to the victim as well as the care they provide to their patients. a randomized controlled feasibility trial of vacant lot greening to reduce crime and increase perceptions of safety eugenia c. garvin, charles c. branas perelman school of medicine at the university of pennsylvania, philadelphia, pa background: vacant lots, often filled with trash and overgrown vegetation, have been associated with intentional injuries. a recent quasi-experimental study found a significant decrease in gun crimes around vacant lots that had been greened compared with control lots. objectives: to determine the feasibility of a randomized vacant lot greening intervention, and its effect on police-reported crime and perceptions of safety. methods: for this randomized controlled feasibility trial of vacant lot greening, we partnered with the pennsylvania horticulture society (phs) to perform the greening intervention (cleaning the lots, planting grass and trees, and building a wooden fence around the perimeter). we analyzed police crime data and interviewed people living around the study vacant lots (greened and control) about perceptions of safety before and after greening. results: a total of sq ft of randomly selected vacant lot space was successfully greened. we used a master database of , vacant lots to randomly select vacant lot clusters. we viewed each cluster with the phs to determine which were appropriate to send to the city of philadelphia for greening approval. the vacant lot cluster highest on the random list to be approved by the city of philadelphia was designated the intervention site, and the next highest was designated the control site. overall, participants completed baseline interviews, and completed follow-up interviews after months. % of participants were male, % were black or african american, and % had a household income less than $ , . unadjusted difference-in-differences estimates showed a decrease in gun assaults around greened vacant lots compared to control. regression-adjusted estimates showed that people living around greened vacant lots reported feeling safer after greening compared to those who lived around control vacant lots (p < . ). conclusion: conducting a randomized controlled trial of vacant lot greening is feasible. greening may reduce certain gun crimes and make people feel safer. however, larger prospective trials are needed to further investigate this link. screening for violence identifies young adults at risk for return ed visits for injury abigail hankin-wei, brittany meagley, debra houry emory university, atlanta, ga background: homicide is the second leading cause of death among youth ages - . prior studies, in nonhealth care settings, have shown associations between violent injury and risk factors including exposure to community violence, peer behavior, and delinquency. objectives: to assess whether self-reported exposure to violence risk factors can be used to predict future ed visits for injuries. methods: we conducted a prospective cohort study in the ed of a southeastern us level i trauma center. patients aged - presenting for any chief complaint were included unless they were critically ill, incarcerated, or could not read english. recruitment took place over six months, by a trained research assistant (ra). the ra was present in the ed for - days per week, with shifts scheduled such that they included weekends and weekdays, over the hours from am- pm. patients were offered a $ gift card for participation. at the time of initial contact in the ed, patients completed a written questionnaire which included validated measures of the following risk factors: a) aggression, b) perceived likelihood of violence, c) recent violent behavior, d) peer behavior, e) community exposure to violence, and f) positive future outlook. at months following the initial ed visit, the participants' medical records were reviewed to identify any subsequent ed visits for injury-related complaints. data were analyzed with chi-square and logistic regression analyses. results: patients were approached, of whom patients consented. participants' average age was . years, with % female, and % african american. return visits for injuries were significantly associated with hostile/aggressive feelings (rr . , ci . , ) , self-reported perceived likelihood of violence (rr . , ci . , . ) , recent violent behavior (rr . , ci . , . ) , and peer group violence (rr . , ci . , . ) . these findings remained significant when controlling for participant sex. conclusion: a brief survey of risk factors for violence is predictive of return visit to the ed for injury. these findings identify a potentially important tool for primary prevention of violent injuries among young adults visiting the ed for both injury and non-injury complaints. background: sepsis is a commonly encountered disease in ed, with high mortality. while several clinical prediction rules (cpr) including meds, sirs, and curb- exist to facilitate clinicians in early recognition of risk of mortality for sepsis, most are of suboptimal performance. objectives: to derive a novel cpr for mortality of sepsis utilizing clinically available and objective predictors in ed. methods: we retrospectively reviewed all adult septic patients who visited the ed at a tertiary hospital during the year with two sets of blood cultures ordered by physicians. basic demographics, ed vital signs, symptoms and signs, underlying illnesses, laboratory findings, microbiological results, and discharge status were collected. multivariate logistic regressions were used to obtain a novel cpr using predictors with < . p-value tested in univariate analyses. the existing cprs were compared with this novel cpr using auc. results: of included patients, . % died in hospital, % had diabetes, % were older than years of age, % had malignancy, and % had positive blood bacterial culture tests. predisposing factors including history of malignancy, liver disease, immunosuppressed status, chronic kidney disease, congestive heart failure, and older than years of age were found to be associated with mortality (all p < . ). patients who developed mortality tended to have lower body temperature, narrower pulse pressure, higher percentage of red cell distribution width (rdw) and bandemia, higher blood urea nitrogen (bun), ammonia, and c-reactive protein level, and longer prothrombin time and activated partial thromboplastin time (aptt) (all p < . ). the most parsimonious cpr incorporating history of malignancy (or . , % ci . - . ), prolonged aptt ( . , . - . ), presence of bandemia ( . , . - . results: there was poor agreement between the physician's unstructured assessment used in clinical practice and the guidelines put forth by the aha/acc/acep task force. ed physicians were more likely to assess a patient as low risk ( %), while aha guidelines were more likely to classify patients as intermediate ( %) or high ( %) risk. however, when comparing the patient's final acs diagnosis and the relation to the risk assessment value, ed physicians proved better predictors of high-risk patients who in fact had acs, while the aha/acc/acep guidelines proved better at correctly identifying low-risk patients who did not have acs. conclusion: in the ed, physicians are far more efficient at correctly placing patients with underlying acs into a high-risk category, while established criteria may be overly conservative when applied to an acute care population. further research is indicated to look at ed physicians' risk stratification and ensuing patient care to assess for appropriate decision making and ultimate outcomes. compartative conclusion: the amuse score was more specific, but the wells score was more sensitive for acute lower limb dvt in this cohort. there is no significant advantage in using the amuse over the wells score in ed patient with suspected dvt. background: the direct cost of medical care is not accurately reflected in charges or reimbursement. the cost of boarding admitted patients in the ed has been studied in terms of opportunity costs, which are indirect. the actual direct effect on hospital expenses has not been well defined. objectives: we calculate the difference to the hospital in the cost of caring for an admitted patient in the ed and in a non-critical care in-patient unit. methods: time-directed activity-based costing (tdabc) has recently been proposed as a method of determining the actual cost of providing medical services. tdabc was used to calculate the cost per patient bed-hour both in the ed and for an in-patient unit. the costs include nursing, nursing assistants, clerks, attending and resident physicians, supervisory salaries, and equipment maintenance. boarding hours were determined from placement of admission order to transfer to in-patient unit. a convenience sample of consecutive non-critical care admissions was assessed to find the degree of ed physician involvement with boarded patients. results: the overhead cost per patient bed-hour in the ed was $ . . the equivalent cost per bed-hour inpatient was $ . , a differential of $ . . there were , boarding hours for medical-surgical patients in , a differential of $ , , . for the year. for the short-stay unit (no residents), the cost per patient hour was $ . and the boarding hours were , . this resulted in a differential cost of $ , . , a total direct cost to the hospital of $ , , . . review of consecutive admissions showed no orders placed by the ed physician after decision-toadmit. conclusion: concentration of resources in the ed means considerably higher cost per unit of care as compared to an in-patient unit. keeping admitted patients boarding in the ed results in expensive underutilization. this is exclusive of significant opportunity costs of lost revenue from walk-out and diverted patients. this study includes the cost of teaching attendings and residents (ed and in-patient) . in a non-teaching setting, the differential would be less and the cost of boarding would be shared by a fee-for-service ed physician group as well as the hospital. improving identification of frequent emergency department users using a regional health information background: frequent ed users consume a disproportionate amount of health care resources. interventions are being designed to identify such patients and direct them to more appropriate treatment settings. because some frequent users visit more than one ed, a health information exchange (hie) may improve the ability to identify frequent ed users across sites of care. objectives: to demonstrate the extent to which a hie can identify the marginal increase in frequent ed users beyond that which can be detected with data from a single hospital. methods: data from / / to / / from the new york clinical information exchange (nyclix), a hie in new york city that includes ten hospitals, were analyzed to calculate the number of frequent ed users ( ‡ visits in days) at each site and across the hie. results: there were , ( % of total patients) frequent ed users, with , ( %) of frequent users having all their visits at a single ed, while , ( %) frequent users were identified only after counting visits to multiple eds (table ) . site-specific increases varied from % to % (sd . ). frequent ed users accounted for % of patients, but for % of visits, averaging . visits per year, versus . visits per year for all other patients. . % of frequent users visited two or more eds during the study period, compared to . % of all other patients. conclusion: frequent ed users commonly visited multiple nyclix eds during the study period. the use of a hie helped identify many additional frequent users, though the benefits were lower for hospitals not located in the relative vicinity of another nyclix hospital. measures that take a community, rather than a single institution, into account may be more reflective of the care that the patient experiences. indocyanine background: due to their complex nature and high associated morbidity, burn injuries must be handled quickly and efficiently. partial thickness burns are currently treated based upon visual judgment of burn depth by the clinician. however, such judgment is only % accurate and not expeditious. laser doppler imaging (ldi) is far more accurate -nearly % after days. however, it is too cumbersome for routine clinical use. laser assisted indocyanine green angiography (laicga) has been indicated as an alternative for diagnosing the depth of burn injuries, and possesses greater utility for clinical translation. as the preferred outcome of burn healing is aesthetic, it is of interest to determine if wound contracture can be predicted early in the course of a burn by laic-ga. objectives: determine the utility of early burn analysis using laicga in the prediction of -day wound contracture. methods: a prospective animal experiment was performed using six anesthetized pigs, each with standardized wounds. differences in burn depth were created by using a . · . cm aluminum bar at three exposure times and temperatures: degrees c for seconds, degrees c for seconds, and degrees c for seconds. we have shown in prior validation experiments that these burn temperatures and times create distinct burn depths. laicga scanning, using lifecell spy elite, took place at hour, hours, hours, hours, and week post burn. imaging was read by a blinded investigator, and perfusion trends were compared with day post-burn contraction outcomes measured using imagej software. biopsies were taken on day to measure scar tissue depth. results: deep burns were characterized by a blue center indicating poor perfusion while more superficial burns were characterized by a yellow-red center indicating perfusion that was close to that of the normal uninjured adjacent skin (see figure) . a linear relationship between contraction outcome and burn perfusion could be discerned as early as hour post burn, peaking in strength at - hours post-burn. burn intensity could be effectively identified at hours post-burn, although there was no relationship with scar tissue depth. conclusion: pilot data indicate that laicga using lifecell spy has the ability to determine the depth of injury and predict the degree of contraction of deep dermal burns within - days of injury with greater accuracy than clinical scoring. the objectives: we hypothesize that real-time monitoring of an integrated electronic medical records system and the subsequent firing of a ''sepsis alert'' icon on the electronic ed tracking board results in improved mortality for patients who present to the ed with severe sepsis or septic shock. methods: we retrospectively reviewed our hospital's sepsis registry and included all patients diagnosed with severe sepsis or septic shock presenting to an academic community ed with an annual census of , visits and who were admitted to a medical icu or stepdown icu bed between june and october . in may an algorithm was added to our integrated medical records system that identifies patients with two sirs criteria and evidence of endorgan damage or shock on lab data. when these criteria are met, a ''sepsis alert'' icon (prompt) appears next to that patient's name on the ed tracking board. the system also pages an in-house, specially trained icu nurse who can respond on a prn basis and assist in the patient's management. months of intervention data are compared with months of baseline data. statistical analysis was via z-test for proportions. results: for ed patients with severe sepsis, the preand post-alert mortality was of ( %) and of ( %), respectively (p = . ; n = ). in the septic shock group, the pre-and post-alert mortality was of ( %) and of ( %), respectively (p = . ). with ed and inpatient sepsis alerts combined, the severe sepsis subgroup mortality was reduced from % to % (p = . ; n = ). conclusion: real-time ed ehr screening for severe sepsis and septic shock patients did not improve mortality. a positive trend in the severe sepsis subgroup was noted, and the combined inpatient plus ed data suggests statistical significance may be reached as more patients enter the registry. limitations: retrospective study, potential increased data capture post intervention, and no ''gold standard'' to test the sepsis alert sensitivity and specificity. ) . descriptive statistics were calculated. principal component analysis was used to determine questions with continuous response formats that could be aggregated. aggregated outcomes were regressed onto predictor demographic variables using multiple linear regression. results: / physicians completed the survey. physicians had a mean of . ± . years experience in the ed. . % were female. eight physicians ( %) reported never having used the tool, while . % of users estimated having used it more than five times. % of users cited the ''p'' alert on the etb as the most common notification method. most felt the ''p'' alert did not help them identify patients with pneumonia earlier (mean = . ± . ), but found it moderately useful in reminding them to use the tool ( . ± . ). physicians found the tool helpful in making decisions regarding triage, diagnostic studies, and antibiotic selection for outpatients and inpatients ( . ± . , . ± . , . ± . , and . ± . , respectively). they did not feel it negatively affected their ability to perform other tasks ( . ± . ). using multiple linear regression, neither age, sex, years experience, nor tool use frequency significantly predicted responses to questions about triage and antibiotic selection, technical difficulties, or diagnostic ordering. conclusion: ed physicians perceived the tool to be helpful in managing patients with pneumonia without negatively affecting workflow. perceptions appear consistent across demographic variables and experience. objectives: we seek to examine whether use of the salt device can provide reliable tracheal intubation during ongoing cpr. the dynamic model tested the device with human powered cpr (manual) and with an automated chest compression device (physio control lucas ). the hypothesis is that the predictable movement of an automated chest compression device will make tracheal intubation easier than the random movement from manual cpr. methods: the project was an experimental controlled trial and took place in the ed at a tertiary referral center in peoria, illinois. this project was an expansion arm of a similarly structured study using traditional laryngoscopy. emergency medicine residents, attending physicians, paramedics, and other acls-trained staff were eligible for participation. in randomized order, each participant attempted intubation on a mannequin using the salt device with no cpr ongoing, during cpr with a manual compression, and during cpr with an automatic chest compression. participants were timed in their attempt and success was determined after each attempt. results: there were participants in the trial. the success rates in the control group and the automated cpr group were both % ( / ) and the success rate in the manual cpr group was % ( / objectives: our primary hypothesis was that in fasting, asymptomatic subjects, larger fluid boluses would lead to proportional aortic velocity changes. our secondary endpoints were to determine inter-and intra-subject variation in aortic velocity measurements. methods: the authors performed a prospective randomized double-blinded trial using healthy volunteers. we measured the velocity time integral (vti) and maximal velocity (vmax) with an estimated - °pulsed wave doppler interrogation of the left ventricular outflow in the apical- cardiac window. three physicians reviewed optimal sampling gate position, doppler angle and verified the presence of an aortic closure spike. angle correction technology was not used. subjects with no history of cardiac disease or hypertension fasted for hours and were then randomly assigned to receive a normal saline bolus of ml/kg, ml/kg or ml/kg over minutes. aortic velocity profiles were measured before and after each fluid bolus. results: forty-two subjects were enrolled. mean age was ± (range to ) and mean body mass index . ± . (range . to ). mean volume (in ml) for groups receiving ml/kg, ml/kg, and ml/kg were , , and , respectively. mean baseline vmax (in cm/s) of the subjects was . ± . (range to ). mean baseline vti (in cm) was . ± . (range . to . ). pre-and post-fluid mean differences for vmax were ) . (± . ) and for vti . (± . ). aortic velocity changes in groups receiving ml/kg, ml/kg, and ml/kg were not statistically significant (see table) . heart rate changes were not significant. background: clinicians recognize that septic shock is a highly prevalent, high mortality disease state. evidence supports early ed resuscitation, yet care delivery is often inconsistent and incomplete. the objective of this study was to discover latent critical barriers to successful ed resuscitation of septic shock. objectives: clinicians recognize that septic shock is a highly prevalent, high mortality disease state. evidence supports early ed resuscitation, yet care delivery is often inconsistent and incomplete. the objective of this study was to discover latent critical barriers to successful ed resuscitation of septic shock. methods: we conducted five -minute risk-informed in-situ simulations. ed physicians and nurses working in the real clinical environment cared for a standardized patient, introduced into their existing patient workload, with signs and symptoms of septic shock. immediately after case completion clinicians participated in a minute debriefing session. transcripts of these sessions were analyzed using grounded theory, a method of qualitative analysis, to identify critical barrier themes. results: fifteen clinicians participated in the debriefing sessions: four attending physicians, five residents, five nurses, and one nurse practitioner. the most prevalent critical barrier themes were: anchoring bias and difficulty with cognitive framework adaptation as the patient progressed to septic shock (n = ), difficult interactions between the ed and ancillary departments (n = ), difficulties with physician-nurse commu-nication and teamwork (n = ), and delays in placing the central venous catheter due to perceptions surrounding equipment availability and the desire to attend to other competing interests in the ed prior to initiation of the procedure (n = and ). each theme was represented in at least four of the five debriefing sessions. participants reported the in-situ simulations to be a realistic representation of ed sepsis care. conclusion: in-situ simulation and subsequent debriefing provides a method of identifying latent critical areas for improvement in a care process. improvement strategies for ed-based septic shock resuscitation will need to address the difficulties in shock recognition and cognitive framework adaptation, physician and nurse teamwork, and prioritization of team effort. the background: the association between blood glucose level and mortality in critically ill patients is highly debated. several studies have investigated the association between history of diabetes, blood sugar level, and mortality of septic patients; however, no consistent conclusion could be drawn so far. objectives: to investigate the association between diabetes and initial glucose level and in-hospital mortality in patients with suspected sepsis from the ed. methods: we conducted a retrospective cohort study that consisted of all adult septic patients who visited the ed at a tertiary hospital during the year with two sets of blood cultures ordered by physicians. basic demographics, ed vital signs, symptoms and signs, underlying illnesses, laboratory findings, microbiological results, and discharge status were collected. logistic regressions were used to evaluate the association between risk factors, initial blood sugar level, and history of diabetes and mortality, as well as the effect modification between initial blood sugar level and history of diabetes. results: a total of patients with available blood sugar levels were included, of whom % had diabetes, % were older than years of age, and % were male. the mortality was % ( % ci . - . %). patients with a history of diabetes tended to be older, female, and more likely to have chronic kidney disease, lower sepsis severity (meds score), and positive blood culture test results (all p < . ). patients with a history of diabetes tended to have lower in-hospital mortality after ed visits with sepsis, controlling for initial blood sugar level (aor . , % ci . - . , p = . ). initial normal blood sugar seemed to be beneficial compared to lower blood sugar level for in-hospital mortality, controlled history of diabetes, sex, severity of sepsis, and age (aor . , % ci . - . , p = . ). the effect modification of diabetes on blood sugar level and mortality, however, was found to be not statistically significant (p = . ). conclusion: normal initial blood sugar level in ed and history of diabetes might be protective for mortality of septic patients who visited the ed. further investigation is warranted to determine the mechanism for these effects. methods: this irb-approved retrospective chart review included all patients treated with therapeutic hypothermia after cardiac arrest during at an urban, academic teaching hospital. every patient undergoing therapeutic hypothermia is treated by neurocritical care specialists. patients were identified by review of neurocritical care consultation logs. clinical data were dually abstracted by trained clinical study assistants using a standardized data dictionary and case report form. medications reviewed during hypothermia were midazolam, lorazepam, propofol, fentanyl, cisatracurium, and vecuronium. results: there were patients in the cohort. median age was (range - years), % were white, % were male, and % had a history of coronary artery disease. seizures were documented by continuous eeg in / ( %), and / ( %) died during hospitalization. most, / ( %), received fentanyl, / ( %) received benzodiazepine pharmacotherapy, and / ( %) received propofol. paralytics were administered to / ( %) patients, / ( %) with cisatracurium and / ( %) with vecuronium. of note, one patient required pentobarbital for seizure management. conclusion: sedation and neuromuscular blockade are common during management of patients undergoing therapeutic hypothermia after cardiac arrest. patients in this cohort often received analgesia with fentanyl, and sedation with a benzodiazepine or propofol. given the frequent use of sedatives and paralytics in survivors of cardiac arrest undergoing hypothermia, future studies should investigate the potential effect of these drugs on prognostication and survival after cardiac arrest. background: the use of therapeutic hypothermia (th) is a burgeoning treatment modality for post-cardiac arrest patients. objectives: we performed a retrospective chart review of patients who underwent post cardiac arrest th at eight different institutions across the united states. our objective was to assess how th is currently being implemented in emergency departments and assess the feasibility of conducting more extensive th research using multi-institution retrospective data. methods: a total of charts with dates from - were sent for review by participating institutions of the peri-resuscitation consortium. of those reviewed, eight charts were excluded for missing data. two independent reviewers performed the review and the results were subsequently compared and discrepancies resolved by a third reviewer. we assessed patient demographics, initial presenting rhythm, time until th initiation, duration of th, cooling methods and temperature reached, survival to hospital discharge, and neurological status on discharge. results: the majority of cases of th had initial cardiac rhythms of asystole or pulseless electrical activity ( . %), followed by ventricular tachycardia or fibrillation ( . %), and in . % the inciting cardiac rhythm was unknown. time to initiation of th ranged from - minutes with a mean time of min (sd . ). length of th ranged from - minutes with a mean time of minutes (sd ). average minimum temperature achieved was . °c, with a range from . - . °c (sd . °c). of the charts reviewed, ( . %) of the patients survived to hospital discharge and ( . %) were discharged relatively neurologically intact. conclusion: research surrounding cardiac arrest has always been difficult given the time and location span from pre-hospital care to emergency department to intensive care unit. also, as witnessed cardiac arrest events are relatively rare with poor survival outcomes, very large sample sizes are needed to make any meaningful conclusions about th. our varied and inconsistent results show that a multi-center retrospective review is also unlikely to provide useful information. a prospective multi-center trial with a uniform th protocol is needed if we are ever to make any evidence-based conclusions on the utility of th for post-cardiac arrest patients. serum results: mean la was . , sd = . . mean age was . years old, sd = . . a statistically significant positive correlation was found between la and pulse, respiratory rate (rr), wbc, platelets, and los, while a significant negative correlation was seen with temperature and hco -. when two subjects were dropped as possible outliers with la > , it resulted in non-significant temperature correlation, but a significant negative correlation with age and bun was revealed. patients in the higher la group were more likely to be admitted (p = . ) and have longer los. of the discharged patients, there was no difference in mean la level between those who returned (n = , mean la of . , sd = . ) and those who did not (n = , mean la of . , sd = . ), p = . . furthermore, mean la levels for those with sepsis (n = , mean la of . , sd = . ) did not differ from those without sepsis (n = , mean la of . , sd = . ), p = . . conclusion: higher la in pediatric patients presenting to the ed with suspected infection correlated with increased pulse, rr, wbc, platelets, and decreased bun, hco -, and age. la may be predictive of hospitalization, but not of -day return rates or pediatric sepsis screening in the ed. background: mandibular fractures are one of the most frequently seen injuries in the trauma setting. in terms of facial trauma, madibular fractures account for - % of all facial bone fractures. prior studies have demonstrated that the use of a tongue blade to screen these patients to determine whether a mandibular fracture is present may be as sensitive as x-ray. one study showed the sensitivity and specificity of the test to be . % and . %, respectively. in the last ten years, high-resolution computed tomography (hct) has replaced panoramic tomography (pt) as the gold standard for imaging of patients with suspected mandibular fractures. this study determines if the tongue blade test (tbt) remains as sensitive a screening tool when compared to the new gold standard of ct. objectives: the purpose of the study was to determine the sensitivity and specificity of the tbt as compared to the new gold standard of radiologic imaging, hct. the question being asked: is the tbt still useful as a screening tool for patients with suspected mandibular fractures when compared to the new gold standard of hct? methods: design: prospective cohort study. setting: an urban tertiary care level i trauma center. subjects: this study took place from / / to / / in which any person suffering from facial trauma presented. intervention: a tbt was performed by the resident physician and confirmed by the supervising attending physician. ct facial bones were then obtained for the ultimate diagnosis. inter-rater reliability (kappa) was calculated, along with sensitivity, specificity, accuracy, ppv, npv, likelihood ratio (lr) (+), and likelihood ratio (lr) (-) based on a · contingency tables generated. results: over the study period patients were enrolled. inter-rater reliability was kappa = . (se + . ). the table demonstrates the outcomes of both the tbt and ct facial bones for mandibular fracture. the following parameters were then calculated based on the contingency table: sensitivity . (ci . - . ), specificity . (ci . - . ), ppv . (ci . - . ), npv . (ci . - . ), accuracy . , lr(+) . ), lr (-) . (ci . - . ). conclusion: the tbt is still a useful screening tool to rule out mandibular fractures in patients with facial trauma as compared to the current gold standard of hct. background: appendicitis is the most common surgical emergency occurring in children. the diagnosis of pediatric appendicitis is often difficult and computerized tomography (ct) scanning is utilized frequently. ct, although accurate, is expensive, time-consuming, and exposes children to ionizing radiation. radiologists utilize ultrasound for the diagnosis of appendicitis, but it may be less accurate than ct, and may not incorporate emergency physician (ep) clinical impression regarding degree of risk. objectives: the current study compared ep clinical diagnosis of pediatric appendicitis pre-and post-bedside ultrasonography (bus). methods: children - years of age were enrolled if their clinical attending physician planned to obtain a consultative ultrasound, ct scan, or surgical consult specific for appendicitis. most children in the study received narcotic analgesia to facilitate bus. subjects were initially graded for likelihood of appendicitis based on research physician-obtained history and physical using a visual analogue scale (vas). immediately subsequent to initial grading, research physicians performed a bus and recorded a second vas impression of appendicitis likelihood. two outcome measures were combined as the gold standard for statistical analysis. the post-operative pathology report served as the gold standard for subjects who underwent appendectomy, while post -week telephone follow-up was used for subjects who did not undergo surgery. various specific ultrasound measures used for the diagnosis of appendicitis were assessed as well. results: / subjects had pathology-proven appendicitis. one subject was pathology-negative post-appendectomy. of the subjects who did not undergo surgery, none had developed appendicitis at the post -week telephone follow-up. pre-bus sensitivity was % ( - %) while post-bus sensitivity was % ( - %). both pre-and post-bus specificity was % ( - %). pre-bus lr+ was ( - ), while post-bus lr+ was ( - ). pre-and post-bus lr-were . and . , respectively. bus changed the diagnosis for % of subjects ( - %). background: there are very little data on the normal distance between the glenoid rim and the posterior aspect of the humeral head in normal and dislocated shoulders. while shoulder x-rays are commonly used to detect shoulder dislocations, they may be inadequate, exacerbate pain in the acquisition of some views, and lead to delay in treatment, compared to bedside ultrasound evaluation. objectives: our objective was to compare the glenoid rim to humeral head distance in normal shoulders and in anteriorly dislocated shoulders. this is the first study proposing to set normal and abnormal limits. methods: subjects were enrolled in this prospective observation study if they had a chief complaint of shoulder pain or injury, and received a shoulder ultrasound as well as a shoulder x-ray. the sonographers were undergraduate students given ten hours of training to perform the shoulder ultrasound. they were blinded to the x-ray interpretation, which was used as the gold standard. we used a posterior-lateral approach, capturing an image with the glenoid rim, the humeral head, as well as the infraspinatus muscle. two parallel lines were applied to the most posterior aspect of the humeral head and the most posterior aspect of the glenoid rim. a line perpendicular to these lines was applied, and the distance measured. in anterior dislocations, a negative measurement was used to denote the fact that the glenoid rim is now posterior to the most posterior aspect of the humeral head. descriptive analysis was applied to estimate the mean and th to th interquartile range of normal and anteriorly dislocated shoulders. results: eighty subjects were enrolled in this study. there were six shoulder dislocations, however only four were anterior dislocations. the average distance between the posterior glenoid rim and the posterior humeral head in normal shoulders was . mm, with a th to th inter-quartile range of . mm to . mm. the distance in our four cases of anterior dislocation was ) mm, with a th to th interquartile range of ) mm to ) mm. conclusion: the distance between the posterior humeral head to posterior glenoid rim may be mm to mm in patients presenting to the ed with shoulder pain but no dislocation. in contrast, this distance in anterior dislocations was greater than ) mm. shoulder ultrasound may be a useful adjunct to x-ray for diagnosing anterior shoulder dislocations. conclusion: in this retrospective study, the presence of rv strain on focus significantly increases the likelihood of an adverse short term event from pulmonary embolism and its combination with hypotension performs similarly to other prognostic rules. background: burns are expensive and debilitating injuries, compromising both the structural integrity and vascular supply to skin. they exhibit a substantial potential to deteriorate if left untreated. jackson defined three ''zones'' to a burn. while the innermost coagulation zone and the outermost zone of hyperemia display generally predictable healing outcomes, the zone of stasis has been shown to be salvageable via clinical intervention. it has therefore been the focus of most acute therapies for burn injuries. while laser doppler imaging (ldi) -the current gold standard for burn analysis -has been % effective at predicting the need for second degree burn excision, its clinical translation is problematic, and there is little information regarding its ability to analyze the salvage of the stasis zone in acute injury. laser assisted indocyanine green dye angiography (laicga) also shows potential to predict such outcomes with greater clinical utility. objectives: to test the ability of ldi and laicga to predict interspace (zone of stasis) survival in a horizontal burn comb model. methods: a prospective animal experiment was performed using four pigs. each pig had a set of six dorsal burns created using a brass ''comb'' -creating four rectangular · mm full thickness burns separated by · mm interspaces. laicga and ldi scanning took place at hour, hours, hours, and week post burn using novadaq spy and moor ldi respectively. imaging was read by a blinded investigator, and perfusion trends were compared with interspace viability and contraction. burn outcomes were read clinically, evaluated via histopathology, and interspace contraction was measured using image j software. results: laicga data showed significant predictive potential for interspace survival. it was . % predictive at hours post burn, % predictive hours post burn, and % predictive days post burn using a standardized perfusion threshold. ldi imaging failed to predict outcome or contraction trends with any degree of reliability. the pattern of perfusion also appears to be correlated with the presence of significant interspace contraction at days, with an % adherence to a power trendline. ventions, isolation, testing, treatment, and ''other'' category intervention were identified. one intervention involving school closures was associated with a % decrease in pediatric ed visits for respiratory illness. conclusion: most interventions were not tested in isolation, so the effect of individual interventions was difficult to differentiate. interventions associated with statistically significant decreases in ed crowding were school closures, as well as interventions in all categories studied. further study and standardization of intervention input, process, and outcome measures may assist in identifying the most effective methods of mitigating ed crowding and improving surge capacity during an influenza or other respiratory disease outbreak. communication background: the link between extended shift lengths, sleepiness, and occupational injury or illness has been shown, in other health care populations, to be an important and preventable public health concern but heretofore has not been fully described in emergency medical services (ems objectives: to assess the effect of an ed-based computer screening and referral intervention for ipv victims and to determine what characteristics resulted in a positive change in their safety. we hypothesized that women who were experiencing severe ipv and/or were in contemplation or action stages would be more likely to endorse safety behaviors. methods: we conducted the intervention for female ipv victims at three urban eds using a computer kiosk to deliver targeted education about ipv and violence prevention as well as referrals to local resources. all adult english-speaking non-critically ill women triaged to the ed waiting room were eligible to participate. the validated universal violence prevention screening protocol was used for ipv screening. any who disclosed ipv further responded to validated questionnaires for alcohol and drug abuse, depression, and ipv severity. the women were assigned a baseline stage of change (precontemplation, contemplation, action, or maintenance) based on the urica scale for readiness to change behavior surrounding ipv. participants were contacted at week and months to assess a variety of pre-determined actions such as moving out, to prevent ipv during that period. statistical analysis (chi-square testing) was performed to compare participant characteristics to the stage of change and whether or not they took protective action. results: a total of , people were screened and disclosed ipv and participated in the full survey. . % of the ipv victims were in the precontemplative stage of change, and . % were in the contemplation stage. women returned at week of follow-up ( . %), and ( . %) women returned at months of followup. . % of those who returned at week, and % of those who returned at months took protective action against further ipv. there was no association between the various demographic characteristics and whether or not a woman took protective action. conclusion: ed-based kiosk screening and health information delivery is both a feasible and effective method of health information dissemination for women experiencing ipv. stage of change was not associated with actual ipv protective measures. objectives: we present a pilot, head-to-head comparison of x and x effectiveness in stopping a motivated person. the objective is to determine comparative injury prevention effectiveness of the newer cew. methods: four humans had metal cew probe pairs placed. each volunteer had two probe pairs placed (one pair each on the right and left of the abdomen/inguinal region). superior probes were at the costal margin, inches lateral of midline. inferior probes were vertically inferior at predetermined distances of , , , and inches apart. each volunteer was given the goal of slashing a target feet away with a rubber knife during cew exposure. as a means of motivation, they believed the exposure would continue until they reached the goal (in reality, the exposure was terminated once no further progress was made). each volunteer received one exposure from a x and a x cew. the exposure order was randomized with a -minute rest between them. exposures were recorded on a hi-speed, hi-resolution video. videos were reviewed and scored by six physician, kinesiology, and law officer experts using standardized criteria for effectiveness including degree of upper and lower extremity, and total body incapacitation, and degree of goal achievement. reviews were descriptively compared independently for probe spread distances and between devices. results: there were exposures ( pairs) for evaluation and no discernible, descriptive reviewer differences in effectiveness between the x and the x cews when compared. background: the trend towards higher gasoline prices over the past decade in the u.s. has been associated with higher rates of bicycle use for utilitarian trips. this shift towards non-motorized transportation should be encouraged from a physical activity promotion and sustainability perspective. however, gas price induced changes in travel behavior may be associated with higher rates of bicycle-related injury. increased consideration of injury prevention will be a critical component of developing healthy communities that help safely support more active lifestyles. objectives: the purpose of this analysis was to a) describe bicycle-related injuries treated in u.s. emergency departments between and and b) investigate the association between gas prices and both the incidence and severity of adult bicycle injuries. we hypothesized that as gas prices increase, adults are more likely to shift away from driving for utilitarian travel toward more economical non-motorized modes of transportation, resulting in increased risk exposure for bicycle injuries. methods: bicycle injury data for adults ( - years) were obtained from the national electronic injury surveillance system (neiss) database for emergency department visits between - . the relationship between national seasonally adjusted monthly rates of bicycle injuries, obtained by a seasonal decomposition of time series, and average national gasoline prices, reported by the energy information administration, was examined using a linear regression analysis. results: monthly rates of bicycle injuries requiring emergency care among adults increase significantly as gas prices rise (p < . , see figure) . an additional , adult injuries ( % ci - , ) can be predicted to occur each month in the u.s. (> , injuries annually) for each $ rise in average gasoline price. injury severity also increases during periods of high gas prices, with a higher percentage of injuries requiring admission. conclusion: increases in adult bicycle use in response to higher gas prices are accompanied by higher rates of significant bicycle-related injuries. supporting the use of non-motorized transportation will be imperative to address public health concerns such as obesity and climate change; however, resources must also be dedicated to improve bicycle-related injury care and prevention. background: this is a secondary analysis of data collected for a randomized trial of oral steroids in emergency department (ed) musculoskeletal back pain patients. we hypothesized that higher pain scores in the ed would be associated with more days out of work. objectives: to determine the degree to which days out of work for ed back pain patients are correlated with ed pain scores. methods: design: prospective cohort. setting: suburban ed with , annual visits. participants: patients aged - years with moderately severe musculoskeletal back pain from a bending or twisting injury £ days before presentation. exclusion criteria included nonmusculoskeletal etiology, direct trauma, motor deficits, and employer-initiated visits. observations: we captured initial and discharge ed visual analog pain scores (vas) on a - scale. patients were contacted approximately days after discharge and queried about the days out of work. we plotted days out of work versus initial vas, discharge vas, and change in vas and calculated correlation coefficients. using the bonferroni correction because of multiple comparisons, alpha was set at . . results: we analyzed patients for whom complete data were available. the mean age was ± years and % were female. the average initial and discharge ed pain scales were . ± . and . ± . , respectively. on follow-up, % of patients were back to work and % did not lose any days of work. for the plots of the days out of work versus the initial and discharge vas and the change in the vas, the correlation coefficients (r ) were . (p = . ), . (p = . ), and . (p = . ), respectively. conclusion: for ed patients with musculoskeletal back pain, we found no statistically significant correlation between days out of work and ed pain scores. background: conducted electrical weapons (cews) are common law enforcement tools used to subdue and repel violent subjects and, therefore, prevent further injury or violence from occurring in certain situations. the taser x is a new generation of cew that has the capability of firing two cartridges in a ''semi-automatic'' mode, and has a different electrical waveform and different output characteristics than older generation technology. there have been no data presented on the human physiologic effects of this new generation cew. objectives: the objective of this study was to evaluate the human physiologic effects of this new cew. methods: this was a prospective, observational study of human subjects. an instructor shot subjects in the abdomen and upper thigh with one cartridge, and subjects received a -second exposure from the device. measured variables included: vital signs, continuous spirometry, pre-and post-exposure ecg, intra-exposure echocardiography, venous ph, lactate, potassium, ck, and troponin. results: ten subjects completed the study (median age . , median bmi . , % male). there were no important changes in vital signs or in potassium. the median increase in lactate during the exposure was . , range . to . . the median change in ph was ) . , range ) . to . . no subject had a clinically relevant ecg change, evidence of cardiac capture, or positive troponin up to hours after exposure. the median change in creatine kinase (ck) at hours was , range ) to . there was no evidence of impairment of breathing by spirometry. baseline median minute ventilation was . , which increased to . during the exposure (p = . ), and remained elevated at . post-exposure (p = . ). conclusion: we detected a small increase in lactate and decrease in ph during the exposure, and an increase in ck hours after the exposure. the physiologic effects of the x device appear similar to previous reports for ecd devices. use background: public bicycle sharing (bikeshare) programs are becoming increasingly common in the us and around the world. these programs make bicycles easily accessible for hourly rental to the public. there are currently active bikeshare programs in cities in the us, and more than programs are being developed in cities including new york and chicago. despite the importance of helmet use, bikeshare programs do not provide the opportunity to purchase or rent helmets. while the programs encourage helmet use, no helmets are provided at the rental kiosks. objectives: we sought to describe the prevalence of helmet use among adult users of bikeshare programs and users of personal bicycles in two cities with recently introduced bicycle sharing programs (boston, ma and washington, dc). methods: we performed a prospective observational study of bicyclists in boston, ma and washington, dc. trained observers collected data during various times of the day and days of the week. observers recorded the sex of the bicycle operator, type of bicycle, and helmet use. all bicycles that passed a single stationary location in any direction for a period of between and minutes were recorded. data are presented as frequencies of helmet use by sex, type of bicycle (bikeshare or personal), time of the week (weekday or weekend), and city. logistic regression was used to estimate the odds ratio for helmet use controlling for type of bicycle, sex, day of week, and city. results: there were observation periods in two cities at locations. , bicyclists were observed. there were ( . %) bicylists riding bikeshare bicycles. overall helmet use was . %, although helmet use varied significantly with sex, day of use, and type of bicycle (see figure) . bikeshare users were helmeted at a lower rate compared to users of personal bicycles ( . % vs . %). logistic regression, controlling for type of bicycle, sex, day of week, and city demonstrate that bikeshare users had higher odds of riding unhelmeted (or . , % ci . - . ). women had lower odds of riding unhelmeted (or . , . - . ), while weekend riders were more likely to ride unhelmeted (or . , . - . ). conclusion: use of bicycle helmets by users of public bikeshare programs is low. as these programs become more popular and prevalent, efforts to increase helmet use among users should increase. background: abusive head trauma (aht) represents one of the most severe forms of traumatic brain injury (tbi) among abused infants with % mortality. young adult males account for % of the perpetrators. most aht prevention programs are hospital-based and reach a predominantly female audience. there are no published reports of school-based aht prevention programs to date. objectives: . to determine whether a high schoolbased aht educational program will improve students' knowledge of aht and parenting skills. . to evaluate the feasibility and acceptability of a school-based aht prevention program. methods: this program was based on an inexpensive commercially available program developed by the national center on shaken baby syndrome. the program was modified to include a -minute interactive presentation that teaches teenagers about aht, parenting skills, and caring for inconsolable crying infants. the program was administered in three high schools in flint, michigan during spring . student's knowledge was evaluated with a -item written test administered pre-intervention, post-intervention, and two months after program completion. program feasibility and acceptability were evaluated through interviews and surveys with flint area school social workers, parent educators, teachers, and administrators. results: in all, high school students ( % male) participated. of these, ( . %) completed the pretest and post-test with ( %) completing the twomonth follow-up test. the mean pre-intervention, postintervention, and two-month follow-up scores were %, %, and % respectively. from pre-test to posttest, mean score improved %, p < . . this improvement was even more profound in young males, whose mean post-test score improved by %, p < . . of the participating social workers, parent educators, teachers, and administrators, % ranked the program as feasible and acceptable. conclusion: students participating in our program showed an improvement in knowledge of aht and parenting skills which was retained after two months. teachers, social workers, parent educators, and school administrators supported the program. this local pilot program has the potential to be implemented on a larger scale in michigan with the ultimate goal of reducing aht amongst infants. will background: fear of litigation has been shown to affect physician practice patterns, and subsequently influence patient care. the likelihood of medical malpractice litigation has previously been linked with patient and provider characteristics. one common concern is that a patient may exaggerate symptoms in order to obtain monetary payouts; however, this has never been studied. objectives: we hypothesize that patients are willing to exaggerate injuries for cash settlements and that there are predictive patient characteristics including age, sex, income, education level, and previous litigation. methods: this prospective cross-sectional study spanned june to december , in a philadelphian urban tertiary care center. any patient medically stable enough to fill out a survey during study investigator availability was included. two closed-ended paper surveys were administered over the research period. standard descriptive statistics were utilized to report incidence of: patients who desired to file a lawsuit, patients previously having filed lawsuits, and patients willing to exaggerate the truth in a lawsuit for a cash settlement. chi-square analysis was performed to determine the relationship between patient characteristics and willingness to exaggerate injuries for a cash settlement. results: of surveys, were excluded due to incomplete data, leaving for analysis. the mean age was with a standard deviation of , and % were male. the incidence of patients who had the desire to sue at the time of treatment was %. the incidence of patients who had filed a lawsuit in the past was %. of those patients, % had filed multiple lawsuits. fifteen percent [ % ci - %] of all patients were willing to exaggerate injuries for cash settlement. sex and income were found to be statistically significant predictors of willingness to exaggerate symptoms: % of females vs. % of males were willing to exaggerate (p = . ), and % of people with income less than $ , /yr vs. % of those with income over $ , / yr were willing to exaggerate (p = . ). conclusion: patients at a philadelphian urban tertiary center admit to willingness to exaggerate symptoms for a cash settlement. willingness to exaggerate symptoms is associated with female sex and lower income. background: current data suggest that as many as % of patients presenting to the ed with syncope leave the hospital without a defined etiology. prior studies have suggested a prevalence of psychiatric disease as high as % in patients with syncope of unknown etiology. objectives: to determine whether psychiatric disease and substance abuse are associated with an increased incidence of syncope of unknown etiology. methods: prospective, observational, cohort study of consecutive ed patients ‡ presenting with syncope was conducted between / and / . patients were queried in the ed and charts reviewed about a history of psychiatric disease, use of psychiatric medication, substance abuse, and duration. data were analyzed using sas with chi-square and fisher's exact tests. results: we enrolled patients who presented to the ed after syncope, of whom did not have an identifiable etiology for their syncopal event. . % of those without an identifiable etiology were male. ( %) patients had a history of or current psychiatric disease ( % male), and patients ( %) had a history of or current substance abuse ( % male). among males with psychiatric disease, % had an unknown etiology of their syncopal event, compared to % of males without psychiatric disease (p = . ). similarly, among all males with a history of substance abuse, % had an unknown etiology, as compared to % of males without a history of substance abuse (p = . ). a similar trend was not identified in elderly females with psychiatric disease (p = . ) or substance abuse (p = . ). however, syncope of unknown etiology was more common among both men and women under age with a history of substance abuse ( %) compared to those without a history of substance abuse ( %; p = . ). conclusion: our results suggest that psychiatric disease and substance abuse are associated with increased incidence of syncope of unknown etiology. patients evaluated in the ed or even hospitalized with syncope of unknown etiology may benefit from psychiatric screening and possibly detoxification referral. this is particularly true in men. (originally submitted as a ''late-breaker.'') scope background: after discharge from an emergency department (ed), pain management often challenges parents, who significantly under-treat their children's pain. rapid patient turnover and anxiety make education about home pain treatment difficult in the ed. video education standardizes information and circumvents insufficient time and literacy. objectives: to evaluate the effectiveness of a -minute instructional video for parents that targets common misconceptions about home pain management. methods: we conducted a randomized, double-blinded clinical trial of parents of children ages - years who presented with a painful condition, were evaluated, and discharged home in june and july . parents were randomized to a pain management video or an injury prevention control video. primary outcome was the proportion of parents who gave pain medication at home. these data were recorded in a home pain diary and analyzed using a chi-square test. parents' knowledge about pain treatment was tested before, immediately following, and days after intervention. mcnemar's test statistic determined odds that knowledge correlated with the intervention group. results: parents were enrolled: watched the pain education video, and the control video. . % completed follow up, providing information about home pain education use. significantly more parents provided at least one dose of pain medication to their children after watching the educational video: % vs. % (difference %, % ci . %, . %). the odds the parent had correct knowledge about pain treatment significantly improved immediately following the educational video for knowledge about pain scores (p = . ), the effect of pain on function (p < . ), and pain medication misconceptions (p < . ). these significant differences in knowledge remained days after the video intervention. the educational video about home pain treatment viewed by parents significantly increased the proportion of children receiving pain medication at home and significantly improved knowledge about at-home pain management. videos are an efficient tool to provide medical advice to parents that improves outcomes for children. methods: this was a prospective, observational study of consecutive admitted cpu patients in a large-volume academic urban ed. cardiology attendings round on all patients and stress test utilization is driven by their recommendation. eligibility criteria include: age> , aha low/intermediate risk, nondynamic ecgs, and normal initial troponin i. patients > and with a history of cad or co-existing active medical problem were excluded. based on prior studies and our estimated cpu census and demographic distribution, we estimated a sample size of , patients in order to detect a difference in stress utilization of % ( -tailed, a = . , b = . ). we calculated a timi risk prediction score and a diamond & forrester (d&f) cad likelihood score on each patient. t-tests were used for univariate comparisons of demographics, cardiac comorbidities, and risk scores. logistic regression was used to estimate odds ratios (ors) for receiving testing based on race, controlling for insurance and either timi or d&f score. results: over months, , patients were enrolled. mean age was ± , and % ( % ci - ) were female. sixty percent ( % ci - ) were caucasian, % ( % ci - ) african american, and % ( % ci - ) hispanic. mean timi and d&f scores were . ( % ci . - . ) and % ( % ci - ). the overall stress testing rate was % ( % ci - ). after controlling for insurance status and timi or d&f scores, african american patients had significantly decreased odds of stress testing (or timi . ( % ci . - . ), or d&f . ( % ci . - . )). hispanics had significantly decreased odds of stress testing in the model controlling for d&f (or d&f . ( % ci . - . )). conclusion: this study confirms that disparities in the workup of african american patients in the cpu are similar to those found in the general ed and the outpatient setting. further investigation into the specific provider or patient level factors contributing to this bias is necessary. the outcomes for hf and copd were sae . %, . %; death . %, . %. we found univariate associations with sae for these walk test components: too ill to walk (both hf, copd p < . ); highest heart rate ‡ (hf p = . , copd p = . ); lowest sao < % (hf p = . , copd p = . ); borg score ‡ (hf p = . , copd p = . ); walk test duration £ minute (hf p = . . copd p = . ). after adjustment for multiple clinical covariates with logistic regression analyses, we found ''walk test heart rate ‡ '' had an odds ratio of . for hf patients and ''too ill to start the walk test'' had an odds ratio of . for copd patients. conclusion: we found the -minute walk test to be easy to administer in the ed and that maximum heart rate and inability to start the test were highly associated with adverse events in patients with exacerbations of hf and copd, respectively. we suggest that the -minute walk test be routinely incorporated into the assessment of hf and copd patients in order to estimate risk of poor outcomes. the objectives: the objective of this study was to investigate differences in consent rates between patients of different demographic groups who were invited to participate in minimal-risk clinical trials conducted in an academic emergency department. methods: this descriptive study analyzed prospectively collected data of all adult patients who were identified as qualified participants in ongoing minimal risk clinical trials. these trials were selected for this review because they presented minimal factors known to be associated background: increasing rates of patient exposure to computerized tomography (ct) raise questions about appropriateness of utilization, as well as patient awareness of radiation exposure. despite rapid increases in ct utilization and published risks, there is no national standard to employ informed consent prior to radiation exposure from diagnostic ct. use of written informed consent for ct (icct) in our ed has increased patient understanding of the risks, benefits, and alternatives to ct imaging. our team has developed an adjunct video educational module (vem) to further educate ed patients about the ct procedure. objectives: to assess patient knowledge and preferences regarding diagnostic radiation before and after viewing vem. methods: the vem was based on icct currently utilized at our tertiary care ed (census , patients/ year). icct is written at an th grade reading level. this fall, vem/icct materials were presented to a convenience sample of patients in the ed waiting room am- pm, monday-sunday. patients who were < years of age, critically ill, or with language barrier were excluded. to quantify the educational value of the vem, a six-question pretest was administered to assess baseline understanding of ct imaging. the patients then watched the vem via ipad (macintosh) and reviewed the consent form. an eight-question post-test was then completed by each subject. no phi were collected. pre-and post-test results were analyzed using mcnemar's test for individual questions and a paired t-test for the summed score (sas version . ). results: patients consented and completed the survey. the average pre-test score for subjects was poor, % correct. review of vem/icct materials increased patient understanding of medical radiation as evidenced by improved post-test score to %. mean improvement between tests was % (p < . ). % of subjects responded that they found the materials helpful, and that they would like to receive icct. conclusion: the addition of a video educational module improved patient knowledge regarding ct imaging and medical radiation as quantified by pre-and posttesting. patients in our study sample reported that they prefer to receive icct. by educating patients about the risks associated with ct imaging, we increase informed, shared decision making -an essential component of patient-centered care. does objectives: we sought to determine the relationship between patients' pain scores and their rate of consent to ed research. we hypothesized that patients with higher pain scores would be less likely to consent to ed research. methods: retrospective observational cohort study of potential research subjects in an urban academic hospital ed with an average annual census of approximately , visits. subjects were adults older than years with chief complaint of chest pain within the last hours, making them eligible for one of two cardiac biomarker research studies. the studies required only blood draws and did not offer compensation. two reviewers extracted data from research screening logs. patients were grouped according to pain score at triage, pain score at the time of approach, and improvement in pain score (triage score -approach score). the main outcome was consent to research. simple proportions for consent rates by pain score tertiles were calculated. two multivariate logistic regression analyses were performed with consent as outcome and age, race, sex, and triage or approach pain score as predictors. results: overall, potential subjects were approached for consent. patients were % caucasian, % female, and with an average age of years. six patients did not have pain scores recorded at all and did not have scores documented within hours of approach and were excluded from relevant analyses. overall, . % of patients consented. consent rates by tertiles at triage, at time of approach, and by pain score improvement are shown in tables and . after adjusting for age, race, and sex, neither triage (p = . ) nor approach (p = . ) pain scores predicted consent. conclusion: research enrollment is feasible even in ed patients reporting high levels of pain. patients with modest improvements in pain levels may be more likely to consent. future research should investigate which factors influence patients' decisions to participate in ed research. conclusion: in this multicenter study of children hospitalized with bronchiolitis neither specific viruses nor their viral load predicted the need for cpap or intubation, but young age, low birth weight, presence of apnea, severe retractions, and oxygen saturation < % did. we also identified that children requiring cpap or intubation were more likely to have mothers who smoked during pregnancy and a rapid respiratory worsening. mechanistic research in these high-risk children may yield important insights for the management of severe bronchiolitis. brigham & women's hospital, boston, ma background: siblings and children who share a home with a physically abused child are thought to be at high risk for abuse. however, rates of injury in these children are unknown. disagreements between medical and child protective services professionals are common and screening is highly variable. objectives: our objective was to measure the rates of occult abusive injuries detected in contacts of abused children using a common screening protocol. methods: this was a multi-center, observational cohort study of child abuse teams who shared a common screening protocol. data were collected between jan , and april , for all children < years undergoing evaluation for physical abuse and their contacts. for contacts of abused children, the protocol recommended physical examination for all children < years, skeletal survey and physical exam for children < months, and physical exam, skeletal survey, and neuroimaging for children < months old. results: among , children evaluated for abuse, met criteria as ''physically abused'' and these had contacts. for each screening modality, screening was completed as recommended by the protocol in approximately % of cases. of contacts who met criteria for skeletal survey, new injuries were identified in ( . %). none of these fractures had associated findings on physical examination. physical examination identified new injuries in . % of eligible contacts. neuroimaging failed to identify new injuries among eligible contacts less than months old. twins were at significantly increased risk of fracture relative to other nontwin contacts (or . ). conclusion: these results support routine skeletal survey for contacts of physically abused children < months old, regardless of physical examination findings. even for children where no injuries are identified, these results demonstrate that abuse is common among children who share a home with an abused child, and support including contacts in interventions (foster care, safety planning, social support) designed to protect physically abused children. methods: this was a retrospective study evaluating all children presenting to eight paediatric, universityaffiliated eds during one year in - . in each setting, information regarding triage and disposition were prospectively registered by clerks in the ed database. anonymized data were retrieved from the ed computerized database of each participating centre. in the absence of a gold standard for triage, hospitalisation, admission to intensive care unit (icu), length of stay in the ed, and proportion of patients who left without being seen by a physician (lwbs) were used as surrogate markers of severity. the primary outcome measure was the association between triage level (from to ) and hospitalisation. the association between triage level and dichotomous outcomes was evaluated by a chi-square test, while a student's t-test was used to evaluate the association between triage level and length of stay. it was estimated that the evaluation of all children visiting these eds for a one year period would provide a minimum of , patients in each triage level and at least events for outcomes having a proportion of % or more. results: a total of , children visited the eight eds during the study period. pooled data demonstrated hospitalisation proportions of %, %, %, %, and . % for patients triaged at level , , , , and respectively (p < . ). there was also a strong association between triage levels and admission to icu (p < . ), the proportion of children who lwbs (p < . ), and length of stay (p < . ). background: parents frequently leave the emergency department (ed) with incomplete understanding of the diagnosis and plan, but the relationship between comprehension and post-care outcomes has not been well described. objectives: to explore the relationship between comprehension and post-discharge medication safety. methods: we completed a planned secondary analysis of a prospective observational study of the ed discharge process for children aged - months. after discharge, parents completed a structured interview to assess comprehension of the child's condition, the medical team's advice, and the risk of medication error. limited understanding was defined as a score of - from (excellent) to (poor). risk of medication error was defined as a plan to use over-the-counter cough/cold medication and/or an incorrect dose of acetaminophen (measured by direct observation at discharge or reported dose at follow-up call). parents identified as at risk received further instructions from their provider. the primary outcome was persistent risk of medication error assessed at phone interview - days post-discharge. a major barrier to administering analgesics to children is the perceived discomfort of intravenous access. the delivery of intranasal analgesia may be a novel solution to this problem. objectives: we investigated whether the addition of the mucosal atomizer device (mad) as an alternative for fentanyl delivery would improve overall fentanyl administration rates in pediatric patients transported by a large urban ems system. we performed a historical control trial comparing the rate of pediatric fentanyl administration months before and months after the introduction of the mad. study subjects were pediatric trauma patients (age < years) transported by a large urban ems agency. the control group was composed of patients treated in the months before introduction of the mad. the experimental group included patients treated in the months after the addition of the mad. two physicians reviewed each chart and determined whether the patient met predetermined criteria for the administration of pain medication. a third reviewer resolved any discrepancies. fentanyl administration rates were measured and compared between the two groups. we used two-sample t-tests and chi-square tests to analyze our data. results: patients were included in the study: patients in the pre-mad group and in the post-mad group. there were no significant differences in the demographic and clinical characteristics of the two groups. ( . %) patients in the control arm received fentanyl. ( . %) of patients in the experimental arm received fentanyl with % of the patients receiving fentanyl via the intranasal route. the addition of the mad was not associated with a statistically significant increase in analgesic administration. age and mechanism of injury were statistically more predictive of analgesia administration. conclusion: while the addition of the mucosal atomizer device as an alternative delivery method for fentanyl shows a trend towards increased analgesic administration in a prehospital pediatric population, age and mechanism of injury are more predictive in who receives analgesia. further research is necessary to investigate the effect of the mad on pediatric analgesic delivery. methods: this was a prospective study evaluating php-se before (pre) and after (post) a ppp introduction and months later ( -mo). php groups received either ppp review and education or ppp review alone. the ppp included a pain assessment tool. the se tool, developed and piloted by pediatric ems experts, uses a ranked ordinal scale ranging from 'certain i cannot do it' ( ) to 'completely certain i can do it' ( ) for items: pain assessment ( items), medication administration ( ) and dosing ( ) , and reassessment ( ). all items and an averaged composite were evaluated for three age groups (adult, child, toddler). paired sample t-tests compared post-and -mo scores to pre-ppp scores. results: of phps who completed initial surveys, phps completed -mo surveys. ( %) received education and ppp review and ( %) review only. ppp education did not affect php-se (adult p = . , child p = . , toddler p = . ). the largest se increase was in pain assessment. this increase persisted for child and toddler groups at months. the immediate increase in composite se scores for all age groups persisted for the toddler group at months. conclusion: increases in composite and pain assessment php-se occur for all age groups immediately after ppp introduction. the increase in pain assessment se persisted at months for pediatric age groups. composite se increase persisted for the toddler age group alone. background: pediatric medications administered in the prehospital setting are given infrequently and dosage may be prone to error. calculation of dose based on known weight or with use of length-based tapes occurs even less frequently and may present a challenge in terms of proper dosing. objectives: to characterize dosing errors based on weight-based calculations in pediatric patients in two similar emergency medical service (ems) systems. methods: we studied the five most commonly administered medications given to pediatric patients weighing kg or less. drugs studied were morphine, midazolam, epinephrine : , , epinephrine : , and diphenhydramine. cases from the electronic record were studied for a total of months, from january to july . each drug was administered via intravenous, intramuscular, or intranasal routes. drugs that were permitted to be titrated were excluded. an error was defined as greater than % above or below the recommended mg/kg dosage. results: out of , total patients, , were pediatric patients. had documented weights of < kg and patients were given these medications. we excluded patients for weight above the %ile or below the %ile, or if the weight documentation was missing. of the patients and doses, errors were noted in ( %; % ci %, %). midazolam was the most common drug in errors ( of doses or %; % ci %, %), followed by diphenhydramine ( / or %; % ci %, %), epinephrine ( / or %; % ci %, %), and morphine sulfate ( / or %; % ci, %, %). underdosing was noted in of ( %; % ci %, %) of errors, while excessive dosing was noted in of ( %; % ci %, %). conclusion: weight-based dosing errors in pediatric patients are common. while the clinical consequences of drug dosing errors in these patients are unknown, a considerable amount of inaccuracy occurs. strategies beyond provision of reference materials are needed to prevent pediatric medication errors and reduce the potential for adverse outcomes. drivers background: homelessness affects up to . million people a year. the homeless present more frequently to eds, their ed visits are four times more likely to occur within days of a prior ed evaluation, and they are admitted up to five times more frequently than others. we evaluated the effect of a street outreach rapid response team (sorrt) on the health care utilization of a homeless population. a nonmedical outreach staff responds to the ed and intensely case manages the patient: arranges primary care follow-up, social services, temporary housing opportunities, and drug/ alcohol rehabilitation services. objectives: we hypothesized that this program would decrease the ed visits and hospital admissions of this cohort of patients. methods: before and after study at an urban teaching hospital from june, -december, in indianapolis, indiana. upon identification of homeless status, sorrt was immediately notified. eligibility for sorrt enrollment is determined by housing and urban development homeless criteria and the outreach staff attempted to enter all such identified patients into the program. the patients' health care utilization was evaluated in the months prior to program entry as compared to the months after enrollment by prospectively collecting data and a retrospective medical record query for any unreported visits. since the data were highly skewed, we used the nonparametric signed rank test to test for paired differences between periods. results: patients met criteria but two refused participation. the -patient cohort had total ed visits ( pre and post) with a mean of . (sd . ) and median of . (range - ) ed visits in months pre-sorrt as compared to a mean of . (sd . ) and median of . ( - ) in months post-sorrt (p = . ). there were total inpatient admissions pre-intervention and post-intervention, with a mean of . (sd . ) and median of . ( . ) per patient in the pre-intervention period as compared to . (sd . ) and . ( - ) in the post-intervention period (p = . ). in the pre-sorrt period . % had at least one inpatient admission as compared to . % post-sorrt (p = . ). there were no differences in icu days or overall length of stay between the two periods. conclusion: an aggressive case management program beginning immediately with homeless status recognition in the ed has not demonstrated success in decreasing utilization in our population. methods: this was a secondary analysis of a prospective randomized trial that included consenting patients discharged with outpatient antibiotics from an urban county ed with an annual census of , . patients unable to receive text messages or voice-mails were excluded. health literacy was assessed using a validated health literacy assessment, the newest vital sign (nvs). patients were randomized to a discharge instruction modality: ) standard care, typed and verbal medication and case-specific instructions; ) standard care plus text-messaged instructions sent to the patient's cell phone; or ) standard care plus voice-mailed instructions sent to the patient's cell. patients were called at days to determine preference for instruction delivery modality. preference for discharge instruction modality was analyzed using z-tests for proportions. results: patients were included ( % female, median age , range months to years); were excluded. % had an nvs score of - , % - , and % - . among the . % of participants reached at days, % preferred a modality other than written. there was a difference in the proportion of patients who preferred discharge instructions in written plus another modality (see table) . with the exception of written plus another modality, patient preference was similar across all nvs score groups. conclusion: in this sample of urban ed patients, more than one in four patients prefer non-traditional (text message, voice-mail) modalities of discharge instruction delivery to standard care (written) modality alone. additional research is needed to evaluate the effect of instructional modality on accessibility and patient compliance. figure) . conclusion: cumulative saps ii scoring fails to predict mortality in ohca. the risk scores assigned to age, gcs, and hco independently predict mortality and combined are good mortality predictors. these findings suggest that an alternative severity of illness score should be used in post-cardiac arrest patients. future studies should determine optimal risk scores of saps ii variables in a larger cohort of ohca. objectives: to determine the extent to which cpp recovers to pre-pause levels with seconds of cpr after a -second interruption in chest compressions for ecg rhythm analysis. methods: this was a secondary analysis of prospectively collected data from an iacuc-approved protocol. fortytwo yorkshire swine (weighing - kg) were instrumented under anesthesia. vf was electrically induced. after minutes of untreated vf, cpr was initiated and a standard dose of epinephrine (sde) ( . mg/kg) was given. after . minutes of cpr to circulate the vasopressor, compressions were interrupted for seconds to analyze the ecg rhythm. this was immediately followed by seconds of cpr to restore cpp before the first rs was delivered. if the rs failed, cpr resumed and additional vasopressors (sde, and vasopressin . mg/kg) were given and the sequence repeated. the cpp was defined as aortic diastolic pressure minus right atrial diastolic pressure. the cpp values were extracted at three time points: immediately after the . minutes of cpr, following the -second pause, and immediately before defibrillation for the first two rs attempts in each animal. eighty-three sets of measurements were logged from animals. descriptive statistics were used to analyze the data. in most cities, the proportion of patients who achieve prehospital return of spontaneous circulation (rosc) is less than %. the association between time of day and ohca outcomes in the prehospital setting is unknown. objectives: we sought to determine whether rates of prehospital rosc varied by time of day. we hypothesized that night ohcas would exhibit lower rates of rosc. methods: we performed a retrospective review of cardiac arrest data from a large, urban ems system. included were all ohcas occurring in individuals > years of age from / / to / / . excluded were traumatic arrests and cases where resuscitation measures were not performed. day was defined as : am- : pm, while night was : pm- : am. we examined the association between time of day and paramedic-perceived prehospital rosc in unadjusted and adjusted analyses. variables included age, sex, race, presenting rhythm, aed application by a bystander or first responder, defibrillation, and bystander cpr performance. analyses were performed using chisquare tests and logistic regression. objectives: determine whether a smei helps to improve physician compliance with ihi bundle and reduce patient mortality in ed patients with s&s. methods: we conducted a pre-smei retrospective review of four months of ed patients with s&s to determine baseline pre-smei physician compliance and patient mortality. we designed and completed a smei attended by of ed attending physicians and of ed resuscitation residents. finally, we conducted a twenty-month post-smei prospective study of ongoing physician compliance and patient mortality in ed patients with s&s. results: in the four month pre-smei retrospective review, we identified patients with s&s, with a % physician overall compliance and mortality rate of %. the average ed physician smei multiple-choice pre-test score was %, and showed a significant improvement in the post-test score of % (p = . ). additionally, % of ed physicians were able to describe three new clinical pearls learned and % agreed that the smei would improve compliance. in the twenty months of the post-smei prospective study, we identified patients with s&s, with a % physician overall compliance, and mortality rate of %. relative physician compliance improved % (p = . ) and relative patient mortality was reduced by % (p < . ) when comparing pre-and post-smei data. conclusion: our data suggest that a smei improves overall physician compliance with the six hour goals of the ihi bundle and reduces patient mortality in ed patients with s&s. conclusion: using a population-level, longitudinal, and multi-state analysis, the rate of return visits within days is higher than previously reported, with nearly in returning back to the ed. we also provide the first estimation of health care costs for ed revisits. background: the ability of patients to accurately determine their level of urgency is important in planning strategies that divert away from eds. in fact, an understanding of patient self-triage abilities is needed to inform health policies targeting how and where patients access acute care services within the health care system. objectives: to determine the accuracy of a patient's self-assessment of urgency compared against triage nurses. methods: setting: ed patients are assigned a score by trained nurses according to the canadian emergency department triage and acuity scale (ctas). we present a cross-sectional survey of a random patient sample from urban/regional eds conducted during the winters of and . this previously validated questionnaire, based on the british healthcare commission survey, was distributed according to a modified dillman protocol. exclusion criteria consisted of: age - years, left prior to being seen/treated, died during ed visit, no contact information, presented with a privacy-sensitive case. alberta health services provided linked non-survey administrative data. results: , surveys distributed with a response rate of %. patients rated health problems as life-threatening ( %), possibly life-threatening ( %), urgent ( %), somewhat urgent ( %), or not urgent ( %). triage nurses assigned the same patients ctas scores of i (< %), ii ( %), iii ( %), iv ( %) or v ( %). patients self-rated their condition as or points less urgent than the assigned ctas score (< % of the time), points less urgent ( %), point less urgent ( %), exactly as urgent ( %), point more urgent ( %), points more urgent ( %), or or points more urgent ( %, respectively). among ctas i or ii patients, % described their problem as life-threatening/possibly life-threatening, % as urgent (risk of permanent damage), % as urgent (needed to be seen that day), and % as not urgent (wanted to be but did not need to be seen that day). conclusion: the majority of ed patients are generally able to accurately assess the acuity of their problem. encouraging patients with low-urgency conditions to self-triage to lower-acuity sources of care may relieve stress on eds. however, physicians and patients must be aware that a small minority of patients are unable to self-triage safely. when the tourniquet was released, blood spurted from the injured artery as hydrostatic pressure decayed. pressure and flow were recorded in three animals (see table) . the concept was proof-tested in a single fresh frozen human cadaver with perfusion through the femoral artery and hemorrhage from the popliteal artery. the results were qualitatively and quantitatively similar to the swine carcass model. conclusion: a perfused swine carcass can simulate exsanguinating hemorrhage for training purposes and serves as a prototype for a fresh-frozen human cadaver model. additional research and development are required before the model can be widely applied. background: in the pediatric emergency department (ped), clinicians must work together to provide safe and effective care. crisis resource management (crm) principles have been used to improve team performance in high-risk clinical settings, while simulation allows practice and feedback of these behaviors. objectives: to develop a multidisciplinary educational program in a ped using simulation-enhanced teamwork training to standardize communication and behaviors and identify latent safety threats. methods: over months a workgroup of physicians and nurses with experience in team training and simulation developed an educational program for clinical staff of a tertiary ped. goals included: create a didactic curriculum to teach the principles of crm, incorporate principles of crm into simulation-enhanced team training in-situ and center-based exercises, and utilize assessment instruments to evaluate for teamwork, completion of critical actions, and presence of latent safety threats during in-situ sim resuscitations. results: during phase i, clinicians, divided into teams, participated in -minute pre-training assessments of pals-based in-situ simulations. in phase ii, staff participated in a -hour curriculum reviewing key crm concepts, including team training exercises utilizing simulation and expert debriefing. in phase iii, staff participated in post-training minute teamwork and clinical skills assessments in the ped. in all phases, critical action checklists (cac) were tabulated by simulation educators. in-situ simulations were recorded for later review using the assessment tools. after each simulation, educators facilitated discussion of perceptions of teamwork and identification of systems issues and latent hazards. overall, in-situ simulations were conducted capturing % of the physicians and % of the nurses. cac data were collected by an observer and compared to video recordings. over significant systems issues, latent hazards, and knowledge deficits were identified. all components of the program were rated highly by % of the staff. conclusion: a workgroup of pem, simulation, and team training experts developed a multidisciplinary team training program that used in-situ and centerbased simulation and a refined crm curriculum. unique features of this program include its multidisciplinary focus, the development of a variety of assessment tools, and use of in-situ simulation for evaluation of systems issues and latent hazards. this program was tested in a ped and findings will be used to refine care and develop a sustainment program while addressing issues identified. objectives: our hypothesis is that participants trained on high-fidelity mannequins will perform better than participants trained on low-fidelity mannequins on both the acls written exam and in performance of critical actions during megacode testing. the study was performed in the context of an acls initial provider course for new pgy residents at the penn medicine clinical simulation center and involved three training arms: ) low fidelity (low-fi): torso-rhythm generator; ) mid-fidelity (mid-fi): laerdal simmanÒ turned off; and ) high-fidelity (high-fi): laerdal simmanÒ turned on. training in each arm of the study followed standard aha protocol. educational outcomes were evaluated by written scores on the acls written examination and expert rater reviews of acls megacode videos performed by trainees during the course. a sample of subjects were randomized to one of the three training arms: low-fi (n = ), mid-fi (n = ), or high-fi (n = ). results: statistical significance across the groups was determined using analysis-of-variance (anova). the three groups had similar written pre-test scores [low-fi . ( . ), mid-fi . ( . ), and high-fi . ( . )] and written post-test scores [low-fi . ( . ), mid-fi . ( . ), and high-fi . ( . )]. similarly, test improvement was not significantly different. after completion of the course, high-fi subjects were more likely to report they felt comfortable in their simulator environment (p = . ). low-fi subjects were less likely to perceive a benefit in acls training from high-fi technology (p < . ). acls instructors were not rated significantly different by the subjects using the debriefing assessment for simulation in healthcareª (dash) student version except for element , where the high-fi group subjects reported lower scores ( . vs . and . in the other groups, p = . ). objectives: we sought to determine if stress associated with the performance of a complex procedural task can be affected by level of medical training. heart rate variability (hrv) is used as a measure of autonomic balance, and therefore an indicator of the level of stress. methods: twenty-one medical students and emergency medicine residents were enrolled. participants performed airway procedures on an airway management trainer. hrv data were collected using a continuous heart rate variability monitoring system. participant hrv was monitored at baseline, during the unassisted first attempt at endotracheal intubation, during supervised practice, and then during a simulated respiratory failure clinical scenario. standard deviation of beat to beat variability (sdnn), very low frequency (vlf), total power (tp), and low frequency (lf) was analyzed to determine the effect of practice and level of training on the level of stress. a cohen's d test was used to determine differences between study groups. results: sdnn data showed that second-year residents were less stressed during all stages than were fourthyear medical students (avg d = . ). vlf data showed third-year residents exhibited less sympathetic activity than did first-year residents (avg d = ) . ). the opportunity to practice resulted in less stress for all participants. tp data showed that residents had a greater degree of control over their autonomic nervous system (ans) than did medical students (avg d = . ). lf data showed that subjects were more engaged in the task at hand as the level of training increased indicating autonomic balance (avg d = . ). conclusion: our hrv data show that stress associated with the performance of a complex procedural task is reduced by increased training. hrv may provide a quantitative measure of physiologic stress during the learning process and thus serve as a marker of when a subject is adequately trained to perform a particular task. objectives: we seek to examine whether intubation during cpr can be done as efficiently as intubation without ongoing cpr. the hypothesis is that the predictable movement of an automated chest compression device will make intubation easier than the random movement from manual cpr. methods: the project was an experimental controlled trial and took place in the emergency department at a tertiary referral center in peoria, illinois. emergency medicine residents, attendings, paramedics, and other acls trained staff were eligible for participation. in randomized order, each participant attempted intubation on a mannequin with no cpr ongoing, during cpr with a human compressor, and during cpr with an automatic chest compression device (physio control lucas ). participants could use whichever style laryngoscope they felt most comfortable with and they were timed during the three attempts. success was determined after each attempt. results: there were participants in the trial. the success rate in the control group and the automated cpr group were both % ( / ) and the success rate in the manual cpr group was % ( / ). the differences in success rates were not statistically significant (p = . and p = . ). the automated cpr group had the fastest average time ( . sec; p = . ). the mean times for intubation with manual cpr and no cpr were not statistically different ( . sec, . sec; p = . ). conclusion: the success rate of tracheal intubation with ongoing chest compression was the same as the success rate of intubation without cpr. although intubation with automatic chest compression was faster than during other scenarios, all methods were close to the second timeframe recommended by acls. based on these findings, it may not always be necessary to hold cpr to place a definitive airway; however, further studies will be needed. background: after acute myocardial infarction, vascular remodeling in the peri-infarct area is essential to provide adequate perfusion, prevent additional myocyte loss, and aid in the repair process. we have previously shown that endogenous fibroblast growth factor (fgf ) is essential to the recovery of contractile function and limitation of infarct size after cardiac ischemia-reperfusion (ir) injury. the role of fgf in vascular remodeling in this setting is currently unknown. objectives: determine the role of endogenous fgf in vascular remodeling in a clinically relevant, closed-chest model of acute myocardial infarction. methods: mice with a targeted ablation of the fgf gene (fgf knockout) and wild type controls were subjected to a closed-chest model of regional cardiac ir injury. in this model, mice were subjected to minutes of occlusion of the left anterior descending artery followed by reperfusion for either or days. immunofluorescence was performed on multiple histological sections from these hearts to visualize capillaries (endothelium, anti-cd antibody), larger vessels (venules and arterioles, antismooth muscle actin antibody), and nuclei (dapi). digital images were captured, and multiple images from each heart were measured for vessel density and vessel size. results: sham-treated fgf knockout and wild type mice show no differences in capillary or vessel density suggesting no defect in vessel formation in the absence of endogenous fgf . when subjected to closed-chest regional cardiac ir injury, fgf knockout hearts had normal capillary and vessel number and size in the peri-infarct area after day of reperfusion compared to wild type controls. however, after days, fgf knockout hearts showed significantly decreased capillary and vessel number and increased vessel size compared to wild type controls (p < . ). conclusion: these data show the necessity of endogenous fgf in vascular remodeling in the peri-infarct zone in a clinically relevant animal model of acute myocardial infarction. these findings may suggest a potential role for modulation of fgf signaling as a therapeutic intervention to optimize vascular remodeling in the repair process after myocardial infarction. the diagnosis of aortic dissections by ed physicians is rare scott m. alter, barnet eskin, john r. allegra morristown medical center, morristown, nj background: aortic dissection is a rare event. the most common symptom of dissection is chest pain, but chest pain is a frequent emergency department (ed) chief complaint and other diseases that cause chest pain, such as acute coronary syndrome and pulmonary embolism, occur much more frequently. furthermore, % of dissections are without chest pain and % are painless. for all these reasons, diagnosing dissection can be difficult for the ed physician. we wished to quantify the magnitude of this problem in a large ed database. objectives: our goal was to determine the number of patients diagnosed by ed physicians with aortic dissections compared to total ed patients and to the total number of patients with a chest pain diagnosis. methods: design: retrospective cohort. setting: suburban, urban, and rural new york and new jersey eds with annual visits between , and , . participants: consecutive patients seen by ed physicians from january , through december , . observations: we identified aortic dissections using icd- codes and chest pain diagnoses by examining all icd- codes used over the period of the study and selecting those with a non-traumatic chest pain diagnosis. we then calculated the number of total ed patients and chest pain patients for every aortic dissection diagnosed by emergency physicians. we determined % confidence intervals (cis). results: from a database of . million ed visits, we identified ( . %) aortic dissections, or one for every , ( % ci , to , ) visits. the mean age of aortic dissection patients was ± years and % were female. of the total visits there were , ( %) with a chest pain diagnosis. thus there is one aortic dissection diagnosis for every ( % ci to , ) chest pain diagnoses. conclusion: the diagnosis of aortic dissections by ed physicians is rare. an ed physician seeing , to , patients a year would diagnose an aortic dissection approximately once every to years. an aortic dissection would be diagnosed once for approximately every , ed chest pain patients. patients were excluded if they suffered a cardiac arrest, were transferred from another hospital, or if the ccl was activated for an inpatient or from ems in the field. fp ccl activation was defined as ) a patient for whom activation was cancelled in the ed and ruled out for mi or ) a patient who went to catheterization but no culprit vessel was identified and mi was excluded. ecgs for fp patients were classified using standard criteria. demographic data, cardiac biomarkers, and all relevant time intervals were collected according to an on-going quality assurance protocol. results: a total of ccl activations were reviewed, with % male, average age , and % black. there were ( %) true stemis and ( %) fp activations. there were no significant differences between the fp patients who did and did not have catheterization. for those fp patients who had a catheterization ( %), ''door to page'' and ''door to lab'' times were significantly longer than the stemi patients (see table) , but there was substantial overlap. there was no difference in sex or age, but fp patients were more likely to be black (p = . ). a total of fp patients had ecgs available for review; findings included anterior elevation with convex ( %) or concave ( %) elevation, st elevation from prior anterior ( %) or inferior ( %) mi, pericarditis ( %), presumed new lbbb ( %), early repolarization ( %), and other ( %). conclusion: false ccl activation occurred in a minority of patients, most of whom had ecg findings warranting emergent catheterization. the rate of false ccl activation appears acceptable. background: atrial fibrillation (af) is the most common cardiac arrhythmia treated in the ed, leading to high rates of hospitalization and resource utilization. dedicated atrial fibrillation clinics offer the possibility of reducing the admission burden for af patients presenting to the ed. while the referral base for these af clinics is growing, it is unclear to what extent these clinics contribute to reducing the number of ed visits and hospitalizations related to af. objectives: to compare the number of ed visits and hospitalizations among discharged ed patients with a primary diagnosis of af who followed up with an af clinic and those who did not. methods: a retrospective cohort study and medical records review including three major tertiary centres in calgary, canada. a sample of patients was taken representing patients referred to the af clinic from the calgary zone eds and compared to matched control ed patients who were referred to other providers for follow-up. the controls were matched for age and sex. inclusion criteria included patients over years of age, discharged during the index visit, and seen by the af clinic between january , and october , . exclusion criteria included non-residents and patients hospitalized during the index visit. the number of cardiovascular-related ed visits and hospitalizations was measured. all data are categorical, and were compared using chi-square tests. results: patients in the control and af clinic cohorts were similar for all baseline characteristics except for a higher proportion of first episode patients in the intervention arm. in the six months following the index ed visit, study group patients ( . %) visited an ed on occasions, and ( %) were hospitalized on occasions. of the control group, patients ( . %) visited an ed on occasions, and ( %) were hospitalized on occasions. using a chi-square test we found no significant difference in ed visits (p = . ) or hospitalizations (p = . ) between the control and af clinic cohorts. conclusion: based on our results, referral from the ed to an af clinic is not associated with a significant reduction in subsequent cardiovascular related ed visits and hospitalizations. due to the possibility of residual confounding, randomized trials should be performed to evaluate the efficacy of af clinics. reported an income of less than $ , . there were no significant associations between sex, race, marital status, education level, income, insurance status, and subsequent -and- day readmission rates. hla score was not found to be significantly related to readmission rates. the mean hla score was . (sd = . ), equivalent to less than th grade literacy, meaning these patients may not be able to read prescription labels. for each unit increase in hfkt score, the odds of being readmitted within days decreased by . (p < . ) and for - days decreased by . (p < . ). for each unit increase in scbs score, the odds of being readmitted within days decreased by . (p = . ). conclusion: health care literacy in our patient population is not associated with readmission, likely related to the low literacy rate of our study population. better hf knowledge and self-care behaviors are associated with lower readmission rates. greater emphasis should be placed on patient education and self-care behaviors regarding hf as a mechanism to decrease readmission rates. comparison of door to balloon times in patients presenting directly or transferred to a regional heart center with stemi jennifer ehlers, adam v. wurstle, luis gruberg, adam j. singer stony brook university, stony brook, ny background: based on the evidence, a door-to-balloon-time (dtbt) of less than minutes is recommended by the aha/acc for patients with stemi. in many regions, patients with stemi are transferred to a regional heart center for percutaneous coronary intervention (pci). objectives: we compared dtbt for patients presenting directly to a regional heart center with those for patients transferred from other regional hospitals. we hypothesized that dtbt would be significantly longer for transferred patients. methods: study design-retrospective medical record review. setting-academic ed at a regional heart center with an annual census of , that includes a catchment area of hospitals up to miles away. patients-patients with acute stemi identified on ed -lead ecg. measures-demographic and clinical data including time from triage to ecg, from ecg to activation of regional catheterization lab, and from initial triage to pci (dtbt , and door to intravascular balloon deployment (d b). methods: the study was performed in an inner-city academic ed between / / and / / . every patient for whom ed activation of our stemi system occurred was included. all times data from a pre-existing quality assurance database were collected prospectively. patient language was determined retrospectively by chart review. results: there were patients between / / and / / . patients ( %) were deemed too sick or unable to provide history and were excluded, leaving patients for analysis. ( %) spoke english and ( %) did not. in the non-english group, chinese was the most common language, in ( %) background: syncope is a common, potentially highrisk ed presentation. hospitalization for syncope, although common, is rarely of benefit. no populationbased study has examined disparities in regional admission practices for syncope care in the ed. moreover, there are no population-based studies reporting prognostic factors for -and -day readmission of syncope. objectives: ) to identify factors associated with admission as well as prognostic factors for -and -day readmission to these hospitals; ) to evaluate variability in syncope admission practices across different sizes and types of hospitals. methods: design -multi-center retrospective cohort study using ed administrative data from albertan eds. participants/subjects -patients > years of age with syncope (icd : r ) as a primary or secondary diagnosis from to june . readmission was defined as return visits to the ed or admission < days or - days after the index visit (including against medical advice and left without being seen during the index visit). outcomes -factors associated with hospital admission at index presentation, and readmission following ed discharge, adjusted using multivariable logistic regression. results: overall, syncope visits occurred over years. increased age, increased length of stay (los), performance of cxr, transport by ground ambulance, and treatment at a low-volume hospital (non-teaching or non-large urban) were independently associated with index hospitalization. these same factors, as well as hospital admission itself, were associated with -day readmission. additionally, increased age, increased los, performance of a head ct, treatment at a low-volume hospital, hospital admission, and female sex were independently associated with - day readmission. arrival by ground ambulance was associated with a decreased likelihood of both -and - day readmission. conclusion: our data identify variations in practice as well as factors associated with hospitalization and readmission for syncope. the disparity in admission and readmission rates between centers may highlight a gap in quality of care or reflect inappropriate use of resources. further research to compare patient out-comes and quality of patient care among urban and non-urban centers is needed. background: change in dyspnea severity (ds) is a frequently used outcome measure in trials of acute heart failure (ahf). however, there is limited information concerning its validity. objectives: to assess the predictive validity of change in dyspnea severity. methods: this was a secondary analysis of a prospective observational study of a convenience sample of ahf patients presenting with dyspnea to the ed of an academic tertiary referral center with a mixed urban/ suburban catchment area. patients were enrolled weekdays, june through december . patients assessed their ds using a -cm visual analog scale at three times: the start of ed treatment (baseline) as well as at and hours after starting ed treatment. the difference between baseline and hour was the -hour ds change. the difference between baseline and hours was the -hour ds change. two clinical outcome measures were obtained: ) the number of days hospitalized or dead within days of the index visit ( -day outcome), and ) the number of days hospitalized or dead within days of the index visit ( -day outcome). results: data on patients were analyzed. the median -day outcome variable was days with an interquartile range (iqr) of to . the median -day outcome variable was days (iqr to . ). the median -hour ds change was . cm (iqr . to . ). the median -hour ds change was . cm (iqr . to . ). the -day and -day mortality rates were % and % respectively. the spearman rank correlations and % confidence intervals are presented in the table below. conclusion: while the point estimates for the correlations were below . , the % ci for two of the correlations extended above . . these pilot data support change in ds as a valid outcome measure for ahf when measured over hours. a larger prospective study is needed to obtain a more accurate point estimate of the correlations. background: the majority of volume-quality research has focused on surgical outcomes in the inpatient setting; very few studies have examined the effect of emergency department (ed) case volume on patient outcomes. objectives: to determine whether ed case volume of acute heart failure (ahf) is associated with short-term patient outcomes. methods: we analyzed the nationwide emergency department sample (neds) and nationwide inpatient sample (nis), the largest, all-payer, ed and inpatient databases in the us. ed visits for ahf were identified with a principal diagnosis of icd- -cm code .xx. eds were categorized into quartiles by ed case volume of ahf. the outcome measures were early inpatient mortality (within the first days of admission), overall inpatient mortality, and hospital length of stay (los). results: there were an estimated , visits for ahf from approximately , eds in ; % were hospitalized. of these, the overall inpatient mortality rate was . %, and the median hospital los was days. early inpatient mortality was lower in the highest-volume eds, compared with the lowest-volume eds ( . % vs. . %; p < . ). similar patterns were observed for overall inpatient mortality ( . % vs. . %; p < . ). in a multivariable analysis adjusting for patient and hospital characteristics, early inpatient mortality remained lower in patients admitted through the highest-volume eds (adjusted odds ratios [or], . ; % confidence interval [ci], . - . ), as compared with the lowest-volume eds. there was a trend towards lower overall inpatient mortality in the highest-volume eds; however, this was not statistically significant (adjusted or, . ; %ci, . - . ). by contrast, using the nis data including various sources of admissions, a higher case volume of inpatient ahf patients predicted lower overall inpatient mortality (adjusted or, . ; %ci, . - . ). the hospital los in patients admitted through the highest-volume eds was slightly longer (adjusted difference, . day; %ci, . - . ), compared with the lowest-volume eds. conclusion: ed patients who are hospitalized for ahf have an approximately % reduced early inpatient mortality if they were admitted from an ed that handles a large volume of ahf cases. the ''practice-makesperfect'' concept may hold in emergency management of ahf. emergency department disposition and charges for heart failure: regional variability alan b. storrow, cathy a. jenkins, sean p. collins, karen p. miller, candace mcnaughton, naftilan allen, benjamin s. heavrin vanderbilt university, nashville, tn background: high inpatient admission rates for ed patients with acute heart failure are felt partially responsible for the large economic burden of this most costly cardiovascular problem. objectives: we examined regional variability in ed disposition decisions and regional variability in total dollars spent on ed services for admitted patients with primary heart failure. methods: the nationwide emergency department sample (neds) was used to perform a retrospective, cohort analysis of patients with heart failure (icd- code of .x) listed as the primary ed diagnosis. demographics and disposition percentages (with se) were calculated for the overall sample and by region: northeast, south, midwest, and west. to account for the sample design and to obtain national and regional estimates, a weighted analysis was conducted. results: there were , weighted ed visits with heart failure listed as the primary diagnosis. overall, over eighty percent were admitted (see table) . fifty-two percent of these patients were female; mean age was . years (se . ). hospitalization rates were higher in the northeast ( . %) and south ( . %) than in the midwest ( . %) and west ( . %). total monies spent on ed services were highest in the south ($ , , ) followed by the northeast ($ , , ), west ($ , , ) and midwest ($ , , ) . conclusion: this large retrospective ed cohort suggests a very high national admission rate with significant regional variation in both disposition decisions as well as total monies spent on ed services for patients with a primary diagnosis of heart failure. examining these estimates and variations further may provide strategies to reduce the economic burden of heart failure. background: workplace violence in health care settings is a frequent occurrence. gunfire in hospitals is of particular concern. however, information regarding such workplace violence is limited. accordingly, we characterized u.s. hospital-based shootings from - . objectives: to determine extent of hospital-based shootings in the u.s. and involvement of emergency departments. methods: using lexisnexis, google, netscape, pub-med, and sciencedirect, we searched reports for acute care hospital shooting events from january through december , and those with at least one injured victim were analyzed. results: we identified hospital-related shootings ( inside the hospital, on hospital grounds), in states, with victims, of whom were perpetrators. in comparison to external shootings, shootings within the hospital have not increased over time (see figure) . perpetrators were from all age groups, including the elderly. most of the events involved a determined shooter: grudge ( %), suicide ( %), ''euthanizing'' an ill relative ( %), and prisoner escape ( %). ambient societal violence ( %) and mentally unstable patients ( %) were comparatively infrequent. the most common injured was the perpetrator ( %). hospital employees comprised only % of victims; physician ( %) and nurse ( %) victims were relatively infrequent. the emergency department was the most common site ( %), followed by patient rooms ( %) and the parking lot ( %). in % of shootings within hospitals, the weapon was a security officer's gun grabbed by the perpetrator. ''grudge'' motive was the only factor determinative of hospital staff victims (or = . , % ci . - . ). conclusion: although hospital-based shootings are relatively rare, emergency departments are the most likely site. the unpredictable nature of this type of event represents a significant challenge to hospital security and deterrence practices, as most perpetrators proved determined, and many hospital shootings occur outside the building. impact of emergency physician board certification on patient perceptions of ed care quality albert g. sledge iv , carl a. germann , tania d. strout , john southall maine medical center, portland, me; mercy hospital, portland, me background: the hospital value-based purchasing program mandated by the affordable care act is the latest example of how patients' perceptions of care will affect the future practice environment of all physicians. the type of training of medical providers in the emergency department (ed) is one possible factor affecting patient perceptions of care. a unique situation in a maine community ed led to the rapid transition from non-emergency medicine (em) residency trained physicians to all em residency trained and american board of emergency medicine (abem) certified providers. objectives: the purpose of this study was to evaluate the effect of the implementation of an all em-trained, abem-certified physician staff on patient perceptions of the quality of care they received in the ed. methods: we retrospectively evaluated press ganey data from surveys returned by patients receiving treatment in a single, rural ed. survey items addressed patient's perceptions of physician courtesy, time spent listening, concern for patient comfort, and informativeness. additional items evaluated overall perceptions of care and the likelihood that the respondent would recommend the ed to another. data were compared for the three years prior to and following implementation of the all trained, certified staff. we used the independent samples t-test to compare mean responses during the two time periods. bonferroni's correction was applied to adjust for multiple comparisons. results: during the study period, , patients provided surveys for analysis: , during the pre-certification phase and , during the post-certification phase. across all six survey items, mean responses increased following transition to the board-certified staff. these improvements were noted to be statistically significant in each case: courtesy p < . , time listening p < . , concern for comfort p < . , informativeness p < . , overall perception of care p < . , and likelihood to recommend p < . . conclusion: data from this community ed suggest that transition from a non-residency trained, abem certified staff to a fully trained and certified model has important implications for patient's perceptions of the care they receive. we observed significant improvement in rating scores provided by patients across all physicianoriented and general ed measures. background: transfer of care from the ed to the inpatient floor is a critical transition when miscommunication places patients at risk. the optimal form and content of handoff between providers has not been defined. in july , ed-to-floor signout for all admissions to the medicine and cardiology floors was changed at our urban, academic, tertiary care hospital. previously, signout was via an unstructured telephone conversation between ed resident and admitting housestaff. the new signout utilizes a web-based ed patient tracking system and includes: ) a templated description of ed course is completed by the ed resident; ) when a bed is assigned, an automated page is sent to the admitting housestaff; ) ed clinical information, including imaging, labs, medications, and nursing interventions (figure) is reviewed by admitting housestaff; ) if housestaff has specific questions about ed care, a telephone conversation between the ed resident and housestaff occurs; ) if there are no specific questions, it is indicated electronically and the patient is transferred to the floor. objectives: to describe the effects on patient safety (floor-to-icu transfer in hours) and ed throughput (ed length of stay (los) and time from bed assignment to ed departure) resulting from a change to an electronic, discussion-optional handoff system. conclusion: transition to a system in which signout of admitted patients is accomplished by accepting housestaff review of ed clinical information supplemented by verbal discussion when needed resulted in no significant change in rate of floor-to-icu transfer or ed los and reduced time from bed assignment to ed departure. background: emergency physicians may be biased against patients presenting with nonspecific complaints or those requiring more extensive work-ups. this may result in patients being seen less quickly than those with more straightforward presentations, despite equal triage scores or potential for more dangerous conditions. objectives: the goal of our study was to ascertain which patients, if any, were seen more quickly in the ed based on chief complaint. methods: a retrospective report was generated from the emr for all moderate acuity (esi ) adult patients who visited the ed from january through december at a large urban teaching hospital. the most common complaints were: abdominal pain, alcohol intoxication, back pain, chest pain, cough, dyspnea, dizziness, fall, fever, flank pain, headache, infection, pain (nonspecific), psychiatric evaluation, ''sent by md,'' vaginal bleeding, vomiting, and weakness. non-parametric independent sample tests assessed median time to be seen (ttbs) by a physician for each complaint. differences in the ttbs between genders and based on age were also calculated. chi-square testing compared percentages of patients in the ed per hour to assess for differences in the distribution of arrival times. results: we obtained data from , patients. patients with a chief complaint of weakness and dizziness waited the longest with a median time of minutes and patients with flank pain waited the shortest with minutes (p < . ) ( figure ). overall, males waited minutes and females waited minutes (p < . ). stratifying by gender and age, younger females between the ages of - waited significantly longer times when presenting with a chief complaint of abdominal pain (p < . ), chest pain (p < . ), or flank pain (p < . ) as compared to males in the same age group ( figure ). there was no difference in the distribution of arrival times for these complaints. conclusion: while the absolute time differences are not large, there is a significant bias toward seeing young male patients more quickly than women or older males despite the lower likelihood of dangerous conditions. triage systems should perhaps take age and gender better into account. patients might benefit from efforts to educate em physicians on the delays and potential quality issues associated with this bias in an attempt to move toward more egalitarian patient selection. background: detailed analysis of emergency department (ed) event data identified the time from completion of emergency physician evaluation (doc done) to the time patients leave the ed as a significant contributor to ed length of stay (los) and boarding at our institution. process flow mapping identified the time from doc done to the time inpatient beds were ordered (bo) as an interval amendable to specific process improvements. objectives: the purpose of this study was to evaluate the effect of ed holding orders for stable adult . ( . - . ) . ( . - . ) . ( . - . ) . ( . - . ) . ( . - . ) . ( . - . ) inpatient medicine (aim) patients on: a) the time to bo and b) ed los. methods: a prospective, observational design was used to evaluate the study questions. data regarding the time to bo and los outcomes were collected before and after implementation of the ed holding orders program. the intervention targeted stable aim patients being admitted to hospitalist, internal medicine, and family medicine services. ed holding orders were placed following the admission discussion with the accepting service and special attention was paid to proper bed type, completion of the emergent work-up and the expected immediate course of the patient's hospital stay. holding orders were of limited duration and expired hours after arrival to the inpatient unit. results: during the -month study period, patients were eligible for the ed holding orders intervention; ( . %) were cared for using the standard adult medicine order set and ( . %) received the intervention. the median time from doc done to bo was significantly shorter for patients in the ed holding orders group, min (iqr , ) vs. min (iqr , ) for the standard adult medicine group, p < . . similarly, the median ed los was significantly shorter for those in the ed holding orders group, min (iqr , ) vs. min (iqr , ) for the standard adult medicine group, p < . . no lapses in patient care were reported in the intervention group. conclusion: in this cohort of ed patients being admitted to an aim service, placing ed holding orders rather than waiting for a traditional inpatient team evaluation and set of admission orders significantly reduced the time from the completion of the ed workup to placement of a bo. as a result, ed los was also significantly shortened. while overall utilization of the intervention was low, it improved with each month. emergency department interruptions in the age of electronic health records matthew albrecht, john shabosky, jonathan de la cruz southern illinois university school of medicine, springfield, il background: interruptions of clinical care in the emergency department (ed) have been correlated with increased medical errors and decreased patient satisfaction. studies have also shown that most interruptions happen during physician documentation. with the advent of the electronic health record and computerized documentation, ed physicians now spend much of their clinical time in front of computers and are more susceptible to interruptions. voice recognition dictation adjuncts to computerized charting boast increased provider efficiency; however, little is known about how data input of computerized documentation affects physician interruptions. objectives: we present here observational interruptions data comparing two separate ed sites, one that uses computerized charting by conventional techniques and one assisted by voice recognition dictation technology. methods: a prospective observational quality initiative was conducted at two teaching hospital eds located less than mile from each other. one site primarily uses conventional computerized charting while the other uses voice recognition dictation computerized charting. four trained observers followed ed physicians for minutes during shifts. the tasks each ed physician performed were noted and logged in second intervals. tasks listed were selected from a predetermined standardized list presented at observer training. tasks were also noted as either completed or placed in queue after a change in task occurred. a total of minutes were logged. interruptions were noted when a change in task occurred with the previous task being placed in queue. data were then compared between sites. results: ed physicians averaged . interruptions/ hour with conventional computerized charting compared to . interruptions/hour with assisted voice recognition dictation (p = . ). conclusion: computerized charting assisted with voice recognition dictation significantly decreased total per hour interruptions when compared to conventional techniques. charting with voice recognition dictation has the potential to decrease interruptions in the ed allowing for more efficient workflow and improved patient care. background: using robot assistants in health care is an emerging strategy to improve efficiency and quality of care while optimizing the use of human work hours. robot prototypes capable of performing vital signs and assisting with ed triage are under development. however, ed users' attitudes toward robot assistants are not well studied. understanding of these attitudes is essential to design user-friendly robots and to prepare eds for the implementation of robot assistants. objectives: to evaluate the attitudes of ed patients and their accompanying family and friends toward the potential use of robot assistants in the ed. methods: we surveyed a convenience sample of adult ed patients and their accompanying adult family members and friends at a single, university-affiliated ed, / / - / / . the survey consisted of eight items from the negative attitudes towards robots scale (normura et al.) modified to address robot use in the ed. response options included a -point likert scale. a summary score was calculated by summing the responses for all items, with a potential range of (completely negative attitude) to (completely positive attitude). research assistants gave the written surveys to subjects during their ed visit. internal consistency was assessed using cronbach's alpha. bivariate analyses were performed to evaluate the association between the summary score and the following variables: participant type (patient or visitor), sex, race, time of day, and day of week. results: of potential subjects approached, ( %) completed the survey. participants were % patients, % family members or friends, % women, % white, and had a median age of . years (iqr - ). cronbach's alpha was . . the mean summary score was . (sd = . ), indicating subjects were between ''occasionally'' and ''sometimes'' comfortable with the idea of ed robot assistants (see table) . men were more positive toward robot use than women (summary score: . vs . ; p = . ). no differences in the summary score were detected based on participant type, race, time of day, or day of week. conclusion: ed users reported significant apprehension about the potential use of robot assistants in the ed. future research is needed to explore how robot designs and strategies to implement ed robots can help alleviate this apprehension. background: emergency department cardioversion (edc) of recent-onset atrial fibrillation or flutter (af) patients is an increasingly common management approach to this arrhythmia. patients who qualify for edc generally have few co-morbidities and are often discharged directly from the ed. this results in a shift towards a sicker population of patients admitted to the hospital with this diagnosis. objectives: to determine whether hospital charges and length of stay (los) profiles are affected by emergency department discharge of af patients. methods: patients receiving treatment at an urban teaching community hospital with a primary diagnosis of atrial fibrillation or flutter were identified through the hospital's billing data base. information collected on each patient included date of service, patient status, length of stay, and total charges. patient status was categorized as inpatient (admitted to the hospital), observation (transferred from the ed to an inpatient bed but placed in an observation status), or ed (discharged directly from the ed). the hospital billing system automatically defaults to a length of stay of for observation patients. ed patients were assigned a length of stay of . total hospital charges and mean los were determined for two different models: a standard model (sm) in which patients discharged from the ed were excluded from hospital statistics, and an inclusive model (im) in which discharged ed patients were included in the hospital statistics. statistical analysis was through anova. results: a total of patients were evaluated for af over an -month period. of these, ( %) were admitted, ( %) were placed in observation status, and ( %) were discharged from the ed. hospital charges and los in days are summarized in the table. all differences were statistically significant at (p < . ). conclusion: emergency department management can lead to a population of af patients discharged directly from the ed. exclusion of these patients from hospital statistics skews performance profiles effectively punishing institutions for progressive care. background: recent health care reform has placed an emphasis on the electronic health record (ehr). with the advent of the ehr it is common to see ed providers spending more time in front of computers documenting and away from patients. finding strategies to decrease provider interaction with computers and increase time with patients may lead to improved patient outcomes and satisfaction. computerized charting adjuncts, such as voice recognition software, have been marketed as ways to improve provider efficiency and patient contact. objectives: we present here observational data comparing two separate ed sites, one where computerized charting is done by conventional techniques and one that is assisted with voice recognition dictation, and their effects on physican charting and patient contact. methods: a prospective observational quality initiative was conducted at two teaching hospitals located less than mile from each other. one site primarily uses conventional computerized charting while the other uses voice recognition dictation. four trained quality assistants observed ed physicians for minutes during shifts. the tasks each physician performed were noted and logged in second intervals. tasks listed were identified from a predetermined standardized list presented at observer training. a total of minutes were logged. time allocated to charting and that allocated to direct patient care were then compared between sites. results: ed physicians spent . % of their time charting using conventional techniques vs . % using voice recognition dictation (p = . ). time allocated to direct patient care was found to be . % with conventional charting vs . % using dictation (p = ). in total, ed physicians using conventional charting techniques spent / minutes charting. ed physicians using voice recognition dictation spent / minutes dictating and an additional . / minutes reviewing or correcting their dictations. the use of voice recognition assisted dictation rather than conventional techniques did not significantly change the amount of time physicians spent charting or with direct patient care. although voice recognition dictation decreased initial input time of documenting data, a considerable amount of time was required to review and correct these dictations. objectives: for our primary objective, we studied whether emergency department triage temperatures detected fever adequately when compared to a rectal temperature. as secondary objectives, we examined the temperature differences when a rectal temperature was taken within an hour of non-invasive temperature, temperature site (oral, axillary, temporal), and also examined the patients that were initially afebrile but were found to be febrile by rectal temperature. methods: we performed an electronic chart review at our inner city, academic emergency department with an annual census of , patients. we identified all patients over the age of who received a non-invasive triage temperature and a subsequent rectal temperature while in the ed from january through february . specific data elements included many aspects of the patient's medical record (e.g. subject demographics, temperature, and source). we analyzed our data with standard descriptive statistics, t-tests for continuous variables, and pearson chi-square tests for proportions. results: a total of , patients met our inclusion criteria. the mean difference in temperatures between the initial temperature and the rectal temperature was . °f, with . % having higher rectal temperatures ‡ °f, and . % having higher rectal temperatures ‡ °f. the mean temperature difference among the , patients who an initial noninvasive temperature and a rectal temperature within one hour was . °f. the mean difference among patients that received oral, axillary, and temporal temperatures was . °f, . °f, and . °f respectively. approximately one in five patients ( . %) were initially afebrile and found to be febrile by rectal temperature, with an average temperature difference of . °f. these patients had a higher rate of admission, and were more likely to be admitted to the intensive care unit. conclusion: there are significant differences between rectal temperatures and non-invasive triage temperatures in this emergency department cohort. in almost one in five patients, fever was missed by triage temperature. background: pediatric emergency department (ped) overcrowding has become a national crisis, and has resulted in delays in treatment, and patients leaving without being seen. increased wait times have also been associated with decreased patient satisfaction. optimizing ped throughput is one means by which to handle the increased demands for services. various strategies have been proposed to increase efficiency and reduce length of stay (los). objectives: to measure the effect of direct bedding, bedside registration, and patient pooling on ped wait times, length of stay, and patient satisfaction. methods: data were extracted from a computerized ed tracking system in an urban tertiary care ped. comparisons were made between metrics for ( , patients) and the months following process change ( , patients). during , patients were triaged by one or two nurses, registered, and then sent either to a -bed ped or a physically separate -bed fast-track unit, where they were seen by a physician. following process change, patients were brought directly to a bed in the -bed ped, triaged and registered, then seen by a physician. the fast-track unit was only utilized to accommodate patient surges. results: anticipating improved efficiencies, attending physician coverage was decreased by %. after instituting process changes, improvements were noted immediately. although daily patient volume increased by %, median time to be seen by a physician decreased by %. additionally, median los for discharged patients decreased by %, and median time until the decisionto-admit decreased by %. press-ganey satisfaction scores during this time increased by greater than mean score points, which was reported to be a statistically significant increase. conclusion: direct bedding, bedside registration, and patient pooling were simple to implement process changes. these changes resulted in more efficient ped throughput, as evidenced by decreased times to be seen by a physician, los for discharged patients, and time until decision-to-admit. additionally, patient satisfaction scores improved, despite decreased attending physician coverage and a % decrease in room utilization. ) . during period , the ou was managed by the internal medicine department and staffed by primary care physicians and physician assistants. during periods and , the ou was managed and staffed by em physicians. data collected included ou patient volume, length of stay (los) for discharged and admitted patients, admission rates, and -day readmission rates for discharged patients. cost data collected included direct, indirect, and total cost per patient encounter. data were compared using chi-square and anova analysis followed by multiple pairwise comparisons using the bonferroni method of p-value adjustment. results: see table. the ou patient volume and percent of ed volume was greater in period compared to periods and . length of stay, admission rates, -day readmission rates, and costs were greater in period compared to periods and . conclusion: em physicians provide more cost-effective care for patients in this large ou compared to non-em physicians, resulting in shorter los for admitted and discharged patients, greater rates of patients discharged, and less -day readmission rates for discharged patients. this is not affected by an increase in ou volume and shows a trend towards improvement. background: emergency department (ed) crowding continues to be a problem, and new intake models may represent part of the solution. however, little data exist on the sustainability and long-term effects of physician triage and screening on standard ed performance metrics, as most studies are short-term. objectives: we examined the hypothesis that a physician screening program (start) sustainably improves standard ed performance metrics including patient length of stay (los) and patients who left without completing assessment (lwca). we also investigated the number of patients treated and dispositioned by start without using a monitored bed and the median patient door-to-room time. methods: design and setting: this study is a retrospective before-and-after analysis of start in a level i tertiary care urban academic medical center with approximately , annual patient visits. all adult patients from december until november are included, though only a subset was seen in start. start began at our institution in december . observations: our outcome measures were length of stay for ed patients, lwca rates, patients treated and dispositioned by start without using a monitored bed, and door-to-room time. statistics: simple descriptive statistics were used. p-values for los were calculated with wilcoxon test and p-value for lwca was calculated with chi-square. results: table shows median length of stay for ed patients was reduced by minutes/patient (p-value < . ) when comparing the most recent year to the year before start. patients who lwca were reduced from . % to . % (p-value < . ) during the same time period. we also found that in the first half-year of start, % of patients screened in the ed were treated and dispositioned without using a monitored bed and by the end of year , this number had grown to %. median door-to-room time decreased from . minutes to . minutes over the same period of time. conclusion: a start system can provide sustained improvements in ed performance metrics, including a significant reduction in ed los, lwca rate, and doorto-room time. additionally, start can decrease the need for monitored ed beds and thus increase ed capacity. . labs were obtained in %, ct in %, us in %, and consultation in %. % of the cohort was admitted to the hospital. the most commonly utilized source of translation was a layman ( %). a professional translator was used in % and translation service (language line, marty) in %. the examiner was fluent in the patient's language in %. both the patient and examiner were able to maintain basic communication in %. there were patients in the professional/ fluent translation group and patients in the lay translation group. there was no difference in ed los between groups vs min; p = . . there was no difference in the frequency of lab tests, computerized tomography, ultrasound, consultations, or hospital admission. frequencies did not differ by sex or age. conclusion: translation method was not associated with a difference in overall ed los, ancillary test use, or specialist consultation in spanish-speaking patients presenting to the ed for abdominal pain. emergency department patients on warfarin -how often is the visit due to the medication? jim killeen, edward castillo, theodore chan, gary vilke ucsd medical center, san diego, ca background: warfarin has important therapeutic value for many patients, but has been associated with signi-ficant bleeding complications, hypersensitivity reactions, and drug-drug interactions, which can result in patients seeking care in the emergency department (ed). objectives: to determine how often ed patients on warfarin present for care as a result of the medication itself. methods: a multi-center prospective survey study in two academic eds over months. patients who presented to the ed taking warfarin were identified, and ed providers were prospectively queried at the time of disposition regarding whether the visit was the result of a complication or side effect associated with warfarin. data were also collected on patient demographics, chief complaint, triage acuity, vital signs, disposition, ed evaluation time, and length of stay (los). patients identified with a warfarin-related cause for their ed visit were compared with those who were not. statistical analysis was performed using descriptive statistics. results: during the study period, , patients were cared for by ed staff, of whom were identified as taking warfarin as part of their medication regimen. of these, providers identified . % ( patients) who presented with a warfarin-related complication as their primary reason for the ed visit. . % ( ) each hours of daily boarding is associated with a drop of . raw score points in both pg metrics. these seemingly small drops in raw scores translate into major changes in rankings on press ganey national percentile scales (a difference of as much as percentile points). our institution commonly has hundreds of hours of daily boarding. it is possible that patient-level measurements of boarding impact would show stronger correlation with individual satisfaction scores, as opposed to the daily aggregate measures we describe here. our research suggests that reducing the burden of boarding on eds will improve patient satisfaction. background: prolonged emergency department (ed) boarding is a key contributor to ed crowding. the effect of output interventions (moving boarders out of the ed into an intermediate area prior to admission or adding additional capacity to an observation unit) has not been well studied. objectives: we studied the effect of a combined observation-transition (ot) unit, consisting of observation beds and an interim holding area for boarding ed patients, on the length of stay (los) for admitted patients, as well as secondary outcomes such as los for discharged patients, and left without being seen rates. methods: we conducted a retrospective review ( months pre-, months post-design) of an ot unit at an urban teaching ed with , annual visits (study ed). we compared outcomes to a nearby communitybased ed with , annual visits in the same health system (control ed) where no capacity interventions were performed. the ot had beds, full monitoring capacity, and was staffed hours per day. the number of beds allocated to transition and observation patients fluctuated throughout the course of the intervention, based on patient demands. all analyses were conducted at the level of the ed-day. wilcoxon rank-sum and analysis of covariance tests were used for comparisons; continuous variables were summarized with medians. results: in unadjusted analyses, median daily los of admitted patients at the study ed was minutes lower in the months after the ot opened, . to . hours (p < . ). control site daily los for admitted patients increased minutes from . to . hours (p < . ). results were similar after adjusting for other covariates (day of week, ed volume, and triage level). los of discharged patients at study ed decreased by minutes, from . hours to . hours (p < . ), while the control ed saw no significant changes in discharged patient los ( . hours to . hours, p = . ). left without being seen rates did not decrease at either site. conclusion: opening an ot unit was associated with a -minute reduction in average daily ed los for admitted patients and discharged patients in the study ed. given the large expense of opening an ot, future studies should compare capacity-dependent (e.g., ot) vs. capacity-independent (e.g, organizational) interventions to reduce ed crowding. fran balamuth, katie hayes, cynthia mollen, monika goyal children's hospital of philadelphia, philadelphia, pa background: lower abdominal pain and genitourinary problems are common chief complaints in adolescent females presenting to emergency departments. pelvic inflammatory disease (pid) is a potentially severe complication of lower genital tract infections, which involves inflammation of the female upper genital tract secondary to ascending stis. pid has been associated with severe sequelae including infertility, ectopic pregnancy, and chronic pelvic pain. we describe the prevalence and microbial patterns of pid in a cohort of adolescent females presenting to an urban emergency department with abdominal or genitourinary complaints. objectives: to describe the prevalence and microbial patterns of pid in a cohort of adolescent patients presenting to an ed with lower abdominal or genitourinary complaints. methods: this is a secondary analysis of a prospective study of females ages - years presenting to a pediatric ed with lower abdominal or genitourinary complaints. diagnosis of pid was per cdc guidelines. patients underwent chlamydia trachomatis (ct) and neisseria gonorrhea (gc) testing via urine aptima combo assay and trichomonas vaginalis (tv) testing using the vaginal osom trichomonas rapid test. descriptive statistics were performed using stata . . results: the prevalence of pid in this cohort of patients was . % ( % ci . %, . %), . % ( % ci . %, . %) of whom had positive sexually transmitted infection (sti) testing: % ( % ci . %, . %) with ct, . % ( % ci . , . %) with gc, and . % ( % ci . %, . %) with tv. . % ( % ci . , . %) of patients diagnosed with pid received antibiotics consistent with cdc recommendations. patients with lower abdominal pain as their chief complaint were more likely to have pid than patients with genitourinary complaints (or . , % ci . , . ). conclusion: a substantial number of adolescent females presenting to the emergency department with lower abdominal pain were diagnosed with pid, with microbial patterns similar to those previously reported in largely adult, outpatient samples. furthermore, appropriate treatment for pid was observed in the majority of patients diagnosed with pid. impact background: in resource-poor settings, maternal health care facilities are often underutilized, contributing to high maternal mortality. the effect of ultrasound in these settings on patients, health care providers, and communities is poorly understood. objectives: the purpose of this study was to assess the effect of the introduction of maternal ultrasound in a population not previously exposed to this intervention. methods: an ngo-led program trained nurses at four remote clinics outside koutiala, mali, who performed , maternal ultrasound scans over three years. our researchers conducted an independent assessment of this program, which involved log book review, sonographer skill assessment, referral follow-up, semi-structured interviews of clinic staff and patients, and focus groups of community members in surrounding villages. analyses included the effect of ultrasound on clinic function, job satisfaction, community utilization of prenatal care and maternity services, alterations in clinical decision making, sonographer skill, and referral frequency. we used qrs nvivo to organize qualitative findings, code data, and identify emergent themes, and graphpad software (la jolla, ca) and microsoft excel to tabulate quantitative findings results: -findings that triggered changes in clinical practice were noted in . % of ultrasounds, with a . % referral rate to comprehensive maternity care facilities. -skill retention and job satisfaction for ultrasound providers was high. -the number of patients coming for antenatal care increased, after introduction of ultrasound, in an area where the birth rate has been decreasing. -over time, women traveled from farther distances to access ultrasound and participate in antenatal care. -very high acceptance among staff, patients and community members. -ultrasound was perceived as most useful for finding fetal position, sex, due date, and well-being. -improved confidence in diagnosis and treatment plan for all cohorts. -improved compliance with referral recommendations. -no evidence of gender selection motivation for ultrasound use. conclusion: use of maternal ultrasound in rural and resource-limited settings draws women to an initial antenatal care visit, increases referral, and improves job satisfaction among health care workers. methods: a retrospective database analysis was conducted using the electronic medical record from a single, large academic hospital. ed patients who received a billing diagnosis of ''nausea and vomiting of pregnancy'' or ''hyperemesis gravidarum'' between / / and / / were selected. a manual chart review was conducted with demographic and treatment variables collected. statistical significance was determined using multiple regression analysis for a primary outcome of return visit to the emergency department for nausea and vomiting of pregnancy. results: patients were identified. the mean age was . years (sd± . ), mean gravidity . (sd± . ), and mean gestational age . weeks (sd± . ). the average length of ed evaluation was min (sd± ). of the patients, ( . %) had a return ed visit for nausea and vomiting of pregnancy, ( %) were admitted to the hospital, and ( %) were admitted to the ed observation protocol. multiple regression analysis showed that the presence of medical co-morbidity (p = . ), patient gravditity (p = . ), gestational age (p = . ), and admission to the hospital (p = . ) had small but significant effects on the primary outcome (return visits to the emergency department). no other variables were found to be predictive of return visits to the ed including admission to the ed observation unit or factors classically thought to be associated with severe forms of nausea and vomiting in pregnancy including ketonuria, electrolyte abnormalities, or vital sign abnormalities. conclusion: nausea and vomiting in pregnancy has a high rate of return ed visits that can be predicted by young patient age, low patient gravidity, early gestational age, and the presence of other comorbidities. these patients may benefit from obstetric consultation and/or optimization of symptom management after discharge in order to prevent recurrent utilization of the ed. prevalence conclusion: there is a high prevalence of ht in adult sa victims. although our study design and data do not allow us to make any inferences regarding causation, this first report of ht ed prevalence suggests the opportunity to clarify this relationship and the potential opportunity to intervene. background: sexually transmitted infections (sti) are a significant public health problem. because of the risks associated with stis including pid, ectopic pregnancy, and infertility the cdc recommends aggressive treatment with antibiotics in any patient with a suspected sti. objectives: to determine the rates of positive gonorrhea and chlamydia (g/c) screening and rates of empiric antibiotic use among patients of an urban academic ed with > , visits in boston, ma. methods: a retrospective study of all patients who had g/c cultures in the ed over months. chi-square was used in data analysis. sensitivity and specificity were also calculated. results: a positive rate of / ( . %) was seen for gonorrhea and / ( . %) for chlamydia. females had positive rates of / ( . %) and / ( . %) respectively. males had higher rates of / ( . %) (p =< . ) and / ( . %) (p = . ). patients with g/c sent received an alternative diagnosis, the most common being uti ( ), ovarian pathology ( ), vaginal bleeding ( ), and vaginal candidiasis ( ); were excluded. this left without definitive diagnosis. of these, . % ( / ) of females were treated empirically with antibiotics for g/c, and a greater percentage of males ( %, / ) were treated empirically (p < . ). of those empirically treated, / ( . %) had negative cultures. meanwhile / ( . %) who ultimately had positive cultures were not treated with antibiotics during their ed stay. sensitivity of the provider to predict presence of disease based on decision to give empiric antibiotics was . (ci . - . ). specificity was . (ci . - . ). conclusion: most patients screened in our ed for g/c did not have positive cultures and . % of those treated empirically were found not to have g/c. while early treatment is important to prevent complications, there are risks associated with antibiotic use such as allergic reaction, c difficile infection, and development of antibiotic resistance. our results suggest that at our institution we may be over-treating for g/c. furthermore, despite high rates of treatment, % of patients who ultimately had positive cultures did not receive antibiotics during their ed stay. further research into predictive factors or development of a clinical decision rule may be useful to help determine which patients are best treated empirically with antibiotics for presumed g/c. background: air travel may be associated with unmeasured neurophysiological changes in an injured brain that may affect post-concussion recovery. no study has compared the effect of commercial airtravel on concussion injuries despite rather obvious decreased oxygen tension and increased dehydration effect on acute mtbi. objectives: to determine if air travel within - hours of concussion is associated with increased recovery time in professional football and hockey players. methods: prospective cohort study of all active-roster national football league and national hockey league players during the - seasons. internet website review of league sties for injury identification of concussive injury and when player returned to play solely for mtbi. team schedules and flight times were also confirmed to include only players who flew immediately following game (within - hr). multiple injuries were excluded as were players who had injury around all-star break for nhl and scheduled off week in nfl. results: during the - nfl and nhl seasons, ( . %) and ( . %) players experienced a concussion (percent of total players), in the respective leagues. of these, nfl players ( %) and nhl players ( %) flew within hours of the incident injury. the mean distance flown was shorter for nfl ( miles, sd vs. nhl , sd ) miles and all were in a pressurized cabin. the mean number of games missed for nfl and nhl players who traveled by air immediately after concussion was increased by % and % (respectively) than for those who did not travel by air nfl: . (sd . ) vs. . games (sd . ) and nhl: . games (sd . ) vs. . (sd . ); p < . . conclusion: this is an initial report of an increased rate of recovery in terms of more games missed, for professional athletes flying commercial airlines post-mtbi compared to those that do not subject their recently injured brains to pressurized airflight. the obvious changes of decreased oxygen tension with altitude equivalent of , feet, decreased humidity with increased dehydration, and duress of travel accompanying pressurized airline cabins all likely increase the concussion penumbra in acute mtbi. early air travel post concussion should be further evaluated and likely postponed - hr. until initial symptoms subside. background: previous studies have shown better in-hospital stroke time targets for those who arrive by ambulance compared to other modes of transport. however, regional studies report that less than half of stroke patients arrive by ambulance. objectives: our objectives were to describe the proportion of stroke patients who arrive by ambulance nationwide, and to examine regional differences and factors associated with the mode of transport to the emergency department (ed). methods: this is a cross-sectional study of all patients with a primary discharge diagnosis of stroke based on previously validated icd- codes abstracted from the national hospital ambulatory medical care survey for - . we excluded subjects < years of age and those with missing data. the study related survey variables included patient demographics, community characteristics, mode of transport to the hospital, and hospital characteristics. results: patients met inclusion criteria, representing , , patient records nationally. of these, . % arrived by ambulance. after adjustment for potential confounders, patients residing in the west and south had lower odds of arriving by ambulance for stroke when compared to northeast (southern region, or . , % ci . - . , western region, or . , % ci . - . , midwest region, or . , % ci . - . ). compared to the medicare population, privately insured and self insured had lower odds of arriving by ambulance (or for private insurance . , % ci . - . and or for self payers . , % ci . - . ). age, sex, race, urban or rural location of ed, or safety net status were not independently associated with ambulance use. conclusion: patients with stroke arrive by ambulance more frequently in the northeast than in other regions of the us. identifying reasons for this regional difference may be useful in improving ambulance utilization and overall stroke care nationwide. objectives: we sought to determine whether there was a difference in type of stroke presentation based upon race. we further sought to determine whether there is an increase in hemorrhagic strokes among asian patients with limited english proficiency. methods: we performed a retrospective chart review of all stroke patients age and older for year of patients that were diagnosed with cerebral vascular accident (cva) or intracranial hemorrhage (ich). we collected data on patient demographics, and past medical history. we then stratified patients according to race (white, black, latino, asian, and other). we classified strokes as ischemic, intracranial hemorrhage (ich), subarachnoid hemorrhage (sah), subdural hemorrhage (sdh), and other (e.g., bleeding into metatstatic lesions). we used only the index visit. we present the data percentages, medians and interquartile ranges (iqr). we tested the association of the outcome of intracranial hemorrhage against demographic and clinical variables using chi-square and kruskal-wallis tests. we performed a logistic regression model to determine factors related to presentation with an intracranial hemorrhage (ich background: the practice of obtaining laboratory studies and routine ct scan of the brain on every child with a seizure has been called into question in the patient who is alert, interactive, and back to functional baseline. there is still no standard practice for the management of non-febrile seizure patients in the pediatric emergency department (ped). objectives: we sought to determine the proportion of patients in whom clinically significant laboratory studies and ct scans of the brain were obtained in children who presented to the ped with a first or recurrent non-febrile seizure. we hypothesize that the majority of these children do not have clinically significant laboratory or imaging studies. if clinically significant values were found, the history given would warrant further laboratory and imaging assessment despite seizure alone. methods: we performed a retrospective chart review of patients with first-time or recurrent non-febrile seizures at an urban, academic ped between july to june . exclusion criteria included children who presented to the ped with a fever and age less than months. we looked at specific values that included a complete blood count, basic metabolic panel, and liver function tests, and if the child was on antiepileptics along with a level for a known seizure disorder, and ct scan. abnormal laboratory and ct scan findings were classified as clinically significant or not. results: the median age of our study population is years with male to female ratio of . . % of patients had a generalized tonic-clonic seizure. laboratory studies and ct scans were obtained in % and % of patients, respectively. five patients had clinically significant abnormal labs; however, one had esrd, one developed urosepsis, one had eclampsia, and two others had hyponatremia, which was secondary to diluted formula and trileptal toxicity. three children had an abnormal head ct: two had a vp shunt and one had a chromosomal abnormality with developmental delay. conclusion: the majority of the children analyzed did not have clinically significant laboratory or imaging studies in the setting of a first or recurrent non-febrile seizure. of those with clinically significant results, the patient's history suggested a possible etiology for their seizure presentation and further workup was indicated. background: in patients with a negative ct scan for suspected subarachnoid hemorrhage (sah), ct angiography (cta) has emerged as a controversial alternative diagnostic strategy in place of lumbar puncture (lp). objectives: to determine the diagnostic accuracy for sah and aneurysm of lp alone, cta alone, and lp followed by cta if the lp is positive. methods: we developed a decision and bayesian analysis to evaluate ) lp, ) cta, and ) lp followed by cta if the lp is positive. data were obtained from the literature. the model considers probability of sah ( %), aneurysm ( % if sah), sensitivity and specificity of ct ( . % and % overall), of lp (based on rbc and xanthochromia), and of cta, traumatic tap and its influence on sah detection. analyses considered all patients and those presenting at less than hours or greater than hours from symptom onset by varying the sensitivity and specificity of ct and cta. results: using the reported ranges of ct scan sensitivity and the specificity, the revised likelihood of sah following a negative ct ranged from . - . %, and the likelihood of aneurysm ranged from . - . %. following any of the diagnostic strategies, the likelihood of missing sah ranged from - . %. either lp strategy diagnosed . % of sahs versus - % with cta alone because cta only detected sah in the presence of an aneurysm. false positive sah with lp ranged from . - . % due to traumatic taps and with cta ranged from . - . % due to aneurysms without sah. the positive predictive value for sah ranged from . - % with lp and from . - % with cta. for patients presenting within hours of symptom onset, the revised likelihood of sah following a negative ct became . %, and the likelihood of aneurysm ranged from . - . %. following any of the diagnostic strategies, the likelihood of missing sah ranged from . - . %. either lp strategy diagnosed . % of sah versus - % with cta alone. false positive sah with lp was . % and with cta ranged from . - . %. the positive predictive value for sah was . % with lp and from . - % with cta. cta following a positive lp diagnosed . - % of aneurysms. conclusion: lp strategies are more sensitive for detecting sah but less specific than cta because of traumatic taps, leading to lower predictive value positives for sah with lp than with cta. either diagnostic strategy results in a low likelihood of missing sah, particularly within hours of symptom onset. background: recent studies support perfusion imaging as a prognostic tool in ischemic stroke, but little data exist regarding its utility in transient ischemic attack (tia). ct perfusion (ctp), which is more available and less costly to perform than mri, has not been well studied. objectives: to characterize ctp findings in tia patients, and identify imaging predictors of outcome. methods: this retrospective cohort study evaluated tia patients at a single ed over months, who had ctp at initial evaluation. a neurologist blinded to ctp findings collected demographic and clinical data. ctp images were analyzed by a neuroradiologist blinded to clinical information. ctp maps were described as qualitatively normal, increased, or decreased in mean transit time (mtt), cerebral blood volume (cbv), and cerebral blood flow (cbf). quantitative analysis involved measurements of average mtt (seconds), cbv (cc/ g) and cbf (cc/[ g x min]) in standardized regions of interest within each vascular distribution. these were compared with values in the other hemisphere for relative measures of mtt difference, cbv ratio, and cbffratio. mtt difference of ‡ seconds, rcbv as £ . , and rcbf as £ . were defined as abnormal based on prior studies. clinical outcomes including stroke, tia, or hospitalization during follow-up were determined up to one year following the index event. dichotomous variables were compared using fisher's exact test. logistic regression was used to evaluate the association of ctp abnormalities with outcome in tia patients. results: of patients with validated tia, had ctp done. mean age was ± years, % were women, and % were caucasian. mean abcd score was . ± . , and % had an abcd ‡ . prolonged mtt was the most common abnormality ( , %), and ( . %) had decreased cbv in the same distribution. on quantitative analysis, ( %) had a significant abnormality. four patients ( . %) had prolonged mtt and decreased cbv in the same territory, while ( %) had mismatched abnormalities. when tested in a multivariate model, no significant associations between mismatch abnormalities on ctp and new stroke, tia, or hospitalizations were observed. conclusion: ctp abnormalities are common in tia patients. although no association between these abnormalities and clinical outcomes was observed in this small study, this needs to be studied further. objectives: we hypothesized that pre-thrombolytic anti-hypertensive treatment (aht) may prolong door to treatment time (dtt). methods: secondary data analysis of consecutive tpatreated patients at randomly selected michigan community hospitals in the instinct trial. dtt among stroke patients who received pre-thrombolytic aht were compared to those who did not receive pre-thrombolytic aht. we then calculated a propensity score for the probability of receiving pre-thrombolytic aht using a logistic regression model with covariates including demographics, stroke risk factors, antiplatelet or beta blocker as home medication, stroke severity (nihss), onset to door time, admission glucose, pretreatment systolic and diastolic blood pressure, ems usage, and location at time of stroke. a paired t-test was then performed to compare the dtt between the propensity-matched groups. a separate generalized estimating equations (gee) approach was also used to estimate the differences between patients receiving pre-thrombolytic aht and those who did not while accounting for within-hospital clustering. results: a total of patients were included in instinct; however, onset, arrival, or treatment times were not able to be determined in , leaving patients for this analysis. the unmatched cohort consisted of stroke patients who received pre-thrombolytic aht and stroke patients who did not receive aht from - (table) . in the unmatched cohort, patients who received pre-thrombolytic aht had a longer dtt (mean increase minutes; % confidence interval (ci) - minutes) than patients who did not receive pre-thrombolytic aht. after propensity matching (table) , patients who received pre-thrombolytic aht had a longer dtt (mean increase . minutes, % ci . - . ) than patients who did not receive pre-thrombolytic aht. this effect persisted and its magnitude was not altered by accounting for clustering within hospitals. conclusion: pre-thrombolytic aht is associated with modest delays in dtt. this represents a feasible target for physician educational interventions and quality improvement initiatives. further research evaluating optimum hypertension management pre-thrombolytic treatment is warranted. post-pds, % had only pre-pds, and % had both. the most common pds included failure to treat post-treatment hypertension ( , %), antiplatelet agent within hours of treatment ( , %), pre-treatment blood pressure over / ( , %), anticoagulant agent within hours of treatment ( , %), and treatment outside the time window ( , %). symptomatic intracranial hemorrhage (sich) was observed in . % of patients with pds and . % of patients without any pd. in-hospital case fatality was % with and % without a pd. in the fully adjusted model, older age was significantly associated with pre-pds (table) . when post-pds were evaluated with adjustment for pre-pds, age was not associated with pds; however, pre-pds were associated with post-pds. conclusion: older age was associated with increased odds of pre-pds in michigan community hospitals. pre-pds were associated with post-pds. sich and in-hospital case fatality were not associated with pds; however, the low number of such events limited our ability to detect a difference. ct background: mri has become the gold standard for the detection of cerebral ischemia and is a component of multiple imaging enhanced clinical risk prediction rules for the short-term risk of stroke in patients with transient ischemic attack (tia). however, it is not always available in the emergency department (ed) and is often contraindicated. leukoaraiosis (la) is a radiographic term for white matter ischemic changes, and has recently been shown to be independently predictive of disabling stroke. although it is easily detected by both ct and mri, their comparative ability is unknown. objectives: we sought to determine whether leukoaraiosis, when combined with evidence of acute or old infarction as detected by ct, achieved similar sensitivity to mri in patients presenting to the ed with tia. methods: we conducted a retrospective review of consecutive patients diagnosed with tia between june and july that underwent both ct and mri as part of routine care within calendar day of presentation to a single, academic ed. ct and mr images were reviewed by a single emergency physician who was blinded to the mr images at the time of ct interpretation. la was graded using the van sweiten scale (vss), a validated grading scale applicable to both ct and mri. anterior and posterior regions were graded independently from to . results: patients were diagnosed with tia during the study period. of these, had both ct and mri background: helping others is often a rewarding experience but can also come with a ''cost of caring'' also known as compassion fatigue (cf). cf can be defined as the emotional and physical toll suffered by those helping others in distress. it is affected by three major components: compassion satisfaction (cs), burnout (bo), and traumatic experiences (te). previous literature has recognized an increase in bo related to work hours and stress among resident physicians. objectives: to assess the state of cf among residents with regard to differences in specialty training, hours worked, number of overnights, and demands of child care. we aim to measure associations with the three components of cf (cs, bo, and te). methods: we used the previously validated survey, proqol . the survey was sent to the residents after approval from the irb and the program directors. results: a total of responses were received ( % of the surveyed). five were excluded due to incomplete questionnaires. we found that residents who worked more hours per week had significantly higher bo levels (median vs , p = . ) and higher te ( vs , p = . ) than those working less hours. there was no difference in cs ( vs , p = . ). eighteen percent of the residents worked a majority of the night shifts. these residents had higher levels of bo background: emergency department (ed) billing includes both facility and professional fees. an algorithm derived from the medical provider's chart generates the latter fee. many private hospitals encourage appropriate documentation by financially incentivizing providers. academic hospitals sometimes lag in this initiative, possibly resulting in less than optimal charting. past attempts to teach proper documentation using our electronic medical record (emr) were difficult in our urban, academic ed of providers (approximately attending physicians, residents, and physician assistants). objectives: we created a tutorial to teach documentation of ed charts, modified the emr to encourage appropriate documentation, and provided feedback from the coding department. this was combined with an incentive structure shared equally amongst all attendings based on increased collections. we hypothesized this instructional intervention would lead to more appropriate billing, improve chart content, decrease medical liability, and increase educational value of charting process. methods: documentation recommendations, divided into two-month phases of - proposals, were administered to all ed providers by e-mails, lectures, and reminders during sign-out rounds. charts were reviewed by coders who provided individual feedback if specific phase recommendations were not followed. our endpoints included change in total rvu, rvus/ patient, e/m level distribution, and subjective quality of chart improvement. we did not examine effects on procedure codes or facility fees. results: our base average rvu/patient in our ed from / / - / / was . with monthly variability of approximately %. implementation of phase one increased average rvu/patient within two weeks to . ( . % increase from baseline, p < . ). the second aggregate phase implemented weeks later increased average rvu/patient to . ( . % increase from baseline, p < . ). conclusion: using our teaching methods, chart reviews focused on - recommendations at a time, and emr adjustments, we were able to better reflect the complexity of care that we deliver every day in our medical charts. future phases will focus on appropriate documentation for procedures, critical care, fast track, and pediatric patients, as well as examining correlations between increase in rvus with charge capture. identifying mentoring ''best practices'' for medical school faculty julie l. welch, teresita bellido, cherri d. hobgood background: mentoring has been identified as an essential component for career success and satisfaction in academic medicine. many institutions and departments struggle with providing both basic and transformative mentoring for their faculty. objectives: we sought to identify and understand the essential practices of successful mentoring programs. methods: multidisciplinary institutional stakeholders in the school of medicine including tenured professors, deans, and faculty acknowledged as successful mentors were identified and participated in focused interviews between mar-nov . the major area of inquiry involved their experiences with mentoring relationships, practices, and structure within the school, department, or division. focused interview data were transcribed and grounded theory analysis was performed. additional data collected by a institutional mentoring taskforce were examined. key elements and themes were identified and organized for final review. results: results identified the mentoring practices for three categories: ) general themes for all faculty, ) specific practices for faculty groups: basic science researchers, clinician researchers, clinician educators, and ) national examples. additional mentoring strategies that failed were identified. the general themes were quite universal among faculty groups. these included: clarify the best type of mentoring for the mentee, allow the mentee to choose the mentor, establish a panel of mentors with complementary skills, schedule regular meetings, establish a clear mentoring plan with expectations and goals, offer training and resources for both the mentor and mentee at institutional and departmental levels, ensure ongoing mentoring evaluation, create a mechanism to identify and reward mentoring. national practice examples offered critical recommendations to address multi-generational attitudes and faculty diversity in terms of gender, race, and culture. conclusion: mentoring strategies can be identified to serve a diverse faculty in academic medicine. interventions to improve mentoring practices should be targeted at the level of the institution, department, and individual faculty members. it is imperative to adopt results such as these to design effective mentoring programs to enhance the success of emergency medicine faculty seeking robust academic careers. background: women comprise half of the talent pool from which the specialty of emergency medicine draws future leaders, researchers, and educators and yet only % of full professors in us emergency medicine are female. both research and interventions are aimed at reducing the gender gap, however, it will take decades for the benefits to be realized which creates a methodological challenge in assessing system's change. current techniques to measure disparities are insensitive to systems change as they are limited to percentages and trends over time. objectives: to determine if the use of relative rate index (rri) better predicts which stage in the system women are not advancing in the academic pipeline than traditional metrics. methods: rri is a method of analysis that assesses the percent of sub-populations in each stage relative to their representation in the stage directly prior. thus, there is a better notion of the advancement given the availability to advance. rri also standardizes data for ease of interpretation. this study was conducted on the total population of academic professors in all departments at yale school of medicine during the academic year of - . data were obtained from the yale university provost's office. results: n = . there were a total of full, associate, and assistant professors. males comprised %, %, and % respectively. rri for the department of emergency medicine (dem) is . , . , and . , for full, associate, and assistant professors, respectively while the percentages were %, %, and % respectively. conclusion: relying solely on percentages masks improvements to the system. women are most represented at the associate professor level in dem, highlighting the importance of systems change evidence. specifically, twice as many women are promoted to associate professor rank given the number who exists as assistant professors. within years, the dem should have an equal system as the numbers of associate professors have dramatically increased and will be eligible to promote to full professor. additionally, dem has a better record of retaining and promoting women than other yale departments of medicine at both associate and full professor ranks. objectives: we examine the payer mixes of community non-rehabilitation eds in metropolitan areas by region to identify the proportion of academic and nonacademic eds that could be considered safety net eds. we hypothesize that the proportion of safety net academic eds is greater than that for non-academic eds and is increasing over time. methods: this is an ecological study examining us ed visits from through . data were obtained from the nationwide emergency department sample (neds). we grouped each ed visit according to the unique hospital-based ed identifier, thus creating a payer mix for each ed. we define a ''safety net ed'' as any ed where the payer mix satisfied any one of the following three conditions: ) > % of all ed visits are medicaid patients; ) > % of all ed visits are self-pay patients; or ) > % of all ed visits are either medicaid or self-pay patients. neds tags each ed with a hospital-based variable to delineate metropolitan/non-metropolitan locations and academic affiliation. we chose to examine a subpopulation of eds tagged as either academic metropolitan or non-academic metropolitan, because the teaching status of non-metropolitan hospitals was not provided. we then measured the proportion of eds that met safety net criteria by academic status and region. results: we examined , , , , and , weighted metro eds in years - , respectively. table presents safety net proportions. the proportions of academic safety net eds increased across the study period. widespread regional variability in safety net proportions existed across all years. the proportions of safety net eds were highest in the south and lowest in the northeast and midwest. table describes these findings for . conclusion: these data suggest that the proportion of safety-net academic eds may be greater than that of non-academic eds, is increasing over time, and is objectives: to examine the effect of ma health reform implementation on ed and hospital utilization before and after health reform, using an approach that relies on differential changes in insurance rates across different areas of the state in order to make causal inferences as to the effect of health reform on ed visits and hospitalizations. our hypothesis was that health care reform (i.e. reducing rates of uninsurance) would result in increased rates of ed use and hospitalizations. methods: we used a novel difference-in-differences approach, with geographic variation (at the zip code level) in the percentage uninsured as our method of identifying changes resulting from health reform, to determine the specific effect of massachusetts' health care reform on ed utilization and hospitalizations. using administrative data available from the massachusetts division of health care finance and policy acute hospital case mix databases, we compared a one-year period before health reform with an identical period after reform. we fit linear regression models at the area-quarter level to estimate the effect of health reform and the changing uninsurance rate (defined as self-pay only) on ed visits and hospitalizations. results: there were , , ed visits and , hospitalizations pre-reform and , , ed visits and , hospitalizations post-reform. the rate of uninsurance decreased from . % to . % in the ed group and from . % to . % in the hospitalization group. a reduction in the rate of the uninsured was associated with a small but statistically significant increase in ed utilization (p = . ) and no change in hospitalizations (p = . ). conclusion: we find that increasing levels of insurance coverage in massachusetts were associated with small but statistically significant increases in ed visits, but no differences in rates of hospitalizations. these results should aid in planning for anticipated changes that might result from the implementation of health reform nationally. with high levels of co-morbidity when untreated in adolescents. despite broad cdc screening recommendations, many youth do not receive testing when indicated. the pediatric emergency department (ped) is a venue with a high volume of patients potentially in need of sti testing, but assessing risk in the ped is difficult given constraints on time and privacy. we hypothesized that patients visiting a ped would find an audio-enhanced computer-assisted self-interview (acasi) program to establish sti risk easy to use, and would report a preference for the acasi over other methods of disclosing this information. objectives: to assess acceptability, ease of use, and comfort level of an acasi designed to assess adolescents' risk for stis in the ped. methods: we developed a branch-logic questionnaire and acasi system to determine whether patients aged - visiting the ped need sti testing, regardless of chief complaint. we obtained consent from participants and guardians. patients completed the acasi in private on a laptop. they read a one-page computer introduction describing study details and completed the acasi. patients rated use of the acasi upon completion using five-point likert scales. results: eligible patients visited the ped during the study period. we approached ( %) and enrolled and analyzed data for / ( %). the median time to read the introduction and complete the acasi was . minutes (interquartile range . - . minutes). . % of patients rated the acasi ''very easy'' or ''easy'' to use, . % rated the wording as ''very easy'' or ''easy'' to understand, % rated the acasi ''very short'' or ''short'', . % rated the audio as ''very helpful'' or ''helpful,'' . % were ''very comfortable'' or ''comfortable'' with the system confidentiality, and . % said they would prefer a computer interface over in-person interviews or written surveys for collection of this type of information. conclusion: patients rated the computer interface of the acasi as easy and comfortable to use. a median of . minutes was needed to obtain meaningful clinical information. the acasi is a promising approach to enhance the collection of sensitive information in the ped. the participants were randomized to one of three conditions, bi delivered by a computer (cbi), bi delivered by a therapist assisted by a computer (tbi), or control, and completed , , and month follow-up. in addition to content on alcohol misuse and peer violence, adolescents reporting dating violence received a tailored module on dating violence. the main outcome for this analysis was frequency of moderate and severe dating victimization and aggression at the baseline assessment and , , and months post ed visit. results: among eligible adolescents, % (n = ) reported dating violence and were included in these analyses. compared to controls, after controlling for baseline dating victimization, participants in the cbi showed reductions in moderate dating victimization at months (or . ; ci . - . ; p < . , effect size . ) and months (or . ; ci . - . ; p < . , effect size . ); models examining interaction effects were significant for the cbi on moderate dating victimization at and months. significant interaction effects were found for the tbi on moderate dating victimization at and months and severe dating victimization at months. the computer-based intervention shows promise for delivering content that decreases moderate dating victimization over months. the therapist bi is promising for decreasing moderate dating victimization over months and severe dating victimization over months. ed-based bis delivered on a computer addressing multiple risk behaviors could have important public health effects. figure . the -only ordinance was associated with a significant reduction of ar visits. this ordinance was also associated with reduction in underage ar visits, ui student visits, and public intoxication bookings. these data suggest that other cities should consider similar ordinances to prevent unwanted consequences of alcohol. background: prehospital providers perform tracheal intubation in the prehospital environment, and failed attempts are of concern due to the danger of hypoxia and hypotension. some question the appropriateness of intubation in this setting due to the morbidity risk associated with intubation in the field. thus it is important to gain an understanding of the factors that predict the success of prehospital intubation attempts to inform this discussion. objectives: to determine the factors that affect success rates on first attempt of paramedic intubations in a rapid sequence intubation (rsi) capable critical care transport service. methods: we conducted a multivariate logistic analysis on a prospectively collected database of airway management from an air and land critical care transport service that provides scene responses and interfacility transport in the province of ontario. background: motor vehicle collisions (mvcs) are one of the most common types of trauma for which people seek ed care. the vast majority of these patients are discharged home after evaluation. acute psychological distress after trauma causes great suffering and is a known predictor of posttraumatic stress disorder (ptsd) development. however, the incidence and predictors of psychological distress among patients discharged to home from the ed after mvcs have not been reported. objectives: to examine the incidence and predictors of acute psychological distress among individuals seen in the ed after mvcs and discharged to home. methods: we analyzed data from a prospective observational study of adults - years of age presenting to one of eight ed study sites after mvc between / and / . english-speaking patients who were alert and oriented, stable, and without injuries requiring hospital admission were enrolled. patient interview included assessment of patient sociodemographic and psychological characteristics and mvc characteristics. level of psychological distress in the ed was assessed using the -item peritraumatic distress inventory (pdi). pdi scores > are associated with increased risk of ptsd and were used to define substantial psychological distress. descriptive statistics and logistic regression were performed using stata ic . (statacorp lp, college station, texas). results: mvc patients were screened, were eligible, and were enrolled. / ( %) participants had substantial psychological distress. after adjusting for crash severity (severity of vehicle damage, vehicle speed), substantial patient distress was predicted by sociodemographic factors, pre-mvc depressive symptoms, and arriving to the ed on a backboard (table) . conclusion: substantial psychological distress is common among individuals discharged from the ed after mvcs and is predicted by patient characteristics separate from mvc severity. a better under standing of the frequency and predictors of substantial psychological distress is an important first step in identifying these patients and developing effective interventions to reduce severe distress in the aftermath of trauma. such interventions have the potential to reduce both immediate patient suffering and the development of persistent psychological sequelae. figure) the predictive characteristics of pets, pesi, and spesi for -day mortality in emperor, including auc, negative predictive value, sensitivity, and specificity were calculated. results: the of patients ( . %; % ci . %- . %) classified as pets low had -day mortality of . % ( % ci . - . %), versus . % ( % ci . %- . %) in the pets high group, statistically similar to pesi and spesi. pets is significantly more specific for mortality than the spesi ( . % v . %; p < . ), classifying far more patients as low-risk while maintaining a sensitivity of % ( % ci . %- . %), not significantly different from spesi or pesi (p > . ). conclusion: with four variables, pets in this derivation cohort is as sensitive for -day mortality as the more complicated pesi and spesi, with significantly greater specificity than the spesi for mortality, placing % more patients in the low-risk group. external validation is necessary. nicole seleno, jody vogel, michael liao, emily hopkins, richard byyny, ernest moore, craig gravitz, jason haukoos denver health medical center, denver, co background: the sequential organ failure assessment (sofa) score, base excess, and lactate have been shown to be associated with mortality in critically ill trauma patients. the denver emergency department (ed) trauma organ failure (tof) score was recently derived and internally validated to predict multiple organ failure in trauma patients. the relationship between the denver tof score and mortality has not been assessed or compared to other conventional measures of mortality in trauma. objectives: to compare the prognostic accuracies of the denver ed tof score, ed sofa score, and ed base excess and lactate for mortality in a large heterogeneous trauma population. methods: a secondary analysis of data from the denver health trauma registry, a prospectively collected database. consecutive adult trauma patients from through were included in the study. data collected included demographics, injury characteristics, prehospital care characteristics, response to injury characteristics, ed diagnostic evaluation and interventions, and in-hospital mortality. the values of the four clinically relevant measures (denver ed tof score, ed sofa score, ed base excess, and ed lactate) were determined within four hours of patient arrival, and prognostic accuracies for in-hospital mortality for the four measures were evaluated with receiver operating characteristic (roc) curves. multiple imputation was used for missing values. results: of the , patients, the median age was (iqr - ) years, median injury severity score was (iqr - ), and % had blunt mechanisms. thirty-eight percent ( , patients) were admitted to the icu with a median icu length of stay of . (iqr - ) days, and % ( patients) died. in the non-survivors, the median values for the four measures were ed sofa . (iqr . - . ); denver ed tof . (iqr . - . ); ed base excess . (iqr . - . ) meq/l; and ed lactate . (iqr . - . ) mmol/l. the areas under the roc curves for these measures are demonstrated in the figure. conclusion: the denver ed tof score more accurately predicts in-hospital mortality in trauma patients as compared to the ed sofa score, ed base excess, or ed lactate. the denver ed tof score may help identify patients early who are at risk for mortality, allowing for targeted resuscitation and secondary triage to improve outcomes in these critically ill patients. the background: both animal and human studies suggest that early initiation of therapeutic hypothermia (th) and rapid cooling improve outcomes after cardiac arrest. objectives: the objective was to determine if administration of cold iv fluids in a prehospital setting decreased time-to-target-temperature (tt) with secondary analysis of effects on mortality and neurological outcome. methods: patients resuscitated after out-of-hospital cardiac arrest (oohca) who received an in-hospital post cardiac arrest bundle including th were prospectively enrolled into a quality assurance database from november to november . on april , a protocol for intra-arrest prehospital cooling with °c normal saline on patients experiencing oohca was initiated. we retrospectively compared tt for those receiving prehospital cold fluids and those not receiving cold fluids. tt was defined as °c measured via foley thermistor. secondary outcomes included mortality, good neurological outcome defined as cerebral performance category (cpc) score of or at discharge, and effects of pre-rosc cooling. results: there were patients who were included in this analysis with patients receiving prehospital cold iv fluids and who did not. initially, % of patients were in vf/vt and % asystole/pea. patients receiving prehospital cooling did not have a significant improvement in tt ( minutes vs minutes, p = . ). survival to discharge and good neurologic outcome were not associated with prehospital cooling ( % vs %, p = . ) and cpc of or in % vs %, (p = . ). initiating cold fluids prior to rosc showed both a nonsignificant decrease in survival ( % vs %, p = . ) and increase in poor neurologic outcomes ( % vs %, p = . ). % of patients received £ l of cooled ivf prior to hospital arrival. patients receiving prehospital cold ivf had a longer time from arrest to hospital arrival ( vs min, p =< . ) in addition to a prolonged rosc to hospital time ( vs min, p = . ). conclusion: at our urban hospital, patients achieving rosc following oohca did not demonstrate faster tt or outcome improvement with prehospital cooling compared to cooling initiated immediately upon ed arrival. further research is needed to assess the utility of prehospital cooling. assessment background: an estimated % of emergency department (ed) patients years of age and older have delirium, which is associated with short-and long-term risk of morbidity and mortality. early recognition could result in improved outcomes, but the reliability of delirium recognition in the continuum of emergency care is unknown. objectives: we tested whether delirium can be reliably detected during emergency care of elderly patients by measuring the agreement between prehospital providers, ed physicians, and trained research assistants using the confusion assessment method for the icu (cam-icu) to identify the presence of delirium. our hypothesis was that both ed physicians and prehospital providers would have poor ability to detect elements of delirium in an unstructured setting. methods: prehospital providers and ed physicians completed identical questionnaires regarding their clinical encounter with a convenience sample of elderly (age > years) patients who presented via ambulance to two urban, teaching eds over a three-month period. respondents noted the presence or absence of ( ) an acute change in mental status, ( ) inattention, ( ) disorganized thinking, and ( ) altered level of consciousness (using the richmond agitation sedation scale). these four components comprise the operational definition of delirium. a research assistant trained in the cam-icu rated each component for the same patients using a standard procedure. we calculated inter-rater reliability (kappa) between prehospital providers, ed physicians, and research assistants for each component. objectives: this study aimed to assess the association between age and ems use while controlling for potential confounders. we hypothesized that this association use would persist after controlling for confounders. methods: a cross-sectional survey study was conducted at an academic medical center's ed. an interview-based survey was administered and included questions regarding demographic and clinical characteristics, mode of ed arrival, health care use, and the perceived illness severity. age was modeled as an ordinal variable (< , - , and ‡ years). bivariate analyses were used to identify potential confounders and effect measure modifiers and a multivariable logistic regression model was constructed. odds ratios were calculated as measures of effect. results: a total of subjects were enrolled and had usable data for all covariates, ( %) of whom arrived via ems. the median age of the sample was years and % were female. there was a statistically significant linear trend in the proportion of subjects who arrived via ems by age (p < . ). compared to adults aged less than years, the unadjusted odds ratio associating age and ems use was . ( % ci: background: we previously derived a clinical decision rule (cdr) for chest radiography (cxr) in patients with chest pain and possible acute coronary syndrome (acs) consisting of the absence of three predictors: history of congestive heart failure, history of smoking, and abnormalities on lung auscultation. objectives: to prospectively validate and refine a cdr for cxr in an independent patient population. methods: we prospectively enrolled patients over years of age with a primary complaint of chest pain and possible acs from september to january at a tertiary care ed with , annual patient visits. physicians completed standardized data collection forms before ordering chest radiographs and were thus blinded to cxr findings at the time of data collection. two investigators, blinded to the predictor variables, independently classified cxrs as ''normal,'' ''abnormal not requiring intervention,'' and ''abnormal requiring intervention'' (e.g, heart failure, infiltrates) based on review of the radiology report and the medical record. analyses included descriptive statistics, inter-rater reliability assessment (kappa), and recursive partitioning. results: of visits for possible acs, mean age (sd) was . ( . ) and % were female. twenty-four percent had a history of acute myocardial infarction, % congestive heart failure, and % atrial fibrillation. seventy-one ( . %, % ci . - . ) patients had a radiographic abnormality requiring intervention. ing the likelihood of coronary artery disease (cad) could reduce the need for stress testing or coronary imaging. acyl-coa:cholesterol acyltransferase- (acat ) activity has been shown in monkey and murine models to correlate with atherosclerosis. objectives: to determine if a novel cardiac biomarker consisting of plasma cholesteryl ester levels (ce) typically derived from the activity of acat is predictive of cad in a clinical model. methods: a single center prospective observational cohort design enrolled a convenience sample of subjects from a tertiary care center with symptoms of acute coronary syndrome undergoing coronary ct angiography or invasive angiography. plasma samples were analyzed for ce composition with mass spectrometry. the primary endpoint was any cad determined at angiography. multivariable logistic regression analyses were used to estimate the relationship between the sum of the plasma concentrations from cholesteryl palmitoleate ( : ) and cholesteryl oleate ( : ) (defined as acat -ce) and the presence of cad. the added value of acat -ce to the model was analyzed comparing the c-statistics and integrated discrimination improvement (idi). results: the study cohort was comprised of participants enrolled over months with a mean age (± . ) years, % with cad at angiography. the median plasma concentration of acat -ce was lm ( , ) in patients with cad and lm ( , ) in patients without cad (p = . ) (figure) . when considered with age, sex, and the number of conventional cad risk factors, acat -ce were associated with a . % increased odds of having cad per lm increase in concentration. the addition of acat -ce significantly improved the c-statistic ( . vs . , p = . ) and idi ( . , p < . ) compared to the reduced model. in the subgroup of low-risk observation unit patients, the ce model had superior discrimination compared to the diamond forrester classification (idi . , p < . ). conclusion: plasma levels of acat -ce, considered in a clinical model, have strong potential to predict a patient's likelihood of having cad. in turn, this could reduce the need for cardiac imaging after the exclusion of mi. further study of acat -ce as biomarkers in patients with suspected acs is needed. background: outpatient studies have demonstrated a correlation between carotid intima-media thickness (cimt) on ultrasound and coronary artery disease (cad). there are no known published studies that investigate the role of cimt in the ed using cardiac ct or percutaneous cardiac intervention (pci) as a gold standard. objectives: we hypothesized that cimt can predict cardiovascular events and serve as a noninvasive tool in the ed. methods: this was a prospective study of adult patients who presented to the ed and required evaluation for chest pain. the study location was an urban ed with a census of , annual visits and -hour cardiac catheterization. patients who did not have ct or pci or had carotid surgery were excluded from the study. ultrasound cimt measurements of right and left common carotid arteries were taken with a mhz linear transducer (zonare, mountain view, ca). anterior, medial, and posterior views of the near and far wall were obtained ( cimt scores total). images were analyzed by carotid analyzer (mailing imaging application llc, coralville, iowa). patients were classified into two groups based on the results from ct or pci. a subject was classified as having significant cad if there was over % occlusion or multi-vessel disease. results: ninety of patients were included in the study; . % were males. mean age was . ± years. there were ( . %) subjects with significant cad and ( . %) with non-significant cad. the mean of all cimt measurements was significantly higher in the cad group than in the non-cad group ( . ± . vs. . ± . ; p < . ). a logistic regression analysis was carried out with significant cad as the event of interest and the following explanatory variables in the model: objectives: to determine the diagnostic yield of routine testing in-hospital or following ed discharge among patients presenting to an ed following syncope. methods: a prospective, observational, cohort study of consecutive ed patients ‡ years old presenting with syncope was conducted. the four most commonly utilized tests (echocardiography, telemetry, ambulatory electrocardiography monitoring, and cardiac markers) were studied. interobserver agreement as to whether tests results determined the etiology of the syncope was measured using kappa (k) values. results: of patients with syncope, ( %) had echocardiography with ( %) demonstrating a likely etiology of the syncopal event such as critical valvular disease or significantly depressed left ventricular function (k = . ). on hospitalization, ( %) patients were placed on telemetry, ( %) of these had worrisome dysrhythmias (k = . ). ( %) patients had troponin levels drawn of whom ( %) had positive results (k = ); ( %) patients were discharged with monitoring with significant findings in only ( . %) patients (k = . ). overall, ( %, % ci - %) studies were diagnostic. conclusion: although routine testing is prevalent in ed patients with syncope, the diagnostic yield is relatively low. nevertheless, some testing, particularly echocardiography, may yield critical findings in some cases. current efforts to reduce the cost of medical care by eliminating non-diagnostic medical testing and increasing emphasis on practicing evidence-based medicine argue for more discriminate testing when evaluating syncope. (originally submitted as a ''late-breaker.'') unusual fatigue was reported by . % (severe . %) and insomnia by . % (severe . %). these findings have led to risk management recommendations to consider these symptoms as predictive of acute coronary syndromes (acs) among women visiting the ed. objectives: to document the prevalence of these symptoms among all women visiting an ed. to analyze the potential effect of using these symptoms in the ed diagnostic process for acs. methods: a survey on fatigue and insomnia symptoms was administered to a convenience sample of all adult women visiting an urban academic ed (all arrival modes, acuity levels, all complaints). a sensitivity analysis was performed using published data and expert opinion for inputs. results: we approached women, with enrollments. see table. the top box shows prevalences of prodromal symptoms among all adult female ed patients. the bottom box shows outputs from sensitivity analysis on the diagnostic effect of initiating an acs workup for all female ed patients reporting prodromal symptoms. conclusion: prodromal symptoms of acs are highly prevalent among all adult women visiting the ed in this study. this likely limits their utility in ed settings. while screening or admitting women with prodromal symptoms in the ed would probably increase sensitivity, that increase would be accompanied by a dramatic reduction in specificity. such a reduction in specificity would translate to admitting, observing, or working up somewhere between % and % of all women visiting the ed, which is prohibitive in terms of personal costs, risks of hospitalization, and financial costs. while these symptoms may or may not have utility in other settings such as primary care, their prevalence, and the implied lack of specificity for acs suggest they will not be clinically useful in the ed. length methods: we examined a cohort of low-risk chest pain patients evaluated in an ed-based ou using prospective and retrospective ou registry data elements. cox proportional hazard modeling was performed to assess the effect of testing modality (stress testing vs. ccta) on the los in the cdu. as ccta is not available on weekends, only subjects presenting on weekdays were included. cox models were stratified on time of patient presentation to the ed, based on four hour blocks beginning at midnight. the primary independent variable was first test modality, either stress imaging (exercise echo, dobutamine echo, stress mri) or ccta. age, sex, and race were included as covariates. the proportional hazards assumption was tested using scaled schoenfield residuals, and the models were graphically examined for outliers and overly influential covariate patterns. test selection was a time varying covariate in the am strata, and therefore the interaction with ln (los) was included as a correction term. after correction for multiple comparisons, an alpha of . was held to be significant. results: over the study period, subjects (of , in the registry) presented on non-weekend days. the median los was . hours (iqr . - . hours), % were white, and % were female. the table shows the number of subjects in each time strata, the number tested, and the number undergoing stress testing vs. ccta. after adjusting all models for age, race, and sex, the hazard ratio (hr) for los is as shown. only those patients presenting between am and noon noted a significant improvement in los with ccta use (p < . ). objectives: determine the validity of a managementfocused em osce as a measure of clinical skills by determining the correlation between osce scores and faculty assessment of student performance in the ed. methods: medical students in a fourth year em clerkship were enrolled in the study. on the final day of the clerkship students participated in a five-station em osce. student performance on the osce was evaluated using a task-based evaluation system with - critical management tasks per case. task performance was evaluated using a three-point system: performed correctly/timely ( ), performed incorrectly/late ( ), or not performed ( ). descriptive anchors were used for performance criteria. communication skills were also graded on a three-point scale. student performance in the ed was based on traditional faculty assessment using our core-competency evaluation instrument. a pearson correlation coefficient was calculated for the relationship between osce score and ed performance score. case item analysis included determination of difficulty and discrimination. the acgme also requires that trainees are evaluated on these ccs during their residency. trainee evaluation in the ccs are frequently on a subjective rating scale. one of the recognized problems with a subjective scale is the rating stringency of the rater, commonly known as the hawk-dove effect. this has been seen in standardized clinical exam scoring. recent data have shown that score variance can be related to evaluator performance with a negative correlation. higher-scoring physicians were more likely to be a stringent or hawk type rater on the same evaluation. it is unclear if this pattern also occurs in the subjective ratings that are commonly used in assessments of the ccs. objectives: comparison of attending physician scores on the acgme ccs with attending ratings of residents for a negative correlation or hawk-dove effect. methods: residents are routinely evaluated on the ccs with a - numerical rating scale as part of their training. the evaluation database was retrospectively reviewed. residents anonymously scored attending physicians on the ccs with a cross-sectional survey that utilized the same rating scale, anchors, and prompts as the resident evaluations. average scores for and by each attending were calculated and a pearson correlation calculated by core competency and overall. results: in this irb-approved study, a total of attending physicians were scored on the ccs with evaluations by residents. attendings evaluated residents with a total of , evaluations completed over a -year period. attending mode score was ranging from to ; resident scores had a mode of with a range of to . there was no correlation between the rated performance of the attendings overall or in each ccs and the scores they gave (p = . - . ). conclusion: hawk-dove effects can be seen in some scoring systems and has the potential to affect trainee evaluation on the acgme core competencies. however, a negative correlation to support a hawk-dove scoring pattern was not found in em resident evaluations by attending physicians. this study is limited by being a single center study and utilizing grouped data to preserve resident anonymity. background: all acgme-accredited residency programs are required to provide competency-based education and evaluation. graduating residents must demonstrate competency in six key areas. multiple studies have outlined strategies for evaluating competency, but data regarding residents' self-assessments of these competencies as they progress through training and beyond is scarce. objectives: using data from longitudinal surveys by the american board of emergency medicine, the primary objective of this study was to evaluate if resident self-assessments of performance in required competencies improve over the course of graduate medical training and in the years following. additionally, resident self-assessment of competency in academic medicine was also analyzed. methods: this is a secondary data analysis of data gathered from two rounds of the abem longitudinal study of emergency medicine residents ( - and - ) and three rounds of the abem longitudinal study of emergency physicians ( , , ). in both surveys, physicians were asked to rate a list of items in response to the question, ''what is your current level of competence in each of the following aspects of work in em?'' the rated items were grouped according to the acgme required competencies of patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, and system-based practice. an additional category for academic medicine was also added. results: rankings improved in all categories during residency training. rankings in three of the six categories improved from the weak end of the scale to the strong end of the scale. there is a consistent decline in rankings one year after graduation from residency. the greatest drop is in medical knowledge. mean self-ranking in academic medicine competency is uniformly the lowest ranked category for each year. conclusion: while self-assessment is of uncertain value as an objective assessment, these increasing rankings suggest that emergency medicine residency programs are successful at improving residents' confidence in the required areas. residents do not feel as confident about academic medicine as they do about the acgme required competencies. the uniform decline in rankings the first year after residency is an area worthy of further inquiry. screening medical student rotators from outside institutions improves overall rotation performance shaneen doctor, troy madsen, susan stroud, megan l. fix university of utah, salt lake city, ut background: emergency medicine is a rapidly growing field. many student rotations are limited in their ability to accommodate all students and must limit the number of students they allow per rotation. we hypothesize that pre-screening visiting student rotators will improve overall student performance. objectives: to assess the effect of applicant screening on overall rotation grade and mean end of shift card scores. methods: we initiated a medical student screening process for all visiting students applying to our -week elective em rotation starting in . this consisted of reviewing board scores and requiring a letter of intent. students from our home institution were not screened. all end-of-shift evaluation cards and final rotation grades (honors, high pass, pass, fail) from to were analyzed. we identified two cohorts: home students (control) and visiting students. we compared pre-intervention ( ) ( ) ( ) ( ) ( ) and postintervention ( - ) scores and grades. end of shift performance scores are recorded using a fivepoint scale that assesses indicators such as fund of knowledge, judgment, and follow-through to disposition. mean ranks were compared and p-values were calculated using the armitage test of trend and confirmed using t-tests. results: we identified visiting students ( pre, post) and home students ( pre, post). ( . %) visiting students achieved honors pre-intervention while ( . %) achieved honors post-intervention (p = . ). no significant difference was seen in home student grades: ( . %) received honors pre- and ( . %) received honors post- conclusion: we found that implementation of a screening process for visiting medical students improved overall rotation scores and grades as compared to home students who did not receive screening. screening rotating students may improve the overall quality of applicants and thereby the residency program. background: there are many descriptions in the literature of computer-assisted instruction in medical education, but few studies that compare them to traditional teaching methods. objectives: we sought to compare the suturing skills and confidence of students receiving video preparation before a suturing workshop versus a traditional instructional lecture. methods: first and second year medical students were randomized into two groups. the control group was given a lecture followed by minutes of suturing time. the video group was provided with an online suturing video at home, no lecture, and given minutes of suturing time during the workshop. both groups were asked to rate their confidence before and after the workshop, and their belief in the workshop's effectiveness. each student was also videotaped suturing a pig's foot after the workshop and graded on a previously validated -point suturing checklist. videos were scored. results: there was no significant difference between the test scores of the lecture group (m = . , sd = . , n = ) and the video group (m = . , sd = . , n = ) using the two-sample independent ttest for equal variances (t( ) = ) . , p = . ). there was a statistically significant difference in the proportion of students scoring correctly for only one point: ''curvature of needle followed'': / in the lecture group and / in the video group (chi = . , df = , p = . ). students in the video group were found to be . times more likely to have a neutral or favorable feeling of suturing confidence before the workshop (p = . , ci . - . ) using a proportional odds model. no association was detected between group assignment and level of suturing confidence after the workshop (p = . ). there was also no association detected between group assignment and opinion of the suturing workshop (p = . ) using a logistic regression odds model. among those students who indicated a lack of confidence before training, there was no detected association (p = . ) between group assignment and having an improved confidence using a logistic regression odds model. conclusion: students in the video group and students in the control group achieved similar levels of suturing skill and confidence, and equal belief in the workshop's effectiveness. this study suggests that video instruction could be a reasonable substitute for lectures in procedural education. background: accurate interpretation of the ecg in the emergency department is not only clinically important but also critical to assess medical knowledge competency. with limitations to expansion of formal didactics, educational technology offers an innovative approach to improve the quality of medical education. objectives: the aim of this study was to assess an online multimedia-based ecg training module evaluating st elevation myocardial infarction (stemi) identification among medical students. methods: a convenience sample of fifty-two medical students on their em rotations at an academic medical center with an em residency program was evaluated in a before-after fashion during a -month period. one cardiologist and two ed attending physicians independently validated a standardized exam of ten ecgs: four were normal ecgs, three were classic stemis, and three were subtle stemis. the gold standard for diagnosis was confirmed acute coronary thrombus during cardiac catheterization. after evaluating the ecgs, students completed a pre-intervention test wherein they were asked to identify patients who required emergent cardiac catheterization based on the presence or absence of st segment elevation on ecg. students then completed an online interactive multimedia module containing minutes of stemi training based on american heart association/american college of cardiology guidelines on stemi. medical students were asked to complete a post-test of the ecgs after watching online multimedia. objectives: our objective was to quantify the number of pre-verbal pediatric head cts performed at our community hospital that could have been avoided by utilizing the pecarn criteria. methods: we conducted a standardized chart review of all children under the age of who presented to our community hospital and received a head ct between jan st, and dec st, . following recommended guidelines for conducting a chart review, we: ) utilized four blinded chart reviewers, ) provided specific training, ) created a standardized data extraction tool, and ) held periodic meetings to evaluate coding discrepancies. our primary outcome measure was the number of patients who were pecarn negative and received a head ct at our institution. our secondary outcome was to reevaluate the sensitivity and specificity of the pecarn criteria to detect citbi in our cohort. data were analyzed using descriptive statistics and % confidence intervals were calculated around proportions using the modified wald method. results: a total of patients under the age of received a head ct at our institution during the study period. patients were excluded from the final analysis because their head cts were not for trauma. the prevalence of a citbi in our cohort was . % ( % ci . %- . %) ( (dti) measures disruption of axonal integrity on the basis of anisotropic diffusion properties. findings on dti may relate to the injury, as well as the severity of postconcussion syndrome (pcs) following mtbi. objectives: to examine acute anisotropic diffusion properties based on dti in youth with mtbi relative to orthopedic controls and to examine associations between white matter (wm) integrity and pcs symptoms. methods: interim analysis of a prospective casecontrol cohort involving youth ages - years with mtbi and orthopedic controls requiring extremity radiographs. data collected in ed included demographics, clinical information, and pcs symptoms measured by the postconcussion symptom scale. within hours of injury, symptoms were re-assessed and a -direction, diffusion weighted, spin-echo imaging scan was performed on a t philips scanner. dti images were analyzed using tract-based spatial statistics. fractional anisotropy (fa), mean diffusivity (md), axial diffusivity (ad), and radial diffusivity were measured. results: there were no group demographic differences between mtbi cases and controls. presenting symptoms within the mtbi group included gcs = %, loss of consciousness %, amnesia %, post-traumatic seizure %, headache %, vomiting %, dizziness %, and confusion %. pcs symptoms were greater in mtbi cases than in the controls at ed visit ( . ± . vs. . ± . , p < . ) and at the time of scan ( . ± . vs. . ± . , p < . ). the mtbi group displayed decreased fa in cerebellum and increased md and ad in the cerebral wm relative to controls (uncorrected p < . ). increased fa in cerebral wm was also observed in mtbi patients but the group difference was not significant. pcs symptoms at the time of the scan were positively correlated with fa and inversely correlated with rd in extensive cerebral wm areas (p < . , uncorrected). in addition, pcs symptoms in mtbi patients were also found to be inversely correlated with md, ad, and rd in cerebellum (p < . ). conclusion: dti detected axonal damage in youth with mtbi which correlated with pcs symptoms. dti performed acutely after injury may augment detection of injury and help prediction of those with worse outcomes. background: sports-related concussion among professional, collegiate, and more recently high school athletes has received much attention from the media and medical community. to our knowledge, there is a paucity of research in regard to sports-related concussion in younger athletes. objectives: the aim of this study was to evaluate parental knowledge of concussion in young children who participate in recreational tackle football. methods: parents/legal guardians of children aged - years enrolled in recreational tackle football were asked to complete an anonymous questionnaire based on the cdc's heads up: concussion in youth sports quiz. parents were asked about their level of agreement in regard to statements that represent definition, symptoms, and treatment of concussion. results: a total of out of parents voluntarily completed the questionnaire ( % response rate). parent and child demographics are listed in table . ninety four percent of parents believed their child had never suffered a concussion. however, when asked to agree or disagree with statements addressing various aspects of concussion, only % (n = ) could correctly identify all seven statements. most did not identify that a concussion is considered a mild traumatic brain injury and can be achieved from something other than a direct blow to the head. race, sex, and zip code had no significant association with correctly answering statements. education ( . ; p < . ) and number of years the child played ( . ; p < . ) had a small effect. fifty-three percent of parents reported someone had discussed the definition of concussion with them and % the symptoms of concussion. see table for source of information to parents. no parent was able to classify all symptoms listed as correctly related or not related to concussion. however, identification of correct concussion definitions correlated with identification of correct symptoms ( . ; p < . ). conclusion: while most parents had received some education regarding concussion from a health care provider, important misconceptions remain among parents of young athletes regarding the definition, symptoms, and treatment of concussion. this study highlights the need for health care providers to increase educational efforts among parents of young athletes in regard to concussion. figure ). / ( %) of patients with baseline liver dysfunction were (oh)d deficient and / ( %) of deaths were patients who had insufficient levels of (oh)d. there was an inverse association between (oh)d level and tnf-a (p = . ; figure ) and il- (p = . ). background: fever is common in the emergency department (ed), and % of those diagnosed with severe sepsis present with fever. despite data suggesting that fever plays an important role in immunity, human data conflict on the effect of antipyretics on clinical outcomes in critically ill adults. objectives: to determine the effect of ed antipyretic administration on -day in-hospital mortality in patients with severe sepsis. methods: single-center, retrospective observational cohort study of febrile severe sepsis patients presenting to an urban academic , -visit ed between june and june . all ed patients meeting the following criteria were included: age ‡ , temperature ‡ . °c, suspected infection, and either systolic blood pressure £ mmhg after a ml/kg fluid bolus or lactate of ‡ . patients were excluded for a history of cirrhosis or acetaminophen allergy. antipyretics were defined as acetaminophen, ibuprofen, or ketorolac. results: one hundred-thirty five ( . %) patients were treated with an antipyretic medication ( . % acetaminophen). intubated patients were less likely to receive antipyretic therapy ( . % vs. . %, p < . ), but the groups were otherwise well matched. patients requiring ed intubation (n = ) had much higher in-hospital mortality ( . % vs. . %, p < . ). patients given an antipyretic in the ed had lower mortality ( . % vs. . %, p < . ). when multivariable logistic regression was used to account for apache-ii, intubation status, and fever magnitude, antipyretic therapy was not associated with mortality (adjusted or . , . - . , p = . ). conclusion: although patients treated with antipyretic therapy had lower -day in-hospital mortality, antipyretic therapy was not independently associated with mortality in multivariable regression analysis. these findings are hypothesis-generating for future clinical trials, as the role of fever control has been largely unexplored in severe sepsis (grant ul rr , nih-ncrr). , and caval index ) . ± . (ci ) . , ) . ) and all were statistically significant. the groups receiving ml/kg and ml/kg had statistically significant changes in caval index; however the ml/kg group had no significant change in mean ivc diameter. one-way anova differences between the means of all groups were not statistically different. conclusion: overall, there were statistically significant differences in mean ivc-us measurements before and after fluid loading, but not between groups. fasting asymptomatic subjects had a wide inter-subject variation in both baseline ivc-us measurements and fluid-related changes. the wide differences within our ml/kg group may limit conclusions regarding proportionality. there were significant differences in performance on ed measures by ownership (p < . ) and region (p = . ). scores on ed process measures were highest at for-profit hospitals ( % above average) and hospitals in the south ( % above average), and lowest at public hospitals ( % below average) and hospitals in the northeast ( % below average). conclusion: there was considerable variation in performance on the ed measures included in the vbp program by hospital ownership and region. ed directors may come under increasing pressure to improve scores in order to reduce potential financial losses under the program. our data provide early information on the types of hospitals with the greatest opportunity for improvement. methods: design/setting -an independent agency mandated by the government collected and analyzed ed patient experience data using a comprehensive, validated multidimensional instrument and a random periodic sampling methodology of all ed patients. a prospective pre-post experimental study design was employed in the eight community and tertiary care hospitals most affected by crowding. two . month study periods were evaluated (pre: / - / / ; post: / / - / / ). outcomes -the primary outcome was patient perception of wait times and crowding reported as a composite mean score ( - ) from six survey items with higher scores representing better ratings. the overall rating of care by ed patients (composite score) and other dimensions of care were collected as secondary outcomes. all outcomes were compared using chi-square and two-tailed student's t-tests. results: a total of surveys were completed in both the pre-ocp and post-ocp study periods representing a response rate of %. we compared in-patient mortality from ami for patients who lived in a community with either . miles or miles of a closure but did not need to travel farther to the nearest ed with those who did not. we used patient-level data from the california office of statewide health and planning development (oshpd) database patient discharge data, and locations of patient residence and hospitals were geo-coded to determine any changes in distance to the nearest ed. we applied a generalized linear mixed effects model framework to estimate a patient's likelihood to die in the hospital of ami as a function of being affected by a neighborhood closure event. results background: fragmentation of care has been recognized as a problem in the us health care system. however, little is known about ed utilization after hospitalization, a potential marker of poor outpatient care coordination after discharge, particularly for common inpatient-based procedures. objectives: to determine the frequency and variability in ed visits after common inpatient procedures, how often they result in readmission, and related payments. methods: using national medicare data for - , we examined ed visits within days of hospital discharge after six common inpatient procedures: percutaneous coronary intervention, coronary artery bypass grafting (cabg), elective abdominal aortic aneurysm repair, back surgery, hip fracture repair, and colectomy. we categorized hospitals into risk-adjusted quintiles based on the frequency of ed visits after the index hospitalization. we report visits by primary diagnosis icd- codes and rates of readmission. we also assessed payments related to these ed visits. results: overall, the highest quintile of hospitals had -day ed visit rates that ranged from a low of . % with an associated . % readmission rate (back surgery) to a high of . % with an associated . % readmission rate (cabg). the most variability was more than -fold and found among patients undergoing colectomy in which the worst-performing hospitals saw . % of their patients experienced an ed visit within days while the best-performing hospitals saw . %. average total payments for the -day window from initial discharge across all surgical cohorts varied from $ , for patients discharged without subsequent ed visit; $ , for those experiencing an ed visit(s); $ , for those readmitted through the ed; and $ , for those readmitted from another source. if all patients who did not require readmission also did not incur an ed visit within the -day window, this would represent a potential cost savings of $ million. conclusion: among elderly medicare recipients there was significant variability between hospitals for -day ed visits after six common inpatient procedures. the ed visit may be a marker of poor care coordination in the immediate discharge period. this presents an opportunity to improve post-procedure outpatient care coordination which may save costs related to preventable ed visits and subsequent readmissions. objectives: we sought to assess the effect of pharmacist medication review on ed patient care, in particular time from physician order to medication administration for the patient (order-to-med time). methods: we conducted a multi-center, before-after study in two eds (urban academic teaching hospital and suburban community hospital, combined census of , ) after implementation of the electronic prospective pharmacy review system (prs). the system allowed a pharmacist to review all ed medication orders electronically at the time of physician order and either approve or alter the order. we studied a -month time period before implementation of the system (pre-prs, / / - / / ) and after implementation (post-prs, / / - / / ). we collected data on all ed medication orders including dose, route, class, pharmacist review action, time of physician order, and time of medication administration. differences in order-to-medication between the pre-and post-prs study periods were compared using a results: ed metrics that were significantly associated with lbtcs varied across ed patient-volume categories (table) . for eds seeing less than k patients annually, the percentage of ems arrivals admitted to the hospital and ed square footage were both weakly associated with lbtcs (p = . ). for eds seeing at least k- k patients, median ed length of stay (los), percent of patients admitted to hospital through the ed, percent of ems arrivals admitted to hospital, and percent of pediatric patients were all positively associated, while percent of patients admitted to the hospital was negatively associated with lbtcs. for eds seeing k- k, median los and percent of x-rays performed were positively associated, while percent of ekgs performed was negatively associated with lbtcs. for eds seeing k- k, percent of patients admitted to the hospital through the ed was negatively associated and percent of ekgs performed was positively associated with lbtcs. for eds with volume greater than k, none of the selected variables were associated with lbtc. conclusion: ed factors that help explain high lbtc rates differ depending on the size of an ed. interventions attempting to improve lbtc rates by modifying ed structure or process will need to consider baseline ed volume as a potential moderating influence. objectives: our study sought to compare bacterial growth of samples taken from surfaces after use of a common approved quat compound and a virtually non-toxic, commercially available solution containing elemental silver ( . %), hydrogen peroxide ( %), and peroxyacetic acid ( %) (shp) in a working ed. we hypothesized that, based on controlled laboratory data available, shp compound would be more effective on surfaces in an active urban ed. methods: we cleaned and then sampled three types of surfaces in the ed (suture cart, wooden railing, and the floor) during midday hours one minute after application of tap water, quat, and shp and then again at hours without additional cleaning. conventional environmental surface surveillance rodac media plates were used for growth assessment. images of bacterial growth were quantified at and hours. standard cleaning procedures by hospital staff were maintained per usual. results: shp was superior to control and quat one minute after application on all three surfaces. quat and water had x and x more bacterial growth than the surface cleaned with shp, respectively. hours later, the shp area produced fewer colonies sampled from the wooden railing: x more bacteria for quat, and x for water when compared to shp. h cultures from the cart and floor had confluent growth and could not be quantified. conclusion: shp outperforms quat in sterilizing surfaces after one minute application. shp may be a superior agent as a non-toxic, non-corrosive, and effective agent for surfaces in the demanding ed setting. further studies should examine sporidical and virucidal properties in a similar environment. objectives: evaluate the effect on patient satisfaction of increasing waiting room times and physician evaluation times. methods: emergency department flow metrics were collected on a daily basis as well as average daily patient satisfaction scores. the data were from july through february , in a , census urban hospital. the data were divided into equal intervals. the arrival to room time was divided by minute intervals up to minutes with the last group being greater than minutes. the physician evaluation times were divided into minute intervals, up to , the last group greater than with days in the group. data were analyzed using means and standard deviations, and well as anova for comparison between groups. results: the overall satisfaction score for the outpatient emergency visit was higher when the patient was in a room within minutes of arrival ( . , std deviation . ), analysis of variation between the groups had a p = . , for the means of each interval (see table ). the total satisfaction with the visit as well as satisfaction with the provider dropped when the evaluation extended over minutes, but was not statistically significant on anova analysis (see table for means). conclusion: once a patient's time in the waiting room extends beyond minutes, you have lost a significant opportunity for patient satisfaction; once they have been in the waiting room for over minutes, you are also much more likely to receive a poor score. physician evaluation time scores are much more consistent but as longer evaluation times occurred beyond total of minutes we started to see a trend downward in the satisfaction score. results: in all three eds, pain medication rates (both in ed and rx) varied significantly by clinical factors including location of pain, discharge diagnosis, pain level, and acuity. we observed little to no variation in pain medication rates by patient factors such as age, sex, race, insurance, or prior ed visits. the table displays key pain management practices by site and provider. after adjusting for patient and clinical characteristics, significant differences in pain medication rates remained by provider and site (see figure) . conclusion: within this health system, the approach to pain management by both providers and sites is not standardized. investigation of the potential effect of this variability on patient outcomes is warranted. results: all measures showed significant differences, p < . . average pts/h decreased post-cpoe and did not recover post transitional period, . ± . vs . ± . , p < . . rvu/h also decreased post-cpoe and did not recover post transitional period, . ± . vs . ± . and . ± . , p < . . charges/h also decreased after cpoe implementation and did not recover after system optimization. there was a sustained significant decrease in charges/h of . % ± . % post cpoe and . % ± . % post optimization, p < . . sub-group analysis for each provider group was also evaluated and showed variability for different providers. conclusion: there was a significant decrease in all productivity metrics four months after the implementation of cpoe. the system did undergo optimization initiated by providers with customization for ease and speed of use. however, productivity measurements did not recover after these changes were implemented. these data show that with the implementation of a cpoe system there is a decrease in productivity that continues even after a transition period and system customization. background: procedural competency is a key component of emergency medicine residency training. residents are required to log procedures to document quantity of procedures and identify potential weaknesses in their training. as emergency medicine evolves, it is likely that the type and number of procedures change over time. also, exposure to certain rare procedures in residency is not guaranteed. objectives: we seek to delineate trends in type and volume of core em procedures over a decade of emergency medicine residents graduating from an accredited four-year training program. methods: deidentified procedure logs from - were analyzed to assess trends in type and quantity of procedures. procedure logs were self-reported by individual residents on a continuous basis during training onto a computer program. average numbers of procedures per resident in each graduating class were noted. statistical analysis was performed using spss and includes a simple linear regression to evaluate for significant changes in number of procedures over time and an independent samples two-tailed t-test of procedures performed before and after the required resident duty hours change. results: a total of procedure logs were analyzed and the frequency of different procedures was evaluated. a significant increase was seen in one procedure, the venous cutdown. significant decreases were seen in procedures including key procedures such as central venous catheters, tube thoracostomy, and procedural sedation. the frequency of five high-stakes/ resuscitative procedures, including thoracotomy and cricothyroidotomy, remained steady but very low (< per resident over years). of the remaining procedures, showed a trend toward decreased frequency, while only increased. conclusion: over the past years, em residents in our program have recorded significantly fewer opportunities to perform most procedures. certain procedures in our emergency medicine training program have remained stable but uncommon over the course of nearly a decade. to ensure competency in uncommon procedures, innovative ways to expose residents to these potentially life saving skills must be considered. these may include practice on high-fidelity simulators, increased exposure to procedures on patients during residency (possibly on off-service rotations), or practice in cadaver and animal labs. objectives: to study the effectiveness of a unique educational intervention using didactic and hands-on training in usgpiv. we hypothesized that senior medical students would improve performance and confidence with usgpiv after the simulation training. methods: fourth year medical students were enrolled in an experimental, prospective, before and after study conducted at a university medical school simulation center. baseline skills in participant's usgpiv on simulation vascular phantoms were graded by ultrasound expert faculty using standardized checklists. the primary outcome was time to cannulation, and secondary outcomes were ability to successfully cannulate, number of needle attempts, and needle-tip visualization. subjects then observed a -minute presentation on correct performance of usgpiv followed by a -minute hands-on practical session using the vascular simulators with a : to : ultrasound instructor to student ratio. an expert blinded to the participant's initial performance graded post-educational intervention usgpiv ability. pre-and post-intervention surveys were obtained to evaluate usgpiv confidence, previous experience with ultrasound, peripheral iv access, usg-piv, and satisfaction with the educational format. objectives: this study examines the grade distribution of resident evaluations when the identity of the evaluator was anonymous as compared to when the identity of the evaluator was known to the resident. we hypothesize that there will be no change in the grades assigned to residents. methods: we retrospectively reviewed all faculty evaluations of residents and grades assigned from july , through november , . prior to july , the identity of the faculty evaluators was anonymous, while after this date, the identity of the faculty evaluators was made known to the residents. throughout this time period, residents were graded on a five-point scale. each resident evaluation included grades in the six acgme core competencies as well as in select other abilities. specific abilities evaluated varied over the dates analyzed. evaluations of residents were assigned to two groups, based on whether the evaluator was anonymous or made known to the resident. grades were compared between the two groups. results: a total of , grades were assigned in the anonymous group, with an average grade of . ( ci . , . ). a total of , grades were assigned in the known group with an average grade of . ( ci . , . ). specific attention was paid to assignment of unsatisfactory grades ( or on the five-point scale). the anonymous group assigned grades in this category, comprising . % of all grades assigned. the known group assigned grades in this category, comprising . % of all grades assigned. unsatisfactory grades were assigned by the anonymous group . % ( ci . , . ) more often. additionally, . % ( ci . , . ) fewer exceptional grades ( or on the five-point scale) were assigned by the anonymous group. conclusion: the average grade assigned was closer to average ( on a five-point scale) when the identity of the evaluator was made known to the residents. additionally, fewer unsatisfactory and exceptional grades were assigned in this group. this decrease of both unsatisfactory and exceptional grades may make it more difficult for program directors to effectively identify struggling and strong residents respectively. testing to improve knowledge retention from traditional didactic presentations: a pilot study david saloum, amish aghera, brian gillett maimonides medical center, brooklyn, ny background: the acgme requires an average of at least hours of planned educational experiences each week for em residents, which traditionally consists of formal lecture based instruction. however, retention by adult learners is limited when presented material in a lecture format. more effective methods such as small group sessions, simulation, and other active learning modalities are time-and resource-intensive and therefore not practical as a primary method of instruction. thus, the traditional lecture format remains heavily relied upon. efficient strategies to improve the effectiveness of lectures are needed. testing utilized as a learning tool to force immediate recall of lecture material is an example of such a strategy. objectives: to evaluate the effect of immediate postlecture short answer quizzes on em residents' retention of lecture content. methods: in this prospective randomized controlled study, em residents from a community based -year training program were randomized into two groups. block randomization provided a similar distribution of postgraduate year training levels and performance on both us-mle and in-training examinations between the two groups. each group received two identical -minute lectures on ecg interpretation and aortic disease. one group of residents completed a five-question short answer quiz immediately following each lecture (n = ), while the other group received the lectures without subsequent quizzes (n = ). the quizzes were not scored or reviewed with the residents. two weeks later, retention was assessed by testing both groups with a -question multiple choice test (mct) derived in equal part from each lecture. mean and median test results were then compared between groups. statistical significance was determined using a paired t-test of median test scores from each group. results: residents who received immediate post-lecture quizzes demonstrated significantly higher mct scores (mean = %, median %, n = ) compared to those receiving lectures alone (mean = %, median = %, n = ); p = . . conclusion: short answer testing immediately after a traditional didactic lecture improves knowledge retention at a -week interval. limitations of the study are that it is a single center study and long term retention was not assessed. background: the task of educating the next generation of physicians is steadily becoming more difficult with the inherent obstacles that exist for faculty educators and the work hour restrictions that students must adhere to. the obstacles make developing curricula that not only cover important topics but also do so in a fashion that helps support and reinforce the clinical experiences very difficult. several areas of medical education are using more asynchronous techniques and self-directed online educational modules to overcome these obstacles. objectives: the aim of this study was to demonstrate that educational information pertaining to core pediatric emergency medicine topics could be as effectively disseminated to medical students via self-directed online educational modules as it could through traditional didactic lectures. methods: this was a prospective study conducted from august , through december , . students participating in the emergency medicine rotation at carolinas medical center were enrolled and received education in a total of eight core concepts. the students were divided into two groups which changed on a monthly basis. group was taught four concepts via self-directed online modules and four traditional didactic lectures. group was taught the same core concepts, but in opposite fashion to group . each student was given a pre-test, post-test, and survey at the conclusion of the rotation. results: a total of students participated in the study. students, regardless of which group assigned, performed similarly on the pre-test, with no statistical difference among scores. when looking at the summative total scores between online and traditional didactic lectures, there was a trend towards significance for more improvement among those taught online. the student's assessment of the online modules showed that the majority either felt neutral or preferred the online method. the majority thought the depth and length of the modules were perfect. most students thought having access to the online modules was valuable and all but one stated that they would use them again. conclusion: this study demonstrates that self-directed, online educational modules are able to convey important concepts in emergency medicine similar to traditional didactics. it is an effective learning technique that offers several advantages to both the educator and student. background: critical access hospitals (cah) provide crucial emergency care to rural populations that would otherwise be without ready access to health care. data show that many cah do not meet standard adult quality metrics. adults treated at cah often have inferior outcomes to comparable patients cared for at other community-based emergency departments (eds). similar data do not exist for pediatric patients. objectives: as part of a pilot project to improve pediatric emergency care at cah, we sought to determine whether these institutions stock the equipment and medications necessary to treat any ill or injured child who presents to the ed. methods: five north carolina cah volunteered to participate in an intensive educational program targeting pediatric emergency care. at the initial site visit to each hospital, an investigator, in conjunction with the ed nurse manager, completed a -item checklist of commonly required ed equipment and medications based on the acep ''guidelines for care of children in the emergency department''. the list was categorized into monitoring and respiratory equipment, vascular access supplies, fracture and trauma management devices, and specialized kits. if available, adult and pediatric sizes were listed. only hospitals stocking appropriate pediatric sizes of an item were counted as having that item. the pharmaceutical supply list included antibiotics, antidotes, antiemetics, antiepileptics, intubation and respiratory medications, iv fluids, and miscellaneous drugs not otherwise categorized. results: overall, the hospitals reported having % of the items listed (range - %). the two greatest deficiencies were fracture devices (range - %), with no hospital stocking infant-sized cervical collars, and antidotes, with no hospital stocking pralidoxime, / hospitals stocking fomepizole, and / hospitals stocking pyridoxine and methylene blue. only one of the five institutions had access to prostaglandin e. the hospitals stated cost and rarity of use as the reason for not stocking these medications. conclusion: the ability of cah to care for pediatric patients does not appear to be hampered by a lack of equipment. ready access to infrequently used, but potentially lifesaving, medications is a concern. tertiary care centers preparing to accept these patients should be aware of these potential limitations as transport decisions are made. background: while incision and drainage (i&d) alone has been the mainstay of management of uncomplicated abscesses for decades, some advocate for adjunct antibiotic use, arguing that available trials are underpowered and that antibiotics reduce treatment failures and recurrence. objectives: to investigate the role of antibiotics in addition to i&d in reducing treatment failure as compared to management with i&d alone. methods: we performed a search using medline, embase, web of knowledge, and google scholar databases (with a medical librarian) to include trials and observational studies analyzing the effect of antibiotics in human subjects with skin and soft-tissue abscesses. two investigators independently reviewed all the records. we performed three overlapping meta-analy-ses: . only randomized trials comparing antibiotics to placebo on improvement of the abscess during standard follow-up. . trials and observational studies comparing appropriate antibiotics to placebo, no antibiotics, or inappropriate antibiotics (as gauged by wound culture) on improvement during standard follow-up. . only trials, but broadened outcome to include recurrence or new lesions during a longer follow-up period as treatment failure. we report pooled risk ratios (rr) using a fixed-effects model for our point estimates with shore-adjusted % confidence intervals (ci). results: we screened , records, of which studies fit inclusion criteria, of which were meta-analyzed ( trials, observational studies) because they reported results that could be pooled. of the studies, enrolled subjects from the ed, from a soft-tissue infection clinic, and from a general hospital without definition of enrollment site. five studies enrolled primarily adults, pediatrics, and without specification of ages. after pooling results for all randomized trials only, the rr = . ( % ci: . - . ). exposure being ''appropriate'' antibiotics (using trials and observational studies) resulted in a pooled rr = . ( % ci: . - . ). when we broadened our treatment failure criteria to include recurrence or new lesions at longer lengths of follow-up (trials only), we noted a rr = . ( % ci: . - . ). conclusion: based on available literature pooled for this analysis, there is no evidence to suggest any benefit from antibiotics in addition to i&d in the treatment of skin and soft tissue abscesses. (originally submitted as a ''late-breaker.'') primary objectives: to compare wound healing and recurrence rates after primary vs. secondary closure of drained abscesses. we hypothesized the percentage of drained ed abscesses that would be completely healed at days would be higher after primary closure. methods: this randomized clinical trial was undertaken in two academic emergency departments. immunocompetent adult patients with simple, localized cutaneous abscesses were randomly assigned to i & d followed by primary or secondary closure. randomization was balanced by center, with an allocation sequence based on a block size of four, generated by a computer random number generator. the primary outcome was percentage of healed wounds seven days after drainage. a sample of patients had % power to detect an absolute difference of % in healing rates assuming a baseline rate of %. all analyses were by intention to treat. results: twenty-seven patients were allocated to primary and to secondary closure, of whom and , respectively, were followed to study completion. healing rates at seven days were similar between the primary and secondary closure groups ( we compared consecutive patients each scanned on the or slice ccta in - . measures and outcomes-data were prospectively collected using standardized data collection forms required prior to performing ccta. the main outcomes were cumulative radiation doses and volumes of intravenous contrast. data analysis-groups compared with t-, mann whitney u, and chi-square tests. results: the mean age of patients imaged with the and scanners were (sd ) vs. ( ) (p = . ). male:female ratios were also similar ( : vs. : respectively, p = . ). both mean (p < . ) and median (p = . ) effective radiation dose were significantly lower with the ( . and msv) vs. the -slice scanner ( . and msv) respectively. prospective gating was successful in % of the scans and only in % of the scans (p < . ). mean iv contrast volumes were also lower for the vs. the -slice scanner ( ± vs. ± ml; p < . ). the % non-diagnostic scans was similarly low in both scanners ( % each). there were no differences in use of beta-blockers or nitrates. conclusion: when compared with the -slice scanner, the -slice scanner reduces the effective radiation doses and iv contrast volumes in ed patients with cp undergoing ccta. need for beta-blockers and nitrates was similar and both scanners achieved excellent diagnostic image quality. background: a few studies have demonstrated that bedside ultrasound measurement of inferior vena cava to aorta (ivc-to-ao) ratio is associated with the level of dehydration in pediatric patients and a proposed cutoff of . has been suggested, below which a patient is considered dehydrated. objectives: we sought to externally validate the ability of ivc-to-ao ratio to discriminate dehydration and the proposed cutoff of . in an urban pediatric emergency department (ed). methods: this was a prospective observational study at an urban pediatric ed. we included patients aged to months with clinical suspicion of dehydration by the ed physician and an equal number of control patients with no clinical suspicion of dehydration. we excluded children who were hemodynamically unstable, had chronic malnutrition or failure to thrive, open abdominal wounds, or were unable to provide patient or parental consent. a validated clinical dehydration score (cds) (range to ) was used to measure initial dehydration status. an experienced sonographer blinded to the cds and not involved in the patient's care measured the ivc-to-ao ratio on the patient prior to any hydration. cds was collapsed into a binary outcome of no dehydration or any level of dehydration ( or higher). the ability of ivc-to-ao ratio to discriminate dehydration was assessed using area under the receiver operating characteristic curve (auc) and the sensitivity and specificity of ivc-to-ao ratio was calculated for three cutoffs ( . , . , . ). calculation of auc was repeated after adjusting for age and sex. results: patients were enrolled, ( %) of whom had a cds of or higher. median age was (interquartile range - ) months, and ( %) were female. the ivcto-ao ratio showed an unadjusted auc of . ( % ci . - . ) and adjusted auc of . ( % ci . - . ). for a cutoff of . sensitivity was % ( % ci %- %) and specificity % ( % ci %- %); for a cutoff of . sensitivity was % ( % ci %- %) and specificity % ( % ci %- %); for a cutoff of . sensitivity was % ( % ci %- %) and specificity % ( % ci %- %). conclusion: the ability of the ivc-to-ao ratio to discriminate dehydration in young pediatric ed patients was modest and the cutoff of . was neither sensitive nor specific. background: while early cardiac computed tomographic angiography (ccta) could be more effective to manage emergency department (ed) patients with acute chest pain and intermediate (> %) risk of acute coronary syndrome (acs) than current management strategies, it also could result in increased testing, cost, and radiation exposure. objectives: the purpose of the study was to determine whether incorporation of ccta early in the ed evaluation process leads to more efficient management and earlier discharge than usual care in patients with acute chest pain at intermediate risk for acs. methods: randomized comparative effectiveness trial enrolling patients between - years of age without known cad, presenting to the ed with chest pain but without ischemic ecg changes or elevated initial troponin and require further risk stratification for decision making, at nine us sites. patients are being randomized to either ccta as the first diagnostic test or to usual care, which could include no testing or functional testing such as exercise ecg, stress spect, and stress echo following serial biomarkers. test results were provided to physicians but management in neither arm was driven by a study protocol. data on time, diagnostic testing, and cost of index hospitalization, and the following days are being collected. the primary endpoint is length of hospital stay (los). the trial is powered to allow for detection of a difference in los of . hours between competing strategies with % power assuming that % of projected los values are true. secondary endpoints are cumulative radiation exposure, and cost of competing strategies. tertiary endpoints are institutional, caregiver, and patient characteristics associated with primary and secondary outcomes. rate of missed acs within days is the safety endpoint. results: as of november st, , of patients have been enrolled (mean age: ± , . % female, acs rate . %). the anticipated completion of the last patient visit is / / and the database will be locked in early march . we will present the results of the primary, secondary, and some tertiary endpoints for the entire cohort. conclusion: romicat ii will provide rigorous data on whether incorporation of ccta early in the ed evaluation process leads to more efficient management and triage than usual care in patients with acute chest pain at intermediate risk for acs. (originally submitted as a ''late-breaker.'') meta background: many studies have documented higher rates of advanced radiography utilization across u.s. emergency departments (eds) in recent years, with an associated decrease in diagnostic yield (positive tests / total tests). provider-to-provider variability in diagnostic yield has not been well studied, nor have the factors that may explain these differences in clinical practice. objectives: we assessed the physician-level predictors of diagnostic yield using advanced radiography to diagnose pulmonary embolus (pe) in the ed, including demographics and d-dimer ordering rates. methods: we conducted a retrospective chart review of all ed patients who had a ct chest or v/q scan ordered to rule out pe from / to / in four hospitals in the medstar health system. attending physicians were included in the study if they had ordered or more scans over the study period. the result of each ct and vq scan was recorded as positive, negative, or indeterminate, and the identity of the ordering physician was also recorded. data on provider sex, residency type (em or other), and year of residency completion were collected. each provider's positive diagnostic yield was calculated, and logistic regression analysis was done to assess correlation between positive scans and provider characteristics. results: during the study period, , scans ( , cts and , v/qs) were ordered by providers. the physicians were an average of . years from residency, % were female, and % were em-trained. diagnostic yield varied significantly among physicians (p < . ), and ranged from % to %. the median diagnostic yield was . % (iqr . %- . %). the use of d-dimer by provider also varied significantly from % to % (p < . ). the odds of a positive test were significantly lower among providers less than years out of residency graduation (or . , ci . - . ) after controlling for provider sex, type of residency training, d-dimer use, and total number of scans ordered. conclusion: we found significant provider variability in diagnostic yield for pe and use of d-dimer in this study population, with % of providers having diagnostic yield less than or equal to . %. providers who were more recently graduated from residency appear to have a lower diagnostic yield, suggesting a more conservative approach in this group. background: the literature reports that anticoagulation increases the risk of mortality in patients presenting to emergency departments (ed) with head trauma (ht). it has been suggested that such patients should be treated in a protocolized fashion, including ct within minutes, and anticipatory preparation of ffp before ct results are available. there are significant logistical and financial implications associated with implementation of such a protocol. objectives: our primary objective was to determine the effect of anticoagulant therapy on the risk of intracranial hemorrhage (ich) in elderly patients presenting to our urban community hospital following bunt head injury. methods: this was a retrospective chart review study of ht patients > years of age presenting to our ed over a -month period. charts reviewed were identified using our electronic medical record via chief complaints and icd- codes and cross referencing with written ct logs. research assistants underwent review of at least % of their contributing data to validate reliability. we collected information regarding use of warfarin, clopidogrel, and aspirin and ct findings of ich. using univariate logistic regression, we calculated odds ratios (or) for ich with % ci. results: we identified elderly ht patients. the mean age of our population was , ( . %) admitted to using anticoagulant therapy, and % were on antiplatelet drugs. ( . %) of the cohort had icb, patients required neurosurgical intervention, and had transfusion of blood products. of the non-anticoagulated patients, ( . %) were found to have ich, half of those ( ) , and mir- ) were measured using real-time quantitative pcr from serum drawn at enrollment. il- , il- , and tnf-a were measured using a bio-plex suspension system. baseline characteristics, il- , il- , tnf-a and micrornas were compared using one way anova or fisher exact test, as appropriate. correlations between mirnas and sofa scores, il- , il- , and tnf-a were determined using spearman's rank. a logistic regression model was constructed using in-hospital mortality as the dependent variable and mirnas as the independent variables of interest. bonferroni adjustments were made for multiple comparisons. results: of patients, were controls, had sepsis, and had septic shock. we found no difference in serum mir- a or mir- between cohorts, and found no association between these micrornas and either inflammatory markers or sofa score. mir- demonstrated a significant correlation with sofa score (q = . , p = . ), il- (q = . , p = . ), but not il- or tnf-a (p = . , p = . ). logistic regression demonstrated mir- to be associated with mortality, even after adjusting for sofa score (p = . ). conclusion: mir- a or mir- failed to demonstrate any diagnostic or prognostic ability in this cohort. mir- was associated with inflammation, increasing severity of illness, and mortality, and may represent a novel prognostic marker for diagnosis and prognosis of sepsis. objectives: to examine the association between emergency physician recognition of sirs and sepsis and subsequent treatment of septic patients. methods: a retrospective cohort study of all-age patient medical records with positive blood cultures drawn in the emergency department from / - / at a level i trauma center. patient parameters were reviewed including vital signs, mental status, imaging, and laboratory data. criteria for sirs, sepsis, severe sepsis, and septic shock were applied according to established guidelines for pediatrics and adults. these data were compared to physician differential diagnosis documentation. the mann-whitney test was used to compare time to antibiotic administration and total volume of fluid resuscitation between two groups of patients: those with recognized sepsis and those with unrecognized sepsis. results: sirs criteria were present in / reviewed cases. sepsis criteria were identified in / cases and considered in the differential diagnosis in / septic patients. severe sepsis was present in / cases and septic shock was present in / cases. the sepsis -hour resuscitation bundle was completed in the emergency department in cases of severe sepsis or septic shock. patients who met sepsis criteria and were recognized by the ed physician had a median time to antibiotics of minutes (iqr: - ) and a median ivf of ml (iqr: - ). the patients who met sepsis criteria but went unrecognized in the documentation had a median time to antibiotics of minutes (iqr: - ) and median volume of fluid resuscitation of ml (iqr: . median time to antibiotics and median volume of fluid resuscitation differed significantly between recognized and unrecognized septic patients (p = . and p = . , respectively). conclusion: emergency physicians correctly identify and treat infection in most cases, but frequently do not document sirs and sepsis. lack of documentation of sepsis in the differential diagnosis is associated with increased time to antibiotic delivery and a smaller total volume of fluid administration, which may explain poor sepsis bundle compliance in the emergency department. background: severe sepsis is a common clinical syndrome with substantial human and financial impact. in the first consensus definition of sepsis was published. subsequent epidemiologic estimates were collected using administrative data, but ongoing discrepancies in the definition of severe sepsis led to large differences in estimates. objectives: we seek to describe the variations in incidence and mortality of severe sepsis in the us using four methods of database abstraction. methods: using a nationally representative sample, four previously published methods (angus, martin, dombrovskiy, wang) were used to gather cases of severe sepsis over a -year period ( ) ( ) ( ) ( ) ( ) ( ) . in addition, the use of new icd- sepsis codes was compared to previous methods. our main outcome measure was annual national incidence and in-hospital mortality of severe sepsis. results: the average annual incidence varied by as much as . fold depending on method used and ranged from , ( / , population) to , , ( , / , ) using the methods of dombrovskiy and wang, respectively. average annual increase in the incidence of severe sepsis was similar ( . - . %) across all methods. total mortality mirrored the increase in incidence over the -year period ( background: radiation exposure from medical imaging has been the subject of many major journal articles, as well as the topic of mainstream media. some estimate that one-third of all ct scans are not medically justified. it is important for practitioners ordering these scans to be knowledgeable of currently discussed risks. objectives: to compare the knowledge, opinions, and practice patterns of three groups of providers in regards to cts in the ed. methods: an anonymous electronic survey was sent to all residents, physician assistants, and attending physicians in emergency medicine (em), surgery, and internal medicine (im) at a single academic tertiary care referral level i trauma center with an annual ed volume of over , visits. the survey was pilot tested and validated. all data were analyzed using the pearson's chi-square test. results: there was a response rate of % ( / ). data from surgery respondents were excluded due to a low response rate. in comparison to im, em respondents correctly equated one abdominal ct to between and chest x-rays, reported receiving formal training regarding the risks of radiation from cts, believe that excessive medical imaging is associated with an increased lifetime risk of cancer, and routinely discuss the risks of ct imaging with stable patients more often (see table ). particular patient factors influence whether radiation risks are discussed with patients by % in each specialty (see table ). before ordering an abdominal ct in a stable patient, im providers routinely review the patient's medical imaging history less often than em providers surveyed. overall, % of respondents felt that ordering an abdominal ct in a stable ed patient is a clinical decision that should be discussed with the patient, but should not require consent. conclusion: compared with im, em practitioners report greater awareness of the risks of radiation from cts and discuss risks with patients more often. they also review patients' imaging history more often and take this, as well as patients' age, into account when ordering cts. these results indicate a need for improved education for both em and im providers in regards to the risks of radiation from ct imaging. background: in nebraska, % of emergency departments have annual visits less than , , and the predominance are in rural settings. general practitioners working in rural emergency departments have reported low confidence in several emergency medicine skills. current staffing patterns include using midlevels as the primary provider with non-emergency medicine trained physicians as back-up. lightly-embalmed cadaver labs are used for resident's procedural training. objectives: to describe the effect of a lightlyembalmed cadaver workshop on physician assistants' (pa) reported level of confidence in selected emergency medicine procedures. methods: an emergency medicine procedure lab was offered at the nebraska association of physician assistants annual conference. each lab consisted of a -hour hands-on session teaching endotracheal intubation techniques, tube thoracostomy, intraosseous access, and arthrocentesis of the knee, shoulder, ankle, and wrist to pas. irb-approved surveys were distributed pre-lab and a post-lab survey was distributed after lab completion. baseline demographic experience was collected. pre-and post-lab procedural confidence was rated on a six-point likert scale ( - ) with representing no confidence. the wilcoxon signed-rank test was use to calculate p values. results: pas participated in the course. all completed a pre-and post-lab assessment. no pa had done any one procedure more than times in their career. pre-lab modes of confidence level were £ for each procedure. post-lab modes were > for each procedure except arthrocentesis of the ankle and wrist. however, post lab assessments of procedural confidence significantly improved for all procedures with p values < . . conclusion: midlevel providers' level of confidence improved for emergent procedures after completion of a procedure lab using lightly-embalmed cadavers. a mobile cadaver lab would be beneficial to train rural providers with minimal experience. background: use of automated external defibrillators (aed) improves survival in out-of-hospital cardiopulmonary arrest (ohca). since , the american heart association has recommended that individuals one year of age or older who sustain ohca have an aed applied. little is known about how often this occurs and what factors are associated with aed use in the pediatric population. objectives: our objective was to describe aed use in the pediatric population and to assess predictors of aed use when compared to adult patients. methods: we conducted a secondary analysis of prospectively collected data from u.s. cities that participate in the cardiac arrest registry to enhance survival (cares). patients were included if they had a documented resuscitation attempt from october , through december , and were ‡ year old. patients were considered pediatric if they were less than years old. aed use included application by laypersons and first responders. hierarchical multivariable logistic regression analysis was used to estimate the associations between age and aed use. results: there were , ohcas included in this analysis, of which ( . %) occurred in pediatric patients. overall aed use in the final sample was , , with , ( . %) total survivors. aeds were applied less often in pediatric patients ( . %, % ci: . %- . % vs . %, % ci: . %- . %). within the pediatric population, only . % of patients with a shockable rhythm had an aed used. in all pediatric patients, regardless of presenting rhythm, aed use demonstrated a statistically significant increase in return of spontaneous circulation (aed used . %, % ci: . - . vs aed not used . %, % ci: . - . , p < . ), although there was no significant increase in survival to hospital discharge (aed used . %; aed not used . %; p = . ). in the adjusted model, pediatric age was independently associated with failure to use an aed (or . , % ci: . - . ) as was female sex (or . , % ci: . - . ). patients who had a public arrest (or . , % ci: . - . ) or one that was witnessed by a bystander (or . . %: ci . - . ) were also predictive of aed use. conclusion: pediatric patients who experience ohca are less likely to have an aed used. continued education of first responders and the lay public to increase aed use in this population is necessary. does implementation of a therapeutic hypothermia protocol improve survival and neurologic outcomes in all comatose survivors of sudden cardiac arrest? ken will, michael nelson, abishek vedavalli, renaud gueret, john bailitz cook county (stroger), chicago, il background: the american heart association (aha) currently recommends therapeutic hypothermia (th) for out of hospital comatose survivors of sudden cardiac arrest (cssca) with an initial rhythm of ventricular fibrillation (vf). based on currently limited data, the aha further recommends that physicians consider th for cssca, from both the out and inpatient settings, with an initial non-vf rhythm. objectives: investigate whether a th protocol improves both survival and neurologic outcomes for cssca, for out and inpatients, with any initial rhythm, in comparison to outcomes previously reported in literature prior to th. methods: we conducted a prospective observational study of cssca between august and may whose care included th. the study enrolled eligible consecutive cssca survivors, from both out and inpatient settings with any initial arrest rhythm. primary endpoints included survival to hospital discharge and neurologic outcomes, stratified by sca location, and by initial arrest rhythm. results: overall, of eligible patients, ( %, % ci - %) survived to discharge, ( %, % ci - %) with at least a good neurologic outcome. twelve were out and were inpatients. among the outpatients, ( %, % ci - %) survived to discharge, ( %, % ci - %) with at least a good neurologic outcome. among the inpatients, ( %, % ci - ) survived to discharge, ( %, % ci - %) with at least a good neurologic outcome. by initial rhythm, patients had an initial rhythm of vf/t and non-vf/t. among the patients with an initial rhythm of vf/t, ( %, ci - %) survived to discharge, all with at least a good outcome, including out and inpatients. among the patients with an initial rhythm of non-vf/t, ( %, ci - %) survived to discharge, ( %, ci - %) with at least a good neurologic outcome, including out and inpatients. conclusion: our preliminary data initially suggest that local implementation of a th protocol improves survival and neurologic outcomes for cssca, for out and inpatients, with any initial rhythm, in comparison to outcomes previously reported in literature prior to th. subsequent research will include comparison to local historical controls, additional data from other regional th centers, as well as comparison of different cooling methods. protocolized background: therapeutic hypothermia (th) has been shown to improve the neurologic recovery of cardiac arrest patients who experience return of spontaneous circulation (rosc). it remains unclear as to how earlier cooling and treatment optimization influence outcomes. objectives: to evaluate the effects of a protocolized use of early sedation and paralysis on cooling optimization and clinical outcomes in survivors of cardiac arrest. methods: a -year ( - ), pre-post intervention study of patients with rosc after cardiac arrest treated with th was performed. those patients treated with a standardized order set which lacked a uniform sedation and paralytic order were included in the pre-intervention group, and those with a standardized order set which included a uniform sedation and paralytic order were included in the post-intervention group. patient demographics, initial and discharge glasgow coma scale (gcs) scores, resuscitation details, cooling time variables, severity of illness as measured by the apache ii score, discharge disposition, functional status, and days to death were collected and analyzed using student's t-tests, man-whitney u tests, and the log-rank test. results: patients treated with th after rosc were included, with patients in the pre-intervention group and in the post-intervention group. the average time to goal temperature ( °c) was minutes (pre-intervention) and minutes (post-intervention) (p = . ). a -hour time target was achieved in . % of the patients (post-intervention) compared to . % in the pre-group (p = . ). twenty-eight day mortality was similar between groups ( . % and . %) though hospital length of stay ( days pre-and days post-intervention) and discharge gcs ( preand -post-intervention) differed between cohorts. more post-intervention patients were discharged to home ( . %) compared to . % in the pre-intervention group. conclusion: protocolized use of sedation and paralysis improved time to goal temperature achievement. these improved th time targets were associated with improved neuroprotection, gcs recovery, and disposition outcome. standardized sedation and paralysis appears to be a useful adjunct in induced th. background: ct is increasingly used to assess children with signs and symptoms of acute appendicitis (aa) though concerns regarding long-term risk of exposure to ionizing radiation have generated interest in methods to identify children at low risk. objectives: we sought to derive a clinical decision rule (cdr) of a minimum set of commonly used signs and symptoms from prior studies to predict which children with acute abdominal pain have a low likelihood of aa and compared it to physician clinical impression (pci). methods: we prospectively analyzed subjects aged to years in u.s. emergency departments with abdominal pain plus signs and symptoms suspicious for aa within the prior hours. subjects were assessed by study staff unaware of their diagnosis for clinical attributes drawn from published appendicitis scoring systems and physicians responsible for physical examination estimated the probability of aa based on pci prior to their medical disposition. based on medical record entry rate, frequently used cdr attributes were evaluated using recursive partitioning and logistic regression to select the best minimum set capable of discriminating subjects with and without aa. subjects were followed to determine whether imaging was used and use was tabulated by both pci and the cdr to assess their ability to identify patients who did or did not benefit based on diagnosis. results: this cohort had a . % prevalence ( / subjects) of aa. we derived a cdr based on the absence of two out of three of the following attributes: abdominal tenderness, pain migration, and rigidity/ guarding had a sensitivity of . % ( % ci: . - . ), specificity of . % ( % ci: . - . ), npv of . % ( % ci: . - . ), and negative likelihood ratio of . ( % ci: . - . ). the pci set at aa < % pre-test probability had a sensitivity of . % ( % ci: . - . ), specificity of . % ( % ci: . - . ), npv of . % ( % ci: . - . ), and negative likelihood ratio of . ( % ci: . - . ). the methods each classified % of the patients as low risk for aa. our cdr identified . % ( / ) of low risk subjects who received ct but being aa (-), could have been spared ct, while the pci identified . % ( / ). conclusion: compared to physician clinical impression, our clinical decision rule can identify more children at low risk for appendicitis who could be managed more conservatively with careful observation and avoidance of ct. negative background: abdominal pain is the most common complaint in the ed and appendicitis is the most common indication for emergency surgery. a clinical decision rule (cdr) identifying abdominal pain patients at a low risk for appendicitis could lead to a significant reduction in ct scans and could have a significant public health impact. the alvarado score is one of the most widely applied cdrs for suspected appendicitis, and a low modified alvarado score (less than ) is sometimes used to rule out acute appendicitis. the modified alvarado score has not been prospectively validated in ed patients with suspected appendicitis. objectives: we sought to prospectively evaluate the negative predictive value of a low modified alvarado score (mas) in ed patients with suspected appendicitis. we hypothesized that a low mas (less than ) would have a sufficiently high npv (> %) to rule out acute appendicitis. methods: we enrolled patients greater than or equal to years old who were suspected of having appendicitis (listed as one of the top three diagnosis by the treating physician before ancillary testing) as part of a prospective cohort study in two urban academic eds from august to april . elements of the mas and the final diagnosis were recorded on a standard data form for each subject. the sensitivity, specificity, negative predictive value (npv), and positive predictive value (ppv) were calculated with % ci for a low mas and final diagnosis of appendicitis. background: evaluating children for appendicitis is difficult and strategies have been sought to improve the precision of the diagnosis. computed tomography is now widely used but remains controversial due to the large dose of ionizing radiation and risk of subsequent radiation-induced malignancy. objectives: we sought to identify a biomarker panel for use in ruling out pediatric acute appendicitis as a means of reducing exposure to ionizing radiation. methods: we prospectively enrolled subjects aged to years presenting in u.s. emergency departments with abdominal pain and other signs and symptoms suspicious for acute appendicitis within the prior hours. subjects were assessed by study staff unaware of their diagnosis for clinical attributes drawn from appendicitis scoring systems and blood samples were analyzed for cbc differential and candidate proteins. based on discharge diagnosis or post-surgical pathology, the cohort exhibited a . % prevalence ( / subjects) of appendicitis. clinical attributes and biomarker values were evaluated using principal component, recursive partitioning, and logistic regression to select the combination that best discriminated between those subjects with and without disease. mathematical combination of three inflammation-related markers in a panel comprised of myeloid-related protein / complex (mrp), c-reactive protein (crp), and white blood cell count (wbc) provided optimal discrimination. results: this panel exhibited a sensitivity of % ( % ci, - %), a specificity of % ( % ci, - %), and a negative predictive value of % ( % ci, - %) in this cohort. the observed performance was then verified by testing the panel against a pediatric subset drawn from an independent cohort of all ages enrolled in an earlier study. in this cohort, the panel exhibited a sensitivity of % ( % ci, - %), a specificity of % ( % ci, - %), and a negative predictive value of % ( % ci, - %). conclusion: appyscore is highly predictive of the absence of acute appendicitis in these two cohorts. if these results are confirmed by a prospective evaluation currently underway, the appyscore panel may be useful to classify pediatric patients presenting to the emergency department with signs and symptoms suggestive of, or consistent with, acute appendicitis and thereby sparing many patients ionizing radiation. background: there are no current studies on the tracking of emergency department (ed) patient dispersal when a major ed closes. this study demonstrates a novel way to track where patients sought emergency care following the closure of saint vincent's catholic medical center (svcmc) in manhattan by using de-identified data from a health information exchange, the new york clinical information exchange (nyclix). nyclix matches patients who have visited multiple sites using their demographic information. on april , , svcmc officially stopped providing emergency and outpatient services. we report the patterns in which patients from svcmc visited other sites within nyclix. objectives: we hypothesize that patients often seek emergency care based on geography when a hospital closes. methods: a retrospective pre-and post-closure analysis was performed of svcmc patients visiting other hospital sites. the pre-closure study dates were january , -march , . the post closure study dates were may , -july , . a svcmc patient was defined as a patient with any svcmc encounter prior to its closure. using de-identified aggregate count data, we calculated the average number of visits per week by svcmc patients at each site (hospital a-h). we ran a paired t-test to compare the pre-and post-closure averages by site. the following specifications were used to write the database queries: of patients who had one or more prior visits to svcmc for each day within the study return the following: a. eid: a unique and meaningless proprietary id generated within the nyclix master patient index (mpi). b. age: thru the age of . persons over were listed as '' + '' c. ethnicity/race d. type of visit: emergency e. location of visit: specific nyclix site. results: nearby hospitals within miles saw the highest number of increased ed visits after svcmc closed. this increase was seen until about miles. hospitals > miles away did not see any significant changes in ed visits. see table. conclusion: when a hospital and its ed close down, patients seem to seek emergency care at the nearest hospital based on geography. other factors may include the patient's primary doctor, availabilities of outpatient specialty clinics, insurance contracts, or preference of ambulance transports. this study is limited by the inclusion of data from only the eight hospitals participating in nyclix at the time of the svcmc closure. upstream methods: data were collected on all ed ems arrivals from the metro calgary (population . million) area to its three urban adult hospitals. the study phases consisted of the months from february to october (pre-ocp) compared against the same months in (post-ocp). data from the ems operational database and the regional emergency department information system (redis) database were linked. the primary analysis examined the change in ems offload delay defined as the time from ems triage arrival until patient transfer to an ed bed. a secondary analysis evaluated variability in ems offload delay between receiving eds. conclusion: implementation of a regional overcapacity protocol to reduce ed crowding was associated with an important reduction in ems offload delay, suggesting that policies that target hospital processes have bearing on ems operations. variability in offload delay improvements is likely due to site-specific issues, and the gains in efficiency correlate inversely with acuity. methods: a pre-post intervention study was conducted in the ed of an adult university teaching hospital in montreal (annual visits = ). the raz unit (intervention), created to offload the acu of the main ed, started operating in january, . using a split flow management strategy, patients were directed to the raz unit based on patient acuity level (ctas code and certain code ), likelihood to be discharged within hours, and not requiring an ed bed for continued care. data were collected weekdays from : to : for months (september -december ) (pre-raz) and for . months (february -march ) (post-raz). in the acu of the main ed, research assistants observed and recorded cubicle access time, and nurse and physician assessment times. databases were used to extract socio-demographics, ambulance arrival, triage code, chief complaint, triage and registration time, length of stay, and ed occupancy. background: telephone follow-up after discharge from the ed is useful for treatment and quality assurance purposes. ed follow-up studies frequently do not achieve high (i.e. ‡ %) completion rates. objectives: to determine the influence of different factors on the telephone follow-up rate of ed patients. we hypothesized that with a rigorous follow-up system we could achieve a high follow-up rate in a socioeconomically diverse study population. methods: research assistants (ras) prospectively enrolled adult ed patients discharged with a medication prescription between november , and september , from one of three eds affiliated with one health care system: (a) academic level i trauma center, (b) community teaching affiliate, and (c) community hospital. patients unable to provide informed consent, non-english speaking, or previously enrolled were excluded. ras interviewed subjects prior to ed discharge and conducted a telephone follow-up interview week later. follow-up procedures were standardized (e.g. number of calls per day, times to place calls, obtaining alternative numbers) and each subject's follow-up status was monitored and updated daily through a shared, web-based data system. subjects who completed follow-up were mailed a $ gift card. we examined the influence of patient (age, sex, race, insurance, income, marital status, usual major activity, education, literacy level, health status), clinical (acuity, discharge diagnosis, ed length of stay, site), and procedural factors (number and type of phone numbers received from subjects, offering two gift cards for difficult to reach subjects) on the odds of successful followup using multivariate logistic regression. results: of the , enrolled, % were white, % were covered by medicaid or uninsured, and % reported an annual household income of <$ , . % completed telephone follow-up with % completing on the first attempt. the table displays the factors associated with successful follow-up. in addition to patient demographics and lower acuity, obtaining a cell phone or multiple phone numbers as well as offering two gift cards to a small number of subjects increased the odds of successful follow-up. conclusion: with a rigorous follow-up system and a small monetary incentive, a high telephone follow-up rate is achievable one week after an ed visit. methods: an interrupted time-series design was used to evaluate the study question. data regarding adherence with the following pneumonia core measures were collected pre-and post-implementation of the enhanced decision-support tool: blood cultures prior to antibiotic, antibiotic within hours of arrival, appropriate antibiotic selection, and mean time to antibiotic administration. prescribing clinicians were educated on the use of the decision-support tool at departmental meetings and via direct feedback on their cases. results: during the -month study period, complete data were collected for patients diagnosed with cap: in the pre-implementation phase and post-implementation. the mean time to antibiotic administration decreased by approximately one minute from the pre-to post-implementation phase, a change that was not statistically significant (p = . ). the proportion of patients receiving blood cultures prior to antibiotics improved significantly (p < . ) as did the proportion of patients receiving antibiotics within hours of ed arrival (p = . ). a significant improvement in appropriate antibiotic selection was noted with % of patients experiencing appropriate selection in the post-phase, p = . . use of the available support tool increased throughout the study period, v = . , df = , p < . . all improvements were maintained months following the study intervention. conclusion: in this academic ed, introduction of an enhanced electronic clinical decision support tool significantly improved adherence to cms pneumonia core measures. the proportion of patients receiving blood cultures prior to antibiotics, antibiotics within hours, and appropriate antibiotics all improved significantly after the introduction of an enhanced electronic clinical decision support tool. background: emergency medicine (em) residency graduates need to pass both the written qualifying exam and oral certification exam as the final benchmark to achieve board certification. the purpose of this project is to obtain information about the exam preparation habits of recent em graduates to allow current residents to make informed decisions about their individual preparation for the abem written qualifying and oral certification exams. objectives: the study sought to determine the amount of residency and individual preparation, to determine the extent of the use of various board review products, and to elicit evaluations of the various board review products used for the abem qualifying and certification exams. methods: design: an online survey instrument was used to ask respondents questions about residency preparation and individual preparation habits, as well as the types of board review products used in preparing for the em boards. participants: as greater than % of all em graduates are emra members, an online survey was sent to all emra members who have graduated for the past three years. observations: descriptive statistics of types of preparation, types of resources, time, and quantitative and qualitative ratings for the various board preparation products were obtained from respondents. results: a total of respondents spent an average of . weeks and hours per week preparing for the written qualifying exam and spent an average of weeks and . hours per week preparing for the oral certification exam. in preparing for the written qualification exam, % used a preparation textbook with % using more than one textbook and % using a board preparation course. in preparing for the oral qualifying exam, % used a preparation textbook while % used a preparation course. sixty-seven percent of respondents reported that their residency programs had a formalized written qualifying exam preparation curriculum of which % was centered on the annual in-training exam. eight-five percent of residency programs had a formalized oral certification exam preparation. respondents reported spending on average $ preparing for the qualifying exam and $ for the certification exam. conclusion: em residents spend significant amounts of time and money and make use of a wide range of residency and commercially available resources in preparing for the abem qualifying and certification exams. background: communication and professionalism skills are essential for em residents but are not wellmeasured by selection processes. the multiple mini-interview (mmi) uses multiple, short structured contacts to measure these skills. it predicts medical school success better than the interview and application. its acceptability and utility in em residency selection is unknown. objectives: we theorized that the mmi would provide novel information and be acceptable to participants. methods: interns from three programs in the first month of training completed an eight-station mmi developed to focus on em topics. pre-and post-surveys assessed reactions using five-point scales. mmi scores were compared to application data. results: em grades correlated with mmi performance (f( . ) = : , p < . ) with honors students having higher mmi summary scores. higher third year clerkship grades trended to higher mmi performance means, although not significantly. mmi performance did not correlate with a match desirability rating and did not predict other individual components of the application including usmle step or usmle step . participants preferred a traditional interview (mean difference = . , p < . ). a mixed format was preferred over a pure mmi (mean difference = . , p < . ). preference for a mixed format was similar to a traditional interview. mmi performance did not significantly correlate with preference for the mmi; however, there was a trend for higher performance to associate with higher preference (r = . , t( ) = . , n.s.) performance was not associated with preference for a mix of interview methods (r = . , t( ) = . , n.s.). conclusion: while the mmi alone was viewed less favorably than a traditional interview, participants were receptive to a mixed methods interview. the mmi appears to measure skills important in successful completion of an em clerkship and thus likely em residency. future work will determine whether mmi performance correlates with clinical performance during residency. background: the annual american board of emergency medicine (abem) in-training exam is a tool to assess resident progress and knowledge. when the new york-presbyterian (nyp) em residency program started in , the exam was not emphasized and resident performance was lower than expected. a course was implemented to improve residency-wide scores despite previous em literature failing to exhibit improvements with residency-sponsored in-training exam interventions. objectives: to evaluate the effect of a comprehensive, multi-faceted course on residency-wide in-training exam performance. methods: the nyp em residency program, associated with cornell and columbia medical schools, has a year format with - residents per year. an intensive -week in-training exam preparation program was instituted outside of the required weekly residency conferences. the program included lectures, pre-tests, high-yield study sheets, and remediation programs. lectures were interactive, utilizing an audience response system, and consisted of core lectures ( - . hours) and three review sessions. residents with previous in-training exam difficulty were counseled on designing their own study programs. the effect on intraining exam scores was measured by comparing each resident's score to the national mean for their postgraduate year (pgy). scores before and after course implementation were evaluated by repeat measures regression modeling. overall residency performance was evaluated by comparing residency average to the national average each year and by tracking abem national written examination pass rates. results: resident performance improved following course implementation. following the course's introduction, the odds of a resident beating the national mean increased by . ( % ci . - . ) and the percentage of residents exceeding the national mean for their pgy year increased by % ( % ci %- %). following course introduction, the overall residency mean score has outperformed the national exam mean annually and the first-time abem written exam board pass rate has been %. conclusion: a multi-faceted in-training exam program centered around a -week course markedly improved overall residency performance on the in-training exam. limitations: this was a before and after evaluation as randomizing residents to receive the course was not logistically or ethically feasible. . years of practice. among the nonresidency trained, non-boarded em physicians, the percentage of individuals with board actions against them was significantly higher ( . % vs. . %, % ci for difference of . % = . to . %), but the incidence of actions was not significant ( . vs. . events/ years of practice, % ci for difference of . / = ) / to + / ), but the power to detect a difference was %. conclusion: in this study population, em-trained physicians had significantly fewer total state medical board disciplinary actions against them than non-em trained physicians, but when adjusted for years of practice (incidence), the difference was not significantly different at the % confidence level. the study was limited by low power to detect a difference in incidence. objectives: we chose pain documentation as a long term project for quality improvement in our ems system. our objectives were to enhance the quality of pain assessment, to reduce patient suffering and pain through improved pain management, to improve pain assessment documentation, to improve capture of initial and repeat pain scales, and to improve the rate of pain medication. this study addressed the aim of improving pain assessment documentation. methods: this was a quasi-experiment looking at paramedic documentation of the pqrst mnemonic and pain scales. our intervention consisted of mandatory training on the importance and necessity of pain assessment and treatment. in addition to classroom training, we used rapid cycle individual feedback and public posting of pain documentation rates (with unique ids) for individual feedback. the categories of chief complaint studied were abdominal pain, blunt injury, burn, chest pain, headache, non-traumatic body pain, and penetrating injury. we compared the pain documentation rates in the months prior to intervention, the months of intervention, and months post intervention. using repeated-measures anova, we compared rates of paramedic documentation over time. results: our ems system transported patients during the study period, of whom were for painful conditions in the defined chief complaint categories. there were paramedics studied, of whom had complete data. documentation increased from of painful cases ( . %) in qtr to of painful cases ( . %) in qtr . the trend toward increased rates of pain documentation over the three quarters was strongly significant (p < . ). paramedics were significantly more likely to document pain scales and pqrst assessments over the course of the study with the highest rates of documentation compliance in the final -month period. conclusion: a focused intervention of education and individual feedback through classroom training, one on one training, and public posting improves paramedic documentation rates of perceived patient pain. background: emergency medical services (ems) systems are vital in the identification, assessment, and treatment of trauma, stroke, myocardial infarction, and sepsis and improving early recognition, resuscitation, and transport to adequate medical facilities. ems personnel provide similar first-line care for patients with syncope, performing critical actions such as initial assessment and treatment as well as gathering key details of the event. objectives: to characterize emergency department patients with syncope receiving initial care by ems and their role as initial providers. methods: we prospectively enrolled patients over years of age who presented with syncope or near syncope to a tertiary care ed with , annual patient visits from june to june . we compared patient age, sex, comorbidities, and -day cardiopulmonary adverse outcomes (defined as myocardial infarction, pulmonary embolism, significant cardiac arrhythmia, and major cardiovascular procedure) between ems and non-ems patients. descriptive statistics, two-sided ttests, and chi-square testing were used as appropriate. results: of the patients enrolled, ( . %) arrived by ambulance. the most common complaint in patients transported by ems was fainting ( . %) or dizziness ( . %); syncope was reported in ( . %). compared to non-ems patients, those who arrived by ambulance were older (mean age (sd) . ( . ), vs. . ( . ) years, p = . ). there were no differences in the proportion of patients with hypertension ( . % vs . %, p = . ), coronary artery disease ( . % vs . %, p = . ), diabetes mellitus ( . % vs . %, p = . ), or congestive heart failure ( . % vs . %, p = . ). sixtynine ( . %) patients experienced a cardiopulmonary event within days. twenty-eight ( . %) patients who arrived by ambulance and ( . %) non-ems patients had a subsequent cardiopulmonary adverse event (rr . , %ci . - . ) within days. the table tabulates interventions provided by ems prior to ed arrival. conclusion: ems providers care for more than one third of ed syncope patients and often perform key interventions. ems systems offer opportunities for advancing diagnosis, treatment, and risk stratification in syncope patients. background: abdominal pain is the most common reason for visiting an emergency department (ed), and abdominopelvic computed tomography (apct) use has increased dramatically over the past decade. despite this, there has been no significant change in rates of admission or diagnosis of surgical conditions. objectives: to assess whether an electronic accountability tool affects apct ordering in ed patients with abdominal or flank pain. we hypothesized that implementation of an accountability tool would decrease apct ordering in these patients. methods: before and after study design using an electronic medical record at an urban academic ed from jul-nov , with the electronic accountability tool implemented in oct for any apct order. inclusion criteria: age >= years, non-pregnant, and chief complaint or triage pain location of abdominal or flank pain. starting oct th , , resident attempts to order apct triggered an electronic accountability tool which only allowed the order to proceed if approved by the ed attending physician. the attending was prompted to enter the primary and secondary diagnoses indicating apct, agreement with need for ct and, if no agreement, who was requesting this ct (admitting or consulting physician), and their pretest probability ( - ) of the primary diagnosis. patients were placed into two groups: those who presented prior to (pre) and after (post) the deployment of the accountability tool. background: there has been a paradigm shift in the diagnostic work-up for suspected appendicitis. edbased staged protocols call for the use of ultrasound prior to ct scanning because of its lack of radiation, and the morbidity related to contrast. a barrier to implementation is the lack of / availability of ultrasound. objectives: to evaluate the impact of the implementation of ed performed appendix ultrasounds (apus) on ct utilization in the staged workup for appendicitis in the emergency department. methods: we performed a quasi-experimental, before/ after study. we compared data from the first months of , before the availability of ed performed apus, with the same interval in after introduction of ed apus. we excluded patients who had appendectomies for reasons other than appendicitis or had been diagnosed prior to arrival. no patient identifiers were included in the analysis and the study was approved by the hospital irb. we report the following descriptive statistics (percentages, sensitivities, and absolute utilization changes conclusion: implementation of an ed apus in the staging work up of appendicitis was associated with a significant reduction in overall ct utilization in the ed. objectives: this study aims to evaluate ed patients' knowledge of radiation exposure from ct and mri scans as well as the long-term risk of developing cancer. we hypothesize that ed patients will have a poor understanding of the risks, and will not know the difference between ct and mri. methods: design -this was a cross-sectional survey study of adult, english-speaking patients at two eds from / / - / / . setting -one location was a tertiary care center with an annual ed census of , patient visits and the other was a community hospital with annual ed census of , patient visits. obser-vations -the survey consisted of six questions evaluating patients' understanding of radiation exposure from ct and mri as well as long-term consequences of radiation exposure. patients were then asked their age, sex, race, highest level of education, annual household income, and whether they considered themselves health care professionals. results: there were participants in this study, (of , total) from the academic center and (of , total) from the community hospital during the study period. overall, only % ( % ci - %) of participants understood the radiation risks associated with ct scanning. % ( % ci - %) of patients believed that an abdominal ct had the same or less radiation as a chest x-ray. % ( % ci - %) believed that there was an increased risk of developing cancer from repeated abdominal cts. only % ( % ci - %) of patients knew that mri scans had less radiation than ct. % ( % ci - %) either didn't know or believed that repeated mris were associated with an increased risk of developing cancer. higher educational level, household income, and identification as a health care professional all were associated with correct responses, but even within these groups, a majority gave incorrect responses. conclusion: in general, ed patients do not understand the radiation risks associated with advanced imaging modalities. we need to educate these patients so that they can make informed decisions about their own health care. background: homelessness has been associated with many poor health outcomes and frequent ed utilization. it has been shown that frequent use of the ed in any given year is not a strong predictor of subsequent use. identifying a group of patients who are chronic high users of the ed could help guide intervention. objectives: the purpose of this study is to identify if homelessness is associated with chronic ed utilization. methods: a retrospective chart review was accomplished looking at the records of the most frequently seen patients in the ed for each year from - at a large, urban academic hospital with an annual volume of , . patients' visit dates, chief complaints, dispositions, and housing status were reviewed. homelessness was defined by self-report at registration. patients were categorized according to their ed utilization with those seen > times in at least three of the five years of the study identified as chronic high utilizers; and those who visited the ed > times in at least three of the five years of the study were identified as chronic ultra-high utilizers. descriptive statistics with confidence intervals were calculated, and comparisons were made using non-parametric tests. results: during the -year study period, , unique patients were seen, of whom . % patients were homeless. patients were identified as frequent users. there were patients who presented on the top utilizer lists from multiple years. ( %, %ci - ) patients were identified as homeless. patients were seen > times in at least three of the years and ( %, - ) were homeless. patients were seen > times in at least three of the years and ( %, - ) were homeless. our facility has a % admission rate; however, non homeless chronic ultra-high utilizers had admission rates of % and homeless chronic ultra-high utilizers were admitted %. conclusion: chronic ultra-high utilizers of our ed are disproportionately homeless and present with lower severity of illness. these patients may prove to be a cost-effective group to house or otherwise involve with aggressive case management. the debate over homeless housing programs and case management solutions can be sharpened by better defining the groups who would most benefit and who represent the greatest potential saving for the health system. background: the prevalence of obese patients presenting to our emergency department (ed) is %: obese patients present in disproportionate number compared to the general population (us rate = %). in spite of this, there is a disconnect in patients' perceptions of weight and health: many patients underestimate their weight and report a key barrier to weight loss is patient-provider communications; such discussions have proven to be highly effective in smoking, drug, and alcohol cessation, an important initial step toward promoting wellness. information about patient provider communication is essential for designing and implementing emergency department (ed) based interventions to help increase patient awareness about weightrelated medical issues and provide counseling for weight reduction. objectives: we assessed patients' perceptions about obesity as disease and patient communication with their providers through two questions: do you believe your present weight is damaging to your health? has a doctor or other health professional every told you that you are overweight? methods: a descriptive cross-sectional study was performed in an academic tertiary care ed. a randomized sample of patients (every fifth) presenting to the ed (n = ) was enrolled. pregnant patients, patients who were medically unstable, cognitively impaired, or who were unable or unwilling to provide informed consent were excluded. percentages of ''yes'' and ''no'' are reported for each question based on patient bmi, ethnicity, sex, and the number of comorbid conditions. regression analysis was used to determine differences in responses between subgroups. results: among overweight/obese, white/black patients, . % do not feel their weight is damaging to their health and . % reported they have not been told by a doctor they are overweight. of individuals who have been told by a doctor they were overweight, . % still believe their present weight is not damaging to their health. of individuals who have not been told by a doctor they were overweight, . % believe their present weight is damaging to their health. differences in race and age were not found. p values < . for all results. conclusion: our data point toward a disconnect regarding patients' perceptions of health and weight. timely education about the burden of obesity may lead to a decrease in its overall prevalence. (originally submitted as a ''late-breaker.'') objectives: to examine the attitudes and expectations of patients admitted for inpatient care following an emergency department visit. methods: a descriptive study was done by surveying a voluntary sample of adult patients (n = ) admitted to the hospital from the emergency department in one urban teaching hospital in the midwest. a short, ninequestion survey was developed to assess patient attitudes and expectations towards hiv testing, consent, and requirements. analyses consisted of descriptive statistics, correlations, and chi-square analyses. results: the majority of patients report that hiv testing should be a routine part of health care screening ( . %) and that the hospital should routinely test admitted patients for hiv ( . %). despite these overall positive attitudes towards hiv testing, the data also suggest that patients have strong attitudes towards consent requirements with % acknowledging that hiv testing requires special consent and % reporting that separate consent should be required. the data also showed a statistically significant difference in the proportion of patients who believed that hiv testing is a part of routine health care screening by race (v = . , df = , p = . ). conclusion: patients attitudes and expectations towards routine hiv testing are consistent with the cdc recommendations. emergency departments are an ideal setting to initiate hiv testing and the findings suggest that patients expect hospital policies outline procedures for obtaining consent and screening all patients who are admitted to the hospital from the ed. results: the analysis revealed a ''hot spot'', a cluster of counties ( . %) with high ca rates adjacent to counties with high ca rates, located across the southeastern us (p < . ). within these counties, the average ca rate was % higher than the national average. a ''cool spot'', a cluster of counties ( . %) with low rates, was located across the midwest (p < . ). in this cool spot the average ca rate was % lower than the national average. figures and show us adjusted rates and spatial autocorrelation of ca deaths, respectively. conclusion: we identify geographic disparities in ca mortality and describe the cardiac arrest belt in the southeastern us. a limitation of this analysis was the use of icd- codes to identify cardiac arrest deaths; however, no other national data exist. an improved understanding of the drivers of this variability is essential to targeted prevention and treatment strategies, especially given the recent emphasis on development of cardiac resuscitation centers and cardiac arrest systems of care. an understanding of the relation between population density, cardiac arrest count, and cardiac arrest rate will be essential to the design of an optimized cardiac arrest system. we defined ed utilization during the past months as non-users ( visits), infrequent users ( - visits), frequent users ( - visits), and super-frequent users ( ‡ visits). we compared demographic data, socioeconomic status, health conditions, and access to care between these ed utilization groups. results: overall, super-frequent use was reported by . % of u.s. adults, frequent use by %, and infrequent ed use by %. higher ed utilization was associated with increased self-reported fair to poor health ( % for super-frequent, % for frequent, % for infrequent, % for non-ed users). frequent ed users were also more likely to be impoverished, with % of superfrequent, % of frequent, % of infrequent, and % of non-ed users reporting a poverty-income ratio < . adults with higher ed utilization were more likely to report the ed as the place they usually go when sick ( % for super-frequent, % for frequent, % for infrequent, . % for non-ed users). they also reported greater outpatient resource utilization, with % of super-frequent, % of frequent, % of infrequent, and % of non-ed users reporting ‡ outpatient visits/year. frequent ed users were also more likely than non-ed users to be covered by medicaid ( % for super-frequent, % for frequent, % for infrequent, % for non-ed users). conclusion: frequent ed users were a vulnerable population with lower socioeconomic status, poor overall health, and high outpatient resource utilization. interventions designed to divert frequent users from the ed should also focus on chronic disease management and access to outpatient services, rather than focusing solely on limiting ed utilization. objectives: we explored factors associated with specialty provider willingness to provide urgent appointments to children insured by medicaid/chip. methods: as part of a mixed method study of child access to specialty care by insurance status, we conducted semi-structured qualitative interviews with a purposive sample of specialists and primary care physicians (pcps) in cook county, il. interviews were conducted from april to september , until theme saturation was reached. resultant transcripts and notes were entered into atlas.ti and analyzed using an iterative coding process to identify patterns of responses in the data, ensure reliability, examine discrepancies, and achieve consensus through content analysis. results: themes that emerged indicate that pcps face considerable barriers getting publicly insured patients into specialty care and use the ed to facilitate this process. ''if i send them to the emergency room, i'm bypassing a number of problems. i'm fully aware that i'm crowding the emergency room.'' specialty physicians reported that decisions to refuse or limit the number of patients with medicaid/chip are due to economic strain or direct pressure from their institutions ''in the last budget revision, we were [told], 'you are losing money, so you need to improve your patient mix'''. in specialty practices with limited medicaid/chip appointment slots, factors associated with appointment success included: high acuity or complexity, personal request from or an informal economic relationship with the pcp, geography, and patient hardship. ''if it's a really desperate situation and they can't find anybody else, i will make an exception''. specialists also acknowledged that ''patients who can't get an appointment go to the er and then i am obligated to see them if they're in the system.'' conclusion: these exploratory findings suggest that a critical linkage exists between hospital eds and affiliated specialty clinics. as health systems restructure, there is an opportunity for eds to play a more explicit role in improving care coordination and access to specialty care. albert amini, erynne a. faucett, john m. watt, richard amini, john c. sakles, asad e. patanwala university of arizona, tucson, az background: trauma patients commonly receive etomidate and rocuronium for rapid sequence intubation (rsi) in the ed. due to the long duration of action of rocuronium and short duration of action of etomidate, these patients require prompt initiation of sedatives after rsi. this prevents the potential of patient awareness under pharmacological paralysis, which could be a terrifying experience. objectives: the purpose of this study was to evaluate the effect of the presence of a pharmacist during traumatic resuscitations in the ed on the initiation of sedatives and analgesics after rsi. we hypothesized that pharmacists would decrease the time to provision of sedation and analgesia. methods: this was an observational, retrospective cohort study conducted in a tertiary, academic ed that is a level i trauma center. consecutive adult trauma patients who received rocuronium in the ed for rsi were included during two time periods: / / to / / (pre-phase -no pharmacy services in the ed) and / / to / / (post-phase -pharmacy services in the ed). since the pharmacist could not respond to all traumas in the post-phase, this was further categorized based on whether the pharmacist was present or absent at the trauma resuscitation. data collected included patient demographics, baseline injury data, and medications used. the median time from rsi to initiation of sedatives and analgesics was compared between the pre-phase group (group ), post-phase pharmacist absent group (group ), and post-phase pharmacist present group (group ) using the kruskal-wallis test. results: a total of patients were included in the study (group = , group = , and group = ). median age was , . , and . years in groups , , and , respectively (p = . ). there were no other differences between groups with regard to demographics, mechanism of injury, presence of traumatic brain injury, glasgow coma scale score, vital signs, ed length of stay, or mortality. median time between rsi and post-intubation sedative use was , , and minutes in groups , and , respectively (p < . ). median time between rsi and post-intubation analgesia use was , , and minutes in groups , , and , respectively (p < . ). the presence of a pharmacist during trauma resuscitations decreases time to provision of sedation and analgesia after rsi. background: outpatient antibiotics are frequently prescribed from the ed, and limited health literacy may affect compliance with recommended treatments. objectives: among patients stratified by health literacy level, multimodality discharge instructions will improve compliance with outpatient antibiotic therapy and follow-up recommendations. methods: this was a prospective randomized trial that included consenting patients discharged with outpatient antibiotics from an urban county ed with an annual census of , . patients unable to receive text messages or voicemails were excluded. health literacy was assessed using a validated health literacy assessment, the newest vital sign (nvs). patients were randomized to a discharge instruction modality: ) usual care, typed and verbal medication and case-specific instructions; ) usual care plus text messaged instructions sent to the patient's cell phone; or ) usual care plus voicemailed instructions sent to the patient's cell phone. antibiotic pick-up was verified with the patient's pharmacy at hours. patients were called at days to determine antibiotic compliance. z-tests were used to compare -hour antibiotic pickup and patient-reported compliance across instructional modality and nvs score groups. results: patients were included ( % female, median age , range months to years); were excluded. % had an nvs score of - , % - , and % - . the proportion of prescriptions filled at hours varied significantly across nvs score groups; self-reported medication compliance at days revealed no difference across different instructional modalities nor nvs scores (table ) . conclusion: in this sample of urban ed patients, hour prescription pickup varied significantly by validated health literacy score, but not by instruction delivery modality. in this sample, patients with lower health literacy are at risk of not filling their outpatient antibiotics in a timely fashion. has been developed, validated, and utilized to study the processes of care involved in successful care transitions from inpatient to outpatient settings, but has not been utilized in the ed. objectives: we hypothesized that the ctm- could be successfully implemented in the ed without differential item difficulty by age, sex, education, or race; and would be associated with measures of quality of care and likelihood of following physician recommendations. methods: a descriptive study design based on exit surveys was used to measure ctm- scores and likelihood of following treatment recommendations. surveys were administered to a daily cross-sectional sample of all patients leaving the ed between a- a by research assistants in an urban academic ed setting for weeks in november . we report means and standard deviations, and analysis of variance to identify differences in ctm- scores for those who planned and did not plan to follow ed recommendations. results: surveys were completed; patients were ± years old, % black, % female, % with at least some college education, and % were admitted. average ctm- score was . ± . (range - ). scores were not associated with sex (p = . ), race (p = . ), or education level (p = . ). lower ctm scores were associated with increasing age (p = . ), patient perceptions that the ed team was less likely to use words that they understood, listen carefully to them, inspire their confidence and trust, or encourage them to ask questions (all p < . ). those who reported they were ''very likely'' to follow ed treatment had an average score of ± , while those who were ''unlikely'' or ''very unlikely'' to follow ed treatment plans had an average score ± (p = . ). conclusion: the ctm- performs well in the ed and exhibited only differential item difficulty by age; there was no significant difference by race, sex, or education level. furthermore, it is highly associated with likelihood of following physician recommendations. future studies will focus on ctm- scores ability to discriminate between patients who did or did not experience a subsequent ed visit or rehospitalization. age and race were found to be significant predictors of the race pathway. regression of the data by race revealed blacks (or . : ci . - . ; p < . ), hispanics (or . : ci . - . ; p = . ), and asians (or . : ci . - . ; p = . ), were more likely to enter the race cohort than were whites; however, much of this discrepancy is accounted for by age. the mean age of minority patients was years, while white patients were older at years (p = . ). conclusion: in a diverse demographic population we found that racial minorities were presenting at younger ages for chest pain and were more likely to receive cardiac testing at bedside than their white counterparts; and hence, were selected to a lower level of care (nonmonitored unit background: expanding insurance coverage is designed to improve access to primary care and reduce use of emergency services. whether expanding coverage achieves this is of paramount importance as the united states prepares for the affordable care act. objectives: we examined ed and outpatient department use after the state children's health insurance program (schip) coverage expansion, focusing on adolescents (a major target group for schip) versus young adults (not targeted). we hypothesized that coverage would increase use of outpatient services and emergency department services would decrease. methods: using the national ambulatory medical care survey and the national hospital ambulatory medical care survey, we analyzed years - as baseline and then compared use patterns in - after schip launch. primary outcomes were populationadjusted annual visits to ed versus non-emergency outpatient settings. interrupted time-series were performed on use rates to ed and outpatient departments between adolescents ( - years old) and young adults ( - years old) in the pre-schip and schip periods. outpatient-to-ed ratios were calculated and compared across time periods. results: the mean number of outpatient adolescent visits increased by visits per persons ( % ci, - ), while there was no statistically significant increase in young adult outpatient visits across time periods. there was no statistically significant change in the mean number of adolescent ed visits across time periods, while young adult ed use increased by visits per persons ( % ci, - ). the adolescent outpatient-to-ed ratio increased by . ( % ci, . - . ), while the young adults ratio decreased by . across time periods ( % ci, ) . to ) . ). conclusion: since schip, adolescent non-ed outpatient visits increased while ed visits remained unchanged. in comparison to young adults, expanding insurance coverage to adolescents improved access to health care services and suggests a shift to non-ed settings. as an observational study we are unable to control for secular trends during this time period. also as an ecological study we are unable to examine individual variation. expanding insurance through the affordable care act of will likely increase use of outpatient services but may not decrease emergency department volumes. background: cancer patients are receiving a greater proportion of their care on an outpatient basis. the effect of this change in oncology care patterns on ed utilization is poorly understood. objectives: to examine the characteristics of ed utilization by adult cancer patients. methods: between july and march , all new adult cancer patients referred to a tertiary care cancer centre were recruited into a study examining psychological distress. these patients were followed prospectively until september . the collected data were linked to administrative data from three tertiary care eds. variables evaluated in this study included basic we have previously shown that reducing non-value-added activities through the application of the lean process improvement methodology improves patient satisfaction, physician productivity and emergency department length of stay. objectives: in this investigation, we tested the hypothesis that non-value-added activities reduce physician job satisfaction. methods: to test this hypothesis, we conducted timemotion studies on attending emergency physicians working in an academic setting and categorized their activities into value-added (time in room with patient, time discussing cases and educating medical learners, time in room with patient and learner), necessary non-valueadded activities (charting, sign out, looking up labs), and unnecessary non-value-added activities (looking for things, looking for people, on the phone). the physicians were then surveyed using a -point likert scale to determine their relative satisfaction with each of the individual tasks ( worst part of day, best part of day). results: physicians spent % of their shift performing value-added work, % of their shift performing necessary non-value-added activities, and % of their shift performing unnecessary non-value-added activities (waste). weighted physician satisfaction (satisfaction x [percent time spent performing the activity / percent time engaged in activity category]) was highest when the physician was performing value-added work ( . ) compared to performing either necessary non-valueadded work ( . ) or waste ( . ). conclusion: the attending physicians we studied spent the majority of their time performing non-value-added activities, which were associated with lower satisfaction. application of process improvement techniques such as lean, which focus on reducing non-value-added work, may improve emergency physician job satisfaction. background: rocuronium and succinylcholine are the most commonly used paralytics for rapid sequence intubation (rsi) in the ed. after rsi, patients need sustained sedation while they are mechanically ventilated. however, the longer duration of action of rocuronium may influence subsequent sedation dosing, while the patient is therapeutically paralyzed. objectives: we hypothesized that patients who receive rocuronium would be more likely to receive lower doses of post-rsi sedation compared to patients who receive succinylcholine. methods: this was an observational, retrospective cohort study conducted in a tertiary, academic ed. consecutive adult patients, who received rsi using etomidate for induction of sedation between / / to / / , were included. patients were then categorized based on whether they received rocuronium or succinylcholine for paralysis. the dosing of post-rsi sedative infusions was compared at , , , and minutes after initiation between the two groups using the wilcoxon rank-sum test. results: a total of patients were included in the final analysis (rocuronium = , succinylcholine = ). mean age was and years in the rocuronium and succinylcholine groups, respectively (p = . ). there were no other baseline differences between groups with regard to demographics, reason for intubation, stroke, traumatic brain injury, glasgow coma scale score, pain scores, or vital signs. in the overall cohort, . % (n = ) of patients were given a sedative infusion or bolus in the ed. most patients were initiated on propofol (n = ) or midazolam (n = ) infusions. median propofol infusion rates at , , , and minutes were , , . , and mcg/kg/min in the rocuronium group and , , , and mcg/kg/ min in succinylcholine group, respectively. the difference was statistically significant at (p < . ) and (p = . ) minutes. median midazolam infusion rates at , , , and minutes were , , , and mg/hour in the rocuronium group and , , , and . mg/hour in succinylcholine group, respectively. the difference was statistically significant at (p = . ) and (p = . ) minutes. conclusion: patients who receive rocuronium are more likely to receive lower doses of sedative infusions post-rsi due to sustained therapeutic paralysis. this may put them at risk for being awake under paralysis. what is the impact of the implementation of an there was a difference in presenting pain (p < . ), stress (p < . ), and anxiety (p < . ) among patients that received an opioid in the ed. there was a difference in presenting pain (p < . ) for patients discharged with an opioid prescription, but not for stress (p = . ) or anxiety (p = . ). conclusion: patient-reported pain, stress, and anxiety are higher among patients who received an opiate in the ed than in those who did not, but only pain is higher among patients who received a discharge prescription for an opioid. methods: this was a prospective, randomized crossover study on the use of gvl and dl by incoming pediatric interns prior to advanced life support training. at the start of the study, the interns received a didactic session and expert modeling of the use of both devices for intubation. two scenarios were used: ( ) normal intubation with a standard airway and ( ) difficult intubation with tongue edema and pharyngeal swelling. interns then intubated laerdal simbaby in each scenario with both gvl and dl for a total of four randomized intubation scenarios. primary outcomes included time to successful intubation and the rate of successful intubation. the interns also rated their satisfaction with the devices using a visual analog scale ( - ) and chose their preferred device for their next intubation. results: interns were included in this study. in the normal airway scenario, there were no differences in the mean time for intubation with gvl or dl ( . ± . vs . ± . seconds, p = ns) or the number of interns who performed successful intubation ( vs , p = ns). in the difficult airway scenario, the interns took longer to intubate with gvl than dl ( . ± . vs . ± . seconds, p = . ), but there were no differences in the number of successful intubations ( vs , p = ns). interns rated their satisfaction higher for gvl than dl ( . ± . vs . ± . , p = . ) and gvl was chosen as the preferred device for their next intubation by a majority of the interns ( / , %). conclusion: for novice clinicians, gvl does not improve the time to intubation or intubation success objectives: to determine the time to intubation, the number of attempts, and the occurrence of hypoxia, in patients intubated with a c-mac device versus those intubated using a standard laryngoscope. methods: randomized controlled trial using exception from informed consent that included patients undergoing endotracheal intubation with a standard laryngoscope at an urban level i trauma center. eligible patients were randomized to undergo intubation using the c-mac or standard laryngoscopy. standard laryngoscopy was performed using a c-mac device laryngoscope with the video output obstructed to ensure equivalent laryngoscope blades in the two groups. data were collected by a trained research assistant at the patient's bedside and video review by the investigators. the number of attempts made, the initial and lowest oxygen saturation (spo ), and the total time until the intubation was successful was recorded. hypoxia was defined as an oxygen saturation < %. data were compared with wilcoxon rank sum and chi-square tests. results: thirty-eight patients were enrolled, ( % male, median age , range to , median spo %, range to ) in the standard laryngoscopy group and ( % male, median age , range to , median spo . %, range to ) in the c-mac group. the median number of attempts for standard laryngoscopy was , range to , and for c-mac was , range to (p = . ). the median time to intubation for the standard laryngoscopy group was seconds (range to ) and for the c-mac group was seconds (range to )(p = . ). hypoxia was detected in / ( %) in the standard laryngoscopy group and / ( %) in the c-mac group (p = . ). the median decrease in oxygen saturation during the attempt was . % (range % to %) for the standard laryngoscopy group and . % (range % to %) for the c-mac group. conclusion: we did not detect a difference in number of attempts, the occurrence of hypoxia, or the diagnosis of aspiration pneumonia between standard laryngoscopy and the c-mac. the time to successful intubation was shorter for patients intubated with the c-mac. the c-mac device appears to be superior to standard laryngoscopy for emergent endotracheal intubation. (originally submitted as a ''late-breaker.'') the background: aspiration pneumonia is a complication of endotracheal intubation that may be related to the difficulty of the airway procedure. objectives: to determine the association of the device used, the time to intubation, the number of attempts to intubate, and the occurrence of hypoxia with the subsequent development of aspiration pneumonia. methods: this was a prospective observational study of patients undergoing endotracheal intubation by emergency physicians at an urban level i trauma center conducted from / / until / / . the device used on the initial attempt to intubate was at the discretion of the treating physician. data were collected by a trained research assistant at the patient's bedside. the device used, the number of attempts made to intubate, the lowest oxygen saturation during the attempt, and the total time until intubation was successfully accomplished were recorded. patient's medical records were reviewed for the subsequent diagnosis of aspiration pneumonia. hypoxia was defined as an oxygen saturation < %. data were analyzed using multinomial logistic regression and odds ratios (or). results: patients were enrolled; ( %) subsequently developed aspiration pneumonia. were intubated with a standard laryngoscope (sl), using the c-mac, with an intubating laryngeal mask, and with nasotracheal intubation (ni) (or . , % ci = . - . ). comparison of individual devices versus sl did not show an association by device type. the median number of attempts for patients with aspiration pneumonia was , range to , and for those without was , range to (or . , %ci = . - . ). the median time to intubation for patients who developed aspiration pneumonia was seconds (range to ) and for those who did not was seconds (range to )(or . , %ci = . - . ). hypoxia during intubation was detected in / ( %) in the aspiration pneumonia group and / ( %) in the no aspiration pneumonia group (or . , % ci = . - . ). conclusion: there was not an association between the device used, the number of attempts, the time to intubation, or the occurrence of hypoxia during the intubation, and the subsequent occurrence of aspiration pneumonia. background: japanese census data estimate that million, or nearly % of the overall population, will be over age by the year . similar trends are apparent throughout the developed world. although increased patient age affects airway management, comprehensive information in emergency airway management for the elderly is lacking. objectives: we sought to characterize emergency department (ed) airway management for the elderly in japan including success rate, and major adverse events using a large multi-center registry. methods: design and setting: we conducted a multicenter prospective observational study using the japanese emergency airway network (jean) registry of eds at academic and community hospitals in japan between and inclusive. data fields included ed characteristics, patient and operator demographics, methods of airway management, number of attempts, success rate, and adverse events. participants: patient inclusion criteria were all adult patients who underwent emergent tracheal intubation in the ed. primary analysis: patients were divided to into two groups defined as follows: to years old and over years old. we describe primary success rates and major adverse events using simple descriptive statistics. categorical data are reported as proportions and % confidence intervals (cis). results: the database recorded patients (capture rate %) and met the inclusion criteria. of patients, patients were to years old ( %) and were over years old ( %). the older group had a significantly higher success rate at first attempt intubation ( / ; . %, % ci . - . %) compared with the younger group ( / ; . %, % ci . - . %). the older group had similar major adverse event rates ( / ; . %, % ci . - . %) compared with the younger group ( / ; . %, % ci . - . %). (see table ) background: the degree to which a patient's report of pain is associated with changes in blood pressure, heart rate, and respiratory rate is not known. objectives: to determine to what degree a standardized painful stimulus effects a change in systolic blood pressure (sbp), diastolic blood pressure (dbp), heart rate (hr), or respiratory rate (rr), and compare changes in vital signs between patients based on pain severity. methods: prospective observational study of healthy human volunteers. subjects had their sbp, dbp, hr, and rr measured prior to pain exposure, immediately after, and minutes after. pain exposure consisted of subjects placing their hand in a bath of degree water for seconds. the bath was divided into two sections; the larger half was the reservoir of cooled water monitored to be degrees, the other half filled from constant overflow over the divider. water drained from this section into the cooling unit and was then pumped up into the base of the reservoir through a diffusion grid. subjects completed a mm visual analog scale (vas) representing their perceived pain during the exposure and graded their pain as minimal, moderate or severe. data were compared using % confidence intervals. results: subjects were enrolled, mean pain vas mm, range to , reported mild pain, moderate pain, and severe pain. the percent change from baseline in vital signs during the exposure and minutes after are presented in the table. conclusion: there was a wide variety in reported pain among subjects exposed to a standard painful stimulus. there was a larger change in heart rate during the exposure among subjects who described a standardized painful exposure as moderate than in those who described it as severe. the small observed changes in blood pressure and respiratory rate seen during the exposure did not differ by pain report or persist after minutes. background: vital signs are often used to validate intensity of pain. however, few studies have looked at the capacity of vital signs to estimate pain intensity, particularly in patients with a diagnosis that a majority of physicians would agree produce significant pain in the ed. objectives: to determine the association between pain intensity and vital signs in consecutive ed patients and in a sub-group of patients with diagnosis known to cause significant pain. methods: we performed a post-hoc analysis of prospectively acquired data in a cohort study done in an urban teaching hospital with computerized triage and nurses records. we included all consecutive ed adult patients ( ‡ years old), who had any level of pain intensity measured during triage, from march to november . the primary outcome was the mean heart rate, systolic and diastolic blood pressure for every pain intensity level from to on a verbal numerical scale. our secondary outcomes where the same but limited to patients with the following diagnosis: fracture, dislocation, and renal colic. we performed descriptive statistics, one-way and two-way anovas when appropriate. results: during our study period, , patients ‡ years old where triaged with a pain intensity of at least / and had a diagnosis known to cause significant pain. . % of patients were female, with a mean pain intensity of . / , mean age of . years (± . ), and . % were ‡ years old. there was a statistically significant difference (p < . ) in mean heart rate, systolic and diastolic blood pressure for each level of pain intensity, ex: difference between / and / for mean heart rate was . beats per minutes, for systolic pressure was . mmhg and for diastolic . mmhg. results are similar for painful diagnosis: difference for mean heart rate was . beats per minutes, for systolic pressure was . mmhg and diastolic . mmhg. however, these differences are not clinically significant. conclusion: although our study is a post hoc analysis, pain intensity, heart rate, systolic and diastolic pressures during triage are usually reliable data and a prospective study would likely produce the same result. these vital signs cannot be used to estimate or validate pain intensity in the emergency department. % had a positive urine drug screen. logistic multivariate regressions analyses revealed the following factors to be significantly associated with the risk of having an abnormal head ct: association with seizure (p = . ); length of time of loss of consciousness, ranging from none to - min to > min (p = . ); alteration of consciousness (p = . ); post-traumatic amnesia (p = . ); alcohol intake prior to injury (p = , ); and initial ed gcs (p = . ). conclusion: in an emergency department cohort of patients with traumatic brain injury, symptoms including loss of or alteration in consciousness, seizure, post traumatic amnesia, and alcohol intake appear to be significantly associated with abnormal findings on head ct. these clinical findings on presentation may be useful in helping triage head injury patients in a busy emergency department, and can further define the need for urgent or emergent imaging in patients without clearly apparent injuries. background: the etiology of neurogenic shock is classically attributed to diminished peripheral vascular resistance (pvr) secondary to loss of sympathetic outflow to the peripheral vasculature. however, the sympathetic nervous system also controls other key elements of the cardiovascular system such as the heart and capacitance vessels and disruptions in their function could complicate the hemodynamic presentation. objectives: we sought to systematically examine the hemodynamic profiles of a series of trauma patients with neurogenic shock. methods: consecutive trauma patients with documented spinal cord injury complicated by clinical shock were enrolled. hemodynamic data including systolic and diastolic blood pressure, heart rate (hr), impedance-derived cardiac output, pre-ejection period (pep), left ventricular ejection time (lvet), and calculated systemic pvr were collected in the ed. data were normalized for body surface area and a validated integrated computer model of human physiology (guyton model) was used to analyze and categorize the hemodynamic profiles based on etiology of the hypotension using a systems analysis. correlation between markers of sympathetic outflow (hr, pep, lvet) and shock etiology category was examined. results: of patients with traumatic neurogenic shock, the etiology of shock was decrease in pvr in ( %; % ci to %), loss of vascular capacitance in ( %; to %), and mixed peripheral resistance and capacitance responsible in ( %; to %). the markers of sympathetic outflow had no correlation to any of the elements in the patients' hemodynamic profiles. conclusion: neurogenic shock is often considered to have a specific well-characterized pathophysiology. results from this study suggest that neurogenic shock can have multiple mechanistic etiologies and represents a spectrum of hemodynamic profiles. this understanding is important for the treatment decisions made in the management of these patients. -year ( - ) , pre-post intervention study of trauma patients requiring massive blood transfusion was performed. we divided the population into two cohorts: a pre-protocol group (pre) which included trauma patients receiving mbt not aided by a protocol, and a post-protocol group (post) who underwent mbt via the mbtp. patient demographics, hour blood component totals, timing of blood component delivery, trauma injury severity score (iss), initial glasgow coma scale (gcs) score, trauma mechanism, and patient mortality data were collected and analyzed using fisher's exact tests, student's t-tests, and mann-whitney u tests. results: fifty-two patients were included for study. median times to delivery of first products were reduced for prbcs ( minutes), ffp ( minutes), and platelets ( minutes) between the pre and post cohorts. median time to delivery of any subsequent blood product was significantly reduced ( minutes) in the post cohort (p = . ). the median number of blood products delivered was increased by . units for prbcs, units for ffp, . units for platelets, and unit for cryoprecipitate after implementation of mbtp. the percentage of patients receiving higher blood product ratios (> : ) was reduced between the pre and post cohorts for prbc to ffp ( % reduction) and prbc to platelet ratio groups ( % reduction). despite improved transfusion timing and ratios, we found no significant difference in mortality (p = . ) between pre and post cohorts when we adjusted for injury severity. conclusion: protocolized delivery of massive blood transfusion might reduce time to product availability and delivery, though it is unclear how this affects patient mortality in all us trauma centers. background: burns are common injuries that can result in significant scarring leading to poor function and disfigurement. unlike mechanical injuries, burns often progress both in depth and size over the first few days after injury, possibly due to inflammation and oxidative stress. a major gap in the field of burns is the lack of an effective therapy that reduces burn injury progression. objectives: since mesenchymal stem cells (msc) have been shown to improve healing in several injury models, we hypothesized that species-specific msc would reduce injury progression in a rat comb burn model. methods: using a gm brass comb preheated to degrees celsius, we created four rectangular burns, separated by three unburned interspaces on both sides of the backs of male sprague-dawley rats ( g). the interspaces represented the ischemic zones surround-ing the central necrotic core. left untreated, most of these interspaces become necrotic. in an attempt to reduce burn injury progression, rats were randomized to tail vein injections of ml rat-specific msc cells/ml (n = ) or normal saline (n = ) minutes after injury. tracking of the stem cells was attempted by injecting several rats with quantum dot-labeled msc. results: by four days post-injury, all of the interspaces in the control rats ( / , %) became necrotic while in the experimental group, / ( %) of the interspaces became necrotic (fisher's exact test; p < . ). at days, the percentage of the unburned interspaces that became necrotic in the msc treated group was significantly less than in the control group ( % vs. %, p < . ). we were unable to identify any quantum dot labeled msc in the injured skin. no adverse reactions or wound infections were noted in rats injected with msc. conclusion: intravenous injection of rat msc reduced burn injury progression in a rat comb burn model. although basic demographics of bicyclists in accidents have been described, there is a paucity of data describing the street surface involved in accidents, and whether designated bicycle roadways offer protection. this lack of information limits informed attempts to change infrastructure in a way that will decrease morbidity and/or mortality of cyclists. objectives: to identify road surface types involved in pedal cyclist injuries and determine the relationship between injury severity and the use of designated bicycle roadways (dbr) versus non-designated roadways (ndr). we hypothesized that more severe injuries would happen at intersections regardless of dbr versus ndr. methods: this retrospective cohort study reviewed the trauma database from a level i trauma center in tucson, az. we identified all bicyclists in the database injured in accidents involving a motor vehicle from january , , through december , . the patients were then linked to a local government database that documents location (latitude/longitude) and direction of travel of the cyclist. seventy-eight total incidents were identified and categorized as occurring on a dbr versus ndr and occurring at an intersection versus not at an intersection. results: only one patient who arrived at the trauma center died. fifty-one of the accidents ( %) occurred on dbrs; % of accidents occurring on dbrs took place in intersections. conversely, % of accidents on ndrs occurred outside of intersections. the odds of an injury occurring at an intersection versus not at an intersection were . times higher ( % ci: . - . ) for dbrs compared to ndrs. the odds of a trauma being severe (admitted) versus not severe (discharged home) were . times higher ( % ci: . - . ) when a collision occurred not at an intersection versus at an intersection. conclusion: contrary to our hypothesis, in this study group severe injuries were more likely outside of an intersection. however, intersections on dbrs were identified as problematic as cyclists on a dbr were more likely to be injured in an intersection. future city planning could target improved cyclist safety in intersections. background: minor thoracic injury (mti) is frequent and a significant proportion will still have moderate to severe pain at days. there is a lack of risk factors to orient specific treatment at ed discharge. objectives: to determine risk factors of having pain ( ‡ / , on a numerical intensity pain score from to ) at days in a population of minor thoracic injury patients discharged from the ed. methods: a prospective multi-center cohort study was conducted in four canadian eds, from november to january . all consecutive patients, years and older, with mti (with or without rib fracture), a normal chest x-ray, and discharged from the ed were eligible. a standardized clinical and radiological evaluation was done at and weeks. standardized phone interviews were done at and days. pain evaluation occurred at five time points (ed visit, and weeks, and days). using a pain trajectory model (sas), we planned to identify groups with different pain evolution at days. the final model was based on the importance of difference in pain evolution, confidence intervals, and number of patients in each group. to judge the adequacy of the final model, we examined whether the posteriori probabilities (i.e., a participant's probability of belonging to a certain trajectory group) averaged at least % for each trajectory group. then using logistic multinomial regression and the low risk group of having pain as the control group, we identified significant predictors of patients in the moderate and high risk groups having pain at days. results: in our cohort of , patients, , had an evaluation at days. we identified three groups at low ( %), moderate ( . %), and high risk ( . %) of having pain ‡ / at days. using risk factor identified by univariate analysis, we created a model to identify patients at risk containing the following predictors: age ‡ years old, women, current smoker, two or more rib fractures, complaint of dyspnea, and saturation < % at initial visit. posteriori probabilities for low, moderate, and high risk were %, %, and %. conclusion: to our knowledge, this is the first study to identify potential risk factor for having pain at days after minor thoracic injury. these risk factors should be validated in a prospective study to guide specific treatment plan. the use of ultrasound to evaluate traumatic optic neuropathy benjamin burt, lisa montgomery, cynthia garza meissner, sanja plavsic-kupesic, nadah zafar ttuhsc -paul l foster school of medicine, el paso, tx background: whenever head trauma occurs, there is the possibility for a patient to have an optic nerve injury. the current method to evaluate optical nerve swelling is to look for proptosis. however, by the time proptosis presents, significant damage has already occurred. therefore, there is a need to establish a method to evaluate nerve injury prior to the development of proptosis. objectives: fundamental to understanding the pathophysiology of optic nerve injury and repair is an understanding of the optic nerve's temporal response to trauma including blood flow changes and vascular reactivity. the aim of our study was to assess the dependability and reproducibility of ultrasound techniques to sequence optic nerve healing and monitor the vascular response of the ophthalmic artery following an optic nerve crush. methods: the rat's orbit was imaged prior to and following a direct injury to the optic nerve, at hours and at days. d, d, and color doppler techniques were used to detect blood flow and the course of the ophthalmic artery and vein, to evaluate the course and diameter of the optic nerve, and to assess the extent of optic nerve trauma and swelling. the parameters used to evaluate healing over time were pulsatility and resistance indices of the ophthalmic artery. results: we have established baseline ultrasound measurements of the optic nerve diameter, normal resistance and pulsatility indices of the ophthalmic artery, and morphological assessment of the optic nerve in a rat model. longitudinal assessment of d and d ultrasound parameters were used to evaluate vascular response of the ophthalmic artery to optic nerve crush injury. we have developed a rat model system to study traumatic optic nerve injury. the main advantages of ultrasound are low cost, non-invasiveness, lack of ionizing radiation, and the potential to perform longitudinal studies. our preliminary data indicate that d and d color doppler ultrasound may be used for the evaluation of ophthalmic artery and total orbital perfusion following trauma. once baseline ultrasound and doppler measurements are defined there is the opportunity to translate the rat model to evaluate patients with head trauma who are at risk for optic nerve swelling and to assess the usefulness of treatment interventions. background: alcoholism is a chronic disease that affects an estimated . million american adults. a common presentation to the emergency department (ed) is a trauma patient with altered sensorium who is presumed to be alcohol intoxicated by the physicians based on their olfactory sense. often ed physicians may leave patients suspected of alcohol intoxication aside until the effects wear off, potentially missing major trauma as the source of confusion or disorientation. this practice often results in delays in diagnosing acute potentially life-threatening injuries in the patients with presumed alcohol intoxication. objectives: this study will determine the accuracy of physicians' olfactory sense for diagnosing alcohol intoxication. methods: patients suspected of major trauma in the ed underwent an evaluation by the examining physician for the odor of alcohol as well as other signs of intoxication. each patient had determination of blood alcohol level. alcohol intoxication was defined as a serum ethanol level ‡ mg/dl. data were reported as means with % confidence intervals ( % ci) or proportions with inter-quartile ranges (iqr %- %). results: one hundred and fifty one patients ( % males) were enrolled in the study, median age years (iqr - ). the median score for glasgow coma scale was . the level of training of examining physician was a median of pgy (iqr pgy -attending). prevalence of alcohol intoxication was % ( % ci: % to %). operating characteristics: physician assessment of alcohol intoxication, sensitivity % ( % ci: % to %), specificity % ( % ci: % to %), positive likelihood ratio . ( % ci: . to . ), negative likelihood ratio . ( % ci: . to . ), and accuracy % ( % ci: % to %). patients who were falsely suspected of being intoxicated were . % ( % ci: % to %). conclusion: although the physicians had a high degree of accuracy in identifying patients with alcohol intoxication based on their olfactory sense, they still falsely overestimated intoxication in a significant number of non-intoxicated trauma patients. the background: optimal methods for education and assessment in emergency and critical care ultrasound training for residents are not known. methods of assessment often rely on surrogate endpoints which do not assess the ability of the learner to perform the imaging and integrate the imaging into diagnostic and therapeutic decisions. we designed an educational strategy that combines asynchronous learning to teach imaging skills and interpretation with a standardized assessment tool using a novel ultrasound simulator to assess the learner's ability to acquire and interpret images in the setting of a standardized patient scenario. objectives: to assess the ability of emergency medicine and surgical residents to integrate and apply information and skills acquired in an asynchronous learning environment in order to identify pathology and prioritize relevant diagnoses using an advanced cardiac ultrasound simulator. methods: em r residents and r surgical residents completed an online focused training program in cardiac ultrasonography (iccu elearning, https:// www.caeiccu.com/lms). this consisted of approximately hours of intensive training in cardiac ultrasound. residents were then given cases with a patient scenario that lacked significant details that would suggest a specific diagnosis. the resident was then given a list of possible diagnoses and asked to rank the top five diagnoses in order of most likely to least likely. each resident (blinded to the pathology displayed by the simulator) then imaged using an ultrasound simulator. after imaging, the residents were given the same list of potential diagnoses, and asked to rank them again from - . results: overall, residents ranked the correct diagnosis in the top five significantly more times post-ultrasound than pre-ultrasound. additionally, the residents made the correct diagnosis significantly more times postultrasound than pre-ultrasound. similar patterns occur for congestive heart failure, pericardial effusion with tamponade, and pleural effusion. there was no significant difference pre-and post-ultrasound for pulmonary embolism and anterior infarction. conclusion: an asynchronous online learning program significantly improves the ability of emergency medicine and surgical residents to correctly prioritize the correct diagnosis after imaging with a standardized pathology imaging simulator. mark favot, jacob manteuffel, david amponsah henry ford hospital, detroit, mi background: em clerkships are often the only opportunity medical students have to spend a significant amount of time caring for patients in the ed. it is imperative that students gain exposure to as many of the various fields within em as possible during this time. if the exposure of medical students to ultrasound is left to the discretion of the supervising physicians, we feel that many students would complete an em clerkship with limited skills and knowledge in ultrasound. the majority of medical students receive no formal training in ultrasound during medical school and we believe that the em clerkship is an excellent opportunity to fill this educational gap. objectives: evaluate the usefulness and effectiveness of a focused ultrasound curriculum for medical students in an em clerkship at a large, urban, academic medical center. methods: prospective cohort study of fourth year medical students doing an em clerkship. as part of the clerkship requirements, the students have a portion of the curriculum dedicated to the fast exam and ultrasound-guided vascular access. at the end of the month they take a written test, and month later they are given a survey via e-mail regarding their ultrasound experience. em residents also completed the test to serve as a comparison group. all data analysis was done using sas . . scores were integers ranging between and . descriptive statistics are given as count, mean, standard deviation, median, minimum, and maximum for each group. due to non-gaussian nature of the data and small group sizes, a wilcoxon two-sample test was used to compare the distributions of scores between the groups. results: in the table, the distribution of scores was compared between the residents (controls) and the students (subjects). the mean and median scores of the student group were higher than those of the resident group. the difference in scores between the two groups was statistically significant (p = . ). conclusion: our data reveal that after completing an em clerkship with time devoted to learning ultrasound for the fast exam and vascular access, fourth year medical students are able to perform better than em residents on a written test. what remains to be determined is if their skills in image acquisition and in performance of ultrasound-guided vascular access procedures also exceed those of em residents. results: there were respondents (total response rate . %). compared to non-em students, students pursuing em ( students, . %) were more drawn to their specialty for work hour control (p < . ) and shorter residency length (p < . ). em students were less likely than non-em students to be drawn to their chosen specialty for future academic opportunities (p < . ). em students formed their mentorships by referral significantly more than non-em students (p < . ), though there was no statistical difference in quality of existing mentorships amongst students. of the students not currently and never formerly interested in em, the most common response ( . %) for why they did not choose em was the lack of a strong mentor in the field. conclusion: the results confirmed previous findings of lifestyle factors drawing students to em. future academic opportunities were less likely to draw students to em than students pursuing other specialties. lack of mentorship in the field was the most common reason given for why students did not consider em. given the lack of direct em exposure until late in the curriculum of most medical schools, mentorship may be particularly important for em and future study should focus on this area. background: misdiagnosis is a major public health problem. dizziness leads to million visits annually in the us, including . million to the emergency department (ed). despite extensive ed workups, diagnostic accuracy remains poor, with at least % of strokes missed in those presenting with dizziness. ed physicians need and want support, particularly in the best method for diagnosis. strong evidence now indicates the bedside oculomotor exam is the best method of differentiating central from peripheral causes of dizziness. objectives: after a vertigo day that includes instruction in head impulse testing, emergency medicine residents will feel comfortable discharging a patient with signs of vestibular neuritis and a positive head impulse test without ordering a ct scan. methods: post graduate year - emergency medicine residents participated in a four hour vertigo day. we developed a mixed cognitive and systems intervention with three components: an online game that began and ended the day, a didactic taught by dr. newman-toker, and a series of small group exercises. the small group sessions included the following: a question and answer session with the lecturer; vertigo special tests (cerebellar assessment, dix hall-pike, epley maneuver); a head impulse hands-on tutorial using a mannequin; and a video lecture on other tests useful in vertigo evaluation (nystagmus, test of skew, vestibulocular reflex, ataxia). results: thirty emergency medicine residents were studied. before and after the intervention the residents were given a survey in which one question asked ''in a patient with acute vestibular syndrome and a history and exam compatible with vestibular neuritis, i would be willing to discharge the patient without neuroimaging based on an abnormal head impulse test result that i elicited''. resident answers were based on a sevenpoint likert scale from strongly agree to strongly disagree. twenty-five residents completed both surveys. of the seven residents who changed their responses pre to post,a significant proportion ( %) changed their answer from disagree/neutral to agree after a hour vertigo day (mcnemar's test, p value = . ). conclusion: in this single-center study, teaching headimpulse testing as part of a vertigo day increases resident comfort with discharging a patient with vestibular neuritis without a ct scan. background: previous studies have been inconsistent in determining the effect of increased ed census on resident workload and productivity. we examined resident workload and productivity after the closure of a large urban ed near our facility, which resulted in a rapid % increase in our census. objectives: we hypothesized that the closure of a nearby hospital closure with a resulting influx of ed patients to our facility would not change resident productivity. methods: this computer-assisted retrospective study compared new patient workups per hour and patient load before and after the closure of a large nearby hospital. specifically, new patient workups per hour and the pm patient census per resident were examined for a one-year period in the calendar year prior to the closing and also for one year after the closing. we did not include the four month period surrounding the closure in order to determine the long-term overall effect. background: emergency medicine residents use simulation for training due to multiple factors including the acuity of certain situations they are faced with, and the rarity of others. current training on highfidelity mannequin simulators is often critiqued by residents over the physical exam findings present, specifically the auscultatory findings. this detracts from the realism of the training, and may also lead a resident down a different diagnostic or therapeutic pathway. wireless remote programmed stethoscopes represent a new tool for simulation education which allows any sound to be wirelessly transmitted to a stethoscope receiver. objectives: our goal was to determine if a wireless remote programmed stethoscope was a useful adjunct in simulation-based cases using a high-fidelity mannequin. our hypothesis was that this would represent a useful adjunct in simulation education of emergency medicine residents. methods: starting june , pgy - emergency medicine residents were assessed in two simulation-based cases using pre-determined scoring anchors. an experimental randomized crossover design was used in which each resident performed a simulation case with and without a remote programmed stethoscope on a highfidelity mannequin. scoring anchors and surveys were used to collect data with differences of means calculated. results: fourteen residents participated in the study. residents noted most realistic physical exam findings associated with the case with the adjunct in / ( %) and that their preference was for the use of the adjunct in / ( %). based off of a five-point likert scale, with being the most realistic, the adjunct-associated case averaged . as compared to . without (difference of means . , p = . ). average scores of residents with the adjunct were . / with the use of the adjunct and . / without (difference of means . , p = . ). average total times were : with the adjunct as compared to : without. conclusion: a wireless remote programmed stethoscope is a useful adjunct in simulation training of emergency medicine residents. residents noted physical exam findings to be more realistic, preferred its use, and had approached significant improvement of scores when using the adjunct. background: prior studies predict an ongoing shortage of emergency physicians to staff the nation's eds, especially in rural areas. to address this, em organizations have discussed broadening access to acgme or aoa accredited em residency programs to physicians who previously trained in another specialty and focusing on physicians already practicing in rural areas. objectives: to investigate whether em program directors (pds) from allopathic and osteopathic residency programs would be willing to accept applicants previously trained in other specialties and whether this willingness is modified by applicants' current practice in rural areas. methods: a five-question web-based survey was sent to u.s. em pds asking questions about their policies on accepting residents with past training and from rural practices. questions included whether a pd would accept a resident with prior training in other specialties, how many years from this training would the applicant be still a competitive candidate and if a physician was practicing in a rural region would the likelihood of acceptance to the program be improved. different characteristics of the residency programs were recorded including length of program, years in existence, size, type, and location of program. we compared responses by program characteristics using chi-square test. results: of the ( %) pds responding to date, a large majority ( %) reported they do accept applicants with previous residency training, although directors of osteopathic programs were less likely to accept these applicants ( % vs % for allopathic; p < . ). overall, % of pds reported no limit on the length of time from prior training to when they are accepted at an em program. % reported it is very or possibly realistic they would accept a candidate who had completed training and was board certified in another specialty. a majority of all respondents ( %) felt a physician practicing in a rural setting might be viewed as a more favorable candidate, even if the resident would only be in the program for years after receiving training credit. directors of newer programs (< years of existence) were more likely to view these candidates favorably than older programs ( % vs %; p = . ). conclusion: there appear to be many em residency programs that would at least review the application and consider accepting a candidate who trained in another specialty. a qualitative assessment of emergency medicine self-reported strengths todd guth university of colorado, aurora, co background: self-reflection has been touted as a useful way to assess the acgme core competencies. objectives: the purpose of this study is to gain insight into resident physician professional development through analysis of self-perceived strengths. a secondary purpose is to discover potential topics for selfreflective narrative essays relating to the acgme core competencies. methods: design: a small qualitative study was performed to explore the self-reported strengths of emergency medicine (em) residents in a single four-year residency. participants: all residents regardless of year of training were also asked to report their selfperceived strengths. observations: residents were asked: ''what do you feel are your greatest strengths as a resident? provide a quick description.'' the author and another reviewer identified themes from within each year of residency with abraham maslow's conscious competence conceptual framework in mind. occurrences of each theme were counted by the reviewers and organized according to frequency. once the top ten themes for each year of residency were identified and exemplar quotes identified, the two reviewers identified trends. inter-rater agreements were calculated. results: representing unconscious incompetency, the first trend was the reported presence of ''enthusiasm and a positive attitude'' from residents early in their training that decreases further along in training. additionally, a ''willingness and motivation to improve and learn'' was reported as a strength throughout all the years of training but most frequently reported in the first two years of residency. entering into conscious incompetence, the second trend identified was ''recognition of limitations and openness to constructive feedback'' that was mentioned frequently in the second and third years of residency. demonstrating conscious competence, the third trend identified was the increase in identification of the strengths of ''educational leadership, teamwork skills and communication, and departmental patient flow and efficiency'' in the later years of residency. conclusion: self-reported strengths has helped to identify both themes within each year of residency and trends among the years of residency that can serve as areas to explore in self-reflective narratives relating to the acgme core competencies. training. pofu can also be used to assess the acgme core competency of practice-based learning. the exact form or frequency of pofu assessment among various em residencies, however, is not currently known. objectives: we aimed to survey em residencies across the country to determine how they fulfill the pofu requirement and whether certain program structure variables were associated with different pofu systems. we hypothesized that implementation of pofu systems among em residencies would be highly variable. methods: in this irb-approved study, all program directors of acgme allopathic em residencies were invited to complete a -question survey on their current approaches to pofu. respondents were asked to describe their current pofu system's characteristics and rate its ease of use, effectiveness, and efficiency. data were collected using surveymonkey(tm) and reported using descriptive statistics. results: of residencies surveyed, ( %) submitted complete data. . % were completed by program directors and over three-fourths ( . %) of em residencies require monthly completion of pofus. the mean total pofus required per year was ( % ci - ), with a median of and a range of - . almost / ( %) of residencies use an electronic pofu system. most ( %) -year em residencies use an electronic pofu system, compared with half ( %) of -year residencies (difference %, p = . , % ci . %- . %). seven commercially available electronic programs are used by % of the residencies, while % use a customized product. most respondents ( %) rated their pofu system as easy to use, but less than half ( %) felt it was an effective learning tool or an efficient one ( %). onethird ( %) would use a different pofu system if available, and almost half ( %) would be interested in using a multi-residency pofu system. conclusion: em residency programs use many different strategies to fulfill the rrc requirement for pofu. the number of required pofus and the method of documentation vary considerably. about two-thirds of respondents use an electronic pofu system. less than half feel that pofu logs are an effective or efficient learning tool. background: certification of procedural competency is requisite to graduate medical education. however, little is known regarding which platforms are best suited for competency assessment. simulators offer several advantages as an assessment modality, but evidence is lacking regarding their use in this domain. furthermore, perception of an assessment environment has important influence on the quality of learning outcomes, and procedural skill assessment is ideally conducted on a platform accepted by the learner. objectives: to ascertain if a simulator performs as well as an unembalmed cadaver with regard to residents' perception of their ability to demonstrate procedural competency during ultrasound (us) guided internal jugular vein (ij) catheterization. methods: in this cross-sectional study at an urban community hospital during july of , residents in their second or third year of training from a -year em residency program performed us guided catheterizations of the ij on both an unembalmed cadaver and a simulator manufactured by blue phantom. after the procedure, residents completed an anonymous survey ascertaining how adequately each platform permitted their demonstration of proficiency on predefined procedural steps. answers were provided on a likert scale of to , with being poor and being excellent. p values < . were considered educationally significant. results: the median overall rating of the simulator (s) to serve as an assessment platform was similar to that of the cadaver (c) with scores of . and . respectively, p = . . median ratings for permitting the demonstration of specific procedural steps were as follows: conclusion: senior em residents positively rate the blue phantom simulator as an assessment platform and similarly to that of a cadaver with regard to permitting their demonstration of procedural competency for us guided ij catheterization, but did prefer the cadaver to a greater degree when identifying and guiding the needle into the ij. methods: in fall , wcmc and wcmc-q students taking the course completed a question pre-and post-test. wcmc-q students also completed a postcourse single-station objective structured clinical examination (osce) that evaluated their ability to identify and perform eight actions critical for a first responder in an emergency situation (table ) . results: on both campuses, mean post-test scores were significantly higher than mean pre-test scores (p £ . ). on the pre-test, mean wcmc student scores were significantly higher than for wcmc-q students (p = . ); however, no difference was found in mean post-test scores (p = . ). there was no association between the scores on the osce (mean = . , sd = . ) and the post-test (p = . ) even after adjusting for a possible evaluators' effect (table ) . clinical skills course was effective in enhancing student knowledge in both qatar and new york as evidenced by the significant improvement in scores from the pre-to post-tests. the course was able to bring wcmc-q student scores and presumably knowledge up to the same level as wcmc students. students performed well on the osce, suggesting that the course was able to teach them the critical actions required of a first responder. the lack of association between the post-test and osce scores suggests that student knowledge does not independently predict ability to learn and demonstrate critical actions required of a first responder. future studies will evaluate whether the course affects the students' clinical practice. assess breathing assess circulation call ems call ems and assess abcs prior to other interventions immobilize localize and control bleeding splint fractured extremity and skills specific to wilderness medicine by incorporating simulated medical scenarios into a day-long adventure race. this event has gained acceptance nationally in wilderness medical circles as an excellent way to appreciate the challenges of wilderness medicine, however its effectiveness as a teaching tool has not yet been verified. objectives: the objective of this study was to determine if improvement in simulated clinical and didactic performance can be demonstrated by teams participating in a typical medwar event. methods: we developed a complex clinical scenario and written exam to test the basic tenets that are reinforced through the medwar curriculum. teams were administered the test and scored on a standardized scenario immediately before and after the midwest medwar race. teams were not given feedback on their pre-race performance. scenario performance was based on the number of critical actions correctly performed in the appropriate time frame. data from the scenario and written exams were analyzed using a standard paired difference t-test. results: a total of teams participated in both the pre-and post-event scenarios. the teams' pre-race scenario performance was . % (sd = . , n = ) of critical actions met compared to a post-race performance of . % (sd = . , n = ). the mean improvement was . % (sd = . , n = , % ci . , . ) with a significant paired two-tailed t-test (p £ . ). a total of individual subjects took the written pre-and posttests. the written scores averaged pre-race . % (sd = . , n = ) and post-race . % (sd = . , n = ). the mean improvement was . % (sd = . , n = , ci ) . , . ), with a significant paired twotailed t-test (p £ . ). conclusion: medwar participants demonstrated a significant improvement in both written exam scores and the management of a simulated complex wilderness medical scenario. this strongly suggests that medwar is an effective teaching platform for both wilderness medicine knowledge and skills. palliative methods: ed residents and faculty of an urban, tertiary care, level i trauma center were asked to complete an anonymous survey ( / - / ). participants ranked statements on a five-point likert scale ( = strongly disagree- = strongly agree). statements covered four main domains of barriers related to: ) education/training, ) communication, ) ed environment; ) personal beliefs. respondents were also asked if they would call pc consult for ed clinical scenarios (based on established triggers). results: / ( %) eligible participants completed the survey ( residents, faculty), average age was years, % ( / ) male, and % ( / ) caucasian. respondents identified two major barriers to ed-pc provision: lack of hour availability of pc team (mean score . ) and lack of access to complete medical records ( . ). listed domain barriers included: communication-related issues (mean . ) like access to family or primary providers, ed environment ( . ) for example chaotic setting with time-constraints, education/training ( . ) related to pain/pc, and personal beliefs regarding end-of-life ( . ). all respondents agreed that they would call pc consult for a 'hospice patient in respiratory distress', and a majority ( %) would consult pc for 'massive intracranial hemorrhage, traumatic arrest, and metastatic cancer'. however, traditional in-patient triggers like frequent re-admits for organ failure issues (dementia, congestive heart failure, and obstructive pulmonary disease exacerbations) were infrequently ( %) chosen for pc consult. conclusion: to enhance pc provision in the ed setting, two main ed physician perceived barriers will likely need to be addressed: lack of access to medical records and lack of - availability of pc team. ed physicians may not use the same criteria to initiate pc consults as compared to the traditionally established inpatient pc consult trigger models. percent of charts with an mse by ait prior to resident evaluation (a measure of reduced diagnostic uncertainty and decision-making), ( ) ed volume. results: there were no educationally significant differences in productivity or acuity between the pre-ait and post-ait groups. mse was recorded in the chart prior to resident evaluation in . % of cases. ed volume rose by . % between periods. conclusion: ait did not affect productivity or acuity of patients seen by em s. while some volume was directed away from residents by ait (patients treated-andreleased by ait only), overall volume increased and made up the difference. this is similar to previously reported rankings that program directors gave to the same criteria. although medical students agreed with program directors on the importance of most aspects of the nrmp application areas of discordance included higher medical student ranking for extracurricular activities and a lower relative ranking for aoa status than program directors. this can have implications for medical student mentoring and advising in the future. background: emergency care of older adults requires specialized knowledge of their unique physiology, atypical presentations, and care transitions. older adults often require distinctive assessment, treatment and disposition. emergency medicine (em) residents should develop expertise and efficiency in geriatric care. older adults represent over % of most emergency department (ed) volumes. yet many em residencies lack curricula or assessment tools for competent geriatric care. the geriatric emergency medicine competencies (gemc) are high-impact geriatric topics developed to help residencies meet this demand. objectives: to examine the effect of a brief gemc educational intervention on em resident knowledge. methods: a validated -question didactic test was administered at six em residencies before and after a gemc focused lecture delivered summer and fall of . scores were analyzed as individual questions and in defined topic domains using a paired student's t-test. results: a total of exams were included. the testing of didactic knowledge before and after the gemc educational intervention had high internal reliability ( . %). the intervention significantly improved scores in all domains (table ) . graded increase in geriatric knowledge occurred by pgy year with the greatest improvement seen at the pgy level (table ) . conclusion: even a brief gemc intervention had a significant effect on em resident knowledge of critical geriatric topics. a formal gemc curriculum should be considered in training em residents for the demands of an ageing population. the overall procedure experience of this incoming class was limited. most r s had never received formal education in time management, conflict of interest management, or safe patient trade-off. the majority lacked confidence in their acute and chronic pain management skills. these entry level residents lacked foundational skill levels in many knowledge areas and procedures important to the practice of em. ideally medical school curricular offerings should address these gaps; in the interim, residency curricula should incorporate some or all of these components essential to physician practice and patient safety. background: the american heart association and international liaison committee on resuscitation recommend patients with return of spontaneous circulation following cardiac arrest undergo post-resuscitation therapeutic hypothermia. in post-cardiac arrest patients presenting with a rhythm of vf/vt, therapeutic hypothermia has been shown to reduce neurologic sequelae and decrease overall mortality. objectives: to explore clinical practice regarding the use of therapeutic hypothermia and compare survival outcomes in post-cardiac arrest patients. a secondary outcome was to assess whether the initial presenting cardiac arrest rhythm (ventricular fibrillation/ventricular tachycardia (vf/vt) versus pulseless electrical activity (pea) or asystole) was associated with differences in outcomes. methods: a retrospective medical record review was conducted for all adult ( ‡ years) post-cardiac arrest patients admitted to the icu of an academic tertiary care centre (annual ed census , ) from - . data were extracted using a standardized data collection tool by trained research personnel. results: patients were enrolled. mean (sd) age was ( ) and . % were male. of ( . %) patients treated with hypothermia, ( . %) presented with an initial rhythm of vf/vt and ( . %) presented with pea or asystole. nine ( . %) patients with vf/vt were treated with therapeutic hypothermia and discharged from hospital compared to ( . %) patients with pea or asystole (d . %; % ci: . %, . %). of patients not treated with hypothermia, ( . %) presented with vf/vt, ( . %) presented with pea or asystole, and ( . %) initial rhythms were unknown. fifteen ( . %) patients with vf/vt, not treated with hypothermia, were discharged from hospital compared to ( . %) patients with pea or asystole (d . %; % ci: . %, . %). regardless of initial presenting rhythm or initiation of therapeutic hypothermia, ( . %) discharged patients had good neurological function as assessed by the cerebral performance category (cpc score - ). conclusion: although recommended, post-cardiac arrest therapeutic hypothermia was not routinely used. patients with vf/vt and treated with hypothermia had better outcomes than those with pea or asystole. further research is needed to assess whether cooling patients with presenting rhtyhms of pea or asystole is warranted. racial background: chronic obstructive pulmonary disease (copd) is a major public health problem in many countries.the course of the disease is characterised by episodes, known as acute exacerbations (ae), when symptoms of cough, sputum production, and breathlessness become much worse. the standard prehospital management of patients suffering from an aecopd includes oxygen therapy, nebulised bronchodilators, and corticosteroids. high flow oxygen is used routinely in prehospital areas for breathless patients with copd. there is little high quality evidence on the benefits or potential dangers in this setting but audits have shown increased mortality, acidosis, and hypercarbia in patients with aecopd treated with high flow oxygen. objectives: to compare standard high flow oxygen treatment with titrated oxygen treatment for patients with an aecopd in the prehospital setting. methods: cluster randomized controlled parallel group trial comparing high flow oxygen treatment with titrated oxygen treatment in the prehospital setting. in an intention to treat analysis (n = ), the risk of death was significantly lower in the titrated oxygen arm compared with the high flow oxygen arm for all patients and for the subgroup of patients with confirmed copd (n = ). overall mortality was % ( deaths) in the high flow oxygen arm compared with % ( deaths) in the titrated oxygen arm; mortality in the subgroup with confirmed copd was % ( deaths) in the high flow arm compared with % ( deaths) in the titrated oxygen arm. titrated oxygen treatment reduced mortality compared with high flow oxygen by % for all patients (p = . ) and by % for the patients with confirmed chronic obstructive pulmonary disease (p = . ). patients with copd who received titrated oxygen according to the protocol were significantly less likely to have respiratory acidosis or hypercapnia than were patients who received high flow oxygen. conclusion: titrated oxygen treatment significantly reduced mortality, hypercapnia, and respiratory acidosis compared with high flow oxygen in aecopd. these results provide strong evidence to recommend the routine use of titrated oxygen treatment in patients with breathlessness and a history or clinical likelihood of copd in the prehospital setting. (originally submitted as a ''late-breaker.'') trial registration australian new zealand clinical trials register actrn . background: toxic particulates and gases found in ambulance exhaust are associated with acute and chronic health risks. the presence of such materials in areas proximate to ed ambulance parking bays, where emergency services' vehicles are often left running, is potentially of significant concern to ed patients and staff. objectives: investigators aimed to determine whether the presence of ambulances correlated with ambient particulate matter concentrations and toxic gas levels at the study site ed. methods: the ambulance exhaust toxicity in healthcare-related exposure and risk [aether] program conducted a prospective observational study at an academic urban ed / level i trauma center. environmental ambient gas was sampled over a continuous five-week period from september to october . two sampling locations in the public triage area (public patient dropoff area without ambulances) and three sampling locations in the ambulance triage area were randomized for -hour monitoring windows with a temporal resolution of minutes to obtain days of non-contiguous data for each location. concentrations of particulate matter less than . microns in aerodynamic size (pm . ), oxygen, hydrogen sulfide (h s), and carbon monoxide (co) as well as lower explosive limit for methane (lel) were monitored with professionally calibrated devices. ambulance traffic was recorded through offline review of / security video footage of the site's ambulance bays. results: , measurements at the public triage nurse desk space revealed pm . concentrations with a mean of . ± . lg/m (median . lg/m ; maximum , . lg/m ). , ambulance triage nurse desk space pm . concentrations recorded a mean of . ± . lg/m (p < . , unpaired t test; median . lg/m ; maximum . lg/m ). oxygen levels remained steady throughout the study period; co, h s, and lel were not detected. ambulance activity levels had the highest correlations with pm . concentrations at the ambulance triage foyer (r = . ) and desk area (r = . ) where patients wait and ed staff work - hr shifts. conclusion: ed spaces proximate to ambulance parking bays had higher levels of pm . than areas without ambulance traffic. concentrations of ambient particulate matter in acute care environments may pose a significant health threat to patients and staff. an ems ''pit crew'' model improves ekg and stemi recognition times in simulated prehospital chest pain patients sara y. baker , salvatore silvestri , christopher d. vu , george a. ralls , christopher l. hunter , zack weagraff , linda papa orlando regional medical center, orlando, fl; florida state university college of medicine, orlando, fl background: prehospital teams must minimize time to ekg acquisition and stemi recognition to reduce overall time from first medical contact to reperfusion. auto-racing ''pit crews'' model rapid task completion by pre-assigning roles to team members. objectives: we compared time-to-completion of key tasks during chest pain evaluation in ems teams with and without pre-assigned roles. we hypothesized that ems teams using the ''pit crew'' model would improve time to recognition and treatment of stemi patients. methods: a randomized, controlled trial of paramedic students was conducted over months at orlando medical institute, a state-approved paramedic training center. we compared a standard ems chest pain management algorithm (control) with a pre-assigned tasks (''pit crew'') algorithm (intervention) in the evaluation of simulated chest pain patients. students were randomized into groups of three; intervention and control groups did not interact after randomization. all students reviewed basic prehospital chest pain management and either the standard or pre-assigned tasks algorithm. groups encountered three simulated patients. laerdal simmanÒ software was used track completion of tasks: taking vital signs, iv access, ekg acquisition and interpretation, asa administration, hospital stemi notification, and total time on scene. results: we conducted simulated-patient encounters ( control / intervention encounters). mean time-to-completion of each task was compared in the control and intervention groups respectively. time to obtain vital signs was : vs. : min (p = . ); time to asa administration was : vs : min (p < . ); time to ekg acquisition was : vs : min (p < . ); time to ekg interpretation was : vs : min (p < . ); time to iv access was : vs : min (p = . ); time to stemi notification was : vs : min (p < . ); and time to scene completion was : vs : min (p < . ). conclusion: paramedic student teams with pre-assigned roles (the ''pit crew'' model) were faster to obtain vital signs, administer asa, acquire and interpret the ekg, stemi notification, and overall time on scene during simulated patient encounters. further study with experienced ems teams in actual patient encounters is necessary to confirm the relevance of these findings. background: use of automated external defibrillators (aed) has remained low in the u.s. understanding the effect of neighborhoods on the probability of having an aed used in the setting of a public arrest may provide important insights for future placement of aeds. objectives: to determine associations between the racial and income composition of neighborhoods (as defined by u.s. census tracts), individual arrest characteristics, and whether bystanders or first responders initiate aed use. methods: cohort study using surveillance data prospectively submitted by emergency medical services systems and hospitals from u.s. sites to the cardiac arrest registry to enhance survival between october , and december , . neighborhoods were defined as high-income vs. low-income based on the median household income being above or below $ , and as white or black if > % of the census tract was of one race. neighborhoods without a predominant racial composition were defined as integrated. arrests that occurred within a public location (excluding medical facilities and airports) were eligible for inclusion. hierarchical multi-level modeling, using stata v . , was used to determine the association between individual and census tract characteristics on whether an aed was used. results: of , eligible cases, an aed was used in arrests ( . %) by a first responder (n = , , . %) or bystander (n = , . %). patients whose arrest was witnessed (odds ratio [or] . ; % confidence interval [ci] . - . ) were more likely to have an aed used (table) . when compared to high-income white neighborhoods, arrest victims in low-income black neighborhoods were least likely to have an aed used (or . ; % ci . - . ). arrest victims in lowincome white (or . ; % ci . - . ) and lowincome integrated (or . ; % ci . - . ) were also less likely to have an aed used. conclusion: arrest victims in black and low-income neighborhoods are least likely to have an aed used by a layperson or first responder. future research is needed to better understand the reasons for low rates of aed use for cardiac arrests in these neighborhoods. the impact of an educational intervention on the pre-shock pause interval among patients experiencing an out-of-hospital cardiac arrest jonathan studnek , eric hawkins , steven vandeventer carolinas medical center, charlotte, nc; mecklenburg ems agency, charlotte, nc background: pre-shock pause duration has been associated with survival to hospital discharge (std) among patients experiencing out-of-hospital cardiac arrest (oohca) resuscitation. recent research has demonstrated that for every -second increase in this interval there is an % decrease in std. objectives: determine if a decrease in the pre-shock pause interval for patients experiencing oohca could be realized after implementation of an educational intervention. methods: this was a retrospective analysis of data obtained from a single als urban ems system from / / to / / and / / to / / . in august , an educational intervention was designed and delivered to approximately paramedics emphasizing the importance of reducing the time off chest during cpr. specifically, the time period just prior to defibrillation was emphasized by having rescuers count every th compression and pre-charge the defibrillator on the th compression. in order to determine if this change resulted in process improvement, months of data were assessed before and months after the educational intervention. pre-shock pause was the outcome variable and was defined as the time period after compressions ceased until a shock was delivered. this interval was measured by a cpr feedback device connected to the defibrillator. inclusion criteria were adult patients who required at least one defibrillation and had the cpr feedback device connected during the defibrillation attempt. analysis was descriptive utilizing means and % ci as well as wilcoxon rank sum test to assess difference between the two time periods. results: in the pre-intervention period there were patients who received defibrillations compared to patients receiving defibrillations in the post-intervention phase. the mean duration of the pre-shock pause pre-intervention was seconds ( % ci - ) while the post-intervention duration was seconds ( % ci - ). the difference in pre-shock pause duration was statistically significant with p < . . conclusion: these data indicate that after a simple educational intervention emphasizing decreasing time off chest prior to defibrillation the pre-shock pause duration decreased. future research must describe the sustainability of this intervention as well as the effects this process measure may have on outcomes such as survival to hospital discharge. background: the broselow tape (bt) has been used as a tool for estimating medication dosing in the emergency setting. the obesity trend has demonstrated a tendency towards insufficient pediatric weight estimations from the bt, and thus potential under-dosing of resuscitation medications. objectives: this study compared drug dosing based on the bt with dosing from a novel electronic tool (et) that accounts for provider estimation of body habitus. methods: data were obtained from a prospective convenience sample of children ages to years arriving to a pediatric emergency department. a clinician performed an assessment of body habitus (average/underweight, overweight, or obese), blinded to the patient's actual weight and parental weight estimate. parental estimate of weight and measured length and weight were collected. epinephrine dosing was calculated from the measured weight, the bt measurement, as well as from a smart-phone tool based on the measured length and clinician's estimate of body habitus, and a modified tool (mt) incorporating the parent estimate of habitus. the wilcoxson rank-sum test was used to compare median percent differences in dosing. results: one hundred children (mean age years) were analyzed; % were overweight or obese. clinicians correctly identified children as overweight/obese % of time (ci . - . ). adding parent estimate of weight improved this to a sensitivity of % (ci . - . ). the median difference between the weight-based epinephrine dose and bt dose was %. for the et the median difference from the weight-based dose was % (p = . compared to the bt), and for the mt was . % (p < . compared to the bt). when a clinically significant difference was defined as ± % of the actual dose, bt was within that range % of the time, et was within range % of the time (p = . ), and mt was within range % of the time ( background: in most out-of-hospital cardiac arrest (ohca) events, a call to - - is the first action by bystanders. accurate diagnosis of cardiac arrest by the call taker depends on the caller's verbal description. if cardiac arrest is not suspected, then no telephone cpr instructions will be given. objectives: we measured the effect of a change in the ems call taker question sequence on the accuracy of diagnosis of cardiac arrest by - - call takers. methods: we retrospectively reviewed the cardiac arrest registry to enhance survival (cares) dataset for january , through june , from a city, population , , with a longstanding telephone cpr program (apco). we included ohca cases of any age who were in arrest prior to the arrival of ems and for whom resuscitation was attempted. in early , - - call takers were taught to follow a revised telephone script that emphasized focused questions, assertive control of the caller, and provision of hands-only cpr instructions. the medical director personally explained the reasons for the changes, emphasizing the importance of assertive control of the caller and the comparative safety of chest compressions in patients not in cardiac arrest. beginning in , call recordings were reviewed regularly with feedback to the call taker by the - - center leadership. the main outcome measure was sensitivity of the - - call taker in diagnosing cardiac arrest. bystander cpr was reported by ems crews attending the event. we compared with and using the v test and odds ratios (or). results: there were ohca cases in , cases in , and in the first half of ( / , population). the mean age was ± years, and % of the events were witnessed. before the revision, % of ohca cases were identified by - - dispatchers; and after the revised questioning sequence, % were identified (or . , % ci . - . ). the false positive rate changed little (from /month to /month). the mean time to question callers was unchanged ( vs seconds). bystander cpr was performed in . % of events in , . % in , and . % of events in (p < . ). conclusion: emphasis on scripted assessment improved sensitivity without loss of specificity in identifying ohca. with repeated feedback, it translated to an increase in victims receiving bystander cpr. in an out-of hospital cardiac arrest population confirmed by autopsy salvatore silvestri, christopher hunter, george ralls, linda papa orlando regional medical center, orlando, fl background: quantitative end-tidal carbon dioxide (etco ) measurements (capnography) have consistently been shown to be more sensitive than qualitative (colorimetric) ones, and the reliability of capnography for assessing airway placement in low perfusion states has sometimes been questioned in the literature. objectives: this study examined the rate of capnographic waveform presence of an intubated out-of-hospital cardiac arrest cohort and its correlation to endotracheal tube location confirmed by autopsy. our hypothesis is that capnography is % accurate in determining endotracheal tube location, even in low perfusion states. methods: this cross-sectional study reviewed a detailed prehospital cardiac arrest database that regularly records information using the utstein style. in addition, the ems department quality manager routinely logs the presence of an alveolar (four-phase) capnographic waveform in this database. the study population included all cardiac arrest patients from january , through december , managed by a single ems agency in orange county, florida. patients were included if they had endotracheal intubation performed, had capnographic measurement obtained, failed to regain return of spontaneous circulation (rosc), and had an autopsy performed. the main outcome was the correlation of the presence of an alveolar waveform and the location of the ett at autopsy. results: during the study period, cardiac arrests were recorded. of these, had an advanced airway placed (ett or laryngeal tube airway), and no rosc. of the advanced airway cases, were managed with an ett. autopsies were performed on of these patients and resulted in our study cohort. the location of the ett at autopsy was recorded on all of these cases. capnographic waveforms were recorded in the field in all of these study patients, and % of the tubes were located within the trachea at autopsy. the sensitivity of capnography in determining proper endotracheal tube location was % in this study. conclusion: in our study, the presence of a capnographic waveform was % reliable in confirming proper placement of endotracheal tubes placed in outof-hospital patients with poor perfusion states. results: over variables were presented to the ems medical directors responding ( % survey population captured). among the myriad of responses, ( %) initiate cardiopulmonary resuscitation (cpr) at compressions to ventilations consistent with il-cor/aha guidelines. seven ( %) initiate continuous chest compressions from the start of cpr with no pause and interposed ventilations. nine ( %) begin chest compressions only during the first - minutes, with either passive oxygenation by oxygen mask (six; %) or no oxygen (three; %). airway management following non-invasive oxygenation and ventilation by primary endotracheal intubation occurs in systems ( %), while six ( %) use supraglottic devices. fourteen ( %) allow paramedics to decide between endotracheal and supraglottic device placement. thirty systems ( %) utilize continuous waveform capnography. the initial approach to non-ems witnessed ventricular fibrillation is chest compression prior to first defibrillation in systems ( %). eighteen systems ( %) escalate defibrillation energy settings, with four systems ( %) utilizing dual sequential defibrillation. twenty ( %) initiate therapeutic hypothermia in the field. conclusion: wide variability in ca care standards exists in america's largest urban ems systems in mid- , with many current practices promoting more continuity in chest compressions than specified in the ilcor/aha guidelines. endotracheal intubation, a past mainstay of ca airway management, is deemphasized in many systems. immediate defibrillation of non-ems witnessed ventricular fibrillation is uncommon. objectives: determine the out-of-hospital cardiac arrest survival in this area of puerto rico using the utstein method. methods: prospective observational cohort study of adult patients presenting with an out-of-hospital cardiac arrest to the upr hospital ed. study endpoints will be survival and neurologically intact survival at hospital discharge, months, and months. results: a total of consecutive cardiac arrest events were analyzed for a period of years. one-hundred fifteen events met criteria for primary cardiac etiology ( . %). the average age for this group was . years. there were female ( . %) and male ( . %) participants. the average time to start cpr was . minutes. transportation to the ed was . % by ems and . % by private vehicle. a total of events were witnessed ( . %). the survival rate to hospital admission was . %. the overall cardiac arrest survival was . % and overall neurologically intact survival was . %. neurologically intact survival at and months was . %. the rate of bystander cpr in our population was . % with a survival rate of . %. conclusion: survival from out-of-hospital cardiac arrest in the area served by the upr hospital is low but comparable to other cities in the us as reported by the cdc cardiac arrest registry to enhance survival (cares). this low survival rate might be due to low bystander cpr rate and prolonged time to start cpr. background: hyperventilation has been directly correlated with increased mortality for out-of-hospital cpr. ems providers may hyperventilate patients at levels above national bls guidelines. real-time feedback devices, such as ventilation timers, have been shown to improve cpr ventilation rates towards bls standards. it remains unclear if the combination of a ventilation timer and pre-simulation instruction would influence overall ventilation rates and potentially reduce undesired hyperventilation. objectives: this study measured ventilation rates of standard cpr (and pre-instruction on effects of hyperventilation) compared to cpr with the use of a commercial ventilation timer (and pre-instruction on effects of hyperventilation). we propose that use of a ventilation timer, measuring and displaying to ems providers real-time ventilations delivered, will have no difference in ventilation rates when comparing these groups. methods: this prospective study placed ems providers into four groups: two controls measuring ventilation rates before ( a) and after instruction ( b) on the deleterious effects of hyperventilation, and a concurrent intervention pair with before ( a) and after instruction ( b), with the second pair measuring ventilation rates with a ventilation timer that provides immediate feedback on respirations given. ventilation rates were measured for a -second period after one minute of simulated cpr using mannequins. the control set without instruction ( a, n = ) averaged . breaths ( % ci = . - . ) and with instruction ( b, n = ) averaged . breaths ( % ci = . - . ). the intervention set without instruction ( a, n = ) averaged . breaths ( % ci = . - . ) and with instruction ( b, n = ) averaged . breaths ( % ci = . - . ). there was a significant improvement (p = . ) in ventilation rates with use of a ventilation timer (control group versus intervention group regardless of pre-instruction). there was no statistically significant difference between groups with respect to instruction alone (p = . ). conclusion: the use of a ventilation timer significantly reduced overall ventilation rates, providing care closer to bls guidelines. the addition of pre-simulation instruction added no significant benefit to reducing hyperventilation. background: in , the american heart association (aha) recommended a compression rate of (roc) / min and a depth of compressions (doc) at least inches for effective cpr. as an educational tool for lay rescuers, the aha as adopted the catch phrase ''push hard, push fast''. objectives: in this irb-exempt study, we sought to determine if persons without formal cpr training could perform non-ventilated cpr as well as those who have been trained in the past or those currently certified. methods: a convenience sample of patrons of the new york state fair was asked to perform minutes of hands-only cpr on a prestan pp-am- m adult cpr manikin. these devices provide visual indicators of acceptable rate and depth of compressions. each subject was video recorded on a dell latitude laptop computer with a logitech quick cam using logitech quick cam . . for windows software. results: a total of volunteers ( male, female) aged - years participated: were never certified (nc) in cpr, were previously certified (pc), and were currently certified (cc). there was no difference in age across the groups. the cc group had a higher proportion of females (chi-square = . , p < . ). cc volunteers sustained roc and doc for an average of . seconds as compared to an average of . seconds (pc) and . seconds (nc) respectively. (f = . , p < . ). the cc maintained roc of closer to / min (mean . /min) when compared to the pc (mean . /min) and nc (mean . /min) groups (f = . , p < . ). a higher proportion of volunteers of the cc group were able to perform adequate doc (chi-square = . , p < . ), and hand placement (chisquare = . , p < . ) when compared to the other two groups. conclusion: compared to the target roc and doc, none of the groups did well and only subjects met target roc/doc. increased out-of-hospital cardiac arrest survivability due to lay rescuer intervention is only assured if cpr is effectively administered. the effect and benefit of maintaining formal cpr training and certification is clear. background: more than , out-of-hospital cardiac arrests (ohcas) occur annually in the united states (us). automated external defibrillators (aeds) are life-saving devices in public locations that can significantly improve survival. an estimated million aeds have been sold in the us; however, little is known about whether locations of aeds match oh-cas. these data could help determine optimal placement of future aeds and targeted cpr/aed training to improve survival. objectives: we hypothesized that the majority (> %) of aeds are not located in close proximity ( feet) to the occurrence of cardiac arrests in a major metropolitan city. methods: this was a retrospective review of prospectively collected cardiac arrest data from philadelphia ems from january , until december , . included were ohcas of presumed cardiac etiology in individuals years of age or older. excluded were oh-cas of presumed traumatic etiology, cases where resuscitation was terminated at the scene, and those dead on arrival. aed locations in philadelphia were obtained from myheartmap, a database of installed and wallmounted aeds in pennsylvania. we used gis mapping software to visualize where ohcas occurred relative to where aeds were located and to determine the radius of ohcas to aeds. arrests within a , , and foot radius of aeds were identified using the attribute location selection option in arcgis. the lengths of radii were estimated based on the average time it would take for a person to walk to and from an aed ( feet minutes; feet minutes; feet minutes). results: we mapped , ohcas and , aeds in philadelphia county. ohcas occurred in males ( %; / ) and the mean age was . years. ventricular fibrillation occurred in % ( / ). aeds were primarily located in schools/universities ( %), office buildings ( %), and residential buildings ( %). aeds were not identified within feet in % ( , ) of ohcas, within feet of % ( , ) of ohcas, and within feet in % ( , ) of ohcas. the figure (large black circles) illustrates aed/ohca within feet on the left and feet on the right. conclusion: aeds were rarely close to the locations of ohcas, which may be a contributor to low cardiac arrest survival rates. innovative models to match aed availability with ohcas should be explored. (originally submitted as a ''late-breaker.'') potential background: early and frequent epinephrine administration is advocated by acls; however, epinephrine research has been conducted primarily with standard cpr (std). active compression-decompression cpr with an impedance threshold device (acd-cpr + itd) has become the standard of care for out of hospital cardiac arrest in our area. the hemodynamic effects of iv epinephrine under this technique are not known. objectives: to determine the hemodynamic effects of iv epinephrine in a swine model undergoing acd-cpr+itd. methods: six female swine ( ± kg) were anesthetized, intubated, and mechanically ventilated. intracranial, thoracic aorta, and right atrial pressures were recorded via indwelling catheters. carotid blood flow (cbf) was recorded via doppler. etc , sp , and ekg were monitored. ventricular fibrillation was induced and went untreated for minutes. three minutes each of standard cpr (std), std-cpr+itd, and acd-cpr+itd was preformed. at minute of the resuscitation, lg/kg of iv epinephrine was administered and acd-cpr+itd was continued for minute. statistical analysis was performed with a paired t-test. results: aortic pressure and calculated cerebral and carotid perfusion pressures increased from std < std+itd < acd-cpr+itd (p £ . ). epinepherine administered during acd-cpr+itd signficantly increased mean aortic ( ± vs ± , p = . ), cerebral ( ± vs ± , p = . ), and coronary perfusion pressures ( ± vs ± , p = . ); however, mean cbf and etco decreased (respectively ± vs ± . , p = . ; ± vs ± , p = . ). conclusion: the administration of epinepherine during acd-cpr+itd signficantly increased markers of macrocirculation, while significantly decreasing etco , a proxy for organ perfusion. while the calculated cerebral perfusion pressures increased, the directly measured cbf decreased. this calls into question the ability of calculated perfusion pressures to accurately reflect blood flow and oxygen delivery to end organs. hypoxia background: during cardiac arrest most patients are placed on % oxygen with assisted ventilations. after return of spontaneous circulation (rosc), % oxygen is typically continued for an extended time. animal data suggest that immediate post-arrest titration of oxygen by pulse oximetry produces better neurocognitive/ histologic outcomes. recent human data suggest that arterial hyperoxia is associated with worse outcomes. objectives: to assess the relationship between hypoxia, normoxia, and hyperoxia post-arrest and outcomes in post-cardiac arrest patients treated with therapeutic hypothermia. methods: we conducted a retrospective chart review of post-arrest patients admitted to an academic medical center between january, and december, who had arterial blood gases (abg) drawn after rosc. demographic variables were analyzed using anova and chi-square tests as appropriate. unadjusted logistic regression analyses were performed to assess the relationship between hypoxia (pao < mmhg), normoxia ( - mmhg), hyperoxia (> mmhg), and mortality. results: on first abg ( patients), ( . %) were hypoxic, ( . %) normoxic, and ( . %) hyperoxic. the average age of the cohort was . years (no difference for hypoxic, normoxic, and hyperoxic patients). overall mortality was . % ( / ). there were no significant differences between initial heart rate, systolic blood pressure, sex, race, or pre-arrest functional status. in-hospital mortality was significantly higher when the first abg demonstrated hypoxia ( . %; / ) than for normoxia ( . %; / ) or hyperoxia ( %; / ). in unadjusted logistic regression analysis of first pao values, hyperoxia was not associated with increased mortality (or . ; % ci . - . ) but hypoxia was associated with increased mortality (or . ; % ci . - . ). conclusion: hypoxia but not hyperoxia on first abg was associated with mortality in a cohort of post-arrest patients. background: there are over , deaths due to cardiac arrest per year in the us. the aha recommends monitoring the quality of cpr primarily through the use of end tidal co (etco ). the level of etco is significantly dependant on minute ventilation and altered by pressor and bicarbonate use. cerebral oximetry (cereox) uses near infrared spectroscopy to non-invasively measure oxygen saturation of the frontal lobes of the brain. cereox has been correlated with cerebral blood flow and jugular vein bulb saturations. objectives: the objective of this study is to compare the simultaneous measurement of etco and cereox to investigate which monitoring method provides the best measure of cpr quality as defined by return of spontaneous circulation (rosc). methods: a prospective cohort of a convenient sample of patients using out-of-hospital and ed cardiac arrest from two large eds. patients were monitored simultaneously by etco and cereox during cpr. patient demographics and arrest data were collected using the utstein criteria. all patients were monitored throughout the resuscitation efforts. rosc was defined as a palpable pulse and a measurable blood pressure for a minimum of thirty minutes. results: twenty two patients were enrolled with complete data sets; % of the subjects had rosc. average down time of rosc subjects was minutes (sd ± . ) and minutes (sd ± . ) for subjects without rosc. the inability to obtain a value of either for etco or cereox was % and % specific with an % and % npv respectively for predicting lack of rosc. obtaining a value of either for etco or cereox was % and % sensitive, respectively in identifying rosc. subjects with rosc had sustained values above for . mins on cereox and . mins on etco prior to rosc. the increase in values over a three minute period prior to rosc was . on cereox and . on etco . conclusion: the inability to obtain a value of on either the etco or cereox strongly predicted lack of rosc. cereox provides a larger magnitude and closer temporal increase prior to rosc than etco . attaining a value of on cereox was more predictive of rosc than etco . an discrepancies due to communicating information to multiple listeners in a short amount of time. this creates a communication barrier not always apparent to practitioners. we examine the perceptions of ems and ed personnel on the transfer of care and its correlation to missing patient data. objectives: evaluate provider perception of information transfer by ems and ed personnel and compare this to an external observer's objective assessment. methods: this is a retrospective quality improvement program at an academic level i trauma center. transfers of medical and trauma patients from ems to ed personnel were attended by trained external observers, research associates (ra). ra recorded the data communicated: name, age, past medical history (pmh), allergies, medications, events, active problems, vital signs (vs), level of consciousness (loc), iv access, and treatments given. then, ems and ed staff rated their perception of transfer on a - rating scale. results: ra evaluated patient transfers ( medical and trauma). transfer time did not differ, . minutes for medical ( % ci: . - . ), . minutes for trauma patients ( % ci: . - . )(p = . ). missing data between the two groups also did not differ, except loc and treatment were missed more in medical transfers, while pmh was missed more in the trauma transfers. comparing the transfers with all vs present ( %, / ) and all vs missing ( %, / ), with all vs missing, there was no difference in perception of transfer for ems ( . / vs present vs . / vs absent) or ed staff ( . / vs present, . / vs absent). when all vital signs were missing, ra rated . % of transfers as poor, whereas when all vs were present . % of transfers were considered good. conclusion: ems and ed staff felt transfers of care were professional, teams were attentive, and had similar amounts of interruptions for both medical and trauma cases. their perception of transfer of care was similar even when key information was missing, although external observers rated a significant amount of transfers poorly. thus, ems and ed staffs were not able to evaluate their own performance in a transfer of care and external observers were found to be better evaluators of transfers of care. swati singh, john brown, prasanthi ramanujam ucsf, san francisco, ca background: ems transports a large number of psychiatric emergencies to emergency departments (ed) across the us. research on paramedic education related to behavioral emergencies is sparse, but based on expert opinion we know that gaps in paramedic knowledge and training exist. in our system, paramedics triage patients to medical, detoxification, and purely psychiatric destinations, so a paramedic's understanding of these emergencies directly affects the flow of patients in our eds. objectives: our objectives were to understand the gaps in current training and develop a targeted curriculum for field providers with a long term goal of appropriately recognizing and triaging subjects to the ed. methods: data were collected using a survey that was distributed during a paramedic association meeting in october . subjects were excluded if they did not complete the survey. survey questions addressed demographics of paramedics, frequency of various psychiatric emergencies and their confidence in managing these emergencies. data were collated, analyzed, and presented as descriptive statistics. results: forty-nine surveys were distributed with a response rate of % (n = / ). of the respondents, % (n = ) were male and % (n = ) had at least five years experience. mood, thought, and cognitive disorders were the most frequently encountered presentations and % (n = ) of respondents came across psychiatric emergencies multiple times a week. many respondents did not feel confident managing agitated delirium (n = , %), acute psychosis (n = , %), and intimate partner or elder abuse (n = , %). a third to a half of the respondents felt they have little or no training in chemical sedation (n = , %), verbal de-escalation (n = , %), and triaging patients (n = , %). conclusion: we identified a need for a revised curriculum on management of psychiatric emergencies. future steps will focus on development of a curriculum and change in knowledge after implementation of this curriculum. background: prehospital endotracheal intubation has long been a cornerstone of resuscitative efforts for critically ill or injured patients. paramedic airway management training will need to be modified due to the acc/aha guidelines to ensure maintenance of competency in overall management of airway emergencies. how best to modify the training of paramedics requires an understanding of current experience. objectives: the purpose of this report is to characterize the airway management expertise of experienced and non-experienced paramedics in a single ems system. methods: we retrospectively reviewed all prehospital intubations from an urban/suburban ambulance service (professional ambulance, inc.) over a five-year period (january , to december , ). characteristics of airway management by paramedics with - years of experience (group ) were compared to those with greater than years of experience (group ). airway management was guided by massachusetts statewide treatment protocols governing direct laryngoscopy and all adjunctive approaches. attempts are characterized by laryngoscope blade passing the lips. difficult and failed airways were managed with extraglottic devices (egd) or needle cricothyroidotomy. we reviewed patient characteristics, intubation methods, rescue techniques, and adverse events. results: patients required airway management: ( %) were performed by group and ( %) were performed by group . group was both faster to intubate ( . vs . attempts, p = . ) and less likely to use a rescue device ( . % vs . %, p = . ). both are equally likely to go directly to a rescue device ( % vs %, p = . ). all patients were successfully oxygenated and ventilated with either an endotracheal tube or egd. no surgical airways were performed and no patients died as a result of a failed airway. conclusion: while intubation success rates of paramedics with less than and greater than five years of experience are similar, less experienced paramedics use fewer attempts and are less likely to use a rescue device. both recognize difficult airways and go directly to rescue devices equally. this highlights difficulties faced maintaining competence. education requirements must be evaluated and redesigned to allow paramedics to maintain competence and emphasize airway management according to the latest resuscitation guidelines. how well do ems - - protocols predict ed utilization for pediatric patients? stephanie j. fessler , harold k. simon , daniel a. hirsh , michael colman emory university, atlanta, ga; grady health systems, atlanta, ga background: the use of emergency medical services (ems) for low-acuity pediatric problems has been well documented. however, it is unclear how accurately general ems dispatch protocols predict the subsequent ed utilization for these patients. objectives: to determine the ed resource utilization rate of pediatric patients categorized as low acuity by - - dispatch protocols and then subsequently transferred to a children's hospital. methods: all transports for pediatric patients from the scene by a large urban general ems provider that were prioritized as low acuity by initial - - dispatch protocols were identified. protocols were based on the national academy of medical priority dispatch system, v . starting on jan , , consecutive cases of patients transported to three pediatric emergency departments (ped) of a large tertiary care pediatric health care system were reviewed. demographics, ped visit characteristics, resource utilization, and disposition were recorded. those patients who received meds other than po antipyretics, had labs other than a strep test, a radiology study, a procedure, or were not discharged home were categorized into the significant ed resource utilization group. results: % of the patients were african american and either had public insurance or self-pay ( %, % respectively). the median age was months ( d- yr). % were female. none of these low-acuity patients were upgraded by ems operators en route. upon arrival to the ped, % of transported patients were classified into the significant utilization group. six of the total patients were admitted, including a y/o requiring emergent intubation, an m/o old with a broken cvl, a y/o with sickle cell pain crisis, and a y/o with altered mental status. the remainder of the significant resource utilization group consisted of children needing procedures, anti-emetics, narcotic pain control, labs, and xrays. conclusion: in this general ems - - system, dispatch protocols for pediatric patients classified as low priority did poorly in predicting subsequent ed utilization with % requiring significant resources. further, ems operators did not recognize a critical child who needed emergent intervention. opportunity exists to refine general ems - - protocols for children in order to more accurately define an ems priority status that better correlates with ultimate needs and resource utilization. the objectives: determine if there is an association between a patient's impression of the overall quality of care and his or her satisfaction with provided pain management. it was hypothesized that satisfaction with pain management would be significantly associated with a patient's impression of the overall quality of care. methods: this was a retrospective review of patient satisfaction survey data initially collected by an urban als ems agency from / / to / / . participants were randomly selected from all patients transported proportional to their paramedic defined acuity; categorized as low, medium, or high with a goal of interviews per month. the proportions of patients sampled from each acuity level were % low, % medium, and % high. patients were excluded if there was no telephone number recorded in the prehospital patient record or they were pronounced dead on scene. all satisfaction questions used a five-point likert scale with ratings from excellent to poor that were dichotomized for analysis as excellent or other. the outcome variable of interest was the patient's perception of the overall quality of care. the main independent variable had patients rate the staff who treated them at the scene on their helping to control or reduce their pain. demographic variables were assessed for potential confounding. results: there were , patients with complete data for the outcome and main independent variable with . % male respondents and an average age of . (sd = . ). overall quality of care was rated excellent by . % of patients while . % rated their pain management as excellent. of patients who rated their pain management as excellent, . % rated overall quality of care as excellent while only . % of patients rated overall quality excellent if pain management was not excellent. when controlling for potential confounding variables, those patients who perceived their pain management to be excellent were . ( % ci . - . ) times more likely to rate their overall quality of care as excellent compared to those with non-excellent perceived pain management. conclusion: patients' perceptions of the overall quality of care were significantly associated with their perceptions of pain management. objectives: the purpose of this study is to determine whether ground-based paramedics could be taught and retain the skills necessary to successfully perform a cricothyrotomy. methods: this retrospective study was performed in a suburban county with a population of , and , ems calls per year. participants were groundbased paramedics in a local ems system who were taught wire-guided cricothyrotomy as part of a standardized paramedic educational update program. as part of the educational program, paramedics were taught wire-guided cricothyrotomy on a simulation model previously developed to train emergency medicine residents. after viewing an instructional video, the participants were allowed to practice using a step checklist. not all of these steps were automatic failures. each paramedic was individually supervised performing a cricothyrotomy on the simulator until successful; a minimum of five simulations was required. retention was assessed using the same -step checklist during annual skills testing, after a minimum of weeks to a maximum of months posttraining. results: a total of paramedics completed both the initial training and reassessment during the time period studied. during the initial training phase, % ( of ) of the paramedics were successful in performing all steps of the wire-guided cricothyrotomy. during the retention phase . % ( of ) retained the skills necessary to successfully perform the wire-guided cricothyrotomy. of the -step checklist, most steps were performed successfully by all the paramedics or missed by only of the paramedics. step # , which involved removing the needle prior to advancing the airway device over the guidewire, was missed by . % ( of ) of the participants. step # was not an automatic failure since most participants immediately self-corrected and completed the procedure successfully. conclusion: paramedics can be taught and can retain the skills necessary to successfully perform a wireguided cricothyrotomy on a simulator. future research is necessary to determine if paramedics can successfully transfer these skills to real patients. helicopter emergency medical services in background: netcare is one of the largest private providers of emergency air medical care in south africa. each hems (helicopter emergency medical service) crew is manned by a physician-paramedic team and is dispatched based on specific medical criteria, time to definitive care, and need for physician expertise. objectives: to describe the characteristics of net-care air medical evacuations in gauteng province and to analyze the role of physicians in patient care and effect on call times. methods: all patients transported by a netcare helicopter over a one year period from january -december were enrolled in the study. injury classifications, demographics, procedures, scene and flight times were collected retrospectively from run sheets. data were described by medians and interquartile intervals. results: a total of patients were transported on flights originating from the netcare gauteng helicopter base. ninety-two percent were traumarelated, with % resulting from motor vehicle accidents. physician expertise was listed % of the time as the indication for air medical response. a total of advanced procedures were performed by physicians on patients, including paralytic-assisted intubations, chest tube placement, and cardiac pacing. the median total call time was minutes with minutes spent on scene, compared with and minutes when advanced procedures were performed by hems (p < . ). conclusion: trauma accounts for an overwhelming majority of patients requiring emergency air medical transportation. advanced medical procedures were performed by physicians in nearly a quarter of the patients. there were significant differences in call times when advanced procedures were performed by hems. objectives: we sought to evaluate the level of awareness and adoption of the off-line protocol guidelines by utah ems agencies. methods: we surveyed all ems agencies in utah months after protocol guideline release. medical directors, ems captains, or training coordinators completed a short phone survey regarding their knowledge of the emsc protocol guidelines, and whether their agency had adopted them. in particular, participants were asked about the pain protocol guideline and their management of pediatric pain. results: of the agencies, participated in the survey ( %). of those participating, agencies ( %) were excluded from the analysis: ( %) who only treat adults and ( %) who do not participate in electronic data entry. of the remaining agencies ( %), ( %) were familiar with the utah emsc protocol guidelines; agencies ( %) have either partially or fully adopted the protocol guidelines. agencies ( %) were familiar with the pain treatment protocol guideline; ( %) had adopted it; ( %) planned to either partially or fully adopt the protocol. overall, agencies ( %) had offline protocols allowing the administration of narcotics to children. of those, ( %) had intranasal fentanyl as an available medication and delivery route. of the agencies with offline protocols for pain, ( %) reported familiarity with the emsc pain protocol guideline. conclusion: the creation and dissemination of statewide emsc protocol guidelines results in widespread awareness ( %) and to date % of agencies have adopted them. future investigation into factors associated with protocol adoption should be explored. background: intranasal (in) naloxone is safe and effective for the treatment of opioid overdose. while it has been extensively studied in the out-of-hospital environment in the hands of paramedics and lay people, we are unaware of any studies evaluating the safety and efficacy of in naloxone administration by bls providers. in recent years in naloxone has been added to the bls armamentarium; however, most services/states require an als unit be dispatched and attempt an intercept if in naloxone is administered by the bls providers. objectives: the purpose of this study is to evaluate the safety and effectiveness of bls-administered in naloxone in an urban environment. methods: retrospective cohort review as part of the ongoing qa process of all patients who had in naloxone administration by bls providers. the study was part of a special projects waiver by massachusetts oems from february through november in a busy urban tiered ems system in the metro-boston area. exclusion criteria: cardiac arrest. demographic information was collected, as well as vital signs, number of naloxone doses by bls, patient response to bls naloxone administration (clinical improvement in mental status and/or respiratory status), als intercept. descriptive statistics and confidence intervals are reported using microsoft excel and spss . . results: fifty-six cases of bls-administered in naloxone were identified, and were excluded as cardiac arrests. the included cases had a mean age of . years ± . (range - ), and % (ci - ) were male. of the included cases, % (ci - ) of patients responded to bls administration of naloxone. of the responders, % (ci - ) required two doses. there were protocol violations representing % (ci . - . ) of the total administrations, however in % of these protocol violations the patients had a positive response to the administration of in naloxone. seven of the protocol violations were patients who required a second mg dose of naloxone. eleven cases did not have an als intercept; only of these patients did not respond to bls administration of naloxone. there were no identified adverse events. conclusion: bls providers safely and successfuly administered in naloxone achieving a response rate consistent with studies of als providers' administration of in naloxone. given the success rate of bls providers, it may be feasible for bls to manage responders without the aid of an als intercept. background: an estimated % of patients arriving by ambulance to the ed are in moderate to severe pain. however, the management of pain in the prehospital setting has been shown to be inadequate, and untreated pain may have negative consequences for patients. objectives: to determine if focused education on pediatric pain management and implementation of a pain management protocol improved the prehospital assessment and treatment of pain in adult patients. specifically, this study aimed to determine if documentation of pain scores and administration of morphine by ems personnel improved. methods: this was a retrospective before and after study conducted by reviewing a county-wide prehospital patient care database. the study population included all adult patients transported by ems between february and february with a working assessment of trauma or burn. ems patient care records were searched for documentation of pain scores and morphine administration years before and years after an intensive pediatric focused pain management education program and implementation of a pain management protocol. frequencies and % cis were determined for all patients meeting the inclusion criteria in the before and after time period and chisquare was used to compare frequencies between time periods. a secondary analysis was conducted using only subjects documented as meeting the protocol's treatment guidelines. results: , ( %) of , adult patients transported by ems during the study period met the inclusion criteria: , in the before and , in the after period. subject demographics were similar between the two periods. documentation of pain score did not change between the time periods ( background: there is a presumption that ambulance response times affect patient outcome. we sought to determine if shorter response times really make a difference in hospital outcomes. objectives: to determine if ambulance response time makes a difference in the outcomes of patients transported for two major trauma (motor vehicle crash injuries, penetrating trauma) and two major medical (difficulty breathing and chest pain complaints) emergencies. methods: this study was conducted in a metropolitan ems system serving a population total of , including urban and rural areas. cases were included if the private ems service was the first medical provider on scene, the case was priority , and the patient was years and older. a -month time period was used for the data evaluation. four diagnoses were examined: motor vehicle crash injuries, penetrating trauma, difficulty breathing, and chest pain complaints. ambulance response times were assessed for each of the four different complaints. the patients' initial vital signs were assessed and the number of vital signs out of range was recorded. a sampling of all cases which went to the single major trauma center was selected for evaluation of hospital outcome. using this hospital sample, number of vital signs out of range were assessed as a surrogate marker indicating severity of hospital outcome. correlation coefficients were used to evaluate interactions between independent and outcome variables. results: of the cases we reviewed over the month period, we found that the ems service responded significantly faster to trauma complaints at . minutes (n = ) than medical complaints at . minutes (n = ) . in the hospital sample of cases, number of vital signs out of range were positively correlated with hospital days (r = . ), admits (r = . ), icu admits (r = . ), and deaths (r = . ), but not response times (r = (-) . ). in the entire sample, there was no correlation between vital signs out of range and response times for any diagnosis (see figure) . conclusion: conclusions: based on our hospital sample which showed that number of vital signs out of range was a surrogate marker of worse hospital outcomes, we find that hospital outcomes are not related to initial response times. adverse effects following prehospital use of ketamine by paramedics eric ardeel baylor college of medicine, houston, tx background: ketamine is widely used across specialties as a dissociative agent to achieve sedation and analgesia. emergency medical services (ems) use ketamine to facilitate intubation and pain control, as well as to sedate acutely agitated patients. published studies of ems ketamine practice and effects are scarce. objectives: describe the incidence of adverse effects occurring after ketamine administration by paramedics treating under a single prehospital protocol. methods: a retrospective analysis was conducted of consecutive patients receiving prehospital ketamine from paramedics in the suburban/rural ems system of montgomery county hospital district, texas between august , and october , . ketamine administration indications were: need for rapid control of violent/agitated patients requiring treatment and transport; sedation and analgesia after trauma; facilitation of intubation and mechanical ventilation. ketamine administration contraindications were: equivalent ends achieved by less invasive means; hypertensive crisis; angina; signs of significantly elevated intracranial pressure; anticipated inability to support or control airway. all patients were included, regardless of indication for ketamine administration. data were abstracted from electronic patient care records and available continuous physiologic monitoring data, and analyzed for the presence of adverse effects as defined a priori in ''clinical practice guidelines for emergency department ketamine dissociative sedation: update.'' results: no patients were identified as experiencing adverse effects as defined by the referenced literature. ketamine was utilized most often for patients with the following nemsis provider's primary impression: ( %) altered level of consciousness, ( %) behavioral/psychiatric, ( %) traumatic injury. overall, combativeness was associated with ( %) patients. the mean age was years (range - years) and ( %) were male. the mean ketamine dose was mg (range - mg) and twenty-four ( %) patients received multiple administrations. conclusion: in this patient population, our data indicate that prehospital ketamine use by ems paramedics, across all indications for administration, was safe. further study of ketamine's utility in ems is warranted. an background: rigorous evaluation of the effect of implementing nationally vetted evidence-based guidelines (ebgs) has been notoriously difficult in ems. specifically, human subjects issues and the health insurance portability and accountability act (hipaa) present major challenges to linking ems data with distal outcomes. objectives: to develop a model that addresses the human subjects and hipaa issues involved with evaluating the effect of implementing the traumatic brain injury (tbi) ebgs in a statewide ems system. methods: the excellence in prehospital injury care (epic) project is an nih-funded evaluation of the effect of implementing the ems tbi guidelines throughout arizona (ninds- r ns - a ). to accomplish this, a partnership was developed between the arizona department of health services (adhs), the university of arizona, and more than ems agencies that serve approximately % of the state's population. results: ebg implementation: implementation follows all routine regulatory processes for making changes in ems protocols. in arizona, the entire project must be carried out under the authority of the adhs director. evaluation: a before-after system design is used (randomization is not acceptable). hipaa: as an adhsapproved public health initiative, epic is exempt from hipaa, allowing sharing of protected health information between participating entities. for epic, the state attorney general provided official verification of hi-paa exemption, thus allowing direct linkage of ems and hospital data. irb: once epic was officially deemed a public health initiative, the university irb process was engaged. as an officially sanctioned public health project, epic was determined to not be human subjects research. this allows the project to implement and evaluate the effect of this initiative without requiring individual informed consent. conclusion: by utilizing an ems-public health-university partnership, the ethical and regulatory challenges related to evaluating implementation of new ebgs can be successfully overcome. the integration of the department of health, the attorney general, and the university irb can properly protect citizens while permitting efficient implementation and rigorous evaluation of the effect of ebgs. this novel approach may be useful as a model for evaluation of implementing ems ebgs in other states and large counties. ( . %- . % by age) were transported to non-trauma centers. the most common reasons cited by ems for hospital selection were: patient preference ( . %), closest facility ( . %), and specialty center ( . %). patient preference increased with age (p for trend . ) and paralleled under-triage ( figure ). iss ‡ patients transported to non-trauma hospitals by patient request had lower unadjusted mortality ( . %, %ci . - . ) than similar patients transported to trauma centers ( . %, %ci . - . ) or transported for other reasons ( . %, %ci . - . ) (figure ) . under-triage appears to be influenced by patient preference and age. self-selection for transport to non-trauma centers may result in under-triaged patients with inherently better prognosis than triagepositive patients. background: only % of all out-of-hospital cardiac arrest (ohca) patients receive bystander cpr (cardiopulmonary resuscitation). the neighborhood in which an ohca occurs has significant influence on the likelihood of receiving bystander cpr. objectives: to utilize geographic information systems to identify ''high-risk'' neighborhoods, defined as census tracts with high incidence of ohca and low cpr prevalence. methods: design: secondary analysis of the cardiac arrest registry to enhance survival (cares) dataset for denver county, colorado. population: all consecutive adults (> years old) with ohca due to cardiac etiology from january , through december , . data analysis: analyses were conducted in arc-gis. three spatial statistical methods were used: local morans i (lmi), getis-ord gi*(gi*), and spatial empirical bayes (seb) adjusted rates. census tracts with high incidence of ohca, as identified by all three spatial statistical methods, were then overlain with low bystander cpr census tracts, which were identified in at least two out of three statistical methods (lmi, gi*, or the lowest quartile of bystander cpr prevalence). overlapping census tracts identified with both high ohca incidence and low cpr prevalence were designated as ''highrisk''. results: a total of arrests in census tracts occurred during the study period, with arrests included in final sample. events were excluded if they were unable to be geocoded (n = ), outside denver county (n = ), or occurred in a jail (n = ), hospital/ physician's office (n = ), or nursing home (n = ). for high ohca incidence: lmi identified census tracts, gi* identified census tracts, and the seb method identified census tracts. twenty-five census tracts were identified by all three methods. for low bystander cpr prevalence: lmi identified census tracts, gi* identified census tracts, and census tracts were identified as being in the lowest quartile of cpr prevalence. twenty-four census tracts were identified by two of the three methods. two census tracts were identified as high-risk having both high ohca incidence and low cpr prevalence (figure) . high-risk census tract demographics as compared to denver county are shown in the table. conclusion: the two high-risk census tracts, comprised of minority and low-income populations, appear to be possible sites for targeted community-based cpr interventions. objectives: we sought to assess the accuracy and correlation of geographic information system (gis) derived transport time compared to actual ems transport time in ohca patients. methods: prospective, observational cohort analysis of ohca patients in vancouver, b.c., one of the sites of the resuscitation outcomes consortium (roc). a random sample from all of the ohca cases from / through / was selected for analysis from one site of the roc epistry. using gis, ems transport time was derived from reported latitude/longitude coordinates of the ohca event to the actual receiving hospital. this was calculated via the actual network distance using arcgis. this gis-derived time was then compared to the actual ems transport time (in minutes) using the wilcoxon signed rank test. scatter plot analysis of actual vs. gis times were created to evaluate the relationship between actual and calculated time. a linear regression model predicting actual ems transport time from the derived gis-time was also developed in order to examine the potential relationship between the two variables. differences in the relationship were also investigated based on time of the day to reflect varying traffic conditions. results: cases were randomly selected for analysis. the median actual transport time was significantly longer than the median gis derived transport time ( . minutes vs. . minutes). scatter plot analysis did not reveal any significant correlation between actual and gis-based time. additionally, there was poor approximation of gis-based time and actual ems time (r = . ) with no evidence of a significant linear relationship between the two. the poorest correlation of time was observed during the morning hours ( : - : ; r = . ) while the strongest correlation was during the overnight hours ( : - : ; r = . ). conclusion: gis derived time does not appear to correlate well with actual ems transport time of ohca patients. efforts should be made to accurately obtain actual ems transport times for ohca patients. objectives: we first sought to describe the incidence of ohca presenting to the ed. we then sought to determine the association between hospital characteristics and survival to hospital admission. methods: we identified patients with diagnoses of cardiac arrest or ventricular fibrillation (icd- . or . ) in the nationwide emergency department sample, a nationally representative estimate of all ed admissions in the us. eds reporting ‡ patient with ohca were included. our primary outcome was survival to hospital admission. we examined variability in hospital survival rate and also classified hospitals into high or low performers based on median survival rate. we used this dichotomous hospital level outcome to examine factors associated with survival to admission including hospital and patient demographics, ed volume, cardiac arrest volume, and cardiac catheterization availability. all unadjusted and adjusted analyses were performed using weighted statistics and logistic regressions. results: of the hospitals, ( . %) were included. in total, , cases of cardiac arrest were identified, representing an estimated , cases nationally. overall ed ohca survival to hospital admission was . % (iqr . %, . %) in adjusted analyses, increased survival to admission was seen in hospitals with teaching status (or . , % ci . - . , p < . ), annual ed visits ‡ , (or . , % ci . - . , p < . ), and pci capability (or . , % ci . - . , p = . ). in separate adjusted analyses including teaching status and pci capabilities, hospitals with > annual cardiac arrest cases (or . , % ci . - . , p < . ) were also shown to have improved survival (figure) . conclusion: ed volume, cardiac arrest volume, and pci capability were associated with improved survival to hospital admission in patients presenting to the ed after ohca. an improved understanding of the contribution of ed care to ohca survival may be useful in guiding the regionalization of cardiac arrest care. background: prior investigations have demonstrated regional differences in out-of-hospital cardiac arrest (ohca) outcomes, but none have evaluated survival variability by hospital within a single major us city. objectives: we hypothesized that -day survival from ohca would vary considerably among one city's receiving hospitals. methods: we performed a retrospective review of prospectively collected cardiac arrest data from a large, urban ems system. our population included all ohcas with a recorded social security number (which we used to determine -day survival through the social security death index) that were transported to a hospital between / / and / / . we excluded traumatic arrests, pediatric arrests, and hospitals receiving less than ohcas with social security numbers over the three-year study period. we examined the associa-tion between receiving hospital and -day survival. additional variables examined included: level i trauma center status, teaching hospital status, ohca volume, and whether post-arrest therapeutic hypothermia (th) protocols were in place in . statistics were performed using chi-square tests and logistic regression. results: our study population comprised arrest cases delivered to unique hospitals with an overall -day survival of . %. mean age was . (sd . ) years. males comprised . % of the cohort; . % of victims were black. thirty-day survival varied significantly among the hospitals, ranging from . % to . % (chi-square . , p = . ). ohcas delivered to level i trauma centers were significantly more likely to survive ( . % vs. . %, p = . ), as were those delivered to hospitals known to offer post-arrest th ( . % vs. . %, p = . ). hospital teaching status and ohca volume were not associated with survival. conclusion: there was significant variability in ohca survival by hospital. patients were significantly more likely to survive if transported to a level i trauma center or hospital with post-arrest th protocols, suggesting a potential role for regionalization of ohca care. limiting our population to ohcas with recorded social security numbers reduced our power and may have introduced selection bias. further work will include survival data on the complete set of ohcas transported to hospitals during the three-year study period. background: traumatic brain injury is a leading cause of death and disability. previous studies suggest that prehospital intubation in patients with tbi may be associated with mortality. limited data exist comparing prehospital (ph) nasotracheal (nt), prehospital orotracheal (ot), and ed ot intubation and mortality following tbi. objectives: to estimate the associations between ph nt, ph ot, and ed ot intubation and in-hospital mortality in patients with moderate to severe tbi, with hypotheses that ph nt and ph ot intubation would be associated with increased mortality when compared to ed ot or no intubation. methods: an analysis using the denver health trauma registry, a prospectively collected database. consecutive adult trauma patients from - with moderate to severe tbi defined as head abbreviated injury scale (ais) scores of - . structured chart abstraction by blinded physicians was used to collect demographics, injury and prehospital care characteristics, intubation status and timing, in-hospital mortality and survival time, and neurologic function at discharge. poor neurologic function was defined as cerebral performance category score of - . multivariable logistic regression and survival analyses were performed, using multiple imputation for missing data. results: of the , patients, the median age was (iqr - ) years. the median ph gcs was (iqr - ), median injury severity score was (iqr - ), and median head ais was (iqr - ). ph nt occurred in . %, ph ot in . %, and ed ot in . %, while mortality occurred in . %. the -, -, and -hour survival analyses are outlined in the table. survival curves for ph nt, ph ot, and ed ot are demonstrated in the figure (p < . ) . conclusion: prehospital intubation in patients with moderate to severe tbi is associated with increased mortality. contrary to our initial hypothesis, there was also a significant association between ed intubation and mortality. these associations persisted despite survival time, and while adjusting for injury severity. background: sbdp is a breakdown product of the cytoskeletal protein alpha-ii-spectrin found in neurons and has been detected in severe tbi. objectives: this study examined whether early serum levels of sbdp could distinguish: ) mild tbi from three control groups; ) those with and without traumatic intracranial lesions on ct (+ct vs -ct); and ) those having a neurosurgical intervention (+nsg vs -nsg) in mild and moderate tbi (mmtbi). methods: this prospective cohort study enrolled adult patients presenting to two level i trauma centers following mmtbi with blunt head trauma with loss of consciousness, amnesia, or disorientation and a gcs - . control groups included uninjured controls and trauma controls presenting to the ed with orthopedic injuries or an mvc without tbi. mild tbi was defined as gcs and moderate tbi as having a gcs < . blood samples were obtained in all patients within hours of injury and measured by elisa for sbdp (ng/ml). the main outcomes were: ) the ability of sbdp to distinguish mild tbi from three control groups; ) to distinguish +ct from -ct and; ) to distinguish +nsg from -nsg. data were expressed as means with %ci, and performance was tested by roc curves (auc and %ci). results: there were patients enrolled: tbi patients ( gcs , gcs - ), trauma controls ( mvc controls and orthopedic controls), and uninjured controls. the mean age of tbi patients was years (range - ) with % males. fourteen ( %) had a +ct and % had +nsg. mean serum sbdp levels were . ( %ci . - . ) in normal controls, . ( . - . ) in orthopedic controls, . ( . - . ) in mvc controls, . ( . - . ) in mild tbi with gcs , and . ( . - . ) in tbi with gcs - (p < . ). the auc for distinguishing mild tbi from both controls was . ( %ci . - . ). mean sbdp levels in patients with -ct versus +ct were . ( . - . ) and . ( . - . ) respectively (p < . ) with auc = . ( %ci . - . ). mean sbdp levels in patients with -nsg versus +nsg were . ( . - . ) and . ( . - . ) respectively (p < . ) with auc = . ( %ci . - . ). conclusion: serum sbdp levels were detectable in serum acutely after injury and were associated with measures of injury severity including ct lesions and neurosurgical intervention. further study is required to validate these findings before clinical application. utility of platelet background: pre-injury use of anti-platelet agents (e.g., clopidogrel and aspirin) is a risk factor for increased morbidity and mortality in patients with traumatic intracranial hemorrhage (tich). some investigators have recommended platelet transfusion to reverse the anti-platelet effects in tich. objectives: this evidence-based medicine review examines the evidence regarding the effect of platelet transfusion in emergency department (ed) patients with pre-injury anti-platelet use and tich on patientoriented outcomes. methods: the medline, embase, cochrane library, and other databases were searched. studies were selected for inclusion if they compared platelet transfusion to no platelet transfusion in the treatment of adult ed patients with pre-injury anti-platelet use and tich, and reported rates of mortality, neurocognitive function, or adverse effects as outcomes. we assessed the quality of the included studies using ''grading of recommendations assessment, development and evaluation'' (grade) criteria. categorical data are presented as percentages with % confidence interval (ci). relative risks (rr) are reported when clinically significant. results: five retrospective, registry-based studies were identified, which enrolled patients cumulatively. based on standard criteria, three studies were of ''low'' quality evidence and two studies had ''very low'' qualities. one study reported higher in-hospital mortality in patients with platelet transfusion (ohm et al), another showed a lower mortality rate in patients receiving platelet transfusion (wong et al). three studies did not show any statistical difference in comparing mortality rates between the groups (table) . no studies reported intermediate-or long-term neurocognitive outcomes or adverse events. conclusion: five retrospective registry studies with suboptimal methodologies provide inadequate evidence to support the routine use of platelet transfusion in adult ed patients with pre-injury anti-platelet use and tich. abnormal levels of end-tidal carbon dioxide (etco ) are associated with severity of injury in mild and moderate traumatic brain injury (mmtbi) linda papa , artur pawlowicz , carolina braga , suzanne peterson , salvatore silvestri orlando regional medical center, orlando, fl; university of central florida, orlando, fl background: capnography is a fast, non-invasive technique that is easily administered and accurately measures exhaled etco concentration. etco levels respond to changes in ventilation, perfusion, and metabolic state, all of which may be altered following tbi. objectives: this study examined the relationship between etco levels and severity of tbi as measured by clinical indicators including glasgow coma scale (gcs) score, computerized tomography (ct) findings, requirement of neurosurgical intervention, and levels of a serum biomarkers of glial damage. methods: this prospective cohort study enrolled adult patients presenting to a level i trauma center following a mmtbi defined by blunt head trauma followed by loss of consciousness, amnesia, or disorientation and a gcs - . etco measurements were recorded from the prehospital and emergency department records and compared to indicators of tbi severity. results: of the patients enrolled, ( %) had a normal etco level and ( %) had an abnormal etco level. the mean age of enrolled patients was (range - ) and ( %) were male. mechanisms of injury included motor vehicle collision in ( %), motor cycle collision in ( %), fall in ( %), bicycle/ pedestrian struck in ( %), and other in ( %). eight ( %) patients had a gcs - and ( %) had a gcs - . of the ( %) patients with intracranial lesions on ct, ( %) had an abnormal etco level (p = . ). of the ( %) patients who required a neurosurgical intervention, % had an abnormal etco level (p = . ). levels of a biomarker indicative of astrogliosis were significantly higher in those with abnormal etco compared to those with a normal etco (p = . ). conclusion: abnormal levels of etco were significantly associated with clinical measures of brain injury severity. further research with a larger sample of mmtbi patients will be required to better understand and validate these findings. background: acetaminophen (apap) poisoning is the most frequent cause of acute hepatic failure in the us. toxicity requires bioactivation of apap to toxic metabolites, primarily via cyp e . children are less susceptible to apap toxicity; one current theory is that children's conjugative pathway (sulfonation) is more active. liquid apap preparations contain propylene glycol (pg), a common excipient that inhibits apap bioactivation and reduces hepatocellular injury in vitro and in rodents. cyp e inhibition may decrease toxicity in children, who tend to ingest liquid apap preparations, and suggests a potential novel therapy. objectives: to compare phase i (toxic) and phase ii (conjugative) metabolism of liquid versus solid prepara-tions of apap. we hypothesize that ingestion of a liquid apap preparation results in decreased production of toxic metabolites relative to a solid preparation, likely due to the presence of pg in the liquid preparations. methods: design-pharmacokinetic cross-over study. setting-university hospital clinical research center. subjects-adults ages - taking no chronic medications. interventions-subjects were randomized to receive a mg/kg dose of a commercially available solid or liquid apap preparation. after a washout period of greater than week, subjects received the same dose of apap in the alternate preparation. apap, apap-glucuronide and apap-sulfate (phase metabolites), apap-cysteinate and apap-mercapturate (phase metabolites) were analyzed via lc/ms in plasma over hours. peak concentrations and measured auc were compared using paired-sample t-tests. plasma pg levels were measured. results: fifteen subjects completed the protocol. peak concentrations and aucs of the cyp e derived toxic metabolites were significantly lower following ingestion of the liquid preparation (table, figure) . the glucuronide and sulfate metabolites were not different. pg was present following ingestion of liquid but not solid preparations. conclusion: ingestion of liquid relative to solid preparations in therapeutic doses results in decreased plasma levels of toxic apap metabolites. this may be due to inhibition of cyp e by pg, and may explain the decreased susceptibility in children. a less hepatotoxic formulation of apap can potentially be developed if co-formulated with a cyp e inhibitor. background: pressure immobilization bandages have been shown to delay mortality for up to hours after coral snake envenomation, providing an inexpensive and effective treatment when antivenin is not readily available. however, long-term efficacy has not been established. objectives: determine if pressure immobilization bandages, consisting of an ace wrap and splint, can delay morbidity and mortality from coral snake envenomation, even in the absence of antivenin therapy. methods: institutional animal care and use committee approval was obtained. this was a randomized, observational pilot study using a porcine model. ten pigs ( . kg to . kg) were sedated and intubated for hours. pigs were injected subcutaneously in the left distal foreleg with mg of lyophilized m. fulvius venom resuspended in water, to a depth of mm. pigs were randomly assigned to either a control group (no compression bandage and splint) or a treatment group (compression bandage and splint) approximately minute after envenomation. pigs were monitored daily for days for signs of respiratory depression, decreased oxygen saturations, and paresis/paralysis. in case of respiratory depression, pigs were euthanized and time to death recorded. chi-square was used to compare rates of survival up to days and a kaplan-meier survival curve constructed. results: average survival time of control animals was ± minutes compared to , ± , minutes for treated animals. significantly more pigs in the treatment group survived to hours than in the control group (p = . ). two of the treatment pigs survived to the endpoint of days, but showed necrosis of the distal lower extremity. conclusion: long-term survival after coral snake envenomation is possible in the absence of antivenin with the use of pressure immobilization bandages. the applied pressure of the bandage is critical to allowing survival without secondary consequences (i.e. necrosis) of envenomation. future studies should be designed to accurately monitor the pressures applied. background: patients exposed to organophosphate (op) compounds demonstrate a central apnea. the kölliker-fuse nuclei (kf) are cholinergic nuclei in the brainstem involved in central respiratory control. objectives: we hypothesize that exposure of the kf is both necessary and sufficient for op-induced central apnea. methods: anesthetized and spontaneously breathing wistar rats (n = ) were exposed to a lethal dose of dichlorvos using three experimental models. experiment (n = ) involved systemic op poisoning using subcutaneous (sq) dichlorvos ( mg/kg or x ld ). experiment (n = ) involved isolated poisoning of the kf using stereotactic microinjections of dichlorvos ( micrograms in microliters) into the kf. experiment (n = ) involved systemic op poisoning with isolated protection of the kf using sq dichlorvos ( mg/kg) and stereotactic microinjections of organophosphatase a (opda), an enzyme that degrades dichlorvos. respiratory and cardiovascular parameters were recorded continuously. histological verification of injection site was performed using kmno injections. animals were followed post-poisoning for hour or death. betweengroup comparisons were performed using a repeated measured anova or student's t-test where appropriate. results: animals poisoned with sq dichlorvos demonstrated respiratory depression starting . min post exposure, progressing to apnea . min post exposure. there was no difference in respiratory depression between animals with sq dichlorvos and those with dichlorvos microinjected into the kf. despite differences in amount of dichlorvos ( mg/kg vs . mg/kg) and method of exposure (sq vs cns microinjection), min following dichlorvos both groups (sq vs microinjection respectively) demonstrated a similar percent decrease in respiratory rate ( . vs . , p = . ), minute ventilation ( background: patients sustaining rattlesnake envenomation often develop thrombocytopenia, the etiology of which is not clear. laboratory studies have demonstrated that venom from several species, including the mojave rattlesnake (crotalus scutulatus scutulatus), can inhibit platelet aggregation. in humans, administration of crotaline fab antivenom (av) has been shown to result in transient improvement of platelet levels; however, it is not known whether platelet aggregation also improves after av administration. objectives: to determine the effect of c. scutulatus venom on platelet aggregation in vitro in the presence and absence of crotaline fab antivenom. methods: blood was obtained from four healthy male adult volunteers not currently using aspirin, nsaids, or other platelet-inhibiting agents. c. scutulatus venom from a single snake with known type b (hemorrhagic) activity was obtained from the national natural toxins research center. measurement of platelet aggregation by an aggregometer was performed using five standard concentrations of epinephrine (a known platelet aggregator) on platelet-rich plasma over time, and a mean area under the curve (auc) was calculated. five different sample groups were measured: ) blood alone; ) blood + c. scutulatus venom ( . mg/ml); ) blood + crotaline fab av ( mg/ml); ) blood + venom + av ( mg/ ml); ) blood + venom + av ( mg/ml). standard errors of the mean (sem) were calculated for each group. results: antivenom administration by itself did not significantly affect platelet aggregation compared to baseline ( . ± . %, p = . ). administration of venom decreased platelet aggregation ( . ± . %, p < . ). concentrated av administration in the presence of venom normalized platelet aggregation ( . ± . %) and in the presence of diluted av significantly increased aggregation ( . ± . %); p < . for both groups when compared to the venom-only group. to control for the effects of the venom and av, each was run independently in platelet-rich plasma without epinephrine; neither was found to significantly alter platelet aggregation. conclusion: crotaline fab av improved platelet aggregation in an in vitro model of platelet dysfunction induced by venom from c. scutulatus. the mechanism of action remains unclear but may involve inhibition of venom binding to platelets or a direct action of the antivenom on platelets. background: routine use of both breathalyzers and hand sanitizers is common across emergency depart-ments. the most common hand sanitizer on the market, purell, contains % ethyl alcohol and a lesser amount of isopropyl alcohol. previous investigations have documented that risk is low to the health care worker who applies frequent hand sanitizers to themselves. however, it is unknown whether this alcohol mixture causes false readings on a breathalyzer machine being used to determine alcohol levels on others. objectives: to determine the effect on the measurement of breathalyzer readings in individuals who have not consumed alcohol after hand sanitizer is applied to the experimenter holding a breathalyzer machine. methods: after obtaining informed consent, a breathalyzer reading was obtained in participants who had not consumed any alcohol in the last hours. three different experiments were performed with different participants in each. in experiment , two pumps of hand sanitizer were applied to the experimenter. without allowing the sanitizer to dry, the experimenter then measured the breathalyzer reading of the participant. in experiment , one pump of sanitizer was applied to the experimenter. measurements of the participant were taken without allowing the sanitizer to dry. in experiment , one pump of sanitizer was placed on the experimenter and rubbed until dry according to the manufacturer's recommendations. readings were recorded and analyzed using paired t-tests. results: the initial breathalyzer reading for all participants was . after two pumps of hand sanitizer were applied without drying (experiment ), breathalyzers ranged from . to . , with a mean above the legalintoxication limit of . (t( ) = ) . , p < . ). after one pump of hand sanitizer was applied without drying (experiment ), breathalyzers ranged from . to . , with a mean of . (t( ) = ) . , p < . ). after one pump of hand sanitizer was applied according to manufacturer's directions (experiment ), breathalyzers ranged from . to . with a mean of . (t( ) = ) . , p < . ). conclusion: use of hand sanitizer according to the manufacturer's recommendations results in a small but significant increase in breathalyzer readings. however, the improper and overuse of common hand sanitizer elevates routine breathalyzer readings, and can mimic intoxication in individuals who have not consumed alcohol. stephanie carreiro, jared blum, francesca beaudoin, gregory jay, jason hack objectives: the primary aim of this study is to determine if pretreatment with ile affects the hemodynamic response to epinephrine in a rat model. hemodynamic response was measured by a change in heart rate (hr) and mean arterial pressure (map). we hypothesized that ile would limit the rise in map and hr that typically follow epinephrine administration. methods: twenty male sprague dawley rats (approximately - weeks of age) were sedated with isoflurane and pretreated with a ml/kg bolus of ile or normal saline, followed by a mcg/kg dose of epinephrine intravenously. intra-arterial blood pressure and hr were monitored continuously until both returned to baseline (biopaq). a multifactorial analysis of variance (manova) was performed to assess the difference in map and hr between the two groups. standardized t-tests were then used to compare the peak change in map, time to peak map, and time to return to baseline map in the two groups. results: overall, a significant difference was found between the two groups in map (p = . ) but not in hr (p = . ). there was a significant difference (p = . ) in time to peak map in the ile group ( sec, % ci - ) versus the saline group ( sec, % ci - ) and a significant difference (p = . ) in time to return to baseline map in ile group ( sec, % ci - ) versus the saline group ( sec, % ci - ). there was no significant difference (p = . ) in the peak change in map of the ile group ( . , mmhg, % ci - ) versus the saline group ( . mmhg, % ci - ). conclusion: our data show that in this rat model ile pretreatment leads to a significant difference in map response to epinephrine, but no difference in hr response. ile delayed the peak effect and prolonged the duration of effect on map but did not alter the peak increase in map. this suggests that the use of ile may delay the time to peak effect of epinephrine if the drugs are administered concomitantly to the same patient. further research is needed to explore the mechanism of this interaction. rasch analysis of the agitation severity scale when used with emergency department acute psychiatry patients tania d. strout, michael r. baumann maine medical center, portland, me background: agitation is a frequently observed and problematic phenomenon in mental health patients being treated in the emergency setting. the agitation severity scale (agss), a reliable and valid instrument, was developed using classical test theory to measure agitation in acute psychiatry patients. objectives: the aim of this study was to analyze the agss according to the rasch measurement model and use the results to determine whether improvements to the instrument could be made. methods: this prospective, observational study was irb-approved. adult ed patients with psychiatric chief complaints and dsm-iv-tr diagnoses were observed using the agss. the rasch rating scale model was employed to evaluate the items comprising the agss using winsteps statistical software. unidimensionality, item fit, response category performance, person and item separation reliability, and hierarchical ordering of items were all examined. a principle components analysis (pca) of the rasch residuals was also performed. results: variable maps revealed that all of the agss items were used to some degree and that the items were ordered in a way that makes clinical sense. several duplicative items, indicating the same degree of agitation, were identified. item ( . ) and person ( . ) separation statistics were adequate, indicating appropriate spread of items and subjects along the agitation continuum and providing support for the instrument's reliability. keymaps indicated that the agss items are functioning as intended. analysis of fit demonstrated no extreme misfitting items. pca of the rasch residuals revealed a small amount of residual variance, but provided support for the agss as being unidimensional, measuring the single construct of agitation. the results of this rasch analysis support the agss as a psychometrically robust instrument for use with acute psychiatry patients in the emergency setting. several duplicative items were identified that may be eliminated and re-evaluated in future research; this would result in a shorter, more clinically useful scale. in addition, a gap in items for patients with lower levels of agitation was identified. generation of additional items intended to measure low levels of agitation could improve clinician's ability to differentiate between these patients. background: attempted suicide is one of the strongest clinical predictors of subsequent suicide and occurs up to times more frequently than completed suicide. as a result, suicide prevention has become a central focus of mental health policy. in order to improve current treatment and intervention strategies for those presenting with suicide attempt and self-injury in the emergency department (ed), it is necessary to have a better understanding of the types of patients who present to the ed with these complaints. objectives: to describe the epidemiology of ed visits for attempted suicide and self-inflicted injury over a year period. methods: data were obtained from the national hospital ambulatory medical care survey (nhamcs). all visits for attempted suicide and self-inflicted injury (e -e ) during - were included. trend analyses were conducted using stata's nptrend (a nonparametric test for trends that is an extension of the wilcoxon rank-sum test) and regression analyses. a two-tailed p < . was considered statistically significant. results: over the -year period, there were an average of , annual ed visits for attempted suicide and self-inflicted injury ( . [ % confidence interval (ci) . - . ] visits per , us population). the overall mean patient age was years, with visits most common among ages - ( . ; %ci . - . ). the average annual number of ed visits for suicide attempt and self-inflicted injury more than doubled from , in - to , in - . during the same timeframe, ed visits for these injuries per , us population almost doubled for males ( . to . ), females ( . to . ), whites ( . to . ), and blacks ( . to . ). no temporal differences were found for method of injury or ed disposition; there was, however, a significant decrease in visits determined by the physician to be urgent/emergent from % in to % in . conclusion: ed visit volume for attempted suicide and self-inflicted injury has increased over the past two decades in all major demographic groups. awareness of these longitudinal trends may assist efforts to increase research on suicide prevention. in addition, this information may be used to inform current suicide and self-injury related ed interventions and treatment programs. benjamin l. bregman, janice c. blanchard, alyssa levin-scherz george washington university, washington, dc background: the emergency department (ed) has increasingly become a health care access point for individuals with mental health needs. recent studies have found that rates of major depression disorder (mdd) diagnosed in eds are far above the national average. we conducted a study assessing whether individuals with frequent ed visits had higher rates of mdd than those with fewer ed visits in order to help guide screening and treatment of depressed individuals encountered in the ed. objectives: this study evaluated potential risk factors associated with mdd. we hypothesized that patients who are frequent ed visitors will have higher rates of mdd. methods: this was a single center, prospective, crosssectional study. we used a convenience sample of noncritically ill, english speaking adult patients presenting with non-psychiatric complaints to an urban academic ed over months in . we oversampled patients presenting with ‡ visits over the previous days. subjects were surveyed about their demographic and other health and health care characteristics and were screened with the phq , a nine-item questionnaire that is a validated, reliable predictor of mdd. we conducted bivariate (chi-square) and multivariate analysis controlling for demographic characteristics using sta-ta v. . . our principal dependent variable of interest was a positive depression screen (phq score ‡ ). our principal independent variable of interest was ‡ visits over the previous days. results: our response rate was . % with a final sample size of . of our total sample, ( . %) had three or greater visits within the prior days. one hundred ( %) frequent visitors had a positive phq mdd screen as compared to ( . %) of subjects with fewer than three visits (p < . ). in our multivariate analysis, the odds for having three or more visits for subjects who had a positive depression screen was . ( . , . ). of subjects with three or more visits with a positive depression screen, only ( %) were actively being treated for mdd at the time of their visit. conclusion: our study found a high prevalence of untreated depression among frequent users of the ed. eds should consider routinely screening patients who are frequent consumers for mdd. in addition, further studies should evaluate the effect of early treatment and follow up for mdd on overall utilization of ed services. access to psychiatric care among patients with depression presenting to the emergency department janice c. blanchard, benjamin l. bregman, dana rosenfarb, qasem al jabr, eun kim george washington university, washington, dc background: literature suggests that there is a high rate of major depressive disorder (mdd) in emergency department (ed) users. however, access to outpatient mental health services is often limited due to lack of providers. as a result, many persons with mdd who are not in active treatment may be more likely to utilize the ed as compared to those who are currently undergoing outpatient treatment. objectives: our study evaluated utilization rates and demographic characteristics associated with patients with a prior diagnosis of mdd not in active treatment. we hypothesized that patients who present to the ed with untreated mdd will have more frequent ed visits. methods: this was a single center, prospective, crosssectional study. we used a convenience sample of noncritically ill, english speaking adult patients presenting with non-psychiatric complaints to an urban academic ed over months in . subjects were surveyed about their demographic and other health and health care characteristics and were screened with the phq , a nine-item questionnaire that is a validated, reliable predictor of mdd. we conducted bivariate (chi-square) and multivariate analysis controlling for demographic characteristics using stata v. . . our principal dependent variable of interest was a positive depression screen (phq ‡ ). our analysis focused on the subset of patients with a prior diagnosis of mdd with a positive screen for mdd during their ed visit. results: our response rate was . % with a final sample size of . ( . %) patients screened positive for mdd with a phq score ‡ . of the patients with a positive depression screen, . % reported a prior history of treatment for mdd (n = ). of these patients, only . % were currently actively receiving treatment. hispanics who screened positive for depression with a history of mdd were less likely to actively be undergoing treatment as compared to non-hispanics ( . % versus . %, p = . ). patients with incomes less than $ , were more likely to actively be receiving treatment as opposed to higher incomes ( . % versus . % p = . ). conclusion: patients presenting to our ed with untreated mdd are more likely to be hispanic and less likely to be low income. the emergency department may offer opportunities to provide antidepressant treatment for patients who screen positive for depression but who are not currently receiving treatment. evaluation of a two-question screening tool (phq- ) for detecting depression in emergency department patients jeffrey p. smith, benjamin bregman, janice blanchard, nasser hashim, mary pat mckay george washington university, washington, dc background: the literature suggests there is a high rate of undiagnosed depression in ed patients and that early intervention can reduce overall morbidity and health care costs. there are several well validated screening tools for depression including the nine-item patient health questionnaire (phq- ). a tool using a two-question subset, the phq- , has been shown to be an easily administered, reasonably sensitive screening tool for depression in primary care settings. objectives: to determine the sensitivity and specificity of the phq- in detecting major depressive disorders (mdd) among adult ed patients presenting to an urban teaching hospital. we hypothesize that the phq- is a rapid, effective screening tool for depression in a general ed population. methods: cross sectional survey of a convenience sample of adult, non-critically ill, english speaking patients with medical and not psychiatric complaints presenting to the ed between am and pm weekdays. patients were screened for mdd with the phq- . we used spss v . to analyze the specificity, sensitivity, positive predictive value (ppv), negative predictive value (npv), and kappa of phq- scores of and (out of possible total score of ) compared to a validated cut-off score of or higher of points on the phq- . the two questions on the phq- are: ''over the last two weeks, how often have you had little interest in doing things? how often have you felt down, depressed or hopeless?'' responses are scored from - based on ''never'',''several days'', ''more than half'', ''nearly every day''. results: subjects of approached agreed to participate ( . % response rate), and ( . %) completed the phq- . the phq- identified ( . %) subjects with mdd. table outlines the percent of subjects who were positive and the sensitivity, specificity, positive, and negative predictive values and kappa for each cut-off on the phq- . conclusion: the phq- is a sensitive and specific screening tool for mdd in the ed setting. moreover, the phq- is closely correlated with the phq- , especially if a score of or greater is used. given the simplicity and ease of using a two-item questionnaire and the high rates of undiagnosed depression in the ed, including this brief, self-administered screening tool to ed patients may allow for early awareness of possible mdd and appropriate evaluation and referral. patients. however, much of this self-harm behavior is not discovered clinically and very little is known about the prevalence and predictors of current ed screening practices. attention to this issue is increasing due to the joint commission's patient safety goal , which focuses on identification of suicide risk in patients. objectives: to describe the prevalence and predictors of screening for self-harm and of presence of current self-harm in eds. methods: data were obtained from the nimh-funded emergency department safety assessment and followup evaluation (ed-safe). eight u.s. eds reviewed charts in real time for - hours a week between / and / . all patients presenting during enrollment shifts were characterized as to whether a selfharm screening had been performed by ed clinicians. a subset of patients with a positive screening was asked about the presence of self-harm ideation, attempts, or both by trained research staff. we used multivariable logistic regression to identify predictors of screening and of current self-harm. data were clustered by site. in each model we examined day and time of presentation, age < years, sex, race, and ethnicity. results: of the , patients presenting during research shift, , ( %) were screened for self-harm. screening rates varied among sites and ranged from % to %, with one outlier at %. of those screened, , ( %) had current self-harm. among those with selfharm approached by study personnel (n = , ), ( %) had thoughts of self-harm (suicidal or non-suicidal), ( %) had thoughts of suicide, ( %) had self-harm behavior, and ( %) had suicide attempt(s) over the preceding week. predictors of being screened were: age < years, male sex, weekend presentation, and night shift presentation (table) . among those screened, predictors of current self-harm were: age < years, white race, and night shift presentation. conclusion: screening for self-harm is uncommon in ed settings, though practices vary dramatically by site. patients presenting at night and on weekends are more likely to be screened, as are those under age and males. current self-harm is more common among those presenting on night shift, those under age , and whites. results: there were out-of-hospital records reviewed, and hospital discharge data were available in non-cardiac arrest patients. of the patients, ( . %) patients survived to hospital discharge and ( . %) died during hospitalization. the mean age of those transported was years (sd ), ( %) were male, ( %) were trauma-related, and ( %) were admitted to the icu. average systolic blood pressure (sbp), pulse (p), respiratory rate (rr), oxygen saturation (o sat), and end-tidal carbon dioxide (etco ) were sbp = (sd ), p = (sd ), rr = (sd ), o sat = % (sd ), and etco = (sd conclusion: of all the initial vital signs recorded in the out-of-hospital setting, etco was the most predictive of mortality. these findings suggest that pre-hospital etco is a useful clinical tool for determining severity of illness and appropriate triage. background: the prehospital use of continuous positive airway pressure (cpap) ventilation is a relatively new management for acute cardiogenic pulmonary edema (acpe) and there is little high quality evidence on the benefits or potential dangers in this setting. objectives: the aim of this study was to determine whether patients in severe respiratory distress treated with cpap in the prehospital setting have a lower mortality than those treated with usual care. methods: randomized, controlled trial comparing usual care versus cpap (whisperflowÒ) in a prehospital setting, for adults experiencing severe respiratory distress, with falling respiratory efforts, due to a presumed acpe. patients were randomised to receive either usual care, including conventional medications (nitrates, furosemide, and oxygen) plus bag-valve-mask ventilation, versus conventional medications plus cpap. the primary outcome was prehospital or in-hospital mortality. secondary outcomes were need for tracheal intubation, length of hospital stay, change in vital signs, and arterial blood gas results. we calculated relative risk with % cis. results: fifty patients were enrolled with mean age ae (sd ae ), male ae %, mortality ae %. the risk of death was significantly reduced in the cpap arm with mortality ae % ( deaths) in the usual care arm compared to ae % ( death) in the cpap arm (rr, ae ; % ci ae to ae ; p = ae ). patients who received cpap were significantly less likely to have respiratory acidosis (mean difference in ph ae ; % ci ae to ae ; p = ae ; n = ) than patients receiving usual care. the length of hospital stay was significantly less in the patients who received cpap (mean difference ae days; % ci ) ae to ae , p = ae ). conclusion: we found that cpap significantly reduced mortality, respiratory acidosis, and length of hospital stay for patients in severe respiratory distress caused by acpe. this study shows the use of cpap for acpe improves patient outcomes in the prehospital setting. (originally submitted as a ''late-breaker.'') trial reg. anzctr actrn ; funding fisher and paykal suppliers of the whisperflowÒ cpap device. background: because emergency service utilization continues to climb, validated methods to safely identify and triage low-acuity patients to either alternate care destinations or a complaint-appropriate level of ems response is of keen interest to ems systems and potentially payers. though the literature generally supports the medical priority dispatch system (mpds) as a tool to predict low-acuity patients by various standards, correlation with initial patient physiologic data and patient age is novel. objectives: to determine whether the six mpds priority determinants for protocol (sick person) can be used to predict initial ems patient acuity assessment or severity of an aggregate physiologic score. our longterm goal is to determine whether mpds priority can be used to predict patient acuity and potentially send only a first responder to do an in-person assessment to confirm this acuity, while reserving als transport resources for higher acuity patients. methods: calls dispatched through the wichita-sedgwick county - - center between july , and october , using mpds protocol (sick person) were linked to the ems patient care record for all patients and older. the six mpds priority determinants were evaluated for correlation with initial ems acuity code, initial vital signs, rapid acute physiology score (raps), or patient age. the ems acuity code scores patients from low to severe acuity, based on initial ems assessment. results: there were calls dispatched using protocol for those years of age and older during the period, representing approximately % of all ems calls. there is a significant difference in the first encounter vital signs among different mpds priority levels. based on the logistic regression model, the mpds priority code alone had a sensitivity of % and specificity of % for identifying low-acuity patients with ems acuity score as the standard. the area under the curve (auc) for roc is . for mpds priority codes alone, while addition of age increases this value to . . if we use the raps score as the standard to the mpds priority code, auc is . . if we include both mpds and age in the model, the auc is . . conclusion: in our system, mpds priority codes on protocol (sick person) alone, or with age or raps score, are not useful either as predictors of patient acuity on ems arrival or to reconfigure system response or patient destination protocols. alternate ambulance destination program c. nee-kofi mould-millman , tim mcmahan , michael colman , leon h. haley , arthur h. yancey emory university, atlanta, ga; grady ems, atlanta, ga background: low-acuity patients calling - - are known to utilize a large proportion of ems and ed resources. the national association of ems physicians and acep jointly support ems alternate destination programs (adps) in which low-acuity patients are allocated alternative resources non-emergently. analysis of one year's adp data from our ems system revealed that only . % of eligible patients were transported to alternate destinations (ambulatory clinics). reasons for this low success rate need investigation. objectives: to survey emts and discover the most frequent reasons given by them for transportation of eligible patients to eds instead of to clinics. methods: this study was conducted within a large, urban, hospital-based ems system. upon conducting an adp for months, a paper-based survey was created and pre-tested. all medics with any adp-eligible patient contact were included. emts were asked about personal, patient, and system related factors contributing to ed transport during the last months of the adp. qualitative data were coded, collated, and descriptively reported. results: sixty-three respondents ( emt-intermediates and emt-paramedics) completed the survey, representing % of eligible emts. thirty-one emts ( %) responded that they did not attempt to recruit eligible patients into the adp in the last program months. of those emts, ( %) attributed their motive to multiple, prior, failed recruitment attempts. the emts who actively recruited adp patients were asked reasons given by patients for clinic transport refusals: ( %) cited that patients reported no prior experience of care at the participating clinics, and ( %) reported patients had a strong preference for care in an ed. regarding system-related factors contributing to non-clinic transport, of the emts ( %) reported that clinic-consenting patients were denied clinic visits, mostly because of non-availability of same-day clinic appointments. conclusion: respondents indicated that poor emt enrollment of eligible patients, lack of available clinic time slots, and patient preference for ed care were among the most frequent reasons contributing to the low success rate of the adp. this information can be used to enhance the success of this, and potentially other adp programs, through modifications to adp operations and improved patient education. the effect of a standardized offline pain treatment protocol in the prehospital setting on pediatric pain treatment brent kaziny , maija holsti , nanette dudley , peter taillac , hsin-yi weng , kathleen adelgais university of utah, school of medicine, salt lake city, ut; university of colorado, school of medicine, aurora, co background: pain is often under treated in children. barriers include need for iv access, fear of delayed transport, and possible complications. protocols to treat pain in the prehospital setting improve rates of pain treatment in adults. the utah ems for children (emsc) program developed offline pediatric protocol guidelines for ems providers, including one protocol that allows intranasal analgesia delivery to children in the prehospital setting. objectives: to compare the proportion of pediatric patients receiving analgesia for orthopedic injury by prehospital providers before and after implementation of an offline pediatric pain treatment protocol. methods: we conducted a retrospective study of patients entered into the utah prehospital on-line active reporting information system (polaris, a database of statewide ems cases) both before and after initiation of the pain protocol. patients were included if they were age - years, with a gcs of - , an isolated extremity injury, and were transported by an ems agency that had adopted the protocol. pain treatment was compared for years before and months after protocol implementation with a wash-out period of months for agency training. the difference in treatment proportions between the two groups was analyzed and % cis were calculated. results: during the two study periods, patients met inclusion criteria. patient demographics are outlined in the table. / ( . %) patients were treated for pain before compared to / ( . %) patients treated after the pain protocol was implemented; a difference of . % ( % ci: . %- . %). patients were more likely to receive pain medication if they had a pain score documented (or: . ; % ci: . - . ) and if they were treated after the implementation of a pain protocol (or: . ; % ci: . - . ). factors not associated with the treatment of pain include age, sex, and mechanism of injury. conclusion: the creation and adoption of statewide emsc pediatric offline protocol guideline for pain management is associated with a significant increase in use of analgesia for pediatric patients in the prehospital setting. background: evidence-based guidelines are needed to determine the appropriate use of air medical transport, as few criteria currently used predict the need for air transport to a trauma center. we previously developed a clinical decision rule (cdr) to predict mortality in injured, helicopter-transported patients. objectives: this study is a prospective validation of the cdr in a new population. methods: a prospective, observational cohort analysis of injured patients ( ‡ y.o.) transported by helicopter from the scene to one of two level i trauma centers. variables analyzed included patient demographics, diagnoses, and clinical outcomes (in-hospital mortality, emergent surgery w/in hrs, blood transfusion w/in hrs, icu admit greater than hrs, combined outcome of all). prehospital variables were prospectively obtained from air medical providers at the time of transport and included past medical history, mechanism of injury, and clinical factors. descriptive statistics compared those with and without the outcomes of interest. the previous cdr (age ‡ , gcs £ , sbp < , flail chest) was prospectively applied to the new population to determine its accuracy and discriminatory ability. results: patients were transported from october -august . the majority of patients were male ( %), white ( %), with an injury occurring in a rural location ( %). most injuries were blunt ( %) with a median iss of . overall mortality was %. the most common reasons for air transport were: mvc with high risk mechanism ( %), gcs £ ( %), loc > minutes ( %), and mvc > mph ( %). of these, only gcs £ was significantly associated with any of the clinical outcomes. when applying the cdr, the model had a sensitivity of % ( . %- %), a specificity of . % ( . %- . %), a npv of % ( . %- %), and a ppv of . % ( . %- . %) for mortality. the area under the curve for this model was . , suggesting excellent discriminatory ability. conclusion: the air transport decision rule in this study performed with high sensitivity and acceptable specificity in this validation cohort. further external validation in other systems and with ground transported patients are needed in order to improve decision making for the use of helicopter transport of injured patients. background: acute non-variceal upper gastrointestinal (gi) bleeding is a common indication for hospital admission. to appropriately risk-stratify such patients, endoscopy is recommended within hours. given the possibility to safely manage patients as outpatients after endoscopy, risk stratification as part of an emergency department (ed) observation unit (ou) protocol is proposed. objectives: our objective was to determine the ability of an ou upper gi bleeding protocol to identify a lowrisk population, and to expeditiously obtain endoscopy and disposition patients. we also identified rates of outcomes including changes in hemoglobin, abnormal endoscopy findings, admission, and revisits. background: acute uncomplicated pyelonephritis (pyelo) requires no imaging but a ct flank pain protocol (ctfpp) may be ordered to determine if patients with pyelo and flank pain also have an obstructing stone. the prevalence of kidney stone and the characteristics predictive of kidney stone in pyelo patients is unknown. objectives: to determine elements on presentation that predict ureteral stone, as well as prevalence of stone and interventions in patients undergoing ct for pyelo. methods: retrospective study of patients at an academic ed who received a ctfpp scan between / and / . ctfpps were identified and randomly selected for review. pyelo was defined as: positive urine dip for infection and > wbc/hpf on formal urinalysis in addition to flank pain/cva tenderness, chills, fever, nausea, or vomiting. patients were excluded for age < y.o., renal disease, pregnancy, urological anomaly, or recent trauma. clinical data ( elements) were gathered blinded to ct findings; ct results were abstracted separately and blinded to clinical elements. ct findings of hydronephrosis and hyrdroureter (hydro) were used as a proxy for hydro that could be determined by ultrasound prior to ct. patients were categorized into three groups: ureteral stone, no significant findings, and intervention or follow-up required. classification and regression tree analysis was used to determine which variables could identify ureteral stone in this population of pyelo patients. results: out of the patients, ( . %) met criteria for pyelo; subjects had a mean age of ± . and % (n = ) were female. ct revealed ( %, % ci = . - . ) symptomatic stones, and ( %, % ci = . - . ) exams with no significant findings. two patients needed intervention/ follow-up ( %, % ci = . - . ), one for perinephric hemorrhage and the other for pancreatitis. hydro was predictive for ureteral stone with an or = . ( % ci = . - , p < . ). eleven ( %) ureteral stone patients were admitted and ( %) of them had procedures. of these patients, % had ct signs of obstruction, ( %) had hydronephrosis, and ( %) had hydroureter. conclusion: hydronephrosis was predictive of ureteral stone and in-house procedures. prospective study is needed to determine whether ct scan is warranted in patients with pyelonephritis but without hydronephrosis or hydroureter. curative objectives: the specific aim of this analysis was to describe characteristics of patients presenting to the emergency department (ed) at their index diagnosis, and to determine whether emergency presentation precludes treatment with curative intent. methods: we performed a retrospective cohort analysis on a prospectively maintained institutional tumor registry to identify patients diagnosed with crc from - . emrs were reviewed to identify which patients presented to the ed with acute symptoms of crc as the initial sign of their illness. the primary outcome variable was treatment plan (curative vs. palliative). secondary outcome variables included demographics, tumor type and location. descriptive statistics were conducted for major variables. chi-squre and fisher's exact tests were used to detect the association between categorical variables. two-sample t-test was used to identify the association between continuous and categorical variables. results: between jan and dec , patients were identified at our institution with crc. ( %) were male and ( %) were female, with mean age . ; sd: . . thirty-three patients ( . %) initially presented to the ed, of whom ( . %) received palliation. of patients who initially presented elsewhere, ( . %) received palliation. acute ed presentation with crc symptoms did not preclude treatment with curative intent (p = . ). patients who presented emergently were more likely to be female ( % vs male %; p = . ) and older ( vs. ; p = . ). there was no statistically significant relationship between age, sex, tumor location, or type and treatment approach. conclusion: patients with crc may present to the ed with acute symptoms, which ultimately leads to the diagnosis. emergent presentation of crc does not preclude patients from receiving therapy with curative intent. cannabinoid (or . , , and white blood cell (wbc) count ‡ , /mm (or . , % ci . - . ). conclusion: age ‡ years is not associated with need for admission from an ed observation unit. older adults can successfully be cared for in these units. initial temperature, respiratory rate, and pulse were not predictive of admission, but extremely elevated blood pressure was predictive. other relevant predictor variables included comorbidities and elevated wbc count. advanced age should not be a disqualifying criterion for disposition to an ed observation unit. older adult fallers in the emergency department luna ragsdale, cathleen colon-emeric duke university, durham, nc background: approximately / of community-dwelling older adults experience a fall each year, and . million are treated in u.s. emergency departments (ed) annually. the ed offers a potential location for identification of high-risk individuals and initiation of fall-prevention services that may decrease both fall rates and resource utilization. objectives: the goal of this study was to: ) validate an approach to identifying older adults presenting with falls to the ed using administrative data; and ) characterize the older adult who falls and presents to the ed and determine the rate of repeat ed visits, both fall-related and all visits, after an index fall-related visit. methods: we identified all older adults presenting to either of the two hospitals serving durham county residents during a six month period. manual chart review was completed for all encounters with icd codes that may be fall-related. charts were reviewed months prior and months post index visit. descriptive statistics were used to describe the cohort. results: a total of older adults were evaluated in the ed during this time period; ( . %) had an icd code for a potentially fall-related injury. of these, record review identified ( %) with a fall from standing height or less. of the fallers, . % of the patients were discharged, % were admitted, and % were admitted under observation. of those who fell, . % had an ed visit within the previous year. approximately / ( . %) of these were fall related. over half ( . %) of the patients who fell returned to the ed within one year of their index visit. a large proportion ( . %) of the return visits was fall-related. follow-up with a primary care provider or specialist was recommended in % of the patients who were discharged. overall mortality rate for fallers over the year following the index visit was %. conclusion: greater than fifty percent of fallers will return to the ed after an index fall, with a large proportion of the visits related to a fall. a large number of these fallers are discharged home with less than fifty percent having recommended follow-up. the ed represents an important location to identify high-risk older adults to prevent subsequent injuries and resource utilization. objectives: we studied whether falls from a standing position resulted in an increased risk for intracranial or cervical injury verses falling from a seated or lying position. methods: this is a prospective observational study of patients over the age of who presented with a chief complaint of fall to a tertiary care teaching facility. patients were eligible for the study if they were over age , were considered to be at baseline mental status, and were not triaged to the trauma bay. at presentation, a questionnaire was filled out by the treating physician regarding mechanism and position of fall, with responses chosen from a closed list of possibilities. radiographic imaging was obtained at the discretion of the treating physician. charts of enrolled patients were subsequently reviewed to determine imaging results, repeat studies done, or recurrent visits. all patients were called in follow-up at days to assess for delayed complications related to the fall. data were entered into a standardized collection sheet by trained abstractors. data were analyzed with fisher's exact test and descriptive statistics. this study was reviewed and approved by the institutional review board. results: two-hundred sixty two patients were enrolled during the study period. one-hundred ninety eight of these had fallen from standing and fell from either sitting or lying positions. the mean age for patients was (sd . ) for those who fell from standing and (sd . ) for those who fell from sitting or lying. there were patients with injuries who fell from standing: three with subdural hematomas, one with a cerebral contusion, one with an osteophyte fracture at c , and one with an occipital condyle fracture with a chip fracture of c . there were patients with injuries who fell from a seated or lying position: one with a traumatic subarachnoid hemorrhage and one with a type ii dens fracture. the overall rate of traumatic intracranial or cervical injury in elders who fell was %. no patients required surgical intervention. there was no difference in rate of injury between elders who fell from standing versus those who fell from sitting or lying (p = ). (table) . conclusion: both instruments identify the majority of patients as high-risk which will not be helpful in allocating scarce resources. neither the isar nor the trst can distinguish geriatric ed patients at high or low risk for or -month adverse outcomes. these prognostic instruments are not more accurate in dementia or lower literacy subsets. future instruments will need to incorporate different domains related to short-term adverse outcomes. background: for older adults, both inpatient and outpatient care involves not only the patient and physician, but often a family member or informal caregiver. they can assist in medical decision making and in performing the patient's activities of daily living. to date, multiple outpatient studies have examined the positive roles family members play during the physician visit. however, there is very limited information on the involvement of the caregiver in the ed and their relationship with the health outcomes of the patient. objectives: to assess whether the presence of a caregiver influences the overall satisfaction, disposition, and outpatient follow-up of elderly patients. we performed a three-step inquiry of patients over years old who arrived to the upenn ed. patients and care partners were initially given a questionnaire to understand basic demographic data. at the end of the ed stay, patients were given a satisfaction survey and followed through days to assess time to disposition, whether the patient was admitted or discharged, outpatient follow-up, and ed revisit rates. chi-square and t-tests were used to examine the strength of differences in the elderly patients' sociodemographics, self-rated health, receiving aid with their instrumental activities of daily living, and number of health problems by accompaniment status. multivariate regression models were constructed to examine whether the presence or absence of caregivers affected satisfaction, disposition, and follow-up. results: overall satisfaction was higher among patients who had caregivers ( . points), among patients who felt they were respected by their physician ( . points), and had lower lengths of stay ( hours). patients with caregivers were also more likely to be discharged home (or . ) and to follow-up with their regular physician (or . ). there was no evidence to suggest caregivers affected the overall rates of revisits back to an ed. conclusion: for older adults, medical care involves not only the patient and physician, but often a family member or an informal care companion. these results demonstrate the positive influence of caregivers on the patients they accompany, and emergency physicians should define ways to engage these caregivers during their ed stay. this will also allow caregivers to participate when needed and can help to facilitate transitions across care settings. background: shared decision making has been shown to improve patient satisfaction and clinical outcomes for chronic disease management. given the presence of individual variations in the effectiveness and side effects of commonly used analgesics in older adults, shared decision making might also improve clinical outcomes in this setting. objectives: we sought to characterize shared decision making regarding the selection of an outpatient analgesic for older ed patients with acute musculoskeletal pain and to examine associations with outcomes. methods: we conducted a prospective observational study with consecutive enrollment of patients age or older discharged from the ed following evaluation for moderate or severe musculoskeletal pain. two essential components of shared decision making, ) information provided to the patient and ) patient participation in the decision, were assessed via patient interview at one week using four-level likert scales. results: of eligible patients, were reached by phone and completed the survey. only % ( / ) of patients reported receiving 'a lot' of information about the analgesic, and only % ( / ) reported participating 'a lot' in the selection of the analgesic. there were trends towards white patients (p = . ) and patients with higher educational attainment (p = . ) reporting more participation in the decision. after adjusting for sex, race, education, and initial pain severity, patients who reported receiving 'a lot' of information were more likely to report optimal satisfaction with the analgesic than those receiving less information ( % vs. %, p < . ). after the same adjustments, patients who reported participating 'a lot' in the decision were also more likely to report optimal satisfaction with the analgesic ( % vs. %, p < . ) and greater reductions in pain scores (mean reduction in pain . vs. . , p < . ) at one week than those who participated less. background: quality of life (qol) measurements have become increasingly important in outcomes-based research and cost-utility analyses. dementia is a prevalent, often unrecognized, geriatric syndrome that may limit the accuracy of patient self-report in a subset of patients. the relationship between caregiver and geriatric patient qol in the emergency department (ed) is not well understood. objectives: to qualify the relationship between caregiver and geriatric patient qol ratings in ed patients with and without cognitive dysfunction. methods: this was a prospective, consecutive patient, cross-sectional study over two months at one urban academic medical center. trained research assistants screened for cognitive dysfunction using the short blessed test and evaluated health impairment using the quality of life-alzheimer's disease (qol-ad) test. when available in the ed, caregivers were asked to independently complete the qol-ad. consenting subjects were non-critically ill, english-speaking, community-dwelling adults over years of age. responses were compared using wilcoxon signed ranks test to assess the relationships between patient and caregiver scores from the qol-ad stratified by normal or abnormal cognitive screening results. significance was defined by p < . . results: patient qol ratings were obtained from patient-caregiver pairs. patients were % female, % african-american, with a mean age of -years, and % had abnormal cognitive screening tests. compared with caregivers, cognitively normal patients had no significant qol assessment differences except for questions of energy level and overall mood. on the other hand, cognitively impaired patients differed significantly on questions of energy level and ability to perform household chores with a trend towards significant differences for living setting (p = . ) and financial situation (p = . ). in each category, the differences reflected a caregiver underestimation of quality compared with the patient's self-rating. conclusion: discrepancies between qol domains and total scores for patients with cognitive dysfunction and their caregivers highlights the importance of identifying cognitive dysfunction in ed-based outcomes research and cost-utility analyses. further research is needed to quantify the clinical importance of the patient-and caregiver-assessed quality of life. background: age is often a predictor for increased morbidity and mortality. however, it is unclear whether old age is a predictor of adverse outcome in syncope. objectives: to determine whether old age is an independent predictor of adverse outcome in patients presenting to the emergency department following a syncopal episode. methods: a prospective observational study was conducted from june to july enrolling consecutive adult ed patients (> years) presenting with syncope. syncope was defined as an episode of transient loss of consciousness. adverse outcome or critical intervention were defined as gastrointestinal bleeding or other hemorrhage, myocardial infarction/percutaneous coronary intervention, dysrhythmia, alteration in antidysrhythmics, pacemaker/defibrillator placement, sepsis, stroke, death, pulmonary embolus, or carotid stenosis. outcomes were identified by chart review and -day follow-up phone calls. results: of patients who met inclusion criteria, an adverse event occurred in % of patients. overall, % of patients with risk factors had adverse outcomes compared to . % of patients with no risk factors. in particular, / ( %; % ci - %) of patients < with risk factors had adverse outcomes, while / ( %; % ci - %) of the elderly with risk factors had adverse outcomes. in contrast, among young people / ( %; % ci . - . %) of patients without risk factors had adverse outcomes while / ( . %; % ci . - %) of patients ‡ without risk factors had adverse outcomes. conclusion: although the elderly are at greater risk for adverse outcomes in syncope, age ‡ or older alone does not appear to be a predictor of adverse outcome following a syncopal event. based on these data, it should be safe to discharge home from the ed patients with syncope, but without risk factors, regardless of age. (originally submitted as a ''late-breaker.'') antibiotics background: adherence to national guidelines for hiv and syphilis screening in eds is not routine. in our ed, hiv and syphilis screening rates among patients tested for gonorrhea and chlamydia (gc/ct) have been reported to be % and %, respectively. objectives: to determine the effect of a sexually transmitted infection (sti) laboratory order set on hiv and syphilis screening among ed patients tested for gc/ct. we hypothesized that a sti order set would increase screening rates by at least %. methods: a -month, quasi-experimental study in an urban ed comparing hiv and syphilis screening rates of gc/ct-tested patients before (control phase) and after the implementation of a sti laboratory order set (intervention phase). the order set linked blood-based rapid hiv and syphilis screening with gc/ct testing. consecutive patients completing gc/ct testing were included. the primary outcome was the absolute difference in hiv and syphilis screening rates among gc/ ct-tested patients between phases. we estimated that subjects per phase were needed to provide % power (p-value of £ . ) to detect an absolute difference in screening rates of %, assuming a baseline hiv screening rate of %. results: the ed census was , . characteristics of patients tested for gc/ct were similar between phases: the mean age was years (sd = ) and most were female ( %), black ( %), hispanic ( %), and unmarried ( % services have recommended the use of immunization programs against influenza disease within hospitals since the s. the emergency department (ed) being the ''safety net'' for most non-insured people is an ideal setting to intervene and provide primary prevention from influenza. objectives: the purpose of this study is to assess whether a pharmacist-based influenza immunization program is feasible in the ed, and successful in increasing the percentage of adult patients receiving the influenza vaccine. methods: implementation of pharmacist-based immunization program was developed in coordination with ed physicians and nursing staff in . the nursing staff, using an embedded electronic questionnaire within their triage activity, screened patients for eligibility for the influenza vaccine. the pharmacist using an electronic alert system within the electronic medical record identified patients who we deemed eligible and if agreed the pharmacist vaccinated the patient. patients who refused to be vaccinated were surveyed to ascertain their perception concerning immunization offered by a pharmacist in the ed. feasibility and safety data for vaccinating patient in the ed were recorded. results: patients were approached and enrolled into the study. of the , % agreed to receive the influenza vaccine from a pharmacist in the ed. the median screening time was minutes and median vaccination time was minutes for a total of minutes from screening time to vaccination time. % were willing to receive the influenza vaccine from a pharmacist, and % were willing to receive the vaccine in the ed. the main reason given for refusing to receive the influenza vaccine was ''patient does not feel at risk of getting the disease''; only . % stated they were vaccinated recently. conclusion: a pharmacist-based influenza immunization program is feasible in the ed, and has the potential to successfully increase the percentage of adult patients receiving the vaccine. . ± . , p < . ). ed visits by hiv-infected patients also had longer lengths of ed stay ( ± . minutes vs. . ± . minutes, p < . ) and were more likely to be admitted ( % vs. %, p < . ), than their non-hiv infected counterparts. conclusion: although ed visits by hiv-infected individuals in the u.s. are relatively infrequent, they occur at rates higher than the general population, and consume significantly more ed resources than the general population. the background: the influence of wound age on the risk of infection in simple lacerations repaired in the emergency department (ed) has not been well studied. it has traditionally been taught that there is a ''golden period'' beyond which lacerations are at higher risk of infection and therefore should not be closed primarily. the proposed cutoff for this golden period has been highly variable ( - hours in surgical textbooks). objectives: to answer the following research question: are wounds closed via primary repair after the golden period at increased risk for infection? methods: we searched medline, embase, and other databases as well as bibliographies of relevant articles. we included studies that enrolled ed patients with lacerations repaired by primary closure. exclusion: . intentional delayed primary repair or secondary closure, . wounds requiring intra-operative repair, skin graft, drains, or extensive debridement, and . grossly contaminated or infected at presentation. we compared the outcome of wound infection in two groups of early versus delayed presentations (based on the cut-offs selected by the original articles). we used ''grading of recommendations assessment, development and evaluation'' (grade) criteria to assess the quality of the included trials. frequencies are presented as percentages with % confidence intervals. relative risk (rr) of infection is reported when clinically significant. results: studies were identified. four trials enrolling patients in aggregate met our inclusion/exclusion criteria. two studies used a -hour cut-off and the other two used a -hour cut-off for defining delayed wounds. the overall quality of evidence was low. the infection rate in the wounds that presented with delay ranged from . % to %. one study with the smallest sample size (morgan et al), which only enrolled lacerations to the hand and forearm, showed higher rates of infection in patients with delayed wounds (table). the infection rates in delayed wound groups in the remaining three studies were not significantly different from the early wounds. conclusion: the evidence does not support the existence of a golden period, nor does it support the role of wound age on infection rate in simple lacerations. background: although clinical studies in children have shown that temperature elevation is an independent and significant predictor of bacteremia in children, the relationship in adults is largely unknown or equivocal. objectives: review the incidence of positive blood cultures on critically ill adult septic patients presenting to an emergency department (ed) and determine the association of initial temperature with bacteremia. methods: july to july retrospective chart review on all patients admitted from the ed to an urban community hospital with sepsis and subsequently expiring within days of admission. fever was defined as a temperature ‡ °c. sirs criteria were defined as: ) temperature ‡ °c or £ °c, ) heart rate ‡ beats/ minute, ) respiratory rate ‡ or mechanical ventilation, ) wbc ‡ , /mm or < , or bands ‡ %. objectives: we examined the utility of limited genetic sequencing of bacterial isolates using multilocus sequence typing (mlst) to discriminate between known pathogenic blood culture isolates of s. epidermidis and isolates recovered from skin. methods: ten blood culture isolates from patients meeting the centers for disease control and prevention (cdc) criteria for clinically significant s. epidermidis bacteremia and ten isolates from the skin of healthy volunteers were studied. mlst was performed by sequencing bp regions of seven genes (arc, aroe, gtr, muts, pyr, tpia, and yqil) . genetic variability at these sites was compared to an international database (www.sepidermidis.mlst.net) and each strain was then categorized into a genotype on the basis of known genetic variation. the ability of the gene sequences to correctly classify strains was quantified using the support vector machine function in the statistical package r. , bootstrap resamples were performed to generate confidence bounds around the accuracy estimates. results: between-strain variability was considerable, with yqil being most variable ( alleles) and tpia being least ( allele). the muts gene, responsible for dna repair in s. epidermidis, showed almost complete separation between pathogenic and commensal strains. when the seven genes were used in a joint model, they correctly predicted bacterial strain type with % accuracy (iqr , %). conclusion: multilocus sequence typing shows excellent early promise as a means of distinguishing contaminant versus truly pathogenic isolates of s. epidermidis from clinical samples. near-term future goals will involve developing more rapid means of sequencing and enrolling a larger cohort to verify assay performance. conference are presented by influenza scenario in table and background: antiviral medications are recommended for patients with influenza who are hospitalized or at high risk for complications. however, timely diagnosis of influenza in the ed remains challenging. influenza rapid antigen tests have short turn-around times, making them potentially useful in the ed setting, but their sensitivities may be too low to assist with treatment decisions. objectives: to evaluate the test characteristics of the binaxnow influenza a&b rapid antigen test (rat) in ed patients. methods: we prospectively enrolled a systematic sample of patients of all ages presenting to two eds with acute respiratory symptoms or fever during three consecutive influenza seasons ( ) ( ) ( ) ( ) . research personnel collected nasal and throat swabs, which were combined and tested for influenza with rt-pcr using cdc-provided primers and probes. ed clinicians independently decided whether to obtain a rat during clinical care. rats were performed in the clinical laboratory using the binaxnow influenza a&b test on nasal swabs collected by ed staff. the study cohort included subjects who underwent both a research pcr and clinical rat. rat test characteristics were evaluated using pcr as the criterion standard with stratified sub-analyses for age group and influenza subtype (pandemic h n (ph n ), non-pandemic influenza a, influenza b). results: subjects were enrolled; subjects were pcr positive for influenza ( ph n , non-pandemic influenza a, and influenza b). for all age groups, rat sensitivities were low and specificities were high ( hiv infection with cd < ; and among nursing home residents, inability to independently perform activities of daily living. sources for bacterial cultures included blood, sputum (adults only), bronchoalveolar lavage (bal), tracheal aspirate, and pleural fluid. only sputum specimens with a bartlett score ‡ + were considered adequate for culturing. results: among children enrolled, ( %) had s. aureus cultured from ‡ specimen, including with methicillin-resistant s. aureus (mrsa) and with methicillin-susceptible s. aureus (mssa). specimens positive for s. aureus included pleural fluid, blood, tracheal aspirates, and bal. two children with s. aureus had evidence of co-infection: influenza a, and streptococcus pneumoniae. among adults enrolled, ( %) grew s. aureus from ‡ specimen, including with mrsa and with mssa. specimens positive for s. aureus included blood, sputum, and bal. five adults with s. aureus had evidence of co-infections: coronavirus, respiratory syncytial virus, s. pneumoniae, and pseudomonas aeruginosa. presenting clinical characteristics and outcomes of subjects with staphylococcal cap are summarized in tables - . conclusion: these preliminary findings suggest s. aureus is an uncommon cause of cap. although the small number of staphylococcal cases limits conclusions that can be drawn, in our analysis staphylococcal cap appears to be associated with co-infections, pleural effusions, and severe disease. future work will focus on continued enrollment and developing clinical prediction models to aid in diagnosing staphylococcal cap in the ed. background: emergency care has been a neglected public health challenge in sub-saharan africa. the goal of global emergency care collaborative (gecc) is to develop a sustainable model for emergency care delivery in low-resource settings. gecc is developing a training program for emergency care practitioners (ecps). objectives: to analyze the first patient visits at karoli lwanga ''nyakibale'' hospital ed in rural uganda to determine the knowledge and skills needed in training ecps. methods: a descriptive cross-sectional analysis of the first consecutive patient visits in the ed's patient care log was reviewed by an unblinded abstractor. data on demographics, procedures, laboratory testing, bedside ultrasounds (us) performed, radiographs (xrs) ordered, and diagnoses were collated. all authors discussed uncertainties and formed a consensus. descriptive statistics were performed. results: of the first patient visits, procedures were performed in ( . %) patients, including ( . %) who had ivs placed, ( . %) who received wound care, and ( . %) who received sutures. complex procedures, such as procedural sedations, lumbar punctures, orthopedic reductions, nerve blocks, and tube thoracostomies, occurred in ( . %) patients. laboratory testing, xrs, and uss were performed in ,( . %), ( . %), and ( %) patients, respectively. infectious diseases were diagnosed in ( . %) patients; ( . %) with malaria and ( . %) with pneumonia. traumatic injuries were present in ( %) patients; ( . %) needing wound care and ( . %) with fractures. gastrointestinal and neurological diagnoses affected ( . %) and ( . %) patients, respectively. conclusion: ecps providing emergency care in sub-saharan africa will be required to treat a wide variety of patient complaints and effectively use laboratory testing, xrs, and uss. this demands training in a broad range of clinical, diagnostic, and procedural skills, specifically in infectious disease and trauma, the two most prevalent conditions seen in this rural sub-saharan africa ed. assessment of point-of-care ultrasound in tanzania background: current chinese ems is faced with many challenges due to a lack of systematic planning, national standards in training, and standardized protocols for prehospital patient evaluation and management. objectives: to estimate the frequency with which prehospital care providers perform critical actions for selected chief complaints in a county-level ems system in hunan province, china. methods: in collaboration with xiangya hospital (xyh), central south university in hunan, china, we collected data pertaining to prehospital evaluation of patients on ems dispatches from a '' - - '' call center over a -month period. this call center services an area of just under km with a total population of . million. each ems team consists of a driver, a nurse, and a physician. this was a cross-sectional study where a single trained observer accompanied ems teams on transports of patients with a chief complaint of chest pain, dyspnea, trauma, or altered mental status. in this convenience sample, data were collected daily between am and pm. critical actions were pre-determined by a panel of emergency medicine faculty from xyh and the university of maryland school of medicine. simple statistical analysis was performed to determine the frequency of critical actions performed by ems providers. results: during the study period, patients were transported, of whom met the inclusion criteria. ( . %) evaluations were observed directly for critical actions. the table shows the frequency of critical actions performed by chief complaint. none of the patients with chest pain received an ecg even though the equipment was available. rapid glucose was checked in only . % of patients presenting with altered mental status. a lung exam was performed in . % of patients with dyspnea, and the respiratory rate was measured in . %. among patients transported for trauma, blood pressure, and heart rate were only measured in % and . %, respectively. conclusion: in this observation study of prehospital patient assessments in a county-level ems system, critical actions were performed infrequently for the chief complaints of interest. performance frequencies for critical actions ranged from to . %, depending on the chief complaint. standardized prehospital patient care protocols should be established in china and further training is needed to optimize patient assessment. trends little is known about the comparative effectiveness of noninvasive ventilation (niv) versus invasive mechanical ventilation (imv) in chronic obstructive pulmonary disease (copd) patients with acute respiratory failure. objectives: to characterize the use of niv and imv in copd patients presenting to the emergency department (ed) with acute respiratory failure and to compare the effectiveness of niv vs. imv. methods: we analyzed the - nationwide emergency department sample (neds), the largest, all-payer, us ed and inpatient database. ed visits for copd with acute respiratory failure were identified with a combination of copd exacerbation and respiratory failure icd- -cm codes. patients were divided into three treatment groups: niv use, imv use, and combined use of niv and imv. the outcome measures were inpatient mortality, hospital length of stay (los), hospital charges, and complications. propensity score analysis was performed using patient and hospital characteristics and selected interaction terms. results: there were an estimated , visits annually for copd exacerbation and respiratory failure from approximately , eds. ninety-six percent were admitted to the hospital. of these, niv use increased slightly from % in to % in (p = . ), while imv use decreased from % in to % in (p < . ); the combined use remained stable ( %). inpatient mortality decreased from % in to % in (p < . ). niv use varied widely between hospitals, ranging from % to % with median of %. in a propensity score analysis, niv use (compared to imv) significantly reduced inpatient mortality (risk ratio . ; % confidence interval [ci] . - . ), shortened hospital los (difference ) days; %ci ) to ) ), and reduced hospital charges ; ) . niv use was associated with a lower rate of iatrogenic pneumothorax compared with imv use ( . % vs. . %, p < . ). an instrumental analysis confirmed the benefits of niv use, with a % reduction in inpatient mortality in the niv-preferring hospitals. conclusion: niv use is increasing in us hospitals for copd with acute respiratory failure; however, its adoption remains low and varies widely between hospitals. niv appears to be more effective and safer than imv in the real-world setting. background: dyspnea is a common ed complaint with a broad differential diagnosis and disease-specific treatment. bronchospasm alters capnographic waveforms, but the effect of other causes of dyspnea on waveform morphology is unclear. objectives: we evaluated the utility of capnographic waveforms in distinguishing dyspnea caused by reactive airway disease (rad) from non-rad in adult ed patients. methods: this was a prospective, observational, pilot study of a convenience sample of adult patients presenting to the ed with dyspnea. waveforms, demographics, past medical history, and visit data were collected. waveforms were independently interpreted by two blinded reviewers. when the interpreters disagreed, the waveform was re-reviewed by both reviewers and an agreement was reached. treating physician diagnosis was considered the criterion standard. descriptive statistics were used to characterize the study population. diagnostic test characteristics and inter-rater reliability are given. results: fifty subjects were enrolled. median age was years (range - ), % were female, % were caucasian. / ( %) had a history of asthma or chronic obstructive pulmonary disease. rad was diagnosed by the treating physician in / ( %) and / ( %) had received treatment for dyspnea prior to waveform acquisition. the interpreters agreed on waveform analysis in / ( %) cases (kappa = . ). test characteristics for presence of acute rad, including %ci, were: overall accuracy % ( . %- . %), sensitivity % ( . %- . %), specificity % ( . %- . %), positive predictive value % ( . %- . %), negative predictive value % ( . %- . %), positive likelihood ratio . ( . - . ) , negative likelihood ratio . ( . - . ). conclusion: inter-rater agreement is high for capnographic waveform interpretation, and shows promise for helping to distinguish between dyspnea caused by rad and dyspnea from other causes in the ed. treatments received prior to waveform acquisition may affect agreement between waveform interpretation and physician diagnosis, affecting the observed test characteristics. asthma background: asthma and chronic obstructive pulmonary disease (copd) patients who present to the emergency department (ed) usually lack adequate ambulatory disease control. while evidence-based care in the ed is now well defined, there is limited inform-ation regarding the pharmacologic or non-pharmacologic needs of these patients at discharge. objectives: this study evaluated patients' needs with regard to the ambulatory management of their respiratory conditions after ed treatment and discharge. methods: over months, adult patients with acute asthma or copd, presenting to a tertiary care alberta hospital ed and discharged after being treated for exacerbations, were enrolled. using results from standardized in-person questionnaires, charts were reviewed by respiratory researchers to identify care gaps. results: overall, asthmatic and copd patients were enrolled. more patients with asthma required education on spacer devices ( % vs %). few asthma ( %) and no copd patients had written action plans; asthma patients were more likely to need adherence counseling ( % vs %) for preventer medications. more patients with asthma required influenza vaccination ( % vs %; p = . ); pneumococcal immunization was low ( %) in copd patients. only % of asthmatics reported ever being referred to an asthma education program and % of the copd patients reported ever being referred to pulmonary rehabilitation. at ed presentation, % of the asthmatics required the addition of inhaled corticosteroids (ics) and % required the addition of ics/long acting beta-agonist (ics/laba) combination agents. on the other hand, % of copd patients required the addition of long-acting anticholinergics while most ( %) were receiving preventer medications. finally, % of copd and % of asthma patients who smoked required smoking cessation counseling. conclusion: overall, we identified various care gaps for patients presenting to the ed with asthma and copd. there is an urgent need for high-quality research on interventions to reduce these gaps. methods: this is an interim, sub-analysis of an interventional, double-blinded study performed in an academic urban-based adult ed. subjects with acute exacerbation of asthma with fev < % predicted within minutes following initiation of ''standard care'' (including a minimum of mg nebulized albuterol, . mg nebulized ipratropium, and mg corticosteroid) who consented to be in a trial were included. all treatment was administered by emergency physicians unaware of the study objectives. patients were randomly assigned to treatment with placebo or an intravenous beta agonist. all subjects had fev and ds obtained at baseline, , , and hours after treatment. fev was measured using a bedside nspire spirometer, and ds was calculated using a modified borg dyspnea score. results: thirty-eight patients were included for analysis. spearman's rho test (rho) was used to measure correlations between fev and ds at , , and hours post study entry and subsequent hospitalization. rho is negative for fev (higher fev correlates to lower rate of hospitalization) and positive for ds (higher ds correlates to higher rate of hospitalization). at each time point, ds were more highly correlated to hospitalization than were fev (see table) . conclusion: dyspnea score at , , and hours were significantly correlated with hospital admission, whereas fev was not. in this set of subjects with moderate to severe asthma exacerbations, a standardized subjective tool was superior to fev for predicting subsequent hospitalization. methods: this is an interim, subgroup analysis of a prospective, interventional, double-blind study performed in an academic urban ed. subjects who were consented for this trial presented with acute asthma exacerbations with fev £ % predicted within minutes following initiation of ''standard care'' (includes a minimum of . mg nebulized albuterol, . mg nebulized ipratropium, and mg of a corticosteroid). ed physicians who were unaware of the study objectives administered all treatments. subjects were randomized in a : ratio to either placebo or investigational intravenous beta agonist arms. blood was obtained at and . hours after the start of the hour long infusion. blood was centrifuged and serum stored at ) °c, and then shipped on dry ice for albuterol and lactate measurements at a central lab. the treatment lactate and d lactate were correlated with hr serum albuterol concentrations and hospital admission using partial pearson correlations to adjust for ds. results: subjects were enrolled to date, with complete data. the mean baseline serum lactate level was . mg/dl (sd ± . ). this increased to . mg/ dl (sd ± . ) at . hrs. the mean hr ds was . (sd ± . ). the correlations between treatment lactate, d lactate, hr serum albuterol concentrations (r, s and total) and admission to hospital are shown (see table) . both treatment and d lactate were highly conrrelated with total serum albuterol, r albuterol, and s albuterol. there was no correlation between treatment lactate or d lactate and hospital admission. conclusion: lactate and d lactate concentrations correlate with albuterol concentrations in patients presenting had asthma. fifty one percent were < years old and % were female. we found a decline of % ( % ci: %- %, p < . ; r = . , p < . ) in the overall yearly asthma visits to total ed visits from to . when we analyzed sex and age groups separately, we found no statistically significant changes for females or for males < years old (r £ . , p ‡ . ). for females and males > years old, yearly asthma visits to total ed visits from to decreased % ( % ci: %- %, p < . ; r = . , p < . ) and % ( % ci: %- %, p < . ; r = . , p < . ), respectively. conclusion: we found an overall decrease in yearly asthma visits to total ed visits from to . we speculate that this decrease is due to greater corticosteroid use despite the increasing prevalence of asthma. it is unclear why this decrease was seen in adults and not in children and why it was greater for adult females than males. objectives: our objectives were to describe the use of a unique data collection system that leveraged emr technology and to compare its data entry error rate to traditional paper data collection. methods: this is a retrospective review of data collection methods during the first months of a multicenter study of ed, anti-coagulated, head injury patients. on-shift ed physicians at five centers enrolled eligible patients and prospectively completed a data form. enrolling ed physicians had the option of completing a one-page paper data form or an electronic ''dotphrase'' (dp) data form. our hospital system uses an epicÒbased emr. a feature of this system is the ability to use dps to assist in medical information entry. a dp is a preset template that may be inserted into the emr when the physician types a period followed by a code phrase (in this case ''.ichstudy''). once the study dp was inserted at the bottom of the electronic ed note, it prompted enrolling physicians to answer study questions. investigators then extracted data directly from the emr. our primary outcomes of interest were the prevalence of dp data form use and rates of data entry errors. results: from / through / , patients were enrolled. dp data forms were used in ( . %; % ci . , . %) cases and paper data forms in ( . %; % ci . , . %). the prevalence of dp data form use at the respective study centers was %, %, %, %, and %. sixty-six ( . %; % ci . , . %) of physicians enrolling patients used dp data entry at least once. using multivariate analysis, we found no significant association between physician age, sex, or tenure and dp use. data entry errors were more likely on paper forms ( / , . %; % ci . , . %) than dp data forms ( / , . %; % ci . , . %), difference in error rates . % ( % ci . , . %, p < . ). conclusion: dp data collection is a feasible means of study data collection. dp data forms maintain all study data within the secure emr environment obviating the need to maintain and collect paper data forms. this innovation was embraced by many of our emergency physicians. we found lower data entry error rates with dp data forms compared to paper forms. background: inadequate randomization, allocation concealment, and blinding can inflate effect sizes in both human and animal studies. these methodological limitations might in part explain some of the discrepancy between promising results in animal models and non-significant results in human trials. whereas blinding is not always possible, in clinical or animal studies, true randomization with allocation concealment is always possible, and may be as important in minimizing bias. objectives: to determine the frequency with which published emergency medicine (em) animal research studies report randomization, specific randomization methods, allocation concealment, and blinding of interventions and measurements, and to estimate whether these have changed over time. methods: all em animal research publications from / through / in ann emerg med and acad emerg med were reviewed by two trained investigators for a statement regarding randomization, and specific descriptions of randomization methods, allocation concealment, blinding of intervention, and blinding of measurements, when possible. raw initial agreement was calculated and differences were settled by consensus. the first (period = - ) and second (period = - ) -year periods were compared with % confidence intervals. results: of em animal research studies, were appropriate for review because they involved intervention in at least two groups. blinding of interventions and measurements were not considered possible in % and %, respectively. significant differences between period and were absent, although there was a trend towards less blinding of interventions and more blinding of measurements. raw agreement was %. conclusion: although randomization is mentioned in the majority of studies, allocation concealment and blinding remain underutilized in em animal research. we did not compare outcomes between blinded and non-blinded, randomized and non-randomized studies, because of small sample size. this review fails to demonstrate significant improvement over time in these methodological limitations in em animal research publications. journals might consider requiring authors to explicitly describe their randomization, allocation, and blinding methods. background: cluster randomized trials (crts) are increasingly utilized to evaluate quality improvement interventions aimed at health care providers. in trials testing ed interventions, migration of eps between hospitals is an important concern, as contamination may affect both internal and external validity. objectives: we hypothesized geographically isolating emergency departments would prevent migratory contamination in a crt designed to increase ed delivery of tpa in stroke (the instinct trial). methods: instinct was a prospective, cluster-randomized, controlled trial. twenty-four michigan community hospitals were randomly selected in matched pairs for study. following selection of a single hospital, all hospitals within miles were excluded from the sample pool. individual emergency physicians staffing each site were identified at baseline ( ) and months later. contamination was defined at the cluster level, with substantial contamination defined a priori as > % of eps affected. non-adherence, total crossover (contamination + non-adherence), migration distance and characteristics were determined. results: emergency physicians were identified at all sites. overall, ( . %) changed study sites. one moved between control sites, leaving ( . %) total crossovers. of these, ( . %) moved from intervention to control (contamination) and ( . %) moved from control to intervention (non-adherence). contamination was observed in of sites, with % and % contamination of the total site ep workforce at follow-up, respectively. two of crossovers occurred between hospitals within the same health system. average migration distance was miles for all eps in the study and miles for eps moving from intervention to control sites. conclusion: the mobile nature of emergency physicians should be considered in the design of quality improvement crts. use of a -mile exclusion zone in hospital selection for this crt was associated with very low levels of substantial cluster contamination ( of ) and total crossover. assignment of hospitals from a single health system to a single study group and/or an exclusion zone of miles would have further reduced crossovers. increased reporting of contamination in cluster randomized controlled trials is encouraged to clarify thresholds and facilitate crt design. objectives: an extension of the lr, the average absolute likelihood ratio (aalr), was developed to assess the average change in the odds of disease that can be expected from a test, or series of tests, and an example of its use to diagnose wide qrs complex tachycardia (wct) is provided. methods: results from two retrospective multicenter case series were used to assess the utility of qrs duration and axis to assess for ventricular tachycardia (vt) in patients with undifferentiated regular sustained wct. serial patients with heart rate (hr) > beats per minute and qrs duration > milliseconds (msec) were included. the final tachydysrhythmia diagnosis was determined by a number of methods independent of the ecg. the aalr is defined as: aalr = /n total [r (n i *lr i ) (for lr > ) + r (n k /lr k ) (for lr < )], where lr i and lr k are the interval lrs, and n i and n k are the number of patients with test results within the corresponding intervals. roc curves were constructed, and interval lrs and aalrs were calculated for the qrs duration and axis tests individually, and when applied together. confidence intervals were bootstrapped with , replications using the r boot package. results: patients were included: with supraventricular tachycardia (svt) and with vt. optimal qrs intervals (msec) for distinguishing vt from svt were: qrs £ , < qrs < , and qrs ‡ . qrs axis results were dichotomized to upward right axis ( - degrees) or not () to degrees). results are listed in the table. conclusion: application of the qrs interval and axis tests together for patients with wide qrs complex tachycardia changes the odds of ventricular tachycardia, on average, by a factor of . ( % ci . to . ), and this is mildly improved over the qrs duration test alone. both a strength and weakness of the aalr is its dependence on the pretest probability of disease. the aalr may be helpful for clinicians and researchers to evaluate and compare diagnostic testing approaches, particularly when strategies with serial non-independent tests are considered. consultation for adults with metastatic solid tumors at an urban, academic ed located within a tertiary care referral center. field notes were grouped into barrier categories and then quantified when possible. patient demographics for those who did and did not enroll were extracted from the medical record and quantified. patients who did not meet inclusion criteria for the study (e.g., cognitive impairment) were excluded from the analysis. results: attempts were made to enroll eligible patients in the study, and were successfully enrolled ( % enrollment rate). barriers to enrollment were deduced from the field notes and placed into the following categories from most to least common: patient refusal ( ); diagnostic uncertainty regarding cancer stage ( ); severity of symptoms preclude participation ( ); patient unaware of illness or stage ( ); and family refusal ( ). conclusion: patients, families, and diagnostic uncertainty are barriers to enrolling ed patients with advanced illness in clinical trials. it is unclear whether these barriers are generalizable to other study sites and disease processes other than cancer. objectives: the purpose of this study was to evaluate the use of a high-fidelity mannequin bedside simulation scenario followed by a debriefing session as a tool to improve medical student knowledge of palliative care techniques. methods: third year medical students participating in a -week simulation curriculum during a surgery/ emergency medicine/anesthesia clerkship were eligible for the study. all students were administered a pretest to evaluate their baseline knowledge of palliative care and randomized to a control or intervention group. during week or , students in the intervention group participated in and observed two end-of-life scenarios. following the scenarios, a faculty debriefer trained in palliative care addressed critical actions in each scenario. during week , all students received a posttest to evaluate for improvement in knowledge. the pre-test and post-test consisted of questions addressing prognostication, symptom control, and the medicare hospice benefit. students were de-identified and pre-and post-tests were graded by a blinded scorer. results: from jan-dec , students were included in the study and were excluded due to incomplete data. the mean score on the pre-test for the intervention group was . , and for the control group was . (p = . the results indicate that educators identify the most important scenarios as protocol-based simulations. respondents also suggested that scenarios of very common emergency department presentations bear a great deal of importance. emergency medicine educators assign priority to simulations involving professionalism and communication. finally, many respondents noted that they use simulation to teach the presentation and management of rare or less frequent, but important disease processes. the identification of these scenarios would suggest that educators find simulation useful for filling in ''gaps'' in resident education. background: prescription drug misuse is a growing problem among adolescent and young adult populations. objectives: to determine factors associated with past year prescription drug misuse defined as using prescription sedatives, stimulants, or opioids to get high, taking them when they were prescribed to someone else or taking more than was prescribed among patients seeking care in an academic ed. methods: adolescents and young adults ( - ) presenting for ed care at a large, academic teaching hospital were approached to complete a computerized screening questionnaire regarding demographics, prescription drug misuse, illicit drug use, alcohol use, and violence in the past months. logistic regression was used to predict past year prescription drug misuse. results: over the study time period, there were participants ( % response rate) of whom ( . %) endorsed past year prescription drug misuse. specifically, rates of past year misuse for opioids was . %, sedatives was . %, and stimulants was . %. significant overlap exists among classes with over % misusing more than one class of medications. in the multivariate analysis significant predictors of past year prescription drug misuse included female gender (or conclusion: approximately one in seven adolescents or young adults seeking ed care have misused prescription drugs in the past year. while opioids are the most common drug misused, significant overlap exists among this population. given the correlation of prescription drug misuse with the use and misuse of other substances (i.e. alcohol, cough medicine, marijuana) more research is needed to further understand these relationships and inform interventions. additionally, future research should focus on understanding the differences in demographics and risk factors associated with misuse of each separate class of prescription drugs. prospective objectives: this study aims to examine the association of depression with high ed utilization in patients with non-specific abdominal pain. methods: this single-center, prospective, cross-sectional study was conducted in an urban academic ed located in washington, dc as part of a larger study to evaluate the interaction between depression and frequency of ed visits and chronic pain. as part of this study, we screened patients using the phq- , a nineitem questionnaire that is a validated, reliable predictor of major depressive disorder. we analyzed the subset of respondents with a non-specific abdominal pain diagnosis (icd- code of .xx). our principal outcome of interest was the rate of a positive depression screen in patients with non-specific abdominal pain. we analyzed the prevalence of a positive depression screen among this group and also conducted a chi-square analysis to compare high ed use among abdominal pain patients with a positive depression screen versus those without a positive depression screen. we defined high ed utilization as > visits in a -day period prior to the enrollment visit. background: numerous studies have found high rates of co-morbid mental illness and chronic pain in emergent care settings. one psychiatric diagnosis frequently associated with chronic pain is major depressive disorder (mdd). objectives: we conducted a study to characterize the relationship between mdd and chronic pain in the emergency department (ed) population. we hypothesized that patients who present to the ed with selfreported chronic pain will have higher rates of mdd. methods: this was a single-center, prospective, crosssectional study. we used a convenience sample of noncritically ill, english speaking adult patients presenting with non-psychiatric complaints to an urban academic ed over months in . we oversampled patients presenting with pain-related complaints (musculoskeletal pain or headache). subjects were surveyed about their demographic and other health and health care characteristics and were screened with the phq , a nine-item questionnaire that is a validated, reliable predictor of mdd. we conducted bivariate (chi-square) and multivariate analysis controlling for demographic characteristics (race, income, sex, age) using stata v. . . our principal dependent variable of interest was a positive depression screen (phq score ‡ ). our principal independent variable of interest was the presence of self-reported chronic pain (greater than months). results: of patients enrolled, did not meet all inclusion criteria. had two or more assessments for comparison. their average age was (range - ), % were male, and % were in police custody. % used methadone alone; % heroin alone; % oxycodone alone; and the rest used multiple opioids. the average dose of im methadone was . mg (range - mg); all but patients received mg. the mean cows score before receiving im methadone was . (range - ), compared to . (range - ) minutes after methadone (p < . ; mean difference = ) . ; % ci = ) . to ) . ). the mean wss before and after methadone was ) . (range ) to ) ) and ) . (range ) to ), respectively (p < . ; % ci = ) . to ) . ). the mean physician-assessed wss was significantly lower than the patient's own assessment by . (p < . ). adverse events included an asthmatic patient with bronchospasm whose oxygen saturation decreased from % to % after receiving methadone, a patient whose oxygen saturation decreased from % to %, and two patients whose amss decreased from ) to ) (indicating moderate sedation). background: as the us population ages, the coexistence of copd and acute coronary syndrome (acs) is expected to be more frequent. very few studies have examined the effect of copd on outcomes in acs patients, and, to our knowledge, there has been no report on biomarkers that possibly mediate between copd and long-term acs patient outcomes. objectives: to determine the effect of copd on longterm outcomes in patients presenting to the emergency department (ed) with acs and to identify prognostic inflammatory biomarkers. methods: we performed a prospective cohort study enrolling acs patients from a single large tertiary center. hospitalized patients aged years or older with acs were interviewed and their blood samples were obtained. seven inflammatory biomarkers were measured, including interleukin- (il- ), c-reactive protein (crp), tumor necrosis factor-alpha (tnf-alpha), vascular cell adhesion molecule (vcam), e-selectin, lipoprotein-a (lp-a), and monocyte chemoattractant protein- (mcp- ). the diagnoses of acs and copd were verified by medical record review. annual telephone follow-up was conducted to assess health status and major adverse cardiovascular events (mace) outcomes, a composite endpoint including myocardial infarction, revascularization procedure, stroke, and death. background: aortic dissection (ad) is an uncommon life-threatening condition requiring prompt diagnosis and management. thirty-eight percent of cases are missed upon initial evaluation. the cornerstone of accurate diagnosis hinges on maintaining a high index of clinical suspicion for the various patterns of presentation. quality documentation that reflects consideration for ad in the history, exam, and radiographic interpretation is essential for both securing the diagnosis and for protecting the clinician in missed cases. objectives: we sought to evaluate the quality of documentation in patients presenting to the emergency department with subsequently diagnosed acute ad. methods: irb-approved, structured, retrospective review of consecutive patients with newly diagnosed non-traumatic ad from to . inclusion criteria: new ad diagnosis via ed. exclusion criteria: ad diagnosed at another facility; chronic, traumatic, or iatrogenic ad. trained/monitored abstractors used a standardized data tool to review ed and hospital medical records. descriptive statistics were calculated as appropriate. inter-rater reliability was measured. our primary performance measure was the prevalence of a composite of all three key historical elements ( . any back pain, . neurologic symptoms including syncope, and . sudden onset of pain.) in the attending emergency physician's documentation. secondary outcomes included documentation of: ad risk factors, pain quality, back pain at multiple locations, presence/absence of pulse symmetry, mediastinal widening on chest radiograph, and migratory nature of the pain. results: / met our inclusion/exclusion criteria. the mean age was . years; % were male, ( . %) were stanford a. ( %) presented with a chief complaint of chest pain. primary outcome measure: / ( . %; %ci = . , . ) documented the presence/ absence of all three key historical elements. [back pain = / ; . % ( . , . ); neuro symptoms = / ; % ( . , . ); sudden onset = / ; . % ( . , . ).] limitations: small number of confirmed ad cases. conclusion: in our cohort, emergency physician documentation of key historical, physical exam, and radiographic clues of ad is suboptimal. although our ed miss rate is lower than that which has been reported by previous authors, there is an opportunity to improve documentation of these pivotal elements at our institution. objectives: this study assessed the opinions of iem and gh fellowship program directors, in addition to recent and current fellows regarding streamlining the application process and timeline in an attempt to implement change and improve this process for program directors and fellows alike. methods: a total of current iem and gh fellowship programs were found through an internet search. an electronic survey was administered to current iem and gh fellowship directors, current fellows, and recent graduates of these programs. results: response rates were % (n = ) for program directors and % (n = ) for current and recent fellows. the great majority of current and recent fellows ( %) and program directors ( %) support transitioning to a common application service. similarly, % of current and recent fellows and % of program directors support instituting a uniform deadline date for applications. however, only % of recent/current fellows and % of program directors would support a formalized match process like nrmp. conclusion: the majority of fellows and program directors support streamlining the application for all iem and gh fellowship programs. this could improve the application process for both fellows and program directors, and ensure the best fit for the candidates and for the fellowship programs. in order to establish effective emergency care in rural sub-saharan africa, the unique practice demographics and patient dispositions must be understood. objectives: the objectives of this study are to determine the demographics of the first patients seen at nyakibale hospital's ed and assess the feasibility of treating patients in a rural district hospital ed in sub-saharan africa. methods: a descriptive cross-sectional analysis of the first consecutive patient visits in the ed's patient care log was reviewed by an unblinded abstractor. data collected included age, sex, condition upon discharge, and disposition. all authors discussed uncertainties and formed a consensus. descriptive statistics were performed. results: of the first patient visits, ( . %) occurred when the outpatient clinic was open. there were ( %) male visits. the average age was . years (sd ± . ). pediatric visits accounted for ( . %) patients, and ( . %) visits were for children under five years old. only one patient expired in the ed, and ( . %) were in good condition after treatment, as subjectively defined by the ed physicians. one person was transferred to another hospital. after treatment, ( %) patients were discharged home. of those admitted to an inpatient ward, ( . %) patients were admitted to medical wards, ( . %) to pediatrics, and ( %) to surgical. only six ( . %) patients went directly to the operating theatre. conclusion: this consecutive sample of patient visits from a novel rural district hospital ed in sub-saharan africa included a broad demographic range. after treatment, most patients were judged to be in ''good condition'', and over one third of patients could be discharged after ed management. this sample suggests that it is possible to treat patients in an ed in rural sub-saharan africa, even in cases where surgical backup and transfers to higher level of care are limited or unavailable. background: communication failures in clinical handoffs have been identified as a major preventable cause of patient harm. in italy, advanced prehospital care is provided predominantly by physicians who work on ambulances in teams with either nurses or basic rescuers. the hand-offs from prehospital physicians to hospital emergency physicians (eps) is especially susceptible to error with serious consequences. there are no studies in italy evaluating the communication at this transition in patient care. studying this, however, requires a tool that measures the quality of this communication. objectives: the purpose of this study is to develop and validate a tool for the evaluation of communication during the clinical handoff from prehospital to emergency physicians in critically ill patients. methods: several previously validated tools for evaluating communication in hand-offs were identified through a literature search. these were reviewed by a focus group consisting of eps, nurses, and rescuers, who then adapted and translated the australian isbar (identification, situation, background, assessment, recommendation), the tool most relevant to local practice. the italian isbar tool consists of the following elements: patient and provider identification; patient's chief complaint; patient's past medical history, medications, and allergies; prehospital clinical assessment (primary survey, illness severity, vital signs, diagnosis); treatment initiated and anticipated treatment plan. we conducted and video-taped the hand-offs of care from the prehospital physicians to the eps in pediatric critical care simulations. four physician raters were trained in the italian isbar tool and used it to independently assess communication in each simulation. to assess agreement we calculated the proportion of agreement among raters for each isbar question, fleiss' kappas for each simulation, as well as mean agreement and mean kappas with standard deviations. results: there was % agreement among the four physicians on % of the items. the mean level of agreement was % (sd . ). the overall mean kappa was . (sd . ). conclusion: the standardized tool resulted in good agreement by physician raters. this validated tool may be helpful in studying and improving hand-offs in the prehospital to emergency department setting. objectives: we hypothesized that residents who were provided with vps prior to hfs would perform more thoroughly and efficiently than residents who had not been exposed to the online simulation. methods: we randomized a group of residents from an academic, pgy - emergency medicine program to complete an online vps case, either prior to (vps group, n = residents) or after (n = ) their hfs case. the vps group had access to the online case (which reviewed asthma management) days prior to the hfs session. all residents individually participated in their regularly scheduled hfs and were blinded to the content of the case -a patient in moderate asthma exacerbation. the authors developed a dichotomous checklist consisting of items recorded as done/not done along with time completed. a two sample proportion test was used to evaluate differences in the individual items completed between groups. a wilcoxon rank sum test was used to determine the differences in overall and subcategory performance between the two groups. median time to completion was analyzed using the log-rank test. results: the vps group had better overall checklist performance than the control group (p-value . ). in addition, the vps group was more thorough in obtaining an hpi (p-value . ). specific actions (related to asthma management) were performed better by the vps group: inquiring about last/prior ed visits ( . ), total number of hospitalizations in the prior year ( . ), prior intubations ( . ), and obtaining peak flow measurements ( . ). overall there was no difference in time to event completion between the two groups. conclusion: we found that when hfs is primed with educational modalities such as vps there was an improvement in performance by trainees. however, the improved completeness of the vps group may have served as a barrier to efficiency, inhibiting our ability to identify a statistical significant efficiency overall. vps may aid in priming the learners and maximize the efficiency of training using high-fidelity simulations. training using an animal model helped develop residents' skills and confidence in performing ptv. retention was found to be good at months post-training. this study underscores the need for hands-on training in rare but critical procedures in emergency medicine. methods: in this cross-sectional study at an urban community hospital, residents in their second or third year of training from a -year em residency program performed us-guided catheterizations of the ij on a simulator manufactured by blue phantom. two board-certified em physicians observed for the completion of pre-defined procedural steps using a checklist and rated the residents' overall performance of the procedure. overall performance ratings were provided on a likert scale of to , with being poor and being excellent. residents were given credit for performing a procedural step if at least one rater marked its completion. agreement between raters was calculated using intraclass correlation coefficients for domain and summary scores. the same protocol was then repeated on an unembalmed cadaver using two different board-certified em physician raters. criterion validity of the residents' proficiency on the simulator was evaluated by comparing their median overall performance rating on the simulator to that on the cadaver and by comparing the proportion of residents completing each procedural step between modalities with descriptive statistics. results: em residents' overall performance rating on the simulator was . ( % ci: . to . ) and on the cadaver was . ( % ci: . to . ). the results for each procedural step are summarized in the attached figure. inter-rater agreement was high for assessments on both the simulator and cadaver with overall kappa scores of . and . respectively. background: the environment in the emergency department (ed) is chaotic. physicians must learn how to multi-task effectively and manage interruptions. noise becomes an inherent byproduct of this environment. previous studies in the surgical and anesthesiology literature examined the effect of noise levels and cognitive interruptions on resident performance during simulated procedures; however, the effect of noise distraction on resident performance during an ed procedure has not yet been studied. objectives: our aim was to prospectively determine the effects of various levels of noise distraction on the time to successful intubation of a high-fidelity simulator. methods: a total of emergency medicine, emergency medicine/internal medicine, and emergency medicine/family medicine residents were studied in a background noise environments of less than decibels (noise level ), - decibels (noise level ), and of greater than decibels (noise level ). noise levels were standardized by a dosimeter (ex tech instruments, heavy duty ). each resident was randomized to the order in which he or she was exposed to the various noise levels and had a total of minutes to complete each of the intubation attempts, which were performed in succession. time, in seconds, to successful intubation was measured in each of these scenarios with the start time defined as the time the resident picked up the storz c-mac video laryngoscope blade and the finish time defined as the time the tube passed through the vocal cords as visualized by an observer on the storz c-mac video screen. analytic methods included analysis of variance, student's t-test, and pearson's chi-square. results: no significant differences were found between time to intubation and noise level nor did the order of noise level exposure affect the time to intubation (see table) . there were no significant differences in success rate between the three noise levels (p = . ). a significant difference in time to intubation was found between the residents' second and third intubation attempts with decreased time to intubation for the third attempt (p = . ). conclusion: noise level did not have an effect on time to intubation or intubation success rate. time to intubation decreased between the second and third intubations regardless of noise level. background: growing use of the emergency department (ed) is cited as a cause of rising health care costs and a target of health care reform. eds provide approximately one quarter of all acute care outpatient visits in the us. eds are a diagnostic center and a portal for rapid inpatient admission. the changing role of eds in hospital admissions has not been described. objectives: to compare if admission through the ed has increased compared to direct hospital admission. we hypothesized that the use of the ed as the admitting portal increased for all frequently admitted conditions. methods: we analyzed the nationwide inpatient sample (nis), the largest us all-payer inpatient care database, from - . nis contains data from approximately million hospital stays each year, and is weighted to produce national estimates. we used an interactive, webbased data tool (hcupnet) to query the nis. clinical classification software (ccs) was used to group discharge diagnoses into clinically meaningful categories. we calculated the number of annual admissions and proportion admitted from the ed for the most frequently admitted conditions. we excluded ccs codes that are rarely admitted through the ed (< %) as well as obstet- background: the optimal dose of opioids for patients in acute pain is not well defined, although . mg/kg of iv morphine is commonly recommended. patient-controlled analgesia (pca) provides an opportunity to assess the adequacy of this recommendation as use of the pca pump is a behavioral indication of insufficient analgesia. objectives: to assess the need for additional analgesia following a . mg/kg dose of iv morphine by measuring additional self-dosing via a pca pump. methods: a three-arm randomized controlled trial was performed in an urban ed with , annual adult visits. a convenience sample of ed patients ages to with abdominal pain of < days duration requiring iv opioids was enrolled between / and / . all patients received an initial dose of . mg/kg iv morphine. patients in the pca arms could request additional doses of mg or . mg iv morphine by pressing a button attached to the pump with a -minute lock-out period. for this analysis, data from both pca arms were combined. software on the pump recorded times when the patient pressed the button (activation) and when he/she received a dose of morphine (successful activation). results: patients were enrolled in the pca arms. median baseline nrs pain score was . mean amount of supplementary morphine self-administered over the hour study period subsequent to the loading dose was . mg and . mg for the and . mg pca groups respectively. patients activated the pump at least once ( %, % ci: to %). figure shows the frequency distribution of the number of times the pump was activated. of those who activated the pump, the median number of activations per person was (iqr: to ). there were activations of the pump. % of activations were successful (followed by administration of morphine), while % were unsuccessful as they occurred during the -minute lock-out periods. % of the activations occurred in the first minutes, % in the second minutes, % in the third minutes, and % in the last minutes after the initial loading dose. conclusion: almost all patients requested supplementary doses of pca morphine, half of whom activated the pump five times or more over a course of hours. this frequency of pca activations suggests that the commonly recommended dose of . mg/kg morphine may constitute initial oligoanalgesia in most patients. marie-pier desjardins, benoit bailey, fanny alie-cusson, serge gouin, jocelyn gravel chu sainte-justine, montreal, qc, canada background: administration of corticosteroid at triage has been suggested to decrease the time to corticosteroid administration in the ed. objectives: to compare the time between arrival and corticosteroid administration in patients treated with an asthma pathway (ap) or with standard management (sm) in a pediatric ed. methods: chart review of children aged to years diagnosed with asthma, bronchospasm, or reactive airways disease seen in the ed of a tertiary care pediatric hospital. for a one year period, % of all visits were randomly selected for review. from these, we reviewed patients who were eligible to be treated with the ap ( ‡ months with previous history of asthma and no other pulmonary condition) and who had received at least one inhaled bronchodilator treatment. charts were evaluated by a data abstractor blinded to the study hypothesis using a standardized datasheet. various variables were evaluated such as age, respiratory rate and saturation at triage, type of physician who saw patient first, treatment prior to visit, in ed, and at discharge, time between arrival and corticosteroid administration, and length of stay (los background: return visits comprise . % of pediatric emergency department (ped) visits, at a cost of >$ million/year nationally. these visits are typically triaged with higher acuity and admission rates and raise concern for lapses in quality of care and patient education during the first visit. objectives: the aim of this qualitative study was to describe parents' reasons for return visits to the ped. methods: we prospectively recruited a convenience sample of parents of patients under the age of years who returned to the ped within hours of their previous visit. we excluded patients who were instructed to return, had previously left without being seen, arrived without a parent, were wards of the state, or did not speak english. after obtaining consent, the principal investigator (ce) conducted confidential, in-person, tape-recorded interviews with parents during ped return visits. parents answered open-ended questions and closed-ended questions using a five-point likert scale. responses to open-ended questions were analyzed using thematic analysis techniques. the scaled responses were grouped into three categories of agree, disagree, or neutral. results: from the closed-ended responses, % of parents agreed that their children were getting sicker, and % agreed that their children were not getting better. % agreed that they were unsure how to treat the illness, however only % agreed they did not feel figure : frequency distribution of number of pca activations comfortable taking care of the illness. only % agreed that the medical condition and/or the instructions were not clearly explained in the first visit. some common themes from the open-ended questions included worsening or lack of improvement of symptoms. many parents reported having unanswered questions about the cause of the illness and hoped to find out the cause during the return visit. conclusion: most parents brought their children back to the ped because they believed the symptoms had worsened or were not improving. although a large proportion of parents believed that the medical condition was clearly explained at the first visit, many parents still had unanswered questions about the cause of their child's illness. while worsening symptoms seemed to drive most return visits, it is possible that some visits related to failure to improve might be prevented during the first ped visit through a more detailed discussion of disease prognosis and expected time to recover. pediatric background: experience indicates that it is difficult to effectively quell many parents' anxiety toward pediatric fevers, making this a common emergency department (ed) complaint. the question remains as to whether athome treatment has any effect on the course of emergency department treatment or length of stay in this population. objectives: to determine whether anti-pyretic treatment prior to arrival in the emergency department affects the evaluation or emergency department length of stay of febrile pediatric patients. methods: a convenience sample of children, ages - years, who presented to a tertiary care ed with chief complaint of fever were enrolled. parents were asked to participate in an eight-question survey. questions related to demographic information, pre-treatment of the fever, contact with primary care providers prior to ed arrival, and immunization status. upon admission or discharge, investigators recorded information regarding length of stay, laboratory tests and imaging ordered, and medications given. results: eighty-one patients were enrolled in the study. seventy-six percent of the patients were pre-treated with some form of anti-pyretic by the caregiver prior to ed arrival. there was no significant effect of pre-treatment on whether laboratory tests or medications were ordered in the ed or whether the patient was admitted or discharged. the length of ed stay was found to be significantly shorter among those who received anti-pyretics prior to arrival ( ± vs. ± minutes; p = . ). conclusion: among febrile children, those who receive anti-pyretics prior to their ed visit had statistically significant shorter length of stays. this also supports implementation of triage or nursing protocols to administer an anti-pyretic as soon as possible in the hope of decreasing ed throughput times. background: during the past two decades, the prevalence of overweight (bmi percentile > ) in children has more than doubled, reaching epidemic proportions both nationally and globally. the public health burden is enormous given the increased risk of adult obesity as well as the adverse consequences on cardiovascular, metabolic, and psychological health. despite the overwhelming prevalence, the effect of obesity on emergency care has received little attention. objectives: the goal of this study is to determine the relation of weight on reported emergency department visits in children from a nationally representative sample. methods: weight (as reported by parents) and height along with frequency of and reason for emergency department (ed) use in the last months were obtained from children aged - y (n = , ) in the cross-sectional, telephone-administered, national survey of children's health (nsch). bmi percentiles were calculated using sex-specific bmi for age growth charts from the cdc ( ). children were categorized as: underweight (bmi percentile£ ), normal weight (> to < ), at-risk for overweight ( to < ), and overweight ( ‡ ). prevalence of ed use was estimated and compared across bmi percentile categories using chisquare analysis and multivariable logistic regression. taylor-series expansion was used for variance estimation of the complex survey design. results: the prevalence of at least one ed use in the past months increased with increasing bmi percentiles (figure , p < . ). additionally, overweight children were more likely to have more than one visit. overweight children were also less likely to report an injury, poisoning, or accident as the reason for ed visit compared to other bmi categories ( , , , % in overweight, at-risk, normal, and underweight respectively, p < . ). conclusion: as rates of childhood obesity continue to grow in the u.s., we can expect greater demands on the ed. this will likely translate into an increased emphasis on the care of chronic conditions rather than injuries and accidents in the pediatric ed setting. results: mean pediatric satisfaction score was . (sd . ) compared with . ( . ) for adult patients (p < . ); monthly sample sizes ranged from - and from - for the two populations, respectively. both populations showed an increase in satisfaction after opening of the ped-ed. for both populations there was no significant trend in patient satisfaction from the beginning of the study period to the opening of the ped-ed, but after the opening the models of the populations differed. the pediatric satisfaction model was an interrupted two-slope model, with an immediate jump of . points in november and an increase of . points per month thereafter. in contrast, adult satisfaction scores did not show a jump but increased linearly (two slope model) after / at a rate of . per month. prior to the opening of the ped-ed, mean monthly pediatric and adult satisfaction scores were . ( . ) and . ( . ), respectively (difference . % ci . - . , p = . ). after the opening the mean scores were . ( . ) and . ( . ), respectively (difference . , % ci . - . , p < . ). conclusion: opening of a dedicated ped-ed was associated with a significant increase in patient satisfaction scores both for children and adults. patient satisfaction for children, as compared to adults, was higher before and after opening a ped-ed. the background: there are racial disparities in outcomes among injured children. in particular, black race appears to be an independent predictor of mortality. objectives: to evaluate disparities among ed visits for unintentional injuries among children ages - . methods: five years of data ( ) ( ) ( ) ( ) ( ) from the national hospital ambulatory cares survey were combined. inclusion criteria were defined as unintentional injury visits (e-code . to . or . to . ) and age - years. visit rates per population (defined by the us census) were calculated by race and age group. weighted multivariate logistic regression analysis was performed to describe associations between race and specific outcome variables and related covariates. primary statistical analyses were performed using sas version . . . results: , , of , , weighted ed visits met our inclusion criteria ( . %). per persons, black children had . times as many ed visits for unintentional injuries as whites (table) . there were no racial differences in the sex ratio ( . boy visits: girl), proportion of visits by age, ed disposition, immediacy with which they needed to be seen, whether or not they were evaluated by an attending physician, metropolitan vs. rural hospital, admission length of stay, mode of transportation for ed arrival, number of procedures, diagnostic services, or ed medications. background: sudden cardiac arrests in schools are infrequent, but emotionally charged events. little data exist that describes aed use in these events. objectives: the purpose of our study was to ) describe characteristics and outcomes of school cardiac arrests (ca), and ) assess the feasibility of conducting bystander interviews to describe the events surrounding school ca. methods: we performed a telephone survey of bystanders to ca occurring in k- schools in communities participating in the cardiac arrest registry to enhance survival (cares) database. the study period was from / - / and continued in one community through . utstein style data and outcomes were collected from the cares database. a structured telephone interview of a bystander or administrative personnel was conducted for each ca. a descriptive summary was used to assess for the presence of an aed, provision of bystander cpr (bcpr), and information regarding aed deployment, training, and use and perceived barriers to aed use. descriptive data are reported. results: during the study period there were , ca identified at cares communities, of which were identified as educational institutions. of these, ( . %) events were at k- schools with ( . %) being high schools. of the arrests, a minority were children ( ( . %) < age ), most ( , . %) were witnessed, a majority ( , . %) received bcpr, and ( . %) were initially in ventricular fibrillation (vf). most arrests / ( %) occurred during the school day ( a- p). overall, ( . %) survived to hospital discharge. interviews were completed for of ( . %) k- events. eighteen schools had an aed on site. most schools ( . %) with aeds reported that they had a training program and personnel identified for its use. an aed was applied in of patients, and of these were in vf and survived to hospital discharge. multiple reasons for aed non-use (n = ) were identified. conclusion: cardiac arrests in schools are rare events; most patients are adults and received bcpr. aed use was infrequent, even when available, but resulted in excellent ( / ) survival. further work is needed to understand aed non-use. post-event interviews are feasible and provide useful information regarding cardiac arrest care. physician background: gastroenteritis is a common childhood disease accounting for - million annual pediatric emergency visits. current literature supports the use of anti-emetics reporting improved oral re-hydration, cessation of vomiting, and reduced need for iv re-hydration. however, there remains concern that using these agents may mask alternative diagnoses. objectives: to assess outcomes associated with use of a discharge action plan using ed-dispensed ondansetron at home in the treatment of gastroenteritis. methods: a prospective, controlled, observational trial of patients presenting to an urban pediatric emergency department (census , ) over a -month period for acute gastroenteritis. fifty patients received ondansetron in the ed. twenty-nine patients were enrolled in the pediatric emergency department discharge action plan (ped-dap) where ondansetron for home use was dispensed by the treating clinician. twenty-one patients were controls. control patients did not receive home ondansetron. ped-dap patients were given instructions to administer the ondansetron for ongoing symptoms any time hours post ed discharge. all patients were followed by phone at - days to assess for the following: time of emesis resolution, alternative diagnoses, unscheduled visits, and adverse events. results: all patients were followed by phone. / ped-dap patients received home ondansetron. / patients had resolution of emesis in the ed. / had resolution of their emesis between time of discharge and hours. / of ped-dap patients reported emesis after hours from ed discharge. five patients reported an unscheduled visit. all five return visits returned to the ed ( / returned for emesis, / for diarrhea). / controls reported resolution of symptoms within the ed. / of controls had resolution between time of discharge and hours. / of the control patients had resolution with between and hours post discharge. / had an unscheduled appointment with the pmd at hours post-discharge for ongoing fever and nausea. in follow-up there were no alternative diagnoses identified. the effect of the ped-dap on resolution of emesis between discharge and hours appears to be statistically significant (p value < . ). conclusion: ondansetron given in schedule with a discharge action plan appears to provide a modest benefit in resolution of symptoms relative to a control population. objectives: to determine the repeatability coefficient of a mm vas in children aged to years in different circumstances: assessments done either at or minute interval, when asked to recall their score or to reproduce it. methods: a prospective cohort study was conducted using a convenience sample of patients aged to years presenting to a pediatric ed. patients were asked to indicate, on a mm paper vas, how much they liked a variety of food with four different sets of three questions: (set ) questions at minute interval with no specific instruction other than how to complete the vas and no access to previous scores, (set ) same format as set except for questions at minute interval, (set ) same as set except patients were asked to remember their answers, and (set ) same as set except patients were shown their previous answers. for each set, the repeatability coefficient of the vas was determined according to the bland-altman method for measuring agreement using repeated measures: . x Ö x s w where s w is the within-subject standard deviation by anova. the sample size required to estimate s w to % of the fraction value as recommended was patients if we obtained three measurements for each patient. results: a total of patients aged . ± . years were enrolled. the repeatability coefficient for the questions asked at minute intervals was mm, and mm when asked at minute interval. when asked to remember their previous answers or to reproduce them, the repeatability coefficient for the questions was mm and mm, respectively. conclusion: the condition of the assessments (variation in intervals or patients asked to remember or to reproduce their previous answers) influence the testretest reliability of the vas. depending on circumstances, the theoretical test-retest reliability in children aged to years varies from to mm on a mm paper vas. background: skull radiographs are a useful tool in the evaluation of pediatric head trauma patients. however, there is no consensus on the ideal number of views that should be obtained as part of a standard skull series in the evaluation of pediatric head trauma patients. objectives: to compare the sensitivity and specificity of a two-and four-film x-ray series in the diagnosis of skull fracture in children, when interpreted by pediatric emergency medicine physicians. methods: a prospective, crossover experimental study was performed in a tertiary care pediatric hospital. the skull radiographs of children were reviewed. these were composed of the most recent cases of skull fracture for which a four-film radiography series was available at the primary setting and controls, matched for age. two modules, containing a random sequence of two-and four-film series of each child, were constructed in order to have all children evaluated twice (once with two films and once with four films). board-certified or -eligible pediatric emergency physicians evaluated both modules two to four weeks apart. the interpretation of the four-film series by a radiologist, or when available, the findings on ct scan, served as the gold standard. accuracy of interpretation was evaluated for each patient. the sensitivity and specificity of the two-film versus the four-film skull xray series, in the identification of fracture, were compared. this was a non-inferiority cross-over study evaluating the null hypothesis that a series with two views would have a sensitivity (specificity) that is inferior by no more than . compared to a series with four views. a total of controls and cases were needed to establish non-inferiority of the two-film series versus the four-film series, with a power of % and a significance level of %. results: ten pediatric emergency physicians participated in the study. for each radiological series, the proportion of accurate interpretation varied between . to . . the four-film series was found to be more sensitive in the detection of skull fracture than a two-film series (difference: . , %ci . to . ). however, there was no difference in the specificity (difference: . , %ci ) . to . ). conclusion: for children sustaining a head trauma, a four-film skull radiography series is more sensitive than a two-film series, when interpreted by pediatric emergency physicians. the objectives: we developed a free online video-based instrument to identify knowledge and clinical reasoning deficits of medical students and residents for pediatric respiratory emergencies. we hypothesized that it would be a feasible and valid method of differentiating educational needs of different levels of learners. methods: this was an observational study of a free, web-based needs assessment instrument that was tested on third and fourth year medical students (ms - ) and pediatric and emergency medicine residents (r - ). the instrument uses youtube video triggers of children in respiratory distress. a series of cased-based questions then prompts learners to distinguish between upper and lower airway obstruction, classify disease severity, and manage uncomplicated croup and bronchiolitis. face validity of the instrument was established by piloting and revision among a group of experienced educators and small groups of targeted learners. final scores were compared across groups using t-tests to determine the ability of the instrument to differentiate between different levels of learners (concurrent validity). cronbach's alpha was calculated as a measure of internal consistency. results: response rates were % among medical students and % among residents. the instrument was able to differentiate between junior (ms , ms , and r ) and senior (r , r ) learners for both overall mean score ( % vs. %, p < . ) and mean video portion score ( vs. %, p = . ). table compares results of several management questions between junior and senior learners. cronbach's alpha for the test questions was . . conclusion: this free online video-based needs assessment instrument is feasible to implement and able to identify knowledge gaps in trainees' recognition and management of pediatric respiratory emergencies. it demonstrates a significant performance difference between the junior and senior learners, preliminary evidence of concurrent validity, and identifies target groups of trainees for educational interventions. future revisions will aim to improve internal consistency. results: the survey response rate was % ( / ). among responding programs, ( %) reside within a children's hospital (vs. general ed); ( %) are designated level i pediatric trauma centers. forty-three ( %) programs accept - pem fellows per year; ( %) provided at least some eus training to fellows, and ( %) offer a formal eus rotation. on average this training has existed for ± years and the mean duration of eus rotations is ± weeks. twenty-eight ( %) programs with eus rotations provide fellow training in both a general ed and a pediatric ed. there were no hospital or program level factors associated with having a structured training program for pem fellows. conclusion: as of , the majority of pem fellowship programs provide eus training to their fellows, with a structured rotation being offered by most of these programs. background: ed visits are an opportunity for clinicians to identify children with poor asthma control and intervene. children with asthma who use eds are more likely than other children to have poor control, not be using controller medications, and have less access to traditional sources of primary care. one significant barrier to ed-based interventions is recognizing which children have uncontrolled asthma. objectives: to determine whether the pacci, a item parent-administered questionnaire, can help ed clinicians better recognize patients with the most uncontrolled asthma and differentiate between intermittent and persistent asthma. methods: this was a randomized controlled trial performed at an urban pediatric ed. parents were asked to answer questions about their child's asthma including drug adherence and history of exacerbations, as well as answer demographic questions. using a convenience sample of children - years presenting with an asthma exacerbation, attending physicians in the study were asked to complete an assessment of asthma control. physicians were randomized to receive a completed pacci (intervention) or not (control group). using an intent-to-treat approach, clinicians' ability to accurately identify ) four categories of control used by the national heart, lung, and blood institute (nhlbi) asthma guidelines, ) intermittent vs. persistent level asthma, and ) controlled / mildly uncontrolled vs. moderate/severely uncontrolled asthma were compared for both groups using chi-square analysis. results: between january and august , patients were enrolled. there were no statistically significant differences between the intervention and control groups for child's sex, age, race and parents' education. conclusion: the pacci improves ed clinicians' ability to categorize children's asthma control according to nhlbi guidelines, and the ability to determine when a child's control has been worsening. ed clinicians may use the pacci to identify those children in greatest need for intervention, to guide prescription of controller medications, and communicate with primary care providers about those children failing to meet the goals of asthma therapy. figure) . fewer than half of physicians reported the parent of a -year-old being discharged from their ed following an mvc-related visit would receive either child passenger safety information or referrals (table) . conclusion: emergency physician report of child passenger safety resource availability is associated with trauma center designation. even when resources are available, referrals from the ed are infrequent. efforts to increase referrals to community child passenger safety resources must extend to the community ed settings where the majority of children receive injury care. background: pediatric subspecialists are often difficult to access following ed care especially for patients living far from providers. telemedicine (tm) can potentially eliminate barriers to access related to distance, and cost. objectives: to evaluate the overall resource savings and access that a tm program brings to patients and families. methods: this study took place at a large, tertiary care regional pediatric health care system. data were collected from / - / . metrics included travel distance saved (round trip between tm presenting sites and the location of the receiving sites), time savings, direct cost savings (based on $ . /mile) and potential work and school days saved. indirect costs were calculated as travel hrs saved/encounter (based on an average speed of miles/hr). demographics and services provided were included. results: tm consults were completed by separate pediatric subspecialty services. most patients were school aged ( % >/= yrs old objectives: to analyze test characteristics of the pathway and its effects on ed length of stay, imaging rates, and admission rate before versus after implementation. methods: children ages - presenting to one academic pediatric ed with suspicion for appendicitis from october -august were prospectively enrolled to a pathway using previously validated lowand high-risk scoring systems. the attending physician recorded his or her suspicion of appendicitis and then used one of two scoring systems incorporating history, physical exam, and cbc. low-risk patients were to be discharged or observed in the ed. high-risk patients were to be admitted to pediatric surgery. those meeting neither low-nor high-risk criteria were evaluated in the ed by pediatric surgery, with imaging at their discretion. chart review and telephone follow-up were conducted two weeks after the visit. charts of a random sample of patients with diagnoses of acute appendicitis or chief complaint of abdominal pain and undergoing a workup for appendicitis in the eight months before and after institution of the pathway were retrospectively reviewed by one or two trained abstractors. results: appendicitis was diagnosed in of patients prospectively enrolled to the pathway ( %). mean age was . years. of those with appendicitis, were not low-risk (sensitivity . %, specificity . %). the high-risk criteria had a sensitivity of . % and specificity of . %. a priori attending physician assessment of low risk had a sensitivity of % and specificity of . %. a priori assessment of high risk had a sensitivity of . % and specificity of . %. we reviewed visits prior to the pathway and after. mean ed length of stay was similar ( minutes before versus after). ct was used in . % of visits before and . % after (p = . ). use of ultrasound increased ( . % before versus . % after, p < . ). admission rates were not significantly different ( . % before versus . % after, p = . ). conclusion: the low-risk criteria had good sensitivity in ruling out appendicitis and can be used to guide physician judgment. institution of this pathway was not associated with significant changes in length of stay, utilization of ct, or admission rate in an academic pediatric ed. computer-delivered alcohol and driver safety behavior screening and intervention program initiated during an emergency department visit mary k. murphy , lucia l. smith , anton palma , david w. lounsbury , polly e. bijur , paul chambers yale university, new haven, ct; albert einstein college of medicine, bronx, ny background: alcohol use is involved in percent of all fatal motor vehicle crashes and recent estimates show that at least , people were injured due to distracted driving last year. patients who visit the emergency department (ed) are not routinely screened for driver safety behavior; however, large numbers of patients are treated in the ed every day creating an opportunity for screening and intervention on important public health behaviors. objectives: to evaluate patient acceptance and response to a computer-based traffic safety educational intervention during an ed visit and one month follow-up. methods: design. pre /post educational intervention. setting. large urban academic ed serving over , patients annually. participants. medically stable adult ed patients. intervention. patients completed a self-administered, computer-based program that queried patients on alcohol use and risky driving behaviors (texting, talking, and other forms of distracted driving). the computer provided patients with educational information on the dangers of these behaviors and collected data on patient satisfaction with the program. staff called patients one month post ed visit for a repeat query. results: patients participated; average age ( - ), % hispanic, % male. % of patients reported the program was easy to use and were comfortable receiving this education via computer during their ed visit. self-reported driver safety behaviors pre, post intervention (% change): driving while talking on the phone %, % () %, p = . ), aggressive driving %, % () %, p = . ), texting while driving %, % () %, p = . ), driving while drowsy %, % () %, p = . ), drinking in excess of nih safe drinking guidelines %,% () %, p = . ), drinking and driving %, % () %, p = . ). conclusion: we found a high prevalence of selfreported risky driving behaviors in our ed population. at month follow-up, patients reported a significant decrease in these behaviors. overall patients were very satisfied receiving educational information about these behaviors via computer during their ed visit. this study indicates that a low-intensity, computer-based educational intervention during an ed visit may be a useful approach to educate patients about safe driving behaviors and promote behavior change. prevalence of depression among emergency department visitors with chronic illness janice c. blanchard, benjamin l. bregman, jeffrey smith, mohammad salimian, qasem al jabr george washington university, washington, dc background: persons with chronic illnesses have been shown to have higher rates of depression than the general population. the effect of depression on frequent emergency department (ed) use among this population has not been studied. objectives: this study evaluated the prevalence of major depressive disorder (mdd) among persons presenting with depression to the george washington university ed. we hypothesized that patients with chronic illnesses would be more likely to have mdd than those without. methods: this was a single center, prospective, crosssectional study. we used a convenience sample of noncritically ill, english-speaking adult patients presenting with non-psychiatric complaints to an urban academic ed over months in . subjects were screened with the phq , a nine-item questionnaire that is a validated, reliable predictor of mdd. we also queried respondents about demographic characteristics as well as the presence of at least one chronic disease (heart disease, hypertension, asthma, diabetes, hiv, cancer, kidney disease, or cerebrovascular disease). we evaluated the association between mdd and chronic illnesses with both bivariate analysis and multivariate logistic regression controlling for demographic characteristics (age, race, sex, income, and insurance coverage). results: our response rate was . % with a final sample size of . of our total sample, ( . %) had at least one of the chronic illnesses defined above. of this group, ( . %) screened positive for mdd as compared to ( . %) of the group without chronic illnesses (p < . ). in multivariate analysis, persons with chronic illnesses had an odds ratio for a positive depression screen of . ( . , . ) as compared to persons without illness. among the subset of persons with chronic illnesses (n = ), . % had ‡ visits in the prior days as compared to . % of persons with chronic illnesses without mdd (p = . ). conclusion: our study found a high prevalence of untreated mdd among persons with chronic illnesses who present to the ed. depression is associated with more frequent emergency department use among this population. initial blood alcohol level aids ciwa in predicting admission for alcohol withdrawal craig hullett, douglas rappaport, mary teeple, daniel butler, arthur sanders university of arizona, tucson, az background: assessment of alcohol withdrawal symptoms is difficult in the emergency department. the clinical institute withdrawal assessment (ciwa) is commonly used, but other factors may also be important predictors of withdrawal symptom severity. objectives: the purpose of this study is to determine whether ciwa score at presentation to triage was predictive of later admission to the hospital. methods: a retrospective study of patients presenting to an acute alcohol and drug detoxification hospital was performed from july through january . patients were excluded if other drug withdrawal was present in addition to alcohol. initial assessment included age, sex, vital signs, and blood alcohol level (bal) in addition to hourly ciwa score. admission is indicated for a ciwa score of or higher. data were analyzed by selecting all patients not immediately admitted at initial presentation. logistic regression using wald's criteria for stepwise inclusion was used to determine the utility of the initially gathered ciwa, bal, longest sobriety, liver cirrhosis, and vital signs in predicting subsequent admission. results: there were patients who fit the inclusion criteria, with admitted for treatment at initial intake and another admitted during the following hours. logistic regression indicated that presenting bal was a strong predictor (p = . ) of admission for treatment after initial presentation, as was presenting ciwa (p = . ). thus, presenting bal provided a substantial addition above initial ciwa in predicting later admission. no other variables added significantly to the prediction of later admission. to determine the interaction between presenting bal and ciwa scores, we ran a repeated measures analysis of the first five ciwa scores (from presentation to hours later), using bal split into low (bal < . ) and high (bal > . ) groups (see figure) . their interaction was significant, f ( , ) = . , p < . , g = . . those presenting with higher initial bal had suppressed ciwa scores that rose precipitously as the alcohol cleared. those with low presenting bal showed a decline in ciwa over time conclusion: initial assessment using the common assessment tool ciwa is aided significantly by bal assessment. patients with higher presenting bal are at higher risk for progression to serious alcohol withdrawal symptom. objectives: to describe patient and visitor characteristics and perspectives on the role of visitors in the ed and determine the effect of visitors on ed and hospital outcome measures. methods: this cross-sectional study was done in an , -visit urban ed, and data were attempted to be collected from all patients over a consecutive -hour period from august to , . trained data collectors were assigned to the ed continuously for the study period. patients assigned to a rapid care section of the ed ( %) were excluded. a visitor was defined as a person other than a health care provider (hcp) or hospital staff present in a patient's room at any time. patient perspectives on visitors were assessed in the following domains: transportation, emotional support, physical care, communication, and advocating for the patient. ed and hospital outcome measures pertaining to ed length of stay (los) and charges, hospital admission rate, hospital los and charges were obtained from patient medical records and hospital billing. data analyses included frequencies, student's t-tests for continuous variables, and chi-square tests of association for categorical variables. all tests for significance were two-sided. objectives: to examine the effect of sunday alcohol availability on ethanol-related visits and alcohol withdrawal visits to the ed. methods: study design was a retrospective beforeafter study using electronically archived hospital data at an urban, safety net hospital. all adult non-prisoner ed visits from / / to / / were analyzed. an ethanol-related ed visit was defined by icd- codes related to alcohol ( .x, .x, . , . ). an alcohol withdrawal visit was defined by icd- codes of delirium tremens ( . ), alcohol psychosis with hallucination ( . ), and ethanol withdrawal ( . ). we generated a ratio of ethanol-related ed visits to total ed visits (ethanol/total) and ratio of alcohol withdrawal ed visits to total ed visits (withdrawal/total). a day was redefined as am to am. the ratios were averaged within the four seasons to account for seasonal variations. data from summer were dropped as it spanned the law change. we stratified data into sunday and non-sunday days prior to analysis to isolate the effects of the law change. we used multivariable linear regression to estimate the association of the ratio with the law change while adjusting for time and the seasons. each ratio was modeled separately. the interaction between time and the law change was assessed using p < . . results: during the study there were a total of , ed visits including , ( % of total) ethanol-related visits and , ( % of total) alcohol withdrawal visits. unadjusted ratios in seasonal blocks are plotted in the figure with associated % ci and best fit regression line for before and after law change, respectively. after adjusting for time and season in the multivariable linear regression, we found no significant association of either ethanol/total or withdrawal/total with the law change. this remained true for both sunday and non-sunday data. all interactions assessed were not significant. conclusion: the change in colorado law to allow the sale of full-strength alcoholic beverages on sundays did not significantly affect ethanol-related or alcohol withdrawal ed visits. background: olanzapine is a second-generation antipsychotic (sga) with actions at the serotonin/histamine receptors. post-marketing reports and a case report have documented dangerous lowering of blood pressure when this antipsychotic is paired with benzodiazepines, but a recent small study found no bigger decreases in blood pressure compared to another antipsychotic like haloperidol. decreases in oxygen saturations, however, were larger when olanzapine was combined with benzodiazepines in alcohol-intoxicated patients. it is unclear whether these vital sign changes are associated with the intramuscular (im) route only. objectives: the assessment of vital signs following administration of either oral (po) or im olanzapine, either with or without benzodiazepines (benzos) and with or without concurrent alcohol intoxication. methods: this is a structured retrospective chart review of all patients who received olanzapine in an academic medical center ed from - who had vital signs documented both before medication administration and within four hours afterwards. vital signs were calculated as pre-dose minus lowest post-dose vital sign within hours, and were analyzed in an anova with route (im/po), benzo use (+/)), and alcohol use (+/)) as factors. significance level was set to < . . results: there were patients who received olanzapine over the study period. a total of patients ( po, im) met inclusion criteria. systolic blood pressures decreased across all groups as patients reduced their agitation. neither the route of administration, concurrent use of benzos, nor the use of alcohol were associated with significant changes in systolic bp (p = ns for all comparisons; see figure ). decreases in oxygen saturations, however, were significantly larger for alcoholintoxicated patients who subsequently received im olanzapine + benzos compared to other groups (route: p < . ; alcohol: p < . ; route x alcohol: p < . ; route x benzos x alcohol: p < . ; see figure ). conclusion: alcohol and benzos are not associated with significant decreases in blood pressure after po olanzapine, but im olanzapine + benzos is associated with potentially significant oxygen desaturations in patients who are intoxicated. intoxicated patients may have differential effects with the use of im sgas such as olanzapine when combined with benzos, and should be studied separately in drug trials. patients with a psychiatric diagnosis rasha buhumaid, jessica riley, janice blanchard george washington university, washington, dc background: literature suggests that frequent emergency department (ed) use is common among persons with a mental health diagnosis. few studies have documented risk factors associated with increased utilization among this population. objectives: to understand demographic characteristics of frequent users of the emergency department and describe characteristics associated with their visits. it was hypothesized that frequent visitors would have a higher rate of medical comorbidities than infrequent visitors. methods: this was a retrospective study of patients presenting to an urban, academic emergency department in . a cohort of all patients with a mental health-related final icd- coded diagnosis (axis i or axis ii) was extracted from the electronic medical record. using a standard abstraction form, a medical chart review collected information about medical comorbidities, substance abuse, race, age, sex, and insurance coverage, as well as diagnosis, disposition, and time of each visit. results: our sample consisted of frequent users ( ‡ visits in a day period) and infrequent users (£ visits in a day period). frequent users were more likely to be male ( % vs. . % p = . ), black ( % vs. % p < . ), and had a higher average number of comorbid conditions ( . , %ci . , . ) as compared to infrequent users ( . , %ci . , . ). a higher percentage of visits in the infrequent user group occurred during the day ( % vs. . % p < . ) while a higher number of visits in the frequent users occurred after midnight ( . % vs. . % p = . ). visits in the frequent user group were less likely to be for a psychiatric complaint ( . % vs. . %) and less likely to result in a psychiatric admission ( . % versus . %) as compared to the infrequent user group (p < . ). conclusion: our data indicate that among patients with psychiatric diagnoses, those who make frequent ed visits have a higher rate of comorbid conditions than infrequent visitors. despite their increased use of the ed, frequent visitors have a significantly lower psychiatric admission rate. many of the visits by frequent users are for non-psychiatric complaints and may reflect poor access to outpatient medical and mental health services. emergency departments should consider interventions to help address social and medical issues among mental health patients who frequently use ed services. background: the world health organization estimates that one million people die annually by suicide. in the u.s., suicide is the fourth leading cause of death between the ages of and . many of these patients are seen in ed, while outpatient visits for depression are also high. no recent analysis has compared these groups in the recent years. objectives: to determine if there is a relationship between the incidence of suicidal and depressed patients presenting to emergency departments and the incidence of depressed patients presenting to outpatient clinics from - . the secondary objective is to analyze trends in suicidal patients in the ed. methods: we used nhamcs (national hospital ambulatory medical care survey) and namcs (national ambulatory medical care survey), national surveys completed by the centers for disease control, which provide a sampling of emergency department and outpatient visits respectively. for both groups, we used mental-health-related icd- -cm, e codes and reasons for visit. we compared suicidal and depressed patients who presented to the ed, to those who presented to outpatient clinics. our subgroup analyses included age, sex, race/ethnicity, method of payment, regional variation, and urban verses rural distribution. results: ed visits for depression ( . %) and suicide attempts ( . %) remained stable over the years, with no significant linear trend. however, office visits for depression significantly decreased from . % of visits in to . % of visits in . non-latino whites had a higher percentage of ed visits for depression ( . %) and suicide attempt ( . %) (p < . ), and a higher percentage of office visits for depression than all other groups. among patients age - years, ed visits for suicide attempt significantly increased from . % in to . % in . homeless patients had a higher percent of ed visits for depression ( . %) and suicide attempt ( background: for potentially high-risk ed patients with psychiatric complaints, efficient ed throughput is key to delivering high-quality care and minimizing time spent in an unsecured waiting room. objectives: we hypothesized that adding a physician in triage would improve ed throughput for psychiatric patients. we evaluated the relationship between the presence of an ed triage physician and waiting room (wr) time, time to first physician order, time to ed bed assignment, and time spent in an ed bed. methods: the study was conducted from / - / at an academic ed with annual visits and a dedicated on-site emergency psychiatric unit. we performed a pre/post retrospective observational cohort study using administrative data, including weekend visits from noon- pm, months pre and post addition of weekend triage physicians. after adjusting for patient age, sex, insurance status, emergency severity index score, mode of arrival, ed occupancy rate, wr count, boarding count, and average wr los, multiple linear regression evaluated the relationship between the presence of a triage physician and four ed throughput outcomes: time spent in the wr, time to first order, time spent in an ed bed, and the total ed los. results: visits met inclusion criteria, in the months before and in the months after physicians were assigned to triage on weekends. table reports demographic data; multivariate analysis results are found in table . the presence of a triage physician was associated with an ( % ci . - . ) minute increase in wr time and no associated change in time to first order, time spent in an ed bed, or in the overall ed los. conclusion: use of triage physicians has been reported to decrease the time patients spend in an ed bed and improve ed throughput. however, for patients with psychiatric complaints, our analysis revealed a slight increase in wr time without evident change in the time to first order, time spent in an ed bed, or total ed los. improvements in ed throughput for psychiatric patients will likely require system-level changes, such as reducing ed boarding and improving lab efficiency to speed the process of medical clearance and reduce time spent in the unsecured wr. these findings may not be generalizable to eds without a dedicated ed psychiatric unit with full-time social workers to assist with disposition. initial assessment included ciwa scoring, repeated hourly, as well as other variables (see table ). treatment and admission to the inpatient hospital was indicated for a ciwa score of or higher. statistical analysis was performed utilizing repeated measures general linear modeling for ciwa scores and anova for all other variables. results: there were patients who fit the inclusion criteria, with admitted for treatment at initial intake and another admitted during the following hours. the table below compares the three most prevalent ethnic populations seen at our hospital. native americans presented at a significantly younger age (p < . ) than the other two ethnicities. initial ciwa scores taken on admission were significantly lower in the native american group than the other two groups (p < . ) and at hour a difference existed but failed to reach significance. repeated measures analysis indicate that ciwa scores progressed in a u-shaped curvilinear fashion (see figure ) conclusion: initial assessment utilizing ciwa scores appears to be affected by ethnicity. care must be taken when assessing and making decisions on a single initial ciwa score. further research is needed in this area as our numbers are small and differences might be seen in subsequent scoring. in addition, our study consists of primarily male patients and does not include african-american patients. background: age is a risk factor for adverse outcomes in trauma, yet evidence supporting the use of specific age cut-points to identify seriously injured patients for field triage is limited. objectives: to evaluate under-triage by age, empirically examine the association between age and serious injury for field triage, and assess the potential effect of mandatory age criteria. methods: this was a retrospective cohort study of injured children and adults transported by ems agencies to hospitals in regions of the western u.s. from - . hospital records were probabilistically linked to ems records using trauma registries, emergency department data, and state discharge databases. serious injury was defined as an injury severity score (iss) ‡ (the primary outcome). we assessed under-triage (triage-negative patients with iss ‡ ) by age decile, different mandatory age criteria, and used multivariable logistic regression models to test the association (linear and non-linear) between age and iss ‡ , adjusted for important confounders. results: , injured patients were evaluated and transported by ems over the -year period. under-triage increased markedly for patients over years, reaching % for those over years ( figure ). mandatory age triage criteria decreased under-triage, while substantially increasing over-triage: one iss ‡ patient identified for every additional patients triaged to major trauma centers. among patients not identified by other criteria, age had a strong non-linear association with iss ‡ (p < . ); the probability of serious injury steadily increased after years, becoming more notable after years ( figure ). conclusion: under-triage in trauma increases in patients over years, which may be reduced with mandatory age criteria at the expense of system efficiency. among patients not identified by other criteria, serious injury steadily increased after years, though there was no age at which risk abruptly increased. background: although limited resuscitation with hemoglobin-based oxygen carriers (hbocs) improves survival in several polytrauma models, including those of traumatic brain injury (tbi) with uncontrolled hemorrhage (uh) via liver injury, their use remains controversial. objectives: we examine the effect of hboc resuscitation in a swine polytrauma model with uh by aortic tear +/) tbi. we hypothesize that limited resuscitation with hboc would offer no survival benefit and would have similar effects in a model of uh via aortic tear +/) tbi. methods: anesthetized swine subjected to uh inflicted via aortic tear +/) fluid percussion tbi underwent equivalent limited resuscitation with hboc, lr, or hboc+nitroglycerin (ntg) (vasoattenuated hboc) and were observed for hours. comparisons were between tbi and no-tbi groups with adjustment for resuscitation fluid type using two-way anova with interaction and tukey kramer adjustment for individual comparisons. results: there was no independent effect of tbi on survival time after adjustment for fluid type (anova, tbi term p = . ) and there was no interaction between tbi and resuscitation fluid type (anova interaction term p = . ). there was a significant independent effect of fluid type on survival time (anova p = . background: intracranial hemorrhage (ich) after a head trauma is a problem frequently encountered in the ed. an elevated inr is recognized as a risk of bleeding. however, in a patient with an inr in normal range, a level associated with a lower risk of ich is not known. objectives: the aim of this study was to identify an inr threshold that could predict a decreased risk of an ich after a head trauma in patients with a normal inr. it is hypothesized that there is a threshold at which the likelihood of bleeding decreases significantly. methods: we did a study using data from a registry of patients with mild to severe head trauma (n = ) evaluated in a level i trauma center in canada between march and february . all the patients with a documented scan interpreted by a radiologist and a normal inr, defined as a value less then . , were included. we determined the correlation between inr value binned by . and the proportion of patients with an ich. threshold was defined by consensus as an abrupt change of more than % in the percentage of patients with ich. univariate frequency distribution was tested with pearson's chisquare test. logistic regression analysis was then used to study the effects of inr on ich with the following confounding factors: age, sex, and intake of warfarin, clopidogrel, or aspirin. results are presented with % confidence intervals. results: patients met the inclusion criteria. the mean age was . years ± . and % were men. patients ( . %) had an ich on brain scan. we found a significantly lower risk of ich at a threshold of inr less than . (p < . , univariate or = . , %ci . - . ) and a strong correlation between the risk of bleeding for every increase of the inr (r = . ). in fact, after adjustment for confounding variables, every . inr increase was associated with an increased risk of having an ich (or . ; % ci . - . ). conclusion: we were able to demonstrate an inr threshold under which the probability of ich was significantly lower. we also found a strong association between the risk of bleeding and the increase in inr within a normal range, suggesting that clinicians should not be falsely reassured by a normal inr. our results are limited by the fact that this is a retrospective study and a small proportion of traumatic brain injured patients in our database had no scan or inr at their ed visit. a prospective cohort study would be needed to confirm our results. background: increasingly, patients with tbi are being seen and managed in the emergency neurology setting. knowing which early signs are associated with prognosis can be helpful in directing the acute management. objectives: to determine whether any factors early in the course of head trauma are associated with shortterm outcomes including inpatient admission, in-hospital mortality, and return to the hospital within days. methods: this irb-approved study is a retrospective review of patients head injury presenting to our tertiary care academic medical center during a -month period. the dataset was created using redcap, a data management solution hosted by our medical school's center for translational science institute. results: the median age of the cohort (n = ) was , iqr = - yrs, with % being male. % had a gcs of - (mild tbi), % - (moderate tbi), and % gcs < (severe tbi). % of patients were admitted to the hospital. the median length of hospital stay was days, with an iqr of - days. of those admitted, % had an icu stay as well. the median icu los was also days, with an iqr of - days. twenty nine ( %) patients died during their hospital stay. lower gcs was predictive of inpatient admission (p = . ) as well as icu days (p < . ). significant predictors of re-admission to the hospital within days included hypotension (p = . ) upon initial presentation. the prehospital and ed gcs scores were not statistically significant. significant predictors of in-hospital death in a model controlling for age included bradycardia (p = . ), hyperglycemia (p = . ), and lower gcs (p = . ). the incidence of bradycardia (hr < ) was . %. conclusion: early hypotension, hyperglycemia, and bradycardia along with lower initial gcs are associated with significantly higher likelihood of hospital admission, including icu admission, as well as intrahospital death and re-admission. background: over , people per day require treatment for ankle sprains, resulting in lost workdays and training for athletes. platelet rich plasma (prp) is an autologous concentration of platelets which, when injected into the site of injury, is thought to improve healing by promoting inflammation through growth factor and cytokine release. studies to date have shown mixed results, with few randomized or placebo-controlled trials. the lower extremity functional scale (lefs) is a previously validated objective measure of lower extremity function. objectives: is prp helpful in acute ankle sprains in the the emergency department? methods: prospective, randomized, double-blinded, placebo-controlled trial. patients with severe ankle sprains and negative x-rays were randomized to trial or placebo. severe was defined as marked swelling and ecchymosis and inability to bear weight. both groups had cc of blood drawn. trial group blood was centrifuged with a magellan autologous platelet separator (arteriocyte, cleveland) to yield - cc of prp. prp along with . cc of % lidocaine and . cc of . % bupivicaine was injected at the point of maximum tenderness by a blinded physician under ultrasound guidance. control group blood was discarded and participants were injected in a similar fashion substituting sterile . % saline for prp. both groups had visual analog scale (vas) pain scores and lefs on days , , , and . all participants had a posterior splint and were made non weight bearing for days after which they were reexamined, had their splint removed, and were asked to bear weight as tolerated. participants were instructed not to use nsaids during the trial. results: patients were screened and were enrolled. four withdrew before prp injection was complete. eighteen were randomized to prp and to placebo. see tables for results. vas and lefs are presented as means with sd in parentheses. demographics were not statistically different between groups. conclusion: in this small study, prp did not appear to offer benefit in either pain control or healing. both groups had improvement in their pain and functionality and did not differ significantly during the study period. limitations include small study size and large number of participant refusals. methods: a structured chart review of all icd- radius fracture coded charts spanning march , to july , was conducted. specific variable data were collected and categorized as follows: age, moi, body mass index, and fracture location. the charts were reviewed by two medical students, with % of the charts reviewed by both students to confirm inter-rater reliability. frequencies and inter-quartile ranges were determined. comparisons were made with fisher's exact test and multiple logistic regression. results: charts met inclusion criteria. charts were excluded due to one of the following reasons: no fracture or no x-ray ( ), isolated ulnar fracture ( ), or undocumented or penetrating moi ( ). of the analyzed patients (n = ), distal radius fractures were most common ( %), followed by proximal ( %) and midshaft ( %). chart reviewers were found to be reliable (j = ). age and moi were significantly associated with fracture location (see table) . ages - and bike accidents were more strongly associated with proximal radius fractures (odds ratio: [ - ] and [ - ], respectively). conclusion: patients presenting to our inner city ed with a radius fracture are more likely to have a distal fracture. adults - and bike accidents had a significantly higher incidence of proximal fractures than other ages or mois. background: trauma centers use guidelines to determine the need for a trauma surgeon in the ed on patient arrival. a decision rule from loma linda university that includes penetrating injury and tachycardia was developed to predict which pediatric trauma patients require emergent intervention, and thus are most likely to benefit from surgical presence in the ed. objectives: our goal was to validate the loma linda rule (llr) in a heterogeneous pediatric trauma population and to compare it to the american college of surgeons' major resuscitation criteria (mrc). we hypothesized that the llr would be more sensitive than the mrc for identifying the need for emergent operative or procedural intervention. methods: we performed a secondary analysis of prospectively collected trauma registry data from two urban level i pediatric trauma centers with a combined annual census of approximately , visits. consecutive patients < years old with blunt or penetrating trauma from through were included. patient demographics, injury severity scores (iss), times of ed arrival and surgical intervention, and all variables of both rules were obtained. the outcome (emergent operative intervention within hour of ed arrival or ed cricothyroidotomy or thoracotomy) was confirmed by trained, blinded abstractors. sensitivities, specificities, and % confidence intervals (cis) were calculated for both rules. results: , patients were included with a median age of . years and a median iss of . emergent intervention was required in patients ( . %). the llr had a sensitivity ranging from . %- . % ( % ci: . %- . %) and specificity ranging from . %- . % ( % ci: . %- . %) between both institutions. the mrc had a sensitivity ranging from . %- . % ( % ci: . %- . %) and specificity ranging from . %- . % ( % ci: . %- . %) between institutions. conclusion: emergent intervention is rare in pediatric trauma patients. the mrc was more sensitive for predicting the need for emergent intervention than the llr. neither set of criteria was sufficiently accurate to recommend their routine use for pediatric trauma patients. droperidol for sedation of acute behavioural disturbance leonie a. calver , colin page , michael downes , betty chan , geoffrey k. isbister calvary mater newcastle and university of newcastle, newcastle, australia; princess alexandra hospital, brisbane, australia; calvary mater newcastle, newcastle, australia; prince of wales hospital, sydney, australia background: acute behavioural disturbance (abd) is a common occurrence in the emergency department (ed) and is a risk to staff and patients. there remains little consensus on the most effective drug for sedation of violent and aggressive patients. prior to the food and drug administration's black box warning, droperidol was commonly used and was considered safe and effective. objectives: this study aimed to investigate the effectiveness of parenteral droperidol for sedation of abd. methods: as part of a prospective observational study, a standardised protocol using droperidol for the seda-acute and delayed behavioral deficits were demonstrated in this rat model of co toxicity, which parallels the neurocognitive deficit pattern observed in humans (see figure) . similar to prior studies, pathologic analysis of brain tissue demonstrated the highest percentage of necrotic cells in the cortex, pyramidal cells, and cerebellum. the collected data are summarized in the table. we have developed an animal model of severe co toxicity evidenced by behavioral deficits and neuronal necrosis. future efforts will compare neurologic outcomes in severely co poisoned rats treated with hypothermia and % inspired o versus hbo to normothermic controls treated with % inspired o . increasing in popularity, attracting more than , annual participants worldwide. prior studies have consistently documented renal function impairment, but only after race completion. the incidence of renal injury during these multi-day ultramarathons is currently unknown. this is the first prospective cohort study to evaluate the incidence of acute kidney injury (aki) in runners during a multi-day ultramarathon foot race. objectives: to assess the effect of inter-stage recovery versus cumulative damage on resulting renal function during a multi-day ultramarathon. methods: demographic and biochemical data gathered via phlebotomy and analyzed by istatÒ (abbott, nj) were collected at the start and finish of day ( miles), ( miles), and ( miles) during racing the planet'sÒ -mile, -day self-supported desert ultramarathons. pre-established rifle criteria using creatinine (cr) and glomerular filtration rate (gfr) defined aki as ''no injury'' (cr < . x normal, decrease of gfr < %), ''risk'' (cr . x normal, decrease of gfr by - %), and ''injury'' (cr x normal, decrease of gfr by - %). results: thirty racers ( % male) with a mean (+/) sd) age of + /- years were studied during the sahara (n = , . %), gobi (n = , %), and namibia (n = , . %) events. the average decrease in gfr from day start to day finish was + /- (p < . , % ci . - . ); day start to day finish was . + /- . (p < . , % ci . - . ); and day start to day finish was . ± . (p < . , % ci . - ). runners categorized as risk and injury for aki after stage was . % and %; after stage was % and %, and after stage was . % and . % conclusion: the majority of participants developed significant levels of renal impairment despite recovery intervals. given the changes in renal function, potentially harmful non-steroidal anti-inflammatory drugs should be minimized to prevent exacerbating acute kidney injury. background: more than % of the elderly abuse prescription drugs, and emergency medicine providers frequently struggle to identify features of opioid addiction in this population. the prescription drug use questionnaire (pduqp) is a validated, -item, patient-administered tool developed to help health care providers better identify problematic opioid use, or dependence, in patients who receive opioids for the treatment of chronic pain. objectives: to identify the prevalence of prescription drug misuse features in elderly ed patients. methods: this cross-sectional, observational study was conducted between / and / in the ed of an urban, university-affiliated community hospi-tal that serves a large geriatric population. all patients aged to inclusive were eligible, and were recruited on a convenience basis. exclusion criteria included known dementia, and critical illness. outcomes of interest included self-reported history of prior prescription opioid use, substance abuse history, aberrant medication-taking behaviors, and pduqp results. results: one hundred patients were approached for participation. two were excluded for inability to read english, three were receiving analgesia for metastatic cancer, had never taken a prescription opioid, and seven refused to participate beyond pre-screening. sixty patients completed the study (see table ). of those, . % reported four or more visits within months; chronic pain was reported by . %; debilitating pain by . %; prior pain management referral by . %; and storing opioids for future use by %. seventeen patients reported current prescription opioid use, and were administered the pduqp (see figure) . in this population, . % thought their pain was not adequately being treated; . % reported having to increase the amount of pain medication they were taking over the prior months; . % saved up future pain medication; . % had doctors refuse to give them pain medication for fear that the patient would abuse the prescription opioids; and . % reported having a previous drug or alcohol problem. conclusion: screening instruments, such as the pduqp, facilitate identification of geriatric patients with features of opioid misuse. a high proportion of patients in this study save opioids for further use. interventions for safe medication disposal may decrease access to opioids and subsequent morbidity. age extremes, male sex, and several chronic health conditions were associated with increased odds of heat stroke, hospital admission, and death in the ed by a factor of - . chronic hematologic disease (e.g. anemia) was associated with a - fold increase in adjusted odds of each of these outcomes. conclusion: hri imposes a substantial public health burden, and a wider range of chronic conditions confer susceptibility than previously thought. males, older adults, and patients with chronic conditions, particularly anemia, are likely to have more severe hri, be admitted, or die in the ed. background: carbon monoxide (co) poisoning is a remarkable cause of death worldwide. co, produced by the incomplete combustion of hydrocarbons, has many toxic effects on especially the heart and brain. co binds strongly to cytochrome oxidase, hemoglobin, and myoglobin causing hypoxia of organs and issues. co converts hemoglobin to carboxyhemoglobin and makes transport of oxygen through the body impossible and causes severe hypoxia. objectives: the aim of this study is to investigate the levels of s b and neuron specific enolase (nse) measured both during admittance and at the sixth hour of hyperbaric and normobaric oxygen therapy carried out on patients with a diagnosis of co poisoning. methods: the study is designed as a prospective observational laboratory study. forty patients were enrolled in the study: underwent normobaric oxygen therapy (nbot) and the other underwent hyperbaric oxygen therapy (hbot). levels of s b and nse were measured both during admittance and at the sixth hour of admittance of all patients. demographic data, clinical characteristics, and outcome measures were recorded. all data were statistically analyzed. results: in both treatment groups, mean levels of nse after therapy were significantly lower than admittance levels. although levels of nse measured before and hours after treatment in hbot group were high, the difference between groups was not statistically significant (p > . ). in both treatment groups, mean levels of s b after therapy were significantly lower than admittance levels; likewise nse. although levels of s b measured before and hours after treatment in hbot group were high, the difference between groups was not statistically significant (p > . ). additionally, while levels of s b measured after treatment in the hbot group were lower compared to the nbot group, the difference between groups was also not statistically significant (p > . ). conclusion: levels of s b and nse as evidence for brain injury elevation in case of co poisoining and decrease by therapy according to our study as well as previous studies. decrease in levels of s b is more significant. according to our results, s b and nse may be useful markers in case of co poisoning; however, we did not meet any data providing more value in determining hbot indications and determining levels of cohb in the management of patients with a diagnosis of co poisoining. neurons objectives: this study was conducted to determine if neurons in the dmh, and its neighbor the paraventricular hypothalamus (pvn), were likewise involved in mdma-mediated neuroendocrine responses, and if serotonin a receptors ( -ht a) play a role in this regional response. methods: in both experiments, male sprague dawley rats (n = - /group) were implanted with bilateral cannulas targeting specific regions of the brain, i.v. catheters for drug delivery, and i.a. catheters for blood withdrawal. experiments were conducted in raturn cages, which allow blood withdrawal and drug administration in free moving animals while recording their locomotion. in the first experiment, rats were microinjected into the dmh, the pvn, or a region between, with the gabaa agonist muscimol ( pmol/ nl/side) or pbs ( nl) and min later were injected with either mdma ( . mg/kg i.v.) or an equal volume of saline. blood was withdrawn prior to microinjections and minutes after mdma for ria measurement of plasma acth. locomotion was recorded throughout the experiment. in a separate experiment of identical design, either the -ht a antagonist way (way, nmol/ nl/side) or saline was microinjected followed by i.v. injection of mdma or saline. in both experiments, increases in acth and distance traveled were compared between groups using an anova analysis. results: when compared to controls, microinjections of muscimol into the dmh, pvn, or the area in between attenuated plasma increases in acth and locomotion evoked by mdma. when microinjected into the dmh or pvn, way had no effect on acth, but when injected into the region of the dmh it significantly increased locomotion. background: poor hand-offs between physicians when admitting patients have been shown to be a major source of medical errors. objectives: we propose that training in a standardized admissions protocol by emergency medicine (em) to internal medicine (im) residents would improve the quality of and quantity of communication of vital patient information. methods: em and im residents at a large academic center developed an evidence-based admission handover protocol termed the ' ps' (table ) . em and im residents received ' ps' protocol training. im residents recorded prospectively how well each of the seven ps were communicated during each admission pre-and post-intervention. im residents also assessed the overall quality of the handover using a likert scale. the primary outcome was the change in the number of 'ps' conveyed by the em resident to the accepting im resident. data were collected for six weeks before and then for six weeks starting two weeks after the educational intervention. results: there were observations recorded in the preintervention (control) group and observations in the post-intervention group. for each of the seven 'ps' the percentage of observation where all of the information was communicated is shown in table . the communication of 'ps' increased following the intervention. this rise was statistically significant for patient information and pending tests. in the control group the mean of total communicated ps was and in the intervention group, the mean increased to (p < . ). the quality of the handover communication had a mean rating of . in the control group and . in the intervention group (p < . ). conclusion: this educational intervention in a cohort of em and im residents improved the quality and quantity of vital information communicated during patient handovers. the intervention was statistically significant for patient information transfer and tests pending. the results are limited by study size. based on our preliminary data, an agreed-upon handover protocol with training improved the amount and quality of communication during patients' hospital admission on simple items that were likely had been taken for granted as routinely transmitted. we recruited a convenience sample of residents and students rotating in the pediatric emergency department. a two-sided form had the same seven clinical decisions on each side: whether to perform blood, urine, spinal fluid tests, imaging, iv fluids, antibiotics, or a consult. the rating choices were: definitely not, probably not, probably would, and definitely would. trainees rated each decision after seeing a patient, but before presenting to the preceptor, who, after evaluating the patient, rated the same seven decisions on the second side of the form. the preceptor also indicated the most relevant decision (mrd) for that patient. we examined the validity of the technique using hypothesis testing; we posited that residents would have a higher degree of concordance with the preceptor than would medical students. this was tested using dichotomized analyses (accuracy, kappa) and roc curves with the preceptor decision as the gold standard. results: thirty-one students completed forms (median forms; iqr , ) and residents completed ( ; iqr , ). preceptors included attending physicians and fellows ( ; iqr , ). students were concordant with preceptors in % (k = . ) of mrd while residents agreed in . % (p = . ), k = . . roc analysis revealed significant differences between students and residents in the auc for the mrd ( . vs . ; p = . ). conclusion: this measure of trainee-preceptor concordance requires further research but may eventually allow for assessment of trainee clinical decision-making. it also has the pedagogical advantage of promoting independent trainee decision-making. background: basic life support (bls) and advanced cardiac life support (acls) are integral parts of emergency cardiac care. this training is usually reserved in most institutions for residents and faculty. the argument can be made to introduce bls and acls training earlier in the medical student curriculum to enhance acquisition of these skills. objectives: the goal of the survey was to characterize the perceptions and needs of graduating medical students in regards to bls and acls training. methods: this was a survey-based study of graduating fourth year medical students at a u.s. medical school. the students were surveyed before voluntarily participating in a student-led acls course in march of their final year. the surveys were distributed before starting the training course. both bls and acls training, comfort levels, and perceptions were assessed in the survey. results: of the students in the graduating class, participated in the training class with ( %) completing the survey. % of students entered medical school without any prior training and % started clinics without training. . % of students reported witnessing an average of . in-hospital cardiac arrests during training (range of - ). overall, students rated their preparedness . (sd . ) for adult resuscitations on a - likert scale with being the unprepared. % and % of students believe that bls and acls should be included in the medical student curriculum respectively with a preference for teaching before starting clerkships. % of students avoided participating in resuscitations due to lack of training. of those, % said they would have participated had they been trained. conclusion: to our knowledge, this is one of the first studies to address the perceptions and needs for bls and acls training in u.s. medical schools. students feel that bls and acls training is needed in their curriculum and would possibly enhance perceived comfort levels and willingness to participate in resuscitations. background: professionalism is one of six core competency requirements of the acgme, yet defining and teaching its principles remains a challenge. the ''social contract'' between physician and community is clearly central to professionalism so determining the patient's understanding of the physician's role in the relationship is important. because specialization has created more narrowly focused and often quite different interactions in different medical environments, the patient concept of professionalism in different settings may vary as well. objectives: we hoped to determine if patients have different conceptions of professionalism when considering physicians in different clinical environments. methods: patients were surveyed in the waiting room of an emergency department, an outpatient internal medicine clinic, and a pre-operative/anesthesia clinic. the survey contained examples of attributes, derived from the american board of internal medicine's eight characteristics of professionalism. participants were asked to rate, on a -point scale, the importance that a physician possess each attribute. an anova analysis was used to compare the sites for each question. results: of who took the survey, were in the emergency department, were in the medicine clinic, and were in the pre-operative clinic. females comprised % of the study group and the average age was with a range from to . there was a significant difference on the attribute of ''providing a portion of work for those who cannot pay;'' this was rated higher in the emergency department (p = . ). there was near-significance (p = . ) on the attribute of ''being able to make difficult decisions under pressure,'' which was rated higher in the pre-op clinic. there was no difference for any of the other questions. the top four professional attributes at each clinical site were the same -''honesty,'' ''excellence in communication and listening,'' ''taking full responsibility for mistakes,'' and ''technical competence/ skill;'' the bottom two were ''being an active leader in the community'' and ''patient concerns should come before a doctor's family commitments.'' conclusion: very few differences between clinical sites were found when surveying patient perception of the important elements of medical professionalism. this may suggests a core set of values desired by patients for physicians across specialties. emergency medicine faculty knowledge of and confidence in giving feedback on the acgme core competencies todd guth, jeff druck, jason hoppe, britney anderson university of colorado, aurora, co background: the acgme mandates that residency programs assess residents based upon six core competencies. although the core competencies have been in place for a number of years, many faculty are not familiar with the intricacies of the competencies and have difficulty giving competency-specific feedback to residents. objectives: the purpose of the study is to determine the extent to which emergency medicine (em) faculty can identify the acgme core competencies correctly and to determine faculty confidence with giving general feedback and core competency focused feedback to em residents. methods: design and participants: at a single department of em, a survey of twenty-eight faculty members, their knowledge of the acgme core competencies, and their confidence in providing feedback to residents was conducted. confidence levels in giving feedback were scored on a likert scale from to . observations: descriptive statistics of faculty confidence in giving feedback, identification of professional areas of interest, and identification of the acgme core competencies were determined. mann-whitney u tests were used to make comparisons between groups of faculty given the small sample size of the respondents. results: there was a % response rate of the faculty members surveyed. eight faculty members identified themselves as primarily focused on education. although those faculty members identifying themselves as focused on education scored higher than non-education focused faculty for all type of feedback (general feedback, constructive feedback, negative feedback), there was only a statistical difference in confidence levels . versus . (p < . ) for acgme core competency specific feedback when compared to noneducation focused faculty. while education focused faculty correctly identified all six of acgme core competencies % of the time, not one of the non-education focused faculty identified all six of the core competencies correctly. non-education focused faculty only correctly identified three or more competencies % of the time. conclusion: if residency programs are to assess residents using the six acgme core competencies, additional faculty development specific to the core competencies will be needed to train all faculty on the core competencies and on how to give core competency specific feedback to em residents. there is no clear consensus as to the most effective tool to measure resident competency in emergency ultrasound. objectives: to determine the relationship between the number of scans and scores on image recognition, image acquisition, and cognitive skills as measured by an objective structured clinical exam (osce) and written exam. secondarily, to determine whether image acquisition, image recognition, and cognitive knowledge require separate evaluation methodologies. methods: this was a prospective observational study in an urban level i ed with a -year acgme-accredited residency program. all residents underwent an ultrasound introductory course and a one-month ultrasound rotation during their first and second years. each resident received a written exam and osce to assess psychomotor and cognitive skills. the osce had two components: ( ) recognition of images, and ( ) acquisition of images. a registered diagnostic medical sonographer (rdms)-certified physician observed each bedside examination. a pre-existing residency ultrasound database was used to collect data about number of scans. pearson correlation coefficients were calculated for number of scans, written exam score, image recognition, and image acquisition scores on the osce. results: twenty-nine residents were enrolled from march to february who performed an average of scans (range - ). there was no significant correlation between number of scans and written exam scores. an analysis of the number of scans and the ocse found a moderate correlation with image acquisition (r = . , p = . ) and image recognition (r = . , p = < . )). pearson correlation analysis between the image acquisition score and image recognition score found that there was no correlation (r = . , p = . ). there was a moderate correlation with image acquisition scores to written scores (r = . , p = . ) and image recognition scores to written scores (r = . , p = . ). conclusion: the number of scans does not correlate with written tests but has a moderate correlation with image acquisition and image recognition. this suggests that resident education should include cognitive instruction in addition to scan numbers. we conclude that multiple methods are necessary to examine resident ultrasound competency. background: although emergency physicians must often make rapid decisions that incorporate their interpretation of an ecg, there is no evidence-based description of ecg interpretation competencies for emergency medicine (em) trainees. the first step in defining these competencies is to develop a prioritized list of ecg findings relevant to em contexts. objectives: the purpose of this study was to categorize the importance of various ecg diagnoses and/or findings for the em trainee. methods: we developed an extensive list of potentially important ecg diagnoses identified through a detailed review of the cardiology and em literature. we then conducted a three-round delphi expert opinion-soliciting process where participants used a five-point likert scale to rate the importance of each diagnosis for em trainees. consensus was defined as a minimum of percent agreement on any particular diagnosis at the second round or later. in the absence of consensus, stability was defined as a shift of percent or less after successive rounds. results: twenty-two em experts participated in the delphi process, sixteen ( %) of whom completed the process. of those, fifteen were experts from eleven different em training programs across canada and one was a recognized expert in em electrocardiography. overall, diagnoses reached consensus, achieved stability, and one diagnosis achieved neither consensus nor stability. out of potentially important ecg diagnoses, ( %) were considered ''must know'' diagnoses, ( %) ''should know'' diagnoses, and ( %) ''nice to know'' diagnoses. conclusion: we have categorized ecg diagnoses within an em training context, knowledge of which may allow clinical em teachers to establish educational priorities. this categorization will also facilitate the development of an educational framework to establish em trainee competency in ecg interpretation. ''rolling refreshers background: cardiac arrest survival rates are low despite advances in cardiopulmonary resuscitation. high quality cpr has been shown to impart greater cardiac arrest survival; however, retention of basic cpr skills by health care providers has been shown to be poor. objectives: to evaluate practitioner acceptance of an in-service cpr skills refresher program, and to assess for operator response to real-time feedback during refreshers. methods: we prospectively evaluated a ''rolling refresher'' in-service program at an academic medical center. this program is a proctored cpr practice session using a mannequin and cpr-sensing defibrillator that provides real-time cpr quality feedback. subjects were basic life support-trained providers who were engaged in clinical care at the time of enrollment. subjects were asked to perform two minutes of chest compressions (ccs) using the feedback system. ccs could be terminated when the subject had completed approximately seconds of compressions with < corrective prompts. a survey was then completed by to obtain feedback regarding the perceived efficacy of this training model. cpr quality was then evaluated using custom analysis software to determine the percent of cc adequacy in -second intervals. results: enrollment included subjects from the emergency department and critical care units ( nurses, physicians, students and allied health professionals). all participants completed a survey and cpr performance data logs were obtained. positive impressions of the in-service program were registered by % ( / ) and % ( / ) reported a self-perceived improvement in skills confidence. eighty-three percent ( / ) of respondents felt comfortable performing this refresher during a clinical shift. thirtynine percent ( / ) of episodes exhibited adequate cc performance with approximately seconds of cc. of the remaining episodes, . ± . % of cc were adequate in the first seconds with . ± . % of cc adequate during the last second interval (p = . ). of these individuals, improved or had no change in their cpr skills, and individuals skills declined during cc performance (p = . ). conclusion: implementation of a bedside cpr skill refresher program is feasible and is well received by hospital staff. real time cpr feedback improved upon cpr skill performance during the in-service session. teaching emergency medicine skills: is a self-directed, independent, online curriculum the way of the future? tighe crombie, jason r. frank, stephen noseworthy, richard gerein, a. curtis lee university of ottawa, ottawa, on, canada background: procedural competence is critical to emergency medicine, but the ideal instructional method to acquire these skills is not clear. previous studies have demonstrated that online tutorials have the potential to be as effective as didactic sessions at teaching specific procedural skills. objectives: we studied whether a novel online curriculum teaching pediatric intraosseus (io) line insertion to novice learners is as effective as a traditional classroom curriculum in imparting procedural competence. methods: we conducted a randomized controlled educational trial of two methods of teaching io skills. preclinical medical students with no past io experience completed a written test and were randomized to either an online or classroom curriculum. the online group (og) were given password-protected access to a website and instructed to spend minutes with the material while the didactic group (dg) attended a lecture of similar duration. participants then attended a -minute unsupervised manikin practice session on a separate day without any further instruction. a videotaped objective structured clinical examination (osce) and post-course written test were completed immediately following this practice session. finally, participants were crossed over into the alternate curriculum and were asked to complete a satisfaction survey that compared the two curricula. results were compared with a paired t-test for written scores and an independent t-test for osce scores. results: sixteen students completed the study. pre-course test scores of the two groups were not significantly different prior to accessing their respective curricula (mean scores of % for og and % for dg, respectively; p > . ). post-course written scores were also not significantly different (both with means of %; p > . ); however, for the post-treatment osce scores, the og group scored significantly higher than the dg group (mean scores of . % and . %; t( ) = . , p < . .) conclusion: this novel online curriculum was superior to a traditional didactic approach to teaching pediatric io line insertion. novice learners assigned to a selfdirected online curriculum were able to perform an emergency procedural skill to a high level of performance. em educators should consider adopting online teaching of procedural skills. background: applicants to em residency programs obtain information largely from the internet. curricular information is available from a program's website (pw) or the saem residency directory (sd). we hypothesize that there is variation between these key sources. objectives: to identify discrepancies between each pw and sd. to describe components of pgy - em residency programs' curricula as advertised on the internet. methods: pgy - residencies were identified through the sd. data were abstracted from individual sd and pw pages identifying pre-determined elements of interest regarding rotations in icu, pediatrics, inpatient (medicine, pediatrics, general surgery), electives, orthopedics, toxicology, and anesthesia. agreement between the sd and pw was calculated using a cohen's unweighted kappa calculation. curricula posted on pws were considered the gold standard for the programs' current curricula. results: a total of pgy - programs were identified through the sd and confirmed on the pw. ninetyone of programs ( %) had complete curricular information on both sites. only these programs were included in the kappa analysis for sd and pw comparisons. of programs with complete listings, of programs ( %) had at least one discrepancy. the agreement of information between pw and sd revealed a kappa value of . ( % ci . - . ). analysis of pw revealed that pgy - programs have an average of . (range, - ), . (range, - ), . (range, - ), and . (range, - ) blocks of icu, pediatrics, elective, and inpatient, respectively. common but not rrc-mandated rotations in orthopedics, toxicology, and anesthesiology are present in , , and percent of programs, respectively. conclusion: publicly accessible curricular information through the sd and pw for pgy - em programs only has fair agreement (using commonly accepted kappa value guides). applicants may be confused by the variability of data and draw inaccurate conclusions about program curricula. from the gravid uterus and improves cardiac output; however, this theory has never been proven. objectives: we set out to determine the difference in inferior vena cava (ivc) filling when third trimester patients were placed in supine, llt, and right lateral tilt (rlt) positions using ivc ultrasound. methods: healthy pregnant women in their third trimester presenting to the labor and delivery suite were enrolled. patients were placed in three different positions (supine, rlt, and llt) and ivc maximum (max) and minimum (min) measurements were obtained using the intercostal window in short axis approximately two centimeters below the entry of the hepatic veins. ivc collapse index (ci) was calculated for each measurement using the formula (max-min)/max. in addition, blood pressure, heart rate, and fetal heart rate were monitored. patients stayed in each position for at least minutes prior to taking measurements. we compared ivc measurements using a one-way analysis of variance for repeated measures. results: twenty patients were enrolled. the average age was years (sd . ) with a mean estimated gestational age of . weeks (sd . ). there were no significant differences seen in ivc filling in each of the positions (see table ). in addition, there were no differences in hemodynamic parameters between positions.ten ( %) patients had the largest ivc measurement in the llt position, ( %) patients in the rlt position, and ( %) in the supine position. conclusion: there were no significant differences in ivc filling between patient positions. for some third trimester patients llt may not be the optimal position for ivc filling. background: although the acgme and rrc require competency assessment in ed bedside ultrasound (us), there are no standardized assessment tools for us training in em. objectives: using published us guidelines, we developed four observed structured competency evalua-tions (osce) for four common em us exams: fast, aortic, cardiac, and pelvic. inter-rater reliability was calculated for overall performance and for the individual components of each osce. methods: this prospective observational study derived four osces that evaluated overall study competency, image quality for each required view, technical factors (probe placement, orientation, angle, gain, and depth), and identification of key anatomic structures. em residents with varying levels of training completed an osce under direct observation of two em-trained us experts. each expert was blinded to the other's assessment. overall study competency and image quality of each required views were rated on a five-point scale ( poor, -fair, -adequate, -good, -excellent), with explicit definitions for each rating. each study had technical factors (correct/incorrect) and anatomic structures (identified/not identified) assessed as binary variables. data were analyzed using cohen's and weighted k, descriptive statistics, and % ci. results: a total of us exams were observed, including fast, cardiac, aorta, and pelvic. total assessments included ratings of overall study competency, ratings of required view image quality, ratings of technical factors, and ratings of anatomic structures. inter-rater assessment of overall study competency showed excellent agreement, raw agreement . ( . , . ), weighted k . ( . , . ). ratings of required view image quality showed excellent agreement: raw agreement . ( . , . ), weighted k . ( . , . ). inter-rater assessment of technical factors showed substantial agreement: raw agreement . ( . , . ), cohen's k . ( . , . ). ratings of identification of anatomic structures showed substantial agreement: raw agreement . ( . , . ), cohen's k . ( . , . ). conclusion: inter-rater reliability is substantial to excellent using the derived ultrasound osces to rate em resident competency in fast, aortic, cardiac, and pelvic ultrasound. validation of this tool is ongoing. a objectives: the objective of this study was to identify which transducer orientation, longitudinal or transverse, is the best method of imaging the axillary vein with ultrasound, as defined by successful placement in the vein with one needle stick, no redirections, and no complications. methods: emergency medicine resident and attending physicians at an academic medical center were asked to cannulate the axillary vein in a torso phantom model. the participants were randomized to start with either the longitudinal or transverse approach and completed both sequentially, after viewing a teaching presentation. participants completed pre-and post-attempt questionnaires. measurements of each attempt were taken regarding time to completion, success, skin punctures, needle redirections, and complications. we compared proportions using a normal binomial approximation and continuous data using the t-distribution, as appropriate. a sample size of was chosen based on the following assumptions: power, . ; significance, . ; effect size, % versus %. results: fifty-seven operators with a median experience of prior ultrasounds ( to iqr) participated. first-attempt success frequency was / ( . ) for the longitudinal method and / ( . ) for the transverse method (difference . , % ci . - . ); this difference was similar regardless of operator experience. the longitudinal method had fewer redirections (mean difference . , % ci . - . ) and skin punctures (mean difference . , % ci ) to . ). arterial puncture occurred in / longitudinal attempts and / transverse attempts, with no pleural punctures in either group. among successful attempts, the time spent was seconds less for longitudinal method ( % ci - ). though % of participants had more experience with the transverse method prior to the training session, % indicated after the session that they preferred the longitudinal method. methods: a prospective single-center study was conducted to assess the compressibility of the basilic vein with ultrasound. healthy study participants were recruited. the compressibility was assessed at baseline, and then further assessed with one proximal tourniquet, two tourniquets (one distal and one proximal), and a proximal blood pressure cuff inflated to mmhg. compressibility was defined as the vessel's resistance to collapse to external pressure and rated as completely compressible, moderately compressible, or mildly compressible after mild pressure was applied with the ultrasound probe. results: one-hundred patients were recruited into the study. ninety-eight subjects were found to have a completely compressible basilic vein at baseline. when one tourniquet and two tourniquets were applied and participants, respectively, continued to have completely compressible veins. a fisher's exact test comparing one versus two tourniquets revealed no difference between these two techniques (p = . ). only two participants continued to have completely compressible veins following application of the blood pressure cuff. the compressibility of this group was found to be statistically significant by fisher's exact test compared to both tourniquet groups (p < . ). furthermore, participants with the blood pressure cuff applied were found to have moderately compressible veins and participants were found to have mildly compressible veins. conclusion: tourniquets and blood pressure cuffs can both decrease the compressibility of peripheral veins. while there was no difference identified between using one and two tourniquets, utilization of a blood pressure cuff was significantly more effective to decrease compressibility. the findings of this study may be utilized in the emergency department when attempting to obtain peripheral venous access, specifically supporting the use of blood pressure cuffs to decrease compressibility. background: electroencephalography (eeg) is an underused test that can provide valuable information in the evaluation of emergency department (ed) patients with altered mental status (ams). in ams patients with nonconvulsive seizure (ncs), eeg is necessary to make the diagnosis and to initiate proper treatment. yet, most cases of ncs are diagnosed > h after ed presentation. obstacles to routine use of eeg in the ed include space limitations, absence of / availability of eeg technologists and interpreters, and the electrically hostile ed environment. a novel miniature portable wireless device (microeeg) is designed to overcome these obstacles. objectives: to examine the diagnostic utility of micro-eeg in identifying eeg abnormalities in ed patients with ams. methods: an ongoing prospective study conducted at two academic urban eds. inclusion: patients ‡ years old with ams. exclusion: an easily correctable cause of ams (e.g. hypoglycemia, opioid overdose). three -minute eegs were obtained in random order from each subject beginning within one hour of presentation: ) a standard eeg, ) a microeeg obtained simultaneously with conventional cup electrodes using a signal splitter, and ) a microeeg using an electrocap. outcome: operative characteristics of micro-eeg in identifying any eeg abnormality. all eegs were interpreted in a blinded fashion by two board-certified epileptologists. within each reader-patient pairing, the accuracy of eegs and were each assessed relative to eeg . sensitivity, specificity, and likelihood ratios (lr) are reported for microeeg by standard electrodes and electrocap (eegs and ). inter-rater variability for eeg interpretations is reported with kappa. results: the interim analysis was performed on consecutive patients (target sample size: ) enrolled from may to october (median age: , range: - , % male). overall, % ( % confidence interval [ci], - %) of interpretations were abnormal (based on eeg ). kappa values representing the agreement of neurologists in interpretation of eeg - were . ( . - . ), . ( . - . ), and . ( . - . ), respectively. conclusion: the diagnostic accuracy and concordance of microeeg are comparable to those of standard eeg but the unique ed-friendly characteristics of the device could help overcome the existing barriers for more frequent use of eeg in the ed. (originally submitted as a ''late-breaker.'') a background: patients who use an ed for acute migraine are characterized by higher migraine disability scores, lower socio-economic status, and are unlikely to have used a migraine-specific medication prior to ed presentation. objectives: to determine if a comprehensive migraine intervention, delivered just prior to ed discharge, could improve migraine impact scores one month after the ed visit. methods: this was a randomized controlled trial of a comprehensive migraine intervention versus typical care among patients who presented to an ed for management of acute migraine. at the time of discharge, for patients randomized to comprehensive care, we reinforced their diagnosis, shared a migraine education presentation from the national library of medicine, provided them with six tablets of sumatriptan mg and tablets of naproxen mg, and if they wished, provided them with an expedited free appointment to our institution's headache clinic. patients randomized to typical care received the care their attending emergency physician felt was appropriate. the primary outcome was a between-group comparison of the hit score, a validated headache assessment instrument, one month after ed discharge. secondary outcomes included an assessment of satisfaction with headache care and frequency of use of migraine-specific medication within that one month period. the outcome assessor was blinded to assignment. results: over a month period, migraine patients were enrolled. one month follow-up was successfully obtained in % of patients. baseline characteristics were comparable. one month hit scores in the two groups were nearly identical ( vs , %ci for difference of : ) , ), as was dissatisfaction with overall headache care ( % versus %, %ci for difference of %: ) , %). not surprisingly, patients randomized to the comprehensive intervention were more likely to be using triptans or migraine-preventive therapy ( % versus %, %ci for difference of %: , %) one month later. conclusion: a comprehensive migraine intervention, when compared to typical care, did not improve hit scores one month after ed discharge. future work is needed to define a migraine intervention that is practical and useful in an ed. background: lumbar puncture (lp) is the standard of care for excluding non-traumatic subarachnoid hemorrhage (sah), and is usually performed following head ct (hct). however, in the setting of a non-diagnostic hct, lp demonstrates a low overall diagnostic yield for sah (< % positive rate). objectives: to describe a series of ed patients diagnosed with sah by lp following a non-diagnostic hct, and, when compared to a set of matched controls, determine if clinical variables can reliably identify these ''ct-negative/lp-positive'' patients. methods: retrospective case-control chart review of ed patients in an integrated health system between the years - (estimated - million visits among eds). patients with a final diagnosis of non-traumatic sah were screened for case inclusion, defined as an initial hct without sah by final radiologist interpretation and a lp with > red blood cells/mm , along with either ) xanthochromic cerebrospinal fluid, ) angiographic evidence of cerebral aneurysm or arteriovenous malformation, or ) head imaging showing sah within hours following lp. control patients were randomly selected among ed patients diagnosed with headache following a negative sah evaluation with hct and lp. controls were matched to cases by year and presenting ed in a : ratio. stepwise logistic regression and classification and regression tree analysis (cart) were employed to identify predictive variables. inter-rater reliability (kappa) was determined by independent chart review. results: fifty-five cases were identified. all cases were hunt-hess grade or . demographics are shown in table . thirty-four cases ( %) had angiographic evidence of sah. five variables were identified that positively predicted sah following a normal hct with % sensitivity ( % ci, - %) and % specificity ( % ci, - %): age > years, neck pain or stiffness, onset of headache with exertion, vomiting with headache, or loss of consciousness at headache onset. kappa values for selected variables ranged from . - . ( % sample). the c-statistic (auc) and hosmer-lemeshow test p-value for the logistic regression model are . and . , respectively (table ) . conclusion: several clinical variables can help safely limit the amount of invasive testing for sah following a non-diagnostic hct. prospective validation of this model is needed prior to practice implementation. background: post-thrombolysis intracerebral hemorrhage (ich) is associated with poor outcomes. previous investigations have attempted to determine the relationship between pre-existing anti-platelet (ap) use and the safety of intravenous thrombolysis, but have been limited by low event rates thus decreasing the precision of estimates. objectives: our objective was to determine whether pre-existing ap therapy increases the risk of ich following thrombolysis. methods: consecutive cases of ed-treated thrombolysis patients were identified using multiple methods, including active and passive surveillance. retrospective data were collected from four hospitals from - , and distinct hospitals from - as part of a cluster randomized trial. the same chart abstraction tool was used during both time periods and data were subjected to numerous quality control checks. hemorrhages were classified using a pre-specified methodology: ich was defined as presence of hemorrhage in radiographic interpretations of follow up imaging (primary outcome). symptomatic ich (secondary outcome) was defined as radiographic ich with associated clinical worsening. a multivariable logistic regression model was constructed to adjust for clinical factors previously identified to be related to postthrombolysis ich. as there were fewer sich events, the multivariable model was constructed similarly, except that variables divided into quartiles in the primary analysis were dichotomized at the median. results: there were patients included, with % having documented pre-existing ap treatment. the mean age was years, the cohort was % male, and the median nihss was . the unadjusted proportion of patients with any ich was . % without ap and . % with ap (difference . %, % ci ) . % to . %); for sich this was . % without ap and % with ap (difference . %, %ci ) to . %). no significant association between pre-existing ap treatment with radiographic or symptomatic ich was observed (table) . conclusion: we did not find that ap treatment was associated with post-thrombolysis ich or sich in this cohort of community treated patients. pre-existing tobacco use, younger age, and lower severity were associated with lower odds of sich. an association between ap therapy and sich may still exist -further research with larger sample sizes is warranted in order to detect smaller effect sizes. background: post-cardiac arrest therapeutic hypothermia (th) improves survival and neurologic outcome after cardiac arrest, but the parameters required for optimal neuroprotection remain uncertain. our laboratory recently reported that -hour th was superior to -hour th in protecting hippocampal ca pyramidal neurons after asphyxial cardiac arrest in rats. cerebellar purkinje cells are also highly sensitive to ischemic injury caused by cardiac arrest, but the effect of th on this neuron population has not been previously studied. objectives: we examined the effect of post-cardiac arrest th onset time and duration on purkinje neuron survival in cerebella collected during our previous study. methods: adult male long evans rats were subjected to -minute asphyxial cardiac arrest followed by cpr. rats that achieved return of spontaneous circulation (rosc) were block randomized to normothermia ( . deg c) or th ( . deg c) initiated , , , or hours after rosc and maintained for or hours (n = per group). sham injured rats underwent anesthesia and instrumentation only. seven days post-cardiac arrest or sham injury, rats were euthanized and brain tissue was processed for histology. surviving purkinje cells with normal morphology were quantified in the primary fissure in nissl stained sagittal sections of the cerebellar vermis. purkinje cell density was calculated for each rat, and group means were compared by anova with bonferroni analysis. results: purkinje cell density averaged (+/) sd) . ( . ) cells/mm in sham-injured rats. neuronal survival in normothermic post-cardiac arrest rats was significantly reduced compared to sham ( . % ( . %)). overall, th resulted in significant neuroprotection compared to normothermia ( . % ( . %) of sham). purkinje cell density with -hour duration th was . % ( . %) of sham and -hour duration th was . % ( . %), both significantly improved from sham (p = . between durations). th initiated , , , and hours post-rosc provided similar benefit: . % ( . %), . % ( . %), . % ( . %), and . % ( . %) of sham, respectively. conclusion: overall, these results indicate that postcardiac arrest th protects cerebellar purkinje cells with a broad therapeutic window. our results underscore the importance of considering multiple brain regions when optimizing the neuroprotective effect of post-cardiac arrest th. the effect of compressor-administered defibrillation on peri-shock pauses in a simulated cardiac arrest scenario joshua glick, evan leibner, thomas terndrup penn state hershey medical center, hershey, pa background: longer pauses in chest compressions during cardiac arrest are associated with a decreased probability of successful defibrillation and patient survival. having multiple personnel share the tasks of performing chest compressions and shock delivery can lead to communication complications that may prolong time spent off the chest. objectives: the purpose of this study was to determine whether compressor-administered defibrillation led to a decrease in pre-shock and peri-shock pauses as compared to bystander-administered defibrillation in a simulated in-hospital cardiac arrest scenario. we hypothesized that combining the responsibilities of shock delivery and chest-compression performance may lower no-flow periods. methods: this was a randomized, controlled study measuring pauses in chest compressions for defibrillation in a simulated cardiac arrest. medical students and ed personnel with current cpr certification were surveyed for participation between july and october . participants were randomized to either a control (facilitator-administered shock) or variable (participantadministered shock) group. all participants completed one minute of chest compressions on a mannequin in a shockable rhythm prior to initiation of prompt and safe defibrillation. pauses for defibrillation were measured and compared in both study groups. results: out of total enrollments, the data from defibrillations were analyzed. subject-initiated defibrillation resulted in a significantly lower pre-shock handsoff time ( . s; % ci: . - . ) compared to facilitator-initiated defibrillation ( . s; % ci: . - . ). furthermore, subject-initiated defibrillation resulted in a significantly lower peri-shock hands-off time ( . s; % ci: . - . ) compared to facilitator-initiated defibrillation ( . s; % ci: . - . ). conclusion: assigning the responsibility for shock delivery to the provider performing compressions encourages continuous compressions throughout the charging period and decreases total time spent off the chest. this modification may also decrease the risk of accidental shock and improve patient survival. however, as this was a simulation-based study, clinical implementation is necessary to further evaluate these potential benefits. objectives: to determine the sensitivity and specificity of peripheral venous oxygen (po ) to predict abnormal central venous oxygen saturation in septic shock patients in the ed. methods: secondary analysis of an ed-based randomized controlled trial of early sepsis resuscitation targeting three physiological variables: cvp, map, and either scvo or lactate clearance. inclusion criteria: suspected infection, two or more sirs criteria, and either systolic blood pressure < mmhg after a fluid bolus or lactate > mm. peripheral venous po was measured prior to enrollment as part of routine care, and scvo was measured as part of the protocol. we analyzed for agreement between venous po and scvo using spearman's rank. sensitivity and specificity to predict an abnormal scvo (< %) were calculated for each incremental value of po . results: a total of were analyzed. median po was mmhg (iqr , ). median initial scvo was % (iqr , ). thirty-nine patients ( %) had an initial scvo < %. spearman's rank demonstrated fair correlation between initial po and scvo (q = . ). a cutoff of venous po < was % sensitive and % specific for detecting an initial scvo < %. twenty-seven patients ( %) demonstrated an initial po of > . conclusion: in ed septic shock patients, venous po demonstrated only fair correlation with scvo , though a cutoff value of was sensitive for predicting an abnormal scvo . twenty percent of patients demonstrated an initial value above the cutoff, potentially representing a group in whom scvo measurement could be avoided. future studies aiming to decrease central line utilization could consider the use of peripheral o measurements in these patients. sessions. ninety-two percent were rns, median clinical experience was - years, and % were from an intensive care unit. provider confidence increased significantly with a single session despite the highly experienced sample (figure ). there was a trend for further increased confidence with an additional session and the increased confidence was maintained for at least - months given the normal sensitivity analysis. conclusion: high fidelity simulation significantly increases provider confidence even among experienced providers. this study was limited by its small sample size and recent changes in acls guidelines. background: recent data suggest alarming delays and deviations in major components of pediatric resuscitation during simulated scenarios by pediatric housestaff. objectives: to identify the most common errors of pediatric residents during multiple simulated pediatric resuscitation scenarios. methods: a retrospective observational study conducted in an academic tertiary care hospital. pediatric residents (pgy and pgy ) were videotaped performing a series of five pediatric resuscitation scenarios using a high-fidelity simulator (simbaby, laerdal): pulseless non-shockable arrest, pulseless shockable arrest, dysrhythmia, respiratory arrest, and shock. the primary outcome was the presence of significant errors prospectively defined using a validated scoring instrument designed to assess sequence, timing, and quality of specific actions during resuscitations based on the aha pals guidelines. residents' clinical performances were measured by a single video reviewer. the primary analysis was the proportion of errors for each critical task for each scenario. we estimated that the evaluation of each resident would provide a confidence interval less than . for the proportion of errors. results: twenty-four of residents completed the study. across all scenarios, pulse check was delayed by more than seconds in % ( %ci: %- %). for non-shockable arrest, cpr was started more than seconds after recognizing arrest in % ( %ci - %) and inappropriate defibrillation was performed in % ( %ci - %). for shockable arrest, participants failed to identify the rhythm in % ( %ci - %), cpr was not performed in % ( %ci - %), while defibrillation was delayed by more than seconds in % ( %ci - %) and not performed in one case. for shock, participants failed to ask for a dextrose check in % ( %ci - %), and it was delayed by more than seconds for all others. conclusion: the most common error across all scenarios was delay in pulse check. delays in starting cpr and inappropriate defibrillation were common errors in non-shockable arrests, while failure to identify rhythm, cpr omission, and delaying defibrillation were noted for shockable arrests. for shock, omission of rapid dextrose check was the most common error, while delaying the test when ordered was also significant. future training in pediatric resuscitation should target these errors. background: many scoring instruments have been described to measure clinical performance during resuscitation; however, the validity of these tools has yet to be proven in pediatric resuscitation. objectives: to determine the external validity of published scoring instruments to evaluate clinical performance during simulated pediatric resuscitations using pals algorithms and to determine if inter-rater reliability could be assessed. methods: this was a prospective quasi-experimental design performed in a simulation lab of a pediatric tertiary care facility. participants were residents from a single pediatric program distinct from where the instrument was originally developed. a total of pgy s and pgy s were videotaped during five simulated pediatric resuscitation scenarios. pediatric emergency physicians rated resident performances before and after a pals course using standardized scoring. each video recording was viewed and scored by two raters blinded to one another. a priori, it was determined that, for the scoring instrument to be valid, participants should improve their scores after participating in the pals course. differences in means between pre-pals and post-pals and pgy and pgy were compared using an anova test. to investigate differences in the scores of the two groups over the five scenarios, a two-factor anova was used. reliability was assessed by calculating an interclass correlation coefficient for each scenario. results: following the pals course, scores improved by . % ( . to . ), . % ( . to . ), . % () . to . ), . % ( . to ), and . % () . to . ) for the pulseless non-shockable arrest, pulseless shockable arrest, dysrhythmia, respiratory, and shock scenarios respectively. there were no differences in scores between pgy s and pgy s before and after the pals course. there was an excellent reliability for each scoring instrument with iccs varying between . and . . conclusion: the scoring instrument was able to demonstrate significant improvements in scores following a pals course for pgy and pgy pediatric residents for the pulseless non-shockable arrest, pulseless shockable, and respiratory arrest scenarios only. however, it was unable to discriminate between pgy s and pgy s both before and after the pals course for any scenarios. the scoring instrument showed excellent inter-reliability for all scenarios. a background: medical simulation is a common and frequently studied component of emergency medicine (em) residency curricula. its utility in the context of em medical student clerkships is not well defined. objectives: the objective was to measure the effect of simulation instruction on medical students' em clerkship oral exam performance. we hypothesized that students randomized to the simulation group would score higher. we predicted that simulation instruction would promote better clinical reasoning skills and knowledge expression. methods: this was a randomized observational study conducted from / to / . participants were fourth year medical students in their em clerkship. students were randomly assigned on their first day to one of two groups. the study group received simulation instruction in place of one of the lectures, while the control group was assigned to the standard curriculum. the standard clerkship curriculum includes lectures, case studies, procedure labs, and clinical shifts without simulation. at the end of the clerkship, all students participated in written and oral exams. graders were not blinded to group allocation. grades were assigned based on a pre-defined set of criteria. the final course composite score was computed based on clinical evaluations and the results of both written and oral exams. oral exam scores between the groups were compared using a two-sample t-test. we used the spearman rank correlation to measure the association between group assignment and the overall course grade. the study was approved by our institutional irb. results: sixty-one students participated in the study and were randomly assigned to one of two groups. twenty-nine ( . %) were assigned to simulation and the remaining ( . %) students were assigned to the standard curriculum. students assigned to the simulation group scored . % ( % ci . - . %) higher on the oral exam than the non-simulation group. additionally, simulation was associated with a higher final course grade (p < . ). limitations of this pilot study include lack of blinding and interexaminer variability. conclusion: simulation training as part of an em clerkship is associated with higher oral exam scores and higher overall course grade compared to the standard curriculum. the results from this pilot study are encouraging and support a larger, more rigorous study. initial approaches to common complaints are taught using a standard curriculum of lecture and small group case-based discussion. we added a simulation exercise to the traditional altered mental status (ams) curriculum with the hypothesis that this would positively affect student knowledge, attitudes, and level of clinical confidence caring for patients with ams. methods: ams simulation sessions were conducted in june and ; student participation was voluntary. the simulation exercises included two ams cases using a full-body simulator and a faculty debriefing after each case. both students who did and did not participate in the simulations completed a written post-test and a survey related to confidence in their approach to ams. results: students completed the post-test and survey. ( %) attended the simulation session. ( %) attended all three sessions. ( %) participated in the lecture and small group. ( %) did not attend any session. post-test scores were higher in students who attended the simulations versus those who did not: (iqr, - ) vs. (iqr, - ); p < . . students who attended the simulations felt more confident about assessing an ams patient ( % vs. %; p = . ), articulating a differential diagnosis ( % vs. %; p = . ), and knowing initial diagnostic tests ( % vs. %; p = . ) and initial interventions ( % vs. %; p = . ) for an ams patient. students who attended the simulations were more likely to rate the overall ams curriculum as useful ( % vs. %; p < . ). conclusion: addition of a simulation session to a standard ams curriculum had a positive effect on student performance on a knowledge-based exam and increased confidence in clinical approach. the study's major limitations were that student participation in the simulation exercise was voluntary and that effect on applied skills was not measured. future research will determine whether simulation is effective for other chief complaints and if it improves actual clinical performance. background: the acgme has defined six core competencies for residents including ''professionalism'' and ''interpersonal and communication skills.'' integral to these two competencies is empathy. prior studies suggest that self-reported empathy declines during medical training; no reported study has yet integrated simulation into the evaluation of empathy in medical training. objectives: to determine if there is a relation between level of training and empathy in patient interactions as rated during simulation. methods: this is a prospective observational study at a tertiary care center comparing participants at four different levels of training: first (ms ) and third year (ms ) medical students, incoming em interns (pgy ), and em senior residents (pgy / ). trainees participated in two simulation scenarios (ectopic pregnancy and status asthmaticus) in which they were responsible for clinical management (cm) and patient interactions (pi). this was the first simulation exposure during an established simulation curriculum for ms , ms , and pgy . two independent raters reviewed videotaped simulation scenarios using checklists of critical actions for clinical management (cm: - points) and patient interactions (pi: - points). inter-rater reliability was assessed by intra-class correlation coefficients (iccs objectives: we explored attitudes and beliefs about the handoff, using qualitative methods, from a diverse group of stakeholders within the ems community. we also characterized perceptions of barriers to high-quality handoffs and identified strategies for optimizing this process. methods: we conducted seven focus groups at three separate gatherings of ems professionals (one local, two national) in / . snowball sampling was used to recruit participants with diverse professional, experiential, geographic, and demographic characteristics. focus groups, lasting - minutes, were moderated by investigators trained in qualitative methods, using an interview guide to elicit conversation. recordings of each group were transcribed. three reviewers analyzed the text in a multi-stage iterative process to code the data, describe the main categories, and identify unifying themes. results: participants included emts, paramedics, physicians, and nurses. clinical experience ranged from months to years. recurrent thematic domains when discussing attitudes and beliefs were: perceptions of respect and competence, professionalism, teamwork, value assigned to the process, and professional duty. modifiers of these domains were: hierarchy, skill/training level, severity/type of patient illness, and system/ regulatory factors. strategies to improving barriers to the handoff included: fostering familiarity and personal connections between ems and ed staff, encouraging two-way conversations, feedback, and direct interactions between ems providers and ed physicians, and optimizing ways for ems providers to share subjective impressions (beyond standardized data elements) with hospital-based care teams. conclusion: ems professionals assign high value to the ed handoff. variations in patient acuity, familiarity with other handoff participants, and perceptions of respect and professionalism appear to influence the perceived quality of this transition. regulatory strategies to standardize the contents of the handoff may not alone overcome barriers to this process. miology, public health) then developed an approach to assign ems records to one of symptom-based illness categories (gastrointestinal illness, respiratory, etc). ems encounter records were characterized into these illness categories using a novel text analytic program. event alerts were identified across the state and local regions in illness categories using either change detection from baseline with (cusum) analysis (three standard deviations) and a novel text-proportion (tap) analysis approach (sas institute, cary, nc). results: . million ems encounter records over a year period were analyzed. the initial analysis focused upon gastrointestinal illness (gi) given the potential relationship of gi distress to infectious outbreaks, food contamination and intentional poisonings (ricin). after accounting for seasonality, a significant gi event was detected in feb (see red circle on graph). this event coincided with a confirmed norovirus outbreak. the use of cusum approach (yellow circle on graph) detected the alert event on jan , . the novel tap approach on a regional basis detected the alert on dec , . conclusion: ems has the advantage of being an early point of contact with patients and providing information on the location of insult or injury. surveillance based on ems information system data can detect emergent outbreaks of illness of interest to public health. a novel text proportion analytic technique shows promise as an early event detection method. assessing chronic stress in the emergency medical services elizabeth a. donnelly , jill chonody university of windsor, windsor, on, canada; university of south australia, adelaide, australia background: attention has been paid to the effect of critical incident stress in the emergency medical services (ems); however, less attention has been given to the effect of chronic stress (e.g., conflict with administration or colleagues, risk of injury, fatigue, interference in non-work activities) in ems. a number of extant instruments assess for workplace stress; however, none address the idiosyncratic aspects of work in ems. objectives: the purpose of this study was to validate an instrument, adapted from mccreary and thompson ( ) , that assesses levels of both organizational and operational work-related chronic stress in ems personnel. methods: to validate this instrument, a cross-sectional, observational web-based survey was used. the instrument was distributed to a systematic probability sample of emts and paramedics (n = , ). the survey also included the perceived stress scale (cohen, ) to assess for convergent construct validity. results: the survey attained a . % usable response rate (n = ); respondent characteristics were consistent across demographic characteristics with other studies of emts and paramedics. the sample was split in order to allow for exploratory and confirmatory fac-tor analyses (n = /n = ). in the exploratory factor analysis, principal axis factoring with an oblique rotation revealed a two-factor, -item solution (kmo = . , v = . , df = , p £. ). confirmatory factor analysis suggested a more parsimonious, two-factor, -item solution (v = . , df = , p £ . , rmsea = . , cfi = . , tli = . , srmr = . ). the factors demonstrated good internal reliability (operational stress a = . , organizational stress a = . ). both factors were significantly correlated (p £ . ) with the hypothesized convergent validity measure. conclusion: theory and empirical research indicate that exposure to chronic workplace stress may play an important part in the development of psychological distress, including burnout, depression, and posttraumatic stress disorder (ptsd). workplace stress and stress reactions may potentially interfere with job performance. as no extant measure assesses for chronic workplace stress in ems, the validation of this chronic stress measure enhances the tools ems leaders and researchers have in assessing the health and well-being of ems providers. effect of naltrexone background: survivors of sarin and other organophosphate poisoning can develop delayed encephalopathy that is not prevented by standard antidotal therapy with atropine and pralidoxime. a rat model of poisoning with the sarin analogue diisoprophylfluorophosphate (dfp) demonstrated impairment of spatial memory despite antidotal therapy with atropine and pralidoxime. additional antidotes are needed after acute poisonings that will prevent the development of encephalopathy. objectives: to determine the efficacy of naltrexone in preventing delayed encephalopathy after poisoning with the sarin analogue dfp in a rat model. the hypothesis is that naltrexone would improve performance on spatial memory after acute dfp poisoning. the sarin analogue dfp was used because it has similar toxicity to sarin while being less dangerous to handle. methods: a randomized controlled experiment at a university animal research laboratory of the effects of naltrexone on spatial memory after dfp poisoning was conducted. long evans rats weighing - grams were randomized to dfp group (n = , rats received a single intraperitoneal (ip) injection of dfp mg/kg) or dfp+naltrexone group (n = , rats received a single ip injection of dfp ( mg/kg) followed by naltrexone mg/kg/day). after injection, rats were monitored for signs and symptoms of cholinesterase toxicity. if toxicity developed, antidotal therapy was initiated with atro-background: one of the primary goals of management of patients presenting with known or suspected acetaminophen (apap) ingestion is to identify the risk for apap-induced hepatotoxicity. current practice is to measure apap level at a minimum of hours post ingestion and plot this value on the rumack-matthew nomogram. one retrospective study of apap levels drawn less than hours post-ingestion found a level less than mcg/ml to be sufficient to exclude toxic ingestion. objectives: the aim of this study was to prospectively determine the negative predictive value (npv) for toxicity of an apap level of less than mcg/ml obtained less than hours post-ingestion. methods: this was a multicenter prospective cohort study of patients presenting to one of five tertiary care hospitals that are part of the toxicology investigator's consortium (toxic). eligible patients presented to the emergency department less than hours after known or suspected ingestion and had the initial apap level obtained at greater than but less than hours post ingestion. a second apap level was obtained at hours or more post-ingestion and plotted on the rumack-matthew nomogram to determine risk of toxicity. the outcome of interest was the npv of an initial apap level less than mcg/ml. a power analysis based on an alpha = . and power of . yielded the requirement of subjects. results: data were collected on patients over a month period from may to nov . patients excluded from npv analysis consisted of: initial apap level greater than mcg/ml ( ), negligible apap level on both the initial and confirmatory apap level ( ), initial apap level drawn less than one hour after ingestion ( ), or an unknown time of ingestion ( ). ninety-three patients met the eligibility criteria. two patients ( . %) with an initial apap level less than mcg/ml ( mcg/ml at min, mcg/ml at min) were determined to be at risk for toxicity based on oh s saem annual meeting abstracts implementation of an emergency department sign-out checklist improves patient hand-offs at change of shift nicole m ma computer-assisted self-interviews improve testing for chlamydia and gonorrhea in the pediatric emergency department is the australian triage system a better indicator of psychiatric patients' needs for intervention than the ena emergency severity index triage system? patients were given an initial dose of mg droperidol intramuscularly followed by an additional dose of mg after min if required. inclusion criteria were patients requiring physical restraint and parenteral sedation. the primary outcome was the time to sedation. secondary outcomes were the proportion of patients requiring additional sedation within the first hour, over-sedation measured as - on the sedation assessment tool, and respiratory compromise measured as oxygen saturation < %. results: droperidol was administered to patients and of these had sedation scores documented. presentations included % with alcohol intoxication. dose ranged from . mg to mg, median mg (interquartile range conclusion: droperidol is effective for rapid sedation for abd and rarely causes over-sedation serum creatinine (scr) is widely used to predict risk; however, gfr is a better assessment of kidney function. objectives: to compare the ability of gfr and scr to predict the development of cin among ed patients receiving cects. we hypothesized that gfr would be the best available predictor of cin. methods: this was a retrospective chart review of ed patients ‡ years old who had a chest or abdomen/pelvis cect between / / and / / . baseline and follow-up scr levels were recorded. patients with initial scr > . mg/dl were excluded, as per hospital radiology department protocol. cin was defined as a scr increase of either %, . mg/dl, or a gfr decrease of % within hours of contrast exposure. gfr was calculated using the ckd epi and mdrd formulae, and analyzed in original units and categorized form (< , ‡ ) with each additional unit decrease in ckd epi, subjects were % more likely to develop cin (or = . ) (p < . ). additionally, subjects with ckd epi < were . (or) times more likely to have cin than subjects with ckd epi ‡ in original units, ckd epi (p < . ) and mdrd (p < . ) both had a significantly higher auc than scr. conclusion: age, as an independent variable, is the best predictor of cin, when compared with scr and gfr. due to a small number of cases with cin, the confidence intervals associated with the odds ratios are wide. future research should focus on patient risk stratification and establishing ed interventions to prevent cin. a rat model of carbon monoxide induced neurotoxicity heather ellsworth non-traumatic subarachnoid hemorrhage diagnosed by lumbar puncture following non-diagnostic head ct: a retrospective case-control study and decision a dass score of > has been previously defined as an indicator of increased stress levels. multivariable logistic regression was utilized to identify demographic and work-life characteristics significantly associated with stress. results: . % of individuals responded to the survey ( , / , ) and prevalence of stress was estimated at . %. the following work-life characteristics were associated with stress: certification level, work experience, and service type. the odds of stress in paramedics was % higher when compared to emt-basics (or = . , % ci = . - . ). when compared to £ years of experience - . ) were more likely to be stressed. ems professionals working in county (or = ci = . - . ) and private services (or = ) were more likely than those working in fire-based services to be stressed. the following demographic characteristics were associated with stress: general health and smoking status finally, former smokers (or = . , % ci = . - . ) and current smokers (or = . , % ci = . - . ) were more likely to be stressed than non-smokers literature suggests this is within the range of stress among nurses, and lower than physicians. while the current study was able to identify demographic and work-life characteristics associated with stress, the long-term effects are largely unknown methods: design: prospective randomized controlled trial. subjects: female sus scrofa swine weighing - kg were infused with amitriptyline . mg/kg/minute until the map fell to % of baseline values. subjects were then randomized to experimental group (ife ml/kg followed by an infusion of . ml/kg/minute) or control group (sb meq/kg plus equal volume of normal saline). interventions: we measured continuous heart rate (hr), sbp, map, cardiac output (co), systemic vascular resistance (svr), and venous oxygen saturation (svo ). laboratory values monitored included ph, pco , bicarbonate, lactate, and amitriptyline levels. descriptive statistics including means, standard deviations, standard errors of measurement, and confidence limits were calculated. results: of swine, seven each were allocated to ife and sb groups. there was no difference at baseline for each group regarding hr, sbp, map, co, svr, or svo . ife and sb groups required similar mean amounts of tca to reach hypotension one ife and two sb pigs survived. conclusion: in this interim data analysis of amitriptyline-induced hypotensive swine, we found no difference in mitigating hypotension between ife and sb lipid rescue : a survey of poison center medical directors regarding intravenous fat emulsion therapy michael r. christian , erin m. pallasch cook county hospital (stroger), chicago, il reliability of non-toxic acetaminophen concentrations obtained less than hours after ingestion evaluating age in the field triage of injured background: hiv screening in eds is advocated to achieve the goal of comprehensive population screening. yet, hiv testing in the ed is sometimes thwarted by a patient's condition (e.g. intoxication) or environmental factors (e.g. other care activities). whether it is possible to test these patients at a later time is unknown. objectives: we aimed to determine if ed patients who were initially unable to receive an hiv testing offer might be tested in the ed at a later time. we hypothesized that factors preventing testing are transient and that there are subsequent opportunities to repeat testing offers. methods: we reviewed medical records for patients presenting to an urban, academic ed who were approached consecutively to offer hiv testing during randomly selected periods from january to january . patients for whom the initial attempted offer could not be completed were reviewed in detail with standardized abstraction forms, duplicate abstraction, and third-party discrepancy adjudication. primary outcomes included repeat hiv testing offers during that ed visit, and whether a testing offer might eventually have been possible either during the initial visit or at a later visit within months. outcomes are described as proportions with confidence intervals. results: of patients approached, initial testing offers could not be completed for ( %). these were % male, % white, and had a median age of ( - ). a repeat offer of testing during the initial visit would have been possible for / ( %), and / ( %) were actually offered testing on repeat approach. of the for whom a testing offer would not have been possible on the initial visit, ( %) had at least one additional visit within months, and / ( %) could have been offered testing on at least one visit. overall, a repeat testing offer would have been possible for / ( %, % ci - %). conclusion: factors preventing an initial offer of hiv testing in the ed are generally transient. opportunities for repeat approach during initial or later ed encounters suggest that, given sufficient resources, the ed could succeed in comprehensively screening the population presenting for care. ed screening personnel who are initially unable to offer testing should repeat their attempt. hiv adopt an ''opt-out'' rapid hiv screening model in order to identify hiv infected patients. previous studies nationwide have shown acceptance rates for hiv screening of - % in emergency departments. however, it is unknown how acceptance rates will vary in a culturally and ethnically diverse urban emergency department.objectives: to determine the characteristics of patients who accept or refuse ''opt-out'' hiv screening in an urban emergency department.methods: a self-administered, anonymous survey is administered to ed patients who are to years of age. the questionnaire is administered in english, russian, mandarin, and spanish. questions include demographic characteristics, hiv risk factors, perception of hiv risk, and acceptance of rapid hiv screening in the emergency department. results: to date patients responded to our survey. of the , ( . %) did not accept an hiv test (group ) in their current ed visit and ( . %) accepted an hiv test (group ). the major two reasons given for opting out (i.e., group ) was ''i do not feel that i am at risk'' ( . %) and ''i have been tested for hiv before'' ( . %). there was no difference between the groups in regards to sex (p = . ), age (p = . ), religious affiliation (p = . ), marital status (p = . ), language spoken at home (p = . ), and whether they had been hiv tested before ( . % in group and . % in group ; p = . ). however, there was a statistically significant difference with regards to educational level and income. more patients in group ( . %) and . % in group had less than a college level education (p < . ). similarly, more patients in group ( . %) and only . % in group had an annual household income of £$ , (p < . ). conclusion: in a culturally and ethnically diverse urban emergency department, patients with a lower socioeconomic status and educational level tend to opt out of hiv screening test offered in the ed. no significant difference in acceptance of ed hiv testing was found to date based on primary language spoken at home or religious affiliation background: antimicrobial resistance is a problem that affects all emergency departments. objectives: our goal was to examine all urinary pathogens and their resistance patterns from urine cultures collected in the emergency department (ed).methods: this study was performed at an urban/suburban community-teaching hospital with an annual volume of , visits. using electronic records, all cases of urine cultures received in were reviewed for data including type of bacteria, antibiotic resistance, and health care exposure (hcx). hcx was defined as no prior hospitalization within the previous six months, hospitalization within the previous three months, hospitalization within the previous six months, nursing home resident (nh), and presence of an indwelling urinary catheter (uc). an investigator abstracted all data with a second re-abstracting a random % for kappa statistics between . and . . group background: approximately - % of patients treated with epinephrine for anaphylaxis receive a second dose but the risk factors associated with repeat epinephrine use remain poorly defined. objectives: to determine whether obesity is a risk factor for requiring + epinephrine doses for patients who present to the emergency department (ed) with anaphylaxis due to food allergy or stinging insect hypersensitivity. methods: we performed a retrospective chart review at four tertiary care hospitals that care for adults and children in new england between the following time periods: massachusetts general hospital ( / / - / / ), brigham and women's hospital ( / / - / / ), children's hospital boston ( / / - / / ), hasbro children's hospital ( / / - / / ). we reviewed the medical records of all patients presenting to the ed for food allergy or stinging insect hypersensitivity using icd cm codes. we focused on anthropomorphic data and number of epinephrine treatments given before and during the ed visit. among children, calculated bmis were classified according to cdc growth indicators as underweight, healthy, overweight, or obese. all patients who presented on or after their th birthday were considered adults.background: transitions of care are ubiquitous in the emergency department (ed) and inevitably introduce the opportunity for errors. despite recommendations in the literature, few emergency medicine (em) residency programs provide formal training or standard process for patient hand-offs. checklists have been shown to be effective quality improvement measures in inpatient settings and may be a feasible method to improve ed hand-offs. objectives: to determine if the use of a sign-out checklist improves the accuracy and efficiency of resident sign-out in the ed as measured by reduced omission of key information, communication behaviors, and time to sign-out each patient. methods: a prospective study of first-and second-year em and non-em residents rotating in the ed at an urban academic medical center with an annual ed volume of , . trained clinical research assistants observed resident sign-out during shift change over a two-week period and completed a -point binary observable behavior data collection tool to indicate whether or not key components of sign-out occurred. time to sign out each patient was recorded. we then created and implemented a computerized sign-out checklist consisting of key elements that should be addressed during transitions of care, and instructed residents to use this during hand-offs. a two-week post-intervention observation phase was conducted using the same data collection tool. proportions, means, and non-parametric comparison tests were calculated using stata. results: one hundred fifteen sign-outs were observed prior to checklist implementation and after; one sign-out was excluded for incompleteness. significant improvements were seen in four of the measured signout components: inclusion of history of present illness increased by % (p < . ), likely diagnosis increased by % (p = . ), disposition status increased by % (p < . ), and patient/care team awareness of plan increased by % (p < . ). (figure ) time data for sign-outs pre-implementation and post-implementation were available. seven sign-outs were excluded for incompleteness or spurious values. mean length of sign out was s ( % ci to ) and . s ( % ci to ) per patient. conclusion: implementation of a checklist improved the transfer of information but did not affect the overall length of time for the sign-out. the objectives: to determine risk factors associated with adult patients presenting to the ed with cellulitis who fail initial antibiotic therapy and require a change of antibiotics or admission to hospital. methods: this was a prospective cohort study of patients ‡ years presenting with cellulitis to one of two tertiary care eds (combined annual census , ). patients were excluded if they had been treated with antibiotics for the cellulitis prior to presenting to the ed, if they were admitted to hospital, or had an abscess only. trained research personnel administered a questionnaire at the initial ed visit with telephone follow-up weeks later. patient characteristics were summarized using descriptive statistics and % confidence intervals (cis) were estimated using standard equations. backwards stepwise multivariable logistic regression models determined predictor variables independently associated with treatment failure (failed initial antibiotic therapy and required a change of antibiotics or admission to hospital). results: patients were enrolled, were excluded, and were lost to follow-up. the mean (sd) age was . ( . ) and . % were male. ( . %) patients were given antibiotics in the ed. ( . %) were given oral, ( . %) were given iv, and ( . %) patients were given both oral and iv antibiotics. ( . %) patients had a treatment failure. fever (temp > °c) at triage (or: . , % ci: . , . ), leg ulcers (or: . , % ci: . , . ), edema or lymphedema (or: . , % ci: . , . ), and prior cellulitis in the same area (or: . , % ci: . , . ) were independently associated with treatment failure. conclusion: this analysis found four risk factors associated with treatment failure in patients presenting to the ed with cellulitis. these risk factors should be considered when initiating empiric outpatient antibiotic therapy for patients with uncomplicated cellulitis. use background: children presenting for care to a pediatric emergency department (ped) commonly require intravenous catheter (iv) placement. prior studies report that the average number of sticks to successfully place an iv in children is . . successfully placing an iv requires identification of appropriate venous access targets. the veinviewer visionÒ (vvv) assists with iv placement by projecting a map of subcutaneous veins on the surface of the skin using near infrared light. objectives: to compare the effectiveness of the vvv versus standard approaches: sight (s) and sight plus palpation (s+p) for identifying peripheral veins for intravenous catheter placement in children treated in a ped. methods: experienced pediatric emergency nurses and physicians identified peripheral venous access targets appropriate for intravenous cannulation of a cross-sectional convenience sample of english speaking children aged - years presenting for treatment of sub-critical injury or illness whose parents provided consent. the clinicians marked the veins with different colored washable marker and counted them on the dorsum of the hand and in the antecubital fossa using the three approaches: s, s+p, and vvv. a trained research assistant photographed each site for independent counting after each marking and recorded demographics and bmi. counts were validated using independent photographic analyses. data were entered into sas . and analyzed using paired t-tests. results: patients completed the study. clinicians were able to identify significantly more veins on the dorsum of the hand using vvv than s alone or s+p, . (p < . , ci . - . ) and . (p < . , ci . - . ), respectively, as well as significantly more veins in the antecubital fossa using vvv than s alone or s+p, . (p < . , ci . - . ) and . (p < . , ci . - . ), respectively. the differences in numbers of veins identified remained significant at p < . level across all ages, races, and bmis of children and across clinicians and validating independent photographic analyses. conclusion: experienced emergency nurses and physicians were able to identify significantly more venous access targets appropriate for intravenous cannulation in the dorsum of the hand and antecubital fossa of children presenting for treatment in a ped using vvv than the standard approaches of sight or sight plus palpation. an background: mental health emergencies have increased over the past two decades, and contribute to the ongoing rise in u.s. ed visit volumes. although data are limited, there is a general perception that the availability of in-person psychiatric consultation in the ed and of inpatient psychiatric beds is inadequate. objectives: to examine the availability of in-person psychiatry consultation in a heterogeneous sample of u.s. eds, and typical delays in transfer of ed patients to an inpatient psychiatric bed. methods: during - , we mailed a survey to all ed directors in a convenience sample of nine us states (ar, co, ga, hi, ma, mn, or, vt, and wy). all sites were asked: ''are psychiatric consults available in-person to the ed?'' (yes/no), with affirmative respondents asked about the typical delay. sites also were asked about typical ed boarding time between a request for patient transfer and actual patient departure from the ed to an inpatient psychiatric bed. ed characteristics included rural/urban location, visit volume (visits/hour), admission rate, ed staffing, and the proportion of patients without insurance. data analysis used chi-square tests and multivariable logistic regression. results: surveys were collected from ( %) of the eds, with > % response rate in every state. overall, only % responded that psychiatric consults were available in-person to the ed. in multivariable logistic regression, ed characteristics independently associated with lack of in-person psychiatric consultation were: location within specific states (eg, ar, ga), rural location, lower visit volume, and lower admission rate. among the subset of eds with psychiatric consults available, % reported a typical wait time of at least hour. overall, % of eds reported that the typical time from request to actual patient transfer to an inpatient psychiatric bed was > hours, and % reported a maximum time in past year of > day (median days, iqr - ). in a multivariable model, location in ma and higher visit volume were associated with greater odds of a maximum wait time of > day. conclusion: among surveyed eds in nine states, only % have in-person psychiatric consultants available. moreover, approximately half of eds report boarding times of > h from request for transfer to actual departure to an inpatient psychiatric bed.background: many emergency departments (ed) in the united states use a five tiered triage protocol that has a limited evaluation of psychiatric patients. the australian triage scale (ats), a psychiatric triage system, has been used throughout australia and new zealand since the early s. objectives: the objective of the study is to compare the current triage system, emergency nurses association (ena) esi -tier, to the ats for the evaluation of the psychiatric patients presenting to the ed. methods: a convenience sample of patients, years of age and older, presenting with psychiatric complaints at triage were given the ena triage assessment by the triage nurse. a second triage assessment, performed by a research fellow, included all observed and reported elements using the ats protocol, a self-assessment survey and an agitation assessment using the richmond agitation sedation scale (rass). the study was performed at an inner city level i trauma center with , visits per year. the ed was a catchment facility for the police department for psychiatric patients in the area. patients were excluded if they were unstable, unable to communicate, or had a non-psychiatric complaint. results were analyzed in spss v . the analysis of data used frequencies, descriptive and anova. results: a total of patients were enrolled in the study: % were african american, % caucasian, % hispanic, % asian, and % indian; % of subjects enrolled were male. the patients' level of agitation using rass showed % were alert and calm, % were restless and anxious, % were agitated, and % combative, violent, or dangerous to self. the only significant correlation found was among the ats and several self assessment questions: ''i feel agitated on a to scale'' (p = . ) and ''i feel violent on a to scale'' (p = . ). there were no significant correlations found among the ena triage, rass scores, and throughput times. conclusion: the ats test was more sensitive to the patient declaring that he or she was agitated or felt violent. this shows that this system might be a more useful system in determining the severity of need of psychiatric patients presenting to the ed. variations background: hemoglobin-based oxygen carriers (hbocs) have been evaluated for small-volume resuscitation of hemorrhagic shock due to their oxygen carrying capability, but have found limited utility due to vasoactive side-effects from nitric oxide (no) scavenging. objectives: to define an optimal hboc dosing strategy and evaluate the effect of an added no donor, we use a prehospital swine polytrauma model to compare the effect of low-vs. moderate-volume hboc resuscitation with and without nitroglycerin (ntg) co-infusion as an no donor. we hypothesize that survival time will improve with moderate resuscitation and that an no donor will add additional benefit. methods: survival time was compared in groups (n = ) of anesthetized swine subjected to simultaneous traumatic brain injury and uncontrolled hemorrhagic shock by aortic tear. animals received one of three different resuscitation fluids: lactated ringers (lr), hboc, or vasoattenuated hboc with ntg co-infusion. for comparison, these fluids were given in a severely limited fashion (sl) as one bolus every minutes up to four total, or a moderately limited fashion (ml) as one bolus every minutes up to seven total, to maintain mean arterial pressure ‡ mmhg. comparison of resuscitation regimen and fluid type on survival time was made using two-way anova with interaction and tukey kramer adjustment for individual comparisons. results: there was a significant interaction between fluid regimen and resuscitation fluid type (anova, p = . ) indicating that the response to sl or ml resuscitation was fluid type-dependent. within the lr and hboc+ntg groups, survival time (mean, %ci) was longer for sl, . min ( injuries are common and result from many different mechanisms of injury (moi). knowing common fracture locations may help in diagnosis and treatment, especially in patients presenting with distracting injuries that may mask the pain of a radius fracture.objectives: we set out to determine the incidence of radius fracture locations among patients presenting to an urban emergency department (ed).background: carbon monoxide (co) is the leading cause of poisoning morbidity and mortality in the united states. standard treatment includes supplemental oxygen and supportive care. the utility of hyperbaric oxygen (hbo) therapy has been challenged by a recent cochrane review. hypothermia may mitigate delayed neurotoxic effects after co poisoning as it is effective in cardiac arrest patients with similar neuropathology. objectives: to develop a rat model of acute and delayed severe co toxicity as measured by behavioral deficits and cell necrosis in post-sacrifice brain tissue.methods: a total of rats were used for model development; variable concentrations of co and exposure times were compared to achieve severe toxicity. for the protocol, six senescent long evans rats were exposed to , ppm of co for minutes then , ppm for minutes, followed by three successive dives at , ppm with an endpoint of apnea or seizure; there was a brief interlude between dives for recovery. a modified katz assessment tool was used to assess behavior at baseline and hours, day, and , , , , , and weeks post-exposure. following this, the brains were transcardially fixed with formalin, and lm sagittal slices were embedded in paraffin and stained with hematoxylin and eosin. a pathologist quantified the percentage of necrotic cells in the cortex, hippocampus (pyramidal cells), caudoputamen, cerebellum (purkinje cells), dentate gyrus, and thalamus of each brain to the nearest % from randomly selected high power fields ( x background: there remains controversy about the cardiotoxic effects of droperidol, and in particular the risk of qt prolongation and torsades des pointes (tdp).objectives: this study aimed to investigate the cardiac and haemodynamic effects of high-dose parenteral droperidol for sedation of acute behavioural disturbance (abd) in the emergency department (ed). methods: a standardised intramuscular (im) protocol for the sedation of ed patients with abd was instituted as part of a prospective observational safety study in four regional and metropolitan eds. patients with abd were given an initial dose of mg droperidol followed by an additional dose of mg after min if required. inclusion criteria were patients requiring physical restraint and parenteral sedation. the primary outcome was the proportion of patients who have a prolonged qt interval on ecg. the qt interval was plotted against the heart rate (hr) on the qt nomogram to determine if the qt was abnormal. secondary outcomes were frequency of hypotension and cardiac arrhythmias. results: ecgs were available from of patients with abd given droperidol. the median dose was mg (iqr - mg; range: to mg). the median age was years (rnge: to ) and were males ( %). a total of four ( %) qt-hr pairs were above the ''at-risk'' line on the qt nomogram. transient hypotension occurred in ( %), and no arrhythmias were detected.conclusion: droperidol appears to be safe when used for rapid sedation in the dose range of to mg. it rarely causes hypotension or qt prolongation. blood background: soldiers and law enforcement agents are repeatedly exposed to blast events in the course of carrying out their duties during training and combat operations. little data exist on the effect of this exposure on the physiological function of the human body. both military and law enforcement dynamic entry personnel, ''breachers'', began expressing sensitivity to the risk of injury as a result of multiple blast exposures. breachers apply explosives as a means of gaining access to barricaded or hardened structures. these specialists can be exposed to as many as a dozen lead-encased charges per day during training exercises.objectives: this observational study was performed by the breacher injury consortium to determine the effect of short-term exposure to blasts by breachers on whole blood lead levels (blls) and zinc protoporphyrin levels (zppls). methods: two -week basic breaching training classes were conducted by the united states marine corps' weapons training battalion dynamic entry school. each class included students and up to three instructors, with six non-breaching marines serving as a control group. to evaluate for lead exposure, venous blood samples were acquired from study participants on the weekend prior and following training in the first training class, whereas the second training class had an additional level performed mid-training. blls and zppls were measured in a whole-blood sample using the furnace atomic absorption method and hematofuorimeter method, respectively. results: analysis of these blast injury data indicated students demonstrated significantly increased blls post-explosion (mean = mcg/dl, sd . , p < . ) compared to pre-training (mean = mcg/dl, sd . ) and control subjects (mean = mcg/dl, sd . , p < . ). instructors also demonstrated significantly increased blls post explosion (mean = mcg/dl, sd . , p < . ) compared to pre-training (mean = mcg/ dl, sd . ) and control subjects (mean = mcg/dl, sd . , p < . ). student and instructor zppls were not significantly different in post-training compared to pretraining or control groups. conclusion: the observation from this study that breachers are at risk of mild increases in blls support the need for further investigation into the role of lead following repeated blast exposure with munitions encased in lead. direct observation of the background: notification of a patient's death to family members represents a challenging and stressful task for emergency physicians. complex communication skills such as those required for breaking bad news (bbn) are conventionally taught with small-group and other interactive learning formats. we developed a de novo multi-media web-based learning (wbl) module of curriculum content for a standardized patient interaction (spi) for senior medical students during their emergency medicine rotation.objectives: we proposed that use of an asynchronous wbl module would result in students' skill acquisition for breaking bad news. methods: we tracked module utilization and performance on the spi to determine whether students accessed the materials and if they were able to demonstrate proficiency in its application. performance on the spi was assessed utilizing a bbn-specific content instrument developed from the griev_ing mnemonic as well as a previously validated instrument for assessing communication skills.results: three hundred seventy-two students were enrolled in the bbn curriculum. there was a % completion rate of the wbl module despite students being given the option to utilize review articles alone for preparation. students interacted with the activities within the module as evidenced by a mean number of mouse clicks of . (sd . ). overall spi scores were . %, (sd . ) with content checklist scores of . % (sd . ) and interpersonal communication scores . % (sd . ). five students had failing content scores (< %) on the spi and had a mean number of clicks of . (sd . ), which is not significantly lower than those passing (p = . ). students in the first year of wbl deployment completed self-confidence assessments which showed significant increases in confidence ( . tobackground: pelvis ultrasonography (us) is a useful bedside tool for the evaluation of women with suspected pelvic pathology. while pelvic us is often performed by the radiology department, it often lacks clinical correlation and takes more time than bedside us in the ed. this was a prospective observational study comparing the ed length of stay (los) of patients receiving ed us versus those receiving radiology us. objectives: the primary objective was to measure the difference in ed los. the secondary objectives were to ) assess the role of pregnancy status, ob/gyn consult in the ed, and disposition, in influencing the ed los; and ) to assess the safety of ed us by looking at patient return to the ed within weeks and whether that led to an alternative diagnosis.methods: subjects were women over years old presenting with a gi or gu complaint, and who received either an ed or radiology us. a t-test was used for the primary objective, and linear regression to test the secondary objective. odds ratios were performed to assess for interaction between these factors and type of ultrasound. subgroup analyses were performed if significant interaction was detected. results: forty-eight patients received an ed us and patients received a radiology us. subjects receiving an ed us spent minutes less in the ed (p < . ). in multivariate analysis, even when controlling for pregnancy status, ob/gyn consult, and disposition, patients who received an ed us had a los reduction of minutes (p < . ). in odds ratio analysis, patients who were pregnant were times more likely to have received an ed us (p < . ). patients who received an ob/gyn consult in the ed were five times more likely to receive a radiology us (p < . ). there was no association between type of us and disposition. in subgroup analyses, pregnant and non-pregnant patients who received an ed us still had a los reduction of minutes (p < . ) and minutes (p < . ), respectively. sample sizes were inadequate for subgroup analysis for subjects who had ob/gyn consults. in patients who did not receive an ob/gyn consult, those who received an ed us had a los reduction of minutes (p < . ). finally, % of subjects returned within two weeks, but none led to an alternative diagnosis. conclusion: even when controlling for disposition, ob/gyn consultation, and pregnancy status, patients who received an ed us had a statistically and clinically significant reduction in their ed los. in addition, ed us is safe and accurate. background: although early surface cooling of burns reduces pain and depth of injury, there are concerns that cooling of large burns may result in hypothermia and worse outcomes. in contrast, controlled mild hypothermia improves outcomes after cardiac arrest and traumatic burn injury. objectives: the authors hypothesized that controlled mild hypothermia would prolong survival in a fluidresuscitated rat model of large scald burns. methods: forty sprague-dawley rats ( - g) were anesthetized with mg/kg intramuscular ketamine and mg/kg xylazine, with supplemental inhalational isoflurane as needed. a single full-thickness scald burn covering % of the total body surface area was created per rat using a mason-walker template placed in boiling water ( deg c) for a period of seconds. the rats were randomized to hypothermia (n = ) and nonhypothermia (n = ). core body temperature was continuously monitored with a rectal temperature probe. hypothermia was induced through intraperitoneal injection of cooled ( deg c) saline. the core temperature was reduced by deg c and maintained for a period of hours, applying an ice or heat pack when necessary. the rats were then rewarmed back to baseline temperature. in the control group, room temperature saline was injected into the intraperitoneal cavity and core temperature was maintained using a heating pad as needed. the rats were monitored until death or for a period of days, whichever was greater. the primary outcome was death. the difference in survival was determined using a kaplan-meier analysis or log rank test. results: the mean core temperatures were . deg c for the hypothermic group and . deg c for the normothermic group. the mean survival times were hours for the hypothermic group ( % confidence interval [ci] = to ) and hours for the normothermic group ( % ci = to ). the seven-day survival rates in the hypothermic and non-hypothermic groups were % and %. these differences were not significant, p = . for both comparisons. conclusion: induction of brief mild hypothermia increases but does not significantly prolong survival in a resuscitated rat model of large scald burns. serum objectives: we sought to determine levels of serum mtdna in ed patients with sepsis compared to controls and the association between mtdna and both inflammation and severity of illness among patients with sepsis. methods: prospective observational study of patients presenting to one of three large, urban, tertiary care eds. inclusion criteria: ) septic shock: suspected infection, two or more systemic inflammatory response (sirs) criteria, and systolic blood pressure (sbp) < mmhg despite a fluid bolus; ) sepsis: suspected infection, two or more sirs criteria, and sbp > mmhg; and ) control: ed patients without suspected infection, no sirs criteria, and sbp > mmhg. three mtdnas (cox-iii, cytochrome b, and nadh) were measured using real-time quantitative pcr from serum drawn at enrollment. il- and il- were measured using a bio-plex suspension array system. baseline characteristics, il- , il- , and mtdnas were compared using one way anova or fisher exact test, as appropriate. correlations between mtdnas and il- /il- were determined using spearman's rank. linear regression models were constructed using sofa score as the dependent variable, and each mtdna as the variable of interest in an independent model. a bonferroni adjustment was made for multiple comparisons.results: of patients, were controls, had sepsis, and had septic shock. we found no significant difference in any serum mtdnas among the cohorts (p = . to . ). all mtdnas showed a small but significant negative correlation with il- and il- (q = ) . to ) . ). among patients with sepsis or septic shock (n = ), we found a small but significant negative association between mtdna and sofa score, most clearly with cytochrome b (p = . ). conclusion: we found no difference in serum mtdnas between patients with sepsis, septic shock, and controls. serum mtdnas were negatively associated with inflammation and severity of illness, suggesting that as opposed to trauma, serum mtdna does not significantly contribute to the pathophysiology of the sepsis syndromes. methods: we consecutively enrolled ed patients ‡ years of age who met anaphylaxis diagnostic criteria from april to july at a tertiary center with , annual visits. we collected data on antihypertensive medications, suspected causes, signs and symptoms, ed management, and disposition. markers of severe anaphylaxis were defined as ) intubation, ) hospitalization (icu or floor), and ) signs and symptoms involving ‡ organ systems. antihypertensive medications evaluated included beta-blockers, angiotensin converting enzyme (ace) inhibitors, and calcium channel blockers (ccb). we conducted univariate and multivariate analyses to measure the association between antihypertensive medications and markers of severe anaphylaxis. because previous studies demonstrated an association between age and the suspected cause of the reaction with anaphylaxis severity, we adjusted for these known confounders in multivariate analyses. we report associations as odds ratios (ors) and corresponding % cis with p-values. results: among patients with anaphylaxis, median age (iqr) was ( - ) and ( . %) were female. eight ( . %) patients were intubated, ( %) required hospitalization, and ( %) had ‡ system involvement. forty-nine ( %) were on beta-blockers, ( %) on ace inhibitors, and ( . %) on ccb. in univariate analysis, ace inhibitors were associated with intubation and ‡ system involvement and ccb were associated with hospital admission. in multivariate analysis, after adjusting for age and suspected cause, ace inhibitors remained associated with hospital admission and beta-blockers remained associated with both hospital admission and ‡ system involvement. conclusion: in ed patients, beta-blocker and ace inhibitor use may predict increased anaphylaxis severity independent of age and suspected cause of the anaphylactic reaction. background: advanced cardiac life support (acls) resuscitation requires rapid assessment and intervention. some skills like patient assessment, quality cpr, defibrillation, and medication administration require provider confidence to be performed quickly and correctly. it is unclear, however, whether high-fidelity simulation can improve confidence with a multidisciplinary group of providers with high levels of clinical experience. objectives: the purpose of the study was to test the hypothesis that providers undergoing high-fidelity simulation of cardiopulmonary arrest scenarios will express greater confidence. methods: this was a prospective cohort study conducted at an urban level i trauma center from january to october with a convenience sample of registered (rn) and license practical nurses, nurse practitioners, resident physicians, and physician assistants who agreed to participate in / high-fidelity simulation (laerdal g) sessions of cardiopulmonary arrest scenarios about months apart. demographics were recorded. providers completed a validated preand post-test five-point likert scale confidence measurement tool before and after each session that ranged from not at all confident ( ) to very confident ( ) in recognizing signs and symptoms of, appropriately intervening in, and evaluating intervention effectiveness in cardiac and respiratory arrests. descriptive statistics, paired t-tests, and anova were used for data analysis. sensitivity testing evaluated subjects who completed their second session at months rather than months. results: sixty-five subjects completed consent, completed one session, and completed at least two background: prehospital studies have focused on the effect of health care provider gender on patient satisfaction. we know of no study that has assessed patient satisfication with patient and prehospital provider gender. some studies have shown higher patient satisfaction rates when cared for by a female health care provider.objectives: to determine the effect of ems provider gender on patient satisfaction with prehospital care. methods: a convenience sampling of all adult patients brought in to our ed, an urban level i trauma center by ambulance. a trained research associate (ra) stationed at triage conducted a survey using press ganey ems patient satisfaction questions. there were thirteen questions evaluating prehospital provider skills such as driving, courtesy, listening, medical care, and communication. each skill was assigned a point value between one and five; the higher the value the better the skill was performed. the patient's ambulance care report was copied for additional data extraction.results: a total of surveys were done. average patient age was , and % were female. scores for all questions totaled (mean . ± . ). prehospital providers pairings were: male-male (n = ), male-female (n = ), and female-female (n = ). there were no statistically significant differences in scores between our pairings (mean scores for male:male . , male:female . , and female:female . ; p = . ). we found nonstatistical differences in satisfaction scores based on the gender of the emt in the back of the ambulance: males had a mean score of . and females had a mean score of . (p = . ). we examined gender concordance by comparing gender of the patient to the gender of the prehospital provider and found that male-male had a mean score of . , female-female . , and when the patient and prehospital provider gender did not match, . (p = . ). conclusion: we found no effect of gender difference on patient satisfaction with prehospital care. we also found that overall, patients are very satisfied with their prehospital care. objectives: we set out to determine the sensitivity and specificity of eps in determining the presence of recently ingested tablets or tablet fragments.methods: this was a prospective volunteer study at an academic emergency department. healthy volunteers were enrolled and kept npo for hours prior to tablet ingestion. over minutes subjects ingested ml of water and tablets. ultrasounds video clips were performed prior to any tablet ingestion, after drinking ml of water, after tablets, after tablets, after tablets, and minutes after the final tablet ingestion yielding six clips per volunteer. all video clips were randomized and shown to three eps who were fellowship-trained in emergency ultrasound. eps recorded the presence or absence of tablets.results: ten volunteers underwent the pill ingestion protocol and sixty clips were collected. results for all cases and each rater are reported in the table. overall there was moderate agreement between raters (kappa = . ). sub-group analysis of , , or pills did not show any significant improvement in sensitivity and specificity.conclusion: ultrasound has moderate specificity but poor sensitivity for identification of tablet ingestion. these results imply that point-of-care ultrasound has limited utility in diagnosing large tablet ingestion. background: intravenous fat emulsion (ife) therapy is a novel treatment that has been used to reverse the acute toxicity of some xenobiotics with varied success. us poison control centers (pcc) are recommending this therapy for clinical use, but data regarding these recommendations are lacking.objectives: to determine how us pcc have incorporated ife as a treatment strategy for poisoning. methods: a closed-format multiple-choice survey instrument was developed, piloted, revised, and then sent electronically to every medical director of an accredited us pcc using surveymonkey in march ; addresses were obtained from the aapcc listserv, participation was voluntary and remained anonymous; three reminder invitations were sent during the study period. data were analyzed using descriptive statistics.results: forty-five of ( %) pcc medical directors completed the survey. all respondents felt that ife therapy played a role in the acute overdose setting. thirty ( %) pcc have a protocol for ife therapy: ( %) recommend an initial bolus of . ml/kg of a % lipid emulsion, ( %) pcc recommend an infusion of lipids, and / pcc recommend an initial infusion rate of . ml/kg of a % lipid emulsion. thirty-three ( %) felt that ife had no clinically significant side effects at a bolus dose of . ml/kg ( % emulsion). forty-four directors ( %) felt that the ''lipid sink'' mechanism contributed to the clinical effects of ife therapy, but ( %) felt that there was a yet undiscovered mechanism that likely contributed as well. in a scenario with cardiac arrest due to a single xenobiotic, directors stated that their center would always or often recommend ife after overdose of bupivicaine ( ; %), verapamil ( ; %), amitriptyline ( ; %), or an unknown xenobiotic ( ; %). in a scenario with significant hemodynamic instability due to a single xenobiotic, directors stated that their pcc would always or often recommend ife after overdose of bupivicaine ( ; %), verapamil ( ; %), amitriptyline ( ; %), or an unknown xenobiotic ( ; %).conclusion: ife therapy is being recommended by us pcc. protocols and dosing regimens are nearly uniform. most directors feel that ife is safe but are more likely to recommend ife in patients with cardiac arrest than in patients with severe hemodynamic compromise. further research is warranted. levels drawn at hours or more ( mcg/ml at hours, mcg ⁄ ml at hours, respectively). npv for toxic ingestion of an initial apap level less than mcg/ml was . % ( % ci . - . %).conclusion: an apap level of less than mcg/ml drawn less than hours after ingestion had a high npv for excluding toxic ingestion. however, the authors would not recommend reliance on levels obtained under hours to exclude toxicity as the potential for up to . % false negative results is considered unacceptable. background: genetic variations in the mu-opioid receptor gene (oprm ) mediate individual differences in response to pain and addiction.objectives: to study whether the common a g (rs ) mu-opioid receptor single nucleotide polymorphism (snp) or the alternative splicing snp of oprm (rs ) was associated with overdose severity, we assessed allele frequencies of each including associations with clinical severity in patients presenting to the emergency department (ed) with acute drug overdose. methods: in an observational cohort study at an urban teaching hospital, we evaluated consecutive adult ed patients presenting with suspected acute drug overdose over a -month period for whom discarded blood samples were available for analysis. specimens were linked with clinical variables (demographics, urine toxicology screens, clinical outcomes) then de-identified prior to genetic snp analysis. in-hospital severe outcomes were defined as either respiratory arrest (ra, defined by mechanical ventilation) or cardiac arrest (ca, defined by loss of pulse). blinded taqman genotyping (applied biosystems) of the snps were performed after standard dna purification (qiagen) and whole genome amplification (qiagen repli-g). the plink . genetic association analysis program was used to verify snp data quality, test for departure from hardy-weinberg equilibrium, and test individual snps for statistical association. results: we evaluated patients ( % female, mean age . ) who overall suffered ras and cas (of whom died). urine toxicology was positive in %, of which there were positives for benzodiazepines, cocaine, opiates, methadone, and barbiturates. all genotypes examined conformed to hardy-weinberg equilibrium. the g allele was associated with . fold increased odds of ca/ra (or . , p < . ). the rs mutant allele was not associated with ca/ ra. conclusion: these data suggest that the g mutant allele of the oprm gene is associated with worse clinical severity in patients with acute drug overdose. the findings add to the growing body of evidence linking the a g snp with clinical outcome and raise the question as to whether the a g snp may be a potential target for personalized medical prescribing practices with regard to behavioral/physiologic overdose vulnerability. key: cord- - sqbqjm authors: nan title: monday: posters date: - - journal: vox sang doi: . /j. - . . .x sha: doc_id: cord_uid: sqbqjm nan from the perspective of causal inference, there is a hierarchy of evidence, ranging from case-series to large randomized controlled trials (rcts). in addressing a particular clinical or policy problem, clinicians or policy-makers can base their decisions on the types of clinical reports that have been published, along with an assessment of the strengths and weaknesses of each study. rcts are controlled clinical experiments in which patients are randomly allocated by the investigators to receive a treatment under study. if randomization is used, all participants are equally likely to be allocated to either the treatment or the control arm of the study. rcts should be distinguished from observational studies in which investigators passively observe patients who happen to receive a treatment under study. because the allocation of subjects to the treatment and control arms of an rct is random, the play of chance should distribute all confounding factors equally between these two arms. thus, the treatment and control arms of an rct should be equivalent with respect to all confounding factors except for the treatment under study. randomization removes selection bias, because neither the investigator nor the participant knows what the treatment allocation will be before a patient enters a study. moreover, if an rct is double-blind, observation bias is also removed, because preconceived notions about benefit from the treatment cannot color the reporting of symptoms by a patient or the assessment of disease activity by an investigator. when the undertaking of rcts is deemed unlikely, meta-analyses of individual patient data, that is, of the data recorded previously on subjects enrolled in published, small rcts may allow investigators to address issues of possible biases ed- - standardizing blood components would allow better monitoring of the effectiveness of transfusion d davenport university of michigan, ann arbor, mi, usa in routine transfusion of red blood cells (rbc) or platelet concentrates (pc), we have only a very rough idea of the dose we administer. the minimum expected hemoglobin content of rbc should be g (fda criteria). however, actual measurements have found a mean hemoglobin content of . ± . g per unit, with variability between manufacturers. percent of units may contain less than . g of hemoglobin while percent may contain more than . g. the effect of storage senescence can magnify these differences. the resulting hematocrit increase, depending on size of recipient and age of a unit, may be . to percent. apheresis collection of rbc can help standardized unit contents, but this technology is relatively expensive and time consuming. knowledge of actual hemoglobin content can be used to optimize red cell transfusion. one trial, using a simple formula incorporating the desired hemoglobin and estimated blood volume, showed that nearly percent of transfusion orders could be met with one unit while achieving a mean target hemoglobin of . g/dl. for pc transfusion, about percent of transfusions achieve the targeted dose of - ¥ platelets in actual practice, with considerable variability between institutions. without knowledge of the actual content of pc, determination of refractoriness and response to matched pc is problematic. standardization and labeling of rbc and pc units for content will permit accurate dosage and quantification of transfusion practice. are transfusion guidelines evidence-based? jp aubuchon dartmouth-hitchcock medical center, lebanon, nh, usa application of the results of randomized, controlled clinical trials to similar clinical situations should increase the predictability of the outcomes of transfusions. unfortunately, too few such trials have been conducted to investigate all the potential situations where transfusion might be applied. however, the ones that have been reported indicate that, in general, transfusion is unlikely to provide substantial benefit in many of the situations where it is routinely used. in the intensive care setting, transfusing red cells at a trigger point of g/dl rather than g/dl not only did not lead to increased anemic morbidity but was actually associated with a reduction in overall mortality. subgroup analyses indicated transfusion at the higher trigger point did not decrease morbidity in patients with cardiac disease nor decrease the time until weaning from a ventilator. following cardiac surgery, a transfusion trigger of a hematocrit of % yielded the same outcomes as one of %. an observational study suggested that patients with peripheral vascular disease and a post-operative hematocrit below % were more likely to suffer a morbid cardiac event, but this group of patients had more evidence of anemia and cardiac ischemia preoperatively, illustrating the pitfalls of observational studies. most would agree that transfusion is necessary below a hb of g/dl and unlikely to be necessary at a hb above g/dl, but most patients fall between these limits, and there are insufficient data in the and residual confounding factors, and may permit them to make a judgment of a causal relationship. sackett proposed that the evidence generated from meta-analyses of individual patient data be regarded as being equivalent in strength to that generated from rcts. meta-analysis is the structured and systematic integration of information from different studies of a given problem. when the results of individual studies are discrepant, the purpose of an overview is to investigate reasons for disagreements among studies. when the results are concordant, the goal of meta-analysis is to derive, through application of a number of quantitative techniques, a measure of the effect of the intervention across combined investigations. this measure is referred to as the 'summary' effect of the treatment under study. meta-analysis differs from the traditional, narrative reviews of the literature, in that: ( ) all completed investigations of the efficacy of an intervention that meet specific, eligibility criteria are retrieved and included in the overview; ( ) the quality of retrieved studies is assessed systematically; ( ) the degree of agreement among studies is evaluated, both conceptually and based on statistical criteria, and the synthesis of the findings proceeds only if the variation in reported results is sufficiently modest to be attributed to chance; and ( ) quantitative methods are used to calculate the summary effect of the intervention and to test that effect for statistical significance. ed- - biology of stem cell mobilization th papayannopoulou university of washington, seattle, wa, usa at baseline hematopoiesis, the majority of developing hematopoietic cells (precursors, progenitors and stem cells) is actively retained in bone marrow (bm), whereas fully mature cells emigrate to peripheral circulation. a small number of stem/progenitor cells are also present in blood, serving presumed physiologic roles for the repopulation of remote damaged areas. however, in several hematopoietic perturbations, i.e. post irradiation, post chemotherapy or by using empiric treatments, a heightened emigration (mobilization) of progenitor/stem cells was noted over years ago. the introduction of g-csf as an efficient mobilizing agent not only had a major clinical impact, but has triggered a flurry of studies exploring the mechanisms of mobilization. from these studies, significant insight has been gained about the molecular pathways leading to mobilization, especially by studying the altered environment within bm post mobilization, and less so by studying cells mobilized in blood. several attractive scenarios have been proposed and their importance was further bolstered by studying genetic mouse models. a prominent role of the sdf- /cxcr pathway has been emphasized, either by down regulation of cxcr , changes in sdf- gradients, or by disruption of sdf- /cxcr signaling. whether this pathway is disrupted by a proteolytic mechanism prevailing within bm post g-csf or by other protease-independent mechanisms has not yet been settled. in addition to sdf- /cxcr , disruption of other pathways responsible for the retention of primitive cells in bm can lead to mobilization. for example, disengagement of the vla /vcam- pathway by anti-functional antibodies or its genetic deficiency in mice results in egress of stem/progenitor cells. mobilization is also seen following the use of other cytokines (i.e. kit-l, flt- l, il- ) or chemokines (i.e. il- , gro?), complement activation, etc., but the detailed mechanisms or the interdependence of these other pathways with the ones already proposed have not been worked out. finally, efforts to improve mobilization efficiency in man has led to the use of combination treatments with g-csf, either by adding another cytokine (i.e. growth hormone), agonistic sdf- molecules (i.e. ctce ), or cxcr antagonists (i.e. amd ) which have yielded synergistic increments, and these will be discussed. a full understanding of the principles of mobilization, as well as the bm homing characteristics of mobilized cells after their i.v. infusion in transplantation, should lead to targeted, more efficient experimental protocols in the future. the possibility of deriving all kinds of mature cell types from embryonic stem (es) cells for the purpose of cell replacement therapies will probably face a major obstacle; a limited supply of available hla types for an ever growing population in demand. one possible solution is to use adult sources of stem cells such as the haematopoietic stem cells (hsc) that can repopulate the entire haematopoietic system after transplantation in a myeloablated host. however cells with the repopulating ability of hscs are still elusive for tissues such as muscle, heart, cns and pancreas. it was therefore exciting news when it was shown that hscs could repopulate other non-haematopoietic tissues arguing for a general role of bmderived cells in tissue regeneration. the term plasticity was thus coined to describe the phenomenon whereby cells of one lineage could trans-differentiate into cells of another tissue. this in turn implied that a certain degree of developmental plasticity was still available in the adult hsc, or their derived progeny, that allowed them to present with novel phenotypes. how exactly this was accomplished was a matter of speculation. in order to address the mechanism we used an animal model of liver failure where bmt with normal (wild type, wt) hsc was shown to rescue the liver failure; the repopulating hepatocytes apparently differentiated from the sole source of wt cells, the bm compartment. by studying the genetic composition of the regenerating liver nodules we observed that both wt and mutant dna was present in the nodules, a finding that was consistent with bm-derived cells fusing with host hepatocytes. the mechanism of plasticity was therefore directly related to the exposure of the donor bm-derived wt nucleus to the transcriptional environment of the hepatocyte and the expression of hepatocyte-specific genes. this fusion mechanism was also shown to underlie perceived cases of haematopoietic cell transdifferentiation to purkinje cells in the cerebellum and to cardiomyocytes. however, there are carefully executed studies that strongly support the alternative transdifferentiation mechanism in tissues such as epithelia or the epidermis. what these observations may imply is that in tissues with high rates of cell turnover, there may be a potent stem cell niche that can reprogram incoming cells to follow relevant cell lineages. if this hypothesis is correct, then the major research effort should focus on what makes the niche and whether it can be recreated faithfully in vitro so as to educate hscs to diverse lineages opening the way for realistic cell replacement therapies. collection and distribution of blood and its products to meet the medical needs of industrialized countries are typically managed through large-scale national or nationally-supported blood programs. the development, maintenance, and ultimate success of such programs are all components of a process that involves the delicate balance of continuously competing pressures, e.g. social, economic, ethical, political, regulatory/legislative. as with all endeavors that directly affect human life, safety is a central, unifying theme of this process. because transactions of blood inherently involve risks at both donation and reception/transfusion ends, efforts to enhance and maintain an acceptable level of safety generally rely on a focused program of risk management (rm). rm involves three equally important elements: identification/evaluation of risk factors in a process, control of exposure to them, and continuous monitoring to assess the effectiveness of countermeasures and the emergence of new risk factors. specific approaches to rm and quality assurance in transfusion medicine will be presented. examples from blood programs currently in effect in selected countries will be discussed. rm efforts within the corresponding blood program in greece will then be examined. the lack of data to adequately assess the status of this program suggests that at least one of the elements of rm -monitoring -can still be improved. a preliminary research effort aims to survey blood donors, transfusion recipients, and physicians in order to build an understanding of the specific factors that drive the perception of risk in the greek population. the findings form important stepping points upon which specific recommendations can be made for the development and maintenance of a comprehensive, effective rm program in greece. ed- - the use of haemovigilance data to increase safety in transfusion medicine haemovigilance is a surveillance of all the procedures in the transfusion chain. the intension is to collect and assess information on unexpected or undesirable effects in bleeding of donors and transfusion of blood components. in europe haemovigilance was introduced as a concept in the middle of the nineties. the first national reports on haemovigilance appeared in the late nineties, and were only dealing with complications related to transfusion. later on other kind of events like 'near miss' events were added. nowadays national reports are dealing with all steps in the transfusion line, and to some extend also with complications in blood donors. the state of the art is haemovigilance with retrospective registration of unwanted events that has happened, but also a more active prospective part with an early warning in a rapid alert system about new threats in the transfusion world. the aim of the different national haemovigilance systems has been to improve safety in the transfusion line. after the first years with haemovigilance in the european countries, what has been the outcome of this big effort? data from national reports do not signify major improvements, but safety is suggested to have improved due to many minor changes of procedures and awareness of dangerous situations. however, in most countries nothing really effective has been done to avoid failures, the most important cause of serious complications in transfusion of patients. systems which can prevent most of the failures are on the market. the cost of these equals the cost of nat screening for virus introduced in the same period of time. the common perception of transfusion risks is still much more focused on the hypothetical risk of virus transmission than to the demonstrated magnitude of severe complications related to bleeding of donors and transfusion of patients. therefore, to increase safety in transfusion medicine the nature and occurrence of the risks should be revealed by haemovigilance and not less important the results should be published with the aim to get a realistic common perception of the transfusion risks. the role of diagnostic testing to identify congenital vs acquired disorders of hemostasis and to optimize the management of perioperative bleeding g despotis washington university school of medicine, st louis, mo, usa excessive bleeding with trauma or after surgery can result in hypoperfusion and anemia related end-organ dysfunction and mortality as well as transfusion-related complications. several large studies have demonstrated that if bleeding is excessive after cardiac surgery to the point that reexploration is required, that overall mortality increases by - fold. transfusion related complications include the following potentially lethal complications: disease transmission of pathogens, acute hemolytic reactions, allergic reactions, transfusion associated acute lung injury, allo-immunization related disease (e.g. post-transfusion purpura, platelet refractoriness, transfusion-associated graft-vs-host disease) and other potential complications (e.g. increased perioperative infection or multi-organ system failure) related to transfusion associated immune modulation. in addition, blood shortages related to increasing consumption (i.e. expanding geriatric population) and/or a shrinking supply (i.e. related to exclusion of donors related to donor exclusion criteria designed to prevent disease transmission) may limit our ability to adequately manage our anemic and bleeding patients. this highlights the relative importance of accurate diagnosis and optimal management of excessive bleeding to minimize bleeding related complications and conserve our blood supply. patients at risk for excessive bleeding include those with an established hereditary disorder (e.g. vwd, hemophilia, connective tissue disorders), end-stage hepatic or renal disease as well as patients with acquired defects of the hemostatic system. in specific, patients with platelet (i.e. platelet refractoriness) or coagulation factor inhibitors at increased risk, extracorporeal circulation related defects or as related to certain pharmacologic agents). patients who require longer periods of extracorporeal circulation for cardiac surgical procedures (e.g. repeat, combined procedures or use of deep hypothermic circulatory arrest) are at a greater risk of developing excessive bleeding (e.g. cpb-related abnormalities). in addition, patients receiving one or more longacting anti-thrombotic medications in the immediate preoperative period (e.g. plavix, reopro, low molecular weight heparin etc) are at increased risk for bleeding. clinicians in the past have resorted to empiric and 'shot gun' approaches when managing excessive bleeding due lack of immediate availability of results from laboratory-based coagulation tests. on this basis, the use of point-of-care (poc) tests of hemostatic function to facilitate the optimal management of excessive bleeding, help differentiate between microvascular vs surgical bleeding and reduce transfusion have been investigated. five of six recently published studies have demonstrated that implementation of a standardized approach to manage bleeding (e.g. algorithm) which when coupled with either point-ofcare or laboratory tests of hemostatic function can optimize the management of bleeding and reduce total donor exposures by %. ddavp has bee shown to be beneficial with uremia-induced platelet dysfunction and with type i von willbrand's disease. although previous studies have not been able to conclusively show that ddavp can reduce bleeding and transfusion when administered prophylactically, more recent evidence indicates that this agent may be useful in preventing excessive bleeding when a test (point-of-care) reveals platelet dysfunction. recombinant activated factor vii (rfviia) is licensed for use in bleeding episodes in hemophiliac patients with inhibitors. although, only anecdotal reports and results from small clinical studies have shown that this agent can reverse life-threatening bleeding after major surgery, other reports indicate that there is variability in the effectiveness of rfviia as well as highlight lifethreatening thrombotic complications in a subset of high risk patients (i.e. patients with congenital or acquired thrombotic disorders or systemic activation of the hemostatic system such as with dic or after cardiac surgery). therefore, large clinical trials evaluating the efficacy and safety of rfviia are needed before any widespread use can be recommended. in recent years, molecular methods of blood grouping have become routine diagnostic procedures in many laboratories throughout the world. they have proved especially valuable for the determination of fetal blood groups. the ability to detect rhd in pregnancies where the fetus is at risk from haemolytic disease of the newborn represents a significant advance in obstetric care. furthermore, the occurrence of fetal dna in the mothers' peripheral blood has allowed this diagnostic procedure to be carried out without the risks that accompany amniocentesis (lo ymd. ( ) ann med : - ). determination of the coding sequence of all the genes giving rise to antigens within the blood group systems currently recognised is virtually complete. by correlating the coding sequence of these genes with the phenotype of red cells from individuals with different blood groups it has been possible to infer the molecular bases of most of the antigens comprising each blood group system (daniels gl ( ) human blood groups, nd ed. blackwell science). the polymorphic antigens of most systems other than abo and rh, are defined by single nucleotide substitutions (snps) which effect a single amino acid sequence change in the gene product. numerous methods, both manual and automated, are available to determine snps and these have been applied to the determination of blood groups. useful applications of snps detection methods include, determination of the blood group phenotype of patients who have been transfused recently and still have donor blood in their circulation (rozman p, dove t, gassner c et al. ( ) transfusion : - ), and donor screening to find compatible units for patients with multiple blood group antibodies or for the management of patients with diseases like the haemoglobinopathies who are going to be transfusion-dependent over many years (castilho l, rios m, bianco c et al. ( ) transfusion : - ). other applications of molecular methods include zygosity determination for rhd, determination of the blood group phenotype of patients with a positive direct antiglobulin test, selection of donors with rare blood group phenotypes, and as aids to the solution of complex blood grouping problems in the reference laboratory. the molecular bases of abo and rh antigens are complex and cannot be determined reliably by a single snp. nevertheless, methodologies are available that allow the comprehensive sequence analysis of individual genes and could be applied to abo and rh typing. whether or not this will ever be a cost-effective procedure is a moot point. it is clear that molecular methods are a useful addition to the range of diagnostic procedures available to transfusion medicine practitioners but it is important to remember that methods based on dna analysis determine phenotype by inference and not by direct measurement. the results of molecular tests should be interpreted with this caveat in mind. ed- - the hla system g stavropoulos general hospital 'g. gennimatas', athens, greece since its discovery in the mouse in the major histocompatibility complex (mhc) has become one of the most important region in the vertebrate genome with respect to infection, autoimmunity and transplantation. mhc primary function is to provide protection against pathogens. this is achieved through sophisticated pathways in which mhc class i molecules present endogenous antiges to cd + t cells and class ii molecules present exogenous antigens to cd + t cells. an increasing number of other proteins are being found that support these two pathways; many of these proteins, together with the class iii complement proteins, also map to the mhc. the mhc molecules were originally studied for their ability to cxonfer tolerance (histocompatibility) following tissue grafts or later, organ transplants. nowadays, the success of unrelated hematopoetic cell transplantation is influenced by the degree of mhc compatibility between the donor and patient. thus, for patients who lack matched donors, the rules that govern permissibility of mhc mismatching still need to be identified. for patients with high risk disease who lack matched donors, use of donors with a single mhc mismatch may permit early treatment before disease progression. scientific evidence to fully answer the questions 'when are platelet components clinically effective' and 'what do we really know?' is limited. despite this limitation and the level of uncertainty it generates with regard to treatment options and policies, it is reassuring to note that current prophylactic platelet transfusion protocols -mostly derived from empirical observations collected during the 's and 's -protect oncology patients from clinically relevant bleeding in more than % of thrombocytopenic days spent in hospital or at home, even in aggressive conditions such as leukemia, lymphoma and other severe blood diseases. this evidence seems to justify the prevalent policy of transfusing platelets when the patient's platelet count falls below per microliter (or in 'unstable' patients). this policy is based on positive outcomes of prospective and retrospective studies performed during the 's including some hundred non-surgical patients and on the desire of balancing the will of reducing patient exposure to limited, expensive, potentially infectious and immunogenic blood products with the objective of preventing clinically relevant hemorrhage. several national and international organizations endorse the above policy. although the role of platelet support in surgery or in specific clinical situations requiring invasive procedures or in patients affected by multi-organ and system co-morbidity suffers from even more limited evidence, the latter has been carefully collected and summarized in the guidelines for platelet transfusion published in j clin oncol ; : - . additional data on lumbar puncture are reported in ann hematol ; : - . another important topic where there is room for improvement and need for further investigation is platelet refractoriness, a condition developed by a proportion of chronic platelet recipients, which causes high hemorrhage risk if compatible platelets are not provided and in which consensus on the diagnosis and treatment is lacking. with regard to the type of platelet product, it will be necessary to determine the clinical impact of buffy-coat derived platelets, consistently used in europe and current object of increased interest in canada, as compared to the platelet-rich plasma method traditionally used in the us, of viral inactivation procedures and of laboratory methods for detection of bacterial contamination of platelet concentrates. in addition, ongoing studies on the clinical impact of high versus low platelet doses will provide novel elements to determine the relative merits of apheresis versus whole-blood derived platelets. as far as the established procedure of white cell reduction by filtration, which shows high technical efficiency and has been implemented as a standard by a number of institutions, debate is still ongoing on its equivalence with serologic screening for the prevention of cmv transmission, whereas general consensus supports its pre-storage use to prevent febrile, non hemolytic transfusion reactions. finally, although the high cost of filters do not allow a generalized use of this technology in many settings, white cell reduced platelets have been unequivocally shown to reduce alloimmune refractoriness from about % to about % of patients. ed- - ffp: appraisal of the evidence for the clinical use of ffp although the indications for transfusion of plasma (fresh frozen plasma; ffp) are limited, the use of ffp continues to rise in the united kingdom and has risen by over % in the past few years. local uk audits continue to document that a significant proportion of ffp transfusions are not consistent with indications reported in guidelines. a systematic review of the evidence base for the effectiveness of ffp was therefore undertaken to identify, select and appraise all relevant randomised controlled trials, as the most robust form of study to assess effectiveness of ffp. in the systematic review of ffp, the criteria for inclusion of full-published studies were: there must have been at least two groups in the study; • allocation to the groups must have been either by formal randomisation or by a quasi random method e.g. alternation; • one of the arms of trial must include ffp or plasma as an intervention; results on the relevant clinical or laboratory outcome must be presented. the main analysis was qualitative, and differentiated between: . studies of interventions comparing ffp with no ffp; . studies of interventions comparing ffp with a non-blood product e.g. solutions of colloids and/or crystalloids; . studies of interventions comparing ffp with a different blood product; . studies comparing different formulations of ffp, e.g. solvent detergent and methodine blue treated. an evaluation of studies comparing ffp with no ffp would be expected to provide the clearest direct evidence for a positive effect of ffp. studies comparing ffp with colloids or crystalloids were separately appraised because these latter products may have variable effects on coagulation tests. studies comparing different formulations of ffp do not directly evaluate effectiveness of ffp but were included because there is now a uk national policy to use these products in younger patients and therefore these trials might identify negative outcomes. the search strategy identified a total publications. although it may appear that this number of randomised trials might provide a reasonable evidence base to help inform clinical policy and decision making, the review identified a number of important concerns about the published trials. few of the identified studies included details of the study methodology (method of randomisation, blinding of patients and study personnel). the sample size of many included studies was very small (range - patients per arm). few studies took adequate account of the extent to which adverse events might negate the clinical benefits of treatment with ffp. many of the identified trials in groups such as cardiac, neonatal, and other clinical conditions, evaluated a prophylactic transfusion strategy. however, when these trials evaluating prophylactic usage were assessed together as a single grouping in the review, it appeared there was no consistent support for a beneficial effect of prophylactic ffp, irrespective of clinical setting. there is a pressing need to develop new trials to determine the effectiveness of ffp, including for those clinical situations in which it has become an accepted part of current transfusion practice. a law decided upon by the riksdag (the swedish parliament) often sets the general standards as a framework and authorises the central government authority concerned to elaborate and decide upon the more detailed regulations. laws and regulations define the level of quality and safety that has to be reached and state what must be done, while establishments and their managers are kept responsible for fulfilling the requirements and how this is done. guidelines (non-binding) present detailed instructions on ways how to fulfil the requirements. making a law is complicated and time-consuming. the ministry draws up a legislative proposal, refers the proposal to relevant bodies for consideration and comments, and then drafts a bill which is referred to the council on legislation for consideration before it is submitted to the riksdag. a parliamentary committee deals with the bill before it is put to the chamber of the riksdag for approval. when adopted, the bill becomes law. regulations elaborated by central government authorities are handled in a principally similar way. however, regulations are more readily adjusted to scientific and technical progress, and when legislation need requirements for technical details, these are preferably presented in a regulation. the ministry of health and social affairs is responsible for elaborating the bill to be submitted to the riksdag on the blood safety law. two central government authorities, designated as competent authorities, are responsible for preparing the appropriate complimentary regulations as well as for inspecting and licensing the blood establishments: • the national board of health and welfare (nbhw), responsible for requirements related to blood components intended for transfusion, and • the medical product agency (mpa), responsible for requirements related to blood components intended for the manufacture of medicinal products. sweden became a member of the eu ten years ago. since then, experts in transfusion medicine have been appointed by the ministry, nbhw and mpa for advice on scientific and technical issues and for representing sweden at expert meetings arranged by the commission. some of these experts are also members of the handbook committee of the national society for transfusion medicine, preparing and revising the national guidelines. consequently, the requirements of the directives are readily implemented in the daily work of the blood establishments before (due to legal and technical reasons) the new blood safety law and the revised nbhw and mpa regulations can be promulgated. to a great extent, requirements of the blood directives are covered by existing swedish legislation. no major problems or obstacles seem to arise when implementing new requirements into law and regulations and into the blood establishments' daily service. a few detailed requirements have been found difficult to follow precisely in the routine work. these minor difficulties, however, will not compromise the high quality and safety of blood components prepared according to the standards set by the blood directives. the landscape for blood collection and distribution includes availability and safety. true international availability of blood has not been reached. the landscape of safety has been mountainous, if viewed by the degree of frustration among the transfusion specialists. the reasons for frustration have varied from serological problems to those of transmissible infections, to which no end is in sight. mistrust in the safety of blood taken by others is one reason for lack of international landscape in blood collection and distribution. increasing demands on safety, availability and economy force the health care providers to reorganise blood services. national systems are winning ground. this may make it easier to achieve international collaboration. the council of europe has pioneered in creation of international recommendations for blood collection and distribution. in a european agreement on the exchange of therapeutic substances of human origin, including human blood, was published. its purpose was to make blood available to other parties of the agreement in case of urgent need. many countries ratified the agreement rapidly, some did it first in the nineties. in practice little exchange of blood components has taken place. the council of europe recommendations lack legal power. the european union is different, and it has taken on its agenda activities aiming at improving confidence in the safety of the blood transfusion chain in the community (commission communication ) . the agenda is based on an agreement reached at a high level eu meeting in adare, ireland in . first in the commission agenda was a recommendation on donor selection criteria, given in . then came the european blood directive / /ec, the aim of which is to improve the safety of blood and blood components within the union so that enough mutual trust between member countries can be achieved to make the exchange of blood components possible. being a legally binding document the directive is undoubtedly helpful in reaching a harmonised standard in europe. hopefully the european commission has the resources to follow its implementation. there are concerns, however. the epidemiological differences among the eu member countries and frequent appearance of new infectious agents potentially transmitted by blood make it difficult to foresee that even effective viral inactivation of blood components could totally erase the national differences in donor approval. blood collection and preparation of components are already the same in eu member countries and the directive helps in their further standardisation. there has not been much distribution of blood components internationally, with the exception of export of red cell concentrates to the us from switzerland and the netherlands. the european legislation opens new horizons and widens the european landscape as its purpose is to simplify the crossing of borders between the member states, but before true movement of blood components is achieved more work is needed on the eu commission blood agenda. the eu directive implemented into the legal act for polish blood transfusion service blood transfusion service (bts) in poland is an integral part of the public polish health service. in the country of nearly million people, approximately one million units of blood and plasma are collected every year from voluntary, nonremunarated donors, which is statistically over donations per inhabitants. blood and plasma are collected in strictly appointed centers and no private collection sites are permitted. the legal basis for the activity of polish bts is polish blood transfusion act of nd august which came into force as of january st . this act was then updated in november according to eu directive / /ec and came into force as of january th . this act introduced the principles for organization, collection, processing, storage, transport and quality assurance in bts. it specified -among others -the system of accreditation, haemovigilence, as well as requirements for bts employees. according to this act the polish bts is obliged to monitor and supervise immunohematology testing and transfusion procedures in all hospitals where blood and blood products are transfused. polish bts consists of regional blood transfusion centers (rbtc), one military center and one ministry of internal affairs and administration center as well as the institute of hematology and blood transfusion (ihbt) which acts as supervisor. the rbtcs have a uniform organization structure, uniform quality assurance system and act according to uniform guidelines issued by ihbt. they have two financing sources -the central budget and hospital reimbursement for distributed blood and blood products. the polish blood transfusion act of nd august , in force since january st , has been supplemented by decrees: . procedures for external bts audits; . requirements for donor selection; . requirements and procedures for organization and safe management of blood transfusion in hospitals; . requirements for implementing of national and regional donor registers; . employment criteria for bts personnel; . training requirements for hospital personnel involved in blood and blood product administration; . national, uniform price list for blood and blood products; . organization requirements for setting up of a national committee for blood and blood transfusion. introduction: several technical aspects must be considered in pediatric apheresis due to the size of the patient. factors that must be evaluated are extracorporeal circuit volume, blood flow rates, type of anticoagulant and vascular access. adverse events are mainly related either to vascular access or to metabolic or hemodynamic changes. aim of the study: in this study we show our experience using fresenius hemocare com.tec for pbsc collection in children. methods: twelve pediatric patients (median age years, range - ; median weight kg, range . - . kg) with solid tumors at onset or on relapse underwent collections with the p y kit of the fresenius hemocare com.tec blood cell separator. our cd + cells target was ¥ e /kg. collections were started if a peak of at least . e /l cd + cells ( per microlitre) were reached in the peripheral blood. in all the patients, leukapheresis were performed through a central venous catheter and temporary peripheral venous access. acd ratio : - : was combined with heparin u/kg. in children with < kg the separator was initialized with a compatible filtered and irradiated red blood cell unit, suspended in % albumin, up to the patient's hematocrit, to avoid transient hypovolemia, due to the volume sequestered in the separator. results: twenty-five procedures were performed. a median blood volume of ml (range . - . ml) was processed in a separation time of min (range - min). the median product weight was g (range - g) and yield of cd + cells was . ¥ e /kg body weight (range . - . ¥ e /kg body weight). three poor mobilizing patients (peripheral blood cd + peak of - cells per microlitre) underwent more than two apheresis to collect the desired transplantation dose ( . and ). all collection procedures were well tolerated. children never required sedation to perform the leukapheresis. only mild hypocalcemia-related symptoms, promptly responding to small i.v. boluses of calcium gluconate, were reported. no circulatory side effects were observed. blood flow alarms occurred in every procedures but no collection had to be terminated due to insufficient flow. conclusion: in summary, leukapheresis in children can be safely and effectively performed with the fresenius hemocare com.tec separator with minimal technical difficulties even in patients under kg. m-pa- alternative methods for prevention of infection transmission (pathogen inactivation etc.), cost-benefit considerations of the procedure itself. however, one must also take the loss of plasma into consideration -and more difficult: calculate the effects of changes in product quality, as reduced content of factor viii, protein s and other labile proteins. for methods involving pooling, there are also concerns about the risks due to the pool sizes. the major benefit of the methods will be the potential reduction of infectious transmission, but also possible advantages as reduction of allergic transfusion reactions and trali must be evaluated. the study types involved in cost-benefit considerations are costeffectiveness analysis where the cost and effects of an intervention and an alternative are presented in a ratio of incremental cost to incremental effect and cost-utility analysis, where quality-adjusted life years (qaly) are used as the effectiveness endpoint. qualityadjusted life years is a method that assigns a preference weight to each health state and estimates life-expectancy as the sum of these products of each preference weight and time spent for each state. a complete glossary of terms is found at http://www.hsph.harvard.edu/cearegistry. in literature, there are several publications on cost-benefit considerations within the field of transfusion medicine. concerning plasma products, the costeffectiveness of solvent-detergent plasma has been the major focus. however, the conclusions of different authors have been conflicting. in , aubuchon and birkmeyer published a paper (jama ; ( ) : - ) where they concluded that the cost was usd per qaly, which is far above the 'acceptable limit' of usd . this estimate was adjusted to usd . mill. per qaly in a letter to jama (jackson, jama ). in , riedler et al. published (vox sang : - ) that the discounted cost/life year saved for sd-ffp use in the uk was gbp for neonates and gbp for patients aged . the main reason for the differences between the two papers (and others) was considered to be different calculation of non-infectious complications. the papers cited above underline the difficulties of the cost-benefit considerations. the age of the patient, the outcome of the treatment, the quality of life in an infected patient and the cost of side effects will differ. in addition, how much are we willing to pay for protection against emerging viruses? this paper will not provide the answers, but introduction: the photodynamic treatment of therapeutic plasma using methylene blue (mb) in combination with visible light is a well established procedure for the inactivation of blood borne viruses. aim of the study: evaluation of the quality and stability of mb/light-treated plasma (mb plasma) prepared under worst case conditions for routine processing. methods: single donor units (n = ) were treated using the macopharma theraflex mb-plasma system which includes plasma membrane filtration (plas ) and addition of mb prior to illumination followed by mb and photoproduct filtration (blueflex). samples were taken before treatment and from the final product. additionally mb-treated plasma was prepared from four different plasma pools and stored for up to months. treatment was done under worst case conditions for the preservation of coagulation factors: maximum mb concentration during illumination ( . mmol/l), maximum storage time of whole blood before separation ( °c, h), maximum storage time of mb plasma before freezing ( h). several plasma parameters and the concentration of mb and its photoproducts (azure a, azure b, azure c and thionine) were determined. results: mb/light treatment had a significant influence on thrombin time (+ . %), fibrinogen (clauss) (- . %), factor v (- . %), factor viii (- . %), factor xi (- . %) and protein c (- . %). no significant changes were detected for at iii, vwf : rco, vwf cleaving protease, plasmin inhibitor and alpha- -antitrypsin. the entire virus inactivation procedure including the filtration steps for leukocyte depletion and mb and photoproduct depletion had no significant effect on activation markers (prothrombin fragment + , thrombin-antithrombin-complex, d-dimers). no further essential loss of coagulation factor activity was observed during storage of the plasma at °c for months. mb and its photoproducts (azure a, azure b, azure c) were depleted to a final concentration of < . mmol/l. thionine was undetectable in all samples. conclusion: photodynamic treatment of fresh frozen plasma (ffp) using the theraflex mb-plasma system leads to only moderate decreases in the activities of different coagulation factors even under worst case conditions for routine production. mb and its photoproducts were effectively removed from the plasma by the blue-flex-filter integrated in the theraflex-system. the quality of mb plasma is well preserved during storage. pulmonary complications, particularly transfusion-related acute lung injury and circulatory overload, are the most common causes of transfusion-associated morbidity and mortality in the developed world. trali is a syndrome characterized by acute respiratory distress, hypoxemia, hypotension and pulmonary edema, occurring within hours (usually - hours) of transfusion of a plasmacontaining blood product. other signs, including hypertension, leucopenia and hypocomplementemia, are less frequent. all blood products, except for albumin and solvent/detergent plasma, have been associated with trali, but red blood cells, platelets and ffp are the most common. the incidence is unknown, but : plasma-containing transfusions is the most commonly cited figure. in % of patients, recovery is well underway within hours, and leads to complete resolution. death occurs in - %. the profile of the at-risk recipient has not been identified. recurrent cases have been infrequently described. there are two prevailing theories of pathogenesis: ( ) antibody-mediated and ( ) -hit hypothesis. evidence supports both concepts and neither is mutually exclusive. more than % of reported cases are associated with blood components containing either hla-specific (class i or ii) or hnaspecific antibodies. in % these antibodies correspond to at least one epitope in the recipient. most implicated components are donated by multiparous women. five percent of patients have hla or hna antibodies in their pre-transfusion serum. treatment requires prompt, assertive respiratory intervention, frequently necessitating mechanical ventilation. because trali has a much better prognosis than ards, it is an important diagnosis. some blood collectors are diverting plasma from multiparous donors away from ffp production or routinely screening for hla antibodies. the most effective method for identifying 'high risk' components has not been identified. introduction: trali is a life threatening adverse reaction of blood transfusion. it is characterized by noncardiogenic pulmonary edema developed soon after blood transfusion. in japan, we built hemovigilance system in and have been collecting the voluntary reports of severe adverse reactions of blood transfusion including trali cases since . since the diagnostic criteria of trali have not been established until recently and no specific diagnostic markers for trali have been discovered so far, it is very difficult to make proper diagnosis of trali in each reported case. we have been collecting the cases with respiratory distress and pulmonary edema developed after blood transfusion as suspected case of trali. we reevaluated each report whether it meet the recommended diagnostic criteria for trali published in transfusion journal in dec. . aim of the study: purpose of this study is to select trali cases which met internationally recognized criteria so that it will reveal the possible causes of trali with laboratory testing for anti-leukocyte antibodies in donors and recipients. methods: the cases with respiratory failure and pulmonary edema are selected for evaluation from the adverse reaction case reports voluntarily reported to japanese red cross. in order to make a proper diagnosis of trali, we have been utilizing the respiratory distress questionnaire which has recently revised. this helps us eliminate other adverse reactions such as circulatory overload, cardiac failure, anaphylaxis and bacterial contamination, which results in selecting out the internationally recognized trali cases properly. for laboratory testing, flowpra and labscreen for hla antibodies and gift-fcm for hna antibodies are performed. the cross-matching test is also performed if possible. results: during past years, cases of trali and cases of possible trali have been confirmed by critical review of each questionnaire. of cases of definite trali, donor specimens were obtained in cases. of cases, anti-leukocyte antibodies were detected in cases ( %) of donors' blood, which was significantly higher than the positive rate of anti-leukocyte antibodies in donors' blood of other adverse transfusion reactions (< %). of cases of antibody positive donors, anti hla antibodies were detected in cases, anti hna antibodies were detected in cases, and both were detected in cases. of cases of positive anti hla antibodies, class i antibodies were detected in cases, class ii antibodies were detected in cases, and both were detected in cases. on the other hand, the anti-leukocyte antibodies were detected in % of trali recipients, and this rate is almost the same with that of positive rate of other adverse reactions of blood transfusion ( %). these results indicate anti-leukocyte antibodies in the blood donors are one of the prerequisites for developing trali from the antibody-hypothesis-oriented point of view. other cases with no detectable antibodies should be investigated in more detail in the future. thus, reevaluating trali cases based on recommended trali criteria will allow us to reveal new information about trali. of adverse events analysed by the serious hazards of transfusion (shot) scheme ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , ( %) were haemolytic transfusion reactions (htrs). were due to incorrect blood component transfused (ibct): / were abo incompatible and / caused by other red cell antibodies. a further cases were reported as acute htrs (ahtrs; i.e. occurring within hours of transfusion) whilst were recognised more than hours after transfusion and reported as delayed htrs (dhtr). / ( %) patients died and suffered major morbidity. htrs associated with ibct result from clinical or laboratory errors and are all preventable. it has been assumed that other htrs are unavoidable. closer scrutiny reveals that this may not always be the case, though review is hampered by incomplete investigations. / ahtrs occurred in group a ( / ) or group b ( / ) patients given group o platelets. of the ahtrs related to red cell transfusion, were due to errors, were in patients with auto-antibodies, in only of whom alloantibodies had been adequately excluded/identified. at least / dhtrs were potentially avoidable; in cases the antibody was detectable retrospectively in the pre-transfusion sample; in cases the presence of a previous antibody was not communicated to the laboratory. two patient deaths related to dhtr might have been avoided by earlier diagnosis and clinical involvement. % htrs reported to shot would have been avoided by compliance with pretransfusion testing guidelines and provision of group a platelets for all group a recipients. htrs can be clinically overlooked and inadequately investigated. national guidelines are needed for the investigation and management of htr, with focus on the identification of underlying causes to guide the choice of future component therapy. reference laboratories can provide valuable support in elucidating complex serological problems. patients treated with high dose chemotherapy and autologous blood progenitor cell (bpc) support may get malignant cells reinfused together with stem cells. we analyzed bpc products collected from patients suffering from germ cell cancer measuring malignant contamination and followed these patients for up to months after transplantation also with the question if transplanted malignant cells influence survival. aliquots of stem cell apheresis products containing one million mononuclear cells were sedimented on glass slides and by immunocytochemistry quantitation of cytokeratin expressing cells was performed manually with light microscopy and by automated image analysis. in of patients ( %) cytokeratin expressing cells were detected in bpc apheresis products of patients treated for germ cell cancer. we followed the activity of the malignant disease of patients for more than eight years in median months after transplantation. no significant difference in survival was demonstrated for our two patient groups. background: the use of adequate number of peripheral blood stem cells (pbsc), collected by mnc apheresis is essential for effective treatment of hematological malignancies, solid tumors, and other disorders by transplantation. aims: the goals of this study were: (a) to obtain an effective apheretic protocol for mnc harvesting, and (b) to compare the hematopoietic reconstitution after hspc transplantations in different clinical settings. methods: in this study, pbsc transplantations - allogeneic from matched sibling healthy donors and autologous -were performed in the management of patients with severe aplastic anemia, leukemias (all, anll, cml), multiple myeloma, hodgkin's and non-hodgkin's lymphoma, breast and ovarial cancer, and extragonadal non-seminal germ cell tumor. pbsc mobilization was achieved with rhg-csf ( - g/kgbm/day). mnc-apheresis procedures (generally one and occasionally two) were performed using blood cell separator cobe-spectra. the first mnc-apheresis was accomplished when the leukocyte cont was - ¥ e /l (autologous setting) or on the th day - hour after the last rhg-csf administration (allogeneic setting). the processed blood volume during one mnc-apheresis was . - . l, and . l for one pbsc transplantation in average. results: using a minimal target dose of cd + cell count ( ¥ e /kgbm), performing one mnc-apheresis procedure for % recipients sufficient number of pbscs were obtained. the mnc yield was . ¥ e /kgbm in allogeneic and . ¥ e /kgbm in autologous setting in average. the mean cd + yields for allogeneic and autologous transplantations were . ¥ e /kgbm and . ¥ e /kgbm, respectively. hematopoietic reconstitution was achieved on the . th day for leukocytes and the . th day for platelets when pbsc transplantation was applied. summary/conclusion: improved mnc and cd + cell yield, as well as rapid hematopoietic reconstitution were observed when: (a) the intention of auditing any clinical practice is, ostensibly, to improve patient care. the term 'audit' implies comparison against a standard. although absolute indications for transfusion have not been defined by clinical trials applicable to most clinical situations, many institutions have established their own transfusion triggers based on their reading of the literature and common practice at that hospital. assuming these represent prudent guidelines, comparison of actual practice to them may allow physicians to re-assess their pattern of hemotherapy and bring it into conformance with the guideline. there are several common ways of performing transfusion audits. retrospective analysis of transfusions allows appreciation of the clinical situation (and its ultimate outcome) but reviews the event through a 'retrospectoscope' that assesses clinical information in a different manner than that available to the clinician making the decision to transfuse. furthermore, the time lapse between the decision to transfusion and feedback about that decision may render the feedback from the reviewing body (e.g., a transfusion committee or blood utilization review committee) of little practical import. to speed the provision of feedback and emphasize educational rather than any punitive outcomes of the audit, some facilities have abolished attempts at determining whether the decision to transfuse was supportable and have used electronic means to feed back to clinicians a non-judgmental informational message summarizing the literature regarding the indications for transfusion. this appears to be at least as effective as the traditional retrospective audit system. prospective review of requests for blood components have the potential to redirect practice in a manner that immediately helps patients. however, such interactions with clinicians may come at inopportune times, may require considerable (unscheduled) time, and are most likely to be fruitful if a knowledgeable transfusion medicine expert can serve as the intermediary. both approaches (or a combination) have been shown to be beneficial in altering practice, but efforts must be diligent and sustained. providing data comparing a physician's practice to colleagues in the same specialty may prompt additional introspection and practice change, particularly if physician leadership of the institution supports the effort as a quality improvement tool. extending the comparison to a group of physicians and contrasting their transfusion habits with benchmark data from other institutions may also be helpful, but one needs to be ready to counter arguments that differences in patient groups are the reason for the differences in practice (studies have shown that, in general, practice patterns are primarily related to training and habit rather than large differences in patient acuity). increased focus on the performance of hospitals as expressed in outcome data may soon extend to transfusion practices as well. the public or governmental institutions may ask to see data illustrating the transfusion practice of an institution and its improvement over time. carefully conducted, diligent, and ongoing transfusion audits are an integral part of an institution's quality improvement program. informed consent: the term informed consent, appeared for the first time in the late s but it was only in the s that it attracted attention with regard to health care. numerous discussions and publications have attempted to define the meaning and the justification of informed consent in recent years. initially it consisted in the obligation of the physician to disclose information to the patient, regarding the procedure he was to undergo, but more recently, ethicists have emphasized the need to ensure the patient's understanding and his autonomous decision to consent. current institutional rules of ethics demand that the physician must obtain the informed consent of a patient 'prior to any substantial intervention' . what is however the meaning of informed consent? is it a mutual decision making between physician and patient? in 'principles of biomedical ethics' beauchamp and childress claim that' it is critically important to distinguish informational exchanges through which patients elect medical interventions, from acts of approving and authorizing those interventions. the elements of consent include: disclosure, voluntariness, decision and authorization. when applying the concept of informed consent in transfusion medicine one can distinguish it into donors' and patients' consent. donor informed consent: information to blood donors constitutes a sensitive issue. it refers to their protection from side-effects of the donation, as well as to protection of the recipient. with regard to whole blood donors a detailed history and information as to side effects are necessary for first-time donors. for repeat donors one needs mainly an updated history. because of time-pressure, whole blood donors are usually given written information and are asked to answer written questions. donors however differ in literacy and even literate ones do not always understand medical terminilogy; so, during the interview one should probe the degree of understanding of each donor. with first time apheresis donors more time is needed in order to explain the procedure and potential side effects. since granulocyte and stem-cell donors require premedication with growth factors and or corticosteroids, the responsibility for detailed information is even greater. the fact that all donors sign the informed consent does not mean that they are all adequately informed! interviewers must be familiar with side effects, their frequency and sequelae and must pass on this information. misses and near-misses, (serious) adverse events and failures in medical practice seem to be not preventable. in medical interventions, preparing and prescribing of medication, assistance by doctors and nurses, medical treatment and follow-up, unwanted and unexpected events occur (http://www.mederrors.com.). these events happen also in transfusion medicine and focus on safety is not unique. haemovigilance which is defined in the eu blood directive as 'a set of organised surveillance procedures relating to serious adverse or unexpected events or reactions in donors or recipients, and the epidemiological follow-up of donors' (eu directive / /ec off. j. european union. . . :l / -l / ) is established to help in trying to identify and minimise the misses and (serious) adverse events in the chain from donor to recipient of blood components. the causes or reasons should be studied in order to prevent re-occurrence. adverse event reporting in blood transfusion and transfusion medicine is complex. it depends on the cooperation between blood establishments with clinicians and hospitals. it implies knowledge of blood banking, transfusion medicine and routine clinical care of all gender and ages, of potential hazards of transfusion, of immune-haematology, of microbiology, and of epidemiology. an adverse event may have its cause in every single part of the blood chain and reference may take place to a proven problem, a potential problem, or to a justified doubt. in almost all blood transfusion centres, a single donation will be processed into a number of different products, and these units might be divided or processed into more products. blood components are produced from whole blood or apheresis donations, and depending of the blood drawing and processing techniques, a high number of products with different specifications is prepared. the products' shelf life is not equal and therefore the moment in time of actual use of each unit prepared from the same donation may differ. in case the unit of platelets harms the recipient, a rapid alert can warn in order not to issue or to transfuse the unit of red cells or the unit of ffp prepared from the same donation because of the potential adverse reaction, which was detected during or after the transfusion of the first unit used. haemovigilance is not only important to blood establishments and to patients and prescribers, but it is also to clinical scientists, and to the public at large. it should provide a basis for minimising adverse reactions on blood components, and it should enable the therapeutic potential of new or established treatments with components to be maximised, since demonstrations of safety during widespread use may lead to extended usage, and wider availability. it is quite worrisome that underreporting is a general problem in medical care. it might be expected that in transfusion medicine the same rates of underreporting can be found, but also that the same mechanisms for improvement are applicable. although medical misses occur and do not seem to be preventable, the handling of these misses is often quite poor. many patients like to hear a detailed explanation, and the majority expects even apologies from the treating physician. it seems desirable to look for new routes in the prevention of unwanted events of transfusion medicine. for problem solving, analysis and improvement of working methods, where needed and possible, are often the most effective methods. attention should be focused on improvement and not on identification of the person who caused the problem ('bad apple'). lack of communication and insufficient insight in each other work are often the causes of problems and unwanted events. it should be recognised that advices given by the haemovigilance officer or the blood transfusion committee about prevention without the input and commitment of the direct responsible persons will lead in most cases to advices which are not effective or which will not be accepted. setting up a haemovigilance system or appointing of haemovigilance officers or installation of blood transfusion committees will not be sufficient. it will be necessary to develop ways of registration, data collection and analysis, but more importantly to support by giving advice and training to prevent reoccurrence of the adverse events or not optimal use of blood components. the confidentiality of the information should be guarded sufficiently. for a physician-patient relation, even after a medical failure, a 'blame-free culture' with a central role for openness and transparency is necessary. for blood establishments and hospitals, there is an important role in the right assistance and help of the physicians concerned both on a practical and on an emotional way. m-pa- years of shot data - : a view of transfusion safety in the uk and reactions. this will require investment in infrastructure, for which there must be a trade-off in improved transfusion safety. transfusion-transmitted infections and serious immunological reactions are rare; shot has highlighted the need for blood services to implement strategies to minimise bacterial contamination and transfusion related acute lung injury and will monitor their effectiveness. from the inception of shot it has been clear that the most frequent transfusion hazard is 'incorrect blood component transfused' i.e. a patient receiving a blood component intended for another person or not meeting appropriate requirements. only a minority of these events results in patient harm and is reportable under the terms of the directive. haemovigilance schemes such as shot, that analyse no-harm errors and near-misses, can reveal clues as to the root causes of 'wrong blood', which contributed to deaths and cases of major morbidity in the uk between and . analysis of such events shows that most errors occur in clinical areas, the most frequent being failure of the 'bedside check' . clinical audit data indicates that % of patients are transfused without a wristband or other form of identification, whilst anecdotal reports suggest that urgent clinical situations, massive transfusions and nocturnal transfusions are particularly error-prone. strategies aimed at reducing errors include structured education and competency testing, and methodologies, both high and low-tech, to ensure accurate patient identification in all circumstances. onethird of errors occurs in hospital laboratories; denominator data on laboratory workload shows that work done outside of 'core hours' accounts for % of all pre-transfusion testing but % of errors, suggesting that biomedical scientists 'on-call' or on shift work are working under pressure and beyond their competency. % of hospitals reported that they participated in shot in , but only % of eligible hospitals reported adverse events suggesting that transfusion hazards remain under-recognised and under-reported. however, benchmarking of 'wrong blood' incidents against transfusion activity shows that the number of observed incidents is roughly proportional to blood use. if haemovigilance data is to contribute to improved transfusion safety, clinicians must be encour-aged to report all events, thus contributing to an evidence base that can be used to effect change and facilitate learning. barriers to reporting include cumbersome systems, lack of time and resource, lack of feedback and fear of blame. transfusion practitioners have a vital role in the recognition and reporting of adverse events, education and clinical audit, but must be adequately resourced and supported by senior clinicians and managers through an active hospital transfusion committee. *provisional. m-pa- passing the borders: when, how and where d pirc-tiljak croatian institute of transfusion med., zagreb, croatia there may come that moment in professional life when you have to follow a strong professional and ethical need and confront your evidence-based statements with the leadership, passing the border of your own small society. in order to protect patient's health and respect human right to be informed about all possible consequences of irregular medical therapy, insisting on professional dignity and truth, you feel responsible and follow-up processing of your serious error report. once you pass the border, trying to warn authorities and find ethical resonance and critical confirmation of your professional fears, you are 'persona non grata' . methods/results: reality checking, personal experiences and observations studying the path of serious error report. although the qc system functions, yet omissions happen . . . the possible reasons could be: lack of knowledge, lack of experience, lack of independency, personal confront of interest, immature leadership, political influence, even corruption . . . how strict do the authorities manage a fault, bearing in mind the responsibility toward the patients under the risk. there is a need to create an available, effective international expert's board which will react and give professional counselling support-asylum for endangered professionals who found enough power to blow the whistle. who will hear it? transfusion transmitted infections (tti) are a major source of concern given the repercussions of hiv, hepatitis c, bacteria and vcjd transmission by blood components. large amounts of resource have been expended in making products safer and in maintaining public confidence in the blood supply. identifying emerging infections of concern is a major activity for many transfusion services. of the long list of emerging infections identified by disease control agencies around the world, identifying those responsible for tti requires, amongst other things, that: • the agent is identifiable. • it is present in blood • it causes a disease of concern. • it is transmitted by transfusion. • it is present at relatively low frequency. • if a test is available (nat, serology or immunoassay) what the infection window period is. once an agent has been identified various approaches are possible, including: • donor selection by testing, geography or lifestyle e.g. wnv; • product selection e.g. erythrovirus (b ) antibody or bacterial testing; • product treatment e.g. pathogen inactivation; • patient selection e.g. cmv matching, immune status. against this background where should our attentions focus? some agents of initial concern are now known to be ubiquitous and have minimal disease association (ttv, gbv) although transmitted by transfusion. for others (coronavirus -sars or the possible kawasaki disease agent, dengue, flavivirus encephalopathies, avian flu, etc.) this is less certain, with agents arising from species crossover being of particular concern (avian flu, vcjd, hiv). • enhancement of automation/computerisation; • process control to provide an 'error-free pathway'; • (national) surveillance and trend analysis of results, preferably based on national working standards; • significantly increased sensitivity, especially from development of antigen/antibody 'combi' assays (e.g. for hiv, and recently, for hcv); • awareness of hbsag vaccine-escape mutants and design of assays to cope with this; • extension of range of agents and markers tested for (varies in different countries); • increasing range of assays available for testing donors with a relevant history of exposure to malaria or chagas' disease infection (for retrieval of otherwise wasted blood); • european union's in vitro diagnostics directive: this has caused some problems and reduced flexibility. nucleic acid testing (nat): nat continues to increase in blood service usage world wide, although not (as yet) to replace serological methods. trends include: • reduction in sample pool size; • increased automation (and process control); • increased multiplexing to detect or more agents in the same assay; • increased number of agents being tested by nat (varies in different countries); • introduction of rapid and flexible nat to detect west nile virus, in north america. bacterial screening of platelet preparations: several countries have introduced (or will introduce) routine screening of platelet concentrates either with biomerieux, bactalert or pall ebds ( depletion assessment). other bacterial testing methods are under active assessment, some rapid enough for possible 'point of use' testing. m-pa- evaluation of in vivo red blood cell recovery after processing with a new filter designed to reduce prions e nelson*, h taylor † , p whitley † and t lieu* *pall medical, covina, ca, † american red cross and evms, norfolk, va, usa background: a filter, called the leukotrap affinity prion reduction filter (prf b filter, pall medical), has been developed to reduce the level of infectious prions, associated with several fatal neurodegenerative diseases including variant creuztfeldt-jakob disease (vcjd), from leukocyte-reduced red cell products. aim: the objective of this study was to evaluate the quality of leukocyte-reduced red cells (lr-rbc) processed through this filter and stored for days. red cell quality was determined by measuring the in vivo red blood cell recovery hours after re-infusion of the -day stored red cells. storage hemolysis and atp were also determined. methods: units of blood ( ml) were collected from normal volunteers into the leukotrap wb system containing cp d/as- anticoagulant/preservative solutions (pall medical). units were either processed to lr-rbc within hours at room temperature (rt units), or after hours at - °c (cold units). the prion filter set was sterilely connected to the units on day , and the units were filtered and stored for days. samples were taken pre-and post-prion filtration and post-storage for plasma hemoglobin and atp determinations. post-storage samples were taken for labeling with -cr radioisotope, re-infusion, and determination of the -hour in vivo rbc recovery. a donor sample was also labeled with m-tc to allow for red cell mass determination. thus, both single-and double-label -hour recovery values were calculated. results: twelve units were collected. in vitro testing was completed on all units. in vivo testing was completed on units. the mean single-label -hour recoveries were . % and . % for the rt and cold units, respectively. the mean double-label recoveries were . % and . % for the rt and cold units, respectively. the overall combined mean in vivo and in vitro results are shown in the table. conclusion: the -hour in vivo red cell recovery means are well above the fda and council of europe's requirement of achieving a mean post-transfusion survival of no less than % of the transfused red cells, and they are comparable to this center's previous results of red cells filtered using the licensed leukotrap rc system with cp d/as- (pall medical introduction: to reduce the risk of platelet transfusion-associated sepsis (tas), methods to routinely screen for bacterial contamination have been implemented. pathogen inactivation treatment of labile blood components provides an alternative means to prevent tas. the intercept blood system for platelets (baxter healthcare) has received the ce mark and has been introduced into clinical practice. aims: this study compared the efficacy of bacterial screening using a culture method (bact/alert system, biomerieux) with pathogen inactivation (intercept blood system) for prevention of transfusion of platelet components contaminated with bacteria. methods: seven strains of bacteria associated with tas, including gram-positive staphylococcus epidermidis, streptococcus agalactiae, and staphylococcus aureus, gram-negative escherichia coli, and klebsiella pneumoniae, and the anaerobes propionibacterium acnes and clostridium perfringens were studied. for each strain, three double-dose platelet concentrates (~ ¥ e platelets in ml of % plasma and % intersol) were collected using the amicus® cell separator. on day of collection, calibrated stocks of bacteria ( , , cfu) were added to the double units. each double unit was divided into two identical products containing , , or cfu of bacteria and stored overnight under conventional blood bank conditions. the control platelet concentrate was not treated. the test platelet concentrate was treated with the intercept process ( mm amotosalen + j/sq cm uva). both units were cultured using the bact/alert system at the time of bacterial inoculation and on days , and of storage. samples ( ml) were taken for both the aerobic and anaerobic cultures. a platelet sample was considered contaminated with bacteria if a positive signal was registered within hours of culture. results: for control platelet concentrates, cultures failed to detect low-dose inocula. the time to positive culture varied with the bacterial strain, contamination level, and time of sampling. at and cfu per product, strains (s. epidermidis, e. coli, c. perfringens, s. agalactiae) and strains (e. coli, c. perfringens) tested negative after days of platelet storage, respectively. k. pneumoniae tested positive after - hours of culture when sampled on day of platelet storage for both and cfu per product. at cfu per product, p. acnes tested negative in aerobic culture and c perfringens tested negative in anaerobic culture after days of platelet storage. the anaerobic cultures of p. acnes became positive after hours of culture when sampled on day of platelet storage. of the strains studied, only s. aureus consistently tested positive after - hours of culture. in contrast, all test platelet concentrates treated with intercept remained negative by bact/alert cultures throughout the entire -day observation period regardless of the strain and the contamination level. conclusions: bacterial detection using cultures may fail to detect low levels of bacteria typically associated with platelet contamination at time of collection and processing. failure to detect bacteria will result in the release of contaminated platelet products with 'test negative-to-date' status. in contrast, inactivation of bacteria is capable of preventing release of contaminated platelet components. background: since nat implementation for hiv- and hcv rna in france, the residual risk (rr) of transfusion-transmitted infections (tti) has dramatically decreased. the rr estimates, for a threeyear period from to showed a significant decrease from / and / before nat implementation to / and / after nat implementation for hiv and hcv respectively. as for hbv, the serological screening is only based on both hbsag and anti-hbc assays. for the same period, the rr estimate for hbv is / , five times higher than hiv one and times higher than hcv one. aims: as the overall rr of tti is mainly related to hbv, and given the availability of hbv nat assays, a study was conducted to determine whether hbv nat has the ability to further reduce the hbv rr and then should be implemented in blood donor screening in france. we have estimated the wp reduction by nat in comparison with one of the most sensitive hbsag screening assays, on commercial seroconversion panels (bioclinical partners, franklin, ma, usa). the nat test was the procleix ultrio assay (genprobe/chiron, san diego, usa). the hbs ag test was the prism hbsag (abbott, france). the comparison was performed on both neat samples and diluted samples / , / , and / , in order to simulate minipools of different sizes. then, we have calculated the yield of hbv-infected donations detected by nat relative to prism hbsag assay. results: on the basis of a window period (wp) of days, ultrio assay is projected to close the wp by an average of days on undiluted samples, days in minipools of samples, days in minipools of samples and only days in minipools of samples. the projected yield calculated on the basis of . million donations collected per year in france, would be . unit per year for minipool-nat and to units per year for individual donation nat. conclusion: introduction of minipool-nat will offer only a little added benefit to transfusion safety relative to current serological screening strategies based on both hbsag and anti-hbc assays. hbv minipool-nat is then unsuitable for hbv screening in french blood donors. single-sample nat or minipool-nat with smaller pool sizes and/or modified procedures (genome enrichment or test improvement) would be more relevant. automation when technologically and practically feasible is a prerequisite for single-donation nat. therefore, decision has been made not to implement hbv nat in the french transfusion network until fully automated systems will be available. however, as the prevalence of hbv infections is higher in the overseas territories than in continental france, and as nat is performed on individual donations in these sites, hbv-nat has been implemented since december in these territories. combined detection of hepatitis c virus core antigen and antibody as an alternative to nucleic acid testing in blood screening grating the capillary cytometer with a robotic workstation and a small footprint centrifuge. significantly, there was no decrement in system performance following automation: of clinical samples ( . %) typed identically with this system and cat, and of the discrepant results were eventually resolved in favor of the automated cytometry method. testing showed high-throughput capabilities (currently samples/day) and was inexpensive. to demonstrate the flexibility of this testing platform, we also developed a method to perform completely automated counting of residual wbcs (rwbc) following leukoreduction of blood components. there were no significant differences in accuracy and precision when rwbc in analytical controls and authentic clinical samples were quantitated by the automated capillary cytometry method or the leucocount method performed manually. given the flexibility of this system, it is very likely that additional blood bank assays could be modified for high performance automated testing on this platform. noninvasive prenatal genotyping on cell free fetal dna in maternal plasma ce van der schoot sanquin research, amsterdam, netherlands in lo et al. demonstrated that in the maternal circulation small amounts of cell free fetal dna are present, concentrations ranging from on average genome equivalents(geq)/ml early in pregnancy to about geq/ml at the end of pregnancy. most likely this dna is derived fom apoptotic syncitiorophoblasts. the human placenta is hemichorial, which means that the syncitiotrophoblast is in direct contact with the maternal blood flow, and apoptotic nuclei are directly released into the maternal circulation. the cell free dna is very rapidly cleared from the circulation, the t / being only minutes. in we have shown that this cell free fetal dna could be used for rhd genotyping. in the last years many groups have shown the successful application of different prenatal genotyping assays such as fetal sexing, thalassemia, achondroplasia, duchenne's disease, adrenogenital syndrome etc. on this source of dna. importantly, no false positive result have been described due to the presence of fetal dna from previous pregnancies, the main draw back of prenatal diagnostics on circulating fetal cells. at present prenatal rhd genotyping has been introduced in routine diagnostics in the united kingdom, france and the netherlands. in large scale high throughput studies it has been shown that the diagnostic accuracy of prenatal rhd genotyping is over %, and it is to be expected that in the netherlands this screening will soon be introduced to restrict the antenatal anti-d immunoprophylaxis to women carrying rhd-positive fetuses. in a large european project (safe, co-ordinator maj hulten, warwick uk) many researchers collaborate to further explore the possibilities of cell free fetal dna for future diagnostics. standard operating procedures for the isolation of plasma dna have been established. control pcrs for the presence of fetal dna have been developed. recent findings on differences in methylation status of placental genes in fetal dna opens new possibilities. the main technical problem that hampers wide application of prenatal genotyping is the impurity of the fetal dna, only - % of the cell free dna in plasma is from fetal origin. this makes diagnostic assays on numerical chromosomal abnormalities impossible. and also for many single nucleotide polymorphisms (snps) such as almost all blood group antigens, assays are hampered by aspecific amplification from maternal dna. our own preliminary results indicate that this latter problem can be solved by pna clamping. the addition of a pna probe specific for the k-allele partial d feature d antigen alteration, often identified as distinct 'partial' d epitope loss. the clinical impact of partial ds is due to the ability of their carriers to form anti-d antibodies upon confrontation with regular d after transfusion, or pregnancy. this leads to the -naively spoken -contradictory finding of an allo anti-d antibody in a d positive individual in connection with a negative autocontrol. the antibodies themselves include the same fatal clinical potential as anti-d antibodies of d negative individuals, but may be even more hazardous since unexpected in d positive individuals a priori. d categories (ii to vii) represent a nomenclatorily defined subgroup of partial ds. the molecular cause of partial d lies within single (caused by point mutation in the respective rhd gene sequence), or multiple amino acid exchanges (caused by gene conversion events leading to rhd-rhce-rhd hybrid genes) which determines a qualitative d antigen alteration, rendering them distinguishable from regular d by a partial d carriers immune system. nowadays, transfusion specialists and gynaecologists are more or less aware of these facts and are taking them into consideration in the clinical setting. most partial d exhibit decreased d antigen density, enabling principal recognition of them. however, routine serological methods may not properly recognise all partial ds and will identify their carriers after immunisation only, which represents a reactive diagnostic/therapeutic attitude second best to an actively prognostic one. this actively prognostic proceeding with respect to early detection of partial ds became widely feasible by rhd dna typing techniques. currently, routine rhd dna typing techniques offer an affordable, accurate and fast approach to an unambiguous identification of partial ds and their reliable discrimination from weak d types, not at risk for allo anti-d immunisation. a reasonable proactive proceeding could e.g. demand for (once in a lifetime) routine rhd dna typing of all weakly expressed ds as defined by serology, since most partial ds also meet this phenotype. rhd allele frequencies and their geographical and regional prevalence will certainly have an important impact on dna typing strategies and their (mandatory) specificities. fluorescence cytometry for completely automated immunohematology testing d roback*, b barclay † and d hillyer † *emory university school of medicine, atlanta, † transfusion & transplantation technologi, decatur, ga, usa we previously described a methodology for accurate immunohematology testing by fluorescence cytometry [roback, j.d. et al. ( ) transfusion ( ), ]. this system utilized low-speed centrifugation of -well filter plates for red cell staining, and a smallfootprint capillary cytometer for data acquisition. when authentic clinical samples from hospitalized patients were tested for abo group, the presence of d antigen, and red cell alloantibodies, the results were well-correlated with those obtained by commerciallyavailable column agglutination technology (cat). this system determined the correct abo group and d type for . % of samples, compared to . % for cat (p > . ). when samples were tested for unexpected alloantibodies, fc determined the correct result for . % of samples, as compared to . % for cat (p > . ). this novel method was better than cat at detecting weak anti-a (p < . ) and alloantibodies. based on these promising results, we sought to completely automate this method by inte-prevents the aspecific amplification of the k-allele, and makes it possible to detect the fetal k-allele in the presence of excess of maternal k-alleles. furthermore, it has been shown that fetal dna is in the plasma present in shorter fragments (< bp) than maternal dna. size separation of cell free fetal dna can therefore be used to increase the relative concentration of fetal dna, which will help the development of new genotyping assays. in conclusion, cell free fetal dna in maternal plasma is nowadays routinely used for prenatal rhd typing and fetal sexing. new technical developments will make it possible to extend these indications to other blood group antigens in the near future. more insight in the characteristics of fetal dna might finally lead to wider applications, including numerical chromosomal aberrations. furthermore, it might become possible to apply genomic dna microarrays for the screening on many different inherited diseases, including hemoglobinopathies. determination of the affinity of anti-d present in the serum of immunized subjects and in anti-d ig preparations by a method using unlabeled antibodies p lambin*, m debbia* and y brossard † *institut national de la transfusion, † chp hopital saint antoine, paris, france introduction: few data are available concerning the affinity of maternal anti-d responsible for the hemolytic disease of the fetus and the newborn (hdn), and the affinity of anti-d immunoglobulin used for the prophylaxis of that disease. we recently described a method to measure the affinity (ka) of untagged anti-d monoclonal antibodies. aims of the study: in this work, a similar method was applied to determine the affinity constant (ka) of polyclonal anti-d present in the serum from d-immunized mothers and donors and from anti-d ig preparations. methods: a constant amount of o r r rbcs was sensitized with increasing concentrations of anti-d present in the sera from immunized subjects, and in anti-d ig preparations. at equilibrium, the amount of anti-d bound to rbcs was measured by elisa. the scatchard equation (linear regression) and the langmuir equation (hyperbolic regression) were used to determine the ka of anti-d. the experimental data fitted well with the scatchard equation (mean r † = . ) but a better correlation was observed with the langmuir equation (mean r † = . ). in maternal sera, the mean ka of anti-d was . ¥ to the m- (from . to ¥ to the m- ). in the sera from immunized donors, the mean ka was . ¥ to the m- (from . to . ¥ to the m- ) and in lots of anti-d ig, the mean ka was . ¥ to the m- (from . to . ¥ to the m- ). the comparison of anti-d affinity measured in cases of hdn in which infants presented a fetal anemia and in cases of hdn in which infants presented only a postnatal anemia showed no significant difference. the mean value of ka in the cases of fetal anemia was . ¥ to the m- whereas in the cases of postnatal anemia the mean value of ka was . ¥ to the m- . conclusion: the method previously described for monoclonal anti-d was applied to polyclonal anti-d present in the serum of d-immunized subjects and in ig preparations. the experimental data fitted well with the langmuir equation, and the affinity of polyclonal of anti-d was measured with accuracy. in addition, no significant difference was observed (at least in the cases of this study) between the affinities of anti-d measured in the most severe cases of hdn (fetal anemia) and in the less severe cases of hdn (post-natal anemia). introduction: cryopreservation of platelets is widely used in platelet immunology to ensure the availability of well characterised panel cells for the detection of hpa antibodies. but recovered platelets do not express the hpa- alloantigens. aim of the study: here we describe a method for the successful preservation of platelets by lyophilization. we report the value of this new reagent for the detection of hpa alloantibodies and especially anti hpa- alloantibodies. methods: rehydrated lyophilised platelets (lyo p) were tested for their reactivity with monoclonal antibodies against gpiibiiia, gpibix, gpiaiia and cd by flow cytometry. the levels of reactivity were comparable with the ones obtained with fresh platelets. the rehydrated platelets were used in the maipa with a panel of hpa antibodies (anti-hpa- a, ; anti-hpa- b, ; anti-hpa- a, ; anti-hpa- a, ; anti-hpa- b, ; anti-hpa- a, and anti-hpa- b, ). results: all hpa antibodies showed the expected pattern of reactivity and in several cases absorbance reading were well above those obtained with fresh platelets. absorbance values produced by inert sera were comparable with those obtained with fresh platelets (ranges . - . ). interestingly, we used lyophilized platelet with a high expression of cd bearing the hpa- system and we have detected anti hpa antibodies among sera previously negative with fresh platelets. nineteen sera concerned patients suffering from hematological diseases and from pregnancy women. conclusion: lyophilized platelets are possibly an ideal reagent for the platelet immunologist to be used for the detection of hpa antibodies. moreover, this work bring new insights on the hpa- system in platelet transfusion. we are now pursuing more extensive validation studies with a larger number of samples representing all known hpa specificities and several diseases. the diagnosis and treatment of sick infants and children requires a broad knowledge of physiology, biochemistry, genetics and the application of sophisticated testing and treatment options. one of these options is transfusion of blood and blood products. transfusion of the infant, especially the premature infant, and sick child, especially those with major organ dysfunction, requires careful consideration of their unique metabolic, hepatic and renal clearance mechanisms. guidelines that direct the indications for transfusion differ from those in adults. non-invasive measures of oxygen delivery and oxygen offloading may assist in guidelines for red blood transfusion. metabolic complications from massive transfusion and/or the manipulation of blood products must also be considered. evidence from a high quality randomised controlled trial suggests that anaemia is also well tolerated by critically ill patients. a restrictive approach to rbc transfusion that maintained the hb concentration between and g/l was found to be as effective as and possibly superior to a more liberal strategy of maintaining the hb concentration between and g/l. there are concerns that some groups of critically ill patients, such as those with cardiovascular disease and patients who are difficult to wean from mechanical ventilation, may benefit from higher hb levels. rbcs also have a role in primary haemostasis and higher triggers may be appropriate in coagulopathic patients. it is important to realise that blood is not a uniform product and the clinical efficacy of rbc transfusion may vary. one factor that may have a considerable effect on the quality of the rbc product is the storage time. rbcs undergo marked changes during refrigerated storage. the implications of these changes on tissue oxygenation are not known but these concerns have led some clinicians to request 'fresh' blood for critically ill patients. there is insufficient evidence to support such practice. it is of great practical importance to determine if, or when, fresh rbcs could be superior to stored rbcs. background: with a decreasing blood donor base, fully tested, fresh unrefrigerated whole blood (fuwb) has been found to be a more efficient and effective use of a limited resource in place of, or as an adjunct to, traditional blood component therapy in surgical situations associated with massive blood loss. aims: to outline the use of fuwb in situations where there is potential for intractable bleeding associated with major surgery, and evaluate platelet function in fuwb versus platelet components. methods: outcomes of fuwb and traditional blood component use were examined for cases of cardiac bypass surgery. in addition, exclusive use of fuwb for burns debridement cases was analysed. an evaluation of platelet function in whole blood compared to platelet components was also performed by measuring platelet aggregation and activation parameters. results: there was a decreased requirement for blood components following administration of whole blood post cardiac surgery. whole blood usage for burns debridement surgery eliminated the requirement for additional blood components. platelet activation was markedly reduced in whole blood compared to component platelets, and this may be one reason for the increased efficacy of whole blood in these clinical settings. conclusion: fuwb appears to have a role in minimising blood product requirements and consequent donor exposure in situations associated with massive blood loss. m-pa- transfusion practice for coronary artery bypass surgery in greece s lakoumenta, m vassili, g hatzidimitriou, t asteri, p stratigi, s kanellas and g palatianos hellenic society of blood transfusion, athens, greece cardiac surgery is associated with a demand for allogenic blood and blood product availability as well as a considerable consumption. the impact of consensus guidelines for allogenic blood transfusion during coronary artery bypass graft surgery (cabg) in us attracted great attention . the present study is conducted in order to reveal the transfusion practice in greece on a similar population i.e. patients undergoing cabg operations. methods: five participating centers collected data concerning transfusion of allogenic blood and blood products in patients undergoing elective first time cabg procedures, as well as parameters that may influence blood loss, such as duration of the operation, cardiopulmonary bypass time (cpb) etc. the total estimated blood loss was calculated as the sum of red blood cell volume reduction [(body weight in kg ¥ ml/kg) ¥ (admission haematocrit-discharge haematocrit)]+(red blood cell volume transfused). results: results are shown in table : means, standard deviations, and p-values of the wilcoxon test comparisons between the hospitals. a preliminary analysis of data from centres ( patients) showed no difference in patient characteristics (age, body weight, male to female ratio). there is a statistically significant difference (p < . ) between the five centers in duration of the operation, cpb, estimated blood loss and volume of transfused plasma. red cell use showed also a variation which however did not reach statistical significance (p < . ). the center with the highest figure for blood loss has the lowest volume of allogeneic red cell transfusion because of the use of cell salvage. conclusions: although variations, as those observed in greek cardiac surgery centers, have been documented in other countries, the variation in the use of plasma is striking and we are in the process of trying to identify the reasons. our study is in progress and additional data are being collected and will be presented. introduction: premature infants and at term newborns have an higher circulating blood volume per kilogram than the adults ( ml/kg in premature; ml/kg in at term), for this reason, in case of neonatal thrombocytopenia, a specific hemocomponent, with a very high platelet concentration, needs for transfusion therapy. the laboratory criteria for platelet transfusion are the following: (a) a plt count < ¥ cells/l if bleeding is observed; (b) a plt count < ¥ cells/l without bleeding; (c) a plt count < ¥ cells/l in newborns showing critical clinical conditions. aim of this study: in this study, we have monitored the plt transfusion therapy in our neonatal intensive care unit (nicu) in the last four years. methods: effects of plt transfusions have been followed in children ( premature infants and at term newborns). the weight of premature infants ranged from - g and at term newborn from - g. gestation age of premature infants ranged from - weeks and of at term ones, of course, from - weeks. for every platelet transfusion in these newborns, the volume of platelet concentrate has been of - ml/kg, with a plt count < ¥ cells/l. results : in the study period, plt transfusions have been performed: children have been only transfused one time, while multiple plt transfusions (ranged - ) needed for children according to clinical conditions. the observed clinical indications for transfusions have been the sepsis with haemorrhagic syndrome ( cases) , haemorrhagic syndrome without sepsis ( cases) and neonatal alloimmune thrombocytopenia without haemorrhagic syndrome ( cases). after hours from transfusion therapy, the absolute plt count and the correct count increment have increased in all little patients. the highest increase in plt count was ¥ cells/l, while the lowest ¥ cells/l. no difference in the efficacy of therapy has been detected between premature group and at term group. % of children have been discharged from hospital in good general conditions without complications in following controls. in conclusion, we can affirm that plt transfusion in premature infants and in at term newborns is an efficient and safe treatment of severe haemorrhagic conditions. however a collaboration between nicu and transfusion center is necessary to choice the adequate platelet concentrate's volume for transfusion and the best plt donor for the newborn. developing transfusion strategies fusion society of turkey (bbtst) in with contribution of blood transfusion centers. according to these figures % of centers attended operates apheresis procedures. two centers informed us that apheresis in the hospital was carried out at blood bank. there was not enough information from one center, so it was excluded. of the blood banks performing apheresis, were university hospital blood banks. another blood banks were producing both productive and therapeutic, produce only productive and produce only therapeutic procedures. one center did not respond. all centers reported to prepare and separate erythrocyte and plasma. however only centers reported to prepare random platelets as well. each center had apheresis machines between - . a total of centers was carrying out around < procedures, around - , at centers about - , at a further centers around - procedures a year (one center was excluded). of the responders to the survey , all procedure were done at blood banks, whereas at of them all were carried out by the hematology clinics. at other centers, productive procedures were conducted by the blood bank, and therapeutics were performed by the hematology division. a total of blood banks stated that they have not kept the platelet suspensions produced and used them straightaway. productive apheresis center capacities were as shown: centers < , centers - , centers - and centers > units have donations a year. around % of all apheresis procedures were carried out by large well run blood banks. conclusion: as the use and production of random platelets increase, and settle of apheresis devices in big centers will eventually decrease the demand of apheresis procedures and keep the welltrained staff at big centers, decrease the cost thereafter. • planning of resources for the financing of the bts, adoption of a methodology for creating and adjusting the price list of products, adoption of the yearly plan of needs for blood/products and services of health institutions which use blood/products. • achieving recognition of real costs of products and services from the health insurance fund and ministry of health. • harmonization of low level of acclaimed costs and real costs of basic transfusion activities. results: acclaimed costs for activities in transfusion practice (collection, testing, processing, storage, distribution and transport) as a reflection on the price of the products are % lower than real costs. the prices of health services in the official price list are much lower than the proportion of costs of material resources needed for the realization of these services. this especially affects the management of independent blood establishments (bti's in serbia) with core blood transfusion activities as their basic field of work, in comparison with the hospital based transfusion services, which are financed within the budget of the whole hospital. the hospitals with hospital based transfusion services involved partly in core transfusion activities are completely financed by the health insurance fund, while independent blood establishments are financed through the price of products and services they provide. conclusion: in order to provide adequate quantities of safe blood/products for the end user -the patient, it is elementary to create stabile and equal financial management conditions for the whole blood transfusion service in serbia. this can be achieved only by continuous cooperation of the health insurance fund, ministry of health and independent blood establishments. sion centers (rbtc). the activities on promotion and organization of voluntary, nonremunerated blood donation, blood collection and patients' services are carried out in the rbtc and in departments of blood transfusion (dbt), part of the district hospitals. the collected units in dbt are transported by special cars to the ncht and the rbtc for processing, testing and control. the same transport is used for the requested by dbt blood components for storage and distribution to hospital departments. thus the issued components are with an equal quality and safety for all patients throughout the country. lbbdbt introduces hemovigilance as a mandatory system, covering the whole chain of the blood transfusion process. it includes as well the creation of registries at a national, regional and district level of blood donors, recipients of blood products and all activities of the blood transfusion service. . seventy hospitals are exclusively users of blood, blood products and services. the current organization of blood transfusion services faces the following problems: fragmented transfusion service, lack of a national blood policy, the blood program is not nationally coordinated, limited knowledge on quality management, inadequately distributed human resources, limited material resources, lack of it system, lack of planned, continuous skill upgrading. as a direct consequence we have: suboptimal blood collection activities, inadequate blood supplies significantly vary between seasons, high percentage of replacement donors, outdated methodologies, old, even obsolete equipment, the quality of blood products is not standard, there is a lack of traceability. aim of study: to reorganize blood collection activities in serbia to increase collection of safe blood up to % ( blood units). methods: division of responsibilities between blood establishments and hospital based transfusion services by: • optimizing organizational structure • implementing blood collection standards to enhance blood safety and donor care • gradually replacing family donors with a network of voluntary non-remunerated blood donors from low risk population groups • creating and implementing a training strategy. results: through the eu funded project support to a national blood transfusion service in serbia, we are in the effort of integrating the services and standardizing their work. the blood collection working group began by dividing serbia into blood collection regions: north, central, and south. each region is divided into sub regions covering approximately half a million population ( in the north, in the central and in the south region). each sub region will have one standard mobile blood collection team to collect blood units daily, i.e. annually. the blood units per teams provide the blood units ( %) to cover hospital needs in serbia. to this effect, the following has been achieved: • blood collection activities in serbia analyzed • performance analysis of bte and hbts mobile teams in place • two model standard mobile teams tested in the field • national blood collection sop's written • national donor questionnaire form prepared • national set of blood collection standards prepared • list of donor deferral criteria prepared • blood collection equipment renewed • regional reorganization plans in progress. the objectives and results can be achieved by the participation and mutual cooperation of all institutions involved in blood transfusion within an integrated, standardized system with clearly delegated responsibilities. p- years of the national blood transfusion institute in serbia n nedeljkovic national blood transfusion institute, belgrade, yugoslavia nbti was founded in . since and unpaid blood donation is mandatory, organized in cooperation with red cross. blood donation is regulated by the law in , / . codex of voluntary blood donation and health care staff has also been established; blood donors donates blood annually. in the past years, there was over million blood donations, performed in accordance with who regulations. over transfusion medicine specialists and technicians specially trained for the work in blood transfusion service (n = ), perform transfusion medicine doctrine of rational labile blood component and stable blood derivatives therapy, based on the selfsufficiency concept in fr yugoslavia with . million inhabitants in serbia, montenegro and kosovo. plastic blood containers and tests are imported or given as humanitarian aid gift and from . now, they have been regulated by tender. in , test to lues was introduced, to hbsag in , to a-hiv in and to a-hcv in . information system was introduced in . nbti includes: national haemovigilance coordinatoin center, center for medical care of haemophiliacs, tissue typing center, center for prenatal and perinatal protection of pregnant women and newborns. activities of nbti are organized through: center for planning, organization and development of blood transfusion service, center for blood collection, preparation and distribution, center for immunology and immunochemistry, plasma fractionation center for plasma in west balkan countries, center for diagnostics means, center for quality control of drugs and medical and diagnostic means, center for education and training and scientific research work. nbti is the third year of gmp, sop, yus iso implementation. in the current reform of transfusiology system we are aiming for percent of voluntary blood donation. nbti is the publisher of the national bulletin of transfusion medicine and it is included in the education system of the belgrade university medical faculty and the estm in belgarde . the problems of blood service in russia ea selivanov and t danilova russian inst. of hematol. & transfusiol., st. petersburg, russian federation background: the blood transfusion service (bts) development as a platform for providing the hospitals with blood and blood derivatives is an important national problem. aims: russian blood service assessment with international comparison. methods: a study was conducted on the base of the reports from all regions of russia followed by a computer statistical analysis. results: blood and blood components were collected in the russian federation in in stations of blood transfusion and in blood transfusion departments at big hospitals. amount of donors in was equal to , voluntary donors being . % of them. the average number of whole blood donations in relation to the general population is per inhabitants, and on average percent of the donor base consists of first time donors. the average number of blood collected in relation to the general population and health care system is . ml per inhabitant and ml per one bed. an average volume of one blood donation is ml. blood was collected into plastic bags containing domestic or foreign anticoagulants. about . % of collected blood is used for procurement of blood components and preparations, . % of banked blood is used for transfusions. amount of donors and the volume of whole blood have been significantly decreased for the last years. at present in russia all donations are tested for abo blood group, rh(d) type, anti-hiv- / , hbsag, anti-hcv and syphilis. the total percentage of blood discarded after testing for transfusion-transmissible infections is . %. % of plasma is obtained by plasmapheresis. blood components collected are as ffp, rbc, frozen rbc, eukocyte-and platelet-depleted rbc, rbc suspension, and preparations: % albumin, immunoglobulins, and cryoprecipitate. as to blood safety measures -implementation of blood components leucodepletion and ffp and rbc quarantine in process. the new national strategy of bts reorganization has been developed. it includes the following: increasing the visibility and resource commitment to blood issues at the national, regional and municipal levels; the national voluntary donor programme promoting; blood safety increasing; blood collection, testing and pro-cessing concentration in federal and regional bts establishments, appropriate blood and blood components usage. calculating the cost of blood in turkey n solaz, s kemahli and s cin ankara university, ankara, turkey background: like other fields of the medicine cost efficacy is gaining importance in blood banking and transfusion medicine since last few years. since last years even the most developed countries started to discuss about the cost of blood. in turkey ministry of health determines the cost of blood annually. aim: to establish a safe, cost effective and reliable prices for blood components. methods: turkish ministry of health (moh) started to determine the cost of blood components as 'all inclusive' principle. this means that cost of a unit of blood component will cover all conventional expenses such as; blood typing, infectious screening, labour, consumables, etc. this system has provided uniformity to blood component costs but if the system is not controlled and followed properly it will cause serious risks. there might be some blood banks which will not respect the safety regulations and may modify the test standards for decreasing the cost of tests. conclusion: current blood product pricing system looks generally reasonable and reliable but moh should establish close follow up systems for avoiding any abuse on the safety of blood. background: a positive direct antiglobulin test occasionally occurs in normal blood donors, and is often discovered when the donor's red cells are found incompatible in a compatibility test. the incidence of a positive dat was expected to increase since more sensitive techniques (gel test) were installed. the aim of our study was to examine whether dat positive otherwise healthy donors presented any clinical or laboratory abnormalities. methods: in the first . cross-matches last year (in months) were found incompatible due to dat positivity of blood donors' red cells ( . %). dat positive [( +)-( +)] samples were only igg positive in cases, only c d positive in and igm positive and c d positive in case. all blood donors were notified and thirty two of them responded to a request for a further sample. a complete blood count, a reticulocyte count, bilirubin (total, direct, indirect), transaminases, serologic immunological tests (ana, anti-dna, anti-ena, rf, anticardiolipin antibodies), quantitative assessment of immunoglobulins, aptt and lupus anticoagulant were performed, as well as serologic tests for markers of viral infections. dat and iat were performed by gel test (id-diamed) according to the manufacturer's instructions. dat were performed with polyvalent and monovalent reagents (anti-igg, -igm, -iga, -c c, -c d). the blood donors were also examined clinically. the donors who had positive immunological tests were referred to a rheumatologist for further investigation. results: among the thirty one blood donors eight had received medication the last hours before blood donation, two had been vaccinated for hepatitis b recently, four presented signs of a viral infection soon after blood donation, three had evidence of an allergic condition, five had positive tests for anticardiolipin antibodies and ana, two were positive for anticardiolipin antibodies only and two had a positive ana test only. in six blood donors we did not find any abnormality that might be interrelated to dat positivity. conclusions: all blood donors with positive dat should be requested to undergo further investigation. some of them are possibly candidates to long medical follow-up, especially those with other immunologic abnormalities such as positive ana and/ or anticardiolipin antibodies. the eligibility of such donors for future donation of whole blood, platelets or plasma needs to be elucidated. tions: usefulness, frequency and sincerity in answering questions. donors could choose one of the offered answers and elaborate in writing the answer they have chosen. results: of the donors that participated in the survey ( . %) answered the questionnaire, ( . %) men and ( . %) women. that the survey was useful thought % and % that it was not. opinions were elaborated by . %. that the questionnaire should be completed before each blood donation was the opinion of . %, % thought it should be filled out only the first time blood is donated and . % that the questionnaire should not be completed at all. the answers given were sincere in . % of blood donors, % were not and . % were given automaticallywithout comprehension. conclusion: most donors believe that completing the questionnaire before each blood donation is an effective way to increase safety by preventing potentially infected individuals from donating blood. they are also aware of the importance of answering questions truthfully because the end result is protecting the wellbeing of both blood donors and receivers. analysis of blood donor's deferral in national institute for transfusion medicine -skopje for the last five years ( ) ( ) ( ) ( ) ( ) p blagoevska*, i nikolovska † and r grubovik* *national institute for transfusion medic, skopje, † medical center, prilep, macedonia introduction: safety of blood and blood products depends on many different factors, starting with selection of blood donors. the aim of this study is to analyze the number of deferred blood donors and the reasons for their deferral, as well as the total number of blood donors in nitm and their correlation (voluntary/family donors). materials and methods: this is a retrospective, epidemiological study and data were taken from the blood donor's registry in nitm from . . till . . . statistical mass includes blood donors who came to nitm to donate blood in the mentioned period. results: there were total donors in nitm and ( . %) deferrals. . % of deferred ones are male, as well as in the group with donated blood (males are predominant). the most common reason for deferral is low hb level in ( . %) blood donors, use of drugs - ( . %), low blood pressure - ( . %), high blood pressure - ( . %), infections - ( . %), cardiovascular diseases - ( . %) and others. relation voluntary/family donors is almost equal ( . : . ). in the last two years the number of voluntary blood donors is increasing ( : ), which is good sign. conclusion: percentage of deferred blood donors in first three years is ~ %, which is result of insufficient data and it is increasing in the last two years (> %). reasons for deferral are predominantly from temporary character ( . %). permanent deferrals are only ( . %), which is probably due to good education of the population and self-deferral. we should establish the national registry for deferred donors, as well as for the donors with positive markers for tti. we should design a strategy for returning of temporary deferred donors. regruting blood donors in multiethnical environment p blagoevska*, r grubovik* and k elezi † *national institute for transfusion medic, skopje, † medical center, gostivar, macedonia introduction: population in r.macedonia consists of % macedonians, % albanians and % others (serbs, gypsies, turks). over % of blood donors are voluntary non-remunerated and ~ % are family donors. transfusion service and red cross should recognize the values and cultural differences of minors groups and recruiters should developed methods for reaching and motivating them to donate blood. the aim of the study is to present the ethnical structure of our donors and to develop strategy for their regrutation and retention. the study reviews the results from the blood donation actions among the high schools and university students in west part of the country (multiethnical environment) from till . results: there were blood donations for the mentioned period. predominant blood donors are employed and high school students in %. family blood donors are ~ %; between them % are from albanian population. the ratio between blood donors macedonians vs. albanians is : . woman blood donors are presented with %. first time blood donors are %, and regular donors arẽ %. conclusion: first step in planning the blood donation in multiethnic society is creation of special teams of important and devoted volunteers, such as religious leaders, teachers, doctors and businessman. for a successful campaign it is necessary to design special promotional material and address personally to the target population on their mother language. background: pursuit of pharmaceutical purity of the blood in the bag has led to a shrinking donor base and a significantly more expensive product. decisions regarding new infectious marker testing and donor deferrals have typically been made emphasizing decreasing one specific risk without considering the effect the intervention will have on the overall safety of blood transfusion. regulations have been formulated by governmental agencies with limited input from the medical community. the decision making process has lacked risk benefit analyses and has not had the robustness associated with spirited discussions. policies made in this manner may result in certain risks being decreased but can also have adverse unintended consequences. discussion: in the u.s., the fda's implementation of donor exclusions to prevent possible transfusion transmitted vcjd has reduced the donor base by more than %. given the demographics of the deferred donors, the impact on plateletpheresis donations has been even greater. to compensate for the loss of donors, blood services will have to persuade present donors to donate more frequently, to recruit new donors, or both. one study has indicated that two-thirds of donors have no intention of donating more frequently. new donors have higher rates of infectious disease markers with positivity for hiv and hcv twice as high as repeat donors. despite sensitive testing techniques, window periods still exist and not all potentially infectious donors will be excluded. another area of concern is the aggressive use of inducements to attract new donors. some blood services are offering lavish incentives such as enrolling donors into drawings to win automobiles. most donors entering the lottery will be low risk; however, it is reasonable to worry that such extreme tactics might also attract persons who should not be donat- conclusion: (a) blood donors who were patients' relatives were many more than volunteers as well as more were men than women. also people of young ages were more than those from older ages. (b) the frequency of the diseases for which the blood units were tested was found to be in low levels in the population of the area. specifically as concerns hcv, it seems that transmission frequency has been reduced after the obligatory testing of hcv in blood transfusion centres and stations. genotype b of hepatitis c virus is the most frequent in blood donors d, from a to f, from a to k, a and a. these are differently distributed in the world: types and are the most common in europe and in usa. aims: considering that, in our region, anti-hcv antibody positivity is variable from . to % of general population, aim of this study has been to evaluate the prevalence of hcv genotypes in blood donors. methods: in period from may to december , blood units were analyzed by nat for viral rna research. nat has been performed on single sample by tma technique. on rna-positive samples, the hcv genotype has been identified by reverse hybridisation with line probe assay. results: blood donors have resulted hcv-rna positive with identification of the following genotypes: a = cases ( . %); b = ( . %); a + b = ( . %); a/ c = ( . %); = ( . %); = ( . %); none was a or a. we have also analyzed the differences between the two sexes in hcv-genotypes distribution. hcv- a has showed a double prevalence in men ( cases, . %) respect in women ( cases, . %), while genotype b is more frequent in women ( cases, . %) than in men ( cases, . %), moreover genotypes and do not compare in women. although an accurate pre-donation selection, discharging all subjects with alt > iu, our results show that . : donors, apparently healthy and without risk factors, have resulted hcv-positive. analyzing our data, the genotype b has resulted the most frequent in blood donors' population, followed by type , while the others have showed a very low prevalence. the high frequency of genotype in blood donors is explained by the observation that hcv is usually associated with low alt levels, for this reason affected subjects may escape to donor's screening only based on dosage of alt. on the contrary subjects affected by other hcv types, associated with high alt levels, may be deferred increasing the hcv b relative prevalence. at the end, the different distribution of hcv genotypes between men and women and between age's classes probably reflects differences in the pathogenic characteristics of the virus, in the transmission way and in the risk factors. in fact, it has been demonstrated that genotype is principally linked to a not transfusion transmission way; genotype is linked to old age, to female sex and to post-transfusion transmission; genotypes and are associated to young age and to an history of drugs abuse, respectively with high and low viral load; genotypes and are still little known because extremely rare in europe. p- kell blood group system and rare blood donors v fakitsa*, p karyda*, s giannoulea † , c antoniou*, j flesiopoulou*, e haliou*, m papakonstantinou*, h dessilla † , e katsadorou*, g lyrakos* and k sofroniadou* *general hospital of nikea, pireas, † blood transfusion center, athens, greece background: the kell blood group system is a compound antigen system exclusively of red blood cells. some of the kell antigens are highly immunogenic. the commoner kell antibody is anti-kel . the kel (cellano) antigen is a high frequency antigen and the blood donors lacking this antigen are quite rare. the blood donors who have not factor cellano are classified in the rare blood donors. rare blood by its very nature is required rarely, but when needed that blood has to be ensured to specified patients. there are other blood donors in their family - ( . %) students, but the number of persons that donate blood from their neighborhood and close environment is much bigger - ( . %). motives for their donation are the following: their wish to help the ones that need blood - ( . %), concern that some day everyone can be a potential recipient of blood - ( . %), because of offered benefits - ( . %), for a friend or relative - ( . %), care for their health - ( . %), because of citizen duty - ( . %), because the others donate - ( . %), curiosity - ( . %). they want to be invited every months - (%) students, every months - ( . %), every months - ( . %) and ( the mean age of case group was / ± / and the mean weight of them was / ± / , / % was male and the mean number of blood donation was / ± / . the mean age of control group was / ± / and the mean weight of them was / ± / . / % of them was male and the mean number of blood donation was / ± / . the blood donors who were female, first time blood donor low wt the rate of vasovegal rx was higher in female, first time, low weight, younger blood donors (p < . ). the rate of vasovegal rx was higher in blood donor (p < . ) who were fatigue or first time blood donor, low wt blood donation, fatigue of them and starvation of them had higher absolute donation reaction than other donors. when each variable was adjusted for other variable by regression analysis. young age, first time blood donation, anxiety, fatigue, starvation were significant (p < . ) and the others were not. conclusion: donation -related vasovegal syncopal reactions are a multi factorial process. these reaction are more prevalent in blood donors who are young, first time donor, anxiety, fatigue, starvation. these reactions might be predicted vasovegal reaction and these some facth donors need more care. with better donation care, syncopal reaction may be decrease this would be improved donor safety, better donor retention, higher donor satisfaction, and reduce cost and increase regular blood donors. to avoid iron deficiency in blood donors, iron compensation is necessary in most females and males who donate more than - and - whole blood units per year, respectively. we present studies dealing with different dose and duration of iron compensation. in the first randomized placebo controlled study iron decreased continuously in males and females at donation intervals of two (males) and three months (females) without iron compensation. mg and mg daily combined with mg ascorbic acid over months (males) or months (females) compensated for iron loss or even overcompensated in females. in the second open study we reduced iron dose to mg daily over one month for both genders. this iron dose was sufficient for compensation of iron loss. a further reduction of iron dose to mg daily over half a month led to negative iron balance in the majority of donors. in all three studies donors with exhausted iron stores profit more from iron compensation, whereas donors with high ferritin values (> mg/ml) tend to loose storage iron. aim of the study: one of our campaign strategy how to increase blood donation among adolescents are periodical seminars and excursions for students of secondary schools (more than per year). the aim of this study is to analyze impact of our campaign educational system on adolescents in period - . methods: the donation of whole blood and aphaeresis platelets from donors of age from to (max. years for each class) were count for the period of five years ( ) ( ) ( ) ( ) ( ) . the percentage of the man´s donation was calculated for each target class ( ) ( ) ( ) ( ) ( ) . results please see tables and . in the tables there is shown observed data in relation to the total number of births in the czech republic in reviewed years. the study showed that number of donation from donors of age from to decreased during objected years. unfavourable state of total number of births in the czech republic ( birth in republic ( birth in , birth in ) and its decreasing tendency ( birth in !) is with high probability a major demographic factor affected number of young donors. despite energy invested in our campaign educational system our recruitment efforts should be intensified to decrease influence of demographic factors. we should find new ways and methods to attract new blood donors and keep the regular ones, too. the aim of the research was to investigate women's attitudes towards blood donation in cyprus. a statistical sample was selected using stratified sampling and consisted of women from the district of limassol (the second largest urban center of cyprus) between the ages of and . using linear logistic regression, the analysis of the data collected revealed that there is a greater probability for a woman to be a blood donor if she is of a higher educational level, a member of an organized group or association, or if she is acquainted with other blood donors. the percentage of female blood donors is higher in rural areas than in urban centers. % of women do not donate blood and attribute their reluctance to do so to health-related problems, while about % of those who have never donated blood claim to fear the blood donation procedure. in addition, more than half of the women who have stated they would never donate blood again have attributed their denial to healthrelated problems. the research revealed that there could be an increase of up to % of the percentage of female blood donors if they were given time off work for a few hours or one or two days afterwards. even though very few female blood donors expressed a preference for the blood donation to take place on a particular weekday, half of them prefer the donation to take place on the discussion: it is about small group of students. the impression is that the altruistic behaviour is present at most of the questioned students. the fact about free school days is not underestimated because it is one of the most important motives of blood donoring of the young population. families where the blood donoring is a tradition have a great influence for young children because the children in these families are better informed for blood donoring. conclusion: including the children in the process of education for young children is of particular importance because the altruistic behaviour as a higher feeling is from an early age of the child and it is under the influence of the environment (family and friends). active participation of the department for transfusion medicine in the educational process, especially in the education of young children, is a guarantee to achieve longlasted positive results. adverse reactions in blood donors taking betablocking antihypertensive medications l paesano*, m d'onofrio*, s misso † , g fratellanza* and e d'agostino* *university federico ii, naples, † hospital san sebastiano, caserta, italy one aim of blood donor's selection is to avoid an adverse reaction to phlebotomy (as vasovagal reaction, syncope and/or hypovolemic cardiac insufficiency). blood donation is surely contraindicated in various pharmacologic therapies, but not in all. in fact a certain degree of discretionarily exists about the assumption, or the period of suspension, relative to a numerous pharmaceutical products, as the antihypertensive agents. according to literature, the deferral of donors taking antihypertensive medication is not indicated when blood pressure is normal, symptoms are absent, and diuretics or similar agents are the only drugs used. on the contrary, it is a common opinion that an antihypertensive therapy by betablockers is not compatible with blood donation for its cardiac effects. nevertheless, in our daily activity, the observation of a blood donor taking beta-blocking drugs may occur for various causes. a possible error is a superficial pharmacological anamnesis, as it can occur in donations on autohemotheca, for a too fast medical visit (due to a large number of donors), or for the inexperience of the selector (often a not specialist of transfusion medicine young doctor). another possibility of observation is constitute by patients, undergoing to elective surgery, included in a program of autologous blood donation, suffering hypertension treated with betablockers. in fact, in this last case, the risk/benefit balance justify the blood letting procedure. in the last year we have just observed two severe post-donation reactions in donors suffering hypertension treated with atenolol. the reactions have been similar, in fact both donors showed lypotimia followed by convulsions about past half hour by the end of phlebotomy. no prodromic symptoms have been observer or referred. cardiac frequencies (cf) before donation were respectively and beat per minutes and blood pressures (bp) were both in the normal range ( / and / mmhg). after donation, during adverse reaction, cf showed no substantial variations, while bp have been decreased respectively to / and / mmhg. immediate treatment has consisted in putting the donors in the trendeleburg's position and in applying a dolorous stimulation. in the first case this treatment has been sufficient to report the bp to / mmhg (with disappearing of all symptoms) in only half hour time. in the second one, the marked hypotension showed a very slow remission, for this reason the subministration of a plasma expander needed, with the complete resolution of the symptoms after two hours. these two donors were not deferred from donation because they were periodic donors that had modified their antihypertensive therapy, without referring it neither in the questionnaire nor during anamnesis. our experience confirms that the blood donation don't must be permitted to subjects taking betablocking antihypertensive drugs. in fact these medications act on cardiac pump decreasing the cardiac rhythm and limiting the postdonation cardiac recover. this effect is very dangerous because it appears relatively in retard respect to the end of donation, when donor may have just leaved the transfusion center. introduction and aim of the study: in society under transition privatisation and marketisation probe all areas of life. transition to market economy is extremely important and sensitive issue in health and welfare services in general, and specifically in the case of blood transfusion service. the aim of the study was to analyze effects of confusing publicity which introduced possible ways of transforming blood transfusion service in serbia (ideas about privatization of some parts of national blood transfusion institute, buying blood from blood donors, selling blood from voluntary blood donors to private clinics, exporting blood from vbd, stories about tradition of paid blood donations in some european countries). publicity was restricted to a small number of sporadic outbreaks concerted in a limited period of time. table. conclusion: surveillance of adverse reactions and injuries or accidents during or after blood donation is essential for maintaining the well being of active blood donors, as well as for the safety and quality of the donated blood components. information on other activities and parameters affecting the quality of blood including materials, reagents and equipment should be collected and any serious deviations from standard operating procedures should be notified to the competent authority using haemovigilance infrastructures. skae has built up such procedures working along the lines of the european haemovigilance network. improvement of existing national haemovigilance systems is expected to follow from the implementation of the eu directive. although inevitable, blood donor deferrals lead to losses in donated blood supply and may affect donor-return rates and subsequent blood donations. to estimate the scope of blood donor deferrals and their causes, we analyzed the - data from regional blood centers using standardized criteria for temporary and permanent blood donor deferrals. within this period ( ) ( ) , . percent of persons who presented for donation were deferred; . % were temporary deferrals ( % due to laboratory test results, among others low hemoglobin, . % due to risk of acquiring a transfusiontransmissible infection) and . % were permanent ( % due to the infectious diseases markers, . % due to cardiovascular diseases). for regional blood centers the temporary deferral rates varied widely (see the table below ). in the case of individual regional centers, the differences as well as the most common causes were often difficult to explain. according to our analysis, some blood centers have a more restrictive approach to donor acceptance than others and this results in increased donated-blood loss. to some extent such losses could be avoided. further studies are recommended to elucidate the problem and eliminate unnecessary deferrals. caption : percentage of deferrals aims: from our experience in selecting blood donors, a certain number of issues have been noticed that remain obscure and need to clarification since those seem to 'haunt' the whole process of blood donation. methods: many first time blood donors and especially volunteers think that rejection reasons are permanent and they are completely incapable of donating blood their entire life. this is a 'tragic' misunderstanding since the doctor did not explain that the reason of the rejection is only temporary and in the future this man is capable of donating blood. those potential donors will never even approach again blood donation centre and when in the future they are asked why they do not donate blood, they repeat the cause of the past rejection. results: one of these rejection reasons is for example low blood pressure ( . % of total causes of rejection). as we all know blood pressure must be determined according to age, sex, weight and from other factors as sleep, emotional status, food and liquid intake. therefore blood pressure is very important but should be evaluated with all the above factors and must not be alone the only reason for rejection. even when one blood donor is rejected it should be made clear to him that this is only temporary and if in the future he is in better physical condition, he could donate blood. in fact - % of those donors rejected for hypotension are readmitted in blood donation after meeting the above mentioned criteria. another matter of equal importance is anemia ( . % of total causes of rejection), especially concerning young women. since most of those women tend to develop anemia due to depletion of iron stores, they should be advised to donate blood at longer periods than regular, to receive proper medication and diet according to their needs. the doctor must explain the donor the reasons for iron depletion, so blood donation should not be considered as the only cause for this situation from the donor. there are many factors contributing to anemia, menses, specific diets, overwhelming stress and exercise, not to mention other medical reasons. it is the duty of the doctor to correct those factors that resulted in iron depletion or anemia and readmits those donors in blood donation in the future ( - % of those rejected are readmitted in our centre). summary/conclusions: at our blood centre we have created a program of regular tests (blood tests-physical examination) for all our blood donors. our experienced and well taught personnel offers advice and provides useful information in every aspect of blood donation and more. we have created a friendly environment for all our volunteers with love, understanding and appreciation and believe that this is the only way to keep a constant 'flow' of blood in our region. introduction: an innovative perception for blood donation in a new and evolving environment must focus on specific matters and ideas and adopt in a certain level lifestyles and concerns of society. aims: the purpose of this study is to find methods and ideas that can help blood donation centers throughout our country to create new blood donors, give a motive and inspiration for blood donation by adopting new trends of society and finally accomplish national need. methods: by having a personal interview with many volunteers about their feelings for healthier life, their nutritional habits, daily physical activity, sports, vitamins, smoking, weight, cholesterol levels. we investigated whether they believe that blood donation has, if any role towards a more hygienic life. results: we divided blood donor volunteers according to their age, educational level, and number of blood donations per year. our results indicated that there is a tendency among young educated people to adopt a personal lifestyle that includes consuming healthier food, keeping their weight low close to the ideal, having some kind of personal activity, not smoking, watching cholesterol levels, following doctors advice and concerning seriously about their health. this dynamic group of blood donor volunteers considers blood donation as a contributing factor to well being and donates blood at specific intervals. besides the yearly run lab tests that are done by our blood centre they also seek advice and discuss any matter concerning their health with the blood centre doctor. it appears that they are extremely sensitive in those matters and they seem to appear well informed about issues concerning their health, they also believe that blood donation is part of the plan they have to keep fit and being well. in our blood centre we encourage this belief and we also provide information concerning this new trend towards healthier habits. summary/conclusions: this approach has already shown some positive results in our blood centre as many people especially young educated women have joined our blood donorship program and donate blood at scheduled intervals. in order to achieve our goal which is to raise the percentage of blood donors in the region we have to be flexible, innovative according to new habits and lifestyles. we have to move with society and modernize the way we attract various groups of people. blood donation against prejudice as saltamavros*, s dimitrakopoulos † , v zacharaki*, p giannaros*, s markou* and p tseliou* *st. andrews hospital patras greece, patras, † pyrgos general hospital, pyrgos, greece introduction: in order to achieve a greater population to be admitted in blood donation we have to provide information concerning any obscure issues that presents in selecting donors. to examine the accuracy of hb measurements obtained by the noninvasive clinical device, as compared to values detected by standard methods, (cell-dyn , abbott laboratories, usa), in a blood donor setting. methods: the nbm- device utilizes a finger base sensor using occlusion red/near-infrared spectroscopy (o-rnirs) to detect and analyze the hb/hct levels. the clinical trials were conducted at two blood donor centers (israel and usa). studies were carried out on a group of subjects ( females, males) aged - . subjects were healthy volunteers who had come to donate whole blood or aphaeresis components. after obtaining informed consent, hb/hct levels of all the study volunteer participants was tested non-invasively, using the nbm- device, followed by a venous blood sample. additionally, the usa center tested a capillary blood sample using the hematastat hct measurement device ( donors). hb levels were considered normal when readings were equal to or > . g/dl. results: venous hb measurements ranged from . - . g/dl. the mean nbm- hb level was . ± . g/dl, only . g/dl lower than the mean hb result obtained by venous sampling, which reached . ± . g/dl. the standard deviation of the difference between the invasive and noninvasive hb readings was found to be ± . g/dl. the mean absolute error (mae) of their difference was . g/dl. when checked against the cell-dyn in the usa center, where subjects had hb of . g/dl or lower, the nbm- and hematastat devices showed comparable sensitivity results. the nbm- using o-rnirs is a promising noninvasive technique for hb screening in blood donors. the device is easy to use and agreeable for both blood donors and personnel. the technique reduces the need for the invasive finger prick or venous blood sampling, thereby enhancing safety, reducing costs, and improving the experience of blood donation. the effect of short-term, temporary deferral on blood donor return rates and subsequent blood donations background: blood donors are deferred for numerous reasons. some deferrals like intravenous drug use, male homosexual contact or certain positive test results are permanent. the majority of donor deferrals, however, are short-term temporary deferrals (sttds) that are resolved in a matter of days, weeks or months, after which time the person is again an eligible blood donor. the effect of sttds on blood donor return rates and subsequent blood donations is studied. materials and methods: donors given sttds during the december to march were computer-matched with non deferred donors on the basis of age, sex, and donation date (case group: donors -control group: donors). computer records were evaluated during the next years ( march to march to determine donor return rates. significance for comparison between the two groups was based on chi-square analysis. results: the most common reasons sttds were elevated blood pressure ( %), deferred for medication ( %) and colds and/or sore throats ( . ). non deferred donors were a little more likely than donors with sttds to return over the next years ( . % vs. . % pv = . ) and non deferred donors donated more whole blood units. . according to ethnic structure, women -ethnic macedonians donate blood in largest numbers - ( %), while all other ethnic groups are present with only %. the most prevalent is the group of adults aged - ( - . %), with high school education - ( . %) and mostly those who donated blood - times ( - %). conclusion: having in mind that % of the population in macedonia is female, the obtained results reveal a significant, yet insufficient participation of women in blood donation with % in relation to the total number of blood donors surveyed in the period - . this is due to insufficient motivation and education of women from all ethnic groups especially those from the younger population and with elementary education. incorporating them in education and organization would contribute to their more extensive participating in blood donation. comparison of serum beta -microglobulin (b -mg) between hbsag positive donor and healthy control f tarabadi*, m shaeigan*, g babaee † , a talabiean* and m khadir* *iranian blood transfusion center, † tarbiat modarrs university, tehran, iran background: beta -microglobulin (b -mg) is a low molecular weight protein ( daltons) and found in all biological fluids it is light chain of histocompatibility class -human present on the most membranes of cells. in the hepatitis infection the viral antigen presentation on the hepatocyte in the presence of class -hla antigen plays a role in the elimination of the virus. method & samples: beta -micro globulin was measured in serum drawn from hbs ag positive blood donors include ( . %) female and ( . %) male in age between - years, and healthy ( %) female and ( %) male in the same age we detected serumic b -mg by enzyme immunoassay (ela). results: our studies showed b mg level increased in ( . %) hbs ag positive donor that was significant differences with healthy control (p = . ). conclusions: it seems that serum b mg is a good marker for hbs ag replication. the role of b mg in monitoring of response therapy needs to be more evaluated. and ( . %) were contributed by vd, rd and dd respectively. over the last / years, voluntary donations have shown a rising trend from . % to . %, where as rd ( . % to . %) and dd ( . % to . %) have shown a declining trend. the percentage of female donors was maximum in voluntary group as compared to rd and dd ( . % vs. . % vs. . %) respectively. the rates of all tti markers reactivity were significantly higher in rd as compared to others donors. the hbsag and anti hcv reactivity in vd and dd is comparable ( . % vs. . % and . % vs. . %). hiv antibodies was found more frequently in vd as compared to dd [ . % vs. . % (p < . )] whereas, vdrl reactivity was lower in formal as compared to latter [ . % vs. . % (p < . )]. conclusion: voluntary blood donation has shown a rising trend over a last few years, thus highlighting efficient donor motivational strategies. these strategies need to be strengthened to increase the female donor base. the safety of dd is equivalent to vd when the rates of tti are compared. thus, dd should be advised to donate blood regularly as voluntary blood donors. blood safety depends on a number of factors. the chain of safe blood starts with the donor. one of the procedures for obtaining safe blood for transfusion is the medical selection based on the completed questionnaire and the possibility of self-exclusion from the process of blood donation, the medical history of the potential donor and the medical examination. donor selection consists of two sets of information necessary for protection of the blood recipient as well as the donor himself. aim: to present the most frequent reasons for declining volunteer blood donors. material: the materials used for analysis were the questionnaires completed by all the potential blood donors at the transfusion department of the medical center in strumica as well as the record books of the blood donors which contain the results of the analysis we make for the potential donors. these donors donated blood in the period between and . results: during this period people volunteered to donate blood, out of which were allowed to donate blood, while were declined. out of the total number of blood donors were male and female donors. the reasons for declining potential donors were the following: . % had low levels of hb, . % were taking antibiotics, . % were ill, . % had low blood pressure, . % had high blood pressure, . % for other reasons. conclusion: donor selection and their care on one side and obtaining safe blood for transfusion on the other side entails obligatory organized medical control. the obligatory completion of questionnaires, the medical examination of the potential donor and their self-exclusion as a result of the feeling of personal responsibility as well as the obtained information are very important for the selection of quality blood donors and obtaining safe blood for transfusion. questionnaire on subjects-students, their knowledge and motivation on blood donation f vladareanu, a bugner and s sirian national institute of heamatology transf, bucharest, romania the research theme of this questionnaire is as follows: 'what is the level of knowledge and of motivation in the non-remunerated and voluntary blood donation at students?' we also tried to see the practical implications that this study will have and how it will influence the knowledge in this area. the purpose of this questionnaire was not dissimulated. the general theme of the knowledge and motivation on blood donation had been studied before through two big questionnaires applied in and , but the general population was their target. students had never been an investigated lot up to now. the hypothesis referring to this problem is as follows: students are not informed either on the act of donation, or on the crisis of blood. . the lack of information is a first cause of the indifference of the studied lot towards the idea of donation. . the lack of motivation of the studied lot is another cause. the questionnaire was applied on a lot of students from seven different cities: bucharest, iasi, constanta, cluj, sibiu, brasov, timisoara. the number of the questions was limited to , which we consider best for a questionnaire applied on the street or at college. as a conclusion, we can say that a passive-defensive attitude towards the blood donation was revealed after this questionnaire. not knowing the issue caused by their lack of information sometimes determines indifference at the statement of the subject. on a general dissolution environment of the responsibility of the youth, the donation problem is not in their aria of preoccupations, the general attitude being of non-involvement for the moment, at this idea which is not yet in every individual conscience and which is normally administrated at an institutional level. the donor data and the details of blood application of the north west transdanubian region of hungary k vÖrÖs*, c bercsÉnyi † , o petrÓ † , r jÁger † and e miskovits ‡ *hungarian national blood transfusion s., györ, † blood bank, tatabánya, ‡ headquarters hungarian n.b.s., budapest, hungary the ongoing fundamental reorganization of the blood service began on the . . in hungary. as the consequence of reorganization till . . , blood banks had been established instead of existing before, under direction of the hhnbts. the working profile of the regional blood centers and local blood banks will be changed step by step. virus screening, blood group serology and processing will be made in the regional centers. one of the regions is the 'north west transdanubian region' (nwtr, city györ as the center, with about inhabitants and hospital beds). local blood banks (tatabánya, sopron, and szombathely) are belonging to nwtr. the regional center and the local blood banks provide the labile blood products and high level clinical-transfusion service (cross-matching, antibody screening, outpatient immunhematology investigations, etc.) for the hospitals. annually donors donate blood in this region. this donation activity covers about the % of all inhabitants. the acceptance ratio of the donors is good ( - % of the donors were deferred). there are hospitals in our region. the regional demand on rbcc is - . u/year, on ffp is . - . u/year and on pc is - . u/year. the poster shows the donor data and the details of blood application of this region since . p- implementation of rbc collection using haemonetics mcs ® +: medical staff training, donor recruitment and acceptance g woimant, c fretz, d puydupin, e pÉlissier and jl beaumont efs ile de france, paris, france background: single donor rbc collection is an approved apheresis technique in france. aims: our goal was to evaluate the implementation of rbc collection in our center in terms of donor recruitment and acceptance, as well as medical staff training and adaptation. methods: donors were selected according to the french requirements for rbc collection (weight ≥ kg, height ≥ cm, hb ≥ . g/dl, ferritin ≥ ng/ml for repeat rbc donors). all personnel were trained on adequate communication with donors. eligible donors were contacted by mail, by phone or during pre-donation interview. among the recruited donors, all donors were male, % were regular whole blood donors, % were regular whole blood or apheresis donors and % were new donors. the medical staff was trained on rbc collection with the sdr protocol and disposable set ln pf on the mcs ® +. most of the medical staff was already used to autologous rbc donation with similar apheresis devices. blood samples were taken from donors pre-and post-donation, as well as to months later for those returning for a subsequent donation. donors were asked to fill out a post-donation survey for assessing donor comfort and information. results: donor profile and clinical follow-up are summarized in table . six percent of the donors had a ferritin level below ng/ml; these donors were regular whole blood donors. the collections were well tolerated and no changes in vital signs were noted. four reactions were reported: hematomas and citrate reactions. no reaction was observed post-donation and hemoglobin levels measured before next donation were back to normal. the technique was easily implemented by the medical staff and fitted well in the existing blood center processes. the medical staff as well as the donors found collection duration short (average of min). the results of the survey were very favorable as more than % of the donors considered their donation and the information they received as satisfying. most of them agreed to donate again and several actually donated twice during the evaluated period. conclusion: the implementation of rbc collection in our center, using haemonetics mcs ® +, was successful in terms of ease of use of the technique, as well as user and donor acceptance. we now plan to evaluate donor loyalty in the longer term. risk from first-time blood donors e zhiburt, s golosova and p reizman federal blood center, moscow, russian federation introduction: each third dose of whole blood in russia is donated by first-time blood donor. there are two reasons for attention to this kind of donors: ( ) possible risk of infectious disease in seronegative study; ( ) possible risk of donation for person with contraindication. aim of the study: we investigated role of regional deferred donors registry (rddr) in by first-time donor selection. methods: moscow rddr includes parts: hiv, viral hepatitis, syphilis, tuberculoses, malaria, drug users, psychiatry, days after blood donation. rddr was complete and our center began actively work with it since last year. each donor has to be registered in rddr and automatically checked for deferral reason. effectiveness of rddr was investigated. results: first-time donors donate less than % blood in our center. about a quarter of them are deferred before possible donation. part of donors deferred by rddr has been significantly increase in (c = . ; p < . ) at the expense of seropositive people. conclusion: rddr is effective for blood donor selection and decreases necessity in laboratory screening. first-time blood donors have to be examined before blood donation. if they have not contraindications, donation can be performed up to days before examination and screening. the double unite platelet production is important especially if the relatives of patient find the donors. we evaluated the effectiveness two apheresis machine for platelet collection. in our blood bank, one fenvall amicus and one cs + apparatus were used for platelet apheresis. apheresis were performed between / / and / / . including criteria of donors are that estimated process time is smaller than minute and estimated postapheresis platelet count is higher than ¥ /l. donors firstly was enrolled to amicus. if amicus was busy, then it was enrolled to cs. the properties of our donor populations were given in blood and plasma cell components are obtained either by traditional manual method from whole blood or by apheresis. modern medical treatment is based on transfusion of deficient components such as erythrocytes, leukocytes or plasma proteins. this involves new solutions to achieve higher yields and better quality of such components. the aim of our study was to estimate the efficacy of blood cell separator cobe trima in obtaining platelet concentrates (pcs) as compared to older-generation cobe spectra blood separator. apheresis procedures were performed on both these blood cell separators. the quality of platelet concentrates was tested during day storage period (see table below ). we have tested the effect of apheresis procedure on donors and estimated the operating comfort of both separators. the tolerance of both separators was satisfactory except for more frequent hypocalcemia when trima separator was used. most donors were more satisfied with trima procedure because of single venipuncture although it involved special donor selection (good vein access). in general we may say that trima is undoubtedly a more modern and more friendly separator. however, cobe spectra may continue to be used with success especially when a more versatile cell separator is necessary (leukocyte concentrates, peripheral blood stem cells or therapeutic apheresis). methods and results: tls ( procedures on patients) were used successfully in patients with acute or chronic leukemia with hyperleukocytosis (white cell count > ¥ e /l or blast count > ¥ e /l) when high cell count would promote leukostasis with vascular occlusion in the microcirculation. performed tl procedures were rapidly reduced both the white cell count and the whole blood viscosity. average fall in white cell count after treatment was . %. tp-treatments ( procedures on patients with symptomatic thrombocythemia and/or platelet count higher than ¥ e /l) were applied in order to prevent the development of 'thrombotic-hemorrhagic syndrome' . the tps performed resulted with rapid platelet counts reduction ( . % in average) and with clearly noted clinical improvements, subsequently. tes ( procedures on patients) were performed using manually technique in patients with 'cellular hyperviscosity syndrome' induced by high red blood cell count. it was shown that te procedures resulted to red blood cell number lowering and decreasing of blood hyperviscosity. average fall in hemoglobin and red blood cell concentrations after te treatments was from . % till . %. rbcx treatment ( procedures on five patients with malaria and two with severe aiha crysis) was performed on an urgent basis, particularly when clinical symptoms indicate life-threatening situations and resulted with rapid and significant reduction of concentration of unwanted pathogen affected rbcs and summary/conclusion: the effects of tcs depended on the nature and stage of the basic hds, of adequate selection of patients and of timely applied apheresis. rapid cytoreduction is obtained justly in patients with excessively high cell count, and this effect did not associated with bone marrow remission. thus, tc should be looked upon as adjunct to the standard treatment of different cithemias, but not as replacement therapy. the present study indicates that the best therapeutic effects were obtained by rbcx. were carried out with continuous flow blood cell separator cobe spectra and all patients underwent large volume leukapheresis (lvl). in all procedures, a blood warmer was connected to the return line and a continuous calcium infusion was administered preventively. six patients, who were under kg body weight, had the extracorporeal circuit primed with irradiated, filtered packed red cells diluted with % albumin solution. seven children had vital signs and ecg continuously monitored during the procedure. results: each patient underwent a median of collections (range - ). the inlet blood flow ranged between . and . ml/min (median . ml/min). the median blood volume processed was ml (range - ). leukapheresis lasted a median of min (range - ). the median total nucleated cell yield was . ¥ e /kg (range . - . ), mononuclear cell (mnc) yield was . ¥ e /kg (range . - . ) and cd + cell yield was . ¥ e /kg (range . - . ). the median of mnc collection efficiencies was . % (range . - . ). in ( . %) patients, in only one apheresis procedure more than ¥ e cd + cell/kg were collected. during ( . %) procedures patients had experienced apheresis-related side effects. the citrate-induced reactions were most commonly observed. the reactions were mild and cessation of collection was required only in one case, because of catheter related complication. mild sedation was required only in few very small children. post-donation platelet count was less than ¥ e /l in cases and these patients required platelet transfusion before subsequent procedure. our results show that lvl in pediatric patients is relatively safe procedure, well tolerated and with a very low risk of serious adverse events. close monitoring of blood counts, especially platelets, between pbsc collections is necessary. the cessation of procedure was required in only one case and no life threatening side effects occurred. neonatal alloimmune thrombocytopenia (natp) caused by fetomaternal mismatch for human platelet (plt) alloantigens (hpas) worsens approximately / pregnancies and can lead to a serious bleeding diathesis, intracranial hemorrhage (ich) and sometimes death of the fetus or newborns. we describe the successful management of a -year-old pregnant woman, alloimmunized to the hpa- a (p a , zwa) antigen, with a history of two previously children with severe thrombocytopenia and ich. the pregnant woman was at her terminal pregnancy and was suddenly admitted. to evaluate the risk of ich in the fetus, cordocente was performed to demonstrate fetal thrombocytopenia (plt . /mmc). to ensure a rapid provision of compatible negative-antigen platelets, we decide to collect platelets from the mother using apheresis. plateletapheresis was performed using com.tec separator, fresenius. blood processed was . ml in a short time procedure ( minutes). no significant adverse effects were observed in the mother and fetus, during and after the procedure. platelets collected ( . ¥ e ) were transferred to the preparation set and plasma was removed after centrifugation to resuspend the platelets in octaplas ab. then we separated the platelets into two units containing . ¥ e each. the day after the donation, the mother gave birth to a girl by caesarean section. after the transfusion, the plt account increased from . /mmc to . /mmc and after a week the child had plt . /mmc without hemorrhagic complication. according to the literature data and our observations of the patients, there are changes of the hemostasis system indexes in the most patients with the endogenous intoxication syndrome and immune disturbances. in the number of cases medicamentous therapy appears to be not enough to normalize the changes, but it is especially important for pregnant women and women in childbirth, because on the background of these disturbances different complications of pregnancy and postnatal period take place. the aim of our study was the substantiation of plasmapheresis using in complex therapy of purulent inflammatory complications in obstetrics and immunoincompatible pregnancy with hemostasiologic disturbances. patients with hemostasis system disturbances: one woman in childbirth with exacerbation of chronic pyelonephritis, who had in the first hours some signs of hypocoagulation on the background of permissible blood loss (prolonged coagulation time up to - minutes with episodes of its absence on the background of the normal indexes of general coagulogramm, quantity and function of thrombocytes and the dilute fibrin monomer complex level in times higher than the norm) and nine pregnant women with the perinatal losses in anamnesis severed by the pregnancy (threat of abortion, places of fetal egg detachment). these women were examined, the following was revealed: the high antibody titer to chorionic gonadotropin, parameters of partially activated thrombin time were higher than the norm ( - seconds), thrombin time ( - seconds), the dilute fibrin monomer complex ( - mg%), coagulation time ( - min). in all these cases the conservative methods of treatment (antibacterial, hemostatic, hormonal therapy) were effective for a short period of time and they didn't succeed to correct the given parameters of hemostasiogramm. the discrete centrifugation plasmapheresis was included in the complex of medical treatment. the woman in birth operations were done, in the programme of plasma replacement during the first two plasmapheresis procedures donor fresh-frozen plasma was included. six pregnant women on the given stage one course consisting of plasmapheresis procedures for plasma replacement with crystalloids was done, the volume of the removed plasma was - % of the circulating plasma volume. three pregnant women before delivery were required two courses of plasmapheresis more consisting of - procedures each. the system heparin was not used. in all patients already after the first procedure of plasmapheresis the normalization of hemostasis indexes was marked, that allowed to prolong pregnancy, to prevent the coagulopathy bleeding and the development of disseminated intravascular syndrome. four women are discharged from the hospital, the other patients are observed with progressive pregnancy. thus, the using of discrete centrifugation plasmapheresis is effective at the signs of hypocoagulation in patients with isoimmunisation with fetal antigens and infectious pathology, and is the reserve in prevention and treatment of obstetric complications. extracorporeal photochemotherapy: an alternative therapeutic approach to control graft versus host disease after allotransplant with reduced intensity conditioning regimen c del fante*, c perotti*, gl viarengo*, p bergamaschi*, p pedrazzoli † and l salvaneschi* *irccs policlinico s. matteo, pavia, † ospedale niguarda cà granda, milano, italy background: extracorporeal photochemotherapy (ecp) can be defined as an immunomodulatory therapy that demonstrated to be efficacious in treating patients affected with graft versus host disease (gvhd) after allotransplants for oncohematological diseases. reduced intensity conditioning regimen (ricr) for allotransplant is a relatively new practice in patients (pts) ineligible for a conventional myeloablative conditioning regimen. the use of immunosuppressive therapy (ist) to control gvhd is limited for the high risk of developing infections and disease relapse due to the strong reduction of graft versus tumor (gvt) effect. aims: to evaluate the effectiveness and safety of ecp in treating pts affected with gvhd post rcr and the possibility to taper, at the same time, the ist. methods: pts ( females, male), median age . years ( - ), affected with agvhd grade ii ( ) and extensive cgvhd ( ) gtx with median total granulocyte doses of ( - ) ¥ per gtx corresponding to . ¥ granulocytes/kg in children and . ¥ granulocytes/kg in adults. the wbc counts increased from baseline values of . ( - . ¥ ) g/l for both pediatric and adult patients to peak values of . ( . - . ) ¥ g/l (children) and . ( . - . ) ¥ g/l (adults) at one hour after gtx and to . ( . - . ) ¥ g/l (children) and . ( . - . ) ¥ g/l (adults) at hours after gtx. in out of patients ( %), the crp levels significantly declined ( ( - )%; p£ . ) during the granulocyte transfusion period; in almost all cases ( / ; %) after the initial or nd transfusion. thirty-eight patients ( %) were alive at day + after termination of neutropenia and gtx. patients without crp response to gtx ( / , %) and patients with severe viral infections / ( %) were not among the day + survivors. background: in recent years, the use of platelet concentrates obtained from single donors by automated apheresis has grown steadily. plateletpheresis donation is considered to be a safe procedure with modern instruments. so far, no studies have identified donor or procedure specific factors that may be associated with serious adverse events. aim: to evaluate the incidence of adverse events during plateletpheresis procedure, over a five-year period in our hospital. materials and methods: eight hundred single-needle plateletpheresis collections were performed by using two automated intermittent-flow cell separators: of them with mcs p and with mcsplus (haemonetics), according to automatic standard protocols a p and ldplp, respectively (with the collection of an additional plasma unit). acd-a was used as the anticoagulant in all apheresis procedures (acd-a: blood ratio was : ). most of the donors ( % men and % women) were patient´s relatives. half-hour before the initiation of the procedure, mg of calcium ( tablet cal-c-vita) were administered to each donor. the mean platelet yield was . e /unit. the overall rate of the donor related adverse events was . %. feeling faint was the most frequent event, which was occurred in . % of donations. hypotension and citrate related rates were . % and . %, respectively. all citrate related symptoms were only transient perioral paresthesias, which were relieved by slowing the i.v. rate, without additional administration of oral calcium. donor unconsciousness was the only observed severe event, the rate of which was . %. other adverse events were venipuncture related ( . %), machine related ( . %) and miscellaneous complications ( . %). ( ) plateletpheresis using the mcs p and the mcsplus automated cell separators is a safe procedure, with a low risk of serious adverse effects. ( ) with the used acd-a-to-blood ratio ( : ) satisfactory platelet concentrates were obtained with very low incidence of citrate-related events. ( ) the peros administration of calcium before the initiation of the procedure, probably lowers the rate and the severity of hypocalcemia symptoms. quality assessment of ffp collected as a byproduct of plateletpheresis . from the donors immediately with the initiation of the procedure (citrated whole blood) and . from the final platelet concentrates after one hour rest at room temperature without agitation. in vitro platelet response to the aggregation-inducing agonists adp, collagen, ristocetin and arachidonic acid was investigated by means of an aggregometer (pap- c, bio/data). results: there were no significant differences between the groups of donors with respect to age, sex, smoking habits, preapheresis wbc and plt counts and hemoglobin concentration, as well as in the harvesting time between the two cell separators. our findings are shown in the following table. mildly decreased response to all agonists was observed (mainly to adp and arachidonic acid) in the samples taken right after the initiation of the procedure, in both groups. platelets from the final component showed a further slight decrease in response to adp, which was more prominent in the mcs p device (p = . ). on the contrary, an increase in platelet response to the other three agonists was observed in both devices, which, however, was statistically significant upon collagen and ristocetin stimulation. conclusions: reduced response to aggregation stimuli is possibly caused immediately with the initiation of the apheresis process. literature reports regarding further platelet traumatisation due to the procedure, are rather conflicting. in our study, such traumatisation was observed only in the case of adp in the mcs p obtained collections and this could be correlated with the technological differences between the two devices. recovery of platelet aggregability, as it was expressed by the upregulation in platelet response in the other stimuli, could be attributed to the resting period and seems not to be affected by the timing of the leucodepletion procedure. background: lupus erythematosus often is accomplished with severe symptoms, such as polyarthritis, nephritis, pericarditis or dermal alterations. in pregnancy cytostatic therapy affects gestation. on the other hand the course of disease can be refractory to corticosteroid therapy. elimination of autoantibody and immuncomplexes by plasmapheresis could be an efficient way to amend the severity of symptoms. a year old pregnant woman in the th gestation week with systemic lupus erythematosus showed severe symptoms like polyarthritis, nephritis and pericarditis. treatment was initially mg/kg bw prednisolone for weeks and subsequently mg/kg bw for weeks. plasmapheresis was applied daily in the beginning and continued depending on the condition of the patient ( table ) . the eliminated plasma was substituted by fresh frozen plasma. the medium volume was . ml per apheresis. after day plasmapheresis treatment was suspended to avoid problems with coagulation and was followed by a cycle of immunoabsorptions to eliminate circulating immuncomplexes. results: prednisolone therapy alone brought no effect even after changing to high-dose treatment. a significant amelioration of all symptoms could be observed after the first plasmapheresis. good condition of the patient remained stable over the period of daily plasmapheresis for days. intermitting apheresis treatment for one day lead to a significant aggravation of symptoms. apheresis no. again lead to a recovery of the patient which held on until day . conclusions: treatment of systemic lupus erythematosus in pregnancy especially in combination with resistance to corticosteroid therapy, is an effective therapy to ease severe symptoms such as polyarthritis, pericarditis and nephritis. exposure to cytostatic drugs can be avoided and therefore the impairment of the fetus can be reduced. background: the collection of mnc represents the first step of photopheresis procedures and could be of critical importance in achieving a therapeutic goal. in this work we compare the cell yield of two collection programs on cobe spectra device: the mnc versus the autopbsc program using the ecp procedure modified by andreu. methods: procedures were carried out with mnc program and procedures with autopbsc on patients with cgvhd. both hemoglobin increased from . ± . to ± mg/tu, k+ from . ± . to . ± . mmol/l, level of glucose decreased from . ± . to . ± . to . ± . mmol/l, ldh from . ± . to . ± . ukat/, lactate from . ± . to . ± . mmol/l, ph from . ± . to . . . the volume of apheresis units was lower than wb-rbc, the leucocyte count was normal in all units. the rbc loss by filtration was . ± . ml/tu and was lower than at wb-rbc. in apheresis rbc there were the differences in hb and ht value between the day of storage and , in wb-rbc there were no differences. during the storage period we found no differences in k+ increasing value and no change in ph value between apheresis rbc and wb-rbc, the increasing of lactate was higher in wb -rbc, increasing of ldh correlated to hemolysis. the plasma hb value increase was higher at apheresis rbc in contradistinction to literature. hb and ht correlation in apheresis units according to predonate value in donors was lower than at wb -rbc. the method is a useful alternative to conventional whole blood donation, we get rbc units with high standard of quality and low correlation according to predonate hb and ht value in donors. acknowledgement: the study is supported by grant iga ministry of healthy cr n. nr/ - . background: in life-threatening exacerbations of sle a satisfying efficient therapy is lacking. despite intensive immunosuppressive therapy some patients are resistant or contraindicated to conventional treatment. in particular circulating antibodies and immune complexes play an important role in the pathogenesis of sle and mctd. an extracorporeal removal of these pathological substances may be effective in the treatment of active disease. methods: five patients with severe therapy-resistant sle/mctd underwent immunoadsorption onto protein a. blood was drawn from patients by using a jugular catheter or a peripheral intravenous catheter. anticoagulation was performed with acd-a and heparine or acd-a and r-hirudine. plasma was separated by centrifugation. the . to -fold total plasma volume was treated in every immunoadsorption. the columns were floated with a maximal plasma flow of ml/min. the procedure was carried out every second day. additionally supplementary intravenous immunglobulin therapy was given only once. results: remission of the disease was achieved in four patients. see table below . conclusion: pa-ia is highly effective regarding the elimination of autoantibodies and circulating immune complexes, might induce a remission in patients with sle/mctd. it is an acceptable alternative treatment option in patients when other therapies are ineffective or contraindicated. background: purification of bone marrow from erythrocytes is used to prevent early hemolysis in major abo incompatible allogeneic hemopoietic cell transplantations. erythrocyte depletion is strongly recommended to reduce product volume and stem cell purification before storing autologous and even allogeneic bone marrow in order to prevent early hemolysis and dmso toxicity that might develop after thawing. centrifugation, sedimentation with hes, and cell separating devices are methods for erythrocytes depletion. aim: in our center, we prefer to use cell separation device, since it is a reliable method and has a high-yield and risk of contamination with erythrocytes is low. success of the process is retrospectively analyzed for high and low volumes. method: erythrocytes depletion of bone marrow harvest was done in hemapharesis unit with cobe spectra device in the last five years in cases with bone marrow volume over ml, and cases with bone marrow volume under ml. fifteen of these cases were allogeneic, and were autologous procedures; a software uploaded with cobe pbsc coll vers . and (catalog no: - - ) set was used in the procedure, and at the same time, double bag system with intermediate connectors were used to prevent re-circulation (catalog no: - - ). results: the mean volume reduction was . % ( . - . ) for volumes over ml, and . % ( . - . ) for volumes less than ml. regarding the success of the procedure no statistically significant difference was found between procedures with high and low volumes. no complication developed related to the device or product, and waste bag never had to be re-used. in none of the patients early massive intravascular hemolysis was observed. conclusion: erythrocyte depletion and volume reducing with cell separation device is a reliable method. this process is successfully applied with high volumes (over ml); and in low volumes as well for reducing erythrocytes, and gain of mononuclear cells and cd + cells. platelet concentrates obtained by apheresis procedure-correlation between the initial count and the final concentration v srejic*, g bogdanovic*, z garic*, n vavic* and b balint † *national blood transfusion institute, † military medical academy, belgrade, serbia apheresis team of the national blood transfusion institute processed and classified data of donors who donated platelets by apheresis procedure from january till april . procedures were performed in accordance with the ldplp protocol, using haemonetics mcs+. initial donors' platelet count and the absolute platelet concentration in the final preparation were followed, as well as red blood cell and leukocyte contamination and the volume of the processed blood. donors' initial platelet count was not less than ¥ /l and the volume of the processed blood was not less than ml. according to histogram, the most frequent donors' initial platelet value ranged from ¥ /l to ¥ /l ( %). final concentration of the samples of tested donors ranged from . ¥ to . ¥ in the average volume of ml. regression analysis demonstrated that there was a correlation between the initial donors' platelet count and the obtained final concentrate. student's t test showed p < . . leukocyte contamination of the final concentrate prepared without the filter ranged from . ¥ /l to . ¥ /l. presence of red blood cells in the final concentrate ranged from . ¥ /l to . ¥ /l. p- therapeutic apheresis (ta) in croatian hospitalsadherence to respectable guidelines z zivkovic*, b jeren strujic*, s boras † , i bojanic † , b golubic cepulic † and z ivankovic † *clinical hospital dubrava, † clinical hospital center zagreb, zagreb, croatia introduction: besides considerable resources, ta requires high costs and risk for patients. therefore, indication for ta often considers interests of patient, hospital and requesting physician. the most respectable guidelines for the implementation of ta were defined by aabb and asfa, classifying total of diseases into categories (ctg), ranging from 'standard therapy' to 'lack of efficacy' . the objective of this study was to determine indications for ta performed in croatian hospitals in the period - , respecting aabb/asfa guidelines. results: during the observed period in croatia, ta was performed in patients suffering from various diseases. in ( %) patients ta was performed by membrane filtration, while in ( %) separation by centrifugation was used (table ) . according to the ctg, s of the aabb/asfa guidelines, ta was performed in ( %) diseases from ctg i, ( %) ctg ii, ( %) ctg iii, and ( %) ctg iv of patients. the most frequent indications included in ctg i were: myasthenia gravis ( %), collection of pbpcs ( %), sy. guillain-barré ( %), and plasmacytoma ( %). in ctg ii frequent indications were: poisonings ( %), systemic lupus erythematodes ( %), and rapidly progressing glomerulonephritis ( %), and in ctgs iii and iv: cytoreduction-polycythaemia ( %), thyroid storm ( %), gvhd ( %), and reumatoid arthritis ( %). ( ) the time spent for resolving h / , ( ) mtp / , ( ) discarded blood units / . iii group: wrong data input / , donor replacement / , marking errors / , error in determining blood group at the first blood taking / , errors in input medical consulting / and disregard of prohibitions / . the consequences are: ( ) the time spent for resolving h / , ( ) mtp . / . , ( ) discarded blood units / . conclusion: the analysis of errors has showed that the number of errors can be decreased by implementation of corrective/preventative action based on continual education of the staff, appropriate sop, effective organization, qmp for equipment. the conclusion of our study is that reducing the rate of work errors will decrease the waste of material and time, also that will decrease the number of discarded blood units. an iso standard for blood transfusion? background: in our search for an independent, objective assessment at western province blood transfusion service, we were unable to find one single model that met the specific requirements of blood transfusion. we therefore resorted to developing our own model but ask the question: why not have one international standard for blood transfusion? aims: our aim was to have a standardised system for the independent, objective assessment of our blood transfusion service with audits carried out by an internationally recognised body. we wanted a formalised, professional system of accreditation with inspection checklists, reports, certificates etc. methods: having moved away from accreditation by the american association of blood banks in mid 's, we evaluated various other options such as inspection by our government department of health or the world health organisation but neither organisation had trained inspectors or systems in place. we also investigated iso certification but, although this was acceptable on the quality management side, it did not cover the technical parameters relating to blood transfusion. results: we therefore developed our own model for accreditation that consists of three parts: • a quality management section incorporating iso principles; • a technical section incorporating specifications from the south african standards of practice (we also consulted the european, american, canadian and australian guides); • a laboratory section incorporating iso parameters (soon to be updated with iso ). we then chose to be accredited by the south african national accreditation system, sanas, an internationally recognised institution. once we had written a national accreditation checklist, sanas submitted this to two international accreditation bodies (iaf and ilac) for approval. the system has been in place for three years now during which time we have had four successful assessments. summary/conclusions: in developing our system, we reviewed what was being done elsewhere in the world and it became evident that, although there are great similarities between countries, there p- software for the management of the scansystem bacterial detection method the scansystem tm was developed for bacterial detection in blood products. to be implemented in blood banks, a specific software is now available in compliance with blood bank regulation in order to manage sample traceability and data file transfer. the software is divided in main levels: an administrator level to create an application configuration in compliance with customer needs (product bar code characteristics, frequency of the positive controls, manual or automatic data file transfer . . .), a technical level to manage the operators (password, id) and to validate some specific results, an operator level for routine testing. the software assess sample traceability when testing pools of samples from to more than . indeed, bacterial detection is performed for pools of to platelet samples and to red cell samples. each sample in the pool is traced through its barcode until the final result. the system is compatible with most of the barcode standard including isbt . in addition, the system checks each barcode protecting the sample against duplicate testing. the software assists and monitors the bacterial detection process from the sampling to the end of the test (final result), each step of the procedure is identified through its barcode and at each time, it is possible to know the test status for each sample. for a pool of samples, results can be obtained: 'negative' or 'on hold' for a positive result. for a 'negative' pool, each sample constituting the pool are determined as 'negative' . for an 'on hold' pool each sample constituting the pool must be tested as a single sample and the final result is 'negative' or 'positive' . data transfer may be manual or automatic. a final technical validation is necessary before the transfer through an active selection of results to download. final results are provided in a compliant format for an easy import into the blood bank database. all necessary information are displayed: 'machine id' 'product/sample barcode id' 'date' 'time of transfer' 'operator id' 'result' ('negative' or 'positive'). the main advantage of this software is a continuous check of each step reducing the risk of error in testing. it makes the scansystem tm test compatible with a routine use in blood banks according to the current regulations and quality assurance programs. is no overall consistency. we feel it would be of benefit to establish an international working group to investigate the feasibility of writing an iso standard for blood transfusion. the standard would harmonise quality management parameters based on iso principles and technical/laboratory parameters specific to blood transfusion. minimum technical specifications would need to be agreed upon based on the various standards and guidelines available around the world. this iso standard could then be used for the purposes of certification/accreditation or government inspections. this would ensure global standardisation of world-class best practices. first world countries would be able to achieve compliance and a subsequent step could be the establishment of an international forum to assist developing countries to work towards compliance in the longer term. residual leukocytes in leukoreduced cellular blood products -evaluation by flow cytometry web-based outcome review: do you know how productive your trima® can be? background: web-based outcome review is a new software tool developed by gambro bct for the management and the interpretation of data from the trima and trima accel tm automated blood collection systems. aim: does the interpretation of reports obtained through outcome review lead to an increase in the number of products per run and the overall productivity of the apheresis center? method: run data files (rdf) from trimaᮀ were collected and transferred onto the outcome review server. these rdf do not contain any donor related data that can lead to possible donor identification. the reports were generated on the outcome review website (gambro bct intranet), interpreted by a gambro bct employee and presented and discussed with the management of blood centers. results: a total of different reports can be generated on the website as a pdf file. for this study, reports were investigated. they are: doses per collection, doses per collection trend, platelet collection trend, platelet procedure performance, platelet procedure performance trend, product distribution, average procedure time, procedure time, machine productivity trend. the results obtained for a center can be compared to word-wide, national, regional or to other individual trima devices in the centre (benchmarks). this benchmarking allows the management of an apheresis center to compare the results, to draw the right conclusions and to develop and implement corrective actions. implementing successfully these corrective action plans will lead over time to productivity results that are more in line with the figures that are generally accepted to be the optimal production capabilities of trima. the reports also help to monitor the effects of the corrective action plan over time and to adjust this plan if the results are not in line with the expectations. reaching and maintaining the optimal production capabilities of trima will also increase the net revenue by procedure or decrease the cost by procedure for the blood centre. conclusion: web-based outcome review allows getting more products from the existing donor base by interpretation of the multiple reports and implementing the required corrective actions until optimal production capabilities of trima are reached and maintained. introduction: to examine the cell vitality of packed rbc's during storage several parameters like atp, free hb or , -dpg are used. less kits for the determination of atp are available and they need either a large sample volume and/or are time consuming. here we present the modification of a commercial testkit for a time-and cost saving detection of atp. methods: samples were analysed with (a) -phosphoglyceratekinase reaction according to bergmeyer, h. methods of enymatic analysis nd. edition. academic press, new york ; (b) detection via hplc and c) using a commercial testkit (r. greiner bio-chemica, germany). the atp-kit were minimized from ml to a total volume of ml and tests were performed in microtiterplates. results: samples were analysed in hplc and modificated commercial testkits, another samples have been examined in all tests. comparison of the results showed no discrepancies in the above mentioned methods. standard curves have been performed (range - mm atp) and statistical analysis demonstrated a given linearity (r = . ). variability has been calculated as . % (intraassay; n = ) and . % (inter-assay; n = ). the hand-on-time calculated for samples has been decreased from . hours to minutes. at least the costs of atp-determination have been reduced from € . to € . per sample. conclusion: performance of test kits in microtiter format is a fast and rapid method, reliable for high-throughput determination of atp in packed rbc's. background: in order to preserve both blood safety and availability it is mandatory that a minimal amount of blood units would be discarded due to defects in the materials and supplies used for blood collection, or to deviations in blood processing or storage. aims: ( ) to monitor the derangements of different materials and disposables used during blood collection and processing, and to study the suppliers' responses and corrective actions taken. ( ) to asses the relative contribution of different defective materials (dm) to the need to discard valuable blood components. materials and methods: about whole blood units were collected and processed by mda national blood services in [ ] [ ] [ ] . as part of the routine quality control activities, derangements of the dm used were recorded and analyzed. some different types of dm were defined. out of reports sent to the corresponding manufacturers for investigation, responses ( %) were received and analyzed. about % of dm were detected during blood collection. manufacturer defects of different materials were the reason for components discard in nearly % of cases. conclusion: defective materials are one of the major causes of the infringements of blood collection and blood component preparation processes. analysis and monitoring of the different defects and of the suppliers' responses and corrective actions are essential to improve products' safety and availability. establishment of a network for the exchange of information among international blood centers would enable the blood banking community to compare between different suppliers and to use the documented cases for training of personnel of both the blood services and the manufacturers. such a system may contribute to the improvement in quality of materials used and might lower the discard rate of valuable blood units. results: table analysis and characteristics of t ( ) comprehension of the blood bank's processes and the interaction between them and between the processes of the whole hospital. ( ) monitor, measure and analyze these processes, in order to improve their effectiveness continuously. ( ) implementation of internal and external quality controls for blood and blood products and implementation of appropriate statistical techniques for monitoring their results. ( ) identification of interested parties (doctors, donors, patients) satisfaction and taking up the necessary preventive or corrective actions to improve their satisfaction. the qms of our blood bank was certified by tuv rheinland in / / and the scope of the certification is: 'blood collection, testing of infections markers, production of blood components, compatibility screening for blood transfusion and other immunological tests and implementation of therapeutic schemes in thalassaemia patients' . the implementation of the qms based on iso : standards ensures the improvement of services provided by the blood bank and the increase in customer satisfaction, whether donors or patients are concerned. the former enjoy the respect and recognition of their social contribution, while the latter are assured of very high levels of service and health protection. finally, we shall not underestimate the positive impact of qms in the motivation of blood bank personnel. quality becomes integrated both in their professional and personal attitude and allows for achieving increased satisfaction from their work. equipment management in the national blood transfusion service in serbia introduction: new equipment was urgently needed in three blood transfusion establishments (bte) in serbia. equipment was mostly inadequate for core blood transfusion activities, placed in inappropriate facilities, very old without routine maintenance or calibration. also, technical documentation for most of the equipment did not exist, and procedures for equipment management and responsibilities were not defined. further more, coordination on equipment issues with the qa department was not recognized. service funded by the european agency for reconstruction, provided various equipment for the three blood transfusion establishments. the new equipment includes blood collection equipment, centrifuges, refrigerators, incubators, automated testing equipment, genetic analyzer and it equipment of . million euros value. before the new equipment is installed the bte's agreed to have the national procedures on installation, validation, calibration and preventative maintenance in place. this will ensure that the equipment can be properly installed and validated before use. the project has provided training on validation to the working group (wg) on quality. the wg has created national procedures related to the equipment, including quite new term validation. the same problems in implementation of procedures were present in all three bte's. significant efforts are made to explain to the staff how the equipment has an impact on quality, how to ensure that the equipment does what it is supposed to do, how to be confident that the results obtained are accurate and how important it is to generate records. qa managers played an important role in the preparation of facilities for equipment installation, making plans for equipment layouts, creating documents (master cards, instruction for use) and designing the validation protocols. the same procedures and records enable an exchange of results, comparability, sharing information on what works and what does not work between bte's. the qa managers also prepared an introduction of equipment requirements to the heads of departments, with special attention to the validation process so that they are able to fully understand what is required and why to validate their equipment. results: national standards in equipment management in serbia are set and are being implemented. qa managers carefully managed that the new, numerous equipment, delivered in the short period of months was correctly installed, validated, obtained with necessary documentation, followed by previously trained staff, so that equipment can be considered as controlled. the additional, positive effect is that validation is performed in one establishment for all bte in the country, allowing a more prompt response to problems and presenting of joint request to suppliers, as well as an easier way of monitoring equipment performance of the three bte's. organized equipment management has affect on every aspect of blood activities and finally to the quality of blood and blood components. background: the vista information system (vista tm ) is used in centers in europe as an apheresis management system. with vista tm it is possible to increase productivity, donor comfort and loyalty and therefore simultaneously improving the overall process in the center. aim: a calculation tool (microsoft excel) was developed to evaluate the added value of vista tm . three blood centers in different european countries completed a questionnaire using their local data. summarizing these figures gives us an idea about the impact of vista tm on the daily work and budget of a blood centre. method: the excel calculation tool that was used investigated major areas where vista tm could show added value: improvement of regulatory compliance, increase the efficiency in operations and improve productivity. results: regulatory compliance: the number of infringements decreased, causing a considerable direct financial gain because these events are very expensive to deal with. the time spent on regulatory reviews decreased with a mean value of %. operational efficiency: the number of reports is very site dependent: sometimes a report is made for every procedure together with the printout of a blood loss history form. because vista tm tracks all procedure related data, some sites decided to stop printing these types of reports and to go completely paperless. the percent time reduction in reporting is therefore very variable. however the % of errors related to these reports decreased considerably with a mean value of %. efficiency in operations was also obtained because of the number of reports that are available in vista tm . productivity, management and process reports allow verifying and correcting the daily operations of the blood center. increased productivity: depending on the center, also an increase in the number of platelet and plasma products collected was detected. the number of product discards caused by infiltration reduced with a mean value of %, mainly due to the possibility to have customized and more donor adapted trima settings. the percentage of whole blood donors targeted for conversion was very site dependent (min . %-max %). but because with vista any procedure brings between . and . products in general, the financial gain was considerable when donors could be converted from whole blood to apheresis. the use of vista allows the apheresis center to work with a reduced error rate and to increase the operational efficiency and the productivity. the financial impact of this has been estimated by the centers between € and € (mean value €) per procedure. establishment of national quality system in blood transfusion service in serbia introduction: the production of blood products is a semiautomated process in which the manual steps may be difficult to control and standardize. aim of the study: we introduced a specialised team for the blood production to test if this improved the control of the quality of the blood products. methods: the blood products tested for statistical process control were red cells in additive solution, buffy coat removed, and leukodepleted (ld) platelet pools prepared from buffy coats. the products were collected in t&b triple opti-pac from baxter and the platelet pools were ld using plx- filters from asahi and stored in platelet bags from baxter. using control charts, namely x-mrchart, exponentially weighted moving average ewma chart and for autocorrelated stationary data the ewmast chart, we examined if time series of quality control values were in statistical control. if not we examined if autocorrelation and/or differences between the technologists producing the blood products could explain the lack of control. data included approximately biweekly measurements of volume, haemoglobin (hb) concentration, hb/unit, haematocrit and log leukocyte count (wbc)/unit of units of red cells, measurements of volume, platelet concentration and platelet count/pool of ld platelet pools produced by a team of technologists and of ld platelet pools produced by a specially trained team of four technologists. results: log wbc/unit was out of statistical control due to systematic differences between technologists. apparent lack of control of volume, hb-concentration, hb/unit caused by autocorrelation disappeared when the ewmast chart was used. platelet concentration and volume of the platelet pools produced by the technologists were out of control. in that some technologists systematically produced low values. this could be explained by inappropriate handling of the platelet product between centrifugation and separation. systematic differences between the four specially trained technologists could not be demonstrated and they produced platelet pools with a significantly higher platelet count/pool. however, standard deviations of the four technologists differed significantly causing occasional outlying values. conclusion: training and routine in blood production or process automation, and also importantly, feed back to the technologists based on control chart quality control data, is recommended. background: one important principle of the use of blood and blood products is the ability to trace the units from donor to the recipient. this study set out to establish whether or not there was sufficient reporting on transfusions from the hospitals supplied by fort portal regional blood bank in western uganda as a means of establishing sound haemovigilance and look back systems. were reported with no unit number and could not be traced to the patients. there was sufficient reporting on the data requested by the blood bank. these results suggest that it is possible to establish effective 'look back' and haemovigilance systems. capture of data on outcomes and adverse effects will be necessary to fully establish the system. further efforts are required to educate those involved in transfusing blood about the need for adequate and accurate documentation. external quality assessment of blood grouping were misinterpreted as rhd-positive samples without the use of control reagent. rbc phenotyping was made correctly by . % of participants. the remaining . % of participants carried out the phenotyping incorrectly, while false-positive and false-negative results were derived in . % and . % of cases correspondingly. polyspecific human sera and monoclonal antibodies were used for abo, rh and antigens typing. the reason of errors in antigen detection was low quality of reagents. antibodies identification was carried out in six distributed exercises. % of participants detected anti-d-k-c alloantibody correctly. the rest of participants did not found alloantibodies or detected their specificity incorrectly. results of testing depended on quality of screening cells. thus, the participants using homemade pooled screening cells had a significant lower detection rate of antibodies comparing with those using diamed ag cell panel. consequently, the results of the first federal external quality assessment scheme show the necessity of improving the quality of red cell reagents produced in russia. in addition, the more appropriate training of staff is required. the importance of iso -quality system in increasing safety of blood transfusion introduction: hadassah hospital transfusion medicine department received on / iso -quality system accreditation. an essential element of this standard is the development of a reliable system to identify, document, analyze and correct actual and near miss events and assess the effectiveness of corrective and preventive actions. aim of the study: assessment of events and corrective actions following implementation of iso quality system. methods: events in the blood bank were identified by the staff, by internal or external audits and by complaints from the wards. all events were recorded and classified into two categories; quality system and technical. the latter were further classified into preanalytical (sample receipt), analytical (abo rh typing, antibody screen and identification, cross matching and phenotyping) and post-analytical (issue of components to wards). all events were graded into levels; -most severe, potentially harmful to patient. -severe, damage to process and result. -moderatly severe, damage to process only. -benign, no harm. events were corrected and effectiveness of corrective actions was assessed by monitoring recurrence of the event. results: during the years - , events were detected and recorded in the blood bank, they comprised . % of all tests performed ( ). most of the events were technical. all events were detected before causing harm to the patients. results are summarized in the table. *the percent analytical value is a summary of rates of events per test types included in this category. events detected in the quality system were mainly of severity level & , whereas technical events were mainly of severity levels & . analysis of event recurrence in the quality system revealed that % of events were resolved, whereas only %- % of technical problems were completely solved. the main source of event identification and documentation, in the quality system were audits whereas in the technical system, staff members revealed most events. the implementation of iso quality system provided a powerful means for recognition, analysis and study of patterns of near misses and actual events. understanding the root causes of events enables to choose the most effective corrective and preventive action to control event recurrence. evaluation of the frequency of events confined to the blood bank revealed a very low rate of . %. these results are in agreement with data in the literature. creating a non-punitive, non-stressing open environment, motivates personnel to identify and document events, which are regarded as opportunities for improvement and serve as important tools for upgrading transfusion safety. the explosive use of information technology and the speed with which it has spread into all life activities has created vulnerabilities for all organizations. those vulnerabilities are compounded by the complexity of information technology, limited time to market, development constraints, and constantly changing relationships between organizations and suppliers. growth in the sophistication of security threats makes it imperative that organizations remain equally competent in identifying vulnerabilities and mitigating security risks. aim: the goal of this document is to explain how isbt intends to provide guidance to the blood banking community on implementation of effective information security policy. when using information for critical activities, blood banks should consider information security as an important aspect of their management policies. evaluation of existing standards, such as iso and hipaa, allows us to establish a framework for information security without regard to the type of organization. it remains very difficult however, due to the complexities involved, to establish an information security policy without guidance. method: the isbt information task force was created to provide guidelines on information security for blood banking organizations of all sizes. the intent is to help them understand existing standards as well as provide tools for implementing information security policy. these guidelines are based on existing standards that are followed by most worldwide countries: iso and hipaa. results: information security can be defined as the 'protection of systems, information and services from accidental and deliberate threats to confidentiality, integrity and availability' . understanding existing information security standards was the first step for establishing a structure for the guidelines. the core is organized within an implementation framework and presented under the three following layers: . administrative for defining the it security organization, the information security policy, and information security awareness and training. . physical for providing solutions that relate to physical environment protection and access, equipment and it infrastructure security, and control for accessing computerized equipment. . technical for maintaining confidentiality of electronic information and ensuring that authorized access to information systems is maintained (technology relating to identification and authentication, logical access, operating system, network management, application access, etc.). strategy guidance is also included for senior managers in charge of establishing organization policy, including responsibilities and methods to successfully implement policy. further, the task force is addressing both risk analysis and management including identification of potential dangers to information systems (threat-source) and existing controls (risk description), as well as a plan to address identified vulnerabilities and mitigation of specific risks. conclusions: information security standards are prerequisite to understanding the issues involved when considering information vulnerability. international guidelines for information security, specifically directed to the blood banking community, are equally necessary if we are to identify, plan for, and mitigate risks associated with vulnerabilities to critical blood banking information. the isbt task force is committed to providing such guidelines. introduction: the important part of quality planning and quality assurance within production of blood components is measurement system analysis (msa). measurement system analysis was performed on microscopic counting of blood cells in our study. aim of the study: aim of this study is determination if microscopy counting of residual elements in whole blood plasma is suitable for quality control of blood components. methods: we practiced measurement system analysis in counting of residual elements (leukocytes and erythrocytes) in whole blood plasma. the counting performed two lab technicians in ten samples of plasma from whole blood. leukocytes and erythrocytes were measured in naggeotte counting chamber. we used the method of mean and range for the determination of reproducibility and repeatability (r&r) and analysis of variance for complex measurement system analysis. regulation diagrams were applied for the graphic statement. we determined the value of repeatability, reproducibility, coefficient r&r, variability among samples of plasma and total variability of measurement system. the important conclusion was to determinate if the microscopic counting of samples of blood components is sufficient with regard to quality parameters specified in guide to the preparation of blood components (erythrocytes: < . ¥ /l, leukocytes: < . ¥ /l). our results show that microscopy counting of residual elements in whole blood plasma is suitable for quality control of blood components. aim of the study: to provide transfusion services with a tool for proper qms implementation, an international collaborative study on qms applications, employing the 'process approach', has been undertaken by a group of transfusion services of varying sizes and structures with experience of qms, in collaboration with a university institute offering a master in qms implementation in health services, and an expert from a quality association. the 'process approach' serves as a tool to manage transfusion activities as a system based upon a network of processes and their interactions. guide-lines have been produced based upon this principle and will be published (volume and cd-rom) and distributed at no cost to all transfusion services of nations participating in the study. the main contents of the guide-lines' chapters are: through definition/analysis of single processes and the correlation network amongst these, the 'process approach' methodology renders the transfusion centre's functioning units completely interdependent, eliminates process interface barriers, provides personnel with a unified focus on the main transfusion objectives, and lays the basis for improvement of transfusion service quality, organization and performance through efficient control of processes' interactions. the blood screening system automated high-throughput nat system for simultaneous screening of hcv, hbv and hiv nucleic acids: full process surveillance e pfeifer*, b alessandri † , hr bachmann † , t barker † , y ohhashi*, c parkhouse*, j pinsl-ober ‡ , p wenzig ‡ and g ziegler ‡ *roche molecular systems, inc., pleasanton, usa, † roche instrument center ag, rotkreuz, switzerland, ‡ roche diagnostics gmbh, penzberg, germany introduction: the blood screening system combines on one deck both automation of dna/rna extraction from blood/plasma samples and multiplex pcr amplification and detection of nucleic acid targets. the system is designed for high-throughput single unit testing and pooled specimen processing. a data management system supervises and controls the complete process from initial sample pipetting through to result compilation and reporting. the objective of this project was to present the system assay and device built-in quality control measures that guarantee process safety and reliability. the study shows how internal control, external batch controls, pipetting sensors, validation & maintenance procedures, and a controlled development & manufacturing process yield an optimal test method and system stability. method: failure modes and effects criticality analysis (fmeca) was used to evaluate a mathematically derived safety metric for optimizing risk reduction. this method makes use of a system risk objective-function (srof), which provides a multivariate description of sample processing, amplification and detection steps. the method for analyzing system behaviour first employs product classification into risk domains, followed by ranking of process steps that are determined to be linked to known system hazards. this provides objective means for directing system design leading to risk minimization. the srof responses associated with redundant liquid sensing channels were shown to substantially reduce risk during sample or reagent transfer steps. the system liquid flow, airpressure-based (plld) and capacity-coupled liquid (clld) sensors detect aspiration and dispensing inaccuracies. sensor signal tolerance band widths studied for fluid classes representative of system reagents and for plasma samples from lipemic, icteric, and hemolized sample sources were shown to correlate with srof multivariate modelling. the impact of surveillance design elements on the srof response demonstrates that risk is functionally dependent on design elements. additional surveillance examples are presented that describes temperature sensing, robotic positioning and motion control. treatment of residual risk is addressed by introducing external controls that are configurable to specific workflow scenarios. the negative external control (nc) is used to check for contamination of reagents. five low concentration armored external controls, i.e. hiv- group m arna, hiv- group o arna, hiv- arna, hcv arna, and protected hbv dna are run at the beginning of a batch as a run-control measure. in addition to these roche controls the system supports running of user-defined external controls for co-validating the batch. the internal control (ic) is based on armored hiv- group m rna that is co-extracted and co-amplified with the external controls and the target nucleic acids potentially present in the sample. lastly, the system resource management monitors the status of samples, ready-to-use reagents and disposables via rack sensors and bar-coded bottles and tubes. the fmeca methodology provides a risk-minimized, comprehensive system design. redundant sensors with internal and external controls are evaluated through comparison of modelled versus actual run results. the system brings a new level of surveillance and throughput for automated pcr testing, and emphasizes roche's commitment to increasing the safety of the global blood supply. technical standards for safe storage and transport of blood components and blood samples objective: to implement standardization of technical specifications for safe storage, transport and distribution of blood samples and blood components intended for transfusion, as part of a quality system in blood transfusion medicine. methods: in the course of implementing a quality system in our blood establishment (distributing % of the national blood supply), we have developed standard operating procedures (sops) for temperature and hygienic conditions to maintain and control storage of blood components during their shelf life and to ensure their safe distribution to other blood services in the country and abroad, in compliance with eu directives / /ec and / /ec and the recommendations of the council of europe and who. procedures are validated and relevant records are kept. a statistical process control is also in place to monitor deviations from specified temperature and time range throughout the period of transportation. blood components collected and prepared for specific purposes (e.g. directed donations, irradiated units, hla-typed units, anti-cmv negative blood components and blood for neonates) are stored separately, and alarms and warning systems are in place. packing and transport conditions of red cells, platelets and ffp are submitted to the tests and criteria of adr (european agreement concerning the international carriage of dangerous goods by road). in greece, the adr legal framework has applied since . blood samples are classified according to adr in division . under un as diagnostic specimens, and the criteria for safe carriage include packaging, specific labelling and vehicle requirements as well as carrier obligations and personnel training. our blood establishment has a contract with biotrans, a private company accredited for packaging, storing and transporting blood, organs, tissues and cells as well as potentially infectious biologic substances and blood samples for diagnostic purposes. assurance system). the approach is specified in the form of requirements of art. . of the standard: the organization shall: (a) identify the process needed for the quality management system and their application throughout the organization, (b) determine the sequence and interactions of these processes, (c) determine criteria and methods needed to ensure that both the operation and control of these processes are effective. regional centre for transfusion medicine in biaĺystok was the first transfusion service in poland which was certified according to iso : standard. our expected profits from the implementation qms were: possibility to overview organization's pathways of operation and to inspire corrective and improvement actions, emphasis on the role of staff in the system, focus on self-control and responsibility for one's own work as a factor of staff's mentality creation/modification. our one year of experience with iso : standard proved the system to be handy tool of management for the organization collecting, processing, testing blood and releasing of blood products for the hospitals and to be well accepted by the staff. the implementation and certification of the internationally nor-malized quality management system simplify and shorten all accreditation and registration procedures required for legal activities of transfusion service as well as for any supplemental medical activities which may be performed by the centre. the implementation of qms facilitates the implementation of other quality systems and simplifies procedures required for the ce certification for the products. red blood cells stored in blood banks, normally undergo a series of chemical alterations, or storage lesions. the ultimate consequence of these lesions is a decrease in the viability of the red cells following transfusion. the chemical alterations are mainly changes in levels of na+, k+, cl-concentrations, ph and , dpg levels and they affect the electrical impedance of blood. the electrical impedance, cole-cole parameters, is determined mainly by the resistance of the red cell extracellular fluid (re), the resistance of the intracellular fluid (ri) and the capacitance of the cell membranes (cm). in this study we aimed to investigate the relation between blood parameters and electrical impedance changes, and their further clinical implication. all parameters were measured on erythrocyte suspension (es) samples during days of storage at oc on days , , , and . for whole blood (wb) samples during days of storage, same parameters were measured on days , , and . the measurement of the complex impedance of blood samples were performed in the frequency range from khz to mhz. by using the a hp lcr meter, the impedance z, and the phase angle a for each sample were read. these values were corrected according to the gain and phase characteristics of the amplifier; and the resistance r and the reactance x were calculated. each data was first fit to the cole-cole model; hence the cole-cole parameters, intracellular resistance ri, extracellular resistance re, characteristic frequency fc and phase angle a were obtained by using lms software. afterwards, cm was calculated by using ri, re, a and fc. whereas ri and cm decreased progressively with time on both wb and es, re changes showed some differences. the electrical impedance alterations were explained by measurements of na+, k+, clconcentrations, ph and , dpg by indicating days. storage of red cells resulted in a rise in extracellular k+ and a fall in extracellular na+, cl-, ph and , dpg. anova was used to evaluate differences in blood measures in relation to storage time. the results were presented as the mean ± sd. according to the regression analysis in spss, the intracellular resistance (ri) on both es and wb was affected more efficiently from all blood parameters among all other electrical parameters. although ri and re were correlated with na+, k+, cl-, ph and , dpg more significantly, cm measurements were failed to show correlations with blood parameters because of the intervening parameters, a and fc. the best relationship between the parameters mentioned above on both es and wb was ri and k+. ph changes were the same for ri and re both for es and wb. the correlation between parameters on es was better than those on wb, because whole blood consists of several particles that may affect our measurements. our study showed that , dpg has an effect on ri and re as efficiently as other blood parameters and therefore electrical impedance measurements may serve future implications. background: issue of quality blood products and donor safety are the main aims of blood transfusion services. a comprehensive quality system should be in place to fulfill these aims, which can be attained through strict adherence to the established standard operating procedures (sops). the drugs and cosmetics act of india, which controls the licensing of blood transfusion services, does not provide clear guidelines regarding plateletpheresis procedure. aim: we therefore established our own sop and operational flow chart for plateletpheresis that can be easily followed by other centers in india. methods: a total of plateletpheresis procedures performed using two cell separators (cs baxter, usa, mcs p, hemonetics, usa) were evaluated following our established sop. the mean platelet yield in cs was . ± . ¥ and in mcs p, it was . ± . ¥ per unit, however, only - % of sdps showed wbc levels < ¥ . six of donors complained of hypocalcemic symptoms. the operational flow chart designed in this study was found to be simple and easy to adapt by blood transfusion services in this country. the first advanced quality management training course for blood transfusion services in the western pacific region mk tan*, jp yu † and d teo* *health sciences authority, singapore, † who regional office for wpr, manila, singapore background: blood transfusion is a key part of modern medicine. a well-organised blood transfusion service (bts) is a prerequisite for the safe and effective use of blood and blood products. in , the world health organization (who) introduced a new initiative of quality management project (qmp) to achieve the goal of safe and adequate global supply of blood. through qmp, regional training centers were identified and quality management training (qmt) courses were established. in , centre for transfusion medicine (ctm) of health sciences authority singapore was appointed as a collaborating center for qmt in the western pacific region (wpr background: spectrophotometric method according to harboe was traditionally used at our institute for determination of free haemoglobin in supernatants of rbc blood components at the end of storage time. in the year hemocue plasma low hb system (hemocue, sweden) was introduced as a replacement method. aim: the aim of the study was to examine reliability and suitability of the hemocue method for measurement of free haemoglobin in supernatants of rccs. methods: hemocue plasma low hb method was validated and compared with harboe method. supernatants of rbc products were tested by two methods and results compared using regression analysis. additional testing was performed to investigate precision of hemocue method (within-run and between-day variation), trueness using reference material and to define optimal sample handling. results: regression analysis showed high correlation between two methods (r = . ), with higher values obtained with hemocue method. immediately after centrifugation one supernatant was measured times in order to determine within-run imprecision. coefficient of variation (cv) calculated from consecutive measurements was . %. to investigate between-day imprecision of the hemocue method one sample was divided in aliquots and frozen. one sample was thawed each day and measured. cv of five measurements was . %. during the period of validation measurements of reference material (low, medium and high) were performed. cv calculated for these measurements were . % (low), . % (medium) and . % (high). in order to investigate possibility of batch testing, supernatants of different rbc products were divided in aliquots and measured periodically during -month period. cvs calculated from measurements of each sample were in range . - . %. conclusion: hemocue plasma low hb method appears to be an excellent replacement for the harboe method. it is consistent, easy to use, measurements are performed in short time, and errors are minimized by eliminating dilutions and manual calculations. background: determination of haemolysis in red cell concentrates (rccs) at the end of storage time is routine method in quality control of blood components at our institute. for this purpose, haemoglobin concentration in supernatant of rccs is measured using hemocue plasma/low hb system (hemocue, sweden). according to manufacturer recommendation, visually turbid samples should be filtered before analysis with a . mm filter. because visual estimation of turbidity is highly subjective and unreliable, filtration of all supernatants before analysis using appropriate filters is possible solution for standardisation of the method. aim: the aim of the study was to investigate the effect of filtration of visually non-turbid samples on results of free haemoglobin measurement. methods: haemoglobin concentrations were measured in visually non-turbid supernatants before and after filtration using hemocue plasma/low hb photometer ( wb negative controls were used for each blood component. in all blood components tested bacterial contamination was detected using both types of bottles. in comparison with sa/sn bottles, nearly all enrolled microorganisms were detected faster in bpa/bpn bottles (see table ). all negative controls were negative (no false positive). the results of the study performed support the use of bact/alert bpa and bpn plastic bottles in quality control testing of different blood components. objective: management of returned blood products is important part of quality assurance activities in transfusion medicine. blood products are returned most frequently because of routine rotation of stock and because of nonconformities discovered after the product has been received. methods: qa data about returned blood products were retrospectively analysed for the -year period ( - ) . only blood products returned because of nonconformities were taken into consideration. data about the reasons for returns are presented and discussed. the top reasons for returns were positive dat, labelling errors, blood bag defects and visual appearance of blood units (see table ). in all cases positive dat was confirmed in our institute, and blood donors managed accordingly. nonconformities related to visual appearance of blood component and other nonconformities related to the quality of blood products were investigated and corrective actions conducted. in case of blood components returned because of damaged bag, significant problem is to investigate the cause of nonconformity (usually inappropriate transport conditions). conclusion: management of returned blood products is important tool in improving the quality of blood products. introduction: hemovigilance is the systematic monitoring of the blood transfusion chain for side effects and adverse incidents from the moment of blood collection until after administration of the unit to the recipient, and comprises all activities that can lead to a safer and more effective use of blood components. attempts to achieve a more safe and effective use of blood components constitute a huge task given the number of interventions and array of medical and not-medical personnel involved in the transfusion process. registration of the impact of all participants is a tremendous job as such. information management may enhance the chances for a successful hemovigilance. aim: the aim is, to establish a basis for all the information related to the chain, such as standard operating procedures, (inter)national guidelines, local transfusion protocols and forms, and procedures to direct the process. additional factors that contribute to the final results are the profile and role of employees, incidents, points of care, product information, prices, budget, contracts, etc. by clarifying and explaining the basis to all participants by means of an existing infra structure, everyone will gain access to identical, consistent and up-to-date information at all times. the primary activity is to create the basis by an outline of every individual link in the transfusion chain from donor to recipient. secondly, the resources, responsibilities, actions, and internal controls (what task, who is performing, why, which help, where, when) are documented. by creating distinct databases for these 'w's' in combination with a separate database for the hemovigilance process itself, it is possible to establish relations, hyperlinks, between the different databases. all the information collected in the foundation, complete with all the resources, responsibilities, actions, and internal controls is made available to target groups by means of the intranet in our hospital as well as in a printed handbook format. collecting and displaying the information on hemovigilance this way, creates a transparent and more easy-to-manage process. it establishes a basis, which incorporates all resources, responsibilities, actions, and internal controls to all participants and enables the organisation to operate both efficiently and effectively. it allows us to show auditors (both internal and external) which processes are related to which guidelines as well as the results in daily. in addition, it reveals which factors determine the genuine application of the guidelines in clinical practice. conclusion: by outlining the process, followed by defining, analysing, securing, on the 'w ' method, the hemovigilance process offers a stable basis and framework for all participants and may stimulate a more safe and effective use of blood components. background: transfusion medicine is a basic post-graduate specialty for medical doctors with a specific national curriculum in bulgaria. in order to improve the post-graduate training of medical doctors in transfusion medicine, a new curriculum was elaborated in . purpose of the new program: independent work of transfusion medicine specialists on all levels of the blood transfusion service (bts) -organization of bts, promotion of voluntary, nonremunerated blood donation, collection, processing, testing, storage and transport of blood and blood components, immunohematologic testing of patients, laboratory hematology, clinical experience, assistance and advice on diagnostic and therapeutic problems of patients, requiring treatment with blood products, teaching transfusion medicine to bts and clinical personnel. admittance and duration to training -medical doctors are admitted to post graduate specialization after a successful state examination. the overall duration of training is years, of which at least are obligatory for training in the national or regional blood transfusion centers. main sections of the curriculum: . organization of blood donation and blood transfusion, including promotion of voluntary, nonremunerated blood donation; organization, planning and information systems; organization of blood transfusion; quality management. . collection, processing, storage and transport of blood and blood components . laboratory hematology and specialized methods (general laboratory methods, immunology, immunohematology, transmissible infections, hemostaseology, nat techniques, flowcytometry) . clinical use of blood components and plasma products (treatment with blood products, adverse events and reactions, alternatives to blood transfusion). the new curriculum of transfusion medicine guarantees a better training of medical doctors, thus leading to safe and effective blood products their proper clinical use. introduction: transfusion medicine is integrated medical discipline based on clinical and laboratory practice. it is closely connected with molecular biology, genetics, as well as with apheresis, automatically techniques and transplantation. the aim of studies in transfusion medicine is proper education, skills, attitudes and knowledge of students at the medical faculty and of doctors on residency in transfusion medicine and other specialties about blood and its usage. material and methods: there will be presented how transfusion medicine is implemented in educational and health sector in r. results: there is -year specialization in transfusion medicine, established years ago (over specialists finished this specialization till now). we have postgraduate studies in tm started years ago. transfusiology, as subject at the medical faculty, is now included in new curricula of medical student, consists of theoretical and practical lectures. also, medical doctors on specialization in surgery, anesthesiology, obstetrics and gynecology, pediatrics, internal medicine, maxillo-facial surgery and others have obligatory -month education in tm. transfusion medicine is integral part in education of nurses and laboratory technicians; all personnel that work in transfusion field in our country finished -mounths course in tm and get certificate. conclusion: although we have already done so much in educational field, we will continue with our efforts to improve our collaboration with clinicians and to involve ourselves more in clinical disciplines. introduction: in hospitals of saint petersburg donor blood, its components and preparations, autoblood and its components, hemocorrectors are applied with the medical purpose at - % of hospital patients. the service of blood and the existing organization transfusion therapy in hospitals should provide maximal immunological and infectious safety and also its high medical efficiency. it demands special preparation for all doctors: general physicians on clinical transfusiology and doctors of blood service on all sections of the general, industrial and clinical transfusiology. clinical gemostasiology, pharmacology of hemotransfusion means and hemocorrectors, the organization of the blood service, the donor service; the organization, technique and technics of preparation of blood, its components and preparations, quality assurance, transfusion therapy programs, technique and technics of transfusion medicine, a problem of maintenance of immunological and infectious safety, preventive maintenance, diagnostics and treatment of posttransfusion complications, feature transfusion therapy in pediatrics and medicine of accidents). clinical physicians master all basic questions of clinical transfusiology, thus the special attention is given questions of clinical immunohematology and clinical gemostasiology, programs and a technique of transfusion therapy, the prevention of posttransfusion complications. employment are carried out in departments of city blood bank, hospitals blood departments. final examination under the test program and at interview shows sufficient mastering a theoretical and practical material (right answers of - %). the described system of postgraduate studies provides an opportunity of successful independent work of doctors on the workplaces both regular increase and qualifications not less often than time in - years. conclusion: the existing system of postgraduate education for doctors on transfusiology provides the blood services and hospital by the qualified staff. introduction: nowadays in hospitals of saint-petersburg more and more it is frequently applied the extracorporal hemacorrection (haemapheresis, haemasorbtion, plasmasorbtion, krhyoplasmasorbtion, ultrafiltration etc.) and photohemotherapy (optical radiation influence on blood) at various diseases and traumas. they are used at treatment almost % from the general number of patients of hospitals with positive results at % from them. for this purpose in hospitals there are specialized branches or cabinets with staff of the doctors -transfusiologists. therefore an actual problem is organization of postgraduate special education for them. because there is no specific blood banking and transfusion medicine training in either under or post graduate medical education those general practitioners have limited knowledge about this field. aim: to give basic knowledge and practice to those general practitioners moh has established a special training programme with the collaboration of medical schools for years. methods: this is a months programme which has basic components; theoretical education, laboratory and blood banking practice. the trainees are evaluated by a final examination. each group has limited cadets and the training is provided in selected blood banks with the collaboration of universities and moh training hospitals. conclusion: almost general practitioners are trained by this programme in the last years and those doctors helped to increase the quality of blood banking and transfusion service at their hospitals. background: even the history of public blood banking in turkey has dates back to , whole blood was comprising the majority of transfused units (more then %) in turkey until the last few years. aim: the main target was to decrease the whole blood use in a short time and establish countrywide effective blood transfusion practice. methods: there were no specific blood banking and transfusion education either at undergraduate and postgraduate medical education in turkey until the last few years. blood banks and transfusion society of turkey (bbtst) was established at with the main aim of education of the related people about blood banking and transfusion medicine. bbts has organized symposiums, national courses, national and international congresses since . due to increased knowledge about the blood components and improved infrastructure of blood banks whole blood consumption has decreased to national average to %. in most of the university hospitals and training hospitals this is around %. conclusion: like most of the public based behaviours dedicated efforts of civil initiative has changed the traditional habit of blood consumption in turkey by the direct affect of well organized educational activities. training of general practitioners in blood banking and transfusion medicine n solaz*, b keskinkilic † and c oruc † *ankara university, ankara, † ministry of health, ankara, turkey background: turkish ministry of health runs majority of the hospital blood banks in turkey. most of the moh hospital blood banks give service under the medical supervision of general practitioners. because there is no specific blood banking and transfusion medicine training in either under or post graduate medical education those general practitioners have limited knowledge about this field. aim: to give basic knowledge and practice to those general practitioners moh has established a special training programme with the collaboration of medical schools for years. methods: this is a months programme which has basic components; theoretical education, laboratory and blood banking practice. the trainees are evaluated by a final examination. each group has limited cadets and the training is provided in selected blood banks with the collaboration of universities and moh training hospitals. conclusion: almost general practitioners are trained by this programme in the last years and those doctors helped to increase the quality of blood banking and transfusion service at their hospitals. background: it has been accepted that during cardiac surgery the complement-system is activated which enhances ischemia-reperfusion injury, leading to postoperative complications as infections and organ failure. the lectin pathway is one of the mechanisms that can activate the complement-system, this pathway can be mediated by mannose-binding-lectin (mbl). the level of mbl in serum shows a wide variation. a low level of mbl can lead to more infections in some conditions and a high level to tissue damage after ischemiareperfusion injury. the effect of transfusions of erythrocyteconcentrates and plasma on the mbl levels and thereby on complications after cardiac surgery are not known. aim of the study: the role of pre-and postoperative mbl levels and the effect of transfusions on postoperative complications after cardiac surgery. in a randomized controlled trial cardiac surgery patients were included and blood samples were taken pre-and postoperatively. mbl measurements were performed by elisa assays. the data were linked with postoperative complications as mortality, infections and multiple-organ-dysfunction-syndrome-mods and with peri-operative erythrocyte and plasma transfusions. results: the mean pre-operative mbl-level was ± and postoperative ± mg/ml. there were no differences in preand post-operative mbl levels between patients with infections or mods compared with non-infected and non-mods patients. the difference in pre-operative mbl between non-survived ( ± ) and survived patients ( ± ) was not significant (p = . ). postoperative mbl levels between survived and non-survived patients was smaller. conclusions: pre-and postoperative mbl levels in cardiac surgery are not related to postoperative infections, mods and hospitalmortality. whether large amount of blood transfusions are affecting the mbl-levels and thereby the patients outcome is not known. introduction: patients undergoing cardiac surgery are receiving high amount of blood transfusions and are at risk for the development of infections and multiple-organ-dysfunction-syndrome (mods), these complications are influencing the survival of the patients. during cardiac surgery pro-and anti-inflammatory cytokines are released by different mechanisms. we found in a randomized trial in cardiac surgery a significant reduction in infections and mortality due to mods by transfusion of leukocytedepleted erythrocyte concentrates (ld) compared to leukocyte-containing, buffy-coat depleted erythrocytes (pc). aim of the study: the effect of ld on the concentration of proinflammatory cytokine il- and anti-inflammatory cytokine il- in relation to clinical outcome and complications after cardiac surgery. methods: in participating patients blood samples were taken before and after surgery. using elisa il- and il- were measured in these samples. the results were linked with the endpoints of the randomized trial: postoperative infections, mods and in-hospital mortality. results: all pre-operative concentrations of il- and il- were low. mean postoperative level for il- was ± and for il- ± . compared with patients without mods and without infections and survived patients only the il- was significant higher in patients who died and in patients with mods. there were no differences in mean levels related to ld and pc. the levels of il- were higher in patients receiving more then units blood transfusions compared to transfusions. conclusion: there is an association between mods and mortality and il- , not with il- . ld has no influence on mean levels of il- and il- . there is a correlation between transfusion of more then units and il- , not with il- . these cytokine-profiles are not associated with the beneficial effect of ld on the postoperative outcome in cardiac surgery patients. anemia and blood transfusion practice in critically ill patients e grouzi*, e tsigou*, p evagelopoulou † , g baltopoulos † and i spiliotopoulou* *kat general hospital, transfusion service, athens, † athens university school of nursing icu, athens, greece background: anemia is a common problem in critically ill patients admitted to intensive care unit (icu), but the consequences of anemia on mortality and morbidity in the critically ill is poorly defined. aim: to define the incidence of anemia and red blood cell (rbc) transfusion practice in critically ill patients in the icu) of our hospital, and to examine the relationship of anemia and rbc transfusion to clinical outcome. patients and methods: the period study was from july to december . patients were enrolled within h of icu admission. follow-up time was days, hospital discharge or death, whichever occurred first. results: a total of patients ( male, female, mean age . ± . years, range - ) were included in the study. the mean hemoglobin (hb) level at baseline was . ± . , which level was descending during the study. overall . % ( / ) of the patients received one or more rbc units while in the icu stay (mean . ± . units per patients). the mean pretransfusion hb was . ± . g/dl and the mean time to first icu transfusion was . ± . days. more rbc transfusions were given in the first week of the icu stay ( units vs , , units in the second, third and forth week respectively). the number of rbc units which a patient received during the study was positive associated with longer icu length of stay and an increase in mortality (r = . , p < . and r = . , p < . respectively). baseline hb level was significantly related to the number of rbc transfusion (r = . , p < . ), but was not an independent predictor risk factor of length of stay or mortality (r = . , p > . and r = . , p > . respectively). the mean baseline apache ii and saps scores were . ± . and . ± . respectively. furthermore both baseline apache ii and saps scores were significantly higher for patients with a baseline hb level of < g/dl ( . ± . vs . ± . and . ± . vs . ± . respectively), while the apache ii values were positive associated with a significantly increased likelihood of rbc transfusion (pearson correlation p < . ). conclusions: anemia is common in the critically ill patients, it appears early in the icu course and persists throughout the duration of the icu stay. rbc transfusion seems to be associated with worse clinical outcome. despite the intensive research for the transfusion practice, which taken place worldwide during recent years, data from our country is limited. the results of our study suggest that approaches to reduce rbc transfusion would be desirable. however, further well designed prospective studies with large number of patients are required to efficiently explore the risk of anemia, optimal transfusion hb threshold and the risk and benefit of rbc transfusion in the critically ill. consumption of blood products in a large, general hospital he heier*, j pillgram-larsen † , m hestnes ‡ , b gran*, a krog* and no skaga ‡ *ullevaal university hospital, oslo, † ullevaal university hospital, dept. of thoracic surgery, oslo, ‡ ullevaal university hospital, dept. of anestesiology, oslo, norway uuh is the largest general hospital in norway, and trauma referral centre for half of the norwegian population ( . mill) the trauma team performed initial assessment and resuscitation of patients, % males, during the first six months of . the aim of our study was to analyze transfusion practice at uuh with specific focus on trauma. materials and methods: blood consumption during this period was recorded. clinical data of trauma patients were collected from our trauma registry and anonymized before analysis. results: units of erythrocytes (er), of thrombocytes (thr) (buffy coat preparations from donors) and of s/d-treated whole plasma (op) (octaplasÒ) were transfused in uuh during this period. . % of er were given to surgical, . % to medical and . % to gynaecological and obstetric patients. % of er were given to patients above years. er units were given to patients (mean . units/patient; range - ). mean age of trauma patients was ± , median , range - years. for transfusion of this group local guidelines state that haemodynamically unstable patients should receive er if hgb < g/dl, irrespective of age and sex. eighty-eight patients ( . %) received er, of them as massive transfusion ( er units in < hours) ( . %), of these died ( %). altogether trauma patients received units of er ( . % of total uuh consumption), . thr ( . % of total) and units of op ( . % of total). massive transfusion consumed er ( %), . thr ( . %) and op ( . %) units. fourteen adult trauma patients ( . % of those transfused) received or er units only. lowest pre-transfusion hgb was . - . g/dl, median . , mean . ± ; highest post-transfusion hgb . - . g/dl, median . , mean . ± . five patients received er transfusion at higher pretransfusion hgb level than g/dl, but in er were given because of a hyperacute clinical situation. fifty-five% of issued er units had been stored for > days, while only % were issued before days of storage. discussion: life-saving effect of transfusion would seem evident in the massively transfused survivors, while in the other transfused patients documentation of clinical effect is inadequate. transfusion practice in trauma at uuh seems fairly well in accordance with internationally accepted guidelines. the trauma unit consumed a surprisingly small part of total uuh transfusion resources. trauma patients deviate from the general uuh patient population by sex and age; transfusion is otherwise mainly given to more elderly patients. further analysis is needed on transfusion indications and results to optimize the total use of blood products in uuh. special focus should be on transfusion to non-bleeding patients without haematological disease. it seems that only a small part of transfusion efforts results in the saving of life. in croatia national guidelines for the use of rhd gamma globulin were laid down in the year . in accordance with the guidelines, rhd gamma globulin is administered intramuscularly in doses of - mg and should be given to rhd negative women after delivery of rh positive children, after abortions, in week of their first pregnancy, as well as in cases pregnancies with an increased risk of fetomaternal hemorrhage. as to the latter, detection and measurement of fetomaternal hemorrhage are recommended. three years after the issuance of the guidelines a survey was conducted regarding the use of rhd gamma globulin that involved health institutions across the country. as many as deliveries and abortions were reported in . the institutions reported the usage of doses of mg rhd gamma globulin or doses/ deliveries + abortions. we compared our data with those obtained from similar surveys conducted in , i.e. before the issuance of the guidelines. in that year deliveries and abortions were reported, and doses of rhd gamma globulin or doses/ deliveries + abortions were administered. institutions were then divided into four categories: clinical hospitals, general hospitals with the capacity of - beds, general hospitals with the capacity of - beds, and institutions of rather limited capacity with gynaecology department. the range of the consumption of rhd gamma globulin/ deliveries + abortions in the first category was - with the median being ; in the second category there were - doses with the median being , in the third category - doses with the median being , while in the fourth category the range was - doses with the median of doses. the number of pregnancies which should have been protected with rhd immunization in year was obtained by the following formula: (frequency of rhd negative subjects) ¥ (frequency of the r gene) = . ¥ . = . . if a complete antenatal and postnatal preventive measures involving rhd immunization had been taken in , doses of rhd gamma globulin or mg/ deliveries + abortions should have been given. our research has shown that, despite of the national guidelines adopted in , the prevention of the rhd immunization in pregnant women is still not adequate in croatia. in fact, it has not improved since a year prior to the adoption of the guidelines. it has also been established that the category of the institution is a factor influencing the implementation of the protective measures. we consider that much more should be done on informing both women and gynaecologists about the importance of prophylaxis of the rhd immunization. consumption of plasma derivates in croatia g jaklin*, b golubic-cepulic † and m dondur* *general hospital, varazdin, † clinical hospital center zagreb, zagreb, croatia a increasing consumption of plasma derivates, their limited supply and insufficient national reserves are problems that croatia is faced with nowadays, as well as many other countries. in a study was carried out regarding the usage of plasma derivates. as many as health institutions took part having the capacity of acute beds out of a total of . the data regarding the use of plasma derivates were collected as follows: albumin, i.v. gamma globulin, and concentrate of coagulation factor viii in two periods of time. we divided institutions into three categories: clinical hospitals, general hospitals with the capacity of - beds and general hospitals with the capacity of - beds. institutional practice patterns regarding the use plasma derivates were compared among them. the parameters considered were the total consumption of plasma derivates, consumption per bed and consumption per inhabitant. data on the use of plasma derivates was obtained from hospital transfusion departments and pharmacies across the country. we compared our data with similar study carried out in . the consumption of albumin was . kg or kg/million inhabitants in and consumption per bed for the first category institutions was in range . - . kg with the median being . , for the second category the range was . - . kg with the median being . , while for the third category the range was . - . kg with the median being . . in in croatia the consumption of albumin was . kg or kg/million inhabitants. the consumption of i.v. gamma globulin was . kg or . kg/million inhabitants in and the consumption per bed for the first category institutions was in range . g- . g. with the median being . , for the second category was in range . - . g. with the median of . and for the third category was in range . - . with the median . g. in in croatia the consumption of i.v. gamma globulin was . kg or . /million inhabitants. the consumption of the concentrate of factor viii was . iu or . iu per inhabitant in . . iu, i.e. . %, was a recombinant factor viii. in the consumption of factor viii was . iu or . iu per inhabitant. discussion: the use of albumin showed stagnation. however, the use of i.v. gamma globulin increased . times and the use of the concentrate of factor viii increased . times if compared with the results in . self-sufficiency has not been reached in plasma derivates in croatia we needed l plasma for gamma globulin and l plasma for concentrate of factor viii for the level of usage of these plasma derivates in . significant differences in the level of usage among hospitals have been observed. these reflected a considerable difference in hospital policy regarding the use of these products in defined clinical settings. therefore, we would recommend that the national society sets out guidelines for the use of the products. background: blood bank good practice requires avoidance of rh alloimmunization. several studies report a probability of immunization of more than % following transfusion with rhd+ rbc's and as many as % in the case of platelets. aims: the purpose of this study was to investigate the development of anti-d and the causes of alloimmunization in a university hospital ( beds), reviewing our practice on the use of rhd+ blood components in rhd-recipients. method: a retrospective study was performed whereby . rhd-patients, from to , were evaluated for the development of anti-d analysing the data on the blood bank information system. results: from the . rhd-patients we found out identified anti-d, % ( ) detected before any transfusion in our hospital. of the left, nine were excluded because no information was available during some years. had history of pregnancy related to the immunization. patients were exposed to rhd+ blood components: were transfused only with rhd+ platelets (including two women of childbearing age); with rhd + rbc's. the remaining had been exposed exclusively to rhd -rbc's suggesting that some units could be mistyped. this idea was corroborated in three patients where there was a common donor (he was called for investigation). conclusions: transfusion services avoid as far as possible administration of rhd+ blood components to rhd-patients, although there are situations in which such transfusions are necessary. the retrospective review of records revealed the need for specific recommendations regarding the use of rh immunoglobulin to prevent anti-d immunization. the possibility of mistyping blood components also appeared in this review, emphasizing the role of these studies in the evaluation of methodologies used at blood banks. the purpose of the work: to present the usage of whole blood (wb) and blood products (bp) in the treatment of patients who are hospitalized in the internal disease department in gevgelija. material and methods: retrospective analysis is done according the data which were analysed in five years period ( ) ( ) ( ) ( ) ( ) . statistical methods which were taken from the history of the hospitalized patients in the internal department were used for analysis and the data of transfused wb units and units of bp were taken from the department of transfusion medicine. results: from the total hospitalized patients who have been analyzed, ( . %) received wb and bp, and there have been transfused units wb and bp. every patient, on an average, has been transfused with . units wb and bp. at the same time ( . %) units have been transfused as a wb, ( . %) have been transfused as red blood cells (rbcs) and ( . %) units have been transfused as a fresh frozen plasma (ffp). the data for every year particularly will be presented in our paper to the congress. the collaboration between doctors of transfusion medicine and health workers from the other medical branches is the most important thing in the medical practice. our aim is to raise the awareness among the health workers for the importance of blood safety and their role though adequate clinical usage of wb and rbcs, minimizing the non-useful transfusions, evaluation of reflexive information from undesirable reactions in the usage of blood and blood products, use the alternatives etc. the necessity of direct involvement of the doctors in transfusion medicine in the process of healthy workers' education from the other branches for regularly transfusion therapy via meetings and lectures is an imperative for regular function of the department of transfusion medicine. femoral neck fracture repair is one of the commonest orthopedic procedures. it mainly concerns intracapsular or intratrochanteric fractures and it may be considerably hemorrhagic, requiring blood transfusion perioperatively. the aim of our study was to investigate blood transfusion requirement in patients with femoral neck fractures repair at katerini general hospital during - and to compare them with other studies. one hundred sixty five ( ) unselected patients of whom ( %) were women and ( %) were men with a mean age of years (range - years) were studied retrospectively. seventy six ( %) patients had intracapsular fracture and ( %) intratrochanteric fracture. the mean hb concentration on admission was . g/dl (range . - g/dl) and the mean hb concentration at discharge was . g/dl (range . - . g/dl). a total of units of rbc were transfused (a mean of . units per patient). blood transfusion occurred in patients ( . %), ( - % in other studies) with a mean of . units per patient (range - units), ( . - . in other studies). patients with preoperative hb values < g/dl were transfused more often than those with hb values > g/dl ( % versus %) p: . . women were transfused more often men ( . % versus . %) p: . . patients aged > years were transfused more often than those aged < years ( % versus %) p: . . finally patients with intratrochanteric fractures were transfused more often than those with intracapsular fractures ( . % versus %) p: . . conclusions: in our study blood transfusion requirement for femoral neck fracture repair are similar with these reported in other studies. blood transfusion frequency is greater in patients with hb < g/dl, in patients older than years, in women and in intratrochanteric fractures repair. fresh frozen plasma guidelines and practices as saltamavros*, g talampouka*, c koumoundourou*, s dimitrakopoulos † and p tseliou* *st. andrews hospital patras greece, patras, † pyrgos general hospital, pyrgos, greece introduction: fresh frozen plasma transfusions should be done according to specific standards and guidelines. aims: we have reviewed the ffp transfusion practices followed in our hospital in an attempt to provide a set of guidelines and principles that will assist physicians and health care workers to make the right decisions for appropriate use of ffp transfusions. methods: retrospective review of ffp transfusions practices during the entire year of . we classified transfusion practices according to the diagnosis of the patient and also of the clinical depart-ment that demanded transfusion. then we analyzed our results by comparing the requests with the internationally approved guidelines for ffp transfusion and counted the percentage of ffp to rbc units. finally we discussed with our fellow physicians the proper use of ffp and informed them about the accepted guidelines. as we can see from the underneath table, diagnoses and departments with high consumption were: internal medicine %, plasmapheresis to patients suffering from guillain barre and ttp (thrombotic thrombopenic purpura) . % and trauma/surgery . %, cancer . %. summary/conclusions: the use of ffp corresponds to . % of the rbc units transfused in our hospital. plasma units should be used properly and according to internationally accepted standards. plasma use should be justified by the physician, in order to avoid unnecessary risks on behalf of the patient for effective treatment and care. to show gradual discontinuation of using whole blood and increased use of red blood cells (rbc) in the management of patients in the transfusion department of the clinical hospital 'zvezdara' . methods: data of wb and rbc use from to in our hospital. results: our data are presented in table . conclusion: after , wb usage rates systematically decreased from % to . %. however, in the period of - , the wb usage rates increased slightly, and we arrived at a generally very low rate of wb use, namely only in about % of the cases. education about transfusion medicine and rational use of blood in the medical curriculum was generally insufficient and very poor. therefore, we started an education program and we established a hospital transfusion committee (htc) with the task of medical control and monitoring the quality of clinical transfusion practice in our hospital. members of the htc are a specialist in transfusion medicine, an internal medicine specialist, an anesthesiologist, surgeon and gynecologist. we have been organizing courses for the medical staff, doctors and medical technicians since . background: platelet transfusions are given mainly to thrombocytopenic patients with malignant haematological diseases. currently the decision to give a prophylactic platelet transfusion is based almost exclusively on the number of circulating platelets in the patient although it is known that various clinical factors might influence the bleeding tendency. by free oscillating rheometry (for), using a reorox® instrument, it is possible to monitor the coagulation over time in whole blood and obtain information about clotting time and coagulum elasticity. aim of the study: the aim of this study was to find out if for using the reorox® instrument could be used to evaluate the hemostatic status of thrombocytopenic patients. methods: the change in elasticity over time in non-anticoagulated whole blood from leukaemia/lymphoma patients with thrombocytopenia was measured in the reorox® pre and post a platelet transfusion (n = ) and was compared with healthy controls (n = ). the effect of platelet concentration on coagulation was studied by diluting platelet rich plasma from healthy subjects with autologous plasma to various platelet counts whereafter the coagulation was monitored with for (n = ). the change in elasticity per minute (g'max slope) and maximum elasticity (g'max) were evaluated from the elasticity curves. results: the g'max, g'max slope and platelet count increased after transfusion for all patients. the thrombocytopenic patients had significantly lower g'max and g'max slope values both pre and post transfusion compared with healthy control subjects (p < . ). the measurement in platelet rich plasma showed that g'max and g'max slope increased with increasing platelet concentration. however patients with similar platelet count developed different clot elasticity. the reorox ® instrument responds to changes in haemostatic function in form of the clot elasticity. the fact that patients with similar platelet concentration developed different elasticity shows that clot elasticity is a function of not only platelet concentration but also of functional properties. the for method seems promising to evaluate platelet function. quality control of pre-storage leukodepleted red cell concentrates vu urlep salinovic, k perbil lazic and l lokar teaching hospital maribor, maribor, slovenia background: the system of quality assurance including quality control (qc) in transfusion medicine is most important for safe blood supply. the safety and quality of blood components are increased by pre-storage leukodepletion of whole blood (wb). aim: the qc of leukodepleted red cell concentrates (rcc), prepared from pre-storage filtration of wb (quadruple blood bag systems imuflex wb-rp terumo) is performed with the aim to be sure that the quality of leukodepleted rcc is in accordance with the guidelines of council of europe. in three years ( ) ( ) ( ) , units of wb were collected, among them ( . %) units were collected for pre-storage filtration and in ( . %) of these qc was done. within hours after collection, wb was filtered at room temperature. filtered wb was centrifuged at g for minutes and separated in rcc and plasma. the samples for qc were collected before and after filtration. for each unit, volume, hemoglobin, hematocrit, % of hemolysis and residual white blood cells (wbc) count were measured. the number of residual wbc after filtration was determined in the nageotte chambre. for all parameters the mean value and standard deviation were calculated. the results of qc for the following parameters were: volume ± . ml ( % corresponds with the guidelines of council of europe), hematocrit . ± . ( %), hemoglobin . ± . g/unit ( %), number of residual leukocytes . ± . ¥ ( %), hemolysis . ± . % ( %), the test of sterility was % negative. during filtration of wb, wbc were removed in approximately . %, the duration of filtration was ± minutes and the loss of hemoglobin was . ± . %. the pre-storage filtration of wb is highly efficient, . % of wbc were removed and the loss of hemoglobin was small. background: the patients of cardiosurgery use big amount of blood components. there is no uniform approach by treatment with blood components in these patients. the safest and the most rational use of blood is based on the individual treatment of a patient and the evaluation of the most clinical and laboratory factors. aim: the aim of our study is to analyse the use of blood components from , when the cardiosurgery department was founded in our hospital, to . the data about use of red cell concentrates (rcc), platelet concentrates (pc) and fresh frozen plasma (ffp) in the period from to were collected from information system datec. the average use of all three blood components per patient is presented. we were interested, if the average use per patient was diminished in the analysed period. results: the use of three blood components and average use of all blood components are presented in the table. the data from the table shows, that the number of patients increased more than three times, but the average use of blood components per patient was not essentially diminished. conclusion: during seven years period the use of blood components per patient in cardiosurgery was not diminished. for more rational use it is necessary to apply all methods of autologous blood transfusion because of the increasing number of cardiac operations and decreased number of voluntary blood donors. background: the presence of leucocytes in blood components is cause for appearance of various adverse posttransfusion reactions such as nhfptrs, urticary, anaphylactic shock, alloimunization and platelet refractorines, infection with bacteria and leucothropyc viruses (cmv, htlv). the removal of leucocytes from blood components through filtration is especially important in the treatment of patients with malignant diseases who need frequent transfusions of blood and blood components. this is because of their lowered immunologic status which is a result of the disease and received immunosuppressive chemotherapy and radiotherapy. aim: to show the prevention of posttransfusion reactions and the positive effect from transfusion of leucoreduced er. concentrates, produced with filtration in therapy of anaemia in patients with malignant diseases, treated in our daily transfusion hospital at medical center -stip. methods: patients with malignant diseases have been treated in our daily transfusion hospital in the last four years. most of these patients suffer from ca pulmonum, ca collonis, ca uteri, ca mammae. also, because of the secondary anaemia, the same patients were transfunded with at least two doses of leucoreduced er. concentrates. the blood donored by voluntary repeated blood donors was filtrated the same day after the donation, separation and the control of the same one. the blood was collected in baxter and terumo bags, and it was filtrated with baxter -sepacell rs - and pall -purecell rn filters. the analyses of leucoreduction were made for every filtrated and transfunded unit before and after filtration. the analyses samples were taken from the tubing system before and after the filter. haemathologic parameters were automatically made in the central clinic laboratory. results: er. concentrates poor with the leucocytes for about - . % were produced with the use od these filters, and platelets from - % with which side effects from frequent transfusions at these patients were prevented. with the routine monitoring of all patients none posttransfusion reactions were registered. the therapeutic effect is also important because of the fact that the number of er and the level of hg and hct remain almost unchanged. the aim of the blood banks is to help and to increase the safety of the blood components. the leucoreduction through of er. concentrates poor with leucocytes is a regular procedure in the therapy of malignant patients with remarkable clinical picture of anaemic syndrome and prevention the cancer recurrence end infection. the time of filtration is also very important which has to be shorter after collection of blood, because the leucocytes should be removed before they become disintegrated and relapse potentially dangerous substances end metabolites in the blood components. we have been applying so called ' prestorage filtration' because it has been proved that it is more efficient that bed -side filtration. background: the effect of leukocyte reduction of rbcs by filtration has been the topic of several rcts. these rcts investigated the effect of leukocyte reduction on mortality; post-operative infections and hospital stay in different patient populations. some rcts came up with answers that conflicted with the results of other rcts. aim of the study: with including the individual patient datasets of several rcts in one database, combined analyses are possible that may explain the differences in the reported results. using this technique, we may come up with answers (or questions) that cannot be obtained by performing standard meta-analyses of these rcts. methods: we coordinated several rcts comparing the perioperative use of buffy-coat depleted rbcs with the use of filtered rbcs. cardiac surgery patients were included in three rcts ( ¥ cabg and/or valve; ¥ re-cabg and/or valve; ¥ valve with or without cabg). oncologic surgery patients were also included in three rcts ( ¥ colorectal cancer; ¥ gi-oncology or vascular surgery; ¥ gi-oncology, vascular surgery or orthopedic surgery). the electronic data files of these rcts were uniformly recoded and entered in a single database. as different primary endpoints were investigated in the rcts, we focused on common endpoints, recorded in or more of the rcts. multivariate analyses were performed on: in-hospital mortality, -day mortality, hospital stay, stay on icu, postoperative infections, and mods. results: in the rcts, individual datasets from surgery patients were collected ( onco; cardiac; vascular; orthopedic, other). in the multivariate analyses, patients in the buffycoat depleted trial arm showed a higher mortality rate both in-hospital (p = . ) and at days post-surgery (p = . ). no association between randomization and stay in hospital (p = . ) or stay on icu (p = . ) was seen in the combined study population. also, no association of randomization with the incidence or duration of mods was seen. the analyses of post-operative infections in the total population showed the trial arm to be associated (p = . ), and 'hospital' to be far stronger associated (p < . ). however, when the oldest rct, that had not yet used our standard definition list for scoring post-operative infections, was excluded, the association with the hospital was lost (p = . ) and the trial arm became more strongly associated with infections (p = . ). in the analyses of surgery patients, the use of filtered rbcs, compared to the use of buffy-coat depleted rbcs, resulted in reduced mortality (both in-hospital and at days postsurgery) and a reduction in post-operative infections. the association of the variable 'hospital' with post-operative infections, as is frequently reported in literature, was initially confirmed in our analyses. however, when a standard definition for post-operative infections was used (excluding the datasets from one of six studies), this association was lost. background/aims: uk neqas for blood transfusion laboratory practice (btlp) operates an eqa service for uk laboratories (including eire) and participants throughout europe, including major groups in denmark (n = ) and portugal (n = ). in november a questionnaire was distributed to determine the criteria used for selecting phenotyped blood for different patient groups, including pre-menopausal women (pmfs). results were analysed by country to establish any variation in practice relating to the selection of k negative (k-) and rhc negative (c-) blood, since antibodies to these antigens are now the major cause of hdn. results: overall return rate was % (uk) and % (non-uk), although only centres treating pmfs were included in this analysis. k-blood was selected for pmfs by % in wales (n = ) and % in england (n = ), but only % in scotland (n = ), % in northern ireland (n = ) and % in eire (n = ). in mainland europe, variation was also observed: % in denmark (n = ), % in portugal (n = ) and % in other countries (n = from countries). fewer laboratories selected c-blood for pmfs: % in england and northern ireland, % in scotland and eire, rising to % in wales. mainland europe showed similar variation: % in denmark, % in portugal (all ccee matched) and % in other countries. there are no guidelines requiring selection of k-and c-blood for pmfs, but in the uk d negative blood is required for d negative females aged < years. trend analysis of questionnaire data in the uk, using theoretical clinical scenarios, shows a decrease in the number of laboratories that would select k + blood for a year old female (with pre-existing antibodies other than anti-k), from % ( ), % ( ) to % in . in this survey, k + blood was selected for a female aged (no antibodies) by %, whilst % selected a k + unit for a female aged (no antibodies), despite this patient being treated as a pmf for provision of d negative blood. a similar distinction was made between the and year old females in portugal and mainland europe. conclusions: variation in practice may at least in part be due to the availability of blood routinely labelled for rh and k. in the uk all donations are labelled, except for those from new donors, as are most units in portugal. uk questionnaire data ( ) suggested that > % laboratories would change to selecting k-blood for pmfs if all units were labelled. however, labelling alone does not account for the differences seen within the uk, and perhaps the trend towards providing k-(and to a lesser extent c-) blood for pmfs is influenced by advice from transfusion services. it would be of great interest to monitor and compare the incidence of hdn due to anti-k and anti-c in different countries to measure the outcome of differing practices for provision of blood to pmfs and to thereby inform future policy. there is no ultimate in ex-vivo assay described, which can predict the outcome of plt transfusion in vivo. current in ex-vivo assays and animal studies are rather very complicated to carry out, cost effective and time consuming. objective: we hypothesized that the quantitative measurement of gpib expression by facs can be used to predict the outcome of platelet survival post transfusion. in our previous studies we demonstrated that our phagocytosis assay can predict the plt survival sensitively (blood dec- ) . we isolated human washed plts by centrifugation and labelled with mepacrine and then incubated with pma-matured thp- cells ( °c). binding was measured by facs analysis of cd b/cd positive particles, and phagocytosis by counting mepacrine/cd positive particles. we measured gpib expression before and after plt-macrophages interaction by facs flowcytometry. results: gpib expression at surface of c fresh showed ± and after hours storage ± % expression. the gpib expression at surface of plt decreased and showed three populations with different densities high (gpib- ), low (gpib- ) and in-between (gpib- ). the binding and phagocytosis of plt showed an increase of ± % which implicates an indirect and negative relation to gpib- , and direct relation to gpib- expression. anti-human pselectin (cd p) delayed ± % the binding and annexing v ± % the phagocytosis of stored plts, after -hour storage. these results show that gpib expression is rather easy, reproducible test which can be standardised and be used as a very sensitive in vitroassay to predict platelet survival posttransfusion. transfusion and lung injury jd dodig*, d sovic † , m tomicic † and h sager* *university hospital 'sestre milosrdnice', zagreb, † institute for transfusion med, zagreb, croatia background: the respiratory tree has been viewed as an infrequent site of injury arising as serious complication of transfusion. in recent years, this view has changed as investigators have shown that two complications-circulatory overload and transfusion related acute lung injury-are relatively frequent events. case report: a -year-old men was admitted due to chronic macrohematuria. he had no history or current evidence of cardiac failure. the hb level was measured g/l. he received ml . % nacl and ml ringer solutions. after that, he was transfused with units of rbcs. during transfusion second unit he developed following symptoms: tachycardia, dyspnea, hypertension. massive pulmonary edema was noted. he was treated with mechanical ventilation, oxygen, diuretics, aminophillin, antihistaminic and corticosteroides. the patient recovered after being on ventilation for hours. two days after the patient was operated. after surgery he was transfused with units of rbcs. all transfusions were regularly performed. results: chest x-ray confirmed bilaterally pulmonary edema. the samples (patient and donors of first two units rbcs) tested were negative for the presence of hla specific and granulocyte antibodies. granulocyte agglutination and lymphocytotoxicity test were negative. tnf-a in recipient serum was slightly increased. conclusion: our patient is the first reported case suspected of trali, but all of the investigations didn't give us the answer. against neutrophils using flowcytometric detection of cell surface cd b expression and l-selectin shedding. methods: a hundred microl of volunteers' heparinized whole blood were incubated for minutes at °c with fmlp, lps or pma. monoclonal antibodies against hna a and hla-i, or patient serum were incubated with whole blood for min. surface cd b and l-selectin were detected using facscalibur. results: neutrophil activation was detected after fmlp, lps or pma stimulation. p map kinase inhibitor reduced activation induced by fmlp and lps. anti-hna a monoclonal antibodies induced neutrophil activation, which were also inhibited by p map kinase inhibitor. ten serum samples obtained from patients or donors who caused transfusion reactions were evaluated. five sera out of samples having anti-neutriphil and/or hla antibodies exhibited neutrophil activation, while two samples without leukocyte antibodies had no effect on any activation. conclusion: these findings indicate that neutrophils activation is regulated through mak kinase and detection of neutrophil activation may be useful to predict transfusion-related reactions. results: out of transfusion reactions were febrile, were anaphylactic, were due to circulatory overload, out of transfusion reactions concerned the transfusion of incorrect blood component. out of transfusion reactions concerned acute haemolytic reaction. post transfusion purpura or suspected trali was not seen. fatal complication was not seen. the reactions to plasma were predominately anaphylactic. we detected no case of bacterial contamination among the cultures of transfusion bags. conclusions: the incidence of reactions among patients malignancy was high, while among surgical patients was lower. the incidence of transfusion reactions during the months had no statistically significant difference. we suggest that the improvement in prevention of transfusion reactions require a continual vigilance system for rapid recognition and information regarding these complications. measurements of ige immunoglobulin in thalassemic patients, before and after blood transfusion background: many studies have reported the implications of proinflammatory cytokines including interleukin (il)- beta, il- and tumor necrosis factor alpha (tnf-alpha) in febrile nonhemolytic transfusion reactions. il- has been shown to accumulate in packed rbcs even after the procedure of filtration, which is explained by the release of il- from rbc receptors into the packed rbc super-natant. stress induced elevation in tnf-alpha levels was demonstrated in healthy individuals. aim: to assess the level of proinflammatory cytokines in peripheral blood of blood donors. material and methods: immediately upon blood collection, plasma was separated from postdonation blood samples obtained from blood donors and frozen at - °c. upon thawing, the level of the il- beta, il- and tnf-alpha cytokines was determined in plasma samples by elisa method using commercial kits for cytokine determination (roche molecular biochemicals). the level of il- beta was at the test detection limit in all donor plasma samples. in ( . %) bd, the level of il- was . pg/ml, exceeding the test sensitivity limit of . pg/ml. in ( . %) bd, the level of tnf-alpha was within the range of - pg/ml, with a test sensitivity limit of pg/ml. tnf-alpha levels > pg/ml were measured in plasma samples of ( . %) blood donors. the increased activity of blood donor's immune cells, indicated by elevated levels of the proinflammatory cytokines il- and tnf-alpha in peripheral circulation some blood donors, may lead to the occurrence of febrile nonhemolytic transfusion reactions in the recipients of the blood products manufactured from the blood of these blood donors. this hypothesis will be thoroughly investigated in our future studies. background: transfusion-related acute lung injury (trali) is a life-threatening complication of transfusion, under-recognized and underreported possibly lacking a consensus definition. aim: we report here a 'probable' case of trali syndrome in an elderly female patient. case presentation: an eighty-two year old female patient was transferred to the intensive care unit on the third postoperative day (pod) following the abrupt onset of acute pulmonary insufficiency (pao = mmhg, o saturation = %), hypotension (bp = / mmhg) and fever ( °c). this occurred ten minutes after initiation of an infusion of a unit of packed red blood cells (prc). the patient had no history of any cardiac or pulmonary disease. she was intubated and placed on mechanical respiration and supported hemodynamically. the cvp ( cm h o) ruled out fluid overload. the chest x-ray revealed bilateral pulmonary oedema, the echo cardiogram and blood cultures ruled out cardiac and infectious aetiology of the episode. after treatment for hours the patient improved significantly, was extubated and returned to the surgical unit on the th pod. reviewing the transfusion history we discovered that the patient did not receive any blood or blood component prior or during the correction of her ileum, but she was transfused a unit of ffp (fresh frozen plasma) five hours prior to the incident. the donor review revealed that the unit of ffp was from a -year old female with a history of multiple abortions whereas the prc unit was from a -year old male, a volunteer of several years who had no history of transfusions. there are some prerequisites for the implementation of a haemovigilance network and some of them have been met, so we can present the first results. methods: traceability of blood components is possible because there is unique information system in place in the whole country, identifying the donor, donation, each single blood component and identification of the recipient, but feed back information of the performed transfusion is still missing. cooperation between blood transfusion service and hospitals was established by introduction of hospital transfusion committees; the intensity and quality of their work is very different. homogeneity of reporting is achieved by the introduction of unique reporting form. a reporting route was defined: patients physician sends notification of atr to the local blood transfusion service. atr reporting form is prepared there and sent to the national blood transfusion service, where the data is collected for the centre for haemovigilance, which is going to be established very soon. data analysis will be responsibility of the centre for haemovigilance at the governmental level. type of adverse transfusion reactions and events is defined. education and information was passed to the health personnel by inclusion of haemovigilance in under and postgraduate programmes as well as seminars, scientific meetings and some publications. results: in the years - there were . blood components issued in slovenia and atrs were reported ( in blood components issued), in of them the severity grade was ( in . blood components issued). in the year there were considerable differences between the number of atr reports compared to the number of blood components issued among slovenian hospitals, ranging from in to atr in blood components issued. . % of all atr were not classified. conclusions: although the number of reported atrs was increased by % and % a year in and respectively, it can be assumed that the collected data is not complete. feed back reports, much more information and cooperation is needed, especially in some hospitals, which should contribute to a better registration of atrs and events in the future. the slovenian haemovigilance system still needs upgrading, but despite this, some important work has been done in building a national haemovigilance system. . considering the multiplicity groups in cattle and since there was no research on repeated blood transfusions reactions in iran's native cattle, we decided to consider crossmatching in different processes of repeated blood transfusion from a head of blood donor to five recipients and observe the clinical and hematological alterations. six healthy iran's native cow, . years old, with average weight of kg were used. the animals were dewormed by albendazole ( my/kg bw) and were kept for two weeks under uniform managemental condition. three days prior to blood transfusion, vital signs registration (temperature, heart rate and respiratory rate) blood collection via jugular vein was done to indicate the baseline of research parameters. after that, blood transfusions were performed from one donor cow to five recipients three times at one-week intervals. cross matching was done at each transfusion. after each transfusion the research parameters do determined. results indicated that one of the recipients cows experienced anaphylactic shock, in the first step of blood transfusion and another cows in the second step and finally in the third steps two other cows showed the serious shock. this is in the contrary of this opinion that the first transfusion can be given safely without crossmatching in cattle practice ( van der valt, et al. ( ) background and objectives: blood transfusion may lead to the manifestation of anti-hla and platelet-specific antibodies that may in turn bring about different problems like platelet refractoriness. it appears that the study of antibodies against hla-class i and platelet-specific antigens are useful for the selection and success of the appropriate treatment protocol. the aim of this study was to detect anti-hla and anti-platelet-specific antibodies by flowcytometry in patients with hematologic disorders (including acute leukemia, aplastic anemia) and patients with itp. in this descriptive study, anti-hla and platelet-specific antibodies were detected by flowcytometric technique, using sera drawn from patients with different haematological disorders who showed a poor response to platelet transfusion and from patients with itp. the results of anti-hla antibodies were then compared by panel reactive antibodies (pra). results: our results showed ( . %) out of ( . %) patients had anti-hla class-i antibodies in their sera. the frequency of each antibody isotype was found to be as follows: igm ( . %), igg ( . %) and iga ( . %). ( . %) out of patients had platelet specific antibodies and the frequency of each antibody isotype was found to be as follows: igm ( . %), igg ( . %) and iga ( . %). ( . %) out of patients had both antibodies. no difference was found between the two groups in platelet specific antibodies. despite significant correlation between flowcytometry and pra methods, pra can only detect antibodies which react with complement. conclusions: with increase in the number of platelet transfusion, immunization to hla antigens occurs; moreover, immunization against platelet specific antigens may also occur during autoimmunity. the presence of these antibodies may be one of the reasons of poor response to platelet transfusion and platelet refractoriness in patients under study. conducting similar studies with higher number of samples, platelet cross-match, and the use of hlamatched platelets for these patients are recommended. post transfusion purpura (ptp) is a rare, severe thrombocytopenia that results from alloimunization to platelet specific alloantigens, following blood transfusion. in this condition, the patient's own platelets are destroyed by the alloantibody even though they are not supposed to carry the 'guilty ' antigen. the disease is rare occurring mainly in multiparous women. the majority of reported cases involved antibodies against the platelet specific alloantigen hpa- a in a homozygous hpa- b patient. in a minority of cases the offending antibodies were directed against hpa- b, - a, - b, a, - a, - b. although self-limiting, the syndrome is characterized by severe bleeding with high morbidity and mortality; therefore prompt diagnosis and appropriate therapy is crucially important. ptp is a challenging diagnosis, because the patients are often critically ill or post-surgery, and have alternative explanations for thrombocytopenia such as infections or drugs. we present three patients with severe thrombocytopenia initially misdiagnosed. the first patient, a -year old women, had a past history of systemic lupus erythematosus and coombs positive autoimmune hemolytic anemia. at the present hospitalization, after antibiotic therapy for endocarditis, a severe hemolytic episode occurred and she need blood transfusion. when severe thrombocytopenia appeared, she was wrongly diagnosed as evans syndrome. the second patient, a -year old man, suffered from sepsis after vascular surgery and revealed clinical and laboratory picture of dic. the third patient, a -year old women, had end-stage renal failure and received heparin during hemodialysis, thus heparin-induced thrombocytopenia was first suspected. history of recent blood transfusion rose the suspicion of ptp in all this cases, and appropriate therapy with high dose iv immunoglobulin was started. adequate laboratory work-up confirmed the diagnosis. three different anti hpa-antibodies were identified: anti hpa- a, anti hpa- b and anti hpa- b, respectively. the platelets genotype of the first patient was hpa- b/ b, of the second hpa- a/ a and of the third patient, hpa- a/ a. the reported cases emphasized the importance of keeping in mind the possibility of ptp. incorrect diagnosis may lead to wrong treatment and fatal outcome. health sciences authority, singapore, singapore introduction: the haemovigilance programme in singapore was started by the centre for transfusion medicine (ctm) in . the system covers registration of collected, produced and transfused blood components, and monitors adverse transfusion reactions (atr). the programme runs on a voluntary, non-punitive and confidential basis. aims of the study: ( ) to gather and analyse reports of all adverse and untoward events occurring during transfusion of blood and components. ( ) to use the information acquired to determine the morbidity of transfusion. ( ) to provide guidance on corrective measures to prevent the recurrence of some accidents, and to improve transfusion safety. ( ) to improve public confidence by demonstrating to public, patients and professionals the safety of the existing transfusion system. methods: ( ) a common report form is used and made available to all participating hospitals. within the reporting system, the identification of the patient and staff involved are not required, to ensure confidentiality and protection of information belonging to the hospital. ( ) reportable events include immediate reactions during transfusion (haemolysis, non-haemolytic febrile transfusion reaction, urticaria, anaphylactic shock, bacterial contamination, trali), delayed untoward effects after transfusion (haemolysis, post-transfusion purpura, acute gvhd), transfusion-transmitted infections, incorrect components transfused, and near misses. ( ) within the hospitals, a responsible person ensures that all adverse events and untoward effects of transfusion are reported on the haemovigilance forms and provided to ctm for collation. within the ctm, the haemovigilance coordinator is designated to assist hospitals in investigating serious adverse events and advise on the reporting formats. results: ( ) the total number of reported cases has steadily increased since the introduction of the programme. ( ) the number of participating healthcare institutions has also increased to % (n = ). please refer to table entitled 'summary of the haemovigilance report - ' . ( ) the implementation of the haemovigilance programme in singapore is feasible with respect to the asian setting, and can significantly contribute to blood safety. ( ) there has been very good participation from the participating healthcare institutions, signifying greater awareness and willingness to partake in the programme. ( ) the results obtained from the programme have given rise to initiatives and recommendations aimed at reducing ( %) were rated for seriousness. of these, ( . %) were rated as grade (moderate to serious morbidity) or worse. ( . %) were rated for imputability to the blood transfusion. of these, a relationship to the transfusion was graded as 'certain' or 'probable' in ( . %) and as 'possible' in ( . %). overall relatively few errors were reported in comparison to other systems. a small number of reports concern (possibly) infected blood components, and imputability was deemed probable or certain only in a minority of these reports. autologous blood components gave rise to five reports (errors as well as mild transfusion reactions) which shows a relatively high risk associated with their use ( . per the rate of post transfusion hepatitis (pth) in israel in unknown. this information is important in order to learn about the residual infection risk in blood recipients. aim: to summarize the data on reported cases of pth. methods: suspected cases of pth are reported to mda blood services. the investigation procedure includes follow up testing of implicated donors and retesting of an archive sample of the transfused unit, if available. donors involved in suspected pth-b are tested for hbsag and anti-hbc. anti-hbc+ donors are tested for anti-hbs. hbv-dna testing is done if anti-hbs is less than miu/ml. donors involved in suspected pth-c, are tested for anti-hcv and alt. since hcv-ag or hcv-rna are performed, when appropriate. investigation is considered complete if all the involved donors are retested > months following the implicated unit. results: between between - suspected pth cases were reported: ( %) were pth-b, were pth-c ( %) and in patient both hbv and hcv infections were reported. investigation was completed in / ( %) cases, with % of the involved donors ( / ) being retested > months after the implicated donation. hbsag was not detected in any of the retested donors. anti-hbc was detected in donors involved in pth-b cases of which were also positive for anti-hbs. pcr for the detection of hbv-dna was performed on the 'anti-hbc+ only' donors, and none was found positive. only in / donors suspected to be involved in pt-hcv, anti-hcv antibodies were subsequently detected. this donation was collected and transfused before the introduction of anti-hcv testing in israel, which was implemented in . in another pth-c case, the implicated donor is still negative for anti-hcv, in follow up samples of up to months, but was found positive for hcv-ag and hcv-rna. pth investigation of all the donors involved was completed in % ( / ) of the cases where the patient received up to blood components. conclusion: in the past years an average of cases/year of suspected pth were reported to the israeli national blood services. investigation was completed in % of the reported cases. so far, there was no clear evidence of hbv transmission. in cases (out of . million blood units collected nationwide during - ) hcv seemed to be associated with blood transfusion: one caseprior to the implementation of anti-hcv testing and the otherprior to the implementation of hcv-ag testing in a donor that did not develop anti-hcv antibodies. these findings suggest that other modes of hbv and hcv transmission should be sought in blood recipients in israel. - . , p < . ). the seroprevalence for a-hiv in the bd population was . % (se: . ; ci: . - . ; p < . ) whereas in the a-hbc positive bd was . % (p < . ) and in the a-hbc negative bd was . %. from a-hiv positive donations, were also positive for a-hbc, that means that the sensitivity of the a-hbc in the detection of a donation a-hiv positive was . %. the relative prevalence (percentaje of positive donations for a-hiv in the a-hbc positive population divided the percentage of this marker in the donations a-hbc negative: rp) was . , which indicates that the number of bd a-hiv positive is . times higher in the a-hbc positive that in the a-hbc negative population of bd. as regards a-htlv, the seroprevalence in the bd population was . % (se: . ; ci: . - . , p < . ), in the a-hbc positive bd was . % (p < . ) and in the a-hbc negative bd was . %. from a-htlv positive donations, were also positive for a-hbc, that means that the sensitivity of the a-hbc in the detection of a donation a-htlv positive was . %. the rp for a-hbc as regards a-htlv was . , which indicates that the number of bd a-htlv positive is . times higher in the a-hbc positive that in the a-hbc negative population of bd. our results suggest that, in our bd population the screening with a-hbc would be useful to prevent other infections transmissible by blood transfusion, like retroviruses, because of the high sensitivity and the relative prevalence. . despite the high specificity of currently available elisas, the positive predictive value is lower in blood donors. therefore, immunoblot tests and polymerase chain reaction (pcr) have been adopted for routine testing in elisa +ve blood donors, by our service. . our data show that the real anti-hcv prevalence of our donor population is very low ( . %). . the selection and evaluation of appropriate assays of all donated blood for hcv infection ensure good laboratory practice and accurate post-notification counselling of infected donors. . given that donors who are elisa positive but persistently negative or indeterminate probably do not represent a risk for transmission, their deferral from donation increases the problem of availability of blood supply. . donor re-entry in the pool of donors is an issue for further discussion. . the introduction of nat technology may elicit more accurate responses and improve the screening process. background: the introduction of hcv antibody screening of all donor blood in represented a major step in the prevention of transfusion-associated hcv hepatitis and in identification of infected donors. the study of infected individuals provides a unique opportunity to define behavioral factors associated with infection. evaluating risk factors in hcv infected blood donors is essential for monitoring blood supply safety, donor screening effectiveness and developing appropriate prevention programs objectives: . to recognize the epidemiology of hepatitis c and how it differs geographically; . to investigate the risk factors for presence of anti-hcv antibody in blood donors; . to evaluate the effectiveness of our donor selection program in local level. methods: serological testing for hcv was performed according to standard procedures. initial screening was performed using secondgeneration eia and, after january , using third-generation eia. our study included a confirmation test (riba) a questionnaire was used to collect data concerning demographic, social and sexual behaviors, and number and type of donations of blood donors. the study also included testing of sexual partners and family members. changes in rates of hcv infections were evaluated by comparing yearly prevalence estimates. the overall prevalence of anti-hcv (eia) was . % out of blood donations. the average prevalence of hcv infection by riba was . %, which reaffirms the very low risk of transfusion-transmitted disease. the cumulative number of hcv infected donors was , with cases in males and cases in females. most infections were found among older persons ( % were aged - , and % aged - ). the seropositivity was higher in family/replacement donors ( %) than in volunteers ( %). the annual prevalence decreased throughout years. the relative importance of risk factors for hepatitis c was: transfusion %, hospitalization %, immigrants %, occupational %, sexual transmission %, injection drug use %, household contacts %, other %, tattooing %, unknown %. according to the criteria for blood donation, certain donors should have been excluded in the predonation interview but these donors had denied risky behaviour when questioned. the importance of sexual activity in the transmission of hcv has not been well-established as we tested sexual partners and family members and none of them was found positive. conclusions: our results suggest that major improvement in the safety and quality of our blood supply has been made in our area. introduction: apart from immuno-haematological complications, blood transfusion recipients are exposed to the risk of viral and bacterial contamination of donor blood. the latter infectious risks are generally associated with the number of donations that are needed in the production of blood products: the pooling effect. one measure recently being discussed is the generalisation of the use of trombocytapheresis for the production of trombocyte concentrates. normally, the trombocyte product is a concentration of trombocyte extractions from a pool of buffy coats: pooled platelet concentrates (ppc). in case of trombocytapheresis sufficient trombocytes for one transfusion can be collected from one single donor. aim of the study: in this presentation the effect of using % trombocytapheresis for the production of single donor platelets (sdp) instead of pooled platelet concentrates (ppc) on contamination risks will be assessed. these risks can be divided in ) the risk of bacterial contamination, ) the risk of viral contamination (e.g. hcv, hbv, hiv) resulting from window period donations, and ) the risk of contamination with tse or emerging infections for which no screening test exists. the contamination probability of sdp versus ppc is assessed on the basis of the production characteristics of both products, e.g. the presumption that the contamination risk per trombocyte product will be reduced by a factor equal to the number of pooled donations (five in our case). reduction of the bacterial contamination risk was estimated using the results of the bacterial testing of pooled and apheresis platelet products. as patients are likely to obtain multiple blood products during treatment, the contamination risk reduction through sdp is not only dependent on the reduction of risk in trombocyte products, but also will also dependent on the total number of blood products transfused and their associated contamination risks. the platelet recipient risk reduction was calculated on basis of the distribution of blood products received by the patient population of the university medical center utrecht (umcu) in the year . results: in the attached table the estimated risk reduction through % trombocytapheresis is shown for the general blood recipient patient and for the trombocyte recipient patients only. our analysis indicate that in platelet recipients, general application of sdp instead of ppc will reduce the risk for transfusion acquired tse infections by %, the risk of known viral infections by %, and transfusion acquired bacterial infections by %. the confidence intervals surrounding the results were obtained by bootstrapping. the large confidence intervals surrounding the reduction of bacterial infection risk is caused by the fact that only a limited set of apheresis trombocyte products were tested. conclusion: our analysis indicates that general application of sdp instead of ppc will not reduce the risk of transmitting infections to platelet recipients as linearly ( : ) as expected. whether it is a costeffective precautionary measure will have to be evaluated by a costbenefit analyses consideration clinical benefits and additional costs and risks of apheresis donations. introduction: hepatitis b is serious health problem world wide. its prevention, particularly in the population of blood donors is essential for providing good health care and protection. aim: the aim of this study is to present the distribution of hbsag(+) and hbsag(-) blood donors according to their profession. methods: specially designed questionnaires are used for interviewing the blood donors who has previously given signed consent for participation in this study. results: table shows the distribution of the blood donors in different professions. administrative clerks with ( . %) and the workers with ( . %) registered in the group of hbsag(+) blood donors, as well as workers with ( %) and administrative clerks with ( %) from the hbsag(-) group of blood donors are dominantly more frequent than the other categories of professions. health care professionals, housewives and farmers in both groups of blood donors are least frequent. taking in consideration the distribution of blood donors by the given professions in both groups, for u = and p > . there is no significant difference found. the analysis of the differences among the different frequencies, in distribution of blood donors according the profession, for d = . and p < . shows a significant difference, where the workers with ( . %) are the most dominantly represented. in relation to the issue of whether the type of profession of the blood donors is production or non production the results are presented on table . in the group of hbsag(+) blood donors the number of those who work in production profession- ( . %), is dominant over the number of those that has non-production profession- ( . %). in the group of hbsag(-) blood donors there is no significant difference between the types of professions. conclusion: having in consideration the professions of blood donors in both groups, for c = . and p < . there is a significant difference in the presented distribution. according to our study, which shows the horizontal transmission of hbv infection in the family in which there is an index case, the biggest number of participants in the study is workers, and the least number of participants are the farmers. introduction: blood donors, as part of the healthy population are tested for hbsag with each blood unit they give. therefore, they can be an epidemiological model for exploring the appearance of hbv infection in general population. aim: this study aims to show the distribution of hbv infection in blood donors in relation with their living conditions, space and facilities. the material needed for the study consists of the data obtained from confirmed hbsag(+) blood donors and confirmed hbsag(-) blood donors as control group. results: the table shows almost equal number of hbsag(+) blood donors that live in houses or flats. in the hbsag(-) group ( %) donors that live in a flat dominate compared to ( %) of those that live in a house. having in consideration the presented distribution (table ) for c = . and p < . there is a significant difference, that comes from the bigger number of blood donors ( ) that live in flat. as for the distribution of blood donors according the living space they use by member of the family (table ) , we can show that ( . %) of the hbsag(+) donors have less than m living space, in compared to ( %) from the hbsag(-) group. the bigger number of hbsag(+) blood donors with small living space gives bigger possibility for transmission of hbv infection in the family. the differences in the two groups for donors that have between and m , and between and m of living space per person, obviously are not very big. for u = and p > . there is no significant difference in the number of the donors in the two groups, when the available living space in m is discussed. introduction: when one of the sexual partners has hbv infection the other is also infected in from cases. aim: the aim of this study is to outline that the risk from transmission of hbv infection between sexual partners is smaller if they use condom as protection. methods: two groups of blood donors-hbsag(+) and hbsag(-) have been interviewed whether they are using condoms as protection, or not. results: table shows the distribution of blood donors concerning the use of condoms. table : in the group of hbsag(+) blood donors those who have not used condoms dominate with number of ( . %), in compared to those ( . %) who used condoms. these data are in favor of eventually possible sexual transmission of hbv infection in hbsag(+) blood donors. in the group of hbsag(-) blood donors dominate those who have used condom- ( %), compared to ( %) who have not. the given distribution of blood donors concerning the use of condoms for c = . and p < . , shows significant difference, which is due to the prevailing of the number of blood donors ( ), who have not used condom. of er -concentrates are leukodepleted. the choice of bacteriological control of empty bags for blood, bags with er -concentrates in additive solution, universal and iso group plasma, as well as the systems for taking of blood are taken on free choice. the control of the erytrocyte concentrates is performed on the first day after the preservation and dekanting, and again between the th- st day and th- th day after the preservation. the pulled plasma is controlled on the day of pouring (spreading), and the control of the iso group plasma on the day of deplasming. three months later the iso group and the universal plasma kept on the temperature of - °c is bacteriologically controlled again. bacteriological control is performed with standard procedures in the institute for health protection in stip. the transfusion transmitted infections are potentially dangerous complications of transfusion therapy in immunocompromised patients. the aim of this study was to determine the prevalence of transmissible infections in blood donor population in kashan, iran. a total of consecutive sera were tested for cmv-igm antibody, hbsag, hepatitis b core (hbc) antibody, hepatitis c (hcv) antibody, and hiv antibody with standard methods. of the sera tested, specimens ( . %) were cmv-igm positive. the frequency of seropositive revealed no significant differences between male and female donors. the frequency rates of cmv-igm seropositive tests tend to decline with increasing the age. there was no relation between the frequency rates of cmv-igm seropositive with the educational level, socioeconomic status, marital status, urban dweller and rural resident patients. the prevalence of hbv, hcv, and hiv antibody were . %, . %, and %, respectively. these findings implied important clinical applications because detection of cmv positive sera may reduce the risk for transmission of cmv in blood transfusion and thereby decrease the risk on cmv-induced complications. introduction: the worlds problem, aids, steel can't be said that is a problem in these three centers in r. macedonia, in which blood is collected, controlled, and distributed. found negative and of them were found positive for one of the three viruses (hiv- , hcv, hbv). with the elisa/axsym assay of the blood units which were negative by the procleix ultrio assay were positive for anti-hbcag and negative for anti-hbsag and hbsag. from those blood units units were given for transfusion following our blood centre protocol and the remaining units were discarded. the protocol consists of a good medical history, liver enzymes (ast, alt, ggt). we must take into consideration that from those that were found positive by the procleix ultrio assay was positive for anti-hcv and were positive for anti-hbsag. summary/conclusions: despite the fact of the short period of time we perform this method, the ability of the nat technique for rapid use, reliability and sensitivity in detecting three viruses simultaneously, indicates the need for immediate use in blood donation as a screening method. in spite of the high cost of the method, it is clear that this assay is a valuable tool in our blood centre to provide fast and safer blood. bacterial contamination of blood products is a persistent, but often overlooked, problem in transfusion medicine. in greece it is recommended that platelets (plt) must be used or discarded within five days post-collection. recent reports from europe have advocated the use of bacterial culturing of platelets on day or and, in case of negative result, prolongation of their storage time to days. aim of the study: to assess the prevalence of bacterial contamination of standard platelet units from whole blood, and to provide evidence that with the use of bacterial culturing it is feasible to extend the self life of platelets to days. materials and methods: eligible blood donors were bled according to standard operating procedures used in greece. plt were prepared from whole blood, solely for the purpose of the present study, by the platelet-rich plasma method. plts were stored for up to days at to °c with end-over-end agitation. other plts prepared from blood collected in triple-pack container system also provided with a predonation sampling device were also tested. plts were sampled in the bacteriology laboratory. plts were sampled on day , and . both aerobic and anaerobic culture bottles were inoculated with a -ml platelet sample. culture bottles were incubated at °c in an automated microbe -detection system (bact/alert system) until a positive reaction was detected or for days. all samples that were reactive were confirmed by routine culture. each reactive sample with bacteria growth on the routine culture was sub cultured for identification of the bacteria. results: a total of plt concentrates were cultured and bacterial contamination was assessed in each unit at day , and after collection. on of storage day two out of ( . %) plt units were found to be positive for bacterial growth. cases of unconfirmed positive results were noted at the beginning of the study. out of the other units which were negative on day and continued to be cultured for the next days, the assessment at day found no other positive. after further storage, at day , defined as the end of the prolonged incubation period, out of the plt concentrates ( . %) grew bacteria although testing of the same units on day and gave no signal. from the platelets units that were prepared from blood collected with a predonation sampling device, none of the plt concentrates gave a positive signal although pouches were found to be positive, and subculture showed bacterial growth of coagulase -negative staphylococcus. despite the relative small number of tested platelet concentrate units, our findings discourage specialists in attempting platelet storage time prolongation to days. bacterial contamination testing on day and a storage time of maximum days seems to be still the safest practice. bacterial screening of platelet concentrates using bact background: bacterial screening of blood components is a routine measure in the evaluation of blood product quality. at our institute bacterial screening is performed using bact/alert system. sampling and culturing of blood products is performed according to paul-erlich institute recommendations. methods: quality control data on the bacterial screening of platelet concentrates performed from - were retrospectively analysed. an initially positive (ip) and true positive (cp) rate, organisms isolated and time of detection are presented. results: a total of platelet products were tested during the year period. thirty ( . %) were found initially positive by bact/alert. the cultures screening positive were subjected to bac-terial identification to distinguish false positive from real positive signals. bacterial contamination was confirmed in ( . %) plt concentrates. positive cultures were confirmed and identified in an independent laboratory ( hbsag, anti-core, anti-hbs, anti-hcv, anti-hiv i/ii, anti-htlv i/ii, rpr. these patients were transfused with - units of concentrated red cells, depending on their problem. a total units were delivered from the beginning of their problem until december . the control were done using last generation enzyme-linked immunoassay (dade behring, ortho, biomeurieux), as also using automated enzyme-linked immunoassay (axgym). the same patients were checked by their physicians before the initiation of transfusions for the same diseases. results: we found: patients anti-hbc (+) and anti-hbs (+). patients anti-hbc (-) and Ánti-hbs (-) patients anti-hbc (-) and anti-hbs (+) patient anti-hbc (+) and anti-hbs (-) patient hbsag (+), anti-hbc (+) and anti-hbs (-). all patients were negative for hcv, hiv, htlv, and rpr. the same results were found also from patients' physicians. conclusions: we conclude that the blood supply for blood transfusion-transmitted diseases is % safe in our centre. these results are in accordance with current international literature. this is due to careful selection of blood donors, to high quality of corporation between departments as also to internal and external quality control. all these factors contribute to safety of transfusions, the quality of life of the patients and the protection of patient's environment. neither in the pipetor nor in the extractor runs was found contamination. no false positive were detected and all the positive samples confirmed. (see tables and ) . for hiv and hcv the specificity was . %. the validation criterion were met, so the system was implemented routinely in our laboratory. the purpose of our study was to analyse the applicability of the pall enhanced bacterial detection system (ebds) in the routine of our transfusion unit which is totally focused on apheresis platelet collection. methods: apheresis pcs, obtained by trima (cobe) and amicus (baxter) separators and re-suspended in % plasma and % ssp solution (macopharma), were submitted to microbiologic control using pall ebds system which uses oxygen percentage decrease as a surrogate marker of bacterial growth. the working steps were the following: - hour after donation, about ml of pc were sampled into the ebds collection pouch and then incubated at °c under continuous agitation (incubator helmer ) for hours. after this period, oxygen percentage was measured using an oxygen analyser (pall bdso ). the test is based on the 'pass/fail' principle. in case of 'fail' result the microbiology department has drawn up the procedure to follow in order to confirm the data and to allow the micro-organism to be identified. the incidence of post transfusion hepatitis has been reduced by blood donor screening for hbsag, but the hbv infection is still responsible for a certain cases of post-transfusion hepatitis in world-wide. in this study the hbsag negative blood units were evaluated for anti-hbc and hbv dna by pcr method. an extra sample was collected from hbsag, anti-hcv, anti-hiv and rpr-negative blood donors. all of samples were examined by approved anti-hbc assay. all of anti-hbc positive samples were tested by hbsab assay and evaluated for hbv dna (pcr). the sensitivity of the hbv dna (pcr) assay was estimated geq/ml according to vqc proficiency and run control panels. ( . %) out of samples were positive for anti-hbc. ( . %) out of anti-hbc positive samples were hbsab positive, and ( . %) were hbsab negative. all of samples were assayed for hbv dna (pcr) single and all of them were negative for hbv dna (pcr). further study for evaluation of anti-hbc test as a screening assay for blood unites in high hbv infection prevalence area strongly recommended. early detection of hepatitis b surface antigen: a comparison of ten assays hbsag detection is the corner stone of detection of hepatitis b virus infection in blood donors and patients with hbv infection. one of the most challenges is sensitivity of the technique and kit. in this study ten different assays evaluated by seroconversion and performance panels. some of them can not be used as screening assay due to low sensitivity. the sensitivity of ten hbsag assays from biorad, dade behring, biomeriux, diasorn, radim, diesse, thermo. biokit, gb and shanghai companies were evaluated by two or three seroconversion and two performance panels from boston biomedica ink. seroconversion panel is a series of samples that collected over a period of time from individual developing antibodies due to a primary infection. for evaluation of the assay sensitivity who and other notified body in the world-wide recommended the seroconversion and performance panels. the hbsag assays are two groups. group one with high sensitivity included six assays. they can detect ad and ay subtypes from . ng/ml bbi to . - . ng/ml bbi respectively. low sensitivity group included four assays and they can detect ad and ay subtypes more than . and . ng/ml bbi respectively. for blood safety, the high sensitivity hbsag assays recommended for blood screening and all assays should be evaluated by seroconversion and performance panels. diagnosis of chronic hdv infection is usually by antibody testing and hbv dna detected by pcr method. it is rare to find patients with two replicating hepatotropic viruses and if the accompanying hbv is replicating, prognosis will be very poor. to clarify the correlation between hepatitis delta virus infection and hepatitis b virus dna positivity, sensitive hbv dna (pcr) assay was used. the presence of hbv dna was investigated in patients referred during the aug. to dec. . all of them were hbsag positive. all samples were evaluated for hbv dna (pcr). the sensitivity of the hbv dna (pcr) assay was estimated geq/ml according to vqc proficiency panel and run control. anti-hdv was tested by commercial available enzyme immunosorbent assay. ( . %) were hbv dna positive and ( . %) were negative. ( . %) out of patients had evidence of delta infection and ( . %) samples of hbv dna (pcr) negative patients were positive for delta agent. the serum alanine aminotransferase (alt) levels in out of hbv dna (pcr) and anti-hdv positive patients were higher than reference interval, but only in out of hbv dna (pcr) negative and anti-hdv positive samples were higher than reference interval. the present data indicate that . % of patients with chronic hepatitis b have hepatitisdelta infection. patients with hbv dna (pcr) negativity had a significantly higher prevalence of delta marker ( . %) than those with hbv dna (pcr) positivity ( . %). delta rna testing in positive hbv dna and anti-hdv patients is recommended. introduction: reduction of the window period of hepatitis c virus (hcv) infection represents an important goal in the transfusional and diagnostic setting and nucleic acid technology-based tests have been introduced in some developed countries to reduce the potential risk of transfusion-associated infection. a prototype assay designed to simultaneously detect circulating hcv antigen and anti-hcv has been developed by biorad (biorad laboratories limited, marnes la coquette, france). aim of the present study: to define the cut-off (co) value of the assay and to evaluate the specificity and sensitivity of this new assay in the detection both of antibody and antigen comparing its efficacy with commercial assays. methods: in order to establish the co value and to evaluate the specificity of the assay, we tested sera samples from the general population and 'difficult' sera from haemodialysis patients (n conclusion: the new assay shows high sensitivity and specificity and could be a useful tool not only in the diagnostic setting, where procedures to reduce the window period, such as antigen or hcv-rna detection, are not currently recommended, but also in the screening of blood donations, when nucleic acid technologies is not feasible due to costs, organization, emergency and/or logistic difficulties. introduction: in recent years the concern with the blood safety regarding the transmission of blood-borne viruses has been improved. this safety has been achieved with the combining of different strategies, such as a careful selection of donors, the screening for relevant virological markers and the viral inactivation/ removal methods. more recently, the implementation of the nucleic acid amplification technologies for the detection of hiv- , hcv and hbv, has increase this aim by reducing the 'window period' of the infections. other viruses, such as parvovirus b (pb ) and hepatitis a virus (hav), can raise problems to the blood safety. these infections could provoke serious complications in some risk groups, like pregnant women, patients with haematological problems, children and patients with immunodeficiency. material and methods: an observational study was performed to determine the prevalence of pb and hav in portuguese blood donors. we gather, during four months, plasma donations and joined them into pools, with no more than donations each. [ ] [ ] [ ] [ ] [ ] in voluntary donors the anti-hcv prevalence ranged from . % to . %, in family replacement donors from . % to . %, autologous donors from % to . %. we observed that the anti-hcv prevalence has a decline tendency during years in blood donors. according to sex the anti-hcv prevalence in men is . % and women . % (p = . ). over the year periods the prevalence in men has a decline tendency ( . % to . %; p = . ) and increasing tendency in women ( . % to . %; p = . ). according to age group the anti-hcv is . % in - age group, . % in - age group, . % in - age group, . % in - age group (p = . ). the prevalence of anti-hcv is higher in fds than vds, but not statistical significant. [ ] [ ] [ ] [ ] [ ] . a total ftd and ad have been tested for hbsag. a sample was considered as hbsag positive when found repeatedly reactive by rd generation. immunoassay method (elisa). the chi-square test was used for statistical analysis. results: the -year overall hbsag prevalence among first time blood donors was . %. and ad . %. among autologous blood donors was observed a decreasing hbv prevalence from . % to . % in . according to age the prevalence was higher in - year group . %, while according to sex was higher in man ( . %) than female . % (p < . ). among ad, a decreased hbsag prevalence according to age was observed in men and women. the same trends by sex and age were observed in ftd. the prevalence of hbsag in ad was lower than in ftd. however, from - hbsag prevalence has decreased in the same proportion in both population. this decreased can explain by to main factor: the improvement hbsag screening method in blood donors and decreased the hbsag prevalence in general population. ( : ) . the hbv dna-emia in hbsag negative samples was . ¥ - . ¥ copies/ml. in two donors anti-hbc total was positive and in one anti-hbe was also detected. in one donor the glycin alanin mutation in the s region was identified. the frequency of hbv dna pos/hbsag neg donors in poland is high ( . %) therefore the decision to introduce routine hbv nat screening is justified. ( / ) with stored apheresis and whole blood derived platelet concentrates. of these failed results there were confirmed positives (presence of bacteria in both the ebds pouch and the platelet mother bag by culture) representing / . the bacteria detected were staphylococcus or streptococcus sp. of the fail results were false positives (no presence of bacteria in the ebds pouch and the platelet mother bag by culture) representing . % or / , and were not confirmed initial positives (no bacteria in the mother bag by culture, ebds pouch not tested) representing / . there was one reported case of a missed detection with confirmed presence of bacteria (staphylococcus epidermidis) in the mother bag by culture. subsequently, the bacteria strain was isolated and inoculated into platelet units in our laboratory at levels as low as cfu/ml. in all cases the pall ebds was able to detect. this supports the hypothesis that this missed detection was the result of a statistical sampling error rather than a system failure. the results from blood centers routinely using pall ebds demonstrated effective detection of bacteria in platelet products stored under routine conditions with a true positive rate of / , and with a low false positive rate (< . %). this is comparable to a recent survey result with other culture based systems. summary/conclusions: the minority group of pregnant women who come to labor without prenatal testing of hepatitis b and c revealed essentially similar prevalence of anti-hcv with healthy bd even if definitive confirmation is probably increased in this minority group. there is however markedly higher prevalence of hbv infection in the pw so that screening for hbv is essential for the prevention of vertical transmission. the systematic screening of bd with anti-hbc serves as further assurance for the prevention posttransfusion hepatitis eliminating only . % of the possibly infectious, a percentage which can be restored to the blood pool after proving their immunity. methods: blood samples were screened for the presence of hbsag, hcv and hiv antibodies using enzyme immune assay and for syphilis using the tpha test. the results were analysed retrospectively. all samples with results at or above the minimum positive value were considered reactive. the tests for hbsag, anti-hiv and anti-hcv were repeated in duplicate in all reactive donations. blood units that were reactive in the primary or secondary assays were discarded. hiv positivity was confirmed by western blot analysis using hiv blot . (genelab diagnostics) results: results from a total of screened donors were analysed. hepatitis b surface antigen rates was . %; anti-hcv seropositivity was . %; anti-hiv seropositivity was . % and tpha seropositivity was . %. one study calculated this risk to be one in for hbv, one in for hiv and one in for hcv. it is therefore important to take a careful history from blood donors to eliminate those at high risk of infection. in view of the high infectivity of hiv positive blood, it is important not only to screen donated blood but also to exclude donations from high-risk individuals, such as males who have engaged in homosexual activity and intravenous drug users. a careful history should identify those who should not give blood. in turkey, among blood donors the average hbsag prevalence in - was . %. but it had decreased to approximately . % in . anti-hcv positivity has been reported to be . % between and . but it was approximately . % in . rpr positivity in blood donors in turkey was reported to be < . % in and . % in . in , the rpr rates was . %. in our study these rates are . %, . %, . % and . % respectively. anti-hiv seropositivity was found around . introduction: the serological detection of specific antibodies to treponema pallidum (tp) is an effective means of diagnosing syphilis, and an automated chemiluminescent assay is ideally suited to testing large numbers of specimens for the laboratory diagnosis of the disease. aims of the study: to develop a qualitative syphilis assay for the detection of tp immunoglobulin m (igm) and g (igg) antibodies. the assay will be used for the serological diagnosis of syphilis using the architect platform, which has the capacity to test specimens/hour. the two-step assay is based on paramagnetic microparticle chemiluminescent technology, utilising microparticles coated with three recombinant tp antigens (tpn , tpn and tpn ) and acridinium labelled anti-human igg and igm monoclonal antibodies as conjugates. in the first step, specimens, microparticles and diluent are incubated together, prior to a wash step; in the second step, acridinium labelled antibodies are added and after washing, pre-trigger and trigger are added to produce chemiluminescence, which is measured as relative light units (rlu). specimens yielding rlus less than the cut-off are considered negative, while those yielding rlus greater than the cut-off are considered positive. the sensitivity of architect syphilis tp was determined to be %, after testing specimens that were previously screened as syphilis positive in fujirebio tppa; no prozoning was observed with high positive specimens (over titer by tppa). the specificity generated from testing hospitalised patients previously screened as tppa negative, was . %. testing a mixture of sera and plasma from random donor specimens, generated donor specificity figures of . %. the precision (cv%) with a positive control was . % ( % confidence interval: . - . %) by the standard -day nccls analysis (ep a ). in a study conducted at asahikawa medical college hospital, in which, positive and negative specimens were tested, concordance with fujirebio tppa was determined to be %. no significant interference to the assay was observed from bilirubin (conjugated type and free type), haemoglobin or lipid. the architect syphilis tp assay is an automated, specific and sensitive test for the detection of antibodies to t. pallidum. background: hcv exposure of blood donors is serologically determined by the detection of anti-hcv antibodies in serum or plasma. however a 'window' period of - days after exposure exists during which specific antibodies to hcv antigens cannot be detected. hcv rna detection and/or hcv core protein testing result in dramatic reductions in the preseroconversion window period. the new bio-rad test, based on the simultaneous detection of hcv core antigen and anti-hcv (core, ns , ns ) antibodies, improves the detection of hcv infection in the early phase. aims: the aim of this study is to assess the performance characteristics of this new screening microplate immunoassay, monolisa hcv ag-ab ultra, by using the bio-rad evolis automated microplate processor system. methods: this two-step elisa assay is based on the combination of an indirect test for the detection of antibodies (core, ns , ns ) and a sandwich test for core antigen detection. results are available within . hours, with sample addition monitoring and color coded reagents. no specimen pretreatment is required. evolis is a self-contained microplate processor designed for full automation of microplate-based eia techniques. the walkaway system can process four microplates at a time with continuous loading of samples and reagents. positive identification of samples, reagents and microplates, usage of disposable tips with clot detection, integrated quality control and complete traceability provide a high level of safety management. the monolisa hcv ag-ab ultra/evolis system performance is evaluated for clinical sensitivity on commercially available and well-documented seroconversion panels. the results are compared to viral rna detection and conventional hcv ab screening assays. specificity is evaluated by using random blood donor samples. results: among the seroconversion panels that begining with samples negative for hcv rna and anti-hcv antibodies, the monolisa hcv ag-ab ultra assay detects exposure to hcv an average of days earlier than the monolisa hcv plus v test. the mean delay of the monolisa hcv ag-ab assay in detecting hcv infection compared to hcv rna testing is around . days. the monolisa hcv ag-ab ultra/evolis system allows simultaneous detection of hcv core antigen and anti-hcv (core, ns , ns ) antibodies, thus significantly reducing the time gap between the initial detection of hcv rna and the first appearance of detectable anti-hcv antibodies. the fully automated system combines high degree of assay performance with optimization of laboratory workflow and safety management. operational evaluation of pall ebds bacterial detection system l larrea gonzalez, ma soler and rj roig centro de transfusion, valencia, spain introduction: regulatory bodies are increasingly mandating the use of bacterial detection systems for platelet products ( ed standards for blood banks and transfusion services). one system currently available is the pall ebds bacterial detection system which utilises percentage oxygen as a surrogate marker for bacterial growth. aims: to evaluate the pall ebds in routine use in our blood centre. in particular, to assess feasibility and adaptability to daily labour routines. the orbisac (gambro bct) system was used to produce leucocyte depleted buffy coat (bc) platelet pools ( bc/pool) stored in platelet additive solution (ssp macopharma). mean platelet count was . ¥ e /pool with mean leucocyte count . ¥ e /pool. ebds installation and training occurred over a day period. platelet pools were tested for bacterial contamination over the subsequent weeks. ebds pouches were sterile connected onto platelet pools hours after blood donation. platelet samples were taken into the pouches and then the pouches were incubated for hours on a shaking agitator at °c. after this time, percentage oxygen was measured. no positive results were found in this study. this was as expected due to the relatively low number of platelet pools tested and it also highlights the absence of false positive results. minimal training was required to use the ebds. the system was easy to use and did not require the use of a laminar flow cabinet to take samples. it was quick and simple to take samples and perform oxygen measurement. after pouch incubation, technician was able to make oxygen measurements in less than minutes. the data management system allowed full traceability of product and work flow. results were very easy to interpret. conclusion: the pall ebds was found to adapt perfectly to a routine blood centre environment. ( ) was . the percentage collected from volunteer blood donors was % (n = ) and the rest % (n = ) was given from patient-related donors. the age of donors ranged from to years old. the assay used for the detection of hbsag, hbeag, anti-hbc igg/total, anti-hbc igm, anti-hbe and anti-hbs was the automated microparticle enzyme immunoassay (axsym) of the abbot company. all the units were tested for hbsag, and anti-hbc igg. if the anti-hbc igg was detected, the specimens were automatically tested for anti-hbs. the units were wasted if the anti-hbs was negative, and the specimens were manually programmed for the testing of the anti-hbc igm, hbeag, and anti-hbe. from the total of tested units, of them were found to be positive to at least one marker of hbv infection, that means the . % of the health adult population was infected in the past by the hbv. the . % (n = ) was previously infected and now immunized with hbsag(-) and anti-core igg(+) and . % (n = ) were chronic carriers of the hbv with hbsag(+). the . % (n = ) of the positive donors were patient related donors and . % (n = ) were volunteer donors. in other words, of the not volunteers ( . %) and of the volunteers ( . %) were detected to be infectious. the combinations of the serologic markers for hbv are illustrated in the table attached. these results indicate that the incidence of hbv infection in the northeastern department of greece is equivalent to the incidence of hbv in other greek regions ( . %) as it is referred to the national haemovigilance data and moreover, the percentage of infectious donors is bigger among replacement donors, . % compared with the . % of voluntary donors. as a consequence, the best source for safe blood collection is the population of volunteers. earlier detection of human immunodeficiency type , hepatitis c and hepatitis b viruses using the procleix® ultrio tm assay on the procleix® system and the study objective was to assess the ability of the ultrio assay and associated discriminatory assays to reduce the detection windows for hiv- , hcv, and hbv. commercially available seroconversion panels were used for testing. methods: hiv- (n = ), hcv (n = ), and hbv (n = ) seroconversion panels were tested neat and diluted ( : and : ) in the ultrio assay. panels were tested neat in the appropriate discriminatory assay. times to detection of hiv- , hcv, and hbv nucleic acids in seroconversion panels were compared to the vendor's historical data on time to detection of antibody and/or antigen using licensed or validated serologic tests. p- effectiveness and limitations of methods for platelet bacteria screening -how to apply which screening method? the successful concept of virus safety in transfusion medicine is not suitable in bacterial contamination. bacteria can grow up in blood components to enormous amounts, whereas the initial number of contaminating bacteria is typically very low. therefore, sample drawing for bacteria screening must not be done immediately after blood donation. the established concept of relevance of clinical microbiology (pathogenic, non-pathogenic, facultative pathogenic species) is not valid for bacteria contaminating blood. here, the currently discussed criterion of clinical relevance is the ability of bacteria strains (not species!) to grow up in blood components. the paul ehrlich institute (pei) developed pei bacteria standards, which are characterized concerning their behavior in blood components. they contain a defined number of living bacteria, they are deep frozen, ready to use and shippable. there are two strategies to improve bacteria safety of blood: screening and pathogen reduction. neither of them is perfect, but screening methods are successfully established since several years in routine (belgium, the netherlands), and represent the current state of the art. further development and collecting of experience will produce the basis for assessments in the future. it is of high importance to apply the screening methods in dependence on their properties. methods implying an incubation/cultivation step ('early methods') have to be distinguished carefully from 'rapid methods' . for example, it is unreasonable to compare (or to advertise with) different sensitivities of methods not considering their detection principle or their informative value. both principles, cultivation methods as well as rapid methods, show advantages and disadvantages. selection of the method has to consider the respective conditions of the given blood service (including logistics up to time frame between issue and transfusion). results from the procleix hiv- /hcv and hiv- /hcv/hbv (procleix ultrio) assays for the detection of hiv- rna, hcv rna and hbv dna in blood donors of two blood transfusion centers of sw greece in discriminatory assay testing, out of ( % of the positive, . % of total) were reactive for hcv rna only and out of ( % of the positive, . % of total) were reactive for hiv- rna only. none were positive for both hiv- and hcv. the standard serological assays gave the same results for the above positive samples. two samples that tested positive by the standard serological assays tested negative in the procleix hiv- /hcv assay. of the samples tested by the ultrio assay, ( . %) tested reactive for hiv- /hcv/hbv. in discriminatory assay testing, out of ( . % of the positive, . % of total) was reactive for hiv- rna, out of ( % of the positive, . % of total) were reactive for hcv rna, and out of ( . % of the positive, . % of the total) were reactive for hbv dna. all were single positive i.e. none tested positive for more than virus. three out of positive samples for hbv dna tested negative by the standard serological tests. the opposite was not observed. the procleix ultrio assay is a definite improvement over the procleix assay in a region with a high incidence of hbv carriers. up until its use, it is obvious that hbv positive blood with very low antibody titers was transfused into patients. more results will show whether procleix ultrio can eventually replace the standard serological tests. the introduction: patients with hemophilia represent a high-risk group for post-transfusion hepatitis whose frequency is closely linked with the number and quantity of blood products used. in albania, the frequency of hepatitis is also linked with hbsag testing with elisa (introduced in ), and hcv testing (introduced in ). aim of the study: evaluation of the prevalence of the markers of hepatitis b, c, and d in patients with hemophilia. methods: our study included patients with hemophilia treated with cryoprecipitate and commercial clotting factors. blood testing for anti-hcv, anti-hdv, and hbsag was performed with elisa -gen. iii. results: of patients tested, cases ( %) were hbsag positive, cases ( %) were anti-hcv positive, and cases ( %) were anti-hdv positive. co-infection of hbsag and hcv was found in cases ( %), whereas co-infection of hcv, hdv, and hbv was found in persons ( %). the highest rates of infections and coinfections were found in patients above years of age. conclusion: mandatory blood testing has decreased the levels of post-transfusion hepatitis. in albania, hemophilia is also still treated with cryo-precipitation, thus patients are at a particularly high risk during the 'window period' . results: / ( . %) samples from rbd were anti hiv + nonreactive and rr for p ag both being nonreactive in the neutralization test, they were interpreted as false positives. / ( . %) sample from fbd was rr for p ag/anti hiv + nonreactive and it was confirmed positive by neutralization. this bd had been autoexcluded himself after blood donation. he showed seroconvertion days later: p ag nonreactive, anti hiv + reactive and western blot positive. the only bd p ag positive/anti hiv + nonreactive during the analized period, was an first time donor and the post donation autoexclusion was effective en this case. although a larger populations of bd is necessary to be studied and in spite of the low prevalence we have found, we consider p ag screening is an alternative up to implementation of nucleic acid testing and simultaneously we should increase the quantity of altruist repeat blood donors, undoubtedly, the best population to give blood. owing to the rather short interval between successive donations (~ days), this suggests that some - infectious units escape the screening annually. to these, one has to add the (now unknown) proportion of potentially hbsag negative + hbv dna positive ftbds. hcv: since the introduction of the screening in , the general incidence in rbd has dropped from . ‰ to . ‰, suggestive of a : escape rate. the prevalence in ftbd has stabilized at ± ‰. based on reasons similar to these employed for hbv, the residual incidence in rbd suggests that potentially infectious donation in rbd escapes the screening (= to a total of aprox. , annually). a limited investigation using hcv-antigen eia evidenced a ‰ escape rate in ftbds (= to a total of aprox. , annually table and are concerned to the fist two months of the implementation, where we had to adjust the volume of the eluate. conclusion: these system adjusts to the laboratory daily routine in the blood bank, with the pools released after first analysis in less than hours. background: the hbsag, anti-hcv, anti-hiv / , p antigen, alt and syphilis tests are performed for blood donations in czech republic. no nat tests are mandatory in czech republic. the aim of this pilot study was: . hcv rna pcr testing in anti-hcv negative blood donations; . correlation between hcv nat and anti-hcv testing results. methods: blood samples (anti-hcv serologically negative, alt not elevated) were pooled using the guardian plus spii into pools of samples. pools of ml were tested using the cobas ampliscreen hcv test v. . (roche). results: pools of samples from a-hcv serologically negative donations were tested from october to july . no one pool was initially reactive. invalid tests: ( . %) run failures were observed, due to: invalid internal controls ( . %) and invalid positive controls ( . %). invalid tests were repeated. in none of pools a positive hcv nat result was observed. conclusions: no discrepancy between hcv nat and a-hcv results was observed in our study. all of the nat tested donors in our study were regular voluntary whole blood or plasma donors who were repeatedly a-hcv serologically negative. the hcv incidence in the czech republic blood donor population is low but it is slightly growing up in general population. hcv nat testing could improve the safety of blood supply by reducing the window period for hcv. introduction: parvovirus b is the only parvovirus known to be a human pathogen. most commonly, it causes a mild childhood rash, erythema infectiosum, but in some cases more serious symptoms can be linked to b , such as acute or persistent arthropathies, critical failures of red cell production, hydrops fetalis, fetal loss, myocarditis or hepatitis. inactivation of the non-enveloped virus has proven difficult. as a consequence, manufacturers of blood products have implemented screening measures to reduce the load of parvovirus b in manufacturing plasma pools by the use of nucleic acid amplification techniques (nat). in our institute all blood donations were screened for human parvovirus b by nat since april . methods: over the last years . million donations were screened for b by nat. samples with a virus load over iu/ml were defined as positive, whereas samples with a virus load between the detection limit ( iu/ml) and iu/ml were defined as weak positive. weak positive products were released, whereas positive products were discarded. in addition infection markers of b positive donors (case group) were determined over a time period of one year. virus load and b antibody status was compared with b negative donors (randomised control group). b antibodies (igg vp , igm vp , ns ) were analysed by two commercial antibody tests. results: overall b nat-positive donors were identified with a virus load over iu/ml out of . million tested. there was a seasonal accumulation during spring and summer, whereas a large epidemic occurred throughout the last year. vp igg was detected in . % and % of the case and control group, respectively (p = . ). these data demonstrated statistically significance (p = . ). all donor samples which were b nat positive for more than three months developed neutralizing vp antibodies. in contrast, ns antibodies were observed in % of the case group and in % of the control group (p < . ). ns antibodies were detected more frequently in samples, which were b nat positive for more than six months. conclusion: b nat could be implemented in blood donor screening as release criterion without causing a shortage in blood supply. all b positive donors of the case group developed neutralizing antibodies within three months and virus load was dropped rapidly below iu/ml. these data support our testing algorithm all components of high positive donations (virus load over iu/ml) were discarded. donors with ns antibodies showed more often signs of a chronic disease with detectable levels of parvovirus b longer than six months. background: on recent years, the syphilis screening of blood donors has become increasingly important not only because of the transmission risk of this infection but also due to the risk behavior that this implies. on account of the importance of this screening the tests used are becoming more and more sensitive. aims: to evaluate an elisa screening test (the tmpa test recombinant is based on the sandwich principle, an immunoenzymatic technology in solid phase, for the measure of anti-treponema pallidum in serum or plasma). methods: in this study samples from blood donors were tested by the rotine 'cardiolipidic reagent for syphilis screening on microplates' -diagast laboratories as well as with 'hdtmpa recombinant' -hoslab diagnostics. positive samples were then confirmed with fta abs/tpha. results: using the mentioned tests we obtained the following results: . ( . %)cases turned out negative with both technologies; . ( . %) cases were positive in both methods; . cases were positive only using tmpa recombinant [of which ( . %) were confirmed positive by tpha/fta abs. as seen we found samples ( . %) that were only positives by tmpa recombinant test and that were confirmed by tpha/fta abs. we concluded that tmpa recombinant seems to be a suitable test for a quick and automated syphilis screening of blood donors and provides maximum safety for the recipients. background: in recent years, there has been substantial evidence indicating that typing and subtyping for hcv is clinically important in understanding hcv disease and its therapeutycal options. 'naive' viral load also seems to influence disease severity and responsiveness to therapy. therefore, viremia and genotype identification have been done routinely in molecular biology laboratory units. aims: the university hospital of coimbra studies and tests his own patients and patients from other hospitals in the central portugal. we also collect and test blood donor candidates from this region. we proposed to analyse the distribution of hcv genotypes in this region, among patients with cronic hcv infection. we have simultaneously analysed the viremia and correlated it with age and severity of liver disease. methods: nucleic acid extraction was done using the semiautomatic 'xstractor' from biomerieux laboratories (boom method). the genotyping used reverse hybridization and was performed using probes from the ¢ non-coding region (innulipa introduction: bacterial contamination of blood products remains a persistent problem. various techniques for the detection of bacteria in blood products exist but none of them has been widely accepted. bacterial detection systems could be divided into culture systems and rapid technologies. hemosystem has developed a rapid and sensitive technology for bacteria detection named scansystem tm . bacterial contamination of platelet concentrates is a rare event with an incidence between : to : per donation. therefore hemosystem developed a positive control in order to validate the scansystem tm platelet kit before use. aim of the study: the current study was designed to evaluate the performance of the scansystem tm positive control. the scansystem tm positive control is a capsule containing lyophilised lactobacillus casei subsp rhamnosus. the bacteria concentration per capsule is at least ¥ cfu. the positive control has to be stored at room temperature and is stable for years. after dilution in pbs, the preparation has to be used within hour. two capsules were tested for ten consecutive days with scansystem tm platelet kit as well as with optimised scansystem tm platelet kit. in an independent experiment three capsules were diluted in platelets stored in additive solution and were tested each with scansystem tm platelet kit and optimised scansystem tm platelet kit. results: microscopic fields were analysed for bacteria specific fluorescence for each sample. the ratio between bacteria specific fluorescence signals and analysed signals was . in all samples for both scansystem tm platelet kit and optimized scansystem tm platelet kit. therefore by definition all tested capsules were positive. the lyophilized positive control capsules enable the user to validate the scansystem tm platelet kit before use. because bacterial contamination of platelet products occurs rarely, the routine use of positive controls improves safety of the screening method. scansystem tm is currently the only method that provides this safety measure. introduction: whereas implementation of nat for blood donor screening reduced the risk for transfusion transmitted hiv and hcv infections currently below one per million transfusions, the risk for bacterial infections is estimated to be : to : . especially platelet products, which are stored at room temperature, are prone to bacterial contamination. aim of the study: several methods are currently developed to prevent the transfusion of bacterial contaminated platelet concentrates. the study investigates a new rapid bacterial detection method. material/methods: pool platelet concentrates were spiked with seven transfusion relevant bacteria strains under sterile conditions at concentrations of cfu/ml to cfu/ml. bacterial concentration was verified on blood agar plates immediately after spiking. five millilitres of spiked platelet concentrates were centrifuged, stained with thiazole orange dye and analysed directly by facs within five minutes after staining. aliquots of pool platelets spiked with concentration of cfu/ml and cfu/ml of each bacteria strain were incubated for two to eight hours in special bouillon at °c and were analysed by facs immediately after incubation. results: sensitivity of facs analysis differed between cfu/ml for e. coli and cfu/ml for klebsiella pneumoniae without preincubation and was enhanced to cfu/ml when a pre-incubation step of two to four hours was included. conclusion: bacteria detection by facs analysis combined with a short pre-incubation ( - h) at °c is a quick and simple method with sensitivity comparable to other commercially available detection systems. the advantage of this new method is the rapid analysis, easy handling, high sensitivity and less expensive price. introduction: detection of bacterial contamination of platelet concentrates represents a major challenge in transfusion medicine. for blood transfusion services the method must have a high sensitivity, an easy performance and a low price. aim of the study: in this spiking study we evaluated the new optimised scansystem tm platelet kit detection method for use in apheresis platelets. methods: apheresis platelet concentrates (apcs) were spiked with strains of ten different bacteria species. after different incubation periods, apcs spiked with cfu/ml were analysed by the optimised scansystem tm platelet kit. the number of bacteria was monitored by plating on blood agar. results: all bacteria strains were detected with the optimised scansystem tm platelet kit when the sample was collected h after spiking. identity of the spiked bacteria was confirmed by gram staining and dna fingerprints. conclusion: in summary, the optimised scansystem tm platelet kit was able to reliably detect ten transfusion relevant bacteria species in apheresis platelet concentrates within minutes when the sample was taken hours after spiking. background: since year our laboratory started routine screening of hcv-rna in plasma minipools for all plasma intended for fractionation. although nat testing is not yet mandatory all blood products are released depending upon nat results. aim: to test and compare two different methods of rna extraction in order to make all the necessary adjustments to the test procedures while preserving the availability of blood products. methods: plasma minipools of donations are prepared either on a tecan genesis robot or on a hamilton at plus. hcv-rna is isolated from ml plasma by using either the qiagen biorobot and qiamp virus biorobot kit or the manual extraction with cobas ampliscreen hcv pcr kit v . . results: between march and december a total of seronegative donations ( pools) were tested for the presence of hcv-rna. four pools were found to be positive for hcv-rna. of the four nat-positive pools with no eia-positive donor, four were confirmed as true positive by donor follow-up testing and/or testing of an independent sample from the index donation. all the positive donations were detected independently of the extraction method used (manual or automated). our experience shows that although the automated extraction method is 'off label' and it has to be validated, the use of biorobot does not pose a detectable contamination risk and it is possible to achieve a detection level for hcv less than iu/ml. the advantage of the manual method is that it has better recovery of nucleic acids than the qiagen extraction. concerning the time needed for the extraction process the automated method runs samples in hours where the manual method needs hours for samples, needing, prior to extraction, an extra centrifugation step for one hour. the automated extraction method results in an assay with a high sample throughput, fast time, sufficiently sensitive, that can be successfully introduced into routine use in laboratories which have more than samples/day while preserving the availability of blood products. anti-hcv similarly was high till ( . - . %), but in trend to decrease afterwards ( . %). anti-hiv reflected the low endemicity of the disease in public setting and was % through the mentioned years. rpr test for syphilis was around . %. directed donors were % of all and volunteer donors consisted nearly %. donors in our blood center are being informed about donation prior to giving their blood and donor questionnaire forms (dqf) are filled out by the donor candidates. using dqfs have been mandatory at all blood banks in turkey by law since . from that time infectious disease marker rates were dramatically reduced at all centers. donor information about the risks of transfusion and the importance of safe blood supply were detailed by the donation staff and physicians, consequently self-exclusion by the donor candidates who have risky behaviors was encouraged at our center. the interviewing staff was trained specifically for this topic. this steps were particularly emphasized in the last three years and the infectious screening results were displayed the outcome of this efforts. conclusion: education of the prospective donors, and recruit the voluntary, non-remunerated and regular donors will be the utmost goal of all blood banks. rigorous donor selection will contribute this ultimate success. we should spend more efforts to maximize enrolling voluntary donors to lower the serological marker results, consequently achieve safe blood. background: human t cell lymphotropic virus type i is endemic in japan, the caribbean, southeastern united states and parts of south america and africa. in non-endemic areas such as europe, htlv-i is less common and most infections are identified in immigrants. the epidemiology of htlv-ii is different, being predominantly found among indigenous american-indian populations and among ivdus, but the routes of transmission are the same. aim: our study's aim was to ascertain the prevalence of htlv i/ii in blood donors in order to understand the epidemiology of htlv in greece and initiate discussions of an acceptable level of risk and appropriate level of screening for rare transfusion-transmitted diseases. overall, anti-htlv seroprevalence levels among blood donors, are low. although the number of annual donations in this study is relatively small, the data for htlv indicate that rates of this infection are low and that infected donors will be seen infrequently. as all blood donations are screened for htlv i/ii during the last six years, a national survey is necessary in order to define the epidemiology of htlv in greece. introduction: toxoplasma gondii is the causative organism of toxoplasmosis. the disease transmitted by ingestion of either oocysts (in the feces of cats) or bradyzoites (in raw or undercooked meat). the parasite can also be acquired transplacentally by organ transplantation or from blood transfusion. the purpose of this study was survey of toxoplasma antibodies in some iranian blood donors at tehran blood center. blood samples were randomly collected for detecting of igg and igm antibodies (by elisa technique).the total numbers of donors was of (% ) were female and (% ) male in age ranged from to years. results: sera tested, ( %) were found to be positive for toxoplasma igg antibodies and ( . %) were igm antibodies positive and of them ( . %) were borderline for igm antibodies. among males the frequency of positivity was higher than woman but this different was not significant. the most frequency of seropositivity was found in age group to years. conclusions: diagnosis of toxoplasmosis can be aided by serologic or histocytologic examination. the acute infection in healthy individuals is generally asymptomatic and not associated with any morbidity but in an immunocompromised host, toxoplasmosis be a very serious disease, and this can occur if a person is infection with toxoplasmosis before or after his/her immunosystem is compromised. in spite of the progress in the development of diagnostic, therapeutic and prophylactic methods, virus hepatitis still presents a serious global health problem. the possibility of transmission of these infections through transfusion of blood and blood derivates implies obligatory control of the donated blood. post-transfusion hepatitis is an important health problem in everyday practice, especially in patients who have to receive transfusion of erythrocyte concentrates as the only possible treatment for many years. objective: to show the prevalence of hepatitis b (hbsag) and hepatitis c (anti hcv antibodies) in multitransfused thalassemic patients. in our region there are patients suffering from thalassemia major who are aged between and , and who have been receiving erythrocytic transfusion - times a month since the age of one or two. they receive washed red blood cells, and in certain periods filtered red blood cells, controlled for viral markers and they mostly receive blood from voluntary, periodic and regular donors. the patients are tested periodically for the presence of viral markers (hbsag, anti hcv antibodies), using tests for hbsag (abbott auxyme monoclonal eia) and for anti hcv (abbott hcv eia . ). the presence of markers for hepatitis b and hepatitis c has not been detected in any of these multitransfused thalassemic patients who receive at least transfusions a year. the tests in all patients were negative. the blood used for transfusion must be tested for viral markers, and for the patients who have to receive blood for their whole life, the blood should be from voluntary, regular and periodic donors who donate blood at least three times a year, because then the risk of transfusion transmissible infections is very small. introduction: we observe yearly the prevalence of transfusion transmitted diseases following instructions of skae (national coordination haemovigilance centre). aims: to investigate the prevalence of the most important blood borne infections in our blood transfusion centre in the state achaia during the last five years ( ) ( ) ( ) ( ) ( ) . materials and methods: the detection of hbsag, anti-hcv, anti-hiv / was made by automated microparticle enzyme immunoassay (axsym, abbott) and by enzyme-linked immunoassay methods (dade behring, ortho, biomerieux) syphilis tests were made by using rpr kits. confirmation for anti-hcv positive samples was made riba or inno-lia, while the confirmation of anti-hiv / positive samples was made by 'st. andrews' general hospital of patras reference centre. results: all the seropositive donors were first time donors. conclusion: ( ) we observe that there is a decrease in all four infections. ( ) the absence of anti-hiv seropositive donors is due to the high percentage of volunteer blood donation which approaches % in our centre during the last four years. methods: a prospective, one-year study has been set up in order to enrol at least out of the estimate of first-time donors, involving blood transfusion centres from of the italian regions. each centre was required to enrol all first-time donors born before december st, , and thus not included in the hbv mass vaccination campaign. the selected donors were tested for hbsag (mandatory by law) and for anti-hbc by commercial assays. all hbsag and/or anti-hbc positive specimens were stored frozen and sent to a reference laboratory for additional serological testing (anti-hbs, anti-hbe, anti-hbc/igm and anti-hbc avidity index by an experimental procedure) and for the determination of hbv-dna (both qualitative and quantitative) by real-time pcr. results: in the first months of the study the sites saw almost first-time donors, of whom . % belonged to the required age groups. among eligible donors, . % were both hbsag and anti-hbc positive, and . % were hbsag negative/anti-hbc positive. hbv positivity rates were higher in southern than in northern regions, although a high variability in hbv prevalence was observed between neighbouring areas in the north. hbsag positives were mostly males, % were positive for anti-hbe, % had raised alt and % were concurrently positive for anti-hbs. among hbsag negative/anti-hbc positive donors, % were negative and % were positive for anti-hbs. among anti-hbs positives, % showed values < miu/ml and % > miu/ml. the avidity index results suggested that approximately % of anti-hbc positive individuals were recently infected. conclusions: our preliminary data indicate that approximately % of the italian first-time donors are older than years of age and thus not belonging to the age groups who underwent to the mandatory vaccination against hbv, and that . % of them have serological markers of ongoing or past hbv infection. anti-hbc alone was detected in nearly % of the study population. hbv-dna testing is underway at the time of this writing. in our country mandatory tests for each blood donations are: hbsag, anti-hcv, anti-hiv / and tp ab. to c + ns + ns , ( . %) to c + ns , ( . %) to c + ns + ns , ( %) to ns + ns + ns , ( %) to c + ns + ns , ( %) to ns + ns . the use of the hcv core ag elisa test system may provide substantially earlier identification of hcv infection than it is possible with current serological assays. although all of six anti-hcv assays are very sensitive and specific screening assays, they didn't detect hcv infection in one patient. majority of anti-hcv positive patients ( . %) had anti-hcv ab for or more different epitopes of hcv. international comparison of performance of abbott prism assays used for blood donor screening background: the national serology reference laboratory, australia (nrl), coordinates a quality control (qc) programme for laboratories that screen for anti-hiv & , anti-hcv, hbsag and anti-htlv i/ii using the abbott prism assays. nineteen laboratories from australia, belgium, canada, ireland, israel, the netherlands, new zealand, norway, singapore, south africa and thailand have submitted data for this programme. aims: to determine the accuracy and precision of results from laboratories, individual prism instruments and different reagent lots by analysing data accumulated between october and january . the multi-marker qc sample 'pelispy s type ' (s ), produced by viral quality control (now acrometrix-viral quality control), was provided to participants. laboratories tested s in each calibration run, in addition to the manufacturer's controls, on each sub-channel of the instrument. pelispy was used as a 'go/nogo control' and results were required to be reactive (s/co > ) for a test run to be deemed valid. data were collected and analysed using the nrl's internet-based application edcnet (https://www.nrlqa.net). after submission, laboratories were able to compare their results with those submitted by other laboratories and investigate differences in results from reagent lots and instruments. data for five different s lots were exported from edcnet and analysed. results: nearly results were submitted: all results were reactive (s/co > ). fifty of these results ( . %) were excluded from analyses because they were reported from invalid test runs [due to pipetting, aspiration or sampling error (n = ) or due to unacceptable results (n = )]. a further results were excluded because data provided by laboratories were inconsistent or incorrect. a total of results, reported using different prism reagent lots ( for anti-hiv, for anti-hcv, for anti-htlv and for hbsag), were analysed. results from prism hbsag and anti-hiv showed the least variation with coefficient of variations (cv) of < % for all s lots. results from prism anti-hcv and anti-htlv produced cvs between . % and . % for all s lots. data reported for s lot ps (n = , range for anti-htlv to for hbsag) were analysed further to review performance of prism reagent lots. hbsag showed the least variability between prism reagent lots with < % bias for the prism hbsag reagent lots used (bias: the difference between the mean ratio for the reagent lot and the weighted mean ratio for all reagent lots, expressed as a percentage of the weighted mean ratio for all reagent lots). prism anti-htlv showed greater variability between reagent lots with a single reagent lot generating a + % bias. prism anti-hcv showed the greatest variability within reagent lot with results from of reagent lots showing a cv between % and %. conclusion: in results in a qc sample distributed to laboratories the abbott prism performance was found to be consistent over four assays. edcnet was robust in supporting laboratories' abilities to follow precision and accuracy of the assays in real time. introduction: since hcv rna testing of all blood donors started in finland in , the nat screening process has continuously been improved. investments in process automation have made the work more efficient and blood safety has further increased since hiv- rna screening of all blood donors started late . aim of the study: to implement hiv- rna testing in the nat screening program cost effectively, without increasing the throughput time of the samples and delay in the result reporting. to study if the sensitivity for both hiv- rna and hcv-rna will be sufficient when a single extraction is used and when the pool size of donations and the sample volume are kept unchanged. methods: the nucleic acids were isolated from plasma samples of ml with the magna pure lc instrument using the magna pure lc total nucleic acid isolation large volume kit. the internal controls from the cobas ampliscreen multiprep specimen preparation and control kit and the cobas amplicor hcv specimen preparation kit were added to the lysis/binding buffer ( ml/ml of each). from the final volume of the nucleic acid eluate ( ml) ml was used for the detection of hiv- rna (roche cobas ampliscreen) and ml for the detection of hcv rna (roche cobas amplicor). a run control containing both hiv- rna ( iu/ml) and hcv rna ( iu/ml) was included in all extraction runs. sensitivity of the both assays was assessed by testing dilution series of the who standards for hiv- rna and hcv rna. specificity was evaluated by testing fractionation plasmapool samples (n = ) and minipool samples (n = ). results: detection limits of the hiv- and hcv assays ( % hit rate) were calculated to be . iu/ml and . iu/ml respectively. specificity for both assays was % and during the validation phase also the robustness was good. the sensitivity of both assays with a pool size of was below the recommendations by the council of europe for blood donor screening (for hiv- rna iu/ml and for hcv iu/ml per individual donation). specificity of the assays was excellent, false reactive results were not observed. implementation of the hiv- nat assay in the screening program did not increase the throughput time of the donor samples when the pool size of donations, ml sample volume and a single extraction for two assays were used. the the very substantial increase in the number of industry-sponsored clinical trials has created challenges for medical schools, academic hospitals, faculty members of these institutions, and the journals that publish the results of these trials. in many cases, authors of reports of industry-sponsored clinical trials are paid consultants to the sponsor, have been paid by the sponsor to lecture on behalf of its products, or have equity in the sponsoring company. these ties to industry create a tension that actually is or can be perceived as • work internationally; • send young volunteers to international youth forums; • employ young people in your organisation; why use volunteers in blood donor recruitment? • they have networks to scout-groups, sports-organizations, tradeunions, rotary, staff of large companies etc. • they bring in fellow volunteers -with different prospects of society; • often paid recruiters are underpaid (!) and tend not to remain • you can not recruit by telephone! • out of donors are recruited by personal contact! • so you need direct personal contact = need many people (e.g. young ambassadors); • a large number of volunteer recruiters is a gift from heaven! paid donation gives the act of blood donation low status. the act of blood donation should be respected, and praised by role models, queens and presidents. efficient work and close cooperation of blood bank staff and volunteer organisations is the key to success in blood donor recruitment and retention! with such a prospect, it was important to evaluate the practices of blood donor selection in the eu. material and methods: a questionnaire was designed and sent in to the relevant institutions of the eu countries plus switzerland. the questionnaire included questions on the interviewing practices before homologous blood donations, regarding non-specific risks to donors and recipients, identified risks to donors, infectious, bacterial, viral, parasitic and prionic risks to recipients and non-infectious risks to recipients. the questionnaire also inquired about each country's exclusion period for each contraindication (ci) to donation. results: predonation interviews were prepared, in all countries, by circulating informative documents to blood donors. they were supported by written questionnaires in nearly all countries. in half of the countries, those interviews had to be led by physicians (nurses or technologists in the others). the - age limits for blood donation ( - for a first donation) were the rule in countries. in other countries the age limit could be brought forward to and extended to years old. the time interval between donations was identical for men and women in countries, and varied from to weeks according to country. the questions of the questionnaires were very similar as regards the identification of risks to donors and recipients, and very close to the requirements that appeared later in the / /ec directive. this particularly concerned how to meet the expectations of european donors, so that they come back to your blood center! know your donors: make regular donor surveys. age, gender, number of donations, number of first time donors, media consumption, education, job situation, income brackets. use local donor organisations let volunteers help! they work for free, but donor recruitment and -retention costs money. each blood center should have a local donor organisation, run by volunteers. the donor organisation should receive a payment for each bag collected. the reputation of the blood system tell the donors, what the blood is used for. that all blood is tested. and that blood provides safe medical treatment safety of the donor. insurance is a must good quality and efficiency in blood services decentralized blood collection no waste, and minimal outdating efficient service: • a friendly environment, • donor friendly opening hours, • pleasant rooms, beds and well equipped waiting rooms, • parking-spaces, transport, • beverages and food, • letters with correct data etc. donors expect to be serviced by trained, medical professionals and that the medical check-up is taken seriously. donors should be recognized continuously. use directed press-coverage to higher the self-esteem of the donors. donors should be well informed: • leaflets, posters and questionnaires should be % correct; • use e-mail and web-sites for quick up-date of donor information. be visible! • have an offensive and comprehensive media approach; • have a yearly national campaign june up to world blood donor day; • have an attractive home-page, constantly updated; • streamline your lay-out; • mail a donor magazine to all regular donors: • send newsletters regularly to volunteers and the press. • use recruitment cards. • easy phone-and fax numbers, e-mail addresses. directed campaign towards young people: • young ambassadors group; • special training sessions for young volunteers; • advertisements in media catering to young people; • poster competitions; • book and leaflets on blood addressed directly to young people; minimum bodyweight, blood pressure, pulse limits, questions involving viral risks, either sexually transmitted or linked to drug abuse, questions investigating risks of malaria transmission, questions aimed at identifying risk of prionic disease transmission. analyzing ineligibility times, on the other hand, revealed wide differences. for example, ineligibility for current multiple sexual partners, sexual relations with risk individuals, tattooing or body piercing, endoscopy, general anesthesia or invasive surgery, could vary from to months. previous transfusion history could not be a ci or could be one varying from months to indefinite ci (this point recently changed in several countries). the results of that survey have revealed some differences between countries in the questions asked and especially in the ineligibility times. however, the conditions under which donor selection interviews are conducted were similar in all countries. the enquiry tool used in this study proved to be well adapted to evaluate the donor selection practices throughout eu. a next step will be to use it to appreciate their evolutions and especially the impact of the /ec/ directive on these practices in the eu countries and furthermore to evaluate the results of this selection (rates and motives of deferral) which is a major factor of patients' transfusional safety. background: in europe on average whole-blood donations are performed per inhabitants and year. whole-blood donation comprises a puncture of a venous vessel and letting of blood (usually ml), which may be repeated several times a year. like other invasive procedures, blood donation has a range of effects on the individual who is subjected to it. aim: the aim of this paper is to review some aspects of the present state of knowledge on effects and complications of whole-blood donations. results: most studies of the effects of whole-blood donations on the donor have focused on negative or unpleasant events and on time in rather close association to the donation. complications related to percutaneous needle insertion (bruise assessed by inspection . % -bruise assessed using post-donation interview . %, sore arm - . %, nerve irritation . %, arterial puncture/pseudoaneurysm/arteriovenous fistula . - . % etc) are most commonly reported, while negative systemic reactions (vasovagal reactions . - . %, syncope . - . %) occurring in connection to blood donation are less frequent (newman bh: blood donor complications after whole-blood donation. curr opin hematol ; : - .) serious complications requiring hospitalization (myocardial infarction, stroke) are extremely rare ( . %). fatigue ( . %- . %) and diminished physical working capacity ( . %) are reported to occur during days after the donation. a recent study of a consecutive sample of swedish blood donors (nilsson sojka b, sojka p: the blood-donation experience: perceived physical, psychological and social impact of blood donation on the donor. vox sang ; : - .) (with a selfadministered questionnaire with an open-ended question: how does blood donation affect you? physically-bodily/psychologicallyspiritually/ethically-morally/socially during or after blood donation?) revealed that perceived negative effects (fatigue, diminished physical working capacity, vertigo/dizziness, susceptibility to infections etc) were less common ( % of the donors) than positive effects (feeling of satisfaction, being more alert, feeling generally better, less migraine, higher physical working capacity, respect from environment, feeling of relaxation etc; % of the donors). the duration of positive effects was regularly reported to be weeks, while negative effects lasted only days. investigations on the long-term effects of blood donation are scarce. yet, they may indicate that the donation of blood is associated with e.g. lower blood pressure and a reduced risk of myocardial infarction (nilsson sojka b, sojka p: the blood-donation experience: perceived physical, psychological and social impact of blood donation on the donor. vox sang ; : - ). conclusion: both the panorama and the frequency of occurrence of the different effects and complications of whole-blood donations vary as a function of how the information was gathered (openended questions, observations, interviews etc). serious reactions to whole-blood donations are extremely rare. more studies are needed in particular with respect to the long-term effects of regular wholeblood donations. t-pa- establishing a national adverse event reporting system for blood donors -a prospective study of . there was no national system and significant regional variation showed that the data was scientifically unsound. a coincidental initiative to remove the mandatory post donation rest period for regular donors further emphasised the lack of reliable, retrospective data to monitor and compare the impact of this new policy. aims: . to develop and implement a high quality, reliable national donor adverse events reporting (daer) system; . to define and categorise adverse events; . to record data systematically and prospectively using the existing computerised donor database. methods: from summer , a small project team of senior clinical and operational staff took months to agree a detailed policy for capturing and recording all donor adverse events, including precise definitions for grades of vasovagal reactions and bruising. detailed training material was written in may and the new protocol was validated in one region. from july to december a formal one day training programme was delivered to over staff working on mobile collection teams, static sites and blood centres. daer was fully implemented by january . adverse events are assessed by health care professionals on session and the relevant code entered onto the donor's computer record by clerical staff. information received after the session is entered by centre based doctors using the same system. the database is interrogated monthly for statistics. results: in the first months . million donors attended sessions throughout england and north wales. results were very consistent month on month. donors ( : ) had vasovagal symptoms but only % of these suffered syncope. % of all vasovagal reactions occurred in women. % occurred in donors aged - and a further % in donors aged - . (donors aged - represent only % of the total donor base.) donors ( : ) reported a delayed reaction, % of whom did lose consciousness. nerve injury, unrelated to haematoma, occurred in donors ( : ) and, more rarely, arterial puncture was diagnosed in donors ( : ). bruising was reported after the session by : donors. summary: a robust system has been developed and successfully implemented across a large, national blood service. based on the data already accumulated our next phase is to develop strategies to minimise adverse events, confident that any intervention will be effectively monitored. the community role in enhancement of voluntary, non-remunerated blood donation in the new millennium introduction: in the developing countries, about % of the blood supply comes from paid or replacement donors, where a high number of infected persons are in the donors population. only % of the global blood supply is donated as voluntary nonremunerated blood donors in countries with low and medium human development indices. and around % of the global blood population has access to only % of a safe blood supply. conclusion: blood is a national resource, it is the responsibility of governments through it's communities to ensure that the blood supply is safe and adequate to meet the needs of patients population and available to all who needs it. background: in response to a documented increase in the average age of donors, a survey was conducted to explore if young people had more unfavourable attitudes towards becoming blood donors. aim: to identify if the increasing difficulty in recruitment and retention of young people as donors, is linked to a low level of motivation for donating blood in this age group. methods: a national telephone-survey was conducted among a cross-sectional sample of the adult norwegian population ( participants). the survey was performed in november . results: five percent reported being active donors (had donated during the last months), % were passive donors (had not donated during the last months), % were non-donors with a positive attitude towards becoming donors, and % non-donors with no intentions ever to donate blood. in the youngest age group (age - ), % reported being active donors and % were passive donors. however, % of the young non-donors reported having intentions of becoming a blood donor. fifty-five percent of young non-donors had a negative attitude towards ever donating blood. all non-donors were asked why they did not donate. thirty-six percent of all non-donors reported health related reasons for not donating blood. thirty-one percent of all non-donors claimed that they did not donate because no one had requested them to do so personally, and % reported they did not care about blood donation. in comparison only % of young non-donors reported medical reasons for not donating. thirty-eight percent claimed lack of personal request, and % reported of lack of interest as the main reason for not donating. summary/conclusion: although the youngest age group was under-represented among active donors, we found that a great proportion ( %) of young non-donors had a positive attitude towards becoming blood donors. the most important reason why young people do not donate was the lack of a personal request. indifference regarding donation was not very widespread. a relatively high proportion of young people considered themselves as not medically disqualified to donate. in light of these findings, efforts to recruit young people as blood donors are strongly recommended. background: the ever-increasing demand for blood, coupled with emerging new threats to blood safety, motivate the strengthening of the blood banking infrastructure. aim: employing new technology as an instrument for building relationships of trust between blood bank and blood donors. material: . a new software module supporting the management of magnetic cards was added to e-aima blood bank management application. the magnetic card supports the following information: • front-side: donor's photograph, surname, name and blood group (including rhesus phenotype & kell) and sign of blood collection centre. • magnetic stripe where data concerning donor's serial number, medical history (risk factors), test results for infections and the number of donations is stored. . specific hardware allowing reading from and writing to magnetic cards is integrated to the software module: • magnetic card scanners were added to pcs serving to donation collection, including laptop for mobile team collection. • web cameras to capture the photograph of the donor to be printed on the card. • card printer was deemed necessary to produce magnetic cards for donors on a need basis. . consumables: blank plastic magnetic cards, ink cartridges for printer. methods: in order to evaluate the performance of magnetic cards compared to the paper-based system, a questionnaire was distributed to first-time and repeat blood donors, in order to be used as an indicant of donor's satisfaction. . first-time donors increased . % in the months of application. among them, . % were donors 'for relatives or friends' turned into volunteer donors and . % were first-time volunteer donors. the questionnaire analysis further revealed: • % were motivated by the use of magnetic card. • % appreciated the presence of their photo on the card and they confessed that they had used it as a spill for recruiting their friends as donors. • % were persuaded that employing new technology would result in safer and more trustworthy procedures combined with reduced waiting time. • % considered magnetic cards more practical compared to paper cards because of their compact size and improved durability. . the turnover of repeat donors also increased . % after replacing their plain old paper cards with new ones. further analysis revealed that: • % appreciated the quick cross-checking of donor's identity. • % were satisfied with the effectiveness and efficiency of magnetic cards in managing donor's data. conclusions: in , greek health policy provided the legal basis for establishing the electronic national health card. the introduction of the national donor's magnetic card is another step towards this direction, being aligned with the modern national health strategy. apart from the positive impact on the number of both firsttime and repeat blood donors, it should be also pointed out that the use of a unique donor serial number on country level results in less error-prone procedures due to the reduction of administrative process overhead and facilitates interoperability between national blood banks using compatible technological infrastructure. t-pa- emerging technologies in transfusion. dna based assays until the late s, mandatory blood screening for transmissible infectious agents depended entirely on antigen/antibody-based detection assays. recent emergence of nucleic acid technologies (nat) has revolutionized viral diagnosis by not only increasing the sensitivity level but also facilitating the detection of several viruses in parallel, by multiplexing specific primers. however, in more complex biological situations when a broad spectrum of pathogens must be screened, the limitations of these first generation technologies became apparent. high throughput systems such as dna arrays permit a conceptually new approach. these miniaturized microsystems allow the detection of hundreds of different targets simultaneously, inducing a dramatic decrease in reagent consumption, in additional confirmation tests and simplify data interpretation. however, the microsystems actually available require additional instrumentation and reagents for sample preparation and target-amplification prior to detection on the dna array. future technologies such as 'lab-on-a-chip' include channels, fluidics and thermal zones allowing extraction, amplification and detection. another major challenge in the area of dna detection is the development of methods that do not rely on target-amplification systems. almost all blood group antigens are bi-allelic and encoded by single nucleotide polymorphisms (snps). to facilitate the direct availability of typed red cells and platelets, we develop a high-throughput technique to genotype by dna microarray the whole donor cohort for all clinically relevant red cell and platelet antigens. methods: a multiplex pcr was developed to both amplify and fluorescently label gene fragments of red cell and platelet antigens in one reaction. each array contains spots of short ( - nt) allelespecific oligonucleotides to discriminate between the two alleles of an antigen system. results: two blinded panels encompassing donors were genotyped for hpa- through - and ; no discrepancies were found. currently, arrays are prepared for the red cell systems. the fya/fyb, fy-gata mutation, jka/jkb, k/k, kpa/kpb, m/n, rhc/c, rhe/e, rhdpseudogen, rhdvi negative, rs, doa/dob, genotypes can be determined. the set up of genotyping assays for rare genotypes is difficult because of lack or insufficient amount of dna. the latter can be overcome by phi dna polymerase-mediated isothermal genomic dna amplification, from minute amounts of dna present in stored red cell fractions or antiserum. the results show that the blood group typing dna microarray will provide a reliable and fast genotyping procedure. the method can be further improved to obtain the necessary automated throughput for typing of large donor cohorts. and , all other weak d types should be regarded as potential anti-d immunizers. for correct determination of weak d both serological typing (polyclonal and monoclonal), as rhd dna typing are mandatory. when serology indicates weak d, more anti-d antibodies are tested ( epitope model) to distinguish partial d from weak d. in addition, an rhd mpx pcr is performed to detect the presence of rhd exons , , , , and . in all known weak d types, all six rhd specific exons are amplified (except for weak d type which lacks rhd exons and ), whereas partial d phenotypes usually show aberrant patterns. aim: the aim of this study was to evaluate the diagnostic scheme for weak d typing. methods: between and , samples were investigated for weak d characteristics. four pcr-ssp assays were developed for identification of weak d types ( t > g), ( g > c), ( c > g) and ( c > a). weak d type was identified by the combination of serology and absence of exons and by rhd mpx pcr. rhd-specific exon sequencing was performed when serology and molecular typing were inconsistent. results: all samples were subjected to the rhd mpx pcr and sample showed absence of rhd exons and , indicative of a weak d type when combined with serology. the remaining samples were analyzed by the weak d pcr-ssps, resulting in weak d type samples, weak d type samples, weak d type samples and weak d type sample. two samples remained undetermined and were sequenced for all rhd exons and the rhd promotor region. one sample showed the mutations corresponding to the dau partial d phenotype ( g>a, g>a and c>t). the other sample had only one, not previously known mutation ( a>t), which is located intracellularly at the coohtail. extensive serology using the epitope model showed a pattern matching weak d. this new weak d variant was registered as weak d type . conclusions: based on these results it may be concluded that weak d phenotypes should be confirmed on molecular level to avoid misinterpretation of partial d that cannot be detected by rhd mpx pcr analyses. patients with weak d phenotypes, except for types , and should be regarded as being at risk for anti-d immunization after transfusion of rhd-positive blood products and should therefore be treated with rhd-negative bloodproducts. in this evaluation, out of patients carried such alleles. introduction: although kell antigens are expressed very early during erythropoiesis and a . % incidence of anti-kel is found in obstetric patients, this is a relatively rare cause of hdn. anemia is produced by immune destruction of fetal rbcs and suppression of erythropoiesis. maternal antibody titers or amniotic/cord blood bilirubin levels are not relevant indicators of the severity of the disease, and the measurement of the fetal haemoglobin by cordocentesis is a procedure with risks of miscarriage and sensitization. pcr techniques for the determination of blood groups using fetal dna isolated from maternal plasma, allows the application of noninvasive methods. clinical cases: we describe two cases of pregnancies in women with anti-kel acquired by transfusion/previous pregnancies: st case: in july , a -year-old woman (gravida , para ), rhdnegative, kel -negative was referred at weeks gestation. the father's phenotype was rhd-positive, kel -positive. a maternal antibody screen revealed d and kel alloantibodies. dna was extracted from amniotic liquid. the kel genotype was determined by pcr-rflp using the bsm i. pcr-ssp was used to studied intron and exon of the rhd gene. the results showed that the fetus was positive for rhd sequences and showed kel homozygosity; nd case: in august , a -year-old woman (gravida , para ) was referred at weeks gestation. she had a history of transfusion with rbcs units in -one of the donors was kel positive. the woman typed rhd-negative and her husband typed rhd-positive. rbcs from both were kel -negative. the maternal antibody screen revealed anti-kel . doubts existed about the putative father of this child. dna was extracted from maternal plasma using the magna pure lc (roche). real-time pcr was applied to analyse: sequences of intron , exons , , and pseudogene of the rhd gene and the sry gene by sybr green; and the alleles kel /kel by hybridization probes. all rhd sequences were detected (with the exception of the pseudogene) and the kel genotype gave a kel /kel result. in both cases the doctors choose not to use any invasive method to monitoring the fetuses regarding a hdn due to anti-kell antibodies, and the results of the molecular analysis were confirmed by testing the cord rbcs after birth. discussion: these cases illustrate the reliability of the molecular biology results, based on the collection of simple peripheral blood samples. a determination that the fetus lacks the relevant antigen obviates the need for expensive and invasive monitoring throughout the pregnancy. evidence-based medicine (ebm) is defined as: 'the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. the practice of ebm requires the integration of individual clinical expertise with the best available external clinical evidence from systematic research and our patient's unique values and circumstances. ' otherwise healthy individuals without cardiopulmonary dysfunction (cdf) tolerate acute reduction of haemoglobin concentration to about g/dl, provided that blood volume is kept normal by a volume expander. however, individuals experience physical fatigue, and there is faint reduction of perception as measured by neurophysiological tests. symptoms are reversed upon retransfusion of fresh, autologous erythrocytes. acute, normovolemic anemia seems to be progressively less tolerated with increasing age and cdf. controversy has existed on whether or not to correct hypoalbuminemia in asb or icp by infusion of albumin. recently a large trial showed no outcome differences between icp patients treated with albumin or saline. thus in general there is no indication for albumin in asb or icp. however, albumin may yet be advantageous in e.g. patients with head injuries. furthermore, fractionated albumin is not equivalent to native albumin, since fractionation stabilizers remain bound to the albumin molecule. thus more refined albumin preparations may carry advantages still to be investigated. erythrocytes are given to increase the total oxygen transportation capacity of the organism. the effect of blood bank stored erythrocytes may differ from that of fresh, autologous erythrocytes, since changes of presumably important erythrocyte properties occur during storage. in the only large trial available, a transfusion trigger of . g/dl was found to be favourable to one of g/dl in icp, except possibly in icp with unstable angina pectoris or heart infarction. however, the erythrocyte concentrates given were not leukocyte filtered, and side effects of infused leukocytes may have hampered the conclusion. on the other hand, a metanalysis showed transfusion as an independent indicator of unfavourable outcome in coronary bypass patients, but again, leukocyte filtered erythrocyte preparations were not applied. the effect on morbidity and mortality of 'top up' transfusions given e.g. to mobilize patients postoperatively has not been studied by trials, although this effect seems evident to many clinicians. grave anemia may reduce the haemostatic effect of thrombocytes because changes of blood rheology reduces the pressure forcing thrombocytes against the walls of small vessels. the transfusion trigger for thrombocytes in asb or icp remains to be established by clinical trials, however. the same applies for fresh frozen plasma, which is infused as a source of coagulation factors. on the other hand, the haemostatic effect of various fibrinolysis inhibitors is well established in asb and icp, but many clinicians appear hesitant to use them. another interesting haemostatic agent is recombinant fviia, the use of which to control asb in blunt trauma is supported by one well controlled clinical trial. evidence by systematic research is insufficient to decide what is optimal transfusion practice. the procurement of such evidence is one of the greatest current challenges to transfusion medicine research. . concerns about the transfusion-related complications, such as infections, tumour behaviour and immuno-modulatory effects, and the costs, necessitated a re-evaluation of the transfusion practice. aims: the goal of this study is to evaluate if a restrictive transfusion policy (hb transfusion trigger < . mmol/l) reduces the amount of red cell transfusion compared to a liberal transfusion trigger (hb < . mmol/l) without a decrease in hrqol. because of concerns about the feasibility of this study early results were analysed and are presented in this abstract. material and methods: after a run in period of months (hb transfusion trigger of hb < . mmol/l) patients are randomised for the restrictive or the liberal transfusion policy. patients are followed then months. hrqol is measured after inclusion, after randomisation, weeks, , , , and months after randomisation. also anaemia related complications and red cell antibodies are scored. hb values were blinded for the patients during the study period. results: from july till june patients were included ( ra, rars, rcmd, raeb, cmmol) in general hospitals and university hospital. two patients died in the run in period. eight patients were randomised for the restrictive transfusion policy and patients for the liberal transfusion policy. the mean follow up period in the liberal group was . months (inclusive run in period) and . months for the restrictive group. two patients in the liberal group died after randomisation. one patient received growth factors. in the restrictive group patients finished the study, received growth factors and patient withdrew informed consent. the mean hb level was lower in the restrictive group and after randomisation about % reduction in amount of transfused red cells was found ( . units per pt per month in the liberal group vs . in the restrictive group). no anaemia related complications were found, e.g. cardiac failure and cerebro vascular ischemia nor a decrease in activity performance. conclusion: there were some concerns after introduction of the restrictive transfusion policy. this preliminary results show, however, that a restrictive transfusion policy leads to a diminished use of red cell transfusion without an increase of cardiac complications or a decrease in activity performance. this study will be continued to compare hrqol scores in both groups. introduction: strong evidence supports the efficacy of blood conservation strategies such as autologous blood donation (abd) and erythropoietin (epo) for reducing exposure to allogeneic blood. however, use of these interventions is highly variable among institutions and frequently sub-optimal. the program to reduce orthopedic blood exposure (probe) evaluated a blood conservation program in patients undergoing total hip joint arthroplasty (thja) at ontario hospitals. aim of the study: the objective of probe was to determine whether a comprehensive blood conservation algorithm (bca) was more effective than usual care (uc) for reducing exposure to allogeneic blood in patients undergoing thja. methods: we randomized hospitals that perform high volume elective primary thja to implement either a bca or to continue with uc. the bca consisted of three components: physician and patient education, blood conservation interventions (use of abd or epo), and transfusion guidelines. t-pa- table) . mortality for non-transfused patients was significantly lower than for patients receiving either lr-or s-prbc at all time points (p < . ). t-pa- thalassaemia: the impact on blood transfusion services thalassaemia major is a genetically determined disease that causes severe chronic anaemia and further complications. it can be managed successfully in the vast majority of cases, so long as public health and other scientific and organizational infrastructures are adequate. although the progress achieved in the field of bone marrow transplantation and other disciplines promises cure of the genetic defect, regular blood transfusion from early childhood remains the cornerstone of treatment of patients with thalassaemia major. this presents national health authorities with the formidable task of assuring an adequate blood supply of high quality and safety for these patients and ensuring that it is transfused in the appropriate way. the basic principle in the modern management of thalassaemia patients is that of a global approach to care. within this approach, a standardized protocol for regular blood transfusions is a prerequisite for the patient's long survival and quality of life. if thalassaemia patients are not transfused effectively, the severe anaemia and over-expansion of bone marrow due to ineffective erythropoesis can lead to poor growth, bone deformities, organomegaly and impairment of normal physical activities. in countries or regions with large numbers of thalassaemic patients, the organizational and technical aspects of meeting their blood requirements represents a heavy additional workload for the blood transfusion services responsible for providing blood for this group of multi-transfused patients. the acquisition and preparation of blood, genotyping the patients' blood group (including at least rh, kell, kidd and duffy systems) preventing the transmission of infectious diseases and other transfusion associated complications, and assessing the patients' blood transfusion indices all have a tremendous impact on blood transfusion and treatment units. blood transfusion services are thus confronted with major challenges that can only be met if appropriate national transfusion policies are in place, both in the laboratory and the clinical setting of blood transfusion. the availability of safe blood is related to the effectiveness of donation programmes aimed at recruiting and retaining voluntary unpaid blood donors who are at low risk for the transmission of infectious diseases. sufficiency is further related to resources, organization and management of the blood transfusion service and continuous education of its staff. high technical standards for the transfused product and quality management systems are required to ensure that the product meets these requirements, as well as pre-transfusion, transfusion and haemovigilance systems and other more stringent quality measures in the whole chain of blood donation and transfusion. additional measures and continuous care are specifically required for the optimal transfusion therapy of the thalassaemic patient. the patients should be transfused with red cell concentrates, (rccs) preferably not more than one week's old and leucodepleted. other processes i.e washing of rccs, use of nutrient additive solutions, irradiation etc may be used to improve the quality and the safety of the transfused product, while other advances in red cell transfusion are expected to improve blood safety by preventing adverse reactions and reducing exposure of the patient to donor blood. should patients with thalassemia intermedia be regularly transfused? thalassemia major (tm) and thalassemia intermedia (ti) share mostly a common basic molecular mechanism, that is the reduced synthesis of the * globin chains. the consequences of the resulting chronic hemolytic anemia are also common and include growth retardation, bone marrow expansion, extramedular hematopoiesis, splenomegaly, increased intestinal iron absorption, susceptibility to infections and hypercoagulability. what differentiates the two forms of the disease is the severity of the clinical phenotype, which in turn depends on a particularly heterogeneous molecular background and imposes diverse therapeutic strategies. the consequences of the genetic defect as well as the effect of the applied therapy seem to be mainly responsible for the clinical course of the disease. in untreated tm cases, the aforementioned consequences occur fast and patients die early in life mainly due to high output heart failure. over the past decades, the gradual adoption of the current transfusion and iron chelation strategies and the patients' compliance with this therapy have resulted in a significant improvement of survival, that according to recent statistics reaches % at age . this rate is even better in well-treated patients, almost % of whom survive at age . regular therapy extends survival mainly by preventing early development of cardiac complications. in addition, a multi-organ improvement is accomplished while patients' physical appearance is almost indistinguishable from that of the general population, hence permitting a normal social behavior with a high overall quality of life. bone marrow expansion and extramedular hematopoiesis are prevented; hepatosplenomegaly is substantially restricted and usually there is no need for splenectomy, while thromboembolic complications are rare and pulmonary hypertension is practically absent. patients with ti remain as a rule without regular therapy until a number of severe complications arise. the consequences of chronic anemia develop slowly compared to untreated tm cases and dominate patients' clinical picture usually by the third decade of life. at this time, all patients have developed hepatosplenomegaly and most of them have been splenectomized. bone marrow expansion results to bone deformities and fractures often occur. extramedular hemaotpoietic masses and bone deformities may lead to various complications depending on their bulk and location, such as neurological symptoms from masses arising in the paraspinal area or dyspnea from lung restriction. hypercoagulability, resulting from defects of native erythrocyte membrane phospholipids, together with the coexistent thrombocytosis in splenectomized patients lead to a wide spectrum of thromboembolic events. pulmonary involvement with respiratory dysfunction and hypoxemia as well as pulmonary hypertension leading to congestive heart failure are well documented in ti patients. nowadays, the beneficial effects of regular transfusion and chelation therapy in tm are beyond any doubt. the occasional application of transfusions in ti has a transient effect and does not seem to inhibit the consequences of chronic hypoxia. intensive and regular transfusion and chelation therapy in ti has proved effective in ameliorating the established complications such as spinal cord compression, hypercoagulability and pulmonary hypertension, without however reversing them. given the -year experience on intensive therapy in tm and the first encouraging data in ti, the earlier application of such treatment seems to be crucial in ti. the timing however of therapeutic intervention in ti in order to prevent anemia-related complications still remains an open issue that needs to be properly addressed. the impact of prestorage leucodepletion on the immediate transfusion adverse events of patients with thalassaemia major backround: regular blood transfusion therapy in patients with bthalassaemia major decreases the complications of anemia but it is associated to many immediate and delayed side effects. febrile non haemolytic transfusion reactions (fnhtr) are common complications due to alloimmunization of recipients against hla and/or specific antigens on donor's wbcs or to the accumulation during storage of biologic response modifiers (bmrs) that are directly pyrogenic or indirectly by stimulating recipients' white cells to produce pyrogenic mediators. post storage leucoreduction (lr) has reduced the fnhtr in these patients from % to . % per unit. it is unknown whether introduction of prestorage leucodepletion (ld) has reduced the incidence of nhftr further. we analyzed the immediate transfusion reactions of adult patients with b-thalassaemia major transfused with a total of . rbc units from january to december . all units were fresh, stored less than days. . units were lr-rbc, . units were ld-rbc and . were washed lr-rbc. results: the incidence of fnhtr and allergic reactions in patients receiving lr-rbc was . % and . %/per unit respectively, in those receiving ld-rbc was . % and . %/per unit respectively, while in those receiving washed lr-rbcs was . % and . %/per unit respectively. the relative risk (rr) of fnhrt and allergic reactions following transfusion of ld-rbc and washed lr-rbc compared to lr-rbc is shown in table. conclusion: prestorage leucodepletion and washing of rbcs reduced the risk of fnhrt in regularly transfused b-thalassaemia patients . times compared to poststorage filtration. these findings show that fnhtr after rbc transfusions are due not only to alloimmunization but also to accumulation of bmrs even in patients transfused with fresh rbcs. washing is as effective as prestorage leucodepletion in reducing fnhtr. prestorage leucodepletion has no effect on allergic reactions or other immediate adverse events in these patients. t-pa- viral inactivation/elimination of plasma derived medicinal products the safety of medicinal plasma products (mpps) relies on a whole range of measures from the quality of the source material to the release of the products after manufacturing under cgmp conditions. viral safety relies on careful donor selection, viral testing of the source material and viral inactivation and/or elimination during the manufacturing process. mpp manufacturing processes must include viral safety steps capable of inactivating, and/or eliminating, a large range of viruses covering the known blood borne viruses as well as anticipating possible future pathogens. it is recognized that one single step is often not sufficient to satisfy this requirement and manufacturing processes very often include two or even three complementary viral safety steps. very efficient methods have been implemented by manufacturers, for two decades, for the inactivation of major blood borne enveloped viruses (hiv, hcv and hbv). additional safety steps have also been introduced to provide a second step for enveloped viruses and to extend the efficacy to nonenveloped viruses (hav and parvovirus b ). pasteurisation (liquid heat treatment at °c) which has been historically used for viral inactivation of albumin solutions has been applied to some other plasma products. solvent-detergent (sd) treatment which is specific to enveloped viruses is used primarily for coagulation factors. since the introduction of sd-treated products, no hiv, hcv or hbv transmission has been reported. viral inactivation of coagulation factors can also be achieved using various conditions of dry-heating. acidic treatment is also an efficient means of inactivating viruses in igg products. nanofiltration using filters of less than nm pore size was introduced in the early s. this technique for viral elimination is based on the size of the agent and is independent of their resistance to other treatments. this property could be helpful in cases of new emerging pathogenic agents. new inactivation tech-niques are currently under development such as uv treatment or gamma irradiation with efficacy reported on enveloped as well as non-enveloped viruses. these new techniques can complement existing methods after careful validation that they do not have harmful effects on proteins in the product. the efficacy of existing techniques is well documented in controlled clinical studies and pharmacovigilance records. their application to each product is extensively validated at laboratory scale, according to international regulations and then carefully evaluated by health authorities. in this context, a recent european guideline established a viral risk assessment model to quantitatively estimate the theoretical safety margins of mpps, by taking into account the different safety measures, such as viral testing of plasma and the efficacy of viral inactivation/elimination steps. whilst technical limitations and some lack of scientific data lead to very conservative estimates, this model gives an overall assessment of the efficacy of the measures in the manufacture of a given product. developments in viral inactivation/elimination methods, in plasma testing as well as in evaluation procedures have together given mpps an excellent level of safety never previously achieved. to date the important safety measures needed to ensure a high safety margin to pooled plasma products are well understood by the plasma fractionation industry. safety nets rely on carefully done: donor selection to exclude high-risk donors, serological and nat viral testing of single donations and, pooled plasma testing using sensitive validated methods, and most particularly, efficient viral reduction treatments that must be validated and implemented at a large-scale following good manufacturing practices. over the last years, successive key breakthrough in plasma product viral safety have included the use of solvent-detergent treatment to inactivate lipid-enveloped viruses, and nat testing of starting plasma pools and viral nanofiltration of products to reduce the risks associated to small non-enveloped viruses. the excellence of the system currently in place is illustrated by the demonstration that these safety barriers have virtually stopped the transmission of known viruses and avoided that of 'emerging' agents, such as west nile virus (wnv). however, multiple viral reduction treatments have generally decreased product recovery. in addition, although the implementation of viral reduction treatments have forced fractionators to introduce significant changes to product manufacturing methods, this period has been understandably followed by a period of relative conservatism of the plasma fractionation industry against further process changes. as time evolves and market dynamics changes struggle for improved economic balance of the plasma product industry is putting product recovery and diversified product portfolio at the forefront of r&d objectives. these developments in the plasma fractionation scene of the western world have been taking place in a context where many patients in the developing world are still treated with sub-standard, non-virally inactivated crude plasma fractions. in this specific area, one can expect that the developing world will bring innovative thoughts and take actions to find ways to improve the quality and safety of their own local plasma product supply. safety strategies adapted to the infrastructure and economy of less solvable countries may have to be considered. the intercept blood system for plasma uses a synthetic psoralen, amotosalen hcl, and long-wavelength ultraviolet light to photochemically inactivate a broad spectrum of bloodborne pathogens in plasma intended for transfusion (intercept plasma, i-ffp). phase clinical trials have shown that i-ffp retains proteins necessary for hemostasis in the treatment of acquired and inherited coagulopathies, and in support of therapeutic plasma exchange for ttp. a prototype plasma processing set was used for the clinical trials. for commercialization, a new processing set has been developed to improve productivity. the prototype set accommodated approximately ml of plasma, whereas the improved set accommodates up to ml of plasma, resulting in up to three i-ffp doses per treatment. aims: this study was designed to characterize pro-and anti-thrombotic proteins in i-ffp prepared using the improved processing set. proteins of interest included components of the intrinsic and extrinsic coagulation cascade, the fibrinolytic pathway, the contact factor pathway, and the complement system, the vonwillebrand complex, endogenous inhibitors, and markers of thrombin generation. methods: six fresh jumbo ( ml) apheresis plasma units, collected using the haemonetics pcs device (gambro), were photochemically treated. sodium citrate was used as the anticoagulant. plasma samples for analysis were collected before and after photochemical treatment, and were frozen below - °c until batch analysis. standardized clinical assays were used for all analyses. results: (results in the table below are expressed as the percent activity in i-ffp in proportion to the activity in plasma before treatment [mean ± sd]). retention of procoagulant factors in i-ffp plasma ranged from % to %. factor viii and vonwillebrand factor activity, antigen, cleaving protease activity (vwf : cp, adamts- ), and multimeric composition remained within normal ranges after treatment. endogenous inhibitors of coagulation were retained % to %. plasminogen and alpha -antiplasmin were retained % and %, respectively. retention of contact factors was variable; some factors were below the reference range prior to pct. with the exception of tat, all markers of coagulation activation were well within normal ranges. the tat level in one i-ffp unit was slightly above the normal range; all other units had tat levels that were well within the normal range. the significance of this is unclear. cept plasma is similar to conventional plasma. the improved processing set, intended for commercialization, allows up to doses of i-ffp to be produced from a single photochemical treatment. background: guidelines of the european directive / /ec require that fresh plasma prior to freezing contains < residual rbcs per litre. this rbcs content is below the sensitivity limit of the automated cell counters used in routine laboratories. aim of the study: it was therefore essential to make available an alternative method to detect and quantify rbcs in plasma. we implemented a method by flow cytometry using a pe conjugated anti-glycophorin a (gpa) monoclonal antibody that recognises rbcs and erythroid precursors. to quantify residual rbcs in fresh plasma, the method uses the same trucount test tubes (becton dickinson) as those used to quantify wbcs and that contain a known number of fluorescent beads. after addition of plasma and pe-gpa antibody, cell counting is performed on flow cytometer (bd facscalibur). validation of the method: assessment of accuracy, linearity, and reproducibility with different pe-gpa antibodies (immunotech and pharmingen) application of the method: quantification of rbcs in fresh plasmas divided into groups: group : plasmas from leucoreduced whole blood, group : plasmas from packed cells after removal of buffy coat and specific filtration, group : : apheresis plasmas. results: validation of the method: for both anti gpa antibodies, detection threshold is . ¥ residual rbcs/l; linearity study with concentrations of . , . , . , . , . , . , and . ¥ rbcs/l showed excellent correlation between observed and expected values (r > . ); reproducibility study showed c.v of respectively . % and %. for values > ¥ rbcs/l, it appeared necessary to introduce a correction factor of . for the anti gpa pharmingen. quantification of rbcs in plasma: group (plasma from leucoreduced whole blood): . ± . rbcs/l; group (plasma from packed cells after removal of buffy coat and filtration): < . °¥ rbcs/l in all the cases; group (apheresis plasma): < . °¥ rbcs/l in all the cases. conclusion: quantification of rbcs in plasma by flow cytometry is a precise, quick and reproducible test. in addition this study shows that even if there are differences in residual rbcs counts according to the origin of plasma, the obtained values are much lower than regulatory requirements. . improving basic transfusion knowledge amongst health workers; . improving pre-operative preparation for surgery . strategies such as cell salvage autotransfusion combined with a conservative transfusion strategy for the use of allogeneic blood. my presentation will outline the approach adopted to ensure that the use of cell salvage autotransfusion both improves the use of allogeneic blood and preserves allogeneic stores. well-organised training can both minimise the risk of using such advanced techniques and decrease the overall risk involved in undergoing surgery where blood loss may be a significant factor in increasing morbidity and mortality. the various training methods employed to improve knowledge in this area will be described. the increasing current perception that the safety of allogeneic blood transfusion has dramatically been improved during the last decade is challenging autologous haemotherapy methods. in addition, growing concern about the unfavourable cost-effectiveness of most autologous haemotherapy methods requires a refinement of the application of these measures to well defined circumstances. in contrast, newly emerging transfusion-transmissible infections or periods of blood shortage might revive interest in these blood sparing techniques. the first two cases of transfusion transmitted vcjd provide a paradigm for this scenario; not so much with respect to a public fear of infection but rather a waning donor population due to more rigorous recruitment criteria. preoperative autologous blood donation (pabd) still plays a significant role in settings with high individual benefit for the patient, high transfusion probabilities and when all opportunities of cost minimization can be applied. adjustment to the individual situation of the patient is the main aim of a medically reasonable and economic use of autologous haemotherapy. this implies consideration of the patient's haematocrit, blood volume, tolerable blood loss, expected blood loss, etc. in order to choose the optimal method in the individual case. in this respect, double red cell apheresis may play a significant role. with this approach, donation schedules assumed to enhance erythropoiesis can be adopted. moreover, inconveniencies caused by long distances between patient home and donation service can be facilitated by withdrawing two red cell units during one session in selected patients. in conclusion, red cell apheresis can be used to promote the proposed approach towards individualized autologous haemotherapy preoperative plasmapheresis is considered to be a sensible adjunct if intraoperative retransfusion of salvaged and washed red cells is planned. acute normovolaemic haemodilution is valuable when the patient's tolerability of the haemodilution and the expected blood loss are carefully examined beforehand. intraor postoperative salvage of wound blood can also be regarded as useful measures to prevent allogeneic transfusions as long as the specific advantages and disadvantages of the different methods are taken into account. finally, alternative and supplemental measures such as iron or erythropoietin administration should always be considered in order to optimize the efficacy and effectiveness of autologous haemotherapy methods. the goal of a 'bloodless medicine' might not be reached but is supposed to be approached closely with an integrated concept exploiting all measures available. however, in times of restricted health care resources, regular sound costeffectiveness analyses, taking the availability and the cur-rent safety profile of allogeneic blood products into account, are always warranted and needed. compensatory fluid replacement of surgical blood losses: the transfusion of allogeneic blood is expensive and -although safer than ever before -still associated with potential complications. to reduce both, costs and immanent risks, allogeneic transfusion should either be completely avoided or at least minimized during surgical procedures. as a consequence an intraoperative blood loss is initially not replaced by red blood cells, but by erythrocyte-free, i.e. cristalloidal or colloidal solutions. when normovolemia is maintained the resulting dilutional anemia is compensated by an increase of cardiac output and enhanced arterial o extraction. however, once the hb has dropped to values recommended as the lower intraoperative limit, or once compensatory mechanisms of acute anemia become exhausted, as a rule transfusion of red blood cells (rbc) is initiated to increase arterial oxygen content (cao ) and to preserve a margin of safety for tissue oxygenation and organ function. as an alternative to immediate rbc transfusion, ventilation with pure o (hyperoxic ventilation) can be employed to rapidly raise cao by increasing the amount of physically dissolved o in plasma (hyperoxia). however, molecular o causes vasoconstriction, mediated by products of the arachidonic acid metabolic pathway. as a consequence hyperoxia has been shown to increase systemic vascular resistance and to decrease cardiac output and o consumption in subjects with normal hemoglobin concentration ( properly scheduled, three women who did not reach the necessary hct level after the first donation and consequently they got out of the protocol, and one woman who had unexpected intraoperative bleeding and received homologous units in addition. the patients undergoing tkr and the patients undergoing removal of implants predeposited and units respectively, but finally and of them have been used. according to our patients data, the . % of unused autologous blood units belongs to patients with tkr and implant removal. therefore a better schedule is needed for these type of surgery. all the autologous donors were supported by oral iron supplementation throughout the predonation and month past surgery. fourteen of our cases were supported by erythropoietin s.c. in a dose of iu/kg every other day. the majority of these patients was female, only one was male with multiple alloantibodies and was scheduled to predonate autologous units. all of them underwent thr except one woman who also had a tkr months later. the autologous blood donation was well tolerated by all patients and only one woman had a reaction during predonation. furthermore a group of patients matched for age, sex and type of surgery, who did not predeposit blood, received a mean of . homologous units per patient, that is more than the patients on pabd program. our results show that autologous transfusion can be used in scheduled orthopedic surgical procedures and can reduce the need for homologous blood. however, every effort should be made to render the practice of pabd more efficient and to minimize its costs. colloid solutions and their establishment in clinical practice background: various situations like trauma, critical ill patients, sepsis, major surgical procedures and anaphylactic reactions are associated with disturbances in fluid homeostasis. this disturbance is related with reduced oxygen delivery, subsequent lactic acidosis and imbalance in oxidative status. the final result will most likely be an increased mortality and morbidity. aim: the important issue from clinical aspect is to define the optimal volume and type of fluid therapy. the debate for the ideal resuscitation solution lasts a couple of decades due to inconclusive and conflicting results. method: we searched the literature for clinical trials and major met analyses concerning patients undergoing scheduled surgical procedures, trauma patients and critical ill who received resuscitation fluids. results: dextrans reduce blood viscosity and von willebrand factor levels more, for the same degree of hemodilution, compared to other plasma expanders. in clinical setting they are effective in reducing the incidence of deep vein thrombosis and pulmonary embolism. after the initiation of dextran for prophylaxis against anaphylactic reactions, they are considered the safest plasma substitutes, except maybe during pregnancy. dextran % is the most like to cause the 'hyperoncotic acute renal failure' syndrome. gelatins also cause a decrease in circulating levels of vwf : ag, vwf r : co, thrombin-antithrombin complexes and f + . in clinical aspect however, there are contradicted results about the effect of gelatins in bleeding diathesis, although they appear to exert a greater effect on rbcs protection from mechanical stress. in respect to anaphylactoid reactions, they have the greatest relative risk. hes has the same effectiveness in volume expansion with albumin and has the advantage of remaining intravascular even if there is an increased capillary permeability. in addition, it may improve splanchnic blood flow and tissue oxygenation. hes / . subsides the inflammatory response in patients undergoing major surgery, compared to a crystalloid-based volume therapy, but has conflicting results about it's effects on neutrophil respiration burst. clinical trials have so far failed to have a unanimous conclusion about the bleeding diathesis after hes administration, especially. caution must be held when administering hes during renal transplantation. albumin became the scapegoat of transfusion strategy during the past years. resent met analysis have contradicted results about the safety of albumin infusion in variouw settings. a positive effect seems to have the early administration of hypertonic solutions in trauma patients, especially in combination with dextrans. conclusions: although some minor conclusions can be extracted, there is still a great lack of large scale multicentre randomized prospective clinical trials for extracting evidence based criteria. instead, we try to extract conclusions through met analysis. results show no evidence that resuscitation with colloids reduces the risk of death compared with crystalloids in patients with trauma, burns, major surgery or sepsis. also, there is lack of evidence that one colloid solution is safer -in clinical aspect -than any other. recombinant human erythropoietin therapy in critically ill patients -a dose response study* objective: the aim of our study was to assess the efficacy of two dosing schedules of recombinant human erythropoietin (rhuepo) in increasing hemoglobin (hb) level and reducing the exposure to red blood cells (rbc) transfusion in critically ill patients. design: a prospective, randomized, multicenter trial. patients: a total of patients who met eligibility criteria were enrolled. intervention: patients were randomly assigned to receive intravenous (i.v.) iron saccharate alone (control group), i.v. iron saccharate and subcutaneous rhuepo units once per week (group a) and i.v. iron saccharate and subcutaneous rhuepo units three times per week (group b). rhuepo was given for a minimum of weeks or until icu discharge or death. the maximum duration of therapy was weeks. the requirement for rbc transfusions was significantly higher in control group than that in group a and b. no significant difference was observed between group a and b. the mean increase in hematocrit (dhct) and hb (dhb) from baseline to final measurement were significantly higher in group b than these in control group. dhct was significantly higher in group b than that in group a. dhct in group a was significantly higher than that in controls, whereas dhb did not differ significantly between control and group a. conclusion: administration of rhuepo in critically ill patients significantly reduced the need for rbc transfusions. the magnitude of the reduction did not differ between the low and high dose of rhuepo, whereas there was a dose response of hct and hb to rhuepo in these patients. in transfusion medicine, antibodies to antigens in the platelet membrane have traditionally been regarded as less significant compared with antibodies towards red cell antigens. there is an increasing awareness of antibodies towards platelet antigens. detection of autoantibodies to platelets can be a diagnostic challenge, but is seldom a problem in transfusion medicine because patients with such antibodies rarely are candidates for platelet transfusions. also, severe foetal thrombocytopenia is seldom present in pregnancies with autoantibodies to platelet antigens. the real challenge in transfusion medicine is related to patients with severe thrombocytopenia who are refractory to platelet transfusion due to alloantibodies towards platelet antigens. in our department, flow cytometry is used for compatibility testing and the choice of compatible blood donor is done without knowledge of antibody specificity. if crossmatch negative random donors cannot be identified, antibody specificity testing is performed and donors are chosen based on the specificity of the antibodies determined by a modified maipa procedure and with hla class i beads (flowpra from one lambda, usa) in flow cytometry. in some cases both hla class i and human platelet antigen (hpa) specific antibodies are detected and hla class i, hpa matched donors are chosen for crossmatch. if the crossmatch is negative, there is > % chance of successful transfusions. in some cases drug induced anti-platelet antibodies are suspected and flow cytometry based antibody tests are performed in the presence and absence of the drug. in the case of suspected heparin induced antibodies, a beads assay is performed (diamed, switzerland). two percent of caucasian women have the platelet type hpa bb. ten percent of these women make anti-hpa a antibodies in their first hpa a incompatible pregnancy. in - new-born has thrombocytopenia due to maternal alloantibodies which have crossed the placenta (neonatal alloimmune thrombocytopenia, naitp). results from a screening study covering the outcome of pregnancies show that only babies were born with intracranial haemorrhage (ich) and there was no still-born babies in the study. pregnant women with a-hpa a antibodies were diagnosed, received careful clinical follow-up and the delivery was performed by caesarean section in week of the pregnancy with immediate transfusion of hpa compatible platelets if the new-born had platelet count < ¥ e /l. in previous studies, it is reported the ich appears in - % of the pregnancies where antibodies are present and that % of the babies with ich, die. our results are different from what is reported from other studies and this may reflect the prospective approach and the clinical interventions. naitp represent a challenge in transfusion medicine both diagnostically, but also related to compatible blood products for the thrombocytopenic new-born and the mother who may have high level of antibodies towards platelet antigens. methods: apheresis platelets ( ¥ e mean) from donors with same blood group were pooled and divided equally into two bags, po- and control (pl , baxter), which have and ml/m *day*atm of oxygen permeability, respectively. on days , , , , , and of storage, swirling, mean platelet volume, po , pco , ph, glucose, lactate, aggregation, and p-selectin expression were evaluated. six experiments were performed. results: the swirling pattern was preserved better for up to days in po- ( / ) than in control ( / ) bags. dropped ph less than . on day was observed / in po- whereas / in the control. aggressive drop of glucose ( mmol/l) with prominent lactate accumulation ( mg/l) was also observed on day in of control bags. the po level in the control dropped more significantly by % ( . mmhg) on day than in po- ( . mmhg) compared with the initial level ( . mmhg) (p < . ). these results suggest that aerobic metabolism of higher concentration platelets was maintained better in a container with higher oxygen permeability. and less lactate generation with slower glucose consumption is also suggested in po- bags than in control bags. the %hsr and aggregation decreased gradually in a similar manner in both bags until day , and became a detrimental defect in of control bags on day . p-selectin expression was higher in control bags than in po- on days and with no statistical difference. in two control bags p-selectin expression reached > % and was accompanied by a loss of swirling. these functional and biochemical characteristics of platelets at a higher concentration were kept better for - days when stored in a container with higher oxygen permeability than in the best of marketed containers. t-pa- background: maintenance of a neutral ph in the range of . - . is essential for preservation of platelet function and viability during storage. furthermore, studies have also indicated that the presence of glucose in the platelet suspending medium is important for maintenance of platelet quality. however, a platelet additive solution (pas) containing glucose having a ph of . - . cannot be manufactured by steam sterilization due to caramelization of glucose. in order to have optimal ph, the currently available pas such as t-sol does not contain any glucose. this study describes a novel twostep approach to provide a glucose containing additive solution (pas-g) by using an acid, glucose containing electrolyte solution (ph . ) for resuspension and processing of the pooled buffy coats (bc), followed by transfer of the processed platelet concentrate (pc) into a storage bag containing bicarbonate for ph neutralization and maintenance during extended storage. aim: compare the platelet quality of pooled bc pc stored in pas-g with pooled bc pc stored in t-sol. methods: a paired study design was used, where a pool of bcs obtained from standard day -old cpd-wb units, was divided into two equal parts: one part was resuspended and processed with a pall leukoreduction system (atsbc) using t-sol, the other part was processed in a similar manner with the acid part of pas-g. percentage plasma carryover ranged from - %. both processed pc products were transferred and stored in elx tm bags with the pas-g pc elx bag containing a bicarbonate tablet. ten replicate studies were performed. results: the yields ( . ± . vs. . ± . °¥ e ) were similar (pags vs t-sol). statistically significant (p < . with paired ttest) improved platelet quality at days , , and of storage was observed with platelets stored in pas-g as compared to t-sol. the table below shows results at and days of storage for ph, extent of shape change (esc) and hypotonic shock response (hsr). the results for t-sol stored platelets correlated highly with initial glucose (% plasma carry over) level (r = . for esc, and r = . for hsr at days storage), while no significant correlations were found for pas-g stored platelets. conclusion: this study demonstrated the practicality of using a two step procedure to store bc pc in a glucose containing additive solution with neutral ph during storage, and confirmed the importance of glucose in the storage medium as nutrient for optimal platelet storage quality. the effect of irradiation on white cell reduced platelet concentrates, stored for days background: the storage of white cell (wbc)-reduced platelet concentrates (pcs) can be extended from to days provided the quality has been validated and bacterial screening is performed. irradiation up to gray (gy) does not affect platelet quality, but the effect of pre storage irradiation with subsequent storage up to days is not known. method: two wbc reduced pcs, each made from buffy coats and a unit of plasma, were pooled and divided into control group 'a' and study group 'b' . pcs in group 'b' were irradiated immediately after preparation with gy. pcs in both groups 'a' and 'b' were then stored on a continuous flat bed shaker at - °c. swirl, ph and cd p expression were determined on day , and . twelve experiments were performed and compared with a paired t-test, p < . was considered significant. results: see table (day values; mean ± sd; n = ). pooling and dividing of the pcs was successful with respect to volume and platelet number. on day , the ph in group 'b' was slightly lower than in group 'a', but the difference is not significant. in group 'a', ph on day was < . in / pcs, versus / in group 'b' (not significant). the cd p expression in irradiated pcs is not significantly higher than in non-irradiated pcs. conclusion: irradiation had no significant effect on platelet quality when stored for up to days after blood collection. - b, - a, - b, pra %, donors. in patient -three transfu-sions were effective (two crossmatches neg by lct and pift, one pos lct, neg pift) but later on, when the patient was in severe clinical status (shortly before his death) two transfusions were ineffective in spite of neg crossmatches. it is very likely that for the same reason patient and were refractory to two and one hpa compatible platelet units respectively. in patient and compatible platelets were not transfused because they died before the whole procedure (diagnosis and finding a proper donor) was completed. conclusions: . the frequency of occurrence of anti-hpa antibodies in transfused patients was: - b, - b, - b, - a, - a; in three patients they were monospecific, in four polyspecific. . in patients who developed anti-hpa alone, transfusions of platelets without relevant hpa antigens were successful. .the effectiveness of compatible platelets in patients with both anti-hpa and -hla was more difficult to assess because of their severe clinical status, which might have been responsible for transfusion failure. in one of these patients, however, the transfusions of compatible platelets were successful when he was in relatively good clinical status, but shortly before death transfusions were ineffective. t-pa- the successful implementation of nucleic acid testing (nat) for hiv, hbv, hcv and further viruses as well as improved donor selection led to a dramatic risk reduction for viral transmission via blood transfusion over the last years. today, other risks get into the focus of haemovigilance. bacterial contamination of blood products can occur via the donor, suffering from a (clinically unapparent) bacterial infection, or via the donation process itself, storage and handling of the blood product. particularly platelet concentrates (pc) are vulnerable to bacterial growth due to their storage conditions. patients receiving such products have a potential risk of severe complications or even death. modern hygiene regimes, e.g. improved disinfection of the donors´ skin or preparation of blood products in fully closed systems as well as diversion, led to a significant reduction of bacterial contamination risk in the past. however, a small risk remains. therefore, two possible ways of further reducing the risk of bacterial contamination of blood products are feasible: (a) testing and/or (b) inactivation. testing for bacterial contamination is possible by different methods: direct detection methods for bacteria (microscopy, flow cytometry) have disadvantages regarding sample size and detection limit. bacteria might rapidly grow in a contaminated pc, so testing should be performed as close as possible to transfusion to the recipient. biochemical methods like oxygen consumption might not detect anaerobic germs. automated culture methods are still the most sensitive technique, but they have their downsides as well (e.g. time and size of aliquot drawn). novel molecular genetic test methods for detection of bacterial nucleic acid are in different states of development, but still have to proof their suitability for routine use. three different principles of pathogen inactivation can be distinguished: photodynamic reactions produce oxygen radicals which in turn inactivate bacterial structures by oxidation processes. examples for these chemicals are phenothiazines like methylene blue and thionin as well as vitamins like riboflavin (vitamin b ). photochemical reactants penetrate cell boundaries and irreversibly inhibit nucleic acid, thus blocking replication and proliferation of pathogens. chemicals of this group are psoralens like amotosalen as well as pen- or s- . the third method, the solvent detergent (sd) method, is used for pooled plasma only and consists of the combination of both solvents and detergents, which interact with membranes and destroy bacteria. methods for inactivation of bacterial contaminants have to proof, that they effectively inhibit bacterial growth while maintaining full functionality of the blood product at the same time. these two qualities have to be fulfilled up to the end of the storage period. toxic or mutagenic compounds must not remain in the final product. the technology must be easily integrated into the existing work cycle of a blood bank. finally, costs per product must be acceptable. in summary, both testing and inactivation have their advantages and disadvantages, which have to be weighed up against costs and benefits of both procedures. pros and cons of introduction of inactivation methods in a blood donor service producing blood components per year will be discussed. bacterial contamination of blood components, particularly platelets, is now recognized as a serious adverse reaction that is preventable. there are many studies that have documented that these reactions occur from platelets stored at room temperature, most commonly arising from a skin contaminant, but originating from donors with asymptomatic bacteremia in about / of cases. the problem is intensified for patients receiving pools of platelets compared to single donor platelets collected by apheresis. reactions are more commonly noted and more severe with platelets stored for greater lengths of time. previous studies at johns hopkins described a series of reactions in years with reactions more common in platelet pools ( : transfusions) than with single donor platelets ( : transfusions). these reactions caused fatalities in of cases. although our data suggests that these reactions are more common than other studies using hemovigilance systems, our case definition requiring culture of all transfusion reactions to platelets led to a more reliable estimate of the incidence of sepsis from platelets, many potential solutions have been proposed to prevent these reactions. improved skin antisepsis should always be sought but will never eliminate the / of reactions due to asymptomatic bacteremia. the same limitation applies to methods that divert potential skin plugs from the collection bag. antibiotics in the bag would lead to manufacturing concerns or problems for patients with drug allergies. although cold storage of platelets is currently being revisited, it is not yet a practical solution. pathogen eradication systems have been developed but they remain unapproved in most of the world and have led to concerns about toxicity of additives, damage to treated cells, and cost. as a result of increasing recognition of the problem, there has been increased interest in bacterial screening to prevent sepsis from platelets. in march , the aabb standards required testing of platelets for bacterial contamination. testing programs have been implemented in the us widely as a result of the aabb action. licensed systems based upon bacterial culture or growth characteristics are available for single donor platelets and have been commonly employed. although these systems have some difficulty with false positive reactions, the evolving national data suggest an incidence of : true positive reactions. these data suggest that a number of serious reactions have been averted, although some cases have persisted due to incomplete adoption, problems with slow growing bacteria, or the use of inferior testing methods with inadequate sensitivity. whole blood derived platelets have become a more difficult issue, since the approved testing methods are limited. the use of ph monitoring, gram stain, glucose measurements, and inspection for swirling have all been attempted. these methods are not sufficiently sensitive or specific to interdict many contaminated units, so that screening for bacteria in pooled platelets is less effective. it is anticipated that new methods may become available to make screening of whole blood derived platelets easier to perform in a reliable manner. it is also hoped that bacterial screening of platelets may form the basis to permit seven day storage and prestorage pooling in the us. results: twenty four hcv rna (+)/anti-hcv(-) repeat donors were previously tested in routine hcv rna in mini-pools and were negative. twenty available look back samples were individually tested for hcv rna and in one the virus was detected. to make sure that the failure of hcv rna detection in routine nat was not due to the pooling procedure, the hcv rna was tested in undiluted look back sample and dilutions of this sample by hcv negative plasma: / repeats of x dilution and / repeats of x dilution were hcv rna negative, whereas / repeat of x dilution and / repeats of undiluted sample were positive. the results of cobas amplicor monitor (sensitivity iu/ml) were negative, which means that viremia in hcv rna mini-pool negative donation was below iu/ml. in the recipient of red blood cell concentrate from this donation hepatitis c was diagnosed. however, the possibility of pretransfusion hcv infection cannot be excluded as no hcv marker tests were performed before transfusion. the patient and the donor were infected with genotype a. the low hcv viremia (below iu/ml) in the preseroconversion window period was responsible for no hcv rna detection in routine mini-pool hcv rna testing. introduction and aim of the study: bacterial contamination is a life threatening risk of blood transfusion, especially with platelet transfusions. bacterial culturing (bc) of platelets as well as pathogen reduction (pr) reduce the likelihood of such contamination. where the costs of bacterial contamination are far less than the costs of pathogen reduction, the latter will reduce not only the risk of bacterial contamination but also risks of other pathogens. therefore, the question arises whether this additional expenditure can be justified in the light of the additional effect achieved. this question we will answer by cost-effectiveness and sensitivity analyses. methods: the balance between costs and effects of preventing adverse events due to platelet transfusion is assessed using a mathematical model and assuming optimal effectiveness of pr. model parameters and valuations of health states were obtained from literature and information from dutch sanquin blood banks. . while the estimates in comparison to the situation without bc or pr are surrounded with large uncertainties, the conclusion that pr is not cost-effective in comparison to bc is very robust. the cost-effectiveness of bc and pr are very sensitive to the estimates concerning sepsis probability and associated complication rate, the cost-effectiveness of pr relative to bc is not. this conclusion is also insensitive to a wide range of assumptions regarding residual risks and costs associated with hiv, hcv and hbv. the estimates indicate that culturing in the netherlands is cost-effective, even with the deviation bag in place. the estimates however appear to be very sensitivity to the probability of sepsis. a decision to use pr will, after the introduction of bc and the use of a deviation bag, never meet cost-effectiveness criteria. even when assuming perfect protection, the conclusion that it is not cost-effective in comparison to bc is very robust and does not alter when varying underlying parameters within their margins of uncertainty. table) . of cb collection. two collections have been transplanted to date and this represents a . % take-up rate ( . % where a sibling is alive). this compares favourably with the numbers transplanted from unrelated cb banks. dcb collection is therefore at least as efficient a method as unrelated cb collection for transplantation albeit in the limited number of cases where a dcb collection is possible. dcb collection has the benefit of a possible immediate transplant combined with the availability of a sibling donor for future donation of both stem cells and lymphocytes. it is therefore a useful service to provide and complements the work of unrelated cord blood banks. increased yield of mature platelets in cultures of cd -enriched cord blood cells maintained at °c introduction: the future use in transplantation of ex vivo expanded hematopoietic stem (hsc) and progenitors cells will facilitate the transplantation of adult patients and speed up hematologic recovery. also ex vivo cultures of hscs may eventually permit to produce donor-free blood components such as platelets for transfusion. culture of animal cells is routinely done at °c. however there is previous clinical evidence suggesting that hematopoiesis may be more active in hyperthermic patients. we have therefore compared the effect of hyperthermia on the ex vivo expansion and differentiation of cord bloodderived hsc in megakaryocytes (mk) and mature platelets. the cord blood-derived cd cells were cultured continuously at °c or °c for days in cytokine conditions optimized for mk development and maturation. the cultures were regularly monitored for various parameters. results: compared to °c, the cultures maintained at °c produced significantly more total cells ( . fold) and total mks ( fold), and showed accelerated and enhanced mk maturation with increased yield of proplatelets and mature platelets ( . fold). accordingly, the cells cultured at °c contained an increased frequency of cfc-mk ( fold) at day . cultures done at °c and °c were also more efficient than at °c but less than at °c. platelets produced in °c cultures could be normally activated by thrombin. as expected, the cells cultured at °c contained an increased amount of the heat shock protein hsp . control experiments showed that the culture of several cell lines was inhibited or unaffected by the °c temperature. the unexpected resistance of hematopoietic cells to the deleterious effects of heat and the stimulatory effect of > °c temperatures on hsc proliferation and differentiation indicate that the routine culture of normal human cells at °c is a paradigm that needs to be revised. the responsible molecular mechanisms remain to be identified but the observation will facilitate the ex vivo expansion of the progenitors of the mk and possibly other lineages. the synchronous generation of a significant number of mature platelets in vitro will facilitate the study of the mechanisms of platelet formation and ageing and could eventually have important applications in transfusion medicine. it remains to be seen if the stimulatory effects of higher than °c temperatures represent a protective response against sustained body fever that is specific to the hematopoietic system. several countries have, in the past few years, included human tissue banking within a regulatory framework similar to that of blood. indeed, tissue safety has come to the forefront of the preoccupations of regulatory agencies after several well publicised morbidity and mortality cases have been reported in the press. tissue safety has many features similar if not identical to blood safety and a review of those common elements will be reported. as well, arguments in favor of integrating tissue banking within a blood system will be discussed, one of the more important aspect of which being the expertise of the blood centre staff with cgmps. the experience of a blood establishment (héma-québec) with the integration of tissue banking such as bone, skin, heart valves within its operations will be reported, emphasizing the medical as well as the management aspects of such an integration. finally, tissue banking is an activity which brings more expertise to a blood centre, expands its knowledge of its customers and gives more opportunities to its personnel. umbilical cord blood (cb) is an important source of stem cells for clinical transplantation and may cause less gvh disease than non-t-depleted bone marrow (bm). the relatively low numerical cell dose available from cb has usually restricted its use for transplantation in adults. only - % of patients have an hla matched sibling and for others an unrelated bm or a stored unrelated cb donation may also not be available. for some children the collection of cb following the birth of a sibling may be the only opportunity for a transplant. directed cb (dcb) donations from matched siblings have been shown to give better long-term overall results than matched unrelated cb or bm. dcb collection is however not as easy to control as cb for banking where dedicated hospitals and trained staff are used. here we review dcb banking in oxford over a . -year period. requests were received for deliveries from mothers and of these, collections were successful including pairs of twins. failed collection was most often due to a damaged cord at delivery. collections were made for siblings possibly requiring transplant (median age ) with for leukaemia, for erythroid disorders, for immune deficiency, for enzyme deficiency and others. the remaining collections were mostly requested where there was a family history of an inherited disorder (majority scid). three collections tested positive for anti-hcv antibody but negative for hcv by pcr. collections were not excluded on the basis of volume or cell number. mean volume was ml (range - , % exceeded mls) and mean tnc count was . ¥ (range . - . , % exceeded . ¥ ^ ). the mean cd +ve count was . ¥ (range . - . ). all collections were cryopreserved within hours using dmso/dextran/saline without volume reduction. the mean tnc viability prior to freezing was % (range - %) and the mean cd +ve viability post freezing was % (range - %). the reliance on the goodwill of midwives and the logistical difficulties that arise when organising collections from many different hospitals do not appear to reduce the success . rhd and rhce typing was performed by multiplex-pcr with fluorescent primer pairs. positive results were obtained for rhd-exons - , , and polymorphisms associated with antigens c, c, cw, e and e. sequencing of rhce-sequences, including exons to and intron/exon borders, were done by direct taq cyclesequencing using bigdye-terminators v. . in an abi (applied biosystems). background: a number of adverse immune reactions associated with blood transfusion result from contamination of blood products by donor white blood cells. among these reactions, transfusionassociated graft-versus-host disease (ta-gvhd) has a mortality of greater than %. mirasol ® pathogen reduction technology (prt) has been developed for the reduction of viruses, bacteria, parasites and white blood cells loads in blood products. the technology is based on light and riboflavin photochemistry. this study was performed in order to evaluate the effectiveness of the mirasol ® prt process for inactivation of human pbmncs. methods: human pbmncs were collected from trima platelet apheresis disposable sets, purified by ficoll-hypaque discontinuous gradient centrifugation and divided into test and control samples. the test cells were treated with mirasol ® prt in autologous plasma on day . both test and control samples (n = ) were tested on day for cellular immunophenotype, t-cell activation using flow cytometry, proliferation in response to mitogen or allogeneic stimulator cells, ability to stimulate the proliferation of allogeneic responder cells and cytokine synthesis in response to lps stimulation was measured using a cba assay kit. results: although mirasol ® prt treatment did not significantly change the distribution of cd +, cd +cd +, cd +cd +, cd + and cd +cd + human lymphocyte subpopulations there were significant functional change. the expression of the activation marker, cd , was observed in . % (sd = . %) of control t cells upon activation with pma, while only a . % (sd = . %) of the test t cells increased cd expression. proliferation assays showed that h-thymidine incorporation did not increase in the test cells in response to either pha or allogeneic stimulator pbmnc compared to the significant increase in thymidine incorporation levels observed with control cells. the test cells, when compared to the controls cells, demonstrated an inability to stimulate allogeneic responder pbmnc proliferation. the release of il- , il- , il- b and il- cytokines after -h incubation in culture media increased significantly to pg/ml (sd = ), > pg/ml, pg/ml (sd = ) and > pg/ml for control cells, respectively. under the same conditions, these cytokines in test samples remained at background levels of . pg/ml (sd = . ) for il- , . pg/ml (sd = . ) for il- , pg/ml (sd = ) for il- b and pg/ml (sd = ) for il- . addition of lps further stimulated the release of tnf-a, il- , il- , il- b and il- in the control samples, but not in the test cell samples. in vitro studies demonstrate that mirasol ® prt treatment does not change lymphocyte immunophenotype, inhibits tcell activation by pma, abolishes pbmnc proliferative activity, eliminates pbmnc stimulatory activity for responder cell proliferation and suppresses the production of cytokines by pbmnc in both the absence or presence of lps. introduction: it has been discovered that vaccination of dendritic cells (dcs) with tumor antigens is a potential strategy to induce tumor-specific immunity in tumor-bearing patients. aim of the study: the purpose of the study was to investigate whether human monocyte-derived dendritic cells (dcs) were able to present p bcr-abl protein and induce antigen-specific ctl responses in vitro after transfected with total rna of k cells (k -rna). methods: dcs were derived from human pbmncs, which were incubated for days in the presence of gm-csf and il- , and then were transfected with k -rna using electroporation or dotap lipofection. to verify the successful transfection of dcs with k -rna, bcr-abl fusion genes expression of dcs was detected by rt-pcr and western blot. the immune phenotypes of the dcs were analyzed by flow cytometry. the cytotoxicity of ctl was assayed by propidium iodide (pi) staining and flow cytometry. results: it was shown that the bcr-abl fusion gene was detected in the dcs immediately after the transfection, but disappeared hours later, while the cells were expressing p bcr-abl protein and expressing increased cd , cd , cd , hla-dr. moreover, the transfected dcs could significantly promote the t lymphocytes to kill the target k cells. conclusion: human dendritic cells transfected with total rna of k cells in vitro could induce effective p bcr-abl proteinspecific immune responses and be used to induce tumor-specific immunity, which implies potential application of immunotherapy to tumors. appear to be relevant to the clinical response. ivig has a remarkably good safety record for long term administration, however the following side effects have been observed: mild, infusion-rate related reactions such as headaches, myalgia or fever; moderate but inconsequential events, such as aseptic meningitis and skin rash; and severe, but rare, complications such as thromboembolic events and renal tubular necrosis. judicial use of ivig based on results from controlled studies is recommended. t-pl - donor-lymphocyte infusion: transfusion immunotherapy following allogeneic hematopoietic transplantation the notion that bone marrow containing immunocompetent cells is capable of mediating an antitumor effect was determined experimentally almost years ago. subsequently, pooled leukocytes from patients with cml were found to effect responses in patients with advanced leukemia. response correlated with cell dose and with severity of gvhd. in the 's, the graft-versus-leukemia (gvl) effect was defined in the transplant setting using a lethallyirradiated mouse model and splenocyte infusions. such studies suggested that gvl could be enhanced without causing severe gvhd. the era of adoptive immunotherapy in the transplant setting began in the 's with reports of donor lymphocyte infusions (dli) for relapsed acute and chronic leukemias after bone marrow transplant. it is now clear that chronic myelocytic leukemia (cml) in chronic phase is highly susceptible to gvl effects mediated by dli which induce durable remission in - % of relapsed patients. the success rate is % or less in patients with accelerated phase or blast crisis. since dli cell dose appears to be important in this setting, strategies of escalating dose infusions have been investigated to enhance gvl without exacerbating gvhd. unfortunately, the response to dli in relapsed acute leukemia and myeloma is less favorable (< %) and less durable. dli have been used successfully to treat viral infections and virus-associated malignancies following transplant. both unfractionated dli and ex vivo-generated tcell clones have suppressed reactivated cytomegalovirus and eradicated epstein-barr virus-induced lymphoproliferative disease, a polyclonal proliferation of donor-origin b cells that occurs after transplant. where tumor-specific antigens have been defined, efforts to target dli have been undertaken and donor and patient immunization has been investigated. acute or chronic gvhd develops in approximately % of patients receiving dli for relapsed hematologic malignancies and for related, but not unrelated transplants, correlates with the donor t-cell dose. dli-induced pancytopenia occurs in approximately % to % of patients, is generally mild, and transient, but in < % of patients, aplasia is severe and prolonged. complications of aplasia include infection, bleeding, increased transfusion requirements. efforts to limit the adverse effects of dli while retaining the therapeutic effects include insertion of 'suicide genes, ' selection of lymphocyte subpopulations, and targetting lineage-specific minor histocompatibility antigens. available clinical and experimental evidence suggests, that in addition to primary and secondary immune deficiencies, a wide spectrum of immune-mediated conditions could benefit from intravenous immunoglobulin (ivig), including acute and chronic/relapsing diseases, autoimmune diseases mediated by pathogenic autoantibodies or by autoaggressive t cells and inflammatory disorders e.g. an imbalance in cytokine networks. trimar-collected apheresis platelet concentrates (pcs) were exposed to . j/ml uv light in the presence of um riboflavin, followed by storage under blood bank conditions with various concentrations of -deoxyglucose from to mm for days. the control platelets were not stressed by uv light exposure and were stored under the same conditions without -dog presence. all test and control platelets were measured for in vitro cell quality including rates of glycolysis, morphology score and activation levels at days , , and . results: lactate production and glucose consumption increased from . mmol/ cells/h (sd = . ) and . mmol/ cells/h (sd = . ) for control samples to . (sd = . ) and . (sd = . ) for uv-treated platelets, respectively. uv treatment also caused a decrease in ph from . (sd = . ) for controls to . (sd = . ) for treated platelets at day , hsr from % (sd = . ) to % (sd = . ), esc from . % (sd = . ) to . % (sd = . ), swirl from . (sd = . ) to . (sd = . ), and increased p-selectin expression from . % (sd = . ) to . % (sd = . ). addition of -dog up to mm significantly reduced lactate production rate to . mmol/ cells/h (sd = . ) and glucose consumption rate to . mmol/ cells/h (sd = . ), and maintained ph above . (sd = . ) for days of storage. the effect of -dog exhibited a dose-dependent response. however, the addition of -dog had no effects on hsr ( . + . % at day ), esc ( . + . % at day ), swirl ( . + . at day ) and p-selectin expression ( . + . % at day ) during platelet storage. atp contents in both treated and control groups were maintained at a relatively constant level above % of the value seen in fresh platelets. furthermore, an exaggeration of uv-stressed platelet aggregation by addition of -dog was also observed. conclusions: increased glycolytic flux is not a direct cause for platelet morphology changes and spontaneous activation incurred during the development of the storage lesion. the results also suggest that a reduction in glucose utilization may foster an increase in platelet loss during storage. aim of the study: was to evaluate analytical sensitivity, sensitivity and inclusivity for subtypes and genotypes of hiv, hcv and hbv, the assay's effectiveness in closing the pre-seroconversion window period, clinical specificity as well as the effect of endogenous substances and microorganisms on the sensitivity and specificity of the assay. methods: secondary standard traceable to who international standard for hiv- ( / ), international standards for hcv ( / ) and hbv ( / ) were used to determine the analytical sensitivity. sensitivity and inclusivity for hiv- subtypes other than hiv- b, for hiv- and for hepatitis b and c genotypes as well as specificity was evaluated with > specimens. results: results from this study indicate that high analytical sensitivities ( iu/ml hiv- m, cp/ml hiv- o and . cp/ml hiv- , iu/ml hcv and iu/ml hbv) and a specificity of > . % are accomplishable for the mpx test. the % detection rate for hiv- m subtype isolates (a through h) was between to iu/ml, for hcv genotype isolates ( a through ) between to iu/ml and for hbv genotype isolates (a through g and precore mutant) between to iu/ml. investigating seroconversion panels, hiv- rna was detected an average of and days earlier than hiv- antigen with abbott hivag- monoclonal and coulter p antigen tests, respectively, hcv rna an average of or days earlier than hcv antibody with the abbott hcv eia . or ortho eia . tests, hbv dna an average of days earlier than hbsag with the abbott hbsag eia imx test. for all targets, no interference was detected with microorganisms tested as well as elevated levels of triglycerides, albumin, hemoglobin, human dna or bilirubin. conclusion: automated pooling, sample preparation, and real time pcr using the blood screening system taqscreen mpx test is an efficient and sensitive method to simultaneously screen for five important viruses in human plasma. the mpx test is another evolution step in the development of pcr automation by roche molecular diagnostics, and further represents roche's commitment to increasing the safety of the global blood supply. aim of the study: a prospective hemovigilance plan was set up in order to establish a registry for future reference, and to detect any unexpected side effect of ip that may occur with significant frequency in populations and indications that were not studied before and outside of a formal trial environment. methods: this plan is proposed to blood establishments and transfusion prescribers who have already decided to implement ip. this is an observational, non randomized, non controlled plan. no patient selection, inclusion or exclusion criteria are required. all ip transfusions are documented using an internet form, whether or not a reaction is observed. patient population data are collected anonymously, for epidemiological purposes. results: between october and september , apheresis ip units have been transfused in sites and registered in the database. ip platelets were considered leucocyte inactivated and were not irradiated, but were antigen matched as indicated ( . %). the population of patients receiving at least one transfusion (n = ) included . % of males, . % of females, the median age was (range - ). the most frequent broad diagnostic categories were hematology-oncology ( . %) and cardiovascular surgery ( . %). the patients received their transfusions either in regular hospital wards ( . %), intensive care units ( . %) or as outpatients ( . %). the number of transfusions by patient ranged from to (mean . ± . , median ). half of the patients ( . %) had previous transfusion experience and . % had previous history of transfusion reaction. transfusion reactions, defined as any deterioration of the patient's state of health observed following transfusion, were observed in . % (n = ) of the transfusions ( % ci . - . ), and . % of patients. only ( . %) were considered serious. after further causality analysis including biological and clinical investigations by the transfusion physician, . % ( % ci . - . ) of the transfusions were confirmed as having caused reactions in . % of patients, none of them serious. the most often reported symptoms were chills ( . %) and fever ( . %). itching, skin rash or urticaria was observed in . % of transfusions. of the serious reactions, one was hypotensive shock in a patient with liver cirrhosis and haemorrhage, and one was septic shock, in which the platelet unit bacterial culture was negative. none of the reactions occurred in cardiovascular surgery patients. patients were more likely to experience reactions if they had previous transfusion history (odd ratio . , p = . ). the active hemovigilance plan is a valid and feasible method to collect epidemiological data on transfusion safety. the risk profile of ip transfusions appears favorable. quality of theraflex mb-plasma during storage and treatment s reichenberg* and n mÜller † *maco pharma international gmbh, langen, † inst. for transfusion medicine, essen, germany background: although in the last decades thanks to the implementation of several methods like donor selection and testing procedures the risk of virus transmission from plasma has decreased, infection of patients still exists. additionally new viruses like west nile virus enter the transfusion chain. therefore, the treatment of therapeutic plasma with methylene blue (mb) is a technique used in several european countries for pathogen inactivation. macopharma has developed the proprietary theraflex mb-plasma bag system including a mb pill and a final mb filtration step. aims: aim of the study is to show the quality of the mb plasma during the preparation procedure and during storage using the theraflex system. methods: for the preparation process every single step was evaluated using single donor plasma units. for the evaluation of the plasma factors ml were drawn at different stages (before treatment, after plasma filtration with plas , after dissolution of the mb pill, after illumination, after treatment). because the sample volume for single sample measurements would be too low the samples were pooled after drawing and measured for the specified factors. six samples of each stage were pooled at three days. a whole panel of plasma factors was measured for the resulting three pools. global tests: quick, inr, aptt, thrombin time coagulation factors: fibrinogen, factor ii, factor v, factor viii:c, factor ix, factor x, factor xi inhibitors: at iii, protein c, protein s fibrinolysis: plasmin inhibitor, alpha -antitrypsin complement: ch activation: tat, factor xiia, d-dimer stability data were generated using three plasma pools. six plasmas were pooled and afterwards divided into six aliquots. each was treated as single unit and then each was divided into six storage samples. the same plasma factors as for the manufacturing process were evaluated. results: a moderate reduction for some coagulation factors during the preparation was found in the illumination step but not in the other preparation stages. this was mainly fibrinogen ( . %), factor viii ( . %), and factor x ( . %). despite this reduction the values were within the ranges found in non-treated plasma. all investigated plasma factors remained stable during the investigated storage time. summary/conclusions: the investigation showed that plasma treated with the theraflex procedure showed slight reduction during treatment and no reduction during storage. all plasma factors remained within the threshold values. the treatment of therapeutic plasma with mb is a valid technique of pathogen inactivation. validation of intercept treatment of pooled platelets g santos, c silva, f pereira and g sousa lisbon regional blood centre, lisbon, portugal background: intercept blood system for platelets uses amotosalen hcl and uva light to inactivate viruses, bacteria, protozoa and leucocytes that may contaminate platelet products. aims: the purpose of the study was to assess the feasibility of introducing this technology in the routine of lisbon regional blood center (crsl) and validate the procedure in our center. material and methods: whole blood units of ml were collected from volunteer blood donors in quadruple top and bottom blood bags (optipure rc soft t& b baxter), kept in n-butanodiol plates; buffy coats with a volume of ml were obtained in the opipress ii and kept overnight at room temperature before pooling. five buffy coats were pooled with ml intersol using the octopus system intercept buffy coat pooling set with an integrated filter. the pools were treated using the intercept. samples were taken before treatment, after cad remotion, on days , and . the following tests were performed: platelet count, mean platelet volume, ph, swirling. results: all pools met the intercept guardbands. platelet yield pre inactivation was . ¥ ( . - . ¥ ; sd- . ). platelet pool volume was . ml (sd- . ). plasma % was within . % and . %. all pools had leucocytes within council of europe specifications. after photoinactivation the platelet concentrates had . ¥ (± . ). the average platelet loss was . ¥ . the ph was within specifications during all the storage period. conclusions: intercept treatment of pooled buffy coat platelets is feasible in the routine of crsl and in vitro parameters do not show significant changes, allowing us to proceed to clinical use. shown ip and conventional platelets (cp), stored for up to days, exhibit comparable hemostatic efficacy and safety. extension of platelet storage duration to days has the potential to improve platelet availability and reduce outdating and inventory shortages. clinical efficacy and safety of ip stored for days were investigated. methods: a randomized, controlled, single-center, crossover, noninferiority design (pilot) study evaluated efficacy and safety of buffy coat ip vs buffy coat cp, each stored for days. patients were randomized to receive one -day ip transfusion and one -day cp transfusion in random order. after each study transfusion, the hour platelet count, ci, and cci; time to next transfusion; bleeding response; transfusion reactions; and serious adverse events (saes) were assessed. the primary endpoint, -hour cci, was analyzed by a one-sided non-inferiority test for the per protocol population (patients with both transfusions and no major protocol deviations interfering with efficacy evaluation). the per protocol population included patients, randomized to the ip-cp sequence and to the cp-ip sequence. more patients received allogeneic stem cell transplant in the cp-ip sequence than the ip-cp sequence ( % vs %; p = . ). mean platelet dose (¥ e ) was . for ip and . for cp (p = . ). there was a significant period by treatment interaction (p = . ) at the . significance level; therefore, the first period only was also analyzed for the primary endpoint. including both treatment periods, mean (±sd) -hour cci (¥ e ) was . ± . for ip vs . ± . for cp. the mean paired difference for both sequences was . ¥ e (p = . by non-inferiority test; upper bound of the % confidence interval = . ). for the first period only, mean -hour cci (¥ e ) was . ± . for ip vs . ± . for cp) the mean paired difference for the first period sequences was . ¥ e (p = . by non-inferiority test; upper bound of the % confidence interval = . ). the non-inferiority margin for the study was . ¥ e for mean treatment difference in cci (cp-ip). median time to next transfusion was h for ip vs h for cp following the first transfusion (p = . log-rank test; data censored at days after transfusion) and h ip vs h cp after the second transfusion (p = . ). bleeding pre-or post-transfusion was uncommon, usually mucocutaneous, and grade or lower, and responded similarly to ip and cp. no significant transfusion reactions or saes were reported. in this double-blinded, two-treatment crossover study the primary endpoint regarding -hour cci was not met. however, transfusion with -day-old platelets treated by the intercept blood system showed only a marginally and probably clinically insignificantly lower -hour cci compared to -day-old conventional platelets. methods: new zealand white rabbits were transfused with syngeneic blood ( ml/kg), across a major antigen (hgd) mismatch. high anti-s- ab titers (≥ : ) were induced after repeated immunization (days , , , , ) with klh-(s- ) hapten (klhhapten) in complete freund's adjuvant. ab titers against srbc were determined by gel card agglutination, or by facscan with fitc-goat_anti-rabbit_igg. survival of infused rbc ( ml/kg) treated with different methods was assessed by rbc biotinylation. blood samples were taken , , , , and days after transfusion, analyzed using streptavidin_pe and facscan to determine the proportion of circulating biotinylated rbc. results: groups (g) of rabbits were transfused with control rabbit rbc (crbc; n = , g ), or o-srbc (n = , g ). no ab against o-srbc developed after biweekly transfusions over weeks in g rabbits. high ab titers to o-srbc could however be induced by klh-hapten immunization in a different group of animals (n = ; g ). transfused rabbits (g & g ) exhibited no change in hematocrit or body weight and maintained good vital signs. high titer anti-s- abs were then induced by klh-hapten immunization in rabbits from g (n = ) and g (n = ), and in a group (n = , g ) of naïve rabbits. non-immunized rabbits (g , n = ), and (g , n = ) were maintained on the biweekly transfusion schedule of crbc and o-srbc, respectively. all rabbits treated with klh-hapten developed comparably high ab titers. klh-hapten immunization did not affect the viability of crbc in g rabbits. transfusion of o-srbc demonstrated reduced viability in hyper-immune g rabbits, but not any of the g rabbits. g rabbits exposed to o-srbc transfusions prior to hyper-immunization with klh-hapten, had viability of o-srbc comparable to crbc, suggesting induction of immune tolerance by repeated exposure to o-srbc. after depletion of labeled o-srbc from circulation, g and g were transfused with m-srbc. viability of m-srbc in all g rabbits (hyper-immune or not) and the hyperimmune g rabbits was equivalent to crbc circulation in g rabbits. in pre-immunized rabbits with high titer anti-s- ab, o-srbc are cleared faster than control. in contrast, m-srbc survive normally in rabbits with high anti-s- ab titers. repeated transfusion of o-srbc does not result in alloimmunization of naive rabbits. the modified s- rbc process offers the potential for pathogen inactivation with elimination of immunoreactivity and retention of rbc viability. introduction: the bombay phenotype is extremely rare and characterized by complete absence of abh activity both on erythrocytes and in secretions. those individuals can produce anti-h, which is active over a wide thermal range. method: using liss indirect antiglobulin technique, the patient's serum showed + reaction by panel of eleven cells at room temperature phase as well as indirect phase while the auto reaction is negative. a cold adsorption using rabbit erythrocyte stroma was done to remove the cold antibodies from the serum; + reaction of an antibody was detected in the patient serum after five folds of rabbit erythrocyte stroma adsorption. introduction: immunohematology reference laboratory in kuwait central blood bank receives samples from all hospitals in kuwait both governmental and private sector. the laboratory performs the tests according to international standards and it is monitored by internal and external quality assessments on periodic basis. material and method: a tube and gel cards are two methods in the reference laboratory for antibody identification. the laboratory can identify the most commonly encountered clinically significant antibodies and investigates causes of positive direct antiglobulin test that occur mostly in autoimmune hemolytic anemia. there are facilities to phenotype most of rare red blood cell antigens. results: records of all patients investigated in the laboratory since the year are kept in computerized system that has patient's records. central blood bank has the potential to identify rare phenotypes such as kpb-, jsb-, lan-, bombay, rzr , rzr , r¢r¢, r¢r≤, r≤r≤, ge- , , and rare red blood cell antibodies such as high frequency antibodies anti-k, anti-ge , anti-h, anti-lan, anti-kpb, anti-jsb, anti-wrb, anti-ena, anti-csa and low frequency antibodies anti-kpa-, anti-jsa-, anti-dia, anti-lua, anti-cob as well as hightiter-low-avidity antibodies such as anti-chido. samples of rare red blood cells and rare serums are kept frozen either by glycerol or liquid nitrogen technique to be used for pre-transfusion compatibility testing and continuing educational program. purpose of the work: to present the substitution of the blood groups o, a, b, ab in abo blood group system and rh (d) blood group in rh (d) blood group system in the population in the gevgelija-valandovo region. material and methods: a retrospective analysis was done on the data of following the blood groups o, a, b, ab and d in the blood group system abo and rh in the gevgelija-valandovo region. the asked population are voluntary blood donors, candidates for drivers, patients, pregnant women and newborn children. the period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) was analysed. the examinations were done with two standard methods (on the plate and in tube), to define blood groups from the most represented blood group systems abo and rh in the population. tests were done with different series of commercial anti serum tests from domestic and foreign origin. results: totally . examinees were typified. with o blood group were . ( . %); with blood group a were . ( . %); b blood group . ( . %) and ab blood group were . ( . %) examinees. totally . ( . %) were d positive and . ( . %) were d negative. discussion: the given results from our examinations for the frequency of o, a, b, ab and rh (d) blood groups from abo and rh (d) blood group systems in the region gevgelija-valandovo show that the most present is the blood group a from abo blood group system . ( . %) and d blood group in rh system with . ( . ) form examined population. the results are in correlation with data from the literature for other european nations. introduction: the policy of our center is to transfuse all heamatologic multitransfused patients with their own rhesus and kell phenotype. in addition, thalassemic and young leukemic patients are being transfused with compatible phenotype of the most clinical important duffy and kidd systems while all the other patients receive blood compatible only with abo and rhesus system. nevertheless, it is observed a significant positivity of the indirect antiglobulin test, due to alloimmunization. aim of the study: in this study we tried to evaluate the prevalence of alloimmunization in patients of our region. the most frequent detectable alloantibody remains the anti-d, with high prevalence . % of anti-d in females versus . % in males, due to alloimmunization during the pregnancy. as a consequence, the high incidence of anti-d is not transfusion related and anti-e is evidenced to be the most frequent transfusion related alloantibody, followed by anti-kell. care must be taken in order to transfuse as more patients as possible with their own phenotype regarding, at least the most immunogenic antigens, like anti-e and anti-kell. severe hemolytic reaction due to anti-j k background: red blood cell alloantibodies directed against antigens of the kidd system are notorious for causing delayed hemolytic transfusion reactions. the antibodies are formed because of pregnancy or transfusion. blood donors with the red blood cell (rbc) phenotype jk(a-b-) are extremely rare in the white population and exhibit a frequency of less than . %. however, the rare phenotype jk(a-b-) is more common in polynesians ( . %). individuals with jk(a-b-) phenotypes typically form anti-jk with inseparable anti-jka and anti-jkb activity. some jk(a-b-) patients' sera may show an additional distinct anti-jka or anti-jkb component when examined with adsorption studies. case report: a years-old caucasian female with a negative antibody screen, no prior history of transfusion, presented with gastrorrhagia. it is reported four pregnancies with no history of haemolytic disease of the newborn (hdn). on admission, her haemoglobin was . g/dl. she was given units of crossmatchcompatible rbc. on day her haemoglobin was . g/dl, with a total bilirubin of . mg/dl and lactate dehydrogenase of u/l. on th day an unexpected fall in hb ( . g/dl) occurred with an increase of bilirubin to . mg/dl and of lactate dehydrogenase to u/l. a new blood sample obtained for antibody screening and additional crossmatches showed a pan-agglutination and incompatible crossmatch. anti-jk antibody high titer was detected in the plasma by gel-test using liss/coombs cards (id-diamed). the dat was negative and the antibody reacted equally with jk(a-b+), and jk(a-b+) panel cells (jka: / and jkb: / ). other alloantibodies could not excluded, because jk(a-b-) cells are not available. she was started with erythropoietin-a (epo), folic acid, fe iv and high dose intravenous immunoglobulin (ivig). the epo was discontinued after four week of therapy when the haemoglobin was g/dl. two months later her haemoglobin was . g/dl and anti-jk was present in the same titer. a year later her blood cell count was normal and the anti-jk was detected in a lessened titer ( / ). no additional distinct anti-jka or anti-jkb component was shown after two adsorptions at °c using carefully selected phenotyped red cell compatible with patient's rh, fy, mnss, lu, le system and jka(+) and jkb(-), but two additional alloantibodies anti-c and anti-e of low titer ( / ) were revealed. the rare anti-jk alloantibody found in this case displayed the erratic nature of many kidd system antibodies. although anti-jk may cause mild hemolytic disease of newborn, she did not have a history of hdn. our patient was sensitized to a kidd antigen during pregnancy, but showed no serologically detectable antibody until challenged with a massive transfusion following a gastrorrhagia. the use of epo and high dose intravenous immunoglobulin succeeded to avoid transfusion with incompatible rbc unit. background: differential warm adsorption is used in the investigation of patients with red cell autoantibodies for searching of underlying alloantibodies, but it is also useful in the detection of clinically significant alloantibodies in patients with alloantibodies to high frequency antigens such as k, kpb, lub and inb. this technique is especially useful in cases when patients when patient's phenotype cannot be identified due to recent transfusion. purpose: differential warm adsorption is performing on cases presented with an antibody reacting with all red cells of the panel and having a negative auto control test. in these cases, even rare cells panels, which allow the identification of a pan antibody, are available, other more common clinical significant antibodies cannot be excluded. methods and result: case . a years-old caucasian female with preexisting myeloproliferative disorder (polycythemia) presented with pancytopenia. anti-k was detected in the plasma. it is reported two pregnancies and no history of transfusion. the dat was negative and the plasma did not react with one k-cell present on the red cell panel in use. the anti-k specificity was confirmed using additional k-cells. the patient's red cell were group a, d+, k+, k-, c-, e-, fy(a-), s-, le(a-), kp(a-), cw-. she was transfused with two units rbc k-. ten days after the first transfusion the dat became positive and the one k-cell present on the red cell panel reacted with her plasma. two adsorptions were carried out at °c using carefully selected phenotyped red cell (compatible with patient's rh, fy, jk, mnss, lu, le system and k positive). an anti-fya was identified in the presence of ant-k. . an antik (titer / ) was suspected. because k-red cell was not present in the panel in use, adsorptions were carried out at °c using carefully selected phenotyped red cell (compatible with patient's rh, fy, jk, mnss, lu, le system and k positive). after the anti-k antibody was totally removed, no additional alloantibodies were revealed. conclusion: differential adsorption in cases with alloantibodies to high frequency antigens represents a useful application of the technique and helps in the identification of clinical significant antibodies present, allowing a more accurate decision for transfusion. evaluation of validity of the expired enzymetreated . % red cells in antibody identification gel tests using nacl cards p chalkia, s intzepeli, v avgoloupi, a tsoukala, e ntinopoulou and p didoudi ahepa hospital, thssaloniki, greece background: expired red blood cells of required phenotypic profile is often used to identify antibody specificities in patients with multiple anti-erythrocytes antibodies. accurate results depend on the integrity of the antigens. purpose: to validate the expired enzyme-treated . % red cells for use in antibody identification gel tests using nacl cards. the serum of nineteen patients with common specificities antibodies in rhesus, kell, duffy, kidd, and mnss systems tested with commercially prepared . % enzyme treated cells rbc panel (id-diamed). gel tests were performed according to the manufacturer's instructions on in-date rbc and simultaneously on rbc month to months past expiration. reactivity of the expired antigen positive and antigen cells was compared to in-date cells. results: twenty antibodies detected with enzyme treated red cells in neutral gel cards [d( ), c( ), e( ), k( ), cw( )] and were tested with enzyme treated red cells in use and rbc to months post expiration. seventeen antibodies tested with enzyme treated cells gave acceptable results with antigen positive cells to months post-expiration, except anti-k antibodies (negative with k positive cells - months post expiration). conclusion: most rbc antigens studied were detectable months after rbcs expiration date. tests with . % cells were valid in gel test (nacl/enzyme) for at least months after manufacturer assigned expiration date and may be helpful for complex identification studies. studies for more antigens specificities are needed to testify the validity of the expired enzyme-treated . % red cells. background: wr(a) is a low-incidence blood group antigen ( : ) in the caucasian population. despite that anti-wr(a) is a common antibody type, it may cause severe transfusion reactions, haemolytic disease of the new-born. anti-wr(a) may occur as an autoantibody or arise without immune stimulus. we report a case of a naturally occurring anti-wr(a) antibody. case report, methods and results: -year-old non-transfused male patient with acute pancreatitis and severe anaemia had been transferred to surgery from a county hospital. the serological status identified by their blood bank was: b rhd positive, with anti-wr(a) antibody in the serum (cellbind card method). our results: the patient's cells were group b rhd positive (microplate method), dat negative (tube and gel test method). the antibody identification showed positive antibody reaction with all enzyme treated test cells but negative reactions in liss iat (tube test) and gel iat (scangel and diamed). discussion: our routine tests for antibody detection didn't detect any specific antibody in patient's serum. he was transfused several units of blood, that was wr(a) negative and showed negative crossmatch reactions. the patient had no transfusion reactions. days after the transfusion anti-wr(a) specificity was confirmed in the serum with cellbind test. only few test cell panels contain wr (a) positive cells, which are usually not present in commercial screening cells. in our case the cross-match was only performed for this patient because of the detected nonspecific antibody reaction in enzyme. the risk of transfusion reactions caused by rare antigens are particularly high in the type and screen cases. background: according to requirements of the french committee for accreditation (comité français pour l'accréditation cofrac, iso standards), it is essential to use validated and standardised methods in immunohematology. this imposes, among various requirements, the knowledge of metrological tolerances for all the techniques. aim: a multicentre study was carried out to define the maximal acceptable deviations concerning incubation temperature and time, volumes of patient plasma and of tests cells for antibody screening using indirect antiglobulin test (iat) in filtration technique. the antibody screenings were performed manually in blood centres using different filtration systems: id diamed, biovue ortho and scangel biorad, the same tests cells, a standard ng/ml anti rh (provided by cnrgs), a positive control anti kel and a negative control. all equipment used (oven, chronometer, pipettes) were calibrated according to cofrac standards. each antibody sample was tested under the following combined conditions ( tests/sample): results: all the tests of antibody screenings from the multiples combinations of the above parameters gave the same results with a + intensity agglutination for positive samples and the absence of agglutination for the negative control. conclusion: this study allowed us to define a range of tolerance for critical physical parameters involved in the antibody screening in iat using commercial filtration systems maryvonne. the authors present a retrospective study involving blood donors from the university hospital of coimbra during the year . the incidence of weak d and rh (d) phenotype was determined in individuals who were rh (d) negative. the ab and rh(d) blood grouping was performed using a column gel agglutination card (diamed). the rh (d) typing was done using a anti-d polyclonal and a anti-d monoclonal antibodies. all donors that gave negative or poor agglutination results were tested for weak d with an indirect antiglobulin test, with anti-igg (gel matrix card) plus anti-d serum (diamed). within our target group of blood donors the rh (d) negative represented . % of the total sample. we also describe ab , rh(d) phenotype (c, c, d, e, e) group frequencies and establish reliable estimates frequency for weak d and rhesus haplotypes. the background: in s and s several authors tried to assess the relationship between the number od igg molecules per rbc and in vivo haemolysis, but determinations usually concerned small groups of tested patients. some of the investigators suggested that the number of igg autoantibody molecules per rbc was a major determinant of the severity of the haemolysis, whereas others found aiha patients with severe haemolysis and undetectable autoantibodies. aim: presentation of our experience with the quantitative elat performed on a large group of aiha patients during long-term observation. material and methods: six hundred fifty eight blood samples from warm-type aiha patients were randomly tested for the number of igg molecules per rbc. eighty six of the patients were tested periodically from to times at one-month intervals. autoantibodies on rbcs were detected by the direct antiglobulin test (microcolumn technology) and measured by the enzyme-linked antiglobulin test (elat). results: in about / of tested samples the number of igg molecules per rbc was small (< ) and the laboratory signs of haemolysis were present in . % of them as well as in . % samples with moderately coated red cells ( - igg/rbc). the large number of igg molecules per rbc (> ) was significantly associated with high frequency ( . %) of severe haemolysis and it was also associated with presence of multiple igg subclasses on rbcs and c d. in % of patients tested periodically, the number of igg molecules per rbc decreased and it significantly correlated with improvement of haemolysis parameters. in % of aiha patients the number of igg fluctuated and it was a poor prognostic factor. conclusion: in aiha patients the dynamics of the changing number of igg autoantibody molecules per rbc is a more helpful diagnostic and prognostic parameter than the number of igg molecules per rbc evaluated in one test. -b+) , -h-negative (using the anti-h lectin). antibody work-up showed a positive antibody screen (liss and peg-tube methods) reacting + with o rbcs at all phases and + with a rbcs. the direct antiglobulin test (dat) was positive with polyspecific ahg as well as anti-c b,-c d (table ) . prewarming of test system did not change the reactivity ( + at antiglobulin phase). a treatment with dithiothreitol (dtt) was performed and abolished all reactivity of the serum ( table ). autoabsorption of the patient's plasma was performed. the absorbed plasma showed a decrease in reactivity from + to + when tested with o red cells, as well as a significant reduction in antibody titer from : to : tested at immediate spin (table ). the patient remained crossmatch incompatible with o and a rbcs, but was compatible with oh rbcs. summary: we report an unusually strong igm anti-h antibody in this patient, who may require oh phenotype units. the patient is not a para-bombay since her red cells type strongly as group a. the cause for the auto-anti-h remains unknown at this time. if a thermal amplitude test shows that the antibody appears to be clinically significant the patient should receive h-units if transfusion is required. introduction: fetomaternal haemorrhage may determine an alloimmunization, in fact the transplacental passage of antibodies may cause the haemolytic disease of newborn. for this reason, in pregnant women, a screening for irregular antibodies research is routinely performed. however the indirect antiglobulin test (iat) may result falsely positive or negative for various causes, as operative mistakes or low specificity/sensitivity of the used techniques. aim of the study. in this study we have retrospectively evaluated the real incidence of alloimmunizations occurred in women screened by private laboratories. methods: we have studied . women, - years old, resulted iat positive at the first screening and successively assisted by our two hospitals. all women were re-tested, using gel-agglutination technique, for both direct antiglobulin test and iat. results: a positive iat was confirmed only in cases; moreover a rbc autoimmunization was found in women. anti-d ( cases), e ( ), c ( ), k ( ), c ( ), s ( ), d + jka ( ), d + s + e ( ), d + c + k ( ), m ( ), c + e ( ), d + c + g ( ) were the identified alloantibody specificities. anti-s, -e, -k, -c and -jka were the specificities in autoimmunized women. conclusion: in conclusion, a real alloimmunization is occurred only in . % of screened women, while in the remaining cases iat resulted falsely positive: this observation forces us to affirm that, in order to minimize errors and alarmisms, the screening for antibody research in pregnant women must be performed only by immunohematology qualified center. background: one of the problems of the rbc transfusion is the alloimmunisation and the delayed haemolytic reactions (dhtr). besides rhesus and kell systems the antibodies against kidd antigens cause both dhtr and difficulties in their detection. aim and methods: the exact recording of all blood units according to abo rhesus kell and kidd systems. the abo-rh-kell systems are identified through automated microcolumn method (autovue, ortho), while kidd antigens are identified manually using microcolumn gel (diamed). results: the percentage of jka+ and jkb+ found in our department ( . %) and ( %) respectively is similar to that of the caucasian population. conclusions: given the fact that there is lack of available freezing rbc system in greece, detailed recording of all units to the above antigenic systems can be proved extremely useful under circumstances of incompatibility. in the latter case suitable donors can be called and cover the shortage. the identification of all antigentic systems of the donated rbc units is underway. background: in many countries transfusion recipients are currently typed and transfused d-positive, if their red cells are agglutinated by igm monoclonal anti-d that do not react with dvi. the transfusion strategy in weak d patients is not clear defined and it depends on the chosen monoclonal reagents and methods. patients who are carrying dw types , and were prone to develop anti-d. aim: the aim of this pilot study was to estimate capability of commercially available monoclonal anti-d reagents to recognize this weak d types as rhd positive. material and methods: edta anticoagulant blood samples were collected from blood donors, previously typed as weak d positive by indirect antiglobulin test. molecular genotyping of rhd gene and weak d alleles by cde-ssp and d weak-ssp kits (inno-train, germany) were performed. direct agglutination was tested in a tubes and microplates using the following antibodies: rum- , th- , ms- (bioscot/serologicals) and d e / - (immucor). results: out of samples molecular typing results were as follows: in samples dw were not determined, in samples, weak d type ; weak d type ; weak d type , weak d type ; weak d type and weak d type were determined. by all monoclonal reagents % weak d type , % weak d type , % weak d type and % weak d type negative results were given. by all monoclonal reagents weak d type and weak d type positive results were given. conclusion: according to weak d types, which were known to be at risk for anti-d immunization further advances may be brought by improved patient's monoclonal typing reagents with a low and donor's monoclonal typing reagents with high affinity for weak d type , type and type . such improved typing strategies with novel reagents would enhance the transfusion safety. background: vel is a high-incidence antigen found in > % of the population. anti-vel can be igm or igg and reacts optimally at iat, although it can also react at immediate spin and c. anti-vel may or may not cause severe hemolytic transfusion reactions and mild to severe hdn. autoanti-vel has also been reported. the aabb technical manual th edition states that the vel antigen is unaffected by protease and sulfhydryl treatment. we have reason to believe that sulfhydryl treatment may have an effect on the vel antigen as evidenced by a recently referred case. case report: a year-old caucasian female presented with symptoms of anemia and renal vascular hypotension. transfusion history indicated multiple red cell transfusions in . according to the patient, previous attempts to locate compatible units were unsuccessful. the case was referred to our laboratory. the patient's red cells (rbcs) typed as group o, d+ with a negative dat. the serological picture revealed an antibody reacting + - + s at c/liss, as well as at the antiglobulin phase. the antibody reacted with all rbcs tested and the autocontrol was negative. further characterization of the antibody showed similar reactivity using enzyme-treated rbcs ( . % ficin) and no reactivity using . m dithiothreitol-(dtt)treated rbcs. a high incidence negative red cell panel (untreated) was selected that lacked antigens reported to be destroyed by dtt. the antibody reacted with all rbcs tested. additional rbcs were tested that lacked high-incidence antigens, including vel. the antibody did not react with four vel-rbcs tested using liss and peg methods. the patient's rbcs typed as vel-negative. all other clinically significant antibodies were ruled out using vel-or dtt-treated rbcs. based on the unusual reactivity demonstrated by the anti-vel, we tested different examples of anti-vel (frozen in our rare sera inventory) against two sets of known vel+ and vel-rbcs. one rbc set was dtt-treated; the other set was tested neat. liss enhancement was used to test both sets. one of the antisera failed to react with the positive control and one reacted with the negative control. both were disqualified from the study. four of ten remaining antisera demonstrated a decrease in reactivity > grade, between the neat and the dtt-treated rbcs. the remaining six antisera showed no change in reactivity. conclusion: contrary to the statement in the aabb technical manual, we discovered that sulfhydryl treatment ( . m dtttreatment) can have an effect on the vel antigen. our experience has demonstrated that in some cases anti-vel may not react or may show reduced reactivity when tested with dtt-treated rbcs. therefore, the presence of anti-vel should not be ruled out if negative reactivity with dtt-treated rbcs is encountered. additionally, dtt treatment may be a useful tool obtaining rule-outs of other clinically significant antibodies in the presence of anti-vel. additional data is needed to confirm these findings. but with no identified specific antibodies were investigated by repeated screening/crossmatch, papainized panel identification, hla antibody screening by lymphocytotoxicity test (lct) and elisa in some cases. patients' age, sex, department, diagnosis, previous transfusions/pregnancies, techniques, reactions' strength, number of positive cells, urgency, subsequent antibody tests, identification and lct were noted. antibody tests were performed: at pretransfusion testing (pt) by liss-coombs (diamed) and at blood grouping (bg) by biovue polyspecific (ortho) microcolumns -manually in urgency and routinely by sampler iif (diamed) and mitis (ortho) systems. results: investigated reactivity was recorded in samples from patients; ( . %) patients had > episode. these findings comprised . % of unexpected results found at pt and bg. incidences were . % at routine and . % at urgent bg ( and bgs, respectively), and . % both at routine and urgent pt ( and pts, respectively). . % patients were female, . % over , but . % < years, coming mostly from surgery ( . %), internal medicine ( . %), hematology ( . %), ginecology ( . %), cardiac diseases ( . %) and cardiac surgery ( . % patients). frequent diagnosis were solid tumors ( . %), cardiac diseases ( . %), hematologic malignancies ( . %), uraemia ( . %), orthopedic surgery ( . %) and hepatic diseases ( . % patients). . % patients were previously transfused, with only . % patients proved as not transfused or pregnant. subsequently positive antibody test during the study had . % tested patients. at pt positive crossmatch was found in . %, antibody screening in . % and both tests in . % cases. majority of reactions were ' +' ( % at pt and . % at bg); reactions ' +' or ' +' were found in only . % cases at pt, compared to % at bg. one crossmatch only was positive in . % positive crossmatches, with / patients having > crossmatched unit. ahg identification was positive in . % tested patients; in % of them papainized panel was also positive. lymphocytotoxic antibodies were found in . % tested patients; . % ( %- %) of lymphocytes were reactive. finally, the cause of reactivity in antibody tests was determined as 'laboratory mistake' in . %, hla lymphocytotoxic antibodies in . %, 'igg antibodies of unknown specificity' in . % (hla noncytotoxic antibodies in / elisa tested samples!), contaminated sample in . %, anti-bga in . %, non-specific cold antibodies in . %, subsequently recognized specific antibodies in . % ( lua, m, kpa, yka), non-specific autoantibodies in . %, carry-over of dat-positive cells and antibody to reagent in . % cases each, while in . % cases antibody screening and in . % cases crossmatch was repeatedly positive without confirmation in panels. discussion: after introducing of sensitive microcolumns, positive antibody tests without detectable specific antibodies require significant laboratory activities, particularly in older patients with malignancies or surgery. such reactivity was frequently caused by laboratory mistake, but often hla and sometimes specific antibodies were later recognized, or reactivity continued without confirmation in panels. relationships that may be helpful are further discussed in abstract part ii. results: significant differences (p < . ) and relationships of interest were noted. sex. in female vs male patients frequent features were: crossmatch as only reactivity at pt ( . % vs . %), positive lct ( . % vs . %), lymphocytotoxic hla antibodies (lytxab) ( . % vs . %) and reactivity 'positive screening, negative panels' ( . % vs . %); in males non-specific cold antibodies ( . % vs . %) and antibodies to reagents ( . % vs ) were noted. age. in patients > vs < reactivity was often found at pt ( . % vs . %), caused by lytxab ( . % vs . %), anti-bga ( . % vs . %) or 'positive crossmatch, negative panels' ( . % vs ), but rarely by laboratory mistake ( . % vs . %) or later recognized antibody ( of patients). subsequent antibody tests: tests were subsequently positive more often if reactivity was found at pt ( . % vs . % at bg), as positive antibody screening ( . % vs . % if positive crossmatch), with positive panels ( . % vs . % if negative). subsequent tests were positive in only . % patients with lytxab, % with anti-bga, of with antibodies to reagent and in no case with 'positive crossmatch, negative panels' . techniques. lct was positive in % and . % tested samples found at urgent and routine pt (diamed), vs at bg. all cases due to lytxab, of anti-bga and of 'positive antibody screening, negative panels' were found by diamed. at bg (ortho) . % cold antibodies and . % laboratory mistakes were found. positive antibody test: identification was negative in . % screening-only cases; % of them were caused by laboratory mistake. lytxab were found in . % crossmatch-only cases; . % reactivities caused by lytxab were crossmatch-only. identification. ahg panel was positive in % cases with lytxab (in with papainized panel) and often due to 'igg antibodies of unknown specificity' ( . %), anti-bga ( . %), contaminated sample ( . %), but also to later recognized specific antibody ( . % cases). strength of reaction: laboratory mistake was noted in . % of 'w', . % of ' +', . % of ' +' and . % of ' + and +' antibody screenings (ns). diagnosis. in patients with solid and hematologic malignancy reactivity was often found at pt ( % and . % of patients, respectively), due to positive crossmatch ( % and %; and . % patients with liver and cardiac diseases) and caused by lytxab ( . % and . %) or 'crossmatch/screening positive, panels negative' ( . % patients with solid tumors). in patients with liver and cardiac diseases reactivity was often found at bg ( . % and . % of patients), due to laboratory mistake ( % and %) or cold antibodies ( . % and %), respectively. discussion: features of non-specific reactivity depended on sex, age, positive antibody test, diagnosis and, moreover, used techniques, sometimes in very distinctive manner. this analysis might be of considerable help in planning of laboratory tests, but also in quick analysis of unexpected results and choice of further testing, particularly in urgent situations. background: worldwide screen and type is a very usual method for pre-transfusional testing. the ultimate objective is to prevent not only the clinically expressed delayed hemolytic transfusion reactions but also the serologically revealed ones. aim: the aim of this study was to determine the frequency of red blood cell (rbc) alloantibodies in patients undergoing cardiac surgery or cardiac procedure, during the pre-transfusion screening. materials and methods: blood samples of patients ( male and female) were evaluated. the mean age of the patients was years. pre-transfusion samples were examined for clinically significant alloantibodies, using antibody screening with gel test (liss -enzyme). in case of a positive result, identification was performed (panel with autologous control). in addition, the serological testing included cold agglutinins´ detection (tube test), as well as titration (tube test) and identification (gel test) in case of a positive result. when the result was marginal ( / ) a new test was carried out after a seven days period. in the presence of a positive autologous control or an autoantibody, samples were examined with direct antiglobulin test (dat). results: alloantibodies were detected in patients with the incidence of . %. antibodies were registered more frequently in females ( / , . %) than in males ( / , . %). patients ( . %) developed single antibody with anti-kell being the most frequent. the incidence and the specificity of the detected antibodies are summarized in the following table (table ). in patients ( . %) multiple antibodies were detected, with most frequent the anti-d and anti-c combination. patients ( . %) were dat positive. autoantibodies were found in patients ( . %), all of which had specificity to rhesus system. cold agglutinins were positive in patients ( . %). no specificity could be assigned in patients ( . %), while in patients ( . %) non specific reactions in enzyme treated rbcs, were observed. one patient developed delayed haemolytic reaction days post-transfusion, due to anti-jka. the antibody, however, was not detected in the pretransfusion sample re-testing. the frequency of the pre-transfusion detection of red blood cell alloantibodies in our center, was . %. the most frequently identified were the anti-kell and anti-rh. the high rates of unidentifiable antibodies and non specific reactions in enzyme treated rbcs are probably attributed to the kind of medication that most of these patients receive, as well as to the degree of inflammatory process which usually accompanies such diseases. the high frequency of unidentifiable antibodies indicates that a larger and more complex erythrocyte panel would be useful for routine testing. the routine pre-transfusion screening for alloantibodies probably assures the prevention of dhtrs and provides sufficient time for blood selection for transfusion. introduction: in the united kingdom, about % of women form red cell allo-antibodies in pregnancy and . % of all pregnant women produce anti-c. before the introduction of prophylactic anti-d, it was reported that % of the total haemolytic disease of the newborn (hdn) cases were due to anti-c. currently, cases of hdn due to anti-c are half as frequent as anti-d and % of the uk population are rhc negative. we present two unusual cases of pregnant women who are d and c negative and have anti-c and anti-d detected in their serum. case studies and results: case : a -year-old asian woman had three previous uneventful pregnancies. in her th pregnancy she presented with miscarriage at weeks gestation. she was group b, d and c negative. her serum contained anti-c and anti-d. anti-d was detected by liss tube iat and anti-c was only detected by manual polybrene technique ( . iu/ml by quantification using r r cells). in a th pregnancy, no antibodies were detected until weeks gestation when this patient presented in early labour. anti-c was then detected by two-stage papain technique only as well as anti-d. case : a -year-old asian woman had a positive antibody screen post caesarean section in jan . no antibody had been detected during the pregnancy. standard prophylactic anti-d was given at and weeks gestation as this patient was d neg. anti-c and anti-d were confirmed in her serum. the anti-c level was . iu/ml using rr cells and the anti-d level was < . iu/ml using r r cells (prophylactic anti-d ig). she was phenotyped as o r¢r¢. at delivery the baby was found to have a negative dat and was phenotyped as r¢r. discussion: cde/cde (r¢r¢) is an uncommon phenotype in the uk population with a frequency of / . in routine antenatal testing, abo/d grouping is only performed for pregnant women at booking and weeks gestation according to bcsh guidelines. full rh phenotyping is not carried out unless the pregnant women has a positive antibody screen. in routine testing of the above cases, this extremely rare phenotype is missed. prophylactic anti-d was given to both patients and immunisation due to anti-d was prevented. there is currently no prophylactic regime developed to prevent anti-c allo-immunisation by the fetus in pregnancy. antenatal management of patients with anti-c and anti-d during pregnancy can be problematic: (i), problem in antibody identification; (ii) monitoring of antibody level (i.e. quantitation by auto analyser for anti-c and anti-d) with two different cells and ( ) provision of blood during pregnancy, at labour and post delivery for both mother and newborn. study on the frequency of red cell phenotypes (e.g. duffy, kidd and mns blood group system) in our local population l leou, yf wong, mbc koh and d teo health sciences authority, singapore, singapore background: the frequency of various red cell antigens in the caucasian population has been well studied. to date, the frequency of these antigens in the local population composed of a multi-racial mixture of chinese, malay, indian and others is still unclear, especially in the malays with paucity of data in the literature. aims: to investigate the frequency of clinically significant red cell antigens duffy, kidd and mns across the local ethnic groups. to investigate the occurrence of rare phenotypes. to be aware of these rare phenotypes so as to facilitate planning of blood inventories and supplies. typing for the duffy, kidd and ss antigen on blood donors was performed using monoclonal as well as polyclonal anti-sera by manual tube method. a total of blood donor samples were tested using specific anti-sera that will agglutinate red blood cells that have the corresponding antigen. agglutination is demonstrated by the indirect antiglobulin technique. result and discussion: table -a higher frequency of the fy(a+b-) phenotype is seen in chinese, malay and others in contrast to the indian and caucasian population. the clinically significant allo-antibody anti-fya is rarer in our local population. it occurs predominantly in malays and indians and usually in combination with other antibodies. it means that provision of antigen negative blood may be difficult. table -all groups show similarity of distribution of the kidd phenotype with the caucasians and distinct from the american blacks. the jk(a+b-) and jk(a+b+) phenotypes are relatively equal in frequency and there should be no problem looking for such a phenotype in the local population. table -the s-s+ phenotype is most common amongst all races. the indians are more similar to the caucasians with a relatively high frequency of s+s+ phenotype. the chinese and malay distribution are unique with > % being s+. conclusion: there is a unique distribution of red cell antigen groups in the races and the data on malays is especially useful. this data will allow the national blood service in its inventory planning and the potential difficulties of providing antigen negative products due to clinically significant allo-antibodies. miltenberger phenotypes among taiwanese table . conjointly, in order to obtain the frequency of mi.v phenotype, we screened samples among with anti-hil and four additional cases of mi.v were found. conclusion: in this study significant miltenberger polymorphism was seen among the taiwanese population. besides previously described mi.iii phenotype ( . %), there were also mi.i/ii phenotype ( . %), mi.v phenotype ( . %), mi.vi phenotype ( . %), mi.x phenotype ( . %), and most interestingly two miltenberger related not yet classified variants ( %). related variant a ( . %) was phenotypes as mia+, anek+ and hil+. related variant b ( . %) was phenotyped as mia+, anek+. interestingly, both variants were mur-(negative). the total estimated frequency of miltenberger variants in taiwanese population (including related variants a and b) is therefore . % (table ). the discovery of unclassified variants (most likely not yet described in the literature) is of great interest in the field of immunohaematology and warrant further molecular genetic study. introduction: the use of column technologies for the detection of rbc antibodies improved significantly the screen test sensitivity. each column-based method has its advantages and disadvantages. aim: to compare antibody detection by two column agglutination tests; the fully automated ortho auto vue tm method and the manual diamedᮀ id-micro typing system. material and methods: during the study period patient samples were screened, of the positive results were evaluated. blood samples with positive screen tests by the ortho auto vue tm method (av) performed with % cell suspension, and patient samples with antibodies identified by the diamedᮀ system (dm), were reciprocally re-screened, respectively. positive samples were tested by diamed panels for antibody identification. sera samples were divided into categories according to antibody specificity; . rh system antibodies (n = ), . clinically significant non rh system antibodies (n = ), . clinically non significant antibodies (n = ), . auto antibodies (n = ), . not identified (ni) antibodies (n = ), . negative screening results by the diamed technique (n = ). the categories were divided, according to the intensity of agglutination in the screen test, into those exhibiting stronger reactions by the auto vue (av > dm), those exhibiting equal strength reactions (av = dm) and those with weaker reactions by the auto vue (av < dm). statistical analysis was carried out using the wilcoxon signed ranks matched-pairs test. results: a total of samples were compared, . % of them gave stronger reactions by av, . % gave equal reaction strength and . % of them gave weaker reactions by av. positive screen tests by av only were detected in samples, no specific antibodies were identified. in contrast to that, positive screen tests by dm only were detected in samples, were rh system related, kell system related and not identified, results are summarized in the table. discussion and summary: the antibodies detected by dm only, are anti-d and antibodies directed to low frequency antigens. the failure of av to detect rh system antibodies is further sustained by the fact that statistically significant weaker reactions for this antibody system were obtained by av technique. recently ortho-clinical diagnostics modified the screening reagent red blood cells to . % suspension, in order to improve the sensitivity of the method (unpublished data). the possible explanation for the failure to detect low frequency antibodies is that ortho screen cells do not consistently carry the low frequency antigens cw and kpa. positive screen tests detected by av only, can be explained either by the fact that antibody identification was carried out on dm panels, or these are false positive reactions. in order to clarify this question we recently repeated these av only positive samples by the manual ortho bio vue technique. preliminary results indicate that no specific antibodies were detected. it can be assumed that these results are false positive. further study of this issue is required. aim of the study: we have detected blood donor with rohar variant which was mistaken as d-and his donations used for d-recipients. we tested these patients in order to evaluate possible anti-d or anti-lfa immunization. methods: rohar variant was tested serologically (commercial and workshop moabs) and on dna level (pcr-ssp). involved recipients were tested by diamed column agglutination (gliat with normal and enzyme treated rbcs) with commercial rbcs and with rh and rh rbcs. results: rohar variant was confirmed on phenotype and genotype levels. in four d-and two d+ recipients of rohar positive units no anti-d not anti-rh or -rh antibodies were detected. in one case anti-le(a) antibody was found. conclusion: in our cases massive exposition of recipients (whole transfusion unit) by rohar red cells did not lead to production of detectable anti-d or anti-lfa. the immunogenic potential of this variant seems to be low. unusual ab grouping discrepancy -inhibition of anti-b reagent by isolated increase of plasmatic b substance in a patient with group ab and pancreatic cancer m pisacka*, k petrtylova † , m kralova* and h flidrova* *uhkt, prague , † blood bank, faculty hospital m, prague , czech republic introduction: in rare pathological conditions excess amount of blood-group specific substances can be observed and can cause neutralization of grouping reagents. changes in abh and related histo-blood group antigens in malignant tissues were described but there are few information about similar changes in secreted bloodgroup specific substances. aim of the study: we describe a case of isolated increase of b group substance in plasma of a group ab patient with pancreatic cancer. methods: ab grouping was performed with registered immucor reagents (immuclone: anti-a birma , anti-b lb ) by slide and tube tests. neutralizing effect was quantified by (i) inhibition od anti-b reaction by titrated patient's serum; and (ii) inhibition of titrated anti-a and anti-b reagents by patient's serum, compared to ab serum of a healthy donor. results: slide test: unwashed rbcs: group a, washed rbcs: ab. tube test (washed rbcs): ab. titrated patient's serum when added in aliquot to anti-b reagent inhibited agglutination up to titre . titration of reagents /+ aliquot of serum added/: anti-a: titre (both patient's serum and control); anti-b + patient's serum: titre , anti-b + control: titre . conclusion: pancreas is known as rich source of blood group specific substances. malignant transformation is known to be associated with either loss or re-expression of cell-bound abh antigens. reported excessive increase of b substance in group ab patient could be either due to loss of a-transferase activity in malignant pancreas cells or isolated increase of b-transferase activity. further studies on larger groups of pancreatic cancer patients will help to understand this observation. weakened abh reactions of unwashed rbcs could be of diagnostic importance, because in other case this observation preceded several years the pancreatic cancer clinical manifestation. implementation of the autovue innova, an upgraded column agglutination technology (cat) for pre-transfusion testing in a large blood establishment c politis, k armyros, a antypas, v malamou and p katsea g. gennimatas general hospital, athens, greece objective: automated cat testing in a blood transfusion laboratory aims at standardization and savings in labour as well as reagents. a new technology is evaluated in comparison to standard methods. materials and methods: we used column agglutination technology with the innova autovue system, ortho, ratrian n.j. according to the manufacturers this system provides priority to the management of the stat samples while the random access feature of the system enhances the system throughput. it provides an extended test menu as well as automated antibody identification with the red cells panels. the autovue innova system supports the bi-directional communication with the lis interface for all the tests including the crossmatches and it provides a continuous traceability and notifying of the instrument's status concerning either the required and available resources or the proper function of the system's submodules. in this study we performed tests including forward and reverse abo group, rh type and phenotype and kell in randomly selected blood donors, as well tests in haematological patients for antibody screening using an untreated three-cell panel and autocontrol in the indirect antiglobulin test (iat). the results and the time performance (specimen handing, operation of testing and recording of results) were compared with those obtained by the semiautomatic id-diamed gel agglutination microtyping system and by standard manual methods. results: test results showed % agreement between all three methods. samples were tested per min with the autovue innova, compared to min required for the same number of tests performed with manual testing and min with the semi-automated method. the technical execution was easy with the autovue innova procedure and it appears that the consumption of testing reagents is smaller with the automated system comparing with the other methods. computerization of the test results with the autovue innova provides an important advantage in record keeping in the blood establishment. conclusion: standardization of sample collection and tests performance in pre-transfusion testing, as well as computerized records and time saving are advantages offered by the autovue innova, a new automated column agglutination technology, comparing with a semi-automated and the classical manual methods. a heavy workload is expected to significantly decrease time performance. clearance of senescent erythrocytes in young and old individuals al racca, a ensinck, c cotorruelo, s garcÍa borrÁs, l racca and cs biondi universidad nacional de rosario, rosario, argentina introduction: after a lifespan of days, human red blood cells (rbc) are captured and phagocytized by monocytes/macrophages. the accumulation of autologous igg on rbc membrane provides a direct mechanism for the removal of senescent (se) rbc. an alternative pathway, immunoglobulin-independent, with participation of sialic acid, has been proposed. the physiological elimination of serbc might be modified by individual's age. aim of the study: to investigate in young and old individuals, the interaction between monocytes and different erythrocytes suspensions: serbc, rbc stored with or without serum and desialinized rbc. methods: healthy individuals blood samples ( - years old, n = and > years old, n = ) were studied. different suspensions from each sample were obtained: (i) se and young (y) rbc by differential centrifugation; (ii) rbc stored with its own serum (rbcs) and without serum (rbcws); and (iii) rbc desialinized with neuraminidase (ne) and tripsine (t). the suspensions were subjected to the erythrophagocytosis assay: peripheral blood monocytes were incubated with the different erythrocyte suspensions for h at °c. two hundred cells were analyzed to determine the percentage of active monocytes (am) with phagocytosed and adherent red cells. non sensitized rbc (nrbc) and ex vivo sensitized rbc (srbc) were used as negative and positive controls respectively. results: the% of am obtained with old individuals were: serbc: . + . , yrbc: . + . , rbcs: . + . , rbcws: . + . , nerbc: . + . , trbc: . + . , nrbc: . + . ; srbc: . + . . the values of am obtained with young individuals were: serbc: . + . , yrbc: . + . , rbcs: . + . , rbcws: . + . , nerbc: . + . , trbc: . + . . nrbc: . + . ; srbc: . + . . conclusions: no differences in the% of am were found when compared to positive and negative controls, indicating that this assay would not detect variations in the phagocytic activity of monocytes from young and old donors. the values of am with serbc were higher (p < . ) than those obtained with yrbc in both populations analysed. the rate of erythrophagocytosis with serbc in old individuals was significantly higher (p < . ) than that obtained in young donors. the increase observed may be due to agedependent changes of rbc that occur with human ageing. the% of am with rbcs were higher (p < . ) in old individuals. no modifications were observed with rbcws. the significant increase in the rate of erythrophagocytosis with serbc and rbcs show the involvement of autologous igg in the selective removal of erythrocytes. these values were higher in old individuals indicating that this process would increase in aged donors. the tripsine activity was not enough to modify the% am. the values of am obtained with neuraminidase treated rbc were higher than those observed with yrbc (p < . ). however these values were similar between young and old individuals, suggesting that the desialylation would not participate in the increased removal of erythrocytes observed in old donors. cell-cell adhesion is a crucial phenomenon for the relationship between the cell and its environment. therefore, the development of experimental methods to obtain quantitative parameters of cellular adhesion is important. erythrocytes are widely available and their membrane properties are well known, so these cells are used as an ideal model for studying the cellular interaction mechanisms. the study of the formation and break-up of receptor-ligand bonds in sheared erythrocyte suspensions is a subject of considerable importance in the blood circulation, where formation and break-up of blood cell aggregates occur in a variety of physiological and pathological conditions. the main two objectives of this work were to study the cellular adhesion phenomenon using erythrocyte adhesion mediated by monoclonal anti-a antibody as a model and to achieve quantitative values of the parameters involved in the intercellular binding and its possible relationship with cellular deformability parameters. agglutinates of two a erythrocytes (doublets) induced by specific monoclonal antibodies anti-a were used. adhesion energy was indirectly quantified by the study of doublet dissociation under the effect of a given shear stress using a controlled flow chamber system. the chamber was installed on the stage of an optical inverted microscope (union optical, magnification ¥) in such a way that the cover glass was the floor of the microchannel. a ccd (charge coupled device) camera was placed in the ocular tube of the microscope and connected to a digital image processor (ipplus system) to digitize, record and analyze microscopic images. the doublets were initially immobilized inside the chamber, and then put under different shear stress values by a controlled laminar flow during a definite time. in this way, a shear stress parallel to the contact surface between both cells was applied, observing that the upper cell detached progressively with time and also with a gradual rise of the shear stress. the sequential microscopical images were registered and digitally processed, measuring the geometrical dimensions that the cells acquire during the deformation process, and the dissociation of the antigen-antibody bond. digital image processing allows the analysis and the quantification of the red blood cells doublets dissociation phenomenon. these results show that, while the shear stress applied is raised, the contact area between both cells diminishes. the obtained parameters give important information that lead to the estimation of the value of adhesion energy between two red blood cells agglutinated by monoclonal antibodies. as consequence, they will allow the characterization of the antibodies used, since it would evaluate their association capacity with cellular antigens. glycophorins (gp) a, b and c are abundant transmembrane integral proteins in red blood cell (rbc). their highly glycosylated nature and high sialic acid content account for the net negative charge of mature rbc membrane, which is physiologically important because it impedes any tendency to stick together in the circulation. in this study, we have tested anti-gp specific mouse monoclonal antibodies (moab) as primary antibody to directly agglutinate rbc. fret technique has been developed to characterize the hemoagglutination based on the interaction of fluorophores (alexa tm, dio and dii) located in the rbc membrane or combined to secondary antibody directed against the primary agglutining moab. combined intensity (spectral) and lifetime (flim) imaging was used to discriminate the fret signal of molecules on their different lifetimes whereas their emission spectra overlap (alexa tm or dio/dii) as independent phenomena of the fluorophore concentration and photobleaching. furthermore, gp-cytoskeleton interactions were analyzed by d-fluorescence microscopy after lipid extraction with triton x- in red cell. all the antibody used was found to directly agglutinate the human rbc. in view of the fluorescence properties depicted in rbc for the pair of fluorophore alexa- tm (donor) and dii (acceptor), it may be expected that upon agglutination of rbc, effective fret should be observed. flim in dynamic-state provides a discrimination of molecules in their fluorescence lifetime, which allows to evaluate the underlying mechanism of energy transfer process in the agglutinated erythrocytes. the results demonstrate that's upon excitation at nm the flim-fret from alexa tm to dii for the anti-gpb moabs only with a lifetime distribution in the picosecond range. similarly, effective fret was not observed for the anti-gpa moabs. the contrast in measured lifetime image is a reliable indicator for spatial variations in donor-acceptor association. d-fluorescence microscopy images showed interactions between gpc or gpb and cytoskeleton and did not show interactions between gpa and cytoskeleton. all together, these results only revealed by fret-flim and d-fluorescence microscopy strongly support the importance of the specific reactivity with glycophorin a or b of agglutining moab. introduction: the frequency of alloimmunization to red blood cell antigens in transfused sickle cell patients can range from to %, but the development of autoantibodies is much less recognized and descried. aim of the study: in order to evaluate the autoantibody formation and observe the blood transfusion association, we analyzed the direct antiglobulin test (dat) as well as the antibody screening results in transfused sickle cell patients. methods: all the patients included in the study had received at least unit of red blood cell concentrate, on the majority of the cases matched for the c, c, e, e, k antigens. the transfusion range was - units. the dat performed was a polyspecific gel test. in cases of positive dat, was performed the monospecific gel test (igg, iga, igm, c c, c d) . in almost all of cases an acid glicin elution was performed and the eluate was tested against a red cell panel (liss/coombs and papain). an antibody screening by gel test (liss/coombs and papain) was performed in all the patients. the dat was positive in ( %) of the patients. in cases ( %), the dat was igg type, in case ( %) igg + c d and in case ( %) igg + c c + c d. the acid elution was performed in cases. the eluate was positive in cases ( %). in ( %), of the cases, autoantibodies were pointed out whose specificity were specificity public, anti-e (rh ), anti-c (rh ), anti-ce (rh ). in cases ( %) we found alloantibodies whose specificity were anti-e(rh ), anti-k(k ), anti-c (rh ) and anti-jka (jk ). in the cases ( %) no antibody was identified on the eluate and the cause of positive dat is unclear. we could correlate the positive dat with a presence of autoantibodies in ( . %) of the patients. of these, ( %) had a blood transfusion association. the global frequency of red cell alloimmunization in this set of patients was %. seventeen patients ( %) of the patient who had autoantibodies had also alloantibodies associated. conclusion: the mechanism by which erythrocyte antibodies form in association with blood transfusion are not well understood, but even though the medical literature indicates strong association with blood transfusion as well erythrocyte alloantibody formation, we could not find support for this association. the loss of splenic to sickle cell patients could be important because experimental studies suggest that the spleen is involved in the regulation of autoantibody formation. forward and reverse blood grouping with lateral flow based assays p schwind*, i aebischer*, k loester † and p monod* *medion diagnostics gmbh, duedingen, switzerland, † prisma diagnostika gmbh, berlin, germany background: recently, a lateral flow assay for simultaneous typing of abod, rhesus subgroups and kell with stable end-point and without a centrifugation step was presented (loester k, fleischhauer s, schwind p: lateral flow assay for simultaneous typing of of abo, rhesus subgroups and kell. vox sang , (suppl. ), ). in many countries, the determination of isoagglutinins in addition to the red cell antigens is mandatory for abo grouping. aims: to develop a lateral flow test for reverse grouping, supplementing the lateral flow typing assay. a lateral flow device was constructed with a separation membrane equipped in a cassette housing having distinct incubation wells, application zones and detection areas. microliters of % suspensions of reagent red cells for reverse grouping (reverse-cyte a , a , b, , medion diagnostics, switzerland) are mixed in each incubation well with microliters of plasma. the resulting suspensions are incubated for min, followed by the transfer of microliters each to the application zones, where migration starts immediately. results can be read after min in the detection areas. a positive result is recognized as a distinct red dot, a negative result is monitored by the absence of a dot. results: the plasmas of donors, previously determined for the respective blood groups and isoagglutinins by the tube technique, have been tested with this method. the results for both methods were in full agreement. conclusions: a simple, rapid and flexible lateral flow method for reverse grouping is presented, allowing now for the determination of forward and reverse typing in similar formats. both methods give results after min with stable end-points without the need of a centrifugation step and are easily applicable to non-laboratory environments. the performance of the autovuetm system for red cell antibody screening of blood donors during background: in israel every donation is tested for the presence of red cell antibodies (rbc abs). screening is performed on the autovuetm system, using ortho screening rbc since the year . aim: (i) to summarize the performance of the autovuetm system for rbc abs, during years ( ) ( ) ( ) ( ) ( ) . (ii) to evaluate if an initial low positive result, with two negative repeats, could be considered a negative result. methods and results: rbc abs screening was performed using igg cassettes. positive results were confirmed by diamed gel cards, with screening rbc, followed by diamed panels for abs identification. results: summary of the results is presented in the table. (i) in . % of , blood donations that were screened, during - , using the autovuetm system, a positive initial result for rbc abs was detected, which was confirmed in . % ( . % of the donations). an increased percentage of confirmed tests is noted, since , probably due to an improvement in the manufacturing of the cassettes by ortho. (ii) during the validation, samples with low positive results (agglutination degree of . ) were retested twice on the autovuetm. / ( %) gave negative results in both repeats. only / was confirmed positive and anti-m was identified by diamed gel test. the remaining samples had at least one positive repeat. / ( . %) of those samples were confirmed positive. summary: autovuetm can be used as a competent method for rbc abs screening, in blood services which require high thoughput automated systems. samples with a low positive agglutination, which were negative in two repeats, can be considered negative. retesting these samples on the autovuetm, can reduce the number of tests sent for confirmation and allow early release of blood components. rk tagi-zadeh*, aa karimov*, ar hasanov † , ly novruzova* and si donskov ‡ *hematology and transfusiology, baku, † blood transfusion centre, ganja, azerbaijan, † centre for hematology, moscow, russian federation background: the main method of treatment of severe homozygous thalassemia forms at the moment is still an anemia control with regular rbc transfusions. the use of adequate transfusion regime for these patients not only prolongs their lives but also promotes normal physical development of the children and improves the quality of their lives. however, necessity to do multiple transfusions increases a risk of post-transfusion reactions and complications due to alloimmunization to rbc antigens. in order to prevent posttransfusion reactions it is essential to know the frequency of blood group distribution in the region and then implement organizational procedures to enhance the transfusion services for these patients. objective: examine the distribution of rbc antigens among thalassemic patients and blood donors. methods: blood samples of homozygous betta-thalassemia patients (who stayed at the daytime inpatient wards of scientific research institute of hematology and transfusiology baku, azerbaijan) and blood donors of azeri nationality were examined. patients' blood samples were typed on rbc rh (c, c, d, e, e) and kell (k, k) antigens. gel test bio-rad (france) was used to detect rbc antigens. results: phenotyping of the patients' rbc rh antigens (d, c, c, e, e, cw) revealed that frequency of occurrence of the antigens in general was higher than in the donors. studying of rh phenotype distribution showed that the patients' ccdee ( . %) •• ccdee ( . %) phenotypes were twice as much higher than the occurrence of those in the donors ( % and . % respectively). phenotype ccdee occurs more frequently in the donors ( %), whereas it is significantly rare in the patients ( . %). the similar picture was observed in relation to ccdee and ccdee phenotypes, which occurred more frequently among donors ( . % and . %) than in thalassemic patients ( . % and . %). additionally, the results demonstrated that k antigen of the kell system was not detected in the thalassemic patients whereas k antigen was detected in all the patients. the same picture was observed with two other antigens of this system. thus among the patients typed on rbc antigens kpa antigen was detected in just one case whereas kpb was detected in the rest the patients. the results of the analysis showed that for thalassemic patients with phenotypes ccdee and ccdee it is easier to find compatible blood than for patients with phenotypes ccdee, ccdee and ccdee. furthermore, it is known, that some congenital diseases are genetically connected with the specific group systems, for example, the mcleod syndrome is genetically associated with the sharp suppression of the kell alloantigen expression (absence of gene kx). the fact of the discovered absence of antigen k in homozygous bthalassemic patients makes it possible to assume, that this group of patients suffer from scarcity along the kell system, like the scarcity in mcleod syndrome. all the mentioned above make it possible for us to conclude, that prior to blood transfusion to thalassemic patients phenotyping of rbc rh and kell antigens must be carried out. hyperhaemolysis in sickle cell disease due to complement activation. tessa thorp rci national blood service manchester uk tm thorp national blood service, manchester, uk introduction: sickle haemoglobin is caused by a genetic mutation in codon of the beta globin gene, resulting in the conversion of glutamic acid to valine. when critical amounts of polymer accumulate within the sickled erythrocyte cellular injury results. clinically sickle cell disease is characterised by chronic haemolysis and intermittent vaso-occlusion. mold et al. demonstrated that deoxygenation and sickling of erythrocytes is related to membrane phospholipid changes and these changes result in the activation of the alternative complement pathway. aim: the objective of this study was to measure the amount of c c and c d bound in vivo to red cells of homozygous and heterozygous sickle cell patients. these levels were then compared to 'normal' sickle negative blood donors. haemoglobin levels and red cell morphology were also examined for signs of active haemolysis. the hypothesis was that an increase in red cell bound complement in vivo could provide an indication of hyperhaemolysis syndrome is sickle patients. method: flow cytometric analysis using rabbit anti-c c or anti-c d and fitc labelled goat anti-rabbit was developed using a beckman epics xlmcl flow cytometer. control samples were prepared using a fruitstone buffer technique of complement coating. results: a total of heterozygous sickle patients and homozygous patients were analysed. of the homozygous patients analysed only one was undergoing a sickle crisis. a positive result was indicated if the mean trait or homozygous sample was coated with complement to a greater degree that the mean normal donor plus two standard deviations. the results obtained in this research project indicate an increase in c c levels bound to red cells of homozygous sickle patients in vivo. statistical analysis of results obtained suggest that there was no increase in c d levels in either sickle trait or homozygous sickle patients. conclusion: these findings support research carried out by mold et al. ( ) and are present in more than % of caucasian population. it has been reported that anti-chido and anti-rogers don't cause hemolitic reaction but may be responsible for life-threatening anaphylactic reaction during transfusion of plasma proteins. case report: positive iat and dat were detected in a years old swedish woman, a rh negative, at th week of pregnancy. previous iat and dat determinations were negative. at time of detection dat wsa weakly positive and igg subclasses identified. antibody identification revealed the presence of high titre ( : ) anti-chido and anti-rogers antibodies. a slight decrease in platelet count (from . /ul to . /ul) was observed. this pattern showed no variation until the end of the pregnancy. at th week a healthy baby was delivered, dat negative. the mother dat and iat remained positive for four months after delivery. the platelets count raised again to . /ul. the same laboratory findings were detected in a previuos pregnancy in sweden. the patient reported the presence of antibodies at th week that disappeared few months after delivery. a healthy baby, dat negative was delivered in this case too. conclusions: this is the first report of the presence of chido and rogers as autoantibodies during the last months of pregnancy. the association with decrease in platelets count and the lack of evident clinical symptoms need further investigation. p- rbc alloantibody frequency and their prevalence within chinese, malay and indian community in singapore e widjaja, mbc koh and d teo health science authority, singapore, singapore background and aim: there is a recognised existence of different alloantibodies in different ethnic groups. while this has been studied in the caucasian population, their frequencies remain less well documented in the asian population. the frequency of different alloantibodies and their distribution in terms of age, sex in singapore population is studied, as were their prevalence within the chinese, malay and indian races in singapore. design and method: we conducted a retrospective study for the frequency of alloantibodies on blood samples over . these blood samples were largely sent by hospitals where preliminary antibody screening had been done and positive result obtained. they were sent to the centre for transfusion medicine for antibody identification. small number of these samples came from hospitals where preliminary antibody testing was not done. the antibody distribution across different ethnic groups (chinese, malays, indians) age and sex were studied. results: the most frequent alloantibodies in the population is mia ( . %), e ( %), le a ( . %), le b ( . %), p ( . %), m ( . %), d ( . %), c ( . %), jka ( . %) and c ( . %). within the chinese community, the most frequent alloantibodies were similar: mia ( . %), e ( . %), le a ( %), le b ( . %) and p ( . %). in the malays, the most frequent alloantibodies were le a ( %), le b ( . %), mia ( . %), e( . %) and p ( . %); while in the indians, these were mia ( . %), le b ( . %), le a ( . %), d ( . %), and e ( . %), with the anti-d reflecting the higher incidence of rh d negativity in the indians race. for the lower incidence antibodies, anti-c was more common in the malays and indians ( %) compared to chinese ( . %). anti jka tended to occur mainly in the malay race and anti-c was rare in all (< %) reflecting the high prevalence of c in the singapore population (r r phenotype). the ratio of alloimmunised male to female (m : f) is : . most alloantibodies demonstrated significant skewing towards to the female, although relatively less so for mia where m : f ratio is almost equal at : . . alloimmunisation increased with age for mia, e, k, p , jka and fyb while the frequency of alloimmunisation to lea, leb, d, m and c decresed with age. the prevalence of patients with multiple alloantibodies ( or more) within the alloimmunised subjects is . %. conclusion: anti mia is very common within the asian population especially in the chinese. anti d is common in the indians. most antibodies show increased frequency with age except for anti lea + b, d and m. the majority of alloimmunised patients are females. study aim: to identify the present antibodies in newborns, after a positive direct antiglobulin test (dat). material and method: during a years period, from / / - / / , we studied newborns and their mothers. each newborn was examined for abo group, rhesus with phenotype, kell and dat. each mother was also tested for abo group, rhesus with phenotype, kell and indirect antiglobulin test (iat). after each positive dat, the study was continued with the elution test, in order to identify the present antibody. dat test was performed with dc screening i-diamed sa, switzerland. for the laboratorial analysis of newborns the sample used was cord blood and in certain cases venous blood. results: the dat test was positive in ( %) of newborns and the antibodies found were igg type immunoglobulin. anti-a antibody was detected in ( . %) (newborns of group a with mothers of group o), anti-b antibody in ( %) (newborns of group b with mothers of group o), anti-d antibody in ( . %) (newborns d+ from d-mothers), anti-e in one case and anti-jka in another one. the eluate test was found negative in newborns and in the rest , no special antibody could be identified. the results are presented in the following table. conclusion: the majority of antibodies in newborns with a positive dat test, is due to abo incompatibility (the mother belongs to group o and the newborn to group a or b). anti-d ( ), anti-e ( ), anti-k ( ), anti-fya ( ), anti-s ( ), anti-jkb ( ), anti-n ( ), anti-kpb ( ). in two patients antibodies were identified, while in / ( . %) no antibody was identified (unspecific). it is remarkable that only in out of patients with both dat and iat positive, an irregular antibody was identified, while the rest patients had unspecific antibodies. in patients with only iat positive, had an irregular antibody and had unspecific antibodies. in out of patients with both dat and iat negative the cause of incompatibility was the positive dat in the corresponding sample of the blood donor, while in the rest patients the reasons were technical problems that include the inappropriate blood sample of the patient, patients under medication and errors during the crossmatching procedure. the results show that the incidence of red cell incompatibility in our hospital is . % and the most common antibodies are anti-k, anti-e, anti-fya, while anti-d is important for d negative patients. . % of the detected antibodies were unspecific and this is still a problem that possibly was due to the lack of additional panels of reagent red cells or antibodies to low-incidence antigens. finally, in some cases the reasons for incompatibility are due to factors affecting the blood donor or to technical problems in the crossmatching procedure. multiple isoforms excluding normal rhd mrna detected in rh blood group del phenotype with rhd a allele introduction: del phenotype is very common in rh-negative chinese. the rates in hans (more than % in china) were reported from % to %. moreover all del individuals in this population were found mainly carrying a same allele, rhd a, through genomic dna analysis. those individuals always possess one or two of this allele with ccee or ccee phenotypes. aim and the study: we focused on the mrna investigations of del individuals carrying rhd a alleles, in chinese, to expect it could be explained that why a silent mutation is associated with del phenotype. the full-length rhd mrna was analyzed in rh-positive donors with cde/cde and cde/cde genotypes, respectively, and del phenotype individuals carrying rhd a allele with cde/cde, cde/cde, cde/cde and cde/cde genotypes, respectively, through reversed-trancriptase pcrs and cdna direct or cloning sequencing. results: five transcripts and isoforms were detected in rh-positive and del, respectively. among them, isoforms have identical sequences, which are transcripts with exon , exons and , exons and , and exons to spliced out. the normal rhd mrna was only observed in rh-positive, but not in del individuals. in stead, two additional transcripts were found in del individuals. its exon or exons - were spliced out, but both possess a bp segment of sequence from intron of rhd. through additional reversedtrancriptase pcrs, which amplified exon to ¢-region and exon to ¢-region, the results showed that exon did not exist in del anyway. conclusion: (i) a normal rhd protein does not exist in a del individual with rhd a allele since the exon was always spliced out in all isoforms. all transcripts in del maintain a normal open reading frame and encode proteins with different numbers of amino acid residues and different c-terminals (genbank ay , ay , ay , ay , ay , ay ). among them, the sequence of del (isoform with exon spliced) transcript was the most similar as normal rhd mrna. this isoform was first described by chang et al. in taiwan in . it encodes amino acid residues and has amino acids more than normal rhd. it is different from rhd after codon . in normal rhd protein, the amino acids after ( residues) are mainly the trans-membrane and intracellular regions. therefore a further study on if a del red cell possesses all epitopes of normal d antigen may be significative. (ii) a normal rh-positive individual has also the transcript of del that was found in del. (iii) there is only one polymorphism in the region of bp segment between rhd intron and of the del transcripts, which indicated that other polymorphisms may exist in intron of rhd a allele compared rhd to explain that this situation was not happened in normal rh-positive individuals. total wbc were enumerated by flow cytometry and cell counting. wbc subsets were analyzed by flow cytometry with three-color fluorescence. in this study, the third generation bags and filters are used. results: before filtration, the total number of wbc, was significantly higher in fresh units compared with stored units, whereas in postfiltration samples the number of white cells was significantly lower in the fresh compared with the stored units. although absolute numbers were significantly reduced, filtration also induced significant changes in the proportions of subsets in hoth fresh and storod units, the percentage of t cells was decreased, whereas the percentage of b cells and monocytes was increased after filtration. in conclusion, both pre and post storage wbc filtration affect the proportions of wbc in the final product but pre storage wbc filtration of platelet concentrates is superior than post storage wbc filtration. the effect of pre-and post-storage filtration on platelet rich plasma: derived platelet concentrations background and objective: the white blood cells (wbc) within transfusion products are a major stimulus for a number of detrirmental biological reactions, including febrile nonhemolytic transfusion reactions, alloimmunization against hla antigens and cytomegalovirus transmission. in this work, our objective was to study the effect of storage time on the filtration of platelet concentrates (pcs). the total number of white blood cells as well as the distribution of wbc subsets, in units filtered before and after storage were compared. materials and methods: platelet rich plasma -derived pcs were filtered either fresh ( pooled we reported earlier that metabolic arrest followed by incubation at °c reduces the platelet storage lesion (badlou et al. transfusion ) . here we report that this treatment also reduces binding and phagocytosis by macrophages. metabolic suppressed platelets (msp) were prepared by incubation in glucose-free, antimycin a containing medium ( min, °c) followed by storage ( h, °c) and recovery with glucose ( h, °c). controls were (i) platelets in glucose-rich medium stored for h at °c and recovery with glucose (c ) and (ii) platelets stored for h at °c (c ) with rewarming. platelets were labelled with mepacrine and incubated with pma-matured thp- cells ( °c). binding was measured by facs analysis of cd b/cd positive particles, and phagocytosis by counting mepacrine/cd positive particles. binding of msp, c , c was ± , ± , ± % of total platelets. phagocytosis of msp, c and c was ± , ± , ± % of total macrophages (means ± sem, n = ). before recovery of msp, binding/phagocytosis was % higher than thereafter, revealing energy-dependent control of the mechanisms that trigger plateletmacrophage interaction. these data show that metabolic suppression prior to cold storage attenuates binding and phagocytosis by phagocytes and may help to develop means to improve platelet survival post-transfusion. platelet compatibility testing and alloimunization in multiply transfused hematologic patients purpose: multiply transfused patients with heamotological malignancy often become refractory to platelets due to alloimmunization. refractoriness is usually defined as an insufficient platelet increment after consecutive platelet transfusions. two major causes of a decreased platelet increment can be distinguished, immune and nonimmune factors. alloimmunization occurs most frequently against the hla, and rarely against the hpa system. nonimmune factors been identified are splenomegaly, fever, sepsis, and disseminated intravascular coagulation as well as the quality of the transfused platelet concentrates. we performed this study in order to investigate platelet crossmatching, compatibility, and antibody determination among thrombocytopenic patients multiply transfused. we performed crossmatchingcompatibility tests of single donor leucodepleted, abo compatible, platelet concentrates been transfused in patients with leukemia and lymphoma, males and females with mean age ± years old. we also obtained samples from the patients for platelet antibody detection. we evaluated the cci (corrected count increment) h after the transfusion. the solid phase rbc adherence assay (modified capture p system/immucor) was used for platelet compatibility and antibody detection. a total of compatibility tests were performed, of which were compatible. twenty five compatible platelet concentrates out of were clinically evaluated. twenty from compatible crossmatches ( %) were resulted in successful transfusion while only from ( %) in unsuccessful. the incompatible platelets been transfused was resulted in unsuccessful transfusion. we found statistically significant difference among patients successfully transfused with compatible and incompatible platelets (p~ . ). additionally patients out of ( . %) had been alloimmunized against multiple hla antibodies. three patients transfused with compatible platelets, during the study, developed alloantibodies. we found a large number of incompatible platelet concentrates that result in unsuccessful transfusion and clinical response. the platelet compatibility testing as well as alloantibody determination of multiply transfused patients is necessary for the identification and selection of compatible, with the patients, donors in order to result in succesful transfusion and clinical outcome. furthermore compatible platelet concentrates provide optimal support for refractory patients and it is known that they are acceptable as an alternative component. naitp is a rare clinical syndrome characterized by marked thrombocytopenia shortly after birth. it is caused by maternal immunization against paternally inherited antigens present on foetal platelets. screening and identification of antibodies in the maternal blood sample is the main support in the diagnosis and management of naitp. we have evaluated the frequency of maternal alloimmunization, the role of the antibodies involved (hpa and/or hla systems) and the pertinent risk of naitp in neonates using a fully automated system with a solid phase red cell adherence methodology (sprc-capture p) and paternal or random donors (indirect test). screening started in june and is still in course: in january , blood samples were examined. identification of antibodies in maternal serum was carried out using elisa methodologies: maipa and commercial kits (pak-plus and quick screen-gti). of the blood samples analysed, were reactive and the specificity of the antibodies were: anti hpa a: , anti hpa b: , anti hpa a + hla: , anti hpa b. , anti hla: , auto hpa- b: . specificity of hpa antibodies was confirmed by determination of parents' hpa genotype (hpa- , , , , , ) using pcr-ssp or pcr-rflp. the infants with hpa immunization suffered from severe (plt count - /ml) and symptomatic naitp (bleeding and petechiae were present), therefore they were treated with platelet transfusion and administration of high doses of intravenous immunoglobulin. we confirm that naitp due to hpa- and hla immunization is clinically less severe: all neonates had mild and self limiting thrombocytopenia at birth; no therapy was administered. it would be advisable to carry out pre-natal screening, at reasonable cost, using maternal serum versus paternal platelets and to proceed to the identification of antibodies only in presence of positive results. background: fetal or neonatal alloimmune thrombocytopenia (fmait) results from a maternal alloimmunization against fetal platelet antigens. it is the commonest cause of severe thrombocytopenia in the neonatal period. the diagnosis of fmait is made initially on clinical grounds, depending on exclusion of other causes of neonatal thrombocytopenia. in caucasians, hpa- a is the most frequently implicated antigen. other antigens such as hpa- a, or hpa- a are less often implicated. during the past few years fmait has been reported associated with rare or private antigens. the diagnosis is straightforward when a maternal alloantibody with a corresponding parental antigen incompatibility is present. however it could be equivocal in the absence of such an antibody or difficult when a private antigen is implicated. if the father is heterozygous for the considered antigen, the infant's platelet typing should be performed to confirm the diagnosis. due to the risk of hemorrhage, particularly intracranial hemorrhage (ich), during the course of severe thrombocytopenia, specific therapy is mandatory. because subsequent siblings may be more severely affected, accurate diagnosis will allow better management of subsequent pregnancies. study design and methods: since the first documented case of feto-maternal alloimmune thrombocytopenia (fmait) due to anti hpa- bw (maxa+), no additional cases have been reported. we present here a retrospective analysis of the cases referred to our laboratories in recent years. since we have screened for rare or private antigens in suspected cases of fmait when there is no incompatibility for the most frequently implicated antigens. the diagnosis was performed by genotyping and identification of the maternal alloantibody by the maipa technique. results: parental genotyping showed hpa- bw (maxa+) mismatch as the sole antigenic incompatibility in out of families. in the last one, incompatibility was found for hpa- without anti hpa- b maternal alloantibody. as the father was found to be hpa- bw (maxa+) heterozygous in all the cases, the infant or fetus was genotyped to ascertain the diagnosis. the maternal alloantibody was identified in the maipa technique. however, our data strongly suggest that recognition of the hpa- bw (maxa+) epitope is not uniform. the neonatal thrombocytopenia was severe in most cases with bleeding. the outcome was good in all the cases but one. conclusion: this analysis confirms that anti hpa- bw (maxa+) fmait is not uncommon and was found to be around % of our confirmed fmait cases with parental incompatibilities and presence of maternal alloantibodies. it is a clinically severe syndrome which requires prompt diagnosis, albeit difficult, and maternal platelet transfusion therapy. laboratory investigation of a suspected fmait case should be carried out in a specialist laboratory wellexperienced in optimal testing. therapy requires strict collaboration between clinicians and blood bank services. appropriate management and antenatal therapy should be considered for successive pregnancies to prevent fetal bleeding. introduction: the human platelet (plt) antigen (hpa) system is independent of the hla system. therefore, host-or donor derived alloimmune thrombocytopenia can develop after allogeneic haematopoietic stem cell transplantation (hsct) even in hlamatched donor-recipient pairs. we report the first case on a stem cell recipient developing thrombocytopenia due to host-derived hpa- a antibodies after non-myeloablative allogeneic hsct. a year-old male patient was diagnosed with multiple myeloma in / . treatment consisted of cycles vincristin, adriamycin and dexamethason followed by tandem autologous stem cell transplantation. because of progressive disease he received cycles of bortezomib, and after complete remission a stem cell allograft ( . ¥ /kgbw cd + cells) from his histocompatible (hla a,b,c,dr identical) brother after reduced intensity conditioning regimen with fludarabine ( ¥ mg/m ) and alkeran ( mg/m ). he had received only twice packed red blood cell concentrates and one plt concentrate before allogeneic hsct. stable bilinear engraftment occurred around d but was accompanied with a continuous decrease of plt counts. between d and d the patient received seven plt transfusions, containing a median of . ¥ plt/unit (range , - , ¥ plt/unit) from random donors. the corrected plt count increments at to h after these transfusions were < /ml. therefore, and because of even a further decline of platelet counts to /ml on d we investigated the presence of plt antibodies. methods: the patient's serum was tested by antigen capture elisa assays (pakplus® and pak ®, gti) and a solid phase assay (capture-p®, immucor). the maipa assay was used to confirm the results obtained by the above mentioned assays. in addition, we tested the patient's serum by the maspat kit (clb) against plt from the donor and against homozygous hpa- a plt obtained from our donor pool. stored recipient's dna from the time before hsct was used for genotyping. genotyping for hpa- , - , - and - of the donor and the recipient was performed by pcr-ssp (hpa, protrans). the patient's serum obtained on d after hsct reacted strongly with the donor's plt due to anti-hpa- a antibodies and antibodies against hla class i antigens. the patient's genotype before transplantation was hpa- bb, - aa, - ab, and - aa; the donor was hpa- ab, - aa, - aa, and - aa. thus, the antibodies were host derived and directed against the donor's plt. serum samples obtained on d , d and d after hsct contained antibodies against hla class i antigens but hpa- a antibodies were not anymore detectable. no hla antibodies were detectable on d after hsct. the severe thrombocytopenia was caused by hostderived hpa- a antibodies. fortunately, plt counts started to increase on d spontaneously and the patient could be discharged at d (plt . /ml) with a complete donor chimerism. the decrease of the serum antibodies parallel to the increase of the plt count strongly suggests a progressive elimination of residual host cells. we conclude that the hpa mismatch between recipient and host affected thrombopoietic engraftment and the success of plt transfusions. severe neonatal alloimmune thrombocytopenia with anti-hpa- b antibodies: case report p moncharmont, m vignal, y mÉrieux and d rigal efs rhone alpes site de lyon, lyon cedex , france usually, in case of feto-maternal incompatibility, the platelet (plt) specific anti-hpa- b antibodies (ab) induce only sometimes a mild neonatal alloimmune thrombocytopenia (nait). contrary to this observation here is reported the case of a severe nait. a -year old mother, gestation /partum , gave birth to a male neonate by caesarean section at weeks of gestation because of intra-uterine growth retardation (iugr) and anamniotic fetus. five years before, she had had a first pregnancy with iugr of the fetus but no nait. the second neonate weighted . g, was . cm tall and had a head circumference of . cm. the apgar score was , , , at , , and min respectively after birth. no bleeding, hepatomegaly, splenomegaly or infectious signs were noted. five hours after birth, a respiratory distress syndrome appeared and an oxygenotherapy was performed during h. the plt count which was . , . and . giga/l at day (d) , d and d respectively dropped dramatically at . giga/l at d . simultaneously, an intracranial hemorrhage grade ii was diagnosed on ultrasound scan. because of the clinical signs and of the decreasing plt count the mother's serum was tested for plt-specific ab by immunocapture and the ab identified by the monoclonal ab-specific immobilization of plt antigen (maipa) assay. a plt genotyping was performed in the neonate and his parents by sequence-specific primers polymerase chain reaction. the mother was hpa- a/a and anti-hpa- b ab were detected in her serum. the baby was heterozygous, hpa- a/b. plt were transfused to the baby and the plt count rose to . , . and . giga/l at d , and respectively. no further transfusion was needed and the development of the baby was satisfactory with a normal electroencephalogram. in conclusion, when a mild thrombocytopenia with iugr and hypoxia but without bleeding signs is present in a neonate immediately after birth, a maternal plt specific ab screening must be performed in case the thrombocytopenia became severe during the newborn monitoring. anti-hpa- b ab can be detected. partial results of the incidence of heparin induced thrombocytopenia type ii osc oliveira*, ra rached*, c cavalheiro-filho*, jc nicolau*, shgl pasqualucci*, daf chamone † and sp bydlowski † *heart institute, university of são paulo, † university of são paulo, são paulo, brazil heparin induced thrombocytopenia type ii (hit) is a severe side effect of heparin, associated with heparin-platelet factor antibodies. hit type ii occurs in up to % of patients who are exposed to unfractionated heparin (ufh). in our institution patients that are under heparin treatment are mostly cardiac patients. the purpose of this study is to determine the incidence of hit type ii in these patients. material and methods: patients from the intensive care unit and cardiac care unit treated with ufh or low molecular weight heparin (lmwh) for or more days were studied. known causes of thrombocytopenia were excluded. platelet count was monitored pre and post heparin therapy. all selected patients were tested for detection of anti heparin/pf antibody test (diamed id-card). results: from the studied patients, ( . %) developed thrombocytopenia (determined by a decrease in the platelet count below %, after the introduction of heparin therapy); ( . %) did not show decrease in the platelet count. six ( . %) out of thrombocytopenic patients were positive for anti-heparin/pf antibody. three ( . %) out of non thrombocytopenic patients were positive for anti-heparin/pf antibody. the results demonstrate that ( . %) patients were positive for anti-heparin/pf antibody and they were no different from those described in the literature regarding the frequency of heparin induced thrombocytopenia. moreover, a higher frequency of patients with heparin/pf antibody was noted without the presence of thrombocytopenia, indicating that other factors should be considered. introduction: neonatal alloimmune thrombocytopenia (natp) due to maternal immunization against fetal platelet antigens affects . - in live births. although it is usually a self-limiting condition, a major complication in cases of severe thrombocytopenia is the occurrence of intracranial haemorrhage leading to death (in up to % of reported cases). the commonest antibodies are anti-hpa- a. treatment consists of ivig, compatible donor platelet concentrates or washed maternal platelets. the administration of random donor platelet transfusions is controversial but has been used successfully in some urgent cases when compatible platelets were not available. case report: a baby born in week of gestation to a healthy mother after first uneventful pregnancy; birth weight g, apgar score . immediately after birth, severe thrombocytopenia ( ¥ /l) and signs of haemorrhagic diathesis (generalized petechiae and ich gr. ii-iii) were observed. coagulation tests were abnormal and k-vitamin, fresh frozen plasma and random donor platelet concentrate (retrospectively genotyped as hpa- a/a) were given. twenty-four hours later platelet count rose to ¥ /l and no new petechiae were observed. on third day of life the blood platelet count was ¥ /l and the newborn received ivig g/kg and corticosteroides. twenty-four hours later the platelet count rose to ¥ /l and further clinical course was uneventful. natp due to hpa- a was serologically confirmed. conclusion: optimal therapy for an infant with severe thrombocytopenia during the first h of life is the transfusion of platelets that will not be destroyed by the maternal alloantibody in the infant circulation. random donor platelet concentrates are controversial in a setting where optimal treatment is not available, however, in this case they led to a significant platelet count improvement in spite of hpa- a incompatibility. accordingly, random donor platelets may be considered appropriate in emergency situations. background: rhd is the most immunogenic blood group antigen, and its correct identification is essential in the blood bank and in the prevention of the haemolytic disease of the newborn. the weak d phenotype is the most common d variant, with a frequency of . % to % in caucasian individuals. there are several weak d types, with different frequencies in european countries, which may pose serologic problems and have the potential for alloimmunization. the objective of the study was to determine the frequency of the principal weak d types in portugal. study design and methods: lisbon regional centre of the portuguese blood institute and oporto são joão university hospital selected samples from blood donors and patients. rhd was tested by two (oporto) or three (lisbon) distinct anti-sera, in direct agglutination tests, at room temperature. when discrepant results were observed, the samples were tested with panels of monoclonal anti-d by liss-iat. samples that reacted weakly with igm anti-d but positive with igg anti-d were sent to the molecular biology centre. pcr with sequence-specific primers was performed using two commercially available kits (inno-train and bagene). real-time pcr, carried out on a light cycler, was applied when the interpretation was dubious. results: samples were referred after being characterized as weak d. in cases we obtained a positive result, with a preponderance of weak d type ( . %) over type ( . %), ( . %) and ( . %). two samples were not categorized. the high incidence of weak d type in our population is in marked contrast to studies performed in other european populations where weak d type was the most frequent. this might be due to our sample selection criteria or ethnic variation in the causes of weak d. there are advantages in genotyping serologically depressed d samples: to avoid the waste of d-negative rbc units and the use of immunoglobulin in pregnant women, who have no risk of alloimmunization. analysis of rhd zygosity in different rh phenotypes cal except for a -bp t insertion. the deletion of the rhd gene, found in most rhd-negative caucasians, was theoretically due to recombination of the upstream and downstream rhesus boxes resulting in the formation of a hybrid rhesus box. thus, the detection of a hybrid rhesus box in an rhd-positive individual denotes an rhd heterozygous status. aim of the study: to determine the rhd zygosity in different rh phenotypes. methods: blood samples from white trios (father, mother and child) were studied. the rh phenotype was performed by hemmaglutination and the rhd zygosity was inferred in each member of the family groups. the rhd deleted allele was determined by a pcr strategy using a forward primer complementary to ¢ end of the identity region of the upstream and hybrid rhesus boxes and a reverse primer complementary to the ¢ end of identity region of the downstream and hybrid rhesus boxes. these primers selectively amplify a -bp segment of the hybrid rhesus box in rhdnegative and rhd-positive heterozygous samples. serological and pcr inconsistencies were studied by a pcr-rflp method to detect another polymorphic site of the hybrid rhesus box. frequencies were obtained analysing only unrelated individuals (fathers and mothers, n = ). results: ( . %) rhd-positive and ( . %) rhd-negative samples were phenotyped. of the rhd-positive donors, ( . %) were rhd homozygous and ( . %) were rhd heterozygous according to pcr. pcr-rflp analysis confirmed the results of pcr in serological and molecular discrepancies. these results were coherent within each family group and did not differ from those published in the literature for caucasians based on the most probable genotype method. however, the homozygosity indexes were significantly higher in the dccee ( . % vs . %) and dccee ( . % vs . %) phenotypes due to an increase of the dce haplotype. in all samples with the dce haplotype the rhces allele, frequent in individuals of african descent, was investigated by pcr-ssp. this allele was found in . % of the dce haplotypes. . rhd and rhce typing was performed by multiplex-pcr with fluorescent primer pairs. positive results were obtained for rhd-exons - , , and polymorphisms associated with antigens c, c, cw, e and e. sequencing of rhce-sequences, including exons to and intron/exon borders, were done by direct taq cycle-sequencing using bigdye-terminators v. . in an abi (applied biosystems). results: see table . the substitutions of rhce-specific nucleotides in exons , and with their rhd-specific counterparts lead to different new rhc-antigens with weakened expression. since one amino acid change in allele lie in extracellular loop of the antigen suggested that this antigen may be involved in allo-immunization. inheritance of a rhd cat vi type ii in a twin pregnancy: a case report introduction: determination of hdn-relevant fetal blood groups in amniocentic fluid with pcr is a routinely used method. misinterpretation of test results -e.g. overlooking rhd category -decreases depending on the number of examinated rhd-specific exons. case report: a -year old mother (w.o.g. ) pregnant with twins was regularly tested for irregular antibodies and was shown to have an anti-d. after amniocentesis of both foetuses tests for the occurrence of rhd intron , exons and were performed in the hospital's lab. the sample of fetus i showed pcr-products for intron , exon and exon while sample of fetus ii lacked rhd-specific intron . therefore we investigated blood samples from the parents as well as amniocentic fluid of both foetuses. methods: total dna was amplified in a multiplex pcr with fluorogenic primers for rhd exons - , & ; polymorphisms for dweak type - , d-vii, d-hmi and rhce polymorphisms for c, c, cw, e, e. capillary electrophoresis for size fractionation and fluorigeneic analysis was done in an abi . rhd zygosity was determined by quantitative real-time pcr with co-amplification of rhdand rhce-specific exon and subsequent calculation of d ct value (ct rhce minus ct rhd). results: while maternal dna sample has been genotyped as rhdnegative, amplification of paternal dna for rhd-specific exons , , , and were possible and failed only in exon - . determination of rhd-zygosity revealed a homozygous constellation of the rhd-gen. investigation of amniocentic fluid from both foetuses resulted in a rhd-wildtyp for fetus i and a rhd cat. vi type ii for fetus ii which was the reason for missing amplification in rhd intron pcr. results: weak d type was not identified in our research population. weak d type was identified in cn, weak d type was identified in cn and weak d type was found in cn, bsa, be, bc and saa. conclusions: although weak d types to represent the majority of all weak d phenotypes in caucasian populations, none of these weak d alleles were found in black populations. since none of the frequent weak d types were identified in non-caucasians one might not expected to find type in all populations. however, regarding rhd phylogeny, the weak d type mutations ( c > g and t > g) form the basis of a cluster of aberrant alleles that are predominantly observed in blacks. therefore, it is not surprising that weak d type was identified in non-caucasians. based on these results it may be concluded that weak d phenotypes have evolved relatively recently since they are present in caucasian and asian methods: dna was extracted from a, b, ab subgroups, and provisional cis-ab after serological abo typing. allelespecific pcr, rflp, direct sequencing of exon and , and allele separation were performed on these samples. results: abo*a allele was observed in an aint subgroup. two new a alleles that showed g > a base change and c > t of intron and a polymorphism of c > t in a(pro) intron were discovered. o and o alleles were also observed. in b subgroups, a silent substitution c > t (leu leu) was observed as a new b allele. another new b allele which showed g > a was also found in b subgroups. conclusion: we discovered new abo alleles and polymorphisms in korean populations. many other polymorphisms and alleles already reported in japanese were also observed in koreans. evaluation of a multiplex snapshot-pcr method for red blood cell marker genotyping c jungbauer*, c hobel*, em dauber † , pk rabitsch*, dwm schwartz* and wr mayr* *austrian red cross, † medical university vienna, vienna, austria once conventional reagents for identification of rare red blood cell phenotypes are scarce, methods using current nucleic acid testing techniques to identify the patient's genotype and possibly to screen for donors would be desirable. the approach of multiplexgenotyping using pcr-ssp has apparently technical constraints so we are currently analyzing whether a modification using snapshot pcr-technique could provide a routine application for such purposes. compared to ssp-technique, the snapshot pcr only requires one single primer (labeling reaction) for the detection of two (or more) alleles instead of one pair of primers for every single allele. briefly, we perform snapshot pcr as follows: in a first step, dna segments covering the essential polymorphic regions for the abo, rhd, kel, jk and fy genes are amplified using a standard pcr step. after purification treatment of the pcr products (roche high pure pcr product purification kit or shrimp alkaline phosphatase (sap)/exo treatment according to the abi prism snapshot multiplex kit protocol) the labeling reaction is performed using the abi prism snapshot multiplex kit. after a second purification step the products are analyzed on a abi prism genetic analyser in fragment analysis mode. our preliminary results show the feasibility of this approach as reliable typing results can be obtained for all tested single nucleotide polymorphisms corresponding to alleles. generally a better signal quality from controls and samples is obtained compared to the ssp-technique with consecutive gel electrophoresis. we also consider the possibility of the automated interpretation of the results as an important improvement, especially when aiming for an application for a large number of samples (donors) or markers (patients). in contrast, the method involves more manual steps and higher costs. we may conclude that the implementation of snapshot-pcr techniques for red cell marker genotyping is a promising alternative to pcr-ssp. the obvious quality improvements compared to pcr-ssp might be critical for a routine application in blood banks (donor screening) or complex questions in clinical laboratories. quantification and quality control of monoclonal antibody using an optical sensor based on the laser reflectometry technique the monoclonal antibodies (moab) are biological reagents of homogeneous activity. they are generally used in the recognition and quantification of very small amounts of biological substances (hormones, enzymes) present in a solution, ag identification, blood group determination, oncology, organs transplant, etc. moab can be characterized by its specificity and affinity. affinity may be expressed as the equilibrium association constant (k). several techniques are available to determine the equilibrium constant of the ag-ab interaction. in this work, is shown an optical sensor for monoclonal antibody quantification by reflectometry technique. the laser reflectometry technique (null ellipsometry technique) can give information about the kinetic of the interactions, stoichiometry of molecular binding and the concentration of molecules in a solution, and also offers detailed and accurate determinations of real-time adsorption kinetics of protein without labeling. a silicon wafer was chosen as reflectant surface. once fixed the principal angle of incidence, an amount of anti-ab is added to the sample. the reflected laser intensity is registered in real time as the protein is being adsorbed onto the wafer. the mathematical analysis of the results verifies that the antibodies adsorption follows langmuir's kinetics. from the curve analysis, the parameters related to the anti-ab concentration are extracted. from them, the calibration curve is constructed. this curve allows the desired commercial monoclonal antibody quantification. the developed technique shows to be sensible and precise. the obtained graphics are very well approximated (r > . ) verifying that the monoclonal anti-ab associa- study aim: to prevent the sensitization to rh (d), to a d-patient who was transfused with d+ blood. material and method: on september , ( / / ), we admitted to our hospital through air-carriage, a female of years old, badly injured after a car-accident. the patient was on an olighemic shock (ht: %) due to retroperitoneal, paracolic and procystic hematomas, had multiple fractures on the left feet, the main important of which was an acetabulum one. she had a blood group: o, d-and her phenotype was ccdee with du-. after her arrival she was urgently admitted to the surgery room and our blood bank was asked for condensed red cells. initially she was transfused with blood of the same group (o, d-) but when we were short out of dblood, we were asked for more units. the necessity of blood was imperative, the patient was on a critical condition and the mechanism of blood transport, from another blood bank would take some time to be put in motion, and so it was decided that the patient would be provided with d+ blood. the indirect antiglobulin test (iat) and papaine were negative, so there would be no problem with the transfusion with d+ blood. the patient received finally units ( ml) of d+ condensed red cells, out of that were initially asked. before the h from the surgery had passed, it was decided that human anti-d immunoglobulin (rhesogamma p) should be provided, in order to prevent the sensitization of the patient to rh (d). the indicted dose was - iu/ ml of the transfused blood, provided piecemeal during a several days period. analyzed by real-time pcr amplification. based on a published report, we selected primer pairs targeting insertion/deletion polymorphisms which are located on different chromosomes, unrelated to each other and not associated with immunocompatibility. we optimized the amplification conditions for all primer pairs using our sybr green real-time quantitative pcr protocols, and investigated analytical sensitivity for each primer pair by performing spiking studies, in which a single copy of positive dna was added into copies of negative dna followed by allele-specific pcr amplification. we also created a theoretical panel of donor-recipient pairs (n = ) to evaluate the clinical sensitivity for detection of ta-mc using both hla-dr and indel panels. results: for the short-term samples, additional mc cases was identified in non-lr group using indel panel; and one additional mc case was detected in lr group (table ) . for the long-term follow-up samples, additional mc cases were found. when evaluating analytical sensitivity, we were able to detect a single copy of positive dna mixed with copies of negative dna in a single amplification tube for all primer pairs. we were also able to calculated the clinical sensitivity that using donor-recipient pairs. . % of donor-recipient had at least one informative allele for detection of ta-mc if we consider both hla-dr and indel panels. conclusion: using our new indel panel, we were able to detect more instances of mc in this cohort of patients. we conclude that the dr assay underestimates the presence of mc. moreover, the tandem use of both panels provides a powerful tool for the detection of mc with . % of recipients having at least one informative allele. background: we reported severe immunesuppression and longterm transfusion-associated microchimerism (ta-mc) in transfused trauma patients. we have also reported, in a murine transfusion model, that sensitivity to -chloro- - dinitrobenzene could be transferred, albeit transiently, by transfusion of fresh blood from a sensitized donor to a naïve immunecompetent recipient. in order to mimic the immunecompromised status of trauma patients and further investigate the mechanism underlying ta-mc, we established an animal model using immunedeficient knock-out mice. aim: our objective was to test virus-specific immune functionality of the chimeric donor leukocytes in a murine ta-mc model. material and methods: female rag- /common gamma double knock-out mice were transfused with fresh blood collected from male balb/c mice, which were either not infected (non-primed, np) or infected twice (primed, p) with million viral particles of murine cmv (mcmv). at different post-transfusion time-points ( h, weeks, weeks, weeks, weeks), different female recipients plus non-transfused female knock-out controls were challenged with million viral particles of mcmv intra-peritoneally, and then monitored weekly for the concentrations of male donor cells as well as mcmv viral load in recipient's circulation. each female knock-out received only one challenge of mcmv. if the subject died, we quantitated mcmv viral load in the brain, spleen, lung and liver. we used real-time quantitative pcr targeting murine y-chromosome, h k and mcmv to quantitate male donor cells, transfused recipient cell dna input, and mcmv vrial load, respectively. the number of recipient cell dna input served as a denominator to calculate the concentration of male donor cells and the mcmv viral load. results: results of overall mortality are summarized in the table. all female knock-out recipients transfused with primed donor blood, except for the post-transfusion weeks, are able to survive mcmv infection. all non-transfused control and recipients transfused with non-primed donor blood died after mcmv infection; these two groups also had higher mcmv viral load in blood than the recipients transfused with primed donor blood. when the subject died, we were able to detect mcmv in all four organs we analyzed, with liver having the highest mcmv viral load. there was no significant difference for the concentration of donor cells in recipients' blood between recipients transfused with non-primed donor blood and recipients with primed donor blood. the preliminary data of our study showed that chimeric primed donor cells, but not non-primed donor cells, are able to protect immune compromised knock-out recipients from murine cmv infection. the time-point of 'post-transfusion weeks' might represent a weak window for the functionality of chimeric donor cells, which requires further investigation and confirmation. aims: to compare the effectiveness and the cost of epoetin-a and darbepoetin in patients undergoing pabd. methods: seven adult patients scheduled for operations were administered aranesp ( mg sc once or q weeks if needed) for pabd (aranesp group) and they were compared with a historical epoetin-a group of seven age-matched adults (eprex iu/kg biweekly). the two groups were matched according to the ht, ferritin levels, number of the predonated units and type of the operation performed. cbc count and reticulocytes were measured weekly during the donation period, the day before, day and day after surgery while ferritin and biochemical indices were measured during the first visit. erythropoiesis-stimulating factor was administered when ht £ % during blood donations and blood donation was not performed if ht < %. results: there was no statistical significant difference in hematological parameters during the donation period, the pre-operation day and after surgery between the two groups. five of seven patients from both groups received one or two autologous blood units. both factors were well tolerated without any side effects. the cost per patient was . € in the aranesp group and . € in the epoetin group. conclusion: despite the small number of patients and the limitations of this preliminary retrospective trial we believe that subcutaneous darbepoetin-a is equally effective with epoetin-a in patients undergoing pabd. darbepoetin has the advantage of less frequent administration and it is possibly superior that epoetin-a in terms of patient compliance. however smaller doses should be examined in order to reduce the cost. larger prospective randomized trials are needed to estimate the cost-effectiveness of the use of darbepoetin-a in pabd. background: incompatibility with many blood units is a major problem in transfusion therapy. in selective operations, preoperative autologous blood donation could solve many problems, when of course the patient's condition and his haemoglobin levels are appropriate. we present here the experience of our blood transfusion centre from operations in patients with anti-erythroid antibodies. materials: three patients ( male and females), aged between - years old, had to undergo selective operations, total hip replacement surgery and aortic aneurysm. introduction: because of improvements in surgical techniques, preoperative autologous blood donation (pabd) in patients undergoing radical retropubic prostatectomy (rp) is contested. aim of the study: we wanted to develop and validate an algorithm to determine the patients who probably do not benefit from pabd. methods: we calculated the perioperative hb-loss of consecutive patients (group ) who donated two red cell units (rbc) of autologous blood and weeks before undergoing rp: hb-loss (g) = preop-hb ¥ bv + (n rbc ¥ ) -(postop-hb ¥ bv) (bv = blood volume (l) = body weight (kg) ¥ . ; postop-hb = hb ( - h after rp); n rbc = number of transfused autologous and allogeneic rbc). hb of rbc was taken as g. rbc requirement is probably if initial-hb -(hb-loss: bv) -trigger-hb (taken as g/l) < (initial-hb = hb at the first contact with the pabd-unit). this assumption was validated by the next patients who were also assigned for pabd (group ). pabd was refused if the probability of rbc requirement (prr) was < %. between - % one rbc was taken after considering the patient's individual risk of pabd. if prr exceeded % two donations were planned. results: both groups did not significantly differ in age or initial hb. preop-and postop-hb were significantly lower in group ( vs and vs g/l). % of autologous blood of group were discarded, / patients needed additional allogeneic rbc. hb-loss caused by rp was ± g. mean prr in group was . %. / patients donated one rbc, which was later discarded, and no patients donated two rbc. / of group needed allogeneic rbc. mean prr of these patients was % (range . - . ). conclusion: postop-hb were lower in rp-patients with pabd because of the lower preop-hb and the restrictive indication for transfusion of autologous blood. the individual calculation of prr, for which only body-weight and initial-hb of the patient are necessary, shows that pabd in patients undergoing rp is indicated only in rare cases. the algorithm also may be used in other major operations, if hb-loss is known. use of darbepoetin-alpha in preoperative autologous blood donation: preliminary results background: preoperative autologous blood donation (pabd) is an alternative practice to eliminate complications of allogeneic blood transfusion although its cost-effectiveness has been questioned. darbepoetin-a (aranesp, genesis pharma sa) is a novel erythropoiesis-stimulating factor that it has been shown to be equivalent to epoetin-a (eprex, janssen-cilag) in patients with chronic renal failure and cancer. darbepoetin-a has a longer serum half-life and higher relative potency than epoetin-a. this property leads to less frequent administration and may reduce drug cost. so far, no clinical trials with darbepoetin have been published in patients with surgical anemia. other ( . %) patients who required autologous and homologous blood, had average predonation hb level of (sd ± . ) g/l. we found a significant relationship between the need for postoperative transfusion and the predonation hb level (p = . ), predonation htc values (p = . ), weight (p = . ) and gender (p = . ): female patients and patients with lower predonation hb and htc, as well as patients with lower body weight more often needed additional homologous blood transfusion. no relationship was found between age of patients and the need for transfusion (p = . ). ( . %) patients with ptka were transfused with autologous blood only, and had average predonation hb level of (sd ± . ) g/l. other ( . %) patients transfused with autologous and homologous blood had average predonation hb level of (sd ± . ) g/l. the significant relationship was found between the need for postoperative transfusion and weight (p = . ): patients with lower body weight more often needed additional homologous blood transfusion. no relationships were found between predonation hb level (p = . ) predonation htc values (p = . ), gender (p = . ) and age (p = . ) of patients and the need for postoperative transfusion. conclusions: our results show that over % of patients needed only autologous blood. in our patients with ptha predonation hb was significant predictive factor for additional transfusion therapy, while in ptka it was not observed. in both groups of patients body weight was significant predictive factor, thus this feature seems important for planning of transfusion therapy in patients with ptha and ptka. aim: prevention results of loosen anastomoses on colon, with fibrin sealent (fs) application and influence on colagen production. materials and methods: investigations were done on rats, weight - g. in control group, after partial resection of left half of colons termino-terminal anastomosis was derivated. fs was applied in examined group. concentration of colagen was done indirectly, with quantitative l-hydroxyproline determination. place of anastomosis, cm proximal and cm distal of anastomosis, was analyzed iii, v, vii and xiii day postoperatively. results: analysis of hydroxyproline on the place of anastomosis showed higher hydroxyproline value in group with fs application. the highest approximate value of hydroxyproline was registered v day postoperatively. distal, cm of anastomosis, the quantity of hydroxyproline is higher iii day postoperatively in control group but v postoperative day value is intensively growing in group with fs application. electronic microscopical was done v postoperative day in control group at the place of anastomosis detected a defect with detritus and absence of larger colagen fibres. in group with fs application on the place on anastomosis, in the shape of bundle, colagen fibres were grouped and completely fills the place of anastomosis. conclusion: fs application accomplish higher concentration of colagen in all segments of isolated colon, that enables better healing of anastomosis. the study of the use of the safest blood (autologous blood transfusion) through preoperative blood donation (pbd) in surgery patients introduction: the use of the autologous blood is already under consideration in developed countries. thus, it is probable that autologous blood donation would be effective in one way or the other in reducing blood transfusion complications. in this study, pbd as the easiest method to use and the most cost-effective one was selected. aim of the study: it aims at improving blood safety and raising blood inventory. methods: in this study, patients, including males and females, intended to undergo elective surgery were selected as subjects to donate their autologous blood. the subjects with hematocrite level of about - percent as ordered by their physician donated their blood by this method. blood collection procedure was followed at - day intervals. the blood volume taken from patients in every collection differed from - ml according to their weight. results: this study showed that in all patients undergoing plastic, gynaecological, jaw, and ent surgeries autologous blood transfusion was used with no need for allogenic transfusion. in other surgeries, including orthopaedics, the need for allogenic transfusion was estimated to be at about percent of cases. to avoid the complications of allogenic blood transfusion, the safest way is the use of autologous blood which involves low cost and is easy to perform. the introduction: the purpose of this study is to describe a technique to perform labelling of autologous platelet-gel with in-oxine and to evaluate its usefulness, after in vivo graft implant, as a marker of bone osteoinduction by means of scintigraphy, in patients with jaws bone defects following the enucleation of cystic lesions and cystic lesion derived from extraction of deeply impacted lower third molar. methods: agp made. consent was obtained by patient to conduct hiv and hbv testing. briefly, cc to cc of blood is withdrawn from the patient. the blood was separated, by means of successive step of centrifugation, in to platelet-rich plasma (prp) , platelet-poor plasma (ppp), and red blood cells (rbc). the red blood cells were discarded. the prp [comprises of approximately % of the total blood volume withdrawn] had platelet counts of - /mm . the procedures of agp labelling were performed in laminar flow chamber. to seconds the solution will assume a gel-like consistency forming platelet gel. imaging: the scintigraphy was performed h after application of labelled agp (early scan) and at , , , h (delayed scan) by means of a gamma camera equipped with medium energy collimator. a later scan was performed at days after graft. the platelet uptake index (pui) was then calculated by dividing the cpm/pixel in the graft roi (recognized in and planar and trans-axial slice) for cpm/pixel in a mirror background roi. in vitro sampling: the radioactivity of the plasma samples collected at , h and at lapse time = h for days, were used for the plasma clearance determinations and for in vitro studies of the platelet loss from the gel. results: all patients presented early high concentration of in oxine agp, at site of the graft, that was easy recognized at scintigraphy performed as in anteroposterior and lateral planar projection of the jaw as in spet slices reconstructions. all labelled agp was well confined within area of original implant and no activity was seen in the surrounding tissues or in the distant organ. conclusion: all patients studied well tolerate the implant of agp; no adverse reactions were observed and follow up -performed months later -showed bone remodelling activity in the site of the graft. serial blood donations in a ko pregnant woman with the use of recombinant erythropoietin for intrauterine transfusions of severe hemolytic disease of the newborn due to anti-ku biweekly) were administered to the mother to ensure an adequate supply of compatible rbcs for intrauterine transfusions and possible perinatal haemorrhage as well. results: intrauterine transfusions were repeated every - weeks. by the th week of gestation the patient had donated four units of blood, her hematocrit was %, anti-ku titre was / and four intrauterine transfusions had been performed. cesarian section was decided and the apgar of the newborn were and at and min. the newborn was treated with phototherapy but without exchange transfusions and two weeks later he was discharged. by the th day of life rh-epo was administrated to him due to anemia. the maternal red cells completely disappeared from the child's blood by the day . the experience of the use of erythropoietin in pregnancy is minimal. as illustrated by this case treatment with rh-epo and iv fe has effectively increased mother's capacity to donate rbcs' for autologous use and intrauterine transfusions as well, with no adverse effects to the mother or the child. however, further research is necessary to evaluate if rh-epo crosses the placenta. introduction: blood components should be transported by a system which has been validated. the containers used for transport should be well insulated, some form of temperature indicator should be used to monitor the in-transit temperature. whole blood should be stored at different temperatures above °c. aim of the study: bags with whole blood collected in a collection site are transported in containers without active cooling. we tested temperature of blood in containers put into the extreme weather conditions (+ °c, - °c) during loading test for transport. methods: the container without active cooling was filled with the exact number of bags with blood and the exact number of passive cooling elements (frozen water cubes in plastic) placed in the exact positions without close contact with the blood bags. the bags with blood of the temperature + °c, + °c and + °c were used. temperature indicators were situated in the bottom, centre and top of the container. filled container was placed into thermostat (+ °c) or freezer (- °c). the temperature was observed in min intervals for three hours, first measurement was min after putting into freezer or termostat. results: (see table ) nt, non tested; tmp, temperature. in the table there are shown minimum and maximum temperature parametres observed during tested time including increasing or decreasing trend. conclusion: loading test for transport of the bags with collected whole blood helps us to optimize transporting system, especially number of cooling elements in relation to the season and its place in the container. in the light of presented data we corrected transporting system to maintain the recommended temperature during transport. background: since , we have produced pooled and filtered platelet concentrates out of four buffy coats in tsol platelet additive solution and have stored them in pall autostop clx bags made out of pvc/totm. the residual plasma content is between - %, the mean volume about ml and the mean platelet-content is . ¥ per unit. for pathogen inactivation or bacterial screening it is necessary to extent the storage time from to days. new foliage like polyolefin is supposed to maintain a good quality environment for prolonged storage of platelets. aims: storage bags made out of polyolefin (pall autostop elx) were tested to prove their suitability for prolonged storage of platelets. methods: twins made out of pools from buffy coats were produced with the standard method, one twin was stored in the conventional bag (cb) the other in the new foliage bag (nfb). the platelet pools were stored on flatbed shakers at °c, and sampled at day , day and day . ph, glucose, lactate, hypotonic shock response (hsr) and p-selectin expression were measured by standard in-house methods. results: mean ph on day with cb was . , with nfb . ; glucose with cb . mmol/l, with nfb . mmol/l; lactate with cb . mmol/l, and with nfb . mmol/l, hsr with cb %, with nfb %; p-selectin with cb % and with nfb %. the new platelet storage bag showed better results of in vitro quality markers, especially after day of storage. prolonging storage time will make it easier to introduce bacterial screening or pathogen inactivation techniques into platelet transfusion. the possibility to filter rbc either at °c or rt simplifies the preparation process. filtration at + °c enables to achieve a better leukoreduction performance. the nbs has successfully implemented this project which has the potential for improvement in patient safety and is predicated upon practical application and risk reduction rather than elimination. the impact of this work on the incidence of trali will require detailed, long term analysis of hemovigilance data using existing mechanisms. active communication, a team approach, perceived value of the initiative and the hard work of all staff involved were key success factors. quality assessment of buffy coat-derived platelets prepared from leucoreduced whole blood background: whole blood can be separated into; plasma, buffy coat and red-cell conc (rcc) by differential centrifugation and separation on a separation device. because of the high hematocrit of the rcc, % of the process time is needed for expression of the rcc. by increasing the internal diameter of the tubing at the bottom of a t&b system by . mm. a decrease of the process time is expected. methods: units of whole blood were collected with the new t 'wide boring' blood pack and separated on a routine base. quality control parameters were checked and the whole process time was monitored. free hemoglobine was measured up to days. results: process time of a 'wide boring' bag is significant shorter compared to a standard blood bag. average decrease: s. slightly increase in free hemoglobine is measured probably due to the increased express rate of the red cells. bloodproducts produced with the new t meet european guidelines. no significant increase of free hemoglobine due to the faster expression is measured. an significant decrease in process time is measured with the wide boring bloodpack. the new fresenius hemocare rcc in-line system: t can be used for routine production which will speed up the production process considerably. introduction: leukoreduction of blood components is required to prevent several transfusion-associated complications. aim: the aim of this study was the full process validation of the pall leukotrap wb system for the preparation of leukoreduced blood components. we collected whole blood units from donors suitable for donation using a quadruple blood-bag, which includes an wbf in-line filter (pall) for the removal of leukocytes and platelets. mixer balances (baxter) were used and donation occurred within min in all cases. after donation whole blood units were stored at room temperature for h. subsequently, whole blood filtration was performed by gravity at a standard height of cm using a blood leukoreduction cart (baby leuko cart, itl-corporation). filtered units were centrifuged at g ¥ min by an heraeus cryofuge i. an automatic extractor (bag press plus-bioelettronica) was used to prepare red cell concentrates in sag-m solution and fresh plasma units. air in the system was automatically expelled by the extractor. complete cell counts and hemoglobin concentration were evaluated in pre-filtration samples and at the end of the blood components preparation using an automated cell counter (pentra dx -abx). we enumerated residual leukocytes in red cell units by flow cytometry (becton dickinson-leucocount kit). results: pre-filtration data of whole blood and end-of-process data of red cell and plasma filtered units, are summarized in table . results are given as mean and standard deviation. whole blood filtration was completed within min in all cases. red cell units were transfused after a mean of days to patients affected from transfusion dependent ( %), post-surgery ( %), and post chemotherapy anemias ( %). no cases of transfusion reaction were observed. the pall leukotrap wb system was easily introduced in our setting. all blood components prepared by the system fulfilled the council of europe requirements with regards to hemoglobin content in red cell units and post-filtration residual leukocytes. future studies are needed to evaluate its cost-effectiveness in the setting of routine blood component preparation. background: during an evaluation of the compodock (fresenius hemocare) sterile connection device (scd), we observed irregularities on the inside of the tubing at the site of the weld. it was our aim to investigate the effect of these observations on the quality of blood products. methods: three leukoreduced red cell concentrates (rccs) were pooled and divided over bag systems: one without weld in the connecting tubing, one with a compodock-weld, and one with a weld made with the terumo scd. the rcc was transferred times over this tubing to have maximum result if the weld had deleterious effects. the rccs were stored in pvc containers, and sampled on day , , and , and free hemoglobin (hb) was measured. the same procedure was also performed using platelet concentrates (pcs), but these were stored in polyolefin containers, sampled on day , and , and cd expression was measured. ten experiments were performed per blood component. according to who standards processing of blood into labile components are considered an expression of quality of transfusion service. in our practice, modern transfusion principles are successfully applied. they cover blood collection, serological processing of blood units, technological preparation of blood products (gmp, sop) and rational utilization of blood components and blood derivatives. in the past four years ( , .) aberrations from these principles have taken place (self-sufficiency). nbti collected x = ( ) blood units into blood bags. in serbia x = ( ) blood units. retrospective analysis: ldpc-bc was administered x = % with the satisfactory haemostatic effect. increase of the cyta and plasmapheresis-manual procedures was also noted ( %). increase of the use of leukocyte poor red blood cells was also registered ( % introduction: according to the relevant recommendations of the council of europe, whole blood is a source material used for the preparation of blood components and blood products. basic concept of the therapeutic use of blood components is the compensation of the lacking or deficient blood component. in that way, a possibility of the infusion of unrequired or deleterious components of whole blood is eliminated. objective of this presentation is to analyze the reasons of non-utilization of certain blood units, the actual quantity and ratio. aim of the study: the purpose of our in vitro study is to compare storage of platelet concentrates at °c with platelets stored at °c, and to determine the in vitro-effects of pre-incubation at °c for h prior to analysis on the basis of the maintenance of platelet metabolic and cellular integrity. methods: platelets concentrates (pcs) were prepared from pooled buffy coats (bc) for paired studies to be stored into different conditions. (i) at - degree on a flat bed agitator; (ii) at - degree on a flat bed agitator and pre-incubated for h prior to analysis; (iii) at °c; and (iv) at °c and pre-incubated for h prior to analysis. this paired in vitro study (n = ) over days include volume, platelet counts, mpv, volume, ph, po , pco , bicarbonate, glucose, lactate, swirling, leucocytecount, hsr, esc, atp, ldh and release of a-granule content (rantes, ß-thromboglobulin and pf ). results: platelet count (day and ; p < . ), mpv (day ; p < . ), ph (day and ; p < . ), pco (day and ; p < . ), bicarbonate (day ; p < . ), glucose (day , , , and ; p < . ), atp (day and ; p < . ) was significantly higher in platelets stored at °c and platelets stored at °c with preincubation. ldh (day ; p < . ), bicarbonate (day and ; p < . ), lactate (day , , , and ; p < . ), ph (day and ; p < . ), esc (day , , , and ; p < . ), hsr (day , and ; p < . ) was significantly lower in platelets stored at °c and platelets stored at °c with pre-incubation. the concentration of rantes, ß-thromboglobulin and pf was significantly higher in platelets stored at °c than in platelets stored at °c (day , , , and ; p < . ). hsr (day and ; p < . ) and esc (day , , and ; p < . ) was significantly higher in preincubated platelets stored at °c compared with platelets stored at °c. conclusion: platelets stored at °c maintain metabolic and cellular characteristics to a great extent during days of storage. we confirm the loss of platelet discoid shape and have shown that loss of discoid shape in platelets stored at °c is associated with decreased metabolic rate and decreased release of a-granule content. aim: as reference centre of the swiss blood transfusion service for new materials and blood products we evaluated that system for routine use and official registration in switzerland. method: whole blood donations were collected in a whole blood filtration set with cpda- and stored at room temperature for h before filtration at room temperature. the leucodepleted whole blood was stored for days. following parameters were analysed on day , , : free haemoglobin in%, k. in addition leucocyte count was performed on day and a blood culture on day (see table) . blood cultures on day remained negative and all counts of residual leucocytes were below ¥ (exponential) /unit. summary and conclusion: as expected there was a clear increase in k and free haemoglobin after day . however the results were within the required specifications from the european and swiss guidelines up to day . we conclude that autologous leucodepleted whole blood can be stored in cpda- -for days without loss of stability of the red cells. we will introduce the system to the offi-cial material list of the swiss blood transfusion service and then implement the procedure to our daily routine. results of ffp production from whole blood, and of ffp and pc produced by use of cell separator over a -month period before and after the introduction of measures for trali prevention are presented. the following measures were undertaken: ( ) blood of female donors was not used for ffp production, and plasma was only used for fractionation ( ) plasma of female donors was not used for kt-bc pools ( ) platelets and plasma were produced on a cell separator only from the female donors without a history of pregnancy. female donors of whole blood: %*; %** ffp produced by plasmapheresis: %*; . %** female donor units on cell separator: . %*; . %** ffp from total plasma units: %*; %** plasma units used for bc-pc pools: %*; %** *period before and **after the introduction of measures for trali prevention the exclusion of female donors had no major impact on the production of ffp and bc-pc pools from whole blood because of the very low rate of female subjects in the croatian blood donor population. the amount of plasma and pc collected from female donors by use of cell separator was significantly lower (~ %), however, without any major impact on total ffp store because of the small rate of plasma and platelets obtained by apheresis. background: platelet concentrates (pcs) are currently stored for a maximum of days. extended storage to days would increase the supply and reduce the waste of pcs. transfusion-associated graftversus-host-disease (ta-gvhd) is a severe transfusion reaction caused by t-lymphocytes in the transfusion product. the risk of developing ta-gvhd can be prevented by gamma irradiation of the pcs. various in vitro tests can be used to study the quality of pcs such as inspection of the swirling phenomenon, hypotonic shock response (hsr), detection of platelet surface markers (e.g. cd p and cd b), metabolic parameters and blood gases. free oscillation rheometry (for) using the instrument reorox® can be used to monitor the coagulation over time in whole blood, pcs and plasma samples, and to obtain information about clotting time and coagulum elasticity. aim of the study: the purpose of this study was to evaluate the quality of pcs obtained by apheresis technique during storage for days and to study the effect of gamma irradiation by using several in vitro methods including for. methods: platelets were collected from healthy donors (n = ) using apheresis technique. the pc from each donor was divided in units, one served as control and the other was gamma irradiated with gy. the pcs were stored on a flatbed agitator at °c for days. samples were taken on day (= day of collection) for analysis of blood gases, metabolic parameters (glucose and lactate), platelet count and swirling. samples taken on day , and were also analysed for hrs, cd p (p-selectin) and cd b (gpib) expression utilising flow cytometry. evaluation of coagulation by for was performed on day , and . the maximum elasticity (g'max) and the time to g' were evaluated from the for elasticity curves. results: there was no difference between irradiated and nonirradiated pcs regarding any of the tested parameters during the storage period. swirling, hsr, platelet count and percentage of cd b expressing cells were well maintained for days of storage. glucose decreased and lactate increased significantly during the storage period, from . mmol/l to . mmol/l for lactate and from . mmol/l to . mmol/l for glucose. the percent cd p expressing cells increased significantly during storage from % on day to % on day . po was well maintained but ph increased and pco decreased significantly between day and whereafter ph decreased and pco continued to decrease. the for parameters g'max and time to g'max increased significantly between day and and the time to g'max continued to increase significantly between day and . the results indicate a well preserved platelet quality after storage for days. gamma irradiation did not affect the platelet quality. cytokine release during storage of buffy coat platelet concentrates produced manually and automatically background: transfusion reactions following platelet transfusion are still a problem even when leukoreduction is included in the production process. platelet derived cytokines released during storage upon activation or lysis, accumulate in the platelet products and have been suggested to be involved in transfusion reactions. rantes (regulated upon activation, normal t cell expressed and presumably secreted) is a chemokine playing an important role in the inflammatory immune response and causes degranulation of eosinophiles and release of histamines from basophiles, which again can cause allergic reactions. tgf-b (transforming growth factor b ) has been shown to be immunosuppressive, inhibits the proliferation of t-and b-lymphocytes and decreases the secretion of igg and igm from b-lymphocytes. aims: as part of our quality control program, we aimed to quantify the amounts of rantes and tgf-b released during storage in platelet concentrates produced from pooled buffy coats by our manual routine method (m-pcs) and by an automated method using the orbisac system (gambro) (a-pcs). methods: pcs were produced from buffy coats. following overnight storage at - °c, buffy coats were pooled with ml t-sol (baxter). forty-two pcs were produced either manually (n = ) using the imugard iii s-pl set (terumo) with integrated soft leuko-reduction filter or by the automated procedure (n = ) using the orbisac validation bc set (gambro) equipped with the lrp leuko-reduction filter (pall). swirling was scored visually, platelet count and mpv were measured on a cell counter (cobas argos, roche), and blood gas analyses, glucose as well as lactate were measured on an abl series analyser (radiometer). samples for testing of cytokines were centrifuged for min at g, °c; supernatants were harvested and frozen at - °c until analysis. cytokines were quantified using quantikine human rantes immunoassay (r&d systems) and human tgf-b elisa immunosorbent assay (bender medsystems gmbh). all analyses were performed on days , and . results: platelet concentrate volume (mean): m-pcs: ml, a-pcs: ml. platelet yield was found to be . ¥ for m-pcs and . ¥ for a-pcs (p < . ). in all pcs ph levels were between . - . . glucose consumption and lactate production from days - and days - did not differ significantly. rantes levels (pg pr plts) were significantly higher in a-pcs than in m-pcs (p = . , repeated measures analysis of variance), but no significant difference was found in tgf-b levels (pg pr plts). summary and conclusions: preparation of buffy coat platelet concentrates by the automated orbisac system improves platelet yield compared to our manual processing procedure, but the levels of the chemokine rantes were significantly highest in the automatically produced products. the clinical importance of these findings is still unclear, but may be related to the shear stress the platelets are subjected to during the automated production process. the quality of cryopreserved vs liquid stored platelets: a comparative study table . the mismatches can be divided into the two categories. the first of them is characterized by differences in allelic groups, i.e. at low-resolution level. allelic group differences were detected in the group with one mismatch, most of them in hla-c locus (this locus was not concluded in primary donor search). in the other category there are differences in alleles within the same group, i.e. at high-resolution level only. differences within the same group in all tested loci were detected in the group with one mismatch. the mismatches described above were heterogeneous and a correlation of specific mismatch with transplantation outcome was not possible in this group. conclusion: the use of high-resolution dna methods makes the identification of hla match/mismatch more accurate and can affect the outcome of unrelated hsct. this work was supported by the grant iga mz, no. nr/ - . pre-freezing and post-thawing quality controls in umbilical cord blood assigned for transplantation p bergamaschi, c perotti, g viarengo, c del fante, c parisi, a marchesi, l bellotti and l salvaneschi irccs policlinico 'san matteo', pavia, italy background and aims: nowadays umbilical cord blood (ucb) represents a well established source of haematopoietic stem cells for unrelated transplantation in children affected with haematological and inherited diseases. thanks to the large-scale banking of unrelated units and the preliminary encouraging results, ucb employ in adults is quickly growing up. in this context, total nucleated cells (tnc) count of the graft is considered the main predictor for clinical outcome; however, other indicators of the haematopoietic potential, such as cd + cell content and short-term culture clonogenic assay, are recommended in accordance to netcord-fact stan-dards. in order to guarantee the safety and the prompt availability of a ucb unit assigned to a matched recipient, a pattern of rigorous quality controls should be carried out not only at the time of cryopreservation but also before the release for transplant. we report the results of the quality controls performed on thawed cryovials referring to the units delivered by our ucb bank compared to the pre-freezing values. methods: every ucb unit stored in our bank is accompanied by satellite cryovials available for subsequent controls. for each unit issued for transplantation, one cryotube was thawed in °c water bath with gentle agitation without washing out dmso. tnc and mononucleated cells (mnc) were estimated by an automated cell counter; viability and cd + cell count were evaluated by flow cytometry with a no-wash, single-platform technique and aminoactinomycin d. cfu assay was performed using commercial reagents (methocult gf h , stemcell technologies) and colonies were counted after days. the same tests were performed before cryopreservation, taking a sample from each fresh unit. moreover, before the delivery for transplant, a second cryotube was thawed to investigate the bacterial contamination by direct microbial culture, whereas the sterility test before freezing was performed by inoculum into ml media (bact/alert®fa/fn, biomérieux inc). results: the ucb characteristics before freezing and after thawing are detailed in the tables , and . post-thawing tnc and mnc, as well as cd + cells, showed no significant difference in comparison to the pre-freezing values. despite of the expected decrease of the overall viability after thawing, we observed a highly satisfactory viability referred to the cd + cells. the colony forming units (cfu) growth after thawing was documented and was always lower as respect to the pre-freezing assay. finally, the results of microbial cultures were negative for all the units on both fresh and thawed specimens. conclusions: in our experience, well standardized evaluation of ucb content could be obtained with regard to tnc, mnc and cd + cell. concerning the results of short-term cultures, the presence of dmso as inhibiting factor may be advocated to explain the discrepancies between fresh and thawed samples. finally, rigorous quality controls documented that the procedures of manipulation and cryopreservation did not affect the quality of ucb to be infused for transplant and provided to the physician all the parameters necessary for a safe transplant in a close and appropriate time. bone marrow transplantation or bmt transplantation of progenitor blood cells to regenerate blood normal cells in patients with blood disorders. bone marrow has an organized and structured architecture in which close relationships exist between a regulatory microenvironment and primitive hematopoietic cells. in fact, normal hematopoietic cells depends on critical interactions that occur between stem cells and their microenvironment. this microenvironment is a complex meshwork composed of growth factors, stromal cells, and extracellular matrix. marrow injury can occur as a consequence of a variety of diseases. some diseases could be due to a microenvironment that fails to support hematopoiesis. a possibility is that aplasia and leukemia share a common etiology such as drug, chemical, radiation, virus or other environmental hazards. we can say that microenvironmental abnormalities in interactions between stromal cells and hematopoietic progenitors may be important in the pathogenesis and clinical expression of hematopoietic malignancies in humans. background: intrauterine growth retardation, with associated low birth weight, represents one of the most important cause of baby mortality and morbidity. understanding the genetic bases of this adverse event is still an open goal. there is evidence that motherchild hla compatibility and hla-drb foetal genotype are associated with a reduced placental growth and a low birth weight. the recent institution of cord blood banks, with their huge amount of hla types, offers an unique opportunity to look inside the molecular bases of normal birth weight. aims: we investigated whether the baby-linked immunogenetic profile, i.e. hla gene frequencies and homozygosity rate, affects the physiological variance of the size at birth. methods: cord blood units ( from males and from females) were hla typed with pcr-ssp and/or reverse pcr-sso techniques and recorded in the cord blood bank database of pavia-italy. all were defined at low resolution level for hla-a and b genes and at high resolution for hla-drb . blood units were also randomly typed for hla-dqa and dqb at high resolution. results: mean birth weight was g and mean relative birth weight (i.e. corrected for gestational age according to the gender) was . g. babies were < th centile ( g) and were > th centile ( g). comparing the hla allele distribution in these extreme bands we found that hla drb * was significantly associated with high relative birth weight: . % in th centile vs . % in th centile, p = . . on the contrary, hla-drb * and dqb * were associated with low relative birth weight: . % and . % respectively in th centile vs . % and . % in th centile p = . and p = . . all infants were analysed as to the effect of the above mentioned alleles. we confirmed the positive association of hla-drb * and higher relative birth weight (mean . vs . ; p = . ) as well as the association of hla-drb * with lower relative birth weight (mean . vs . , p = . ). no significant association was found as far as hla homozygosity was concerned. conclusions: the present findings confirm the role of foetal hla-drb gene in the intrauterine growth. about the specific involved alleles, one possible explanation comes from the studies of crystallography and amino acid sequencing of hla-dr binding groove. it has been demonstrated that hla-drb * and hla-drb * genes encode for different amino acid sequences in the pocket of the molecule (aa , , ). this implies distinct functional restriction patterns. the sequence motif of hla-dr is characteristic of some autoimmune conditions, such as hashimoto's thyroiditis, and preeclampsia which is associated with intrauterine growth retarda- which provides a high yield and excellent purity without lymphocyte and erythrocyte contamination. in a month period, we studied blood samples from bone marrow transplant patients and from normal subjects. the extraction of leukocyte polymorphonuclear was obtained with a %- % dextran solution in . % saline. after incubation at room temperature with lymphopre solution, the mixture was centrifuged. two clear and separate rings of mononuclear and pmn leukocytes were obtained. to eliminate any red blood cells, pmnl ring was separated and washed three times with cold ammonium chloride. after a short period of incubation °c, mixture was centrifuged and the pmnls were isolated. the purity and viability of total leukocyte population was counted and the percentage of pmnl obtained was established. the total blood samples studied were divided in two groups, i.e., bone marrow transplant patients and normal subjects. in both cases the pmns isolated were of high purity and viability. the overall percentage of pmnls obtained from both groups under study was % to % when stained with gimsa or wright staining method. the viability of isolated pmnls was also % too, which is excellent for numerous immunological or molecular studies. the pmnls isolated by this method were highly pure and viable in comparison with standard methods used to isolate human pmnls. generation a high amount of pmnls is another advantage of the suggested method. this method to separate pmnls is recommended for in vitro studies of different subjects. et al. .) the object of exchange transfusion (et) is to remove bilirubin already present in the plasma or remove alloantibody which can cause hemolytic disease (in order anti-d, anti-c and anti-k are easily the most important) or remove anti-d positive red cells. we have studied exchange transfusion in our hospital in neonatal intensive care unit, during to . at delivery cord samples were taken for determination blood group, rhesus, hb and ht have been counted. also direct antiglobulin test (dat) has been performed. in cases of positive dat, hb and bilirubin levels were monitored. newborn body-weight were weighted (ranged g to g). the blood for et was of group o, d negative and kell negative and was compatible with the serum of mothers; it was less than days old. the blood was screened for hbs and for anti-cmv as well as being submitted to all usual tests. the method has been determined by using the umbilical vein; the multi-way tap makes it possible to draw blood from the infant into the syringe, to discard the blood into a sterile empty vessel, then to draw blood from a donor unit into the syringe and inject this into the infant. results: exchange transfusions were carried out. four out of et due to abo incompatibility mother-newborn. five out of due to rhesus incompatibility mother-newborn and eight out of due to jaundice undetermined origin and immaturity. the last two years only three et were carried out due to immaturity. conclusions: phototherapy, when applied early enough and with sufficient intensity, can avoid the need for exchange transfusion in many infants. phototherapy alone or phototherapy plus high dose igg therapy has been used to minimize exchange transfusions in this population. detection abo blood group system antibodies of neonatal using fully automated column agglutination technology (auto-vue) background: the abo blood group system remains the most important in transfusion practice. this is because of the regular occurrence of the antibodies anti-a, anti-b and anti-a, b reactive at °c, in persons whose red cells lack the corresponding antigens. the regular presence of anti-a and anti-b is used in the routine determination of abo blood groups; in addition to testing red cells for a and b antigens, the group is checked, in serum or reverse grouping, by testing the serum against red cells of known abo groups. methods: samples were taken from newborns at first h of life for abo blood group typing during - . simultaneously the presence of anti-a and anti-b antibodies has been studied using fully automated column agglutination technology (auto vue ortho diagnostic systems) with bio-vue cassettes aborh/reverse. the column agglutination technology is based upon the ability of glass beads to form a physical barrier between agglutinated and unagglutinated red cells. to determine the abo serum group, test serum and abo reagent red cells were added to the top of column containing diluents. the abo grouping columns were centrifuged and examined for agglutination. the presence or absence of agglutination has been recorded. results: in out of newborns were found detected antibodies anti-a, anti-b. in out of newborns no antibodies were found. in out of were found antibodies maternal origin. the automated reader detected all positive reactions. positive results were recorded on a scale from + . to + . conclusions: the technical performance of device allows objectivity and precision to detect abo blood group antibodies of newborn. the origin and the type of antibodies and also factors that influence their presence are to be studied. introduction: diagnosis, management and prevention of red blood cell immunization have improved, so hemolytic disease of the newborn (hdn) has changed from a common to a rare pathology. aim of the study. in this study we have retrospectively evaluated the benefits of the immunohematological screening for the management of pregnancies with alloimmunization. methods: in the last years, we have performed an immunohematological screening on all pregnant women assisted by our hospitals. ab and rh typing, antibody screening and, eventually, identification and titration were performed on maternal specimens by microcolumn technique. results: not considering ab incompatibilities, we have discovered alloimmunized women with the following specificities: anti-d, anti-c, anti-c, anti-e, anti-jka, anti-d + anti-jka, anti-d + anti-s, anti-d + anti-c, anti-d + anti-c + anti-k, anti-s, anti-k, anti-m, anti-c + anti-e and anti-d + anti-c + anti-g. the most severe hdn were the d + c + g, the c + e and out of c newborns, with mean hemoglobin between and g/l, bilirubin = . g/l, reticulocyte count = %. in these exchange transfusion needed at the delivery. other newborns were only treated with phototherapy. conclusion. thanks to the immunohematological monitoring, the diagnosis of alloimmunization, the correct management of pregnancy and the adequate neonatal therapy were possible. in fact all newborns survived and showed no neurological lesions in the following controls. conclusion: in order to provide a highly specialized perinatal care, immunohematologist, obstetric and pediatric should provide a good antenatal and perinatal screening. this is an interesting case of rhd immunisation in rhd negative woman despite the application of rhd immunoprophylaxis. case report: a blood sample of pregnant woman, years of age, in th gestation week, was sent to our laboratory for serological analysis. her blood group was o, ccddee and she had an anti-d antibody reactive only with enzyme treated panel of test erythrocytes. her husband was a, ccdee, and two children were both a, ccddee. on the next visit, she gave the data of one arteficial and one missed abortion before the th gestation week covered with mg of rhd immunoprophylaxis, but without the measurement of fetomaternal haemorrhage (fmh). both of abortions were after the deliveries. until the end of the pregnancy, detailed serological analysis showed anti-d specificity of antibody in her sera which remained reactive only with enzyme treated red blood cells. the fetus was under permanent ultrasound control. she delivered a mature, rhd positive, ccdee male child, without any sign of haemolytic disease. the proper personal history, measurement of the size of fmh, distinguishing the anti-d and anti-g specificity of the antibody, administration of rhd immunoprophylaxis and cooperation between transfusion medicine specialists, gyneacologists and neonatologists still remain major principles of prenatal and perinatal care concerning haemolytic deisease of the fetus and newborn caused by anti-d antibody. anti d antibody, reactive only with enzyme treated red blood cells is usually harmless for fetus and the newborn. introduction: red blood cell (rbc) transfusion is widely used in neonatal intensive care units for acute or chronic pathological conditions. clinical indications for rbc transfusion are shock, sepsis and/or anemia with the following laboratory criteria: a) hematocrit (hct) < % or hemoglobin (hb) < g/dl and reticulocytes < %; b) hct < % or hb < g/dl in these conditions: o required < %, recurrent apnoea and bradicardia, cardiac rate > bpm and respiratory rate > bpm for more h; c) hct < % or hb < g/dl with severe respiratory distress. aim of the study. aim of this study has been to evaluate the effectiveness of rbc transfusion therapy in premature and at term newborns independently of initial pathological conditions. methods: our therapeutic objective has been to achieve an hct of % after the whole cycle of transfusion therapy. for each little patient, the volume of transfused rbc unit has been calculated, according to international guide lines, using the following criteria: weight (kg) ¥ blood volume ( ml per kg if premature or ml per kg if at term newborn) ¥ (hct desired -hct observed)/hct of unit transfused. particularly we have considered that premature infants (with a gestation age of - weeks) show a range of weight from to . g, while at term newborns from . to . g. in order to avoid a circulatory overload, the indicated hemocomponent has been always packed rbc with higher possible hematocrit. for the same reason, the rate of infusion has been always - ml/kg/hour. methods: this is a descriptive study. the name of the neonates who received transfusion was obtained from the blood bank of beheshti hospital. information concerning the type of blood product, frequency and indication of transfusion, sex, gestational age and weight of infants was recorded in questionnaire and analyzed. results: out of neonates admitted during one year, ( male, female) received blood components. fifty four percent received one, % two and % received three types of blood components. the frequency of transfusions were times. the most common used blood products were fresh frozen plasma ( %), red blood cell ( %), whole blood ( %) and platelets ( %). all the blood products except whole blood were used more common in premature and low birth weight infants. appropriateness of transfusion of red cells, fresh frozen plasma, platelets and whole blood were %, %, % and % respectively. (hdn) . in accordance to current regulations, this study is carried out in all pregnant women attending in our service. according to our protocol, when an alloantibody of any specificity is detected through the liss-coombs gel technique, the same determination is made using papain-treated screen cells to detect any association with other antibodies which could be of clinical relevance for a hdn. there are scientific evidences that the use of enzymatic techniques increase the test's sensitivity, though clinical relevance of 'enzyme only antibodies' may be questioned. aims: demonstrate the importance of a routine identification of irregular antibodies in pregnant by two methods (liss-coombs -enzymatic) and the prevalence of anti-d associated antibodies, only detected by using enzymatic technique. analyze the need to carry out a follow up of sensitized patients to determine if the associated antibodies only detected with in an enzymatic medium can be detected with a liss-coombs medium during pregnancy, thus acquiring clinical significance for hdn. materials and methods: between january and december we studied d-negative pregnant women. the studies performed were: abo grouping, d and weak d, rh phenotype, direct antiglobulin test and irregular antibody detection (iad) against commercial screen cells with liss-coombs (diamed) ® gel-medium technique, according to the manufacturer's specifications. when iad were positive, an antibody identification using two commercial cell panels with gel techniques (liss-coombs-enzymatic) was performed. along the pregnancy, periodic controls were carried out to determine the exact moment when antibodies, previously only identified in an enzymatic medium, could be detected in a liss-coombs medium (clinically significant antibodies). results: out of d-negative studied samples, ( . %) had a positive dai and it was only showed anti-d specificity in a liss-coombs medium. after analyzing this specificity against enzymetreated erythrocytes, it was possible to determine that patients ( . %) had in their serum other anti-d associated alloantibodies: anti-k ( . %), anti-c ( . %), anti-e ( . %) and anti-c + e ( . %). during the immunohematologic follow up, it was determined that in / patients some of the antibodies which were previously only detected in an enzymatic medium, could be identified in a liss-coombs medium and later they were identified in the red cell elution of the newborn. conclusions: these results confirm the relevance of a screening for irregular antibodies of clinical importance by means of a conven-tional technique and one of increased sensitivity in all pregnant women. the detection of an association of antibodies provides information for the undertaking of diagnostic and therapeutic measures, both by the obstetrician, as for any eventual transfusional requirements for hdn. it was also concluded that, although antibodies detected in an enzymatic medium are considered of low clinical significance, its investigation and follow up is suggested in pregnant women to determine the moment in which they can be detected in an antiglobulinic medium, thus revealing their clinical significance. background: fibrin glue is one of the most complex human plasma derivatives both in terms of composition and clinical applications. this product mimics the last step of coagulation cascade through activation of fibrinogen by thrombin, leading to the formation of a fibrin clot in the presence of factor xiii. in contrast to synthetic adhesives, the significant advantage of this plasma-derived sealant is its biocompatibility and biodegradability as well as the fact that it does not induce inflammation, foreign body reaction or extensive fibrosis. readsorption of the fibrin clot is achieved during wound healing within days/weeks following application, depending upon the type of surgery, the amount and type of product used or the proteolytic activity of the treated site. the risk of virus transmission by commercial fibrin glue products is still debated and investigators are looking for alternative fibrinogen sources. many of these studies rely on autologous on single donor cryoprecipitate as source of fibrinogen. aims: the aim of this study was to compare single and double methods of cryoprecipitation of fibrin glue. the influence of different plasma preparation methods and plasma storage temperatures (- °c and - °c) on the quality of fibrinogen concentrate was examined. methods: whole blood was collected by standard phlebotomy technique and centrifuged at ¥ g for min within h of collection. plasma was removed. four units of plasma were pooled into a ml bag, mixed, divided into parts (aprox. . ml) and immediately frozen. two of these units were stored at - °c and units of ffp at - °c. after one month the plasma was thawed at °c during - h. the fibrinogen concentrates ( - ml) were received by single and double cryoprecypitation. to compare single and double methods of cryoprecipitation, the levels of fibrinogen, fibronectin, plasminogen and factor xiii were determined. results and conclusion: the levels of fibrynogen were significantly higher in fibrynogen concentration obtained by double cryoprecypitation from plasma stored at - °c. there were no significant differences in the level of plasminogen in both tested groups. double cryoprecipitation of a single unit of plasma (stored - °c) is an efficient, simple and safe method of obtaining fibrin glue. background: talking about professional risk we generally consider the risk of acquiring some kind of infective disease through accidental injury. in this article i would like to point out another side of the problem-the risk of making preventable medical error. with all its consequences. aim: how blood transfusion errors are among the most serious types of medical errors, the final goal is to initiate nationwide, regular, mandatory error reporting. information obtained, distributed and openly discussed at professional meetings will contribute to improving the patient safety. at the same time it would contribute to avoidance of blaming and shaming of many health care providers. prevent what preventable could be! method: retrospective analyze was conducted at the middle size blood transfusion center ( donations per year and utilization of approximately of components). results: after clearly distinguishing adverse events due to underlying patient condition from preventable medical error we fined out that: -great majority of adverse events resulted from medical error -every part of blood transfusion center, from blood donation ward, through laboratory testing to component issuing has it' weak points' or vulnerable places -any educational level is equally liable to error there is no significant difference about occurrence time: -working day/holiday -emergency/routine request -routine h/out of routine h -main error cause were as follows: -donor sample misidentification -rhd typing error -abo typing error -incorrectly performed cross match -recipient misidentification -wrong component prepared -sample confusion during freezing preparation conclusion: the truth incidence of transfusion medical errors is underestimated. mandatory report of fatal or 'only' harmful errors to the referent institution and its periodical announcement is the step ahead in preventing errors. those reports should be discussed at professional meetings (not at the 'yellow pages') and served as educational tool. but, as the most of the errors are system related, the key to reduce them is to focus on improvement of the system and nil for plasma. wastage rate was highest for plasma components. the influence of local practices on such discarding and whether avoidable shall be discussed. audit for blood discarding and corrective actions to minimize discarding is essential for all transfusion services and blood centers. designed technical and economic support. options include importing finished products and/or procuring products made from locally collected plasma. one approach is to consider local fractionation of plasma by building and operating a plasma fractionation facility, which may produce, finished products, or may produce intermediate products that are further manufactured in another facility. an alternative approach is the implementation of a plasma fractionation program where local plasma is sent to an established fractionator, and the plasma is fractionated following preagreed terms. the end products are returned to the country of the plasma supplier. in the national center for the production of blood products was established, under the direction of elias politis and years later in begun the production of dried plasma from greek donors. by the year the center started the production of fibrinogen and by the year the production of antihaemophilc factor. in all the activities of the center settled down due to administrative aspects. at the beginning of s a contract fractionation program was instituted (under the direction of k. sofroniadou) concerning the fractionation of liquid plasma and production of albumin, which by the end of year stopped and was replaced with a new contract for the fractionation of source plasma and the production of albumin. the challenge of adapting to the new and more stringent regulations governing the manufacture of blood products was great and brought a lot of changes in the structure of our center. a new bar-coding system ensuring the traceability of blood donations was instituted together with complex software for packaging and preparation of plasma shipments to the fractionation center together with all necessary paper work. a close collaboration with the medicines regulatory authority in order to be able to fulfill all the requirements that regulate issues associated to the quality and safety of human derived medicinal products. collaboration with blood collection establishments was promoted in order to increase the amount of plasma produced. there is a continuous effort from all the implicated parts in order to follow defined quality assurance procedures as highlighted by international guidelines for the blood donor selection, collection procedures, testing methods, donation handling, storage and transportation of plasma. the plasma contract fractionation program may serve, as an initial step prior to switching production to a locally built facility. this lapse of time may be used to expand the plasma collection potential, and to permit appropriate design, qualification and validation of the facility as well as training of local personnel. background: fibrin glue became a reality in the early s, when techniques for the isolation and concentration of clotting factors were improved. in , matras et al. described successful application of fibrin glue for peripheral nerve repair. this encouraging report prompted the use of fibrin glue in wound closure, skin grafting and bone union of osteotomies. the fibrinogen component of fibrin glue is produced from single unit donations of fresh frozen plasma. such procedure helps to reduce the risk of transfusion transmitted infections encountered by exposure to pools from large numbers of donors or by use of fibrinogen prepared from autologous blood prior to surgery. the second component, a mixture of thrombin and cacl , is commercially available. thrombin is applied to the operation site simultaneously and in equal volume to the fibrinogen but from a separate syringe. there are many methods of fibrinogen concentrate preparation but none of them has been described in detail. aims: the aim of this study was to choose/select the most effective, simple and safe method of obtaining fibrinogen concentrate (basic component of fibrinogen glue) which would also be easy to prepare in blood transfusion centers. methods of precipitation of fibrinogen by polyethylene glycol (peg), ammonium sulphate, ethanol or cryoprecipitation were compared. methods: plasma was obtained after centrifugation ( ¥ g for min) of whole blood. four units of plasma were pooled into a ml bag, mixed, divided into parts and immediately frozen. one of them was stored at - °c and after one month the plasma was thawed at °c during - h. fibrinogen was obtained by cryprecipitation and each of the three remaining units was precipitated with ethanol, peg and ammonium sulphate. the levels of fibrinogen, fibronectin, plasminogen and factor xiii were determined in each fibrinogen concentrate. results and conclusion: the level of fibrynogen ratio in fibrinogen concentration, obtained by peg and ammonium sulphate was significantly higher. cryoprecipitation is a simple, economic and reproducible procedure with the advantage of being performed in a closed system. plasma fractionation program in greece: an unknown history the provision of safe and sufficient plasma derivatives to meet the needs of local population requires special consideration and a well- (light cycler, roche diagnostic systems, nj) was used for the identification of the c y, h d and the s c point mutations of the hemochromatosis gene, and were based on protocols developed, for c y by the unidad de medicina molecular (ingo, santiago de compostela, espanha), and for the other two mutations by bolhalder m et al. the primers and probes were designed by tib molbiol (berlin, germany). results: the analysis of the percentages of genotypes and allele frequencies of the hemochromatosis gene mutations are described in the table. no differences were found between the patients and the controls. when we compared subgroups of patients based on their hepatitis c genotypes, a higher value for the c y allele was obtained ( . %) in individuals with genotype , however without statistical significance. discussion: hereditary hemochromatosis is a common disorder and is associated, in some studies, with a worst prognosis in patients with viral hepatitis. follow-up studies are necessary in order to evaluate if the presence of these mutations can cause a more severe course of the illness (greater risk to develop fibrosis or cirrhosis) and a different outcome when treated with antiviral drugs. also, it will be important to evaluate if aggressive phlebotomies will modify their clinical evolution. introduction: portugal has a higher prevalence of viral hepatitis, with probably more than . patients chronic infected with hepatitis b and/or c. hereditary hemochromatosis (hfe) is one of the most common causes of known hereditary illnesses with hepatic repercussion. hfe mutations are also found in linkage desiquilibrium with particular hla haplotypes, conferring, eventually, a different response to viral agents and antiviral drugs. in this study we evaluated the prevalence of the main mutations c y, h d and s c for the hfe in a population with chronic hepatitis b and/or c and in a cohort control. background: haemolytic disease of the newborn (hdn) is the destruction of the red blood cells of the fetus and neonate by antibodies produced by the mother. although postpartum rhig prophylaxis reduced the incidence of alloimmunization from pregnancy from % to - %, the doubt subsists if it is appropriate to use it as routine antenatal prophylaxis. material and methods: a total of samples ( mothers and newborns), from / / and / / , were studied. all abo, rh typing, antibody tests and dat were carried out in column agglutination tests. results: from the cases studied it was found cases without incompatibility ( %). from the incompatibilities, . % were abo, . % were rhd, . % were other rh incompatibilities, and . % were due to auto-antibodies. % of the mothers were rhd+ and % rhd-. conclusion: of the pregnant women studied, only were rhd-. from this group ( %) delivered rhd-newborns, what revealed that the antenatal prophylaxis they were submitted was unnecessary. from the pregnant women rhd-, % had incompatibility abo, which decreases to near % the risk of development of rhd immunization. being anti-d immunoglobulin a product that has the potential risk of infection transmission, is it appropriate to use indiscriminately as a routine antenatal prophylaxis? the introduction of molecular methods to determine the fetal rhd genotype could rationalize the use of antenatal anti-d immunoglobulin prophylaxis. introduction: the frequency of hla a haplotype expression has been found about - % in caucasian and in greek population particularly, . %. because of the high frequency, it is used widely in anticancer immunization. the immune system plays an important role in the defense against neoplastic disease and immune response show temporal chances related to circadian variation of antibodies and total lymphocytes in the peripheral blood. aim: the probable difference in the frequency of hla a expression and their lymphocyte phenotype into a group of cancer patients and a group of healthy donors, during screening of immunization with hla-combined peptides. materials and methods: healthy donors who proceeded in the department of transfusion medicine, university hospital of heraklion crete were tested for the hla a expression. in of these donors the expression of cd , cd , cd , cd , cd , cd , hla dr, cd +cd +, cd +cd +, cd -cd +, cd +cd -cd +, cd -cd -cd +, cd -cd -cd + was examined. meanwhile, patients with metastatic cancer who were hospitalized in the department of medical oncology, university hospital of heraklion crete, were tested for their hla a expression, while in of them for their lymphocyte phenotype. the antigens expression was examined in flow cytometry. the hla a expression in healthy donors was . % and in cancer patients % (p > . ). in table the mean, standard error, t-test and p of the two groups are included. (see table ). the two groups (healthy donors and cancer patients) revealed no statistical significant difference on lymphocyte phenotype, except of the cd expression, which was higher in cancer patients. summary and conclusion: the expression of hla a in cancer patients and in healthy donors was comparable. also, the lymphocyte phenotype among the two groups has not statistical significant difference, except of the cd (total b-cells). the significance of this result has to be investigated. in the course of original documents research i found out that dr. kalic, head of the first organized blood transfusion institution in the balkan region (at beograd, serbia, in ), set himself a professional goal: blood should be awaiting all patients and transfusion should not be a privilege of large city inhabitants only. dr. kalic's idea was that blood transfusion should be administered according to clearly given instructions and using simple blood sets. encouraged by the conclusions of the congress held in paris in , dr. kalic started preparations for the transport of blood to the inland. he concluded bravely that citrated blood could be sent by regular mail, as an ordinary parcel, without particular protection from the outside temperature. he advised his colleagues to use blood as an intravenous injection. blood was taken from voluntary female donor in belgrade (capital), march . after keeping it for days at storage, blood was forwarded on a two-day journey to a small town, kilometres away from belgrade. there it was kept on a room temperature before its final use for a treatment of a patient suffering from secondary anaemia. the patient underwent the procedure without side effects and responded to the transfusion with blood sent in this manner much better in comparison to earlier methods of direct blood transfused. reminding ourselves of the courage of our ancestors to implement their professional knowledge and personal original ideas in a new way with the desire to help the patient as successfully as possible, we pay them the deserved respect and gratitude for inspiring and encouraging us in this way to try the same. conclusions: automation leads to increased standardization, faster specimen processing and reporting, elimination of manual specimen identification, uniform interpretation of serological reaction patterns and objective reading of haemagglutination endpoints. using auto-vue allowed the staff uninterrupted time to perform quality assurance duties, extended antibody identifications, preventative maintenance, inventory control. the instrument allowed us to leverage current staff to a more productive, less stressful level. introduction: exosomes are - nm secreted vesicles produced by antigen-presenting cells (apcs). the finding that exosomes from dc pulsed with tumor-derived peptides elicited potent antitumor tcell responses and tumor regression in mice has led to the proposal that human exosomes could be effective vectors for antigen delivery in the context of cancer immunotherapy. aim of the study: to establish the method of producing a new kind of tumor vaccine -exosomes secreted by dc, pulsed with tumor peptides. methods: exosomes used in this study were generated from monocyte-derived dc pulsed with peptides from k tumor cell lines. exosomes were purified by the methods of ultrafiltration and ultracentrifugation. the methods of dynal magnetic beads, flow cytometry and western-blotting were used to determine the surface molecules of the exosomes. the function of the exosomes was deter- objective: to develop an immunoheatological technique for the study of erythrocyte hyaluronic acid sodium salt (cd ) receptor expression in red blood cells (rbcs) from adults and newborns. materials and methods: samples of anticoagulated blood from adults (n = ) and umbilical cordon (n = ) were used. several dilutions oh hailuronic acid sodium salt solution % (sigma l- h ) were confronted with % erythrocyte suspension in phosphate saline buffer (pbs) ph . . the rbcs were previously treated with an enzymatic solution of % bromeline in pbs ph . (sigma l h ). agglutination readings' were been by slow sharking after of h incubation at °c. the results were expressed through the sensibility parameter which involves titer and score. this is defined by a mathematical expression a = à si. di- . - (i = , , . . .) where si represent the score and di- is dilution inverse. the adult' rbcs showed a = ± , while en the newborn the parameter was a = ± . our results showed significant differences between both groups. conclusions: in this work, we present a simple immunohematological technique for the hyaluronic acid sodium salt (cd ) receptor expression in red blood cells, which could be a useful tool to evaluate the alterations of the receptor's expression in rbc. a new technology for crossmatching tests adapted to a fully automated system l gaillard, v desvigne, a boulet, l fauconnier and jm pelosin diagast, loos, france we have developed a new automated technology for crossmatching (compatibility) test suitable for automation and high throughput. the method does not require centrifugation steps thanks to the use of magnetised red blood cells (rbc). all the steps described are performed on the fully automated qwalys system. this methodology requires washing steps under magnetic field and is based on the fixation of sensitised rbc on the surface of a well coated with monoclonal anti-human globulins. in a first step, the red blood cells from target blood bags were magnetised during min. then the patient plasma is distributed on a microplate and incubated with the previously magnetised rbc during min at °c. excess of unbound immunoglobulins is removed by washing steps. in a third step, sensitised magnetised rbc were transferred in the antiglobulins coated plate and placed min on a magnet plate. wells in which antigen-antibody interactions have occurred display a confluent layer of rbc (positive reaction). the negative reaction appeared as a pellet in the middle of the well. the test can be read by an automatic reader or by naked eye. the patterns in the well are stable for at least h at room temperature. the plasma samples are provided by the laboratory of haematology of the chru of lille. the red blood cells are collected from segment of tubing of blood bags coming from the laboratory of blood donors of the efs (french blood services) nord de france-lille. the results are obtained in min. comparative studies showed that our new technology, without any centrifugation steps, is reliable and sufficiently sensitive and specific enough to perform cross matching tests using a high throughput automated system. the mechanisms of p -dependent apoptosis involve a set of genes that possess the ability to modulate oxidative stress. one of them pig , is induced by p through a microsatellite in its promoter region. this microsatellite has been proposed to represent an evolutionary adaptation of tumor suppressor mechanisms. microsatellite instability and genetic constitution, comprising the presence of the low repetition allele ( tgycc repeats), at this locus have been hypothesized to provide an increased risk for cancer development. aim: in the present analysis we examined this polymorphism in blood samples from voluntary health donors and compared it with human lung cancer samples, employing two different ethnic groups, greek and british. results: analysis of this locus in both types of samples showed: (i) the homozygous presence of the repeats allele only in the samples from healthy blood donors; (ii) a very low frequency of microsatellite instability (< %) and no loss of heterozygosity in matched normal-tumor tissues; and (iii) a non-significant increase of the most frequent allele ( repeats) in the cancer groups as compared to samples from healthy blood donors. the last two observations were found in both greek and british populations. conclusion: taken together, these data do not support the notion that this pig polymorphism is associated with an increased risk for cancer susceptibility. background: blood group determinations are routinely performed by the sensitive technique 'gel test' for the last few years. many weak d and partial d phenotypes which react as d negative or weak d by slide test, are assigned the rh d + status by gel test. this is most desirable in the case of blood donors but creates concern in case of patients and antenatal women with a partial d phenotype. case report: we report a female patient (blood group o, c+, c+, e-, e+) whose red blood cells gave a positive reaction of different strength and speed with different anti-d antibodies in slide tests. we were asked to type the patient and provide the appropriate blood units. the patient's cells gave a +/ + reaction in the standard screening procedure for the rh d in gel test micro-typing system that contains a polyclonal reagent of human origin (which allows a direct detection of most weak ds), a + reaction in a test with monoclonal anti-d and a +/ + reaction in the gel test micro-typing system destined to detect du and which contains polyclonal anti-d of human origin. however, since the slide test gave a rather slow onset of agglutination with one commercial reagent (made up of a blend of polyclonal and monoclonal anti-d) we tested the patient's red cells against anti-d reagents in the id-partial d typing system. one of these (number ) gave negative reactions and the remaining five gave positive reactions (ranging from +/ + to +), indicative of a partial d category vii phenotype. the patient's red cells were also tested in the id-card 'diaclon abo/d' . this card provides the complete profile for abo/rh d in one single procedure step, including the confirmation of rh d. it contains two different anti-d reagents within the gel matrix in two consecutive microtubes. the first anti-d (polyclonal human) is expected to give a positive result with d+ red cells and partial d category vi, while the second (monoclonal rabbit) is expected to give a negative result with dvi+ red cells. our patient's cells gave a negative reaction with the first and a +/ + reaction with the second anti-d in this system, indicating a d variant other than dvi. finally the patient was assigned the partial d category vii phenotype (according to the pattern of the reactions obtained with the id-partial d typing set) and rhesus d negative blood units were issued. this case illustrates the diversity of reagents used for rhesus typing in different laboratories. failure to disclose some d variants is a disadvantage when typing patients. a combination of techniques is often needed to reveal the real rh d phenotype. the only single system that could have revealed a d variant in our patient from the beginning, is the id-card 'diaclon abo/d' with two different anti-d reagents in two consecutive microtubes as described above. a cost-benefit analysis should be undertaken to show whether it should replace other screening tests for abo and rh d when typing patients. who cares about the quality of life of the chronic patients treated with blood products? d ilcenco*, e hanganu-turtureanu † , c burcoveanu † , c vartolomei ‡ and d azoicai § *blood transfusion center, † hospital 'sfantul spiridon', ‡ institute of hygiene, § university of medicine, iasi, romania quality of life is one of the methods used to appreciate the quality of the health system. romania is going to join soon the european union, so there must be a concern regarding the improvement of the national health system. blood receiver's life quality never been researched before in romania. we have been chosen a batch of chronic ill patients who have been received blood transfusion with blood or blood components, and asked them to complete two types of questionnaires regarding their life. we used nottingham health profile and beck's depresion index. results shows that this kind of patients need special care, because they all (with one single exception) feel frustrated and feel like a burden to the other normal persons. evolution of the pain index, mobility index, energy index, emotions index, sleep index and social isolation index was in concordance with the depression index. in conclusion, this type of patients needs special attention and medical authorities should make more efforts to assure their life quality support. transfusion medicine practice in surgically treated urology patients: our experience il ilincic*, bm bozovic* and ts tadic † *clinical center dr dragisa misovic, † natio. blood transfusion inst., belgrade, serbia objective: multiple studies demonstrate that the use of blood/blood products in patients undergoing elective urology surgeries, as well as the actual needs assessment, present the issue of numerous debates. method: using the retrospective method, utilization of blood/blood products was analyzed, as well as the ratio of prepared/used blood units in urology patients in the surgical ward, in the intensive care unit (icu) and at the urology center within the cc dr dragisa conclusion: due to a rather liberal use of primarily ffp in certain cases (cystectomiae in the first place), and a discrepancy between the prepared and actually used blood units, hospital transfusion committees should be an imperative in order to solve current dilemmas regarding justified use and proper administration of blood and blood products. background: the safe collection, production, distribution and application of blood and blood products in a high quality needs logistic on a high level. since the seventies computers, special software and barcode are used in transfusion medicine and improved the safety of processing data. in the last years a new technology was developed for industrial use, the radio frequency identification (rfid). aim: the aim of our studies was to check whether rfid can use reasonable in transfusion medicine. methods: at first we developed a flow chart, where we can use the technology and where are the problems by introduction. so we tested in the red cross donation centre in saxony about passive rfid smart label under real conditions. in cooperation between the akh vienna and novatech research a new handheld pc software 'labelview' for all steps around the transfusion was developed, including the identification of the patient and the processing of the haemovigilance data, and tested in first time. results: passive and semiactive (with temperature control) rfid labels survives all hard steps during the working up of the whole blood (e.g. centrifugation by g, separation, etc.). as a result of the contactless identification they are help to make easier the documentation of all processing steps according good manufacturing practice. in clinical practice they are a good supplement to bed side transfusion software. conclusion: for all lot of problems by the logistic and the safe identification around the transfusion existing various single point solutions such as patient-wristband, bed-side test, double check of blood group typing and donor -donation registry in software, etc. the lecture will deal with new developments in logistics and data management, which can help to reduce the problems associated with documentation, safe identification and reporting of haemovigilance data. our experiences with the immunohaematological analyser olympus pk applied conventional and no conventional (hemolytic medium time) techniques in sera of patients with ascariasis. results: the ai and hk tests showed: b epithopes in ae from b patients and in ae from ab patients; a epithopes in ae from ab patient and in ae from a patients; p and p epithopes in ae and only p epithopes in ae. these patients had both epithopes in their erythrocytes. the hemolytic techniques showed: anti b immune antibodies in sera and anti a immune antibodies in sera. the presence of abo and p epithopes in ae and immune antibodies in patients with ascariasis show a relation about blood groups and ascariasis. the fact of to find the same abo and p antigens in a. umbricoides and in its hosts suggests that the parasite might absorb them during its life cycle. these epithopes would be involved in the molecular mimicry. the use of filters for leucocyte depletion in anemic patients on maintenance hemodialysis g poposki*, s kovaceski*, b krstanoski*, s mena* and n solaz † *institute of nephrology, struga, macedonia, † ankara university, faculty of medicine, ankara, turkey introduction: renal anemia is one of the major chronic complications in end stage renal disease. it is caused by reduced production of erythropoietin (epo) due to uremic toxin effects, reduced halflife of rbc, iron deficiency, aluminum intoxication, blood loss during hemodialysis, gastrointestinal hemorrhage, epistaxis, infections etc. allogenic blood transfusion is transplantation of certain or all cell types. however, allogenic blood transfusion can contribute to many immune system disturbances with clinical side effects. besides erythrocytes, mononuclear, t and b-lymphocytes, are also transfused, which cause immunomodulatory disturbances in immune system of recipient. leukocytes are responsible for frequent febrile non-hemolytic transfusion reactions, alloimmunization toward leukocytes and hla antigen and transmission of cmv. anti-le antibodies, forming of immune-complexes, complement activation with pirogenic c a and c a immunoinflamatoric citokines cause febrile reactions. commercial use of filters for leukocyte depletion with removal of leukocytes and degraded products of microagregates and cytokines, cause minimum harmful immunomodulatory effects and prevent transmission of cmv. aim: the aim of the study was to present the effects of transfusion of erythrocytes with residual number of leukocytes in anemic patients on chronic hemodialysis at institute of nephrology in struga. matherial and methods: during - period all anemic patients on hemodialysis were divided in groups. the first group pts with febrile non-hemolitic transfusion reaction. the second group- pts immunized toward leukocyte and hla antigen. the third group young candidates for kidney transplantation for prevention of hla immunization. the fourth group pts with sle (for immune-complexes and autoantibodies). total patients ( males and females) received units of rbc with residual number of leukocytes. commercial filters of baxterÔ (lekostop lds) and terumoÔ (imugard iii rc) of second and third generation with microagregate filter and synthetic polyurethane fibers, with - microns pores that remove leukocytes, platelets, microagregates and fibrin were used. erythrocyte concentrates are filtered until days of collection. result: aabb permits maximum < ¥ wbcs/unit for prevention of febrile non-hemolytic reaction. the filters we used reach residual leukocyte number of ¥ the le reduction of - . %. the number of rbc after filtration is minimum % - g hb per unit. in none of the patients who have received the leuco-filtered blood, no adverse post transfusion reactions were noticed. conclusion: the used filters for leucocyte depletion are characterized with superior biocompatibility, excellent elimination of all types of leucocytes and high 'recovery' of erythrocytes. the use of filters for le depletion reduces and minimizes the side effects of allogenic blood transfusion in patients on chronic hemodialysis who are alloimmunized, in patients with sle, and particularly in young patients candidates for kidney transplantation. background: fv leiden, prothrombin g a, mthfr c t are three most common and important prothrombotic inherited mutations. aims: the aim of the case-control study was to assess the prevalence of mutations and their single or combined effects as risk factors for thrombosis. methods: the study included thrombotic patients (venous thromboembolism, chronical venous diseases, different etiology) and asymptomatic healthy individuals as control group. extraction of genomic dna was followed with genotyping of fvl by pcr-ssp, prothrombin and mthfr mutation by pcr-rflp. results: a statistically significantly higher prevalence of fvl mutation was found in thrombotic patients ( . % heterozygous, . % homozygous) compared to controls ( . % heterozygous), p < . . the or for heterozygous carriers was . ( % ci . - . ), confirming the association of fvl mutation with the risk of thrombosis. there was no statistically significant difference in the prevalence of the prothrombin mutation in patients ( . %) and controls ( . %), or . ( % ci . - . ), p = . . although the group of thrombotic patients showed a higher prevalence of homozygous carriers of c t mthfr than the control group ( . % vs . %), or was not significant ( . , % ci . - . ), p = . . analysis of combined effects of mutations showed an additional thrombotic risk for carriers of fvl mutation and both mutated alleles of c t mthfr gene (tt and ct) (or . , % ci . - . ), p < . . conclusions: fv leiden mutation was detected as significant single risk factor for thrombosis in studied patients group. additional prothrombotic risk have carriers of fvl mutation and c t mthfr gene mutation. a female patient in a high fever due to urinary tract infection does not respond being given antibiotics. on the contrary, leukocytes rose (to ¥ /l), anaemia became even deeper, as well as thrombocytopenia. hemocultures were negative. hematologist decided to search for hematological disease. the first citology results of bone marrow aspirate suggested lymphoproliferative disease ( % atipical plasma cells). to treat heavy anaemia (hgb g/l) hematologist asked for red blood cell concentrate. pretransfusion testing revealed warm autoantibodies in the patient serum and on red blood cells. antibodies had no apparent specificity. biochemical parameters (bilirubin, ldh, haptoglobin) suggested mild hemolitic process. electroforesis revealed polyclonal hypergamaglobulinaemia. the th day of hospital treatment, the therapy with corticosteroids was introduced (solu-medrol mg per day). coagulation parameters were tested: pt . inr, aptt s, fibrinogen . g/l, trb ¥ /l, d-dimer mg/l, atiii %. dic was suspected. liver enzymes showed mild liver dysfunction (normal ast, alt, elevated ggt, low che). substitution therapy started with dose of cryoprecipitate, dose of fresh frozen plasma, iu atiii, doses of red blood cells and vitamin k mg. two days after the substitution therapy we saw pt . inr, aptt s, fibrinogen < . g/l, trb ¥ /l, atiii %. during the next few days erythrocytes and thrombocytes rose, but due only to corticosteroid therapy and not to substitution therapy. the patient had neither signs of con-sumptive coagulopathy, nor hypoproduction of coagulation factors, except for fibrinogen. till th day of therapy, fibrinogen was below . g/l. there was no hemorrhagic diathesis. after that, fibrinogen rose, and on the st day the patient was recovered, in both clinical and laboratory terms. the results of immunological tests, collected later, confirm the diagnosis of systemic lupus erythematosus. we did not have any specific test to confirm antibody mediated hypofibrinogenaemia, but in the setting of sle, without any specific treatment except corticosteroids, fibrinogen recovered. we assume it is quite enough for highly suspected immunological hypofibrinogenaemia. results: twenty-four-year-old male patient with severe hemophilia type a suffering from low incoercible digestive bleeding secondary to ischemic colitis caused by autoimmunity (vasculitis) without response to current management. treatment was initiated with mg/kg/dose of rfviia (*) for days, after which there was clinical and endoscopic recovery, and an inh decrease to . ub/ml (fviii dosage %) . he began to take meprednisone ( mg/kg/day) for days, after which the inh titre was . ub/ml. (table a ,b) the patient underwent surgery the following year (correction of equinus foot). he entered the operating room with an inh of . ub/ml and was treated with mg/kg/dose of rfviia (*) for days, obtaining an excellent hemostatic response. he had two autologous blood units, but it was not necessary to be administered. the inh titre decreased again (down to . ub/ml) during the intratreatment stage. thirty-five days after rfviia, the inh titre was . ub/ml. (table a ,b) the presence of high titre inh against fviii is a critical problem in cases of bleeding or surgery need due to the inefficacy of the available therapeutic options and the severity of the events. in this case, we have observed that, apart from inducing hemostasia through the activation of the coagulation extrinsic path, rfviia could reduce the inh titre in sequential dosages. we have introduced the case of a -year-old patient with hemophilia complicated by a high titre inh against fviii. in this case, we have observed that, apart from inducing an effective hemostasia through the activation of the coagulation extrinsic path, rfviia could reduce the inh titre in sequential dosages. there was also a decrease in the inh titre concomitantly with an increase of the plasma fviii level during its use. this phenomenon suggests that rfviia could produce a modulation in the immune response. evaluation of an automated blood collection system with standard ratio of anti-coagulation and integrated filter for whole blood leucodepletion l dadiotis, a kolokytha, m dimou, a perdiou, c alepi, p spyropoulou, e igoumenides, c velidou, v panagopoulou and s matsagos tzaneion general hospital, pireas, greece automated blood collection system (abc) is a device manufactured by macopharma which collects by gravity a preset volume of blood and mixes it with anticoagulant (ac) in standard ratio ( : ). this is managed by passing the ac, which is stored in a special bag, anti-erythrocyte antibodies are immunoglobulins that belong to the igg, igm and iga classes. their common characteristic is a specific reaction with antigens that are located on the erythrocyte surface. they can emerge as auto antibodies and alloantibodies. the blood transfusion in patients may induce a post-transfusion hemolytic reaction (pthr). in order to avoid or reduce the danger of the pthr it is necessary to examine whether there are irregular anti-erythrocyte antibodies in the patient's serum as well as in the serum of the voluntary blood donors. all the irregular anti-erythrocyte antibodies are not clinically relevant. the experience shows that the clinically significant antibodies most often belong to abo, rh, kell, kidd, duffy and ssu blood groups. in the period from april, to november, , we monitored and examined, at the institute for blood transfusion, clinically significant antibodies in the serum of the patients who are treated with blood transfusions as well as in the serum of the voluntary blood donors. we used the following tests for detecting irregular anti-erythrocyte antibodies: enzyme test, indirect coombs test, screening test by the commercial test erythrocytes and gel filtration method. the detected irregular antierythrocyte antibodies are identified by means of the commercial test erythrocytes for identification. our results are the following: voluntary blood donors: anti d, anti c + d and anti-leb antibodies. patients: anti-d, anti-k, anti-fya, anti-c and anti-e antibodies. in nine patients, anti-erythrocyte antibodies were discovered, namely, those that react at the temperature higher than °b ut whose specificity we could not discover with the existing techniques. improved predictive factors of response for myelodysplastic syndrome patients treated by the combination of erythropoietin and g-csf s park*, c kelaidi † , s grabar ‡ , v bardet ‡ , d vassilieff ‡ , f picard ‡ , m guesnu ‡ , mc quarre ‡ , p fenaux § and f dreyfus ‡ *service hématologie, hopital cochin, † hématologie, hopital avicenne, ‡ service hématologie, hopital cochin, § hématologie, hopital avicenne, paris, france it has previously been shown that serum epo level and number of previous red blood cell transfusions are predictive factors of response to epo + g-csf treatment of myelodysplastic syndromes (mds). in a subgroup of patients with mds having sepo < ui/l, known to be good responders to epo + g-cscf, the gfm group wanted to refine the model predicting the response to epo + g-csf, especially with cytology (who classification with dysplasia and percentage of erythroblasts and blasts). in a population of patients (ra, rars and raeb < % blasts) receiving epo ± gcsf between and and having serum epo < ui/l, the response rate at week (iwg criteria) was %. six variables were associated with response to epo ± g-csf for mds: age > years (p = . ), number of prior red blood cell transfusions < packs/months (p = . ), serum epo level < ui/l (p = . ), percentage of blasts < % (p = . ), percentage of erythroblasts > % (p = . ) and low ipss score (p = . ). we did not found any influence of dysplasia, type of rhepo (darbopoietin alfa or epoietin alfa) and karyotype on response rate. in multivariate analysis, age through a rotating pump. the abc can be used with all types of p- pan-european blood safety alliance the pan-european blood safety alliance is a unique alliance of patient organizations, formed to promote the highest level of blood safety for all in europe. it was formerly established on february , during the course of the first general meeting of the pbsa, which comprised of founding patient organizations. the objectives of the pbsa are: . to promote the fundamental right and duty to safety of all patients in need of blood transfusions and blood products. . to ensure the availability of sufficient amounts of safe blood, to meet all treatment need through: -the education of all staff handling blood components, to reduce human error. -the implementation of and access to, proactive blood safety technologies, for each patient across europe. -haemovigilance -the adequate access to blood transfusion services, which should be provided free of charge to the patient. other objectives are to raise awareness on a local and european level regarding blood safety, to promote eu legislation that improves safety standards of blood transfusion services, including stem cell preparation and storage across europe and to lobby for increased patient influence on eu health policy makers. very importantly, the alliance aims at providing a forum for patients, healthcare professionals, health policy makers and relevant industry, as well as acting as a point of reference to the national health authorities, the european commission and other european institutions, when seeking the opinions of patients on blood safety. cerns of insertional mutagenesis and the safety of some viral vectors that randomly insert genes through the genome have been recently resurfaced following the development of a haematological malignancy in a child treated with a retroviral vector. particularly questions also remain as to, whether gene therapy and the production of ectopic factor viii and ix will be a risk for inhibitor development or indeed whether it might promote tolerance in those patients with inhibitors. w-pl - gene therapy for thalassemia: will it become reality? university of washington, seattle, wa, usa experiments aimed to develop gene therapy approaches for the beta chain hemoglobinopathies, sickle cell disease and beta thalassemia started about years ago. in the beginning results were dismal because of the extremely low and variable expression of globin genes contained in the therapeutic vectors. a major development occurred in with the discovery of powerful regulatory elements that could guarantee high level of globin gene expression. these elements when incorporated into viral vectors allow expression of therapeutic levels of the transferred globin genes. a second major progress was achieved with the development of safe lentiviral vectors that can efficiently infect the human pluripotent repopulating hemopoietic stem cells. as a result of this progress, today beta thalassemia and sickle cell disease can be cured in murine models of these disorders. considerable effort is already being devoted into further improvement of lenti viral vectors with emphasis on incorporating elements which will decrease the probability of insertional mutagenesis and leukemogenesis. the major challenge for the clinical application of stem cell gene therapy of thalassemia is the need for genetic correction of large numbers of mutant stem cells. in vivo selection of corrected stem cells is being investigated but there are questions about its safety because of the possibilities of clonal expansion of stem cell lines carrying undesirable integrants. other major challenges have to do with logistics: production of therapeutic vectors, infrastructure required for stem cell gene therapy delivery, and sponsoring and funding of the clinical trials. gene therapy trials on limited number of patients are expected to be initiated relatively soon. if these trials are successful and cures of beta thalassemia ensue, the major challenge will be the delivery of this molecular therapy in the context of medical practice. w-pl - gene therapy for haemophilia haemophilia is an ideal target for gene therapy because only a small rise in factor levels to - u/dl would achieve the goals of prophylaxis without regular infusions of concentrate and deliver a substantial improvement in lifestyle for patients with severe haemophilia. gene therapy for haemophilia today relies upon addition of normal factor viii or ix genes. with present technology gene therapy can offer the prospect of a true 'cure' for haemophilia in animal models, although this may not be currently realizable in man. more than patients with haemophilia have now been treated in phase gene therapy protocols. all studies have failed to conclusively show that therapeutic levels of factor viii and ix can be reliably obtained. the first trial reported used im injection of a factor ix containing recombinant adeno associated virus (raav) in adult patients with severe haemophilia b. only very modest increases in factor ix level, < u/dl rise, in / patients enrolled were observed, although less factor ix concentrate was needed in / subjects. a similar study using the same raav vector via intrahepatic artery infusion has been conducted. this has been complicated by the observation of aav vector in the semen of subjects. in six patients enrolled, no durable levels of ix above u/dl were seen. further development of this raav vector is suspended. for haemophilia a, three systems are have been tried. the first study was an ex vivo addition of factor viii gene to autologous fibroblasts and then laparoscopic reimplantation. preclinical assessments demonstrated durable expression of factor viii (> % of normal) for > year in mice following a single treatment. in / patients treated repeated factor viii rises ( . - . u/dl) were seen, but no improvements lasted beyond months. the second protocol used a murine leukemia retrovirus containing factor viii, injected intravenouslya development of preclinical data in rabbits and haemophilic dogs. / patients enrolled sustained levels of factor viii > u/dl. the third study, using a modified, 'gutless', adenovirus containing factor viii gene has recruited one patient. this patient demonstrated transient liver toxicity and thrombocytopenia at doses lower than those that cause toxicity in primates. sustained levels of factor viii of ~ u/dl have been observed over a number of months. accrual to the study has been poor. haemophilia remains a prime target for gene therapy. however, haemophilia is no longer a life threatening disease with current therapy that is both safe and efficacious. a balance between the benefits and theoretical risks must be borne in mind when considering gene-based approaches to therapy. con- reference: petz ld, garratty g. immune hemolytic anemias. nd ed. philadelphia: churchill livingstone, , pp - . w-pa- autoimmune neutropenia introduction: autoimmune neutropenia (ain), a granulocytic disorder due to the presence of anti-neutrophil antibodies, may present as neutropenia of varying degree with or without recurrent infections un previously healthy individuals (primary or idiopathic ain) or in patients with a known underlying disease such as lupus erythematosus, lymphoid malignancies, etc (secondary ain). the condition affects more frequently infants of small ages while it is rare in adults [ ] [ ] [ ] [ ] [ ] [ ] [ ] . in some patients, diagnosis is established in occasion of a respiratory, urinary or cutaneous infection, but in many cases is simply a finding of cell blood counting performed for unrelated reasons [ ] . clinical and laboratory findings: in general, physical examination is negative. laboratory investigation reveals the existence of isolated neutropenia. association of the disorder with autoimmune hemolytic anemia or autoimmune thrombocytopenia is rarely seen [ ] . blood biochemistry is normal while serologic tests for bacterial, viral or other pathogens may be positive depending on the underlying infection. bone marrow is hypercellular without maturation arrest of granulocytic series. hemopoietic stem cell reserves and function are normal or increased, and stromal cell function is within the range of the normality [ ]. methods for the detection of granulocyte-specific antibodies: serology for the detection of granulocyte-specific antibodies has been marred, compared to erythrocyte serology, because the target cell here, the granulocyte, is short-lived, fragile and becomes easily activated. the former two of these difficulties require absolutely freshly (< h old) isolated neutrophils from a panel of donors to be used every day to run the tests with sera from patients, while the third difficulty is more important since spontaneous cell clumping in vitro is very common and nay mimic the specific aggregation caused by cross-linkage of surface bound antibodies in the granulocyte agglutination test (gat). in order to overcome these problems, the second international granulocyte serology workshop [ ] recommended a combination of two tests as the best screening procedure for the detection of granulocyte autoantibodies in patient sera, gat and granulocyte immunofluorescence test (gift). gat is mainly mediated by igm antibodies and is positive in about % of cases. gift detects igg antibodies and is positive in about % of cases. it is to be noted that flow-cytometry fluorescence may arise not only from the surface but also from the cytoplasm of neutrophils, necessitating assessment of membrane fuorescence by microscopy. a good direct anti-granulocyte test is not available today. this is due to the fact that too few neutrophils can be obtained from the blood of neutropenic patients, and also to the observation that neutrophils are often activated in vivo because if an underlying infection or other inflammatory process, thus expressing fcgrii and fcgriiib to which nonspecific binding of w-pa- practical approach to transfusion in autoimmune hemolytic anemia (aiha) g garratty american red cross blood services, pomona, ca, usa a major problem when transfusing patients with aiha is that often all units are incompatible. this may be due to autoantibodies (autoab) and/or alloantibodies (allo-ab). if the incompatibility is due to only auto-ab, then transfusion of incompatible blood will not usually result in a clinically significant reaction, but if due to alloab, the result may be similar to that seen in any other patient (i.e. a hemolytic transfusion reaction ranging from mild to severe). thus, it is essential (as in any other patient) to exclude the presence of allo-ab. it is wise to phenotype all patients, for as many antigens as possible, before the patient receives transfusion. there are two popular approaches to determine if allo-abs are present but being masked by 'warm' auto-ab activity. the preferred method is to remove the auto-ab by adsorbing the patient's serum with autologous rbcs treated with enzymes, or preferably, with zzap reagent. the latter reagent contains an enzyme leading to optimal adsorption of auto-ab, and dtt. these two chemicals will destroy significant antigens other than rh and kidd (e.g. mns, duffy, kell, lutheran, dombrock, cromer, lw, some yta and ge, inb, jmh, ch, rg, pr antigens), thus will not adsorb alloantibodies to these antigens. if autoadsorption is not possible (e.g. patient has been transfused recently or there are too few rbcs), one has to perform adsorption with enzymes or zzap-treated allogeneic rbcs. one does not have to be concerned with covering any antigens destroyed by zzap (e.g. kell and duffy systems). we use a rough guide relating the strength of the indirect antiglobulin test to the number of adsorptions needed to remove auto-ab ( + = adsorption; + = adsorptions; + = adsorptions; + = or more adsorptions). if there is no activity left after the adsorptions, then one can suspect that the incompatibility was due to auto-ab, but on rare occasions one can be wrong and an allo-ab to a high-frequency antigen has been removed. this is a major disadvantage of using allogeneic adsorptions, and is why adsorptions with autologous rbcs are preferred. if time ( - h) does not allow for adsorptions, one can dilute the patient's serum (e.g. in , or in ) and test the dilution against a panel to see if any alloantibody specificity becomes obvious. another approach is to select units matching the patient's phenotype as closely as possible. when dealing with cold agglutinin syndrome one can usually exclude allo-ab activity by testing strictly at c. this can be helped by performing adsorptions with enzyme-treated autologous rbcs at c, but it is difficult to adsorb all of the powerful cold autoagglutinin activity. it is reported that - % of aiha have allo-abs; the incidence is even higher in patients who have received multiple transfusions. thus, we feel that procedures such as those discussed above must be performed before transfusing incompatible blood if time allows. one should always negotiate with the attending physician regarding the time it will take to perform adsorptions. a decision may be made not to perform adsorptions if the patient has life-threatening hemolysis, and especially if the patient has never been transfused, or pregnant. serum igg may occur (naig). the presence of immune-comlexes in the serum, such as in patients with felty's syndrome, lupus erythematosus and other diseases, as well as the presence of immune aggregates formed in sera stored frozen for long time, may give false-positive tests given that they may bind to fcgriiib molecules expressed on the surface of neutrophils. elimination of immunecomplexes and immune aggregates can be easily obtained by ultracentrifugation [ ] . another cause of false-positive results may be the presence of anti-hla antibodies because of allo-immunization. these allo-antibodies react with hla molecules found not only on neutrophils but also on the surface of many other cells including lymphocytes. these allo-antibodies can be eliminated by platelet absorption. it seems that the best method in the search of true antigranulocyte antibodies is the monoclonal antibody-specific immobilization of granulocyte antigens (maiga) [ ] . with this method one can specify anti-granulocyte antibodies using a panel of known granulocyte antigenic specificity. finally, it is notable that the levels of serum antibodies to neutrophils may vary considerably over the time. one negative test does not exclude ain. usually, two to three tests have to be run over a period of months [ ] . antigenic specificity: human neutrophil antigens (hna) are classified according to an international granulocyte antigen working party [ ] . three glycoproteins have been found to be involved in the determination of antigenic specificity, fcgriiib, gpnb (cd ) and gp - . the respective antigens, frequencies and alleles are illustrated in table . antigenic specificity can also be studied by using methods applied in molecular biology. a promising approach is transfection of mammalian cells by cdna derived from granulocyte antigen specific mrna. cell lines have been established with cells expressing the respective human granulocyte antigen, making the detection of anti-granulocyte antibodies more easier. genotyping of hna antigens can also be stydied with the pcr technique [ ] . references are available from the author upon request. w-pa- a rare case of 'coombs negative' autoimmune haemolytic anaemia due to red cell autoantibodies of iga class warm autoimmune haemolytic anaemia (waiha) is usually associated with red cell auto-antibodies of the igg class, which can be detected by polyspecific direct antiglobulin test (dat). routine polyspecific direct antiglobulin tests contain anti-igg and anti-c d components, and are not standardized to react with iga-or igmsensitized red blood cells. haemolytic anaemia caused by warmreacting auto-antibodies solely of the iga class is exceedingly rare. those cases of autoimmune haemolytic anaemia can be difficult to diagnose because of the negative polyspecific coombs' test, which is a standard in investigation of possible causes of haemolysis. we present a case of severe warm autoimmune haemolytic anaemia caused by iga class autoantibodies. a -yr old male patient was admitted with anaemia, haemoglobinuria, and other signs of severe haemolytic disease. he received multiple transfusions but haemoglobin level did not rise above g/dl. the initial polyspecific direct antiglobulin test, containing an anti-igg and anti-c d antiserum, was negative. tests for cold agglutinins and other possible causes of haemolysis were negative. only by using a monospecific, anti-iga antiserum could we show that the warm iga auto-antibodies against red blood cells were present on patient's erythrocytes. we have not detected signs of complement activation by iga autoantibodies in this patient. the patient received corticosteroids with good initial effect. his haemoglobin level stabilized and he did not require more transfusions. anti-iga direct antiglobulin test became negative about to weeks after the therapy was initiated. however, in spite for the initial effect of steroid therapy haemolysis continued, and splenectomy was performed months after diagnosis was made. it has been shown that human lymphocytes, granulocytes and monocytes contain specific fc receptors for iga, and both monocyte-mediated phagocytosis and antibody-dependent cellular cytotoxicity due to iga auto-antibodies has been demonstrated. there is also increasing evidence that iga auto-antibodies can activate complement, both via the classical and the alternative pathway. a phenomenon of 'reactive haemolysis', which involves c -independent binding of c b complexes to 'bystander' red blood cells, has also been described. we emphasize the importance of performing additional testing in cases of apparent 'coombs' negative' haemolytic anaemia due to iga, igm or 'low affinity' igg autoantibodies, and serological aids that are available for that purpose. described. both siblings were born on term, in good general clinical status, free from any signs of infection, and with isolated severe neutropenia ( and neutrophils/ml). the diagnosis of annanti hna- a was made upon exclusion of other possible causes of neonatal neutropenia, and confirmed by serological testing of granulocyte antigens and antigranulocyte antibodies. in both cases, the course of the disease was mild, with bacterial omphalitis on day and , respectively. omphalitis was successfully treated with -day antibiotic therapy according to antibiotic sensitivity report. the first neonate received standard dosage of intravenous gammaglobulins for days without success. this was followed by an attempt at neutrophil count increase with -week corticosteroid therapy, also without response. the second neonate received no specific therapy for neutrophil count increase. the children were discharged for home care with clinical and laboratory control examinations at -week intervals. in spite of prolonged neutropenia ( and months, respectively), no other infections were recorded. discussion and conclusion: in our patients, the therapeutic approach to ann was individualized, based on standard antibiotic therapy, intravenous gammaglobulins, corticosteroids, available literature data, and our own clinical experience. although in the last few years rh-gcsf is successfully used in patients with neutropenia, we decided to postpone its use in case the neonatal sepsis developed. the reasons for such decision were: ( ) the fact that both neonates were in good general clinical status, with a mild course of the disease with only short-term umbilical infection successfully managed with antibiotic therapy; ( ) literature reports suggesting the unexpected failure to respond to rh-gcsf therapy in patients with neutropenia induced by anti hna- a immunization, and ( ) the unknown effect of rh-gcsf on developing tissues of the neonate. the choice and efficacy of specific therapy for neutrophil count increase in the management of alloimmune neonatal neutropenia have not yet been fully defined and require additional evaluation in the majority of cases. male donors for the production of fresh frozen plasma: a special issue for trali patients trali is a significant cause of transfusion associated morbidity and mortality, and has been reported as the third most common cause of fatal transfusion reactions. there is no good evidence on which to base transfusion support policy for patients who have experienced trali. the hypothesis that there may be patient associated factors that contribute to the risk of trali is generally accepted. for this reason it seems reasonable to try to avoid further transfusion during the period of illness. if this is unavoidable the next best solution to reduce the risk of recurrence seems to be the avoidance of using plasma containing blood components (especially ffp) as there is a high chance of positivity for leucocyte antibodies especially for those coming from female donors. as fresh frozen plasma transfusion accounts for up to half of all trali cases and as our center is the only in greece responsible for the testing and processing of blood from blood donors representing military recruits, the last two years we tried to set up a project in order to provide components from male donors on request. our donor base consists predominantly from males donors ( . %), aged between and years old, with a small chance of having a positive history for transfusion the difficulty of the project consisted on the fact that these donors are assigned to military camps throughout greece, which makes difficult the on time arrival of the units to our establishment in order to be processed for the production of ffp conform the european council quality requirements. this was the main reason why, till now, all plasma produced from these donations was regarded as plasma for fractionation. the first step for implementing the new project was to evaluate the number of donations that, by minor changes on the time of arrival, could be processed for ffp production. the next step was to re-schedule the shifts of the personnel for the on time production of ffp. during , % of donations were fulfilling the specifications for the production of ffp and with the flexibility of the schedule the % of them were successfully processed to ffp. during , % of the donations were fulfilling the specifications and . % of them were processed to ffp. so it is feasible to increase the proportion of male ffp by organizing better the transportation of blood from the donation sites to the blood establishment and by retaining available specialized personnel to cover the extra shifts. maximising the blood supply chain in times of shortage shortages in the blood supply chain may occur for a variety of reasons. they may be temporary e.g. due to a flu epidemic or prolonged e.g. due to the exclusion of a high proportion of donors due to new pre-donation tests or because of a lack of volunteer donors. increasing awareness of the possibility of blood shortages mainly related to increased precautions associated with the possible transmission of vcjd by transfusion has been the driver for the development of blood shortage contingency plans in the uk. in england and north wales, hospitals and the national blood service (nbs) have worked together to develop an integrated blood shortage plan (ibsp) designed to ensure that hospitals and the nbs work together within a consistent, integrated framework giving patients equal access to available blood on the basis of need. an essential element of the plan is the principle that shortages can, in most cases be avoided by reducing the current usage of blood through appropriate use programmes. the impetus for hospitals to implement these programmes was a government circular (hsc / ). hospitals have embraced the circular and have recruited specialist hospital transfusion practitioners, introduced lower hb triggers, cell salvage and hospital transfusion teams and are participating in the blood stocks management scheme (bsms). audits of compliance with the circular have taken place, and a web based tool kit is available. the demand for blood has declined for the last three years, with a decrease of about % during - , suggesting that the drive for improvement has been successful. the shortage plan introduced in england and north wales has two key aims: that the national pool of blood is available for all essential transfusions for all patients and that overall usage is reduced to ensure the most urgent cases receive blood. the plan is structured to provide actions for the nbs and hospitals in three phases, 'normal' circumstances, reduced availability and severe prolonged shortage. hospitals should have documented emergency blood management arrangements for each of the phases. the national plan is activated when the nbs red cell stock level falls to pre-defined levels, hospitals are informed by fax that they should reduce their normal stock holding levels according to guidance in the ibsp and comply with the daily hospital usage budget. the bsms has used its knowledge of hospital inventory levels and demand to provide guidance on appropriate inventory levels for normal and reduced status, it also provides the daily hospital budget. to monitor progress against the recommendations in hsc / hospitals will be benchmarked against a number of performance indicators. these include the presence of emergency blood management arrangements, median red cell usage for a number of surgical procedures and percentage wastage of blood. there have been no shortages within the nbs for more than six years, it is hoped that the implementation of the ibsp will help to ensure that in the unlikely event of reduced availability blood will be available to the maximum number of patients requiring a blood transfusion. w-pa- transfusion during disaster g klein nih, bethesda, md, usa publicity given to blood donation during wartime has created a powerful association between the need for blood and occurrence of a disaster. blood is rarely needed in excessive quantities at the moment a disaster occurs. the outpouring of blood donors, especially at the site of a disaster, often proves counterproductive. the terrorist attacks on the world trade center on september , , with almost deaths and more than injuries, provides an instructive model. more than a million potential donors contacted blood-collection centers. hundreds of thousands of prospective blood donors crowded collection facilities and many waited for hours, often to be turned away. qualified staff were in short supply and screening errors occurred as minimally qualified staff were recruited and as collection personnel fatigued. supplies and storage capabilities were pushed to their limit. some blood was inadequately processed and stored. resources were diverted from needed apheresis collections and component preparation to whole blood collection. in the aftermath of the disaster, blood outdated and volunteer donors became disillusioned as their 'gift of life' was refused or unused. similar responses have occurred numerous times over the -year period since blood-donor programs were introduced. in virtually every civilian disaster in the u.s. during the past century, all the blood that was needed was immediately available from blood inventory. in only four cases were more than units of blood used in the first to h. in in new york, the five hospitals closest to the disaster site admitted only disaster victims. the new york blood center, which supplies percent of blood for the city's hospitals, added units to routine inventory at hospitals. the center received telephone calls and collected more than units of blood in the first h. in the area of the pentagon, the chesapeake and potomac red cross blood center supplemented hospital blood inventories within h of the disaster. meanwhile, spurred by well-meaning media and federal officials, lines of blood donors were being processed at local hospitals, makeshift collection centers, the small research hospital at nih, and at a building next to the white house. in the week after september , america's blood centers collected more units of blood, and the american national red cross collected more units than in the same period the previous year. more than units were collected for the disaster victims, but only units were used. u.s. blood collectors and federal agencies have created a disaster plan that acknowledges the need for altruistic people to volunteer for blood donation in the time of disaster and speaks with a single voice to avoid needless collection activity while harnessing the good will of well-intentioned people to supplement the ongoing need for volunteer blood donation. rehabilitation of blood transfusion service in azerbaijan cd asadov, ga huseynov and ab hagiyev institute of hematology and transfusiolo, baku, azerbaijan at the end of th years of the last century in azerbaijan as well as in other republics of the former ussr began process of progressive deterioration of blood service parameters. in result there was an essential reduction of prepared blood and blood components quantity, manufacture of preparations from blood's plasma has completely stopped. it is connected by that our republic experiences a heavy transition period from scheduled to market economy. after reception by azerbaijan of the sovereignty on development of a national policy the big work has been lead to areas blood transfusion and development of national rules and the standards regulating functioning of establishments of blood service. in the law about ' the donorship of blood and its components in the azerbaijan republic' has been accepted, instructions on physical examination of donors and preparations of blood and its components are authorized, and also the new speciality transfusiology has been entered into the nomenclature of medical specialities. now the national program of blood service development is developed. at drawing up of the program social and economic conditions of the country, ethnic both cultural traditions and a mental potential of the nation are considered. within the framework of this program is planned to refuse gradually a paid blood donation during the certain period of time to reach %s' voluntary unpaid blood donorship. however in connection with limitation of resources, the state is not capable to allocate enough of means for its realization. the big work on attraction of the international organizations has been carried out. now the project of the united nations development program (undp) 'rehabilitation of blood transfusion service in azerbaijan' is carried out at sponsor's support of the norwegian government. realization of this project will lead to reorganization of blood transfusion service in our country according to practice of the european countries. within the framework of project realization it is planned to make changes and additions to a existing law about a blood and its components donorship to bring it into accord with recommendations of the europe council. updating of the russian law 'concerning the donation of blood and blood components' on june , , a law, 'concerning the donation of blood and blood components, ' was signed by the first russian president, boris eltsin. now, after more than ten years of market economy and democratic evolution in russia, this law was significantly changed on august , , as shown in the following sections: . the development of a voluntary blood donor system. . removal of the upper age limit for blood donors. . funding for blood donations. from january , , each level of the state power budgets for a blood donor service to supply blood products for federal, regional, or municipal hospitals. costs of these drugs and the need of prolonged growth factor treatment in these disorders. w-pa- can iron administration reduce peripartum blood transfusion c breymann university of zurich, zurich, switzerland the prevalence of iron-deficiency anemia in different regions of the world ranges from to %. the increased iron requirement in pregnancy and the puerperium carry with it an increased susceptibility to iron deficiency and iron-deficiency anemia and perioperative or peripartal blood transfusion. however, if ever possible administration of blood transfusion should be avoided for several reasons which will be pointed out in the talk. infections: it is well known that various pathogens such as bacteria and virus can be transmitted by administration of blood. around . % of are contaminated by bacteria such as yersinia or pseudomonas species but are not screened routinely for bacteria. in addition there is no donor screening for hepatitis a, herpes species (cmv, ebv, hhv , hhv ), parvovirus b , hepatitis g ( . %) and tt (transfusion transmitted) virus ( . %). numbers for positive testings for 'classic' virus such as hiv, hep. b and hep. c vary from country to country and lie around : to : depending on quality of donor screening programs, pcr sensitivity etc. recently there is increasing evidence that even prions which cause the jakob creutzfeld disease variation ('mad cow disease') might be transmitted by transfusions. therefore the fda has determined that blood donors from countries with high prevalence of prion positive persons are not permitted to give blood in the us (e.g. donors from uk). beside infections, other well known effects of transfusion are problems due to incorrect blood or components transfused, post transfusion purpura, acute and delayed lung injury, graft versus host disease and other acute and delayed allergic reactions. beside these negative effects it was also shown that patients who receive blood transfusion liberally after operations or in icu show higher morbidity and mortality compared to patients with restrictive transfusion policy. this might be due to negative effects on immune functions and inflammatory reactions and lack of stored blood to efficiently improve organ oxygenation. for example it is known that stored blood has worse capillary perfusion and worse viscosity properties compared to fresh blood. taken together there is increasing scientific evidence that blood transfusion is not the gold standard for anaemia management and alternatives such as endogenous blood pooling and efficient treatment of any anaemia must be enforced in the clinical settings. prevention and correction presuppose reliable laboratory parameters and a thorough understanding of the mechanisms of iron therapy. in order to correctly diagnose the type and degree of anaemia, a prerequisite for selection of the proper therapy, one must first of all correctly differentiate between the relative, i.e. the physiological anaemia of pregnancy due to the normal plasma volume increase during pregnancy, and 'real anaemias' with various different pathophysiological causes. when defining the hb cutoff value for anaemia in pregnancy, the extent of the plasma volume changes with respect to the gestational age must be taken into consideration. it has been found that haemoglobin values < . g/dl in the first and third trimesters, and < . g/dl in the second trimester may point to an anaemic situation which should be further clarified. the first important steps for diagnosing anaemia in a pregnant patient include a thorough check of her medical w-pa- impact of epo treatment on transfusion requirements in myelodysplasia c gardin and p fenaux hopital avicenne, aphp, university of paris , bobigny, france myelodysplastic syndromes (mds) are clonal disorders of hematopoeisis, associated with bone marrow failure and an increased risk of evolution to acute myeloid leukemia (aml). despite an normal or increased bone marrow cellularity in most cases, cytopenias worsen with time due to increased apoptosis and defective differentiation of blood lineage precursors. incidence of mds increases with age and reach / above years of age. bone marrow cytogenetics number of cytopenia and percentage of bone marrow blasts are strong predictors of survival and evolution to aml. a composite international prognosis scoring system (ipss) is used in everyday practice to guide the management of these diseases. these disorders are heterogeneous and include 'low risk' patients (less than % bone marrow blasts) with a prolonged evolution marked by chronic anemia, and 'high-risk' patients (excess of bone marrow blasts > %) evolving in a short timespan with severe cytopenias, and to aml in approximately % of cases. at diagnosis, % of mds patients are anemic, with an hemoglobin level less than g/l, and % of them will require chronic blood components transfusion, during the evolution of their disease. chronic anemia and multiple blood products transfusions are associated with an altered quality of life, clinical iron overload, and important health care costs. although transfusion practices and patient's transfusion need are variable, elderly mds patients require a mean of - units/year of follow-up, in recent surveys. therapies able to diminish or abolish the need for rbc transfusion have therefore a major role in the management of mds, as allogeneic bone marrow transplantation, the only curative therapy of these diseases, is limited to a small subset of mds patients. high-doses of recombinant erythropoetin (epo) ( - u/kg tiw, or a - u as single weekly dose) are typically used in low-risk mds. the response rate to epo is - %, including major responses (suppression of rbc dependency or rise of hemoglobin level of more than g/l). absent or low rbc transfusion needs and a serum epo level less than u/l are strongly predictive of response to epo, in patients with low-risk mds. the duration of response is variable ( - months) in most studies, with some long-term responders. the use of higher doses of epo or its prolonged administration may be associated with higher response rates, although no randomized studies are available combination of epo and low-dose granulocyte-colony stimulating factor (g-csf) increases the response rate to - %, including in patients not responding to several weeks of treatment with epo alone. two randomized trials published in , compared g-csf-epo to rbc transfusions and confirmed the efficacy of this combination, and a longer survival of epo-g-csf responding patients. studies are ongoing in mds, including with darbepoetin, a modified erythropoetin with longer half-life, administered once a week. two such studies have been recently reported, (darbepoetin or ug/week) with response rates varying from % to % in low-risk mds. in both studies, a response to darbepoetin was observed in some patients, who failed to respond to previous treatments with alpha or beta epoetin. further assessment of the optimal dosage, administration schedule of these drugs, and validation of their likely impact on qol are required, in order to epo and its derivatives to gain acceptance in mds, due the high history and a medical examination. this procedure often lays the basis for a correct diagnosis. the current gold standard to detect iron deficiency remains the serum ferritin value. to be reliable, this requires the ruling out of an infection (chronic or acute) as a cause of the anaemia. we recommend a complete laboratory test for the exact haematological status as well as the assessment of specific chemical laboratory parameters. these should the hb level alone is insufficient to guide management. a complete work-up (ferritin, transferrin saturation) is essential, preferably with haematological indices such as hypochromic and microcytic red cells and reticulocytes, classified by degree of maturity, in particular, before parenteral therapy is given. since ferritin acts as both an iron-storage and acute-phase protein, it cannot be used to evaluate iron status in the presence of inflammation. a high ferritin level thus requires the presence of an inflammatory process to be eliminated before it can be taken at face value. if the c-reactive protein level is also raised, the soluble tfr concentration can be used, since it is unaffected by inflammation. inadequate understanding of the complex chemistry of parenteral iron administration was previously responsible for serious side effects, such as toxic and allergic reactions, and even anaphylactic shock, in particular with dextran preparations. however, the current type ii iron complexes that release iron to the endogenous iron-binding proteins with a half-life of about h are not only effective but carry a minimal risk of allergic accident and overload, especially after a comprehensive pretreatment work-up. after correct diagnosis, major emphasis should be put on safe and effective treatment of anemia which again depends on severity of anemia, time for restoration and patients characteristics. today effective alternatives to oral iron only or blood transfusion such as parenteral iron sucrose complex and in selected cases also recombinant erythropoietin have been investigated and show promising results concerning effective treatment of anemia during pregnancy and postpartum. our departmental data collected over years and backed by postmarketing experience in countries indicate that iron sucrose complex therapy is a valid first-line option for the safe and rapid reversal of iron-deficiency anemia. w-pa- iron therapy in orthopaedic surgery surgery of the vertebral column, hip or knee is considered a bloody procedure (blood loss > l) and as a consequence represents the main indication for red blood cell transfusion in orthopaedics. because of the non-negligible residual risk of transmission of infectious agents by transfusion, but mainly because of immunologic complications induced by the administration of foreign proteins and cells, an alternative solution has been actively sought. studies have clearly shown that in patients undergoing such surgery, transfusion risk correlates inversely with pre-operative hemoglobin level. correction of even slight preoperative anemia is thus mandatory. in the elderly, iron and vitamin deficiency (b and/or folic acid) should be looked for as a matter of routine. we recommend the use of iron + epo whenever a rapid correction (< weeks) of the anemia is desirable in cases with transferrin saturation < % and ferritin levels < mg/l. with this regime it is possible to collect up to autologous blood units in cases of increased perioperative blood loss (e.g. double hip replacement). in the post-operative period, anemia worsens because of the existing inflammatory state. this inhibits iron absorption from the intestine and iron release from the macrophages while it affects epo function and production. there is increasing evidence that i.v. iron combined with epo induces a rapid correction of post-operative anemia. it is thus recommended to stimulate erythropoiesis by i.v. iron and epo starting on the first post-operative day and to avoid transfusions in asymptomatic patients even in cases with hb as low as g/l. background: hereditary hemochromatosis is one of the most common inherited disorders in which an excessive amount of iron is absorbed from the diet and then deposited in organs. the effective treatment is the regular whole blood removal which causes erythropoesis activation and leads to decrease of iron stores. red cell apheresis is an optional method for removing of higher amount of erytrocytes in one session. we performed red cell apheresis in patients with diagnosis of hereditary hemochromatosis ( ¥ c y homozygotes, ¥ c y + h d heterozygote) using haemonetics mcs p cell separator (protocol tae) in which red cells are removed from patients in - cycles; plasma and buffy-coat are reinfused. collection time, donor convenience, side effects and red cell yield were recorded and analysed. samples for hematology and iron studies in patients were drawn, analyzed and compared to baseline levels. background: the collection of units of red blood cells by apheresis (drbc) has been reported to be safe and effective in increasing the yield of rbc units from a donor population. however several reports demonstrated the risk of inducing iron depletion when the interval between a drbc donation and a subsequent rbc donation is shorter than days. aims: to evaluate the recovery from anaemisation and iron stores depletion after drbc donation. methods: donors who underwent drbc donation between december , and february , have been enrolled in a follow up program to monitor haemoglobin (hb), htc, serum iron and ferritin values. these parameters have been assessed on the day of donation and, thereafter and days after drbc procedure. donors suitable to drbc apheresis had to have: age between and years, weight > kg, hb > . g/dl and serum ferritin between and ng/ml. a written informed consent about the collection procedure and the follow-up program has been obtained from all the enrolled donors. drbc collection procedures have been performed by using a mcs + (haemonetics) cell separators. results: out of donors who donated drbc during the study period, only males completed the follow up program and have been analysed. baseline haematological values and iron metabolism parameters were: mean hb . ± . g/dl, ferritin ± ng/ml, serum iron ± microg/dl. on day mean hb was . ± . g/dl (p < . ). on day mean hb was . ± . g/dl (p < . ), ferritin ± ng/ml (p < . ), serum iron ± (p ns). only out of donors ( %) had a ferritin value > ng/ml. in the studied donors the collection of units of rbcs induced an expected reduction of about grams of hb, however only % of this reduction was recovered after days (p < . ). similarly, also iron stores have not been restored after months from donation, as shown by a % reduction in mean serum ferritin value. according to these data it appear that the amount of iron 'lost' with the donation of units of rbcs (approximately - mg of elemental iron) could not be completely compensated by iron absorption from the diet intake. further data are necessary to define the risk of iron depletion after the donation of a drbc, however, at least in areas where iron intake by diet is not very high, the opportunity to prolong the interval between a drbc and a subsequent rbcs donation beyond six months or to provide adequate iron supplementation therapy should be carefully considered. background: increased transferrin saturation and/or serum ferritin have been observed in italy in approximatively % of subjects at first blood donation and, in these subjects, hfe mutations prevalence was . for c y and . for h d (velati et al., ) . aims: the role of the c y mutation is well known in the patho-genesis of iron overload, whereas the role of the h d mutation remains uncertain. the aims of the present study were first to study the main hfe mutations prevalence in a random group of repeat blood donors and second to evaluate iron parameters and iron depletion in repeat blood donors heterozygous for the h d mutation in comparison to a population of blood donors wt/wt for the h d mutation. methods: a total of repeat blood donors were examined in italian transfusion centers ( in northern italy and in southern) for c y and h d mutations. out of those, blood donors heterozygous for the h d mutation and wt/wt for the same hfe mutation, both groups wt/wt for the c y, were enrolled to evaluate iron parameters and iron depletion. these two groups were similar for number of blood donations (expressed as iron loss) and for sex distribution. serum ferritin (sf) was the iron index recorded at first and second observation. results: table summarizes the allelic frequencies in the blood donors. table reports the haematological evaluation in the subjects heterozigous for h d mutation and the wt/wt for the same mutation. conclusions: these data suggest that subjects with h d mutation of the hfe gene have, at first observation, a higher ferritin levels than subjects wt/wt. this seems to be more evident in blood donors of southern italy than in northern. blood donation induces significant reduction of the iron stores both in h d heterozygous and in wt/wt subjects. although our observation is preliminary and restricted to a limited number of subjects, it seems worthwhile to extend the follow-up of blood donors h d heteroxygotes or even homozygotes when available, in order to get further insights on the h d role in iron metabolism. background: cd is a sialylated glycoprotein expressed on the surface of most hematopoietic cells and has been implicated in cell adhesion and signaling. consequently the levels of soluble cd as well as the expression on the cell surface is a marker of cell activation. furthermore, downregulation of this molecule has been correlated with increased susceptibility to infections. the myelodysplastic syndromes (mds) are a group of stem cell disorders characterized by ineffective hematopoiesis, refractory cytopenias and an increased risk of leukemic transformation. the mds patients are often introduced to transfusions for anemia improvement and present increased susceptibility to infections. aims: we studied cd expression in transfusion-dependent and non-transfused mds patient in an effort to investigate mechanisms of regulation of this molecule. we also studied other activationassociated antigens in the absence of manifest infection. material and methods: forty-two patients were included in the study suffering from refractory anaemia (ra). thirty-one were males and females aged to (median ). twenty of them had never been transfused (group a) and were regularly transfused (group b). nineteen age matched healthy individuals were used as controls (group c). cell surface antigens were detected by direct immuno-fluorescence evaluated by flow cytometer. the following mouse monoclonal antibodies were tested: anti-cd b, anti-cd , anti-cd , and anti-cd . leukocytes were gated according to cd . we used a sensitive sandwich enzyme linked immunoassay to measure the level of soluble vascular adhesion molecule as an indicator of endothelial cell activation. the r&d elisa kit was used according to the manufacturer's instructions. results: the cd was found down-regulated in the transfusiondependent mds patients compared with the non-transfused ones (p < . ) and controls (p = . ). this downregulation concerned the proportion of cd + cells, that was lower in the transfused patients than the non-transfused (p < . ) and controls (p = . ), and the rfi (relative fluorescence intensity) value that was also lower in the group a compared to the group b (p < . ) and group c (p = . ). negative correlation was observed between the cd expression and cd b (p = . ) and cd (p = . ). cd b was found up-regulated in the transfused patients. the rfi value was significantly elevated in the transfused patient compared with the non-transfused and controls (p = . and . respectively) while the percentage of cd b cells did not differ significantly between the various groups. increased expression of cd was also found in the group a compared to group b (p < . ) and c (p = . ). the proportion of cd + cells did not differ between the various groups. the levels of immuno-reactive svcam- as determined by elisa were found . + . in group a, . + in group b and . + . in the control group. conclusions: activated hemopoietic and endothelial cells are found in mds that may be associated to the vascular disorders found in these patients. cd downregulation may also be associated to increased susceptibility to infections in these patients. despite improved safety of the blood supply, allogeneic blood transfusion continues to be associated with risks that can be eliminated or reduced by autologous transfusion. preoperative autologous blood donation (pad) prevents transfusion-transmitted viral infection, red cell alloimmunization, and some adverse transfusions reactions. it may decrease the risk of postoperative wound infection because immunosuppression as a result of allogeneic blood transfusion is avoided. pad also supplements the blood supply, provides compatible blood for patients with alloantibodies and rare red cell phenotypes, accelerates erythropoiesis, and provides peace of mind to patients. as any medical intervention, pad has both advantages and disadvantages. with proper patient selection and dedicated attention to process control and quality assurance, the advantages outweigh. background: prestorage pooling of whole blood derived (wbd-pc's) buffy coat platelet concentrates (pc) is common practice in europe event-free survival was significantly better in patients who responded to epo + g-csf. we have reviewed data in centers and the gfm has the intention to extend the study to a larger population in at least centers in france blood components and preparations. the new law prohibits the mixing of different blood products, i.e. blood components and blood fractions. different methods are necessary for the quality control of blood components and blood preparations privileges for blood donors include: -a paid day off work on the day of blood donation and medical examination for blood donation additional paid day off work after blood donation an extra paid day off work if blood is given during vacation or on a holiday this award will be given to non-remunerated donors after blood donations or plasma donations. before , each 'honoured donor of russia' or 'honoured donor of the ussr' had three privileges: free use of public transportation, receipt of certain pharmaceuticals free of charge, and a discount on apartment utilities previously, municipalities also could have their own blood establishments. this resulted in more than blood establishments in the russian federation. from both administrative and financial points of view, many of these are too small to be costeffective, and should be discontinued. services, and wider implementation of modern technology for blood collection, testing, processing, storage, and distribution acknowledgements: we thank ksw microtec ag, dresden/ germany for sponsoring the rfid-labels and novatech research gmbh, vienna/austria for developing the clinic-software. background: the national preparation human immunoglobulin g % for intravenous use (ivig) that is produced at the serbian institute for blood transfusion is used in therapy of neurological, heartand haemolytic diseases and on patients that have undergone surgery. aims: it is our aim to prove the impact of this national medical preparation human immunoglobulin g % for intravenous use on patients that have been infected with sepsis as a consequence of surgery. material and methods: human immunoglobulin g % for intravenous use (ivig) has been used in the study. the preparation is liquid, % stabilised with glucose of a ph value of . ± . . it is used in those cases where sepsis developed after surgery. both an ivig group (n = ) and a control group (n = ) were viewed; the control group not being treated with ivig. the number of specimens with the ivig therapy cholecystitis is (n = ), and the control group (n = ); pancreatitis (n = ) control group (n = ); intestinal obstruction (n = ) control group (n = ); abdominal organ perforation (n = ) control group (n = ); abdominal perforate injuries (n = ) control group (n = ); serious abdominal interventions (n = ) control group (n = ). the period of hospitalisation of the patients in the ivig group was ± days while the period of hospitalisation in the control group was ± days. the mortality rate in the ivig group was % counter . % in the control group. summary: toxic gram -negative bacteria caused synergistic damage of human tissues and generalized inflammatory responsesepsis. by using human immunoglobulin g % for intravenous use, in cases of severe disease, the mortality rate is significantly lowered, depending of course on the anamnesis of the patient prior to surgery and the presence of other diseases such as diabetes mellitus, neoplasma, cardiac diseases etc. background: manual production pc from buffy coats (bc) is a procedure with some consecutive manipulations. the orbisac system (gambro bct) automates the steps and we assessed its performance. material and methods: pc were produced by this device and some parameters were studied. for the preparation of pc, bc were pooled using the orbisac set, with an integrated filter (pall lrp ). bc pool was resuspended in the additive solution t-sol in order to obtain a final ratio plasma/t-sol / . the pc was stored in a gambro elp bag. results: the average platelet count per unit was . ¥ e . the platelet recovery from pooled bc was . % (range . %- . %). all products of the tested pc containing < ¥ e wbc (by flow cytometry). the values of ph on day and of storage were . and . . the swirling phenomenon was good until day °. the average loss of haemoglobin per bc was . g.conclusions:the orbisac system is very suitable for routine pc preparation and it allows increased productivity and better standardization method for pc preparation. platelet concentrates met the requirements for leucodepleted product. increased production of plasma components from male donors background: we routinely separate whole blood (wb) after hard centrifugation into a red cell concentrate (rcc), a buffy coat (bc) and plasma (pl) by an automated expresser (compomat, fresenius). the bcs are subsequently processed into platelet concentrates (pcs) by soft centrifugation and an additional (manual) expression step. the atreus c system (gambro bct) eliminates several of those hand-on steps by combining them into one integrated process. a processing 'circular' bag is placed in the device and filled with the wb. while the bag is centrifuged, the system expresses pl, pc and rcc into separate containers. the rccs are subsequently leukoreduced (manually) with a filter (lr-rccs). this study was designed to evaluate the storage characteristics of the rccs obtained with a prototype of the atreus system in comparison to rccs obtained by routine procedure. methods: whole blood ( ml) was collected in top-and-bottom bags, and randomly selected to be processed by either ( ) current routine or ( ) atreus c. rccs were leukoreduced with the integrated inline filter: fresenius (routine group) or pall rc d (atreus). lr-rccs were stored at °c and sampled until day . various in vitro measurements were performed (n = per group).results: see table (mean ± sd). the lr-rccs contained significantly more leukocytes in the atreus group. despite the rbc loss in the bc, hemoglobin (hb) content was % lower in the atreus group, but met the requirements. in vitro storage characteristics for the rccs were similar in both groups. the atreus pcs contained ± ¥ platelets in ± ml. although plasma volume was higher in the routine group, subsequent preparation of pcs would have resulted in an additional loss of ml per unit in the control group. atreus plasma had extremely low levels of residual wbc and rbc. . ± . . ± . < < . aims: the aim of this study was to examine platelet quality of prestorage pooled prp-derived pc's for up to days storage. methods: pc's were manufactured from wbd-pc's using in-line filtration of prp on day . on day , either , , , or pc's were pooled into an elx® container using a sterile connecting device. studies were performed on days , and for the following measure of platelet quality. ph, morphology score (ms), extent of shape change (esc), hypotonic shock response (hsr), percent in surface expression of p-selectin (p-sel), phosphatidyl serine (ps), glycoprotein b (gp b) and by thromboelastography of the prp (maximum aplitude, ma). results: a total of pools were studied, each of , , and pc's. the mean platelet yield was . ¥ e with a range of . - . ¥ e . the five pc's had a mean yield of . ¥ e and all maintained a ph > . on day . all products had less than ¥ e residual wbc. platelet quality data is presented in the table. data are the mean ± sd, n = . conclusion: platelet pools manufactured from pc's produced by inline filtered prp and stored in elx® containers show good quality preservation to day over a range of platelet yields. introduction: the big progress in treatment of critically ill children significantly increases the need for blood and blood products. loss of blood (lowering of the total erythrocyte mass), as well as decreasing of oxygen capacity of blood that can influence cardiovascular function, is main indication for the erythrocyte transfusion. aim of the study: to present the number of erythrocyte concentrates (ek) that were issued to the pediatric clinic in skopje, as well as to point out how they were distributed. material and method: this is a retrospective study performed in nitm-skopje from january till may . the following criteria were followed: hemoglobin (hb), hematocrit (htc), as well the clinical evaluation, and then final decision for transfusion was made.results: there were blood units (ek) issued for the mentioned period to pediatric clinic for pediatric patients (~ , % units/per child). the biggest consumers are children at intensive care unit and at the hematology-oncology unit. one unit of leukodepleted erythrocytes (er) was split equally to - bags. for small and prematurely born children and for some other selected patients er unit was filtered and irradiated. the dosage was - ml er (depends on age and body weigh). ek was issued as washed concentrates, ek were filtered and ek were resuspended in ab plasma. distribution among abo system was the following: conclusion: gynecologic patients consumed rbc more than times than obstetric ones ( vs ) and the number of given transfusions is high. the a blood group is the most needed one. we should insist on using the who guidelines for the proper clinical use of blood and try to minimize the percentage of given transfusion. and z. cermakova university hospital, ostrava, czech republic background: fully automated system olympus pk is an immunohaematological analyser for detection of red blood cells antigens of ab , rh (d, c, c, e, e) and kell systems without centrifugation by mam (microplate agglutination method) on unique terraced microplate olympus. in the czech republic analyser pk is used only in blood center ostrava. aim: to evaluate the validity of results, sensitivity of microplate agglutinaton method, cause of abortive tests, requirements for analyst, capacity and reliability. methods: blood samples of donors were tested between july and january . all samples were analysed for ab blood group. samples were tested for rhd antigen and ones for rh (c, c, e, e) and k antigen. the validity of the results was evaluated for ab with parallel testing antigens and antibodies, while for rh (d, c, c, e, e) and k using two diagnostic serums. sensitivity of mam i.e. occurrence false negative or positive results were found out when results were confronted with previous ones in our data bank acquired testing classical manual tube or microplate methods. requirements for analyst were evaluated in according to demands for needful knowledge for new analyst, necessity of control pk during testing and maintenance. capacity were evaluated as a number of samples tested per day. reliability determine by occurrence disorders. results: ab , rh (d, c, c, e, e) and k were investigated truly by first testing at . % samples. two diagnostic serums anti-d olymp igm and totem differentiate directly rhd negative and rhd positive donors. false negative or positive results were not founded out due to mam or quality of diagnostic serums. about . % samples with abortive tests were analysed next time the same testing or manual technique. causes of abortive tests were microagglutination several samples except for anticoagulative edta, weak solution of red blood cells prepared by analyser, damage of microplate, hemolysis due to impurity of microplate. in one case analyser evaluated false ab blood group due to hemolysis. analyser has friendly software, simple maintenance and sound control during testing, capacity about samples per day and minimal occurrence of weighty disorders. conclusion: analyser olympus pk is an effective alternative full automation for medium serological laboratory and together with mam easy and truly proves blood groups of majority samples with minimal necessity repetition due to abortive tests. introduction and aim of the study: the purpose of this study is to establish nested-pcr for the detection of hepatitis b virus (hbv) in blood and blood products. methods: the primer pair set was designed to amplify bp in sregion of hbv genome in the first pcr and bp of first pcr amplicon with rubisco (internal control) in the second pcr. to assess the specificity of pcr results, all the samples were tested cross-reactivity or interference in the assay. results: in case of hbv spiked blood products such as immunoglobulin and coagulation factors, this method could detect hbv dna up to . iu/ml. nested-pcr was compared with pcr-elisa and hybrid capture ii (hc-ii), the pcr-elisa showed a sensitivity of % (hc-ii; %) and a specificity of % (hc-ii; %) (p < . ). the results of the study show that nested-pcr and pcr-elisa could be used equally in the management for hbv detection in blood and blood products. p- blood component therapy: slow improvement a mrdja health center subotica, subotica, serbia background: transfusion department at general hospital was founded in . since that time till now it has answered to all demands in blood and blood components. aim: the aim is to present development of the transfusiology department in the last years, so that we could see how much of scientific knowledge we have adopted and in which direction our department goes at the moment. method: retrospective analysis of blood/component utilization in period from . january to . december . results: in whole blood participated in the consumption with . %, packed red blood cells with (rbc) only . %, washed rbc were used in . % of the cases. in whole blood participated in the consumption with . %, packed rbc with . %, washed rbc with . % and rbc in additive solution with . %. as far as plasma preparations are concerned, there has been, since , a great consumption of plasma -witch was separated from whole blood in period up to five day in . % cases, and small consumption of fresh frozen plasma (ffp) only . %. since , there has completely been cancelled the production of five day old plasma, only ffp is being used. from to for the patients who needed platelets, platelet rich plasma (prp) was prepared and applied right after preparation. the consumption rate was from units to units per year. in , after the purchase of platelet shaker, began the production of platelet concentrates (pc) and consumption suddenly rose from units in to units in . conclusions: it is obvious from the analysis that irrational consumption of whole blood was reduced to more acceptable values and therefore the use of component therapy got increased. variation in blood consumption and its slight increase is obvious though application red blood cells was conducted according to strict indications. in the production of plasma old up to five days was cancelled and instead we produced only ffp. pc we prepared for patients only in agreement of treating physician. although very slow progress in development of transfusion therapy in our department can be seen in accepting scientific knowledge. transfusion specialist are active participants in patient treatment and by accepting scientific achievement are able to set standards and help our colleagues, clinics, in successful hemotherapy. introduction: blood groups may act as receptors of parasites, bacteria and viruses. there is evidence that they perform a function and play a biological role. objective: the aim was to detect abo and p epithopes in ascaris lumbricoides extracts (ae) and to study the presence of immune antibodies in patients with ascariasis. materials and methods: ae were prepared by refrigerated mechanical rupture of adult specimens. agglutination inhibition (ai) and haemogglutination kinetics (hk) tests were made with the ae. the patients´ abo and p blood groups were determined. we total febrile non haemolitic male transfusion reaction f e m a l e alloimunisation on le/hla male antigens f e m a l e kandidates of renal male transplantation female lupus nephritis male f e m a l e total female male introduction: irradiation of blood product has been in routine use to prevent graft-versus-host disease (gvhd) in certain recipients for many yeas. gamma irradiation can abrogate the ability of lymphocytes to proliferate in vitro, cgy of gamma radiation reduce lymphocyte response to mitogens by %.the aim of the study: . to estimate potassium level increment in stored irradiation blood units. . to compare the increment in potassium level between leucodepleted and non leucodepleted, irradiated stored blood units. . to evaluate the expiratory date of blood units post irradiation. the study included units of blood collected in cpd-adsol (as- ). in twenty units the blood collection bag was with inline leucodepletion, while the other units were non leucodepleted. all the units were irradiated using caesium as a source of irradiation, with a dose of - cgy. baseline samples from the bags were obtained for measuring of extra cellular potassium (k+). control samples included. results: there is statistically significant increment in potassium level in the irradiated samples compared to the non irradiated samples starting from st day post irradiation and continues to day post irradiation. comparing the group of irradiated leucodepleted, with irradiated non leuconondepleted, for potassium level estimation during the days of storage post irradiation. there is no statistically significant difference between the two groups during all the days of storage, starting from base line samples and other samples post irradiation until day , p value of more than . . . gamma irradiation of bloods units can cause cell damage that the use of such components needs to be modified. . there is a significant increment in the extra cellular potassium level in irradiated blood units that shows doubling value within h post irradiation. . there is no significant difference in extra cellular potassium level increment post irradiation when prestorage leucodepleted units are compared with non leucodepleted units. . an out date of days post collection (unless they expired before) for irradiated red blood units seems reasonable to ensure transfusion of irradiated units without serious complications, except in neonates and massive transfusion cases where irradiated blood units should be fresh and used within - h post irradiation. . the percentage of irradiated blood units requested by our physicians ( . %) is very less that reflects the needs of physicians awareness of the indications for requesting irradiated components that can prevent serious post transfusion complications. the use of whole blood and blood components in treatment of surgical patients in ten years period was analyzed in iran. in accordance with world trend of using blood component therapy, in medical centers throughout the country in ten years period, there are decreasing trend of using whole blood from % ( ) to . % ( ) and increasing trend of using packed red cells component therapy from . % ( ) to . % ( ) . there is also increasing trend of using fresh frozen plasma (ffp) from . % ( ) to . % ( ) . comparing and year, in use of blood therapy related to hospitalized patients at surgical department who received blood and patients who did not received blood; it appears that there is statistically significant difference between these two years. results: during year period, a total of units of blood and units of f.f.p were used. more specifically, the results can be shown in the following table . a high rate of f.f.p usage is observed both in surgery and pathology clinics. the main causes of its usage are: haemodynamic disorders -volume depletion, and coagulation disorders and low blood protein, for the two clinics respectively. conclusion: the only way for rational usage of f.f.p is the regular reminding of plasma transfusion indications to the clinical doctors, so that undesirable side-effects caused by plasma transfusion will be reduced and the percentage of plasma used for fractionation will increase. acquired factor v inhibitor is extremely rare and is associated with diverse clinical symptomatology that varies from asymptomatic forms of the disease to very severe hemorrhagic episodes with a potentially lethal outcome. it may occur spontaneously or as a result of various clinical conditions. a -year-old man was admitted to our hospital with a diagnosis of left-sided periscrotal abscess and scheduled for an incision procedure. during the routine preoperative procedure screening coagulation tests showed pathologic values: aptt s, pt %, fibrinogen . g/l, fv % (other factors were in normal range), platelet count ¥ /l. factor v inhibitor was detected by a modified bethesda assay. the assay showed a low level of inhibitor of about . bethesda units (bu). the patient's medical history showed no major morbidity except appendectomy performed years ago. the patient was prepared for operative procedure, with preventive preoperative administration of fresh frozen plasma (ffp) in a dose of mg/kg (~ ml). upon ffp transfusion, repeated determination of the factor v plasma was unchanged from the initial finding ( %), indicating a failure of therapeutic response. as the measured level of factor v activity was at the borderline hemostatic level, and the operative procedure was not associated with a high risk of hemorrhage, the patient underwent abscess incision. the procedure and postoperative course were uneventful and without major hemorrhage. laboratory testing for the possible systemic autoimmune disorder produced normal findings. control examination performed two years later revealed no major clinical or laboratory variation, while a low factor v level persisted ( %) along with the presence of factor v inhibitor at a level of . bu. we have evaluated two groups of rcc's, one we routinely use (quadruple leucoflex lcr t/t cpd/sagm) (macopharma) and one using an automated collection device which gives the ability to collect whole blood in cpd with a rate of : respectively during the whole donation. the mentioned system has been evaluated using the suitable, quadruple leu-coflex lcr t/t cpd/sagm (macopharma). whole blood ml in cpd was collected from random donors. in both groups the whole system was stored at scaled r.t. ± °c for to h. after component separation (beckman coulter j mi-optipress i-baxter), the red cell concentrates were filtered immediately at r.t. ± °c. sampling was done after filtration and wbc measurements were determinated using nageotte champer (bright line-detection limit . wbc/ml) with leucoplate solution (sobioda). the other parameters were measured with (celldyne abbott). conclusion: all products met the accordance of national and european norms for blood components quality. leucodepletion with leucoflex lcr and abc leucoflex lcr ( . and . ) is highly efficient. the use of abc leucoflex lcr showed better scaled donation in terms of collection (statistical analysis mann-whitney, minitab p-value = . < . ). additionally less hb-loss occurred, due to the filtration process, most probably due to the total absence of clots (analysis man-whitney, minitab, p-value = . < . ). this new generation of collection gives the ability in blood services to collect well calibrated donations, indoors or outdoors. smaller quantities of donations theoretically can be valid because of the stable : , rate of donation. the abc system gives the ability of fully traceability during donation. macopharma's blood collection bags, with or without integrated filters, provided they have this modified system of storing the ac. the device can keep records for many parameters and can transfer them to the data base server of the blood center. to evaluate the performance of the abc, we conducted a comparative study between abc leucoflex lst system and leucoflex lst system we currently use. the later is a well known macopharma's system for collection of whole blood with integrated whole blood filter and the final production of one unit of leucodepleted crcs and one unit of leucodepleted plasma. the abc was handled with the same system modified with the storage bag for the ac. issues of comparison were the accuracy in donation volume, the duration of filtration, the loss of blood in the filter and the residual wb cells after filtration. we performed donations with the lst system and donations with the abc lst system. all the donors were random male volunteers and they were meant to donate mls of whole blood. our results analysed by mann-whitney, minitab statistical analysis have as follows: . no significant difference was found between the two systems concerning the whole blood volume, but there was broader distribution of the values in the lst system compared to the abc lst system. . the duration of filtration has been found without statistically significant differences between the two systems. . the loss of volume in the filter of lst is higher than in the abc lst (p = . < . , which is statistically significant). . there was very good leucodepletion with the lst systems (median reduction of the wb cells . log) but there was a superiority of the abc lst over the lst concerning the leucodepletion per litter and per unit (p: . and p: . respectively). . the personnel after a very short period of training accepted fully the abc procedure.in conclusion abc is an easy to handle device which provides with high quality blood products in combination with leucoflex lst . evaluation of a post-storage filter for wbcs with an incorporated waste bag for washing rccs leucolab lcg is a system manufactured by macopharma for poststorage filtration of a rcc unit (with or without an incorporated waste bag for further washing of the filtered product). to evaluate the efficiency and reliability of the above system we conducted a study with twenty three random units of rccs stored in cpd/sag-m, aged - days, filtered and consecutively washed with ml of normal saline, span down in the regular way and the supernatant extracted in the waste bag. issues for evaluation were: . the duration of priming and filtering the rccs. . the loss of volume in the filter. . the efficiency of the filtration. . the acceptance of the personnel of a new (to them) filtration system.our results have as follows: . we counted the duration of priming and filtration. median time of priming was s (range - ) and of filtration was min (range - ). . the median volume lost in the filter (as calculated) was . ml (ranging from . to . ). this narrow range is apparently due to the non-flexible cell of the filter. . the efficiency of the leucodepletion was counted by flow cytometry. the median wbc counted per lt was . ¥ (range . - . ¥ ) and per unit was . ¥ (range . - . ¥ ). the median reduction of the wbc count was . log (range . - . ). . the personnel involved in the procedure found the system easy to handle, even without specific training. in conclusion the lcg is a reliable and easy to handle system, for leucodepleting (and washing) rccs, very efficient in removing wbcs with negligible loss of volume. objective: standardization of blood banks and establishing quality assurance are important landmarks in the new era of transfusion medicine. as the number of blood banks grows and the capacities of them changes, centralization need arises and trends to nationally coordinated blood services eventually appear. aim: to investigate the types and capacities of blood bank in the country and evaluate the statistics of them. material and method: blood banks and transfusion society of turkey conducted a nation-wide survey of a comprehensive questionnaire. this is a preliminary report of this investigation and illustrates the capacities of the most blood banks in turkey. it also guides the nationally planned renewing structure of blood banks. results: there are nearly blood banks and blood stations in whole country. the overall blood collected at those centers is about . . units. nearly one in third is being collected at government hospitals ( . %), nearly the same is collected at university hospital blood banks ( . %). the third major group is the red crescent society blood centers-rcsbc ( . %), followed by the social security hospitals ( . %). blood collecting capacities are not appearing in the same order. the major blood banks belong to the rcsbcs, whereas the small ones are mostly government hospitals. the only donor recruitment organization is run by the rcsbcs. yearly blood collecting capacity blood banks (%) > . . . - . . . - . . . - . . < . . conclusion: there are many steps for improving blood safety in a country, and the prior ones are structuring the blood transfusion system and donor organization on a national basis, and then establishing good manufacturing practices. these are only possible after centralization of all existing blood banks. in our country, we should first arrange all small capacity blood banks and standardize them. controversial clinical questions considered in a medical opinion forum by physicians for the advancement of transfusion medicine (patm) patm is a newly formed group of close to physicians drawn from pathology and hematology, transfusion services, hospital blood banks and blood centers. its mission is to address the concern that patient oriented medical opinion and influence has been diminished in transfusion medicine (tm). they believe that a patient oriented voice should be distinct from institutional, commercial or regulatory weight and have a common focus on patients and the therapeutics of transfusion and related therapies. therefore, their first objective is to create a new medical, patient oriented voice that weighs in on national policy pertaining to treatments related to tm. as such, patm held its first medical opinion forum where members of the group debated important questions pertaining to tm clinical practice. the forum was held just prior to the aabb annual meeting and attracted physicians. the questions debated were preselected by patm membership via an email survey. respondents were asked to select their top four preferences from among topics in five broad categories. the top two topics were selected for the forum from the completed surveys. the subjects selected and debated were (i) what are the medical considerations for reducing the rate of mistransfusion? and (ii) what are the medical considerations for managing a limited blood inventory? the participants were divided into four groups, with each topic assigned to two groups. all the groups were given two h to debate and arrive at consensus on their topic. each group then presented a summary of their discussions along with specific recommendations for addressing these clinical practice issues. there was remarkable consensus between the groups debating the same issue. the conclusions and recommendations on these two topics will be presented in detail. patm is a new organization that will add an important medical voice and opinion on current topics in tm. at its first meeting, two topics were successfully discussed and debated with broad consensus achieved on current issues confronting the field. key: cord- -upv o f authors: prior, sarah jane; mather, carey; ford, karen; bywaters, danielle; campbell, steven title: person-centred data collection methods to embed the authentic voice of people who experience health challenges date: - - journal: bmj open qual doi: . /bmjoq- - sha: doc_id: cord_uid: upv o f nan the patient or consumer voice in healthcare has evolved from an aspiration to becoming an expectation, which in some developed countries is respected by inclusion in nationally auditable standards (australian commission on safety and quality in health-care. inclusive and appropriate research about patient perspectives requires skills and resources to ensure that sound quality assurance processes are designed, delivered and evaluated. understanding the characteristics of the population is key to ensuring appropriate representation of consumers in person-centred or patient involvement research methods. vulnerable patients, those with ongoing health and literacy challenges, can benefit from advocacy, and often are not used to being valued in terms of their own views, lacking empowerment to present their own opinions. additionally, traditional methods need to be used more sensitively to ensure that these consumers can be included and participate equitably in the quality assurance process. meaningful person-centred engagement is occurring more often in healthcare settings through the process of codesign. originating from design science, codesign is defined as the engagement of patients and other consumers, to capture their experiences in the design or redesign, of healthcare services and is a central concept of health improvement initiatives. codesign includes core principles of equity, understanding of experience and service improvement and provides an avenue for person-centred participation, recognising that consumer experience and knowledge is increasingly being considered important to complement professional knowledge. direct engagement of patients and other consumers in research and health service improvement activities requires careful methodological planning around desirability and feasibility and the practical implications for the involvement of patients and consumer as participants. the following examples of person-centred research methods enable the authentic voice of individuals who experience health challenges to be collected. the five approaches provide opportunities for the voice of consumers to be heard. each of the methods can be used to emphasise active participation by consumers in the design, delivery and evaluation of health services safety and quality systems. a review of person-centred research methods in the literature was undertaken to scope for current techniques to ensure currency of the information. patients or consumers were not involved in this review of methods as the focus was on different strategies, rather than recruitment of participants in any study. the search strategy employed a pragmatic approach as it allowed the research methods to be the focus. the authors initially searched individually for articles using multiple databases including cinahl, medline and scopus. articles that described personcentred strategies for the methods within their area of expertise were sought. a further search using references of articles and updates over the time period of development of the manuscript was also undertaken. the research group met monthly over a -month period to discuss the research methods, literature and develop the article. the authors included research that specifically related to methods deployed for researching personcentred issues, rather than reports of findings from consumer involvement in research studies. interviews can be used to gather information as part of qualitative and quantitative data collection for research, education or quality assurance purposes. understanding the characteristics of the group of interest, identifying potential issues with recruitment, ethical concerns such as consent, privacy and confidentiality need to be addressed. the development of the interview schedule usually depends on the methodology. for example, semistructured questions with prompts may be more valuable for encouraging narratives, whereas a more structured schedule could promote eliciting specific information from participants. a previous study used face-to-face interviews to engage with immigrant patients and ascertain factors influencing their ability to trust healthcare providers. the findings outlined the complexity in developing rapport and creating trust in intercultural healthcare, a valuable outcome for improving person-centred care and overall quality in healthcare. additionally, sandvik and mccormack highlighted the importance of deploying a person-centred framework that promoted mutuality of understanding between the researcher and interviewee. skill in interviewing relies on the interviewer being able to prompt and elicit required information in partnership with participants without creating bias or leading the voice of the participant's opinions, experiences or descriptive accounts. initially, it is important to develop rapport and ensure the participant understands the purpose of the data collection and willingly consents. the setting of this type of interview may also alter the patient-researcher relationship. conducting an interview in the patient's home may differ from being carried out in healthcare environments and should be considered when planning. it is also important to ensure that the participant knows there are no right or wrong answers. studies have shown telephone or digital technology can be as effective as face-to-face interviews. [ ] [ ] [ ] however, other considerations are needed when telephone interviews are selected as a cost-effective method of data collection. as visual cues are lacking, it is important that patients can hear adequately, that there are no distractions and that there is an understanding of what the interviewer is asking. the participant may divulge information such as using a hearing aid or hands-free telephone that could be useful for ensuring a successful interview. preparation is important for both parties including confidence in using the technology for interviewing or providing assistance to the participant. a previous study comparing the use of telephone and face-to-face interviews found that there were some advantages to the telephone method. the authors suggest that participants who agree to be interviewed about sensitive topics may prefer the anonymity; it is easier to reach a wider participant group and that interviewer and participant safety is more easily controlled. following completion of an interview, it is important to ask the participant whether they would like to add any other information. this opportunity may be where participants provide vital information in their own words without the constraints of scheduled questions. similarly, asking participants whether they would like to be sent a copy of the transcript, so they can verify the discussion during the interview is important if the participant has difficulty with expression or other comorbidities, such as deafness or poor digital voice connection that may have hindered understanding during the interview. focus groups use group discussions, facilitated in a specific manner to gather informal information on a selected topic. in healthcare, focus groups can assist in generating a rich understanding of consumer experiences, beliefs and values, and developing strategic goals aligned with these outcomes. while one-on-one interviews can be suitable to obtain a measure of personal feelings and opinions, which can be beneficial for eliciting the opinions of minority groups, focus groups may be useful for obtaining opinions that are likely to reflect the majority. codesign using focus groups is an opportunity for patients and other consumers to consider and discuss their experiences within healthcare systems and services in a collaborative, participatory setting. theis et al held focus groups to determine what factors were important to patients during their healthcare journey. this information was then utilised to develop 'report cards' as a strategy for consumer choice in healthcare, commonly used in the usa to compare providers and health plans as well as incentivise quality improvement. the size of a focus group can determine the progression of discussions and, although sometimes difficult and unpredictable, ensuring optimum number of participants can assist with achieving the desired outcomes. six to eight people per group are generally recommended, however, focus groups can work with as little as or up to participants. to encourage respectful and active conversations among all participants, the moderation of focus groups requires a complex set of skills. the moderator needs to be able to guide the discussions without introducing bias such as leading the group or unconsciously providing positive or negative cues. they need to be able to encourage a relaxed and comfortable space for participants to engage. the composition of focus groups plays an important role in determining the data that will be gained from the discussions. for example, purposive sampling, considering the socioeconomic status of potential participants, has been shown to be beneficial in focus groups with chronically ill participants where it was demonstrated that societal norms are flexible and can be challenged and reformulated during focus group discussions. however, forming a representative focus group does not ensure participants will be equally represented in discussion. participants with higher education, health literacy and better knowledge of health systems have the potential to dominate conversations because they are better equipped to do so. individuals participating in focus groups of this nature often construct their 'patient view' by establishing themselves as knowledgeable, or by validating or challenging another's claims, depending on the dynamics of the group. a further limitation that can hinder focus group participation is poor moderation. tausch and menold describe inadequate moderation as a major barrier to successful focus group discussion for a variety of reasons including poor group dynamic, inability to use various communication methods, concentrated attention and poor preparation. there has been recent interest in the use of online focus groups which due to the covid- and social distancing measures may become more accepted by groups who could be impacted by potential exposure to pathogens by leaving home. additionally, consumers who are less mobile, lack transport or have difficulty attending a face to face focus group could join remotely to participate in data collection processes. conversely, the use of online focus groups may also preclude citizens who do not have access, or know how to use digital technology. additionally, some people with specific health challenges such as hearing loss may not be able to fully participate or prefer to use a traditional face to face approach where visual cues are more easily interpreted. a citizen jury is a participatory action research method that draws on the symbolism of a jury trial. it is a deliberative and inclusive approach for community engagement that is increasingly being used to gain understanding about issues of health concern and policy. key tenets of citizen juries are inclusivity, deliberation and active citizenship. it is these features that indicate citizen juries can allow representation and give a voice to those who might normally be less visible. in a citizen jury, evidence and opinions of experts are presented to a representative group (jury) who then deliberate to reach an outcome-for example, a consensus or priority list. citizen juries are based on the notion that any person, given the opportunity, time, support and resources is capable of decision making about complex technical, health, scientific and ethical issues, including diverse subjects such as population ethical issues; resource allocation; health policy; environmental health and community well-being. citizens' juries acknowledge representation is not just for the very literate and advantaged, but is, by intent, inclusive of people who experience wide-ranging disadvantage and inequity. the approach provides a presence or 'voice' of marginalised or minority groups so that their interests and perspectives are included. the process is overseen by a steering committee to guide question development, evidence presentation, oversight, stakeholder engagement and dissemination or implementation. recruitment occurs by word of mouth; via community or government organisations; electoral role or random digit dialling or more deliberative. jury size may be - citizens who meet for a period of time, usually between and days to 'hear, question, challenge and clarify expert witness testimony from a range of perspectives'. in healthcare, expert witnesses may include clinicians, policy-makers and health consumers who provide testimony about their personal experience of the aspect of healthcare under deliberation. a study involved a citizen jury to assess health needs in an area with high levels of social deprivation and social exclusion, including poverty; poor housing; high levels of death, illness and disability; alcohol and drug abuse; poor access to health services and low literacy. rejecting traditional methods of jury selection, recruitment occurred by way of talking to people at post offices, supermarkets, outside schools and at bus stops to ensure a diverse group reflecting the needs and interests of the community. this example of citizen juries shows how, with careful planning regarding recruitment and support during the period of participation, the method can be inclusive of some of the most marginalised in communities. photo elicitation interview (pei) refers to the use of photographs to trigger dialogue in the context of research interview. in pei, interview is stimulated and guided by images. these images can be chosen from archives or magazines, or created by the researcher or the participant. when photographs are taken by the participant, the method is referred to as native, reflexive or autodriven pei. autodriven pei shifts the balance of control over generation of data from the researcher to the participant. the increased control autodriven pei gives participants makes it a person-centred data collection method. images change the focus and energy of conversation and can lead to information and understandings that traditional oral interviews may not. language processing uses different areas of the brain compared with processing visual information, so the use of image-based research methods enables ways of creatively expressing thoughts, concepts and experiences. in doing so the methods can present a different way of telling as well as a different way of knowing. participatory interview activities can be more engaging and can facilitate a more relaxed atmosphere, reduces the power imbalance that can exist between participant and researcher. this participatory method is an effective way of achieving partnerships with patients and consumers within health services and provides a way for inclusion of those less visible and lacking representation. this was demonstrated in a study where children took photos to explain things that were important to them, thereby facilitating children's control over the data. when photos taken by patients form part of the data there are specific ethical considerations as participants are more visible, including, but not limited to, their physical open access appearance and representation. details of their lives are revealed making them much more identifiable than they might be in traditional research. robust approaches and clear guidance are required about the taking of and use of photographs and specific consent obtained around the use of images in papers, conferences and other forms of dissemination. video-reflexive ethnography (vre) is a participatory research method that regards consumer and clinician participants as experts and encourages their involvement in the research process. vre studies tend to start with participant observation and interviews to build relationships with participants. the method involves video recording episodes of clinical care, conducted in healthcare settings in real time, known as video ethnography and showing these video recordings back to participants, known as video-reflexivity to elicit their responses and collectively identify practice change. vre is a strength-based method and is about opening up or exnovating healthcare and recognising what works well in practice. exnovation is more than visualising a clinical episode of care, as its impact is evident in the videoreflexive sessions where clinical care is made explicit. wyer et al used vre to explore how patients nursed in isolation identify infection risks. wyer et al showed the patient a video recording of an episode of their care, and the video recording produced of the video-reflexive session was then shown to clinicians. video-reflexivity can act as a catalyst as clinicians become privy to how the patient experienced their care, triggering clinicians to identify strategies to change their practice to improve health service provision. this type of active patient involvement is vital for ensuring quality, person-centred healthcare initiatives. australian standards suggest that health service organisations must develop, implement and maintain systems to partner with consumers. capturing the consumer voice and experience is an important part of quality assurance across many facets of healthcare. the five methods described highlight a variety of useful tools for engagement with individuals who experience health challenges. the research method chosen to involve and represent consumers depends on the type of data that is necessary to guide maintenance of safety and quality assurance processes. collaborative management, including patient involvement in design, delivery and evaluation of health services has been shown to drive quality improvement as well as improve health economics and satisfy the legal and moral rights to person-centred care and autonomy in health. patients need to know they are a valuable part of the healthcare team and that their experiences matter. person-centred research methodologies capture the patient. interview methods such as semistructured interviews or the use of interview charts are supported for participants with health challenges as they can be a flexible and personal way of eliciting information for validation or as an experiential account. similarly, focus groups can provide a level of social cohesiveness and support while building relationships with participants to allow them to share their experiences. the use of citizen juries has capacity to involve the wider community in decisionmaking, regardless of their status, while pei and vre methods provide alternative participatory approaches enabling improved communication in healthcare. patient or consumer involvement can take multiple forms in healthcare and there is no single strategy that can be considered to reflect best practice. improving the health status and promoting the quality of life for individuals with ongoing health challenges necessitates cultural change at an individual, organisation and systems level. incorporating a variety of person-centred approaches in routine quality assurance activities provides a means of capturing the experiences of representative consumer groups for the benefit of all stakeholders to ensure high safety and quality in healthcare is maintained. twitter sarah jane prior @snezzajane contributors all authors were involved in the conception of this paper. each author led one section. a final draft of the paper was prepared by sjp and cm. all authors provided feedback for revisions of the paper and a final edited copy was prepared by sjp and cm. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests none declared. patient and public involvement patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. patient consent for publication not required. provenance and peer review not commissioned; externally peer reviewed. data availability statement all data relevant to the study are included in the article. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. sarah jane prior http:// orcid. org/ - - - australian commission on safety and quality in health care. patient-centred care: improving quality and safety through partnerships with patients and consumers australian commission on safety and quality in health care. national safety and quality health service standards co-design of a patient experience survey for arthritis central intake: an example of meaningful patient engagement in healthcare design co-design for implementing patient participation in hospital services: a discussion paper being person-centred in qualitative interviews: reflections on a process advanced mixed methods research designs distrust and patients in intercultural healthcare: a qualitative interview study comparing telephone and face-to-face qualitative interviewing: a research note am i not answering your questions properly?' clarification, adequacy and responsiveness in semistructured telephone and face-to-face interviews computer-mediated communication to facilitate synchronous online focus group discussions: feasibility study for qualitative hiv research among transgender women across the united states interviewing to develop patient-reported outcome (pro) measures for clinical research: eliciting patients' experience defining 'quality' from the patient's perspective: findings from focus groups with medicaid beneficiaries and implications for public reporting comparing focus groups and individual interviews: findings from a randomized study focus groups as social arenas for the negotiation of normativity the impact of status and social context on health service co-design: an example from a collaborative improvement initiative in uk primary care methodological aspects of focus groups in health research: results of qualitative interviews with focus group moderators online focus group discussions: an attractive approach to data collection for qualitative health research citizens' jury: exploring opinions on treatment options for incontinence and research priorities the use of citizens' juries in health policy decision-making: a systematic review do consumer voices in healthcare citizens' juries matter? from passive subject to active agent: the potential of citizens' juries for nursing research citizens' juries and deliberative democracy grounded citizens' juries: a tool for health activism? talking about pictures: a case for photo elicitation photo elicitation interview (pei): using photos to elicit children's perspectives auto-driven photo elicitation interviews in research with children: ethical and practical considerations dear critics: addressing concerns and justifying the benefits of photography as a research method national safety and quality health service standards user guide for measuring and evaluating partnering with consumers blending video-reflexive ethnography with solution-focused approach: a strengths-based approach to practice improvement in health care anonymisation and visual images: issues of respect, 'voice' and protection visualising health care practice improvement creating spaces in intensive care for safe communication: a video-reflexive ethnographic study researching reflexively with patients and families: two studies using video-reflexive ethnography to collaborate with patients and families in patient safety research involving patients in understanding hospital infection control using visual methods patient and public involvement in chronic illness: beyond the expert patient key: cord- -f ciho o authors: nan title: tuesday plenary session tuesday: posters date: - - journal: vox sang doi: . /j. - . . .x sha: doc_id: cord_uid: f ciho o nan from the perspective of causal inference, there is a hierarchy of evidence, ranging from case-series to large randomized controlled trials (rcts). in addressing a particular clinical or policy problem, clinicians or policy-makers can base their decisions on the types of clinical reports that have been published, along with an assessment of the strengths and weaknesses of each study. rcts are controlled clinical experiments in which patients are randomly allocated by the investigators to receive a treatment under study. if randomization is used, all participants are equally likely to be allocated to either the treatment or the control arm of the study. rcts should be distinguished from observational studies in which investigators passively observe patients who happen to receive a treatment under study. because the allocation of subjects to the treatment and control arms of an rct is random, the play of chance should distribute all confounding factors equally between these two arms. thus, the treatment and control arms of an rct should be equivalent with respect to all confounding factors except for the treatment under study. randomization removes selection bias, because neither the investigator nor the participant knows what the treatment allocation will be before a patient enters a study. moreover, if an rct is double-blind, observation bias is also removed, because preconceived notions about benefit from the treatment cannot color the reporting of symptoms by a patient or the assessment of disease activity by an investigator. when the undertaking of rcts is deemed unlikely, meta-analyses of individual patient data, that is, of the data recorded previously on subjects enrolled in published, small rcts may allow investigators to address issues of possible biases ed- - standardizing blood components would allow better monitoring of the effectiveness of transfusion d davenport university of michigan, ann arbor, mi, usa in routine transfusion of red blood cells (rbc) or platelet concentrates (pc), we have only a very rough idea of the dose we administer. the minimum expected hemoglobin content of rbc should be g (fda criteria). however, actual measurements have found a mean hemoglobin content of . ± . g per unit, with variability between manufacturers. percent of units may contain less than . g of hemoglobin while percent may contain more than . g. the effect of storage senescence can magnify these differences. the resulting hematocrit increase, depending on size of recipient and age of a unit, may be . to percent. apheresis collection of rbc can help standardized unit contents, but this technology is relatively expensive and time consuming. knowledge of actual hemoglobin content can be used to optimize red cell transfusion. one trial, using a simple formula incorporating the desired hemoglobin and estimated blood volume, showed that nearly percent of transfusion orders could be met with one unit while achieving a mean target hemoglobin of . g/dl. for pc transfusion, about percent of transfusions achieve the targeted dose of - ¥ platelets in actual practice, with considerable variability between institutions. without knowledge of the actual content of pc, determination of refractoriness and response to matched pc is problematic. standardization and labeling of rbc and pc units for content will permit accurate dosage and quantification of transfusion practice. are transfusion guidelines evidence-based? jp aubuchon dartmouth-hitchcock medical center, lebanon, nh, usa application of the results of randomized, controlled clinical trials to similar clinical situations should increase the predictability of the outcomes of transfusions. unfortunately, too few such trials have been conducted to investigate all the potential situations where transfusion might be applied. however, the ones that have been reported indicate that, in general, transfusion is unlikely to provide substantial benefit in many of the situations where it is routinely used. in the intensive care setting, transfusing red cells at a trigger point of g/dl rather than g/dl not only did not lead to increased anemic morbidity but was actually associated with a reduction in overall mortality. subgroup analyses indicated transfusion at the higher trigger point did not decrease morbidity in patients with cardiac disease nor decrease the time until weaning from a ventilator. following cardiac surgery, a transfusion trigger of a hematocrit of % yielded the same outcomes as one of %. an observational study suggested that patients with peripheral vascular disease and a post-operative hematocrit below % were more likely to suffer a morbid cardiac event, but this group of patients had more evidence of anemia and cardiac ischemia preoperatively, illustrating the pitfalls of observational studies. most would agree that transfusion is necessary below a hb of g/dl and unlikely to be necessary at a hb above g/dl, but most patients fall between these limits, and there are insufficient data in the and residual confounding factors, and may permit them to make a judgment of a causal relationship. sackett proposed that the evidence generated from meta-analyses of individual patient data be regarded as being equivalent in strength to that generated from rcts. meta-analysis is the structured and systematic integration of information from different studies of a given problem. when the results of individual studies are discrepant, the purpose of an overview is to investigate reasons for disagreements among studies. when the results are concordant, the goal of meta-analysis is to derive, through application of a number of quantitative techniques, a measure of the effect of the intervention across combined investigations. this measure is referred to as the 'summary' effect of the treatment under study. meta-analysis differs from the traditional, narrative reviews of the literature, in that: ( ) all completed investigations of the efficacy of an intervention that meet specific, eligibility criteria are retrieved and included in the overview; ( ) the quality of retrieved studies is assessed systematically; ( ) the degree of agreement among studies is evaluated, both conceptually and based on statistical criteria, and the synthesis of the findings proceeds only if the variation in reported results is sufficiently modest to be attributed to chance; and ( ) quantitative methods are used to calculate the summary effect of the intervention and to test that effect for statistical significance. ed- - biology of stem cell mobilization th papayannopoulou university of washington, seattle, wa, usa at baseline hematopoiesis, the majority of developing hematopoietic cells (precursors, progenitors and stem cells) is actively retained in bone marrow (bm), whereas fully mature cells emigrate to peripheral circulation. a small number of stem/progenitor cells are also present in blood, serving presumed physiologic roles for the repopulation of remote damaged areas. however, in several hematopoietic perturbations, i.e. post irradiation, post chemotherapy or by using empiric treatments, a heightened emigration (mobilization) of progenitor/stem cells was noted over years ago. the introduction of g-csf as an efficient mobilizing agent not only had a major clinical impact, but has triggered a flurry of studies exploring the mechanisms of mobilization. from these studies, significant insight has been gained about the molecular pathways leading to mobilization, especially by studying the altered environment within bm post mobilization, and less so by studying cells mobilized in blood. several attractive scenarios have been proposed and their importance was further bolstered by studying genetic mouse models. a prominent role of the sdf- /cxcr pathway has been emphasized, either by down regulation of cxcr , changes in sdf- gradients, or by disruption of sdf- /cxcr signaling. whether this pathway is disrupted by a proteolytic mechanism prevailing within bm post g-csf or by other protease-independent mechanisms has not yet been settled. in addition to sdf- /cxcr , disruption of other pathways responsible for the retention of primitive cells in bm can lead to mobilization. for example, disengagement of the vla /vcam- pathway by anti-functional antibodies or its genetic deficiency in mice results in egress of stem/progenitor cells. mobilization is also seen following the use of other cytokines (i.e. kit-l, flt- l, il- ) or chemokines (i.e. il- , gro?), complement activation, etc., but the detailed mechanisms or the interdependence of these other pathways with the ones already proposed have not been worked out. finally, efforts to improve mobilization efficiency in man has led to the use of combination treatments with g-csf, either by adding another cytokine (i.e. growth hormone), agonistic sdf- molecules (i.e. ctce ), or cxcr antagonists (i.e. amd ) which have yielded synergistic increments, and these will be discussed. a full understanding of the principles of mobilization, as well as the bm homing characteristics of mobilized cells after their i.v. infusion in transplantation, should lead to targeted, more efficient experimental protocols in the future. the possibility of deriving all kinds of mature cell types from embryonic stem (es) cells for the purpose of cell replacement therapies will probably face a major obstacle; a limited supply of available hla types for an ever growing population in demand. one possible solution is to use adult sources of stem cells such as the haematopoietic stem cells (hsc) that can repopulate the entire haematopoietic system after transplantation in a myeloablated host. however cells with the repopulating ability of hscs are still elusive for tissues such as muscle, heart, cns and pancreas. it was therefore exciting news when it was shown that hscs could repopulate other non-haematopoietic tissues arguing for a general role of bmderived cells in tissue regeneration. the term plasticity was thus coined to describe the phenomenon whereby cells of one lineage could trans-differentiate into cells of another tissue. this in turn implied that a certain degree of developmental plasticity was still available in the adult hsc, or their derived progeny, that allowed them to present with novel phenotypes. how exactly this was accomplished was a matter of speculation. in order to address the mechanism we used an animal model of liver failure where bmt with normal (wild type, wt) hsc was shown to rescue the liver failure; the repopulating hepatocytes apparently differentiated from the sole source of wt cells, the bm compartment. by studying the genetic composition of the regenerating liver nodules we observed that both wt and mutant dna was present in the nodules, a finding that was consistent with bm-derived cells fusing with host hepatocytes. the mechanism of plasticity was therefore directly related to the exposure of the donor bm-derived wt nucleus to the transcriptional environment of the hepatocyte and the expression of hepatocyte-specific genes. this fusion mechanism was also shown to underlie perceived cases of haematopoietic cell transdifferentiation to purkinje cells in the cerebellum and to cardiomyocytes. however, there are carefully executed studies that strongly support the alternative transdifferentiation mechanism in tissues such as epithelia or the epidermis. what these observations may imply is that in tissues with high rates of cell turnover, there may be a potent stem cell niche that can reprogram incoming cells to follow relevant cell lineages. if this hypothesis is correct, then the major research effort should focus on what makes the niche and whether it can be recreated faithfully in vitro so as to educate hscs to diverse lineages opening the way for realistic cell replacement therapies. collection and distribution of blood and its products to meet the medical needs of industrialized countries are typically managed through large-scale national or nationally-supported blood programs. the development, maintenance, and ultimate success of such programs are all components of a process that involves the delicate balance of continuously competing pressures, e.g. social, economic, ethical, political, regulatory/legislative. as with all endeavors that directly affect human life, safety is a central, unifying theme of this process. because transactions of blood inherently involve risks at both donation and reception/transfusion ends, efforts to enhance and maintain an acceptable level of safety generally rely on a focused program of risk management (rm). rm involves three equally important elements: identification/evaluation of risk factors in a process, control of exposure to them, and continuous monitoring to assess the effectiveness of countermeasures and the emergence of new risk factors. specific approaches to rm and quality assurance in transfusion medicine will be presented. examples from blood programs currently in effect in selected countries will be discussed. rm efforts within the corresponding blood program in greece will then be examined. the lack of data to adequately assess the status of this program suggests that at least one of the elements of rm -monitoring -can still be improved. a preliminary research effort aims to survey blood donors, transfusion recipients, and physicians in order to build an understanding of the specific factors that drive the perception of risk in the greek population. the findings form important stepping points upon which specific recommendations can be made for the development and maintenance of a comprehensive, effective rm program in greece. ed- - the use of haemovigilance data to increase safety in transfusion medicine haemovigilance is a surveillance of all the procedures in the transfusion chain. the intension is to collect and assess information on unexpected or undesirable effects in bleeding of donors and transfusion of blood components. in europe haemovigilance was introduced as a concept in the middle of the nineties. the first national reports on haemovigilance appeared in the late nineties, and were only dealing with complications related to transfusion. later on other kind of events like 'near miss' events were added. nowadays national reports are dealing with all steps in the transfusion line, and to some extend also with complications in blood donors. the state of the art is haemovigilance with retrospective registration of unwanted events that has happened, but also a more active prospective part with an early warning in a rapid alert system about new threats in the transfusion world. the aim of the different national haemovigilance systems has been to improve safety in the transfusion line. after the first years with haemovigilance in the european countries, what has been the outcome of this big effort? data from national reports do not signify major improvements, but safety is suggested to have improved due to many minor changes of procedures and awareness of dangerous situations. however, in most countries nothing really effective has been done to avoid failures, the most important cause of serious complications in transfusion of patients. systems which can prevent most of the failures are on the market. the cost of these equals the cost of nat screening for virus introduced in the same period of time. the common perception of transfusion risks is still much more focused on the hypothetical risk of virus transmission than to the demonstrated magnitude of severe complications related to bleeding of donors and transfusion of patients. therefore, to increase safety in transfusion medicine the nature and occurrence of the risks should be revealed by haemovigilance and not less important the results should be published with the aim to get a realistic common perception of the transfusion risks. the role of diagnostic testing to identify congenital vs acquired disorders of hemostasis and to optimize the management of perioperative bleeding g despotis washington university school of medicine, st louis, mo, usa excessive bleeding with trauma or after surgery can result in hypoperfusion and anemia related end-organ dysfunction and mortality as well as transfusion-related complications. several large studies have demonstrated that if bleeding is excessive after cardiac surgery to the point that reexploration is required, that overall mortality increases by - fold. transfusion related complications include the following potentially lethal complications: disease transmission of pathogens, acute hemolytic reactions, allergic reactions, transfusion associated acute lung injury, allo-immunization related disease (e.g. post-transfusion purpura, platelet refractoriness, transfusion-associated graft-vs-host disease) and other potential complications (e.g. increased perioperative infection or multi-organ system failure) related to transfusion associated immune modulation. in addition, blood shortages related to increasing consumption (i.e. expanding geriatric population) and/or a shrinking supply (i.e. related to exclusion of donors related to donor exclusion criteria designed to prevent disease transmission) may limit our ability to adequately manage our anemic and bleeding patients. this highlights the relative importance of accurate diagnosis and optimal management of excessive bleeding to minimize bleeding related complications and conserve our blood supply. patients at risk for excessive bleeding include those with an established hereditary disorder (e.g. vwd, hemophilia, connective tissue disorders), end-stage hepatic or renal disease as well as patients with acquired defects of the hemostatic system. in specific, patients with platelet (i.e. platelet refractoriness) or coagulation factor inhibitors at increased risk, extracorporeal circulation related defects or as related to certain pharmacologic agents). patients who require longer periods of extracorporeal circulation for cardiac surgical procedures (e.g. repeat, combined procedures or use of deep hypothermic circulatory arrest) are at a greater risk of developing excessive bleeding (e.g. cpb-related abnormalities). in addition, patients receiving one or more longacting anti-thrombotic medications in the immediate preoperative period (e.g. plavix, reopro, low molecular weight heparin etc) are at increased risk for bleeding. clinicians in the past have resorted to empiric and 'shot gun' approaches when managing excessive bleeding due lack of immediate availability of results from laboratory-based coagulation tests. on this basis, the use of point-of-care (poc) tests of hemostatic function to facilitate the optimal management of excessive bleeding, help differentiate between microvascular vs surgical bleeding and reduce transfusion have been investigated. five of six recently published studies have demonstrated that implementation of a standardized approach to manage bleeding (e.g. algorithm) which when coupled with either point-ofcare or laboratory tests of hemostatic function can optimize the management of bleeding and reduce total donor exposures by %. ddavp has bee shown to be beneficial with uremia-induced platelet dysfunction and with type i von willbrand's disease. although previous studies have not been able to conclusively show that ddavp can reduce bleeding and transfusion when administered prophylactically, more recent evidence indicates that this agent may be useful in preventing excessive bleeding when a test (point-of-care) reveals platelet dysfunction. recombinant activated factor vii (rfviia) is licensed for use in bleeding episodes in hemophiliac patients with inhibitors. although, only anecdotal reports and results from small clinical studies have shown that this agent can reverse life-threatening bleeding after major surgery, other reports indicate that there is variability in the effectiveness of rfviia as well as highlight lifethreatening thrombotic complications in a subset of high risk patients (i.e. patients with congenital or acquired thrombotic disorders or systemic activation of the hemostatic system such as with dic or after cardiac surgery). therefore, large clinical trials evaluating the efficacy and safety of rfviia are needed before any widespread use can be recommended. in recent years, molecular methods of blood grouping have become routine diagnostic procedures in many laboratories throughout the world. they have proved especially valuable for the determination of fetal blood groups. the ability to detect rhd in pregnancies where the fetus is at risk from haemolytic disease of the newborn represents a significant advance in obstetric care. furthermore, the occurrence of fetal dna in the mothers' peripheral blood has allowed this diagnostic procedure to be carried out without the risks that accompany amniocentesis (lo ymd. ( ) ann med : - ). determination of the coding sequence of all the genes giving rise to antigens within the blood group systems currently recognised is virtually complete. by correlating the coding sequence of these genes with the phenotype of red cells from individuals with different blood groups it has been possible to infer the molecular bases of most of the antigens comprising each blood group system (daniels gl ( ) human blood groups, nd ed. blackwell science). the polymorphic antigens of most systems other than abo and rh, are defined by single nucleotide substitutions (snps) which effect a single amino acid sequence change in the gene product. numerous methods, both manual and automated, are available to determine snps and these have been applied to the determination of blood groups. useful applications of snps detection methods include, determination of the blood group phenotype of patients who have been transfused recently and still have donor blood in their circulation (rozman p, dove t, gassner c et al. ( ) transfusion : - ), and donor screening to find compatible units for patients with multiple blood group antibodies or for the management of patients with diseases like the haemoglobinopathies who are going to be transfusion-dependent over many years (castilho l, rios m, bianco c et al. ( ) transfusion : - ). other applications of molecular methods include zygosity determination for rhd, determination of the blood group phenotype of patients with a positive direct antiglobulin test, selection of donors with rare blood group phenotypes, and as aids to the solution of complex blood grouping problems in the reference laboratory. the molecular bases of abo and rh antigens are complex and cannot be determined reliably by a single snp. nevertheless, methodologies are available that allow the comprehensive sequence analysis of individual genes and could be applied to abo and rh typing. whether or not this will ever be a cost-effective procedure is a moot point. it is clear that molecular methods are a useful addition to the range of diagnostic procedures available to transfusion medicine practitioners but it is important to remember that methods based on dna analysis determine phenotype by inference and not by direct measurement. the results of molecular tests should be interpreted with this caveat in mind. ed- - the hla system g stavropoulos general hospital 'g. gennimatas', athens, greece since its discovery in the mouse in the major histocompatibility complex (mhc) has become one of the most important region in the vertebrate genome with respect to infection, autoimmunity and transplantation. mhc primary function is to provide protection against pathogens. this is achieved through sophisticated pathways in which mhc class i molecules present endogenous antiges to cd + t cells and class ii molecules present exogenous antigens to cd + t cells. an increasing number of other proteins are being found that support these two pathways; many of these proteins, together with the class iii complement proteins, also map to the mhc. the mhc molecules were originally studied for their ability to cxonfer tolerance (histocompatibility) following tissue grafts or later, organ transplants. nowadays, the success of unrelated hematopoetic cell transplantation is influenced by the degree of mhc compatibility between the donor and patient. thus, for patients who lack matched donors, the rules that govern permissibility of mhc mismatching still need to be identified. for patients with high risk disease who lack matched donors, use of donors with a single mhc mismatch may permit early treatment before disease progression. scientific evidence to fully answer the questions 'when are platelet components clinically effective' and 'what do we really know?' is limited. despite this limitation and the level of uncertainty it generates with regard to treatment options and policies, it is reassuring to note that current prophylactic platelet transfusion protocols -mostly derived from empirical observations collected during the 's and 's -protect oncology patients from clinically relevant bleeding in more than % of thrombocytopenic days spent in hospital or at home, even in aggressive conditions such as leukemia, lymphoma and other severe blood diseases. this evidence seems to justify the prevalent policy of transfusing platelets when the patient's platelet count falls below per microliter (or in 'unstable' patients). this policy is based on positive outcomes of prospective and retrospective studies performed during the 's including some hundred non-surgical patients and on the desire of balancing the will of reducing patient exposure to limited, expensive, potentially infectious and immunogenic blood products with the objective of preventing clinically relevant hemorrhage. several national and international organizations endorse the above policy. although the role of platelet support in surgery or in specific clinical situations requiring invasive procedures or in patients affected by multi-organ and system co-morbidity suffers from even more limited evidence, the latter has been carefully collected and summarized in the guidelines for platelet transfusion published in j clin oncol ; : - . additional data on lumbar puncture are reported in ann hematol ; : - . another important topic where there is room for improvement and need for further investigation is platelet refractoriness, a condition developed by a proportion of chronic platelet recipients, which causes high hemorrhage risk if compatible platelets are not provided and in which consensus on the diagnosis and treatment is lacking. with regard to the type of platelet product, it will be necessary to determine the clinical impact of buffy-coat derived platelets, consistently used in europe and current object of increased interest in canada, as compared to the platelet-rich plasma method traditionally used in the us, of viral inactivation procedures and of laboratory methods for detection of bacterial contamination of platelet concentrates. in addition, ongoing studies on the clinical impact of high versus low platelet doses will provide novel elements to determine the relative merits of apheresis versus whole-blood derived platelets. as far as the established procedure of white cell reduction by filtration, which shows high technical efficiency and has been implemented as a standard by a number of institutions, debate is still ongoing on its equivalence with serologic screening for the prevention of cmv transmission, whereas general consensus supports its pre-storage use to prevent febrile, non hemolytic transfusion reactions. finally, although the high cost of filters do not allow a generalized use of this technology in many settings, white cell reduced platelets have been unequivocally shown to reduce alloimmune refractoriness from about % to about % of patients. ed- - ffp: appraisal of the evidence for the clinical use of ffp although the indications for transfusion of plasma (fresh frozen plasma; ffp) are limited, the use of ffp continues to rise in the united kingdom and has risen by over % in the past few years. local uk audits continue to document that a significant proportion of ffp transfusions are not consistent with indications reported in guidelines. a systematic review of the evidence base for the effectiveness of ffp was therefore undertaken to identify, select and appraise all relevant randomised controlled trials, as the most robust form of study to assess effectiveness of ffp. in the systematic review of ffp, the criteria for inclusion of full-published studies were: there must have been at least two groups in the study; • allocation to the groups must have been either by formal randomisation or by a quasi random method e.g. alternation; • one of the arms of trial must include ffp or plasma as an intervention; results on the relevant clinical or laboratory outcome must be presented. the main analysis was qualitative, and differentiated between: . studies of interventions comparing ffp with no ffp; . studies of interventions comparing ffp with a non-blood product e.g. solutions of colloids and/or crystalloids; . studies of interventions comparing ffp with a different blood product; . studies comparing different formulations of ffp, e.g. solvent detergent and methodine blue treated. an evaluation of studies comparing ffp with no ffp would be expected to provide the clearest direct evidence for a positive effect of ffp. studies comparing ffp with colloids or crystalloids were separately appraised because these latter products may have variable effects on coagulation tests. studies comparing different formulations of ffp do not directly evaluate effectiveness of ffp but were included because there is now a uk national policy to use these products in younger patients and therefore these trials might identify negative outcomes. the search strategy identified a total publications. although it may appear that this number of randomised trials might provide a reasonable evidence base to help inform clinical policy and decision making, the review identified a number of important concerns about the published trials. few of the identified studies included details of the study methodology (method of randomisation, blinding of patients and study personnel). the sample size of many included studies was very small (range - patients per arm). few studies took adequate account of the extent to which adverse events might negate the clinical benefits of treatment with ffp. many of the identified trials in groups such as cardiac, neonatal, and other clinical conditions, evaluated a prophylactic transfusion strategy. however, when these trials evaluating prophylactic usage were assessed together as a single grouping in the review, it appeared there was no consistent support for a beneficial effect of prophylactic ffp, irrespective of clinical setting. there is a pressing need to develop new trials to determine the effectiveness of ffp, including for those clinical situations in which it has become an accepted part of current transfusion practice. a law decided upon by the riksdag (the swedish parliament) often sets the general standards as a framework and authorises the central government authority concerned to elaborate and decide upon the more detailed regulations. laws and regulations define the level of quality and safety that has to be reached and state what must be done, while establishments and their managers are kept responsible for fulfilling the requirements and how this is done. guidelines (non-binding) present detailed instructions on ways how to fulfil the requirements. making a law is complicated and time-consuming. the ministry draws up a legislative proposal, refers the proposal to relevant bodies for consideration and comments, and then drafts a bill which is referred to the council on legislation for consideration before it is submitted to the riksdag. a parliamentary committee deals with the bill before it is put to the chamber of the riksdag for approval. when adopted, the bill becomes law. regulations elaborated by central government authorities are handled in a principally similar way. however, regulations are more readily adjusted to scientific and technical progress, and when legislation need requirements for technical details, these are preferably presented in a regulation. the ministry of health and social affairs is responsible for elaborating the bill to be submitted to the riksdag on the blood safety law. two central government authorities, designated as competent authorities, are responsible for preparing the appropriate complimentary regulations as well as for inspecting and licensing the blood establishments: • the national board of health and welfare (nbhw), responsible for requirements related to blood components intended for transfusion, and • the medical product agency (mpa), responsible for requirements related to blood components intended for the manufacture of medicinal products. sweden became a member of the eu ten years ago. since then, experts in transfusion medicine have been appointed by the ministry, nbhw and mpa for advice on scientific and technical issues and for representing sweden at expert meetings arranged by the commission. some of these experts are also members of the handbook committee of the national society for transfusion medicine, preparing and revising the national guidelines. consequently, the requirements of the directives are readily implemented in the daily work of the blood establishments before (due to legal and technical reasons) the new blood safety law and the revised nbhw and mpa regulations can be promulgated. to a great extent, requirements of the blood directives are covered by existing swedish legislation. no major problems or obstacles seem to arise when implementing new requirements into law and regulations and into the blood establishments' daily service. a few detailed requirements have been found difficult to follow precisely in the routine work. these minor difficulties, however, will not compromise the high quality and safety of blood components prepared according to the standards set by the blood directives. the landscape for blood collection and distribution includes availability and safety. true international availability of blood has not been reached. the landscape of safety has been mountainous, if viewed by the degree of frustration among the transfusion specialists. the reasons for frustration have varied from serological problems to those of transmissible infections, to which no end is in sight. mistrust in the safety of blood taken by others is one reason for lack of international landscape in blood collection and distribution. increasing demands on safety, availability and economy force the health care providers to reorganise blood services. national systems are winning ground. this may make it easier to achieve international collaboration. the council of europe has pioneered in creation of international recommendations for blood collection and distribution. in a european agreement on the exchange of therapeutic substances of human origin, including human blood, was published. its purpose was to make blood available to other parties of the agreement in case of urgent need. many countries ratified the agreement rapidly, some did it first in the nineties. in practice little exchange of blood components has taken place. the council of europe recommendations lack legal power. the european union is different, and it has taken on its agenda activities aiming at improving confidence in the safety of the blood transfusion chain in the community (commission communication ) . the agenda is based on an agreement reached at a high level eu meeting in adare, ireland in . first in the commission agenda was a recommendation on donor selection criteria, given in . then came the european blood directive / /ec, the aim of which is to improve the safety of blood and blood components within the union so that enough mutual trust between member countries can be achieved to make the exchange of blood components possible. being a legally binding document the directive is undoubtedly helpful in reaching a harmonised standard in europe. hopefully the european commission has the resources to follow its implementation. there are concerns, however. the epidemiological differences among the eu member countries and frequent appearance of new infectious agents potentially transmitted by blood make it difficult to foresee that even effective viral inactivation of blood components could totally erase the national differences in donor approval. blood collection and preparation of components are already the same in eu member countries and the directive helps in their further standardisation. there has not been much distribution of blood components internationally, with the exception of export of red cell concentrates to the us from switzerland and the netherlands. the european legislation opens new horizons and widens the european landscape as its purpose is to simplify the crossing of borders between the member states, but before true movement of blood components is achieved more work is needed on the eu commission blood agenda. the eu directive implemented into the legal act for polish blood transfusion service blood transfusion service (bts) in poland is an integral part of the public polish health service. in the country of nearly million people, approximately one million units of blood and plasma are collected every year from voluntary, nonremunarated donors, which is statistically over donations per inhabitants. blood and plasma are collected in strictly appointed centers and no private collection sites are permitted. the legal basis for the activity of polish bts is polish blood transfusion act of nd august which came into force as of january st . this act was then updated in november according to eu directive / /ec and came into force as of january th . this act introduced the principles for organization, collection, processing, storage, transport and quality assurance in bts. it specified -among others -the system of accreditation, haemovigilence, as well as requirements for bts employees. according to this act the polish bts is obliged to monitor and supervise immunohematology testing and transfusion procedures in all hospitals where blood and blood products are transfused. polish bts consists of regional blood transfusion centers (rbtc), one military center and one ministry of internal affairs and administration center as well as the institute of hematology and blood transfusion (ihbt) which acts as supervisor. the rbtcs have a uniform organization structure, uniform quality assurance system and act according to uniform guidelines issued by ihbt. they have two financing sources -the central budget and hospital reimbursement for distributed blood and blood products. the polish blood transfusion act of nd august , in force since january st , has been supplemented by decrees: . procedures for external bts audits; . requirements for donor selection; . requirements and procedures for organization and safe management of blood transfusion in hospitals; . requirements for implementing of national and regional donor registers; . employment criteria for bts personnel; . training requirements for hospital personnel involved in blood and blood product administration; . national, uniform price list for blood and blood products; . organization requirements for setting up of a national committee for blood and blood transfusion. introduction: several technical aspects must be considered in pediatric apheresis due to the size of the patient. factors that must be evaluated are extracorporeal circuit volume, blood flow rates, type of anticoagulant and vascular access. adverse events are mainly related either to vascular access or to metabolic or hemodynamic changes. aim of the study: in this study we show our experience using fresenius hemocare com.tec for pbsc collection in children. methods: twelve pediatric patients (median age years, range - ; median weight kg, range . - . kg) with solid tumors at onset or on relapse underwent collections with the p y kit of the fresenius hemocare com.tec blood cell separator. our cd + cells target was ¥ e /kg. collections were started if a peak of at least . e /l cd + cells ( per microlitre) were reached in the peripheral blood. in all the patients, leukapheresis were performed through a central venous catheter and temporary peripheral venous access. acd ratio : - : was combined with heparin u/kg. in children with < kg the separator was initialized with a compatible filtered and irradiated red blood cell unit, suspended in % albumin, up to the patient's hematocrit, to avoid transient hypovolemia, due to the volume sequestered in the separator. results: twenty-five procedures were performed. a median blood volume of ml (range . - . ml) was processed in a separation time of min (range - min). the median product weight was g (range - g) and yield of cd + cells was . ¥ e /kg body weight (range . - . ¥ e /kg body weight). three poor mobilizing patients (peripheral blood cd + peak of - cells per microlitre) underwent more than two apheresis to collect the desired transplantation dose ( . and ). all collection procedures were well tolerated. children never required sedation to perform the leukapheresis. only mild hypocalcemia-related symptoms, promptly responding to small i.v. boluses of calcium gluconate, were reported. no circulatory side effects were observed. blood flow alarms occurred in every procedures but no collection had to be terminated due to insufficient flow. conclusion: in summary, leukapheresis in children can be safely and effectively performed with the fresenius hemocare com.tec separator with minimal technical difficulties even in patients under kg. m-pa- alternative methods for prevention of infection transmission (pathogen inactivation etc.), cost-benefit considerations of the procedure itself. however, one must also take the loss of plasma into consideration -and more difficult: calculate the effects of changes in product quality, as reduced content of factor viii, protein s and other labile proteins. for methods involving pooling, there are also concerns about the risks due to the pool sizes. the major benefit of the methods will be the potential reduction of infectious transmission, but also possible advantages as reduction of allergic transfusion reactions and trali must be evaluated. the study types involved in cost-benefit considerations are costeffectiveness analysis where the cost and effects of an intervention and an alternative are presented in a ratio of incremental cost to incremental effect and cost-utility analysis, where quality-adjusted life years (qaly) are used as the effectiveness endpoint. qualityadjusted life years is a method that assigns a preference weight to each health state and estimates life-expectancy as the sum of these products of each preference weight and time spent for each state. a complete glossary of terms is found at http://www.hsph.harvard.edu/cearegistry. in literature, there are several publications on cost-benefit considerations within the field of transfusion medicine. concerning plasma products, the costeffectiveness of solvent-detergent plasma has been the major focus. however, the conclusions of different authors have been conflicting. in , aubuchon and birkmeyer published a paper (jama ; ( ) : - ) where they concluded that the cost was usd per qaly, which is far above the 'acceptable limit' of usd . this estimate was adjusted to usd . mill. per qaly in a letter to jama (jackson, jama ). in , riedler et al. published (vox sang : - ) that the discounted cost/life year saved for sd-ffp use in the uk was gbp for neonates and gbp for patients aged . the main reason for the differences between the two papers (and others) was considered to be different calculation of non-infectious complications. the papers cited above underline the difficulties of the cost-benefit considerations. the age of the patient, the outcome of the treatment, the quality of life in an infected patient and the cost of side effects will differ. in addition, how much are we willing to pay for protection against emerging viruses? this paper will not provide the answers, but introduction: the photodynamic treatment of therapeutic plasma using methylene blue (mb) in combination with visible light is a well established procedure for the inactivation of blood borne viruses. aim of the study: evaluation of the quality and stability of mb/light-treated plasma (mb plasma) prepared under worst case conditions for routine processing. methods: single donor units (n = ) were treated using the macopharma theraflex mb-plasma system which includes plasma membrane filtration (plas ) and addition of mb prior to illumination followed by mb and photoproduct filtration (blueflex). samples were taken before treatment and from the final product. additionally mb-treated plasma was prepared from four different plasma pools and stored for up to months. treatment was done under worst case conditions for the preservation of coagulation factors: maximum mb concentration during illumination ( . mmol/l), maximum storage time of whole blood before separation ( °c, h), maximum storage time of mb plasma before freezing ( h). several plasma parameters and the concentration of mb and its photoproducts (azure a, azure b, azure c and thionine) were determined. results: mb/light treatment had a significant influence on thrombin time (+ . %), fibrinogen (clauss) (- . %), factor v (- . %), factor viii (- . %), factor xi (- . %) and protein c (- . %). no significant changes were detected for at iii, vwf : rco, vwf cleaving protease, plasmin inhibitor and alpha- -antitrypsin. the entire virus inactivation procedure including the filtration steps for leukocyte depletion and mb and photoproduct depletion had no significant effect on activation markers (prothrombin fragment + , thrombin-antithrombin-complex, d-dimers). no further essential loss of coagulation factor activity was observed during storage of the plasma at °c for months. mb and its photoproducts (azure a, azure b, azure c) were depleted to a final concentration of < . mmol/l. thionine was undetectable in all samples. conclusion: photodynamic treatment of fresh frozen plasma (ffp) using the theraflex mb-plasma system leads to only moderate decreases in the activities of different coagulation factors even under worst case conditions for routine production. mb and its photoproducts were effectively removed from the plasma by the blue-flex-filter integrated in the theraflex-system. the quality of mb plasma is well preserved during storage. pulmonary complications, particularly transfusion-related acute lung injury and circulatory overload, are the most common causes of transfusion-associated morbidity and mortality in the developed world. trali is a syndrome characterized by acute respiratory distress, hypoxemia, hypotension and pulmonary edema, occurring within hours (usually - hours) of transfusion of a plasmacontaining blood product. other signs, including hypertension, leucopenia and hypocomplementemia, are less frequent. all blood products, except for albumin and solvent/detergent plasma, have been associated with trali, but red blood cells, platelets and ffp are the most common. the incidence is unknown, but : plasma-containing transfusions is the most commonly cited figure. in % of patients, recovery is well underway within hours, and leads to complete resolution. death occurs in - %. the profile of the at-risk recipient has not been identified. recurrent cases have been infrequently described. there are two prevailing theories of pathogenesis: ( ) antibody-mediated and ( ) -hit hypothesis. evidence supports both concepts and neither is mutually exclusive. more than % of reported cases are associated with blood components containing either hla-specific (class i or ii) or hnaspecific antibodies. in % these antibodies correspond to at least one epitope in the recipient. most implicated components are donated by multiparous women. five percent of patients have hla or hna antibodies in their pre-transfusion serum. treatment requires prompt, assertive respiratory intervention, frequently necessitating mechanical ventilation. because trali has a much better prognosis than ards, it is an important diagnosis. some blood collectors are diverting plasma from multiparous donors away from ffp production or routinely screening for hla antibodies. the most effective method for identifying 'high risk' components has not been identified. introduction: trali is a life threatening adverse reaction of blood transfusion. it is characterized by noncardiogenic pulmonary edema developed soon after blood transfusion. in japan, we built hemovigilance system in and have been collecting the voluntary reports of severe adverse reactions of blood transfusion including trali cases since . since the diagnostic criteria of trali have not been established until recently and no specific diagnostic markers for trali have been discovered so far, it is very difficult to make proper diagnosis of trali in each reported case. we have been collecting the cases with respiratory distress and pulmonary edema developed after blood transfusion as suspected case of trali. we reevaluated each report whether it meet the recommended diagnostic criteria for trali published in transfusion journal in dec. . aim of the study: purpose of this study is to select trali cases which met internationally recognized criteria so that it will reveal the possible causes of trali with laboratory testing for anti-leukocyte antibodies in donors and recipients. methods: the cases with respiratory failure and pulmonary edema are selected for evaluation from the adverse reaction case reports voluntarily reported to japanese red cross. in order to make a proper diagnosis of trali, we have been utilizing the respiratory distress questionnaire which has recently revised. this helps us eliminate other adverse reactions such as circulatory overload, cardiac failure, anaphylaxis and bacterial contamination, which results in selecting out the internationally recognized trali cases properly. for laboratory testing, flowpra and labscreen for hla antibodies and gift-fcm for hna antibodies are performed. the cross-matching test is also performed if possible. results: during past years, cases of trali and cases of possible trali have been confirmed by critical review of each questionnaire. of cases of definite trali, donor specimens were obtained in cases. of cases, anti-leukocyte antibodies were detected in cases ( %) of donors' blood, which was significantly higher than the positive rate of anti-leukocyte antibodies in donors' blood of other adverse transfusion reactions (< %). of cases of antibody positive donors, anti hla antibodies were detected in cases, anti hna antibodies were detected in cases, and both were detected in cases. of cases of positive anti hla antibodies, class i antibodies were detected in cases, class ii antibodies were detected in cases, and both were detected in cases. on the other hand, the anti-leukocyte antibodies were detected in % of trali recipients, and this rate is almost the same with that of positive rate of other adverse reactions of blood transfusion ( %). these results indicate anti-leukocyte antibodies in the blood donors are one of the prerequisites for developing trali from the antibody-hypothesis-oriented point of view. other cases with no detectable antibodies should be investigated in more detail in the future. thus, reevaluating trali cases based on recommended trali criteria will allow us to reveal new information about trali. of adverse events analysed by the serious hazards of transfusion (shot) scheme ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , ( %) were haemolytic transfusion reactions (htrs). were due to incorrect blood component transfused (ibct): / were abo incompatible and / caused by other red cell antibodies. a further cases were reported as acute htrs (ahtrs; i.e. occurring within hours of transfusion) whilst were recognised more than hours after transfusion and reported as delayed htrs (dhtr). / ( %) patients died and suffered major morbidity. htrs associated with ibct result from clinical or laboratory errors and are all preventable. it has been assumed that other htrs are unavoidable. closer scrutiny reveals that this may not always be the case, though review is hampered by incomplete investigations. / ahtrs occurred in group a ( / ) or group b ( / ) patients given group o platelets. of the ahtrs related to red cell transfusion, were due to errors, were in patients with auto-antibodies, in only of whom alloantibodies had been adequately excluded/identified. at least / dhtrs were potentially avoidable; in cases the antibody was detectable retrospectively in the pre-transfusion sample; in cases the presence of a previous antibody was not communicated to the laboratory. two patient deaths related to dhtr might have been avoided by earlier diagnosis and clinical involvement. % htrs reported to shot would have been avoided by compliance with pretransfusion testing guidelines and provision of group a platelets for all group a recipients. htrs can be clinically overlooked and inadequately investigated. national guidelines are needed for the investigation and management of htr, with focus on the identification of underlying causes to guide the choice of future component therapy. reference laboratories can provide valuable support in elucidating complex serological problems. patients treated with high dose chemotherapy and autologous blood progenitor cell (bpc) support may get malignant cells reinfused together with stem cells. we analyzed bpc products collected from patients suffering from germ cell cancer measuring malignant contamination and followed these patients for up to months after transplantation also with the question if transplanted malignant cells influence survival. aliquots of stem cell apheresis products containing one million mononuclear cells were sedimented on glass slides and by immunocytochemistry quantitation of cytokeratin expressing cells was performed manually with light microscopy and by automated image analysis. in of patients ( %) cytokeratin expressing cells were detected in bpc apheresis products of patients treated for germ cell cancer. we followed the activity of the malignant disease of patients for more than eight years in median months after transplantation. no significant difference in survival was demonstrated for our two patient groups. background: the use of adequate number of peripheral blood stem cells (pbsc), collected by mnc apheresis is essential for effective treatment of hematological malignancies, solid tumors, and other disorders by transplantation. aims: the goals of this study were: (a) to obtain an effective apheretic protocol for mnc harvesting, and (b) to compare the hematopoietic reconstitution after hspc transplantations in different clinical settings. methods: in this study, pbsc transplantations - allogeneic from matched sibling healthy donors and autologous -were performed in the management of patients with severe aplastic anemia, leukemias (all, anll, cml), multiple myeloma, hodgkin's and non-hodgkin's lymphoma, breast and ovarial cancer, and extragonadal non-seminal germ cell tumor. pbsc mobilization was achieved with rhg-csf ( - g/kgbm/day). mnc-apheresis procedures (generally one and occasionally two) were performed using blood cell separator cobe-spectra. the first mnc-apheresis was accomplished when the leukocyte cont was - ¥ e /l (autologous setting) or on the th day - hour after the last rhg-csf administration (allogeneic setting). the processed blood volume during one mnc-apheresis was . - . l, and . l for one pbsc transplantation in average. results: using a minimal target dose of cd + cell count ( ¥ e /kgbm), performing one mnc-apheresis procedure for % recipients sufficient number of pbscs were obtained. the mnc yield was . ¥ e /kgbm in allogeneic and . ¥ e /kgbm in autologous setting in average. the mean cd + yields for allogeneic and autologous transplantations were . ¥ e /kgbm and . ¥ e /kgbm, respectively. hematopoietic reconstitution was achieved on the . th day for leukocytes and the . th day for platelets when pbsc transplantation was applied. summary/conclusion: improved mnc and cd + cell yield, as well as rapid hematopoietic reconstitution were observed when: (a) the intention of auditing any clinical practice is, ostensibly, to improve patient care. the term 'audit' implies comparison against a standard. although absolute indications for transfusion have not been defined by clinical trials applicable to most clinical situations, many institutions have established their own transfusion triggers based on their reading of the literature and common practice at that hospital. assuming these represent prudent guidelines, comparison of actual practice to them may allow physicians to re-assess their pattern of hemotherapy and bring it into conformance with the guideline. there are several common ways of performing transfusion audits. retrospective analysis of transfusions allows appreciation of the clinical situation (and its ultimate outcome) but reviews the event through a 'retrospectoscope' that assesses clinical information in a different manner than that available to the clinician making the decision to transfuse. furthermore, the time lapse between the decision to transfusion and feedback about that decision may render the feedback from the reviewing body (e.g., a transfusion committee or blood utilization review committee) of little practical import. to speed the provision of feedback and emphasize educational rather than any punitive outcomes of the audit, some facilities have abolished attempts at determining whether the decision to transfuse was supportable and have used electronic means to feed back to clinicians a non-judgmental informational message summarizing the literature regarding the indications for transfusion. this appears to be at least as effective as the traditional retrospective audit system. prospective review of requests for blood components have the potential to redirect practice in a manner that immediately helps patients. however, such interactions with clinicians may come at inopportune times, may require considerable (unscheduled) time, and are most likely to be fruitful if a knowledgeable transfusion medicine expert can serve as the intermediary. both approaches (or a combination) have been shown to be beneficial in altering practice, but efforts must be diligent and sustained. providing data comparing a physician's practice to colleagues in the same specialty may prompt additional introspection and practice change, particularly if physician leadership of the institution supports the effort as a quality improvement tool. extending the comparison to a group of physicians and contrasting their transfusion habits with benchmark data from other institutions may also be helpful, but one needs to be ready to counter arguments that differences in patient groups are the reason for the differences in practice (studies have shown that, in general, practice patterns are primarily related to training and habit rather than large differences in patient acuity). increased focus on the performance of hospitals as expressed in outcome data may soon extend to transfusion practices as well. the public or governmental institutions may ask to see data illustrating the transfusion practice of an institution and its improvement over time. carefully conducted, diligent, and ongoing transfusion audits are an integral part of an institution's quality improvement program. informed consent: the term informed consent, appeared for the first time in the late s but it was only in the s that it attracted attention with regard to health care. numerous discussions and publications have attempted to define the meaning and the justification of informed consent in recent years. initially it consisted in the obligation of the physician to disclose information to the patient, regarding the procedure he was to undergo, but more recently, ethicists have emphasized the need to ensure the patient's understanding and his autonomous decision to consent. current institutional rules of ethics demand that the physician must obtain the informed consent of a patient 'prior to any substantial intervention' . what is however the meaning of informed consent? is it a mutual decision making between physician and patient? in 'principles of biomedical ethics' beauchamp and childress claim that' it is critically important to distinguish informational exchanges through which patients elect medical interventions, from acts of approving and authorizing those interventions. the elements of consent include: disclosure, voluntariness, decision and authorization. when applying the concept of informed consent in transfusion medicine one can distinguish it into donors' and patients' consent. donor informed consent: information to blood donors constitutes a sensitive issue. it refers to their protection from side-effects of the donation, as well as to protection of the recipient. with regard to whole blood donors a detailed history and information as to side effects are necessary for first-time donors. for repeat donors one needs mainly an updated history. because of time-pressure, whole blood donors are usually given written information and are asked to answer written questions. donors however differ in literacy and even literate ones do not always understand medical terminilogy; so, during the interview one should probe the degree of understanding of each donor. with first time apheresis donors more time is needed in order to explain the procedure and potential side effects. since granulocyte and stem-cell donors require premedication with growth factors and or corticosteroids, the responsibility for detailed information is even greater. the fact that all donors sign the informed consent does not mean that they are all adequately informed! interviewers must be familiar with side effects, their frequency and sequelae and must pass on this information. misses and near-misses, (serious) adverse events and failures in medical practice seem to be not preventable. in medical interventions, preparing and prescribing of medication, assistance by doctors and nurses, medical treatment and follow-up, unwanted and unexpected events occur (http://www.mederrors.com.). these events happen also in transfusion medicine and focus on safety is not unique. haemovigilance which is defined in the eu blood directive as 'a set of organised surveillance procedures relating to serious adverse or unexpected events or reactions in donors or recipients, and the epidemiological follow-up of donors' (eu directive / /ec off. j. european union. . . :l / -l / ) is established to help in trying to identify and minimise the misses and (serious) adverse events in the chain from donor to recipient of blood components. the causes or reasons should be studied in order to prevent re-occurrence. adverse event reporting in blood transfusion and transfusion medicine is complex. it depends on the cooperation between blood establishments with clinicians and hospitals. it implies knowledge of blood banking, transfusion medicine and routine clinical care of all gender and ages, of potential hazards of transfusion, of immune-haematology, of microbiology, and of epidemiology. an adverse event may have its cause in every single part of the blood chain and reference may take place to a proven problem, a potential problem, or to a justified doubt. in almost all blood transfusion centres, a single donation will be processed into a number of different products, and these units might be divided or processed into more products. blood components are produced from whole blood or apheresis donations, and depending of the blood drawing and processing techniques, a high number of products with different specifications is prepared. the products' shelf life is not equal and therefore the moment in time of actual use of each unit prepared from the same donation may differ. in case the unit of platelets harms the recipient, a rapid alert can warn in order not to issue or to transfuse the unit of red cells or the unit of ffp prepared from the same donation because of the potential adverse reaction, which was detected during or after the transfusion of the first unit used. haemovigilance is not only important to blood establishments and to patients and prescribers, but it is also to clinical scientists, and to the public at large. it should provide a basis for minimising adverse reactions on blood components, and it should enable the therapeutic potential of new or established treatments with components to be maximised, since demonstrations of safety during widespread use may lead to extended usage, and wider availability. it is quite worrisome that underreporting is a general problem in medical care. it might be expected that in transfusion medicine the same rates of underreporting can be found, but also that the same mechanisms for improvement are applicable. although medical misses occur and do not seem to be preventable, the handling of these misses is often quite poor. many patients like to hear a detailed explanation, and the majority expects even apologies from the treating physician. it seems desirable to look for new routes in the prevention of unwanted events of transfusion medicine. for problem solving, analysis and improvement of working methods, where needed and possible, are often the most effective methods. attention should be focused on improvement and not on identification of the person who caused the problem ('bad apple'). lack of communication and insufficient insight in each other work are often the causes of problems and unwanted events. it should be recognised that advices given by the haemovigilance officer or the blood transfusion committee about prevention without the input and commitment of the direct responsible persons will lead in most cases to advices which are not effective or which will not be accepted. setting up a haemovigilance system or appointing of haemovigilance officers or installation of blood transfusion committees will not be sufficient. it will be necessary to develop ways of registration, data collection and analysis, but more importantly to support by giving advice and training to prevent reoccurrence of the adverse events or not optimal use of blood components. the confidentiality of the information should be guarded sufficiently. for a physician-patient relation, even after a medical failure, a 'blame-free culture' with a central role for openness and transparency is necessary. for blood establishments and hospitals, there is an important role in the right assistance and help of the physicians concerned both on a practical and on an emotional way. m-pa- years of shot data - : a view of transfusion safety in the uk and reactions. this will require investment in infrastructure, for which there must be a trade-off in improved transfusion safety. transfusion-transmitted infections and serious immunological reactions are rare; shot has highlighted the need for blood services to implement strategies to minimise bacterial contamination and transfusion related acute lung injury and will monitor their effectiveness. from the inception of shot it has been clear that the most frequent transfusion hazard is 'incorrect blood component transfused' i.e. a patient receiving a blood component intended for another person or not meeting appropriate requirements. only a minority of these events results in patient harm and is reportable under the terms of the directive. haemovigilance schemes such as shot, that analyse no-harm errors and near-misses, can reveal clues as to the root causes of 'wrong blood', which contributed to deaths and cases of major morbidity in the uk between and . analysis of such events shows that most errors occur in clinical areas, the most frequent being failure of the 'bedside check' . clinical audit data indicates that % of patients are transfused without a wristband or other form of identification, whilst anecdotal reports suggest that urgent clinical situations, massive transfusions and nocturnal transfusions are particularly error-prone. strategies aimed at reducing errors include structured education and competency testing, and methodologies, both high and low-tech, to ensure accurate patient identification in all circumstances. onethird of errors occurs in hospital laboratories; denominator data on laboratory workload shows that work done outside of 'core hours' accounts for % of all pre-transfusion testing but % of errors, suggesting that biomedical scientists 'on-call' or on shift work are working under pressure and beyond their competency. % of hospitals reported that they participated in shot in , but only % of eligible hospitals reported adverse events suggesting that transfusion hazards remain under-recognised and under-reported. however, benchmarking of 'wrong blood' incidents against transfusion activity shows that the number of observed incidents is roughly proportional to blood use. if haemovigilance data is to contribute to improved transfusion safety, clinicians must be encour-aged to report all events, thus contributing to an evidence base that can be used to effect change and facilitate learning. barriers to reporting include cumbersome systems, lack of time and resource, lack of feedback and fear of blame. transfusion practitioners have a vital role in the recognition and reporting of adverse events, education and clinical audit, but must be adequately resourced and supported by senior clinicians and managers through an active hospital transfusion committee. *provisional. m-pa- passing the borders: when, how and where d pirc-tiljak croatian institute of transfusion med., zagreb, croatia there may come that moment in professional life when you have to follow a strong professional and ethical need and confront your evidence-based statements with the leadership, passing the border of your own small society. in order to protect patient's health and respect human right to be informed about all possible consequences of irregular medical therapy, insisting on professional dignity and truth, you feel responsible and follow-up processing of your serious error report. once you pass the border, trying to warn authorities and find ethical resonance and critical confirmation of your professional fears, you are 'persona non grata' . methods/results: reality checking, personal experiences and observations studying the path of serious error report. although the qc system functions, yet omissions happen . . . the possible reasons could be: lack of knowledge, lack of experience, lack of independency, personal confront of interest, immature leadership, political influence, even corruption . . . how strict do the authorities manage a fault, bearing in mind the responsibility toward the patients under the risk. there is a need to create an available, effective international expert's board which will react and give professional counselling support-asylum for endangered professionals who found enough power to blow the whistle. who will hear it? transfusion transmitted infections (tti) are a major source of concern given the repercussions of hiv, hepatitis c, bacteria and vcjd transmission by blood components. large amounts of resource have been expended in making products safer and in maintaining public confidence in the blood supply. identifying emerging infections of concern is a major activity for many transfusion services. of the long list of emerging infections identified by disease control agencies around the world, identifying those responsible for tti requires, amongst other things, that: • the agent is identifiable. • it is present in blood • it causes a disease of concern. • it is transmitted by transfusion. • it is present at relatively low frequency. • if a test is available (nat, serology or immunoassay) what the infection window period is. once an agent has been identified various approaches are possible, including: • donor selection by testing, geography or lifestyle e.g. wnv; • product selection e.g. erythrovirus (b ) antibody or bacterial testing; • product treatment e.g. pathogen inactivation; • patient selection e.g. cmv matching, immune status. against this background where should our attentions focus? some agents of initial concern are now known to be ubiquitous and have minimal disease association (ttv, gbv) although transmitted by transfusion. for others (coronavirus -sars or the possible kawasaki disease agent, dengue, flavivirus encephalopathies, avian flu, etc.) this is less certain, with agents arising from species crossover being of particular concern (avian flu, vcjd, hiv). • enhancement of automation/computerisation; • process control to provide an 'error-free pathway'; • (national) surveillance and trend analysis of results, preferably based on national working standards; • significantly increased sensitivity, especially from development of antigen/antibody 'combi' assays (e.g. for hiv, and recently, for hcv); • awareness of hbsag vaccine-escape mutants and design of assays to cope with this; • extension of range of agents and markers tested for (varies in different countries); • increasing range of assays available for testing donors with a relevant history of exposure to malaria or chagas' disease infection (for retrieval of otherwise wasted blood); • european union's in vitro diagnostics directive: this has caused some problems and reduced flexibility. nucleic acid testing (nat): nat continues to increase in blood service usage world wide, although not (as yet) to replace serological methods. trends include: • reduction in sample pool size; • increased automation (and process control); • increased multiplexing to detect or more agents in the same assay; • increased number of agents being tested by nat (varies in different countries); • introduction of rapid and flexible nat to detect west nile virus, in north america. bacterial screening of platelet preparations: several countries have introduced (or will introduce) routine screening of platelet concentrates either with biomerieux, bactalert or pall ebds ( depletion assessment). other bacterial testing methods are under active assessment, some rapid enough for possible 'point of use' testing. m-pa- evaluation of in vivo red blood cell recovery after processing with a new filter designed to reduce prions e nelson*, h taylor † , p whitley † and t lieu* *pall medical, covina, ca, † american red cross and evms, norfolk, va, usa background: a filter, called the leukotrap affinity prion reduction filter (prf b filter, pall medical), has been developed to reduce the level of infectious prions, associated with several fatal neurodegenerative diseases including variant creuztfeldt-jakob disease (vcjd), from leukocyte-reduced red cell products. aim: the objective of this study was to evaluate the quality of leukocyte-reduced red cells (lr-rbc) processed through this filter and stored for days. red cell quality was determined by measuring the in vivo red blood cell recovery hours after re-infusion of the -day stored red cells. storage hemolysis and atp were also determined. methods: units of blood ( ml) were collected from normal volunteers into the leukotrap wb system containing cp d/as- anticoagulant/preservative solutions (pall medical). units were either processed to lr-rbc within hours at room temperature (rt units), or after hours at - °c (cold units). the prion filter set was sterilely connected to the units on day , and the units were filtered and stored for days. samples were taken pre-and post-prion filtration and post-storage for plasma hemoglobin and atp determinations. post-storage samples were taken for labeling with -cr radioisotope, re-infusion, and determination of the -hour in vivo rbc recovery. a donor sample was also labeled with m-tc to allow for red cell mass determination. thus, both single-and double-label -hour recovery values were calculated. results: twelve units were collected. in vitro testing was completed on all units. in vivo testing was completed on units. the mean single-label -hour recoveries were . % and . % for the rt and cold units, respectively. the mean double-label recoveries were . % and . % for the rt and cold units, respectively. the overall combined mean in vivo and in vitro results are shown in the table. conclusion: the -hour in vivo red cell recovery means are well above the fda and council of europe's requirement of achieving a mean post-transfusion survival of no less than % of the transfused red cells, and they are comparable to this center's previous results of red cells filtered using the licensed leukotrap rc system with cp d/as- (pall medical introduction: to reduce the risk of platelet transfusion-associated sepsis (tas), methods to routinely screen for bacterial contamination have been implemented. pathogen inactivation treatment of labile blood components provides an alternative means to prevent tas. the intercept blood system for platelets (baxter healthcare) has received the ce mark and has been introduced into clinical practice. aims: this study compared the efficacy of bacterial screening using a culture method (bact/alert system, biomerieux) with pathogen inactivation (intercept blood system) for prevention of transfusion of platelet components contaminated with bacteria. methods: seven strains of bacteria associated with tas, including gram-positive staphylococcus epidermidis, streptococcus agalactiae, and staphylococcus aureus, gram-negative escherichia coli, and klebsiella pneumoniae, and the anaerobes propionibacterium acnes and clostridium perfringens were studied. for each strain, three double-dose platelet concentrates (~ ¥ e platelets in ml of % plasma and % intersol) were collected using the amicus® cell separator. on day of collection, calibrated stocks of bacteria ( , , cfu) were added to the double units. each double unit was divided into two identical products containing , , or cfu of bacteria and stored overnight under conventional blood bank conditions. the control platelet concentrate was not treated. the test platelet concentrate was treated with the intercept process ( mm amotosalen + j/sq cm uva). both units were cultured using the bact/alert system at the time of bacterial inoculation and on days , and of storage. samples ( ml) were taken for both the aerobic and anaerobic cultures. a platelet sample was considered contaminated with bacteria if a positive signal was registered within hours of culture. results: for control platelet concentrates, cultures failed to detect low-dose inocula. the time to positive culture varied with the bacterial strain, contamination level, and time of sampling. at and cfu per product, strains (s. epidermidis, e. coli, c. perfringens, s. agalactiae) and strains (e. coli, c. perfringens) tested negative after days of platelet storage, respectively. k. pneumoniae tested positive after - hours of culture when sampled on day of platelet storage for both and cfu per product. at cfu per product, p. acnes tested negative in aerobic culture and c perfringens tested negative in anaerobic culture after days of platelet storage. the anaerobic cultures of p. acnes became positive after hours of culture when sampled on day of platelet storage. of the strains studied, only s. aureus consistently tested positive after - hours of culture. in contrast, all test platelet concentrates treated with intercept remained negative by bact/alert cultures throughout the entire -day observation period regardless of the strain and the contamination level. conclusions: bacterial detection using cultures may fail to detect low levels of bacteria typically associated with platelet contamination at time of collection and processing. failure to detect bacteria will result in the release of contaminated platelet products with 'test negative-to-date' status. in contrast, inactivation of bacteria is capable of preventing release of contaminated platelet components. background: since nat implementation for hiv- and hcv rna in france, the residual risk (rr) of transfusion-transmitted infections (tti) has dramatically decreased. the rr estimates, for a threeyear period from to showed a significant decrease from / and / before nat implementation to / and / after nat implementation for hiv and hcv respectively. as for hbv, the serological screening is only based on both hbsag and anti-hbc assays. for the same period, the rr estimate for hbv is / , five times higher than hiv one and times higher than hcv one. aims: as the overall rr of tti is mainly related to hbv, and given the availability of hbv nat assays, a study was conducted to determine whether hbv nat has the ability to further reduce the hbv rr and then should be implemented in blood donor screening in france. we have estimated the wp reduction by nat in comparison with one of the most sensitive hbsag screening assays, on commercial seroconversion panels (bioclinical partners, franklin, ma, usa). the nat test was the procleix ultrio assay (genprobe/chiron, san diego, usa). the hbs ag test was the prism hbsag (abbott, france). the comparison was performed on both neat samples and diluted samples / , / , and / , in order to simulate minipools of different sizes. then, we have calculated the yield of hbv-infected donations detected by nat relative to prism hbsag assay. results: on the basis of a window period (wp) of days, ultrio assay is projected to close the wp by an average of days on undiluted samples, days in minipools of samples, days in minipools of samples and only days in minipools of samples. the projected yield calculated on the basis of . million donations collected per year in france, would be . unit per year for minipool-nat and to units per year for individual donation nat. conclusion: introduction of minipool-nat will offer only a little added benefit to transfusion safety relative to current serological screening strategies based on both hbsag and anti-hbc assays. hbv minipool-nat is then unsuitable for hbv screening in french blood donors. single-sample nat or minipool-nat with smaller pool sizes and/or modified procedures (genome enrichment or test improvement) would be more relevant. automation when technologically and practically feasible is a prerequisite for single-donation nat. therefore, decision has been made not to implement hbv nat in the french transfusion network until fully automated systems will be available. however, as the prevalence of hbv infections is higher in the overseas territories than in continental france, and as nat is performed on individual donations in these sites, hbv-nat has been implemented since december in these territories. combined detection of hepatitis c virus core antigen and antibody as an alternative to nucleic acid testing in blood screening grating the capillary cytometer with a robotic workstation and a small footprint centrifuge. significantly, there was no decrement in system performance following automation: of clinical samples ( . %) typed identically with this system and cat, and of the discrepant results were eventually resolved in favor of the automated cytometry method. testing showed high-throughput capabilities (currently samples/day) and was inexpensive. to demonstrate the flexibility of this testing platform, we also developed a method to perform completely automated counting of residual wbcs (rwbc) following leukoreduction of blood components. there were no significant differences in accuracy and precision when rwbc in analytical controls and authentic clinical samples were quantitated by the automated capillary cytometry method or the leucocount method performed manually. given the flexibility of this system, it is very likely that additional blood bank assays could be modified for high performance automated testing on this platform. noninvasive prenatal genotyping on cell free fetal dna in maternal plasma ce van der schoot sanquin research, amsterdam, netherlands in lo et al. demonstrated that in the maternal circulation small amounts of cell free fetal dna are present, concentrations ranging from on average genome equivalents(geq)/ml early in pregnancy to about geq/ml at the end of pregnancy. most likely this dna is derived fom apoptotic syncitiorophoblasts. the human placenta is hemichorial, which means that the syncitiotrophoblast is in direct contact with the maternal blood flow, and apoptotic nuclei are directly released into the maternal circulation. the cell free dna is very rapidly cleared from the circulation, the t / being only minutes. in we have shown that this cell free fetal dna could be used for rhd genotyping. in the last years many groups have shown the successful application of different prenatal genotyping assays such as fetal sexing, thalassemia, achondroplasia, duchenne's disease, adrenogenital syndrome etc. on this source of dna. importantly, no false positive result have been described due to the presence of fetal dna from previous pregnancies, the main draw back of prenatal diagnostics on circulating fetal cells. at present prenatal rhd genotyping has been introduced in routine diagnostics in the united kingdom, france and the netherlands. in large scale high throughput studies it has been shown that the diagnostic accuracy of prenatal rhd genotyping is over %, and it is to be expected that in the netherlands this screening will soon be introduced to restrict the antenatal anti-d immunoprophylaxis to women carrying rhd-positive fetuses. in a large european project (safe, co-ordinator maj hulten, warwick uk) many researchers collaborate to further explore the possibilities of cell free fetal dna for future diagnostics. standard operating procedures for the isolation of plasma dna have been established. control pcrs for the presence of fetal dna have been developed. recent findings on differences in methylation status of placental genes in fetal dna opens new possibilities. the main technical problem that hampers wide application of prenatal genotyping is the impurity of the fetal dna, only - % of the cell free dna in plasma is from fetal origin. this makes diagnostic assays on numerical chromosomal abnormalities impossible. and also for many single nucleotide polymorphisms (snps) such as almost all blood group antigens, assays are hampered by aspecific amplification from maternal dna. our own preliminary results indicate that this latter problem can be solved by pna clamping. the addition of a pna probe specific for the k-allele partial d feature d antigen alteration, often identified as distinct 'partial' d epitope loss. the clinical impact of partial ds is due to the ability of their carriers to form anti-d antibodies upon confrontation with regular d after transfusion, or pregnancy. this leads to the -naively spoken -contradictory finding of an allo anti-d antibody in a d positive individual in connection with a negative autocontrol. the antibodies themselves include the same fatal clinical potential as anti-d antibodies of d negative individuals, but may be even more hazardous since unexpected in d positive individuals a priori. d categories (ii to vii) represent a nomenclatorily defined subgroup of partial ds. the molecular cause of partial d lies within single (caused by point mutation in the respective rhd gene sequence), or multiple amino acid exchanges (caused by gene conversion events leading to rhd-rhce-rhd hybrid genes) which determines a qualitative d antigen alteration, rendering them distinguishable from regular d by a partial d carriers immune system. nowadays, transfusion specialists and gynaecologists are more or less aware of these facts and are taking them into consideration in the clinical setting. most partial d exhibit decreased d antigen density, enabling principal recognition of them. however, routine serological methods may not properly recognise all partial ds and will identify their carriers after immunisation only, which represents a reactive diagnostic/therapeutic attitude second best to an actively prognostic one. this actively prognostic proceeding with respect to early detection of partial ds became widely feasible by rhd dna typing techniques. currently, routine rhd dna typing techniques offer an affordable, accurate and fast approach to an unambiguous identification of partial ds and their reliable discrimination from weak d types, not at risk for allo anti-d immunisation. a reasonable proactive proceeding could e.g. demand for (once in a lifetime) routine rhd dna typing of all weakly expressed ds as defined by serology, since most partial ds also meet this phenotype. rhd allele frequencies and their geographical and regional prevalence will certainly have an important impact on dna typing strategies and their (mandatory) specificities. fluorescence cytometry for completely automated immunohematology testing d roback*, b barclay † and d hillyer † *emory university school of medicine, atlanta, † transfusion & transplantation technologi, decatur, ga, usa we previously described a methodology for accurate immunohematology testing by fluorescence cytometry [roback, j.d. et al. ( ) transfusion ( ), ]. this system utilized low-speed centrifugation of -well filter plates for red cell staining, and a smallfootprint capillary cytometer for data acquisition. when authentic clinical samples from hospitalized patients were tested for abo group, the presence of d antigen, and red cell alloantibodies, the results were well-correlated with those obtained by commerciallyavailable column agglutination technology (cat). this system determined the correct abo group and d type for . % of samples, compared to . % for cat (p > . ). when samples were tested for unexpected alloantibodies, fc determined the correct result for . % of samples, as compared to . % for cat (p > . ). this novel method was better than cat at detecting weak anti-a (p < . ) and alloantibodies. based on these promising results, we sought to completely automate this method by inte-prevents the aspecific amplification of the k-allele, and makes it possible to detect the fetal k-allele in the presence of excess of maternal k-alleles. furthermore, it has been shown that fetal dna is in the plasma present in shorter fragments (< bp) than maternal dna. size separation of cell free fetal dna can therefore be used to increase the relative concentration of fetal dna, which will help the development of new genotyping assays. in conclusion, cell free fetal dna in maternal plasma is nowadays routinely used for prenatal rhd typing and fetal sexing. new technical developments will make it possible to extend these indications to other blood group antigens in the near future. more insight in the characteristics of fetal dna might finally lead to wider applications, including numerical chromosomal aberrations. furthermore, it might become possible to apply genomic dna microarrays for the screening on many different inherited diseases, including hemoglobinopathies. determination of the affinity of anti-d present in the serum of immunized subjects and in anti-d ig preparations by a method using unlabeled antibodies p lambin*, m debbia* and y brossard † *institut national de la transfusion, † chp hopital saint antoine, paris, france introduction: few data are available concerning the affinity of maternal anti-d responsible for the hemolytic disease of the fetus and the newborn (hdn), and the affinity of anti-d immunoglobulin used for the prophylaxis of that disease. we recently described a method to measure the affinity (ka) of untagged anti-d monoclonal antibodies. aims of the study: in this work, a similar method was applied to determine the affinity constant (ka) of polyclonal anti-d present in the serum from d-immunized mothers and donors and from anti-d ig preparations. methods: a constant amount of o r r rbcs was sensitized with increasing concentrations of anti-d present in the sera from immunized subjects, and in anti-d ig preparations. at equilibrium, the amount of anti-d bound to rbcs was measured by elisa. the scatchard equation (linear regression) and the langmuir equation (hyperbolic regression) were used to determine the ka of anti-d. the experimental data fitted well with the scatchard equation (mean r † = . ) but a better correlation was observed with the langmuir equation (mean r † = . ). in maternal sera, the mean ka of anti-d was . ¥ to the m- (from . to ¥ to the m- ). in the sera from immunized donors, the mean ka was . ¥ to the m- (from . to . ¥ to the m- ) and in lots of anti-d ig, the mean ka was . ¥ to the m- (from . to . ¥ to the m- ). the comparison of anti-d affinity measured in cases of hdn in which infants presented a fetal anemia and in cases of hdn in which infants presented only a postnatal anemia showed no significant difference. the mean value of ka in the cases of fetal anemia was . ¥ to the m- whereas in the cases of postnatal anemia the mean value of ka was . ¥ to the m- . conclusion: the method previously described for monoclonal anti-d was applied to polyclonal anti-d present in the serum of d-immunized subjects and in ig preparations. the experimental data fitted well with the langmuir equation, and the affinity of polyclonal of anti-d was measured with accuracy. in addition, no significant difference was observed (at least in the cases of this study) between the affinities of anti-d measured in the most severe cases of hdn (fetal anemia) and in the less severe cases of hdn (post-natal anemia). introduction: cryopreservation of platelets is widely used in platelet immunology to ensure the availability of well characterised panel cells for the detection of hpa antibodies. but recovered platelets do not express the hpa- alloantigens. aim of the study: here we describe a method for the successful preservation of platelets by lyophilization. we report the value of this new reagent for the detection of hpa alloantibodies and especially anti hpa- alloantibodies. methods: rehydrated lyophilised platelets (lyo p) were tested for their reactivity with monoclonal antibodies against gpiibiiia, gpibix, gpiaiia and cd by flow cytometry. the levels of reactivity were comparable with the ones obtained with fresh platelets. the rehydrated platelets were used in the maipa with a panel of hpa antibodies (anti-hpa- a, ; anti-hpa- b, ; anti-hpa- a, ; anti-hpa- a, ; anti-hpa- b, ; anti-hpa- a, and anti-hpa- b, ). results: all hpa antibodies showed the expected pattern of reactivity and in several cases absorbance reading were well above those obtained with fresh platelets. absorbance values produced by inert sera were comparable with those obtained with fresh platelets (ranges . - . ). interestingly, we used lyophilized platelet with a high expression of cd bearing the hpa- system and we have detected anti hpa antibodies among sera previously negative with fresh platelets. nineteen sera concerned patients suffering from hematological diseases and from pregnancy women. conclusion: lyophilized platelets are possibly an ideal reagent for the platelet immunologist to be used for the detection of hpa antibodies. moreover, this work bring new insights on the hpa- system in platelet transfusion. we are now pursuing more extensive validation studies with a larger number of samples representing all known hpa specificities and several diseases. the diagnosis and treatment of sick infants and children requires a broad knowledge of physiology, biochemistry, genetics and the application of sophisticated testing and treatment options. one of these options is transfusion of blood and blood products. transfusion of the infant, especially the premature infant, and sick child, especially those with major organ dysfunction, requires careful consideration of their unique metabolic, hepatic and renal clearance mechanisms. guidelines that direct the indications for transfusion differ from those in adults. non-invasive measures of oxygen delivery and oxygen offloading may assist in guidelines for red blood transfusion. metabolic complications from massive transfusion and/or the manipulation of blood products must also be considered. evidence from a high quality randomised controlled trial suggests that anaemia is also well tolerated by critically ill patients. a restrictive approach to rbc transfusion that maintained the hb concentration between and g/l was found to be as effective as and possibly superior to a more liberal strategy of maintaining the hb concentration between and g/l. there are concerns that some groups of critically ill patients, such as those with cardiovascular disease and patients who are difficult to wean from mechanical ventilation, may benefit from higher hb levels. rbcs also have a role in primary haemostasis and higher triggers may be appropriate in coagulopathic patients. it is important to realise that blood is not a uniform product and the clinical efficacy of rbc transfusion may vary. one factor that may have a considerable effect on the quality of the rbc product is the storage time. rbcs undergo marked changes during refrigerated storage. the implications of these changes on tissue oxygenation are not known but these concerns have led some clinicians to request 'fresh' blood for critically ill patients. there is insufficient evidence to support such practice. it is of great practical importance to determine if, or when, fresh rbcs could be superior to stored rbcs. background: with a decreasing blood donor base, fully tested, fresh unrefrigerated whole blood (fuwb) has been found to be a more efficient and effective use of a limited resource in place of, or as an adjunct to, traditional blood component therapy in surgical situations associated with massive blood loss. aims: to outline the use of fuwb in situations where there is potential for intractable bleeding associated with major surgery, and evaluate platelet function in fuwb versus platelet components. methods: outcomes of fuwb and traditional blood component use were examined for cases of cardiac bypass surgery. in addition, exclusive use of fuwb for burns debridement cases was analysed. an evaluation of platelet function in whole blood compared to platelet components was also performed by measuring platelet aggregation and activation parameters. results: there was a decreased requirement for blood components following administration of whole blood post cardiac surgery. whole blood usage for burns debridement surgery eliminated the requirement for additional blood components. platelet activation was markedly reduced in whole blood compared to component platelets, and this may be one reason for the increased efficacy of whole blood in these clinical settings. conclusion: fuwb appears to have a role in minimising blood product requirements and consequent donor exposure in situations associated with massive blood loss. m-pa- transfusion practice for coronary artery bypass surgery in greece s lakoumenta, m vassili, g hatzidimitriou, t asteri, p stratigi, s kanellas and g palatianos hellenic society of blood transfusion, athens, greece cardiac surgery is associated with a demand for allogenic blood and blood product availability as well as a considerable consumption. the impact of consensus guidelines for allogenic blood transfusion during coronary artery bypass graft surgery (cabg) in us attracted great attention . the present study is conducted in order to reveal the transfusion practice in greece on a similar population i.e. patients undergoing cabg operations. methods: five participating centers collected data concerning transfusion of allogenic blood and blood products in patients undergoing elective first time cabg procedures, as well as parameters that may influence blood loss, such as duration of the operation, cardiopulmonary bypass time (cpb) etc. the total estimated blood loss was calculated as the sum of red blood cell volume reduction [(body weight in kg ¥ ml/kg) ¥ (admission haematocrit-discharge haematocrit)]+(red blood cell volume transfused). results: results are shown in table : means, standard deviations, and p-values of the wilcoxon test comparisons between the hospitals. a preliminary analysis of data from centres ( patients) showed no difference in patient characteristics (age, body weight, male to female ratio). there is a statistically significant difference (p < . ) between the five centers in duration of the operation, cpb, estimated blood loss and volume of transfused plasma. red cell use showed also a variation which however did not reach statistical significance (p < . ). the center with the highest figure for blood loss has the lowest volume of allogeneic red cell transfusion because of the use of cell salvage. conclusions: although variations, as those observed in greek cardiac surgery centers, have been documented in other countries, the variation in the use of plasma is striking and we are in the process of trying to identify the reasons. our study is in progress and additional data are being collected and will be presented. introduction: premature infants and at term newborns have an higher circulating blood volume per kilogram than the adults ( ml/kg in premature; ml/kg in at term), for this reason, in case of neonatal thrombocytopenia, a specific hemocomponent, with a very high platelet concentration, needs for transfusion therapy. the laboratory criteria for platelet transfusion are the following: (a) a plt count < ¥ cells/l if bleeding is observed; (b) a plt count < ¥ cells/l without bleeding; (c) a plt count < ¥ cells/l in newborns showing critical clinical conditions. aim of this study: in this study, we have monitored the plt transfusion therapy in our neonatal intensive care unit (nicu) in the last four years. methods: effects of plt transfusions have been followed in children ( premature infants and at term newborns). the weight of premature infants ranged from - g and at term newborn from - g. gestation age of premature infants ranged from - weeks and of at term ones, of course, from - weeks. for every platelet transfusion in these newborns, the volume of platelet concentrate has been of - ml/kg, with a plt count < ¥ cells/l. results : in the study period, plt transfusions have been performed: children have been only transfused one time, while multiple plt transfusions (ranged - ) needed for children according to clinical conditions. the observed clinical indications for transfusions have been the sepsis with haemorrhagic syndrome ( cases) , haemorrhagic syndrome without sepsis ( cases) and neonatal alloimmune thrombocytopenia without haemorrhagic syndrome ( cases). after hours from transfusion therapy, the absolute plt count and the correct count increment have increased in all little patients. the highest increase in plt count was ¥ cells/l, while the lowest ¥ cells/l. no difference in the efficacy of therapy has been detected between premature group and at term group. % of children have been discharged from hospital in good general conditions without complications in following controls. in conclusion, we can affirm that plt transfusion in premature infants and in at term newborns is an efficient and safe treatment of severe haemorrhagic conditions. however a collaboration between nicu and transfusion center is necessary to choice the adequate platelet concentrate's volume for transfusion and the best plt donor for the newborn. developing transfusion strategies fusion society of turkey (bbtst) in with contribution of blood transfusion centers. according to these figures % of centers attended operates apheresis procedures. two centers informed us that apheresis in the hospital was carried out at blood bank. there was not enough information from one center, so it was excluded. of the blood banks performing apheresis, were university hospital blood banks. another blood banks were producing both productive and therapeutic, produce only productive and produce only therapeutic procedures. one center did not respond. all centers reported to prepare and separate erythrocyte and plasma. however only centers reported to prepare random platelets as well. each center had apheresis machines between - . a total of centers was carrying out around < procedures, around - , at centers about - , at a further centers around - procedures a year (one center was excluded). of the responders to the survey , all procedure were done at blood banks, whereas at of them all were carried out by the hematology clinics. at other centers, productive procedures were conducted by the blood bank, and therapeutics were performed by the hematology division. a total of blood banks stated that they have not kept the platelet suspensions produced and used them straightaway. productive apheresis center capacities were as shown: centers < , centers - , centers - and centers > units have donations a year. around % of all apheresis procedures were carried out by large well run blood banks. conclusion: as the use and production of random platelets increase, and settle of apheresis devices in big centers will eventually decrease the demand of apheresis procedures and keep the welltrained staff at big centers, decrease the cost thereafter. • planning of resources for the financing of the bts, adoption of a methodology for creating and adjusting the price list of products, adoption of the yearly plan of needs for blood/products and services of health institutions which use blood/products. • achieving recognition of real costs of products and services from the health insurance fund and ministry of health. • harmonization of low level of acclaimed costs and real costs of basic transfusion activities. results: acclaimed costs for activities in transfusion practice (collection, testing, processing, storage, distribution and transport) as a reflection on the price of the products are % lower than real costs. the prices of health services in the official price list are much lower than the proportion of costs of material resources needed for the realization of these services. this especially affects the management of independent blood establishments (bti's in serbia) with core blood transfusion activities as their basic field of work, in comparison with the hospital based transfusion services, which are financed within the budget of the whole hospital. the hospitals with hospital based transfusion services involved partly in core transfusion activities are completely financed by the health insurance fund, while independent blood establishments are financed through the price of products and services they provide. conclusion: in order to provide adequate quantities of safe blood/products for the end user -the patient, it is elementary to create stabile and equal financial management conditions for the whole blood transfusion service in serbia. this can be achieved only by continuous cooperation of the health insurance fund, ministry of health and independent blood establishments. sion centers (rbtc). the activities on promotion and organization of voluntary, nonremunerated blood donation, blood collection and patients' services are carried out in the rbtc and in departments of blood transfusion (dbt), part of the district hospitals. the collected units in dbt are transported by special cars to the ncht and the rbtc for processing, testing and control. the same transport is used for the requested by dbt blood components for storage and distribution to hospital departments. thus the issued components are with an equal quality and safety for all patients throughout the country. lbbdbt introduces hemovigilance as a mandatory system, covering the whole chain of the blood transfusion process. it includes as well the creation of registries at a national, regional and district level of blood donors, recipients of blood products and all activities of the blood transfusion service. . seventy hospitals are exclusively users of blood, blood products and services. the current organization of blood transfusion services faces the following problems: fragmented transfusion service, lack of a national blood policy, the blood program is not nationally coordinated, limited knowledge on quality management, inadequately distributed human resources, limited material resources, lack of it system, lack of planned, continuous skill upgrading. as a direct consequence we have: suboptimal blood collection activities, inadequate blood supplies significantly vary between seasons, high percentage of replacement donors, outdated methodologies, old, even obsolete equipment, the quality of blood products is not standard, there is a lack of traceability. aim of study: to reorganize blood collection activities in serbia to increase collection of safe blood up to % ( blood units). methods: division of responsibilities between blood establishments and hospital based transfusion services by: • optimizing organizational structure • implementing blood collection standards to enhance blood safety and donor care • gradually replacing family donors with a network of voluntary non-remunerated blood donors from low risk population groups • creating and implementing a training strategy. results: through the eu funded project support to a national blood transfusion service in serbia, we are in the effort of integrating the services and standardizing their work. the blood collection working group began by dividing serbia into blood collection regions: north, central, and south. each region is divided into sub regions covering approximately half a million population ( in the north, in the central and in the south region). each sub region will have one standard mobile blood collection team to collect blood units daily, i.e. annually. the blood units per teams provide the blood units ( %) to cover hospital needs in serbia. to this effect, the following has been achieved: • blood collection activities in serbia analyzed • performance analysis of bte and hbts mobile teams in place • two model standard mobile teams tested in the field • national blood collection sop's written • national donor questionnaire form prepared • national set of blood collection standards prepared • list of donor deferral criteria prepared • blood collection equipment renewed • regional reorganization plans in progress. the objectives and results can be achieved by the participation and mutual cooperation of all institutions involved in blood transfusion within an integrated, standardized system with clearly delegated responsibilities. p- years of the national blood transfusion institute in serbia n nedeljkovic national blood transfusion institute, belgrade, yugoslavia nbti was founded in . since and unpaid blood donation is mandatory, organized in cooperation with red cross. blood donation is regulated by the law in , / . codex of voluntary blood donation and health care staff has also been established; blood donors donates blood annually. in the past years, there was over million blood donations, performed in accordance with who regulations. over transfusion medicine specialists and technicians specially trained for the work in blood transfusion service (n = ), perform transfusion medicine doctrine of rational labile blood component and stable blood derivatives therapy, based on the selfsufficiency concept in fr yugoslavia with . million inhabitants in serbia, montenegro and kosovo. plastic blood containers and tests are imported or given as humanitarian aid gift and from . now, they have been regulated by tender. in , test to lues was introduced, to hbsag in , to a-hiv in and to a-hcv in . information system was introduced in . nbti includes: national haemovigilance coordinatoin center, center for medical care of haemophiliacs, tissue typing center, center for prenatal and perinatal protection of pregnant women and newborns. activities of nbti are organized through: center for planning, organization and development of blood transfusion service, center for blood collection, preparation and distribution, center for immunology and immunochemistry, plasma fractionation center for plasma in west balkan countries, center for diagnostics means, center for quality control of drugs and medical and diagnostic means, center for education and training and scientific research work. nbti is the third year of gmp, sop, yus iso implementation. in the current reform of transfusiology system we are aiming for percent of voluntary blood donation. nbti is the publisher of the national bulletin of transfusion medicine and it is included in the education system of the belgrade university medical faculty and the estm in belgarde . the problems of blood service in russia ea selivanov and t danilova russian inst. of hematol. & transfusiol., st. petersburg, russian federation background: the blood transfusion service (bts) development as a platform for providing the hospitals with blood and blood derivatives is an important national problem. aims: russian blood service assessment with international comparison. methods: a study was conducted on the base of the reports from all regions of russia followed by a computer statistical analysis. results: blood and blood components were collected in the russian federation in in stations of blood transfusion and in blood transfusion departments at big hospitals. amount of donors in was equal to , voluntary donors being . % of them. the average number of whole blood donations in relation to the general population is per inhabitants, and on average percent of the donor base consists of first time donors. the average number of blood collected in relation to the general population and health care system is . ml per inhabitant and ml per one bed. an average volume of one blood donation is ml. blood was collected into plastic bags containing domestic or foreign anticoagulants. about . % of collected blood is used for procurement of blood components and preparations, . % of banked blood is used for transfusions. amount of donors and the volume of whole blood have been significantly decreased for the last years. at present in russia all donations are tested for abo blood group, rh(d) type, anti-hiv- / , hbsag, anti-hcv and syphilis. the total percentage of blood discarded after testing for transfusion-transmissible infections is . %. % of plasma is obtained by plasmapheresis. blood components collected are as ffp, rbc, frozen rbc, eukocyte-and platelet-depleted rbc, rbc suspension, and preparations: % albumin, immunoglobulins, and cryoprecipitate. as to blood safety measures -implementation of blood components leucodepletion and ffp and rbc quarantine in process. the new national strategy of bts reorganization has been developed. it includes the following: increasing the visibility and resource commitment to blood issues at the national, regional and municipal levels; the national voluntary donor programme promoting; blood safety increasing; blood collection, testing and pro-cessing concentration in federal and regional bts establishments, appropriate blood and blood components usage. calculating the cost of blood in turkey n solaz, s kemahli and s cin ankara university, ankara, turkey background: like other fields of the medicine cost efficacy is gaining importance in blood banking and transfusion medicine since last few years. since last years even the most developed countries started to discuss about the cost of blood. in turkey ministry of health determines the cost of blood annually. aim: to establish a safe, cost effective and reliable prices for blood components. methods: turkish ministry of health (moh) started to determine the cost of blood components as 'all inclusive' principle. this means that cost of a unit of blood component will cover all conventional expenses such as; blood typing, infectious screening, labour, consumables, etc. this system has provided uniformity to blood component costs but if the system is not controlled and followed properly it will cause serious risks. there might be some blood banks which will not respect the safety regulations and may modify the test standards for decreasing the cost of tests. conclusion: current blood product pricing system looks generally reasonable and reliable but moh should establish close follow up systems for avoiding any abuse on the safety of blood. background: a positive direct antiglobulin test occasionally occurs in normal blood donors, and is often discovered when the donor's red cells are found incompatible in a compatibility test. the incidence of a positive dat was expected to increase since more sensitive techniques (gel test) were installed. the aim of our study was to examine whether dat positive otherwise healthy donors presented any clinical or laboratory abnormalities. methods: in the first . cross-matches last year (in months) were found incompatible due to dat positivity of blood donors' red cells ( . %). dat positive [( +)-( +)] samples were only igg positive in cases, only c d positive in and igm positive and c d positive in case. all blood donors were notified and thirty two of them responded to a request for a further sample. a complete blood count, a reticulocyte count, bilirubin (total, direct, indirect), transaminases, serologic immunological tests (ana, anti-dna, anti-ena, rf, anticardiolipin antibodies), quantitative assessment of immunoglobulins, aptt and lupus anticoagulant were performed, as well as serologic tests for markers of viral infections. dat and iat were performed by gel test (id-diamed) according to the manufacturer's instructions. dat were performed with polyvalent and monovalent reagents (anti-igg, -igm, -iga, -c c, -c d). the blood donors were also examined clinically. the donors who had positive immunological tests were referred to a rheumatologist for further investigation. results: among the thirty one blood donors eight had received medication the last hours before blood donation, two had been vaccinated for hepatitis b recently, four presented signs of a viral infection soon after blood donation, three had evidence of an allergic condition, five had positive tests for anticardiolipin antibodies and ana, two were positive for anticardiolipin antibodies only and two had a positive ana test only. in six blood donors we did not find any abnormality that might be interrelated to dat positivity. conclusions: all blood donors with positive dat should be requested to undergo further investigation. some of them are possibly candidates to long medical follow-up, especially those with other immunologic abnormalities such as positive ana and/ or anticardiolipin antibodies. the eligibility of such donors for future donation of whole blood, platelets or plasma needs to be elucidated. tions: usefulness, frequency and sincerity in answering questions. donors could choose one of the offered answers and elaborate in writing the answer they have chosen. results: of the donors that participated in the survey ( . %) answered the questionnaire, ( . %) men and ( . %) women. that the survey was useful thought % and % that it was not. opinions were elaborated by . %. that the questionnaire should be completed before each blood donation was the opinion of . %, % thought it should be filled out only the first time blood is donated and . % that the questionnaire should not be completed at all. the answers given were sincere in . % of blood donors, % were not and . % were given automaticallywithout comprehension. conclusion: most donors believe that completing the questionnaire before each blood donation is an effective way to increase safety by preventing potentially infected individuals from donating blood. they are also aware of the importance of answering questions truthfully because the end result is protecting the wellbeing of both blood donors and receivers. analysis of blood donor's deferral in national institute for transfusion medicine -skopje for the last five years ( ) ( ) ( ) ( ) ( ) p blagoevska*, i nikolovska † and r grubovik* *national institute for transfusion medic, skopje, † medical center, prilep, macedonia introduction: safety of blood and blood products depends on many different factors, starting with selection of blood donors. the aim of this study is to analyze the number of deferred blood donors and the reasons for their deferral, as well as the total number of blood donors in nitm and their correlation (voluntary/family donors). materials and methods: this is a retrospective, epidemiological study and data were taken from the blood donor's registry in nitm from . . till . . . statistical mass includes blood donors who came to nitm to donate blood in the mentioned period. results: there were total donors in nitm and ( . %) deferrals. . % of deferred ones are male, as well as in the group with donated blood (males are predominant). the most common reason for deferral is low hb level in ( . %) blood donors, use of drugs - ( . %), low blood pressure - ( . %), high blood pressure - ( . %), infections - ( . %), cardiovascular diseases - ( . %) and others. relation voluntary/family donors is almost equal ( . : . ). in the last two years the number of voluntary blood donors is increasing ( : ), which is good sign. conclusion: percentage of deferred blood donors in first three years is ~ %, which is result of insufficient data and it is increasing in the last two years (> %). reasons for deferral are predominantly from temporary character ( . %). permanent deferrals are only ( . %), which is probably due to good education of the population and self-deferral. we should establish the national registry for deferred donors, as well as for the donors with positive markers for tti. we should design a strategy for returning of temporary deferred donors. regruting blood donors in multiethnical environment p blagoevska*, r grubovik* and k elezi † *national institute for transfusion medic, skopje, † medical center, gostivar, macedonia introduction: population in r.macedonia consists of % macedonians, % albanians and % others (serbs, gypsies, turks). over % of blood donors are voluntary non-remunerated and ~ % are family donors. transfusion service and red cross should recognize the values and cultural differences of minors groups and recruiters should developed methods for reaching and motivating them to donate blood. the aim of the study is to present the ethnical structure of our donors and to develop strategy for their regrutation and retention. the study reviews the results from the blood donation actions among the high schools and university students in west part of the country (multiethnical environment) from till . results: there were blood donations for the mentioned period. predominant blood donors are employed and high school students in %. family blood donors are ~ %; between them % are from albanian population. the ratio between blood donors macedonians vs. albanians is : . woman blood donors are presented with %. first time blood donors are %, and regular donors arẽ %. conclusion: first step in planning the blood donation in multiethnic society is creation of special teams of important and devoted volunteers, such as religious leaders, teachers, doctors and businessman. for a successful campaign it is necessary to design special promotional material and address personally to the target population on their mother language. background: pursuit of pharmaceutical purity of the blood in the bag has led to a shrinking donor base and a significantly more expensive product. decisions regarding new infectious marker testing and donor deferrals have typically been made emphasizing decreasing one specific risk without considering the effect the intervention will have on the overall safety of blood transfusion. regulations have been formulated by governmental agencies with limited input from the medical community. the decision making process has lacked risk benefit analyses and has not had the robustness associated with spirited discussions. policies made in this manner may result in certain risks being decreased but can also have adverse unintended consequences. discussion: in the u.s., the fda's implementation of donor exclusions to prevent possible transfusion transmitted vcjd has reduced the donor base by more than %. given the demographics of the deferred donors, the impact on plateletpheresis donations has been even greater. to compensate for the loss of donors, blood services will have to persuade present donors to donate more frequently, to recruit new donors, or both. one study has indicated that two-thirds of donors have no intention of donating more frequently. new donors have higher rates of infectious disease markers with positivity for hiv and hcv twice as high as repeat donors. despite sensitive testing techniques, window periods still exist and not all potentially infectious donors will be excluded. another area of concern is the aggressive use of inducements to attract new donors. some blood services are offering lavish incentives such as enrolling donors into drawings to win automobiles. most donors entering the lottery will be low risk; however, it is reasonable to worry that such extreme tactics might also attract persons who should not be donat- conclusion: (a) blood donors who were patients' relatives were many more than volunteers as well as more were men than women. also people of young ages were more than those from older ages. (b) the frequency of the diseases for which the blood units were tested was found to be in low levels in the population of the area. specifically as concerns hcv, it seems that transmission frequency has been reduced after the obligatory testing of hcv in blood transfusion centres and stations. genotype b of hepatitis c virus is the most frequent in blood donors d, from a to f, from a to k, a and a. these are differently distributed in the world: types and are the most common in europe and in usa. aims: considering that, in our region, anti-hcv antibody positivity is variable from . to % of general population, aim of this study has been to evaluate the prevalence of hcv genotypes in blood donors. methods: in period from may to december , blood units were analyzed by nat for viral rna research. nat has been performed on single sample by tma technique. on rna-positive samples, the hcv genotype has been identified by reverse hybridisation with line probe assay. results: blood donors have resulted hcv-rna positive with identification of the following genotypes: a = cases ( . %); b = ( . %); a + b = ( . %); a/ c = ( . %); = ( . %); = ( . %); none was a or a. we have also analyzed the differences between the two sexes in hcv-genotypes distribution. hcv- a has showed a double prevalence in men ( cases, . %) respect in women ( cases, . %), while genotype b is more frequent in women ( cases, . %) than in men ( cases, . %), moreover genotypes and do not compare in women. although an accurate pre-donation selection, discharging all subjects with alt > iu, our results show that . : donors, apparently healthy and without risk factors, have resulted hcv-positive. analyzing our data, the genotype b has resulted the most frequent in blood donors' population, followed by type , while the others have showed a very low prevalence. the high frequency of genotype in blood donors is explained by the observation that hcv is usually associated with low alt levels, for this reason affected subjects may escape to donor's screening only based on dosage of alt. on the contrary subjects affected by other hcv types, associated with high alt levels, may be deferred increasing the hcv b relative prevalence. at the end, the different distribution of hcv genotypes between men and women and between age's classes probably reflects differences in the pathogenic characteristics of the virus, in the transmission way and in the risk factors. in fact, it has been demonstrated that genotype is principally linked to a not transfusion transmission way; genotype is linked to old age, to female sex and to post-transfusion transmission; genotypes and are associated to young age and to an history of drugs abuse, respectively with high and low viral load; genotypes and are still little known because extremely rare in europe. p- kell blood group system and rare blood donors v fakitsa*, p karyda*, s giannoulea † , c antoniou*, j flesiopoulou*, e haliou*, m papakonstantinou*, h dessilla † , e katsadorou*, g lyrakos* and k sofroniadou* *general hospital of nikea, pireas, † blood transfusion center, athens, greece background: the kell blood group system is a compound antigen system exclusively of red blood cells. some of the kell antigens are highly immunogenic. the commoner kell antibody is anti-kel . the kel (cellano) antigen is a high frequency antigen and the blood donors lacking this antigen are quite rare. the blood donors who have not factor cellano are classified in the rare blood donors. rare blood by its very nature is required rarely, but when needed that blood has to be ensured to specified patients. there are other blood donors in their family - ( . %) students, but the number of persons that donate blood from their neighborhood and close environment is much bigger - ( . %). motives for their donation are the following: their wish to help the ones that need blood - ( . %), concern that some day everyone can be a potential recipient of blood - ( . %), because of offered benefits - ( . %), for a friend or relative - ( . %), care for their health - ( . %), because of citizen duty - ( . %), because the others donate - ( . %), curiosity - ( . %). they want to be invited every months - (%) students, every months - ( . %), every months - ( . %) and ( the mean age of case group was / ± / and the mean weight of them was / ± / , / % was male and the mean number of blood donation was / ± / . the mean age of control group was / ± / and the mean weight of them was / ± / . / % of them was male and the mean number of blood donation was / ± / . the blood donors who were female, first time blood donor low wt the rate of vasovegal rx was higher in female, first time, low weight, younger blood donors (p < . ). the rate of vasovegal rx was higher in blood donor (p < . ) who were fatigue or first time blood donor, low wt blood donation, fatigue of them and starvation of them had higher absolute donation reaction than other donors. when each variable was adjusted for other variable by regression analysis. young age, first time blood donation, anxiety, fatigue, starvation were significant (p < . ) and the others were not. conclusion: donation -related vasovegal syncopal reactions are a multi factorial process. these reaction are more prevalent in blood donors who are young, first time donor, anxiety, fatigue, starvation. these reactions might be predicted vasovegal reaction and these some facth donors need more care. with better donation care, syncopal reaction may be decrease this would be improved donor safety, better donor retention, higher donor satisfaction, and reduce cost and increase regular blood donors. to avoid iron deficiency in blood donors, iron compensation is necessary in most females and males who donate more than - and - whole blood units per year, respectively. we present studies dealing with different dose and duration of iron compensation. in the first randomized placebo controlled study iron decreased continuously in males and females at donation intervals of two (males) and three months (females) without iron compensation. mg and mg daily combined with mg ascorbic acid over months (males) or months (females) compensated for iron loss or even overcompensated in females. in the second open study we reduced iron dose to mg daily over one month for both genders. this iron dose was sufficient for compensation of iron loss. a further reduction of iron dose to mg daily over half a month led to negative iron balance in the majority of donors. in all three studies donors with exhausted iron stores profit more from iron compensation, whereas donors with high ferritin values (> mg/ml) tend to loose storage iron. aim of the study: one of our campaign strategy how to increase blood donation among adolescents are periodical seminars and excursions for students of secondary schools (more than per year). the aim of this study is to analyze impact of our campaign educational system on adolescents in period - . methods: the donation of whole blood and aphaeresis platelets from donors of age from to (max. years for each class) were count for the period of five years ( ) ( ) ( ) ( ) ( ) . the percentage of the man´s donation was calculated for each target class ( ) ( ) ( ) ( ) ( ) . results please see tables and . in the tables there is shown observed data in relation to the total number of births in the czech republic in reviewed years. the study showed that number of donation from donors of age from to decreased during objected years. unfavourable state of total number of births in the czech republic ( birth in republic ( birth in , birth in ) and its decreasing tendency ( birth in !) is with high probability a major demographic factor affected number of young donors. despite energy invested in our campaign educational system our recruitment efforts should be intensified to decrease influence of demographic factors. we should find new ways and methods to attract new blood donors and keep the regular ones, too. the aim of the research was to investigate women's attitudes towards blood donation in cyprus. a statistical sample was selected using stratified sampling and consisted of women from the district of limassol (the second largest urban center of cyprus) between the ages of and . using linear logistic regression, the analysis of the data collected revealed that there is a greater probability for a woman to be a blood donor if she is of a higher educational level, a member of an organized group or association, or if she is acquainted with other blood donors. the percentage of female blood donors is higher in rural areas than in urban centers. % of women do not donate blood and attribute their reluctance to do so to health-related problems, while about % of those who have never donated blood claim to fear the blood donation procedure. in addition, more than half of the women who have stated they would never donate blood again have attributed their denial to healthrelated problems. the research revealed that there could be an increase of up to % of the percentage of female blood donors if they were given time off work for a few hours or one or two days afterwards. even though very few female blood donors expressed a preference for the blood donation to take place on a particular weekday, half of them prefer the donation to take place on the discussion: it is about small group of students. the impression is that the altruistic behaviour is present at most of the questioned students. the fact about free school days is not underestimated because it is one of the most important motives of blood donoring of the young population. families where the blood donoring is a tradition have a great influence for young children because the children in these families are better informed for blood donoring. conclusion: including the children in the process of education for young children is of particular importance because the altruistic behaviour as a higher feeling is from an early age of the child and it is under the influence of the environment (family and friends). active participation of the department for transfusion medicine in the educational process, especially in the education of young children, is a guarantee to achieve longlasted positive results. adverse reactions in blood donors taking betablocking antihypertensive medications l paesano*, m d'onofrio*, s misso † , g fratellanza* and e d'agostino* *university federico ii, naples, † hospital san sebastiano, caserta, italy one aim of blood donor's selection is to avoid an adverse reaction to phlebotomy (as vasovagal reaction, syncope and/or hypovolemic cardiac insufficiency). blood donation is surely contraindicated in various pharmacologic therapies, but not in all. in fact a certain degree of discretionarily exists about the assumption, or the period of suspension, relative to a numerous pharmaceutical products, as the antihypertensive agents. according to literature, the deferral of donors taking antihypertensive medication is not indicated when blood pressure is normal, symptoms are absent, and diuretics or similar agents are the only drugs used. on the contrary, it is a common opinion that an antihypertensive therapy by betablockers is not compatible with blood donation for its cardiac effects. nevertheless, in our daily activity, the observation of a blood donor taking beta-blocking drugs may occur for various causes. a possible error is a superficial pharmacological anamnesis, as it can occur in donations on autohemotheca, for a too fast medical visit (due to a large number of donors), or for the inexperience of the selector (often a not specialist of transfusion medicine young doctor). another possibility of observation is constitute by patients, undergoing to elective surgery, included in a program of autologous blood donation, suffering hypertension treated with betablockers. in fact, in this last case, the risk/benefit balance justify the blood letting procedure. in the last year we have just observed two severe post-donation reactions in donors suffering hypertension treated with atenolol. the reactions have been similar, in fact both donors showed lypotimia followed by convulsions about past half hour by the end of phlebotomy. no prodromic symptoms have been observer or referred. cardiac frequencies (cf) before donation were respectively and beat per minutes and blood pressures (bp) were both in the normal range ( / and / mmhg). after donation, during adverse reaction, cf showed no substantial variations, while bp have been decreased respectively to / and / mmhg. immediate treatment has consisted in putting the donors in the trendeleburg's position and in applying a dolorous stimulation. in the first case this treatment has been sufficient to report the bp to / mmhg (with disappearing of all symptoms) in only half hour time. in the second one, the marked hypotension showed a very slow remission, for this reason the subministration of a plasma expander needed, with the complete resolution of the symptoms after two hours. these two donors were not deferred from donation because they were periodic donors that had modified their antihypertensive therapy, without referring it neither in the questionnaire nor during anamnesis. our experience confirms that the blood donation don't must be permitted to subjects taking betablocking antihypertensive drugs. in fact these medications act on cardiac pump decreasing the cardiac rhythm and limiting the postdonation cardiac recover. this effect is very dangerous because it appears relatively in retard respect to the end of donation, when donor may have just leaved the transfusion center. introduction and aim of the study: in society under transition privatisation and marketisation probe all areas of life. transition to market economy is extremely important and sensitive issue in health and welfare services in general, and specifically in the case of blood transfusion service. the aim of the study was to analyze effects of confusing publicity which introduced possible ways of transforming blood transfusion service in serbia (ideas about privatization of some parts of national blood transfusion institute, buying blood from blood donors, selling blood from voluntary blood donors to private clinics, exporting blood from vbd, stories about tradition of paid blood donations in some european countries). publicity was restricted to a small number of sporadic outbreaks concerted in a limited period of time. table. conclusion: surveillance of adverse reactions and injuries or accidents during or after blood donation is essential for maintaining the well being of active blood donors, as well as for the safety and quality of the donated blood components. information on other activities and parameters affecting the quality of blood including materials, reagents and equipment should be collected and any serious deviations from standard operating procedures should be notified to the competent authority using haemovigilance infrastructures. skae has built up such procedures working along the lines of the european haemovigilance network. improvement of existing national haemovigilance systems is expected to follow from the implementation of the eu directive. although inevitable, blood donor deferrals lead to losses in donated blood supply and may affect donor-return rates and subsequent blood donations. to estimate the scope of blood donor deferrals and their causes, we analyzed the - data from regional blood centers using standardized criteria for temporary and permanent blood donor deferrals. within this period ( ) ( ) , . percent of persons who presented for donation were deferred; . % were temporary deferrals ( % due to laboratory test results, among others low hemoglobin, . % due to risk of acquiring a transfusiontransmissible infection) and . % were permanent ( % due to the infectious diseases markers, . % due to cardiovascular diseases). for regional blood centers the temporary deferral rates varied widely (see the table below ). in the case of individual regional centers, the differences as well as the most common causes were often difficult to explain. according to our analysis, some blood centers have a more restrictive approach to donor acceptance than others and this results in increased donated-blood loss. to some extent such losses could be avoided. further studies are recommended to elucidate the problem and eliminate unnecessary deferrals. caption : percentage of deferrals aims: from our experience in selecting blood donors, a certain number of issues have been noticed that remain obscure and need to clarification since those seem to 'haunt' the whole process of blood donation. methods: many first time blood donors and especially volunteers think that rejection reasons are permanent and they are completely incapable of donating blood their entire life. this is a 'tragic' misunderstanding since the doctor did not explain that the reason of the rejection is only temporary and in the future this man is capable of donating blood. those potential donors will never even approach again blood donation centre and when in the future they are asked why they do not donate blood, they repeat the cause of the past rejection. results: one of these rejection reasons is for example low blood pressure ( . % of total causes of rejection). as we all know blood pressure must be determined according to age, sex, weight and from other factors as sleep, emotional status, food and liquid intake. therefore blood pressure is very important but should be evaluated with all the above factors and must not be alone the only reason for rejection. even when one blood donor is rejected it should be made clear to him that this is only temporary and if in the future he is in better physical condition, he could donate blood. in fact - % of those donors rejected for hypotension are readmitted in blood donation after meeting the above mentioned criteria. another matter of equal importance is anemia ( . % of total causes of rejection), especially concerning young women. since most of those women tend to develop anemia due to depletion of iron stores, they should be advised to donate blood at longer periods than regular, to receive proper medication and diet according to their needs. the doctor must explain the donor the reasons for iron depletion, so blood donation should not be considered as the only cause for this situation from the donor. there are many factors contributing to anemia, menses, specific diets, overwhelming stress and exercise, not to mention other medical reasons. it is the duty of the doctor to correct those factors that resulted in iron depletion or anemia and readmits those donors in blood donation in the future ( - % of those rejected are readmitted in our centre). summary/conclusions: at our blood centre we have created a program of regular tests (blood tests-physical examination) for all our blood donors. our experienced and well taught personnel offers advice and provides useful information in every aspect of blood donation and more. we have created a friendly environment for all our volunteers with love, understanding and appreciation and believe that this is the only way to keep a constant 'flow' of blood in our region. introduction: an innovative perception for blood donation in a new and evolving environment must focus on specific matters and ideas and adopt in a certain level lifestyles and concerns of society. aims: the purpose of this study is to find methods and ideas that can help blood donation centers throughout our country to create new blood donors, give a motive and inspiration for blood donation by adopting new trends of society and finally accomplish national need. methods: by having a personal interview with many volunteers about their feelings for healthier life, their nutritional habits, daily physical activity, sports, vitamins, smoking, weight, cholesterol levels. we investigated whether they believe that blood donation has, if any role towards a more hygienic life. results: we divided blood donor volunteers according to their age, educational level, and number of blood donations per year. our results indicated that there is a tendency among young educated people to adopt a personal lifestyle that includes consuming healthier food, keeping their weight low close to the ideal, having some kind of personal activity, not smoking, watching cholesterol levels, following doctors advice and concerning seriously about their health. this dynamic group of blood donor volunteers considers blood donation as a contributing factor to well being and donates blood at specific intervals. besides the yearly run lab tests that are done by our blood centre they also seek advice and discuss any matter concerning their health with the blood centre doctor. it appears that they are extremely sensitive in those matters and they seem to appear well informed about issues concerning their health, they also believe that blood donation is part of the plan they have to keep fit and being well. in our blood centre we encourage this belief and we also provide information concerning this new trend towards healthier habits. summary/conclusions: this approach has already shown some positive results in our blood centre as many people especially young educated women have joined our blood donorship program and donate blood at scheduled intervals. in order to achieve our goal which is to raise the percentage of blood donors in the region we have to be flexible, innovative according to new habits and lifestyles. we have to move with society and modernize the way we attract various groups of people. blood donation against prejudice as saltamavros*, s dimitrakopoulos † , v zacharaki*, p giannaros*, s markou* and p tseliou* *st. andrews hospital patras greece, patras, † pyrgos general hospital, pyrgos, greece introduction: in order to achieve a greater population to be admitted in blood donation we have to provide information concerning any obscure issues that presents in selecting donors. to examine the accuracy of hb measurements obtained by the noninvasive clinical device, as compared to values detected by standard methods, (cell-dyn , abbott laboratories, usa), in a blood donor setting. methods: the nbm- device utilizes a finger base sensor using occlusion red/near-infrared spectroscopy (o-rnirs) to detect and analyze the hb/hct levels. the clinical trials were conducted at two blood donor centers (israel and usa). studies were carried out on a group of subjects ( females, males) aged - . subjects were healthy volunteers who had come to donate whole blood or aphaeresis components. after obtaining informed consent, hb/hct levels of all the study volunteer participants was tested non-invasively, using the nbm- device, followed by a venous blood sample. additionally, the usa center tested a capillary blood sample using the hematastat hct measurement device ( donors). hb levels were considered normal when readings were equal to or > . g/dl. results: venous hb measurements ranged from . - . g/dl. the mean nbm- hb level was . ± . g/dl, only . g/dl lower than the mean hb result obtained by venous sampling, which reached . ± . g/dl. the standard deviation of the difference between the invasive and noninvasive hb readings was found to be ± . g/dl. the mean absolute error (mae) of their difference was . g/dl. when checked against the cell-dyn in the usa center, where subjects had hb of . g/dl or lower, the nbm- and hematastat devices showed comparable sensitivity results. the nbm- using o-rnirs is a promising noninvasive technique for hb screening in blood donors. the device is easy to use and agreeable for both blood donors and personnel. the technique reduces the need for the invasive finger prick or venous blood sampling, thereby enhancing safety, reducing costs, and improving the experience of blood donation. the effect of short-term, temporary deferral on blood donor return rates and subsequent blood donations background: blood donors are deferred for numerous reasons. some deferrals like intravenous drug use, male homosexual contact or certain positive test results are permanent. the majority of donor deferrals, however, are short-term temporary deferrals (sttds) that are resolved in a matter of days, weeks or months, after which time the person is again an eligible blood donor. the effect of sttds on blood donor return rates and subsequent blood donations is studied. materials and methods: donors given sttds during the december to march were computer-matched with non deferred donors on the basis of age, sex, and donation date (case group: donors -control group: donors). computer records were evaluated during the next years ( march to march to determine donor return rates. significance for comparison between the two groups was based on chi-square analysis. results: the most common reasons sttds were elevated blood pressure ( %), deferred for medication ( %) and colds and/or sore throats ( . ). non deferred donors were a little more likely than donors with sttds to return over the next years ( . % vs. . % pv = . ) and non deferred donors donated more whole blood units. . according to ethnic structure, women -ethnic macedonians donate blood in largest numbers - ( %), while all other ethnic groups are present with only %. the most prevalent is the group of adults aged - ( - . %), with high school education - ( . %) and mostly those who donated blood - times ( - %). conclusion: having in mind that % of the population in macedonia is female, the obtained results reveal a significant, yet insufficient participation of women in blood donation with % in relation to the total number of blood donors surveyed in the period - . this is due to insufficient motivation and education of women from all ethnic groups especially those from the younger population and with elementary education. incorporating them in education and organization would contribute to their more extensive participating in blood donation. comparison of serum beta -microglobulin (b -mg) between hbsag positive donor and healthy control f tarabadi*, m shaeigan*, g babaee † , a talabiean* and m khadir* *iranian blood transfusion center, † tarbiat modarrs university, tehran, iran background: beta -microglobulin (b -mg) is a low molecular weight protein ( daltons) and found in all biological fluids it is light chain of histocompatibility class -human present on the most membranes of cells. in the hepatitis infection the viral antigen presentation on the hepatocyte in the presence of class -hla antigen plays a role in the elimination of the virus. method & samples: beta -micro globulin was measured in serum drawn from hbs ag positive blood donors include ( . %) female and ( . %) male in age between - years, and healthy ( %) female and ( %) male in the same age we detected serumic b -mg by enzyme immunoassay (ela). results: our studies showed b mg level increased in ( . %) hbs ag positive donor that was significant differences with healthy control (p = . ). conclusions: it seems that serum b mg is a good marker for hbs ag replication. the role of b mg in monitoring of response therapy needs to be more evaluated. and ( . %) were contributed by vd, rd and dd respectively. over the last / years, voluntary donations have shown a rising trend from . % to . %, where as rd ( . % to . %) and dd ( . % to . %) have shown a declining trend. the percentage of female donors was maximum in voluntary group as compared to rd and dd ( . % vs. . % vs. . %) respectively. the rates of all tti markers reactivity were significantly higher in rd as compared to others donors. the hbsag and anti hcv reactivity in vd and dd is comparable ( . % vs. . % and . % vs. . %). hiv antibodies was found more frequently in vd as compared to dd [ . % vs. . % (p < . )] whereas, vdrl reactivity was lower in formal as compared to latter [ . % vs. . % (p < . )]. conclusion: voluntary blood donation has shown a rising trend over a last few years, thus highlighting efficient donor motivational strategies. these strategies need to be strengthened to increase the female donor base. the safety of dd is equivalent to vd when the rates of tti are compared. thus, dd should be advised to donate blood regularly as voluntary blood donors. blood safety depends on a number of factors. the chain of safe blood starts with the donor. one of the procedures for obtaining safe blood for transfusion is the medical selection based on the completed questionnaire and the possibility of self-exclusion from the process of blood donation, the medical history of the potential donor and the medical examination. donor selection consists of two sets of information necessary for protection of the blood recipient as well as the donor himself. aim: to present the most frequent reasons for declining volunteer blood donors. material: the materials used for analysis were the questionnaires completed by all the potential blood donors at the transfusion department of the medical center in strumica as well as the record books of the blood donors which contain the results of the analysis we make for the potential donors. these donors donated blood in the period between and . results: during this period people volunteered to donate blood, out of which were allowed to donate blood, while were declined. out of the total number of blood donors were male and female donors. the reasons for declining potential donors were the following: . % had low levels of hb, . % were taking antibiotics, . % were ill, . % had low blood pressure, . % had high blood pressure, . % for other reasons. conclusion: donor selection and their care on one side and obtaining safe blood for transfusion on the other side entails obligatory organized medical control. the obligatory completion of questionnaires, the medical examination of the potential donor and their self-exclusion as a result of the feeling of personal responsibility as well as the obtained information are very important for the selection of quality blood donors and obtaining safe blood for transfusion. questionnaire on subjects-students, their knowledge and motivation on blood donation f vladareanu, a bugner and s sirian national institute of heamatology transf, bucharest, romania the research theme of this questionnaire is as follows: 'what is the level of knowledge and of motivation in the non-remunerated and voluntary blood donation at students?' we also tried to see the practical implications that this study will have and how it will influence the knowledge in this area. the purpose of this questionnaire was not dissimulated. the general theme of the knowledge and motivation on blood donation had been studied before through two big questionnaires applied in and , but the general population was their target. students had never been an investigated lot up to now. the hypothesis referring to this problem is as follows: students are not informed either on the act of donation, or on the crisis of blood. . the lack of information is a first cause of the indifference of the studied lot towards the idea of donation. . the lack of motivation of the studied lot is another cause. the questionnaire was applied on a lot of students from seven different cities: bucharest, iasi, constanta, cluj, sibiu, brasov, timisoara. the number of the questions was limited to , which we consider best for a questionnaire applied on the street or at college. as a conclusion, we can say that a passive-defensive attitude towards the blood donation was revealed after this questionnaire. not knowing the issue caused by their lack of information sometimes determines indifference at the statement of the subject. on a general dissolution environment of the responsibility of the youth, the donation problem is not in their aria of preoccupations, the general attitude being of non-involvement for the moment, at this idea which is not yet in every individual conscience and which is normally administrated at an institutional level. the donor data and the details of blood application of the north west transdanubian region of hungary k vÖrÖs*, c bercsÉnyi † , o petrÓ † , r jÁger † and e miskovits ‡ *hungarian national blood transfusion s., györ, † blood bank, tatabánya, ‡ headquarters hungarian n.b.s., budapest, hungary the ongoing fundamental reorganization of the blood service began on the . . in hungary. as the consequence of reorganization till . . , blood banks had been established instead of existing before, under direction of the hhnbts. the working profile of the regional blood centers and local blood banks will be changed step by step. virus screening, blood group serology and processing will be made in the regional centers. one of the regions is the 'north west transdanubian region' (nwtr, city györ as the center, with about inhabitants and hospital beds). local blood banks (tatabánya, sopron, and szombathely) are belonging to nwtr. the regional center and the local blood banks provide the labile blood products and high level clinical-transfusion service (cross-matching, antibody screening, outpatient immunhematology investigations, etc.) for the hospitals. annually donors donate blood in this region. this donation activity covers about the % of all inhabitants. the acceptance ratio of the donors is good ( - % of the donors were deferred). there are hospitals in our region. the regional demand on rbcc is - . u/year, on ffp is . - . u/year and on pc is - . u/year. the poster shows the donor data and the details of blood application of this region since . p- implementation of rbc collection using haemonetics mcs ® +: medical staff training, donor recruitment and acceptance g woimant, c fretz, d puydupin, e pÉlissier and jl beaumont efs ile de france, paris, france background: single donor rbc collection is an approved apheresis technique in france. aims: our goal was to evaluate the implementation of rbc collection in our center in terms of donor recruitment and acceptance, as well as medical staff training and adaptation. methods: donors were selected according to the french requirements for rbc collection (weight ≥ kg, height ≥ cm, hb ≥ . g/dl, ferritin ≥ ng/ml for repeat rbc donors). all personnel were trained on adequate communication with donors. eligible donors were contacted by mail, by phone or during pre-donation interview. among the recruited donors, all donors were male, % were regular whole blood donors, % were regular whole blood or apheresis donors and % were new donors. the medical staff was trained on rbc collection with the sdr protocol and disposable set ln pf on the mcs ® +. most of the medical staff was already used to autologous rbc donation with similar apheresis devices. blood samples were taken from donors pre-and post-donation, as well as to months later for those returning for a subsequent donation. donors were asked to fill out a post-donation survey for assessing donor comfort and information. results: donor profile and clinical follow-up are summarized in table . six percent of the donors had a ferritin level below ng/ml; these donors were regular whole blood donors. the collections were well tolerated and no changes in vital signs were noted. four reactions were reported: hematomas and citrate reactions. no reaction was observed post-donation and hemoglobin levels measured before next donation were back to normal. the technique was easily implemented by the medical staff and fitted well in the existing blood center processes. the medical staff as well as the donors found collection duration short (average of min). the results of the survey were very favorable as more than % of the donors considered their donation and the information they received as satisfying. most of them agreed to donate again and several actually donated twice during the evaluated period. conclusion: the implementation of rbc collection in our center, using haemonetics mcs ® +, was successful in terms of ease of use of the technique, as well as user and donor acceptance. we now plan to evaluate donor loyalty in the longer term. risk from first-time blood donors e zhiburt, s golosova and p reizman federal blood center, moscow, russian federation introduction: each third dose of whole blood in russia is donated by first-time blood donor. there are two reasons for attention to this kind of donors: ( ) possible risk of infectious disease in seronegative study; ( ) possible risk of donation for person with contraindication. aim of the study: we investigated role of regional deferred donors registry (rddr) in by first-time donor selection. methods: moscow rddr includes parts: hiv, viral hepatitis, syphilis, tuberculoses, malaria, drug users, psychiatry, days after blood donation. rddr was complete and our center began actively work with it since last year. each donor has to be registered in rddr and automatically checked for deferral reason. effectiveness of rddr was investigated. results: first-time donors donate less than % blood in our center. about a quarter of them are deferred before possible donation. part of donors deferred by rddr has been significantly increase in (c = . ; p < . ) at the expense of seropositive people. conclusion: rddr is effective for blood donor selection and decreases necessity in laboratory screening. first-time blood donors have to be examined before blood donation. if they have not contraindications, donation can be performed up to days before examination and screening. the double unite platelet production is important especially if the relatives of patient find the donors. we evaluated the effectiveness two apheresis machine for platelet collection. in our blood bank, one fenvall amicus and one cs + apparatus were used for platelet apheresis. apheresis were performed between / / and / / . including criteria of donors are that estimated process time is smaller than minute and estimated postapheresis platelet count is higher than ¥ /l. donors firstly was enrolled to amicus. if amicus was busy, then it was enrolled to cs. the properties of our donor populations were given in blood and plasma cell components are obtained either by traditional manual method from whole blood or by apheresis. modern medical treatment is based on transfusion of deficient components such as erythrocytes, leukocytes or plasma proteins. this involves new solutions to achieve higher yields and better quality of such components. the aim of our study was to estimate the efficacy of blood cell separator cobe trima in obtaining platelet concentrates (pcs) as compared to older-generation cobe spectra blood separator. apheresis procedures were performed on both these blood cell separators. the quality of platelet concentrates was tested during day storage period (see table below ). we have tested the effect of apheresis procedure on donors and estimated the operating comfort of both separators. the tolerance of both separators was satisfactory except for more frequent hypocalcemia when trima separator was used. most donors were more satisfied with trima procedure because of single venipuncture although it involved special donor selection (good vein access). in general we may say that trima is undoubtedly a more modern and more friendly separator. however, cobe spectra may continue to be used with success especially when a more versatile cell separator is necessary (leukocyte concentrates, peripheral blood stem cells or therapeutic apheresis). methods and results: tls ( procedures on patients) were used successfully in patients with acute or chronic leukemia with hyperleukocytosis (white cell count > ¥ e /l or blast count > ¥ e /l) when high cell count would promote leukostasis with vascular occlusion in the microcirculation. performed tl procedures were rapidly reduced both the white cell count and the whole blood viscosity. average fall in white cell count after treatment was . %. tp-treatments ( procedures on patients with symptomatic thrombocythemia and/or platelet count higher than ¥ e /l) were applied in order to prevent the development of 'thrombotic-hemorrhagic syndrome' . the tps performed resulted with rapid platelet counts reduction ( . % in average) and with clearly noted clinical improvements, subsequently. tes ( procedures on patients) were performed using manually technique in patients with 'cellular hyperviscosity syndrome' induced by high red blood cell count. it was shown that te procedures resulted to red blood cell number lowering and decreasing of blood hyperviscosity. average fall in hemoglobin and red blood cell concentrations after te treatments was from . % till . %. rbcx treatment ( procedures on five patients with malaria and two with severe aiha crysis) was performed on an urgent basis, particularly when clinical symptoms indicate life-threatening situations and resulted with rapid and significant reduction of concentration of unwanted pathogen affected rbcs and summary/conclusion: the effects of tcs depended on the nature and stage of the basic hds, of adequate selection of patients and of timely applied apheresis. rapid cytoreduction is obtained justly in patients with excessively high cell count, and this effect did not associated with bone marrow remission. thus, tc should be looked upon as adjunct to the standard treatment of different cithemias, but not as replacement therapy. the present study indicates that the best therapeutic effects were obtained by rbcx. were carried out with continuous flow blood cell separator cobe spectra and all patients underwent large volume leukapheresis (lvl). in all procedures, a blood warmer was connected to the return line and a continuous calcium infusion was administered preventively. six patients, who were under kg body weight, had the extracorporeal circuit primed with irradiated, filtered packed red cells diluted with % albumin solution. seven children had vital signs and ecg continuously monitored during the procedure. results: each patient underwent a median of collections (range - ). the inlet blood flow ranged between . and . ml/min (median . ml/min). the median blood volume processed was ml (range - ). leukapheresis lasted a median of min (range - ). the median total nucleated cell yield was . ¥ e /kg (range . - . ), mononuclear cell (mnc) yield was . ¥ e /kg (range . - . ) and cd + cell yield was . ¥ e /kg (range . - . ). the median of mnc collection efficiencies was . % (range . - . ). in ( . %) patients, in only one apheresis procedure more than ¥ e cd + cell/kg were collected. during ( . %) procedures patients had experienced apheresis-related side effects. the citrate-induced reactions were most commonly observed. the reactions were mild and cessation of collection was required only in one case, because of catheter related complication. mild sedation was required only in few very small children. post-donation platelet count was less than ¥ e /l in cases and these patients required platelet transfusion before subsequent procedure. our results show that lvl in pediatric patients is relatively safe procedure, well tolerated and with a very low risk of serious adverse events. close monitoring of blood counts, especially platelets, between pbsc collections is necessary. the cessation of procedure was required in only one case and no life threatening side effects occurred. neonatal alloimmune thrombocytopenia (natp) caused by fetomaternal mismatch for human platelet (plt) alloantigens (hpas) worsens approximately / pregnancies and can lead to a serious bleeding diathesis, intracranial hemorrhage (ich) and sometimes death of the fetus or newborns. we describe the successful management of a -year-old pregnant woman, alloimmunized to the hpa- a (p a , zwa) antigen, with a history of two previously children with severe thrombocytopenia and ich. the pregnant woman was at her terminal pregnancy and was suddenly admitted. to evaluate the risk of ich in the fetus, cordocente was performed to demonstrate fetal thrombocytopenia (plt . /mmc). to ensure a rapid provision of compatible negative-antigen platelets, we decide to collect platelets from the mother using apheresis. plateletapheresis was performed using com.tec separator, fresenius. blood processed was . ml in a short time procedure ( minutes). no significant adverse effects were observed in the mother and fetus, during and after the procedure. platelets collected ( . ¥ e ) were transferred to the preparation set and plasma was removed after centrifugation to resuspend the platelets in octaplas ab. then we separated the platelets into two units containing . ¥ e each. the day after the donation, the mother gave birth to a girl by caesarean section. after the transfusion, the plt account increased from . /mmc to . /mmc and after a week the child had plt . /mmc without hemorrhagic complication. according to the literature data and our observations of the patients, there are changes of the hemostasis system indexes in the most patients with the endogenous intoxication syndrome and immune disturbances. in the number of cases medicamentous therapy appears to be not enough to normalize the changes, but it is especially important for pregnant women and women in childbirth, because on the background of these disturbances different complications of pregnancy and postnatal period take place. the aim of our study was the substantiation of plasmapheresis using in complex therapy of purulent inflammatory complications in obstetrics and immunoincompatible pregnancy with hemostasiologic disturbances. patients with hemostasis system disturbances: one woman in childbirth with exacerbation of chronic pyelonephritis, who had in the first hours some signs of hypocoagulation on the background of permissible blood loss (prolonged coagulation time up to - minutes with episodes of its absence on the background of the normal indexes of general coagulogramm, quantity and function of thrombocytes and the dilute fibrin monomer complex level in times higher than the norm) and nine pregnant women with the perinatal losses in anamnesis severed by the pregnancy (threat of abortion, places of fetal egg detachment). these women were examined, the following was revealed: the high antibody titer to chorionic gonadotropin, parameters of partially activated thrombin time were higher than the norm ( - seconds), thrombin time ( - seconds), the dilute fibrin monomer complex ( - mg%), coagulation time ( - min). in all these cases the conservative methods of treatment (antibacterial, hemostatic, hormonal therapy) were effective for a short period of time and they didn't succeed to correct the given parameters of hemostasiogramm. the discrete centrifugation plasmapheresis was included in the complex of medical treatment. the woman in birth operations were done, in the programme of plasma replacement during the first two plasmapheresis procedures donor fresh-frozen plasma was included. six pregnant women on the given stage one course consisting of plasmapheresis procedures for plasma replacement with crystalloids was done, the volume of the removed plasma was - % of the circulating plasma volume. three pregnant women before delivery were required two courses of plasmapheresis more consisting of - procedures each. the system heparin was not used. in all patients already after the first procedure of plasmapheresis the normalization of hemostasis indexes was marked, that allowed to prolong pregnancy, to prevent the coagulopathy bleeding and the development of disseminated intravascular syndrome. four women are discharged from the hospital, the other patients are observed with progressive pregnancy. thus, the using of discrete centrifugation plasmapheresis is effective at the signs of hypocoagulation in patients with isoimmunisation with fetal antigens and infectious pathology, and is the reserve in prevention and treatment of obstetric complications. extracorporeal photochemotherapy: an alternative therapeutic approach to control graft versus host disease after allotransplant with reduced intensity conditioning regimen c del fante*, c perotti*, gl viarengo*, p bergamaschi*, p pedrazzoli † and l salvaneschi* *irccs policlinico s. matteo, pavia, † ospedale niguarda cà granda, milano, italy background: extracorporeal photochemotherapy (ecp) can be defined as an immunomodulatory therapy that demonstrated to be efficacious in treating patients affected with graft versus host disease (gvhd) after allotransplants for oncohematological diseases. reduced intensity conditioning regimen (ricr) for allotransplant is a relatively new practice in patients (pts) ineligible for a conventional myeloablative conditioning regimen. the use of immunosuppressive therapy (ist) to control gvhd is limited for the high risk of developing infections and disease relapse due to the strong reduction of graft versus tumor (gvt) effect. aims: to evaluate the effectiveness and safety of ecp in treating pts affected with gvhd post rcr and the possibility to taper, at the same time, the ist. methods: pts ( females, male), median age . years ( - ), affected with agvhd grade ii ( ) and extensive cgvhd ( ) gtx with median total granulocyte doses of ( - ) ¥ per gtx corresponding to . ¥ granulocytes/kg in children and . ¥ granulocytes/kg in adults. the wbc counts increased from baseline values of . ( - . ¥ ) g/l for both pediatric and adult patients to peak values of . ( . - . ) ¥ g/l (children) and . ( . - . ) ¥ g/l (adults) at one hour after gtx and to . ( . - . ) ¥ g/l (children) and . ( . - . ) ¥ g/l (adults) at hours after gtx. in out of patients ( %), the crp levels significantly declined ( ( - )%; p£ . ) during the granulocyte transfusion period; in almost all cases ( / ; %) after the initial or nd transfusion. thirty-eight patients ( %) were alive at day + after termination of neutropenia and gtx. patients without crp response to gtx ( / , %) and patients with severe viral infections / ( %) were not among the day + survivors. background: in recent years, the use of platelet concentrates obtained from single donors by automated apheresis has grown steadily. plateletpheresis donation is considered to be a safe procedure with modern instruments. so far, no studies have identified donor or procedure specific factors that may be associated with serious adverse events. aim: to evaluate the incidence of adverse events during plateletpheresis procedure, over a five-year period in our hospital. materials and methods: eight hundred single-needle plateletpheresis collections were performed by using two automated intermittent-flow cell separators: of them with mcs p and with mcsplus (haemonetics), according to automatic standard protocols a p and ldplp, respectively (with the collection of an additional plasma unit). acd-a was used as the anticoagulant in all apheresis procedures (acd-a: blood ratio was : ). most of the donors ( % men and % women) were patient´s relatives. half-hour before the initiation of the procedure, mg of calcium ( tablet cal-c-vita) were administered to each donor. the mean platelet yield was . e /unit. the overall rate of the donor related adverse events was . %. feeling faint was the most frequent event, which was occurred in . % of donations. hypotension and citrate related rates were . % and . %, respectively. all citrate related symptoms were only transient perioral paresthesias, which were relieved by slowing the i.v. rate, without additional administration of oral calcium. donor unconsciousness was the only observed severe event, the rate of which was . %. other adverse events were venipuncture related ( . %), machine related ( . %) and miscellaneous complications ( . %). ( ) plateletpheresis using the mcs p and the mcsplus automated cell separators is a safe procedure, with a low risk of serious adverse effects. ( ) with the used acd-a-to-blood ratio ( : ) satisfactory platelet concentrates were obtained with very low incidence of citrate-related events. ( ) the peros administration of calcium before the initiation of the procedure, probably lowers the rate and the severity of hypocalcemia symptoms. quality assessment of ffp collected as a byproduct of plateletpheresis . from the donors immediately with the initiation of the procedure (citrated whole blood) and . from the final platelet concentrates after one hour rest at room temperature without agitation. in vitro platelet response to the aggregation-inducing agonists adp, collagen, ristocetin and arachidonic acid was investigated by means of an aggregometer (pap- c, bio/data). results: there were no significant differences between the groups of donors with respect to age, sex, smoking habits, preapheresis wbc and plt counts and hemoglobin concentration, as well as in the harvesting time between the two cell separators. our findings are shown in the following table. mildly decreased response to all agonists was observed (mainly to adp and arachidonic acid) in the samples taken right after the initiation of the procedure, in both groups. platelets from the final component showed a further slight decrease in response to adp, which was more prominent in the mcs p device (p = . ). on the contrary, an increase in platelet response to the other three agonists was observed in both devices, which, however, was statistically significant upon collagen and ristocetin stimulation. conclusions: reduced response to aggregation stimuli is possibly caused immediately with the initiation of the apheresis process. literature reports regarding further platelet traumatisation due to the procedure, are rather conflicting. in our study, such traumatisation was observed only in the case of adp in the mcs p obtained collections and this could be correlated with the technological differences between the two devices. recovery of platelet aggregability, as it was expressed by the upregulation in platelet response in the other stimuli, could be attributed to the resting period and seems not to be affected by the timing of the leucodepletion procedure. background: lupus erythematosus often is accomplished with severe symptoms, such as polyarthritis, nephritis, pericarditis or dermal alterations. in pregnancy cytostatic therapy affects gestation. on the other hand the course of disease can be refractory to corticosteroid therapy. elimination of autoantibody and immuncomplexes by plasmapheresis could be an efficient way to amend the severity of symptoms. a year old pregnant woman in the th gestation week with systemic lupus erythematosus showed severe symptoms like polyarthritis, nephritis and pericarditis. treatment was initially mg/kg bw prednisolone for weeks and subsequently mg/kg bw for weeks. plasmapheresis was applied daily in the beginning and continued depending on the condition of the patient ( table ) . the eliminated plasma was substituted by fresh frozen plasma. the medium volume was . ml per apheresis. after day plasmapheresis treatment was suspended to avoid problems with coagulation and was followed by a cycle of immunoabsorptions to eliminate circulating immuncomplexes. results: prednisolone therapy alone brought no effect even after changing to high-dose treatment. a significant amelioration of all symptoms could be observed after the first plasmapheresis. good condition of the patient remained stable over the period of daily plasmapheresis for days. intermitting apheresis treatment for one day lead to a significant aggravation of symptoms. apheresis no. again lead to a recovery of the patient which held on until day . conclusions: treatment of systemic lupus erythematosus in pregnancy especially in combination with resistance to corticosteroid therapy, is an effective therapy to ease severe symptoms such as polyarthritis, pericarditis and nephritis. exposure to cytostatic drugs can be avoided and therefore the impairment of the fetus can be reduced. background: the collection of mnc represents the first step of photopheresis procedures and could be of critical importance in achieving a therapeutic goal. in this work we compare the cell yield of two collection programs on cobe spectra device: the mnc versus the autopbsc program using the ecp procedure modified by andreu. methods: procedures were carried out with mnc program and procedures with autopbsc on patients with cgvhd. both hemoglobin increased from . ± . to ± mg/tu, k+ from . ± . to . ± . mmol/l, level of glucose decreased from . ± . to . ± . to . ± . mmol/l, ldh from . ± . to . ± . ukat/, lactate from . ± . to . ± . mmol/l, ph from . ± . to . . . the volume of apheresis units was lower than wb-rbc, the leucocyte count was normal in all units. the rbc loss by filtration was . ± . ml/tu and was lower than at wb-rbc. in apheresis rbc there were the differences in hb and ht value between the day of storage and , in wb-rbc there were no differences. during the storage period we found no differences in k+ increasing value and no change in ph value between apheresis rbc and wb-rbc, the increasing of lactate was higher in wb -rbc, increasing of ldh correlated to hemolysis. the plasma hb value increase was higher at apheresis rbc in contradistinction to literature. hb and ht correlation in apheresis units according to predonate value in donors was lower than at wb -rbc. the method is a useful alternative to conventional whole blood donation, we get rbc units with high standard of quality and low correlation according to predonate hb and ht value in donors. acknowledgement: the study is supported by grant iga ministry of healthy cr n. nr/ - . background: in life-threatening exacerbations of sle a satisfying efficient therapy is lacking. despite intensive immunosuppressive therapy some patients are resistant or contraindicated to conventional treatment. in particular circulating antibodies and immune complexes play an important role in the pathogenesis of sle and mctd. an extracorporeal removal of these pathological substances may be effective in the treatment of active disease. methods: five patients with severe therapy-resistant sle/mctd underwent immunoadsorption onto protein a. blood was drawn from patients by using a jugular catheter or a peripheral intravenous catheter. anticoagulation was performed with acd-a and heparine or acd-a and r-hirudine. plasma was separated by centrifugation. the . to -fold total plasma volume was treated in every immunoadsorption. the columns were floated with a maximal plasma flow of ml/min. the procedure was carried out every second day. additionally supplementary intravenous immunglobulin therapy was given only once. results: remission of the disease was achieved in four patients. see table below . conclusion: pa-ia is highly effective regarding the elimination of autoantibodies and circulating immune complexes, might induce a remission in patients with sle/mctd. it is an acceptable alternative treatment option in patients when other therapies are ineffective or contraindicated. background: purification of bone marrow from erythrocytes is used to prevent early hemolysis in major abo incompatible allogeneic hemopoietic cell transplantations. erythrocyte depletion is strongly recommended to reduce product volume and stem cell purification before storing autologous and even allogeneic bone marrow in order to prevent early hemolysis and dmso toxicity that might develop after thawing. centrifugation, sedimentation with hes, and cell separating devices are methods for erythrocytes depletion. aim: in our center, we prefer to use cell separation device, since it is a reliable method and has a high-yield and risk of contamination with erythrocytes is low. success of the process is retrospectively analyzed for high and low volumes. method: erythrocytes depletion of bone marrow harvest was done in hemapharesis unit with cobe spectra device in the last five years in cases with bone marrow volume over ml, and cases with bone marrow volume under ml. fifteen of these cases were allogeneic, and were autologous procedures; a software uploaded with cobe pbsc coll vers . and (catalog no: - - ) set was used in the procedure, and at the same time, double bag system with intermediate connectors were used to prevent re-circulation (catalog no: - - ). results: the mean volume reduction was . % ( . - . ) for volumes over ml, and . % ( . - . ) for volumes less than ml. regarding the success of the procedure no statistically significant difference was found between procedures with high and low volumes. no complication developed related to the device or product, and waste bag never had to be re-used. in none of the patients early massive intravascular hemolysis was observed. conclusion: erythrocyte depletion and volume reducing with cell separation device is a reliable method. this process is successfully applied with high volumes (over ml); and in low volumes as well for reducing erythrocytes, and gain of mononuclear cells and cd + cells. platelet concentrates obtained by apheresis procedure-correlation between the initial count and the final concentration v srejic*, g bogdanovic*, z garic*, n vavic* and b balint † *national blood transfusion institute, † military medical academy, belgrade, serbia apheresis team of the national blood transfusion institute processed and classified data of donors who donated platelets by apheresis procedure from january till april . procedures were performed in accordance with the ldplp protocol, using haemonetics mcs+. initial donors' platelet count and the absolute platelet concentration in the final preparation were followed, as well as red blood cell and leukocyte contamination and the volume of the processed blood. donors' initial platelet count was not less than ¥ /l and the volume of the processed blood was not less than ml. according to histogram, the most frequent donors' initial platelet value ranged from ¥ /l to ¥ /l ( %). final concentration of the samples of tested donors ranged from . ¥ to . ¥ in the average volume of ml. regression analysis demonstrated that there was a correlation between the initial donors' platelet count and the obtained final concentrate. student's t test showed p < . . leukocyte contamination of the final concentrate prepared without the filter ranged from . ¥ /l to . ¥ /l. presence of red blood cells in the final concentrate ranged from . ¥ /l to . ¥ /l. p- therapeutic apheresis (ta) in croatian hospitalsadherence to respectable guidelines z zivkovic*, b jeren strujic*, s boras † , i bojanic † , b golubic cepulic † and z ivankovic † *clinical hospital dubrava, † clinical hospital center zagreb, zagreb, croatia introduction: besides considerable resources, ta requires high costs and risk for patients. therefore, indication for ta often considers interests of patient, hospital and requesting physician. the most respectable guidelines for the implementation of ta were defined by aabb and asfa, classifying total of diseases into categories (ctg), ranging from 'standard therapy' to 'lack of efficacy' . the objective of this study was to determine indications for ta performed in croatian hospitals in the period - , respecting aabb/asfa guidelines. results: during the observed period in croatia, ta was performed in patients suffering from various diseases. in ( %) patients ta was performed by membrane filtration, while in ( %) separation by centrifugation was used (table ) . according to the ctg, s of the aabb/asfa guidelines, ta was performed in ( %) diseases from ctg i, ( %) ctg ii, ( %) ctg iii, and ( %) ctg iv of patients. the most frequent indications included in ctg i were: myasthenia gravis ( %), collection of pbpcs ( %), sy. guillain-barré ( %), and plasmacytoma ( %). in ctg ii frequent indications were: poisonings ( %), systemic lupus erythematodes ( %), and rapidly progressing glomerulonephritis ( %), and in ctgs iii and iv: cytoreduction-polycythaemia ( %), thyroid storm ( %), gvhd ( %), and reumatoid arthritis ( %). ( ) the time spent for resolving h / , ( ) mtp / , ( ) discarded blood units / . iii group: wrong data input / , donor replacement / , marking errors / , error in determining blood group at the first blood taking / , errors in input medical consulting / and disregard of prohibitions / . the consequences are: ( ) the time spent for resolving h / , ( ) mtp . / . , ( ) discarded blood units / . conclusion: the analysis of errors has showed that the number of errors can be decreased by implementation of corrective/preventative action based on continual education of the staff, appropriate sop, effective organization, qmp for equipment. the conclusion of our study is that reducing the rate of work errors will decrease the waste of material and time, also that will decrease the number of discarded blood units. an iso standard for blood transfusion? background: in our search for an independent, objective assessment at western province blood transfusion service, we were unable to find one single model that met the specific requirements of blood transfusion. we therefore resorted to developing our own model but ask the question: why not have one international standard for blood transfusion? aims: our aim was to have a standardised system for the independent, objective assessment of our blood transfusion service with audits carried out by an internationally recognised body. we wanted a formalised, professional system of accreditation with inspection checklists, reports, certificates etc. methods: having moved away from accreditation by the american association of blood banks in mid 's, we evaluated various other options such as inspection by our government department of health or the world health organisation but neither organisation had trained inspectors or systems in place. we also investigated iso certification but, although this was acceptable on the quality management side, it did not cover the technical parameters relating to blood transfusion. results: we therefore developed our own model for accreditation that consists of three parts: • a quality management section incorporating iso principles; • a technical section incorporating specifications from the south african standards of practice (we also consulted the european, american, canadian and australian guides); • a laboratory section incorporating iso parameters (soon to be updated with iso ). we then chose to be accredited by the south african national accreditation system, sanas, an internationally recognised institution. once we had written a national accreditation checklist, sanas submitted this to two international accreditation bodies (iaf and ilac) for approval. the system has been in place for three years now during which time we have had four successful assessments. summary/conclusions: in developing our system, we reviewed what was being done elsewhere in the world and it became evident that, although there are great similarities between countries, there p- software for the management of the scansystem bacterial detection method the scansystem tm was developed for bacterial detection in blood products. to be implemented in blood banks, a specific software is now available in compliance with blood bank regulation in order to manage sample traceability and data file transfer. the software is divided in main levels: an administrator level to create an application configuration in compliance with customer needs (product bar code characteristics, frequency of the positive controls, manual or automatic data file transfer . . .), a technical level to manage the operators (password, id) and to validate some specific results, an operator level for routine testing. the software assess sample traceability when testing pools of samples from to more than . indeed, bacterial detection is performed for pools of to platelet samples and to red cell samples. each sample in the pool is traced through its barcode until the final result. the system is compatible with most of the barcode standard including isbt . in addition, the system checks each barcode protecting the sample against duplicate testing. the software assists and monitors the bacterial detection process from the sampling to the end of the test (final result), each step of the procedure is identified through its barcode and at each time, it is possible to know the test status for each sample. for a pool of samples, results can be obtained: 'negative' or 'on hold' for a positive result. for a 'negative' pool, each sample constituting the pool are determined as 'negative' . for an 'on hold' pool each sample constituting the pool must be tested as a single sample and the final result is 'negative' or 'positive' . data transfer may be manual or automatic. a final technical validation is necessary before the transfer through an active selection of results to download. final results are provided in a compliant format for an easy import into the blood bank database. all necessary information are displayed: 'machine id' 'product/sample barcode id' 'date' 'time of transfer' 'operator id' 'result' ('negative' or 'positive'). the main advantage of this software is a continuous check of each step reducing the risk of error in testing. it makes the scansystem tm test compatible with a routine use in blood banks according to the current regulations and quality assurance programs. is no overall consistency. we feel it would be of benefit to establish an international working group to investigate the feasibility of writing an iso standard for blood transfusion. the standard would harmonise quality management parameters based on iso principles and technical/laboratory parameters specific to blood transfusion. minimum technical specifications would need to be agreed upon based on the various standards and guidelines available around the world. this iso standard could then be used for the purposes of certification/accreditation or government inspections. this would ensure global standardisation of world-class best practices. first world countries would be able to achieve compliance and a subsequent step could be the establishment of an international forum to assist developing countries to work towards compliance in the longer term. residual leukocytes in leukoreduced cellular blood products -evaluation by flow cytometry web-based outcome review: do you know how productive your trima® can be? background: web-based outcome review is a new software tool developed by gambro bct for the management and the interpretation of data from the trima and trima accel tm automated blood collection systems. aim: does the interpretation of reports obtained through outcome review lead to an increase in the number of products per run and the overall productivity of the apheresis center? method: run data files (rdf) from trimaᮀ were collected and transferred onto the outcome review server. these rdf do not contain any donor related data that can lead to possible donor identification. the reports were generated on the outcome review website (gambro bct intranet), interpreted by a gambro bct employee and presented and discussed with the management of blood centers. results: a total of different reports can be generated on the website as a pdf file. for this study, reports were investigated. they are: doses per collection, doses per collection trend, platelet collection trend, platelet procedure performance, platelet procedure performance trend, product distribution, average procedure time, procedure time, machine productivity trend. the results obtained for a center can be compared to word-wide, national, regional or to other individual trima devices in the centre (benchmarks). this benchmarking allows the management of an apheresis center to compare the results, to draw the right conclusions and to develop and implement corrective actions. implementing successfully these corrective action plans will lead over time to productivity results that are more in line with the figures that are generally accepted to be the optimal production capabilities of trima. the reports also help to monitor the effects of the corrective action plan over time and to adjust this plan if the results are not in line with the expectations. reaching and maintaining the optimal production capabilities of trima will also increase the net revenue by procedure or decrease the cost by procedure for the blood centre. conclusion: web-based outcome review allows getting more products from the existing donor base by interpretation of the multiple reports and implementing the required corrective actions until optimal production capabilities of trima are reached and maintained. introduction: to examine the cell vitality of packed rbc's during storage several parameters like atp, free hb or , -dpg are used. less kits for the determination of atp are available and they need either a large sample volume and/or are time consuming. here we present the modification of a commercial testkit for a time-and cost saving detection of atp. methods: samples were analysed with (a) -phosphoglyceratekinase reaction according to bergmeyer, h. methods of enymatic analysis nd. edition. academic press, new york ; (b) detection via hplc and c) using a commercial testkit (r. greiner bio-chemica, germany). the atp-kit were minimized from ml to a total volume of ml and tests were performed in microtiterplates. results: samples were analysed in hplc and modificated commercial testkits, another samples have been examined in all tests. comparison of the results showed no discrepancies in the above mentioned methods. standard curves have been performed (range - mm atp) and statistical analysis demonstrated a given linearity (r = . ). variability has been calculated as . % (intraassay; n = ) and . % (inter-assay; n = ). the hand-on-time calculated for samples has been decreased from . hours to minutes. at least the costs of atp-determination have been reduced from € . to € . per sample. conclusion: performance of test kits in microtiter format is a fast and rapid method, reliable for high-throughput determination of atp in packed rbc's. background: in order to preserve both blood safety and availability it is mandatory that a minimal amount of blood units would be discarded due to defects in the materials and supplies used for blood collection, or to deviations in blood processing or storage. aims: ( ) to monitor the derangements of different materials and disposables used during blood collection and processing, and to study the suppliers' responses and corrective actions taken. ( ) to asses the relative contribution of different defective materials (dm) to the need to discard valuable blood components. materials and methods: about whole blood units were collected and processed by mda national blood services in [ ] [ ] [ ] . as part of the routine quality control activities, derangements of the dm used were recorded and analyzed. some different types of dm were defined. out of reports sent to the corresponding manufacturers for investigation, responses ( %) were received and analyzed. about % of dm were detected during blood collection. manufacturer defects of different materials were the reason for components discard in nearly % of cases. conclusion: defective materials are one of the major causes of the infringements of blood collection and blood component preparation processes. analysis and monitoring of the different defects and of the suppliers' responses and corrective actions are essential to improve products' safety and availability. establishment of a network for the exchange of information among international blood centers would enable the blood banking community to compare between different suppliers and to use the documented cases for training of personnel of both the blood services and the manufacturers. such a system may contribute to the improvement in quality of materials used and might lower the discard rate of valuable blood units. results: table analysis and characteristics of t ( ) comprehension of the blood bank's processes and the interaction between them and between the processes of the whole hospital. ( ) monitor, measure and analyze these processes, in order to improve their effectiveness continuously. ( ) implementation of internal and external quality controls for blood and blood products and implementation of appropriate statistical techniques for monitoring their results. ( ) identification of interested parties (doctors, donors, patients) satisfaction and taking up the necessary preventive or corrective actions to improve their satisfaction. the qms of our blood bank was certified by tuv rheinland in / / and the scope of the certification is: 'blood collection, testing of infections markers, production of blood components, compatibility screening for blood transfusion and other immunological tests and implementation of therapeutic schemes in thalassaemia patients' . the implementation of the qms based on iso : standards ensures the improvement of services provided by the blood bank and the increase in customer satisfaction, whether donors or patients are concerned. the former enjoy the respect and recognition of their social contribution, while the latter are assured of very high levels of service and health protection. finally, we shall not underestimate the positive impact of qms in the motivation of blood bank personnel. quality becomes integrated both in their professional and personal attitude and allows for achieving increased satisfaction from their work. equipment management in the national blood transfusion service in serbia introduction: new equipment was urgently needed in three blood transfusion establishments (bte) in serbia. equipment was mostly inadequate for core blood transfusion activities, placed in inappropriate facilities, very old without routine maintenance or calibration. also, technical documentation for most of the equipment did not exist, and procedures for equipment management and responsibilities were not defined. further more, coordination on equipment issues with the qa department was not recognized. service funded by the european agency for reconstruction, provided various equipment for the three blood transfusion establishments. the new equipment includes blood collection equipment, centrifuges, refrigerators, incubators, automated testing equipment, genetic analyzer and it equipment of . million euros value. before the new equipment is installed the bte's agreed to have the national procedures on installation, validation, calibration and preventative maintenance in place. this will ensure that the equipment can be properly installed and validated before use. the project has provided training on validation to the working group (wg) on quality. the wg has created national procedures related to the equipment, including quite new term validation. the same problems in implementation of procedures were present in all three bte's. significant efforts are made to explain to the staff how the equipment has an impact on quality, how to ensure that the equipment does what it is supposed to do, how to be confident that the results obtained are accurate and how important it is to generate records. qa managers played an important role in the preparation of facilities for equipment installation, making plans for equipment layouts, creating documents (master cards, instruction for use) and designing the validation protocols. the same procedures and records enable an exchange of results, comparability, sharing information on what works and what does not work between bte's. the qa managers also prepared an introduction of equipment requirements to the heads of departments, with special attention to the validation process so that they are able to fully understand what is required and why to validate their equipment. results: national standards in equipment management in serbia are set and are being implemented. qa managers carefully managed that the new, numerous equipment, delivered in the short period of months was correctly installed, validated, obtained with necessary documentation, followed by previously trained staff, so that equipment can be considered as controlled. the additional, positive effect is that validation is performed in one establishment for all bte in the country, allowing a more prompt response to problems and presenting of joint request to suppliers, as well as an easier way of monitoring equipment performance of the three bte's. organized equipment management has affect on every aspect of blood activities and finally to the quality of blood and blood components. background: the vista information system (vista tm ) is used in centers in europe as an apheresis management system. with vista tm it is possible to increase productivity, donor comfort and loyalty and therefore simultaneously improving the overall process in the center. aim: a calculation tool (microsoft excel) was developed to evaluate the added value of vista tm . three blood centers in different european countries completed a questionnaire using their local data. summarizing these figures gives us an idea about the impact of vista tm on the daily work and budget of a blood centre. method: the excel calculation tool that was used investigated major areas where vista tm could show added value: improvement of regulatory compliance, increase the efficiency in operations and improve productivity. results: regulatory compliance: the number of infringements decreased, causing a considerable direct financial gain because these events are very expensive to deal with. the time spent on regulatory reviews decreased with a mean value of %. operational efficiency: the number of reports is very site dependent: sometimes a report is made for every procedure together with the printout of a blood loss history form. because vista tm tracks all procedure related data, some sites decided to stop printing these types of reports and to go completely paperless. the percent time reduction in reporting is therefore very variable. however the % of errors related to these reports decreased considerably with a mean value of %. efficiency in operations was also obtained because of the number of reports that are available in vista tm . productivity, management and process reports allow verifying and correcting the daily operations of the blood center. increased productivity: depending on the center, also an increase in the number of platelet and plasma products collected was detected. the number of product discards caused by infiltration reduced with a mean value of %, mainly due to the possibility to have customized and more donor adapted trima settings. the percentage of whole blood donors targeted for conversion was very site dependent (min . %-max %). but because with vista any procedure brings between . and . products in general, the financial gain was considerable when donors could be converted from whole blood to apheresis. the use of vista allows the apheresis center to work with a reduced error rate and to increase the operational efficiency and the productivity. the financial impact of this has been estimated by the centers between € and € (mean value €) per procedure. establishment of national quality system in blood transfusion service in serbia introduction: the production of blood products is a semiautomated process in which the manual steps may be difficult to control and standardize. aim of the study: we introduced a specialised team for the blood production to test if this improved the control of the quality of the blood products. methods: the blood products tested for statistical process control were red cells in additive solution, buffy coat removed, and leukodepleted (ld) platelet pools prepared from buffy coats. the products were collected in t&b triple opti-pac from baxter and the platelet pools were ld using plx- filters from asahi and stored in platelet bags from baxter. using control charts, namely x-mrchart, exponentially weighted moving average ewma chart and for autocorrelated stationary data the ewmast chart, we examined if time series of quality control values were in statistical control. if not we examined if autocorrelation and/or differences between the technologists producing the blood products could explain the lack of control. data included approximately biweekly measurements of volume, haemoglobin (hb) concentration, hb/unit, haematocrit and log leukocyte count (wbc)/unit of units of red cells, measurements of volume, platelet concentration and platelet count/pool of ld platelet pools produced by a team of technologists and of ld platelet pools produced by a specially trained team of four technologists. results: log wbc/unit was out of statistical control due to systematic differences between technologists. apparent lack of control of volume, hb-concentration, hb/unit caused by autocorrelation disappeared when the ewmast chart was used. platelet concentration and volume of the platelet pools produced by the technologists were out of control. in that some technologists systematically produced low values. this could be explained by inappropriate handling of the platelet product between centrifugation and separation. systematic differences between the four specially trained technologists could not be demonstrated and they produced platelet pools with a significantly higher platelet count/pool. however, standard deviations of the four technologists differed significantly causing occasional outlying values. conclusion: training and routine in blood production or process automation, and also importantly, feed back to the technologists based on control chart quality control data, is recommended. background: one important principle of the use of blood and blood products is the ability to trace the units from donor to the recipient. this study set out to establish whether or not there was sufficient reporting on transfusions from the hospitals supplied by fort portal regional blood bank in western uganda as a means of establishing sound haemovigilance and look back systems. were reported with no unit number and could not be traced to the patients. there was sufficient reporting on the data requested by the blood bank. these results suggest that it is possible to establish effective 'look back' and haemovigilance systems. capture of data on outcomes and adverse effects will be necessary to fully establish the system. further efforts are required to educate those involved in transfusing blood about the need for adequate and accurate documentation. external quality assessment of blood grouping were misinterpreted as rhd-positive samples without the use of control reagent. rbc phenotyping was made correctly by . % of participants. the remaining . % of participants carried out the phenotyping incorrectly, while false-positive and false-negative results were derived in . % and . % of cases correspondingly. polyspecific human sera and monoclonal antibodies were used for abo, rh and antigens typing. the reason of errors in antigen detection was low quality of reagents. antibodies identification was carried out in six distributed exercises. % of participants detected anti-d-k-c alloantibody correctly. the rest of participants did not found alloantibodies or detected their specificity incorrectly. results of testing depended on quality of screening cells. thus, the participants using homemade pooled screening cells had a significant lower detection rate of antibodies comparing with those using diamed ag cell panel. consequently, the results of the first federal external quality assessment scheme show the necessity of improving the quality of red cell reagents produced in russia. in addition, the more appropriate training of staff is required. the importance of iso -quality system in increasing safety of blood transfusion introduction: hadassah hospital transfusion medicine department received on / iso -quality system accreditation. an essential element of this standard is the development of a reliable system to identify, document, analyze and correct actual and near miss events and assess the effectiveness of corrective and preventive actions. aim of the study: assessment of events and corrective actions following implementation of iso quality system. methods: events in the blood bank were identified by the staff, by internal or external audits and by complaints from the wards. all events were recorded and classified into two categories; quality system and technical. the latter were further classified into preanalytical (sample receipt), analytical (abo rh typing, antibody screen and identification, cross matching and phenotyping) and post-analytical (issue of components to wards). all events were graded into levels; -most severe, potentially harmful to patient. -severe, damage to process and result. -moderatly severe, damage to process only. -benign, no harm. events were corrected and effectiveness of corrective actions was assessed by monitoring recurrence of the event. results: during the years - , events were detected and recorded in the blood bank, they comprised . % of all tests performed ( ). most of the events were technical. all events were detected before causing harm to the patients. results are summarized in the table. *the percent analytical value is a summary of rates of events per test types included in this category. events detected in the quality system were mainly of severity level & , whereas technical events were mainly of severity levels & . analysis of event recurrence in the quality system revealed that % of events were resolved, whereas only %- % of technical problems were completely solved. the main source of event identification and documentation, in the quality system were audits whereas in the technical system, staff members revealed most events. the implementation of iso quality system provided a powerful means for recognition, analysis and study of patterns of near misses and actual events. understanding the root causes of events enables to choose the most effective corrective and preventive action to control event recurrence. evaluation of the frequency of events confined to the blood bank revealed a very low rate of . %. these results are in agreement with data in the literature. creating a non-punitive, non-stressing open environment, motivates personnel to identify and document events, which are regarded as opportunities for improvement and serve as important tools for upgrading transfusion safety. the explosive use of information technology and the speed with which it has spread into all life activities has created vulnerabilities for all organizations. those vulnerabilities are compounded by the complexity of information technology, limited time to market, development constraints, and constantly changing relationships between organizations and suppliers. growth in the sophistication of security threats makes it imperative that organizations remain equally competent in identifying vulnerabilities and mitigating security risks. aim: the goal of this document is to explain how isbt intends to provide guidance to the blood banking community on implementation of effective information security policy. when using information for critical activities, blood banks should consider information security as an important aspect of their management policies. evaluation of existing standards, such as iso and hipaa, allows us to establish a framework for information security without regard to the type of organization. it remains very difficult however, due to the complexities involved, to establish an information security policy without guidance. method: the isbt information task force was created to provide guidelines on information security for blood banking organizations of all sizes. the intent is to help them understand existing standards as well as provide tools for implementing information security policy. these guidelines are based on existing standards that are followed by most worldwide countries: iso and hipaa. results: information security can be defined as the 'protection of systems, information and services from accidental and deliberate threats to confidentiality, integrity and availability' . understanding existing information security standards was the first step for establishing a structure for the guidelines. the core is organized within an implementation framework and presented under the three following layers: . administrative for defining the it security organization, the information security policy, and information security awareness and training. . physical for providing solutions that relate to physical environment protection and access, equipment and it infrastructure security, and control for accessing computerized equipment. . technical for maintaining confidentiality of electronic information and ensuring that authorized access to information systems is maintained (technology relating to identification and authentication, logical access, operating system, network management, application access, etc.). strategy guidance is also included for senior managers in charge of establishing organization policy, including responsibilities and methods to successfully implement policy. further, the task force is addressing both risk analysis and management including identification of potential dangers to information systems (threat-source) and existing controls (risk description), as well as a plan to address identified vulnerabilities and mitigation of specific risks. conclusions: information security standards are prerequisite to understanding the issues involved when considering information vulnerability. international guidelines for information security, specifically directed to the blood banking community, are equally necessary if we are to identify, plan for, and mitigate risks associated with vulnerabilities to critical blood banking information. the isbt task force is committed to providing such guidelines. introduction: the important part of quality planning and quality assurance within production of blood components is measurement system analysis (msa). measurement system analysis was performed on microscopic counting of blood cells in our study. aim of the study: aim of this study is determination if microscopy counting of residual elements in whole blood plasma is suitable for quality control of blood components. methods: we practiced measurement system analysis in counting of residual elements (leukocytes and erythrocytes) in whole blood plasma. the counting performed two lab technicians in ten samples of plasma from whole blood. leukocytes and erythrocytes were measured in naggeotte counting chamber. we used the method of mean and range for the determination of reproducibility and repeatability (r&r) and analysis of variance for complex measurement system analysis. regulation diagrams were applied for the graphic statement. we determined the value of repeatability, reproducibility, coefficient r&r, variability among samples of plasma and total variability of measurement system. the important conclusion was to determinate if the microscopic counting of samples of blood components is sufficient with regard to quality parameters specified in guide to the preparation of blood components (erythrocytes: < . ¥ /l, leukocytes: < . ¥ /l). our results show that microscopy counting of residual elements in whole blood plasma is suitable for quality control of blood components. aim of the study: to provide transfusion services with a tool for proper qms implementation, an international collaborative study on qms applications, employing the 'process approach', has been undertaken by a group of transfusion services of varying sizes and structures with experience of qms, in collaboration with a university institute offering a master in qms implementation in health services, and an expert from a quality association. the 'process approach' serves as a tool to manage transfusion activities as a system based upon a network of processes and their interactions. guide-lines have been produced based upon this principle and will be published (volume and cd-rom) and distributed at no cost to all transfusion services of nations participating in the study. the main contents of the guide-lines' chapters are: through definition/analysis of single processes and the correlation network amongst these, the 'process approach' methodology renders the transfusion centre's functioning units completely interdependent, eliminates process interface barriers, provides personnel with a unified focus on the main transfusion objectives, and lays the basis for improvement of transfusion service quality, organization and performance through efficient control of processes' interactions. the blood screening system automated high-throughput nat system for simultaneous screening of hcv, hbv and hiv nucleic acids: full process surveillance e pfeifer*, b alessandri † , hr bachmann † , t barker † , y ohhashi*, c parkhouse*, j pinsl-ober ‡ , p wenzig ‡ and g ziegler ‡ *roche molecular systems, inc., pleasanton, usa, † roche instrument center ag, rotkreuz, switzerland, ‡ roche diagnostics gmbh, penzberg, germany introduction: the blood screening system combines on one deck both automation of dna/rna extraction from blood/plasma samples and multiplex pcr amplification and detection of nucleic acid targets. the system is designed for high-throughput single unit testing and pooled specimen processing. a data management system supervises and controls the complete process from initial sample pipetting through to result compilation and reporting. the objective of this project was to present the system assay and device built-in quality control measures that guarantee process safety and reliability. the study shows how internal control, external batch controls, pipetting sensors, validation & maintenance procedures, and a controlled development & manufacturing process yield an optimal test method and system stability. method: failure modes and effects criticality analysis (fmeca) was used to evaluate a mathematically derived safety metric for optimizing risk reduction. this method makes use of a system risk objective-function (srof), which provides a multivariate description of sample processing, amplification and detection steps. the method for analyzing system behaviour first employs product classification into risk domains, followed by ranking of process steps that are determined to be linked to known system hazards. this provides objective means for directing system design leading to risk minimization. the srof responses associated with redundant liquid sensing channels were shown to substantially reduce risk during sample or reagent transfer steps. the system liquid flow, airpressure-based (plld) and capacity-coupled liquid (clld) sensors detect aspiration and dispensing inaccuracies. sensor signal tolerance band widths studied for fluid classes representative of system reagents and for plasma samples from lipemic, icteric, and hemolized sample sources were shown to correlate with srof multivariate modelling. the impact of surveillance design elements on the srof response demonstrates that risk is functionally dependent on design elements. additional surveillance examples are presented that describes temperature sensing, robotic positioning and motion control. treatment of residual risk is addressed by introducing external controls that are configurable to specific workflow scenarios. the negative external control (nc) is used to check for contamination of reagents. five low concentration armored external controls, i.e. hiv- group m arna, hiv- group o arna, hiv- arna, hcv arna, and protected hbv dna are run at the beginning of a batch as a run-control measure. in addition to these roche controls the system supports running of user-defined external controls for co-validating the batch. the internal control (ic) is based on armored hiv- group m rna that is co-extracted and co-amplified with the external controls and the target nucleic acids potentially present in the sample. lastly, the system resource management monitors the status of samples, ready-to-use reagents and disposables via rack sensors and bar-coded bottles and tubes. the fmeca methodology provides a risk-minimized, comprehensive system design. redundant sensors with internal and external controls are evaluated through comparison of modelled versus actual run results. the system brings a new level of surveillance and throughput for automated pcr testing, and emphasizes roche's commitment to increasing the safety of the global blood supply. technical standards for safe storage and transport of blood components and blood samples objective: to implement standardization of technical specifications for safe storage, transport and distribution of blood samples and blood components intended for transfusion, as part of a quality system in blood transfusion medicine. methods: in the course of implementing a quality system in our blood establishment (distributing % of the national blood supply), we have developed standard operating procedures (sops) for temperature and hygienic conditions to maintain and control storage of blood components during their shelf life and to ensure their safe distribution to other blood services in the country and abroad, in compliance with eu directives / /ec and / /ec and the recommendations of the council of europe and who. procedures are validated and relevant records are kept. a statistical process control is also in place to monitor deviations from specified temperature and time range throughout the period of transportation. blood components collected and prepared for specific purposes (e.g. directed donations, irradiated units, hla-typed units, anti-cmv negative blood components and blood for neonates) are stored separately, and alarms and warning systems are in place. packing and transport conditions of red cells, platelets and ffp are submitted to the tests and criteria of adr (european agreement concerning the international carriage of dangerous goods by road). in greece, the adr legal framework has applied since . blood samples are classified according to adr in division . under un as diagnostic specimens, and the criteria for safe carriage include packaging, specific labelling and vehicle requirements as well as carrier obligations and personnel training. our blood establishment has a contract with biotrans, a private company accredited for packaging, storing and transporting blood, organs, tissues and cells as well as potentially infectious biologic substances and blood samples for diagnostic purposes. assurance system). the approach is specified in the form of requirements of art. . of the standard: the organization shall: (a) identify the process needed for the quality management system and their application throughout the organization, (b) determine the sequence and interactions of these processes, (c) determine criteria and methods needed to ensure that both the operation and control of these processes are effective. regional centre for transfusion medicine in biaĺystok was the first transfusion service in poland which was certified according to iso : standard. our expected profits from the implementation qms were: possibility to overview organization's pathways of operation and to inspire corrective and improvement actions, emphasis on the role of staff in the system, focus on self-control and responsibility for one's own work as a factor of staff's mentality creation/modification. our one year of experience with iso : standard proved the system to be handy tool of management for the organization collecting, processing, testing blood and releasing of blood products for the hospitals and to be well accepted by the staff. the implementation and certification of the internationally nor-malized quality management system simplify and shorten all accreditation and registration procedures required for legal activities of transfusion service as well as for any supplemental medical activities which may be performed by the centre. the implementation of qms facilitates the implementation of other quality systems and simplifies procedures required for the ce certification for the products. red blood cells stored in blood banks, normally undergo a series of chemical alterations, or storage lesions. the ultimate consequence of these lesions is a decrease in the viability of the red cells following transfusion. the chemical alterations are mainly changes in levels of na+, k+, cl-concentrations, ph and , dpg levels and they affect the electrical impedance of blood. the electrical impedance, cole-cole parameters, is determined mainly by the resistance of the red cell extracellular fluid (re), the resistance of the intracellular fluid (ri) and the capacitance of the cell membranes (cm). in this study we aimed to investigate the relation between blood parameters and electrical impedance changes, and their further clinical implication. all parameters were measured on erythrocyte suspension (es) samples during days of storage at oc on days , , , and . for whole blood (wb) samples during days of storage, same parameters were measured on days , , and . the measurement of the complex impedance of blood samples were performed in the frequency range from khz to mhz. by using the a hp lcr meter, the impedance z, and the phase angle a for each sample were read. these values were corrected according to the gain and phase characteristics of the amplifier; and the resistance r and the reactance x were calculated. each data was first fit to the cole-cole model; hence the cole-cole parameters, intracellular resistance ri, extracellular resistance re, characteristic frequency fc and phase angle a were obtained by using lms software. afterwards, cm was calculated by using ri, re, a and fc. whereas ri and cm decreased progressively with time on both wb and es, re changes showed some differences. the electrical impedance alterations were explained by measurements of na+, k+, clconcentrations, ph and , dpg by indicating days. storage of red cells resulted in a rise in extracellular k+ and a fall in extracellular na+, cl-, ph and , dpg. anova was used to evaluate differences in blood measures in relation to storage time. the results were presented as the mean ± sd. according to the regression analysis in spss, the intracellular resistance (ri) on both es and wb was affected more efficiently from all blood parameters among all other electrical parameters. although ri and re were correlated with na+, k+, cl-, ph and , dpg more significantly, cm measurements were failed to show correlations with blood parameters because of the intervening parameters, a and fc. the best relationship between the parameters mentioned above on both es and wb was ri and k+. ph changes were the same for ri and re both for es and wb. the correlation between parameters on es was better than those on wb, because whole blood consists of several particles that may affect our measurements. our study showed that , dpg has an effect on ri and re as efficiently as other blood parameters and therefore electrical impedance measurements may serve future implications. background: issue of quality blood products and donor safety are the main aims of blood transfusion services. a comprehensive quality system should be in place to fulfill these aims, which can be attained through strict adherence to the established standard operating procedures (sops). the drugs and cosmetics act of india, which controls the licensing of blood transfusion services, does not provide clear guidelines regarding plateletpheresis procedure. aim: we therefore established our own sop and operational flow chart for plateletpheresis that can be easily followed by other centers in india. methods: a total of plateletpheresis procedures performed using two cell separators (cs baxter, usa, mcs p, hemonetics, usa) were evaluated following our established sop. the mean platelet yield in cs was . ± . ¥ and in mcs p, it was . ± . ¥ per unit, however, only - % of sdps showed wbc levels < ¥ . six of donors complained of hypocalcemic symptoms. the operational flow chart designed in this study was found to be simple and easy to adapt by blood transfusion services in this country. the first advanced quality management training course for blood transfusion services in the western pacific region mk tan*, jp yu † and d teo* *health sciences authority, singapore, † who regional office for wpr, manila, singapore background: blood transfusion is a key part of modern medicine. a well-organised blood transfusion service (bts) is a prerequisite for the safe and effective use of blood and blood products. in , the world health organization (who) introduced a new initiative of quality management project (qmp) to achieve the goal of safe and adequate global supply of blood. through qmp, regional training centers were identified and quality management training (qmt) courses were established. in , centre for transfusion medicine (ctm) of health sciences authority singapore was appointed as a collaborating center for qmt in the western pacific region (wpr background: spectrophotometric method according to harboe was traditionally used at our institute for determination of free haemoglobin in supernatants of rbc blood components at the end of storage time. in the year hemocue plasma low hb system (hemocue, sweden) was introduced as a replacement method. aim: the aim of the study was to examine reliability and suitability of the hemocue method for measurement of free haemoglobin in supernatants of rccs. methods: hemocue plasma low hb method was validated and compared with harboe method. supernatants of rbc products were tested by two methods and results compared using regression analysis. additional testing was performed to investigate precision of hemocue method (within-run and between-day variation), trueness using reference material and to define optimal sample handling. results: regression analysis showed high correlation between two methods (r = . ), with higher values obtained with hemocue method. immediately after centrifugation one supernatant was measured times in order to determine within-run imprecision. coefficient of variation (cv) calculated from consecutive measurements was . %. to investigate between-day imprecision of the hemocue method one sample was divided in aliquots and frozen. one sample was thawed each day and measured. cv of five measurements was . %. during the period of validation measurements of reference material (low, medium and high) were performed. cv calculated for these measurements were . % (low), . % (medium) and . % (high). in order to investigate possibility of batch testing, supernatants of different rbc products were divided in aliquots and measured periodically during -month period. cvs calculated from measurements of each sample were in range . - . %. conclusion: hemocue plasma low hb method appears to be an excellent replacement for the harboe method. it is consistent, easy to use, measurements are performed in short time, and errors are minimized by eliminating dilutions and manual calculations. background: determination of haemolysis in red cell concentrates (rccs) at the end of storage time is routine method in quality control of blood components at our institute. for this purpose, haemoglobin concentration in supernatant of rccs is measured using hemocue plasma/low hb system (hemocue, sweden). according to manufacturer recommendation, visually turbid samples should be filtered before analysis with a . mm filter. because visual estimation of turbidity is highly subjective and unreliable, filtration of all supernatants before analysis using appropriate filters is possible solution for standardisation of the method. aim: the aim of the study was to investigate the effect of filtration of visually non-turbid samples on results of free haemoglobin measurement. methods: haemoglobin concentrations were measured in visually non-turbid supernatants before and after filtration using hemocue plasma/low hb photometer ( wb negative controls were used for each blood component. in all blood components tested bacterial contamination was detected using both types of bottles. in comparison with sa/sn bottles, nearly all enrolled microorganisms were detected faster in bpa/bpn bottles (see table ). all negative controls were negative (no false positive). the results of the study performed support the use of bact/alert bpa and bpn plastic bottles in quality control testing of different blood components. objective: management of returned blood products is important part of quality assurance activities in transfusion medicine. blood products are returned most frequently because of routine rotation of stock and because of nonconformities discovered after the product has been received. methods: qa data about returned blood products were retrospectively analysed for the -year period ( - ) . only blood products returned because of nonconformities were taken into consideration. data about the reasons for returns are presented and discussed. the top reasons for returns were positive dat, labelling errors, blood bag defects and visual appearance of blood units (see table ). in all cases positive dat was confirmed in our institute, and blood donors managed accordingly. nonconformities related to visual appearance of blood component and other nonconformities related to the quality of blood products were investigated and corrective actions conducted. in case of blood components returned because of damaged bag, significant problem is to investigate the cause of nonconformity (usually inappropriate transport conditions). conclusion: management of returned blood products is important tool in improving the quality of blood products. introduction: hemovigilance is the systematic monitoring of the blood transfusion chain for side effects and adverse incidents from the moment of blood collection until after administration of the unit to the recipient, and comprises all activities that can lead to a safer and more effective use of blood components. attempts to achieve a more safe and effective use of blood components constitute a huge task given the number of interventions and array of medical and not-medical personnel involved in the transfusion process. registration of the impact of all participants is a tremendous job as such. information management may enhance the chances for a successful hemovigilance. aim: the aim is, to establish a basis for all the information related to the chain, such as standard operating procedures, (inter)national guidelines, local transfusion protocols and forms, and procedures to direct the process. additional factors that contribute to the final results are the profile and role of employees, incidents, points of care, product information, prices, budget, contracts, etc. by clarifying and explaining the basis to all participants by means of an existing infra structure, everyone will gain access to identical, consistent and up-to-date information at all times. the primary activity is to create the basis by an outline of every individual link in the transfusion chain from donor to recipient. secondly, the resources, responsibilities, actions, and internal controls (what task, who is performing, why, which help, where, when) are documented. by creating distinct databases for these 'w's' in combination with a separate database for the hemovigilance process itself, it is possible to establish relations, hyperlinks, between the different databases. all the information collected in the foundation, complete with all the resources, responsibilities, actions, and internal controls is made available to target groups by means of the intranet in our hospital as well as in a printed handbook format. collecting and displaying the information on hemovigilance this way, creates a transparent and more easy-to-manage process. it establishes a basis, which incorporates all resources, responsibilities, actions, and internal controls to all participants and enables the organisation to operate both efficiently and effectively. it allows us to show auditors (both internal and external) which processes are related to which guidelines as well as the results in daily. in addition, it reveals which factors determine the genuine application of the guidelines in clinical practice. conclusion: by outlining the process, followed by defining, analysing, securing, on the 'w ' method, the hemovigilance process offers a stable basis and framework for all participants and may stimulate a more safe and effective use of blood components. background: transfusion medicine is a basic post-graduate specialty for medical doctors with a specific national curriculum in bulgaria. in order to improve the post-graduate training of medical doctors in transfusion medicine, a new curriculum was elaborated in . purpose of the new program: independent work of transfusion medicine specialists on all levels of the blood transfusion service (bts) -organization of bts, promotion of voluntary, nonremunerated blood donation, collection, processing, testing, storage and transport of blood and blood components, immunohematologic testing of patients, laboratory hematology, clinical experience, assistance and advice on diagnostic and therapeutic problems of patients, requiring treatment with blood products, teaching transfusion medicine to bts and clinical personnel. admittance and duration to training -medical doctors are admitted to post graduate specialization after a successful state examination. the overall duration of training is years, of which at least are obligatory for training in the national or regional blood transfusion centers. main sections of the curriculum: . organization of blood donation and blood transfusion, including promotion of voluntary, nonremunerated blood donation; organization, planning and information systems; organization of blood transfusion; quality management. . collection, processing, storage and transport of blood and blood components . laboratory hematology and specialized methods (general laboratory methods, immunology, immunohematology, transmissible infections, hemostaseology, nat techniques, flowcytometry) . clinical use of blood components and plasma products (treatment with blood products, adverse events and reactions, alternatives to blood transfusion). the new curriculum of transfusion medicine guarantees a better training of medical doctors, thus leading to safe and effective blood products their proper clinical use. introduction: transfusion medicine is integrated medical discipline based on clinical and laboratory practice. it is closely connected with molecular biology, genetics, as well as with apheresis, automatically techniques and transplantation. the aim of studies in transfusion medicine is proper education, skills, attitudes and knowledge of students at the medical faculty and of doctors on residency in transfusion medicine and other specialties about blood and its usage. material and methods: there will be presented how transfusion medicine is implemented in educational and health sector in r. results: there is -year specialization in transfusion medicine, established years ago (over specialists finished this specialization till now). we have postgraduate studies in tm started years ago. transfusiology, as subject at the medical faculty, is now included in new curricula of medical student, consists of theoretical and practical lectures. also, medical doctors on specialization in surgery, anesthesiology, obstetrics and gynecology, pediatrics, internal medicine, maxillo-facial surgery and others have obligatory -month education in tm. transfusion medicine is integral part in education of nurses and laboratory technicians; all personnel that work in transfusion field in our country finished -mounths course in tm and get certificate. conclusion: although we have already done so much in educational field, we will continue with our efforts to improve our collaboration with clinicians and to involve ourselves more in clinical disciplines. introduction: in hospitals of saint petersburg donor blood, its components and preparations, autoblood and its components, hemocorrectors are applied with the medical purpose at - % of hospital patients. the service of blood and the existing organization transfusion therapy in hospitals should provide maximal immunological and infectious safety and also its high medical efficiency. it demands special preparation for all doctors: general physicians on clinical transfusiology and doctors of blood service on all sections of the general, industrial and clinical transfusiology. clinical gemostasiology, pharmacology of hemotransfusion means and hemocorrectors, the organization of the blood service, the donor service; the organization, technique and technics of preparation of blood, its components and preparations, quality assurance, transfusion therapy programs, technique and technics of transfusion medicine, a problem of maintenance of immunological and infectious safety, preventive maintenance, diagnostics and treatment of posttransfusion complications, feature transfusion therapy in pediatrics and medicine of accidents). clinical physicians master all basic questions of clinical transfusiology, thus the special attention is given questions of clinical immunohematology and clinical gemostasiology, programs and a technique of transfusion therapy, the prevention of posttransfusion complications. employment are carried out in departments of city blood bank, hospitals blood departments. final examination under the test program and at interview shows sufficient mastering a theoretical and practical material (right answers of - %). the described system of postgraduate studies provides an opportunity of successful independent work of doctors on the workplaces both regular increase and qualifications not less often than time in - years. conclusion: the existing system of postgraduate education for doctors on transfusiology provides the blood services and hospital by the qualified staff. introduction: nowadays in hospitals of saint-petersburg more and more it is frequently applied the extracorporal hemacorrection (haemapheresis, haemasorbtion, plasmasorbtion, krhyoplasmasorbtion, ultrafiltration etc.) and photohemotherapy (optical radiation influence on blood) at various diseases and traumas. they are used at treatment almost % from the general number of patients of hospitals with positive results at % from them. for this purpose in hospitals there are specialized branches or cabinets with staff of the doctors -transfusiologists. therefore an actual problem is organization of postgraduate special education for them. because there is no specific blood banking and transfusion medicine training in either under or post graduate medical education those general practitioners have limited knowledge about this field. aim: to give basic knowledge and practice to those general practitioners moh has established a special training programme with the collaboration of medical schools for years. methods: this is a months programme which has basic components; theoretical education, laboratory and blood banking practice. the trainees are evaluated by a final examination. each group has limited cadets and the training is provided in selected blood banks with the collaboration of universities and moh training hospitals. conclusion: almost general practitioners are trained by this programme in the last years and those doctors helped to increase the quality of blood banking and transfusion service at their hospitals. background: even the history of public blood banking in turkey has dates back to , whole blood was comprising the majority of transfused units (more then %) in turkey until the last few years. aim: the main target was to decrease the whole blood use in a short time and establish countrywide effective blood transfusion practice. methods: there were no specific blood banking and transfusion education either at undergraduate and postgraduate medical education in turkey until the last few years. blood banks and transfusion society of turkey (bbtst) was established at with the main aim of education of the related people about blood banking and transfusion medicine. bbts has organized symposiums, national courses, national and international congresses since . due to increased knowledge about the blood components and improved infrastructure of blood banks whole blood consumption has decreased to national average to %. in most of the university hospitals and training hospitals this is around %. conclusion: like most of the public based behaviours dedicated efforts of civil initiative has changed the traditional habit of blood consumption in turkey by the direct affect of well organized educational activities. training of general practitioners in blood banking and transfusion medicine n solaz*, b keskinkilic † and c oruc † *ankara university, ankara, † ministry of health, ankara, turkey background: turkish ministry of health runs majority of the hospital blood banks in turkey. most of the moh hospital blood banks give service under the medical supervision of general practitioners. because there is no specific blood banking and transfusion medicine training in either under or post graduate medical education those general practitioners have limited knowledge about this field. aim: to give basic knowledge and practice to those general practitioners moh has established a special training programme with the collaboration of medical schools for years. methods: this is a months programme which has basic components; theoretical education, laboratory and blood banking practice. the trainees are evaluated by a final examination. each group has limited cadets and the training is provided in selected blood banks with the collaboration of universities and moh training hospitals. conclusion: almost general practitioners are trained by this programme in the last years and those doctors helped to increase the quality of blood banking and transfusion service at their hospitals. background: it has been accepted that during cardiac surgery the complement-system is activated which enhances ischemia-reperfusion injury, leading to postoperative complications as infections and organ failure. the lectin pathway is one of the mechanisms that can activate the complement-system, this pathway can be mediated by mannose-binding-lectin (mbl). the level of mbl in serum shows a wide variation. a low level of mbl can lead to more infections in some conditions and a high level to tissue damage after ischemiareperfusion injury. the effect of transfusions of erythrocyteconcentrates and plasma on the mbl levels and thereby on complications after cardiac surgery are not known. aim of the study: the role of pre-and postoperative mbl levels and the effect of transfusions on postoperative complications after cardiac surgery. in a randomized controlled trial cardiac surgery patients were included and blood samples were taken pre-and postoperatively. mbl measurements were performed by elisa assays. the data were linked with postoperative complications as mortality, infections and multiple-organ-dysfunction-syndrome-mods and with peri-operative erythrocyte and plasma transfusions. results: the mean pre-operative mbl-level was ± and postoperative ± mg/ml. there were no differences in preand post-operative mbl levels between patients with infections or mods compared with non-infected and non-mods patients. the difference in pre-operative mbl between non-survived ( ± ) and survived patients ( ± ) was not significant (p = . ). postoperative mbl levels between survived and non-survived patients was smaller. conclusions: pre-and postoperative mbl levels in cardiac surgery are not related to postoperative infections, mods and hospitalmortality. whether large amount of blood transfusions are affecting the mbl-levels and thereby the patients outcome is not known. introduction: patients undergoing cardiac surgery are receiving high amount of blood transfusions and are at risk for the development of infections and multiple-organ-dysfunction-syndrome (mods), these complications are influencing the survival of the patients. during cardiac surgery pro-and anti-inflammatory cytokines are released by different mechanisms. we found in a randomized trial in cardiac surgery a significant reduction in infections and mortality due to mods by transfusion of leukocytedepleted erythrocyte concentrates (ld) compared to leukocyte-containing, buffy-coat depleted erythrocytes (pc). aim of the study: the effect of ld on the concentration of proinflammatory cytokine il- and anti-inflammatory cytokine il- in relation to clinical outcome and complications after cardiac surgery. methods: in participating patients blood samples were taken before and after surgery. using elisa il- and il- were measured in these samples. the results were linked with the endpoints of the randomized trial: postoperative infections, mods and in-hospital mortality. results: all pre-operative concentrations of il- and il- were low. mean postoperative level for il- was ± and for il- ± . compared with patients without mods and without infections and survived patients only the il- was significant higher in patients who died and in patients with mods. there were no differences in mean levels related to ld and pc. the levels of il- were higher in patients receiving more then units blood transfusions compared to transfusions. conclusion: there is an association between mods and mortality and il- , not with il- . ld has no influence on mean levels of il- and il- . there is a correlation between transfusion of more then units and il- , not with il- . these cytokine-profiles are not associated with the beneficial effect of ld on the postoperative outcome in cardiac surgery patients. anemia and blood transfusion practice in critically ill patients e grouzi*, e tsigou*, p evagelopoulou † , g baltopoulos † and i spiliotopoulou* *kat general hospital, transfusion service, athens, † athens university school of nursing icu, athens, greece background: anemia is a common problem in critically ill patients admitted to intensive care unit (icu), but the consequences of anemia on mortality and morbidity in the critically ill is poorly defined. aim: to define the incidence of anemia and red blood cell (rbc) transfusion practice in critically ill patients in the icu) of our hospital, and to examine the relationship of anemia and rbc transfusion to clinical outcome. patients and methods: the period study was from july to december . patients were enrolled within h of icu admission. follow-up time was days, hospital discharge or death, whichever occurred first. results: a total of patients ( male, female, mean age . ± . years, range - ) were included in the study. the mean hemoglobin (hb) level at baseline was . ± . , which level was descending during the study. overall . % ( / ) of the patients received one or more rbc units while in the icu stay (mean . ± . units per patients). the mean pretransfusion hb was . ± . g/dl and the mean time to first icu transfusion was . ± . days. more rbc transfusions were given in the first week of the icu stay ( units vs , , units in the second, third and forth week respectively). the number of rbc units which a patient received during the study was positive associated with longer icu length of stay and an increase in mortality (r = . , p < . and r = . , p < . respectively). baseline hb level was significantly related to the number of rbc transfusion (r = . , p < . ), but was not an independent predictor risk factor of length of stay or mortality (r = . , p > . and r = . , p > . respectively). the mean baseline apache ii and saps scores were . ± . and . ± . respectively. furthermore both baseline apache ii and saps scores were significantly higher for patients with a baseline hb level of < g/dl ( . ± . vs . ± . and . ± . vs . ± . respectively), while the apache ii values were positive associated with a significantly increased likelihood of rbc transfusion (pearson correlation p < . ). conclusions: anemia is common in the critically ill patients, it appears early in the icu course and persists throughout the duration of the icu stay. rbc transfusion seems to be associated with worse clinical outcome. despite the intensive research for the transfusion practice, which taken place worldwide during recent years, data from our country is limited. the results of our study suggest that approaches to reduce rbc transfusion would be desirable. however, further well designed prospective studies with large number of patients are required to efficiently explore the risk of anemia, optimal transfusion hb threshold and the risk and benefit of rbc transfusion in the critically ill. consumption of blood products in a large, general hospital he heier*, j pillgram-larsen † , m hestnes ‡ , b gran*, a krog* and no skaga ‡ *ullevaal university hospital, oslo, † ullevaal university hospital, dept. of thoracic surgery, oslo, ‡ ullevaal university hospital, dept. of anestesiology, oslo, norway uuh is the largest general hospital in norway, and trauma referral centre for half of the norwegian population ( . mill) the trauma team performed initial assessment and resuscitation of patients, % males, during the first six months of . the aim of our study was to analyze transfusion practice at uuh with specific focus on trauma. materials and methods: blood consumption during this period was recorded. clinical data of trauma patients were collected from our trauma registry and anonymized before analysis. results: units of erythrocytes (er), of thrombocytes (thr) (buffy coat preparations from donors) and of s/d-treated whole plasma (op) (octaplasÒ) were transfused in uuh during this period. . % of er were given to surgical, . % to medical and . % to gynaecological and obstetric patients. % of er were given to patients above years. er units were given to patients (mean . units/patient; range - ). mean age of trauma patients was ± , median , range - years. for transfusion of this group local guidelines state that haemodynamically unstable patients should receive er if hgb < g/dl, irrespective of age and sex. eighty-eight patients ( . %) received er, of them as massive transfusion ( er units in < hours) ( . %), of these died ( %). altogether trauma patients received units of er ( . % of total uuh consumption), . thr ( . % of total) and units of op ( . % of total). massive transfusion consumed er ( %), . thr ( . %) and op ( . %) units. fourteen adult trauma patients ( . % of those transfused) received or er units only. lowest pre-transfusion hgb was . - . g/dl, median . , mean . ± ; highest post-transfusion hgb . - . g/dl, median . , mean . ± . five patients received er transfusion at higher pretransfusion hgb level than g/dl, but in er were given because of a hyperacute clinical situation. fifty-five% of issued er units had been stored for > days, while only % were issued before days of storage. discussion: life-saving effect of transfusion would seem evident in the massively transfused survivors, while in the other transfused patients documentation of clinical effect is inadequate. transfusion practice in trauma at uuh seems fairly well in accordance with internationally accepted guidelines. the trauma unit consumed a surprisingly small part of total uuh transfusion resources. trauma patients deviate from the general uuh patient population by sex and age; transfusion is otherwise mainly given to more elderly patients. further analysis is needed on transfusion indications and results to optimize the total use of blood products in uuh. special focus should be on transfusion to non-bleeding patients without haematological disease. it seems that only a small part of transfusion efforts results in the saving of life. in croatia national guidelines for the use of rhd gamma globulin were laid down in the year . in accordance with the guidelines, rhd gamma globulin is administered intramuscularly in doses of - mg and should be given to rhd negative women after delivery of rh positive children, after abortions, in week of their first pregnancy, as well as in cases pregnancies with an increased risk of fetomaternal hemorrhage. as to the latter, detection and measurement of fetomaternal hemorrhage are recommended. three years after the issuance of the guidelines a survey was conducted regarding the use of rhd gamma globulin that involved health institutions across the country. as many as deliveries and abortions were reported in . the institutions reported the usage of doses of mg rhd gamma globulin or doses/ deliveries + abortions. we compared our data with those obtained from similar surveys conducted in , i.e. before the issuance of the guidelines. in that year deliveries and abortions were reported, and doses of rhd gamma globulin or doses/ deliveries + abortions were administered. institutions were then divided into four categories: clinical hospitals, general hospitals with the capacity of - beds, general hospitals with the capacity of - beds, and institutions of rather limited capacity with gynaecology department. the range of the consumption of rhd gamma globulin/ deliveries + abortions in the first category was - with the median being ; in the second category there were - doses with the median being , in the third category - doses with the median being , while in the fourth category the range was - doses with the median of doses. the number of pregnancies which should have been protected with rhd immunization in year was obtained by the following formula: (frequency of rhd negative subjects) ¥ (frequency of the r gene) = . ¥ . = . . if a complete antenatal and postnatal preventive measures involving rhd immunization had been taken in , doses of rhd gamma globulin or mg/ deliveries + abortions should have been given. our research has shown that, despite of the national guidelines adopted in , the prevention of the rhd immunization in pregnant women is still not adequate in croatia. in fact, it has not improved since a year prior to the adoption of the guidelines. it has also been established that the category of the institution is a factor influencing the implementation of the protective measures. we consider that much more should be done on informing both women and gynaecologists about the importance of prophylaxis of the rhd immunization. consumption of plasma derivates in croatia g jaklin*, b golubic-cepulic † and m dondur* *general hospital, varazdin, † clinical hospital center zagreb, zagreb, croatia a increasing consumption of plasma derivates, their limited supply and insufficient national reserves are problems that croatia is faced with nowadays, as well as many other countries. in a study was carried out regarding the usage of plasma derivates. as many as health institutions took part having the capacity of acute beds out of a total of . the data regarding the use of plasma derivates were collected as follows: albumin, i.v. gamma globulin, and concentrate of coagulation factor viii in two periods of time. we divided institutions into three categories: clinical hospitals, general hospitals with the capacity of - beds and general hospitals with the capacity of - beds. institutional practice patterns regarding the use plasma derivates were compared among them. the parameters considered were the total consumption of plasma derivates, consumption per bed and consumption per inhabitant. data on the use of plasma derivates was obtained from hospital transfusion departments and pharmacies across the country. we compared our data with similar study carried out in . the consumption of albumin was . kg or kg/million inhabitants in and consumption per bed for the first category institutions was in range . - . kg with the median being . , for the second category the range was . - . kg with the median being . , while for the third category the range was . - . kg with the median being . . in in croatia the consumption of albumin was . kg or kg/million inhabitants. the consumption of i.v. gamma globulin was . kg or . kg/million inhabitants in and the consumption per bed for the first category institutions was in range . g- . g. with the median being . , for the second category was in range . - . g. with the median of . and for the third category was in range . - . with the median . g. in in croatia the consumption of i.v. gamma globulin was . kg or . /million inhabitants. the consumption of the concentrate of factor viii was . iu or . iu per inhabitant in . . iu, i.e. . %, was a recombinant factor viii. in the consumption of factor viii was . iu or . iu per inhabitant. discussion: the use of albumin showed stagnation. however, the use of i.v. gamma globulin increased . times and the use of the concentrate of factor viii increased . times if compared with the results in . self-sufficiency has not been reached in plasma derivates in croatia we needed l plasma for gamma globulin and l plasma for concentrate of factor viii for the level of usage of these plasma derivates in . significant differences in the level of usage among hospitals have been observed. these reflected a considerable difference in hospital policy regarding the use of these products in defined clinical settings. therefore, we would recommend that the national society sets out guidelines for the use of the products. background: blood bank good practice requires avoidance of rh alloimmunization. several studies report a probability of immunization of more than % following transfusion with rhd+ rbc's and as many as % in the case of platelets. aims: the purpose of this study was to investigate the development of anti-d and the causes of alloimmunization in a university hospital ( beds), reviewing our practice on the use of rhd+ blood components in rhd-recipients. method: a retrospective study was performed whereby . rhd-patients, from to , were evaluated for the development of anti-d analysing the data on the blood bank information system. results: from the . rhd-patients we found out identified anti-d, % ( ) detected before any transfusion in our hospital. of the left, nine were excluded because no information was available during some years. had history of pregnancy related to the immunization. patients were exposed to rhd+ blood components: were transfused only with rhd+ platelets (including two women of childbearing age); with rhd + rbc's. the remaining had been exposed exclusively to rhd -rbc's suggesting that some units could be mistyped. this idea was corroborated in three patients where there was a common donor (he was called for investigation). conclusions: transfusion services avoid as far as possible administration of rhd+ blood components to rhd-patients, although there are situations in which such transfusions are necessary. the retrospective review of records revealed the need for specific recommendations regarding the use of rh immunoglobulin to prevent anti-d immunization. the possibility of mistyping blood components also appeared in this review, emphasizing the role of these studies in the evaluation of methodologies used at blood banks. the purpose of the work: to present the usage of whole blood (wb) and blood products (bp) in the treatment of patients who are hospitalized in the internal disease department in gevgelija. material and methods: retrospective analysis is done according the data which were analysed in five years period ( ) ( ) ( ) ( ) ( ) . statistical methods which were taken from the history of the hospitalized patients in the internal department were used for analysis and the data of transfused wb units and units of bp were taken from the department of transfusion medicine. results: from the total hospitalized patients who have been analyzed, ( . %) received wb and bp, and there have been transfused units wb and bp. every patient, on an average, has been transfused with . units wb and bp. at the same time ( . %) units have been transfused as a wb, ( . %) have been transfused as red blood cells (rbcs) and ( . %) units have been transfused as a fresh frozen plasma (ffp). the data for every year particularly will be presented in our paper to the congress. the collaboration between doctors of transfusion medicine and health workers from the other medical branches is the most important thing in the medical practice. our aim is to raise the awareness among the health workers for the importance of blood safety and their role though adequate clinical usage of wb and rbcs, minimizing the non-useful transfusions, evaluation of reflexive information from undesirable reactions in the usage of blood and blood products, use the alternatives etc. the necessity of direct involvement of the doctors in transfusion medicine in the process of healthy workers' education from the other branches for regularly transfusion therapy via meetings and lectures is an imperative for regular function of the department of transfusion medicine. femoral neck fracture repair is one of the commonest orthopedic procedures. it mainly concerns intracapsular or intratrochanteric fractures and it may be considerably hemorrhagic, requiring blood transfusion perioperatively. the aim of our study was to investigate blood transfusion requirement in patients with femoral neck fractures repair at katerini general hospital during - and to compare them with other studies. one hundred sixty five ( ) unselected patients of whom ( %) were women and ( %) were men with a mean age of years (range - years) were studied retrospectively. seventy six ( %) patients had intracapsular fracture and ( %) intratrochanteric fracture. the mean hb concentration on admission was . g/dl (range . - g/dl) and the mean hb concentration at discharge was . g/dl (range . - . g/dl). a total of units of rbc were transfused (a mean of . units per patient). blood transfusion occurred in patients ( . %), ( - % in other studies) with a mean of . units per patient (range - units), ( . - . in other studies). patients with preoperative hb values < g/dl were transfused more often than those with hb values > g/dl ( % versus %) p: . . women were transfused more often men ( . % versus . %) p: . . patients aged > years were transfused more often than those aged < years ( % versus %) p: . . finally patients with intratrochanteric fractures were transfused more often than those with intracapsular fractures ( . % versus %) p: . . conclusions: in our study blood transfusion requirement for femoral neck fracture repair are similar with these reported in other studies. blood transfusion frequency is greater in patients with hb < g/dl, in patients older than years, in women and in intratrochanteric fractures repair. fresh frozen plasma guidelines and practices as saltamavros*, g talampouka*, c koumoundourou*, s dimitrakopoulos † and p tseliou* *st. andrews hospital patras greece, patras, † pyrgos general hospital, pyrgos, greece introduction: fresh frozen plasma transfusions should be done according to specific standards and guidelines. aims: we have reviewed the ffp transfusion practices followed in our hospital in an attempt to provide a set of guidelines and principles that will assist physicians and health care workers to make the right decisions for appropriate use of ffp transfusions. methods: retrospective review of ffp transfusions practices during the entire year of . we classified transfusion practices according to the diagnosis of the patient and also of the clinical depart-ment that demanded transfusion. then we analyzed our results by comparing the requests with the internationally approved guidelines for ffp transfusion and counted the percentage of ffp to rbc units. finally we discussed with our fellow physicians the proper use of ffp and informed them about the accepted guidelines. as we can see from the underneath table, diagnoses and departments with high consumption were: internal medicine %, plasmapheresis to patients suffering from guillain barre and ttp (thrombotic thrombopenic purpura) . % and trauma/surgery . %, cancer . %. summary/conclusions: the use of ffp corresponds to . % of the rbc units transfused in our hospital. plasma units should be used properly and according to internationally accepted standards. plasma use should be justified by the physician, in order to avoid unnecessary risks on behalf of the patient for effective treatment and care. to show gradual discontinuation of using whole blood and increased use of red blood cells (rbc) in the management of patients in the transfusion department of the clinical hospital 'zvezdara' . methods: data of wb and rbc use from to in our hospital. results: our data are presented in table . conclusion: after , wb usage rates systematically decreased from % to . %. however, in the period of - , the wb usage rates increased slightly, and we arrived at a generally very low rate of wb use, namely only in about % of the cases. education about transfusion medicine and rational use of blood in the medical curriculum was generally insufficient and very poor. therefore, we started an education program and we established a hospital transfusion committee (htc) with the task of medical control and monitoring the quality of clinical transfusion practice in our hospital. members of the htc are a specialist in transfusion medicine, an internal medicine specialist, an anesthesiologist, surgeon and gynecologist. we have been organizing courses for the medical staff, doctors and medical technicians since . background: platelet transfusions are given mainly to thrombocytopenic patients with malignant haematological diseases. currently the decision to give a prophylactic platelet transfusion is based almost exclusively on the number of circulating platelets in the patient although it is known that various clinical factors might influence the bleeding tendency. by free oscillating rheometry (for), using a reorox® instrument, it is possible to monitor the coagulation over time in whole blood and obtain information about clotting time and coagulum elasticity. aim of the study: the aim of this study was to find out if for using the reorox® instrument could be used to evaluate the hemostatic status of thrombocytopenic patients. methods: the change in elasticity over time in non-anticoagulated whole blood from leukaemia/lymphoma patients with thrombocytopenia was measured in the reorox® pre and post a platelet transfusion (n = ) and was compared with healthy controls (n = ). the effect of platelet concentration on coagulation was studied by diluting platelet rich plasma from healthy subjects with autologous plasma to various platelet counts whereafter the coagulation was monitored with for (n = ). the change in elasticity per minute (g'max slope) and maximum elasticity (g'max) were evaluated from the elasticity curves. results: the g'max, g'max slope and platelet count increased after transfusion for all patients. the thrombocytopenic patients had significantly lower g'max and g'max slope values both pre and post transfusion compared with healthy control subjects (p < . ). the measurement in platelet rich plasma showed that g'max and g'max slope increased with increasing platelet concentration. however patients with similar platelet count developed different clot elasticity. the reorox ® instrument responds to changes in haemostatic function in form of the clot elasticity. the fact that patients with similar platelet concentration developed different elasticity shows that clot elasticity is a function of not only platelet concentration but also of functional properties. the for method seems promising to evaluate platelet function. quality control of pre-storage leukodepleted red cell concentrates vu urlep salinovic, k perbil lazic and l lokar teaching hospital maribor, maribor, slovenia background: the system of quality assurance including quality control (qc) in transfusion medicine is most important for safe blood supply. the safety and quality of blood components are increased by pre-storage leukodepletion of whole blood (wb). aim: the qc of leukodepleted red cell concentrates (rcc), prepared from pre-storage filtration of wb (quadruple blood bag systems imuflex wb-rp terumo) is performed with the aim to be sure that the quality of leukodepleted rcc is in accordance with the guidelines of council of europe. in three years ( ) ( ) ( ) , units of wb were collected, among them ( . %) units were collected for pre-storage filtration and in ( . %) of these qc was done. within hours after collection, wb was filtered at room temperature. filtered wb was centrifuged at g for minutes and separated in rcc and plasma. the samples for qc were collected before and after filtration. for each unit, volume, hemoglobin, hematocrit, % of hemolysis and residual white blood cells (wbc) count were measured. the number of residual wbc after filtration was determined in the nageotte chambre. for all parameters the mean value and standard deviation were calculated. the results of qc for the following parameters were: volume ± . ml ( % corresponds with the guidelines of council of europe), hematocrit . ± . ( %), hemoglobin . ± . g/unit ( %), number of residual leukocytes . ± . ¥ ( %), hemolysis . ± . % ( %), the test of sterility was % negative. during filtration of wb, wbc were removed in approximately . %, the duration of filtration was ± minutes and the loss of hemoglobin was . ± . %. the pre-storage filtration of wb is highly efficient, . % of wbc were removed and the loss of hemoglobin was small. background: the patients of cardiosurgery use big amount of blood components. there is no uniform approach by treatment with blood components in these patients. the safest and the most rational use of blood is based on the individual treatment of a patient and the evaluation of the most clinical and laboratory factors. aim: the aim of our study is to analyse the use of blood components from , when the cardiosurgery department was founded in our hospital, to . the data about use of red cell concentrates (rcc), platelet concentrates (pc) and fresh frozen plasma (ffp) in the period from to were collected from information system datec. the average use of all three blood components per patient is presented. we were interested, if the average use per patient was diminished in the analysed period. results: the use of three blood components and average use of all blood components are presented in the table. the data from the table shows, that the number of patients increased more than three times, but the average use of blood components per patient was not essentially diminished. conclusion: during seven years period the use of blood components per patient in cardiosurgery was not diminished. for more rational use it is necessary to apply all methods of autologous blood transfusion because of the increasing number of cardiac operations and decreased number of voluntary blood donors. background: the presence of leucocytes in blood components is cause for appearance of various adverse posttransfusion reactions such as nhfptrs, urticary, anaphylactic shock, alloimunization and platelet refractorines, infection with bacteria and leucothropyc viruses (cmv, htlv). the removal of leucocytes from blood components through filtration is especially important in the treatment of patients with malignant diseases who need frequent transfusions of blood and blood components. this is because of their lowered immunologic status which is a result of the disease and received immunosuppressive chemotherapy and radiotherapy. aim: to show the prevention of posttransfusion reactions and the positive effect from transfusion of leucoreduced er. concentrates, produced with filtration in therapy of anaemia in patients with malignant diseases, treated in our daily transfusion hospital at medical center -stip. methods: patients with malignant diseases have been treated in our daily transfusion hospital in the last four years. most of these patients suffer from ca pulmonum, ca collonis, ca uteri, ca mammae. also, because of the secondary anaemia, the same patients were transfunded with at least two doses of leucoreduced er. concentrates. the blood donored by voluntary repeated blood donors was filtrated the same day after the donation, separation and the control of the same one. the blood was collected in baxter and terumo bags, and it was filtrated with baxter -sepacell rs - and pall -purecell rn filters. the analyses of leucoreduction were made for every filtrated and transfunded unit before and after filtration. the analyses samples were taken from the tubing system before and after the filter. haemathologic parameters were automatically made in the central clinic laboratory. results: er. concentrates poor with the leucocytes for about - . % were produced with the use od these filters, and platelets from - % with which side effects from frequent transfusions at these patients were prevented. with the routine monitoring of all patients none posttransfusion reactions were registered. the therapeutic effect is also important because of the fact that the number of er and the level of hg and hct remain almost unchanged. the aim of the blood banks is to help and to increase the safety of the blood components. the leucoreduction through of er. concentrates poor with leucocytes is a regular procedure in the therapy of malignant patients with remarkable clinical picture of anaemic syndrome and prevention the cancer recurrence end infection. the time of filtration is also very important which has to be shorter after collection of blood, because the leucocytes should be removed before they become disintegrated and relapse potentially dangerous substances end metabolites in the blood components. we have been applying so called ' prestorage filtration' because it has been proved that it is more efficient that bed -side filtration. background: the effect of leukocyte reduction of rbcs by filtration has been the topic of several rcts. these rcts investigated the effect of leukocyte reduction on mortality; post-operative infections and hospital stay in different patient populations. some rcts came up with answers that conflicted with the results of other rcts. aim of the study: with including the individual patient datasets of several rcts in one database, combined analyses are possible that may explain the differences in the reported results. using this technique, we may come up with answers (or questions) that cannot be obtained by performing standard meta-analyses of these rcts. methods: we coordinated several rcts comparing the perioperative use of buffy-coat depleted rbcs with the use of filtered rbcs. cardiac surgery patients were included in three rcts ( ¥ cabg and/or valve; ¥ re-cabg and/or valve; ¥ valve with or without cabg). oncologic surgery patients were also included in three rcts ( ¥ colorectal cancer; ¥ gi-oncology or vascular surgery; ¥ gi-oncology, vascular surgery or orthopedic surgery). the electronic data files of these rcts were uniformly recoded and entered in a single database. as different primary endpoints were investigated in the rcts, we focused on common endpoints, recorded in or more of the rcts. multivariate analyses were performed on: in-hospital mortality, -day mortality, hospital stay, stay on icu, postoperative infections, and mods. results: in the rcts, individual datasets from surgery patients were collected ( onco; cardiac; vascular; orthopedic, other). in the multivariate analyses, patients in the buffycoat depleted trial arm showed a higher mortality rate both in-hospital (p = . ) and at days post-surgery (p = . ). no association between randomization and stay in hospital (p = . ) or stay on icu (p = . ) was seen in the combined study population. also, no association of randomization with the incidence or duration of mods was seen. the analyses of post-operative infections in the total population showed the trial arm to be associated (p = . ), and 'hospital' to be far stronger associated (p < . ). however, when the oldest rct, that had not yet used our standard definition list for scoring post-operative infections, was excluded, the association with the hospital was lost (p = . ) and the trial arm became more strongly associated with infections (p = . ). in the analyses of surgery patients, the use of filtered rbcs, compared to the use of buffy-coat depleted rbcs, resulted in reduced mortality (both in-hospital and at days postsurgery) and a reduction in post-operative infections. the association of the variable 'hospital' with post-operative infections, as is frequently reported in literature, was initially confirmed in our analyses. however, when a standard definition for post-operative infections was used (excluding the datasets from one of six studies), this association was lost. background/aims: uk neqas for blood transfusion laboratory practice (btlp) operates an eqa service for uk laboratories (including eire) and participants throughout europe, including major groups in denmark (n = ) and portugal (n = ). in november a questionnaire was distributed to determine the criteria used for selecting phenotyped blood for different patient groups, including pre-menopausal women (pmfs). results were analysed by country to establish any variation in practice relating to the selection of k negative (k-) and rhc negative (c-) blood, since antibodies to these antigens are now the major cause of hdn. results: overall return rate was % (uk) and % (non-uk), although only centres treating pmfs were included in this analysis. k-blood was selected for pmfs by % in wales (n = ) and % in england (n = ), but only % in scotland (n = ), % in northern ireland (n = ) and % in eire (n = ). in mainland europe, variation was also observed: % in denmark (n = ), % in portugal (n = ) and % in other countries (n = from countries). fewer laboratories selected c-blood for pmfs: % in england and northern ireland, % in scotland and eire, rising to % in wales. mainland europe showed similar variation: % in denmark, % in portugal (all ccee matched) and % in other countries. there are no guidelines requiring selection of k-and c-blood for pmfs, but in the uk d negative blood is required for d negative females aged < years. trend analysis of questionnaire data in the uk, using theoretical clinical scenarios, shows a decrease in the number of laboratories that would select k + blood for a year old female (with pre-existing antibodies other than anti-k), from % ( ), % ( ) to % in . in this survey, k + blood was selected for a female aged (no antibodies) by %, whilst % selected a k + unit for a female aged (no antibodies), despite this patient being treated as a pmf for provision of d negative blood. a similar distinction was made between the and year old females in portugal and mainland europe. conclusions: variation in practice may at least in part be due to the availability of blood routinely labelled for rh and k. in the uk all donations are labelled, except for those from new donors, as are most units in portugal. uk questionnaire data ( ) suggested that > % laboratories would change to selecting k-blood for pmfs if all units were labelled. however, labelling alone does not account for the differences seen within the uk, and perhaps the trend towards providing k-(and to a lesser extent c-) blood for pmfs is influenced by advice from transfusion services. it would be of great interest to monitor and compare the incidence of hdn due to anti-k and anti-c in different countries to measure the outcome of differing practices for provision of blood to pmfs and to thereby inform future policy. there is no ultimate in ex-vivo assay described, which can predict the outcome of plt transfusion in vivo. current in ex-vivo assays and animal studies are rather very complicated to carry out, cost effective and time consuming. objective: we hypothesized that the quantitative measurement of gpib expression by facs can be used to predict the outcome of platelet survival post transfusion. in our previous studies we demonstrated that our phagocytosis assay can predict the plt survival sensitively (blood dec- ) . we isolated human washed plts by centrifugation and labelled with mepacrine and then incubated with pma-matured thp- cells ( °c). binding was measured by facs analysis of cd b/cd positive particles, and phagocytosis by counting mepacrine/cd positive particles. we measured gpib expression before and after plt-macrophages interaction by facs flowcytometry. results: gpib expression at surface of c fresh showed ± and after hours storage ± % expression. the gpib expression at surface of plt decreased and showed three populations with different densities high (gpib- ), low (gpib- ) and in-between (gpib- ). the binding and phagocytosis of plt showed an increase of ± % which implicates an indirect and negative relation to gpib- , and direct relation to gpib- expression. anti-human pselectin (cd p) delayed ± % the binding and annexing v ± % the phagocytosis of stored plts, after -hour storage. these results show that gpib expression is rather easy, reproducible test which can be standardised and be used as a very sensitive in vitroassay to predict platelet survival posttransfusion. transfusion and lung injury jd dodig*, d sovic † , m tomicic † and h sager* *university hospital 'sestre milosrdnice', zagreb, † institute for transfusion med, zagreb, croatia background: the respiratory tree has been viewed as an infrequent site of injury arising as serious complication of transfusion. in recent years, this view has changed as investigators have shown that two complications-circulatory overload and transfusion related acute lung injury-are relatively frequent events. case report: a -year-old men was admitted due to chronic macrohematuria. he had no history or current evidence of cardiac failure. the hb level was measured g/l. he received ml . % nacl and ml ringer solutions. after that, he was transfused with units of rbcs. during transfusion second unit he developed following symptoms: tachycardia, dyspnea, hypertension. massive pulmonary edema was noted. he was treated with mechanical ventilation, oxygen, diuretics, aminophillin, antihistaminic and corticosteroides. the patient recovered after being on ventilation for hours. two days after the patient was operated. after surgery he was transfused with units of rbcs. all transfusions were regularly performed. results: chest x-ray confirmed bilaterally pulmonary edema. the samples (patient and donors of first two units rbcs) tested were negative for the presence of hla specific and granulocyte antibodies. granulocyte agglutination and lymphocytotoxicity test were negative. tnf-a in recipient serum was slightly increased. conclusion: our patient is the first reported case suspected of trali, but all of the investigations didn't give us the answer. against neutrophils using flowcytometric detection of cell surface cd b expression and l-selectin shedding. methods: a hundred microl of volunteers' heparinized whole blood were incubated for minutes at °c with fmlp, lps or pma. monoclonal antibodies against hna a and hla-i, or patient serum were incubated with whole blood for min. surface cd b and l-selectin were detected using facscalibur. results: neutrophil activation was detected after fmlp, lps or pma stimulation. p map kinase inhibitor reduced activation induced by fmlp and lps. anti-hna a monoclonal antibodies induced neutrophil activation, which were also inhibited by p map kinase inhibitor. ten serum samples obtained from patients or donors who caused transfusion reactions were evaluated. five sera out of samples having anti-neutriphil and/or hla antibodies exhibited neutrophil activation, while two samples without leukocyte antibodies had no effect on any activation. conclusion: these findings indicate that neutrophils activation is regulated through mak kinase and detection of neutrophil activation may be useful to predict transfusion-related reactions. results: out of transfusion reactions were febrile, were anaphylactic, were due to circulatory overload, out of transfusion reactions concerned the transfusion of incorrect blood component. out of transfusion reactions concerned acute haemolytic reaction. post transfusion purpura or suspected trali was not seen. fatal complication was not seen. the reactions to plasma were predominately anaphylactic. we detected no case of bacterial contamination among the cultures of transfusion bags. conclusions: the incidence of reactions among patients malignancy was high, while among surgical patients was lower. the incidence of transfusion reactions during the months had no statistically significant difference. we suggest that the improvement in prevention of transfusion reactions require a continual vigilance system for rapid recognition and information regarding these complications. measurements of ige immunoglobulin in thalassemic patients, before and after blood transfusion background: many studies have reported the implications of proinflammatory cytokines including interleukin (il)- beta, il- and tumor necrosis factor alpha (tnf-alpha) in febrile nonhemolytic transfusion reactions. il- has been shown to accumulate in packed rbcs even after the procedure of filtration, which is explained by the release of il- from rbc receptors into the packed rbc super-natant. stress induced elevation in tnf-alpha levels was demonstrated in healthy individuals. aim: to assess the level of proinflammatory cytokines in peripheral blood of blood donors. material and methods: immediately upon blood collection, plasma was separated from postdonation blood samples obtained from blood donors and frozen at - °c. upon thawing, the level of the il- beta, il- and tnf-alpha cytokines was determined in plasma samples by elisa method using commercial kits for cytokine determination (roche molecular biochemicals). the level of il- beta was at the test detection limit in all donor plasma samples. in ( . %) bd, the level of il- was . pg/ml, exceeding the test sensitivity limit of . pg/ml. in ( . %) bd, the level of tnf-alpha was within the range of - pg/ml, with a test sensitivity limit of pg/ml. tnf-alpha levels > pg/ml were measured in plasma samples of ( . %) blood donors. the increased activity of blood donor's immune cells, indicated by elevated levels of the proinflammatory cytokines il- and tnf-alpha in peripheral circulation some blood donors, may lead to the occurrence of febrile nonhemolytic transfusion reactions in the recipients of the blood products manufactured from the blood of these blood donors. this hypothesis will be thoroughly investigated in our future studies. background: transfusion-related acute lung injury (trali) is a life-threatening complication of transfusion, under-recognized and underreported possibly lacking a consensus definition. aim: we report here a 'probable' case of trali syndrome in an elderly female patient. case presentation: an eighty-two year old female patient was transferred to the intensive care unit on the third postoperative day (pod) following the abrupt onset of acute pulmonary insufficiency (pao = mmhg, o saturation = %), hypotension (bp = / mmhg) and fever ( °c). this occurred ten minutes after initiation of an infusion of a unit of packed red blood cells (prc). the patient had no history of any cardiac or pulmonary disease. she was intubated and placed on mechanical respiration and supported hemodynamically. the cvp ( cm h o) ruled out fluid overload. the chest x-ray revealed bilateral pulmonary oedema, the echo cardiogram and blood cultures ruled out cardiac and infectious aetiology of the episode. after treatment for hours the patient improved significantly, was extubated and returned to the surgical unit on the th pod. reviewing the transfusion history we discovered that the patient did not receive any blood or blood component prior or during the correction of her ileum, but she was transfused a unit of ffp (fresh frozen plasma) five hours prior to the incident. the donor review revealed that the unit of ffp was from a -year old female with a history of multiple abortions whereas the prc unit was from a -year old male, a volunteer of several years who had no history of transfusions. there are some prerequisites for the implementation of a haemovigilance network and some of them have been met, so we can present the first results. methods: traceability of blood components is possible because there is unique information system in place in the whole country, identifying the donor, donation, each single blood component and identification of the recipient, but feed back information of the performed transfusion is still missing. cooperation between blood transfusion service and hospitals was established by introduction of hospital transfusion committees; the intensity and quality of their work is very different. homogeneity of reporting is achieved by the introduction of unique reporting form. a reporting route was defined: patients physician sends notification of atr to the local blood transfusion service. atr reporting form is prepared there and sent to the national blood transfusion service, where the data is collected for the centre for haemovigilance, which is going to be established very soon. data analysis will be responsibility of the centre for haemovigilance at the governmental level. type of adverse transfusion reactions and events is defined. education and information was passed to the health personnel by inclusion of haemovigilance in under and postgraduate programmes as well as seminars, scientific meetings and some publications. results: in the years - there were . blood components issued in slovenia and atrs were reported ( in blood components issued), in of them the severity grade was ( in . blood components issued). in the year there were considerable differences between the number of atr reports compared to the number of blood components issued among slovenian hospitals, ranging from in to atr in blood components issued. . % of all atr were not classified. conclusions: although the number of reported atrs was increased by % and % a year in and respectively, it can be assumed that the collected data is not complete. feed back reports, much more information and cooperation is needed, especially in some hospitals, which should contribute to a better registration of atrs and events in the future. the slovenian haemovigilance system still needs upgrading, but despite this, some important work has been done in building a national haemovigilance system. . considering the multiplicity groups in cattle and since there was no research on repeated blood transfusions reactions in iran's native cattle, we decided to consider crossmatching in different processes of repeated blood transfusion from a head of blood donor to five recipients and observe the clinical and hematological alterations. six healthy iran's native cow, . years old, with average weight of kg were used. the animals were dewormed by albendazole ( my/kg bw) and were kept for two weeks under uniform managemental condition. three days prior to blood transfusion, vital signs registration (temperature, heart rate and respiratory rate) blood collection via jugular vein was done to indicate the baseline of research parameters. after that, blood transfusions were performed from one donor cow to five recipients three times at one-week intervals. cross matching was done at each transfusion. after each transfusion the research parameters do determined. results indicated that one of the recipients cows experienced anaphylactic shock, in the first step of blood transfusion and another cows in the second step and finally in the third steps two other cows showed the serious shock. this is in the contrary of this opinion that the first transfusion can be given safely without crossmatching in cattle practice ( van der valt, et al. ( ) background and objectives: blood transfusion may lead to the manifestation of anti-hla and platelet-specific antibodies that may in turn bring about different problems like platelet refractoriness. it appears that the study of antibodies against hla-class i and platelet-specific antigens are useful for the selection and success of the appropriate treatment protocol. the aim of this study was to detect anti-hla and anti-platelet-specific antibodies by flowcytometry in patients with hematologic disorders (including acute leukemia, aplastic anemia) and patients with itp. in this descriptive study, anti-hla and platelet-specific antibodies were detected by flowcytometric technique, using sera drawn from patients with different haematological disorders who showed a poor response to platelet transfusion and from patients with itp. the results of anti-hla antibodies were then compared by panel reactive antibodies (pra). results: our results showed ( . %) out of ( . %) patients had anti-hla class-i antibodies in their sera. the frequency of each antibody isotype was found to be as follows: igm ( . %), igg ( . %) and iga ( . %). ( . %) out of patients had platelet specific antibodies and the frequency of each antibody isotype was found to be as follows: igm ( . %), igg ( . %) and iga ( . %). ( . %) out of patients had both antibodies. no difference was found between the two groups in platelet specific antibodies. despite significant correlation between flowcytometry and pra methods, pra can only detect antibodies which react with complement. conclusions: with increase in the number of platelet transfusion, immunization to hla antigens occurs; moreover, immunization against platelet specific antigens may also occur during autoimmunity. the presence of these antibodies may be one of the reasons of poor response to platelet transfusion and platelet refractoriness in patients under study. conducting similar studies with higher number of samples, platelet cross-match, and the use of hlamatched platelets for these patients are recommended. post transfusion purpura (ptp) is a rare, severe thrombocytopenia that results from alloimunization to platelet specific alloantigens, following blood transfusion. in this condition, the patient's own platelets are destroyed by the alloantibody even though they are not supposed to carry the 'guilty ' antigen. the disease is rare occurring mainly in multiparous women. the majority of reported cases involved antibodies against the platelet specific alloantigen hpa- a in a homozygous hpa- b patient. in a minority of cases the offending antibodies were directed against hpa- b, - a, - b, a, - a, - b. although self-limiting, the syndrome is characterized by severe bleeding with high morbidity and mortality; therefore prompt diagnosis and appropriate therapy is crucially important. ptp is a challenging diagnosis, because the patients are often critically ill or post-surgery, and have alternative explanations for thrombocytopenia such as infections or drugs. we present three patients with severe thrombocytopenia initially misdiagnosed. the first patient, a -year old women, had a past history of systemic lupus erythematosus and coombs positive autoimmune hemolytic anemia. at the present hospitalization, after antibiotic therapy for endocarditis, a severe hemolytic episode occurred and she need blood transfusion. when severe thrombocytopenia appeared, she was wrongly diagnosed as evans syndrome. the second patient, a -year old man, suffered from sepsis after vascular surgery and revealed clinical and laboratory picture of dic. the third patient, a -year old women, had end-stage renal failure and received heparin during hemodialysis, thus heparin-induced thrombocytopenia was first suspected. history of recent blood transfusion rose the suspicion of ptp in all this cases, and appropriate therapy with high dose iv immunoglobulin was started. adequate laboratory work-up confirmed the diagnosis. three different anti hpa-antibodies were identified: anti hpa- a, anti hpa- b and anti hpa- b, respectively. the platelets genotype of the first patient was hpa- b/ b, of the second hpa- a/ a and of the third patient, hpa- a/ a. the reported cases emphasized the importance of keeping in mind the possibility of ptp. incorrect diagnosis may lead to wrong treatment and fatal outcome. health sciences authority, singapore, singapore introduction: the haemovigilance programme in singapore was started by the centre for transfusion medicine (ctm) in . the system covers registration of collected, produced and transfused blood components, and monitors adverse transfusion reactions (atr). the programme runs on a voluntary, non-punitive and confidential basis. aims of the study: ( ) to gather and analyse reports of all adverse and untoward events occurring during transfusion of blood and components. ( ) to use the information acquired to determine the morbidity of transfusion. ( ) to provide guidance on corrective measures to prevent the recurrence of some accidents, and to improve transfusion safety. ( ) to improve public confidence by demonstrating to public, patients and professionals the safety of the existing transfusion system. methods: ( ) a common report form is used and made available to all participating hospitals. within the reporting system, the identification of the patient and staff involved are not required, to ensure confidentiality and protection of information belonging to the hospital. ( ) reportable events include immediate reactions during transfusion (haemolysis, non-haemolytic febrile transfusion reaction, urticaria, anaphylactic shock, bacterial contamination, trali), delayed untoward effects after transfusion (haemolysis, post-transfusion purpura, acute gvhd), transfusion-transmitted infections, incorrect components transfused, and near misses. ( ) within the hospitals, a responsible person ensures that all adverse events and untoward effects of transfusion are reported on the haemovigilance forms and provided to ctm for collation. within the ctm, the haemovigilance coordinator is designated to assist hospitals in investigating serious adverse events and advise on the reporting formats. results: ( ) the total number of reported cases has steadily increased since the introduction of the programme. ( ) the number of participating healthcare institutions has also increased to % (n = ). please refer to table entitled 'summary of the haemovigilance report - ' . ( ) the implementation of the haemovigilance programme in singapore is feasible with respect to the asian setting, and can significantly contribute to blood safety. ( ) there has been very good participation from the participating healthcare institutions, signifying greater awareness and willingness to partake in the programme. ( ) the results obtained from the programme have given rise to initiatives and recommendations aimed at reducing ( %) were rated for seriousness. of these, ( . %) were rated as grade (moderate to serious morbidity) or worse. ( . %) were rated for imputability to the blood transfusion. of these, a relationship to the transfusion was graded as 'certain' or 'probable' in ( . %) and as 'possible' in ( . %). overall relatively few errors were reported in comparison to other systems. a small number of reports concern (possibly) infected blood components, and imputability was deemed probable or certain only in a minority of these reports. autologous blood components gave rise to five reports (errors as well as mild transfusion reactions) which shows a relatively high risk associated with their use ( . per the rate of post transfusion hepatitis (pth) in israel in unknown. this information is important in order to learn about the residual infection risk in blood recipients. aim: to summarize the data on reported cases of pth. methods: suspected cases of pth are reported to mda blood services. the investigation procedure includes follow up testing of implicated donors and retesting of an archive sample of the transfused unit, if available. donors involved in suspected pth-b are tested for hbsag and anti-hbc. anti-hbc+ donors are tested for anti-hbs. hbv-dna testing is done if anti-hbs is less than miu/ml. donors involved in suspected pth-c, are tested for anti-hcv and alt. since hcv-ag or hcv-rna are performed, when appropriate. investigation is considered complete if all the involved donors are retested > months following the implicated unit. results: between between - suspected pth cases were reported: ( %) were pth-b, were pth-c ( %) and in patient both hbv and hcv infections were reported. investigation was completed in / ( %) cases, with % of the involved donors ( / ) being retested > months after the implicated donation. hbsag was not detected in any of the retested donors. anti-hbc was detected in donors involved in pth-b cases of which were also positive for anti-hbs. pcr for the detection of hbv-dna was performed on the 'anti-hbc+ only' donors, and none was found positive. only in / donors suspected to be involved in pt-hcv, anti-hcv antibodies were subsequently detected. this donation was collected and transfused before the introduction of anti-hcv testing in israel, which was implemented in . in another pth-c case, the implicated donor is still negative for anti-hcv, in follow up samples of up to months, but was found positive for hcv-ag and hcv-rna. pth investigation of all the donors involved was completed in % ( / ) of the cases where the patient received up to blood components. conclusion: in the past years an average of cases/year of suspected pth were reported to the israeli national blood services. investigation was completed in % of the reported cases. so far, there was no clear evidence of hbv transmission. in cases (out of . million blood units collected nationwide during - ) hcv seemed to be associated with blood transfusion: one caseprior to the implementation of anti-hcv testing and the otherprior to the implementation of hcv-ag testing in a donor that did not develop anti-hcv antibodies. these findings suggest that other modes of hbv and hcv transmission should be sought in blood recipients in israel. - . , p < . ). the seroprevalence for a-hiv in the bd population was . % (se: . ; ci: . - . ; p < . ) whereas in the a-hbc positive bd was . % (p < . ) and in the a-hbc negative bd was . %. from a-hiv positive donations, were also positive for a-hbc, that means that the sensitivity of the a-hbc in the detection of a donation a-hiv positive was . %. the relative prevalence (percentaje of positive donations for a-hiv in the a-hbc positive population divided the percentage of this marker in the donations a-hbc negative: rp) was . , which indicates that the number of bd a-hiv positive is . times higher in the a-hbc positive that in the a-hbc negative population of bd. as regards a-htlv, the seroprevalence in the bd population was . % (se: . ; ci: . - . , p < . ), in the a-hbc positive bd was . % (p < . ) and in the a-hbc negative bd was . %. from a-htlv positive donations, were also positive for a-hbc, that means that the sensitivity of the a-hbc in the detection of a donation a-htlv positive was . %. the rp for a-hbc as regards a-htlv was . , which indicates that the number of bd a-htlv positive is . times higher in the a-hbc positive that in the a-hbc negative population of bd. our results suggest that, in our bd population the screening with a-hbc would be useful to prevent other infections transmissible by blood transfusion, like retroviruses, because of the high sensitivity and the relative prevalence. . despite the high specificity of currently available elisas, the positive predictive value is lower in blood donors. therefore, immunoblot tests and polymerase chain reaction (pcr) have been adopted for routine testing in elisa +ve blood donors, by our service. . our data show that the real anti-hcv prevalence of our donor population is very low ( . %). . the selection and evaluation of appropriate assays of all donated blood for hcv infection ensure good laboratory practice and accurate post-notification counselling of infected donors. . given that donors who are elisa positive but persistently negative or indeterminate probably do not represent a risk for transmission, their deferral from donation increases the problem of availability of blood supply. . donor re-entry in the pool of donors is an issue for further discussion. . the introduction of nat technology may elicit more accurate responses and improve the screening process. background: the introduction of hcv antibody screening of all donor blood in represented a major step in the prevention of transfusion-associated hcv hepatitis and in identification of infected donors. the study of infected individuals provides a unique opportunity to define behavioral factors associated with infection. evaluating risk factors in hcv infected blood donors is essential for monitoring blood supply safety, donor screening effectiveness and developing appropriate prevention programs objectives: . to recognize the epidemiology of hepatitis c and how it differs geographically; . to investigate the risk factors for presence of anti-hcv antibody in blood donors; . to evaluate the effectiveness of our donor selection program in local level. methods: serological testing for hcv was performed according to standard procedures. initial screening was performed using secondgeneration eia and, after january , using third-generation eia. our study included a confirmation test (riba) a questionnaire was used to collect data concerning demographic, social and sexual behaviors, and number and type of donations of blood donors. the study also included testing of sexual partners and family members. changes in rates of hcv infections were evaluated by comparing yearly prevalence estimates. the overall prevalence of anti-hcv (eia) was . % out of blood donations. the average prevalence of hcv infection by riba was . %, which reaffirms the very low risk of transfusion-transmitted disease. the cumulative number of hcv infected donors was , with cases in males and cases in females. most infections were found among older persons ( % were aged - , and % aged - ). the seropositivity was higher in family/replacement donors ( %) than in volunteers ( %). the annual prevalence decreased throughout years. the relative importance of risk factors for hepatitis c was: transfusion %, hospitalization %, immigrants %, occupational %, sexual transmission %, injection drug use %, household contacts %, other %, tattooing %, unknown %. according to the criteria for blood donation, certain donors should have been excluded in the predonation interview but these donors had denied risky behaviour when questioned. the importance of sexual activity in the transmission of hcv has not been well-established as we tested sexual partners and family members and none of them was found positive. conclusions: our results suggest that major improvement in the safety and quality of our blood supply has been made in our area. introduction: apart from immuno-haematological complications, blood transfusion recipients are exposed to the risk of viral and bacterial contamination of donor blood. the latter infectious risks are generally associated with the number of donations that are needed in the production of blood products: the pooling effect. one measure recently being discussed is the generalisation of the use of trombocytapheresis for the production of trombocyte concentrates. normally, the trombocyte product is a concentration of trombocyte extractions from a pool of buffy coats: pooled platelet concentrates (ppc). in case of trombocytapheresis sufficient trombocytes for one transfusion can be collected from one single donor. aim of the study: in this presentation the effect of using % trombocytapheresis for the production of single donor platelets (sdp) instead of pooled platelet concentrates (ppc) on contamination risks will be assessed. these risks can be divided in ) the risk of bacterial contamination, ) the risk of viral contamination (e.g. hcv, hbv, hiv) resulting from window period donations, and ) the risk of contamination with tse or emerging infections for which no screening test exists. the contamination probability of sdp versus ppc is assessed on the basis of the production characteristics of both products, e.g. the presumption that the contamination risk per trombocyte product will be reduced by a factor equal to the number of pooled donations (five in our case). reduction of the bacterial contamination risk was estimated using the results of the bacterial testing of pooled and apheresis platelet products. as patients are likely to obtain multiple blood products during treatment, the contamination risk reduction through sdp is not only dependent on the reduction of risk in trombocyte products, but also will also dependent on the total number of blood products transfused and their associated contamination risks. the platelet recipient risk reduction was calculated on basis of the distribution of blood products received by the patient population of the university medical center utrecht (umcu) in the year . results: in the attached table the estimated risk reduction through % trombocytapheresis is shown for the general blood recipient patient and for the trombocyte recipient patients only. our analysis indicate that in platelet recipients, general application of sdp instead of ppc will reduce the risk for transfusion acquired tse infections by %, the risk of known viral infections by %, and transfusion acquired bacterial infections by %. the confidence intervals surrounding the results were obtained by bootstrapping. the large confidence intervals surrounding the reduction of bacterial infection risk is caused by the fact that only a limited set of apheresis trombocyte products were tested. conclusion: our analysis indicates that general application of sdp instead of ppc will not reduce the risk of transmitting infections to platelet recipients as linearly ( : ) as expected. whether it is a costeffective precautionary measure will have to be evaluated by a costbenefit analyses consideration clinical benefits and additional costs and risks of apheresis donations. introduction: hepatitis b is serious health problem world wide. its prevention, particularly in the population of blood donors is essential for providing good health care and protection. aim: the aim of this study is to present the distribution of hbsag(+) and hbsag(-) blood donors according to their profession. methods: specially designed questionnaires are used for interviewing the blood donors who has previously given signed consent for participation in this study. results: table shows the distribution of the blood donors in different professions. administrative clerks with ( . %) and the workers with ( . %) registered in the group of hbsag(+) blood donors, as well as workers with ( %) and administrative clerks with ( %) from the hbsag(-) group of blood donors are dominantly more frequent than the other categories of professions. health care professionals, housewives and farmers in both groups of blood donors are least frequent. taking in consideration the distribution of blood donors by the given professions in both groups, for u = and p > . there is no significant difference found. the analysis of the differences among the different frequencies, in distribution of blood donors according the profession, for d = . and p < . shows a significant difference, where the workers with ( . %) are the most dominantly represented. in relation to the issue of whether the type of profession of the blood donors is production or non production the results are presented on table . in the group of hbsag(+) blood donors the number of those who work in production profession- ( . %), is dominant over the number of those that has non-production profession- ( . %). in the group of hbsag(-) blood donors there is no significant difference between the types of professions. conclusion: having in consideration the professions of blood donors in both groups, for c = . and p < . there is a significant difference in the presented distribution. according to our study, which shows the horizontal transmission of hbv infection in the family in which there is an index case, the biggest number of participants in the study is workers, and the least number of participants are the farmers. introduction: blood donors, as part of the healthy population are tested for hbsag with each blood unit they give. therefore, they can be an epidemiological model for exploring the appearance of hbv infection in general population. aim: this study aims to show the distribution of hbv infection in blood donors in relation with their living conditions, space and facilities. the material needed for the study consists of the data obtained from confirmed hbsag(+) blood donors and confirmed hbsag(-) blood donors as control group. results: the table shows almost equal number of hbsag(+) blood donors that live in houses or flats. in the hbsag(-) group ( %) donors that live in a flat dominate compared to ( %) of those that live in a house. having in consideration the presented distribution (table ) for c = . and p < . there is a significant difference, that comes from the bigger number of blood donors ( ) that live in flat. as for the distribution of blood donors according the living space they use by member of the family (table ) , we can show that ( . %) of the hbsag(+) donors have less than m living space, in compared to ( %) from the hbsag(-) group. the bigger number of hbsag(+) blood donors with small living space gives bigger possibility for transmission of hbv infection in the family. the differences in the two groups for donors that have between and m , and between and m of living space per person, obviously are not very big. for u = and p > . there is no significant difference in the number of the donors in the two groups, when the available living space in m is discussed. introduction: when one of the sexual partners has hbv infection the other is also infected in from cases. aim: the aim of this study is to outline that the risk from transmission of hbv infection between sexual partners is smaller if they use condom as protection. methods: two groups of blood donors-hbsag(+) and hbsag(-) have been interviewed whether they are using condoms as protection, or not. results: table shows the distribution of blood donors concerning the use of condoms. table : in the group of hbsag(+) blood donors those who have not used condoms dominate with number of ( . %), in compared to those ( . %) who used condoms. these data are in favor of eventually possible sexual transmission of hbv infection in hbsag(+) blood donors. in the group of hbsag(-) blood donors dominate those who have used condom- ( %), compared to ( %) who have not. the given distribution of blood donors concerning the use of condoms for c = . and p < . , shows significant difference, which is due to the prevailing of the number of blood donors ( ), who have not used condom. of er -concentrates are leukodepleted. the choice of bacteriological control of empty bags for blood, bags with er -concentrates in additive solution, universal and iso group plasma, as well as the systems for taking of blood are taken on free choice. the control of the erytrocyte concentrates is performed on the first day after the preservation and dekanting, and again between the th- st day and th- th day after the preservation. the pulled plasma is controlled on the day of pouring (spreading), and the control of the iso group plasma on the day of deplasming. three months later the iso group and the universal plasma kept on the temperature of - °c is bacteriologically controlled again. bacteriological control is performed with standard procedures in the institute for health protection in stip. the transfusion transmitted infections are potentially dangerous complications of transfusion therapy in immunocompromised patients. the aim of this study was to determine the prevalence of transmissible infections in blood donor population in kashan, iran. a total of consecutive sera were tested for cmv-igm antibody, hbsag, hepatitis b core (hbc) antibody, hepatitis c (hcv) antibody, and hiv antibody with standard methods. of the sera tested, specimens ( . %) were cmv-igm positive. the frequency of seropositive revealed no significant differences between male and female donors. the frequency rates of cmv-igm seropositive tests tend to decline with increasing the age. there was no relation between the frequency rates of cmv-igm seropositive with the educational level, socioeconomic status, marital status, urban dweller and rural resident patients. the prevalence of hbv, hcv, and hiv antibody were . %, . %, and %, respectively. these findings implied important clinical applications because detection of cmv positive sera may reduce the risk for transmission of cmv in blood transfusion and thereby decrease the risk on cmv-induced complications. introduction: the worlds problem, aids, steel can't be said that is a problem in these three centers in r. macedonia, in which blood is collected, controlled, and distributed. found negative and of them were found positive for one of the three viruses (hiv- , hcv, hbv). with the elisa/axsym assay of the blood units which were negative by the procleix ultrio assay were positive for anti-hbcag and negative for anti-hbsag and hbsag. from those blood units units were given for transfusion following our blood centre protocol and the remaining units were discarded. the protocol consists of a good medical history, liver enzymes (ast, alt, ggt). we must take into consideration that from those that were found positive by the procleix ultrio assay was positive for anti-hcv and were positive for anti-hbsag. summary/conclusions: despite the fact of the short period of time we perform this method, the ability of the nat technique for rapid use, reliability and sensitivity in detecting three viruses simultaneously, indicates the need for immediate use in blood donation as a screening method. in spite of the high cost of the method, it is clear that this assay is a valuable tool in our blood centre to provide fast and safer blood. bacterial contamination of blood products is a persistent, but often overlooked, problem in transfusion medicine. in greece it is recommended that platelets (plt) must be used or discarded within five days post-collection. recent reports from europe have advocated the use of bacterial culturing of platelets on day or and, in case of negative result, prolongation of their storage time to days. aim of the study: to assess the prevalence of bacterial contamination of standard platelet units from whole blood, and to provide evidence that with the use of bacterial culturing it is feasible to extend the self life of platelets to days. materials and methods: eligible blood donors were bled according to standard operating procedures used in greece. plt were prepared from whole blood, solely for the purpose of the present study, by the platelet-rich plasma method. plts were stored for up to days at to °c with end-over-end agitation. other plts prepared from blood collected in triple-pack container system also provided with a predonation sampling device were also tested. plts were sampled in the bacteriology laboratory. plts were sampled on day , and . both aerobic and anaerobic culture bottles were inoculated with a -ml platelet sample. culture bottles were incubated at °c in an automated microbe -detection system (bact/alert system) until a positive reaction was detected or for days. all samples that were reactive were confirmed by routine culture. each reactive sample with bacteria growth on the routine culture was sub cultured for identification of the bacteria. results: a total of plt concentrates were cultured and bacterial contamination was assessed in each unit at day , and after collection. on of storage day two out of ( . %) plt units were found to be positive for bacterial growth. cases of unconfirmed positive results were noted at the beginning of the study. out of the other units which were negative on day and continued to be cultured for the next days, the assessment at day found no other positive. after further storage, at day , defined as the end of the prolonged incubation period, out of the plt concentrates ( . %) grew bacteria although testing of the same units on day and gave no signal. from the platelets units that were prepared from blood collected with a predonation sampling device, none of the plt concentrates gave a positive signal although pouches were found to be positive, and subculture showed bacterial growth of coagulase -negative staphylococcus. despite the relative small number of tested platelet concentrate units, our findings discourage specialists in attempting platelet storage time prolongation to days. bacterial contamination testing on day and a storage time of maximum days seems to be still the safest practice. bacterial screening of platelet concentrates using bact background: bacterial screening of blood components is a routine measure in the evaluation of blood product quality. at our institute bacterial screening is performed using bact/alert system. sampling and culturing of blood products is performed according to paul-erlich institute recommendations. methods: quality control data on the bacterial screening of platelet concentrates performed from - were retrospectively analysed. an initially positive (ip) and true positive (cp) rate, organisms isolated and time of detection are presented. results: a total of platelet products were tested during the year period. thirty ( . %) were found initially positive by bact/alert. the cultures screening positive were subjected to bac-terial identification to distinguish false positive from real positive signals. bacterial contamination was confirmed in ( . %) plt concentrates. positive cultures were confirmed and identified in an independent laboratory ( hbsag, anti-core, anti-hbs, anti-hcv, anti-hiv i/ii, anti-htlv i/ii, rpr. these patients were transfused with - units of concentrated red cells, depending on their problem. a total units were delivered from the beginning of their problem until december . the control were done using last generation enzyme-linked immunoassay (dade behring, ortho, biomeurieux), as also using automated enzyme-linked immunoassay (axgym). the same patients were checked by their physicians before the initiation of transfusions for the same diseases. results: we found: patients anti-hbc (+) and anti-hbs (+). patients anti-hbc (-) and Ánti-hbs (-) patients anti-hbc (-) and anti-hbs (+) patient anti-hbc (+) and anti-hbs (-) patient hbsag (+), anti-hbc (+) and anti-hbs (-). all patients were negative for hcv, hiv, htlv, and rpr. the same results were found also from patients' physicians. conclusions: we conclude that the blood supply for blood transfusion-transmitted diseases is % safe in our centre. these results are in accordance with current international literature. this is due to careful selection of blood donors, to high quality of corporation between departments as also to internal and external quality control. all these factors contribute to safety of transfusions, the quality of life of the patients and the protection of patient's environment. neither in the pipetor nor in the extractor runs was found contamination. no false positive were detected and all the positive samples confirmed. (see tables and ) . for hiv and hcv the specificity was . %. the validation criterion were met, so the system was implemented routinely in our laboratory. the purpose of our study was to analyse the applicability of the pall enhanced bacterial detection system (ebds) in the routine of our transfusion unit which is totally focused on apheresis platelet collection. methods: apheresis pcs, obtained by trima (cobe) and amicus (baxter) separators and re-suspended in % plasma and % ssp solution (macopharma), were submitted to microbiologic control using pall ebds system which uses oxygen percentage decrease as a surrogate marker of bacterial growth. the working steps were the following: - hour after donation, about ml of pc were sampled into the ebds collection pouch and then incubated at °c under continuous agitation (incubator helmer ) for hours. after this period, oxygen percentage was measured using an oxygen analyser (pall bdso ). the test is based on the 'pass/fail' principle. in case of 'fail' result the microbiology department has drawn up the procedure to follow in order to confirm the data and to allow the micro-organism to be identified. the incidence of post transfusion hepatitis has been reduced by blood donor screening for hbsag, but the hbv infection is still responsible for a certain cases of post-transfusion hepatitis in world-wide. in this study the hbsag negative blood units were evaluated for anti-hbc and hbv dna by pcr method. an extra sample was collected from hbsag, anti-hcv, anti-hiv and rpr-negative blood donors. all of samples were examined by approved anti-hbc assay. all of anti-hbc positive samples were tested by hbsab assay and evaluated for hbv dna (pcr). the sensitivity of the hbv dna (pcr) assay was estimated geq/ml according to vqc proficiency and run control panels. ( . %) out of samples were positive for anti-hbc. ( . %) out of anti-hbc positive samples were hbsab positive, and ( . %) were hbsab negative. all of samples were assayed for hbv dna (pcr) single and all of them were negative for hbv dna (pcr). further study for evaluation of anti-hbc test as a screening assay for blood unites in high hbv infection prevalence area strongly recommended. early detection of hepatitis b surface antigen: a comparison of ten assays hbsag detection is the corner stone of detection of hepatitis b virus infection in blood donors and patients with hbv infection. one of the most challenges is sensitivity of the technique and kit. in this study ten different assays evaluated by seroconversion and performance panels. some of them can not be used as screening assay due to low sensitivity. the sensitivity of ten hbsag assays from biorad, dade behring, biomeriux, diasorn, radim, diesse, thermo. biokit, gb and shanghai companies were evaluated by two or three seroconversion and two performance panels from boston biomedica ink. seroconversion panel is a series of samples that collected over a period of time from individual developing antibodies due to a primary infection. for evaluation of the assay sensitivity who and other notified body in the world-wide recommended the seroconversion and performance panels. the hbsag assays are two groups. group one with high sensitivity included six assays. they can detect ad and ay subtypes from . ng/ml bbi to . - . ng/ml bbi respectively. low sensitivity group included four assays and they can detect ad and ay subtypes more than . and . ng/ml bbi respectively. for blood safety, the high sensitivity hbsag assays recommended for blood screening and all assays should be evaluated by seroconversion and performance panels. diagnosis of chronic hdv infection is usually by antibody testing and hbv dna detected by pcr method. it is rare to find patients with two replicating hepatotropic viruses and if the accompanying hbv is replicating, prognosis will be very poor. to clarify the correlation between hepatitis delta virus infection and hepatitis b virus dna positivity, sensitive hbv dna (pcr) assay was used. the presence of hbv dna was investigated in patients referred during the aug. to dec. . all of them were hbsag positive. all samples were evaluated for hbv dna (pcr). the sensitivity of the hbv dna (pcr) assay was estimated geq/ml according to vqc proficiency panel and run control. anti-hdv was tested by commercial available enzyme immunosorbent assay. ( . %) were hbv dna positive and ( . %) were negative. ( . %) out of patients had evidence of delta infection and ( . %) samples of hbv dna (pcr) negative patients were positive for delta agent. the serum alanine aminotransferase (alt) levels in out of hbv dna (pcr) and anti-hdv positive patients were higher than reference interval, but only in out of hbv dna (pcr) negative and anti-hdv positive samples were higher than reference interval. the present data indicate that . % of patients with chronic hepatitis b have hepatitisdelta infection. patients with hbv dna (pcr) negativity had a significantly higher prevalence of delta marker ( . %) than those with hbv dna (pcr) positivity ( . %). delta rna testing in positive hbv dna and anti-hdv patients is recommended. introduction: reduction of the window period of hepatitis c virus (hcv) infection represents an important goal in the transfusional and diagnostic setting and nucleic acid technology-based tests have been introduced in some developed countries to reduce the potential risk of transfusion-associated infection. a prototype assay designed to simultaneously detect circulating hcv antigen and anti-hcv has been developed by biorad (biorad laboratories limited, marnes la coquette, france). aim of the present study: to define the cut-off (co) value of the assay and to evaluate the specificity and sensitivity of this new assay in the detection both of antibody and antigen comparing its efficacy with commercial assays. methods: in order to establish the co value and to evaluate the specificity of the assay, we tested sera samples from the general population and 'difficult' sera from haemodialysis patients (n conclusion: the new assay shows high sensitivity and specificity and could be a useful tool not only in the diagnostic setting, where procedures to reduce the window period, such as antigen or hcv-rna detection, are not currently recommended, but also in the screening of blood donations, when nucleic acid technologies is not feasible due to costs, organization, emergency and/or logistic difficulties. introduction: in recent years the concern with the blood safety regarding the transmission of blood-borne viruses has been improved. this safety has been achieved with the combining of different strategies, such as a careful selection of donors, the screening for relevant virological markers and the viral inactivation/ removal methods. more recently, the implementation of the nucleic acid amplification technologies for the detection of hiv- , hcv and hbv, has increase this aim by reducing the 'window period' of the infections. other viruses, such as parvovirus b (pb ) and hepatitis a virus (hav), can raise problems to the blood safety. these infections could provoke serious complications in some risk groups, like pregnant women, patients with haematological problems, children and patients with immunodeficiency. material and methods: an observational study was performed to determine the prevalence of pb and hav in portuguese blood donors. we gather, during four months, plasma donations and joined them into pools, with no more than donations each. [ ] [ ] [ ] [ ] [ ] in voluntary donors the anti-hcv prevalence ranged from . % to . %, in family replacement donors from . % to . %, autologous donors from % to . %. we observed that the anti-hcv prevalence has a decline tendency during years in blood donors. according to sex the anti-hcv prevalence in men is . % and women . % (p = . ). over the year periods the prevalence in men has a decline tendency ( . % to . %; p = . ) and increasing tendency in women ( . % to . %; p = . ). according to age group the anti-hcv is . % in - age group, . % in - age group, . % in - age group, . % in - age group (p = . ). the prevalence of anti-hcv is higher in fds than vds, but not statistical significant. [ ] [ ] [ ] [ ] [ ] . a total ftd and ad have been tested for hbsag. a sample was considered as hbsag positive when found repeatedly reactive by rd generation. immunoassay method (elisa). the chi-square test was used for statistical analysis. results: the -year overall hbsag prevalence among first time blood donors was . %. and ad . %. among autologous blood donors was observed a decreasing hbv prevalence from . % to . % in . according to age the prevalence was higher in - year group . %, while according to sex was higher in man ( . %) than female . % (p < . ). among ad, a decreased hbsag prevalence according to age was observed in men and women. the same trends by sex and age were observed in ftd. the prevalence of hbsag in ad was lower than in ftd. however, from - hbsag prevalence has decreased in the same proportion in both population. this decreased can explain by to main factor: the improvement hbsag screening method in blood donors and decreased the hbsag prevalence in general population. ( : ) . the hbv dna-emia in hbsag negative samples was . ¥ - . ¥ copies/ml. in two donors anti-hbc total was positive and in one anti-hbe was also detected. in one donor the glycin alanin mutation in the s region was identified. the frequency of hbv dna pos/hbsag neg donors in poland is high ( . %) therefore the decision to introduce routine hbv nat screening is justified. ( / ) with stored apheresis and whole blood derived platelet concentrates. of these failed results there were confirmed positives (presence of bacteria in both the ebds pouch and the platelet mother bag by culture) representing / . the bacteria detected were staphylococcus or streptococcus sp. of the fail results were false positives (no presence of bacteria in the ebds pouch and the platelet mother bag by culture) representing . % or / , and were not confirmed initial positives (no bacteria in the mother bag by culture, ebds pouch not tested) representing / . there was one reported case of a missed detection with confirmed presence of bacteria (staphylococcus epidermidis) in the mother bag by culture. subsequently, the bacteria strain was isolated and inoculated into platelet units in our laboratory at levels as low as cfu/ml. in all cases the pall ebds was able to detect. this supports the hypothesis that this missed detection was the result of a statistical sampling error rather than a system failure. the results from blood centers routinely using pall ebds demonstrated effective detection of bacteria in platelet products stored under routine conditions with a true positive rate of / , and with a low false positive rate (< . %). this is comparable to a recent survey result with other culture based systems. summary/conclusions: the minority group of pregnant women who come to labor without prenatal testing of hepatitis b and c revealed essentially similar prevalence of anti-hcv with healthy bd even if definitive confirmation is probably increased in this minority group. there is however markedly higher prevalence of hbv infection in the pw so that screening for hbv is essential for the prevention of vertical transmission. the systematic screening of bd with anti-hbc serves as further assurance for the prevention posttransfusion hepatitis eliminating only . % of the possibly infectious, a percentage which can be restored to the blood pool after proving their immunity. methods: blood samples were screened for the presence of hbsag, hcv and hiv antibodies using enzyme immune assay and for syphilis using the tpha test. the results were analysed retrospectively. all samples with results at or above the minimum positive value were considered reactive. the tests for hbsag, anti-hiv and anti-hcv were repeated in duplicate in all reactive donations. blood units that were reactive in the primary or secondary assays were discarded. hiv positivity was confirmed by western blot analysis using hiv blot . (genelab diagnostics) results: results from a total of screened donors were analysed. hepatitis b surface antigen rates was . %; anti-hcv seropositivity was . %; anti-hiv seropositivity was . % and tpha seropositivity was . %. one study calculated this risk to be one in for hbv, one in for hiv and one in for hcv. it is therefore important to take a careful history from blood donors to eliminate those at high risk of infection. in view of the high infectivity of hiv positive blood, it is important not only to screen donated blood but also to exclude donations from high-risk individuals, such as males who have engaged in homosexual activity and intravenous drug users. a careful history should identify those who should not give blood. in turkey, among blood donors the average hbsag prevalence in - was . %. but it had decreased to approximately . % in . anti-hcv positivity has been reported to be . % between and . but it was approximately . % in . rpr positivity in blood donors in turkey was reported to be < . % in and . % in . in , the rpr rates was . %. in our study these rates are . %, . %, . % and . % respectively. anti-hiv seropositivity was found around . introduction: the serological detection of specific antibodies to treponema pallidum (tp) is an effective means of diagnosing syphilis, and an automated chemiluminescent assay is ideally suited to testing large numbers of specimens for the laboratory diagnosis of the disease. aims of the study: to develop a qualitative syphilis assay for the detection of tp immunoglobulin m (igm) and g (igg) antibodies. the assay will be used for the serological diagnosis of syphilis using the architect platform, which has the capacity to test specimens/hour. the two-step assay is based on paramagnetic microparticle chemiluminescent technology, utilising microparticles coated with three recombinant tp antigens (tpn , tpn and tpn ) and acridinium labelled anti-human igg and igm monoclonal antibodies as conjugates. in the first step, specimens, microparticles and diluent are incubated together, prior to a wash step; in the second step, acridinium labelled antibodies are added and after washing, pre-trigger and trigger are added to produce chemiluminescence, which is measured as relative light units (rlu). specimens yielding rlus less than the cut-off are considered negative, while those yielding rlus greater than the cut-off are considered positive. the sensitivity of architect syphilis tp was determined to be %, after testing specimens that were previously screened as syphilis positive in fujirebio tppa; no prozoning was observed with high positive specimens (over titer by tppa). the specificity generated from testing hospitalised patients previously screened as tppa negative, was . %. testing a mixture of sera and plasma from random donor specimens, generated donor specificity figures of . %. the precision (cv%) with a positive control was . % ( % confidence interval: . - . %) by the standard -day nccls analysis (ep a ). in a study conducted at asahikawa medical college hospital, in which, positive and negative specimens were tested, concordance with fujirebio tppa was determined to be %. no significant interference to the assay was observed from bilirubin (conjugated type and free type), haemoglobin or lipid. the architect syphilis tp assay is an automated, specific and sensitive test for the detection of antibodies to t. pallidum. background: hcv exposure of blood donors is serologically determined by the detection of anti-hcv antibodies in serum or plasma. however a 'window' period of - days after exposure exists during which specific antibodies to hcv antigens cannot be detected. hcv rna detection and/or hcv core protein testing result in dramatic reductions in the preseroconversion window period. the new bio-rad test, based on the simultaneous detection of hcv core antigen and anti-hcv (core, ns , ns ) antibodies, improves the detection of hcv infection in the early phase. aims: the aim of this study is to assess the performance characteristics of this new screening microplate immunoassay, monolisa hcv ag-ab ultra, by using the bio-rad evolis automated microplate processor system. methods: this two-step elisa assay is based on the combination of an indirect test for the detection of antibodies (core, ns , ns ) and a sandwich test for core antigen detection. results are available within . hours, with sample addition monitoring and color coded reagents. no specimen pretreatment is required. evolis is a self-contained microplate processor designed for full automation of microplate-based eia techniques. the walkaway system can process four microplates at a time with continuous loading of samples and reagents. positive identification of samples, reagents and microplates, usage of disposable tips with clot detection, integrated quality control and complete traceability provide a high level of safety management. the monolisa hcv ag-ab ultra/evolis system performance is evaluated for clinical sensitivity on commercially available and well-documented seroconversion panels. the results are compared to viral rna detection and conventional hcv ab screening assays. specificity is evaluated by using random blood donor samples. results: among the seroconversion panels that begining with samples negative for hcv rna and anti-hcv antibodies, the monolisa hcv ag-ab ultra assay detects exposure to hcv an average of days earlier than the monolisa hcv plus v test. the mean delay of the monolisa hcv ag-ab assay in detecting hcv infection compared to hcv rna testing is around . days. the monolisa hcv ag-ab ultra/evolis system allows simultaneous detection of hcv core antigen and anti-hcv (core, ns , ns ) antibodies, thus significantly reducing the time gap between the initial detection of hcv rna and the first appearance of detectable anti-hcv antibodies. the fully automated system combines high degree of assay performance with optimization of laboratory workflow and safety management. operational evaluation of pall ebds bacterial detection system l larrea gonzalez, ma soler and rj roig centro de transfusion, valencia, spain introduction: regulatory bodies are increasingly mandating the use of bacterial detection systems for platelet products ( ed standards for blood banks and transfusion services). one system currently available is the pall ebds bacterial detection system which utilises percentage oxygen as a surrogate marker for bacterial growth. aims: to evaluate the pall ebds in routine use in our blood centre. in particular, to assess feasibility and adaptability to daily labour routines. the orbisac (gambro bct) system was used to produce leucocyte depleted buffy coat (bc) platelet pools ( bc/pool) stored in platelet additive solution (ssp macopharma). mean platelet count was . ¥ e /pool with mean leucocyte count . ¥ e /pool. ebds installation and training occurred over a day period. platelet pools were tested for bacterial contamination over the subsequent weeks. ebds pouches were sterile connected onto platelet pools hours after blood donation. platelet samples were taken into the pouches and then the pouches were incubated for hours on a shaking agitator at °c. after this time, percentage oxygen was measured. no positive results were found in this study. this was as expected due to the relatively low number of platelet pools tested and it also highlights the absence of false positive results. minimal training was required to use the ebds. the system was easy to use and did not require the use of a laminar flow cabinet to take samples. it was quick and simple to take samples and perform oxygen measurement. after pouch incubation, technician was able to make oxygen measurements in less than minutes. the data management system allowed full traceability of product and work flow. results were very easy to interpret. conclusion: the pall ebds was found to adapt perfectly to a routine blood centre environment. ( ) was . the percentage collected from volunteer blood donors was % (n = ) and the rest % (n = ) was given from patient-related donors. the age of donors ranged from to years old. the assay used for the detection of hbsag, hbeag, anti-hbc igg/total, anti-hbc igm, anti-hbe and anti-hbs was the automated microparticle enzyme immunoassay (axsym) of the abbot company. all the units were tested for hbsag, and anti-hbc igg. if the anti-hbc igg was detected, the specimens were automatically tested for anti-hbs. the units were wasted if the anti-hbs was negative, and the specimens were manually programmed for the testing of the anti-hbc igm, hbeag, and anti-hbe. from the total of tested units, of them were found to be positive to at least one marker of hbv infection, that means the . % of the health adult population was infected in the past by the hbv. the . % (n = ) was previously infected and now immunized with hbsag(-) and anti-core igg(+) and . % (n = ) were chronic carriers of the hbv with hbsag(+). the . % (n = ) of the positive donors were patient related donors and . % (n = ) were volunteer donors. in other words, of the not volunteers ( . %) and of the volunteers ( . %) were detected to be infectious. the combinations of the serologic markers for hbv are illustrated in the table attached. these results indicate that the incidence of hbv infection in the northeastern department of greece is equivalent to the incidence of hbv in other greek regions ( . %) as it is referred to the national haemovigilance data and moreover, the percentage of infectious donors is bigger among replacement donors, . % compared with the . % of voluntary donors. as a consequence, the best source for safe blood collection is the population of volunteers. earlier detection of human immunodeficiency type , hepatitis c and hepatitis b viruses using the procleix® ultrio tm assay on the procleix® system and the study objective was to assess the ability of the ultrio assay and associated discriminatory assays to reduce the detection windows for hiv- , hcv, and hbv. commercially available seroconversion panels were used for testing. methods: hiv- (n = ), hcv (n = ), and hbv (n = ) seroconversion panels were tested neat and diluted ( : and : ) in the ultrio assay. panels were tested neat in the appropriate discriminatory assay. times to detection of hiv- , hcv, and hbv nucleic acids in seroconversion panels were compared to the vendor's historical data on time to detection of antibody and/or antigen using licensed or validated serologic tests. p- effectiveness and limitations of methods for platelet bacteria screening -how to apply which screening method? the successful concept of virus safety in transfusion medicine is not suitable in bacterial contamination. bacteria can grow up in blood components to enormous amounts, whereas the initial number of contaminating bacteria is typically very low. therefore, sample drawing for bacteria screening must not be done immediately after blood donation. the established concept of relevance of clinical microbiology (pathogenic, non-pathogenic, facultative pathogenic species) is not valid for bacteria contaminating blood. here, the currently discussed criterion of clinical relevance is the ability of bacteria strains (not species!) to grow up in blood components. the paul ehrlich institute (pei) developed pei bacteria standards, which are characterized concerning their behavior in blood components. they contain a defined number of living bacteria, they are deep frozen, ready to use and shippable. there are two strategies to improve bacteria safety of blood: screening and pathogen reduction. neither of them is perfect, but screening methods are successfully established since several years in routine (belgium, the netherlands), and represent the current state of the art. further development and collecting of experience will produce the basis for assessments in the future. it is of high importance to apply the screening methods in dependence on their properties. methods implying an incubation/cultivation step ('early methods') have to be distinguished carefully from 'rapid methods' . for example, it is unreasonable to compare (or to advertise with) different sensitivities of methods not considering their detection principle or their informative value. both principles, cultivation methods as well as rapid methods, show advantages and disadvantages. selection of the method has to consider the respective conditions of the given blood service (including logistics up to time frame between issue and transfusion). results from the procleix hiv- /hcv and hiv- /hcv/hbv (procleix ultrio) assays for the detection of hiv- rna, hcv rna and hbv dna in blood donors of two blood transfusion centers of sw greece in discriminatory assay testing, out of ( % of the positive, . % of total) were reactive for hcv rna only and out of ( % of the positive, . % of total) were reactive for hiv- rna only. none were positive for both hiv- and hcv. the standard serological assays gave the same results for the above positive samples. two samples that tested positive by the standard serological assays tested negative in the procleix hiv- /hcv assay. of the samples tested by the ultrio assay, ( . %) tested reactive for hiv- /hcv/hbv. in discriminatory assay testing, out of ( . % of the positive, . % of total) was reactive for hiv- rna, out of ( % of the positive, . % of total) were reactive for hcv rna, and out of ( . % of the positive, . % of the total) were reactive for hbv dna. all were single positive i.e. none tested positive for more than virus. three out of positive samples for hbv dna tested negative by the standard serological tests. the opposite was not observed. the procleix ultrio assay is a definite improvement over the procleix assay in a region with a high incidence of hbv carriers. up until its use, it is obvious that hbv positive blood with very low antibody titers was transfused into patients. more results will show whether procleix ultrio can eventually replace the standard serological tests. the introduction: patients with hemophilia represent a high-risk group for post-transfusion hepatitis whose frequency is closely linked with the number and quantity of blood products used. in albania, the frequency of hepatitis is also linked with hbsag testing with elisa (introduced in ), and hcv testing (introduced in ). aim of the study: evaluation of the prevalence of the markers of hepatitis b, c, and d in patients with hemophilia. methods: our study included patients with hemophilia treated with cryoprecipitate and commercial clotting factors. blood testing for anti-hcv, anti-hdv, and hbsag was performed with elisa -gen. iii. results: of patients tested, cases ( %) were hbsag positive, cases ( %) were anti-hcv positive, and cases ( %) were anti-hdv positive. co-infection of hbsag and hcv was found in cases ( %), whereas co-infection of hcv, hdv, and hbv was found in persons ( %). the highest rates of infections and coinfections were found in patients above years of age. conclusion: mandatory blood testing has decreased the levels of post-transfusion hepatitis. in albania, hemophilia is also still treated with cryo-precipitation, thus patients are at a particularly high risk during the 'window period' . results: / ( . %) samples from rbd were anti hiv + nonreactive and rr for p ag both being nonreactive in the neutralization test, they were interpreted as false positives. / ( . %) sample from fbd was rr for p ag/anti hiv + nonreactive and it was confirmed positive by neutralization. this bd had been autoexcluded himself after blood donation. he showed seroconvertion days later: p ag nonreactive, anti hiv + reactive and western blot positive. the only bd p ag positive/anti hiv + nonreactive during the analized period, was an first time donor and the post donation autoexclusion was effective en this case. although a larger populations of bd is necessary to be studied and in spite of the low prevalence we have found, we consider p ag screening is an alternative up to implementation of nucleic acid testing and simultaneously we should increase the quantity of altruist repeat blood donors, undoubtedly, the best population to give blood. owing to the rather short interval between successive donations (~ days), this suggests that some - infectious units escape the screening annually. to these, one has to add the (now unknown) proportion of potentially hbsag negative + hbv dna positive ftbds. hcv: since the introduction of the screening in , the general incidence in rbd has dropped from . ‰ to . ‰, suggestive of a : escape rate. the prevalence in ftbd has stabilized at ± ‰. based on reasons similar to these employed for hbv, the residual incidence in rbd suggests that potentially infectious donation in rbd escapes the screening (= to a total of aprox. , annually). a limited investigation using hcv-antigen eia evidenced a ‰ escape rate in ftbds (= to a total of aprox. , annually table and are concerned to the fist two months of the implementation, where we had to adjust the volume of the eluate. conclusion: these system adjusts to the laboratory daily routine in the blood bank, with the pools released after first analysis in less than hours. background: the hbsag, anti-hcv, anti-hiv / , p antigen, alt and syphilis tests are performed for blood donations in czech republic. no nat tests are mandatory in czech republic. the aim of this pilot study was: . hcv rna pcr testing in anti-hcv negative blood donations; . correlation between hcv nat and anti-hcv testing results. methods: blood samples (anti-hcv serologically negative, alt not elevated) were pooled using the guardian plus spii into pools of samples. pools of ml were tested using the cobas ampliscreen hcv test v. . (roche). results: pools of samples from a-hcv serologically negative donations were tested from october to july . no one pool was initially reactive. invalid tests: ( . %) run failures were observed, due to: invalid internal controls ( . %) and invalid positive controls ( . %). invalid tests were repeated. in none of pools a positive hcv nat result was observed. conclusions: no discrepancy between hcv nat and a-hcv results was observed in our study. all of the nat tested donors in our study were regular voluntary whole blood or plasma donors who were repeatedly a-hcv serologically negative. the hcv incidence in the czech republic blood donor population is low but it is slightly growing up in general population. hcv nat testing could improve the safety of blood supply by reducing the window period for hcv. introduction: parvovirus b is the only parvovirus known to be a human pathogen. most commonly, it causes a mild childhood rash, erythema infectiosum, but in some cases more serious symptoms can be linked to b , such as acute or persistent arthropathies, critical failures of red cell production, hydrops fetalis, fetal loss, myocarditis or hepatitis. inactivation of the non-enveloped virus has proven difficult. as a consequence, manufacturers of blood products have implemented screening measures to reduce the load of parvovirus b in manufacturing plasma pools by the use of nucleic acid amplification techniques (nat). in our institute all blood donations were screened for human parvovirus b by nat since april . methods: over the last years . million donations were screened for b by nat. samples with a virus load over iu/ml were defined as positive, whereas samples with a virus load between the detection limit ( iu/ml) and iu/ml were defined as weak positive. weak positive products were released, whereas positive products were discarded. in addition infection markers of b positive donors (case group) were determined over a time period of one year. virus load and b antibody status was compared with b negative donors (randomised control group). b antibodies (igg vp , igm vp , ns ) were analysed by two commercial antibody tests. results: overall b nat-positive donors were identified with a virus load over iu/ml out of . million tested. there was a seasonal accumulation during spring and summer, whereas a large epidemic occurred throughout the last year. vp igg was detected in . % and % of the case and control group, respectively (p = . ). these data demonstrated statistically significance (p = . ). all donor samples which were b nat positive for more than three months developed neutralizing vp antibodies. in contrast, ns antibodies were observed in % of the case group and in % of the control group (p < . ). ns antibodies were detected more frequently in samples, which were b nat positive for more than six months. conclusion: b nat could be implemented in blood donor screening as release criterion without causing a shortage in blood supply. all b positive donors of the case group developed neutralizing antibodies within three months and virus load was dropped rapidly below iu/ml. these data support our testing algorithm all components of high positive donations (virus load over iu/ml) were discarded. donors with ns antibodies showed more often signs of a chronic disease with detectable levels of parvovirus b longer than six months. background: on recent years, the syphilis screening of blood donors has become increasingly important not only because of the transmission risk of this infection but also due to the risk behavior that this implies. on account of the importance of this screening the tests used are becoming more and more sensitive. aims: to evaluate an elisa screening test (the tmpa test recombinant is based on the sandwich principle, an immunoenzymatic technology in solid phase, for the measure of anti-treponema pallidum in serum or plasma). methods: in this study samples from blood donors were tested by the rotine 'cardiolipidic reagent for syphilis screening on microplates' -diagast laboratories as well as with 'hdtmpa recombinant' -hoslab diagnostics. positive samples were then confirmed with fta abs/tpha. results: using the mentioned tests we obtained the following results: . ( . %)cases turned out negative with both technologies; . ( . %) cases were positive in both methods; . cases were positive only using tmpa recombinant [of which ( . %) were confirmed positive by tpha/fta abs. as seen we found samples ( . %) that were only positives by tmpa recombinant test and that were confirmed by tpha/fta abs. we concluded that tmpa recombinant seems to be a suitable test for a quick and automated syphilis screening of blood donors and provides maximum safety for the recipients. background: in recent years, there has been substantial evidence indicating that typing and subtyping for hcv is clinically important in understanding hcv disease and its therapeutycal options. 'naive' viral load also seems to influence disease severity and responsiveness to therapy. therefore, viremia and genotype identification have been done routinely in molecular biology laboratory units. aims: the university hospital of coimbra studies and tests his own patients and patients from other hospitals in the central portugal. we also collect and test blood donor candidates from this region. we proposed to analyse the distribution of hcv genotypes in this region, among patients with cronic hcv infection. we have simultaneously analysed the viremia and correlated it with age and severity of liver disease. methods: nucleic acid extraction was done using the semiautomatic 'xstractor' from biomerieux laboratories (boom method). the genotyping used reverse hybridization and was performed using probes from the ¢ non-coding region (innulipa introduction: bacterial contamination of blood products remains a persistent problem. various techniques for the detection of bacteria in blood products exist but none of them has been widely accepted. bacterial detection systems could be divided into culture systems and rapid technologies. hemosystem has developed a rapid and sensitive technology for bacteria detection named scansystem tm . bacterial contamination of platelet concentrates is a rare event with an incidence between : to : per donation. therefore hemosystem developed a positive control in order to validate the scansystem tm platelet kit before use. aim of the study: the current study was designed to evaluate the performance of the scansystem tm positive control. the scansystem tm positive control is a capsule containing lyophilised lactobacillus casei subsp rhamnosus. the bacteria concentration per capsule is at least ¥ cfu. the positive control has to be stored at room temperature and is stable for years. after dilution in pbs, the preparation has to be used within hour. two capsules were tested for ten consecutive days with scansystem tm platelet kit as well as with optimised scansystem tm platelet kit. in an independent experiment three capsules were diluted in platelets stored in additive solution and were tested each with scansystem tm platelet kit and optimised scansystem tm platelet kit. results: microscopic fields were analysed for bacteria specific fluorescence for each sample. the ratio between bacteria specific fluorescence signals and analysed signals was . in all samples for both scansystem tm platelet kit and optimized scansystem tm platelet kit. therefore by definition all tested capsules were positive. the lyophilized positive control capsules enable the user to validate the scansystem tm platelet kit before use. because bacterial contamination of platelet products occurs rarely, the routine use of positive controls improves safety of the screening method. scansystem tm is currently the only method that provides this safety measure. introduction: whereas implementation of nat for blood donor screening reduced the risk for transfusion transmitted hiv and hcv infections currently below one per million transfusions, the risk for bacterial infections is estimated to be : to : . especially platelet products, which are stored at room temperature, are prone to bacterial contamination. aim of the study: several methods are currently developed to prevent the transfusion of bacterial contaminated platelet concentrates. the study investigates a new rapid bacterial detection method. material/methods: pool platelet concentrates were spiked with seven transfusion relevant bacteria strains under sterile conditions at concentrations of cfu/ml to cfu/ml. bacterial concentration was verified on blood agar plates immediately after spiking. five millilitres of spiked platelet concentrates were centrifuged, stained with thiazole orange dye and analysed directly by facs within five minutes after staining. aliquots of pool platelets spiked with concentration of cfu/ml and cfu/ml of each bacteria strain were incubated for two to eight hours in special bouillon at °c and were analysed by facs immediately after incubation. results: sensitivity of facs analysis differed between cfu/ml for e. coli and cfu/ml for klebsiella pneumoniae without preincubation and was enhanced to cfu/ml when a pre-incubation step of two to four hours was included. conclusion: bacteria detection by facs analysis combined with a short pre-incubation ( - h) at °c is a quick and simple method with sensitivity comparable to other commercially available detection systems. the advantage of this new method is the rapid analysis, easy handling, high sensitivity and less expensive price. introduction: detection of bacterial contamination of platelet concentrates represents a major challenge in transfusion medicine. for blood transfusion services the method must have a high sensitivity, an easy performance and a low price. aim of the study: in this spiking study we evaluated the new optimised scansystem tm platelet kit detection method for use in apheresis platelets. methods: apheresis platelet concentrates (apcs) were spiked with strains of ten different bacteria species. after different incubation periods, apcs spiked with cfu/ml were analysed by the optimised scansystem tm platelet kit. the number of bacteria was monitored by plating on blood agar. results: all bacteria strains were detected with the optimised scansystem tm platelet kit when the sample was collected h after spiking. identity of the spiked bacteria was confirmed by gram staining and dna fingerprints. conclusion: in summary, the optimised scansystem tm platelet kit was able to reliably detect ten transfusion relevant bacteria species in apheresis platelet concentrates within minutes when the sample was taken hours after spiking. background: since year our laboratory started routine screening of hcv-rna in plasma minipools for all plasma intended for fractionation. although nat testing is not yet mandatory all blood products are released depending upon nat results. aim: to test and compare two different methods of rna extraction in order to make all the necessary adjustments to the test procedures while preserving the availability of blood products. methods: plasma minipools of donations are prepared either on a tecan genesis robot or on a hamilton at plus. hcv-rna is isolated from ml plasma by using either the qiagen biorobot and qiamp virus biorobot kit or the manual extraction with cobas ampliscreen hcv pcr kit v . . results: between march and december a total of seronegative donations ( pools) were tested for the presence of hcv-rna. four pools were found to be positive for hcv-rna. of the four nat-positive pools with no eia-positive donor, four were confirmed as true positive by donor follow-up testing and/or testing of an independent sample from the index donation. all the positive donations were detected independently of the extraction method used (manual or automated). our experience shows that although the automated extraction method is 'off label' and it has to be validated, the use of biorobot does not pose a detectable contamination risk and it is possible to achieve a detection level for hcv less than iu/ml. the advantage of the manual method is that it has better recovery of nucleic acids than the qiagen extraction. concerning the time needed for the extraction process the automated method runs samples in hours where the manual method needs hours for samples, needing, prior to extraction, an extra centrifugation step for one hour. the automated extraction method results in an assay with a high sample throughput, fast time, sufficiently sensitive, that can be successfully introduced into routine use in laboratories which have more than samples/day while preserving the availability of blood products. anti-hcv similarly was high till ( . - . %), but in trend to decrease afterwards ( . %). anti-hiv reflected the low endemicity of the disease in public setting and was % through the mentioned years. rpr test for syphilis was around . %. directed donors were % of all and volunteer donors consisted nearly %. donors in our blood center are being informed about donation prior to giving their blood and donor questionnaire forms (dqf) are filled out by the donor candidates. using dqfs have been mandatory at all blood banks in turkey by law since . from that time infectious disease marker rates were dramatically reduced at all centers. donor information about the risks of transfusion and the importance of safe blood supply were detailed by the donation staff and physicians, consequently self-exclusion by the donor candidates who have risky behaviors was encouraged at our center. the interviewing staff was trained specifically for this topic. this steps were particularly emphasized in the last three years and the infectious screening results were displayed the outcome of this efforts. conclusion: education of the prospective donors, and recruit the voluntary, non-remunerated and regular donors will be the utmost goal of all blood banks. rigorous donor selection will contribute this ultimate success. we should spend more efforts to maximize enrolling voluntary donors to lower the serological marker results, consequently achieve safe blood. background: human t cell lymphotropic virus type i is endemic in japan, the caribbean, southeastern united states and parts of south america and africa. in non-endemic areas such as europe, htlv-i is less common and most infections are identified in immigrants. the epidemiology of htlv-ii is different, being predominantly found among indigenous american-indian populations and among ivdus, but the routes of transmission are the same. aim: our study's aim was to ascertain the prevalence of htlv i/ii in blood donors in order to understand the epidemiology of htlv in greece and initiate discussions of an acceptable level of risk and appropriate level of screening for rare transfusion-transmitted diseases. overall, anti-htlv seroprevalence levels among blood donors, are low. although the number of annual donations in this study is relatively small, the data for htlv indicate that rates of this infection are low and that infected donors will be seen infrequently. as all blood donations are screened for htlv i/ii during the last six years, a national survey is necessary in order to define the epidemiology of htlv in greece. introduction: toxoplasma gondii is the causative organism of toxoplasmosis. the disease transmitted by ingestion of either oocysts (in the feces of cats) or bradyzoites (in raw or undercooked meat). the parasite can also be acquired transplacentally by organ transplantation or from blood transfusion. the purpose of this study was survey of toxoplasma antibodies in some iranian blood donors at tehran blood center. blood samples were randomly collected for detecting of igg and igm antibodies (by elisa technique).the total numbers of donors was of (% ) were female and (% ) male in age ranged from to years. results: sera tested, ( %) were found to be positive for toxoplasma igg antibodies and ( . %) were igm antibodies positive and of them ( . %) were borderline for igm antibodies. among males the frequency of positivity was higher than woman but this different was not significant. the most frequency of seropositivity was found in age group to years. conclusions: diagnosis of toxoplasmosis can be aided by serologic or histocytologic examination. the acute infection in healthy individuals is generally asymptomatic and not associated with any morbidity but in an immunocompromised host, toxoplasmosis be a very serious disease, and this can occur if a person is infection with toxoplasmosis before or after his/her immunosystem is compromised. in spite of the progress in the development of diagnostic, therapeutic and prophylactic methods, virus hepatitis still presents a serious global health problem. the possibility of transmission of these infections through transfusion of blood and blood derivates implies obligatory control of the donated blood. post-transfusion hepatitis is an important health problem in everyday practice, especially in patients who have to receive transfusion of erythrocyte concentrates as the only possible treatment for many years. objective: to show the prevalence of hepatitis b (hbsag) and hepatitis c (anti hcv antibodies) in multitransfused thalassemic patients. in our region there are patients suffering from thalassemia major who are aged between and , and who have been receiving erythrocytic transfusion - times a month since the age of one or two. they receive washed red blood cells, and in certain periods filtered red blood cells, controlled for viral markers and they mostly receive blood from voluntary, periodic and regular donors. the patients are tested periodically for the presence of viral markers (hbsag, anti hcv antibodies), using tests for hbsag (abbott auxyme monoclonal eia) and for anti hcv (abbott hcv eia . ). the presence of markers for hepatitis b and hepatitis c has not been detected in any of these multitransfused thalassemic patients who receive at least transfusions a year. the tests in all patients were negative. the blood used for transfusion must be tested for viral markers, and for the patients who have to receive blood for their whole life, the blood should be from voluntary, regular and periodic donors who donate blood at least three times a year, because then the risk of transfusion transmissible infections is very small. introduction: we observe yearly the prevalence of transfusion transmitted diseases following instructions of skae (national coordination haemovigilance centre). aims: to investigate the prevalence of the most important blood borne infections in our blood transfusion centre in the state achaia during the last five years ( ) ( ) ( ) ( ) ( ) . materials and methods: the detection of hbsag, anti-hcv, anti-hiv / was made by automated microparticle enzyme immunoassay (axsym, abbott) and by enzyme-linked immunoassay methods (dade behring, ortho, biomerieux) syphilis tests were made by using rpr kits. confirmation for anti-hcv positive samples was made riba or inno-lia, while the confirmation of anti-hiv / positive samples was made by 'st. andrews' general hospital of patras reference centre. results: all the seropositive donors were first time donors. conclusion: ( ) we observe that there is a decrease in all four infections. ( ) the absence of anti-hiv seropositive donors is due to the high percentage of volunteer blood donation which approaches % in our centre during the last four years. methods: a prospective, one-year study has been set up in order to enrol at least out of the estimate of first-time donors, involving blood transfusion centres from of the italian regions. each centre was required to enrol all first-time donors born before december st, , and thus not included in the hbv mass vaccination campaign. the selected donors were tested for hbsag (mandatory by law) and for anti-hbc by commercial assays. all hbsag and/or anti-hbc positive specimens were stored frozen and sent to a reference laboratory for additional serological testing (anti-hbs, anti-hbe, anti-hbc/igm and anti-hbc avidity index by an experimental procedure) and for the determination of hbv-dna (both qualitative and quantitative) by real-time pcr. results: in the first months of the study the sites saw almost first-time donors, of whom . % belonged to the required age groups. among eligible donors, . % were both hbsag and anti-hbc positive, and . % were hbsag negative/anti-hbc positive. hbv positivity rates were higher in southern than in northern regions, although a high variability in hbv prevalence was observed between neighbouring areas in the north. hbsag positives were mostly males, % were positive for anti-hbe, % had raised alt and % were concurrently positive for anti-hbs. among hbsag negative/anti-hbc positive donors, % were negative and % were positive for anti-hbs. among anti-hbs positives, % showed values < miu/ml and % > miu/ml. the avidity index results suggested that approximately % of anti-hbc positive individuals were recently infected. conclusions: our preliminary data indicate that approximately % of the italian first-time donors are older than years of age and thus not belonging to the age groups who underwent to the mandatory vaccination against hbv, and that . % of them have serological markers of ongoing or past hbv infection. anti-hbc alone was detected in nearly % of the study population. hbv-dna testing is underway at the time of this writing. in our country mandatory tests for each blood donations are: hbsag, anti-hcv, anti-hiv / and tp ab. to c + ns + ns , ( . %) to c + ns , ( . %) to c + ns + ns , ( %) to ns + ns + ns , ( %) to c + ns + ns , ( %) to ns + ns . the use of the hcv core ag elisa test system may provide substantially earlier identification of hcv infection than it is possible with current serological assays. although all of six anti-hcv assays are very sensitive and specific screening assays, they didn't detect hcv infection in one patient. majority of anti-hcv positive patients ( . %) had anti-hcv ab for or more different epitopes of hcv. international comparison of performance of abbott prism assays used for blood donor screening background: the national serology reference laboratory, australia (nrl), coordinates a quality control (qc) programme for laboratories that screen for anti-hiv & , anti-hcv, hbsag and anti-htlv i/ii using the abbott prism assays. nineteen laboratories from australia, belgium, canada, ireland, israel, the netherlands, new zealand, norway, singapore, south africa and thailand have submitted data for this programme. aims: to determine the accuracy and precision of results from laboratories, individual prism instruments and different reagent lots by analysing data accumulated between october and january . the multi-marker qc sample 'pelispy s type ' (s ), produced by viral quality control (now acrometrix-viral quality control), was provided to participants. laboratories tested s in each calibration run, in addition to the manufacturer's controls, on each sub-channel of the instrument. pelispy was used as a 'go/nogo control' and results were required to be reactive (s/co > ) for a test run to be deemed valid. data were collected and analysed using the nrl's internet-based application edcnet (https://www.nrlqa.net). after submission, laboratories were able to compare their results with those submitted by other laboratories and investigate differences in results from reagent lots and instruments. data for five different s lots were exported from edcnet and analysed. results: nearly results were submitted: all results were reactive (s/co > ). fifty of these results ( . %) were excluded from analyses because they were reported from invalid test runs [due to pipetting, aspiration or sampling error (n = ) or due to unacceptable results (n = )]. a further results were excluded because data provided by laboratories were inconsistent or incorrect. a total of results, reported using different prism reagent lots ( for anti-hiv, for anti-hcv, for anti-htlv and for hbsag), were analysed. results from prism hbsag and anti-hiv showed the least variation with coefficient of variations (cv) of < % for all s lots. results from prism anti-hcv and anti-htlv produced cvs between . % and . % for all s lots. data reported for s lot ps (n = , range for anti-htlv to for hbsag) were analysed further to review performance of prism reagent lots. hbsag showed the least variability between prism reagent lots with < % bias for the prism hbsag reagent lots used (bias: the difference between the mean ratio for the reagent lot and the weighted mean ratio for all reagent lots, expressed as a percentage of the weighted mean ratio for all reagent lots). prism anti-htlv showed greater variability between reagent lots with a single reagent lot generating a + % bias. prism anti-hcv showed the greatest variability within reagent lot with results from of reagent lots showing a cv between % and %. conclusion: in results in a qc sample distributed to laboratories the abbott prism performance was found to be consistent over four assays. edcnet was robust in supporting laboratories' abilities to follow precision and accuracy of the assays in real time. introduction: since hcv rna testing of all blood donors started in finland in , the nat screening process has continuously been improved. investments in process automation have made the work more efficient and blood safety has further increased since hiv- rna screening of all blood donors started late . aim of the study: to implement hiv- rna testing in the nat screening program cost effectively, without increasing the throughput time of the samples and delay in the result reporting. to study if the sensitivity for both hiv- rna and hcv-rna will be sufficient when a single extraction is used and when the pool size of donations and the sample volume are kept unchanged. methods: the nucleic acids were isolated from plasma samples of ml with the magna pure lc instrument using the magna pure lc total nucleic acid isolation large volume kit. the internal controls from the cobas ampliscreen multiprep specimen preparation and control kit and the cobas amplicor hcv specimen preparation kit were added to the lysis/binding buffer ( ml/ml of each). from the final volume of the nucleic acid eluate ( ml) ml was used for the detection of hiv- rna (roche cobas ampliscreen) and ml for the detection of hcv rna (roche cobas amplicor). a run control containing both hiv- rna ( iu/ml) and hcv rna ( iu/ml) was included in all extraction runs. sensitivity of the both assays was assessed by testing dilution series of the who standards for hiv- rna and hcv rna. specificity was evaluated by testing fractionation plasmapool samples (n = ) and minipool samples (n = ). results: detection limits of the hiv- and hcv assays ( % hit rate) were calculated to be . iu/ml and . iu/ml respectively. specificity for both assays was % and during the validation phase also the robustness was good. the sensitivity of both assays with a pool size of was below the recommendations by the council of europe for blood donor screening (for hiv- rna iu/ml and for hcv iu/ml per individual donation). specificity of the assays was excellent, false reactive results were not observed. implementation of the hiv- nat assay in the screening program did not increase the throughput time of the donor samples when the pool size of donations, ml sample volume and a single extraction for two assays were used. the the very substantial increase in the number of industry-sponsored clinical trials has created challenges for medical schools, academic hospitals, faculty members of these institutions, and the journals that publish the results of these trials. in many cases, authors of reports of industry-sponsored clinical trials are paid consultants to the sponsor, have been paid by the sponsor to lecture on behalf of its products, or have equity in the sponsoring company. these ties to industry create a tension that actually is or can be perceived as • work internationally; • send young volunteers to international youth forums; • employ young people in your organisation; why use volunteers in blood donor recruitment? • they have networks to scout-groups, sports-organizations, tradeunions, rotary, staff of large companies etc. • they bring in fellow volunteers -with different prospects of society; • often paid recruiters are underpaid (!) and tend not to remain • you can not recruit by telephone! • out of donors are recruited by personal contact! • so you need direct personal contact = need many people (e.g. young ambassadors); • a large number of volunteer recruiters is a gift from heaven! paid donation gives the act of blood donation low status. the act of blood donation should be respected, and praised by role models, queens and presidents. efficient work and close cooperation of blood bank staff and volunteer organisations is the key to success in blood donor recruitment and retention! with such a prospect, it was important to evaluate the practices of blood donor selection in the eu. material and methods: a questionnaire was designed and sent in to the relevant institutions of the eu countries plus switzerland. the questionnaire included questions on the interviewing practices before homologous blood donations, regarding non-specific risks to donors and recipients, identified risks to donors, infectious, bacterial, viral, parasitic and prionic risks to recipients and non-infectious risks to recipients. the questionnaire also inquired about each country's exclusion period for each contraindication (ci) to donation. results: predonation interviews were prepared, in all countries, by circulating informative documents to blood donors. they were supported by written questionnaires in nearly all countries. in half of the countries, those interviews had to be led by physicians (nurses or technologists in the others). the - age limits for blood donation ( - for a first donation) were the rule in countries. in other countries the age limit could be brought forward to and extended to years old. the time interval between donations was identical for men and women in countries, and varied from to weeks according to country. the questions of the questionnaires were very similar as regards the identification of risks to donors and recipients, and very close to the requirements that appeared later in the / /ec directive. this particularly concerned how to meet the expectations of european donors, so that they come back to your blood center! know your donors: make regular donor surveys. age, gender, number of donations, number of first time donors, media consumption, education, job situation, income brackets. use local donor organisations let volunteers help! they work for free, but donor recruitment and -retention costs money. each blood center should have a local donor organisation, run by volunteers. the donor organisation should receive a payment for each bag collected. the reputation of the blood system tell the donors, what the blood is used for. that all blood is tested. and that blood provides safe medical treatment safety of the donor. insurance is a must good quality and efficiency in blood services decentralized blood collection no waste, and minimal outdating efficient service: • a friendly environment, • donor friendly opening hours, • pleasant rooms, beds and well equipped waiting rooms, • parking-spaces, transport, • beverages and food, • letters with correct data etc. donors expect to be serviced by trained, medical professionals and that the medical check-up is taken seriously. donors should be recognized continuously. use directed press-coverage to higher the self-esteem of the donors. donors should be well informed: • leaflets, posters and questionnaires should be % correct; • use e-mail and web-sites for quick up-date of donor information. be visible! • have an offensive and comprehensive media approach; • have a yearly national campaign june up to world blood donor day; • have an attractive home-page, constantly updated; • streamline your lay-out; • mail a donor magazine to all regular donors: • send newsletters regularly to volunteers and the press. • use recruitment cards. • easy phone-and fax numbers, e-mail addresses. directed campaign towards young people: • young ambassadors group; • special training sessions for young volunteers; • advertisements in media catering to young people; • poster competitions; • book and leaflets on blood addressed directly to young people; minimum bodyweight, blood pressure, pulse limits, questions involving viral risks, either sexually transmitted or linked to drug abuse, questions investigating risks of malaria transmission, questions aimed at identifying risk of prionic disease transmission. analyzing ineligibility times, on the other hand, revealed wide differences. for example, ineligibility for current multiple sexual partners, sexual relations with risk individuals, tattooing or body piercing, endoscopy, general anesthesia or invasive surgery, could vary from to months. previous transfusion history could not be a ci or could be one varying from months to indefinite ci (this point recently changed in several countries). the results of that survey have revealed some differences between countries in the questions asked and especially in the ineligibility times. however, the conditions under which donor selection interviews are conducted were similar in all countries. the enquiry tool used in this study proved to be well adapted to evaluate the donor selection practices throughout eu. a next step will be to use it to appreciate their evolutions and especially the impact of the /ec/ directive on these practices in the eu countries and furthermore to evaluate the results of this selection (rates and motives of deferral) which is a major factor of patients' transfusional safety. background: in europe on average whole-blood donations are performed per inhabitants and year. whole-blood donation comprises a puncture of a venous vessel and letting of blood (usually ml), which may be repeated several times a year. like other invasive procedures, blood donation has a range of effects on the individual who is subjected to it. aim: the aim of this paper is to review some aspects of the present state of knowledge on effects and complications of whole-blood donations. results: most studies of the effects of whole-blood donations on the donor have focused on negative or unpleasant events and on time in rather close association to the donation. complications related to percutaneous needle insertion (bruise assessed by inspection . % -bruise assessed using post-donation interview . %, sore arm - . %, nerve irritation . %, arterial puncture/pseudoaneurysm/arteriovenous fistula . - . % etc) are most commonly reported, while negative systemic reactions (vasovagal reactions . - . %, syncope . - . %) occurring in connection to blood donation are less frequent (newman bh: blood donor complications after whole-blood donation. curr opin hematol ; : - .) serious complications requiring hospitalization (myocardial infarction, stroke) are extremely rare ( . %). fatigue ( . %- . %) and diminished physical working capacity ( . %) are reported to occur during days after the donation. a recent study of a consecutive sample of swedish blood donors (nilsson sojka b, sojka p: the blood-donation experience: perceived physical, psychological and social impact of blood donation on the donor. vox sang ; : - .) (with a selfadministered questionnaire with an open-ended question: how does blood donation affect you? physically-bodily/psychologicallyspiritually/ethically-morally/socially during or after blood donation?) revealed that perceived negative effects (fatigue, diminished physical working capacity, vertigo/dizziness, susceptibility to infections etc) were less common ( % of the donors) than positive effects (feeling of satisfaction, being more alert, feeling generally better, less migraine, higher physical working capacity, respect from environment, feeling of relaxation etc; % of the donors). the duration of positive effects was regularly reported to be weeks, while negative effects lasted only days. investigations on the long-term effects of blood donation are scarce. yet, they may indicate that the donation of blood is associated with e.g. lower blood pressure and a reduced risk of myocardial infarction (nilsson sojka b, sojka p: the blood-donation experience: perceived physical, psychological and social impact of blood donation on the donor. vox sang ; : - ). conclusion: both the panorama and the frequency of occurrence of the different effects and complications of whole-blood donations vary as a function of how the information was gathered (openended questions, observations, interviews etc). serious reactions to whole-blood donations are extremely rare. more studies are needed in particular with respect to the long-term effects of regular wholeblood donations. t-pa- establishing a national adverse event reporting system for blood donors -a prospective study of . there was no national system and significant regional variation showed that the data was scientifically unsound. a coincidental initiative to remove the mandatory post donation rest period for regular donors further emphasised the lack of reliable, retrospective data to monitor and compare the impact of this new policy. aims: . to develop and implement a high quality, reliable national donor adverse events reporting (daer) system; . to define and categorise adverse events; . to record data systematically and prospectively using the existing computerised donor database. methods: from summer , a small project team of senior clinical and operational staff took months to agree a detailed policy for capturing and recording all donor adverse events, including precise definitions for grades of vasovagal reactions and bruising. detailed training material was written in may and the new protocol was validated in one region. from july to december a formal one day training programme was delivered to over staff working on mobile collection teams, static sites and blood centres. daer was fully implemented by january . adverse events are assessed by health care professionals on session and the relevant code entered onto the donor's computer record by clerical staff. information received after the session is entered by centre based doctors using the same system. the database is interrogated monthly for statistics. results: in the first months . million donors attended sessions throughout england and north wales. results were very consistent month on month. donors ( : ) had vasovagal symptoms but only % of these suffered syncope. % of all vasovagal reactions occurred in women. % occurred in donors aged - and a further % in donors aged - . (donors aged - represent only % of the total donor base.) donors ( : ) reported a delayed reaction, % of whom did lose consciousness. nerve injury, unrelated to haematoma, occurred in donors ( : ) and, more rarely, arterial puncture was diagnosed in donors ( : ). bruising was reported after the session by : donors. summary: a robust system has been developed and successfully implemented across a large, national blood service. based on the data already accumulated our next phase is to develop strategies to minimise adverse events, confident that any intervention will be effectively monitored. the community role in enhancement of voluntary, non-remunerated blood donation in the new millennium introduction: in the developing countries, about % of the blood supply comes from paid or replacement donors, where a high number of infected persons are in the donors population. only % of the global blood supply is donated as voluntary nonremunerated blood donors in countries with low and medium human development indices. and around % of the global blood population has access to only % of a safe blood supply. conclusion: blood is a national resource, it is the responsibility of governments through it's communities to ensure that the blood supply is safe and adequate to meet the needs of patients population and available to all who needs it. background: in response to a documented increase in the average age of donors, a survey was conducted to explore if young people had more unfavourable attitudes towards becoming blood donors. aim: to identify if the increasing difficulty in recruitment and retention of young people as donors, is linked to a low level of motivation for donating blood in this age group. methods: a national telephone-survey was conducted among a cross-sectional sample of the adult norwegian population ( participants). the survey was performed in november . results: five percent reported being active donors (had donated during the last months), % were passive donors (had not donated during the last months), % were non-donors with a positive attitude towards becoming donors, and % non-donors with no intentions ever to donate blood. in the youngest age group (age - ), % reported being active donors and % were passive donors. however, % of the young non-donors reported having intentions of becoming a blood donor. fifty-five percent of young non-donors had a negative attitude towards ever donating blood. all non-donors were asked why they did not donate. thirty-six percent of all non-donors reported health related reasons for not donating blood. thirty-one percent of all non-donors claimed that they did not donate because no one had requested them to do so personally, and % reported they did not care about blood donation. in comparison only % of young non-donors reported medical reasons for not donating. thirty-eight percent claimed lack of personal request, and % reported of lack of interest as the main reason for not donating. summary/conclusion: although the youngest age group was under-represented among active donors, we found that a great proportion ( %) of young non-donors had a positive attitude towards becoming blood donors. the most important reason why young people do not donate was the lack of a personal request. indifference regarding donation was not very widespread. a relatively high proportion of young people considered themselves as not medically disqualified to donate. in light of these findings, efforts to recruit young people as blood donors are strongly recommended. background: the ever-increasing demand for blood, coupled with emerging new threats to blood safety, motivate the strengthening of the blood banking infrastructure. aim: employing new technology as an instrument for building relationships of trust between blood bank and blood donors. material: . a new software module supporting the management of magnetic cards was added to e-aima blood bank management application. the magnetic card supports the following information: • front-side: donor's photograph, surname, name and blood group (including rhesus phenotype & kell) and sign of blood collection centre. • magnetic stripe where data concerning donor's serial number, medical history (risk factors), test results for infections and the number of donations is stored. . specific hardware allowing reading from and writing to magnetic cards is integrated to the software module: • magnetic card scanners were added to pcs serving to donation collection, including laptop for mobile team collection. • web cameras to capture the photograph of the donor to be printed on the card. • card printer was deemed necessary to produce magnetic cards for donors on a need basis. . consumables: blank plastic magnetic cards, ink cartridges for printer. methods: in order to evaluate the performance of magnetic cards compared to the paper-based system, a questionnaire was distributed to first-time and repeat blood donors, in order to be used as an indicant of donor's satisfaction. . first-time donors increased . % in the months of application. among them, . % were donors 'for relatives or friends' turned into volunteer donors and . % were first-time volunteer donors. the questionnaire analysis further revealed: • % were motivated by the use of magnetic card. • % appreciated the presence of their photo on the card and they confessed that they had used it as a spill for recruiting their friends as donors. • % were persuaded that employing new technology would result in safer and more trustworthy procedures combined with reduced waiting time. • % considered magnetic cards more practical compared to paper cards because of their compact size and improved durability. . the turnover of repeat donors also increased . % after replacing their plain old paper cards with new ones. further analysis revealed that: • % appreciated the quick cross-checking of donor's identity. • % were satisfied with the effectiveness and efficiency of magnetic cards in managing donor's data. conclusions: in , greek health policy provided the legal basis for establishing the electronic national health card. the introduction of the national donor's magnetic card is another step towards this direction, being aligned with the modern national health strategy. apart from the positive impact on the number of both firsttime and repeat blood donors, it should be also pointed out that the use of a unique donor serial number on country level results in less error-prone procedures due to the reduction of administrative process overhead and facilitates interoperability between national blood banks using compatible technological infrastructure. t-pa- emerging technologies in transfusion. dna based assays until the late s, mandatory blood screening for transmissible infectious agents depended entirely on antigen/antibody-based detection assays. recent emergence of nucleic acid technologies (nat) has revolutionized viral diagnosis by not only increasing the sensitivity level but also facilitating the detection of several viruses in parallel, by multiplexing specific primers. however, in more complex biological situations when a broad spectrum of pathogens must be screened, the limitations of these first generation technologies became apparent. high throughput systems such as dna arrays permit a conceptually new approach. these miniaturized microsystems allow the detection of hundreds of different targets simultaneously, inducing a dramatic decrease in reagent consumption, in additional confirmation tests and simplify data interpretation. however, the microsystems actually available require additional instrumentation and reagents for sample preparation and target-amplification prior to detection on the dna array. future technologies such as 'lab-on-a-chip' include channels, fluidics and thermal zones allowing extraction, amplification and detection. another major challenge in the area of dna detection is the development of methods that do not rely on target-amplification systems. almost all blood group antigens are bi-allelic and encoded by single nucleotide polymorphisms (snps). to facilitate the direct availability of typed red cells and platelets, we develop a high-throughput technique to genotype by dna microarray the whole donor cohort for all clinically relevant red cell and platelet antigens. methods: a multiplex pcr was developed to both amplify and fluorescently label gene fragments of red cell and platelet antigens in one reaction. each array contains spots of short ( - nt) allelespecific oligonucleotides to discriminate between the two alleles of an antigen system. results: two blinded panels encompassing donors were genotyped for hpa- through - and ; no discrepancies were found. currently, arrays are prepared for the red cell systems. the fya/fyb, fy-gata mutation, jka/jkb, k/k, kpa/kpb, m/n, rhc/c, rhe/e, rhdpseudogen, rhdvi negative, rs, doa/dob, genotypes can be determined. the set up of genotyping assays for rare genotypes is difficult because of lack or insufficient amount of dna. the latter can be overcome by phi dna polymerase-mediated isothermal genomic dna amplification, from minute amounts of dna present in stored red cell fractions or antiserum. the results show that the blood group typing dna microarray will provide a reliable and fast genotyping procedure. the method can be further improved to obtain the necessary automated throughput for typing of large donor cohorts. and , all other weak d types should be regarded as potential anti-d immunizers. for correct determination of weak d both serological typing (polyclonal and monoclonal), as rhd dna typing are mandatory. when serology indicates weak d, more anti-d antibodies are tested ( epitope model) to distinguish partial d from weak d. in addition, an rhd mpx pcr is performed to detect the presence of rhd exons , , , , and . in all known weak d types, all six rhd specific exons are amplified (except for weak d type which lacks rhd exons and ), whereas partial d phenotypes usually show aberrant patterns. aim: the aim of this study was to evaluate the diagnostic scheme for weak d typing. methods: between and , samples were investigated for weak d characteristics. four pcr-ssp assays were developed for identification of weak d types ( t > g), ( g > c), ( c > g) and ( c > a). weak d type was identified by the combination of serology and absence of exons and by rhd mpx pcr. rhd-specific exon sequencing was performed when serology and molecular typing were inconsistent. results: all samples were subjected to the rhd mpx pcr and sample showed absence of rhd exons and , indicative of a weak d type when combined with serology. the remaining samples were analyzed by the weak d pcr-ssps, resulting in weak d type samples, weak d type samples, weak d type samples and weak d type sample. two samples remained undetermined and were sequenced for all rhd exons and the rhd promotor region. one sample showed the mutations corresponding to the dau partial d phenotype ( g>a, g>a and c>t). the other sample had only one, not previously known mutation ( a>t), which is located intracellularly at the coohtail. extensive serology using the epitope model showed a pattern matching weak d. this new weak d variant was registered as weak d type . conclusions: based on these results it may be concluded that weak d phenotypes should be confirmed on molecular level to avoid misinterpretation of partial d that cannot be detected by rhd mpx pcr analyses. patients with weak d phenotypes, except for types , and should be regarded as being at risk for anti-d immunization after transfusion of rhd-positive blood products and should therefore be treated with rhd-negative bloodproducts. in this evaluation, out of patients carried such alleles. introduction: although kell antigens are expressed very early during erythropoiesis and a . % incidence of anti-kel is found in obstetric patients, this is a relatively rare cause of hdn. anemia is produced by immune destruction of fetal rbcs and suppression of erythropoiesis. maternal antibody titers or amniotic/cord blood bilirubin levels are not relevant indicators of the severity of the disease, and the measurement of the fetal haemoglobin by cordocentesis is a procedure with risks of miscarriage and sensitization. pcr techniques for the determination of blood groups using fetal dna isolated from maternal plasma, allows the application of noninvasive methods. clinical cases: we describe two cases of pregnancies in women with anti-kel acquired by transfusion/previous pregnancies: st case: in july , a -year-old woman (gravida , para ), rhdnegative, kel -negative was referred at weeks gestation. the father's phenotype was rhd-positive, kel -positive. a maternal antibody screen revealed d and kel alloantibodies. dna was extracted from amniotic liquid. the kel genotype was determined by pcr-rflp using the bsm i. pcr-ssp was used to studied intron and exon of the rhd gene. the results showed that the fetus was positive for rhd sequences and showed kel homozygosity; nd case: in august , a -year-old woman (gravida , para ) was referred at weeks gestation. she had a history of transfusion with rbcs units in -one of the donors was kel positive. the woman typed rhd-negative and her husband typed rhd-positive. rbcs from both were kel -negative. the maternal antibody screen revealed anti-kel . doubts existed about the putative father of this child. dna was extracted from maternal plasma using the magna pure lc (roche). real-time pcr was applied to analyse: sequences of intron , exons , , and pseudogene of the rhd gene and the sry gene by sybr green; and the alleles kel /kel by hybridization probes. all rhd sequences were detected (with the exception of the pseudogene) and the kel genotype gave a kel /kel result. in both cases the doctors choose not to use any invasive method to monitoring the fetuses regarding a hdn due to anti-kell antibodies, and the results of the molecular analysis were confirmed by testing the cord rbcs after birth. discussion: these cases illustrate the reliability of the molecular biology results, based on the collection of simple peripheral blood samples. a determination that the fetus lacks the relevant antigen obviates the need for expensive and invasive monitoring throughout the pregnancy. evidence-based medicine (ebm) is defined as: 'the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. the practice of ebm requires the integration of individual clinical expertise with the best available external clinical evidence from systematic research and our patient's unique values and circumstances. ' otherwise healthy individuals without cardiopulmonary dysfunction (cdf) tolerate acute reduction of haemoglobin concentration to about g/dl, provided that blood volume is kept normal by a volume expander. however, individuals experience physical fatigue, and there is faint reduction of perception as measured by neurophysiological tests. symptoms are reversed upon retransfusion of fresh, autologous erythrocytes. acute, normovolemic anemia seems to be progressively less tolerated with increasing age and cdf. controversy has existed on whether or not to correct hypoalbuminemia in asb or icp by infusion of albumin. recently a large trial showed no outcome differences between icp patients treated with albumin or saline. thus in general there is no indication for albumin in asb or icp. however, albumin may yet be advantageous in e.g. patients with head injuries. furthermore, fractionated albumin is not equivalent to native albumin, since fractionation stabilizers remain bound to the albumin molecule. thus more refined albumin preparations may carry advantages still to be investigated. erythrocytes are given to increase the total oxygen transportation capacity of the organism. the effect of blood bank stored erythrocytes may differ from that of fresh, autologous erythrocytes, since changes of presumably important erythrocyte properties occur during storage. in the only large trial available, a transfusion trigger of . g/dl was found to be favourable to one of g/dl in icp, except possibly in icp with unstable angina pectoris or heart infarction. however, the erythrocyte concentrates given were not leukocyte filtered, and side effects of infused leukocytes may have hampered the conclusion. on the other hand, a metanalysis showed transfusion as an independent indicator of unfavourable outcome in coronary bypass patients, but again, leukocyte filtered erythrocyte preparations were not applied. the effect on morbidity and mortality of 'top up' transfusions given e.g. to mobilize patients postoperatively has not been studied by trials, although this effect seems evident to many clinicians. grave anemia may reduce the haemostatic effect of thrombocytes because changes of blood rheology reduces the pressure forcing thrombocytes against the walls of small vessels. the transfusion trigger for thrombocytes in asb or icp remains to be established by clinical trials, however. the same applies for fresh frozen plasma, which is infused as a source of coagulation factors. on the other hand, the haemostatic effect of various fibrinolysis inhibitors is well established in asb and icp, but many clinicians appear hesitant to use them. another interesting haemostatic agent is recombinant fviia, the use of which to control asb in blunt trauma is supported by one well controlled clinical trial. evidence by systematic research is insufficient to decide what is optimal transfusion practice. the procurement of such evidence is one of the greatest current challenges to transfusion medicine research. . concerns about the transfusion-related complications, such as infections, tumour behaviour and immuno-modulatory effects, and the costs, necessitated a re-evaluation of the transfusion practice. aims: the goal of this study is to evaluate if a restrictive transfusion policy (hb transfusion trigger < . mmol/l) reduces the amount of red cell transfusion compared to a liberal transfusion trigger (hb < . mmol/l) without a decrease in hrqol. because of concerns about the feasibility of this study early results were analysed and are presented in this abstract. material and methods: after a run in period of months (hb transfusion trigger of hb < . mmol/l) patients are randomised for the restrictive or the liberal transfusion policy. patients are followed then months. hrqol is measured after inclusion, after randomisation, weeks, , , , and months after randomisation. also anaemia related complications and red cell antibodies are scored. hb values were blinded for the patients during the study period. results: from july till june patients were included ( ra, rars, rcmd, raeb, cmmol) in general hospitals and university hospital. two patients died in the run in period. eight patients were randomised for the restrictive transfusion policy and patients for the liberal transfusion policy. the mean follow up period in the liberal group was . months (inclusive run in period) and . months for the restrictive group. two patients in the liberal group died after randomisation. one patient received growth factors. in the restrictive group patients finished the study, received growth factors and patient withdrew informed consent. the mean hb level was lower in the restrictive group and after randomisation about % reduction in amount of transfused red cells was found ( . units per pt per month in the liberal group vs . in the restrictive group). no anaemia related complications were found, e.g. cardiac failure and cerebro vascular ischemia nor a decrease in activity performance. conclusion: there were some concerns after introduction of the restrictive transfusion policy. this preliminary results show, however, that a restrictive transfusion policy leads to a diminished use of red cell transfusion without an increase of cardiac complications or a decrease in activity performance. this study will be continued to compare hrqol scores in both groups. introduction: strong evidence supports the efficacy of blood conservation strategies such as autologous blood donation (abd) and erythropoietin (epo) for reducing exposure to allogeneic blood. however, use of these interventions is highly variable among institutions and frequently sub-optimal. the program to reduce orthopedic blood exposure (probe) evaluated a blood conservation program in patients undergoing total hip joint arthroplasty (thja) at ontario hospitals. aim of the study: the objective of probe was to determine whether a comprehensive blood conservation algorithm (bca) was more effective than usual care (uc) for reducing exposure to allogeneic blood in patients undergoing thja. methods: we randomized hospitals that perform high volume elective primary thja to implement either a bca or to continue with uc. the bca consisted of three components: physician and patient education, blood conservation interventions (use of abd or epo), and transfusion guidelines. t-pa- table) . mortality for non-transfused patients was significantly lower than for patients receiving either lr-or s-prbc at all time points (p < . ). t-pa- thalassaemia: the impact on blood transfusion services thalassaemia major is a genetically determined disease that causes severe chronic anaemia and further complications. it can be managed successfully in the vast majority of cases, so long as public health and other scientific and organizational infrastructures are adequate. although the progress achieved in the field of bone marrow transplantation and other disciplines promises cure of the genetic defect, regular blood transfusion from early childhood remains the cornerstone of treatment of patients with thalassaemia major. this presents national health authorities with the formidable task of assuring an adequate blood supply of high quality and safety for these patients and ensuring that it is transfused in the appropriate way. the basic principle in the modern management of thalassaemia patients is that of a global approach to care. within this approach, a standardized protocol for regular blood transfusions is a prerequisite for the patient's long survival and quality of life. if thalassaemia patients are not transfused effectively, the severe anaemia and over-expansion of bone marrow due to ineffective erythropoesis can lead to poor growth, bone deformities, organomegaly and impairment of normal physical activities. in countries or regions with large numbers of thalassaemic patients, the organizational and technical aspects of meeting their blood requirements represents a heavy additional workload for the blood transfusion services responsible for providing blood for this group of multi-transfused patients. the acquisition and preparation of blood, genotyping the patients' blood group (including at least rh, kell, kidd and duffy systems) preventing the transmission of infectious diseases and other transfusion associated complications, and assessing the patients' blood transfusion indices all have a tremendous impact on blood transfusion and treatment units. blood transfusion services are thus confronted with major challenges that can only be met if appropriate national transfusion policies are in place, both in the laboratory and the clinical setting of blood transfusion. the availability of safe blood is related to the effectiveness of donation programmes aimed at recruiting and retaining voluntary unpaid blood donors who are at low risk for the transmission of infectious diseases. sufficiency is further related to resources, organization and management of the blood transfusion service and continuous education of its staff. high technical standards for the transfused product and quality management systems are required to ensure that the product meets these requirements, as well as pre-transfusion, transfusion and haemovigilance systems and other more stringent quality measures in the whole chain of blood donation and transfusion. additional measures and continuous care are specifically required for the optimal transfusion therapy of the thalassaemic patient. the patients should be transfused with red cell concentrates, (rccs) preferably not more than one week's old and leucodepleted. other processes i.e washing of rccs, use of nutrient additive solutions, irradiation etc may be used to improve the quality and the safety of the transfused product, while other advances in red cell transfusion are expected to improve blood safety by preventing adverse reactions and reducing exposure of the patient to donor blood. should patients with thalassemia intermedia be regularly transfused? thalassemia major (tm) and thalassemia intermedia (ti) share mostly a common basic molecular mechanism, that is the reduced synthesis of the * globin chains. the consequences of the resulting chronic hemolytic anemia are also common and include growth retardation, bone marrow expansion, extramedular hematopoiesis, splenomegaly, increased intestinal iron absorption, susceptibility to infections and hypercoagulability. what differentiates the two forms of the disease is the severity of the clinical phenotype, which in turn depends on a particularly heterogeneous molecular background and imposes diverse therapeutic strategies. the consequences of the genetic defect as well as the effect of the applied therapy seem to be mainly responsible for the clinical course of the disease. in untreated tm cases, the aforementioned consequences occur fast and patients die early in life mainly due to high output heart failure. over the past decades, the gradual adoption of the current transfusion and iron chelation strategies and the patients' compliance with this therapy have resulted in a significant improvement of survival, that according to recent statistics reaches % at age . this rate is even better in well-treated patients, almost % of whom survive at age . regular therapy extends survival mainly by preventing early development of cardiac complications. in addition, a multi-organ improvement is accomplished while patients' physical appearance is almost indistinguishable from that of the general population, hence permitting a normal social behavior with a high overall quality of life. bone marrow expansion and extramedular hematopoiesis are prevented; hepatosplenomegaly is substantially restricted and usually there is no need for splenectomy, while thromboembolic complications are rare and pulmonary hypertension is practically absent. patients with ti remain as a rule without regular therapy until a number of severe complications arise. the consequences of chronic anemia develop slowly compared to untreated tm cases and dominate patients' clinical picture usually by the third decade of life. at this time, all patients have developed hepatosplenomegaly and most of them have been splenectomized. bone marrow expansion results to bone deformities and fractures often occur. extramedular hemaotpoietic masses and bone deformities may lead to various complications depending on their bulk and location, such as neurological symptoms from masses arising in the paraspinal area or dyspnea from lung restriction. hypercoagulability, resulting from defects of native erythrocyte membrane phospholipids, together with the coexistent thrombocytosis in splenectomized patients lead to a wide spectrum of thromboembolic events. pulmonary involvement with respiratory dysfunction and hypoxemia as well as pulmonary hypertension leading to congestive heart failure are well documented in ti patients. nowadays, the beneficial effects of regular transfusion and chelation therapy in tm are beyond any doubt. the occasional application of transfusions in ti has a transient effect and does not seem to inhibit the consequences of chronic hypoxia. intensive and regular transfusion and chelation therapy in ti has proved effective in ameliorating the established complications such as spinal cord compression, hypercoagulability and pulmonary hypertension, without however reversing them. given the -year experience on intensive therapy in tm and the first encouraging data in ti, the earlier application of such treatment seems to be crucial in ti. the timing however of therapeutic intervention in ti in order to prevent anemia-related complications still remains an open issue that needs to be properly addressed. the impact of prestorage leucodepletion on the immediate transfusion adverse events of patients with thalassaemia major backround: regular blood transfusion therapy in patients with bthalassaemia major decreases the complications of anemia but it is associated to many immediate and delayed side effects. febrile non haemolytic transfusion reactions (fnhtr) are common complications due to alloimmunization of recipients against hla and/or specific antigens on donor's wbcs or to the accumulation during storage of biologic response modifiers (bmrs) that are directly pyrogenic or indirectly by stimulating recipients' white cells to produce pyrogenic mediators. post storage leucoreduction (lr) has reduced the fnhtr in these patients from % to . % per unit. it is unknown whether introduction of prestorage leucodepletion (ld) has reduced the incidence of nhftr further. we analyzed the immediate transfusion reactions of adult patients with b-thalassaemia major transfused with a total of . rbc units from january to december . all units were fresh, stored less than days. . units were lr-rbc, . units were ld-rbc and . were washed lr-rbc. results: the incidence of fnhtr and allergic reactions in patients receiving lr-rbc was . % and . %/per unit respectively, in those receiving ld-rbc was . % and . %/per unit respectively, while in those receiving washed lr-rbcs was . % and . %/per unit respectively. the relative risk (rr) of fnhrt and allergic reactions following transfusion of ld-rbc and washed lr-rbc compared to lr-rbc is shown in table. conclusion: prestorage leucodepletion and washing of rbcs reduced the risk of fnhrt in regularly transfused b-thalassaemia patients . times compared to poststorage filtration. these findings show that fnhtr after rbc transfusions are due not only to alloimmunization but also to accumulation of bmrs even in patients transfused with fresh rbcs. washing is as effective as prestorage leucodepletion in reducing fnhtr. prestorage leucodepletion has no effect on allergic reactions or other immediate adverse events in these patients. t-pa- viral inactivation/elimination of plasma derived medicinal products the safety of medicinal plasma products (mpps) relies on a whole range of measures from the quality of the source material to the release of the products after manufacturing under cgmp conditions. viral safety relies on careful donor selection, viral testing of the source material and viral inactivation and/or elimination during the manufacturing process. mpp manufacturing processes must include viral safety steps capable of inactivating, and/or eliminating, a large range of viruses covering the known blood borne viruses as well as anticipating possible future pathogens. it is recognized that one single step is often not sufficient to satisfy this requirement and manufacturing processes very often include two or even three complementary viral safety steps. very efficient methods have been implemented by manufacturers, for two decades, for the inactivation of major blood borne enveloped viruses (hiv, hcv and hbv). additional safety steps have also been introduced to provide a second step for enveloped viruses and to extend the efficacy to nonenveloped viruses (hav and parvovirus b ). pasteurisation (liquid heat treatment at °c) which has been historically used for viral inactivation of albumin solutions has been applied to some other plasma products. solvent-detergent (sd) treatment which is specific to enveloped viruses is used primarily for coagulation factors. since the introduction of sd-treated products, no hiv, hcv or hbv transmission has been reported. viral inactivation of coagulation factors can also be achieved using various conditions of dry-heating. acidic treatment is also an efficient means of inactivating viruses in igg products. nanofiltration using filters of less than nm pore size was introduced in the early s. this technique for viral elimination is based on the size of the agent and is independent of their resistance to other treatments. this property could be helpful in cases of new emerging pathogenic agents. new inactivation tech-niques are currently under development such as uv treatment or gamma irradiation with efficacy reported on enveloped as well as non-enveloped viruses. these new techniques can complement existing methods after careful validation that they do not have harmful effects on proteins in the product. the efficacy of existing techniques is well documented in controlled clinical studies and pharmacovigilance records. their application to each product is extensively validated at laboratory scale, according to international regulations and then carefully evaluated by health authorities. in this context, a recent european guideline established a viral risk assessment model to quantitatively estimate the theoretical safety margins of mpps, by taking into account the different safety measures, such as viral testing of plasma and the efficacy of viral inactivation/elimination steps. whilst technical limitations and some lack of scientific data lead to very conservative estimates, this model gives an overall assessment of the efficacy of the measures in the manufacture of a given product. developments in viral inactivation/elimination methods, in plasma testing as well as in evaluation procedures have together given mpps an excellent level of safety never previously achieved. to date the important safety measures needed to ensure a high safety margin to pooled plasma products are well understood by the plasma fractionation industry. safety nets rely on carefully done: donor selection to exclude high-risk donors, serological and nat viral testing of single donations and, pooled plasma testing using sensitive validated methods, and most particularly, efficient viral reduction treatments that must be validated and implemented at a large-scale following good manufacturing practices. over the last years, successive key breakthrough in plasma product viral safety have included the use of solvent-detergent treatment to inactivate lipid-enveloped viruses, and nat testing of starting plasma pools and viral nanofiltration of products to reduce the risks associated to small non-enveloped viruses. the excellence of the system currently in place is illustrated by the demonstration that these safety barriers have virtually stopped the transmission of known viruses and avoided that of 'emerging' agents, such as west nile virus (wnv). however, multiple viral reduction treatments have generally decreased product recovery. in addition, although the implementation of viral reduction treatments have forced fractionators to introduce significant changes to product manufacturing methods, this period has been understandably followed by a period of relative conservatism of the plasma fractionation industry against further process changes. as time evolves and market dynamics changes struggle for improved economic balance of the plasma product industry is putting product recovery and diversified product portfolio at the forefront of r&d objectives. these developments in the plasma fractionation scene of the western world have been taking place in a context where many patients in the developing world are still treated with sub-standard, non-virally inactivated crude plasma fractions. in this specific area, one can expect that the developing world will bring innovative thoughts and take actions to find ways to improve the quality and safety of their own local plasma product supply. safety strategies adapted to the infrastructure and economy of less solvable countries may have to be considered. the intercept blood system for plasma uses a synthetic psoralen, amotosalen hcl, and long-wavelength ultraviolet light to photochemically inactivate a broad spectrum of bloodborne pathogens in plasma intended for transfusion (intercept plasma, i-ffp). phase clinical trials have shown that i-ffp retains proteins necessary for hemostasis in the treatment of acquired and inherited coagulopathies, and in support of therapeutic plasma exchange for ttp. a prototype plasma processing set was used for the clinical trials. for commercialization, a new processing set has been developed to improve productivity. the prototype set accommodated approximately ml of plasma, whereas the improved set accommodates up to ml of plasma, resulting in up to three i-ffp doses per treatment. aims: this study was designed to characterize pro-and anti-thrombotic proteins in i-ffp prepared using the improved processing set. proteins of interest included components of the intrinsic and extrinsic coagulation cascade, the fibrinolytic pathway, the contact factor pathway, and the complement system, the vonwillebrand complex, endogenous inhibitors, and markers of thrombin generation. methods: six fresh jumbo ( ml) apheresis plasma units, collected using the haemonetics pcs device (gambro), were photochemically treated. sodium citrate was used as the anticoagulant. plasma samples for analysis were collected before and after photochemical treatment, and were frozen below - °c until batch analysis. standardized clinical assays were used for all analyses. results: (results in the table below are expressed as the percent activity in i-ffp in proportion to the activity in plasma before treatment [mean ± sd]). retention of procoagulant factors in i-ffp plasma ranged from % to %. factor viii and vonwillebrand factor activity, antigen, cleaving protease activity (vwf : cp, adamts- ), and multimeric composition remained within normal ranges after treatment. endogenous inhibitors of coagulation were retained % to %. plasminogen and alpha -antiplasmin were retained % and %, respectively. retention of contact factors was variable; some factors were below the reference range prior to pct. with the exception of tat, all markers of coagulation activation were well within normal ranges. the tat level in one i-ffp unit was slightly above the normal range; all other units had tat levels that were well within the normal range. the significance of this is unclear. cept plasma is similar to conventional plasma. the improved processing set, intended for commercialization, allows up to doses of i-ffp to be produced from a single photochemical treatment. background: guidelines of the european directive / /ec require that fresh plasma prior to freezing contains < residual rbcs per litre. this rbcs content is below the sensitivity limit of the automated cell counters used in routine laboratories. aim of the study: it was therefore essential to make available an alternative method to detect and quantify rbcs in plasma. we implemented a method by flow cytometry using a pe conjugated anti-glycophorin a (gpa) monoclonal antibody that recognises rbcs and erythroid precursors. to quantify residual rbcs in fresh plasma, the method uses the same trucount test tubes (becton dickinson) as those used to quantify wbcs and that contain a known number of fluorescent beads. after addition of plasma and pe-gpa antibody, cell counting is performed on flow cytometer (bd facscalibur). validation of the method: assessment of accuracy, linearity, and reproducibility with different pe-gpa antibodies (immunotech and pharmingen) application of the method: quantification of rbcs in fresh plasmas divided into groups: group : plasmas from leucoreduced whole blood, group : plasmas from packed cells after removal of buffy coat and specific filtration, group : : apheresis plasmas. results: validation of the method: for both anti gpa antibodies, detection threshold is . ¥ residual rbcs/l; linearity study with concentrations of . , . , . , . , . , . , and . ¥ rbcs/l showed excellent correlation between observed and expected values (r > . ); reproducibility study showed c.v of respectively . % and %. for values > ¥ rbcs/l, it appeared necessary to introduce a correction factor of . for the anti gpa pharmingen. quantification of rbcs in plasma: group (plasma from leucoreduced whole blood): . ± . rbcs/l; group (plasma from packed cells after removal of buffy coat and filtration): < . °¥ rbcs/l in all the cases; group (apheresis plasma): < . °¥ rbcs/l in all the cases. conclusion: quantification of rbcs in plasma by flow cytometry is a precise, quick and reproducible test. in addition this study shows that even if there are differences in residual rbcs counts according to the origin of plasma, the obtained values are much lower than regulatory requirements. . improving basic transfusion knowledge amongst health workers; . improving pre-operative preparation for surgery . strategies such as cell salvage autotransfusion combined with a conservative transfusion strategy for the use of allogeneic blood. my presentation will outline the approach adopted to ensure that the use of cell salvage autotransfusion both improves the use of allogeneic blood and preserves allogeneic stores. well-organised training can both minimise the risk of using such advanced techniques and decrease the overall risk involved in undergoing surgery where blood loss may be a significant factor in increasing morbidity and mortality. the various training methods employed to improve knowledge in this area will be described. the increasing current perception that the safety of allogeneic blood transfusion has dramatically been improved during the last decade is challenging autologous haemotherapy methods. in addition, growing concern about the unfavourable cost-effectiveness of most autologous haemotherapy methods requires a refinement of the application of these measures to well defined circumstances. in contrast, newly emerging transfusion-transmissible infections or periods of blood shortage might revive interest in these blood sparing techniques. the first two cases of transfusion transmitted vcjd provide a paradigm for this scenario; not so much with respect to a public fear of infection but rather a waning donor population due to more rigorous recruitment criteria. preoperative autologous blood donation (pabd) still plays a significant role in settings with high individual benefit for the patient, high transfusion probabilities and when all opportunities of cost minimization can be applied. adjustment to the individual situation of the patient is the main aim of a medically reasonable and economic use of autologous haemotherapy. this implies consideration of the patient's haematocrit, blood volume, tolerable blood loss, expected blood loss, etc. in order to choose the optimal method in the individual case. in this respect, double red cell apheresis may play a significant role. with this approach, donation schedules assumed to enhance erythropoiesis can be adopted. moreover, inconveniencies caused by long distances between patient home and donation service can be facilitated by withdrawing two red cell units during one session in selected patients. in conclusion, red cell apheresis can be used to promote the proposed approach towards individualized autologous haemotherapy preoperative plasmapheresis is considered to be a sensible adjunct if intraoperative retransfusion of salvaged and washed red cells is planned. acute normovolaemic haemodilution is valuable when the patient's tolerability of the haemodilution and the expected blood loss are carefully examined beforehand. intraor postoperative salvage of wound blood can also be regarded as useful measures to prevent allogeneic transfusions as long as the specific advantages and disadvantages of the different methods are taken into account. finally, alternative and supplemental measures such as iron or erythropoietin administration should always be considered in order to optimize the efficacy and effectiveness of autologous haemotherapy methods. the goal of a 'bloodless medicine' might not be reached but is supposed to be approached closely with an integrated concept exploiting all measures available. however, in times of restricted health care resources, regular sound costeffectiveness analyses, taking the availability and the cur-rent safety profile of allogeneic blood products into account, are always warranted and needed. compensatory fluid replacement of surgical blood losses: the transfusion of allogeneic blood is expensive and -although safer than ever before -still associated with potential complications. to reduce both, costs and immanent risks, allogeneic transfusion should either be completely avoided or at least minimized during surgical procedures. as a consequence an intraoperative blood loss is initially not replaced by red blood cells, but by erythrocyte-free, i.e. cristalloidal or colloidal solutions. when normovolemia is maintained the resulting dilutional anemia is compensated by an increase of cardiac output and enhanced arterial o extraction. however, once the hb has dropped to values recommended as the lower intraoperative limit, or once compensatory mechanisms of acute anemia become exhausted, as a rule transfusion of red blood cells (rbc) is initiated to increase arterial oxygen content (cao ) and to preserve a margin of safety for tissue oxygenation and organ function. as an alternative to immediate rbc transfusion, ventilation with pure o (hyperoxic ventilation) can be employed to rapidly raise cao by increasing the amount of physically dissolved o in plasma (hyperoxia). however, molecular o causes vasoconstriction, mediated by products of the arachidonic acid metabolic pathway. as a consequence hyperoxia has been shown to increase systemic vascular resistance and to decrease cardiac output and o consumption in subjects with normal hemoglobin concentration ( properly scheduled, three women who did not reach the necessary hct level after the first donation and consequently they got out of the protocol, and one woman who had unexpected intraoperative bleeding and received homologous units in addition. the patients undergoing tkr and the patients undergoing removal of implants predeposited and units respectively, but finally and of them have been used. according to our patients data, the . % of unused autologous blood units belongs to patients with tkr and implant removal. therefore a better schedule is needed for these type of surgery. all the autologous donors were supported by oral iron supplementation throughout the predonation and month past surgery. fourteen of our cases were supported by erythropoietin s.c. in a dose of iu/kg every other day. the majority of these patients was female, only one was male with multiple alloantibodies and was scheduled to predonate autologous units. all of them underwent thr except one woman who also had a tkr months later. the autologous blood donation was well tolerated by all patients and only one woman had a reaction during predonation. furthermore a group of patients matched for age, sex and type of surgery, who did not predeposit blood, received a mean of . homologous units per patient, that is more than the patients on pabd program. our results show that autologous transfusion can be used in scheduled orthopedic surgical procedures and can reduce the need for homologous blood. however, every effort should be made to render the practice of pabd more efficient and to minimize its costs. colloid solutions and their establishment in clinical practice background: various situations like trauma, critical ill patients, sepsis, major surgical procedures and anaphylactic reactions are associated with disturbances in fluid homeostasis. this disturbance is related with reduced oxygen delivery, subsequent lactic acidosis and imbalance in oxidative status. the final result will most likely be an increased mortality and morbidity. aim: the important issue from clinical aspect is to define the optimal volume and type of fluid therapy. the debate for the ideal resuscitation solution lasts a couple of decades due to inconclusive and conflicting results. method: we searched the literature for clinical trials and major met analyses concerning patients undergoing scheduled surgical procedures, trauma patients and critical ill who received resuscitation fluids. results: dextrans reduce blood viscosity and von willebrand factor levels more, for the same degree of hemodilution, compared to other plasma expanders. in clinical setting they are effective in reducing the incidence of deep vein thrombosis and pulmonary embolism. after the initiation of dextran for prophylaxis against anaphylactic reactions, they are considered the safest plasma substitutes, except maybe during pregnancy. dextran % is the most like to cause the 'hyperoncotic acute renal failure' syndrome. gelatins also cause a decrease in circulating levels of vwf : ag, vwf r : co, thrombin-antithrombin complexes and f + . in clinical aspect however, there are contradicted results about the effect of gelatins in bleeding diathesis, although they appear to exert a greater effect on rbcs protection from mechanical stress. in respect to anaphylactoid reactions, they have the greatest relative risk. hes has the same effectiveness in volume expansion with albumin and has the advantage of remaining intravascular even if there is an increased capillary permeability. in addition, it may improve splanchnic blood flow and tissue oxygenation. hes / . subsides the inflammatory response in patients undergoing major surgery, compared to a crystalloid-based volume therapy, but has conflicting results about it's effects on neutrophil respiration burst. clinical trials have so far failed to have a unanimous conclusion about the bleeding diathesis after hes administration, especially. caution must be held when administering hes during renal transplantation. albumin became the scapegoat of transfusion strategy during the past years. resent met analysis have contradicted results about the safety of albumin infusion in variouw settings. a positive effect seems to have the early administration of hypertonic solutions in trauma patients, especially in combination with dextrans. conclusions: although some minor conclusions can be extracted, there is still a great lack of large scale multicentre randomized prospective clinical trials for extracting evidence based criteria. instead, we try to extract conclusions through met analysis. results show no evidence that resuscitation with colloids reduces the risk of death compared with crystalloids in patients with trauma, burns, major surgery or sepsis. also, there is lack of evidence that one colloid solution is safer -in clinical aspect -than any other. recombinant human erythropoietin therapy in critically ill patients -a dose response study* objective: the aim of our study was to assess the efficacy of two dosing schedules of recombinant human erythropoietin (rhuepo) in increasing hemoglobin (hb) level and reducing the exposure to red blood cells (rbc) transfusion in critically ill patients. design: a prospective, randomized, multicenter trial. patients: a total of patients who met eligibility criteria were enrolled. intervention: patients were randomly assigned to receive intravenous (i.v.) iron saccharate alone (control group), i.v. iron saccharate and subcutaneous rhuepo units once per week (group a) and i.v. iron saccharate and subcutaneous rhuepo units three times per week (group b). rhuepo was given for a minimum of weeks or until icu discharge or death. the maximum duration of therapy was weeks. the requirement for rbc transfusions was significantly higher in control group than that in group a and b. no significant difference was observed between group a and b. the mean increase in hematocrit (dhct) and hb (dhb) from baseline to final measurement were significantly higher in group b than these in control group. dhct was significantly higher in group b than that in group a. dhct in group a was significantly higher than that in controls, whereas dhb did not differ significantly between control and group a. conclusion: administration of rhuepo in critically ill patients significantly reduced the need for rbc transfusions. the magnitude of the reduction did not differ between the low and high dose of rhuepo, whereas there was a dose response of hct and hb to rhuepo in these patients. in transfusion medicine, antibodies to antigens in the platelet membrane have traditionally been regarded as less significant compared with antibodies towards red cell antigens. there is an increasing awareness of antibodies towards platelet antigens. detection of autoantibodies to platelets can be a diagnostic challenge, but is seldom a problem in transfusion medicine because patients with such antibodies rarely are candidates for platelet transfusions. also, severe foetal thrombocytopenia is seldom present in pregnancies with autoantibodies to platelet antigens. the real challenge in transfusion medicine is related to patients with severe thrombocytopenia who are refractory to platelet transfusion due to alloantibodies towards platelet antigens. in our department, flow cytometry is used for compatibility testing and the choice of compatible blood donor is done without knowledge of antibody specificity. if crossmatch negative random donors cannot be identified, antibody specificity testing is performed and donors are chosen based on the specificity of the antibodies determined by a modified maipa procedure and with hla class i beads (flowpra from one lambda, usa) in flow cytometry. in some cases both hla class i and human platelet antigen (hpa) specific antibodies are detected and hla class i, hpa matched donors are chosen for crossmatch. if the crossmatch is negative, there is > % chance of successful transfusions. in some cases drug induced anti-platelet antibodies are suspected and flow cytometry based antibody tests are performed in the presence and absence of the drug. in the case of suspected heparin induced antibodies, a beads assay is performed (diamed, switzerland). two percent of caucasian women have the platelet type hpa bb. ten percent of these women make anti-hpa a antibodies in their first hpa a incompatible pregnancy. in - new-born has thrombocytopenia due to maternal alloantibodies which have crossed the placenta (neonatal alloimmune thrombocytopenia, naitp). results from a screening study covering the outcome of pregnancies show that only babies were born with intracranial haemorrhage (ich) and there was no still-born babies in the study. pregnant women with a-hpa a antibodies were diagnosed, received careful clinical follow-up and the delivery was performed by caesarean section in week of the pregnancy with immediate transfusion of hpa compatible platelets if the new-born had platelet count < ¥ e /l. in previous studies, it is reported the ich appears in - % of the pregnancies where antibodies are present and that % of the babies with ich, die. our results are different from what is reported from other studies and this may reflect the prospective approach and the clinical interventions. naitp represent a challenge in transfusion medicine both diagnostically, but also related to compatible blood products for the thrombocytopenic new-born and the mother who may have high level of antibodies towards platelet antigens. methods: apheresis platelets ( ¥ e mean) from donors with same blood group were pooled and divided equally into two bags, po- and control (pl , baxter), which have and ml/m *day*atm of oxygen permeability, respectively. on days , , , , , and of storage, swirling, mean platelet volume, po , pco , ph, glucose, lactate, aggregation, and p-selectin expression were evaluated. six experiments were performed. results: the swirling pattern was preserved better for up to days in po- ( / ) than in control ( / ) bags. dropped ph less than . on day was observed / in po- whereas / in the control. aggressive drop of glucose ( mmol/l) with prominent lactate accumulation ( mg/l) was also observed on day in of control bags. the po level in the control dropped more significantly by % ( . mmhg) on day than in po- ( . mmhg) compared with the initial level ( . mmhg) (p < . ). these results suggest that aerobic metabolism of higher concentration platelets was maintained better in a container with higher oxygen permeability. and less lactate generation with slower glucose consumption is also suggested in po- bags than in control bags. the %hsr and aggregation decreased gradually in a similar manner in both bags until day , and became a detrimental defect in of control bags on day . p-selectin expression was higher in control bags than in po- on days and with no statistical difference. in two control bags p-selectin expression reached > % and was accompanied by a loss of swirling. these functional and biochemical characteristics of platelets at a higher concentration were kept better for - days when stored in a container with higher oxygen permeability than in the best of marketed containers. t-pa- background: maintenance of a neutral ph in the range of . - . is essential for preservation of platelet function and viability during storage. furthermore, studies have also indicated that the presence of glucose in the platelet suspending medium is important for maintenance of platelet quality. however, a platelet additive solution (pas) containing glucose having a ph of . - . cannot be manufactured by steam sterilization due to caramelization of glucose. in order to have optimal ph, the currently available pas such as t-sol does not contain any glucose. this study describes a novel twostep approach to provide a glucose containing additive solution (pas-g) by using an acid, glucose containing electrolyte solution (ph . ) for resuspension and processing of the pooled buffy coats (bc), followed by transfer of the processed platelet concentrate (pc) into a storage bag containing bicarbonate for ph neutralization and maintenance during extended storage. aim: compare the platelet quality of pooled bc pc stored in pas-g with pooled bc pc stored in t-sol. methods: a paired study design was used, where a pool of bcs obtained from standard day -old cpd-wb units, was divided into two equal parts: one part was resuspended and processed with a pall leukoreduction system (atsbc) using t-sol, the other part was processed in a similar manner with the acid part of pas-g. percentage plasma carryover ranged from - %. both processed pc products were transferred and stored in elx tm bags with the pas-g pc elx bag containing a bicarbonate tablet. ten replicate studies were performed. results: the yields ( . ± . vs. . ± . °¥ e ) were similar (pags vs t-sol). statistically significant (p < . with paired ttest) improved platelet quality at days , , and of storage was observed with platelets stored in pas-g as compared to t-sol. the table below shows results at and days of storage for ph, extent of shape change (esc) and hypotonic shock response (hsr). the results for t-sol stored platelets correlated highly with initial glucose (% plasma carry over) level (r = . for esc, and r = . for hsr at days storage), while no significant correlations were found for pas-g stored platelets. conclusion: this study demonstrated the practicality of using a two step procedure to store bc pc in a glucose containing additive solution with neutral ph during storage, and confirmed the importance of glucose in the storage medium as nutrient for optimal platelet storage quality. the effect of irradiation on white cell reduced platelet concentrates, stored for days background: the storage of white cell (wbc)-reduced platelet concentrates (pcs) can be extended from to days provided the quality has been validated and bacterial screening is performed. irradiation up to gray (gy) does not affect platelet quality, but the effect of pre storage irradiation with subsequent storage up to days is not known. method: two wbc reduced pcs, each made from buffy coats and a unit of plasma, were pooled and divided into control group 'a' and study group 'b' . pcs in group 'b' were irradiated immediately after preparation with gy. pcs in both groups 'a' and 'b' were then stored on a continuous flat bed shaker at - °c. swirl, ph and cd p expression were determined on day , and . twelve experiments were performed and compared with a paired t-test, p < . was considered significant. results: see table (day values; mean ± sd; n = ). pooling and dividing of the pcs was successful with respect to volume and platelet number. on day , the ph in group 'b' was slightly lower than in group 'a', but the difference is not significant. in group 'a', ph on day was < . in / pcs, versus / in group 'b' (not significant). the cd p expression in irradiated pcs is not significantly higher than in non-irradiated pcs. conclusion: irradiation had no significant effect on platelet quality when stored for up to days after blood collection. - b, - a, - b, pra %, donors. in patient -three transfu-sions were effective (two crossmatches neg by lct and pift, one pos lct, neg pift) but later on, when the patient was in severe clinical status (shortly before his death) two transfusions were ineffective in spite of neg crossmatches. it is very likely that for the same reason patient and were refractory to two and one hpa compatible platelet units respectively. in patient and compatible platelets were not transfused because they died before the whole procedure (diagnosis and finding a proper donor) was completed. conclusions: . the frequency of occurrence of anti-hpa antibodies in transfused patients was: - b, - b, - b, - a, - a; in three patients they were monospecific, in four polyspecific. . in patients who developed anti-hpa alone, transfusions of platelets without relevant hpa antigens were successful. .the effectiveness of compatible platelets in patients with both anti-hpa and -hla was more difficult to assess because of their severe clinical status, which might have been responsible for transfusion failure. in one of these patients, however, the transfusions of compatible platelets were successful when he was in relatively good clinical status, but shortly before death transfusions were ineffective. t-pa- the successful implementation of nucleic acid testing (nat) for hiv, hbv, hcv and further viruses as well as improved donor selection led to a dramatic risk reduction for viral transmission via blood transfusion over the last years. today, other risks get into the focus of haemovigilance. bacterial contamination of blood products can occur via the donor, suffering from a (clinically unapparent) bacterial infection, or via the donation process itself, storage and handling of the blood product. particularly platelet concentrates (pc) are vulnerable to bacterial growth due to their storage conditions. patients receiving such products have a potential risk of severe complications or even death. modern hygiene regimes, e.g. improved disinfection of the donors´ skin or preparation of blood products in fully closed systems as well as diversion, led to a significant reduction of bacterial contamination risk in the past. however, a small risk remains. therefore, two possible ways of further reducing the risk of bacterial contamination of blood products are feasible: (a) testing and/or (b) inactivation. testing for bacterial contamination is possible by different methods: direct detection methods for bacteria (microscopy, flow cytometry) have disadvantages regarding sample size and detection limit. bacteria might rapidly grow in a contaminated pc, so testing should be performed as close as possible to transfusion to the recipient. biochemical methods like oxygen consumption might not detect anaerobic germs. automated culture methods are still the most sensitive technique, but they have their downsides as well (e.g. time and size of aliquot drawn). novel molecular genetic test methods for detection of bacterial nucleic acid are in different states of development, but still have to proof their suitability for routine use. three different principles of pathogen inactivation can be distinguished: photodynamic reactions produce oxygen radicals which in turn inactivate bacterial structures by oxidation processes. examples for these chemicals are phenothiazines like methylene blue and thionin as well as vitamins like riboflavin (vitamin b ). photochemical reactants penetrate cell boundaries and irreversibly inhibit nucleic acid, thus blocking replication and proliferation of pathogens. chemicals of this group are psoralens like amotosalen as well as pen- or s- . the third method, the solvent detergent (sd) method, is used for pooled plasma only and consists of the combination of both solvents and detergents, which interact with membranes and destroy bacteria. methods for inactivation of bacterial contaminants have to proof, that they effectively inhibit bacterial growth while maintaining full functionality of the blood product at the same time. these two qualities have to be fulfilled up to the end of the storage period. toxic or mutagenic compounds must not remain in the final product. the technology must be easily integrated into the existing work cycle of a blood bank. finally, costs per product must be acceptable. in summary, both testing and inactivation have their advantages and disadvantages, which have to be weighed up against costs and benefits of both procedures. pros and cons of introduction of inactivation methods in a blood donor service producing blood components per year will be discussed. bacterial contamination of blood components, particularly platelets, is now recognized as a serious adverse reaction that is preventable. there are many studies that have documented that these reactions occur from platelets stored at room temperature, most commonly arising from a skin contaminant, but originating from donors with asymptomatic bacteremia in about / of cases. the problem is intensified for patients receiving pools of platelets compared to single donor platelets collected by apheresis. reactions are more commonly noted and more severe with platelets stored for greater lengths of time. previous studies at johns hopkins described a series of reactions in years with reactions more common in platelet pools ( : transfusions) than with single donor platelets ( : transfusions). these reactions caused fatalities in of cases. although our data suggests that these reactions are more common than other studies using hemovigilance systems, our case definition requiring culture of all transfusion reactions to platelets led to a more reliable estimate of the incidence of sepsis from platelets, many potential solutions have been proposed to prevent these reactions. improved skin antisepsis should always be sought but will never eliminate the / of reactions due to asymptomatic bacteremia. the same limitation applies to methods that divert potential skin plugs from the collection bag. antibiotics in the bag would lead to manufacturing concerns or problems for patients with drug allergies. although cold storage of platelets is currently being revisited, it is not yet a practical solution. pathogen eradication systems have been developed but they remain unapproved in most of the world and have led to concerns about toxicity of additives, damage to treated cells, and cost. as a result of increasing recognition of the problem, there has been increased interest in bacterial screening to prevent sepsis from platelets. in march , the aabb standards required testing of platelets for bacterial contamination. testing programs have been implemented in the us widely as a result of the aabb action. licensed systems based upon bacterial culture or growth characteristics are available for single donor platelets and have been commonly employed. although these systems have some difficulty with false positive reactions, the evolving national data suggest an incidence of : true positive reactions. these data suggest that a number of serious reactions have been averted, although some cases have persisted due to incomplete adoption, problems with slow growing bacteria, or the use of inferior testing methods with inadequate sensitivity. whole blood derived platelets have become a more difficult issue, since the approved testing methods are limited. the use of ph monitoring, gram stain, glucose measurements, and inspection for swirling have all been attempted. these methods are not sufficiently sensitive or specific to interdict many contaminated units, so that screening for bacteria in pooled platelets is less effective. it is anticipated that new methods may become available to make screening of whole blood derived platelets easier to perform in a reliable manner. it is also hoped that bacterial screening of platelets may form the basis to permit seven day storage and prestorage pooling in the us. results: twenty four hcv rna (+)/anti-hcv(-) repeat donors were previously tested in routine hcv rna in mini-pools and were negative. twenty available look back samples were individually tested for hcv rna and in one the virus was detected. to make sure that the failure of hcv rna detection in routine nat was not due to the pooling procedure, the hcv rna was tested in undiluted look back sample and dilutions of this sample by hcv negative plasma: / repeats of x dilution and / repeats of x dilution were hcv rna negative, whereas / repeat of x dilution and / repeats of undiluted sample were positive. the results of cobas amplicor monitor (sensitivity iu/ml) were negative, which means that viremia in hcv rna mini-pool negative donation was below iu/ml. in the recipient of red blood cell concentrate from this donation hepatitis c was diagnosed. however, the possibility of pretransfusion hcv infection cannot be excluded as no hcv marker tests were performed before transfusion. the patient and the donor were infected with genotype a. the low hcv viremia (below iu/ml) in the preseroconversion window period was responsible for no hcv rna detection in routine mini-pool hcv rna testing. introduction and aim of the study: bacterial contamination is a life threatening risk of blood transfusion, especially with platelet transfusions. bacterial culturing (bc) of platelets as well as pathogen reduction (pr) reduce the likelihood of such contamination. where the costs of bacterial contamination are far less than the costs of pathogen reduction, the latter will reduce not only the risk of bacterial contamination but also risks of other pathogens. therefore, the question arises whether this additional expenditure can be justified in the light of the additional effect achieved. this question we will answer by cost-effectiveness and sensitivity analyses. methods: the balance between costs and effects of preventing adverse events due to platelet transfusion is assessed using a mathematical model and assuming optimal effectiveness of pr. model parameters and valuations of health states were obtained from literature and information from dutch sanquin blood banks. . while the estimates in comparison to the situation without bc or pr are surrounded with large uncertainties, the conclusion that pr is not cost-effective in comparison to bc is very robust. the cost-effectiveness of bc and pr are very sensitive to the estimates concerning sepsis probability and associated complication rate, the cost-effectiveness of pr relative to bc is not. this conclusion is also insensitive to a wide range of assumptions regarding residual risks and costs associated with hiv, hcv and hbv. the estimates indicate that culturing in the netherlands is cost-effective, even with the deviation bag in place. the estimates however appear to be very sensitivity to the probability of sepsis. a decision to use pr will, after the introduction of bc and the use of a deviation bag, never meet cost-effectiveness criteria. even when assuming perfect protection, the conclusion that it is not cost-effective in comparison to bc is very robust and does not alter when varying underlying parameters within their margins of uncertainty. table) . of cb collection. two collections have been transplanted to date and this represents a . % take-up rate ( . % where a sibling is alive). this compares favourably with the numbers transplanted from unrelated cb banks. dcb collection is therefore at least as efficient a method as unrelated cb collection for transplantation albeit in the limited number of cases where a dcb collection is possible. dcb collection has the benefit of a possible immediate transplant combined with the availability of a sibling donor for future donation of both stem cells and lymphocytes. it is therefore a useful service to provide and complements the work of unrelated cord blood banks. increased yield of mature platelets in cultures of cd -enriched cord blood cells maintained at °c introduction: the future use in transplantation of ex vivo expanded hematopoietic stem (hsc) and progenitors cells will facilitate the transplantation of adult patients and speed up hematologic recovery. also ex vivo cultures of hscs may eventually permit to produce donor-free blood components such as platelets for transfusion. culture of animal cells is routinely done at °c. however there is previous clinical evidence suggesting that hematopoiesis may be more active in hyperthermic patients. we have therefore compared the effect of hyperthermia on the ex vivo expansion and differentiation of cord bloodderived hsc in megakaryocytes (mk) and mature platelets. the cord blood-derived cd cells were cultured continuously at °c or °c for days in cytokine conditions optimized for mk development and maturation. the cultures were regularly monitored for various parameters. results: compared to °c, the cultures maintained at °c produced significantly more total cells ( . fold) and total mks ( fold), and showed accelerated and enhanced mk maturation with increased yield of proplatelets and mature platelets ( . fold). accordingly, the cells cultured at °c contained an increased frequency of cfc-mk ( fold) at day . cultures done at °c and °c were also more efficient than at °c but less than at °c. platelets produced in °c cultures could be normally activated by thrombin. as expected, the cells cultured at °c contained an increased amount of the heat shock protein hsp . control experiments showed that the culture of several cell lines was inhibited or unaffected by the °c temperature. the unexpected resistance of hematopoietic cells to the deleterious effects of heat and the stimulatory effect of > °c temperatures on hsc proliferation and differentiation indicate that the routine culture of normal human cells at °c is a paradigm that needs to be revised. the responsible molecular mechanisms remain to be identified but the observation will facilitate the ex vivo expansion of the progenitors of the mk and possibly other lineages. the synchronous generation of a significant number of mature platelets in vitro will facilitate the study of the mechanisms of platelet formation and ageing and could eventually have important applications in transfusion medicine. it remains to be seen if the stimulatory effects of higher than °c temperatures represent a protective response against sustained body fever that is specific to the hematopoietic system. several countries have, in the past few years, included human tissue banking within a regulatory framework similar to that of blood. indeed, tissue safety has come to the forefront of the preoccupations of regulatory agencies after several well publicised morbidity and mortality cases have been reported in the press. tissue safety has many features similar if not identical to blood safety and a review of those common elements will be reported. as well, arguments in favor of integrating tissue banking within a blood system will be discussed, one of the more important aspect of which being the expertise of the blood centre staff with cgmps. the experience of a blood establishment (héma-québec) with the integration of tissue banking such as bone, skin, heart valves within its operations will be reported, emphasizing the medical as well as the management aspects of such an integration. finally, tissue banking is an activity which brings more expertise to a blood centre, expands its knowledge of its customers and gives more opportunities to its personnel. umbilical cord blood (cb) is an important source of stem cells for clinical transplantation and may cause less gvh disease than non-t-depleted bone marrow (bm). the relatively low numerical cell dose available from cb has usually restricted its use for transplantation in adults. only - % of patients have an hla matched sibling and for others an unrelated bm or a stored unrelated cb donation may also not be available. for some children the collection of cb following the birth of a sibling may be the only opportunity for a transplant. directed cb (dcb) donations from matched siblings have been shown to give better long-term overall results than matched unrelated cb or bm. dcb collection is however not as easy to control as cb for banking where dedicated hospitals and trained staff are used. here we review dcb banking in oxford over a . -year period. requests were received for deliveries from mothers and of these, collections were successful including pairs of twins. failed collection was most often due to a damaged cord at delivery. collections were made for siblings possibly requiring transplant (median age ) with for leukaemia, for erythroid disorders, for immune deficiency, for enzyme deficiency and others. the remaining collections were mostly requested where there was a family history of an inherited disorder (majority scid). three collections tested positive for anti-hcv antibody but negative for hcv by pcr. collections were not excluded on the basis of volume or cell number. mean volume was ml (range - , % exceeded mls) and mean tnc count was . ¥ (range . - . , % exceeded . ¥ ^ ). the mean cd +ve count was . ¥ (range . - . ). all collections were cryopreserved within hours using dmso/dextran/saline without volume reduction. the mean tnc viability prior to freezing was % (range - %) and the mean cd +ve viability post freezing was % (range - %). the reliance on the goodwill of midwives and the logistical difficulties that arise when organising collections from many different hospitals do not appear to reduce the success . rhd and rhce typing was performed by multiplex-pcr with fluorescent primer pairs. positive results were obtained for rhd-exons - , , and polymorphisms associated with antigens c, c, cw, e and e. sequencing of rhce-sequences, including exons to and intron/exon borders, were done by direct taq cyclesequencing using bigdye-terminators v. . in an abi (applied biosystems). background: a number of adverse immune reactions associated with blood transfusion result from contamination of blood products by donor white blood cells. among these reactions, transfusionassociated graft-versus-host disease (ta-gvhd) has a mortality of greater than %. mirasol ® pathogen reduction technology (prt) has been developed for the reduction of viruses, bacteria, parasites and white blood cells loads in blood products. the technology is based on light and riboflavin photochemistry. this study was performed in order to evaluate the effectiveness of the mirasol ® prt process for inactivation of human pbmncs. methods: human pbmncs were collected from trima platelet apheresis disposable sets, purified by ficoll-hypaque discontinuous gradient centrifugation and divided into test and control samples. the test cells were treated with mirasol ® prt in autologous plasma on day . both test and control samples (n = ) were tested on day for cellular immunophenotype, t-cell activation using flow cytometry, proliferation in response to mitogen or allogeneic stimulator cells, ability to stimulate the proliferation of allogeneic responder cells and cytokine synthesis in response to lps stimulation was measured using a cba assay kit. results: although mirasol ® prt treatment did not significantly change the distribution of cd +, cd +cd +, cd +cd +, cd + and cd +cd + human lymphocyte subpopulations there were significant functional change. the expression of the activation marker, cd , was observed in . % (sd = . %) of control t cells upon activation with pma, while only a . % (sd = . %) of the test t cells increased cd expression. proliferation assays showed that h-thymidine incorporation did not increase in the test cells in response to either pha or allogeneic stimulator pbmnc compared to the significant increase in thymidine incorporation levels observed with control cells. the test cells, when compared to the controls cells, demonstrated an inability to stimulate allogeneic responder pbmnc proliferation. the release of il- , il- , il- b and il- cytokines after -h incubation in culture media increased significantly to pg/ml (sd = ), > pg/ml, pg/ml (sd = ) and > pg/ml for control cells, respectively. under the same conditions, these cytokines in test samples remained at background levels of . pg/ml (sd = . ) for il- , . pg/ml (sd = . ) for il- , pg/ml (sd = ) for il- b and pg/ml (sd = ) for il- . addition of lps further stimulated the release of tnf-a, il- , il- , il- b and il- in the control samples, but not in the test cell samples. in vitro studies demonstrate that mirasol ® prt treatment does not change lymphocyte immunophenotype, inhibits tcell activation by pma, abolishes pbmnc proliferative activity, eliminates pbmnc stimulatory activity for responder cell proliferation and suppresses the production of cytokines by pbmnc in both the absence or presence of lps. introduction: it has been discovered that vaccination of dendritic cells (dcs) with tumor antigens is a potential strategy to induce tumor-specific immunity in tumor-bearing patients. aim of the study: the purpose of the study was to investigate whether human monocyte-derived dendritic cells (dcs) were able to present p bcr-abl protein and induce antigen-specific ctl responses in vitro after transfected with total rna of k cells (k -rna). methods: dcs were derived from human pbmncs, which were incubated for days in the presence of gm-csf and il- , and then were transfected with k -rna using electroporation or dotap lipofection. to verify the successful transfection of dcs with k -rna, bcr-abl fusion genes expression of dcs was detected by rt-pcr and western blot. the immune phenotypes of the dcs were analyzed by flow cytometry. the cytotoxicity of ctl was assayed by propidium iodide (pi) staining and flow cytometry. results: it was shown that the bcr-abl fusion gene was detected in the dcs immediately after the transfection, but disappeared hours later, while the cells were expressing p bcr-abl protein and expressing increased cd , cd , cd , hla-dr. moreover, the transfected dcs could significantly promote the t lymphocytes to kill the target k cells. conclusion: human dendritic cells transfected with total rna of k cells in vitro could induce effective p bcr-abl proteinspecific immune responses and be used to induce tumor-specific immunity, which implies potential application of immunotherapy to tumors. appear to be relevant to the clinical response. ivig has a remarkably good safety record for long term administration, however the following side effects have been observed: mild, infusion-rate related reactions such as headaches, myalgia or fever; moderate but inconsequential events, such as aseptic meningitis and skin rash; and severe, but rare, complications such as thromboembolic events and renal tubular necrosis. judicial use of ivig based on results from controlled studies is recommended. t-pl - donor-lymphocyte infusion: transfusion immunotherapy following allogeneic hematopoietic transplantation the notion that bone marrow containing immunocompetent cells is capable of mediating an antitumor effect was determined experimentally almost years ago. subsequently, pooled leukocytes from patients with cml were found to effect responses in patients with advanced leukemia. response correlated with cell dose and with severity of gvhd. in the 's, the graft-versus-leukemia (gvl) effect was defined in the transplant setting using a lethallyirradiated mouse model and splenocyte infusions. such studies suggested that gvl could be enhanced without causing severe gvhd. the era of adoptive immunotherapy in the transplant setting began in the 's with reports of donor lymphocyte infusions (dli) for relapsed acute and chronic leukemias after bone marrow transplant. it is now clear that chronic myelocytic leukemia (cml) in chronic phase is highly susceptible to gvl effects mediated by dli which induce durable remission in - % of relapsed patients. the success rate is % or less in patients with accelerated phase or blast crisis. since dli cell dose appears to be important in this setting, strategies of escalating dose infusions have been investigated to enhance gvl without exacerbating gvhd. unfortunately, the response to dli in relapsed acute leukemia and myeloma is less favorable (< %) and less durable. dli have been used successfully to treat viral infections and virus-associated malignancies following transplant. both unfractionated dli and ex vivo-generated tcell clones have suppressed reactivated cytomegalovirus and eradicated epstein-barr virus-induced lymphoproliferative disease, a polyclonal proliferation of donor-origin b cells that occurs after transplant. where tumor-specific antigens have been defined, efforts to target dli have been undertaken and donor and patient immunization has been investigated. acute or chronic gvhd develops in approximately % of patients receiving dli for relapsed hematologic malignancies and for related, but not unrelated transplants, correlates with the donor t-cell dose. dli-induced pancytopenia occurs in approximately % to % of patients, is generally mild, and transient, but in < % of patients, aplasia is severe and prolonged. complications of aplasia include infection, bleeding, increased transfusion requirements. efforts to limit the adverse effects of dli while retaining the therapeutic effects include insertion of 'suicide genes, ' selection of lymphocyte subpopulations, and targetting lineage-specific minor histocompatibility antigens. available clinical and experimental evidence suggests, that in addition to primary and secondary immune deficiencies, a wide spectrum of immune-mediated conditions could benefit from intravenous immunoglobulin (ivig), including acute and chronic/relapsing diseases, autoimmune diseases mediated by pathogenic autoantibodies or by autoaggressive t cells and inflammatory disorders e.g. an imbalance in cytokine networks. trimar-collected apheresis platelet concentrates (pcs) were exposed to . j/ml uv light in the presence of um riboflavin, followed by storage under blood bank conditions with various concentrations of -deoxyglucose from to mm for days. the control platelets were not stressed by uv light exposure and were stored under the same conditions without -dog presence. all test and control platelets were measured for in vitro cell quality including rates of glycolysis, morphology score and activation levels at days , , and . results: lactate production and glucose consumption increased from . mmol/ cells/h (sd = . ) and . mmol/ cells/h (sd = . ) for control samples to . (sd = . ) and . (sd = . ) for uv-treated platelets, respectively. uv treatment also caused a decrease in ph from . (sd = . ) for controls to . (sd = . ) for treated platelets at day , hsr from % (sd = . ) to % (sd = . ), esc from . % (sd = . ) to . % (sd = . ), swirl from . (sd = . ) to . (sd = . ), and increased p-selectin expression from . % (sd = . ) to . % (sd = . ). addition of -dog up to mm significantly reduced lactate production rate to . mmol/ cells/h (sd = . ) and glucose consumption rate to . mmol/ cells/h (sd = . ), and maintained ph above . (sd = . ) for days of storage. the effect of -dog exhibited a dose-dependent response. however, the addition of -dog had no effects on hsr ( . + . % at day ), esc ( . + . % at day ), swirl ( . + . at day ) and p-selectin expression ( . + . % at day ) during platelet storage. atp contents in both treated and control groups were maintained at a relatively constant level above % of the value seen in fresh platelets. furthermore, an exaggeration of uv-stressed platelet aggregation by addition of -dog was also observed. conclusions: increased glycolytic flux is not a direct cause for platelet morphology changes and spontaneous activation incurred during the development of the storage lesion. the results also suggest that a reduction in glucose utilization may foster an increase in platelet loss during storage. aim of the study: was to evaluate analytical sensitivity, sensitivity and inclusivity for subtypes and genotypes of hiv, hcv and hbv, the assay's effectiveness in closing the pre-seroconversion window period, clinical specificity as well as the effect of endogenous substances and microorganisms on the sensitivity and specificity of the assay. methods: secondary standard traceable to who international standard for hiv- ( / ), international standards for hcv ( / ) and hbv ( / ) were used to determine the analytical sensitivity. sensitivity and inclusivity for hiv- subtypes other than hiv- b, for hiv- and for hepatitis b and c genotypes as well as specificity was evaluated with > specimens. results: results from this study indicate that high analytical sensitivities ( iu/ml hiv- m, cp/ml hiv- o and . cp/ml hiv- , iu/ml hcv and iu/ml hbv) and a specificity of > . % are accomplishable for the mpx test. the % detection rate for hiv- m subtype isolates (a through h) was between to iu/ml, for hcv genotype isolates ( a through ) between to iu/ml and for hbv genotype isolates (a through g and precore mutant) between to iu/ml. investigating seroconversion panels, hiv- rna was detected an average of and days earlier than hiv- antigen with abbott hivag- monoclonal and coulter p antigen tests, respectively, hcv rna an average of or days earlier than hcv antibody with the abbott hcv eia . or ortho eia . tests, hbv dna an average of days earlier than hbsag with the abbott hbsag eia imx test. for all targets, no interference was detected with microorganisms tested as well as elevated levels of triglycerides, albumin, hemoglobin, human dna or bilirubin. conclusion: automated pooling, sample preparation, and real time pcr using the blood screening system taqscreen mpx test is an efficient and sensitive method to simultaneously screen for five important viruses in human plasma. the mpx test is another evolution step in the development of pcr automation by roche molecular diagnostics, and further represents roche's commitment to increasing the safety of the global blood supply. aim of the study: a prospective hemovigilance plan was set up in order to establish a registry for future reference, and to detect any unexpected side effect of ip that may occur with significant frequency in populations and indications that were not studied before and outside of a formal trial environment. methods: this plan is proposed to blood establishments and transfusion prescribers who have already decided to implement ip. this is an observational, non randomized, non controlled plan. no patient selection, inclusion or exclusion criteria are required. all ip transfusions are documented using an internet form, whether or not a reaction is observed. patient population data are collected anonymously, for epidemiological purposes. results: between october and september , apheresis ip units have been transfused in sites and registered in the database. ip platelets were considered leucocyte inactivated and were not irradiated, but were antigen matched as indicated ( . %). the population of patients receiving at least one transfusion (n = ) included . % of males, . % of females, the median age was (range - ). the most frequent broad diagnostic categories were hematology-oncology ( . %) and cardiovascular surgery ( . %). the patients received their transfusions either in regular hospital wards ( . %), intensive care units ( . %) or as outpatients ( . %). the number of transfusions by patient ranged from to (mean . ± . , median ). half of the patients ( . %) had previous transfusion experience and . % had previous history of transfusion reaction. transfusion reactions, defined as any deterioration of the patient's state of health observed following transfusion, were observed in . % (n = ) of the transfusions ( % ci . - . ), and . % of patients. only ( . %) were considered serious. after further causality analysis including biological and clinical investigations by the transfusion physician, . % ( % ci . - . ) of the transfusions were confirmed as having caused reactions in . % of patients, none of them serious. the most often reported symptoms were chills ( . %) and fever ( . %). itching, skin rash or urticaria was observed in . % of transfusions. of the serious reactions, one was hypotensive shock in a patient with liver cirrhosis and haemorrhage, and one was septic shock, in which the platelet unit bacterial culture was negative. none of the reactions occurred in cardiovascular surgery patients. patients were more likely to experience reactions if they had previous transfusion history (odd ratio . , p = . ). the active hemovigilance plan is a valid and feasible method to collect epidemiological data on transfusion safety. the risk profile of ip transfusions appears favorable. quality of theraflex mb-plasma during storage and treatment s reichenberg* and n mÜller † *maco pharma international gmbh, langen, † inst. for transfusion medicine, essen, germany background: although in the last decades thanks to the implementation of several methods like donor selection and testing procedures the risk of virus transmission from plasma has decreased, infection of patients still exists. additionally new viruses like west nile virus enter the transfusion chain. therefore, the treatment of therapeutic plasma with methylene blue (mb) is a technique used in several european countries for pathogen inactivation. macopharma has developed the proprietary theraflex mb-plasma bag system including a mb pill and a final mb filtration step. aims: aim of the study is to show the quality of the mb plasma during the preparation procedure and during storage using the theraflex system. methods: for the preparation process every single step was evaluated using single donor plasma units. for the evaluation of the plasma factors ml were drawn at different stages (before treatment, after plasma filtration with plas , after dissolution of the mb pill, after illumination, after treatment). because the sample volume for single sample measurements would be too low the samples were pooled after drawing and measured for the specified factors. six samples of each stage were pooled at three days. a whole panel of plasma factors was measured for the resulting three pools. global tests: quick, inr, aptt, thrombin time coagulation factors: fibrinogen, factor ii, factor v, factor viii:c, factor ix, factor x, factor xi inhibitors: at iii, protein c, protein s fibrinolysis: plasmin inhibitor, alpha -antitrypsin complement: ch activation: tat, factor xiia, d-dimer stability data were generated using three plasma pools. six plasmas were pooled and afterwards divided into six aliquots. each was treated as single unit and then each was divided into six storage samples. the same plasma factors as for the manufacturing process were evaluated. results: a moderate reduction for some coagulation factors during the preparation was found in the illumination step but not in the other preparation stages. this was mainly fibrinogen ( . %), factor viii ( . %), and factor x ( . %). despite this reduction the values were within the ranges found in non-treated plasma. all investigated plasma factors remained stable during the investigated storage time. summary/conclusions: the investigation showed that plasma treated with the theraflex procedure showed slight reduction during treatment and no reduction during storage. all plasma factors remained within the threshold values. the treatment of therapeutic plasma with mb is a valid technique of pathogen inactivation. validation of intercept treatment of pooled platelets g santos, c silva, f pereira and g sousa lisbon regional blood centre, lisbon, portugal background: intercept blood system for platelets uses amotosalen hcl and uva light to inactivate viruses, bacteria, protozoa and leucocytes that may contaminate platelet products. aims: the purpose of the study was to assess the feasibility of introducing this technology in the routine of lisbon regional blood center (crsl) and validate the procedure in our center. material and methods: whole blood units of ml were collected from volunteer blood donors in quadruple top and bottom blood bags (optipure rc soft t& b baxter), kept in n-butanodiol plates; buffy coats with a volume of ml were obtained in the opipress ii and kept overnight at room temperature before pooling. five buffy coats were pooled with ml intersol using the octopus system intercept buffy coat pooling set with an integrated filter. the pools were treated using the intercept. samples were taken before treatment, after cad remotion, on days , and . the following tests were performed: platelet count, mean platelet volume, ph, swirling. results: all pools met the intercept guardbands. platelet yield pre inactivation was . ¥ ( . - . ¥ ; sd- . ). platelet pool volume was . ml (sd- . ). plasma % was within . % and . %. all pools had leucocytes within council of europe specifications. after photoinactivation the platelet concentrates had . ¥ (± . ). the average platelet loss was . ¥ . the ph was within specifications during all the storage period. conclusions: intercept treatment of pooled buffy coat platelets is feasible in the routine of crsl and in vitro parameters do not show significant changes, allowing us to proceed to clinical use. shown ip and conventional platelets (cp), stored for up to days, exhibit comparable hemostatic efficacy and safety. extension of platelet storage duration to days has the potential to improve platelet availability and reduce outdating and inventory shortages. clinical efficacy and safety of ip stored for days were investigated. methods: a randomized, controlled, single-center, crossover, noninferiority design (pilot) study evaluated efficacy and safety of buffy coat ip vs buffy coat cp, each stored for days. patients were randomized to receive one -day ip transfusion and one -day cp transfusion in random order. after each study transfusion, the hour platelet count, ci, and cci; time to next transfusion; bleeding response; transfusion reactions; and serious adverse events (saes) were assessed. the primary endpoint, -hour cci, was analyzed by a one-sided non-inferiority test for the per protocol population (patients with both transfusions and no major protocol deviations interfering with efficacy evaluation). the per protocol population included patients, randomized to the ip-cp sequence and to the cp-ip sequence. more patients received allogeneic stem cell transplant in the cp-ip sequence than the ip-cp sequence ( % vs %; p = . ). mean platelet dose (¥ e ) was . for ip and . for cp (p = . ). there was a significant period by treatment interaction (p = . ) at the . significance level; therefore, the first period only was also analyzed for the primary endpoint. including both treatment periods, mean (±sd) -hour cci (¥ e ) was . ± . for ip vs . ± . for cp. the mean paired difference for both sequences was . ¥ e (p = . by non-inferiority test; upper bound of the % confidence interval = . ). for the first period only, mean -hour cci (¥ e ) was . ± . for ip vs . ± . for cp) the mean paired difference for the first period sequences was . ¥ e (p = . by non-inferiority test; upper bound of the % confidence interval = . ). the non-inferiority margin for the study was . ¥ e for mean treatment difference in cci (cp-ip). median time to next transfusion was h for ip vs h for cp following the first transfusion (p = . log-rank test; data censored at days after transfusion) and h ip vs h cp after the second transfusion (p = . ). bleeding pre-or post-transfusion was uncommon, usually mucocutaneous, and grade or lower, and responded similarly to ip and cp. no significant transfusion reactions or saes were reported. in this double-blinded, two-treatment crossover study the primary endpoint regarding -hour cci was not met. however, transfusion with -day-old platelets treated by the intercept blood system showed only a marginally and probably clinically insignificantly lower -hour cci compared to -day-old conventional platelets. methods: new zealand white rabbits were transfused with syngeneic blood ( ml/kg), across a major antigen (hgd) mismatch. high anti-s- ab titers (≥ : ) were induced after repeated immunization (days , , , , ) with klh-(s- ) hapten (klhhapten) in complete freund's adjuvant. ab titers against srbc were determined by gel card agglutination, or by facscan with fitc-goat_anti-rabbit_igg. survival of infused rbc ( ml/kg) treated with different methods was assessed by rbc biotinylation. blood samples were taken , , , , and days after transfusion, analyzed using streptavidin_pe and facscan to determine the proportion of circulating biotinylated rbc. results: groups (g) of rabbits were transfused with control rabbit rbc (crbc; n = , g ), or o-srbc (n = , g ). no ab against o-srbc developed after biweekly transfusions over weeks in g rabbits. high ab titers to o-srbc could however be induced by klh-hapten immunization in a different group of animals (n = ; g ). transfused rabbits (g & g ) exhibited no change in hematocrit or body weight and maintained good vital signs. high titer anti-s- abs were then induced by klh-hapten immunization in rabbits from g (n = ) and g (n = ), and in a group (n = , g ) of naïve rabbits. non-immunized rabbits (g , n = ), and (g , n = ) were maintained on the biweekly transfusion schedule of crbc and o-srbc, respectively. all rabbits treated with klh-hapten developed comparably high ab titers. klh-hapten immunization did not affect the viability of crbc in g rabbits. transfusion of o-srbc demonstrated reduced viability in hyper-immune g rabbits, but not any of the g rabbits. g rabbits exposed to o-srbc transfusions prior to hyper-immunization with klh-hapten, had viability of o-srbc comparable to crbc, suggesting induction of immune tolerance by repeated exposure to o-srbc. after depletion of labeled o-srbc from circulation, g and g were transfused with m-srbc. viability of m-srbc in all g rabbits (hyper-immune or not) and the hyperimmune g rabbits was equivalent to crbc circulation in g rabbits. in pre-immunized rabbits with high titer anti-s- ab, o-srbc are cleared faster than control. in contrast, m-srbc survive normally in rabbits with high anti-s- ab titers. repeated transfusion of o-srbc does not result in alloimmunization of naive rabbits. the modified s- rbc process offers the potential for pathogen inactivation with elimination of immunoreactivity and retention of rbc viability. introduction: the bombay phenotype is extremely rare and characterized by complete absence of abh activity both on erythrocytes and in secretions. those individuals can produce anti-h, which is active over a wide thermal range. method: using liss indirect antiglobulin technique, the patient's serum showed + reaction by panel of eleven cells at room temperature phase as well as indirect phase while the auto reaction is negative. a cold adsorption using rabbit erythrocyte stroma was done to remove the cold antibodies from the serum; + reaction of an antibody was detected in the patient serum after five folds of rabbit erythrocyte stroma adsorption. introduction: immunohematology reference laboratory in kuwait central blood bank receives samples from all hospitals in kuwait both governmental and private sector. the laboratory performs the tests according to international standards and it is monitored by internal and external quality assessments on periodic basis. material and method: a tube and gel cards are two methods in the reference laboratory for antibody identification. the laboratory can identify the most commonly encountered clinically significant antibodies and investigates causes of positive direct antiglobulin test that occur mostly in autoimmune hemolytic anemia. there are facilities to phenotype most of rare red blood cell antigens. results: records of all patients investigated in the laboratory since the year are kept in computerized system that has patient's records. central blood bank has the potential to identify rare phenotypes such as kpb-, jsb-, lan-, bombay, rzr , rzr , r¢r¢, r¢r≤, r≤r≤, ge- , , and rare red blood cell antibodies such as high frequency antibodies anti-k, anti-ge , anti-h, anti-lan, anti-kpb, anti-jsb, anti-wrb, anti-ena, anti-csa and low frequency antibodies anti-kpa-, anti-jsa-, anti-dia, anti-lua, anti-cob as well as hightiter-low-avidity antibodies such as anti-chido. samples of rare red blood cells and rare serums are kept frozen either by glycerol or liquid nitrogen technique to be used for pre-transfusion compatibility testing and continuing educational program. purpose of the work: to present the substitution of the blood groups o, a, b, ab in abo blood group system and rh (d) blood group in rh (d) blood group system in the population in the gevgelija-valandovo region. material and methods: a retrospective analysis was done on the data of following the blood groups o, a, b, ab and d in the blood group system abo and rh in the gevgelija-valandovo region. the asked population are voluntary blood donors, candidates for drivers, patients, pregnant women and newborn children. the period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) was analysed. the examinations were done with two standard methods (on the plate and in tube), to define blood groups from the most represented blood group systems abo and rh in the population. tests were done with different series of commercial anti serum tests from domestic and foreign origin. results: totally . examinees were typified. with o blood group were . ( . %); with blood group a were . ( . %); b blood group . ( . %) and ab blood group were . ( . %) examinees. totally . ( . %) were d positive and . ( . %) were d negative. discussion: the given results from our examinations for the frequency of o, a, b, ab and rh (d) blood groups from abo and rh (d) blood group systems in the region gevgelija-valandovo show that the most present is the blood group a from abo blood group system . ( . %) and d blood group in rh system with . ( . ) form examined population. the results are in correlation with data from the literature for other european nations. introduction: the policy of our center is to transfuse all heamatologic multitransfused patients with their own rhesus and kell phenotype. in addition, thalassemic and young leukemic patients are being transfused with compatible phenotype of the most clinical important duffy and kidd systems while all the other patients receive blood compatible only with abo and rhesus system. nevertheless, it is observed a significant positivity of the indirect antiglobulin test, due to alloimmunization. aim of the study: in this study we tried to evaluate the prevalence of alloimmunization in patients of our region. the most frequent detectable alloantibody remains the anti-d, with high prevalence . % of anti-d in females versus . % in males, due to alloimmunization during the pregnancy. as a consequence, the high incidence of anti-d is not transfusion related and anti-e is evidenced to be the most frequent transfusion related alloantibody, followed by anti-kell. care must be taken in order to transfuse as more patients as possible with their own phenotype regarding, at least the most immunogenic antigens, like anti-e and anti-kell. severe hemolytic reaction due to anti-j k background: red blood cell alloantibodies directed against antigens of the kidd system are notorious for causing delayed hemolytic transfusion reactions. the antibodies are formed because of pregnancy or transfusion. blood donors with the red blood cell (rbc) phenotype jk(a-b-) are extremely rare in the white population and exhibit a frequency of less than . %. however, the rare phenotype jk(a-b-) is more common in polynesians ( . %). individuals with jk(a-b-) phenotypes typically form anti-jk with inseparable anti-jka and anti-jkb activity. some jk(a-b-) patients' sera may show an additional distinct anti-jka or anti-jkb component when examined with adsorption studies. case report: a years-old caucasian female with a negative antibody screen, no prior history of transfusion, presented with gastrorrhagia. it is reported four pregnancies with no history of haemolytic disease of the newborn (hdn). on admission, her haemoglobin was . g/dl. she was given units of crossmatchcompatible rbc. on day her haemoglobin was . g/dl, with a total bilirubin of . mg/dl and lactate dehydrogenase of u/l. on th day an unexpected fall in hb ( . g/dl) occurred with an increase of bilirubin to . mg/dl and of lactate dehydrogenase to u/l. a new blood sample obtained for antibody screening and additional crossmatches showed a pan-agglutination and incompatible crossmatch. anti-jk antibody high titer was detected in the plasma by gel-test using liss/coombs cards (id-diamed). the dat was negative and the antibody reacted equally with jk(a-b+), and jk(a-b+) panel cells (jka: / and jkb: / ). other alloantibodies could not excluded, because jk(a-b-) cells are not available. she was started with erythropoietin-a (epo), folic acid, fe iv and high dose intravenous immunoglobulin (ivig). the epo was discontinued after four week of therapy when the haemoglobin was g/dl. two months later her haemoglobin was . g/dl and anti-jk was present in the same titer. a year later her blood cell count was normal and the anti-jk was detected in a lessened titer ( / ). no additional distinct anti-jka or anti-jkb component was shown after two adsorptions at °c using carefully selected phenotyped red cell compatible with patient's rh, fy, mnss, lu, le system and jka(+) and jkb(-), but two additional alloantibodies anti-c and anti-e of low titer ( / ) were revealed. the rare anti-jk alloantibody found in this case displayed the erratic nature of many kidd system antibodies. although anti-jk may cause mild hemolytic disease of newborn, she did not have a history of hdn. our patient was sensitized to a kidd antigen during pregnancy, but showed no serologically detectable antibody until challenged with a massive transfusion following a gastrorrhagia. the use of epo and high dose intravenous immunoglobulin succeeded to avoid transfusion with incompatible rbc unit. background: differential warm adsorption is used in the investigation of patients with red cell autoantibodies for searching of underlying alloantibodies, but it is also useful in the detection of clinically significant alloantibodies in patients with alloantibodies to high frequency antigens such as k, kpb, lub and inb. this technique is especially useful in cases when patients when patient's phenotype cannot be identified due to recent transfusion. purpose: differential warm adsorption is performing on cases presented with an antibody reacting with all red cells of the panel and having a negative auto control test. in these cases, even rare cells panels, which allow the identification of a pan antibody, are available, other more common clinical significant antibodies cannot be excluded. methods and result: case . a years-old caucasian female with preexisting myeloproliferative disorder (polycythemia) presented with pancytopenia. anti-k was detected in the plasma. it is reported two pregnancies and no history of transfusion. the dat was negative and the plasma did not react with one k-cell present on the red cell panel in use. the anti-k specificity was confirmed using additional k-cells. the patient's red cell were group a, d+, k+, k-, c-, e-, fy(a-), s-, le(a-), kp(a-), cw-. she was transfused with two units rbc k-. ten days after the first transfusion the dat became positive and the one k-cell present on the red cell panel reacted with her plasma. two adsorptions were carried out at °c using carefully selected phenotyped red cell (compatible with patient's rh, fy, jk, mnss, lu, le system and k positive). an anti-fya was identified in the presence of ant-k. . an antik (titer / ) was suspected. because k-red cell was not present in the panel in use, adsorptions were carried out at °c using carefully selected phenotyped red cell (compatible with patient's rh, fy, jk, mnss, lu, le system and k positive). after the anti-k antibody was totally removed, no additional alloantibodies were revealed. conclusion: differential adsorption in cases with alloantibodies to high frequency antigens represents a useful application of the technique and helps in the identification of clinical significant antibodies present, allowing a more accurate decision for transfusion. evaluation of validity of the expired enzymetreated . % red cells in antibody identification gel tests using nacl cards p chalkia, s intzepeli, v avgoloupi, a tsoukala, e ntinopoulou and p didoudi ahepa hospital, thssaloniki, greece background: expired red blood cells of required phenotypic profile is often used to identify antibody specificities in patients with multiple anti-erythrocytes antibodies. accurate results depend on the integrity of the antigens. purpose: to validate the expired enzyme-treated . % red cells for use in antibody identification gel tests using nacl cards. the serum of nineteen patients with common specificities antibodies in rhesus, kell, duffy, kidd, and mnss systems tested with commercially prepared . % enzyme treated cells rbc panel (id-diamed). gel tests were performed according to the manufacturer's instructions on in-date rbc and simultaneously on rbc month to months past expiration. reactivity of the expired antigen positive and antigen cells was compared to in-date cells. results: twenty antibodies detected with enzyme treated red cells in neutral gel cards [d( ), c( ), e( ), k( ), cw( )] and were tested with enzyme treated red cells in use and rbc to months post expiration. seventeen antibodies tested with enzyme treated cells gave acceptable results with antigen positive cells to months post-expiration, except anti-k antibodies (negative with k positive cells - months post expiration). conclusion: most rbc antigens studied were detectable months after rbcs expiration date. tests with . % cells were valid in gel test (nacl/enzyme) for at least months after manufacturer assigned expiration date and may be helpful for complex identification studies. studies for more antigens specificities are needed to testify the validity of the expired enzyme-treated . % red cells. background: wr(a) is a low-incidence blood group antigen ( : ) in the caucasian population. despite that anti-wr(a) is a common antibody type, it may cause severe transfusion reactions, haemolytic disease of the new-born. anti-wr(a) may occur as an autoantibody or arise without immune stimulus. we report a case of a naturally occurring anti-wr(a) antibody. case report, methods and results: -year-old non-transfused male patient with acute pancreatitis and severe anaemia had been transferred to surgery from a county hospital. the serological status identified by their blood bank was: b rhd positive, with anti-wr(a) antibody in the serum (cellbind card method). our results: the patient's cells were group b rhd positive (microplate method), dat negative (tube and gel test method). the antibody identification showed positive antibody reaction with all enzyme treated test cells but negative reactions in liss iat (tube test) and gel iat (scangel and diamed). discussion: our routine tests for antibody detection didn't detect any specific antibody in patient's serum. he was transfused several units of blood, that was wr(a) negative and showed negative crossmatch reactions. the patient had no transfusion reactions. days after the transfusion anti-wr(a) specificity was confirmed in the serum with cellbind test. only few test cell panels contain wr (a) positive cells, which are usually not present in commercial screening cells. in our case the cross-match was only performed for this patient because of the detected nonspecific antibody reaction in enzyme. the risk of transfusion reactions caused by rare antigens are particularly high in the type and screen cases. background: according to requirements of the french committee for accreditation (comité français pour l'accréditation cofrac, iso standards), it is essential to use validated and standardised methods in immunohematology. this imposes, among various requirements, the knowledge of metrological tolerances for all the techniques. aim: a multicentre study was carried out to define the maximal acceptable deviations concerning incubation temperature and time, volumes of patient plasma and of tests cells for antibody screening using indirect antiglobulin test (iat) in filtration technique. the antibody screenings were performed manually in blood centres using different filtration systems: id diamed, biovue ortho and scangel biorad, the same tests cells, a standard ng/ml anti rh (provided by cnrgs), a positive control anti kel and a negative control. all equipment used (oven, chronometer, pipettes) were calibrated according to cofrac standards. each antibody sample was tested under the following combined conditions ( tests/sample): results: all the tests of antibody screenings from the multiples combinations of the above parameters gave the same results with a + intensity agglutination for positive samples and the absence of agglutination for the negative control. conclusion: this study allowed us to define a range of tolerance for critical physical parameters involved in the antibody screening in iat using commercial filtration systems maryvonne. the authors present a retrospective study involving blood donors from the university hospital of coimbra during the year . the incidence of weak d and rh (d) phenotype was determined in individuals who were rh (d) negative. the ab and rh(d) blood grouping was performed using a column gel agglutination card (diamed). the rh (d) typing was done using a anti-d polyclonal and a anti-d monoclonal antibodies. all donors that gave negative or poor agglutination results were tested for weak d with an indirect antiglobulin test, with anti-igg (gel matrix card) plus anti-d serum (diamed). within our target group of blood donors the rh (d) negative represented . % of the total sample. we also describe ab , rh(d) phenotype (c, c, d, e, e) group frequencies and establish reliable estimates frequency for weak d and rhesus haplotypes. the background: in s and s several authors tried to assess the relationship between the number od igg molecules per rbc and in vivo haemolysis, but determinations usually concerned small groups of tested patients. some of the investigators suggested that the number of igg autoantibody molecules per rbc was a major determinant of the severity of the haemolysis, whereas others found aiha patients with severe haemolysis and undetectable autoantibodies. aim: presentation of our experience with the quantitative elat performed on a large group of aiha patients during long-term observation. material and methods: six hundred fifty eight blood samples from warm-type aiha patients were randomly tested for the number of igg molecules per rbc. eighty six of the patients were tested periodically from to times at one-month intervals. autoantibodies on rbcs were detected by the direct antiglobulin test (microcolumn technology) and measured by the enzyme-linked antiglobulin test (elat). results: in about / of tested samples the number of igg molecules per rbc was small (< ) and the laboratory signs of haemolysis were present in . % of them as well as in . % samples with moderately coated red cells ( - igg/rbc). the large number of igg molecules per rbc (> ) was significantly associated with high frequency ( . %) of severe haemolysis and it was also associated with presence of multiple igg subclasses on rbcs and c d. in % of patients tested periodically, the number of igg molecules per rbc decreased and it significantly correlated with improvement of haemolysis parameters. in % of aiha patients the number of igg fluctuated and it was a poor prognostic factor. conclusion: in aiha patients the dynamics of the changing number of igg autoantibody molecules per rbc is a more helpful diagnostic and prognostic parameter than the number of igg molecules per rbc evaluated in one test. -b+) , -h-negative (using the anti-h lectin). antibody work-up showed a positive antibody screen (liss and peg-tube methods) reacting + with o rbcs at all phases and + with a rbcs. the direct antiglobulin test (dat) was positive with polyspecific ahg as well as anti-c b,-c d (table ) . prewarming of test system did not change the reactivity ( + at antiglobulin phase). a treatment with dithiothreitol (dtt) was performed and abolished all reactivity of the serum ( table ). autoabsorption of the patient's plasma was performed. the absorbed plasma showed a decrease in reactivity from + to + when tested with o red cells, as well as a significant reduction in antibody titer from : to : tested at immediate spin (table ). the patient remained crossmatch incompatible with o and a rbcs, but was compatible with oh rbcs. summary: we report an unusually strong igm anti-h antibody in this patient, who may require oh phenotype units. the patient is not a para-bombay since her red cells type strongly as group a. the cause for the auto-anti-h remains unknown at this time. if a thermal amplitude test shows that the antibody appears to be clinically significant the patient should receive h-units if transfusion is required. introduction: fetomaternal haemorrhage may determine an alloimmunization, in fact the transplacental passage of antibodies may cause the haemolytic disease of newborn. for this reason, in pregnant women, a screening for irregular antibodies research is routinely performed. however the indirect antiglobulin test (iat) may result falsely positive or negative for various causes, as operative mistakes or low specificity/sensitivity of the used techniques. aim of the study. in this study we have retrospectively evaluated the real incidence of alloimmunizations occurred in women screened by private laboratories. methods: we have studied . women, - years old, resulted iat positive at the first screening and successively assisted by our two hospitals. all women were re-tested, using gel-agglutination technique, for both direct antiglobulin test and iat. results: a positive iat was confirmed only in cases; moreover a rbc autoimmunization was found in women. anti-d ( cases), e ( ), c ( ), k ( ), c ( ), s ( ), d + jka ( ), d + s + e ( ), d + c + k ( ), m ( ), c + e ( ), d + c + g ( ) were the identified alloantibody specificities. anti-s, -e, -k, -c and -jka were the specificities in autoimmunized women. conclusion: in conclusion, a real alloimmunization is occurred only in . % of screened women, while in the remaining cases iat resulted falsely positive: this observation forces us to affirm that, in order to minimize errors and alarmisms, the screening for antibody research in pregnant women must be performed only by immunohematology qualified center. background: one of the problems of the rbc transfusion is the alloimmunisation and the delayed haemolytic reactions (dhtr). besides rhesus and kell systems the antibodies against kidd antigens cause both dhtr and difficulties in their detection. aim and methods: the exact recording of all blood units according to abo rhesus kell and kidd systems. the abo-rh-kell systems are identified through automated microcolumn method (autovue, ortho), while kidd antigens are identified manually using microcolumn gel (diamed). results: the percentage of jka+ and jkb+ found in our department ( . %) and ( %) respectively is similar to that of the caucasian population. conclusions: given the fact that there is lack of available freezing rbc system in greece, detailed recording of all units to the above antigenic systems can be proved extremely useful under circumstances of incompatibility. in the latter case suitable donors can be called and cover the shortage. the identification of all antigentic systems of the donated rbc units is underway. background: in many countries transfusion recipients are currently typed and transfused d-positive, if their red cells are agglutinated by igm monoclonal anti-d that do not react with dvi. the transfusion strategy in weak d patients is not clear defined and it depends on the chosen monoclonal reagents and methods. patients who are carrying dw types , and were prone to develop anti-d. aim: the aim of this pilot study was to estimate capability of commercially available monoclonal anti-d reagents to recognize this weak d types as rhd positive. material and methods: edta anticoagulant blood samples were collected from blood donors, previously typed as weak d positive by indirect antiglobulin test. molecular genotyping of rhd gene and weak d alleles by cde-ssp and d weak-ssp kits (inno-train, germany) were performed. direct agglutination was tested in a tubes and microplates using the following antibodies: rum- , th- , ms- (bioscot/serologicals) and d e / - (immucor). results: out of samples molecular typing results were as follows: in samples dw were not determined, in samples, weak d type ; weak d type ; weak d type , weak d type ; weak d type and weak d type were determined. by all monoclonal reagents % weak d type , % weak d type , % weak d type and % weak d type negative results were given. by all monoclonal reagents weak d type and weak d type positive results were given. conclusion: according to weak d types, which were known to be at risk for anti-d immunization further advances may be brought by improved patient's monoclonal typing reagents with a low and donor's monoclonal typing reagents with high affinity for weak d type , type and type . such improved typing strategies with novel reagents would enhance the transfusion safety. background: vel is a high-incidence antigen found in > % of the population. anti-vel can be igm or igg and reacts optimally at iat, although it can also react at immediate spin and c. anti-vel may or may not cause severe hemolytic transfusion reactions and mild to severe hdn. autoanti-vel has also been reported. the aabb technical manual th edition states that the vel antigen is unaffected by protease and sulfhydryl treatment. we have reason to believe that sulfhydryl treatment may have an effect on the vel antigen as evidenced by a recently referred case. case report: a year-old caucasian female presented with symptoms of anemia and renal vascular hypotension. transfusion history indicated multiple red cell transfusions in . according to the patient, previous attempts to locate compatible units were unsuccessful. the case was referred to our laboratory. the patient's red cells (rbcs) typed as group o, d+ with a negative dat. the serological picture revealed an antibody reacting + - + s at c/liss, as well as at the antiglobulin phase. the antibody reacted with all rbcs tested and the autocontrol was negative. further characterization of the antibody showed similar reactivity using enzyme-treated rbcs ( . % ficin) and no reactivity using . m dithiothreitol-(dtt)treated rbcs. a high incidence negative red cell panel (untreated) was selected that lacked antigens reported to be destroyed by dtt. the antibody reacted with all rbcs tested. additional rbcs were tested that lacked high-incidence antigens, including vel. the antibody did not react with four vel-rbcs tested using liss and peg methods. the patient's rbcs typed as vel-negative. all other clinically significant antibodies were ruled out using vel-or dtt-treated rbcs. based on the unusual reactivity demonstrated by the anti-vel, we tested different examples of anti-vel (frozen in our rare sera inventory) against two sets of known vel+ and vel-rbcs. one rbc set was dtt-treated; the other set was tested neat. liss enhancement was used to test both sets. one of the antisera failed to react with the positive control and one reacted with the negative control. both were disqualified from the study. four of ten remaining antisera demonstrated a decrease in reactivity > grade, between the neat and the dtt-treated rbcs. the remaining six antisera showed no change in reactivity. conclusion: contrary to the statement in the aabb technical manual, we discovered that sulfhydryl treatment ( . m dtttreatment) can have an effect on the vel antigen. our experience has demonstrated that in some cases anti-vel may not react or may show reduced reactivity when tested with dtt-treated rbcs. therefore, the presence of anti-vel should not be ruled out if negative reactivity with dtt-treated rbcs is encountered. additionally, dtt treatment may be a useful tool obtaining rule-outs of other clinically significant antibodies in the presence of anti-vel. additional data is needed to confirm these findings. but with no identified specific antibodies were investigated by repeated screening/crossmatch, papainized panel identification, hla antibody screening by lymphocytotoxicity test (lct) and elisa in some cases. patients' age, sex, department, diagnosis, previous transfusions/pregnancies, techniques, reactions' strength, number of positive cells, urgency, subsequent antibody tests, identification and lct were noted. antibody tests were performed: at pretransfusion testing (pt) by liss-coombs (diamed) and at blood grouping (bg) by biovue polyspecific (ortho) microcolumns -manually in urgency and routinely by sampler iif (diamed) and mitis (ortho) systems. results: investigated reactivity was recorded in samples from patients; ( . %) patients had > episode. these findings comprised . % of unexpected results found at pt and bg. incidences were . % at routine and . % at urgent bg ( and bgs, respectively), and . % both at routine and urgent pt ( and pts, respectively). . % patients were female, . % over , but . % < years, coming mostly from surgery ( . %), internal medicine ( . %), hematology ( . %), ginecology ( . %), cardiac diseases ( . %) and cardiac surgery ( . % patients). frequent diagnosis were solid tumors ( . %), cardiac diseases ( . %), hematologic malignancies ( . %), uraemia ( . %), orthopedic surgery ( . %) and hepatic diseases ( . % patients). . % patients were previously transfused, with only . % patients proved as not transfused or pregnant. subsequently positive antibody test during the study had . % tested patients. at pt positive crossmatch was found in . %, antibody screening in . % and both tests in . % cases. majority of reactions were ' +' ( % at pt and . % at bg); reactions ' +' or ' +' were found in only . % cases at pt, compared to % at bg. one crossmatch only was positive in . % positive crossmatches, with / patients having > crossmatched unit. ahg identification was positive in . % tested patients; in % of them papainized panel was also positive. lymphocytotoxic antibodies were found in . % tested patients; . % ( %- %) of lymphocytes were reactive. finally, the cause of reactivity in antibody tests was determined as 'laboratory mistake' in . %, hla lymphocytotoxic antibodies in . %, 'igg antibodies of unknown specificity' in . % (hla noncytotoxic antibodies in / elisa tested samples!), contaminated sample in . %, anti-bga in . %, non-specific cold antibodies in . %, subsequently recognized specific antibodies in . % ( lua, m, kpa, yka), non-specific autoantibodies in . %, carry-over of dat-positive cells and antibody to reagent in . % cases each, while in . % cases antibody screening and in . % cases crossmatch was repeatedly positive without confirmation in panels. discussion: after introducing of sensitive microcolumns, positive antibody tests without detectable specific antibodies require significant laboratory activities, particularly in older patients with malignancies or surgery. such reactivity was frequently caused by laboratory mistake, but often hla and sometimes specific antibodies were later recognized, or reactivity continued without confirmation in panels. relationships that may be helpful are further discussed in abstract part ii. results: significant differences (p < . ) and relationships of interest were noted. sex. in female vs male patients frequent features were: crossmatch as only reactivity at pt ( . % vs . %), positive lct ( . % vs . %), lymphocytotoxic hla antibodies (lytxab) ( . % vs . %) and reactivity 'positive screening, negative panels' ( . % vs . %); in males non-specific cold antibodies ( . % vs . %) and antibodies to reagents ( . % vs ) were noted. age. in patients > vs < reactivity was often found at pt ( . % vs . %), caused by lytxab ( . % vs . %), anti-bga ( . % vs . %) or 'positive crossmatch, negative panels' ( . % vs ), but rarely by laboratory mistake ( . % vs . %) or later recognized antibody ( of patients). subsequent antibody tests: tests were subsequently positive more often if reactivity was found at pt ( . % vs . % at bg), as positive antibody screening ( . % vs . % if positive crossmatch), with positive panels ( . % vs . % if negative). subsequent tests were positive in only . % patients with lytxab, % with anti-bga, of with antibodies to reagent and in no case with 'positive crossmatch, negative panels' . techniques. lct was positive in % and . % tested samples found at urgent and routine pt (diamed), vs at bg. all cases due to lytxab, of anti-bga and of 'positive antibody screening, negative panels' were found by diamed. at bg (ortho) . % cold antibodies and . % laboratory mistakes were found. positive antibody test: identification was negative in . % screening-only cases; % of them were caused by laboratory mistake. lytxab were found in . % crossmatch-only cases; . % reactivities caused by lytxab were crossmatch-only. identification. ahg panel was positive in % cases with lytxab (in with papainized panel) and often due to 'igg antibodies of unknown specificity' ( . %), anti-bga ( . %), contaminated sample ( . %), but also to later recognized specific antibody ( . % cases). strength of reaction: laboratory mistake was noted in . % of 'w', . % of ' +', . % of ' +' and . % of ' + and +' antibody screenings (ns). diagnosis. in patients with solid and hematologic malignancy reactivity was often found at pt ( % and . % of patients, respectively), due to positive crossmatch ( % and %; and . % patients with liver and cardiac diseases) and caused by lytxab ( . % and . %) or 'crossmatch/screening positive, panels negative' ( . % patients with solid tumors). in patients with liver and cardiac diseases reactivity was often found at bg ( . % and . % of patients), due to laboratory mistake ( % and %) or cold antibodies ( . % and %), respectively. discussion: features of non-specific reactivity depended on sex, age, positive antibody test, diagnosis and, moreover, used techniques, sometimes in very distinctive manner. this analysis might be of considerable help in planning of laboratory tests, but also in quick analysis of unexpected results and choice of further testing, particularly in urgent situations. background: worldwide screen and type is a very usual method for pre-transfusional testing. the ultimate objective is to prevent not only the clinically expressed delayed hemolytic transfusion reactions but also the serologically revealed ones. aim: the aim of this study was to determine the frequency of red blood cell (rbc) alloantibodies in patients undergoing cardiac surgery or cardiac procedure, during the pre-transfusion screening. materials and methods: blood samples of patients ( male and female) were evaluated. the mean age of the patients was years. pre-transfusion samples were examined for clinically significant alloantibodies, using antibody screening with gel test (liss -enzyme). in case of a positive result, identification was performed (panel with autologous control). in addition, the serological testing included cold agglutinins´ detection (tube test), as well as titration (tube test) and identification (gel test) in case of a positive result. when the result was marginal ( / ) a new test was carried out after a seven days period. in the presence of a positive autologous control or an autoantibody, samples were examined with direct antiglobulin test (dat). results: alloantibodies were detected in patients with the incidence of . %. antibodies were registered more frequently in females ( / , . %) than in males ( / , . %). patients ( . %) developed single antibody with anti-kell being the most frequent. the incidence and the specificity of the detected antibodies are summarized in the following table (table ). in patients ( . %) multiple antibodies were detected, with most frequent the anti-d and anti-c combination. patients ( . %) were dat positive. autoantibodies were found in patients ( . %), all of which had specificity to rhesus system. cold agglutinins were positive in patients ( . %). no specificity could be assigned in patients ( . %), while in patients ( . %) non specific reactions in enzyme treated rbcs, were observed. one patient developed delayed haemolytic reaction days post-transfusion, due to anti-jka. the antibody, however, was not detected in the pretransfusion sample re-testing. the frequency of the pre-transfusion detection of red blood cell alloantibodies in our center, was . %. the most frequently identified were the anti-kell and anti-rh. the high rates of unidentifiable antibodies and non specific reactions in enzyme treated rbcs are probably attributed to the kind of medication that most of these patients receive, as well as to the degree of inflammatory process which usually accompanies such diseases. the high frequency of unidentifiable antibodies indicates that a larger and more complex erythrocyte panel would be useful for routine testing. the routine pre-transfusion screening for alloantibodies probably assures the prevention of dhtrs and provides sufficient time for blood selection for transfusion. introduction: in the united kingdom, about % of women form red cell allo-antibodies in pregnancy and . % of all pregnant women produce anti-c. before the introduction of prophylactic anti-d, it was reported that % of the total haemolytic disease of the newborn (hdn) cases were due to anti-c. currently, cases of hdn due to anti-c are half as frequent as anti-d and % of the uk population are rhc negative. we present two unusual cases of pregnant women who are d and c negative and have anti-c and anti-d detected in their serum. case studies and results: case : a -year-old asian woman had three previous uneventful pregnancies. in her th pregnancy she presented with miscarriage at weeks gestation. she was group b, d and c negative. her serum contained anti-c and anti-d. anti-d was detected by liss tube iat and anti-c was only detected by manual polybrene technique ( . iu/ml by quantification using r r cells). in a th pregnancy, no antibodies were detected until weeks gestation when this patient presented in early labour. anti-c was then detected by two-stage papain technique only as well as anti-d. case : a -year-old asian woman had a positive antibody screen post caesarean section in jan . no antibody had been detected during the pregnancy. standard prophylactic anti-d was given at and weeks gestation as this patient was d neg. anti-c and anti-d were confirmed in her serum. the anti-c level was . iu/ml using rr cells and the anti-d level was < . iu/ml using r r cells (prophylactic anti-d ig). she was phenotyped as o r¢r¢. at delivery the baby was found to have a negative dat and was phenotyped as r¢r. discussion: cde/cde (r¢r¢) is an uncommon phenotype in the uk population with a frequency of / . in routine antenatal testing, abo/d grouping is only performed for pregnant women at booking and weeks gestation according to bcsh guidelines. full rh phenotyping is not carried out unless the pregnant women has a positive antibody screen. in routine testing of the above cases, this extremely rare phenotype is missed. prophylactic anti-d was given to both patients and immunisation due to anti-d was prevented. there is currently no prophylactic regime developed to prevent anti-c allo-immunisation by the fetus in pregnancy. antenatal management of patients with anti-c and anti-d during pregnancy can be problematic: (i), problem in antibody identification; (ii) monitoring of antibody level (i.e. quantitation by auto analyser for anti-c and anti-d) with two different cells and ( ) provision of blood during pregnancy, at labour and post delivery for both mother and newborn. study on the frequency of red cell phenotypes (e.g. duffy, kidd and mns blood group system) in our local population l leou, yf wong, mbc koh and d teo health sciences authority, singapore, singapore background: the frequency of various red cell antigens in the caucasian population has been well studied. to date, the frequency of these antigens in the local population composed of a multi-racial mixture of chinese, malay, indian and others is still unclear, especially in the malays with paucity of data in the literature. aims: to investigate the frequency of clinically significant red cell antigens duffy, kidd and mns across the local ethnic groups. to investigate the occurrence of rare phenotypes. to be aware of these rare phenotypes so as to facilitate planning of blood inventories and supplies. typing for the duffy, kidd and ss antigen on blood donors was performed using monoclonal as well as polyclonal anti-sera by manual tube method. a total of blood donor samples were tested using specific anti-sera that will agglutinate red blood cells that have the corresponding antigen. agglutination is demonstrated by the indirect antiglobulin technique. result and discussion: table -a higher frequency of the fy(a+b-) phenotype is seen in chinese, malay and others in contrast to the indian and caucasian population. the clinically significant allo-antibody anti-fya is rarer in our local population. it occurs predominantly in malays and indians and usually in combination with other antibodies. it means that provision of antigen negative blood may be difficult. table -all groups show similarity of distribution of the kidd phenotype with the caucasians and distinct from the american blacks. the jk(a+b-) and jk(a+b+) phenotypes are relatively equal in frequency and there should be no problem looking for such a phenotype in the local population. table -the s-s+ phenotype is most common amongst all races. the indians are more similar to the caucasians with a relatively high frequency of s+s+ phenotype. the chinese and malay distribution are unique with > % being s+. conclusion: there is a unique distribution of red cell antigen groups in the races and the data on malays is especially useful. this data will allow the national blood service in its inventory planning and the potential difficulties of providing antigen negative products due to clinically significant allo-antibodies. miltenberger phenotypes among taiwanese table . conjointly, in order to obtain the frequency of mi.v phenotype, we screened samples among with anti-hil and four additional cases of mi.v were found. conclusion: in this study significant miltenberger polymorphism was seen among the taiwanese population. besides previously described mi.iii phenotype ( . %), there were also mi.i/ii phenotype ( . %), mi.v phenotype ( . %), mi.vi phenotype ( . %), mi.x phenotype ( . %), and most interestingly two miltenberger related not yet classified variants ( %). related variant a ( . %) was phenotypes as mia+, anek+ and hil+. related variant b ( . %) was phenotyped as mia+, anek+. interestingly, both variants were mur-(negative). the total estimated frequency of miltenberger variants in taiwanese population (including related variants a and b) is therefore . % (table ). the discovery of unclassified variants (most likely not yet described in the literature) is of great interest in the field of immunohaematology and warrant further molecular genetic study. introduction: the use of column technologies for the detection of rbc antibodies improved significantly the screen test sensitivity. each column-based method has its advantages and disadvantages. aim: to compare antibody detection by two column agglutination tests; the fully automated ortho auto vue tm method and the manual diamedᮀ id-micro typing system. material and methods: during the study period patient samples were screened, of the positive results were evaluated. blood samples with positive screen tests by the ortho auto vue tm method (av) performed with % cell suspension, and patient samples with antibodies identified by the diamedᮀ system (dm), were reciprocally re-screened, respectively. positive samples were tested by diamed panels for antibody identification. sera samples were divided into categories according to antibody specificity; . rh system antibodies (n = ), . clinically significant non rh system antibodies (n = ), . clinically non significant antibodies (n = ), . auto antibodies (n = ), . not identified (ni) antibodies (n = ), . negative screening results by the diamed technique (n = ). the categories were divided, according to the intensity of agglutination in the screen test, into those exhibiting stronger reactions by the auto vue (av > dm), those exhibiting equal strength reactions (av = dm) and those with weaker reactions by the auto vue (av < dm). statistical analysis was carried out using the wilcoxon signed ranks matched-pairs test. results: a total of samples were compared, . % of them gave stronger reactions by av, . % gave equal reaction strength and . % of them gave weaker reactions by av. positive screen tests by av only were detected in samples, no specific antibodies were identified. in contrast to that, positive screen tests by dm only were detected in samples, were rh system related, kell system related and not identified, results are summarized in the table. discussion and summary: the antibodies detected by dm only, are anti-d and antibodies directed to low frequency antigens. the failure of av to detect rh system antibodies is further sustained by the fact that statistically significant weaker reactions for this antibody system were obtained by av technique. recently ortho-clinical diagnostics modified the screening reagent red blood cells to . % suspension, in order to improve the sensitivity of the method (unpublished data). the possible explanation for the failure to detect low frequency antibodies is that ortho screen cells do not consistently carry the low frequency antigens cw and kpa. positive screen tests detected by av only, can be explained either by the fact that antibody identification was carried out on dm panels, or these are false positive reactions. in order to clarify this question we recently repeated these av only positive samples by the manual ortho bio vue technique. preliminary results indicate that no specific antibodies were detected. it can be assumed that these results are false positive. further study of this issue is required. aim of the study: we have detected blood donor with rohar variant which was mistaken as d-and his donations used for d-recipients. we tested these patients in order to evaluate possible anti-d or anti-lfa immunization. methods: rohar variant was tested serologically (commercial and workshop moabs) and on dna level (pcr-ssp). involved recipients were tested by diamed column agglutination (gliat with normal and enzyme treated rbcs) with commercial rbcs and with rh and rh rbcs. results: rohar variant was confirmed on phenotype and genotype levels. in four d-and two d+ recipients of rohar positive units no anti-d not anti-rh or -rh antibodies were detected. in one case anti-le(a) antibody was found. conclusion: in our cases massive exposition of recipients (whole transfusion unit) by rohar red cells did not lead to production of detectable anti-d or anti-lfa. the immunogenic potential of this variant seems to be low. unusual ab grouping discrepancy -inhibition of anti-b reagent by isolated increase of plasmatic b substance in a patient with group ab and pancreatic cancer m pisacka*, k petrtylova † , m kralova* and h flidrova* *uhkt, prague , † blood bank, faculty hospital m, prague , czech republic introduction: in rare pathological conditions excess amount of blood-group specific substances can be observed and can cause neutralization of grouping reagents. changes in abh and related histo-blood group antigens in malignant tissues were described but there are few information about similar changes in secreted bloodgroup specific substances. aim of the study: we describe a case of isolated increase of b group substance in plasma of a group ab patient with pancreatic cancer. methods: ab grouping was performed with registered immucor reagents (immuclone: anti-a birma , anti-b lb ) by slide and tube tests. neutralizing effect was quantified by (i) inhibition od anti-b reaction by titrated patient's serum; and (ii) inhibition of titrated anti-a and anti-b reagents by patient's serum, compared to ab serum of a healthy donor. results: slide test: unwashed rbcs: group a, washed rbcs: ab. tube test (washed rbcs): ab. titrated patient's serum when added in aliquot to anti-b reagent inhibited agglutination up to titre . titration of reagents /+ aliquot of serum added/: anti-a: titre (both patient's serum and control); anti-b + patient's serum: titre , anti-b + control: titre . conclusion: pancreas is known as rich source of blood group specific substances. malignant transformation is known to be associated with either loss or re-expression of cell-bound abh antigens. reported excessive increase of b substance in group ab patient could be either due to loss of a-transferase activity in malignant pancreas cells or isolated increase of b-transferase activity. further studies on larger groups of pancreatic cancer patients will help to understand this observation. weakened abh reactions of unwashed rbcs could be of diagnostic importance, because in other case this observation preceded several years the pancreatic cancer clinical manifestation. implementation of the autovue innova, an upgraded column agglutination technology (cat) for pre-transfusion testing in a large blood establishment c politis, k armyros, a antypas, v malamou and p katsea g. gennimatas general hospital, athens, greece objective: automated cat testing in a blood transfusion laboratory aims at standardization and savings in labour as well as reagents. a new technology is evaluated in comparison to standard methods. materials and methods: we used column agglutination technology with the innova autovue system, ortho, ratrian n.j. according to the manufacturers this system provides priority to the management of the stat samples while the random access feature of the system enhances the system throughput. it provides an extended test menu as well as automated antibody identification with the red cells panels. the autovue innova system supports the bi-directional communication with the lis interface for all the tests including the crossmatches and it provides a continuous traceability and notifying of the instrument's status concerning either the required and available resources or the proper function of the system's submodules. in this study we performed tests including forward and reverse abo group, rh type and phenotype and kell in randomly selected blood donors, as well tests in haematological patients for antibody screening using an untreated three-cell panel and autocontrol in the indirect antiglobulin test (iat). the results and the time performance (specimen handing, operation of testing and recording of results) were compared with those obtained by the semiautomatic id-diamed gel agglutination microtyping system and by standard manual methods. results: test results showed % agreement between all three methods. samples were tested per min with the autovue innova, compared to min required for the same number of tests performed with manual testing and min with the semi-automated method. the technical execution was easy with the autovue innova procedure and it appears that the consumption of testing reagents is smaller with the automated system comparing with the other methods. computerization of the test results with the autovue innova provides an important advantage in record keeping in the blood establishment. conclusion: standardization of sample collection and tests performance in pre-transfusion testing, as well as computerized records and time saving are advantages offered by the autovue innova, a new automated column agglutination technology, comparing with a semi-automated and the classical manual methods. a heavy workload is expected to significantly decrease time performance. clearance of senescent erythrocytes in young and old individuals al racca, a ensinck, c cotorruelo, s garcÍa borrÁs, l racca and cs biondi universidad nacional de rosario, rosario, argentina introduction: after a lifespan of days, human red blood cells (rbc) are captured and phagocytized by monocytes/macrophages. the accumulation of autologous igg on rbc membrane provides a direct mechanism for the removal of senescent (se) rbc. an alternative pathway, immunoglobulin-independent, with participation of sialic acid, has been proposed. the physiological elimination of serbc might be modified by individual's age. aim of the study: to investigate in young and old individuals, the interaction between monocytes and different erythrocytes suspensions: serbc, rbc stored with or without serum and desialinized rbc. methods: healthy individuals blood samples ( - years old, n = and > years old, n = ) were studied. different suspensions from each sample were obtained: (i) se and young (y) rbc by differential centrifugation; (ii) rbc stored with its own serum (rbcs) and without serum (rbcws); and (iii) rbc desialinized with neuraminidase (ne) and tripsine (t). the suspensions were subjected to the erythrophagocytosis assay: peripheral blood monocytes were incubated with the different erythrocyte suspensions for h at °c. two hundred cells were analyzed to determine the percentage of active monocytes (am) with phagocytosed and adherent red cells. non sensitized rbc (nrbc) and ex vivo sensitized rbc (srbc) were used as negative and positive controls respectively. results: the% of am obtained with old individuals were: serbc: . + . , yrbc: . + . , rbcs: . + . , rbcws: . + . , nerbc: . + . , trbc: . + . , nrbc: . + . ; srbc: . + . . the values of am obtained with young individuals were: serbc: . + . , yrbc: . + . , rbcs: . + . , rbcws: . + . , nerbc: . + . , trbc: . + . . nrbc: . + . ; srbc: . + . . conclusions: no differences in the% of am were found when compared to positive and negative controls, indicating that this assay would not detect variations in the phagocytic activity of monocytes from young and old donors. the values of am with serbc were higher (p < . ) than those obtained with yrbc in both populations analysed. the rate of erythrophagocytosis with serbc in old individuals was significantly higher (p < . ) than that obtained in young donors. the increase observed may be due to agedependent changes of rbc that occur with human ageing. the% of am with rbcs were higher (p < . ) in old individuals. no modifications were observed with rbcws. the significant increase in the rate of erythrophagocytosis with serbc and rbcs show the involvement of autologous igg in the selective removal of erythrocytes. these values were higher in old individuals indicating that this process would increase in aged donors. the tripsine activity was not enough to modify the% am. the values of am obtained with neuraminidase treated rbc were higher than those observed with yrbc (p < . ). however these values were similar between young and old individuals, suggesting that the desialylation would not participate in the increased removal of erythrocytes observed in old donors. cell-cell adhesion is a crucial phenomenon for the relationship between the cell and its environment. therefore, the development of experimental methods to obtain quantitative parameters of cellular adhesion is important. erythrocytes are widely available and their membrane properties are well known, so these cells are used as an ideal model for studying the cellular interaction mechanisms. the study of the formation and break-up of receptor-ligand bonds in sheared erythrocyte suspensions is a subject of considerable importance in the blood circulation, where formation and break-up of blood cell aggregates occur in a variety of physiological and pathological conditions. the main two objectives of this work were to study the cellular adhesion phenomenon using erythrocyte adhesion mediated by monoclonal anti-a antibody as a model and to achieve quantitative values of the parameters involved in the intercellular binding and its possible relationship with cellular deformability parameters. agglutinates of two a erythrocytes (doublets) induced by specific monoclonal antibodies anti-a were used. adhesion energy was indirectly quantified by the study of doublet dissociation under the effect of a given shear stress using a controlled flow chamber system. the chamber was installed on the stage of an optical inverted microscope (union optical, magnification ¥) in such a way that the cover glass was the floor of the microchannel. a ccd (charge coupled device) camera was placed in the ocular tube of the microscope and connected to a digital image processor (ipplus system) to digitize, record and analyze microscopic images. the doublets were initially immobilized inside the chamber, and then put under different shear stress values by a controlled laminar flow during a definite time. in this way, a shear stress parallel to the contact surface between both cells was applied, observing that the upper cell detached progressively with time and also with a gradual rise of the shear stress. the sequential microscopical images were registered and digitally processed, measuring the geometrical dimensions that the cells acquire during the deformation process, and the dissociation of the antigen-antibody bond. digital image processing allows the analysis and the quantification of the red blood cells doublets dissociation phenomenon. these results show that, while the shear stress applied is raised, the contact area between both cells diminishes. the obtained parameters give important information that lead to the estimation of the value of adhesion energy between two red blood cells agglutinated by monoclonal antibodies. as consequence, they will allow the characterization of the antibodies used, since it would evaluate their association capacity with cellular antigens. glycophorins (gp) a, b and c are abundant transmembrane integral proteins in red blood cell (rbc). their highly glycosylated nature and high sialic acid content account for the net negative charge of mature rbc membrane, which is physiologically important because it impedes any tendency to stick together in the circulation. in this study, we have tested anti-gp specific mouse monoclonal antibodies (moab) as primary antibody to directly agglutinate rbc. fret technique has been developed to characterize the hemoagglutination based on the interaction of fluorophores (alexa tm, dio and dii) located in the rbc membrane or combined to secondary antibody directed against the primary agglutining moab. combined intensity (spectral) and lifetime (flim) imaging was used to discriminate the fret signal of molecules on their different lifetimes whereas their emission spectra overlap (alexa tm or dio/dii) as independent phenomena of the fluorophore concentration and photobleaching. furthermore, gp-cytoskeleton interactions were analyzed by d-fluorescence microscopy after lipid extraction with triton x- in red cell. all the antibody used was found to directly agglutinate the human rbc. in view of the fluorescence properties depicted in rbc for the pair of fluorophore alexa- tm (donor) and dii (acceptor), it may be expected that upon agglutination of rbc, effective fret should be observed. flim in dynamic-state provides a discrimination of molecules in their fluorescence lifetime, which allows to evaluate the underlying mechanism of energy transfer process in the agglutinated erythrocytes. the results demonstrate that's upon excitation at nm the flim-fret from alexa tm to dii for the anti-gpb moabs only with a lifetime distribution in the picosecond range. similarly, effective fret was not observed for the anti-gpa moabs. the contrast in measured lifetime image is a reliable indicator for spatial variations in donor-acceptor association. d-fluorescence microscopy images showed interactions between gpc or gpb and cytoskeleton and did not show interactions between gpa and cytoskeleton. all together, these results only revealed by fret-flim and d-fluorescence microscopy strongly support the importance of the specific reactivity with glycophorin a or b of agglutining moab. introduction: the frequency of alloimmunization to red blood cell antigens in transfused sickle cell patients can range from to %, but the development of autoantibodies is much less recognized and descried. aim of the study: in order to evaluate the autoantibody formation and observe the blood transfusion association, we analyzed the direct antiglobulin test (dat) as well as the antibody screening results in transfused sickle cell patients. methods: all the patients included in the study had received at least unit of red blood cell concentrate, on the majority of the cases matched for the c, c, e, e, k antigens. the transfusion range was - units. the dat performed was a polyspecific gel test. in cases of positive dat, was performed the monospecific gel test (igg, iga, igm, c c, c d) . in almost all of cases an acid glicin elution was performed and the eluate was tested against a red cell panel (liss/coombs and papain). an antibody screening by gel test (liss/coombs and papain) was performed in all the patients. the dat was positive in ( %) of the patients. in cases ( %), the dat was igg type, in case ( %) igg + c d and in case ( %) igg + c c + c d. the acid elution was performed in cases. the eluate was positive in cases ( %). in ( %), of the cases, autoantibodies were pointed out whose specificity were specificity public, anti-e (rh ), anti-c (rh ), anti-ce (rh ). in cases ( %) we found alloantibodies whose specificity were anti-e(rh ), anti-k(k ), anti-c (rh ) and anti-jka (jk ). in the cases ( %) no antibody was identified on the eluate and the cause of positive dat is unclear. we could correlate the positive dat with a presence of autoantibodies in ( . %) of the patients. of these, ( %) had a blood transfusion association. the global frequency of red cell alloimmunization in this set of patients was %. seventeen patients ( %) of the patient who had autoantibodies had also alloantibodies associated. conclusion: the mechanism by which erythrocyte antibodies form in association with blood transfusion are not well understood, but even though the medical literature indicates strong association with blood transfusion as well erythrocyte alloantibody formation, we could not find support for this association. the loss of splenic to sickle cell patients could be important because experimental studies suggest that the spleen is involved in the regulation of autoantibody formation. forward and reverse blood grouping with lateral flow based assays p schwind*, i aebischer*, k loester † and p monod* *medion diagnostics gmbh, duedingen, switzerland, † prisma diagnostika gmbh, berlin, germany background: recently, a lateral flow assay for simultaneous typing of abod, rhesus subgroups and kell with stable end-point and without a centrifugation step was presented (loester k, fleischhauer s, schwind p: lateral flow assay for simultaneous typing of of abo, rhesus subgroups and kell. vox sang , (suppl. ), ). in many countries, the determination of isoagglutinins in addition to the red cell antigens is mandatory for abo grouping. aims: to develop a lateral flow test for reverse grouping, supplementing the lateral flow typing assay. a lateral flow device was constructed with a separation membrane equipped in a cassette housing having distinct incubation wells, application zones and detection areas. microliters of % suspensions of reagent red cells for reverse grouping (reverse-cyte a , a , b, , medion diagnostics, switzerland) are mixed in each incubation well with microliters of plasma. the resulting suspensions are incubated for min, followed by the transfer of microliters each to the application zones, where migration starts immediately. results can be read after min in the detection areas. a positive result is recognized as a distinct red dot, a negative result is monitored by the absence of a dot. results: the plasmas of donors, previously determined for the respective blood groups and isoagglutinins by the tube technique, have been tested with this method. the results for both methods were in full agreement. conclusions: a simple, rapid and flexible lateral flow method for reverse grouping is presented, allowing now for the determination of forward and reverse typing in similar formats. both methods give results after min with stable end-points without the need of a centrifugation step and are easily applicable to non-laboratory environments. the performance of the autovuetm system for red cell antibody screening of blood donors during background: in israel every donation is tested for the presence of red cell antibodies (rbc abs). screening is performed on the autovuetm system, using ortho screening rbc since the year . aim: (i) to summarize the performance of the autovuetm system for rbc abs, during years ( ) ( ) ( ) ( ) ( ) . (ii) to evaluate if an initial low positive result, with two negative repeats, could be considered a negative result. methods and results: rbc abs screening was performed using igg cassettes. positive results were confirmed by diamed gel cards, with screening rbc, followed by diamed panels for abs identification. results: summary of the results is presented in the table. (i) in . % of , blood donations that were screened, during - , using the autovuetm system, a positive initial result for rbc abs was detected, which was confirmed in . % ( . % of the donations). an increased percentage of confirmed tests is noted, since , probably due to an improvement in the manufacturing of the cassettes by ortho. (ii) during the validation, samples with low positive results (agglutination degree of . ) were retested twice on the autovuetm. / ( %) gave negative results in both repeats. only / was confirmed positive and anti-m was identified by diamed gel test. the remaining samples had at least one positive repeat. / ( . %) of those samples were confirmed positive. summary: autovuetm can be used as a competent method for rbc abs screening, in blood services which require high thoughput automated systems. samples with a low positive agglutination, which were negative in two repeats, can be considered negative. retesting these samples on the autovuetm, can reduce the number of tests sent for confirmation and allow early release of blood components. rk tagi-zadeh*, aa karimov*, ar hasanov † , ly novruzova* and si donskov ‡ *hematology and transfusiology, baku, † blood transfusion centre, ganja, azerbaijan, † centre for hematology, moscow, russian federation background: the main method of treatment of severe homozygous thalassemia forms at the moment is still an anemia control with regular rbc transfusions. the use of adequate transfusion regime for these patients not only prolongs their lives but also promotes normal physical development of the children and improves the quality of their lives. however, necessity to do multiple transfusions increases a risk of post-transfusion reactions and complications due to alloimmunization to rbc antigens. in order to prevent posttransfusion reactions it is essential to know the frequency of blood group distribution in the region and then implement organizational procedures to enhance the transfusion services for these patients. objective: examine the distribution of rbc antigens among thalassemic patients and blood donors. methods: blood samples of homozygous betta-thalassemia patients (who stayed at the daytime inpatient wards of scientific research institute of hematology and transfusiology baku, azerbaijan) and blood donors of azeri nationality were examined. patients' blood samples were typed on rbc rh (c, c, d, e, e) and kell (k, k) antigens. gel test bio-rad (france) was used to detect rbc antigens. results: phenotyping of the patients' rbc rh antigens (d, c, c, e, e, cw) revealed that frequency of occurrence of the antigens in general was higher than in the donors. studying of rh phenotype distribution showed that the patients' ccdee ( . %) •• ccdee ( . %) phenotypes were twice as much higher than the occurrence of those in the donors ( % and . % respectively). phenotype ccdee occurs more frequently in the donors ( %), whereas it is significantly rare in the patients ( . %). the similar picture was observed in relation to ccdee and ccdee phenotypes, which occurred more frequently among donors ( . % and . %) than in thalassemic patients ( . % and . %). additionally, the results demonstrated that k antigen of the kell system was not detected in the thalassemic patients whereas k antigen was detected in all the patients. the same picture was observed with two other antigens of this system. thus among the patients typed on rbc antigens kpa antigen was detected in just one case whereas kpb was detected in the rest the patients. the results of the analysis showed that for thalassemic patients with phenotypes ccdee and ccdee it is easier to find compatible blood than for patients with phenotypes ccdee, ccdee and ccdee. furthermore, it is known, that some congenital diseases are genetically connected with the specific group systems, for example, the mcleod syndrome is genetically associated with the sharp suppression of the kell alloantigen expression (absence of gene kx). the fact of the discovered absence of antigen k in homozygous bthalassemic patients makes it possible to assume, that this group of patients suffer from scarcity along the kell system, like the scarcity in mcleod syndrome. all the mentioned above make it possible for us to conclude, that prior to blood transfusion to thalassemic patients phenotyping of rbc rh and kell antigens must be carried out. hyperhaemolysis in sickle cell disease due to complement activation. tessa thorp rci national blood service manchester uk tm thorp national blood service, manchester, uk introduction: sickle haemoglobin is caused by a genetic mutation in codon of the beta globin gene, resulting in the conversion of glutamic acid to valine. when critical amounts of polymer accumulate within the sickled erythrocyte cellular injury results. clinically sickle cell disease is characterised by chronic haemolysis and intermittent vaso-occlusion. mold et al. demonstrated that deoxygenation and sickling of erythrocytes is related to membrane phospholipid changes and these changes result in the activation of the alternative complement pathway. aim: the objective of this study was to measure the amount of c c and c d bound in vivo to red cells of homozygous and heterozygous sickle cell patients. these levels were then compared to 'normal' sickle negative blood donors. haemoglobin levels and red cell morphology were also examined for signs of active haemolysis. the hypothesis was that an increase in red cell bound complement in vivo could provide an indication of hyperhaemolysis syndrome is sickle patients. method: flow cytometric analysis using rabbit anti-c c or anti-c d and fitc labelled goat anti-rabbit was developed using a beckman epics xlmcl flow cytometer. control samples were prepared using a fruitstone buffer technique of complement coating. results: a total of heterozygous sickle patients and homozygous patients were analysed. of the homozygous patients analysed only one was undergoing a sickle crisis. a positive result was indicated if the mean trait or homozygous sample was coated with complement to a greater degree that the mean normal donor plus two standard deviations. the results obtained in this research project indicate an increase in c c levels bound to red cells of homozygous sickle patients in vivo. statistical analysis of results obtained suggest that there was no increase in c d levels in either sickle trait or homozygous sickle patients. conclusion: these findings support research carried out by mold et al. ( ) and are present in more than % of caucasian population. it has been reported that anti-chido and anti-rogers don't cause hemolitic reaction but may be responsible for life-threatening anaphylactic reaction during transfusion of plasma proteins. case report: positive iat and dat were detected in a years old swedish woman, a rh negative, at th week of pregnancy. previous iat and dat determinations were negative. at time of detection dat wsa weakly positive and igg subclasses identified. antibody identification revealed the presence of high titre ( : ) anti-chido and anti-rogers antibodies. a slight decrease in platelet count (from . /ul to . /ul) was observed. this pattern showed no variation until the end of the pregnancy. at th week a healthy baby was delivered, dat negative. the mother dat and iat remained positive for four months after delivery. the platelets count raised again to . /ul. the same laboratory findings were detected in a previuos pregnancy in sweden. the patient reported the presence of antibodies at th week that disappeared few months after delivery. a healthy baby, dat negative was delivered in this case too. conclusions: this is the first report of the presence of chido and rogers as autoantibodies during the last months of pregnancy. the association with decrease in platelets count and the lack of evident clinical symptoms need further investigation. p- rbc alloantibody frequency and their prevalence within chinese, malay and indian community in singapore e widjaja, mbc koh and d teo health science authority, singapore, singapore background and aim: there is a recognised existence of different alloantibodies in different ethnic groups. while this has been studied in the caucasian population, their frequencies remain less well documented in the asian population. the frequency of different alloantibodies and their distribution in terms of age, sex in singapore population is studied, as were their prevalence within the chinese, malay and indian races in singapore. design and method: we conducted a retrospective study for the frequency of alloantibodies on blood samples over . these blood samples were largely sent by hospitals where preliminary antibody screening had been done and positive result obtained. they were sent to the centre for transfusion medicine for antibody identification. small number of these samples came from hospitals where preliminary antibody testing was not done. the antibody distribution across different ethnic groups (chinese, malays, indians) age and sex were studied. results: the most frequent alloantibodies in the population is mia ( . %), e ( %), le a ( . %), le b ( . %), p ( . %), m ( . %), d ( . %), c ( . %), jka ( . %) and c ( . %). within the chinese community, the most frequent alloantibodies were similar: mia ( . %), e ( . %), le a ( %), le b ( . %) and p ( . %). in the malays, the most frequent alloantibodies were le a ( %), le b ( . %), mia ( . %), e( . %) and p ( . %); while in the indians, these were mia ( . %), le b ( . %), le a ( . %), d ( . %), and e ( . %), with the anti-d reflecting the higher incidence of rh d negativity in the indians race. for the lower incidence antibodies, anti-c was more common in the malays and indians ( %) compared to chinese ( . %). anti jka tended to occur mainly in the malay race and anti-c was rare in all (< %) reflecting the high prevalence of c in the singapore population (r r phenotype). the ratio of alloimmunised male to female (m : f) is : . most alloantibodies demonstrated significant skewing towards to the female, although relatively less so for mia where m : f ratio is almost equal at : . . alloimmunisation increased with age for mia, e, k, p , jka and fyb while the frequency of alloimmunisation to lea, leb, d, m and c decresed with age. the prevalence of patients with multiple alloantibodies ( or more) within the alloimmunised subjects is . %. conclusion: anti mia is very common within the asian population especially in the chinese. anti d is common in the indians. most antibodies show increased frequency with age except for anti lea + b, d and m. the majority of alloimmunised patients are females. study aim: to identify the present antibodies in newborns, after a positive direct antiglobulin test (dat). material and method: during a years period, from / / - / / , we studied newborns and their mothers. each newborn was examined for abo group, rhesus with phenotype, kell and dat. each mother was also tested for abo group, rhesus with phenotype, kell and indirect antiglobulin test (iat). after each positive dat, the study was continued with the elution test, in order to identify the present antibody. dat test was performed with dc screening i-diamed sa, switzerland. for the laboratorial analysis of newborns the sample used was cord blood and in certain cases venous blood. results: the dat test was positive in ( %) of newborns and the antibodies found were igg type immunoglobulin. anti-a antibody was detected in ( . %) (newborns of group a with mothers of group o), anti-b antibody in ( %) (newborns of group b with mothers of group o), anti-d antibody in ( . %) (newborns d+ from d-mothers), anti-e in one case and anti-jka in another one. the eluate test was found negative in newborns and in the rest , no special antibody could be identified. the results are presented in the following table. conclusion: the majority of antibodies in newborns with a positive dat test, is due to abo incompatibility (the mother belongs to group o and the newborn to group a or b). anti-d ( ), anti-e ( ), anti-k ( ), anti-fya ( ), anti-s ( ), anti-jkb ( ), anti-n ( ), anti-kpb ( ). in two patients antibodies were identified, while in / ( . %) no antibody was identified (unspecific). it is remarkable that only in out of patients with both dat and iat positive, an irregular antibody was identified, while the rest patients had unspecific antibodies. in patients with only iat positive, had an irregular antibody and had unspecific antibodies. in out of patients with both dat and iat negative the cause of incompatibility was the positive dat in the corresponding sample of the blood donor, while in the rest patients the reasons were technical problems that include the inappropriate blood sample of the patient, patients under medication and errors during the crossmatching procedure. the results show that the incidence of red cell incompatibility in our hospital is . % and the most common antibodies are anti-k, anti-e, anti-fya, while anti-d is important for d negative patients. . % of the detected antibodies were unspecific and this is still a problem that possibly was due to the lack of additional panels of reagent red cells or antibodies to low-incidence antigens. finally, in some cases the reasons for incompatibility are due to factors affecting the blood donor or to technical problems in the crossmatching procedure. multiple isoforms excluding normal rhd mrna detected in rh blood group del phenotype with rhd a allele introduction: del phenotype is very common in rh-negative chinese. the rates in hans (more than % in china) were reported from % to %. moreover all del individuals in this population were found mainly carrying a same allele, rhd a, through genomic dna analysis. those individuals always possess one or two of this allele with ccee or ccee phenotypes. aim and the study: we focused on the mrna investigations of del individuals carrying rhd a alleles, in chinese, to expect it could be explained that why a silent mutation is associated with del phenotype. the full-length rhd mrna was analyzed in rh-positive donors with cde/cde and cde/cde genotypes, respectively, and del phenotype individuals carrying rhd a allele with cde/cde, cde/cde, cde/cde and cde/cde genotypes, respectively, through reversed-trancriptase pcrs and cdna direct or cloning sequencing. results: five transcripts and isoforms were detected in rh-positive and del, respectively. among them, isoforms have identical sequences, which are transcripts with exon , exons and , exons and , and exons to spliced out. the normal rhd mrna was only observed in rh-positive, but not in del individuals. in stead, two additional transcripts were found in del individuals. its exon or exons - were spliced out, but both possess a bp segment of sequence from intron of rhd. through additional reversedtrancriptase pcrs, which amplified exon to ¢-region and exon to ¢-region, the results showed that exon did not exist in del anyway. conclusion: (i) a normal rhd protein does not exist in a del individual with rhd a allele since the exon was always spliced out in all isoforms. all transcripts in del maintain a normal open reading frame and encode proteins with different numbers of amino acid residues and different c-terminals (genbank ay , ay , ay , ay , ay , ay ). among them, the sequence of del (isoform with exon spliced) transcript was the most similar as normal rhd mrna. this isoform was first described by chang et al. in taiwan in . it encodes amino acid residues and has amino acids more than normal rhd. it is different from rhd after codon . in normal rhd protein, the amino acids after ( residues) are mainly the trans-membrane and intracellular regions. therefore a further study on if a del red cell possesses all epitopes of normal d antigen may be significative. (ii) a normal rh-positive individual has also the transcript of del that was found in del. (iii) there is only one polymorphism in the region of bp segment between rhd intron and of the del transcripts, which indicated that other polymorphisms may exist in intron of rhd a allele compared rhd to explain that this situation was not happened in normal rh-positive individuals. total wbc were enumerated by flow cytometry and cell counting. wbc subsets were analyzed by flow cytometry with three-color fluorescence. in this study, the third generation bags and filters are used. results: before filtration, the total number of wbc, was significantly higher in fresh units compared with stored units, whereas in postfiltration samples the number of white cells was significantly lower in the fresh compared with the stored units. although absolute numbers were significantly reduced, filtration also induced significant changes in the proportions of subsets in hoth fresh and storod units, the percentage of t cells was decreased, whereas the percentage of b cells and monocytes was increased after filtration. in conclusion, both pre and post storage wbc filtration affect the proportions of wbc in the final product but pre storage wbc filtration of platelet concentrates is superior than post storage wbc filtration. the effect of pre-and post-storage filtration on platelet rich plasma: derived platelet concentrations background and objective: the white blood cells (wbc) within transfusion products are a major stimulus for a number of detrirmental biological reactions, including febrile nonhemolytic transfusion reactions, alloimmunization against hla antigens and cytomegalovirus transmission. in this work, our objective was to study the effect of storage time on the filtration of platelet concentrates (pcs). the total number of white blood cells as well as the distribution of wbc subsets, in units filtered before and after storage were compared. materials and methods: platelet rich plasma -derived pcs were filtered either fresh ( pooled we reported earlier that metabolic arrest followed by incubation at °c reduces the platelet storage lesion (badlou et al. transfusion ) . here we report that this treatment also reduces binding and phagocytosis by macrophages. metabolic suppressed platelets (msp) were prepared by incubation in glucose-free, antimycin a containing medium ( min, °c) followed by storage ( h, °c) and recovery with glucose ( h, °c). controls were (i) platelets in glucose-rich medium stored for h at °c and recovery with glucose (c ) and (ii) platelets stored for h at °c (c ) with rewarming. platelets were labelled with mepacrine and incubated with pma-matured thp- cells ( °c). binding was measured by facs analysis of cd b/cd positive particles, and phagocytosis by counting mepacrine/cd positive particles. binding of msp, c , c was ± , ± , ± % of total platelets. phagocytosis of msp, c and c was ± , ± , ± % of total macrophages (means ± sem, n = ). before recovery of msp, binding/phagocytosis was % higher than thereafter, revealing energy-dependent control of the mechanisms that trigger plateletmacrophage interaction. these data show that metabolic suppression prior to cold storage attenuates binding and phagocytosis by phagocytes and may help to develop means to improve platelet survival post-transfusion. platelet compatibility testing and alloimunization in multiply transfused hematologic patients purpose: multiply transfused patients with heamotological malignancy often become refractory to platelets due to alloimmunization. refractoriness is usually defined as an insufficient platelet increment after consecutive platelet transfusions. two major causes of a decreased platelet increment can be distinguished, immune and nonimmune factors. alloimmunization occurs most frequently against the hla, and rarely against the hpa system. nonimmune factors been identified are splenomegaly, fever, sepsis, and disseminated intravascular coagulation as well as the quality of the transfused platelet concentrates. we performed this study in order to investigate platelet crossmatching, compatibility, and antibody determination among thrombocytopenic patients multiply transfused. we performed crossmatchingcompatibility tests of single donor leucodepleted, abo compatible, platelet concentrates been transfused in patients with leukemia and lymphoma, males and females with mean age ± years old. we also obtained samples from the patients for platelet antibody detection. we evaluated the cci (corrected count increment) h after the transfusion. the solid phase rbc adherence assay (modified capture p system/immucor) was used for platelet compatibility and antibody detection. a total of compatibility tests were performed, of which were compatible. twenty five compatible platelet concentrates out of were clinically evaluated. twenty from compatible crossmatches ( %) were resulted in successful transfusion while only from ( %) in unsuccessful. the incompatible platelets been transfused was resulted in unsuccessful transfusion. we found statistically significant difference among patients successfully transfused with compatible and incompatible platelets (p~ . ). additionally patients out of ( . %) had been alloimmunized against multiple hla antibodies. three patients transfused with compatible platelets, during the study, developed alloantibodies. we found a large number of incompatible platelet concentrates that result in unsuccessful transfusion and clinical response. the platelet compatibility testing as well as alloantibody determination of multiply transfused patients is necessary for the identification and selection of compatible, with the patients, donors in order to result in succesful transfusion and clinical outcome. furthermore compatible platelet concentrates provide optimal support for refractory patients and it is known that they are acceptable as an alternative component. naitp is a rare clinical syndrome characterized by marked thrombocytopenia shortly after birth. it is caused by maternal immunization against paternally inherited antigens present on foetal platelets. screening and identification of antibodies in the maternal blood sample is the main support in the diagnosis and management of naitp. we have evaluated the frequency of maternal alloimmunization, the role of the antibodies involved (hpa and/or hla systems) and the pertinent risk of naitp in neonates using a fully automated system with a solid phase red cell adherence methodology (sprc-capture p) and paternal or random donors (indirect test). screening started in june and is still in course: in january , blood samples were examined. identification of antibodies in maternal serum was carried out using elisa methodologies: maipa and commercial kits (pak-plus and quick screen-gti). of the blood samples analysed, were reactive and the specificity of the antibodies were: anti hpa a: , anti hpa b: , anti hpa a + hla: , anti hpa b. , anti hla: , auto hpa- b: . specificity of hpa antibodies was confirmed by determination of parents' hpa genotype (hpa- , , , , , ) using pcr-ssp or pcr-rflp. the infants with hpa immunization suffered from severe (plt count - /ml) and symptomatic naitp (bleeding and petechiae were present), therefore they were treated with platelet transfusion and administration of high doses of intravenous immunoglobulin. we confirm that naitp due to hpa- and hla immunization is clinically less severe: all neonates had mild and self limiting thrombocytopenia at birth; no therapy was administered. it would be advisable to carry out pre-natal screening, at reasonable cost, using maternal serum versus paternal platelets and to proceed to the identification of antibodies only in presence of positive results. background: fetal or neonatal alloimmune thrombocytopenia (fmait) results from a maternal alloimmunization against fetal platelet antigens. it is the commonest cause of severe thrombocytopenia in the neonatal period. the diagnosis of fmait is made initially on clinical grounds, depending on exclusion of other causes of neonatal thrombocytopenia. in caucasians, hpa- a is the most frequently implicated antigen. other antigens such as hpa- a, or hpa- a are less often implicated. during the past few years fmait has been reported associated with rare or private antigens. the diagnosis is straightforward when a maternal alloantibody with a corresponding parental antigen incompatibility is present. however it could be equivocal in the absence of such an antibody or difficult when a private antigen is implicated. if the father is heterozygous for the considered antigen, the infant's platelet typing should be performed to confirm the diagnosis. due to the risk of hemorrhage, particularly intracranial hemorrhage (ich), during the course of severe thrombocytopenia, specific therapy is mandatory. because subsequent siblings may be more severely affected, accurate diagnosis will allow better management of subsequent pregnancies. study design and methods: since the first documented case of feto-maternal alloimmune thrombocytopenia (fmait) due to anti hpa- bw (maxa+), no additional cases have been reported. we present here a retrospective analysis of the cases referred to our laboratories in recent years. since we have screened for rare or private antigens in suspected cases of fmait when there is no incompatibility for the most frequently implicated antigens. the diagnosis was performed by genotyping and identification of the maternal alloantibody by the maipa technique. results: parental genotyping showed hpa- bw (maxa+) mismatch as the sole antigenic incompatibility in out of families. in the last one, incompatibility was found for hpa- without anti hpa- b maternal alloantibody. as the father was found to be hpa- bw (maxa+) heterozygous in all the cases, the infant or fetus was genotyped to ascertain the diagnosis. the maternal alloantibody was identified in the maipa technique. however, our data strongly suggest that recognition of the hpa- bw (maxa+) epitope is not uniform. the neonatal thrombocytopenia was severe in most cases with bleeding. the outcome was good in all the cases but one. conclusion: this analysis confirms that anti hpa- bw (maxa+) fmait is not uncommon and was found to be around % of our confirmed fmait cases with parental incompatibilities and presence of maternal alloantibodies. it is a clinically severe syndrome which requires prompt diagnosis, albeit difficult, and maternal platelet transfusion therapy. laboratory investigation of a suspected fmait case should be carried out in a specialist laboratory wellexperienced in optimal testing. therapy requires strict collaboration between clinicians and blood bank services. appropriate management and antenatal therapy should be considered for successive pregnancies to prevent fetal bleeding. introduction: the human platelet (plt) antigen (hpa) system is independent of the hla system. therefore, host-or donor derived alloimmune thrombocytopenia can develop after allogeneic haematopoietic stem cell transplantation (hsct) even in hlamatched donor-recipient pairs. we report the first case on a stem cell recipient developing thrombocytopenia due to host-derived hpa- a antibodies after non-myeloablative allogeneic hsct. a year-old male patient was diagnosed with multiple myeloma in / . treatment consisted of cycles vincristin, adriamycin and dexamethason followed by tandem autologous stem cell transplantation. because of progressive disease he received cycles of bortezomib, and after complete remission a stem cell allograft ( . ¥ /kgbw cd + cells) from his histocompatible (hla a,b,c,dr identical) brother after reduced intensity conditioning regimen with fludarabine ( ¥ mg/m ) and alkeran ( mg/m ). he had received only twice packed red blood cell concentrates and one plt concentrate before allogeneic hsct. stable bilinear engraftment occurred around d but was accompanied with a continuous decrease of plt counts. between d and d the patient received seven plt transfusions, containing a median of . ¥ plt/unit (range , - , ¥ plt/unit) from random donors. the corrected plt count increments at to h after these transfusions were < /ml. therefore, and because of even a further decline of platelet counts to /ml on d we investigated the presence of plt antibodies. methods: the patient's serum was tested by antigen capture elisa assays (pakplus® and pak ®, gti) and a solid phase assay (capture-p®, immucor). the maipa assay was used to confirm the results obtained by the above mentioned assays. in addition, we tested the patient's serum by the maspat kit (clb) against plt from the donor and against homozygous hpa- a plt obtained from our donor pool. stored recipient's dna from the time before hsct was used for genotyping. genotyping for hpa- , - , - and - of the donor and the recipient was performed by pcr-ssp (hpa, protrans). the patient's serum obtained on d after hsct reacted strongly with the donor's plt due to anti-hpa- a antibodies and antibodies against hla class i antigens. the patient's genotype before transplantation was hpa- bb, - aa, - ab, and - aa; the donor was hpa- ab, - aa, - aa, and - aa. thus, the antibodies were host derived and directed against the donor's plt. serum samples obtained on d , d and d after hsct contained antibodies against hla class i antigens but hpa- a antibodies were not anymore detectable. no hla antibodies were detectable on d after hsct. the severe thrombocytopenia was caused by hostderived hpa- a antibodies. fortunately, plt counts started to increase on d spontaneously and the patient could be discharged at d (plt . /ml) with a complete donor chimerism. the decrease of the serum antibodies parallel to the increase of the plt count strongly suggests a progressive elimination of residual host cells. we conclude that the hpa mismatch between recipient and host affected thrombopoietic engraftment and the success of plt transfusions. severe neonatal alloimmune thrombocytopenia with anti-hpa- b antibodies: case report p moncharmont, m vignal, y mÉrieux and d rigal efs rhone alpes site de lyon, lyon cedex , france usually, in case of feto-maternal incompatibility, the platelet (plt) specific anti-hpa- b antibodies (ab) induce only sometimes a mild neonatal alloimmune thrombocytopenia (nait). contrary to this observation here is reported the case of a severe nait. a -year old mother, gestation /partum , gave birth to a male neonate by caesarean section at weeks of gestation because of intra-uterine growth retardation (iugr) and anamniotic fetus. five years before, she had had a first pregnancy with iugr of the fetus but no nait. the second neonate weighted . g, was . cm tall and had a head circumference of . cm. the apgar score was , , , at , , and min respectively after birth. no bleeding, hepatomegaly, splenomegaly or infectious signs were noted. five hours after birth, a respiratory distress syndrome appeared and an oxygenotherapy was performed during h. the plt count which was . , . and . giga/l at day (d) , d and d respectively dropped dramatically at . giga/l at d . simultaneously, an intracranial hemorrhage grade ii was diagnosed on ultrasound scan. because of the clinical signs and of the decreasing plt count the mother's serum was tested for plt-specific ab by immunocapture and the ab identified by the monoclonal ab-specific immobilization of plt antigen (maipa) assay. a plt genotyping was performed in the neonate and his parents by sequence-specific primers polymerase chain reaction. the mother was hpa- a/a and anti-hpa- b ab were detected in her serum. the baby was heterozygous, hpa- a/b. plt were transfused to the baby and the plt count rose to . , . and . giga/l at d , and respectively. no further transfusion was needed and the development of the baby was satisfactory with a normal electroencephalogram. in conclusion, when a mild thrombocytopenia with iugr and hypoxia but without bleeding signs is present in a neonate immediately after birth, a maternal plt specific ab screening must be performed in case the thrombocytopenia became severe during the newborn monitoring. anti-hpa- b ab can be detected. partial results of the incidence of heparin induced thrombocytopenia type ii osc oliveira*, ra rached*, c cavalheiro-filho*, jc nicolau*, shgl pasqualucci*, daf chamone † and sp bydlowski † *heart institute, university of são paulo, † university of são paulo, são paulo, brazil heparin induced thrombocytopenia type ii (hit) is a severe side effect of heparin, associated with heparin-platelet factor antibodies. hit type ii occurs in up to % of patients who are exposed to unfractionated heparin (ufh). in our institution patients that are under heparin treatment are mostly cardiac patients. the purpose of this study is to determine the incidence of hit type ii in these patients. material and methods: patients from the intensive care unit and cardiac care unit treated with ufh or low molecular weight heparin (lmwh) for or more days were studied. known causes of thrombocytopenia were excluded. platelet count was monitored pre and post heparin therapy. all selected patients were tested for detection of anti heparin/pf antibody test (diamed id-card). results: from the studied patients, ( . %) developed thrombocytopenia (determined by a decrease in the platelet count below %, after the introduction of heparin therapy); ( . %) did not show decrease in the platelet count. six ( . %) out of thrombocytopenic patients were positive for anti-heparin/pf antibody. three ( . %) out of non thrombocytopenic patients were positive for anti-heparin/pf antibody. the results demonstrate that ( . %) patients were positive for anti-heparin/pf antibody and they were no different from those described in the literature regarding the frequency of heparin induced thrombocytopenia. moreover, a higher frequency of patients with heparin/pf antibody was noted without the presence of thrombocytopenia, indicating that other factors should be considered. introduction: neonatal alloimmune thrombocytopenia (natp) due to maternal immunization against fetal platelet antigens affects . - in live births. although it is usually a self-limiting condition, a major complication in cases of severe thrombocytopenia is the occurrence of intracranial haemorrhage leading to death (in up to % of reported cases). the commonest antibodies are anti-hpa- a. treatment consists of ivig, compatible donor platelet concentrates or washed maternal platelets. the administration of random donor platelet transfusions is controversial but has been used successfully in some urgent cases when compatible platelets were not available. case report: a baby born in week of gestation to a healthy mother after first uneventful pregnancy; birth weight g, apgar score . immediately after birth, severe thrombocytopenia ( ¥ /l) and signs of haemorrhagic diathesis (generalized petechiae and ich gr. ii-iii) were observed. coagulation tests were abnormal and k-vitamin, fresh frozen plasma and random donor platelet concentrate (retrospectively genotyped as hpa- a/a) were given. twenty-four hours later platelet count rose to ¥ /l and no new petechiae were observed. on third day of life the blood platelet count was ¥ /l and the newborn received ivig g/kg and corticosteroides. twenty-four hours later the platelet count rose to ¥ /l and further clinical course was uneventful. natp due to hpa- a was serologically confirmed. conclusion: optimal therapy for an infant with severe thrombocytopenia during the first h of life is the transfusion of platelets that will not be destroyed by the maternal alloantibody in the infant circulation. random donor platelet concentrates are controversial in a setting where optimal treatment is not available, however, in this case they led to a significant platelet count improvement in spite of hpa- a incompatibility. accordingly, random donor platelets may be considered appropriate in emergency situations. background: rhd is the most immunogenic blood group antigen, and its correct identification is essential in the blood bank and in the prevention of the haemolytic disease of the newborn. the weak d phenotype is the most common d variant, with a frequency of . % to % in caucasian individuals. there are several weak d types, with different frequencies in european countries, which may pose serologic problems and have the potential for alloimmunization. the objective of the study was to determine the frequency of the principal weak d types in portugal. study design and methods: lisbon regional centre of the portuguese blood institute and oporto são joão university hospital selected samples from blood donors and patients. rhd was tested by two (oporto) or three (lisbon) distinct anti-sera, in direct agglutination tests, at room temperature. when discrepant results were observed, the samples were tested with panels of monoclonal anti-d by liss-iat. samples that reacted weakly with igm anti-d but positive with igg anti-d were sent to the molecular biology centre. pcr with sequence-specific primers was performed using two commercially available kits (inno-train and bagene). real-time pcr, carried out on a light cycler, was applied when the interpretation was dubious. results: samples were referred after being characterized as weak d. in cases we obtained a positive result, with a preponderance of weak d type ( . %) over type ( . %), ( . %) and ( . %). two samples were not categorized. the high incidence of weak d type in our population is in marked contrast to studies performed in other european populations where weak d type was the most frequent. this might be due to our sample selection criteria or ethnic variation in the causes of weak d. there are advantages in genotyping serologically depressed d samples: to avoid the waste of d-negative rbc units and the use of immunoglobulin in pregnant women, who have no risk of alloimmunization. analysis of rhd zygosity in different rh phenotypes cal except for a -bp t insertion. the deletion of the rhd gene, found in most rhd-negative caucasians, was theoretically due to recombination of the upstream and downstream rhesus boxes resulting in the formation of a hybrid rhesus box. thus, the detection of a hybrid rhesus box in an rhd-positive individual denotes an rhd heterozygous status. aim of the study: to determine the rhd zygosity in different rh phenotypes. methods: blood samples from white trios (father, mother and child) were studied. the rh phenotype was performed by hemmaglutination and the rhd zygosity was inferred in each member of the family groups. the rhd deleted allele was determined by a pcr strategy using a forward primer complementary to ¢ end of the identity region of the upstream and hybrid rhesus boxes and a reverse primer complementary to the ¢ end of identity region of the downstream and hybrid rhesus boxes. these primers selectively amplify a -bp segment of the hybrid rhesus box in rhdnegative and rhd-positive heterozygous samples. serological and pcr inconsistencies were studied by a pcr-rflp method to detect another polymorphic site of the hybrid rhesus box. frequencies were obtained analysing only unrelated individuals (fathers and mothers, n = ). results: ( . %) rhd-positive and ( . %) rhd-negative samples were phenotyped. of the rhd-positive donors, ( . %) were rhd homozygous and ( . %) were rhd heterozygous according to pcr. pcr-rflp analysis confirmed the results of pcr in serological and molecular discrepancies. these results were coherent within each family group and did not differ from those published in the literature for caucasians based on the most probable genotype method. however, the homozygosity indexes were significantly higher in the dccee ( . % vs . %) and dccee ( . % vs . %) phenotypes due to an increase of the dce haplotype. in all samples with the dce haplotype the rhces allele, frequent in individuals of african descent, was investigated by pcr-ssp. this allele was found in . % of the dce haplotypes. . rhd and rhce typing was performed by multiplex-pcr with fluorescent primer pairs. positive results were obtained for rhd-exons - , , and polymorphisms associated with antigens c, c, cw, e and e. sequencing of rhce-sequences, including exons to and intron/exon borders, were done by direct taq cycle-sequencing using bigdye-terminators v. . in an abi (applied biosystems). results: see table . the substitutions of rhce-specific nucleotides in exons , and with their rhd-specific counterparts lead to different new rhc-antigens with weakened expression. since one amino acid change in allele lie in extracellular loop of the antigen suggested that this antigen may be involved in allo-immunization. inheritance of a rhd cat vi type ii in a twin pregnancy: a case report introduction: determination of hdn-relevant fetal blood groups in amniocentic fluid with pcr is a routinely used method. misinterpretation of test results -e.g. overlooking rhd category -decreases depending on the number of examinated rhd-specific exons. case report: a -year old mother (w.o.g. ) pregnant with twins was regularly tested for irregular antibodies and was shown to have an anti-d. after amniocentesis of both foetuses tests for the occurrence of rhd intron , exons and were performed in the hospital's lab. the sample of fetus i showed pcr-products for intron , exon and exon while sample of fetus ii lacked rhd-specific intron . therefore we investigated blood samples from the parents as well as amniocentic fluid of both foetuses. methods: total dna was amplified in a multiplex pcr with fluorogenic primers for rhd exons - , & ; polymorphisms for dweak type - , d-vii, d-hmi and rhce polymorphisms for c, c, cw, e, e. capillary electrophoresis for size fractionation and fluorigeneic analysis was done in an abi . rhd zygosity was determined by quantitative real-time pcr with co-amplification of rhdand rhce-specific exon and subsequent calculation of d ct value (ct rhce minus ct rhd). results: while maternal dna sample has been genotyped as rhdnegative, amplification of paternal dna for rhd-specific exons , , , and were possible and failed only in exon - . determination of rhd-zygosity revealed a homozygous constellation of the rhd-gen. investigation of amniocentic fluid from both foetuses resulted in a rhd-wildtyp for fetus i and a rhd cat. vi type ii for fetus ii which was the reason for missing amplification in rhd intron pcr. results: weak d type was not identified in our research population. weak d type was identified in cn, weak d type was identified in cn and weak d type was found in cn, bsa, be, bc and saa. conclusions: although weak d types to represent the majority of all weak d phenotypes in caucasian populations, none of these weak d alleles were found in black populations. since none of the frequent weak d types were identified in non-caucasians one might not expected to find type in all populations. however, regarding rhd phylogeny, the weak d type mutations ( c > g and t > g) form the basis of a cluster of aberrant alleles that are predominantly observed in blacks. therefore, it is not surprising that weak d type was identified in non-caucasians. based on these results it may be concluded that weak d phenotypes have evolved relatively recently since they are present in caucasian and asian methods: dna was extracted from a, b, ab subgroups, and provisional cis-ab after serological abo typing. allelespecific pcr, rflp, direct sequencing of exon and , and allele separation were performed on these samples. results: abo*a allele was observed in an aint subgroup. two new a alleles that showed g > a base change and c > t of intron and a polymorphism of c > t in a(pro) intron were discovered. o and o alleles were also observed. in b subgroups, a silent substitution c > t (leu leu) was observed as a new b allele. another new b allele which showed g > a was also found in b subgroups. conclusion: we discovered new abo alleles and polymorphisms in korean populations. many other polymorphisms and alleles already reported in japanese were also observed in koreans. evaluation of a multiplex snapshot-pcr method for red blood cell marker genotyping c jungbauer*, c hobel*, em dauber † , pk rabitsch*, dwm schwartz* and wr mayr* *austrian red cross, † medical university vienna, vienna, austria once conventional reagents for identification of rare red blood cell phenotypes are scarce, methods using current nucleic acid testing techniques to identify the patient's genotype and possibly to screen for donors would be desirable. the approach of multiplexgenotyping using pcr-ssp has apparently technical constraints so we are currently analyzing whether a modification using snapshot pcr-technique could provide a routine application for such purposes. compared to ssp-technique, the snapshot pcr only requires one single primer (labeling reaction) for the detection of two (or more) alleles instead of one pair of primers for every single allele. briefly, we perform snapshot pcr as follows: in a first step, dna segments covering the essential polymorphic regions for the abo, rhd, kel, jk and fy genes are amplified using a standard pcr step. after purification treatment of the pcr products (roche high pure pcr product purification kit or shrimp alkaline phosphatase (sap)/exo treatment according to the abi prism snapshot multiplex kit protocol) the labeling reaction is performed using the abi prism snapshot multiplex kit. after a second purification step the products are analyzed on a abi prism genetic analyser in fragment analysis mode. our preliminary results show the feasibility of this approach as reliable typing results can be obtained for all tested single nucleotide polymorphisms corresponding to alleles. generally a better signal quality from controls and samples is obtained compared to the ssp-technique with consecutive gel electrophoresis. we also consider the possibility of the automated interpretation of the results as an important improvement, especially when aiming for an application for a large number of samples (donors) or markers (patients). in contrast, the method involves more manual steps and higher costs. we may conclude that the implementation of snapshot-pcr techniques for red cell marker genotyping is a promising alternative to pcr-ssp. the obvious quality improvements compared to pcr-ssp might be critical for a routine application in blood banks (donor screening) or complex questions in clinical laboratories. quantification and quality control of monoclonal antibody using an optical sensor based on the laser reflectometry technique the monoclonal antibodies (moab) are biological reagents of homogeneous activity. they are generally used in the recognition and quantification of very small amounts of biological substances (hormones, enzymes) present in a solution, ag identification, blood group determination, oncology, organs transplant, etc. moab can be characterized by its specificity and affinity. affinity may be expressed as the equilibrium association constant (k). several techniques are available to determine the equilibrium constant of the ag-ab interaction. in this work, is shown an optical sensor for monoclonal antibody quantification by reflectometry technique. the laser reflectometry technique (null ellipsometry technique) can give information about the kinetic of the interactions, stoichiometry of molecular binding and the concentration of molecules in a solution, and also offers detailed and accurate determinations of real-time adsorption kinetics of protein without labeling. a silicon wafer was chosen as reflectant surface. once fixed the principal angle of incidence, an amount of anti-ab is added to the sample. the reflected laser intensity is registered in real time as the protein is being adsorbed onto the wafer. the mathematical analysis of the results verifies that the antibodies adsorption follows langmuir's kinetics. from the curve analysis, the parameters related to the anti-ab concentration are extracted. from them, the calibration curve is constructed. this curve allows the desired commercial monoclonal antibody quantification. the developed technique shows to be sensible and precise. the obtained graphics are very well approximated (r > . ) verifying that the monoclonal anti-ab associa- study aim: to prevent the sensitization to rh (d), to a d-patient who was transfused with d+ blood. material and method: on september , ( / / ), we admitted to our hospital through air-carriage, a female of years old, badly injured after a car-accident. the patient was on an olighemic shock (ht: %) due to retroperitoneal, paracolic and procystic hematomas, had multiple fractures on the left feet, the main important of which was an acetabulum one. she had a blood group: o, d-and her phenotype was ccdee with du-. after her arrival she was urgently admitted to the surgery room and our blood bank was asked for condensed red cells. initially she was transfused with blood of the same group (o, d-) but when we were short out of dblood, we were asked for more units. the necessity of blood was imperative, the patient was on a critical condition and the mechanism of blood transport, from another blood bank would take some time to be put in motion, and so it was decided that the patient would be provided with d+ blood. the indirect antiglobulin test (iat) and papaine were negative, so there would be no problem with the transfusion with d+ blood. the patient received finally units ( ml) of d+ condensed red cells, out of that were initially asked. before the h from the surgery had passed, it was decided that human anti-d immunoglobulin (rhesogamma p) should be provided, in order to prevent the sensitization of the patient to rh (d). the indicted dose was - iu/ ml of the transfused blood, provided piecemeal during a several days period. analyzed by real-time pcr amplification. based on a published report, we selected primer pairs targeting insertion/deletion polymorphisms which are located on different chromosomes, unrelated to each other and not associated with immunocompatibility. we optimized the amplification conditions for all primer pairs using our sybr green real-time quantitative pcr protocols, and investigated analytical sensitivity for each primer pair by performing spiking studies, in which a single copy of positive dna was added into copies of negative dna followed by allele-specific pcr amplification. we also created a theoretical panel of donor-recipient pairs (n = ) to evaluate the clinical sensitivity for detection of ta-mc using both hla-dr and indel panels. results: for the short-term samples, additional mc cases was identified in non-lr group using indel panel; and one additional mc case was detected in lr group (table ) . for the long-term follow-up samples, additional mc cases were found. when evaluating analytical sensitivity, we were able to detect a single copy of positive dna mixed with copies of negative dna in a single amplification tube for all primer pairs. we were also able to calculated the clinical sensitivity that using donor-recipient pairs. . % of donor-recipient had at least one informative allele for detection of ta-mc if we consider both hla-dr and indel panels. conclusion: using our new indel panel, we were able to detect more instances of mc in this cohort of patients. we conclude that the dr assay underestimates the presence of mc. moreover, the tandem use of both panels provides a powerful tool for the detection of mc with . % of recipients having at least one informative allele. background: we reported severe immunesuppression and longterm transfusion-associated microchimerism (ta-mc) in transfused trauma patients. we have also reported, in a murine transfusion model, that sensitivity to -chloro- - dinitrobenzene could be transferred, albeit transiently, by transfusion of fresh blood from a sensitized donor to a naïve immunecompetent recipient. in order to mimic the immunecompromised status of trauma patients and further investigate the mechanism underlying ta-mc, we established an animal model using immunedeficient knock-out mice. aim: our objective was to test virus-specific immune functionality of the chimeric donor leukocytes in a murine ta-mc model. material and methods: female rag- /common gamma double knock-out mice were transfused with fresh blood collected from male balb/c mice, which were either not infected (non-primed, np) or infected twice (primed, p) with million viral particles of murine cmv (mcmv). at different post-transfusion time-points ( h, weeks, weeks, weeks, weeks), different female recipients plus non-transfused female knock-out controls were challenged with million viral particles of mcmv intra-peritoneally, and then monitored weekly for the concentrations of male donor cells as well as mcmv viral load in recipient's circulation. each female knock-out received only one challenge of mcmv. if the subject died, we quantitated mcmv viral load in the brain, spleen, lung and liver. we used real-time quantitative pcr targeting murine y-chromosome, h k and mcmv to quantitate male donor cells, transfused recipient cell dna input, and mcmv vrial load, respectively. the number of recipient cell dna input served as a denominator to calculate the concentration of male donor cells and the mcmv viral load. results: results of overall mortality are summarized in the table. all female knock-out recipients transfused with primed donor blood, except for the post-transfusion weeks, are able to survive mcmv infection. all non-transfused control and recipients transfused with non-primed donor blood died after mcmv infection; these two groups also had higher mcmv viral load in blood than the recipients transfused with primed donor blood. when the subject died, we were able to detect mcmv in all four organs we analyzed, with liver having the highest mcmv viral load. there was no significant difference for the concentration of donor cells in recipients' blood between recipients transfused with non-primed donor blood and recipients with primed donor blood. the preliminary data of our study showed that chimeric primed donor cells, but not non-primed donor cells, are able to protect immune compromised knock-out recipients from murine cmv infection. the time-point of 'post-transfusion weeks' might represent a weak window for the functionality of chimeric donor cells, which requires further investigation and confirmation. aims: to compare the effectiveness and the cost of epoetin-a and darbepoetin in patients undergoing pabd. methods: seven adult patients scheduled for operations were administered aranesp ( mg sc once or q weeks if needed) for pabd (aranesp group) and they were compared with a historical epoetin-a group of seven age-matched adults (eprex iu/kg biweekly). the two groups were matched according to the ht, ferritin levels, number of the predonated units and type of the operation performed. cbc count and reticulocytes were measured weekly during the donation period, the day before, day and day after surgery while ferritin and biochemical indices were measured during the first visit. erythropoiesis-stimulating factor was administered when ht £ % during blood donations and blood donation was not performed if ht < %. results: there was no statistical significant difference in hematological parameters during the donation period, the pre-operation day and after surgery between the two groups. five of seven patients from both groups received one or two autologous blood units. both factors were well tolerated without any side effects. the cost per patient was . € in the aranesp group and . € in the epoetin group. conclusion: despite the small number of patients and the limitations of this preliminary retrospective trial we believe that subcutaneous darbepoetin-a is equally effective with epoetin-a in patients undergoing pabd. darbepoetin has the advantage of less frequent administration and it is possibly superior that epoetin-a in terms of patient compliance. however smaller doses should be examined in order to reduce the cost. larger prospective randomized trials are needed to estimate the cost-effectiveness of the use of darbepoetin-a in pabd. background: incompatibility with many blood units is a major problem in transfusion therapy. in selective operations, preoperative autologous blood donation could solve many problems, when of course the patient's condition and his haemoglobin levels are appropriate. we present here the experience of our blood transfusion centre from operations in patients with anti-erythroid antibodies. materials: three patients ( male and females), aged between - years old, had to undergo selective operations, total hip replacement surgery and aortic aneurysm. introduction: because of improvements in surgical techniques, preoperative autologous blood donation (pabd) in patients undergoing radical retropubic prostatectomy (rp) is contested. aim of the study: we wanted to develop and validate an algorithm to determine the patients who probably do not benefit from pabd. methods: we calculated the perioperative hb-loss of consecutive patients (group ) who donated two red cell units (rbc) of autologous blood and weeks before undergoing rp: hb-loss (g) = preop-hb ¥ bv + (n rbc ¥ ) -(postop-hb ¥ bv) (bv = blood volume (l) = body weight (kg) ¥ . ; postop-hb = hb ( - h after rp); n rbc = number of transfused autologous and allogeneic rbc). hb of rbc was taken as g. rbc requirement is probably if initial-hb -(hb-loss: bv) -trigger-hb (taken as g/l) < (initial-hb = hb at the first contact with the pabd-unit). this assumption was validated by the next patients who were also assigned for pabd (group ). pabd was refused if the probability of rbc requirement (prr) was < %. between - % one rbc was taken after considering the patient's individual risk of pabd. if prr exceeded % two donations were planned. results: both groups did not significantly differ in age or initial hb. preop-and postop-hb were significantly lower in group ( vs and vs g/l). % of autologous blood of group were discarded, / patients needed additional allogeneic rbc. hb-loss caused by rp was ± g. mean prr in group was . %. / patients donated one rbc, which was later discarded, and no patients donated two rbc. / of group needed allogeneic rbc. mean prr of these patients was % (range . - . ). conclusion: postop-hb were lower in rp-patients with pabd because of the lower preop-hb and the restrictive indication for transfusion of autologous blood. the individual calculation of prr, for which only body-weight and initial-hb of the patient are necessary, shows that pabd in patients undergoing rp is indicated only in rare cases. the algorithm also may be used in other major operations, if hb-loss is known. use of darbepoetin-alpha in preoperative autologous blood donation: preliminary results background: preoperative autologous blood donation (pabd) is an alternative practice to eliminate complications of allogeneic blood transfusion although its cost-effectiveness has been questioned. darbepoetin-a (aranesp, genesis pharma sa) is a novel erythropoiesis-stimulating factor that it has been shown to be equivalent to epoetin-a (eprex, janssen-cilag) in patients with chronic renal failure and cancer. darbepoetin-a has a longer serum half-life and higher relative potency than epoetin-a. this property leads to less frequent administration and may reduce drug cost. so far, no clinical trials with darbepoetin have been published in patients with surgical anemia. other ( . %) patients who required autologous and homologous blood, had average predonation hb level of (sd ± . ) g/l. we found a significant relationship between the need for postoperative transfusion and the predonation hb level (p = . ), predonation htc values (p = . ), weight (p = . ) and gender (p = . ): female patients and patients with lower predonation hb and htc, as well as patients with lower body weight more often needed additional homologous blood transfusion. no relationship was found between age of patients and the need for transfusion (p = . ). ( . %) patients with ptka were transfused with autologous blood only, and had average predonation hb level of (sd ± . ) g/l. other ( . %) patients transfused with autologous and homologous blood had average predonation hb level of (sd ± . ) g/l. the significant relationship was found between the need for postoperative transfusion and weight (p = . ): patients with lower body weight more often needed additional homologous blood transfusion. no relationships were found between predonation hb level (p = . ) predonation htc values (p = . ), gender (p = . ) and age (p = . ) of patients and the need for postoperative transfusion. conclusions: our results show that over % of patients needed only autologous blood. in our patients with ptha predonation hb was significant predictive factor for additional transfusion therapy, while in ptka it was not observed. in both groups of patients body weight was significant predictive factor, thus this feature seems important for planning of transfusion therapy in patients with ptha and ptka. aim: prevention results of loosen anastomoses on colon, with fibrin sealent (fs) application and influence on colagen production. materials and methods: investigations were done on rats, weight - g. in control group, after partial resection of left half of colons termino-terminal anastomosis was derivated. fs was applied in examined group. concentration of colagen was done indirectly, with quantitative l-hydroxyproline determination. place of anastomosis, cm proximal and cm distal of anastomosis, was analyzed iii, v, vii and xiii day postoperatively. results: analysis of hydroxyproline on the place of anastomosis showed higher hydroxyproline value in group with fs application. the highest approximate value of hydroxyproline was registered v day postoperatively. distal, cm of anastomosis, the quantity of hydroxyproline is higher iii day postoperatively in control group but v postoperative day value is intensively growing in group with fs application. electronic microscopical was done v postoperative day in control group at the place of anastomosis detected a defect with detritus and absence of larger colagen fibres. in group with fs application on the place on anastomosis, in the shape of bundle, colagen fibres were grouped and completely fills the place of anastomosis. conclusion: fs application accomplish higher concentration of colagen in all segments of isolated colon, that enables better healing of anastomosis. the study of the use of the safest blood (autologous blood transfusion) through preoperative blood donation (pbd) in surgery patients introduction: the use of the autologous blood is already under consideration in developed countries. thus, it is probable that autologous blood donation would be effective in one way or the other in reducing blood transfusion complications. in this study, pbd as the easiest method to use and the most cost-effective one was selected. aim of the study: it aims at improving blood safety and raising blood inventory. methods: in this study, patients, including males and females, intended to undergo elective surgery were selected as subjects to donate their autologous blood. the subjects with hematocrite level of about - percent as ordered by their physician donated their blood by this method. blood collection procedure was followed at - day intervals. the blood volume taken from patients in every collection differed from - ml according to their weight. results: this study showed that in all patients undergoing plastic, gynaecological, jaw, and ent surgeries autologous blood transfusion was used with no need for allogenic transfusion. in other surgeries, including orthopaedics, the need for allogenic transfusion was estimated to be at about percent of cases. to avoid the complications of allogenic blood transfusion, the safest way is the use of autologous blood which involves low cost and is easy to perform. the introduction: the purpose of this study is to describe a technique to perform labelling of autologous platelet-gel with in-oxine and to evaluate its usefulness, after in vivo graft implant, as a marker of bone osteoinduction by means of scintigraphy, in patients with jaws bone defects following the enucleation of cystic lesions and cystic lesion derived from extraction of deeply impacted lower third molar. methods: agp made. consent was obtained by patient to conduct hiv and hbv testing. briefly, cc to cc of blood is withdrawn from the patient. the blood was separated, by means of successive step of centrifugation, in to platelet-rich plasma (prp) , platelet-poor plasma (ppp), and red blood cells (rbc). the red blood cells were discarded. the prp [comprises of approximately % of the total blood volume withdrawn] had platelet counts of - /mm . the procedures of agp labelling were performed in laminar flow chamber. to seconds the solution will assume a gel-like consistency forming platelet gel. imaging: the scintigraphy was performed h after application of labelled agp (early scan) and at , , , h (delayed scan) by means of a gamma camera equipped with medium energy collimator. a later scan was performed at days after graft. the platelet uptake index (pui) was then calculated by dividing the cpm/pixel in the graft roi (recognized in and planar and trans-axial slice) for cpm/pixel in a mirror background roi. in vitro sampling: the radioactivity of the plasma samples collected at , h and at lapse time = h for days, were used for the plasma clearance determinations and for in vitro studies of the platelet loss from the gel. results: all patients presented early high concentration of in oxine agp, at site of the graft, that was easy recognized at scintigraphy performed as in anteroposterior and lateral planar projection of the jaw as in spet slices reconstructions. all labelled agp was well confined within area of original implant and no activity was seen in the surrounding tissues or in the distant organ. conclusion: all patients studied well tolerate the implant of agp; no adverse reactions were observed and follow up -performed months later -showed bone remodelling activity in the site of the graft. serial blood donations in a ko pregnant woman with the use of recombinant erythropoietin for intrauterine transfusions of severe hemolytic disease of the newborn due to anti-ku biweekly) were administered to the mother to ensure an adequate supply of compatible rbcs for intrauterine transfusions and possible perinatal haemorrhage as well. results: intrauterine transfusions were repeated every - weeks. by the th week of gestation the patient had donated four units of blood, her hematocrit was %, anti-ku titre was / and four intrauterine transfusions had been performed. cesarian section was decided and the apgar of the newborn were and at and min. the newborn was treated with phototherapy but without exchange transfusions and two weeks later he was discharged. by the th day of life rh-epo was administrated to him due to anemia. the maternal red cells completely disappeared from the child's blood by the day . the experience of the use of erythropoietin in pregnancy is minimal. as illustrated by this case treatment with rh-epo and iv fe has effectively increased mother's capacity to donate rbcs' for autologous use and intrauterine transfusions as well, with no adverse effects to the mother or the child. however, further research is necessary to evaluate if rh-epo crosses the placenta. introduction: blood components should be transported by a system which has been validated. the containers used for transport should be well insulated, some form of temperature indicator should be used to monitor the in-transit temperature. whole blood should be stored at different temperatures above °c. aim of the study: bags with whole blood collected in a collection site are transported in containers without active cooling. we tested temperature of blood in containers put into the extreme weather conditions (+ °c, - °c) during loading test for transport. methods: the container without active cooling was filled with the exact number of bags with blood and the exact number of passive cooling elements (frozen water cubes in plastic) placed in the exact positions without close contact with the blood bags. the bags with blood of the temperature + °c, + °c and + °c were used. temperature indicators were situated in the bottom, centre and top of the container. filled container was placed into thermostat (+ °c) or freezer (- °c). the temperature was observed in min intervals for three hours, first measurement was min after putting into freezer or termostat. results: (see table ) nt, non tested; tmp, temperature. in the table there are shown minimum and maximum temperature parametres observed during tested time including increasing or decreasing trend. conclusion: loading test for transport of the bags with collected whole blood helps us to optimize transporting system, especially number of cooling elements in relation to the season and its place in the container. in the light of presented data we corrected transporting system to maintain the recommended temperature during transport. background: since , we have produced pooled and filtered platelet concentrates out of four buffy coats in tsol platelet additive solution and have stored them in pall autostop clx bags made out of pvc/totm. the residual plasma content is between - %, the mean volume about ml and the mean platelet-content is . ¥ per unit. for pathogen inactivation or bacterial screening it is necessary to extent the storage time from to days. new foliage like polyolefin is supposed to maintain a good quality environment for prolonged storage of platelets. aims: storage bags made out of polyolefin (pall autostop elx) were tested to prove their suitability for prolonged storage of platelets. methods: twins made out of pools from buffy coats were produced with the standard method, one twin was stored in the conventional bag (cb) the other in the new foliage bag (nfb). the platelet pools were stored on flatbed shakers at °c, and sampled at day , day and day . ph, glucose, lactate, hypotonic shock response (hsr) and p-selectin expression were measured by standard in-house methods. results: mean ph on day with cb was . , with nfb . ; glucose with cb . mmol/l, with nfb . mmol/l; lactate with cb . mmol/l, and with nfb . mmol/l, hsr with cb %, with nfb %; p-selectin with cb % and with nfb %. the new platelet storage bag showed better results of in vitro quality markers, especially after day of storage. prolonging storage time will make it easier to introduce bacterial screening or pathogen inactivation techniques into platelet transfusion. the possibility to filter rbc either at °c or rt simplifies the preparation process. filtration at + °c enables to achieve a better leukoreduction performance. the nbs has successfully implemented this project which has the potential for improvement in patient safety and is predicated upon practical application and risk reduction rather than elimination. the impact of this work on the incidence of trali will require detailed, long term analysis of hemovigilance data using existing mechanisms. active communication, a team approach, perceived value of the initiative and the hard work of all staff involved were key success factors. quality assessment of buffy coat-derived platelets prepared from leucoreduced whole blood background: whole blood can be separated into; plasma, buffy coat and red-cell conc (rcc) by differential centrifugation and separation on a separation device. because of the high hematocrit of the rcc, % of the process time is needed for expression of the rcc. by increasing the internal diameter of the tubing at the bottom of a t&b system by . mm. a decrease of the process time is expected. methods: units of whole blood were collected with the new t 'wide boring' blood pack and separated on a routine base. quality control parameters were checked and the whole process time was monitored. free hemoglobine was measured up to days. results: process time of a 'wide boring' bag is significant shorter compared to a standard blood bag. average decrease: s. slightly increase in free hemoglobine is measured probably due to the increased express rate of the red cells. bloodproducts produced with the new t meet european guidelines. no significant increase of free hemoglobine due to the faster expression is measured. an significant decrease in process time is measured with the wide boring bloodpack. the new fresenius hemocare rcc in-line system: t can be used for routine production which will speed up the production process considerably. introduction: leukoreduction of blood components is required to prevent several transfusion-associated complications. aim: the aim of this study was the full process validation of the pall leukotrap wb system for the preparation of leukoreduced blood components. we collected whole blood units from donors suitable for donation using a quadruple blood-bag, which includes an wbf in-line filter (pall) for the removal of leukocytes and platelets. mixer balances (baxter) were used and donation occurred within min in all cases. after donation whole blood units were stored at room temperature for h. subsequently, whole blood filtration was performed by gravity at a standard height of cm using a blood leukoreduction cart (baby leuko cart, itl-corporation). filtered units were centrifuged at g ¥ min by an heraeus cryofuge i. an automatic extractor (bag press plus-bioelettronica) was used to prepare red cell concentrates in sag-m solution and fresh plasma units. air in the system was automatically expelled by the extractor. complete cell counts and hemoglobin concentration were evaluated in pre-filtration samples and at the end of the blood components preparation using an automated cell counter (pentra dx -abx). we enumerated residual leukocytes in red cell units by flow cytometry (becton dickinson-leucocount kit). results: pre-filtration data of whole blood and end-of-process data of red cell and plasma filtered units, are summarized in table . results are given as mean and standard deviation. whole blood filtration was completed within min in all cases. red cell units were transfused after a mean of days to patients affected from transfusion dependent ( %), post-surgery ( %), and post chemotherapy anemias ( %). no cases of transfusion reaction were observed. the pall leukotrap wb system was easily introduced in our setting. all blood components prepared by the system fulfilled the council of europe requirements with regards to hemoglobin content in red cell units and post-filtration residual leukocytes. future studies are needed to evaluate its cost-effectiveness in the setting of routine blood component preparation. background: during an evaluation of the compodock (fresenius hemocare) sterile connection device (scd), we observed irregularities on the inside of the tubing at the site of the weld. it was our aim to investigate the effect of these observations on the quality of blood products. methods: three leukoreduced red cell concentrates (rccs) were pooled and divided over bag systems: one without weld in the connecting tubing, one with a compodock-weld, and one with a weld made with the terumo scd. the rcc was transferred times over this tubing to have maximum result if the weld had deleterious effects. the rccs were stored in pvc containers, and sampled on day , , and , and free hemoglobin (hb) was measured. the same procedure was also performed using platelet concentrates (pcs), but these were stored in polyolefin containers, sampled on day , and , and cd expression was measured. ten experiments were performed per blood component. according to who standards processing of blood into labile components are considered an expression of quality of transfusion service. in our practice, modern transfusion principles are successfully applied. they cover blood collection, serological processing of blood units, technological preparation of blood products (gmp, sop) and rational utilization of blood components and blood derivatives. in the past four years ( , .) aberrations from these principles have taken place (self-sufficiency). nbti collected x = ( ) blood units into blood bags. in serbia x = ( ) blood units. retrospective analysis: ldpc-bc was administered x = % with the satisfactory haemostatic effect. increase of the cyta and plasmapheresis-manual procedures was also noted ( %). increase of the use of leukocyte poor red blood cells was also registered ( % introduction: according to the relevant recommendations of the council of europe, whole blood is a source material used for the preparation of blood components and blood products. basic concept of the therapeutic use of blood components is the compensation of the lacking or deficient blood component. in that way, a possibility of the infusion of unrequired or deleterious components of whole blood is eliminated. objective of this presentation is to analyze the reasons of non-utilization of certain blood units, the actual quantity and ratio. aim of the study: the purpose of our in vitro study is to compare storage of platelet concentrates at °c with platelets stored at °c, and to determine the in vitro-effects of pre-incubation at °c for h prior to analysis on the basis of the maintenance of platelet metabolic and cellular integrity. methods: platelets concentrates (pcs) were prepared from pooled buffy coats (bc) for paired studies to be stored into different conditions. (i) at - degree on a flat bed agitator; (ii) at - degree on a flat bed agitator and pre-incubated for h prior to analysis; (iii) at °c; and (iv) at °c and pre-incubated for h prior to analysis. this paired in vitro study (n = ) over days include volume, platelet counts, mpv, volume, ph, po , pco , bicarbonate, glucose, lactate, swirling, leucocytecount, hsr, esc, atp, ldh and release of a-granule content (rantes, ß-thromboglobulin and pf ). results: platelet count (day and ; p < . ), mpv (day ; p < . ), ph (day and ; p < . ), pco (day and ; p < . ), bicarbonate (day ; p < . ), glucose (day , , , and ; p < . ), atp (day and ; p < . ) was significantly higher in platelets stored at °c and platelets stored at °c with preincubation. ldh (day ; p < . ), bicarbonate (day and ; p < . ), lactate (day , , , and ; p < . ), ph (day and ; p < . ), esc (day , , , and ; p < . ), hsr (day , and ; p < . ) was significantly lower in platelets stored at °c and platelets stored at °c with pre-incubation. the concentration of rantes, ß-thromboglobulin and pf was significantly higher in platelets stored at °c than in platelets stored at °c (day , , , and ; p < . ). hsr (day and ; p < . ) and esc (day , , and ; p < . ) was significantly higher in preincubated platelets stored at °c compared with platelets stored at °c. conclusion: platelets stored at °c maintain metabolic and cellular characteristics to a great extent during days of storage. we confirm the loss of platelet discoid shape and have shown that loss of discoid shape in platelets stored at °c is associated with decreased metabolic rate and decreased release of a-granule content. aim: as reference centre of the swiss blood transfusion service for new materials and blood products we evaluated that system for routine use and official registration in switzerland. method: whole blood donations were collected in a whole blood filtration set with cpda- and stored at room temperature for h before filtration at room temperature. the leucodepleted whole blood was stored for days. following parameters were analysed on day , , : free haemoglobin in%, k. in addition leucocyte count was performed on day and a blood culture on day (see table) . blood cultures on day remained negative and all counts of residual leucocytes were below ¥ (exponential) /unit. summary and conclusion: as expected there was a clear increase in k and free haemoglobin after day . however the results were within the required specifications from the european and swiss guidelines up to day . we conclude that autologous leucodepleted whole blood can be stored in cpda- -for days without loss of stability of the red cells. we will introduce the system to the offi-cial material list of the swiss blood transfusion service and then implement the procedure to our daily routine. results of ffp production from whole blood, and of ffp and pc produced by use of cell separator over a -month period before and after the introduction of measures for trali prevention are presented. the following measures were undertaken: ( ) blood of female donors was not used for ffp production, and plasma was only used for fractionation ( ) plasma of female donors was not used for kt-bc pools ( ) platelets and plasma were produced on a cell separator only from the female donors without a history of pregnancy. female donors of whole blood: %*; %** ffp produced by plasmapheresis: %*; . %** female donor units on cell separator: . %*; . %** ffp from total plasma units: %*; %** plasma units used for bc-pc pools: %*; %** *period before and **after the introduction of measures for trali prevention the exclusion of female donors had no major impact on the production of ffp and bc-pc pools from whole blood because of the very low rate of female subjects in the croatian blood donor population. the amount of plasma and pc collected from female donors by use of cell separator was significantly lower (~ %), however, without any major impact on total ffp store because of the small rate of plasma and platelets obtained by apheresis. background: platelet concentrates (pcs) are currently stored for a maximum of days. extended storage to days would increase the supply and reduce the waste of pcs. transfusion-associated graftversus-host-disease (ta-gvhd) is a severe transfusion reaction caused by t-lymphocytes in the transfusion product. the risk of developing ta-gvhd can be prevented by gamma irradiation of the pcs. various in vitro tests can be used to study the quality of pcs such as inspection of the swirling phenomenon, hypotonic shock response (hsr), detection of platelet surface markers (e.g. cd p and cd b), metabolic parameters and blood gases. free oscillation rheometry (for) using the instrument reorox® can be used to monitor the coagulation over time in whole blood, pcs and plasma samples, and to obtain information about clotting time and coagulum elasticity. aim of the study: the purpose of this study was to evaluate the quality of pcs obtained by apheresis technique during storage for days and to study the effect of gamma irradiation by using several in vitro methods including for. methods: platelets were collected from healthy donors (n = ) using apheresis technique. the pc from each donor was divided in units, one served as control and the other was gamma irradiated with gy. the pcs were stored on a flatbed agitator at °c for days. samples were taken on day (= day of collection) for analysis of blood gases, metabolic parameters (glucose and lactate), platelet count and swirling. samples taken on day , and were also analysed for hrs, cd p (p-selectin) and cd b (gpib) expression utilising flow cytometry. evaluation of coagulation by for was performed on day , and . the maximum elasticity (g'max) and the time to g' were evaluated from the for elasticity curves. results: there was no difference between irradiated and nonirradiated pcs regarding any of the tested parameters during the storage period. swirling, hsr, platelet count and percentage of cd b expressing cells were well maintained for days of storage. glucose decreased and lactate increased significantly during the storage period, from . mmol/l to . mmol/l for lactate and from . mmol/l to . mmol/l for glucose. the percent cd p expressing cells increased significantly during storage from % on day to % on day . po was well maintained but ph increased and pco decreased significantly between day and whereafter ph decreased and pco continued to decrease. the for parameters g'max and time to g'max increased significantly between day and and the time to g'max continued to increase significantly between day and . the results indicate a well preserved platelet quality after storage for days. gamma irradiation did not affect the platelet quality. cytokine release during storage of buffy coat platelet concentrates produced manually and automatically background: transfusion reactions following platelet transfusion are still a problem even when leukoreduction is included in the production process. platelet derived cytokines released during storage upon activation or lysis, accumulate in the platelet products and have been suggested to be involved in transfusion reactions. rantes (regulated upon activation, normal t cell expressed and presumably secreted) is a chemokine playing an important role in the inflammatory immune response and causes degranulation of eosinophiles and release of histamines from basophiles, which again can cause allergic reactions. tgf-b (transforming growth factor b ) has been shown to be immunosuppressive, inhibits the proliferation of t-and b-lymphocytes and decreases the secretion of igg and igm from b-lymphocytes. aims: as part of our quality control program, we aimed to quantify the amounts of rantes and tgf-b released during storage in platelet concentrates produced from pooled buffy coats by our manual routine method (m-pcs) and by an automated method using the orbisac system (gambro) (a-pcs). methods: pcs were produced from buffy coats. following overnight storage at - °c, buffy coats were pooled with ml t-sol (baxter). forty-two pcs were produced either manually (n = ) using the imugard iii s-pl set (terumo) with integrated soft leuko-reduction filter or by the automated procedure (n = ) using the orbisac validation bc set (gambro) equipped with the lrp leuko-reduction filter (pall). swirling was scored visually, platelet count and mpv were measured on a cell counter (cobas argos, roche), and blood gas analyses, glucose as well as lactate were measured on an abl series analyser (radiometer). samples for testing of cytokines were centrifuged for min at g, °c; supernatants were harvested and frozen at - °c until analysis. cytokines were quantified using quantikine human rantes immunoassay (r&d systems) and human tgf-b elisa immunosorbent assay (bender medsystems gmbh). all analyses were performed on days , and . results: platelet concentrate volume (mean): m-pcs: ml, a-pcs: ml. platelet yield was found to be . ¥ for m-pcs and . ¥ for a-pcs (p < . ). in all pcs ph levels were between . - . . glucose consumption and lactate production from days - and days - did not differ significantly. rantes levels (pg pr plts) were significantly higher in a-pcs than in m-pcs (p = . , repeated measures analysis of variance), but no significant difference was found in tgf-b levels (pg pr plts). summary and conclusions: preparation of buffy coat platelet concentrates by the automated orbisac system improves platelet yield compared to our manual processing procedure, but the levels of the chemokine rantes were significantly highest in the automatically produced products. the clinical importance of these findings is still unclear, but may be related to the shear stress the platelets are subjected to during the automated production process. the quality of cryopreserved vs liquid stored platelets: a comparative study table . the mismatches can be divided into the two categories. the first of them is characterized by differences in allelic groups, i.e. at low-resolution level. allelic group differences were detected in the group with one mismatch, most of them in hla-c locus (this locus was not concluded in primary donor search). in the other category there are differences in alleles within the same group, i.e. at high-resolution level only. differences within the same group in all tested loci were detected in the group with one mismatch. the mismatches described above were heterogeneous and a correlation of specific mismatch with transplantation outcome was not possible in this group. conclusion: the use of high-resolution dna methods makes the identification of hla match/mismatch more accurate and can affect the outcome of unrelated hsct. this work was supported by the grant iga mz, no. nr/ - . pre-freezing and post-thawing quality controls in umbilical cord blood assigned for transplantation p bergamaschi, c perotti, g viarengo, c del fante, c parisi, a marchesi, l bellotti and l salvaneschi irccs policlinico 'san matteo', pavia, italy background and aims: nowadays umbilical cord blood (ucb) represents a well established source of haematopoietic stem cells for unrelated transplantation in children affected with haematological and inherited diseases. thanks to the large-scale banking of unrelated units and the preliminary encouraging results, ucb employ in adults is quickly growing up. in this context, total nucleated cells (tnc) count of the graft is considered the main predictor for clinical outcome; however, other indicators of the haematopoietic potential, such as cd + cell content and short-term culture clonogenic assay, are recommended in accordance to netcord-fact stan-dards. in order to guarantee the safety and the prompt availability of a ucb unit assigned to a matched recipient, a pattern of rigorous quality controls should be carried out not only at the time of cryopreservation but also before the release for transplant. we report the results of the quality controls performed on thawed cryovials referring to the units delivered by our ucb bank compared to the pre-freezing values. methods: every ucb unit stored in our bank is accompanied by satellite cryovials available for subsequent controls. for each unit issued for transplantation, one cryotube was thawed in °c water bath with gentle agitation without washing out dmso. tnc and mononucleated cells (mnc) were estimated by an automated cell counter; viability and cd + cell count were evaluated by flow cytometry with a no-wash, single-platform technique and aminoactinomycin d. cfu assay was performed using commercial reagents (methocult gf h , stemcell technologies) and colonies were counted after days. the same tests were performed before cryopreservation, taking a sample from each fresh unit. moreover, before the delivery for transplant, a second cryotube was thawed to investigate the bacterial contamination by direct microbial culture, whereas the sterility test before freezing was performed by inoculum into ml media (bact/alert®fa/fn, biomérieux inc). results: the ucb characteristics before freezing and after thawing are detailed in the tables , and . post-thawing tnc and mnc, as well as cd + cells, showed no significant difference in comparison to the pre-freezing values. despite of the expected decrease of the overall viability after thawing, we observed a highly satisfactory viability referred to the cd + cells. the colony forming units (cfu) growth after thawing was documented and was always lower as respect to the pre-freezing assay. finally, the results of microbial cultures were negative for all the units on both fresh and thawed specimens. conclusions: in our experience, well standardized evaluation of ucb content could be obtained with regard to tnc, mnc and cd + cell. concerning the results of short-term cultures, the presence of dmso as inhibiting factor may be advocated to explain the discrepancies between fresh and thawed samples. finally, rigorous quality controls documented that the procedures of manipulation and cryopreservation did not affect the quality of ucb to be infused for transplant and provided to the physician all the parameters necessary for a safe transplant in a close and appropriate time. bone marrow transplantation or bmt transplantation of progenitor blood cells to regenerate blood normal cells in patients with blood disorders. bone marrow has an organized and structured architecture in which close relationships exist between a regulatory microenvironment and primitive hematopoietic cells. in fact, normal hematopoietic cells depends on critical interactions that occur between stem cells and their microenvironment. this microenvironment is a complex meshwork composed of growth factors, stromal cells, and extracellular matrix. marrow injury can occur as a consequence of a variety of diseases. some diseases could be due to a microenvironment that fails to support hematopoiesis. a possibility is that aplasia and leukemia share a common etiology such as drug, chemical, radiation, virus or other environmental hazards. we can say that microenvironmental abnormalities in interactions between stromal cells and hematopoietic progenitors may be important in the pathogenesis and clinical expression of hematopoietic malignancies in humans. background: intrauterine growth retardation, with associated low birth weight, represents one of the most important cause of baby mortality and morbidity. understanding the genetic bases of this adverse event is still an open goal. there is evidence that motherchild hla compatibility and hla-drb foetal genotype are associated with a reduced placental growth and a low birth weight. the recent institution of cord blood banks, with their huge amount of hla types, offers an unique opportunity to look inside the molecular bases of normal birth weight. aims: we investigated whether the baby-linked immunogenetic profile, i.e. hla gene frequencies and homozygosity rate, affects the physiological variance of the size at birth. methods: cord blood units ( from males and from females) were hla typed with pcr-ssp and/or reverse pcr-sso techniques and recorded in the cord blood bank database of pavia-italy. all were defined at low resolution level for hla-a and b genes and at high resolution for hla-drb . blood units were also randomly typed for hla-dqa and dqb at high resolution. results: mean birth weight was g and mean relative birth weight (i.e. corrected for gestational age according to the gender) was . g. babies were < th centile ( g) and were > th centile ( g). comparing the hla allele distribution in these extreme bands we found that hla drb * was significantly associated with high relative birth weight: . % in th centile vs . % in th centile, p = . . on the contrary, hla-drb * and dqb * were associated with low relative birth weight: . % and . % respectively in th centile vs . % and . % in th centile p = . and p = . . all infants were analysed as to the effect of the above mentioned alleles. we confirmed the positive association of hla-drb * and higher relative birth weight (mean . vs . ; p = . ) as well as the association of hla-drb * with lower relative birth weight (mean . vs . , p = . ). no significant association was found as far as hla homozygosity was concerned. conclusions: the present findings confirm the role of foetal hla-drb gene in the intrauterine growth. about the specific involved alleles, one possible explanation comes from the studies of crystallography and amino acid sequencing of hla-dr binding groove. it has been demonstrated that hla-drb * and hla-drb * genes encode for different amino acid sequences in the pocket of the molecule (aa , , ). this implies distinct functional restriction patterns. the sequence motif of hla-dr is characteristic of some autoimmune conditions, such as hashimoto's thyroiditis, and preeclampsia which is associated with intrauterine growth retarda- which provides a high yield and excellent purity without lymphocyte and erythrocyte contamination. in a month period, we studied blood samples from bone marrow transplant patients and from normal subjects. the extraction of leukocyte polymorphonuclear was obtained with a %- % dextran solution in . % saline. after incubation at room temperature with lymphopre solution, the mixture was centrifuged. two clear and separate rings of mononuclear and pmn leukocytes were obtained. to eliminate any red blood cells, pmnl ring was separated and washed three times with cold ammonium chloride. after a short period of incubation °c, mixture was centrifuged and the pmnls were isolated. the purity and viability of total leukocyte population was counted and the percentage of pmnl obtained was established. the total blood samples studied were divided in two groups, i.e., bone marrow transplant patients and normal subjects. in both cases the pmns isolated were of high purity and viability. the overall percentage of pmnls obtained from both groups under study was % to % when stained with gimsa or wright staining method. the viability of isolated pmnls was also % too, which is excellent for numerous immunological or molecular studies. the pmnls isolated by this method were highly pure and viable in comparison with standard methods used to isolate human pmnls. generation a high amount of pmnls is another advantage of the suggested method. this method to separate pmnls is recommended for in vitro studies of different subjects. et al. .) the object of exchange transfusion (et) is to remove bilirubin already present in the plasma or remove alloantibody which can cause hemolytic disease (in order anti-d, anti-c and anti-k are easily the most important) or remove anti-d positive red cells. we have studied exchange transfusion in our hospital in neonatal intensive care unit, during to . at delivery cord samples were taken for determination blood group, rhesus, hb and ht have been counted. also direct antiglobulin test (dat) has been performed. in cases of positive dat, hb and bilirubin levels were monitored. newborn body-weight were weighted (ranged g to g). the blood for et was of group o, d negative and kell negative and was compatible with the serum of mothers; it was less than days old. the blood was screened for hbs and for anti-cmv as well as being submitted to all usual tests. the method has been determined by using the umbilical vein; the multi-way tap makes it possible to draw blood from the infant into the syringe, to discard the blood into a sterile empty vessel, then to draw blood from a donor unit into the syringe and inject this into the infant. results: exchange transfusions were carried out. four out of et due to abo incompatibility mother-newborn. five out of due to rhesus incompatibility mother-newborn and eight out of due to jaundice undetermined origin and immaturity. the last two years only three et were carried out due to immaturity. conclusions: phototherapy, when applied early enough and with sufficient intensity, can avoid the need for exchange transfusion in many infants. phototherapy alone or phototherapy plus high dose igg therapy has been used to minimize exchange transfusions in this population. detection abo blood group system antibodies of neonatal using fully automated column agglutination technology (auto-vue) background: the abo blood group system remains the most important in transfusion practice. this is because of the regular occurrence of the antibodies anti-a, anti-b and anti-a, b reactive at °c, in persons whose red cells lack the corresponding antigens. the regular presence of anti-a and anti-b is used in the routine determination of abo blood groups; in addition to testing red cells for a and b antigens, the group is checked, in serum or reverse grouping, by testing the serum against red cells of known abo groups. methods: samples were taken from newborns at first h of life for abo blood group typing during - . simultaneously the presence of anti-a and anti-b antibodies has been studied using fully automated column agglutination technology (auto vue ortho diagnostic systems) with bio-vue cassettes aborh/reverse. the column agglutination technology is based upon the ability of glass beads to form a physical barrier between agglutinated and unagglutinated red cells. to determine the abo serum group, test serum and abo reagent red cells were added to the top of column containing diluents. the abo grouping columns were centrifuged and examined for agglutination. the presence or absence of agglutination has been recorded. results: in out of newborns were found detected antibodies anti-a, anti-b. in out of newborns no antibodies were found. in out of were found antibodies maternal origin. the automated reader detected all positive reactions. positive results were recorded on a scale from + . to + . conclusions: the technical performance of device allows objectivity and precision to detect abo blood group antibodies of newborn. the origin and the type of antibodies and also factors that influence their presence are to be studied. introduction: diagnosis, management and prevention of red blood cell immunization have improved, so hemolytic disease of the newborn (hdn) has changed from a common to a rare pathology. aim of the study. in this study we have retrospectively evaluated the benefits of the immunohematological screening for the management of pregnancies with alloimmunization. methods: in the last years, we have performed an immunohematological screening on all pregnant women assisted by our hospitals. ab and rh typing, antibody screening and, eventually, identification and titration were performed on maternal specimens by microcolumn technique. results: not considering ab incompatibilities, we have discovered alloimmunized women with the following specificities: anti-d, anti-c, anti-c, anti-e, anti-jka, anti-d + anti-jka, anti-d + anti-s, anti-d + anti-c, anti-d + anti-c + anti-k, anti-s, anti-k, anti-m, anti-c + anti-e and anti-d + anti-c + anti-g. the most severe hdn were the d + c + g, the c + e and out of c newborns, with mean hemoglobin between and g/l, bilirubin = . g/l, reticulocyte count = %. in these exchange transfusion needed at the delivery. other newborns were only treated with phototherapy. conclusion. thanks to the immunohematological monitoring, the diagnosis of alloimmunization, the correct management of pregnancy and the adequate neonatal therapy were possible. in fact all newborns survived and showed no neurological lesions in the following controls. conclusion: in order to provide a highly specialized perinatal care, immunohematologist, obstetric and pediatric should provide a good antenatal and perinatal screening. this is an interesting case of rhd immunisation in rhd negative woman despite the application of rhd immunoprophylaxis. case report: a blood sample of pregnant woman, years of age, in th gestation week, was sent to our laboratory for serological analysis. her blood group was o, ccddee and she had an anti-d antibody reactive only with enzyme treated panel of test erythrocytes. her husband was a, ccdee, and two children were both a, ccddee. on the next visit, she gave the data of one arteficial and one missed abortion before the th gestation week covered with mg of rhd immunoprophylaxis, but without the measurement of fetomaternal haemorrhage (fmh). both of abortions were after the deliveries. until the end of the pregnancy, detailed serological analysis showed anti-d specificity of antibody in her sera which remained reactive only with enzyme treated red blood cells. the fetus was under permanent ultrasound control. she delivered a mature, rhd positive, ccdee male child, without any sign of haemolytic disease. the proper personal history, measurement of the size of fmh, distinguishing the anti-d and anti-g specificity of the antibody, administration of rhd immunoprophylaxis and cooperation between transfusion medicine specialists, gyneacologists and neonatologists still remain major principles of prenatal and perinatal care concerning haemolytic deisease of the fetus and newborn caused by anti-d antibody. anti d antibody, reactive only with enzyme treated red blood cells is usually harmless for fetus and the newborn. introduction: red blood cell (rbc) transfusion is widely used in neonatal intensive care units for acute or chronic pathological conditions. clinical indications for rbc transfusion are shock, sepsis and/or anemia with the following laboratory criteria: a) hematocrit (hct) < % or hemoglobin (hb) < g/dl and reticulocytes < %; b) hct < % or hb < g/dl in these conditions: o required < %, recurrent apnoea and bradicardia, cardiac rate > bpm and respiratory rate > bpm for more h; c) hct < % or hb < g/dl with severe respiratory distress. aim of the study. aim of this study has been to evaluate the effectiveness of rbc transfusion therapy in premature and at term newborns independently of initial pathological conditions. methods: our therapeutic objective has been to achieve an hct of % after the whole cycle of transfusion therapy. for each little patient, the volume of transfused rbc unit has been calculated, according to international guide lines, using the following criteria: weight (kg) ¥ blood volume ( ml per kg if premature or ml per kg if at term newborn) ¥ (hct desired -hct observed)/hct of unit transfused. particularly we have considered that premature infants (with a gestation age of - weeks) show a range of weight from to . g, while at term newborns from . to . g. in order to avoid a circulatory overload, the indicated hemocomponent has been always packed rbc with higher possible hematocrit. for the same reason, the rate of infusion has been always - ml/kg/hour. methods: this is a descriptive study. the name of the neonates who received transfusion was obtained from the blood bank of beheshti hospital. information concerning the type of blood product, frequency and indication of transfusion, sex, gestational age and weight of infants was recorded in questionnaire and analyzed. results: out of neonates admitted during one year, ( male, female) received blood components. fifty four percent received one, % two and % received three types of blood components. the frequency of transfusions were times. the most common used blood products were fresh frozen plasma ( %), red blood cell ( %), whole blood ( %) and platelets ( %). all the blood products except whole blood were used more common in premature and low birth weight infants. appropriateness of transfusion of red cells, fresh frozen plasma, platelets and whole blood were %, %, % and % respectively. (hdn) . in accordance to current regulations, this study is carried out in all pregnant women attending in our service. according to our protocol, when an alloantibody of any specificity is detected through the liss-coombs gel technique, the same determination is made using papain-treated screen cells to detect any association with other antibodies which could be of clinical relevance for a hdn. there are scientific evidences that the use of enzymatic techniques increase the test's sensitivity, though clinical relevance of 'enzyme only antibodies' may be questioned. aims: demonstrate the importance of a routine identification of irregular antibodies in pregnant by two methods (liss-coombs -enzymatic) and the prevalence of anti-d associated antibodies, only detected by using enzymatic technique. analyze the need to carry out a follow up of sensitized patients to determine if the associated antibodies only detected with in an enzymatic medium can be detected with a liss-coombs medium during pregnancy, thus acquiring clinical significance for hdn. materials and methods: between january and december we studied d-negative pregnant women. the studies performed were: abo grouping, d and weak d, rh phenotype, direct antiglobulin test and irregular antibody detection (iad) against commercial screen cells with liss-coombs (diamed) ® gel-medium technique, according to the manufacturer's specifications. when iad were positive, an antibody identification using two commercial cell panels with gel techniques (liss-coombs-enzymatic) was performed. along the pregnancy, periodic controls were carried out to determine the exact moment when antibodies, previously only identified in an enzymatic medium, could be detected in a liss-coombs medium (clinically significant antibodies). results: out of d-negative studied samples, ( . %) had a positive dai and it was only showed anti-d specificity in a liss-coombs medium. after analyzing this specificity against enzymetreated erythrocytes, it was possible to determine that patients ( . %) had in their serum other anti-d associated alloantibodies: anti-k ( . %), anti-c ( . %), anti-e ( . %) and anti-c + e ( . %). during the immunohematologic follow up, it was determined that in / patients some of the antibodies which were previously only detected in an enzymatic medium, could be identified in a liss-coombs medium and later they were identified in the red cell elution of the newborn. conclusions: these results confirm the relevance of a screening for irregular antibodies of clinical importance by means of a conven-tional technique and one of increased sensitivity in all pregnant women. the detection of an association of antibodies provides information for the undertaking of diagnostic and therapeutic measures, both by the obstetrician, as for any eventual transfusional requirements for hdn. it was also concluded that, although antibodies detected in an enzymatic medium are considered of low clinical significance, its investigation and follow up is suggested in pregnant women to determine the moment in which they can be detected in an antiglobulinic medium, thus revealing their clinical significance. background: fibrin glue is one of the most complex human plasma derivatives both in terms of composition and clinical applications. this product mimics the last step of coagulation cascade through activation of fibrinogen by thrombin, leading to the formation of a fibrin clot in the presence of factor xiii. in contrast to synthetic adhesives, the significant advantage of this plasma-derived sealant is its biocompatibility and biodegradability as well as the fact that it does not induce inflammation, foreign body reaction or extensive fibrosis. readsorption of the fibrin clot is achieved during wound healing within days/weeks following application, depending upon the type of surgery, the amount and type of product used or the proteolytic activity of the treated site. the risk of virus transmission by commercial fibrin glue products is still debated and investigators are looking for alternative fibrinogen sources. many of these studies rely on autologous on single donor cryoprecipitate as source of fibrinogen. aims: the aim of this study was to compare single and double methods of cryoprecipitation of fibrin glue. the influence of different plasma preparation methods and plasma storage temperatures (- °c and - °c) on the quality of fibrinogen concentrate was examined. methods: whole blood was collected by standard phlebotomy technique and centrifuged at ¥ g for min within h of collection. plasma was removed. four units of plasma were pooled into a ml bag, mixed, divided into parts (aprox. . ml) and immediately frozen. two of these units were stored at - °c and units of ffp at - °c. after one month the plasma was thawed at °c during - h. the fibrinogen concentrates ( - ml) were received by single and double cryoprecypitation. to compare single and double methods of cryoprecipitation, the levels of fibrinogen, fibronectin, plasminogen and factor xiii were determined. results and conclusion: the levels of fibrynogen were significantly higher in fibrynogen concentration obtained by double cryoprecypitation from plasma stored at - °c. there were no significant differences in the level of plasminogen in both tested groups. double cryoprecipitation of a single unit of plasma (stored - °c) is an efficient, simple and safe method of obtaining fibrin glue. background: talking about professional risk we generally consider the risk of acquiring some kind of infective disease through accidental injury. in this article i would like to point out another side of the problem-the risk of making preventable medical error. with all its consequences. aim: how blood transfusion errors are among the most serious types of medical errors, the final goal is to initiate nationwide, regular, mandatory error reporting. information obtained, distributed and openly discussed at professional meetings will contribute to improving the patient safety. at the same time it would contribute to avoidance of blaming and shaming of many health care providers. prevent what preventable could be! method: retrospective analyze was conducted at the middle size blood transfusion center ( donations per year and utilization of approximately of components). results: after clearly distinguishing adverse events due to underlying patient condition from preventable medical error we fined out that: -great majority of adverse events resulted from medical error -every part of blood transfusion center, from blood donation ward, through laboratory testing to component issuing has it' weak points' or vulnerable places -any educational level is equally liable to error there is no significant difference about occurrence time: -working day/holiday -emergency/routine request -routine h/out of routine h -main error cause were as follows: -donor sample misidentification -rhd typing error -abo typing error -incorrectly performed cross match -recipient misidentification -wrong component prepared -sample confusion during freezing preparation conclusion: the truth incidence of transfusion medical errors is underestimated. mandatory report of fatal or 'only' harmful errors to the referent institution and its periodical announcement is the step ahead in preventing errors. those reports should be discussed at professional meetings (not at the 'yellow pages') and served as educational tool. but, as the most of the errors are system related, the key to reduce them is to focus on improvement of the system and nil for plasma. wastage rate was highest for plasma components. the influence of local practices on such discarding and whether avoidable shall be discussed. audit for blood discarding and corrective actions to minimize discarding is essential for all transfusion services and blood centers. designed technical and economic support. options include importing finished products and/or procuring products made from locally collected plasma. one approach is to consider local fractionation of plasma by building and operating a plasma fractionation facility, which may produce, finished products, or may produce intermediate products that are further manufactured in another facility. an alternative approach is the implementation of a plasma fractionation program where local plasma is sent to an established fractionator, and the plasma is fractionated following preagreed terms. the end products are returned to the country of the plasma supplier. in the national center for the production of blood products was established, under the direction of elias politis and years later in begun the production of dried plasma from greek donors. by the year the center started the production of fibrinogen and by the year the production of antihaemophilc factor. in all the activities of the center settled down due to administrative aspects. at the beginning of s a contract fractionation program was instituted (under the direction of k. sofroniadou) concerning the fractionation of liquid plasma and production of albumin, which by the end of year stopped and was replaced with a new contract for the fractionation of source plasma and the production of albumin. the challenge of adapting to the new and more stringent regulations governing the manufacture of blood products was great and brought a lot of changes in the structure of our center. a new bar-coding system ensuring the traceability of blood donations was instituted together with complex software for packaging and preparation of plasma shipments to the fractionation center together with all necessary paper work. a close collaboration with the medicines regulatory authority in order to be able to fulfill all the requirements that regulate issues associated to the quality and safety of human derived medicinal products. collaboration with blood collection establishments was promoted in order to increase the amount of plasma produced. there is a continuous effort from all the implicated parts in order to follow defined quality assurance procedures as highlighted by international guidelines for the blood donor selection, collection procedures, testing methods, donation handling, storage and transportation of plasma. the plasma contract fractionation program may serve, as an initial step prior to switching production to a locally built facility. this lapse of time may be used to expand the plasma collection potential, and to permit appropriate design, qualification and validation of the facility as well as training of local personnel. background: fibrin glue became a reality in the early s, when techniques for the isolation and concentration of clotting factors were improved. in , matras et al. described successful application of fibrin glue for peripheral nerve repair. this encouraging report prompted the use of fibrin glue in wound closure, skin grafting and bone union of osteotomies. the fibrinogen component of fibrin glue is produced from single unit donations of fresh frozen plasma. such procedure helps to reduce the risk of transfusion transmitted infections encountered by exposure to pools from large numbers of donors or by use of fibrinogen prepared from autologous blood prior to surgery. the second component, a mixture of thrombin and cacl , is commercially available. thrombin is applied to the operation site simultaneously and in equal volume to the fibrinogen but from a separate syringe. there are many methods of fibrinogen concentrate preparation but none of them has been described in detail. aims: the aim of this study was to choose/select the most effective, simple and safe method of obtaining fibrinogen concentrate (basic component of fibrinogen glue) which would also be easy to prepare in blood transfusion centers. methods of precipitation of fibrinogen by polyethylene glycol (peg), ammonium sulphate, ethanol or cryoprecipitation were compared. methods: plasma was obtained after centrifugation ( ¥ g for min) of whole blood. four units of plasma were pooled into a ml bag, mixed, divided into parts and immediately frozen. one of them was stored at - °c and after one month the plasma was thawed at °c during - h. fibrinogen was obtained by cryprecipitation and each of the three remaining units was precipitated with ethanol, peg and ammonium sulphate. the levels of fibrinogen, fibronectin, plasminogen and factor xiii were determined in each fibrinogen concentrate. results and conclusion: the level of fibrynogen ratio in fibrinogen concentration, obtained by peg and ammonium sulphate was significantly higher. cryoprecipitation is a simple, economic and reproducible procedure with the advantage of being performed in a closed system. plasma fractionation program in greece: an unknown history the provision of safe and sufficient plasma derivatives to meet the needs of local population requires special consideration and a well- (light cycler, roche diagnostic systems, nj) was used for the identification of the c y, h d and the s c point mutations of the hemochromatosis gene, and were based on protocols developed, for c y by the unidad de medicina molecular (ingo, santiago de compostela, espanha), and for the other two mutations by bolhalder m et al. the primers and probes were designed by tib molbiol (berlin, germany). results: the analysis of the percentages of genotypes and allele frequencies of the hemochromatosis gene mutations are described in the table. no differences were found between the patients and the controls. when we compared subgroups of patients based on their hepatitis c genotypes, a higher value for the c y allele was obtained ( . %) in individuals with genotype , however without statistical significance. discussion: hereditary hemochromatosis is a common disorder and is associated, in some studies, with a worst prognosis in patients with viral hepatitis. follow-up studies are necessary in order to evaluate if the presence of these mutations can cause a more severe course of the illness (greater risk to develop fibrosis or cirrhosis) and a different outcome when treated with antiviral drugs. also, it will be important to evaluate if aggressive phlebotomies will modify their clinical evolution. introduction: portugal has a higher prevalence of viral hepatitis, with probably more than . patients chronic infected with hepatitis b and/or c. hereditary hemochromatosis (hfe) is one of the most common causes of known hereditary illnesses with hepatic repercussion. hfe mutations are also found in linkage desiquilibrium with particular hla haplotypes, conferring, eventually, a different response to viral agents and antiviral drugs. in this study we evaluated the prevalence of the main mutations c y, h d and s c for the hfe in a population with chronic hepatitis b and/or c and in a cohort control. background: haemolytic disease of the newborn (hdn) is the destruction of the red blood cells of the fetus and neonate by antibodies produced by the mother. although postpartum rhig prophylaxis reduced the incidence of alloimmunization from pregnancy from % to - %, the doubt subsists if it is appropriate to use it as routine antenatal prophylaxis. material and methods: a total of samples ( mothers and newborns), from / / and / / , were studied. all abo, rh typing, antibody tests and dat were carried out in column agglutination tests. results: from the cases studied it was found cases without incompatibility ( %). from the incompatibilities, . % were abo, . % were rhd, . % were other rh incompatibilities, and . % were due to auto-antibodies. % of the mothers were rhd+ and % rhd-. conclusion: of the pregnant women studied, only were rhd-. from this group ( %) delivered rhd-newborns, what revealed that the antenatal prophylaxis they were submitted was unnecessary. from the pregnant women rhd-, % had incompatibility abo, which decreases to near % the risk of development of rhd immunization. being anti-d immunoglobulin a product that has the potential risk of infection transmission, is it appropriate to use indiscriminately as a routine antenatal prophylaxis? the introduction of molecular methods to determine the fetal rhd genotype could rationalize the use of antenatal anti-d immunoglobulin prophylaxis. introduction: the frequency of hla a haplotype expression has been found about - % in caucasian and in greek population particularly, . %. because of the high frequency, it is used widely in anticancer immunization. the immune system plays an important role in the defense against neoplastic disease and immune response show temporal chances related to circadian variation of antibodies and total lymphocytes in the peripheral blood. aim: the probable difference in the frequency of hla a expression and their lymphocyte phenotype into a group of cancer patients and a group of healthy donors, during screening of immunization with hla-combined peptides. materials and methods: healthy donors who proceeded in the department of transfusion medicine, university hospital of heraklion crete were tested for the hla a expression. in of these donors the expression of cd , cd , cd , cd , cd , cd , hla dr, cd +cd +, cd +cd +, cd -cd +, cd +cd -cd +, cd -cd -cd +, cd -cd -cd + was examined. meanwhile, patients with metastatic cancer who were hospitalized in the department of medical oncology, university hospital of heraklion crete, were tested for their hla a expression, while in of them for their lymphocyte phenotype. the antigens expression was examined in flow cytometry. the hla a expression in healthy donors was . % and in cancer patients % (p > . ). in table the mean, standard error, t-test and p of the two groups are included. (see table ). the two groups (healthy donors and cancer patients) revealed no statistical significant difference on lymphocyte phenotype, except of the cd expression, which was higher in cancer patients. summary and conclusion: the expression of hla a in cancer patients and in healthy donors was comparable. also, the lymphocyte phenotype among the two groups has not statistical significant difference, except of the cd (total b-cells). the significance of this result has to be investigated. in the course of original documents research i found out that dr. kalic, head of the first organized blood transfusion institution in the balkan region (at beograd, serbia, in ), set himself a professional goal: blood should be awaiting all patients and transfusion should not be a privilege of large city inhabitants only. dr. kalic's idea was that blood transfusion should be administered according to clearly given instructions and using simple blood sets. encouraged by the conclusions of the congress held in paris in , dr. kalic started preparations for the transport of blood to the inland. he concluded bravely that citrated blood could be sent by regular mail, as an ordinary parcel, without particular protection from the outside temperature. he advised his colleagues to use blood as an intravenous injection. blood was taken from voluntary female donor in belgrade (capital), march . after keeping it for days at storage, blood was forwarded on a two-day journey to a small town, kilometres away from belgrade. there it was kept on a room temperature before its final use for a treatment of a patient suffering from secondary anaemia. the patient underwent the procedure without side effects and responded to the transfusion with blood sent in this manner much better in comparison to earlier methods of direct blood transfused. reminding ourselves of the courage of our ancestors to implement their professional knowledge and personal original ideas in a new way with the desire to help the patient as successfully as possible, we pay them the deserved respect and gratitude for inspiring and encouraging us in this way to try the same. conclusions: automation leads to increased standardization, faster specimen processing and reporting, elimination of manual specimen identification, uniform interpretation of serological reaction patterns and objective reading of haemagglutination endpoints. using auto-vue allowed the staff uninterrupted time to perform quality assurance duties, extended antibody identifications, preventative maintenance, inventory control. the instrument allowed us to leverage current staff to a more productive, less stressful level. introduction: exosomes are - nm secreted vesicles produced by antigen-presenting cells (apcs). the finding that exosomes from dc pulsed with tumor-derived peptides elicited potent antitumor tcell responses and tumor regression in mice has led to the proposal that human exosomes could be effective vectors for antigen delivery in the context of cancer immunotherapy. aim of the study: to establish the method of producing a new kind of tumor vaccine -exosomes secreted by dc, pulsed with tumor peptides. methods: exosomes used in this study were generated from monocyte-derived dc pulsed with peptides from k tumor cell lines. exosomes were purified by the methods of ultrafiltration and ultracentrifugation. the methods of dynal magnetic beads, flow cytometry and western-blotting were used to determine the surface molecules of the exosomes. the function of the exosomes was deter- objective: to develop an immunoheatological technique for the study of erythrocyte hyaluronic acid sodium salt (cd ) receptor expression in red blood cells (rbcs) from adults and newborns. materials and methods: samples of anticoagulated blood from adults (n = ) and umbilical cordon (n = ) were used. several dilutions oh hailuronic acid sodium salt solution % (sigma l- h ) were confronted with % erythrocyte suspension in phosphate saline buffer (pbs) ph . . the rbcs were previously treated with an enzymatic solution of % bromeline in pbs ph . (sigma l h ). agglutination readings' were been by slow sharking after of h incubation at °c. the results were expressed through the sensibility parameter which involves titer and score. this is defined by a mathematical expression a = à si. di- . - (i = , , . . .) where si represent the score and di- is dilution inverse. the adult' rbcs showed a = ± , while en the newborn the parameter was a = ± . our results showed significant differences between both groups. conclusions: in this work, we present a simple immunohematological technique for the hyaluronic acid sodium salt (cd ) receptor expression in red blood cells, which could be a useful tool to evaluate the alterations of the receptor's expression in rbc. a new technology for crossmatching tests adapted to a fully automated system l gaillard, v desvigne, a boulet, l fauconnier and jm pelosin diagast, loos, france we have developed a new automated technology for crossmatching (compatibility) test suitable for automation and high throughput. the method does not require centrifugation steps thanks to the use of magnetised red blood cells (rbc). all the steps described are performed on the fully automated qwalys system. this methodology requires washing steps under magnetic field and is based on the fixation of sensitised rbc on the surface of a well coated with monoclonal anti-human globulins. in a first step, the red blood cells from target blood bags were magnetised during min. then the patient plasma is distributed on a microplate and incubated with the previously magnetised rbc during min at °c. excess of unbound immunoglobulins is removed by washing steps. in a third step, sensitised magnetised rbc were transferred in the antiglobulins coated plate and placed min on a magnet plate. wells in which antigen-antibody interactions have occurred display a confluent layer of rbc (positive reaction). the negative reaction appeared as a pellet in the middle of the well. the test can be read by an automatic reader or by naked eye. the patterns in the well are stable for at least h at room temperature. the plasma samples are provided by the laboratory of haematology of the chru of lille. the red blood cells are collected from segment of tubing of blood bags coming from the laboratory of blood donors of the efs (french blood services) nord de france-lille. the results are obtained in min. comparative studies showed that our new technology, without any centrifugation steps, is reliable and sufficiently sensitive and specific enough to perform cross matching tests using a high throughput automated system. the mechanisms of p -dependent apoptosis involve a set of genes that possess the ability to modulate oxidative stress. one of them pig , is induced by p through a microsatellite in its promoter region. this microsatellite has been proposed to represent an evolutionary adaptation of tumor suppressor mechanisms. microsatellite instability and genetic constitution, comprising the presence of the low repetition allele ( tgycc repeats), at this locus have been hypothesized to provide an increased risk for cancer development. aim: in the present analysis we examined this polymorphism in blood samples from voluntary health donors and compared it with human lung cancer samples, employing two different ethnic groups, greek and british. results: analysis of this locus in both types of samples showed: (i) the homozygous presence of the repeats allele only in the samples from healthy blood donors; (ii) a very low frequency of microsatellite instability (< %) and no loss of heterozygosity in matched normal-tumor tissues; and (iii) a non-significant increase of the most frequent allele ( repeats) in the cancer groups as compared to samples from healthy blood donors. the last two observations were found in both greek and british populations. conclusion: taken together, these data do not support the notion that this pig polymorphism is associated with an increased risk for cancer susceptibility. background: blood group determinations are routinely performed by the sensitive technique 'gel test' for the last few years. many weak d and partial d phenotypes which react as d negative or weak d by slide test, are assigned the rh d + status by gel test. this is most desirable in the case of blood donors but creates concern in case of patients and antenatal women with a partial d phenotype. case report: we report a female patient (blood group o, c+, c+, e-, e+) whose red blood cells gave a positive reaction of different strength and speed with different anti-d antibodies in slide tests. we were asked to type the patient and provide the appropriate blood units. the patient's cells gave a +/ + reaction in the standard screening procedure for the rh d in gel test micro-typing system that contains a polyclonal reagent of human origin (which allows a direct detection of most weak ds), a + reaction in a test with monoclonal anti-d and a +/ + reaction in the gel test micro-typing system destined to detect du and which contains polyclonal anti-d of human origin. however, since the slide test gave a rather slow onset of agglutination with one commercial reagent (made up of a blend of polyclonal and monoclonal anti-d) we tested the patient's red cells against anti-d reagents in the id-partial d typing system. one of these (number ) gave negative reactions and the remaining five gave positive reactions (ranging from +/ + to +), indicative of a partial d category vii phenotype. the patient's red cells were also tested in the id-card 'diaclon abo/d' . this card provides the complete profile for abo/rh d in one single procedure step, including the confirmation of rh d. it contains two different anti-d reagents within the gel matrix in two consecutive microtubes. the first anti-d (polyclonal human) is expected to give a positive result with d+ red cells and partial d category vi, while the second (monoclonal rabbit) is expected to give a negative result with dvi+ red cells. our patient's cells gave a negative reaction with the first and a +/ + reaction with the second anti-d in this system, indicating a d variant other than dvi. finally the patient was assigned the partial d category vii phenotype (according to the pattern of the reactions obtained with the id-partial d typing set) and rhesus d negative blood units were issued. this case illustrates the diversity of reagents used for rhesus typing in different laboratories. failure to disclose some d variants is a disadvantage when typing patients. a combination of techniques is often needed to reveal the real rh d phenotype. the only single system that could have revealed a d variant in our patient from the beginning, is the id-card 'diaclon abo/d' with two different anti-d reagents in two consecutive microtubes as described above. a cost-benefit analysis should be undertaken to show whether it should replace other screening tests for abo and rh d when typing patients. who cares about the quality of life of the chronic patients treated with blood products? d ilcenco*, e hanganu-turtureanu † , c burcoveanu † , c vartolomei ‡ and d azoicai § *blood transfusion center, † hospital 'sfantul spiridon', ‡ institute of hygiene, § university of medicine, iasi, romania quality of life is one of the methods used to appreciate the quality of the health system. romania is going to join soon the european union, so there must be a concern regarding the improvement of the national health system. blood receiver's life quality never been researched before in romania. we have been chosen a batch of chronic ill patients who have been received blood transfusion with blood or blood components, and asked them to complete two types of questionnaires regarding their life. we used nottingham health profile and beck's depresion index. results shows that this kind of patients need special care, because they all (with one single exception) feel frustrated and feel like a burden to the other normal persons. evolution of the pain index, mobility index, energy index, emotions index, sleep index and social isolation index was in concordance with the depression index. in conclusion, this type of patients needs special attention and medical authorities should make more efforts to assure their life quality support. transfusion medicine practice in surgically treated urology patients: our experience il ilincic*, bm bozovic* and ts tadic † *clinical center dr dragisa misovic, † natio. blood transfusion inst., belgrade, serbia objective: multiple studies demonstrate that the use of blood/blood products in patients undergoing elective urology surgeries, as well as the actual needs assessment, present the issue of numerous debates. method: using the retrospective method, utilization of blood/blood products was analyzed, as well as the ratio of prepared/used blood units in urology patients in the surgical ward, in the intensive care unit (icu) and at the urology center within the cc dr dragisa conclusion: due to a rather liberal use of primarily ffp in certain cases (cystectomiae in the first place), and a discrepancy between the prepared and actually used blood units, hospital transfusion committees should be an imperative in order to solve current dilemmas regarding justified use and proper administration of blood and blood products. background: the safe collection, production, distribution and application of blood and blood products in a high quality needs logistic on a high level. since the seventies computers, special software and barcode are used in transfusion medicine and improved the safety of processing data. in the last years a new technology was developed for industrial use, the radio frequency identification (rfid). aim: the aim of our studies was to check whether rfid can use reasonable in transfusion medicine. methods: at first we developed a flow chart, where we can use the technology and where are the problems by introduction. so we tested in the red cross donation centre in saxony about passive rfid smart label under real conditions. in cooperation between the akh vienna and novatech research a new handheld pc software 'labelview' for all steps around the transfusion was developed, including the identification of the patient and the processing of the haemovigilance data, and tested in first time. results: passive and semiactive (with temperature control) rfid labels survives all hard steps during the working up of the whole blood (e.g. centrifugation by g, separation, etc.). as a result of the contactless identification they are help to make easier the documentation of all processing steps according good manufacturing practice. in clinical practice they are a good supplement to bed side transfusion software. conclusion: for all lot of problems by the logistic and the safe identification around the transfusion existing various single point solutions such as patient-wristband, bed-side test, double check of blood group typing and donor -donation registry in software, etc. the lecture will deal with new developments in logistics and data management, which can help to reduce the problems associated with documentation, safe identification and reporting of haemovigilance data. our experiences with the immunohaematological analyser olympus pk applied conventional and no conventional (hemolytic medium time) techniques in sera of patients with ascariasis. results: the ai and hk tests showed: b epithopes in ae from b patients and in ae from ab patients; a epithopes in ae from ab patient and in ae from a patients; p and p epithopes in ae and only p epithopes in ae. these patients had both epithopes in their erythrocytes. the hemolytic techniques showed: anti b immune antibodies in sera and anti a immune antibodies in sera. the presence of abo and p epithopes in ae and immune antibodies in patients with ascariasis show a relation about blood groups and ascariasis. the fact of to find the same abo and p antigens in a. umbricoides and in its hosts suggests that the parasite might absorb them during its life cycle. these epithopes would be involved in the molecular mimicry. the use of filters for leucocyte depletion in anemic patients on maintenance hemodialysis g poposki*, s kovaceski*, b krstanoski*, s mena* and n solaz † *institute of nephrology, struga, macedonia, † ankara university, faculty of medicine, ankara, turkey introduction: renal anemia is one of the major chronic complications in end stage renal disease. it is caused by reduced production of erythropoietin (epo) due to uremic toxin effects, reduced halflife of rbc, iron deficiency, aluminum intoxication, blood loss during hemodialysis, gastrointestinal hemorrhage, epistaxis, infections etc. allogenic blood transfusion is transplantation of certain or all cell types. however, allogenic blood transfusion can contribute to many immune system disturbances with clinical side effects. besides erythrocytes, mononuclear, t and b-lymphocytes, are also transfused, which cause immunomodulatory disturbances in immune system of recipient. leukocytes are responsible for frequent febrile non-hemolytic transfusion reactions, alloimmunization toward leukocytes and hla antigen and transmission of cmv. anti-le antibodies, forming of immune-complexes, complement activation with pirogenic c a and c a immunoinflamatoric citokines cause febrile reactions. commercial use of filters for leukocyte depletion with removal of leukocytes and degraded products of microagregates and cytokines, cause minimum harmful immunomodulatory effects and prevent transmission of cmv. aim: the aim of the study was to present the effects of transfusion of erythrocytes with residual number of leukocytes in anemic patients on chronic hemodialysis at institute of nephrology in struga. matherial and methods: during - period all anemic patients on hemodialysis were divided in groups. the first group pts with febrile non-hemolitic transfusion reaction. the second group- pts immunized toward leukocyte and hla antigen. the third group young candidates for kidney transplantation for prevention of hla immunization. the fourth group pts with sle (for immune-complexes and autoantibodies). total patients ( males and females) received units of rbc with residual number of leukocytes. commercial filters of baxterÔ (lekostop lds) and terumoÔ (imugard iii rc) of second and third generation with microagregate filter and synthetic polyurethane fibers, with - microns pores that remove leukocytes, platelets, microagregates and fibrin were used. erythrocyte concentrates are filtered until days of collection. result: aabb permits maximum < ¥ wbcs/unit for prevention of febrile non-hemolytic reaction. the filters we used reach residual leukocyte number of ¥ the le reduction of - . %. the number of rbc after filtration is minimum % - g hb per unit. in none of the patients who have received the leuco-filtered blood, no adverse post transfusion reactions were noticed. conclusion: the used filters for leucocyte depletion are characterized with superior biocompatibility, excellent elimination of all types of leucocytes and high 'recovery' of erythrocytes. the use of filters for le depletion reduces and minimizes the side effects of allogenic blood transfusion in patients on chronic hemodialysis who are alloimmunized, in patients with sle, and particularly in young patients candidates for kidney transplantation. background: fv leiden, prothrombin g a, mthfr c t are three most common and important prothrombotic inherited mutations. aims: the aim of the case-control study was to assess the prevalence of mutations and their single or combined effects as risk factors for thrombosis. methods: the study included thrombotic patients (venous thromboembolism, chronical venous diseases, different etiology) and asymptomatic healthy individuals as control group. extraction of genomic dna was followed with genotyping of fvl by pcr-ssp, prothrombin and mthfr mutation by pcr-rflp. results: a statistically significantly higher prevalence of fvl mutation was found in thrombotic patients ( . % heterozygous, . % homozygous) compared to controls ( . % heterozygous), p < . . the or for heterozygous carriers was . ( % ci . - . ), confirming the association of fvl mutation with the risk of thrombosis. there was no statistically significant difference in the prevalence of the prothrombin mutation in patients ( . %) and controls ( . %), or . ( % ci . - . ), p = . . although the group of thrombotic patients showed a higher prevalence of homozygous carriers of c t mthfr than the control group ( . % vs . %), or was not significant ( . , % ci . - . ), p = . . analysis of combined effects of mutations showed an additional thrombotic risk for carriers of fvl mutation and both mutated alleles of c t mthfr gene (tt and ct) (or . , % ci . - . ), p < . . conclusions: fv leiden mutation was detected as significant single risk factor for thrombosis in studied patients group. additional prothrombotic risk have carriers of fvl mutation and c t mthfr gene mutation. a female patient in a high fever due to urinary tract infection does not respond being given antibiotics. on the contrary, leukocytes rose (to ¥ /l), anaemia became even deeper, as well as thrombocytopenia. hemocultures were negative. hematologist decided to search for hematological disease. the first citology results of bone marrow aspirate suggested lymphoproliferative disease ( % atipical plasma cells). to treat heavy anaemia (hgb g/l) hematologist asked for red blood cell concentrate. pretransfusion testing revealed warm autoantibodies in the patient serum and on red blood cells. antibodies had no apparent specificity. biochemical parameters (bilirubin, ldh, haptoglobin) suggested mild hemolitic process. electroforesis revealed polyclonal hypergamaglobulinaemia. the th day of hospital treatment, the therapy with corticosteroids was introduced (solu-medrol mg per day). coagulation parameters were tested: pt . inr, aptt s, fibrinogen . g/l, trb ¥ /l, d-dimer mg/l, atiii %. dic was suspected. liver enzymes showed mild liver dysfunction (normal ast, alt, elevated ggt, low che). substitution therapy started with dose of cryoprecipitate, dose of fresh frozen plasma, iu atiii, doses of red blood cells and vitamin k mg. two days after the substitution therapy we saw pt . inr, aptt s, fibrinogen < . g/l, trb ¥ /l, atiii %. during the next few days erythrocytes and thrombocytes rose, but due only to corticosteroid therapy and not to substitution therapy. the patient had neither signs of con-sumptive coagulopathy, nor hypoproduction of coagulation factors, except for fibrinogen. till th day of therapy, fibrinogen was below . g/l. there was no hemorrhagic diathesis. after that, fibrinogen rose, and on the st day the patient was recovered, in both clinical and laboratory terms. the results of immunological tests, collected later, confirm the diagnosis of systemic lupus erythematosus. we did not have any specific test to confirm antibody mediated hypofibrinogenaemia, but in the setting of sle, without any specific treatment except corticosteroids, fibrinogen recovered. we assume it is quite enough for highly suspected immunological hypofibrinogenaemia. results: twenty-four-year-old male patient with severe hemophilia type a suffering from low incoercible digestive bleeding secondary to ischemic colitis caused by autoimmunity (vasculitis) without response to current management. treatment was initiated with mg/kg/dose of rfviia (*) for days, after which there was clinical and endoscopic recovery, and an inh decrease to . ub/ml (fviii dosage %) . he began to take meprednisone ( mg/kg/day) for days, after which the inh titre was . ub/ml. (table a ,b) the patient underwent surgery the following year (correction of equinus foot). he entered the operating room with an inh of . ub/ml and was treated with mg/kg/dose of rfviia (*) for days, obtaining an excellent hemostatic response. he had two autologous blood units, but it was not necessary to be administered. the inh titre decreased again (down to . ub/ml) during the intratreatment stage. thirty-five days after rfviia, the inh titre was . ub/ml. (table a ,b) the presence of high titre inh against fviii is a critical problem in cases of bleeding or surgery need due to the inefficacy of the available therapeutic options and the severity of the events. in this case, we have observed that, apart from inducing hemostasia through the activation of the coagulation extrinsic path, rfviia could reduce the inh titre in sequential dosages. we have introduced the case of a -year-old patient with hemophilia complicated by a high titre inh against fviii. in this case, we have observed that, apart from inducing an effective hemostasia through the activation of the coagulation extrinsic path, rfviia could reduce the inh titre in sequential dosages. there was also a decrease in the inh titre concomitantly with an increase of the plasma fviii level during its use. this phenomenon suggests that rfviia could produce a modulation in the immune response. evaluation of an automated blood collection system with standard ratio of anti-coagulation and integrated filter for whole blood leucodepletion l dadiotis, a kolokytha, m dimou, a perdiou, c alepi, p spyropoulou, e igoumenides, c velidou, v panagopoulou and s matsagos tzaneion general hospital, pireas, greece automated blood collection system (abc) is a device manufactured by macopharma which collects by gravity a preset volume of blood and mixes it with anticoagulant (ac) in standard ratio ( : ). this is managed by passing the ac, which is stored in a special bag, anti-erythrocyte antibodies are immunoglobulins that belong to the igg, igm and iga classes. their common characteristic is a specific reaction with antigens that are located on the erythrocyte surface. they can emerge as auto antibodies and alloantibodies. the blood transfusion in patients may induce a post-transfusion hemolytic reaction (pthr). in order to avoid or reduce the danger of the pthr it is necessary to examine whether there are irregular anti-erythrocyte antibodies in the patient's serum as well as in the serum of the voluntary blood donors. all the irregular anti-erythrocyte antibodies are not clinically relevant. the experience shows that the clinically significant antibodies most often belong to abo, rh, kell, kidd, duffy and ssu blood groups. in the period from april, to november, , we monitored and examined, at the institute for blood transfusion, clinically significant antibodies in the serum of the patients who are treated with blood transfusions as well as in the serum of the voluntary blood donors. we used the following tests for detecting irregular anti-erythrocyte antibodies: enzyme test, indirect coombs test, screening test by the commercial test erythrocytes and gel filtration method. the detected irregular antierythrocyte antibodies are identified by means of the commercial test erythrocytes for identification. our results are the following: voluntary blood donors: anti d, anti c + d and anti-leb antibodies. patients: anti-d, anti-k, anti-fya, anti-c and anti-e antibodies. in nine patients, anti-erythrocyte antibodies were discovered, namely, those that react at the temperature higher than °b ut whose specificity we could not discover with the existing techniques. improved predictive factors of response for myelodysplastic syndrome patients treated by the combination of erythropoietin and g-csf s park*, c kelaidi † , s grabar ‡ , v bardet ‡ , d vassilieff ‡ , f picard ‡ , m guesnu ‡ , mc quarre ‡ , p fenaux § and f dreyfus ‡ *service hématologie, hopital cochin, † hématologie, hopital avicenne, ‡ service hématologie, hopital cochin, § hématologie, hopital avicenne, paris, france it has previously been shown that serum epo level and number of previous red blood cell transfusions are predictive factors of response to epo + g-csf treatment of myelodysplastic syndromes (mds). in a subgroup of patients with mds having sepo < ui/l, known to be good responders to epo + g-cscf, the gfm group wanted to refine the model predicting the response to epo + g-csf, especially with cytology (who classification with dysplasia and percentage of erythroblasts and blasts). in a population of patients (ra, rars and raeb < % blasts) receiving epo ± gcsf between and and having serum epo < ui/l, the response rate at week (iwg criteria) was %. six variables were associated with response to epo ± g-csf for mds: age > years (p = . ), number of prior red blood cell transfusions < packs/months (p = . ), serum epo level < ui/l (p = . ), percentage of blasts < % (p = . ), percentage of erythroblasts > % (p = . ) and low ipss score (p = . ). we did not found any influence of dysplasia, type of rhepo (darbopoietin alfa or epoietin alfa) and karyotype on response rate. in multivariate analysis, age through a rotating pump. the abc can be used with all types of p- pan-european blood safety alliance the pan-european blood safety alliance is a unique alliance of patient organizations, formed to promote the highest level of blood safety for all in europe. it was formerly established on february , during the course of the first general meeting of the pbsa, which comprised of founding patient organizations. the objectives of the pbsa are: . to promote the fundamental right and duty to safety of all patients in need of blood transfusions and blood products. . to ensure the availability of sufficient amounts of safe blood, to meet all treatment need through: -the education of all staff handling blood components, to reduce human error. -the implementation of and access to, proactive blood safety technologies, for each patient across europe. -haemovigilance -the adequate access to blood transfusion services, which should be provided free of charge to the patient. other objectives are to raise awareness on a local and european level regarding blood safety, to promote eu legislation that improves safety standards of blood transfusion services, including stem cell preparation and storage across europe and to lobby for increased patient influence on eu health policy makers. very importantly, the alliance aims at providing a forum for patients, healthcare professionals, health policy makers and relevant industry, as well as acting as a point of reference to the national health authorities, the european commission and other european institutions, when seeking the opinions of patients on blood safety. cerns of insertional mutagenesis and the safety of some viral vectors that randomly insert genes through the genome have been recently resurfaced following the development of a haematological malignancy in a child treated with a retroviral vector. particularly questions also remain as to, whether gene therapy and the production of ectopic factor viii and ix will be a risk for inhibitor development or indeed whether it might promote tolerance in those patients with inhibitors. w-pl - gene therapy for thalassemia: will it become reality? university of washington, seattle, wa, usa experiments aimed to develop gene therapy approaches for the beta chain hemoglobinopathies, sickle cell disease and beta thalassemia started about years ago. in the beginning results were dismal because of the extremely low and variable expression of globin genes contained in the therapeutic vectors. a major development occurred in with the discovery of powerful regulatory elements that could guarantee high level of globin gene expression. these elements when incorporated into viral vectors allow expression of therapeutic levels of the transferred globin genes. a second major progress was achieved with the development of safe lentiviral vectors that can efficiently infect the human pluripotent repopulating hemopoietic stem cells. as a result of this progress, today beta thalassemia and sickle cell disease can be cured in murine models of these disorders. considerable effort is already being devoted into further improvement of lenti viral vectors with emphasis on incorporating elements which will decrease the probability of insertional mutagenesis and leukemogenesis. the major challenge for the clinical application of stem cell gene therapy of thalassemia is the need for genetic correction of large numbers of mutant stem cells. in vivo selection of corrected stem cells is being investigated but there are questions about its safety because of the possibilities of clonal expansion of stem cell lines carrying undesirable integrants. other major challenges have to do with logistics: production of therapeutic vectors, infrastructure required for stem cell gene therapy delivery, and sponsoring and funding of the clinical trials. gene therapy trials on limited number of patients are expected to be initiated relatively soon. if these trials are successful and cures of beta thalassemia ensue, the major challenge will be the delivery of this molecular therapy in the context of medical practice. w-pl - gene therapy for haemophilia haemophilia is an ideal target for gene therapy because only a small rise in factor levels to - u/dl would achieve the goals of prophylaxis without regular infusions of concentrate and deliver a substantial improvement in lifestyle for patients with severe haemophilia. gene therapy for haemophilia today relies upon addition of normal factor viii or ix genes. with present technology gene therapy can offer the prospect of a true 'cure' for haemophilia in animal models, although this may not be currently realizable in man. more than patients with haemophilia have now been treated in phase gene therapy protocols. all studies have failed to conclusively show that therapeutic levels of factor viii and ix can be reliably obtained. the first trial reported used im injection of a factor ix containing recombinant adeno associated virus (raav) in adult patients with severe haemophilia b. only very modest increases in factor ix level, < u/dl rise, in / patients enrolled were observed, although less factor ix concentrate was needed in / subjects. a similar study using the same raav vector via intrahepatic artery infusion has been conducted. this has been complicated by the observation of aav vector in the semen of subjects. in six patients enrolled, no durable levels of ix above u/dl were seen. further development of this raav vector is suspended. for haemophilia a, three systems are have been tried. the first study was an ex vivo addition of factor viii gene to autologous fibroblasts and then laparoscopic reimplantation. preclinical assessments demonstrated durable expression of factor viii (> % of normal) for > year in mice following a single treatment. in / patients treated repeated factor viii rises ( . - . u/dl) were seen, but no improvements lasted beyond months. the second protocol used a murine leukemia retrovirus containing factor viii, injected intravenouslya development of preclinical data in rabbits and haemophilic dogs. / patients enrolled sustained levels of factor viii > u/dl. the third study, using a modified, 'gutless', adenovirus containing factor viii gene has recruited one patient. this patient demonstrated transient liver toxicity and thrombocytopenia at doses lower than those that cause toxicity in primates. sustained levels of factor viii of ~ u/dl have been observed over a number of months. accrual to the study has been poor. haemophilia remains a prime target for gene therapy. however, haemophilia is no longer a life threatening disease with current therapy that is both safe and efficacious. a balance between the benefits and theoretical risks must be borne in mind when considering gene-based approaches to therapy. con- reference: petz ld, garratty g. immune hemolytic anemias. nd ed. philadelphia: churchill livingstone, , pp - . w-pa- autoimmune neutropenia introduction: autoimmune neutropenia (ain), a granulocytic disorder due to the presence of anti-neutrophil antibodies, may present as neutropenia of varying degree with or without recurrent infections un previously healthy individuals (primary or idiopathic ain) or in patients with a known underlying disease such as lupus erythematosus, lymphoid malignancies, etc (secondary ain). the condition affects more frequently infants of small ages while it is rare in adults [ ] [ ] [ ] [ ] [ ] [ ] [ ] . in some patients, diagnosis is established in occasion of a respiratory, urinary or cutaneous infection, but in many cases is simply a finding of cell blood counting performed for unrelated reasons [ ] . clinical and laboratory findings: in general, physical examination is negative. laboratory investigation reveals the existence of isolated neutropenia. association of the disorder with autoimmune hemolytic anemia or autoimmune thrombocytopenia is rarely seen [ ] . blood biochemistry is normal while serologic tests for bacterial, viral or other pathogens may be positive depending on the underlying infection. bone marrow is hypercellular without maturation arrest of granulocytic series. hemopoietic stem cell reserves and function are normal or increased, and stromal cell function is within the range of the normality [ ]. methods for the detection of granulocyte-specific antibodies: serology for the detection of granulocyte-specific antibodies has been marred, compared to erythrocyte serology, because the target cell here, the granulocyte, is short-lived, fragile and becomes easily activated. the former two of these difficulties require absolutely freshly (< h old) isolated neutrophils from a panel of donors to be used every day to run the tests with sera from patients, while the third difficulty is more important since spontaneous cell clumping in vitro is very common and nay mimic the specific aggregation caused by cross-linkage of surface bound antibodies in the granulocyte agglutination test (gat). in order to overcome these problems, the second international granulocyte serology workshop [ ] recommended a combination of two tests as the best screening procedure for the detection of granulocyte autoantibodies in patient sera, gat and granulocyte immunofluorescence test (gift). gat is mainly mediated by igm antibodies and is positive in about % of cases. gift detects igg antibodies and is positive in about % of cases. it is to be noted that flow-cytometry fluorescence may arise not only from the surface but also from the cytoplasm of neutrophils, necessitating assessment of membrane fuorescence by microscopy. a good direct anti-granulocyte test is not available today. this is due to the fact that too few neutrophils can be obtained from the blood of neutropenic patients, and also to the observation that neutrophils are often activated in vivo because if an underlying infection or other inflammatory process, thus expressing fcgrii and fcgriiib to which nonspecific binding of w-pa- practical approach to transfusion in autoimmune hemolytic anemia (aiha) g garratty american red cross blood services, pomona, ca, usa a major problem when transfusing patients with aiha is that often all units are incompatible. this may be due to autoantibodies (autoab) and/or alloantibodies (allo-ab). if the incompatibility is due to only auto-ab, then transfusion of incompatible blood will not usually result in a clinically significant reaction, but if due to alloab, the result may be similar to that seen in any other patient (i.e. a hemolytic transfusion reaction ranging from mild to severe). thus, it is essential (as in any other patient) to exclude the presence of allo-ab. it is wise to phenotype all patients, for as many antigens as possible, before the patient receives transfusion. there are two popular approaches to determine if allo-abs are present but being masked by 'warm' auto-ab activity. the preferred method is to remove the auto-ab by adsorbing the patient's serum with autologous rbcs treated with enzymes, or preferably, with zzap reagent. the latter reagent contains an enzyme leading to optimal adsorption of auto-ab, and dtt. these two chemicals will destroy significant antigens other than rh and kidd (e.g. mns, duffy, kell, lutheran, dombrock, cromer, lw, some yta and ge, inb, jmh, ch, rg, pr antigens), thus will not adsorb alloantibodies to these antigens. if autoadsorption is not possible (e.g. patient has been transfused recently or there are too few rbcs), one has to perform adsorption with enzymes or zzap-treated allogeneic rbcs. one does not have to be concerned with covering any antigens destroyed by zzap (e.g. kell and duffy systems). we use a rough guide relating the strength of the indirect antiglobulin test to the number of adsorptions needed to remove auto-ab ( + = adsorption; + = adsorptions; + = adsorptions; + = or more adsorptions). if there is no activity left after the adsorptions, then one can suspect that the incompatibility was due to auto-ab, but on rare occasions one can be wrong and an allo-ab to a high-frequency antigen has been removed. this is a major disadvantage of using allogeneic adsorptions, and is why adsorptions with autologous rbcs are preferred. if time ( - h) does not allow for adsorptions, one can dilute the patient's serum (e.g. in , or in ) and test the dilution against a panel to see if any alloantibody specificity becomes obvious. another approach is to select units matching the patient's phenotype as closely as possible. when dealing with cold agglutinin syndrome one can usually exclude allo-ab activity by testing strictly at c. this can be helped by performing adsorptions with enzyme-treated autologous rbcs at c, but it is difficult to adsorb all of the powerful cold autoagglutinin activity. it is reported that - % of aiha have allo-abs; the incidence is even higher in patients who have received multiple transfusions. thus, we feel that procedures such as those discussed above must be performed before transfusing incompatible blood if time allows. one should always negotiate with the attending physician regarding the time it will take to perform adsorptions. a decision may be made not to perform adsorptions if the patient has life-threatening hemolysis, and especially if the patient has never been transfused, or pregnant. serum igg may occur (naig). the presence of immune-comlexes in the serum, such as in patients with felty's syndrome, lupus erythematosus and other diseases, as well as the presence of immune aggregates formed in sera stored frozen for long time, may give false-positive tests given that they may bind to fcgriiib molecules expressed on the surface of neutrophils. elimination of immunecomplexes and immune aggregates can be easily obtained by ultracentrifugation [ ] . another cause of false-positive results may be the presence of anti-hla antibodies because of allo-immunization. these allo-antibodies react with hla molecules found not only on neutrophils but also on the surface of many other cells including lymphocytes. these allo-antibodies can be eliminated by platelet absorption. it seems that the best method in the search of true antigranulocyte antibodies is the monoclonal antibody-specific immobilization of granulocyte antigens (maiga) [ ] . with this method one can specify anti-granulocyte antibodies using a panel of known granulocyte antigenic specificity. finally, it is notable that the levels of serum antibodies to neutrophils may vary considerably over the time. one negative test does not exclude ain. usually, two to three tests have to be run over a period of months [ ] . antigenic specificity: human neutrophil antigens (hna) are classified according to an international granulocyte antigen working party [ ] . three glycoproteins have been found to be involved in the determination of antigenic specificity, fcgriiib, gpnb (cd ) and gp - . the respective antigens, frequencies and alleles are illustrated in table . antigenic specificity can also be studied by using methods applied in molecular biology. a promising approach is transfection of mammalian cells by cdna derived from granulocyte antigen specific mrna. cell lines have been established with cells expressing the respective human granulocyte antigen, making the detection of anti-granulocyte antibodies more easier. genotyping of hna antigens can also be stydied with the pcr technique [ ] . references are available from the author upon request. w-pa- a rare case of 'coombs negative' autoimmune haemolytic anaemia due to red cell autoantibodies of iga class warm autoimmune haemolytic anaemia (waiha) is usually associated with red cell auto-antibodies of the igg class, which can be detected by polyspecific direct antiglobulin test (dat). routine polyspecific direct antiglobulin tests contain anti-igg and anti-c d components, and are not standardized to react with iga-or igmsensitized red blood cells. haemolytic anaemia caused by warmreacting auto-antibodies solely of the iga class is exceedingly rare. those cases of autoimmune haemolytic anaemia can be difficult to diagnose because of the negative polyspecific coombs' test, which is a standard in investigation of possible causes of haemolysis. we present a case of severe warm autoimmune haemolytic anaemia caused by iga class autoantibodies. a -yr old male patient was admitted with anaemia, haemoglobinuria, and other signs of severe haemolytic disease. he received multiple transfusions but haemoglobin level did not rise above g/dl. the initial polyspecific direct antiglobulin test, containing an anti-igg and anti-c d antiserum, was negative. tests for cold agglutinins and other possible causes of haemolysis were negative. only by using a monospecific, anti-iga antiserum could we show that the warm iga auto-antibodies against red blood cells were present on patient's erythrocytes. we have not detected signs of complement activation by iga autoantibodies in this patient. the patient received corticosteroids with good initial effect. his haemoglobin level stabilized and he did not require more transfusions. anti-iga direct antiglobulin test became negative about to weeks after the therapy was initiated. however, in spite for the initial effect of steroid therapy haemolysis continued, and splenectomy was performed months after diagnosis was made. it has been shown that human lymphocytes, granulocytes and monocytes contain specific fc receptors for iga, and both monocyte-mediated phagocytosis and antibody-dependent cellular cytotoxicity due to iga auto-antibodies has been demonstrated. there is also increasing evidence that iga auto-antibodies can activate complement, both via the classical and the alternative pathway. a phenomenon of 'reactive haemolysis', which involves c -independent binding of c b complexes to 'bystander' red blood cells, has also been described. we emphasize the importance of performing additional testing in cases of apparent 'coombs' negative' haemolytic anaemia due to iga, igm or 'low affinity' igg autoantibodies, and serological aids that are available for that purpose. described. both siblings were born on term, in good general clinical status, free from any signs of infection, and with isolated severe neutropenia ( and neutrophils/ml). the diagnosis of annanti hna- a was made upon exclusion of other possible causes of neonatal neutropenia, and confirmed by serological testing of granulocyte antigens and antigranulocyte antibodies. in both cases, the course of the disease was mild, with bacterial omphalitis on day and , respectively. omphalitis was successfully treated with -day antibiotic therapy according to antibiotic sensitivity report. the first neonate received standard dosage of intravenous gammaglobulins for days without success. this was followed by an attempt at neutrophil count increase with -week corticosteroid therapy, also without response. the second neonate received no specific therapy for neutrophil count increase. the children were discharged for home care with clinical and laboratory control examinations at -week intervals. in spite of prolonged neutropenia ( and months, respectively), no other infections were recorded. discussion and conclusion: in our patients, the therapeutic approach to ann was individualized, based on standard antibiotic therapy, intravenous gammaglobulins, corticosteroids, available literature data, and our own clinical experience. although in the last few years rh-gcsf is successfully used in patients with neutropenia, we decided to postpone its use in case the neonatal sepsis developed. the reasons for such decision were: ( ) the fact that both neonates were in good general clinical status, with a mild course of the disease with only short-term umbilical infection successfully managed with antibiotic therapy; ( ) literature reports suggesting the unexpected failure to respond to rh-gcsf therapy in patients with neutropenia induced by anti hna- a immunization, and ( ) the unknown effect of rh-gcsf on developing tissues of the neonate. the choice and efficacy of specific therapy for neutrophil count increase in the management of alloimmune neonatal neutropenia have not yet been fully defined and require additional evaluation in the majority of cases. male donors for the production of fresh frozen plasma: a special issue for trali patients trali is a significant cause of transfusion associated morbidity and mortality, and has been reported as the third most common cause of fatal transfusion reactions. there is no good evidence on which to base transfusion support policy for patients who have experienced trali. the hypothesis that there may be patient associated factors that contribute to the risk of trali is generally accepted. for this reason it seems reasonable to try to avoid further transfusion during the period of illness. if this is unavoidable the next best solution to reduce the risk of recurrence seems to be the avoidance of using plasma containing blood components (especially ffp) as there is a high chance of positivity for leucocyte antibodies especially for those coming from female donors. as fresh frozen plasma transfusion accounts for up to half of all trali cases and as our center is the only in greece responsible for the testing and processing of blood from blood donors representing military recruits, the last two years we tried to set up a project in order to provide components from male donors on request. our donor base consists predominantly from males donors ( . %), aged between and years old, with a small chance of having a positive history for transfusion the difficulty of the project consisted on the fact that these donors are assigned to military camps throughout greece, which makes difficult the on time arrival of the units to our establishment in order to be processed for the production of ffp conform the european council quality requirements. this was the main reason why, till now, all plasma produced from these donations was regarded as plasma for fractionation. the first step for implementing the new project was to evaluate the number of donations that, by minor changes on the time of arrival, could be processed for ffp production. the next step was to re-schedule the shifts of the personnel for the on time production of ffp. during , % of donations were fulfilling the specifications for the production of ffp and with the flexibility of the schedule the % of them were successfully processed to ffp. during , % of the donations were fulfilling the specifications and . % of them were processed to ffp. so it is feasible to increase the proportion of male ffp by organizing better the transportation of blood from the donation sites to the blood establishment and by retaining available specialized personnel to cover the extra shifts. maximising the blood supply chain in times of shortage shortages in the blood supply chain may occur for a variety of reasons. they may be temporary e.g. due to a flu epidemic or prolonged e.g. due to the exclusion of a high proportion of donors due to new pre-donation tests or because of a lack of volunteer donors. increasing awareness of the possibility of blood shortages mainly related to increased precautions associated with the possible transmission of vcjd by transfusion has been the driver for the development of blood shortage contingency plans in the uk. in england and north wales, hospitals and the national blood service (nbs) have worked together to develop an integrated blood shortage plan (ibsp) designed to ensure that hospitals and the nbs work together within a consistent, integrated framework giving patients equal access to available blood on the basis of need. an essential element of the plan is the principle that shortages can, in most cases be avoided by reducing the current usage of blood through appropriate use programmes. the impetus for hospitals to implement these programmes was a government circular (hsc / ). hospitals have embraced the circular and have recruited specialist hospital transfusion practitioners, introduced lower hb triggers, cell salvage and hospital transfusion teams and are participating in the blood stocks management scheme (bsms). audits of compliance with the circular have taken place, and a web based tool kit is available. the demand for blood has declined for the last three years, with a decrease of about % during - , suggesting that the drive for improvement has been successful. the shortage plan introduced in england and north wales has two key aims: that the national pool of blood is available for all essential transfusions for all patients and that overall usage is reduced to ensure the most urgent cases receive blood. the plan is structured to provide actions for the nbs and hospitals in three phases, 'normal' circumstances, reduced availability and severe prolonged shortage. hospitals should have documented emergency blood management arrangements for each of the phases. the national plan is activated when the nbs red cell stock level falls to pre-defined levels, hospitals are informed by fax that they should reduce their normal stock holding levels according to guidance in the ibsp and comply with the daily hospital usage budget. the bsms has used its knowledge of hospital inventory levels and demand to provide guidance on appropriate inventory levels for normal and reduced status, it also provides the daily hospital budget. to monitor progress against the recommendations in hsc / hospitals will be benchmarked against a number of performance indicators. these include the presence of emergency blood management arrangements, median red cell usage for a number of surgical procedures and percentage wastage of blood. there have been no shortages within the nbs for more than six years, it is hoped that the implementation of the ibsp will help to ensure that in the unlikely event of reduced availability blood will be available to the maximum number of patients requiring a blood transfusion. w-pa- transfusion during disaster g klein nih, bethesda, md, usa publicity given to blood donation during wartime has created a powerful association between the need for blood and occurrence of a disaster. blood is rarely needed in excessive quantities at the moment a disaster occurs. the outpouring of blood donors, especially at the site of a disaster, often proves counterproductive. the terrorist attacks on the world trade center on september , , with almost deaths and more than injuries, provides an instructive model. more than a million potential donors contacted blood-collection centers. hundreds of thousands of prospective blood donors crowded collection facilities and many waited for hours, often to be turned away. qualified staff were in short supply and screening errors occurred as minimally qualified staff were recruited and as collection personnel fatigued. supplies and storage capabilities were pushed to their limit. some blood was inadequately processed and stored. resources were diverted from needed apheresis collections and component preparation to whole blood collection. in the aftermath of the disaster, blood outdated and volunteer donors became disillusioned as their 'gift of life' was refused or unused. similar responses have occurred numerous times over the -year period since blood-donor programs were introduced. in virtually every civilian disaster in the u.s. during the past century, all the blood that was needed was immediately available from blood inventory. in only four cases were more than units of blood used in the first to h. in in new york, the five hospitals closest to the disaster site admitted only disaster victims. the new york blood center, which supplies percent of blood for the city's hospitals, added units to routine inventory at hospitals. the center received telephone calls and collected more than units of blood in the first h. in the area of the pentagon, the chesapeake and potomac red cross blood center supplemented hospital blood inventories within h of the disaster. meanwhile, spurred by well-meaning media and federal officials, lines of blood donors were being processed at local hospitals, makeshift collection centers, the small research hospital at nih, and at a building next to the white house. in the week after september , america's blood centers collected more units of blood, and the american national red cross collected more units than in the same period the previous year. more than units were collected for the disaster victims, but only units were used. u.s. blood collectors and federal agencies have created a disaster plan that acknowledges the need for altruistic people to volunteer for blood donation in the time of disaster and speaks with a single voice to avoid needless collection activity while harnessing the good will of well-intentioned people to supplement the ongoing need for volunteer blood donation. rehabilitation of blood transfusion service in azerbaijan cd asadov, ga huseynov and ab hagiyev institute of hematology and transfusiolo, baku, azerbaijan at the end of th years of the last century in azerbaijan as well as in other republics of the former ussr began process of progressive deterioration of blood service parameters. in result there was an essential reduction of prepared blood and blood components quantity, manufacture of preparations from blood's plasma has completely stopped. it is connected by that our republic experiences a heavy transition period from scheduled to market economy. after reception by azerbaijan of the sovereignty on development of a national policy the big work has been lead to areas blood transfusion and development of national rules and the standards regulating functioning of establishments of blood service. in the law about ' the donorship of blood and its components in the azerbaijan republic' has been accepted, instructions on physical examination of donors and preparations of blood and its components are authorized, and also the new speciality transfusiology has been entered into the nomenclature of medical specialities. now the national program of blood service development is developed. at drawing up of the program social and economic conditions of the country, ethnic both cultural traditions and a mental potential of the nation are considered. within the framework of this program is planned to refuse gradually a paid blood donation during the certain period of time to reach %s' voluntary unpaid blood donorship. however in connection with limitation of resources, the state is not capable to allocate enough of means for its realization. the big work on attraction of the international organizations has been carried out. now the project of the united nations development program (undp) 'rehabilitation of blood transfusion service in azerbaijan' is carried out at sponsor's support of the norwegian government. realization of this project will lead to reorganization of blood transfusion service in our country according to practice of the european countries. within the framework of project realization it is planned to make changes and additions to a existing law about a blood and its components donorship to bring it into accord with recommendations of the europe council. updating of the russian law 'concerning the donation of blood and blood components' on june , , a law, 'concerning the donation of blood and blood components, ' was signed by the first russian president, boris eltsin. now, after more than ten years of market economy and democratic evolution in russia, this law was significantly changed on august , , as shown in the following sections: . the development of a voluntary blood donor system. . removal of the upper age limit for blood donors. . funding for blood donations. from january , , each level of the state power budgets for a blood donor service to supply blood products for federal, regional, or municipal hospitals. costs of these drugs and the need of prolonged growth factor treatment in these disorders. w-pa- can iron administration reduce peripartum blood transfusion c breymann university of zurich, zurich, switzerland the prevalence of iron-deficiency anemia in different regions of the world ranges from to %. the increased iron requirement in pregnancy and the puerperium carry with it an increased susceptibility to iron deficiency and iron-deficiency anemia and perioperative or peripartal blood transfusion. however, if ever possible administration of blood transfusion should be avoided for several reasons which will be pointed out in the talk. infections: it is well known that various pathogens such as bacteria and virus can be transmitted by administration of blood. around . % of are contaminated by bacteria such as yersinia or pseudomonas species but are not screened routinely for bacteria. in addition there is no donor screening for hepatitis a, herpes species (cmv, ebv, hhv , hhv ), parvovirus b , hepatitis g ( . %) and tt (transfusion transmitted) virus ( . %). numbers for positive testings for 'classic' virus such as hiv, hep. b and hep. c vary from country to country and lie around : to : depending on quality of donor screening programs, pcr sensitivity etc. recently there is increasing evidence that even prions which cause the jakob creutzfeld disease variation ('mad cow disease') might be transmitted by transfusions. therefore the fda has determined that blood donors from countries with high prevalence of prion positive persons are not permitted to give blood in the us (e.g. donors from uk). beside infections, other well known effects of transfusion are problems due to incorrect blood or components transfused, post transfusion purpura, acute and delayed lung injury, graft versus host disease and other acute and delayed allergic reactions. beside these negative effects it was also shown that patients who receive blood transfusion liberally after operations or in icu show higher morbidity and mortality compared to patients with restrictive transfusion policy. this might be due to negative effects on immune functions and inflammatory reactions and lack of stored blood to efficiently improve organ oxygenation. for example it is known that stored blood has worse capillary perfusion and worse viscosity properties compared to fresh blood. taken together there is increasing scientific evidence that blood transfusion is not the gold standard for anaemia management and alternatives such as endogenous blood pooling and efficient treatment of any anaemia must be enforced in the clinical settings. prevention and correction presuppose reliable laboratory parameters and a thorough understanding of the mechanisms of iron therapy. in order to correctly diagnose the type and degree of anaemia, a prerequisite for selection of the proper therapy, one must first of all correctly differentiate between the relative, i.e. the physiological anaemia of pregnancy due to the normal plasma volume increase during pregnancy, and 'real anaemias' with various different pathophysiological causes. when defining the hb cutoff value for anaemia in pregnancy, the extent of the plasma volume changes with respect to the gestational age must be taken into consideration. it has been found that haemoglobin values < . g/dl in the first and third trimesters, and < . g/dl in the second trimester may point to an anaemic situation which should be further clarified. the first important steps for diagnosing anaemia in a pregnant patient include a thorough check of her medical w-pa- impact of epo treatment on transfusion requirements in myelodysplasia c gardin and p fenaux hopital avicenne, aphp, university of paris , bobigny, france myelodysplastic syndromes (mds) are clonal disorders of hematopoeisis, associated with bone marrow failure and an increased risk of evolution to acute myeloid leukemia (aml). despite an normal or increased bone marrow cellularity in most cases, cytopenias worsen with time due to increased apoptosis and defective differentiation of blood lineage precursors. incidence of mds increases with age and reach / above years of age. bone marrow cytogenetics number of cytopenia and percentage of bone marrow blasts are strong predictors of survival and evolution to aml. a composite international prognosis scoring system (ipss) is used in everyday practice to guide the management of these diseases. these disorders are heterogeneous and include 'low risk' patients (less than % bone marrow blasts) with a prolonged evolution marked by chronic anemia, and 'high-risk' patients (excess of bone marrow blasts > %) evolving in a short timespan with severe cytopenias, and to aml in approximately % of cases. at diagnosis, % of mds patients are anemic, with an hemoglobin level less than g/l, and % of them will require chronic blood components transfusion, during the evolution of their disease. chronic anemia and multiple blood products transfusions are associated with an altered quality of life, clinical iron overload, and important health care costs. although transfusion practices and patient's transfusion need are variable, elderly mds patients require a mean of - units/year of follow-up, in recent surveys. therapies able to diminish or abolish the need for rbc transfusion have therefore a major role in the management of mds, as allogeneic bone marrow transplantation, the only curative therapy of these diseases, is limited to a small subset of mds patients. high-doses of recombinant erythropoetin (epo) ( - u/kg tiw, or a - u as single weekly dose) are typically used in low-risk mds. the response rate to epo is - %, including major responses (suppression of rbc dependency or rise of hemoglobin level of more than g/l). absent or low rbc transfusion needs and a serum epo level less than u/l are strongly predictive of response to epo, in patients with low-risk mds. the duration of response is variable ( - months) in most studies, with some long-term responders. the use of higher doses of epo or its prolonged administration may be associated with higher response rates, although no randomized studies are available combination of epo and low-dose granulocyte-colony stimulating factor (g-csf) increases the response rate to - %, including in patients not responding to several weeks of treatment with epo alone. two randomized trials published in , compared g-csf-epo to rbc transfusions and confirmed the efficacy of this combination, and a longer survival of epo-g-csf responding patients. studies are ongoing in mds, including with darbepoetin, a modified erythropoetin with longer half-life, administered once a week. two such studies have been recently reported, (darbepoetin or ug/week) with response rates varying from % to % in low-risk mds. in both studies, a response to darbepoetin was observed in some patients, who failed to respond to previous treatments with alpha or beta epoetin. further assessment of the optimal dosage, administration schedule of these drugs, and validation of their likely impact on qol are required, in order to epo and its derivatives to gain acceptance in mds, due the high history and a medical examination. this procedure often lays the basis for a correct diagnosis. the current gold standard to detect iron deficiency remains the serum ferritin value. to be reliable, this requires the ruling out of an infection (chronic or acute) as a cause of the anaemia. we recommend a complete laboratory test for the exact haematological status as well as the assessment of specific chemical laboratory parameters. these should the hb level alone is insufficient to guide management. a complete work-up (ferritin, transferrin saturation) is essential, preferably with haematological indices such as hypochromic and microcytic red cells and reticulocytes, classified by degree of maturity, in particular, before parenteral therapy is given. since ferritin acts as both an iron-storage and acute-phase protein, it cannot be used to evaluate iron status in the presence of inflammation. a high ferritin level thus requires the presence of an inflammatory process to be eliminated before it can be taken at face value. if the c-reactive protein level is also raised, the soluble tfr concentration can be used, since it is unaffected by inflammation. inadequate understanding of the complex chemistry of parenteral iron administration was previously responsible for serious side effects, such as toxic and allergic reactions, and even anaphylactic shock, in particular with dextran preparations. however, the current type ii iron complexes that release iron to the endogenous iron-binding proteins with a half-life of about h are not only effective but carry a minimal risk of allergic accident and overload, especially after a comprehensive pretreatment work-up. after correct diagnosis, major emphasis should be put on safe and effective treatment of anemia which again depends on severity of anemia, time for restoration and patients characteristics. today effective alternatives to oral iron only or blood transfusion such as parenteral iron sucrose complex and in selected cases also recombinant erythropoietin have been investigated and show promising results concerning effective treatment of anemia during pregnancy and postpartum. our departmental data collected over years and backed by postmarketing experience in countries indicate that iron sucrose complex therapy is a valid first-line option for the safe and rapid reversal of iron-deficiency anemia. w-pa- iron therapy in orthopaedic surgery surgery of the vertebral column, hip or knee is considered a bloody procedure (blood loss > l) and as a consequence represents the main indication for red blood cell transfusion in orthopaedics. because of the non-negligible residual risk of transmission of infectious agents by transfusion, but mainly because of immunologic complications induced by the administration of foreign proteins and cells, an alternative solution has been actively sought. studies have clearly shown that in patients undergoing such surgery, transfusion risk correlates inversely with pre-operative hemoglobin level. correction of even slight preoperative anemia is thus mandatory. in the elderly, iron and vitamin deficiency (b and/or folic acid) should be looked for as a matter of routine. we recommend the use of iron + epo whenever a rapid correction (< weeks) of the anemia is desirable in cases with transferrin saturation < % and ferritin levels < mg/l. with this regime it is possible to collect up to autologous blood units in cases of increased perioperative blood loss (e.g. double hip replacement). in the post-operative period, anemia worsens because of the existing inflammatory state. this inhibits iron absorption from the intestine and iron release from the macrophages while it affects epo function and production. there is increasing evidence that i.v. iron combined with epo induces a rapid correction of post-operative anemia. it is thus recommended to stimulate erythropoiesis by i.v. iron and epo starting on the first post-operative day and to avoid transfusions in asymptomatic patients even in cases with hb as low as g/l. background: hereditary hemochromatosis is one of the most common inherited disorders in which an excessive amount of iron is absorbed from the diet and then deposited in organs. the effective treatment is the regular whole blood removal which causes erythropoesis activation and leads to decrease of iron stores. red cell apheresis is an optional method for removing of higher amount of erytrocytes in one session. we performed red cell apheresis in patients with diagnosis of hereditary hemochromatosis ( ¥ c y homozygotes, ¥ c y + h d heterozygote) using haemonetics mcs p cell separator (protocol tae) in which red cells are removed from patients in - cycles; plasma and buffy-coat are reinfused. collection time, donor convenience, side effects and red cell yield were recorded and analysed. samples for hematology and iron studies in patients were drawn, analyzed and compared to baseline levels. background: the collection of units of red blood cells by apheresis (drbc) has been reported to be safe and effective in increasing the yield of rbc units from a donor population. however several reports demonstrated the risk of inducing iron depletion when the interval between a drbc donation and a subsequent rbc donation is shorter than days. aims: to evaluate the recovery from anaemisation and iron stores depletion after drbc donation. methods: donors who underwent drbc donation between december , and february , have been enrolled in a follow up program to monitor haemoglobin (hb), htc, serum iron and ferritin values. these parameters have been assessed on the day of donation and, thereafter and days after drbc procedure. donors suitable to drbc apheresis had to have: age between and years, weight > kg, hb > . g/dl and serum ferritin between and ng/ml. a written informed consent about the collection procedure and the follow-up program has been obtained from all the enrolled donors. drbc collection procedures have been performed by using a mcs + (haemonetics) cell separators. results: out of donors who donated drbc during the study period, only males completed the follow up program and have been analysed. baseline haematological values and iron metabolism parameters were: mean hb . ± . g/dl, ferritin ± ng/ml, serum iron ± microg/dl. on day mean hb was . ± . g/dl (p < . ). on day mean hb was . ± . g/dl (p < . ), ferritin ± ng/ml (p < . ), serum iron ± (p ns). only out of donors ( %) had a ferritin value > ng/ml. in the studied donors the collection of units of rbcs induced an expected reduction of about grams of hb, however only % of this reduction was recovered after days (p < . ). similarly, also iron stores have not been restored after months from donation, as shown by a % reduction in mean serum ferritin value. according to these data it appear that the amount of iron 'lost' with the donation of units of rbcs (approximately - mg of elemental iron) could not be completely compensated by iron absorption from the diet intake. further data are necessary to define the risk of iron depletion after the donation of a drbc, however, at least in areas where iron intake by diet is not very high, the opportunity to prolong the interval between a drbc and a subsequent rbcs donation beyond six months or to provide adequate iron supplementation therapy should be carefully considered. background: increased transferrin saturation and/or serum ferritin have been observed in italy in approximatively % of subjects at first blood donation and, in these subjects, hfe mutations prevalence was . for c y and . for h d (velati et al., ) . aims: the role of the c y mutation is well known in the patho-genesis of iron overload, whereas the role of the h d mutation remains uncertain. the aims of the present study were first to study the main hfe mutations prevalence in a random group of repeat blood donors and second to evaluate iron parameters and iron depletion in repeat blood donors heterozygous for the h d mutation in comparison to a population of blood donors wt/wt for the h d mutation. methods: a total of repeat blood donors were examined in italian transfusion centers ( in northern italy and in southern) for c y and h d mutations. out of those, blood donors heterozygous for the h d mutation and wt/wt for the same hfe mutation, both groups wt/wt for the c y, were enrolled to evaluate iron parameters and iron depletion. these two groups were similar for number of blood donations (expressed as iron loss) and for sex distribution. serum ferritin (sf) was the iron index recorded at first and second observation. results: table summarizes the allelic frequencies in the blood donors. table reports the haematological evaluation in the subjects heterozigous for h d mutation and the wt/wt for the same mutation. conclusions: these data suggest that subjects with h d mutation of the hfe gene have, at first observation, a higher ferritin levels than subjects wt/wt. this seems to be more evident in blood donors of southern italy than in northern. blood donation induces significant reduction of the iron stores both in h d heterozygous and in wt/wt subjects. although our observation is preliminary and restricted to a limited number of subjects, it seems worthwhile to extend the follow-up of blood donors h d heteroxygotes or even homozygotes when available, in order to get further insights on the h d role in iron metabolism. background: cd is a sialylated glycoprotein expressed on the surface of most hematopoietic cells and has been implicated in cell adhesion and signaling. consequently the levels of soluble cd as well as the expression on the cell surface is a marker of cell activation. furthermore, downregulation of this molecule has been correlated with increased susceptibility to infections. the myelodysplastic syndromes (mds) are a group of stem cell disorders characterized by ineffective hematopoiesis, refractory cytopenias and an increased risk of leukemic transformation. the mds patients are often introduced to transfusions for anemia improvement and present increased susceptibility to infections. aims: we studied cd expression in transfusion-dependent and non-transfused mds patient in an effort to investigate mechanisms of regulation of this molecule. we also studied other activationassociated antigens in the absence of manifest infection. material and methods: forty-two patients were included in the study suffering from refractory anaemia (ra). thirty-one were males and females aged to (median ). twenty of them had never been transfused (group a) and were regularly transfused (group b). nineteen age matched healthy individuals were used as controls (group c). cell surface antigens were detected by direct immuno-fluorescence evaluated by flow cytometer. the following mouse monoclonal antibodies were tested: anti-cd b, anti-cd , anti-cd , and anti-cd . leukocytes were gated according to cd . we used a sensitive sandwich enzyme linked immunoassay to measure the level of soluble vascular adhesion molecule as an indicator of endothelial cell activation. the r&d elisa kit was used according to the manufacturer's instructions. results: the cd was found down-regulated in the transfusiondependent mds patients compared with the non-transfused ones (p < . ) and controls (p = . ). this downregulation concerned the proportion of cd + cells, that was lower in the transfused patients than the non-transfused (p < . ) and controls (p = . ), and the rfi (relative fluorescence intensity) value that was also lower in the group a compared to the group b (p < . ) and group c (p = . ). negative correlation was observed between the cd expression and cd b (p = . ) and cd (p = . ). cd b was found up-regulated in the transfused patients. the rfi value was significantly elevated in the transfused patient compared with the non-transfused and controls (p = . and . respectively) while the percentage of cd b cells did not differ significantly between the various groups. increased expression of cd was also found in the group a compared to group b (p < . ) and c (p = . ). the proportion of cd + cells did not differ between the various groups. the levels of immuno-reactive svcam- as determined by elisa were found . + . in group a, . + in group b and . + . in the control group. conclusions: activated hemopoietic and endothelial cells are found in mds that may be associated to the vascular disorders found in these patients. cd downregulation may also be associated to increased susceptibility to infections in these patients. despite improved safety of the blood supply, allogeneic blood transfusion continues to be associated with risks that can be eliminated or reduced by autologous transfusion. preoperative autologous blood donation (pad) prevents transfusion-transmitted viral infection, red cell alloimmunization, and some adverse transfusions reactions. it may decrease the risk of postoperative wound infection because immunosuppression as a result of allogeneic blood transfusion is avoided. pad also supplements the blood supply, provides compatible blood for patients with alloantibodies and rare red cell phenotypes, accelerates erythropoiesis, and provides peace of mind to patients. as any medical intervention, pad has both advantages and disadvantages. with proper patient selection and dedicated attention to process control and quality assurance, the advantages outweigh. background: prestorage pooling of whole blood derived (wbd-pc's) buffy coat platelet concentrates (pc) is common practice in europe event-free survival was significantly better in patients who responded to epo + g-csf. we have reviewed data in centers and the gfm has the intention to extend the study to a larger population in at least centers in france blood components and preparations. the new law prohibits the mixing of different blood products, i.e. blood components and blood fractions. different methods are necessary for the quality control of blood components and blood preparations privileges for blood donors include: -a paid day off work on the day of blood donation and medical examination for blood donation additional paid day off work after blood donation an extra paid day off work if blood is given during vacation or on a holiday this award will be given to non-remunerated donors after blood donations or plasma donations. before , each 'honoured donor of russia' or 'honoured donor of the ussr' had three privileges: free use of public transportation, receipt of certain pharmaceuticals free of charge, and a discount on apartment utilities previously, municipalities also could have their own blood establishments. this resulted in more than blood establishments in the russian federation. from both administrative and financial points of view, many of these are too small to be costeffective, and should be discontinued. services, and wider implementation of modern technology for blood collection, testing, processing, storage, and distribution acknowledgements: we thank ksw microtec ag, dresden/ germany for sponsoring the rfid-labels and novatech research gmbh, vienna/austria for developing the clinic-software. background: the national preparation human immunoglobulin g % for intravenous use (ivig) that is produced at the serbian institute for blood transfusion is used in therapy of neurological, heartand haemolytic diseases and on patients that have undergone surgery. aims: it is our aim to prove the impact of this national medical preparation human immunoglobulin g % for intravenous use on patients that have been infected with sepsis as a consequence of surgery. material and methods: human immunoglobulin g % for intravenous use (ivig) has been used in the study. the preparation is liquid, % stabilised with glucose of a ph value of . ± . . it is used in those cases where sepsis developed after surgery. both an ivig group (n = ) and a control group (n = ) were viewed; the control group not being treated with ivig. the number of specimens with the ivig therapy cholecystitis is (n = ), and the control group (n = ); pancreatitis (n = ) control group (n = ); intestinal obstruction (n = ) control group (n = ); abdominal organ perforation (n = ) control group (n = ); abdominal perforate injuries (n = ) control group (n = ); serious abdominal interventions (n = ) control group (n = ). the period of hospitalisation of the patients in the ivig group was ± days while the period of hospitalisation in the control group was ± days. the mortality rate in the ivig group was % counter . % in the control group. summary: toxic gram -negative bacteria caused synergistic damage of human tissues and generalized inflammatory responsesepsis. by using human immunoglobulin g % for intravenous use, in cases of severe disease, the mortality rate is significantly lowered, depending of course on the anamnesis of the patient prior to surgery and the presence of other diseases such as diabetes mellitus, neoplasma, cardiac diseases etc. background: manual production pc from buffy coats (bc) is a procedure with some consecutive manipulations. the orbisac system (gambro bct) automates the steps and we assessed its performance. material and methods: pc were produced by this device and some parameters were studied. for the preparation of pc, bc were pooled using the orbisac set, with an integrated filter (pall lrp ). bc pool was resuspended in the additive solution t-sol in order to obtain a final ratio plasma/t-sol / . the pc was stored in a gambro elp bag. results: the average platelet count per unit was . ¥ e . the platelet recovery from pooled bc was . % (range . %- . %). all products of the tested pc containing < ¥ e wbc (by flow cytometry). the values of ph on day and of storage were . and . . the swirling phenomenon was good until day °. the average loss of haemoglobin per bc was . g.conclusions:the orbisac system is very suitable for routine pc preparation and it allows increased productivity and better standardization method for pc preparation. platelet concentrates met the requirements for leucodepleted product. increased production of plasma components from male donors background: we routinely separate whole blood (wb) after hard centrifugation into a red cell concentrate (rcc), a buffy coat (bc) and plasma (pl) by an automated expresser (compomat, fresenius). the bcs are subsequently processed into platelet concentrates (pcs) by soft centrifugation and an additional (manual) expression step. the atreus c system (gambro bct) eliminates several of those hand-on steps by combining them into one integrated process. a processing 'circular' bag is placed in the device and filled with the wb. while the bag is centrifuged, the system expresses pl, pc and rcc into separate containers. the rccs are subsequently leukoreduced (manually) with a filter (lr-rccs). this study was designed to evaluate the storage characteristics of the rccs obtained with a prototype of the atreus system in comparison to rccs obtained by routine procedure. methods: whole blood ( ml) was collected in top-and-bottom bags, and randomly selected to be processed by either ( ) current routine or ( ) atreus c. rccs were leukoreduced with the integrated inline filter: fresenius (routine group) or pall rc d (atreus). lr-rccs were stored at °c and sampled until day . various in vitro measurements were performed (n = per group).results: see table (mean ± sd). the lr-rccs contained significantly more leukocytes in the atreus group. despite the rbc loss in the bc, hemoglobin (hb) content was % lower in the atreus group, but met the requirements. in vitro storage characteristics for the rccs were similar in both groups. the atreus pcs contained ± ¥ platelets in ± ml. although plasma volume was higher in the routine group, subsequent preparation of pcs would have resulted in an additional loss of ml per unit in the control group. atreus plasma had extremely low levels of residual wbc and rbc. . ± . . ± . < < . aims: the aim of this study was to examine platelet quality of prestorage pooled prp-derived pc's for up to days storage. methods: pc's were manufactured from wbd-pc's using in-line filtration of prp on day . on day , either , , , or pc's were pooled into an elx® container using a sterile connecting device. studies were performed on days , and for the following measure of platelet quality. ph, morphology score (ms), extent of shape change (esc), hypotonic shock response (hsr), percent in surface expression of p-selectin (p-sel), phosphatidyl serine (ps), glycoprotein b (gp b) and by thromboelastography of the prp (maximum aplitude, ma). results: a total of pools were studied, each of , , and pc's. the mean platelet yield was . ¥ e with a range of . - . ¥ e . the five pc's had a mean yield of . ¥ e and all maintained a ph > . on day . all products had less than ¥ e residual wbc. platelet quality data is presented in the table. data are the mean ± sd, n = . conclusion: platelet pools manufactured from pc's produced by inline filtered prp and stored in elx® containers show good quality preservation to day over a range of platelet yields. introduction: the big progress in treatment of critically ill children significantly increases the need for blood and blood products. loss of blood (lowering of the total erythrocyte mass), as well as decreasing of oxygen capacity of blood that can influence cardiovascular function, is main indication for the erythrocyte transfusion. aim of the study: to present the number of erythrocyte concentrates (ek) that were issued to the pediatric clinic in skopje, as well as to point out how they were distributed. material and method: this is a retrospective study performed in nitm-skopje from january till may . the following criteria were followed: hemoglobin (hb), hematocrit (htc), as well the clinical evaluation, and then final decision for transfusion was made.results: there were blood units (ek) issued for the mentioned period to pediatric clinic for pediatric patients (~ , % units/per child). the biggest consumers are children at intensive care unit and at the hematology-oncology unit. one unit of leukodepleted erythrocytes (er) was split equally to - bags. for small and prematurely born children and for some other selected patients er unit was filtered and irradiated. the dosage was - ml er (depends on age and body weigh). ek was issued as washed concentrates, ek were filtered and ek were resuspended in ab plasma. distribution among abo system was the following: conclusion: gynecologic patients consumed rbc more than times than obstetric ones ( vs ) and the number of given transfusions is high. the a blood group is the most needed one. we should insist on using the who guidelines for the proper clinical use of blood and try to minimize the percentage of given transfusion. and z. cermakova university hospital, ostrava, czech republic background: fully automated system olympus pk is an immunohaematological analyser for detection of red blood cells antigens of ab , rh (d, c, c, e, e) and kell systems without centrifugation by mam (microplate agglutination method) on unique terraced microplate olympus. in the czech republic analyser pk is used only in blood center ostrava. aim: to evaluate the validity of results, sensitivity of microplate agglutinaton method, cause of abortive tests, requirements for analyst, capacity and reliability. methods: blood samples of donors were tested between july and january . all samples were analysed for ab blood group. samples were tested for rhd antigen and ones for rh (c, c, e, e) and k antigen. the validity of the results was evaluated for ab with parallel testing antigens and antibodies, while for rh (d, c, c, e, e) and k using two diagnostic serums. sensitivity of mam i.e. occurrence false negative or positive results were found out when results were confronted with previous ones in our data bank acquired testing classical manual tube or microplate methods. requirements for analyst were evaluated in according to demands for needful knowledge for new analyst, necessity of control pk during testing and maintenance. capacity were evaluated as a number of samples tested per day. reliability determine by occurrence disorders. results: ab , rh (d, c, c, e, e) and k were investigated truly by first testing at . % samples. two diagnostic serums anti-d olymp igm and totem differentiate directly rhd negative and rhd positive donors. false negative or positive results were not founded out due to mam or quality of diagnostic serums. about . % samples with abortive tests were analysed next time the same testing or manual technique. causes of abortive tests were microagglutination several samples except for anticoagulative edta, weak solution of red blood cells prepared by analyser, damage of microplate, hemolysis due to impurity of microplate. in one case analyser evaluated false ab blood group due to hemolysis. analyser has friendly software, simple maintenance and sound control during testing, capacity about samples per day and minimal occurrence of weighty disorders. conclusion: analyser olympus pk is an effective alternative full automation for medium serological laboratory and together with mam easy and truly proves blood groups of majority samples with minimal necessity repetition due to abortive tests. introduction and aim of the study: the purpose of this study is to establish nested-pcr for the detection of hepatitis b virus (hbv) in blood and blood products. methods: the primer pair set was designed to amplify bp in sregion of hbv genome in the first pcr and bp of first pcr amplicon with rubisco (internal control) in the second pcr. to assess the specificity of pcr results, all the samples were tested cross-reactivity or interference in the assay. results: in case of hbv spiked blood products such as immunoglobulin and coagulation factors, this method could detect hbv dna up to . iu/ml. nested-pcr was compared with pcr-elisa and hybrid capture ii (hc-ii), the pcr-elisa showed a sensitivity of % (hc-ii; %) and a specificity of % (hc-ii; %) (p < . ). the results of the study show that nested-pcr and pcr-elisa could be used equally in the management for hbv detection in blood and blood products. p- blood component therapy: slow improvement a mrdja health center subotica, subotica, serbia background: transfusion department at general hospital was founded in . since that time till now it has answered to all demands in blood and blood components. aim: the aim is to present development of the transfusiology department in the last years, so that we could see how much of scientific knowledge we have adopted and in which direction our department goes at the moment. method: retrospective analysis of blood/component utilization in period from . january to . december . results: in whole blood participated in the consumption with . %, packed red blood cells with (rbc) only . %, washed rbc were used in . % of the cases. in whole blood participated in the consumption with . %, packed rbc with . %, washed rbc with . % and rbc in additive solution with . %. as far as plasma preparations are concerned, there has been, since , a great consumption of plasma -witch was separated from whole blood in period up to five day in . % cases, and small consumption of fresh frozen plasma (ffp) only . %. since , there has completely been cancelled the production of five day old plasma, only ffp is being used. from to for the patients who needed platelets, platelet rich plasma (prp) was prepared and applied right after preparation. the consumption rate was from units to units per year. in , after the purchase of platelet shaker, began the production of platelet concentrates (pc) and consumption suddenly rose from units in to units in . conclusions: it is obvious from the analysis that irrational consumption of whole blood was reduced to more acceptable values and therefore the use of component therapy got increased. variation in blood consumption and its slight increase is obvious though application red blood cells was conducted according to strict indications. in the production of plasma old up to five days was cancelled and instead we produced only ffp. pc we prepared for patients only in agreement of treating physician. although very slow progress in development of transfusion therapy in our department can be seen in accepting scientific knowledge. transfusion specialist are active participants in patient treatment and by accepting scientific achievement are able to set standards and help our colleagues, clinics, in successful hemotherapy. introduction: blood groups may act as receptors of parasites, bacteria and viruses. there is evidence that they perform a function and play a biological role. objective: the aim was to detect abo and p epithopes in ascaris lumbricoides extracts (ae) and to study the presence of immune antibodies in patients with ascariasis. materials and methods: ae were prepared by refrigerated mechanical rupture of adult specimens. agglutination inhibition (ai) and haemogglutination kinetics (hk) tests were made with the ae. the patients´ abo and p blood groups were determined. we total febrile non haemolitic male transfusion reaction f e m a l e alloimunisation on le/hla male antigens f e m a l e kandidates of renal male transplantation female lupus nephritis male f e m a l e total female male introduction: irradiation of blood product has been in routine use to prevent graft-versus-host disease (gvhd) in certain recipients for many yeas. gamma irradiation can abrogate the ability of lymphocytes to proliferate in vitro, cgy of gamma radiation reduce lymphocyte response to mitogens by %.the aim of the study: . to estimate potassium level increment in stored irradiation blood units. . to compare the increment in potassium level between leucodepleted and non leucodepleted, irradiated stored blood units. . to evaluate the expiratory date of blood units post irradiation. the study included units of blood collected in cpd-adsol (as- ). in twenty units the blood collection bag was with inline leucodepletion, while the other units were non leucodepleted. all the units were irradiated using caesium as a source of irradiation, with a dose of - cgy. baseline samples from the bags were obtained for measuring of extra cellular potassium (k+). control samples included. results: there is statistically significant increment in potassium level in the irradiated samples compared to the non irradiated samples starting from st day post irradiation and continues to day post irradiation. comparing the group of irradiated leucodepleted, with irradiated non leuconondepleted, for potassium level estimation during the days of storage post irradiation. there is no statistically significant difference between the two groups during all the days of storage, starting from base line samples and other samples post irradiation until day , p value of more than . . . gamma irradiation of bloods units can cause cell damage that the use of such components needs to be modified. . there is a significant increment in the extra cellular potassium level in irradiated blood units that shows doubling value within h post irradiation. . there is no significant difference in extra cellular potassium level increment post irradiation when prestorage leucodepleted units are compared with non leucodepleted units. . an out date of days post collection (unless they expired before) for irradiated red blood units seems reasonable to ensure transfusion of irradiated units without serious complications, except in neonates and massive transfusion cases where irradiated blood units should be fresh and used within - h post irradiation. . the percentage of irradiated blood units requested by our physicians ( . %) is very less that reflects the needs of physicians awareness of the indications for requesting irradiated components that can prevent serious post transfusion complications. the use of whole blood and blood components in treatment of surgical patients in ten years period was analyzed in iran. in accordance with world trend of using blood component therapy, in medical centers throughout the country in ten years period, there are decreasing trend of using whole blood from % ( ) to . % ( ) and increasing trend of using packed red cells component therapy from . % ( ) to . % ( ) . there is also increasing trend of using fresh frozen plasma (ffp) from . % ( ) to . % ( ) . comparing and year, in use of blood therapy related to hospitalized patients at surgical department who received blood and patients who did not received blood; it appears that there is statistically significant difference between these two years. results: during year period, a total of units of blood and units of f.f.p were used. more specifically, the results can be shown in the following table . a high rate of f.f.p usage is observed both in surgery and pathology clinics. the main causes of its usage are: haemodynamic disorders -volume depletion, and coagulation disorders and low blood protein, for the two clinics respectively. conclusion: the only way for rational usage of f.f.p is the regular reminding of plasma transfusion indications to the clinical doctors, so that undesirable side-effects caused by plasma transfusion will be reduced and the percentage of plasma used for fractionation will increase. acquired factor v inhibitor is extremely rare and is associated with diverse clinical symptomatology that varies from asymptomatic forms of the disease to very severe hemorrhagic episodes with a potentially lethal outcome. it may occur spontaneously or as a result of various clinical conditions. a -year-old man was admitted to our hospital with a diagnosis of left-sided periscrotal abscess and scheduled for an incision procedure. during the routine preoperative procedure screening coagulation tests showed pathologic values: aptt s, pt %, fibrinogen . g/l, fv % (other factors were in normal range), platelet count ¥ /l. factor v inhibitor was detected by a modified bethesda assay. the assay showed a low level of inhibitor of about . bethesda units (bu). the patient's medical history showed no major morbidity except appendectomy performed years ago. the patient was prepared for operative procedure, with preventive preoperative administration of fresh frozen plasma (ffp) in a dose of mg/kg (~ ml). upon ffp transfusion, repeated determination of the factor v plasma was unchanged from the initial finding ( %), indicating a failure of therapeutic response. as the measured level of factor v activity was at the borderline hemostatic level, and the operative procedure was not associated with a high risk of hemorrhage, the patient underwent abscess incision. the procedure and postoperative course were uneventful and without major hemorrhage. laboratory testing for the possible systemic autoimmune disorder produced normal findings. control examination performed two years later revealed no major clinical or laboratory variation, while a low factor v level persisted ( %) along with the presence of factor v inhibitor at a level of . bu. we have evaluated two groups of rcc's, one we routinely use (quadruple leucoflex lcr t/t cpd/sagm) (macopharma) and one using an automated collection device which gives the ability to collect whole blood in cpd with a rate of : respectively during the whole donation. the mentioned system has been evaluated using the suitable, quadruple leu-coflex lcr t/t cpd/sagm (macopharma). whole blood ml in cpd was collected from random donors. in both groups the whole system was stored at scaled r.t. ± °c for to h. after component separation (beckman coulter j mi-optipress i-baxter), the red cell concentrates were filtered immediately at r.t. ± °c. sampling was done after filtration and wbc measurements were determinated using nageotte champer (bright line-detection limit . wbc/ml) with leucoplate solution (sobioda). the other parameters were measured with (celldyne abbott). conclusion: all products met the accordance of national and european norms for blood components quality. leucodepletion with leucoflex lcr and abc leucoflex lcr ( . and . ) is highly efficient. the use of abc leucoflex lcr showed better scaled donation in terms of collection (statistical analysis mann-whitney, minitab p-value = . < . ). additionally less hb-loss occurred, due to the filtration process, most probably due to the total absence of clots (analysis man-whitney, minitab, p-value = . < . ). this new generation of collection gives the ability in blood services to collect well calibrated donations, indoors or outdoors. smaller quantities of donations theoretically can be valid because of the stable : , rate of donation. the abc system gives the ability of fully traceability during donation. macopharma's blood collection bags, with or without integrated filters, provided they have this modified system of storing the ac. the device can keep records for many parameters and can transfer them to the data base server of the blood center. to evaluate the performance of the abc, we conducted a comparative study between abc leucoflex lst system and leucoflex lst system we currently use. the later is a well known macopharma's system for collection of whole blood with integrated whole blood filter and the final production of one unit of leucodepleted crcs and one unit of leucodepleted plasma. the abc was handled with the same system modified with the storage bag for the ac. issues of comparison were the accuracy in donation volume, the duration of filtration, the loss of blood in the filter and the residual wb cells after filtration. we performed donations with the lst system and donations with the abc lst system. all the donors were random male volunteers and they were meant to donate mls of whole blood. our results analysed by mann-whitney, minitab statistical analysis have as follows: . no significant difference was found between the two systems concerning the whole blood volume, but there was broader distribution of the values in the lst system compared to the abc lst system. . the duration of filtration has been found without statistically significant differences between the two systems. . the loss of volume in the filter of lst is higher than in the abc lst (p = . < . , which is statistically significant). . there was very good leucodepletion with the lst systems (median reduction of the wb cells . log) but there was a superiority of the abc lst over the lst concerning the leucodepletion per litter and per unit (p: . and p: . respectively). . the personnel after a very short period of training accepted fully the abc procedure.in conclusion abc is an easy to handle device which provides with high quality blood products in combination with leucoflex lst . evaluation of a post-storage filter for wbcs with an incorporated waste bag for washing rccs leucolab lcg is a system manufactured by macopharma for poststorage filtration of a rcc unit (with or without an incorporated waste bag for further washing of the filtered product). to evaluate the efficiency and reliability of the above system we conducted a study with twenty three random units of rccs stored in cpd/sag-m, aged - days, filtered and consecutively washed with ml of normal saline, span down in the regular way and the supernatant extracted in the waste bag. issues for evaluation were: . the duration of priming and filtering the rccs. . the loss of volume in the filter. . the efficiency of the filtration. . the acceptance of the personnel of a new (to them) filtration system.our results have as follows: . we counted the duration of priming and filtration. median time of priming was s (range - ) and of filtration was min (range - ). . the median volume lost in the filter (as calculated) was . ml (ranging from . to . ). this narrow range is apparently due to the non-flexible cell of the filter. . the efficiency of the leucodepletion was counted by flow cytometry. the median wbc counted per lt was . ¥ (range . - . ¥ ) and per unit was . ¥ (range . - . ¥ ). the median reduction of the wbc count was . log (range . - . ). . the personnel involved in the procedure found the system easy to handle, even without specific training. in conclusion the lcg is a reliable and easy to handle system, for leucodepleting (and washing) rccs, very efficient in removing wbcs with negligible loss of volume. objective: standardization of blood banks and establishing quality assurance are important landmarks in the new era of transfusion medicine. as the number of blood banks grows and the capacities of them changes, centralization need arises and trends to nationally coordinated blood services eventually appear. aim: to investigate the types and capacities of blood bank in the country and evaluate the statistics of them. material and method: blood banks and transfusion society of turkey conducted a nation-wide survey of a comprehensive questionnaire. this is a preliminary report of this investigation and illustrates the capacities of the most blood banks in turkey. it also guides the nationally planned renewing structure of blood banks. results: there are nearly blood banks and blood stations in whole country. the overall blood collected at those centers is about . . units. nearly one in third is being collected at government hospitals ( . %), nearly the same is collected at university hospital blood banks ( . %). the third major group is the red crescent society blood centers-rcsbc ( . %), followed by the social security hospitals ( . %). blood collecting capacities are not appearing in the same order. the major blood banks belong to the rcsbcs, whereas the small ones are mostly government hospitals. the only donor recruitment organization is run by the rcsbcs. yearly blood collecting capacity blood banks (%) > . . . - . . . - . . . - . . < . . conclusion: there are many steps for improving blood safety in a country, and the prior ones are structuring the blood transfusion system and donor organization on a national basis, and then establishing good manufacturing practices. these are only possible after centralization of all existing blood banks. in our country, we should first arrange all small capacity blood banks and standardize them. controversial clinical questions considered in a medical opinion forum by physicians for the advancement of transfusion medicine (patm) patm is a newly formed group of close to physicians drawn from pathology and hematology, transfusion services, hospital blood banks and blood centers. its mission is to address the concern that patient oriented medical opinion and influence has been diminished in transfusion medicine (tm). they believe that a patient oriented voice should be distinct from institutional, commercial or regulatory weight and have a common focus on patients and the therapeutics of transfusion and related therapies. therefore, their first objective is to create a new medical, patient oriented voice that weighs in on national policy pertaining to treatments related to tm. as such, patm held its first medical opinion forum where members of the group debated important questions pertaining to tm clinical practice. the forum was held just prior to the aabb annual meeting and attracted physicians. the questions debated were preselected by patm membership via an email survey. respondents were asked to select their top four preferences from among topics in five broad categories. the top two topics were selected for the forum from the completed surveys. the subjects selected and debated were (i) what are the medical considerations for reducing the rate of mistransfusion? and (ii) what are the medical considerations for managing a limited blood inventory? the participants were divided into four groups, with each topic assigned to two groups. all the groups were given two h to debate and arrive at consensus on their topic. each group then presented a summary of their discussions along with specific recommendations for addressing these clinical practice issues. there was remarkable consensus between the groups debating the same issue. the conclusions and recommendations on these two topics will be presented in detail. patm is a new organization that will add an important medical voice and opinion on current topics in tm. at its first meeting, two topics were successfully discussed and debated with broad consensus achieved on current issues confronting the field. key: cord- -pol qm authors: nan title: third international congress on the immune consequences of trauma, shock and sepsis —mechanisms and therapeutic approaches date: journal: intensive care med doi: . /bf sha: doc_id: cord_uid: pol qm nan this issue of the journal contains the abstracts for the third international congress on the immune consequences of trauma, shock and sepsis -mechanisms and therapeutic approaches. we hope that the information contained in this special issue will stimulate you to participate in the congress, to contribute to the knowledge being developed in this field and to use this information to help you in providing better care for your patients. we thank the editors and the editorial board and publishers of the journal for their interest and support in preparation of this special issue. we also, on behalf of the scientific committee, welcome you to the third international congress in munich on - march . when, in the mid- s, we thought of having a worldwide congress, we hoped to bring together investigators to discuss this theme. the explosion of knowledge occurring around that time provided an excellent background against which the first conference in provided stateof-the-art information and consensus on factors involved in injury and sepsis. in , the second congress was held at the time of another resurgence of research, study and information on injured and operated patients. it seemed then that there would be a lull in the development of new information and therapy, and that another state-of-the art conference might not be necessary until or . however, the explosion in molecular biology has continued. the wonderful world of cytokines has gone from ill to il- to il- , il- and il- and beyond. the vast amount of information about mediators and their importance in disease is impressive. this has all suggested a magic bullet that might be used to alter or block inflammatory responses. this has not happened, however, and the question is "why not"? our science is powerful, but our therapy is still weak. what are the issues, then, in , to be dealt with at this symposium and congress? ( ) proposals for new terminology. there have been a number of proposals for new terminology and new classifications of injury, sepsis, inflammation and various other problems related to human illness. the question is whether this is the way to go. will this contribute to better clinical trials, information basis and better research? the pros and cons of this development will be reviewed by those making the proposals and those questioning the need for and wisdom of this effort. ( ) magic bullets: the prospect of a magic bullet to deal with inflammation in injury and infection seemed highly promising earlier. many preclinical trials and a lot of animal research suggested the possibility of a great breakthrough in clinical care. what has become, then, of all the expensive and extensive multi-institution randomized, placebo-controlled, double-blind clinical trials of agents that block mediators and endotoxin. many such studies have yielded equivocal, marginal or negative results. the reasons for this and the future of clinical research will be the subject of presentations and discussions to set the stage for further work. ( ) should future clinical trials be based on new classifications of illness such as mods, sirs, apache iii, sap ii, mrm, etc., or should trials be dedicated to specific diseases -urinary tract infections, pneumonia, trauma patients, cardiac surgery and other specific problems, rather than generalized problems of sepsis, the sepsis syndrome and other classifications? in other words, should we now begin to have clinical trials on specific diseases with causes that are known and can be attacked? the causality of disease becomes an important consideration in this regard. ( ) a multitude of potential therapeutic agents has been proposed on the basis of animal studies. how should we decide which of them should be brought to clinical trial? the possibilities are endless as we develop new clinical information about the mechanisms and pathogenesis of human disease. ( ) information on the pathogenic mechanism of disease states and of injury continued to emerge in an explosive fashion, and in light of our gathering knowledge we can look forward to working out a cohesive system of response to injury. ( ) additional information will be provided in plenary sections, many symposia and free communication sessions and posters, which will update the participants on a variety of relevant topics presented by many of the leading in-iv vestigators in these fields. topics will range from molecular mechanisms, such as signal transduction, through the explosive growth of information on the role of cytokines and pathophysiology, to practical considerations in the design of immunomodulatory therapeutic regimens. these merely touch on a few areas, from the basic to the clinical, which will be the subjects of those symposia. all this information will fit into the jigsaw of this exciting area and its stimulus to further research study. this promises to provide an exciting, educational programme with experts and participants from all over the world. we hope it will set the stage for many years to come and will increase our understanding of trauma, shock and sepsis and help us to provide better therapy for those of our patients who are affected by such problems. a. the clinical syndrome of mods versus mof will be reviewed in detail by those who have made these proposals. b. an extensive review of the design and interpretation of clinical trials in patients with shock and injury will be provided. the reasons why so many clinical studies in the recent past have been negative will be reviewed. the therapeutic strategies that are being developed for the treatment or prevention of mods or mof will be the subject of another panel discussion by experts who have been involved in and contributed to this area. a consensus conference or controversy conference will be presented about various aspects of mods or mof, including the benefits of supernormal oxygen delivery, bacterial translocation, parenteral nutrition, the immune response and other aspects. the successes and failures of completed clinical trials will be presented by those who are involved in these clinical trials, with a refreshing review of the problems related to that injury. there will be late news about studies just being completed at present or after the beginning of and where they stand. c. the mechanisms and biochemical profiles of specific organ dysfunction or failure will be reviewed. what are the definitions? what are the mechanisms? how can organ dysfunction and/or failure be defined? an extensive review of the biological mechanisms involved in production of injury by mediators will be presented. a session will be devoted to how future ongoing trials might be better designed and what can be done about the studies recently completed, many of which are negative. d. the immunological or inflammatory pathways resulting in organ injury will be reviewed in detail in presentations and a panel discussion. we look forward to welcoming you to an exciting and rewarding conference, which undoubtedly possesses the potential to become a landmark event and major reference point for any scientific discussion about the complex of host defense dysfunctions following trauma, shock and sepsis. studies over the past years have established that the contact system, which forms bradykin/~, is gax important mediator in hypotensive septicemia. in addition to hradyk{nln, another product of the contact system, kailikrein, can mediate inflammation by virtue of its chemotaetic mad neutrophj/activating properties. using functional and immunochemical tech~ ques, we have demonstrated activation of the contact system in the adult respiratory distress syndrome in typhoid fever and clin/cal sepsis. we have also been able to inhibit the hypotension but not the disseminated intravaseular coagulation in a model of primate sepsis by the use of a monoclonal antibody directed agsi~st factor xii, the initiating protein of the contact system, in volunteers given e. coil endotoxin, who did not develop hypotension, we were also able to demonstrate activation of the contact system with a rise of alpha- macrogiebulin-kalllkrein complex. we have also examined, j~ an i~tensive care situation, patients with sirs. we found that serial measuremezzts of the contact system were useful in eva~u~ting prognosis+ these studies suggest that inhibition of kalllkrein a~d l e r bradykinin actions might be useful i~ obviating many .of the features seen in sepsis and septic shock. dextran sulfate (dxs) activates the contact system and, in vivo, produces transient hypotension. in order to better define the mechanisms underlying the dxs-induced hypotension, we investigated the effects of either the plasma kallikrein inhibitor, des-pro -iarg] ]aprotinin (bay ) or the b kinin antagonist, hoe on the hypotensive response to dxs. in the first study, anesthetized miniature pigs ( pigs/group, randomly assigned) were given one of the following treatment protocols: ) dxs ( mg/kg), - ) dxs plus bay ( , , , or rag), or ) saline. dxs alone produced a profound but transient systemic arterial hypotension with a corresponding reduction in plasma kinin-containing kininogen. circulating kinin levels, complement fragment c adesarg and fibrin mom)mer were all increased. bay produced a dose-dependent delay or attenuation in these effects with the highest dose completely blocking dxs-induced hypotension and elevations of kinin, c adesarg and fibrin monomer levels. thus, the effects of dxs are solely dependent on contact system activation and this activation is sensitive to bay . llowev~:r, contact system activation is known to produce changes in a variety of vasoactive mediators, all of which can affect blood pressure. in a second study, two groups of pigs ( /group) were given either dxs alone ( mg/kg) or dxs minutes after a bolus injection of hoe ( #g/kg). dxs alone produced transient hypotenmon. this response was completely blocked by hoe pretreatment. both groups had identical reductions in kinin-containing kininogen. we conclude that dxs-induced hypotension is produced by activation of the contact system which results in the production of bradykinin. liberation of bradykinin is both necessary and sufficient to produce all of the hemodynamic changes observed. dr. matthias siebeck, department of surgery, university of munich, klinikum lnnenstadt, nussbaumstrasse , d- munich, germany in experimental animals exposed to i.v. injection of endotoxin accumulation of leukocytes in various organs as lungs and the liver is a prominent feature. as a part of these morphological changes damages of endothelial ceils are regularly seen. this process, which is a part of endothelial-cellular interaction, leeds to exposure of the sub-endothelial basement membran. the basement membran is known f r its capacity to activate the contact system of plasma. during this cascade activation, coagulation factor xii is converted to the active factor xii. this activation might produce increased plasma kallikrein activities and thereby give release of the vasoactive substance bradykinin. using a porcine model we have noticed that endotoxin infusion ( , mg/kg) induces elevated plasma kailikrein activities within two hours after the start of the infusion. this enzyme activity remained increased during the next hours and reached value of up to u/ . in patients with sepsis we also have observed elevated plasma kallikrein activities with enzyme activities up to u/ . in order to further elucidate the significance of these elevated enzyme activities, we prepared human plasma kallikrein and injected it intravenously in anaesthetized pigs ( ). when very small plasma kailikrein activities ( , u/kg bodyweight) were given intravenously a % decrease in arterial blood pressure was seen in the animals. in the patients with sepsis also decreases in prekallikrein values and functional plasma kallikrein inhibition are frequently seen. furthermore, degradation of high molecular weight kioinogen is found in these patients indicating formation of bradykinin. these experimental and clinical studies underline that contact activation in sepsis might results in the release of very powerful mediator substances which can be of pathophysiological importance in this disease. a number of pathological disorders as reperfusion injury, bone marrow transplantation, polytrauma and septic shock are associated with capillary leakage. as the activation of the complement system and the contact phase play a major role in these diseases we investigated whether cl-lnhibitor (c -inh), which inactivates cl-esterase, kallikrein and clotting factors xii and xl, could abolish vascular leakage. a capillary leakage was induced in rats by the administration of interleukin- ( x iu/kg). the increased vascular permeability was monitored for one hour as the extravasation of fitc marked rat serum albumin from a mesenterial vessel by a video-image processing system. ci-inh (berinert®, behringwerke) given as a single i.v. bolus in concentrations of , or u/kg dose-dependently prevented the capillary leakage. carrageenaninduced inflammation in the rat leads to vascutar leakage and to edematous swelling of the paw. ci-inh in this model leads to a dose-dependent decrease in paw edema formation. finally, we investigated the effect of ci-inh (infusion ( - u/kg x h) on a lps-induced shock in the rat by combination therapy with the antithrombotlc agents antithrombin ill (kybernin®) or rec. hirudin (both substances from behringwerke). in this animal model mortality was % in the untreated control. both antithrombotic agents decreased mortality rates by inhibiting formation of dic; a further significant improvement of survival was achieved by the treatment with ci-inh. thus+ it could be concluded that c -inh has a beneficial effect in diseases associated with a vascular leakage. iclb and laboratory for experimental and clinical immunology, university of amsterdam, the netherlands; thrombosis research center, temple university, penn., usa; oklahoma medical research foundation,. ok. city, usa. to evaluate the contribution of the contact system to activation of other mediator systems in an experimental model of sepsis, we investigated the effect of mab c b which inhibits activation of factor xli, on activation of complement and fibrinolytic cascades and activation of neutrophils in baboons suffering from a lethal sepsis. activation of the complement system was assessed by measuring circulating levels of c b/c and c b/c, and a significant reduction was observed in animals that had received a lethal dose of e. coli together with mab c (treatment group), compared to animals that had received a lethal dose of e. coil only (control group). activation of the fibrinolytic system as reflected by circulating plasmin-= antiplasmin complexes and tissue plasminogen activator, and activation of neutrophils, assessed by measuring circulating elastase-=l-antitrypsin complexes, was also significantly less in the treatment group. we conclude that activation of the contact system protein factor xll during the inflammatory response to a lethal dose of e. coil in this baboon model, modulates directly or indirectly activation of the complement and fibrinolytic systems and that of neutrophils. in a prospective study, plasma levels of c a, c , and c a were measured in patients from an internal intensive care unit. patients were clinically septic defined by the criteria of bone et al.(l) . the remaining patients were critically ill but didn't fulfill the clinical criteria of sepsis. from both groups of patients blood samples were taken over a l days period. during the first days blood samples were drawn every h, on day - every h and the last days once daily. mean plasma concentrations of c a within the first h after clinical onset of sepsis were + pg/ml, whereas non-septic-patients exhibited mean values of only +_ p_g/m/. c levels were lower for septic-patients ( + lag/ml) than for non-septic-patients ( _+ lag/ml). the most profound difference between both groups was found, when the c a/c ratio was compared ( . + . for septic-patients and . _+_ . for the control group). no significant differences between both patient groups were observed in c a plasma levels ( . + . ng/ml in septic-patients vs. . _+ . ng/ml in control patients). in of cases of clinically defined sepsis causative organisms like bacteria, protozoa or fungi could be cultured from blood, bronchoalveolar lavages and/or section materials. application of the complement parameters to survivors (n= ) and non-survivors (n=l ) within the septic-group revealed, that the c a/c ratio could also be used as a prognostic parameter for clinical outcome. the possibility of rapid and easy measurement of c a and c in only - minutes ( ) and the significant difference of the c ajc ratio between the septic and non-septic group renders this parameter a good candidate for early diagnosis of sepsis in the intensive care unit. hirudin, a single polypeptide chain composed of amino acids with cysteine residues (mr daitons), is the most potent and specific thrombin inhibitor, which is now available as a genetically engineered product (rec. hirudin -hbw , behringwerke; marburg). the aim of our study was to establish a rabbit model of tissue factor (tf) induced activation of the extrinsic pathway of coagulation and to evaluate the therapeutic efficacy of rec. hirudin. coagulation was induced in female nzw rabbits by infusion of . p.g/kgxh thromboplastin for hours. development of disseminated clotting was manifested by a decrease of fibrinogen and platelets to . % and , % respectively, and by an increase of fibrin monomers from . to > . ~tg/ml. we administered rec. hirudin to rabbits in different concentrations ( . , . and . mg/kg); treatment started simultaneously with the infusion as an i.v. bolus. rec. hirudin significantly prevented the decrease of fibrinogen, platelets and the increase of fibrin monomers. this effect was dose dependent and long lasting, even hours after the administration of rec. hirudin, clotting was still significantly reduced. as could be drawn from the plasma levels, rec. hirudin had been cleared from plasma at this time. in a post-treatment study we administered rec. hirudin ( . , . and . mg/kg i.v. bolus) as late as hours after the start of tf infusion. at this time there was already a prominent activation of coagulation. even in this post-treatment regimen rec. hirudin significantly prevented disseminated clotting. hence, it was concluded, that rec. hirudin by inkihiting thrombin could be effective in the prevention of coagulation disorders including disseminated intravascular clotting (dic) induced by a septic disease. research laboratories of behringwerke ag, marburg, germany $ novel protease inhibitory activities of the second domain of urinary trypsin inhibitor (r- ) and its effect on sepns-lnduced organ injury in rat atsuo murata , hitoshi toda , ken'ichi uda , hidewaki nakagawa , takesada mori , hideaki morishita , tom yamakawa , jiro hirese , atsushi ni~ , nariaki matsuura osaka university medical school, osaka, mochida pharmaceutical co. ltd. tokyo, wakayama medical schoof, wakayama, japan inhibitory-activities of the second kuntz-type inhibitor domain of human urinary trypsin inhibitor (uti) and its effect on sepsis-induced organ injury in rat were investigated by using the recombinant protein. uti is a glycoprotein with a structure in which kunitz-type inhibitor domains are linked in a row. we isolated the gene encoding the second kunitz-type inhibitor domain of uti, and then constructed expression plasmids by ligating it to the e. coli phoa signal peptide gene. these plasmids expressed the second domain in e. coil strain je which lacks the membrane lipoprotein. the recombinant second domain (r- ) innb[ted trypsin, plasmin, neutrophil elastase and chymotrypsin. in addition it inhibited blood coagulation factor xa and plasma kallikrein in a concentration dependent and competitive manner. the in vivo effect of the recombinant r- was investigated in a rat model of septic shock induced by cecal ligation and puncture. the administration of r- significantly improved the survival rate of the rats and attenuated the pathological changes of lung and iiver. we found out the novel protease inhibitory activities of the second domain of uti and its protective effects on sepsis-induced organ injury. macrophages are known to secrete lysosomal proteinases,mainly cathepsin b and cathepsin l, and also ~-proteinase inhibitor (pi),related to acute phase proteins.disturbances of proteinases/ proteinase inhibitors correlates with inflammatory process,leading sometimes to noncontrol "pathglogical" proteolysis (jochum et ai., ) . the cathepsin l-like and cathepsin b-like activity were measured in serum of patients with chronic bronchitis ( -with obstructive, -with nonobstructive bronchitis),acute bronchitis ( ) and healthy persons.simultaneously the level of~pi was determined in the same groups.cysteine proteinases were measured with help of fluorogenic substrates,as was presented earlier (korolenko et ai., ) , ~pi with help of immune enzyme method. it was shown increase of cathepsin l-like and cathepsin b-like activities during aggravation of chronic bronchitis comparatively to the controls ( - fold) .after treatment there was a tendency to normalization of indices,but the increase was about - % more than the control values.~pi level in this group was also increased (two-fold),in patients with acute bronchitis - - -times more comparatively to the control.it is possible to conclude that chronic bronchitis induced increased secretion both cysteine proteinases and d{pi into blood. some peculiarities of ratio were noted in patients with emphysema. endotoxins are microbial products derived from the outer cell membrane of gram negative bacteria. the active component of endotoxin is lipopolysaccharide (lps), a complex macromolecule consisting of polysaccharide covalently bound to a unique lipid, termed lipid a. now recognized to embody the endotoxic principle of lps, lipid a consists of a/ - diglucosamine backbone, both ester and amide linked fatty acids, some of which are acyloxyacylated, and charged constituents such as phosphate, phosphorylethanolamine and amino arbinose lps, exerts its biological effects in vivo by noncytotoxic interactions with a variety of host inflammatory mediator cells, primarily the mononuclear phagocyte and the endothelial cell, although other host cells also participate. these interactions are modulated by lps-specific binding proteins found in plasma, including lps-binding protein (lbp) scd and perhaps other proteins as well. specific receptors for lps have been identified on mammalian cells which mediate signal transduction via multiple pathways. lps-activated host cells are stimulated to secrete or express multiple proinflammatory mediators, including tnf-a, illa, il- / , ifn-a, il- , il- , il- , paf, pge, ltb and procoagulant activity. the overproduction of these proinfiammatory mediators results in the manifestations of endotoxemia, observed experimentally as fever, hypotension, disseminated intravascular coagulation and death. modulation of activity of these mediators protects animals against lethality. similar pathways are thought to be operative in gram negative sepsis, and control studies with human volunteers support such conclusions. immunotherapeutic approaches in clinical gram negative sepsis have, to date, been less successful. in vitro experiments and studies in animal models have recently shown that several proteinaceous bacterial exotoxins can evoke cytotoxic effects that ultimately lead to cardiovascular collapse and shock. since the possible relevance of bacterial exotoxins in the pathogenesis of septic shock has received very little attention in the past, an attempt will be made here to provide a brief overview of this generaily neglected topic. protein toxins act intracellularly or they dz~nage the integrity and function of the plasma membrane. major representatives of the former group are the adenosine diphosphate (adp)-ribosylating toxins, e.g. cholera and cholera-like toxins, diphtheria toxin), and the neurotoxins. most medically relevant toxins of this category have been studied in great detail. although often responsible for severe and sometimes fatal disease, their association with septic shock is rare. in contrast, experimental evidence is accumulating for a role of membrane<lamaging toxins in the pathogenesis of inflammatory lesions. formation of transmembrane pores is probably the most widespread mechanism via which such physical membrane perturbation can occur ( , ), the present discussion will be restricted to this category of toxins. the author shall first discuss basic properties of pore-forming proteins, and consider the factors that direct their attack to specific targets. thereafter, attention will be drawn to diverse functional consequences that may follow membrane damage so that a general concept of how pore-forming toxins may contribute towards the development of shock will evolve. i. bhakdi, s. and tranum-jensen. j. gram positive bacteria produce exotoxins that, at least in part, exhibit the unusual properties of superantigens. superantigens (sag) activate v/ selectively t cells to produce lymphokines including i - and tnf/lymphotoxin. systemic application of the sag staphylococcal enterotoxin b (seb) to d-galactosamine sensitized mice causes lethal shock within hours. seb reactive v/ + t cells accumulate within - min mrna for the ii- , i - , tnfai~ and ifn- ,. parallel in time high concentrations of bloodborne i - and tnf are noted. anti tnf t~// neutralizing mab protect mice against seb induced t cell dependent lethal shock thus indicating a key role of tnf in effecting lethal toxicity. within - h distinct levels of tolerance to seb become discernable on ligand reactive v/ t ceils, dependent of the dose of seb used. these levels include anergy, t cell receptor downregulation, loss of cd , cd , cd accessory molecules and programmed cell death. m.freudenberg, y.yaegashi, p.nielsen, c.galanos. the sensitivity towards endotoxin (lps) is genetically determined, however it may be increased under different experimental conditions. these include treatment with hepatotoxic agents such as d-galactosamine, and with live (infection) or killed bacteria. it is well established now that d-galactosamine sensitizes to lps by increasing the susceptibility of the host to toxic activity of lps-induced tnf~. sensitization by bacteria, especially by gram-negative once is of especial interest because it implies that infecting microorganisms not only produce lps, but als sensitize the host to its lethal activity. sensitization to lps by bacteria proceeds in all lps-sensitive (lps n) mouse strains that have been investigated so far. it also proceeds in lps-resistant (lps d) c h/hej mice. the absence of sensitization to lps in lps d c bl/ sccr mice was identified as being due to their inability to produce interferon- (ifn?). administration of exogenous ifn? to these mice conferred sensitivity to lps. conversely, administration of anti-ifn? to lpsn; mice inhibited the development of sensitization'by bacteria. it may be concluded therefore that ifn is the mediator of sensitization to lps by bacterial infection. the ifn? defect of c bl/ sccr mice concerns only the ifn response to bacteria, since the response to the t-cell mitogen con a and to cd monoclonal antibodies was not impaired. the ifn?producing cells themselves were shown to be intact. on closer investigation the impaired ifn? response was identified as the result of a defective accessory function of macrophages. macrophages of c bl/ sccr mice are incapable of producing interferon-~ (ifn~) which we could show to be obligatory for the production of ifn? in response to bacteria. although antibiotics are required to clear bacteremia, they do not reverse evolving shock, because endotoxin free in the bloodstream or exposed on the surface of circulating bacteria continues to activate the production of inflammatory mediators, furthermore, antibiotics have been shown to induce release of endotoxin from gram-negative bacteria during the treatment of severe infection. in an in-vitro study, using live escherichia coil, we have observed the release of endotoxin upon treatment with several antibiotics like cefuroxim, imipenem, ceftazidime and aztreonam. incubation with imipenem or ceftazidime induced an early lyeis and a mild rise in endotoxin levels, whereas incubation with cefuroxime or aztreonam resulted in the formation of filaments with a late but dramatic rise in endotoxin levels. in a second study we studied the influence of different antibiotics on the tnf-= production of e.coli stimulated human monocytes. we found again great differences in the production of this important cytokine among the different antibiotics according to their capacity to induce liberation of endotoxin. these differences in the amount of endotoxin release are probably caused by penicillin-binding-proteins (pbp) specificities of the antibiotics with resultant differential morphological changes, in a rat sepsis model treatment with imipenem or ceftazidime resulted in a transient increase in il- levels, whereas treatment with aztreonam resulted in progressively increasing levels of il- and a significant increase in mortality. the increased mortality in pbp- specific aztreonam treated rats might have been the result of filament formation in the abdominal cavity of the septic rats. the endotoxin sequestered at local sites may account for the precipitation of gram-negative shock. finally, we've also demonstrated that in patients under treatment for septic shock endotoxin release can be related to the administration of antibiotics. carbapenem-and cephalosporin-lnduced release of lps from smooth and rough pseudomonas aeruginosa: in-vivo relevance j. jackson and h. kropp, merck research laboratories, rahway, nj b-lactam (cell-wall active) antibiotics are generally deemed the class of antibiotics most responsible for the release of free endotoxin (lps) from gram-negative bacteria due to their cell lytic actions although all antibiotic classes studied thus far induce release of endotoxin. we have recently shown in-vitro that antibiotics within the b-lactam class (i.e. imipenem , meropenem and ceftazidime , with equivalent mics) differ in their propensities to release excessive amounts of lps from both smooth-(s-) and rough-(r-) lps laboratory and clinical and antibiotic-sensitive and -resistant p. aeruginosa isolates and that lps release is independent of cell lysis. additionally, variations in the induction of endotoxin release is antibiotic concentration dependant and correlate with antibiotic penicillin-binding protein (pbp) affinities which result in morphological changes. these studies also show that lps differences measured via chromogenic lps (c-lal) assay correlate with lps lethality in lps-sensitive mice. release of lps was compared to changes in cfus, cell mass, morphology and antibiotic pbp-specificity. corresponding in-vivo studies in cd mice against s-lps p. aeruginosa isolates show that, despite equivalent in-vitro protection, antibiotic efficacy in mice differ as much as -to lo -fold. to establish a possible in-vivo role for antibiotic-induced release of free lps we compared antibiotic efficacy results in mice challenged with virulent parent s-lps and its relatively avirulent r-lps mutant (lacking only its side chain) p. aeruginosa isolates. results show the relevance of quantity and physiochemical composition (bioreactivity) of free lps to virulence and in-vivo antibiotic efficacy. in other in-vivo studies chemical agents that destroy cells (m~) which mediate lps lethality in-vivo were used to pretreat mice prior to antibiotic therapy and bacterial challenge with wild type pseudomonas. we conclude that circumstances in which antibiotic-induced filamentation occurs are also conditions that yield excessive lps release, the in-vivo effects of which are shown through the requirement of larger amounts of antibiotic to afford equivalent protection. bacterial endotoxins have been reported to play a significant role in the pathogenesis of gram negative sepsis by their interaction with, and stimulation of, host inflammatory mediator cells to produce cytokines, biologically active lipid intermediates, and procoagulant activity (tfa). although both microbe-associated and free endotoxin are capable of stimulating mediator production, studies from our laboratory suggest that free endotoxin may be the more potent stimulus for tnf and tfa. further, our studies suggest that the majority of the proinflammatory activity released from antibiotictreated e. coli coisolates with lps by two different fractionation techniques. to assess whether actions of endotoxin directly contribute to lethality in gram negative sepsis, an experimental model was developed in which mice were made hypersusceptihle to the lethal effects of endotoxin by treatment with d-galactosamine (dgaln). challenge of cf- dgaln-treated mice with e. coli olll:b resulted in an lds of approximately . x cfu. resolution of the peritonitis and bacteremia by treatment with cell wall-active antibiotics resulted in an increase in the ldso. ceftazidime and imipenem, which differ in their mechanism of action and in their capacity to effect endotoxin release in vitro, also differed in their in vivo capacity to provide chemotherapeutic protection ( fold vs fold respectively, p< . ). parallel studies with endotoxin hyporesponsive c h/hej mice indicate significantly greater levels of protection with imipenem (> fold vs saline controls). collectively these data suggest that endotoxin may contribute directly to the pathogenesis of experimental gram negative sepsis. bacterial lipopolysaccharides (lps) are the endotoxins of gram-negative bacteria and represent their major surface antigens. lps is made up of three chemically, biologically and genetically disctinct regions, i.e, the o-chain, the core region and the lipid a moiety whereby the latter represents the endotoxic center. it is our current understanding that lps is responsible for many of the pathophysiological events observed during gramnegative infections and that one of the major mechanisms leading to shock and death is the lps-induced activation of macrophages resulting in the production and release of lipid and peptide mediators, among which tumor necrosis factor seems to be the most important. therefore, in the fight against the lethal outcome of gram-negative infections, modern strategies, in addition to antibiotic treatment, aim at i) the neutralization of tumor necrosis factor, ii) the inhibition of the production of tumor necrosis factor or iii) the neutralization of the activation potential of lps for macrophages by monoclonal, preferably human antibodies. the latter approach, to be effective against a broad spectrum of gram-negatives, must be directed against common structures of lps (lipid a and core region). the molecular basis of this approach and the controversy in this field will be discussed. passive immunotherapy has been used since , when von behring described the administration of immune horse serum to treat a patient with diphteria infection. even if this therapy was sometimes successful in bacterial infections, it has been largely replaced by antibiotics. however, antibiotics have their limitations, especially in critically-ill patients. to improve outcome, adjunctive therapies such as immunotherapy with polyclonal and monoclonal antibodies particularly against endotoxin are again considered. the role of humoral immunity in host defenses against bacterial infections is weu known. for instance, tile importance of antibodies in the defense against gramnegative infections has been established clinically by studies relating the outcome of patients with gram-negative bacteremia to tilers of antibodies directed at the offending pathogens at the onset ofbacteremia (mccabe ; pollack ) . ever since we know the role of endotoxins in the pathophysiology of sepsis, antibodies against the s-and r-lps have also been detected in sepsis patients. the aim of the administration of iv/g to the sepsis patient is as follows: ) enhancing of opsonization and phagocytosis(antibactericidai activity) ) synergistic effects with [ - actam antibiotics ) neutralization of endotoxin, the main pathogenic mediator of gram-negative sepsis ) modulation and/or inhibition of cytokine release the enhancement of opsonic-and phagocytic-activity especially with igg via fc and c receptors has been well documented. monoclonal antiendotoxin antibodies, proven in clinical studies, do not appear to neutralize endotoxin in vitro and are not reproducibly protective in animal models of sepsis. also they can not suppress endotoxin-induced tnf-~, il- release in mice (baumgartner , corriveau and danner ) . in conlrast, recent studies of a polyclonal immunoglobulin preparation, containing high levels of antibodies against gram-negative bacteria and their o-antigen of lps in igg, igm and iga classes (pentaglobin®) provide evidence to neutralize endotoxin. this effect is demonstrated in vitro (berger (berger , , in animal models (stephan , berger and also in prospective, randomized, controlled clinical trials (schedel , poynton , behre . furthermore mortali b' was reduced statistically in patients with septic shock and endotoxemia by using this preparation, as has been demonstrated by sehedel. anti-core lps monoolonal antibodies: binding specificity and biological properties f.e. di padova, r. barclay, e.th. rietschel. bacterial lps and cytokines are responsible for the pathological processes of gram-sepsis and are suitable targets for therapeutic interventions. chemical characterization and structural analysis of different lps have revealed common features. the inner core region of lps shows a high degree of similarity among e. coli, salmonella and shigella. among a large number of broadly cross-reactive murine anti-core lps mab one of these igg ak) has been selected and chimerized into a human igglk (sdz - ). in elisa and in immunoblots on purified lps both sdz - and wni - show a strong reactivity with all smooth lps from e. coli and salmonella. reactivity with all the known complete core structures from e. coli and salmonella (ra) is evident. reactivity with re structures or free lipid a is not observed. this mab cressreacts with all clinical e. coli isolates from blood, urine and feces and with other enterobacteriaceae. sdz - and wni - have biological activity as they inhibit the lal assay and the secretion of monokines (il- and tnf) by mouse and human macrophages. moreover, sdz - and wni - inhibit the release of il- and tnf in vivo. in vivo sdz - as well as wni - neutralize the pyrogenic activity of e. coli lps and protect mice from lethality in d-gain-sensitized mice. the possibility to use wni - as a capture antibodies in the immunolimulus assay opens the possibility to differentiate the origin of the lps in patients with endotoxemia. franco di padova, sandoz pharma ag, ch basel, $chweiz $ presentation of lps to cd by lps binding protein peter s. tobias, julie gegner, katrin soldau, lois kline, loren hatlen, douglas mintz, and richard j. ulevitch. the activation of myeloid cells by lipopolysaccharides (lps) has been shown to require the serum glycoprotein lps binding protein (lbp) and binding of lps to membrane bound cd (mcd ). other cells such as human umbilical vein endothelial cells (huvec), smooth muscle cells, and some epithelial cells, which do not express mcd but nevertheless respond to lps in the presence of serum, have receptors for complexes of lps with the soluble form of cd (scd ). these complexes of lps with scd are only formed efficiently in the presence of lbp. we have begun to characterise the mechanisms by which lbp enables lps to bind to cd , either soluble or membrane bound. with the use of fluorophore and radiolabelled reagents we have developed procedures for quantitative measurement of the association of lps with lbp and of lps-lbp complexes with cd . these results show that the delivery of lps to scd is catalysed by lbp, i.e., lbp is not included with the lps-scd complex. in contrast, on the surface of cells, lbp does not dissociate from the cells after lps binds to mcd . the kinetics, equilibria and stoichiometry of these reactions will be discussed in the context of models for cellular activation by lps and cellular uptake of lps. supported by nltt grants gm , ai , ai , gm , and assistance from the pharmaceutical research institute of johnson and johnson. the scripps research institute, imm- , n. torrey pines rd. la jolla, ca usa . modulation of endotoxin-induced cytokine production by lps partial structures h.-d. flad, h. loppnow, t. mattern, and a.j. ulmer department of immunology and cell biology, forschungsinstitut borstel, d- borstel lipid a constitutes the active moiety of endotoxin (lps) of gramnegative bacteria. it activates mononuclear phagocytes to produce cytokines, such as tnf, i _- , and il- , which are the major mediators of the endotoxic effect of lps in vivo. lipid a precursor la (synthetic compound ) does not induce cytokines, but is able to specifically antagonize lps-or lipid a-induced mediator production in human mononuclear cells, vascular endothelial cells, and smooth muscle cells. furthermore, we present evidence for the first time that t-lymphocytes proliferate in response to lps and express mrna for interleukin- and interferon-~ and that these responses are also antagonized by synthetic lipid a precursor la. when comparing the agonistic and antagonistic activity of lipid a and different partial structures at the functional and binding level, the number and length of the fatty acids and the number of phosphoryl groups were pound to be of crucial importance. unexpectedly, lipid a precursor la, although biologically inactive, turned out to be both the most potent antagonist and competitor in inhibiting the binding of lps. taken together, our results provide evidence for a model in which lipid a partial structures compete with lps for specific cell surface receptor(s). in this sense, biologically inactive lipid a analogues may be good candidates as therapeutic agents for the prevention of gram-negative septic shock. two mammalian lipid a-binding proteins have been identified that are believed to have important roles in mediating the host response to endotoxin: lipopolysaccharide-binding protein (lbp) and bactericidal/ permeability-increasing protein (bpi). human lbp shares a % amino acid sequence identity with human bpi. despite the sequence homology, the two lipid a-binding proteins have very different functional activities. lbp is an acute phase serum protein that markedly potentiates the proinfiammatory host response to gram-negative infection by a mechanism which involves binding of the lbp-lps complex to cd receptors on monocytes, neutrophils and endothelial cells. in contrast, bpi is a neutrophil granule protein with potent bactericidal and lps-neutralizing activities. the divergent functional properties of these two lps-bindlng proteins can be explained by the inability of bpi-lps complexes to bind to cell-surface cd receptors. a recombinant protein (rbpi ), corresponding to the amino terminal kd fragment of human bpi, has been shown to retain the potent biological activities of the hdlo protein and may represent a novel therapeutic agent for the treatment of gram-negative infections, sepsis and endotoxemia. for therapeutic effectiveness in many clinical situations, rbpi will have to successfully compete with relatively high serum levels of lbp ( - ~g/mi) for binding to endotoxin and gram-negative bacteria. to evaluate this issue, experiments were conducted to compare the relative binding affinities of rbpi and human recombinant lbp (rlbp) for lipid a. the binding of both proteins to iipid a was specific and saturable with apparent kd's of . nm for rbpi and nm for rlbp. in a competition assay format rbpi was approximately -fold more potent than rlbp in inhibiting the binding of nsi-rlbp to lipid a. these results demonstrate that rbpi has a significantly higher affinity for endotoxin than does rlbp and may explain the potent inhibitory activity of low concentrations of rbpi in a variety of in vitro functional assays for lps activation of cells despite the presence of high lbp levels. for example, rbpi at . ~tg/mi was able to totally inhibit lps-induced tnf release from monocytes despite a -fold weight excess of rlbp over rbpi . and for heparin binding. three separate domains which inhibit the lal reaction to lps and bind to heparin were identified in amino acid regions - , - and - . a single synthetic peptide ( - ) was bactericidal. these results suggest that rbpi contains three separate functional domains which may contribute to its high affmity interaction with gram-negative bacteria and heparin. the individual activity of each domain and the cooperative interaction among domains provide the basis for developing rbpi analogues with increased biologic efficacy. a considerable body of experimental data has accumulated implicating tumour necrosis factor (tnf) as a principal mediator of the pathophysiological features of septic shock. these data prompted the development of clinical strategies designed to limit excess (inappropriate) tnf production. monoclonoal antibodies (mobs) were developed and a phase ii dose escalation trial in patients confirmed that the mab was safe, and suggested that it was having a beneficial effect on certain parameters. preliminary results of a large phase iii study indicated that (a) the mob was safe; (b) that it was of no discernible benefit in non-shocked patients; (c) that it reduced mortality in shocked patients, especially during the first days. an alternative strategy was to take advantage of the high binding affinity of soluble receptors for tnf (stnfr). stnfr-iggfc constructs were made for both the p and p receptors. both were effective in animal models of lps challenge, but when a clinical trial was done with the p stnfr-fc there was unexpected mortality in the treated arm. using an animal model of live e.coli sepsis, we have shown that this may have been due to the release of bound tnf from the construct. plasma enhances while bpi inhibits lps-induced cytokine production from peripheral blood mononuclear cells (pbmc). pseudomonas species produce cytokine-inducing substances which are different from lps as indicated by the fact that polymyxin b blocks only % of the cytokine-inducing activity of these pyrogens. we now tested the effect of plasma and bpi on the il- [ -inducing activity of pseudomonas maltophilia -derived pyrogens (pmp). bacteria were cultured to the log phase and filtered ( kd) to obtain prop. dilutions of pmp or lps were added to pbmc alone or to pbmc in % plasma +/-bpi ( ng/ml). pbmc were incubated for hours at °c and total il-i~ was measured by ria. results: il-i[~ in ng/ml (n= , mear~+sem, *p< . vs control). control . _+ + bpi . + % plas. . _+ + bpi . _+ pmp (ng/ml) lps (ng/ml) . _+ . _+ . _+ . _+. . +. . _+. . _+. " _+ " . _+ " . _+ " . _+. . + _+ _+. * _+ " . +. " . + -+ . -+ " . _+. " cba, c bl/ , balb/c, akr, dba, swiss mice, guinea pigs, rabbits have been used in research work. the toxicity, immunogenicity, mitogenic and immunomodulating activity of lps have been studied. the possibility of reduction of the toxic activity of lps on macroorganism by bioglycansimmunomodulators obtained from sea invertebrates anymals (crenomytilus grayanus, stromhus gigas) have been investigated too. lps has been shown to induce specific antibody response of laboratory animals. cba mice are high responsive to lps. lps stimulates humoral immune response of mice to tdependent and t-independent antigens and suppresses intensity of the delayed hypersensitivity. the small doses of lps stimulate functional activity of macrophages, the large doses of lps -decrease one and show the cytotoxic effect. the bioglycans enhance the resistance of mice to the lethal effect of lads and provide protection - % of mice. one opens possibility to use of bioglicans for reduction of toxinemia in generalizated forms of pseudotuberculosis. thus, lps from y.pseudotuberculosis is immunogen and immunomodulator wich has influence on humoral and cellular factors of immunity and plays the important role in immunopathogenesis of infection. endotoxaemia is implicated in the pathophysiology of obstructive jaundice. the lirnulus lysate (lal) assay is the gold standard method for measuring endotoxin concentrations, but inherent biochemical and technical problems limit the usefulness of this assay. the endocab elisa is a novel assay which measures endogenous antibody (igg) to the inner core region of circulating endotoxins (acga). objectives we evaluated the significance of endotoxaemia in biliary obstruction using the endocab assay and subsequently the specificity of the humoral response to endotoxin compared with an exogenous antigenic challenge [tetamls toxoid (tt) ]. materials and methods in experiment i three groups of male wistar rats ( - g) were studied [no operation (n= ) , sham operation (n= ), and bile duct ligation for days (bdl)(n= )]. plasma was collected and assayed for bilirubin, endntoxin(lal) and acga(endocab). in experiment ii rats were actively immunised with tetanus toxoid ('it) and then randomised to have no op(n= ), sham op(n= ) or bdl(n=i ). blood was taken at this time (to) and days later(t at sacrifice for acga concentrationslendocab] and igg produced to tt(ttab) [elisa] . antibody concentrations are expressed as % increase from control values.results in bdl rats, acga concentrations were significantly increased compared with controlslp< . , mann-whitney]. endotoxin concentrations were sporadically elevated in the jaundiced rats but the rise was not significant. in experiment [i there was no difference between the acga or ttab concentrations in the fllree groups at to, bdl rats had a significant rise in acga concentrations by t [p< , ,paired t-test] and humoral response to tt was significantly impaired in bdl rats compared with control groupslp< . , paired ttest data plasma endotoxin was measured by means of an endotoxinspecific endospecy test after pretreatment of the plasma with a new perchloric acid method that we developed. the normal value of plasma endotoxin is less than . pglml. polymyxin b was administered at a dose of , u every hours. plasma endotoxin rapidly decreased to the normal range in of the patients. body temperature fall significantly. apache ii scores were also significantly improved. tumor necrosis factor-o~ and interleukin decreased in survivors, while in high values tended to persist in patients died. no side effects were observed in any of the patients. in conclusion, intramuscular injection of minute of polymyxin b was useful in the treatment of endotoxemia. - uchimaru, morioka , japan. l e v a n t g r a m n e g a t i v organisms. m e t h o d s : u n d e r general anesthesia, n o r w e g i a n b r e d landrace pigs ( - kg) of either sex, pr group, u n d e r w e n t t r a c h e o s t o m y a n d w e r e v e n t i l a t e d on a / air a n d o x y g e n m i x t u r e a i m e d at m a i n t a i n i n g a n o r m a l p h a n d a isocapnic level. ventilation w a s not readjusted d u r i n g the observation period. the anesthesia w a s k e t a m i n e . m g / k g h a n d d i a z e p a m . m g / k g h i n t r a v e n o u s l y . h e m o d y n a m i c m o n i t o r i n g of m e a n aorta, p u l m o n a r y artery, central v e n o u s a n d p u l m o n a r y capillary w e d g e pressures w a s p e r f o r m e d w i t h a f s w a n -g a n z catheter a n d an aorta catheter. a continous infusion of r i n g e r ' s acetate ( m l / k g h ) w a s g i v e n intravenously. w h e n stabilised, the a n i m a l s w e r e g i v e n . x l cfu of e colt intraperitoneally as a bolus in ml saline, the a n t i b o d y g r o u p received in a d d i t i o n m g / k g e a n t i e n d o t o x i n i n t r a v e n o u s l y over h o u r via a n infusion p u m p at the start of the observation period. the a n i m a l s w e r e observed for hours. results : a t a n d hours, the o x y g e n c o n s u m p t i o n increased by % in the a n t i b o d y treated g r o u p w h e r e a s there w a s a significant fall of % in the sepsis group. in the a n t i b o d y group, the arterial p h a n d the cardiac index were also significantly h i g h e r at the s a m e p o i n t s in time. there w a s no significant difference in arterial po . in severe bacterial infections it would be beneficial to neutralize the plasma endotoxin content with complex forming compounds. the phenothiazines are able to form complexes with endoto×in and the existence of these complexes were already shown in differential speetrophotometry and animal experiments, however, the mechanism of partial neutralization was not clarified. therefore some representative phenothiazines and structurally related compounds were tested for anti-endotoxin activity. the endotoxin neutralizinb effects of several benzophenothiazines were investigated in differential speotrophotemetry, tnf induction and in the conventional limulus test. in animal experiments some beneficial effect of complex forming compounds was found. the benzophenothiazines were not able to inactivate the biological effect of endotoxin in the limulus test. the recent findings indicates that a multifocal effect can be responsible for "anti-endotoxin action in vivo". effects of tnf inducing effect of endotoxin in leukocytes and bypotensiv action in experimental animals were reduced by some phenothiazine derivatives. monophosphoril lipid a was without effect. of microbiology, albert szemt-gydrbyi medical university, odm t~r lo, h- szeged~ hunbary involvement of streptococcus pyogenes erythrogenic toxins in the induction oflstreptococcal toxic shock syndrome heide mgller-alou~* , joseph e. alouf , die [er gerlach , ~atherine fitting., and jean-marc ca~aillon . unit des toxines microbiennes and "unit d'immuno-allergie, institut pasteur, , rue du docteur roux - paris (france) ; institut f~r experimentelle mikrobiologie, jena (germany). superantigen erythrogenic toxin a (eta) is thought to be involved in toxic shock syndrome in humans by inducing massive release of cytokines by patient immune cells. the cytokineinducing capacity of eta w~:s £:ompa~ed to that of lps, a gram-negative bacterial cell wall component. eta elicited weak production of il- d and ~, tnf ~ and il- in purified human monocytes whereas lps stimulated the production of high amounts of these cytokines. in the presence of t cells, eta elicited the production of significant amounts of il-i~, il-i~, il- and il- . however, the most preponderant cytokine was tnf~, which peaked at i ng/ml after stimulation with i ~g eta. comparable amounts of tnfd (ca ng) were induced by .i ~g eta and .i ~g lp$. in contrast to lps, eta was a strong inducer of tnf~ which was produced only in marginal amounts by lps. these results suggest that the septic shock induced by gramnegative bacteria (lps) and by gram-positive bacteria {extracellular superantigens) follows different pathogenic pathways. lps-induced shock is mainly mediated by monocytes and monocyte-produced cytokines (il-i and tnf). the eta-induced shock is mediated by t-cells or depends on t cell help for the production of monocyte-liberated cytokines. production of t cell cytokines such as tnf~ and interferon in addition to the other cytokines contribute very likely to the severity of the toxic-shock resulting from s. auzeus and s. pyogenes infections in humans. the present study was utidertakc~l to cvalu~tlc the effect of soluble chemically modified giucan during septic shock. carboxylnethyl-b-i, -glucan (ram ) was injected twice and h before the shock i.v. in a dose of ing/kg. shock was induced in u~?esthetizcd (sodikm~. l)mntobarbital) rats by i.v. injection of endotoxin of escherichia colli bs, mg/kg. aiiofcmg pretreated ruts survived during first haher ¢ndotoxine, while in controi shock group the lethality was %. the concentration of ~col)terin in serum was significantly elevated hafterthc second cmginjection (appare~tly % if compare with the control rats), but didu't chartged rain and s rain after endotoxin injectjom cardiac output in cmogroup was higher a* the i and min after endotoxine onset ( i % trod ~, respectively of initial level) than in the control shock group ( % and % at the same time). pretreatment of rals with soh~ble giucan w~ts associated with beneficial effects o~ the hepatic c~ergy $ia[tls after h after challenge of endotoxiae: the tissue level of lactale was ahnost twice lower than in the control ruts, me~mthne the tissue atf in cmg pretreated group was higher at %. twice injected macrophage stimuhttor soluble glucan can prevent the endotoxic shock, and extremely ir~creased survival rate after endotoxine injection. the national committee of surgical infections of the spanish association of surgeons have produced a computer program for the collection and analysis of information on surgical infections. the program is suitable for ibm compatible hard disk personal computers and works through the ms-dos system. the main menu is called up on the screen when the operating disk has been installed; it reads as follows: i. new record; . modify records; . erase records; . searches; . reports; . configure; o. ouit. if you ask fdr a new record the screen will prompt you to enter the number of case, record number, hospital, age and sex. the next screen will come up and the words "topographic diagnosis" will flash. a menu of areas or organs will be displayed. then, the words "type of pathology" (inflammatory, neoplastic, traumatic and other). days of postoperative period. type of surgery (programmed and emergency). type of operation (clean, clean contaminated, contaminated and dirty). duration of surgery. this is followed by "order of operation" and the "type of anaesthesia (general, regional or local). you are then required to supply the "diagnostic code of who" (icd ) and the "procedure code of who. analytic and concurrent illnesses (total proteins, albumin, haemoglobin, haematocrit, leucocytes, red corpuscles, glucose and bilirubin). the next screen asks for "risk factors" (obesity, uraemia, neoplasia, malnutrition, urinary catheter, distant infection, artificial valve, immunosuppressive drugs, over years and anergy. this is followed by a screen headed "postoperative complications". "evolution" (the questions asked are drainage, systemic antibiotics, and on each ocasion a choice of antibiotics is displayed), local antiseptics, reoperation, etc. under "microhiology" is a choice of organisms and the chance of identifyin organisms. finally, "sepsis score". our recent work had shown that renshen-fuzi-chaihu mixture could increase the survival rate in experimented study. the purpose of this study was to determine the effect of combined administration of renshen-fuzi-chaihu mixtuer and antibitics (sa) in patients with septic shock. the result showed that, in sa group ( cases), the total effective rate was , %, in the contral group (combined administration of gentamycin and dexamethasone, cases) the total effective rate was %. however the obviously effective rate in sa group % was significantly higher than in contral group % (p<o.os). sa group appeared to be more obvious than the contral group in raising arterial pressure, recovering consciousness and pulse, improving cold lilmbs and reducing fever (p<o.o ). it was found that sa could inhibit the pathogeneses changes of septic shock such as the decreases of superotide dismutase (sod) and glutathione peroxidase (gsh-px) in erythrocytes and the increases of plasma free hemoglobin (phb), plasma malondialdehyde (mda) and -glucuronidase ( -gc) occured in septic shock. sa had stronger effect than gd in inhibiting the changes mentioned above. hence, these results suggest that sa has beneficial effect in the treatment of septic shock. sa could diminish the decrease of the antioxdase activities and inhibit lipid peroxidization and stabilize cellmembrance. this may be one of the principal mechanisms of the beneficial effect of sa in the treatment of septic shock. donna l. lehman, heather a. childers, irshad h. chaudry and alfred ayala. the thymus is thought to be a privileged sight for tcell generation. here the t-lymphocytes are either selected for their potential to recognize and react competently to foreign antigens or de-selected, due to their potential to react to auto-antigens, de-selected. tcells with this latter capacity are thought to be deselected through a process referred to as programmed cell death or apoptosis. while it is known that thymic apoptosis is elevated by a variety of stressers associated with infection and inflammation, little or no information is available concerning its presence in polymicrobial sepsis. it was, therefore, the aim of this study to determine whether thymocytes exhibit increased apoptosis during sepsis. to assess this, thymocytes were harvested from c h/hen mice at i and h following cecal ligation and puncture (clp; to induce sepsis) or sham-clp (sham). thymic yields were assessed and the extent of apetosis determined by staining the cells with propidium iodide (a dna intercalating dye) for facs analysis or by examining the extracted dna electrophoretically for the endogenous endonuclease activity the results (n= /grp) indicate that at i h post-clp there was no marked changes in any of these parameters. however, at h the thymic cell yield from clp mice was significantly decreased (sham: . ! . x l vs clp: . i . x * cells; *,p< . ), the % of cells apoptotic by facs analysis increased from . i . % in sham to . ± . %* in clp, and the septic mouse genomic dna exhibited dna degradation these results indicate that clp, but not simple laparotomy, induces marked thymic apetosis, which may contribute to the lymphocytic immune deficiency seen in these mice the purpose of this retrospective study was to evaluate effectiveness of irrigation to treat septic knee joints from longterm results. from to patients with septic knee joints have been treated. treatment in acute cases started with asp#at[on of the effusion to evaluate for cultures. without awaiting the result treatment was continued with immediate joint irrigation under arthroscopic control. three redon tubes ( ch ) were introduced for continuous irrigation and for intermittent distention of the joint cavity. in case of chronic joint infection additionally all foreign and synthetic material was removed. systemic antibiotics were given. patients could be re -examined with a mean follow-up of years. re-examination showed that immediate arthroscopic lavage started at the onset of septic sings had best results (less signs of osteoarthr[tis, less synovitis, less pain while loading and less range of motion loss ). patients ( %) out of patients with s tre_=.tsd acute se.~tic knee joint had excellent functional recovery, whereas all patients with chronic septic knee joints showed poor results. additionally, in of these patients with chronic septic knee joint after irrigation a further procedure was necessary due to recurrent septic knee joint. the concept that bacteria can translocate across the intestinal mucosa under a variety of circumstances is well established. however, due to the inherent limitations of in vivo studies, the cellular mechanisms underlying the process of bacterial translocation (bt) across the epithelial barrier are poorly understood. this is especially true in those circumstances in which there is no merphologic evidence of mucosal injury. consequently, we have utilized an in vitro cell culture model system to investigate the cellular events involved in the translocation process. in this model system, a polarized monolayer of intestinal cells (caco- cell line) is grown on a micron filter in a two compartment system. after tight junction integrity is established, bacteria are placed in the apical surface chamber and bt across the caco- monolayer is measured by culturing the basal chamber. the results of our studies utilizing the caco- system indicates that; l) several strains of non-pathogenic bacteria will translocate across the caco- monolayer in a time-dependent and dose-dependent fashion. however, the incidence and magnitude of bt are highest for those strains of bacteria (gram-negative enterics) that are most commonly cultured in vivo. ) caco- cells are actively involved in the transcellular passage of bacteria across the caco- monolayer, since inhibition of caco- microtubule or microfilament function decreases the magnitude of st. ) lectin but not integrin receptors are involved in bacterial translocation of e. col~ across the caco- cell monolayer. ) caco- cells have the ability to ingest and kill certain strains of bacteria. the mechanisms involved in caco- bactericidal activity appear similar to that of pmns to the extent that both are oxidant but not nitric oxide mediated. these in vitro studies suggest that caco- cells can function as "nonprofessional" phagocytes and that both bacteria and enterocytes are involved in the translecation phenomenon. bacterial translocation due to gut barrier dysfunction is considered to be a major cause of septic complications and multiple organ failure following trauma, burn injury, hypoxia, shock and shock-like states. the invasion of bacteria into the circulation from the gastrointestinal tract or even from other sources, however, should not necessarily result in systemic infection or organ cohinisation, as long as the humoral and cellular defense mechanisms are not impaired. thus, a reduced res clearance capacity and hepatic clearance function of bacteria and toxins can be observed under the same conditions which enable bacterial translocation from the gut. in order to evaluate the influence of circulatory, metabolic and humorul disorders on the elimination of bacteria out of the blood circulation, a series of experiments were performed in anesthetized and ventilated rabbits which received defined numbers ( . x colony-furming units) of escherichia coli as a bolus injection. in unaffected control animals the intravenously injected bacteria are eliminated about . % within the first minutes and are totaiy cleared within minutes. % offue total cfu counted in the cultures of the organ homogenates were found in liver and spleen, whereas only very low numbers could be detected in the lungs and kidneys. systemic injury of the animals by hemorrhagic shock, endotoxinemia, hypoxia, coagulation disorder, systemic vasoconstriction by norepinephrine and other types of injury reduced the elimination rate of bacteria and changed the pattern and degree of their dissemination and tissue distribution. the bacterial clearance was delayed mostly in rabbits subjected to hypoxemic hypoxia in which about cfu of viable e.eoli per ml blood could still be counted hours following their injection. the number of viable bacteria was some ten powers higher in organs of hypoxic rabbits in comparison to control ardmais, and an excessive colonisation of the lungs and kidneys with % respectively % of the total cfu of the cultared organ homoganates was observed. unilateral iscbemia of the kidney prior to the intravenous injection of e.coli only moderately delayed the bacterial clearance, bowever, caused an intense eohinisation of the affected reperfused organ. in contrast to this, inhalation injury did not promote the accumulation of bacteria in the lungs. conclusion: shock, systemic and local affections reduce the clearance of bacteria from the blood circulation and enable their dissemination and accumulation in vital organs. the degree of this reduction and the organ pattern of the bacterial distribution varies with the type of injury. thus, these factors seem to be essentially involved whether or not bacterial translocation and multiple organ failure will follow the invasion of bacteria into the circulation as in the ease of gut barrier dysfunction. movement of enteric baaterla from gut to extralumeaal sites (bacterial tra~sloeation) m~y play a role ~. nraltipl~ orga~ failure. traumatic stress (shock, hffectiort, and im~lammation) and severe illness are common alateeedents. tnt~st~aal lleus is e common proximme causal factor. we have exanlined the hypothesis that bacterial ttanslecation from the gut in expe~me~tal paaerestitis is due to bacterial overgrowth as a cuas~ucnee of a deere~ae in intestinal transit. ne~rotit_.~g pancreatitls fbliowlng bile duct iigation in the opossum is associated with colonization of the pa,se ~re, aa by gut derived organisms or salmonella of biljary origin in infected animals (previously reported). to ti~rther define the mechanism of transloemdon in panereati* inflammation, pancteatitis was induced hy iigatlon of t~e lower bile duet distal to the pancreatic duets m the rat. intestinal transit, enteric bacteriology, and tromsloeatien of bacteria to mesanterie lymph nodes, blood stream and splanelmie organs wen deletmhaed at (n~ ), g (n ~ ), and (n~ ) hours with the fallowing results: ly~testinai,..transfi". geometric mean of fluorescent marker - % at hour~ with return to % of gut leugth (similar to ~m) at hour~. bacterial overgrowt_hff -increase in total bsctetia ~ad gram negative rod.~ at ,; hours with return to sham control at hours ( log cfu/g veraus log cfu/g ia ileum). translocation to mesenteric nodes - , , and percent at , , and fi hours compared to b in sham controls (n=l of ). conclusion -bacterial translocation following panetoatieobiliary duct ljgation induced panereatitls ha the rat is tighlly linked to intestinal trausit and bacterial overgrowth within the gut lumen. speclrjlation -the ilens in in/~arm~ation may be related to activation of eytokiaes and mediated by nitric oxide. preliminary evidence for this notion will be discussed. in a series of studies we investigated: a) the time course of bacterial translocation (bt), b) the kinetics of lps and cytokine appearance (tnf, il- , soluble tnf receptor [stnf-r] ) in the circulation, and c) the role of lps and/or tnf with regard to haemorrhagic shock (hs) related pathophysiologie alterations and mortality in baboons and/or rats. method: baboons were subjected to femur fracture, soft tissue trauma (acute experiment), and hs ( mmhg mean arterial pressure: map for - h terminated at an accumulated oxygen debt of - ml/kg followed by resuscitation). a chronic model of hs was set up by administration of zymosan activated plasma (zap) before and after hs but without trauma. hs was induced in rats by bleeding the animals to map of - mmhg - rain followed by resuscitation. results and conclusion: in rats, lps increased in the systemic circulation, plasma tnf levels were found to be significantly elevated at min and were still markedly increased at rain postshock. plasma tnf, il- , and stnf-r levels increased already during the shock period in baboons, while tnf was not detectable. our data suggest that haemorrhagic shock may lead to early bt in the intestinal wall (at min following resuscitation in rats subjected to hs for min, similarly at h after the end of oxygen debt period in baboons ) and transient access of gut-derived lps into the circulation (levels became significant at min, while in baboons higher levels up to pg/ml were found at the end of shock and h after reinfusion, partially accompanied by bacteremia). in addition, since the treatment of rats with anti lps measures or anti tnf therapy significantly improved the -hour survival rate it can be assumed that endogenous lps and lps-induced mediator(s), in particular tnf, may lead to organ injury and mortality following haemorrhagic shock. alteration of the mesenteric blood flow and the consequent ischemia / reperfusion injury to the intestine appear to be one of the earliest events in the systemic inflammatory response following severe thermal injuries. the causative relationship between the subsequent disruption of the intestinal integrity and the potentiation of the translocation of indigenous bacteria and/or endotoxins to remote body organs and the systemic circulation has been deeumented in several studies. among other effects, endotoxemia solely or acting synergistically with thermal injuries has been shown to promote bacterial translocation. as these sequences continue without adequate intervention, multiple organ failure and eventually death may become inevitable. hence, the crucial need of treatment modalities with the capacity of modulating the intestinal blood flow and preventing the manifestations of these pathological incidents. although the underlying mechanisms of this process have not yet been fully elucidated, there is accumulating evidence that various interacting vasomediators are involved. the actions of these mediators can probably be modulated by either nonspecific or selective agents. among the nonspecific agents, the composition, volume and timing of the resuscitation fluids appear to play an important role in this process. nitropmsside, a nonspecific vasodilator, has been shown to prevent the decrease of the postbum mesentefic blood flow when selectively infused in the mesenteric artery. the nonspecificity of various vasodialators with their possible undesirable systemic effects emphasizes the importance of the identification and modulation of selective vasomniiators. thromboxane a (txa ) and angiotensin ii (a-ii) appear to be the primary mediators of the postburn vasoconstriction. both mediators were found to be elevated following thermal injuries. in a previous study, pretreatment with oky- , a thromboxane synthetese inhibitor was found to attenuate the postbarn mesenteric vasoconstriction. in a bum/sepsis porcine model the efficacy of dup , an a- receptor antagonist as a posthum treatment modality was evaluated. treatment with dup prevented the early posthum and the late posteodotoxin elevation in the mesenteric vascular resistance and subsequently abrogated the fall in the mesenteric blood flow. the incidence of burn & endotoxin induced bacterial translocation was significantly reduced by dup from % to % (p< . , fisher's exact test). the indigenous flora of the gastrointestinal tract exerts a potent influence on the developmental maturation of normal systemic immunologic responsiveness. moreover, both oral and intraportal administration of experimental antigen is associated with a systemic state of immunologic hyporesponsiveness, known as oral tolerance. since trauma and critical illness are associated with changes in the flora of the gut and with altered systemic immune reactivity, we have hypothesized that the interactions of an altered gut flora with immune tissues in the gut and liver play a role in the pathogenesis of the immunologic derangements of critical illness. prolonged feeding of two clinically relevant killed organisms-pseudomonas and candida-to a rat results in significant impairment of cutaneous delayed hypersensitivity (dh) reactivity. conversely, measures directed against gram negative bacterial overgrowth in experimental peritonitis result in partial restoration of impaired dh reactivity. to ascertain the role of the liver in the pathogenesis of these alterations, we studied the differential immunologic sequelae of portal versus systemic (ivc) infusion of killed bacteria. experimental infusion of live or killed gram negative organisms into the portal vein produces dh suppression in rive, and profound suppression of mitogen-driven lymphocyte proliferation in vitro; systemic administration of the same organism has no effect on these phenomena. suppression is tgf -dependent, and mediated by a soluble factor released by fixed tissue macrophages of the lung and spleen. the suppressive influence appears to be mediated at the level of interactions between il- and its high affinity receptor. release of this factor can be induced by a second circulating factor present in the plasma of portally-, but not systemically-infused animals two hours after bacterial administration. these studies suggest that the release of inducible immunoregulatory factors from the liver, and possibly from the gut, may play a role in the pathogenesis of the profound derangements of systemic immune homeostasis that accompany trauma and critical illness. acad.hospital st. radboud,postbus , lib nijmegen introduction. the central question being tested in this study was whether liposome encapsulated dichloromethylene-diphosphonate (ci mdp) mediated elimination of liver and splenic maorophages would influence zymosan induced systemic toxicity (st) and bacterial lranslocation (bt). materia|s and methods. male swiss (icr) mice were used weighing - g elimination of liver and spleen macrophages was accomplished by intravenous injection of / suspension of ci mdp-liposome suspension. control mice received an i.v. injection with pt phosphate-buffered saline (pbs) . two days later all mice were challenged with an i.p. injection of zymosan suspended in paraffin (z) at a dosage of either mg/g, . mg/g or . mg/g body weight (n= in each group), signs of st and bacterial translocation bt were measured hours later the st was assessed by blindly grading the degree of lethargy, conjunctivitis, diarrhea, and ruffled fur of each mouse on a four point scale. bt to the mesenteric lymph nodes (mln) and systemic organs (liver, spleen, lung and blood) was tested by culturing on blood and macconkey's agar at the time of sacrifice sections of the distal ileum were taken for histology. an additional two control groups (n= in each group) were tested to verify that neither paraffin nor pbs or ci mdpqiposome suspension alone induced bt or st. furthermore survival over a -day period was assessed in a control and macrophage-depleted group with a dose of d mg/g z. results. neither the paraffin nor ci mdp-tiposome suspension induced bt or st the incidence of bacterial translocation to the mln was similar between macrophage depleted and control groups. however, macrophage depletion was associated with a significantly higher incidence of systemic spread of bacteria. data expressed as positive tissues/total tissues tested: / vs. / at . mg/g zymosan (p~o. ); vs. at mg/g zymosan (p~q ); / vs. / st . mg/g zymosan (p~o.o ).the magnitude of bt however did not show any differences. although systemic bt was greater in the macrophage depleted groups, the systemic toxic response was significantly less at doses of . mg/g zymosan ( . -+ . vs. . -+ , p~o. ) and . mg/g zymosan ( . -+ . vs. . -+ . , p<_.o. ) . the day mortality after . mg/g zymosan was % in the control group and % in the macrophage depleted group (p=o. ). histology did not show any differences between the control and macrophage depleted groups. conclusion. the lethal and toxic effects of zymosan in this model appear to be more related to the excessive activation of macrophages than to the systemic spread of bacteria. bacterial translocation (bt) in hemorrhagic shock was studied using a porcine model. in this study three groups were randomized: one control (n= ) and two experimental (n= each). a portal vein catheter was placed and remained in situ hrs. a femoral artery and vein catheter were in place hrs. the arterial eaanula was used for monitoring mean arterial pressure (map) in all animals and to bleed the experimental animals and the venous cannula to repelfuse with ringer's lactate (rl) or autologous blood (ab). baseline samples and values were taken in this period. control animals were observed for a sham shock period of . hrs., given more hours of anesthesia, and studied for further hrs. % of the estimated blood volume was withdrawn from each experimental animal over min. these animals were kept in shock for . hrs. at the end of the shock one group was perfused with rl and the other with ab. two hours later they were extubated and further studied for hrs. samples from portal blood for cultures and measurement of leukotriene b (ltb ), prostaglandin e (pge ), and nitric oxide (no) metabolites were taken from all animals at intervals beyond baseline up to hrs. after hrs. under general anesthesia a second laparotomy was performed and samples for culture from mesenteric lymph nodes (min), liver and spleen were taken; as well as samples for histologic study with light and scanning electron microscopy were taken from jejunum, ileum, and colon. animals were then euthanized. results: significant shock was induced as indicated by map and arterial blood gases. significant bt to min was observed in all groups. no significant bt was observed in cultures from liver and spleen in any of the groups. increased values for ltb , pge and no metabolites were found during the period of shock. these results suggest that the isehemic phenomenon triggers a significant inflammatory response, and that bt to min may be an epiphenomenon without apparent significant influence on the inflammatory response. objective: to study the potential effects and mechanisms of action of systemic administration of monoclonal antibodies anti-endotoxin (ha- a) in a animal model of gut-origin sepsis. materials and methods: exoeriment a. balb/c mice were transfused with allogeneic blood (from c hb-iej mice). five days post-transfusion the animals were gavaged with lxl viable escherichia coil and randomized into groups (n= /group) to receive a sham burn (sb group) or a % thermal injury immediately followed by the systemic administration, via a tail vein, of monoclonal antibodies ( mg/kg) (ha- a group) or a % burn injury and administration of equal volume of sterile saline (c group). all groups were resuscitated by intraperitoneal injection of . ml of saline. the animal survival rate was observed for days post-burn. experiment b, transfusion and burn procedures were identical to experiment a but the mice (n= /group) were gavaged with viable e.coli labeled with mmndium oxine. four hours after burn the mesenteric lymph nodes (mln), liver, lungs and blood were harvested to determine plasma endotoxin levels and the magnitude of transtocation of labeled bacteria as measured by the residual radioactivity (dpm) in the organs. circulating endotoxin levels were determined by limulus colorimetric assay. diamine xidae(dao) is an enzyme existing in the mucosa of small intestines, but its activity is low in the plasma. it is evoked in the blood with the intravenous injection of much heparin. it is well known that da declines under the chronic mueosal injury when the small intestines are cut off or the mucosae become atrophied. aim of this paper is to confirm that da goes up to the measureable level by the intravenous injection of a small amounts of low molecular heparin(lmh objectives: the aims of this study is to investigate the inhibitor" effect of the prolease inhibitor, urinastatin, on endotoxin induced bacterial transleeation in mice. materials and methods:lcr mice were divided in six groups as the fotlows, group i: control mice receiving intraperitoneal injections (ip) of saline . and hr prior to sacrifice, group ih treated mice receiving ip of utinastatin . hr and endotoxin ( mg/kg) hr prior to sacrifice,group ilk sham reated mice receiving ip of saline . hr and endotoxin ( mg/kg) hr prior to sacrifice,group iv: saline control mice receiving ip twice during rain intervals,group v: mice received ip of utinasmtin, and min later they were received ip of endotoxin ( mg/kg), group vi: mice received ip of saline,and min later they received ip of endotoxin ( mg/kg). in group l,ii and ill ,the mice were killed by cervical dislocation.using stetile techniques,a middle-line incision was made and the mesenteric lymph nodes were harvested in order to culture on selective agars for quantitation of bacterial trauslocation. in group iv, v and vi, survival was recorded for days. unnastatin pretreatment could rednce mortality significantly. first surgey, shiga university of medical science, seta ,ohtsu - ,japan increased gut permeability correlates with inflammatory response in multiple trauma aptients. pape, h.-c. dwenger, a. grotz, m. regel, g. purpose: disturbances of intestinal permeability have been advocated as a pathogenetic factor of posttranmatic multisystem organ failure (mof). a close relationship with impairment of the stationary reticulocndothelial system (res) and a systemic inflammatory response (sir) was discussed. these tactors were investigated prospectively in patients with multiple trauma showing posttraumatie complications (multiple organ failure, mof). methods: polytranmatized patients were studied prospectively. according to a mof-score (goris) those with posttrattmatic complications were selected (> points at days), others were excluded. every second day gut permeability according to the ratio of urine concentrations of lactulose and mannitol (l/m) was evaluated (enteral application). at parallel time points res clearance capacity (k-value, invasion constant, normal range . - . mind) was studied after i.v. injection of mbq rotehuman albumin. liver perfusion was calculated from these data, total serum bilirubin (/zmol/l) was documented. serum elastase (#g/l) levels were determined enzymatieally. results . + + liver perfusion did not ehangu, bilirubin showed progressive worsening indicating mof. a positive correlation was present between l/m and k (r= . ) and between l/m and ela (r= . ). conclusions: there is a positive correlation between the time pattern of intestinal permeability dysfunction and res hyperactivity as well as between intestinal permeability and the systemic intlammatory response (elastase levels). the results speak in favor of an interaction between intestinal and extraintestinal inflammatory systems, which in eombiuation are likely to be responsible for post~anmafic complications. endotoxemia, il- release and consecutive acute phase reaction are observed as a host response to surgical trauma. as well vasodilative prostaglandins (pg) and thromboxane (tx) are released after abdominal meaenteric traction (mt). the following hypotension and acute hypoxeraja are duo to prostacyelin (pgiz) arm can be avoided by perioperative cyclooxygenase inhibition. we therefore focused on the effect of pg and tx liberated following mt on the induction of endotoxemia. methods: in a prospective, randomized double-blinded protocol patients, who were scheduled for major abdominal surgery (pancreatic or infrarenal abdominal surgery), were studied. ibuprofen ( mg i.v.) or a placebo equivalent was administered minutes before skin incision. mt was applied in a uniform fashion. baseline values were obtained before induction of anesthesia. further measurements followed before the incision of the peri[onenm (tl) and , , , min, . the plasma concentrations (,pc) of -keto-pgft,, txb: and-ki- -pgf ~ (stable metabolites of pgi , txa and pge~) were determined by ria. we measured endotoxin pc by limulus-amoebocyte-lysate test and il- levels by elisa. data are given as mean+sem (* p< . placebo vs. [ibuprofen] ). results: endotoxin plasma levels increased before incision of the peritoneum tl both in the ibuprofen pretreated and in the placebo group. peak pc were observed minutes after mt. endotoxin pc were significantly higher in the ibuprufen treated group (t . + . e[ . + . ] eu/ml). il- pc demonstrated an increase continuously from t to t (t + [ + ] ng/l) in both groups. after intentional abdominal mesenteric traction we observed a marked increase of -keto-pgf~,, pc up to h after mt in untreated patients with a peak of *[ ] ng/ at tl. also txb: and kh pge pc showed a considerabe increase up to h after mt in the placebo group. in ibuprofen pretreated patients the pg and tx pc remained within the normal range. discussion: our data clearly indicate a significant endotoxemia and il- release following major surgical trauma which is not initiated either by prostaglandin or thromboxane release. moreover endotoxemia is accentuated by ibuprofen pretreatment. therefore we hypothesize that in major abdominal surgery prostacyclin release-after mt may play a crucial physiological role in maintaining splanclmic microcirculation and thus preserving gut mucosal barrier function. objectives of the study it has been shown recently that parenteral and certain euteral diets promote the translocation of gut flora to the mesenteric lymph nodes (mln) and systemic organs, a process termed bacterial translocation (bt). in chow fed rats bt usually does not occur without further promoting factors. the goals of the present study were to determine whether the provision of defined amounts of standard lab chow during iv-tpn administration wotfld redane the incidence of bt, materials und methods male spf spragnle-dawley rats were divided into groups. group received standard laboratory chow feeding ad lib. in group a central venous catheter was placed, ligated and secured by a spring coil tether attached to a swivel allowing free movement in the housing cage and chow was fed ad lib. in group % of the calculated daily required calory intake (drci) ( /kcal/kg) was given by iv-tpn ( % glucose, , % amino acids) and % by limited chow administration. groups and received % and % of the drci by i.v. tpn and % and % respectively by chow feeding. group received iv-tpn only. after days the rats were sacrificed and the mln, liver, spleen and cecum removed aseptically, homogenized and cultured for bt samples of distal ileum were taken for light microscopy. the group with the least amount of chow shown to be protective against bt received the amount of non-fermentable fiber of that chow regimen during iv-tpn feeding and bt was studied. , + , , - , , / + ~ " , -+ , , -+ ~ - , / +~ + _+ , + , , - , -+ + , ~ , , -+ ~ conclusions: the administration of % of drci by chow feeding during iv-tpn significantly reduced the incidence of bt and maintained gut barrier function. the addition of the respective amount of dietary fiber of this group did not prevent iv-tpn-indueed bt. dr. med. m naruhn., dep. of general surgery, eberhard-karls-university, hoppe-seyler-str. previous experimental studies have suggested that a disturbed ecology of the enteric bacterial population might contribute to the development of bacterial translocation from the gut in acute liver failure (alf). in the present study, the effect of oral administration of lactobacillus reuteri r lc and oat fiber on bacterial overgrowth and translocation was investigated in rats with acute liver failure induced by subtotal ( %) liver resection. the oatmeal soup base was anaerobically inoculated with lactobacillae and fermented for hours, after which the animals were fed with either fermented or unfermented oatmeal or saline daily for days prior to the operation. bacterial translocation to mesenteric lymph nodes (mln) and the systemic circulation was determined, as well as the intestinal bacterial flora and enterocyte protein content. the incidence of bacterial translocstion to the systemic circulation was nit in rats subjected to sham operation and saline treatment and % in animals subjected to % bepatectomy and lreatment with fermented oatmeal, while - % and - %, respectively, in rats subjected to hepatectomy and treatment with either saline or unfermented oatmeal. only one rat with fermented oatmeal demonstrated bacterial growth in mln (p < . vs hepatectomy and treatment with saline or unfermented oatmeal). the enterocyte protein content significantly decreased (p < . ) in salinetreated animals following % hepatectomy, while there was no significant difference between bepatectomized animals with oral administration of fermented or unfermented oatmeal. the number of anaerobic bacteria, gram-negative anaerobes and lactobacillus significantly decreased and the number of e.cnli increased in the distal small intestine and colon in hepatectomized animals with enteral saline or unfermented oatmeal as compared with animals subjected to sham operation or bepatectomy with fermented oatmeal. our results thus show that the occurrence of bacterial translocatiou from the gut in % hepatectomy-induced alf could be prevented by enteral administration of fermented oatmeal, maybe partly due to a positive effect on the enteric bacterial ecology. _+ " +_ " . " data=mean_+sd, * stats anova p< . vs control. l+air and lap groups, both exposed to exogenous i.ps shnwm:t m significant increase (p<. ) in lps gut translocation compared to control and l+co . this correlated with a significant increase in peritoneal inflammatory responses (o -,tnf) above that of the control and l+co groups, while mac- and cr opsonized phagocytosis were significantly impaired. the absence of significant differences between l+air and lap groups indicates that lps rather than wound factors is the principle mediator. thus, lps plays a significant role in regulating peritoneal responses in the early post-operative period dept of surgery, rcsi, beaumont hospital, dublin , ireland brlke e, berger d, staneseu a, buttenschsn k, vasilescu c, seidelmann m, beger hg in patients undergoing a colonoscopy, endotoxin, endotoxin neutralizing capacity (enc), thromboxane b o (stabile metabolite of tbmomboxane ~), -keto-prostaglansin, leueotriene c , interleukin and the incidence of bacteremia were determined before and then every five minutes during the procedure. twenty-one of patients showed a significant increase of endotoxin plasma levels during colonoscopy (p= . ), whereas only one patient had a positive blood culture with bacteria obviously derived from the gastro-intestinal tract. the enc decreased significantly five minutes after the beginning of eolonoscopy and was diminished further thereafter. the baseline values were reached after hours. ~hromboxane b o levels also increased after five min. from to pgyml peaking at min. with pg/ml. -keto-prostaglandin,leucotriene c , ii- and crp remained unchanged. a control group of i volunteers who were not subjected to endoscopy, were prepared for eolonoscopy by orthograde lavage. the blood sampling procedure remained identical. no differences were seen in all described parameters for the controls. these data show that the gut barrier can be compromised by mininml invasive procedures, at least, concerning bacterial products. living bacteria, on the contrary, do not pass the gastro-intestinal wall. endotoxin, when determined by enc, is more sensitive than the conventional limulus-amebocyte-lysate test. no acute-phase reaction was induceri by the observed endotoxin translocation. it can be speculated from the dramatically enhanced thromboxane b levels, together with its hemodynamie effects, that the thromboxane release may support translocation of bacterial products. sepsis is common after hemorrhagic shock. this study aims to demonstrate that hemorrhagic shock alone can promote translocation of gut bacteria from intestinal tract to its regional nodes and subsequently to blood. one hundred twenty mice, divided into groups were subjected to , and minutes of %, % and % of hemorrhagic shock. on the specified time, blood cultures were taken and mice were sacrificed. the intestinal tract were histologically examined for any changes which allows translocation and its regional nodes were quantitatively cultured for translocated bacteria. there was a direct relationship between duration and degree of hemorrhagic shock and incidence of translocation (p . ). there was a high incidence of gut bacterial translocation to the mesenteric and mesocolic nodes in all degrees of shock (p . ). bacterial growth in the regional intestinal nodes increased and blood cultures were positive in direct proportion to degree and duration of shock. histologic evaluation of segments of git showed submucosal congestion to allow bacteria normally contained within the gut to cause systemic infections. translocation of gut bacteria in untreated hemorrhagic shock is clearly shown in this study on animal models. in this study, guotobiotic rats with known species of bacteria were subjected to total parenteral nutrition(tpn) and subsequent hemorrhagic shock. the purpose of the study was to observe the impairment of gut barrier function following tpn and hemorrhagic shock and to study the mechanism of enterogenic infection induced by tpn and shock.the results were as follows: .long term( - days) tpn induced impairment of gut barrier function, evidenced by atrophy of intestinal mucosa, significant decrease in diamine oxidase activity of intestinal mucosa and blood, and marked microecologic imbalance of the intestinal mucosa flora with dorminant growth of aerobes and relative decrease in anaerobes. the degree of mucosal damage were proportional to the duration of tpn. .in tpn+shock groups, failure of gut barrier function was found. ri,~ere were further damage in the mucosa, with a large number of gramnegative organisms invading mucosa and submucosa and a significant decrease in dao activity as compared with each relative tpn groups. these changes were significantly correlated with enhanced bacterial translocation, elevation of lps and mda levels in the plasma. these findings suggested that long term standard tpn impaired the gut barrier function, precipitating posttraumatic gut barrier failure. thus infec. fion following shock might be oi'iginated from the gut and it was obviously related to the impaired gut defence resulted from antecedent tpn. the determination of plasma dao activity might provide a valuable tool for the ear. ly diagnosis of gut injut;y during tpn and after trauma. in our earlier studies we have investigated the dynamics of granuloayte infiltration of the ischemic/reperfused s~all intestine (g. illy~s, j. hamar int. j. exp. athol. . . .) . there was a increasing infiltration of the mucosa c m~nating at the d to th hours of reperfusion. in the present series we have studied sc~e of the conseqn/ences and the possible role of this cellular reaction. ~in isehemia was followed by a hour reperfusion in the anesthetized rat. arterial ~/ad mesenteric venous blood samples were collected at m_in, i, ~ , and hours of reperfusion. elastase and lactate concentrations were determined and hamoculture was carried out from the blood samples, and tissue pieces from the heart, lung, liver and kidney were collected for histological analyses at the above mentioned times of reperfusion. all blood samples were free of cell bacteria. staphylococci appeared only occasionally at the th hour in the arterial blood .and at the d and th hours in the venous blood, respectively. arterial and venous elastase activities were high throughout the reperfusion, venous concentrations being higher at all times. lactate concentrations of the arterial and mesenteric venous blood samples increased during shock. ~ranuloeyte infiltration of all organs studied appeared during the d hour and it increased at later times of reperfusion. it is concluded that heavy infiltration of the intestinal mucosa can block bacterial translocation in most of the cases during reperfusion. granulocytes activated either by the reperfused area or by the released cytokines infiltrate other organs contributing by this way to the mesenteric shock s!rndrc~e. intestinal motility plays an important role for maintaining nutrient transport and absorption and for balancing the enteric bacterial population. disturbances of intestinal motility may be one of the earliest notable changes in intestinal function. in the present study, we aimed at determining early alterations in intestinal transit time following ischemia-reperfusion injury induced by occlusion of the superior mesenteric artery in the rat. intestinal ischemia was induced for and minutes by applying a microvascular clip on the superior mesenteric artery followed by reperfusion , and hours after clip removal. intestinal transit time was measured by the propulsion of a radiolabelled solution (cr ). light microscopy was performed on intestinal samples. macroscopical pathological changes were not observed. however, microscopically, mucosal epithelial oedema, degeneration or slight ulceration occurred in rats hours after reperfusion in ischemia- rain group and and hours after reperfusion in the ischemia- rain group. delayed small intestinal transit time was seen from hours and on after intestinal ischemia for both and rain ischemia followed by reperfusion. the distribution of radioactivity demonstrated that most radioactivity was accumulated in the first two segments following intestinal ischemia and reperfusion, significantly differing from what was seen in animals subjected to sham operation (p < . ). the distribution of radioactivity in segments and in the group with repeffusion hours after intestinal iscbemia for rain was significantly higher than that noted in the group with repeffusion hours after intestinal ischemia for min (p < . ). q'he results indicate that a delayed intestinal transit time may be one of the earliest pathophysiological alterations noted, associated with duration of gut ischemia, and a potential factor for the development of bacterial overgrowth, gut barrier failure and bacterial translocation, in hypovolemic conditions. bacterial infections still constitute a major cause of morbidity and mortality in patients with acute liver failure. the present study aimed at evaluating the effect of ethylhydroxyethyl cellulose (ehec) on bacterial translocation following surgically induced acute liver failure. acute liver failure was induced by subtotal hepatectomy ( %) in the rat. water-soluble ehec was administered orally and hours prior to hepatectomy. the incidence of bacterial translocation from the gut to mesenteric lymph nodes (mlns) and systemic and portal circulation was evaluated and the number of isolated bacteria from these samples and from intestinal content were determined. intestinal transit time, bacterial adherence onto the intestinal surface, intestinal mucosal mass, bacterial growth and dna synthesis, bacterial surface characteristics (hydrobiology: hydrophobicity, hydrophilicity and neutrality; surface charges: positive, negative and neutral) were also determined. hepatectomized animals showed a - % translocation rate to mlns or blood and hours after operation, while only - % of rats subjected to sham operation or animals with % hepatectomy and pre-treatment with ehec (p < . ). bacterial overgrowth, increased bacterial adherence onto the intestinal surface as well as decreased intestinal mucosal masses were observed in animals with subtotal liver resection alone, alterations that were prevented by enteral ehec treatment. a delay in intestinal -hour transit time occurred in both groups with subtotal liver resection, with or without enteral ehec. ehec inhibited bacterial growth and dna synthesis, and altered bacterial surface properties following hour incubation with bacteria. in conclusion, the findings in the present study imply that ehec alters enterobacterial capacities for metabolism, proliferation and invasion by effects on e.g. bacterial surface characteristics. furthermore, ehec seems to possess a trophic action on the intestine, rather than exerting its effect by enhancing intestinal motility. department of surgery, lund university hospital, s- lund, sweden disturbances in intracellular calcium signalling can potentially result in impairments of cellular responses vital to the functional integrity of both immune and non-immune cells, and thus contribute to a decrease in host resistance against infection and to multiple organ system failure during sepsis. studies in our laboratory have focused on assessments of intracellular ca ÷ regulation and ca~+-depended cellular responses in the liver, skeletal muscle and splenic tlymphocytes harvested from rats subjected to gram-negative intraabdominal sepsis. cytosolic ca + concentration, [ca *]i, and ca + fluxes were measured by the use of fluorescent ca + chelating dyes (fura- or indo- ) and ca respectively. to assess sepsis-related changes in ca + dependent cellular responses, we measured the acute phase protein response in the liver, the regulation of protein and sugar metabolism in the skeletal muscle, and the proliferation response in the splenic tlymphocytes. altered ca + i signalling with sepsis was correlated with an exaggerated inappropriate acute phase protein response ( % ¢) in the liver, and a blunted insulin mediated sugar utilization ( % ) and increased proteolysis ( % ~) in the skeletal muscle. in t-lymphocytes, a decrease in mitogen induced elevation of [ca +]i by - % was correlated with a significant depression in their proliferative capacity. these studies clearly suggest that altered calcium signalling is correlated with disturbances in cellular responses in both immune and non-immune cells during sepsis. the altered cellular responses adversely effect the outcome of the septic injury. (supported by nih grant gm ). alfred ayala, ping wang and irshad h. chaudry. changes in macrophage capacity to respond to foreign pathogens are thought to be central to the developing immunosuppression associated with traumatic injury. in this respect, the suppression seen in m~ functions following hen (a common component of traumatic injury) may be mediated by the direct or indirect inhibition of their capacity to perceive external stimuli (e.g., opsonized & non-opsonized bacteria, and their cellular components, etc.} due to the breakdown of the receptormediated signal transduction system. results of a number of studies by our laboratory and others indicate that this inability to respond to external stimuli is in part due to the loss of cell surface receptors. decreases have been documented for not only la antigen, but also c b, fc, and tnf receptors following hem in mice. furthermore, studies which have examined second messenger generation in these cells indicate that m~ derived from the peritoneum and spleen exhibit a decreased capacity to mobilize ca + from intracellular stores. this protein kinase dependent process of [ca+ ] i mobilization appears to be linked to the inability to synthesize inositol triphosphate. of interest, the depression in ca + signal generation appears to be inversely related to presence of elevated levels of camp in m~ from hen mice. we have reported that m~ priming agents, such as ifn- (which exhibits salutary effects on m~ function following hem), appear to restore cell signal transductive capacity while reducing the levels of camp. nonetheless, the extent to which depressed receptor signal transduction in hem, is due to receptor loss~dysfunction or elevated antagonistic second messenger levels remains to be determined. conclusions: significant impairment of calcium signaling occurs at all time-points prior to and following pha stimulation in trauma patients. tcell activation failure can, in part, be explained by the inadequacy of this essential intracellular second messenger system. restoration of immunocompetence following trauma will have to address strategies to better assess and restore this vital step in the activation sequence leading to proliferation during the antigen recognition process. patrick a. bseuerle institute biochemistry, albert-ludwigs-university, hermann-herder-str. , d- freiburg, germany the active form of the transcriptional activator nf-~b is a heteredimer composed of a and kda polypeptide. in this form, nf-'<b can bind with high affinity to decameric sequence motifs (consensus: "-gggpunnf'ypycc- ") found in enhancers and promoters of many genes activated upon a wide variety of pathogenic conditions, including viral and bactedai infections, acute phase response, oxidative stress and uv and gamma irradation. clinically important target genes for nf-k:b encode inflammatory cytokines (il- b, tnf, [l- , il- , gm-csf etc), cell adhesion molecules (icam- , elam- , vcam- ), acute phase proteins and immunoregulatory ceil surface receptors. in most cell types, nf-~:b is sequestered in the cytoplasm and, therefore, unable to initiate transcription of these genes. the cytoplasmic form of nf-~:b contains one additionai subunit, referred to as h,;:b. i~b can reversibly suppress dna binding and nuclear uptake of nf-~b by virtue of its association with p . upon stimulation of cells, ikb is proteolytically destroyed, allowing nf-kb to enter the nucleus and activate genes upon binding to transcriptional enhancers. we have demonstrated that various antioxidative compounds inhibit the activation of nf-~b in response to many inducers. moreover, nf-~:b was shown to be activated upon treatment of cell cultures with p.m-amounts of hydrogen peroxide. these data suggested that nf-~b prinicipaliy is an oxidative stress-responsive transcnption factor. the notion is supported by numerous reports on the induction of oxidative stress by many nf-nb-inducing agents. nf-~b activition can likewise be suppressed by protease inhibitors. these drugs apparently inhibit a yet unidentified protease responsible for the inducible decay of inb. we propose to use nf-nb inhibifors as novel drugs with a very broad application under acute phases el inflammation, injury and infection. northern blot experiments revealed that expression of the recently discovered lipopolysaccharide binding protein (lbp), a / kd glycoprotein, in the liver rises substantially during the acute phase response. experiments with an in-vivo acute phase model using new-zealand-white rabbits and also in-vitro experiments employing stimulated hep-g cells showed that lbp transcripts could be induced to ford within hours after induction with cytokines. by using a newly established nonradioactive nuclear run-on technique we show that induction of lbp during the acute phase is transcriptionally regulated. furthermore we screened a human genomic library and were able to clone the lbp gone, containing the promoter . kb upstream. several liver-specific and "acute-phase-typical" potential binding sites were found fn the promoter region and reporter gone assays were set up. several caat-boxes, the il- responsive elements hstf-hsp . and h-apf- rs as well as the transcription factor hnf- and the glucocrticoid-responsive elements oct- -d and gcre were found, which correlates with the induction pattern of lbp mrna in hep-g cells by il- , il- and dexamethasone. pcr-based analysis of the exon-intron pattern of the lbp gene revealed similarities with the genes of two other lps binding proteins, namely bpi and cetp. further analysis of this novel acute phase protein, that also has an important role in endotoxin recognition and immunomodulation will help in understanding the complex acute phase mechanism and potentially lead the way to new therapeutic strategies. lps activation of nucle?/r fa-ctor:~b " (nf:~bj"in cd .transfected fi'broblasts does not appear to require tyrosine kinase activity d. t. golenbock, r. delude, r. savedra, s. vogel and m. j. fenton lipopolysaccharide (lps) is the major constituent of the outer leaflet of gram-negative bacteria. during the course of serious infection, shock may occur as a result of the interaction of lps with macrophage lps receptors. cd , a kda glycosyl phosphatidylinositol (gpi)-linked protein, functions as an lps receptor. a critical issue in lps activation concerns the mechanism by which cd , which has no transmernbrane domain, transduces a sig,nal after lps binding. evidence exists which suggests that cd may signal cells after lps binding by interacting with an lps signal transducer with tyrosine kinase (tk) activity. wild-type chinese hamster ovary fibroblasts (cho) normally do not respond to lps, but can be activated following transfection with cd (cho/cd ). stimulation of cho/cdi with as little as ng of lps/ml resulted in the release of h-arachidonic acid ( h- : ) into the culture supernatant. in addition to h- : release, we examined lps-imiuced activation (transl cation) of the transcription factor nf-~b. similar to lps-induced h- : release, these responses were observed only in cho cells lransfected with cd closely resembling the same response in the marine macrophage cell line raw . . maximum nf-~cb expression occurred at minutes. in contrast to lps-induced h- : release, dexamethasone, cycloheximide, and actinomycin d had no effect on activation of nf-r,.b in cho/cd , suggesting that nf-r,b activation begins early after lps binding to cd and does not require transcription or translation. we then examined cells for lps-induced tk activity by western blotting cellular ly~ates with anti-phcsphot-'rosin:~ anl',bodie~" although tk activity was seen in lps-stimulated raw cells and phorbol ester stimulated cho/cd , lps-induced tk activity in cho/cd was not observed. although the tk inhibitor herbimycin inhibited the release of h- : in cho/cd and raw cells, neither herbimycin nor genestein effectively blocked nf-r,b activation in either cell type. these results suggest that tk activity is involved in a portion of the signaling pathway that is distal to initial signal transduction. the absence of observable lps-induced phosphotyrosine residues in cho/cd cells as well as the failure of tk antagonists to inhibit lps-induced nf-~cb activation suggest that the proposed cd -related lps signal transducer in cho/cd is not a tymsine ldnase. dimished cardiac inotropic function and response to -adrenergic receptor ( -ar) stimulation are frequently seen in septic patients, these cardiac defects are also seen in animal models of entoxemia. to determine the characteristics of the decreased transmembrane signal associated with the decreased beta adrenergic response we measured the force and rate of contraction of atria harvested from sprague-dawley rats exposed to endotoxin ( : gm/kg). to stimulate various components of the transmembrane signal cascade of -ar was isoproterenol (i -ar), acetylcholine (m ach receptor), naf(gs and gi proteins), forskolin (adenylate cyclase), and calcium (intracellular contracttile signal) were used. to eliminate the transmembrane control of calcium and test the intrinsic contractile response, hypothermia ( °c) was used the results showed alterations in the inotropic function with no significant difference in chronotropic response. the inotropic reponse for the endotoxin exposed atria and controls is shown below these results show that there is a transmembrane signal defect both for the i~-ar signal and for ca +. these data indicate that the level of the defect appears to be at the g proteins. ischemia-reperfusion of the rat intestine produces an injmry both to the intestine and to distal organs, notably the lungs and liver. prior studies have shown that h of intestinal ischemia leads to a nemtrophil independent reperfusion injury of the gut. thus, rats rendered neutropenic by pl~l antiserum have been shown to express a severe local gut injury when subjected to ischemia and reperfusion. this gut injury is postulated to he mediated at least in part by the complement system. the soluble (s) cri receptor which binds to c b and cdb was given to rats at a dose of mg/kg by intravenous bolus, min before reperfusion of the ischemic gut. a control group was given pbs buffer. at h of rmperfmsion the animals were sacrificed. pbs treatment led to a significant activation of both classical and alternate complement pathways while scri inhibited both pathways (fall to zero of chbo ). intestinal mucosal injury score, assessed by histological grading was reduced by scri ( . ± . to . _+ . ,p< . ) . intestinal neutrophil sequestration estimated by assay of myeleperoxidase was also reduced ( . ± . to . ± . u/g). c was detected in the gut hy i~unohistochemistry. remote organ injury was modified that is lung permeability (ration of concentration of radiolabelled albumin in broncho-alveolar lavage fluid to that in blood) was reduced ( . ± . x i to . ± . x , p<o. ). however, neutrophil sequestration by the lungs was unaffected. this remote protection is thougth to be related to prevention of ic b deposition on imng andotheli~ which activates adherent neutrophils. these findings support the hypothesis of complement mediated local and remote injury. we postulate that complement fragments may be deposited either as a result of the ischemia induced loss of membrane bound complement regulatory proteins, such as decay accelerating factor or membrane cofactor protein, which allow complement fragments to accumulate on the endothelial cell surface. alternatively, increased expression of p-selectin on the endothelial cell surface may, by means of its complement binding domains, act as a lattice for complement deposition. indeed, p-selectin has been detected on the surface of endothelial cells ans platelet-neutrophil aggregates recovered from the intestine of these animals. ischemia ( hr) followed by reperfusion (dhr) of rat hind limbs resuits in local (muscle) injury as well as in remote (lung) injury, which is characterized by increased vascular permeability (leakage of j sl labeled albumin) and neutrophil accumulation (tissue content of myeloperoxidase, mpo). within minutes of reperfusion following ischemia, tumor necrosis factor-o~ (tnfc , interleukin-i ( l-i) and il- plasma levels increased significantly, reaching maximum levels after hours ofreperfusion. polyclonal antibodies to tnfet and l-i provided significant protection against muscle and lung injury. muscle and lung vascular permeability decreased in anti-tnfct treated rats by % and % respectively and mpo was reduced by % and %. antml- yielded a protection in muscle and lung vascular permeability of . °, and . % respectively whereas muscle mpo was reduced by . % and lung mpo by . °, . these results were confirmed by the use of soluble tnf~ receptor and il-i receptor antagonist (il-ira). when icam-i expression in vivo was examined using mabeled antmcam-i, constititive expression of icam- was evident only in lung but not in muscle. during reperfusion icam- expression increased by . %. treatment with anti-tnfcx or il-ira reduced icam-i upregulation by . °, and . % respectively. frozen sections of normal rat lung revealed no evidence of e-selectin expression, whereas lung sections obtained after ischemia and reperfusion immunhistochemically demonstrated expression of e-sdectin. lungs from rats pretreated with anti-tnfct were negative for e-selectin staining. our data indicate a role for cytokines in the upregulation of adhesion molecules in ischemia/reperfusion injury. adherence of neutrophils to the coronary endothelium is associated with significant myocardial injury following min of ischemia (mi) and . h of reperfusion (r). p-selectin is expressed by activated endothelial ceils and platelets within min and tethers polymorphonuclear leukocytes (pmns) to the endothelium. we examined the cardioprotective effects of a monoclonal antibody (mab) designated pb . to p-selectin in a feline model of mi+r. pb . ( mg/kg) administered rain post-occlusion ( min prior to reperfusion) significantly attenuated myocardial necrosis compared to a non-blocking mab (nbp . ) for p-selectin ( + vs + % of area-at-risk, p< . ). endothelial dependent relaxation to acetylcholine was also significantly preserved in ischemic-reperfused coronary arteries isolated from cats treated with pb . compared to nbp . ( + vs + , p< . ). furthermore, pmn adherence to ischemic-reperfused coronary endothelium was significantly attenuated in pb . treated cats ( + vs + pmns/mm z, p< . ). also, normal coronary endothelium activated with thrombin ( u/mt) had increased pmn adherence under conditions of shear stress, an effect which was significantly (p< . ) blocked by pb . , but not by nbp . . furthermore, p-selectin is markedly upregulated - min post-reperfusion in coronary arterial and venous endothelinm. similar results were obtained in a rat model of mesenteric ischemia/reperfusion, including upregulation of p-selectin on mesenteric vascular endothelium. these results demonstrate that tethering of neutrophils to endethelium by p-selectin is an important early consequence of reperfusien injury, and a specific monoclonal antibody to p-selectin exerts significant endothelial preservation and cardioprotection in ischemia and reperfusion states. as recent interest has increased in the role of extracellular matrix proteins in inflammation, we examined the role and relationship of laminin and fibronectin to the processes of cell infiltration in a rat model of heart isografts. changes occurring in this system are on a nonimmunological basis and may be an effect of the initial surgical manipulation and the warm and cold ischemic times of transplantation. lewis (lew) donor hearts were transplanted into lew recipients, naive lew acted as naive controls (nc). grafts were harvested , , , , , , , and h after transplantation (n= /time point) . snap frozen sections of organs were stained for cd- (w / ), cd- (ox ), t-lymphecytes (tl) (ox- ), macrophages (ed , ed ), neutrophils (pmn) (mom), icam-i (iap ), laminin and fibrinogen. results were evaluated visually by counting cells/field of view (cf) for w / , ox , ox , ed , ed and mom, staining for icam , lain and fib was assessed visually using a scale (ve= - ). as early as h after transplantation, fibrinogen and laminin expression increased in i, peaking h after transplantation (ve= . ; nc: ve=i. ) . at and h in i, on both vessels and interstitial cells laminin and fibrinogen expression had declined to baseline (ve=i. ) but rose again at h, peaking at h (ve= ) and remaining elevated thereafter (ve= ). the high expression at h correlated well with the maximal pmn infiltration at that time (cf= ) in i returning to baseline at h (cf= . ) and thereafter. the second peak at h correlated with the onset of macrophage and t-lymphocyte infiltration. thus, laminin and fibrinogen seem to guide leucocyte infiltration following graft ischemia during the time of reperfusion. background. reperfusion of ischemic kidneys with xenogeneic blood leads to activation of endothelial cells and circulating leucocytes with the final consequence of microvascular thrombosis. in concordant systems, the mechanisms of rejection can be studied due to cross-reactivity of mediators with anti-human monoclona~ antibodies. aim of the study. to obtain information about the kinetics of proinflammatory cytokines and production of soluble adhesion molecules in the acute phase of reperfusion, eight kidneys from rhesus monkeys were perfused ex-vivo with human blood (group b/o) for one hour in a closed system. blood levels of il-lb, il- , tnf-a, soluble icam and e-selectin were measured in elisa-technique under steady-state conditions. results. cytokine levels rose significantly within the minute interval (il-lb: , __+ , to , __+ , pg/ml; il- : . - , to , __+ , pg/ml; tnf-a: , __+ , to , + , pg/ml; p< . ). immediately after the beginning of reperfusion, soluble icam- and selectin levels were abnormally high and constantly rising throughout the observation period, reaching significance at minutes. discussion. high levels of proinflammatory cytokines may lead to an induction of adhesion molecules, thus upregulating the leukocyte-endothelial interaction in an complement-independent mechanism. specific pretreatment with monoclonal antibodies against icam- , lfa- or other soluble mediators may be useful in downregulating hyperacute rejection in transspecies transplantation. prolonged ischemia has been associated with later dysfunction of solid organs as it may cause upregulation of adhesion molecules, production of cytokines on vascular endothelium and migration of host cells into the graft. these early events may lead to irreversible organ injury. this study evaluates the effects of global ischemia on early immunohistological changes in cardiac grafts transplanted in rats. isografted hearts (lewis->lewis) were were divided into ischemic and non-ischemic groups (n= /group). all donor hearts were flushed immediately with cold saline. non-ischemic hearts were then transplanted within rain, ischemic hearts were stored in cold ringer's solution for hours before revascularization. representative grafts were removed after . , hrs, and days, and evaluated immunohistologically (cells/field of view=c/f). restitution of ventricular activity was significantly delayed in ischemic grafts ( vs rain). after hrs, all ischemic grafts exhibited an extensive interstitial edema, declining slowly thereafter. at the same time, numbers of pmn peaked ( vs c/f in non-ischemic grafts), whereas edl+macrophages ( vs c/f) and tnfe expression peaked by hrs. by hrs t-lymphocytes began to enter ischemic myocardium and icam- was moderately increased. after days cellular infiltration had returned to baseline, and no differences were seen among both groups after days. global myocardial ischemia inhibits initial graft function, and engenders a brisk inflammatory reponse, primarily pmn and macrophages, with increased mhc class ii and cytokine expression. leukocyte -endothelial interactions are the result of endothelial activation, leukocyte activation or combination of both, which are accompanied by nee-expression, upregulation or shedding of adhesion molecules (selectins, inlegrins). such interactions differ with regard to the stimulus (e.g. thrombin or histamine for p-selectin, endotoxin or tnf/il- for e-selectin), the time course of response (minutes versus hours) and the localisation in different organs. recently assays are available for circulating soluble fragments of the cell bound adhesion molecules e.g. se-seleetin was found to be increased in plasma concurrent with high circulating endoloxin and cytokine levels. the importance of adhesion molecules for the sepsis event is evident, while effectiveness of anti-adhesion inolecu]e therapy is controversial e.g. beneficial anti-e-selectin therapy in baboon bacleremia but deleterious effects of amti-cd treatment in the same model. in other species similar controversial results with anti-cd therapy in sepsis were reported. steven l. kunkel,theodore standiford* and robert m. stricter. the migration of leukocytes to the lung during endotoxemia is dependent upon the coordinated expression of lung vascular adhesion molecules and the subsequent production of appropriate leukocyte chemotactic proteins. in experimental animals, neutrophils accumulate within the lung soon after the administration of endotoxin, while mononuclear cell infiltration occurs in a more distal manner. a kinetic analysis of lung leukocyte levels revealed a -fold increase in neutrophil numbers associated with dispersed lullg tissues hours after lps treatment, while macrophage levels increased by -fold at the hour time point. thus, the recruitment of different leukocyte populations to the lungs during endotoxemia is likely directed by different mechanisms. recent studies have identified a supergene family of small inducible chemotactic cytokines (chemukines) which possesses chemotactic and activating properties for neutrophils. the prototype of this family is interleukin- (il- ). interestingly, a related supergene family has been identified which possesses activity for recruiting mononuclear cells. examples of this group of inflammatory chemukines are monocyte chemotactic protein-i (mcp-i) and macrophage inflammatory protein-i alpha (mip-i). in initial in viva studies we examined whether mip-i was expressed systemically or in a compartmentalized fashion post lps challenge. assessment of plasma cytokine levels revealed maximal tnf levels occurred i hour post lps administration, returning to baseline by hours, while mip-i levels were maximal at hours ( , ng/ml), with a second peak at hours after lps challenge. interestingly, aqueous extracts of liver homogenates from lps treated animals demonstrated no mip-i levels, while aqueous extracts of lung revealed a -fold increase in mip-i levels over control lungs. immunohistochemical analysis of the lungs from hour lps treated animals demonstrated the alveolar macrophage was a rich source of mip-i protein. cell-associated mip-i was also expressed by blood monocytes adherent to the pulmonary vascular endotheliun, however the expression of monocyte-mip-i was observed by hours post lps administration. immunohistochemical analysis also demonstrated that mip-i antigen is associated with the extracellular matrix on the interstitial side of the endothelium. this suggests that the extracellular matrix, which is produced during inflammation, can bind mip-i and this may serve as a depot for the prolonged presence of nip- . in additional studies we have demonstrated that the intratracheal instillation of rmui [ip-l(loong) activation of polymorphonuclear leukocytes by inflammatory stimuli may contribute to the development of multiple organ failure in septic patients. thereby pmnl are proposed to avidly adhere to vascular endothelium causing damage by the subsequent release of toxic agents. as cellular adhesion is primarily mediated by -integrins and lselectins, the present study compares the expression of these adhesionmolecules on pmnl in septic patients and healthy volunteers. methods: expression of -integrins and l-selectins on pmnl was measured in whole blood by flow cytometry using the monoclonal antibodies ib and dreg , baseline values were determined immediatley after drawing blood. in addition cells were incubated min at °c to allow for spontaneous regulation of adhesion molecules. blood specimens from septic patients were obtained during the course of their illness. control values were determined in healthy volunteers. results: baseline expression of -integrins and l-selectins was not signifcantly different in septic and in healthy subjects. in contrast, there was a significant upregulation of g -integrins and shedding of l-selectins of pmnl in septic patients (sp) compared to healthy volunteers (hv). the local or systemic production of inflammatory cytokines, such as tumor necrosis factor alpha (tnfc~), can serve to modulate multiple aspects of neutrophil function. the ability of neutrophils to leave the circulation and migrate to areas of infection is one essential component of host defense. l-selectin, a leucocyte-associated adhesion molecule, is responsible for the initial reversible contact between neutrophils and endothelium and the subsequent roiling action of neutrophils along the vessel wall. in contrast to other adhesion molecules, l-selectin expression is rapidly down-regulated after neutrophil activation. the loss of l-seleclin may thus be a critical determinant of how neutrophils become unbound from their endothelial attachments and enabled to proceed towards an underlying extravascular area of infection. we hypothesize that the shedding of l-selectin is a strictly controlled process, occurring primarily at localized sites of inflammation, which may be modulated by tnf~, a flow cytometric method of staining neutrophhs by monoclonal antibodies in whole blood is described whereby the kinetics of l-selectin shedding may be followed in real time. the dose response and time course of in-vitro l-selectin shedding by neutrophils from normal human subjects was assayed after exposure to n-formyl-methionylleucyl-phenylalanine (fmlp) and tnfc~. either singly or in combination, our results show that l-selectin shedding can be reliably followed over time. a significant percentage of cells shed l-selectin after exposure to pg/ml tnfc~ or nm fmlp (but not at pg/ml tnfc~ or nm fmlp). greater numbers of cells were able to shed their l-selectin when fmlp and tnf~x were presented in combination rather than alone. high levels of tnfc~ did not appear to alter the threshold concentration of fmlp required to induce shedding, we conclude that the extent and rapidity of l-selectin shedding may be modified by different combinations of ligands and that shedding, by vidue of the high concentrations of cytokines or chemotactic factors required, is a process localized to sites of infection or inflammation. we prospectively studied patients with severe sepsis syndrome; group a : septic shock with or without adult respiratory distress syndrome lards) (n = , bacteremia = ); group b : sepsis syndrome without septic shock (n = , bacteremia = ). serial plasma samples obtained on day , , , , and , were assayed using elisas method (british biotechnology), normal control levels of soluble icam- and e-selectin, obtained from healthy volunteers, were respectively ± . ng/ml and ± . ng/ml (mean _+ se), acute lung injury was quantified dally on a tour-point score system (murray, am rev respir dis, ) . compared to control mean values, initial levels of groups a and b were significantly higher for icam- (p < - ) and e-selectin (p < - ). comparisons of group a and [] (* = p< . ; ** = p< . t) soluble icam- levels of group a enhanced significantly (p< . ) during the first hours, and a sustained high levels was of bad prognosis ( % of survivors at day ). the evolution of soluble icam- and e-selectin levels were significantly correlated with murray's score (spearman test : p < . ). conclusion: these results suggest that endothelial adhesion molecules are released into the plasma of patients with severe sepsis syndrome. soluble icam- and e-selectin are correlated with endothelial lung damage, and loam- seems to be a better indicator of the severity of endothelial injury. introductory remarks to anti-adhesion molecule strategies as a therapeutic modality ch wortel, repligen corporation, one kendall square, building , cambridge, ma , usa. the development of antimicrobial therapy represented a major breakthrough in the struggle against disease. it strengthened the notion that disease could be overcome by eliminating foreign invaders threatening the host. this paradigm has proven to be very successful, the threat of many infectious diseases has significantly changed, some have even been eradicated. nevertheless, sepsis has remained a severe condition, increasing in incidence while mortality remained very high. more recently, it has become increasingly clear that besides the nature and treatment of an exogenous agent, the reaction of the host defense itself plays a pivotal role in the outcome of the event. endogenous mediators, such as tnf, il-i, il- and il- , govem many of the actions of the host defense system. while the expression of these cytokines more often than not benefit the host, (over)-expression can cause severe damage. based on this hypothesis,anticytokine strategies, such as those targeted against tnf or il- , have been evaluated for the treatment of sepsis. results of these early studies have not yet indicated success in improving the outcome of the disease. it has been difficult to define a patient population where a benefit could be reproducibly shown. furthermore, it has been documented that synergy between cytokines occurs, but detailed knowledge of the cytokine network is not yet available. it is conceivable, that neutralization of one cytokine prompts the induction of another which will evoke the intended response in the host. recent data obtained in human endotoxemic volunteer models seem to confirm this. if this turns out to be the case, neutralizing a single cytokine may not be a successful approach. cytokines in tum, induce various adhesion molecules, such as icam- . such molecules regulate for instance the neutrophil-endothelial cell interactions, which are thought to play an important role in the pathogenesis of systemic organ injury. the potential for monoclonal antibodies to adhesion proteins to reduce vascular and tissue damage has been studied in a large number of experimental models. protective effects have been observed in a wide variety of inflammatory, immune, and ischemia-reperfusion injuries. thus, altering the host response by modulating the function of adhesion molecules may attenuate the inadvertent injury caused by inappropriate behavior of host defense cells. targeting cellular surface interactions has been added to the efforts to change the outcome of disease. modulation oftheseprocesses seems very promising, but may temporarily leave the host without effective defense mechanism. great care therefore, must be exerted when studying this powerful two-edged sword in a clinical setting. our knowledge of the role of adhesion molecules in the intlammatory response has increased rapidly due to the availability of new reagents and mice geneticly deficient in adhesion molecules. these molecules are important in interactions of leukocytes with endothelial cells, other leukocytes, platelets, and epithelial cells. when these molecules are engaged, they can also play a role in activating leukocytes and their effector functions. in the venules of the systemic circulation, adhesion often occurs through a series of sequential interactions. initial interactions are mediated by members of the selectin family to loosely associate the leukocytes with the endothelium and are followed by firm adhesion requiring members of the integrin and immunoglobulin family. later interactions with endothelium may require pecam. adhesion molecules are usually required for leukocyte emigration in response to extravascular stimuli and for neutrophil-mediated endothelial cell injury. they are critical for host response in many diseases including infections. however, when the inflammatory response results in damage to host tissues, patients may benefit from blocking the leukocyte response. anti-adhesion molecule agents are an important potential antiinflammatory therapy. the focus of anti-adhesion therapy may be at any step of the sequence. diseases where anti-adhesion molecule therapy may benefit patients include ischemia/reperfusion injury in many organs, ards and mof, and transplantation, both to protect the donor organ from ischemia/reperfusion injury and to inhibit graft vs host disease. many strategies have been considered and include: ) blocking the ability of adhesion molecules to recognize their ligand using antibodies that have been humanized or soluble receptors linked to igg to prolong their circulating halflife, ) blocking the ligands for adhesion molecules using soluble adhesion molecules, peptide analogues, or oligosaccharides, and ) blocking the production of the adhesion molecule using anti-sense oligonucleotides. because the synthesis of adhesion molecules is usually regulated by cytokines, inhibiting the action of cytokines is another potential site for interrupting the adhesion process. although important issues of safety must be evaluated, the potential for modulating the inflammatory response make this an exciting area of improvement in health care delivery. claire m. doerschuk, m.d.; riley hospital for children, room ; barnhill drive; indianapolis, in usa. modulation of neutrophil-endothelial cell adhesion with anti-cdl i/cd monoclonal antibodies as a therapeutic modality. ch wortel, repligen corporation, one kendall square, building , cambridge, ma , usa. the central role of inflammatory cells in the pathogenesis of lung and systemic organ injury is well recognized. binding of neutrophils to endothelial cells and migration into the parenchyma are largely regulated by complementary adhesion molecules. the leukocyte integrins are glycoproteins expressed on the neutrophil surface and in the cytoplasmic granules. integrins consist of a common beta or cluster differentiation (cd) chain covalently linked to one of three different alpha chains (cdlla, cdllb, cdilc) and exist on the cell surface as three distinct heterodimers. cdlla/cd is expressed on all leukocytes, whereas cd b/cd and cd c/cd . are restricted to cells of myeloid origin. cd i / cd interacts with intracellular adhesion molecule- (icam-i), its ligand on endothelial cells. the potential for monoclonal antibodies to adhesion proteins to reduce vascular and tissue damage has been studied in a large number of experimental models. protective effects with anti-cd antibodies have been observed in a wide variety of inflammatory, immune, and isehemia-reperfusion injuries, such as arthritis, burns, endotoxic shock, bacterial meningitis, autoimmune diabetes, nerve degenemrion, allograft rejection, allergic asthma, acute lung inflammation, skin lesions, and ischemia-reperfusion models of the intestine, myocardium, lung, skeletal muscle, and central nervous system. protective effects have also been observed in animals resuscitated following hemorrhagic shock. blockage of cd , however, would affect all leukocytes, as would antibodies to cdlla/cdi . targeting cdllb/cd would affect cells of the myeloid lineage only, which could prove to be beneficial. cd b/cd is not only involved in transendothelial migration, but is also implicated in adherencedependent formation of reactive oxygen species. blocking cd lb/cd may therefore not only reduce the numbe r of leukocytes accumulating in the tissue, but also attenuate the oxidant stress of infiltrated neutrophils. anti-cd b treatment has been used effectively to reduce tissue injury initiated by ischemia-reperfusion, complement activation and endotoxemia. altering the host response by modulating the function of adhesion molecules may attenuate the inadvertent injury caused by leukocytes, but may also temporarily leave the host without effective defense machinery. overall, animal studies suggest that it may be safe to inhibit neutrophil adhesion for a limited period of rime. these observations will have to be confirmed in carefully designed clinical trials. c, arbobydrams are ubiquizom constir~uts of cell sv.rfaees, and possess many c~xssfies ttm~ m~,e ~em ide~. canaidates for r~ognifioa mole~ule& in m~y systems whe,~ cer udhesioa ~lays a critical ro~ car~hydram l:~dtag ~otegas have been shown to b~ad tocell surfa~ earbohydzaxes ~nd pzrl~pate in cell-ceil lumtaefion& such sys,.ems include ~rti~za~io=, deveaopmeat, l~thoge~-hcet reeog--ition ~d i~zmmadon_ in particular, tb.z recent di%~ve~ of lhe selec~ and th~ impo.~a~c~ in teukccy~udo~lelium adh~ion has -~f~m av.c~on ok l~in m~ted cell adhe~on. s~vere/poten~s/cs.rbohydr~ l~ga~s hrve ~e~l ~u~ilied for ~he s~lcc~ins. the,~ c~u be broadly di,,sded la~o ~wo m'oups -sibyl l~wis x m~ mh~.~l oligo~chadd~s, ~d sf/~ ca~ohydmma, all ~:~ ~l~dns bind m siflyl l~wis x (sie$ o!igos~ccb.e.rkms, zlthou~ w~ differing avi~re~. 'we have i~¢n~ed the functional g~oups a s~ex ~n~ med/a~ ~he b~u ~di~g of ~h~ c~b hydmm = e-se/sedm we have used ~hat iv.formation to sya~esize sle ~ '~mt gs r.he, t focus on replacing slslic ~sd ~nd fuc s¢ wi~ simpler, more stable strunt~es. a[~ou~a ~ proeer~ is ongoing, we hve been ~ucee,.~ful a~ rep~aein t.ke si~ic a~id. residue wi~ std.fzte. ~ce~ or la~c amd groupa we t'we ex aninad &e ten, bunion of ezed~ hydroxyl group of the fizeose residue ~ billding of e-, l-~nd p-selees..u. we have also found m~fi~fio~ of the reducing end ~¢.cha'i~ ~z increase mtagovsst activity. the, m¢ond. group of figs,rids a.r eontzin su~a~ u a ea.rbohydr~t¢ support,, und seem to bi~.d to t~e sele~ti~s wi~ dlf:ferem characteristics c .an does sle:, s=h compounds are m ogniz~d by l-selects. md p-selectia, bur., in genera/, not e, selecti~ these dam may mdicam r.hat l-and p-s~ ¢at~ h~d via o, second ~te thaz operates lu~.ead of, or in conjunction with ~tc sle" b~ding ~iite. dam rela~&~g to ±e, se two types of ,ml~ liga~ds have beam t~ed to desig~ potential the ~peutics for i~fi~anmat ry disease. lr:rng maimai models of acute lung lu ury we can demo~trate that eompmmds that inhibit seleetiu birding ~ ~i~o hzve ber~ficial effects when uc~d in rive. progressive microvascular damage in the tissue adjacent to a cutaneous burn injury results in extension of burn size. the role of leukocytes in the pathogenesis of microvascular injury was investigated by inhibition of their adherence to the microvascular endothelium using monoclonal antibodies directed to leukocyte cdi or its endothelial ligaud, intercellular adhesion molecule- (icam- , cd ). a model of thermal injury was developed using new zealand white rabbits. two sets of three full-thickness burns separated by two x -mm zones were produced by applying brass probes heated to °c to the animals' backs for sec. cutaneous blood flow determinations carried out with a laser doppler blood flowmeter were obtained for hours. there were five experimental groups: controls given saline alone; animals given monoelonal antibody to the cd r . prior to burn injury (pre-r . ); animals given r . min after burn injury (post-r . ); animals given a monoclonal antibody to icam-i, r . prior to burn (pre-r . ); and animals given the r . min postburn injury (post-r . ). blood flow in the marginal "zone of stasis" between burn contact sites was significantly higher in the antibody-treated animals. administration of the antibodies min after injury was as effective as preburn administration in preserving blood flow. at hr post-burn all antibody -treated animals had blood flow in the areas at risk for progression (i.e., the zone of stasis) at or above baseline levels while the control animals had levels equal to . _+ % of baseline (p < . by analysis of variance and mann-whitney u test). these results indicate that leukocytes play an important role in the pathogenesis of burn wound progression, and that this progression can be attenuated by moduiating adherence to endothelial cells. a wealth of information now supports the hypothesis that inhibition of cell adhesive mechanisms will nter the course of immunologicand inflammatory processes. what remains unclear is whether inhibition of specific mechanisms wfl[ be of therapeutic benefit in any specific human disease. current data derived from animal models are not inconsistent with the hope of therapeutic benefit, but techniques for inhibition (e.g., antibodies, antisense oligonucleotides, inhibitory peptides, inhibitory carbohydrates, smaii synthetic inhibitors, etc), tissue and species differences in the relative contributions of adhesion molecules to the inflammatory process, and the cascade model of adhesive interactions are all confounding issues, making predictions of therapeutic benefit in any specific human disease process very difficult. additional concerns involve the potential roles of adhesive mechanisms in host resistance to infection. as human therapeutictdals are initiated, more exact information on the roles qf specific adhesion molecules in human disease should emerge. inhibition of leukocyte adherence to endothelial cells can represent a novel therapeutic approach to septic shock. we performed a pilot study to evaluate the safety and tolerability to cy- , a monoclonal antibody against human e-selectin, in patients with septic shock. septic shock was defined by clinical signs of sepsis, a documented source of infection, and fluid-resistant hypotension requiring the use of vasopressors. eleven patients entered the study, but patients who died during the first hours were excluded, as this was part of the protocol. cy- was administered as a single intravenous bolus of . mg/kg (n= ), . mg/kg (n= ) or i mg/kg (n= ) mg/kg. the antibody was well tolerated. none of the patients died during the day follow-up period. organ failure was assessed for organs (cns, lungs, liver, kidneys and coagulation). the mean number of organs failing, which was initially . ± . , decreased to . ± . at the end of the study (p<o.o ). these results are therefore encouraging. administration of an antibody to e-selectin in patients with septic shock requires further study. the importance of cytotoxic t lymphocytes (ctl) in the host defense mechanism against viral as well as parasitic and bacterial diseases is becoming increasingly appreciated. the design of vaccines to generate cytotoxic t ceils from nonviable or subunit constructs, however, poses challenges due to the unique characteristics of antigen processing and presentation by class i major histocompatibility complex (mhc) molecules. since the final antigen recognized by ctl are short peptides capable of high affinity binding to class i mhc molecules, we have designed strategies: a) to define the structural characteristics of peptides that are required for their high affinity binding to mhc; and b) to formulate these peptides into immunogenic vaccines that are capable of generating cytotoxic t lymphocytes. the strategy and results to accomplish these two goals will be discussed. amnon altman and erich gulbins ras proteins represent essential intermediates in receptor-mediated growth and differentiation pathways. they couple signals initiated by receptor or nonreceptor protein tyrosine kinases (ptks) at the cell surface to cytoplasmic targets which coordinate signal transduciion to the nucleus. ras also participates in t lymphocyte activation initiated by the antigen-specific t cell receptor (tcr)/cd complex, which leads to lymphokine production and proliferation. receptor ligation causes activation of associated ptks of the src and syk families as the earliest identifiable event in this pathway. the importance of ras in t cell activation is indicated by the findings that an oncogenic ras protein activates the interleukin- (il- ) gene promoter; conversely, a transdominant inhibitory ras mutant inhibits this event and the activation of map kinases. the rate-limiting step in ras activation is the exchange of bound gdp for gtp, which is catalysed by guanine nucleotide exchange factors (gefs). we identified the sh /sh domain-containing vav protein, which is selectively expressed in hematopoietic cells, as a ras-specific gef coupled to several hematopoietic receptors. vav can be activated by two pathways, i.e., by ptk-mediated phosphorylation or by binding of diglyceride second messengers to a cysteine-rich, protein kinase c (pkc)homologous vav domain. these pathways are independent as demonstrated by structure/function analysis and the use of pharmacological inhibitors. the two activation pathways may enable vav to integrate signals from distinct hematopoietic cell receptors, and couple them to ras. t cells express another, ubiquitous ras gef, i.e., sos, which is known to be coupled to activated tpk receptors. t cell activation leads to membrane association of a signaling complex consisting of sos and two other signaling proteins, grb- and shc, via direct binding of the shc sh domain to the tyrosine-phosphorylated chain of the tcr/cd complex. thus, multiple receptors, ptks and ras activators participate in signaling pathways that lead to hematopoieitc cell growth and differentiation. the interactions and function of these various signal transducers will be reviewed. phagocytes. immunity is mediated by specific t lymphocytes, cytokines produced by these specific t cells activate antimicrobial capacities in mononuclear phagocytes, thus contributing to protection. other immune mechanisms also participate in the acquisition of resistance. on the other hand, t cells are also crucial for many pathologic sequelae of intracellular bacterial infections. although ifn-y is central to macrophage activation, synergistic and antagonistic effects with other cytokines occur. the cd/ t cells, representing the major t cell population in experimental mice, are the main mediators of antibacterial immunity; an auxiliary role for y/~ t cells appears likely. the c~// t cell population further segregates into cd t cells which recognize microbial peptides in the context of gene products of the major histocompatibility complex (mhc) and cd t cells which see their peptide in the context of mhc class i. the -y/~ t cells are generally double-negative. knock-out mice in which the genes for various t cell receptor chains, for mhc class i or mhc class ii molecules, for cytokines or cytokine receptors had been deleted, have provided extremely helpful tools for analyzing the role of t cell subsets and cytokines in antimicrobial immunity. using these mutant mice, the role of distinct t cell subsets and cytokines in bacterial elimination and granuloma formation was analyzed in detail. these studies underline the central role of a// t cells and ifn-y in antibacterial immunity and, furthermore, show a distinct function of /$ t cells. moreover, these studies show that the relative contribution of cd or cd t cells to antimicrobial immunity varies in response to different pathogens. apoptosis is an active form of cell death in which the cell participates in its own demise, providing the biochemical pathways that trigger and mediate the complex events of the process. although this phenomenon has been studied for many years, it is only recently that significant progress has been made towards the elucidation of the molecular mechanisms that control apoptosis. once such mechanism came as something of a surprise: in a number of eases, apoptosis can be promoted by the action of the c-myc protein, a protooncogene product that had previously been associated only with cell proliferation (and presumably, survival) . expression of c.myc in cells can cause them to enter an apoptotic pathway or proliferate, mad this "decision" depends upon additional signals, such as growth factors that inhibit apoptosis and allow the ceils to proliferate. thus, c-myc directs cells out of rest and the choice of proliferation or death depends upon the presence or absence of survival signals. other survival signals are generated by oncogene products that can cooperate with my¢, including bcl- and abl there are implications of this interplay between apoptotie and anti-apoptorlc signals in cell iransformation and the resistance of some tumor ceils to therapeutic agents capable of inducing apoptosis. oncogene interactions therefore control the life or death of transformed ceils but also have important roles in normal, development processes. in the immune system, developing t ceils are "screened" for potential self-reactivity by a process of negative selection, in which activation via the t cell receptor (tcr) induces apoptosis. this process can be mimicked in t cell hybridomas, and appears to depend upon the expression of the c-mye protein. evidence that this represents a requirement for the myc/max heterodimer will be presented. as above, these cells are presented with the "choice" to proliferate or die and this depends not only upon myc but also other signals. thus, expression of functional v-an kinase in these ceils can render them resistant to the activation of apoptosis via tcr ligation, surprisingly, bcl- does not appear to be capable of blocking this form of apoptosis, and the reasons for this will provide new insights into the development of the immune system and the process of apoptosis. although the oncogene products discussed here probably do not directly participate in the biochemical process of apoptosis, they represent molecular controls on this complex mechanism. as such, they gave us new ways to look at the life and death of a cell recent attention has focused on macrophage release of cytokines, such as il- , il- and tnf as important mediators of septic shock. however, serum cytokine levels have correlated poorly with outcome of septic shock. the purpose of this study was to compare the functional status of macrophages to serum cytokine levels in early sepsis by an analysis of splenic macrophage protein synthesis during abdominal sepsis. macrophage total protein distribution and biosynthetic activity was assessed by large format -d page, autoradiography of s-labeled proteins and computer assisted densitometric analysis. sepsis was induced in sprague dawley mts by cecal ligation and puncture (clp). untreated and sham operated rats served as controls. splenic macrophages were harvested at and hrs. following clp. serum il- levels were determined at , , and hours by the tdi bioassay. by hrs. % of the clp mls exhibited multi-microbiaj bacteremia. control or sham operated rats did not show bacteremia. clp resulted in a significant % elevation (p < . ) in serum il- levels at hrs. there was no difference in il- at and hrs. when compared to the control groups. d page studies examined splenic macrophage total protein distribution and biosynthetic activity at and hrs. post-clp. at hrs. macrophages from clp rats showed a substantial decrease in total protein pattern ( protein spots vs protein spots) when compared to non-septic control macrophages. a decrease in the number of lower molecular weight proteins (< kd) was observed. at hrs. post-clp, splenic macrophages from clp rats showed a substantial increase in the synthesis of low molecular weight (< kd) proteins, when compared to non-septic controls. we conclude that: l) fulminate abdominal sepsis induces an early ( hrs.) staining with cd and cd mabs will identify two monocyte subpopulations in human blood: a major population of regular monocytes, which strongly expresses the cd antigen (cd ++) and a minor population with weak expression of cd and expression of the cd antigen lcd +/ cd + cells). in healthy control donors(n= ) the latter cells account for + cells/mm and %+ % of the monocytes. in sepsis patients, the cd] +/cd + cells can become a major population with more than % of all monocytes in of patients and with more than cells/mm in of cases. there was no correlation of cd +/ cd + cells to any clinical parameter except for cd +/cd + percentage and body temperature (p= . ). the cd ++ monocytes showed a substanttial decrease in cd antigen density in of patients. three-color-if shows that the cd +/ cd + cells in sepsis patients when compared with the cd ++ monocytes exhibit a higher level of class ii antigen and a lower level of cdiib and cd antigens, consistent with a more mature nature of the cd +/cd + cells. levels of il- were increased in sepsis patients: of patients with high numbers of cdi +/cd + cells ( /mm ) had high levels of il- ( u/ml). these data suggest that septicemia may lead to substantial changes in blood monocyte composition and this may be related to elevated levels of cytokines such as il- . human peritoneal macrophages were exposed to increasing doses of lipopolysaccharide (lps) or a synthetic lipid a analogue (mrl ) and production of the cytokines il-lb, il- , tnf-a and g-csf was assessed at the protein-and mrnalevel. cells were also stimulated with low doses of lps and mrl to study their "adaptation" to a secondary challenge with high doses of lps. tnf-a production after stimulation with lps could be almost completely relieved by preincubation of cells with low doses of lps and similarly, il- production was suppressed. surprisingly, however, "adapted" cells were able to synthesize even larger quantities of of g-csf and il-lb when exposed to a secondary lps challenge. the changes in tnf-a, il- and g-csf protein synthesis could a/so be detected on the mrna level, whereas transcript levels for il-lb remained unaltered as assessed by northern blot analysis. high doses of the synthetic lipid a analogue mrl were also able to "adapt" macrophages for a secondary lps challenge by downregulating tnfa-and il- -production, while priming secretion of g-csfand il-lb as well. taken together, here we describe for the first time the discordant adaptation of human peritoneal macrophages to a secondary lps stimulus in vitro. these findings appear to bear ramifications for the in-vivo endotoxin response during inflammation and gramnegative septicemia. shock states with inadequate cellular oxygen delivery may contribute to macrophage (mo) activation or dysregulation. in this study we compared the effect of transient hypoxia and endotoxin pretreatment (lps ) on mo mediator release with a second endotoxin stimulus (lps ). methods: in vitro cultures of marine peritoneal exudate mo were exposed to hr. of hypoxic or normoxic conditions, then incubated hr under identical normoxic conditions _+ ng/ml of lps pretreatment. during the final hours all m~l were exposed to a range of lps concentrations. m~i supernatants were assayed for tnf, il- , il- , pge , nitric oxide (no), and superoxide release. results: lps markedly inhibited mo tnf release by lps but hypoxia had no effect on lps -triggered tnf release. hypoxia increased mo il- production in the absence of lps , but inhibited lps augmentation seen under normoxic conditions. pretreatment with lps increased no production from lps under normoxic conditions, but bypoxiainhibited this effect. pretreatment with lps signifcantly augmented mo release of il-i and pge , but hypoxia had no significant effect (data not shown) superoxide production was increased by lps under normoxic conditions, but hypoxia significantly inhibited superoxide release (not shown a. lepape, c. docile, f. arpin, m. c. gutowski, v. banssillon and j. bienvenu. i aim of the study. increased levels of tnf are inconsistently correlated with the severity of sepsis. one possible explanation is a decrease ability of ceils to produce eytokines. the objectives of this study were m compare at different levels of of clinical severity the responsiveness of cytokine producing cells. this was evaluated by the response to a stimulation by lps as well as to the inhibitory effect of ptx. the technic used is a whole blood ex-vivo model, as described by desch et al. ( ) . h materials and methods. different groups of icu patients, postoperative (n= ), sepsis (n= ), septick shock (n= ), and healthy control (n= ), were studied. blood was drawn in endotoxio free heparinized robes. stimulation was achieved by addition nf pl oflps ( ng/ml) to id of whole blood in presence of various concentrations of ptx ( , " , - , " , i " m). after hrs incubation at °c, the tubes were centrifuged and supematants frozen at - °c. tnfa and/l were measured by elisa (medgenix r and immunotech r respectively). monocytes were quantified on a technicon h . the results are expressed as median values. non parametric tests are used for testing differences between groups. hi results, tnftx and , , corrected for monocytes count, are given as % of their initial value, the baseline before stimulation or inhibition being %, ) stimulation by lps. the control group is much more stimulated (> % for il , > % for tnfa). blood samples taken postoperatively and in patients with simple sepsis are significantly less stimulated (> % for il , > % for tnfa ). the lowest stimulation was observed in patients with septic shock (median = %), some patients being not stimulated at all. )effects of ptx.the inhibitory effect of ptx on tnftx production is effective in all groups at - m (reduction to less than '¼ of the median values), and is almost complete at " m. the septic shock group has a decreased sensitivity to ptx. il production exhibits a lesser reduction at - m (~ 'a to ½ of the median values), further increased at - m. the septic shock group is again less sensitive to ptx. iv conclusion: the reduced ability of circulating monocytes to produce cytokines during severe infections is confirmed here. ptx is able to reduce significantly tnfc~ at - m and the inhibition is nearly complete at - m. surprisingly, there is a lesser, but significant suppressive action of ptx on il , not found in experiments using purified monocytes. one possible explination could be the interplay between cytokines production. ( ) lymphokine research ( ) cdna sequencing constitutes a powerful method of measuring steady-state mrna levels for all genes transcribed in a given cell or tissue at a particular stage of differentiation. by comparing transcript abundance both prior to and following differentiation, individual genes can be identified whose transcription is regulated both positively and negatively. in order to examine monocyte activation, the human monocyte line thp- was induced with phorbol ester ( h) and activated for h with lipopolysaccharide (lps) after which polya + rna was purified. the rna from control and lps-treated cells were each used to construct a cdna library under identical conditions, and all resulting clones were selected for cdna sequence analysis. each clone sequence was evaluated by matching with both genbank and our own gene databases. very different patterns of gene expression were seen in the two libraries, the latter reflecting very high levels of known inflammatory mediators such as il- and tnf. a second set of libraries were made from umbilical vein endothelial cells (huvec), both with and without lps stimulation, and were analyzed in a similar fashion. the effects of lps induction on specific gene transcription in both cell types will be discussed. t. tadros, md, th wobbes, me) phd, rja goris, md phd to investigate whether the preactivation of regional macrophuges by liposomes containing muramyl tripeptide (mtp-pe) can counteract the detrimental effect of blood transfusions on both anastomotic repair and host susceptibility to infections. methods eighty lewis rats received lmg/kg of either empty or mtp-pe encapsulated liposomes, intraperitoneally (ip). twenty-four hours thereafter, the animals underwent resection and anastomosis of both ileum and colon, and received ml of either saline or blood from brown norway donors,iv. the animals were killed or days after surgery and examined for septic complications and anastomotic repair. the average anastomotic strength, as assessed by bursting pressure (+sd), was significantly diminished in the transfused animals, as compared to the non-transfused animals (ileum;day ; -+ vs + , p< . ). transfused animals pretreated with mtp-pe encapsulated liposomes showed a significant improvement of their anastomotic bursting pressure ( + , p< . vs transfusion). pretreatment with mtp-pe encapsulated liposomes decreased significantly the incidence of anastomotic abscesses in transfused animals ( from % in ileum on day to %, p< . ). conclusions preactivation of regional macrophges by intraperitoneal administration of mtp-pe encapsulated liposomes prevents the detrimental effects of transfusions on anastomotic repair and reduces the incidence of intraabdominal sepsis. academic hospital nijmegen, dept of general surgery, pb i, hb nijmegen, the netherlands. leukemia cell line, teip- . robin s. wa, gner*, perry v. halushka "~, and james a. cook*, departments of physiology , pharmacology "l" and medicine "t, medical university of south carolina, charleston, s.c. . adherence of monoeytes to endothelium and extracella/ar matrix proteins is essential for accumulation at sites of inflammation. txa , an arachidonic acid metabolite, inhibits human monocyte chemotactic responses suggesting that txa may alter monocyte adhesiveness. we selected the thp- cell line, a human monocytic leukemia cell line to further investigate the effect of txa on adhesion. we tested the hypothesis that txa alters lpsinduced adhesion of thp- cells and that txa exerts its effect on adhesion via a camp dependent mechanism. thp-i cells were exposed to s. enteritidis endotoxin (lp.g/ml) _+ the cyelooxygenase inhibitor lndomethacin (in), the txa mimetic i-bop ( . .tm,) or txa receptor antagonists bms and l ( ~m). cells were allowed to adhere for hours and adherent protein/well was determined. lps-induced a significant (p< . ;n= ) increase in adherence of thp- cells (basal, . + . gg protein/well; lps, . +_ . p.g protein/well). the amino acid glutamine is an essential compound for synthesis of purine and pyrimidine basis and therefore necessary for rna-and dna synthesis. in human plasma the concentration of glutamine is between . - . mm, and is reduced in septic patients up to % ( . - . mm). monocytes play a central part in the inunune system and it was of interest, whether glutamine is involved in the modulation of cell surface markers and phagocytosis of these cells. human peripheral blood mononuclear ceils were obtained from ml heparinized blood of apparently healthy donors by ficoll-paque density gradient and isolated by counterflow elutriation. the puritiy was more than %. subsequently cells were cultured in phenolred-free rpmi medium with various concentrations of glutamine ( . , . , . , . , . , , mm) in teflon-fluorinated ethylene propylene bottles to exclude cell adhesion and possible cell activation. aider seven days culture, cell viabilty was determined by trepan blue exclusion and varied between and %, independent of glutamine concentrations. cell surface markers were detected by flow cytometry, noaspecifie phagoeytosis was measured with latex beads and specific phagocytosis with opsonizied e.eoli using a facscan. lower concentrations of glutamine decreased the expression of hla-dr and icam- /cd on monocytes in a dose-dependent manner. the receptor for fc'/rucd as well as the receptors for complement cr /cdllb and cr /cdllc were down-regulated. cr /cd which is only slightly expressed on monocytes was not influenced. furthermore, no effects on the expression of cdi , the receptor for transferrin cd and fc'friii/cd were seen. our data indicate, that lower concentrations of glutamme influence the phenotype of monocytes. we are now interested to study whether glutmnine influences non-specific phagocytosis, or whether specific phagocytosis correlates with the decreased expression of fc'/r and complement receptors. we investigated immunologically more than patients who were admitted to icu because septic syndrom during the last four years. patients were immunologically followed up - times per week until release from icu. the expression of hla-dr antigen on monocytes turned out to be the best prognostic parameter. the persistence (> days) of low hla-dr expression (< %) predicts fatal outcome (mortality > %). the altered phenotype was associated with a functional deactivation of monocytes (diminished apc, ros formation, cytokine secretion). we called this phenomenon "immunoparalysis". ifn-gamma and gm-csf were able to restore the altered phenotype and function in vitro. however, addition of autologous plasma from septic patients with "immunoparalysis" to these cultures prevented the cytokine-induced restitution. the inhibitory activity could not be removed by dialysis. therefore, we started a study to prove the therapeutic efficacy of plasmapheresis. indeed, [ of patients recovered from "immunoparalysis" following repeated plasmapheres; of them survived ( %). patients recovered temporarely and patients did not respond (all died). the survival rate in the control group of septic patients with persistent "immunoparalysis" was of ( %; p< , ). in summary, plasmapheresis in association with immune monitoring may be an alternative strategy to improve survival rate in severe sepsis. taurolidine, a synthetic taurine-formaldehyde derivative has antiadherent, bactericidal and anti-lps properties functioning primarily through binding of the lipid a region of the lps molecule. the active derivative of taurolidine, taurine, modulates calcium channel activity, critical to the initiation of a number of immunostimulatory pathways. we hypothesised that taurolidine may have direct immunostimulatory activity. the aim of this study was to investigate the immune effects of taurolidine on peritoneal macrophage (pmo) function and then determine the role of taurine in this response. study : in vivo stimulation:cd- mice (n= ) were randomized to receive taurolidine ( mg/kg bw/i.p.) or saline cor~trol. peritoneai cells were harvested after hours and were assessed for pm function [superoxide anion generation (o -), nitric oxide (no), tumor necrosis factor (tnf), fc/cr -mediated phagocytic function (phago) study : control pm were harvested and cultured in vitro with taurine ( . mg/ml for hrs), after which time they were assayed for -and tnf release. in vivo stimulation with taurolidine taurolidine has specific immunological effects on m . release of the inflammatory mediators -and tnf, and fc/cr -mediated phagocytosis were significantly increased, while release of the endothelial relaxing factor no was significantly reduced. in addition, the amino acid taurine, which is released as a byproduct of taurolidines breakdown has an immunostimulatory effect on pmo and may be the active moeity of the compound tanrolidine. in sepsis, a number of mediators which affect vasomotor tone and cardiovascular function are produced. inasmuch as sepsis causes decrease in systemic vascular resistance (svr), attention is usually focussed on vasodilators such as lactate, tumor necrosis factor, interleukin-i & , and nitric oxide. but injury and inflammation als cause production of several vasoconstrictors whose effect may not be evident in changed svr, but may significantly affect organ blood flow or function in the paracrine environment. endothelin (et) is a amino acid peptide vasoconstrictor produced by ischemic or injured endothelial cells (ec's). et is also a potent constrictor for renal mesangial and coronary vessels, an endocrine regulator, and a negative cardiac inotrope. systemic et levels increase significantly in hypoperfusion and ischemia. while et is principally produced by ec's, we asked if human monocytes might also produce et and thereby regulate vasomotor tone in areas of inflammation. monocytes from healthy donors were separated on ficoll, resuspended in rpmi + % fetal calf serum and stimulated with i ug/ml endotoxin (lps). et was measured by radioimmunoassay. lps-stimulated monocytes produced ! fm of et/ cells (vs. unstimulated controls of < ). this calculates to - % of the amount of et observed in patients with low cardiac output, sepsis or ischemia. we conclude that et is a cytokine produced by both ec's and monocytes with potent effects on numerous cells and organs in the critically ill. wuppertal , germany we and other authors showed that fatal outcome in septic disease is associated with a decreased capacity of peripheral blood monocytes for the in vitro production of proinflammatory cytokines, especially tnf-alpha. we found that this monocytic deactivation is completed by a persistent and marked decrease of hla-dr expression on monocytes (< % hla-dr+ monocytes) and a diminished antigen presenting activity whereas the capacity to form the antiinflammatory il- receptor antagonist remains high. in order to evaluate the in vivo situation and to determine at which level tnfproduction/secretion is altered we assessed the tnf-alpha mrna expression in freshly isolated peripheral blood mononuclear cells (pbmnc) from septic patients. tnf-mrna was onty rarely detected by semiqaantitative polymerase chain reaction in pbmnc's from septic patients with monocyte deactivation. meanwhile, it was found in almost all pbmncs from septic patients without monocytic deactivation. we wondered, whether il-i , which ,is known to depress monocytic proinflammatoly response and mhc class ii expression, could be one of the mediators in fatal sepsis. in fact, we found that il- message in pbmncs of septic patients peaked in the beginning phase of monocytic deactivation. in further investigations we found that tnf-administration can induce monocytic deactivation in a murine model/n vivo and provoke il- message in human pbmncs in vitro. these results support our hypothesis that an excessive delivery of proinflammatory cytokines in a first phase can induce an overwheiming inhibitory feedback, mediated by immuninhibitory mediators like il-l , which leads to often fatal monocytic deactivation in a second phase. interferon-gamma which is known to counteract il- production and the effects of il- on monocytes restores the function and phenotype of monocytes from septic patients with monoq, te deactivation in vitro and could be a possible therapeutic agent in otherwise fatal sepsis. our laboratory previously reported that lps dependent macrophagederived tnf-a production can be enhanced by pretreatment with lps at substimulatory lps priming doses coincident with a suppression of lps dependent nitric oxide (no) production (zhang and morrison, j. exp. med : , ) . in order to extend the characterization of these lps priming effects in mouse macrophages, we examined the capacity of substimulatory lps to modify lps dependent il- production. macrophages were obtained from peritoneal exudate of thioglycollate treated c heb/fej mice and cultured in rpmi medium containing % fetal bovine serum. macrophages were pretreated with various subthreshold stimulatory concentrations of lps (olll:b ) for hours, washed three times, and then stimulated with the effective stimulatory concentration of lps for hours. the amount of il- in the supernatant was measured by il- dependent cell line (b and td ) proliferation assay. il- was produced by macrophages at lower threshold doses of lps than those required for tnf-o~ or no production. subthreshold doses of lps modulated il- production in a biphasic manner characterized by an initial suppression and then potentiation. higher doses resulted in secretion of il- during the initial incubation with lps and subsequent desensitization. il- , like tnf-~ and no, is, therefore, also affected by lps pretreatment. moreover, tnf-a and il- shared the similar potentiational pathway, but differed by the fact that only il- was inhibited. (supported by r ai and po a .) department of microbiology, molecular genetics and immunology and the cancer center, wahl east, university of kansas medical center, kansas city, ks - . korolenko t.,urazgaliev k.,and arkhipov s. the role of macrophage (mph) stimulation in mechanism of protective effect of new immunomodulators yeast polysaccharides -heteropolysaccharide cryelan and homopolysaccharide mannan rhodexman (both produced by petersburg chem.-pharm. inst.) was studied. in vitro according to nst test incubation of murine peritoneal mphs with cryelan or rhodexman, ~g/ml, min was followed by increase of potencial microbicidic activity of mphs. in vivo mph stimulation by immunomodulators studied included increase rate of carbon particles phagocytosis during single i.v. or i.p. mode of administration to mice - days after (peak at nd day for i.v. and th day for i.p. mode of administration of the same dose of mg/ g b.w.).the preliminary injection of cryelan ( mg/ g, or h before) to mice with acute cold stress (- ° c, h) revealed protective effect restorating the value of depressed phagocytosis up to the normal level;the positive effect on ultrastructure of hepatocytes was noted also.there was no changes of plasma corticosterone level between group with acute cold stress and mice with cryelan + acute cold stress (several fold increase comparatively to the control mice).as was suggested, the mechanism of protection can include mph stimulation and secretion of some acute phase proteins responsible for positive effect of immunomodulators. new yeast polysaccharides cryelan and rhodexman can be used for macrophage stimulation,especially in pathological states. immunomodulators were shown to increase production and secretion of lysosomal enzymes (like zymosan). secreted enzymes,especially cysteine proteinasescathepsins b and l -involve in the process of inflammation;however, excessive release of these enzymes may lead to noncontrolled proteolysis followed by tissue degradation (assfalg-machleidt et al., ) .the effect of zymosan,bcg and new immunomodulator carboxymethylglucan (cmg), second fraction on secretion of lysosomal enzymes by murine peritoneal macrophages was studied. zymosan increased the secretion of n-acetyl-~-d-glucosaminidase and ~-galactosidase into the culture medium ( - fold); bcg possessed similar effect.cmg in the same concentrations ( /~g/ml) increased release of these enzymes only saightly ( . times).it's known that zymosan-induced secretion reflects the enzyme release from formed lysosomes (warren, ) .it was suggested that cmg activated macrophages via interaction with scavenger-receptors,followed by weak secretion of lysosomal enzymes and as a result decrease of tissue damage. in vivo zymosan induced stimulation of mononuclear system of phagocytes followed by increase of cysteine proteinases activity in liver at the th day. in the same time in blood n-acetyl-~-d-glucosaminidase and n-acetyl-~-d-galactosidase activity increased - fold. it was concluded that in drug design it's possible to select such immunomodulators,e.g. cmg,which can activate mononuclear system of phagocytes and do not damage tissue. endothelin-i (et-i) is produced by injured/ ischemic endothelium, mobilizes intracellular ca ++ and is a potent vasoconstrictor. it is also a ca ++ agonist for anterior pituitary or renal mesangial cells and monocytes. et-i causes monocytes to produce interleukin-l, , , prostaglandin e , and substances which trigger neutrophil superoxide production. et-i levels increase in shock and et may play a role in activating leukocytes post shock causing reperfusion injury. but blood flow experiments suggest splanchnic circulation changes more profoundly in shock than peripheral circulation. we therefore asked if et- (or vic), the et which predominates in splanchnic vessels, had any effect on monocyte cytokine production. human monocytes from health~ blood donors were separated on ficoll. . x ucells/ ml in rpmi + % fcs were incubated i min., & hrs. with - m et-i, - m vic or i ug/ml of lps. supernatants were assayed by elisa. we have shown that low dose endotoxin pretreatment (lps ) for hrs markedly inhibits the macrophage (mo) release of tumor necrosis factor (tnf) and increases interleukin- (il-i) in response to a subsequent endotoxin stimulus (lps ). in this study we examined the kinetics of lps inhibition of tnf and augmentation ofil- . methods: murine peritoneal exudate mo from balbc mice were exposed in vitro to medium or ng/ml of lps for intervals of to hours. culture medium was then replaced with , or ng/ml of lps for hrs. tnf and il- in mo supernatants were measured by specific bioassays. during sepsis endotoxin (lps) activates macrophages (mo) to release mediators such as tumor necrosis factor (tnf), interleukin- (il- ), interleukin-i (il-i) and prostaglandin e (pge ). we showed that preexposure to lps (lps ) alters the response of murine m~i to subsequent lps stimulation (lps ). we hypothesized that in vitro cytokine release by lps in human monocytes (mo) is also be altered by preexposure to lpsi. methods: human peripheral blood mo were obtained from healthy volunteers (n= ), cultured in vitro hrs, then pretreated hr _+ lps -cultures were then stimulated with lps and mediators in mo supernatant measured: tnf, il-i, and il- by specific bioassays, pge by immunoassay kit. serum cytokine levels (specific elisa kits) were compared to in vitro supernatant levels. data is expressed as % control_+sem, lps = ng/mh the table shows that all mediators were increased, in the absence of lps . pretreatment with lps resulted in complete inhibition of lps -triggered tnf release. in contrast, lps significantly increased mo secretion of il- , il- and pge (data not shown). serum cytokine levels were as follows: tnf _+ , il-i + , and il- . -+ . ng/ml. these serum levels were low, showed an extremely wide variation, and did not correlate with in vitro lps -triggered mediator production. conclusion: human monoeyte mediator production is differentially regulated by preexposure to lps . provocative in vitro testing of monocytes may ultimately be clinically useful to identify prior in vivo lps exposure or mo macrophages release numerous secretory products involved in host defense and inflammation. activated macrophages with cytokines produced have been implicated in tissue damage in sepsis and multiple organ dysfunction. aimed to elucidate the organ-association phenomena,this study is to compare peritoneal macrophage(pm),alveolar macrophage(am), and kupffer cells(kc) during sepsis in terms of cellular protein contents as symbol of activation by flow cytometry analysis. sepsis were produced by cecal ligatien and perforation (clp) in wistar rats weighing - g.pm were obtained by peritoneal lavage,am by bronchial lavage and kc by incubating the collegenase digested liver with pronase-e. leukocytes have been implicated as a mediator of the microvascular dysfunction associated with reperfasion of ischemic tissues. a role for ieukocytes is largely based on observations that rendering animals anutropenic with anti-neutrophil serum or preventing leukocyte adhesion with monoclonal antibodies attenuates the increased fluid and protein leakage from the vaseulature that is normally observed in postischemic tissues. we have recently undertaken studies designed to determine the relationship between leukocyte-endothelial cell adhesion and albumin leakage ia rat mesenterlc venules exposed ~o ischemia-reperfusion (i/r). leukocyte adherence and emigration as well as albumin extravasafion were monitored in single postcapillary venules using iatravital fluorescence microscopy, lschemia was induced by complete occ!usion of the superior mesenteric artery and ~dl parameters were monitored at various intervals following reperfusion. the magnitude of the leukocyte adherence and emigration, and albumin leakage elicited by i/r was positively con-elated with the duration of ischemia. the albumin leakage response was also highly correlated with the number of adherent and emigrated leukocytes. monoclonal antibodies against the adhesion glycoproteins cd , cdllb, icam- and l-selectin, but not p-or e-selecdn, reduced i/r-induced leukocyte adherence and emigration as well as albumin leakage. phauoidln, an f-aetin stabilizer, largely prevented the emigration (but not adherence) of leukocytes and greatly reduced, the raicrovascular protein leakage. plateletleukocyte aggregates were formed in postischemic vemdes; the number of aggregates was reduced by antibodies against p-selecdh, cdilb, cd , and icam- , but not e-selectin or lselectin. a significant fraction of the mast ceils surrounding the posteapillary venules degranulated in response to ischemia/repeffusion, but mast cell stabilizers did not afford protection against the albumin leakage elicited by i/r. these results indicate that reperfusloninduced albumin leakage is tightly coupled to the adherence and emigration of leukocytes in posteapillary venules. this adhesiomdependent injury response is primarily mediated by cdllb/cdi on activated neutrophils and icam- on venular endothellum, and appears to require l-selecda dependent leukocyte rolling. mast cell degranulation does not appear to conwibate to the vascular pathology associated with i/r. m.d. rod=iek, boston, ma, usa the polymorphonuclear neutrophil (pmn) has long been known to pa~tlcipats in the inflammatory rebpons~ as a phagocyte and killer of invading organisms, but little attention has been given to its potential as a participant in the in~une interaction of lymphocytes and macrophages. we and others have shown that the pmn may have i~m~/nomcdulatory effects both in vitro and in vlvo. more recently it has been proven that the pmn can make mrna for and secrete the proinflammatory oytokines illa, il-ib, tnfs, il- and il- as does the other major circulating phagocyte, the monocyte/macrophags. furthermore it has been shown to make the potentially autoregulatory oytokines gcsf and gmcsf. these functional capabilities suggest that the pmn is not an wend cell ~, but one which has a potential role in regulation cf ~he immune response and that this potential ~cle should no longer be ignored when considering the immune abnormalities existing in patients following majo~ injury or surgery. we have investigated the proinflaznmatory oytokine secretion patter~ by pmn in patients following major ~hermal or tra~matic injury and in volunteers fellowinq endotoxemia. ?ollowing major injury there is variable pmn secretion of these cytokines when stimulated in vlero. following endotoxemia in a group of human volunteers pmn showed a hypo=esponsivenesa to lps hrs following endotoxin infusion followed at hre by an overshoot. pretreatment with steroids modulated this overshoot phenomenon, suggesting that receptors for steroids are involved in the regulation of cytokin® secretlon by fmn. these results sugges~ that the pmn, the most numerous cell in the circulation and the first to respond to an ins~l~ may be a so~rce of the prolnflammatory cytokine cascade following injury that has been recognized as significant in the process which often leads to multiple o;gan failure, the immunosuppresslon which occurs following major thermal injury may predispose these individuals to infection and sepsis, which remain a significant cause of morbidity and mortality. included among the many immune aheratlons are the p integrln (cdlla, b,c/cd ) dependent activities of adhesion, chemotaxls, diapodesls, and phagocytosls. our investigations indicate that, following major thermal injuries, the expression of the [~ integrlns, but not cd , is significantly decreased on neutrophlls (pmns). it remains unclear if pmns from thermally injured patients respond normally to lps, the effects of treatment in vitro with lps and f-met-leu-phe (fmlp) on the expression of cdtlb was examlned on pmns from the peripheral blood of healthy volunteers and non-septic burn patients (> ~; total body surface area, >ls~ full thickness), the pmns were incubated with lps (]ng- p.g/ml) or f'mlp ( " to " m) et oc for mln, in ~; human ab serum, the expression of the ]ntegrins was detected using monoclonat antibodies and flow cytometry. lps and f'mlp resulted in a slight increase ( fold) in the expression of cd b on pmns from burned patients compared to an and fold increase, respectively, on pmns from healthy individuals. this inability of lps or fmlp to increase cd b expression was not due to the amount of lps bound to the two cell populations. because the same defect is seen after either lps or fmlp stimulation, it is speculated that the defect must be in the amount of preformed cd ] b or its transport to the plasma membrane. platelet-activating factor (paf) and neutrophils have been implicated in the patbophysiology of ischemia-repeffusion injury, in addition, paf stimulates neutrophi[ (pmn) oxidative metabolism in vitro. the present study examined the potential role of paf in repeffusion injury in an in viva rabbit model. eight anesthetized rabbi~s underwent retroperitoneal exposure of the infrarenal abdominal aorta after percutaneous insertion of a catheter through the jugular vein into the infrahepatic inferior vena cava. doppler flow probes were placed around the abdominal aorta and the right common femoral artery to assess flow through these vessels. an occlusive ligature was placed around the abdominal aorta (superior to the flow probe) at t = and total occlusion of blood flow to the lower extremities was maintained for g mins., after which the ligature was released allowing for reperfusion of the ischemic lower limbs. effluent blood from the ischemic hind-limbs was collected through the ivc catheter at the times indicated below and assayed for paf by a direct radioimmunoassay. in addition, neutrophil h production was determined by a previously described ' '-dichlorofluorescein flowcytametric assay. _+ amean _+ s.e.m, pg/ml blood; brelative fluoresenee (% of baseline); caortic and femoral artery flow (% of baseline); *p < . vs. baseline; "p < . vs. baseline. a significant elevation of paf was observed in ischemic hind-limb effluent blood at min. after release of the aortic ligature during the repeffusion phase, as compared to baseline levels. in addition, pmn h production was increased by . -fold above baseline values by hour after ligature release during the reperfusion phase. both of these elevations were transient and returned toward baseline by hours post-isehemia. tatar occlusion of hind-limb flow was achieved as evidenced by the absence of aortic or femorat flow at rain. post-ischemia, however after release the ligature a significant reactive hyperemia was observed by mln. into the rapeffusion phase. histolog[c examination of reper[used gastrocnemius muscle revealed moderate pmn infiltration into the interstitium. in conclusion, these data indicate that paf is released into the circulation during repeffusion, and is likely involved as a mediator in the observed pmn oxidative burst activity, thereby contributing to reperfusien injury. following thermal injury and infection granulocyte function ts abnormal. to elucidate the mechanism by which thermal injury and infection affect the granulocyte's ability to polymerize and depolymedze actin, we serially measured f-actin levels in granulocytes from burned patients (mean age , +_ . years, mean burn size . % _+ . %) during the first s weeks post injury. six of the patients had infections during the course of the study, (septicemia, wound invasion and pneumonia). actin levels in granulocytes from eleven healthy volunteers (mean age years) were measured repeatedly and served as controls. lysecl white blood cell preparations were brought to c and incubated with n-formyl-met-leu-phe (stim) or with dulbecco's phosphate unbuffered sellne (unstim). the cells were concomitantly stained and fixed with formaldehyde, lysoleclthln and fiuoresceln phafioidin. actin depolymedzation (depol) was measured by incubating stimulated cells at °c before the stain-fixative was added. baseline (base) f-actln levels were assessed by adding stsln-fixatlve to icecold unstimulated cells. fluorescence was estimated in a facscan and expressed as ilnesr mean channel fluorescence_+ sem (mcf). figure displays granulecyle fectln levels in infected and uninfected patients as compared to controls. f-actln levels were consistently lower in control cells than in those from burned or burn-infected patients under all measured conditions. granulocytes from infected burned patients demonstrated a significant decrement in their ability to depofymerlze f.actin compared to both uninfected burned patients and controls, while there were no significant differences between infected and ,~ uninfected patients in the baseline, unstlmuleted and stimulated conditions. those results indicate la that grsnulocytas from burned and bum-infected patients contain higher levels of polymerized actln than ~ , s control cells. in order to study tumor necrosis factor (tnf) receptor sensitivity in septic critically ill patients we investigated blood samples of such people in reaction of leucocyte migration inhibition. migration of their polymorphonuclear leucocytes (pmns) was studied with stimulation with human recombinant tnf in concentration of . u/ml (recommended by manufacturer is the range of - o/ml) and without such. ten healthy blood donors formed control group. the results obtained showed diminished pmn reactivity to tnf in patients (migration inhibition was absent) oscaring with significantly increased migration ability of their pmns ( . % of that in control group). at the same time normal pmns in control group did show migration changes upon tnf stimulation. considering all the above we come to a conclusion that externally added tnf fails to activate pmns in critically ill patients more than they are by their endogenous tnf. moreover, this tnf no longer serves a positive chemotactic factor for such pmns. these findings may suggest that in critically ill septic patients reactivity of pmns to tnf is deeply altered. tnf receptors of pmns are either exhausted as such by excessive stimulation with endogenous tnf or further transmission of their message is impossible due to "fatigue" of the cell's activation mechanisms. we express our gratitude to reanal factory of laboratory chemicals for generously providing us with a tnf com~rcial sample. ~-sanguis medical, ekaterineburg russia; s-urals med.lnst. activated neutrophils infiltrating the local site of inflammation following trauma release high amounts of destructive lysosomal enzymes into the extracellular space. cytokines were discussed to be involved in regulation of this early process. the task of this investigation was to evaluate the possible regulatory role of interleukin- (il- ) and its potential immunosupressive opponent, the transforming growth factor-&, in regulation of neutrophil degranulation. we analysed the concentration of the al-proteinase-inhibitor complex of the lysosomal elastase as marker for the degranulation of neutrophils as well as the levels of il- and tgf- in the plasma probes of patients undergoing multiple trauma and severe surgeries. the time courses of il- and elastase were found to be highly correlated, wheras the concentrations of the cytokine tgf-e~ were found to be not significantly altered in comparison to the control group. this close temporal correlationship was confirmed by investigation of fluids derived from sites of inflammation. interstingly, the inhibitory potential (~zcproteinase inhibitor, antithrombin iii) was dramatically reduced in the early inflammatory phase. to prove this in vivo findings, the effects of il- and tgf-i~ on the degranulation of isolated human neutrophils of healthy donors was investigated in vitro. pathological high concentrations of rhll- up to u/ml (as detected in fluids derived from local inflammatory site) were found to be capable to induce a significant release of lysosomal elastase in a concentration-dependent manner, whereas the degranulation of neutrophils was uneffected by tgf- . in conclusion, these data suggest a contribution of il- in regulation of neutrophil activation at sides of inflammation. the immunosuppressive cytokine tgf-i&~ seems to have no direct regulatory effect beside its described chemotactic function on neutrephils. postirradiation chan~es of adhesive properties arid supercoiled nucleoid dna structure of blood leukocytes were studied in macaca nemestrina andrats. the dynamics of membrane chan~es after nonlethal irradiation of rats demonstrated the temporary increase of the leukocyte adherence at h followed by return of this parameter to normal levels at h. after lethal irradiation of both animal species the increase in adhesive leukooytes fraction was detected as early as at h. this hi~her index persisted until the end of experiments ( days). the early ( - h) temporary loosin~ of supercoiled dna structure was demonstrated in the leukocytes of nonlethally irradiated animals. this phenomenon seems to be connected with the lymphocyte fraction chan~es. this process was not dependent on altered adhesive properties of leukocyte membranes. the membrane chan~es of leukocytes preceded decondensation of supercoiled dna after lethal irradiation of animals, in this case loosin~ of supercoiled dna pro-~ressively increased at h and at the later terms of postirradiation period. the systemic inflammatory response syndrome (sirs) involves many inanunological reactions of the host including acfivatinn of inflammatory mediator cascades and depression of cellular reactivity in t-lymphecytes ( ). there are reports of nentrophil dysfunction in inflammatory disorders of the skin ( ), are there dysfunctions concerning the unspecific host defense in sirs, as well? in this study, we examined the reactivity of neutrophil granolocytes from patients suffering from sirs. twenty-one patients (apache ii-score ± ) with diagnosis of sirs entered the study. granulocytes were prepared as reported previously ( ) . in parallel, granulocytes from healthy individuals were tested. two granulocyte functians were studied in vitro: . migration of the ceils in a boyden chamber through a filter matrix following stimulation with different receptor dependent stimuli (c a, intefleukin- , platelet-activating-factor, leukotrien b , fmlp). . release of glucuronidase following stimulation with the aforementioned activators. the results demonstrate, that the release of -glucuronidase in patients suffering from sirs was comparable to the enzyme release of granulocytes prepared from healthy individuals. each stimulant induced release of p-glucuronidase in a characteristic dose dependent fashion. all granulocyte preparations from the healthy donors showed a positive chemotaxis response in the migration-assay. in contrast, only ten out of twenty-one patients had granulocytes migrating after stimulation. the two groups of patients displaying reactive or non-reactive granulocytes differed clinically: the nonreactive group consisted of patients with multiple organ failure ( / ) and nonsurvivors ( / ), whereas / patients in the reactive group survived. thus, the in vitro chemotaxis of granulocytes is impaired in a subgroup of patients with sirs. this defect of the non-specific host defense may contribute to poor prognosis and outcome of these patients. dermatol. : - , klinik ffir an~isthesiologie und operative intensivmedizin der cau kiel, schwanenweg , kiel, germany. objectives of the study: major emphasis has been given to the analysis of interactions of antibiotics with microorganisms. effects of antibiotics on cells of primary host defense mechanisms, such as the neutrophils, are less well known. therefore, attention has been focused on clindamycin, a member of the lincoseamide family. materials and methods: the effect of clindamycin (i -i ~g/ml) on granulocyte functions (healthy volunteers) such as random migration, chemotaxis (agarose method), ingestion (radiometric assay), superoxide (cytochrom c reduction) and hydrogen peroxide production (phenol red oxidation), lucigenin-and luminol-amplified chemiluminescence (luminometry) and degranulation (turbidometry with micrococcus lysodeicticus) were investigated in vitro. results: motility and degranulation were inhibited, ingestion of saccharomyces cerevisiae, zymosan-induced lucigenin-and luminol-amplified chemiluminescence, superoxide and hydrogen peroxide production were stimulated in a dose dependent fashion. conclusion: clindamycin has granulocyte function modulating properties. recognition of immunomodulating effects of antibiotics may have therapeutic significance, especially in patients with long-term antibiotic therapy or immune deficiencies. the intense muscle activity (ea) of rats resulted in increase of neutrophil influx in muscles during the recovery. we investigated neutrophil proteinases involvement in neutral proteinases balance of skeletal muscles by na. the rats were submited to swim with the load ( % of body mass) till exhaustion. immediately after na the neutrophil antiserum was injected i.p. to rats of experimental group. saline was injected to control animals° injections were repeated in h of the recovery and cytosol proteolytic activity (ph . ; fitc-casein) was determined. isolated soleus muscles were incubated also in vitro and proteolytic activity of incubation media was measured. it was found that there was - -fold proteinases activity increase in cytosols of all investigated muscles (soleus, white and red portions of quadriceps) of control animals by h of the recovery (the comparison was done with the sedentary rats). in h cytosol proteolytic activity decreased and then increased again by h of the fast. antiserum injections resulted in relible decrease of the proteolytic activities at every investigated time. when incubating m. soleus in vitro the activities of proteinases in incubation media turned out reliably less if soleus muscles were isolated from the animals to which antiserum was injected. the conclusion is that neutrophil proteinases can be involved in the balance of rat skeletal muscle neutral proteinases after ~a. a lot and new clinical problems complicating the outcome of polytrauma, burn and septic patients in surgical intensive care units, have arisen as the care improvement prolonged the patient's survival: a progressive degradation of organ and system functions often develops, usually making its first clinical appearance by ards, followed by the other organ failure (mof) and sepsis symptoms. the clinical picture is polymorphic, the end result of a complex systemic pathophysiological reaction trigg~ed off by trauma consequences (tissues disruption, hypo~xygenatiun and necrosis). nowadays there is not a preventi~ or specific therapy to lower the mortality rate ( - %) and-'mdy-a~ early, aggressive surgical approach .-evacuating haematomas, stopping bleeding, toileting all septic, necrotic foci and restoring anatomic continuity-, seems to be of some help this complex clinical entity has not an univocal denomination yet. the proper labelling of an illness should come from the full understanding of its pathopysiology and suggest the proper treatment choice. clinical and experimental studies demonstrated that pathophysiologic mechanisms involved in the past-traumatic illness, share the same anatomo-pathological elemem: the interstitial edema, due to a generalised endothelial micro circulatory injury. this alteration, as constantly seen in polytrauma patients, develops in a few hours after trauma as a consequence of the deregulation of the homoeostatic and immune mechanisms. in fact the overproduced oxygen free radicals and r~ombinam cytokines (il ,tnf), together with the complement degradation fragments, the proteolytic enzymes and many other mediators are all strongly h~l ~ ,_he e,,j,yheha! ceils. our~osect, atim~,-bnsed on examination of autopsical specimens from polytraanm patients, showed that such endothelial damage, supporting the interstitial edema, is widely and simultaneensly distributed, ensues shortly arer trauma and shows its effects in different organs at different times, only because each apparatus has different fimctienal reserves: the lung is the first organ to fail just because its ah, celocapillary membrane is one of the most delicate bodily structure, and its function is irroplace~le. we think it will be of a great help, in planning a preventive therapy, to chose a denomination focusing the physician's attention on the earl)" generalized endothelial injury and its effects, as in trauma patients it is present -even if latenflysince the first few hours. we would like to see the generalised endothelial microcircolatory injury properly highlighted when considering the best definition and the optimal nomenclature for the post-traumatic s mdrome. the presence of interleukin (il)- in bronchoalveolar lavage fluid of critically ill patients correlates clinically with the development of the adult respiratory distress syndrome lards), and inhibition of il- in animal models can attenuate lung injury. collectively, evidence to date suggests that il- attracts and activates neutrophiis (pmn), which are then responsible for the capillary leak of ards. however, an alternative explanation is that il- is directly toxic to the endothelial cell (ec). in this study, we have hypothesized that il- can disrupt endothelial integrity independent of pmn. meth ods: human umbilical vein (huv) ec monolayers were cultured to confluency on collagen-coated micropore filters. to assess ec integrity, .albumi n leak was quantitated by measuring the counts which crossed the monolayer, using a gamma counter. il- (lpg/ml) was incubated in the culture medium with .albumi n for hrs. the il- dose was not cytotoxic. to determine the involvement of protein synthesis in this process, selected monolayers were pretreated with cycloheximide (ch) prior to .- addition. statistical analysis was performed using anovmfisher plsd. we have previously shown that platelet activating factor (paf) enhances cdt expression and primes pmn's for subsequent generation. both are important steps in pmn mediated injury and are assumed to occur in concert. following major trauma non-specific pmn inflammation is activated, however, unbridled systemic pmn activity needs to be minimized. since circulating catecholamines are high early post-injury, we hypothesised that they downregu/ate cd expression and pmn priming via the [ adrenergic signal transduction pathway. methods: normal human pmns were primed with paf ( ng/ml for min) or pre-treated with - m of isoproterenol (i) or forskoklin (f) for rain and then primed with paf. cd expression was measured by flow cytometry (fig.l) and -generation in response to -rm fmlp was determined as sod inhibitable reduction of cytochrome c ( fig. holler** and georg w. bornkamm* lymphocyte-endothelial interactions are crucial for various immune responses, including cytokine driven inflammatory processes. protein kinase c (pkc)-inhibitors on the other hand are discussed as potential cytokine antagonists. in the present study we investigated the influence of the pkc-inhibitor gf x on cytokine-and endotoxin induced expression of intercellular adhesion molecule (icam- ) and on adhesion of lymphocytes to cytokine activated endothelial cells. we found that tumor necrosis factor alpha (tnfo -and lipopolysaccharide (lps)-induced icam- expression on human endothelioma celts (eahy ) were unaffected by the pkc-inhibitor and thus appeared to be independent of pkc activation. in contrast, gf x significantly reduced icam- expression induced by interferon-y (ifn-?) and interleukin- (il- ). the functional relevance of these findings was evaluated in an adhesion assay using human umbilical vene endothelial cells (huvec) and peripheral blood mononuclear cells (pbmc). in fact, the ifn-? and il- induced adhesion of pbmc to cytokine treated huvec could be downregulated by the pkc-inhibitor, whereas tnfc~-and lps-mediated adhesion was not influenced. additionally, the il- driven icam- expression on eahy cells as well as the il- induced adhesion of pbmc to huvec was found to be tnf-dependent, since both effects could be inhibited by an anti-tnf monoclonal antibody ( f) . these in vitro data further support the idea of examining pkc-inhibitors, such as gf x, for their biological relevance in cytokine related dysregulations. seiffge, d., bissinger, t., laux, v., during inflammation there are some key processes, which occur in the microcirculation: the release of mediators from various cell types, the migration of inflammatory cells towards a chemotactic stimulus in the tissue, the expression of adhesion molecules on different cells, and the extravasation of plasma proteins. the aim of the present study was to elucidate the mediator induced interaction of leukocyte adhesion and plasma leakage in postcapillary venules. using an analogous video-image analysing system we have studied the effect of different mediators on leukocyte adhesion and macromolecular permeability in the mesentery of the rat. the increase in permeability was measured as changes in optical density. we found that topical administration of leneotriene b (ltb , x " tool/l) or intravenous injection of interleuldn- (il- , - iu/kg b.w.) and lipopolysaccharide (lps, mg/kg b.w.) resulted in a significant extravasation of fitc-labelled rat serum albumin (fitc-rsa) in venules but not in arterioles. we could correlate the changes in vascular permeability with a locally increased number of rolling and sticking leukocytes in venules. both effects were dose dependently inhibited by different drugs. pentoxlfylline inhibits lps-indueed fitc-rsa extravasation and leukocyte adhesion at a dose of mg/kg b.w., superoxid-dismutase (sod, . iu/kg b.w.) was able to decrease the ltb effect, and the immuumodulating drug leflunomide (hwa ) exerted inhibitory effects on il- -induced permeability at a dose of mg/kg b.w.i.v. the obtained results demonstrate that lps, ltb or il- induced extravasation of fitc-rsa is mediated by activated leukocytes and can be deminished following administration of different drugs. platelet-endothelial cell adhesion molecule-i (pecam-i), a member of the immunoglobulin superfamily, is constitutively expressed at high levels on the endothelial cell surface. in vitro data have suggested that pecam-i functions as a vascular adhesion molecule, specifically in neutrophil transmigration across the endothelium. this current work is the first demonstrating the in vivo role of pecam- in neutrophil migration. blocking antibodies to human pecam- , in which the antibodies are crossreactive with rat pecam- , were able to block the movement of neutrophils into the rat lungs after igg immune complex deposition. furthermore, when human foreskin was transplanted into mice with severe combined immunodeficiency and the site injected with tnf-alpha, anti-pecam-i blocked neutrophil emigration into the dermal interstitium. it has already been established that neutrophil recruitment is dependent upon selectin mediated rolling, followed by firm adherence that is icam- / integrin mediated. these data suggest, for the first time, that a third endothelial adhesion molecule (pecam-i) is involved in the coordinated recruitment of neutrophils in vivo. to test whether trauma causes generalized activation or priming of pmns, cdi adherence receptors were measured with iinmunomonitoring in whole blood after lps stimulation ex vivo. anesthetized (fentanyl) mongrel pigs ( - kg) were subjected to % arterial hemorrhage + soft tissue injury and after liar, resuscitated with all the shed blood + supplemental fluid. blood was collected at hr intervals from unanesthetized animals with indwelling catheters, pmns were counted, and lps was added ( , , , i.tg/ml) ex vivo. after hr incubation at - °c, %cd (+) pmns were determined with fitc-ib and flow cytometry from mean channel fluorescence histograms. ± # p< . vs baseline * p< . vs sham $p< . vs no anesthesia these observations provide direct evidence for time-dependent changes in pmn priming following major injury because cd expression was depressed for at ]east hr after trauma relative to sham but by hr, was enhanced, relative to sham, and because fentanyl anesthesia at hr had a greater effect on cd expression in trauma vs sham. neutrophil (pmn) adhesion to vascular endothelial cells (•c) is a key element in the inflammatory response and tissue injury. inflammatory mediators such as lps (exogenous) and tnf (endogenous) can promote pmn-ec interaction which is believed to be responsible for capillary leakage and subsequent organ injury. however, the mechanism of this injury remains unclear.we hypothesised that the mechanism of tissue injury is due to ec necrosis with release of toxic products and that activated pmn are responsible. human pmn were obtained from healthy donors, separated by density gradient, and activated with lps ( ng/ml), tnf( ng/ml), and lps/tnf( ng/ ng/ml). cultures of the human ec tine(ecv- ) were used as surrogates of the microvasculature, were exposed to either lps, tnf, lps/tnf and pmn activated with lps, tnf, lps/tnf and incubated for , , , and hrs. ec necrosis was assessed by a cr release cytotoxicity assay. pmn activation was assessed by cd lb receptor expression and respiratory burst activity hr _+ . -+ -+ . _+ _+ . _+ _+ . _+ . hr + . _ _+ . _+ _+ _+ " +_ +-- . " lghr - . _+ +_ - " o:fo , " ~ +- . * hr _+ . - -+ +_ * _+ _+ * _+ _+ " data = ec % necrosis mean_+sd stats: student's t-test with significance (*) set at p< . vs control. ( our previous studies have indicated that despite the increased cardiac output and maintenance of tissue perfusion, hepatoceliular dysfunction occurs during early sepsis. nonetheless, it remains unknown whether vascular endothelial cell function (i.e., the release of endothelium-derived relaxing factor/nitric oxide) is depressed under such conditions and, if so, whether endothelial cell dysfunction also occurs at the microcirculatory level. to determine this, rats were subjected to sepsis by cecal ligation and puncture (clp), following which these and corresponding shams received ml/ g bw normal saline. at hr after clp (hyperdynamic sepsis) or sham operation, the thoracic aorta was isolated, cut into rings, and placed in organ chambers. norepinephrine (ne, xi - m) was used to achieve near-maximal contraction. responses for an endothelium-dependeut vasodilator, acetylcholine (ach, via nitric oxide), were determined. in additional studies, the small gut was isolated at hr post-clp. after pre-contraction of blood vessels in the isolated gut with xl m ne, vascular responses to ach ( x m) and an endotheliumindependent vasodiiator, nitroglycerine (ntg, xl - m), were determined. total vascular resistance (tvr, mmhg/mi/min/ g) was then calculated as pressure/ perfusinn rate. ach-induced relaxation (%, n= /group) in the aortic rings were: ach lxl i~s, st-in ~ ~ significantly at hr post-clp (i.e., increased *p(o vs. sham; n- per group. tvr) in the absence of any changes in ntginduced relaxation (fig. a) . thus, the vascular endothelial cell dysfunction observed in the aorta in early sepsis also occurs at the microcirculatory level. introduction: the cytokine-mediated adherence of leulcooytes to vascular endothelium is considered as an early step in the cascade of pathologic reactions culminating in the "systemic inflammatory response syndrome" (sirs); the purpose of this study was to evaluate the influence of interleakin- on leukooyteendothelial cell-interactions and microoirculation in the liver after hemorrhagic shock by means of intravital microscopy. methods: in anesthetized female sprdrats co.w. - g) shook was induced by fractionated withdrawl of arterial blood within rain and maintained for h (map at mm hg, cardiac output % of baseline). rats were adequately resuscitated with % of shed blood and twice the volume in ringer's solution additionally. following h of reperfusinn (map > mm hg, co > % of baseline) the microcirculation in liver lobules was examined by intravital fluorescence microscopy after labelling of leukocytes. continuous administration of il-lra (synergen, boulder, colorado, mg/kg/h) was started at different time points in a randomized and blinded manner. the animals in group p (n= ) received the il-lra as pretreatment beginning min prior to shock induction. in the group t (n= ) the application of il-lm started at the beginning of the reperfusion period with a bolus injection of mg/kg and was followed by continuons administration of mg/kg/h. the control group c (n= ) received equal volumes in nac , %, the sham-operated group s (n= ) was not exposed to shock. results: macrohemodynamics were comparable in all shook groups. the increased percentage of permanendy adherent leukocytes after hemorrhagic shook (s: , % + , %; c: , % _+ , %) was significantly reduced by pretreatment or treatment with il-lra (p: , % -+ , %; p< . , t: , % -+ , %, p< . , anova). temporary adhesion of leukocytes was unaffected by application of il-lra. liver microcirculation measured by volumetric blood flow in liver sinusoids and sinusoidal diameters was impaired after hemorrhagic shock in all groups and was not affected (c: iam /s + um /s, p: llm /s + }am /s, t: ams/s -+ lam /s, s: am /s -+ am /s). di.seu~sinn: the results demonstrate that permanent adherence of leukocytes to endothelium is in part regulated by il- . pathological adherence could be reduced by application of illra, even given at die time of resuscitation. the effect of ll-lm on permanent adhesion is a specific event and might be caused by reduced expression of specific receptors on sinusoidal endothelial cens and leukocytes. objectives of the study. the adhesion of activated neutrophils (pmn) to endothelial ceils (ec) and the concomitant production of reactive oxygen metabolites (rom) initiates organ damage after trauma, sepsis, shock and organ reperfusion. aien of this study was to investigate the effect on adhesion and rom production of the highly water-soluble, membrane-permeable and physiological ascorbic acid (asc). materials and methods. adhesion of pmn to nylon fiber (cell count) and simultaneous rom production (chemiluminescence-cl-response) were measured up to retool/ asc as well as adhesion, rom production and ec damage (lllln-release from labeled ec) of endotoxin-activated pmn to cultered ec moanlayers. in an in vivo animal model (sheep with lung lymph fistulas) the effect of asc ( g/kg bw bolus, followed by . g/ kg-h infusion) on the endotoxin-induced ( . ixg/kg bw) neutropenia (cell count), lung capillary permeability damage (lung lymph protein clearance) and rom production of neutrophils (zymosan-induced cl response) was measured. results. asc scavenged rom dose-dependently during adhesion of pmn to nylon fiber (p< . at mmol/l asc), adhesion itself was unchanged. during the activated pmn/ec interaction asc scavenged rom (p< . at mmol/l asc) and reduced the adhesion dose-dependently (p< . at mmol/l asc); ec damage was also reduced (p< . at retool/ asc). in the in rive model asc increased the endotoxin-induced blood pmn decrease (p< . ), decreased the protein clearance (p< . ) as well as the zymosan-induced rom production (p< . ), indicating the asc-mediated reduction of adhesion, rom production and lung tissue damage processes. conclusions. by in vitro and in rive experiments ascorbic acid reduced the adhesion-and rom production-initiated tissue damage. therefore, i.v. administration of ascorbic acid is recommended for oxidative stress-associated states after trauma, sepsis, shock and organ reperfusion. for neut rophi l-accumulat ion and activation. we investigated the influence of or to the activation and the expression of lecam-i and cdiib,cdi on neutrophils and lymphocytes. methods: from blood samples (n= ) all white blood cells (wbc) and neutrophils (nc) were isolated and cultured. or were produced via the xanthine oxidase/hypoxanthine system. after , , , , and minutes a giemsa-staining to determine the granulation of neutrophils (n: normal, r : reduced ) and a facs-analysis with monoclonal antibodies detecting cdiib,cdi and lecam-i was performed. results: under the influence of or a degranulation of neutrophils starting at min was observed in wbc-cultures (n/r: min / , min / , min / , min / , min / ). these data were confirmed in the dot-plots of facs-analysis. only in wbc-cultures or induced a significant increase of lecam-i expression on neutrophils up to min followed by a decrease to normal values at min. lecam-i on lymphocytes disappeared totally during the observed period. cdllb,cdl -expression was not altered. conclusion:increased lecam-i expression on neutrophils due to or could enhance the 'rolling' of neutrophils along the endothelium which is a prerequisite for neutrophil sticking and migration. further or are able to activate neutrophils without endothelium. these changes seem to be mediated by other wbc. introduction. multiple organ failure (mof) has been hypothesized to be the result of an excessive uncontrolled autedestructive inflammatory response. since the complement system is an important mediator and initiator of the inflammatory response, interruption of this cascade could theoretically lead to an attenuation of mof. in order to test this hypothesis we evaluated the response of c -delicient mice in a model of zymesan indt~ed mof. materials and methods. c -deficient b d /oid and c -sufficient b d /new mice were used in this study. on day all mice received an intraperitoneal injection with zymosan suspended in paraffin in a dose of mg/g body weight. between day and , biological parameters (temperature, body weight and clinical condition) were measured daily and mortality was monitored. clinical condition was assessed by blindly grading the degree of lethargy, conjunctivitis, diarrhea, and ruffled fur of each mouse on a two point scale (maximum score= ). on day all surviving mice were sacrificed and relative organ weights of lungs, liver, spleen and kidneys (relative organ weight= (organ weight/body weight)x ) wore calculated. earlier experiments with our model have shown a good correlation between histological organ damage and relative organ weights. statistical analysis of biological parameter was performed using the koziol curve analysis. analysis was divided in an acute phase (day - ) and a late phase (day - ). relative organ weights were analyzed using wilcoxon's test and mortality rate using fischor's exact test. results. all zymosan injected mice showed a typical triphesic illness. deterioration of the clinical condition as indicated by the symptom score and the decrease in temperature and body weight in the acute phase were all significantly lass severe in c deficient mice (all p< . ). in the late phase no differences could be noticed in the courses of biological parameters. overall mortality was / ( %) in c deficient mice and / ( %) jn c sufficient mice (p= . ), a difference mainly due to a difference in the acute phase. organ damage assessed as the relative organ weights did not show any statistical differences for any organ between both strains. conclusion. complement factor c appears to play an important role in the acute hyperdynamic septic response in this model but deficiency of c could not prevent organ damage in the late mof phase. this suggests that other factors could be more important in the development of the inflammatory response leading to mof. proinflammatory cytokines are thought to play a critical role in the pathophysiology of multiple organ failure (mof). in mice, zymosan-lnduced generalized inflammation (ztgi) leads to mof. therefore we performed a sequential study into plasma levels of, and macrophage production capacity for, four cytokines during the development of mof in the zigi model. male young-adult c bl/ mice received zymosan ( mg/g body weight) intraperitoneally. groups of animals were killed after , , , and h and subsequently at each day until day . plasma was collected and peritoneal macrophages were isolated and cultured overnight with or without lipopolysaccharide (lps). interleukin -ct, and - (il-lc~,~,), and tumour necrosis factor-o~ (tnf-c were measured in plasma and culture fluid by means of a ria (detection limit . ng/ml). interleukin- (il~) levels were assayed using the b hybddoma cell proliferation assay. zymosan induces a three-phase disease in mice. after an acute phase the animals recover. around day , they start to develop clinical signs which resemble mof. plasma tnf-~ peaked within h after zymosan injection and disappeared within h. from day onwards, tnf levels started to rise again. plasma il- behaved almost similarly in the acute phase, but in the mof phase plasma il- remained low. no circulating il- could be detected at any time point. macrophage lps-stimulated production of il-lcq il- ~ and tnf--c~ was suppressed immediately after zymosan injection. production of il- and tnf-~ was normalized within h, while production of il-lc~ remained lower than that in macrophages from untreated control mice. only at day did production of il-i~ reach control values. il- production was higher than control values from day onwards. il production was similar to that of ili-il the production of tnf-ct was strongly elevated between days and and again during days to . the development of mof-like symptoms during zlgi in mice is accompanied by increased plasma levels of tnf-ct without enhanced il- or il- . also, the ability of macrophages to produce excessive amounts of il- and tnf--~, as well as the suppressed capacity to produce il-lcq could be important mechanisms in the pathophysiology of mof. when conjugated to an asialoglycoprotein, dna and oligonucleotides are specifically taken up by the hepatocytes via the asialoglyccprotein receptor which is unique to the liver. human asialoglycoprotein (~ -acid, asgp) was derivatized with low molecular weight poly(l)lysine(pll) and complexed with antisense dna's (as) complementary to the ' region of the il- gpl receptor. the antisense were '-agtttagggatgagg- ' (asl), '-atcttcatcttctgaat- ' (as ), '-aagtgaatgattaaaacact- ' (as ), '-aaacctttataggcg- ' (as ), and '-cgttctacaactgcaacgt- ' (as ). using hepg , the biological effects of these antisense complexes on the high affinity il- receptor were evaluated by scatchard analysis, cellular proliferation, and acute phase protein expression by radioimmunoprecipitation and two dimensional gel electrophoresis. scatchard analysis demonstrated that high affinity receptor expression was inhibited by incubation of cells with asgp-pll-asi for h. underivatized asl was less effective and the complex, asgp-pll-as , had minimal effects on high affinity binding. when the cells were treated with the conjugates and stimulated with il- (i units) asgp-pll-asi alone showed a dose dependent ( .i- . ~m) inhibition of ss fibrinogen synthesis. two dimensional gel electrophoresis showed that expression of other acute phase proteins was also blocked. these results indicate that the targeted delivery of antisense molecules via conjugates recognized by the asialoglycoprotein receptor can block the cytokine stimulated acute phase protein response in hepatocytes, this approach may be relevant to the therapeutic management of patients with severe injury and sepsis. it has been established that immune cells are able to express neuropeptide genes and to release products that were considered to be of neuroendocrine origin. we have shown that proenkephalin (penk), a neuropeptide encoding gene, is expressed in lymphoid cells in culture. to study the physiological significance of these observations we have used the model of experimental endotoxemia. in this model, a disease state is induced by bacterial lipopolysaccharide (lps), that activates the immune system, the adrenocortical axis and the nervous system. we found that the expression of penkmrna is markedly enhanced in vivo immediately after lps injection both in the adrenal glands and in the lymph nodes. in situ hybridization analysis combined with immunohisto-chemistry indicated that the induced penk expression is confined to macrephages within the lymph nodes and chromaffin cells in the adrenal medulla. furthermore, this expression in lymph nodes is modulated by ligands of the adrenergic system. our results strongly support the notion that immune derived opioids participate in the bidirectional communication between the nervous and immune systems. of neurology hadassah university hospital, jerusalem , israel. objectives of the study: multiple-organ-failure is recognized as the most severe, and often lethal, complication after multiple trauma. however there is no adeqate animal model available. our goal was to develop an animal model, in which reproducable irreversible failure of parenchymal organs is achieved in the late phase after insults in the early phase (trauma). materials and methods: l female merino-sheep were included (mean weight: kg). day : hemorrhagic shock (mean arterial pressure (map) mmhg for hrs.), closed femoral nailing (ao-technique), day - : bolusinjection of endotoxin (et) ( , ~tg/kgbw) und zymosan-activated plasma (zap) ( ml) every hrs., day - : observation. bronchoalveolar lavage (bal): day , , . the course of representative parameters of organ function was documented: cocardiac output (i/min), svr -systemic vascular resistence (dyn ~ s cm- ), pap -putm.art.pressure (mmhg), pap -arterial oxygen pressure (mmhg), bill -bilirubin (;xmov ), crci -creatinin clearence (ml/min) statistics: data as means+sem, *significant from baseline (wileoxon test; p< ) results: baseline day day day day heart: co , _+ , , _+ , , _+ , , _+ , * , _+ , * svr _+ + _+ +_ " +- " lung: pap , _- , , _+ , " , +- , " , + , " , +- , ' pap , + , , +- , , _+ , , +- , , +_ , * liver: bill , _+ , , _+ , ' , _+ , ' , _+ , " , _+ , " kidney:crcl , +_ , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , _+ , , + , , + , histologic specimens showed all signs of fulminant mof. combination of hemorrhagic shock, femoral nailing, et und zap (insults in the early phase) lead to an irreversible organ failure in the late phase. prostaglandin e (pge) levels are elevated by trauma, shock or sepsis and can profoundly affect the immune response. pge is produced by many cell types including fibroblasts, macrophages, monoeytes, follicular dendritic cells, and epithelial cells and is induced by il-i, bacterial lps, components of the complement cascade, tnf, il- and crosslinking of surface fc receptors for igg, iga and ige. our research has shown that pge inhibits b cell activation (specifically enlargement, class ii ~c and fc~ rii expression), proliferation, igm and igg responses, t cell proliferation, and il- synthesis in the mouse model. in contrast, pge greatly promotes class switching to ige,the isotype responsible for type i allergic hypersensitivity. thus, our model mirrors th~ general immunosuppression and elevated ige titers of the trauma or sepsis patient. pge increases the number of cells secreting ige and iggl, acts on surface igm positive b cells, synergizes with il- and lp$ to induce preswitch germline transcripts, and induces more rapid expression of mature vdj~ mp~a than in eontro~ pge intracellular signalling occurs through cyclic adenosine monophosphate (camp) levels and can be mimicked by camp-inducing agents and blocl~ed by an inhibitor of campdependent protein kinase a. pge action requires de novo protein synthesis and candidate pge-inducible regulatory proteins have been identified by d gel eleetrophoresis. thus, pge inhibits a number of immune mechanisms while promoting ige production. a deeper understanding of pge immune regulation may lead to more effective treatment of immune perturbations as sequelae of trauma, shock or sepsis. during infrarenai aortic surgery mesetueric traction (re.t.) results in prostacyclin (pgi:) release and consecutively in hemodynamic disturbances (decreased systemic vascular resisteace, mean arterial pressure; increased cardiac output, heartrate). these symptomes are bypassed by cyclooxygenase inhibition. hemodynamic symptoms vanish after - rain even without cyclooxygenase inhibition although pgi levels remain elevated. to study the endocrine vasopressor system in a prospective double blinded protocol, we investigated patients undergoing major abdominal surgery as compared to ibuprofen ( rag, i.v.) pretreated (ibu) patients. the surgeon applied m.t. in a uniform fashion. we chose a general anesthesia combined with a supplemental thoracic epidural anesthesia. at the points in time , , , , , , , rain after and before (to) mesentzrie traction we determined the plasma concentrations (pc) of -keto-pgf~o~pr~, epinephrine, norepinephrine, dopamine, renin, aldosterone, adh and cortisol. pc of -k-pgf~,tp~, peaked minutes after m.t. ( _+ , ibu: _+ , to: +i ng/l) and declined monotonously over h ( +_ , ibu: _+ ng/ ). catecholamine pc "s did not exceed the reference range during the observation period. reninpc peaked after rain ( _+ , ibu: + , to: -+ /~u/ml); aldosteronc also presented a maximum after rain ( + , ibu: -+ , to: +- pg/ml), whereas cortisol demonstrated irrespectively of circadian rhythms a maximum h after m.t. ( +_ , ibu: -+ , to: +_ ~g/ ). adh pc peaked min after m.t. ( + , ibu: -+ , to: +_ pg/ml) and showed analogously to -k-pgft~j~ pc a monotone decline over the observation period. our data demonstrate a counteractive reaction to pgiz mediated vasodilation via adh secretion. the second regulative is the renin-angiotensin-aldosterone system (raas), which is activated min after m.t., the aldosterone pc does not paratlel the cortisol pc, which peaked post operafionem in both groups, probably due to the end of anaesthesia. a regulative release of catecholamines could not be documented. the activation of adh and raas after mt is not a hormonal response primaryly related to surgical trauma and/or stress but a counterregulation to systemic vasoditafion induced by prostacyclin. although adh and raas support systemic circulation, angiotensin and vasopressin may compromise local organ blood flow (e.g. splancimic vascular bed). insfitut f. klin. chemic, anaesthesiologie ~, chirurgie l*, univ. ulm, elm, expression of c-fos protein in rat brain following occlusion of superior mesenterie artery. takanobu there is general agreement that neurologic abnormalities are seen in sepsis. the aim of this study is to examine what effect does the brain receive in case of sma occlusion by immunohistochemistry using antibody to c-fos, an immediate early gene, which is recently recognized as a genetic marker of activated neurons. moreover, we investigated the correlation between c-fos induction in the brain and plasma endotoxiu level. rats of them received sma clipping and others wee used as control. control and treated rats at , , , hours were perfused and fixed. the brain were sectioned at pm and stained by abc method using c-fos antibody. plasma endotoxin level of rats were measured at , , , , hours after the treatment by chromogenic limulus method. immunohistochemical study showed scarcely no immunoreactivity in control rat brain. in treated rat brain, the significant expression of c-los was detected in specific nuclei including the habenula, some hypothalamie nuclei, amygdala, locus ceruleus and nucleus tractus solitarii. such immunoreactivities were increased in time curse, which well corresponded plasma endotoxin levels. the mean plasma endotoxin level of , , , , hours after the treatment were . ± . , . _- - . , . _+ . , . ± . and . ± . pg/ml, respectively. the results indicate that limbic and hypothalamic-brainstem systems are involved in sma occlusion, and suggest that such neuronal actival.jon may precede the elevation of plasma endotoxin icy.el. systemic vascular resistance and increased cardiac output accompanied presumingly by a increased pulmonary shunt (qs/qt). this response is induced by prostacyclin (pgi ). we examined oxygen transport after traction on the mesentery root and the transpulmonary prostacyclin levels in a prospective placebo controlled study with intravenous ibuprofen. methods: with approval of the human [nvestigadon review board we studied patients in a prospective, randomized double-blinded protocol who were scheduled for major abdominal surgery. ibuprofen ( mg i.v.) or a placebo equivalent was administered minutes before skin incision. pulmonary artery thermodilution and radial artery catheters were placed after induction of anesthesia. mt was applied in a uniform fashion. baseline values preceded the incision of the peritoneum (to). fulther assessments followed , , , , . tile plasma concentrations (pc) of -keto-pgft, (stable metabolite of pgi ) were determined in arterial and mixed venous blood by radioimmunoassay. at all points in time we measured arterial and mixed venous blood gases. qs/qt was calculated by standard formula. data are given as median (p < . placebo vs. [ibuprofen] [ ] mmhg (*p< . i). these changes were accompanied by a marked increase of -keto-pgf~ pc up to rain after mt in arterial and mixed venous blood of untreated patients with a peak of *[ ] ng/l tl (*p< . ol). there was no difference between arterial and mixed venous pc. ibuprofen pretreated patients (n=zr) demonstrated stabile qs/qt and pao while -keto-pgf~ pc remained within the normal range. discussion: our data clearly indicate that mesenteric traction response includes a critical rise in qs/qt followed by significant decrease of paov stable oxygen transport determinants following cyclooxygenase inhibition signify an action mediated by prostacyclin. an indicative transpulmonary gradient for -keto-pgft~ was not detectable. a splanchnic vascular source for pgi release seems to be likely, but could not be proved by our current data. department of anesthesiology, cliu. chemistry * and surgery*; university clinics uim, prittwitzstral]e , ulm, germany it is unclear whether injuries like bums, in general, directly result in alterations of cell-mediated immunity that, in turn, promote endotoxic and bacterial translocation or, alternatively, whether these conditions allow increased bacterial invasion that, in turn, inhibits cmi. aim: to determine whether infectious challenge, as clp alone or combined with ti causes further immune abnormalities in the days following clp. study plan: on day , two groups of n= week old aj mice were subjected to either a % scold burn (ti), or were untreated (c) n= . on day , mice (ti+clp) and mice (clp) were subjected to clp. the two other groups (ti and c) were untreated. at days , and after thermal injury splenocytes (sp) were harvested and cultured with cona for an assay of il- and adherent splenocytes (as) were cultured with lps for il- , tnf, il- and pge . results: either ti + clp or clp alone result in significantly decreased secretion of all cytokines tested. in the ti group almost every cytokine production determined was elevated in comparison to ti + clp and prosmcyclin (pgi ) has been implicated in the pathophysiology of septic shock. however, pgi~'s role in the inflammatory response to sepsis is not well-defined. the purpose of this study was to identify which acute septic events are mediated by pgi during graded bacteremia. methods: eleven ~nesrhetized, hemodynamically monitored adult swine were infused iv with aeromonas h. ( /ml) at rates increased incrementally from . to . mi/kg/hr over hours. animals were studied in two groups: septic control (sc), graded bacteremia only (n= ); pga (n= ), graded bacteremta plus anti-pgiz antibody, ml/hr iv, beginning at hours. mean systemic (map) and pulmonary arterial (pap) pressures and arterial po , mmhg, cardiac index (ci), l/min/m , oxygen delivery index (do i) and consumption index (vozi), ml/min/m , and oxygen extraction (er), %, )latelet aggregometry (plt), %max., plasma pg -keto f alpha ; in the first instance~ peak values of lt ~ after i~ hrs post infarction were times higher than in the controls and excess leucocyte infiltration was noted at the infarction zone. in second instance two levels of lt b led to weak infiltration of the infarction zone by leucocytes. a. mo~e~o, in~.~p~siolo~,d~t.e~.cardiolo~,bogotsolets , ~ev , ukrmne systemic lesion$of erythron in traumatic disease and possibilities of their regulation by opioid peptides. redkin y. v., fominih s. g. using clinical ( patients) and experimental material( rats and dogs) we revealed general regularities of erythron lesions after hard mechanical trauma of various genesis as well as some mechanisms of development of posttraumatic anemia and possibilities of its correction with preparations of opioid peptides. the condition of central and peripheral compartments of erythron was studied with unified morphologic, immunogematological, biochemical and radiological methods. it was revealed that irrespective of the experimental animal species (dogs, rats) or in clinical experiments (patients) and irrespective of the injuring factor type (skeletal trauma, craniocerebral trauma, loss of blood) in erythron can be observed one-directed unspecific reaction realized by the considerable lowering of hemoglobin concentration, erythrocytes number and hematocrit. in the initial period ( - days) in the system of erythron prevail processes of distraction and elimination of er~zthrocytes relatively to the general production of stimulated erythropoiesis. the primary alterating factor is the prolonged intensification of peroxydation of membrane iipids of erythrocytes with simultaneous lowering of reserves of reduced glutathione. the distraction of erythrocytes is supported by the developing phenomena of autoallergization of organism that becomes apparent by the appearance of sensitized t cells and antierythrocyte antibodies. the intensified production of erythropoietin rules to the realization of he program of fetal and terminal (reserved) erythropoiesis. failure of erythropoiesis function is supported by disturbances of the processes of the injuring of cell metabolic apparatus. using of dalargin ( microgram per kilogram of body mass intrap'eritoneally within days after the trauma) showed the precise pharmacotherapeutic effect revealed by the diminishing of anemia of experimental rats, more . fiberbronohoscopic procedures are known to produce "peep-like" effects and to increase pulmonary artery (pa) resistance [ ] . peep can affect rv function by reducing preload and ejection fraction (ef) [ ] . since changes of rv function during bronchoscopy in septic patients are not reported, we measured rv parameters before, during and after fiberoptic bronchoalveolar lavage (bal). method: this -year-old patient (apache-ii: ) developed a hyperdynanlic septic state due to staphylococcus aureus (blood culture). we inserted a "fast response" thermistor pa-catheter (baxter-edwards) to evaluate rv performance [ ] . the therapeutic procedure included volume replacement, vasopressors (dopamine , dobutamine gg/kg/min. iv) and analgosedatior/. before bronchoscopy (olympus bf- , od= mm) the patient received pancmonium for muscle relaxation. ventilation was not changed during the procedure (endotracheal tube: id= ram, bennett a, pressure controlled mode, pm~x= mbar, peep= mbar, i:e=i:i, fio = . ). we measured rv enddiastolic volume (edv), stroke volume (sv), ef, heart rate (hr), cardiac index (ci) and mean pa pressure (mpap gerlach h, gerlach m, clauss m, falke kj renal hypoxia and/or ischemia initiates the development of a deteriorated medullary perfusion based on fibrin deposition in the peritubular capillaries, vasoconstriction, and perivascular edema, which is followed by a swelling of the tubular epithelial ceils, intraluminal tubular obstruction, and a backleak of fluid through the injured tubules into the renal interstitium, finally leading to an acute tubular necrosis (atn) [ ], clinically diagnosed as acute renal failure (arf). one important pathway for induction of enhanced vascular procoagulant activity and permeability is based on the synthesis and expression of macrophage-derived cytokines, which bind to specific endothelial cell surface receptors. we recently described the identification and purification .of a new , dalton polypeptide, which is synthesized and expressed by murine macrophages after stimulation with lipopolysaccharide, and exerts procoagulant activity on cultured endothelial cells [ ] . in the presented study, we demonstrate that the new polypeptid is also synthesized by macrophages under hypoxic conditions. the protein binds to specific receptors, which are expressed by endothelial cells dependent on the environmental oxygen tension. animal studies were performed after approval by the local committee for animal safety; the animals were anesthetized, treated and supervised in accordance with the guidelines of this committee. in contrast to other authors, who performed long-term hypoxia experiments in awake animals, we preferred to implement the studies under anesthesia for ethical reasons, although regulatory functions for ventilation might be influenced. animal studies demonstrated that the intravenous injection of the polypeptide initiates fibrin formation in the peritubular vessels. keeping the animals under hypoxic conditions induces similar effects, which are reduced by a rabbit-antiserum against the new protein. in conclusion, the new polypeptide obviously contributes to the pathogenesis of acute renal failure by tubular necrosis during and after hypoxic events. the use of verapamil as cardioprotective agents for management of patients with acute ischemic/reperfused heart is based on the assumption that the increased intracellular ca+ level is a key factor in causing cell death. our in vitro study was designed to focus on effects of verapamil on the metabolic potential of cardiac slices after reversible ischemia in rats. the material consisted of two main groups : group a (non ischemia/reperfusion group) and group b (ischemia/reperfusion group), each is subdivided into two subgroups (a and b). each subgroup included rat hearts. group aa is the control group, group ab is verapami] added group. group ba is ischemia group without verapamil. group bb is verapamil added group. ischemic cardiac slices were obtained from rats subjected to min. haemorrhage to induce reversible global ischemia. both nonischemic and ischemic cardiac slices were placed in well oxygenated krebs ringer phosphate buffer containing mg% glucose & gm% bovine albumin and incubated in dubnoff shaking water bath for min at °c the results revealed that there was an enhancement in release of free fatty acids (ffa) ( %) and lactate ( %) and in glucose uptake ( %) in group ba as compared with group aa. these metabolic alternations produced by ischemic cardiac slices were reversed by verapamil addition ( ml%) but in group ab verpamil did not alter the release of ffa & lactate from non-ischemic cardiac slices, whereas it inhibited glucose uptake from these slices by %. the improvement of the metabolic intervention of ischemic myocardium indicates that verapamil may be of importance in reducing the extent and severity of acute myocardial ischemic injury in acute haemorrhage. severe endothelial dysfunction occurs following injury to carotid arteries which is characterized by a decreased ability of these arteries to dilate when challenged with ach or a , but not with a direct vasodilator (nano ). this failure to relax to ach and a reflects an inability of endothelium to generate edrf, but relaxation recovers gradually to control values by weeks. exogenous no donors (e.g., c - or spm- ), accelerate the recovery of the injured endothelium in rat carotid arteries. intravenous infusion of an no donor ( p.g/day) with an implanted osmotic pump significantly accelerated the recovery of regenerated endothelium to produce edrf at days. rat carotid artery rings relaxed only + % and + % to gm ach in vehicle treated rats and in inactive no donor treated rats respectively days following injury compared with + % in no donor rats (p< . ). relaxation to gm nan was normal in all groups indicating that the differences in relaxation were not the result of damage to vascular smooth muscle. contraction to l-name ( mm) was markedly reduced by injury, but was protected by no donors (p< . ). thus, exogenous no donors enhance the ability of the endothelium to regenerate and to release edrf in response to endothelium-dependent vasodilators. this may be due to an anti-proliferative and anti-mitogenic effect of no on vascular smooth muscle cells, allowing the endothelium to regenerate without intimal thickening. no also has been shown to inhibit platelet aggregation, and to attenuate neutrophil adherence and activation. the superoxide scavenging effect of no is not the basis for these effects since hsod is inactive in preserving endothelial function in injured arteries. thus, no exerts a variety of cytoprotective effects which may be of importance in protecting against vascular injury. much evidence has now accumulated to show that the excess production of the vasodilator nitric oxide (no) in sepsis is an important contributor to the hypotension and multiorgan failure characteristic of this condition. various cytokines play an important role in this process through their ability to induce the production of one of the enzymes responsible for no synthesis, the inducible no synthase (inos). we have studied the effects of cytokines on the induction of this enzyme both in vitro using vascular smooth muscle cells, and in a murine model of gram-negative sepsis. tn smooth muscle ceils, the cytokines il- , ifnq', and tnf-oc show strong synergy with one another in the production of inos. in order to define the molecular basis for this synergic effect, we have linked the promoter of the inos gene to a "reporter" gene, chloramphenicol acetyl transferase (cat), and transfected these constructs into vascular smooth muscle cells. assays of cat activity reflect the activity of the promoter in this system, and by generating sets of deletion mutants of the promoter sequence we have been able to define the area within the promoter which mediates the synergic effect of these cytokines. in addition to stimufatory effects on inos production, certain cytokines are able to down-regulate the production of inos in vascular smooth muscle cells, and the effects of these counterregulatory cytokines will be discussed. the interaction of these cytokine effects in the whole organism has been studied in a murine model of gramnegative sepsis. widespread induction of inos occurs in this model as assayed by enzyme activity and through use of specific antisera to inos. neutralizing antibodies to tnf-~ and tfn-y are both able to prevent death in this model, but it is only the anti-ifn-y which attenuates the induction of inos assayed in the liver. clearly there is some redundancy in the effects of cytokines on the production of inos in sepsis, and greater understanding of the most important factors in inos production is required in order to target anti-cytokine therapy most appropriately. effects of nitric oxide on hepatocyte metabolism in inflammation. j. stadler, department of surgery, tu mqnchen, frg hepatocellular nitric oxide (no) synthesis is induced by proinflammatory mediators such as tumor necrosis factor, interleukin- and interferon gamma or by bacterial toxins such as lipopolysaccharide. stimulation of the hepatocytes (hc) with a combination of these agents leads to an output of no in quantities which are not seen in any other celltype. it has been demonstrated by various investigators that important effects of these cytokines and bacterial toxins on hc metabolism can be attributed to the action of no. in contrast to other celltypes hc seem to be relatively resistant to suppression of basic metabolic functions such as energy metabolism by no. therefore, cell damage has not been described to a significant extent following exposure to no. however, no does inhibit total protein synthesis. the exact biochemical mechanism of this phenomenon has not been uncovered yet, but it has been demonstrated for some specific proteins that their production is inhibited at a posttransscriptional level. as in many other celltypes cgmp generation is elevated in hc by no through activation of the soluble guanylate cyclase. cyclic gmp may possibly exert a plethora of metabolic functions, but it is interesting to note that most of the cgmp seems to be transported out of the cell. some very specific effects of no on hc metabolism include the inhibition of the glyceraldehyde- -phosphate dehydrogenase (gapdh) and the cytochrome p (cyp) enzymes. inhibition of gapdh activity is mediated through nitrosylation of critical domains of the enzymes by no which enhances auto-adpribosylation. this effect on gapdh activity might be responsible for the inhibition of gluconeogenesis by no, which has been described recently. finally, no-mediated inhibition of cyps may help to explain the suppression of hiotransformation processes which is a characteristic featur,'~ r ~ "~flamed liver. nitric oxide (no) is an endogenous inhibitor of polymorphonuclear leukocyte (pmn) adhesion which limits pmn-endothelial cell interactions under normal conditions. we have previously demonstrated that following ischemia, no production by the vascular endothelinm is dramatically reduced. accordingly, we investigated the effects of no-donors on pmn accumulation and tissue injury following hemorrhagic shock and ischemia. hemorrhagic shock was induced in anesthetized rats by bleeding to mmhg for hours followed by reperfusion. segments of superior mesenteric artery (sma) were isolated and suspended in organ baths. in rats receiving saline sma relaxation to acetylcholine (ach, nm) was reduced by % compared to control sma segments (p< . ) while relaxation to sodium nitrite ( gm) was unaffected. in addition, mesenteric tissue pmn accumulation as determined by myeloperoxidase (mpo) activity was significantly elevated compared to controls (p< . l). interestingly, treatment with the no-donating agent, s-nitroso-n-acetylpenicillamine (snap) significantly preserved sma relaxation (p< . ), attenuated mesenteric mpo (p< . ) activity, and significantly improved survival compared to saline vehicle. in anesthetized, open-chest dogs we investigated the cardioprotective actions of a novel no-donor, spm- (schwarz pharma), following regional myocardial ischemia ( hour) and reperfusion ( . hours) . treatment with spm- ( rim) significantly reduced myocardial necrosis by % (p< . ) compared to an no-deficient analog of spm- , spm- . furthermore, mpo activity within the ischemic-reperfused zone was also significantly (p< . ) reduced following treatment with spm- compared to spm- ( . + . vs. . + . u/ mg tissue). these data strongly suggest that no is a potent inhibitor of pmn-mediated tissue injury following hemorrhagic shock as well as in acute myocardial ischemia-reperfusion injury. overproduction of nitdc oxide (no') may contribute to sepsis-induced hypotension. during septic shock, excess no" is produced by an isoform of nitric oxide synthase (nos) which is induced by inflammatory mediators. nonselective nos inhibitors have been proposed as a new therapeutic approach to treating hypotension in septic shock. we studied the differential hemodynamic effects of n~-methyi-l-arginine (l-nma), a nos inhibitor, in normal canines versus those challenged with endotexin (lps) and compared the activity of this drug across the venous, pulmonary and systemic vascular beds. awake canines were challenged with lps ( mg/kg, n= : mg/kg, n= ; or mg/kg, n= ) and treated with l-nma ( , , , , mg/kg/hr) for hours following a , , or mg/kg loading dose. animals were resuscitated with iv ringers solution ( ml/kg/hr). hemodynamic data were collected at , , , , , and hours using intravascular catheters and radionuclide heart scans and analyzed by anova. in both normal and endotoxemic animals, l-nma at all doses studied similarly increased mean arterial pressure (p= . ), and systemic vascular resistance index (p= .ol) and decreased cardiac index (p= . ) and oxygen delivery index (p= . ). in contrast, the effect of l-nma on mean pulmonary artery pressure, central venous pressure, pulmonary capillary wedge pressure, and pulmonary vascular resistance index was greater in lps-challenged canines compared to normal animals (p< . ), but this differential effect on the venous and pulmonary circulation occurred, > hours after lps challenge. l-nma did not significantly increase survival rates or times at any of the doses studied ( , , , or mg/kg/h) in either the low ( mg/kg) or high dose ( mg/kg) lps-challenge groups. a nonsignificant (p> . ) trend toward a beneficial effect on survival ol low dose l-nma ( mg/kg/h) in animals given the mg/kg lps-cha[lenge was not enhanced by increasing the lethality of the model or by administering higher l-nma doses. at the highest l-nma dose used in this study ( mg/kg/h), survival time decreased significantly for both the low and high dose lps-challenge animals (p< . ). this increased mortality was not explained by changes in plasma concentrations of either lps or tnfc~. thus, l-nma did not have a greater effect on the systemic arterial circulation in endotoxemic compared to normal canines. however, in the venous and pulmonary vascular beds, the effect of l-nma increased with time after endotoxin-challenge these data suggest the induction of nos activity by endotoxin in canines may be relatively greater in venous and pulmonary vessels compared to systernic arteries. l-nma, a nonselective nos inhibitor, did not decrease mortality in endoloxemic canines and the highest dose studied was harmful. pulmonary hypertension (ph) and arterial hypoxemia are characteristic features of the adult respiratory distress syndrome (ards). reducing pulmonary vascular pressures may promote the resolution of pulmonary edema. intravenously infused vasodilators lower ph in ards, but, as a result of their general vasodilatatory effects, systemic mean arterial pressure may also decrease. furthermore, blood flow may be increased to non-ventilated or poorly ventilated lung areas resulting in a rise of intrapulmonary shunt, thus causing a further fall in pad . recently, short term inhalation of low concentrations of the gas nitric oxide (no), an endogenous endothelium derived relaxing factor, which is rapidly inactivated in blood by hemoglobin, was reported to decrease ph without causing systemic vasodilation in sheep [ ]. similar changes have been observed in patients with severe ards during repeated short term inhalation of no ( and ppm), which rapidly and selectively decreased the mean pulmonary artery pressure (pap) and, in contrast to intravenously infused prostacyclin, induced a remarkable increase of pad [ ] . this improvement in oxygenation was caused by a redistribution in blood flow away from intrapulmonary shunt areas to normal ventilated lung regions. continuous no inhalation ( - ppm) consistently lowered the pap and augmented the pao /f.o for up to days. no negative side effects were observed during the whole time span examined. in particular methemoglobin levels always remained below . %. following these investigations, it could be shown that these effects may also occur using concentrations in the parts per billion range [ ] , which may reduce possible toxic side effects. however, in the same study it was demonstrated that the dose-response curves for pa and pap have different patterns. whereas pap presented a continuous dose-dependent downward tendency with an eds o of approximately - ppm, the improvement of oxygenation had a maximum at ppm and, at higher doses, drifted back towards the baseline data. the ed~o was estimated at approximately ppb, i.e. more than ten times lower than for the reduction of pap. in conclusion, inhalation of no by patients with severe ards may result in persistent and reproducible decreases in pap associated with an evident improvement in pad , thus allowing reduction of the f.o . no inhalation should be performed using low concentrations which are less toxic, although any possible risks still have to be considered carefully. dose-response studies for the individual patients are recommended urgently. finally, controlled randomized studies are required to demonstrate that additional no inhalation is able to reduce mortality of ards. inhibition of the activity of glyceraldehyd- -phosphate dehydrogenase (gapdh), an enzyme of the glycolysis/gluconeogenetic pathway, through adp-ribosylation is promoted by nitric oxide (no). since no is produced in the septic liver and hypoglycemia is a major problem of late sepsis, it was investigated whether no interferes with gluconeogenesis of hepatocytes. hepatocytes (hc) were isolated from sprague-dawley rats using a collagenase perfusion technique and differential centrifugation. exogenous no was applied by incubation with the no-donors s-nitrosyl-acetylpenicillamine and sodium-nitroprusside. endogenous no synthesis was induced by incubation with cytokines (tnfcq il- , ifnj and lipopolysacchafide (lps). hrs later the incubation medium was changed to a solution containing lactate, ornithine, lysine, ammoniumchloride and glucagon for optimal conditions of gluconeogenesis. after more hrs glucose and nitrite levels were determined spectrophotometrically. gapdh activity was measured by the nadh-dependent conversion of , -diphosphoglycerate to glyceraldehyde- -phosphate. incubation of hc with no-donors led to a concentrationdependent inhibition of gluconeogenesis and gapdh activity. however, gapdh activity was about times more sensitive to the inhibitory effect of exogenous no. incubation of hc with cytokines and lps induced nq synthesis as measured by an increase in nitrite concentrations. endogenously produced no suppressed gluconeogenesis by _+ %. in contrast to exogenously applied no, the effect of endogenous no synthesis was less on gapdh activity resulting in an inhibition of only _+ %. in conclusion, exogenous and endogenous no inhibited gluconeogenesis as well as gapdh activity. however, there was no correlation between the extent of inhibition of these two parameters of hepatocellular glucose metabolism. we have shown that inhibition of hepatocyte (hep) synthesis of nitric oxide (no) potentiates cell injury in a model of acetaminopheninduced oxidative stress and the extent of damage was paralleled by depletion of reduced glutathione (gsh) stores. to clarify the role of no in modulating the redox state of hep, we studied the effect of inhibition of cytokine-mediated no production on hep gsh stores, in a system of isolated rat hep in primary culture, no synthesis was induced (stim) by exposure to il- , tnf, ifn, and lps for hours. , , and ~m of n-monomethyi-l-arginine (nmma), a specific inhibitor of no synthesis, was added. cells incubated in media alone served as controls (cont). the no metabolite (no ); aspartate aminotransferase (ast), an indicator of cell injury; and gsh were assayed. (data presented as mean + sem; n= .) gsh (nmovma orotein) ..~ (nmol/ma orotein) cont . + . + . # stim . + . + stim+ o tzm nmma . + . + . # stim+ ~m nmma . _..+ . * + . # stim+ pm nmma . + . * + . # stim+ )lm nmma . + . * + . # anova , . (* p < . versus stim, # p < . versus stim; anova with neuman-keuls) gsh in cont+ i~m l-nmma was equivalent to that of cont ( . vs. . ). ast release was equivalent in all treatment groups. these data show that inhibition of hep synthesis of no depletes intracellular stores of reduced gsh. we conclude that hepatocyte no production modulates cellular gsh homeostasis and as a result, may be hepatoprotective in oxidative injury. nitric oxide (no) is a modulator of immune response and may be involved in the changes in immune reactivity after major trauma and operations. we investigated no-generation in rat and mice spleen cells (sc) after partial hepatectomy (ph). c bl/ mice and lew rats underwent a % and % ph, respectively. sc were prepared - days after ph and plated at to x ecells per well. after h incubation at °c, no-production was measured as nitrite levels (griess reagent). normal mouse sc did not produce no, neither basal nor in response to lps or con a starting at the second day after ph, we found a substantial production of no. in rats, also sc from control animals were able to generate no; both basal and stimulated no-generation were further enhanced after ph (table, values expressed as mean --se). after shame operation, there was only a modest elevation of noproduction in rat and mouse sc. in first experiments we could demonstrate no-production also in phagocytes from a patient days aider liver partial resection ( . nmol nitrite/ cells) enhanced no-production in macrophages may contribute to the changes of immune reactivity after partial hepatectomy. nitric oxide (no) is recognized as an important mediator in endotoxemia and sepsis. increased synthesis of no has been demonstrated in septic humans and animals, and no inhibitors have been used in the treatment of septic shock. recent reports have, however, suggested that this form of therapy may cause serious organ damage. in the present investigation circulatory and metabolic changes in the liver were studied during treatment with the no-synthase inhibitor n-nitro-l-arginine-methyl ester (l-name) in endotoxemia. methods: juvenile pigs were randomized to one of the following treatment groups: ) encletoxin and l-name, ) endotoxin, ) naci and l-name, ) nach preliminary results from groups (n= ) and (n= ) are presented. catheters for pressure measurement were introduced into the aorta, hepatic and portal veins and ultrasonic transit time flow probes were placed on the hepatic artery and portal vein. a catheter was introduced into the pulmonary artery. endotoxin ( . gg/kg/h) was given as a continous portal infusion over the entire observation period of hrs. l-name ( mg/kg) was given as a bolus after hrs. of endotoxemia. results: endotoxin transiently reduced portal vein flow (pvf) by %* and hepatic artery flow (hal e) by %*, while l-name caused a further and lasting reduction in flow (pvf %, haf %)*. transhepatic (portal-hepatic vein) vascular resistance increased to times baseline value during endotoxemia while l-name caused a further marked increase in resistance to times initial value. portal oxygen saturation (so ) decreased by %* during endotoxemia. l-name caused a reduction in portal so by %*. arterial so was unchanged in both groups. hepatic oxygen uptake was not changed by endotoxin, but was markedly reduced after addition of l-name. endotoxin caused a % reduction in cardiac output (co). the addition of l-name reduced co by a total of %*. *: p < . . conclusion: is the present model of endotoxemia treatment with the nitric oxide synthase inhibitor l-name markedly reduced liver perfusion and portal oxygen supply. this might explain the increased liver damage reported in previous studies using no-inhibitors. the increase in transhepatic resistance found after l-name treatment will tend to cause pooling of blood in the splanchnic veins, resulting in reduced filling of the heart and thus contribute to the observed reduction in cardiac output. institute for surgical research, rikshospitalet, the national hospital, university of oslo, oslo, norway. we have investigated the role of tumour necrosis factor (tnf) and interleukin-i (il-i) in the induction of nitric oxide synthase (nos) by bacterial endotoxin (lipopolysaccharide; lps; mg kg -i i.v.) in vivo. in anaesthetized rats, pretreatment with a monoclonal antibody for tnf (tnfab; mg kg -i s.c., at h prior to lps) or with an il-i receptor antagonist (il-ira; mg/kg bolus and . mg/kg/h infusion) ameliorated the fall in mean arterial blood pressure (map) at - min after lps. for instance, endotoxaemia for min resulted in a fall in map from -+ (control) to -+ mmhg (p< . ; n= ). in contrast, animals pretreated with tnfab or il-ira prior to lps injection maintained significantly higher map at min when compared to lps-control: -+ mmeg (n= ) and -+ mmhg (n= ), respectively (p< . ). three hours of endotoxaemia significantly reduced the contractile effects of noradrenaline (na) in the thoracic aorta ex vivo. the hyporeactivity to na was partially restored by in vitro treatment of the vessels with ng-nitro-l-arginine methyl ester (l-name, min, x - m). pretreatment of rats with tnfab or il-ira significantly (p< . ) prevented the lps-induced hyporeactivity of rat aortic rings ex vivo. l-name did not alter or only slightly enhanced the contractions of aortic rings obtained from tnfab or il-ira treated lps-rats, respectively. at min after lps there was an induction of calcium-independent nos activity in the lung ( . -+ . pmol citrulline/mg/min, n= ), which was attenuated by tnfab and !l-ira by -+ % and -+ %, respectively (n= ; p< . ). thus, the production of both tnf and il-i contributes to the induction of nos by lps in vivo. the protective effect of agents which inhibit the release or action of tnf or il-i in shock may be, in part, due to inhibition of nos induction. neal garrison, md objective: sepsis is often accompanied by organ dysfunction, in part due to impaired microvascular perfusion. recently, nitric oxide (no) has been described as an important mediator of the hemodynamic changes of sepsis, and no synthase (no-s) inhibitors have been advocated for treatment of septic shock, but their visceral microcirculatory effects are inadequately characterized. we postulated that no-s inhibition would exacerbate the impaired organ perfusion of sepsis. methods: six groups ofdecerebrate rats were studied. bacteremia was induced with live e. coli, which consistently increased cardiac output - % above baseline (bl). the no-s inhibitor nm-nitro-larginine methyl ester (l-name, mg/kg iv), prevented this increase and elevated map by - %. in the first groups, total hepatic blood flow (thbf, ml/min by time transit flowmetry) and microvascular perfusion (mi-ibf, ¼ bl by laser doppler flux) were measured. in the other groups, in vivo videomicroscopy was used to observe renal microvascular responses (ila=interlobular artery, aff=afferent arteriole, eff=efferent arteriole; % bl for all). results: data are rains after e. cob. n= - /group. * p< . vs bl by remanova and § p< . vs e. coli alone by anova. ec+l-name -+ - _+ " § - _+ * § - _+ * § - + * - + * § conclusions: l-name administration in controls decreased renal blood flow, indicating no contributes to basal renal tone. bacteremia decreased mtlbf but not thbf, and mi-ibf was further impaired by no-s inhibition. e. coli caused renal preglomemlar, but not postglomerular constriction and reduced flow. l-name exacerbated these e. coli-induced alterations and caused eff constriction. these data indicate that no-s inhibition exacerbates bacteremia-induced impairment of renal and hepatic blood flow, suggesting that no is an importam compensatory dilator mechanism in these organs during sepsis. irf (iron responsive factor) is the central regulatory protein of intracellular iron metabolism able to bind to responsive rna elements (ires) present atthe 'untranslated region (utr) of ferritin mrna and 'utr of transferrin receptor mrna. binding of irf to ires results in repression of ferritin mrna translation and increased stability of transferrin receptor mrna leading to enhancement of transferrin receptor translation. we describe here that either tetrahydrobiopterin dependent stimulation as well as cytokine (ifn-~)/lipopolysaccharidemediated induction of nitric oxide synthase activates irf, which is due to direct interaction of nitric oxide with the iron-sulphur-cluster of irf. this was shown by gene expression studies using a plasmid containing a ferritin ire and a cat indicator box which was transfected into k myelomonocytic cells, which were shown to have a constitutive form of nitric oxide synthase (nos). furthermore, the increased binding of re to irf due to irf activation of irf by nitric oxide was demonstrated by gel shift assays. irf activity was much more increased in cellular extracts from murine macrophages (j ) where a cytokine inducible form of nos has been characterized earlier as compared with irf activity in k cells, where nos was stimulated by increasing the availability of the essential nos cofactor , , , -tetrahydrobiopterin. we then demonstrated that activation of irf by nitric oxide is accompanied by alterations in ferritin translation as checked by metabolic labeling and immunoprecipitation. these results suggest a reasonable mechanism for the regulation of iron disturbances under chronic inflammatory disorders, characterized by increased concentration of immune activation parameters like ifn- or neopterin and low serum iron and hemoglobin concentrations. taken nitric oxide, no, the putative endothelial derived relaxant factor, edrf, has been shown to be a potent inhibitor ofplatelet aggregation in vitro. in vivo evidence however, is scarce. accumulation of platelets in the lungs has been shown to occur during extracorporeal circulation. the aim of the present study was to investigate the effect of inhaled no on this reaction. materials and methods: the animals were divided into two groups, each consisting of pigs. platelets were selectively labelled with luln-oxine. dialysis was instituted via catheters in the femoral vessels. in group , no, ppm, was added to the inhaled gas from the start of dialysis. in group no was not given. the activity over the lungs was followed dynamically with a gamma camera. central hemodynamics was monitored via a swan -ganz catheter. results: the activity was significantly lower in group , from minutes after start of dialysis and onwards, indicating diminished accumulation of platelets in the lungs. parallel to this the hemodynamic response in terms of increased pulmonary artery pressure and pulmonary vascular resistance was blunted in this group conclusion: inhaled no in this model seems to affect pulmonary platelet sequestration. an associated attenuation of the changes in central hemodynamics was also seen. previous studies from our laboratory have demonstrated that vascular contractility decreased in endothelium-intact blood vessel rings in early and late stages of sepsis. although endothelium removal in early sepsis restored vascular contraction, the depressed smooth muscle contractility observed in late sepsis was not restored by endothelium removal. this indicates that impairment of smooth muscleper se may be responsible for such dysfunction in late sepsis. the aim of this study, therefore, was to determine whether or not smooth muscle-derived nitric oxide (no) plays a role in producing vascular smooth muscle dysfunction during late stages of sepsis. to study this, rats ( - g, n= - /group) were subjected to sepsis by cecal ligation and puncture (clp). septic and shamoperated rats then received rrd/ g bw normal saline. the animals were killed at , , or h post-clp ( h post-clp=early sepsis; - h post-clp=late sepsis), and thoracic aortic rings were prepared for contraction studies using organ chambers. the complete removal of endothelial cells was tested by the absence of any significant acetylcholine-induced vascular relaxation. contractile responses to norepinephrine (ne, to - m) were determined in the aortic rings without intact endothelium. ng-monomethyl-l-arginine (l-nmma, /~m, an inhibitor of no synthase) was then added to the organ chamber and ne-induced peak contraction was determined before and after the addition of l-nmma. the peak contraction (rag/rag tissue, mean_+sem) is shown below: the results indicate that the addition of l-nmma did not significantly affect ne-lnduced peak contraction in endothelium-denuded vessel rings at and h after clp. in contrast, l-nmma administration produces an % increase (p< . ) in peak contraction during late sepsis. therefore, the vascular smooth muscle contractile dysfunction observed at h post-clp is partially due to smooth muscle-derived no over-production. thus, unlike macrophages in which inducible nitric oxide synthase (inos) is observed in early sepsis, the inos in vascular smooth muscle appears prominent only in the late stages of sepsis. in three cases of human septic shock in which ng-monomethyi-l-arginine, (l-nmma) a nitric-oxide-synthase-inhibitor was applied, we isolated three completely different types of pathogens: candida, pseudomonas aeruginose and multiresistant coagulase-negative staphylococci. this observation suggests that endotoxin alone is not the main factor triggering hypotension in septic shock by the nitric oxide pathway. in a -years-old woman in severe septic shock due to a candida and pseudomonas aeruginosa infection complicated by adult-respiratorydistress-syndrome conditions deteriorated despite adequate conventional therapy. in this trial, effects of l-nmma on cytokin-levels were investigated. the study-protocol was approved by the ethical committee of the department of surgery. after two boll of mg of l-nmma, a continuous infusion was installed ( . mg/minute and kg body weight l-nmma). as expected mean arterial blood pressure rose ( to mmhg}, heart rate stayed stable ( + b/rain), systemic vascular resistance increased ( to dyne.sec/cm ), cardiac output decreased ( to . l/rain), and cardiac index declined ( . to . l/min/m }. before and after minutes while the infusion of l-nmma, blood samples for immunological measurements were taken and processed together. pulmonary-shunt-volume was observed before the application of l-nmma, after one hour and after matutes. neopterine increased from . to . ng/ml, tumour-necrosis-factor-a increased from . to . pg/ml and intedeukin- increased from . to . pg/ml. immunoglobulines a, g, and m ( . to . , . to . , . to . g/i), complement factor c- c and c- ( . to . , . to . g/i), alpha-l-antitrypsine ( . to . g/i), c-reactive-protein ( . to . rag/i), interleukin- ( pg/ml) and soluble interleukin- ( to units/ml) did not change significantly. pulmonary-shuntvolume decreased from . % to . % within one hour and to . % after minutes. in septic shock blocking nitric oxide as an intervention at the end of a not ~,et ful!y understood cascade might have important influences on pulmonary-shunt-volume and inter-cell-communication. department of surgery, pharmacy* and immunology**, university hospital of zurich, r~imistrasse , zurich, switzerland we previously reported that hypoferremic cba mice had an increased resistance to salmonella infection, and that injection of ammonium ferric citrate (afc) to these mice led to enhanced infection (ganthier et at. . microbiol.immuno : ) . because nitric oxide (no) is involved in the antimicrobial activity of routine macmphages towards various inttacellular pathogens, we investigated the influence of iron on the bactericidal activity of cba mouse macrophages towards s.typhimurium and on the production and activity of reactive nitrogen intermediates (rni). peritoneal macrophages hum cba mice were cultured in the presence (or not) of afc ,um, ifn-,/ u/ml, lps fig/m/, ngmonomethyl-l--arginine (mmla) ram. nitrite (no -) content of the supematants was determined by a standard griess reaction, and h release was measured by the peroxidese dependant oxidation of phenol red. for intracellular killing, macrophages monolayers were infected, and, at various intervals, lysed by triton x- , and surviving bacteria enumerated by colony counting on agar. for in vivo experiments, mice were infected ip with . ml of a suspension of . ~" s.typhimurium, strain c , and injected with aminoguanidine (ag) mg/ml in saline. our results show that the rn[ inhibitor ag strongly accelerates the mortality of infected mice, the survival rate decreasing from % in the control group to % in the treated group, days after challenge. correlatively the rni inhibitor mmla induces in vitro a decrease in the rate of bacterial killing, fxom % to %, in macrophages triggered with ifn-? + lps. the cultivation of macrophages in the presence of afc leads to a decreased no -accumulation, . nmole/well v.s. nmole/well. conversely h production is enhanced from nmole/well up to , nmole/well. nevertheless, macrophages cultivated in the presence of afc exhibit an increased tale of intracellular killing, % in iron exposed macrophages v.s, % in control macrophages. when triggered with ifn-~, alone, macrophages have a reduced antibacterial activity ( % v.s. %) whereas the addition of afc to these macrophagas restores an elevated ( %) rate of killing. in conclusion, the results show that bactericidal activity of cba macrophages towards s.typhimurium depends on the production of no by these macrophages ; but they also demonstrate that no is not the only reactive species involved in the intracellular kil/ing of s.thyphimurium ; indeed afc which strongly inhibits rni production, stimulates h release by these macrophages and increase their bactericidal activity in vitro. nevertheless afc may promote bacterial growth in vivo. crssa. unit de microbiologie. bp . la tronche cedex france. henning jahr, ulrike noack, karin braun the large amounts of no produced by the inducible no synthase in rat macrophages have direct antimicrobial effects, but inhibit the activation of the lymphocyte-dependent host defense system. the aim of this study was to investigate if complement activation influences no-generation. spleen cells from lew rats were incubated at °in tcm- / % fcs, with or without additional rat serum. after h, nitrite (end product from no metabolism) was measured by oriess reagent. in rat spleen cell preparations, most of the no is produced by macrophages. complement activation in vivo was carried out by i.v. injections of u cobra venom factor/kg b.w. at days and . significantly higher (p<o.o ) lps-stimulated no-generation was found in spleen cells prepared at day ( . - . nmol nitrite/ cells, n= ) compared to spleen cells from non-treated animals ( . ± . nmol, n= ) complement activation was effective also in vitro. when incubated in % zymosan-activated rat serum, both basal and lps-stimulated noproduction were enhanced in spleen cells (table, values increased production of nitric oxide (no) is associated with sepsis, however, the effect of no inhibition on survival during sepsis is unclear. we examined the effect of no inhibition on host's ability to eliminate bacteria and survival in mice sepsis model. sixty female balb/c mice were injected with e.coli ( qbody) into peritoneal cavity. the treated group received n-ultro-l-arginine-methyl-ester (l-name), an inhibitor of nos, one hour before bacterial challenge. thirty mice were observed for survival after e.coli challenge and the other mice were sacrificed at hours. blood was obtained by cardiac puncture and peritoneal lavage fluid (plf), liver and lung were harvested. the number of peritoneal exudative cell (pec) was counted and colony forming units (cfld of bacteria in the tissues, blood, and plf were also determined. in addition, pec was cultured in vitro with or without lipopolysaecharide (lps). tnf levels in the blood, plf, and supematants of cultured pec were measured by l bioassay. survival rate (%) qrql/,p n hr hr dav control (normal saline . ml/body i.p.) n (l-name mg/kg i. administration of l-name before e.coli injection increased the number of bacteria in plf and tnf level in plasma, the result suggests that nos inhibitor may depress the host's ability to kill the injected bacteria and that it may induce greater systemic tnf production. we conclude that nos inhibitor is detrimental to animals in sepsis. the hypothesis that sod prevents reperfusion injury to the liver by protecting the endogenous endothelium derived vascular relaxing factor (no) from being inactivated by oxygen free radicals should be investigated. male wistar rats were subjected to min of partial liver ischemia ( %) and min of consecutive reperfusion in situ. some rats were pretreated with the no synthase inhibitor nitro-l-arginin (nla: i mg/kg). sod, when used, was given as mn-containing preparation at a dose of u. i.v. i min prior to ischemia. results (sod/ nla+sod/ ni~,, respectively): bile flow (~i/g/min) : . ± . "#/ . ± . / . ± . . alt (u/ ) • ± ~#/ ± / ± . gldh (u/l): . ± . e#/ . ± . #/ . ± . . in absence of nla, sod enhanced postischemic bile flow and reduced leakage of alt and gldh into the plasma, while the effects of sod disappeared, when endogenous ~synthesis was inhibited by nla. nla had no ~ffect on untreated animals submitted to the same protocol. these results may suggest, that oxygen free radicals interfe~:e with the endogenous vasodilator no and that the benefit of sod can be attribuated in large part to a protection of no during reperfusion. nitric oxide (no) reduces pulmonary vascular resistance and increases oxygenation by inhalation in ards patients [ ] . animal studies on the endogeneous no production proved that no is exhaled after synthesis in the respiratory tract [ ] . with approval by the hospital ethics committee, we studied healthy volunteers and ventilated patients by measurement of inand exhaled no by no/no -chemiluminescence in segments of the upper respiratory tract. we found that no is synthesized predominantly in the nose and in the upper nasopharynx, leading to inspiratory tracheal no concentrations of . - . parts per million in non-smoking volunteers; data during mask ventilation per nose were as follows: non . . . . , parts per million (ppm) no, mean, n = ; ~ p < . (t-test) between smokers and non-smokers; p < . (t-test) between in-and expiration. about % of no is resorbe.d by the lung, and the exhaled no -in contrast to former presumptions -is the remaining part of the autoinhaled no. intubated and ventilated patients are deprived of no autoinhalation, and the exhaled no in the trachea decreases more than % {o. ppm before intubation vs. . ppm after intubation, ~, < . ), whereas the nasal no concentration increases by cumulation. hence, low-dose no inhalation in ards patients might be considered as a no replacement, especially since the tracheal no concentrations we measured in volunteers are similar to those which could be demonstrated to be effective for ards in former studies [ ] . the data demonstrate that no is synthesized in the nose, and inhaled and resorbed by the lung. this phenomenon of no autoinhalation, which is reduced in smokers and in ventilated patients, does possibly contribute to the regulation of the ventilation-perfusion ratio in the lung. kikuchi , yoshihiro inoue , masao yoshida critical care and emergency center, and department of bacteriology, iwate medical university. nitric oxide (no) is produced by macrophages and vascular endothelial cells. it is thought to be the true form of endotheliumderived relaxing factor, and to be involved in the fall of blood pressure during septic shock. we have reported previously that endotoxin (lps), tnf-c~ and il- contribute to the occurrence of septic shock (circ shock : ; . the present study investigated the in vitro effects of lps, tnf-o~, il- and ifn-'i on the production of no by macrophages. peritoneal macrophages were cultured with lps, il- , tnf-~ and ifn-¥. in culture with lps, no was produced in a dose-dependent manner, and the production was suppressed by a no production inhibitor, l-nmma. ifn-y, il- and tnf-c~ used alone did not promote the production of no, but helped lps to facilitate no production. a combination of il- and tnf-c( enhanced lps-facilitated no production to a greater extent than il- or tnf-c~ alone. the above results suggest that these cytokines are involved in endotoxin shock through the mechanisms that facilitate no production. - uchimaru, morioka . japan. t. yolk , , i. ioannidis , w.j. kox and h. de groot objectives: nitric oxide (no.) is known to play an important role in neurotransmission, vasoregulation, and bactericidal as well as tumoricidal cellular defense systems. by means of no-donating agents we studied the mechanism of no-mediated cytotoxicity against rat liver microvascular endothelial cells. materials and methods: -morphoiinosydnonimine-n-ethylcarbamide (sin-l) and sodium nitroprusside (snp) were used as no. donators, ldh release and trypan blue exclusion were applied to indicate cell viability. results: sin- ( mm), which releases both no. and o -., caused a time-dependent cytoreduction of % and % after and hrs, respectively. this effect was not inhibited by superoxide dismutase (sod), which removes --to form h and . in contrast, the addition of catalase (cat), which removes h to form h and , diminished the cytotoxic effect ot sin- to %, equivalent to high concentrations of snp ( mm), which solely releases no.. in addition, the amount of h formed by mm sin- equaled the amount ot enzymaticany produced h by mu/l glucose oxidase (god). whereas god in this concentration and snp in low concentration ( mm) alone were not toxic to endothelial cells, the combination caused an % reduction of viability, comparable to the effect observed with sin- ( mm) alone. moreover, toxicity mediated by high concentrations of snp ( mm and ram) was reduced by % under hypoxic conditions indicating synergism with no-and . conclusions: we conclude, that no.-induced toxicity against endothelial cells is enhanced slightly in the presence of oxygen and is not due to an interaction with -. however, toxicity increases dramatically in the presence of h . this may possibly occur either by a chemical formation of more potent reactive hydroxyl radicals or by independent actions on different cellular targets. although it is becoming increasingly clear that nitric oxide (no) is associated with otxan dysfunctions in septic patients, little is known as to die kinetics of no production in these patients to clarify these kinetics, we have investegated serum arid monocyte associated no in septic patients. five patients who had undergone gastrointestinal surgeries mid were complicated postoperatively with severe sepsis served as the subjects in this study (sgroup), using twelve healthy volunteers as a control group (c group). serum no and no levels were measul*d sliectrophotometricallymonocyte cultures were done for itrs with or without lps+ifn-t stimulation mid no and no levels in the supernat,'utts were also measured spectrophotometrically. furthermore,using an no selective electrode,time course of the lps+ifn-t induced no production by monocytes was studied. l) serum no levels in s group were slightly lfigher than dmse in c group,bnt there were no significoatt differences between the two. )both no levels in the supematmlts of monocytes cultured with lps+ifn-t mid no , no levels ill lhe supernatants of monocytes cultured without lps+ifn-y were significantly higher in s group. further,the time required for the no production by enltnred monoeytes was siglfificantly shorter also in s groap. conclusions l)in severe septic patients, monocyte no productions wei~ not only primed, but also activated concomitantly, suggesting that these monocyte activations m'e strongly associated with organ dysfunctions in sepsis. )based on the restdts of serum no nteasuremeuts, it can be deduced that no p~'oduced by monocytes in septic patients affects tissues and org~s ioeoregiomflly. objectives of the study: nitric oxide (no) is an important messenger which accounts for a wide spectrum of physiological and pathophysiological processes, e.g. mediating vasodilation in endoloxin shock investigating the signal lransducfion pathways involved in the regulation of the inducible nitric oxide synthase (inos), we report the involvement of phosphatidylcholinespecific phospholipase c (pc-plc) and proteinkinase c (pkc). materials and methods: no-production was induced in the murine macrophage cell line j with lipopolysaccharide (lps) [lljg/ml] and interferon ;f (ifny) [ u/ml]. after hours of incubation no-release was determined as nitrite (no ) by using a colorimetric assay based on the griess-reaetion. results: preincubation of cells with the pkc-inhibitors staurosporine (stp), chelerythrine, bisindolylmaleimide (bim) and d , that recently has been identified as a selective inhibitor of pc-plc, diminished significantly lpsand ]fnt-induced no -production (p<o, ). although we observed no toxic effect on cell viability, no -production was related to protein concentrations to exclude any inhibitory effect on celt growth. celts preincubated with stp [lo nm] released % less no in response to lps and ifn,[ compared to control cells cultured without inhibitor. chelerythrine [ }jm] and bim [ioijm] reduced the no -formation by % and %, respectively. interestingly, the most potent inhibitor of no-production turned out to be the xanthate d cells pretreated with d [ ~g/mt] released % less no than stimulated controls the inhibitory effect on no production decreased the later the inhibitore were added after stimulation; e.g. bim added and hours after stimulation reduced no -production only by % and %, respectively. accordingly, inqs activity present in stimulated cell lysates supplemented with l-arginine and co-factors was not suppressed by the inhibitors tested. conclusions: our findings suggest, that the induction of inos but not its activity is a pkc and particularly pc-plc dependent process. dr. k tschaikowsky, institut for anaesthesiologie, universital erlangen--nqrnberg, krankenhausstr , erlangen interleukin- (il- ) affects nearly every cell type by increasing the expression of a variety of genes associated with the promotion of inflammatory processes. these include upregulation of cyclooxygenase and nitric acid synthases. the il- ri transmits a signal(s) through the cytoplasmic domain which is structurally related to the fruit fly toll protein. we have recently cloned the promotor most proximal to the ' utr of the human il- ri gene. the genomic sequences reveal a lack of tata and caat boxes but rather a considerable ( %) gc rich region. the translation of the type i il- r appears under a significant suppression and may limit the biological activities of il- by low level of expression. on the other hand, the type ii il- r, lacking a significant cytoplasmic domain, does not transmit a signal and acts as a decoy receptor preventing the binding to the type i receptor. there are several approaches to reducing il- activity; inhibition of il- converting enzyme which cleaves pro-il-l[ , anti-il- ri, the il-i receptor antagonist (il- ra) and soluble (extracellular) il- ri and il- rii. il- ra is structurally related to il- and binds at °c to the il- ri with near equal affinity as that of bona fide il-i; however, il- ra does not transduce a signal. il- ra has been given to humans in pharmacologic levels (mean plasma levels of gg/ml) without evidence of agonist activity. in addition, there has been no affect on normal homeostatic parameters, suggesting that il-i does not play a role in health. in healthy humans given intravenous endotoxin, il-ira reduced endotoxin-associated neutrophilia by % and completely reversed endoloxin-iuduced immunosuppression, il-tra is produced naturally and is elevated in the circulation in several diseases. in a variety of diseases, plasma levels of il- ra are in -fold molar excess to those of il-i [ . it is unclear whether these endogenous levels of il- ra are sufficient to block il- activity in disease. a single injection of ]l- or ifna in humans does not induce il- but rather high levels of il- ra ( ng/ml). prof.dr.l.a. aarden interleukin (il ) is a multifunctionai cytokine with a central role in host defense mechanisms and consequently in inflammation. il is thought to be involved in the pathogenesis of various diseases. therefore, specific inhibitors could have therapeutic value. a human-mouse chimeric monoclonal antibody to il has been applied in a phasei clinical trial in patients with multiple myeloma and in primate models of sepsis. no toxicity was observed and the most remarkable outcome of this study was the build up in the circulation of il -anti-il complexes, suggesting that plasma il measurements represent a gross underestimation of il production in the patient. until now no natural antagonists of il have been described. the biological activities of il results from binding to a lowaffinity il -receptor (il r). the il /il r complex induces disulfide-linked homodimerization of the signal transducing receptor component, gp . studies on the structure-function relation of il revealed that disruption of the gpl -interaction site on il gives rise to a mutant il that, by virtue of its intact binding to the il r, acts as a potent antagonist on human hepatocytes and on human b cells. in vivo studies using this molecule will be initiated in the near future. the evolution of infla~ation involves a dynamic series of cellular events controlled by specific signals which are important to the initiation, maintenance, and final resolution of the inflammatory response. the various phases of inflammation are influenced via the expression and subsequent regulation of a number of key mediators which play a predominant role during each particular stage of the developing lesion. for example, the initial elicitation of blood born leukocytes to on inflamed area is a complex system that is dependent upon the expression of early response cytokineso these proximal mediators, including both interleukin-i (il-i) and tumor necroisis factor (tnf), are important in the initiation phase by activating both immune and non-immune cells and establishing a series of cytokine networks, thus, the above proximal mediators can stimulate endothelial cells, epithelial cells, smooth muscle cells, and fibroblasts to generate more distal cytokines. these latter cytokines include interleukin- (il- ), macrophage inflammatory protein-i (mip-i), and monocyte cbemoattractant protein-i (mcp-i). the importance of the above chemukines can be found in the role they play in leukocyte elicitation, as well as wound repair. numerous investigations have shown the diverse cellular sources of il- and the ability of il- to elicit neutrophils in vitro at pm to nm concentrations, however, recent studies have sho%~ an additional role for il- during the resolution phase of the inflammatory process. using corneal pocket animal models of angiogenesis/neovascularization, il- was found to be a potent angiogenic factor at concentrations ranging from - ng/ml. sequential fluorescein angiograms demonstrated that il- induced neovascularization by days, which regressed by weeks. in further analyses, both conditioned media recovered from either inflamed human heumatoid synovial tissue macrophages or lps-stimulated peripheral blood monocytes were found to possess potent angiogenic activity, which was effectively blocked by neutralizing antibodies directed against human il- . in addition, an il- antisense nligomunclentide blocked the expression of a functionally active angiogenic factor from lps treated monocytes. the above data demonstrate that il- has multifumctional activities during the initiation, maintenance, and resolution of a local inflammatory response. inhibits specific t-cell responses to soluble protein antigens and alloantigens. the proliferative responses of th , thl and th cd ÷ t-cell clones and cytokine production by these t-cell subsets are equally well inhibited. the inhibitory effects of il- are indirect and related to inhibition of antigen-presenting capacity and accessory function of the antigen-presenting cells (apc). however, il- also directly inhibits t-cell proli/eration induced by cross]inked anti-cd or anti-cd mabs (e.g. in the absence of professional apc), by specifically inhibiting il- gene transcription and il- protein production. il- also inhibits the production of the pro-inflammatory cytokines il-l-a, ~, il- , and tnf-a and the chemokines il- and mip-i-u, which are strong chemo attractants for neutrophils and macrophage, respectively. in contrast, il- enhances the production of the il- receptor antagonist, a cytokine with anti-inflammatory activity. il-l produced by monocytes downregulates class ii mhc expression and il- production by these cells in an autoregulatory fashion. collectively, these in vitro data indicate that il- is a powerful suppressor factor for immune-and inflammatory responses and therefore may have potential clinical utility as an anti-inflammatory agent. this notion is supported by recent studies which indicated that il- also prevents lethal lps-induced toxic shock in mice. five of the chamekines (hip-i~,era~tes. ip-io and il ) also chemoattraet t lymphocytes, while others act on mast cells. we have studied the effaces of these chemokines on t cell subsets. il preferentially chemoattracts uns~imulated t cells. raises ~ttracte resting as well as activated cd and cd memory t cells. ip- chemoattracts only preactivated (not resting) cd or cd t cells. hip-l~ preferentially chemoattracts gd t calla, while hip- more readily attracts the cd t call subset. the chemoklnes and ip-io were also sho~rn to promote the adherence of ~he same subsets of anti-cd activated t cells to ili activated human umbilical vein endothelial cells (hitvec). this was not associated with a~y i~crease in the number of lymphocyte adhesion molecules, bu~ could be inhibited by neutralizing monoclonal antibodies re lfa-i and vla- . these chemokines also rapidly increased ~ha adhesion of resting t l~phoeytes to plates coated wi~h integrlns (i-cam or v-cam) or matrix proteins such as f~bronectln. this induction of adhesion began wiehln ', peaked by hr and was completed in hr. this suggests that chemoklnee rapldly increase the binding affinity of adhesion prote~ns on t cells. we also recently observed ~hat mcaf/mcpi and rantes chemoattract unatimulated mast calls. furthermore, igs actlvared mast calls were chemoattraeted by mcaf, ra~tes, pf and mip.i~. however. ~he chemoklnee did not induce mast cells ~o release histamines. presumably, chemokines as regulators of the adhesion, migration and homing of all kinds of leukocytes participate in many types of inflammatory diseases. natural killer cell stimulatory factor or interleukin- (il- ) is an heterodimerie cytokine formed by two covalently linked glycosylated chains of kd and kd. il- was originally purified from the supermatant fluids of ebv-transformed human b ly~phobiastoid cell lines. however, in addition to b cells, phagocytic cells, i.e. monocytes, macrophages, and neutrophils, have been identified as the major physiological producers of il- . phagocytic cells produce il- in response to bacteria, bacterial products such as lps, and intracellular parasites. the cell types on which il- exert biological activity are t and nk cells. the major direct biological function of il- on these cell types are the induction of cytokine production, primarily ifn-y, the enhancement of a generation of cytotoxic cells, and a mitogenic effect on antlgen-activated lymphocytes. in part thromgh its ability to induce ifn-y production, il- , produced in response to infections, represents an important functional link between effector cells of innate resistance, phagocytic cells and nk cells, and effector cells of adaptiye resistance, t and b lymphocytes. the ability of il- to induce ifn-y production from circulating. nk cells and at least a proportion of t cells determines a rapid, antigen-independet production of ifn-y during infections. ifn-y acts as a potent enhancer of phagocytic and bacteriocidal activity of phagocytic cells, participating early in infection to activate some of the inflammatory mechanisms that represent the first innate resistance against infection. this antigem-independet activation of phagocytic cells that involves, in addition to il- , other monocyte derived cytokines such as tnf and il-l, has been shown to be important in experimental animals for the resistance against infection by microorganisms such as limteria monocytogens and toxoplasma gondii. in addition to this role, early in infection in the antigen-independet phagocytic cell activation, il- has a major effect in the ensuing antigenspecific admptive immune response by facilitating the generation of t helper type (th-i) response and suppressing a th- response. the presence of il- during antigen stimulation in vitro using human peripheral blood lymphocytes, or both in vivo and in vitro in experimental animals, induces generation of th-i cells producing ifn-y and il- , and inhibits the generation of th- cells producing il- . il- induces a direct differentiative effect on th-cells, priming them for high ifn-y production. ~is priming effect is stable and maintained even when t cell clones are cultured for extended periods in the absence of il- , however, il- needs to be present during the first few days after stimulation with antigen or mitogen and established th clones are resistant to the priming effect of ifn-y. unlike the generation of high ifn-y producing clones, the il- -mediated inhibition of il- producing cells in probably due to selective mechanisms, which may include a selective mitegenic effect of il- for thl cells and an inhibitory effect of ifn-y on th cell proliferation. in several experimental systems, it has been shown that the enhancing effect of il- on th-i responses is dependent on production of if~-y and on the presence of nk cells, possibly needed for the early production of ifn-y. the importance of phagocytic cells and nk cells in determining the characteristics of the th response during antigenic stimulation indicated that the mechanisms of innate resistance have a determining influence on the subsequent antigen-specific immune response: il- appears to have a key role in mediating the interaction between phagocytic cells. nk cells, and t lympocytes in these proccessem. trinchieri, g. , interleukin- and its role in the generation of t e cells, imm~ol. on peripheral blood monocyte/macrophages, il- behaves like il- in a variety of assays, and shows both similar and contrasting, activties with either il- or ifn-y. il- reduces inflammatory monokine and il- production. it reduces the pyrogen-induced expression of tissue factor (herbert et el, , febs lett. , ) . it mpregulates manmose receptor and ~c class ii expression, while reducing cdi expression. il- produces morphological changes (extensive cell processes, aggregation, giant cell formation) which have previously been observed with il- . it inhibits niv-i production (montaner et el, , i. exp. mad. , ) , and interferes with hiv-induced cell fusion. the activities of il- and il- differ on t-ly•ocyte and large granular lymphocyte population. in particular il- does not exhibit the suppressive effects of il- on thl-type-helper functions (ifny production) and cytotoxic functions (perforin production). data will be presented showing that il- and il-l share a common receptor on a nu~er of cell types, but not on t-lympocytes (see also zmrawski st el. , embo j. . - ), explaining both thai common and divergent activities. the levels of il- ~a in activated peripheral blood lymphocytes are greater than or equivalent to those of il- mp~ja and the two ml{nas are expressed by different t lympocyte population: in particular, t cytotoxic lymphocytes express markedly higher levels of il- ~rna. in vivo, il- may thus be contributing, significantly to some of the activites previously ascribed to il- il- . recently, we cloned the human cdna encoding interleukin- (il- ). human il- is a non-glycosylated protein of aa with a molecular mass (mr) of kd and has biological activities on monocytes and b cells, il- , like il- , strongly enhanced the expression of class ii mhc antigens on monocytes and induced expression of cd (fc~rii). furthermore, il- , like il- and il~ , inhibited the production of pro-inflammatory cytokines il- , ]l- , tnfo~ and chemokines miplc~ and tl- by lps activated monocytes. both il- and il- enhanced the production of il-lra by monocytes. in contrast, il- lacked the t cell stimulating activities of il- . the responses of monocytes to il- and il- were not additive or synergistic, supporting the hypothesis that il- and il- receptors are complex and share a common component which is important for signal transduction, taken together, these data indicate that il- , il~ and il- have important anti-inflammatory activities on human monocytes. in addition, these results indicate that il- is unique in that it can modify inflammatory reactions without stimulating (as does il- ) or inhibiting (as does il- ) t cell responses. transforming growth factor beta i (tgf-fll) belongs to a family of proteins that have potent immunoregulatory properties ranging ftom effects on the growth and dfflerentiafion of primitive stem cells to the differentiated functions of immune system effector cells. tgf-i~i is synthesized as a large secretory precursor polypeptide of amino acids that is inactive until processed to a disulfide linked homodimeric molecule of t amino acids each. recently it has been found that tgf-[~i can have autocrine as well as paracrine effects on the immune system indicating that immune cells can activate the inactive secreted form of tgi~-~i. in addition, tgf-i~i has differential intraceuular effects on cell surface receptor modulation, tyrosine phosphorylation and cytokine gene transcription as well as cell mediated cytotoxicity. the systemic administration of tgf- has proven beneficial in a variety of animal models such as septic shock, allograft rejection and experimental forms of autoimmunity including collagen induced arthritis and experimental autoimmune encephalomyelitis. moreover the increased levels of tgf-ill and other tgf- isoforms found in several disease states associated with immunosuppression such as different forms of malignancy, chronic degenerative diseases and aids implicate the involvement of tgt~-i~ in the pathogenesis of some diseases. hopefully, well designed clinical trials will define the potential roles of the tgf-[ family of proteins in the treatment of diseases of man. patient development of systemic inflammatory response syndrome (sis) after severe trauma is accompanied by a wide range of immune aberrations and altered cytokine production. in particular, t lymphocyte proliferation and ifn, t production is suppressed while monocyte (mo) tnfc~, il- , pge and tgf~ production is massively increased concomitant to decreased antigen presenting capacity. recently, two new cytokines, il- and il- , have been characterized as critical in regulation of mo tnfa and il- , as well as in induction of t lymphocyte proliferation and ifn production. in this study, peripheral blood leukocytes (pbl) from severe trauma patients (injury severity score > ) were analyzed for their il- levels, their in vitro proliferation to mitogen (pha) and their response after il- addition. since il- produced either by mo or by t lymphocytes can depress m~ antigen presenting capacity, inhibit t cell ifn,/production and directly diminish t cell proliferation, it might be suggested that immunosuppressed patients' mo and/or t lymphocytes would have increased il- levels. increased patient il- production might also be resulting from the high levels of tnfa a known stimulator of il- . conversely, since il- augments mo antigenpresenting capacity, thl induction and proliferation, post-trauma leukocytes might be il- deficient. pbl of trauma patients were compared to normals' pbl, either unstimulated or ptta induced, and their levels of il- found to be dramatically and significantly reduced. patients' isolated m~, either stimulated with the bacterial cell wall analogue, mdp, or unstimulated, also had depressed il- production concomitant to elevated tnfa production when compared to normals' mo. mechanisms for the depressed patients' mo il- were explored. increases in tgf[ may have partially contributed to the patients' depressed il- level, but elevated pge had no effect. addition of il- to patients' pbl significantly increased their mitogen responses. these data imply that sis is characterized by disruption in the interactions between mci and t lymphocytes so that patients' m~i produce excesses of some mediators (tnfa, il- , pge ) and a dearth of other monokines (il- , il-io). t lymphocytes are not activated and, therefore, unable to function in both immune defense and monocyte regulation. it is known that lge receptor-mediated or ca-ionophore-induced activation of mouse bone marrow-derived mast cells ( mmc) may result in the production of different cytokines including the interleukins (il) , , , and as well as gm-csf and tnf-a. in the present study we analyzed the effects of exogeneously applied pro-inflammatory cytokines (il- , l- , tnf-c as well as various mast cell growth factors (il- , il- , il- , il- , ngf, kl (kit ligand)) on cytokine production in primary mouse bmmc using a standard activation protocol (lxl bmmc/ml; ll.um ionomycin; - h). the actixdties of bmmc supernatants were assessed in specific biological (il- , il- il- , l- ) and/or elisa assays (il- , il- ). here we show that homogeneous populations of bmmc (> %alcian blue+/safranln-; in vitro age: weeks) generated in the presence of recombinant (r) rail- from normal balb/c mice produced modest amounts of l- and low or undetectable levels of il- , - , and - after induction with lp.m ionomycin only. however, a dramatic increase ( -to -fold) of these cytokine activities was noted, when in addition to ionomycin also human ( ) rll-la was provided during the induction period. this il- effect was dose dependent with a maximgm at - u/ml hrll-la and specific, as pre-incubation (lh) of bmmc with ng/ml hrll- receptor antagonist abolished the action of u/ml hrll-lcc similar effects were noted with hrll-lg or rurll-lb (lng/ml, respectively), but not with rhll- or rmtnf-~. both mrll- and hrll- substantially enhanced ionomycin-induced l- production of bmmc in the absence or presence of il- . il- significantly enhanced il- and il- production while decreasing il- activities to abont - % of control levels, when il-i was provided in the presence of il-l/ionomycin. a monoclonal anti-nfil-t antibody (ascites : ) abrogated the effects of mrll- . other mast cell-active cy~okines (] ,- , il- , l- , ngf, or kl) added to ionomycia-or l- /ionomycin-treated bmmc had no major effects on cytokine production. il- and il-i did not induce significant cytokine release in the absence of ionomycin suggesting tlmt cadependent signalling was required. at doses of " m, dexamethasone, corticosterone, or hydrocortisone almost completely abolished ionomycin/il- /ll- induced cytokine production. the inducer cocktails per se did not interfere with the cytokine bio-assays. in case of il- inducibility of this cytokine in bmmc was confirmed at the mrna level by northern blot analysis. hence our data show that activated mast cells are a source of il- previously recognized as a product of th type lymphocytes only. moreover, our study reveals novel functional roles for i-l-i, il- , and ghicecorticoids in the regulation of cytoldne production in mast ceils. accumulating data suggests that cytokines, peptides involved in regulation of both physiological and pathological immunological responses, predominantly are produced at the local site of antigen stimulation. a new method was used to detect cytokine-producing cells in haman tissue at the protein level. single-cell production of different httman cytokines, ilia, ill [ , illra, il , il , il , il , il , ils, ill , gm-csf, tnfa, ifn and tgf[ . , was identified by indirect immunohistochemical staining procedures and use of carefully selected cytokine-specific mab's. frozen sections were fixed with % paraformaldehyde and permeabilized by . % saponin treatment, eluting cholesterol from the membranes. the intracellular presence of all cytokines except ill, illra (late) and tfg[ _ , could be demonstrated by a characteristic perinuclear configuration in producer cells. in addition, the immunoreactivity extended over a large extracellular area encompassing the producer cell. a localization of the cytokine to the golgi-organelle was established by use of two culour staining including a haman golgi complex specific mab. this staining pattern was only evident in producer cells because injection of recombinant human cytgkines into the tissue caused a membraneous and extracellular staining pattern. both the extra-and the intracellular types of staining reaction could, however, be blocked by preincubating the cytokine specific mab with pure human interleukins. oxygen radicals (or) directly induce lipid peroxidation, indirectly they trigger adhesion and activation of pmn leukocytes. we investigated whether or also lead to a release of acute-phase response cytokins such as tnf-alpha, il-i beta or il- in whole blood cultures to maintain the induced inflammatory reaction. methods: blood samples from healthy volunteers (n= ) were incubated at °c. or were produced by the xanthine oxidase (xo)/ hypoxanthine (hx) system. after , , , , and minutes plasma levels of tnf-alpha, il-i beta and il- were determined with elisa kits. results: under the influence of or tnf-alpha plasma levels increased from , pg/ml at min to pg/ml, pg/ml, pg/ml after , and min. il-ibeta ( , pg/ml, , pg/ml, , pg/ml, pg/ml and pg/ml after , , , and min) and il- ( , pg/ml, l,lpg/ml, , pg/ml, pg/ml and , pg/ml after , , , and min) plasma levels were increased min later than tnf-alpha. summary: these data suggest that or do not only play an important role in initial accumulation and activation of pmn leukocytes but also lead to a stimulation of monocytes to produce the acute phase reaction cytokins tnf-alpha, il-i beta and il- to maintain and strengthen the inflammatory reaction. department of general surgery, steinhsvelstr. , ulm, germany jan k. horn md, greg a. hamon md, robert h. mulloy md, greg chen bs, rebecca chow bs, and christof birkenmaier md. transforming growth factor-i~l (tgf- ) is released from inflammatory ceils following injury and in sepsis. in vitro experiments have confirmed that low concentrations of tgf- ( . - . ng/ml) are chemoattractive for monocytes, whereas higher levels of tgf- (> . ng/ml) potentiate production of the immunedepressive prostaglandin e . other investigators have shown that tgf-] can cause the appearance of cd (fc immunoglobulin receptor) on monocytes exposed to ng/ml of tgf-[~i for hours. monocytes also express on their surface a glycoprotein that binds complexes of lipopolysaceharide (lps) and lpsbinding protein (lbp). such binding is associated with generation of proinflammatory cytokines such as tumor necrosis factor alpha. we have shown that cd is depressed in septic patients and therefore we hypothesized that tgf- could account for the down-regulation of cd observed in these individuals. we incubated normal human monocytes with platelet-derived tgf-[ for and hours at °c and examined ceils for cd and cd expression using flow cytometry after immunnfluoreseent staining with appropriate monoclonal antibodies. monocytes were selected on the by usual criteria for size and granularity. non-viable ceils were excluded with the use of propidium iodide. two populations of monocytes could be found afcer incubation at °c alone. one displaying high density of cd had increased fluorescence over the homogeneous expression of cd in cells maintained at °c (baseline). the other population displayed decreased cd expression relative to the baseline cells. tgf-i~i ( - ng/ml) caused a shift of ceils from the high density into the low density cd population. this trend was observed within hours of incubation and was complete by hours. we observed a net decrease in cd expression f % for all subjects studied (p< . vs controls). phorbol myristate acetate ( ng/ml) also caused down-regulation of cd to a similar degree as tfg-i~i. we also confirmed that monocytes could be induced to express cd after incubation with tgf- ( ng/ml) for hours. these studies demonstrate that monocytes incubated with immunodepressive levels of regulation of cd by tgf- deplete their surface expression of cd while generating cd . this down-regulation of cd by tgf- correlates with our clinical observations of lower cd expression on monocytes obtained from septic patients. for over years, activated t lymphocytes have been considered to be the cellular source of mif. we recently isolated and cloned the murine homolog of mif after identifying the specific secretion of this protein by lpsstimulated pituitary cells in vitro and in vivo. however, further experiments showed that mif protein is detectable both in t-cell deficient (nude) and hypophyseetomized mice, suggesting that yet additional cell types may produce mif in vivo. since monocytes/macrophages are a major source of the cytokines that appear in response to lps administration, we examined the possibility that mif also is expressed in cells of the monocyte/macrophage lineage. we found that mif is expressed constitutively in the murine macrophage-line raw . and in thioglycollate-elicited peritoneal macrophages. significant amounts of mif mrna (rt-pcr) and protein (western blotting) were observed in cell lysates. in raw . cells, mif secretion was induced by as little as pg/ml of lps (e.coli l:b ), peaked at ng/ml, but was not detectable at lps concentrations > txg/ml. similar data were obtained with elicited macrophages, but higher lps concentrations were required, unless the cells had been preincubated with ifn . production of mif by lps-stimulated (l ng/ml) macrophages peaked at hr. expression ofmif mrna and tnf mrna by lps-stimulated raw . macrophages was investigated by rt-pcr. as expected tnf mrna expression increased over the range of lps concentrations ( pg/ml to p_g/ml). in contrast, levels of mif mrna correlated inversely with lps concentration. by competitive pcr, mif mrna was observed to increase approximately -fold after lps induction ( pg/ml). mif secretion also was induced by tnfoc ( ng/ml) and ifn? ( iu/ml), but not by il- and il- (up to ng/ml). lps and ifn had additive effects in inducing mif secretion. in separate experiments, macrophages stimulated with recombinant mouse mif ( gg/ml) were found to secrete bioactive tnf~ (> pg/ml by l cytotoxicity). we conclude that the macrophage is an important albeit overlooked cellular source of mif in vivo. mif secretion is induced by lps, tnfc~ and ifn?. mif also stimulates macrophages to secrete tnf. taken together with previous observations that anti-mif antibody protects against lethal endotoxemia, these data implicate mif as a critical mediator of inflammation and septic shock. inflammation is characterized by an exacerbation of proinflammatory cytokine production. cytokines such as il- , il- , and tgf , have been identified as anti-inflammatory mediators thanks to their ability to down regulate the production of il- , il- , il- , tnfc~ by activated monocytes / macrophages. however, other cells, including polymorphonuclear cells (pmn) do contribute to the release of pro-inflammatory cytokines. we investigated the capacity of the so-called anti-inflammatory cytokines to control the release of il- by activated neutrophils. human pmn were purified following glucose-dextran sedimentation and ficoli-hypaque centrifugation. the cells were cultured at °c for h in the absence or presence of lipopolysaccharide (lps) or tnfa. il- release was measured in the supernatants using a specific elisa. among tested cytokines, il- was the most efficient inhibitor of il- production by lps-activated pmn. il- was also active, whereas no down regulation was noticed with tgfp~i. when tnfa was used as a triggering agent, none of the cytokine could prevent il- production. northern analysis are under investigation to precise the level of the il- -and il- -induced inhibition of il- production by pmn. our data illustrate that il- and il- possess the capacity to down regulate the production of il- by both monocytes and pmn, whereas tgfb has a more limited inhibitory activity. ciliary neurotrophic factor (cntf), a member of the il- superfamily, has recently been shown to promote axonal growth and neuronal healing. cntf production is also increased during neuronal and muscle damage, associated with soft tissue injury or trauma. we postulated that production of cntf may explain the loss of skeletal muscm protein that occurs in inflammation. female, wistar ( - gm) rats received either or pg/kg bw s.c. injections of recombinant rat cntf for seven days, or received sham injections and were freely-fed. additional animals were pretreated with mg/kg ibuprofen lp prior to pg/kg bw cntf. rats treated with ,ug/kg bw cntf lost . _+ . gms bw as compared to freely-fed controls which gained . _+ . gms (p<o. by anova and lsd), and ibuprofen treatment had no effect on cntf-induced weight loss (- . _+ . ). animals pair fed to the high dose cntf gained body weight ( . -+ . ), although weight gain was less than seen in freely-fed controls. rats treated with pg/kg bw had reduced body weight gain (+ . +_ . gin). food intake was also reduced by % in pg/kg cntf (from . +_ . gm/day to . _+ . gm/day; p<o. ) and was also unaffected by prior ibuprofen treatment ( . +- . gm/day). despite the loss in body weight noted in the high dose cntf animals, there was no appreciable hepatic acute phase response, since liver weight ( . + , gms vs. . _+ . gins), total protein ( . +- . gms/l vs . +- . gins/l) and albumin ( . + . gms/l vs. . +_ . gms/l) were not different between cntf and freely fed animals. we conclude that cntf causes anorexia, and increases body weight loss in excess of the associated anorexia. unlike the cachexia associated with il- and tnf infusions, which is associated with an acute phase response, cntf acts predominantly on food intake and carcass weight through a prostaglandin-independent mechanism and has only minimal acute phase inducing properties, n. joseph espat, md. university of florida, department of surgery, j-box , gainesville, fl. . of cytokines by neurotrophic factors, the neuroendocrine system and phenotiazines. cytokines, including tnf and il- , have a pathogenetic role in various diseases related to infection and inflammation. the action and/or production of cytokines can be regulated by drugs or endogenous mechanisms that involve the cetral nervous system (cns) we found that the antipsychotic chlorpromazine (cpz) potently inhibits tnf production and protects mice against endotoxic shock. cpz also inhibits brain tnf production in mice intracerebrally injected with endotoxin, whereas cpz analogs that do not cross the blood-brain barrier inhibit only perypheral, not brain, tnf. tnf production and susceptibility to the toxicity of endotoxin, tnf and il- are increased in adrenalectomized mice, indicating that endogenous corticosterone (cs) controls cytokine production and toxicity, in a feedback fashion since endotoxin and cytokines increase serum cs. increased tnf production was also observed in mice where the hypothalamus-pituitary-adrenal axis was blocked by chronic administration of dexamethasone, following a two-day washout. administration of cytokines acting through the gp signal transd,uction protein, including il- and ciliary neurotrophic factor, cntf potentiated il-l-induced elevation of cs. il- and cntf also induced hepatic acute-phase proteins. thus il- and cntf might have antiinflammatory activity, by potentiating the feedback responses of the neuroendocrine axis. these data indicate how complex can be the interregulatory relationships between the brain and the immune system, how they can be used to pharmacomodulate cytokine action and how their disregulation might exacerbate il- -and tnf-mediated pathologies. lipopolysaccharide (lps) constitutes a well established activator of monocytes/ macrophages (mizi) and murine b lymphocytes. the hydrophobic part of lps, termed lipid a, represents the endotoxic principle of lps. we now demonstrate that lps is also capable of inducing proliferation of human t cells at a dose of to pg/ml. the specificity of this stimulation was analysed by the following experiments: i) the synthetic hexaacyl escherichia coiltype lipid a (compound ) also stimulated human t cells; ii) the synthetic tetraacyl lipid a precursor (compound ) or the phosphono-oxyethyl analogue pe- , structures known to antagonize lps-induced monokine production in human mz, also inhibited lpsinduced t-cell proliferation. the t-cell proliferation expressed the following features: i) cd ÷-as welt as cd ÷ t cells proliferate in response to lps, ii) limiting dilution analyses reveal that the frequency of responding cells was between / to / cells; iii) purified t cells alone cannot be stimulated by lps, but need the help of monocytes. this help cannot be replaced by b cells or fixed monocytes. furthermore, for activation a direct cell-to-cell contact between t cells and monocyte is neccessary; iv) t cells stimulated with lps express mrna for il- and ifnf, but not for il- or il- (determined by pcr). in supernatants, ifnf was detectable (elisa); v) lps-activated cd ÷ as well as cd + t cells express cd , the high affinity il- receptor. our results indicate that in contrast to previous reports human t cells respond to lps with il- receptor expression, lymphokine production, and proliferation. the reactive cells appear to belong to the t, cell type, the finding that human t cells can be activated by lps is of important relevance for the understanding of the pathomechanisms of infections by gramnegative bacteria. this may lead to new strategies for the therapy of sepsis. we have recently shown that human eosinophils produce mrna for interleukin (il)- when stimulated with calcium ionophore (eur. j. immunol. ( ), ). we now present evidence that human eosinophils contain preformed il- protein although they do not express mrna for il- as measured by rt-pcr. il- protein expression was determined using specific anti-human il- monoclonal antibodies by western blotting, facs analysis and immunohistochemistry. moreover, preformed il- was re/eased into supernatant by % pure eosinophils after priming with gm-csf or il- and subsequent -min stimulation with paf, rantes, ionomycin or pma, however not with il- or il- , as measured by elisa. this observation implies that activation of protein kinase c and/or intracellular calcium mobilization are necessary events for il- release in human eosinophils. the determined amounts of preformed il- protein was higher in patients with asthma compared to normal individuals suggesting a role for eosinonhi! derived il- in asthma. since the eosinopnit is the ,,r~:=z~mmant cell in the asthmatic airways, we determined il- concentrations in bronchoaiveolar lavage (bal. ~ids from normal !i~.~ijvtduals and asthmatic patients. indeed, il- concentrations in bals from both groups were similar to those seen in the supernatants released by activated eosinophils. the role for il- in asthma remains to be determined. based on a well established rat model named activity-induced ulceration (asu) or activity based anorexia (aba), we have developed a rat model for chronic stress. male rats were exposed to a feeding schedule in order to reduce body weight by - % within days. while one group of rats was kept sedentary, the other had access to a running wheel. food restricted rats allowed to exercise developed highly increased activity as compared to ad libitum fed rats in wheels (ca. versus kin/day). they developed elevated plasma corticosterone levels ( _+ gg/dl) at their circadian peak, increased adrenal weight and decreased thymus and spleen weight as compared to control rats and weight matched sedentary rats, establishing this paradigm as a model of chronic stress. no differences in plasma acth were seen among the various groups, suggesting increased sensitivity of the adrenal glands to acth. the effect of chronic stress accompanied by hypercorticism on baseline and endotoxin-induced cytokine levels was studied in this model. under baseline conditions,splenic il- a was suppressed in both food-restricted groups. this was more pronounced in rats with access to a running wheel. il- and tnf activity in plasma was not affected. after administration of .tg/kg lipopolysaccharide (lps), tnf activity in plasma was suppressed by food restriction but there were no differences between sedentary or exercising rats. in addition, no differences were found among groups for corticosterone, spleen il-lc~ and plasma il- activity. we conclude, that the food restriction-induced hyperactive rat model is a useful model for studies on the effects of chronic stress. in this model, under basal conditions il-le~ in tissues may be subject to downregulation by glucocorticoids, whereas after lps-stimulation of cytokine production only tnf activity is regulated by fast acting feedback loop between cytokines and the hypothalamo-pituitary-adrenal axis (hpa-axis). this is supported by strong correlations between plasma tnf activity and corticosterone in stressed rats. cytokine antagonists modulate cytokine actions and it appears that a balance between production of cytokines and cytokine antagonists is important to control of host responses. recent observations show that during myocardial infarction there is an increase in circulating cytokines such as tumor necrosis factor (tnf) and interleukin (il- ). we tested the idea that compensatory increases in cytokine antagonists likewise occur and investigated changes in plasma concentrations of tnf and interleukin i (il- ) and those of their specific antagonists interleukin- receptor antagonist (il- ra) and soluble tumor necrosis factor receptor type i (s tnf r-i). we also measured plasma concentrations of ~-melanocyte-stimulating hormone (~-msh), an endogenous neuropeptide that occurs in pituitary, brain, skin, gut and other tissues. when administered to laboratory animals, this peptide has potent antiinflammatory and antipyretic activity, perhaps by mimicking an endogenous modulatory influence on cytokine actions. samples were obtained from patients with acute myocardial infarction at presentation in the coronary unit, every three hours for hours, and daily thereafter until discharge. we found elevations in the plasma cytokines il- and tnf only in a proportion of subjects whereas cytokine antagonists c~-msh, il-lra, and stnfr were elevated in all patients, o~-msh was elevated at presentation but it decreased progressively in successive tests, reaching normal values within hr whereas stnfr and l-lra peaked at - hr or later. there were significant correlations between plasma concentrations of cytokine antagonists and enzymes released from injured myocardium, including creatine kinase (ck), aspartate serum transferase (ast), and lactate dehydrogenase (ldh). the data show that cytokine antagonists increase in the circulation of patients with acute myocardial infarction likely to modulate prninflammatory effects of cytokines. objects of the study: interleukin- (il- ) is a multifunctionai cytokine known to be involved in important homeostatic processes. il- levels are increased in many pathological situations, and correlates with disease activity and patient outcome. to exert its effect il- binds to its receptor on the membrane of its target cell. this receptor is also present in a soluble form in plasma and in urine. in this study we quantitatively measured the availability of soluble il- receptor (sll- r) in biological fluids in healthy volunteers. materials and methods: blood, urine, cerebrospinal fluid (csf), and synovial fluid (sf) are obtained from healthy volunteers, sil- r and il- are measured using elisa's. both elisa's are tested for interference of sil- r mid il- . the effect of sll- r in the il- bio-assay (b ) is tested. results: baseline levels are (mean + sd): . -+ . ng/ml in serum, . -+ . ng/ml in urine, . _+ . ng/ml in csf and . + . ng/ml in sf. there is no interference of sll- r in the il- elisa or bio-assay and no interference of l- in the sil- r elisa. conclusions: in all investigated biological fluids sll- r can be found. these data provide baseline values for investigations concerning pathological situations. both elisa's described are useful tools to do these investigations. trauma-associated immune aberrations coincide with augmented release of immunoregulatory and proinflammatory cytokines. the present study examines the effect of thermal trauma on the capacity for specific (receptormediated) response of lymphoid cells to interleukin (il ) and to turnout necrosis factor ~x (tnfc . methods. bum patients (n= , -> % total body surface area) were studied weekly up to days post-injury. the limulus amoebocyte lysate (lal) test was used to measure plasma endotoxin levels. the percentage of il ~-and tnfcz-binding t(cd ) lymphocytes was assessed by flow cytometry analysis. levels of il receptor antagonist (il lra) in patients' plasma and cultures of peripheral blood ceils (pbc) were determined by immunoassay. results. plasma endotoxin concentrations were significantly (p< . ) increased up to weeks post-bum (means . + in non-surviving and . + . u/ml in surviving patients vs < u/ml in the control). within weeks of bum, the percentage oft ceils expressing receptors for tnfa and il [~ constitutively was elevated (by - fold). in contrast, the capacity for de novo receptor expression by activated pbc was reduced. serum levels of il ira were significantly increased (range . - x j pg/ml vs < . x j pg/ml in the control). in all patients, high concentrations of il lm were released spontaneously in unstimulated cultures of adherent ceils (range - x - pg/ml vs - x j pg/ml in the control). however, its secretion was decreased in lps-stimulated parallel preparations. conclusions. in the bum patient, susceptibility to the immunoregulatory effect of tnfcz and tl ~ may be modulated by infection-related products. alterations in the capacity for receptor expression and secretion of l lra may affect il -regulated biological responses including specific immune reactions. while studies suggest that il- is an important lymphokine involved in cell-mediated immunity, little is known about this mediator's role in hem-induced immunesuppression. our aims, therefore, were to determine: i) if il- contributes to depressed t-cell responses seen following hem; and ) how other agents, known to play a role in hem, effect il- release. to study this, c h/hen mice were bled to and maintained at a map of mmhg for h and then adequately resuscitated. mice were killed h post-hem to obtain splenic t-cells (nylon-wool purified). il- 's immunosuppressant role was demonstrated by the ability of monoclenal antibody (mab) to il- to markedly improve the t-cell proliferative response [ . #g the marked increase in capacity of t-cells from hem mice to produce il- was significantly reduced by treatment with either ibu or mabs. since ibu, tgf-~, as well as il- are all reported to directly/indirectly influence prostanoid synthesis, this implies that eicosanoids play a major role in inducing il- release by t-cells following hem which depresses t-cell function. the mechanisms underlying immunosuppression induced by thermal injury and alcohol ingestion are in part due to cytokine dysregulatinn. il- down-regulates production of eytokines by maerophages and may be an important regulator of the initiation of the immune response. il- has also been demonstrated to inhibit the production of no by macrophages. this study examined the alterations in eytokine production and effect of inhibition of no production on immunologic function in a routine thermal injury model. methods: balb/c mice (n= ) were randomized to groups: saline-sham(ns-sham), alcohol-sham(etoh-sham), ns-bum, etoh-bum. animals received % etoh or ns daily for days by gavage. a % full thickness bum was induced hrs after the last dose of etoh or ns. animals were resuscitated, then sacrificed days post bum. splenic lymphocytes were cultured for days with lps, and lps with two concentrations of n-monomethyl-l-arginine, a nitric oxide inhibitor (l-nmma . ug/ml, ug/ml). splenocyte production of il- , interferon-gamma, il- , pge were measured, and lymphocyte proliferative response examined. results: il- production was significantly suppressed in thermal injury. exogenous l-nmma normalized the suppression of .- in a dose-dependent manner, indicating nitric oxide may modulate il- and interferon-gamma production in thermal injury. il- production is normal in etoh-burn animals. conclusion: il- and interferon-gamma production is altered in this murine thermal injury model, and may contribute to this injury-induced immunosuppression. inhibition of no synthesis normalizes il- production and should be investigated further as an immanomodalator in thermal injury. surgery, infection and inflammation results in the production of pro-inflammatory cytokines which mediate metabolic and immunologic host responses. the aim of this study was to characterise the elaboration of cytokine release following a variety of surgical procedures. twenty one patients undergoing elective intermediate, hip, knee and major gastrointestinal surgery were studied. levels of interleukin- (i - ), interleukin- (i - ), the interleukin- receptor antagonist (i - ra) and the acute phase c-reactive protein (crp) were measured in bloods drawn , , , , , , and hours following operation. a portion of the results are shown (mean -+ sem). + -+ _+ one and two factor anova; *p< . , #p< . , §p< . , ¶p< . , for differences between groups i - was not detected at any time point. both ii-ira and i - increased after surgery. maximum responses occurred following major git and hip surgery, minimal responses were seen after intermediate and knee surgery. ii-ira levels increased within two hours and remained elevated for hours; the b-ira increase was a thousand fold greater than the rise in i - levels. i - levels increased up to hours after surgery. crp levels reflected maximum ii-ira and i - levels (r =. , p< . and r =. , p< . respectively). high ii- ra and i - levels reflect major surgery, however the ii-ira response is more rapid and of greater magnitude. the strong i - ra correlation with crp may indicate that this regulatory cytokine is itself a mediator of host responses to surgery. dept. of surgery, meath/adelaide hospitals, heytesbury st., dublin , ireland. change of il- and soluble il- receptor levels after surgery s. hisano, k. sakamoto, s. mita, t. ishiko, m. ogawa [objectives] under surgical stress, il- plays a main role in producing acute phase proteins and contributes to host defense mechanism. soluble il- receptor (sll- r) is considered to be agonistic to il- , unlike other soluble type receptors of cytokines. here we measured il- and sll- r levels in the serum and drain fluid from surgical field in order to investigate the changes of il- and sll- r after surgery and their origins. [materials and methods] serum and drain fluid samples from cases ( of esophagectomy and of gastrectomy ) were serially collected before and after surgery. il- and sll- r levels were measured by elisa. [results] ( ) serum il- : all cases reached the maximum level on pod-l, more precisely - hours after operation. ( ) il- in the drain : maximal il- levels in the drain were recognized - hours after operation, at almost the same time as serum il- . furthermore the il- values in the drain were much higher, about times, than those in serum. ( ) sll- r in the serum : all cases reached minimum levels - hours after operation and recovered to the preoperative levels a few days later (decrease ratio : . + . ~,, range : - ~'). ( ) sll- r in the drain : sll- r levels in the drain showed almost the same value and change as serum sll- r. [conclusions] ( ) il- is produced from the cells gathering around operative fields whereas sll- r is considered to be produced in the cells which do not gather around the operative fields. ( ) there may be a mechanism that down-regulates sll- r in the early stage of surgery. [objectives] il- plays an important role in host defense in the early stage after surgery. in the present study, we examined changes in il- concentration after major thoracoabdominal surgery and elucidated the effect of surgical trauma and factors influencing postoperative elevation of serum il- . [materials and methods] thirty-eight patients undergoing elective surgery of the thoracoabdomen were classified into groups according to the location of the operation. bloods and drain fluids were serially obtained and samples were frozen until measured, keukocytes were simultaneously collected for northern blot analysis. concentration of il- was measured by elisa and il- mrna was detected by northern blotting after total rna was extracted by the acid guanidium phenol chloroform method. [results] ( ) serum il- levels reached the maximum concentration on the st postoperative day in all patients. ( ) the il- peak was significantly correlated with surgical trauma as defined by the operation length and the volume of blood loss during operation (r= . , p< . , r= . , p< . , respectively). ( ) the peak concentration of serum il- in patients undergoing esophagectomy was significantly higher than in those undergoing pancreaticoduodenectomy (p< . ), despite a similar degree of surgical trauma. ( ) peak l- concentration observed in a patient who underwent esophagectomy was about fold greater in the drain fluid of thorax than in the peripheral blood. ( ) il- mrna was demonstrated in leukocytes from thoracic and abdominal exudate at , and hours after surgery. in contrast, il- mrna could not be detected in leukocytes from the peripheral blood. [conclusion] il- is mainly produced in the operative field and subsequently enter the peripheral blood to induce cytokinemia. the operation length, volume of blood loss and thoracotomy are factors influencing the concentration of cytokine in the blood. zaragoza spain age may be an important factor influencing the function of immunocompeteut cells releasing cytokines after both accidental and surgical trauma the aim of the present paper is to ascertain if patients (pts) over years old show a different serum level cytokine pattern than pts under after a standard surgical procedure considered as a "medium strength trauma". patients and methods: pts( females males)with gallstone disease were perspectively studied, pts were allotted in two groups: gr.a: pts under years(mean age: . +- )gr.b: pts over years(mean age: . _+ ). all pts underwent cholecystectomy and cholangiography. pts in gr.a and pts in gr. b underwent common duct exploration. spbintercctomy was performed in each group. on the day of surgery (pre) and on the st and th postoperative day(leo, po) : percentages of cd , cd , cd , cd and cd cells we measured by means of flow cytometry using moab. and levels of il- , il- , il- and tnf "in vivo" by elisa using moab. results: ere: cd % was . _+ in gr.a and . objectives of the study. after surgery for esophageal cancer multiple organ damage has been reported to be caused by polymorphonuclear leukocyte (pmn)-mediated injury. we measured serum granulocyte colony-stimulating factor (g-csf) and interleukin (il- ) levels to determine a role of g-csf and il- in pmn function after surgery for esophageal cancer. materials and methods. peripheral pmn counts, peripheral pmn chemiluminescence, serum g-csf levels, and serum il- levels were measured before and after surgery in patients with esophageal cancer (ec), and patients of gastric cancer (gc). esophagectomy with thoracotomy and laparotomy were performed for patients with ec, while subtotal gastrectomy with laparotomy were performed for patients with gc. results. peripheral pmn counts (p< . ) and peripheral pmn chemiluminescence (p< . ) of patients with ec were significantly decreased compared to those of patients with gc at and hours after surgery. serum g-csf levels of patients with ec were significantly (p< . ) increased compared to those of patients with gc at and hours after surgery. serum il- levels of patients with ec were significantly (p< . ) increased compared to those of patients with gc at , and hours after surgery. significant inverse correlations (p< . l) between peripheral pmn count and serum g-csf and il- levels were seen at hours after surgery. conclusion. these results suggest that many circulating pmns, which are excessively activated by g-csf and il- , may adhere to the endotherial cells and then migrate into the tissues, and cause multiple organ damage after surgery for esophageal cancer. immunnogical changes in patients with severe brain trauma receive increasing attention since morbidity and mortality ere still high. interleukin- (il- ) was previously detected in the cerebrospinal fluid (csf) during different pathologies of the nervous system ( , , ). in our study we monitored il- and nerve growth factor (ngf) production in the csf after human brain trauma. since astrocytes within the brain constitute one of the major cell type contributing to the inflammatory response through the release of cytokines and other factors after injury, we investigated the functional relationship of il- and ngf on a single cell niveau using cultured astrocytes. methods csf was obtained from patients with severe brain injury (glasgow coma score (gcs) < and ct abnormatities or gcs < over hours) after implantation of intraventricular icp monitoring device for therapeutic purpose and collected over hours csf and serum. il- and ngf were assayed by elisa. astrocytes were isolated from neonatal mouse brain as described ( ) . ngf production by cultured astrocytes was measured by elisa in the presence of csf, il- and il- antibody. astrocyte migration was tested in a chemstaxis chamber. results head trauma patients were included in this study (approved by the university hospital medical ethics board) and the csf was obtained through intraventricular catheters. high levels of il- were detected in the csf of these patients when compared to serum during the first days after brain trauma. furthermore ngf could be found inside the intracerebral compartment. csf containing high levels of il- could stimulate ngf production in cultured astrocytes. this effect could be [nhibited partially by il- antibodies, purified il- exposed to cultured astrocytes in vitro, stimulated the migratory activity of these cells in a dose response fashion. il- was found in the csf of brain injured patients, suggesting a role for this cytokine in the pathophysiology of brain injury. since astrocytes are involved in maintaining the homeostasis of the brain, we further investigated the possible role o il- on astrocyte functions, il- promoted ngf production in vivo and in vitro, thus contributing to neuronal cell survival and regeneration. furthermore il- stimulated astrocyte migration in a dose response fashion, potentially contributing to astrocytosis following brain injury and inflammation, these results show that il- represents a key cytokine in traumatic human brain injury with possible systemic effects, which are at preserlt under investigation. we studied a) the role of tnf and b) the therapeutic effect of a mab to tnf with regard to haemorrhagic shock (hs) related ,pathophysiologic alterations and mortality in rats. method: a prolonged hs was induced by bleeding to a blood pressure of - mmhg for pin followed by reinfusion of shed blood (sb) and resuscitation with two times of sb volume of ringer's lactate over rain. animals received a bolus dose ( mg/kg) of tnf mab (celltech, berkshire, uk) at min after resuscitation (tn ). the control group (n = ) was treated similar to the tn group but received ringer's lactate (con). results: at min the prolonged hs resulted in a metabolic acidosis indicated by a significant decrease of blood ph ( . + . ), hco -( . ___ . mm), and base excess (- . + . ram) values with pco ( . + . mmhg) and po ( . + . mmhg) in the tn with no difference to the con group. immediately after resuscitation ( min) plasma endotoxin levels were found to be increased in both groups ( . + . in tn vs . _ . pg/ml in con group) . prior to the treatment with tnf mab ( min) there was also no difference between plasma tnf levels of the two groups ( . + . in tn vs + . pg/ml in con group). treatment with the tnf mab at rain post-hs improved the hour survival rate to . % as compared to . % in the control group. macropathologic evaluations revealed frequency of intestinal bleeding in oniy animals in the tn vs in the con group. no bleeding in the kidneys was found in the tn but in rats in the con group. the significant increase in lung wet weight observed in non-survivors in the con (n = ) was prevented in animals which died in the tn (n = ) group (( . +_ . vs . +_ . g/kg). conclusion: our data suggest that tnf formation induced by hs in rats is an important mediator for pathophysiologic alterations leading to multi organ failure and lethality. antibodies to tnf might be a useful agent in the treatment of haemorrhagic shock related disorders. -+ n=ll*$ -+ n= _+ n= * * p< . vs baseline :~p< . no anesthesia vs anesthesia thus ) tnf production increased - fold by - hrs following trauma in unstimulated blood, but was reduced or not changed after lps stimulation, so circulating leukocytes are probably not an important source of tnf post trauma; ) anticd had no obvious effect on tnf production in unstimulated or lps stimulated blood, relative to vehicle, which suggests that the protective mechanism of anticd does not involve tnf suppression; ) fentanyl anesthesia at hrs following trauma unexpectedly decreased lps-evoked tnf production, which suggests that anesthesia alone can influence an inflammatory response. proinflamrnato~ cytokines have been shown to play a signific~t role in the pathogenesis of sepsis, which is a very common occurrence in born injury. tnfa is infrequently detected in the blood of burned patients, the ability to detect the shed receptors of stnfg has not been determined. serial serum mmples from burn patients were collected from the time of admission until death from septic shock. these samples were analyzed using an enzyme-linked immunosorbent assay (elisa) for stnfr, l-ira, tnf-a, and il-ib. the patients ranged in age from to yeas of age. the percentages of bum ranged from % - %. cytokine concenlrntions vmled from patient to padent irrespective of bum size. tnfa levels were consistentiy in the range of pgjml - pg/ml. peaks in the tnfa values were above pg/ml and were also associated with a peak in the stnfr levels. these levels began at < , pghnl within the in,st ins of injury and gradually increased with time. clinically. ti~ appearance of eytoklnes was independent of positive wound, blood, or respiratory cultures however peak values in tnfa and stnfr were ~ialed with a fluid requirnmenl levels of il-i ra were also elevated independent of clinical findings as well as extent of injury. in pl there is a significant corresponding peak in il-trn (> ~ /ml) at the same time as t/~:a and stnfr levels. we aimed to characterise the pattern of secretion of interleukin- beta l-ii ), intefleukin- (il- ) and tumour necrosis factor alpha (tnfa) in multiply injured patients and to relate these results to their clinical condition and outcome. two hourly blood samples were taken from ten patients from the time of injury until hours. cytokine levels were measured using sandwich enzyme-linked immunosorbent assays (elisas). injury severity scores (iss) were calculated and haemorrhage was assessed from the blood transfusion requirement over the hours. patients' ages ranged from to years. iss varied from to and transfusion requirement from to units. five patients died after the study period. ] ,- was raised in / patients (max level , pg/ml) but was unrelated to condition or outcome. / showed a rise in il- b (max level pg/ml) which was negatively correlated to iss (i=- . , p< . ). tnfa was raised in / (max level pg/ml). peak tnfc~ was positively correlated with iss ( = . , p< . ) and haemorrhage (i= . but p< . ). il-ib and tnfa production was mutually exclusive. there was no common cytokine profile for these patients. unlike elective surgery there was no correlation between peak ,- and severity of injury: tissue damage may not be the stimulus for the cytokine response to multiple injury. periods of ischemia or hypoxia produce endothelial damage in peripheral organs. tumor necrosis factor-alpha (tnf) plays a central role for regulation of endothelial physiology during septic events, taking influence on vascular permeability and coagulant activity [ ] . animal experiments demonstrated a synergism between hypoxia and septic shock on letality, leading to the hypothesis that low oxygen tension leads to enhanced sensitivity of target cells for tnf [ ] . radioligand binding studies with ~ odid-tnf on cultured human endothelial cells were performed after incubation in several environmental oxygen tensions (pc ) for hours. data were achieved by nonlinear regression of an idealized saturation curve according to the equation: b = n " k./( + k,); b = totally bound tnf; k,: association constant (concentration for half-maximal binding); n: number of binding sites per cell. p_o o (mm h¢i): _k, (nm}: n (molecules/cell): - . ± . _+ - . ± . + - , ± . -+ - . + . -+ presented are calculated values on the idealized curve + % percentiles. hypoxia induces enhanced binding of tnf to specific receptors on the endothelial cell surface in a time-and dose-dependent manner by a mechanism, which is not dependent on oxygen radicals, as shown by additional protocols with radical-scavenging drugs. with respect to former findings about a correlation between growth and tnf receptor affinity [ ] , these data lead to the hypothesis that enhanced tnf binding during hypoxia is due to a biochemical conversion of the receptor protein from the low affinity to the high affinity state, possibly by posttranslational phosphorylation of the binding protein by intracel)ular kinases. the proposed involvement of tnf-dependent pathways in pathogenesis of organ dysfunction and multiple organ failure after hypoxia/ischemia may provide a basis for understanding the initiation of hypoxic vascular injury, as manifested by increased permeability and prothrombotic tendency, and, thus, merits further attention. the levels of activity of circulating cytokines (ill, il- and tnf-alpha) which are believed to play important regulatory role in response to trauma are determined (by hioassays and respective anti-cytokine antibodies) in mice and rats subjected to scald injury ion c, see, ° v bsa, ld ) and ( c, see, ~ b ~^)~ , respectively. biphasic increase of cytokine activity was noted in mice: initial increase of il-i and il- , - hr following injury and of try activity hr after scald, followed by elevated levels of il-i and il- at hr, with tendency of decrease of activity at later time points. increased activity of tnf was noted hr following injury, in rats, initial, short-lived increase of il-i and tnf activity was detected lhr following injury, folowed by increase on days i and postburn. il- increase peaked - hr after scalding and levels remained elevated - days following injury. similar kinetics of appearance of proinflammatory cytokines (il-i and tnf-alpha) both in lethal and ncnlethal injury concomitant with differential profile of circulating il- activity (early,short-lived increase and later slow decrease of activity in lethal burn injury) with late persistent high levels of activity in nonlethai injury demonstrated in the present study highlight the need for investigation the relationship of these cytokines in burn-injury induced inflammation. zikica jovicic,lnstitute for medical research, mma,crnotravska , belgrade~yu. asadullah k ( ), woiciechowsky c ( ), liebenthai c ( ), doecke wd ( ), volk hd ( ), vogel s ( ), v. baehr r ( ); depts. of med. immunology ( ) and neurosurgery ( ) , medical school (char#d), humboldt university berlin, frg in patients after polytrauma or major abdominal surgery a hyperinflammatory phase seems to be followed by the development of a phase of monocyte inactivation. the latter is charaeterised by a decrease of monocytic hla-dr expression and a shift to anti-inflammatory cytokine production. as shown, by us and others, this phenomenon indicates severe immunodepression with a high risk of infection. however, the mechanisms leading to monocyte inactivation in the above mentioned syndromes may be multiple. to elucidate the influence of a selective, sterile trauma to the central nervous system (cns) on immune reactivity the neurosurgieal patient is an interesting model. initially, patients who developed a systemic inflammatory response syndrome following neurosurgery were analysed. in all of them a marked decrease of monocytic hla-dr expression was observed soon after the operation. these results suggest that neurosurgery alone can induce immunodepression and lead us to conduct a prospective study, in which we closely monitored l patients undergoing neurosurgery from the first preoperative day until at least day after the operation. hla-dr expression was decreased hi all patients to various extent only hours after surgery. in one patient only we found a persistently reduced hla-dr expression and this was the only patient to develop sepsis syndrome. this suggests that a prolonged, postoperatively decreased hla-dr expression is predictive of infection following cns trauma. in order to assess, whether a decrease of hla-dr expression was associated with a preceding inflammatory response, local cytokine release in the cns was compared with systemic cytokine release. for this purpose, paired samples of earebrospinal fluid (csf) from a vantricle drainage and peripheral blood plasma were obtained. in the csf extremely elevated futerleakin (il)- levels, peaking already a few hours after the operation were found. in plasma, by eontrast, il- ( and tnf-alpha) was detectable not until days later and only if infection was present. the antiinflammatory ili-ra, on the other hand, was also present in csf but peaked after il- and was detectable in peripheral plasma too. we believe there is an association between the inflammatory response in the cns and the following depression of hla-dr expression on peripheral blood monocytes. our results suggest that even a sterile cns-trauma by itself may contribute to general immunodepressinn leading to septic complications. the aim of this study was to evaluate the effect of haemorrhagic shock (hs) a) on total capacity of the host, and b) the circulating blood cells to produce tnf immediately after bleeding. in vivo studies: baboons were subjected to a limited oxygen deficit ( - ml/kg) hypotension phase (mean arterial pressure = map of - mmhg for - hours followed by adequate resuscitation). rats subjected to hs (map of - mmhg for rain followed by reinfusion of shed blood and fluid resuscitation) were challenged with endotoxin ( ~g/kg i.v.) at the end of shock (rhs group). the control group (rco) received the same dose of endotoxin as rhs group but without prior bleeding. in vitro studies: whole blood (wb) obtained from both baboons and rats before and at the end of hs were incubated with endotoxin ( ng/ml) for hrs at °c. results: at min post-lps challenge we found significantly higher plasma tnf levels in rats that were subjected to hs prior to the endotoxin challenge as compared to the control group ( _+ vs + pg/ml) . after hs the tpc was significantly decreased in in vitro stimulated cbc of both rats ( + post-hs vs + ng tnf/ml pre-hs) and baboons ( ± post-hs vs ± pg tnf/ml pre-hs). in contrast, the il- productive capacity was increased in baboons cbc (not yet analysed in rats) stimulated at the end of hs ( ± pre-vs ±_ pg il- /ml post-hs). conclusion: from our data we suggest that despite of down regulation of the cbc to produce tnf the overall tpc is enhanced at the early stage of i-is. with regard to the related literature (chaudry's group) it can be assumed that among the macrophage/monocyte populations, as the main source only the kupffer cells (kc) exhibit enhanced tnf production capacity following haemorrhage. the mechanisms of down/up regulation of cytokine response of cbc and/or kc following hs remain to be examined. d. eg~er, s. geuenich °, c. dertzlin~er °, e. schmitt*, r. mailhammer, h ehrenreich #, p. drrmer, and l. h mer gsf-instimt fox experimentelle h~znatologie, °medizinische kliulk iii, klinikum groghadern, munich, *institut for immunologic, johannes gutenberg universit/it, malnz, and #psychiatrische k/in& der georg-aagust-universi~t, grttingen, germany. it has been shown previously (ehranreich et al., , new biol. : ) that mouse bone marrow-derived mast cells (bmmc) synthesize and secrete endothelin- (et-i) and express eta-type endothelin receptors (eta). so far, however, no functions of et- /et a in bmmc have been described. in the present study we investigated the effect of exogeneously administered et- on the release of histamine, serotonin, and leukotriene c (ltc ) by primary mouse bmmc (in vitro age: weeks) caltured with different recombinant mttrine cytokines (interleukin (il- ) and/or kit ligand (kl) in the presence or absence of il ) for two weeks prior to activation. et- ( x - to lxl - m) induced an extremely rapid (_<lmin) and dose-dependent release of histamine and serotonin (up to % and % of total mediator content, respectively, comparable to ige/ag-indueed mediator release) from bmmc cultured with il- and il- . only when cultured in the additional presence of il- rather than in medium containing kl or kl plus il- alone, bmmc released histamine and serotoaln upon challenge with et- .furthermore, et- stimulated ltc biosynthesis up to -fold in bmmc cultured in the presence of il- . in contrast, the peptide was without major effect on ltc biosynthesis in bmmc culturd without il- . the release of histamine and sereotonin was not altered if bmmc were preincubated for i h with il- prior to activation with et-i, suggesting that a differentiation process rather than a functional priming effect had been initiated by ]l- . et- ( " m) -induced histamine and serotouln release from bmmc was inhibited by an eta-specific antagonist (cyclic id-asp-pro-d-val-leu-d-tel ) in a dose-dependent manner, with a complete inhibition observed at an antagonist concentration of - m. crude peritoneal cells (containing - % serosal mast cells) obtained from normal balb/c-mice released % histamine upon challenge with et- ( - m; rain). taken together, these resu/ts demonstrate that et- can directly function as a histamine and serotohin secretagogue and as a stimulator of ltc production in mast cells. il- appears to be involved in the differentiation of immature mast cell prec~trsors towards an et-l-reactive functional phenotype. when inflammatory reactions are advanced, type ii phospholipase a (type ii pla ) is produced in high levels by various cells at the site of inflammation. cytokines such as tnf-a and il-i activate type ii pla and promote the production of eicosanoid, which is one of the mechanisms by which they enhance the inflammatory reaction. in the present study, the blood levels of type ii pea , endotoxin, tnf-c~, il- and il- were determined in patients with sepsis to examine the relationship between these levels and the patients' pathological conditions. the levels of type ii pla and tnf-a in these patients were . ± . ng/ml and . ± . pg/ml, respectively, the two parameters being significantly correlated (r = . , p = . ). there were also a significant correlation between the level of type ii pla an il- (r = . , p = . ). there was no significant correlation between the level of type ii pla and il- . these in vivo findings suggest that tnf-a may be involved in the production of type ii pla . a. filzmaver, g. reisbach, e. schmitt °, r. mailhammer, and l. hiittner. gsf-iustitut ff~r experimentelle h~imatologie, munich, and °iustitut fttr immunelone , johannes gutenberg universit~t, mainz, germany the product of c-kit, a transmembrane tyrosin ldnase receptor, and a corresponding kit ligand (kl) are critically involved in the control of different hemopoietic cell lineages including the proliferation, maturation, migration, and function of mast cells. it has been reported previously that interleukin (il)- down-regulates kit receptors in human primary myeloid leukemic cells and in a human mast celt line (sinaber et al. , j. immunol. : ) . transforming growth factor (tgf) gl, was also found to down-modulate c-kit mrna and kit receptor proteins in human aml blasts, a mechanism probabely contributing to the anti-proliferative effect of tgfih on kl-stimulated aml ceils in vitro (de vos et at. , cancer res. : ) . in porcine endothelial cells transfected with a retroviral construct carrying the human (hu) e-kit gena, exogenous hu kl transiently down-regulated kit receptors (blume-jeusen et al. , embo j : ) . in the light of these previous findings we analyzed the effects of these exogenously applied cytokines (il- , tgfgl, kl) on kit receptor expression and kl-mediated proliferation and chemotactic migration of primary mouse bone marrow-derived mast cells (bmmc) (in vitro age: weeks). our results show that in bmmc cultures initiated with recombinant (r) marine (mu) il- the additional presence of rmull- for or days did not change the expression of kit protein (assessed by facs analysis with the anti-mouse c-kit antibody ack- ) nor kl-mediated proliferation or chemotaxis. in contrast, il- syeergistically increased kl-stimulated growth of bmmc in a short-term proliferation assay (mtt-tes . pre-incubation of bmmc with rhutgfl~ ( . , . , or . ng/ml) for h had no effect on kit receptor expression, although tgffil at concentrations of . - . ng/ml completely suppressed the proliferative action of kl on these ceils. similar anti-proliferative effects of tgfg were observed in various factor-dependent mast cell lines stimulated with different mast cell growth factors (il- , i,- , il- , and/or il- ). moreover, pre-incuhation ( h) of bmmc with tgf-gl (> pg/ml) significantly enhanced spontaneous undirected cell movement (chemokinesis) and synergistically increased il- -or kl-induced chemetaxis. when bmmc were preancuhated with rmukl ( ng/ml) for , . or days, a transient down-modulation of kit receptors with a maximum effect on day was demonstrated by facs analysis and correlated well with a decreased chemotactic response of these cells. in conclusion our results show that neither il- nor tgfi affect expression of kit receptors in primary murine bmmc. it is reasonable to suggest that c-kit expression is controlled in a cell type-specific manner.interestingly, tgfgl is obviously able to dissect the proliferative from the migrational signal transducted by kl in these cells. objectives of the study: antisense strategies using dna-otigonucleofides (odn) to modulate the cytokine response are presently under investigation. odn are thought to act very specifically with little or no relevant negative side effects. we now report that odn unspeeifically protect wehi cells from tnf-mediated cytolysis. material and methods: wehi subclone ceils ( x ), that are highly sensitive to the cytolytic activity of tnf, were grown on -well culture plates in rpm medium. after hours, phosphorothioate(ps)and partially ps-modified-odn as well as phesphodiester-odn ( - bp) were added ( . , and pm). four hours after incubation with odn, ce(i lysis was induced by recombinant murina tnf. after hours the plates were washed and stained with crystal violet cell lysis was determined by reading the absorbance (abs) at nm. results: wehi ceils incubated with tnf ( - ng/ml) were completely lysed after hours ( % abs). interestingly, wehi cells incubated with tnf and odn resisted complete lysis, eg cells incubated with . ng/ml tnf and jm odn showed still % of the absorbance observed in control ceils without tnf ( % abs). the protective effect of odn started at . pm, reached a maximum at ,um, and diminished at jm. with increasing amounts of tnf the protective effect of qdn decreased and no protection was detectable at ng tnf per ml conclusions: dna-oligonucleotides were found to unspecifically inhibit tnf-induced cytolysis. we hypothesize, that this protective effect of qdn results from an inhibition of the binding of tnf to its receptor, or from interference of odn with the subsequent signal transduction mechanisms. as a consequence, to discriminate the specific effect of odn in biologic systems, several control odn should be used. secondly, whether dna released by degradation of tumor cells or leukocytes can significantly impair tumor-and immune-defense mechanisms merits further investigation dr. med. michael meisner, institut for anaesthesiologie der universitat erlangen-nqmberg, krankenhausstral~e , d- erlangen. in this study we investigated the involvement of serine protease and free radical generation in the systemic release of tumor necrosis factor-alpha (tnf) and interieukin i(il- ), in the sepsis model of lipopolysaccharide (lps, mg/kg i.p.) induced hepatitis in galactosamine (gain, rag/mouse, i.p.) sensitized mice. treatment of gain-sensitized mice with lps (gain/lps) led to dramatic increase in serum cytokine (tnf and il-i) ievels and transaminase activity at hr and hr respectively. pretreatment of serine protease inhibitor, c~jantitrypsin (a j-at, mg/kg i.p.), rains prior to gain/lps treatment, fully protected the animals against the hepatotoxic challenge with significantly reduced serum tnf and il- levels. in order to block and scavenge superoxide generation, the mice were pretreated with xanthine oxidase inhibitor, allopurinol (al, x mg/kg i.p.) and pyran polymer-conjugated superoxide dismutase (sod, x unit/mouse i.v) r spectively. pretreatment with al and sod ( and hr prior to gain/lps) prevented gain/lps hepatitis and blocked lps induced released of tnf and il- into serum of the mice. the protective agents like cq-at or al/sod did not protect the mice against th~ hpp~totoxi£ ch~llpn-e indllee b'~ th~ recombinant mmlse tnf-o' ( . ~/rno~e j.p.) ~d oi~lps ~ caln-.~dlfa%aed mlce. it-l cett~aged la tnf (x/gain treated mjde was not detectable in animals pretreated with oq-at or al/sod. our study suggests that a serine protease sensitive to cq-antitrypsin is responsible in regulating tnf release, possibly by proteolytic cleavage of a tnf-precursor or membrane bound tnf. in addition our evidence suggest that the balance of extracellular protease/antiprotease activity may be regulated by free radical generation, possible superoxide anion, resulting in inactivation of the antiprotease. il- release may be subsequent to tnf release. objective: during sepsis one can observe a dramatically impaired production of proinflammatory cytokines like the tumor necrosis factor alpha (tnf-a), interleukin i-alpha (il-la), intedeukin i-beta (il-i&) and interferon gamma (if~) upon in vitro stimulation of circulating cells. however there is also evidence of a decreased ability to produce cytokines in other immuno-deficient states. in this study we compared the capacity to secrete proinflammatory cytokines upon in vitro stimulation of patients in severe sepsis and patients with malignant tumors. methods: heparinized blood samples of ten patients ( + years) in severe sepsis (sepsis score > according to e}ebute and stoner) were drawn at onset of disease, from fifteen patients with solid growing carcinoma ( + years) blood was drawn at diagnosis prior to any therapy. controls were obtained from fifteen healthy volunteers. pl of whole blood were incubated either with / of a standard medium or with pl of a standard medium and pl of phytohemagglutinin (pha) a potent mitogen. after an incubation period of hours plasma concentrations of tnf-a, il-la, il- and if-~ were determined by elisa. comments: our results suggest that down-regulation of cytokine secretion or of cell responsiveness to non-specific mitogens during sepsis has occurred. we observe a similar phenomenon for the group of carcinoma patients vs control significant for stimulated tnf-a and stimulated if-t. sustained immunological interactions between tumorcells and cytokine producing cells could effect responsiveness of the latter, a general increased immuno-tolerant state in patients with carcinoma has to be discussed. however we found significant differences between sepsis and cancer concerning the in vitro capacity of responsable cells to produce il-la and il-i#. the dramatically decrease of the ability to produce il-i upon in vitro stimulation could be more sensitive for a septic state than stimulated tnf-a or if- ,. objective: tumor necrosis factor alpha (tnf-a) has been implicated as a central mediator of sepsis and its sequelae. increased systemic levels of this cytoklne seem to be correlated with severity of sepsis and outcome. however mechanism of action and metabolism of tnf-g are not fully understood. in most studies blood samples for tnf-a determinations are obtained either by peripheral venipuncture, a central venous catheter or by an indwelling arterial catheter. very often blood samples are taken in different manners within the same study. in this study we measured circulating tnf-a and the amount of tnf-a released upon in vitro stimulation in arterial and central venous blood. methods: heparlnized arterial and central venous blood samples of ten patients ( males, females, mean age +_ ) with severe sepsis (sepsis score > , elebute and stoner} were drawn on day , , , , and of disease. blood was immediately placed on ice and processed within hour. pl of whole blood were incubated with pl rpmi-medium supplemented with antibiotics and l-glutamlne or with pl of rpmi-medium and pl phytohemagglutinin (pha) a potent mitogen. after an incubation period of hours samples were centrifuged and plasma was harvested and stored at - ° celsius before assessment of tnf-a concentration by elisa. statistical analysis was performed with the paired student-t-test. results: we found a significant difference (p < , ) for circulating mean arterial tnf-a concentration ( pg/ml _+ sem} and central venous tnf-a ( pg/ml +_ sem). upon in vitro stimulation there was also a significant difference (p < , ) between released arterial tnf-~' { pg/ml _+ sem) and venous tnf-a ( pg/ml +_ semi. conclusions: these results are difficult to interprete but could reflect the influence of pao and sao on tnf a release. it could also be the result of different concentrations of tnf-o release influencing factors like for example endotoxin, interferon-f or prostaglandin. a possible pulmonary and/or a hepatic metabolism of tnf-n and tnf-a producing cells cannot be ruled out. however for better interpretations of tnf-a release in septic states it is necessary to use either arterial or venous blood samples. early inflammatory processes following trauma and/or infections were found to be associated with the secretion of high amounts of proinflammatory cytokines. besides intedeukin-t (il- ), tumor necrosis factor-a (tnf-c and interleukin- (il- ) the multifunctional cytokine intedeukin- (il- ) was described to be a central regulatory element of the primary cellular and humeral defence reaction. the previously described close temporal correlation of pathologically elevated il- -concentrations and the extracellulary release of lysosomal enzymes from activated pelymorphnuclear neutrophils suggests, that il- may be a potential substrate of these preteases. the serine preteases elastase (ec . . . ) and cathepsin g (ec . . . ) derived from the azurophilic granules were assumed to be mainly involved in unspecific proteolysis at sites of inflammation by cleavage of structural as well as soluble proteins at random sites, if the inhibitory potential is decreased. the possible proteolytic activity of elastase and cathepsin g toward the proinflammatory cytokine interleukin- (il- ) was investigated. the addition of purified neutrephil elastase and cathepsin g to recombinant human il- leads to a rapid sequential degradation in vitro. at least two intermediate products could be detected by silver staining and western blotting following protein separation under reducing conditions. the serine protease inhibitor g-anitrypsin was shown to prevent the proteolytical degradation of intedeukin- . furthermore the loss of the biological activity of both, recombinant and natural human il- , was demonstrated by determination of the capacity of protease-treated il- to stimulate hybddoma growth ( td bioassay). these data suggest a possible downregulation of pathologically elevated il- levels by proteolytic activity of extracellulary released enzymes at sites of inflammation. the aim of the study was to compare circulating levels of three cytokines -il- , il- , _- -between critically ill subjects who developed gram-negative sepsis and who did not. materials and methods: the patient population consisted of patients admitted to an intensive cars unit, with different underlying diseases. sepsis diagnosis was given according to pre-estabilished cdteda. nineteen cases were enrolled in sepsis group, twenty in control group. serum sampling was collected in sterile tubes at study entry and every three days until study dismissal. serum concentrations of il- , _- and il- were measured using commercially available test kits, based on the dual immunometric sandwich principle. results: the causative patogens of sepsis were: pseudomonas aeruginosa, acinetobacter, eseherichia co~i, serratia marceseens, proteus mirobilis and citrobacter freundl the time of observation was equal to days, for a total of four tests performed (to, tl, t , t ). i .- was not detected in any samples. the serological profiles of the two cytokines .- and _- were similar; augmented levels were found at study entry and throughout the observation period, peaking at t and decreasing at t . however, in patients with sepsis, il- and _- concentrations were significantly higher in respect to control group. conclusion: our observations shown that in icu patients increased il- and il- release may be induced by cdtical illness; however, in subjects in which sepsis occurred, il- and il- production appears more significantly elevated, suggesting a role of il- and _- in the pathophysiology of sepsis. the fact that ii. objective: to check whether continuous veno-venous haemofiltration (cvvh) could remove the cytokines, namely tumour necrosis factor alpha (tnfc and interleukin (il- ) from the circulation of critically ill patients with sepsis ad multiple organ failure (mof). setting: the intensive therapy unit of the medical school teaching hospital. patients: nine critically ill patients with sepsis and mof treated with cvvh. methods: blood samples were collected before the cvvh had been started. then, blood and ultrafiltrate samples were collected simultaneously after hours and every hour. tnfct and il- levels were measured using the bioassays with cell lines wehi- ci and td , respectively. other data were recorded from the patient notes and intensive therapy unit charts. results: no measurable concentrations of tnfct were detected in either blood or ultrafiltrate samples. il- was found in all the patients' plasma samples and five patients' ( . %) ultrafiltrate samples. the il- blood level ranged from . to . u/ml (mean . , sd . ). the il- level in positive ultrafiltrate samples ranged from . to . u/ml (mean . , sd . ). conclusions: our preliminary results suggest that il- is present in bloodstream of septic patients. we assume we could not detect tnfa in any sample because we usually started observations when septic state had developed. cvvh could extract cytokines from the circulating blood. it remains under discussion, whether that extraction may be beneficial to patients with mof. the pattern of some significant cytokines tnf, il- and il- and their pharmacomodulation were evaluated in an experimental model of polimicrobial sepsis induced in cd- mice by cecal ligation and puncture (clp) in order to understand their roles. this model of sepsis, which resembles the clinical situation of bowel perforation, was also compared with that induced by administration of pure endotoxin (lps). tnf was detectable in serum and tissues during the first h with a peak h after clp at a significantly lower level than after lps. il- was measurable in serum only after h, significantly increased in spleen and liver after and h and in mesenteric lymphonodes from to h after clp compared with shammice. il- was significantly increased in serum throughout the first h after clp. pretreatment with dexamethasone (dex), ibuprofen (ibu) and nitro-l-arginine (n-arg) significantly reduced the survival time while chlorpromazine (cpz) and tnf did not affect it. only the antibiotics and pentoxifylline (ptx) significantly increased the survival in clp. however cpz and dex protected from lps-mor~ality. in conclusion, by inhibiting tnf with dex, cpz, ptx a reduced, unchanged and increased survival time was observed and by increasing tnf with ibu and tnf administration the survival was decreased or unchanged respectively suggesting that the modulation of this cytokine does not seem to play a significant role in clp unlike lps_ moreover the negative effects of ibu and n-arg suggest an important and protective role by prostaglandins and no in clp. to gain more insigths on the contribution of tnf~, il-i~ and if to lps toxicity, we explored the time-course of the cytokine production in ealb/c mice given different doses, from the lethal (= ld ) to the sublethal (= / ld ) of three different lps (e.coli oiii:b and :b ; p.aeruginosa r ) endowed with different degree of toxicity cytokines were measured in serum and organs with specific elisas up to i h after lps administration. results demonstrate that i) circulating and organ levels of tnf~ do not reflect lps toxicity. in fact, the lethal dose of lps :b induced as much tnf~ as the sublethal dose of lps :b ; furthermore, lps r , whose cytokine inducing capability is far lower than that of lps from e.coli, induced higher tnf~ levels at the sublethal than at the lethal dose. in addition, policlonal anti tnf ab, that were able to protect mice from e.coli lps induced mortality, failed in mice treated with lps r ) circulating il-i~ levels are generally low and increase significantly only in muribond animals. on the contrary, in spleen and lung very high levels of il-i~ are persistent from i to h post lps administration moreover, the treatment with mgr of neutralizing policlonal anti il-i~ ab, did not modify survival in lps challenged mice. ) circulating and organ levels of if are proportional to the dose and degree of toxicity of all the administered lps even if lps r was again a less efficient cytokine inducer than lps from e.coli. csa is an immunos~ppressive drug, able to inhibit gene expression for many cytokines, including if . to study the effect of cytokines modulation on lps toxicity, csa was administered to mice twice at the oral dose of i mg/kg before the challenge with lps. mice were monitored in terms of mortality and tnf~, il-i~ and if production. together with the total ablation of if , the strong reduction of tnfu and unmodified il-i~ levels, a significant increase of lps toxicity was also observed. these results suggest the hypothesis that the numerous factors that jointly mediate lps toxic effects, can also be protective, the final outcome depending on their relative ratio rather than on the absolute amount interleukin- (il- ) mediates the septic shock syndrome and affects intestinal secretion in vitro. we studied the intestinal production of il-t and its effects on diarrhea during endotoxic shock. cd- mice were randomized to mg/kg e.coli :b lps or saline infusion (i.p. or i.v.). diarrhea invariably occurred following lps infusion. mice were sacrificed at , ', lh, . h, h, h, h, and h ( mice/group/time-point). the small bowel was compressed and the intestinal contents were weighed and expressed per g sb weight. the small (sb) and large bowels (lb) were eventually frozen, weighed, and homogenized for either cytosolic protein or total rna. il-i~ (cell-associated agonist) was measured with a radioimmunoassay specific for mouse il-l~ (detection limit pg/ml) and expressed as ng/g weight + sem (lowest detectable amount ng/gwt). northern analysis of total rna and in sfu hybridization of paraformaldehyde-fixed frozen tissue were done with [ ~- p]-iabeled mouse il-lc~ cdna probes. only sb had il-i~ constitutively present ( . + . ng/gwt). lps i.p. or i.v. induced elevation of il-lc¢ in both organs in a biphasic pattern; lps i.v. induced -fold more il-i~ than lps i.p. following lps i.p., il-i~ in sb was . + . ng/gwt at lh, reached maximal levels at . h ( . -+ . ng/gw-i) and returned to baseline at h. saline controls maintained their constitutive il-i~ levels. sb had fold more il- ¢ than lb and identical kinetics, but lb showed a clearer doseresponse. northern analysis of sb-total rna showed induction of il-i~ mrna by lps in correlation with il-lc¢ kinetics. il-i~ mrna producing cells were mononuclear cells in the lamina propda and epithelial cells at the bottom of the crypts of ueberkuhn. mucus and fluid were increased in the small bowel post-lps in correlation with intestinal il-lc~ kinetics (r = . ). separate mice were pretreated with saline i.p. orthe il- receptor antagonist (irap, mg/kg bolus i.p.) and were challenged rain later with . mg/kg lps i.p. or saline i.p. specific blockade of il- by irap decreased intestinal secretion at h and h post-lps challenge (p<_. . , student's-t-test). these data indicate that local (intrinsic) intestinal il-i~ mediates sepsis-induced intestinal changes. inflammatory cytokines initiate the host response to endotoxemia, causing severe physiological and hemodynamic changes which may lead to septic shock. among the regulatory systems that play an important rote in controlling host inflammatory responses is the pituitary. it has been known for many years for example, that hypophysectomized animals are extremely sensitive to lps lethality. while investigating the possibility that protective, pituitary mediators might explain this phenomenon, we identified the cytoldne mif to be a specific secretory product produced by pituitary cells in vitro and in vivo after lps challenge. analysis of serum mif levels in control, t-cell deficient (nude), and hypophysectomized mice revealed that pituitary-derived mif contributes significantly to the rise in serum mif that occurs after lps administration. of note, pituitary mif content ( . % of total pituitary protein) and peak serum mif levels ( - ng/ml) were determined to be within the range observed for other pituitary hormones that are released after pituitary stimulation. to investigate a possible beneficial role for mif in septic shock, we co-injected mice with purified, recombinant murine mif (rmif) together with lps ( mg/kg). surprisingly, rmif markedly potentiated lps lethality compared to control mice that were injected with lps alone ( % vs. %, p = . ). to confirm these results, mice were treated with anti-rmif antibody prior to injection of a high dose of lps ( . mg/kg). anti-rmif antibody fully protected mice against lps lethality, increasing survival from % to % (p = . ). serum levels of tnf,~, the first cytokinc that appears in the circulation after lps challenge, were reduced by . _+ . % in anti-rmif-treated mice. we conclude that pituitary derived mif contributes significantly to circulating mif in the post-acute response in endotoxemia and may act in concert with other pituitary mediators to regulate both pro-and antiinflammatory effects. moreover, mif may play a critical regulatory role in the systemic host response in septic shock. our results suggest that anti-rmif antibody might be of potential therapeutic use in the treatment of septic shock. although anti-interleukin- (il- ) antibodies and il- receptor antagonist have been shown to improve survival in animal models of endotoxemia and abrogate the lethal effects of tnf, the presence of il- in the serum does not correlate well with outcome. we hypothesized that this may be because il- acts mainly in a paracrine fashion and is metabolized before it diffuses into the circulation. methods: we measured the il-i~ mrna expression with the differential reverse transcription polymerase chain reaction (rt-pcr) using g-actin as internal standard in the peritoneal macrophages and lung tissue in normal controls and mice after cecal ligation and puncture (clp). clp resembles human intra-abdominal sepsis in that it is characterized by very slight elevations of serum il- levels. results: il-lg mrna levels after clp are expressed as % of normal (mean+sem, n= in several experimental models of infection exacerbation of disease was observed, when infected animals were depleted of tuajor necrosis factor (tnf). after sublethal cecal ligation and puncture (clp) leading to peritonitis and sepsis the survival of mice also critically depends on tnf as demonstrated in earlier studies, when clp-treated mice injected with anti-tnf antibody died, whereas mice injected with a control antibody survived after clp (echtenacher et al. , j. inununol. : ) . from a panel of different cell types (macrophages, neutrophils, t lymphocytes, natural killer cells, mast cells) able to produce tnf upon activation~ the mast cell is apparantly the only one capable of storing in cytoplasmic granules preformed tnf-ct which is rapidly released following challenge. in the present study-we analyzed serum tnf after lps injections as well as the outcome of clp in severely mast cell deficient mutant mice (wav v) as compared to syngeaeic wild-type littermates (+/+). we proposed that concentrations and/or kinetics of serum tnf should be different between wavv mutants and wild-type mice, if mast cell-derived tnf significantly contributes to the rise in serum tnf levels following systemic stimulation with endotoxin. although similar levels of increased tnf were detected in the sera of both genotypes after and hours of lps injection ( btg/ . ml / mouse i. p.), mast ceil-deficient mice indeed showed decreased serum tnf levels iron after injection amounting to only to % of the concentrations observed in the corresponding sera of normal wildtype mice. in the clp model of septic peritonitis we found that mast celldeficient mutant mice were dramatically more sensitive to clp than syngeneic normal mice resulting in % mortality in w/w v versus % mortality in +/+ mice . days after initiation of clp. further experiments with w/w v mutants selectively reconstituted with cultured bone marrow-derived mast cells from normal syngeneic wild-type mice and the use of an antibody specifically blocking the action of tnf tn vivo should clarify a potential protective function of mast cells in this model of septic peritonitis. interleukin- (il- ) inhibits cytokine production, including tumor necrosis factor (tnf), by lipopolysaccharide (lps)-aetivated maerophages. we recently observed that lps injection (e.coli :b , gg ip) into balb/c mice induces the rapid release of circulating il- ( ± u/ml at min). blocking endogenous il- using monocional antibody (jes - a , mg, h before lps) resulted in a massive increase in tnf production ( ± in lps+anti-il- treated mice vs ± ng/ml in lps alone, p< . , n= to mice per group) and an enhanced lps-induccd lethality ( % vs % in anti-il- +lps or lps alone respectively, p= . , n= mice per group). irrelevant igg rat monoclonal antibody (lo-dnp) did not influence neither tnf production nor lethality associated with endotoxin shock. this led us to study the production of il- during human septicemia. plasma samples were obtained from patients with gramnegative (gns, n= ) or gram-positive septicemia (gps, n= ) and from healthy volunteers. among these patients, suffered from septic shock at the time of sampling. il- levels were measured by elisa (detection limit: i pghrd). we found that patients ( %) had increased il- plasma levels (range to pg/nd). patients with gps had il- levels similar to the ones observed in gns (median: vs . pg/m, respectively). patients with septic shock had higher il- values (median: pg/ml) than septicemic patients without shock ( pg/ml, p= . ). no il- was detected in plasma from healthy volunteers. we conclude that il- is produced daring human septicemia. our experimental data suggest that il- might be involved in the control of the inflammatory response induced by bacterial products. dr arnand marchant, immunology department, hopital erasme, route de lennik, brussels, belgium. to provide information about the role of tnf in sepsis and mods we measured tnf and stnfr-i levels in septic patients and investigated if there is a relation between plasma concentration of these molecules and the severity of sepsis evaluated by two scores (apache i and sss). patients and melhods: septic patients fullfilling sepsis criteria of american college of chest physician and society of critical care medicine were studied. tnf-cc and stnfr-i ( kda) were measured by enzyme immuneassays (norms values = + pg/ml and . _+ a ng/ml respectively). results: the mean tnf and stnfr-i values for each patient (mean+sd) were + pg/ml and . + . ng/ml respectively. these values are approximately seven and ten times greater than those observed in normal healthy volunteers (p< . ). mean tnf concentrations for each patient were significantly greater in non survivors ( + vs _+ pg/ml p< . ); stnfr-i levels also were greater in this group, but the difference was not statistically significant ( . + . vs . _+ . ng/ml). plasma tnf and stnfr-i concentrations were significantly correlated (r = . p< . ). mean tnf levels were significantly correlated with apache ii (r = . p< . ) and sss (r = . p<o. ); stnfr-i levels were likewise correlated with both scores (r = . p< . and r = . p< . respectively). tnf and stnfqgi levels increase with the number of dysfuctional organs; in particular tnf and stnfr-i increase when hemodynamics deteriorate and kidney failure ensues. conclusions: the correlations between tnf and stnfr-i levels and sepsis severity scores suggests that tnf is involved in sepsis and may influence the occurrence of mods and finally clinical outcome. tnf and stnfr-i are in fact especially increased when mods occurs. in particular their concentrations are elevated when cardiovascular system and kidney failure ensue, suggesting that tnf can have a direct role in hemodynamic derangements caused by sepsis and that kidneys are involved in tnf and stnfr-i excretion. lif is a pleiotropic cytokine that has been implicated in the pathogenesis of sepsis in animal models. we conducted a prospective study in septic patients to correlate lif plasma levels with patient's clinical and biological data (among them il- ). plasma was drawn daily from day one to .ten and lif presence was determined with a specific elisa and with the dai,a bioassay (sensitivity of pg/ml and ngml respectively). risk factor associated wftt~ with elevated lif plasma level was determined by an univariate analysis. a multivariate stepwise logistic regression analysis was subsequently performed with a bmdp statistical software. lif was detected with the elisa and with the bioassay in and out of the patients, respectively. lif peak plasma levels were statistically associated with high creatmin levels, temperature and il- . multivariate regression analysis showed that high serum creatinin level was the major independent risk factor associated with elevated lifplasma levels. this correlation was also found for il- . peak plasma levels of both lif and il- correlated inversely with patients survival duration. cox's analysis for plasma levels of lif > pg/ml yelded a hazard ratio of [exp ( . )= . ]. our study indicates that lif levels were associated with clinical and biological parameters of illness severity and significantly increased (cut-off value pg/mi) in patients with fatal outcome. current consensus exists about the central role of tumor necrosis factor (tnf) alpha in initiating the systemic inflammatory response syndrome (sirs). a correlation with sirs has inconsistently been found. tnf effects its pleiotropic reactions upon two distinct cellular receptors. soluble extracel]ular fragments of the human kda tnf receptor (stnfri) and the kda receptor (stnfrii) are detectable in the circulation. the kinetics of these endogenously produced tnf-inhibitors were measured to evaluate their role in patients with sirs. fourteen patients of an operative icu were included with the diagnossis of sirs (mean apache ii score: points). serial blood samples were obtained within h after diagnosis of sirs, every hrs for the first hrs and every hrs thereafter until patients died or recovered. soluble tnfri and stnfrii were assayed by an enzymed-linked immunological binding assay. soluble tnfri and ii could be detected in all samples with a significantly higher level (p<o,o ) compared to healthy controls (normal value: tnfrh , ng/ml; tnfrii: , ng/ml). the serum concentration of tnfri ( , ng/ml) as well as tnfrii ( , ng/ml) were significantly higher in nonsurvivors (n= ) compared to survivors ( , and , ng/ml; n= ) at the onset of sirs and during the course of the inflammation response (p< , ). a positive correlation exists between both receptors (r- , ; p < , ). increasing levels and maximal values of stnfri ( ng/ml) and i ( ng/mi) were detected only in patients who died. the serum concentrations of patients who recovered did not change and are remaining at the initial level. tnf alpha bioactivity was detected in out of patients. no significant correlation exists between the concentration of both receptors and tnf alpha as well as the apache ii score at the onset of sirs. elevated serum concentration of stnfri and are found in patients with sirs. these naturally occuring antagonists reflect the inflammatory process. the measurement of soluble tnf receptor levels may be useful in monitorina sirs and in the prediction of outcome. - is given to patients with advanced melanoma or renal carcinoma. however, this therapy is accompanied by severe side effects, including the vascular leak syndrome (vls) that closely resembles septic shock. to investigate the involvement of cytokines and phospholipase a z in the pathogenesis of the vls we collected serial plasma samples from patients during the first hours after administration of il- . in these patients we monitored temperature, blood pressure and heart rate and assessed levels of the cytokines tnf, il- and il- using immuno assays. in these plasma samples we also measured phospholipase a activity using an enzyme activity assay, since this enzyme is beleived to play a major role in the generation of lipid mediators. we demonstrate that during il- therapy the cytokines tnf, il- , and il- are produced and that the release of these cytokines is followed by an induction of phospholipase az activity in the plasma of these patients, we further discuss the role of these mediators in the development of the vascular leak syndrome observed in patients receiving il- . objectives of the study: sepsis caused by candida albicans (ca) is no longer a clinical rarity but a common consequence of immunosuppression and surgery, and is associated with high mortality. tumor necrosis faetor-c¢ (tnf-<~), interlcukin-lg (il-lg) and interleukin- (il- ) are thought to play an important role in the pathogenesis of the sepsis syndrome. we therefore studied the in vitro production of tnf-<x, il-ib and il- by human peripheral blood mononuclear cells (pbmc) stimulated by ca compared to stimulation by bacterial lipopolysaccharide (lps). materials and methods: pbmc were isolated from venous blood of healthy volunteers and cultured at a concentration of . • ~ eells/ml in culture medium with a dose-range of either heat-killed ca or lps. supernatants were harvested after hours. using elisa, tnf-c~, il-ib and il- concentrations were measured. ca was isolated from a patient with ca sepsis and cultured under sterile conditions. results: ca and lps stimulate the production of tnf-~t, il- ] and il- by human pbmc. we observed a dose-dependent synthesis of these three cytokines in human pbmc. tnf-c¢, il-ib and il- in ng/ml as mean _+ standard error. ca/ml . . ( ) we constructed a single-chain fv-fragment (sc-fv) from the variable domains of a neutralizing antibody to human tumornecrosisfactor-alpha (tnf) because sc-fv should have some advantages in vivo. the sc-fv has a similar affinity ( , x - m) as the fab-fragment ( , x - m) but bind the antigen with a eightfold lower avidity compared to the parental mab ( , x - ). the parental mab as well as its fragments can compete the binding of rhutnf to both tnf-receptors. this was shown by competitive binding to the cell line hl- and to immobilized rtnf-receptors. in the nutralization assay on the cell line, l , the sc-fv can neutralize tnf but in comparison to the mab or its fabfragment, the capacity was three-fold lower as expected from the molar ratio of the dissociation constants. the in rive-neutralizing capacity was tested in a mice receiving toxic dose of rhutnf. the sc-fv showed a -fold lower neutralizing capacity in comparison with the fab-fragment. this could be explained in different manners: i) partial instability of scfv at c, ii) shorter half-life because sc-fv but not fab-fragments are eliminated via kidney, iii) elimination of tnf-immunocomplexes may be improved by opsonization mechanisms which requires some structures of the constant region (as in fab or mab). in summary, despite the encouraging in vitro experiments, the in vivo data suggest that sc-fv are not the right strategy for neutralizing tnf in vivo. tnf production in endotoxin non-responder mice, effect of a glucocorticoid antagonist g. iazgtr jr, e. duda, j. ol~th, e. husztik, g. iazar glucocorticoids inhibit lipopolysaccharide (lps)-induced tnf production and tnf can stimulate pituitary adrenocorticotropin secretion, resulting in the release of corticosterone. earlier studies ( ) reveales that the glucocorticoid antagonist ru , nufepristone, sensitizes both endotoxin responder and nonresponder, c h/hej, mice to endotoxin lethality. we have also shown that the glucocorticoid antagonist ru sensitizes endotoxin-tolerant (endotoxin-pretreated) and normal mice to the lethal effect of septic and endotoxin shock. on this basis, we set out to study the influence of ru on tnf production induced by endotoxin in endotoxin responder and non-responder mice. one and hrs following lps injection, ru significantly increased the tnf concentration in the serum, liver and spleen of treated animals as compared with the control and methylprednisolonetreated groups. in tissue cultures, ru induced the tnf synthesis of myeloid cells and increased the tnf production of genetically modified hela cells, which synthesize tnf constitutively. normal and tumor cell cultures exhibited an increased sensitivity toward tnf in the presence of ru . however, the same dose of lps did not induce tnf production in the serum, liver and spleen of endotoxin non-responder mice and this was not influenced by concomitant ru treatment. these studies suggest that ru aggravates lps lethality via factors other than tnf in endotoxin non-responder, c h/hej mice. the cytokine response to a novel exnacellular mitogenic factor, mf, produced by the group a streptococci (gas), and to the streptococcal pyrogenic exotoxins (spe) a and b, was determined by in vitro stimulation of peripheral blood mononuclear cells (pbmc) obtained from healthy blood donors. the induction and kinetics of different cytokines was studied at single-cell level using cytokine specific monoclonal antibodies and intracellular immunofluorescent staining. all three mitogens induced a massive ifny and tnfi response in - % of the pbmc after - hours of cell stimulation. in contrast, il and tnfc~ containing cells was only detected in - % of the pbmc. the induction ofil , il , il , and ill , was weak or completely absent. thus, the response indicates activation of th cells. however, illc~, illl , illra and il , were consistently found and gradually produced, peaking at hems in approximately - % of the pbmc. mf induced an equally extensive cytokine as well as proliferative inducing capacity, as did spea and speb, which suggests that also mf is a superantigen. a marked inter-individual variation could be noted between lymphocytes isolated from different individuals, both in the toxin induced proliferation and cytokine induction. this may be one explanation for the varying clinical severity noted in patients after infection with clonal gas strains. introduction -tumour necrosis factor (tnf) is released by mononuclear cells in response to inflammation and sepsis. it has been implicated as a possible mediator in inflammatory bowel disease (ibd) but its pathogenic role remains uncertain. this study assessed the relationship between tnfct and disease activity by measuring plasma and faecal tnf concelnmtions in an experimcntai model of ibd. methodologo' -colitis was induced in male wistar rats by intmcolonic instillation of rag , , -trinitrobenzenesulphunic acid in . ml % ethanol (n= ). control animals received an isovohlmetric instillation of normal saline (n= ). faecal pellets were collected before induction of colitis (day ) and throughout the experiment. after days the colon was excised, ueighed and the colon macroscopic score (cms) assessed plasma tnf (ptnf) samples were assayed by bioassay and elisa. faecal samples were vortcxed in water and the supernatant removed for estimation of protein and faecal tnf (itnf) content (elisa). there is a significant increase in itnf on day -#p= alld the total ftnf measured during the study correlatcs with the cms oll day -p= . there is no correlation between ftnf and ptnf. conclusions -therc is evidence of coloific tnf excretion by macroscopically normal animals and following induction of colitis there is increased faecal tnf which correlates with disease actmty. there is no significant elevation in bioactive or imnmnoreactive plasma tnf in colitie animals this data would suggest that faecal tnf is a marker of colonic inflamrnatiort and serial tnf assessment inay be useful as an indicator &severity in ibd. to study the effect of in-vivo hypoxia/reoxygenation on cytokine elaboration by routine peritoneal macrophages. materials and methods: adult male cba mice ( - g) were primed intraperitoneauy with either lipopolysaccharide (lps) ug]anlmal or saline. five days later, the animals were subjected to hypoxia ( % ) for , followed by of normoxia. harvested peritoneal macrophages were plated in-vitro, culture supernatants were collected at , , and and assayed for tumor necrosis factor (tnf), prostaglandin e (pge ) and nitric oxide (no). control animals underwent the same procedures, but were maintained in normoxia ( %o disease , berlin, germany the precise mechanisms of reactivation of latent human cytomegalovirus (cmv) infection are still unknown. apart from the permissive effect of diminished cellular immunity there is evidence of a cytokine mediated cmv reactivation as it is known for other systemic virus infections (e.g. hiv). we found that tumor necrosis factor-alpha (tnf) -in contrast to all other cytokines tested -can stimulate the activity of the cmv-ie-enhancer/promoter region in the human monocytic cell line, hl . we wondered whether our in vitro results were actually reflected by the incidence of cmv reactivation in diseases which go together with high tnfalpha levels. cellular immunodeficiency as well as at least temporarily increased tnf levels are known to occur in septic disease. we tested for the presence of cmv infection in peripheral blood mononuclear cells (pbmnc) by means of h centrifugation culture, immunocytological detection of different cmv antigens (apaap-technique), and pcr technique (cmv-ie dna). in striking contrast to healthy controls almost all examined septic patients were positive, irrespective of the method for cmv-ddtection applied, including the less sensitive immunocytology. follow-up studies showed that cmv-antigen positive pbmnc ceased to be detectable in patients with good outcome once septicaemia had been overcome. to further back up our hypothesis, we looked for a coincidence of enhanced tnf-alpha serum levels and cmv antigenaemia (immunocytology) in some other diseases which are known to have either enhanced tnf serum levels or increased incidence of active cmv infection and found the majority of patients with b-cell chronic lymphocytic leukemia, liver cirrhosis, and common variable immunodeficiency to be positive for these two parameters. we now wondered whether, apart from cmv reactivation, tnf-alpha could also cause cellular immunodeficiency this way promoting cmv replication and spreading and eventually causing cmv disease. in summary, we were able to show that a diminished cellular immune response results from/n vitro or in vivo methylprednisolone (mps) is used to suppress both inflammatory and immune responses. il- receptor antagonist (il-lra) and tnf binding protein (tnfbp) are naturally occuring anti-cytokine proteins, possibly modulating inflammatory and immunological responses. to define mps modulation of cytokine and anticytokine responses, we examined effects of mps on il-lra production and tnfbp generation as well as il-i~ and tnfa production by human peripheral blood mononuclear cells (pbmc) stimulated with lipopolysaccharide (lps). pbmc were purified from the blood of healthy volunteers, then incubated with lps ( ng/ml) supplemented with different concentrations of mps ( , pg/ml, mg/ml). after hrs incubation, the supernatants were collected for rias of secreted cytokines. the cell lysates obtained by cycles of freeze-thaw, were also collected for r ias of cell-associated cytokines. both the supernatant for secreted cytokines and the cell lysates for the cell-associated cytokines were subjected to rias for il-i~, tnfa, il- ra, and tnfbp-i (tnfsrp ). il-la, il- ra, and tnfbp were produced mainly as cell-associated forms in response to lps, whereas most tnfa was secreted into the supernatant of lps-stimulated pbmc. mps supplement resulted in reduction of il-la, il-lra, and tnfa production. il-la production was reduced up to . + . %( mg/ml) by mps in a dose dependent fashion, whereas about % decrease in tnfc, and il-lra production was observed at both high and low dose mps supplement. however, total tnfbp generation was not reduced significantly by mps supplement. furthermore, tnfbp secretion was increased times more in the supernatant of lps-stimulated pbmc with gg/ml of mps. these data suggest that mps could effectively block tnf activity by both reducing its production and up-regulating tnfbp generation and that mps works as an anti-inflammatory drug as well as an immunosuppressant by modulating cytokine and anticytokine responses. in severe gram-negative sepsis, excess of proinflammatory cytokines is associated with increased morbidity and the mortality. we have found that immunocytes possess functional -adrenergic receptors (~-ar) which, when activated, down regulate the lipopolysaccharide (lps) induced gene expression and subsequent secretion of tnf-~ in vitro. in the present study, we used a lethal endotoxic model in mice to test the hypothesis that -ar stimulation will down regulate the gene expression thus decreasing the circulatory levels of proinftammatory cytokines and improve the survivals in severe endotoxicosis. the animals (iso group) were injected times with ! -ar agohist isoproterenol ( . mg/kg i.m. and . mg/kg s.c.) , and hours prior to a lethal dose of lps injection ( mg/kg i.p.). control group (ctl) received same volume of saline at the same times before the lps insult. at the appropriate time points after lps injection animals were sacrificed and venous blood was collected from the inferior vena cava. the plasma levels of tnf-cc and il-loc were determined by elisa. in the mortality study, each grou the data showed that isoproterenol significantly decreased the mortality and the circulatory levels of tnf-c~ and il-lcc (fig. ) . these data suggest that -ar activation of immunocytes down regulates cytokine gene expression, decreasing circulatory eytokine levels thus reducing endotoxicosis mortality. these results provide a new pharmacological approach to reduce the excess of proinflammatory cytokines and mortality in sepsis. introduction: cytokines released from monocytic cells are thought to play an important role in the pathophysiology of sepsis. during the last few years several investigations have been performed aimed at modulating this mediator response. in the present investigation using a full blood model we have studied the effect of a standard immune globulin and an antitipopolysaccharide (lps) immune globulin preparation and a monoclonal anti-lps antibody in modulating the endotoxin induced cytokine response. methods: citrated blood from healthy human donors was incubated at °c in rotating polystyrene tubes. samples were taken before addition of x ng/l e. col± endotoxin and after hours. plasma was assayed for the cytokines minor necrosis factor alpha (tnf-~) and interleukin- (il- ) using elisa methods. the eodotoxin concentration was assayed by lal and end-point chromogenic substrate technique. the blood was preincubated with standard immune globuline (human igg from pooled plasma, gammagardr, baxter) or with an anti-lps immune glubuline (human anti-lps igg obtained by screening of blood donors, novo nordisk) in the concentrations of mg/ml or mg/ml or with the monoclonal lipid a igm antibody ha- a for ten minutes before the endotoxin was added. results: two hours after endotoxin addition markedly elevated tnf-~ and il- values were found.in the plasma. cytokine values at hours: tnf-ec pg/ml (mean) and l- pg/ml (mean). preincubalion with mg/ml standard immune globulins reduced il- values by % (mean) while there were no effects on tnf-c~ values at hours. a slight reduction in il- values was also found with the lower concentration, mg/ml, but this was not statistically significant. preincubation with anti-lps immune globulins had no effect on il- nor on tnf-cc values. preincubation with the monoclottal lipid a igm antibody ha- a in variable concentrations had no effect on cytokine release in this model. in this full blood in vitro model standard immune globuline reduced endotoxin induced l- release while tnf-cc values were unchanged.the anti-lps immune glubuline preparation and the monoclonal lipid a igm antibody ha- a had no effect on the il- or tnf-ct release. the effect of anti-tnf treatment in severe haemorrhagic/traumatic shock was investigated in a conscious rabbit model. the jugular vein (for administration of substances and blood withdrawal) and right femoral artery (for measurement of bp) were cannulated and an aortic thermistor probe inserted into the left; femoral artery for the measurement of cardiac output (co). the following day, upto % of the estimated blood volume was withdrawn over - rain, to reduce bp to - mmttg and co by / mad withheld for rain. shed blood ( %) was then reinfused followed by lactate solution to give a total potential dreulat%ag fluid volume of %. zymoeen activated plasma ( , gg/ml) was given rain prior to haemorrhage and during blood r~n%eion, all ~,~ir, ak were killed at h and o~gane removed for histology. rabbita received either monoclonal antirabbit tnf (r , rat igg , mgkg i.e. n= ) or emine (nffi ), rain prior to haemorrhage. the cardiovascular and biochemical changes during the haemorrhage and hypotensive phase (is. haemorrhagic stimulus) were similar in both groups. upon reinfusion, haematccrit and white cell count remained sigutfia~utly (p< . ) higher in saline compared to r -treated animals, indicating a relative haemoconcentration (i,e. reduced circulating volume) in saline animals. the lettkocytosis persisted in the saline animals upto h. plasma glucose, lactate and asparteto .m~-o transferase all rose similarly in both gorups but plasma ¢rea~!~+-e levels were markedly (p< . ) higher in ealine ve r animals at and h indicative of kidney damage, using a macro and micro. pathological scoring system, major organ damage was seen in the lung, liver and kidney which was significantly (p< . ) attenuated in r treated animals. in the hmg and liver, this was primarily due to a reduced bleeding and pmn infiltrate and to an additional maintenance of tubular integri~:y in the kidney. hence, in tlais model anti-tnf treatment markedly reduced the biochemical and histological indices of severe ,, ~gan damage during liaemorrhage and ranerfn~ion. thermal injuries and systemic bacterial sepsis produce a wasting diathesis with anorexia and marked loss of lean tissue and body fat. endogenously produced cytokines, including interleukin- (il- ), are thought to mediate many beneficial as well as pathologic host changes that occur during burn injury and infection. to evaluate whether bluckade of il- in vivo would affect survival and attenuate the anorexia and cachex[a associated with a thermal injury and chronic fulminant gram negative infection, sprague-dawley rats were studied. anesthetized rats were divided in groups, implanted with alzet r minipumps and randomized to receive the following treatment for days:i: gg/kgbw/min of il-lcc; ii: ~tg/kgbw/min of il- receptor antagonist (il-ira); iii: buffered vehicle. the animals were subjected to a % bsa, full thickness scald burn and the wounds then infected with + cfu/ml pseudomonas aeruginosa. eight additional rats were anesthetized, but were not burned, and served as healthy controls. . il-hx reduced food intake transiently but was otherwise without effect however, il-lra significantly attenuated weight loss over the first days and improved food intake between days and . we conclude that blockade of il- after a thermal injury with superimposed infection does not adversly affect the progression of the disease, but does attenuate the anorexia and weight loss associated with this model. these data indicate that il-i receptor blockade may offer a means to minimize the morbidity associated with catabolic illness. tumor necrosis factor (tnf) and its downstream induced mediators have pivotal roles in the pathogenesis of sepsis and septic shock. the suppressive effect of pentoxyfillin (ptx) on tnf production may be of clinical importance. when peripheral white blood ceils were stimulated with either lps or staphylococcus aureus, pentoxyfillin inhibited tnf production. in contrast, no inhibitory effect was observed on the induction of il- . ptx inhibited not only the tnf production of monocytes but also the tnf secretion of both granulocytes, and unseparated whole blood. the facs analysis revealed that the expression of cd antigen on monocytes was not influenced by pentoxyfillin. the in vitro tnf and il- producing capacity in septic patients were higher than in the control group, but decreased on subsequent days especially in fatal cases. administration of ptx ( mg/day) in septic patients resulted in tnf and il- productions similar to those found in control donors. it also subsequently led to an improvement of the clinical status. a further improvement in apache score could be achieved by administration of pentaglobin ° (biotest)( ml/kg/day ). the prevention of lpsinduced in vitro tnf and il- production by pentaglobin ° could be demonstrated in in vitro experiments involving the use of whole blood rather than purified lymphocytes, very probably because of the presence of lps binding protein in the plasma. the level of soluble icam- in sera of septic patients was significantly higher ( - ng/ml) than in normal individuals ( - ng/ml), but it decreased following the ptx and pentaglobin ° therapy. it is presumed that ptx and pentaglobin ° can antagonize eytokine production at different levels, resulting synergistic action being beneficial in the treatment of sepsis. albert szent-gy rgyi medical university, institute of microbiology, szeged, hungary h- ddm t. . e~i~im~/tii, septic sh ~ '. tnf alfa/pge, and somatostatln lands ji., alvarez j., gram m., llanos k., alcalde j., sanchez ja., balibr~d jl. taurine, a semi-essential sulphur-containing t:~-amian acid, promotes neutrophil phagocytic activit ' against yeasts and enhances intracellular killing of e.coli. paradoxically it protects against hypochlorous acidmediated biomembmne oxidatio~ and abrogates the pyrogenic effects of intracerebral endotoxin. it is therefore possible that taurine mediates some of these effects by modulating the cytokine cascade. aim to assess the cytekine responses in a rat model of intraperitoneal sepsis, pretreated with supplenmntary taurine, by measuring tnf and il- concentrations. methodology female wistar rats (wt - g) (n- per group) were prefed with % tanrine, . % glyciuc ( in tap water) or tap water (tw) for days prior to caecal ligation aud puncture (clp). normothermia was maintained intraoperatively and the animals received . % saline subcutaneously ( mls/ g) post-procedure. animals were venosected by direct cardiac puncture at or hours post-operation and the blood placed in endotoxin-free tubes. centrifilgation and storage of plasma at - °c was completed within hours. tnf and il- were measured using wehi and b bioassays respectively. results (means ± sem) bioactivc tnf concentrations were not significantly different between clp or sham groups. however plasma il- estimation revealed a statistically significant reduction at hours in tanrine-treated animals compared to glycino and tw controls ( objective: to evaluate the effects of allogeneic blood transfusion, thermal injury and bacterial garage on interteukin (il- ), tumor necrosis factor alpha (tnf) production and host mortality and to study if the administration of thymopentth (thy) could affect these events. materials and methods: balb/c mice were transfused with allogeneic blood (from c h/hej mice) and treated daily with thy (i mg/kg)(t+thy) . control animals were transfused but not treated (t). after days systemic blood was harvested to determine the circulating levels of il and tnf. a second group was treated with thy for days and then received a gavage wide lxl escherichia coli and a % burn injury (bg+thy). one hour post-bum, blood was collected to measure cytokins. control animals received the same treatment but thy (bg). a third group was transfused, treated with thy for days and then received gavage and burn (tbg+thy). one hour post-burn, blood was collected to measure cytokins. control animals received the same treatment but thy (tbg). all treated and control groups had mice/group. in separate groups (n= /group), receiving the same treatments, mortality was observed for days post-burn or transfusion. the production and release of oxygen radicals by phagocytic leukomytee is one of the most relevant and important functions of these substances in biology. when neutrophilic granulocytes or certain macrophages phagocytize they produce super oxide and hydrogen peroxide and form secondary products of these activated species. all of these substances are released in to the phagosome. it has been appreciated since that the amount of oxygen consumed by phagocytes in producing free radicals is prodigious. what has not been totally appreciated is the significant contribution this consumption contributes to total body oxygen consumption. our understanding of increased oxygen consumption following sepsis is compounded by a paradox of increased cardiac index and a narrow av difference. it was mclean in a study reported in that showed an increase in cardiac index and a narrowing of the avo z difference in humans following sepsis. other studies documented similar changes in humans and it has recently been speculated that increasing o~ delivery might have a favorable impact on outcome. at least three different explanations have been put forward as to why there are possible alterations in energy metabolism during sepsis. these include decreases in oxygen supply, peripheral shunts and direct action o~ cellular mediators on o~ delivery, a provocative review by hodgkiss and nark in shewed that in experimental animals sepsis did not cause any evidence of bioenergatic failure in muscle i liver, heart or brain tissue. they further showed that the increase in serum lactate is mot necessarily due to cellular hypoxia. they conclude that cellular hypoxia and defects in energy producing metabolites are not the cause of metabolic abnormalities in sepsis. we set out on a series of experiments to try to explain the paradox in cellular metabolism and whether or not white cells might contribute to total body oxygen consumption during sepsis. the first set of experiments involved growing rat cardiac myocytes on tissue culture. pyruvate was added to the medium as substrata and physiologic levels of peroxide were also added simultaneously, carbon labeled co~ production was measured as was nucleotides and degradation products from the cell. the peroxide induced a significant inhibition of pyruvate dehydrogenase. in addition, there was a loss of cellular atp and a corresponding rise in the release of inosine and adenine from the cell. we concluded from this first sst of experiments that physiologic levels of peroxide are a potent inhibitor of pyruvate dehydrogenase in isolated cardiac mitochendria as well as the cultured myocyte. we further showed that pyruvate dehydrogenase inhibition blocks the aerobic oxidation of glucose and leads te adenine nucleotide metabolism with adenosine and inosine release from the cell. other enzymes within the tca cycle did not appear to be specifically blocked by peroxide. this would explain the increase in lactate and the ability of the cell to continue to make high energy phosphate by entry of metabolites in to other entry points of the tca cycle, the second set of experimbnts was designed to estimate the magnitude of whole body reactive oxygen generation via nadph oxidase following granuloeyte activation invivo. using a guinea pig model baseline oxygen consumption was determined. ~iaphenyl iodinium (dpi) was used as a specific inhibitor of granulocyte nadph oxidase. animals were divided into two groups; those that received dpi and those that served as control, all animals were then injected with phorbcl myristate acetate (pma) intravenously. pma is a potent stimulus for granulocyte activation and subsequent reactive oxygen generation. whole body oxygen consumption measurements were then repeated after the p~la injection. in addition, arterial blood gas amalysis was performed, circulating neutrophils were collected and assayed for their ability to generate hydrogen peroxide and the r~ght lung was removed for wet and dry weight measurement. total body oxygen consumption increased by percent after pma injection. arterial oxygen tension fell significantly in the control animal. neutrophil hydrogen peroxide generation rate doubled and lung water in the untreated animals increased by percent. in this animal model we could show that granulocyte activation substantially increases whole body oxygen consumption to approximately percent of control values. the nadph oxidase inhibitor, dpi, decreases granulocyte hydrogen peroxide generation invivo and prevents the pulmonary injury induced by pma. using this animal modal it is possible to transpose this to the human septic state. if we assume there are , neutrophils per cubic millimeter of blood, a kg man would have ~ . xi u circulating neutrophils. when activated ixl ~ neutrophils generate one nanemole of hydrogen peroxide per minute. t~erefore, the circulating neutrophil pool could generate - . xi nanomoles of hydrogen peroxide per minute. this corresponds to an oxygen consumption of - . ml/ojmin by the circulating neutrophil pool alone. this does not take into account the production of oxygen by macrophages or the amount of oxygen consumed to produce nitric oxide. manipulation of oxygen delivery in human sepsis may or may not be beneficial. irshad h. chaudry, ping wang, and alfred ayala life threatening blood loss, due to soft tissue and bony injuries, is a frequent complication in trauma victims. although numerous organs and cells are adversely affected by hemorrhage, the focus here will be to discuss whether or not there are any differential alterations in splenic and hepatic immune functions. in particular, m~ antigen presentation (ap) and associated processes will be described since one of the important functions of the m is to activate resting t-cell lymphocytes by processing and presenting foreign antigens in a mhc class ii-restricted fashion. studies have shown that splenic m and kupffer cell (kc) ap was significantly depressed following hemorrhagic shock and remained so for at least h alter resuscitation. the presentation of antigenic fragments associated with mhc class ii antigen itself was not decreased following hemorrhage, but the catabolism of antigens in antigen-presenting cells was decreased. this is likely due to a significant loss of cellular atp. although m ap was depressed in splenic, as well as kc, only kc showed an enhanced capacity to produce inflammatory cytokines, il- , il- , and tnf. this difference in response between kc and splenic md may be due to differences in the microenvironment in which these cell populations are found, as well as potential differences in the effects that hemorrhage has on the environment from which these cells are obtained. splenic m from hemorrhage-resuscitated mice exhibited a significantly reduced cytotoxic response, whereas kc showed an enhanced cytotuxic capacity. the increased kc cytotoxicity is probably mediated through the increased expression of cell-associated tnf and the release of reactive nitrogen. the enhanced production of reactive nitrogen may play an important role in the clearance of microbes translocated from the gut following hemorrhage. however, excessive release of reactive nitrogen by kc may have deleterious effects on the adjacent hepatncytes. such an effect could, in part, explain the reduction in active hepatocellular function, which is seen following hemorrhage-resuscitation. thus, hemorrhage induces differential effects on splenic and kc m populations; it decreases splenic m but increases kc capacity to mount a cytotoxic response. the depressed splenic md and kc ap was, however, significantly improved by posttreatment of animals with atp-mgcia, chloroquine, diltiazem or interferon-'/. these agents also decreased the susceptibility to sepsis following hemorrhage. thus, the use of atp-mgci~, dfltiazem, chloroquine or interferon- offers new therapeutic modalities in the treatment of immunosuppression and for decreasing the susceptibility to sepsis, which is observed following severe blood loss. the production of macrophages from bone marrow precursor cells is a dynamic and highly regulated process. the differentiation of myeloid lineage-restricted progenitor cells is initially controlled by interleukin- , which drives the progenitors along a maturation pathway that leads to their response to specific lineagerestricted colony-stimulating factors(csfs) we have previously hypothesized that thermal injury can initiate a self perpetuating cycle of production of defective immune cells: thermal injury can initially affect circulating immune cells. then these cells, by unbalanced production of colony stimulating factors and other mediators, can cause a derangement of hematopoiesis resulting in an abnormal production profile of tnf, il-i, and il- and cytotoxic activity of bone marrow derived cells. the results of our studies so far have supported parts of this hypothesis. il- and il- +m-csf treatments increased the production of tnf in burn day macrophages and progenitor cells compared to normal cells. il- +m-csf+il- increased the production of il- by burn progenitor cells compared to normal macrophagee. preliminary results for the ratios of tnf/~ actin mrna indicate that il- +m-csf increased the mrna for tnf in the -day macrophages derived from burned animals compared to macrophages derived from normal animals. ratios of il- /~ actin mrna indicated that il- , il- +m-csf, and m-csf increased the il- ~rna in progenitor cells from burn animals compared to progenitor cells from normal animals. these preliminary results support our hypothesis that bone marrow derived macrophages and progenitor cells from burned animals act differently compared to cells from unburned animals regarding the production of inflanunatory cytokines. more specifically, the results suggest that the different cell types are regulated in different ways by cytokines, and cells from burned animals are regulated differently than cells from unburned animals. it i,~ to ~ssume that the translneatinn is due to a ixx~h,v functioning ~astroiutestlnal surface pro|ection system, which leads to an unacceptably high load ¢ln the imrsunc dcfcncc system, partlcul~ly the local system in the gastrointestinal wall, leading tu exh~ustiou of ihi~ system. tlae g&~lrointesliual i]'ac( can be regal'deal a.s a t~ servojf of appr m ~ separating i~ eucayotic ceils of the hosl ttom l ~ bacterial culls. in the human body the the myriad of cndngan¢nts micrix)rganistns, exogenous itl,~ttdittg micro~ganisms altd taxies m-'e sepia"areal li'otll lhe rest of the body by a simple epithclhd layer. the barrier function is heavily tlcpcnding tm =~ proleclive layer cmtsisting ie. surl~:emts, nluclts, probiotic bacteria, and ,~ub~tances with strong antioxid~lt, antipfotease al~d other i~rotective eft'ecru, the surfaet~ml htycr consists at tile besl if i(.) bimolecular layers, fl is thus very iltil~, the epilhelial layer is renewed every hours , and tile tanuwer of the mucus is ~so fa,~t, all attdphy of die epithelial layei induced by g&sttointestinal st~'vation does also include the mu~usprndocing cells, gnhlet cells, which leaduhg lu slmnage aad luwer quality of gi mucus, altered viscoelas,jc properties and reduced protection, ]~'obioiic bactcrla keeps the ppm's low, produce nutrients for the intestinal mllcosa, eliminates tuxia~ and stimulates the local immune system, the gl surface is conslanlly under hc wv wearing by ingested bacteria and their enzymes, ingested substaucas, chefftie,'ds at~d toxins. 'll~e n~tective flora is reduced in disease, by stress and by cm'clcss antibiotic therapy. wc have made attempts tn recondition the i,,.astroiniesli!l~d. tnucosa by rcstlpply of surfactants or sttrfactanfliko glyc~lipids, gels with pseudomuein [until.oil, and probiotl¢ laetobaeilli. by supply of glycolipids we have bt:cn able m prevent and heal intlammatory and tlleerallve injuries (and io p)'cveut microbe transhteatkln) in uppe~' and lower (. u'acl, this c~al be fu~'ther augmentented by shnultaueos supply el' a p.~uedomucin,likc gel like pectin. ()at contain~ one hundred times more ot membrane lipid$ th~a =nay other food, much of fiber, ~spceially watcrsnlnhlc betaglucaal~, at~d has an close to ideal amino acid cornpo~ition, <')at, termented by species-specific lactobacilli, has a strol~ ability to prevent local inflammatory and ulcerative chunges,transh)cadnn and sepsis in experimeut~d attimals mid to pl~ven~ revert mof in ba,nan.~.lt seems us, that it the mucos~lnucus/probiotic bacterial filnclinns cat'= %' restated by mucosa reconditioning, even in severely sick iudividuals) the hx:~d iuuuuue ~y,~teme will be capable tu pr~)tec! the ix~y ag~lls~ sepsis ~nd mof. the impaired immune response associated with multiple system organ failure (msof) has been most widely studied following surgery for inflammatory disease and trauma. the majority of late deaths following trauma are due to infection and msof. not all patients with multiple organ failure have concomitant infection present, yet most have been septic at some time in their hospital course. their generalized inflammatory condition often persists whether or not organisms have been recovered. immune failure probably precedes msof with or without overt infection and indeed may perpetuate such widespread sepsis. macrophage tumor necrosis factor-alpha (tnf) production is thought to represent an important pathogenic mechanism by which this is mediated. cecal ligation and puncture (clp) is a clinically relevant murine model of intra-abdominal infection and sepsis. serum tnf and endotoxin levels, and peritoneal macrophage tnf production are only slightly elevated in this model even in endotoxin sensitive animals. mortality in this model, therefore, does not appear to be attributed to overwhelming endotoxemia and/or tnf production. it has therefore been postulated that tnf and other cytokines may act in a paracrine fashion to cause local injury. tnf messenger rna (mrna) expression was therefore measured and found to be increased in the lung and liver following clp. a different pattern of expression was seen after endotoxin administration, characterized by a more rapid rise and fall, and enhanced tnf mrna expression in the spleen as well. route of spread of infection as well as the type of stimulus may determine the organ specific cytokine response. these data support the concept of locally produced tnf as a contributing factor in tissue damage and multiple organ failure during sepsis. the estimation of histamine's role in sirs changed over the years based on increased knowledge in shock pathogenesis, evidence later found to be faulty, and the discovery of other, more fashionable mediators. over the decades, the prevailing view has been that histamine is a noxious mediator contributing to the fatal outcome of shock. the analysis of experimental data on exogenously administered, endogenously released and/or newly formed histamine in septic/endotoxic shock suggests that histamine contributes to the early cardiovascular changes via hi-receptor vasoconstriction thus excerbating (directly and indirectly) the effects of catecholamines. in the later phase of septic shock (low out-put, high resistance states), however, it can be assumed that histamine exerts strong vasodilator and positive inotropic effects via h -receptors. these effects are considered beneficial in counteracting or attenuating the effects of sympathetic responses of catecholamines and other mediators. thus, a blockade of the early reaction with hi-antagonists and a stimulation of the h -receptors by h -agonists are worthwhile therapeutic approaches. shock produc~s ~ij alterations, an encrgy crisis and eventual c~ll damage, however, shock in itse|f do~ not lead freqoenfly to r~mote organ damage. in animal ~xpcrhnents and clinical expariez:ces in korea and vietnam, shock i~r s¢ was not associated with lung damage, renal failure or ards. the same is true with g.l bleeding. however, when shock is due to trauma or associated with tlssus injmy, then organ malfunction m~d damage is frequent. shock is bclleved to increase the frequency of infection, but clinical evidcnc~ for this is scant. hemonhsgio shock akme is an unusual o~orrenee dinica[ly. immune dysfolletion dons occur witl~ experhnental hypovolemic shock and in pailcnts with hypotcnsion or after receiving blood ~ansfosions. tbc most significant factor affecting reoorrcnce of resented ca,lorectal liver mclastasis was hypotensivc episodes during operation. blood transfosions depress immune function, improve transplant ~raft survival and increase ttll'rmr rec~r'tcnos ill co[eli and head and nc~k cancers. in experimental hemorrhagic shock, we found decreased response of [ymphocytes to mitogens, el:clad mixed lymphocyte reactilln and i[,- decreased. othe~.x hsvc found decreased macrophage and t and b ¢¢lt function, deci~ased re,ease of/l~i, increased poe v depressed macrophagc antigen presanlatiota, increased ien y, decreased il- , and , and shared mscrophags funclion with loss nr f and c b r~ccpto~s. this is inhibited by chlornqoine, ibuprofen, dihiazem, and atp. shock may activate ncutrophils contributing to ilappitlg in cspillarics, no refluw, increased adhesion, cytotoxicity and organ damage. this may be related to decreased clearance of bacteria after shock. t~lls shock, hypotcnsion and decreased microcirculatory blued flow initiate or set the stage for immune dysfmtction. they, along with tissue injury trigger inflammatory cascades. this also contributes to immunologic dysfonctitm, which is associated with increased lufoction. thus altered bh,od flow and mediator cascades are bolh involved, the question now is can wc rapidly improve microcirculatory blood flow, and dg'masa inflsrmnatory fosponss, which is also necessary for survival the effe~ of ~nterferon ~amma @n wour~ healing was ewaluated ~n a routine mo~el. ~mma ~n~erferon we g~ven in doses of ~ . to ~ , u~%$ synchronous with ereatio~ of a pa~splnal woumd then daily for is ~lays. ~mteet~on ~amma impaired tensile strength a% all ~oses relative to control. m zphology suggested ~reas~ ¢oll~gen deposition and r~du~-~ neovag~ulaeit¥ ~n t~eat~ animals, interferon ~amma was a so ~valuated in a murine mo~el of cecal llgatlon and punneure. one hundred to ,s uni~ vere ~iv.n following ~nju~ an~ than daily. interferon qamma was associated with inco:ea~ed mortalit~ and earlier death a~/a~n ~n a dose dependant manner (p< , ). afmlnistra~ion the proinfiammatory cytokines tumor necrosis factor-c~ (tnf-c , interleukin- (il-ii ), interleukin- (il- ), and interleukin- (il- ) have been implicated in the pathogenesis of the multiple organ dysfunction syndrome (mods) following shock and trauma. these mediators which are released in high concentrations by activated macrophages, endothelial cells, and connective tissue cells cause a systemic inflammatory response syndrome (sirs), thus leading to a shock-like state and tissue destruction. recently, a number of proteins have been characterized in in vitro and in vivo studies demonstrating potent anti-inflammatory properties. these latter cytokines include interleukin- (il- ), interleukin- (il= ), transforming growth factor- (tgf-j ), and the newly sequenced interleukin- (il-i ). they are considered antiinflammatory, since in vitro studies using purified macrophage cultures or whole blood assays revealed an inhibitory effect of these antmnfiammatory cytokines on ~he synthesis and release of tnf-cl and il-u . in addition, they reduced the severity of disease and reduce plasma levels of tnf-c~ and il-ii when administered to animals with infection or inflammation. furthermore, naturally occurring substances have been described that specifically neutralize the bioactivity of il- b and tnf-a. the il- receptor antagonist (il-i ra) is related structurally to il-i and binds to the same cell-surface receptors, but does not stimulate the cell. in animal models ore. cob-induced shock, inflammatory bowel disease, and peritonitis, injection of il-lra significantly reduced the severity of disease. the cytotoxicity of tnf-c~ can be inhibited through two types of soluble tnf receptors (stnfr) type i (p ) and type ii (p ). these stnfrs are proteolytic cleavage products of the cell-bound tnfreceptors. when given to baboons to combat e. coil-induced shock, soluble receptm's to the tnf type [ receptor decreased the severi~ of the shock-like state. it has been well accepted that shock and severe injury result in an increased release of proinflammatory cytokines with a high incidence of sirs and mods. our studies investigating plasma levels of anti-inflammatory mediators (il- , il-lra, stnfrs) in patients after severe injury further suggest that shock and injury lead to an activation of anti-inflammatory processes with altered plasma levels of these mediators. however, while plasma levels of il- and l-lra were significantly increased in trauma patients compared to healthy volunteers, stnfrs did not differ from control samples. thus, shock and severe injury result in different activation patterns of anti-inflammatory processes. m,l. rodrick, boston, b~usa following severe thermal injury significant suppression of the immune response has been demonstrsfed. these changes are associated with increased susceptibility not only to co,on human pathogens, but to organisms not normally pathogenic in the uncompromlsed host. early observations included prolonged graft rejection and skin test anergy in patients following burn injury. work from our laboratory and that of numerous others has shown that the~e is a profound £mmunoeuppresslon following severe thermal injury. i~mune deficiency has been identified in these patients hyz ii lack cf t nell responses to mitogens, ) early decreases in total t and helper t cells in the peripheral bloo~ } lack of response to tetanus toxoid i~uniza~io~ in spite of increased non-speoifi~ i~k~unoglobulin praduction and ) severe and prolongei deficiency of interleukin- (il- ) prcductlon by peripheral blood mononuclear cells (pbmo). this il- deficiency could be an underlyin~ cause of all the afo~ementloned immune defects by failing to activate both helper and suppressor t cell functions. mo~a recent work has focused on the molecular mechanisms of this il- deficiency end shown that the defect lies post-transcrlptionally since mrna for il- is also depressed following thermal injury. we have also investigated the potential of a defect in ii- receptor status on peripheral blood mononuclear uolls from patients fqllowing burn injury and in a murine model. in both oases no decrease in il- r was found either by phenotypic markers or by funational assays. another hallmark of thermal injury is hyperao~ivatlon of proinflammatory ~ytok~ne secretion, which may play a significant role in multiple organ failure following burn injury. therapy o~ major burn injury may reasonably be aimed, therefore, at up-regulating t cell ~unction and down-regulating hyperactive secretion of proieflaam~ntory cytokines. the majority of patients dying of bums succumb to sepsis which coincides with dysfunction in the specific and non-specific host defences. generally, concepts relating to the mechanism(s) of specific immune failure in thermal trauma imply that inhibition of t (cd +) cell responses is imposed by the injury or infection-related factors. however, the same factors elicit strong biological reactions within the lymphoid compartment. recent evidence indicates that systemic activation is inherent in the burn patient. to establish the relation of molecular and cellular events to the development of post-bum anergy we examined the state of and the capacity for t cell activation with regard to: ) occurrence of activation-induced cell death (aicd), ) activation-related phenotypic and functional_ diversity in the pool of peripheral cd + t cells. initially, (up to days post-bum), peripheral blood lympliocytes from severely injured (> % total body surface area) patients exhibited high levels of constitutive expression of surface receptor for ]l (cd ) and spontaneous blastogenesis. the presence of activation-related t cellproducts in bum plasma was also apparent. subsequent impairment of the t cell receptor (tcr)-regulated t cell responses in vitro was accompanied by significantly increased dna fragmentation that is associated with cell death by the mode of apoptosis. using molecular markers we established that flesh peripheral blood ceils from immunosuppressed patients also contain large numbers of apoptotic cells. fluctuations in the number of viable (pi-) peripheral blood lymphocytes involved primarily cd +/cd ro+ (memory) subset of t ceils. the above observations suggest that thermal trauma-associated t cell anergy develops through aicd, a phenomenon commonly associated with the tolerogenic activity of bacterial superantigens. persistence of staphylococcal infections in the burn patient may support this assumption. response following trauma jane shelby, ph.d. the immune system is integrated with other physiologic systems, and is exquisitely sensitive to changes in nervous and endocrine systems changes following traumatic stress challenge. the immune, nervous and endocrine systems interact via both direct and indirect pathways which utilize neuro and endocrine hormones, neurotransmitters, neurepeptides and immune cell products. it is now known that the immune system may be affected by all of the neuroendocrine products produced during a stress response, with evidence for innervation of iymphoid organs, lymphoid cell receptors for neuroendocdne products, and leukocyte production of chemicals which are virtually identical to certain neuroendocdne peptides (acth, endorphins). trauma induced alterations in the equilibrium of various neuropeptides and neuroendocdne hormones have a significant impact on immune response potential, affecting control of proliferation, differentiation and function of immune cells. for example, the neurohormone melatonin is thought to be a natural antagonist to counteract glucocorticeid associated immunosuppression resulting from stressful challenges, such as surgery and trauma, plasma melatonin levels are known to be significantly reduced in burn patients. the administration of exogenous me[atonin improved cellular immune response following burn injury in an animal model. melatonin was also shown to have in vivo cytokine regulatory activity, increasing the potential for il- secretion and downregulating excessive il- and ifn~ in burn injured, stress susceptible mice. the regulatory interactions between the immune, nervous and endocrine systems provide mechanistic pathways for trauma associated immune dysfunction. increased knowledge of these interactions will enhance the potential for the design of novei clinical interventions to improve immune response and decrease the risk for infection in trauma and surgical patients. . animals receiving e were given a single dose daily of either . g/kg of e in a % solution by garage (ge), or . g/kg of sterile ive in saline. four hours following the last dose, bum animals were subjected to a % body surface area bum injury to their dorsum. twentyfour hours following injury, the animals were sacrificed and spleen cells were harvested for assessment of lymphocyte function. splenocytes were prepared by mincing the spleen, followed by incubation on glass petri dishes to remove adherent macrophages. non-adherent cells were then tested for proliferative response to t-cell mitogen concanavalin a (con a) and b-cell mitogen lipopolysaccharide (lps). data were analyzed by anova. results: chronic alcohol exposure and burn injury independently inhibit lymphocyte response to con a but not to lps. the combination of e plus bum injury, however, pmfouedly decreases this response to both con a and lps as outlined in the this data clearly identifies the synergistic impairment of immune function produced by ethanol and bum injury. it is furthermore apparent that ibis effect is gut mediated and that gastrointestinal exposure to alcohol is necessary to produce this effect. further studies will work to identify cellular and subcellular mechanisms to explain this effect. in experimental animal studies and investigations on human volunteers endotoxin infusion is mgulary accompanied by the release of the cytokine tumor necrosis factor a (tnf-~) determined by elisa technique. in patients with menigococcal sepsis also elevated tnf-a values have been found using a functional assay. we have studied the role of tnf-et in surgical icu patients with sepsis. using functional technique, we were not able to detect tnf-~ activities in the patient plasmas. when this cytokine, however, was determined by immunochemicai technique (el sa) elevated tnf-e~ values where frequently oberserved. in order to further elucidate these observations, we studied shedding of tnf receptors in the patients. in these studies, we noticed that shedding of tnf receptors oecured regulary in the patients. at the time of diagnosis, soluble tnf receptor p and p were both - fold higher than values found in plasma samples obtained prior to die diagnosis of sepsis. we also observed that the sepsis patients revealed higher maximum values of p and p during the icu stay compared to values found in surgical icu patients without sepsis. these observations indicate that soluble tnf receptors are available in sufficient amounts to bind tnf-ot which is released in surgical patients developing sepsis. this mechanism may explain why functional tnf-c~ was not detected in the patients. institute for surgical research, rikshospitalet, the national hospital, university of oslo, oslo, norway. decker, d., sch ndorf, m., bidlingrnaier, f., hirner, a., yon rfcker, a. the advantage oflaparoscopic cholecystectomy over conventional open surgical approaches in the treatment of symptomatic cholelithiasis has been shown convincingly by clinical studies. in order to facilitate comparisons of different surgical approaches, we evaluated the cell biological characteristics of tissue trauma by measuring changes in various cell surface markers on leukocytes and eytokines in plasma as a possible means to assess tissue trauma in choleeystectomy. patients recruited into our study had experienced at least one typical bifiary colic, had ultrasound-proven cholelithiasis (stages -ii according to me sherry), were - years old, and presented for elective choleeysteetomy. patients could choose between laparoscopic and conventional eholeeystectomy after being informed about the advantages and disadvantages of each procedure. cell surface markers on leukoeytes were determined using whole blood techniques with the help of commercially available fluorescent monocloml antibodies and flow cytometry. shed cell surface markers in plasma and cytoldnes were measured with the help of sandwich-elisa kits. blood samples were drawn h before surgery, immediately before incision (after anaesthesia), h and h after incision. seventeen cell surface markers were examined on different cell populations and cellular subsets in laparoscopic and open-surgery patients. three soluble cell surface markers and six cytokines were monitored. by statistical analyses (multivariate regression analysis, student's t test, wilcoxommann-whituey's rank sum test) the six markers/cytekines that best distinguished open surgical from laparoscopic procedurea were determined. these were . the interleuldn- receptor and im soluble form (cd /scd ); . the activation antigen fd- and its soluble form (cd /scd ), a member of the nerve-growth-factor receptor family; . the cd ro epitope which characterizes t memory ceils; . the trausferrin receptor cd ; . the soluble adhesion molecule icam- ; and . the cytokines interieukin- and interleuldn- . on the basis of these results, a tissue trauma activation (tta) index was calculated by combining the marker/cytoldne measurements by simple multiplication. anaesthesia and pre-ineision maneuvers did not significantly change cell marker or cytokine levels in either surgical approach as compared to h before surgery. h after incision the tra index in open cholecystectomy showed a distinct - fold increase, whereas in laparoseopic surgery a mere - fold increase was noted. h after incision, the tra-index returned to near pre-surgery levels. in conclusion, our results demonstrate that changes in cell surface markers and cytokines can help evaluate the magnitude of tissue trauma in diffei'ent surgical approaches. the relationship between lymphocyte subpopulation changes after thermal injury and the increased susceptibility of burned patients to infection is unclear. in this study, we have attempted to correlate such subpopulation changes with the presence of infection in burned patients. peripberal blood from patients was monitored for lymphocyte subpopulation changes three times weekly for three weeks postburn and weekly thereafter for three additional weeks. mean bum size was . % (range %- %) of total body surface and mean age was years. infection was diagnosed by carefully defined clinical and laboratory criteria and its presence or absence noted each time blood was drawn. samples taken when patients had wound infection, bacteremia, or pneumonia were compared with samples taken in the absence of systemic infection. whole blood samples were stained with four monoclonal antibodies, the red blood cells lysed and the leukocytes fixed and analyzed by flow cytometry. for each patient sample, the proportion of lymphocytes falling within the light scatter gates was determined as the percentage of cells negative for cd and most strongly positive for cd . this percentage was used to correct each sample for the presence of debris or nonlymphocytic cells. the proportion of cd and cd positive cells was slightly greatc~ in the samples from infected patients, while the proportion of b cells (cd +) was unchanged and nk (cd +) cells were decreased by ahnos[ % compared to sampie~ li'om uuiuleclcd patients. the percentage of cells positive for cdilb (c~ integrin) decreased sharply and cd ro (memory cells) decreased slightly in samples from infected patients while the expression of the lymphocyte homing receptor and cd were unchanged. cd (il receptor) and cd (early activation marker) were significantly increased in the samples from the infected patients while hladr was unchanged. these changes in lymphocyte phenotype correlate with the presence of infection. if they closely precede or occur during the early development of infection they may be valuable clues to the mechanism of susceptibility following thermal injury. trauma patients are subjected to an immediate massive impact on their host defense integrity due to the combined effect of tissue trauma, shock and endotoxemia. cytoldnes are playing a crucial role within the course of an impaired cell mediated immune response (cmi) resulting from a disruption of intact m%/tcell interaction. the current study was undertaken to further elucidate the mechanisms of dysfimctional cmi following major burn and mechanical trauma -via comparative analysis of mrna expression and protein release. the major regulatory levels for different cytokines were determined in mitogen, respectively lps stimulated peripheral blood mononuclear cell (pbmc) cultures of trauma patients on consecutive days ( ) t, , , and post injury. we analyzed the cumulative data for interleukin- beta (il-i[ ), il- , il- as well as tumor necrosis factor alpha (tnf-~) and saw a considerable impairment of the protein release in the stimulated pbmc cultures until d post-trauma and recovery thereafter. *p < . , ** p < . vs control comparing the autoradiographies of the specific cytokine mrna expression with the protein release in the supernatants, we saw a good correlation between mrna signal intensity and protein synthesis for il- and ,- , suggesting that for these cytokines the main regulatory mechanisms are located at the pre-/transcriptional level. for the other cytokines investigated one has to suppose posttranseriptional mechanisms. the analysis of our data clearly indicates a severe impairment of forward regulatory immune mechanisms following trauma. most likely the regulatory mechanisms, that are involved are greatly different among the cytokines investigated. it may be concluded, that depressed cmi responses post-trauma are partly due to an impaired pro-inflammatory cytokine production. the severity of the injury (iss) correlated with the development at multiple organ failure (mof-score; r= . ). the levels of mediators and markers of the inflammatory response were generally higher in the more severely injured group (iss> , n= ). i - , - , g-csf, fpa, and c a -levels differed significantly (p< . ) between the iss-groups (>-< iss ) at the time of admission, whereas on day tnfa, c a, - , and ealpi showed significant differences. beyond the first week, major differences were restricted to pge and c a. the formation of two groups with respect to later multiple organ failure (mof < ; mof > n= ) yielded similar results. leukocyte-facs analysis revealed significant differences mainly in the cd (monocytes), cd /cd (i - r + t-cells), and cd /cd (th calls) populations. summarizing our findings we were able to detect some alterations in the surface antigens of immunocompetent cells. the inflammato d response, however, seemed to be more pronounced and correlates wi~ the further clinical course. using an experimental bum model in rodents, we have demonstrated that administration of a full thickness, scald burn involving % or more of the total body surface area (tbsa) elicits systemic responses which are characterized by numerous alterations in t-ceu function (i.e., lymphokine production and contact hypersensitivity (ch) responses) plus an enhanced susceptibility to bacterial infection. in the present study we questioned whether the apparent systemic effects mediated by large burns would be elicited as site-specific alterations in immune function following administration of small area burn trauma ( % tbsa). following a % tbsa burn, ch responses to contact sensitizing antigens were found to be altered. the depression in ch responses could be induced independent of the site used for topical skin sensitization. following a % tbsa thermal injury, development of ch responses were affected in a site-specific manner. immunization of % tbsa thermally injured mice in a site near the position of the burn resulted in depressed responsiveness, whereas immunization through a contralateral site resulted in responses that displayed both the intensity and kinetics of a ch response equivalent to sham-bumed mice. similar systemic and site-limited changes in lymphokine production were observed with % and % tbsa thermal injuries, respectively. a % tbsa injury affected the lymphokine producing potential of all cells regardless of which lymphoid tissue the cells were isolated from. the effect of a % tbsa burn was significant but site-specific. thus, ceils from lymph nodes receiving drainage from thermally injured tissue were specifically affected, whereas lymphokine production by cells from lymphoid organs receiving drainage from unaffected skin was normal. it was concluded that modulation of lymphokine production and cellular immune responses may be a normal consequence of burntrauma regardless of the size of the burn. changes in immune competence can be mediated either regionally or systemically in direct proportion to the area of skin exposed to the burn injury. this work is supported by phs grant gm and the office of navy research n - -j- . division of cell biology and immunology, department of pathology, university of utah school of medicine, salt lake city, ut . post spleneetomy septic sequelae may be fatal, but the mechanisms remain unclear. the objectives ef this study were to assess the mortality from concomitant splen-'etomy and ]~eritoneal bacterial challenge and to elucidate the local cetkdar responses. cd- mice were randomised to receive laparotomy and sham splenectomy (l) or splenectomy (s) with simultaneous ca'-cal ligation and "):mcture and the survival patterns assessed. subsequently, cd- mice were randomised into control (c), l or s groups and peritoneal cells studied at hours for bacterial phagocytosis and killi:~g, superoxide ( -) and tumour necrosis factor (tnf) production and macrophage activation vsing mac-i(cd- b) receptor in~.ensity expressed es mean channel of fluorescence (mcf). these resides indicate that sf!enectomy predisposes to nrortal~ty from bacterial sepsis ia the early pos~ operative period compared to sham operated animals. failure ~f p'.acrophages to kill bacteria in the splenectomv group '~:cured in t?~e absence of impairment of oxygen freeradical or tnf pred:~ctien. the macrovh~ge ac!ivotion marker mac- was significantly reduced in both l and s groups and impaired phagocytosis of bacteria oceured in both operative groups compared to controls. laparotomy a!one reduces macrophage activity in terms of surface re:eptor mac- expression and !ingestive capacity. splenectomy however s~gnificantiy ~mpairs r-acrophage-wediated l~,acterial killing and this qefect rttav co~tribut~ sig~ifjcav'ly to th-~ dissemination of local infection and to n':ortalit). depts of haem~ tology & surgery, beaumont hosoital, dub!in ,eire. introduction: loss of cell membrane integrity appears to be a common pathway of injury to tissues subjected to high-voltage electrical shock. the cell membrane is the most heat labile structure in the cell, and is also the most vulnerable to externally-imposed electrical forces. skeletal muscle and nerve cells are particularly susceptible to electroporation by clinically relevant electric fields. restoration of membrane integrity is essential for cell survival in victims of electrical shock. we have studied the effect of non-ionic triblock copolymers ( poloxamer class) on the transport properties of isolated rat skeletal muscle cells following electroporation-induced membrane disruption. - mm long adult skeletal muscle fibers were isolated by enzymatic digestion from the rat flexor digitorium brevus and maintained under standard culture conditions. they were loaded with the calcein-am dye and placed in a ,c chamber for recording by real-time video confocal microscopy. the cells were subjected to msec, v/era, a field pulses with a low duty cycle to allow thermal relaxation. peak temperature rise was , .c. the uye content of the cell was monitored in real time. experiments were carried out in calcium-free phosphate buffered saline, with mm mg%. experiments were repeated with mm neutral dextran ( the aim of the present paper is to ascertain if thuracotomy induces a different pattern of variations of cytokines, immunocompetent cells and antibodies from laparotomy in the early postoperative period. patients ( males females,mean age: . _+ ) with gallstone disease and with non neoplastic pulmonary disease were studied. none of these patients received blood transfusion, biological response modifiers, radiotherapy or surgery for at least months before being included in our study. anaesthetic procedures were similar in all patients and none were matnourished. on the day of surgery and on the st and th postoperative days (pre, lpo, po) percentages of cd , cd , cd , cds, cdi were measured by means of flow cytometry using moab., and levels of ig a, lgg, igm, ige. by nephelometry cytokine levels in peripheral blood(il- , il- , il- , il- , tnf) were measured in pts. of each group by means of elisa using moab. _r. esults:variations of il- and il- were not s.s.. il- increased but differences between groups were not statistically significant (s.s). il-i decreased on po and increased on po in both groups but were only s.s. in the th.g., and therefore, the differences between groups were s.s (p< . ).tnf decreased in the l.g. and increased in the th.g. on the po, the difference was s.s(p< . ); on po, tnf decreased in the l.g. and decreased in the th.g. but these variations were not s.s. cell percentages decreased an lpo and increased on po, except for %cd cell that increased on lpo and decreased on po ,in both groups of pts. differences were not s.s. ig a, igm decreased and ige increased in both groups (p< . i), but differences between them were not s.s. in contrast, igg decreased on po (p< . ) and increased on po in both groups, but the decrease iu the th.g. was greater than in the l.g. twenty male children,aged from six months to years,admitted for elective inguinal operation were studied. the operations were performed under balanced combined anaesthesia (fentanyl,thiopemtone,vecuronium, % nitrous oxide in oxygen) and blood samples were collected before flunitrazepam premedication,after anaesthesia, and hours after anaesthesia. cells from the wound were collected with cellstick sponge which was removed from the wound or hours after anaesthesia. the study was approved by the local ethical committee. the percentage of neutrophils was increased and that of lymphocytes was decreased in perpheral blood after the operation.the values in the wound were close to the values found in peripheral blood. the percentage of t-lymphocytes (cd ) and helper-t-cells (cd ) decreased in peripheral blood being lower in the wound than in peripheral blood after the operation. the percentage of t-eytotoxic cells (cd ) also decreased in peripheral blood and was similar to that in the wound. b-lymphocyte (cd ) percentage was increased in pe~pheral blood after the operation and was higher than in the wound. the percentage of activated t-cells (cd +hla-dr-positive cells) in peripheral blood increased while that of natural killer cells (cd +cd +leu -pos) was increased just after anaesthesia being decreased at g and hours after the operation. spontaneous lymphocyte proliferative responses didn't change while phytohemagglutinin a and concavalin a induced responses were decreased in peripheral blood samples hours after the operation with recovery at hours.pokeweed mitogen induced lymphocyte proliferative responses were decreased at hours (p<o. ) and hours after the operation we previously reported that plasma ige increased after traumatic injury. in this study, we measured plasma ige ievels in trauma patients on hospital admission and x weekly in the intensive care unit to evaluate ige kinetics. patient characteristics were: mean age -+ years ( m, f), mean injury severity score (iss) + , sepsis ( patients), sepsis syndrome ( patients), ards ( patients), renal failure ( patients). ige increased in patients ( %). the mean increase was ng/ml (range to ng/ml; % ci was to ng/ml). increase in plasma ige was significantly greater in patients with sepsis syndrome (p= . ) and renal failure (p< . ). although mean plasma ige was higher with ards, pneumonia, hepatic dysfunction, and shock, these differences were not significant (p> . ). plasma ige increase was not related to severity of injury by iss score (p = . ). the mean day to highest ige was . -+ . . the day sepsis was first observed preceded the day of highest ige by . + . days. there was a significant association between the day of sepsis onset and the day of highest ige (p= . ). eight of nine patients with sepsis syndrome had > % increase in plasma ige from admission. one patient's ige levels were normal ( - ng/ml) for days and then increased to ng/ml over the next days, after onset of sepsis syndrome. changes in ige plasma levels may reflect the action of cytokines, such as il- , which concurrently regulate production of ige and il- receptor antagonist in a response to sepsis. sepsis remains a leading cause of late mortality in trauma and hs. although hs-induced bacterial translocation is supposed to be the major cause of sepsis and mof, depression of the res increases susceptibility to infection after injury. the purposes of this study were: a) to evaluate the res in the lung, spleen and liver after hs and subsequent hypertonic saline (hsl) treatment, and b) to document the patterns of phagocytic activity in these organs during hrs. adult male wistar rats ( +_ gin) were submitted to hs (sbp tort) and after t hr (shock i hr) and hrs (shock hrs) hsl (nac . %, . ml/kg) treatment, e. coli (i ) was injected into the portal vein ~tci (n_> ). twenty minutes later, the lungs, spleen and liver were harvested and scintilographic counts obtained. data is depicted as mean_%+sem * p< . , ~" p< . and statistical analysis was performed by analysis of variance and wilcoxon tests. one hr after treatment, lung uptake was increased and liver and spleen uptake were reduced compared to sham. twenty four hrs after treatment, all organs, except lung uptake, returned to normal values. radioautographic histological analysis revealed radiolabeled particles inside phagocytic cells of all organs. we conclude that pulmonary phagocytic activity increases after hr of hs hsl reatment, diminishing by hrs although still above normal values. in contrast, res suppression occurs in liver and spleen after hr hs hsl treatment, returning to normal values by hrs. these results may explain lung complications and immunosuppression after trauma. infusion of endotoxin as well as major surgery is followed by lymphopenia in peripheral blood. the purpose of this study was to investigate to which tissues the lymphocytes are redistributed in response to endotoxaemia and major surgery. in addition changes in lymphocyte subpopulations and expression of mecii was measured. lymphocytes were isolated from peripheral blood of rabbits, labelled with indium-tropolene and reinjected intravenously into the rabbits, i rabbits received an infusion of escherichia coli endotoxin ~g/kg, while i rabbits were subjected to a major sham operation and i rabbits served as a control group. the redistribution of lymphocytes were imaged with af gamma camera, and calculated with an interfaces computer before, and , and hours after major surgery or infusion of endotoxin or saline. interleukin-l~ and serum cortisol were measured. in addition we followed cd , cd , cdlla/b, cdis, cd , cd , mhcii and cd /cd ratio. following endotoxaemia interleukin-lf~ increased significantly, following endotoxaemia as well as major surgery serum cortisol increased significantly. following major surgery as well as endotoxaemia there was significant lomphocytepenia in peripheral blood with a decreased cd /cd ratio while the cd positive subpopulation increased. in addition there was a decrease in the expression of mhcii on the lymphocytes peripheral blood. the radioactivity of the lymphatic tissue in and around the intestine increased to % of initial values following endotoxaemia and to % following major surgery. the results indicate that endotoxaemia as well as major surgery induces redistribution of lymphocytes from peripheral blood to lymphatic tissue. among the lymphocytes staying in peripheral blood there was a decreased expression of mhcii and a relative decrease in cd cells compared to cd positive lymphocytes. in order to analyze the effects of immune suppressive substances on expression of mrna of interleukin- (il- ) and interleukin- reeeptor(il- r), this study was carried out. twenty male rabbits with comminuted fracture were used in the study. ten ml blood were taken at , i, , , days after injury. the sera were tested for the effects on lymphocyte blastogenesis and induction of il- stimulated by concanavalin a(con a): the sera from the rabbits days after injury were analyzed with sds-page gel eleetrophoresis, and divided into three groups by ultrafiltration (ufpi ttk, kd,milipore; centricon- , kd,amicon), that are less than kd, between i and kd, and more than kd. each group of the substances also was tested for the expression of il- and il- r by the dot blot hybridization. the results showed that: i) all sera from the rabbits after injury had significant suppression on lymphocyte proliferation and secretion of il- by the con a-stimulated splenocyte in mice; ) the sera from the rabbits days after injury had more profound suppression than other injured sera; ) there was a marked band at about kd in sera from the rabbits days after injury, but nothing at the same position in normal sera analyzed with electrophoresis; ) the substance with molecular weight of about iokd had more obvious suppressive action on expression of mrna of il- and il- r than other groups substances, of which molecular weights are more than kd. it is concluded that: i) the sera from the injured rabbits can reduce immune response; ) there is kind of substance, of which molecular weight is about kd, it is probable the main factor involved in the pathogenesie of postinjury suppression immune; } the substance can depress the expression of mrna of both il- and il- r. research institute of surgery daping, chongqing, p. r. china acute ethanol uptake prior to injury modulates monocyte tnfo~, production and mononuclear cell apoptosis. g. szabo, b. verma, p. mandrekar, d. catalano monocytes (mo) have been shown to contribute to immunosuppression after both major injury and alcohol consumption. we reported that acute ethanol exposure of m( results in decreased antigen presentation, induces tgf- and pge while inhibiting inflammatory monokine production. we also showed that post-trauma immunosuppression is mediated by hyper-elevated mo tnfc~ and il- . consequently, here we investigated rnonokine production in trauma patients (n= ) who had elevated (>o.lmg/dl) or had no blood alcohol level (n=t ) at the time of emergency room admission. none of the patients had chronic alcohol use history. met tnfc~ production from trauma patients with prior alcohol uptake was undetectable during days - post-injury in contrast to patients without alcohol exposure. furthermore, decreased tnf~x levels were found in alcoholic patients' mci after mdp or ifny + mdp induction. however, mcl tnfc~ levels during the - days post injury period became higher in alcoholic trauma patients. furthermore, over days post-injury, alcoholic trauma patients showed significantly elevated mci tnfo~ production after adherence isolation, mdp, or ifn+mdp stimulation compared to patients without alcohol. these results suggest that acute ethanol uptake prior to injury decreases tnf(x inducibility in the early post-trauma period, but these patients' mo produce hyper-elevated tnfa levels later post-injury, thereby prolonging their cytokine shock risk. tnf ng/ml - days post-injury days post injury stimulus ale. pt. pt . . . . immunosuppression might also be increased by the elevated apoptotic activity found in trauma patients' mononuclear ceils, which was even greater in alcoholic trauma patients' cells. in non-alcoholic trauma patients' preactivated mo, in vitro acute ethanol ( - mm) exposure resulted in a significant down-regulation of tnfc~ (p< . ) and il- (p< . ) production. in contrast, in vitro ethanol exposure increased the production of inhibitory monokine, tgfi]. these results provide both in vivo and in vitro evidence for the effect of acute ethanol exposure increasing immunosuppression and cytokine shock. the 'systemic inflammatory response syndrome' (sirs) with consecutive septic multi-organ dysfunction represents the major cause of late death following major mechanical and burn trauma. systemic hyperinflammation and concurrent depression of cell mediated immune response (cmi) render the traumatized host anergic, resulting in profound susceptibility to opportunistic infection. monooytes/macrophages (mo) play a central role within the host defense system in developing and manifesting states of injury, shock and sepsis. the mechanistic scrutiny of the synthesis patterns of crucial cccytokines appears to be a helpful tool to further analyse mo behaviour in the compromised individual. the objective of this study was to further dissect the characteristics of cytokine regulation in pbmc under stressful conditions, via analysis of the expression of cd + receptor, the proinflammatory mediator il- , the macrophage activating factor ifn- ,, and neopterin (npt) a metabolite of activated mo. we investigated pbmc's on consecutive days , , , and after mechanical trauma of and after bum trauma of patients (mean age ~ years; mean iss ± pts). in trauma patients we saw a massive increase of pha induced neopterin synthesis compared to controls. however, when discriminating the npt levels in the supernatants for the amount of mo stimulated, the npt output of the individual cell was lower compared to mo of nontraumatized individuals. interestingly there was a contrary coarse in the cumulative protein release patterns of il- and ifn- in mechanical versus burn trauma patients. wheras in burn patients ifn-y was decreased significantly ( + u/ml) compared to controls ( + u/ml) as well as mechanical trauma ( + u/ml). il- showed a significant suppression following mechanical trauma ( + u/ml) vs control ( + u/ml) and bum patients. the rt~,na signal intensity for beth eytokines was in concurrence with the protein release in more than % of the individual patients investigated. from these data we can conclude that the inadequate low npt synthesis predominantly in bum patients appears to be a sign of cellular immaturity and is probably partly due to low t-cell ifno t signals. in addition we could state that the quality of trauma is apparently responsible for the different synthesis patterns of ]l- and ifn-q,. it has been postulated that bacterial invasion or endotoxemia are necessary for cytokine production following burn injury. we studied the organ distribution and kinetics pattern of il-fc~ (cell-associated il- agonist) in eutrophic rats subjected to either % tbsa cutaneous scald injury (bi), muscle scald injury of equivalent % tbsa (mbi), sham muscle bum (resection of skin only, up to % tbsa) (smbi), and sham cutaneous burn (sbi), followed by saline resuscitation ( mukg i.p.). separate rats were infused with mg/kg e.coli :b lps or saline lv. unmanipulated rats were baseline normal controls. liver, lung, spleen, ileum, thymus, kidney, skin, and plasma were harvested at various time-points within the first h. tissues were frozen, weighed, homogenized, the homogenates centrifuged and the supernates assayed with a radioimmunoassay specific for rat il-l(z (detection limit pg/rnl). il-lc~ was expressed as ng/g weight + sem (lowest detectable amount . ng/gwt). il-lo~ was constitutively present only in the skin ( + . ng/gwt). cutaneous burn and sham cutaneous bum induced biphasic elevations of il-lcc in the liver and lung only, with maximal levels at . h (in the liver, bi = . _+ . ng/gwt, sbi = . + . ng/gwt, p _< . ; in the lung, bi = . + . ng/gwt, sbi = . + . ng/gwt, p -< . ). of note, both bi and sbi rats had detectable il-i~ in the liver at timepoint already ( min real-time). these levels increased in parallel until min and became eventually different by log at - . h. all other organs as well as plasma were below detection limits. muscle burn injury and sham muscle burn (skin resection) induced similar elevations of il- ~ in the liver at lh, indistinguishable from each other and from cutaneous burn. in contrast, lps challenge induced dramatic elevation of il-t~ in all organs tested except for the kidney; the spleen was the most responsive organ to lps-induced il-lo~ production. these data indicate that thermal or mechanical injuries induce very early and organ specific production of il- c~ in vivo by mechanisms other than endotoxemia. injury-induced complement and platelet activation may be involved as well as the neuro-endocrine axis, which may explain the low levels of il-lo~ induction observed in all rats at the very early time-points. trauma services, massachusetts general hospital, and department of surgery, harvard medical school. fruit, st, boston, ma . j. f. schmand *#, a. ayala* and i. h. chaudry* studies indicate that i.v. infusion of the colloid hes in normal animals does not adversely affect non-specific immunity. it remains unknown, however, if lies affects cell mediated, specific immune functions after trauma and hemorrhage (hem). to study this, non-heparinized c h/hen mice underwent midline laparotomy to induce trauma and were then bled to and maintained at a bp of mmi-ig for rain. the animals were then resuscitated with either times (x) the shed blood vohune as lactated ringer's solution (lrs) or x lrs + lx % lies. sham mice were neither hemorrhaged nor resuscitated. at or hours post hem serum, peritoneal (pm~) and splenic macrophages (sm~) were obtained. bioassayes were employed to assess the levels of ii-l, il- ( alternatively pmqb showed no differences in il- release between all groups at and h, while sm~ from the lrs + hen group showed a depression at h. tnf production by pm~ was depressed in all groups at h and remained so in the lrs + hes group at h. sm~b showed decreased tnf release values in both hem groups at and h. in summary, the levels of inflammatory cytokines (particularly the values of circulating il- ) after trauma/hem are positively influenced by the administration of hes. this might be due to a protective effect on pmqb and sm~, but also on other cytokine producing cells, e.g. kupffer ceils. we conclude that hes is not only a safe, but also beneficial agent in the resuscitation of patients atler trauma/bemorrhagic shock. this study investigated endotoxemia and consecutlve immune response in patients with multiple trauma (median injury severity score = , ). blood samples.were collected shortly after injury and after , , , , s and l days. endotoxin was measured with limulus-amebocyte lysate test and the specific antibody content (sac) against endotoxins of the classes igg, igm and lga by elisa-technique. five antigens were used: lipopolysaccaride (lps) of e.coli (ec), lipid a of e.coli (la), lps of pseudomonas aerog. (pa), lps of vibrin cholerae (vc) and cx-hemolysin of staphylococcus anreus (oth). a nephelometer indicated the total concentrations of igg, igm and iga. differences were checked with wilcoxon-test and p< , s was considered significant. cross-reactivity was calculated with rank correlation coefficients. results: endotoxemia peaked shortly after injury ( - h) at , eki/ml (median), decreased thereafter to , eh/ml at day s and remained on this level. sac oflgmclass increased to all endotoxins and peaked at day revealing the lfighest level to la followed by pa (= % of la-sac), ec (= % of la-sac) and vc (= % of la-sac). lga antibodies increased as well but only slightly and not significant (exception: sac to la was elevated significantly at day ). igg antibodies increased similar to iga class only slightly and again only sac to la was significantly higher at day and . however sac to (xh of all ig-classes remained continuously on the same level troughout the observation time. correlation analysis revealed strong cross-reactivity (r> , ; p< , ) most often between antibodies of igm-elass ( %) followed by igaclass ( %) and lgg class ( %]. conclusions: multiple trauma is associated with temporary endotoxemia. endotoxins probably translocated from the gut cause specific increase of anti endotoxin antibodies in blood of the igm-class. endotoxins cause no increase of antibodies to gramposilave bacteria. igm antibodies are most unspecific. during cardio-pulmonary bypass, as well as postoperatively, high levels of endotoxin, interleukin- (ii- ) and c-reactive protein (crp) were measured in patients. i female and male, ageing from to with a median age of . blood sampling was done preoperatively, immediately after induction of anaesthesia, after thoracotomy, after cannulation of the aorta and right atrium after the first half of the reperfusion phase, after closure of the thorax, and hours after the operation and then every morning until the th postoperative day. blood was drawn into heparinized tubes (i iu/ml) which were free of endotoxin. crp levels were determined through the use of the behring nephelometer. - levels were measured by using commercially-available elisa test. the endotoxin level was determined by a chromogenic modification of the limulus amebocyte test. the statistical analysis was done using the wilcoxon ranks test and correlation analysis. a significant increase {p . ) in endotoxin plasma occurred during surgery, culminating in a peak (median value of . eu/m!) during reperfusicn. plasma levels of endotoxin continued to be slightly raised till the th day after surgery, whereas those of interleukin- rose at the end of the operation and were at their highest hours later (median value of . pg/ml). crp levels were also high postoperatively with a median value of mg/l, and were markedly raised on day ( mg/l). a definite, statistically significant correlation between the plasma levels of endotoxin and - during the operation was establisthed (p . ), leading us to conclude that the endotoxin liberated during cardiac surgery acts as the main trigger in the releasing of - , and thus induces the postoperative acute phase reaction. there was no evidence of a correlation between crp and endotoxin or - plasma levels. impaired immune function is well described following trauma and hemorrhagic shock (hs). prior studies have utilized peripheral blood or spleen cells to index immune function following hs. however, changes in mucosal immunity are not weii characterized in this setting. gut origin sepsis is thought to be an important cause of organ failure and death following trauma. a rodent model was utilized to allow comparison of mucosal-associated immune function vs, systemic compartments after hs. fischer rates underwent hs (map ± mm hg) for minutes followed by resuscitation with shed blood and lr. sham animals were instrumented only. rat tears were collected at and hours following hs for quantitation of slga by ria. animals were sacrificed at hours and spleen (spl), peripheral lymph nodes (pln), and mesenteric lymph nodes (mln) harvested for cell population analysis using flow cytometry and mitogen stimulation analysis. cell marker expression analysis revealed no changes in t or b ceil populations following hs. mitogen mucosal immune function appears relatively spared following hs. the mechanism(s) for this variability in immune function requires further investigation. we have found that transplantation of bone marrow in a hind-limb graft to syngeneic lethally irradiated recipient is followed not only by rapid repopulafion but also overpopulation of bone marrow cavities. the question arises whether this unexpected phenomenon could be the result of stimulation of stem cells by factors (cytokines) released from surgical wound at the site of anastomosis of graft with recipient. aim of the study was to investigate which tissues damaged during the procedure of limb transplantation may be a potential source of humoral factors accelerating in vivo bone marrow proliferation. methods. experiments were carried out on lew rats in groups. in group i, the hind limb was transplanted orthotopically to a syngeneic recipient; in group ii, sham operation was performed; in group iii, a four-cm long cutaneous wound was made on the dorsum; in group iv, limb skin was harvested, fragmented and implanted into peritoneal cavity; in group v, bm from femur and tibia was implanted intraperitoneally. bm, lymphoid tissues and blood were sampled and days later for cell concentration and phenotype evaluation. results. the yield of nucleated cells from tibia was on day in the control . + . , in group . + . , in group ii . + . , in group iii . + . , in group iv . _+ . , in group v . _+ . x ( ). the evident increase in bmc yield in all groups continued until day . increase in weight and total cell count of spleen and mesenteric lymph nodes in all but group iii was also found. no differences in percentage of maturing erythroid cells, but higher of mature myeloid cells and lower of lymphocytes were observed. conclusions. trauma of skin, muscles, and bone brought about an increase in bone marrow cellularity and acceleration of maturation of myeloid lineage. transplantation of bm ceils alone did not produce this effect. transplantation of bm in limb graft is a good model for studies of natural factors reaulatin~ bm hemormesis. this study sought to determine a relationship, if any, between the degree of hypochclesterolemia upon trauma patients' admission and their subsequent outcome. all blunt and penetrating trauma patients admitted to a level i facility from through , and who had serum cholesterol assayed during the first hrs were retrospectively studied for development of death or significant organ dysfunction. the mantel-kaenzel chisquared test was used to determine significance of data at the p< . level. results: trauma patients were admitted during the four-year period who had serum cholesterol assays performed in the first hrs. patients had cholesterol levels less than mg/dl; of these ( . %) died, ( . %) developed ards, ( . %) developed acute renal failure, and ( . %) developed multisystem organ dysfunction; hypocholesterolemia in these patients was not due to liver injury or massive fluid administration. the risk of death was times greater and risk of multi-organ failure times greater in this group than in those with a normal serum cholesterol (>if mg/dl; patients; p< . ). conclusions: admission serum cholesterol level in the trauma patient serves as a powerful marker for those at risk of subsequent organ failure or death. hypocholesterolemia in this setting may result from organ hypoperfusion and humeral mediator release. lung tissue contains many immunocompetent cells. resection, therefore, is expected to activate extensively inflammatory mediators such as pmn-elastase, pmstanoids and pteridines. in a prospective clinical study we compared patients (pts) undergoing either thomcotomy with or without lung tissue msectioh and tboracoscopic lung resection concerning activation of inflammatory response. material & methods: group a pts (n= ) had thoraantomy but no lung tissue injury; group b pts (n=ls) had thoracotomy and lung tissue resection due to benign diseases; group c (n= ) represents group b tissue resection but using a thomcoscopic procedure. the following parameters were determined pre-, peri-, and postoperatively: elastase and crp as indicators of activation of pmn-leukocytes and injury severity; prostacyclin (pgi ) and thromboxane (txa~) as parameters of lung endothelial response; prostaglandin f ~ (pgf~) and pgm representing pulmonaly metabolic activity; pge a and neopterin as proof of macmphage activation. statistics were performed using analysis of variance for repeated measures. results: group b pts revealed postoperatively an increase in crp (p< . ) indicating a higher injury severity in comparison to the thoracoscopic procedure (c). both, controls (a) and group c pts did not show pmn-activation, whereas group b demonstrated a reversible increase in elastase. surgical trauma caused in all groups a release of pgi z and txa which was more pronounced in c (p< . ) and most in b (p< . ). similar results were found for pge~ and pgf =. there was no activation of maerophages since neopterin did not increase. apparently, metabolic lung function was not impaired because there was no marked rise in pgm except in b (p< . vs. c). discussion: our results demonstrate that lung tissue injury aggravates the mediator release induced by thoracic traum. these mediators among others are able to increase capillary pressure and hence lung edema formation. impairment of lung function, however, seems dependent on the extent of the liberation. therefore, the maximal release reactions occured in group b and c after lung tissue resection, whereas the controls showed the highest levels immediately after the incision. we conclude that thoracoscopic procedures are superior in reducing the resection trauma per se and hence might prevent severe mediamr-induced (pulmonary/systemic) sequelae. in a prospective study we investigated patients using radiochemical method according to sch~dlich (s) and photometric method according to hoffmann (h). serum of severly traumatized patients was withdrawn directly after admission at our emergency room and in narrow time intervals during first hours after trauma. follow up control samples were taken daily until day ten. whereas no elevated pla-ca was found during first hours, a peak was regularly observed around day four. there was high correlation between pla-ca and iss (r= . , p<o.o ) except patients suffering from thoracic trauma, thoracic trauma {tt) provoked similar gons-score-and pla-ca-values compared to multiple trauma (mt) despite significantly lower iss: pla-ca (h) mt . + . tt , +_ , n.s. pla-ca(s) mt . +_ . tt . _+ . n.s. goris mt . - . tt . _+ . n.s. iss mt - tt - p< . we found delayed elevation of pla-ca after severe trauma, however detection of delayed pla-ca in the serum of traumatized patients cannot give reliable information about the exact role of pla in the inflammatory reaction after trauma as latest results show that pla is secreted early but bound at lipophilic sites of vascular membranes. hern~mdez m j, amiguet ja, monreal ji, vid~n jr, jim nez f j, l pez-vivanco g acute phase reactant proteins increment in serum of patients with traumatisms and inflammation has been previously reported. alpha- antitrypsin (aat), alpha- macroglobulin (amg) and ceruloplasmin (cp) are evaluated in the following of patients, males and females (mean age: years), with compound fractures. % of them were located in tibia and fibula. intercurrent infection developed in patients and internal fixation rejection in one. measurements were made by radial immunodiffusion on days , , , , , and . a control group of healthy volunteers was also evaluated. aat and cp showed increased values from day which kept elevated untill the end of the study. amg elevated from day . when infection developed, aat and cp values were even higher whereas amg values decreased. fixation rejection caused aat, amg and cp increment. aat and cp increment in non complicated fractures might be due to accompanying inflamation, by means of cytokines release and aprps hepatic synthesis induction. therefore, increment is higher when infection or rejection develop. amg behaviour at early stages of evolution is secondary to hiperconsumption, considering mean life shortening after proteases ligation. amg modifications in fixation rejection remain obscure. aprps increment modulates inflammation and bony callus formation by means their antyprotease and antioxidant properties. clinically, aprps might be useful parameters in determining complications onset in fractures evolution. hemorrhagic shock (hs) is a common complication of trauma, as well as some major surgical procedures. the alteration of the immune system by hs is thought to contribute to the increased septic morbidity and mortality seen in these patients. multiple mediators are released following hs. il- , il- , tnf, pge and tgf-b have all been implicated in these immune system changes. in vitro, pge causes many of the immune system changes following hs, yet the time course of pge release has not been well deliniated. the aim of this study was to determine the time course of pge release by peritoneal and splenic macrophages following hs. c h/hen mice were bled to a mean bp of + mm hg for minutes. the animals were resuscitated with the shed blood and normal saline. control animals were cannalated, but blood was not withdrawn. the animals were sacrificed at , , , , and hours following hs. peritoneal and splenic macrophages were harvested from each animal and cultured with lps for hours. the supernatants were collected and frozen until assayed. pge was assayed using an elisa (cayman chemical). results are shown below for the peritoneal macrophages: pge release by peritoneal macrophages was significantly elevated at , and hours over control. it was maximal at hours, but by hours it had started to decline. splenic macrophage pge release was much more variable. (data not shown.) there was less consistency between time points and no clear trend was seen. in conclusion, pge is significantly elevated at hours following hs, and reaches a peak at hours. pge release may be responsible for the immune system changes seen in the first few days following hs. splenic and peritoneal macrophages respond differently in their release of pge following hs; which may be due to differences in their milieu. there is an obvious association between the altered immunocompetence of patients following traumatic injury of various types and the increased riskto develop complications. the present investigation was undertaken in order to analyze the value of both neopterin (n) and c-reactive protein (crp) in monitoring disease course in patients with multiple trauma. we were interested to compare nconcentrations as marker of t-cell/macrophage activation with crp levels as indicator of the inflammatory acute-phase response daily serum concentrations(n and crp) were measured in patients ( male, female, mean age . ), admitted to our icu following serious trauma (mean iss= ) and in control subjects. the clinical course of each patient was evaluated with apacheii score according to knaus. mean stay in icu was . (range - ). patients didn't develop organ failure(nof-group), patients survived, developing mof (s,mof-group), patients died with mof (ns, mofgroup). three patients(one s and two ns) showed signs of septicemia and septic shock. the serum samples were measured for neopterin (immu-test-ria, henning-berlin) and for crp (immunoturbidimetric method) -at the university hospital for internal medicine, innsbruck, austria. the highest crp levels were measured h after trauma, but they were not accompanied by significant increase in n-values. we found significantly elevated n-concentrations from the days - . n and crp levels showed a parallel release peaks on the days - and the values discriminated significantly among the three outcome groups(the second crp peak is lower in comparison to the first posttrauma peak). by the ns-group we found constant and parallel increasing crp and n levels, reaching extremly high values - h and preceding clinical signs of mof and sepsis. the values increased dramatically before death. the serum levels by all control subjects were upper the normal limit for n and crp.. the parallel occured peak changes in n and crp concentrations showed a significant correlation with clinical status, using a disease activity score (apac h eli). our findings suggest that both-cellular and humoral mediated immune mechanisms are activated after multiple trauma and that simultaneous determination of n-crp may be of advantage as diagnostic and prognostic parameter in polytrauma-patient monitoring panel. it is apparent, that measurement of very high levels may be of value as a srong indicator in developing of mof or septic complications and thus offer the possibility for earlier therapeutic intervention. the modification of t-cell/macrophage and acute-phase responses may be potentially useful in the treatment of icu patients, resuscitated after severe trauma, and suggest that n-crp may be relevant indicator for testing experimental immunomodulating therapies. although several in vitro studies suggested the catalytic action of iron in oxygen free radical generation, few data are available concerning iron-metabolism following ischemia-reperfusion injury and hemorrhage in vivo. aim of the present studies was to evaluate iron metabolism following mild and severe hemorrhage in the presence and absence of intraperituneal hematoma. methods. male lewis rats ( g) divided in groups (observation time hrs): a: mild hemorrhage by sequential blood sampling ( . ml each)( , , , , , , , , hrs). b: a with hemoperitoneum (hp)( ml/ g), c: hemorrhagic shock: blood withdrawal of ml/ g over min and resuscitation with ringer's lactate ( x shed blood) and isogenic donor blood; d: c with hp. parameters: serum iron ([g/dl], ferrozin-method); fe labeling of erythrocytas (application of ci fe i.a. into a donor rat, days later bleeding of the rat and injection intraperitoneally in experimental rat; plasma transferrin ([g/ml], ria). t-tests and mann whitney. data are expressed as mean + sem. results. compared to baseline, mild and severe hemorrhage caused a significant increase in serum iron at and hrs, respectively ( + vs. + ; +_ vs. +_ ). hp reduced this increase ( +_ vs. + ; + vs. +- , p<. ). i-ip significantly increased hemoglobin between to hrs in mild ( . +_. vs. . +. ) and severe hemorrhage ( . +. vs. . +. ). in mild and severe hemorrhage comparable maximal resorption ( fe labeled erythrocytes in circulating blood) of intraperitoneal hematoma occured at hrs (mild: +_ vs. severe: +- counts/rain). hp increased survival-rate following hemorrhagic shock (no hp: / ; hp: / ). in mild hemorrhage no alterations of plasma transferrin concentrations. in shock group without hp, there was at hrs a significant higher transferrin level than with hp alone ( . +_. vs. . + . ). in conclusion, hemoperitoneum with hemorrhage prevents increase in plasma iron levels by increasing hemoglobin through resorption of erythrocytes and thereby suppressing iron mobilization from endogenous iron resources, e.g. liver. this suggests that intraperitoneal hematoma not necessarily promotes iron-mediated oxygen free radical production, especially since survival in these groups was improved. increased transfarrin levels in group c at the end of the experiment suggest increased iron turnover which was not observed in shock groups associated with hemoperitoneum. primary immune response to thymus-dependent (srbc) and thymus-independent (vi-polysaccharide) antigens was determined during days after cct. antigenic challenge was made on day i, , or . number of spleen plaque forming cells (pfc) and serum haemagglutinin (ha) titre were studied on day after immunization. cct stimulated immune response to t-dependent, but not to t-independent antigen. enhanced response was noted when srbs were given in posttraumatic day i, it was higher than preceding one after injection on day and reached a maximum when antigen was presented on day after trauma (pfc number . times exceeded the level of immunized, but nontraumatized rats). the rise of pfc number in spleen correlated with increased ha level. thymectomy had been performed days before cct completely abolished posttraumatio stimulation of immune response to t-dependent antigen. standard thoracotomy also enhanced humoral response when srbc were administered on day after the operation. thymus trauma modeled by pincett squeezing of its right lobe and performed at the same time with thoracotomy fully abrogated as well as thymectomy stimulation of immune reaction. thus, different experimental chest traumas are able to increase antibody production via thymus-dependent mechanisms. endothelin is a amino acid peptide produced by ischemic or injured endothelial cells. in vitro and in animal studies, et is also a potent constrictor for renal mesangial and coronary vessels, a negative cardiac inotrope and an endocrine regulator. our lab has shown that et is an agonist for monocyte production of interleukins i, & , prostaglandin e (pge ) , and substances which trigger superoxide production. systemic et levels increase in hypoperfused and septic patients, and et may be yet another important cytokine in critical illness. but while et has been shown to be a potent vasoconstrictor in healthy dogs, systemic vascular resistance does not increase in critically ill patients with high et levels. (we hypothesize that this might be due to pgez-mediated vasodilation predominating over et-mediated vasoconstriction.) we next asked what happened to systemic et levels in patients with major burns (> %.) ten hemodynamically stable patients resuscitated by a modified parkland formula to a urine output > cc's per hour had et levels drawn on admission, at i, , , and hrs. et levels were measured by radioimmunoassay. mean levels were elevated at ± pg/ml at all time points versus levels in healthy controls of ± . in summary, systemic et levels increase significantly in patients with major burns. et may be yet another cytokine playing a significant role in the immune, inflammatory and multiorgan dysfunction observed with major burns. restoration processes in an organism after ischemic damage are realized through ~n~lammatory mechanisms~ the intensity of which is significantly defined by blood levels of neuropeptides. myocardial infarction (mi) was chosen for studyin these processes since it eradicates the influence of infectious factc~rs. dogs~ in whom mi underwent different forms o¢ healer, g; bhn~ed ~h~t during the acute phase of the disease there was a characteristic rise of ne!~ropeptides in the blood. these neuropeptides had nociceptive and antinociceptive effects. particularly substance p and -endorphins triggered off the development of compensatory and adaptive mechanisms and defined the intensity of inflammatory reaction at the zone of ischem~t: damage-notable fall in substance p levels after an ~nitial increase, while the ~-endorphins stayed high was an important condition for non complicated healing of mi. on the other hand high levels of substance p with low ~-endorphin concentrations lead to increased infiltration o~ neutrophils into the infarction zone and weakened the activity of synthetic processes~ thereby leading to left ventricular aneurysm. at the same time low intitial levels of substance p slowed down the development of necrotic processes which lead to delay in refunctioning of the heart and complicated the healing process. thus, regulation of the levels of neuropeptides in the blood in trauma forms a perspective method of its treatment. of laparascopic versus open choleocystectomy c. schinkel, s. zimmer, v. lange, d. fuchs, e. faist the impairment of immune function due to surgical trauma may be followed by deleterious septic sequelae. compared to open abdominal surgical procedures (lap), laparaseopic surgery (lsc) is associated with a decrease in hospital stay and in accelerated patient recover. the aim of the study was to evaluate the sensitivity of the immune sermn parameters of il- , saa and neopterin, the percentage of cd + cells, the in-vitro il- synthesis after mitogen stimulation and lymphocyte proliferation, in order to purposefully discriminate differences in the severity of trauma. we investigated the blood of patients with cholecystolithiasis undergoing either laparascopic ( ) or open (i ) cholecystectomy on consecutive perioperative days - , , and . there was no significant difference between the two groups concerning age and sex. patients with clinical signs of acute cholecystitis were excluded from the study. operation time and hospital stay were obviously longer in lap patients ( versus minutes, versus days) compared to the lsc group. concerning the unspecific acute phase reaction we could show no difference in the increment of senun amyoid a (saa) synthesis in the lsc group (d-i + lng/ml, d + ng/ml) versus lap group (d- + ng/ml, d + ng/ml), while in serum il- levels we saw a less steep increment in the lsc group ( -fold from d- to d ) compared to the lap group ( -fold from d- to d ). the analysis of cd + receptor expression and serum neopterin did not reveal any difference between the groups. lymphocyte function showed an impairment of proliferation to antigen stimulation in lap (d - : . + . cpm, d : . + . cpm) compared to the lsc group (d -h . + . cpm, d h . + . cpm). in both groups il- synthesis was decreased post-operatively. our data indicate that laparascopic cholecystectomy reusults in a less distinct unspecific acute phase reaction post-trauma compared to that following lap. neopterin serum levels and cd receptor expression show that these parameters apparently are less useful markers to detect differences of surgical trauma severity while it appears that the impact of lap is reflected most impressively on the lymphocyte compartment. trauma alters the host resistance of organism and is accompained by appearence of excgenic and endogenic proteins in the body. to understand the molecular mechanisms of host resistans disorders in trauma, as a first step, the genetic regulatory mechanisms of immune response after antigen injection has been studed. the appearence of specific protein factors ( - and kda), in the nucleus of rat splenic and brain cells, accordingly, was shown after immunization with sheep erythrocytes. the stimulatory effect of these factors on the il- mrna and il- production was detected. the nucleotide sequences of the human il- gene regulatory region bounding by the splenic nuclear proteins were determined between + - b.p. the il- trans-factors shows the affinity to splenic and thymic lymphocytes in vitro. thus, the antigen causes the appearence of specific protein factors in the cells,which act on the gene level,stimulate il- production and the host resistance. these results cause the next step of experiments using the same model, but after trauma. these investigations will let us verify the hypothesis that the protein il- gene trans-factors may play a definite role in the decrease of the cell immune responce after trauma. confronted with the routine procedure of prophylactic treatment of candidates for surgery in a rural african hospital, we initiated studies on the fre'quency of post-surgical malaria. in tanzania non-pregnant patients from rural areas were followed. of preoperative patients % had a parasitaemia and those maintaining it showed no increase or complaints. nine percent of patients without detectable parasitaemia before surgery came down afterwards and one-third had malaria-like complaints. spinal and general anaesthesia were equally applied in these last patients. in burkina faso we studied patients of which % had a parasitaemia on admission and % had postoperative malaria. half of the surgical patients came from rural areas, whilst only % of those with malaria lived in the city (with much less exposure and immunity). % underwent major surgery and % minor. bloodtransfusions ( % with parasites) never evoked a parasitaemia in recipients. post-surgical malaria is thus a reality in about % of the adult cases, both in east and west africa. surgery evokes a cascade of factors, varying from cortison to interleukines and acute phase proteins; immune responses may temporarily be suppressed. clinical attacks of malaria in otherwise immunes could be evoked by one of these factors. though malaria can easily be cured, the differential diagnosis is difficult because of post-surgery fevers; we found that % was treated without justified indication. the involvement of "student-doctors" a. this study examines glucose uptake and hexose monophosphate (i~ip) shunt activity in normal human peripheral lymphocytes and polymorphonuclear leukocytes (pmn). glucose uptake was determined by measurir,g the uptake of tritiated deoxyglucose, a non-metabolized glucose analogue. adsorption of co derived from [i- c] glucose was used to determine knp shunt activity. in vitro assays were carried out in hormone concentrations approximating normal and elevated trauma blood levels. (normal -cortisol . ~g/ml, glucagon #g/m , epinephrine ~g/ml, insulin t~u/ml; traumaeortisol . ~g/ml, glucagon /*g/ml, epinephrine ~g/ml, insulin ~ij/ml. analysis of twenty subjects showed a reduction of ° ~mp shunt activity by lymphoeytes and a ] % reduction in glucose uptake by p~n in normal vs. trauma hontc,nes p < . . lymphocyte glucose uptake was also reduced by trauma hormones p~ . . it ha~ be.ea~ suggested thgt idiopatno pulmonary fibrous (y.pf) [s a consequence of severe alveolar epithelial injury and is associated with an nveolar irnammamry reactio~ and the presence f.neutr phils. there~bre, neutr pk~ chemoattra~ant~ are probably important in the genegs oft.he infial lesions of ipf. the obse,"wson that stimulated macrophages are or~n histologically promin~t in fibmfio [-~gs ~.nd am capable of p~oducmg a v~dery f flbrogenic pep'ides also a~gues for their role ~n the pathogenic prc~e~ oflpf. the observation that stimume~ maerophages ere often histologica[iy prominent in fibrotio lungs and ~re ~pable of producing a varie~, offibroge.~e peptide~ also argues for tkek role in the pathogenic process, therefore, we ha-~e tested the potentn for iater!eukln- (i ..- ) and mo~tocyte chemotacde pop, de (x¢cp- ) to induce neutro~hil ~d mononuclear phagocyte accumuhdon in lungs of pafient~ with pulmonary .~r~idosis and i~f. brenet~o.alveolar lavabo (bal) fluids from ipf and sar~qidosis patient were conexntratea by reversed-phase chromatography, ~d ii. arid mcp-i asso.~ed by ells& ehemotaxis mad enzyme-reieasing ~ssas's on msnocyte~ and neatrophiis. elisa revealed significenfly elevated b al-eoneentrations o£mcp-i ( . ng]mg aibumm) in purisms with p~monary sarcoidodis artd in ipf ( . ng!mg) in comparises to . normal individuals ( . ng/mg) and to patients w~th obreic bronentis (cb) (~, rig/rag). similarly, chemota*dc ac~a~' for monocles (mcp- e.qu/va]ent) was strongly increased in sareoidosis ( . ngjmg) as well as ~n f pag,nts ( . ng/mg). norra.al indlvidu~s and cb patiants hzd a . or -fold lower ~cn%i~y, re~peefively. patients with ipf and sarcoidosi~ also h~l eievated il- ievei~ ( . and . rig/rag, respe~veiy; nomzls: . rig/rag; cb: . ng/mg) mad nvatropmi ohemotax~ ( . ~'~d . nnmg, res!z~ztiveiy; aormals: . ng,'mg; cb: l ngmg). these data suggest that increased ievels of born mcp. ~d il- may be oharacted~tie for ~arcoidosis or ipf_ it appears iikely that both ehernoattraetants ~ontribute to the influx ofmonocytes and neutrophils into the pulmonary alveoius and interstit~um in these dlsea~es. we have recently shown that the combined administration of noninjurious doses of lps and paf in the rat produce ards-like lung injury characterized by neutrophil adhesion to lung capillary venules, neutrophil accumulation in lung parenchyma, pulmonary edema, and increased protein and neutrophil count in bal fluid. this new paradigm of lung injury was associated with elevated serum tnfc~ and pretreatment with anti tnfa mab dose-dependently prevented these responses. also, the combined administration of lps and paf induced lung mrna levels of tnfe~ ( fold vs. lps or paf alone), ll-lg ( fold), kc ( fold) and il- . taken together, these data suggest that this new paradigm of lung injury is cytokinemediated and that lps/paf in vivo can functionally couple to the activation of gone expression of a multi-cytokine network system, all of which may be involved in the pathogenesis of ards. materials and methods. the sheep model included hemorrhagic shock and closed femoral nailing at day , hourly injections of e. coli endotoxin and zymosan-activated autologous plasma at clays - and further observation and measurements at days - . from venous blood and bronchoalveolar lavage(bal)fluid of ten merino sheep (mean weight kg) neutrophil counts ( e pmn/ml blood or epithelial lining fluid-elf-), the elf/ plasma ratio of albumin (r), and the zymosan-induced (stim) and non-induced (spont) chemiluminescence response (cl) of blood ( e cpm/ , pmn), and of blood-and bal-isolated pmn ( e cpm/ , pmn) were measured. for statistical calculations the wilcoxon test was used. data of the changes in polymorphonucleur leukocyte (pivinl) metabolism have been suggested to play a pivotal part in the post-traumatic systemic inflammatory response syndrome. the underlying cellular mechanisms which control this response are not yet completely understood. since the 'ca + second messenger'-system has been shown to be involved in regulation of pmnl-'respiratory burst', we investigated changes in pmnl-ca z÷ regulation in relation to oxygen free radical mediated injury. methods. in polytranmatized patients (mean injury severity score = ) arterial and venous blood samples during days. daily evaluation of horowitz-quotiant (po /fio ), plasma lactate (mg/dl) and body temperature ( results. body temperature peaked at day and (day : +. ; day : . +. ). plasma lactate was significantly increased at day l ( + ) and day ( . + ). hurowitz-quotient (day : + ) was low at day ( + ) and day to ( + )(p<. ). at day a substantial rise in venous pmnl-superoxide production (day : . +_. , day : . +. , day : . +_. ), oecured with significant increase in plasma lipid peroxidation (day : . + . ; day : . + . ). pivin~-myeloperoxidase activity was high at day ( . +--. ) and then continuously declined (day : . +. ). plasma antiexidant activity (glutathione pemxidase) was reduced by % at day (day : . +. ; day : . +_. ; day : . +. ). whereas basal ca + concentration remained unchanged (day : +_ , day : +_ ), fmlp-stimulated cytosolic ca + mobilization increased at day (day : + , day : , day : + ). conclusion. the present study in polytraumatized patients shows, that seven days after injury the agonist-induced pmnl ca + mobilization is significantly enhanced. at the same time, pmnl-oxygen free radical release and phagocytotic activity, systemic fever response and lactate concentrations were maximal. these observations were accompanied by post-tranmatic respiratory failure and in some patients by clinical signs of multiple organ failure. preliminary data from an ongoing study using hes-and dextran-infusions in these patients show attenuation of this inflammatory response. stefan rose, m.d., trauma surgery, univ. of saarland, homburg/saar donnelly sc, haslett c, dransfield i, robertson ce, grant is, carter c, ross ja, tedder tf. dept's of respiratory medicine, accident & emergency, intensive care, surgery, university of edinburgh, scotland and dept. tumor immunology, dana farber cancer institute, boston. the selectins are a family of adhesion molecules (l-selectin, e-selectin, pselectin), all of whom are implicated in inflammatory cell transendothelial migration. they, as a family can be proteolytieally cleaved from their parent cell and exist in a soluble form within the circulation. ards is a disease state in whic neutrophils and neutrophil transendotheliat migration have been implicated. in this study we wished to investigate whether the levels of these circulating soluble receptors from patients at-risk of ards at initial hospital presentation, correlated with subsequent ards progression. eighty-two patients were enrolled (pancreatitis (n= ), perforated bowel (n= ), and multiple trauma (n= )), of whom progressed to ards. assays for soluble l,p & e-selectin were performed on collected plasma samples via a sandwich elisa. (ns = not significant, **** = p<o. ) we have found a highly significant inverse correlation between a low circulating soluble l-selectin (and not soluble e & p-selectin) and subsequent ards. these results further our understanding of neutrophilendothelial interactions in the early stages of ards pathogenesis and offer the promise of sl-selectin in combination with other markers of inflammatory events being used to identify individuals at particularly high risk of ards progression on initial hospital presentation. it has been suggested that polymorphonuclear leukocytes aggregate in the lung capillaries of patients developing the adult respiratory distress syndrome (ards) and account for the endothelial damage while releasing toxic metabo-iites such as o.a. free oxygen radicals. among many antioxidants which have been investigated in in vitro systems and in animal models, n-acetylcysteine (nac) has been established to be useful as a free radical scavenger in vivo. to assess the influence of n-acetylcysteine (nac) on the activation of neutrophils in patients undergoing cardiopulmonary bypass (cpb) surgery with extracorporeal circulation (ecc), we evaluated the plasma levels of elastase and myeloperoxidase (mpo) throughout the operation and up to hours after surgery. four hours after surgery also a bronchoalveolar lavage was performed. a spectrophotometric method was used for the detection of plasma elastase activity and mpo levels were measured using a radioimmunoassay. we found that pretreatment with intravenous nac prevented the increase in elastase activity ( _+ pmol/i vs _+ ; p - . ), but not the release of neutrophil related mediators ( . _+ . ng/i vs . _+ . ; p= . ). besides, nac had the capability to prevent the enhancement of neutrophil numbers in lavage fluid as is normally seen during cpb ( . + . % vs . _+ . ; p = . ). although not significant, nac prevented also the increase in elastase levels in lavage fluid ( . + . pmol/i vs . + . ; p = . ). it is concluded that nac is able to protect against the inactivation of a -proteinase inhibitor, the main inhibitor of elastase activity, and that nac interferes with adhesion and migration of neutrophils. therefore nac may be useful in the prevention of tissue damage. this study is supported by inpharzam belgium. sodium nitroprnsside (snp) has previously been shown to attenuate the neutrophil induced lung injury associated with limb ischaemia and repeffusion. glyceryl trinitrate (gtn), already widely used in aortic surgery, also increases nitric oxide but has a less marked splanchnic "steal" effect. we examined the effect of gtn on lung injury, neutrophil infiltration and activation in a model of aortic occlusion ( rain) and repeffusion ( min). sprague dawley rats were randomized into: control (n=i ); ischaemia repeffusion (ir) (n= ); and ir treated with gtn ( ug/kg/min) during repeffusion (n= ). myeloperoxidase activity (mpo) measured pulmonary neutrophil influx. pulmonary endothelial permeability was measured by wet to dry weight ratio (w/d), broncboalveolar lavage protein (bal) and neutrophil counts (bal pmn). neutrophil superoxide release (mean channel fluorescence mcf) was measured by flow cytometry in a further ir v gtn experiment (n= per group). control _+t "* _+ _+ ** bal pmn/mm l+- " + # _~ *p< . , #p< . v control/gtn;**p< . v ir. students t test the significant increase in mpo activity produced by ir was attenuated by gtn. the increase in pulmonary microvascular leakage after reperfusion was also prevented by gtn. neutrophil superoxide release increased significantly from . + . to . _+ . mcf after minutes repeffusion (p<. ). this increase in superoxide was prevented in the gtn treated group. these results indicate that gtn inhibits neutropbil superoxide release during limb reperfusion, thus preventing pulmonary vascular leakage and neutrophil infiltration. these data suggest that the beneficial effects of gtn in aortic surgery may be due in part to a protective effect onpulmonary microvasculature. department of surgery, beaumont hospital, dublin , ireland. lipton adult respiratory distress syndrome (ards) is marked by increased vascular permeability of the lung to white blood ceils (wbc). indeed, influx of wbc into the lung is believed to be the central mechanism in acute lung injury of ards. evidence is developing that the neuropeptide c~-melanocyte stimulating hormone (c~-msh), a proopiomelanocortin derivative, inhibits inflammatory reactions in animai models of inflammatory responses in humans. to test the influence of a-msh on experimental ards, the peptide was administered to rats after intratraeheal infusion of endotoxin (s. typhosa, #g in . ml saline). three groups (n= each) received: intratracheai infusion of endotoxin plus ip injections of o~-msh ( ~tg in . ml saline) at , , and hr post-endotoxin treatment; intratracheal endotoxin infusion plus saline injections; control intratracheal saline infusion plus saline injections. the bal data showed overall differences among groups (f , = . , p<. ), o~-msh treatment inhibited endotoxin-induced wbc migration into the pulmonary tree (p<. ). circulating wbc counts were markedly lower in both groups given endoroxin than in the control group (p<. ), but there was no difference in wbc count between these two endotoxin-treated groups. the results indicate that c~-msh can reduce wbc migration in experimental lung injury. in further experiments we tested the hypothesis that c~-msh, administered alone or in combination with an inhibitor of gram-negative bacterial growth, increases survival in a model of peritonitis/endotoxemia/septie shock. cecal ligation and puncture were performed under sodium pemobarbital anesthesia ( mg/kg, i.p.) in female balb/c mice ( - g) that were then randomly assigned ( - mice per group) to receive at time and hr later: control saline thjectioas (i.p.), injections of ~-msh ( ~tg), gentamicin sulfate (i mg/kg), or both ~-msh and gentamicin. one ml of normal saline was given s.c. to each animal for fluid replacement. both ix-msh and gentamicin treatments administered singly improved survival; when given in combination survival was even greater these findings suggest that the anticytokine ot -msh molecule might be useful for treatment of systemic inflammation, perhaps particularly when used in combination with agents that inhibit bacterial growth. previous studies showed a close relationship between xanthine oxidase activation, membrane damage and postischemic cardio-respiratory failure following aortic clamping and reperfusion. aim of the present study was to evaluate alterations of polymorphonuclear leukocyte (pmnl)-metabolism and signal lransduction systems during ischemia/reperfusion induced by aortic clamping in man. methods, in patients ( female, + years) with elective reconstruction of infrarenal aortic anearysms, arterial (a) and venous (v) blood samples were obtained before clamping and declamping, and min after declamping. arterial pla concentrations were higher than venous ( + vs. + ). while cytosolic basal pmnl ca + concenlxation was not altered at the end of ischemia (v: . + ; a: _+ ) and during reperfusion (v: + ; a: + ), fmlp-stimulated cytosolic ca + mobilization showed a significant arterial increase as compared to venous ( _+ vs. + , p < . ). these presented data indicate that the reperfusion syndrome after infrarenal aortic clamping is characterized by ) pulmonary membrane damage possibly due to pmnl-degranulation, ) activation of pmnl-superoxide radical production with release of activated pmnl in arterial circulation, and ) a significant arterial increase of pmnl cytosolic ca + mobilization after fmlp-stimulation parallel to pmnl-activation. in conclusion, ischemia/reperfusion in man induces pulmonary damage and activation of pmnl superoxide production possibly due to an altered pmnl-ca + messenger system by inflammatory mediators (e,g. ii- , tnf, paf). the septic lung diseases (i.e. ards) generally show distinct alveolar damage and surfactant disturbances. it is thought that alveolar macrophages are involved in specific release products like h and cytokines like tnf. in this pathway the type ii alveolar epithelial cell (p cell) is not only an important target, but as recently shown it is also capable of producing h . the aim of this study was to investigate the influence of endotoxin on h release of p cells. we obtained p cells from lungs of female wistar rats and investigated the effect of lipopolysaccharid (lps) on h release of fresh isolated cells and on cells cultured for days in a fibronectin matrix. furthermore we conditioned isolated alveolar macrophages for hours with p.g/ml lps and tested the conditioned medium (mcm) on cultured p cells. p cells h ex vivo were _> % pure, _> % vital and had an basal h release of . _+ . nmol h per hour and million cells. adding p.g/ml lps to the incubation medium the h release decreases slightly but significantly to . _+ . nmol. adding . p.g/ml phorbol myristate acetate (pma) to the basal incubation medium the h release increased -fold to . _+ nmol. pma induced h release decreased to . + . nmol after addition of p.g/ml lps. after culture days the p cells were _> % pure and showed a pma inducible h release of . _+ . nmol addition of p.g/ml lps had the inverse effect as on freshly isolated cells as it increased the h release up to . _+ . nmol. addition of mcm to cultured p cells increases pma-stimulated h release to . +_ . nmol. the release decreased to . _+ . nmol when an murine anti-tnf-alpha antibody was added. vitality of cultured cells was > % in all experiments. the results show that lps has an direct effect on p cells cultured on fibronectin. we conclude that the observed additional stimulatory effects of mcm seems to depend on tnf-alpha. the induction of h release of p cells could be important for generating internal oxidative stress in p cells before external oxygen radicals exceed. the produced h did not necessarily damage p ceils, but it can effect surfactant metabolism, especially when extracellular h release of alveolar macrophages following an immune response is increasing. introduction: primary stabilization of femoral shaft fractures in patients with multiple trauma is beneficial. however, in patients with associated lung contusion we have found an increased incidence of ards, apparently associated with primary reamed femnral nailing (rfn). previous animal studies revealed, that perioperative disturbances of lung ftmetion appear to be related to the reaming procedure, ix~ssibly due to pulmonary embolizafion of bone marrow fat. in a prospective clinical analysis we compared effects of intrameduuary nailing with and withont reaming on parameters known to be related to ards-pathoganesis. in order to gain further insight into the role of endotoxin and cytokines in the pathogenesis of the adult respiratory distress syndrome (ards), we enrolled patients with severe lung injury after sepsis ( ) or polytrauma ( ) and obtained multiple blood samples ( days) for endotoxin, tumor necrosis factor e (tnfa), interleukin (il- ) and interleukin (il- ) determination. to evaluate the cytokine releasing capacity of the blood, plasma concentrations of tnfe, il-l and il- were also determined after the "in vitro" stimulation of the whole blood samples with lipopolysaccharide (lps, . ng/ml) for hours at c (stimulated values). the difference among stimulated cytokines levels and the basal plasma concentrations were defined as "delta values", an expression of the cytokine releasing capacity of the blood. the pao /fiao quotient was used as an index of the severity of lung injury (sli). the endotoxin plasma level was significantly higher in patients with sli < ( . ± . eu/ml, mean values ± sem) versus the patients with a sli > ( . ± . eu/ml, p<o. ). the basal plasma concentration of ll- also correlates with the sli index (p<o.o ). the delta tnfe and delta il- values were s~gnificantly decreased in patients with a severe lung injury. compared with the survivors (n: ), the deceased patients (n= ) showed higher endotoxin level, a reduced tnfa and il- releasing capacity of the blood and higher basal il- levels. we can conclude that endotoxemia, high il- plasma level and a decreased capacity of the blood to release tnfa an il- under endotoxin stimulation associates with the severity of lung injury. [objectives] experimental and clinical findings implicate the involvement of inflammatory cytokines in the pathogenesis of the decreased oxygenation in the lung after major surgery, though the mechanism remains unclear. in the present study, we elucidated the involvement of il- in the pathogenesis of lung injury defined by deterioration of pulmonary oxygenation after esophagectomy. [materials and methods] seventeen patients underwent subtotal esophagectomy through a right thoracotomy. in all patients, tbe alveolar-arterial oxygen tension difference (aado ) was measured everyday and bronchoalveolar lavage fluid (balf) samples were obtained from a single segment ($ or $ ) of the right and left lung through a bronchoscope on days l, , and days after surgery. they were then examined for cell analysis, measurement of cytokines by elisa, and measurement of neutrnphil elastase (ne) by elisa. [results] aado unexceptionally deteriorated postoperatively and the mean aado in patients reached the maximum (mean ± sem; _+ mmhg) on the rd postoperative day. the mean concentrations of il- , ne and neutrophil count in balf also increased postoperatively and reached their maximum level ( + pg/ml, -+ gg/l, and ± x cells/ml, respectively) on the rd postoperative day. these increases in balf were recognized in both the right and left lung. a highly significant correlation was observed between il- and ne levels in balf (r= . , p= . ). also, significant correlations between aado and the neutropbil count, and the concentration of ne or l- were observed. in contrast to il- , neither il- , il- nor tnfa was detected in balf. [conclusion] major surgical trauma such as esophagectomy may induce recruitment of neutrophils to the lung and cause lung injury. il- increased in the lung is an important mediator of neutrophil recruitment and activation in the lung. phorbol myristate acetate (pma) is commonly used to cause edema and other tissue damages in the lung. lung injuries induced by the administration of pma has been shown to be mediated mainly by neutrophils. neutrophils recruited to the lower respiratory tract may damage lung tissues by releasing reactive oxygen species, neutral proteases and lysosomal enzymes. the present study was conducted to investigate whether c~tocopherol, entrapped in dipalmitoylphosphatidylcholine liposomes and delivered directly to the lung, could counteract some of the pma-induced lung injuries. plain liposomes or c~tocopherol-containing liposomes ( mg c~-tocopherol/kgbody wt.) were instilled into the lungs of rats h prior to pma exposure ( pg/kg, intratracheally) and treated rats were killed h later. lungs of control animals exposed to pma developed increases in lung weight and lipid peroxidation as well as decreases in lung angiotensin converting enzyme (ace) and alkaline phosphatase (akp) activities. pma treatment also caused an increase in myeloperoxidase (mpo) activity in the lung, suggestive of neutrophi] infiltration. pretreatment of pma-treated rats with plain liposomes had no effect on pma-induced injuries. in contrast, pretreatment of rats with liposomal c~-tocopherol, h prior to pma administration, resulted in a significant elevation of pulmonary a-tocopherol concentration, accompanied by a concomitant reduction in mpo activity and reversal of pmainduced changes in lung edema, lipid peroxidation, ace and akp activities. these results appear to demonstrate that the intratracheal administration of a liposome-associated lipophilic antioxidant, such as a-tocopherol, can significantly ameliorate the toxic effects of reactive oxygen species, released from pmastimulated pulmonary target cells and infiltrating neutrophils. jk wojcik, g palasiewicz, w roszkowski immunology department,institute of tuberculosis and lung diseases~ warszawa, poland, m~larhospital, eskilstuna, sweden. introduction:the critical point in neutrophil migration to the alveolar space in the course of ards is the attachment between giyeoproteins of neotrophil membranes(sialyl lewis x carbohydrate epitope containing u-l-fucose) and lectin domains of endothelial p and e selectins (gmp- ,elam-i). a potential beneficial therapeutic strategy may be designep to suppress neutrophil recruitment to the lungs by preventing their rolling and attachment to the pulmonary endothelial cells. objeclive:to investigate if tz-l-fueose prevent experiments pulmonary hypertension in ards as effective as metylpredniselone. methods:only healthy rabbits (n- ) weighing .d- . kg oaselinepao> kpa and mean pulmonary arterial pressure (mpap)<i. kpa were included in this study. anaesthesia was induced with thiopental - mg/kg bw and "blind" jntubation was performed. a f swan ganz catheter was introduced via the left jugular vein into the pulmonary artery. pma, as was used in our experiments activates neutrophils and produces acute respiratory failure with pulmonary hypertension and pulmonary edema. eight rabbits serving as control animals received pma ug/kg bw iv only. sixteen other animals were divided into two groups receiving either ~-l-fucose mg iv or metylprednisolone mg iv min before pma admininstration. results:after pma administration notable physiological changes including marked increase in mpap( . -+o.~ kpe ..lere found. the increase of npap was observed to be completely blocked in both groups of animals which received ~-l-fucose or metylprednisolone. conclusion:in aur rabbit model ards cz-l-fucose pretreatment prevents pulmonary hypertension after pma administration. the effect is comparable with high dose metylprednisolone. the possible explanation is that g-l-fueose molecules block iectin domains of gnp- or elam-i preventing the adhesion of the neutrophils to the pulmonary endotheliom. bartens c, elmadfa i, steltzer h, fischer m, druml w introduction: various micronutrients and vitamins are particulary effective in modulating immune functions and host defense. the nutritive ant±oxidants vitamin c, e and b-carotene, as well as selenium lower the burden of reactive free radicals and protect the structural integrity of cells and tissues of the immune system, as well as other systems in the body. certain cells of the immune system like polymorphonuclear leucocytes (pmn's) use free radicals as a weapon to destroy invading pathogens. these reactive molecules, when released into the surrounding area, mediate lipid peroxidation and tissue injury. there is growing evidence that pmn's are activated in vivo by complement or immune complexes in disorders such as ards. the respiratory host defense mechanisms of patients with adult respiratory distress syndrome (ards) may be defective. the aim of this study was ta evaluate the status of the free radical scavengers and their activity in ards and to investigate the respiratory burst of ards patients. methods: seven ards patients ( sepsis, trauma) with an fie of . + .( , a peep of . ± . , and a murray score of . ± . were included in this study. healthy adults served as controls. superoxide anion production in granulocytes was measured photometrically, and the hydrogen peroxides by fluorimetric assay. vitamin a, e, and g-carotene concentrations were assessed by hplc, and plasma vitamin c photometrically. plasma selenium was determined by dectrothermal aas. plasma lipid peroxidation pruducts, expressed as malondialdehyde (mda), were determined by thiobarbituric acid assay and hplc. results: mda-plasma (/xmol/l) . ~: . * . ± . *= < . , **=p< . condusion: ards patients showed significantly decreased plasma concentrations of vitamin c, e and g-carotene, as well as selenium. these nutritive ant±oxidants are consumed during increased oxidative stress. mda, a final product of lipid peroxidation, is increased. however, a difference in rates of release of hydrogen peroxides and superoxide-anion of pmn could not be detected. therefore, oxygen radical accumulation is more likely a result of excessive inspiratory oxygen concentrations (f.io ), pro-oxidant drugs, and a high settlement of pmn in the lungs, and not an increased release of free radicals of the single pmn. kd glycoprotein secreted by the alveolar type ii cells. recent study showed that sp-a exists in the sera from normal healthy adults and that the significantly elevated serum sp-a levels were observed in the patients with interstitial pneumonia and pulmonary alveolar proteinosis. these findings means there may be a mechanism that the sp-a produced in the alveoli escapes into the bloodstream. here we examined the serum sp-a levels in the patients with critical illness including sepsis and ards. ]clinical subjects & methods] a total of serum samples were collected from patients hospitalized in the division of critical care medicine(icu), sappom medical college hospital. serum sp-a levels were measured by an enzyme-linked immunosorbent assay using monoclonal antibodies to human sp-a. ]results] there was no significant difference between the septic (n= ) and non-septic (n= ) patients. patients with ards (n= , . + . ng/ml) and with respiratory disease other than ards (n= , . +- . ng/ml) showed significantly higher levels of serum sp-a than those with non-respiratory disease (n= , . _+ . ng/ml). as to the ards patients, it was likely that the serum sp-a levels were getting higher in their clinical courses. however, there was no significant correlation between the serum sp-a levels and the pa%/fio ratio. ]discussion] at the present time, the exact mechanism of the escape of sp-a into the bloodstream remain to be unclear. our results may suggested that there was some relation between this leakage of sp-a and the alveolar-capillary permeability because of the higher sp-a levels observed in the ards patients. however it is also likely that higher serum sp-a level represents the proliferation of alveolar type ii cells as the regeneration of damaged lung. further studies are now being done. neutrophils contain a number of enzymes within intracellular granules,potentially damagingto lung tissue.release of these enzymes into the lung tissue from the sequestred activated neutrophils is felt to play significant role in lung injury in the course of aros. using -hours acute animal model of aros the activity of cathepsins,beta-glucuronidase and acid phosphatase was determined in the lung tissue. results of this research were compared with neutrophil proteases activity in serum and broncho-alveolar lavage.also hemodynamic,respiratory and biochemical investigations were performed before beginning of experiment,and in a two-hours time intervals of its duration.after hours was determined total and free activity of cathepsins,beta-glucuronidase and acid phosphatase in full homogenate of the lung tissue,mitochondriallysosomal fraction and the final supernatant. in the course of our experiment we observed an increase ( .i- . %) both total and free activity of neutrophil proteases in all fractions of the lung tissue.generally accepted current pharmacological treatment of aros only attenuated this increase but never caused reversion to the level before beginning of our investigations. the presence of aros was histologically proved.an activity of acid phosphatase in serum and the lung tissue fractions was compared with histochemical pictures of the lung. results of our research indicate that neutrophil proteases are a very important mediators in aros and they are a cause of the lung injury. in addition neutrophil-derived proteases can amplify the inflamatory process by enzymatitally activating of many other mediators and they also may to increase an oxidant induced injury by imparing of antioxidant defenses. oepartment of general surgery, sk~odowskiej a - ~ia~ystok, poland, tel/fax + . in vitro studies demonstrated that paf activates polymorplionuclear leukocyte (pmn) - ipoxygenase, but the generation of leukotrienes (lts) is critically dependent on exogenous arachidunic acid (aa) disposal (f. grimminger et at., mol. pharmacol. : , ) . we investigated the features of paf-evoked lt synthesis in a model of pulmonary microvascular leukostasis, in the presence and absence of intravascular n- -and n- -prescursor fatty acid supply. human neutrophils were infused into isolated, ventilated and perfused rabbit lungs to achieve microvascular sequestration of ligand-responsive leukecytes. leukotrienes (lt) and hydroxyeicosatetra(penta)enoic acids (het(p)e) were quantified by itplc techniques. intravascular application of paf ( um) or arachidonic acid (aa;ioum) provoked the generation of limited quantities of -series lts and -hete (total sum of - ipoxygenade products rd. and rd. pmol/ml.; both in pmn-preloaded and non-preloaded lungs). combined administration of pat r and aa caused amplification of - ipoxygenase product formation with predominance of cysteinyl-lt synthesis both in lungs without (total sum rd. pmol/ml) and, much more strikingly, with pro-application of neutrophils (total sum rd. pmofml). eicosapentaeooic acid ( um) elicited exclusive generation of -series lts and -hepe (total sum rd. pmol/mi). dual stimulation with paf and epa provoked amplification of epa-derived - ipoxygenase product formation, again with predominance of cysteinyl-lts, in lungs without (total sum rd. pmul/ml) and in particular in those with preceding microvascular pmn entrapment (total sum rd. pmol/ml). we conclude that the paf-evoked - ipoxygenase product formation in the neutrophil-harbouring lung capillary bed is critically dependent on intravascular precursor fatty acid supply, with epa representing the preferred substrate as compared to aa. pmn-related transcellular eicosanoid synthesis is suggested to underly the predominant generation of cysteinyl-lts. these findings may be relevant for lipid mediator profiles provoked by infusion of n- -versus n- enriched lipid emulsions in diseases with pmn-related inflammators events. adult respiratory distress syndrome (ards) involves damage to the alveolar epithelium and microvascular endothelium. products released from neutrophils (pmn) are thought to be among the chief causes of this damage, while the role of mononuclear cells (mnc) is uncertain. we studied patients at risk of or with acute ards. we measured the concentration of myeloperoxidase (mpo) and elastase (el) within circulating pmn as an index of pmn activation, elastin degradation products (edp) in the plasma as an index of tissue damage, as well as the cytotoxici~y of pmn and mnc to endothelial cells (ec) in vitro. cells and plasma were prepared from venous blood of healthy controls; or systemic arterial blood of patients on ventilators in intensive care but not at risk of ards; at risk of ards because of sepsis; at risk because of multiple transfusion/major trauma; or with acute ards. lung injury, multi-organ failure and apache h scores were recorded. to measure cytotoxicity, human umbilical vein ec were labelled with cr- , incubated with either pmn or mnc for hours, and the supernatant counted. the adherence of the pmn and the mnc to the ec was also measured. standard assays were used to measure mpo and el in the pmn, mad edp in the plasma. the mnc cytotoxicity did not differ between the groups. the pmn cytotoxicity was higher in the transfusion/trauma patients compared to each other group, which did not differ from each other. there was no correlation between cytotoxicity and adherence for any group. the mpo and the el concentrations were significantly decreased in the pmn from each of the patient groups, including the patient controls, compared to healthy controls. the edp were only increased in patients at risk of or with ards. thus pmn degrannlation occurred in patients not at risk of ards, but tissue damage as measured by increased edp only occurred in patients with or at risk of ards, suggesting that factors additional to pmn activation and degranulation are required for the progression to ards. there was no correlation between the parameters measured and the indices of disease activity, or outcome. these measures of pmn and mnc activation and function are not of value as prognostic indicators in patients with or at risk of ards. the liver is made up of several different cell types which subserve distinct functions in vivo. in addition to the different functions of the distinct cell types, it is now evident that even within the population of hepatocytes substantial functional heterogeneity exists. this heterogeneity occurs in a very organized fashion in the normal liver based upon the position of the hepatocyte in the acinus. although it has been proposed that the acinar heterogeneity of hepatocytes arises from migration of immature hepatocytes from the periportal region to the perivenous region where they become senescent and die, many of the heterogeneous responses can be accutely reversed by reversal of the oxygen gradient via retrograde perfusion. under normal conditions in which the acinus is exposed to unidirectional flow, the periportal hepatocytes are exposed to relatively high levels of oxygen, substrates and hormones. as these substances are extracted along the aeinus their concentration decreases leaving relatively low concentrations for the perivenous hepatocytes. in the normal liver, the heterogeneity of response is attenuated by extensive communication via gap junctions. the major liver gap junctions are made up of hexamers of connexin (cx ) which forms channels between cells capable of pas.~ing any molecule smaller than d. coupling is sufficient to allow diffusion of molecules such as atp or camp from one hepatocyte into > adjacent hepatocytes within seconds. during stress conditions such as endotoxemia or zymozan inflammation, expression of cx is markedly decreased while the secondary gap junction protein cx is either unchanged or even increased. while cx readily effects electrical coupling, molecules > d pass only very slowly. this would result in restriciton of transmission of moecules the size of atp or camp. since inhibition of gap junctions also attentuates metabolic response to hormone or nerve stimulation, it is evident that modulation of hepatocyte hetereogeneity by gap junctions must be considered in determining the mechanisms of metabolic alterations during stress. already minor haemorrhage decreases portal venous blood supply to the fiver and the reduction in portal blood flow becomes more pronounced with more profound btood loss. severe hacmorrhagic hypovolemia also reduces hepatic arterial blood supply which, however, is maintained over a vide range of haemorthage. the net effect of blood loss is a reduction in liver oxygee supply and this reduction is in proportion to the vulume iossed. however, oxygen supply to the liver exceeds the demands of the normal liver and this is the ca~ stilt following reduction of % of blood volume. the situation in sepsis is more complicated. po~l venous supply to the liver is redur.~i fairly early following normovolemic sepsis while hepatic arterial blood supply is maintained at le,~t initialiy, oxygen saturation might be maintained in arterial blood but may also be slightly reduced during sepsis, oxygen saturation of portal venous blood is significantly reduced during sepsis due to increased extraction of the intestines. therefore oxygea delivery to the liver during sepsis becomes sigalfkzntly reduced. at the s,~ne time and for mai.v.ly unknown reasons the need for oxygen becomes significantly increased in the ~-~ptic liver. as a consequence liver oxygen consumption becomes flow dependent and the liver is likely to suffer from ischemia during septic conditions. $ although liver failure is well recognized in sepsis, it is generally thought to be a late complication following pulmonary and renal failure. jaundice, hypoglycemia, encephalopathy and bleeding secondary to low levels of liver-synthesizing clotting factors are, however, signs of rather severe end-stage hepatic failure. furthermore, elevated liver enzymes (sgot and sgpt) represent hepatucyte damage and not hepatocellular dysfunction. in view of this, a more sensitive indicator of hepatic function is desirable in order to detect early hepatic abnormality. in this respect, indocyanine green (icg) is a tricarbocyanine dye that possesses several properties which makes it particularly valuable inthe assessment ofhepatic function. this dye is bound m albumin and is cleared exclusively by the liver through an energydependent membrane transport process and is nontoxic at lower doses. we propose that maximal velocity (vm~,) of icg clearance is a valuable measure of active hepatocellular function, since the total concentration of functioning receptors is directly proportional to vm~. we have utilized a fiber optic catheter and an in vivo hemoreflectometar to continuously measure the administered icg in vivo and consequently determine its clearance without the need of blood sampling. using this technique, we have found that in the early stages of sepsis (i.e., and h following cecal ligation and puncture), the vm~ and kinetic constant (k=) of icg clearance was significantly depressed. it should be noted that at this stage of sepsis, there was no elevation in serum enzyme levels. furthermore, hepatic blood flow and cardiac output increased at the above mentioned time points. thus, the extremely early depression in active hepatocellular function in sepsis, despite the increased hepatic blood flow and cardiac output, may form the basis for cellular dysfunctions leading to multiple organ failure during sepsis. additional studies indicated that following hemorrhage, active hepatocellular function was markedly depressed. this returned to prehemorrhage levels after ringers lactate resuscitation, however, this function was not maintained and decreased significantly after fluid resuscitation. nevertheless, the depressed active hepatocelinlar function following hemorrhage was markedly improved by post-treatment of animals with either atp-mgci , peutoxifylline or diltiazem. thus, the use of icg clearance provides an early sensitive indicator of hepatic abnormality during sepsis and following hemorrhage and this method should be used, not only experimentally, but also in the clinical arena for the early detection of hepatocellular abnormality. although multiple organ dysfunction syndrome (mods) remains a major cause of mortality and morbidity in intensive care units, very little is known about the mechanisms that precipitate its development. since an episode of inadequate tissue oxygenation is considered to be the trigger for mods, we have proposed that a primary localized injury such as ischemia/reperfusion may be sufficient to cause a change of gene expression of remote and apparently unaffected organs. such modulation of remote organ gene expression may decrease the organ's tolerance to a subsequent stress contributing to the development of mofs. to test this hypothesis, rats were subjected to hepatic regional ischemia by clamping the blood flow (hepatic artery and portal venous inflow) of the left and median liver lobes. intestinal congestion was prevented by allowing flow through the smaller right and caudate lobes. after minutes of ischemia, the clamp was removed and the blood flow restored. the animals were allowed to recover for , and hours. kidneys were removed, total rna was isolated and poly(a) ÷ selected by affinity chromatography on oligo(dt) columns. message was in vitro translated using rabbit reticulocyte iysates in the presence of radioactive amino acids. the gene products (radiolabeled polypeptides) were fractionated by two dimensional gel electrophoresis, and visualized by fluorography. analyses of the two dimensional fluorograms indicate that there is a dramatic change in the electrophoretic pattern of in vitro translated products in samples corresponding to kidneys obtained after minutes of hepatic ischemia and hours of reperfusion with respect to kidney samples obtained after sham operation or from control rats. the latter were not subjected to any surgical manipulation. these studies suggest that the gene expression of the kidneys is specifically modified after a remote organ injury (hepatic ischemia/reperfusion). we speculate that this change of gene expression in kidneys after an indirect injury may be part of the early events leading to the development of mods. a priming event, e.g. local ischemia, in combination with a second insult, e.g. sepsis, may amplify a host's response and lead to multiple organ failure. to better understand the mechanisms involved in the pathophysiology, male fischer rats were subjected to min of hepatic ischemia followed by reperfusion (rp) and injection of . mg/kg salmonella enteritidis endotoxin (et) at min of rp. et injection potentiated the postischemic liver injury as indicated by histopathology and an increase of plasma alt activities from + u/l (i/rp only) to + u/l at h rp. inhibition of kupffer cells (kc) with gadolinium chloride ( mg/kg) attenuated liver injury in this model by %, however, monoclonal antibodies (cl , wt ) directed against adhesion molecules ( integrins, cd ) on neutrophils had no effect on the injury despite the substantial accumulation of neutrophils in the liver at that time ( + pmns/ hpf; baseline: + ). isolation of kc and neutrophils from the postischemic liver indicated a -fold increase of the spontaneous superoxide formation only in the kc fractions [ . + . nmol o -/h/ %elts (kc ); . _+ . (kca) ] at h rp compared to control cells. in addition, stimulation with phorbol ester or opsonized zymosan revealed a substantial priming of kc for reactive oxygen formation. in contrast to the short-term experiments ( h), the antibody wt ( mg/kg) attenuated liver injury by % at h of rp and improved survival. conclusion: liver injury during the early rp phase is mediated mainly by kc generating excessive amounts of reactive oxygen while neutrophils are primarily responsible for organ damage during the later rp period. (es- and gm- ) tumor necrosis factors (tnf) are cytokines which are cytotoxic towards some tumors in vivo and certain tumor lines in vitro. moreover, these polypeptides are powerful immunomodulators and have been found to be distal mediators in several models of septic shock and septic organ failure. one of the best-characterized experimental systems is the hepatitis caused by lps or tnf in galactosamine (galn)-sensitized mice. here we describe a cell culture system, in which the direct toxicity of tnf towards mouse hepatocytes was examined. the toxicity of tnf, as determined by ldh-release or formazan-formation, was dose-and time-dependent. the threshold of toxicity was ng/ml, which corresponds to serum concentrations found in mice after lpsinjection. toxicity was only observed in hepatocytes sensitized with transcriptional inhibiters such as galn, actinomycin d (actd) or cxamanitin. sensitization was neither observed with different translational inhibitors nor with various other metabolic inlaibitors or toxins. inhibitors of protein synthesis or protein processing such as cycloheximide, puromycin, tunicamycin and ricin protected actdsensitized hepatocytes from tnf-induced cytotoxicity. tnf induced apoptotic changes and dna-fragmentation in sensitized hepatocytes which is in line with the above findings that cell death is dependent on protein synthesis. thus tnf may be a trigger of programmed cell death during inflammatory organ damage. with the purpose of studying the role of complement activation in tissue injury after ischaemia and reperfusion we blocked the complement cascade in a model of rat liver isehaemia and reperfusion, either by administration of soluble human complement receptor type (scri), mg/kg iv after vascular occlusion (n= ) or by depleting the complement system using cobra venom factor (cvf), . mg im, and hours before ischaemia (n= ). non-ischaemic rats (n= ) and ischaemic non-treated rats (n= ) were used as controls. the experimental procedure consists of the temporary interruption of arterial and portal blood flow to the left lateral and medial lobes of the liver during minutes, followed by reperfusion, recording the liver blood flow and haemoglobin saturation with a laser doppler flowmeter and photometer during one hour after declamping; alt levels were assayed and immunoperoxidase stainings for c and c were performed. there were statistically significant differences between the experimental ~roups and the untreated ischaemic control group in terms of post-isehaemic blood flow (p< . ) and haemoglobin saturation (p< . ). c and c were present in the endothelium of the ischaemic control group. no deposits of c or c were found in the cvf group. few c and no c were found in scri treated rats. these results show that the effect of reperfusion injury in the rat liver is ameliorated either by depleting complement with cvf or by regulating complement activation with scri. hepatic dysfunction, a major cause of mortality following hemorrhagic shock, has not yet been well characterized. the present study was designed to assess the effects of liver blood flow and cytokine levels on hepatic function following resuscitation from severe hemorrhagic shock in normal and cin-hotic rats. methods: aftor pentobarbltal anesthesia, control and cirrhotic sprague-dawley rats were subjected to severe hemorrhage to reduce their systolic blood pressure to + mm hg. this level of hypotension was maintained until the skeletal muscle transmembrane potential (era) depolarized by %.; the animals were then resuscitated with ringer's lactate solution in three times the volume of the shed blood. serial blood samples for tumor necrosis factor (tnf) determination (a modified flow-cytomeuic wehi cell bioassay) were obtained at baseline, during hemorrhage and following resuscitation. liver blood flow measurements by low dose galactose clearance (glc) and functional bepatocyte mass (fhm; defared as galactose elimination capacity [gec] from the zero order portion of the plasma disappearance curve following an intravenous galactose bolus [ mg/kg], divided by liver weight) were measured before shock and after resuscitation. results: higher survival rates (p < . ) were observed in control as compared with cirrhotic rats. shock produced a significant reduction in gec (to < . ); fhm ( < . ); and liver blood flow (p < . ) in normal and cirrhotic rats. decreases in gec and fi-im were greater (p < . ) in cirrhotic rots. tnf levels were higher (p < . ) in cirrhotic rats at baseline and during induction of shock. pre gap junctions provide pathways for metabolic signals between cells. in the liver, the majority of gap junctions are composed of connexin (cx ) polypeptide subunits, and are regulated by gluconeogenic hormones. since sepsis and other inflammatory states alter hepatic glucoregulatory control, we have evaluated the contribution of gap junctional conductance to the metabolic dysregulation in the liver. an acute inflammation was induced in rats by injection with e. coli endotoxin (lps lmg/kg). northern blot/hybridization analysis of total rna isolated from livers after endotoxin injection show a decrease in the steady state transcript levels of cx to % of sham controls. immunostaining of liver sections using anti-cx revealed punctate fluorescent staining on the plasma membrane at regions of call-cell contact in saline injected animals, whereas, staining was only observed in cytoplasmic vesicles hrs after animals were treated with lps, suggesting the internalization of cx without replacement on the cell surface. the staining was quantitated and expressed as % of pixels above threshold. at hr post injection . % ofpixels exceeded threshold, compared to . % in sham controls. functional gap junctional communication was assessed by dye coupling using lucifer yellow in an isolated perfused liver under intravital fluorescence microscopy. dye diffusion was markedly decreased hr after endotoxin injection. this suggests that decreased metabolic coupling after lps injection results from decreased gap junction abundance. the present data suggest that metabolic dysregulation during sepsis may arise in part from changes in intercellular communication caused by a decrease in gap junctional expression and communication. given the marked metabolic heterogeneity of hepatocytes with respect to acinar location, metabolic signaling via gap junctions most likely serves to moderate this heterogeneity, contributing to a coordinated metabolic response. altered cellular ca ÷ regulation might be a critical step in organ dysfunction during sepsis and ischemia/reperfusion events. the aim of the present study was to evaluate hepato-ceuular ca ÷ regulation in isehemiah'eperfusion after hemorrhage and to assess effectiveness of tnfc~-monoclonal antibody (tnfo~-moab). methods. male sprague-dawley rats ( g, n>_ /group; pentobarbital mg/kg) with hemorrhage for rain at mm hg. reperfusion by ringer's lactate ( x maximal bleed out/ min) and % of citrated shed blood. tnfcz-moab (tn , ceutech, mg/kg in . % nac ) infused during flrst min of reperfusion. at baseline, end of ischemia and min of reperfusion, hepatecyte isolation by liver collagenase perfusion. " hepatocyte incubation ( mg w.w./ml) with caci ( . + + + mbq/ml) for rain (ca influx [slope, /mini; ca uptake [nmol ca /mg protein]) w/ and w/o epinephrine (epi, nm). hepatecyte resuspension in radioisotope-free medium and farther incubation (exchangeable ca + (ca +ex) [nmol ca +/mg protein]; ca + membrane flux [nmol ca +/mg protein'min]). during incubation, aliquots ( ~tl) were centrifuged through oil/lanthanum gradient and acivity measured by scintillation counting. statistics: anova. mean + sem. results. hepatocyte ca +ex and membrane ca + flux were significantly increased at both, the end of ischemia ( . +. ; . +. ) and reperfusion ( . +. ; . +. ), as compared to sham-operated animals ( . +_. ; . +. )( <. ). tnfc~-moab treatment significantly prevented reperfusion-induced increase of ca +ex ( +. ) and membrane ca + flux ( . +. )(p<. ). fast ca + influx was significantly increased by epinephrine in hepatecytes from sham-operated rats ( . +. vs. epi: . +. , p< . ). this hormone effect was not observed in isehemia ( . +. , epi: . !-_. ) or reperfusion (untreated: . +. , epi: . +. ; tnft~-moab: . _+. , epi: . +. ). conclusion. the present study clearly demonstrated hepato-cellular ca + overload in ischemia and reperfusion as a result of hemorrhagic shock. analysis of membrane ca + fluxes and hormone ca + mobilization suggests disturbances of membrane ca + transport mechanisms, e.g. through ca +-atpases. reperfusion-induced oxygen free radical generation which affect exchange kinetics of cellular ca + buffering compartments might also be operative. prevention by tnfct-moab indicates the pivotal role of tnf as an early inflammatory mediator of hepatocellular alterations in signal transduetion mechanisms and cellular homeostasis. although the precise mechanism has not yet been elucidated, bacterial translocation and endotoxin absorption have been frequently shown after burn, and have been postulated to be one of the underlying processes of sepsis. the purpose of the current study is to define the hemodynamic response of the liver to endotoxin release in burns, in correlation to bacterial translocation. twelve female minipigs, weighing - kg, underwent a laparotomy & transition time ultrasonic flow probes were positioned on the portal vein, the common hepatic artery, and the superior mesenteric artery. . fr catheters were inserted in the superior mesenteric vein and the left hepatic vein. a jejunostomy was also performed. after five days all animals were anaesthetized and randomized to receive % of tbs a third degree burn. eighteen hours after burn. gg/kg e. coli lps was intravenously administered over rain. ali animals were studied for additional hours and then sacrificed. several recent data suggest that in severe injuries, such as shock state, the gradual activation of kupffer cells and the excessive release of destructive and immunosuppresive products from macrophages may contribute to the development of "multiple organ failure". in in vivo experiments in mice, the effect of kupffer cell phagocytosis blockade on the correlation between the tissue distribution of lps, endotoxin sensitivity and lps-induced tnf production was investigated. to depress the activity of the kupffer cells, gadolinium chloride (gdc ) or carrageenan was used. th~e studies indicate the dissociation of tissue localisation of cr jllabelled endotoxin and endotoxin lethalithy. both gdc and carrageenan depressed kupffer cell activity, but endotoxin sensitivity was enhanced only by carragenan treatment. however, there was a close correlation between the sensitivity to lps and lps-induced tnf production as measured in the serum, since lpsinduced tnf production was enhanced only by carrageenan treatment. on the other hand, gdc pretreatment significantly increased tnf production in the spleen. these results support our earlier findings that gdc -indueed kupffer cell phagocytosis blockade leads to activation of the spleen, and may explain some of the immunological effects of gdc . inositol(l, , ) triphosphate (ip ) has been proposed as a second messenger for calcium mobilization. the addition of ip at low concentration has been shown to cause calcium release from intracellular microsomal store in rat hepatocytes. the effects of sepsis on the ip binding from microsomal fraction of rat hepatocytes during sepsis were investigated. sepsis was induced by cecal ligation & puncture (clp). control rats were sham-operated. three microsomal fractions (rough, intermediate and smooth) were isolated from rat liver. study of ip receptor binding was performed with tridium label ip . the results shewed that the ip binding was significantly depressed by - % (p< . ) during late sepsis ( hrs after clp), but not in early sepsis ( hrs after clp). the ip binding depression during late sepsis was most significant on rough and intermediate endoplasmic reticulum (p< . ), but not on smooth subfraction. since ip binding plays an important role in the regulation of intracellular calcium homeostasis in hepatocytes, an impairment in the calcium release due to depressed ip binding on smooth and intermediate endoplasmic reticulum during late sepsis may have a pathophysiological significance in contributing to the development of altered hepatic metabolism during septic shock. septic organ failure is currently recognized as an overactivation of the nonspecific immune system by bacterial stimuli giving rise to proinflammatory mediators. little is known about the mechanisms of the resulting cellular injury. here, a synergism is described between tnf as a major mediator of septic organ injury released by macrophages and hydrogen peroxide (h ) as a representative of reactive oxygen species as formed by e.g. neutrophils. rat hepatocytes are only slightly sensitive to either agent alone. when treated with a conbination of tnf and h# a stronq synergistic toxicity was found, especially w~e~ tnf-treatment preceeded challenge with h~o~. we have recently described a coculture model bfzrat liver macrophaqes and hepatocytes where lps induces hepatocyte cell death partially mediated by macrophage tnf release. when h was also employed in fhis more complex cellular system a similar synergism was found: the ecc~ of lps was consecutive patients with liver cirrhosis admitted to the department of surgery over a year period from january to december were studied for their complement profiles in relation to other parameters of liver function, the aim of the study was to determine if a direct correlation existed between low complement levels and end stage liver cirrhosis. cirrhotic patients were divided into child's a, b and c categories using child's classification. complement levels (c , c ) were measured and functional assay for complement (ch ) were performed in each of these groupings in addition to normal blood donor controls. these results show that the qualitative c , c and the functional chs complement assays have good predictive values in assessing deteriorating liver function• in particular, the functional assay for complement (ch ) showed marked impairment in child's c patients (p< . ) confirming the impaired immunological status of these patients. sera from this group of patients (child's c) were titrated with pig red blood cells (rbcs) in a haemolytic assay. the results showed that there were significantly less haemolysis of pig rbcs in these patients (p= . ) as compared to the controls. this findings strongly support an impaired immunological status in child's c liver cirrhosis and may explain the high incidence of sepsis as a terminal event in these patients. aim:kupffer cells(kc) have an importamt play to cause hepatocellular injury in sepsis, because these cells release many kinds of substances. we reported that oxygem radicals released by kcs stimulated by lipopolysaccharide (lps) caused hepatocellular injury. aim of this study is to investigate the relationship between imtracellmlar calcium(ca) concentration of cultured rat kcs stimulated by lps and release of oxygen radicals, and effect of prostaglandin e~ (pge~) on imtracellular ca concentration. production of acute phase proteins (c-reactive protein, crp, transferrin, tf) and £erritin (f) in rat hepatocytes (hps) and its dependence on extracellular matrix components were studied. hps isolated from the liver by collagenase perfusion were cultured at ~o per . ml medium fi +dmem ( : ) with % fetal calf serum for days on uncoated or type i collagen coated plastic surface or in the presence of dextrane sulphate in the medium. hps were stimulated by conditioned medium (gm) from i~ia-p or e. coli lps preineubated human blood mononuclear cells. production of crp, tf and f by hps was detected by elisa. it was found that both cms decreased tf synthesis in hps by - % (p<o.os). the level of f synthesis didn't change or only slightly decreased. the addition of cms led to the enhancement of crp synthesis more than . times. the most reproducible results were obtained when plastics had been coated with collagen. dextran sulphate markedly increased crp synthesis. thus using this model of an acute phase reaction in vitro we found the enhancement of crp synthesis and the decrease of tf synthesis. our data correspond with nublished materials on the acute phase in vivo and point to relevance of the proposed model. metabolism of hepatocytes under traumatic illness has not been sufficiently investigated. therefore we have applied absorption and fluorescent cytophotometry techniques to study the content of rna, glycogen and its fractions in hepatocytes of patients with severe mechanical trauma, both with and without endointoxication at various stages. for these purposes slides were prepared from the repeated aspiration biopsy material according to special techniques (kudryavtseva et al., ) . slides were stained by gallocyanin-chromalum to measure rna or underwent fluorescent pas-reaction to measure glycogen and its fractions (kudryavtseva et al., (kudryavtseva et al., , the ability of metabolites derived from the xanthine-xanthine oxidase system to inhibit mitochondrial function was examined using freshly isolated rat liver mitochondria. under uncoupled conditions, mitochondria exposed to free radicals exhibited a significant decrease in consumption supported by nad+-iinked substrates, but showed almost no change in consumption in the presence of succinate and ascorbate. the activity of electron transfer complex i (nadh oxidase and nadh-cytochrome c oxidoreductase) and the energy-dependent reduction of nad+ by succinate were unaltered by oxidative stress. exposure to free radicals also had an uncoupling effect at all three coupling sites. the degree of mitochondrial swelling was closely correlated with the inhibition of state oxidation of site i substrates and with the increase in state oxidation of succinate. the immunosuppressive agent cyclosporin a (cya) completely prevented the mitochondrial damage induced by oxygen free radicals (swelling, ca + release, sucrose trapping, uncoupling, and selective inhibition of the mitochondrial respiration of site i substrates). the same protective effect was found when ca + cycling was prevented, either by chelating ca + with egta or by inhibiting ca + re-uptake with ruthenium red. these findings suggest that the deleterious effect of free radicals on mitochondria in the present experimental system was triggered by the cya-sensitive and ca ÷-dependent membrane transition, and not by direct impairment of the mitochondrial inner membrane enzymes. correspondence should be addressed to: naoshi takeyama the aim of this study was to clarify the critical role of reduced glutathione (gsh) on the progression of lipopolysaccharide (lps)induced liver damage of mouse. the conditions of gsh-depletion and -richness were produced by intraperitoneal administration of buthionine sulfoximine (bso), a specific inhibitor of gsh synthetase, and of gsh-monoethyl ester (gsh-me), respectively. gsh-me, which was esterified the caboxyl group of the glycine residue, is readily transported into cells and is hydrolyzed intracellularly; this leads to greatly increased the cytosolic and mitochondrial levels of gsh. bso and gsh-me were administered intraperitoneally mmol/kg and mmollkg, respectively, and lps ( mg/kg) given h later. hepatocytes were isolated by in situ perfusion of the liver with collagenase h after lps injection. the degree of hydrogen peroxide (h ) synthesis and mitochondrial membrane potential were measured by flow cytometry using fluorescence probe dichrolofluorescein diacetate and tetrametyl rhodamine ethyl ester, respectively. the degree of mitochondria membrane permeability transition (mmp) was assessed by [ ]sucrose entrapment. we found that lps treatment results in a decrease in hepatic gsh level and mitochondrial membrane potential, and an increase in h synthesis and mmp. lps administration to bsq-pretreated mouse worsened at[ these parameters. in contrast, gsh-me pretreatment ameliorates. all together, gsh may acts an important role in cellular defence against lps-mediated liver damage, and mmp may result in the decrease in mitochondrial membrane potential. it has been shown, up to now, that disturbances of enzymatic processes in the cell organella are the basic factor of the changes taking place during endotoxin shock it has been observed that lysosomes are biochemically changed as result of the effect of lipopotysacharides of gram negative endotoxic bacteria. the purpose of the experiment was: .evaluation nfthe course of the ees due to the biochemic changes .determination of the influence of the ees on the activity of lysosomal enzymes in liver cell .deterrmnatian of the influence of h and d on the activity of some lysosomal enzymes in liver cell during ees material and method: examinations ware carried out on dogs. the shock was evoked by i.v. administration of endotoxin e.coli. the dogs were divided into groups: icontrols, i[ -dogs with untreated shock, iii-dogs in shock treated with h, ivdogs in shock treated with d, v -dogs in shock treated with h and d. the following parameters were determined: .activity of acid phosphatase in the venous blood serum. - .total and free activity of acid phosphatase and catepsins in the full liver cell homogenate, in mitochondrial-and-lysosomal fraction, and in the superuatunt (all after hours of the experiment). conclusions . essential increase of activity of lysosomal enzymes was observed in the ees. . increased activity of lysosomal hydrolases in the liver cell homogenate corresponds, as a result of the endotoxin effect, with increased enzymatic activity in the peripherial blood. extensive investigations from our laboratory of the pathophysiology of hepatic no-flow ischemia ( min) -reperfusion injury demonstrated substantial kupffer cell activation with reactive oxygen formation during the first few hours of reperfusion as indicated by increases in plasma glutathione disulfide (gssg) levels in vivo (am. j. physiol. : g , ) and enhanced superoxide formation by kupffer cells (kc) isolated from the postischemic livers (free radic. res. commun. : , ) . the early kc-induced injury initiated the later, primarily neutrophilmediated reperfusion injury (faseb j. : , ). to test whether or not similar mechanisms are operative during hepatic ischemia induced by hemorrhagic shock, male fischer rats ( - g) were subjected to rain of hemorrhage (mean arterial pressure mm hg) followed by resuscitation (rs) (reinfusion of shed blood). hepatic atp levels declined from . + . txmol/g to . _+ . ( min shock) indicating severe ischemia, and recovered to . -- . at min rs. to test for potential oxidant stress during rs, plasma gssg conc. were measured. although gssg levels increased by % compared to baseline levels ( . !-_ . i.tm), there was no significant difference to shamoperated controls. spontaneous superoxide formation of isolated kc was . + . nmol o -/min/ ecells (kc ) and . + . (kc ) in controls and did not change significantly after shock and rain rs. addition of phorbol ester or opsonized zymosan to isolated kc did not indicate a priming of these cells. conclusion: in striking contrast to our previous findings with hepatic no-flow ischemia, there is no evidence for a significant kc activation after min of hemorrhagic shock and up to rain of resuscitation. objectives-this study investigates morphometric changes in kc nltrastmcture which might account for this diminution in phagacytosis. materials and methods -three groups of wistar rats were studied: control, sham-operated [sham] and bile duct ligated [edl] . after weeks animals were sacrificed and livers were "perfusion fixed" with % glntaraldehyde and processed for transmission electron microscopy and image analysis. results -in the the bdl group kupffer cell numbers were greatly increased. biliary ductular proliferation was evident and sinusoidal spaces were compromised. eleven nuclear and cytoplasmic parameters were measured and statistically significant results are summarised in the results: ascorbic acid levels were slightly elevated after the hs and returned to basal values after rain. glutathione concentrations were increased significantly after the hs and the gsh levels kept rising continuously to as much as -fold of basal levels at the end of min. mda showed no significant variation before and after the hemorrhagic shock. plasma concentrations of ratine, teucine, isoleucine, phenylalanine, proline, threonine and serine showed significant increase over basal levels during the whole ischemic period. glutamic acid was slightly elevated at the onset of hs and remained the same for the rest of ischemic period. hydroxyproline was significantly below the basal value at the mid-point of ischemic period. alanine, glycine, histidine and aspartate did not change significantly throughout experimental time course. conclusions: ( ) oxidative stress might not be severe in the systemic hemorrhagic shock for pigs since no significant variations were observed for ascorbic acid and mda ( ) the increase of gsh might be that it was released from hepatocytes when the animal was under systemic ischemia. ( ) celzain amino acids might be acting as transmitters in the event of ischemia. however, fm"lher investigations are needed to clarify the detailed mechanism in regard with antioxidants and amino acids. dr. fang-ku p'eng taichung veterans general hospital talchung, taiwan , r.o.c. jia shi yong, huang zhi oiang and men xian jun. in patients underi~ent major hepatic surgery,obstructive jaundice has been implicated with fnoreased susceptibility to sepsis and liver failure. jaundice was said to he associated with derangement of iamune function and result in expression of pr,:.inflar...aatory cytoki~es that cause hepatooellular damage. this study is ~.o investigate the effects ,.,t lip,~polysaccharide(lps)rats. jaundice were produced in healthy ~istar rats of either sex weighing - m~ by common hi l~ duet l igation(bl)l).seven days post l igation, rats were given lps( .gg. ) . rag/kg intraperitoneally. at the end ,:,f l,gand hours after lp$ ehanllenge, liver were removed and prepared for forzen sections immediately. i)emonstration of inf in liver parenchyna were performed by method of abu i~munohistochemistry using r~onoolonal antibody against tnf, leve of mrna for tnf ~ere measured by in-situ hybridization using biotin-labeled edna probe. results sho'~ed that tnf stained granules appeared in kup~'fer eell~ and polymorphonuclear leukocytes(pnnl,but not in hepatoeytes nor endothelial eel is. they ~'ere located within cytoplasms and peaked at - hours after lps ohal lenge. there was vocomitant tnfmrna expression but peaked earlier hour post lps challenge. tnfmrna vcere detected notably in necrotic area and barely in bdl rats ~ithout lps challenge. it is therefore postulated that production of tnf by inflammatory effeetor cells-kupffer cell and phn in site, in the obstructive jaundice rats during sepsis may atribute to the hepatocellular damage. it also provide evidence for the beneficial effects of early release of biliary obstruction. in the present study, an animal model of a c in wlstar rats was developed by tigatlng the common bite duct and injecting d. mt solution of e. goli % b, (g× ' efm/mt) into the bite duct. the mortality rate was ~ at h after aoc. at , , , h after aoc, kcs were isotated and cultured atone or cocuttured with hepatocytes to evaluate the modulation effect of kgs on hepatoeyte protein synthesis. the results showed that tactodehydrogenase leakage was increased progressively as the injured k~ function and structure developed. tnf and il-i tn the supernatant were detected with the peak values at h after aoc. at h after aoc, ~-teueine incorporation was obviousty decreased in the normal hepatocytes eocuttured with stimulated kcs compared to the uormai hepatocyte cultured group (p< . ), but it was slgnificantiy increased in the group cocultured with normal kcs. in the a c group, 'h-teuclne ineorporatien was decreased progressively in the injured hepatoeytes cocuttured with stimulatedkgs and it was markedly elevated when cocuttured wlthnormat kcs at h after a c (p< . og). it is concluded that the impaired hepatocyte proterin synthesis was directly mediated hy the stimulated kc function during aoc. such a mechanism possibly may be involved in the patho ensis of hepatic dysfunction and m f following h . " the project supported by nsfc. in the past few years it has become evident that cytokines are implicated in various pathophysiological mechanisms. therefore measurement of cytokines and their potential inhibitors in biological fluids may be helpful in diagnosing and monitoring of diseases. however, dependent on the type of assay used investigations performed in different laboratories have often yielded conflicting results. in order to assess reliability and reproducibility of cytokine measurements two comparative studies for the determination of cytokines in biological fluids were launched by several investigators interested in this field: one national austrian ~tudy and one european study in the context of the european workshop for rheumatnlogy research. serum and synovial fluid samples were distributed by the organisers, and participants had to measure one or several of the following cytokines in all samples: il- , il- , l- , i , tnf-alpha, ifn-gamma, gm-csf, and the soluble receptors for il- and tnf; both commercially available immunoassays and home-made assays were allowed. so far, the main conclusions emerging from these preliminary studies are: ( ) the same immurzoassay (elisa) yielded comparable results in different laboratories; ( ) immunoassays from different manufactureres usually measured the highest concentrations in the same samples, yielded similar relative values but disparate absolute values; ( ) assays for soluble receptors yielded less discrepant results; ( ) some assays seem to be more suitable for measuring cytokines in biological fluids than others. the mean retrieval of exogenous recombinant human cytokines was approximately % for most cytokines tested. however, it must be borne in mind that natural and recombinant cytokines may behave differently in immunoassays. this raises the question as to the necessity of setting up international standards for all cytokines. possible interferences by serum components such as (lipo)proteins, complement, rheumatoid factors, etc., which may either decrease assay sensitivity or yield false positive results, must also be considered. in addition, natural cytokine binding proteins (e.g. soluble receptors) might interfere with cytokine determination in immunoassays. the problem of immunoassays versus bioassays has not yet been approached, but is without any doubt worth indepth investigation. thus, these studies are a promising first approach to deal with the difficulties of cytokine analysis in biological samples, and it is hoped that they will help to overcome some of the major methodological problems in the near future. tumor necrosis factor (tnf) is a pleiotropic cytokine which plays a key role in a number of immunologically mediated disorders like septicemia or cachexia. tnf receptors are found on the surface of a variety of cells, where they provide molecular signals for the cytokine effect. there exist two types of soluble tnf receptors (stnf-rs), tnf-r p and tnf-r p . these stnf-rs can compete with the cell surface receptors and block their activity. the expression on and shedding from the cell surface of stnf-rs is enhanced by interferon gamma. increased concentrations of stnf-rs can be found in patients with infectious as well as malignant disorders. in patients undergoing immune stimulatory therapy with interleukin- and interferon alpha a simultaneous increase of tnf and its soluble receptors can be seen. in patients with hiv infection a strong correlation exists between the levels of stnf-rs and markers of immune activation like neopterin or beta- -microglobulin. likewise patients with hematological disorders show elevated stnf-r levels. patients with weight loss have higher concentrations than patients with stable weight. the final value of stnf-rs within the complex network of cytokines is not yet clear. however, there exist striking parallels between infectious and malignant disorders pointing to a key role of endogenous immune activation. biochemicatly, d-erythro-neopterin derives from guanosine triphosphate. in vitro studies show that large amounts of neopterin are produced by human monocytes/macrophages stimulated with interferon-j (ifn-j). neopterin is biologically stable, and its halflife in the blood seems to solely depend on renal excretion. specimen for neopterin determination can be stored without special precautions. increased concentrations of neopterin have been described in body fluids of patients suffering from diseases which are apparently associated with an activated cellular immune response and with enhanced endogenous formation of ifn-~', e.g,, ) increasing neopterin levels predict rejection episodes in allograft recipients ) virus infections induce increased neopterin concentrations, and the degree of neopterin elevation predicts prognosis in these patients which is particularly true in hiv- infection ) in autoimmune disorders such as systemic lupus erythematosus or rheumatoid arthritis neopterin levels reflect activity of the disease ) increased neopterin concentrations in patients suffering from certain types of cancer indicate poor prognosis. significant associations between changes of neopterin and decrease of hemoglobin as well as the development of weight loss and cachexia, e.g., in cancer patients and in patients with hiv- infection, support the concept that endogenously formed cytokines such as ifn-~" and tumor necrosis factor-~( are involved in the pathogenesis of such symptoms. in conclusion, neopterin monitoring is a sensitive tool to detect the activation status of the cell-mediated immune system in vivo. repair and healing or perpetuation of acute inflammation is characterized by a complex network of interacting cellular and humoral defence mechanisms. of the numerous inflammatory mediators/effectors investigated hitherto, the proteolydc lysosomal enzyme pmn elastase has turned out to be highly destructive when released extracellularly thus contributing considm:ably to organ dysfunctions in severe posttraumatic and postoperative courses. besides various cytokines, elastase in complex with its main antagonist c¢ -proteinase inhibitor (a pi) is also supposed to induce the shedding of intercellular adhesion molecules from inflammatory cells (pmns, monocytes/macrophages, endothelial cells). these soluble adhesion molecules may modulate the inflammatory process in many different ways, e.g. via acting as chemotaxins, blocking neutrophil activation or competing with the membrane-bound forms in cell-cell adhesion. thus, measuring circulating or local levels of elastase-a pi and soluble adhesion molecules (icam, e-selectin,-pselectin, l-selectin) may be a helpful tool in judging the severity of an acute inflammatory process. in several clinical studies on surgical patients suffering from multiple trauma and/or sepsis we could demonstrate that the measurement of these parameters in consecutive plasma samples and local body fluids was highly valuable for early diagnosis and prognosis of multiple organ failure. prof. dr. m./ochum, institut fdr klinischechemie und biochemie, lmu miinchen, nufibaumstrage , m nchen, germany procalaitonin (proct) a aa peptide is dramatically increased in the blood of patients with various sepsis and infections. the increase begins as soon as hours after the andoto:edn release and readied maximal level with a to b-fold increase h after li~ edrmrdstration. prcc, alcitorfin response was temporally different from these of tnf~ and ii- , that reached peak levels at h and h respectively. at the opposite of eytokine (tnfcz, ild, j, is), proct is a very stable molecule. the half iife of proct in ~he blood is surprising if we consider the half llfe (about nine mirtute) of mature ¢alcitonin (co. we have found that it is due to the binding of proct with a protein on the n-termktal part. thin complex of about daltons is unable to cross the kidney and the c_n barriers and the half life is at least elghteen hours. this long half llfe is very useful in the evaluation of a sepsis. a very sensitive and specific sandwich in'ununoassay has been developped. the results cart be delivered in two hours. at time, we know that in the healthy adults, the values are less thau . ng/ml. it is also clear that proct is not increased ~n patients wlth inflammatory dleeasea without lnfectlon. for instance, proct is not signlffcat vely increased in purpura rhumatom, arthritis, crohn's disease, rectocolitis, also in various cancer patients with inflammatory components. am other interesting finding, is the absence of increase or a very low increase in the viral infections. at the opp site, in all the patients with bacterial sepsis or in the malaria pat/ants, progt was dramatically increased, from i to fold. p~oct can be useful to the follow up of patients with sepsis. actually, we don't know the origin of this proct production, in the united states, will also be discussed. the septest portion of this study will eventually enroll over patients tentatively diagnosed as septic. the results of septest will be compared with commonly accepted symptoms and criteria associated with sepsis in order to determine the clinical utility of this endotoxin assay. preclinical results of patients and normals be presented as well as data on the time course of endotoxemia and clinical outcome of selected septic patients. preparation of dna libraries clifford w. schweinfest, ph.d. a fundamental tool of the molecular biologist today is the ability to work with purified dnas representing genes of interest with respect to the investigator's field of study. originally applied almost years ago to the genetic dissection of simple organisms such as viruses and bacteria, molecfllar cloning was rapidly applied to study the more complex genetics of the mammalian cell. today, virtually any study of cell physiology which depends upon specific gene expression is approachable using the tools of the molecular biologist. therefore, stress induced gene expression (such as the heat shock gene, hsp ) or the regulation of the nitric oxide synthetase gene or the induction of cytokines and growth factors as a result of trauma or injury lend themselves to investigation at the level of the gene. during these workshops, we will discuss the means by which cdnas and genes are isolated, amplified and identified. we will discuss the strategies and methods for cloning cdnas and genomic dnas, for organizing such cloned libraries, for finding specific genes and for characterizing those genes. this speaker will focus on the techniques and considerations involved in the synthesis of cdna libraries. topics include rna isolation, mrna quality, reverse transcription, choice of cloning vectors and library quality. genomic dna library synthesis will also be discussed with respect to the vector/host systems available and applications which are specific to genomic dna. finally, polymerase chain reaction (pcr) will be discussed briefly with regard to its impact on dna cloning. the identification of the genes or gene products that have a role in cellular processes is fundamental to our understanding of genetic control and methodologies to achieve this aim are currently available. all levels of the various signal transduction pathways can b~ molecularly analyzed to define the mechanism by which critical steps in each pathway are achieved. the questions that are unresolved in each area of investigation serve to direct the scientist towards analyses of gene products or gene regulation of the gene itself. thus, selection of the type of library (genomic or cdna) to be used is dependent upon the specific goals of each investigator. to facilitate resolution of this question, an overview of the uses for the different types of libraries will be presented. at least four methodologies are currently available for screening a library, which are dependent upon specific interaction between nucleic acids, nucleic acids and proteins, antibodies and antigens or between different proteins. the use and advantages of each of these methodologies will be discussed along with a description of probe preparation. sequence methodologies required to begin characterization of gene clones will be presented. hopefully, the participants in the workshop will help define areas of emphasis and allow time for directed interaction to discuss specific applications based upon their own experimental systems. alterations of physiological conditions, such as those occurring after shock and sepsis, induce changes in gene expression of cells composing the major organ systems. the challenge is to detect and characterize these changes in geae expression and relate them to the injury. the development of cloning techniques has emerged as the methodology of choice. changes in gene expression are usually characterized by variations in the concentration of cellular messages because synthesis of the final product "the polypoptide" is usually proportional to the concentration of mrna. due to the rapid regulation of gene expression the cellular concentration of messages changes very quickly. this is commonly referred to as steady-state levels, a balance between transcription and degradation. steady-state levels of mrna can be detected in a single cell (in situ hybridization) or in total rna isolated from cells or organs and separated in agarose gels (northern blots). although analysis of mrna steady-state levels are very useful, they do not provide information about the mechanisms that regulate gene expression. changes in gene expression primarily occur at the level of transcription; characterization of the rna species being synthesized at a given time is performed by the nuclear run-off technique. when there is no a priori information about the gene that may be regulated after a particular situation such as sepsis, the total pool of messages present in cells at given time can be characterized by a combination of in vitro translation of the cellular messages and fractionation of the in vitro translated products by two dimensional gel electrophoresis. such approach permits the visualization of the general pattern of gene expression, a "finger print", of the physiologic state. in summary, researchers now have access to a great variety of techniques to identify and characterize genes expressed in response to a physiological condition that may be utilized as "molecular tools" to study the organism's responses to shock and sepsis. the acute phase proteins are a set of plasma proteins with greatly increased plasma concentrations during acute inflammations and after tissue trauma, e.g. after major surgery. the proteins counteract the source of injury, facilitate clearance of infectious particles by phagocytes, assist immune responses and initiate wound healing. the corresponding genes are expressed in liver hepatocytes and regulated by the inflammatory mediators interleukin and interleukin (ill, il ). class acute phase genes are mainly controlled by ill and by combinations of ill plus il ; class genes mainly by ii, . the human c-reactive protein(crp), serum amyloid a(saa) and complement c genes will be discussed as examples of class genes, and rat c~ macroglobulin as a prototypical class gene. both classes of genes use different types of ¢ytokine response elements in their promoter-proximal transcription control regions; class genes use the transcription factor nf-il or c/ebp as the key factor to mediate cytokine responsiveness; class genes use a different, so far unidentified factor to achieve responsiveness to il . ongoing efforts to purify this factor, called the il -response factor (il -rf), from rat liver nuclear protein extracts will be described. the il -rf apparently mediates the effects of il in a broad range of cell types, including b lymphocytes and other hematopoietic cells. it is therefore likely to be of equal general importance for gene regulation by il as nf-il . the importance of transcription factors as potential targets for novel bioactive substances and possibly therapeutic agents will be discussed with the help of several recent examples. new methods for altering the germ lines of mice provide powerful tools for understanding the roles of individual genes in normal and pathological processes, and for reproducing specific genetic mutations that result in congenital disease. three approaches will be discussed. conventional transgeulc mice are frequently constructed using artificial transgenes that express genes from a promoter other than the normal gene promoter. this paradigm is used to produce very high levels of a gene product, for example, with a viral promoter, or to attempt to regulate gene expression using an inducible promoter. alternatively, normal promoter sequences can be hooked to a gene whose expression is lethal to the cell (e.g., diptheria toxin a chain) to ablate all cells expressing that gene. another approach uses an intact gene with its normal regulatory sequences. here, an elevated level of the gene product is delivered from the correct cells in the correct tissues at the correct developmental stages or in response to natural signals. this approach has been refered to as "genetic pharmacology," and provides a precise delivery of the gene product to the target. however, to be most effective, the transgene should contain arl regulatory sequences as welt as the entire genomic segment containing gene coding regions. the introduction of conventional transgenes is limited to roughly kilobases, while genes containing all regulatory sequences frequently stretch over dozens or even hundreds of kilobases. to overcome this problem, procedures have been developed recently to introduce yeast artificial chromosomes (yacs) into mouse embryonic stem (es) cells. yacs can include over mb of human dna, large enough to encompass the largest known human genes. es cells are also useful for targeted gene deletions and mutations. homologous recombination can be targeted to any known gene in es cells. when these modified cells are injected into a mouse blastocyst, they can be incorporated into all tissues of the resulting mouse, including germ cells, so subsequent generations will pass the genetic modification as an inherited trait. assessment of the effects of a null allele on development can provide valuable insights into its normal role. ultimately, these technologies may be adapted to human cells -not for embryonic intervention, but to provide modified stem cells for various tissues (e.g., gut, eye, hematopoietic system) which could then be applied to somatic therapies. with major illness/injury that respirswy faihne fi'equently followed sepsis, tilney el al nse, d the term "soqueutial syste~ failure" for patients with renal failure after solmir of ruptured abdominal aortic ~aeurysms, i then reviewed our experiences after inju~ and oporstion and suggested that multiple, progsesslve or sequential systems or organ failure was a syndrome to be reckoned with in the, 's. eiseman et al then wrote about "multiple organ failure", especially with liver failure. polk el m found that renmte orgau failure often signalled occult anita-abdominal infection. fry et al ampbasized the role of uncontrolled infection in organ failure, border et ai described metabolic alterations with mof and used the term multiplesystems organ feilmo (msof). other early conltibutots to our knowledge of mof include faist, trunkey and miller, marshall and dimic&, cassone, catlleo, meakins and marshall, (}otis et at., mater and many others. mof or msof were used eommoifly. cerra coined the terms "post-trsumatic septic sfndromc" and "hyper metabolism otgau failure complex", and border et al, used lhe ex ~ression "gut origin seplic states" to illdioate important eurrem aspects of abe gt.'nerlc problem of organ failure and death, other terms include acute organ-system failure, multiple organ injury syndrome, post-traumatic multi-system organ failure nod post-~aumatic organ system infection s~dmmc (fi~sis), i bdieve the latin "maltiple organ failure" is clean, neat and says it all, now there is a proposal for a new set of torminolugios -mods and sirs. will they be helpful in the study and esro of patients? our speakers in this session will review thcsa proposals and the evidence as we strlvo for eoasensns. it has been well demonstrated that the administration of pro-inflammatory cytokines, and especially tumor necrosis factor (tnf) can result in a picture similar to septic shock with secondary multiple organ failure. it is also clear that tissue hypoxia can lead to organ damage. we believe that it is the interaction between the two phenomenons that can lead to mof. on the one hand, the inflammatory response is amplified in the presence of hypoxia. on the other hand, the release of the mediators of sepsis can increase tbe oxygen demand ef the tissues, alter their oxygen extraction and decrease myocardial contractility, and the combination of these elements accounts for the development of septic shock. this hypothesis is supported by two lines of evidence. first, mof is usually preceded by an episode of acute circulatory failure (even though frank circulatory shock may not be evident). second, recent experimental and clinical studies indicated that immunotherapy (especially antibodies to tnf) is particularly effective in the most severe forms of sepsis, associated with circulatory shock. hence, an effective way to prevent mof may be a combination of aggressive cardiovascular management and immunotherapy. development of the multiple organ dysfunction syndrome (mods) in the critically ill follows an heterogeneous group of stimuli including infection, sterile inflammmion, extensive tissue injury, ischemia, intoxication with a variety of substances, and immune system activation. whether the resulting physiologic abnormalities reflect a common pathologic process, or are simply a non-specific manifestation of tissue injury is unknown. moreover, the lack of clearly-defined functional criteria for the characterization of the syndrome on the one hand, and of reliable biochemical markers of its evolution on the other, has made attempts to define its epidemiology and natural history difficult. using a numeric scoring system to quanfimte the clinical severity of mods, we demonstrated that, although mods is more common in patients who have significant infection at the time of icu admission, a much stronger correlation is evident between the severity of mods and the subsequent development of nosocomial icu-acquired infection. furthermore the severity of mods correlates strongly with the severity of the clinical septic response, and with the degree of immunologic compromise evident on delayed type hypersensitivity skin testing. to determine the relative importance of the initial stimulus, and the host response to that stimulus, to the subsequent emergence of mods, we undertook a matched cohort study of critically ill patients admitted to the icu with infection, matched by age, sex, and apache ii score to uninfected controls. organ dysfunction scores were higher in patients admitted with infection, but were also significantly associated with the expression of a septic response at the time of icu admission, independent of the presence of infection. by stepwise regression analysis, the magnitude of the septic response was the most powerful predictor of the severity of mods in both infected and uninfected patients. these data suggest a model of mods in which a stimulus (eg infection) and the host response to that stimulus (eg the septic response) result in a state of altered systemic homeostasis (manifested in this example by immunologic dysfunction). moreover they suggest that the principle determinant of the emergence of mods is the response of the host, rather than the nature of the stimulus, and are consistent with the hypothesis that a stereotypie systemic response to an heterogeneous group of injurious stimuli underlies the pathogenesis of mods. arthur e. baue, m.d, ever since the attorapt build the tower ef babel, as desclibcd in the old testament of the biblc, it has been difficult to got agreement o;x common definitions or language, although mof has served well, there will always he now classifications proposed with good reasons for them, thus mods and sirs are not the final oxpressinns in the lexico~aphic sweepstakes. attcmpts to develop standard animal shock and scpsis models (hemorrhage, endotoxin, foes[ pellets, cecal ligation and puncture, e. colt hlf sioi to evaluate therapy have net been suoca.ssf~. clinical syndromes of mof, sepsis, sepsis syndrome and athers have not been aeacpte.d by all. our problem is that we arc tryittg tu d¢ffino a non-emily. mof or mods or sirs is net a disease or oven a syndrome. it is a series of complications of injury, disease and intensiva care which loads to death for many patients in intensive care units, it is not a fixed entity, but an ewilving picture. we have lumped (ugethet for therapy and definition a number of diseases and problems according to clinical manifestatieos rather than the eause of ihe problem, the search for unified mechanisms has not bean successful. will we benefit oleo from a more precise classification and definition of a non-outjty, a hodgu-podge of human disorders which have charsmeristic.s and manifestations of tissue injury, inflammation and infactian? re.hi clinical trials of potential "magle ballets" suggest that we should go in a different direction--instead of lumpors, we should be splitters, to seek effective therapy, we must fucus on specific disorders such as trauma, specific infections, inflammatory disease and chronic or acute organ damage (copd -renal failure, etc.), i will say more aboet this later ha the me.ethag. thcre is cue potentially important pert of the mods proposal, and that would be do~mcntation of organ dysfunction before fsiiure occurs and before tile need for external supporl dovelope. this could lead to hatter methods of preventing organ failure. preveution is ultimately the only answer to organ failure, m mof, mods and sirs. have wo reached a consensus?--only that we arc dealing wilh a diffl~x:lt probtolr looking for solutlons. acute lung injury (ali) and its most severe form, acute respiratory distress syndrome (ards) characterized by severe hypoxemia, diffuse infiltration of both lungs, a reduction of compliance and a wedgepresure lower than mm hare related to direct or indirect injury. when aliresults from direct injury (toxic agents, lung contusion, pneumonia), the lesions of epithelial barrier and the activation of lung macrophages are the first events leading to the release of inflammatory mediators wh:ch are responsible for alteration of the membranar permeability and for invasion of the alveoli by fluids, proteins and cells. an inflammatory reaction develops, with injury to endothelial cells, adhesion of polymorpbonuclear leucocytes (pmn) and the release in blood stream of intlammatory mediators dispersing the inflammatory reaction to other organs and tissues. the failure of lung function also results into hypoxia in other organs, leading to tissular ischemia, triggering an inflammatory reaction leading to organ dysfunction. frequent complications of direct lung injury are septic pneumonia with endotoxin release, phagocytes activation and cytokine production disseminating inflammation. by this way, direct lung injury can be at the origin of the multiple organ dysfunction syndrome (mods), the frequence of which having been estimated to % and is increased when all has occured in patients alreadypresenting an organ dysfunction (immunodepresslon, cancer...). when ali results from redirect or extrathoraclc injury (trauma, infections, hypovolemic shock, acute pancreatitis...), inflammatory mediators and micro-aggregates released in particular organs or tissues reach the lung via the blood and lymph streams, are filtered in the organ or trapped in the lung capillaries, and are responsible for a local inflammatory reactaon (endothelial cell activation, pmn trapping and adhesion, platelet aggregation, release of mediators). sepsis acts by the way of endotoxiu and sequential eytokines release (tnf, ill,...) while trauma with important blood loss acts especially by the way of hypoperfusionreperfusion phenomena leading to a disseminatedinflammatory reaction and to a possible bacterial transloeation when intestinal hypopeffnsion is present. in these conditions of indirect injury, all (or ards) is a iocal early (often the first) manifestation of a general phenomenon of altered membrane permeability and inflammatory reaction, easily and rapidly recognized by its clin~cai signs. the iung is one of the numerous organs participating to the mods, in these conditions, the mortality rate is high, reaching more than % when sepsis is present or when at least organs are implicated in mods. by direct or redirect injury, lung is so a target organ for mods and injured lung can be the cause of mods or simply a participant to this syndrome. jorge cervts-navarro main determinants for brain dysfunction are breakdown of the blood-brainbarrier and raise of intracranial pressure (icp), in second place decrease of systemic blood pressure, disorders of blood coagulation and respiratory function. the blood-brain-barrier of cerebral blood vessels can be opened by stroke, cerebral trauma, inflammation, convulsions, acute hypertension and changes in the blood osmolarity. the consequence is brain oedema, increase of lop and decrease of the perfusion pressure. a close correlation between intraventricular pressure and the fate of patients with severe brain injuries has been established. regional cbf values of to ml/ g/min are reflected in isoelectric eeg, and values about t ml/ g/min, result in loss of somatosensory evoked potentials. for ionic pump failure the threshold has been determined by values of about ml/ g/min and is reflected in massive release of intracellular potassium. in stroke and in brain trauma when the oedematogenous condition is initially localized the tissue pressure variance within and between the hemispheres lead to tentorial and falciform herniations are the common cause of death even before the critical threshold of intracranial pressure is reached. the increase of the icp over the level of the perfusion pressure leads to the arrest of the cbf. if this persists {or periods exceeding seconds of global brain ischemia loss of conciousness and developing seizures appear. if it exceeds min irreversible injuries of the brain appear. following cerebral ischemia and after severe head injury a tendency to increased coagulation can be detected. vascular occlusion may develop either as a result of local thrombus formation or from emboli caused by circulating platelet aggregates. the formation of microthrombi is triggered by the plateletactivating factor a mediator in central nervous injury also responsible for aggravation of posttraumatic brain edema. acute hemorrhagic leucoencephalitis and brain purpura are known to arise as complications of acute viral infections and following gram-negative septicaemia. institute of neuropathology, free university of berlin, hindenburgdamm , berlin, germany undoubtedly, attempts to quantify as objectively as possible the degree of dysfunction of the various organs is very valuable. however, cardiovascular failure has a peculiar place in the context of sepsis. the development of acute circulatory failure (shock) is of paramount importance as a cause rather than as a consequence of organ failure. it is therefore essential to clearly separate patients with and without circulatory failure. once this has been done, attempts to list the cardiovascular system among the other systems have been unconvincing. in a number of studies, cardiovascular complications are assimilated to a low systemic vascular resistance (svr), but since svr is basically the ratio of blood pressure over cardiac output, and since hypotension is already included in the definition of shock, then a low svr is basically equivalent to a high cardiac output, which is a characteristic rather than an ominous complication of severe sepsis. development of a low cardiac output unresponsive to fluids is usually a terminal event. it is not advisable to list other problems such as severe arrhythmias, myocardial infarction or tamponade as complications of severe sepsis. host defense dysfunction following trauma, shock and sepsis e. faist, g. f. babcock * major accidental, burn and operative injury often precipitates a profound multicentric immunologic depression that is believed to predispose patients to become anergic and thus to develop towards a higb probability of infection. anergy or a lack of immunologic reactivity stands for a total elimination of skin test reactivity and recall antigen responses in the inununocompromised patient. anergy following overwhelming trauma or major septic conditions results from a massive impairment of cell mediated immunity (cmi) together with a whole body malignant inflammationiike state. we and others have demonstrated clearly that the skeration of cmi following trauma is mainly due to the disruption of intact monocyte (moo) / t-cell interaction. within this phenomenon we see a shift of the cell ratio in the compartment of peripheral blood mononuclear cells (pbmc) with a considerable increase of prostaglandin e synthesizing m~ and a simultaneous decrease of functionally competent cd + and cd + lymphocytes. t-cell dysfunction in states of profound stress is characterized by impaired synthesis of two crucial lymphokines -interleukin- (il- ) and gamma-interferon (y-ifn). the inability to produce adequate amounts of il- , most likely attributable to alterations in the transmission of signals from the cell membrane to the nucleus, results in incomplete proliferative t-cell responses to antigenic stimuli, while a lack of ?-ifn results in inadequate m~ antigen processing and presentation. the role of the two functionally distinct t-helper subsets, t-helper- (thl) secreting principally il- and ?-ifn and t-helper- (th ) acting principally in inducing antibody formation with a secretion of il- , il- , il- and tnf-[ has still to be established within the context of major trauma. antibody formation to common protein antigens is impaired, the predominant finding is a shift from igm to igg synthesis. although excessive secretion of prninflammatory cytokines (il-u , tnf-c~, il- , il- ) has been considered to be deleterious for the host in states of major inflammation and infection, in-vitro and whole blood investigation of me function has clearly revealed that there is initially a marked suppression of moo from septic patients to synthesize and secrete proinflammatory cytokines to endotoxin. this probably will result in immunodeficiency of traumatized as well as septic patients, since these cytokines in low concentrations are involved in the upregulation of the essential humoral and cellular immune functions. abnormalities of pmn function noted after serious injury have been interpreted by some investigators as signs of unresponsiveness of this cell population, others have demonstrated signs of pmn byperactivation. latest findings revealed that there is a clear pmn dysfunction in circulating blood: % of all pmn's in this compartment show downregulated or non existent ~-integrins within hours posttrauma -these cells do not phagocytose, have a reduced respiratory burst and appear to be completely degranulated. restoration of these cell functions within days post-trauma is significantly correlated to survival of traumatized patients. other reports however stress increased expression of cr + receptors (cdll/cd complex) on circulating pmn's, increasing the ability of these cells to adhere to intercellular adhesion molecules, thus contributing to play a major role in inducing the pulmonary capillary leakage. our knowledge about the perturbation of host defenses associated with serious injury and sepsis is continuously increasing and represents the precondition for the design of effective therapeutic measures to prevent and counteract the resistance to invading microorganisms. dept. of surgery, klinikum grosshadern, ludwig-maximilians-university, munich, germany. * dept. of surgery, university of cincinnati, cincinnati, ohio, usa lg thijs~ ce n~ck sepsis is the most common cause of acute disseminated intravascular coagulation (dic) and coagulation disorders as well as abnormalities of fibrinolysis are common in septic patients. some clinical and experimental studies indicate that dic is a pathogenetic factor for the development of multiple organ failure. endotoxin and various mediators (tnf, il-i) enhance tissue factor and decrease expression of thrombomodulin on endothelial cells in vitro. also, tpa activity is suppressed and release of pai-i is stimulated. in such a way the endothelial surface becomes procoagulant whereas fibrinolysis is inhibited. following administration of endotoxin to normal volunteers levels of prothrombin fragments (fi+ ) and thrombin-antithrombin (tat) complexes increase, indicating thrombin generation. also the fibrinolytic system is activated as evidenced by a rise of levels of tpa and plasmin-antiplasmin (pap) complexes but this is counteracted by a subsequent release of pai-i. in severely ill septic patients levels of tat complexes are increased and concentrations of the natural inhibitors of coagulation (at iii, protein c) are usually decreased. also, tpa levels snd pap complexes as well as concentrations of pai-i are elevated. the severity of many of these alterations is related to mortality. thus, both coagulation and fibrinolysis are activated in sepsis, but not in a balanced way, thereby promoting coagulation. one of the hallmsxk pathological alterations associated with sepsis is the development of microvascular thrombosis, an entity ~lmre~erizod by microvas~tlar plugbing with leukoeyies (predominately nentrophils) and fibrin deposits. preranably, ischemia remlt~g fibm ve~-'ttlac ow,.luwion contributes sisni.ficantly to end orgen darnaje and consequent dysfatlctlon. p, er~t srldies haw focused pmdominately on the role of adhesion molecules in the pathogenesis of neu~ophil sequestration during infection and s~sis. this preparation will review the mechanisms underlying intravak-'v.ler i~brin deposition and its contribution to organ injury. the normal endothelial cell sure is generally conddered o be anticos~am. this state is maintained by two major anticoag~lam molecules on the cell so,ace: hepax'an su,lfale and thmmbomodulin. studies performed over the past decade have do~mentod a general shii~ towards a procoa~qtlant staw during gram negative hffeodon, aft e~| mediated mainly by changes in the endothalial cell surface. antt-tf antibodies have been shown to be pro~ective during l~'ml endotexemia. in summary, ~erova~'~ler fibrin deposition, in ~rt mediated by ~rcgulation of cellular tf, is a consistemt patholo~cal flndin~ during sepsis and contributes to organ injury. strategies designed to abrogate this event may n~nimjze the magnitude of erg~ dysftm~on. n, v, christou md phd, department of surgery, megill university, montreal, quebec, canada interactions between immune calls and the endothelium vie adhesion molecules serve to modulate immune cell traffic between the blood strum and the extrmvascular space, these families of molecules acting in a cascade and closely integrated with the oytoklna network, blood coagulation and the complement system, are responsible for the homing of leukocytes to areas of inflammation and the realrculatlon of tymphocytes. there are three types of immune ceils that must exit the blood stream into the extravascular space: lymphocytes ; polymorphonuclear leukocytes; and non-lymphocyta mononuclaar cells (monooytes, basophlls, aoslncphils). b lymphocytes exit the blood stream and recircu}ate mostly via the high endothelial venule (hev) in lymphatic tissue, rarely, in chronic }nfectlon=, they may recirqulate vie hev in non-lymphoi:t tissue. t-lymphocyte recircutation on the other hand can occur via hev in lymphoid tissue, as well as, the endothalium of the skin, returning to peripheral lymph nodes via the lymphatic channels. lymphocyte recirculation is the mechanism which allows ¢ontaot between the immune repertoire and pathogens, and homing delivers these cells to the appropriate environment for activation and for effeotor function, pmns exit the blood stream through endotbelium in close proximity to the site of inflammation after appropriate endothelial membrane receptor expression. they must reach the site of pathogen tnveslon quickly in order to be effective. their exudation to the inflammatory site can be modulated by their intravascular pdmlng, which results from appropriate receptor expression. because endotoxin leak from the gut has been postulated as an important trigger mechanism for the systemic inflammatory response syndrome seen after serious injury, the immunologic and metabolic effects of bacterial endotoxin infusion into normal volunteers can be expected to shed considerable light on the validity of this hypothesis. we and ethers have used tbis model to show that endotoxin causes a temporary paralysis in the ability of circulating monocytes to prudce the proinflammatory cytokines interleukin-i (il-i) and tnf-a. endotoxin, however, causes increased production of pge by the same cell population. endotoxin infusion causes significant suppression of circulating t-cell numbers and a profound suppression in the ability of the circulating t-cell population to proliferate and to produce interle~in- (il- ) upon in vitro stimulation. after endotoxin circulating t-cells are also more sensitive to the inhibitory action of exogenous pge . administration of cyclooxygenase inhibitors at the time of endotoxin infusion largely abrogates the effect of endetexin on t-cell proliferation and il- production. endotoxin infusion also causes the release of increased levels of circulating catabolic hormones including cortisol. administration of cortisol alone or cortisol along with endetowin to volunteers has allowed dissection of cortisol effects from those of endotoxin itself. cortisol infusion alone causes a diminution in the circulating t-cell population but the remaining ceils continue to produce il- after appropriate stimulation. cortisol infused along with endotoxin blocks the overshoot in monocyte proinflammatory cytokine production seen - hours after endetoxin infusion. at present, one may conclude that administration of sublethal doses of bacterial endetoxin to human volusteers produces alterations in cytokime production and tlymphocyte activation which are both similar and dissimilar to those seen following serious injury. hemodynamic support is based first on intravenous fluids and second on vasoactive agents. colloids are usually preferred to crystalloids, for their more rapid hemodynamic effects and their lesser passage in the interstitial space. in the presence of hypotension, the pharmacological profile of dopamine makes it the first agent of choice. it is only when high doses of dopamine are insufficient to restore a sufficient tissue perfusion pressure that norepinephrine should be added. even when cardiac output is not decreased, a dobutamine infusion is often indicated to counteract the myocardial depression, prevent vasoconstriction, and increase oxygen delivery to the tissues. the benefit derived from the administration of "renal" doses of dopamine is doubtful, but stimulation of dopaminergic receptors may increase blood flow also to the gut. in any case, none of these catecholamines has been shown to significantly improve the oxygen extraction capabilities of the tissues. agents with antiinflammatory properties but also with some vasodilating properties, such as n-acetylcysteine, prostaglandin el or pentoxifylline represent more attractive options to increase oxygen extraction. cardiovascular support should aim not only at the restoration of a sufficient arterial pressure but also at the maintenance of an optimal oxygen delivery to the cells. it should thus be guided also by measurements of cardiac output, mixed venous oxygen saturation and oxygen extraction, and indexes of cellular hypoxia, such as blood lactate levels, gastric intramucosal ph or vanearterial pc gradients. supranorma[ delivery contributes to the prevention of tissue hypoxia tissue hypoxia is considered to be the common final pathway in the pathogenesis of multipte systems organ failure. it may directly contribute to cellular injury and organ dysfunction as well as enhance further mediator activation and release by a positive feed back mechanism. prevention of tissue hypoxia, is therefore, one of the most important aims in the supportive therapy of critically ill patients, especially in those with sepsis and septic shock. mismatch of cellular o= supply and demand in these patients may resuit from the impairment of the cardiocircu[atory system on all levels. . myocardial depression with a drop in delivery (do~) . redistribution of blood flow between the different organ systems . inadequate nutritive blood flow due to tissue edema and endothelial damage (gic, leucocyte swelling etc.) these pathological changes may go along with increased metabolic needs. cellular and organ supply may therefore be inadequately matched with cellular needs in patients with normal and even supral normal doz. hyperdynamic circulation is often present in adequately volume resusucitated patients. it is most likely that one of the bodys main compensatory mechanisms would maintain cellular o= supply in the face of increased metabolic needs and impaired oz extraction capabillities. this pathophysiology may explain the findings in several clinical investigations that patients with normal or even supranormal doz can have signs of inadequate regional tissue oxygenation. it is also consistent with the results of different studies which demonstrated that the achievement of supranormal doz levels, either spontanuously or due to adequate supportive therapy, resuits in better patient outcome. any attempt to prevent or treat tissue hypoxia in these patients, however, has to take into account the effects of therapy not only on global dgz but especially on regional and microcirculatory blood flow. r. rossaint, d. pappert, k. lewandowski, h. gedach, k. slama, k.j. falke klinik for anaesthesiologie und operative intensivmedizin, ukrv, freie universit §t berlin, germany important contributory factors to the high mortality of severe acute respiratory distress syndrome lards) are the aggressive therapies required, such as mechanical ventilation with high inspiratory oxygen concentrations and airway pressures. as specific therapies for reducing or preventing the general inflammatory reaction of the lung resulting in severe hypoxemia is unknown, today's therapy is limited to procedures which predominantly support or maintain pulmonary function, i.e. pressure limited ventilation with peep and permissive hypercapnea, avoiding or treatment of fluid overloading, and positional maneuvers. extracorporeal lung assist combined with low frequency positive pressure ventilation has been recommended, when conventional therapy fails. today, extracorporeal gas exchange may be carried out using a system internally coated with covalently bound heparin. this allows for a lower level of systemic heparinzation reducing the risk of severe hemorrhagic complications of extracorporeal respiratory support. from april to august patients, aged from months to years, were transferred to our intensive care unit (icu) for treatment of severe ards. all fulfilled at least the slow entry criteria of the u.s. national ecmo study. due to hypoxemia patients required veno-venous extracorporeal membrane oxygenation (ecmo) immediately after transfer to our icu. the other patients were first treated with pressure controlled mechanical ventilation, permissive hypercapnea, prone position, and dehydration, if necessary. in out of these patients, in which the gas exchange did not improve in the following days, veno-venous ecmo with heparin-coated systems was additionally performed. heparin was given to achieve a partial thrombin time between - s and an activated clotting time between - s. if surgery was performed during ecmo, heparin infusion was interrupted. no severe bleeding complications related to anticoagulation for the extracorporeal bypass could be observed, however, in some patients, after three weeks of ecmo thrombi in the drainage cannula were observed. a problem of of membrane leakage shortened the life span of the membrane lungs to a mean of about four days. in the conventionally treated group % survived and in the additionally with ecmo treated group % survived, representing a % survival rate in patients whose risk of death is considered more than %. on the basis of these experiences, we conclude that the described strategy, including veno-venous ecmo with heparin-coeted systems, may improve the survival in patients suffering from severe ards. abnormally high skeletal muscle po in septic patients and its normalization during recovery: evidence against tissue hypoxia but for impaired oxygen metabolism of skeletal muscle? p. boekstegers, k. werdan department of medicine i, gro hadern university hospital, munich, germany a pathological oxygen uptake supply dependence was suggested to indicate tissue hypoxia in sepsis-a hypothesis which is discussed controversially. because the detection of reduced oxygen transport to tissue and &tissue hypoxia would have important implications for therapy, skeletal muscle oxygenation was studied in patients with sepsis. intermittent and continuous determination of skeletal muscle po by polarographic needle or catheter probes provided no evidence for skeletal muscle hypoxia even in severe stage of sepsis (boekstegers et al., crit care med ) . in contrast, mean skeletal muscle po was found to be abnormally high in patients with sepsis ( _+ , mmhg, n= ) compared to patients with limited infection ( , + , mmhg, p< . , n= ) , to patients with cardiogenic shock ( , + , mmhg, p< . , n=ls) and to healthy subjects ( , _+ , mmhg, p< . , n= ). furthermore, serial measurements in patients with sepsis showed that skeletal muscle po was higher ( , _+ , mmhg) on days with severe sepsis than on days with intermediate state ( , _+ mmhg) and than on days without sepsis ( , _+ , i mmhg) . thus, a decrease of abnormally high skeletal muscle po was related to improvement of sepsis. this was also demonstrated by comparing the decrease of abnormally high skeletal muscle po with the decrease of apache ii score or elebute score as well as interleukin- serum levels in a separate study (boekstegers et el., shock, in press). in summary, our data provide no evidence for skeletal muscle hypoxia in patients with sepsis but support the assumption &impaired oxygen metabolism in severe sepsis. neutropnlic emigration from the vascular space into the extracellular matrix is important for the response to tissue injury or contamination by providing a large recruitable pool of tissue-based phagocytes. the consequences of neutrophil exposure to intravaseular chemoattractants, likely relevant for il- and c a in sepsis, trauma, and in burn injury, are suppression of neutrophil attachment to endothelial cells and matrix proteins. it is probable that proteoglycan-bound attractants are of considerable biologic relevance, and may result in enhancement of responses to subsequently encountered cytokines. in the presence of connective tissue proteins expressing integrin-specific binding ligands, neutrophils respond to tnf-cq gm-csf and other cytokines by producing large amounts of hydrogen peroxide. this response is likely important in the digestion of contaminated or injured tissue by facilitating activity of neutrnphil granular proteases and inactivating plasma anti-proteases. this matrix-dependent oxidative response is important in defining potential novel targets for therapeutic intervention. the response appears to involve signalling by integrin-linked tyrosine kinases. the net effect of matrix protein injury through this mechanism is enhancement of the fibrotic response which underlies much of the prolonged ventilator dependence of patients with the adult respiratory distress syndrome. this adherence dependent response has also been implicated in direct hepatocyte injury, and may represent an early component of the syndrome of multisystem organ failure. study purpose: in this patient (pat.) population with a considerable sepsis morbidity and mortality, parameters proposed for sepsis assessment (elebute sepsis score [ele], sirs) were investigated with regard to their use in the early classification of pop. pat. at risk for developing sepsis. patients and methods: in a previous observational study on consecutive pat. after elective open-heart surgery, we had determined ele daily for at least pop. days (in pat. with a longer stay: until icu discharge). after publication of the newly proposed sirs definition, these criteria were retrospectively calculated and compared to ele. results: on the total of n = patient-days, both ele and sirs showed significant (p< . ) correlations with parameters reflecting the general and sepsis-related severity of the pop. clinical course. compared to sirs, the ele correlations were better (icu mortality: . vs. . ; icu treatment days: , vs. . ; days on mechanical ventilation: , vs. . ; days with vasopressor requirement: . vs. . ; number of microbiological findings: . vs. . ), the optimal classification criteria for the mainly sepsis-related outcome gave maximal youden indices of . for ele (ele >_ on >_ days, accuracy: %) compared to . for sirs (sirs present on > days, accuracy: %). accordingly, ele roc curve areas for both overall ( . ) as well as sepsis-related prognostic evaluation ( . ) were significantly (p< , ) larger compared to sirs ( . and . , resp.), this higher overall accuracy of the ele criterion was primary due to a more valid assessment already on the first and second pop. day, where sirs still had a high false positive classification rate ( % and %, compared to % and %, resp.). conclusion: in the early postoperative course after cardiac surgery, the sirs definition displayed a high false-positive classification rate (low specificity) for subsequent sepsis-related mortality compared to better classification results obtained by the elebute sepsis score. from the departments of medicine i and of "cardiac surgery, grosshadern university hospital, marchioninistr. , d- munich, frg. correlation between physiological and immunological parameters in critically ill septic patients. ma rogy, h oldenburg, r trousdale, s coyle, l moldawer, sf lowry a relationship between physiological parameters of severe sepsis and immunological function has not been established. in an effort to assess such a relationship we prospectively evaluated nine severely ill septic patients. physiological risk was assessed by the apache iii score , while one component of immunologic function was evaluated by peripheral blood mononuclear cells (pbmc) eytokine production after in vitro lps stimulation . four of the nine patients died. apache iii scores at h were lower in survivors (s) than in non-survivors (ns), ( -+ vs -+ p< . ), while apache iii scores at admission were not significant different between s and ns ( -+ vs -+ ). down regulation of cytokine production by pbmc upon lps stimulation was a transient event in s. while s demonstrated an fold increase of tnf-a bioactivity with[r~ hours, ns did not demonstrate any increase at all. a similar pattern was demonstrated for il- [ and il- immunoactivity. tnf was measured by wehi bioactivity, il- [~ and il- immunoactivity were determined by elisa. the sensitivity was pg/ml for tnf, pg/ml for il-ll and pg/ml for il- , respectively. in conclusion, both physiological as well as immunological functions of severe critically ill septic patients demonstrate predictive value for ultimate survival. while patients biological status seems to be more predictable by apache iii at day , p< . , the pattern of cytokine production by pbmc upon lps stimulation over the first h might be a reliable predictor as well. introduction: therapy of sepsis and its sequelae depends largely on its early recognition. many studies have investigated the change of certain mediators during sepsis and their potential to predict multiple organ failure and outcome. it was the objective of this study to investigate whether the onset of sepsis can be predicted by alterations of levels of interleukin- (il- ), tumour-necrosis-factor (tnf), pmn-elastase and c-reactive protein (crp). materials and methods: over a one year period, polytraumatized patients were prospectively studied (mean age y, % male, iss ). serum and edta-plasma samples were taken in h intervalls until the patient left the icu. il- , tnf, elastase, and crp were determined immunologically. sepsis was defined according to the criteria of 'systemic sepsis' (veterans" administration study, ) with at least of clinical signs: ( ) tachycar-dia> /min, ( ) temperature > , °c, ( ) blood pressure < mmhg, ( ) mechanical ventilation, ( ) leukocytosis > . /ml, ( ) thrombocytopenia < . /ml and ( ) presence of an obvious septic focus. clinical parameters, sepsis severity and serum levels were documented on a daily basis, beginning on day after trauma. results: of patients developed a systemic sepsis ( . %), and died. all mediator levels were elevated under septic conditions. the clinical severity of sepsis correlated well with the respective levels of mediators. in patients, who developed a sepsis the following day, il- ( vs. ng/l; p= . ), crp ( vs. mg/l; p= . ) and tnf ( vs. ng/l; p= . ) were significantly increased as compared to those patients who remained non-septic. elastase levels were considerably elevated but did not reach the level of significance. we conclude that il- , tnf and crp appear to be sensitive markers for prediction of septic complications in polytraumatized patients. objectives of the study: the assessment of liver function in polytraumatized patients who are at risk of developing mof is too inaccurate and late by using conventional biochemical parameters. methats: the injury severity of the patients (n= ) was determined by the injury severity score (iss). lidocaine is given at a dose of mg/kgbw over rain. i.v. and is metabolized in the liver by a cytochrome p- mechanism to monoethylglycinexylidide (megx). the metabolite is measured by a fluorescence polarization immunoassay. serial determinations of the test were performed between the ~t and the ~ day after trauma and were compared with other liver function tests (bilimbin, gldh, alt, ast). the systemic inflammatory response syndrome (sirs) is still a challenge concerning early diagnosis, therapy and prognosis. therefore, evaluation of inflammatory and disease activity becomes more important. c-reactive protein (crp) is a well established acute phase protein in chronic inflammatory diseases. recent reports suggest an induction of crp by interteukin- (il- ), a cytokine involved in the mediator cascade of sirs. on the other hand, tumornecmsisfactor alpha (tnfcx) is a very early released mediator in sirs removed very rapidly from circulation. in addition, soluble tnf receptors (stnfr~ , stnfr ) are released into circulation in the acute phase response. this study examines the kinetics of five acute phase proteins (crp, il- , tnfot, stnfr , stnfr ) in patients suffering from sirs. eighteen patients entered the study after diagnosis of sirs. blood samples were drawn every six hours during the first two days and every twelve hours thereafter. crp was measured in an routine turbimetric assay. il- was detected in an biological assay using the/l- dependent -cell line / . detection of tnfc~ was performed in an elisa system using a monoclonal antibody" for tnfo~. soluble tnf receptors were also measured by elisa. crp levels were elevated (> mg/l) in all patients and at all time points. crp values did neither differ significantly in patients with ( ± mg/l) or without ( a: ) multiple organ failure (mof) nor in survivors ( ± ) or non-survivors ( :t: ). in contrast, l- was elevated in patients wilh mof (mean pg/ml, range - pg/ml). il- levels correlated especially with lung dysfunction. tnf(x levels were consistently elevated in patients with mof. crp, il- and tnfoc did not correlate with each other. in contrast, levels for both stnfr showed a positive correlation (r= . ). patients could be divided into two groups by values for stnfr~ and stnfr : the group with higher soluble tnf receptor levels showed increasing values combined with a poor prognosis. the group with lower levels of soluble tnf receptor consisted of patients surviving mof or without mof. in conclusion, crp does not monitor the course of sirs adequately. in contrast, il- correlates with mof and episodes of high disease activity. high stnfr levels may indicate poor prognosis. klinik f r an/isthesiologie and operative intensivmedizin der cau kiel, schwanenweg , kiei, germany. ch. waydhas, md; d. nast-kolb, ivid; m. jochum, phi); l. schweiberer, mi) objective: to evaluate the irfflarranatory response after different types of orthopedic operations and compare them with the systemic effects of accidental trauma of varying severity. patients: in consecutive patients with multiple injuries (iss . ) the inflammatory response to trauma was prospectively studied. the patients were divided into groups according to their iss points. additionally, the alterations after secondary operations (> hr) were determined (msteosynthesis of the femur (n= ), pelvic girdle (n=ll) and spine (n= ), facial reconstruction (n= ), smaller osteosynthesis (n= ) and others (n= )). methods: specific and unspecific parameters of the inflammatory response were determined in the trauma patients every h, beginning on admission of the patient to the emergency room for a period of hr, and in the operative patients on the morning of the operation, at the end of the procedure and every hr during the first two days. results: lactate, neutrophil elastase, heart rate, po /fio -ratio, and other parameters discriminated significantly between the injury severity groups during the first hr (kruskal-wallis-test, p<. ). the degree of postoperative changes differed significantly (kmskal-wallis-test, p<. ) between the types of operations for lactate, heart rate, po /fio -ratio, nitrogen excretion and showed a strong discriminating tendency for neutrophil elastase and c-reactive protein. the extent of changes were highest after operations of the pelvic girdle, followed by procedures on the femur, spine, smaller bones, and the facial region. the postoperative changes after osteosynthesis of the femur or pelvis were comparable to the alterations noticed after smaller (iss to ) or moderate (iss to ) accidental trauma for neutrophil elastuse, heart rate, po /fio -ratio and parameters of the coagulation system. conclusions: there is a considerable inflammatory response to operative procedures that varies with the type of surgery. large operations cause changes in the body homeostasis that resemble those after multiple injuries. it remains to be established whether the inflammatory sequelae of surgical trauma are additive to the changes caused by accidental trauma. objective of the study: we retrospectively compared characteristics of elderly patients (~ years) and yeunger patients admitted to a surgical {sicu) and a medical intensive care unit (micu). we further studied the relations between advancing age, chronic disease, sepsis, organ system failure (osf) and mortality in the elderly group. material and methods: during a -year period, patients were consecutively admitted into the icu; and during a -year period, patients were consecutively admitted to t~mich. criteria for chronic disease, sepsis, osfsi.e. cardiovascular (cf), pulmonary (pf), renal (rf), neurological (nf), haematological (hf), hepatic (lf), and gastrointestinal failure (gf)-were derived from the literature. results: patients from the sicu and~cu were similar in age, number of osf, and length of stay. however, when compared to sicu patients, micu patients had more cf (p<o.o ), sepsis (p<o.o ), and mortality rate ( % vs. ii~, p<o.ool). in contrast, sicu patients had more hp and nf, and prior chronic disease (all, p<o.o ). of the total group of , patients, there were ( %) patients years of age or older. elderly and younger patients had comparable length of stay in the icj, but elderly patients had significantly more chronic disease, sepsis, and number of osf (all, p<o.o ). all osfs, except hf and nf, were more ~o~mon i~ mdeljl, eompard to you-ger patients. ~he mortality is also higher in elderly patients ( % vs. % in younger patients). after multiple logistic regression, only number of osf increased mortality by a factor of . ( % confidence limits, . - . ), age did not increased [odds ratio . (i. i.i )], while admission to the sicu reduced risk of death by a factor of . ( . - . ). conclusions: based on these results, we conclude that age does not have any impact on icu outcome in the elderly. the only prognostic factor is the extent of acute disease, as measured by the number of osf. hence, prevention of oaf may influence outcome in elderly patients with critical illness. the lower risk of death in sicupatients may be explained by the large proportion of postoperative elective patients with relative mild chronic disease, and the lower incidence of sepsis. department of surgery, free university hospital, de boelelaan , ~v amsterdam, the netherlands. septic shock and low output syndrome h.miyakawa, t.noguchi, s.hattori, a. mizutani, m. mori and n.honda objectives: cytckines are thought to cause the acute phase reactions under several critical conditions. we had investigated the relationships between cytokines network which included il- , l- ,acth and cortisol,and the outcome of the patients with septic shock or low output syndrome (los). materials and methods: in the septic group and los group,nine and four patients were enrolled respectively. furthermore, the patients in the septic group were divided into two groups,survival (n= ) and non-survival group (n= ).tn these patients,ll- , l- ,acth and cortisol had been measured every day after diagnosis of septic shock or los.the total number of measurements were points in survival septic group, l l points in non-survival septic group and points in los group.statistical analysis was used student's t-test to compare the mean of each group,and the changes were reported as clinicat significant if p< . . results: il- levels in non-survival septic group were higher than in both survival septic and los group.ll- levels in non-survival septic group were more significant than in both survival and los group.otherwise,there were no differences with respect to acth and cortisol among three groups. conclusions: we assumed that los would make several organs dysfunction as well as septic shock. but our results showed septic shock, especially non-survival,had different cytokins network mechanism for organs failure from los. lasson ,~, g/ ransson j, jijnsson k. eady diagnosis of complications after trauma is imperative to decrease morbidity and mortality. for this purpose an easy, cheap and fast diagnostic method is needed. the aim of this study was to analyse if complications after surgical trauma of various extent could be diagnosed earlier using preoperative or daily postoperative measurements of various plasma proteins than by using climcal signs of complications. material and methods: two acute phase proteins (c-reactive protein and antichymotrypsin), lbur main plasma protease inhibitors (alpha- -maeroglobulin, c estemse inhibitor, antithrombin ill and alpha- -antiplasmin) and one collagen precursor (procollagen iii peptide) were measured preoperatively and then once dally for days postoperatively. for the plasma protease inhibitors immunorcactive as well as functional levels were measured. haemoglbin, albumin and the white blood cell count were also measured. measurements were done preoperatively in patients and continued postoperatively in patients, % of the patients were operated on for malignancy. resulls: preoperative plasma c-reactive protein levels were higher in patients developing postoperative complications. this discrimination increased when plasma was sequentially analysed postoperatively, when a remaining high level ora second increase in plasma levels depicted a complication - days earlier than clinical signs. high levels were seen both in patients developing local as well as in patients developing general complications. there was no clear correlation between plasma protease inhibitory levels and complications, neither pre-nor postoperatively. procollagen iii paptide levels were slightly (but not significantly) higher postoperatively in patients developing complications. contusions: the acute phase response, especially concerning c-reactive protein, predicts postoperative complications better than both plasma protease inhibitors or collagen precursors. preoperative plasma c-reactive protein levels indicate the risk of postoperative complications, while daily postoperative measurements more readily depicts a complication, usually preceeding the clinical signs of complication by - days. dept. of surgery m'alm general hospital, s- i malmr, sweden. mof is a major threat to the extensive burned patients and associated with a high mortality rate. the role of endotoxemia in the pathogenesis of mof in burned patients remains controversial. in this study, we examined the relationship of plasma endotoxin levels to development of mof, and outcome in patients with thermal injury. methods: a prospective cohort study of patients admitted with burns covering more than per cent of body surface area was undertaken. circulating endotoxin concentrations were measured by modified limulus amebocyte lysate assay in serial samples of plasma. results: out of burned patients developed mof according to multiple criteria. the plasma endotoxin concentrations of patients with mof were . -- . eu/ml, significantly higher than that of patients without mof ( . - . eu/ml) on , , and days postburn (p< . -- . ). significantly more incidence of positive endotoxin test (>_ . eu/ml) was found in patients who developed mof as compared to that of non-mof during the observation period (p< . ). as the mean endotoxin levels increased, the prevalence of mof and death also increased (see table below), persistent endotoxemia carried a poor prognosis. conclusions: the present investigation provide further evidence that endotoxemia in severely burned patients commonly occur. cimulating endotoxin has also been found to be strongly associated with development of mof and mortality following major burn injury. multiple hemostatic changes occur in sepsis mad multiple organ failure (mof). to evaluate the role of platelcts in patients with sepsis and mof, we examined changes in surface glyeoproteins on circulating platelets of t patients with suspected sepsis and mof. the severity of sepsis and mof was assessed by eiebute and apache i scoring system, respectively.using flow cytometric techniques and platelets specific monoclonal antibodies, platelet surface expression of fibrinogen receptor on gpiib-iiia, ofvon willebrand receptor gpib, and of granula glycoproteins (thrombospondin, gmp- , and gp ) was measured. receptor density of gpiib-illa mad gpib on circulating platelets was not affected by sepsis or mof. in septic patients surface expression of activated fibrinogen receptor (libs expression) was significantly elevated (p< . ) and correlated well with severity of disease (f . ). no significant change in surface expression ofthrombospondin, gmp- or gp was noted in septic patients. in contrast, degranulation ofgraanle glycoproteins was significantly elevated in mof (! < . ) that correlated well with severity of mof (gmp- , r= . ; thrombospondin, r= . ).we speculate, that platelets in sepsis circulate in a hyperaggregable (fibrinogen receptor activation ) but still reversible state that results in increased risk of microthrombotic events. in the course of the disease, irreversible platelet degranulation might occur and may play an important role in development of mof. abdominal sepsis is still associated with high morbidity and mortality. the present study aimed at evaluating patients with abdominal sepsis treated at our surgical intensive care unit during a -year period with the aim of identifying potential prognostic factors, bacteriological cultures, diagnostic procedures, treatment and outcome. during the period - i patients with abdominal sepsis were treated at the icu at our university hospital. patients were women and men with a mean age of ( - ) years. in cases, the abdominal sepsis occurred as a postoperative complication. the patients were scored according to apache ii and bacteriological cultures and the occurrence of organ failure were noted. the patients were hospitalized in median for (- ) days out of which (- ) in the intensive care unit. out of patients ( %) died in median after ( - ) days. the primary cause of mortality was multiple organ failure ( / ; %). apache ii scoring could not predict a fatal outcome. abdominal bacterial cultures were dominated by bacteria of enteric origin ( %) and in % cultures grew multiple bacteria. patients bad organ failure and multiple organ failure. / patients ( %) had abdominal sepsis due to diffuse peritonitis despite a morphologically intact gastrointestinal tract and the absence of localized abscess formation. mortality in this group was significantly higher as was the percentage of positive blood cultures and the occurrence of multiple organ failure. abdominal sepsis is still associated with a high mortality, predominantly caused by multiple organ failure. abdominal culture findings are dominated by bacteria of enteric origin. in about / of patients with severe abdominal sepsis a diffuse peritonitis with intact gastrointestinal tract without localized abscess formation was found. in this group the mortality was increased as well as the risk of developing multiple organ failure. during the period from january to september patients, mean age + years were referred to our department of resuscitologywith the diagnosis of eclampsia. all the patients were delivered by cesarian section and were mechanically ventilated for . _+ . days. diagnosis of sepsis was confirmed in cases by clinical and microbiological methods. patients were divided in two groups: lnon septic patients, -patients with sepsis, the control group consisted of patients after cesarian section without symptoms of eclampsia or infection. we determined plasma concentrations of immunoglobulins a,g,m(a,g,m), complement factors (c ,c ), alphal-antitrypsin (aat), trausferrin (trf) and albumin (alb) using beckman (usa) analyzer,protein concentration, using kone (finland) analyzer. a(mg/dl) g(mg/dl) m(mg/dl) c (mg/dl) c (mg/dl) k +- + _+ + +- -+ " -+ * _+ " -+ ' _+ " +_ '* -+ ** -+ "* -+ "* _+ " in a prospective study we investigated serum of severly traumatized patients withdrawn directly after admission at our hospital (tr i). follow up controls were taken daily until day ten after trauma (tr ii). two control groups were performed: serum of healthy volunteers (co, n = ) was investigated as. well as serum of patients undergoing elective herniotomy (n= ) hours before (op i) and hours after operation (op ii). serum bactericidal index (sbi) was determined using a hemolytic e.coli strain :k :h . / suspension with a final concentration of - cfu were incubated with l oopl serum. after overnight incubation sbi was calculated according a special formula. results: co . _+ . opi . _+ . opii . _+ . * tri . _+ . "* trii . + . ** (*:p< . ; **:p<o. ) sbi represents a simple and reproducible method to detect immunobiological alterations after trauma and elective surgery. patients undergoing elective surgery showed slight but significant diminuation of sbi h after operation. deterioration of sbi was observed in serum of traumatized patients directly withdrawn after admission at our hospital. ten days after trauma significant improvement of sbi was found. further investigations have to be done to proof sensitivity and prospectivity of this simple but reliable test. a sepsis like syndrome (sls) occurs in i % of our patients following cardiac surgery. sls is characterized by a severe decrease in systemic vascular resistance requiring the use of vasopressors to maintain adequate hemodynamics in the presence of negative blood cultures. in order to determine whether preoperative factors predict the occurrence sls we retrospectively studied patients with sls (group i: age . ~ . years); they were compared to control patients (group : age ± . years). treatment of sls consisted of aggressive fluid replacement and norepinephrine infusion. rydrocortisone ( mg/ hrs) was given on the first day. antibiotics were switched prophylactic to cover gramnegative bacteria in pts. preoperatively pts in group revealed a significantly lower cardiac index ( . ± i/min/m ) compared to group ( . ± . i/min/m ; p < . ) higher left atrial pressure (group i: . ~ . mmhg; group : . ~ . mmhg; p < . ) and lower ejection fraction (group i: . z . %; group . ± . %; p < . ). bypass time, minimum and mean blood pressure on bypass and aortic clamp time were not different between the groups. immediately postoperatively (pop), the white blood count was elevated (group i: , ± , /ui; group : , ~ , /ui; p < . ) and core temperature hours pop was higher (group i: . . °c; group : . ~ . °c; p < . ). serum lactate was already elevated on arrival on the icu pop (group i: , z . mmol/l, group : . ~ . mmol/l) but dropped within hours (p < . ). icu stay (group i: . ! . ; group : . ± . days; p < . ) and mortality over months (group i: . %; group : . %; p < . ) were significant higher in group i. sls is observed more frequently in patients with preoperative cardiac congestion and results in longer icu stay and higher mortality. although intraoperative hemodynamics are similar in both groups, the white blood count and serum lactate levels suggest an intraoperative cause for sls. further investigations will focus on possible intraoperative causes of sls. the objectives of the study were to estimate the problem of stress ulcers in critically ill patients and to compare ranitidine and omeprazole to determine their efficacy in the prophylaxis of stress ulcers. patients who were admitted to the intensive care units between january and july ' with polytrauma, sepsis or those requiring ventilatory support for more than hours were selected for the study. the patients were randomized into groups to receive ranitidine, omeprazole or a placebo. the changes in gastric ph were monitored hourly and the patients underwent an upper gi endoscopy hours after the start of the study to look for stress ulcers and hemorrhage. the drugs were withdrawn one week after the start of the study. of the patients selected for the study, had undergone cardiac surgery, had polytrauma and had sepsis. the change in average pre and post drug gastric ph was + . in the omeprazole group, + . in the ranitidine group and -). in the placebo group (p < . ). endoscopic evidence of stress ulcers was seen in % of patients not on prophylaxis, . % of those on omeprazole and . % of those on ranitidine. while all the patients in the placebo group who had stress ulcers showed endoscopic evidence of hemorrhage, % of the patients with ulcers in the ranitidine group and none of the patients with ulcers in the omeprazole group showed hemorrhage (p < . ). in critically ill patients the incidence of stress ulceration is high. an alkaline gastric ph is protective against stress ulcers. omeprazole when used for prophylaxis against stress ulcers in critically ill patients or those on short term ventilation will reduce the incidence of formation and hemorrhage from stress ulcers. the early and accurate diagnosis of sepsis is of key importance for critically ill patients survival. many studies have shown that tumor necrosis factor ~x (tnf ~) and interleukin- (il- ) are mediators of the inflammatory response in sepsis. bacterial antigens interact also with antigen specific t cell receptors and the activation of t ceils takes place. activated t cells release soluble interteuldn- receptors (sil- r). the aim of this study was to evaluate: the significance oftnf c~, il- and sll- r in the diagnosis of bacterial sepsis and to evaluate the correlation of clinical and laboratory parameters with serum levels of tnf ~x, il- and sll- r. we examined patients with clinical signs of sepsis treated in the intensive care units of university medical centre ljubljana. venous blood was drawn from each patient within hours after the first clinical signs of sepsis. clinical data (body temperature, blood pressure), laboratory dam (peripheral white blood cell count with differential, platelet count, c-reactive protein), and quantitative blood cultures were recorded. serum levels of tnf c~, ,- and sil- r were measured in septic patients and in adult healthy controls. tnf ct, il- and sil- r serum levels were measured by commercially available ria and elisa (amersharn and eurogenetics) kits. the differences in serttm levels of tnf ~, il- and sil- r between healthy control and patients and correlation between clinical and laboratory parameters were calculated. we found that only sll- r serum levels were significantly (p< . , student t test) increased in patients in comparison with healthy controls. of all indicators of sepsis that we compared, only hypotension was significantly correlated with tnf ~x levels and leukocytosis with ] ,- levels. we conclude that only the increased serum sil- r levels were predictive of bacterial sepsis within hours after the first septic signs. tnf c~ and il- levels were not significantly increased at that time in lifts small group of patients. in order to create high precision prognostic system for patients with sepsis and septic shock we have made prospective and retrospective analis of cases of sepsis. patients were included in this analis according bone's criterions of sepsis. comparing with apache-h, we have excluded such phisiologic variables as:temperature,na+ ,k+ ,}it, ph,which had a little influence on prognos of illness. we have added the other, more important variables: biilirubin, plateles,pti. we took into account: the seat arrangement, methods of respiratory support, comorbid conditions as: caneer, diabets,obersity. in general new score has headings: -physiologic variables, -age, -seat arrangement, -chronic comorbid conditions, -methods of respiratory support. roc -analis have showed a greater precision of our score, compared with apache-ii score. there is significant difference between the roc-curve of apache-ii scare. the k.p.tit~v.,i.e.gurmanchuk. objectives of the study. sepsis is a severe complication of the local infection, th e fever and the systemic inflammatory response syndrome may take place in such a case as manifistations of the inflammation induced by bacteria. the systemic fever observed in infection is known to develop due to the action of certain cytoldnes. other systemic manffistation of inflammation are the production of acute phase reactants, acute phase proteins, the activation of the complement system. ivratertals and methods. we observed children with light and children with severe course(l- class of serionuess) of the sepsis. the ftmetional activity of the complement system (ch , level of c -c , factors b told d, c a), level of c-reactive protein (crp} and tumor necrosis factor (tnf) were investigated, results. the level of crp was increased in the children with more severe class of the septic process in both group ( %- st and ioo%- nd}( with light and hard eours of disese) of patients. parameters of the complement system -the activity of cl, c , c components, activity of b and d factors-were increased in the seram of children with light course of sepsis. in children with severe course of sepsis these parameters were signffieantty decreased, especially in the group of chiidrellwith higer level of crp. we found the negative correlation of the tnp-alfa concentration with the functional activity of classical pathway components (cl~ ) and the positive onewith the funfional activity of the alternative pathway factors b-and d of the complement system. conclusions. thus, in children with different course of sepsis certain changes in levels and functional activity of an acute phase o[ inflammation proteins -crp and the complement system ones -&ire characteristic. the relationship between the tnf-alfa level and the activity of classical and alternative pathways proteins indicates on its role in the complement proteins genes expression. schr der j, braun j, rennekampff ha, schr der dw various alterations of the immune response are known in trauma, but the course will not be complicated by multiple organ dysfunction syndrome (mods) in all patients. phenotyping of cells offers a rapid system of evaluation certain aspects of the immune response. different subsets of lymphocytes and neutrophils were determined to evaluate their prognostic role in developement of mods. in trauma patients with an injury severity score (iss) > (mean iss = ; mean age years) lymphocyte and neutrophil phenotypes cd (t-cells), cd (t-helper cells), cd (t-suppressor cells), ratio cd /cd , cd b (receptor for cr ) and cd (fcriii) were measured on day , , , , and post trauma. the expression of class ii histocompatibility antigen (hladr) on monocytes (hladr+ cd ) and il -receptors on t-helper cells (cd /cd were determined as well. the percentage of cells was monitored by immunofluorescence using monoclonal antibodies and three color cytometry. the percentage of hladr+ cd were significantly lower an day , , and in patients who developed mods (p< , ) compared to patients without mods and a healthy control (p<o,o ). the expression of il receptors on cd was significantly different only on day . no differences could be measured in lymphocyte phenotypes cd , , and cd /cd -ratio as well as in expression of cd b and cd on neutrophils. class ii histocompatibility antigen (hladr) on monocytes offers the best ability to reflect cellular immunosuppression in trauma. this parameter allows the best differentiation of patients with and without mods. we retrospectively studied the relative importance of age, prior chronic disease, sepsis and organ system failure (osf) to determine outcome in critically ill patients with acute renal failure (arf). arf was defined as serum creatinine > /zmol/i, a twofold creatinine rise in prior renal insufficiency or the need of acute renal replacement therapy. definitions for prior chronic disease and other osfs -i.e. cardiovascular (cf), pulmonary (pf), neurological (nf), haematological (hf), hepatic (lf), and gastrointestinal failure (gf)-were derived from the literature and described previously. of the consecutively admitted patients to a surgical and a medical intensive care unit during -ye r period, ( %) had arf. arf mortality was %. ninety-eight percent had other osf. overall, cf, pf, gf, and nf was significantly more common in nonsurvivors than in survivors (all, p<o, ). although both the number of osf before and after arf was higher in nonsurvivors than in survivors (p< . ), the number of osf before was higher compared to after arf in both groups of patients (p< . ). furthermore, age, cf and pf before the ontset of arf, nf thereafter, and renal replacement therapy were related to mortality (all, p< . ). however, prior chronic disease was not related to mortality and chronic renal insufficiency was inversely related to outcome (p< . ). after multiple logistic regression, advancing age, cardiopulrnonary failure and sepsis before arf, and nf after arf remained significant. these results show the high prevalence of arf in critically ill patients and that arf rarely occurs alone. the prognosis of arf in critically ill patients is poor, especially if associated with advancing age, additional osf, particularly cardiopulmonary failure and sepsis before arf, and nf after arf. hence, prevention of cardiopulmonary and sepsis before the outset of arf may influence outcome in arf in patients with critical illness. the search cominnes for a magic bullet ta help critically ill petienta, bat recent elini ',.ml rials of agents that showed ixomise in animal studies raise questions about such trials. expcrlmemai uvidan~ :in anlmats and human volanteet~ for concepts, mechanisms and treatment of inju~ ur illness can be substentlal, l~rauasive and exciting but the positive effects of potential therapy suggested by such animal and ctinieal research may be difficult to prove in sick patients. efficacy of a new txeatment can be difficult to prove became elinie.al situations, hi spi~e of important biologic phenomena, are v~iable and conrplex. there is redundancy and overlap of mediators ~d problems of timing of therapy. a majt~r cause of this dilemtns is not with the trials or hypotheses, but rather the promem of the cause or the causability of the human dise~.se that is trebled. this is/hu "causa nets" or '*specific cause" as described by stehbens, when prevention or tre.atmcnt is based em the sauna nero, extinetiem of the disease is ix~ssible as with saul/ pox. only elimination of the cause wl cure the disease. careful animal studit~s evaluate single pcrturbmiuns for survival or other changes. an ldso preparation may be infiuancad aignificantly by a ~mall clangs which may be insignific~lt ht pstiants, most human experiments ate carried out in normal volunleers with a single porlurbation, such as a low-level, non-lethal dose of a substance. such studies are huportant in defining mechanisms attd mediators of disease, in our world of injm'ed, operated, infected and inflslned patients, there are many diseases, mof is not one of lhem. it isn't even a syndrume, it is the final pathway for a number of diseaaes~ each of which has a cause. mecormock believes thal a "multi-causal" etiology is a euphemism for ignoranc# or a synonym fo~ unknown etiology. admission iv sn icu, a high apache seer% the sepsis syndrome, mof, muds, or sirs and having predictors indicating potential mortality, are not diseases. the inmpors are getting negative results in trials of agents on eiek or septic icu patients and aru now becoming splitters, dafining subgaoups at higher risk for death. such an approach may produce positive results if the diseases are identified and the treatmeul is specific for them, a major challenge in deterraintng the efficacy of new therapies for sepsis nnd shock is identifying patients whose e#temtc inflammatory response is appropriate from those in whom the mediator| are contributing to end organ system damage end death, traditional and recently revised categorical patient descriptions such as sepsis syndrome, sepsis syndrome with shock, multiple organ system failure, or the recently proposed systemic inflammatory response syndrome (sirs) may not be sufilcient since they identify individuals at varying levels of risk for short term mortality, the efficacy of new lmmunotherapy may be directly related to the patient's severity end risk of mortality at entry to the study. we recently reported (jama ; : z - ~ ) a comprehensive risk assessment approach for patients with sepsis syndrome, a common eategarlcal description used as an entry eriterlon for many trials. by screening s database of , recent admissions to hospitals in the united states and western europe, we identified , patients who met sepsis syndrome criteria but were not enrolled tn clinical trinh, we then developed a survival model end severlty assessment method to estimate their g.day mortality risk. k..ente physiologic abnormalities were the most important prognostic factors ( % of total chl square) influencing outcome. the specific disease resulting in ice admission and the days the patient spent in the hospital and icu before qualification were independent risks, as were age and a clinical history of cirrhosis. the predictive model was cross-validated within the original , patients with a receiver d_perator characteristics (roc) area of . and in two independent databases, the first independent database contained hospitalized patients with gram-negative infection meeting criteria for sepsis syndrome (roc= . ); in the second, the placebo patients withtn the recently completed phase ill e~aluatlan of il- ra (rocffi . ). in all databases the risk model was able to accurately risk stratify patients throughout the range of risks that varled from a very low % to a very hlglt %. by drawing on the ready avatlabillty of large clinically aeuurate, current databases and using the power of modern statistical techniques to model the bodfs response to sepsis, we are able to produce very aeettrate pre-treatment risk estimates, these prospectively defined and continuous risk estimates reduce reliance on multiple subgroups and data dredging that can compromise a stady's integrity. they cart provide a nnlform method for patient description across clinical trials of different attempts at immmlotherapy. risk calculations can also be useful in developing entry criteria for phase ii evaluations in order to initially test efficacy on a limited number of high risk patients, fonowing sueeessinl completion of a definitive trial, the risk estimates can be used to develop specific |ndlcattons for s drug's use and can monitor the impact of both new and multiple compounds on patient outrome, when dealing with therapeutic trials for the treatment of sepsis, there are ways of checking the comparability of the groups (placebo and treated groups) -to use several description items such as age, sex, preexisting disease, number and nature of organ failures, physiology score, such as saps il ( ) -to use a model for risk of death either from a score (apache ii, lii, ( ) saps ii) or directly (mpm ii system ( )) before using the model for risk of death in septic patients, is it mandatory to validate it (by calibration, i.e. goodness of fit, and discrin'dnation, i.e., roc curves) first on a data base using the same definition for sepsis as in the trial and secondly on the placebo group of the trial ? or is it better to use a specific model for each trial ? the general models usually do uot fit for septic patients. there are methods to make them fit : either to add variables to the original score (model for sepsis using the apache iii system ( )) or to customize the model. for saps ii the customization is applied to the equation regression, using the same saps ii score. for mpm i each component of the model can be customized. several remarks : only one model is published to be applied at the icu entry ( mpm ii ) before any therapy. -most of the published scores are calculated from the lsl icu day. applying these scores to the let day of sepsis could have a very different significance. -is the accp classification of sepsis useful at the bedside to select oatients ? ( the pathophysiology of sepsis involves a dynamic interaction between the host and the infecting microorganism(s). a multitude of biochemical and hemodynamic interactions occur which function in concert to determine the ultimate outcome of the septic episode. the complexities of the septic process preclude outcome analysis by in vitro systems or computer models, animal studies have become indispensable in evaluating new therapeutic agents in the treatment of sepsis. these studies provide valuable information on safety, pharmacokinetics, relative efficacy and dosing strategies for potential therapeutic agents in the treatment of sepsis. there are three basic types of animal models: ( ) toxicity models with injection of bacterial endotoxin or exotoxins; ( ) live or killed bacterial challenge models; ( ) actual infection models. all models employ some form of external manipulation under controlled conditions to induce sepsis and to analyze potential therapeutic efficacy. these experimental requirements may limit the ability of animal models to accurately predict the clinical value of new agents in human sepsis. four major end points are analyzed in the various animal models: ( ) hemodynamic parameters; ( ) modulation of host-derived inflammatory mediators; ( ) resolution of end organ injury; or ( ) lethality. each animal model has certain advantages and limitations. species-specific differences in physiologic and immunologic features make it difficult to directly extrapolate the results of animal experiments into clinical medicine. while no ideal animal model exists, consistent benefit of a new immunotherapeutic agent in multiple animal systems provides the most compelling preclinical evidence of its therapeutic potential in septic patients. consensus-assisted development of a study protocol on sepsis: an important difference from previous randomized trials there have been several, and perhaps too many metaanalyses of cliuical trials on surgical infections, but their results have only rarely been incorporated into the design of new randomized trials in sepsis. metaanalysis is retrospective. it seems more important to analyse and to criticize the design of tria/s before they are ongoing. incorporation of that into development of a study protocol is the aim of the following procedure: the time-schedule of about two years should include further cell culture and animal experiments after the first successful studies showing effectiveness. exhaustive evidence for a dose-dependent cost-banefit and near complete explanations of the pathomechanism should not be awaited for development of the protocol of the clinical study. however, a discussion forum of experts should be performed in a recently published, almost perfect trial in order to see the frontiers of the present research in cell and molecular biology, clinical pharmacology, statistics and decision making. this should be followed by a metaanalysis of at least study designs on sepsis with methods of formalized medical decision making (decision tree). clinical algorithms -developed by objective methods including nominal group processes -should be developed to standardize any concomitant treatment in the centers considered for a multinentre trial. the latter is usually necessary in the field of sepsis. finally, a pilot study should be performed to demonstrate not only feasability, but to learn about all possible types of interventions which modify endpoints as response variables. especially mortality is not free from such effects. the time for the individual phases of this consensus-assisted process of protocol development have to be shortened by their temporal hiterloeldug. due to the fast discovery of new chemical factors in sirs it wilt otherwise be impossible to come up with results of randomized trials which are fascinating enough to be incorporated in daily routine treatment. severity scoring systems are intended to provide a population-based estimate for the risk of an unwanted outcome resulting from some disease process. in the area of infections and the "septic" response, this has routinely been defined as death. for anti-infective trials, there has been a reasonable correlation of severity (apache ll) with outcome measured as persistent or recurrent infection, but this is not as robust as the association with mortality. it is expected that non-lethal failure would not immediately correlate with disturbed physiology: the basis for antiinfective failure depends on a variety of factors not measured in severity scoring, such as type of infecting organisms, density and susceptibility to administered antimicrobia[s, and anatomic features of infection (e.g., pancreatic). severity scoring is important in differentiating these "categorical" variables from continuous (physiologic) variables. there are, additionally, a series of problems related to the cause of death in relation to severity scoring. in those tdals in which cause of death is analyzed, high severity scores did not routinely predict death as an immediate sequelae of sepsis/septic shock. many of the predicted deaths occurred remotely of progressive background diseases. other important problems with severity scoring have to do with lead-time bias: hew long patients were ill before entry into the study. statistical techniques for condensing various categorical and continuous variables, as well as factoring in information requiring the pharmacodynamics of agents which affect outcome, are being developed to further refine deviation from predictive equations as an outcome measure. stepwise logistic regression analysis has identified the presence of shock, intm-abdominal or unknown source of infection, hospital acquired infection, age greater than years, neutropenia and inappropriate antimicmbial therapy as independent variables associated with increased mortality in sepsis. maldistribution or" these variables is a concern in targe randomized clinical studies. it should be noted that only the selection of antimicrobiai therapy could be addre.~'sed and altered at the time of enrollment in a sepsis clinics] trial. inappropriate antimicrobial therapy has been noted in %- % of septic patients. well designed, randomized sepsis trials do not assure the absence of imbalance between treatment and control groups with regard to inappropriate antibiotic therapy, especially with subgroup analysis. statistical manipulation to correct for any imbalance is appropriate but avoiding imbalance is ideal. selection of antibiotics in septic patients requires such considerations as clinical setting (history, physical examination and underlying disease), appropriate laboratory tests (such as gram stain), identification of source and associated bacterial flora, antibiotic susceptibility patterns for that hospital and likelihood of resistant organisms. determination of inappropriate antibiotic therapy is made retrospectively after culture results are available. in some circunmtances the organism and antibiotic sensitivities cannot be predicted, while in others it can. leibovici et al identified hospital acquired infection, antibiotic treatment before a bacteremic episode, endotracheal intubetion and thermal trauma as independent variables which predicted isolation of a multiresistant organism. the same authors developed a predictive index for resistant organisms, which when compared to prescriptions of attending physicians, improved antibiotic selection in critically ill patients. including a standard antibiotic regimen for all septic patients in a clinical trial is impractical. there is too much interhopsital variability in flora and antibiotic susceptibility. in addition, the aggressive broad spectrum coverage necessary for some patients is inappropriate for others. a protocol which guides a prescribing physician through a logical chain of reasoning might improve antibiotic selection in critically ill patients and could be included in the design of a clinical trial in sepsis. although this approach might minimize potential for maldistribution of inappropriate antimierobial therapy, it would likely create multiple problem areas. will the patient's physicians agree to the protocol choice? what is the availability of speciftc antibiotics at a participating hospital? what is the aplpiieability of study results in typical clinical situations? if there is agreement that thin is an appropriate antibiotic protocol, should it not be used in all seriously ill septic patients in the hospital? in other conditions such as ards, the success of protocol therapy is dependent upon measurable goals such as pao and highest plateau pressure, while measurable goals are not as clear in choosing antibiotics. based on the above confounding issues, a complex and extensive algorithm covering many potential possibilities of error and specific antibiotics seems impractical; however, an algorithm focusing on three to four major common errors in antibiotic selection and dealing with classes of antibiotics is plausible for inclusion in sepsis clinical trials. in this session we will attempt to outline the methodology of such a future study, emphasizing the immense difficulties involved in its proper conduction including: design, selection of patients, surgical considerations, supportive treatment, the "human factor" and ~nd points. only a close cooperation between a few dedicated surgeons, obsessively studying a large number of well selected and stratified patients over years, could make such a study possible. algorithmis have frequently been mistaken for the graphic format in which they are presented. however, an algorithm is neither a flow chart nor a list of instructions; it is a step-by-step approach to solving a problem. likewise, a clinical algorithm is a step-by-step approach to solving a clinical problem. cas are deterministic, which does not mean that they are rigid. they are practical rather than mathematical algorithms, that tan be used only with clinical judgment, and must be tailored to each patient. there are a number of types of, or uses for, cas that can improve sepsis management, including: diagnostic or severity scorm cas, a management ca for managing sepsis constructed according to recently published standards for use in teaching research protocol algorithms that must be used to collect data or guide implementation of a clinical trial aimed at validating one or more dicisions in the management ca; finally, protocol-style cas drawn from the management ca and should be validated using matching outcome studies. organisational problems peculiar to multicentre trials the organisation of any randomised clinical trial is fraught with difficulties, and that of a multicentre trial particularly so. there are problems associated not only with the principles on which the investigation is based but also with the detailed organisation and analysis. are all the participants truly unbiased about the relative merits of the regimens being studied? is like being compared with like -are all the end points and the standards for measuring them clearly defined so that they cannot be misunderstood? are all eligible patients being studied, and their results reported? is truly informed consent being sought that will satisfy not only the patient's right to choose what happens to him, but also the law of the land? and, finally, how can the participants be sure that the trial will be stopped at the right time, to ensure that no treatment is given to any patient that might be harmful? these questions may seem insoluble, but until we tackle them we shall never be certain. dr.m. ev~s, scar~mu~ hospital, scarborough, nonhyo~s~ y ql, u.k. increasing knowledge of the pathogenesis of sepsis and septic shock has led to the development of many new therapies and technologies capable of preventing, blocking or even reversing the deleterious cycle of events. recent results of subsequent multicenter trials testing some novel therapeutic drugs, however, did not confirm the promising sometimes overwhelming effects obtained experimentally. it is postulated that this is largely due to inappropriate design and conduct of multicenter trials as currently performed. one of the shortcomings emphasized in this paper is the "treatment mix" problem. multicenter trials in sepsis are performed because no single center is able to recruit the necessary number of eligible subjects within a reasonable time. each single center (icu) has its own individual policy which cannot be standardized for the trial (treatment mix). even if we ascribe that each icu did the "best" for their patients, it is highly probable that the outcome differs between the icus. this translates to the effect of the new therapy under investigation. ]t is therefore worthwhile to consider that icus must first demonstrate a certain standard based on the patients' outcome (audit) before becoming accepted as a participating center. this prerequisite ensures comparable quality between participating centers, led to the reduction of "noise level" and increases the probability of positive study results. the riyadh-icu program based on standard mortality ratios is recommended as an audit instrument. during the last decade most clinical trials of potential therapeutic agents in systemic sepsis have failed to demonstrate benefit from the drug under study. although in many instances it is entirely possible that the agent in question does not have clinical efficacy, an equally plausible explanation for the multitude of negative results is that the studies were improperly designed and thus could not show therapeutic benefit, if it existed. problems which have been identified in these various trials include inappropriate or unrealistic definitions of response to the drug; inadequate sample size, with attendant insufficient statistical power to demonstrate a difference, if it existed; insufficient standardization of customary therapeutic maneuvers in septic patients; imprecise criteria for patient entry into the study, which creates unacceptable inhomogeneity between control and treatment groups and invites unjustified post-study subgroup analysis; the lack of a formal sequential monitoring procedure for interim data analysis, which could potentially affect patient safety; and a primary analysis of study results that excludes protocol deviants and is not according to intent-to-treat. these and other problems have impacted upon the validity of the various trials conducted to date and may well have prevented the resolution of controversies surrounding the use of certain agents in the treatment of septic patients. the complexity of bacterially-induced septic shock involves a cascade of events that evolve over time, beginning with the proliferation of offending organisms and followed by the release of toxic mediators from the bacteria. endotoxins [e.g. lipopolysaccharides) from gram-negative bacteria initiate septic shock by precipitating a systemic inflammatory response syndrome (sirs) through release of a broad spectrum of hostderived mediators. over the last century, hundreds of these endogenous mediators have been proposed to serve as pathophysiological substances in this "alphabet soup" of cytokines, eieosanoids, biogenic amines, kinins, peptides, ions and hormones. an evaluation of the literature on septic shock leaves the investigator with a sense that, although many pieces of the septic shock puzzle have been presented, no clue was provided to indicate how these pieces fit together, in an attempt to assess objectively the causal role of individual mediators, we recently completed a collective meta-analysis of mediators that were individually reviewed and subjected to koch-dale analysis of causality by distinguished authorities in the field ( ). in summary, our attempt analyze available evidence to support a cause-and-effect relationship for putative mediators of septic shock revealed that only eight of the mediators analyzed could be strongly inferred as playing a causal role in septic shock. evidence supported the involvement of endotoxln, endorphins, complement, interleukins, tumor necrosis factor, eieosanoids, platelet activating factor and calcium. other mediators either lacked adequate supportive evidence or were not conclusively involved. posttraumatic outcome may be reduced by an amplified stress response mediated by neural and humoral stimuli. the classical hormonal catabolic response is predominantly mediated directly or indirectly by neural stimuli, while most changes in inflammatory responses such as leukocytosis, acute phase proteins and changes immunofunction are mediated by humoral mediators. clinical experience from controlled studies suggest afferent neural blockade and modification of stress response to improve organ function and postoperative outcome, and limited experimental studies also suggest neural blockade to be of beneficial value in shock states. of special value may be the improved gastro-intestinal motility after neural (visceral) blockade. no outcome studies are available from patients with major truma, multiple organ failure or sepsis, conditions where humorai mediators may be more important to modify than neurally mediated responses. future studies should investigate the clinical outcome effect of combined neural and humoral mediated blockade, as well as the potential role of an initial neural blockade in elective trauma (first hit) to improve the metabolic scene and outcome if a postoperative complication (second hit) should occur. neutrophil elastase is the predominant protease of the human neutrophil. this enzyme, and a variety of other enzymes, including neutrophil collagenase, are released by activated neutrophils in the setting of high concentrations of reactive oxygen metabolites. in addition, in this extracellular environment, the normal antiprotease defense mechanisms of the organism may have been severely inactivated oxidatively especially along capillary endothelial cells. accordingly, release of neutrophil elastase which mediates inflammation and degrades most extracellular matrix proteins, including elastin, fibronectin and many forms of collagen, may contribute to tissue injury and organ failure in a variety of diseases ranging in severity and acuity from pulmonary emphysema to the adult respiratory distress syndrome (ards). as a result, significant efforts by the pharmaceutical industry have been directed not only toward the development of human neutrophil elastase inhibitors, but also toward their characterization in a variety of animal models of neutrophil mediated diseases, and their evaluation as potential therapeutics for the treatment of a variety of human clinical conditions. data from animal models of organ injury and failure along with data collected from a series of patients at risk for ards and with ards will be presented and discussed as a rationale for inhibition of neutrophil elastase. parameters that need to be monitored to obtain success in future clinical studies will also be presented in this context. have turned out to initiate and maintain organ dysfunctions in severe posttraumatic and postoperative courses. such proteolysis-induced disorders are especially rendered possible by the concurrently arising consumption of inhibitory regulators (e.g. a vproteinase inhibitor=a pi, antithrombin iii=at iii) via cofnplex formation and/of proteolytic/oxidative inactivation. besides the well-known destructive potency against protein substrates, proteinases such as elastase or thrombin (active or in complex with the serpin inhibitors ~ pi or at iii) are also supposed to increase the inflammatory reaction by inducing cytokine release or shedding of soiuble adhesion molecules from various inflammatory cells (pmns, monocytes/macrophages, endothelial cells). those cell-derived mediators may provoke further cell activation through an autocrine/paracrine loop thus increasing significantly the proteinase burden at the inflammatory focus. therefore, this noxious circle might be interrupted by a convenient proteinase inhibitor therapy to ameliorate the inflammatory process. to verify this hypothesis, high dosis of at iii (mean plasma levels up to %) were applied in first controlled randomized studies on surgical patients suffering from multiple trauma or severe sepsis. in control patients we could clearly demonstrate the sequential appearance of proteinase/serpin-complexes (fa pi, tat), cytokines (il- , il- ), and soluble intercellular adh sion molecules (icam, elan, p-selectin) in the circulation. these factors turned out to be a helpful tool for early diagnosis and prognosis of forthcoming organ dysfunctions. interestingly, m at iii-treated patients a significantly reduced release/production of inflammatory mediators became obvious concomitant with the improved clinical course in comparision to an increasing deterioration in control patients. soluble mediators of inflammation are cytokines (e.g. il- , il- and tnfe) as well as breakdown products of complement proteins (e.g. c a and terminal complement complex). therefore, attenuation of both, release and generation of these synergistically functioning mediators together with stimulation of release of antagonists including soluble forms of receptors are potentially beneficial in all kind of inflammatory diseases. intravenous immunoglobulins (ivigs) are known to have an anti-inflammatory effect in humans (nih consensus conference on wig, ) . the mechanism of action becomes more and more clear. in single cells stimulated by anti-cd mab wig was able to down-regulate production of il- , il- , ifn% and tnfj~ significantly. igg coated solid-phase stimulates release from monocytes of interleukin- receptor antagonist (il-lra) but not of il- ; this observation is very much in contrast to the effect of endotoxin in the same in vitro system. furthermore, naturally occurring anti-cytokine antibodies can be demonstrated in apparently healthy individuals and in wig prepared from plasma pools. some of these antibodies can be detected by antigen/antibody reactions in fluid phase (anti-ll-le, anti-il- ), some only by solid-phase detection systems (anti-ll- , anti-ifn% anti-tnfc . infusion of wig to patients suffering from inflammatory disorders have resulted in a decrease in il- in circulation. during infusion wig might induce an acute but transient rise of tnfo~, il- , and il- . self limitiation of this process might be due to demonstrable instant release of il- ra and soluble tnfo~ receptors. in vitro ivig has also been shown to attenuate complement activation via the classical pathway. furthermore, acid haemolysis of erythrocytes in paroxysmal nocturnal haemoglobinuria could partially be prevented by ivig. ivig was able to attenuate forssman shock in guinea pigs. we have seen a patient with congenitally elevated turnover of alternative pathway of complement who repeatedly showed an increase of haemolytic titres after administration of ivig. thus, wigs apparently have multiple potencies including attenuation of soluble mediators of inflammation and might therefore be of benefit in trauma, shock, and sepsis. significance of sinusoidal liuing cells and of humoral factors on hepatic function following sepsis and major surgery hirata k, katsuramaki t, yamaguchi h, mukaiya m, yamashiro k. regeneration of the liver after hepatic necrosis or partial removal has been extensively studied, but uncontrolled mechanisms to irreversible hepatic failure following sepsis or major surgery of liver or with hepatic dysfunction have so far not been well documented. we suggested the importance of the intrasinusoidal aggregation between sinusoidal lining cells and intrasinusoidal running ceils in the mechanisms of hepatocyte dysfunction. thus, the purposes of this study was to investigate the changes in each sinusoidal lining cell during this process and the effect of cytokine on hepatocyte under various oxygenation. [ materials and methods ] ( ) clinical study : thirty two patients with histologically proved malignant tumor underwent major hepatectomy were devided in two groups, i_e. the cirrhotic liver group and the non-cirrhotic [aver group. most of the former were the patients with hepatocellular carcinoma and most of the latter were the patients with metastatic carcinoma of colorectal cancer. five patients were complicated septic conditions with hepatic failure. following operation in each patient, a verous blood sample was taken for measurement of serum il- , il- , tnf and c-reactive protein concentration. and hepatic biopsies were sometimes undergone in patients with anomalous hepatic function. ( ) experimental study : kupffer ceils, sinsoidal endothelial cells and hepatocytes were separated from mouse ( c hhen ) liver. and also polymorphonuclear cells and platelets were purified from blood and peritoneal macrophages were from peritoneal cavity of mouse. co-cultures between or among these cells with iipopolysaccharide were performed. cytokine concentrations in media and hepatocytic function were compared. [ results and conclusion ] our findings in above experiments demonstrated the cleanly different concept for the mechanism of hepatocyte dysfunction following sepsis or major surgery. namely, the effect of hepatoeytie function by cytokines or superioxide were significantly affected under low oxygenation, but not significant under good oxygenation. hirata m.d.,nishi ,hokkaido,japan $ immune complexes as .mediators of sepsis and immune dyafumcffon laa k horn, chxistof birkenmaier, and greg h mon departmen~ of surgery, san frandsco general hospital, urdversr , of calif(~rrda, san frandsco. immune complexes (ic) a;:e commonly found circulating in parians during infection and sepsis; and following traumm, bums, and massive l~ensfusion. clearance of c occurs by phago~'tmsis of esll-bou_nd or opsonized p~tlcles. monocyte activation du~jng phmgocytos/s could lead ~o release of cytokilies ieletexiot~ to the hosh to examine tb/s phenomenon, we formed insoluble ic by precipitating iow-endotoxin bovine serun~ albumin (bsa) with rabbit ant/-bsa igg. we have ~town that these ic are ingested by monocytes and concomitantly stimv/ate re~pizatory bu~t activity measuxed by assay of in%racellul~ peroxldaffon. we have shown that ic ingesffon produces signlqcant el,era,lore in the monoey~e phenotype. spedacally, cdi is down-regu/ated, along wl~ cd and cd . thus responsiveness to lipopolysacchmdde ( ) a~xd i=m~unoglobulin fe st~mu/mtlon is reduced. in cert,+rest, the complement rote.p tot cdc is u~-regulamd, indicaling mcremsed re~ponalx=~ness to opsonized pat,rotes, we examined monocyte superna~n~s for production of hzmor necrosis factor alpha (tnfg) following ic stimulation and showed that ic are capable of provoking ~elaase of hrmaunl)reac~ve tni~. j[c also increase mono=yte produchon of prnstaglandin e . in summary, ~/~ese results demonstrate lhmt ic are capable of indudng production of ¢ytokines and the imrau-nosuppressive prostaglandin pge . ic also allez ~he surface expression of important receptors involved in actlvaffon by lp~ and phagocyiosis. thus, ic aze competent for indud/on of the mepl/e s! otlse. by examining m n cyte phenotypms, it may be possible to d~mrmkne extent ohn'u~u~e complex activation and predict immune depression iu criffcally ill pa~ents. a great deal of experimental work has focused on preventing and/or treating sepsis and organ failure following injury. many of these strategies have tried to attack mediator substances released during the systemic inflammatory response following injury. sugermann has demonstrated the improvement of pulmonary function, but not eappillary leak using [buprofen in the porcine model. in a clinical trial, faist demonstrated the effectiveness of indomethacine in amelierating the post trauma of cellular amenity using in vitro parameters. morbidity and mortality, however, were not different between control and treatment groups. baue und chaudry have suggested that atp magnesium chloride may have protective effect in renal failure um kupfer cell dysfunction seen after shock. pentoxiphyllin has been found to be effective in improving tissue oxygenation and oxygen consumption following hemorrhage, and there may be promise for this drug in the ischemia reperfusion injury. monoclonal antibodies against endothxin and inflammatory mediators seemed promising at first glance; however, preliminiary clinical data of the treatment of sepsis with either ha-ia or e monoelonoal antibodies against bacterial cell wall have been disappointing. initial studies with il-i receptor antagonist also appeared encouraging, but no difference was seen in the most recent trial. currently studies are ongoing with monoclonal antibodies to tumor necrosis factor which may have more efficacy given the fact that it is a macrophage mediator released by endotoxin. although we seem closer to understanding and preventing the problems of sepsis and organg failure after trauma, we must continue to appreciate the complex interrelationships and delicate balances inherent in the host defense system. overzealous attempts at restoring immunity in the absence of understanding pathophysiology may be just as dangerous at post-traumatic immlmospremsion. severe acute pancreatitis was caused by different etiologic factors, but once pancreatic tissues were infected, patients show a similar pattern of aggravation and develop organ failure. remarkable elevation of serum il- was unexceptionally observed in patients with severe acute pancreatitis. the serum levels were more than pg/ml (normal: less than pg/ml) during the first one or two days after onset. there was a significant correlation between the peak serum il- level and the number of organs showing failure (r= . ). tnf-a production by isolated peritoneal macrophages following lipopolysaccharide (lps) stimulation was significantly increased in cerulein-induced pancreatitis rats. serum tnf-a activity was elevated following intraperitoneal administration of lps as the septic challenge both in pancreatitis rats and in control rats, being significantly higher in the former (p< . ). histological findings and liver function tests revealed that lps induced more severe liver damage in pancreatitis rats than in control rats. these results indicate that increased tnf-a production by peritoneal macrophages in acute pancreatitis augmented lps-induced liver injury. organ failure in severe acute pancreatitis could be caused, at least in part, by increased cytokine production. it is clear now, that in mods, organ injury is not directly due to exogenous factors, such as bacteria or toxins, but instead is largely a consequence of the host's own endogenously produced mediators. there is an extensive body of literature on the inhibition of mediator production, release and action in different cascade systems by glucocorticoids. they can serve as a host protection against overactive defense reactions if used adequately. a new understanding of the regulation of cytokine synthesis, especially tnf, may lead to an insight of the conflicting findings between the benefits of glucocorticoid therapy in animals and its current failure in recent clinical trials. glucocorticoid shares its role with other novel therapeutic approaches also shown to be successful only in experimental settings. a mete-analysis of steroids in sepsis, however, revealed a beneficial effect in the subgroup of patients with gram-negative infections. there is now a series of arguments to reevaluate the indication for steroid thera-py and/or prophylaxis in mods and sepsis. honjo i- - , kumamoto , japan in septic shock j. briegel, m. halter, h. forst, w. kellermaun, m. bittl, k. peter imrodnetlea and methods: hydrocortisone (hc) at an infusion rate similar to the maximal secretory rate of cortisol in man improves hemodynamics in human septic shock ( ). we hypothesized that the hc-induced hypercortisolemia prevents a harmful overshoot of immune reactions. to test this hypothesis we prospectively investigated patients admitted to the icu in refractory septic shock. after resuscitation (mechanical ventilation, fluid resuscitation, titration of vasopressors, and initiation of antimicrobial therapy) hc was started with a loading dose of mg/ rain, followed by a continuous infusion ( mggh). with hemodynamic improvement (dopamine < gg/kg/min) the infusion rate nfhc was tapered over a period of days. phospbolipase a (pla ), c-reactive protein (crp), and elastase-proteinase inhibitor complex (e-pi) were deierminated daily. results: according to our previous results hemodynamics improved during hc infusien. after days dopamine requirements decreased to less than gg&g/min in all patients. this corresponded to an attenuation of the systemic inflammatory response syndrome (sirs) indicated by the abrogation of fever and the decrease in heart rate and inflammatory mediators. pla activity and e-pi concentrations decreased to near normal values and crp concentrations decreased as well. after cessation of hc infusion (between day and ) a reinforcement nfthe sirs was observed despite cortisol levels within the normal range. this was first indicated by e-pi, followed by fever, increases in heart rate, crp, pla , and finally by the relapse of septic shock in four patients on days , , and o. a second infusion of hc again resulted in shock reversal and in a decrease in pla , crp, and e-pi in the patients under study. discussion: there is growing evidence that the endogenous steroid hc and proinflammatory cytokines integrate a complex immunoregulatory feec~ack circuit. the elaboration of tnf, il- , il- , and il- is attenuated by- rag hc prior to endotoxin challenge in humans ( , ) . cytokines like tnf, il- , il- , and il- are potent proinflammatory signals for acute reactants (--, clip), neutrophil degranulation (--, e-pi), and pla synthesis and secretion. our data provide evidence that hc at an infusion rate similar to the maximal secretory rate of cortisol in man attenuates the systemic inflammatory response in human septic shock. to evaluate the feasibility of a nigh-dose regimen of antithrombin iii (at iii) treatment in patients with multiple injuries regarding blood levels of antithrombin iii and undesired side effcts and to analyse effects of the initibitortherapy on the systemic inflammatory response. patients and methods: patients with an iss nf more than points who could be treated with at iii administration within rain after trauma were randomized to receive either at iii or placebo. at iii was given to reach an antithrombin iii inhibitory capacity in plasma of % by using the following calculation: at iii to administer = ( % -at iii measured) x body weight. at iii was given every six hours for a period nf hours and on the th day. patients were followed up throughout their stay in the icu but at least days. in this abstract the data of the first patients are included. results: the patients' median injury severity score was points with a median age of years. the patients were equally distributed between verum and placebo groups with respact to age , iss, prehospital treatment, blood pressure, hemoglobin and at nmevel on admission, and time from the accident until the test solution was given. the patients of the at iii group received , units of the inhibitor on average during the first days. with our regimen, the at iii levels could be kept between % and % of normal, whereas control patients an at hi concentration of % to % was observed. patients with at ni treatment required less red blood cells bur received the same amount of ffp and fluids. there were no differences with respect to platelet count, partial thromboplastin time, l~rothrombin time and prothrombim. we did not observe bleeding disorders or any other side effect with peak concetrations of up to % of normal. white blood count, pmn--elastase, interleukin and and c-reactive protein tended to be lower in the at iii group. there were no differences with respect to renal and hepatic function parameters but the duration od mechanical ventilation was shorter in the at ii group ( . vs. . days) conclusions: we conclude that our treatment protocol (a) was able to restore at iil levels to the desired range of %, (b) did not lead to coagulation disorders, (c) did not increase transfusion requirements, (d) did not reveal other undesired side effects, and (e) showed a tendency towards reduced posttranmatic inflammation and mechanical ventilation requirements department of trauma surgery, essen, germany antithrombin-lll (at-ill) acts as an inhibitor of thrombin, further proteases and the alternative pathway of the complement system. inhibiting thrombin, at-ill works as a functional antagonist of paf~ therefore, in state of hypevolemic-traumatic shock, continuous supranormal serum -and tissue -concentrations of at-ill may be efficient to reduce the local posttraumatic reactions resulting from complement and pmn-activation. patients with severe multiple trauma ( treatment [at-ill] -- controls [c]) were investigated. study cdteda were age > and < years, injury severity (iss) > points and glasgow-coma-scale > points; randomization and treatment has to be started within hours after trauma. permission for the clinical study was given by the local ethic committee. bradykinin (bk) and related kinins are potent inflammatory peptides which possess the ability to induce, vasodilation, increased vascular permeability and hyperalgesia. cp- , a novel homodimer bk antagonist has previously been shown to increase survival in rat and rabbit models of lethal endotoxin shock and is now in clinical trials for sepsis. we have now evaluated the effect of cp- in other models of inflammation. male rats were precannulated with a catheter in the carotid artery. h later bk was injected ia and the pain score ranked from (no responses) to (vocalization). cp- at . umoles/kg completely inhibited the pain responses for a period of . - h. cp- at . umoles/kg s.c. was also found to inhibit the increase in paw volume and hyperalgesia induced in rats over a - h period by an intraplantar injection of . % carrageenan. the abdominal constriction response o an intraperitoneal injection of kaolin was inhibited in a dose-dependent manner by cp- . when ul of . % formalin was injected into the paw of a mouse a characteristic licking response was observed which was biphasic in nature. cp- significantly inhibited both the first ( - min) and second ( - min) phase responses. ]n a rat burn model, where the hind paw is immersed in water at °c for sec the increase in paw volume was significantly reduced by pretreatment with cp- , . umoles/kg s.c. finally cerebrai edema was induced in rats by applying cold (- °c for sec) to the dural surface following a craniectomy. cp- at . umoles/kg s.c. produced a significant reduction in the amount of edema compared with sham controls h later. these data suggest that bk is an important mediator of inflammation and hyperalgesia and that the bradykinin antagonist, cp- , may be useful in the treatment of such inflammatory, hyperalgesic disorders. partial hepatectomy in humans is associated with a considerable morbidity due to hemodynamic and metabolic derangements, which increase the risk for organ failure and mortality. we hypothesized that endotoxemia may play a pivotal role in these complications. we therefore, investigated whether peri-operative infusion of rbpi , a recombinant protein of the human neutrophil bpi with bactericidal and endotoxin-binding capacity, could prevent postoperative derangements following partial hepatectomy. male wistar rats ( - g.) received a % liver resection (phx) or a sham operation (sh), and a continuous intravenous infusion of either . mg/kg/hr rbpi (phx-bpi, n= ; sh-bpi, n= ) or the (iso-electric, iso-kd) control protein thaumatin (phx-con, n= ; sh-con, n- ). various parameters were measured h after the resection or sham operation. mean arterial pressure, cardiac output and heart rate were significantly decreased in phx-con rats compared with sh rats, which effects were not observed in phx rats treated with rbpi . blood ph was significantly decreased in the phx-eon group, whereas the leucocyte count, hematocrite and il- levels were significantly increased compared to sham levels. in the phx-bpi group, these parameters were restored to near sham levels. in vitro experiments with rat plasma and human mononuclear cells (mncs) revealed that plasma of phx-con rats is highly capable of activating mncs, accompanied by the release of cytokines. this activation is attenuated with phx-bpi plasma. in vitro added acd or polymyxin b was able to reduce the activation by phx-con rat plasma to the levels of phx-bpi rats thus, these data suggest that systemic endctoxemia, possibly of gut origin, is a major cause of postoperative hemodynamic and metabolic derangements following phx and that rbpizz can prevent these changes. more recently we reported a transient appearance of both endotoxin and tnf in the circulation of rats subjected to the haemorrhagic shock (hs) already at - rain. similar to bpi, recombinant bpi was found to bind lps and inhibit tnf formation in vitro. the aim of this study was to investigate the effects of rbpi (kindly provided by xoma corporation, berkeley, ca) against haemorrhage related endotoxemia and mortality in rats. method: a prolonged hs was induced by blood withdrawal to a mean arterial pressure of - mmhg for rain followed by reinfusion of shed blood (sb) and resuscitation with two times of sb volume of ringer's lactate over rain. rbplg. was administered at a total dose of mg/kg i.v. ( . mg/kg at the -eginning followed by two doses of . mg/kg each at end of shock and the end of resuscitation). the control group was treated similar to the bpi group but received thaumatin as a protein control preparation at the same dose as rbpi . results: imrffe?diately after resuscitation ( min) the detected plasma endotoxin levels in the control group (mean = , range = - pg/ml) were almost neutralized by rbpi treatment (mean = , range = - pg/ml) . plasma tnf levyis were not significantly influenced by rbpi treatment at the two time points and min of experiment (means: and in bpi vs , pg/ml in the control group). the -hour survival rate was improved from / ( . %) in the control to / ( %). conclusion: these data suggest that haemorrhagic shock may lead to bacterial translocation and/or transient endotoxemia with concomitant cytokine formation that may play an important role in the pathogenesis after shock and trauma, rbpi might be a useful therapeutic agent against endogenous bacterfal/endotoxin related disorders in hemorrhagic shock. morbidity and mortality after hypoxia of the vital organs had been correlated to the production of oxygen radicle which is mediated by xanthine oxidase activity, in this study we have evaluated the survival rate after allopurinol. rabbits weighed + grams divided into two groups. group i included tabbits were treated with allopurinol mg/kg for seven days before induction of haemorrhage. group ii as a control included rabbits. all rabbits were subjected to % arterial blood loss through the central ear artery for one hour then resusciatation was done by the heparinized withdrawn blood through a marginal ear vein. during the experiment blood pressure and heart rate were monitored through the central ear artery. also uric acid, lactic acid, glutathione activity were estimated. animal survival was followed for days. postmortem vital organ histochemistry and histopathology examinations were done. in group i the survival after three days was out of while in group ii it was two out of . our conc|usion, allopurinol had increased the survival in aiiopurinol pretreated rabbits which may indicate the value of allopurinol premedication for patient prepared for elective bloody surgical intervention . h receptor antagonists are commonly used for stress ulcer prophylaxis, but their actions on the septic response are largely unknown, in an experimental model, pigs were first anesthetized, then injured with joules of energy to the posterior thigh, then hemorrhaged - % of their blood volume. after i hr of shock, all the shed blood plus x the hemorrhage volume as lactated ringers was infused. following resuscitation, ranitidine ( . mg/kg iv twice daily) or saline placebo was begun. the treatment group was randomly assigned in a blinded fashion. after hrs, a septic challenge was administered ( bg/kg of e. coil endotoxin (lps)). serial gastroscopy, gastric ph, hemodynamics, abg's, physiologic dead space ventilation, leukocyte counts, and tumor necrosis factor (tnf) levels were recorded for min. baseline values and units were cardiac index _+ ml/min/kg (ci), arterial po + mmhg(pao ), base excess . -+ meq (be), physiologic dead space fraction +_ % (pds), and tnf . + . units/ml. baseline gastric ph was . -+ . and . _+ . in the placebo and ranitidine groups, respectively. the gastritis following hemorrhage was marginally attenuated in the ranitidine group. following lps infusion the following were obtained: ci pao * be* gastric* pds* peak* rain rain rain ph min tnf ranitidine _+ _+ - . ± . bum injury results in hypermetabolism, fever and nitrogen wasting. endotoxin (lps) has been proposed to mediate these effects, either directly or via activation of macrophages to produce cytokines such as interleukin- (ii- ). this study was designed to clarify the role of lps and - in the metabolic response to bum injury. twenty-five burn patients ( -+ %; + % ft bsa burn; _+ years old) were studied serially for three weeks post bum. patients underwent partitional calorimetry to assess metabolic rate and compartmented heat loss. nitrogen was assayed using chemiluminescence. lps and i - were measured with limulus amebocyte lysate assay and elisa. patients were excluded if they suffered smoke inhalation, showed any sign of sepsis or failed to rapidly meet their nutritional needs via the enteral route. ten patients received intravenous polymixin b ( , u/kg/day to bind lps). these patients did not differ for the remainder. all patients were hypermetabolic and febrile in proportion to the size of their bum wound but were not endotoxemic ( . +_ . pg/ml; normal < pg/ml). i - did demonstrate a significant correlation with cole temperature (tr~ = . + . ogi - , p= . ) and with nitrogen excretion (nou t = - . - . ogi - + . tr, p= . ). administration of polymixin b had no effect on metabolic rate, temperature or i - levels but did reduce nitrogen excretion resulting in more positive nitrogen balance ( .t grn/day vs. - . gm/day, p= . ). although bum injury does not produce an obligatory endotoxemia, i - does appear to play a role in the fever and nitrogen wasting seen with such injuries. the effect ofpolymixin b on nitrogen excretion suggests that lps may play a role either locally or in the portal system. introduction: there is substantial evidence that release of inflammatory mediators by activated kupffer cells contribute to the course of a systemic inflammatory process, e.g. after shock or lrauma. besides the systemic effects of mediators such as tnf, paf or interleukines, local actions on hepatic microvasculature and hepatic inflammatory response have to be considered. our aim was to assess the role of tnf and paf by blocking their effects using anti-tnf monoclonal antibody, pentoxifylline and a paf antagonist. methnds: in anesthetized sprd-rats, hemorrhagic shock was induced by withdrawl of arterial blood within rain and shock state was hold for h at a map of mm hg (cardiac output of %). following adequate resuscitation with % of shed blood and twice of this volume as ringer's solntion, animals recovered to map > mm hg and co > %. hepatic microcirculation and sinusoidal leukocyte-endothelium interactions were examined by intravital epi-fluorescence microscopy at , , or hours after resuscitation. in a blinded fashion, a rat-specific monoclonal anti-tnf antibody [ mg/kg, celltech, uk) , pentoxffylline (ptx, mg/kg, hoechst, d), and a paf antagonist (web , boehringer, ingh., d) were given either as pretreatment or at the time of resuscitation (n= - group bolla. k*., duchateau, j., hajos, gy., mbzes, t., hern~di, f. prevention of temporary/secondary immune deficiencies or reduction of their severity and/or duration as well as the reduction of the perifocal inflammatory processes belong to the rational targets of posttraumatic/pedsurgical medication. such a targeted medication can result in less frequently occurring nosocomial infections, and in reducing the duration of the intensive care and convalescence period. the results of in vitro studies performed with the amino acid sequence - of thymopoietin, i.e., with thymocartin in whole blood and peripheral mono-nuclear celi(pbnc) cultures clearly show some characteristic effects of this immunomodulator. preincubation with the tetrapeptide significantly (p<o.ol) and concentration-dependent reduced the endotoxin(lps)-induced tnfalfa production from , to about pglml, but did not abolish it. the inhibition of the lps( . ug/ml)-induced tnf production occured already in presence of , pg peptide/ml and peaked at the concentration of , ng/ml. higher concentrations did not increase this effect. in contrast to the other two small thymic peptides (tp- and tp- ), thymocartin did not enhanced the pwm-induced pge production in pbmc cultures up to a concentration of ng/ml, inclusive. the selection of thymocartin (tp- ) for perisurgical medication and/or for treatment of trauma-induced temporary immune depression has been strongly supported also by targeted animal experiments. thus, mortality of about % registered in mice infected with pseudomonas aeruginosa after bum injury could be reduced with the tetrapeptide treatment to a level which did not differ significantly from that of the infected non-burned controls. moreover, observations gathered first of all with the inflammatory model of air poach/croton oil grenuloma (selye) clearly showed, that a very definite, antiexudative effect can be achieved with this thymic peptide. as to this effect, thymocartin has been confirmed, e.g., to be equipotent with locally administered fluocinolone acetonide and/or s.c. injected prednisolone. the interim results of two explorative double-blind clinical studies (involving more than patients after polytrauma and hip-fracture untill now, respectively) correspond to the expectations. the treatment significantly reduced the occurence of nosocomial infections, the days spend in intensive care and on antibiotics as well as it shortened the bed-out time and reduced the additional medication. objective of this prospective randomized study was to further delineate the mechanisms leading to these alterations and to investigate the effects of immunomodulatory intervention. patients and methods: patients (pts) formed control group a. group b pts received x mg indomethacin (indo) from the first (dl) to the fourth postoperative day (d ) intravenously to block prostaglandin e induced suppression of cmi response as well as mg thymopentin (tp- ) subcutaneously preop., on d and d to augment cmi reactivity. in vitro investigations preoperatively, on dl and d included measurements of the percentage of cd + t-helper (th) cells, pbytohemagglutinin (pha)induced synthesis of interleukin (il)- as one cytokine primarily produced by thl-cells, and pha-induced synthesis of il- as one cytokine primarily produced by th -cells. delayed type hypersensitivity (dth) skin response to an antigen skin test battery and specific antibody (ab) production following tetanus vaccination preoperatively and on d were used as in vivo tests for thl-and th -induced immune response respectively. results: postoperatively, group a pts showed a persistent significant reduction of cd + th cells, il- /il- ratio, and dth skin response as compared to baseline values (bl), while ab production increased (p< . vs.bl). in group b pts no change in cd + th cells, il- /il- ratio, or dth skin response was observed (p< . vs.group a), and postoperative ab production increased significantly (n.s. vs. group a). conclusions: .these results clearly indicate a significant suppression of th induced cmi response, while th induced response remains normal following ohs. .these alterations may gain clinical significance whenever a postoperative infection requires a th response and may explain the susceptibility to opportunistic microorganisms observed in pts after ohs. the aim of this study was to find out whether the establishment of administration of thymostimulin (tp-i) in jaundiced and anergic rats would return the rats to the state of immunocompetence. material and methods. male wistar rats weighing - g were injected with haemocyanin (klh). all rats with a positive response were included in the study and we evalu ated the t cell subpopulations and il- . they underwent laparotomy and the common duct was ligated and divided. those rats whic become jaundiced and anergic one week after the operation, were divided in two groups: control group ( objective of study. the goal of this study was to prove the necessity of thymus derived immunomodulators treatment in acute period of infantine sepsis, materials and methods. immune status was investigated in o infants. clinical conditions of children were defined by syndrome of multiple polyorgan]c insufficiency. the heaviness nf condition was estimated as the sum of points according to efforts needed to restore of basic living functions -respiration, hemodynamjcs, hemocoagulatlon, metabolism, functions of liver and kidneys. it was expressed in form of clinic condition classes from to . results.it was found that in % of infants with - classes of heaviness immunode[iciency took place simultaneously with ii and iii stages of hemocoagulattve syndrome. amounts of t cells and t helpers were decreased more then times, ratio th/ts was reduced to . or lower. concentration of lgg and igawas reduced almost a hull in comparison to control. phagocytic and metabolic activities nf neutrophils were depressed. complement system state was changed: the functional activity of the alternative pathway factors b, d and the level or c a subcomponent were increased but the level of c , c ,, c and c components of the classic pathway were decreased. during the development of coagnlopathy the direct correlation between chso, levels of plasminogen and antithrombine iii was found. in greater extent the function of immune system was disodered in accordance with point metabolic violations and hemocoagulative disturbances considered as disseminated inmtravaseular clotting syndrome on ii or ili stages. conclusions. the rehabilitation of the immune system functions was promoted by taetivine and thymaline in doses of i- mcg/kg per day and mg/kg per day accordingly during a week in children with - classes el heaviness. aiter - days tactivine had advantage. when eoagulopathy took place thynaaljne promoted restoration of ( - )-~-d-glucan (bgc) is a major cell wall compornent of pathogenic fungi and shows many immunopharmacological activities on experimental animals. lps is also derived from gram-negative bacteria and have in~ttnomodulating activities on immune systems positively or negatively. because of difficulty to cure contaminating lps from bgc preparations, it is very hard to evaluate the exact activities of bgc. in this study, we compared the immunological activities of lps ans highly purified bgc on murine system. materials and methods: c h/hen or c h/hej mice, to wkolds of both sexes were used through experiments. highly purified ( - )-{ -d-glucan (gurdran; bgc)was courteous gift from seikagaku kogyo co. tokyo, japan and resolved in endotoxin-free ultra-pure water. escherichia cell lps was purchased from sigma chemicals, usa. mitogenic activities of bgc or lps on splenic cells were measured by mit dye assay. in vitro activation of peritoneal exudate macrophage (pen) have moniotored by phagocytosis and intraphagocytic killing of pseudomonas aeruginosa (z~b- . induction of cytokine productions from pem or spleen cells induced by bgc or lps were detected by cytotoxic assay. results and (bnclnsions: i ) in vitro cultures of pem with bgc have induced enhanced phagocytic and bactecidal activities in c h/hen and c h/hej mice, whereas lps only induced such activities in c h/hen mice. most effective dose of bgc was ug/ml. ) bgc-dependent proliferative response of c h/hen splenic cells was not detected under the culture condition used. ) induction of tnf~ prodction was apparently observed in bgc-stimulated c h/hej pd cultures, but not in lps stimulated one. these findings indicate that activation mechanisms of pr and splenic cells by bgc are different from that by lps. to investigate the bsc-induced p~ activation, intracellular signaling pathways of p~ by bgc-stimulation are under consideration. yamagami k, uedono y, kawakami k, kitazawa y and tanaka t according to the latest reports of use of il- in a burned-sepsis model, the dose was too high to adjust for human therapy. adoptive transfer of l~ymphokine-activated killer (lak) cells has been demonstrated as a means of enhancing therapy in malignant tumors. we therefore attempt to use lak therapy on burned-infected mice instead of il- . under anesthesia, -weekold male c h-hej mice were subjected to a % scald or sham burn and then resuscitated. sham burned mice served as controls. scald burn mice were subjected to peritonitis by intraperitoneal innoculation of organisms of p. aeruginosa hr after burn. burned-infected-mice were divided into two groups. one group had no further treatment, and the other group received lak cells ( x ) intraperitonelly after septic challenge. the mice were scored for survival daily. on day after burn, using moabs dual-color flow cytometry, we studied lymphocyte expression in mice with use of blood and spleen. simultaneousely we studied the alteration of il- and il- in their serum using immunoassy kits. sham burned animals had no mortality. the mortality of the lak-treated mice was significantly reduced when compared with that of the burned-infected mice. the most consistent changes observed were depressions in percentages of thyl, positive cells and a remarkable depression of nk cells in spleen. after lak cell treatment, those two percentages of cells significantly increased. all the data of assay of ill and [l were not detected on sham burn mice serum. due to burn and septic challenge the levels of illand il (n= ) were raised to . _+ . and _+ pg/ml, while the levels in lak treated mice were reduced to . _+ . and _+ pg/ml, respectively. the results reported here demonstrate that lak therapy is able to improve cell-mediated immunity in burned-infected mice. this is associated with a significantly improved survival rate, since ill has been demonstrated to mediate immune and inflammatory responses. also a cause effect relationship between elevated endetoxin levels and increases of [l has been recently established. the aim of our present study was to investigate the effect of parenteral indomethacin on the immune system of patients under major operations. our study included operated patients, of which received mg indomethacin before and , and days after surgery (group a) and patients received no antiinflammatory therapy (group b). we measured total t-cells helper (cd ), suppressor (cd ), nk-cells and interleukin- and tnf production by pha or endodoxin (lps) stimulated peripheral blood mononuclear cells at day and , and days after operation. in group a we detected a significant (p< . ) increase in cd /cd ratio on day while no differences were ~oted in nk-cells or cytokine production in both groups (table ) . it seems, therefore, that parenterai indomethacin may have a benefitial effect on the immune system of patients under major operations by increasing the t-helper /t-suppressor cell ratio while having no effect on the production of cytokines by peripheral blood mononuclear cells. this study was undertaken td dete~nnine the role of prostaglandin synthesis inhibitor on survival post traulna sepsis. analysis of the effects of prostaglandin synthesis inhibitor on survival of four groups of mice each were made after laparatomy and intravenous administration of live e.coli. post trauma sepsis, group a received no treatment; group b received antibiotics im; group c received prostaglandin synthesis inhibitor im and group d received both antibiotics and prostaglandin synthesis inhibitor im. survival time was longest in group treated with prostaglandin synthesis inhibitor and antibiotics post trauma sepsis. the singular use of either antibiotic or prostaglandin synthesis inhibitor did not alter the outcome on survival. mortality rate was lowest in the group treated with combined prostaglandin synthesis inhibitor and antibiotics. use of this combination showed a reduction in bacterial growth in peritoneal and blood samples, mild morphologic changes secondary to sepsis in the heart, lungs, liver, kidney and stomach and marked enhancement of mean level of activity. the study indicates that addition of prostaglandin synthesis inhibitor in treatment of trauma-sepsis has clear beneficial effects. interferon-? (ifn-y) is a potent immunostimulant which has been shown to be detrimental when administered during septic shock. blockade of this cytokine however is beneficial during the acute septic response. the aim of this study was to evaluate the cellular effects of this cytokine and its blocking monoclonal antibody (moab) in lethal sepsis following injury. female cd- mice were randomized into two groups: septic=lps vs injury=hind limb amputation (hla vs igg. nstats= anova=p< . vs lgg ifn-y was detrimental when given to control septic animals. however its blocking moab was protective (p< . ). conversely ifn-y was proteetive in injured septic animals compared with anti-ifn-? (p< . ). these findings demonstrate that the immune stimulant ifn-? has therapeutic potential in the immunosuppressed injured host predisposed to sepsis, while blockade of this cytokine is required for protection in the septic host with a normal immune response. dept of surgery, rcsi, beaumont hospital, dublin , ireland. oxidants play a role in physiology. the potential noxious oxidant biochemistry is restrained by chemically distinct antioxidants. these antioxidants, which may reside in different cellular compartments, can act synergistically. in normal physiology an oxidant/antioxidant bai&nce exists. unbalance in favour of the oxidants is called oxidative stress. oxidative stress has been implicated in many pathologies including lung diseases(e.g, doxorubicin induced cardiotoxicity), ischemia/reperfnsion damage and central nervous system trauma. transition metals such as iron are involved in the early events leading to oxidative damage in these pathologies. this has been underlined by the finding that postischemic cns pathology closely resembles that caused by a chemical oxidative insult (e.g. iron microinjection). moreover, a protective effect of oxygen-radical scavening agents or compounds that inhibit lipid peroxidation (antioxidants) in brain ischemia/trauma is apparent. some known drugs (e.g. anti-arrhythmics or histamine h -antagonists may act as non-specific antioxidants. howe~er, recently, interesting new membrancespecific antioxidants (e.g. -aminosterdids) have been designed. subt&e effects on iron redox chemistry contributes to the potent antioxidant activity of these aminosteroids. since a few years, one area that greeted enthusimastlcally in clinical medicine is that of reoxygenatlon injury or ischemia-repeffusion, a phenomenon accepted to make a majo:" contribution to organ dysfunction in trauma, shock and sepsis through the formation o( oxygenated free radical species. however, thei detection in vivo always remains a difficult challenge. efforts have been made recently to directly establish the formation of free radicals in biological samples as complex as blood, plasma or tissue with the use of electron spin resonance (esr) spectroscopy. using spin trapping agents, the presence of reactive carbon-and oxygen-centered radicals has been demonstrated in animals blood submitted to heart, renal and intestinal ischemia-repeffusion or to liver transplantation. recently, the in vivo formation of free radicals in the cerebra; extracellnlar fluid during cerebral isehemia-repeffusion has been assessed by the spin trapping technique coupled to brain microdialysis. esr investigations have also been conducted to detect endotoxin-induced free radical generation in rat or baboon liver and oxygen free radicals (ofr), produced both at intra-and extra-cellular levels, seem to play a major role in the pathophysiology of tissue injury and organ dysfunction in sepsis, through induction of lipid pemxidation in cell membranes. oxidative damage can result both to an ofr-overpmduction or to a depletion of endogenous antioxidant defenses, which are represented by scavenger enzymes (e.g. sod), hydrosoluble and liposoluble antioxidants (e.g. ascorbate, vitamin e), and other mechanisms such as metal-ion sequestration. in animal models, oxidative damage has been proved by detection of increased levels of lipoperoxidative products, and a depletion of antioxidant defenses was found both in plasma and tissues. in the few clinical studies a similar results have been reported, and oxidative damage appears to correlate with dic, with organ dysfunction and with red blood cell deformability. in a group of critically ill septic patients we found increased levels of conjugated dienes (cd) (bioproducts of lipoperoxidation) and decreased plasma levels of alpha-tocopherol and coenzyme qlo (coqi )(endogenous liposoluble antioxidants). a relationship between cd and uric acid (p< . ) was found, may be related to xantine-dehydmgenase to xantine-oxidase conversion. antioxidant depletion is due both to overconsumption and to a nutritional deficiency, even if a reduced synthesis can also be present. in fact one more relationship between coqi and plasma cholesterol (p< . ) demonstrates the commun hepatic biosynthetic defect. is there any role for antioxidative therapy in sepsis? can it achives a significant improvement in the septic course, organ dysfunction, and final outcome? several antioxidant drugs, have been evaluated in experimental and clinical sepsis: scavenger enzymes, natural antioxidants, alloporinol, -aminosteroids or lazaroids, have been proved to reduce lipopemxidative damage, to protect organ dysfunction, and in some cases to improve survival. several questions must be addressed in evaluating safety and utility of antioxidative therapy. more specific and standardized methods must be applied to detect and quantify the lipoperoxidative damage. antioxidant drags must act selectively on ofr-production, without interference with other than that are beneficial for the organism. antioxidants must be able to achive in adequate amount the tissue or cellular compartment where their action is required. many antioxidants have also a pro-oxidative effect which can he detrimental in some conditions. the timing of administration, the dosage used and the association wih others antioxidant drugs must be defined. nutrition plays an important role as antioxidative therapy, since it supplies all compounds needed to maintain adequately levels of endogenous antioxidant or to support their synthesis. thiobarbituric acid reactive substances (tbars) concentration in serum has been determined in a large population of healthy subjects and in patients suffering acute hepatitis and chronic cases of hepatitis c, as well as several other processes. the correlation with different physiological and clinical parameters in these populations is also presented. treatment with interferon of the chronic active hepatitis c patients, x u three times a week during two months, led in those patients whose sgpt activity normalized in serum, to a concomitant decrease in serum tbars content. the possible theoretical involvement of peroxidation and antioxidants in this beneficial effect of i~terferon in hepatitis c patients is discussed. the results presented confirm the value of tbars as laboratory test in the management of disease and as a useful tool for the study of pathogenic and/or therapeutic mechanisms. -hydroxyalkenals are among the different substances measured by the tbars assay. these compounds show several biological effects that have been demonstrated mainly in different experimental models. we have studied the capacity of different tissues to conjugate these compounds patients surviving the initial subarachnoid hemorrhage (sah) from a ruptured in~raeranial aneurysm are prone to develop cerebra] ischemia from vasospasm which is associated with significant morbidity and mortality. among the many treatments that have been prol~osed to treat this condition, none has been shown to be satisfactorily effective. recently, a new drug, namely the -aminosteroid tirilazadmesylats, has been studied in a large, prospective, multicentor trial for its effectiveness to improve the outcome of patients with aneurysma! said. the study was conducted in europe and australia in neurosurgical centers and included patients. all patients received presently accepted standard treatment, including nimodipine. patients were randomized to four different groups: placebo and groups of tirilazad in escalating dosage ( . - mg/kg/day). the clinical outcome was compared for these groups and cerebral a~giography was performed in % of patients on day - follovang sah, to study the effect f'the dflf~ off cerebral vasospasm. the study reached its planned endpoint months ago. preliminary results ~how a significant improvement with regardto mortality in those patients receiving the highest tirilazad dose as compared to placebo and the two lower dose groups. additional beneficial effects were seen in the rag/day groups with regard to the occurence of symptomatic vasospasm and good clinical outcome. although the final analysis of all data is still pending, these results suggest that tirilazad-mesylate could represent a major improvement for the treatment of patients with sail. experimentally lipidperoxidation products (lpo) are increased in acute pancreatitis (ap) due to oxygen radicals (or). the purpose of this clinical study was to determine the antioxidant status and lpo in patients suffering from ap and to evaluate the effect of antioxidant treatment with sodium selenite (se) thus improving the function of the se dependant glutathione peroxidase which is the major detoxifying system for or. materials and methods: in z patients sufferin s from severe ap (c-reactlve protein > me/l) we determined on day and day after admission the lpo ma!ondialdehyd (mda), conjugated dishes (cd), reduced (gsr) and oxidized (gssg) glutathione, the vitamins a,c,e and se. moreover the patients were evaluated clinically using the ranson and the apache ii score. i patients were randomly treated with ug/day of se for days. results: all patients suffered from a severe depletion of antioxidants,especially a low concentration of se (only / of normal). thereby the increase in lpo correlated with the clinical course. during se treatment lpo decreased and the levels of antioxidant vitamins improved. se had no influence on leth-slity the lenl or the chan in rs or ap ii. background: since reperfusion injury occurs when oxygen is reintroduced into ischemic tissue, the ideal timing for administration of therapeutic compounds aimed at ameliorating oxygen radical mediated injury is at the time of initial fluid resuscitation. currently used colloid or crystalloid preparations do not provide optimal, or even significant, anti-oxidant protection. systemic iron chelation affords protection against the iron catalyzed components of oxygen and lipid radical mediated tissue injury. the conjugate resulting from chemical attachment of the clinically approved iron chelator, deferoxamine (dfo, desferal ®, ciba), to hydroxyethyl starch (hes) represents a novel approach to colloid based fluid resuscitation. hes-dfo contains % hes and % chemically bound dfo. the polymer-drug conjugate has a lower molecular weight than that of hes in order to allow more rapid excretion. results: preclinical and initial clinical trials indicate that hes-dfo is well tolerated, even at high doses. in animal studies, fluid resuscitation with hes-dfo does not significantly improve central hemodynamic recovery beyond that observed with hes, but hes-dfo seems to afford better protection of microcirculation in organs at risk (lung, liver and gut), possibly by decreasing neutrophil sequestration. in a burn model, total fluid requirements are lower and oxygen utilization higher in hes-dfo treated animals compared to hes controls, suggesting decreased vascular leak and improved tissue perfusion. conclusion: hes-dfo represents a means by which potent antioxidant protection can be administered at resuscitation. iron has been suggested to play a pivotal role in oxygen flee radical mediated tissue injury. in vitro experiments indicated its critical role as a katalyst in hydroxyl free radical generation fenton-reaction). since iron chelator deferoxamine administered in shock alone demonstrated severe side effects, a hydroxyethylstarch (hes)daferoxamine (dfo)-conjugute was used to modulate oxygen free radical injury during the ischemia/reperfi~ion syndrome induced by hemorrhagic shock. methods. female lewis rats ( - g, n> ; pentobarbital anesthesia mgjkg), in hemorrhagic shock ( the aim of the study was to elucidate ( ) whether the generation of or would affect lung and kidneys as primary shock organs in the very early phase of sepsis and ( ) whether dfo-hes could prevent this tissue damage. methods: in rats sepsis was induced by cecal ligation puncture (clp) peritonitis. the animals were randomly assessed to groups: one group was treated with ml dfo-hes ( mg/kg iv), the other rats received solely ml of the carrier starch solution. , , , and min after induction of sepsis respectively, the animals were sacrificed, the organs collected, and tissue contents of glutathione (gsh), malondialdehyde (mda), myeloperoxidase (mpo) and conjugated dienes (cd) determined. plasma samples were obtained for analyses of endotoxin (chromogenic lal test). blood pressure (map) was measured via a carotid artery catheter. results: clp caused sepsis with high (> . eu/ml) endotoxin levels. map in both groups decreased slightly but significantly during sepsis regardless any treatment. in the lungs mpo concentration was increased (p< . ) in the lies group already min after sepsis induction. concomitantly, tissue gsh level decreased and lipid peroxidation was pronounced as shown by elevated mda and cd levels. dfo-hes diminished tissue pmn accumulation and mpo concentration. moreover, at each time point lung mda and cd levels were lower (p< . ). histomorphological examination showed marked micro-atelectases, destruction of the alveolar septa, and splicing of the basal membranes in the lies group. in contrast, in dfo-hes treated rats the alveoli remained well-ventiiated and only some enlarged reticular fibers without splicing were observed. almost similar results were found for the kidneys. mpo levels differed neither within nor between both groups. the slight decrease in gsh levels seen after min in the dfo-hes group seems to demonstrate an oxidative stress to a lesser degree. the most impressive effect of iron chelation, however, was revealed by the lipid peroxidation products. at each time point, mda and cd levels were lower (p< . ) compared to the hes group. light and electron microscopic examination disclosed tubulotoxic and mitochondriat damages while dfo-hes lxeatment prevented that alterations. conclusion: both the biochemical and histological results of this study reveal an early and remarkable generation of or in peritonitis-induced sepsis. thereby, these or obviously cause pulmonary and renal tissue damages, intravenous application of dfo-hes may, however, benefit by preventing early lipid peroxidation of the tissue. the proteolytic irreversible conversion of xanthine dehydrogenase (xd) to xanthine oxidase (xo) is triggered by calcium flux. the aim of our study is to clarify ~he link between intracellular ca + levels and xo activity determined by uric acid release, and to evaluate the efficacy of verapamil, on the generation of hydrogen peroxide associated with reperfusion by assaying lactate & pyruva~e release and the levels of cytosolic free nad /nadh ratio. experimental protocol consisted of :(a) non ischemic/reperfused experiment in which normal cardiac slices of rats were perfusated with oxygenated kreb's ringer phosphate buffer containing glucose ( mg%) and bovine albumine ( gm%) for min at °c.it composed of groups, group aa (control group), and groups ab & ac (perfusate supplemented with verapamil in the dose of loo& mi% respectively). (b) ischemic reperfused experiment in which ischemic cardiac slices were obtained from rats subjected to min ~aemorrhage.lt was also divided into two groups; group ba and bb (verapam~/ mi% added to perfusate}. verapamil stimulated uric acid release from normal rat cardiac slices were % in group ab and % in group ac(dose related). rates of uric acid release is enhanced by verapamil in group bb. moreover, rates of uric acid release in groups ac & bb are insignificant. in verapmil added groups (group ab, ac & bb), increase uric acid release is associated with an enhancement in pyrurate release and with increase levels of cytosolic free nad+/nadh ratio, although it is not evident ~ ischemic group (group ba).it is concluded that the conversion of xd to xo is calcium independent. eicosanoids like thromboxane a , leukotriene b and leukotriene c are known as promoters of initial inflammatory reactions. we investigated whether oxygen radicals (or) are able to induce a release of these eicosanoids in whole blood. blood from healthy volunteers was incubated with xanthine oxidase/hypoxanthine to generate oxygen radicals. after , , , and minutes plasma levels of thromboxane b (txb ), leukotriene b (ltb ) and leukotriene c (ltc ) were determined via elisa technique. another volunteer had taken mg aspirin one day before taking the blood sample (no ). results: txb plasma levels increased from pg/ml at min to pg/ml, pg/ml, pg/ml and pg/ml at , , and min (p< , ) . ltb and ltc plasma levels showed an increase during the first few minutes (ltb : min: llpg/ml, min: pg/ml; ltc : min: pg/ml, min: pg/ml (p< , )) followed by a decrease to normal values at min. in the sample no the cyclooxigenase-pathway was completely inhibited, the txb plasma-levels did not alter at all, whereas ltb and ltc -plasma levels weren't affected. opallogeneic blood transfusion jane shelby, ph.d., and edward w, nelson, m.d, there have been numerous investigations dudng the last two decades examining the effect of surgery, anesthesia, blood loss and transfusion on vadous immune parameters in humans and animal models. there appears to be concurrence among several well controlled studies that transfusion of whole blood (containing leukocytes), has regulatory effects on immune ceil function which include decreased cell mediated immune response, and inhibition of il- secretion. these effects occur following transfusion alone and in con.cart with the distinct immune effects of surgery, trauma and anesthesla, the clinical consequences of this immune modulation by transfusion include decreased allogeneic response to transplanted organs, which has been exploited clinicelly in renal transplant patients. additionally, there is evidence for a strong association with increased risk for infection in transfused patients following surgical procedures. aiiogeneio blood transfusions have been shown to inhibit cellular anti.bacterial mechanisms, causing increased susceptibility to bacterial pathogens, in humans and in animal models. there is also concern that allog~neic transfusion may adversely affect cancer patients, resulting in decreased disease-free survival. several stategies have been proposed to minimize the adverse effects of blood transfusion. there is evidence that the risk of immune mediated infectious complications associated with transfusion may be greatly minimized wlth the use of autologous blood and leukocyte free allogeneic blood.products in surgical and trauma patients, it also appears that the inhibition of cellular immune response and il- productiorl following atlogeneic blood transfusion may be mediated by increased prostaglandin e secretion, and that immune response may be preserved in allogeneio whole blood transfused subjects receiving c lc~oxygenase inhibitors such as ibuprofen. among these are various alterations in immune function. efforts have therefore been made to utilize alternatives to homologous transfusions. these include the use of autologous predonation, supplemental iron therapy, and recombinant human erythropoietin. although initially considered innocuous, these therapies are now recognized to have potential deliterious immune sequelae. erythropoietin, by its ability to lower serum iron levels, can impair both lymphocyte and nk cell activity. autologous donation impairs nk cell function. finally, supplemental iron therapy can stimulate bacterial growth and increase the rate of infectious complications. this talk will present a discussion of these factors as well as a weighting of their importance. r.l rutan, rn;bsn, shriners burns institute and the university of texas medical branch, galveston tx, usa the serious sequelae of homologous blood transfusions have resulted in vigorous efforts at identifying alternate therapies for correcting red blood cell (rbc) deficits. erythropoietin (epo) was hypothesized to exist in the early th century, however the protein was not isolaled until . the human gene was identified and cloned in , which permitted the production of epo through recombinant techniques. the earliest clinical trials were performed in anemic end-stage renal failure palients on hemodialysis. treated patients experienced increases in erythropoiesis with normalization of hematocrit and hemoglobin levels, cessation of lrans-fusion requirements and improvement in general wellbeing. these studies, however, identified side effects of epo treatment such as hypertension, seizures and ee deficiency. volunteer trials have established that the hypertension is not a direct pressor effect but rather the result of abnormally rapid increases in red cell mass in the face of the incompetent volume-controlling mechanisms of the end stage renal failure patient. lower doses of epo and the subsequent gradual increases in red cell mass are associated with significantly lower incidences of hypertensive complications of epo therapy. likewise, seizure activity is not the result of a direct epileptogenie effect but parallels the incidence of hyper-tensive-related sequelae during high.dose epo treatment. in cross-over designed studies, pre-existing iron deficiency has been demonstrated to decrease or negate stimulated erythropoiesis but effective-hess can be restored with appropriate fe supplementation. exogenous epo is effective whether given by iv or sq routes and dose response curves do not vary with route of administration. increases in rbc mass are directly related to the dose of epo, both in amount and frequency of administration although there is a - day time lag between the first epo dose and laboratory indications of its action (i.e. increase in the number of reticulceytes in peripheral wood). epo is currently labelled for use in the treatment of anemias associated with end-stage renal disease and aids. however, its use in the surgical population has been explored because of its unique direct dose-response, epo has been used to effectively increase the blood harvest amounls in autologous pre-donation, significantly increase hematocrils in children following thermal trauma and successfully increase red blood cell mass following essential surgical procedures in patients with religious aversion to transfusion. by blood transfusion in colorectal cancer surgery mm heiss md, ch delanoff md, r stets md, j hofinann, e faist md, kw jauch md, fw schildberg md allogeneic blood transfusions are associated with an increased risk for postoperative infections in colorectal surgery when compared with autologous blood transfusions. attribution of this effect to immunomodulation was suspected in our previous study (lancet ; : - ) . task of the recent investigations was to analyze which specific effector systems were affected in-vivo by this transfusion-associated modulation. for global in-viva assessment of cell-mediated immunity (cmi) multiple recall skin-reactions were applied prior and post-operative. the specific humoral immune mechanisms were investigated by applying tetanus-toxoid one day preoperatively and deterimnating the quantitative igg-response. for indication of macrophage stimulation in-vivo tnf-levels were determinated by bioassay. dth-responses were significantly suppressed (p< . ) in patients receiving allogeneic blood (n= ) or operated without blood transfusions (n= ). dthresponses were not suppressed and tendentiously increased in patients with autologous blood transfusions (n= ). in contrast, specific igg-levels increased sigmficantly (p< . ) in patients receiving allogeneie blood (from . + . to . _+ . ie/ml) whereas in patients receiving autologous blood a smaller increase (from . + . to . + . ; p= . ) was observed. tnflevels demonstrated a similar pattern with a higher increase in patients receiving allogeneic transfusions (l . + . to . + . u/ml) compared to those patients with autologous blood ( . + . to . + . ). in conclusion these data indicate that allogeneic blood transfusions lead to a remarkable macrophage/rhs stimulation. this is corroborated by the boostered humoral igg-response which was initiated before onset of surgical trauma and blood transfusion. concerning cmi this caused a substancial suppression probably due to a stimulated secretion of immunosuppressive monokines. objective: firstly, to analyse the concentrations of the cytokines tumor necrosis factor (tnc), interleukin- (il-i), interleukin- (il- ) and coagulatioo/fibrinolysis parameters in postoperatively retrieved blood from a surgical area, secondly to characterize the correspanding cytokine patters in the patients and thirdly to study cytokine concentrations in the initial portion of drainage blood from a surgical area. materials and methods: blood retrieval was performed in a closed-loop system without anticoagulant during - hours after surgery in patients undergoing arthroplasty ( hips and knee). kf, il- , it- , thrembin-antithrombin complexes (tac) and antithrombin (at) ~ere determined in shed blood. patient plasma tn v, il-i and il- concentrations ~ere analysed at the beginnlqg and end of the - hour blood retrieval period. in a separate study ( hip arthroplasties) f~f, il-i and il- ~ere determined in the initial portion of drainage blood. cytekine analyses ~re performed usiog ipmuooassays. an omidolytic method was used for at determinaf.ion and tac was analysed by elisa. n~n-poram~tric tests was used for the statistical comparison. results: the patient plasma il- coocemtratiems rose from a median value of to pg/ml, p<o. , during the blood ret.rieval period. in c was detectable in patients, range: - pg/ml. il-i was not detectable in the patients. in retrieved blood tag was > mg/ml in all samples (ref:< . mg/ml) and at was . - . units/ml (ref:o. - . ) . the il- concentrations in retrieved blood was > pg/ml in all samples. tn v or il-i was not detectable. in the separate study, (n= ), characterlzing eytokine content in the initial portiere of drainage blood, in= (range: - pg/ml) and il-i (range: - pg/ml) ~re present in all samples but ii- (range:o- pg/ml) was detectable in o.qly one semple. conclusion: theses findings indicate that hypereoagulability and hic~ ccrcentratioos are present in retrieved blood. the cytokine pattern in the initial portion of blood from a surgical area differed from these observed in retrieved blood and in the systemic circulation. to identify the role of both autologous and homologous blood on postoperative infections in elective cancer surgery. materials and methods: patients with colo-rectal cancer submitted to curative elective surgery were prospectively studied. on hospital admission the following nutritional measurements were assessed: serum level of albumin, cholinesterase, delayed hypersensivity response , total lymphocyte count and weight loss, as were age and sex, duration of operation , operative blood loss, amount and type of blood given, pathological dukes' stage of the disease and the attending surgeon were also recorded. results : eighty-four patients ( . %) were perioperatively transfused. thirty-six ( . %) patients were given autologous blood , while ( . %) received homologous blood. no patients received both autologous and homologous blood. twenty eight ( . %) patients developed postoperative infections. non transfused patients had a . % infection rate , those receiving autologous blood had a . % infection rate, whi]e in the homologous blood group the infection rate was . % (p < . ). univariate analysis showed that infections were significantly related to operative blood loss (p< . ), length of operation (p< . ) blood transfusion (p< . ) and attending surgeon (p< . ) . multivariate analysis identified homologous blood transfusion as the only variable related to the occurrence of postoperative infections , while the other variables failed to reach statistical significance. blood transfusion (bt) remains an essential life-saving treatment for surgical patients. however, besides the beneficial short-term impacts, negative longer-term effects are observed, which include various alterations in the immune responsiveness. in surgical patients these alterations may contribute to the increased risk for infections and cancer recurrence. since relatively few data demonstrate immunologic changes occurring in other lymphoid compartments than blood after bt, we studied the effect of et on the frequency and responsiveness of immune cells in bone marrow (bm), spleen (spl) and blood (b) in a rat model. normovalemic, month old rats were transfused intravenously with syngeneic heparinized venous blood ( x ml, every other day), and , and days after the last transfusion bm cells ( leh is an experimental oxygen-carrying resuscitation fluid. since leh is cleared from the circulation primarily by the mps, its effect on the development of sepsis and the nature of its relationship with the mps remain a major concern. preliminary in vivo data from our laboratory failed to show any leh effect on the hemodynamic and hematologic responses to endotoxin lipopolysaccharide (lps) in the rat. in contrast, leh exacerbated the lps-induced tnfa production and early mortality. the exacerbation of early mortality by leh was attenuated by pretreatment with the tnfu synthesis inhibitor rolipram. ex vivo, peritoneal macrophages from rats treated with leh and lps have shown increased il-lg mrna signal as compared to lps alone. also, leh increased tnftx production by peritoneal macrophages in response to lps stimulation in vitro. additionally, recent pilot studies indicate that leh attenuates pma-induced superoxide production from rat peritoneal macrophages and that leh augments fmlp-induced migration of human monocytes. taken together, these data strongly support possible interactions of leh with the mps and therefore the nature of such interactions should be further explored. over the last decade, we have developed liposome encapsulated hemoglobin (leh) as an artificial oxygen carrying fluid, or blood substitute. our efforts have focused on studies to define the safety and efficacy of this resuscitative solutions. leh consists of distearoyl phosphatidylcholine, cholesterol, dimyristoyl phosphatidylglyeerol, and alpha tocopherol in a : : . : . mole ratio and can encapsulate hemoglobins of different origin (bovine, human, recombinant human). leh is fabricated using hydrodynamic shear to create an average particle size of . microns. leh can be lyophilized using disaccharides and stabilized in the dry state and easily reconstituted before administration. histopathology and clinical chemistries indicate that leh rapidly accumulates in tissue resident macrophages in small animals injected in the tail vein, principai y in the liver and spleen. the consequences of accumulation in the reticuloendothelial system are manifest by transient increases in liver transaminases (ast, alt), bilirubin, and bun over - hours with no change in biliary function (ggt, ap) . clearance through the liver and spleen is observed over the course of - -weeks. more recent attention has been focused on secondary consequences of leh administration especially with regard to inflammatory eytokines. leh does not elicit expression of tumor necrosis factor in vivo and in isolated macrophage cultures, but does result in a transient increase in serum il- . we have also examined the interaction of leh with lps in vitro macrophage culture to further understand how this blood substitute may effect the immune system. we have labeled leh with technetium- m ( mtc) to study the biodistribution of leh non-invasively in anesthetized rabbits. rabbits were infused with a % topload of leh ( mg of phospholipid, . g of hemoglobin per kg of body weight) and imaged continuously with a gamma camera. at hours, images were again acquired. animals were then sacrificed and tissue counts obtained, images revealed an initial rapid uptake bythe liver, % at minutes and % by hours. the spleen accumulated activity at a slower rate, % at minutes and % at hours. at hours, autopsy biodistribution studies revealed that approximately . % of the dose is in the blood pool, . % in liver, . % in spleen, . % in lungs, . % in muscle and . % in urine, with trace levels in kidney, brain and heart (< °/o). in a hypovolemic model, rats were % or % exchange transfused with mtc-leh. in the % exchange model, mtc-leh was rapidly taken up by the liver and spleen with minimal activity in the circulation at hours. with the % exchange, % of the leh was in circulation at hours. the interaction of leh with platelets labeled with indium- was also studied. after infusion of leh, the labeled platelets rapidly moved from the circulation to the lungs and liver. over the next minutes, the platelets gradually returned to circulation. this effect was not seen with iiposomes of the same lipid composition but containing no hemoglobin. non-invasive imaging is proving to be a very useful tool for the investigation of leh. the need for a safe, efficacious and commercially viable blood substitute is unequivocal. of the several strategies pursued to invent an adequate blood substitute, liposome entrapped hemoglobin (leh) has been already established as a leading possibility. major advances in liposome technology have already resulted in liposome preparations compatible with clinical use for drug delivery. recent technological advances made by the u.s. naval research laboratories resulted in the capacity to entrap hemoglobin into liposomes in a way which secludes hemoglobin from interacting freely with biological systems. the leh produced has already been tested in in vivo systems and was foun.d to be well tolerated. moreover, the leh originally produced as a solution can be transformed into a lyophilized form which can be reconstituted and delivered as a fresh solution. while important milestones in leh development for a practical blood substitute have been achieved, several issues remain to be explored. most notably, the long term consequences of leh on host defense mechanisms and, in particular, immune cell function. in addition, it is important to understand more fully the metabolic fate and repercussions of leh delivered at clinically relevant dose/schedule regimens. finally, while leh is a highly promising strategy for a blood substitute, the present formulations consist of human hemoglobin derived from human blood, to improve the safety profile, a recombinant preparation for liposome entrapment will be much desired, aa-ginine, a semi-essendai dietary amino acid, possesses several unique and potentially pharmacologic properties. argirdun is a potent secretagogue for pituitary growth hormone and prolacfin and for pancreatic insulin and glueagon; it modulates host protein metabolism by increasing nkmgen retention and enhancing wound collagen synthesis. it also is a potent t call function regulator. ait of these effects coupled with its relative lack of toxicity and safety make it an a~antive nulritionai pharmacologic agem (t). rodents fed supplemeutal arginine exhibit increased thymsc weight which is due to increased numbers of thymic lymphocytes present in the gland. thymic lymphocytes from animals fed supplemental ar~e demonstrate increased blastogenesis in response to coma. and pha ( ) . peripheral blood lymphocytes from humans given supplemental arginine also have heightened mitogunic responses to mitogen or antigens ( ) . in postsurgery padents supplemental arginine abrogates or diminishes the deleterious effects of trauma on lymphocyte responsiveness and restores peripheral blood lymphocyte responses much faster than observed in controls. overall host immunity is also enhanced by arginine. allograft rejection is enhanced and septic animals survive longer when given supplemental arginine ( ) . tumor bearing urginine-supplemented animals have decreased tumor growth and enhanced survival (i). lastly, asgmine can induce t cell maturation and t cell mediated responses in athyrnic nude mice. arginine also has remarkable effects on host nitrogen metabolism post-injury. in increases nitrogen retention in healthy human volunteers and in surgical patients. this beneficial effect on overall nitrogen metabolism is accompanied by a unique effect on the healing wound. supp]emental arginine increases wound collagen synthesis which also translates into increased wound breaking strength ( ) . arginine has no effect ou epithelialization. douglas w. wilmom, m.d. boston, ma gintamine is the most abundant amino acid in the body, but it has long been considered a nonessential amino aeid because it is synthesized in many tissues. fohov~g st,~'vation~ injury or infection, skeletal muscle pmteln inoresses its net tale of degradation and releases amino acids into the blunds~mm at an aocelerared rate. app~o)~mately one-third of the amino nitmgea is ghitamine, which is metabolized by the kidney where it parth:~pates in acid-base homeostasis, is the primly ~ for lymphocytes, mac~optmgcs and untexocyms, and contm'butcs to the synthesis of giumth~une. olmamine degrades slowly while in ~olu~ou, especially at usual room teml~mtums. because giulamine was considered nonessential, it has beer absent r'om nil intravenous and most gluts.mine should be considered a cendittona]ly essential nutrient for individuals with serious ilinesses, uspccially those confoanded by infcctinn and inflammation. over the uc~:t - years, glutamine will be incorgorated into most feeding formulas designed for patients with critical illness. o]~ga- pufa there continues to much interest in the application of the mega- pufa in clinical nutrition. the basic principle has been that the mega- pufa will displace arachidunic acid and result in a decrease in eic san id production. in addition these changes in pufa will after the physical characteristics of the membrane including flujdity, receptor function and transmembrane signals. animal studies have shown that there is omega- incorporation with continuou~ enteral feeding both in control and endotoxic animals within days. this includes the liver, spleen, circulating and alveolar marc phages and the lung. this incorporation resuls in significant changes in the eicosan id production including pgf and ket -pgflalpha. there is improvement in the cardio-vascular reep nse of these animals with ~ecreamed lactic acidosis and improved cardiac contractility. as well there is improved immune function with improved t cell response to mit gens. the ~ of a mumber of pharmacological agents blocking cicosanoid production can enhance the cell effects of mega- pufa. clinical studies using short term entsral nutrition with mega- either alone or with other enteral supplements in a number of clinical settings have shown significant mesa- incorporation and decreased eicosan id production. these positive results must be discussed with the additional evidence that long term omega- supplementation decrease eic san id production but als induce a state of immune suppression that is capable of increasing transplant sunvival. these ng te~ inune effects may benefit clinical conditions including rheumatoid arthritis and cr hn' disease early enteral nutrition instituted i~mediately afte~ injury will decrease the entry of bacteria into the intestinal wall and decrease the number of bacteria that translocate into the portal blood. these reductions are associated with & decreased catabolic response, decreased plasma cortisnl levels, end decreased vma excretion in the urine and prevention of mueosal atrophy. sdecific nutrients also affect the transloeation process. addition of arginlne to the diet significantly improves the ability to kill translocated organisms. however. translooetion across the gastrointestinal barrier is not affected. in contrast, glutamine diminishes the rate of translooation across the imtestinal barrier and also improves killing of the beetarla that do translooate. the omega fatty acids in the form of fish oil slightly decrease the rate of translocation but more significantly increase the ability of the animal to kill translo~ated organisms, all three dietary additives, i.e. argini~e, glu=amine and fish nil. significantly improve survival, hut adding glyoine or medium chain triglyeeridem do not, combinations of srginine and glutamlns, glutamine and fish oil, and fish ell end arginine each improve survival, and to a greater degree than a combination of all three. these studies add further evidence that translocation is an important determinant of survival after injury, early feeding with immunonutrlent enriched dices will improve survival and dsarease transloeation to varying degrees, depending upon the nutrients provided. objectives: we studied effects of supplementing a commercial enteral diet, impact r (imp, sander nutr lnc), with fiber (imp/fib) or alanyl-glutamine (imp/ag, exogenous glutamine (gln) gms/l) on influencing the incidence of bt to mesenteric lymph nodes (mln) in burned mice. fiber has been shown to improve gi integrity under certain stress/treatment conditions. the dipeptide ag is a water-stable source of gln, which is a specific fuel for many cells including enterocytes. traumacal (trcal), a high-protein, high-fat enteral diet (mead johnson iuc), was also studied, as well as rodent chow (harlan teklad inc), which contains very high protein & fiber. methods: anesthetized cf- mice aged - wks received % tbsa fullthickness dorsal burns & were resuscitated with cc ip saline. diets were allowed ad lib; caloric intakes were comparable in all gps except fasted gp (fast hrs, chow hrs). at hrs postburn mln were sterily removed, homogenized and plated on heart brain infusion agar; cfu/g mln tissue were determined. bt was analyzed by fishers exact test, cfu/g by anova-bonferroni. * p< . , ** p< . compared to imp and burn-fast gps. background. infectious complications following trauma, major operation, or critical illness adversely affect hospital cost and length of stay (los). some key nutrients have been shown to possess immune enhancing properties. this multicenter trial was conducted to determine if early administration of an enteral formula supplemented with arginine, dietary nucleotides and fish oil can decrease los and infectious complications in icu patients. methods. this was a prospective, randomized, double-blind study of adult icu patients who required enteral feeding for > days. patients entered the study within hr of the event, were stratified by age and disease, and were randomized to receive either the supplemented formula (impact®) or the conventional formula (osmolite ® hn). feedings were initiated at full strength and advanced to at least ml/hr by hr after event. results. both groups tolerated administration of formula well. for patients fed > days, the median los was % shorter (p=o.ol) for the--supplemented group ( days) compared to the conventional group ( days). the incidence of most infectious complications was lower in the supplemented group, but this difference reached significance only for urinary tract infections (p=o.o ). the supplemented group had a significantly shorter los from onset of infectious complication until discharge for patients with pneumonia ( vs. days) and skin/soft tissue infection ( vs. days). conclusions. administration of the supplemented formula was safe and well tolerated. when fed > days, it reduced the incidence of most infectious complications, and significantly reduced los. materials and methods: twenty-seven patients were randomised into groups ( n= each) to receive either a standard enteral formula, the same formula enriched with arginine, rna and omega fatty acids (enriched group) or isonitrogen, isocaloric parenteral nutrition. early enteral nutrition was started within hours following surgery ( ml/hour). it was progressively increased reaching a full regimen on day . on hospital admission and on post-operative day and , the following parameters were assessed: serum level of transferrin , albumin , prealbumin, retiool binding protein (rbp), cholinesterase. delayed hypersensitivity response, igg, igm, iga, lymphocyte subsets and monocyte phagocytosis ability were evaluated on admission and on post-operative day , , . the three groups were comparable for sex, age, cancer stage, type and duration of surgery, intra-operative blood loss and amount of blood transfused . in all groups a significant drop in all the nutritional and immunological parameters was observed on postoperative day . comparing post-operative day versus day a significant increase of prealbumin (p< . ) and rbp (p< . ) was found only in the enriched group. with respect to immunological variables an increased phagocytosis ability (p< . ) and a significant recovery in delayed hypersensitivity response (p< . ) was observed only in the enriched group. conclusions : these data are suggestive for a more effective post-operative recovery of both. nutritional and immunological status in cancer patients fed with enriched enteral formula. gastrointestinal intolerance was equivalent ( % in each group) and laboratory screening confirmed that both diets were safe. when analyzing clinical outcome for all patients, there were no significant differences in septic complications (immun-aid = % vs vivonex ten = %), mean mof score (immun-aid = l.b vs vivonex ten = . ), or mortality (immun-aid % vs vivonex ten = %) . kowever, when analyzing the subgroup of patients with severe injury (iss or ati _> ), patients receiving immun-aid appeared to have fewer septic complications ( % vs %) and their mean mof was significantly lower ( . _+ . vs . + . , p = . , student's t-test) . these preliminary data indicate that immun-aid is tolerated well when aggressively delivered immediately postinjury. the ultimate affect on clinical outcome appears ~avorable for immun-aid, but needs to be confirmed in larger patient groups. kemp?n, m., neumann, h.a., he i[michh b: as both increased, normal and reduced phagocytic capabilities of polymorphonuclear leukocytes (pmn) and monocytes in acute batterial infections have been reported, the role of phagocytes in patients with severe sepsis is less clear.we examined pmn and monocytes from patients in septic shock and heailhy votunteers for phagocytic function. phagocytosis was determined by flow cytometry (facscan) and was measured by the ability of pmn and monocytes to phagocytose e.coli marked with fluorescent antibodies. a septic shock was defined by the presence of a ~ource of i, nfoctiqn with a known bacteriology, distinct signs of a systemic response and defined minimum scores in icu scoring systems indicating the presence of a multiple organ failure. additionally we examined how phagocytosis is influenced when a new enteral diet formulation containing substrates suggested to improve immune function or arginine, one of its major compononts, is added in vitro in defined concentrations and incubated for minutes. pmn (p{o, ) and monocytes (p<o, ) of the septic patients showed a significantly enhanced phagocytosis compared tolhe phagocytes of the healthy group. the incubation with the enteral diet in vitro was followed by a higher dose-related rate of phagocytosis, especially in the healthy group, that was not statistically significant. after addition of l-argintne we atso observed an iqcrease in phagocytosis, that was lower than in the group with the complete diet. using a modern immunefluorescence-cytometric essay we founfl an improved phagocytic function in septic shosk. there are signs for an influence of nutrient substrates on phagocytosis which seems to be complex and should be further investigated. arg and gln were lower in the %-bcaa vs %-bcaa group; arg was related directly to arg dose and inversely to bcaa dose (p<o.o for all). clearances of bcaa increased with increasing bcaa dose (p<o.o ); arg and gln clearances were directly related to the bcaa clearances (rz=o. , p<o.o i). relationships between arg, gln and other aa seem to be ruled by patterns involving specific intracellular aa transport systems. regulation of arg and gln clearances through bcaa administration may be related to an increased flux of aa into synthetic processes. intestinal segments from rats immunized by infection with the nematode trichinella spiruus undergo intestinal anaphylaxis or type i hypersensitivity when challenged in vitro with parasite antigen. immunized rats exposed to t-radiation ( gy) and sustained on rat chow,fail to fully express type i hypersensitivity up to days post irradiation (dpi). we hypothesized that enteral nutritional support immediately following irradiation may be effective in preserving mucosal immune responsiveness or in reducing the recovery time after radiation-induced injury. rats were infected with x t.spiralis larvae. thirty to fifty days later rats received gy t-radiation from a co source as total abdominal irradiation (tai). immediately following tai, rats were fed an elemental amino acid diet (eaad) and at various dpi sacrificed and tested in ussing chambers for local anaphylaxis, expressed as antigen-induced ci secretion. the normal ci secretory response to antigenic challenge which is suppressed after irradiation,was restored by dpi when rats were placed on the eaad. antigen-induced c[ secretion is dependent on the interaction o~ antigen with specific ige antibodies on the surface o mucosal mast cells and their subsequent degranulation. mast cell-derived -ht,histamine and pg, together effect ci secretion.in irradiated rats on rat chow,the failure to respond to antigenic challenge appears to be associated with the destruction of mast cells. they are undetectable with standard staining procedures and mucosal histamine levels are drastically reduced. also,el secretion can be induced by direct stimulation of epithelium with cr secrctagogues and circulating ige levels are normal. despite a more rapid recovery of immune responsiveness in irradiated rats receiving eaad,mast cells were not restored. we conclude that the eaad contributes to an adaptation that supports the expression of local anaphylaxis in the absence of mast cells. total parenteral nutrition (pn) and bowel rest may influence the host response to infection. this study examined the different host response to infection in parenterally and enterally fed animals. forty-three rats were divided into pn group and total enteral nutrition (en) group. they received identically constituted isocaloric isonitxogenous diets for seven days. animals were then challenged intraperitoneauy with xl(y escherichia coli and survival were observed. in other experiments, they were sacrificed before and two hours after bacterial challenge. peritoneal cavity was lavaged with ml saline and peritoneal exudative cells (pec) were harvested and cultured in vitro for hours with and without lipopolysaccharide (lps). colony f(m, ning units of bacteria (cfu-b) in the peritoncal lavaged fluid (plf) were determined and tnf in the plf, serum and pec culture supernal,ants were measured by l bioassay. twenty-fonr hour survival rate in en group was significantly greater than that in pn group ( % vs %). the data suggest that local immune responses of pn-treated animals may be depressed with consequent disturbance in the clearance of bacteria. this may lead to a greater systemic cytokine response and resulting in a poor survival after bacterial challenge in pn group. the effects of intragastfic tube feeding of diets enriched with m- polyunsaturated fatty acids (pufa) from safflower oil (so) or (o- pufa from menhaden oil (mo) on eicosanoid production, and onthe membrane phospholipid fatty acid composition were investigated in a severe acute septic shock model. the percent calories from fat maintained at % in the diets was adjusted to provide % each of saturated, monounsaturated, and pufa using olive oil and palm oil as filler fats. after feeding for days, lipopolysaccharide (lps, mg/ g) was injected through the tail vein. the percent of animals surviving in the mo group was % ( / ), and did not differ significantly compared to % ( / ) in the so group. the plasma concentrations of tnf ct for the groups of animals fed so ( . + . ng/ml) and those fed mo ( . + . ) did not differ significantly. the levels of prostaglandin(pg)e , -keto-pgflc~ and tumor necrosis factor-ct (tnf-c were determined min after lps injection. the fatty composition (relative mole%) of the liver was determined before (lps-) and h after the lps administration (lps+). the data (mean_+sd; n= ) are as follows. group these data indicate that a marked reduction in the plasma levels of poe and -keto-pgflct for rats fed mo diet was associated with a reduction in aa which was displaced by epa in the membrane phospholipids. further, in these rats, we observed that there was a . % reduction in the percent of epa following lps challenge compared to the basal levels. however, for the group of rats maintained on so diet, the liver membrane phospholipid fatty acid composition before and after lps administration was unaltered. these finding suggest that although a reduction in aa was associated with a decrease in the production of pro inflammatory eicosanoids after days of continuous mo feeding, there was no marked effect on the survival following lps challenge. animal models have been used to examine the effects of various nutrients and nutrient combinations upon the immune system. we studied the effects of standard and specialized enteral formulations on the response of mice to infectious challenge with listeria monocytogenes, influenza a or candida albicans in order to test the efficacy of specialized ingredients. cf- outhred female mice ( - g) were fed purina # chow, commercially available osmolite hn ®, perative ® or impact*. mortality and tissue burden of pathogen were examined during the d period following induced infection. the results indicate that there were no differences between the groups fed the liquid formulas with regards to mean survival time or % survivors in these models of infection. examination of spleens in the groups challenged with l. monocytogenes and kidneys in the groups challenged with c. albicans revealed no differences in tissue burden of pathogenic organisms. alterations in the length of pre-feeding from to days prior to infection did not affect these results. these data demonstrate that, contrary to previous reports, the use of specialized nutrients did not improve resistance to disease in mice challenged with l. monocytogenese, influenza a or c. albicans as compared with mice fed osmolite hn. animals fed standard chow tended to be more resistant to infectious disease than those fed the liquid formulas perhaps due to the form of diet or complexity of ingredients. the results indicate that these animal models of infectious challenge may be of limited use to distinguish effects of modified nutrient composition of enteral formulas. laboratories the beneficial effects of sesame oil (ses) have been attributed to the presence ofsesamin, a non-fat constituent which is claimed to iultibit a- desaturase activity. we investigated the effects of ad libidum feeding of ses enriched diet on fatty acid composition of phospholipids from plasma, liver, on eicosanoid production, and on the protective effects in mice after cecal ligation and puncture (clp) and compared with safflower oil (so) diets. olive and palm otis were added as filler fats to the so diet to maintain the ratios of saturated, and unsaturated fatty acids similar to ses diet. thus, while the total fat remained at wt%, the only difference between the two diets is the presence ofsesamin in ses diet. the animals were fed for weeks. the incorporation of dihomo-y-linolealc acid (dgla: : o)- ) in the phospholipids from plasma and from the liver for the group of mice fed so diet ranged between - % compared to the undetectable levels for those fed so diet. there were no significant differences in the incorporation of other fatty acids either in plasma or in the cell membranes between the two groups. following an intraperitoneal administration oflps ( p.g/kg body wt), the plasma levels of both pge , and txb , were significantly decreased (p< . ) by nearly % for the group of animals maintained on ses diet compared to those maintained on so diet. these findings suggest that sesamin inhibited the release of arachidonic acid (aa) which upon accumulation is retroconverted to dgla which could reflect a modest increase in the content of dgla. failure to decrease the formation of aa could mean that the effects of sesamin on chain elongation process may be after aa is formed, and that sesamin may not inhibit a- desaturase activity. on the other hand, our data suggest that sesamin present in sesame oil inhibited the activity of cyclooxygenase which converts aa to its metabolites), or alternatively could block the activity of phosphalipase a (pla ) (which releases aa from membrane phospholipids) as is evident from a marked decrease in eicosanoid production. the percentage of animals surviving after cecal ligation and puncture in rite group of mice fed ses diet was % ( / ) which was markedly higher (p< . ) compared to only % ( / ) for the so group. increase in survival in the group of mice fed ses diet was associated with nearly % reduction in the production of tnf in response to lps i.p. challenge, for ses group compared to so fed animals. our data suggest that sesamin, present in sesame oil, decreased the production tnf~, inhibited the activity ofpla and consequently offered a significant protection against clp. thus sesamin or sesame oil appear to be novel antiinflammatory agents which are present naturally in many edible products. [dept. surgery, ~e. deasoness hosp.,harvard medical school, boston, usa] stress causes alterations in the homeostasis of an organism with major changes in various organs, lifespans of cells, protein turnovers, metabolic pathways of activation or stimulation, energy mobilization, etc. punctual changes have been described in several organs and various cell types of the nervous, endocrine and immune systems. many stored or newly synthesized proteins are released to the bloodstream to be transported to target organs or to be disposed of. as stress alters protein synthesis and requirements in the targets, the bloodstream is a useful system for monitoring the relevant changes. we present here the pattern of newly synthesized or released serum proteins in c bl/ mice that have been stressed by immobilization. the proteins have been labelled with ssmethionine in vivo and the study was performed by two dimensional gel electrophoresis based on the method originally described by o'farrel. the electrophoretic run was carried out in an isodalt apparatus. a molecular dynamics laser scanner and the kepler image analysis system (lsb, rockville, usa) were used for modelling the radiofluorographic images. the radiofluorographic images of the gels from serum samples obtained from mice injected with i mci of ss-methionine reveal about protein spots, from which a small fraction -about are altered in both qualitative and quantitative manner. the major changes are in the range of to . d. the analysis displays a highly reproducible pattern, where clear differences between stressed and non-stressed conditions are shown. differences between patterns attributed to chronic vs. acute stress will be presented. patients with severe trauma or major surgery are known to acquire alterations in neutrophil functions which contribute to their enhanced susceptibility towards microbial infections. we analyzed neutrophil functions from fourty patients admitted for major surgery days and days preoperatively and on the ist and th postoperative days (study-days i, , , and ) in a randomized placebo-controlled double-blind study. patients were divided into two groups, one ~eceived days preoperatively an enteral nutrition enriched with omega- fatty acids, arginiee, and rna (impact), the other an isocaloric, not enriched control nutrition (placebo). meutrophils were isolated from the peripheral blood and stimulated with the ca-ionophor a ( . pm). the capacity of the respective neutrophils to generate leukotrienes was analyzed by rp-hplc. neutrophils from impact group generated significantly higher amounts of ltb (mean values . ng/l x i~ cells) compared to the placebo group ( . ng) at study-day [p, . ). in contrast, the capacity of neutrophils to produce ltb was not significantly different in both patients populations at study-days and . the omega-oxidation of ltb to its biologically less active metabolites oh-ltb and cooh-ltb was not significantly different in both groups. however, neutrophils from group f patients generate more ltc at study-day (p( / ). the capacity of the patients'neutrophils to generate reactive oxygen radicals upon stimulation with fmlp, pma or the caionopbore a exhibited patient dependent differences but no correlations to the repective nutritional supplementation as was measured by luminol dependent ohemiluminescense= these data indicate that an enteral nutrition enriched in omega- fatty acids lead to alterations in distinct parameters of neutrophil functions. clinical patient characteristics and mean caloric intake were similar between the two groups. both formula were tolerated well and the incidence of diarrhea was low. the number of infectious and wound complications as well as the apache ii score was evaluated for the two study groups. although the number of complications in the group supplemented with arginine, rna and omega- fatty acids was lower no significant difference in the occurance of infectious and wound complications has been observed between the two groups. however, the apache ii score indicated a significantly improved clinical outcome in patients with supplemented diet. in conclusion, early enteral nutrition with an arginine, omega- fatty acids and rna supplemented diet helps to recover more rapidly after surgical total parenteral nutrition (tpn} is associated with intestinal atrophy and dysfunction attributed to the absence of the non-essential amino acid glutamine in current parenteral nutrition solutions. in this animal study with male wistar-rats we tested the hypothesis that glutamine-dipeptide supplementation during tpn for days would restore small bowel atrophy and tpn induced dysfunction. a conventional tpn solution ( kcai/kg bw) was compared to an isocaloric and isonitrogenous tpn ( , g n/animal/d) supplemented with alanin-glutamin (ala-gin) dipeptide ( , g n derived from ala-gin = % gin-n). an enteral fed cqntrol group was included. mucosal thickness, villous height and architecture, absorption of water and glucose as well as dissacharidase activity of maltase and alkaline phosphatase were evaluated. total parenteral nutrition in rats causes villous atrophy, a significantly reduced absorption rate and a decreased activity of villous enzymes compared to an enteral fed control (p<o, ). addition of ala-gin to parenteral nutrition solutions prevents intestinal atrophy and restores functional alterations with a significantly increased rate of water and glucose absorption as well as a higher dissacharidase activity compared to the standard tpn group (p< , ). there was no significant difference found between the enteral fed control and the dipeptide supplemented animals concerning intestinal structure and absorption, the enzyme activity was significantly decreased in the ala-gin supplemented group compared to the enteral fed control (p< , ). in this rat model supplementation of parentera] nutrition solutions with ala-gin dipeptide restores tpn induced intestinal atrophy and dysfunction. boston. ~ usa injury, infection and major o ~'ations s~nulate a variety of factors whi~ initiate the body's response to th~ st~..sses. 'i"hese reactions are m~liated by a cbmage ia the neta'al hormonal, eac.ranmemt, by the elaboration of eytokines and tl~ougb the stimu/ation of other inflammatory mediators. this eatabolio setting zesulis in body protein loss, which g-taduai y erodes both fimetianal and stm~ tissue. wiu _b the normally nom'ished individual can withslzod "d~ response for a brief period of time, ircolonged eatabollsm l~ associated with ~,nmunosuppmssion, poor wound healing, and proioagcd convalescence. surgeons have rej ed on intraveaous or eater~ feedings to ~everse this process. a va~ety of data now indicates that it is extremely di~edt to replete protein-containing tissue d~g the eataholie state of illness; the umutt response to hypercaloise feedings in this setting is the incxeased accretion of body fat md water. administration of gxow~ ho~moae ~cesults i.a n shift of the body's oxidative machinery to fat rather than eazbohydmte utiq~afic~; ¢oncomitaatiy, protein synthesis is stimulated. this metabolic state may have clinical utility in p~e.n.ts who need to heal large wotmds, in those who need to gain strength in order to be w~ed ore veatilatory support, or those patients who ~ve mulfiorgan failure and nee~ to ealaaace protein syatsesis to in.suze recovery. als are now in progress to dcterm~e the benefit of growth hormone in these and other disease state.s, rn the fature, the increased use of growth hormone, will occur;, this and other growth factors will serve to su~ po~ the host and shorten convalesceace following catabolic diseases. our objective was to study effects of pre-trauma growth hormone (gh) treatment on liver and skeletal muscle metabolism in a trauma model in piglets. twenty-four piglets were randomized to three treatment groups; one group was pretreated with gh iu daily three days before the experiment (gh- ), another group treated with gh ie at the start of the surgical procedure (gh- ) and one group served as untreated controls (con). they underwent a standardized surgical procedure to place sampling cathethers in the portal, hepatic and femoral veins and doppler flow probes around the portal vein, the hepatic and the femoral arteries. all pigs recieved a primed constant infusion of u- c-glutamine. substrate fluxes were measured one (lh) and five ( b) hours after termination of the surgery. nitrogen excretion was significantly decreased in the gh treated animals (gh- : . + . mg/kg, gh-i: . +_. . mg/kg, con: . +- . mg/kg, p= . ). in the hindieg, there was reduced net glutamine efflux due to decreased absolute glutamine release (gh- : . + . gmol/min at lh and - . + . in.tool/rain at h, gh-i: - . + . i.tmol/min at lh and - . + . pmol/min at h, con: - . +_ . g mol/min at lh and - . + . /amol/min at h, p= . , p= . ), whereas the absolute uptake of glutamine in hindleg was unchanged (p= . ). glucose uptake in the hindleg was decreased (p= . ). net glutamine uptake in liver was attenuated (p= . at h), whereas net glutamate release from liver was increased (p= . ). thus, pre-trauma treatment with gh improved nitrogen economy, attenuated net glutamine loss from hindieg due to decreased absolute release, and attenuated hindleg glucose uptake. liver net glutanaine uptake was decerased and net glutamate release increased. patients with major abdominal surgery exhibit a considerable catabolic response with negative nitrogen balance and protein breakdown, which may have detrimental effects on outcome. we investigated the effects recombinant human growth hormone on substrate metabolism in parenterally fed patients. metabolic healthy patients were randomized to receive either placebo or hgh in a dosage of , ; , or , i.u. per kg bw. substrate oxidation rate, energy expenditure as well as short life proteins were measured daily. six patients were excluded from analysis as drop outs, due to surgical complications. we could find a dose-dependend effect of growth hormone on resting energy expenditure, carbohydrate oxidation, fat and proteine oxidation. with increasing growth hormone resting energy expenditure increased from . calories per kg body weight to . calories. this was mainly due to an increased carbohydrate and fat oxidation, while proteine oxidation decreased. this was in accordance with a decreased urea.production rate and an improvement in cumulative nitrogene balance, which increased from minus . to plus . g n / days. in consequence short life proteins were also increased. the only negative side effect was an increased blood glucose concentration in some of the patients, making insuline administration mandatory in patients. our results are in accordance with other studies showing improvement of nitrogen balance, maintainance of lean body mass and muscular strength. if growth hormone administration may have any impact on morbidity, mortality and length of hospital stay in these patients it should be evaluated in a larger number of patients. in patient after liver transplantation (oltx) the effect of recombinant human growth hormone (rhgh) on protein metabolism and hormonal changes was studied. patients and methods: the underlying disease in all patients was end stage liver cirrhosis, non of the patients included in the study was suffering from malignancies. the patients were randomly allocated to receive either u of rhgh bid (sc) or no alternative medication. the study period lasted days. from daily hrs udne collection urinary nitrogen loss and daily loss of urea were determined. body compostion analysis (bca, bioimpedance, akern-ltaly) was performed preoperativly and at the postoperative days and to evaluate changes in body water and body cell mass (bcm). the effect on resting energy expenditure (ree) was analysed using indirekt calorimetry wrhin the same intervalls (metabolic monitor, datex). blood levels of gh, igf and igf , igfbp were measured daily during the study period, on day a hour profile of gh was.performed. samples were collected each minutes. results: cumulative udnary nitrogen and urea loss were not signifcantly different for the whole study period but for the first study days. bia indicated for the rhgh-group a loss of bcm to a lesser extent than for the controls (n.s.), changes in bodywater where similar for both groups. ree changes (kcal/kg bcm) were not significantly different for the two groups. blood levels of gh and igf differed significantly between the groups for the whole study period, but not igf and igfbp- . the circadian rhythm of endogenous gh-excretion had not been altered by gh, but absolute levels of gh were increased. conclusion: during the first days after oltx we could proof the protein sparing effect of gh treatment. although the differences between the two groups were not significantly different for the whole study period the results showed on all days a less catabolic situation for the rhgh treated patients. to possibly improve protein balance after major abdominal surgery we studied the effects of gh on protein metabolism after ltx. excluding malignant diseases, candidates for ltx were randomized to either postoperatively receive the usual treatment (co=control group, n= , age range - yr, bmi . + . kg/m ) or for days additional gh ( x i.u.s.c.) (gh group, n= , - yr, . + . kg/m ). metabolic studies (calorimetry and lsc-leucine infusion) were performed (test a) and days (test b) after surgery. tracer analysis was done by gas chromatography-mass spectrometry. during the -week study clinical parameters did not differ significantly between groups; however, there was a tendency for increased glucose levels, insulin need, and energy expenditure at the time of test b in the gh group. leucine oxidation (x+se) during test a;b was + ; + (co) and + ; ± (gh) pmol/kg ffm/h (n.s.). protein breakdown was ± ; + (co) and + ; + (gh) pmol/kg ffm/h (n.s.). nonoxidative-leuine disposal was ± ; + (co) and ± ; + (gh) pmol/kg ffm/h (p< . for the rise in the gh group). tracer data were supported by cumulative urea nitrogen excretion (days - : gh + vs co ± g; p< . ). we conclude that after major abdominal surgery gh lowers nitrogen excretion by increasing total body protein synthesis. it is not known which organs contribute to this effect. in several investigations it has been shown that the protein saving effect of recombinant human growth hormone (rhgh) in the postoperative state is accompanied by raised igf- levels in plasma. it was concluded that the anabolic effects of rhgh were probably, at least in part, mediated by igf- . this study was aimed at detecting the efficacy of igf-i on modulation of the protein metabolism in the catabolic state. patients and methodes: patients (both sexes, age: - years, bmi - kg/m ) with major upper gastrointestinal surgery (gastrectomy or partial gastrectomy) received ug rhlgf- /kg body weight/twice daily or placebo during treatment days beginning on the first postoperative day in a double-blind, randomized study. all patients received hypocaloric and hyponitrogenous total parenteral nutrition ( g chng, o. g aa/kg) troughout the whole study period. cumulated nitrogen balance, -methyl-histidin exretion in urine as well as serum-igf- levels have been determined. the two tailed wilcoxon test was used for statistical analysis results: first results will be presented previous studies have suggested that growth hormone (gh) potentiates various activities of leukecytes. however, it is not clear whether gh can improve survival of animals with gram-negative sepsis. we investigated the effects of gh on host response to infection in septic mice model. methods balb]c mice were randomized to groups (n= /gronp): gh-high ( + mg/kg/day), gh-iow ( a mg/kg/day) or control (saline). following subcutaneous treatment (every hours for days) with gh or saline, mice were challenged i.p. with e.coli (lxl /body). survival rate was recorded every hours. in the next experiment, gh-high and control animals were sacrificed hours after bacterial challenge. peritoneal cavity was lavaged with ml saline and the peritoneal exudative cells (pec) were harvested and counted. colony forming units (cfu) of bacteria in the peritoneal lavaged fluid (plf), liver, lung and blood were determined. pec were cultured in vitro for hours with lipopolymccharide ( p.g/ml in normotensive adults growth hormone (gh) rises when clonidine challenge is performed. recently evidence was shown for gh to accelerate wound healing. while gh secretion patterns are inconstant the gh-dependant insulin like growth factor (igf- ) and the insulin like growth factor binding protein (igfbp- ) reflect the integrated gh secretion over days. since we administer clonidine to patients with acute alcohol abuse we determined plasma levels of igf- and igfbp- . materials and methods: patients sheduled for esophagus resection were investigated once they had given written informed consent. patients showed acute alcohol abuse and were treated with clonidine postoperatively• patients with no history of acute alcohol abuse served as controls. besides liver enzymes igf- and igfbp- were determined. results: both groups had a comparable hepatic capacity of synthesis with decreased cholinesterase levels as to be expected after a major operation. regression analysis of igf- and igfbp- levels showed no differences between the groups. discussion: igf- and igfbp- plasma levels are not increased in normotensive patients who are treated with clonidine for prevention of postoperative alcohol withdrawl syndrom. further studies are required to discriminate whether our results are due to impaired postoperative liver function or if clonidine has not any impact on the gh-igf-axis in patients with alcohol abuse. recent studies have revealed that igf-i has several immanoregulatory roles. however, little is known about its effects on septic animals. we tested whether igf-i could increase the survival o f mice challenged intraperitoneally (i.p.) with e. coli. m~thqd$ balb/c mice received either high dose igf-i (n= , mg/kg/day), low dose igf-i (n= , . mg/kg/day) or saline ( = ) every eight hours subcutaneously for six days. animals were then challenged i.p. with lx e. coli. survival was observed every two hours. in the other experiment, mice that received high dose igf-i or saline were sacrificed four hours after bacterial challenge. peritoneal cavity was lavaged with ml saline and the peritoneal exudative ceils (pec) were harvested and counted. colony forming units (cfu) of bacteria in the peritoneal lavaged fluid (plf), liver, lung and blood were determined. in addition, pec were cultured/n vitro for hours with lipopolysaccharide ( ).tg/ml). tumor necrosis factor (tnf) in the supernatants of pec culture, plf and serum were measured by l bioassay. results igf-i improved the survival rate at a dose of mg/kg/day. severe chronic neutropenia (scn) is a disorder characterized by severe neutropenia secondary to either a maturational arrest of myelopoiesis at the level of promyelocytes (kostmann-syndrome; scn) or regular cyclic fluctuations in the number of blood neutrophils with a median absolute neutrophil count (anc) of less than /~tl (cyclic neutropenia). patients suffering from scn have an impaired acute inflammatory response to injury and an increased susceptibility to infections, i.e. bacterial or fungal infections, resulting in chronic oral inflammation, severe pneumonia, abscess formation and bacteraemia. we have treated patients ( scn, cyclic neutropenia) with r-methug-csf (filgrastim). thirty of patients with scn and all cyclic neutropenia patients responded to this treatment with an increase of the median anc to greater than /~tl. the dose of r-methug-csf needed to achieve and maintain the response varied between . and ~tg/kg/d. long-term treatment did not exhaust myelopoiesis: the anc remained stable after up to years of treatment and antibodies to r-methug-csf were not detected. the increase of anc was associated with dramatic clinical responses: significant reduction of severe bacterial infections, reduction of intravenous antibiotic treatment, and reduction of hospitalizations. no severe bacterial infections occurred in any of the r-rnethug-csf responders during longterm treatment. severe adverse events, most likely due to the underlying disease, included the development of mds/leukemia in two patients, and osteopenia/osteoporosis in patients. these results demonstrate the beneficial effects of r-methug-csf treatment in severe chronic neutropenia patients. the newborn is predisposed to mortality during infections due in large part to developmentally immature host defenses. recently cytokines have been identified that regulate the development of these defenses. one such cytokine is specific for neutrophils and is termed granulocyte colony stimulating factor (g-csf). in the studies to be discussed, we have attempted to impact hematopoiesis in the fetus using exogenous rhg-csf delivered through the pregnant dam. our rationale was that an enhanced myeloid system may result from such in utero treatment leading to, perhaps, enhanced protection to microbial insult. rhg-csf crossed the placenta and reached peak fetal serum concentrations hours after administration. these levels were -fold lower than the levels detected in the adult dams serum. white blood cell counts were elevated approximately - -fold over control newborn blood. this increase was due to circulating numbers of neutrophils. the marrows from these pups were hyperplastic consisting of predominately immature and mature neutrophilic cells. no changes were seen in the thymus or livers. pups born to mothers treated with rhg-csf since day of gestation (parturition in rodents occurs on approximately day ) survived a lethal challenge of group b- hemolytic streptococcus. in contrast their untreated yet infected counterparts did not survive. recent clinical developments have led to trials of rhg-csf in certain neutropenic states including cyclic and chronic neutropenia. we have identified several of these patients who were pregnant during treatment with rhg-csf. biologically and anfigenically identifiable rhg-csf was detected at increased levels in the cord serum of these neonates. we will discuss our findings with these patients in light of our animal model of neonatal myeloid development. we have previously demonstrated decreased g-csf production and g-csf mrna expression from activated mononuclear cells from newboms compared to adults (cairo, pediatr res : , ) . we have also recently observed that administration of a single dose of rhg-cse to one-day-old newborn rats induced significant neatrophilia, while administration for days induced neulrophilia and increased the bone marrow (bm) neutrophil storage and progenitor pools (cairo, blood : , cairo, pediatr res : , ) . we embarked on a phase i trial exploring the safety, pharmacokinetics, and biological efficacy of g-csf in newborns with presumed sepsis. infants < hrs old with a diagnosis of presumed sepsis were stratified into three groups: very preterm ( - wk), preterm ( - wk), and term (> wk) and randomized to receive either a placebo or , , and gg/kg/qd or and p.g/kg/bid of rhg-csf infused by pump over hour for consecutive days. cbcs were obtained at , , , , and hrs. tibial bone marrow aspirations were performed hrs after study entry and differential counts and cfu-gm pools were determined. c bi expression was determined at and hrs after rhg-csf, and g-csf pharmacokinetics were performed after the first dose of rhg-csf utilizing a sandwich elisa. a significant increase in the anc was observed at , and hrs following administration of both and ~tg/kg/d of rhg-csf. the maximum increase in the anc occurred hrs after and ~tg/kg/d ( - %) (p< . ) and ( % -+ %) (p< . ), respectively. there was a significant dose-dapendeat increase in the bm neutrophil storage pool ( _+ % vs. + %) (p< . ) (placebo vs. ~tg/kg/d). there was no significant difference in the nantrophil proliferative pool. an increase in cfu-gm and cfu-gemm was seen at all doses tested, compared to placebo ( . _+ . vs. -+ ) (colonies/l(p cells/plate). c bi expression was significantly increased hrs after bg/kg/d of rhg-csf ( + % vs. +- %) (p< . ). peak serum g-csf levels occurred at hrs and were dosedependent. the half-life of rhg-cse was . + . hrs. most importantly, there was no observed toxicity from g-csf in all patients studied. of patients were on ventilators prior to administration of rhg-csf and there was no increase in pulmonary toxicity. these preliminary data suggest that rhg-csf is well tolerated at all gestational ages in newborns with presumed sepsis. a multi-center phase ii/iii randomized double-blindad placebo controlled trial is required to determine the efficacy of rhg-csf in this clinical setting. we investigated the effects of recombinant canine granulocyte-colony stimulating factor (g-csf) on survival, cardiopulmonary function, serum endotoxin levels and tumor necrosis factor (tnf) levels in a canine model of lethal bacterial septic shock (clinical research. : , ) . methods: awake ylo beagles had serial cardiopulmonary and laboratory studies before and for up to days after intraperitoneal placement of an e. celi infected clot. nine days before and daily until days after clot placement, animals received high (n= ) or low dose (n= ) g-csf or protein control (n= ) subcutaneously. results: survival in high dose g-csf animals ( / ) was significantly improved compared to low dose ( ) and controls ( ) (p< . wilcoxon). high dose g-csf also improved cardiovascular function evidenced by a higher mean left ventricular ejection fraction (day after clot, p< . ) and mean arterial pressure (day , p< , ) compared to low dose and controls. high dose rcg-csf increased (p< . ) peripheral neutrophil numbers both before and after clot implantation ( hours to days) compared to low dose and controls. in addition, high dose rcg-csf produced a more rapid (p< . ) rise (day ) and fall (day ) in alveolar neutrophils determined by bronchoalveolar lavage compared to low dose and controls. lastly, high dose rcg-csf decreased serum endotoxin ( to h, p< . ) and tumor necrosis factor (tnf, h, p< . ) levels compared to low dose and controls. discussion: these data suggest that therapy with g-csf sufficient to increase peripheral neutrophil numbers during peritonitis and septic shock may augment host defense and endotoxin clearance, reduce cytokine levels (tnf) and improve cardiovascular function and survival. the use of g-csf in sepsis prophylaxis in neutropenic patients is well established and has been ascribed to accelerated recovery in granulccyte counts. here, an additional sepsis-prophylactic property could be demonstrated in healthy volunteers: eleven volunteers were employed in a sinqle-btind, controlled study and were given uq g-csf or saline placebo via subcutaneous injection. blood was withdrawn immediately before and or hours later. lps-inducible tnf, il- , stnf-r p and il-lra were assessed in the supernatant of whole blood incubations stimulated with ug/ml lps from salmonella abortus equi. similarly to previous animal studies, lps-inducible tnf was attenuated by about % hrs. after treatment. the same was true of il-lb. in contrast, lps-inducible stnf-r p which was indetectable in blood incubations from untreated donors increased dramatically hrs. after g-csf treatment. il-lra found after lps challenge was increased tenfold by g-csf treatment. it is concluded that g-csf treatment switches peripheral leukocytes to an antiinflammatery state characterized by an attenuation of il-i and tnf releasing capacity and an augmentation of the release of cytokine antagonists. this findinq minht offer a novel concept in septic shock prophylaxis. objective.the aim of the study was to investigate the effect of recombinant human g-csf (rhg-csf) on survival, bone marrow neutrophil myelopoiesis, neutrophil counts, levels of bacteria and some important sepsis mediators in a model of rat abdominal sepsis. lethal peritonitis was induced with a mm coecal perforation (cp) in male wistar rats. rhg-csf was administered as /.tg/kg iv every h, first dose at sepsis induction. bone marrow neutrophi] progenitors were determined as blast colonies, cfu-gm and cfu-g. neutrophils and bacteria were determined in peripheral blood and peritoneal fluid. lps, tnf, endothelin and lactate were measured in blood from femoral vein. mortality rates were registered with g-csf treatment starting either or days before or hours after cp. results. mortality was reduced from % to about % with rhg-csf intervention and there was no difference between the pretreatment and treatment groups. bone marrow blast colonies were not influenced while neutrophil myelopoiesis was augmented at the stages of cfu-gm and cfu-g. neutrophils in blood and peritoneal cavity were enhanced and numbers of bacteria in the same compartments were substantially reduced. circulating lps, tnf, endothelin and lactate were attenuated the first hours after cp. neutrophil myelopoiesis is augmented with increased number of neutrophils in blood and peritoneal cavity, resulting in enhanced clearance of pathogens. lps, tnf, endothelin and lactate are suppressed the first hours during sepsis course. a. wendel, j. barsig, g. tiegs gm-csf stimulates the proliferation and differentiation of granulocytic and monocytic progenitor cells. in addition the hemopoietic cytokine activates the inflammatory response in mature leukocytes. the priming effect of gm-csf towards lipopolysaccharide (lps)-induced cytokine production in vitro has been described, but little is known about proinflammatory gm-csf effects in vivo. we detected gm-csf in plasma of lps-challenged mice with kinetics similar to tnf, reaching peak levels h after lps administration. gm-csf pretreatment ( ~tg/kg i.v.) enhanced mortality in mice challenged by a sublethal dose of lps. plasma levels of tumor necrosis factor (tnf) and interleukin- (il- ) were significantly enhanced. a monoclonal antibody, which neutralizes gm-csf bioactivity, rendered mice less sensitive towards lethal lps-challenge. tnf-and il- -tevels were reduced in these mice compared to control animals without antibody treatment. in addition, severalfold potentiation of lps-induced cytokine release by gm-csf was observed in vitro in murine bone marrow cell cultures. these data demonstrate the proinflammatory capacity of gm-csf and suggest that the hemopoietic cytokine plays also a role as an endogenous modulator of lps toxicity. immune dysfunction, developing in the wake of multiple trauma, overwhelming infection and other forms of critical surgical illnes% is associated with increased infections, morbidity and mortality. the mechanisms responsible for alterations in immune regulation are incompletely understood but monocyte appear to play a central role. polymorphonuclear leukocytes (pmn) are known to play a central role in the inflammatory response of the host toward invading microrganisms. reports of defects in all the aspeots of pmn function have been accumulated in recent years. the possible role of gm-csf in modifing the state of immuno suppression detected in severe intraabdominal infected pt~. inspite of surgical appropriate procedures and in reducing the expected mortality is investigated. the safety of rh-gm-csf administration in sepsis is also evaluated. a double blind randomized study is proposed. this study include icu patients who do not exhibit signs of shock and/or ards, with clinical signs and symptoms of abdominal infection. immunodepressed patients-aids, chronic chemotherapy or chronic steroid administration do not partecipate to the study. patients will receive rgm-csf (l~g/kg/day) or placebo in hs. continuous infusion for days. safetyandefyieacy will be assessed till to day . the apache ii score is adopted for risk stratification of patients because it is reliable and validated, objective and composed of information that is indipendent of diagnostic criteria. patient's entry criteria is apache ii > (score corresponds to expected mortality rate of %).in this protocol the surgeons report the judgement of the efficacy of surgical procedure to remove or not the focus of infection. objectives: infections and subsequent septic responses remain the leading cause of death among surgical intensive care (sicu) patients despite tmprovetaunts in supportive care and brond-epectrum antibiotics. usually invading bacteria are efficiently cleared by neutrophil granulocytes. however, during sepsis various neatrophil dysfunctions have been demonstrated, leading to impaired host defense. granulocyte colony-stimulating factor (g-csf) induces a sustained increase in circulating neutrophils and enhances various noutrophil functions. it was the purpose of the present study, to evaluate the safety and efficacy of g-csf (filgrastim) in sicu patients at risk of sepsis. materiel a.d methods: the study was designed as an open-label phase-ll study of filgrastim. ten consecutive slcu patients, with a therapeutic interveotion score greater than , were included in the study. filgrastim was given by daily continuous intravenous infusion for days or discharge from the sicu. apache ll-score, multiple-organ-failure (mof) score, definitions of infections, sepsis, systemic inflammatory response syndrome (sirs), and acute respiratory failure were applied daily. a response to filgrastinl th_erapy was defined as an improvement in disease severity quantified by a decrease of > apache i score points on day after onset of treatment. results: none of the patients developed a sepsis or mof later on and no patient died during hospitalization. specific postoperative complications occured in one patient ~jth a leekage of the oesophagou-gastric anastomosis after oesophageus resection. at study entry the leucocytes amounted to . + . /~tl (mean + sem) and reached a level of . +_ . /tal at day after onset offilgrastim therapy. the apache ii score initally was + . (mean + sem) and as an indicator of filgrastim response a decrease of points ~dthin days oceured in out ot patients. filgrastim was well tolerated, side effects were not noted. growth of solid tumors might be modulated by the activity of inflammatory and/or immune effector cells of undefined specificity. in this study patients undergoing surgical treatment for gastric (n= ) or colorectal (n= ) cancers were evaluated for endogenous serum levels of granulocyte colony-stimulatingfactor (g-csf) during a pre-and postoperative time period. from the same blood specimens mononuelcar cells (mnc) were prepared. the release of ifn-%, and il- , which are secreted by thl cells, were stimulated in vitro by pha during a cell culture period up to hours. the patients were further classified for their immunreactivity by responses in dth skin testing to seven different antigens (e.g. tetanus toxoid, ppd, diphtheria toxin, trichophyton, streptococcus, candida and proteus antigens). dth testing has been repeated in each patient two remarkable results were obtained. the serum levels of endogenous g-cse showed a biphasic increase with maximum values of pg/ml (preoperative < pg/ml) on day and day to after surgical treatment. similar patterns of g-csf production were found in both groups of patients with gastric or colorectal cancers. high serum levels of g-csf were significantly (p < , ) correlated with infectious complications in patients whh gastric cancer (n= / ). secondly patients could be arranged into two groups according to an anergic (n= ) or normergi¢ (n = ) responsiveness in dth testing. the frequency of anergi¢ responsiveness was similar in both patients with gastric (n= / ) or colorectal (n= / ) cancers. interestingly we found a significant correlation (p < , ) between low serum levels of g-csf and anergy during the postoperative period in both groups. stimulation of mncs from anergic patients (n= ) within the pre-and postoperative period resulted in reduced mean values (about %) for ifn-ff release (preoperative means llo pg/nfl), if compared to patients with normergic dth (n= , preoperative means pg/ml). similar, but less significant results were obtained for il- secretion. our results confirm a correlation between infectious complications and g-csf in the postoperative period, however elevated levels were also found in some patients without any signs of infections. more interestingly there might be an association between cytokine (c~csf, ifn-% and il- ) release and dth, which is known to be mediated by activated thl calls. to recognize anergic dth as a possible higher risk in the postoperative outcome of cancer patients extended periods of observation are needed. objectives of the study effects of recombinant huraan granulocyte colony-stimulating factor(rhc-csf)a galnst severe septic infections were investigated by its single use or by its corn b{nation with cephera antibiotlcs.we examined its effects on the mortality,and circulating blood neutrophyis counts and functlons,such as phagocytic activity and h production using the rat severe septic model. rats were subcutaneously administsrd rhc~csf(s orl o ~ g/k~ body wt)after on set of peritonitis brought about by cecal ]igation and one puncture withe -gaug e needle once a day for three days.in addjtlon,cefmetazol na(cmz)( m$/k bo dy wt)was injected intrarnustularly to the rats tv~ce a day for three days. cirehlatlng blood neutrophyls counts were determoned electronically with a hem ocytometer,and blood smears stained with may~runwaldm.qlemsa~taln. neutrophyls functions in vltro,such as phagocytic activity and h producti on using the rat severe septic model was analyzvd by automated flow cytometri c single cell-analysis methods. the reortallty rate after weeks was significantly decreased by administratlon of rh~-csf(p< , ).ln addjtion,a combination therapy of rhg-csf wlte cephern ant~biotics(cmz)showed a significantly survive] advantage and the rate had b een reached . %. nextly,treatn%ent wlth rhg-csf(s ~ $/k body wt)increased the nuzaber of the peripheral blood neutrophjls slgn[fieantly(p< . ). iv~oreover,functions of neutrophlis which were phagocytic activity and h p roduction were remarkably enhanced by admlnlstratlon of rhg-cs~( ~ /ks b ody wt) (p< .( ). these findings suggest that combination therapy of rhcrcsf with cephern antib iotlcs(cmz)is an efficient regime against severe infectlons.and the increased ne utrophils counts and enhanced neutrophiis functions were played a important ro le about the survival advantage. granulocyte macrophage colony-stimulating factor (gm-csf) is a haematopoietic growth factor active on neutrophils and macrophages. leukopenia often occurs following renal transplantation and can be associated with infection and/or the myelosuppressive effect of azathioprine. aim: we report the use of gm-csf in renal allograft recipients with leukopenia. nonglycosylated recombinant gm-csf was obtained from e. coli transvected by human gm-csf gene. m~terial ~,nd methods : written informed consent was obtained from all patients. patients were suffering from toxic neutropenia (neutrophils < /mm ) with medullar hypocellularity on bone marrow aspiration, or leukopenia (neutrophils < /ram ) with cytomegalovirus infection requiring ganciclovir administtation. gm-csf was given subcutaneously at a dally dose of to mcg/kg/day, according to renal function. results : in all cases, neutrophil counts returned to normal levels within to days. in most of them, spectacular correction was observed within hours, with a single injection. adverse events due to gm-csf at this dose were mild and easily managed ( cases of bone pain treated with paracetamol). one acute rejection episode was observed after correction of leukopenia. conclusion : on the basis of this study, it appears that gm-csf at a dose below mcg/kg/day is an effective treatment for renal transplant recipients with leukopenia associated with cmv infection or toxic neutropenia. department of nephrology, , rue de s~vres, hopital necker, paris, france. changes in serum g-csf and il- after surgical intervention hitoshi toda , atsuo murata , hidewaki nakagawa , takesada mori , nariaki matsuura osaka university medical school, osaka, wakayama medical school, wakayama, japan we measured serum immunoreactive interleukin (il- ) and granulocyte colony-stimulating factor (g-csf) levels of the patients undergoing major thoraco-abdominal surgery for esophageal cancer. serum samples were collected from eight patients on the day before surgery, at the time of operation, and thereafter at suitable intervals for one week. il- and g-csf were measured by means of enzyme linked immunoassay. the normal range of serum ]l- was less than pg/ml and g-csf less than pg/ml. values between groups were compared with linear regression analysis. both serum g-csf and il- levels reached their maximal levels at the first postoperative day and decreased thereafter. the correlation between g-csf (y) and il- (x) was y= . x+ . (r= . , n= , p< . ), showing a significant correlation. in the case who suffered from aspiration pneumonia and ards at the second postoperative day, the peak level of il- was pg/ml and g-csf pg/ml respectively. the estimated value of g-csf was pg/mi by the regression equation. this means the real g-cse level was less than half of the estimated value. it suggests that low responsiveness of g-csf is one of the reason of immunodeficient state after the major surgery, neutrophils from injured patients ingest and kill bacteria less efficiently as compared to those of healthy individuals, probably reflecting the suppression in respiratoly burst which occurs after severe trauma. one of the main mechanisms of killing bacteria by neutrophil granulocytes is production of oxygen radicals (respiratory burst). granulocyte colony-stimulating factor (g-csf), a kilodalton cytokine, leads to a sustained, dose-dependent increase in circulating neutrophils. thus, it was investigated whether filgrastim (recombinant human granulocyte colony-stimulating factor, rhg-csf) therapy fits for prophylaxis of sepsis in postoperative/posttraumatic patients, and whether, besides an expected increase in neutrophil count, filgrastim would also augment neutrophil function. material and methods: this study was designed as an open label, prospective phase ii study of filgrastim and performed in a surgical intensive care unit (sicu) (university hospital). postoperative/post-traumatic patients with a therapeutic intervention scoring system (tiss) score greater than were treated with filgrastim ( . - l.tg/kg/day) for prophylaxis of sepsis on days or until discharge from the sicu. production of oxygen radicals can be quantified by analysis of fmlp-and zymosan-induced chemiluminescence. neutrophil oxygen radical production was tested by fmlp-and zymosan-induced chemiluminescence by the polymorphonuclear cells (pmn) of these patients in multiple blood samples over a period of up to days. results: none of the patients treated with filgrastim for prophylaxis of sepsis developed sepsis. in vitro fmlp-induced ( - reel/l) neutrophil oxygen radical production was significantly increased under therapy with filgrastim by a maximum of % +- % ( % - %) compared to pretreatment values of %. tapering of filgrastim resulted in a reduction of fmlp-induced neutrophil oxygen radical production within hours. in contrast, zymosan-induced neutrophil oxygen radical production was not affected by filgrastim treatment. conclusions: besides its quantitative effect on neutrophil counts enhanced neutrophil function, documented here as increased fmlp-induced oxygen radical production, may account for the beneficial effect of filgrastim for prophylaxis of sepsis in posttraumatic/post-operative patients. granulocyte colony stimulating factor (g-csf) and granulocytemacrophage colony stimulating factor (gm-csf) have been recently introduced in the treatment of chemotherapy-induced neutropenia. effects of these csfs on cellular immune system were evaluated in neutropenic gynecological cancer patients during chemotherapy. g-csf and gm-csf were equally able to induce a rapid recovery of white cell count within one or two days. g-csf treatment resulted in a significantly higher concentration of leukocytes measured in the peripheral blood although by gm-csf a sufficient effect was achieved (p< . ). before initiation of csf treatment urinary neopterin was similar in both groups of patients ( +/- and +/- lamol/mol creatinine for gm-csf and g-csf respectively expressed as mean +/-one sd). in g-csf treated patient only a marginal induction of neopterin was observed. on day the mean value was about % above the basal level (p< . ). on the other hand gm-csf treated patients were characterized by a pronounced increase in urinary neopterin levels. in comparison with the basal level a more than fold induction was noted and the difference between g-csf and gm-csf was highly significant (p< . ). this effect was confirmed in vitro by investigating the effects of these csfs on interferon-gamma mediated pathways in thp- human myelomonocytic cells. results suggest activation of immune effector cells by gm-csf which may help the organism to overcome infections. however, activated macrophages produce several growth factors which may increase malignant proliferation, and augmented neopterin production as sign of macrophage activation has also been associated with poor prognosis m several malignancies. more data are therefore necessary to clarify whether csf mediated immune activation is beneficial or deleterious for cancer patients but considering our results caution in applying csfs in oncology seems advised. from a historical perspective, the development of humoral immunity to bacterial endotoxin has assumed a prominent position in the spectrum of therapeutic approaches which have been explored for the treatment of gram negative septic shock. predicated upon the fact that rough strains of bacteria manifest lps containing exclusively conserved structural features common to lps from all gram negatives, specific antibodies were elicited which conveyed cross protective immunity in experimental models of bacteremia and endotoxemia. such studies culminated in a well-conducted, randomized, double-blind placebo-controlled clinical trial using passively administered human polyclonal antiserum to treat patients with suspected gram negative sepsis. the efficacy of treatment established in that trial spurred efforts to develop monoclonai reagents which, to date, have not been uniformly successful in reproducing those earlier studies with polyclonai antibodies. nevertheless, the numerous successes which have been documented in experimental models of endotoxemia continue to foster promise for this immunotherapeutie approach. several recent studies with human polyclonalimrnunoglobulin preparations containing antibodies reactive with lps and lipid a have yielded promising results in treatment of patients with sepsis. in addition, the recent development of an antiidiotypic monoclonal antibody which reflects an internal image of a kdo specific monoclonal antibody has provided an alternative experimental approach to generate anti-lps antibody. immunization of mice with the antiidiotype provides significant protection against subsequent lps lethality consistent with the development of circulating immunoglobulin specific for lps. thus, the use of polyclonal immunoglobulins contrives to provide an alternative and potentially cost effective method for the treatment of endotoxin shock. supported by r a and pot ca . john holaday, anne fortier, shawn green, glenn swartz, john madsen, carol naey, and jan dijkstra entremed, inc.. rockville, md, . at the time of diagnosis, the signs and symptoms of septic shock are an indication that the systemic inflammatory response is well underway; thus, it has been argued that the endotoxin "cat is out of the bag", and that subsequent passive immunization may be too late to achieve therapeutic benefit. our approach has been to evaluate active immunization as a prophylax~s against sepsis. mice were inoculated twice (two weeks apart) with liposomes containing dmpc[i. ], dmpg[ . ], cholesterol [ . ] , and monophosphoryl lipid a [ - gg/txmole phospholipid] by several routes (i.p., i.m.), and serum was collected - days after each inoculation. after a single injection, highest tilers of ab were produced in mice inoculated i.p., but mice inoculated by all routes produced anti-lipid a ab. following the second injection. ab levels were roughly equivalent in mice inoculated by all routes, regardless of lipid a concentration. mice vaccinated i.p. with liposomes containing , or gg lipid a were treated with cyclophosphamide to produce neutroperda and then challenged with e. cole in an infection model of gram negative sepsis. the lds for control (liposomes with no lipid a) mice was x bacteria; ld for mice vaccinated with p.g was x ( -fold increase in resistance) and with ~tg was x bacteria ( -laid increase in resistance). mice vaccinated as before were also treated with actinomyein d to increase sensitivity to lps (salmonella minnesota) challenge in an endotoxemia model of grain negative sepsis. the ld for control (liposomes with no lipid a) mice was ng lps; the ld for gg lipid a was rig lps ( -fold increase in resistance) and for xg was ng lps ( -fold increase in resistance). mice were similarly vaccinated and challenged with an aggressive gram negative pathogen, francfsella tularensis. the ld of franciseua in normal mice or mice inoculated with liposomes without lipid a was - bacteria. in contrast, mice vaccinated with liposomal lipid a ( ggl survived challenges as high as , bacteria, ( logs of protection). the impressive protective capacity of this vaccine did not correlate with ab liter in any of the sepsis models, nor did it correlate with classic nonspeeific events, such as macrophage activation. maerophages harvested from the peritoneum of mice vaccinated and protected against sequelae of gram negative infections did not spontaneously kill the bacteria in vitro, but could be activated by ifn-y for antimicrobial activity equivalent to that of macrophages from unt#eated mice. research is underway to defme the protective mechanism(s) activated by this liposomal-lipid a vaccine. intervention by monophosphoryl lipid a in septic shock jon a. rudbach, ribi immunochem research, inc., hamilton, montana, usa monophosphoryl lipid a (mla), the clinical form of which is called mpl®-immunostimulant, has been tested extensively as an intervenient material in septic shock. mla is protective when given to experimental animals prior to a live microbial challenge or challenge with lethal doses of microbial products or certain cytokines. this is shown with gram negative and gram positive bacteria, gram negative bacterial endotoxins, and gram positive bacterial exotoxins. furthermore, animals treated with a regimen of mla which results in a refractory state to a lethal dose of gram negative bacterial endotoxin concomitantly display increased resistance to a live bacterial challenge. thus, both endotoxin tolerance and nonspeciflc resistance to infection can be manifested simultaneously. also, prophylactic doses of mla do not interfere with other therapies given subsequently; an additive or a synergistic protective effect can be demonstrated with certain combinatorial treatment regimens, such as mla followed by antiendotoxin monoclonal antibodies. the preclinical studies were extended to human trials wherein the safety of agonistic doses of mla was verified. furthermore, when mla was administered to human volunteers hr before challenge with a pharmacologically active dose of reference endotoxin, febrile, cardiac, tnf, il- , and il- responses were all decreased significantly as compared with the responses of subjects pretreated with a control solution and challenged with endotoxin. human trials with mla are being extended into patient cohorts which have high probabilities of developing septic shock; this will expand the safety base and establish clinical efficacy for mpl®-immunostimulant. a considerable body of in vitro evidence supports the concept that the effects of lps on cells of the immune/inflammatory systems are controlled by interactions of lps with cd . to evaluate if blocking lps-cd interactions has potential as a therapeutic in septic shock we have evaluated the effect of anti-cdi monoclonal antibody (mab) on lps-induced cytokine production and physiologic changes in an experimental model of endotoxin shock performed in cynomolgus monkeys. a novel model has been established where animals were treated with interferongamma for three days prior to infusion of highly purified lps over an eight hour period. in this model lps challenge resulted in marked release of eytokines in the blood, substantial hemodynamic changes, release of liver enzymes and alteration in lung permeability observed over a hour period. to evaluate the effect of treatment with anti-cd mab, animals were given either nothing, an isotype control or anti-cd mab ( mg/kg) rains, prior to the beginning of the lps infusion. evaluation of physiologic changes including mean arterial blood pressure and cardiac output, quantitative analysis of eytoldne levels including tnfct, il- , i,- , il- and il- , and liver enzymes during a hour period revealed that treatment with anti-cd mab markedly attenuated all parameters of injury including decreased mean arterial blood pressure, increased cytnkine levels and the release of liver enzymes observed in animals given the isotype control mab or those not treated. administration of anti-cd mab to interferon-gamma treated animals not challenged with lps did not induce any detectable physiologic changes or increases in cytoldnes. these studies suggest that strategies to block lps-cd interactions will have utility in diseases such as septic shock or ards where lps plays a central role in initiating injury. preclinical studies with recombinant bactericidal/permeability increasing proteins (rbpi and rbpi ). p.w. "frown, dept. of preclinical science, xoma corporation, berkeley, california, usa. bactericidal/permeability increasing protein (bpi), from neutrophils, binds to and neutralizes lipopolysaccharide (lps); it also specifically kills gram-negative bacteria (gnb). these properties, which reside in the n-terminal half of the molecule, indicate potential therapeutic application in the treatment of gram-negative sepsis. the gene for human bpi has been cloned and recombinant holoprotein (rbpi) and a kd n-terminal fragment (rbpi; ) have been produced in sufficient quantities for preclinical studies. both rbpi and rbpi bind to lipid a and neutralize the biological activities of lps derived from a variety of organisms, rbpi has equivalent antibacterial activity to bpi against rough gnb but is up to x more potent than bpi vs. serum-resistant and smooth gnb. rbpi and rbpi compete with lps-binding protein (lbp) for binding to lps under physiological conditions. consequently, both rbpi and rbpi block the cd -dependent lpsinduced synthesis of the cytokines tnf, il- , el- and il- in vitro. rbpi has also been shown to inhibit the lps-induced synthesis of reactive metabolites, endothelial adhesion molecules and the procoagulant molecule tissue factor. in animals, rbpi has been reported to increase survival of endotoxin-challenged rats and mice, to inhibit the dermal schwartzman reaction in rabbits and to increase survival of neutropenic rats with pseudomonas bacteremia, rbpi increases survival and decreases cytokine production in endotoxin challenged mice and rats. it normalizes lps-induced changes in hemodynamic, pulmonary and/or metabolic parameters in lps-induced rats, rabbits and pigs. treatment with rbpi also increases survival and decreases cytokine production in bacterial challenge models in rats and mice. rbpi was not toxic to rats after daily consecutive i.v. doses of mg/kg. this combination of properties indicate that recombinant bpi may be useful in the treatment of sepsis. phase i/ii clinical trials of rbpi have begun. the discovery of lps binding protein (lbp) and subsequent identification of cd as a receptor for lps or lps-lbp complexes has resulted in a new understanding o£ how lps responsive ceils are stimulated. cd is found either as a glycosylphosphatidyl-inositol (gpi)-anehored membrane glycoprotein (mcd ) of myeloid cells or as a soluble serum protein (scd ) lacking the gpi-anchor. binding of lps to mcd triggers cell activation while binding of lps-scd complexes to cells such as endothelial or epithelial cells that normally do not express mcd activates these cells. these pathways are shown in schematic form below. ~di mcd plays a crucial role in presentation of lps to additional membrane components that make up a functional lps receptor. an immediate consequence of engagement of this functional receptor is protein tyrosine phosphorylation. the molecular mechanisms leading to these events will be discussed. understanding of these pathways will lead to the development of new therapeutic approaches to controlling host responses to lps. pretreatmen t posttreatment (before or after tnf peak) d) with different antibody dosages: mg/kg --- . mg/kg pretreatment with anti-tnfab prevented death in most model situations (except peritonitis), but also posttreatment up to h after sepsis induction was successful in the few studies performed. there is additional evidence that low-dose tnfab is partially effective. especially baboon anti-tnfab studies provided many insights into the pathophysiological sequences of sepsis induction, due to crossreactivity with human reagents. those events include the cytokine sequence with tnf-dependent il-i, il- , or il- , but also il-lra or stnf receptor release. granulocyte as well as endothelial cell activation were shown to be partly tnf related, and the procoagulatory response was influenced by anti-tnf treatment. from many animal studies the concept that tnf plays a pivotal role in sepsis is clearly evident and therefore anti-tnf therapy is a major candidate tbr clinical studies. the beneficial or harmful effects of tnf-mediated inflammatory responses depend on the clinical context. decreasing exaggerated tnf-mediated inflammatory responses may be useful in some patients with organ failure. tnfr:fc (immunex, seattle, wa) is a recombinant human protein composed of two identical extracellular p tnf receptors linked by the fc region of iggl. it neutralizes tnf with an affinity for tnf<z of - m and has a t / of • h in normal humans. methods: normal volunteers were randomized to receive either tnfr:fc vehicle (n= ), or low dose (ld) tnfr:fc ( mg/m iv, n= ), or high dose (hd) tnfr:fc ( mg/m iv, n= ) infused over rain prior to endotoxin (e) (escherichia coil : ; ng/kg iv) administration. plasma cytokines were measured using elisa and tnf bioactiv'dy. systemic hemodynamics were evaluated with indwelling arterial and pulmonary artery catheters and radionuclide heart scans and compared before and after fluid loading in subjects given vehicle with hd tnfr:fc. results: endotoxin-related symptoms were unchanged after ld or hd. peak temperature occurred at a later time point ( - h) in subjects given tnfr:fc compared to vehicle ( h) (p=. ). at h, h (post fluid load ), and h, subjects given vehicle developed increased cardiac index and heart rate and decreased systemic vascular resistance index (all p=. ). hd tnfr:fc did not alter this hyperdynamic cardiovascular response. ld and hd inhibited the e-induced teukopenta at i h post endotoxin (p<. ) and later leukocytosis (p< . ). peak tnf bioactivity in subjects given vehicle was + pg/ml and < pg/ml in the ld or hd tnfr:fc groups (p<. ). two immunoassays for tnf were performed because the detection of receptor bound tnf varies with elisa. tnf (biosource) was decreased in ld vs vehicle or hd (p=. ) whereas tnf (r&d systems) was increased after hd or ld vs vehicle (p<. ). decreased levels of il- (p=. t), granulocyte colony stimulating factor (p=. ), and il- receptor antagonist (p=. ) were found after ld or hd vs vehicle. il- levels were lower after ld vs vehicle or hd (p=. ). il- levels were similar among subjects given vehicle, ld, and hd tnfr:fc. conclusions: ld and hd tnfr:fc delayed the febrile response to e but did not alter the early hyperdynamic cardiac response. this suggests that mediators other than tnf play an important role in the initial cardiovascular response to e in humans. tnfr:fc attenuated the release of some e and tnf-induced cytokines. ti~e antiinflammatory responses of tnfr:fc may be useful in some patients with disease processes resulting from excessive tnf-mediated inflammatory responses. the biosynthesis of tnf within macrophages is regulated both at the transcriptional and the translational levels. the ' flanking region of the tnf gene contains several transcriptional control elements, including two kb enhancers similar to those of immunoglobulin genes and a "y box" similar to that of the mhc class ii promoter. these elements are critical for the enhancement of transcription noted after stimulation of macrophages with lps. despite these and other elements, transcriptional regulation alone accounts neither for the absence of tnf protein during normal homeostasis nor the profound increasein tnf production following stimulation with lps or other secretagogues. the translation of tnf mrna into protein is also tightly regulated via mechanisms involving the octameric "ttatttat" motif present in the 'untranslated region of tnf, human inducible no synthase, and several other cytokine genes. this region not only destabilizes mrna, but also confers a translational blockade so that tnf protein is not normally synthesized despite leaky basal transcription. lps stimulation releases translational blockade and, together with enhanced trancriptional rate, accounts for significantly increased tnf secretion. opportunities for inhibition of tnf production are available at each of these two levels. agents which increase intracellular camp (pentoxif¥ ine, amrinone) inhibit accumulation of tnf mrna; in contrast, corticosteroids act primarily at the level of translation, inhibiting lps induced translational activation. understanding the regulation of tnf biosynthesis may assist in clinical strategies designed to regulate tnf secretion. the serine protease thrombin is formed by enzymatic conversion from its proenzyme form after coagulation activation and may enhance the inflammatory response in various ways. in the last step of the coagulation cascade, thrombin cleaves its substrate fibrinogen, thus forming fibrin. the fibrin clot may prevent phagocytosis of bacteria and promote local bacterial growth. thrombin can also stimulate a specific th.rombin receptor that exists on a variety of cells. for example, minute amounts of thrombin ma), stimulate platelets to develop tissue factor and boost the activation of more thrombin, thus initiating a positive feedback loop. other cellular effects of thrombin receptor stimulation include increase in intracellular calcium of platelets and monocytes, contraction of smooth muscle cells, increase in endothelial permeability, thromboxane generation by neutrophils and lymphocytes, pulmonary vasoconstriction, and enhanced cytokine production. animal experiments have been conducted with a variety of thrombin inhibitors including heparin, antithrombin ili, hiradin, and hirudin-like peptides. an alternative approach is the inhibition of the coagulation cascade at an earlier point in the cascades, or administration of the anticoagulant enzyme protein c work from our own group in a porcine model of lipopolysaccharide-(lps)-induced shock with disseminated intravascular coagulation has shown that prelreatment with recombinant desulfatohirudin (r-h) or with a preformed complex of human donor antithrombin iii with heparin or post treatment with r-h are able to block the degradation of fibrinogen and the formation of fibrin monomer. in addition, after pretreatment with r-h it was found that lps-induced lung injury was reduced. since both natural hirudin as well as r-h were well tolerated by healthy volunteers, adminislration of r-h may be a promising therapeutic approach in patients with sepsis and sirs. corticosteroids have been used in the management of various shock syndroms including sepsis. the data concerning the effects of this therapy is, however, conflicting and in large prospective studies, the use of early administration of high doses of corticosteroids have been found to give no beneficial effects in patients with sepsis. we have particularly been engaged in studies on possible effects of corticosteroids on the plasma cascade systems and on the mediator release from leukocytes. in in vitro studies, high doses of methylprednisolone were found to facilitate endotoxin induced generation of plasma kallikrein. furthermore, plasma prekallikrein and kallikrein inhibitor values decreased together with formation of kallikrein-c inhibitor complexes ( ). in this in vitro plasma model we also found that methylpredoisolone alone in doses of mg/ml induced contact activation with the formation of kallikrein-c inhibitor complexes. methylprednisolone was also found to have an additive effect on endotoxine induced decreases in kallikrein inhibitor functions. in the same experimental model on endotoxemia methylprednisoione was found to give an additive effect on activation of the initial part of the complement cascade ( ) . activation of the terminal part of complement, however, was inhibited by the same dose of methylprednisolone. addition of methylprednisolone alone to plasma was also found to activate the initial part of complement. using a full blood model, we studied the effect of methylpredoisolone in modulating the endotoxin induced cytokine response. when ng/l e. coli endotoxin was added to citrated blood from healthy human donors preinkubation with gg/ml methylprednisolone significantly reduced the release of tumor necrosis factor et ( %) and interleukin- ( % ) at two hours after exposure to endotoxin. in conclusion, these studies show that corticosteroids might facilitate contact activation of plasma and reduce the function of major protease inhibitors. furthermore, we also observed that this drag in in vitro conditions facilitated activation of complement. on the other hand, corticosteroids were found to reduce endotoxin induced cytokine release from leukocytes in whole blood. these studies also showed a dose dependence of the effects of corticosteroids on endotoxin induced cellular and cascade system activation. different predisposing conditions like extensive trauma, infection or pancreatitis result in a remarkably similar inflammatory response. although thls inflammatory response primarily aims at the removal of devitalized tissues, destruction of bacteria and reestablishment of the integrity of host tissues, it may potentially become unregulated and generalized and thereby producing deleterious effects to vital organs or the body" as a whole. cytokines play an important role in the development of the systemic inflammatory response. most of their biological effects, however, are not directly mediated but exerted through other mediator systems. when the inflammatory response results in the formation of capillary leak syndrome and refractory hypotension, the unregulated activation of complement and contact systems appears to be the cause. both systems are almost exclusively regulated by c - nhibitor. am unbalanced degradation of the inhibitor protein was found to be associated with the onset of capillary leakage in various conditions such as bone marrow transplantation, severe burns, and septic shock. these observations suggest a relative deficiency of biologically active c - nhibitor in these septic shock like syndromes. therapeutic intervention studies were initiated using high doses of c - nhibitor concentrate. first results are promising, as in most patients the administration of the drug was followed by a quick and marked improvement of the patient's hemodynamics. whether the administration of c - nhibitor alone or in combination with other drugs is also sufficient to improve long-time survival has to be investigated in double-blind, placebocontrolled studies. salutary effect of human soluble complement receptor type- in models of adult respiratory distress syndrome g. feuerstein, m. dimartino, and *r. rabinovici, smithkline beecham pharmaceuticals, king of prussia, pa, usa, and *jefferson medical college, philadelphia, pa, usa adult respiratory distress syndrome (ards) is a severe pulmonary insufficiency syndrome associated with diverse diseases and injuries. ards is believed to be the consequence of a massive acute inflammatory reaction consisting of activated neutrophils infiltration into the lung. neutrophil activation is likely the result of multiple factors of which complement is believed to play a major role. a potent complement regulatory system in the form of the complement receptor type- (cr- ) exists on many cells where protection against complement injury is provided by inhibition of both the alternative and classical pathways for c /c convertase formation. we have recently purified the human recombinant cr- in a truncated form (brl , tp-io, scr- ) and tested this soluble protein for protective effects in several models of ards. specifically, we have used the following rat models: ) endotoxin-induced ards in paf primed animals; ) .- induced ards; ) thermal injury ( % body surface)-induced ards; ) acid aspiration-induced ards. ards-like features included edema (increase in lung wet weight and water content), neutrophil accumulation (histological inspection and myeloperoxidase assay) and increase in cells and protein in the bronchoalveolar lavage (bad. scr- , - mg/kg, i,v., given as prophylactic (and in some cases, therapeutic) treatment significantly inhibited edema formation and leukocyte infiltration and, in some cases (e.g., endotoxin/paf or il- ), virtually completely. these comprehensive studies strongly support the therapeutic potential of scr- in ards due to diverse injuries. the xanthine derivative pentoxifylline (ptx) and several analogs of ptx have been evaluated for their protective effect in various animal models of septic shock. data from these in vivo studies demonstrate that ( ) ptx suppresses lps-induced tnf release from activated macrophages; ( ) ptx prevents tnf-induced pmn activation; ( ) ptx attenuates lps-or tnfinduced acute lung injury as evidenced by prevention of increased pulmonary vascular permeability and detoriation of gas exchange; ( ) ptx exerts its .protective effects even when administered following initiation of sepsis. the sum of these actions suggest that administration of ptx in sepsis may have therapeutic potential. hans hoffmann md, dept. of surgery, klinikum grosshadern, ludwig-maximilians-universit~.t, marchioninjstrasse , d- m nchen, germany. pentoxifylline [pof] and related xanthins are drugs of known haemorrheologieal activity and widely used clinically. recently, new pharmacological aspects of these established drugs could be demonstrated. it was found that pof selectively inhibits the formation of tnf but not il- most likely by causing accumulation of intraceliular camp via inhibiting phosphodiestersse activity, and, secondly, by inducing prostacyclin in different cell types. furthermore, pof is able to counteract tnf-mediated adherence of neutrophils to vascular endothelium and to inhibit fmlp-indueed respiratory burst in neutrophils. we and others have, therefore, studied its effect in different animal models. it was found that pof protected from increased pulmonary vascular permeability and sequestration of neutrophils into the lung in different animal models of acute lung injury. moreover, in pigs with induced faecal peritonitis the drug improved haemodyrmmle variables as well as pulmonary compliance and reduced the number of pulmonary neutrophila and lymphocytes. consequently, as a general outcome, pof could be found to improve survival in different models of haemorrhagie and endotoxie shock. the protective effect of pof was dose-dependent and observed even when pof was given up to hours after endotoxin. in order to evaluate these pharmacological effects of pof in humans, we studied pof under controlled conditions of endotoxlnemia in volunteers. we found that pof selectively inhibits the lps-indueed endogenous formation of tnf without affecting il- and il- . moreover, pof counteracts the lps-indueed initial leukocytopenia by interfering with the adherence of neutrophils in the microvasculature. meanwhile the inhibition of endogenous formation of tnf by pof could be demonstrated under different clinical conditions of acute and chronic cytokine release syndromes, {okt first-dose reaction, cancer-or tuberculosis-induced cachexla}. it appears worthwile and promising to investigate wether pof exhibits beneficial effects also in septic patients. objectives: to determine the specific role of paf in both lethal primate bacteremia and nonlethal human endotoxemia. materials and methods: two double-blinded placebo controlled studies were performed. first, ten baboons ( . +. kg), were randomized to a control group receiving ° cfu/kg of intravenously administered e. co/i (n= ) and a treatment group (n = ), pretreated with . mg/kg of paf receptor antagonist ro - two hours prior to e. co/i infusion. in a second study, ten healthy male volunteers were randomized to a control group receiving ng/kg of intravenously administered endotoxin (lps) (n= ) and a treatment group (n= ) pretreated with mg of ro - eighteen hours prior to lps administration. physiologic parameters and cytokine levels were measured continuously in both studies for hours. results: baboons pretreated with the paf antagonist had improved oxygenation ( + mm hg v -+ in controls, p < . ) and creatinine clearance hours post e.coli ( . + . ml/min v . _+ . in controls, p < . ). similarly, volunteers pretreated with the paf antagonist experienced fewer symptoms, including rigors and myalgias at hour post lps. this was in concert with a diminished peak cortisol ( +_ mmot/l v +- mmol/l in controls, p < . ), epinephrine secretion ( + nmol/l v + nmol/l in controls, p < . ). hemodynamics and circulating tnfa levels (data not shown) were unaffected in either study by prior paf antagonism. concluslons: paf influences some components of the multi-organ failure syndrome in lethal gram negative sepsis and the counter-regulatory hormonal system in human endotoxemia through tnf-independent mechanisms. paf antagonists may serve as adjuncts to cytokine blockade in the treatment of gram negative sepsis. the mediator role of platelet-activating factor in gramnegative septic shock pierre g. braquet, david hosford and matyas koltai institut henri beaufour, le plessis robinson, france considerable evidence has been accumulated to support the concept that a paf/cytokine autogenerated feedback network is responsible for priming and amplification of inflammatory mediator release in septic shock. cytokines, such as tnf~x, il- and other interleukins interact with paf which then amplifies cytokine production, therefore, paf may be the principle mediator in endotoxin shock. a single factor identified as tnf is suggested to play a pivotal role in the fatal phase of septic shock. presumably excess tnf release is the result of amplification process primarily triggered by paf. one may assume that the high tnf concentration in the blood of 'non survivors' is the consequence rather than the cause of cell death. the dubious results of clinical trials with anti-tnf antibodies and il- ra, a naturally occurring il- antagonist protein, have risen debate around the exceptional role of cytokines in the pathomechanism of septic shock or systemic inflammatory response syndrome (sirs) induced by gramnegative microorganisms. there are similar problems with the interpretation of the results obtained in clinical trials of monoclonal igm antibodies against e. coli endotoxin, ha- a and e . future studies will answer the question as to the effectivity of inefficiency of this treatment. perhaps when the plasma concentrations of lps and cytokines exceed a critical level, treatment fails to save the patients life. with regard the causal role of lps in septic shock, the putative role of bacterial porins may have to be taken into consideration. the marked release of paf induced by endotoxin leading to excess txa production may be responsible for the microvascular failure and death in septic shock. antagonists of paf markedly protect against the release of txa , and may interrupt the vicious circle of amplification process. no produced by the inducible no synthase plays a pivotal role in causing vascular paralysis in lps-induced sirs. to explore the relationship of paf to no synthesis will provide better understanding of the pathomechanism of septic shock. several paf antagonists, including bn , have undergone phase ii and phase iii clinical trials. the strategy in the treatment of sirs, however, remains multifactorial, since little is known about the sirs caused by microorganisms other than gram-negative bacteria. evidence has begun to accumulate which suggests that in sepsis excess production of lps and cytokines can lead to uncontrolled production of inos and that this might in part explain the severe unresponsive hypotension seen in some septic patients. a number of strategies have been explored in an attempt to limit excess no production. a favourite target has been competitive inhibition of nos by arginine analogues such as l-nmma. in animals, some investigators have shown that the haemodynamic effects of lps challenge can be attenuated by l-nmma, but there is a narrow toxic-therapeutic ratio. in a model of live e. cell sepsis, we have been unable to reproduce these findings. localisation of no production by immunohistochemistry suggests that no production is compartmentalised, and more subtle methods of regulation may be required if this approach is to have clinical valuc. anti-adhesion molecule strategies ch wortel, repligen corporation, one kendall square, building , cambridge, ma , usa. the neutrophil has been implicated as a pivotal player in the pathogenesis of multiple organ dysfunction. an important first step in the process of neutrophilmediated organ injury involves the binding of neutrophils to endothelial ceils. this process is largely regulated by complementary adhesion molecules, some of which are present constitutively on the cell surface and others that can be upregulated in response to chemotactic and pro-inflammatory stimuli. several different adhesion molecules have been described. l-selec tin is expressed on the plasma membrane of neutrophils and is shed from the surface early in the inflammatory process. it is therefore thought to mediate the initial interactions with endothelial cells. e-selectin and p-selectin are endothelial adhesion molecules. e-selectin is not constitutively expressed but is upregulated by inflammatory mediators, particularly il- and tnf. p-selectin is present in the weibel-palade bodies within the endothelial cytoplasm and can be upregulated rapidly in response to thrombin, histamine, and oxidants. all selectins recognize oligosaccharides, particularly sialylated lewis x antigen. this carbohydrate moiety is expressed on many proteins, including the selectins themselves. the leukocyte integrins are glycoproteins expressed on the neutrophil surface and in the cytoplasmic granules. integrins consist of a common beta or cluster differentiation (cd)i chain covalently linked to one of three different alpha chains (cd a, cd lb, cd lc) and exist on the cell surface as three distinct heterodimers. cd l a/cdi is expressed on all leukocytes, whereas cd l b/ cd and cd lc/cd are restricted to cells of myeloid origin. cd i/cd interacts with intracellular adhesion molecule- (icam- ), its ligand on endothelial cells. icam- is a member of the immunoglobulin family of adhesion molecules. it is constitutively expressed on endothelial cells and can be upregulated by cytokines. the potential for monoclonal antibodies to adhesion proteins to reduce vascular and tissue damage has been studied in alarge number of experimental models. protective effects have been observed in a wide variety of inflammatory, immune, and ischemia-reperfusion injuries such as arthritis, bums, endotoxic shock, bacterial meningitis, autoimmune diabetes, nerve degeneration, allograft rejection, allergic asthma, acute lung inflammation, skin lesions, and ischemia-reperfusion models of the intestine, myocardium, lung, skeletal muscle, and central nervous system. protective effects have also been observed in animals resuscitated following hemorrhagic shock. since modulating the function of adhesion molecules may temporarily leave the host without effective defense machinery, safety evaluations are of utmost importance in evaluating this therapeutic approach. treatment of gram-negative septic shock with an immunoglobulin preparation: a prospective, randomized clinical trial ingolf schedel, ursula dreikhausen; birgit nentwig; marion hockenschnteder, dirk rauthmann, salim balikcioglu, rolf coldewey, helmuth deicher, md endotoxin may play a major role in the pathogenesls of muitiorgan failure in the context of the toxic process in septicemia induced by gram-negative pathogens. the hypothesis which has led to a prospective clinical study consisted in the idea of inhibiting the biological effects ofendotoxin during the early phase of septic process, and thereby attampting to attain a positive effect on the clinical course of the disease. -objecave: to evaluate the effectiveness ofa polyclonal immunoglobulln (ig) preparation containing igg, lgm, and iga as an adjunctive therapy for septic shock. -desigru prospective, randomized clinical trial. patients: fifty-five patients w~th septic shock were randomly allocated to two groups according to criteria of septic shock. -intervention: one group of patients (n = ) received a commercially available immunoglobulin preparation (containing high titers of antibodies specific for determinants to bacteria endotoxin) during the first days after inciosion in the study. the other randomized group (n = ) did not receive any immunogiobulin preparation. -measuremems and main resmts: during the period of < wks after the beginning of clinically apparent septic shock, death related to the septic process occurred in one ( %) of patients who received immunoglobulln. by comparison, nine ( %) of control group patients died during this period (p <. ). within the first hrs after onset of the clinically apparent septie process, significaptly increased activity of circulating endotoxin and simultaneously decreased specifie igg serum titers to lipid a were detected in the group of nonsurvivors. the rationale for the use of polyvalent intravenous immunogiobulins (ivig) to treat severe infections stems from in vitro and animal studies documenting that high-dose igg enhance opsonization and phagocytosis of pathogenic bacteria. moreover, recent clinical studies have shown that in septic patients the phagocytic function of circulating polymorphonuclear neutrophils (pmn) is defective; the degree of such impairment correlates to the severity of the septic state, the beneficial effect of administering high dose igo in septic patients can be two-fold: i) ivig provides large quantities of antibodies against invading pathogens; the igg bound to the pathogens can opsonize their phagocytosis; ) the opsonization of phagocytosis by exogenously administred polyvalent igo would be of special importance in those patients who present a significant defect of their phagocytic function, when they are challanged by a large bacterial invasion. a prospective, randomized, double-blind study was carried out comparing the administration of ivig (sandoglobulin@) vs, paeebo (human albumin) in severely septic surgical patients, only patients with gepis score >_ (meaning a mortality risk > %) were accepted into this protocol. patients were randomized to receive . g/kg of ivig or placebo on day (when they reached sepsis score> ), repeated on day + and + . at the beginning of icu treatment, the two groups of patients were similar for severity of sepsis, age, concomitant disease, type of surgical procedures, antra and perioperative procedures, antibiotic administration. the results of the study indicated a significantly reduced mortality in patients with severe surgical sepsis treated with ivig as compared to placebo control patients (mortality: % vs, % respectively; p< , ). in conclusion, the results of our study in patients with severe surgical sepsis were the following: ) ivig plus multimodal treatment of sepsis, including antibiotics, reduce mortality significantly', ) the reduction of mortality seems to be due to a decreased incidence of lethal septic shock. despite substantial clinical research, the avallable data regarding the effectiveness of supplemental immunoglobulin (ig) treatment in sepsis in adult patients do not yet allow definitive conclusions. in view of the persistently high sepsis mortality there is a need to continue clinical investxqations regarding supplemental sepsis treatmen~ in general, as well as concerning ig administration in particular. we present and discuss the protocol of the ongoing ,,score-based-immuneglobulin therapy of sepsis (sbits)" study. the protocol (theoret surg ( ) - ) of this multicenter, randomized, prospective and double-blind trfal relies on the results of an observational trial on i.v. igg treatment in patients with sepsis and septic shock (infection ~ ) - ), carried out as a prerequisite for the present trial. using microcomputer-based bedside routine score monitoring, we regard quantitative measures of severity of disease and sepsis: only patients with a certain degree of both severity of disease (apache ii score - ) and severity of sepsis (elebute sepsis score - ) will be included. by observing these previously validated inclusion criteria, this trial snould iqentify a priori and include patients with potentially optimal response to therapy, consisting o~ either placebo ( .i % albumin) or polyglobin n" - ml ( . g)/kg on day and ml ( . g)/kg on day i. with an anticipatedpopulation size of patients the study should comply with the statlstical requirements (estimated mortality: %, with a % reduction in -day mortality in the treatment groupl to prove or disprove the question of igg effectiveness in sepsis in terms of improved prognosis. up to november , more than patients had been included; patient enrollment will be finished in . previous studies have demonstrated rhll-i ra, a naturally occurring antagonist of il- , increases survival in animal models of andotoxemia and eschehchia coli bacteremia and attenuates the decrease in mean arterial pressure resulting from challenge with both gram-negative and gram-positive bacteria. previously, in patients, rhll-lra was demonstrated to increase survival in patients with sepsis syndrome and septic shock in a dose-dependent manner. methods: a randomized, double-blind, placebo-controlled, malticenter, clinical trial enrolled patients at academic medical centers in europe aad north america. eligible patients received either placebo (vehicle) or rhil-lra (anakinra) . or . mg/kg/hr by continuous intravenous infusion for hours. the presence of organ dysfunction (i.e., ards, dic, renal, and hepatic) at study entry was determined prospectively by a clinical evaluation committee using definitions which were developed a-priori. survival time was evaluated over days utilizing a linear dose-response model, assuming a log-normal distribution. results: patients had one or more sepsis-induced organ dysfunction(s) at study entry. a dose-related increase in survival time was observed with rhll-lra compared to placebo in patients with ards, dic, and renal dysfunction (p --< . endotoxin infusion releases platelet-activating factor (paf), a potent phospholipid mediator which leads to an autocatalytic amplification of cytokine release. bn (ginkgolide b), a natural paf receptor antagonist, has provided significant protection against sepsis in different animal models• a randomized, placebo-controlled, double blind, multicenter trial on efficacy (mortality at d ) and tolerance of bn ( iv infusion of mg x /day over days) in severe sepsis has enrolled pts. the day mortality rate was % for the placebo group and % for the bn group (p = . ). the efficacy of bn was greater in pts with gram-negative sepsis: the -day mortality rate was % for the placebo group and % for the bn group (p = . ). bn also reduced mortality among pts with gram-negative septic shock (mortality was % for placebo vs % for bn ; p = . ). using statistical adjusments for pronostic factors, the relative risk of death of the bn group was . ( . - . , % confidence interval; p = . ). this risk corresponds to an adjusted reduction in mortality of % for pts receiving bn . no differences in mortality rates were found between the placebo and the bn groups in the absence of gram-negative sepsis• there were no differences in adverse events between the placebo and the bn groups. bn is a safe and promising treatment for patients with severe gram-negative sepsis. a confirming study, focused on gram negative sepsis, is in progress. v~ lliam a. kanus m.d. and the rhll-lra it has been traditional within the field of infection and sepsis to think in terms of specific indications for drugs based on the type of infecting organisms, advances in antibiotic therapy now control or ltnflt the growth of bacteria. the majority of deaths are now caused by either an initial overwhelming response to infection or subsequent multiple organ system failure attributed, in part, to the effects of intrinsic biologic responses of the host. type of organism, therefore, may not be as critical as determining the exact severity of the host's severity or risk of death from infection. we also know that both the relative benefit of a new treatment across groups and its absolute benefit for an individual patient will vary with their risk in a predictable fashion. we recently iuve~iguted the relationship between one measure of host response, the acute risk of death as prospectively estimated by u comprehensive risk mode[ for -day mortality (jamb. ; : , - ) , by its retrospective application to the results from the phase in evaluation of recombinant human intcrlenkin- receptor antagonist (rhll. ira). we found that there was a significant interaction between the patient's predicted risk of mortality at the time of entry to the study and the ability of rhil-lra to prolong survival time (x = . , p [] . , log.normal) for all patients in the trial• survival benefit began st approximately % baseline risk of -day mortality. for the $ patients with a predicted risk > %, there was a % reduction (p= , $ log normal). when we examined the variation in patients above and below the % risk level with hazard functions, i.e., their daily risk of death during the study period, we found that placebo patients with < % risk had lltile acute daffy risk during the hlltial two days follawh~g study entry and this risk was little affected by rhil-lra, in contrast, patients with > % risk had high daily mortality risks during the tuttlal two days that high dose rhtl-lro substantially reduced. these results are compatible with our current understanding of outcome from sepsis and the proposed mechanism of action o£ immunotherapy, the earliest deaths from sop sis are secondary to an immediate inflammatory response followed closely by deaths secondary to multiple organ system failure, later deaths (after days) are not as closely related to the acute effeete of the inflammatory cascade. because of the timing and action of most proposed tmmunotherapy, they may be capable of preventing mortality primarily in these initial two phases. in this study, an independent predicted risk of mortality reflected this mortality pattern ned illustrated the potential benefit of immtmotherapy. use of a predicted risk of mortality in the design and analysis of clinical trials could improve our understanding of the clinical benefit of these new therapeutic approaches. the systemic inflammatory response syndrome (sirs) is a term recently proposed to describe patients with systemic inflammatory responses to insults such as infections (sepsis), trauma, burns, pancreatitis, and other initiating events. patients with sirs may have similar activation of inflammatory mediators and similar outcomes independent of the initiating event. these outcomes include organ dysfunction and failure, shock, and death. challenges to the successful conduct of clinical trials in sirs include the complexity of illness in these patients and the important--but limited--clinical benefits of novel compounds that may be limited to selected patient subsets. addressing these challenges will require new tools and approaches. these will include more sensitive and appropriate endpoints, and the use of methods such as baseline risk adjustment, to allow detection of drug risk interactions not captured adequately by categorical definitions, such as sepsis syndrome. on the basis of supportive preclinical and phase i safety studies, we have initiated phase ii clinical trials of a novel bradykinin antagonist, cp- , in four sirs subcategofies: sepsis, multiple trauma, burns, and pancreatitis. each of these studies is designed to measure the effect of cp- on mortality, organ dysfunction and failure, and activation of mediators. in addition to investigating rates of organ failure using standard definitions--a new endpoint--a continuous summary measure of organ dysfunction (the acute physiology score of apache tm iii) is being used to quantify the degree of organ dysfunction and the speed and pattern of recovery of physiologic stability. in the sepsis study, another new approach--a study specific risk model based on the apache ill database--has been developed which will be used to assign a pre-treatment baseline risk to each patient enrolled. the primary outcome variable will be risk adjusted survival time to days. this type of risk-adjusted analysis may allow for more efficient and powerful trials and more accurate and useful indications for use. study purpose: in post-cardiac surgical patients (pat.) at risk for sepsis, the efficacy of early i.v. immunoglobulin (ig) treatment was compared to a matching historical control (con.) population. postoperative risk assessment: using apache ii scores lap) (first postoperative [pop.] day) in a pilot study phase, we were able to differentiate between the large population ( . %) of pop. low-risk pat. (ap< ; mortality: %) and the small groups of pop. pat. at risk lap= - ) and high risk lap_ ) with a significantly higher mortality ( % and %, mainly due to sepsis). subsequently, among consecutive pop. pat. we prospectively identified and treated these pat. iq treatment reqimens: first study period (n = ): (gg (psomaglobin n a, tropon biologische pr~parate, cologne, frg, day : ml/kg, day : ml/kg). second study period (n= ): iggma (pentaglobin r, biotest, dreieich, frg, ml/kg on days to ). results: ig pat. and con. were comparable in demographic data, operation characteristics and baseline disease severity lap and elebute sepsis scores). in contrast to con. (risk: n= , high-risk: n- ), the ig pat. showed a marked improvement in disease severity (fall in ap), especially in the high-risk group (igg, n= : p<o. ; iggma, n= : p: . ). in this group, ig led to higher (p< . ) response rates, defined as an ap score decrease -> within four days (igg: %, iggma: %; con.: %), and reduction in mortality (igg: %, iggma: %; con.: %), statistically significant (p< . ) for ig treatment as a whole (igg and iggma). conclusion: given the good comparability of the study groups, our results indicate, despite the non-randomized design, that early supplemental ig treatment can improve disease severity and may improve prognosis in prospectively apache ii score-identified high-risk patients after cardiac surgery. objective. elevated plasma levels of endothelin (et) have been demonstrated in both experimental and human sepsis. et has been proposed as a sepsis mediator leading to vasoconstriction with tissue hypoperfusion and organ failure. the aim of the study was to determine the effects of sepsis treatment with volume resuscitation, antibiotics and the anti-lps monoclonal antibody es® on big et and active, aminoacids et (et ) in rat abdominal sepsis. methods. lethal peritonitis was induced with a mm coecal perforation (cp) in male wistar rats. plasma levels of big et and et were determined with amersham tm endothelin rias , and h after sepsis induction. experimental groups: . cp control, . volume replacement (vr); , % saline ml/kg/h continous iv infusion started after h, . antibiotic; imipenem mg/kg iv after h, . e ®; mg/kg iv after h, . vr + imipenem + es® after h. results. high concentrations of both big et and et could be demonstrated after h and lasting for h after cp. neither volume replacement nor imipenem did influence the elevated plasma et. e ® significantly reduced et both , and h after sepsis induction, but did not reduce big et. when es® was combined with vr and imipenem, reduction of et was the same as for e ® alone. these results strongly suggest that bacteria and hypovolemia per se are not decisive stimuli for et production during sepsis. e ® reduces circulating lps and tnf which is the probable mechanism of the suppressed et synthesis. the unaltered big et fraction after e ® treatment indicates conversion of big et to et as the site of action responsible for reduced et . conclusion. lethal peritonitis in the rat is followed by elevated plasma levels of big et and et . e ® anti-lps antibody significantly reduces plasma et while volume resuscitation and antibiotics failed to do the same. es® did not reduce plasma big et. pmx treatment on severe endotoxemia with multiple organ failure was safety and effect in prognosis, and sepsis related parameters. it was certified that reduction of plasma endotoxin was effective in severe endotoxemia. a. lechleuthner,s. aymaz, g. grass, c. stosch, s. dimmeler, m. nagelschmidt, e. neugebauer. ii. dept. surgery, university of cologne, germany. introduction: the cardiovascular therapy of hypodynarnic shock states is a challenging problem. in clinical as well as experimental studies beneficial functions of a new hg-agonist bu-e- in congestive heart failure has been demonstrated aumann, ). therefore, we investigated the effect of bu-e- in hypodynamic shock in pigs. materials and methods: pigs (deutsches hausschwein, pitrain, [ ] [ ] [ ] [ ] [ ] [ ] were anesthesized with fentanyl/dormicum, ventilated (n :o = : ) and cardiovascular parameters were monitored with a complete icu-eqnipment. the hypodynamic model was established in a pilot study ( animals) to evaluate the effective concentration of bue- in healthy and endotoxin (lps)-treated animals. endotoxic shock was induced by continous infusion of ~g lps/kgkg/h ( :b , fa. difco). the hypodynamic state was defined as a decrease of cardiac output by % of steady state levels. a wedge pressure of - mmhg was kept constant by volume resucitation during the experiment. in a subsequent randomized controlled trial (rtc) groups with animals per group were studied. the groups were treated as follows: group i, lps and , % nac ; group ii, lps and bu-e- ( #g/kgkg/h); group iii, famotidine (h -blocker) pretreatment ( mg/kgkg), lps and bu-e- . results: the pilot study in healthy pigs revealed, that bu-e- had positive inotropic effects. these effects were inhibited by the h antagonist famotidin. bu-e- however had no beneficial effects in the hypodynamic phase of endotoxic shock in the rct. cardiac index (ci) and the oxygen delivery (do ) were not significantly influenced by bu-e- application (group i versus group ii). bu-e- did not ameliorate the negative inotropic effect measuring left ventricular stroke work (lvsw) in hypodynamic shock phases. on the contrary, bu-e- led to a further significant decrease of lvsw (p < , ). famotidin pretreatment did not affect the response (group iii versus group ii). conclusion: in hypodynamic shock states the h -agonism seemed to have no beneficial effect under these experimental conditions. receptor down regulation or changes of signal transduction under septic conditions may be responsible. cellular studies may help to identify these mechanisms. objectives. antithrombin iii inactivation of proccagulant proteases is so far the only inhibitory therapeutic approach to disseminated intravascutar coagulation (dic). we therefore set out to investigate whether cll substitution reduces coagulation activation in an endotoxin induced rabbit dic model. materials and methods. male rabbits chbb:hm(spf) were randomty assigned to one of the following groups. group k : naci . % (control without endotoxin, n= ). group e : endotoxin tjg kg " bolus i.v. + naci . % (control with endotoxin, n= ). group c : endotoxin pg kg - bolus i.v. + cll u kg - bolus + u kg " h "~ i,v. (treatment group, n= ). all animals were anesthetized and mechanically ventilated. blood samples were drawn prior to endotoxin administration (m ) and after (m ) and rain. (m ). thereafter, lung and liver tissue samples were taken intravitatly in a standardized fashion for h&e microscopic fibrin quantification using a triple score (fibs). from all blood samples the prothrombin time (pt), activated partial thromboplastin time (aptt), fibrin monomers (fm), and d-dimers (dd) were measured. for statistical significance of differences between the groups anovas and the wilcoxon test (fibs) were performed. results. fibs for lung/liver were significantly different (p< . ) between group e (lung , liver ) and c (lung , liver ) (group k : lung , liver ). , a synthetic serine proteinase inhibitor, has an anticoagulant activity in the absence of" antithrobim iii. gabexate has been reported to be useful in the treatment of disseminated intravascular coaguiation due to neoplastic diseases. in this study, we investigated gabexate therapy for the treatment of dic due to sepsis in the postoperative critical patients. materials and methods: from july to june , patients in the surgical intensive care unit met the criteria of dic or pre-dic. eleven were male and four were female with the mean age of . years. all these patients suffered from some complication of operations which led to the development of sepsis. foy was administered at the rate of mg/kg/hr untii the coagulation profile retumed to normal or the patient died. the coagulation parameters were monitored before and on the st, rd, th and th day. results: fourteen of these fifteen patients died despite transient improvement of the coagulation parameters in five patients. these patients suffered from sepsis resulting from surgical complications which could not be well controlled. the only survival was a case of recurrent intrahepatic duct stone with biliary tract infection complicated with sepsis and dic. after choledocholithotomy and the use of foy, the patient recovered gradually. conclusion: dic is a late manifestation of sepsis in the critical surgical patients. the most important thing is to eradicate the cause of sepsis. if the underlying septic focus cannot be controlled, dic will persist despite the use of gabexate mesilate. emergency surgery, taipei veterans general hospital, taipei, taiwan. there are main types of bradykinin (bk) receptor, namely bk~ and bk z. the bk receptor is constitutive. the bk receptor is also constitutive but in the majority of cases is inducible and involved in chronic inflammatory syndromes such as sepsis, hyperalgesia and airways hyperreactivty in animals. the mechanism(s) involved in the upregulation of the bk receptor is unclear, however a variety of agents including lps, e coil and ill are particularly efficacious in vitro and in vivo. ill and bradykinin acting at their respective receptors are believed to be involved in sirs/sepsis. we have investigated the effect of antagonists at ill (antril), bk (bradycor [cp- ]),bk~ (cp- ) and bkz/bk (cp- ) receptors on the de novo generation of bk~ receptors (reflected by hypotensive responses to a bk agonist) in the lps-treated ( ug iv) rabbit. in lps treated rabbits hypotensive responses to bk~ but not bk agonists increased with time and at time min appeared maximally induced. constant iv infusions of cp- blocked bk but not bk~ and cp- bk~ but not bk responses. cp- ,cp- +cp- and antril+cp- blocked both bk and bk~ responses. antril alone had no effect on bk or bk~ responses. within - min after stopping the infusions of antagonists the responses to bk~ and bk z agonists were the same as those in nonantagonist infused rabbits. these results indicate, at least in the lps-treated rabbit, that neither bk ,bk ~ or ill receptors alone or in combination, are involved in the de novo generation of bk receptors. in vitro studies demonstrated that beth bradycor and cp- (but not antril) were antagonists at both bk z and bk~ receptors. if both bk z and bk receptors are significantly involved in chronic inflammatory situations in man such as sirs/sepsis then the rationale for the use of compounds such as bradycor or cp- is clear. infection is a major cause of or contributor for morbidity and mortality in liver transplant recipients. effectiveness of prophylactic and therapeutic protocols is important for the success of liver transplantation ( olt ). sdd is used as prophylaxis for reduction of infection caused by gram negative or fungal microorganisms. between september and july olt's in patients were performed at our department. the actuarial -year patient survival is %. infection prophylaxis is started with sdd and ciprofloxacin once the patient is accepted as an olt candidate. perioperatively metronidazol, tobramycin and cefotaxim, postoperatively cotrimoxazol are prescribed additionally. the table shows pneumonia, peritonitis, major wound and urinary tract infection are common nosocomial infections following severe injury. in a series of severely injured patients from the university of louisville hospital, pneumonia was the most common infection followed by peritonitis, intra-abdominal abscess formation and burn wound infection. pneumonia is actually the leading cause of death from nosocomial infection. these are defined as occurring from to hours after hospital admission. this definition has important implications for antibiotic therapy because the likely pathogens and their respective sensitivities are different for community acquired pneumonia. the diagnosis of nosocomial pneumonia is difficult following major injury as many patients will have pre-existing fever, leukocytosis, tachypnea, and chest x-ray changes. reliance on sputum gram stain and culture is important and best obtained by a bronchoalveolar lavage or protected specimen brush during bronchoscopy. predisposing risk factors include severe head injury, emergent intubation and shock, and such patients have been shown to benefit by early tracheostomy. staph aureus has been the most common pathogen isolated from the sputum and the remainder gram-negative organisms with pseudomonas aeruginosa, and klebsiella pneumonia predominating. bacteria recovered by site as well as by intensive care unit is published in the six month antibiogram which also includes recent antibiotic sensitivities. this aids in empiric antibiotic selection against such nosocomial organisms. in a series of severely injured patients (iss - ), mean temp. was . f, leukocytosis was k, pan was , fin was . , and peep was . at the time of diagnosis (ards excluded). there was marked reduction in class ii histocompatibility antigen (hla-dr) density on peripheral and bal monocyte/macrophages which recovered over time with resolution of pneumonia. immune suppression occurred prior to development of pneumonia, was especially localized to the infected tissue, but recovered with clinical improvement. specific immune modulation targeted to pulmonary white cells may hasten clinical recovery and minimize pulmonary dysfunction. -clinical experience j. tnllemar amphntericin b remains the drug of choice for many systemic fungal infections. its advantages include a broad spectrum of activity and intravenous administration. the major disadvantages of amphoterlcin b is its severe side-effects, especially the nephrotoxicity. to decrease the toxic side..cffccts various liposomal amphoteficin b formulations have been produced. it was found that these liposemal formulations were as effective as amphotericin b but in contrast had a low incidence of toxicity. at present there are three ~different variations of lipid formulations under assessment: amphotericin b lipid complex (ablc), amphotericin b coloidal dispersion (abcd) or true liposomes. the ablc has a ribbon like structure. it has been shown to have a reduced toxicity and an efficacy ranging from being as effective to four times less effective that conventional amphotericin b. regarding abcd the particles have a disk-like structure with a diameter of around t am and a thickness of nm. the ami-fungal efficacy is - times less than that of conventional amphotedcin b. both ablc and abcd are presently investigated in phase ii/iii studies in the us. ambiseme is currently the only commefieally available true lipesome. ambiseme is a spherical small unilamellar lipesome with a diameter less than nm with a mutina ld of > mg/kg. it has been used in dosages up to mg/kg/day in compassionate based studies with good tolerability. the mycological efficacy range from a % response rate for invasive candida infections to % response rate for aspergillosis. ambisomc have been evaluated as anti-fungal prophylaxis in randomized trials in bone marrow (bmt) and liver transplant (ltx) recipients. it was well tolerated. in bmt recipients the incidence of proven fungal infections was % among placebo treated patients compared to % for the ambisome treated patients (ns). in ltx recipients ambisome prophylaxis was effective, significantly reducing the incidence of deep fungal infections from % to % ill placebo and ambisome treated patients respectively (p< . ). prospective randomized trials comparing these various amphotericin b preparations with conventional amphotericin b is needed to determine their future place in the therapeutical arsenal. two patlentgroups ere particularly at risk to develop serious cmv disease: cmv seronegative transplant recipients of seroposltlva donors and those patlants treated for rejection with anti t-ceil preparations, we have evaluated the value of prophylactic anti-cmv immunoglobulin (cytotect", biotest pbarma gmbh, dreieich, frg) administration in high risk heart and kidney transplant recipients, in a double blind placebo controlled study kidney transplant recipients, treated for biopsy proved re)action with rabbit atg, received globullntplacebo infusions. the preparatlons were given i,v, in a dose of mg/kg at day , , , , and after the initiation of anti = rejection therapy, passive immunization completely prevented cmv related death, although it did not reduce th~ incidence of cmv isolation, viraemia or disease, this effect was mainly observed in cmv saronegativa recipients of a serop sitive donorktdney. seroposltive recipients did not benefit from treatment and seronegatlve recipients of a seronegetlye donor were not et risk for cmv infection at e!l. in a open study the incidence of cmv infection and disease was evaluated in consecutive i~eart sllograft recipients. sixty-five patients were cmv seronagatlve and they all received passive immunlzation according to the dosage schedule used in the kidney patients, but starting on the day of transplantation, this scheme resulted in median snti-cmv igg titers of elisa units during months. cmv infection occurred in / ~eronegetlve and in / seropositive recipients (n,s,), in ssronegetive donor-recipients pairs the incidence was significantly lower ( / ] , the passively immunized seronegstive recipients of e seroposltlve donorheart showed comparable incidence of cmv infection f t ) vs the seropositive recipients. primary infection more often resulted in disease than secondary infection ( v / ), but no difference in incidence of disease ( vs / ) or severity in symptoms was noted between the immunoglobulln treated serone(]ative patients and the seropositiva recipients. apparently passive immunization induces anti-cmv immunity which crossly resembles naturally acquired resistance. abdulkadirov k.,chebotkevich v., moiseev s. the incidence of infection is still high in patients underwent bmt. this complication is the major cause of mortality if it is not recognized and treated promptly and properly. our data showed that from patients with different types of leucemia after autologous and allogenzc bmt had the episodes of fever. in the ma i ority of these episodes the bacterial etiolog$ gram negative bacflli and gram positive cocci) can be proved. on the other hand, in % of the fever cases we detected also viral respiratory (corona-, adeno-, rs-and other) infection. our previous investigations showed that even in healthy persons the viral infection has influence on antibacterial immunity, in the cases of model experimental reaction in volunteers we found the decrease of delayed hypersensitivity - days after intranasal inoculation of influenza virus a (h n - ) to bacterial (staphylococcal, streptococcal and pneumococcal) and ~iycoplasma pneumoniae antigens in the leucocyte migration inhibition test. these results showed that respiratory viruses may be the important pathogenic factor in the development of bacterial infection in posttransplanted period. we consider the constant control of latent and visual respiratory viral infection in bmt patients to be very important. ficcb the ~ter£~li of the nation~l institute of trad/~atoloqy in budapest . consecutive cases of revision hip grafting were carried out arthroplasties wlth hemoloquous bone between the years and . in the same period of time pri~ total hlp replacen~nts were performed under i entieal technical conditions. the average septic rate for the 'total hip althroplasties was less than %. in the selected i cases the septic rate was % indicating the role of bone grafting° homografts were prepared by deep freezing~ it .is recognized that the cells of the hl~grafts become destroyed by the ium~unological, response of the host~ and the patients develop ~ti-hl~, ar~tib'o~ies. the dead ~trix, however, has a bone-inducing capacity that stimulates host osteoblasts to recolonize the *i~/trix which serves as scaffolding. the sequence of events favours the infections. for this reason, beside preventive perioperative systemic ant/biotic treatment, local ~ntibioties were also applied in the form of antibiotic-//npregnated cement. the role of age and the .immune status of the patients .is discussed.. the purpose of this study is to evaluate the rate of toxemia in patients with acute panereatitis and to find this coudition to the activation of cascade systems that are encountered in the subsequent complications of the disease. we studied a series of patients with acute pancreatitis, the severeness of which was evaluated by the ranson's criteria and the apach-ii scoring system. all of them were considered to have severe acute puncreatitis. the determination of toxemia was made using the limulus test (lal test). we also determined the levels of the third (c ) and fourth (c ) complement components as weu as the coagulation factors, iibrinolysis faeters and kimns by serial measurements. the severity of the disease was serially determined by the apach-ii scoring system. it was found that complement activation ( which was also assessed using a graphically illustrated method by a aggregometer ) was followed by an increase of morbitity and mortality .we also detected that toxemia (positive lal-test) was closely correlated with complement activation and more of the ranson's criteria. a clear relation existed between the number of ranson's signs and the enmplieations' rate ( "= - . , p < . ). the documentation of toxemia and the complement activation cannot predict the kind and the severity of complications. the study of coagulation, fibrinolysis and kinms systems didn't reveal any results with statistical significance. necrotizing pancreatitis still represents a life-threatenthg disease. infectious complications dominate among the causes of death. differences in the individual immune response could possibly explain different clinical courses even in patients with comparable pancreatic morphology. to explore the inflammatory response in acute pancreatitis, the following investigation was performed. methods: peripheral-venous blood was withdrawn on admission and furthermore twice weekly in as yet patients with acute pancreatitis and tested for the parameters mentioned below. in parallel, polymorphounciear granaiocytes were isolated using density gradient centrifugation and assessed for superoxide anion and hydroxyl radical producing capacity using electron spin resonance techniques. results: total leukocyte cotmt and total lymphocyte count did neither reflect the clinical course nor predict complications. this comes tree also for serum igg, igm, iga, c , c , crp, alpha-l-antitrypsin and neopterth as well as for plasma il-la, il-ib, il- ra, il- , il- r, il- r, tnf-ct, tnf-~r (p ) and icam- . in contrast, pmn-elastase, il- and il- closely correlated to the clinical course. isolated pmn's in vitro capacity to produce oxygen radicals depended on the respective radical species and was slightly elevated (superoxide anions) or decreased (hydroxyl radicals), respectively. patients with a cd +/cd + ratio below i were seen at risk of developing septic complications. in contrast, a percentage of monocytes of % or more among total mononuclear cells indicated an uncomplicated course, in general. conclusions: the immune status of the individual patient may significantly influence the course of acute pancreatitis. the cytokine pattern in peripheral blood is very complex and most parameters are of little use for the clinician. the pmn-elastase, il- and il- , however, closely correlate to the clinical course and may prove valuable for follow-up. the cd +/cd + ratio was found the best predictor of septic complications, but it failed in non-septic patients. a percentage of % or more of monocytes among total mononuclear ceils indicated a rather mild course. the reduced ability of the pmns to produce hydroxyl radicals may help to explain the frequent development of septic complications in severe necmtizing pancreatitis. peroxidation of membrane lipids contributes to ceil injury in pancreatitis. overwhelming release of toxic metabolites by infiltrating neutrophils is regarded a major pathogenetic factor, too. as yet little is known about the mechanisms by which oxidative stress and leukocytes damage pancreatic cells. the present study examines (i) the susceptibility of pancreatic acinar cells to attacks by oxidants and leukocytes and ( ) the potential of antioxidants to prevent such damage in order to better understand the cellular mechanisms of pancreatic injury in inflammatory states. methods: freshly isolated rat pancreatic acinar ceils were exposed to a model system of oxidative stress consisting of mu/ml xanthine oxidase (xod), mm hypoxanthine (hx), mm fec and mm edta. in a second set of experiments, acinar cells were exposed to excess autologous neutrophils or neutrophils obtained from patients with acute pancreatitis. neutrophils were stimulated by zymosan a, pma, and il- . cell viability was assessed by both cellular uptake of trypan blue (tb) and by release of ldh. results: the xod/hx system caused a time-dependent acinar cell injury. this injury was effectively prevented by catalase (cat) and gfutathione peroxidase (gpx). in comrast, superoxide dismutase (sod) enhanced cell injury. addition of both sod and cat abolished the damage seen with sod alone. the non-enzymatic scavengers mannitol, dmso, dmtu and the iron chelator deferoxamine were not protective and at a higher concentration even accelerated cell decline. the newly developed antioxidants of the lazaroid type effectively prevented oxidative acinar cell damage. stimulated neutrophils, both autologous and heterologous, did not damage healthy acinar cells but had even protective effects. conclusion: pancreatic acinar ceils are very susceptible to oxidative injury. a combination of catalase and sod prevented cell damage effectively. sod when given alone may rather damage than protect aelnar cells when h is generated in concentrations overwhelming the capacity of endogenous catalase. therapeutic approaches to pancreatic disease using antioxidants should, therefore, include combinations of protective substances. the lazaroids seem to be candidates for clinical use as antioxidants in pancreatitis. the results argue against direct toxic effects of stimulated neutrophils to pancreatic acinar cells. are ch~act~z~ by the presence of a polymicrobial flora, the pmtotyi~ cffthese inf~ons is secend~,y bacterial pedtonitlw, whereby a pathololoeal process in the ~trointesfimd tract r~ful~ in tim disrup~on ofi~ inteffrlty and ¢ollseqtlent sptl]nge of inte~.i,o~.l gontents into the peritoneal c~iry. the ensuing infection invariably contains a mixtm~ of gt~m negative enteric bacilli, gram positive b~eria and anaerobe& experimental and clinical =t~ies have de~ed the eantrlbution of each of th¢~ components to ti~ ovemu virulence of these in~ons, gram negative enteri~ such as f.veher~chla coil ere endowed with a virulent l~l~x~lyse~haride ptill~ly t~sponsible for lethality, by contrast, bacteroldes sl~cles, which rarely c~se death, prornot~ abscess fonllation, a uniqm~ capsul~ polyseccluu'ide, particularly on b.j~ogiljs slrai~, oontributes to tjtis erect, several mecltanims have bccn pml~ed whereby or~ microorganism mi~t interact with its microbial ~net to augment the overall virulence of a r~xed im~edan. these include: l) provision of nutrients by one apexes which stimulates the growth of its ~opathoge& ) inhibition of host deletes by one of the migroorganisms so that the other microbes might persist and exert their virulence, ) the trant~ of vim.©n~e traits between ~renr~a.,dsms and ) the ~.mizatian d the mi~oe~vironmental con~tion$ by one d the baetez'isl pa#, so that the other might persist. exampl~ for each of these m~banisms imv~ been provided by experimental ttudies i~stigating e.co!l-b.p~flls synergistic in~ra~ons. byproducts ofg.coli metabolim l~¢ovide essential short ebath fatty acids £~ optimal b,frosili~ ga'owth. fm-ther, oxygen ¢ons~tmption by kcelt lowers oxygen tension end redox potantial to levels eomlucive to b#a#lts gro~h. coawr~ely, b,~agtlis rolea~s proteases and fatty acids wl~¢h impair pl'tsgocy~¢ ~lt rmctlon tnd permit f-..¢oli proliferation and expression of its intrinsic virulent. in summaxy, interactions among the separate microbial cemponents of mixed infections heighten the overall virttienee of these lafectiot~, this knowledge provides ~r rationale for targetting of antibiotic therapy against the knowa eantributors of these synergistic pro~¢sses, intraabdominal abscess formation and the macrophage william g. cheadle, m.d., department of surgery, university of louisville school of medicine, louisville, ky inflammation of the peritoneal cavity following bacterial contamination has been classified into primary, secondary and tertiary, the last two relating to bacteria originating from the gastrointestinal lumen. the natural history of such infection is either resolution without clinical sequelae, which is uncommon, abscess formation, or generalized peritonitis, which occurs as a result of failure of peritoneal host defenses. early clearance of microorganisms by peritoneal fluid circulation and filtration througti subdiaphragmatic lymphatics into the thoracic duct and systemic circulation occurs as well. simultaneously peritoneal macrophages and the omentum approach the area of inflammation and lead to neutrophil influx and abscess formation adjacent to the affected viscus. we have found a shift in peritoneal macrophage function from antigen presentation to proinflarnmatory cytokine production that occurs early after experimental peritonitis produced by cecal ligation and puncture. this is also reflected by reduced class ii histocompatibility antigen expression on peripheral blood mononuclear cells and peritoneal macrophages. this is accempauied by an influx of both neutrophils and macrophages into the peritoneum and subsequent abscess formation. interestingly, there is little serum endotoxin or tnf seen in this model despite tnf mrna expression in peritoneal macrophages. we believe this model is more clinically relevant than other models of endotoxemia or bacteremia in which different patterns of cytokine expression are seen. newer agents aimed at reduction of systemic manifestations of sepsis originating from intra-abdominal infection such as monoclonal antibodies against cytokines or il- receptor antagonists may need to be directed against remote organ macrophage populations while preserving peritoneal macrophage function. inflammation is a complex process involving microcirculatory changes, extravasation of fluid and a cellular influx in the affected body area. in our communication, we will only consider the regulation of the cellular infiltrate which plays a major role in the defense of the peritoneum against microbial invasion. until recently, it was thought that the influx of leukocytes in the abdomen was induced by bacterial products, local humeral factors and secretions of resident macrophages. there is now increasing evidence that this view is too simplistic. many other cell types present in the abdominal cavity or composing the peritoneal membrane (mast-cells, mesothelial cells, fibroblasts) are able to release or secrete vasoactive or chemotactic substances such as histamine, prostagtandines, or cytokines. they are most likely to play a role in the regulation of intraperitoneal inflammatory reactions. the emigration of leukocytes towards the abdominal cavity is also modulated by a previous contact with gram negative bacteria. in the rat, this intriguing phenomenon is long lasting, cannot be transferred by serum and seems independent from t lymphocytes. the clinical relevance of these various regulating mechanisms has still to be determined. kinnaert paul, h pital erasme, route de lennik , bruxelles belgium generalized response in secondary peritonitis the clinical course of an intraabdominal infection may depend on a variety of variables including the capacity of host defense mechanisms and the degree of the inflammatory response. if local defense mechanisms fail to restrict the inflammation to the abdominal cavity a generalized inflammatory reponse will result. in a first stage generalized signs of a local inflammation become detectable whereas the second stage comprises the overwhelming systemic inflammatory response. the extent of this systemic response determines the outcome. sometimes it may appear to be unrelated to the severity of the intraperitoneal findings. the activation of plasma systems and cellular elements leads to a fast release of cytokines, inflammatory mediators and other substances. these parameters precisely reflect the degree of the generalized response. inflammation of the peritoneum causes significant morbidity. objektives: to test the hypothesis that peritoneal mesothelial cells play a role in regulating inflammatory responses within the peritoneal cavity, we examined neutrophil-chemotactic activity (interleukin ) and monocyte-chemotactic cytokine (mcp) release by sytokine-etimulated mesothelial cells. confluent human peritoneal mesothelial cells were exposed to varying concentrations of phorbolmyristate-acetate (pma) and the cytokines tumorneerosis factor a (tnf a) and interleukin i~ (il-i~). the supernatant was examined for il- by elisa and for mcp by investigating the ehemotactic activity for isolated human monocytes. mesothelial cells express low levels of il and monocyte chemotactic activity when cultured. these activies were significantly increased ( -fold) after stimulation with either tnf a or il-i~. additionally macrophage inflammatory protein was detected. these observations provide a probably important mechanism whereby peritoneal mesothelial cells respond to imflammatory stimuli released during peritonitis and how leucocyte recruitment by liberation of chemotactic cytokines is regulated. the perioperative course of lps, tnfa and il- in patients with bacteriologic proven abdominal infection (intraabdominal abscess , diffuse peritonitis , pancreatic necrosis , pancreatic abscess ) was followed prospectively and evaluated for possible correlation with septic state and organ function. methods: patients were studied in a to hours period during their first surgical intervention because of intraabdominal infection. all were monitored for their cardiovascular, respiratory, hepatic and renal function. plasma samples for lps. tnfa and il- determination were drawn preoperatively, intraoperatively, and until h postoperatively in regular intervals (min /pat), results: preoperative apache ii was in median (rain , max ). patients fulfilled the criteria of sirs. of them were in septic shock.there was a significant correlation between preoperative tnfa and apache ii (p= , i, spearman coefficient). preoperative cardiovascular (systol. rr< mmhg) and respiratory (pao < mm hg) dysfunction were associated with significantly elevated tnfa (cardial: p= , i, wilcoxon; pulmonal: p= , ) and il- (cardial: p= , ; pulmonal: p= . ) overall, lps, tnfa and il- values varied considerably during the observation period. however, tnfa was markedly higher in patients with sirs and septic shock (group a: n= i , mean pg/ml) than in those who did not fulfill these criteria (group b; n= , mean pg/ml; p= , i, wilcoxon). il- was significantly higher in group a (mean pg/ml) than in group b (mean pg/ml; p= , o i wilcoxon). conclusion: perioperative tnfa and il- were shown to correlate significantly with preoperative organ function, apache ii and the severity of sepsis. these results could help to define patients that might benefit from further therapeutic strategies, e.g. antibody administration. department of surgery, university vienna, akh wien, wahringer gurtel - , wien. aim of the study: the purpose of this pilot study was to establish and to prove a standardized reproducible animal model of intraperitoneal sepsis induced by e.coli-endotoxinaemia in lew.lw-rats in order to investigate early immunoserological responses to find a mediator based evaluating system of peritonitis sepsis. materials and methods: in lew. lw-rats, diffuse peritonitis was induced by intraperitoneal injection of a mixture of e.coli (khu +) and autogenous haemoglobin solution. in the control animal group (n= ) an intraperitoneally injection of physiological saline solution was done. blood samples were obtained by heart puncture after hours. stastistieal calculations were performed on a personal computer with the spss programm vers. . (correlation with pearson's r, mann-whitney-u-test, descriptives statistics, discriminant analysis). results: in contrast to the sham treated rats, the peritonitis animals showed significant differences in the concentrations of endotoxin, interferon-gamma (wn-y), the pteridin derivate biopterin and serum pla -activities [endotoxin range from . eu/i, sd= . to . eu/ , sd- . (p < ), ifn-¥ levels, range from . pg/ml, sd- . , to pg/ml, sd= (p < . ), circulating pla -activities range from . , sd= . to . u/ , sd= . (p < . ) and biopterin range from . nmol/l sd= . to . nmol/l, sd= . (p < . )]. for the peritonitis group we found strong correlations between the degree of endotoxinaemia to elevated levels of ifn-'~ (rp = . , p < . ) and bioptefin synthesis (rv= . , p < . ). the increase of ifn-t levels was correlated to the regulatory synthesis of biopterin (r = p < . .. p • , . . ) and to the pla -actwtues (rp = . , p < . ). the biopterin synthes~s correlates slightly with the pla -actn,ities (rp= : . ; p < . ). using the para, meters of endotoxin, ifn-y levels, biopterin and the pla~ -activities only, the statistical procedure of the linear discriminant analysis makes it possible, to distinguish between non-septic animals and septic animals correctly at a rate of %. anaerobes were found in . %, anaerobes were isolated in . %. there were aerobic and anaerobic associations in . % and microflora was not found in . % of the cases. express method of anaerobes discovering let to receive information on - days early than in generally accepted nethods. intraaotal transfusion of oxygenate blood and laser irradiation of blood reduces the duration of anaerobic sow, disminishes intoxication and accelerate the patients recovery. patients with abdominal sepsis are subject to long periods of hospitalization and high associated morbidity and mortality rates. this category of patients is thus consuming extensive facilities and costs. as the age-related outcome of abdominal sepsis is not fully known, the aim of the present study was to investigate abdominal sepsis in the elderly. out of patients with abdominal sepsis treated at the surgical intensive care unit during a -year period, ( %) had an age of years or more. were women and were men, a sex distribution not differing with patients younger than years. the patients were scored according to apache ii and septic severity score (sss) upon arrival to the intensive care unit. bacterial cultures, the occurrence of organ failure, hospitalization and outcome was noted. in median two operations were performed for both "younger and elderly" patients. the median time of hospitalization in the elderly was (- ) days including in median days in the icu. figures in patients less than years of age were comparable ( (- ) days out of which in median days in the icu). apache ii and sss-scores did not significantly differ ( . vs and . vs . , respectively), between the groups. neither did the incidence of organ failure differ ( / vs / ). however, the incidence of multiple organ failure was significantly lower in elderly patients ( / vs / (p < . )). the mortality rate, however, did not differ between the groups ( / vs / ). in conclusion, severe abdominal sepsis in the elderly was not associated with an increase in mortality, incidence of organ failure or hospital stay. with the help of light transmissional scanning electron microscopy morphology of erythrosytes of peripheric blood was studied in patients with different stages of diffuse peritonitis before and after intravascu!ar irradiation of blood with heliun-neon laser. peritoneal morphology was investigated in patients who died from peritonitis, it was established that in all phases of peritonitis occured stomatocytoric and echinocytoric transformation of erythrocytes which progressed simultaneously with increase of intoxication. it combined with strongly pronounced vessels variability of microcirculatory peritoneal bed which displaied by erythrocytes aggregation, stasis and microtrombogenesis. in intravascular laser irradiation of blood number of erythrocytes which underwent to stomatocytoric and echinooytorie transformation was lower than in patients without laser irradiation. it indicated that the intravascular irradiation of blood with helium-neon laser can prevent development of severe alterations of rheological property of blood and consequently variability of microcirlatory peritoneal bed in patients with diffuse peritonitis. abdominal sepsis is still associated with high morbidity and mortality rates, frequenfly caused by multiple organ failure. it has been reported that changes in capillary permeability play a role in the pathogenesis of multiple organ failure. the present study aimed at evaluating the influence of intraabdominal sepsis induced by cekal ligation and puncture on capillary permeability in multiple organs and tissues. adult male sprague-dawley rats were subjected to laparotomy with separation of the cekum (sham operation) or induction of intraabdominal sepsis by cekal ligation and puneatre (n-- in each group). at , , , , and hours (n= /timepoint), the animals were evaluated concerning mortality and capillary permeability as determined by the passage of : i-labelled albumin from capillaries to the peritoneum, the proximal and distal small intestine, cekum, colon, spleen, kidneys, lungs. the mortality rate in rats with intraabdominal sepsis was % both at and hours. capillary permeability in the peritoneum, cekum, colon and kidneys significantly increased from hours and on in rats with intraabdominal sepsis. in septic animals, capillary permeability in the lungs and spleen increased from hours and on and in the proximal and distal small intestine from hours and on. different types of alterations in capillary permeability seem to appear: ) a temporary short increase e.g. in the proximal small intestine and spleen; ) a temporary longer increase e.g. in the colon and kidneys; ) a persisting increase e.g. in the peritoneum, cekum, distal small intestine and lungs. we conclude that experimentally induced intraabdominal sepsis induces early alterations in capillary permeability in multiple organs and tissues. such changes may contribute to explain the development of sepsis-induced multiple organ failure. despite a number of significant advances in the care of burn and non-burn traumatic injury, infection and sepsis remain major causes of morbidity and mortality. the severe immunosuppresslon often seen in patients with severe trauma or large burns may predispose these patients to life threatening infections. included among the many immune alterations are changes in the functional capabilities of neutrophlls (pmns). we have examined the expression of the p integrins (cd l a, b,c/cd ), and the fc'?r (cd , cd , and cd ), as well as several functional parameters, on pmns from thermal and non-thermal traumatic injury, pmns were obtained from patients sustaining severe trauma (initial apache ii score > ) or thermal injury (> ~ total body surface area, % full thickness), and healthy controls. the expression of cd b and c and to a lesser degree cdi a was significantly reduced on pmns. the expression of cd and cd but not cd was also significantly reduced. pmns displaying this reduction in receptor expression have a significantly reduced ability to phagocytose bacteria and undergo the oxidative metabolic burst response. thermal and traumatic injury result in global reduction in the expression of integrins and for which may lead to decreased functional capabilities, these abnormalities may in turn account at least in part for the increased rate of infection in these patlems, institute, dept. of surgery, ~ ethesda ave, cincinnalt, oh, usa, - s b, antibiotic-phagocytic cell interactions: their effect on endotoxin release. c g c-emmet , dep[baeteriolog.z, univer_sitv of glasgow, scotlan~_d increasingly it is recognised that pathogenic bacteria are capable of surviving intracellularly within phagocytic cells in addition to their capacity to produce disease whilst in the extracellular milieu. as well as providing protection from certain antibiotics which fail to penetrate the phagocyte, such intraceltular bacteria may be transported from the initial site of infection to a distant more vulnerable body site wherein they may proliferate. it is also known that some antibiotics are capable of becoming concentrated within phagocytic cells mid displaying bioactivity therein. such bioactivity might be responsible for the release of endotoxia #orn gram-negative bacteria which when liberated from the celt could ~gger the cytokine cascade. anfib,.'otic-induced damage to the ultrastructure of bacteria can also occur when the target bacteria are exposed to low (sub-mic) concentrations of certain drugs. such bacteria may present quite altered surface components m host-defense cells as well as releasing biologically active ceil wall components such as endotoxin. the nature of these interactions at the cellular level as well as the consequences for the host will be discussed. new jersey medical school: umd, newark, nj a technique of physiologic state classification has been developed based on the m~itlvariable analysis of patient derived data sets of seventeen physiologic variables. these multivariable data sets obtained from critically ill patients requiring intensive care, were aormallsed by the mean and the standard deviation of recoverin~ trauma patients who were not critically ill, the resulting normalized seventeen variable sets were then clustered. seven independent data groupings were developed. the normal stress response hyperdynamic state seen post-trauma and in compensated sepsis (a stets)/ metabolic insufficiency seen in septic decompsnsation (b stste}; early (c,) and late (e ) respiratory insufficiency associated with ards; cardlogenlc dscompensation (n state); post-trauma hyvolemla without shock (r stats). the stats closest to a new patient's values allows patient classifi atlon with regard to his previous physiologic state. classifying observations f~om patients who lived or died who fell into these physiologic states enables a probability of death (p death) to be obtalned. utilizing this criteria for the staging of severity in recent trauma patients the physiologic states accurately and significantly predicted the likelihood that the patient had an increased circulating level of the eytoklnes tnf and il- . the probability of death (p death) as well as the cytoklne levels appear to be a function of the physiologic b state with the highest levels being seen in the b state of metabolic insufficiency and the c~ state of oombined respiratory and metabolic insqffioienoy characteristic of septlc ards. the increase in the magnltude of metabolic abnormalities associated with the transition from non-sepsls to septic a, septic b, or septic c z states was associated with an increasing probability of death (p denth)(mean a state =. , mean b state = . , mean ~ state = . ). the accuraay of this estimate was prospectively analyzed in this group of m~itlple patients of whom % had sepsis and % had ssptlo ards. the survivors had a mean p death of . and the deaths had a mean p death of . . the severity of post-trauma sepsis can be quantified by probability analysis and stra~ifie~ by physiologic state. serologic tests have not been extensively tes'~ed in surgical patients but seem to be of limited value. we use nystatin as the main form of chemoprophyhxis. patients "~'ith signs of infection who do not rapidly improve with antibacterial therapy are candidates for anti-funsal therapy, amphoteradn b remains the first llne of therapy although combination therapy '~'ith flueonazole is use;l with increasing freque~;c)', the recovery of c~dida from an antra-abdominal site represents a challenging problem, anti~ngal therapy in such patients depends on the underlying disease, the nature of the infected material and overall patient risk. role of neural stimuli and pain principles and practice of anesthesiology effect of combined prednisolone, epidural analgesia and indomethacin on the systemic response after colonic surgery arginine: biochemistry, physiology and therapeutic irnplications immunosfimulatory effects of arginine in normal and injured rats arginine stimulates lymphocyte immune response in heahhy humans rote of arginine in trauma, sepsis and immunity arginine enhances wound healing in humans if labrecque t, gv campion t, and the rhll-lra phase i//sepsis syndrome study group the cleveland clinic foundation a murine-anti-human tnf-monoclonal antibody known as cb was the first anti-tnf mab which was studied in a phase ii multinational trial in the treatment of patients with severe sepsis.this was an open-label, dose-escalation trial consisting of patients who were enrolled into one of four treatment groups: ( ) . mg/kg of anti-tnf mab, ( ) . mg/kg, ( ) mg/kg or ( ) . mg/kg at study entry and the second dose hours later. the small sample size in each group (n= ) precludes detailed statistical inference in this study. nonetheless, a considerable amount of useful information was obtained from this investigation. irst, this study demonstrated the clinical feasibility of specific anticytoldne therapy in septic patients. second, the measurement systemic levels of tnf proved to be an elusive target; interleukin- may prove to be a more useful indicator of cytokine activation. third, immunologic reactions including tnf: anti-tnf mab immune complexes and human anti-routine antibodies were frequently found in these patients. despite their apparent lack of overt toxicity in this study, these immunologic reactions may complicate this form of anticytokine therapy. additionally, the potential benefits of anti-tnf mab therapy occur within the first hours of therapeutic administration in these septic patients. infecting organisms differ in their potential to induce tnf in vitro and these differences correlate with circulating tnf levels observed in septic patients. rapid methods to define those patients most likely to respond to anticytokine therapy are needed to determine the ultimate therapeutic potential of these agents in clinical medicine. wherry, j., abraham e., wunderink r., silverman h., perl t., nasraway s., levy h., bone r., wenzel r., balk r., allred r., pennington j. and the tnfa mab sepsis study group.tnfa mab (bay x ) is a murine monoclonal antibody raised against human tumor necrosis factor. tnf~ mab has been shown to reduce morbidity and mortality in animal models of septic shock and has been safely administered to septic and non septic patients.to evaluate the efficacy and safety of tnf~ mab in patients with sepsis syndrome, a prospective, multicentered, double-blind, placebo-controlled trial was conducted in hospitals in north america. patients were prospectively stratified into shock or nonshock groups and then randomized to receive a single intravenous infusion either of mg/kg tnf~ mab, . mg/kg tnf~ mab or placebo ( . % human albumin).patients received standard aggressive medical/surgical care during the day post dosing period.the three treatment arms were well balanced with respect to demographics, apache ii score and other parameters. for all infused sepsis syndrome patients, those who received tnf~ mab had slightly reduced day all cause mortality compared to placebo. among shock patients there was a more pronounced trend towards efficacy at day post dosing with lower mortality rates in both active treatment arms. among nonshock patients tn~ mab did not appear beneficial. the initial clinical experience with a chimeric anti-tnf monoclonal antibody, ca , was undertaken in septic patients. the objectives of the study were to determine the safety, pharmacokinetics and effects on cytokine levels of ca . as a single infusion or in combination with ha- a in septic patients. the study was conducted with the intent to progress to an efficacy trial based on the information collected.the trial was conducted in three stages. stage was an open label trial in which groups of patients each with the clinical diagnosis of sepsis received ascending doses of ca ( . , , , mg/kg). stage was a randomized, double blind study in which patients received a single dose of ha- a ( mg) and placebo or one of doses of ca ( , , mg/kg). stage was a randomized, double blind study in which patients received a single dose of placebo or one of doses of ca ( . , , mg/kg). in addition to usual laboratory tests, the following assays were performed: chimeric anti-tnf concentration, anti-chimeric antibody, endotoxin, tnf, il- , and il- levels.a total of patients were enrolled from clinical sites ( in stage , in stage and in stage ). primary analyses were performed on patients in stage and . there were patients who received ca exclusively and patients received placebo. administration of ca was well tolerated at doses up to mg/kg. no patient discontinued treatment due to adverse events. human anti-chimeric antibody responses were positive in % ( / ) of evaluated patients. mean cma × and auc increased proportionally with increasing doses of ca . the mean half-life was - hrs ( - hrs). a dose related decrease in tnf concentration was observed hr post infusion of ca . tnf is considered to be one of the central endogenous mediators for the inili'ation of the pathophysiological changes in patients with sepsis and septic shock. high tnf levels were demonstrated to correlate with patient outcome. blocking or neutralising tnf with specific antibodies was effective in preventing death in some animal modets of sepsis. in a placebo controlled prospective randomized study we tested the mur~ne derived antibody mak f. it is a f(ab') fragment. the fragment rather the complete antibody was selected in order to reduce the potential immunogenicity and to facilitate tissue penetration. patients with severe sepsis or septic shdck were enrolied in the study, three different doses of mak f or placebo were administered ( , ; , and i mg/kg) over a perid of hours in random order. the patients were evaluated for side effects, hemodynamics, organ dysfunction, cytokines (il , il and tnf), and outcome. at this time only an interim analysis of patients is available i indicating that mak f in all dosage groups resulted in a decrease in il . this contrasted to a further in crease of il in the placebo patients. no serious side effects have been reported so far. a more detailed analysis on all patients in the study will be presented and discussed.$ s staubach,k.h., otto, v., kooistra,a,, rosenfeid,j.a., bruch, h.p., univ. lfibeek, germany once endotoxinemia occurs in sepsis a vieieus cycle with translocation of et can be established. increasing the clearance capacity for et would therapeutically be the ulimate aim. we developed a new et on-line adsorption (ad) system in whole blood by means of polymyxin b (pb) coupled eovalently to a matrix (acrylic particles) via a atom-chain spacer. the detoxification capacity was ug[et/ml column material. the biocompatbility resulted in ~ platelet recovery. the column contained ml of admaterial and was sterilized by high steam autoclave, anticoagulation was achieved by heparine . iu/h in the inflowline after bolus injection of . iu. hp was performed on pigs at a rate of ml/min by means of a roller-pump until the animals succumbed (h). animals served as controls (c). serum et levels rose from . pg/ml to , pg/ml after hours in the c and from . pg/ml only to pg/ml in the h group after hours whieh was highly significant. survival time could be extrended from to min. results are listed in the following l. blinzler, p. zaar, m. leier, r. b( rger, d. heuser clinic of anaesthesiology , city hospital nuremberg, germany sepsis and multiple organ failure (mof) are still related with poor prognosis inspire of pharmacological and technical progress. impressed by revealing reports about blood purification the continuous veno-venous hemofiltration (cvvh) was used as supporting treatment beside the critical cam basic therapy of mof. from to consecutive patients were treated by cwh. mof was caused by hemolrhagic-traumatic noxa in °, and by septic-toxic event in %. all patients required mechanical ventilation (fio > , ) . ° showed hyperdynamic shock. % had renal and % hepatic failure. medium appache ii score amounted to , points. cvvh was performed in postdilution mode with a polyamide membrane (fh ) and high volume exchange ( l/die). anticoagulation was done with heparin. hemofiltration in mof was installed, when critical cam basic therapy including adequate respiratory and hemodynamic management, pamnteral nutrition, antibiotic treatment, etc., failed to stabilize organ functions. during consequent application of cvvh most of these patients showed improvement of their clinical course. pulmonary stabilization was seen in %, hemodynamic in % and renal in % of the cases. % of the patients survived and were discharged from hospital. of non-survivors ( %) died because of fatal mof within h after admission to icu. patients with early application of cvvh in mof showed a better survival rate.mediators of mof, i.e. products of the complement cascade measured in blood and nitrafiltrate by elisa, were partially removed by cvvh. the testing ultrafiltrate by hplc demonstrated decreasing spikes ofpolypeptides during hemofiltration. mof seems to be generated by cascade-activation of immune competent cells and plasmatic mediators (e.g. bmdykinin, eicosanoides, cytokines, anaphylatoxins, etc.). therapeutic approaches aim to inactivate or eliminate single substances. cwh with high-flux membranes in combination with high-volume exchange allows elimination of many mediators with different molecular weight and therefore may contribute to improve the prognosis of mof. other significant advantages of this teqalnique like adequate nutrition, optimized fluid balance and control of body temperature should not be negicctod. introductioni pseudomonas (p) aeruginosa has to be considered an important pathogen of nosocomial pneumonia and septic organ failure. the lung seems to be the predominant target organ for the pore-forming p. aeruginosa cytotoxin, thus inducing microvascular injury. with respect to therapeutical consequences, the potential protective effects of paf-antagonist (web ), cyelooxygenase inhibitor (diclofenac) and specific and unspecific antibodies on cytotoxin-induced pulmonary vascular reaction and mediator release were studied in the isolated perfused rabbit lung. methods: cytotoxin ( p_g/ml) was administered into the perfusion fluid in all groups, either in the absence of inhibitors (n= ), or after pretreatment with web ( xl -gm, n= ), or diclofenac ( #g/ml, n- ). furthermore, the application of specific antitoxin (mg/ml, n= ) was tested in comparison with the unspecific immunoglobulins (venimmun®, behring, . mg/ml) (n= ) and the combination of immunogiobulins, web and diclofenac (n= ). six experiments without toxin served as controls. the arterial pressure mad the weight gain as an indicator of edema formation were continuously monitored during the three hour peffusion phase. arachidonic-ucid metabolites, as well as lactate dehydrogenase (ldh) and k + concentrations were determined at rain intervals. results: cytotoxin caused a gradual increase in pulmonary arterial pressure, reaching a maximum value of . times higher than the control, starting after min and a delayed onset of edema formation resulting in a mean weight gain of g after min. this was paralleled by a significant increase in prostacyclin generation and a continuous release of k + and ldh. thromboxane synthesis exceeded about times that of controls in the toxin treated lungs. pretreatment with web or diclofenac significantly attenuated the pressure response and edema formation evoked by cytotoxin. the addition of the unspecific immunognbulin preparation alone induced a transient pressure increase within the first minutes, but mean values remained below those of the cytotoxin group in the continuing observation period. mmost complete inhibition of the pressure reaction, the edema formation and the metabolic alterations was achieved mainly by the combination of immunoglobulin, web and diclofenac and to lesser extend by the specific toxin antibody. conclusion: the current results point towards the crucial role of paf and aa-metabolites as mediators of cytotoxin induced microvascular injury. the systemic or local application of cytotoxin antibodies or even unspecific immunoglobolins in combination with paf-antagonist and diclofenac appears to be a promising therapeutic approach in the case of infection with cytotoxin-preducing strains. cytokines have long been shown to be of particular importance in the metabolic derangements occurring in lps-induced shock. recent studies strongly imply the involvement of platelet aggregating factor (paf) in the pathogenesis of gram-negative bacterial sepsis. an autocatalytic feedback network has been postulated to exist between paf and tumor necrosis factor (tnf), a key cytokine involved in septic metabolic cascade, leading to an uncontrolled amplification of inflammatory mediator release. we have previously shown that st ( -n,n,n trimethylammonium-(r)- -isovaleroyloxy-butanoic acid z- -( -chlorphtalidiliden) ethyl ester bromide) was quite effective in inhibiting the "in vitro" binding of h-paf (ki= . x - m) to rabbit platelets. the present study shows that pretreatment of c bl/ mice with st , administered by different routes, dose-dependently and significantly reduces the lethality induced by endotoxin (e.coli :b injected at mg/kg intraperitoneally). very interestingly, st administered at the same doses as above (i.e. . , . , and mg/kg body weight) results to be significantly effective in reducing the endotoxin-induced release of serum tnf. the reported dual activity of st (i.e. paf antagonism and decreased circulating tnf levels) may turn out to be greatly beneficial, in combination with current therapies, in the treatment of diseases that involve overproduction of tnf and paf such as septic shock. introduction: recently, we reported that prophylactic whole body hyperthermia ( . °c) induces heat shock protein ('asp) and increases smvival - fold in a mouse endotoxin model (am. j. physiol. in press). other investigators reported that prophylactic pharmacologic induction of hsp- by sodium arsenite improves survival in a rat sepsis model (abstract a am. rev. resp. dis. vol. , ) . the effects of heat are complex and in addition to formation of lisp- include release of cytokines, changes in cellular ph etc. thus, the protective mechanisms of heat may differ from those due to pharmacologically induced . the purpose of this study was to compare the protection of heat vs the protection of pharmacologically induced hsp- in a mouse endotoxin model to determine if different protective mechanisms were likely to be involved.. i%'lethods: both sodium arsenite ( mg/kg) and ethanol ( ~ of % ethanol) caused marked induction of hsp- in lung, gut, kidney, and liver, which was comparable to heat-induced hsp- . female nd mice weighing - gms were pretreated with arsenite or alcohol hours prior to challenge with escherichia coli endotoxin (-ld ) and survival was compared to control mice. results: survival at hrs. for arsenite treated and alcohol treated mice was % and % respectively and was statistically different from the % survival for control mice. (p< . ) (n= mice per group). however, at days post endotoxin, there were no differences in survival in the groups, i.e., ~ % survival for all groups. in contrast, the protective effect of hyperthermia remains present at days, i.e., ~ % survival vs % survival control. conclusion: the protective effect of heat is probably due to other factors such as the effect of hyperthermia to release il-lc~ and is not due solely to hsp- formation. it was the aim of the study to examine whether bacteria play a causative role in the pathogenesis of anastomotic insufficiency following gastrectomy in man.the study was carried out in form of a prospective, randemised, double-blind, multicenter trial. primary endpoints were the rate of anastomotic insufficiencies, infectious-and uncomplicated postoperative courses. all pat. received a periop, i.v. prophylaxis with cefotaxim. identical numbered vial either contained placebo or polymyxin b, tobramycin, vancomycin and amphotericin b . the vials were administered x per day from the day be ~ fore the operation until the th postop, day. insufficiencies were detected by gastrographin swallow and recorded by x-ray on day postop.. evaluation was carried out on an "intention to treat'basis. statistical analysis was done with the pearson's chi square and fisher's exact tests~ results: interim analysis was carried out in / after pat. had been recruited. along with a significant reduction of s.aureus and enterobacteria there was a reduction in the rate of anastomotic insufficiency of the esophago-jejunostomy from . % in the placebo-group to . % in the treatment group. the difference was not yet significant. the rate of nosocomial infections (e.g. respiratory tract infection and uti) were significantly reduced from . % in the placebo-group to . % in the treatment-group (p ~ . ;fisher's exact test). in march final results with more than patients will be presented for the first time. (= po < mm hg, b s-creatinin > mg%). respiratory insufficiency was the most frequent systemic complication followed by sepsis and respiratory insufficiency. etiology of pancreatitis and initial serum increase of pancreatic enzymes predicted neither complications nor outcome. only of deaths occurred during the st week, all other deaths occurred late (after - weeks), generally as the consequence of septic complications and multi-organ failure. high levels of crp were correlated with a compliacted course and a fatal outcome. although same cytokines (e.g. -- ) were found increased in severe disease, the predictive value of these markers was not better than the combination of ctinical scores (ranson, imrie, apache ii) with gt or crp. conclusions: intensive care medicine can often control the inital shock situation in severe pancreatitis. thus. only % of deaths today occur eady in the course of the disease, whereas this percentage varied between - % just years ago. nowadays, most deaths are caused by late septic complications and multi-organ failure. ranson-and ct-scores as well as serum crp predict a course with systemic complications; they are less helpful for prediction of sepsis and late mortality. it is doubtful whether measurements of cytokines will help to better predict the late outcome. as yet, only careful and continuous monitoring of patients (e.g. by apache scores) may help to early identify those who develop septic complications and multi-organ failure. the classic description of severe acute pancreatitis has hinged upon the release of large volumes of activated enzymes into the peritoneal cavity and thertce the lymphatics and blood stream. these activated enzymes escape from the pancreas due to disruption of cells with associated ischaemia and occasional infarction of tissue. for to years it has been postulated that the bocly's defence system to activated pancreatic enzymes required supplementation iu the form of anti-protease support either in the vascular space or in the peritoneal cavity. all controlled studies have shown that this is either impracftcal or unnecessary.hore recently release of a large number of cytokines from monocytes, macrophages and neutrophils have been considered to be harmful to the body and various agent~ which oppose the action of tnf alpha, paf and similar cytokines are being examined in experimental anim~is and certain clinical trials, it has clearly been shown that higher levels of cytokines are released in the patients with objectively graded severe acute pancreatitis than in those with milder disease. we now seem to be moving into an exciting phase of potentially beneficial therapy in acute pancreatitis which has had no specific effective therapy through studies utilising aprotinin, gabexate mesilate and fresh frozen plasma. inflammation cascades may play a role in the pathogenesis of acute pancreatitis. to evaluate the status of the cellular immune system we examined serum concentrations of immune activation markers in patients with acute pancreatitis ( males, females; median age: years, range: - years). concentrations of neopterin, serum soluble tumor necrosis factor receptor (stnf-r) and serum soluble intercellular adhesion molecule type (slcam- ) were determined using immunoassays (henning, bender, t cell sciences). / had increased concentrations of stnf-r compared to the th percentile obtained in healthy controls (> . ng/ml), and / patients had increased neopterin (> . nmol/i), / presented with elevated slcam- (> u/i). all patients with increased neopterin also had increased stnf-r, patients had concentrations of all three markers outside the normal range. there existed a significant correlation between neopterin and stnf-r (rs = . , p < . ). weak associations between age and stnf-r (rs= . , p=o. ) or neopterin (rs= . , p = . ) were also found. our results demonstrate activation of the cell-mediated immune system taking place in a sub-group of patients with acute pancreatitis. the finding of increased neopterin and stnf-r levels implies that activated monocytes/macrophages are involved in the pathogenesis of the disease. further data are necessary to evaluate potential associations between changes of marker concent-rations and the course of the disease. pancreatic injury after heart surgery was reported as soon as ( , ) and characterized by increased serum or urine amylase levels (in about % of patients) in the fi~t postoperafi.'ve days. this pancreatic injury, which sometimes led to acute pancreatitis, was atreaay at~buted to inappropriate perfusion of this organ. in the ffs, studies were published dealing with pancreatic suffering alter heart surgery, in large series of patients, concluding ~n~at panc~a~c injury (with a low incidence of pancreatifis) is more common than previously recognized and is a potential source of complication after camliac surgery ( , , ) . in a recent study ( ), evidence of pancreatic cellular injury was found in out of patients undergoing cardiac surgery, with out of these patients presenting abdominal signs or symptoms and developing severe pancreafitis. this injury was associated w~th preoperative renal insufficiency, valve surgery, ~..stoperalive hytxxension, calcium administered periopuratively and length of bypass. we studied patients submitted to cardiopulmunary bypass (cpb) for heart surgery and used the measurement of un:~sin, pancreatic iso-amylase and lipase in plasma for biochemical characterization of pancreatic cellular injury. blood samples were obtained before surgery, directly aller surgery (return to inte~ve care unit), hours alter surgery and in the folfowing days alter surgery (days , , , and ). computed tomography scan of pancreas was performed in patients presenting hi~ levels of amylase on day . we measured abnormal levels of trypsin and pancteatic iso-amylase in % of patients and observed simultaneous releases of these enzymes, the fi,'st one in the hours after surgery and the second more intense from day and pa~icularly on day after smgery. this second release was concomitant with abnormal levels of llpase. these biochemical observations were accompanied by radiological and clinical signs of pancreatic injury in about % of our patients : pancrealic abnormalities were revealed by scan in patients and acute pancreatitis in i patient. more pronounced pancreatic suffering was observed in patients undergoing valve replacement than in patients undergoing coronam-anrtic bypass grafm~g. analysis of trypsin and pare're, tic so-amylase are sw.cific of pancreatic cellular injury and their simultaneous ir~rease in plasma alter cpb in our padents confirms the presence of an exocrine pancreatic injury. the presence of a simultaneous peak of lipase mcaezse~ the specificity of overt pancreatic injtu diagnosis. the precise cause of th/s injury could he related to hypoperfnsion leading to ischemic injury of foe splancbnic area, pancreas being largely sensible to hypoperfnsion ( ). this hypoperfosion could he responsible for the ftmt release of pancrealac enzymes observed in our patients and would contribute to the deterioration of other organs leading to an inflammatory reaction developing in the following days and responsible for the second release of pancreatic enzymes observed in our patients. patients with necrotizing pancreatitis show a heigh rate of pulmonary, renal and septic complications, whereas the course in acute interstitial pancreatitis is generally very mild. we have prospectively analysed the value of endotoxin, interleukin- (il- ) and transferrin in compare with c-reactive protein(crp) for the early assessment of the severity of acute pancreatitis. patients aud methods: the values of endotoxin(measured by limulus-lysate-test), ii- (elisa), transferrin and crp (nephelometry) were analysed daily along the first i days of hospitalisation by patients with acute pancreatitis admitted to our hospital from / to / . it was judged whether the patients have either interstitial (aip) (n= ) or necrotizing (anp) (n=lg) pancreatitis. patients with anp have died during the course of pancreatitis (mortality= . %). results: -severity o~ pancreatitis: signifcant differences (p<o. , mann-whitney test) could be calculated between aip and anp for endotoxin, il- , transferrin and crp during the i days of monitoring. -mortality: except of il- on days , , and after ad-mission there were no significant differences between the values of analysed parameters in patients who survived and those values in patients who died. -organ failure: the patients with pulmonary, renal or multiorgan failure have significantly heigher values of endotoxin, il- and crp along the i days of monitoring in compare with those patients without an organ failure. conclusions: endotoxin, il- and transferrin, an important endotoxin carrier, are promising parameters to differentiate between the severe and mild form of pancreatitis comparable with crp. this parameters may be helpfull in the early clinical assessment of patients with acute panereatitis. the determination of cytokines may elucidate the pathophysiologic mechanisms that produce early systemic complications in acute interstitial (i) or necrotizing (n) pancreatitis (ap). the appearence of respiratory insufficiency (ri) is used to appraise the early systemic complications and is compared to the results of cytokine blood levels. in a prospective clinical trial from / - / , patients with ap were recruited and blood samples taken for cytokine determination with commercial elisa-kits. the differentiation between i (n= ) and n (n=l ) ap was made through ct-scan in all and laparotomy for drainage and necrosectomy in patients. the etiology of ap was gallstones in , alcohol abuse in , hyperlipidemia in and other or unknown causes in patients.five of patients with nap died early (n=l) or of late septic complications. none died of iap.the peak of cytnkine level in the first three days of hospitalisation was used for calculation. ri was diagnosed in the first week of hospitalisation, if oxygenmask or iutubation for at least days was nescessary to treat arterial hypoxemia. for statistical analysis u-test of wilcoxon, mann and whitney was applicated.the il- concentration in blood reached up to pg/ml in the first days depending on the severity of ap and dropped to almost zero in the next days, independently of the clinical course. the differentiation of i-versus nap, using a cutoff-line of pg/ml was correct in patients ( %, sensitivity (se): %= specificity (sp): %, (z: , ). high levels of il- over pg/ml correlated well with the prognosis ifri in the first week (accuracy: %, se: %, sp: %, c~: , ). the blood levels of il- reached a maximum of pg/ml in the first days, depending on the severity of ap, and showed a correlation to the clinical course in the following days. the peak of l,- blood levels indicated correctly the severity of ap in out of patients using a cut offtevel of pglml (accuracy: %, se: %, sp: %, ~: , ). there was no correlation between cytokine blood levels and mortality, also there seemed to be no correlation between the levels of il- and il- . in the bloodsamples of five patients with i-or nap no c~-tnf was detectable.the blood levels of il- , and to a lesser extent of [l- , can predict the severity and early systemic complications of ap in men. the excessive rise of cytokines can be explained by the stimulation of immunological cells ( macrophages, lymphocytes and endothelial cells) in the course of ap. objectives: in an opossum model, ligation of the sphincter of oddi or separate ligation of the bile and the pancreatic duct together leads to severe haemorrhagic pancreatffis while single ligation of the pancreatic duct causes only an exocdne atrophy. since bo has been discussed to be a contdbutor t¢, res dysfunction, this may depdve the organism of a potent defensive mechanism thus promoting the course of pancreatitis. the present study wa,,; carded out tc develop a new method for measuring dynamic liver res func.. tion and to test the hypothesis that bo causes a res dysfunction. material & methods: opossums were randomly placed in three groups. all received a central venous line. after midline laparotomy, a specially designe tourniquet was placed around the common hepatic duct above its junction with the pancreatic duct (group a, n= ), around the pancreatic duct (group b, n= ) or around both ducts (group c, n= ). after one week, the tourniquets were closed. using a scintillation camera, the liver uptake of nanocoll, a mtcalbumin colloid with a diameter of nm, was measured before, , and days after the obstruction. the curves were analysed by a computer and two parameters (r, s) were calculated using natural logarithmic regression. as a common measure for res function, the corrected granulopexic index (a) wa,,; determined, after day , the pancreas of each opossum was searched for necrosis by morphometdc methods. results: all animals survived till day . the opossums in groups a & had a macro-and microscopic normal pancreas, while those in group c showed a severe hemorrhagic pancreatitis. the granuinpexic index showed a significan~ change to the worse starting at day in group a & b (p<o, ) and at day it~ group c (p< ,ol). at day , res function in group c was significantly worse than that in group a & b (p< , ). the regression parameter r showed no significant change in groups a & b, but a highly significant decrease in group c starting at day (p< . ), thus showing a dysfunction of the hepatic res. conclusions: obstruction of the hepatic or pancreatic duct alone does no{ result in immediate dysfunction of the hepatic res, while obstruction of beth ducts does. because only ligation of both ducts is followed by a severe hereof.. rhagic pancreatitis, res dysfunction could be an important factor in the pathogenesis of pancreatitis and resulting organ failure.logarithmic regressinrl has proven to be a valuable tool to analyse dynamic hepatic res function. (b ) in lewis rats weighing - g. there were five groups: group a (n= ) were untreated controls; group b (n= ) were given isotonic saline intraperitoneally and observed for hours; group c (n= ) ml x e. coli intraperitoneally and observed for hours; group d (n= ) were given ml x e. coli and observed for hours; group e (n= ) ml x i e. coli and observed for hours, the rats were than killed, the spleens were removed and heparinised blood taken for immunological tests. total t-ceils, helper t-ceils, suppressor t-cells, monocytes, and the interleukin receptor were determined by monoclonal antibodies, indirect immunfluorescence, and flow cytometry (facs analyser ). statistical analysis was by the t test on rank transformed data.in group b (isotonic saline) the total t-ceils increased in the blood (p= , ) and spleen (p= , )com pared with the untreated rats (group a), in the groups with peritonitis (c, d, and e) we found highly significant rises in suppressor t-cells in the blood and spleen (both p< , ) compared with the non-infected control groups a and b. this increase was significantly higher in group d than in groups c and e. as well as other alterations, we found a uniform increase in the number of t suppressor ceils in our model of acute peritonitis that was both time and dose dependent, department of surgery, university vienna, akh wien, w~hringer gurtel - , wien. d~'na~'aics of som~ l~mnunologic indices in children with abdo;~tinal shock v.z.i~ioskalenko, s.f.vesiol$,t.v.p~bina serum (iga,:~i,g, circulating imaune co!~plexes, co:apleaentary serum activity, antimesothelialvisceral and parietal antibodies) and cellular (i-l~q~hocytes, ~s/th,b-lyaphoeytes,i nlaunoleukosis to aesothelial allergens; spontaneous blast cell transformation to phytohemaaglutinin and .nesoth<-~lial ~,togen; phagooftic neutrophil activity) im:~une indices v.'ere studied in children operated v:ith symi~to'as of abdo~ainal shock. ,'~!-~ of them had appendicnlar( - ocalized jo-diffuse, -~eneralized) and -hemoperitoni-~is (dull abdominal trau;na with injayy of 'the spleen- , the spleen and liver-q), flo patients tjere operated on for co~iplete iieus (~-intussnsc.sption, -com:lissural ileus). he follo~'~ing serum factors: cireula:;ing im~aune complexes and ~).esothelial antibodies are the aost i~portant ~ar~ers of the abdominal shock course. :yith the progress of the process the indices increase irresponsive of t.l~e cha±.aeter of pathology. in case of ileus regress and hemoperitonotis an abrupt drop in ~he titer of anti~aesothelial antibodies is noted. in bacterial peritonitis a high ~iter of anti:aesothelial parietal antibodies in great dilutions ("+++","++++"-q ; ) persisted even in the period of clinical recovery. cellular factors cham'acterize dfnaaics of the abdominal shock coulees less specifically llast cell transfor~aation and phagocyue neut~ophil activit can inderectly characterize transition of shock f~orn reversible into irreversible phases. the past so years have brought a number of major advances in burn care. the initial advance was the discovery that burn victims required large volumes of resuscitation fluid in the initial hours to maintain hsmodynamic stability, this was followed hy the dsvelopmsnt of topical antimicrohlal agents to prevent end treat infections. next, was the reporting that early excision of burn wounds, with autografting of the excised wounds was possible.finally, was the identification of the importance of aggrsssive nutritional support for the hypermstabolic burn patient.these advances have markedly increaesd survival rates for given burn mimes, s~ch that burns which would previously have been considered to be aniformly fetal, are now readily survivable.thsre remain two unsolved problems in burn care, which are limiting survivability cf burn patients.the first ie ths treatment of inhalation injury. ths sscond is how to obtain coverage of ths maaaivsly burned patient, who has limited skin graft donor sites available.this ssssion will focus on the new treatments being developed to obtain permanent coverage of burn wounds.these include the use of various tcplcal growth £aotore which can speed the rate of reepithelialization of wounds, both the beneficial and dstrimental effects of using cultured karatinooyte preparations, to obtain in excess of one squats meter of a pseudoskin from a single fifteen square centimeter biopsy of unburned skin, will be discussed, finally, the used for artificlal dermal preparations will be discussed. integumentary wound healing consists of simultaneous epithelializalion and contraction. not long ago, it was thought that healing proceeds at an optimum fixed rate and could only be delayed. the recent explosion in molecular biology and recombinant gene techniques have produced information on the biological activity of compounds previously believed to be biologically inert. many current attempts to modulate the rate of wound healing center on the topical application of various growth factors produced by integumentary cells or agents designed to modulate growth factor expression or response. epidermal growth factor (egf), plateiet derived growth factor (pdgf), transforming growth factor (tgf) and fibroblast growth factor (fgf) have been demonstrated, both in vitro and in vivo, to stimulate the proliferation and diferentiation of their designated cells types. egf and pdgf have been clearly demonstraled to increase the rate of wound closure in partial and full thickness wounds. pdgf also has demonstrated efficacy in the closure of recalcitrant pressure sores, whereas tgf increases the tensile strength of incisiona[ wounds and fgf stimulates angiogenesis. it appears that epidermal keratinocyte migration during wound healing depends on integrin-mediated interactions with compounds and ceils extracellular matrix. additionally, the activities of extracellular glycoproteins such as fibronectin, fibrinogen, laminin and thrombospondin are coordinated by multiple integrins with specific distributions and binding affinities. currently, agents which incorporate specific protein sequences essential for the interaction of the glycoproteins with the cells of the extracellular matrix are being investigated. it is has been clearly established that the rate and nature of wound healing can be influenced by the application of various agents and that sufficient quantities of these agents can be manufactured. the future challenge is to develop techniques to now the objective evaluation of the clinical efficacy of these various agents and to employ the appropriate agents in a cost-effective manner. transplantation; and ) the immune status/manipulation of the host.multiple interactive variables will determine the effect of employing allogeneic cells and tissue in wound coverage design and a batter understanding of the dynamics of the wound-graft microenvironment will facilitate the dove opment of clinicauy beneficial graft composites. cadaver allograft skin (cas) is the "gold standard" for wound coverage, but has limitations including varied availability & quality, immunogenicity leading to rejection, & potential for disease transmission. our development of a temporary living skin replacement (tlsr) addresses these issues; the tlsr consists of highly screened human neonatal fibroblasts (hf) cultured in biobrane a, a bilayer dressing consisting of nylon mesh laminated to a thin silicone membrane which controls water-vapor transmission. studies in our lab indicated that "fresw ~ tlsr grafts reproducibly close full-thickness wounds in mice & perform better than bb controls. we studied wound adherence & structural/molecular properties of fresh & cryopreserved (cryo) tlsr. methods: tlsrs were prepared by seeding /co hf in bb nylon mesh in dmem. hf quickly attached to the nylon mesh & were allowed to proliferate - wks. fibroblast mitochondrial activity was assayed by mtt assay. matrix proteins were identified by immunostaining, mrnas for specific growth factors were identified by reverse-transcription polymerase chain reaction amplification, & quantitated by gel scans. bb structure was studied by scanning electron microscopy & stretching measurements pro/post cryo. grafts were cryo'd in % dmso, quick-thawed & sutured onto x cm excised full-thickness dorsal wounds on athymic mice. "fresh" grafts were similarly placed. controls grafts were cas and aeellular bb. adherence was quantitated by a device which peeled grafts from wounds at intervals following placement, using a serve motor and a strain gauge. results: postcryo, storage and subsequent thawing tile tlsrs maintained > % cell viability by the mtt assay, indicating continued mitochondrial activity, and bb structure & stretchability were maintained. multiple matrix proteins secreted and deposited in the bb nylon mesh (types l/iii collagen, decorin, fibroneetin) were identified by specific immunostaining. growth factor mrnas in the tlsrs (afgf, bfgf, kgf, tgf~,p~,) were present in - , x higher levels in fresh/cryo tlsrs than in adult hcs. grafts adhered to wounds on mice through days of followup. histologic exams on days - showed excellent vascular ingrowth and minimal inflammation. adherence of tlsrs to wounds was >cas adherence. burn wound coverage in the massively burned patient remains a difficult problem. although cultured keratinocytes have been utilized for burn wound coverage, their impact on the patient with burns greater than % total body surface area has not been spectacular, with poor graft take and unstable epithelium.current investigations have been directed toward dermal replacement beneath either very thin split-thickness autografts (stag) or utilizing cultured keratinocytes. current products include: collagen dermal replacement with thin stag (burke, et al). collagen dermal replacement with cultured keratinocytes and fibroblasts (boyce, et ai). allograft dermis with cultured keratinocytes (cnno, et al). allograft dermis with thin stag (life cell). polyglactin acid mesh and neonatal human fibroblasts with thin stag (hansbrnngh, et al).investigations regarding culture media, use of growth factors, topical nutrients and antibiotics, and melanocytes for pigmentation as well as safety and efficacy are needed before any of the current products become viable options for coverage of the massively burned patient. the~ is a growing world-wide problem with the ujc of cadaver tissues and ocgans bae, au~ of the tren~m~s~km of dilemma such a; cmutzfeldt.jukob disease and iiiv as we ] as ready availability of urdform lis~ue~. on dec~mt~r , , the fda assumed control of as tissue bar~s in the uldtod st=tea in an attempt to bflng ~s difficult problem of dise~s~ transmission under ¢onlrol. in europe, ~om¢ of the governments are consldofll~ a c~mplcte bat) on the use of cadaverlc fissu~s such as ddn, 'this |ncroam in regulation of cadavefle ~s,quct will incmar¢ the difficulty of obtain~g and dlslflbulmg them. however, thc nc~ for these tissues contlnue~ m incrcaso, we will discuss ~'l¢ solulion to this important pmbl~n: tissue engineering. tlssu~ engineering is an in~rdisdpllnary field that applies pdnclplc~ of angin~edng and die life sclcnce~ reward the development of ~olok~¢al sub~dtute,~ ih= mslom, maintain, or improve tissue function, " ssuc ongln~cdng can provide ~ho nccassary tlssuoa for wound repair ~d ibe assuranoe fl'~t the lissuos are d.ls¢~¢ free. in addition, a ds~uo-cng~ne~n~l wound covering will bo u~lvemally acceptable and evntlublc as "off g~o shell", consis~t products, them are several approaches to restating thls function in a large wound, 'l'nosc i~elud~ tmmcdiete long term coverage, short t=nn coverage, uandtl~el coverage and compost= dssu¢ coverage, "flssuo onglncrcd wound coverings that meet those vaflous ne,.cds will he r~vlowod.cllni~:sl and experimental d~la in venous ulcer, dlabctl¢ ulcers, prossur~ ulcers and bum wounds wgj be mvlcw~, a~ welt as new approacl~s u~ csrtilag¢, bone, liver and bone marrow it~suos. c oomplon, k nadirs, w press, g wetland, j fallen iv, shrtners burns institute and massachusetts general hospital, boston, ma~schusetts, usa the clinical "take" rate o? cultured epithelial autografts (cea) has been observed to increase with transplantation to allodermls, but the reasons for the improved clinical performance have not yet been defined. the aim of this study was to determine the biological impact of normal human dermis on cea differentiation and maturation, biopsies of cea transplanted to engrafted and de-opldermlzed human homograft dermis have been compared to nopsles of cea transplanted to granulation tissue in tullthickness burn wound beds on the same patient, each patient serving as hls or her own control. paired test and control biopstes from six patients have acquired from as early as one week postgrafting to as late as years postgrafting (one patient) and analyzed histopathologlcally, ultrastructurally and immunoh[stochemloally, results demonstrate more rapid normalization of differentiation markers (e,g., involucfln, fllaggrln, cytokeratln profiles) in the cea transplanted to allodermls compared to their corresponding controls by in all patients, the proliferation rate within the basal layer ot the epidermis as determined by ki- (proliferation-associated antigen) is seen to norh~altze more quickly in the cea transplanted to allodermls in every case, persistence of allodermal matrix can be dooumented in all patients by elastic tlssue-trichrome stain, allowing visualization of the dermal elastin network. the popu;atlon densities ot intraepldarmal langerhans cells are conslstently and signlflcantly higher in cea transplanted to ,allodermls, possibly reflectlng an immunologlcal reaction to the underlying allogenlc tissue. overall, these preliminary results indicate that transplantation to a normal human dermal matrix accelerates the maturation of cea-deflved epidermis, wound closure continues to be a major problem in patients who have sustained a major thermal injury, cultured epidermal autografts (cea) have been utilized extensively since when galllco et el reported theh'use in two brothers with greater than % total body surface area burn. unfortunately, cea take rate varies widely and the resultant skin coverage is often fragile and the cosmetic results are less than optimal however the overall take rate and durability of the coverase can be markedly improved by using nn allodermls base as the recipient bed. a review of cea applications performed by physicians using cultured outologens epithelium obtained from blusurfaoe teclmology, inc. shows a marked discrepancy in the results obtained utilizing different methods of wound bed preparation. tgf-b is an important modulator coordinating complex physiological events associated with growth and development. it is assumed that tgf-b is also involved in the well-coordinated process of cutaneous wound healing by regulating proliferation, differentiation, chemotaxis and matrix deposition. the purpose of our study was to analyze the spatial and temporal pattern of tgf-b expression during granulation tissue formation in patients with accidanutl surgical trauma (monotraumata mid polytraumata) and bum wounds. after debridement (day ), the full thickness wounds were covered with epigard, a synthetic dressing until day . after this time the granulated wounds were closed by transplantation of mesh graft. biopsies of the wound center were taken from patients at the beginning of surgical treatment (day ) and after , , and days. cryosections were stained with antibodies against tgf-fi s using the apaap technique and -for standard histology -with hematoxylin-eosin. for identification of the cell type expressing tgf- , double staining immunofluorescence experiments were conducted using antibodies specific for monocytes/macrophages, polymorphoanclear neutropkils and fibroblasts. the results showed a characteristic pattern of tgf-t~ distribution during wound development. tgf-fi appearence was mainly cell-associated znd the absolute and relative number of cells that were positive increased with lime. infiltrating cells and developing blood vessels were most prominently stained; epithelial and t-cells showed no immuno-reactivity. a delay of emergence for tgf-b during the time course could be seen in one patient group. this might reflect various regulation patterns depending on the type and severity of injury.( ) pharmatec gmbh, frankfurt ( ) institut fiir immonologie and serologic, heidelberg ( immune cells extravasating specifically in skin recognize and eliminate the invading antigens (bacteria, viruses, etc.) either in situ or transport them to regional lymph nodes. they also participate in the process of skin wound healing. cells which traffic through the skin can be harvested from efferent lymph drained from a given area of skin. the type of migrating cells changes after trauma, heating and infection. we have developed a method for collection of human afferent lymph in lower limbs. the method allows obtaining immune cells from normal and injured skin and their characterization. aim of the study was to characterize skin immune cells in situ and in skin lymph with use of immunohistological methods (staining, facs). results. group , cells migrating through skin: + % t lymphocytes (cd ), + % langerhans and dendritic cells (cdla, hla dr, s ), + % cd , + % cd , no b cells (cd , ), % cd r (memory cells), + % il r. approximately % cells possessed cdlla and antigens. cd lc was expressed only on large cells. the frequency of all phenotypes was different from the blood populations. group , cells in skin: langerhans cells were found only in epidermis, cd , and , cd r , rb, ila/ cells around venules, cd (macrophages) uniformly dispersed, no il r and b cells. hla dr positive were endothelial and some dispersed mononuclear cells. group , one, three and thirty days after surgical wound (simple varicous vein extirpation): high density of epidermal langerhans cells, hla dr positive keratinocytes and all endothelial ceils, few il r cells, perivenular infiltrates of cd , r but less cd cells, high density of cdlla/ cells. classic staining of isolated and in situ located ccl!s with mgg or he did not allow to follow kinetics of changes. conclusions. this study presents the first in the literature quantitative data of immune cell traffic through normal and injured human skin. in the controlled release of biological response modifiers for soft tissue regeneration. alan s. rudolph, helmut speilberg, mariam monshipouri, and florence rollwagen, and barry j. spargo. we have employed lipid microstructures as controlled release vehicles for the delivery of growth factors in wound repair. traditional liposomes as well as novel lipid based microcylinders have been examined for their in vitro kinetics of the release of transforming growth factor beta (tgf-b). in vitro reiease has been examined by setting up models with examine the physical release of iodinated tgf-b as well as a cell based bioassay (based on the ht bioassay). the hollow lipid microcylinders ( microns in length and i micron in diameter) show an initial burst ( - ng) followed be zero order kinetics which result in the release of approximately i ng tgf/day. this release behavior can be modified by temperature based on the phase behavior of the lipid bilayer which comprises the microcylinder.we have also examined the cellular response to lipid microcylinders applied in vivo. the lipid microcylinders are mixed in agarose and implanted as a composite hydrogel block under the flank of a mouse. the blocks are removed , , and days following implant and the cells analyzed by facs sorter analysis. the observed pattern of ceil recruitment to the blocks mimics that seen in a local inflammatory response. cell surface phenotype studies included the determination of cd and cd , mac-l, and ig bearing cells. we have also begun to examine the change in cell surface phenotype and kinetics of recruitment following the inclusion of tgf-beta in the lipid microcylinders.center for biomolecular science and engineering, code , naval research laboratory, washington, dc. - . expression pattern of heat shock proteins in acute, good healing and chronic human wound tissue. abstract: wound healing is a complex biologic process that is well characterized at the histological level, but its molecular regulation is poorly understood. after clot formation, inflammatory cells are rapidly drawn into the wound, followed by migration of fibroblasts and epithelial cells that divide and repopulate the wound area. during the last decade peptide growth factors and cytokine are thought to play a key role in initiating and sustaining the phase of tissue repair. these factors which are released from different cells appear to initiate the cascade of events that lead to healing. different studys described the rapid activation of a family of proteins,named heat shock proteins (hsp) in differnt tissue that were exposed to various forms of stress (heat, toxic agents, mechanical). in this context hsp's have the ability to regulate protein folding and assembly, to transport proteins across cytoplasm and membranes, to disrupt protein complexes, to stabilize, degrade and regulate the synthesis of proteins and to take part in dna replication and repair. we now attempted to find out if hsp-gene activation is also involved in injury and wound healing, which likewise resemble a stress situation for cells. therefore we collected tissue samples during operation and single biopsies from chronic wounds (decubitus for example) and granulation tissue. after rna preparation from these samples we used rna-pcr and nothern analysis to study the expression of objectives of the study chronic, non-healing cutaneous tflcers are a challenging clinical and socioeconomic problem. several animal studies have shown that cytukines (e.g. egf, pdgf, fgf, tgfb) accelerate the healing process and tissue repair in general. results from first clinical trials indicate a promising value of cytokines in the treatment of chronic non-healing diabetic and venous ulcers. recent reports in the literature indicate that the biological activity of the solution of platlet derived wound healing formula (pdwt~) released from c~-granules (mainly pdgf & tgfi~) is greater than the activity of the recombiant single factors like e.g. pdgf-bb (robson, lancet ) . the aim of our study was to determine whether a correlation exits between the concentration of tgfi~ & pdgf and the time course of wound healing. materials and methods pdwhf was prepared from ml of auto]ogous patient blood and diluted with a special buffer to a final concentration of ng/ml g-thromboglobulin. the concentrations of pdgf and tgfg were determined by elisa-tests developed in our laboratory. patients with chronic non-healing ulcers have been evaluated alter treatment by topical application of pdwhf. pdfg and tgff~ concentrations of the topical solution were measured and two patient groups formed for analysis the time course of wound healing was regularly and meticulously documented and evaluated by photography and casting. the time from initiation of treatment instil o wound volume reduction to go of the origional size (t %) was noted• results: healing of extensive burn wounds can be accelerated by grafting cultured autologous or allogeneic keratinocytes. the stimulation of granulation tissue formation and reepithelialization is presumably based on growth factors and cytokines released by keratinocytes. we wanted to prove this hypothesis by investigating the bfgf expression during wound development, bfgf is mainly described as an angiogenic protein with mitogenic activity on various mesodermal and ectodermal cell types pointing to its stimulating potential in wound heating. in the present study we compared the pattern of human bfgf m-rna expression and the localization of bfgf protein during the first days of wound healing. biopsies were taken from juvenile human bum patients, immediately after wound debridemerit mad on day after transplantation of cultured allografts. biopsies were snap frozen and cryosected. the pattern of bfgf expression was assessed by in situ hybridization of the bfgf m-rna with a digoxigenin-labelled antisense-rna and the parallel detection of the mature protein with an anfi-bfgf monoclonal antibody. our study revealed typical patterns of bfgf-m-rna-expression and intense bfgfprotein deposition during granulation tissue formation and reepithelialjzation of healing bum wounds. 'it, is known that major thermal injuries cause early impairment of wound healing followed by decreased influx of granuiocytes st. the site of injury. the role of granuiocytes in the process of wound healing is not ~"~ "" elucidated, it is now assumed that they are not merely phagocytic cells but active participants in ~n~*' ~.,.,a+~o~: processes secreting_ a number of various cvt-;kines, in order to investigate the effect of there is accumulating evidence that neuropeptides could be involved in the pathogenesis of several inflammatory reactions. vasocactive intestinal polypeptide (vip) and substance p (sp) have been detected by immunohistochemistry in normal as well as inflammed skin mostly in perivascular and periglandular location. both vip and sp are involved in vasodilatation, mast cell degranulation and irnmunomodulation.we determined the influence of sp and vip on the proliferation of lymphocytes in patients with psoriasis and healthy individuals. peripheral blood t-lymphocytes of psoriatics and healthy controls were isolated by density gradient centrifugation and passage over nylon wool. cell enrichment was controlled by facs analysis, lx t-lymphocytes were then incubated alone or in coculture with x irradiated autologous lymphocytes in culture medium containing - mol/i sp or vip. cell proliferation was measured semiquanfitatively by tdr uptake in a betacounter. significance was tested by the wilcoxon signed-rank test.our results show that sp and vip exert only an effect on unstirnulated t-cells. in healthy individuals but not in patients with psoriasis sp increases significantly proliferation of t-cells. vip, however stimulates significantly the blastogenesis of t-lymphocytes only in psoriatics.our results confirm the psychoneuroimmunologic component in inflammatory reactions and vip and sp could be partially implicated in their pathogenetic mechanisms. moreover psoriatic lymphocytes show an altered reaction to sp and vip. this might be due to a preexisting (genetic?) or more likely to an epiphenomenal receptor defect. the adhesive interactions between endothelial cells and circulating ~enkocytes in shock and innammatory vondltions is mediated by several distinct families of ce -surface determinants. of particular importance are the leukocyte integrins cdib / cdlla-c. in this study monoclonal antibodies to two of the u chains (cdlla & cdiib) and the common [~ chain (cdib) have been used to investigate leukocyte-dependent and leukocyte-independent plasma leakage in tee skin of rabbite. plasma leakage was measured as the local accumulation of t si-hsa over a rain period, the chemotac~c peptide imlp ( . . ng) and bradykinin were used to induce cell.dependent and cell- ndependent leakage respectively, the antibodies used were . e (cdis), nri (cdlla) and antibody (cdllb). ]ntradermal in~ections of bradyklnin and ~dlp both caused a dose dependent increase in plasma extravasatien ( .~. ffi . p.l to . z b.bttl and . ,- . ~ to . z . d respectively. . e ( . - . mf,/k~ iv) caused a dose dependent inhibition of imlp-induced but not bradyldnin.inducecl plasma exudation. at . mk/kg, the plasma leakage was completely inhibited, antibody nr produced similar results, treatment with antibody did not cause inhibition o£ plasma leakage due to either tnedi~tor. in vitro, the irmnune system ex~nination in persons with bone, chest and abdominal traumatic injury (i group . patients without infectious coz~lications and group - patients with wound infections development) was carried out. to restore found immunity disorders and host defense to infection patients of the group were treated with thymalin-the biologically active peptides prepared from bovine thymus. the examination on t~e i- days after injury revealed a considerable decrease of lymphocytes, ed ",$d ~ and cd cells amo~it in the blood, cd /cd ratio and indexes of let~ocyte migration inhibition test in both groups of patients. the imm~lity disorders recovered to norm on the - days in pateents of+the i group. but stable ~eple$ion of cd and cd cells amount, lower cd /cd ratio and indexes of leukocyte migration inhibition test in patients of the group were observed~ besides that, these persons showed higher cd cells amount and ig level in the blood. after thymalin therapy valid ii~rovement of inun~e status was discovered. also good clinical effect of immunotherapy and best wo~id healing observed in % of cases. these results allow us to propose that the thymus involution and the reduction of cell-mediated immunity responsiveness with disturbances of immu_uoregulatio~ on the level of restriction of activated cd tho cells play the most important role in the pathogenesis of wound infections development in persons with traumatic injury.dept. of immunology, military-nedical academy, lebedeva str. , , st.petersburg, russia a severe impairment of neutrophil (pmn) function often occurs following severe thermal or non-thermal traumatic injury. our laboratory has previously reported that following severe burn or non-burn traumatic injury the expression of the p integrlns (cd a,b,c/cd ) and the fw receptors (cd , and cd ) were significantly decreased on pmns, in this study, the effects of gm and g-csf on the expression of the f~ r and the ~ integrln family on pmns were examined, pmns were obtained from severe trauma (initial apache ii score ;z ) or thermal injury (> ~; total body surface area, > ~ full thickness) and incubated /n v/tro with gm or g-csf. the j integrins or fcyr were detected with monoclonal antibodies and flow cytometry. gm end g-csf induced a sllght increase in the percentage of pmns expressing cd lb, cd , and cd while gm bur not c-csf induced an increase in the percentage expressing cdi a, cd lc, and cd , gm-csf and to a lesser extent g-csf induced an increase in the density ( , fold) of the ~ integrlns on pmns from normal, burn, and trauma patients, these data suggest that cytoklne modulation with csfs could have a role clinically in certain situations. institute, dept. of surgery, bethesda ave, cincinnati, oh, usa, - . funl~al infections after solid organ transplantatlon(sot) lewis flint, md and ed,~-afd e. etheredge, me) dept. of surgery tullrte univ. school of medicine new orleans. louisiana infections contribute to increased gra loss and mortaliw following sot. pr~isposing facton include diabetes, hepatitis, leukopenia, cc.¢xistem infection, and intense, especially triple drug, immunosuppression. funga] infections occur ~s isolated conditions in % and in association with bacterial infection(l %), viral infection( */.), and combined infections(it%), candida sp. is the most common fungus recovered but aspecgillus, coccidiodies, cryptococcus, histoplasma, mueor~ ghizopus, tinea, and toruiop~is s?. also are pathogens. clinical syndromes vary among orga.aizms or may be variable with a single p~tthogen, for ~ample, with aggressive immunosuppression, candlda my be localized esophagitis or cystitis or systemically iavaslve with an associated high mortality. aspergilius presents ~ a diffuse pneumonia while cryptococcus causes pulmonary and centrad nervons sy'stem infection, clinical examination, ct scanning and aggressive sampling for c'ultures a.s wall as serologic tests contribute to diagnosis. empiric the~py is ind',cated where there is a high level of suspicion. preventlon of ca.adlda izfection is ~ci~itated by early remov-a. of central }ants, ca~hetess and stents as well as by the use of oral nystatin. amphotericin ]~ remains the drug of choice for treatment of in.save fungd infection, surgical resection of infectious loci in the lung and brain is indicated in selected patients. the main problems of diagnosis in lower respirator-), tract infection are the differentation of infection from colonization or contamination, and the isolation of a reliable and true pathogen. expectorated sputum may be unreliable in pneumonia, because of contamination by oropharyngeal flora. although blood cultures may be negative, they provide a precise diagnosis and should be obtained in all pneumonias. other more invasive procedures are transtracheal needle aspiration, fibrobronchoscopic techniques including protected specimen brush and bronchoalveolar lavage with quantitative culturing and cytological analysis, transthoracic needle aspiration, thoracoscopy -guided biopsy and open lung biopsy. recently m. e -ebiary, a. torres et al, reported quantitative cultures of endotracheal aspirates for the diagnosis of ventilator-associated pneumonia offering reliable results in these patients and should be further investigated. any invasive procedure in a severely ill patient should be carefully directed weighing the risks as well as the benefits, whilst taking the underlying diseases and expected survival into consideration. -current therapeutic approach is based mainly on monotherapy with broad spectrum antibiotics. combination therapy is apparently indicated only in p. aeruginosa infections and severe s. aureus pneumonia. graft infection can lead to fulminant graft failure or rapid progressive cirrhosis. for prevention of graft infection immunoprophylaxis, i,e. administration of human polyclonal anti hbs hypedmmunoglobutin (hig), starting in the anhepatic phase during operation, has proved to be at least partially succesful when performed on a long term basis.from a total of olt in adult patients olt were performed for hbsag positive liver disease (cirrhosis n= , fulminant liver failure n= , retransplantation n= ) in pat. all pat. received . u hig in the anhepatic phase and . u/per day for the first week. a small group of pat. received hig only for i week (short term immunoprophylaxis), in all other pat. hig is administered on a long term basis to keep anti hbs serum levels above uii or until graft infection occurs (long term immunoprophylaxis);one-year survival rates are % in pat. who were transplanted for fulminant hepatitis, % in pat. with cirrhosis and long term prophylaxis, and % ir~ pat. with short term prophylaxis. all fatalities were related to hbv graft infection. the total rate of graft infection was % under short term prophylaxis and was independent from preoperative hbv dna status, under long term prophylaxis graft infection occurad in % in pat, negative for hbv dna. in hbv dna positive pat. infection rate was %, the total rate of reinfection for all pat. with long term prophylaxis was %the results of liver transplantation in hbsag positive pat. are comparable to other indications, graft infection with hepatitis b virus ist the major risk factor for these patients. under long term therapy with hig the rate of graft infection can be significantly reduced. the crucial cellular element for mods-mof: monocyi'f_./m acrophaoe ronald v. meier, m,d., f.a,c,s. the severely :injured or crldcally ill surgical patient is at high risk for immune dysfunction. a major consequence of this immune dysfunction is multiple organ dysfunction and failure leading to death, the underlying etiology is now recognized to be an uncontrolled, unfocused, disseminated activation of the host normally protective inflammatory. ,, cascades.. the resultant "mahgnant' systemic" inflan'a'natlon produces d~ffuso multiple organ bystander injury !eading to progressive organ dysfunction and failure. systemic malignant inflammation involves diffuse actlvatton of all components of the humoral and cellular inflammatory host response. of these various components, the macropha~e is the crucial central cellular element. the tissue fixed macrophage is ideally located diffusely throughout the various organs injured to orchestrate the inflammatory process. the macrophage is long-lived and highly metabolic, the macrophage regulates both the extent and the dissemination of the inflammatory processes. the macrophage is an exu'emely active c¢ capable of producing and releasing not only directly eytotoxlc agents, s irnil~, to the neutrophil, including oxidants and numerous proteases out also the multitude of other cytokines and initiators of the interacting inflammatory cascades. the macrophage is the central source for ehemotactic agents (il- , ltb , c a) for neutrophils and other inflammatory cells, production of vasoaetive arachidonie acid metabolites (tx, pgi , poe, lt's), complement components (c a, csa), thrombotic agents (pca, tx), metabolic and physiologic modulators (il, , il- or tnf), and immunosuppressivc agents (poe , il- ). these products of the macrophage are highly effective in enhancing and augmenting the inflammatory response. disseminated activation otthe macrophage is critical to the induction of the long-term diffuse activation of inflammation necessary to induce multiple organ injury and failure. our ability to elucidate the molecular mechanisms that control the macrophage will lead to our ability to conu'ol the maerophage response and prevent mods-mof.flarborview medical center, - th ave za- , seattle, wa usa key: cord- -rz cglyt authors: gwizdałła, tomasz title: viral disease spreading in grouped population date: - - journal: comput methods programs biomed doi: . /j.cmpb. . sha: doc_id: cord_uid: rz cglyt background and objective the currently active covid- pandemic has increased, among others, public interest in the computational techniques enabling the study of disease-spreading processes. thus far, numerous approaches have been used to study the development of epidemics, with special attention paid to the identification of crucial elements that can strengthen or weaken the dynamics of the process. the main thread of this research is associated with the use of the ordinary differential equations method. there also exist several approaches based on the analysis of flows in the cellular automata (ca) approach. methods in this paper, we propose a new approach to disease-spread modeling. we start by creating a network that reproduces contacts between individuals in a community. this assumption makes the presented model significantly different from the ones currently dominant in the field. it also changes the approach to the act of infection. usually, some parameters that describe the rate of new infections by taking into account those infected in the previous time slot are considered. with our model, we can individualize this process, considering each contact individually. results the typical output from calculations of a similar type are epidemic curves. in our model, except of presenting the average curves, we show the deviations or ranges for particular results obtained in different simulation runs, which usually lead to significantly different results. this observation is the effect of the probabilistic character of the infection process, which can impact, in different runs, individuals with different significance to the community. we can also easily present the effects of different types of intervention. the effects are studied for different methods used to create the graph representing a community, which can correspond to different social bonds. conclusions we see the potential usefulness of the proposition in the detailed study of epidemic development for specific environments and communities. the ease of entering new parameters enables the analysis of several specific scenarios for different contagious diseases. the recent pandemic related to the worldwide expansion of the covid- coronavirus redirected the attention of scientists and entire societies to techniques that can be helpful when analyzing and predicting the spread of diseases in communities. viruses are always present in our environment, and this presence is usually uninteresting. for example, we are so familiar with most influenza virus mutations that the epidemics caused by them are widely considered mainly in economic discussions. only occasionally, when some particularly aggressive mutations emerge or during pandemics caused by some coronaviruses (sars, mers), is the public alerted about the potential danger. with the knowledge about possible directions of disease transfer and the number of people at risk, the identification of the most vulnerable groups is crucial. in , kermack and email address: tomasz.gwizdalla@uni.lodz.pl (tomasz gwizdałła) mackendrick published their paper [ ] , which is now considered the first approach to the mathematical modeling of epidemic processes. they introduced the crucial concepts by classifying members of a population, when considering an illness, as susceptible and infected and tried to find the relationships between these classes with the help of differential calculus. this division is also used today, and the number of applications using, based on their approach, ordinary differential equations (ode) continues to increase. we want to emphasize a topic that is difficult to address when using the ode approach -the inclusion of stochastic effects. indeed, there are different models in which some external force, either a periodic, e.g., seasonality [ ] , or purely stochastic [ ] , here for the sis model, force, assuming the susceptibility of an individual recovering from a disease, is used. in our approach, we follow another approach that is related to the analysis of the distribution of particular groups in real human communities. this approach is often related to the cellular automata model. the typical approach can be found, e.g., in sirakoulis' paper [ ] . in the model, the population is distributed over a two-dimensional space, and this space is, as is typical for ca, divided into squares. the spread of disease is modeled by the deterministic rules describing the transitions between states. many investigations use similar models, e.g., the famous model proposed by ferguson's group [ ] conducts much more soft division to generate the areas. we pay special attention to this model since it was later widely used to study the possibilities of preventing disease. in [ , ] , the expected results of different intervention procedures during the influenza epidemic in asia and the united states, respectively, are shown. the same model has recently been applied to the covid- [ ] pandemic. great britain and the united states were the areas of application, but according to authors' remarks, every high-income country can be studied with this model. a similar approach using ca can also be observed in [ ] , where the transfer between cells is the main factor supporting the spread of disease. the exchange of people is also a crucial feature of the model presented by holko [ ] . the results are here reproduced for the whole area of poland, divided into × squares, showing the possible spread of the influenza epidemic. in our earlier paper [ ] , we showed, taking into account the same area of inhabitance as in this paper, that the model requires special attention, primarily due to the existence of so-called size effects. although similar to the approaches based on cellular automata, our approach is different, mainly due to the change in the definition of the topology of interpersonal links. we do not consider the aggregate number of individuals in a particular state and a particular area, but we create direct links between them. thus, we can regard our model as an agent-based model. after defining the topology and the set of features characterizing agents, we can individualize their behavior. in the paper, we use the barabasi-albert (ba) model of the creation of a community graph [ , ] . this approach currently seems to be the most popular among the numerous attempts to model communities, dated from the seminal paper on random graphs by erdos and renyi [ ] . the main property of the ba model is that it leads to a power-law distribution of nodes according to their degree (the scale-free property), which is typical of communities. therefore, several real-world networks can be described by a ba model, e.g., a world wide web network, an actor or scientific collaboration, or even the e. coli metabolism [ , ] . several authors have already proposed the use of the ba network [ , , , ] , but their models concentrate on other problems. for simplicity, we do not introduce the differences in the behavior of agents. there are also papers where some of the concepts used in our paper were considered. ramos [ ] studied the case of grouping on some form of a two-dimensional grid. balcan [ ] studied the role of hubs, well known from complex network theory, in outbreak prevention by their identification and vaccination. hellewell [ ] studied the graph of direct links, where a negative binomial distribution determined the probability of the creation of links. among the papers related to the current covid- pandemic, we want to pay attention especially to these documents that can be used in our calculations or give some additional ideas for disease analysis. we mention here the reports concerning the incubation time [ , , ] and the ones that present information about important parameters, such as the basic reproduction number r [ , ] . boldog's paper [ ] also draws interesting conclusions concerning the potential risks for particular countries when taking into account their connections with china. this paper is organized as follows: in the next section, we present a model emphasizing two revealed problems -the construction of a graph describing a society and the procedure of the transfer of illness. we also justify the idea of division into groups based on some, generally arbitrary, factor. in the section devoted to the presentation of results, we concentrate on the epidemic curves, which are presented in two forms, i.e., the number of new cases and the number of recovered persons (in the absence of the mortality rate), and on the analysis of intervention, considered as the minimization of the number of contacts between neighbors in the network. we also show the effect of using different procedures on the possibility of people in different groups becoming sick. the most popular way to model the disease-spreading process is the method of kermack [ ] , which is based on individuals being assigned to one of several groups. in their original paper, the authors did not use the contemporary terminology, but later, the acronym sir began to be used. in the sir model, the members of a population can be classified as belonging to one of three groups concerning a disease: susceptible (s) -those who can become ill; infective (i) -those who can infect others; and recovered (r), those who are permanently immune. the set of ordinary differential equations determines the number (or fraction) of individuals in a particular state and at a particular time. in the above formula, s , i, and r are the numbers of people in the respective phases of illness, a is the contact rate, and b is the inverse of the infectious period. this approach was later extended by including a fourth phase -exposed (e) -between phases s and i. this fourth phase describes the fraction of the population in the latent (incubation) phase of an illness. this addition enables us to include more realistic processes when considering the majority of infectious diseases. the set of odes now takes the form: some parameters in formula are the same as in : β is the contact rate, and γ is the inverse of the infectious period. additionally, we have to consider n(t) -the total number of people in a community, satisfying the condition n(t) = s (t) + e(t) + i(t) + r(t) = const -and some new parameters, such as δ, which is the inverse of the latent period, and µ, i.e., the mortality (and also birth) rate. the equality of mortality and birth rates is certainly the condition enabling us to consider a constant n(t). we should emphasize that both of the above sets of equations are exemplary since their detailed forms depend strongly on the system's assumptions, but they present the idea of the calculations. the presented models also offer many opportunities to be modified or expanded. we can mention here, e.g., seis, where no immunity is assumed after a disease is passed on, or seijr, where an additional j phase (isolated individuals with treatment) is placed between the i and r phases. this continuous approach enables easy calculation of one of the most interesting values describing the potential effect of an outbreak, i.e., the basic reproduction number, which is a simple function of the ode parameters: although continuous models based on the odes give many interesting and practical results, it is well known [ ] that there exists a large stochastic effect in the epidemic process. therefore, we propose considering epidemics in a more individual manner. we start from two assumptions: • every infection is a result of the interaction between infected and susceptible, • we have to find the network of interpersonal connections initially and then model the spread of an illness. the second of these two points distinguishes our proposition from some of the abovementioned approaches, being based mainly on the cellular automata methodology, where the particular cells in a two-dimensional lattice correspond to different sections, covering the whole real area under investigation, for example, certain parts of cities or countries (see, e.g., [ , ] ). we instead numerically follow a scheme in which the possibility of every individual interaction is considered separately. the fundamental idea of the ba model is the observation regarding the growth of the network. instead of creating links between the existing nodes, the preferential character of this growth is assumed, which governs the creation of a graph corresponding to a community network. in conclusion, the individuals are added to the existing graph one after the other, and during this process, the straightforward formula: is used when determining the probability of linking a new node to an existing node indexed by i. k i here is the degree of node i, and the summation in the denominator runs over all existing nodes. we present the results for the two cases of graph modeling. the first one is the pure ba model, as it is well known from the seminal papers. however, we propose a modified approach, which is related to the fact that every individual is a member of different groups. as a group, we understand here different subsets of a community described by some common interest or features. good examples include the place of residence or the workplace. even if we do not consider someone connected in the sense of a typical social network, we can more easily meet him/her in a local store or the company hallway. this is why we decided to modify the probability given by formula , trying to take into account the mentioned effects. the solution that imposes itself is to change the relative probabilities of acceptance for links connecting nodes/individuals belonging to the same group when compared to those from other groups. however, no clear evidence exists regarding how we can introduce these changes. it could strongly depend on several additional details, for example, an individual living in a block of flats and shopping at the supermarket can accidentally meet many more unknown people than a resident of a cottage in the suburbs, who shops only at a local store. since we have to aggregate all these possibilities, we decided to use the mechanism where the probability of connecting nodes is tripled for nodes belonging to the same group, while for different groups, it is divided by . this procedure has a different significance in different phases of the creation of a graph of connections. in the early phase, the values of probabilities ( ) are relatively large; thus, almost all nodes in the same group are connected (probability is close to ), and the decreased probability for different groups starts to play an important role just after the initialization. the later added nodes usually have smaller degrees; hence, both formulas have comparable significance. the choice of particular multipliers ( and . ) in equations has no particular background. we want to clearly distinguish between the case where belonging to some environment strongly influences an individual's ability to be connected with another person and that where no particular preferences are possible. in this paper, we use three types of graphs describing communities: • the pure ba graph; • a graph based on assignment to one of four groups with completely artificial sizes; • a graph based on assignment to one of groups with sizes based on the inhabitance of particular areas of a selected medium-sized city in poland. we create the four groups mentioned in the second of the above points to introduce the visible differences in their sizes. the idea is to observe the effects of the proposed division in the simplified case, and the percentages of people in successive groups are { . , . , . , . }. the second division is based on a real analysis of our city -Łódź (lodz). easily accessible information [ ] shows that we can approximate the city's symmetric shape as a square with an edge length close to km. the number of inhabitants in lodz can be estimated to be approximately . the large square is further divided into smaller squares ( rows by columns). for this approach, we can establish the number of inhabitants in particular parts of the city. the results of this division are schematically presented in fig. (a) . the shades correspond to the number of inhabitants in a particular area, and the numbers inside the squares are the populations of groups in thousands. to show in more detail the distribution of people in the studied case, we also added fig. (b) , where a similar division is shown for the system of × = smaller groups. it is a fundamental assumption that this community is isolated; thus, we do not have the chance for potential secondary outbreaks, although it is not difficult to introduce this effect. the modification of the probability distribution in creating the connection is shown in fig. . we show the distributions for the three types of graphs mentioned above when creating them for individuals. we can observe that the algorithm creates less than − of pairs with a probability greater than . . the differences are visible, but it may seem that they are not able to produce a significant effect on the spreading process. there is also no significant difference between distributions for different divisions ( groups or groups). the process of disease transfer is, in reality, difficult to describe in the language of mathematical formulas. when con- sidering the direct contact results, we have to take into account many details, such as the duration of contact or the distance between individuals. indeed, there are also many features of medical origin, such as the individual immune system or blood group [ ] . due to these problems, a much more simplified approach is typically used. for example, in schimit's paper [ ] , the probability of infection depends on the number of infected neighbors (ν): . in our approach, we consider the process of possible infection separately during every step and for every possible pair of neighbors. there are two probabilities that are the basis of our model: • p m -probability of meeting (contact), • p i -probability of infection. the first value (p m ) is related to the social reasons for infection -without contact with a pathogen, we cannot become ill. therefore, we have to define the value that describes the probability that two individuals can meet during the time corresponding to one time step. thus, p m is the value that describes the possibility of a situation when contact is long enough to enable the transmission of illness. the second value (p i ) is related to the medical-related processes of infection and should, in general, correspond to the characteristics of the pathogen causing the disease. in the simplification, to meet the current paper's needs, this value is the probability of transferring an illness during a meeting, which occurs with probability p m . in general, this value can undoubtedly correspond to many processes related to the pathogen transfer between two individuals. as a result, this method enables distinguishing the influence of processes of different origin on the result of simulation. by changing p m , we can introduce, e.g., the effect of a quarantine, and by changing p i , we can distinguish different diseases. it is very important to mention here that p i does not change during the simulation run. this change would be a good model for the reaction of a pathogen to the environmental conditions, such as the temperature, humidity, or uv radiation level. the crucial problem when studying the expansion of an epidemic is to parametrize the seir model by introducing into the calculations the realistic times at which an individual stays in the exposed (t e ) and infectious (t i ) states. in this paper, we show the results for two pairs of times, making it possible to distinguish between the two types of infections. as a first case, we choose the times typical for influenza (t e = , t i = ), following the cases studied in [ , ] . for the second case, we choose times that best resemble the covid- data. since there exist some preliminary data [ , , ] , we decide to set (t e = , t i = ). finally, the scheme of disease transfer is as follows: • we start from exactly one "patient ". • the location of this patient varies between simulation runs, but it is always unambiguously defined. usually, "patient " is the hub of the selected group, and sometimes it is a less connected node. the detailed information about him/her is always given when describing a particular result. • one time step is equivalent to one day. • during the day, an individual is in group i -infectiousif he/she can transfer the disease to every one of his/her connected individuals with total probability p t = p m * p i . • after the infection time, every individual stays recovered (r) and does not return to the susceptible group (s). • the mortality and birth rates are assumed to be . in table , we present a summary of the simulation parameters. three fields in the table need further explanation. unless stated otherwise, the outbreak starts in the so-called hub in the most populous group. in the concept of social networks, hubs are those nodes that are characterized by the highest degree. this means that the selection of the initial point of the outbreak is not random but is assigned to the node with a relatively high possibility of spreading the disease. we also decide to propose the model of intervention in the form of the separation of individuals. the main idea of prevention forced by authorities during the covid- outbreak is to keep people at home. certainly, for most of the population, it is not possible to completely resign from leaving places of isolation; hence, they significantly decrease the number and intensity of outside contacts. we model this by decreasing the p m factor. if we force an intervention, every day after its start, p m is halved (p m,t+ = . * p m,tt enumerates the time steps) until it reaches a value lower by one order of magnitude compared to the starting value p m = . . for the initial calculations, we assume that intervention, if it occurs, starts on the th day. in this section, we present the results of calculations made for the model presented above. we start the analysis from the information on the size of graphs used in particular simulations. two values are chosen, i.e., and , with several reasons justifying these choices. first, we can expect the existence of a size effect. the size effect is typical for dynamical system simulations and manifests itself in the dependence of results on the size of the sample. we have observed this effect for disease spreading [ ] models, and we can also expect its existence for these calculations. the choice of particular values is done to achieve easy scaling and comparison with the number of nodes in the subsequent sections of fig. thus, the real number of persons in the upper-left section corresponds to or for and , respectively. a smaller number of nodes can also make the calculations faster and, therefore, enable collecting more extensive statistics. the most time-consuming process is the creation of the networkits time complexity is o(n ). in fig. and , we show the epidemic curves and the cumulative epidemic curves for selected cases described by the parameters listed in table . in fig. , we show the daily number of new cases. in fig. , as cumulative data, we consider all individuals who passed the infectious state (i). for simplicity, we call them recovered in the figure. the results presented in the plots are averaged over ten runs for every set of parameters. this procedure makes all curves smoother, and all statistical effects disappear; we will return to them later. we prepare both figures in the same style. having the data for two illnesses and two cases related to reducing the contact probability (denoted as a form of intervention), we show them in such a way that the upper plots correspond to the influenza-related data and the lower ones to the covid- related data. the left plots show the results without any intervention, while the right ones correspond to the inclusion of the social distancing effect by decreasing the p m parameter. the pure epidemic curves (fig. ) show that every factor included in the simulation parameters can influence the course of epidemics. since we show percentages, we can directly compare all curves. the most visible differences can be observed for the influenza-related data. as one can expect, when starting the disease in the hub of the most populated group (described as a hub), we obtain the highest rate of total infected persons. this result is, however, obtained for the particular division into four groups. with this division, the increase in connection probabil- figure : the course of cumulative epidemic curves for the same sets of parameters as in fig. . the organization of the image is the same as in fig. . ity plays such a significant role that it causes a large increase in the number of persons with illness. interestingly, the same case but considered for the pure ba model or for a larger number of groups ( ) does not cause this significant effect. it can also be observed that the maximum of epidemics takes place earlier than for the corresponding larger number of groups for the smaller groups. this effect is visible for all pairs of curves prepared for the same set of parameters but different sizes. it is also essential that the difference in maximum percentages for different parameters can differ by approximately an order of magnitude, and epidemics can last a long time. indeed, it never expires, as is known for influenza, certainly with different intensities. when looking at the plots for influenza with intervention, we can estimate the progress of influenza when we assume that the restrictions, similar to those introduced during covid- , are implemented on the th day from the time of outbreak. we can expect that in approximately three weeks ( days after implementing social distancing), the disease will disappear. indeed, we can consider this situation as a thought experiment, since no government would impose restrictions due to the seasonal flu. when looking at the covid- -related data in the lower plot of fig. , we notice that the differences here are visibly less important. as we observed earlier, the maxima of the curves for smaller sizes occur slightly earlier than for the corresponding curves for larger sizes. this difference is, however, visibly smaller. the longer infectious time causes the disease to be more aggressive and faster. for almost all cases, after approximately three months, the disease disappears. the number of people spreading the disease can be seen in fig. . the final number of ill persons reaches a value in the interval [ %, %]. this result is certainly unacceptable, especially taking into account the fact that the real mortality index for covid- is reported to be approximately %. the influence of intervention on the tenth day is shown in fig. (d) . the crucial observation is that the disease distinctly decreases its intensity after several dozens of days. this profile is similar to the curves obtained, for example, in some western european countries (see, e.g., https://www.worldometers.info/coronavirus for the netherlands or spain). the disease stays significantly weaker after approximately two months from the first infection. indeed, these systems are not closed ones. we can show that the size effect is present in this particular type of calculation. except for the data for covid- parameters without intervention, every other case strongly depends on community size. the most straightforward way to notice this effect is to observe the curves drawn with the same line type but different colors. this means that the spread of disease depends strongly not only on the relative ratio of connections inside and outside groups but also on the absolute number of links. some extended calculations may be needed, especially to describe the influenza-type epidemic. the interesting effect that we can observe is the change in characteristics with the increase in the number of groups. we can see that the total number of ill persons for the division into four groups is usually higher than for the pure ba model and later decreases when dividing the community into groups. in fig. , this relation is observed, e.g., when comparing the plots for size = , initialized in the hub of a large group, and models described as ba, gr, and gr. we think that the reason for this property is the fact that we strongly support the creation of links inside groups (see eq. ). thus, if there is a small number of relatively numerous groups, the average number of links could increase, strengthening the effect of disease transfer. we should emphasize the magnitude of these changes, which can make some results even ten times greater than others. we also tested the significance of the choice of the first infected individual. to prevent the plot from being unreadable, we limited the number of different cases to just two. for the first one, for which most of the calculations are made, "patient " is in the most populous group. for three selected individuals, described as "hub other group", he/she is also a hub but located in the less populated group. the difference in the final number of ill persons can be, when analyzing this feature, approximately up to % higher than when starting from the more populated subgroup. considering once more the effect of intervention (see plots (b) and (d) in fig. and ) , we can observe that, with intervention included, the duration of the epidemic does not strongly depend on the parameters of the model. some dispersion certainly exists but is not significant. to show some characteristics, we sampled the selected averaged values for particular simulation types in table . we choose to present three points in time: • the time when the cumulative curve changes its character for all types of simulation (a-d), the data are averaged over the whole set of parameters, and averages (along with standard deviations) are shown. the results show that for the virus with the longer infectious period, the duration is shorter (but certainly causes many more cases) than for those with shorter times t e and t i . we must pay attention to the fact that the results here are strongly correlated with the model used. the size effect is observable and characterized by a stronger influence of intervention for larger samples, and the division into groups prevents the spread of disease. these data also give us information about the final phase of an epidemic. the most important result is shown in plot (d). even with a fast, radical, and widely accepted mechanism of intervention, we can still expect that after ten weeks, approximately person in every ( per mil due to t . being approximately percent the total number of ill persons) can get sick. one of the most important questions when analyzing an epidemic is the significance of early intervention. the assumed start time of interventions above was ten days. this is a very short period and, for covid- , is within the estimations of the incubation period. hence, we decided to perform calculations assuming different values of delay. the results, averaged over runs, are shown in fig. . the results confirm that stochastic effects are much more important for influenza-like diseases. the differences in the values of recovered persons depend very strongly on the graph creation method following the order mentioned by analyzing the epidemic curves. the introduction of groups leads initially to the worsening of results (increase in the number of infected persons) before improvement occurs (fewer ill persons when divided into groups). however, the dispersion of results is so significant here than in every set of runs, and a run exists in which the disease is not transferred to other individuals. the more important conclusion comes from plot (b) of fig. . although the results for the pure ba model and those of the sample divided into groups are almost indistinguishable on the logarithmic scale, these results differ by a factor of - in the same manner as in fig. . the very important observation, however, is that if the assumption about much stronger links in groups is realistic, by decreasing the frequency of contact between people, we can reduce the number of infected persons by up to an order of magnitude. this effect can lead to the conclusion that greater social segregation can slow down or even stop epidemics. in this case, the stochastic effects are much stronger than for the case of a smaller number of groups, which can decrease this ratio by another two orders of magnitude. finally, we present the effect of taking into account the stronger links inside groups related to the real-space separation. as we wrote earlier, the percentage of individuals in groups, when divided into groups, correspond to the inhabitance of figure : the effect of the delay of intervention. plot (a) is prepared for data used for influenza (t e = , t i = ); plot (b), for covid- -related parameters (t e = , t i = ). we perform the calculations for a sample size equal to and with the start of the outbreak in the hub of the most populous group. then, we prepare plots for three cases: pure ba model, four groups, and groups. the descriptions are the same as in the earlier figure, i.e., ba, gr, and gr, respectively. the bars correspond to the range obtained during different runs for particular parameters. parts of lodz. the plots in fig. show the percentage of people in successive areas selected from the city's total area. the outbreak starts, as usual in our calculations, in the most numerous cell. in the case considered, it is the cell in the third row and third column (see fig. ). one may observe that the grouping causes a larger distinction between the characteristics obtained for different areas. in the suburbs, the rate of sickness is significantly lower, except for cases where it is passed to a local hub (see lowest-right squares in plots (d) and (h)). it is essential to mention here that there exists no preference for choice, as for links in the community graph, regarding the individuals from neighboring squares. when isolated, people in less urbanized areas have an approximately ten times lower probability of getting sick. we also emphasize an interesting effect observed when comparing some of the plots. in fig. , we have four pairs of plots prepared for the same disease and intervention option but for different divisions. they are as follows: (a,c), (b,d), (e,g), and (f,h). although the plots in pairs are usually different, one pair is visibly similar. a difference in the scale certainly exists. we can show that pair (e,g), corresponding to the covid- pa-rameters without intervention, results in the same pattern of illness in particular areas. since the corresponding plots (f and h) with intervention are explicitly different, we can say that for this aggressive disease, an accurate description of the relations inside the community graph is more important for the correct prediction of the possible course of the disease. every epidemic has two components: a social one and a medical one. we presented a model that integrates both components by considering the spread of disease as the effect of individual acts. these acts correspond to the direct transfer of pathogens between two individuals in a community network, modeled with the popular social network modeling. the study shows the influence of the community structure (the structure of links concerning affiliation to particular groups). these results show the great significance of the knowledge related to a society's observations when anticipating the potential course of an epidemic. the formulation of the model enables easy calculation of one of the basic values related to its progression -the basic repro- duction number, r . following the formula given in [ ] , i.e., r = kbd, we can easily adapt the notions used in our paper. because d is the duration of infectiousness, it corresponds to t i . b is the probability of transmission by contact and equals p i . the determination of k -the number of contacts of infectious persons per unit time -needs some explanation. it can be calculated by analyzing the average node degree of the constructed graph < k n >. these calculations are not presented in this paper, but the estimation gives an interval (dependent on the size and model) from to . . this allows us to calculate k =< k n > * p m . finally, the values of r can be estimated as being between . and . for influenza and between . and . for covid- . the above value corresponds very well to the summary given for covid- in boldog's paper [ ] . we can also easily calculate the effective reproductive number (r). usually, it is obtained by the multiplication of r by the number of individuals in the s state. here, we can add the multiplication by the p m parameter; as a result, we can observe the effect of the intervention on r and estimate the time at which r passes the critical value r = . in our opinion, the very important property of the proposed model is its natural way of including the stochastic character of the disease-spreading process. applying the random approach to every possible contact, we can estimate not only the average profiles of epidemic curves but also the range in which the real number of ill persons can lie. we can try to find the crucial nodes/individuals whose identification will allow us to reduce the range of an epidemic. we can also try to estimate the possible result of this identification. importantly, by individualizing the features of agents, we can also individualize the transfer of illness between them. the model enables the easy introduction of different forms of intervention as well as new potential outbreaks. considering intervention, we show the results of its typical form -isolation and quarantine. there is, however, a very simple way to introduce different procedures, i.e., vaccination, but other forms, as shown in [ ] , can be enlisted for the model. when entering a new illness, we have to change the attribute of the selected, either intentionally or randomly, individual. another important piece of information that can be estimated from the presented model is the one about the anticipated epidemic duration. by trying to recognize the inflection point (time), we can determine the time at which the disease can be significantly impaired. in our calculations, these values are limited to one per one thousand total ill persons and reaches a value approximately three times greater than the time between outbreak and inflection. a contribution to the mathematical theory of epidemics seasonality and period-doubling bifurcations in an epidemic model hamiltonian dynamics of the sis epidemic model with stochastic fluctuations a cellular automaton model for the effects of population movement and vaccination on epidemic propagation strategies for containing an emerging influenza pandemic in southeast asia strategies for mitigating an influenza pandemic cooley, modeling targeted layered containment of an influenza pandemic in the united states impact of non-pharmaceutical interventions (npis) to reduce covid mortality and healthcare demand modeling epidemics using cellular automata epidemiological modeling with a population density map-based cellular automata simulation system size effect in cellular automata based disease spreading model emergence of scaling in random networks statistical mechanics of complex networks on random graphs i the largescale organization of metabolic networks the metabolic world of escherichia coli is not small network structure and the biology of populations complex networks: structure and dynamics on analytical approaches to epidemics on networks simulation of the spread of infectious diseases in a geographical environment disease spreading on populations structured by groups seasonal transmission potential and activity peaks of the new influenza a(h n ): a monte carlo likelihood analysis based on human mobility for the mathematical modelling of infectious diseases covid- working group, feasibility of controlling covid- outbreaks by isolation of cases and contacts estimate the incubation period of coronavirus (covid- ) incubation period and other epidemiological characteristics of novel coronavirus infections with right truncation: a statistical analysis of publicly available case data the incubation period of -ncov from publicly reported confirmed cases: estimation and application risk assessment of novel coronavirus covid- outbreaks outside china modelling the epidemic trend of the novel coronavirus outbreak in china map of districts in lodz relationship between the abo blood group and the covid- susceptibility disease spreading in complex networks: a numerical study with principal component analysis realistic distributions of infectious periods in epidemic models: changing patterns of persistence and dynamics estimate the incubation period of coronavirus (covid- ), medrxiv transmission dynamics and control of severe acute respiratory syndrome managing epidemics: key facts about major deadly diseases, world health organization key: cord- -f ky ds authors: zarogoulidis, paul; constantinidis, theodoros; steiropoulos, paschalis; papanas, nikolaos; zarogoulidis, kostas; maltezos, efstratios title: are there any differences in clinical and laboratory findings on admission between h n positive and negative patients with flu-like symptoms? date: - - journal: bmc res notes doi: . / - - - sha: doc_id: cord_uid: f ky ds background: the world health organization alert for the h n influenza pandemic led to the implementation of certain measures regarding admission of patients with flu-like symptoms. all these instructions were adopted by the greek national health system. the aim of this study was to retrospectively examine the characteristics of all subjects admitted to the unit of infectious diseases with symptoms indicating h n infection, and to identify any differences between h n positive or negative patients. patients from the ed (emergency department) with flu-like symptoms (sore throat, cough, rhinorhea, or nasal congestion) and fever > . °c were admitted in the unit of infectious diseases and gave pharyngeal or nasopharyngeal swabs. swabs were tested with real-time reverse-transcriptase-polymerase-chain-reaction (rt-pcr). findings: patients were divided into two groups. group a comprised h n positive patients and group b (control group) comprised of h n negative patients. the two groups did not differ in terms of patient age, co-morbidities, length of hospitalization, temperature elevation, hypoxemia, as well as renal and liver function. there were also no significant differences in severity on admission. c-reactive protein (crp) (mean . vs. . ) and white blood count (wbc) (mean . vs. . ) were significantly higher in group b than in group a upon admission. obesity was noted in patients of group a (mean . ) and patients of group b (mean . ). body mass index (bmi) was lower in h n positive than in h n negative patients (mean . vs. . , respectively; p = . ). conclusions: the majority of patients in both groups were young male adults. crp, wbc and bmi were higher among h n negative patients. finally, clinical course of patients in both groups was mild and uneventful. in june , the world health organization signaled that a novel h n flu pandemic was underway [ ] [ ] [ ] [ ] [ ] . the h n virus is a triple-reassortant influenza virus containing genes from human, swine, and avian influenza viruses. this is a case control study. patients were selected from the influenza special clinic (emergency flu department) according to their attendance. control group were patients with flu symptoms and signs with negative serological test. most patients with h n infection present flu-like symptoms with a benign course [ ] . patients with co-morbidities may have a serious clinical presentation with hypoxemia. the main cause of death is acute respiratory distress syndrome (ards) [ ] [ ] [ ] [ ] . the first case of influenza a (h n ) virus infection in the area of thrace, greece was documented in the university hospital of alexandroupolis on th august . the purpose of this study was to investigate the potential differences on admission between h n positive and negative patients with flu-like symptoms. the university hospital of alexandroupolis is a report center of the h n virus for the region of thrace in greece. the hospital consists of more than fifty departments, one of which is the unit of infectious diseases. during the influenza epidemic a special department for flu was established in which all patients with flu symptoms and/or signs were referred. patients with positive flu test were transferred in an bed unit with negative pressure especially designed to quarantine and isolate patients with airborne transmitted viral infections. from th august until st december , cases of confirmed h n influenza a virus were hospitalized and quarantined in the unit of infectious diseases. all patients with flu-like symptoms (sore throat, cough, rhino rhea, or nasal congestion) and fever > . °c were admitted in the unit of infectious diseases and gave pharyngeal or nasopharyngeal swabs. the swabs were tested with real-time reverse-transcriptase-polymerasechain-reaction (rt-pcr) as in previous reported studies [ ] [ ] [ ] . it should also be mentioned that although rt-pcr is the most sensitive and specific test for the diagnosis of influenza virus infection, upper respiratory tract specimens are not as specific (~ %) as lower respiratory tract specimens (~ %) [ ] . all results were given in a period of time from to hours, and all patients remained under quarantine and isolation in negative pressure chambers according to who guidelines [ ] . our department prefers to use the pneumonia severity index in order to evaluate the severity of the disease. however, this score was not different between the two groups. the pneumonia score index was calculated for patients in both groups and the class range was between ii-iv [ ] . we repeated hini test days after admission and no patient negative in the initial test became positive. in total, patients were admitted in a four month period, of whom were h n positive (group a) and negative (group b). the h n positive patients remained under quarantine and isolation, while the negative patients were moved to the department of internal medicine. patients were monitored until discharge, with symptoms and signs recorded daily. return to normal body temperature was defined as a temperature of less than °c for day after withdrawal of antipyretic treatment [ ] . the criteria for discharge were absence of hypoxemia, normal chest x-ray and temperature < °c for day without antipyretic treatment. upon admission procalcitonin (pct) evaluation was performed in patients ( group a/ group b), for nine patients this exam was not available due to lack in reagents in our laboratory. also urine antigen for legionella and streptococcus pneumoniae was tested upon admission in all patients but they were negative. upon admission sputum stain was given in / patients in group a and / in group b. the rest of the patients did not produce enough sputum quantity for staining or did not cooperate in giving sputum. finally blood cultures were collected in / patients when the body temperature exceeded °c, but no results came positive. continuous variables were summarized as mean (±sd) or median (with interquartile ranges). for categorical variables, the percentages of patients in each category were calculated. unpaired t test was used in normal distribution parameters comparing the mean values of the parameters of the two groups. a p value of less than . was considered to indicate statistical significance. characteristics of the groups and clinical laboratory parameters were compared between the two groups (a, b). all analyses were carried out with the use of spss statistical software package (spss version . ; spss, chicago, il, usa). . %) as in previous reported studies [ , ] . (table .) only patients in group a and in group b had acute asthma exacerbation and none of the females in this study was pregnant. all female patients who were sexually active ( / group a) had negative pregnancy tests. all patients were treated with oseltamivir regimen (mean time . days in group a vs. . days in group b). in patients of group a, additional treatment with azithromycin/moxifloxacin or ceftriaxone was added at the time of admission, due to local patchy shadowing on the chest x-rays and fever > . °c. in / patients of group a and / of group b the second chest film was positive for pneumonia infiltrates. the patient's chest x-ray status upon admission is presented in table . in out of patients of group a from whom sputum culture was received, a pathognomonic isolation (> cfu) of bacteria was achieved ( streptococcus pneumoniae species, mycoplasma species and moraxella catarrhalis). on the other hand from group b only in out of patients a pathognomonic isolation was achieved ( streptococcus pneumoniae species and mycoplasma species). in group b, all patients were treated with double antibiotic regimen amoxicillin-clavulanic acid+azithromycin or ceftriaxone+moxifloxacin/ciprofloxacin (mean time of hospitalization was . days). empiric antibiotic treatment was added upon admission based on elevated values of crp, wbc and chest x-ray findings and since early antibiotic treatment prevents progression of the disease and these markers are known to be elevated in infection diseases [ ] [ ] [ ] . reiquelme et al [ ] also initiated early antiviral and antibiotic treatment in order to prevent further progress and co-infection of the clinical status. patients in our study were discharged when their chest radiograph became normal and their temperature < °c for day. seven patients of group a and patients of group b had severe hypoxemia upon admission (po ≤ mmhg) on room air. (table .) hypoxemia was defined as decreased partial pressure of oxygen in blood ≤ mmhg [ ] . there was no difference between the two groups for smoking (a: n = / vs. b: n = / ). (table .) obesity was observed higher in patients from group b (mean . ) and a small number in group a (mean . ) (p value = . ). (table .) according to who global database on body mass index a patient is considered obese when bmi is ≥ [ ] . leucopenia grade (≥ , to < , /mm ) was observed in / patients diagnosed with lymphoma in group a. (table .) in group b, only patient had lymphoma and presented pneumonia. on admission, abnormal liver function (elevated levels of serum liver enzymes or bilirubin) was found in / patients in group a vs. / patients group b. (table .) these patients were under no treatment. moreover, there was no platelet abnormality in any patient of the two groups. c-reactive protein (crp normal laboratory values < . mg/dl) and white blood count (wbc) were elevated in group b in comparison to group a (mean . vs. . ). among the white blood count (wbc) subgroups there were no significant differences observed. the white blood count (wbc) returned to normal in / patients of group a and in / of group b between - days of hospitalization. c-reactive protein (crp) returned to table .) none of the patients had acute renal failure and none of the patients in the unit of infectious diseases had to be intubated and admitted to the icu in comparison to other studies [ , ] . also all patients were asked if they had vaccination for h n , but none of them had been vaccinated, even for seasonal influenza. there was no difference in mean saturation among the two groups. (table .) only / patients in group a with hypoxemia had to be hospitalized for days and days. the one of these patients was recently diagnosed with idiopathic pulmonary fibrosis, while the other had no comorbidities. no significant differences were observed for mean temperature, saturation and partial o between the two groups. (table .) we described a case series of sixty patients who were hospitalized in the unit of infectious diseases from th august to st december with flu-like symptoms and were tested with rt-pcr for h n virus. of these, patients were positive for h n , while the remaining were negative. the main differences between these two groups and corresponding clinical messages are summarized underneath. in this case control study we included all patients with influenza symptoms admitted to the emergency flu department according to their attendance. limitations of the study include that our data represent the experience of a single center, that procalcitonin test was given only in / patients and also erythrocyte sedimentation rate (esr) was sporadically collected during the follow up of the patients and so was not evaluated. bacterial pneumoniae in association with influenza has been considered a important factor leading to poor patients outcomes in prior pandemics [ ] . even though none of the blood cultures were positive, we were unable to evaluate the effect of bacterial co-infection on patient outcomes, since blood cultures were obtained in only % of the study population (when fever ≥ °c) and workup for atypical pathogens was not performed. although bacterial co-infection was not documented, the majority of the study population was treated with antibiotics. prior publications failed to demonstrate any significant involvement of bacterial pathogens in hospitalized patients with h n virus pneumonia [ , [ ] [ ] [ ] . during the initial evaluation in / patients of group b and / of group a an antibiotic treatment was prescribed by a general practitioner and none of these patients had a sputum culture at that time. furthermore, we did not receive cultivable sputum samples from all patients. we supposed that false negative culture in pneumonia patients is mainly due to mixed microbial flora or the natural colonization admixture of the upper airway. the subgroup of patients with pneumonia in both groups is so small that any statistical analysis is impossible and the power of the sample is quite small. future studies are necessary to define the best treatment of h n virus pneumonia and the role of combination antiviral therapy. the lack of significant differences in the percentages of patients with hypoxemia between the two groups is probably due to the proximal number of patients with local patchy shadowing observed in group b and group a. (table .) obesity is known to be associated with influenza a (h n ) viral infection, but in this cohort we observed that in group b there was a larger number of obese patients in opposition to group a ( . % vs. . %) (p = . ). we were unable to explain the reason that the majority of h n patients were not obese in our study as in previous reported studies [ , ] . obesity is not a risk factor for poor outcomes in patients with seasonal influenza, but obesity has been suggested as a risk factor for poor outcomes in patients with h n influenza infection in the usa [ ] . in our case control study a large number patients suffering from lymphoma were observed, because these patients received chemotherapy regimen making them vulnerable to respiratory infections. patients in group b had elevated c-reactive protein (mean . vs. . ) and white blood count wbc in comparison to group a (mean . vs. . ) suggesting a microbial infection already upon admission [ ] [ ] [ ] . these elevated values (c-reactive protein and wbc) are known to be associated with bacterial infection and early antibiotic treatment prevents progression of the disease as reported in previous studies [ ] [ ] [ ] . symptoms from oseltamivir were mainly observed in group a (nausea . % vs. . %, diarrhea . % vs. . %, vomiting . vs. . %) probably because of the larger dose and prolonged treatment with oseltamivir ( . vs. . ) as previously reported [ , [ ] [ ] [ ] . however, it was difficult to distinguish the pharmaceutical side effects of osetalmivir (tamiflu) from influenza symptoms in patients receiving antiviral treatment for less than days [ ] . oseltamivir should be given until proof of negative rt-pcr result, since if a patient is positive, it prevents progression of the disease as shown in previous observational studies [ , , ] . moreover, mean duration of hospital stay was . in group b vs. . days in group a, because of the time needed for normalization of chest radiographs. nevertheless, there were no significant differences between the two groups and the days of hospitalization were limited due to early oseltamivir for group a and antibiotic treatment for group b as previously explained. lastly the mean young age of the patients in both groups, and the small number of co-morbidities observed in our sample of patients, possibly were also responsible for having overall mild clinical course. all the patients in general, had a mild clinical course and none of the patients had to be admitted in the icu. an outbreak of swine-origin influenza a (h n ) virus with evidence for human-to-human transmission influenza a (h n ) -update . geneva: world health organization novel swine-origin influenza a (h n )virus investigation team. emergence of a novel swine-origin influenza a (h n )virus in humans pandemic (h n ) -update update: infections with a swine-origin influenza a (h n ) virus-united states and other countries national influenza a pandemic (h n ) clinical investigation group of china: clinical features of the initial cases of pandemic influenza a (h n ) virus infection in china studies on influenza in the pandemic of - . ii. pulmonary complications of influenza the comparative pathology of severe acute respiratory syndrome and avian influenza a subtype h n -a review impact of influenza on mortality in relation to age and underlying disease the american-european consensus conference on ards. definitions, mechanisms, relevant outcomes, and clinical trial coordination geneva: world health organization human case of swine influenza (h n ) triple reassortant virus infection characterization of the influenza virus polymerase genes united states centers for disease control and prevention: interim recommendations for clinical use of influenza diagnostic tests during the - influenza season world health organization a prediction rule to identify low-risk patients with community-acquired pneumonia cases of swine influenza in humans: a review of the literature pneumonia and respiratory failure from swine-origin influenza a (h n ) in mexico the utility of serum c-reactive protein in differentiating bacterial from nonbacterial pneumonia in children: a meta-analysis of children does a high wbc count signal infection? nursing c-reactive protein is an early predictor of septic complications after elective colorectal surgery characteristics of hospitalised patients with h n influenza in chile mason md: murray & nadel's textbook of respiratory medicine the impact of influenza epidemics on mortality: introducing a severity index predominant role of bacterial pneumonia as a cause of death in pandemic influenza: implications for pandemic influenza preparedness world health organization: transcript of statement by margaret chan, director general of the world health organization hospitalized patients with h n influenza in the united states prevention: intensive-care patients with severe novel influenza a (h n ) virus infection-michigan a cohort study of the effectiveness of influenza vaccine in older people performed using the united kingdom general practice research database treatment and prevention of influenza: swedish recommendations writing committee of the who consultation on clinical aspects of pandemic (h n ) : clinical aspects of pandemic influenza a (h n ) virus infection impact of oseltamivir treatment on influenza-related lower respiratory tract complications and hospitalizations confounding by indication in nonexperimental evaluation of vaccine effectiveness: the example of prevention of influenza complications are there any differences in clinical and laboratory findings on admission between h n positive and negative patients with flu-like symptoms? none. authors' contributions pz collected and analyzed data, and wrote the manuscript; tk analyzed data and provided critical insights; kz, np and ps provided interpretation of data and finalized the version of the manuscript; em collected and interpreted data and provided critical insight. all authors read and approved the final version of the manuscript. the authors declare that they have no competing interests. key: cord- - bwhaga authors: aydogdu, ugur; coskun, alparslan; atas, ahmet duran; basbug, onur; agaoglu, zahid tevfik title: the determination of treatment effect of chitosan oligosaccharide in lambs with experimentally cryptosporidiosis date: - - journal: small ruminant research doi: . /j.smallrumres. . . sha: doc_id: cord_uid: bwhaga abstract in this study, it was aimed to investigate the efficacy of chitosan oligosaccharide administrations in different doses of experimental infected lambs with cryptosporidium parvum. male lambs were used in the study and the lambs were divided into groups with lambs in each group. groups , and , twice a day, were administered chitosan oligosaccharide at a dose of , , and mg/kg for days, respectively, with milk replacer. in group , lambs with cryptosporidiosis were subjected to normal feeding as control without drug administration. clinical examinations of lambs were made before treatment (day ) and on days , , and after treatment and ml of blood was collected from vena jugularis for blood analysis of all lambs. weight changes of lambs were recorded at , , , and days. stool specimens were collected pre-treatment (day ) and on days , , , , and post-treatment to determine oocyst excretion of lambs with cryptosporidiosis. lambs with a mean oocyte counts > after stool examination were included to the treatment. changes in clinical hematology, blood gases and biochemical parameters were observed during the course of treatment, but these changes were limited. weight loss was observed at th day according to th day the lambs with experimental cryptosporidiosis but gradually weight increase was observed at th and st days and these changes were similar in all groups. oocyst excretion decreased in all groups during treatment. according to th day, there was a significant (p < . ) decrease in oocyte excretions in the third day in group and , and in day in the group and . significant changes (p < . ) were observed in oocyst excretions on the third and fifth days among the groups. as a result, in lambs with experimental cryptosporidiosis, chitosan oligosaccharide improved in clinical signs and stool character shorter than the positive control group and the administration of chitosan oligosaccharide at doses of , and mg/kg for days significantly reduced oocyst excretion but not enough to remove cryptosporidiosis completely. infection caused by cryptosporidium parvum is common among young ruminants and is seen in various mammalians including humans. the disease has a high prevalence across the world and is among the important causes of diarrhea in neonatal farm animals (scott, ; paraud and chartier, ; constable et al., ) . c. parvum is one of the primary causes of diarrhea seen in young lambs and goats. diarrhea can develop as a result of c. parvum infection alone; however, it mostly develops due to mixed infection. infection can occur as a severe diarrhea outbreak which can cause high mortality in lambs aged - days (zorana et al., ; goma et al., ; paraud and chartier, ; constable et al., ) . there is no specific treatment for cryptosporidiosis. it has been reported that paromomycin, lasalocid, halofuginone lactate, sulfoxinoxalin, azithromycin and toltrazuril have partial or demonstrable effect against in neonatal ruminants with cryptosporidiosis (viu et al., ; wright and coop, ; giadinis et al., ; navarre et al., ; yagci et al., ; aydogdu et al., ) . chitosan is a natural polysaccharide produced by deacetylation of chitin. it is non-toxic, biocompatible and biodegradable (huang et al., ; zhao et al., ) . chitin is the main component of crustaceans (crab, shrimp, etc.) and is also found in skeletons of insects and cell walls of fungi. there are many derivatives of chitin and the most important one is chitosan (kumar, ) . chitosan and chitosan oligosaccharide (cos) have important uses in the medical field, such as controlled drug release, artificial blood vessels, antidiabetic, antibacterial, antifungal and hemostatic effect (baldrick, ; xia et al., ; muanprasat and chatsudthipong, ) . in a study on the treatment of calves with diarrhea, oral chitosan oligosaccharide administration has been reported to be successful in treatment (alam et al., ) . in studies conducted, chitosan has been reported to inhibit the in vitro development of c. parvum (luzardo Álvarez et al., ; adjou et al., ; mammeri et al., ) . there is no study found in which the efficacy of chitosan oligosaccharide in the treatment of cryptosporidiosis in neonatal ruminants has been determined. according to this information, this study is the first to determine the efficacy of chitosan oligosaccharide in the treatment of cryptosporidiosis in lambs. considering that chitosan inhibits the development of c. parvum in in vitro studies, we hypothesized that oral chitosan administration may be used in the treatment of lambs with experimentally cryptosporidiosis. the aim of this study was to determine the treatment efficacy of oral chitosan oligosaccharide in lambs with experimental cryptosporidiosis. ethics committee approval of the project was taken from sivas cumhuriyet university animal experiments local ethics committee ( . . / ). the study was conducted between - . experimental procedure was started simultaneously in all groups. in our study, a total of male lambs younger than days of age, lambs in every groups, were used. stool specimens of lambs were collected and tested using rapid pen-side test (bio-x diagnostics s.a. belgium) in terms of cryptosporidium parvum, rotavirus, escherichia (e) coli and clostridium perfringens. stained stool samples were also examined for cryptosporidium detection. positive ones were excluded from the study. to prevent contact between lambs, each was housed separately in individual compartments. c. parvum oocysts needed for the formation of infection were obtained from rectal stool samples taken from naturally infected calves with diarrhea. stool samples of the calves were examined using a rapid pen-side test (bio-x diagnostics s.a. belgium) in terms of the presence of rotavirus, coronavirus and e. coli and negative ones were used. the oocysts required for infection formation were obtained as reported in a study conducted on goat kids (koudela and jiri, ) . for the formation of infection in lambs, ml distilled water containing c. parvum oocysts were given using an intraorally catheter (nasogastric catheter ch, mm, bicakcilar co. ltd., istanbul, turkey). the development of the infection was monitored through the collection of rectal stool samples daily and microscopic examination of the stained preparations. the stained preparations from stool samples was made according to koudela and jiri ( ) . lambs with an average of > oocysts in stained stool preparations were considered to be infected, and treatment was initiated. when infection developed the following treatment protocols were applied to groups, each including lambs. oocyst shedding started in the lambs on the th and th days, and it had reached to peak level between on day and . as a treatment procedure, doses of , and mg/kg chitosan oligosaccharide were given to the lambs in st, nd, and rd groups at intervals of h. no drug was given to the infected lambs in the th group and they were fed normally for positive control. considering dehydration degree and blood gas analysis findings, required fluid treatments were given to the lambs in which diarrhea caused dehydration developed (oral fluid treatment was applied to the lambs with mild or moderate dehydration and metabolic acidosis (ph = . - . ), intravenous ml/kg/hour isotonic sodium bicarbonate was applied to the lambs with severe dehydration and metabolic acidosis (ph < . ), % dextrose was applied in case of hypoglycemia). during the study, lambs were fed with lamb food (optimilk, optima, kirklareli, turkey) at an amount of - % of their body weight at a proper temperature in two meals. in addition, adlibitum water was provided to lambs. in the study, water-soluble ( %) chitosan oligosaccharide with a deacetylation degree > % and a molecular weight < daltons was used as the treatment material (glycobio company, dalian, china). routine clinical examinations of the lambs (body temperature, heart frequency, respiratory rate, capillary refill time, assessment of dehydration degree) were conducted before the treatment (day ) and on st, rd, th and th days of the treatment. during the treatment, lambs were examined daily clinically and in terms of the stool analysis. . . collection of blood samples and analyses ml of blood samples were collected from lambs before the treatment (day ) and on st, rd, th and th days during treatment for blood gas analysis, hematological analyses (into k edta tubes) and biochemical analyses (into ml anticoagulant free gel tubes). blood hydrogen ion concentration (ph), partial carbon dioxide pressure (pco ), partial oxygen pressure (po ), bicarbonate (hco − ), total carbon dioxide (tco ), base excess (be), oxygen saturation (o sat), glucose and lactate levels were measured using blood gas analyzer (epoc, canada) immediately after blood sample collection without adding anticoagulant agents. using blood samples collected in k edta tubes, white blood cell (wbc), red blood cell (rbc), hemoglobin (hgb), hematocrit (hct), mean corpuscular volume (mcv), mean cell hemoglobin concentration (mchc), red cell distribution width (rdw) and platelet (plt) values were determined by automatic cell counter (bc- vet, mindray, china). hematological analyses were conducted within min after blood collection. the tubes without anticoagulant were kept at room temperature for clotting and centrifuged at rpm for min to obtain serum. serum samples were stored at - °c until the analysis. urea, creatinine, total protein, albumin, aspartate aminotransferase (ast), gamma-glutamyltransferase (ggt) and alkaline phosphatase (alp) levels in serum samples were determined using autoanalyzer (bs , mindray, china). stool samples of lambs were collected from the rectum into sterile stool container before the treatment (day ) and on the st, rd, th, th and st days of the treatment. stool samples were evaluated in terms of physical [normal(solid), loose and formless, semi-fluid, watery] and oocysts. the presence of c. parvum oocysts in stools was determined using kinyoun acid-fast staining method (korkmaz and ok, ) . stained preparations were examined using immersion oil at x magnification in the light microscope. the concentration of c. parvum oocysts in the stool was averaged by counting the oocysts in different microscope fields in each preparation, and semi-quantitative scoring was made as follows; the absence of oocysts ( ), oocyst < ( ) oocysts between - ( ), oocysts > ( ). lambs with a mean number of oocysts > were included in the study (koudela and jiri, ) . examination of stool samples were made by the same personnel. lambs were weighed using a digital scale before treatment (day ) and on post-treatment th, th and st days and weight changes were recorded. the data were expressed as mean and standard error of the mean (sem). kolmogorov-smirnov test was used for normality. one-way anova and tukey multiple range tests were used to evaluate differences between each treatment group during the experiment and significance levels of variation. the statistical significance level was accepted to be p < . . the spss software program (version . , spss inc., chicago, il, usa) was used for statistical analysis. after oral administration of oocysts, as of rd day, it was observed that there were changes in the characteristics of stool, that there was a decrease in the stool consistency and that oocyst excretion started with the presence of mucus. after oral administration of oocysts in lambs, as of th- th days, diarrhea ranging from the pasty to liquid in consistency containing a high number of oocysts was observed and lambs that were suitable to the experimental procedure were taken to treatment protocols. infection occurred in all lambs in groups, and experimental procedure was applied to all lambs (n = ). stools with mucus were observed in , , and lambs in groups , , , and , respectively. when intense oocysts began to be excreted, stools were in yellowgreenish color and sometimes brown color and had a condensed mucus appearance. there was no blood observed in stools. there was no death in groups - for days; however, lamb in group died on the rd day and lamb on the th day. both lambs died in the th group had condensed mucus and liquid diarrhea and dehydration were observed in these lambs. inappetence, abdominal distension, severe diarrhea and hypoglycemia were observed on the last day in the dead lamb. the lambs did not respond to fluid treatment applications and died. lambs that developed cryptosporidiosis generally had a dynamic appearance, normal mucosa, and good sucking reflex. however, depression, reluctance to stand up, dehydration (max. % level), prolonged capillary refill time ( s) and a decrease in sucking reflex were observed in some lambs. dehydration occurred only in of lambs in a maximum level of %. changes in the body temperature, heart and respiratory frequencies of lambs are presented in table . the body temperature of the lambs was observed to range from . to . ᵒc. there was a significant difference (p < . ) observed on day between the groups in terms of body temperature and no significant difference was found for the other days. moreover, the body temperature of lambs decreased in all groups compared to day and this decrease was statistically significant except for the th group (p < . ). a significant difference was found on the st day between the groups in terms of respiratory frequency (p < . ). changes in the oocyst excretion of the lambs before the treatment (day ) and on post-treatment st, rd, th, th, th and st days are given in table . it was found that oocyst excretion in group and significantly decreased from the rd day compared to day (p < . ). on the other hand, it was found that oocyst excretion in group and significantly decreased from the th day compared to day (p < . ). as between groups, a significant decrease was observed in group on the rd day and in group on the th day compared to group (p < . ). body weight measurements of lambs were performed before the treatment (day ) and on post-treatment th, th and st days. the changes in the body weight of the lambs by days are given in table . it was found that lambs in all groups had weight loss on the th day and that there was a gradual increase in the weight on th and st days. there was no significant difference observed between groups in terms of weight changes of lambs. when the in-group differences between the days were examined, significant differences were found in the groups except for the third group (p < . ). the blood gas analysis results of the lambs before and during treatment by days are given in table . in all groups, the mean blood ph was within the normal range ( . - . ) during the treatment. ingroups, there was no statistically significant change in blood ph between the days; however, there was a statistically significant difference between the groups on the th and th days (p < . ). metabolic acidosis was observed in cases in the group on day and ; case in the group on day ; cases in the group on day and ; cases in the group on day and . while pco levels were similar between groups, increases and decreases were observed in-groups between the days. however, these increases and decreases were statistically significant only in st and nd groups (p < . ). blood po and o sat levels did not show significant change between groups and in-groups between days. the lactate level of group was significantly higher than the other groups on day and the lactate level of group was significantly higher than those of group and group on the second day. there were increases and decreases in lactate level in-group between days and a statistically significant difference was observed in st and th groups (p < . ). there were increases and decreases in hco , be and tco levels of lambs during the treatment. however, these changes were not significant to affect ph. the difference in hco , be and tco levels in-group between days was significant (p < . ) only in the nd group. there were significant differences determined between the groups in terms of hco , be and tco levels on th and th days (p < . ). changes in the hematological parameters of the lambs by days before and during the treatment are given in table . although there were increases and decreases in hematological parameters in-group between days, there was no statistically significant difference found. there was significant (p < . ) difference in wbc levels on the st day between the groups and there was no significant difference found on the other days. there was a similarity between the groups in terms of rbc, hgb, hct, mchc and plt levels. in addition, between the groups, mcv levels were different at a statistically significant level on th, st and rd days and rdw levels on the st day (p < . ). changes in the biochemical parameters of the lambs by days before and during the treatment are given in table . while ast levels of the lambs increased during the treatment compared to pre-treatment (day ), alp, tp and ggt levels decreased. however, only changes in ast and alp activities of the st group and the change in total protein level of the nd group were statistically significant (p < . ). while there were increases and decreases in urea and creatinine levels of the groups by days, changes in the creatinine levels only in the st and nd groups were significant (p < . ). when the glucose levels of the groups were examined by days, glucose levels of the st, nd and th groups decreased on the nd day compared to day and increased in the following days. the glucose level of the rd group decreased on the st and rd days compared to day and increased gradually in the following days. statistical significance was determined only in the st group (p < . ). significant differences (p < . ) between the groups were determined only in tp and creatinine levels on the th day. a major problem about cryptosporidiosis is the lack of an effective tool for the prevention and treatment of this disease. more than substances have been tested to treat cryptosporidiosis (dinler and ulutas, ). some have shown promising effects; however, none of them have been reported to control clinical findings consistently or eliminate the infection completely. on the other hand, the use of certain drugs may reduce the oocyst excretion and thus probably the environmental pathogen level, the subsequent exposure, and infection of susceptible hosts (shahiduzzaman and daugschies, ) . it has been reported that paromomycin, halofuginone lactate, lasalocid, and sulfaquinoxaline have partial or demonstrable effect against cryptosporidium in infected neonatal ruminants (wright and coop, ; aydogdu et al., ) . however, knowledge about the treatment of cryptosporidiosis in sheep is limited. halofuginone exhibits -fold toxicity of the recommended doses of lactate, and its use is contraindicated in severely dehydrated or inappetent animals (wright and coop, ) . in addition, many drugs such as paromomycin, azithromycin, and sulfaquinoxaline that have been determined to reduce oocyst excretion in cryptosporidiosis have a risk to leave antibiotic residues. in recent years, serious concerns about antibiotic residues have emerged worldwide. in recent years, there have been studies carried out about the effects of chitosan and its derivatives on the underlying mechanism of antimicrobial activity of chitosan microparticles in the medical field and on the treatment of infectious diseases (jeon et al., ) . kim et al. ( ) reported that oral chitosan oligosaccharide applications at doses of , and mg/kg/day did not cause any side effects different letters in the same rows (a, b) and columns (a, b) are statistically significant (p < . ). group : mg/kg cos, group : mg/kg cos, group : mg/kg cos at intervals of h, group : no drug was given to the infected lambs. . ± . a . ± . a . ± . a,a . ± . a,b . ± . c . ± . d . ± . d different letters in the same rows (a, b, c, d, e) and columns (a, b) are statistically significant (p < . ). group : mg/kg cos, group : mg/kg cos, group : mg/kg cos at intervals of h, group : no drug was given to the infected lambs. in rats. in a study conducted, protective activity of chitosan oligosaccharide has been determined in mice in which colitis was formed experimentally (yousef et al., ) . chung et al. ( ) , found that oral administering of chitosan oligosaccharide with a low molecular weight reduced the allergic inflammation in mice in which experimental asthma model was formed. abdel-latif et al. ( ) reported that it had "anticoccidial" effects on eimeria papillata-infected mice. in the same study, it has been reported that both excreted oocysts and developmental stage parasites were reduced and chitosan had anti-inflammatory activity (abdel-latif et al., ) . in a study, oral chitosan oligosaccharide administering in the treatment of diarrheal calves has been reported to be very successful (alam et al., ) . in addition, chitosan has been used to create excipients in a microparticle system and it has been reported that it might play a role as a physical barrier against cryptosporidium parvum (blanco-garcía et al., ) . in the studies conducted, it has been reported to inhibit the in vitro development of c. parvum (luzardo Álvarez et al., ; adjou et al., ; mammeri et al., ) . in addition, mammeri et al. ( ) reported that chitosan nag and chitosan mix demonstrated in vivo anticryptosporidial properties in cd- mice, a highly sensitive animal model against c. parvum infection. therefore, it has been stated that both of these compounds have a promising potential in therapeutic and preventive applications against c. parvum infection. in this study, oocyst excretion decreased significantly (p < . ) in the st and nd groups by the rd day compared to pre-treatment and in the rd and th groups by the th day. as between groups, a significant decrease was observed in group on the rd day and in group on the th day compared to group (p < . ). although stool characteristics became normal on the th and st days, it was observed that oocyst excretion still continued in the lambs. while all the lambs in the positive control group had oocyst excretion at the level of + on the th and st days, this level was found to be lower in treatment groups compared to the positive control group. however, there was no statistical difference found. these results showed that chitosan oligosaccharide significantly reduced oocyst excretion compared to the positive control group; however, it was not efficacious to eliminate cryptosporidiosis completely. according to the findings of this study, the use of chitosan oligosaccharide to be used in the treatment of experimental cryptosporidiosis at doses of and/or mg/kg was found to provide an earlier reduction in oocyst excretion compared to mg/kg dose. the use of higher doses had no negative effect; however, it increases the costs and does not show more positive affects compared to lower doses. considering this, a dose of mg/kg was thought to be the most appropriate dose. the results indicated that low dose of chitosan oligosaccharide was better to reduce oocyst excretion and improve clinical findings in lambs with cryptosporidiosis. studies ph: concentration of hydrogen ions, pco : partial pressure of carbon dioxide, po : partial pressure of oxygen, hco − : bicarbonate, tco ; total amount of carbon dioxide, be: base excess, o sat: oxygen saturation. different letters in the same rows (a, b) and columns (a, b) are statistically significant (p < . ). group : mg/kg cos, group : mg/kg cos, group : mg/kg cos at intervals of h, group : no drug was given to the infected lambs. (mammeri et al., ) on the exact mechanism of action of chitosan continue. it has been reported that it is possible for chitosan to cause effects on the production of trophozoites and oocysts via various mechanisms (direct effects on parasitic viability and/or infectivity and/or parasitic growth in intestines and/or oocyst formation) (mammeri et al., ) . however, further studies are required to determine the exact mechanism of action. the limitations of this study are the absence of a negative control group without infection and treatment and the absence of groups treated with cos without cryptosporidiosis infection. generally, if there is no mix infection, the clinical findings in cryptosporidiosis are not severe and are transient and mild levels. in mix infections, clinical findings are more severe and mortality rates are higher. morbidity rates are high and mortality is low in cryptosporidiosis infections alone (constable et al., ) . in this study, it was observed that the changes in the clinical findings were not severe in all groups; however, there were some individual differences. the characteristics of diarrhea improved day by day in the treatment groups and in the positive control group. in the treatment groups (g - ), stools became normal or pasty in consistency on the th day, while there was still diarrhea in liquid level in cases in the positive control group on the th day. these results showed that chitosan oligosaccharide provided faster recovery in clinical findings and stool characteristics in lambs with cryptosporidiosis compared to the positive control group. the most important clinical finding in cryptosporidiosis is diarrhea in varying levels. endogenous forms of cryptosporidium lead to loss of mature enterocytes, shortening, and fusion of villus. they disrupt the microvilli boundary which causes the elongation of crypts caused by increased cell division and edema. this causes the loss of membranebound digestive enzymes, reduces intestinal absorption capacity and reduces intake of liquids, electrolytes, and nutrients from the intestinal lumen (foster and smith, ; constable et al., ) . in this study, it was found that although some significant in-group and/or intragroup changes were observed in blood gases, hematological and biochemical parameters in both treatment groups and in the positive control group, these changes remained limited and progressed generally within the reference limits. metabolic acidosis was observed in cases in the group on day and ; case in the group on day ; cases in the group on day and ; cases in the group on day and . however, it was determined that metabolic acidosis was at moderate and severe levels in only st and th groups in case in each. in other cases, the severity of metabolic acidosis remained mild. these results show that experimentally developed cryptosporidiosis alone in lambs leads to changes in blood gases and hematological and biochemical parameters; however, these changes were not at a level to disrupt the general condition. in conclusion, it was found that experimental cryptosporidiosis can be formed successfully through the oral inoculation of the solution containing oocysts in lambs aged < days, that oral administering of chitosan oligosaccharide in lambs at doses of , and mg/ kg had no side effect, that chitosan oligosaccharide provided faster recovery in clinical findings and stool characteristics in lambs in which cryptosporidiosis was formed experimentally compared to positive control group and that administering of chitosan oligosaccharide at doses of , , mg/kg for days significantly decreased oocyst excretion; however, it was not efficient enough to completely eliminate cryptosporidiosis. in this study, the appropriate chitosan oligosaccharide dose to treat cryptosporidiosis in lambs was observed to be - mg/kg, whereas new studies on this subject are required. we think that this study will provide a basic knowledge for further studies on the use of chitosan and its derivatives in the treatment of cryptosporidiosis in veterinary medicine. the authors declare that they have no conflict of interest. rdw: red cell distribution width; plt: platelet. different letters in the same rows (a, b) and columns (a, b) are statistically significant (p < . ) anticoccidial activities of chitosan on eimeria papillata-infected mice efficacy of chitosan, a natural polysaccharide, against cryptosporidium parvum development in infected hct- and caco- enterocytic cells effects of chitosan-oligosaccharide on diarrhoea in hanwoo calves comparison of the effectiveness of halofuginone lactate and paromomycin in the treatment of calves naturally infected with cryptosporidium parvum the safety of chitosan as a pharmaceutical excipient development of particulate drug formulation against c. parvum: formulation, characterization and in vivo efficacy anti-inflammatory effects of low-molecular weight chitosan oligosaccharides in ige-antigen complex-stimulated rbl- h cells and asthma model mice veterinary medicine. a textbook of the diseases of cattle, horses, sheep, pigs and goats pathophysiology of diarrhea in calves efficacy of halofuginone lactate for the treatment and prevention of cryptosporidiosis in goat kids: an extensive field trial the prevalence and molecular characterisation of cryptosporidium spp. in small ruminants in zambia uptake and cytotoxicity of chitosan molecules and nanoparticles: effects of molecular weight and degree of deacetylation underlying mechanism of antimicrobial activity of chitosan microparticles and implications for the treatment of infectious diseases subacute toxicity of chitosan oligosaccharide in sprague-dawley rats laboratory in parasitology. the turkish society for parasitology experimental cryptosporidiosis in kids a review of chitin and chitosan applications in vitro evaluation of the suppressive effect of chitosan/poly(vinyl alcohol) microspheres on attachment of c. parvum to enterocytic cells efficacy of chitosan, a natural polysaccharide, against cryptosporidium parvum in vitro and in vivo in neonatal mice chitosan oligosaccharide: biological activities and potential therapeutic applications diseases of the gastrointestinal system cryptosporidiosis in small ruminants sheep medicine therapy and prevention of cryptosporidiosis in animals field trial on the therapeutic efficacy of paromomycin on natural cryptosporidium parvum infections in lambs cryptosporidiosis and coccidiosis biological activities of chitosan and chitooligosaccharides the efficacy of a combination of azithromycin and toltrazuril for the treatment of calves naturally infected with cryptosporidiosis: a randomised, double-blind, placebo-controlled comparative clinical trial chitosan oligosaccharide as potential therapy of inflammatory bowel disease: therapeutic efficacy and possible mechanisms of action biomedical applications of chitosan and its derivative nanoparticles cryptosporidium infection in lambs and goat kids in serbia this project supported by the scientific and technological research council of turkey (project number: o ). ast: aspartate aminotransferase, alp: alkaline phosphatase, ggt: gamma-glutamyltransferase, tp: total protein. different letters in the same rows (a, b) and columns (a, b) are statistically significant (p < . ). group : mg/kg cos, group : mg/kg cos, group : mg/kg cos at intervals of h, group : no drug was given to the infected lambs. key: cord- - nhr hv authors: patel, samir n.; hsu, jason; sivalingam, meera d.; chiang, allen; kaiser, richard s.; mehta, sonia; park, carl h.; regillo, carl d.; sivalingam, arunan; vander, james f.; ho, allen c.; garg, sunir j. title: the impact of physician face mask use on endophthalmitis after intravitreal anti-vascular endothelial growth factor injections date: - - journal: am j ophthalmol doi: . /j.ajo. . . sha: doc_id: cord_uid: nhr hv purpose: to evaluate the effect of physician face mask use on rates and outcomes of post-injection endophthalmitis. design: retrospective, comparative cohort study methods: . setting: single-center study population: eyes receiving intravitreal anti-vascular endothelial growth factor injections from / / to / / . intervention: cases were divided into “face mask group” if face masks were worn by the physician during intravitreal injections or “no talking group” if no face mask was worn but a no talking policy was observed during intravitreal injections. main outcome measures: rate of endophthalmitis, visual acuity, and microbial spectrum. results: of , intravitreal injections administered, out of , ( . %) cases of endophthalmitis occurred in the “no talking” group, and out of , ( . %) cases occurred in the face mask group (odds ratio, . ; %ci, . – . ; p= . ). sixteen cases of oral flora-associated endophthalmitis were found in the “no talking” group ( in , injections) compared to none in the face mask group (p= . ). mean logmar visual acuity at presentation in cases that developed culture-positive endophthalmitis was significantly worse in the “no talking” group compared to the face mask group ( . lines lost from baseline acuity vs . lines lost; p= . ), though no difference was observed at six months following treatment (p= . ). conclusion: physician face mask use did not influence the risk of post-injection endophthalmitis compared to a no talking policy. however, no cases of oral flora-associated endophthalmitis occurred in the face mask group. future studies are warranted to assess the role of face mask use to reduce endophthalmitis risk, particularly due to oral flora. the use of intravitreal anti-vascular endothelial growth factor (anti-vegf) injections has become the standard of care for the treatment of common retinal diseases including neovascular age-related macular degeneration, retinal vein occlusion, and diabetic macular edema. since the introduction of intravitreal anti-vegf therapy, intravitreal injections have become one of the most commonly performed procedures in all of medicine. although these medications have excellent safety profiles, acute bacterial endophthalmitis remains an uncommon but potentially devastating complication. multiple prior studies have evaluated patient-related and procedure-related risk factors associated with post-injection endophthalmitis. [ ] [ ] [ ] [ ] [ ] in particular, one study found that oral flora-associated endophthalmitis was reduced after instituting a "no talking" policy where speaking was minimized during the procedure. understanding potential risk factors for oral flora-associated endophthalmitis is of particular importance given its poor visual prognosis. [ ] [ ] [ ] [ ] surgical face masks reduce transfer of nasopharyngeal flora from respiratory emissions. previous studies demonstrated that surgical masks reduced forward bacterial dispersion into the surgical field. , two laboratory investigations involving simulated intravitreal injections suggest that face mask use may reduce bacterial dispersion associated with speech. , partly due to this data, some have suggested including face mask use as part of the standard of care for intravitreal injections. , however, it is unclear whether decreased bacterial dispersion in these simulations correlates with an impact on clinical practice. both studies also found that maintaining silence during the simulated injection was equally effective as wearing a face mask. , however, other studies have suggested that face mask use may increase bacterial dispersion and infection risk. [ ] [ ] [ ] [ ] there are no known clinical studies, to our knowledge, investigating the potential impact of physician face mask use during intravitreal injection administration in a clinicbased setting on the rates of endophthalmitis. this lack of data is particularly relevant given that the use of personal protective equipment like face masks has become a standard of care for routine medical care by ophthalmic providers since the covid- pandemic. prior to the covid- precautions, within our practice, a subset of physicians have consistently worn face masks while performing intravitreal injections, while other physicians have used a no talking technique without face mask use during the procedure. the purpose of this study is to evaluate the rate and outcomes of postinjection endophthalmitis with physician face mask use compared to a no talking policy without face masks. this retrospective, single-center, comparative cohort study received prospective approval from the institutional review board at wills eye hospital. data were collected in accordance with health insurance portability and accountability act of guidelines, and the study conformed to the tenets of the declaration of helsinki. billing records and j o u r n a l p r e -p r o o f endophthalmitis logs were used to identify patients who developed endophthalmitis following anti-vegf injections. billing data was used to determine the total number of intravitreal injections, patients, type of anti-vegf injection (bevacizumab, ranibizumab, and aflibercept) used, gender, age, and indication for treatment. charts of all patients who were treated for endophthalmitis were reviewed, and the diagnosis was confirmed. recorded data included date of causative injection; date of tap and injection and/or vitrectomy; best available visual acuity (va) based on the better of habitual correction or pinhole testing before causative injection, at time of tap and inject and/or vitrectomy, at months post-procedure, and at last follow-up; and microbial culture results. physician face mask use was determined by a survey of physician practice patterns. all patients diagnosed with presumed infectious endophthalmitis following an intravitreal injection of bevacizumab, ranibizumab, or aflibercept were included in this study. dates of inclusion were july , to september , . endophthalmitis was defined as patients who presented with a clinical suspicion that was high enough to warrant either intravitreal antibiotic injection with vitreous/aqueous tap or pars plana vitrectomy with injection of antibiotics. in general, these patients presented with decreased visual acuity and pain, and had signs of intraocular inflammation on examination (generally ≥ + anterior segment cellular reaction and/or posterior segment vitritis). culture-positive endophthalmitis was defined as any patient with bacterial growth on culture or a positive gram stain from a vitreous or anterior chamber tap. a culture was considered to be oral flora-associated when enterococcus or streptococcus species was grown on culture. endophthalmitis was considered culture-negative when both the gram stain and culture plates were negative. patients with presumed inflammatory endophthalmitis treated with topical steroids without additional interventions were excluded. all intravitreal anti-vegf injections were performed in office-based settings, either in a designated procedure room or in a clinical room where the exam was conducted. all eyes were routinely prepared with topical anesthetic. no physicians routinely used lidocaine gel, topical pledgets, or subconjunctival lidocaine for anesthesia. after ocular anesthesia, all eyes received topical % povidone-iodine at least seconds prior to injection, and povidone-iodine administration was repeated just prior to injection at physician discretion. injections were performed with a -gauge needle for ranibizumab and aflibercept injections, or -gauge needle for bevacizumab injections, and inserted . - mm from the limbus. lid retraction was achieved through manual lid retraction with no routine use of lid speculum by any of the providers. surgical gloves, surgical caps, and sterile drapes were not used by physician providers for intravitreal injection administration during the study period. injection techniques were not altered during the study period and were otherwise similar between the two groups (supplementary table available at ajo.com). for the "no talking" group, all injections were administered under a strict policy of silence in which the physician, patient, and others in the room including technicians and family members did not speak during the injection procedure. during the informed consent portion of the procedure, patients are informed of the importance of minimizing speech during the procedure prior to entering the injection room. families are asked to not come into the injection room unless required for certain reasons such as help with mobility as their presence may encourage conversation. technicians are trained not to talk during preparation of the injection or during the procedure. physicians do not talk during the procedure except to cue the patient to look in a certain direction prior to uncapping the injection needle. when speaking close to the patient, physicians directed their faces away from the eye to be injected. for the face mask group, a subset of physicians wore a surgical mask (procedure mask mckesson pleated earloops # - , mckesson, irving, tx) when administrating an intravitreal injection. additionally, technicians who assisted with drawing drug from the vial, placing the needle on a prefilled syringe, or assisting with lid retraction wore a face mask. during the timeframe of the study, patients did not wear face masks during the injection administration. patients and others in the room were still asked not to speak during the procedure as per the "no talking" policy above, but the physician could speak to give instructions and reassurance. all eyes developing presumed infectious endophthalmitis immediately underwent a pars plana vitreous tap with aspiration or anterior chamber paracentesis with injection of intravitreal antibiotics or consideration for immediate pars plana vitrectomy with vitreous culture and intravitreal antibiotics. patients typically received intravitreal vancomycin ( mg/ . ml) and ceftazidime ( mg/ . ml). intravitreal amikacin ( μg/ . ml) was substituted for ceftazidime for patients with penicillin allergy at the discretion of the treating physician. a subset of patients did not have microbiologic specimens sent for processing if they were being treated at a satellite office without immediate access to a microbiology facility. patients were variably prescribed cycloplegic agents, topical antibiotics, and topical steroid drops based on physician discretion. all data were analyzed using statistical software (ibm spss statistics, armonk, ny, usa). the primary outcome was the rate of endophthalmitis following intravitreal injection in the face mask group compared to the "no talking" group. the secondary outcomes were va and microbial spectrum of culture-positive cases. va at months was used for the analysis based on prior studies. snellen va was converted to logmar equivalent for the purpose of statistical analysis. as established by prior studies, , vision levels of counting fingers, hand motion, light perception, and no light perception were assigned va values of . / , . / , . / , and . / (logmar equivalent . , . , . , . respectively). for categorical variables, significant differences between groups were analyzed using a pearson's chi-squared test or fisher's exact test. for continuous variables, significant differences between groups were analyzed using two sample t-test, mann-whitney u test, or analysis of variance with a tukey's honest significant difference post-hoc test. statistical significance was considered to be a -sided p value < . . during the study period, physicians contributed cases with a mean (sd) , ( , ) (range, - , ) injections per physician. a total of , intravitreal anti-vegf injections ( , bevacizumab, , ranibizumab, and , aflibercept) were performed with , injections in the "no talking" group and , injections in the face mask group. overall, a total of cases of suspected endophthalmitis after intravitreal injection were identified ( . %; in injections). over the six-year study period, the annualized rate of post-injection endophthalmitis ranged from . % ( in injections) to . % ( in injections) with no significant difference among the annualized rates (p = . ). cultures were performed in of these cases, and mean follow-up for all suspected endophthalmitis cases was . months (range, days - . months). mean (sd) duration of follow-up was . ( . ) months (range, . - . months) for the face mask group and . ( ) months (range, - months) for the "no talking" group (p = . ). in the "no talking" group, suspected endophthalmitis occurred in cases of , injections ( . %; in , injections), of which cases were culturepositive ( table ). the most common causative organism was staphylococcus epidermidis in cases. there were cases of oral flora-associated endophthalmitis ( . %; in , injections), and causative organisms included cases of streptococcus mitis, cases of streptococcus viridians, cases of streptococcus pneumoniae, and cases of undifferentiated streptococcus. in the face mask group, suspected endophthalmitis occurred in cases of , injections ( . %; in , injections) of which cases were culture-positive (table ). causative organisms included cases of gram-positive cocci (by stain), case of staphylococcus epidermis, and case of staphylococcus aureus. there were no cases of oral flora-associated endophthalmitis. overall, patients with presumed endophthalmitis presented an average of . days after intravitreal anti-vegf injection (range, - days). the vast majority of cases presented within days of intravitreal injection ( . %). patients in the face mask group presented an average of . days after injection compared to an average of . days in the "no talking" group (p = . ). of the cases sent for culture, in the face mask group, / ( %) cases were culture-positive compared to / ( %) endophthalmitis cases in the "no talking" group (p = . ). endophthalmitis cases in the face mask group were oral floraassociated in / ( %) cases compared to / ( %) cases for the "no talking" group (p = . ). of the , injections in the face mask group, , ( %) were bevacizumab, , ( %) were aflibercept, and , ( %) were ranibizumab. of the , injections in the "no talking" group, , ( %) were bevacizumab, , ( %) were aflibercept, and , ( %) were ranibizumab. compared to the "no talking" group, the face mask group was more likely to use aflibercept (p < . ) and less likely to use ranibizumab (p < . ). overall, there were cases of endophthalmitis after ranibizumab injection ( . %; in ranibizumab injections), cases of endophthalmitis after aflibercept injection ( . %; in aflibercept injections), and cases of endophthalmitis after bevacizumab injection ( . %; in bevacizumab injections). endophthalmitis cases were associated with ranibizumab in / ( %) cases, aflibercept in / ( %) cases, and bevacizumab in / ( %) cases. endophthalmitis cases in the "no talking" group were associated with bevacizumab in / ( %) cases, aflibercept in / ( %) cases, and ranibizumab in / ( %) cases. endophthalmitis cases in the face mask group were associated with bevacizumab in / ( %) cases, aflibercept in / ( %) cases, and ranibizumab in / ( %) cases. there was no significant difference in the risk of endophthalmitis between the face mask group and the "no talking" group based on drug type (table ) . overall average baseline va at the causative injection prior to endophthalmitis was logmar . (approximately / ) with no significant difference between the face mask group (logmar . ; approximately / ) and the "no talking" group (logmar . ; approximately / ) (p = . ) ( table ). at -months follow-up, average va was logmar . (approximately / ) for the face mask group vs. logmar . (approximately / ) for the "no talking" group (p = . ). for the face mask group, / ( %) cases had a va of count fingers or worse at -months follow-up compared to / ( %) for the "no talking" group (p = . ). at -months follow up, / ( %) cases in the face mask group lost or more lines of va from baseline compared to / ( %) cases in the "no talking" group (p = . ). at last follow-up, average va was logmar . (approximately / ) for the face mask group vs. logmar . (approximately / ) for the "no talking" group (p = . ). for the face mask group, / ( %) cases had a va of count fingers or worse at last follow-up compared to / ( %) for the "no talking" group (p = . ). average va at presentation for culture-positive endophthalmitis cases was logmar . (approximately / ) in the face mask group compared to logmar . (approximately / ) in the "no talking" group (p = . ) ( table ). at -months follow-up, average va for the culture-positive endophthalmitis cases was logmar . (approximately / ) in the face mask group vs. logmar . (approximately / ) in the "no talking" group (p = . ). for the culture-positive endophthalmitis cases in the face mask group, / ( %) cases had a visual acuity of count fingers or worse at months follow-up compared to / ( %) for the "no talking" group (p = . ) furthermore, at -months follow up, / ( %) cases in the culture-positive face mask group lost or more lines of va from baseline compared to / ( %) cases in the culture-positive "no talking" group (p = . ). at last follow-up, average va for culture-positive endophthalmitis cases was logmar . (approximately / ) in the "no talking" group vs. logmar . (approximately / ) in the face mask group (p = . ). for the culture-positive endophthalmitis cases in the face mask group, / ( %) cases had a va of count fingers or worse at last follow-up compared to / ( %) for the "no talking" group (p = . ). overall, visual outcomes were significantly worse for culture-positive and oral flora-associated endophthalmitis cases. comparing vision loss from baseline, at months follow up, oral flora-associated cases lost an average of lines of visual acuity, non-oral flora-associated culture-positive cases lost . lines of visual acuity, and culture-negative cases lost . lines of visual acuity (p < . ). this study examined the impact of physician face mask use on the rates and outcomes of endophthalmitis after intravitreal anti-vegf injections. in this single-center study of , intravitreal injections, we found that physician face mask use did not affect the overall rate of post-injection endophthalmitis. injection techniques for both the face mask and "no talking" groups were similar. however, the injecting physicians in the face mask group likely did not uniformly adhere to a strict policy of silence for all people in the room during the procedure compared to the physicians in the "no talking" group. in spite of this, no cases of oral flora-associated endophthalmitis were observed in the face mask group. although all forms of endophthalmitis are visually threatening, oral floraassociated endophthalmitis is associated with a particularly poor visual prognosis. [ ] [ ] [ ] therefore, there is significant interest in understanding potential risk factors and prophylaxis measures for reducing the incidence of oral flora-associated endophthalmitis. a meta-analysis of the literature covering , intravitreal injections from to found that streptococcal species were three times more likely to be the causative organism in post-injection endophthalmitis cases than in intraocular surgeries in which a surgical mask is typically worn. furthermore, prior studies have established that oral flora-associated endophthalmitis may be reduced with the implementation of a strict "no-talking" policy by the physician and patient during intravitreal injection administration. , refraining from speaking during an intravitreal injection is thought to minimize the potential to contaminate the uncapped needle or conjunctival surface with oral flora immediately before or during the injection. similarly, face mask use by the physician administering the injection may serve to further limit bacterial dispersion during speech. within the neurology literature, multiple outbreaks of iatrogenic oral flora associated meningitis have been reported. as a result, face mask use has become the standard of care for any clinician performing spinal injections. [ ] [ ] [ ] in one case of iatrogenic meningitis, the causative bacteria was genotyped and shown to be identical to that of a throat swab taken from the neurologist who performed the lumbar puncture. within ophthalmology, an in vitro study involving surgeons and simulated intravitreal injection scenarios found that the rate of oral flora bacteria was significantly reduced when speaking with face masks compared to speaking without face masks. furthermore, another in vitro study of volunteers who underwent simulated intravitreal injection administrations demonstrated significantly more bacterial dispersion occurred when speaking without a face mask compared to speaking while wearing a face mask. however, there was no significant difference in bacterial dispersion when speaking with a face mask compared to not speaking without a face mask (simulating a "no-talking" policy). these in vitro studies correlate with our study findings as all intravitreal injections were administered with either a "no-talking" policy or face mask use by the physician. some studies have suggested that the presence of a beard or the tendency to excessively move one's face beneath a surgical mask , may increase bacterial dispersion and shedding, presumably from the beard and facial skin. in addition, other studies have suggested that extended use of the same face mask may increase infectious risk as the external surface can function as a fomite. furthermore, physicians speaking with a loose fitting face mask may result in upward or downward bacterial dispersal. collectively, these concerns may explain why the majority of retina physicians surveyed in two recent studies did not wear face masks during intravitreal injections. , at a minimum, our study findings suggest that physician face mask use does not increase the risk of post-injection endophthalmitis and may be equivalent to a strict "no talking" policy. these findings are particularly relevant as routine use of face masks by physicians has exponentially increased with the emergence of the covid- pandemic, and it is unclear what the duration of these precautions will be. although this study focused on the impact of physician and technician assistant face mask use, current covid- guidelines recommend universal face mask protocols for all individuals in the injection room which includes the patient. with regard to patient face mask use, it is possible that bacterial dispersion around the edges of the face mask may be directed towards the eye, which could potentially increase the risk of endophthalmitis. indeed, current guidelines from the center for disease control and prevention recommend cloth face covering, which may not adhere to the face as well. further studies are indicated to understand the effects of universal face mask use on rates of various types of endophthalmitis. overall, va outcomes following endophthalmitis were similar in the face mask group compared to the "no talking" group. va at the causative injection, endophthalmitis presentation, and six months following treatment were similar between the two groups. patients in the "no talking" group were more likely to have a visual acuity of cf or worse at months compared to the face mask group ( % vs %), though these findings were not statistically significant. regardless of face mask use, our findings were similar to prior studies that have established that visual outcomes are worse for culture-positive cases compared to culture-negative cases. , when assessing culture-positive endophthalmitis cases, visual outcomes at endophthalmitis presentation were worse for the "no talking" group with a mean loss of . lines of vision from baseline acuity compared to a loss of . lines for the face mask group. furthermore, at -months follow up, patients in the "no talking" group were more likely to have a va of cf or worse compared to the face mask group ( % vs %), though these findings were not statistically significant. strengths of the study include the large number of intravitreal injections from a single institution with a standardized injection protocol, including injection technique and preparation, amongst multiple retina specialists. endophthalmitis following intravitreal injection is an uncommon event with reported incidence rates ranging from as high as in approximately injections to as low as in , injections with the majority of large recent studies reporting an incidence rate of in - injections. , , , - . therefore, any prophylaxis measure to potentially lower the risk of endophthalmitis requires an assessment of a large number of intravitreal injections to achieve adequate power to detect a difference. although we report one of the largest single center studies of post-injection endophthalmitis, our study findings may be limited by the study's imbalanced sample size with , injections in the face mask group compared to , injections in the "no talking" group. assuming the risk of oral flora-associated endophthalmitis is in , injections as reported in this study, and that face mask use may reduce the risk of oral flora-associated endophthalmitis to in , injections, a study would need , injections to be sufficiently powered to detect a j o u r n a l p r e -p r o o f significant difference between the two groups with a confidence of . and power of . . ideally, a randomized controlled study could evaluate the risk of endophthalmitis with and without physician face mask use; however, the low incidence of endophthalmitis makes such a study prohibitive. furthermore, the granularity of physician-specific practice patterns, like face mask use, may not be captured in large-scale insurance claims databases or clinical registries. another limitation is the imbalance in medication distribution as the face mask group was more likely to use aflibercept and less likely to use ranibizumab compared to the "no talking" group. these findings may be particularly relevant as the prefilled syringe use for ranibizumab was introduced during the study period, and prior studies have reported prefilled syringes may reduce the risk of endophthalmitis. , furthermore, during the study period, there was a clustered spike in cases with intraocular inflammation after intravitreal aflibercept injections, which may explain the increased proportion of endophthalmitis associated with aflibercept compared to ranibizumab or bevacizumab in this study. the authors' standard practice is to have a low threshold to administer intravitreal antibiotics whenever the examining physician believes there is a possibility the case could represent infectious endophthalmitis; however, when sterile inflammation is suspected, topical medications alone were typically prescribed. regardless, there were no differences in endophthalmitis risk between the face mask group and "no talking" group based on drug type. another limitation is that microbiologic cultures were obtained in of ( %) cases. however, there were similar rates between the two groups as cultures were performed in of ( %) cases for the "no talking" group and of cases ( %) for face mask group (p > . ). recent studies have suggested that culture results have limited impact on clinical management. , furthermore, another limitation is that a positive gram stain was considered culture-positive even if there was no bacterial growth on culture. however, prior studies have suggested that any bacteria detected on gram stain of a sterile site specimen, such as vitreous or aqueous samples, should be considered significant. in addition, a culture result was considered to be oral flora-associated when enterococcus or streptococcus species was grown, which may not represent all potential oral flora. however, there were no cultures that grew other common oral flora including lactobacilli, corynebacteria, or bacteroides in either group. furthermore, streptococcal associated post-injection endophthalmitis is of particular concern given the poor visual prognosis relative to other forms of endophthalmitis. - additional limitations of this study are inherent in its retrospective nature. it is possible that patients could have developed endophthalmitis and sought treatment at an outside institution, although it is unlikely given the tertiary care nature of our institution. in summary, our study indicates that physician face mask use did not influence the risk of endophthalmitis or visual outcomes compared to a strict no talking policy during the injection procedure. no cases of oral flora-associated endophthalmitis occurred in the group in which the injecting physician wore a face mask though this study was underpowered to detect a difference. these findings are particularly relevant as routine use of face masks by retina specialists has increased with the emergence of the covid- pandemic. however, it is important to note that patients in the face mask group did not wear a mask which is unlike the current universal face mask protocols in place. additional studies are warranted to assess the potential role of face mask use to reduce the risk of endophthalmitis, particularly those due to oral flora. table . visual acuity outcomes for culture-positive endophthalmitis after intravitreal anti-vascular endothelial group factor injection in the face mask group vs. "no talking" group this study evaluated the rate of post-injection endophthalmitis with physician face mask use compared to a "no talking" policy without face mask use. in evaluating , intravitreal injections, physician face mask use did not reduce the rate of post-injection endophthalmitis compared to a "no talking" policy. no cases of oral flora-associated endophthalmitis were identified with physician face mask use. trends of anti-vascular endothelial growth factor use in ophthalmology among privately insured and medicare advantage patients international practice patterns for the management of acute postsurgical and postintravitreal injection endophthalmitis: european vitreo-retinal society endophthalmitis study report endophthalmitis following intravitreal injections performed in the office versus operating room setting outcomes and risk factors associated with endophthalmitis after intravitreal injection of antivascular endothelial growth factor agents the role of topical antibiotic prophylaxis to prevent endophthalmitis after intravitreal injection the impact of prefilled syringes on endophthalmitis following intravitreal injection of ranibizumab effect of a strict 'no-talking' policy during intravitreal injection on post-injection endophthalmitis microbial spectrum and outcomes of endophthalmitis after intravitreal injection versus pars plana vitrectomy endophthalmitis after intravitreal injection: the importance of viridans streptococci endophthalmitis following intravitreal injection effect of surgical mask position on bacterial contamination of the operative field unmasking the surgeons: the evidence base behind the use of facemasks in surgery bacterial dispersal associated with speech in the setting of intravitreous injections reducing oral flora contamination of intravitreal injections with face mask or silence endophthalmitis after intravitreal injections: should the use of face masks be the standard of care? mask wiggling as a potential cause of wound contamination the effect of facial hair and sex on the dispersal of bacteria below a masked subject surgical face masks and downward dispersal of bacteria surgical masks as source of bacterial contamination during operative procedures preparedness among ophthalmologists: during and beyond the covid- pandemic long-term visual outcomes and clinical features after anti-vascular endothelial growth factor injection-related endophthalmitis functional status and quality of life measurement among ophthalmic patients novel method for analyzing snellen visual acuity measurements meta-analysis of endophthalmitis after intravitreal injection of antivascular endothelial growth factor agents: causative organisms and possible prevention strategies iatrogenic meningitis by streptococcus salivarius following lumbar puncture iatrogenic meningitis: the case for face masks guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings current practice preferences and safety protocols for intravitreal injection of anti-vascular endothelial growth factor agents real-world trends in intravitreal injection practices among american retina specialists use of cloth face coverings to help slow the spread of covid- changes in management based on vitreous culture in endophthalmitis after intravitreal anti-vascular endothelial growth factor injection trends in vitreoretinal procedures for medicare beneficiaries eliminating antibiotic prophylaxis for intravitreal injections: a consecutive series of , injections by a single surgeon endophthalmitis: then and now association of acute endophthalmitis with intravitreal injections of corticosteroids or anti-vascular growth factor agents in a nationwide study in france aflibercept-related sterile intraocular inflammation outcomes endophthalmitis after cataract surgery: changes in management based on microbiologic cultures the spinal tap: a new look at an old test key: cord- -ev fzly authors: almawly, j.; prattley, d.; french, n.p.; lopez-villalobos, n.; hedgespeth, b.; grinberg, a. title: utility of halofuginone lactate for the prevention of natural cryptosporidiosis of calves, in the presence of co-infection with rotavirus and salmonella typhimurium date: - - journal: vet parasitol doi: . /j.vetpar. . . sha: doc_id: cord_uid: ev fzly halofuginone lactate (hl) is registered in several countries for the prevention of calf cryptosporidiosis, but the compound's utility in the presence of co-infection with other enteropathogens is not well understood. we performed a randomized controlled field trial of the efficacy of hl for the prevention of natural calf cryptosporidiosis, in the presence of co-infection with rotavirus and salmonella typhimurium. newborn calves on one farm were sequentially enrolled and allocated to a full dose (n = ), half dose (n = ), or a placebo control group (n = ), using a randomized block design. the cryptosporidium oocysts in fecal specimens collected on days , , , and were counted and the severity of the diarrhea was assessed using fecal consistency scores (solid, semisolid, or liquid). the oocyst numbers and fecal consistency scores were statistically compared between the groups. ninety one percent of the calves shed cryptosporidium parvum oocysts during the trial. the full dose group had a longer prepatent period than the control group, but no statistical difference in the number of oocysts was identified between the groups after controlling for the effects of sex and breed. the fecal consistency scores and mortality rates did not differ between the groups. these results indicated that the anti-cryptosporidium activity and clinical benefit of hl were limited. it is concluded that in order to maximize the clinical efficacy of hl in the field, diagnostic efforts should aim to rule out the presence of other enteropathogens. the cosmopolitan protozoan parasite cryptosporidium parvum infects humans and a range of other hosts, and is a common agent of calf diarrhea during the first four weeks of life (gulliksen et al., ; lanz uhde et al., ; millemann, ; trotz-williams et al., ) . the spectrum of severity of cryptosporidiosis in calves varies from subclinical infection to severe diarrhea and dehydration (fayer et al., ; klein et al., ; o'handley et al., ) . typically, natural and experimental infections with c. parvum in calves have a pre-patent period of - days, followed by a patent period characterized by a bell-shaped oocyst excretion curve, with the number of fecal oocysts peaking and then rapidly decreasing to undetectable levels in a matter of - days (fayer et al., ; grinberg et al., ) . oocyst numbers as high as oocysts per gram of feces have been reported at the peak of excretion (fayer et al., ; grinberg et al., ) . whereas infection rates as high as % have been reported in calves in the first month of life, a lower infection prevalence has been consistently observed in weaned animals (bartels et al., ; brook et al., ; fayer and xiao, ; fayer et al., ; garber et al., ) . newborn calves are therefore considered major amplifiers of potentially zoonotic c. parvum in nature, and the prevention of calf cryptosporidiosis is relevant from both animal and human health perspectives (hunter and thompson, ; kiang et al., ; smith et al., ; grinberg et al., ; xiao and feng, ; zhou et al., ) . several features of the c. parvum life cycle make the control of cryptosporidiosis on-farms extremely difficult to be achieved by means of hygienic measures alone. calves can excrete hundreds of millions of oocysts (naciri et al., ; grinberg et al., ) , and considering there is a high probability of infection with a dose as low as oocysts (moore et al., ) , an infected calf could produce enough oocysts to infect thousands of new animals. attempts to interrupt the transmission of c. parvum should therefore include the immediate isolation of every infected animal, but this is rarely feasible on commercial farms. in addition, the c. parvum oocysts are insensitive to the action of numerous disinfectants (chen et al., ; quilez et al., ) and are excreted sporulated and fully infectious (smith et al., ) , requiring daily cleaning for their removal. therefore, in the absence of effective immunizing agents, pharmacological control strategies remain central for the prevention of cryptosporidiosis in calves. a number of compounds, such as halofuginone lactate (hl) (lefay et al., ; jarvie et al., ; klein, ; de waele et al., ; trotz-williams et al., ) , paromomycin sulphate (fayer and ellis, ; grinberg et al., ) , nitazoxanide (ollivett et al., ; schnyder et al., ) and decoquinate (moore et al., ; lallemond et al., ) have been tested for the prevention of cryptosporidiosis in calves, with variable results. hl is a synthetic derivative of a quinazolinone alkaloid with cryptosporidiostatic activity, but a mode of action that is poorly characterized. in naturally and experimentally infected calves, the oral administration of g/kg hl for seven consecutive days from the first day of life delays the onset of oocyst shedding, reduces the number of oocysts excreted, and lowers the severity of diarrhea joachim et al., ; klein, ; lefay et al., ; trotz-williams et al., ; villacorta et al., ) . a formulation containing hl (halocur, intervet ltd., republic of ireland) is currently the only prescription drug registered for the prevention of cryptosporidiosis of calves in several countries. the use of hl has a number of limitations, including a substantial market price and a narrow therapeutic index, with toxicity observable at approximately twice the recommended dose (villacorta et al., ; naciri et al., ; trotz-williams et al., ; http://www.msd-animal-health.co. uk/products public/halocur/ product datasheet.aspx, accessed july ). remarkably, notwithstanding the frequent occurrence of co-infections with cryptosporidium and other enteropathogens in the field (de la fuente et al., ; naciri et al., ; tzipori et al., ) , the utility of hl in the presence of such co-infections is not well understood. indeed, with some exceptions (klein, ; lefay et al., ) , most anti-cryptosporidium efficacy studies of hl did not analyze or took into account the presence of co-infections. co-infections might modify the anti-cryptosporidium effect of hl in different ways. the increased fluid content and intestinal motility determined by the presence of co-infecting pathogens may reduce the activity of hl by dilution, or by reducing the transit time of the drug in the intestinal tract. furthermore, enteric infection with rotavirus or other agents may cause exfoliation of infected cells, altering intestinal cellular function (ramig, ) , potentially increasing the toxicity of hl via systemic absorption. motivated by the need of more data on the utility hl in the presence of co-infections with other pathogens, we performed a randomized controlled field trial of the anti-cryptosporidium preventive efficacy of the compound in calves on a new zealand farm enzootically infected with c. parvum, bovine rotavirus and salmonella typhimurium. the study was performed between july and october , on a farm situated in the taranaki district, new zealand. consent for this study was obtained from the farmer and the use of animals was approved by the animal ethics committee, massey university. the farm managed a seasonal (spring) calving dairy herd of approximately milking cows and a smaller herd of beef cattle. it was recruited following a post-mortem investigation performed in march on two calves conducted by one of the authors (ag), which indicated the presence of cryptosporidium oocysts in the feces of two calves. salmonella was ruled out by culture and rotavirus and coronavirus by antigen elisa. sequence analysis of the cryptosporidium s rrna gene subsequently confirmed c. parvum in both animals. notwithstanding the microbiological results performed in march, bovine rotavirus and salmonella spp. were subsequently identified in multiple enrolled calves during the study (see below). the study was a randomized controlled field trial (see randomization procedure below). a commercial product (halocur, intervet ltd., republic of ireland) registered in new zealand for the prevention and treatment of cryptosporidiosis of calves was used to test the efficacy of hl. the product's recommended preventive dose is mg ( ml) for calves weighing - kg, and mg ( ml) for calves weighing - kg, for seven consecutive days, from birth. the initial aim was to assess the preventive efficacy of half the recommended dose of hl as compared with the full dose and no treatment, and the following treatment groups were established: group (full dose regime; n = ), calves treated orally with ml halocur; group (half dose regime; n = ), calves treated with ml halocur; group (placebo control group; n = ), calves treated with ml water delivered using the product's dispenser. the group sizes were estimated using power analysis for the detection of a difference between means, using pass software (ncss, kaysville, ut). assumptions for the calculations were a log -transformed mean number of oocysts per gram of feces of . for the full dose and . for the untreated-control group at the peak of shedding, and a common standard deviation of . . these means were estimated from a previously published study of efficacy of paromomycin sulphate (grinberg et al., ) . group sizes of calves per group achieved % power to reject the null hypothesis that both group means are . . thus, assuming a conservative infection rate of ∼ %, calves per group were required. management of the enrolled calves followed the same routine procedures used on the farm. briefly, newborn calves were left on the calving paddock for - h after birth, as commonly done in new zealand pasture-based farms to allow for colostrum intake directly from the dam. then the newborns were transferred to a large shed and allocated to a pen for newborn calves, of a capacity of about calves. calves were left in this pen for - days and then transferred to a new pen, in order to create space for new calves in the first pen. subsequently, the calves progressed to new pens (often adjacent) containing - animals of the same age group every - days, until weaning. the allocation of calves to pens was done by caretakers who were not aware of the nature of the treatments given to each calf, effectively creating a commingled pen design. adjacent pens were separated by slatted wooden fences. sawdust was used as bedding material. the feeding regimen included the administration of complete commercial milk replacement for the first two weeks using a tank with multiple nipples, followed by feeding ad libitum using automatic feeders until weaning. roughage was available from the second week of life. no routine vaccinations, preventive treatments or supplementations were administered to the calves during the study. however, inappetent calves could be tube-fed and severely diarrheic calves treated with oral electrolytes and/or other treatments by the caretakers. severely sick calves were transferred to an isolation shed. the study protocol stipulated that the tube fed calves could continue in the study, but animals treated by the farmer other means or transferred to the isolation pen, were removed. newborn calves were sequentially enrolled in the mornings, at arrival from the calving area to the rearing shed. any calf born on the farm was eligible for enrolment, provided no congenital or pathological conditions were identified. at the day of enrolment (day ), calves were identified by the ear or neck tag number, given a sequential number and allocated to one of the three treatment groups. allocation of calves to treatment groups was done using a randomized block design, with blocks of three (one calf per group), using a random list prepared in advance. the fourth calf presented to the investigator after each block of three was systematically left unenrolled and continued its normal life cycle on the farm. treatments were administered in the morning using the commercial product (see above). fecal specimens were collected at the time of treatment from the rectum of each calf using disposable gloves, on days , , , and . at the time of collection, each specimen was scored according to its consistency as , solid (specimen conserved its original shape); , semi-solid (specimen spread across the bottom of the container but was not liquid); or , liquid specimen. specimens were transported on ice to massey university and kept in refrigeration and analyzed between december and april , as described below. the fecal specimens were analyzed by a quantitative method that estimated the number of cryptosporidium oocysts present. briefly, after mixing the specimen with a spatula, g of feces was suspended in ml tap water and strained through a tea sieve. the filtrate was centrifuged at × g for min and the sediment re-suspended in ml of normal saline. a l aliquot of this suspension was deposited as a drop on a slide using a micropipette, airdried and fixed in methanol. fixed drops were stained using a commercial immunofluoresecent anti-giardia and cryptosporidium monoclonal antibody (aqua-glo g/c direct comprehensive kit, waterborne inc., new orleans, usa), according to the manufacturer's instructions. the applegreen fluorescent oocysts present on the entire area of the stained drop were counted using a fluorescent microscope using an excitation wavelength of nm and a × magnification lens. this total number of oocysts (ton) on the slide was used for statistical analysis (see below). samples containing > oocysts were difficult to count and were re-processed by a further dilution of the fecal suspension at − in water, followed by the staining of a l drop as above. the ton present on each rediluted specimen was estimated by multiplying the result by . when the available fecal material was insufficient for counting, a direct fecal smear was stained and a qualitative result (presence/absence of oocysts) was obtained. these qualitative results could not be used for the statistical comparison of the number of oocysts between the treatment groups, but were used for any comparison between proportions of cryptosporidium-positive and negative specimens. in march , dna from three cryptosporidiumpositive specimens from each treatment group was extracted from the stored feces using a dna extraction kit (qiaamp, dna stool mini kit, qiagen, hilden, gmbh), and cryptosporidium parasites were identified by means of pcrsequencing of the s rrna gene. primers were -gtt aaa ctg cga atg gct ca- (forward) and -cca ttt cct tcg aaa cag ga- (reverse) (learmonth et al., ) . amplification was performed in l containing l x pcr buffer, l dntp ( mm), l mgcl ( mm), l nonacetylated bovine serum albumin ( mg/ml) (new england biolabs, usa), picomoles of each primer, and . l of platinum ® taq dna polymerase ( mg/ml) (invitrogen corporation, carlsbad ca, usa). the pcr amplification was carried out in a thermocycler (sensoquest, goettingen, germany) with initial denaturation at • c for min, followed by cycles at • c for s, • c for s and • c for s. pcr products were purified using an in-house ethanol purification protocol, and bidirectional sequencing of an internal segment of the amplicon was performed using primers -ctcgactttatggaagggttg- (forward) and -cct ccaatctctagttg gcata- (reverse). forward and reverse sequences were aligned and edited manually using geneious software version . . (biomatters ltd., http://www.geneious. com/). distal and proximal segments that could not be verified were trimmed and the resulting edited sequences aligned with sequences deposited in genbank using the alignment algorithm blast (http://blast.ncbi.nlm.nih.gov/blast.cgi, accessed on april ). in addition to the analysis for cryptosporidium, fecal specimens taken haphazardly from the three treatment groups were analyzed for the presence of rotavirus, coronavirus, enterotoxigenic k + escherichia coli (k ) and salmonella spp. the analysis for rotavirus, coronavirus and k -positive e. coli was performed by a commercial diagnostic laboratory using antigen-elisa (institut pourquier, montpellier, france). the analysis for salmonella included parallel inoculation of fecal material into tetrathionate and rappaport-vassiliadis soy peptone (rvs) broths, and incubation for h at • c and • c, respectively. this was followed by subculture onto xylose lactose deoxycholate agar plates incubated as above. colonies consistent with salmonella were sub-cultured into triple-sugar iron agar slopes (tsi) and l-lysine decarboxylase broth. lysinepositive bacteria exhibiting tsi patterns consistent with salmonella were subjected to salmonella poly-o slide agglutination using a commercial antiserum (institut für immunpräparate und nährmedien gmbh berlin, berlin, germany), and agglutinating isolates were sent to the salmonella reference laboratory (institute of environmental science and research, porirua, new zealand) for serotyping. the parasitological and clinical effects of the three treatments were statistically compared. the parasitological effects were analyzed by comparing the tons between the groups using an analysis of variance for repeated measurements (rmanova) implemented by the proc mixed procedure of sas (statistical analysis system, , sas institute, cary, nc, usa). tons were log-transformed as log (ton + ) and analyzed using mixed models. the first model (model ) included the fixed effects of treatment (variable 'treatment group'), the day of sampling as repeated factor (variable 'sampling day'), and the interaction of treatment group and sampling day. model included the fixed effects as in model plus the fixed effect of sex of the calves, and model included the same factors as in model plus the effect of breed of the calves as a co-variable (variable 'breed'; friesian calf = ; non-friesian calf = ). fixed effects for variable breed were not included as a class due to unbalanced designs deriving from the uneven distribution of breeds across treatments. finally, model was similar to model , but did not include the data obtained from non-freisian calves, effectively removing any variability due to the breed. all the models included the random effect of calf, to account for the within-calf variability. using the akaike's information criterion, an unstructured error structure was determined as the most appropriate residual covariance structure for repeated measures over time, within animals. finally, the parasitological efficacy was also assessed by comparing the decline of the proportion of parasitologically negative calves as a function of time between the three groups using the nonparametric kaplan-meier method (km) (kaplan and meier, ) . also in this case, the analysis was repeated after omitting all the data from the non-friesian calves. the km analysis was implemented using a code available in "r" (terry therneau, ; a package for survival analysis in r package version . - ). the clinical effects of the treatments were assessed by comparing the fecal consistency scores (considered ordinal data) between the groups on each sampling day, using the non-parametric kruskal-wallis test. these tests were performed using the codes available in "r" (kruskal-wallis: http://stat.ethz.ch/r-manual/r-patched/library/stats/ html/kruskal.test.html; wilcoxon: http://stat. ethz.ch/ r-manual/r-patched/library/stats/html/wilcoxon.test. html). comparisons between proportions of interest were performed using two-tailed fisher's exact tests, which were interpreted using bonferroni-adjusted critical p-values for multiple testing. finally, the existence of association between the fecal consistency and the number of oocysts shed was tested by means of logistic regression, using the log (ton + ) as independent variable and the presence/absence of a liquid specimen (fecal score ) as outcome variable. this analysis was performed using a code available in "r" (http://www.ats.ucla. edu/stat/r/dae/logit.htm; r package version . - ). all the calves were enrolled within h from birth, over a -day period, between july and august . a total of / ( . %) calves were females and there were no statistical differences between the proportion of males and females among the treatment groups. there were ( %) friesian, ( %) angus, ( %) hereford calves and one ( %) jersey × angus crossbred calf (table ) . six calves haphazardly selected at enrolment and weighted using electronic scales had bodyweights between and kg (mean = . , standard deviation = ), indicating under/over-dosing of calves was unlikely to have occurred. one calf that died on the same day of enrolment (calf number ; table ) was substituted by the subsequent calf presented to the investigator (calf number ; table ). all the enrolled calves remained in their pens during the study and no calf was withdrawn due to concomitant treatment. thirty eight calves ( . %) were followed up for the entire observation period, and seven ( . %) died at different stages during the study. the causes of death were defined by the farmer as following: two calves from group died on days and , two from group on days and , and one from group on day , from severe diarrhea. two calves (group and group ) died from improper tube-feeding (possibly, milk inhalation) on day and day . there were deaths in group , three in group and one in group , and these rates were not statistically different (table ) . only / ( . %) fecal specimens could not be retrieved and were not analyzed (table ) . a total of / ( %) calves were cryptosporidiumpositive by immunofluorescence at some stage during the study. two calves belonging to group , that were able to be followed up for the entire observation period, remained parasitologically negative throughout the study (table ) . sequence analysis of the srrna gene of the fecal specimens analyzed by pcr-sequencing indicated the presence of c. parvum in all cases. out of specimens analyzed for other enteropathogens, ( %) were positive for rotavirus and ( %) for salmonella typhimurium. as expected for calves of this age, no e. coli k -positive specimens were identified. although analysis for giardia spp. was not the subject of this study (as the parasite it is not widely considered pathogenic for calves), we note for completeness that giardia cysts were observed in calves by immunofluorescence. the number of cryptosporidium-negative/positive fecal specimens stratified by the treatment groups and sampling days. on the same day, similar superscripts indicate comparisons between proportions resulting in two-tailed fisher's exact test p < . (less than bonferroni-adjusted critical probability). sampling day group (full dose) group (half dose) group (placebo-control) group (full dose) group (half dose) group (placebo-control) day / / / / / / day / * / + / * + / / * / * day / * / / * / / / day / / / / / / day / * / * / / / / the calves in group (control group) showed an oocyst shedding curve which was typical for natural cryptosporidiosis, with the majority of the animals becoming parasitologically positive by day and again negative by day (tables and ) . group started shedding earlier than the other two groups. in this group, the highest mean log (ton + ) was observed on day , and on day oocysts were observed only in two calves (table ). in contrast, in group the peak mean log (ton + ) was lower and occurred later (day ) than in group , and on day , the calves in this group were shedding more oocysts than the other two groups. however, when only friesian calves were considered, groups and showed a very similar oocyst shedding curve, which peaked in both groups on day . comparisons between the crude mean log (ton + ) of the three treatment groups at the various sampling days are reported in fig. . model (which included the effects of treatment group, sampling day and their interaction term), indicated a significant difference between the three treatments (p = . ). post hoc comparisons identified a significant difference between group (full dose) and group (control) (group < log (ton + ) than group ; p = . ), and no significant difference between group and the other two groups. in model , which included also the fixed effect of sex, the significance between the treatment groups was preserved (p = . ), but there was no significant effect of sex on the outcome (p = . ). when variable 'breed' was introduced as a covariate in model , the pvalue of the effect of treatment increased to p = . , and the covariable 'breed' was also significant (friesian < log (ton + ) than non-friesian; p = . ). this increase in the p-value was supported by model (friesian only), which showed p = . for the effect of treatment. all these models produced similar p-values when the interaction of treatment × day was removed (not shown). in order to cross-validate these results we compared the mean log (ton + ) between the treatment groups using bivariate anova for each sampling day separately (not shown), with consistent results: whereas the inclusion of all the animals resulted in statistically significant difference between treatment groups and on days , and (p < . ), all the p-values were > . when only friesian calves were analyzed. the results of the kaplan-meier test indicated a significantly longer prepatent period in group as compared with group . in fact, calves ( %) in group were parasitologically positive on day , whereas only three calves from group ( %) were shedding oocysts on the same day (tables and ). the duration of the prepatent period in group was intermediate, although not statistically different from the other groups. similar results were observed when only data from friesian calves were analyzed (fig. ) . the results of the fisher's exact tests showed that on days and , the proportion of cryptosporidiumpositive calves was significantly greater in group than in group (two-tailed fisher's exact test p < bonferroniadjusted critical value of . ). on the other hand, most calves ( %) in group and only two calves in group and two in group were shedding oocysts on that day (table ) . twenty three calves ( %) passed at least one liquid specimen in the course of the study, and the proportion of liquid specimens on day was relatively high, and very similar in the three treatment groups (table ). the results of kruskal-wallis and wilcoxon tests test did not indicate any significant difference (p > . ) between the fecal consistency scores of the three groups on any sampling day (not shown). except one significant difference between group and group on day , the proportion of liquid specimens did not differ between the groups (table ) , and these result persisted when only friesian calves were included in the analysis (not shown). there was no association between the log (ton + ) and the presence of liquid specimen by logistic regression (p > . ). halofuginone lactate is registered for the prevention of calf cryptosporidiosis in several countries, but the compound has a relatively narrow therapeutic index and a substantial market price. this study was initially designed to assess the efficacy of a reduced dosage regime of hl on a farm infected with c. parvum, with no evidence for the presence of co-infection. however, the identification of rotavirus and salmonella typhimurium in multiple calves provided an opportunity to collect much needed data of the utility of the compound in the presence of such common co-infections. when the study was designed, we predicted a longer prepatent period and a decreased number of oocysts and fecal consistency scores in the full dose group, as reported for hl in the absence of documented co-infections. the coinfections with rotavirus and salmonella typhimurium did not affect the ability of hl (full dose) to delay the onset of shedding. whereas most calves ( / ) in group were still shedding oocysts on day , the majority of the calves in the control group were already parasitologically negative by that day (table ). the prolongation of the prepatent period was not coupled with statistically significant differences between the mean log (ton + ) of the treatment groups after controlling for the repeated measurements, the sex, and the breed of the calves (models and ) . we hypothesize that hl suppressed the parasite's life cycle during the first days of treatment, when the diarrhea caused by the other pathogens was not yet overt, effectively prolonging the prepatent period in group . conversely, about % of the calves in group were passing liquid feces on day , and this early diarrhea (probably caused by the co-infecting pathogens) could have shortened the intestinal transit time of hl in the last days of treatment, effectively abolishing its anti-cryptosporidium effect. some authors suggested that co-infections with multiple agents could cause a more severe diarrhea than mono-infections (de la fuente et al., ; garcia et al., ) . consequently, it could be hypothesized that suppression of one organism could reduce the severity of the table the number of liquid feces (fecal score )/total specimens assessed, stratified by sampling days, treatment groups (the corresponding proportions are in brackets). on the same sampling day, an asterisk indicates a two-tailed fisher's exact test p < . (bonferroni-adjusted critical probability). group (full dose) group (half dose) group (placebo-control) ( ) diarrhea. in this study, there was no significant difference between the fecal consistency scores of the treated and untreated groups, and no association between the ton and the presence of liquid feces was found by logistic regression. furthermore, in agreement with the results of a metaanalysis of the literature (silverlås et al., ), the mortality rates did not differ between the groups. therefore, the results do not allow conclusions to be drawn on a clinical benefit of hl in the presence of co-infections. finally, the statistically significant effect of breed on the intensity of oocyst shedding observed in this study was intriguing. other studies have previously reported lower cryptosporidium infection prevalence in beef calves than in dairy calves (geurden et al., ; kváč et al., ) . the anti-cryptosporidium activity of hl was not fully preserved and the use of the drug was not associated with a clinical benefit in the presence of enzootic co-infection with rotavirus and salmonella typhimurium in calves. diagnostic efforts should therefore aim to rule out the presence of other common enteropathogens in order to maximize the clinical efficacy of hl in the field. one year after the completion of this study, the authors requested and obtained funding from msd animal health new zealand (the new distributors of halocur) to perform an epidemiological study of neonatal calf diarrhea in dairy farms. the current study was performed before such funds were requested and the company was not consulted during the preparation of this manuscript. prevalence, prediction and risk factors of enteropathogens in normal and non-normal feces of young dutch dairy calves prevalence and risk factors for cryptosporidium spp. infection in young calves cryptosporidium and concurrent infections with other major enterophatogens in to -day-old diarrheic dairy calves in central spain control of cryptosporidiosis in neonatal calves: use of halofuginone lactate in two different calf rearing systems cryptosporidium and cryptosporidiosis, second ed paromomycin is effective as prophylaxis for cryptosporidiosis in dairy calves cryptosporidium parvum infection in bovine neonates: dynamic clinical, parasitic and immunologic patterns epidemiology of cryptosporidium: transmission, detection and identification potential risk factors for cryptosporidium infection in dairy calves rotavirus and concurrent infections with other enteropathogens in neonatal diarrheic dairy calves in spain prevalence and genotyping of cryptosporidium in three cattle husbandry systems in zambia controlling the onset of natural cryptosporidiosis in calves with paromomycin sulphate genetic diversity and zoonotic potential of cryptosporidium parvum causing foal diarrhoea enteropathogens and risk factors for diarrhea in norwegian dairy calves the zoonotic transmission of giardia and cryptosporidium effect of halofuginone lactate on the occurrence of cryptosporidium parvum and growth of neonatal dairy calves prevalence and control of bovine cryptosporidiosis in german dairy herds nonparametric estimation from incomplete observations recurrent outbreaks of cryptosporidiosis associated with calves among students at an educational farm programme preventive and therapeutic efficacy of halofuginonelactate against cryptosporidium parvum in spontaneously infected calves: a centralised, randomised, double-blind, placebo-controlled study effect of cryptosporidium parvum infection on the absorptive capacity and paracellular permeability of the small intestine in neonatal calves age-related and housingdependence of cryptosporidium infection of calves from dairy and beef herds in south bohemia field study of the efficacy of halofuginone and decoquinate in the treatment of cryptosporidiosis in veal calves prevalence of four enteropathogens in the feces of young diarrhoeic dairy calves in switzerland genetic characterization and transmission cycles of cryptosporidium species isolated from humans in new zealand efficacy of halofuginone lactate in the prevention of cryptosporidiosis in suckling calves diagnosis of neonatal calf diarrhea prophylactic use of decoquinate for infections with cryptosporidium parvum in experimentally challenged neonatal calves the effect of halofuginone lactate on experimental cryptosporidium parvum infections in calves role of cryptosporidium parvum as a pathogen in neonatal diarrhea complex in suckling and dairy calves in france effect of nitazoxanide on cryptosporidiosis in experimentally infected neonatal dairy calves duration of naturally acquired giardiosis and cryptosporidiosis in dairy calves and their association with diarrhea efficacy of two peroxygen-based disinfectants for inactivation of cryptosporidium parvum oocysts pathogenesis of intestinal and systemic rotavirus infection systematic review and metaanalyses of the effects of halofuginone against calf cryptosporidiosis cryptosporidium and giardia as foodborne zoonoses cryptosporidium excystation and invasion: getting to the guts of the matter prophylactic and therapeutic efficacy of nitazoxanide against cryptosporidium parvum in experimentally challenged neonatal calves prevalence of cryptosporidium parvum infection in southwestern ontario and its association with diarrhea in neonatal dairy calves efficacy of halofuginone lactate in the prevention of cryptosporidiosis in dairy calves an outbreak of calf diarrhea attributed to cryptosporidial infection efficacy of halofuginone lactate against cryptosporidium parvum in calves zoonotic cryptosporidiosis food-borne parasitic zoonoses in china: perspective for control the authors thank the farm owners and staff for their co-operation, and mark stevenson (massey university) for contributing to the statistical analysis. this work was funded by the lewis fitch veterinary research fund, new zealand. the funding body had no active role in this study. bh was funded by a pfizer (currently zoetis) undergraduate summer scholarship. key: cord- -bverdk w authors: zhou, yefei; zhou, meixian; zhang, dunlin; zhang, honglin; zhang, liyang title: immune response of aa broilers to ibv h vaccine and sodium new houttuyfonate date: - - journal: research in veterinary science doi: . /j.rvsc. . . sha: doc_id: cord_uid: bverdk w abstract in this report, healthy one-day-old aa broilers were divided into six groups. groups – received , , and mg/l of sodium new houttuyfonate (snh) with ib vaccine h respectively. group received pbs and h and group il- and h . the chickens were inoculated at and days of age. on , , , , and post first vaccination, the dynamic changes of peripheral lymphocyte proliferation, cytokine assays and serum antibody titers were assayed respectively by mtt method, elisa and hemagglutination inhibition assay (hi). the results showed that sodium new houttuyfonate significantly raised ib antibody titer in the chickens and also markedly promoted lymphocyte proliferation. the serum levels of ifn-γ and il- in groups – were higher than those in groups and . hence, the immunologic enhancement of snh was slightly superior to that of il- adjuvant. following challenge with ibv, chickens inoculated with snh showed fewer and less severe clinical signs, lower death rate and less kidney pathology, as compared to those of the control groups. it indicated that snh could enhance immune responses and increase protection against virulent ibv challenge in chickens. infectious diseases of animals, especially viral, often cause great losses in the domestic animal industries. infectious bronchitis (ib) is an acute and highly contagious respiratory disease of chickens, and is still a major health problem in the chicken industry. infectious bronchitis virus (ibv), an enveloped coronavirus containing an unsegmented, single-stranded, positive-sense rna genome, is one of the primary causes of respiratory disease in domestic fowl. infection with ibv reduces the performance of broilers and causes drops in egg production and egg quality (bijlenga et al., ; cavanagh and naqi, ; cavanagh, ) . there are problems with vaccines against infectious bronchitis applied in the field. live attenuated vaccine may spread to unvaccinated flocks (farsang et al., ) ; inactivated vaccine does not elicit an immune response against coronavirus (yang et al., ; stohlman et al., ) , and severe side effects and long-lasting local response may occurs after inoculation. clinical practice has indicated that the application of vaccine with adjuvant or immunopotentiator could improve efficacy. however, chemical adjuvants (e.g. aluminium hydroxide (al(oh) ), aluminium phosphate (alpo ), and mineral oil) commonly cause side effects, such as strong local reaction and carcinogenesis. sometimes a chemical adjuvant may fail to enhance the immunogenicity of a weakly antigenic vaccine (xie, ; gong and wu, ; sun, ) . therefore, there is a need to assess an immunopotentiator that is both safe and efficacious. sodium new houttuyfonate (snh, sodium lauroyl-a-hydroxyethyl sulfonate) is a novel antimicrobial medicine that has been recently developed (the chemical structure is shown in fig. ) . previous studies showed that houttuyfonate homologues (hou-cn) had immunoregulatory activities and typical adjuvanticity, and could improve the immune ability of mice and inhibit the growth of staphylococcus aureus, bacillus subtilis and pneumococci (ye et al., ; wang et al., wang et al., , . it was reported that the immunoregulatory and antibacterial activity of snh were higher and stronger than that of sodium houttuyfonate (yuan et al., a; ye et al., ; yang et al., ) . because of its potential pharmaceutical effects on health, the purpose of this study was to evaluate the immune enhancement properties of snh as a new type of immunopotentiator. snh was obtained from jangsu jichun pharmaceutical co., ltd. ib disease vaccine virus h strain (ha titer  ) was supplied by jiangsu provincial academy of agricultural science. after safety was tested by injecting the virus into -day-old spf chicken embryos, the virus and snh were mixed (v/v = : ), and four inocula, containing mg/l (group ), mg/l (group ), mg/l (group ) and mg/l (group ) of snh, were prepared. two additional inocula, pbs and h (group , negative control) and il- and h (group , positive control), were prepared. all vaccines contained the same antigen content. filtered ( . lm) rpmi media (gibco) supplemented with benzylpenicillin ( iu/ml), streptomycin ( iu/ml) and % fetal bovine serum (sijiqing, zhejiang province) was used for culturing the cells. the same formula, minus bovine serum, was used for washing and diluting the mitogen. cona (sigma), as the t-lymphocytes mitogen, was dissolved to . mg/ml in rpmi media without fetal bovine serum, which was added ( % of final concentration) after the cona solution was filtered ( . lm), and then stored at À °c. the -( , -dimethylthiazol- -yl)- , -diphenyltetrazolium bromide (mtt, amresco co.) was dissolved to mg/ml in calcium and magnesium-free (cmf) phosphate-buffered saline (pbs, ph . ) and filtered ( . lm). lymphocyte separation media (ficoll-hypaque, q: . ± . , rong-sheng biostix inc., shanghai) and mtt solution were stored at °c in the dark. dimethyl sulfoxide (dmso, zheng-xing institute of chemical engineering, suzhou) was ar. one hundred and twenty chickens were randomly divided into six groups. at seven days of age, the average maternal antibody titer was . log and the average body weight was g. on and days of age, each chicken was injected intramuscularly with inocula according to group. five chickens were sampled randomly from each group for assay of lymphocyte proliferation by mtt method and chickens from each group for assessment of serum hi antibody titer by the micro-method and cytokines by elisa kits at , , , and days post the primary immunization (dpi). all chickens were challenged with eid of the ibv m strain (f passage) in . ml by the nasal-ocular route at days of age, and the animals monitored for days for clinical signs such as coughing, sneezing, ataxia, dyspnoea or death. . . sample collection and assay . . . peripheral lymphocyte proliferation assay blood samples ( ml per chicken and the birds were alternately used) were collected by cardiac puncture and transferred immediately into aseptic capped tubes with sodium heparin, then diluted with an equal volume of hank's solution and carefully layered on the surfaces of the lymphocyte separation media. after min centrifugation at g, the white cloud-like lymphocyte band was collected and washed twice with rpmi media without fetal bovine serum. the resulting pellet was re-suspended to  /ml in rpmi media with fetal bovine serum and incubated in -well culture plates (nunclon), ll/well, then another ll/well of the cona (four wells) or rpmi with % fetal bovine serum (four wells) was added and each sample seeded eight wells. after h of incubation at °c in a humid atmosphere of % co (revco, co., usa), ll/well of mtt was added, and the plates re-incubated for h. the plates were centrifuged ( min at g, room temperature) and the supernatant carefully discarded. hundred microlitre/well of dmso was added and the plates shaken for min to dissolve the formazan crystals. the absorbance of cell in each well was measured by microliter enzyme-linked immunosorbent assay reader (model dg- , east chinavacuum tube manufacturer) at a wave length of nm and the stimulation index (si) was calculated. the stimulation index was determined from the formula: stimulation index (si) = experimental od/negative od (barta et al., ; maheswaran and thies, ) . to determine the immune activity of snh, the levels of ifn-c and il- in the vaccinated animals were examined. for the detection of ifn-c and il- production in the chickens, sera were obtained at , , , , and dpi and determined quantitatively using commercially available cytokine elisa kits (chicken ifn-c/il- kits, sensitivity: pg/ml, adlitteram diagnostic laboratories (adl), usa) as per protocol. blood samples ( ml per chick) were drawn from the main brachial vein into eppendorf tubes and allowed to clot at °c for h. serum was separated by centrifugation and inactivated ( °c, min) for use. briefly, two-fold serial dilutions of serum were made in a -well, v-shaped bottom microtiter plate containing ll of pbs in all wells. ll of ibv antigen (without purification, diluted to ha units with pbs) was added to all the wells except the last row, which served as a control. serum dilutions ranged from : to : . the antigen-serum mixture was incubated for min at °c. twenty five microliter of a % rooster erythrocyte suspension was added to each well and the plates were re-incubated for min. a positive serum, a negative serum, erythrocytes, and antigen were also included as controls. the highest dilution of serum causing complete inhibition was considered the endpoint. the geometric mean titer was expressed as reciprocal log values of the highest dilution that displayed hi. all chickens were challenged with eid of the ibv m strain in . ml by intramuscular injection (i.m.) at days, and were examined daily for weeks for clinical signs such as coughing, sneezing, ataxia, dyspnea or death. dead chicks were necropsied to confirm the death due to ibv infection. data are expressed as the mean ± s.d. duncan's multiple range test was used to determine the difference among every adjuvant and control groups. differences between means were considered significant at p < . . the dynamic changes of stimulation index (si) value are listed in fig. . on day after primary vaccination, the values of groups - were larger than those of il- and pbs groups. at dpi, the si values of mg/l group were significantly higher than those for the pbs or il- groups (p < . ). at dpi, the values for group were higher than those for groups , and ; however, there was no significant difference between these groups. at , and dpi, the values of mg/l group were significantly larger than those of il- or pbs groups (p < . ). at , and dpi, the values of mg/l group were significantly larger than those of , and mg/l groups (p < . ). the elisa kits were employed to detect the production of ifn-c and il- in sera. the results showed that the mean concentration of ifn-c was higher in groups - compared to groups and . the mg/l group was significantly higher than the pbs or il- group at and dpi (p < . ), but there was no significant difference between the , and mg/l groups. at and dpi, the mg/l group was significantly higher than the pbs or il- (p < . ), but there was no significant difference between other experimental groups (fig. a) . at dpi, high levels of the experimental groups were observed comparing to the pbs or il- , but there was no significant difference (p > . ). similarly, there was almost the same change in il- between groups - and group after vaccination, but only at and dpi. including , and mg/l groups at , and dpi a significantly higher level of il- was observed compared to that in the pbs or il- groups (groups and ) (p < . ), whereas there was no significant difference between groups , and (p > . ) (fig. b) . the results indicated snh could promote both th -type and th -type cytokine responses, and there was a dose-dependant effect. the dynamic changes of hi antibody titer are listed in table . on day after primary vaccination, the antibody titers of groups - were higher than those of groups and . at and dpi, group was significant higher than the pbs or il- group (p < . ). except for groups and , the titers of groups and at dpi were significantly higher than those of groups and (p < . ). at and dpi, in comparison of other groups, the titer of group was significantly larger (p < . ). chickens started to show clinical signs or die from viral infection on day after challenge, but deaths occurred only in group . the chickens immunized with pbs were not protected and developed coughing, nasal discharge and dyspnea. the morbidity and mortality of the pbs immunized group were % ( / ) and % ( / ), respectively, after challenge with ibv m stain (fig. ) . chickens in groups - had lower morbidity, mortality and pathological changes when compared to those of the pbs group , but the difference was insignificant. groups - showed clinical signs such as depression, anorexia, a shrinking neck and fluffed down feathers, but no chicken died except for those in groups and . this suggests that snh confers resistance against a virulent ibv challenge. the use of houttuyfonate as an adjuvant has been accompanied by side effects (e.g., anaphylactic shock, systemic anaphylaxis, dyspnea), and so its clinical use has been limited. recent pharmacological studies have shown that snh and houttuyfonate have similar pharmacological properties, with a variety of biological functions, in addition to antibacterial, diuretic, antitussive, but also play a strong role in immune regulation. in addition snh is safer and has fewer side effects than houttuyfonate (jiang et al., ; zhu et al., a,b; yuan et al., b) . however, its application in the poultry industry has seldom been reported. in this study, with chicken ibv h strain live attenuated vaccine in chickens, by measuring peripheral blood lymphocyte proliferation and serum cytokines and antibody titers, the humoral and cellular immunity induced with snh was researched. the results indicated snh could enhance immune function in a dose-dependent manner. the results show that snh played an important role in protecting against challenge by virulent virus. it is well known that in both mouse and human systems, the th and th paradigm has emerged as a critical concept governing cellular and humoral immune responses. ifn-c and il- are prototype th and th cytokines, respectively, whose antagonistic actions against each other have been widely reported (mosman and sad, ) . they reciprocally regulate not only th and th cell survival and subsequent differentiation, but also activation and differentiation of b cells as well as monocytes (constant and bottomly, ; snapper and paul, ; cao et al., ) . specific target molecules that are counter-regulated by ifn-c and il- play fig. . dynamic change of lymphocyte proliferation responses in chicken (si value). an asterisk indicates the si value is significantly higher than the control group (p < . ). data were shown as mean ± s.d. error bars represent group standard deviations. arrows (;) indicate time of initial immunization and boost. important roles in mediating th or th immune responses. serum levels of the two cytokines increased, and this effect shows a certain degree of dose-effect relationship, especially obvious with the mg/l dose. therefore it was important to determine the fig. . serum concentrations (pg/ml) of ifn-c (a) and il- (b) in the serum. samples (n = ) were examined by using commercially available chicken cytokine elisa kits. an asterisk indicates the concentration of cytokine is significant (p < . ). data were shown as mean ± s.d. error bars represent group standard deviations. arrows (;) indicate time of initial immunization and boost. table the dynamic variation of antibody titers in chicken (log ). groups dpi appropriate dose of snh to take advantage of the body's immune system. at the same time, t lymphocyte-mediated cellular immunity was also researched. the results show that snh can significantly enhance the immune function of chicken cells by promoting lymphocyte proliferation. so, snh improved cellular immunity in comparison with pbs or il- . hi tests are mostly used to monitor antibody levels induced by ibv live attenuated vaccine. therefore, the hi titer was considered the key factor in the appraisal of the vaccine adjuvant in this study. although the maternal antibody ibv titers influence the results, the final result indicated no influence. the co-administration of antigen and snh increased hi titers, and the titers of the snh groups were significantly higher than those of the pbs or il groups, which confirmed that snh could improve antibody formation. thus, it qualifies as a new-type immunopotentiator. data within a column with different letters differ significantly (p < . ); the same letters means no significance. fig. . morbidity and mortality ratio of each group after challenging with ibv m strains optimum conditions for the chicken lymphocyte transformation test development and use of the h strain of avian infectious bronchitis virus from the netherlands as a vaccine: a review differential regulation of class ii mhc determinants on macrophages by ifn-c and il- severe acute respiratory syndrome vaccine development: experiences of vaccination against avian infectious bronchitis coronavirus infectious bronchitis induction of th and th cd + t cell response: the alternative approaches molecular epizootiology infectious bronchitis virus in sweden indicating the involvement of a vaccine strain research actuality and tendency of immune adjuvant study of sodium houtluyfonate on acute toxicity development of a micro-culture system for stimulation of chicken peripheral blood lymphocytes with concanavalin a the expanding universe of t-cell subsets: th th and more interfern c and b cell stimulatory factor reciprocally regulate ig isotype production mouse hepatitis virus nucleocapsid protein specific cytotoxic t lymphocytes are ld restricted and specific for the carboxy terminus research headway of immunopotentiator. helongjiang ani. hus studies on adjuvanticity of sodium houttuyfonate and its mechanism effects of sodium houttuyfonate on phosphorylation of camk ii, creb and erk / and expression of c-fos in macrophages progress in the study of grave epidemic diseases immune prevention and cure of domestic animals and poultry a dna vaccine induces sars coronavirus neutralization and protective immunity in mice chemiluminescence determination of sodium new houttuyfonate in pharmaceutical preparations based on tween rhodamine b system effect of the surface activity on the antibacterial activity of octadecanoyl acetal sodium sulfite series interaction between houttuyfonate homologues and erythrocyte plasma membrane of rabbit in vitro relativity of surfactivity and antibacterial motive of houttuynine analogies effects of houttuyfonate homologues on immunity of mouse effects of sodium houtluyfonate on chicken cellar immune response effects of sodium new houtluyfonate on chicken immune response this work was supported by grants from the jiangsu province natural science foundation ( kjd ), nanjing xiaozhuang college key program ( nxy ). key: cord- -tbndldhr authors: schippa, serena; frassanito, antonella; marazzato, massimiliano; nenna, raffaella; petrarca, laura; neroni, bruna; bonfiglio, giulia; guerrieri, francesca; frasca, federica; oliveto, giuseppe; pierangeli, alessandra; midulla, fabio title: nasal microbiota in rsv bronchiolitis date: - - journal: microorganisms doi: . /microorganisms sha: doc_id: cord_uid: tbndldhr respiratory syncytial virus (rsv) is the leading cause of bronchiolitis, and the severity may be influenced by the bacterial ecosystem. our aim was to analyze the nasal microbiota from infants affected by bronchiolitis from rsv virus and infants with bronchiolitis but negative for the virus. results showed a significantly lower biodiversity in the rsv-positive group with respect to the rsv-negative group, a specific microbial profile associated with the rsv-positive group different from that observed in the negative group, and significant modifications in the relative abundance of taxa in the rsv-positive group, as well as in the rsv-a group, with respect to the negative group. furthermore, microbial network analyses evidenced, in all studied groups, the presence of two predominant sub-networks characterized by peculiar inter- and intra-group correlation patterns as well as a general loss of connectivity among microbes in the rsv-positive group, particularly in the rsv-a group. our results indicated that infants with more severe bronchiolitis disease, caused by rsv-a infection, present significant perturbations of both the nasal microbiota structure and the microbial relationships. patients with a milder bronchiolitis course (rsv-b-infected and patients who have cleared the virus) presented less severe alterations. bronchiolitis is the most frequent acute respiratory viral infection in children less than one year of age, and it is the main cause of hospitalization in this age group. a viral etiology is detected in % of the patients, and respiratory syncytial virus (rsv) remains the most common etiological agent [ ] . several studies have shown that bronchiolitis can be caused also by other respiratory viruses different from rsv, and in some cases a virus cannot be detected. clinical characteristics of the disease may also be influenced not only by the presence of a specific virus but also by rsv genotype [ ] . recent studies have shown that the composition of the nasopharyngeal microbiome may influence the different clinical phenotypes of bronchiolitis [ , ] . in infants with bronchiolitis, the respiratory tract microbiota undergoes a perturbation; several studies showed that the most important qualitative alteration is represented by the increase of proteobacteria and the decrease of bacteroidetes [ ] . other studies underline the role of staphylococcus-dominant airway microbiota during early infancy as "risky microbiota" to enhance viral pathogenesis [ ] . a recent study showed that rhinovirus significantly increased the invasive ability of staphylococcus aureus [ ] . rosas et al. highlight that nasopharyngeal detection and increased abundance of the genus lactobacillus during rsv infection in infancy is associated with a reduced risk of childhood wheezing illnesses at age years [ ] . in , a study from hasegawa et al. [ ] conducted with infants (median age months) hospitalized with bronchiolitis identified four distinct fecal microbiota types in infants. the bacteroides-dominant profile was associated with a higher probability of bronchiolitis, while the enterobacter-/veillonella-dominant profile was associated with lower possibility of bronchiolitis. another important recent study, connecting bronchiolitis severity with nasal microbiota composition [ ] , highlighted four differently dominated nasopharyngeal microbiota profiles: one dominated by haemophilus, another by moraxella, another by streptococcus, and the fourth one showed the highest bacterial richness. infants in intensive care showed principally haemophilus-dominant profiles. a more recent study, aimed to comprehend the influence of interfaces between the host transcriptome nasal microbiome and the clinical outcomes of rsv infection [ ] , indicated that specific microbial taxa affect host immune responses. all these studies linked specific bacterial species with rsv bronchiolitis, but no comparisons were carried out between rsv-positive and virus-negative bronchiolitis patients. understanding the differences of nasal microbiota structures between rsv-positive and virus-negative bronchiolitis patients would give us information on rsv impact/interfere on nasal microbiota structure, and this useful information for new treatments aimed at microbiota rebuilding could promote a non-severe outcome of the disease. in our study, we analyzed nasal microbiota from a total of subjects affected by bronchiolitis, of which were positive for the rsv virus and were negative, in order to explore the nasal microbiota composition. we also analyzed nasal microbiota compositions in infants with bronchiolitis from rsv subtypes a and b. we conducted a prospective observational study. from october to may we enrolled children < months, admitted to the department of paediatric emergency, "sapienza" university of rome for an acute episode of bronchiolitis, who had not been on antibiotic therapy within the last days or with probiotics. infants with risk factors for severe bronchiolitis (prematurity, congenital heart malformations, chronic lung diseases, and neurological and/or neuromuscular diseases) were excluded. bronchiolitis was clinically defined as the first episode of acute lower respiratory tract infection, characterized by the acute onset of cough, tachypnea, retraction, and diffuse crackles on chest auscultation in infants younger than months [ , ] . epidemiological and demographic variables such as gender, age, gestational age, birth weight, delivery, breastfeeding history, presence of siblings, and presence of smoking cohabitants were obtained from the infant's parents with a structured questionnaire. the following clinical and laboratory data were taken from patient medical files: days of hospitalization, heart rate, respiratory rate, arterial oxygen saturation in room air, presence of retractions, o therapy, intravenous fluid (iv) therapy, white blood cell count (wbc), lymphocyte count, and c-reactive protein blood concentration (crp). a clinical severity score ranging from to , according to respiratory rate, arterial oxygen saturation in room air, presence of retractions, and iv fluid treatment, was assigned to all infants at admission and every day during hospitalization as previously described [ ] . the worst score during hospitalization was used for analysis. written informed consent was obtained from parents. the study was conducted in accordance with the declaration of helsinki and it was approved by institutional review boards of the hospitals (rif.ce , n. prot. / , march ). two nasopharyngeal washes (npws) were obtained during the first day of hospitalization instilling ml of sterile saline in each nostril and collected with a syringe [ ] (the lavages of one nostril were used for virus detection, while the lavage performed on the other nostril was employed for microbiota studies). npw samples were delivered within h to the virology laboratory for virus detection and to the department of public health and infectious diseases for analysis of the nasal microbiota composition. an aliquot of nasopharyngeal washes was used for nucleic acid extraction using a total nucleic acid isolation kit (roche diagnostics, mannheim, germany). rt-pcr was used to detect the respiratory viruses: influenza a and b viruses (iv-a/b), human coronavirus (hcov) c e, nl- , huk , adenovirus (av), parainfluenza virus - (piv - ), human metapneumovirus (hmpv), human bocavirus (hbov), respiratory syncytial virus (rsv), and rhinovirus (hrv) [ ] . the npws collected were stored at − • c or immediately transported to the microbiology lab for nasal microbiota characterization. total dna was extracted from all collect nasal samples following the instructions provided by the kit dneasy blood & tissue (qiagen, hilden, germany) starting from µl of nasal wash sediment, obtained by centrifuging npws at , rpm and discarded supernatant. to ensure maximum dna extraction efficiency, even from gram-positive bacteria, the protocol was modified by adding the incubation of samples with proteinase k at • c, followed by a h incubation at • c with mg/ml (final concentration) of lysozyme (sigma-aldrich, milan, italy). nanodrop spectrophotometer determined the dna concentration. all dna samples obtained were normalized to a final dna concentration of ng/µl in a final volume of µl, and an aliquot was used to characterize nasal bacterial community via next-generation sequencing (ngs) on an illumina miseq platform at the italian institute of technology. to this purpose, the v -v region of the bacterial s rrna gene was amplified by pcr with specific universal bacterial barcoded primer using total dna extracted as template, and the library obtained was sequenced. the italian institute of technology (iit) executed the amplicon sequencing by means of next-generation sequencing (ngs) on an illumina miseq platform. bioinformatic analyses, encompassing metagenomic analysis (multivariate statistics/non-parametric tests and ecological indices analysis), in order to quantify the significant differences in the structure of bacterial communities and cross-correlation of all collected data, were carried out at the department of public health and infectious diseases. briefly, raw fastq files were analyzed with mothur pipeline v. . . for quality check and filtering (sequencing errors, chimerae) on a workstation dell t (round rock, tx, usa). raw reads (on average > k per sample) were filtered (on average > k per sample) and clustered into operational taxonomic units (otus), followed by elimination of low-populated otus (till reads) and by de novo otu picking at % pair-wise identity using standardized parameters and the silva rdna database v. . for alignment. sample coverage was computed with mothur and resulted to be, on average, higher than % for all samples, thus meaning a suitable normalization procedure for subsequent analyses. bioinformatic and statistical analyses on recognized otus were performed with python v. . . . the most representative and abundant read within each otu (as evidenced in the previous step with mothur v. . . ) underwent a nucleotide blast using the national center for biotechnology information (ncbi) blast software (ncbi-blast- . . ) and the latest ncbi s microbial database accessed. a matrix of bacterial relative abundances was built at each taxon level (phylum, class, order, family, genus, species) for subsequent multivariate statistical analyses. α-diversity (within sample diversity) was evaluated, in qiime [ ] , by computing the shannon index, the simpson index and the number of observed otus at the species level. the analysis of β-diversity (between-sample diversity) was performed by calculating both the bray-curtis dissimilarity and the weighted-unifrac distance. principal coordinate analysis (pcoa) was performed to compare the overall composition of the bacterial community between samples. the differential abundance analysis of taxa was performed at phylum, genus, and species levels by univariate statistical methods (see statistical analysis). a co-occurrence network was computed, at species level, for each group separately (virus negative, rsv positive, rsv-a and rsv-b), by using the sparcc algorithm between abundance of taxa [ ] . only taxa showing a mean relative abundance ≥ . % in almost one group were included in the network analysis, while sparcc correlations less than − . and greater . with a p ≤ . based on bootstrapping of repetitions were retained. generated networks were imported and visualized in cytoscape v. . . . topological parameters of networks were calculated by using the network analyzer plugin included in cytoscape. firstly, a descriptive analysis of the samples was performed with tables and graphs corresponding to the type of qualitative or quantitative variables. statistical analysis was carried out using both parametric and nonparametric tests according to the analyzed variable. in particular, non-parametric univariate statistical tests, x and fisher's exact post-hoc tests, were used for the discrete variables; non parametric mann-whitney u test and kruskal-wallis tests followed by dunn's post hoc test were performed to determine significant differences with respect to continuous variables for pairwise or multiple comparisons, respectively. in each case a p-value ≤ . was considered statistically significant. when necessary, the p values were corrected by using the benjamin-hochberg procedure to account for multiple hypothesis testing. statistical analyses were performed using spss version . (spss inc., chicago, il, usa). infants hospitalized with bronchiolitis were tested for respiratory viruses during the winter season / . the main clinical characteristics of the studied population are provided in table . out of npw samples taken for nasal microbiota characterization, were positive for rsv, and resulted negative to the respiratory viruses tested (v neg ); samples positive for other respiratory viruses or co-infected were excluded to avoid bias in the analysis. after quality assessment of ngs reads (see below), the study analyses included virus-negative patients and patients infected with rsv. the samples positive only to rsv (rsv pos ) were sequenced for subtyping as described [ ] ; of these, were rsv a, were rsv b, and could not be subtyped. the children included in our study were males ( . %) and had a mean age of . days (range - ). significantly lower severity scores were observed in the v neg group with respect to the rsv pos (p = . ). consistently, the percentage of infants who received o treatment and were admitted in the pediatric intensive care unit was significantly lower in the virus-negative group compared to either rsv pos groups (respectively p = . and p = . ). the absolute number of blood lymphocytes was significantly higher in virus-negative infants with respect to the rsv-positive infants ( table ) . for the other clinical variables, no significant differences were found between the v neg group compared to the rsv pos . evaluation of α diversity by the shannon and simpson indexes, as well as the number of observed otus, showed a significant lower biodiversity in the rsv-positive group with respect to the virus-negative one, suggesting the presence of a microbial shifts in the nasal microbiota of rsv-positive subjects (figure a) . a statistically significant difference was found between the rsv-a and the virus-negative group (shannon p = . , simpson p = . , observed otu p = . ). no differences were observed between rsv-a and rsv-b groups. the β diversity analysis showed statistically significant separations between the virus-negative group and both the rsv-positive (p = . ) and the rsv-a (p = . ) groups (figure b) . no significant partitions were observed between infants negative for the virus and rsv-b groups. considering only taxa having a mean relative abundance ≥ . % in at least one of the studied groups, we generated microbial profiles at taxonomy levels of phylum, genera, and species ( figure ). as shown, distinctive microbial profiles were associated to the different groups (v neg , rsv pos ), but no significant differences in the relative abundance of taxa were observed at phylum level among all groups. the analysis of the relative abundance of the genera among the different groups ( figure ) showed that bacteroides, pseudoflavonifractor, alistipes, kineothrix, and oscillibacter were significantly lower in abundance in the rsv pos group compared to the v neg . at species level, the relative abundance of streptococcus pneumoniae was significantly higher in the rsv pos group. the same statistically significant differences observed between rsv pos and v neg groups were kept when we matched the rsv-a and the v neg groups. no significant differences were highlighted between v neg and rsv-b groups nor between the rsv-a and rsv-b ones, although we cannot exclude that the lack of statistical significance was due to the limited number of infants positive for rsv-b. evaluation of α diversity by the shannon and simpson indexes, as well as the number of observed otus, showed a significant lower biodiversity in the rsv-positive group with respect to the virus-negative one, suggesting the presence of a microbial shifts in the nasal microbiota of rsvpositive subjects (figure a) . a statistically significant difference was found between the rsv-a and the virus-negative group (shannon p = . , simpson p = . , observed otu p = . ). no differences were observed between rsv-a and rsv-b groups. the β diversity analysis showed statistically significant separations between the virus-negative group and both the rsv-positive (p = . ) and the rsv-a (p = . ) groups (figure b) . no significant partitions were observed between infants negative for the virus and rsv-b groups. considering only taxa having a mean relative abundance ≥ . % in at least one of the studied groups, we generated microbial profiles at taxonomy levels of phylum, genera, and species ( figure ). as shown, distinctive microbial profiles were associated to the different groups (vneg, rsvpos), but no significant differences in the relative abundance of taxa were observed at phylum level among all groups. only taxa for which a mean relative abundance ≥ . % was determined in at least one group are shown. taxa are sorted in ascending order with respect to their mean relative abundance in the vneg group. the analysis of the relative abundance of the genera among the different groups ( figure ) showed that bacteroides, pseudoflavonifractor, alistipes, kineothrix, and oscillibacter were significantly lower in abundance in the rsvpos group compared to the vneg. at species level, the relative abundance of streptococcus pneumoniae was significantly higher in the rsvpos group. the same statistically significant differences observed between rsvpos and vneg groups were kept when we matched the rsv-a and the vneg groups. no significant differences were highlighted between vneg only taxa for which a mean relative abundance ≥ . % was determined in at least one group are shown. taxa are sorted in ascending order with respect to their mean relative abundance in the v neg group. significantly lower in abundance in the rsvpos group compared to the vneg. at species level, the relative abundance of streptococcus pneumoniae was significantly higher in the rsvpos group. the same statistically significant differences observed between rsvpos and vneg groups were kept when we matched the rsv-a and the vneg groups. no significant differences were highlighted between vneg and rsv-b groups nor between the rsv-a and rsv-b ones, although we cannot exclude that the lack of statistical significance was due to the limited number of infants positive for rsv-b. interactions between taxa were explored by performing a network analysis based on the sparcc algorithm, which is able to reduce bias introduced by the compositionality and sparsity of microbiome data. the graphical representation of the microbial networks constitutes a sort of "correlation map" describing the positive and negative relationships between microbes drawn as edges with different colors. in this context, positive and negative correlations could reflect synergistic and antagonistic interactions between microbial groups such as metabolic interdependencies or competitions for the same ecological niches. results evidenced the presence of two predominant microbial assemblages (named assemblage and ) in analyzed networks (v neg , rsv pos ), in which taxa correlated with synergic interactions within the assemblage. differently competitive interactions between the taxa belonging to the two different assemblages were observed (figure ) . remarkable are the taxa compositions of the two assemblages. in both cases, assemblage was characterized by bacterial species resulting to be significantly more abundant within the virus-negative group, while s. pneumoniae, the unique species significantly associated with the rsv pos group, was within assemblage . the co-occurrence networks were evaluated for topological properties including centrality measures ( table ) . obtained results showed a decrease in the number of nodes (taxa participating to the network) in rsv pos. similarly, results were obtained for the number of correlations (edges) indicating a network with less connection among bacteria in rsv pos with respect to the network determined for the v neg group. concerning correlation type, a decrease in both positive/synergic and negative/competitive was found in the rsv pos network with respect to v neg ; however, this could be due to the overall lower number of connections present in the rsv pos network. the decrease of relationships among bacterial species strongly evidenced that changes happened in the nasal microbial ecosystem structure, leading to an impoverished microbial network characterized by weaker interactions among microbes, a reduced interconnection among species (figure ) , and the loss of reciprocal control between microbes. these characteristics depict a condition in which the eubiotic state has been lost, determining a state of dysbiosis. correlated with synergic interactions within the assemblage. differently competitive interactions between the taxa belonging to the two different assemblages were observed (figure ) . remarkable are the taxa compositions of the two assemblages. in both cases, assemblage was characterized by bacterial species resulting to be significantly more abundant within the virus-negative group, while s. pneumoniae, the unique species significantly associated with the rsvpos group, was within assemblage . rsvpos networks, computed at species level performed on taxa with a mean relative abundance ≥ . % in at least one group. the thickness of edges represents the level of association between taxa based on the sparcc score. the size of nodes is proportional to the number of edges departing from the node, indicating its degree of interaction the co-occurrence networks were evaluated for topological properties including centrality measures (table ) . obtained results showed a decrease in the number of nodes (taxa participating to the network) in rsvpos. similarly, results were obtained for the number of correlations (edges) figure . co-occurrence network analysis. graphical representations of (a) virus-negative and (b) rsv pos networks, computed at species level performed on taxa with a mean relative abundance ≥ . % in at least one group. the thickness of edges represents the level of association between taxa based on the sparcc score. the size of nodes is proportional to the number of edges departing from the node, indicating its degree of interaction. the main aim of the present study was to characterize the nasal microbiota in pediatric patients hospitalized for bronchiolitis from rsv and in infants affected by bronchiolitis but negative for a respiratory virus. furthermore, we attempted to characterize the nasal microbiota in infants with bronchiolitis from rsv-a and patients with bronchiolitis from rsv-b. nasal microbiota characterization was firstly carried out by evaluating the ecological indexes (α diversity). the ecological perception is fundamental to better understand the dynamic of the microbial ecosystem, and it is important to develop therapeutic approaches aimed to rebuild a balanced microbiota [ ] . subsequently, we evaluated the β diversity to exploit the differences in the nasal microbial composition among the groups studied. we highlighted significant differences among the groups; in particular, we showed the following: (i) a significantly higher biodiversity in the virus-negative group with respect to the rsv-positive and to the rsv-a groups; (ii) a specific nasal microbiota composition in the virus-negative group, different from that of the rsv-positive and rsv-a groups; and (iii) a significant modification in taxa relative abundance, among rsv-positive, in particular the rsv-a, with respect to the virus-negative group. several of the bacterial species less abundant in the virus-positive group are known to be potentially beneficial species such as butyrate producers, species proposed as probiotic, or anti-inflammatory species [ ] [ ] [ ] . the infants were negative to pcr-based tests for respiratory viruses. they probably experienced a viral infection causing acute respiratory symptoms, but may have tested negative at the time of hospitalization due to viral load decline. concomitantly, they had a less severe clinical course of bronchiolitis. it can be considered a group in which the viral clearance of the upper airways is actually more efficient and faster (this could derive from a more resistant environment or from a more efficient immune response), or it could be a group of patients in which we were unable to isolate the virus because it is not part of our identification panel for the respiratory viruses. interestingly, these infants' nasal microbiota are characterized by a relatively high alpha diversity, by the presence of potentially beneficial species, and by more connections in their microbial ecosystem that could be associated to a milder clinical course. on the other hand, a higher severity was observed in the rsv-a-infected group, characterized by the abundance of the unique species s. pneumoniae that is associated with several diseases such as pneumonia, otitis, and meningitis, but that can be part of the respiratory microbiota without causing any pathology. our results indicate that in rsv-a-positive group, the relative abundance of s. pneumoniae was significantly higher than that in the virus-negative group. these data support the clinical evidence that s. pneumoniae colonization is associated with increased severity during rsv infection in young children [ ] . the presence of s. pneumoniae in our rsv-negative group is easily explained by the fact that our virus-negative group was affected by bronchiolitis too. furthermore, s. pneumoniae should be considered as a pathobiont bacterial species, meaning a potentially pathogenic species present in low quantity in healthy subjects that, in specific conditions under a specific selective pressure (maybe virus presence), could become predominant by establishing a dysbiosis status in the ecosystem. it has been reported that s. pneumoniae colonization and its density can enhance the risk of severed subsequent rsv infection [ ] , but this association may have bidirectional interactions. rsv-a somehow promotes s. pneumoniae growth, directly [ ] or through the inflammatory response induced by the viral infection, as shown for influenza virus [ , ] . as reported in the literature for influenza virus co-infections, the nasal microbiota composition could affect individual predisposition to secondary bacterial infections, commonly triggered by gram-positive bacteria like s. pneumoniae [ ] , and has a direct impact on pneumococcal attitude [ ] . moreover, in host infected with influenza virus, the pro-inflammatory immune response represents a key aspect relevant to lethal pneumococcal infection, and it denotes a potential target for therapeutic intervention [ , ] . our results corroborate results by other authors indicating the presence of streptococcus species associated with rsv bronchiolitis and its severity. a study from de steenhuijsen piters et al. [ ] aimed to evaluate, in infants less than years of age, if definite nasopharyngeal microbiota were associated with different host transcriptome profiles. they found rsv infection severity related to five nasopharyngeal microbiota groups, categorized by the enhancement of a specific bacterial species. children with rsv infection were associated with a microbiota dominated by h. influenzae and streptococcus. furthermore, the study showed that communications among rsv and nasopharyngeal microbiota might regulate the host immune response, hypothetically affecting clinical disease severity. another recent study [ ] pointed out that streptococcus abundance was greater in samples collected during rsv infection compared with samples collected one month later. finally, we evaluated the relations among microbial community members by networks analysis, as edges that join pairs of nodes (the system components, taxa). microbial networks analyses evidenced two predominant sub-networks in all groups studied (virus negative, rsv positive); it would seem that the two sub-networks control each other. interestingly, the majority of taxa resulted to be significantly more abundant in the virus-negative group and were placed in sub-network , while the unique species significantly more abundant in the rsv pos group, s. pneumoniae, was in sub-network and, therefore, in negative/competitive correlation with the others in both groups studied. despite the overall similarity of the two sub-networks found, we observed variations among groups in taxa interactions. a microbial ecosystem with fewer connections among microbes, and probably more susceptible to colonization by outdoor microbes, was observed in the rsv-positive group with respect to the virus-negative group. several taxa in the rsv-positive group are no longer connected and present as isolated elements. the lower connection between microbes could indicate dysbiosis, in which the mutualistic relationships among taxa are lost. enrolled infants were between weeks and months of age and experiencing their first severe acute respiratory infection that caused hospitalization. during this period of our life nasal microbiota composition is still very mutable, in particular in the second and third months of age [ ] . the first colonizing microbes have a strong influence on what will be the following colonizers, through the expression modulation of genes coding for adhesion sites [ , ] . notwithstanding, we found interesting differences in microbiota composition in infants when comparing, on the basis of rsv infection, groups that were similar for mean age, weight, and type of feeding, and differed for bronchiolitis severity. this is the first study that pointed out differences in nasal microbiota composition among rsv-positive and virus-negative bronchiolitis patients, and it denoted, for the first time, a more robust impact on nasal microbiota structure seemed to be related to rsv subtype a compared to rsv subtype b. although no significant differences were determined between the rvs-b group and the v neg or the rsv-a groups, we cannot exclude that the lack of statistical significance could be due to the limited number of analyzed rsv-b subjects, which represents a clear limit for this study. undoubtedly, the presence of rsv represents a disturbing factor during the first colonization phase of the nasal site, which could profile microbiota not in eubiotic equilibrium, increasing the risk of illnesses caused by microbes whose growth is favored by rsv (e.g., s. pneumoniae) as well as the risk of respiratory sequelae [ , ] . differently, a resilient respiratory microbiota may favor a decrease in viral load and a less severe illness course. in conclusion, our results showed that two specific sub-clusters are present in the networks of the nasal microbiota in all our bronchiolitis patients, independently from rsv presence. moreover, this analysis highlighted, for the first time, a network in the rsv pos group where several taxa species have lost interaction with others and remain as bacterial species apparently disconnected from the ecosystem, shaping a state of dysbiosis ( figure ) . accordingly, the infants affected by rsv bronchiolitis presented more perturbations in the nasal microbiota structure compared to the v neg group, thus favoring colonization of pathobiont species, such as s. pneumonia, and negatively influencing potentially beneficial species growth, defining a state of dysbiosis. all of this goes with the higher disease severity score, indicating that a dysbiosis status emphasized by rsv presence could itself act as a predisposing factor for bronchiolitis severity. longitudinal study approaches are necessary to clarify whether the observed associations are causally linked and whether the control of pathobionts overgrowth, by therapies aimed at improving the nasal microbiota composition, may contribute to prevent a severe bronchiolitis course. the study was partially funded by a sapienza university grant "ricerca " n. rm b fc d to ap. a. for the marc- investigators prospective multicenter study of viral etiology and hospital length of stay in children with severe bronchiolitis how respiratory syncytial virus genotypes influence the clinical course in infants hospitalized for bronchiolitis early respiratory microbiota composition determines bacterial succession patterns and respiratory health in children the infant nasopharyngeal microbiome impacts severity of lower respiratory infection and risk of asthma development nasopharyngeal proteobacteria are associated with viral etiology and acute wheezing in children with severe bronchiolitis airway microbiota and acute respiratory infection in children rhinovirus promote internalization of s.aureus into non-fully permissive cultered pneumocytes. microbes infect nasopharyngeal lactobacillus is associated with a reduced risk of childhood wheezing illnesses following acute respiratory syncytial virus infection in infancy the fecal microbiota profile and bronchiolitis in infants association of nasopharyngeal microbiota profiles with bronchiolitis severity in infants hospitalised for bronchiolitis microbiome-transcriptome interactions related to severity of respiratory syncytial virus infection respiratory syncytial virus, human bocavirus and rhinovirus bronchiolitis in infants inferring correlation networks from genomic survey data cytoscape: a software environment for integrated models of biomolecular interaction networks interpreting infective microbiota: the importance of an ecological perspective the human gut firmicute roseburia intestinalis is a primary degrader of dietary β-mannans roseburia intestinalis inhibits interleukin- excretion and promotes regulatory t cells differentiation in colitis alistipes: the influence of a commensal on anxiety and depression streptococcus pneumoniae colonization of the nasopharynx is associated with increased severity during respiratory syncytial virus infection in young children streptococcus pneumoniae enhances human respiratory syncytial virus infection in vitro and in vivo respiratory syncytial virus increases the virulence of streptococcus pneumoniae by binding to penicillin binding protein a. a new paradigm in respiratory infection influenza and bacterial superinfection: illuminating the immunologic mechanisms of disease influenza a virus infection predisposes hosts to secondary infection with different streptococcus pneumoniae serotypes with similar outcome but serotype-specific manifestation the co-pathogenesis of influenza viruses with bacteria in the lung interaction between the nasal microbiota and s. pneumoniae in the context of live-attenuated influenza vaccine in vivo neutralization of pro-inflammatory cytokines during secondary streptococcus pneumoniae infection post influenza a virus infection nasopharyngeal microbiota, host transcriptome, and disease severity in children with respiratory syncytial virus infection airway response to respiratory syncytial virus has incidental antibacterial effects dynamics of the nasal microbiota in infancy: a prospective cohort study factors influencing the composition of the intestinal microbiota in early infancy dna isolation protocols affect the detection limit of pcrapproaches of bacteria in samples from the human gastrointestinal tract nasopharyngeal pneumococcal density during asymptomatic respiratory virus infection and risk for subsequent acute respiratory illness nasopharyngeal microbiome in respiratory syncytial virus resembles profile associated with increased childhood asthma risk this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license acknowledgments: valerio iebba, gustave roussy cancer campus (grcc) and institut national de la santé et de la recherche medicale (inserm) and equipe labellisée-ligue national contre le cancer, france. the authors declare no conflict of interest. key: cord- - i zbmm authors: pan, feng; yang, lian; li, yuncheng; liang, bo; li, lin; ye, tianhe; li, lingli; liu, dehan; gui, shan; hu, yu; zheng, chuansheng title: factors associated with death outcome in patients with severe coronavirus disease- (covid- ): a case-control study date: - - journal: int j med sci doi: . /ijms. sha: doc_id: cord_uid: i zbmm rationale: up to date, the exploration of clinical features in severe covid- patients were mostly from the same center in wuhan, china. the clinical data in other centers is limited. this study aims to explore the feasible parameters which could be used in clinical practice to predict the prognosis in hospitalized patients with severe coronavirus disease- (covid- ). methods: in this case-control study, patients with severe covid- in this newly established isolation center on admission between january to march were divided to discharge group and death event group. clinical information was collected and analyzed for the following objectives: . comparisons of basic characteristics between two groups; . risk factors for death on admission using logistic regression; . dynamic changes of radiographic and laboratory parameters between two groups in the course. results: patients with severe covid- on admission were included and divided into discharge group (n= ) and death event group (n= ). sex, spo , breath rate, diastolic pressure, neutrophil, lymphocyte, c-reactive protein (crp), procalcitonin (pct), lactate dehydrogenase (ldh), and d-dimer were significantly correlated with death events identified using bivariate logistic regression. further multivariate logistic regression demonstrated a significant model fitting with c-index of . (p< . ), in which spo ≤ %, lymphocyte≤ . × ( )/l, crp> . mg/l, pct> . μg/l, and ldh> u/l were the independent risk factors with the ors of . , . , . , . , and . , respectively (p< . ). in the course, persistently lower lymphocyte with higher levels of crp, pct, il- , neutrophil, ldh, d-dimer, cardiac troponin i (ctni), brain natriuretic peptide (bnp), and increased cd +/cd + t-lymphocyte ratio and were observed in death events group, while these parameters stayed stable or improved in discharge group. conclusions: on admission, the levels of spo , lymphocyte, crp, pct, and ldh could predict the prognosis of severe covid- patients. systematic inflammation with induced cardiac dysfunction was likely a primary reason for death events in severe covid- except for acute respiratory distress syndrome. since the outbreak of covid- in wuhan, it spread rapidly worldwide with a severity spectrum from asymptomatic to critical illness with the overall rate of approximately % [ ] [ ] [ ] . up to date, an increasing number of more than forty-thousand fatalities were reported [ ] . owing to the genomic homologies of the pathogen from the coronaviruses causing the severe acute respiratory syndrome (sars) and the middle east respiratory syndrome (mers), covid- presented a similar clinical course and pathological feature [ ] [ ] [ ] [ ] . although most of the covid- patients were mild who could gradually recover after two weeks, about - % of patients developed severe interstitial pneumonia [ , , ] . patients with severe illness usually developed acute respiratory distress syndrome (ards) that requires invasive mechanical ventilation therapy in the intensive care unit (icu), and the mortality rate was reported around - % [ , ] . to date, the clinical studies revealed different clinical and laboratory features between survivors and non-survivors, or between the non-severe and severe patients, and some prognostic risk factors were preliminarily discovered, such as age and d-dimer [ ] [ ] [ ] [ ] [ ] [ ] [ ] . however, most of these results were from or involving the same center in wuhan, china, at a similar period, leading to potential selection bias. moreover, the same patients in different articles were suspected [ ] . this study systematically analyzed the clinical features, laboratory investigations, and radiographic estimation in a temporary isolation center in wuhan, china, established specially for severe covid- patients by an emergency directive of the wuhan anti-epidemic headquarters since january . all severe patients had to fulfill the who criteria for admission to hospital for a respiratory illness, which was slightly modified and adopted by both the who and the chinese national diagnosis and treatment protocols to define a severe case of covid- [ ] [ ] [ ] [ ] . these criteria defined severe covid- as fever and/or respiratory infection with positive covid- nucleic acid detection, plus one of the following: respiratory rate > breaths/min; severe respiratory distress; or spo ≤ % on room air. this study examined the factors associated with mortality in patients who fulfilled these criteria of severity at the time of hospital admission. it excluded patients who at the time of admission had, according to who criteria, mild illness, pneumonia, or had already progressed to ards, sepsis, or septic shock [ ] . for further speculation, it tried to explore the fatal course of covid- . this study was approved by the ethics of committees of union hospital, tongji medical college, huazhong university of science and technology (no. - ), and followed the helsinki declaration and its later amendments or comparable ethical standards. only the anonymous data was collected and informed consent for this retrospective study was waived. the consecutive admission records were reviewed retrospectively for the period from january to regular bedside chest digital radiographs (drs) were regularly performed every to days instead of conventional computed tomography (ct) scans after admission owing to the risk during the transfer of severe patients. a conventional semi-quantitative scoring system for dr was used to evaluate the pulmonary involvement area of the abnormalities including air-space and reticular opacities [ , ] . each lung was divided into three equidistant zones (upper, middle, and lower), resulting in a total of six zones to be scored. each zone was visually scored from to as: score , % involvement; score , %- % involvement; score , %- % involvement; score , - % involvement; and score , ≥ % involvement. the dr score was the sum of the score of each zone. the analysis was performed by two radiologists (cz and ly, who had and years of experience in thoracic radiology, respectively) and the decisions were reached in consensus. all radiologists were blinded to the clinical progress of the patients to avoid information bias. two groups were divided based on the clinical outcomes: discharge group and death event group. three objectives were explored in this study: . comparisons of basic characteristics between two groups, including the occurrence of ards, which was defined as worsening respiratory symptoms with pao /fio ≤ mmhg based on the berlin definition and who criteria [ , ] ; . risk factors for death on admission; . dynamic changes in dr scores and laboratory investigations between two groups in the follow-up. statistical analysis was performed using ibm spss statistics software (version ; ibm, new york, usa). quantitative data were presented as median with inter-quartile range (iqr) and counting data were presented as the percentage of the total unless otherwise specified. the comparisons of the quantitative data were statistically evaluated using the mann-whitney u test, according to the non-normal distribution assessed by the shapiro-wilk test. the quantitative parameters were stratified into binary variables with the cutoffs of median values. the comparisons of counting data were evaluated using the chi-square test. the bivariate and multivariate logistic regressions were used to investigate the risk factors for death events involving the stratified clinical, radiographic, and laboratory parameters with significant differences between two groups on admission, and the odds ratio (or) with % confidence interval ( %ci) were calculated. variables were excluded in the multivariate logistic regression if: . the univariate analysis demonstrated no statistical significance (p< . ); . the multivariate analysis demonstrated the probability of p≥ . when using forward-lr method; . variable had obvious colinearity with other variables resulting in variance inflation factor (vif) of more than [ ] . c-index of predicted probability calculated using the optimal multivariate logistic model was evaluated by roc curve estimation. a p-value of < . was defined as the statistical significance. after retrieving the electronic records, patients were eventually included in the further analysis from consecutive records (figure ) . the basic information of included patients was summarized in table . the median age of patients was yrs (iqr - yrs), and . % of patients were male. half of the patients had hypertension history and patients had copd (gold ii grade) history which was controlled well after quitting smoking and ipratropium treatment. fever and cough were the most common initial symptoms ( . % and . %, respectively). the median interval between the admission and symptom onset was days (iqr - days). on admission, the median body temperature on admission reached . °c (iqr: . - . °c). the median breath rate was /min (iqr: - /min) and median spo was % (iqr: - %). in most patients ( / , . %), drs demonstrated bilateral opacities with the median dr score of (iqr: - ). multiple abnormities of biochemical and hematological parameters were observed as well, including neutrophil, lymphocyte, c-reactive protein (crp), procalcitonin (pct), lactate dehydrogenase (ldh), d-dimer, cardiac troponin i (ctni), and brain natriuretic peptide (bnp), and so on. in the course, patients ( . %) aggravated to ards with the median period of days after admission (iqr - days), who were transferred to icu afterwards. eventually, patients ( . %) with ards complications died who were included in death event group, while patients ( . %) were recovered and discharged who were included in discharge group. compared between the two groups, the patients in death event group had significantly higher male proportion ( . % vs. . %), lower spo ( % vs. %), and higher breath rate ( vs /min) ( table ). in the course, ards was more predominantly occurred in death event group compared with discharge group ( vs. ). patients with ards in death event group refused endotracheal intubation. the median survival period in death event group was days (iqr - days), while the median hospitalized period in discharge group was days (iqr - days) ( table ) . on admission, the bedside drs showed larger pulmonary opacities in death event group compared with discharge group, but without a significant difference ( vs. , p= . ) ( table ) . besides, more abnormities of biochemical and hematological parameters were observed in death event group compared with discharge group, such as neutrophil, lymphocyte, crp, pct, ldh, d-dimer, ctni, and bnp ( table ) . the bivariate logistic regression was performed on the clinical, radiographic, and laboratory parameters ( table ) . as a result, ten stratified parameters including male sex, spo ≤ %, breath rate> /min, diastolic pressure≤ mmhg, neutrophil > . × /l, lymphocyte≤ . × /l, crp> . mg/l, pct> . μg/l, ldh> u/l, and d-dimer> . mg/l showed significant risks with death events ( table ) . no obvious multicollinearity was observed with the variance inflation factor (vif) value of less than . in each involved variable (table s ). further multivariate logistic regression showed a significant model fitting involving stratified spo , lymphocyte, crp, pct, and ldh. the results demonstrated that spo ≤ %, lymphocyte≤ . × /l, crp> . mg/l, pct> . μg/l, and ldh> u/l were the independent risk factors with the ors of . , . , . , . , and . , respectively (p< . ). the c-index of the predicted probability calculated using this multivariate logistic model was . (p< . ) (figure ). in the course, dr scores increased in death event group with a significant difference between the two groups after to days from admission (figure and ). after days, dr scores slowly declined in discharge group while increasing in death event group (figure and ) . in death event group, the neutrophil gradually increased to more than . × /l, and lymphocyte stayed at the lower level from . to . × /l in the course, with significant differences from discharge group ( figure ) . in discharge group, lymphocyte gradually increased from . × /l to normal level (≥ . × /l) after nine days. besides, it demonstrated the significantly higher levels of crp, pct, ldh, and d-dimer in death event group, which gradually decreased or stayed at the relatively lower levels in discharge group (figure ) . ctni and bnp demonstrated dramatic fluctuation with significantly higher levels at some time points in death event group compared with discharge group (figure ) . no obvious abnormalities of total bilirubin (tb), aspartate aminotransferase (ast), and serum creatinine (scr) in the course were observed in both groups (table s ) . among all patients, patients underwent consecutive cytokine profile and lymphocyte subsets analysis in the course, including patients in charge group and patients in death event group. the levels of il- , il- , tnf-α, and inf-γ didn't show significant differences between two groups and stayed in the normal reference ranges at most of time ( figure ) . compared with discharge group, il- was significantly elevated in death event group. and il- was significantly increased after days in death event group ( figure ) . cd +, cd +, and cd + t-lymphocyte ratio stayed in the normal range in both groups, though approaching the upper or lower reference at some time points (figure ). cd + and cd + t-lymphocyte ratios were significantly higher in discharge group at several time points, but the cd +/cd + t-lymphocyte ratio seemed higher in death group compared with discharge group reaching significant difference at the time point of - days (figure ). the quantitative data were summarized in table s . this study reported the differences between the discharged and died patients with severe covid- in the clinical course. on admission, spo ≤ %, lymphocyte≤ . × /l, crp> . mg/l, pct> . μg/l, and ldh> u/l were the independent risk factors associated with death events. besides, in the clinical course, significantly higher levels of dr score, neutrophil, il- , d-dimer, ctni, and bnp were also observed in death event group. thus, the results indicated that severe systematic inflammation with cardiac impairment played an important role in the fatal process of covid- . corresponding to the previous reports, old patients with a median age of yrs (iqr - yrs) presenting more coexisting illnesses such as hypertension and cvd were more likely to develop severe covid- [ , ] . male patients in this study were more inclined to occurred ards and death events, in agreement with a retrospective report with a cohort of , patients where male patients over years of age with comorbidities had a higher death risk [ ] . in the course, patients in death event group showed a significantly higher ratio of ards than discharge group ( . % vs. . %). it indicated the survival rate was very low if the patients aggravated to this critical status and further exploration of the treatment to prevent ards is imperative. although no significant difference in the period between initial symptom onset and admission was found between two groups, attention still should be paid to early diagnosis and treatment because the mean period of days from symptom onset to admission in this study was probably too late when the severe progression had occurred [ ] . because the dr demonstrated a good consistency to chest ct which was also capable of estimating the covid- in the follow-up, it was consecutively performed in this cohort in order to reduce the transferring risk of the severe patients and x-ray exposure [ ] . on admission, bilaterally diffuse pulmonary opacities in drs were observed in most patients ( . %), similar to the demonstrations in sars and mers [ , ] . the higher dr scores in death event group on admission were presented with a lower spo level and a higher breath rate when compared with discharge group, though no significant difference was revealed. however, more rapid progression of pulmonary opacities with a significantly higher dr score was observed afterwards in death event group. different from no absorption in death event group, the pulmonary lesions were slowly absorbed after half a month from admission in discharge group. due to the limited medical resources in this provisional center, lung ultrasound was not routinely performed. from the previous studies, lung ultrasound could also be performed at the bedside and has been used in diagnosing and monitoring pneumonia with higher sensitivity and specificity (≥ %) than dr but without x-ray exposure [ , ] . thus, it might be a good alternative to conventional bedside dr in severe covid- patients. up to date, some previous studies already revealed multiple risk factors associated with poor prognosis, such as compromised respiratory status, older age, male sex, lymphocytopenia, high sequential organ failure assessment score, and elevated levels of crp, pct, ldh, and d-dimer [ , [ ] [ ] [ ] [ ] [ ] [ ] [ ] . however, these studies did not consider the impacts of the disease severities on admission in the analysis. as a complementary, this study provided a risk-factor analysis only in the population of severe covid- who presented a higher mortality rate than moderate covid- [ ] . as a case-control study, the bivariate logistic regression returned with ten stratified risk factors for death with statistical significances, including male sex, spo ≤ %, breath rate> /min, diastolic pressure≤ mmhg, neutrophil > . × /l, lymphocyte≤ . × /l, crp> . mg/l, pct> . μg/l, ldh> u/l, and d-dimer> . mg/l. further multivariate logistic regression using the forward-lr method resulted in a significant fitting model with good discriminatory power (c-index= . ). the results revealed spo ≤ %, lymphocyte≤ . × /l, crp> . mg/l, pct> . μg/l, and ldh> u/l on admission were the independent risk factors, among which the lymphocyte≤ . × /l demonstrated the highest or of . . moreover, the abnormalities of lymphocyte, crp, pct, and ldh stayed or continuously aggravated in death event group but gradually recovered to normal levels in discharge group. therefore, the dynamic monitoring of these laboratory parameters could estimate the prognosis in clinical practice for severe patients. in further analysis of the lymphocyte subsets in limited groups, no obvious abnormalities of cd +, cd +, and cd + t-lymphocyte ratio were found in both groups. however, relatively high cd +/cd + t-lymphocyte ratio above or near the upper normal reference was observed in both groups, while it seemed higher in death event group. therefore, it indicated no obvious impairment of the immune function, though lymphocyte reduced in severe covid- . as an evidence, a previous post-mortem autopsy study of covid- , it revealed reduced cd + and cd + t-lymphocyte in peripheral blood with overactivation of t-lymphocyte manifested by an increase of th and high cytotoxicity of cd + t-lymphocytes [ ] . as a result, severe immune injury could occur in severe patients. to date, no confirmed evidence of the viral attack on solid organs other than lung was observed in pathological analysis and autopsy [ , ] . two previous studies in the same center found significantly elevated levels of multiple serum cytokines in severe covid- patients, such as il- β, il- , il- , tnf-α, and inf-γ, which were associated with the disease severity [ , ] . it was suspected a phenomenon named "cytokine storm" might result in the progression of the disease in viral pneumonia [ , ] . in previous studies, covid- was thought to induce "cytokine storm" that then caused multi-organ impairment involving the heart, liver, and kidney [ , , , ] . however, the clinical course of our patients did not appear to follow this sequence of events. among multiple cytokines, only il- as one major proinflammatory factor significantly increased with time in death event group with the simultaneous increase of il- as an anti-inflammatory factor, while il- , il- , tnf-α, and inf-γ neither showed significant differences between two groups nor demonstrated obvious abnormalities in the course. besides, the hepatic and renal related parameters were not significantly elevated. therefore, the result of this study didn't support this fatal hypothesis of "cytokine storm" with induced multi-organ impairments in severe covid- . it was speculated that in those published studies, the dynamic changes of the related laboratory parameters were demonstrated as the mean value which might be not appropriate due to the non-normal distribution of the data [ , ] . thus, the dynamic demonstration with the median value was more reliable in this study. on the other hand, crp, pct, il- , and bnp as the major indicators of inflammatory severity in intensive care medicine, had significantly increased or stayed at a relatively high level in death event group, corresponding to the aggravated sepsis in these patients which could cause life-threatening organ dysfunction [ , ] . as indirect evidence, increased cd +/cd + t-lymphocyte ratio in death group was also a typical abnormality in sepsis [ ] . meanwhile, gradually increased neutrophil was observed indicating progressive inflammation as part of the inadequate host response to viral aggression [ ] . in summary, all of these abnormalities could be ascribed to severe systematic inflammation caused by covid- . more than this, the virus-induced inflammation could initiate the activation of the fibrinolytic system and fibrin catabolism resulting in the elevation of the d-dimer level in severe patients which was also observed in this study [ , , ] . as a complication, a persistently high level of ldh, ctni, and bnp indicated potential cardiac impairment in the course like reported in other studies [ , ] . however, the elevated levels of d-dimer, ctni, and bnp fluctuated or decreased in the course but not persistently aggravated, while these parameters progressively deteriorated with time in non-survivors in previous studies [ , ] . as speculation, these differences might be ascribed to more attention paid to the cardiac protection and microcirculation improvement for the patients in this cohort. in brief, it was concluded that the systematic inflammation with induced cardiac dysfunction was the leading cause of death events in severe covid- except for ards. thus, the use of corticosteroids should still be considered for critical patients to prevent severe inflammatory response [ ] [ ] [ ] . in one recent study, it was found treatment with methylprednisolone significantly decreased death risk [ ] . serum cytokine profiling and lymphocyte subsets analysis might be useful to guide the immunomodulatory treatment [ ] . this case-controlled study has limitations. first, the sample size is limited in this study and not all patients underwent sequential cytokine profile and lymphocyte subsets tests. second, the study was limited by the heterogeneity of treatments based on the disease status with time, which was impossible to summarize in this cohort. thus, only the speculation was made to explain the fluctuation of some abnormal laboratory parameters in the course. third, the dynamic changes of vital signs and oxygen saturation were not presented, because they were continuously monitored in the course and sort of affected by the adjusted treatments. at last, some important subsets of lymphocytes including th and treg were not measured due to the limitation of the laboratory techniques in this provisional isolation center, thus the identification of the immune function was not comprehensive. in summary, this study revealed the clinical course of severe covid- patients from admission with different outcomes. dynamic monitoring of lymphocyte, crp, pct, and ldh could be meaningful to predict the prognosis of severe patients. besides, the fatal feature of covid- is mostly attributed to severe systematic inflammation with induced cardiac dysfunction except for ards. the novel coronavirus pneumonia emergency response epidemiology team. the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- ) in china world health organization epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study world health organization pathological findings of covid- associated with acute respiratory distress syndrome. the lancet respiratory medicine clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan clinical features of patients infected with novel coronavirus in wuhan clinical characteristics of coronavirus disease in china time course of lung changes on chest ct during recovery from novel coronavirus (covid- ) pneumonia clinical course and outcomes of critically ill patients with sars-cov- pneumonia in wuhan, china: a single-centered, retrospective, observational study. the lancet respiratory medicine clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study. the lancet risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease clinical predictors of mortality due to covid- based on an analysis of data of patients from wuhan, china. intensive care med editorial concern-possible reporting of the same patients with covid- in different reports national health commission of the people's republic of china. diagnosis and treatment protocols of pneumonia caused by a novel coronavirus (trial version ) national health commission of the people's republic of china. diagnosis and treatment protocols of pneumonia caused by a novel coronavirus clinical management of severe acute respiratory infection when novel coronavirus (ncov) infection is suspected world health organization. imai district clinician manual: hospital care adolescents and adults : guidelines for the management of illnessess with limited-resources radiographic-clinical correlation in severe acute respiratory syndrome: study of patients in hong kong clinical implication of radiographic scores in acute middle east respiratory syndrome coronavirus pneumonia: report from a single tertiary-referral center of south korea acute respiratory distress syndrome: the berlin definition clinical management of severe acute respiratory infection when novel coronavirus (ncov) infection is suspected: interim guidance variance inflation factor: as a condition for the inclusion of suppressor variable(s) in regression analysis portable chest x-ray in coronavirus disease- (covid- ): a pictorial review lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study lung ultrasound for the diagnosis of pneumonia in adults: a systematic review and meta-analysis a gross observational report of systematic autopsy in covid- pneumonia endothelial-platelet interactions in influenza-induced pneumonia: a potential therapeutic target plasma inflammatory cytokines and chemokines in severe acute respiratory syndrome study on the levels of main inflammatory factors in septic shock and their clinical significance the third international consensus definitions for sepsis and septic shock (sepsis- ) coincidence of pro-and anti-inflammatory responses in the early phase of severe sepsis: longitudinal study of mononuclear histocompatibility leukocyte antigen-dr expression, procalcitonin, c-reactive protein, and changes in t-cell subsets in septic and postoperative patients neutrophil activation during septic shock. shock (augusta, ga) the association between plasma d-dimer levels and community-acquired pneumonia we express our sincere gratitude to the emergency services, nurses, doctors and a lot of medical supports from other provinces for their efforts to combat the covid- outbreak in wuhan. besides, we are grateful to dr. jiazheng wang and dr. dandan zheng for many useful discussions through the formation and design of this work. supplementary figures and tables. http://www.medsci.org/v p s .pdf fp, ly, and yl contributed equally to this article. fp, ly, yl, yh, and cz designed this study and had full access to all data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. fp, ly, yl, and bl wrote the initial manuscript together with all authors providing critical feedback and edits to subsequent revisions. yl, bl, lin li, lingli li, ty, dl, and sg carried out the retrieving work and information input including clinical, radiological, and laboratory data from the institutional electronic database. cz and ly take responsibility for the integrity of the data and the accuracy of the data analysis. cz and ly were blinded to perform the semi-quantitative analysis of the radiological images on the vue pacs system. fp and yh finished the statistical data analysis, and ly, bl, ly, and cz performed the proofreading work. all authors approved the final draft of the manuscript and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. the authors have declared that no competing interest exists. key: cord- - jcccv authors: woo, yu ri; park, seo-yeon; choi, keonwoo; hong, eun sun; kim, sungjoo; kim, hei sung title: air pollution and atopic dermatitis (ad): the impact of particulate matter (pm( )) on an ad mouse-model date: - - journal: int j mol sci doi: . /ijms sha: doc_id: cord_uid: jcccv air pollution reportedly contributes to the development and exacerbation of atopic dermatitis (ad). however, the exact mechanism underlying this remains unclear. to examine the relationship between air pollution and ad, a clinical, histological, and genetic analysis was performed on particulate matter (pm)-exposed mice. five-week-old balb/c mice were randomly divided into four groups (control group, ovalbumin (ova) group, pm group, ova + pm group; n = ) and treated with ova or pm( ,) alone or together. cutaneous exposure to ova and pm( ) alone resulted in a significant increase in skin severity scores, trans-epidermal water loss (tewl) and epidermal thickness compared to the control group at week . the findings were further accentuated in the ova + pm group showing statistical significance over the ova group. a total of , , and genes were found to be differentially expressed following ova, pm( ), and ova + pm( ) exposure, respectively. strongly upregulated genes included rnase a, s a , sprr d, thrsp, sprr a (ova vs. control), sprr d, s a , stfa , chil , dbp, il b (pm vs. control) and s a , sprr d, sprr b, s a , sprr a (ova + pm vs. control). in comparing the groups ova + pm with ova, genes were differentially expressed with s a , sprr b, saa , s a , sprr d being the most highly upregulated in the ova + pm group. taken together, our study demonstrates that pm( ) exposure induces/aggravates skin inflammation via the differential expression of genes controlling skin barrier integrity and immune response. we provide evidence on the importance of public awareness in pm-associated skin inflammation. vigilant attention should be paid to all individuals, especially to those with ad. air pollution is an important environmental issue and a major threat to global health [ ] . particulate matter (pm), a key component of air pollution, is a designated carcinogen [ ] , and is well known to increase the risk of cardiovascular and respiratory diseases [ , ] . in recent years, the damaging effect of pm on the skin has raised great interest [ ] [ ] [ ] . atopic dermatitis (ad) is an inflammatory, chronically relapsing, and intensely pruritic skin condition. with a prevalence of to % (approximately % in children and young adults), it is one of the most common skin diseases in industrialized countries. ad has a strong genetic predisposition, but its recent surge in incidence also stresses the role of the environment in the pathogenesis of ad. according to epidemiologic studies, air pollution/pm significantly influences the symptoms of ad [ , [ ] [ ] [ ] [ ] [ ] [ ] [ ] . however, there is little definitive mechanistic evidence supporting this [ ] . pm is a heterogenous mixture of solid and liquid particles suspended in air. based on particle size, pm is categorized into pm . (ultrafine particles, ≤ . µm), pm . (fine particles, ≤ . µm), and pm (inhalable particles, ≤ µm). pm encompasses pm . and varies in composition depending on the source [ ] . for this study, we employed a standard reference material ® (srm ), issued by the national institutes of standards and technology (nist). the srm is "natural" (field collected) pm composed of polycyclic aromatic hydrocarbons (pahs), nitro-pahs, polybrominated diphenyl ethers (pbdes), dioxins, sugars, and trace elements (i.e., hg, al, ca, cu, fe, pb, mn, mg, ni), with a mean particle diameter of ≤ µm [ ] . as an important interface with the outside environment, the skin, along with the oral and respiratory routes, is a common pathway, through which ambient pollutants enter the body [ , ] . with that said, the potential mechanisms by which pm exerts cutaneous detrimental effects include direct insult by localization (adherence or penetration of pm to the skin) and indirect injury by systemic inflammation and oxidative stress (i.e., systemic increase of reactive oxygen species (ros) through the respiratory system) [ ] . taking into account that epithelial barrier dysfunction and cutaneous inflammation are crucial in the pathogenesis of ad [ ] , the aim of the present work was to evaluate the ability of topically delivered pm to clinically promote ad, and to assess the mechanisms involved in this process by gene analysis (i.e., focusing on genes associated with skin barrier function and the inflammatory pathway). to approximate the condition of ad, we used ovalbumin (ova)-challenged mice as the animal model. repeated topical application of ova to the dorsal skin ( × cm) of balb/c mice induced ad-like skin lesions with erythema, edema, excoriation, and scaling ( figure a ). the skin severity score at week was higher in the ova group ( . ± . ) and the pm group ( . ± . ) compared to control ( . ± . ) (p < . ). the skin severity score of the ova + pm group ( . ± . ) was significantly higher than that of the ova group and the pm group (p < . ). the skin severity score was similar between the ova group and the pm group (p > . ) ( figure b) . ova (ova group) and pm (pm group) application caused an increase in trans-epidermal water loss (tewl). tewl at week was significantly higher in the ova group ( . ± . ) and the pm group ( . ± . ), compared to control ( . ± . ) (p < . ). tewl of the ova + pm group ( . ± . ) was significantly higher than that of the ova group and the pm group at week (p < . ). the tewl was similar between the ova and the pm group (p > . ) ( figure c ). figure a demonstrates the hematoxylin and eosin (h&e) and toluidine blue staining of the dorsal skin. there was marked epidermal thickening after ova (ova group) and pm (pm group) application at week compared to control ( . ± . and . ± . µm vs. . ± . µm) (p < . ). the epidermis of the ova + pm group ( . ± . ) was significantly thicker than that of the ova group and the pm group at week (p < . ). the epidermal thickness was similar between the ova and the pm group (p > . ) ( figure b ). ova (ova group) and pm (pm group) application caused an increase in trans-epidermal water loss (tewl). tewl at week was significantly higher in the ova group ( . ± . ) and the pm group ( . ± . ), compared to control ( . ± . ) (p < . ). tewl of the ova + pm group ( . ± . ) was significantly higher than that of the ova group and the pm group at week (p < . ). the tewl was similar between the ova and the pm group (p > . ) ( figure c ). figure a demonstrates the hematoxylin and eosin (h&e) and toluidine blue staining of the dorsal skin. there was marked epidermal thickening after ova (ova group) and pm (pm group) application at week compared to control ( . ± . and . ± . μm vs. . ± . μm) (p < . ). the epidermis of the ova + pm group ( . ± . ) was significantly thicker than that of the ova group and the pm group at week (p < . ). the epidermal thickness was similar between the ova and the pm group (p > . ) ( figure b ). as shown in figure a , ova and pm increased mast cell infiltration in the dermis. the mast cell number was significantly higher in the ova group ( . ± . / high power fields) and the pm group ( . ± . ), compared to control ( . ± . ) (p < . ). the number of mast cells in ova treated groups (the ova group, the ova + pm group: . ± . / high power fields) were significantly higher than that of the pm treated group (p < . ). the mast cell number was similar between the ova + pm and the ova group (p > . ) ( figure c ). as shown in figure a , ova and pm increased mast cell infiltration in the dermis. the mast cell number was significantly higher in the ova group ( . ± . / high power fields) and the pm group ( . ± . ), compared to control ( . ± . ) (p < . ). the number of mast cells in ova treated groups (the ova group, the ova + pm group: . ± . / high power fields) were significantly higher than that of the pm treated group (p < . ). the mast cell number was similar between the ova + pm and the ova group (p > . ) ( figure c ). total serum ige at week was higher in ova treated groups (the ova group: ± , the ova + pm group: ± ng/ml), compared to control ( ± . ng/ml) (p < . ) and the pm group ( ± ng/ml) (p < . ). total serum ige was similar between the ova group and the ova + pm group, and between the pm group and control (p > . ) ( figure d ). according to rna-seq analysis, a total of genes were found to be differentially expressed by ova exposure (greater than . -log folds up and down and a raw p-value < . ). among the genes, genes were upregulated, and downregulated. in the pm exposed group, a total of genes were differentially expressed ( upregulated and downregulated). with ova + pm application, the differentially expressed gene (deg) count was ( upregulated and downregulated). between the ova + pm and the ova group, the number of degs was ( upregulated and genes downregulated). in comparing ova + pm application to pm only those genes exhibiting log fold change (fc) ≥ . and p < . were considered differentially expressed genes. for the deg (differentially expressed gene) set, hierarchical clustering analysis was done using complete linkage and euclidean distance as a measure of similarity. the top significantly up-regulated genes ranked according to the fold change are presented in supplementary table s . among them, sprr d, s a , stfa , chil , dbp, il b, sprr a , lce h, sprr b, lce g (group pm vs. control), rnase a, s a , sprr d, thrsp, sprr a , s a , serpinb a, sprr b, c qtnf , cxcl (group ova vs. control), s a , sprr d, sprr b, s a , sprr a , serpinb a, stfa , sprr a , sprr e, bc (group ova + pm vs. control), s a , sprr b, saa , s a , sprr d, sprr a , serpinb a, sprr e, gm , stfa (group ova + pm vs. group ova), s a , s a , saa , sprr b, sprr d, sprr a , serpinb a, sprr e, gm , sprr a (group ova + pm vs. group pm), npy, fam b, guca a, wfdc , il ra , ugt a , tesc, serpine , crabp , ptgs (group pm vs. group ova) were most significantly up-regulated ( table ). the degs are also presented in table according to their function. the top significantly up-regulated genes ranked according to the fold change are presented in supplementary table s . among them, sprr d, s a , stfa , chil , dbp, il b, sprr a , the major gene ontology (go) terms and pathways of ova + pm vs. ova group are shown in figure . as for the biological process, the top terms of go functional analysis were immune system process, immune response, regulation of immune system process, defense response, positive regulation of immune system process, response to external stimulus, response to other organism, response to external biotic stimulus, response to biotic stimulus, and inflammatory response ( figure a ). the cellular component included cornified envelope and the nadph (nicotinamide adenine dinucleotide phosphate oxidase) complex ( figure b ), and the molecular function included cytokine binding, oxidoreductase activity acting on nadph, pattern recognition receptor activity and peptidase regulator activity ( figure c ). kegg analysis showed that up-regulated degs for both ova + pm vs. ova group and pm vs. control group were enriched in metabolic pathways (mmu ), ras signaling pathway (mmu ), rap signaling pathway (mmu ), mapk signaling pathway (mmu ), jak-stat signaling pathway (mmu ), nf-kappa b signaling pathway (mmu ), tnf signaling pathway (mmu ), hif- signaling pathway (mmu ), calcium signaling pathway (mmu ), cytokine-cytokine receptor interaction (mmu ), toll-like receptor signaling pathway (mmu ), nodulation (nod)-like receptor signaling pathway (mmu ), c-type lectin receptor signaling pathway (mmu ), th cell differentiation (mmu ), il- signaling pathway (mmu ), inflammatory mediator regulation of trp channels (mmu ), and pathways in cancer (mmu ). the nod-like receptor signaling pathway is shown in figure . among the relevant genes, cutaneous pm this study explored how exposure to pm modulates the development and exacerbation of ad using ova-treated balb/c mice. the endpoints of this study included: ( ) the extent of clinical and histological skin inflammation including hallmarks of allergic inflammation; and ( ) the expression of various genes involved in the skin barrier and immune response to gain insight into the pm modulation of ad. our ova exposed mice successfully captured the characteristics of ad (i.e., increase in serum ige, mast cell infiltration in the dermis, elevated gene expression of chil (related to th response), fcer a (fc fragment of ige receptor a), il- (an epithelial cell-derived cytokine that promotes th cytokine responses), and rnase a (important for eosinophil recruitment and function)). key ad genes, including the th and th cytokines (il- , il- , il- ) are usually present at less than detection level on microarrays, requiring real-time pcr (rt-pcr) [ ] [ ] [ ] . this was also the case with our samples-although absent from microarray, we were able to detect il- in the ova treated groups through real-time pcr (rt-pcr) (data not shown). no single murine model fully captures all aspects of the ad profile. ewald et al. [ ] have recently compared the transcriptomic profiles of common ad-like murine models and identified that the ova-challenged model has significant overlap with genes upregulated in human ad, but does not capture the downregulated signature of human ad. accordingly, we tried to focus on the upregulated genes in our study. the degs of our ova exposed mice and those of ewald et al.'s [ ] ova-challenged model were highly similar, which confirmed the reliability of our ad mouse model. pm displayed adjuvant-like effects, enhancing skin inflammation/barrier damage upon ova challenge (i.e., enhanced skin severity scores, tewl, epidermal thickness, and increased expression of skin barrier genes (epidermal differentiation complex: krt , b, ; lce a, b, e, f; s a , a ; sprr a , a , b, d, e, i; protease: mmp ; serpinb a, b; stfa , ; bc ; klk , , ; antimicrobial response: defb ), and pro-inflammatory genes (il- b, tnf ip ). the expression of allergy genes (il- ra , il- , fcerig, chil ) was also enhanced in the ova + pm group when compared to the ova group indicating the possible exacerbation of ad. we were also intrigued to see if pm affects intact skin. in a prior study, jin et al. [ ] have detected pm inside hair follicles in both intact and barrier-disrupted skin. additionally, repeated pm application was shown to induce epidermal thickening and dermal inflammation with neutrophil infiltration. although we failed to detect pm in the appendageal structures/dermis of our skin sections, our findings were similar with that of jin et al. [ ] , where enhanced skin severity scores, tewl, epidermal thickness, and increased expression of skin barrier genes (epidermal differentiation complex: krt ; lce f, g, h; lce e, f; s a , a ; sprr a , a , b, d, e, i; protease: serpinb a, b; stfa , ; bc ; klk , , ; antimicrobial response: defb ; other: a rik) and pro-inflammatory genes (il- b, cxcl ) were noted. the increase in mast cell number, heightened expression of an allergy-related gene (chil ), and detection of il- through rt-pcr (data not shown) suggest that ad can perhaps develop following pm exposure alone. the main cause of pm-inflicted skin damage has been identified as polycyclic aromatic hydrocarbons (pahs), the main organic constituent of pm [ , , ] . pahs exert their biological effect via binding to the ligand-activated transcription factor aryl hydrocarbon receptor (ahr), which is widely expressed on skin cells [ ] . ahr is a major sensor of environmental signals, but at the same time, ahr ligands are abundant in the skin from exogenous or endogenous sources [ ] . the quality and duration of ahr activation by various ligands directs the level and spectrum of the genes which are induced, and are thus pivotal in the outcome, including a "toxic" outcome [ , ] . three important groups of genes are targeted by ahr [ ] . first, a battery of genes encoding detoxifying enzymes (xenobiotic metabolizing enzymes, xmes), such as the cytochrome p (cyp) gene cyp a (phase i xme) and phase ii enzymes (nadph dehydrogenase quinone , nqo ; glutathione s-transferases, gsta ; uridine -diphospho-glucuronosyltransferases; ugt a , ugt a , ugt a ) [ ] [ ] [ ] ; second, genes related to epidermal differentiation and skin barrier integrity; and finally, genes related to immunity. the ahr battery genes are noteworthy in that we have found evidence of aberrant ahr activation with our model (ova group, pm group, ova + pm group) based on elevated gene expression levels of xmes. xenobiotic small chemicals have strong affinity to ahr and cause persistent activation of the receptor [ ] . the pathogenic implication of ahr and its gene polymorphism in ad remain elusive but it has been suggested that most ahrs lack physiological ligands in the th -prone milieu in ad [ , ] . transgenic mice expressing constitutively active form of ahr (ahr-ca) [ ] (surmised to be equivalent to pah-liganded ahr) have shown a gene profile with an increase in structural protein genes (krt , b, ), protease genes (i.e., mmp), interleukins/chemokine genes (i.e., il- b, cxcl , ccl ), fc receptor genes (fcerig), and antimicrobial peptide genes (i.e., defb) reproduced in our mouse models (pm group, ova + pm group), which indicates the role of the pah-liganded ahr in pm induced skin barrier dysfunction/immune deviation. the ligation of ahr by xenobiotic small chemicals (i.e., pah, dioxin) was reported to preferentially affect the differentiation and propagation of th cells [ , , ] , as seen in our pm exposed mouse models (enrichment of upregulated degs in the th cell differentiation (mmu ), and il- signaling pathway (mmu )), which too suggests that the pah-ahr axis underlies the allergic response to pm. pah itself has also been suggested to provoke inflammation as a primary irritant or allergen [ , [ ] [ ] [ ] . other lines of evidence suggest that reactive oxygen species (ros) generated by oxygenated pahs enhance the allergic response [ , ] . pahs have also been shown to stimulate an increase in the dna-binding activity of nf-kb [ ] , which, in turn, induces cytokine gene expression provoking the allergic response. to note, the nf-kappa b signaling pathway (mmu ) was found to be enriched with upregulated degs in our ova + pm and pm group. in summary, we demonstrate that pm exacerbates ad when exposure occurs during simultaneous allergen sensitization/elicitation. the enhancement of the allergic immune response by pm is characterized by increased mast cells in the dermis, elevated serum ige level, upregulated expression of the skin barrier genes (epidermal differentiation complex; protease; antimicrobial response), pro-inflammatory genes, and allergy genes (microarray: il- ra , il- , fcerig, chil ; rt-pcr: il- ; kegg analysis: th cell differentiation, il- signaling pathway). pm-mediated toxicity may be the result of pahs modulating immunity and the epidermal barrier via the ahr. since pm is also able to initiate ad in intact skin, further work is needed to investigate if pm enhances the antigen-presenting capabilities of dendritic cells, and if this translates to enhanced b and t cell adaptive responses, as well as the critical role of the ahr in these processes. our identification of the molecular mechanisms through which pm mediates its toxicological effects and enhances immune-mediated inflammation and barrier damage sheds light on the sharp rise of ad in the past decades. in conclusion, we provide evidence on the importance of public awareness in pm-associated skin inflammation. vigilant attention and preventive measures should be paid to all individuals, especially to those with ad. pm was collected in from an air intake filtration system of a major exhibition center in prague, czech republic (nist, srm ). pm suspension was freshly prepared by resuspending pm particles in phosphate-buffered saline (pbs) at a concentration of . mg/ml, and vortexing for min at maximum speed. four-week-old female balb/c mice were procured from orient bio inc., sungnam, korea. animals were housed in specific pathogen-free (spf) environment, exposed to a -h light/dark cycle, and were provided with autoclaved water and food ad libitum. the mice were randomly divided into groups (control group, ova group, pm group, ova + pm group; n = ). after a week of acclimatization, the back of the mice was shaved with an electric clipper (day ) and was kept hair-free with hair removal cream (veet) and tape strips (nad's body wax strip) twice weekly for the entire study period. the study protocol was approved by the institutional animal care and use committees (iacucs) of the college of medicine, the catholic university of korea ( - - , august ). the schematic experimental procedure is described in figure . the schematic experimental procedure is described in figure . the mice in the ova group and ova + pm group were intraperitoneally (ip) injected with μg chicken egg ovalbumin (ova) (a - g, sigma-aldrich, mo, usa) and mg of aluminum hydroxide ( - g, sigma-aldrich, mo, usa) in μl of pbs on days , and using a modified protocol [ , ] . those in the control group and the pm group were ip injected with an equal volume of pbs on the same date. from day , a pm patch ( μg/cm of pm applied on a nonwoven × cm polyethylene sheet (scotch brite tm , m, st. paul, mn, usa) and fixed with a transparent adhesive film dressing (tegaderm tm , m, st. paul, mn, usa) was applied daily to the backs of the pm group (until week ) and the ova + pm group (until week ) mice. a pbs patch ( μl of pbs applied on a × cm nonwoven polyethylene sheet and fixed with a transparent adhesive film dressing) was employed in the same manner in the control group (until week ) and the ova group (until week ). seven days after the final ip injection, mice in the ova group and the ova + pm group were challenged with ova ( μg of ova dissolved in μl of pbs applied on a × cm nonwoven polyethylene sheet and fixed with a transparent adhesive film dressing) and ova + pm ( μg of ova + μg/cm of pm in μl of pbs applied on a nonwoven × cm polyethylene sheet and fixed with a transparent adhesive film dressing patches respectively, until the end of the study (week ). clinical assessments were made twice a week for the entire study period. the trans-epidermal water loss (tewl) was assessed on the dorsal skin of the balb/c mice using the vapometer (delfin technologies, kuopio, finland). a modified scoring atopic dermatitis (scorad) (defined as the sum of individual scores for each of the following signs and symptoms: erythema, edema, excoriation, and dryness. each item was scored as (none), (mild), (moderate), and (severe), as previously described) was used to measure the clinical severity. scoring was performed by assessors masked to the study purpose and hypothesis. they were not involved in treatment administration or assignment. the mice were sacrificed in week . the dorsal skin samples were fixed in % vol. phosphatebuffered formalin solution, embedded in paraffin, and sectioned at μm. the tissue sections were stained clinical assessments were made twice a week for the entire study period. the trans-epidermal water loss (tewl) was assessed on the dorsal skin of the balb/c mice using the vapometer (delfin technologies, kuopio, finland). a modified scoring atopic dermatitis (scorad) (defined as the sum of individual scores for each of the following signs and symptoms: erythema, edema, excoriation, and dryness. each item was scored as (none), (mild), (moderate), and (severe), as previously described) was used to measure the clinical severity. scoring was performed by assessors masked to the study purpose and hypothesis. they were not involved in treatment administration or assignment. the mice were sacrificed in week . the dorsal skin samples were fixed in % vol. phosphate-buffered formalin solution, embedded in paraffin, and sectioned at µm. the tissue sections were stained with hematoxylin and eosin (h&e) for microscopic examination. for identification of mast cells, skin sections were stained with toluidine blue. the mast cells were counted in randomly chosen visuals fields at × magnification. the evaluation was performed at a central laboratory, where slides were made available for a central reading by an assessor masked to the experiment. blood was collected from the retroorbital plexus using heparinized glass capillary tubes at the end of the experiment (week ). serum samples obtained by centrifugation ( × g for min at • c) were stored at − • c until use. concentration of total ige serum was determined using the mouse ige elisa kit (shibayagi co. ltd., gunma, japan), according to the manufacturer's instruction. laboratory evaluations were performed at a central laboratory. total rna concentration was calculated by quant-it ribogreen (r , invitrogen, carlsbad, ca, usa). to assess the integrity of the total rna, samples were run on the tapestation rna screentape (# - , agilent, santa clara, ca, usa). only high-quality rna preparations, with rin greater than . , were used for rna library construction. cdna libraries were constructed with the truseq rna library kit (rs- - , illumina inc., san diego, ca, usa) where µg of rna was used per sample. rna was polya-selected, fragmented, reverse transcribed and sequenced with illumina hiseq (san diego, ca, usa). libraries were quantified with the qpcr-based kapa library quantification kit (kk ) and qualified with an agilent technologies bioanalyzer (santa clara, ca, usa). the raw reads were preprocessed and then aligned to mus musculus (mm ) with hisat v . . (http: //ccb.jhu.edu/software/hisat /) [ ] . hisat employs two kinds of indexes and creates spliced alignments faster than bwa and bowtie. downloads of the reference genome sequence and annotation data are available from http://genome.uscs.edu. stringtie v . . d (http://ccb.jhu.edu/software/stringtie/) [ , ] was used to build aligned reads into transcripts and calculate fragments per kilobase of exon per million fragments mapped (fpkm) values. standardized fpkm values were utilized to compare gene's expression levels. sixteen samples (control, ova, pm, ova + pm groups; samples per group) were examined in total. all data are expressed as the mean ± sd. one-way analysis variance (anova,) followed by the tukey multiple comparison test, was used to assess differences in the measurements between multiple groups. statistical analyses were performed using graph pad prism . (san diego, ca, usa). a p-value of less than . was considered statistically significant. statistical analysis was carried out to find degs. transcripts with zeroed fpkm values were eliminated. filtered data were log -transformed and quantile normalized. statistical significance of the deg data was verified with independent t-test and fold change with a null (no difference) hypothesis. the false discovery rate (fdr) was corrected with the benjamini-hochberg algorithm. hierarchical clustering analysis was performed employing euclidean distance and complete linkage. gene-enrichment and functional annotation analysis and pathway analysis for significant gene list were carried out according to gprofiler (http://biit.cs.ut.ee/gprofiler/orth) and kegg pathway (http://www.genome.jp/kegg/pathway.html). baculovial iap repeat containing ccr c-c chemokine receptor cxcr c-x-c chemokine receptor csf r colony stimulation factor- receptor pf platelet the impact of airborne pollution on atopic dermatitis: a literature review an approach to estimating the environmental burden of cancer from known and probable carcinogens: application to ontario ambient particulate matter and biomass burning: an ecological time series study of respiratory and cardiovascular hospital visits in northern thailand air microbiome and pollution: composition and potential effects on human health, including sars coronavirus infection air pollution and skin diseases: adverse effects of airborne particulate matter on various skin diseases air pollution, autophagy, and skin aging: impact of particulate matter (pm( )) on human dermal fibroblasts the impact of airborne pollution on skin the role of air pollutants in atopic dermatitis annesi-maesano, i. long-term exposure to close-proximity air pollution and asthma and allergies in urban children traffic-related air pollution, climate, and prevalence of eczema in taiwanese school children association between particulate matter concentration and symptoms of atopic dermatitis in children living in an industrial urban area of south korea adult atopic dermatitis and exposure to air pollutants-a nationwide population-based study short-term effects of weather and air pollution on atopic dermatitis symptoms in children: a panel study in korea the effects of air pollution on the development of atopic disease the aryl hydrocarbon receptor ahr links atopic dermatitis and air pollution via induction of the neurotrophic factor artemin outdoor air pollution and asthma development of two fine particulate matter standard reference materials (< µm and < µm) for the determination of organic and inorganic constituents cutaneous responses to environmental stressors skin damage mechanisms related to airborne particulate matter exposure atopic dermatitis nonlesional atopic dermatitis skin is characterized by broad terminal differentiation defects and variable immune abnormalities progressive activation of t(h) /t(h) cytokines and selective epidermal proteins characterizes acute and chronic atopic dermatitis rna sequencing atopic dermatitis transcriptome profiling provides insights into novel disease mechanisms with potential therapeutic implications major differences between human atopic dermatitis and murine models, as determined by using global transcriptomic profiling urban particulate matter in air pollution penetrates into the barrier-disrupted skin and produces ros-dependent cutaneous inflammatory response in vivo ultrafine particles from diesel vehicle emissions at different driving cycles induce differential vascular pro-inflammatory responses: implication of chemical components and nf-kappab signaling differential effects of the particle core and organic extract of diesel exhaust particles the aryl hydrocarbon receptor in barrier organ physiology, immunology, and toxicology functions of the aryl hydrocarbon receptor in the skin timing is everything: consequences of transient and sustained ahr activity aryl hydrocarbon receptor in atopic dermatitis and psoriasis coordinate regulation of phase i and ii xenobiotic metabolisms by the ah receptor and nrf role of the aromatic hydrocarbon receptor and [ah] gene battery in the oxidative stress response, cell cycle control, and apoptosis a tryptophan metabolite of the skin microbiota attenuates inflammation in patients with atopic dermatitis through the aryl hydrocarbon receptor constitutive expression of aryl hydrocarbon receptor in keratinocytes causes inflammatory skin lesions the aryl hydrocarbon receptor: multitasking in the immune system cytochrome p -inhibiting chemicals amplify aryl hydrocarbon receptor activation and il- production in t helper cells metabolic requirements for induction of contact hypersensitivity to immunotoxic polyaromatic hydrocarbons role of alterations in ca( +)-associated signaling pathways in the immunotoxicity of polycyclic aromatic hydrocarbons photocontact dermatitis and chloracne: two major occupational and environmental skin diseases induced by different actions of halogenated chemicals organic compounds from diesel exhaust particles elicit a proinflammatory response in human airway epithelial cells and induce cytochrome p a expression environmental polycyclic aromatic hydrocarbons, benzo(a) pyrene (bap) and bap-quinones, enhance ige-mediated histamine release and il- production in human basophils polycyclic aromatic hydrocarbons induce il- expression through nuclear factor kappab activation in a cell line a ccr antagonist ameliorates atopic dermatitis-like skin lesions induced by dibutyl phthalate and a hydrogel patch containing ovalbumin topical application of herbal mixture extract inhibits ovalbumin-or , -dinitrochlorobenzene-induced atopic dermatitis hisat: a fast spliced aligner with low memory requirements stringtie enables improved reconstruction of a transcriptome from rna-seq reads transcript-level expression analysis of rna-seq experiments with hisat, stringtie and ballgown this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we acknowledge jung woo suh for technical support. the authors declare no conflict of interest. key: cord- - d zvg authors: jang, hyesun; koo, bon-sang; jeon, eun-ok; lee, hae-rim; lee, sang-myeong; mo, in-pil title: altered pro-inflammatory cytokine mrna levels in chickens infected with infectious bronchitis virus date: - - journal: poult sci doi: . /ps. - sha: doc_id: cord_uid: d zvg infectious bronchitis virus (ibv) replicates primarily in the respiratory tract and grows in various organs in chickens, with or without pathological effects. the diversity of this virus has been verified by sequence analysis of the s glycoprotein gene, but this method must be supplemented with further analysis for characterization of the agent. to increase our understanding of the pathogenesis of the disease caused by this virus, we investigated the response of chickens to ibv with different genotypes, kiia and chvi. the clinical signs induced by the viruses were observed. in addition, the mrna levels of the pro-inflammatory cytokines, il- , il- β, and lipopolysaccharide-induced tumor necrosis factor-α factor and the serum levels of α( )-acid glycoprotein, which is a major acute phase protein, were measured. the kiia genotype (kr/adl / ) induced clinical signs accompanied by the excessive production of pro-inflammatory cytokines and a higher viral load. in chickens infected with this isolate, simultaneous peaks in the viral copy number and cytokine production were observed at dpi in the trachea and d postinoculation in the kidney. on the other hand, the chickens infected with the chvi genotype (kr/adl / ) did not show a response other than a mild upregulation of cytokines at d postinoculation, which appears to indicate the invasion of the virus. in summary, we confirmed a differential innate response following infection with distinct ibv. we hypothesize that an excessive innate response contributes to the scale of the pathophysiologic effect in chickens. infectious bronchitis (ib) is a common, highly contagious, and acute viral disease of poultry. the disease is caused by a coronavirus known as ib virus (ibv). the virus initiates infection via the respiratory tract and replicates in various types of epithelial cells, including those of the kidney, gonads, and alimentary tract (villegas, ; saif et al., ) . after the identification of the virus, a high diversity among isolates was reported, not only in antigenicity, but also in pathogenicity, and the nature of this virus motivated researchers to develop an efficient way to classify the isolates (hofstad, ; gelb et al., ; lee et al., ) . genotyping is a relatively recent method of viral classification that is preferred today because of its ability to rapidly detect new strains. it is based on sequence analysis of the s portion of the s protein gene, which encodes the virus-neutralizing epitope and is responsible for viral attachment to cells (ma et al., ) . at least genotypes of ibv have been identified in korea by s sequence analysis (lim et al., ) . the kii type, one of the antigenic clusters of the korean isolates, has frequently been isolated in field outbreaks and is related to nephropathogenic chinese ibv strains (e.g., the ch/qxibv strain; lee et al., ) . the rapid detection of variant isolates is the strongest aspect of the s sequence analysis method. however, because the presumed tissue tropism from this system is not always in agreement with the actual tissue tropism (sapats et al., ) , a more detailed understanding of the immunopathogenesis of ib infections is required. such an understanding will enable scientists to be prepared for the emergence of variants with unusual tissue tropisms (raj and jones, ) . the study of immunopathogenesis has been used to verify disease progress in diverse viral infections. the hyesun jang ,* bon-sang koo ,* eun-ok jeon ,* hae-rim lee ,* sang-myeong lee , † and in-pil mo * * preventive veterinary medicine, college of veterinary medicine, chungbuk national university , cheongju, chungbuk, republic of korea; and † cell biology & molecular immunology laboratory, division of biotechnology, college of environmental & bioresource sciences, chonbuk national university, iksan, jeonbuk, , republic of korea abstract infectious bronchitis virus (ibv) replicates primarily in the respiratory tract and grows in various organs in chickens, with or without pathological effects. the diversity of this virus has been verified by sequence analysis of the s glycoprotein gene, but this method must be supplemented with further analysis for characterization of the agent. to increase our understanding of the pathogenesis of the disease caused by this virus, we investigated the response of chickens to ibv with different genotypes, kiia and chvi. the clinical signs induced by the viruses were observed. in addition, the mrna levels of the pro-inflammatory cytokines, il- , il- β, and lipopolysaccharide-induced tumor necrosis factor-α factor and the serum levels of α -acid glycoprotein, which is a major acute phase protein, were measured. the kiia genotype (kr/adl / ) induced clinical signs accompanied by the excessive production of pro-inflammatory cytokines and a higher viral load. in chickens infected with this isolate, simultaneous peaks in the viral copy number and cytokine production were observed at dpi in the trachea and d postinoculation in the kidney. on the other hand, the chickens infected with the chvi genotype (kr/ adl / ) did not show a response other than a mild upregulation of cytokines at d postinoculation, which appears to indicate the invasion of the virus. in summary, we confirmed a differential innate response following infection with distinct ibv. we hypothesize that an excessive innate response contributes to the scale of the pathophysiologic effect in chickens. correlation between immunopathogenesis and disease progress is widely accepted in diverse studies. in the case of severe acute respiratory diseases, such as sars, immunopathogenesis has been suggested to contribute to disease progression, providing the rationale for therapy with corticosteroids (muñoz-fernandez, ) . during h n influenza infection, an excessive cytokine level in the blood and the innate immune response were suggested to play a role in disease progression peiris et al., ) . in poultry, a role for cytokines in disease progression was suggested in marek's disease, mycoplasmosis, salmonellosis, and coccidiosis (laurent et al., ; swaggerty et al., ; withanage et al., ; jarosinski et al., ; mohammed et al., ) . especially in ib infections, analyzing the correlation between immunopathogenesis and disease progression appears to be valid and effective, considering that the severity of ib infection depends significantly on host factors such as immune status, age, and breed. in a previous study, the renal disease induced by an ib isolate was reproduced at different scales according to the age of the infected chickens (dolz et al., ) . the discrepancy in pathogenicity among different genetic lines of specific pathogen-free (spf) chickens following the same nephropathogenic strain has also been documented (otsuki et al., ; ignjatovic et al., ) . however, little is known about immunopathogenesis during ib infection in chickens (asif et al., ) . one report investigated the overexpression of il- induced by the t strain and its role in exaggerated pathogenicity in s-line chickens (asif et al., ) . this report demonstrated that the overexpression of il- by the host may be responsible for the pathological sequelae, but it remains to be verified whether similar dysregulation could be induced by distinct pathotypes, including nonpathogenic strains (asif et al., ) . in this study, we observed changes in the transcriptional levels of pro-inflammatory cytokines that are known to be involved in the innate immune response in chickens (hong et al., ; davison et al., ) after inoculation with ib isolates. because these isolates are distinct in genotype, we expected to confirm that the scale of change in the cytokines in the trachea and kidney would be correlated with pathogenicity. from this observation, we expected to suggest a strategy to reduce loss from ib infection and to provide helpful information about the immunopathogenesis of ib infection (cook and huggins, ) . among ibv isolated from chickens showing significant clinical signs, field isolates were chosen for this study (table ) . briefly, the isolate of the kiia genotype (kr/adl / ) was isolated from kidneys of -wk-old broilers suffering from severe nephritis, respiratory signs, and increased mortality ( % per day). according to s sequence analysis, this isolate belongs to the kiia type, which is closely related to the qx-ib strain. the isolate of the chvi genotype (kr/ adl / ) was derived from -wk-old layers with a slight decrease in egg production. this genotype (chvi) does not belong to major clusters of korean ib isolates but appears to be derived from a chinese strain (liu et al., ) . the virus stock for the challenge study was produced by inoculating field isolates into embryonated spf chicken eggs via the allantoic cavity and collecting the infectious allantoic fluid h postinoculation. reverse-transcription (rt) pcr targeting the ibv s gene was carried out, and each -bp s amplicon was sequenced for genotyping by the direct sequencing method. the median embryo infective dose (eid ) was determined by the reed and munch formula. the isolates were shown to be free from contamination by other avian pathogens by inoculating -wk-old spf chicks and testing their sera at least wk later using the procedures for the accreditation of spf flocks. in this preliminary experiment, the chickens inoculated with the isolate kr/adl / showed severe nephritis after prolonged infection (> d), whereas no significant clinical symptoms were observed in chickens inoculated with the same dose of the isolate kr/adl / . during the experiment, the chickens were raised in a hepa-filtered isolation system. all procedures, including euthanasia, followed the guidelines of the institute of laboratory animal resources (confirmation number: cbnua- - - ). forty-five -wk-old spf chickens (valo biomedia north america, adel, ia) were used and were divided into groups of : an unchallenged control group (group ), a group challenged with an isolate of the kiia genotype (kr/adl / , group ), and a group challenged with an isolate of the chvi genotype (kr/adl / , group ; table ). the chickens were inoculated with an eye drop of . ml of eid of the ib isolates or . ml of sterilized pbs. at , , , , and d postinoculation (dpi), birds in each group were bled before euthanasia, followed by necropsy and sample collection. the blood was kept at room temperature for approximately h, and the serum was separated and stored at − °c. during necropsy, tissues of the trachea and kidney were collected and immediately treated with trizol reagent (invitrogen, carlsbad, ca) for total rna isolation; tissue samples were taken from the upper one-third of the trachea by the horizontal long axis and the upper left lobe of the kidney. total rna was isolated from tissues obtained from necropsy using trizol reagent (invitrogen, carlsbad, ca) according to the manufacturer's instructions. homogenized tissue samples were treated with trizol reagent followed by phenol-chloroform phase separation. the rna was precipitated using -propanol, washed with % ethanol, dried, and resuspended in μl of diethylpyrocarbonate-treated water. the rna was quantified by measuring the absorbance at nm on a spectrophotometer, and the purity was assessed using the : nm ratio. the viral copy number was determined by semiquantitative rt-pcr. semiquantitative rt-pcr was conducted as previously described, with slight modifications (liu et al., ) . briefly, rna samples and primers targeting the n gene of the ib virus (table ) were added to maxime rt-pcr premix tubes (intron biotechnology, seongnam-si, gyeonggi-do, korea) and brought to μl with sterilized distilled water. the rt-pcr reaction was performed as follows: one cycle of min at °c and min at °c, followed by cycles of °c for s, °c for s, and °c for min. upon completion of the last cycle, the reaction mixtures were incubated at °c for min. then, μl of each product was separated by % agarose gel electrophoresis. the band intensity of the pcr products was calculated using the image j . v program (http://rsb.info.nih. gov/ij). to generate a standard curve, eid of viral stock was serially diluted -fold, and rna was extracted from each diluent. the rt-pcr, agarose gel electrophoresis, and image analysis were conducted as described above, and the results were plotted against the dilution factor. for comparison, the corresponding value of a dilution of the viral stock on the x-axis was normalized to , and the relative viral load for each sample was calculated according to the standard curve ( figure ). the cdna synthesis from the rna samples was performed using the primescriptrt reagent kit (perfect real time, takara biotechnology co., ltd., dalian, china) according to the manufacturer's recommendations. briefly, μl of reaction mixture (primescript buffer, primescript rt enzyme mix i, pmol of oligo(dt) primer, and . μg of total rna) was incubated at °c for min and °c for s. then, qrt-pcr was performed using a smart cycler (cepheid, sunnyvale, ca). all reactions were performed in independent samples derived from chickens in -μl reaction mixtures containing . μl of × sybr premix ex taq ii (tlirnasehplus, takara), . μl of distilled water, μl of cdna template, and . μm of each primer ( table ). the pcr conditions were the same for each targeted gene: s at °c, followed f: ′-tgtgtatgtgcagcaacccgtagt- ′ ay r: ′-ggcattgcaatttggacagaagt- ′ by cycles of °c for s and °c for s. cycling was terminated after cycles, and dissociation curves of the products were generated by increasing the temperature incrementally from to °c as the final step of the real-time pcr. to calculate the fold-change over the control chickens treated with pbs, the ratio of the concentration of the target gene to a reference gene (gapdh) in samples from pbs-inoculated controls (calibrator) was normalized. the normalized ratio was then compared with the ratio of the concentration of the target gene to the reference gene in individual samples from ib-isolate inoculated chickens. the mann-whitney u test (spss . k for windows) was used to determine significant differences between fold change values. the sd was calculated using the fold-change values of replicates for each gene measured. alpha- acid glycoprotein (agp), an acute phase protein, was measured in serum using a commercially available elisa kit (chicken α -acid glycoprotein (ogchi) elisa kit, cusabio biotech. co. ltd., wuhan, hubei, china). the elisa was conducted according to the manufacturer's instructions. to determine the agp level in the serum, a standard curve was generated, and a regression assay was conducted. to de-termine significant differences, a -tailed independent student t-test was used (spss . k for windows, spss inc., chicago, il). until dpi, no clinical sign was observed in chickens in the unchallenged control group (group ) or the challenged groups (group and ). however, in chickens of group (kiia genotype), apparent clinical signs were began to be observed; at dpi, all chickens infected with ibv of kiia genotype sat crouched while the water consumption increased % (p < . ). the mortality ( out of birds) was observed only in group at dpi. during necropsy of chickens of group , however, we could not observe gross lesions related with these symptoms in kidneys or other organs. in the microscopic examination of chickens of group (kiia genotype), acute response lesions, such as the loss of cilia, acute necrosis of tracheal epithelial cells, and multifocal areas of acute tubular necrosis without any cellular infiltration in the kidney, were observed ( figure ). on the other hand, no mortality or clinical sign observed in chickens of group , such as increase in water consumption and depression, was observed in chickens of group (chvi genotype). the n-gene of ibv was amplified by rt-pcr, and the band intensity was rated on a scale of to , ( figure ) . until dpi, the viral gene was not detected by rt-pcr. in the tracheae of chickens in group (kiia genotype), the viral copy number was first detected at dpi ( , . ± . ) , and the peak ( , . ± , . ) was observed at dpi. in the kidneys of chickens in the same group, the viral copy number was first detected at dpi ( . ± . ), and the peak copy number was observed at dpi ( , . ± . ). in group (chvi), the viral gene was first observed at dpi, whereas the viral copy number remained at approximately in the trachea and kidney. these results indicate that the copy number was higher in the chickens from group , and their viral replication peaked in the trachea and the kidney at and dpi, respectively. the changes in pro-inflammatory levels are illustrated in figure . at dpi, a significant increase in il- and il- β transcription levels was observed in the . the rt-pcr products were separated on a % agarose gel, and the signals were calculated using imagej software (http://rsb. info.nih.gov/ij). a: a standard curve was constructed by amplifying the -fold diluted viral stock. lane m is a -bp ladder. b: amplification products from different concentrations of the n gene of ibv. the size of the amplification product was bp. estimated viral copy numbers were assumed as , , , and , . kidney and trachea of group (kiia), whereas in group (chvi), an increase was observed only in the kidney il- level (p = . ; figure a ). in the case of lipopolysaccharide-induced tumor necrosis factor (tnf)-α factor (litaf) in the kidney, the arithmetic mean of triplicates in the challenged groups was higher compared with the control group, but a significant difference was not observed among the groups. at dpi, the levels returned to the range of the unchallenged control ( figure b) , and the levels of il- in the trachea were suppressed. the litaf transcription level in the tracheae of both challenged groups was significantly decreased compared with the control group (p = . ) at dpi. at dpi, the mrna levels of il- and litaf were higher in the kidneys from group (kiia genotype; figure c ), whereas no obvious change was observed in the tracheae at dpi. at dpi, the litaf levels were significantly increased in the tracheae of both challenged groups ( figure d ). at the same time, the il- levels of the tracheae appeared to be higher; however, a significant difference was not observed. at dpi, the levels of all of pro-inflammatory cytokines were substantially increased in the kidneys in chickens from group . considering the viral copy numbers (figure ) and the transcription profiles at and dpi, the peak viral copy number occurred simultaneously with peak cytokine production in each organ. table shows the serum agp level after inoculation with ib isolates. in the unchallenged control group, the agp level was in the range of to μg/ml. the agp level of both challenged groups was compared with the unchallenged group. no significant difference was observed among all groups at dpi. at dpi, the level of agp in chickens from group (kiia genotype) had increased to approximately μg/ml (p = . ; table ). at dpi, the agp levels in group (kiia genotype) reverted to the range of the unchallenged control, and no further increase was observed until dpi. at dpi, the agp level increased almost -fold in both challenged groups (p < . ). these findings appear to reflect viral invasion but do not appear to be associated with pathogenicity. in this study, we confirmed that the pro-inflammatory response could be induced on a diverse scale depending on the ibv genotype. the kiia genotype (kr/adl / ), which is closely related to the nephropathogenic strain, induced clinical symptoms of depression and a stronger pro-inflammatory response. on the other hand, an active infection of the chvi genotype isolate kr/adl / , which resulted in an increase in serum agp level at dpi (table ) , evoked only a limited range of pro-inflammatory responses. according to the data collected at dpi, the excessive production of pro-inflammatory cytokines was temporally associated with clinical signs related to renal damage, such as an increased drinking of water and lesions observed in the kidney, including renal tubular necrosis. these data suggest that excessive pro-inflammatory cytokine production contributes to disease severity. in particular, the excessive production of il- in ib infections was already suspected to contribute to the exaggerated disease severity in specific genetic lines (asif et al., ) . our data have different implications than the results of that study; we have demonstrated that specific ib genotypes induce pro-inflammatory cytokines and that differences in the scale of the induction could contribute to the disease severity induced by ibv of diverse genotypes. in addition to the il- profiling, it was meaningful to observe the pattern of change in the levels of cy-tokines, il- β and litaf, during ib infection because these immune mediators do not act alone in vivo (perrone et al., ) . in chickens, litaf has been investigated as a substitute for tnf-α in viral infections (ruby et al., ; esnault et al., ) , even though its involvement in viral infections was not demonstrated. in mammals, litaf was reported to regulate tnf-α gene expression (myokai et al., ) and to modulate pro-inflammatory cytokines (tang et al., b) . it is still debatable whether litaf could be used as an indicator during viral infection, but our findings at dpi demonstrate the upregulation of litaf following ib infection, so a subsequent increase in transcription of tnf-α could be anticipated. in mammals, il- β and tnf-α are known to have tissue-damaging potential, including inducing apoptosis (dinarello, ; eizirik, ; hehlgans and männel, ) and local damaging effects on the kidney (van de kar et al., ; jo et al., ; malaponte et al., ) . in this study, these features, which were not previously reported in chickens, suggest that these cytokines may contribute to the pathological changes of renal disease in ib infection. at and dpi, temporal associations between peak viral copy number and peak cytokine production were observed. however, the kinetics of viral load were not precisely in accord with those of the pro-inflammatory cytokines. in previous studies of influenza viruses, the differential hyper-induction of cytokines was not explained by differences in viral replication kinetics (chan et al., ) , but the accumulation of double- stranded rna within the h n -infected cell appears to induce pro-inflammatory cytokines in the absence of productive virus replication (chan et al., ) . in case of sars-cov infection, the upregulation of the pro-inflammatory cytokine il- was observed during in vivo studies (wong et al., ) , but a similar finding was not observed in in vitro studies of productively in-fected cells (tang et al., a) . instead, the induction of il- was more significant in macrophages primed by bacterial lipopolysaccharide (tseng et al., ) . thiel and weber ( ) speculated that the pro-inflammatory response appears to be a secondary response of immune activation, not a direct response of cells against viral infection (thiel and weber, ) . based on these alterations of pro-inflammatory cytokine mrna expression level in the trachea and kidney at , , , , and d postinoculation (dpi). the results are expressed as relative expression; the average normalized ratio of the unchallenged control group (group ) was adjusted to and was compared with those of the challenged groups (groups and ). column values represent the mean of triplicates, and vertical bars represent the sd value. *statistical significance (p ≤ . ) was determined by the mann-whitney u test. group : unchallenged control group; group : challenge group inoculated with an isolate of the kiia genotype (kr/adl / ); group : challenge group inoculated with an isolate of the chvi genotype (kr/adl / ); litaf: lps-induced tnf-α factor. reports, we assume that the pro-inflammatory response is not a direct sequela of viral infection but is instead a secondary response, and the discordance in the kinetics is consistent with that assumption. in conclusion, we confirmed that a different proinflammatory response was associated with isolates of ibv with different genotypes. the induction of excess cytokine production appears to have a detrimental effect on tissues, and these findings suggest the need for an anti-inflammatory strategy to address the loss from ib infection. interleukin- expression after infectious bronchitis virus infection in chickens proinflammatory cytokine responses induced by influenza a (h n ) viruses in primary human alveolar and bronchial epithelial cells proinflammatory cytokine response and viral replication in mouse bone marrow derived macrophages infected with influenza h n and h n viruses newly isolated serotypes of infectious bronchitis virus: their role in disease avian immunology biologic basis for interleukin- in disease new insights on infectious bronchitis virus pathogenesis: characterization of italy serotype in chicks and adult hens a choice of death-the signal-transduction of immune-mediated beta-cell apoptosis a novel chicken lung epithelial cell line: characterization and response to low pathogenicity avian influenza virus variant serotypes of infectious bronchitis virus isolated from commercial layer and broiler chickens the tnf-tnf receptor system antigenic differences among isolates of avian infectious bronchitis virus molecular cloning and characterization of chicken lipopolysaccharide-induced tnf-alpha factor (litaf) susceptibility of three genetic lines of chicks to infection with a nephropathogenic t strain of avian infectious bronchitis virus pro-inflammatory responses in chicken spleen and brain tissues after infection with very virulent plus marek's disease virus inflammatory cytokines and lipopolysaccharide induce fas-mediated apoptosis in renal tubular cells analysis of chicken mucosal immune response to eimeria tenella and eimeria maxima infection by quantitative reverse transcription-pcr genetic diversity of avian infectious bronchitis virus isolates in korea between live attenuated nephropathogenic infectious bronchitis virus vaccine provides broad cross protection against new variant strains genetic diversity of avian infectious bronchitis coronavirus strains isolat a bovine herpesvirus type mutant virus specifying a carboxylterminal truncation of glycoprotein e is defective in anterograde neuronal transport in rabbits and calves genetic diversity of avian infectious bronchitis coronavirus in recent years in china il- b, tnf-a and il- release from monocytes in haemodialysis patients in relation to dialytic age rapid differentiation of current infectious bronchitis virus vaccine strains and field isolates in australia chemokine and cytokine gene expression profiles in chickens inoculated with mycoplasma gallisepticum strains rlow or gt challenge group inoculated with an isolate of the kiia genotype (kr/adl / , group ), and challenge group inoculated with an isolate of the chvi genotype dpi = days postinoculation agp level in the serum (arithmetic mean ± sd) at dpi in group (kiia genotype), only chickens were available for blood collection , **p ≤ . using the student t-test (spss . k for windows severe acute respiratory syndrome, a pathological immune response to the new coronavirus-implications for understanding of pathogenesis. therapy, design of vaccines, and epidemiology viral immunol a novel lipopolysaccharide-induced transcription factor regulating tumor necrosis factor alpha gene expression: molecular cloning, sequencing, characterization, and chromosomal assignment comparison of the susceptibility to avian infectious bronchitis virus infection of two inbred lines of white leghorn chickens re-emergence of fatal human influenza a subtype h n disease h n and pandemic influenza virus infection results in early and excessive infiltration of macrophages and neutrophils in the lungs of mice infectious bronchitis virus: immunopathogenesis of infection in the chicken transcriptional profiling reveals a possible role for the timing of the inflammatory response in determining susceptibility to a viral infection sequence analysis of the s glycoprotein of infectious bronchitis viruses differential cytokine mrna expression in heterophils isolated from salmonella-resistant and -susceptible chickens comparative host gene transcription by microarray analysis early after infection of the huh cell line by severe acute respiratory syndrome coronavirus and human coronavirus e lps induces the interaction of a transcription factor, lps-induced tnf-alpha factor, and stat (b) with effects on multiple cytokines interferon and cytokine responses to sars-coronavirus infection pathology of fatal human infection associated with avian influenza a h n virus tumor necrosis factor and interleukin- induce expression of the verocytotoxin receptor globotriaosylceramide on human endothelial cells: implications for the pathogenesis of the hemolytic uremic syndrome viral diseases of respiratory system rapid expression of chemokines and proinflammatory cytokines in newly hatched chickens infected with salmonella enterica serovar typhimurium plasma inflammatory cytokines and chemokines in severe acute respiratory syndrome key: cord- -qwinggg authors: viswanathan, ramaswamy; myers, michael; fanous, ayman title: support groups and individual mental health care via video conferencing for frontline clinicians during the covid- pandemic date: - - journal: psychosomatics doi: . /j.psym. . . sha: doc_id: cord_uid: qwinggg background: the current covid- pandemic has put an enormous stress on the mental health of frontline healthcare workers. objective: psychiatry departments in medical centers need to develop support systems to help our colleagues cope with this stress. methods: we developed recurring peer support groups via videoconferencing and telephone for physicians, resident physicians, and nursing staff, focusing on issues and emotions related to their frontline clinical work with covid patients in our medical center which was designated as a covid-only hospital by the state. these groups are led by attending psychiatrists and psychiatry residents. in addition, we also deployed a system of telehealth individual counseling by attending psychiatrists. results: anxiety was high in the beginning of our weekly groups, dealing with fear of contracting covid or spreading covid to family members, and the stress of social distancing. later the focus was also on the impairment of the traditional clinician patient relationship by the characteristics of this disease, and the associated moral challenges and trauma. clinicians were helped to cope with these issues through group processes such as ventilation of feelings, peer support, consensual validation, and peer-learning, and interventions by group facilitators. people with severe anxiety or desiring confidentiality were helped through individual interventions. conclusions: our experience suggests that this method of offering telehealth peer support groups and individual counseling is a useful model for other centers to adapt, to emotionally support frontline clinical workers in this ongoing worldwide crisis. the current coronavirus disease (covid- ) pandemic is placing an enormous emotional stress on frontline healthcare workers. [ ] [ ] [ ] [ ] psychiatrists and other mental health professionals are being called upon to address the mental health threats posed to several clinicians of different disciplines, in numbers to which they are altogether unaccustomed. never before has the mental health profession been faced with delivering such help on this scale. at the same time, the threat of contagion requires that such help be delivered from a distance via virtual means, a challenging departure from traditional psychiatric intervention. this calls for innovative service delivery. data are sparse in this area because of the short time since this devastating pandemic started. nevertheless, there are suggestions for individual interventions and systems interventions. [ ] [ ] [ ] [ ] [ ] to our knowledge, group intervention in this area has not been described in detail in the literature so far, though some systems in the usa, including ours, have begun offering them. here, we report the methods we have developed at the group and individual levels to help our peers, and describe in a qualitative manner our preliminary experience. since march , , our university hospital of brooklyn has been designated as a covid- only facility by new york state. from late march , our department of psychiatry began offering support group and individual video-conference sessions to help our frontline attending physicians, resident physicians, nurses and other healthcare professionals, and students. later we began support group conference calls by telephone for our nurses as they preferred this modality over video-conference. participation in our groups is voluntary. a support group is defined as "a group of people with common experiences and concerns who provide emotional and moral support for one another." our groups for attending physicians are organized around their roles and specialties, such as hospitalists, emergency medicine physicians, and pediatricians redeployed into adult covid units. while in the beginning we thought it might be advantageous to have separate groups for attending physicians and residents, later we relaxed that policy at the request of the attending physicians who desired their residents to be included. this has not presented any problems, probably because in this crisis they both face similar issues, and have a sense of solidarity in a desperate fight against a common enemy . in fact, attending physicians provided great solace and a calming effect to their junior colleagues. we have two facilitators per group, drawn from psychiatry faculty and residents. for the nursing group, there is also a nursing leader serving as a co-facilitator. the groups meet weekly for about minutes. in the meetings we emphasize that these are peer-support groups, encourage spontaneous expression of thoughts and feelings, and acknowledge that some may not feel ready to talk, but they can still benefit by listening. the supportive interventions that we employ are explained in the discussion section. we have also set up a system to provide individual counseling sessions to any employee or student in our medical center in a confidential manner. all licensed faculty members in our department have made themselves available during certain periods for these sessions via telehealth. our institution's employees or students can leave a voice or text message in a confidential manner at a dedicated telephone number, or send an email to a dedicated email address. senior psychiatry residents screen the messages, and schedule an appointment for the caller with a faculty clinician, based on availability and the knowledge of each clinician's areas of expertise. the faculty clinician can initiate a video conference call from the scheduling software, do a brief evaluation, provide counseling, and if necessary schedule additional sessions, issue prescriptions for medications, or make outside referrals. we estimate that about attending physicians, residents, and nurses, all frontline healthcare professionals, have participated in the group sessions, and people have used the individual sessions. some times more than one person use the same computer or speaker-phone. the number of individual sessions for a person has generally been two. both the group and individual sessions have been found to be helpful by the participants, as told to us by them in the group and individual sessions, and to their peers by them, who in turn told us. for example, two residents disclosed in their individual sessions with one of the authors (mm) that they have found both individual and group meetings helpful. a few nurses, physicians and administrators not involved with the groups have told us that they have heard from the participants how helpful the groups were. we did not collect formal measures of distress or outcome data as these were not patients or research subjects, and the interventions were done during a dire period of lifethreatening collective crisis. the individual sessions tend to be used by people who do not want to participate in support groups because the problems they are experiencing are sensitive, they want to preserve confidentiality, or their issue is of a nature or severity that cannot be adequately dealt with in a peer support group. they are also used by employees who are not frontline clinical workers. the presenting symptoms have been mostly anxiety-related, including some work deployment issues. because of the private nature of these sessions, we are not giving here details of the discussions in these sessions. in the physicians' and nurses' weekly groups the content of the discussions evolved over time. at first they focused on anxiety related to contracting covid- and fear of spreading it to one's family and friends; on the strain imposed by taking extraordinary precautions to prevent this, including social distancing and isolation from one's own family, wearing masks at home, taking care one's clothing or the places one touches do not place the family at contagion risk; and guilt over putting one's family at risk. some individuals opted not to go home at all after work, but instead stay in the hospital or a hotel or rental apartment, in order to reduce contact risk to their families. many disliked being bombarded by news and conversations about the coronavirus when they were off work. people also complained of the difficulties and discomfort imposed by having to wear full personal protective equipment (ppe) all the time for long hours in their clinical work, and the interference with their collegial relationship at work because of it. there was also anger and dismay at the shortage of ppe. people used the analogy of soldiers being sent into the battle without armor or arms. in later sessions, a prominent theme has been the threat to the intimacy of the doctor-patient or nurse-patient relationship. physicians and nurses are concerned about dehumanized interactions with patients because they wear their ppe at all times, which conceals their facial expressiveness and identifying features as a human being. they spoke of how this deprives very ill or anxious patients of the personal comforting they need from their healthcare professionals, and frightens the cognitively impaired. some are also afraid that communicating traumatic news often in quick succession is making them become numb or robotic in such interactions, and they fear an erosion of their humanity. because of institutional policies aiming to reduce the risk of contagion, they have been prevented from allowing family members to be with their loved ones in their dying moments. this has been heart-wrenching for physicians and nurses to bear, as they are used to the role of being a bridging and consoling presence between dying patients and their families. physicians and nurses also struggle with a feeling of lack of control and a sense of futility, in that with many patients they can do little to halt the progress of this disease. while attending physicians may have more experience with this clinical dilemma than trainees, it has never been on such a massive scale. exacerbating this sense of lack of control is the fact that there are very few data on prognostic factors in hospitalized covid- patients that they can rely on, for their own guidance or to reassure patients and families. many patients deteriorate unpredictably and quickly, and die. death of their own colleagues and family members of colleagues from covid resulted in intense bereavement-focused sessions. the deaths of a critical care specialist physician and an emergency department nurse, both of whom had worked in our medical center for decades and were widely beloved, were especially hard to bear. those who got covid and stayed at home for a period of time felt guilty that they were not at the frontline helping when their colleagues were overworked. people also expressed guilt about getting free food from wellintentioned donors, while they knew that many people in the community they serve were fooddeprived. people were appreciative of the enormous outpouring of community support, and the support they received from their colleagues and the institutional leadership. how do we, as mental health professionals, respond in a therapeutic manner to these themes? we utilize reflective listening, clarification, reassessment of perceptions employing socratic dialogue, and relabeling of emotions. an example: emergency physician: "the patient was dying. i knew his wife was just outside the emergency room in the waiting area. yet i could not bring her to the dying person's bedside. it tore my heart". facilitator: "so it was heart-wrenching for you that you could not do a basic humane thing, and had to let your patient die without family we encourage people to take minibreaks during their stressful work, and use brief mental relaxation strategies during the course of their work, such as the meditation outlined above. we emphasize the importance of proactively looking after one's physical and mental health, including physical exercise, sleep, healthy nutrition, recreation, and social connectedness. we advocate limited or titrated exposure to covid- media "breaking news" programming. to counteract the relentless feeling of powerlessness expressed by some physician participants, simply reminding them of the basic tenets of the doctor-patient relationship goes a long way. we urge them never to underestimate how much they help their patients and their families by their presence, commitment, and acts of kindness. we lauded one physician who in response to his patient's plaintive query "doctor, am i going to die?", said "we are going to do everything we can to treat this, to help you." although the patient did die within a few hours, there was a collective sense in the group that his physician's words provided some solace, without the physician being untruthful. we have to keep in mind that our healthcare professionals have not faced before deaths of their patients on such a massive scale in such a rapid manner. as of may , , kings county (brooklyn), new york, where our hospital is located, had recorded covid- related deaths, the highest number among all the counties in the usa. this happened in a period of two and a half months. this is bound to have a demoralizing effect. group interventions help reach a larger number of people with a limited number of mental health professionals, and can offer some additional healing elements that individual approaches do not. such therapeutic factors include sharing experiences in a peer setting, consensual validation, support and learning from peers, and building a sense of solidarity and camaraderie with fellow group members. examples are given in table . all our nurses prefer audio-only groups over audio-visual groups. some nurses have told us that they and their colleagues would not want to show their faces when they are emotionally upset "because it is not in their culture". we do not know how much of this preference has to do with differences between nursing culture and physician culture in our institution, accessibility to a private space in the work place where computer or smart phone use is feasible, or cultural issues related to demographics. even in the physicians' videoconference groups about half the participants keep their video muted (they are not seen) even though their identity is visible, and some selectively unmute their video so that they can be seen at times. because of the crisis nature of these-support groups we did not do a deeper investigation of this issue. what's most important is to honor and implement whatever format helps. as pointed out before, some people and problems require individual sessions. telehealth interventions minimize the risk of contagion to providers and participants, which is important during the covid pandemic. they also facilitate access. people can participate without losing too much work time or rest time. telehealth support groups for patients have been successfully deployed before. they would be easier to set up to help health professionals. some of the pointers other institutions can take from our experience: psychiatrists and other mental health professionals are not peripheral to this covid- crisis, but can be at the front and center, helping frontline health care professionals preserve their mental health while being effective in helping the patients and the community. both group and individual sessions need to be offered. groups work best if one member of the clinical service takes responsibility of organizing the weekly videoconference or teleconference, and serves as the group's liaison with the group facilitators. one has to be flexible with some traditional ways of running groups. some people may participate by telephone or computer audio only, and some listen without uttering a word but still seem to be benefiting by such participation. the groups need to be offered at different periods of day and evening to accommodate different work schedules. weekly groups at set times work well. the employer needs to give time for the employees to participate in these groups, recognizing that this wellness intervention ultimately helps patient care. some people prefer participating while they are on site and some others while they are off work. the sessions need to be shorter than the traditional -minute sessions, because of the time constraints imposed by conducting them during work hours. our groups typically run for about minutes. we hope that peer group support and individual interventions like these will help protect the mental health of a number of clinicians who are doing such commendable and courageous work, so that they can continue to effectively help the countless severely ill patients with covid- . other institutions can adapt these methods to their own needs. this is a significant way the field of behavioral health can assist in this moment of world crisis. conflict of interest disclosure for all the authors relevant to this manuscript: none helped me a lot with helping my mom who lives alone in california." peer support "sometimes i am so overwhelmed at work that i feel a need to decompress". group: "speak to the supervisor about being given a short-break in those situations. we will support you." mental health outcomes among health care workers exposed to coronavirus disease covid- -associated psychiatric symptoms in health care workers: viewpoint from internal medicine and psychiatry residents mental health needs of health care workers providing frontline mental health and the covid- pandemic progression of mental health services during the covid- outbreak in china covid- : peer support and crisis communication strategies to promote institutional resilience attending to the emotional well-being of the health care workforce in a new york city health system during the covid- pandemic reflections: the value of patient support groups. otolaryngol head neck surg johns hopkins university: covid- united states cases by county therapeutic factors in group psychotherapy: a review telehealth interventions delivering home-based support group videoconferencing: systematic review key: cord- -fg hk b authors: umemura, yutaka; yamakawa, kazuma; kiguchi, takeyuki; nishida, takeshi; kawada, masahiro; fujimi, satoshi title: hematological phenotype of covid- -induced coagulopathy: far from typical sepsis-induced coagulopathy date: - - journal: j clin med doi: . /jcm sha: doc_id: cord_uid: fg hk b background: blood coagulation disorders commonly occur with severe coronavirus disease (covid- ). however, there is only limited evidence on differentiating the pattern of the hemostatic parameters from those of typical sepsis-induced coagulopathy (sic). methods: to elucidate the specific pattern of coagulopathy induced by covid- pneumonia, this retrospective, observational study targeted consecutive adult patients with covid- -induced acute respiratory distress syndrome (ards) and compared hemostatic biomarkers with non-covid- -induced septic ards. multilevel mixed-effects regression analysis was performed and kaplan–meier failure curves were constructed. results: we enrolled patients with covid- -induced ards and patients with non-covid- -induced ards. platelet count, antithrombin activity, and prothrombin time in the covid- group were almost within normal range and time series alterations of these markers were significantly milder than the non-covid- group (p = . , . , and . , respectively). however, fibrin/fibrinogen degradation product and d-dimer were significantly higher in the covid- group (p = . , . , respectively). covid- patients had moderately high levels of thrombin–antithrombin complex and plasmin-alpha -plasmin inhibitor complex but normal plasminogen activator inhibitor- level. conclusions: the hematological phenotype of covid- -induced coagulopathy is quite different from that in typical sic characterized by systemic hypercoagulation and suppressed fibrinolysis. instead, local thrombus formation might be promoted in severe covid- . the novel corona virus infection (coronavirus disease : , originating in wuhan, china, has rapidly spread worldwide [ ] . as of july , , more than . million cases and approximately , deaths were reported from all over the world. along with acute respiratory distress syndrome (ards), coagulation disorders are reported to be induced by severe covid- pneumonia and to be associated with increased risk of death [ ] [ ] [ ] [ ] . besides, a previous study reported that severe acute respiratory syndrome coronavirus (sars-cov- ) this was a single-center, retrospective, observational study conducted at a tertiary care hospital in japan. all adult patients who were admitted to the icu with covid- -induced ards and required mechanical ventilation during march through april in were consecutively enrolled in this study. as a control group, we included consecutive adult patients who were admitted to the icu with the diagnosis of septic ards induced by non-covid- community-acquired bacterial pneumonia and required mechanical ventilation from january to february . the exclusion criteria included the use of warfarin/acetylsalicylic acid/thrombolytic therapy before study entry; the limitation of sustained life care or post-cardiopulmonary arrest resuscitation status; history of fulminant hepatitis, decompensated liver cirrhosis, or other serious liver disorder; history of hematologic malignant disease; and other conditions increasing the risk of thrombosis at study entry. this study followed the principles of the declaration of helsinki. the protocol was approved by the institutional review board for clinical research of osaka general medical center (irb no. s ). the diagnosis of covid- was performed according to world health organization interim guidance [ ] and confirmed by rna detection of sars-cov- in a clinical laboratory of the osaka institute of public health. in this study, sepsis was diagnosed based on sepsis- criteria proposed in [ ] . ards was diagnosed according to the berlin definition [ ] as fulfilling the following criteria: ( ) onset within week after predisposing diseases, ( ) bilateral infiltration on chest roentgenogram, ( ) pao /fio (p/f ratio) ≤ with peep ≥ cm h o, and ( ) no clinical signs of cardiac failure or fluid overload. we defined the first day of mechanical ventilation as "day " both in the covid and non-covid pneumonia groups. patients were followed up until hospital discharge or death. patient information collected included demographic characteristics, pre-existing comorbidities, laboratory tests, severity scores, and therapeutic interventions. laboratory tests included several hemostatic biomarkers, such as platelet count, prothrombin time (pt), fibrinogen level, fibrin/fibrinogen degradation products (fdps), d-dimer level, antithrombin activity, thrombin-antithrombin (tat) complex, plasmin-a -plasmin inhibitor complex (pic), and plasminogen activator inhibitor (pai)- . tat, pic, and pai- were evaluated only on day in the covid- group; however, the other biomarkers were measured in both groups at each time point from day to day . severity of illness was evaluated according to the sequential organ failure assessment (sofa) score and the acute physiology and chronic health evaluation (apache) ii score. the apache ii score was evaluated on day , and the sofa score was evaluated at each time point from day to day . the incidence of disseminated intravascular coagulation (dic) was evaluated at each time point from day to day based on the international society on thrombosis and hemostasis (isth) overt dic and the japanese association for acute medicine (jaam) dic criteria. we also evaluated the incidence of sic at each time point [ ] . the isth overt dic scoring system was adopted as proposed by the scientific subcommittee on dic of the isth for platelet counts, pt, fdp, and fibrinogen level [ ] . to calculate the isth overt dic score, fdp values were chosen as the fibrin-related marker and scored according to the cut-off levels and ranges previously published by gando et al. [ ] . the jaam dic scoring system consists of the sirs (systemic inflammatory response syndrome) score and global coagulation tests including platelet counts, pt, and fdp/d-dimer levels. [ ] we used prophylactic low-dose unfractionated heparin for both the covid- and control groups when patients had a high risk of venous thromboembolism (vte), such as severe obesity, cancer, orthopedic surgery, and prior history of vte. the aim of this study was to reveal the specific pattern of coagulopathy induced by severe covid- pneumonia by comparing the hemostatic parameters chronologically with those in patients with ards induced by non-covid- pneumonia. therefore, to assess the time series variation in the hemostatic parameters, we fitted multilevel mixed-effects regression models with fixed effects assigned to patient categorization (covid- or non-covid- ), time points (from day to day ), and two-way interaction term for these independent variables, and random effects assigned to individual identification numbers. we also performed multilevel mixed-effects regression analysis to evaluate the time series differences during the first seven days in other organ dysfunction parameters, including p/f ratio, serum creatinine level, serum bilirubin level, glasgow coma scale, and sofa subscore for the cardiovascular component between the covid- and non-covid- groups. kaplan-meier failure curves were constructed to evaluate the cumulative incidence of jaam dic, isth overt dic, and sic over time (from day to day ). log rank tests were conducted to compare the kaplan-meier curves between two groups. descriptive statistics were calculated as medians (interquartile range) or proportions (numbers), as appropriate. univariate differences between groups were assessed using the mann-whitney u test or chi-square test, as appropriate. missing values were not imputed in any of the regression models. all statistical inferences were performed with a two-sided p at the % significance level. because of the underpowered nature of the interaction analysis, we used a two-sided significance level of % with statistical inferences for the interaction analyses [ ] . all statistical analyses were conducted using stata data analysis and statistical software version . (statacorp, college station, tx, usa). baseline characteristics, laboratory tests, and illness severity scores on day in the two groups are shown in table . age, sex, and pre-existing comorbidities were similar between the groups. although the platelet counts on day were similar between the two groups, there were statistically significant differences in other hemostatic biomarkers. pt (%), fibrinogen level, and antithrombin activity in the covid- group were almost within the normal range and were significantly higher compared with those in the non-covid- group. baseline characteristics, laboratory tests, and illness severity scores on day in the two groups are shown in table . age, sex, and pre-existing comorbidities were similar between the groups. although the platelet counts on day were similar between the two groups, there were statistically significant differences in other hemostatic biomarkers. pt (%), fibrinogen level, and antithrombin activity in the covid- group were almost within the normal range and were significantly higher compared with those in the non-covid- group. there were no significant differences between groups in mental status and respiratory function, as indicated by the glasgow coma scale and p/f ratio, respectively. dic scores and sic score were significantly lower in the covid- group compared with those in the non-covid- group. a multilevel mixed-effects regression model suggested that the changes in platelet counts over time during the first seven days were significantly different between the two groups (p for interaction = . ), and the covid- group had constantly higher platelet counts after day ( figure ) . similarly, we detected significant time series differences in pt, fdp, d-dimer, and antithrombin activity between the two groups (p for interaction = . , . , . , and . , respectively). the covid- group had higher levels (almost within normal range) of pt and antithrombin activity at all day points but higher levels of fdp and d-dimer after day . we also show the levels of several hemostatic molecular biomarkers, such as tat, pic, and pai- , in the covid- group in figure . the median levels of tat and pic were . ng/ml and . µg/ml, respectively, and tended to be higher compared with the upper limits of normal range for these two biomarkers ( . ng/ml and . µg/ml, respectively). however, the median level of pai- was . ng/ml and was within the normal range (< . ng/ml). we show the time series differences in several parameters related to organ dysfunction other than coagulation in figure . although the p/f ratio in the non-covid- patients improved with time, that in the covid- group worsened with time, and there were significant time series differences between the two groups (p for interaction < . ). in contrast, serum levels of creatinine tended to be lower at all time points in the covid- group. only slight differences were detected in serum bilirubin level and the sofa subscore for the cardiovascular component between the covid- and non-covid- groups. we also show the levels of several hemostatic molecular biomarkers, such as tat, pic, and pai- , in the covid- group in figure . the median levels of tat and pic were . ng/ml and . g/ml, respectively, and tended to be higher compared with the upper limits of normal range for these two biomarkers ( . ng/ml and . g/ml, respectively). however, the median level of pai- was . ng/ml and was within the normal range (< . ng/ml). we show the time series differences in several parameters related to organ dysfunction other than coagulation in figure . although the p/f ratio in the non-covid- patients improved with time, that in the covid- group worsened with time, and there were significant time series differences between the two groups (p for interaction < . ). in contrast, serum levels of creatinine tended to be lower at the cumulative incidence curve constructed with the kaplan-meier method showed that there were no statistically significant differences in the incidence of jaam dic and isth-overt dic during the first seven days between the groups (log rank test, p = . and . , respectively). however, the incidence of sic in the covid- group during the first seven days was only . % ( of patients) and was significantly lower compared with that in the non-covid- group (log rank test, p = . , figure ). one of the two sic patients survived to hospital discharge, however, another patient developed multiple organ dysfunction syndrome and died despite full intensive care support. the cumulative incidence curve constructed with the kaplan-meier method showed that there were no statistically significant differences in the incidence of jaam dic and isth-overt dic during the first seven days between the groups (log rank test, p = . and . , respectively). however, the incidence of sic in the covid- group during the first seven days was only . % ( of patients) and was significantly lower compared with that in the non-covid- group (log rank test, p = . , figure ). one of the two sic patients survived to hospital discharge, however, another patient developed multiple organ dysfunction syndrome and died despite full intensive care support. to date, several studies have reported on covid- -related coagulopathy [ , , , ] ; however, in terms of the phenotypes or incidence of dic, there remains little evidence about whether it can be differentiated from overall sic. in the present study, we compared the pattern and incidence of to date, several studies have reported on covid- -related coagulopathy [ , , , ] ; however, in terms of the phenotypes or incidence of dic, there remains little evidence about whether it can be differentiated from overall sic. in the present study, we compared the pattern and incidence of coagulopathy over time between severe covid- pneumonia and non-covid- -induced severe pneumonia using multilevel time series analyses and the kaplan-meier method. a recent study reported that the baseline levels of platelet count, pt, antithrombin activity, and fibrinogen were significantly higher in covid- patients compared to patients with non-covid- ards [ ] . a similar pattern of hemostatic markers was observed in the present analysis at day : pt, antithrombin activity, and fibrinogen in the covid- group were almost within normal range and significantly higher compared with the values in the non-covid- group. furthermore, we showed that the chronological alterations of platelet count, antithrombin activity, and pt in the covid- group were significantly milder, whereas elevations of fdp and d-dimer were significantly higher in the covid- group. decreased platelet counts and prolonged prothrombin time are the most common hematologic signs induced by systemic hypercoagulation and therefore are involved in all widely used dic criteria [ , , ] . antithrombin activity is also known to be markedly decreased in sepsis-induced coagulation, due to consumption as a result of ongoing thrombin generation [ ] . however, elevations of fdp and d-dimer are generally within a mild range in the early phase of sic, mainly due to the impaired fibrinolysis driven by an increase in pai- [ , ] . high levels of fdp and d-dimer with normal or mild alterations of other coagulation markers are typical in local thrombus formation, such as pulmonary embolism and deep venous thrombosis [ , ] . indeed, several studies have reported high incidences of pulmonary embolism in covid- patients with or without underlying deep venous thrombosis [ , ] . according to these insights, our results suggested that systemic hypercoagulation was hardly induced by covid- infection, but the risk of local thrombus formation increased in the acute phase of severe covid- pneumonia. we also evaluated several hemostatic biomarkers and found that covid- patients had moderately high levels of tat and pic but a normal level of pai- . vascular endothelial cell dysfunction is an essential feature in the pathogenesis of sic. because the secretion of pai- is mainly regulated by endothelial cells, sepsis-related endothelial cell dysfunction causes a marked increase in the pai- level leading to disrupted fibrinolysis, and this key event represents the typical feature of the thrombotic type of dic [ ] . therefore, our results regarding the levels of pai- suggested that vascular endothelial cell dysfunction and the thrombotic type of dic were hardly induced by severe covid- pneumonia. then, what phenotype of coagulopathy is induced by covid- pneumonia? severe coagulopathy can be classified into three common phenotypes according to the underlying disease: ( ) enhanced fibrinolytic phenotype typically induced by acute promyelocytic leukemia, ( ) balanced fibrinolytic phenotype typically induced by cancer, and ( ) suppressed fibrinolytic phenotype typically induced by sepsis. in the present study, patients with covid- pneumonia had moderate elevations of tat and pic and a normal level of pai- , which are characteristic of the balanced fibrinolytic phenotype [ ] . one possible explanation for this specific phenotype of coagulopathy is that a pulmonary-restricted intravascular coagulopathy initially occurs due to the extensive alveolar and interstitial inflammation that occurs in patients with covid- pneumonia, and this causes the expression of active tissue factor leading to balanced fibrinolytic coagulopathy [ ] . as mentioned above, the marked elevation of fibrin degradation products was a main characteristic of covid- -induced coagulopathy. therefore, the incidence of jaam dic and isth overt dic involving the component of fibrin degradation products was equal between the two groups during the first seven days, whereas the incidence of sic, which does not involve the component of fibrin degradation products, was much lower in the covid- group. these findings suggested that the typical coagulopathy in covid- was distinct from sic, even though it could meet several of the dic criteria. we acknowledge several limitations of our study. first, the single-center design and short study duration resulted in a relatively small sample size, which may have influenced the precision of our findings. second, we enrolled patients with different pathophysiology (bacterial ards) as the control group for the study purpose of evaluating the specific phenotype of severe covid- -induced coagulopathy by comparing it to other types of sepsis. as a result, there were no differences in baseline characteristics and pre-existing comorbidities, but the pattern of organ dysfunction between the groups reflected the unique clinical manifestation of severe covid- pneumonia. however, we are not confident that the effect of potential ascertainment bias can be completely excluded despite robust adjustment with regression models. third, the long-term design of the control group might be another source of bias. although the type and severity of patients and the key concepts for the management of ards were not greatly changed, physician staffing and several supportive therapies, such as antimicrobials and nutrition, might change according to the time course, which possibly influenced the study findings. finally, the control group included only bacterial sepsis and did not include non-covid- viral infections. further investigation is thus required to compare the coagulation disorders between covid- -induced ards and non-covid- -viral-infection-induced ards. in the present study, the pattern of coagulopathy in severe covid- pneumonia was quite different from that in other severe pneumonias. systemic hypercoagulation, suppressed fibrinolysis, and vascular endothelial cell dysfunction, typically observed in sepsis-induced dic, might be hardly induced; instead, local thrombus formation was possibly triggered by pulmonary-restricted intravascular coagulopathy in covid- pneumonia. further investigations are required to confirm our findings and establish appropriate management for severe covid- pneumonia. a novel coronavirus from patients with pneumonia in china abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia epidemiological and clinical characteristics of cases of -novel coronavirus ( -ncov) pneumonia in wuhan clinical features of patients infected with novel coronavirus in wuhan, china. lancet. more on covid- coagulopathy in caucasian patients endothelial cell infection and endotheliitis in covid- endotheliopathy in covid- -associated coagulopathy: evidence from a single-centre, cross-sectional study tissue plasminogen activator (tpa) treatment for covid- associated acute respiratory distress syndrome (ards): a case series anticoagulant treatment is associated with decreased mortality in severe coronavirus disease patients with coagulopathy classifying types of disseminated intravascular coagulation: clinical and animal models efficacy and safety of anticoagulant therapy in three specific populations with sepsis: a meta-analysis of randomized controlled trials clinical management of severe acute respiratory infection when novel coronavirus (ncov) infection is suspected: interim guidance the third international consensus definitions for sepsis and septic shock acute respiratory distress syndrome scientific and standardization committee on dic, and the scientific and standardization committee on perioperative and critical care of the international society on thrombosis and haemostasis diagnosis and management of sepsis-induced coagulopathy and disseminated intravascular coagulation scientific and standardization committee communications: towards a definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation natural history of disseminated intravascular coagulation diagnosed based on the newly established diagnostic criteria for critically ill patients: results of a multicenter, prospective survey* a multicenter, prospective validation of disseminated intravascular coagulation diagnostic criteria for critically ill patients: comparing current criteria* oxidative stress and inflammation are associated with adiposity in moderate to severe ckd coagulopathy and antiphospholipid antibodies in patients with covid- covid- -related severe hypercoagulability in patients admitted to intensive care unit for acute respiratory failure clinical research in intensive care and sepsis trial group for global evaluation and research in sepsis); et al. high risk of thrombosis in patients with severe sars-cov- infection: a multicenter prospective cohort study platelet drop and fibrinolytic shutdown in patients with sepsis fibrin-related markers in patients with septic shock: individual comparison of d-dimers and fibrin monomers impacts on prognosis review of d-dimer testing: good, bad, and ugly laboratory biomarkers for venous thromboembolism risk in patients with hematologic malignancies: a review autopsy findings and venous thromboembolism in patients with covid- high incidence of venous thromboembolic events in anticoagulated severe covid- patients advance in the management of sepsis-induced coagulopathy and disseminated intravascular coagulation immune mechanisms of pulmonary intravascular coagulopathy in covid- pneumonia author contributions: y.u. conceived and designed this study; contributed to acquisition, analysis, and interpretation of the data; and was responsible for drafting, editing, and submission of the manuscript. k.y. contributed to the study design; acquisition, analysis, and interpretation of the data; and drafting of the manuscript. t.k., t.n., m.k., and s.f. had a significant influence on the interpretation of the data and critical appraisal of the manuscript. all of the authors contributed to the acquisition of data and reviewed, discussed, and approved the final manuscript. all authors have read and agreed to the published version of the manuscript funding: this research received no external funding. the authors thank all of the emergency medical service personnel, nurses, and physicians who have confronted the covid- outbreak, and the patients who contributed to this study. the authors declare no conflict of interest. key: cord- - cgct authors: zanuzzi, c.n.; nishida, f.; portiansky, e.l.; fontana, p.a.; gimeno, e.j.; barbeito, c.g. title: effects of solanum glaucophyllum toxicity on cell proliferation and apoptosis in the small and large intestine of rabbits date: - - journal: res vet sci doi: . /j.rvsc. . . sha: doc_id: cord_uid: cgct vitamin d regulates mineral homeostases and enterocyte proliferation and differentiation. hypervitaminosis d generates changes in cell proliferation, differentiation and apoptosis in several organs. we analysed morphometric parameters and proliferative and apoptotic indices in the intestinal epithelium of rabbits with hypervitaminosis d induced by the chronic treatment with the calcinogenic plant solanum glaucophyllum. rabbits were treated for or days. a group was treated for days and led to possible recovery for days. another group was nutritionally restricted for days. morphological, morphometric, proliferative and apoptotic changes were found in the treated animals. mild atrophy and reduced proliferation was found in the jejunum and ileum. apoptosis increased in the crypts of the ileum and in the superficial epithelium and crypts of the rectum. most of the alterations were partially recovered. the possible involvement in these changes of the hypervitaminosis d-like state induced by s. glaucophyllum is discussed. vitamin d has been associated with increased absorption of dietary calcium and phosphate (wesley et al., ; bikle, ) and enterocyte proliferation and differentiation (suda et al., ; newmark and lipkin, ; menard et al., ; holt et al., ) in the gastroenteric tract. it induces the expression of genes involved in environmental intestinal toxin detoxification (kutuzova and deluca, ) , and in the preservation of the mucosal barrier integrity (kong et al., ) . cell proliferation, differentiation and apoptosis continuously occur in the intestine, and they are tightly regulated to ensure epithelial renewal (potten, ; potten et al., ) . these processes can be altered under starvation (holt et al., ; chappell et al., ) , fasting (park et al., ) and chronic psychological stress in rats (boudry et al., ) , as well as under escherichia coli infection in rabbits (wada et al., ; heczko et al., ) . solanum glaucophyllum (s. glaucophyllum) (synonym of solanum malacoxylon) is a calcinogenic plant responsible for enzootic calcinosis in ruminants of south america, a cause of considerable economic losses in argentina, brazil and uruguay (worker and carrillo, ) . the toxic principles, mainly contained in the leaves, consist of vitamin d analogues, mostly , (oh) d , associated with glycoside derivatives. the chronic ingestion of this plant induces a hypervitaminosis d-like state (wasserman, ; dallorso et al., ; mello, ) . spontaneous intoxication occurs in ruminants when the active principle is released into the rumen. the intoxication of non-ruminant species, such as pigs (campero and odriozola, ) and horses (ruager and gimeno, ) , shows that the toxic principle does not need to suffer structural modifications such as the hydrolysis of the glycosides accounted in the rumen, as it has been previously suggested (boland et al., ; mello and habermehl, ) . intoxicated animals show mineralization in heart, arteries, lungs and kidneys, join erosions, stiffness, painful gait, kyphosis, anorexia and loss of body condition. in severe cases, emaciation is also observed (worker and carrillo, ) , although the cause remains unknown. rabbits are useful as experimental model. they are highly susceptible to experimental treatment with s. glaucophyllum in a way similar to the natural intoxication that occurs in ruminants (dallorso et al., ; gimeno et al., ; fontana and zanuzzi, ; zanuzzi et al., ; ) . experimental studies performed in animal models treated with s. glaucophyllum have shown changes in cell proliferation, differentiation and apoptosis in aorta, lungs (barros and gimeno, ; portiansky et al., ) , skin ) , thymus, lymph nodes and spleen (fontana and zanuzzi, ; fontana, ; fontana et al., ) . in the intestine the effects of this treatment include specific changes in paneth cells (zanuzzi et al., ) and in the carbohydrate expression pattern of enterocytes and goblet cells (zanuzzi et al., ) . the experimental model of hypervitaminosis d in transgenic mice used by razzaque and lanske ( ) and medici et al. ( ) showed changes in cell proliferation and apoptosis in the intestine, skin and kidneys. in the present work we studied the morphometry and the changes in cell proliferation and apoptosis in the intestine of rabbits treated with s. glaucophyllum. we aimed to contribute to the understanding of the pathogenesis of the hypervitaminosis d-like state induced by s. glaucophyllum intoxication. twenty-five three-month-old new zealand male rabbits were used. all animals were clinically healthy at the beginning of the experiment. they were housed at the experimental unit for one week prior to the experiment in order to reduce stress effects due to environmental changes. each animal was housed in an individual cage. all the procedures were carried out in accordance to the ''guide for the care and use of laboratory animals'' of the national research council (national academy press, , washington, usa). s. glaucophyllum leaves were collected in the locality of chascomús (buenos aires, argentina), an area of high incidence of enzootic calcinosis, during springtime. the active principle is stable for up to four years (puche et al., ) . the leaves were air-dried, powdered with a blender and administered as pellets, which consisted of a mix of standard diet, tap water and mg/kg of powered leaves, a dose chosen based on previous works (dallorso et al. ; gomar, ; fontana and zanuzzi, ; zanuzzi et al., ; fontana, ; fontana et al., ) . animals were orally treated three times a week with these pellets and water ad libitum, whereas control group received water and standard diet ad libitum during the study. animals were intramuscularly anesthetized with ketamine ( mg/kg) and xylazine ( mg/kg) and then cardiac puncture was performed. five rabbits were killed after days of treatment (group a); other five were treated for days and killed thereafter (group b); five animals that were treated for days were led to possible recovery for days (group c -recovery group). six animals were used as controls and killed in pairs at day , and . during s. glaucophyllum-intoxication the treated animals reduced the ingestion of food and suffered a reduction in their body weight. a group of four rabbits (group d) was then selected to determine whether changes in the body weight were a consequence of a reduction in the ingestion of food, the treatment or a combination of both. for this purpose group d animals were fed with the same standard diet as that given to control group, but in an amount equal to that consumed by the treated animals. group d animals were killed after days. clinical signs were observed and recorded every day during the entire study. rabbits were weighed once a week. in order to compare weight variations between groups the relative weight index was calculated for each animal using the following formula: relative weight index ¼ body weight on the day of measurement=body weight on day all rabbits were necropsied and samples of small and large intestine were collected. samples were obtained from jejunum (middle region, m from the pyloric sphincter), ileum ( cm from the ileocecal junction) and rectum, and then rinsed in . m pbs, fixed in % neutral buffered formalin for h and embedded in paraffin wax. paraffin blocks were sectioned on a semiautomatic microtome (leica rm , gmbh, nussloch, germany) and six -lm-thick non-contiguous ( lm apart) sections of each intestinal region of every tested animal were routinely stained with haematoxylin and eosin (he) according to bancroft and stevens ( ) . all morphological measurements were conducted by two blinded researchers. sections stained with he were examined under a light microscope. a minimum of well-oriented crypt-villous units or crypts of each section from jejunum, ileum and rectum were analysed for each animal. the length and width of villi and crypts were measured. images of each sample section were captured from a microscope (olympus bx , tokyo, japan), with objectives of  or  magnification, using an attached digital video camera (olympus dp , tokyo, japan) connected to a computer containing an image analysis program (imagepro plus, v . , media cybernetics, usa), and stored in rgb tiff bits format. sections ( lm thick) were mounted on slides coated with gmethacryloxypropyltrimethoxy-silane (m , sigma, st. louis, mo, usa), passed through a decreasing graded alcohol scale and incubated with . % h o in methanol (purum p . %) for min at room temperature. sections were then rinsed twice in pbs and exposed to microwave antigen retrieval using a buffer citrate solution (ph . ) (taylor et al., ) . sections were then incubated with % bsa in pbs for min, followed by overnight incubation with anti-ki antibody (monoclonal mouse antihuman ki- antigen clone mib- , ready-to-use, dakocytomation, carpinteria, ca, usa). the envision Ò detection system + hrp system labelled anti-mouse polymer (dakocytomation) was applied for min. sections were then rinsed three times in pbs for min each time. liquid , -diaminobenzidine tetrahydrochloride (dab) (dakocytomation) was used as chromogen and hill's haematoxylin for counterstaining. control negative sections were prepared by omitting primary antibody. a section of feline squamous cell carcinoma was used as a positive control. at least cells per section were counted using a  objective and the number of labelled and non-labelled epithelial cells was recorded. proliferation index was expressed as the percentage of labelled cells over the total epithelial cells using the following formula: proliferation index ¼ number of epithelial labelled cells  =total number of epithelial cells in the he-stained sections apoptotic cells were identified using the following morphological criteria: cell shrinkage, acidophilic cytoplasm and condensation and fragmentation of nuclear chromatin. apoptosis was confirmed by the use of the modified terminal deoxynucleotidyl transferase (tdt)-mediated deoxyuridine triphosphate (dutp) nick-end labelling technique (tunel kit apoptag chemicon international, temecula, ca, usa). we followed the manufacturer's suggested protocol. all tunel labelled samples were counterstained with methylene green. tunel protocol included negative controls excluding the tdt step of the original method. as positive control we used the positive sample provided by the commercial kit. to calculate the apoptotic index in the villi we measured the perimeter of the villi and counted the number of apoptotic cells along that perimeter. the apoptotic index was expressed as: apoptotic index ¼ number of apoptotic epithelial cells in the villi  =total number of epithelial cells to calculate the apoptotic index in the crypts in the three anatomic segments and in the superficial epithelium of the rectum we counted at least cells per slide using a  objective. the apoptotic index was expressed as: apoptotic index ¼ number of apoptotic epithelial cells in the crypt  =total number of epithelial cells . . statistical analysis an analysis of variance (anova) with one factor was used. significance was assumed at values of p < . . the fisher least significant difference (lsd) test was used for the post hoc comparisons. for these comparisons, the p < . level was used to define significance between groups. all the treated animals from groups a and b reduced the ingestion of food after - h. compared to control animals, all the groups showed a significant reduction in their body weight index from day up to the end of the experiment (fig. ) . treated animals also showed other clinical signs, such as diarrhoea, rhinitis, conjunctivitis or external otitis. animals from group c showed clinical signs only during the treatment time, and partially recovered body weight during the remaining days. animals from group d also showed a gradual body weight reduction. in contrast to treated animals, they were more aggressive and hyperkinetic. at necropsy, animals from groups a and b showed reduction of adipose tissue compared to control animals, muscular atrophy and calcification of the cardiovascular system (tricuspid and mitral valves, inner surface of aorta and pulmonary arteries), lungs and renal cortices. animals from group c only showed calcification of the cardiovascular system. the mucosa of the jejunum, ileum and rectum from the treated groups during (group a) and days (group b) showed atrophy (fig. ) . in jejunum and ileum the degree of atrophy of the villi was about %. in some animals lymphangiectasia extended up to the tunica muscular (fig. ) . the mucosal layer of the animals from group d appeared slightly atrophic with oedema and lymphangiectasia in the lamina propria. villous length was significantly reduced in groups a as compared to control and d groups, whereas villous width was significantly higher in group c in comparison to control group. crypt width increased in group c as compared to all groups except group d (fig. ) . villous length (fig. ) was significantly reduced in group a as compared to control and d groups. villous width increased in group c compared to group a. crypt length was significantly reduced in group a compared to control animals. . morphometric study of crypts and villi. significant differences ( ⁄ ) in villi length of jejunum were observed (group a vs. control and group d) or villi width (#) (group c vs. control). significant differences in crypt width (#) were observed (group c vs. all groups except group d). significant differences ( ⁄ ) in villi length of ileum were observed (group a vs. control and group d) or villi width (#) (group c vs. group a). significant differences in crypt length of rectum ( ⁄ ) were observed (group a vs. controls). the figure shows the means of the experimental groups and the % confidence interval on the treatment means. ⁄ , # = p < . . no significant differences were found in crypt length or width neither between treated animals nor with controls (fig. ) . proliferation index was significantly decreased in animals from group b compared to controls and group d (fig. ) . no significant difference in the apoptotic index was observed between groups (fig. ) . proliferation index was significantly reduced in group a compared to the rest of the groups (fig. ) . there was a significant increase in the apoptotic index of the crypts in group a compared to the rest of the groups (fig. ) . the proliferation index was significantly reduced in group d compared to group b (fig. ) . the apoptotic index of the superficial epithelium and crypts was significantly increased in group a in comparison to group c and d (fig. ) . vitamin d regulates cell proliferation, differentiation and apoptosis in the intestine (menard et al., ; díaz et al., ; biol-n' garagba et al., ; holt et al., ; ) . several studies have shown that , (oh) vitamin d inhibits cell proliferation in normal rectal mucosa (thomas et al., ) , adenomatous polyps (holt et al., ) and colonic and rectal cancer cell lines (díaz et al., ) . these findings have supported its use in the prevention and treatment of hyperproliferative disorders (bikle, ; ) . changes in cell proliferation, differentiation and apoptosis have been reported in several organs under a hypervitaminosis d state (barros and gimeno, ; gimeno et al., ; portiansky et al., fig. . ki- proliferation index in the intestine. the proliferation index was reduced in some s. glaucophylum-treated animals. in the jejunum, significant differences ( ⁄ ) were observed between group b vs. control and d groups. in the ileum, significant differences (#) were observed between group a and the rest of the groups. in the rectum significant differences (&) were observed between group d vs. group b. the figure shows the means of the experimental groups and the % confidence interval on the treatment means. ⁄ , #, & = p < . . fig. . apoptosis of epithelial cells. in ileum crypts ( ⁄ ) significant differences vs. the remaining groups were observed. in the superficial epithelial cells and crypts of the rectum ( ⁄ ) significant differences vs. groups c and d were found. the figure shows the means of the experimental groups and the % confidence interval on the treatment means. ⁄ = p < . . ; gimeno et al., ; razzaque and lanske, ; fontana and zanuzzi, ; medici et al., ; zanuzzi et al., ; fontana et al., ; fontana, ; zanuzzi et al., ) . morphological modifications have been reported in the crypts of the small intestine of rats treated with metrotrexate (verburg et al., ) , and in the mucosa and lamina propria of young rats fed with low protein content diet (rodrigues et al., ) . according to drozdowski and thomson ( ) dynamic morphological parameters, such as enterocyte proliferation and migration, are associated with intestinal adaptation to internal and external environmental stimuli. modifications in the proliferation and apoptosis may explain the changes in the size of villi and crypts found in several pathological conditions. in the present study, we observed morphological and morphometrical alterations in the intestines of rabbits fed with the calcinogenic plant s. glaucophyllum. besides, cell proliferation and death were affected. cell proliferation in the jejunum and in the ileum was reduced after and days of treatment, respectively. in contrast, in the rectum the changes in apoptosis seemed to play a primary role. in other experimental studies, variations in proliferation rate within intestinal regions have also been reported, e.g. in rats subjected to thermal stress (greant et al., ) and in the colon of mice fed with a vitamin d-deficient diet (sadava et al., ) . specific adaptive responses of each anatomical region and differences in the expression of vitamin d receptors within the gastrointestinal tract have been reported in goats, sheep (liesegang et al., ; riner et al., ) and rabbits (duncan et al., ) . variations in the number and distribution of vitamin d receptors in the intestine might also explain the results obtained in the present study. in addition, the hormonal and metabolic profile of animals from group c during and after the treatment period, and the differences in the mechanism of adaptation or recovery of each intestinal section could account for their partial recovery. the response of the intestinal mucosa to different injuries or stressors reveals the great plasticity of this organ to adapt to most of them, a property known as enteroplasticity (drozdowski and thomson, ) . in some circumstances the response to similar injuries might differ. holt et al. ( ) observed a hyperplasic response in the ileum of nutritionally restricted animals, and a reduced cell proliferation in the duodenum. other authors (chappell et al., ) found a decreased cell proliferation in the proximal intestine of rats subjected to progressive nutritional restriction, with changes in cell death only during complete fasting. in contrast, the apoptosis was increased in the crypts of animals under intermittent water avoidance stress (boudry et al., ) . the results from group d differed from those of control or treated groups according to the intestinal section analysed and the measured parameters. thus, the alterations found in the treated animals might result from the reduction in food ingestion, from a specific response to s. glaucophyllum treatment or a combination of both. taking into account the present results and the wellknown vitamin d antiproliferative effects in the intestine (thomas et al., ; holt et al., ; bikle, ; ) , it is possible that the changes observed in affected animals were primarily induced by s. glaucophyllum treatment. atrophy and changes in cell proliferation and death have been also reported in knockout mice for fgf- and klotho genes that exhibit a hypervitaminosis-d like status (razzaque and lanske, ; lanske and razzaque, ) . they show hyperphosphatemia, hypercalcemia, atherosclerosis, emphysema, kyphosis, alopecia, loss of body weight, osteopenia/osteoporosis, hypogonadism, soft tissue calcifications and atrophy of several organs, such as thymus and spleen (razzaque and lanske, ; medici et al., ) . most of the aforementioned clinical signs are frequently found in naturally and experimentally s. glaucophyllum-intoxicated animals. particularly, in the intestine of fgf- and klotho-knockout mice, intestinal mucosa and villi are atrophic (razzaque and lanske, ; lanske and razzaque, ) . the reduced proliferation and the increased apoptosis explain those morphological alterations (razzaque and lanske, ; lanske and razzaque, ; medici et al., ) . the changes described in these knockout mice have been attributed to the hypervitaminosis d status, and considered premature ageing-like features (razzaque and lanske, ; lanske and razzaque, ; medici et al., ) . we also found significant differences in the proliferation index of the small intestine and in the apoptotic index of the ileum and rectum in the treated animals. in line with these observations, the similarity between the results of our model and those from transgenic mice further support the involvement of vitamin d in the changes found in the treated rabbits. the reduced body weight in the treated animals supports that reported in naturally intoxicated cows by worker and carrillo ( ) , and in experimentally intoxicated rabbits by dallorso et al. ( ) . it has been shown that high calcium levels reduce weight gain (davies et al., ; heaney et al., ) . thus, the intestinal atrophy, the reported modifications on the glycosylation process (zanuzzi et al., ) , and the hypercalcemic state found in the treated rabbits (fontana, ) could lead to alterations in the digestive and absorption processes, and explain the gradual and progressive loss of weight. vitamin d has immunomodulatory effects (bikle, ) . although we did not evaluate the specific impact of hypervitaminosis d state on the adaptive and innate immunity the clinical signs and lesions found in the treated animals strongly suggest local or systemic immunological impairment. in addition, atrophy of lymphoid organs, changes in proliferation and apoptosis, and hyperplasia and hypertrophy of paneth cells, were other changes reported in cattle and rabbits treated with s. glaucophyllum (fontana and zanuzzi, ; zanuzzi et al., ; fontana et al., ; fontana, ) . the otitis, rhinitis, conjunctivitis or diarrhoea described in this study have been previously reported in rabbits treated with s. glaucophyllum by several authors (dallorso et al., ; gomar, ; fontana, ) who did not observe anatomopathological characteristic lesions suggestive of diseases induced by infectious agents, such as rotavirus, coronavirus or escherichia coli. in conclusion, the findings described in this work show that s. glaucophyllum treatment induced a hypervitaminosis d-like state that alters cellular proliferation and apoptosis in the intestinal epithelium. these results will help to better understand the clinical signs observed in naturally intoxicated animals. all the authors declare that there is no actual or potential conflict of interest including any financial, personal or other relationships with other people or organizations within three years of beginning the submitted work that could inappropriately influence, or be perceived to influence, their work. theory and practice of histological techniques cell differentiation and bone protein synthesis in the lungs of sheep with spontaneous calcinosis what is new in vitamin d nonclassic actions of vitamin d polyamine participation in the maturation of glycoprotein fucosylation, but not sialylation, in rat small intestine isolation of the vitamin d metabolites from solanum malacoxylon leaf extracts incubated with ruminal fluid chronic psychological stress alters epithelial cell turn over in rat ileum a case of solanum malacoxylon toxicity in pigs effects of incremental starvation on gut mucosa (oh) vitamin d concentration in the plasma of solanum glaucophyllum-treated rabbits calcium intake and body weight apoptosis is induced by the active metabolite of vitamin d and its analogue eb in colorectal adenoma and carcinoma cells: possible implications for prevention and therapy intestinal mucosal adaptation ontogenesis of the rabbit intestinal receptor for , -dihydroxyvitamin d -evidence for increased receptor content during late suckling and lactating periods cambios estructurales y funcionales de órganos y células del sistema inmune de bovinos experimentalmente intoxicados con solanum glaucophyllum evaluación morfológica y funcional del sistema inmune y de células asociadas al mismo, en animales intoxicados con solanum glaucophyllum evaluation of immunotoxic effects of plant-induced hypervitaminosis d on cattle thymus effects of plant-induced hypervitaminosis d on cutaneous structure, cell differentiation and cell proliferation in cattle calcinosis in ruminants due to plant poisoning. contributions on the pathogenesis efectos de la hipervitaminosis d vegetal en la diferenciación y proliferación celulares cutáneas, aórticas y pulmonares del conejo influence of stress on epithelial cell proliferation in the gut mucosa of rats calcium and weight: clinical studies decreased apoptosis in the ileum and ileal peyer's patches: a feature after infection with rabbit enteropathogenic escherichia coli o ileal hyperplastic response to starvation in the rat colonic epithelial cell proliferation decreases with increasing levels of serum -hydroxy vitamin d. cancer epidemiology calcium plus vitamin d alters preneoplastic features of colorectal adenomas and rectal mucosa novel role of the vitamin d receptor in maintaining the integrity of the intestinal mucosal barrier -dihydroxyvitamin d regulates genes responsible for detoxification in intestine premature aging in klotho mutant mice: cause or consequence? effects of gestation and lactation on vitamin d receptor amounts in goat and sheep fgf- -klotho signaling stimulates proliferation and prevents vitamin d-induced apoptosis kalzinogene pflanzen und der inkubations effekt durch pansensaft calcinosis-calcinogenic plants effects of calcitriol on proliferation and differentiation of human fetal jejunum calcium, vitamin d and colon cancer suppression of intestinal mucosal apoptosis by ghrelin in fasting rats collagenous and elastic system fibres in the aorta of cattle poisoned by solanum glaucophyllum regeneration in epithelial proliferative units as exemplified by small intestinal crypts regulation and significance of apoptosis in the stem cells of the gastrointestinal epithelium the antirachitic activity of solanum glaucophyllum leaves hypervitaminosis d and premature aging: lessons learned from fgf and klotho mutant mice vitamin d receptor distribution in intestines of domesticated sheep ovis ammon f.aries morphometric study of the small intestinal mucosa in young, adult, and old rats submitted to protein deficiency and rehabilitation enteque seco en equinos, caprinos y ovinos hyperplasia, hyperproliferation and decreased migration rate of colonic epithelial cells in mice fed a diet deficient in vitamin d the role of vitamin d in bone and intestinal cell differentiation comparative study of antigen retrieval heating methods: microwave, microwave and pressure cooker, autoclave, and steamer vitamin d and its metabolites inhibit cell proliferation in human rectal mucosa and a colon cancer cell line selective sparing of goblet cells and paneth cells in the intestine of metrotrexate-treated rats apoptosis of enterocytes induced by inoculation of a strain of attaching and effacing escherichia coli and verotoxin calcium absorption and calcium binding protein synthesis: solanum malacoxylon reverses strontium inhibition vitamin d : synthesis, actions, and mechanisms in the intestine and colon enteque seco'', calcification and wasting in grazing animals in the argentine paneth cells: histochemical and morphometric study in control and solanum glaucophyllum-treated rabbits glycoconjugate histochemistry in the small and large intestine of normal and solanum glaucophyllum-treated rabbits we thank mr. rubén mario, mrs. rosa villegas and miss maría guadalupe guidi for their technical assistance. financial support was provided in part by grants from agencia nacional de promoción científica (anpcyt) (pict - ), consejo nacional de investigaciones científicas (conicet) and academia nacional de agronomía y veterinaria (anav), argentina. cnz, fn, elp, ejg and cgb are members of conicet (national scientific research council). key: cord- - lqlx rv authors: nan title: poster sessions date: - - journal: j diabetes doi: . / - . _ sha: doc_id: cord_uid: lqlx rv nan polycystic ovarian syndrome (pcos) is the most common endocrinopathy in women before menopause, the purpose of this study was to determine the effects of a diet and physical activity trial for improving pcos clinical and laboratory findings in obese women. this semi-experimental single-blind controlled trial was conducted among women with pcos ( cases and controls). initially, all the patients′ information was evaluated in terms of: demographic, menstrual status, clinical characteristics of hyperandrogenemia, as well as biochemical, hormonal and abdominal ultra-sonography. the intervention plan consisted of a -week exercise and diet program for the experimental group. all baseline assessments were repeated in both groups within months after beginning of the trial, and the results were analyzed. the comparison between the two groups revealed that in the experimental group, the interventions have been effective for the following variables: follicle stimulating hormone (p = . ), the luteinizing hormone (p = . ), total testosterone (p = . ), free testosterone (p = . ), estradiol (p = . ), selfglobulin band sex hormone (p = . ), triiodotyronine (p = . ), thyroxine (p = . ), tsh (p = . ), hydroxy progesterone (p = . ), triglycerides (p = . ), total cholesterol (p = . ), body mass index (bmi; p = . ), the ultrasound exam (p < . ), oligomenorrhea (p < . ), of hirsutism (p < . ), acne (p < . ) and alopecia (p = . ). it seems that regular exercise and dietary intervention are effective to improve pcos among obese women. a series of studies have recently demonstrated that the oxidative stress, nuclear factor-kappa b (nf-jb) activation and the subsequent coordinated inflammatory responses played an important role in the pathogenesis of urate nephropathy (un). polydatin has been suggested to have the properties of anti-oxidative, anti-inflammatory and nephroprotective effects. however, the possible protective and beneficial effects of polydatin on un are not fully elucidated. therefore, we investigated the potential beneficial effects and possible mechanisms of polydatin on un. in this study, polydatin showed inhibitory activities on xanthine oxidase to repress the level of serum uric acid in vivo and in vitro. further investigations revealed that polydatin displayed little toxic effects and significantly ameliorated the renal function in fructose-induced un mice. the nephroprotective activities of polydatin was not only due to the effects on remarkably attenuating the oxidative stress induced by uric acid, but also on markedly suppressing the oxidative stress-related inflammatory cascade, including decreasing the expressions of nf-jb p , cox- and inos proteins and inhibiting the productions of tnf-a, pge and il- β. these findings elucidated that polydatin exhibited prominent nephroprotective activities and low toxic effects. drug discovery, obetherapy, evry, france many obesity related genes have been proposed as targets for the treatment of obesity. however, these obesity genes did not provide efficient drug therapy for obesity treatment. this is mainly due to the redundancy of the biochemical pathway involved in obesity and the lack of specificity of the gene targets. it is therefore a challenge to identify crucial gene(s) targets involved in energy metabolism associated with "lean or starvation phenotype". congenital enteropeptidase defficiency is an extremly rare pathology which answer to all these criteria. enteropeptidase catalyzes the conversion of inactive trypsinogen into active trypsin via the cleavage of the acidic propeptide from trypsinogen. we have generated knock out transgenic mice for enteropeptidase which shows the same phenotype like in human. these data and in vivo preclinical data using per os small molecule for long term treatment ( weeks) will be presented. f. nasiri amiri , f. ramezani tehrani , m. simbar babol medical sciences university, babol, shahid beheshti university of medical sciences, tehran, iran polycystic ovary syndrome (pcos) is the most common chronic endocrine disorder with a prevalence estimated at - % depending on the diagnostic criteria used. it has significant and diverse clinical consequence including reproductive, metabolic, psychological morbidity and some cancer. it is unclear how pcos symptom influences such women's experiences of their bodies. this study aimed to explain women's experiences of their health concerns when living with pcos. this research is a qualitative study. semi-structured opened interviews were conducted with women aged - years who were diagnosed with pcos. interviewing the participants were continued to reach data saturation. all the interviews were recorded and transcribed. the data were analysed using content analysis. four closely intertwined themes were disclosed: physical consequences of pcos, fear of future, economic burden of desease and coming to terms with a chronic condition. our findings suggest that healthcare professionals working with pcos patients should consider providing peer support groups as a means to alleviate patients concern and to promote self management activities such as lifestyle modification. ideally, groups should be designed to meet patients support needs and expectations, and should be evaluated regularly. m. kidron , e. arbit oramed pharmaceuticals, jerusalem, israel, biomedical engineering, nyu -oramed pharmaceuticals, englewood, nj, usa introduction: the major cause of hyperglycemia in t dm is inappropriate, non-suppressible hepatic glucose production due to hepatic insulin resistance (hir)) and elevated glucagon levels. hir is a result of fat deposition in the liver which in turn begets a local inflammatory process, a common thread observed in t dm, the metabolic syndrome and obesity which are all known risk factors for morbidity. the only antidiabetic drug that addresses specifically hir, up to now is metformin and its effects wanes over time. there is an unmet need for other drugs that target the liver specifically. insulin has a direct effect on hepatocytic receptors and thus has shown to be capable to reduce hepatic steatosis and improve glycemic control, as well as reduce hepatic insulin resistance. insulin administered orally is absorbed into the portal-hepatic vein and reaches the liver at high concentrations. this route of administration may confer physiologic advantages over systemic insulin administration and lower the risk of hypoglycemia. results: bmi, hdl and cu levels were found to be significantly higher in women compared to men (p < . ). _ it was established that blood copper levels, similar to hscrp, predicted ms and ms parameters, but predicted different ms parameters at different sensitivities and specifities. we obereved that there was a more significant correlation between tg level, blood pressure and cu, compared to hscrp (tables , and ). conclusion: based upon these results, it may be stated that cu predicts ms and ms parameters as well as hscrp does and that it is even a better predictor for ms and atherosclerosis since it is less influenced from inflammatory events than crp. short-chain fatty acids which then up regulate proglucagon (precursor to glp ) and pyy gene. these gut hormones are collectively known as "incretin" and they primarily regulate insulin level after eating. very recently, two new classes of drugs based on incretin action have been approved for lowering blood glucose levels in type diabetes milliets. one is exenatide, long-acting agonist of the glp- receptor and other is incretin enhancer known as sitagliptin, a dpp inhibitor. however, glp- agonist reduces body weight (anti-obesity therapy) and leads to hypoglycemia. similarly, liraglutide, dpp-iv-resistant glp- receptor agonists is also synthesized using glp- sequence with prolongs half-life. in conclusion, polysaccharides might be a way to decrease the hurdle in diabetes managements and special attention should be paid to naturally derived polysaccharides. ms is often associated with inflammation caused by latent infections or sibo. we investigated whether treatments of such items may help to control ms. method: we prospectively studied patients presenting with ms and three concomitant causes of inflammation [helicobacter pylori (hp = cases); oral papillomavirus virus (hpv = ) or ebv ( ); sibo (h or ch breath tests: cases)] who were all successfully treated for hp, hpv or ebv, and sibo (decrease of h or ch > % and decrease of circulating th cells > % which are correlated with intestinal chronic inflammation). patients were followed-up months. conclusion: treatment of latent infection and sibo benefits mainly to patients younger than , without methanogenic flora and with few circulating th cells. and increases the gastric emptying time, intestinal transit time, gastric acid secretion in the ms bark juice treated group. there was significant (p < . ) decrease in the t max , t / and increase in the c max of met in ms bark juice treated group as compare to diabetic group. present study suggests that the bark juice of ms shows significant effects in the treatment of gastroparesis and it improves the pharmacokinetic of met compared to diabetic group of rat. type diabetes mellitus (t dm) is a complex metabolic disorder. its prevalence is expected to increase exponentially around the world. insulin resistance, inflammation and dysregulation of adipokines play a major role in the pathogenesis of t dm. among the huge growing adipose secretome, nicotinamide phosphoribosyl transferase (nampt) and vaspin emerged as novel interesting adipokines having insulinmimetic and -sensitizing effects, respectively. however, their role in t dm is still controversial. accordingly, this study was designed to investigate their levels in t dm patients compared to healthy control subjects, and to study the correlation between these two novel adipokines and the correlation between each of them with anthropometric parameters, insulin resistance, hyperglycemia, dyslipidemia, and also the inflammatory marker interleukin- (il- ). the levels of these two novel adipokines and other parameters were measured in non-obese and obese t dm patients together with matched healthy non-diabetic control subjects. the nampt, vaspin and il- levels were measured by elisa while insulin levels by chemiluminescence technique. the nampt and vaspin levels were found to be significantly elevated in non-obese ( . ae . and . ae . ng/ml, respectively) and obese t dm patients ( . ae . and . ae . ng/ml, respectively) compared to control subjects ( . ae . and . ae . ng/ml, respectively) at p < . . furthermore, nampt as well as vaspin were found to be significantly correlated with one another and with various metabolic parameters. in conclusion, nampt and vaspin are potential candidates to play important role in the development and progression of t dm. . to compare insulin resistance in sub-clinical and overt thyroid hypo-function. methods: one hundred eighteen patients with the diagnosis of hypothyroidism based on their clinical and thyroid function test profile were included in this cross sectional hospital based descriptive study with their informed consent. homa-ir as an index of insulin resistance was calculated for each subject from their fasting plasma glucose and serum insulin levels. autoimmunity against thyroid was evaluated by estimating anti tpo antibodies. results: homa-ir as an index of insulin resistance was comparable in overt ( . ae . ) and subclinical hypothyroidism ( . ae . ) but was above the reference range for this population. hypothyroid anti tpo positive cases has high tsh compared to negative cases in both overt hypothyroidism and subclinical hypothyroidism. conclusions: hypothyroidism induces insulin resistance but the degree of insulin resistance is not dependent on severity of thyroid hypofunction however is associated with autoimmunity against thyroid. . ae . in smoker and . ae . in non-smoker, insulin: . ae . and . ae . (p < . ), control: glucose level was . ae . in and . ae . mmole/l, insulin level: . ae . and . ae . mkiu/ ml, respectively. both growth in height and weight gain are accelerated during puberty. they are mainly affected by sex hormone, growth hormone and igf- , and influenced by various factors either directly or indirectly. the aim of this study is to find out the association of various cytokines with obesity and early-or precocious puberty in female children. twenty-eight female children with breast budding before years old, who underwent the lhrh stimulation test as well as cytokine analysis in their blood, were included in this study. the height, weight, and bmi were measured. we defined obesity when the bmi was percentile or more, and puberty when the maximum lh level was iu/l or more during lhrh stimulation test. adiponectin, leptin, ghrelin, il- β, il- , il- , resistin, and tnfa levels in the blood were analyzed by luminex multiple bead technology (milliplex; millipore co., billerica, ma, bio-plex; bio-rad laboratories, hercules, ca). nineteen out of children were categorized as having early-or precocious puberty. their mean il- level was lower in pubertal children than that in prepubertal state ( . ae . vs. . ae . , p = . ). the leptin and resistin levels were significantly higher in obesity group (n = ) than in non-obesity group, while the ghrelin was significantly lower in obesity group (p < . ). in conclusion, the female children younger than years of age in early-or precocious puberty did not show the increment of leptin or resistin comparing with the female prepubertal children, although the obesity group showed significantly higher levels of leptin and resistin. aims: arterial stiffness is independent risk factor of cardiovascular events. suggest that the statins benefit associated with improvement in arterial stiffness parameters beyond lipidslowering effects. to evaluate changes in pulse-wave shape in obese high risk patients with ah and dyslipidemia treated with rosuvastatin compared with atorvastatin. methods: eighty-two obese patients (age . ae years) with ah, dyslipidemia were randomized to atorvastatin group (n = ) or rosuvastatin (n = ). acei and thiazide diuretics added blood pressure control. pulse-wave characteristics measured before and after weeks of treatment using finger photoplethysmographic device. stiffness index (si), reflection index (ri), augmentation index (aix), systolic bp in aorta (spa), digital pulse amplitude augmentation (paa) were accessed. results: before the treatment impared si, elevated ri, aix, spa were shown. lipids and bp goals were achieved in all patients validating further analysis. decrease in si (d si, м/c À . atorva and À . rosuva), ri (dri, % À . atorva and À . rosuva) were revealed in both treatment arms (p > . ), whereas significant trends towards aix decrease were demonstrated only in rosuvastatin-treated patients (dai, % À . atorva and À . rosuva, p < . ) rosuvastatin group demonstrated better increasing in paa than atorvastatin group (paa (atorva): before treatment . ae . and after weeks: . ae . , p = . vs. paa (rosuva): before . ae . and after weeks . ae . , p < . ). conclusions: pulse-wave analysis in obese ah patients demonstrated increasing vascular stiffness. both atorvastatin and rosuvastatin treatment resulted in arterial stiffness parameters, whereas only rosuvastatin treatment was significantly associated with trends in aix and paa improvement in short-term follow-up. z. wang , m. xu methods: four thousand two hundred and twenty-six adults above years of age and adults under years from a cohort investigated in - at the medical examination center of zhongnan hospital were recuited. cases of fld was identified through ultrasound imaging. the risk factors measured were bmi, and plasma concentrations of alt, ast, tc, tg, hdl, ldl and serum uric acid (sua). the probability of steatohepatitis with advanced fibrosis was calculated according to the body mass index, age, alt, and triglyceride (baat) and ast/alt ratio (aar). results: the prevalence of fld was higher in elderly ( . %) than in non-elderly ( . %) and similar in elderly between men and women ( . % vs. . %, p > . ). multiple regression analyses showed that obesity, high tc, tg, sua, low hdl, and elevated alt, aar < were closely related to the elderly fld the prevalence of steatohepatitis estimated as baat index ! was . % in all subjects, and was higher elderly fld patients than in the non-elderly fld patients. conclusion: the prevalence of fld is higher in the elderly, and is broadly related to the same metabolic risk factors as in the nonelderly. however, female-sex is no longer protective with increasing age, and the prevalence of steatohepatitis with advanced fibrosis is estimated to be considerably higher in the elderly fld patients than in the non-elderly fld controls. vanderbilt, nashville, tn, usa bariatric surgery improves glucose tolerance and may be a viable strategy to prevent the progression from obesity-induced insulin resistance to overt diabetes; however, the recurrence of diabetes is significant following the surgery. we sought to determine whether gastric bypass surgery protected pancreatic beta cells and prevented disease progression to overt diabetes. gastric bypass (roux-en-y gastric bypass, rygb) was performed in young ( weeks old) prediabetic blks db/db null (bks-db) mice, young ( weeks old) new zealand obese (nzo) male mice that were fed high-fat diet (hfd) post-surgery, c bl/ db/db null (b -db) mice that developed insulin resistance, and streptozotocin (stz)-induced diabetic mice. rygb resulted in sustained normoglycemia and improved glucose tolerance in pre-diabetic bks-db mice and hfd-fed nzo mice. remarkably, rygb preserved beta-cell mass and increased plasma insulin with reduced beta-cell apoptosis which was independent of weight loss and body fat reduction. rygb neither reversed hyperglycemia when performed in diabetic bks-db and nzo mice nor resulted in resolution of diabetes in stz-induced diabetic mice. the results demonstrate that gastric bypass prevents beta-cell failure if performed prior to onset of severe beta-cell damage in genetic obese mice. l. ruzic , g. sporis , m. prasek sport and exercise medicine, applied kinesiology, faculty of kinesiology, university of zagreb, vuk vrhovac university clinic, zagreb, croatia the aim of the study was to examine the influence of strength training program on pre-and post workout glycemia. twelve able-bodied diabetic patients using insulin pump (mean age . ae . , m/ f) were enrolled into gym programs /week ( min warm-up aerobic workout, intensity at % hrmax plus strength training exercises involving different muscle groups) for months. no other interventions were introduced. we were interested in effects of the programe on pre-and post workout glycemia, so the comparisons between the first weeks and the last weeks of the study were performed. also the subjects were asked about hypoglycemic episodes. there was a great variability observed in pre-and post glucose concentration within and between subjects. the mean pre-workout glucose concentration in the first weeks of the program was . ae . vs. . ae . mmol/l in last weeks of the program and the difference was not significant (p = . ). nevertheless, the mean glucose decrease after workout was higher in the last weeks of the program (deltaglu: . ae . vs. . ae . mmol/l; p < . ). no hypoglycemic episodes were reported. the months strength training program did not influence large variability in glucose levels before the workout as it depends on many other factors. the only observed effect were larger pre-to post workout glucose differences. it seems that over the time, the strength training may stimulate the body to use more glucose during the workout, which might be explainable with the expected increase of lean body mass. aim: the aim of this study was to evaluate the level of c-reactive protein in gestational diabetes mellitus. materials and methods: sixty-five healthy pregnant women aged . ae . years between the th and th weeks of gestation were studied. all women referred for a -g oral glucose tolerance test following an abnormal result on a screening. the demographic data, waist circumference, height, and weight of the participants were recorded. fasting levels of insulin, triglycerides (tg), c-reactive protein (crp), fasting blood glucose (fbg) and hba c were measured. results: based on oral glucose tolerance testing participants were divided into two groups: normal glucose tolerance (ngt; n = ) and gestational diabetes mellitus (gdm; n = ). the mean crp level was highest in gdm group ( . ae . mg/l), followed by ngt ( . ae . mg/l), (p < . ). the mean fbg ( . ae . vs. . ae . mmol/l, p < . ), homa-ir ( . ae . vs. . ae . , p < . ) and tg levels ( . ae . vs. . ae . mmol/l, p < . ) in the women with gdm were significantly higher than those in the ngt group. methods: in , an observational, prospective study started in france on request of the health authorities (has). one thousand seven hundred and two type diabetic patients treated by vildagliptin were recruited through a national representative sample of gps and diabetologists. we report the data of interim analyses after months of follow-up. results: one thousand four hundred and sixty-three patients are included in this interim analysis: % males, aged ae years, with mean bmi of kg/m . hba c was equal to . ae . % at vildagliptin initiation, then . ae . %, . ae . % and . ae . %, while mean weight decreased from to , and kg at , and months respectively. vildagliptin, rarely prescribed when not recommended, was well tolerated: asat and/or alat were > ui in . % at initiation of vildagliptin then . % at months, with a slight decrease for mean asat and alat. mean gfr was ml/mn at initiation of vildagliptin then ml/mn at months, with a stable percentage of gfr < ml/mn ( %) and < ml/mn ( . %). six severe hypoglycemic episodes occurred in six patients (incidence = . / patient-years), all treated by insulin and/or sulfonylurea in addition to vildagliptin. the proportion of patients still treated by vildagliptin at months was . %. conclusions: over months, in real-life conditions of care, vildagliptin showed a sustained effectiveness in terms of hba c reduction, a good tolerance, very few severe hypoglycemic episodes, rare treatment discontinuations and was most often prescribed as recommended. background: hdl lipoproteins are known to play a causative role in atherosclerosis and its clinical manifestation-coronary artery disease (cad). carotid intima media thickness (imt) is considered as a marker of atherosclerosis and in prediction clinical coronary events. aim: to determine the associations between plasma lipids and subclinical atherosclerosis measured by the common carotid intimamedia thickness (imt) in cad patients. methods: hdl subclasses were separated with - % pag electrophoresis, and imt was determined using high-resolution b-mode ultrasound in cad patients, with normal levels of traditional lipid risk factors. results: mean value of left and right carotid artery measurement was selected as value for correlation with hdl subclass size in each patient. the mean hdl size was . ae . nm, and the mean imt in all patients was . ae . mm ( . - . mm). hdl size was not correlated with imt (r = À . ; p > . ). by univariate analyses, carotid imt was the most closely related to systolic pressure (r = . , p < . ), followed by diastolic pressure (r = . , p < . ) and age (r = . , p < . ). stepwise multiple linear regression analysis revealed that diastolic pressure (β = . , p < . ), systolic pressure (β = . , p < . ) and age (β = . , p < . ) were independent predictors of determining carotid imt (adjusted r < . , p < . ). conclusion: these results indicate that diastolic pressure, systolic pressure and age are an important, independent determinants of carotid imt in cad patients. no other traditional risk factors imparted imt. objective: antinuclear antibodies (ana) are present in approximately - % of patients with non-alcoholic steatohepatitis (nash). a recent study implied the relationship between obesity and autoimmunity. the purpose of this study was to investigate the relationship between seropositivity for ana and metabolic abnormalities including insulin resistance, obesity and hepatic steatosis in patients with nash. methods: the severity of hepatic steatosis and fibrosis was scored by the nafld activity score system. seropositivity for ana was defined as titers of : or higher by an indirect immunofluorescence method using hep- cells. insulin resistance and obesity were evaluated by the value of homa-ir and bmi, respectively. the diagnosis of autoimmune hepatitis (aih) was based on the simplified scoring system. results: nine ( %) of patients with nash had ana. overall bmi in nash patients with ana was higher than that in those without ana. laboratory analyses revealed significantly higher mean igg level ( ae vs. ae mg/dl, p = . ) and the mean value of homa-ir ( . ae . vs. . ae . , p = . ) in nash patients with ana than those in those without ana. histological examinations exhibited that nash patients with ana had higher scores in hepatic steatosis ( . ae . , vs. . ae . , p = . ) and fibrosis ( . ae . vs. . ae . , p = . ) than those without ana. however, none of nash patients fulfilled the criteria for "definite" aih. conclusion: nash patients with ana had clinical characteristics of significantly higher serum igg levels and severe insulin resistance, and they tended to have more severe obesity, hepatic steatosis and fibrosis than nash patients without ana. r.f. alponti , , p.f. silveira pharmacology, instituto butantan, physiology, instituto de biociencias/universidade de sao paulo, sao paulo, brazil introduction: although irap (ec . . . ) is well-known, the existence of other aminopeptidases (aps) related to energy homeostasis remains unclear. objectives: to search a diverse array of aps in high (hdm) and low (ldm) density microsomes and in plasma membrane (mf) of retroperitoneal adipocytes from healthy control (c), monosodium glutamate (msg) obese and food deprived (fd) rats with their in vitro responses to insulin (is), vasopressin (avp), angiotensin (ang)-ii and ang-iv. methods: ultracentrifugation and spectrofluorometry. results: dipeptidyl-peptidase-iv (dppiv) and aps basic (apb), neutral puromycin-sensitive (psa) and -insensitive (apm), and methionyl (metap) were found. compared with non-stimulated, these aps were unaffected by is; avp increased apb/apm (ldm) and dppiv/psa (hdm) of msg-fd and metap/psa (hdm) of c; ang-ii increased apm (fm-ldm) of c, dppiv (fm) of msg and psa (fm) of fd; ang-iv increased apb (fm) of fd, apm (hdm) of msg and dppiv (fm) of c and msg. aps were modulated by avp in hdm-ldm, by ang-ii in fm-ldm and by ang-iv in fm-hdm. compared with ldm, metap decreased in fm of c and increased in fm of msg-fd without peptide stimuli; and only diabetes-related enzyme dppiv exhibited peptide-mediated intracellular translocation, which was from ldm to hdm (stimulated by avp) in msg-fd, and from ldm and hdm to fm in msg and msg-fd (stimulated by ang-ii) and in c and msg (stimulated by ang-iv). conclusion: novel peptide-modulated apb, apm, psa, metap and dppiv are found in adipocyte, this last with altered subcellular trafficking under metabolic distress. supported by fapesp, cnpq and capes. nutritional and environmental sciences, university of shizuoka, shizuoka city, japan previous studies have suggested that (-)-epigallocatechin- -gallate (egcg) exerts antioxidative and anti-inflammatory actions in various tissues, which might be beneficial for reducing risks of development of diabetes. however, an optimum intake level of egcg is unknown. in this study, we have examined the effect of a diet containing egcg on the expression of inflammation-related genes in various tissues including visceral adipose tissue and the muscle of non-obese type- diabetes animal model, goto-kakizaki (gk) rats. gk rats at weeks of age were fed a control high-fat diet ( energy% as fat) or the high-fat diet containing . %, . % or . % egcg for weeks. the mrna and protein levels of il- β, il- , mcp- , cd s, il- , tnf-a, resistin and pai- were significantly reduced in the adipose tissue of rats fed a diet containing . % egcg, but not in those fed diets containing . % or more egcg, as compared with control. the mrna levels of tnf-a, ifn-g, il- b, il- and il- in the muscle of rats fed a diet containing . % egcg were also significantly lower than those in the control. these results suggest that there is an optimum range of intake of egcg, which may suppress the expression of genes involved in inflammation in the adipose tissue and the muscle. diabetes and hypertension are the most relevant factors leading to vascular disease and cardiovascular problems. since both pathologies are greatly increasing nowadays, there is a need to detect at early stages the occurrence of target organ damage associated with them. this is the relevance of identifying biomarkers that can detect or predict the onset of cardiovascular and renal damage associated with diabetes and hypertension. given that the role of osteoprotegerin in bone metabolism is well known, and some evidence of its putative relationship with diabetes-associated pathologies has been found, to this date there is no evidence linking this molecule with target organ damage associated with diabetes. in this study, we analyze whether osteoprotegerin may be used to detect and evaluate cardiovascular and renal pathologies associated with diabetes in an in vivo model. we used normotensive and hypertensive rats, a subset of rats of each group receiving a single streptozotocin injection in order to induce diabetes. we performed an -month followup, periodically collecting blood and urine samples and monitoring both blood pressure and blood flow in the lower limbs. our results showed that osteoprotegerin was associated with the presence of diabetes, suggesting that it might be used as a biomarker for the occurrence of cardiovascular damage or to detect cardiovascular risk under these circumstances. blood flow in the lower limbs decreased soon after diabetes onset, as osteoprotegerin levels increased. our data suggest the potential use of serum levels of osteoprotegerin as a biomarker for diabetes and hypertension-associated endothelial dysfunction. purpose: this study examined whether breakfast meal composition alters the incretin response and glycemic control following both the breakfast and lunch meal. methods: seven subjects with t d completed two conditions where they consumed either a kcal high protein (pro: % carbohydrate, % protein, % fat) or high carbohydrate (cho: % cho, % protein, % fat) breakfast for days of acclimatization. on day , they underwent meal testing in which they consumed the respective breakfast followed by a lunch meal ( kcal: % cho, % pro, % fat). blood samples were collected over the -h period and analyzed for glucagon, insulin, glucagon-like peptide- (glp- ) and glucose-dependent insulinotropic polypeptide (gip) concentrations. incremental area under the curve (iauc) for the -h post-breakfast and -h post-lunch period was calculated. results: the iauc for insulin, glucose and glp- were not significantly different between conditions or between meals. the gip response to the pro breakfast ( ae pg/ml*min for -h) was lower (p = . ) compared to the cho breakfast ( ae pg/ ml*min for -h), with the opposite effect occurring in response to the lunch meal (pro: lunch ae ; cho: lunch ae pg/ ml*min for -h, p < . ). conclusion: despite no differences in glucose and insulin levels, a pro breakfast, compared to a cho breakfast, resulted in lower gip levels for the initial meal with a greater second meal effect after a lunch meal. however, a pro breakfast potentiates gip levels after a lunch meal. further research is needed to determine the physiological role of changes in circulating gip. high risk pregnancy, kasralainy university, cairo, egypt background: pregnancy tends to reset the glucose homeostasis in the direction of diabetes. about - % of all pregnant women develop an abnormal glucose tolerance in pregnancy, but most often glucose tolerance returns to normal postpartum. this condition is called gestational diabetes mellitus (gdm). aims: comparative study between gestational and pregestational diabetes in relation to glycemic control as regarding fetal and neonatal outcome. methods: this study was conducted in kasralainy maternity hospital from september to march and it included pregnant women complicated by dm attending outpatient clinic or inpatient. patients were classified into two groups, gestational diabetes: pregnant women complicated by dm which is diagnosed for the first time during pregnancy and pregestational diabetes: pregnant women who have dm that has been diagnosed prior to pregnancy. the two groups were compared according to fetal (macrosomia and intrauterine fetal death) and neonatal (respiratory distress syndrome and birth injuries) complications. all patients were - years old, singltone pregnancy, with time of termination after completed weeks. results: fetal macrosomia occurred more with gdm, on the otherhand birth injuries and rds occurred more with pre-gdm. macrosomia and rds were commoner among poor glycemic control in pregnant diabetic females than birth injuries and iufd. conclusions: glycemic control started as early as possible (the best being preconceptional) is important to decrease the incidence of birth injuries, macrosomia, fetal mortality, the need for nicu admission (rds). adiponectin, an adipocyte-derived hormone, is implicated in type diabetes and atherosclerosis. this study was designed to investigate whether serum adiponectin levels in coronary artery disease (cad) patients with type diabetes (t dm) are lower than in patients with cad alone and healthy controls. we measured serum adiponctin levels in subjects, patients with cad ( subjects of whom had both cad and t dm), and also healthy subjects were selected as controls. all patients were subjected to anthropometric indexes assessment and biochemical measurement of serum adiponectin, interleukin six (il- ), insulin, lipid profile and glucose by standard methods. the results revealed significant differences in serum adiponectin levels between cad patients with t dm and cad patients without t dm ( . ae . vs. . ae . lg/ml, p = . ), between patients with cad and healthy controls ( . ae . vs. . ae . lg/ml, p = . ), and between men and women ( . ae . vs. . ae . , p = . ). serum adiponectin levels were correlated significantly with insulin, total cholesterol, low density lipoprotein, body mass index, glucose, homa-ir, il- (r = À . , p = . , r = À . , p = . ; r = À . , p = . ; r = À . , p = . ; r = À . , p = . ; r = À . , p = . ; r = À . , p = . , respectively). adiponectin was correlated positively only with high density lipoprotein (r = . , p = . ). conclusions: we conclude that low serum adiponectin levels and insulin resistance coexist in cad patients with t dm. it is speculated that subjects who have very low levels of serum adiponectin may be at increased risk of developing both t dm and cad. objective: to simultaneously examine the impact of self-reported and newly-identified hypertension upon subsequent type diabetes (t d). methods: two community-based adult prospective cohort studies, with the same protocols, instruments and questionnaires, were conducted during - and - in urban areas of nanjing, china. data from these two cohorts were pooled and analyzed. t d (outcome variable) was identified using the world health organization diagnosis criteria. based on status of blood pressure (independent variable), participants were categorized into three groups: (i) people with normal blood pressure at baseline survey and during follow-up period (normal blood pressure), (ii) subjects with self-reported hypertension at baseline survey (self-reported hypertension) and (iii) those who did not report hypertension at baseline but were diagnosed having hypertension during follow-up period (newly-identified hypertension). all covariates were assessed at baseline and in the third-year follow-up survey. results: among participants, the -year cumulative incidence of t d was . %, . % and . % for participants with newly-identified hypertension, self-reported hypertension and normal blood pressure, respectively. after adjustment for potential confounders, compared to people with normal blood pressure, participants with newly-identified (or = . ; %ci = . , . ) or self-reported (or = . ; % ci = . , . ) hypertension were more likely to develop t d. furthermore, subjects with newly-identified hypertension (or = . ; % ci = . , . ) were at elevated risk of developing t d relative to their counterparts with self-reported hypertension. the similar associations of hypertension with t d were also found in both men and women, separately. hypertension, either self-reported or newly-identified, is an independent risk factor for developing t d among urban chinese adults. methods: a total of patients with type diabetes receiving standard glucose-lowering therapy were enrolled. efficacy of the lowcalorie diet ( kcal/day) with inclusion of specialized nutrison advanced diason product was assessed in two similar groups in during weeks: main group patients (n = ) received diet with nutrison advanced diason in the amount of ml as the only food for the day twice a week for weeks; control group patients (n = ) received a low-calorie diet with the inclusion of a standard meal at calories twice a week. results: the average weight loss in the main group was ae g, in the control group - ae g per day. according bioimpedance complex therapy with specialized product increased the content of lean mass by an average of . ae . kg and decreased fat mass by an average of . ae . kg. in main droup was a reduction of the basal level of glucose to . ae . - . ae . mmol/l (p = . ), in control groupfrom . ae . to . ae . mmol l (p = . ). total cholesterol level in the main group decreased from . ae . to . ae . mmol/l (p = . ), in the control groupfrom . ae . to . ae . mmol/l. the inclusion of the specialized product nutrison advanced diason in the standard low-calorie diet allows to raise the efficacy of dietary therapy in patients with type diabetes. liver injury and regeneration involve complicated processes and are affected by various physio-pathological factors. this study was designed to investigate the mechanisms of steatosis-associated liver injury and impaired regeneration in a mouse partial hepatectomy model. male c bl/ j and db/db mice were used as mice with normal and steatotic liver, respectively. liver regeneration and injury were evaluated chronologically after hepatectomy. initial regeneration of the steatotic liver was markedly impaired after hepatectomy. although hepatocyte proliferation was not significantly suppressed, intense liver injury with oxidative stress occurred immediately. fasl/fas expression was up-regulated in the steatotic liver, whereas the expression of anti-oxidative and anti-apoptotic molecules (catalase/mn-sod/ref- and bcl- /bcl-xl/flip, respectively) and p /sqstm , a steatosis-associated protein, were down-regulated. interestingly pro-survival akt was not activated/phosphorylated in response to hepatectomy though it was sufficiently expressed/ phosphorylated even before hepatectomy. suppression of p /sqstm increased fasl/fas-expression and reduced nrf- -dependent are activity and anti-oxidative responses in steatotic and non-steatotic hepatocytes. exogenously added fasl induced intense cellular oxidative stress and necrosis/apoptosis in steatotic hepatocytes, only the necrosis being inhibited by pretreatment with anti-oxidants, suggesting that fasl/fas-induced oxidative stress mainly leads to necrosis. furthermore, p /sqstm re-expression in the steatotic liver markedly reduced liver injury and improved tissue regeneration. in the steatotic liver, reduced expression of p /sqstm induced fasl/fas expression and suppressed anti-oxidant genes through nrf- inactivation, which together with hypo-responsiveness of akt, caused post-hepatectomy necrotic and apoptotic liver injury in redoxdependent and -independent manners, respectively. p /sqstm may be a key molecule in post-hepatectomy acute liver injury and impaired regeneration in fatty liver in mice. objective: mastication can accelerate satiety sensation and lipolysis through activation of histamine neurons; however, the data on antiobesity effects of mastication are limited. we therefore examined the effect of chewing on postprandial satiety and energy metabolism in humans. methods: satiety, energy expenditure, and fat oxidation were measured in lean young women on separate occasions, before and h after consumption of a solid meal with chewing per bite or after swallowing the same mashed meal without chewing, in a randomized, crossover design. each test meal consisting of kj ( % of energy as carbohydrate, % of energy as protein, and % of energy as fat) was consumed between and min regardless of texture difference. the thermic effect was greater after the solid meal ( . ae . %) than after the mashed meal ( . ae . %, p < . ). time course of fat oxidation tended to be higher after the solid meal than after the mashed meal (p = . ). in addition, solid meal was more satiating than mashed meal (p = . ). the results suggest that mastication contributes to postprandial satiety and thermic effect of meal. chewing meal thoroughly could be a useful eating behavior for preventing weight gain. introduction: raven noted an association between insulin resistance and cardiovascular consequences and type dm. mathew prescribed the method of insulin resistance designation using mathematic model homa-ir. aim: to estimate insulin resistance homa-ir in adult population according to gender, assess selected parameters in people with homa-ir ! . (i group) and homa-ir < . (ii group) and determine dependence between homa-ir and the above parameters. materials and methods: one hundred and fifty-four people medium age . years, from tarnawa city constituted the material. bp was examined. blood samples were obtained for plasma glycaemia, lipidogram and serum insulinaemia. all people were measured and weighed, bmi and homa ir were calculated, waist circumference was obtained. the cut-off point . for homa-ir was accepted. results: . % of the examined population had insulin resistance without a difference between women and men. significant differences between i and ii group were observed according to tg and waist circumference. in women all examined parameters were significantly different except hdl. in men bmi, waist circumference and hdl were significantly different in i and ii group. in the female group correlations between homa ir concerned all examined parameters, in the male group-hdl and waist circumference. conclusions: there was no significant difference between women and men according to insulin resistance in the whole study group. the difference between selected parameters in the two examinated groups were more strongly in women. body mass was the main factor determining insulin resistance in the whole study group as well as in men and women. background: the immune system is altered in obesity and diabetes, through changes in adipocytes, liver, pancreatic islets, vasculature and circulating leukocytes, with increased cytokine and leukocytes activation, suggesting inflammation participation in diabetes. minocycline presents a potent anti-inflammatory activity, as evaluated in vivo and in vitro. objectives: minocycline anti-diabetic effects were assessed in alloxaninduced diabetes through biochemical parameters measurements, histological and immunohistochemistry analyses. methods: alloxan was injected to rats, blood collected h later and after oral treatments ( , and days) for glycemia, triglycerides, cholesterol and transaminases measurements. diabetic controls and diabetic plus minocycline ( and mg/kg) or glibenclamide ( mg/ kg) were used. furthermore, pancreas, liver and kidney were submitted to histological and immunohistochemistry (cox- and tnf-a) analyses. results: decreases in glycemic and triglyceride levels, at the th and mainly th days after minocycline treatments, were observed. he staining showed that minocycline partly reversed tissue alterations, and decreased expressions of cox- and tnf-a, as compared to untreated animals. conclusions: beneficial minocycline effects in diabetes could be due to its anti-inflammatory and antioxidant properties and, by inhibiting microglial activation, it may be an important therapeutic strategy in diabetes where inflammation plays a significant role. methodology: forty-eight hours after alloxan-induced diabetes, blood from male wistar rats was collected for biochemical measurements. then, diabetic rats untreated or treated ( week, or months) with pentoxifylline ( , , and mg/kg, p.o.) or glibenclamide ( or mg/kg, p.o., alone or associated to pentoxifylline) were divided into eight groups with - animals each. after treatments, biochemical measurements were repeated. glycated hemoglobin determinations, and histological and immunohistochemistry analyses for inos were also performed. results: pentoxifylline brought hyperglycemia and triglycerides towards normality. glycated hemoglobin was improved. the use of diazoxide showed the mechanism of action of pentoxifylline partly related to atp-dependent k + channels. pentoxifylline improved histological alterations in pancreas, liver and kidney, and decreased inos cell expression. conclusions: pentoxifylline effects are probably related to its action on oxidative stress and inflammation, decreasing pro-inflammatory cytokines. thus, pentoxifylline is a potential candidate for diabetes mellitus therapy, since patients with vascular complications present beneficial effects, as shown in clinical practice. recently, a close relationship between the development of adiposity and gut-derived hormonal dysregulation has been clearly established. for instance, studies of gut-derived peptides such as pyy - , glp- , oxyntomodulin, discovered more than years ago and, later on ghrelin have significantly improved our understanding of mechanisms underlying ectopic lipid infiltration in organs and tissues. the etiology of non-alcoholic fatty liver disease (nafld) is intimately related to the capacity of hepatocytes to acquire an "adipocyte-like" phenotype. we previously reported that unacylated ghrelin (uag) is more potent than acylated ghrelin (ag) to stimulate adipogenesis. the present study intends to investigate the relevance of uag and ag as mediators of lipid accumulation in hepatocytes. hepg hepatocytes were treated with a control, uag or ag ( nmol/l and pmol/l) in the presence or absence of oleate ( nmol/l) to measure lipid droplet (ld) number and size. gene expression analyses were performed for key mediators of pre-adipocyte differentiation or liver functions. in response to uag or ag treatment in the presence or absence of oleate, ld number was markedly increased in hepg cells. similarly, increased ld size was noted following the treatment of hepg cells with uag or ag. however this effect could not be detected in the presence of oleate. gene expression of ppar-c and c/ebp-a was increased while that of ppar-a was decreased in response to ag treatment. these results are first to describe mechanisms through which uag and ag could promote the development of lipid infiltration in liver. deakin university, melbourne, vic., australia the world health organization believes that type diabetes mellitus is an important public health problem in the world. however some statistics showed that only . % of all world population had diabetes in , but the health professionals argue, this amount will reach to % in . diabetes australia -nsw estimates that almost million australians have diabetes and also around . million australian populations are at risk of this disease and unfortunately, the number of australian with diabetes will be approximately . millions in . obviously, direct and indirect medical costs due to health care of diabetic's patients are very high and % of the australian government's health budget is spent on health care of type diabetes. therefore, the health professionals have tried to provide the optimal public health programs for control and management of type diabetes. many researchers and health professionals argue that control of weight by change diet habits and exercise are major keys in lifestyle programs for prevention of type diabetes. in this case, the results of several studies like the finnish study, american study, the swedish malmo study and chinese study showed that the focus on diet and exercise programs are significant approaches in type diabetes prevention, while some other studies claim that the change diet habits and exercise may not sufficient and some medicines for control of insulin sensitivity and energy expenditure may also be necessary. therefore, lifestyle intervention programs and pharmacologic intervention programs are the major prevention programs. objectives: metabolic responses to acute endurance exercise may be affected by time of day because the nervous and endocrine systems have circadian rhythms clearly. the purpose of this study was to investigate the influence of acute endurance exercise in the morning and evening on metabolic responses in young men. methods: ten healthy young men completed two trials in a randomized cross-over design: . morning ( : - : ) and . evening ( : - : ) trials. in the morning and evening trials, participants walked for min at % of maximal oxygen uptake on a treadmill. pulmonary gas exchange was determined breath-by-breath by a gas analyzer. blood samples were collected to determine hormones and metabolites at preexercise, immediately and h after exercise. results: plasma interleukin- and adrenaline concentrations were significantly higher immediately after exercise in the evening trial than in the morning trial (p < . and p < . , respectively). serum growth hormone concentrations were significantly higher immediately after exercise in the evening trial than in the morning trial (p < . ). serum free fatty acids concentrations were significantly higher in the evening trial than in the morning trial at h after exercise (p < . ). however, there was no significant difference in fat oxidation between the morning and evening trials. conclusion: these findings suggest that acute endurance exercise in the evening is more effective on lipolysis compared to that in the morning in young men. nutrition, school of public health, university of sao paulo, sao paulo, brazil background: the rs snp of fto (t>a) has been associated with obesity and its comorbidities. in a allele carriers, physical activity (pa) minimizes the deleterious impact on body weight, which could reduce cardiovascular risk. objectives: to investigate whether pa level and television viewing modulate the effects of a allele of fto on adiposity and markers of inflammation in individuals at high cardiometabolic risk. methods: this cross-sectional study included prediabetic individuals ( women, . ae . years, bmi . ae . kg/m²). physical activities were measured by the long-version of ipaq; individuals were genotyped and stratified according to total pa (< or ! min/week) and television watching (< or ! h/week). anthropometric, biochemical and inflammatory data were obtained. subgroups of individuals with or without a allele were compared by student's t test. results: among individuals who watched tv < h/week, those carrying the a allele had significantly higher concentrations of total and ldl-cholesterol, apolipoprotein b ( . ae . vs. . ae . mg/dl) and interleukin- ( . ae . vs. . ae . pg/ ml), but did not differ regarding anthropometric measures. among those who watched tv ! h/week, no difference in any clinical data was detected comparing carriers and non-carriers of a allele. regarding pa, the presence of the variant allele did not influence the metabolic profile. the presence of the variant allele at fto gene seems to favor a deleterious metabolic and inflammatory profiles particularly for individuals less exposed to sedentary activities such as watching tv. for inactive individuals, the allele presence might not affect predisposition to adiposity-induced disturbances. cardiovascular disease is the leading cause of death in brazil and in the world and its development is directly related to lifestyles and habits acquired in childhood. the objective of this study was to evaluate the anthropometric data and blood pressure levels of schoolchildren to verify that the body mass index and waist circumference maintain a relationship with blood pressure. the descriptive study was conducted with schoolchildren of both sexes in schools of cruzeiro do oeste, a small town in southern of brazil. the evaluations consisted of: measurement of weight (w) and height (e) to calculate the body mass index (bmi), waist circumference (wc) and blood pressure (bp). associations between variables were determined using the chi-square test. we observed a high percentage of overweight, wc modified and high pressure measurements. both bmi and wc showed significant association with the high pressure measurements. there is an association between increased blood pressure and increasing age. increases in bmi and central adiposity are associated with higher risks of high pressure measurements, and consequently other chronic diseases in - years old children. this study, descriptive and cross-sectional, had as objective to evaluate the relationships between anthropometric measures and lifestyle habits with the lipid profile of brazilian schoolchildren (n = ). the variables obtained were: weight and height to calculate body mass index (bmi), waist circumference (wc), blood pressure (bp), physical activity and dietary habits, serum lipid profile and glycemia. the results were analyzed by the mann-whitney test, the chi-square test and a relative measure of effects odds ratio. the significance was set at % (p < . ). anthropometric variables showed . % of schoolchildren are overweight, . % showed elevated levels of total cholesterol. there was no significant association between nutritional status and lipid profile. this evidence suggests that an appropriate bmi is not indicative of the absence of changes in lipid profile components. the risk factors associated with the development of cardiovascular disease among the children evaluated were: absence of mean meals, lack of daily physical activity, physical activity < times a week, and the consumption of salty snacks more than four times a week. the physical activity was negatively associated with dyslipidemia, suggesting that physical activity may underlying mechanisms by which zinc and magnesium influence glucose metabolism involved oxidative stress and inflammation. this crosssectional study investigated whether intakes of zinc and magnesium are useful to indicate oxidative stress, inflammation and insulin resistance in individuals at cardiometabolic risk. two hundred and five individuals ( . ae . years) with pre-diabetes were evaluated regarding dietary ( -h food recalls) and clinical variables and compared according to zinc and magnesium intake tertiles by anova. multiple linear regression analysis was employed including adjustments for age, gender and bmi (model ), and saturated fat acid intake, smoking status and physical activity (model ). stratified according to tertiles of magnesium intake, no significant differences in anthropometric, plasma glucose, lipid variables, superoxide dismutase (sod), oxidized ldl, inflammatory markers and homa-ir were found. mean values of fat mass ( . ae . . ae . . ae . %) and homa-ir ( . ae . . ae . . ae . ) were significantly lower in the highest tertile of zinc intake; significant trends to decrease fat mass, homa-ir and c-reactive protein were also observed (p-trend < . ). in linear regression models, intakes of both micronutrients were inversely associated with homa-ir but not with inflammatory markers. direct associations were found between magnesium intake and sod concentrations in adjusted models. our findings suggest that assessment of zinc and magnesium intakes may indicate oxidative stress, inflammatory status and insulin resistance in at risk individuals. our design does not allow establishing cause-effect relationship. longitudinal studies are needed to clarify if increased consumption of these micronutrients would ameliorate these pathophysiological processes. a. cezaretto, b. almeida-pititto, c.r. barros, a. siqueira-catania, s.r.g. ferreira nutrition, school of public health/university of sao paulo, sao paulo, brazil introduction: lifestyle changes remain a major challenge for reducing cardiometabolic risk. psychological disorders coexist with risk factors such as unhealthy life habits, decreasing quality of life (qol) and favoring dropouts during interventions. objectives: to compare clinical and psychological characteristics of individuals who dropped or not from lifestyle interventions, traditional or interdisciplinary. methods: one hundred and eighty-three prediabetic individuals ( . ae . years; bmi . ae . kg/m²) were allocated to month interventions on diet, physical activity and stress management. traditional intervention was based on quarterly medical visits, while participants of interdisciplinary intervention also had psychoeducative group sessions. depressive symptoms were assessed by the beck depression inventory (score ! ) and qol by the sf- . independent t-test was used to compare dropouts and non-dropouts. results: body adiposity, blood pressure, fasting glycemia, lipids, depression and qol improved in both interventions, but, in general, improvements were greater in the interdisciplinary intervention. comparing baseline data of dropouts and non-dropouts at the th month, dropouts of traditional intervention had higher bmi ( . vs. . ; p = . ), depression score ( . vs. . ; p = . ) and lower qol ( . vs. . ; p = . ) than non-dropouts. however, no difference between individuals who dropped or not was found in the interdisciplinary intervention. conclusion: interdisciplinary approach may be more effective to improve clinical features and qol. in addition, this intervention avoids dropout of individuals with worse risk profile concerning adiposity, depression and qol when compared with those having only medical visits. interdisciplinary approach may favor the retention of a subset of individuals at higher risk, which may result in long-term cardiovascular protection. aims: consumption of high fat diet (hfd) leads to accumulation of intramuscular bioactive lipids: long-chain acyl-coa (lcacoa), diacylglycerols (dag) and ceramides (cer) which are implicated in induction of muscle insulin resistance. the aim of this study was to elucidate the role of hfd, myriocin (an inhibitor of ceramide de novo synthesis) and metformin on skeletal muscle lcacoa, dag, cer and acyl-carnitine content and their impact on proteins of insulin pathway. the experiments were performed on male wistar rats: -fed standard rodent chow (control), -fed hfd, -fed hfd treated with myriocin, (hfd/myr) and -fed hfd treated with myriocin and metformin (hfd/myr/met). muscle bioactive lipids were analyzed by lc/ms/ms and plasma glucose and insulin concentration by standard assays. content and phosphorylation of akt and glycogen synthase (gs) was measured by western blot. results: compared to control, all measured lipids were elevated in hfd group. these changes were accompanied by decreased phosphorylation of akt and gs and impaired glucose disposal. myriocin caused a decrease in cer but an increase in the other lipids content as compared to hfd. introducing metformin to hfd/myr group attenuated levels of lipid metabolites known to interfere with insulin signaling (cer, dag, lcacoa) and increased acyl-carnitine content as compared to hfd/myr. in hfd/myr and hfd/myr/met groups insulin-sensitizing effects were accompanied by enhanced akt and gs phosphorylation when compared to hfd. conclusions: simultaneous treatment with myriocin and metformin redistributes fatty acids to β-oxidation which attenuates muscular content of bioactive lipids and improves glucose tolerance by promoting akt phosphorylation. pro-inflammatory state leading to abnormal production of hormones like leptin and adiponectin. the present study was designed to explore endocrine dysfunction of adipose tissue in metabolic syndrome. the study included subjects; metabolic syndrome cases as defined by international diabetes federation and age and sex matched controls. the blood samples were collected for estimation of serum triglycerides, hdl-c, insulin, leptin, adiponectin and fasting plasma glucose. leptin and adiponectin were estimated by elisa and insulin by electrochemiluminescence immunoassay. other biochemical parameters were estimated on clinical chemistry analyzer by standard methods. homa-ir as an index of insulin resistance was calculated from fasting plasma glucose and serum insulin levels. results: serum leptin level was significantly higher in metabolic syndrome patients ( . ae . ng/ml) in comparison to control group ( . ae . ng/ml). serum adiponectin was significantly lower in metabolic syndrome patients ( . ae . lg/ml) in comparison to control group ( . ae . lg/ml) levels. significant difference of homa-ir was between metabolic syndrome cases and controls (p < . ). conclusions: it is concluded that altered endocrine functions of adipocytes are associated with metabolic syndrome and leptin and adiponectin has potential to be incorporated as components of diagnostic criteria of metabolic syndrome. aim: to devise noninvasive method to diagnose nafld. methods: one hundred and eight patients were examined: biochemical blood analysis, endotoxin and nitric oxide in blood, shortchain fat acids (sfa) in faeces, biopsy of liver. patients have been divided into two groups depending on activity of hepatitis: . steatosis; . steatohepatitis, and into three groups according to the therapy: . statin; . probiotic; results: we didn′t revealed direct correlation between biochemical parameters of liver function and heaviness of morphological changes in liver. however patients with steatohepatitis had increased level of endotoxin ( . ae . ) and nitric oxide ( . ae . ) in blood. total quantity of sfa in faeces was also decreased in those patients. there was more effective decrease of lipids, endotoxin and nitric oxide in those patients, who received probiotic in combination with statin. if patient received only probiotic there was not any changes of lipids, but the level of endotoxin and nitric oxide became lower. if nafld progressed in steatohepatitis and there was high level of c-gtp and transaminases we didn′n notice such effective decrease of cholesterol. . the increase level of endotoxin and nitric oxide in blood is the marker of steatohepatitis. . application of statin in combination with probiotic is more effective in achievement of target levels of lipids and decreasing endotoxin and nitric oxide. . if patient has steatohepatitis, effectiveness in the hypolipidemic therapy decreases (in comparison with steatosis), because the metabolism of drugs in liver decrease. methods: one hundred and eight patients with nafld were examined: biochemical blood analysis, endotoxin and no in blood, shortchain fat acids (sfa) in faeces, biopsy of liver (index of steatosis (is) and index of histological activity (iha)). patients have been divided into two groups: . steatosis; . steatohepatitis. results: total quantity of sfa in faeces was decreased in all patients, but there wasn′t difference between i and ii groups. all patients with had increased level of endotoxin ( . ae . ) and nitric oxide ( . ae . ). there was correlation between alt and ggtp with endotoxin and no (ast/endotoxin r = . ; ggtp/endotoxin r = . ; ast/no r = . ; ggtp/no r = . ; p < . ). the biopsy of liver showed all signs of nafld including changes of tiny bilious ductules. we didn′t revealed direct correlation between biochemical parameters of liver function and heaviness of morphological changes in liver (appearance of morphological attributes of steatohepatitis precedes development of cytolytic and cholestatic syndrome). however there was reliable direct correlation between endotoxin and no with histological parameters of nafld (is and iha): is/endotoxin r = . ; iha/endotoxin r = . ; is/no r = . ; iha/no r = . ; p < . . . endotoxin and no may be used in diagnosing of nafld. . increase of level of endotoxin and no in blood in patients with nafld is associated with progression of inflammation in liver. thereby blood analysis for endotoxin and no can be used in diagnosing of nafld progression. . we also can judge about effectiveness of treatment of nafld by the level of endotoxin and no in blood. of this study was to analyze incidence obesity and insulin resistance in patients with fatty liver. the study involved patients with diagnosis non alcoholic fatty liver at the clinical centre pristina. there were analyzed demographic and anthropometric characteristics of the examined patients. of clinical characteristics, there were determined smoking habit, arterial pressure. routine biochemical analyses were carried out by a standard laboratory procedure. homa-ir was used to evaluate insulin resistance. results: in the study group, fatty liver was demonstrated by ultrasound in ( . %) subjects and in the control group there were respondents ( . %) without pathological findings of ultrasound and with the level of p < . . the values of bmi ( . ae . kg/m vs.; p < . ), waist circumference ( . ae . vs. . ae . cm; p < . ) and glucose ( . ae . vs. . ae . mmol/l; p < . ), level of insulin ( . vs. . mu/i; p < . ) and homa-ir ( . vs. . ; p < . ) were significantly higher. conclusions: these results confirm that obesity and insulin resistance are associated with fatty liver infiltration. background and aim: this study was designed to determine the impairment of the skin structure in experimentally-induced diabetes with injection of streptozotocin (stz). material and methods: experimental groups consisted of controls (group , n = ) and diabetes groups (group , n = ). dorsal skin was removed for routine histological tissue procedures. hematoxylene and eosin (he), masson's trichrome and periodic acid schiff (pas) stainings, immunohistochemical connexin (cx ) and type iv collagen stainings were applied. morphometry of epidermal thickness were also determined. results: group revealed decrease in epidermal thickness with disintegration of epithelium and decrease of dermal collagen fibers. stratum spinosum were morphologically abnormal for group . measurements of epidermal thickness revealed statistically significant decrease (p . ). pas staining for group revealed disruption of the basement membrane. epithelial scar formation, deterioration of transformation in the polyhedral cells, degradation of epidermis and decrease in pas staining for vascular structures were observed, whereas the reticular dermis and hair follicles were normal. collagen fiber density in group were found to be prominently decreased in dermis with masson's trichrome staining. evident decrease in immunostaining of cx and type iv collagen were also shown in diabetic group in comparison to the controls. conclusion: diabetes not only induced impairment of the epidermal integrity and deterioration in the epidermis via loss of gap junctions (the most prominent cellular junctional complex), but also caused dramatically negative impact on the dermal collagen content, and integrity of the basement membrane. background and aims: obesity, a major obstacle in the improvement of human health, is associated with an increased risk of development of numerous diseases. on the other hand, plant metabolites showed various bioactivities on affecting food intake, lipase activity, energy expenditure and lipid metabolism that may have potential on preventing body weight gain. therefore, this study aims to discover a new metabolite with anti-obesity efficiency. brief methods: adipocyte differentiation was induced by dexamethasone, -iso-butyl- -methylxanthine and insulin in t -l preadipocyte. in vivo, male c bl/ mice were fed a normal diet (nd), high-fat diet (hfd), a lucidone-supplemented hfd in lower dosage of mg/kg of diet (lsh/l) or in higher dosage of mg/ kg of diet (lsh/h) for weeks. record the changes of body weight and food consumptions. physiological parameters in plasma were determined after sacrificed. epididymal and perirenal adipose tissues were collected for further histological analysis. results: lucidone at mmol/l suppressed adipogenesis in t -l cells by reducing transcription levels of adipogenic genes, including pparg, c/ebpa, lxr-a, lpl, ap , glut and adiponectin. lsh/ h mice showed lowered body and liver weights, decreased food efficiency, and lowered plasma cholesterol, triglyceride, glucose, and insulin levels. dissection of adipose tissue from lucidone-fed mice showed reductions in the average fat-cell size and percentage of large adipocytes. conclusion: these results provided evidence that dietary intake of lucidone alleviates high fat diet-induced obesity in c bl/ mice and reveals the potential of lucidone as a nutraceutical on preventing obesity and consequent metabolic disorders under unhealthy eating habits. introduction and aim: obesity and type diabetes (t d) are accompanied by intramyocellular lipid accumulation which might lead to mitochondrial dysfunction and insulin resistance. our aim was to compare changes in peripheral insulin sensitivity and mitochondrial respiration after a diet-and subsequently a gastric bypass induced weight loss in obese patients with or without t d. materials and methods: sixteen subjects ( m/ f; with (t dm) and (ob) without t d) reported thrice to the lab after an overnight fast: prior to weight loss (a), mo later just prior to operation (b) and mo after operation (c). at each visit tree tests were performed: day : dexa scan for body composition and stationary graded bicycle test for vo max. day : hyperinsulinaemic euglycemic clamp for peripheral insulin sensitivity. prior to the clamp a vastus lateralis muscle biopsy for high resolution respirometry was obtained. respiration protocol is shown in fig. . results: anthropometric, body composition and vo max data are shown in fig. . insulin sensitivity (gir ffm ) and maximally coupled respiration (gmso ) data are shown in fig. . conclusion: in spite of a marked difference in insulin sensitivity, maximally coupled mitochondrial respiration was similar in the two groups. moreover, with marked improvements in t dm insulin sensitivity, due to the massive weight loss, mitochondrial respiration remained unchanged. these results speak against an association of mitochondrial respiratory capacity and insulin resistance in skeletal muscle in obese and t d patients. introduction: increased circulating levels of resistin was proposed as a possible link between obesity and insulin resistance. we investigated if increased resistin expression in adipose tissue affected age-related changes in insulin resistance of peripheral tissues, including brown adipose tissue (bat), and oxidative stress parameters in the spontaneously hypertensive rats (shr). methods: sixteen months old male shrs expressing the mouse resistin gene under control of adipose tissue specific ap promoter (shr-tg) and age matched non-transgenic shrs were used. results: transgenic expression of resistin was associated with impaired glucose tolerance measured during ogtt (auc ae vs. ae mmol/l/ h, p < . ); elevated serum insulin ( . ae . vs. . ae . nmol/l, p < . ) and triacylglycerols ( . ae . vs. . ae . mmol/l, p < . ) levels. shr-tg exhibited lower insulin sensitivity measured as insulin stimulated incorporation of c-glucose into lipids in epididymal adipose tissue ( ae vs. ae nmol gl./g/ h, p < . ) and into skeletal muscle glycogen (p < . ). glucose oxidation in soleus muscle (p < . ), and bat (p < . ) were reduced. shr-tg displayed decreased c-palmitate oxidation to co in bat ( . ae . vs. . ae . nmol/g/ hod, p < . ). in adipose tissue of shr-tg rats was increased concentration of lipid peroxidation products (conjugated dienes and tbars), reduced activity of antioxidant enzymes: superoxide dismutase ( . ae . vs. . ae . u/ mg protein, p < . ) and glutathione peroxidase ( ae vs. ae lmol nadph/min/mg protein, p < . ). conclusion: chronic transgenic expression of resistin gene might contribute to insulin resistance and associated metabolic disorders suggesting possible involvement of reduced bat metabolic activity in age-induced prodibetogenic effect of resistin. examination of patients with type diabetes mellitus (t dm) revealed patients ( . %) with non-alcoholic fatty liver disease (nafld). nafld met more often in the patients with obesity ( . %) and overweight ( . %) and only in . % patients with normal body weight. all the patients had abdominal type of adipose tissue distribution regardless of body weight. in patients with t dm and normal body weight the nafld met more often in women, and in overweight and obesity in men. in the examined patients with t dm and nafld complaints peculiar to dyspepsia and asthenovegetative syndrome prevailed. the average level of hba c corresponded the state of subcompensated carbohydrate exchange ( . %). these patients had marked dyslipidemia with predominance of ii and iib types of hyperlipidemia. cytolytic, cholestatic, mesenchymal-inflammatory syndromes were marked out as well as syndrome of hepatic-cellular insufficiency. increased level of immunoreactive insulin iri ( . ae . ) mu/ml and index of homa ir ( . ae . ) mu/ml testified the presence of expressed insulin resistance in the patients with t dm and nafld. the patients revealed the increase of free fatty acids level ( . ae . ) mmol/l/ml, that meaningfully differed from such indexes in the control group (p < . ) and low level of adiponektin ( . ae . ) mg/ml that confirms their role in development of nafld even for persons with normal body weight after the presence of abdominal type of adipose tissue distribution. study object: diene (dc), triene (tc), oxydien (odc), tetraen (trc) conjugates, malondialdehyde (mda), aspartate aminotransferase (ast), alanine aminotransferase (alt). the study involved patients with type diabetes mellitus and non-alcoholic fatty liver disease (nafld) - men and women among them and diabetes women without nafld. all subjects are representative on age and diabetes duration. correlation analysis has been conducted with the calculation of spierman rank correlation coefficient. study results: the increase of tc and odc levels has been marked in type diabetes men with nafld vs. women -( . ae . ); ( . ae . ) and ( . ae . ); ( . ae . ), respectively, p < . , as well as ast and alt levels -( . ae . ); ( . ae . ) and ( . ae . ); ( . ae . ), respectively, p < . , p < . . the positive correlation of ast, alt with odc and trc has been found among type diabetes women with nafld (r = . , r = . , p < . ) and (r = . , r = . , p < . ) unlike women without nafld -(r = À . ) between ast and trc and (r = . ) between alt and trc. ast, alt are in positive correlation with ct in men (r = . , r = . , p < . ). in type diabetes men with nafld the oxidative stress displays are more clearly seen. it is expressed in increasing of tc and odc combined with ast and alt hyperactivity. trc levels are increased in women group with ast and alt increasing vs. type diabetes women without nafld. the above mentioned can serve as a diagnostic marker of nafld in type diabetes women. i. kara, b. bonardo, f. peiretti umr , inserm, marseille, france gamma secretase and the triggered notch signalling are involved in the regulation of the differentiation/proliferation equilibrium of progenitor cells. gamma secretase consists of four subunits: presenilin or , nicastrin, pen- and aph (stoichiometry : : : ). in humans, there are two aph proteins (aph a and aph b). in rodents there is an additional protein, aph c issued from a duplication of the aph b gene. it has been reported that inhibition of c-secretase improves insulin resistance and stimulates adipogenesis. these data led us to study the impact of obesity in the regulation of the c-secretase composition. expression of c-secretase subunits was measured by quantitative pcr (tissues and cells) and western blot (cells). the expression of aph b is significantly increased in the adipose tissue of obese mice whereas the expression of the other subunits of the c-secretase is not altered. the increased expression of aph b is not observed in muscles and liver of obese mice. the expression of aph b is also increased in visceral adipose tissue of human obese subjects. in addition, the expression of aph b/c increases during adipocyte differentiation of t l cells. in conclusion, the c-secretase composition is specifically altered in hypertrophied adipocytes. this result provides the first evidence of a pathophysiological regulation of aph b/c expression. an approach to knockdown adipocyte expression of aph b/c is in progress. the analysis of the consequences of this manipulation on csecretase activity, notch signalling and the biology of the adipocyte will help assess the importance of the alteration of c-secretase composition during adipocyte differentiation. background and aim: certain legumes and barley kernels may favorably modify metabolic risk parameters in semi-acute studies in healthy subjects. this investigation assessed the medium-term effect of a diet combining specific legume and whole grain barley products on markers associated with the metabolic syndrome (mets) in mature women. design and methods: randomized crossover intervention in women ( - years-old, bmi - , normal fasting glycemia), comparing a diet rich in kernel-based barley products, brown beans and chickpeas (d ) with a control diet (d ) of similar macronutrient composition but lacking legumes and barley. d included g (as eaten)/day legumes, g whole grain barley kernels and g barley kernel bread. both diets followed the nordic nutrition recommendations and provided similar amounts of dietary fiber ( . g/day, d ; . g/ day, d ), with wheat-based products as main fiber supplier in d . each diet was consumed for week under weight-maintenance conditions. blood lipids, glucose, insulin, crp, gamma-glutamyl transferase (ggt) and blood pressure were the measured outcomes. results: both diets decreased serum cholesterol fractions, but d had greater effect (p < . ) on total and ldl-cholesterol (changes from baseline: À % and À %, respectively) than d . d also reduced ggt (À %, p < . ), diastolic blood pressure (À %, p < . ) and the framingham cardiovascular risk estimate (À %, p < . ), while d had no effect. methods: group i (n = )women with ms were examined proinflammatory cytokines polymorphisms, group ii (n = )testing for hereditary and acquired forms of thrombophilia. all subjects had the fetal loss syndrome, fetoplacental insufficiency, severe preeclampsia in previous pregnancies. results: group ipolymorphisms il- β - t/c in . %, il- - g/c-in . %, tumor necrosis factor-a - g/ain . % of cases. in ii group the multigenic defects were verified in % of cases; the feature of multigenic defects is that the g/ g polymorphism of plasminogen activator inhibitor- (pai- ) gene was found in . % of cases, the g/ g phenotype of the gene pai- was verified in . % of cases. the polymorphism in the tissue-type plasminogen activator i/d gene, in the angiotensin-converting enzyme i/d gene, in the fibrinogen g/a gene were found in . %, . %, . % respectively. acquired antiphospholipid antibodies were verified in . % of cases. all women received antithrombotic therapy from the fertile cycle involved low molecular-weight heparin (enoxaparin sodium, daily dose . - . ml), vitamins b, folic acid. pregnancy was achieved in %. there were not recurrent fetal loss, severe pre-eclampsia, placental abruption in the study groups. live births was in all cases. conclusions: we suggest that proinflammatory and thrombophilic status is an important pathogenetic factor of recurrent fetal loss, severe pre-eclampsia and other obstetric complications in women with ms. timely antithrombotic prophylaxis may be a key of successful outcome of pregnancy. the prescription of an individualized rehabilitation program based on the crossover point of substrate utilization (cop) could be particularly relevant in patients with metabolic syndrome (ms). the aim of the study was to examine: . the effects of a week rehabilitation program at an intensity corresponding to cop on the anthropometric characteristics of women with ms, and . these effects after a month follow-up period without supervision. nineteen women with ms ( . ae . years; . ae . kg; bmi = . ae ) performed an indirect calorimetry test to determine their cop and then participated in a supervised rehabilitation program ( min/week at cop on cycle-ergometer over weeks). afterward, they were instructed to continue to practice a physical activity without supervision over months. the target exercise intensity at cop was . ae . % maximal aerobic power. mass, body mass index, waist and hip circumferences, waist-hip ratio, relative fat mass and fat-free mass were significantly decreased whereas energy balance was significantly increased after the rehabilitation program. there were no significant differences at the end vs. months after the rehabilitation program. two months after the rehabilitation program, only both circumferences, waist-hip ratio and energy balance were not significantly different from baseline values. an individualized rehabilitation program over weeks at cop allowed to improve the anthropometric characteristics in women with ms. however, although the energy balance remains unchanged during the month follow-up period, only the effects on circumferences are maintained months after the rehabilitation program. objective: hypoxia contributes to adipose tissue inflammation and fibrotic remodeling in obesity. we have recently shown that longchain n- polyunsaturated fatty acids (pufa) ameliorate adipose tissue inflammation in obese subjects. here we investigated, whether long-chain n- pufa also reduce adipose tissue hypoxia and may prevent adipose tissue remodeling. patients and methods: in a randomized controlled clinical trial we treated severely obese subjects (bmi > kg/m ) with either . g/ day highly purified long-chain n- pufa or control for weeks. at the end of the treatment we sampled visceral and subcutaneous adipose tissue (vat and sat) during elective bariatric surgery. we quantified gene expression of hypoxia and fibrosis markers in tissue specimen by real-time quantitative rt-pcr. statistical analyses were performed by one-way anova. results: adipose tissue gene expression of hif a correlated positively with cd expression, a m macrophage marker and expression of both genes was significantly reduced after n- pufa treatment in sat (p < . ). furthermore, hif a expression correlated negatively with the anti-inflammatory fatty acid index in the treatment group. n- pufa significantly downregulated the pro-fibrotic markers tgfb, mmp and col a in sat. conclusions: mitigation of adipose tissue inflammation by n- pufa is paralleled by the amelioration of hypoxia and prevention of tissue remodeling as estimated by marker gene expression. these data emphasize beneficial effects of high-dose n- pufa in obesity. biochemistry, university of medicine and pharmacy "carol davila", faculty of medicine, university "titu maiorescu", delta hospital, nidnmd "n.c. paulescu," bucharest, romania background and aim: the diabetes "epidemic" nowadays appeared at the same time with the obesity "epidemic", their relationship being a causal one. weight gain cannot be conceived without a good sensitivity to insulin. all three paraoxonases have antioxidant properties. these protect vascular tissues from oxidative damage by modulating the effects of the main actors in the atherosclerotic process, namely the hdl and ldl particles and the macrophage. in this study we aimed to investigate the role of paraoxoanse (pon ) in the relationship between obesity and type diabetes. materials and methods: ten obese patients with type diabetes mellitus were compared with non-diabetic obese subjects. we determined the pon in preadipocytes cells obtained from bariatric interventions and in differentiated adipocytes (day , , , , ) . elisa method was used for leptin and adiponectin measurements. results: the obesity antropometric markers (waist and hip circumference, visceral fat index) were positively correlated with the value for leptin and negatively with the value for adiponectin (p < . ). the intracellular pon tented to be lower with the degree of diferentiation and these was associated with adipokines changes both in serum and cell lysates. conclusion: resuming our data, we presume that pon is present in pre/adipocytes and could be implicated in prevention of type diabetes obesity associated complications. acknowledgements: this work was supported by a grant of the romanian national authority for scientific research, cncs-uefiscdi, project numer pn-ii-id-pce- - - ". dr. lixandru was supported by the postdoctoral program posdru/ / . /s/ , from european social fund. . the effects of a week individualized rehabilitation program (irp) coached at an intensity corresponding to the crossover point of substrate utilization (cop) on hqrol, peak of oxygen uptake (vo peak ) and power out peak (p peak ); . the effects on hqrol after a month follow-up period without coach. nineteen women with metsyn ( . ae . years; . ae . kg) performed a test to exhaustion to estimate the vo peak and p peak , and an indirect calorimetry test to determine their cop used during a irp ( min/week) on cycle-ergometer over weeks. afterward, they were instructed to continue their physical activity without coach over months. vo peak and p peak were increased after the irp (p < . ). hrqol were no different in every domain at the end and months after the irp. only the question about their change of health compared to year ago has improved but it was at the verge of significativity (p = . ). women with metsyn undergoing irp coached at cop improved vo peak and p peak, but showed no improvement in hrqol after a week coached irp nor after the month follow-up period without coach. consequently, physical fitness seems not be associated with self-perceived quality of life in women with metsyn. t.b. domagala , k. kotula-horowitz , r. januszek , m. janczura , j. zagajewski , j. musial micronized fenofibrate ( mg/day) for months. fifty cardiovascular risk male volunteers (mean age years) with no prior myocardial infarction or stroke were enrolled as the controls. brachial fmd and homocysteine levels were measured at baseline and after months. the respective groups also differed in: bmi (p < . ), plasma total (p = . ), hdl cholesterol (p = . ) and triglycerides (p = . ), but not in baseline plasma homocysteine levels ( . ae . vs. . ae . lmol/l; p = ns). at baseline, mean brachial fmd were lower in the subjects with metabolic syndrome ( . ae . % vs. . ae . %; p < . ). in those subjects fenofibrate therapy significantly improved fmd ( . ae . % vs. . ae . %; p < . ) and increased plasma homocysteine levels ( . ae . vs. . ae . lmol/l; p < . ). no such differences were noted in the controls, neither before nor after months. conclusions: fenofibrates improve endothelium-dependent fmd of the brachial artery, irrespective of the simultaneously induced hiperhomocysteinemia. a. picu , l. petcu , d. lixandru , i. stoian , c. cristescu , e. rusu , c. ionescu-tirgoviste nidnmd "n.c. paulescu", biochemistry, university of medicine and pharmacy "carol davila", "titu maiorescu" university, bucharest, romania background and aims: oxidative stress leading to macrophage foam cell formation is the hallmark of the early atherosclerotic lesion. the aim of these study was to assess the relationship between clinical, biochemical and oxidative stress risk factors with obesity in newly diagnosed type diabetes (n-dm). materials and methods: one hundred and forty-five patients with n-dm registered in the nidnmd ambulatory, "n.c.paulescu" and healthy volunteers were included. the n-dm patients were divided into two subgroups according to the bmi (body mass index): group overweight (bmi = . - . kg/m²) and group -obese (bmi ! kg/m²). in circulating monocytes, the ability to produce free radicals vs. their neutralizing capacity was determined by measuring nadph oxidase activity (respiratory burst; rb) and intracellular activity of pon . we also determined the serum leptin and adiponectine by elisa, total antioxidant capacity (teac) and the concentration of non-protein thiols (shneproteic) by spectrophotometric methods. results: in diabetic patients vs. normal subjects, leptin, proinsulin and rb were increased (p < . ), while adiponectin and pon decreased (p < . ). the differences were accentuated in the obese group. the strongest correlation was between proinsulin and leptin (r = . , p < . ) and both contribute for the high cardiovascular risk in type diabetes. our results showed imbalance pro/antioxidant of obese diabetic patients, low pon activity and increased rb being influenced by the degree of obesity. introduction: cardio-protective role of human hdl-associated serum paraoxonase (pon ) is believed to be due, at least partly, to its antioxidative properties. pon activity is genetically determined by major polymorphism q r. brachial flow-mediated dilation (fmd) is a non-invasive physiological measurement used to quantify endothelial dysfunction. fibrates are known to exert hypolipidemic effects, while their effect on pon activity remains unclear. aim: to assess pon activity and fmd in the subjects with metabolic syndrome on fenofibrate treatment. methods: forty male subjects (mean age years) with hipertriglicerydemia, as well as metabolic syndrome, were treated with micronized fenofibrate ( mg/day) for months. pon activity in serum and brachial fmd were measured at baseline and after months. pon q r polymorphism was determined by pcr amplification and restricted digestion; serum pon activity was assayed spectrophotometrically. results there were subjects with qq genotype (group a) and carriers of r allele (group b). at baseline both groups differed in pon activity only ( ae vs. ae u/l; p < . ). fenofibrate treatment reduced pon activity in all subjects, nonetheless significantly in those with qq genotype ( ae vs. ae u/l; p = . ), unlike in the r allele carriers (p = ns). at baseline mean brachial fmd did not differ between groups a and b. fenofibrate therapy significantly improved fmd ( . ae . % vs. . ae . %; p = . ) in group a subjects, unlike group b ( . ae . % vs. . ae . %; p = ns). this study was to investigate the effect of nicotine on insulin sensitivity and explore the underlying mechanisms. treatment of sprague-dawley rats with nicotine ( mg/kg/day) for weeks significantly reduced blood insulin level but had no effect on blood glucose level. both insulin tolerance test and glucose tolerance test demonstrated that nicotine treatment enhanced insulin sensitivity. pretreatment of rats with hexamethonium ( mg/kg/day) to antagonize peripheral nicotinic receptors except for a nicotinic acetylcholine receptor (a -nachr) had no effect on the insulin sensitizing effect of nicotine. however, the insulin sensitizing effect of nicotine was totally abrogated in a -nachr knockout mice, indicating the involvement of a -nachr. further, chronic treatment with pnu- ( . mg/kg/day), a selective a -nachr agonist, significantly enhanced insulin sensitivity not only in normal mice but also in amp-activated kinase-a knockout mice, an animal model of insulin resistance with no sign of inflammation. moreover, pnu- treatment enhanced phosphorylation of signal transducer and activator of transcription (stat ), a molecule involved in regulating insulin signaling, in skeletal muscle, adipose tissue and liver in normal mice. pnu- treatment also improved glucose uptake in c c myotubes and this effect was totally abrogated by stat inhibitor, s i- . all together, these findings indicate that nicotine enhances insulin sensitivity in animals with or without insulin resistance, at least in part via stimulation of a -nachr-stat pathway independent of inflammation. our results not only contribute to the understanding of the pharmacological effects of nicotine, but also identify new therapeutic targets against insulin resistance and type diabetes. calorie restriction (cr) is one of the most reproducible treatments for weight loss and slowing aging. however, how cr induces these alterations is still unclear. this study was designed to understand whether nicotinamide phosphoribosyltransferase (nampt, also known as visfatin) plays a role in the beneficial effects induced by cr using a specific chemical inhibitor of nampt (fk ). sprague-dawley rats were treated for weeks in four groups: ad libitum (al), cr, al + fk and cr + fk groups. al and al + fk animals were allowed unlimited access to standard chow, while the cr and cr + fk animals were restricted to % of the food intake consumed by al and al + fk animals. fk ( mg/kg/ day) was given via drinking water. we found cr upregulated nampt mrna and protein levels in rat skeletal muscle and white adipose tissue. inhibition of nampt did not affect the sirt upregulation by cr but suppressed the cr-induced sirt activity and deacetylation of foxo- . furthermore, inhibition of nampt not only weakened the cr-induced decrease of oxidative stress (ros, superoxide o À˙a nd mda levels), but also greatly abolished the crinduced improvements of anti-oxidative activity (total-sod, gsh and gsh/gssg ratio) and mitochondrial biogenesis. in addition, inhibition of nampt blocked the cr-induced insulin sensitization, akt signaling activation and enos phosphorylation. collectively, our data demonstrate that cr-induced beneficial effects in oxidative stress, mitochondrial biogenesis and insulin sensitivity require functional nampt. background: the anti-diabetic effect of camel milk (cmk) gained increasing recognition in folk medicine and recent clinical and experimental studies. however, the mechanism(s) by which cmk influence the glucose homeostasis is yet unclear. objectives: to investigate the effects of cmk on the blood glucose regulatory mechanisms in control and diabetic animals. materials and methods: experimental diabetes was induced by intrapertional injection of streptozotocin in wistar rats divided into (d & d-cmk) groups. two healthy (c& c-ckm) groups served as control. camel milk ( ml/rat/day) was administered orally to the (d-cmk) and (c-cmk) groups for weeks. the (d) and (c) groups received no treatment. the changes in body weight, blood glucose, glucose tolerance, serum insulin, blood lipids, incretin hormones (glp- and gip), tnf-a, tgf-β , homa-ir and atherogenic index (ai) were investigated. results: the untreated diabetic animals (d-group) exhibited significant hyperglycemia, hyperlipidemia, increased homa-ir and ai, elevated serum icretins, tnf-a and tgf-β levels. this was associated with weight loss and high mortality. camel milk administration to the d-cmk group inhibited the weight loss and mortality and caused significant hypoglycemia, hypolipidemia, insulin secretion, low homa-ir and ai. serum glp- and gip levels show significant elevation but tnf-a and tgf-β were reduced. conclusion: augmented insulin release and decreased insulin resistance together with enhanced incretin hormones release are anticipated to contribute to the anti-diabetic effect of cmk. besides, the peculiar composition of cmk and its anti-inflammatory properties propose it as a valuable adjuvant anti-diabetic therapy. however large-sized clinical studies are still needed. prediabetics reflect dysregulation in glucose homeostasis with obesity is known risk factor in western countries. different degree of obesity contribution toward prediabetics is observed in lean populations. aim: to investigate the role of plasma leptin as a predictor of prediabetics in lean subjects. method: plasma leptin were measured in non-diabetic subjects aged - years old with bmi < . prediabetes (n = ) was defined based on fasting plasma glucose and -h oral glucose tolerance test. plasma leptin were measured in all subjects using commercial elisa kit. binary logistic regressions were used to estimate the age and sex adjusted odds ratio of leptin and other metabolic parameters. results: plasma leptin levels were significantly and positively correlated with bmi, percent total body fat, fasting plasma insulin and blood sugar and homa-ir values. plasma leptin were significantly higher in lean prediabetics ( . ae . ) compared to euglycemic lean subjects ( . ae . ; p < . ). increase in plasma leptin value by one increases the risk of prediabetics with or . ( % ci: . - . ). discussion: in a population of relatively lean and non-diabetic subjects, plasma leptin levels were associated with insulin resistance and prediabetes. furthermore, plasma leptin levels increases risk of prediabetics in non-obese subjects independent of age and sex. our data suggest that leptin as biomarker for screening individuals at high risk for prediabetes in lean population. f. al-zadjali, r. bayoumi latest update from the international diabetes federation shows that the prevalence of type diabetes (t dm) in the arabian gulf countries is among the top worldwide. the rapid increase in t dm prevalence in these countries suggests that psychological and behavioral factors, more than genetic factors, are primarily responsible for this trend. aim: to estimate heritability of plasma levels of adipocytokines in a large isolated arab pedigree. method: blood samples and anthropometric data were obtained from a large arab pedigree of individuals with high level of consanguinity. plasma levels of il- , il- b, leptin, total adiponectin, svcam- were measured using commercial kits. heritability parameters were measured using measured genotype analysis. results: fout hundred and sixty-nine individuals were structured in a large pedigree which consisted of interrelated nuclear families founded by founders. the heritability values were adjusted using age and gender as covariates. percentage of variation of plasma adipocytokines attributed to genetic factors were as following: leptin ( %), total adiponectin ( %), il- b ( %), il- ( %) and svcam- ( %). discussion: adipocytokines play central role in the development of t dm. our data shows high degree of heritability of leptin, il- and svcam- indicating their production is under tight genetic control. furthermore, our heritability values are different from previously reported heritability values of these adipocytkines studied in different ethnic populations. therefore, our results suggests that arab population are distinct and further genetic association and behavioral studies should be conducted for better understanding of the nature of t dm and its increasing trend in middle-east region. results: all treatments were well tolerated and no subjects was withdrawn from the study. compared to the baseline, the group treated with chrome picolinate only experienced a mild but significant decrease in fpg (À . ae . mg/dl). compared to the baseline, the group treated with chrome picolinate-berberine experienced a mild but significant decrease in bmi (À . ae . kg/m ), tc (À . ae . mg/dl), tg (À . ae . mg/dl), non-hdl cholesterol (À . ae . mg/dl), and fpg (À . ae . mg/dl). compared to the baseline, the group treated with chrome picolinate-berberine-banaba experienced a significant reduction in bmi (À . ae . kg/m ), waist circumference (À . ae . cm), sbp (À . ae . mmhg), tc (À . ae . mg/dl), tg (À . ae . mg/dl), ldl-c (À . ae . mg/dl), non-hdl cholesterol (À . ae . mg/dl), fpg (À . ae . mg/dl), insulin (À . ae . mu/l), homa index (À . ae . ) and hba c (À . ae . %), while hdl-c increased (+ . ae . mg/dl). waist circumference, sbp, ldl-c, hdl-c, insulin, homa index and hba c, also significantly improved when compared with other groups. the tested combined nutraceutical appears to significantly improve insulin-sensitivity and a large number of related parameters in subjects with ifg and metabolic syndrome. antioxidative mechanisms prevent human body from the damaging action of free radicals and reactive oxygen species. glutathione and related to it enzyme systems detoxicate h o and hyperoxide and from there, reduced glutathione is a potential marker of oxidative stress level. purpose: to investigete glutathione of erythrocytes in patients with prediabetes (igt and ifg) and type diabetes. matherial and methods: we examined patients with t d and concomitant coronary heart disease (chd) and atherosclerosis (group ), patients with prediabetes (igt and ifg) newly diagnosed and the same co-morbidity (group ) and almost healthy person (group ). examinations included clinical laboratory evaluation, fasting glicose, hba c. total glutathione (gsht) and oxidized glutathione (gssg) were measered by use of glutathione reductase reaction. redox potential (e h ) of glutathione was evaluated by use of nernst equation. results: concentrations of gsht and gsh were greater in group to compare with groups and (by . times, p = . and by . times, p = . respectively). inrease of concentration of gssg in group may change extracellular redox condition. calculation of e h revealed its change to oxidized condition in group to compare with group ( . mv greater) and group ( . mv greater). conclusion: antioxidant defense in red-cells is overactivated during prediabetes (igt and ifg) with concomitant chd and atherosclerosis while in patients with t d was noticed depletion of compensatory mechanisms with increased gssg and e h . reduction in gsh/gssg suggests that intracellular antioxidant is lost; herewith cells become sensitive to oxidative stress. clozapine increases meal size and meal duration, effects similar to the pharmacological blockade or congenital deficiency of cck- (cck- r) receptor. we aimed to investigate the role of cck- r in clozapine-induced weight gain (wg) and insulin sensitivity (is) in cck- r deficient, male otsuka long evans tokushima fatty rats (oletf). long evans tokushima otsuka (leto) rats served as healthy control. animals were orally treated with either clozapine or its vehicle over days. daily food intake was measured by means of metabolic cages. the is was determined by hyperinsulinemic euglycemic glucose clamping (hegc). hypothalamic mrna expression of cck- r and cck- r was measured by real-time pcr, plasma insulin was determined by radioimmunoassay. clozapine failed to induce wg or increment in food intake in either oletf or leto rats. the fasting plasma insulin and blood glucose level was significantly higher in oletf than in leto rats, but clozapine failed to modify these parameters. the glucose infusion rate during the steady state of the hegc was lower in oletf than in leto rats and clozapine did not modify it. the insulin sensitivity index (isi) was lower in oletf rats than in leto and the isi was further decreased by clozapine. the metabolic clearance rate of insulin changed parallel with isi indicating the possible source of the surplus of insulin, which is responsible for the decrement in is. clozapine induced insulin resistance without hyperphagia and wg in male leto and oletf rats. changes in cck- r and cck- r expression were inconsistent with the changes in the isi. clinical biochemistry & immunology, peterborough and stamford nhsft, peterborough, uk the national institute for clinical evidence has published guidelines for the treatment of prediabetes. these stress diet and exercise as shown by the dpp study a decade ago. however, recently published dpp follow-up data show how difficult it is for patients to follow that advice long-term. metformin was also found to be effective and is cheap and generally well-tolerated. this study shows the long-term effectiveness of routine metformin use in patients with igt. all patients attending two rural lipid clinics from who were found to have igt after a standard g ogtt were offered metformin mg bd or given diet and exercise advice if they did not wish medication. metformin was preferred over diet and exercise despite being shown to be inferior in dpp because of the extra cardiovascular benefits shown in ukpds. in , after a mean (range) follow-up of . ( . - . ) years, it was decided to review the data to see if the (off-label) treatment was effective. metformin significantly reduced t dm threefold after years ( % v %). further, it was possible to estimate that metformin could prevent / ever becoming diabetic (p = . ). the effect was due to restoring normoglycymia (fbg < . mmol/l) as the patients' weights and triglyceride levels did not change significantly. patients regularly present to lipidologists with fasting hypertriglyceridaemia. those with igt appear particularly likely to revert to normoglycaemia with metformin. routine use of this inexpensive and well-tolerated drug reduces the lifetime risk of developing t dm by over %. k. salehzadeh, m. shirmohammad zadeh azarbaijan shahid madani university, tabriz, iran as a fermented drink probiotic doogh [ ] can help promote the health of the society. studying crp [ ] changes as an important inflammatory index that predicts coronary-heart diseases such as arteriosclerosis has received attention in medical and nutrition studies. the present study was carried out to study the effects of week drinking different types of dough (probiotic and plain) on the changes of liver crp and other blood factors of male athletes with normal weight. the research sample of this study included healthy male athlete students with equal bmi characteristics that were divided into two testing groups ( each) and were homogenized and randomly divided and went through some exercises. the results of the paired t test showed that drinking plain doogh resulted in significant reduction of blood's urea ( . %) and crp ( . %) and significant increase of hdl ( . %; p < . ). the probiotic doogh also resulted in significant reduction of crp ( . %) and significant increase of hdl ( . %). the comparison of the two groups showed that the only statistically significant difference was in the amount of crp and the reduction effect of probiotic doogh on crp was more compared to the plain doogh (p < . ). also the amount of record changes in the probiotic group (À s) was significantly better than the plain doogh (+ s). background and aims: nutrition has significant effects on human health and diseases. diabetes is a chronic disease that can be affect by nutritional status. therefore, monitoring of nutritional status in these patients is one of the main components of prevention and controlling of complications. therefore, in this study the nutritional status of patients that referred to health center in songhor city was assessed. materials and methods: this descriptiveanalytical study was done on patients with type diabetes ( ae years old) with no insulin therapy. anthropometric mesearments and dietary intake assessment were done. ffq and three recall quessionare were filled with face to face interview. n software were used for analysis. mean ae sd of variables were reported. background: the aetiology of type diabetes and obesity may involve dysregulation of brain appetite control networks. we explored the impact of systemic insulin resistance, common to both conditions, on the effect of meal ingestion on brain responses to food cues. methods: eight insulin resistant (ir, homa -ir . ae . ) and insulin sensitive (is, homa -ir . ae . ) non-obese non-diabetic right-handed men were studied twice, min after consuming ml water (fasted) or kcal mixed meal (fed) in random order. brain responses upon viewing high (hc) and low (lc) calorie food images vs. non-food object (nf) and gaussian blurred (gb) images presented in a block design paradigm were measured using blood oxygenation level dependent functional magnetic resonance imaging. results: the meal reduced hunger (f = . , p = . ) and increased fullness (f = . , p < . ). meal ingestion had no specific impact on responses to lc in either group. in contrast, on viewing hc, there were decreased precuneus responses (vs. gb and nf) and superior temporal gyrus/insula responses to hc (vs. nf) in ir subjects, whilst in is subjects, meal ingestion increased responses to hc (vs. gb) in somatosensory cortex and to all food images vs. gb in putamen/insula, with a trend towards increased dorsolateral prefrontal cortex activity. conclusions: meal ingestion augmented activity in brain regions involved in sensation, interoception and inhibitory control in is subjects during food cue exposure. by diminishing activity in regions involved in imagery and interoception, insulin resistance may influence central appetite control networks to promote further eating after consuming a satiating meal. methods: we examined children with obesity in the endocrinological department of university hospital (minsk) over the year . the number of boys (b) ( . %), mean ae sd age . ae . years; girls (g) ( . %), mean ae sd age . ae years (p = . ). ultrasound (u/s) of the abdominal cavity; the levels of insulin (i); total cholesterol (tc); triglycerides (tg); high-density (hdlc), low-density (ldlc), very low-density (vldlc) lipoprotein cholesterol; atherogenic coefficient (ac); standart oral glucose tolerance test (ogtt) with the calculation of homa-ir and caro indexes; the levels of blood pressure (bp) and body mass index (bmi) were held to all patients. results: sds bmi b was . ae . , g . ae . (p = . ). bp more than th percentile was in ( . %) b and ( %) g (p = . ). the signs of steatohepatosis were determined in ( . %)b, ( %)g. the average levels of tc and tg were in normal limits, gender differenses weren′t noted (p = . ), (p = . ). the concentration of vldlc . ae . mmol/l ( . - . ), . ae . (p = . ). hdlc b and ldlc b didn′t exceed normal limits in boys and girls (p = . ), (p = . ). ac b . ae . ( - ), g . ae . (p = . ). basal and postprandial plasma glucose levels didn′t exceed normal limits regardless of gender (p = . ), (p = . ). the levels of i b . ae . mu/ml ( . - ), g . ae . (p = . ). homa-ir b . ae (< . ), g . ae (p = . ), caro . ae . (> . ), . ae . (p = . ). conclusions: obesity in children was accompanied with arterial hypertension, steatohepatosis and dyslipidemia. the development of insulin resistance with maintaining the basal and postrandial normoglycemia was noted by conducting ogtt in all patients regardless of gender. objective: to evaluate the effect of short-term, moderately high-fat diets on body weight, lipid profile and serum leptin levels. the study was undertaken to create a model with an acute metabolic stress without marked obesity. design: the laboratory mice were fed either a moderately high-fat diet or control diet. body weight, energy intake, body composition, and fasting plasma leptin were compared after and week of dietary treatment. results: after week, abdominal fat mass was % greater in mice fed the high-fat diet than in those fed the control diet (p < . ). however, plasma leptin concentrations did not change much in animals fed the high-fat diet. from to week, animals fed the highfat diet gained weight twice the normal diet group and consumed kj/day more than controls (both p < . ). at week, plasma leptin concentrations per unit abdominal fat mass were % lower in mice fed the high-fat diet (p = . ) and there was a significant negative association between leptin concentrations per unit abdominal fat mass and body weight (r = . , p < . ). conclusions: feeding for weeks moderately high-fat diet is associated with lower than expected circulating leptin concentrations, which correlate with a higher body weight. a high-fat diet may therefore contribute to weight gain by reducing leptin secretion in adipose tissue. the significance of these findings will be discussed. objective: to describe diabetes-related risk factors associated with lower respiratory tract infection (pneumonia) complications among children. methods: we obtained claims data on all hospital admissions to acute care hospitals for children patients with diabetes and pneumonia who were aged - years in bosnia and herzegovina and sarajevo between november , , and november , . these data are checked for accuracy and validity by the pulmologist and diabetologist pediatricians that oversee data collection. in both data sets, we linked diabetic kids patient charts to allow for calculation of previous admission and rehospitalization diabetic kids rates with complications of pneumonia in children. children prescribed more than one antibiotic class contributed to determining the rates of each class. objectives: to examine the extent to which adherence with multiple concomitant healthy lifestyle traits will be associated with the avoidance of the future development of t d. methods: five independent cohorts comprising , men and , women aged - and free of diabetes and cvd at baseline were examined in , , , objective: to investigate the effects of raloxifene on the insulin sensitivity and lipid profile in insulin sensitive and insulin resistant postmenopausal women. study design: this placebo-controlled, double-blind, randomized study involved postmenopausal women aged between and years. all subjects were screened with the insulin resistance homeostasis model assessment (ir-homa) and those patients in the lowest quartile (n = ) were assigned as insulin sensitive and those in the highest quartile as insulin resistant (n = ). patients in both groups received either raloxifene hydrochloride ( mg/day) or a placebo, for a period of weeks. insulin sensitivity, the serum lipid profile, and anthropometric measurements were established before and after therapy. results: women with the highest ir-homa scores were associated with a significantly higher weight, body mass index, waist, and waistto-hip ratio (p < . ). raloxifene significantly reduced the ir-homa scores from . ae . to . ae . (p = . ) and modified the lipid profile in insulin resistant patients when compared to the placebo group and those patients receiving raloxifene in the insulin sensitive group. conclusion: raloxifene reduced insulin resistance and modified the lipid profile in insulin resistant postmenopausal women. diseases, smoking, alcohol consumption, the use of sleeping pills and other potential confounders was also gathered. statistical analyses were done by spss ver. . the average age of the participants was . years old; % was reported current pet ownership. mean hba c was . %, bmi was , and systolic and diastolic blood pressure was and mmhg respectively. pet owners were significantly younger and slightly more overweight; and dog owners were much younger and more overweight than cat owners. in unadjusted analyses, dog owners had a lower rate of taking sleeping tablets than cat owners (p = . %), and dog owners were more likely to be smokers than cat owners (p = . %). however, pet ownership was not associated with hba c, systolic or diastolic blood pressure, bmi, or the prevalence of diabetic complications. conclusions: our results suggest that pet ownership may be associated with insomnia and smoking habits. however, pet ownership is not independently associated with control of diabetes, obesity and prevalence of diabetic complications. objectives: to non-invasively assess the muscular oxygenation response using near-infrared spectroscopy (nirs) and to determine the association between increasing levels of a c and oxygenation response in subjects with type diabetes. materials and methods: forty-five subjects with uncomplicated type diabetes were categorized into two groups: group i (a c < ) and group ii (a c ! ). nirs measurement of vastus lateralis was performed at rest and during a symptom-limited maximal treadmill exercise test to determine muscular oxygenation response. at rest and during peak exercise, deoxygenated hemoglobin (deoxy-hb), oxygenated hemoglobin (oxy-hb) and total hemoglobin (total-hb) were measured with characteristics of light absorptance from nirs. muscle saturation (%) was expressed as the ratio of oxy-hb to total hb volume, an index of tissue de-oxygenation. results: group i subjects (n = with females, . ae . years) were older than subjects in group ii (n = with females, aged . ae . years). the peak vo was comparable between groups. significant lower muscle saturation ( . ae . % vs. . ae . %, p < . ) and more decline (À . ae . % vs. À . ae . %, p < . ) at peak exercise, was noted in group ii. a significant correlation between a c and decline of saturation (r = À . , p < . ) was noted in this study, whereas no other significance were demonstrated in deoxy-hb or oxy-hb. conclusions: this study provided evidence of imbalance of oxygen supply to exercising muscle in asymptomatic and uncomplicated diabetic subjects with elevated a c levels. the insufficient perfusion occurred before vasculopathy and might develop metabolic impairments even myopathy in diabetic subjects with poor glycemic control. study design and method: the lifestyle intervention was conducted as a cluster randomized trial (n = ) in semi-urban setting in sri lanka. the intervention group ( ) received a family centered lifestyle intervention package from family health workers while the control group ( ) received a brief advice from a doctor. duration of the study was -months. results: this study has shown effectiveness in reduction in fasting blood glucose (p < . ), systolic blood pressure (p = . ), diastolic blood pressure (p = . ), weight (p = . ), added sugar (p = . ) and fat consumption (p < . ) while improving physical activity (p < . ) and insulin sensitivity (p < . ) in the intervention group when compared with the control group at follow up assessment. this lifestyle intervention sessions ( ) were carried out by family health workers during their routine house visits. aim: we aimed to compare an experimental type diabetic animal model generated by applying high fat diet combined with single shot of streptozotocin (stz) at mg/kg bw sprague-dawley (sd) rats. methods: we generated and selected rats based on fasting glucose, oral glucose tolerance, and %hba c. once sever type diabetic rats were identified, serum proteins were subjected to d-dige proteomics or comparative d-proteomics after phosphorylation or glycation. results: seven protein targets differentially expressed in severe type diabetic rats (st d) were identified as albumin, vitamin d-binding protein precursor, and transthyretin, respectively. in terms of serum proteins extracted by affinity columns for phosphorylation and glycation, the affinity of phosphorylated protein targets and glycated protein targets were modified under st d condition. results of the ingenuity pathway analysis (ipa) for those targets indicated that antigen presentation, humoral immune response, and inflammatory response are associated networks highly modified in st d group. kidney and liver damages under those st d rats were proposed by ipa and validated by histopathology. polymorphism of patatin-like phospholipase- (pnpla ) has been associated with susceptibility to non-alcoholic fatty liver disease (nafld); whereas genetic studies of nafld in asian indians are not investigated. we investigated the association of polymorphism rs of pnpla with clinical, anthropometric and biochemical profiles in asian indians with nafld. methods: in this case-control study, cases and controls were recruited. abdominal ultrasound, clinical, anthropometry and biochemical profiles were determined. fasting insulin levels and value of homeostasis model assessment of insulin resistance (homa-ir) was determined. polymerase chain reaction and restriction fragment length polymorphism of pnpla gene was performed. the associations of this polymorphism with clinical, anthropometric and biochemical profiles were investigated. results: higher frequency of c/g and g/g genotypes of rs polymorphism was obtained in cases as compared to controls (p = . ), as a consequence frequency of the minor allele g was significantly higher in cases (p = . ). the c/g+g/g genotypes was associated with significantly higher fasting insulin (p = . ), homa-ir (p = . ), alanine transaminase (p = . ) and aspartate transaminase (p = . ). using a multivariate logistic regression model after adjusting for age, sex, body mass index and fasting insulin, subjects with g/g genotype showed higher risk of nafld (or, . , % ci: . - . , p = . ). results: group ; before diet: bg- . ae . mmol/l; months on diet: ae . mmol/l ( . - . mmol/l) months: . ae . mmol/l ( . - . mmol/l); histology: marked necrosis and destruction of bcells on - % islet's surface in islets from ( %); in % not marked necrobiosis or without changes; decreasing of insulin content in b-cells: ig- . ae . (intact- . ae . ); histology: without changes; group : before diet: bg- . ae . mmol/l; months on diet + vitamin b : -bg- . ae . ( . - . mmol/l); months diet + vitamin b : bg- . ae . mmol/l ( . - . mmol/l); histology: partial necro-biosis on - % islet surface in islets from ( %); in other % -without changes; ig- . ae . (intact- . ae . ). conclusions: . months prolonged administration of vitamin b result not marked decreasing of insulin content in b-cells of animals contained on diabetogenic diet and treated by pyridoxin but not protect b-cells of part islets of necrobiosis. aim of this study: to determine the behavior of oxidative stress markers and mitocondrial dysfuncton in non-proliferative diabetic retinopathy. patients and methods: a cross-sectional study was designed with four groups: group : healthy-volunteer subjects. group : patients with mild-non-proliferative diabetic retinopathy (npdr). group : patients with moderate-npdr. group : patients with severe-npdr. serum oxidative stress markers: lipid-peroxidation (lpo measured by malondialdehyde and -hidroxyalkenals), nitric oxide (no metabolites measured by nitrites/nitrates), total antioxidant capacity (tac), activities of antioxidant-scavenger-enzymes in erythrocytes (gpx glutathione-peroxidase and catalase), and mitochondrial dysfunction (expressed in erythrocyte/platelet membrane fluidity and platelet hydrolytic activity of adenosine-thriphosphatase enzyme; atpase). the markers were quantified by colorimetric method. results: patients with npdr had a significant increased serum lpo and no metabolites levels compared to the group . the tac in patients with npdr had a significant decreased compared to the control group. a significant increased in the activities of gpx, catalase and atpase was shown in the experimental groups compared to healthy-volunteer subjects. a significant reduction was shown in membrane fluidity in patients with npdr. the results show that oxidative stress and mitochondrial dysfunction are associated to npdr and its severity. background: weight loss after rous-y gastric bypass (rygb) surgery is associated with alteration of body composition and visceral fat mobilization. we analyzed the amount of fat and fat-free mass reduction in order to identify factors that induce more favorable adiposity change. methods: morbidly obese patients (age = ae years) underwent rygb between september and july . anthropometry, dual-energy x-ray absorptiometry (dexa), computed tomography (ct), life style report, and laboratory test results were registered prior to and year after rygb. results: follow-up rate was . %. dexa demonstrated . ae . of %ffml (percentage of weight lost as fat-free mass) with reduction of % of total fat amount. ct demonstrated higher rate of visceral adipose tissue (vat) reduction rather than subcutaneous adipose tissue with . of %dv/%ds (percentage change in vat vs. sat). patients with diabetes mellitus preoperatively showed more favorable visceral fat reduction (%dv/%ds were . in dm and . in non-dm) even though they lost more fat-free mass. objective: prader-willi syndrome (pws), a genetic disorder characterized by childhood-onset obesity, is reported to have elevated levels of adiponectin. the actions of adiponectin are mediated by adiponectin receptors (adipors) which include adipor and adipor . several cytokines such as adiponectin, tnf-a, and il- , have been known to be involved in insulin sensitivity. methods: thirty pws children (median age . year, boys, girls) who were being receiving growth hormone (gh) therapy and obese children not receiving gh therapy (median age . year, boys, girls) were compared. the relative expression of adiponectin, adipors, several proinflammatory cytokines including tnf-a, and il- measured in peripheral blood mononuclear cells (pbmcs) using real-time pcr. their correlation was analyzed by homeostasis model assessment insulin resistance index (homa-ir). the pws children showed increased expression of adipor (p = . ) and decreased expression of il- (p = . ) compared to the obese children. there was a significant positive correlation between the adipors and tnf-a (adipor vs. tnf-a: r = . , p < . in pws, r = . , p < . in control group; adipor vs. tnf-a: r = . , p < . in obese group). the adipors in the obese group showed significant negative correlation with homa-ir (adipor vs. homa-ir; q = . , p = . , adipor vs. homa-ir; q = . , p < . ). conclusion: in result, inflammatory cytokine expression was closely associated with the expression of the adipors in the pbmcs of both the children with pws and the obese group. adipor expression was highly expressed in the pbmcs of the children with pws. august to november , homeostasis model assessment of insulin resistance (homa-r) were calculated. as a control, subjects were selected, who received oral glucose tolerance test (ogtt) between the same period showing normal glucose tolerance pattern. we used mann-whitney u-test and p-values < . were considered statistically significant. results: there was no significant difference in sex, age ( . ae . vs. . ae . ), bmi ( . ae . vs. . ae . ), hba c ( . ae . vs. . ae . ) and fasting plasma glucose level ( . ae . vs. . ae . ) between the gd group (n = : two males and four females) and control group (n = : one male and five females). the gd group showed significantly higher homa-r than control group ( . ae . vs. . ae . , p < . ). discussion: this study showed that gd patients with normal thyroid function had insulin resistance independent of bmi and hba c. conclusion: gd, even in euthyroid state, is associated with insulin resistance. introduction: it is still remain uninvestigated the correlation of prebiotics and leptin and ghrelin level in frame of inflammatory process in liver. aims and methods: the aim of our study was investigation of nifuroxazide and prebiotic therapy influence on leptin and ghrelin levels in nonalcoholic fatty liver disease patients. determination of leptin and ghrelin (elisa), insulin, il -β, tnf-a were performed in all patients. results: n = patients, female, age ae years, bmi ae kg/m . nafld in %, nash in % and ir in %. leptin was higher in women ( . ae . vs. . ae . ng/dl, p = . ), but ghrelin was similar ( . ae . vs. . ae . pg/ml). leptin positively correlated with bmi (r = . , p = . ) and ghrelin correlated (r = . , p = . ). ghrelin correlated with glycaemia (r = . , p = . ) and correlated to homa (r = . , p = . ). both hormones positively correlated to il -β and tnf-a (ghrelin: r = . , p = . ; r = . , p = . , respectively; leptin: r = . , p = . ; r = , p = . , respectively). prebiotic (npc bic) consumption significantly decreased ghrelin, insulin, il -β, tnf-a level and had no influence on leptin level. the results of liver biopsy (histological examination) and fibromax test showed, that in patients additionally treated by prebiotics, the progress of hepatic fibrosis was significantly slowly, then in cg (fibromax test result: f vs. f ; p < . ). conclusion: our data showed that nifuroxazide and prebiotic therapy decreased inflammation activity and ghrelin level in nafld. cardiology, physiology, medical university of białystok, bialystok, poland aim: ceramide (c) is considered to be an important factor reducing insulin sensitivity. the aim of the present study was to investigate the effect of reduction of the sphingolipid synthesis in the solid tissues on the level of c, and other bioactive sphingolipids, namely sphingosine- -pohosphate (s p) sphingosine (sp), sphinganine (sa) and sphinganine- -phosphate (sa p) in different blood compartments. the experiments were carried out on three groups of male wistar rats, - g of body weight fed ad libitum on a commercially available diet: (i) control, (ii)treated with myriocin (an inhibitor of sphingolipid de novo synthesis) and (iii) treated with nicotinic acid (it reduces the level of plasma free fatty acids). the level of the above mentioned bioactive sphingolipis was determined with the use of mass spectrometry. results: both treatments reduced profoundly the level of each of the examined compounds in the plasma. treatment with nicotinic acid did not affect the level of either compound in erythrocytes but reduced it to a great extend in the platelets. treatment with myriocin reduced the level of each compound, with the exception of sh, in erythrocytes. the compound reduced the level of each compound in the platelets to the level comparable to nicotinic acid. . the level of the examined sphingolipids in the plasma, erythrocytes and platelets depends thoroughly on their supply from solid tissues. . short-term reduction in the plasma free fatty acids level very efficiently reduces the level of bioactive sphingolipids in different blood compartments. background: maternal nutrition plays major role in fetal growth and development. low birth weight and impaired early postnatal growth predispose the offspring to an increased risk for future chronic diseases such as metabolic syndrome. stunting in south african children has previously been documented. the study aimed to investigate effects of maternal nutrition on fetal and early postnatal growth in the population of black urban pregnant south african women, employing ffq, ultrasound and anthropometry measurements. results: based on the z-scores (at birth, weeks and month), babies in the current study were born lighter (À . ) and shorter (À . ) with larger head circumference (+ . ) in comparison with the who child growth standards. the z-scores for both the weight and the lengthfor-age decreased after birth with subsequent increase at months, being significant for length (À . , p = . ) after birth and for weight (+ . , p < . ) at months. maternal intake of polyunsaturated fat in early pregnancy and of total protein in late pregnancy were found associated with the fetal head-to-abdomen circumference (β = À . , p = . and β = À . , p < . respectively) and with the lengthfor-age z-score at weeks (β = . , p = . and β = . , p = . respectively). early plant protein intake significantly correlated with fetal growth rate (β = . , p = . ). conclusion: low maternal pregnancy intake of protein, namely of plant protein, and of polyunsaturated fat affected fetal linear growth, and resulted in a possible "brain sparing effect" in fetus. maternal dietary manipulation during pregnancy may therefore affect fetal and postnatal growth and thus modulate the risk of chronic disease later in life. aims and methods: to assess the efficacy of hb in cp patients in a two centre randomised, double-blind, placebo-controlled, crossover trial. one hundred and twenty-six patients with chronic pancreatitis were exposed to screening blood tests and test of elastase in stool before randomization to placebo or hb (buscopan, boehringer ingelheim) for weeks. all patients followed the basic treatment scheme include dietary and physical regimen. drug effect was optimized by dose titration during weeks - starting at mg daily, increasing (max mg t.d.s) or decreasing as required. methods: brown beans, or white wheat bread (wwb, reference product) were provided as evening meals to healthy young adults in a randomized crossover design. markers of glucose-and appetite regulation, glp- , and markers of inflammation were measured at a following standardized breakfast, i.e. - h after the evening meals. colonic fermentation activity was estimated from measurement of plasma short chain fatty acids (scfa) and breath hydrogen (h ) excretion. results: an evening meal of brown beans, in comparison with wwb, lowered blood glucose (À %, p < . )-and insulin (À %, p < . ) responses, increased satiety hormones (pyy %, p < . ), suppressed hunger hormones (ghrelin: À %, p < . ), and hunger sensations (À %, p = . ), increased glp- ( . %, p < . ) and suppressed inflammatory markers (il- À %, and il- À . %, p < . ) at a subsequent standardized breakfast. breath h ( %, p < . ) and plasma scfa (propionate % and isobutyrate %, p < . ) were significantly increased after brown beans. results: the present study revealed significantly lower levels of adiponectin in diabetic children compared to the controls ( . ae . vs. . ae . lg/ml). it also showed significantly increased carotid intima media thickness (cimt) in diabetic children compared to the control group ( . ae . vs. . ae . mm). there was also positive correlation between the mean cimt and age of the patient, age of onset of diabetes mellitus, hba c, and bmi measurements in diabetic children. there was negative correlation between mean cimt and adiponectin level. conclusions: subclinical microvascular disease in type diabetes mellitus begins early in diabetic children, which emphasize the importance of early detection and control of vascular risks in diabetic children. the study also suggests that adiponectin may prove to be useful marker of cardiovascular risks, and potential therapeutic target for risk prevention in diabetics. in overweight and obese individuals ( f/ m; age ae years, bmi = ae kg/m ). an intra-venous glucose tolerance test, hyperinsulinaemic-euglycaemic clamp and circulating markers relevant to age signalling were performed before and after each diet. results: the high age diet was fivefold higher in age content than the low age diet. the high age diet reduced insulin sensitivity by À . mg/kg/min ( % ci, À . to À . ; p = . ) while the low age diet improved insulin sensitivity by + . mg/kg/min (+ . to + . ; p = . ). the overall change in insulin sensitivity was . mg/ kg/min ( . - . , p = . ). the change insulin secretion was correlated inversely with the change in plasma age (cml) concentration (r = À . , p = . ). to investigate the level of transforming growth factor (tgfbl) and basic fibroblast growth factor (bfgf), non-specific markers of inflammation: interleukin- (il- ), tumor necrosis factor-a (tnf-a) in patients with coronary heart disease (chd) depending on the presence of dm . the study involved people: one group À patients with chd without carbohydrate metabolism disorders, two group - patients with dm and chd. blood samples were taken from the cubital vein and the aorta during coronary angiography. . )], as in arterial and venous blood in the presence of chd and dm (p < . ). . availability dm in patients with chd was associated with significant increase in the level of tgfb , il- . these observation reflect the effect of chronic hyperglycemia on the restructuring of the connective tissue and the vascular wall. . tgfb direct correlation with lipid markers confirms the relationship of connective tissue disorders and lipid metabolism in the pathogenesis of atherosclerosis. obesity can be induced with high fat diets (hfd) and is associated with inflammation in white adipose tissue (wat) and liver. the factors that control the early metabolic responses to hfd and that trigger inflammatory gene expression are only poorly understood. a time-resolved analysis of differentially expressed genes in expanding adipose tissue of mice ( weeks hfd feeding) identified specific clusters of lipid metabolism-related genes and inflammation-related genes with similar time expression profiles. subsequent promoter analysis of the clustered genes revealed that specific master regulators (among which fos, esr , hnf a, jun, ppara, pparg, nr h /lxrb, nfkb, srebf and , sfpi , smad , sp ) orchestrate metabolic adaptations and early inflammatory responses in wat. some of these transcription factors (esr , jun, fos, pparg, sp ) have a dual role and regulate the adjustment of lipid metabolism as well as expression of inflammatory genes such as cxcl /kc, ccl /rantes, complement factors, asc, granzyme a ccl /rantes, ccl , ccl /mcp . subsequent analysis of corresponding livers revealed comparable molecular responses on the level of transcription factors. more specifically, many master regulators identified in wat were also involved in the liver response to hfd as demonstrated by analysis of hepatic target gene expression in conjunction with transcription factor binding activity analysis. our findings support the view that metabolic and inflammatory processes are interlinked in wat and liver, and that responses to hfd are controlled in a similar way on the transcription factor level. distortions of the mechanisms which control metabolic homeostasis in these organs may thus also affect their inflammatory tone. aim: to investigate the effects of iptakalim, a novel sur b/kir . type atp-sensitive potassium channel opener, on endothelial dysfunction induced by insulin resistance (ir) and to determine whether iptakalim improved ir associated with hypertension in fructose-fed rats (ffrs) and spontaneously hypertensive rats (shrs). methods: the levels of endothelial vasoactive mediators and enos protein expression were determined usingelisas or western blot. in both ffrs and shrs, hyperinsulinemic-euglycemic clamp was used to evaluate ir states. . cultured human umbilical vein endothelial cells (huvecs) incubated with the pi -kinase inhibitor wortmannin ( nmol/l) and insulin ( nmol/l) induced endothelial dysfunction characterized by reduced release of no and expression of enos protein, and increased production of et- . pretreatment with iptakalim ( . - lmol/l) could potently prevent the endothelial dysfunction by increasing no production and inhibiting et- release. . in ffrs, the levels of sbp, fasting plasma glucose and insulin were elevated, whereas the glucose infusion rate (gir) and insulin sensitive index (isi) were significantly decreased, and the endothelium-dependent vascular relaxation response to ach was also impaired. these changes could be prevented by administration of iptakalim for weeks. the imbalance between serum no and et- was also ameliorated by iptakalim. . in - month-old shrs (ir was established at the age of months), oral administration of iptakalim for weeks significantly ameliorated hypertension and increased the gir to the normal level. conclusion: iptakalim could protect against ir-induced endothelial dysfunction, and ameliorate ir associated with hypertension, via restoring the balance between no and et- signaling. m. ste z pie n , a. ste z pie n , r.n. wlazeł , m. paradowski , m. banach , j. rysz material and methods: patients (f , m ) were divided according to bmi into three groups: a-obesity i (n = ); b-obesity ii (n = ) and c-obesity iii (n = ) and into other four groups: females and males and patients treated with statins or fibrates (n = ) or untreated (n = ). results: leptin was significantly higher in group c compared to group a and b [ . ( . - . ) vs. . ( . - . ) ng/ml, p < . and vs. . ( . - . ) ng/ml, p < . respectively]; hs-crp were higher in group c than in group a [ . ( . - . ) vs. . ( . - . ) mg/ l, p < . ]. adiponectin and leptin were higher in females [ . ( . - . ) vs. . ( . - . ), p < . and . ( . - . ) vs. . ( . - . ), p < . , respectively]. resistin, hs-crp and il- were higher in untreated patients' group [ . ( . - . ) vs. . ( . - . ) ng/ ml, p < . ; . ( . - . ) vs. . ( . - . ) mg/l, p < . and . ( . - . ) vs. . ( . - . ) pg/ml, p < . respectively]. leptin positively correlated with hs-crp in the whole population (r = . , p < . ), in treated patients' group (r = . , p < . ) and with tnf-a in group c (r = . , p = . ). conclusions: leptin may be associated with chronic inflammation in obese hypertensive patients. serum leptin and adiponectin levels are sex dependent. hypolipemic treatment has impact on chronic inflammation and resistin. lean body mass in genetically obese (ob/ob) or anorectic/cachectic subjects is severely reduced. similar outcomes of two different pathological states prompted us to wonder if leptin, adipokine well known from its control of appetite interacts with myogenesis. apparently, recombinant leptin ( ng/ml) stimulated dna synthesis in mononuclear myoblasts together with the increase of t /y p-erk / protein expression levels. additionally, leptin reduced cell viability and muscle fiber formation from c c mouse myoblasts. detailed short-and long-term examination with the use of metabolic inhibitors revealed that both jak/stat and mek/mapk but not pi -k/akt/gsk- beta signaling pathways were stimulated by leptin, and that stat (y p-stat ) and mek (t /y p-erk / ) control these effects. in turn, insulin promoted pi -k-dependent phosphorylation of akt (s ) and gsk- beta (s ) and insulin overruled leptin-dependent inhibition of myogenic differentiation in pi -k-dependent manner. gsk- beta might play dual role in muscle development. insulin-induced effect on gsk- beta (s p-gsk- beta) facilitated myotube formation. in contrast, leptin through mekdependent manner led to gsk- beta phosphorylation (y p-gsk- beta) with resultant retardation of myoblast fusion. in summary, to some extent opposite effects of insulin and leptin on skeletal muscle development emphasize the importance of intercellular signaling between adipose tissue and skeletal muscle. insulin and leptin determine how muscle mass is gained or lost, respectively. objective: obesity is linked to both increased metabolic disturbances and increased adipose tissue macrophage infiltration. however, whether macrophage infiltration directly influences human metabolism is unclear. the aim of this study was to investigate if there are obesity-independent links between adipose tissue macrophages and metabolic disturbances. methods: expression of macrophage markers in adipose tissue was analyzed by dna microarrays in the sos sib pair study and in patients with type diabetes and a bmi-matched healthy control group. results: the expression of macrophage markers in adipose tissue was increased in obesity and associated with several metabolic and anthropometric measurements. after adjustment for bmi, the expression remained associated with insulin sensitivity, serum levels of insulin, c-peptide, high density lipoprotein cholesterol (hdl-cholesterol) and triglycerides. in addition, the expression of most macrophage markers was significantly increased in patients with type diabetes compared to the control group. conclusion: our study shows that infiltration of macrophages in human adipose tissue, estimated by the expression of macrophage markers, is increased in subjects with obesity and diabetes and associated with insulin sensitivity and serum lipid levels independent of bmi. this indicate that adipose tissue macrophages may contribute to the development of insulin resistance and dyslipidemia. hp gene has been demonstrated to be a major determinant of susceptibility to cvd and in the development and progression of dn. hp allele is defective in its ability to protect against oxidative stress cvd and dn. we decide to assess the intracellular localization of iron in the pctcells and its potential toxicity in the development and progression of dn. methods: wild type c b / mice have only an hp allele. we genetically engineered a murine hp allele and inderted it in the murine hp locus by homologous recombinatiobn. we induced dm, by stz for days, at weeks of age we assessed lysosomal membrane integrity, redox-active iron in kidney lysosomes. . increased iron-rich deposits in lysosomes of pct cells in hp - dm vs. hp - dm ( ae % of all lysosomes) compared with hp - dm mice ( ae % of all lysosomes, p < . ). . intralysosomal redox-active iron concentrations are markedly increased in hp - dm mouse kidneys lysosomes of hp - dm mice ( . ae . lmol/l) as compared with those from hp - dm mice ( . ae . lmol/l, p = . ). lysosomal membrane lipid peroxides are increased in hp - dm proximal tubule cell (p < . ). vitamin e supplementation resulted in a % reduction in lysosomal redox-active iron in hp - dm mice (p < . ). conclusion: a novel mechanism whereby the hp genotype may predispose to renal injury in the setting of dm via increased iron deposition in the lysosomes of pct. purpose: we aimed to use other less hazardous route of insulin injection to prevent pharmacokinetic problems of sc insulin and find out response categories in diabetics and prediabetic patients. besides, fbs and hba c are markers for treatment evaluation; we wondered whether aitt could be a marker of residual pancreatic activity regeneration or decelerating progression of type ii diabetes. methods: five hundred diabetic and patients with impaired glucose tolerance were enrolled to this trial. three hours after breakfast they receive - unit equivalents of insulin into the external auditory cannel. blood glucose level was measured every min for h. this was repeated months later in both groups; while prediabetic patients received some sorts of therapy while the other patients remained on their previous lifestyle. auc and best fit curve were evaluated by partial mathematical integration. results: six different prototypic curves were extrapolated from diabetic patients with the possibility of excellent theoretic explanations about etiology and multifactoriality, lifestyle change, drug(s) of choice and prognosis. parallel to this prediabetic patients showed comparable curves. the area under curve in treated prediabetics showed a small but significant reduction compared to untreated ( vs. , p = . ). conclusions: as shown elsewhere the area under curve after an auditory insulin tolerance test is a nice marker in diabetes response evaluation and prognosis and an excellent marker for progression to diabetes and effectiveness of treatment in prediabetics (< compared to > ). introduction: type ii dm is generally regarded as a progressive disease with control of bs becoming more difficult with time. we wondered whether optimal therapy with "mega-treatments" that can let the pancreas rest could reverse the disease. materials and methods: thirty five patients received optimal doses of insulin through the auditory channel for months. contributing factors such as obesity, anxiety, h. pylori infection and reduced physical activity were treated appropriately. at beginning and every month they were evaluated by way of auditory insulin tolerance test after h of drug vacation. the general appearance of the curve, the partial integration of it and the overall area under curve were compared monthly. results: auc declined from a mean of - from first to sixth month meaning reduced insulin resistance (p < . ). this decline was steady during the whole months and minor variations in different patients were not significant. with mathematical calculation it seems very unlikely that this decline becomes asymptotic so that on extension of the curve for - years at least % of the patients eventually fall into the nondiabetic range with auc under . (p < . ) although different definitions exist for dm, auditory insulin tolerance test might be functionally more illuminating. these results are in concordance with available literature that denotes early aggressive treatment might be better. we add to this notion that early aggressive treatment can possibly reverse type ii diabetes. physiology, universidad de guadalajara, guadalajara, mexico background: c-reactive protein (crp) is an acute stage protein whose serum levels become raise by infection or because an undergoing metabolism disruption. our group has found crp variable serum levels in hypertensive patients that course with obesity and dyslipidaemia. the crp polymorphism rs g>a has been associated to lowered crp serum levels in autoimmune diseases. the role of c-reactive protein (crp), a marker and mediator of inflammation, in the pathogenesis of metabolic syndrome and its complications such as non-alcoholic fatty liver disease (nafld) remains to be elucidate. in this study we investigated whether increased levels of human crp itself can promote increase of glucose and lipid metabolism disorders associated with metabolic syndrome. materials and methods: spontaneously hypertensive rats (shr) with transgenic expression of human crp gene under apolipoprotein e promoter (shr-tg) in age -year and age matched non-transgenic shr controls were used. both groups were fed a high fructose diet ( % cal fructose) for weeks. parameters of insulin resistance and oxidative stress were measured by commercially available kits. results: transgenic expression of crp was associated with significant increase of serum triacylglycerols ( . ae . vs. . ae . mmol/l, p < . ) and insulin levels (p < . ), markedly decrease in insulin stimulated c-glucose incorporation into muscle glycogen ( ae vs. ae nmol/g/ h, p < . ), reduced serum adiponectin ( . ae . vs. . ae . mmol/l, p < . ), and microalbuminuria (p < . ). transgenic expression of crp was associated with increased liver triglyceride concentrations ( . ae . vs. . ae . lmol/g, p < . ), decreased liver glutathione peroxidase activity (p < . ) and reduced glutathione concentration (p < . ). liver lipidperoxidation were elevated in shr-tg rats: tbars (p < . ). conclusion: overexpression of human crp induced insulin resistance, oxidative stress and liver steatosis in shr rats. these finding indicate that chronically inflammation might directly contribute to the pathogenesis of metabolic syndrome and nafld. one of the most topical issues of modern pediatrics is obesity in children and adolescents, which has a tendency to doubling every three decades in almost all countries. the aim of our research was to investigate the fatty acid composition of the blood in children with obesity. patients and method: we investigated children aged from to years, divided into two groups: group i - children ( % boys and % girls) who are overweight or obese (bmi . ae . kg/ m ), group ii - persons ( % boys and % girls) with normal body weight (bmi . ae . kg/m ). research methods: quantitation of omega- and omega- polyunsaturated fatty acids, determination of the total amount of fatty acids, the total content of eicosapentaenoic and docosahexaenoic acids by gas chromatography with mass selective detection and determination of the omega- index (the ratio of the sum of eicosapentaenoic and docosahexaenoic acids to total content of fatty acids in %). results: there was a direct correlation between the value of bmi and the increasing of omega- index and the omega- pufas in children with obesity, while for the children with normal body weight the connection of bmi with the change of the fatty acid composition of blood was not obtained. thus changes of the quantitative and qualitative fatty acid composition of blood in obesity children and adolescents had multidirectional nature and require further dynamic study. a. kopp, a. schmid, m. mü ller, a. schä ffler internal medicine i, university hospital regensburg, regensburg, germany introduction: proteins secreted by adipocytes (adipokines) play an important role in the pathophysiology of type diabetes mellitus and the associated chronic and low-grade state of inflammation. it was the aim to characterize the anti-inflammatory potential of the new adipokine, c q/tnf-related protein- (ctrp- ), which shows structural homologies to the pleiotropic adipokine adiponectin. in earlier studies, recombinant ctrp- has been shown to inhibit lps and lauric acid induced release of pro-inflammatory cytokines and chemokines dose-dependently in monocytes and adipocytes. methods: for in vivo analysis, male c bl/ mice were treated by intraperitoneal lps administration for h. anti-inflammatory effects were tested by pre-treatment ( min) with ctrp- . after killing, epididymal adipose tissue was collected for cytokine mrna expression analysis (real-time rt-pcr) and blood for measurements of circulating cytokine levels (elisa). the anti-inflammatory potential previously found in vitro is also seen in lps-treated c bl/ mice. animals pre-treated with ctrp- have lower levels of inflammatory cytokines such as interleukin- (il- ) and macrophage inflammatory protein- (mip- ). furthermore, mrna expression of il- and mip- in the epididymal adipose tissue is significantly reduced by ctrp- . conclusion: ctrp- acts anti-inflammatory in cells and tissues that are involved in obesity and type diabetes mellitus. therefore, it might be an interesting drug target in treating obesity-related chronic inflammation. objective: the aim of the study was to assess the burden of some metabolic syndrome (ms) risk factors in polish adolescents from two less-urbanized regions as well as the relationship between abdominal obesity, dyslipidemia and hypertension incidence. the study involved adolescents aged - . all subjects lived in two less-urbanized regions of poland (small towns and villages in the central and north-eastern regions). the concentration in blood of triglycerides (tg) and hdl-cholesterol (hdl-c), as well as systolic blood pressure (sbp) and waist-to-height ratio (whtr) were determined. using logistics regression, an odds ratio (or) of the incidence of high whtr ( ! percentiles), high tg ( ! mg/dl), high spb (> percentiles) and low hdl-c (boys: < mg/dl; girls: < mg/dl) was calculated. results: high whtr was found in % of adolescents, high tg in %, high spb in % and low hdl-c in %. adolescents with abdominal obesity (whtr ! percentiles) had an or rated as high spb at . ( % ci = . - . ; p < . ), an or rated as high tg at . ( % ci = . - . ; p > . ) and an or rated as low hdl-c at . ( % ci = . - . ; p > . ) in comparison to adolescents with normal whtr (between and percentiles). adolescents from north-eastern poland had an or rated as high spb at . ( % ci = . - . ; p < . ) and an or rated as high tg at . ( % ci = . - . ; p < . ) in comparison with the central region (or = . ). conclusions: dyslipidemia and hypertension were the main metabolic syndrome risk factors in polish adolescents from less-urbanized regions, especially in central poland. the risk of hypertension rose over times in adolescents with abdominal obesity. objective and aims: as employment has become more sedentary in nature, there is a potential for more working individuals to be at risk of developing the metabolic syndrome (mets). physical activity (pa) is recommended for prevention of such chronic conditions. this study investigates self-reported pa and presence of mets in the workplace as part of the established "prosiect sir gâr" initiative in south wales, uk. methods: two hundred and twenty-one male steel workers (sw) and male local health board (lhb) employees were screened and their data analysed. anthropometric data, blood pressure and self-reported physical activity (gppaq) were all recorded alongside obtained blood samples which were subsequently analysed for high-density-lipoprotein cholesterol (hdl-c). presence of the mets was determined based on the following idf criteria: central obesity (waist circumference: ! cm), reduced hdl-c levels (< . mmol/l) and either systolic ( ! mmhg) or diastolic ( ! mmhg) hypertension. results: the proportion of males diagnosed with mets was comparable between worksites (sw: . % vs. lhb: . %; p = . ) despite the sw reporting being more physically "active" or "moderately active" than their lhb counterparts ( . % vs. . %; p < . ). central obesity, reduced hdl-c levels and diastolic hypertension were comparable between worksites (p > . ), although systolic hypertension was higher amongst lhb employees ( . % vs. . %; p < . ). however, more sw were found to be clinically obese ( . % vs. . %; p = . ). introduction: diabetes mellitus is often a silent disease and its prevalence is increasing rapidly worldwide. nonalcoholic steatohepatitis is certainly the less estimated complication of diabetes in frequency and severity. the aim of our study was to evaluate the prevalence of steatohepatitis and to identify its clinical and biological risk factors. materials and methods: the prospective transversal study was comparative between type diabetics (group ) and healthy people (group ) with no chronic hepatopatic diseases, no alcoholism and no intake of hepatotoxic drugs. all have benefit from a clinical exam, biological assay and abdominal echography seeking for steatohepatitis. results: group has statistically a higher frequency of android obesity, insulin resistance, steatohepatitis, high blood pressure, hypertriglyceridemia, chronic inflammation and silent myocardial ischemia in comparison with group . the steatohepatitis was present in % of patients vs. . % of healthy people; p < . . also, patients from group with steatohepatitis (group a) had a body mass index (bmi), waist circumference, a percentage of fat mass, a level of triglycerides, of alanine aminotransferase (alat) higher than diabetics without steatohepatitis (group b), with a risk of metabolic syndrome multiplied by three. with multivariate analysis, we found that in group , alat and bmi were directly associated to steaohepatitis. our study notifies the frequency of steatohepatitis in diabetics. it could be prevented and treated by loss of weight and regular physical activity in order to reduce insulin resistance. objectives: vascular dysfunction and complications are the major cause of mortality in diabetic patients. arterial stiffness has been known as a useful predictor of atherosclerosis and lipoprotein level is one of major risk factors of atherosclerosis. to investigate the association of lipoprotein level with arterial stiffness, we studied the vascular characteristics of patients with diabetes. methods: fifty patients (male:female = : , mean age . ae . years), with diabetes and without coronary artery disease, were enrolled and evaluated. all patients have been taking angiotensin receptor blocker or angiotensin converting enzyme inhibitor. arterial stiffness was assessed by measuring the carotid-radial pulse wave velocity (pwv). the cardiovascular risk factors, including body mass index, lipid profile, pulse pressure, c-reactive protein, flow-mediated vasodilatation (fmd) were also measured. the pwv was significantly higher in patients with metabolic syndrome than those without metabolic syndrome ( ae vs. ae cm/s, p = . ) in diabetic patients. multivariate analysis revealed that hdl cholesterol level, body mass index and metabolic syndrome were highly associated with pwv (p = . ). pulse pressure, crp, hdl cholesterol level and metabolic syndrome were significantly associated with fmd. conclusion: in diabetic patients, metabolic syndrome and hdl cholesterol level were highly associated with arterial stiffness and fmd as in non-diabetic patients. objective: our goal was to compare a weight loss diet with high caloric intake during breakfast to an isocaloric diet with high caloric intake at dinner. research design and methods: obese women (bmi . ae . kg/m ) with metabolic syndrome were randomized into two isocaloric (~ kcal) weight loss groups, a breakfast (bf; kcal breakfast, kcal lunch, kcal dinner) or a dinner (d) group ( kcal breakfast, kcal lunch, kcal dinner) for weeks. anthropometric measurements, oral glucose tolerance test (ogtt) and meal tests were performed. the bf group showed greater weight loss (À . ae . vs. À . ae . kg) and waist circumference reduction (À . ae . vs. À . ae . cm) compared with the d group. although fasting glucose, insulin and ghrelin were reduced in both groups, fasting glucose, insulin and homa-ir decreased significantly to a greater extent in the bf group. mean triglyceride levels decreased by . % in the bf group, but increased by . % in the d group. after ogtt, the extent of reduction of aucglucose and aucinsulin was greater in the bf (À % and À %, respectively) compared with the d group (À % and À %, respectively). in response to meal challenges, the overall daily aucglucose aucinsulin, aucghrelin and mean hunger scores were significantly lower, whereas mean satiety scores were significantly higher in the bf group. conclusions: an isocaloric diet with switched caloric intake during breakfast or dinner differentially influences weight loss and metabolism. high-calorie breakfast with reduced intake at dinner might be a useful alternative for the management of obesity and metabolic syndrome. centre for biomedical sciences, cardiff metropolitan university, cardiff, uk introduction: we have reported that exercise alters markers of monocyte/macrophage polarisation in peripheral polymorphonuclear cells, decreasing the m :m marker ratio. since the m phenotype is considered "anti-atherosclerotic", this may be beneficial in reducing cardiovascular disease risk. this study aimed to determine whether exercise specifically promotes m marker expression in purified monocytes, and to elucidate the molecular mechanisms involved in this process. methods: twenty-six healthy, sedentary individuals ( ae years) participated in a low-intensity exercise programme (walking, min, thrice weekly for weeks). peripheral monocytes were isolated using magnetic immuno-separation, and gene expression was determined by rt-pcr. serum lipids, insulin and glucose levels were measured by standard biochemical methods. the presence of serum pparc ligands was determined by gene reporter assay. results: during the -week exercise programme, pparc ligand generation and cox- gene expression were increased [ . ae . -and . ae . -fold, respectively (p < . )]. similarly, pparc-dependent genes (e.g. cd ) and m marker (e.g. dectin- ) expression increased ( . ae . -(p < . ) and . ae . -fold (p < . ), respectively), while exercise-associated increases in pro-inflammatory m markers were blunted [e.g. mcp- . ae . -fold (p < . conclusion: low-intensity exercise may prime monocytes for differentiation into m -polarised macrophages (possibly via pparcdependent events) and contributes to improved insulin sensitivity. this data supports exercise prescription for the prevention and management of inflammatory-linked diseases such as atherosclerosis and diabetes. quantify and determine possible differences and their correlation with plasma leptin and ghrelin levels. for this study, male rats were underwent a case control study. the fecal bacteria composition was investigated by pcr-denaturing gradient gel electrophoresis and realtime qpcr. in restricted eaters, we have found a significant increase in the number of proteobacteria, bacteroides, clostridium, enteroccoco and prevotella and a significant decrease in the quantities of actinobacteria, firmicutes, bacteroidetes, b. coccoides-e. rectale group, lactobacillus and bifidobacterium with respect to unrestricted eaters. we also found a significant positive correlation between the quantity of bifidobacterium and lactobacillus and plasma leptin levels, and a significant and negative correlation among the number of clostridium, bacteroides and prevotella and plasma leptin levels in all the experimental groups. furthermore, plasma ghrelin levels were negatively correlated with the quantity of bifidobacterium, lactobacillus and b. coccoides-eubacterium rectale group and positively correlated with the number of bacteroides and prevotella. in conclusion, nutritional status and physical activity may have an impact on the gut microbiota composition affecting the diversity and similarity. the significant increase in the quantity of lactic acidproducing bacteria and butyrate-producing bacteria that would also implied an increase in their bacterial metabolites in the exercise rats without dietary restriction could be responsible of the plasma ghrelin levels decrease found in these rats which affect the food intake and the body weight. the aim of this study was to evaluate the relation between weight gain classified according to iom recommendations and macronutrient intake. methods: a cross-sectional study was conducted on women hospitalized in the maternity during august-september . prepregnancy weight was self-reported. gestational weight gain and weight rate gain was determined by means of the weight registered in the maternity before delivery. nutrient intake during pregnancy was evaluated with a -item food frequency questionnaire. results: on average, protein provided . % ( %ci: . - . ), carbohydrate . % ( %ci: . - . ) and fat . % ( % ci: . - . ) of the total energy intake. there was a positive and consistent association between energy intake and maternal weight gain among the pregnant women (p = . ). the percent of energy from protein was associated with maternal weight gain rate (p = . ). women with a weight gain higher then media + sd had a higher intake of protein compared with those with medium (p = . ) and lower (p = . ) weight rate gain. no significant differences regarding fats and carbohydrates intake was noted. similarily, women with weight gain above the iom recommendations had a significant higher protein intake compared with those with a lower weight gain (p = . ). conclusion: a strong association was found only between protein intake and weight gain in the studied sample. a dietary pattern analyses would clarify the relation with weight gain during pregnancy. excessive weight gain and obesity before pregnancy was associated with large for geastational age newborns and prematurity. the aim of the study was to analyse the relation between maternal anthropometric indicators and apgar score. a cross-sectional study was conducted on women hospitalized in the maternity during august-september . multiple pregnancy and obstetrical pathology represented exclusion criteria. self-reported weight was used to estimate prepregnancy bmi. gestational weight gain was determined by means of the weight registered in the maternity before delivery. apgar score was determined by the neonatologist immediately after birth. results: in the sample studied, . % newborn had an apgar score lower than , thus indicating neonatal distress. there weren't noticed significant differences according to weight gain during pregnancy. among the mothers with newborns which had an apgar score lower than , . % had a weight gain lower, . % higher and . % within the iom′ s recommendations. however, excessive prepregnancy weight was associated with neonatal distress (p = . ): . % of women with prepregnacy bmi ! kg/m ; . % of the normal weight and % of the underweight gave birth children with low apgar score. conclusion: prepregnancy excesive weight was associated with neonatal distress, strenghtening the importance of achieving an ideal weight before conception. patients and methods used: six obese women (age . ae . years, bmi . ae . kg/m ) had fasting metabolic measurements taken via indirect calorimetry before and after weeks of a low starch diet. respiratory gases were collected for min using standard procedures in order to determine resting metabolic rate (rmr), respiratory exchange ratio (rer), and macronutrient oxidation (carbohydrate and fat). a paired sample t-test was used to evaluate significant mean differences from pre-to post-diet. results: after weeks on a low starch diet, subjects lost an average of . ae . kg despite the fact that this was not designed as a weight loss diet. rer decreased from . ae . to . ae . (p = . ) from pre-to post-diet measurements. further, carbohydrate oxidation decreased from . ae . to . ae . g/min (p = . ), and fat oxidation increased from . ae . to . ae . g/min (p = . ). changes in rmr were not significantly different. background: weight loss improves insulin resistance and hyperandrogenism in obese women with pcos but is unnecessary in lean women with pcos; however, meal timing and composition may influence glucose metabolism and hyperandrogenism. objective: to investigate the effects of two isocaloric diets with different meal timing on insulin resistance and hyperandrogenism in lean women with pcos. methods: sixty lean women with pcos were randomized to one of two kcal isocaloric diets with different meal timing: the number of young adults with ms is steadily increasing, but ms in children mainly incomplete according to the pediatricians' reports. so it was suggested that there are some flaws in the diagnostic criteria that lead to ms hypodiagnosis. hypothesis: using the clarified criteria may improve quality of ms detection in children. methods: in obese adolescents the ms components were analyzed by idf and clarified criteria. additionally abdominal obesity was analyzed by bmi sd and waist to height ratio; glucose intolerance by ogtt and homa-ir; dyslipidemia by fasting tg, ldl, hdl, tc (according to percentiles by ncep for children); blood pressure by the fourth report on the diagnosis, evaluation and treatment of high blood pressure in children and adolescents. results: the total number of detected ms components by idf vs. clarified ones: " " in . ae . % by idf; " " in . ae . % vs. . ae . % (p < . ); " " in . ae . % vs. . ae . % (p < . ); " " - . ae . % vs. . ae . % (p = . ); " " in . ae . % vs. . ae . % (p < . ); " " in . ae . % vs. . ae . % (p < . ). conclusion: using clarified criteria improves the quality of ms detection in children, which corresponds to a ms global concept of identifying high cardiovascular risk group. aim: polycystic ovary syndrome (pcos) is the most common endocrinopathy among women of reproductive age. pcos is connected with ovulatory disorders, oligomenorrhea, hyperandrogenism, infertility, and an increased miscarriage rate, and is frequently associated with insulin resistance (ir). multiple factors in the follicular fluid affect the fertilization and early embryonic development, including in women with pcos. the aim of this study is to evaluate the predictive value of follicular adiponectine regarding pregnancy outcomes in pcos vs. non pcos patients who underwent in vitro fertilization. material/methods: we designed a prospective study. group : (n: ) non pcos and group : (n: ) pcos patients according to roterdam criteria were included the study. basal ovarian reserve parameters, endometrial thickness, follicular luid adiponectine levels, clinical and laboratory ivf outcomes, pregnancy rates were studied. results: there were statistically significant differences in used gonadotropine dose, total oocyte number, mii oocyte number in non pcos vs. pcos groups (p: . ). but there were no statisticaly significant differences between the groups according to follicular fluid adiponectine levels (p > . ). we evaluated the correlation with adiponectine and ivf outcomes as endometrial thickness, mii oocytes number, fertilization rates and pregnancy rates, but there were no statisticaly significant correlation (p > . ). we could not find differences of follicular fluid adiponectine levels in the pcos vs. non pcos groups. although we could not find correlation with adiponectine and pregnancy rates, further investigations with larger numbers of cases are needed to clarify this subject. hypothesis: using the clarified criteria may improve quality of cardiovascular risk (cvr) evaluation in pediatric group. methods: comparative ms components detection in obese children by idf and clarified criteria as well as prognostic value relative to the myocardial remodeling and diurnal blood pressure patterns. results: it was established that the idf criteria (> ) are highly specific (sp = . ), but low sensitive (se = . ) with deterioration negative predictive value (npv = . ). clarified criteria (sum score > ) correspond to higher sensitivity (se = . ) without loss of specificity (sp = . ). conclusion: using the clarified criteria improves screening sensitivity and helps determine exact cvr. obesity is a global problem associated with numerous health issues includes type diabetes. bariatric surgery provides sustained weight loss and partial or complete diabetes resolution. micrornas (approximately nucleotides long) are post transcription regulators, which play important roles in conditions such as obesity and diabetes. the aim of this study is to investigate whether microrna profile is changed by bariatric surgery in postprandial state and if the altered microrna expression could contribute to long term post bariatric surgery benefits. both bariatric and sham-operated rats were given g of food min before sacrifice. total plasma and tissue rna from post-operative bariatric and sham operated rats were isolated and the microrna component was examined. principle component analysis clearly showed that bariatric surgery dramatically changed circulating microrna expression. correlation between microrna expression and metabonomics data indicated that certain plasma metabolites (for example, ketone bodies) are highly correlated. we also investigated liver microrna expression, microrna targeted mrna and metabonomics profile. mirna regulated key metabolic enzymes and receptors involved in the tca cycle, pentose phosphate pathway, gluconeogenesis and amp-activated protein kinase pathway. liver alanine, pyruvate and glucose levels were altered in bariatric compared to sham-operated rats. in summary, our data show that bariatric surgery changed both circulating and tissue microrna expression. we suggest that these alterations contribute to post bariatric surgery benefits by regulating key metabolic enzymes and receptors. the purpose of the study was to investigate serum concentrations of the asymmetric (adma) and symmetric dimethylarginine (sdma) and high sensitivity c-reactive protein (hs-crp) in hyperuricemic adolescents. patients and methods: the study group consisted of hyperuricemic patients aged median . years. the control group (c) contained healthy individuals with normal serum uric acid (sua) level. serum adma and sdma were measured by immunoenzymatic elisa commercial kits and were expressed in lmol/l. serum hs-crp was determined using nephelometric method (behring) and expressed in mg/l, sua was measured on the hitachi apparatus. results: hyperuricemic patients showed increased sdma (median: . q -q ( . - . ) lmol/l vs. controls . q -q ( . - . ) lmol/l, p < . ). serum adma values did not differ between two estimated groups (p > . ). the positive correlation was observed between adma and sua (r = . , p < . ) and sdma with sua and hs-crp concentrations (r = . , p < . ; r = . , p < . , respectively). we demonstrated that in adolescents with hyperuricemia increased serum sdma, but not adma levels were observed. no significant differences for adma and sdma between hypertensive and normotensive patients with hyperuricemia were found. the large, multicentre, prospective studies are needed to confirm if sdma might play a role in chronic inflammation in patients with hyperuricemia. objective and aim: supplementation of n- polyunsaturated fatty acids expresses anti-diabetic effect by enhancing insulin sensitivity and improving lipid metabolism. in this study we wanted to assess whether supplementation of n- can improve antioxidant status, preferably pon level, in the serum of type diabetic (t dm) patients. subjects and methods: twenty t dm patients ( females, eight males, age . ae . years, bmi . ae . kg/m ) were randomized to intake g marine oil ( . g epa and dha) during weeks, after weeks washout period. anthropometry, blood pressure measurements and fasting blood samples for metabolic parameters (glucose, hba c, insulin, cholesterol, hdl-cholesterol, triglycerides), hscrp, as well as oxidative stress enzymes [pon- , catalase (cat), superoxide dismutase (sod), glutathione peroxidase (gsh-px)] were obtained before and after treatment period. results: serum pon- activity response was increased by % from . to . (p < . ) as well as sod from . to . (p < . ) by epa and dha supplementation. it was associated with serum n- pufa increase by % (p < . ). there were no changes in anthropometry, glycemic control, insulin resistance index, the levels of total cholesterol, triglycerides and parameter of chronic inflammation (hscrp). only hdl-cholesterol increased after supplementation, from . to . mmol/l, with borderline significance (p = . ). conclusion: supplementation with . g n- pufa improves antioxidative status, pon activity and sod level, and repairs dyslipidemia in t dm patients. aim of this study: to determine the behavior of endogenous antioxidants markers and metabolic profile in non-proliferative diabetic retinopathy patients and methods: a cross-sectional study was designed with four groups: group : five healthy-volunteer subjects. group : patients with mild non-proliferative diabetic retinopathy (npdr). group : patients with moderate npdr. group : patients with severe npdr. serum endogenous antioxidants markers (determined by ua and b), glycemic profile (measured by fasting plasma glucose and hemoglobin a c), lipid profile (measured by total colesterol, triglycerides, high and low density lipoproteins-cholesterol), arterial pressure, renal profile (urea and creatinine analysis). serum-markers were quantified using enzymatic-colorimetric methods. results: patients with npdr had a significant increased serum lipid profile, glycemic profile and renal profile levels compared to the control group. ua and b levels showed increased trend in retinopathy groups compared with group . introduction: bone tissue has been recognized as an endocrine organ. recently it′s been found that levels of osteocalcin, a protein produced by osteoblast, is associated with glucose metabolism and lipids in human being. experimental studies showed associations between adiposity and levels of osteocalcin, however in the adolescent population is not quiet elucidated. objective: to establish the association between adiposity indexes and serum levels of osteocalcin in children and adolescents. materials and methods: in this study we included children and adolescents participants of the project "health worker cohort study" adiposity index were establish through bmi, waist circumference and dexa. the total concentration of osteocalcin was determined by chemiluminescence. through multiple lineal regression we evaluated the association between osteocalcin levels and the adiposity index. results: prevalence of overweight and obesity was . % abdominal obesity . %. it was observed a negative correlation between bmi, percentage of fat mass, waist circumference (p < . ). independently of the adiposity index included in the model, have obesity increases the risk of presenting low levels of osteocalcin (or: . ; % ci: . - . , p < . ) and adolescents with higher percentage of fat mass have five times more risk than adolescents with less fat mass of present low levels of osteocalcin (or: . ; % ic: . - . , p < . ). conclusions: adolescents with higher adiposity have more probability of have low levels of osteocalcin. objective: to evaluate the association between physical activity (pa) with presence of burnout syndrome (bs) and its three dimensions: emotional exhaustion, despersonalization and low personal accomplishment in health workers and educational sector. methods: a sample of imss workers, insp and uaem was obtained. after signing informed consent subjects answer a lifestyle questionnaire that included a pa questions and the burnout scale designed by maslach. anthropometric measurements were performed by previously standardized personnel (concordance coefficient of . - . ), with conventional stadiometer and calibrated scales previously tanita brand. we determined body mass index (bmi) based on the criteria of the center for disease control (cdc). pa was considered sufficient to perform or more minutes of daily pa. the data analysis was performed in the stata statistical package version . results: from the analysis of health workers and educational study participants′ cohort health workers. "female sex predominated by %. the mean age was ae years. seven out of ten participants performed < min of pa per day. a trend of higher prevalence of bs in those performing < min of pa per day was showed, to perform ! min of pa reduces the likelihood of developing bs in a % according to grunfeld criteria and % according to the ramı´rez's criteria. conclusions: to perform at least min a day is a protective factor to avoid the presence of bs, but only three out of ten participants to perform af. aims: with research showing that more than one third of this current generation of australian teenagers likely to become obese in adulthood, the need to arm our children with the skills to maintain a healthy weight has never been so urgent. the need for feed cooking program has been developed for teenagers to improve their ability to prepare and cook healthy food, and boost their knowledge about nutrition and support them to develop healthy habits for the future. methods: need for feed is delivered using school facilities and home economics teachers, but is delivered outside of school hours in an informal and engaging format. the program, which delivers h of tuition, focuses on improving participants' food preparation and cooking skills, budgeting and meal planning, basic nutrition knowledge, and attitudes and behaviours associated with healthy eating. results: evaluation demonstrates that participants improve in both skills and confidence in preparing and cooking healthy food, improve their knowledge of healthy eating guidelines and make tangible changes to their eating habits through increased consumption of fruit and vegetables, and reduced consumption of sugary soft drinks, cakes, chocolate and potato chips. conclusion: while the factors contributing to the obesity epidemic and growing rates of type diabetes are complex, the importance of arming the community with skills and confidence in cooking at home is being increasingly recognised. this program has shown that teenagers can develop the necccessary skills to support healthy eating through a targeted and engaging cooking education program. postprandial hyperglycemia is an early defect of type diabetes and the one of primary antidiabetic targets. the therapeutic approach for the treatment of postprandial hyperglycemia can be achieved by inhibiting a-amylase and a-glucosidase, key enzymes for starch digestion and further glucose absorption. in this study, the inhibitory activities of microalgal fucoxanthin against a-amylase and aglucosidase were determined as well as antidiabetic effect to induce differentiation in t -l preadipocytes using oil red-o staining. fucoxanthin exhibited weak inhibitory activity against rat-intestinal aglucosidase, while strong inhibitory activity against pancreatic aamylase in a concentration-dependent manner with ic values of . mmol/l and lmol/l, respectively. microalgal fucoxanthin significantly increased glucose uptake in t -l cell by . % at lmol/l. fucoxanthin inhibited lipid accumulation during adipocyte differentiation of t -l cell and no cytotoxicity was recorded for preadipocytes up to lmol/l. these results suggested that fucoxanthin may be useful approach for the prevention of type diabetes by inhibiting carbohydrate-hydrolyzing enzymes. university of vermont, burlington, vt, usa aims: we compared the effects of ad libitum low-fat, high-fiber and low-carbohydrate diets on caloric intake, anthropometry, and cardiometabolic risk markers in adults with the metabolic syndrome. methods: twenty-three women and men ( - years) with the metabolic syndrome completed a randomized crossover comparison of two -week diets. all meals (low-fat, high-fiber: - % carbohydrate, - % fat, - % protein, - g fiber/day; low-carb: - % carbohydrate, - % fat, - % protein, - g fiber/day) were prepared by a research dietician and consumed ad libitum. results: caloric intake was lower on low-carb ( ae vs. ae kcal/day; p = . ). only low-carb reduced body fat (À . ae . %; p = . ) and tended to produce greater weight loss (À . ae . kg vs. À . ae . kg; p = . ). both diets reduced fasting insulin (À . % to À . %; p < . ) and non-hdl cholesterol (À . % to À . %; p < . ). low-fat, high-fiber reduced serum cholesterol (À . %), while triglycerides (À . %) and vldl cholesterol (À . %) were reduced on low-carb (all p < . ). plasma ffa were elevated on low-carb (+ . %; p = . ). although flow-mediated dilation (fmd) was unchanged after low-fat, high-fiber ( . ae . % vs. . ae . %; p = . ), a trend for reduced fmd was observed after low-carb ( . ae . % vs. . ae . %; p = . ), producing a significant diet interaction (p = . ). introduction: better insulin schedules are needed to prevent hypoglycemic attacks. materials and methods: bs/time curve was plotted in a series of diabetic patients with and without treatment. the best fit curve was used by partial integration and mathematical extrapolation. the first and second derivatives of these curves were plotted by the use of special software and modified matlab. points of major mathematical and lifestyle interest were marked within the curve for correlation. daily variations were also registered. based on mathematical results, patients received auditory insulin and were compared with themselves and other patients under the same dose of insulin. results: although the bs/time curve and its first derivative are completely chaotic due to daily activity and unplanned meal intake the second derivative has some regularities and in regard to cutting the x axis every lambda minutes ( min ( min under % confidence interval. this shows that the innate glucose reducing potential of the body is exhausted after this time giving us the opportunity to treat with lower doses at these points. with this schedule patients needed less insulin and showed extremely better bs control. conclusion: preventing superimposition of innate bs reducing potency and external drugs can give rise to smoother bs control and less hypoglycemic attacks. besides, this can also be exploited in the management of prediabetic patients. introduction: type ii dm is generally regarded as a progressive disease with control of bs becoming more difficult with time. we wondered whether optimal therapy of the disease with "megatreatments" that can let the pancreas rest could reverse the disease. materials and methods: ten patients received optimal doses of insulin through the auditory channel for months. they were previously on oral hypoglycemic agents and relatively in good control. their bs were measured daily for months during the oral regimens before and after the auditory instillation. these two sets of measurements in addition to other subjective and objective parameters such as weight, sense of well being and hba c were compared. results: insertion of a strict insulin regimen in the form of auditory insulin instillation between two intervals of the same oral hypoglycemic agents (sandwich effect) causes a significant improvement in glycemic control and possibly needed dose. conclusion: as fairly good controlled patients were selected there is probably no doubt that more strict control of bs can reverse type ii diabetes progression. we have postulated that rest of the pancreas in the form of auditory insulin or strict diet can restore normal pancreatic response in a later occasion. based on a mathematical model of extrapolation we suggested that strict bs control for - years with a mean bs of mg/dl and possibly no attacks above mg/dl can reverse type ii diabetes in at least % of the patients. the diabetes epidemic could be controlled with effective prevention programs. these programs require accurate identification of subjects at risk. unfortunately, current prediction models have several deficiencies and are not being used. we present results comparing a novel model using association rule mining (arm) against three traditional models applied to data from the electronic medical record (emr). we used a cohort of , adults olmsted county, mn, residents without diagnosis of diabetes who visited mayo clinic between and . we collected pertinent baseline characteristics available as structured data in the emr. we assessed -year incidence of diabetes; a total of subjects developed diabetes during the follow up period. we used c-statistic (mean ae sd) to compare risk of diabetes estimated by framingham score, san antonio index, finrisk index and our arm model. results: some variables used by traditional risk models were not available as structured data in the emr. they were imputed as the mean of the variable as measured on the population in which the index was developed. with the exception of finrisk, all indices preformed similarly. the c-statistic for framingham score, san antonio index, finrisk index and arm model was . ae . , . ae . . , . ae . and . ae . , respectively. conclusions: our novel risk model using arm compares favorably to traditional models and has the advantage that it does not depend on a limited number of risk factors. this model is implementable at the point-of-care or population-based care where emr is in use, assuring universal utilization and improving implementation of preventive management. this study aimed to compare the effects of two types of interventions: diet vs. diet plus sea buckthorn pulp oil intake, in childhood obesity. the results were focused on fmd and imt values and risk factors for endothelial dysfunction. two groups of matched age, sex and bmi obese children (n = , - years old) and controls were enrolled. the measurements in the obese children were done before and after interventions: diet (low caloric, lipid, sugar intake for months) or diet plus sea buckthorn pulp oil intake ( mg/day for months). ultrasounds were used for fmd and imt measurements and colorimetric and elisa methods for biochemical parameters. obese children vs. lean ones had significantly increased values for imt, leptin, apob/apoa ratio, fasting c peptide, c reactive protein (crp), and reduced values for fmd and adiponectin. in the obese group treated only with diet, a light reduction in weight was observed, but no modification of atherosclerotic markers or metabolic improvement. in the obese group treated with diet and sea buckthorn pulp oil, fmd and adiponectin were unchanged, while imt was significantly reduced (p < . ), together with the other atheroscleroric risk factors: fasting c peptide (p < . ), leptin (p < . ). in conclusion, this study shows that sea buckthorn pulp oil intake has beneficial effects by preventing atherosclerosis in obese children. aims: as the rates of type diabetes continue to skyrocket across the globe, public health measures to reduce obesity appear to have limited success. while social marketing campaigns for obesity prevention have their place amongst a suite of strategies, their impact can be limited due to the gap between the campaign messages and individual's ability to identify opportunities for change in their own life. in queensland, a group of peak health agencies are working together to bridge that gap. methods: swap it, don′t stop it is an australian social marketing campaign promoting simple, everyday food and activity changes people can make to improve overall health. a multi channel health promotion and public relations strategy has been implemented to integrate the key messages of the swap it don't stop it campaign with grassroots healthy lifestyle opportunities to support individuals to make changes. this has been achieved by harnessing the collective actions of the non-government health sector to promote clear and consistent obesity prevention messages and by implementing a communications strategy that has connected community and stakeholders with tangible opportunities for healthy lifestyle changes at the local level. outcomes: through collaborative action amongst a broad network of service providers, the national campaign messages have been amplified through community events, radio, print and television stories that have highlighted examples of personal success and provided information that has inspired queenslanders to make small steps towards better health and reduce the risk of type diabetes and other chronic diseases. background and aims: proposed changes to gdm diagnostic criteria are anticipated to increase diagnosis rates leading to rising demand for support during pregnancy. lack of awareness of risks associated with gdm acts as a barrier to healthy lifestyle adaptation and postpregnancy screening ( , ) . the you program delivers a range of strategies to support women at diagnosis, facilitate behaviour modification ( ) and re-enforce importance of post pregnancy screening. methods: newly diagnosed women and their support networks are educated about gdm, risk reducing behaviours and the health care system through a purpose built website and a suite of print resources. specific resources were developed for at risk groups including indigenous australians and women from non-english speaking backgrounds. women are encouraged to join a national register to receive post pregnancy screening reminder letters and text messages in conjunction with regular newsletters containing family-friendly information on healthy lifestyle behaviours and screening. nominated gp's are also sent screening reminders to prompt women to attend screening. results: engagement with the website and newsletters is high, screening reminders evaluated positively with focus groups and participants indicated that they intended to attend their post natal screening. conclusion: you delivers a multi-strategy approach that engages and supports women at diagnosis and re-enforces the importance of screening and behaviour modification during and post pregnancy. family members and peers were recognised as important sources of support and educated to encourage screening and behavioural changes. these low-cost interventions can help reduce prevalence or morbidity in women affected by gdm associated type diabetes. however smoking cessation has many benefits for smokers, but the most important challenge for smoking cessation is withdrawal symptoms during the first days and months of cessation which can be an important reason for unsuccessful in the smoking cessation process. however, many methods are available to help quit smoking, but acupuncture is used for the treatment of nicotine dependency with the aim of reducing of withdrawal symptoms experience. therefore, the aim of this study is to determine the role of acupuncture in success at quit smoking in the iranian samples. methods: one hundred and thirty-two men smokers who were ready to quit smoking were participated in the study. the participants were divided to two groups by randomized sample method. one group was for acupuncture and another group was for acupuncture in shame points. the mean age of smokers was ae years. all participants followed for year and the quit rate evaluated in , , months of the study. the results show, while . % in case-control and . % in control group could quit smoking in the first month of study; but in the month of the study . % in case-control and . % in control group were at quit rate. the quit rate short and long term in case group was higher than control group. therefore, physicians should play an active rate in control of smoking by ensuring and counseling and use of various pharmacology and non pharmacology methods for increase quit rate. panjab university, pgimer, chandigarh, india introduction: , -dimethylhydrazine (dmh)-induced colon carcinogenesis in rats is a reliable model to explore molecular mechanism involved in progression of colorectal cancer from adenoma to carcinoma sequence. objective: to study the transcriptional and translational levels of various genes involved in tumorigenesis pathway of dmh induced rat model. methods: two groups of chow-diet-fed, male sprague-dawley rats, aged weeks (n = /group) were fed a normal diet and injected subcutaneously for two time durations of and weeks dmh at a dose of mg/kg body weight/week or with ethylene diamine tetraacetic acid (edta)-saline. macroscopic and microscopic analyses were performed for confirmation of adenoma and carcinoma. mrna expression of nfkb and caspase- genes were determined by real-time pcr. immunohistochemistry was also performed for expression of above genes. results: gross examination of weeks dmh treated colon showed polypoid lesions and multiple tumors were formed after weeks dmh treatment. histopathological studies confirmed the colon carcinogenesis from adenoma-carcinoma sequence by type of tumor, degree of differentiation and invasion of tumors. in adenomatous and carcinomatous colonic tissues, mrna expression of nfkb was increased by . and . fold respectively, whereas expression of caspase- was reduced by . and . fold respectively. immunohistochemistry studies showed the increase expression of nfkb and reduced expression of caspase- in colonic tissues of dmh induced rat model as compared to controls. the observed data strongly implicates that dmh induced colon carcinogenesis altered the apoptotic machinery by modulating the expression of various genes involved in this pathway. objective: identify anthropometric indicators that present the greatest correlation in the diagnosis of some metabolic syndrome components in adolescents and its association with gender, age, and family history. methods: cross-sectional study with adolescents between and years of age of a public high school in the mexico city. bmi was used to diagnose overweight and obesity according to cut-offs proposed by the international obesity task force. waist circumference (wc) and waist-to-height ratio (whr) were used as fat distribution indexes. results: . % of the students were male. the prevalence of overweight and obesity were . % and . %. there were association between overweight-obesity and the average values of wc, whr, and blood pressure (p < . ). the correlation between waist circumference and bmi and waist-height were the strongest (r = . and r = . , respectively). we recommend using wc and whr in clinical practice as simplified indicators to predict risk of metabolic syndrome in mexican adolescents. c. saely, a. muendlein, a. vonbank, k. geiger, p. rein, h. drexel background: the novel adipocytokine chemerin has been suggested to be linked to insulin resistance and to the metabolic syndrome (mets). its association with coronary artery disease (cad) is unclear. we hypothesized that chemerin is associated with both angiographically determined cad and with the mets. we measured serum chemerin in patients undergoing coronary angiography for the evaluation of established or suspected stable cad; the mets was defined according to ncep-atpiii criteria; significant cad was diagnosed when coronary stenoses ! % were present. results: chemerin was higher in mets patients (n = ) than in subjects without the mets ( ae vs. ae ng/ml; p < . ). it did not differ significantly between patients with significant cad (n = ) and those without significant cad (p = . ). when both, mets and cad status were considered, chemerin was higher in mets patients both among those who had significant cad ( ae vs. ae ng/ml; p = . ) and among those who did not have significant cad ( ae vs. ae ng/ml; p < . ); it did not differ significantly between patients with significant cad and subjects without significant cad among mets patients (p = . ) nor among subjects without mets (p = . ). analysis of covariance (ancova) showed that a large waist circumference as well as elevated trigylcerides were independent predictors of elevated serum chemerin (f = . ; p < . and f = . ; p = . ). we conclude that chemerin is significantly associated mets but not with angiographically determined cad. the overall association of chemerin with the mets is carried by its association with visceral obesity and elevated triglycerides. objective: resistin is a novel adipocyte-secreted hormone proposed to link obesity with diabetes. the role of resistin gene polymorphism in insulin resistance and metabolic syndrome is controversial till date. the present study was attempts to investigate the relationship between resistin gene polymorphism with circulating resistin level, metabolic risk factor and insulin resistance in north indian population. methods: this is a case-control study; total healthy subjects were selected for the study. out of which (age . ae . years) were with metabolic risk factor and age matched control (age . ae . years) were without metabolic risk factors. we estimated homeostatic model assessment (homa) index, circulatory resistin, and lipid profiles. the genotyping of resistin-c g were carried out using pcr-rflp method digested with bbsi restriction enzyme. results: homozygous mutant genotype (cc) (cc v/s cg + gg) (p = . : or = . : % ci = . - . ) and mutant allele (g) (p = . : or = . : % ci = . - . ) of the c/g polymorphism was significantly less frequently observed in the control population as compared to study group. furthermore, on dividing the subjects into two groups according to the absence (resistin - ) or presence (resistin- ) of the mutant g allele, significantly high levels of resistin (p = . , or = . , %ci = . - . ) and insulin resistance (p = . , or = . , %ci = . - . ) were observed in resistin- group as compared to resistin- group. conclusion: our results suggest that the c/g mutation of the resistin gene is likely to play an important role in the development of metabolic syndrome and metabolic abnormalities. king george's medical university, lucknow, rims, saifai, etawah, india objective: adiponectin has been shown to be an insulin-sensitizing hormone and negatively associated with components of metabolic syndrome. present study was attempted to investigate the adiponectin polymorphism in metabolic syndrome and insulin resistance. methods: the adiponectin t g and g t polymorphism has been studied in females with metabolic syndrome and control without metabolic syndrome according to ncep atp iii criteria, . circulating adiponectin and leptin levels were determined by sandwich elisa method and insulin resistance by the homeostasis model assessment (homa) index. the polymorphism of adiponectin t/g and g/t gene were determined by pcr-rflp method. results: significant difference were found for circulating leptin level except adiponectin level ( . ae . vs. . ae . ), and in metabolic risk factors among metabolic syndrome and without metabolic syndrome females. homozygous mutant genotype (gg) (tt vs. tg + gg) (p = . : or = . : % ci = . - . ) and mutant allele (g) (p = . : or = . : % ci = . - . ) of the -t g gene and mutant allele (t) (p = . : or = . : % ci = . - . ) of the g t polymorphism were significantly less frequently observed in the control population as compared to study group. the results of the present study concluded that the mutation of the adiponectin t/g and g/t gene might play a important role in obesity associated metabolic syndrome and metabolic abnormalities except insulin resistance, glucose level and insulin levels in the north indian women due to mutation of the adiponectin gene is associated with decreased adiposity which is protective one for metabolic syndrome design: cross-sectional study of patients with good (excess body mass index lost (ebl) > %) and poor weight loss (ebl %) > months after rygb. material and methods: sixteen patients with good weight loss and patients with poor weight loss were included in the study. the patients underwent dual energy x-ray absorptiometry scan, indirect calorimetry and a -h multiple-meal test with measurements of glucose, insulin, total bile acids (tba), glucagon-like peptide (glp)- , peptide yy - (pyy), cholecystokinin (cck), ghrelin, neurotensin, and pancreatic polypeptide (pp) as well as assessment of early dumping and appetite. results: suppression of hunger was more pronounced in the good than the poor weight loss group in response to the multiple-meal test (p = . ). in addition, the good weight loss group had a larger release of glp- (p = . ) and a greater suppression of ghrelin (p = . ) during the test, whereas the postprandial secretion of cck was highest in the poor weight loss group (p = . ). pyy, neurotensin, pp and tba release did not differ. early dumping was also comparable. differences in resting energy expenditure between the groups were entirely explained by differences in body composition. conclusion: favorable meal-induced changes in hunger and gut hormone release in patients with good compared to poor weight loss support the role of gut hormones in the weight loss after rygb. background: the objective of this study is to explore changes in the vascular tone over the endothelial, neurogenic and myogenic frequency ranges during a contralateral cold pressor test by performing the wavelet analysis of skin temperature fluctuations and to compare the results obtained in healthy subjects and in patients with metabolic syndrome (ms) and type diabetes. methods: thirteen adults with type diabetes aged - years (average diabetes duration of . ae . years) and adults with ms aged - years participated in this pilot study. the control group included practically healthy men and women aged - . the lowfrequency fluctuations of skin temperature in the appropriate frequency ranges, registered during contralateral cold test, were used as a characteristic reflecting the mechanisms of vascular tone regulation. results: the response to cold pressor test in patients with type diabetes and with ms differs essentially from that of healthy subjects. patients with ms show changes in the amplitude of skin temperature fluctuations similar for patients with type diabetes in the endothelial range. the endothelial dysfunction occurs in the pre-clinical stage of diabetes and manifests, in particular, as a disturbance of the endothelial part of vascular tone regulation. with progression of the glucose metabolic disorders the pathological process is worsened due to violation of the neurogenic vasodilatation mechanisms. fetal metabolic programming states that early life nutrition is implicated with the risk of later disease development and both underand overnutrition during gestation might predispose individuals to develop obesity or diabetes later in life. obesity operations called "gastric bypass" operations have shown unexpected involvement of the small intestine in diabetes pathophysiology as it in most cases result in a complete resolution of the diabetes before weight loss. therefore we hypothesize that the small intestine is a subject of metabolic programming and that this programming can predispose for diabetes development. twin-pregnant ewes where fed a normal, a low or a high diet during the last weeks of gestation and the twin lambs where fed either a conventional or a high fat, high carbohydrate (hchf) diet during the first months of life. feeding challenge tests were performed on all lambs and some were slaughtered with collection of intestinal tissue for qpcr. the hchf diet increased the blood level of glucose, insulin and tg and increased the intestinal expression of a range of genes involved in growth, vascularization as well as digestion and absorption. the maternal low and high diet had effects on gene-expression, however the results vary between genes. these observations suggest that small intestine function has been programmed by the late-gestation low or high diet at gene expression level, whereas the physiological metabolic functions has mainly been affected by the hchf diet at such a young age. further investigations on the long-term effects of early nutrition are required. background: liposuction is considered as the treatment for the metabolic complications of obesity. the aim of this study was to evaluate the effect of abdominal liposuction on leptin and interleukin- (il- ) expression in adipose tissue and serum concentration. material and methods: the study included consecutive patients ( females, seven males) aged ae years with bmi ae kg/m , non-diabetic, apparently healthy, who underwent liposuction in mandala beauty clinic in pozna n, poland. the patients were examined clinically and the blood was withdrawn for routine laboratory tests (hematology, glucose, lipids, coagulation). leptin (r&d) and high sensitivity il- (hsil- ) (abcam) were analyzed in the supernatant of adipose tissue homogenate and in serum, by means of elisa. results: the expression of leptin in adipose tissue positively correlated with white blood cells count before liposuction (rs = . , p = . ). it was also higher (p = . ) in patients with bmi ! . ( . ; . - . ng/mg protein; median, interquartile range) than in subjects with bmi < . ( . ; . - . ng/mg protein). following liposuction, after month, serum leptin levels were lowered in smokers ( . ; . - . ng/ml), when comparing with baseline ( . ; . - . ng/ml). serum level of the adipokine, both before (rs = . , p = . ), and after (tau kendall = . , p = . ) liposuction correlated with tissue expression of leptin. no differences in adipose tissue expressions and serum levels of hsil- were observed month after liposuction. conclusion: a count of circulating leukocytes, even presented within references, affects the increasing adipose tissue expression of leptin. smoking status favorably affected the influence of liposuction on serum leptin levels. liposuction has no short-term effect on serum il- concentrations. r.a.l. sertié , s.a. sertié , a.r.g. proenc ßa, t. lima-salgado, a.c. oliveira, f.b. lima introduction: all adaptations acquired through physical training are reversible during inactivity. significant reductions in maximal oxygen uptake (vo max ) are observed within two-four weeks of detraining. conversely, the consequences of detraining on adipose tissue are poorly known. aim: to investigate the physical detraining effects on metabolism and cellularity of rat periepididymal adipose tissue. methods and results: male wistar rats, ageing weeks, were divided in three groups: trained (t) for weeks; detrained (d), (trained for weeks and detrained for weeks), and age-matched sedentary (s). training consisted in treadmill running sessions ( h/day, day/week, - % of the maximal capacity). the morphometric analysis of pe tissue disclosed significant differences between the groups. the adipocyte sectional area of group d was significantly bigger than t and s ( ae . lm vs. . ae . lm vs. . ae . lm , respectively). compared to t the cells of d animals showed % increased ability to perform: lipogenesis, either spontaneously or insulin stimulated and isoproterenol-stimulated lipolysis. basal lipolysis did not change. a % reduction in apoptosis was observed in groups t and d in relation to s. some gene expressions were changed in d vs. s: adiponectin (three-fold up) and ppar-gamma (two-fold up). pref- gene was three-fold higher in t vs. s. conclusions: these results suggest that adipogenesis was stimulated in this group. detraining causes significant increase in adipocyte size and lipogenic capacity. as pe fat cell apoptosis was reduced in d and t. background: chronic red wine (rw) consumption has been associated with a decreased cardiovascular disease risk, mainly attributed to an improvement in lipid profile. rw intake is also able to change gut microbiota composition. high-fat intake has recently been reported to increase metabolic endotoxemia. the gut microbiota has been proposed as the main resource of plasma lipopolysaccharides (lps) in metabolic endotoxemia. objective: to analyze the effect on lps concentrations of chronic rw consumption and acute rw intake in relation to high-fat intake in middle-aged men. design: for the chronic study middle-aged male volunteers were randomized in a crossover trial and after a washout period all received rw, dealcoholized red wine (drw), or gin for days. the serum lps concentration and changes in fecal microbiota were quantified before and after the treatments. for the acute study, five adult men underwent a fat overload or a fat overload together with rw, drw or gin. baseline and postprandial serum lps concentrations and postprandial chylomicron lps concentrations were measured. results: chronic rw consumption led to a significant decrease in lps concentrations compared to baseline. in addition, lps concentrations correlated negatively with bifidobacterium and prevotella levels. there were no differences in postprandial serum or chylomicron lps concentrations between acute rw, drw or gin intake together with a fatty meal. postprandial chylomicron lps concentrations correlated positively with the increase in triglyceride concentrations. conclusions: chronic rw consumption decreases lps concentrations, but it is not able to attenuate the postprandial lps increase induced by a fat overload. physical inactivity increases the risk of metabolic disease, associated with perturbations of muscle energy metabolism. the aim of this study was to assess the effect of exercise training on adiposity, physical fitness and muscle energy metabolism in obese individuals with attributes of ms. methods: sedentary individuals (m/f / ; age . ae . years, bmi . ae . kg/m ) completed -months endurance or strength (n = / ) training program ( h, -times/week). subcutaneous and visceral adiposity was measured by mri. phosphorus mr spectroscopy ( p-mrs) was used to assess the energetic status of muscle in vivo by measuring phosphocreatine (pcr), atp, inorganic phosphate (pi) and maximal oxidative flux (q max ), after exercise-or magnetic-induced equilibrium perturbation (n = ). the samples of skeletal muscle were taken by needle biopsy (vastus lateralis). cytochrome c oxidase (cox) activity of permeabilized muscle fibers was measured by oxymetry and maximal aerobic capacity (vo max) by bicycle ergometry. free-living ambulatory activity was monitored by accelerometers. results: subcutaneous adiposity did not change with training. however, strength training decreased visceral adiposity (p < . ). training increased physical fitness (vo max, n = , p = . ) and in vivo muscle energy metabolism ( p-mrs: q max , pcr, atp, n = , p < . ), without a significant effect on cox activity (n = . ). depletion of muscle pcr was negatively associated with cox activity (p = . ). vo max was not associated with muscle metabolism (p > . ). free-living activity increased during training (p < . ). conclusions: three months training of obese individuals was sufficient to increase both cardiorespiratory fitness and muscle metabolism, assessed by p-mrs. strength training was more efficient in decreasing visceral adiposity. background: the amelioration of metabolic complications of excessive body mass by liposuction is intensively discussed, as the metabolic surgery is proposed for future diabetes therapy. we have undertaken the study on the short-term effect of liposuction on insulin resistance parameters. material and methods: we included in the study consecutive patients ( females, seven males) aged ae years with bmi ae kg/m , who underwent liposuction in mandala beauty clinic in pozna n, poland. the non-diabetic, apparently healthy patients were examined clinically, blood was withdrawn for baseline routine laboratory tests (hematology, glucose, lipids, coagulation). insulin levels in serum and its content in adipose tissue were evaluated by means of elisa (diasource, sunrise tekan). insulin resistance/ sensitivity indexes: homa-ir, quicki and mcauley were calculated. one month observation included re-evaluation of glucose, lipids and insulin along with the indexes. data are presented as mean ae sd or median; interquartile range. we have observed the decrease in glucose concentrations ( ae vs. ae mg/dl, p = . ) and insulin levels ( ; - vs. ; - mu/l, p = . ) month after liposuction, comparing to baseline. homa-ir ( . ae . vs. . ae . , p = . ) and mcauley index ( . ae . vs. . ae . , p = . ) were improved month after liposuction, however no effect on quicki has been found. triglycerides concentrations month after liposuction were lowered comparing to baseline ( ; - mg/dl vs. ; - mg/dl; p = . ). in multiple regression analysis age was independent factor that affected insulin content in adipose tissue in males (b = . , p = . ). conclusion: liposuction causes beneficial effect on insulin resistance parameters in short-term observation of non-diabetic patients. background: a large number of studies showed that community-based health promotion is an effective way of preventing and treating chronic diseases. however, participation rate is very low for health education programs in community health centers (chcs); that of the program is not attractive, in part, because it is not individualized. using diabetes risk assessment tool based on electronic health records (ehr) data for diabetes risk prediction could help to early identify high-risk groups and reduce the incidence of diabetes through health education and lifestyle changes to control risk factors. objectives: to conduct community research to understand the situation of community diabetes prevention and control; to initially established prediction model of diabetes risk factors based on ehr data in chcs. the project randomly selects four districts in shanghai, using a combination of quantitative research and qualitative research method. get ehr data from each chc, attempts to establish the predicted model for diabetes, and test the sensitivity and specificity of the model. outcome measures: the prediction model include age, gender, blood pressure, smoking, drinking, body mass index, family history of diabetes based on ehr data. as pr(d) ! . , the sensitivity is . %, specificity is . % and area under roc curve (auc) is . . the empirical results will contribute to a better understanding of how the diabetes management in chc is important and provider the targeted self-management materials to improve health outcomes as well as evidences directly applicable in improving china's health policy reforms. a. schmid, a. kopp, m. bala, s. leszczak, i. ober, m. mü ller, a. schä ffler internal medicine i, university hospital regensburg, regensburg, germany introduction: the adipokine chemerin has an important role in insulin sensitivity and insulin secretion. elevated systemic chemerin concentrations correlate with obesity and insulin resistance. this study investigated chemerin serum levels of healthy volunteers undergoing an oral fat tolerance test (oftt) and their correlations with gender and markers of insulin sensitivity and inflammation. we further tested effects of the sex hormones estradiol and testosterone on chemerin secretion from adipocytes in vitro. methods: hundred overnight fasted healthy volunteers participating in the study underwent an oftt. after oral uptake of lipid suspension, venous blood was drawn at , , and h. subjects were characterized by anthropometric and standard laboratory parameters. chemerin levels were measured by elisa. mature murine t -l adipocytes were stimulated with estradiol and testosterone. concentrations of secreted chemerin were measured by elisa. results: while there were no significant changes in individual chemerin concentrations resulting from the lipid load, mean chemerin levels in sera of female probands were found to be significantly higher when compared to males ( . ae . vs. . ae . ng/ml, p = . ). the correlation of chemerin with insulin and c-peptide concentrations also was gender-specific. along with these findings, chemerin secretion from mature t -l adipocytes was shown to be affected by estradiol and testosterone treatment. conclusion: human chemerin concentrations are higher in females and there is a gender specific regulation upon stimulation with sex steroids. chemerin is not responsive to an oral lipid load. objective: to study the predictors of change in bmi with respect to time among physically active subjects. methodology: the present study was conducted among physically active individuals in delhi. data was collected longitudinally with a monthly follow up of months. various anthropometric and physiological measurements were taken using standard protocol. the analysis has been performed with mixed effect modeling to assess subject's variation for parameters with respect to time. r . . software with nlme package was used. an akaike information criterion (aic) was applied to find the consistency and measure the relative goodness of fit of a statistical model. : bmi as an important factor was taken as dependent variable and using aic, gender, blood pressure and weight were independent variables or fixed and random variables for months of longitudinal study. using generalized linear model (glm), bmi was dependent variable and other parameters i.e. gender, systolic blood pressure (sbp), diastolic blood pressure (dbp) and weight were independent variables. the regression coefficient obtained for gender with respect to bmi (as response variable) was À . . the estimated values for sbp, dbp and weight were À . , . and . respectively. the reduction of bmi among females was more in comparison to males. the reduction rate of sbp, dbp and weight with bmi was very low with respect to time. a.e. andreazzi , s. grassiolli , j.c. de oliveira , r. torrezan , s.t. paes , m.s. silva , r.m.g. garcia , p.c.d.f. mathias department of physiology, federal university of juiz de fora, juiz de fora, biology, state university of maring a, maring a, biology, federal university of juiz de fora, juiz de fora, brazil obesity is a worldwide epidemic and the most important factor in metabolic syndrome onset. the involvement of sympathoadrenal axis activity in obesity onset was investigated using the experimental model of treating neonatal rats with monosodium l-glutamate (msg). to access general sympathetic nervous system activity, we recorded the firing rates of sympathetic superior cervical ganglion nerves in animals. catecholamine content and secretion from isolated adrenal medulla were measured using the trihydroxyindole fluorescence method. high-performance liquid chromatography (hplc) was used to measure plasmatic adrenaline. intravenous glucose tolerance test was performed, and isolated pancreatic islets were stimulated with glucose and adrenergic agonists. msg treatment increased the epididymal and retroperitoneal fat pad mass by . % and . %, respectively, compared with control animals (p < . ). the nerve firing rate of obese rats was decreased . % compared to the rate for lean rats (p < . ). pre-diabetic rats showed a % reduction in basal catecholamine secretion from the adrenal medulla and % lower plasma adrenaline concentration compared with the control animals (p < . ); whereas catecholamine secretion induced by carbachol, elevated extracellular potassium and caffeine in the isolated adrenal medulla were all increased in obese rats compared to control. both glucose intolerance and hyperinsulinaemia were observed in obese rats. adrenaline strongly inhibited glucose-induced insulin secretion in obese animals ( %, p < . ). these findings suggest that low sympathoadrenal activity contributes to impaired glycaemic control in pre-diabetic obese rats. objective: the aim of the present study was to evaluate the influence of physical activity patterns on cardiovascular health. the study was conducted in delhi, among adult punjabi males and females. total sample of subjects was taken for the study. data was collected crosssectionally using multistage stratified sampling. according to pattern of physical activity using self administered proforma, two groups were formed, one regular physical activity group (rpa; at least days/week brisk walk for min, doing yoga for min), and the other irregular physical activity group (ipa; < days a week with no consistency). various anthropometric and physiological measurements were taken using standard protocol. results: higher percentage of subjects with irregular pattern of pa was at risk of developing high bp, obesity and triglycerides. higher values of whr, whtr among them showed that group was more disposed to cardiovascular health problem. males with ipapattern had . times, . times and . times more risk of increasing regional adiposity using whtr, whr and wc respectively. among females, whtr, whr and wc respectively showed . times, . times and . times higher risk of developing regional adiposity with irregular pattern of pa. the increased risk of being obese was . times more among males with irregular pattern of physical activity while among females fat percentage and obesity level using bmi category were found to be at a risk of . times and . times respectively. conclusion: subjects with regular pattern of pa showed higher percentage of normal values of various cardiovascular and obesity markers. irregular pattern of pa increased the risk of regional and general adiposity markers besides that of high bp. materials and methods: serum glycemia, insulin and c-peptide level were measured at ogl hours - st- nd in: seven healthy controls, patients with ms and with cushing; mean age was . - . - . , bmi - - , ogl glycemia: . - . - . ; . - . - . ; . - . - . respectively. all patients had bp > / mmhg and triglyceride level > . mmol/l. homa assessment: (fasting insulin, pmol/l fasting glucose, mmol/l): . . c-peptide and insulin increase above fasting level (in pmol) per g of ingested glucose was calculated. results: (*p < . vs. control). homa was . - . *- . * and fasting c-peptide and insulin level were / , / *, / * pmol/l in control, ms and cushing respectively. to the st hour of ogl the corresponding data were: / , / * and / * and increase of c-peptide and insulin concentration per g of ingested glucose was almost equal: / . - / . - / . pmol/l. the degree of c-peptide increase to the st hour was twice less than in control and increased fasting hepatic insulin clearance lowered almost to control level (judging by c-peptide/insulin ratio). to the nd hour of ogl c-peptide and insulin level became similar to fasting data. conclusion: ir characteristics were similar in ms and cushing disease. insulin requirement increase on the top of ogl was equal to control. judging by c-peptide/insulin changes ir stops manifesting on the top of glycemia during ogl (probably due to normalizing hepatic insulin clearance). introduction: ir is atfr of high potential, but also one of the first signs of a ateroscl. process. condition when the body has too much insulin at in the same time too much glucose is the resistance of peripheral tissues to the action of insulin. objectives: to investigate the relationship of concentrations of insulin and glucose in the peripheral blood, but also the conc. of gh, becose normalisation of gh secretion could corrects hiperinsulinemia and insulin resistance. on the other hand reduced gh secretion often points to the high expression of somatostatin and the presence of stress, which leads to secretion of somatostatin. further increase in visceral adipose tissue and ffa relise under stress can worsen the condition of and insulin resistance. aims of study: conducted therapeutic program (combination of dietary and physical activity), in which only the group edu implemented and behavioral therapy. monitoring parameters of glycemic control: fasting glucose, fasting insulin and gh and insulin sensitivity of peripheral tissues to insulin, always from in one blood sample, parallely in two different phases of therapy. we used anova-manova statistics to determine the significance of an differencies. material and methods: determining of glucose, insulin, and growth hormone. as and qucki index for determining od insulin sensitivy conclusion: ours finding indicate that the synergistic effects of dieting and increased physical activity improves glucoregulation, reduce excessive insulin secretion and restoration of gh secretion. but only behavioral therapy may lead to permanent changes in nutritional habits and lifestyle. the metabolic and endocrine dysfunctions that may occur with polycystic ovary syndrome (pcos) can be associated with future comorbidities such as diabetes, cardiovascular disease, and endometrial cancer. although a definitive link between pcos and these chronic illnesses has not been demonstrated, there is significant overlap in the clinical characteristics of these disorders. consequently, the issue of identifying and measuring potential conditions that may be associated with pcos is a priority and should be the standard of practice in its management. hiperhomocysteinemia has been shown as independent predictor of cardiovascular events in patients with atherosclerosis. the aim of our study was to determinate levels of homocysteine in woman with polycystic ovary syndrome compared with healthy woman. thirty patients (age, , ae . ) with pcos and (age, . ae . ) healthy woman were involved in the study. blood samples were collected in early follicular phase. total homocysteine was measured using fluorescent immunoassay. statistically significant differences in serum concentration of homocysteine were observed between groups. mean homocysteine level we found as ( . ae . vs. . ae . ) in pcos and normal group respectively (p < . ). for macedonian population we found statistically significant increased homocysteine levels in woman with pcos. although the mean homocysteine levels are within normal limits, there are significant higher mean homocysteine concentrations between these two groups. because an increased concentration of thcy has been shown as and independent risk factor for cardiovascular alterations, it is essential in this group of woman to be taken measures for early prevention. a. alkandari, n.j. gooderham, h. ashrafian surgery and cancer, imperial college london, london, uk globally million people are obese and prevalence is increasing. obesity and its many co-morbidities are leading causes of mortality and morbidity and pose substantial socioeconomic burdens on health services. bariatric surgery is a form of gastrointestinal surgery that leads to sustained weight loss, a decrease in cancer risk and resolution of type diabetes. micrornas are a family of small, endogenous, non-coding rnas that regulate gene expression at the posttranscriptional level. micrornas control expression of over half the human transcriptome and are involved in processes fundamental to both normal physiology and disease, including obesity, diabetes and cancer. we hypothesise that urinary micrornas are biomarkers for bariatric surgery reduction of type diabetes. here, we looked at expression of micrornas involved in diabetes in urine samples prior to bariatric surgery and at months and year postoperatively. urinary rna was obtained using the mirvana paris kit and microrna expression was determined through quantitative pcr. we found significant increases of two to three fold postoperatively in the expression of three micrornas involved in diabetic nephropathy. these findings are consistent among patients undergoing laparoscopic roux-en-y gastric bypass and sleeve gastrectomy. our results indicate that bariatric operations can modulate post-translational effects in end-organs postoperatively and may contribute to the beneficial effects noted after these procedures. hepatic insulin resistance and the ensuing impairment of hepatic glucose metabolism is a major contributor to hyperglycemia in metabolic syndrome. various factors appear to act in parallel to elicit hepatic insulin resistance. while impaired fatty acid handling with a resulting activation of pkc isoforms is one established route, a subacute inflammation also appears to contribute and the impact of cytokines on the insulin signaling cascade is well established. by contrast, the role of small lipid mediators e.g. prostaglandins and sphingolipids, which are also affluent in inflamed tissue, is not well characterized. the current study addressed this question. in a wide array of genetic and diet-induced mouse models of the metabolic syndrome, hepatic expression of key enzymes of prostaglandin formation was induced. prostalgandin e , which is released predominantly from kupffer cells, directly attenuated insulindependent hepatic glucose utilization by an erk / -dependent serinephosphorylation of irs and hence attenuation of insulin-dependent akt-phosphorylation. in addition, pge enhanced lipid accumulation in hepatocytes by inhibiting mitochondrial fatty acid oxidation and vldl formation. furthermore, pge in an autokrine feed forward loop increased the formation of oncostatin m in kupffer cells, which in turn inhibited insulin signaling in hepatocytes by inducing socs . similar to pge , sphingosine- -phosphate, whose production was strongly enhanced by exposing hepatocytes to palmitate, attenuated insulin-stimulated glucose use and the induction of glycolytic enzymes in hepatocytes. in summary, the study provides first evidence that in addition to the established mechanism, small lipid mediators like prostaglandins and sphingolipids may impact on hepatic insulin resistance. background: the progression of childhood cardio-metabolic risk factor to adulthood suggests early origin of pathogenic pathways leading to chronic non-communicable disease as diabetes. objective: we sought to examine the distribution of insulin resistance (homa-ir) among children inhabiting delhi and clustering of cardio-metabolic risk variables among them. research design and methods: a cross sectional study was conducted among children aged - years. estimates of insulin resistance were derived on the basis of homeostatic model assessment. the th percentile of homa-ir for normal weight subjects with normal fasting glucose was considered as cutoff for insulin resistance. total body fat was assayed using body composition analyser (tbf- h a) employing bioelectric impedance technique. bmi was converted to age-and sex-standardized percentiles and subjects were classified as underweight if bmi < th and overweight if bmi was > th percentile. children with blood pressure > th percentile, adjusted for age and sex were categorised as hypertensive. information on socio-demographic features and family history of diabetes was obtained through standardized questionnaire. result: independent student t-tests showed significantly higher percentage of body fat among girls ( . %) as compared to boys ( . %). mann-whitney u-test analysis depicts significantly higher level of fasting sugar among girls ( . mmol/ml) than boys ( . mmol/ml). out of children ( . %) were insulin resistant. among them five were underweight while seven were overweight, / (sbp/dbp) were hypertensive and had family history of diabetes. conclusion: high prevalence of insulin resistance, a precursor of diabetes among these children foreshadows a worrisome trend for the burden of type diabetes in near future. both aims, losing weight as well as improving metabolic conditions, should be reached within the first weeks of an intervention program already. therefore, results of a short-time intervention concept should be presented. in answer to a regional tv-report dealing with "successful weight loss", overweight adults contacted the freiburg institute of preventive medicine (ipm) to participate in a -week intervention program. after looking for exclusion criteria, patients ( . ae . years, . ae . m/kg bmi) could be included. the ipm concept consists of an initial consultation in energy balance and life style changes, the use of a soy-yoghurt-honey product (almased â , per day as meal replacement), and the facility for guidance by phone. forty patients completed the program attending the exit examination. starting from a comparable bmi, the females were younger (n = ; . ae . years) than the males (n = ; . ae . years) and showed less associated risk factors. of significantly older age was the subgroup of patients with metabolic syndrome (ms) or type diabetes mellitus (t dm) (n = ; . ae . years). all completers were successful in losing weight (pre-post diff. . ae . kg) and showed a comparable weight reduction after intervention: females À . %, males À . %, ms/t dm patients À . %. the weight reduction was impressively accompanied by improvements of the metabolic milieu (tg, ldl-c, fbg, hba c) particularly in the ms/ t dm patients. the results confirm that the ipm concept is a successful way to lose weight initially and to improve the metabolic milieu within a shorttime period using a product with a high impact of bioactive compounds. objective: menopause-related changes in female body are associated with the greater risk of metabolic syndrome (ms), which includes obesity, dyslipidemia, impaired glucose tolerance, hypertension. the purpose of our study: was to reveal peculiarities of fat and lean mass distribution between postmenopausal women with abdominal obesity and with ms. design and method: the sample consisted of postmenopausal - years old women (age: mean = . ; sd = . ); duration of menopause: mean = . ; sd = . ). the diagnosis of ms was considered according to idf ( year) criteria. lean and fat mass distrubution were measured by dual-energy x-ray absortiometry, and were compared for the cohorts with and without ms. data were analyzed using statistical package . (statsoft). background and aims: attempts to curb the ongoing epidemic of obesity and diabetes in the us and other developed countries will benefit from better understanding of the broad and upstream determinants of the population prevalence of these conditions. this study explores how individual psychosocial characteristics in addition to the social and physical community environment correlate with prevalent obesity and markers of pre-diabetes in a statewide representative sample of the population of wisconsin, usa. methods: we used cross-sectional data from the to cycles of the ongoing survey of the health of wisconsin (show) a geographically diverse population-based research study of adults, age - years (n = ). obesity (bmi ! kg/m ) and hemoglobin a c levels were the main outcomes. independent variables included individual socioeconomic status (ses), food insecurity, psychosocial status (depression, anxiety and stress), perceived discrimination and neighborhood resources, and access to health are. contextual predictors included county and census-block group socioeconomic nutrition, and built environment indicators. results: the prevalence of obesity and prediabetes was positively associated with lower ses, food insecurity, markers of depression and anxiety, perceptions about lower access to healthy food and physical activity resources in the neighborhood, and poor health care access. lower community-level ses and a poor nutritional and built environment were also associated with higher frequency of obesity and prediabetes. conclusion: our findings on the psychosocial and contextual correlates of obesity and prediabetes offer insights regarding the profile of individuals and subgroups and where tailored individual and community level interventions are most needed. objective: gastric bypass (gbp) is currently the most effective way of treating obesity. interestingly, the majority of type diabetes (t d) patients display remission of the disease after gbp. the underlying mechanisms behind this remission are not known. we used a porcine model to study how hormonal and metobolite profiles are affected by gbp. in addition we studied the impact of gbp on endocrine cell populations in the gut and pancreatic islets. methods: gbp-pigs were subjected to oral (ogtt) and intravenous (ivgtt) glucose tolerance tests before and after surgery. shamoperated, pair-fed pigs served as controls. results: during ivgtt gbp-pigs displayed lower glucose and higher insulin levels compared to controls. during ogtt, gbp-pigs displayed higher glucose and a more rapid and robust insulin response than controls. in line with this, gbp-pigs had higher beta cell mass and more extra-islet beta cells. further, during ogtt gbp-pigs displayed robustly elevated gip levels, whereas glp- levels were unchanged. furthermore, gbp-pigs displayed elevated density of gipproducing k-cells, but reduced density of glp- -producing l-cells in the gut. metabolomic analyses revealed a difference in the metabolite pattern between the two groups, mainly explained by the fact that gbp provoked lower levels of free fatty acids (ffa) and higher levels of branch-chain amino acids (bcaa). conclusions: gbp in pigs provokes, . enhanced insulin secretion and increased beta cell mass. background: several authors have recently reported that both hiv replication and antiretroviral therapy (art) may influence adiponectin expresion which is correlated with insulin sensitivity via glucose transporter type recruitment to plasma membrane. we assessed serum adiponectin patterns in a cohort of hiv- positive caucasian patients undergoing cart in relation to insulin resistance (ir) and hiv replication. a cross-sectional study was performed in a cohort of hiv- infected patients attending the national institute of infectious diseases, bucharest. blood samples were tested for hiv viral load and adiponectin. insulin resistance was estimated by homoeostasis model assessment. in order to evaluate differences between groups we used mann-whitney-wilcoxon and t-tests. results: eighty patients ( . % males) with a median age of years (iqr years) were included in the study. the median time from hiv diagnosis was . months and the median time on cart was . months. most patients ( . %) had undetectable serum hiv loads. median adiponectin serum value was . lg/ml (iqr ). most patients ( . %) had insulin resistance. insulin resistant patients had significantly lower median levels of adiponectin ( . vs. . lg/ ml, p = . ). there were no significant differences between median adiponectin serum levels in groups with persistent and undetectable hiv replication (p = . ). no significant correlation was noted between insulin resistance and hiv replication. conclusions: in our cohort of young hiv- patients with a high prevalence of ir decreased adiponectin serum levels were associated with decreased insulin sensitivity. hiv replication may not influence in vivo adiponectin expression. objective: to examine obesity and metabolic disorders associated with vitd deficiency/insufficiency in children older people. methods: cross sectional study in community-dwelling subjects - year ( women) residing in santiago chile. plasma levels of (oh)d were determined by radioimmunoassay. glucose, insulin and crpus, were measured in a fasting blood sample. blood pressure and complete anthropometry were measured. results: mean serum (oh)d was . ae . nmol/l (men . ae . ; women . ae . , p < . ). (oh)d levels were under nmol/l in . % of men and . % of women (p = . ). insulin resistance was present in . % of all subjects and obesity in . % of women and . % of men (p < . ). significant negative crude association between (oh)d across bmi categories was found in the total sample (p < . ). crude association of vitd < nmol/l with obesity (p = . ), waist circumference (p = . ), insulin resistance (p < . ), metabolic syndrome (p = . ), hta (p < . ) and age ! year (p < . ) was observed. after age, sex, waist circumference and season adjustment, vitd < nmol/l was associated with increased risk of insulin resistance, or . (ic % . - . ) p = . . conclusion: high prevalence of vitd deficiency/insufficiency was observed in the chilean older people. vitd deficiency is associated with insulin resistance. in the future, randomized controlled trials are needed to establish a cause-effect relationship between vitd deficiency, obesity and its metabolic consequences. surrogate markers are used to estimate degree of steatosis and liver fibrosis in nafld. oxidative stress is important in the pathophysiology of nafld. the aim of this study is to find correlations between blood antioxidants and laboratory variables that are routinely determined in patients with nafld in clinical practice and used in fibrosis test. thirty-five obese children ( - years old) with increased liver echogenicity on ultrasounds and healthy lean children were enrolled. other causes of chronic hepatitis, such as chronic viral hepatitis, were excluded. erythrocyte superoxid dismutase (sod), glutathione peroxidase (gpx) activities and plasma levels for albumin, uric acid and bilirubin were measured as antioxidants. the nafld fibrosis score was calculated by an altgoritm including: age, bmi, glycaemia, platelet number, albumin, ast/alt. pearson correlations were calculated. none of the obese children had fibrosis according to the test score. obese children with nafld had lower levels for albumin (p < . ), but higher levels for uric acid (p < . ), sod and gpx activities (p < . ) vs. lean children. all the measured antioxidants were related with variables included in the fibrosis test. for p < . , the calculated correlations were: sod activity with alt activity (r = À . ) and albumin (r = . ), gpx activity with ast/alt ratio (r = . ), uric acid with alt activity, age and bmi (r = . ). this study demonstrates strong relations between blood antioxidant defence systems with fibrosis test variables in nafld in obese children. women; diabetes prevention programs (dpp) are only available for adults at high risk of developing t d. . to develop a dpp for post-gd women. . to assess the feasibility/acceptability of this dpp through a pilot rollout. methods: a working group was formed to develop a dpp that incorporated the needs of a mother with a young family around established lifestyle modification goals. this program was piloted with a group of nine post-gd women. the pilot had high attendance levels ( - % for group sessions), but only % of participants attended all sessions (illness and travel commitments causing non-attendance). the original magda dpp was restructured to: an individual session, five group sessions and two follow-up telephone conversations. childcare arrangements were investigated, but participants elected to have their children attend sessions. participants reported the program to be acceptable and suited to their needs. the pilot determined that the program was feasible and met the needs of the target population. currently, recruitment is underway for post-gd women from three hospital sites for the magda study, which uses a dpp designed for post-gd women and has a whole-of-family focus and tackles common barriers to success. objectives: assess the risk factors associated to physical inactivity (pi). a cross-sectional study was performed in in subjects aged ! years, in the urban area of montes claros, brazil. the physical inactivity level was determined by the international physical activity questionnaire short version. the subjects were classified in active ( ! min per week) and sedentary (< min per week). the univariate analysis was first performed and were included in the model when associated with p < . . the poisson regression with robust variance was realized and the prevalence ratio (pr)-crude and adjusted-and % confidence intervals (ci) were estimated to determine the relationship between pi and risk factors like sex, age group, skin color, marital status, income, education, hypertension, dyslipidemia and overweight. the variables that remained significant when adjusted. the statistic was performed in stata. results: a sample of individuals were studied ( . % women). the prevalence of pi was of . %. the variables were associated with pi were sex, the age group, marital status, education, hypertension, dyslipidemia and overweight with p < . . the following variables were significantly associated with pi after adjustment for confounding variables were: sex, female (rp = . ; ic: . - . ) and marital status, separated/divorced/widowed (rp = . ; ic: . - . ). the gender and marital status were associated with pi with pr higher for these variables in this population, which shows the need for development of effective public policies, integrated to investigate the biological causes, but also the social risk factors. objective: to determine whether an interactive mhealth exercise intervention is more effective than standard of care exercise in patients with metabolic syndrome. methods: participants [n = , mean age . (sd . ) year, % female] reported to the laboratory at baseline (v ) and follow-up [ (v ) and (v ) weeks]. anthropometrics, heart rate (hr) and blood pressure (bp) were measured and blood drawn to examine fasting glucose (fg) and glycated hemoglobin (hba c ). fitness (vo max ) was assessed and individualized exercise programs were prescribed. the intervention group received a smartphone data portal and bluetooth tm enabled biometric tracking. differences between groups in outcomes (v -v ) were examined using analyses of covariance, which adjusted for baseline levels of the outcome of interest. group differences from v to v were examined with two-way repeated measures anovas. results: at v , systolic bp was reduced in both groups but significantly more in the control group (difference in mean change: À . ; % ci: À . , À . , p = . ). there were no differences between groups at v for other outcomes. across the follow-up period, systolic bp, diastolic bp, resting hr, weight, body mass index, waist circumference and hba c were decreased, and vo max and target hr were increased for the entire study population (p < . ) with no difference in rate of change between groups. fg was significantly higher in the intervention group across the entire follow-up period (p = . ) and both groups had increasing levels over time (p = . ). conclusion: over weeks, cardio-metabolic risk factors improved with both standard and mhealth supported exercise interventions. background and aims: breastfeeding improves glucose tolerance in the early postpartum period of women with prior gestational diabetes (gdm), but it is unclear whether future risk of metabolic alterations, like type diabetes, is reduced. the aim of this study was to investigate the effect of lactation, years after pregnancy, on glucose metabolism and beta cell function in women with prior gdm. material and methods: women with prior gdm (carpenter and coustan criteria) were evaluated with comparison of results for "lactating" [bf] vs. "non lactating women" [non bf]. breastfeeding was defined exclusive if lasting more than weeks. each woman performed a -g ogtt to analyze glucose tolerance, insulin sensitivity/resistance and b-cell function. lipid and inflammatory profile was also studied. statistics: paired and un-paired t-test, mann-whitney and v tests. methods: subjects completed three randomly ordered conditions: mie ( % vo peak), hie ( % vo peak), and seated rest (control). exercise energy expenditure was equated to -kcal. one-hour postexercise (or control), subjects received a -g oral glucose tolerance test (ogtt). plasma glucose and insulin concentrations were measured before and at frequent intervals after glucose ingestion. si was derived using the following models (i) oral minimal model (omm), (ii) matsuda composite index, (iii) cederholm index, and (iv) stumvoll index. exercise induced changes in insulin action were expressed relative to the control condition (exercise-control). spearman correlation coefficients and rm-anova were used to compare relative changes in insulin sensitivity. results: si calculated during the control condition was moderately correlated among the various indices (r-value range: . - . , pvalues: . - . ). relative to control, si after mie ranged from % higher (cederholm) to % higher (omm), and after hie ranged from % lower (matsuda index) to % higher (omm excess caloric intake leads to metabolic overload and is associated with development of type diabetes (t dm). current disease management concentrates on risk factors of the disease such as blood glucose, however with limited success. we hypothesize that normalizing blood glucose levels by itself is insufficient to treat the disease and the development of complications, and that dietary interventions which diminish metabolic overload may be more efficacious in retarding the disease. we explored the efficacy and systems effects of pharmaceutical interventions vs. dietary lifestyle interventions (dli) in developing t dm and complications. high fat diet (hfd)-fed ldlr À/À mice with already established disease phenotype, to mimic the human situation, were treated with different drugs mixed into hfd or subjected to dli (switch to lowfat chow), for weeks. interventions were compared to untreated reference mice kept on hfd or chow only. although most of the drugs improved hfd-induced hyperglycemia, drugs only partially affected other risk factors and also had limited effect on disease progression towards microalbuminuria, hepatosteatosis and atherosclerosis. by contrast, dli normalized t dm risk factors, fully reversed hepatosteatosis and microalbuminuria, and attenuated atherosclerosis. the comprehensive beneficial effect of dli was reflected by normalized metabolite profiles in plasma and liver. analysis of disease pathways in liver confirmed reversion of the metabolic distortions with dli. this study demonstrates that the pathogenesis of t dm towards complications is reversible with dli and highlights the differential effects of current pharmacotherapies and their limitation to resolve the disease. introduction: obesity may induce an oxidative stress in adipose tissue, leading to deregulated expression of inflammatory cytokines which could be an early instigator of obesity-associated diabetes and cardiovascular diseases. thus, the biological effect of natural micronutrients such as plant polyphenols that may increase the antioxidant capacity of the body is of high interest. aim: our objective was to explore the antioxidant polyphenol content of three medicinal plants (gouania mauritiana, antirhea borbonica, doratoxylon apetalum) and their impact on the viability, production of reactive oxygen species (ros) and inflammatory response of preadipocytes exposed to oxidative stress. methods: polyphenol-rich extracts from plants were analyzed for their radical-scavenging capacity by dpph method. then, their ability to modulate t -l preadipocyte viability and protection against h o induced oxidative stress was assessed by both mtt viability and ldh death assays, as well as by dcfh-da test evaluating intracellular ros production. finally, il- secretion was measured by elisa. results: all plant extracts exhibited high levels of antioxidant polyphenols which protected preadipocytes against oxidative stress by decreasing ros generation and modulating the inflammatory response. such an antioxidant activity of plant extracts could be partly mediated through their radical-scavenging capacity. we identified three medicinal plants naturally rich in antioxidant polyphenols which exerted antioxidant and antiinflammatory properties on preadipocytes exposed to oxidative stress. further studies are in progress to clarify the molecular mechanism as well as in vivo potential effects of such medicinal plants to protect against metabolic and inflammatory disorders known to play a key role in obesity-related insulin resistance. background: increased fasting plasma glucose is known to lead to diabetes, and diabetes associated complications often manifesting prior to the identification of type diabetes. we aimed to determine the association of fasting plasma glucose levels with cholesterol levels and oxidative stress markers. methods: one hundred and sixty two participants attended the diabetes screening clinic, at charles sturt university, australia between february and june . participants were investigated based on the american diabetes association′s diagnostic criteria of diabetes mellitus and prediabetes, i.e. fasting bgl. results: atherogenic index of plasma (aip) was elevated in the prediabetes group ( . ae . ) and continued to increase in the diabetes group ( . ae . ) compared to controls (À . ae . ; p < . ). serum -hydroxy- -deoxy-guanosine ( -ohdg) level was greater in the prediabetes ( . ae . pg/ml) compared to controls ( . ae . pg/ml; p < . ). the diabetes group ( . ae . pg/ml) had the highest level of -ohdg. these changes paralleled by a reduction in erythrocyte reduced glutathione (gsh) from controls ( . ae mg/ ml, p < . ) to prediabetes ( . ae mg/ ml; p < . ) and the diabetes group ( . ae . mg/ ml, p < . ). conclusion: this increase in -ohdg may be related to the decrease in erythrocyte gsh antioxidant capacity. a statistical significant positive correlation (pearson's r = . ; p < . ) between aip and -ohdg suggests that -ohdg may be a useful additional biomarker to determine the degree atherogenic risk in the presence of elevated lipids. rowett institute of nutrition and health, university of aberdeen, aberdeen, uk, ilsi europe, brussels, belgium, lund university, lund, sweden, mechanistic evidence suggests that elevated blood glucose levels contribute to the development of t dm. adoption of a nutritional approach to manage postprandial glycaemia could deliver a cost-effective t dm prevention and management strategy, applicable across the population. to implement a successful strategy it is essential to understand the impact of dietary modulation on the postprandial rise in blood glucose concentrations. for this reason, a systematic and comprehensive literature review was undertaken, using the highest quality data. included were the major macronutrients (carbohydrate, protein, fat), micronutrient vitamins and minerals, non-nutrient phytochemicals and additional foods including low-calorie sweeteners, vinegar and alcohol. the strongest corroboration of efficacy for improving glucose homeostasis was for insoluble and moderately fermentable cereal-based fibre and monounsaturated fatty acids as replacement of saturated fat. postprandial glucose levels were decreased by intake of viscous soluble fibre and this was considered to be predominantly by delaying absorption of coingested carbohydrates. weaker but substantial evidence demonstrated that certain phytochemical-rich foods were likely to be effective and this may be associated with the suggestion that the gut microbiota plays an important role in metabolic regulation, including provision of phytochemical and other metabolites. it is clear that dietary components have significant and clinically relevant effects on blood glucose modulation. this suggests that employing a dietary regimen to attenuate the postprandial rise in blood glucose levels along with previously identified targets (reducing excess body weight and an increase in physical activity) will benefit the health of the population and limit the increasing worldwide incidence of t dm. knowing their metabolic control, and lipid profile, through an early intervention, we can reduce their risk factors for cardiovascular disease, and diabetes complications. the aim of our study was to determine the lipid profile of patients newly diagnosed with type diabetes. patients and methods: hundred patients, selected at the outpatient policlinic nr. in tirana, the capital of albania. all the patients had completed anthropometric measures, hba c and lipid profile after a -h fast. the persons younger than years, diabetes diagnosed prior to months, or uncompleted data were excluded from the study. results: we obtained all the data for patients. males ( %), mean age . ae . years, mean bmi . ae . kg/m², mean hba c . ae . %. . % of the patients had a total cholesterol > mg/dl, % of the patients had triglycerides > mg/dl, and . % of them had tg < mg/dl, and % had the ldl > mg/ dl . % of males had hdl < mg/dl and % of women had hdl < mg/dl respectively. conclusions: in our study the lipid profile of albanian patients was somehow different from the common profile of patients newly diagnosed with t diabetes. even in the previous studies we have found a lipid profile with high total cholesterol levels, and especially very low hdl levels, probably due to the sedentary lifestyle, which needs further evaluation, because the metabolic control of our patients was not very bad. background and aims: physical activity (pa) in people with type diabetes helps to improve metabolic control, lipid profile, and to reduce weight. the aim of our study was to demonstrate the effect of a single session of pa to the glycaemic profile, and the effect of increasing daily physical activity on the weight and lipid profile. patients and method: fifty patients were recruited for a weeks training session. every pa session lasted min of fast walking. the number of daily steps was measured through a pedometer, and all the participants were encouraged to complete at least , steps/day. all the patients had completed anthropometric measures, fat body composition and lipid profile at the beginning and the end of study period. background: homocysteine is a cardiovascular risk factor for the development of vascular pathology. large population studies have been conducted demonstrating a positive association between homocysteine levels and risk of developing cardiovascular disease. paradoxically in type diabetes, if renal function is within a normal range, homocysteine levels are either similar or reduced when compared to levels in the normal non-diabetic population. whether the same is true for pre-diabetes has not been previously explored. our study examines the plasma levels of homocysteine in controls, and participants with prediabetes and diabetes from a screening program in regional new south wales. methods: seven hundred and forty-four participants attended the diabetes screening clinic, at charles sturt university, australia. participants were investigated based on the american diabetes association′s diagnostic criteria of diabetes mellitus and prediabetes, i.e. fasting blood sugar levels. venous plasma homocysteine samples were measured using the fluorescence polarization immunoassay on the imx â analyzer (abbott laboratories, abbott park, il). results: median age across the three groups ranged from to years. the median levels for plasma homocysteine between groups were not significantly different. there was a trend for plasma homocysteine (μmol/l) levels to be higher in the prediabetic group . ae . (sd) compared to the control group with . ae . (sd) and in the diabetic group of . ae . (sd). conclusion: there is a non-significant median increase in homocysteine in the pre-diabetes group. further larger cross-sectional population studies would be able to address whether this is a chance effect and also establish statistical significance if present. clinical endocrinology, institute for endocrine pathology problems, kharkiv, ukraine introduction: active acromegaly is associated with increased morbidity attributed by systemic complications such as carbohydrate dysfunction. aims: to evaluate the effects of chronic excess of gh and igf-i on prevalence and structure of carbohydrate dysfunction in patients with active acromegaly. subjects and methods: ninety-seven patients ( men and women; aged - years) with macroadenoma of hypophysis ( somatotropinoma, -somatomammo-tropinoma) were under investigation. blood samples for gh, igf- , immuno-reactive insulin (iri), glucose were taken in fasting state and on min ottg. insulin sensitivity and b-cell function were estimated by homa calculator v. . data are given as m ae se and coefficient of determination (r ) of multiple regression analysis. results: in . % of patients with acromegalia (gh - . ae . ng/ ml; igf- - . ae . ng/ml) different types of carbohydrate dysfunctions (cd) were found out: fasting hyperglycemia ( . %); impaired glucose tolerance ( . %), and diabetes mellitus ( . %). . % of patients have had hyperinsulinemic state. it was no sex differences in the cd structure. iri level was . ae . mu/ml, insulin sensitivity - . ae . %, β-cell activity - . ae . %. homa _ir was positively associated with gh (r = . %, p = . ) and igf- (r = . %, p = . ). homa _b% was positively associated with gh (r = . %, p = . ) and igf- (r = . %, p = . ), and negatively with disease duration (r = . %, p = . ). the gh hypersecretion and length of its pathologic action predetermine the stage of carbohydrate dysfunction from fasting hyperglycemia, impaired glucose tolerance to overt diabetes mellitus. a. vlassopoulos, m. lean, e. combet human nutrition, school of medicine, university of glasgow, glasgow, uk background: protein glycation is a key mechanism behind chronic diseases in both diabetic and non-diabetic individuals. about - % of circulating proteins are glycated in vivo in normoglycaemic blood, but in-vitro studies have hitherto failed to demonstrate glucose-driven glycation below concentration of mmol/l. methods: albumin, mercaptalbumin ( g/l) and plasma was incubated with glucose at different concentrations ( - mmol/l) for weeks at °c. to investigate the effect of oxidation on protein glycation, all protein models were used as native proteins or oxidized proteins (exposed to nmol/l h for h prior to incubation with glucose and throughout the incubation period). fructosamine was measured at and weeks (nitroblue tetrazolium method). oxidised mercaptalbumin and plasma had higher fructosamine concentrations at weeks at mmol/l glucose compared to native controls (p < . ). at mmol/l glucose, the same effect was observed for albumin and mercaptalbumin but not plasma. only oxidized albumin was significantly glycated at weeks with mmol/l glucose (compared to glucose-free control) when native was not. at weeks no effect of oxidation was observed. the current study has for the first time demonstrated the importance of oxidative stress in physiological protein glycation, interacting with glucose and promoting glycation in the early stages of the process. k. elksne , z. paunina , a. jurka , d. rezeberga , p. tretjakovs obstetrics and gynecology, physiology, rigas stradins university, riga, latvia introduction: a growing number of obese women in their reproductive years increases their risk for obstetric complications, but still the exact mechanisms is not known. we created a prospective study in which clinical data were collected from antenatal visits in pregnant women. obstetric outcomes were assessed at delivery. obstetrical outcomes depending on fetal macrosomia and maternal bmi were analysed using the fisher exact test. relationships between pre-pregnacy bmi, gestational weight gain and fetal weight were analysed using spearman rank correlations. results: overweight women had lower total weight gain during pregnancy, but higher risk for obstetric complications such as fetal macrosomia, uterine dysfunction, ceasarean section and ruptures of the birth canal. fetal macrosomia positively correlated with pre-pregnancy weight, but not with gestational weight gain during pregnancy. also male gender is a risk factor for birth weight above g. it is important to increase the number of planned pregnancies, pre-pregnancy visits to doctor in order to inform women about the impact of excess weight on perinatal outcome as fetal macrosomia is associated with impaired maternal bmi. women with bmi normal before pregnancy increased their weight above recommendations during gestation. as excessive weight gain may be a risk factor for long term complications, more information about diet should be provided in antenatal visits. obesity and fetal macrosomia correlate with complications during labour, so additional attention in birth conducting should be paid. background: the obesity epidemic is widely blamed for the rise in type diabetes, but new research suggests it is also linked to the increase in type diabetes (t d). the combination of obesity and t d has a negative impact on metabolic control in patients with t d in particular during pregnancy. aim: to evaluate the rate of overweight or obese women with t d at pregnancy onset according to their body mass index (bmi) and its relation to metabolic control. we performed an analysis of singleton pregnancies of women with t d, who consulted our diabetes outpatient clinic since . results: all women were caucasians with mean age of ae years and average diabetes duration of ae years. only % of all women with t d had a bmi of < kg/m , % were overweight with bmi between . % and . % and % were obese. the metabolic control was similar between the group with normal bmi and bmi > kg/m ( . ae . % vs. . ae . %). in the patients with normal bmi only % started the pregnancy with a hba c < %, which was mainly due to unplanned pregnancies. conclusion: our data revealed a high proportion of overweight women with t d at onset of their pregnancy, confirming the worldwide trend of rising obesity rates and which calls for preventive measures in the preconception counseling. hypertension is more prevalent in hivinfected subjects than in general population, contributing to increased cardiovascular risk in hiv+ patients. moreover, hiv patients more frequently showed metabolic alteration than general population. aim of this study was to evaluate the effect of weeks of administration with telmisartan mg daily in hiv+ patients. we enrolled hiv+ caucasian male patients treated with combined antiretroviral therapy (cart) and discovered to be na€ ıve hypertensive. systolic (sbp) and diastolic (dbp) blood pressure, viro immunological parameters and triglycerides, cholesterol, insulin resistance (homa-ir), inflammatory markers, c-reactive protein (crp), indexes of renal function and cardiovascular risk, microalbuminuria, cystatin c, were measured at baseline (t ), and after (t ), (t ), (t ), (t ), (t ) and (t ) weeks. treatment with telmisartan decreased sbp and dbp levels during the weeks of observation. we also observed improved in totalcholesterol, triglycerides, and in total cholesterol/hdl cholesterol ratio. we also observed an microalbuminuria and cystatin c improvement at the end of study. throughout in the course of the trial our patients showed a significant improvement of the percentage of cd + and cd . telmisartan doesn't interfere with the recovery of immunological parameters in this patients. telmisartan has confirmed durability and effectiveness, excellent tolerability and an high persistance with a good blood pressure control. therefore telmisartan should be the first choice in the treatment of hypertension in hiv+. methods: the subjects studied were patients diagnosed with gdm at ska˚ne university hospital, lund, sweden, - . sera were analyzed for antibody positivity (gada, ia- a and znt a) with commercially available elisa and snps were studied with restriction fragment length polymorphism. results: combinations of two or more autoantibodies ( . %) were less frequent than single positivity for gada ( . %) or znt a ( . %), but not ia- a ( . %). patients that developed t d postpartum often had combinations of autoantibodies. heterozygosity for r w was increased ( %) in patients that developed znt a compared to znt a negative patients ( %). however this was not statistically significant (p = . ). conclusions: the previously reported prevalence of znt a in gdm was confirmed. positivity for znt a did not seem to be a good independent predictor for development of t d. the tendency of increased r w heterozygosity in znt a positive gdm patients is a novel finding and of interest since the snp has been suggested to be of importance in both t d and t d. among several consequences, obesity seems to have detrimental effects on reproductive function, causing low levels of sex hormones and reduced sperm concentration. the excess of lipids on diet influences metabolism and affects testis reproductive function. the relationship between obesity, reproductive changes and metabolic syndrome is not yet fully clarified. thus, the aim of the study was evaluate the effect of high fat diet, containing soybean oil, on body composition and male reproductive system of young rats. wistar rats, at days, received diet containing % (control diet) or % (high fat diet, hf) of soybean oil, until and days of age. food intake and body mass were monitored. at the end, body composition was evaluated by dexa and blood, liver, adipose tissue, testis and epidydimis were collected. glucose, triglycerides, cholesterol, hdl, vldl, insulin and leptin were measured. food intake, body mass gain, lean mass, total fat mass and bone mineral content did not differ between the groups at and days. at days, glycemia and epidydimal adipose tissue mass were increased in rats fed with hf. at days, glycemia, leptinemia and the mass of mesenteric adipose tissue, liver and epidydimis were high after hf ingestion, while tg was low. the excess of lipids reflected negatively on intra-abdominal adipose tissue since days, accompanied by hyperglycemia. the hf ingestion maintained high glucose and leptin concentrations without insulin alteration. at the same time, it could predict some testis function change, once epidydimis mass increased in these young animals. adipose tissue is linked to cardio-vascular and metabolic complications of obesity by increased local production of adipokines.to investigate serum levels of adipokines (adiponectin and leptin) and relationship with obesity anthropometric markers and insulin resistance in overweight/obese patients with type diabetes. two groups of subjects were selected: group with type diabetes mellitus (n = ) and control group (n = ). the first group was subdivided in two subgroups, according with bmi (overweight and obese). in all individuals were assessed bmi, waist and hip circumference, visceral fat index, serum levels of adiponectin, leptin, insulin and proinsulin and homa-ir was calculated. the determined parameters were modified significantly in the diabetic patients vs. control. comparing the obese diabetic patients with the overweight, serum levels of leptin were higher on obese/overweight (p < . ) and levels of adiponectin were lower (p < . ). also, serum levels of insulin and proinsulin were higher in diabetic vs. control group maintained their statistical significance difference in the subgroups of overweight/obese (p < . and, respectively, p < . ). bmi was positively correlated with leptin (p < . ) and adiponectin negatively (p < . ). moreover, leptin was positively correlated with visceral fat index (p < . ), waist circumference (p < . ) and homa-ir (p < . ); adiponectin was negatively correlated with waist circumference (p < . ), visceral fat index (p < . ) and homa-ir (p < . ). in conclusion positive correlation (leptin) and negative (adiponectin) with anthropometric markers of obesity and homa-ir, demonstrating the role of adipokines in the pathogenesis of peripheral insulin resistance in patients with "diabesity." materials and methods: based on research institute of nutrition we randomly chose patients with varying class obesity, who were outpatient for this disease. all patients were tested on the personal scale manifestations of anxiety (d. teylor in adapting t. nemchina). patients were asked to read a set of sentences ( questions) about their traits. if they agreed with the statement they should answer "yes" if they did not agree -"no". the test had a ball-evaluation, in which anxiety is defined as very high, high, medium and low. objectives: the process of converting prediabetes to diabetes remains a matter of debate. the aim of the study was to assess insulin sensitivity/resistance indices and markers of oxidative stress in prediabetic persons. methods: obese non-smoking caucasians, using neither special diet nor medication, without acute and chronic disorders, were qualified for ogtt and assigned to groups: normal glucose tolerance-ngt, impaired fasting glycemia-ifg, impaired glucose tolerance-igt and newly diagnosed type diabetes-t dm, each group n = subjects: f/ m; age : - (median: quartiles - ). plasma glucose (siemens) and insulin (biosource) were determined during ogtt ( ', '). plasma total antioxidant status-tas (randox), thiobarbituric acid-reacting substances-tbars (sigma), lipids and hscrp (siemens), as well as hba c (hplc) were assayed fasting. different indices of insulin sensitivity/resistance, fasting steady-state and derived from ogtt, were calculated. results: the groups did not differ according to age, bmi, waist, blood pressure, lipids and hscrp. insulin sensitivity/resistance indices presented variety of sensitivities and specificities for prediction of dysglycaemia categories, as well as different correlations with metabolic parameters, including oxidative stress, i.e. isi , &tas (r = . ), isi , &tbars (r = À . ) in the population n = . the comparison of ngt-ifg-igt-t dm, showed the highest tas in ifg and the lowest in t dm (p = . ), together with increasing tbars from ngt to t dm (p = . ). the results of roc curves analysis pointed isi , ( % sensitivity; % specificity) for prediction of igt, and tas ( % sensitivity; % specificity) in differentiation between igt and t dm. conclusions: insulin-sensitivity indices predict prediabetes in obese subjects near perfectly, while the development of diabetes is preceded by antioxidant insufficiency rather. m. smiraglia , g. bott a , e. orsi endocrinology and diabetolgy, fondazione ca' granda irccs -ospedale maggiore policlinico di milano, biomolecular sciences and biotechnology, university of milan, milan, italy t dm is a metabolic disorder and evidences show that medical nutrition therapy improving glucose metabolism reducing the risk of complications, leads to an improvement in life quality and increase life expectancy. the aims of diabetes management are normalize blood glucose levels and weight control. obesity influences the development of t dm and complicates its management. the study aim was to value the effect of two different nutritional treatments (nt) on the anthropometric parameters and glucose metabolism in patients with t dm and obesity. the two nt are: the "low gi diet" that promotes the carbohydrates quality and the food choice is made on the glycemic index; the "low-carbohydrate diet" is based on the concept that glucose metabolism is influenced also by the carbohydrates amount. subjects, selected on including and excluding criteria, were randomly divided in two groups, to each of which one of the two nt was assigned. during the study participants were measured three times. all statistic differences in the values were analyzed with the use of anova test. the "low-gi group" showed a significant decrease in hba c (À . %; p = . ). data suggest that this nt positively influences the glycemic control. the "low-carb group" showed a significant decrease in insulin level (À . %; p = . ), a greater reduction in bmi and whr and a homa-insulin resistance index reduction (À . %; p = . ). the daily reduction of carbohydrate intake influenced positively the blood glucose response and significantly reduced plasmatic insulin levels. data suggest that either nt improves glycemic control and peripheral insulin sensitivity. aims of study: the use of metformin to control glucose in pregnant women with gestational diabetes mellitus (gdm) to evaluate its safty use during the first trimester of pregnancy. design: cases report of four patients with gdm from the first trimester of pregnancy non smoking with no family history of congenital malformation disease, aged between ( and ) and have no liver diseases put on metformin were participated in this study and who had indicating good comliance at more than one visit over several month until delivery. result: all four patient in oure study delivered healthy babies. internal medicine, ist medical clinic, umf iuliu hatieganu cluj-napoca, immunology laboratory, emergency county clinical hospital, cluj-napoca, romania introduction: the potential role of oxidative stress (os) in metabolic syndrome (mets) is rapidly evolving. reported results support the concept that increased os may play a key role in the development of atherosclerosis, hypertension and diabetes. study aim: the purpose of the present study was to analyze the impact of mets and its individual components on os and on the antioxidant status. material and methods: seventy-two hospitalized patients with a mean age . ae . years were taken under study between october and june . mets was diagnosed based on aha/nhlbi/idf definition. os was assessed by urinary iso-prostaglandinf a ( iso-pgf a) (immunometric assays) and plasmatic uric acid. antioxidant status was evaluated by plasmatic gluthatione peroxidase (gpx). these data were compared to those of biologically and clinically healthy subjects (mean age . ae . years). results: all biomarkers were significantly higher in mets patients as compared with healthy individuals (p < . ), except gpx which was significantly lower (p < . ). gpx and uric acid were statistically significant correlated. in multivariate analysis iso-pgf a concentrations were influenced by hypertension, fasting glucose and triglycerides, uric acid levels were directly influenced by hypertension, waist circumference, fasting glucose and triglycerides. gpx levels were inversely correlated with blood pressure (all p < . ). only gpx was influenced by the number of mets components. objective: the purpose of this study was to compare changes in the plasma metabolome during an intravenous glucose tolerance test (ivgtt) among persons with low or high insulin sensitivity (si < . or > . ). methods: ivgtts were performed in men and women, ae years, with low si ( . ae . ) and men and women, ae years, with high si ( . ae . ). targeted electrospray ionization, tandem mass spectrometry was used to measure plasma concentrations of amino acids and acylcarnitines during the first phase of the ivgtt. other metabolites (glucose, insulin, etc.) were measured by conventional methods. results: fasting glucose, insulin, triglycerides, glycerol, free fatty acids, leucine/isoleucine, tyrosine, glutamate/glutamine, -hydroxypalmitoleylcarnitine (c : -oh)/dicarboxytetradecanoylcarnitine (c : -dc), and docosanoylcarnitine (c ) were significantly higher in the low si group, whereas ornithine was significantly lower. in response to glucose infusion, rates of disappearance of alanine, proline, valine, leucine/ isoleucine, methionine, and phenylalanine were %, %, %, %, %, and % lower, respectively, in the low si group. there were no group differences in changes in circulating concentrations of free fatty acids, glycerol, triglycerides, or acylcarnitines. conclusions: insulin resistance is associated with lower rates of disappearance of neutral, non-polar amino acids during the first phase of the ivgtt, suggesting insulin-mediated clearance of amino acids and/or suppression of protein catabolism may be impaired. cigarette smoking is worrisome in adults and also in adolescents. actually, smoking rates have grown, especially among girls, and little is known about the damages caused in these organisms still young or the consequences in adulthood. this study aim evaluates the influence of smoking in puberty and the consequences of withdrawal, body composition of female and male mice. at days, mice were exposed to r f cigarette (tobacco and health research institute) smoke, h/day for days (s, n = ). then, half of animals were evaluated and the other half was maintained and evaluated days after stop exposure ( d as). an unexposed group accompanied the events (ns, n = ). body mass, body composition (dexa), food intake, blood, ipgtt and adipose tissue were evaluated. during exposure food intake was similar all groups, however, s groups showed low body mass gain. das, s groups increased body mass and food intake in females. no alterations body composition were in males, while in females, increased total body and trunk fat during exposure and lean mass das. fat was high epidydimal and retroperitoneal in females. in regard blood, males did not alter insulin or ipgtt during exposure whilst females had high insulin levels and glycemia at min. withdrawal induced in males, high insulin and low glycemia the ipgtt and in females normal insulin and low glycemia. the set of results indicates different response cigarette smoke in young that seem to start in females and lead malefic metabolic alterations in adulthood. methods: this retrospective study included children and youths ( boys) from the children's obesity clinic. data were measured at the time for inclusion and included values of body mass index (bmi) standard deviation score (sds), blood pressure, gender, and biochemical measures, including the fasting concentrations of blood glucose, serum insulin, hba c, and serum lipids. the bmi sds was median . (range . - . ) and the age was median . (range . - . ) years. prediabetes was classified as a fasting blood glucose ! . and < . mmol/l. the mann-whitney-wilcoxon test was used for the analyses. results: prediabetes was present in ( boys) patients. these patients were older, age median . vs. . years (p = . ), had a higher bmi sds median . vs. . (p = . ), an increased fasting hba c median vs. mmol/mol (p < . ), an increased fasting serum insulin median . vs. pmol/l (p < . ), and an increased median homa-ir . vs. . (p < . ), respectively, compared to the patients with a fasting plasma glucose < . mmol/l. no differences were found in any of their fasting serum lipid levels or blood pressure (p > . ). in this large group of overweight and obese children prediabetes is prevalent. thus it seems important to identify obese subjects with prediabetes in order to prevent development of diabetes during childhood. introduction: epidemiological spreading of diabetes and developing in early age urge for finding causes and prevention before manifestation. aim of the study was testing accelerator hypothesis t. wilkin and colleges. method: the study is combined retrospective prospective. we examined history and follow up till age of years children who were referred to pediatrician endocrinologist because of obesity or diabetes. results: children from obese mothers and children with lower birth weight have more metabolic disturbances (insulin resistance, neonatal hypoglycemia, obesity, diabetes, precocious puberty, menstrual irregularity). subjects and methods: twenty-two obese women (bmi ae kg/m ) were followed during di that consisted of a days′ very-low-caloriediet (vlcd) and subsequent months low-calorie-diet followed by a months′ weight maintenance diet (wm). mrna expressions of adipokines (leptin, adiponektin, interleukines (il) - ,- ,- , tnfa, macrophage-chemoattractant-protein (mcp- ), haptoglobin) were measured, using rt-pcr, in samples obtained from abdominal scat at baseline and at the end of vlcd and wm, respectively. results: body weight (bw) and plasma crp decreased during vlcd and at the end of wm (bw: . ae . vs. . ae . vs. . ae . kg (p < . ), crp: . ae . vs. . ae . vs. . ae . mg/l (p < . ), respectively). the decrease of plasma crp during the entire months′ di correlated positively with the decreases of mrna expression of mcp- . (r = . , p < . ) and il- (r = . , p < . ) during the entire di and with the decrease of leptin mrna during initial vlcd (r = . , p < . ). no correlations were found for other adipokines. objective: to determine associations between change in lean body mass (lbm), fat mass and muscle strength with is following month of resistance training in obese postmenopausal women. methods: thirty-four ( with and without metabolic syndrome) non-diabetic obese postmenopausal were recruited. participants completed a month resistance training program ( times/week). body composition (dxa), handgrip strength and quadriceps strength were measured. fasting glucose and insulin levels as well as ogtt derived is indices (stumvoll, matsuda) and homa were also measured. non parametric correlations were performed with spss ( . ). results: significant increases in muscle strength, is and lbm as well as decreases in fat mass were observed after the intervention. however, no correlations were observed between changes in is with changes in muscle strength, lbm or fat mass in all participants as well as in subjects with or without the metabolic syndrome. conclusion: our results suggest that the changes in muscle strength, lbm and fat mass may not be associated with changes of is in obese postmenopausal women. therefore, other potential variables seem to be implicated in the changes of is in our cohort. objective: to examine the relation between total work (tw) performed and total heart rate work performed (trimps) with changes in cardiometabolic risk factors after resistance training in obese postmenopausal women. methods: thirty seven postmenopausal women (age: ae . , bmi: . ae . ) completed a month resistance training program ( times/week). body composition (dxa), blood pressure, metabolic risk factors (insulin sensitivity, h glucose, lipid profile and crp) and muscle strength were measured before and after the intervention. moreover, tw was calculated in each session by multiplying the number of repetitions, sets, weight and range of motion. thereafter, we added all training sessions. a heart rate monitor was used to assess trimps during each session. subjects were also categorized into two groups based on the top or lower th percentile of tw and trimps (high (n = ) vs. low (n = )). results: we showed that tw negatively correlated with systolic blood pressure and h glucose levels (p < . ). in addition, crp was negatively associated with trimps (p < . ). furthermore, high workers had lower levels of fat mass percentage and h glucose as well as higher lean body mass content than low workers. as for the high trimps group, we observed lower levels of crp compared to the low tripms group (p < . ). conclusion: results indicate that the quantity of work performed during resistance training is associated with better changes in metabolic risk factors in obese postmenopausal women. research design and methods: this cross sectional study included gestational diabetes patients who were diagnosed with gdm by a g ogtt and who underwent a standardized mixed meal tolerance test (mmtt). patients were divided into three groups according to the number of abnormal hyperglycemic values (group i for values, group ii for values, and group iii for values). glycemic parameters were compared to assess glycemic control (glucose, a c, ga) and gluco-metabolic homeostasis (homa-β, homa-ir). results: a total of gdm patients were recruited for this study. subjects whit a greater number of hyperglycemic values were also more hypertensive and obese, and had decreased insulin secretory functions than those with a lower number of hyperglycemic values (lnhoma-β, . ae . vs. . ae . , . ae . , p < . ). those with higher hyperglycemic values tended to have increased insulin resistance, but this result was not significant (lnhoma-ir, . ae . vs. . ae . , . ae . , p = . ). lnhoma-β correlated negatively with fasting glucose, a c, ga and ga/a c. multivariable regression analysis revealed that age and ga were significant independent predictors for lnhoma-β (standardized β = À . , À . , respectively, p < . ) but not a c. conclusions: korean women with dysfunctional pancreatic β-cells and increased insulin resistance are prone to gestational diabetes. ga, but not a c, is significantly correlated with pancreatic β-cell function. conclusion: altered adipokine profile is associated with increased cvd risk in pcos patients. these markers can serve as potential therapeutic target for decreasing their cv risk. objective: to determine the prevalence and determinants of nonalcoholic fatty liver disease (nafld) in a sample of adult iranian general population. method: this was a cross-sectional study being performed in shiraz, southern iran during a -month period from november to september through cluster random sampling of iranian general population in shiraz region. all individuals underwent anthropometric and blood pressure measurements and thorough medical history and physical examinations. laboratory measurements included fasting blood glucose (fbs), lipid profile, complete blood count (cbc) and liver function tests. nafld was diagnosed by transabdominal ultrasonography. result: overall we included subjects in this study among which there were males ( . %) and females ( . %) with the mean age of . ae . years. nafld was diagnosed in ( . %) subjects. patients with nafld were significantly older (p < . ), had higher proportion of male gender (p = . ) and had higher bmi (p < . ). they also had higher prevalence of hypertension (p < . ), high fbs (p < . ), high cholesterol (p = . ), high triglyceride (p < . ) and high waist circumference (p < . ). taking all these together, patients with nafld had significantly higher prevalence of metabolic syndrome when compared to healthy subjects (p < . ). conclusion: the prevalence of nafld in this group of iranian adult general population is . %. nafld in iranian population is associated with male gender, old age, obesity, and features of metabolic syndrome. a. othman , t. hornemann university hospital zü rich, clinical chemistry, university hospital zü rich, zü rich, switzerland -deoxysphingolipds (dsl) are atypical and neurotoxic sphingolipids which are formed by the enzyme serine-palmitoyltransferase (spt) due to a promiscuous use of l-alanine over its canonical substrate l-serine. pathologically elevated dsl levels were identified as a cause for the rare and inherited sensory neuropathy hsaniwhich is associated with several missense mutations in spt. significantly elevated dsl levels were also found in patients with mets or t dm as demonstrated in various clinical studies. principal component analysis identified the dsls as important descriptors for the mets statecomparable to triglycerides and superior to conventional mets biomarkers like fasting glucose or wcf. partial correlation analysis showed an independent correlation to plasma glucose and triglycerides. strikingly, recent data from prospective clinical studies identified plasma dsls as highly significant and independent predictors for the risk to develop t dm. elevated dsl levels were also confirmed in plasma and liver of stz rats. the dsls are therefore clinically relevant blood biomarkers for an impaired glucose homeostasis but might also be directly involved in the pathology of diabetes related sequelae. like observed in hsan the -dsl formation is significantly suppressed in response to an oral l-serine supplementation. feeding an l-serine enriched diet to stz rats resulted in a significant reduction of plasma dsls, a significant improvement of neuropathic symptoms and reduced cataract formation. our findings strongly support the value of dsls as novel and clinically relevant biomarkers in mets and t dm but also as therapeutic targets for the treatment of the diabetic neuropathy and other sequelae. objectives: prevention of cardiovascular disease focused on the early stages of atherosclerosis, including endothelial dysfunction, should arouse attention of clinicians in dysglycaemia patients especially. the aim of the study was to assess plasma e-selectin concentrations in newly diagnosed type diabetes (t dm) and in t dm patients treated with metformin, comparing with normoglycaemic individuals. material and methods: excess body mass non-smoking males and females, - years old, presented with neither acute nor chronic disease, were enrolled into the study. oral glucose tolerance test (ogtt) was performed to find normal glucose tolerance, group- (n = , age: median ; interquartile range - ) and newly diagnosed t dm, group- (n = , age: ; - ). group- consisted of t dm patients who take medication (metformin) for at least year (n = , age: ; - ) and present no retinopathy, nephropathy and neuropathy, as well as no history of coronary incident or stroke. all participants were measured plasma glucose (g- , g- ), fasting lipids and insulin, and hba c level. e-selectin concentration in plasma was assessed using elisa method (r&dsystems). data are shown as median and interquartile range. results: groups - - did not differ in respect to their age and bmi. the comparison among groups, followed by post hoc analysis, revealed different (p = . ) e-selectin concentrations, ng/ml: group- : . ( . - . ), group- : . ( . - . ), group- : . ( . - . ). in combined group + (n = ) the correlation e-selectin&g- ' was observed independently from bmi and triglycerides (multiple regression β = . ; r = . ; p = . ). conclusion: metformin therapy may limit early stages of atherosclerosis in t dm patients not only works to decrease plasma glucose. aim: to evaluation clinical efficacy of candesartan and its effect on parameters of vascular elasticity, lipid profile, lipid peroxidation and antioxidative protection against a background of single-candesartan therapy in females with arterial hypertension (ah) and abdominal obesity (ao) during menopause. methods: forty-six patients were divided into two groups. group ( subjects) were given candesartan and group ( subjects)enalapril. twenty-four hour blood pressure monitoring (bpm), pulse wave velocity; plasma lipids, diene conjugates (dc), malonic dialdehyde, superoxide dismutase (sod) and homocysteine, uric acid were estimated. the dynamics of all parameters was evaluated initially and in weeks. results: candesartan is a more effective hypertensive drug that has a valid effect on the readings of systolic blood pressure (sbp) and diastolic blood pressure (dbp) measured in the doctor's office and on the parametrs of bpm (daily sbp and dbp, daytime and nighttime sbp and dbp, sbp and dbp variability, the rate of morning rise in sbp and dbp). we revealed a favorable effect of the medication on vascular wall elasticity, valid reduction of cholesterol, low-density lipoprotein cholesterol, triglycerides, dc, homocysteine and uric acid increase in sod in group . the proved antihypertensive effect of the candesartan therapy against a background of normalization of vascular wall elasticity, plasma lipids and processes of lipid peroxidation, in the presence of differently directed correlations between clinical and biochemical characteristics, shows that candesartan has pathogenetic mechanisms of correcting ah in females with ah and ao during menopause. background: high intensity interval training (hiit) may improve insulin action in skeletal muscle, but this has never been shown. objective: to study the effect of hiit on insulin mediated glucose uptake rate in skeletal muscle. methods: four healthy sedentary males [age ae years (mean ae se), bmi . ae . kg/m ] were included. a total of eight one-legged training sessions were performed on an ergometer bicycle as min high intensity exercise (workload > % of one-legged vo -peak, and heart rate > % of maximal heart rate) with min recovery between each interval. lean leg mass before and after the training period was assessed using dual-energy x-ray absorptiometry. forty hours after the last training session, a two-step isoglycemic, hyperinsulinemic clamp was performed in combination with arteriofemoral venous catheterization. blood flow was measured with doppler ultrasonography. data were expressed per kg lean leg mass, and differences were tested by t-test. results: insulin stimulated glucose clearance rates were significantly higher in trained compared with untrained legs in both steps of the clamp (figure). the lean mass of the trained legs did not significantly differ from the untrained legs (p = . ). conclusion: hiit increases insulin stimulated glucose uptake in skeletal muscle in the leg after a very short training period. it is a time-effective training modality which may be attractive in the treatment of insulin resistance and type diabetes. (htgpos) and that this htgpos is related with the degree of insulin resistance. our aim was to characterize the adipose tissue of morbidly obese patients with mild or severe htgpos after a fat overload though the expression of a battery of genes involved in lipid metabolism. methods: we studied morbidly obese patients who had mild or severe htgpos after fat overload (patent p ). measurements of anthropometric and biochemical variables and oxidative stress biomarkers were done. samples of visceral adipose tissue were obtained during bariatric surgery in the morbidly obese patients. the rna isolation from adipose tissues was done using rneasy lipid tissue mini kit and the gene mrna expression levels were assessed by real-time pcr using an abi prism sequence detection system. results: no significant differences were observed in biochemical variables except in triglyceride levels between the two groups of morbidly obese patients with postprandial mild or severe htgpos. the morbidity obese patients with severe htgpos had a higher oxidative stress levels. genes involved in the management of triglycerides or lipid metabolism were up-regulated in morbidly obese patients with severe htgpos. conclusion: morbidly obese patients with severe htgpos had a more active adipose tissue regarding the expression of genes involved in lipid metabolisms, these data could indicate a greater flow of lipids and a greater insulin resistance in these patients. patients and methods: three hundred and nine workers ( m/ f; aged ae ; bmi . ae . kg/m ), without previous cardiovascular events, were enrolled. all subjects were evaluated for biochemical analytes (fibrinogen, c-reactive protein, uric acid, creatinine, triglycerides, t-cholesterol, hdl, ldl, homocysteine, glucose, insulin, hba c, (oh) d). all parameters were routinely assayed in corelab. these parameters together with homa-ir, systolic and diastolic blood pressure, bmi, age, percent of fat and waist circumference were processed by neural networks (autocm). the autocm matrix of connections preserves non linear associations among variables, while at the same time capturing elusive connection schemes among clusters that are often overlooked by traditional cluster analyses. results: with an appropriate pre-processing able to handle each variable according to its high and low values, auto-cm showed a clear association between (oh) d and metabolic status with graph links suggesting a protective role of high (oh) d against increase in bmi, waist circumference and abdominal fat. these associations were not clearly visible with traditional data mining tool. the neural networks map identifies the key role of vitamin d respect to all metabolic parameters considered in our study in the development of prediabetes drawing a physiopathologic road map for obesity and type diabetes. patients and methods: the study included type diabetic patients and healthy volunteer of the same age and sex. blood sample was taken for assessment of omentin and oxldl by elisa technique. also blood sample were taken for analysis of glycosylated hemoglobin, lipid profile and urine sample was taken for assessment of albumin/creatinine ratio. twenty-four hour holter was also done. the study included patients with type diabetes, their mean age were . ae . years ( . - . years), and mean duration of diabetes were . ae . years ( . - . years). omentin was significantly lower, while oxldl was significantly higher than controls. omentin had a significant negative correlation with oxldl and albumin/creatinine ratio and h holter (minimal hr, rms) and positive correlation with vldl. conclusion: a significant reduction of omentin and elevation of oxldl imply that they influence glucose metabolism in type diabetes. omentin had a significant relation to h holter may reflect its role in cardiac affection. while, albumin/creatinine ratio had a significant negative correlation with omentin and positive correlation with oxldl reflect their role in renal affection. patients and methods: the study included type diabetic patients and healthy volunteer of the same age and sex. blood sample was taken for assessment of chemerin, vaspin, adma and oxldl by elisa technique. also blood sample were taken for analysis of glycosylated hemoglobin, lipid profile and urine sample was taken for assessment of albumin/creatinine ratio. twenty-four hour holter was also done. the study included patients with type diabetes, their mean age were . ae . years ( . - . years), and mean duration of diabetes were . ae . years ( . - . years). chemerin, vaspin and oxldl were significantly higher, while adma was significantly lower than controls. chemerin had a significant positive correlation with vaspin, adma and oxldl. vaspin had a significant positive correlation with waist/height ratio, sdann, sdrr and sddrr. albumin/creatinine ratio had a significant positive correlation with chemerin, adma and oxldl. conclusion: a significant reduction of adma and elevation of chemerin, vaspin and oxldl imply that they influence glucose metabolism in type diabetes. vaspin had a significant relation to h holter may reflect its role in cardiac affection. while, albumin/ creatinine ratio had a significant positive correlation with chemerin, adma and oxldl reflect their role in renal affection. patients and methods: the study included type diabetic patients and healthy volunteer of the same age and sex. blood sample was taken for assessment of apelin, nitrous oxide and preptin by elisa technique. also blood sample were taken for analysis of glycosylated hemoglobin, lipid profile and albumin/creatinine ratio in urine. m mode echocardiography was also done. results: the study included patients with type diabetes, their mean age were . ae . years ( . - . years), and mean duration of diabetes were . ae . years ( . - . years). nitrous oxide was significantly lower, while apelin, preptin and albumin/creatinine ratio were significantly higher than controls. nitrous oxide had a significant positive correlation with lvedd, lvesd, pwt and lv mass and negative correlation with preptin and albumin/creatinine ratio. conclusion: a significant reduction of nitrous oxide and elevation of apelin and preptin and their relation to echocardiographic data imply that early assessment of these markers may unmask the initial endothelial dysfunction in type diabetic patients before overt microalbumin and renal impairment supervenes. obesity co-morbidities may appear already early in life in high-risk individuals. today we have no means to identify which obese children who are at highest risk. consequently, we have implemented a study with the objective to identify factors in obese children that could indicate early development of related co-morbidities. in this abstract we have concidered fasting glucose, h ogtt, and degree of obesity as predictors. severely obese children and adolescents treated for obesity between and (n = ), but not undergone bariatric surgery, are included. currently, follow-up measurements have been conducted in subjects. study participants undergo extensive examinations during days including e.g. cardio respiratory fitness, body composition, both oral and intravenous (ivfsgtt) glucose tolerance tests. average age of the first subjects is . years ( . - . ). follow-up time varies from . to . with an average of . years. bmissds at baseline . ( . - . ) correlates with bmi at follow-up (y = . x + . , r = . ). no other correlations with degree of obesity at baseline could be found. fasting glucose at baseline correlates with crp . years later. however, fasting glucose was not correlated with h ogtt, insulin sensitivity, diabetes, or prediabetes at follow-up. no correlations between h ogtt value at baseline and later co-morbidity was found. in the first studied subjects all, but one, of the severely obese children remained obese in early adulthood. higher level of fasting glucose at baseline predicted higher crp at follow-up. analyses from more collected data will be presented. background: obesity acts as an independent cardiovascular risk factor by mechanisms that are not fully understood. elevated levels of the pro-inflammatory cytokines interleukin(il)- , il- and plasminogen activator inhibitor (pai)- are found in obese patients. recent studies suggest that inflammation could be an adaptive response to hypoxia within the expanding adipose tissue mass. in this study we investigated the impact of hypoxia on pai- , il- and il- regulation in human adipose tissue ex vivo and in vitro. methods: primary human preadipocytes and adipocytes were prepared from subcutaneous and visceral adipose tissue. explants, preadipocytes and adipocytes were cultured under hypoxic conditions. pai- , il- and il- antigen were quantified by elisas, mrna levels were determined by realtimepcr. results: pai- , il- and il- secretion was significantly increased under hypoxic conditions in subcutaneous and visceral adipose tissue explants. hypoxia significantly upregulated il- production in preadipocytes and adipocytes up to -fold and -fold. il- and pai- were significantly increased by hypoxia in preadipocytes and adipocytes up to -fold and -fold (il- ) and . -fold and . -fold (pai- ), respectively. these results were confirmed on the level of mrna expression. conclusion: our data show that hypoxia increases il- , il- and pai- production in adipose tissue explants and in cultured human preadipocytes and adipocytes. we therefore hypothesize that hypoxia promotes the pro-inflammatory state seen in obese patients and thus could contribute to the elevated risk for cardiovascular diseases. this study sought to characterize the antioxidant properties and interaction of phenolic (free and bound) extracts from clerodendrum volubile (a leafy vegetable commonly grown and consumed in south eastern part of nigeria), with key enzymes relevant to non-insulin dependent diabetes mellitus (a-amylase and a-glucosidase) in vitro. the free phenolics of clerodendrum volubile were extracted with % acetone, while the bound phenolics were extracted from the alkaline and acid hydrolyzed residue with ethyl acetate; and their interaction with the enzymes were assessed. the phenolic extracts inhibited a-amylase, aglucosidase and fe + -induced lipid peroxidation in pancreas (in vitro) in a dose-dependent manner. however, bound phenolics had significantly higher (p < . ) a-glucosidase inhibitory activities, than free phenolics while there was no significant difference (p > . ) in their a-amylase inhibitory activities. the stronger inhibition of a-glucosidase when compared to a-amylase in both extracts is of pharmacological relevance. the stronger action of the bound phenolic extract on a-glucosidase may explain the possible bioactivity of the phenolics at the brush border end. the phenolic profile in both extracts revealed the presence of phenolic acids and flavonoids. moreover, the inhibitory properties of phenolic rich extracts from clerodendrum volubile on a-amylase, a-glucosidase and fe + -induced lipid peroxidation in pancreas could be attributed to the antioxidant properties of the extracts. from the study, clerodendrum volubile could serve as functional foods and nutraceuticals for early intervention and management of non-insulin dependent diabetes mellitus. department of kinesiology and nutrition, university of illinois at chicago, chicago, il, usa background: alternate day fasting (adf), consisting of a feed day ( -h ad libitum food intake) alternated with a fast day ( % energy restriction), is effective in reducing body weight and modulating adipose tissue physiology. however, the ability of adf in combination with endurance exercise to improve the above variables has never been tested. objective: accordingly, this study examined whether the combination of adf plus exercise produces superior changes in body weight and plasma adipokine levels, when compared to each treatment alone. methods: obese subjects (n = ) were randomized to one of four groups for weeks: . combination (adf + endurance exercise), . adf, . exercise, or . control. results: body weight was reduced (p < . ) by ae , ae , and ae kg, and fat mass decreased (p < . ) by ae , ae and ae kg in the combination, adf and exercise group, respectively. fat free mass was retained in all groups. adiponectin and resistin values did not change in any group post-treatment. leptin levels significantly decreased (p < . ) by ae , ae and ae ng/ ml in the combination, adf, and exercise group, respectively. conclusion: these findings suggest that the combination of adf plus exercise produces superior changes in body weight, body composition and leptin levels, when compared to each intervention alone. the plasma total cholesterol and triglycerides concentration were higher than other groups. adipokines results were that resistin, adiponectin, leptin, and tnf-a were significantly lower than [hf], [br] and [hc] . so it had a effect on anti-obesity. these results showed that functional rice especially giant embryonic components will probably be useful in the management of high fat diet-induced chronic disease. m.g. watve , m.s. diwekar , p. patil biology, indian institute of science eduction and research, physiology, bharati vidyapeeth medical college, pune, india a crucial link in the classical thinking of type diabetes (t d) is that insulin resistance (ir) is primary and hyperinsulinemia develops to compensate. high levels of insulin are associated with an insulin resistant state. there have been alternative suggestions that insulin overproduction is primary and ir develops to compensate it. it is also likely that both are secondary effects of an unknown primary cause. we critically examine the alternative possibilities in the light of theory and evidence. temporally hypoglycemia and/or hyperinsulinemia precede insulin resistance in human and animal iugr models. various gene knockouts show that primary muscle and adipose insulin resistance does not lead to hi. in insulinomas, where hyperinsulinemia is primary, insulin resistance develops almost invariably and removal of such tumors increases insulin sensitivity. if ir sets in first, pancreas must sense the ir and increase the insulin production accordingly. if raised blood glucose mediates the response, we expect a positive correlation between fasting glucose and fasting insulin in prediabetic individuals. however, such a correlation is not seen in a large set of data on normoglycemics. no other mechanisms have been postulated that can measure the level of ir and in turn regulate the insulin secretion by beta cells. on the other hand many pathways exist that can induce ir when beta cells overproduce insulin. overall there is substantially more evidence for the hyperinsulinemia-first hypothesis. this can potentially undermine our current understanding of t d and the entire chain of processes leading to t d needs to be re-examined. non-alcoholic fatty liver disease (nafld) is emerging as the most common liver disease in industrialized countries. the discovery of food components that would ameliorate nafld is therefore of interest. betulinic acid (ba) is a pentacyclic triterpenoid showing many pharmacological activities, but effect of ba on fatty liver is largely unknown. to explore the anti-fatty liver activity and mechanism of ba, insulin resistant hepg cells, primary rat hepatocytes and liver tissue of icr mice fed on hfd were utilized. oil red o staining revealed that ba significantly suppressed the excessive triglyceride accumulation in hepg cells and liver of mice fed on hfd. ca + -calmodulin dependent protein kinase kinase (camkk) and amp-activated protein kinase (ampk) were both activated by ba treatment. in contrast, protein expression of sterol regulatory element-binding protein (srebp ), mammalian target of rapamycin (mtor) and s kinase (s k) were all suppressed when hepatocytes were treated with ba for up to h period. ba activated ampk by phosphorylation, suppressed srebp mrna expression and nuclear translocation and repressed srebp target gene expression in hepg cells and primary hepatocytes, leading to reduced lipogenesis and lipid accumulation. these effects were completely abolished in the presence of sto- (a camkk inhibitor) or compound c (an ampk inhibitor), indicating that bainduced anti-hepatic steatosis was mediated through modulation of camkk-ampk-srebp signaling pathway. taken together, our results suggest that ba can effectively ameliorate intracellular lipid accumulation in liver cells, and thus it may be a potential therapeutic agent for treating fatty liver disease. blood glucose concentration, insulin level, glucokinase, g pase and pepck were significantly decrease relative to the [hf] . in addition, antioxidantresults were that cat, sod and gpx were higher than [hf] . effect of rice supplementation type of giant embryonic on erythrocyte tbars and plasma tbars showed significantly decrease than other groups. these experiments suggest that components of giant embryonic help to lower the level of and blood glucose which reduces the risk of heart disease and diabetes. method: a g o-gtt was performed in normal-weight (n) healthy females, females with overweight and females with obesity (grades - ), with measurements of glucose and insulin. homa-insulin resistance (ir) and belfiore-insulin sensitivity (is) were caldulcated. the th percentile in the n group was used as cut-off. results: ir was present in . % of women with normal weight and in . % of women with overweight/obesity. . %, . % and . % of women have ir in the obesity grade , and , respectively. further risk factors for ir are age, hip-waist ratio, triglycerides, hdl, uric acid, pai- and fibrinogen (p < . ). hba c is irrelevant for the detection of ir. hormonal imbalances (hyperandrogenemia, igf deficiency, hypothyroidism, elevated estradiol) play a major role in obese women. postmenopausal women receiving hormone replacement therapy (hrt) develop hyperglycemia, as expected by age, but not ir. hrt improves is. discussion: ir is the common pathogenetic factor for risk components summarized as "metabolic syndrome": dyslipidemia, hypertension, hyperandrogenism and obesity. the vicious circle is intensified with the degree of ir. during the to -year interval between the onset of ir and the manifestation of dm, significant micro-and macroangiopathies can develop. early detection of ir is therefore crucial for the prevention of dm and cvd. the costs involved for diagnosis are minimal ( - €) compared to the cost of treatment for dm and cvd. the effect of dietary feeding of "superjami" on the glucose metabolism and antioxidative status in mice under high fat diet conditions was investigated. the mice were randomly divided and given experimental diets for weeks: normal control (nc group), high fat (hf group), and high fat supplemented with heukjinju (hf + hj group), suwon (hf + sw group) and superjami (hf + sj group). at the end of the experimental period, the hf group exhibited markedly higher blood glucose level. however, diet supplementation of superjami was found to counteract the high fatinduced hyperglycemia and oxidative stress via regulation of antioxidant and hepatic glucose-regulating enzyme activities. these findings illustrate that superjami was similarly effective in improving the glucose metabolism and antioxidant defense system in high fat-fed mice and they may be beneficial as functional biomaterials in the development of therapeutic agents against high fat diet-induced hyperglycemia and oxidative stress. objective: to evaluate the effectiveness of two types of intervention: personal and group therapy in preventing or delaying diabetes. methods: two hundred and twenty-two pre diabetes adults were assigned to both interventions, which included physicians, dietitians, social workers and physical activity consultants, to modify patients' lifestyle and reduce weight. glucose, total cholesterol, ldl, hdl; tryglesirides and bmi were measured before (t ), immediately after (t ) and post months (t ) of the intervention. mix linear; logistic regression and cox models were employed. results: mean age was . and . (p = . ) for the personal and group therapy, respectively. no significant differences in time trends for all the clinical measurements between the groups were observed. however, (i) reduction (À . p < . ) in glucose for the personal therapy group between t and t ; (ii) reduction in total cholesterol (À . p = . ; À . p < . ) in personal and group therapy, respectively, between t and t ; (iii) significant hdl increase in both groups between t , t and t ; and (iv) significant decline in ldl, triglycerides and bmi between t t and t . . % and . % of the group and personal therapy, respectively (p = . ), developed type diabetes during the study period. no differences to time to onset of the disease between the two groups. conclusion: for patients with pre diabetes, both types of intervention were effective in delaying and preventing the disease. group therapy is recommended since it requires fewer resources and can be implemented for the benefit larger population. methods: the present population-based case-control study was performed in shiraz, southern iran, over a -month period from december to , on a randomly selected study population group consisting of inhabitants of the metropolis of shiraz in southern iran. all the patients underwent anthropometric and blood pressure measurements as well as thorough medical history and physical examinations. laboratory parameters including fasting blood glucose, lipid profiles, liver enzymes and ferritin, in addition to liver ultrasonography and cimt, were performed for all subjects. the cutoff value for the cimt was set at . mm and the measured values were correlated with other risk factors. we evaluated patients with nafld and the same number of controls. subjects with nafld had a significantly higher prevalence of increased cimt (or: . , p < . ). in patients with nafld the age of years represented an appropriate cut-off value for predicting increased cimt. a systolic blood pressure (sbp) of mmhg and a diastolic blood pressure (dbp) of mmhg were shown to be appropriate cut-off values for predicting increased cimt. conclusion: cardiovascular risk factors such as increased intimamedia thickness (imt) occur more frequently among nafld patients when compared to healthy individuals. we recommend a careful evaluation of not only the liver, but also of the cardiovascular system in these patients, in order to prevent later morbidity related to atherosclerosis. mitochondrial capacity of oxidizing fatty acids and increased mitochondrial ros production. the peroxisomal β-oxidation, which starts the oxidation of the long-chain fatty acid and contributes with approximately % of all oxygen peroxide produced in the cell, was increased in ovx mice. these effects could lead to oxidative damage, a condition that was, in fact, evidenced by the reduced levels of reduced glutathione and elevated levels of tbars found in livers of ovx mice. the decreased mitochondrial capacity of oxidizing fatty acids could contribute, at least in part to development of hs in ovx mice. besides, the higher mitochondrial and peroxisomal ros generation resulted in oxidative damage in livers from ovx mice. background: elevations in high-sensitivity c-reactive protein (hs-crp) are associated with an increased risk of insulin resistance (ir). investigation of relationship between hs-crp, parameters of glucose metabolism and leptin in patients with t dm and igt could be help to assess the role of hs-crp in development of ir. aim: of the study was investigation of relationship between hs-crp and hepatic glucose production (hgp), leptin and hba c in women with t dm and igt. materials and methods: forty-eight women with igm ( newly diagnosed t d and igt were observed). hs-crp and leptin were assessed in fasting states. intravenous glucose tolerance test was performed ( . г glucose on kg of body mass). mathematical analysis of results with definition of hgp (the h-index, mmol/l) was done with the special program (accessible in internet: www.diabet.ru/ivgtt). results: bmi was significantly correlated with hs-crp, r = . , p < . and the level of hs-crp in women with bmi > kg/m was almost four times greater compare to hs-crp in women with bmi > kg/m [ . ( . - . ) and . ( . - . ) accordingly, (p < . )]. between hs-crp and hgp and between hs-crp and leptin direct correlation (r = . , p < . ) and (r = . , p < . , accordingly) was revealed. correlation between hs-crp and hba c wasn't found. conclusions: association between hs-crp and leptin level, hs-crp and hgp could be demonstrate the role of hs-crp in development of insulin resistance. institute for sport and physical activity research (ispar), university of bedfordshire, bedford, uk objective: hypertriglyceridemic waist (hw) and waist-to-height ratio (whtr) are simple clinical tools that identify adults at risk of cardiometabolic disorders and cardiovascular disease. whether this applies in youth is under-researched and this study therefore investigated whether the hw phenotype and whtr are associated with cardiometabolic disorders in children and adolescents. methodology: this was a cross-sectional design study. anthropometry, biochemical variables, and cardiorespiratory fitness were assessed in participants ( girls) aged - years from bedfordshire, united kingdom. the hw phenotype was defined as a waist circumference ! th percentile for age and sex, and triglyceride concentrations ! . mmol/l, and a high whtr defined as > . . ancova and logistic regression were used in the analysis. results: in participants with the hw phenotype, clustered risk score was lower (p < . ), the odds of having high cardiorespiratory fitness (ml/kg/min) lower ( . ; % ci . , . ), and the odds of having low hdl-cholesterol ( . ; . , . ), impaired fasting glucose ( . ; . , . ), and ! ( . ; . , . ) and ! risk factors ( . ; . , . ) higher than those without the phenotype. those with a high whtr had lower clustered risk (p < . ), higher odds of having low hdl-cholesterol ( . ; . , . ), high diastolic blood pressure ( . ; . , . ) , and ! risk factors ( . ; . , . ) than those with normal whtr. conclusion: the hw phenotype may be a better simple marker than whtr for identifying children and adolescents at risk for cardiometabolic disorders. treatment with ace inhibitors (acei) and at receptor blockers (arbs) has been shown to reduce the number of new-onset dm , improve insulin sensitivity and reduce adipocyte size , . we investigated additional metabolic effect of renin-angiotensin system (ras) blockade with arb in comparison with acei. specifically we studied the effect of candesartan cilexetil therapy on glucose metabolism and parameters of subcutaneous adipose tissue (sat) in hypertensive subjects. antihypertensive treatment with acei was replaced by candesartan for months in subjects with essential hypertension. experimental procedures involved measurements of anthropometric data, blood pressure, oral glucose tolerance test, ras components and adipokines gene expression in sat obtained by biopsy. intersticial fluid from sat was collected by using microdialysis. six months after replacement acei by candesartan, the systolic blood pressure decreased by . ae . mmhg (p < . ), diastolic blood pressure decreased by . ae . mmhg (p < . ) and fasting plasma glucose decreased by . ae . mmol/l (p < . ). insulin sensitivity index (matsuda) tended to increase (p = . ). among the adipokine and ras genes studied in sat only pparc expression tended to increase (p = . ) after candesartan treatment. as expected, candesartan had blood pressure lowering effects comparable to those of acei. seeing that candesartan reduced fasting glycemia and strongly tended to increase pparc expression in sat, we speculate that arbs treatment might have additional positive effect on glucose metabolism compared to acei. the study is continuing and samples of serum and microdialysate are currently under analysis of ras peptide content. purpose: diastolic dysfunction in the metabolic syndrome/type diabetes (d) is an epidemic without evidence-based treatment strategies. studies on dietary interventions are scarce. we tested the hypothesis, that a low-carbohydrate diet (lc) improves cardiac function in overweight-obese d more than the traditionally recommended low-fat diet (lf). methods: two groups of d without cardiac disease (bmi ae kg/m ) were studied in a parallel and partial cross-over design during a -week rehabilitation program with either lc or lf. the group on lf (carbohydrate %, fat %, protein %) had subsequent weeks on lc ( %, %, %, respectively). cardiac function was assessed as myocardial velocity during systole and diastole (e′) and metabolic control before and h after (pp) a standardized breakfast ( kcal). both groups had supervised aerobic training h a day. results: in the parallel groups, both diets induced similar and significant reductions of weight, hba c and cholesterol. lc considerably improved insulin resistance, triglycerides, systolic and diastolic blood pressure and e′ ( . ae . - . ae . cm/s, p = . ), but lf did not whereas all these variables improved significantly after subsequent lc (e′ from . ae . to . ae . cm/s, p = . ). intact proinsulin was unchanged with lf but decreased with subsequent lc fasting and pp (p = . and . ). conclusions: these data indicate, that a lc but not lf nutrition modulates diastolic dysfunction in overweight diabetics, improves insulin resistance and may prevent or delay the onset of diabetic cardiomyopathy and the metabolic syndrome. methods: we studied adolescents, males (n = ) and females (n = ), who were collected waist circumference, office bp, serum glucose and lipids. they underwent a -h abp monitoring (abpm) to record -hs, awake and sleep bp, and the bpv was calculated as the standard deviation bp. the ms was defined according to the national cholesterol education program, adult treatment panel iii modified for adolescents. statistical analysis: the variance ratio test (f-test) was applied to compare the bpv between adolescents with ms and those without ms. results: the ms prevalence was . % (n = ) in all, . % (n = ) in males and . % (n = ) in females (p < . ). the abp values (systolic/diastolic) were the following: / , / and / mmhg in adolescents with ms; and / , / and / mmhg in adolescents without ms, for -hs, awake and sleep periods, respectively. the highest statistically significant values in systolic and diastolic abp during -hs and awake and systolic abp in sleep were showed by ms group. likewise, adolescents with ms showed significant higher -hs systolic bpv than those without ms ( . vs. . mmhg, p < . ). the ms has important effects on the abp values in adolescents. also, systolic bp variability during -hs is associated with ms. these findings suggest that ambulatory blood pressure monitoring is important in adolescents with ms to detect subjects in cardiovascular risk. montfort hospital research institute, university of ottawa, ottawa, on, canada organochlorine compounds (oc), are chemicals that were mostly used historically as pesticides, solvents, flame retardants, and other applications. oc have been recognized to be of environmental and potential toxicologic concern. due to their persistence and lipophilicity, these compounds will remain present in the environment for decades and accumulate in living organisms. the presence of oc is a major concern since they could act as endocrine disruptors and have recently been associated with the development of hepatic steatosis and lipotoxicity. the objective of this project is to define intra-hepatic molecular mechanisms implicated in the development of hepatic steatosis and lipotoxicity in oc exposed hepatocytes and rats. results: lipid quantification was assessed in human hepatocytes using steatosis colorimetric assay (cayman chemical company). lipid accumulation was higher in hepatocytes exposed to pcb [ . lmol/l] for h compared to chloroquine ( %), a potential lipid droplet infiltration inducer, as well as our control group treated with dmso ( %). conclusion: understanding the emerging role of oc in the physiology of hepatic steatosis and lipotoxicity is of great importance as it is becoming clear that chronic lipotoxicity is strongly related to the suppression of insulin receptor signaling in the liver and activation of the apoptotic pathway. these results only represent the necessary first step on oc and their impact on the liver metabolic activity. experiments in oc-contaminated rats are presently undertaken, as well as protein quantification involved in intra-hepatic mechanisms in cells. nutrition, nutrition research institute, the university of north carolina at chapel hill, kannapolis, nc, usa insulin a precursor of t dm, various cardiocerebrovascular disorders, non-alcoholic fatty liver, alzheimer's disease, and many other major health problems associated with excess calories. to study the mechanism of insulin resistance, we investigated the role of insulin and each category of macronutrients (glucose, fat, and amino acids) in the development of insulin resistance. our results show that glucose (hyperglycemia) does not cause insulin resistance in the absence of insulin in cultured cells or animals. dietary carbohydrate is not necessary for high fat diet (hfd) induction of insulin resistance but a small amount of it can promote insulin resistance in the maximal level in animals on hfd. our results also show that fat is necessary for the development of insulin resistance although fat can't induce insulin resistance in the absence of insulin. supplementation of amino acids such as leucine does not necessary cause insulin resistance in animals on hfd. finally, our results show that insulin can cause insulin resistance through (i) accumulation of long-chain acyl coas and cholesterol in mitochondria, (ii) inhibition of production of new mitochondria; and (iii) turnover of aged/damaged mitochondria. in summary, our results show that insulin and each category of macronutrients are necessary for the development of persistent insulin resistance. wellness institute, cleveland clinic, cleveland, oh, usa background: lifestyle factors are key in the development and progression of chronic disease. here we report outcomes for prediabetic participants in the lifestyle â program, a -month intervention for patients with chronic diseases that integrates education in cooking, nutrition, exercise, and stress management. methods: pre-post changes in biometric, laboratory, and psychosocial variables were evaluated by paired student's t-test or wilcoxon test. results: of participants who met ada criteria for prediabetes (n = ), most were female ( %) and obese ( %) and had hyperlipidemia ( %) or hypertension ( %). one fifth ( %) had depression. average age was ae years. at month , biometric, laboratory, and psychosocial data were available for ( %), ( %) and ( %) participants, respectively. average bmi decreased by % ( . ae . - . ae . ) and there were decreases in waist circumference, blood pressure, resting heart rate, fasting glucose, and hba c (p < . for all). insulin decreased from . ae . - . ae . μu/ml (À . %; p < . ). more diabetic medications were stopped or reduced in dose than were started or increased in dose (ratio . : ). average depression (ces-d ) and perceived stress (pss- ) scores decreased by % and % respectively (p < . for both). physical, mental, and perceived health (measured by veterans rand item health survey) improved from % to % (p < . ). conclusion: participation in a comprehensive lifestyle modification program of adults with prediabetes results in significant and clinically meaningful improvements in biometric, laboratory, and psychosocial outcomes. diabetes is frequently associated with both extracellular and intracellular magnesium (mg) depletion. epidemiologic studies found high prevalence of hypomagnesaemia in subjects with type diabetes, especially with poorly controlled glycemic control. erythrocyte and serum magnesium levels were measured in healthy control subjects, non-diabetic normal glucose tolerant offspring of type diabetic subjects and non-diabetic impaired glucose tolerant offspring of type diabetic subjects in addition to routine laboratory investigations, hba c, lipid profile, fasting insulin by elisa and homa-ir. our study showed that fasting, h postprandial plasma glucose, serum insulin level, hba c, homa-ir index, serum ldl-c, serum triglycerides, serum cholesterol and serum malondialdehyde levels were higher and serum hdl-c and both serum and erythrocyte magnesium levels were lower in impaired glucose tolerant offspring of type diabetes as compared to each of normal glucose tolerant group and control group, while there was no significant difference in those parameters between normal glucose tolerant and control groups. we can conclude that the magnesium depletion and the increase in malondialdehyde level in non diabetic impaired glucose tolerant offspring of type dm were associated with increasing severity of insulin resistance and dyslipidemia and, this may increase the risk of development of type diabetes complications in there offspring. possily use of mg suplemenaion in those subject may delay and prevent the development of type diabetes. obstetrics and gynaecologist, catholic university of sacred heart, rome, italy background and aims: gdm, overweight and gestational weight gain (gwg) are important determinants for an adverse pregnancy outcome and particularly for having large for gestational age (lga) newborn. the aim of this study was to evaluate the pregnancy outcome among women affected by a gdm, belonging four different classes of pre-pregnant bmi and to investigate the specific role of the anthropometric parameters and therapeutic regimen on the foetal growth. material and methods: this was a prospective study including pregnancies affected by gdm. only women with a mean pre-prandial glucose level < mg/dl and h post-prandial values < mg/dl were enrolled. we considered other variables such as gwg, excessive gwg (egwg), therapeutic regimen used and maternal age to investigate their role in foetal growth. results: at the linear univariate analysis, a dependence of neonatal birth weight from pre-pregnant bmi class, egwg, gwg and gestational week at delivery was found (p < . ). the dependence from the pre-pregnant bmi (p = . ) and the egwg (p = . ) was confirmed even when the percentile was considered. at the multivariate analysis the birth percentile resulted associated both with the prepregnant bmi (p < . ) and the gwg (p = . ). conclusions: pre-gestational bmi, gwg and egwg are important parameters involved in fetal growth. their control during pregnancy could be an important way to improve pregnancy outcome even in women with gdm. obstetrics and gynaecologist, internal medicine, catholic university of sacred heart, rome, italy background and aim: continuous subcutaneous insulin infusion (csii) may be an alternative treatment to multiple daily injections (mdi) in pregnant subjects with type diabetes(¹). the aim of this study was to compare metabolic control and obstetric outcome of these pregnancies treated with csii vs. pregnancies treated with different type of insulin analogs administrated by mdi. material and methods: we studied pregnancies in women, three twin pregnancies, affected by type diabetes. thirty-four pregnancies treated with csii and treated with mdi treatment were evaluated. in the group of women treated with mdi women used human analogs, used insulin aspart and used insulin lispro. metabolic control and obstetric outcome were compared between the groups. statistically significant differences were found in metabolic control in term of hba c mean level for each trimester of pregnancy. conclusion: no clear advantage of csii vs. mdi treatment is shown in our study for pregnancies complicated by type diabetes in term of metabolic control or obstetric outcome(²). however, it might be that some selected patients with unstable metabolic control or high hba c levels, who become pregnant with a better metabolic profile after csii treatment, may have a better pregnancy outcome. poblations and methods: a cross-sectional study was performed on children and adolescents ( female and male) between and years old, without cardiovascular, metabolics, oncology and immunology diseases. were excluded all subjects who took drugs with effects on glucose, insulin, lipids or weight. each subject was determined: weight, height, bmi, neck, waist, hip circumferences, adiposity, blood pressure and glucose, insulin, cholesterol, tryglicerides, c-ldl, c-hdl. was performed oral glucose tolerance test to glucose and insulin postprandial. was estimated insulin secretion and insulin sensitivity. conclusi on: neck circumference is a potential marker for to identify children and adolescents with metabolic and cardiovascular risk factors. aim: to assess the efficacy of a lifestyle modification in preventing diabetes mellitus type (dm ) among subjects with risk factors of dm including impaired glucose tolerance and impaired fasting glucose (igt/ifg), obese adults and first-degree relatives of patients with diabetes. materials and methods: the study included patients ( m, f) - years old at risk factors of dm . all patients received recommendation on a balanced diet and physical activity. we measured fasting plasma glucose (fpg), -h plasma glucose concentrations. fasting serum insulin (fi) levels were detected by sensitive elisa. index homa-r were used as the index of insulin resistance. results: in weeks our study patients carried out this recommendations (research group) and patients did not it (control group). patients of the research group demonstrated mean reduction of weight (À . kg), bmi (À . kg/m ) and whr (À . ) (p < . ) and persons of the control group had significant increase these parameters (p < . ). among subjects with igt, glucose levels normalized in % of patients from the research group and . % in control group (p < . ). fi and homa-r in research group decreased from . ae . to . ae . lu/ml and from . ae . to . ae . accordingly (p < . ). in control group the specified parameters had increased significantly (p < . ). the risk reduction of development dm among patients of the research group was . % comparer the control group. conclusion: thereby, lifestyle modifications are effective in preventing dm development in individuals at risk living in belarus. objectives: it is suggested that the kind and frequency of snacks as well as dairy consumption can influence body weight and composition. as the number of students are increasing rapidly in iran and regarding their unhealthy food habits, we decided to carry out this study. methods: one hundred and twelve female students who were selected from university dormitories inhabitants randomly, participated in this cross-sectional study. weight, height and waist circumference (wc) of the participants were measured. demographic and food frequency questionnaires were filled face to face. data were analyzed using spss # . the results showed that . % of participants were under weight, % normal and . % overweight. besides, . % and . % had normal and above normal wc respectively. sixty-one percent of female students had just one snack. fruits ( %) and confectionaries ( %) were the most popular snacks. mean ae sd of the dairy consumption was . ae . serving per day. there were no correlations between bmi and wc and snacking pattern or dairy intake. conclusion: it is assumed that as most of our subjects had normal weight and wc, we did not find any correlation between bmi and wc and snacking pattern or dairy intake. conducting similar studies, using both overweight and normal weight subjects is suggested. obstetrics and gynaecologist, catholic university of sacred heart, rome, italy background and aims: the management of pregnancies complicated by t dm has changed with the introduction of new short acting insulin analogs. the aim of this study was to have a comparison of obstetric outcome among the different insulin regimens. methods: one hundred and sixty singleton pregnancies were assessed. seventy-four women were treated with human analogs, with insulin aspart and with insulin lispro. results: no significative differences were found in term of incidence of pre-eclampsia, iugr, large for gestational age newborn, cesarian sections, preterm delivery, apgar score < , mean week at delivery, mean birth percentile. a significative difference was found in term of incidence of newborn infants with a birth weight ! g ( . % in the human analogs group, . % in the aspart group t and . % in the lispro group; p = . ); a trend (p = . ) was observed comparing the mean birth weight among the groups ( . ae . g in human analogs group, . ae . g in aspart group and . ae . g in lispro group). no significative differences were found in term of hba c mean levels for each trimester of pregnancy. conclusions: the use of insulin aspart is correlate with a lower incidence of fetal macrosomia and with a lower mean birth weight. in vitro observations highlighted that lispro and aspart have a similar affinity for insulin receptor; regarding the affinity for igf- receptor lispro is . fold more potent than human insulin in binding igf- receptor. further investigations are necessary to explain the correlation between insulin affinity for igf- receptor and fetal growth. methods: this study was performed on women diagnosed with gdm (gestational dm) - months after delivery. the jewish and bedouin women were divided into, intervention and control groups. the intervention group was instructed in healthy lifestyle habits every several months by a dietician and sports instructor. the control group was informed of the potential risks for diabetes following gdm and advised to improve lifestyle. all women had fasting insulin, glucose and lipid level tests - months post partum. height, weight, bmi, blood pressure, waist circumference were measured. food frequency and exercise questionnaires were filled. the same tests were repeated at and years follow up. results: the prevalence of gdm was . % in jewish and . % in bedouin women. lack of pregnancy care was greater among the bedouin. all the metabolic tests post gdm period improved in the intervention group in both ethnicities compared to control. there was a decrease in insulin, glucose, ldl, triglycerides and homa-ir (homeostasis model assessment) values and an increase in hdl. a significant decrease in carbohydrate consumption, calorie consumption, fat consumption and increase in protein consumption was observed and an increase in physical activity. the intervention program significantly improved the metabolic indices measured in both jewish and bedouin populations. the results underscore the need to provide lifestyle optimization guidance to women with gdm in order to reduce the risk of type diabetes. introduction: fatty liver is strongly associated with type diabetes. however, it is unclear whether hepatic triglyceride accumulation causes diabetes, or merely is a consequence of excess adipose tissue, that is related to insulin resistance. we aimed to investigate the association between hepatic triglyceride content (htgc) and insulin resistance, and whether this association could be explained by measures of adiposity. methods: in this cross-sectional analysis of the netherlands epidemiology of obesity (neo) study, fasting glucose and insulin concentrations were measured. abdominal fat depots were measured using mri, htgc using mrs. we performed linear regression analysis of htgc with the updated homeostasis model assessment (homa -ir), adjusting for age, sex, ethnicity, education, smoking, alcohol consumption, visceral adipose tissue (vat) and total body fat (tbf). results: after exclusion of participants with missing data (n = ) or known diabetes (n = ), alchohol consumption > glasses/day (n = ), participants were included with a median (iqr) age of ( . ) years, mean fasting glucose: . ae . mmol/l, % men. per sd htgc ( . %), the homa -ir increased with % ( % ci: %, %), this attenuated to % ( % ci: %, %) after adjustment for vat and to % ( % ci: %, %) after additional adjustment for tbf. per sd vat ( . dm ) the homa -ir increased with % ( % ci: %, %), this attenuated to % ( % ci: %, %) after adjustment for htgc and to % ( % ci: %, %) after additional adjustment for tbf. the association between hepatic fat and insulin resistance was for a large part explained by vat. vat may be most important in the etiology of insulin resistance. the aim was to carry out complex estimation of mutual relations between the proinflammatory condition and basic components of the metabolic syndrome (ms) in patients with ischemic heart disease hospitalized for coronary artery bypass grafting. forty-three patients were examined by standard methods and were divided into three groups depending on presence of separate ms components: st group with abdominal obesity (ao), arterial hypertension (ah), type ii diabetes, dyslipidemia; nd group with ao, ah, hyperglycemia; rd group with ao, ah, dyslipidemia. indicators of chronic subclinical inflammation have been revealed before operation in all groups of patients. the strongest ones have appeared in the nd group of patients. hyperuricemy was more frequently registered in patients of the rd group ( . %). the correlation analysis revealed authentic interrelations of uric acid level with lipid profile and inflammation markers. a strong inverse relation with triglycerides, a strong direct relation with low density lipoprotein cholesterol and inverse one with total amount of leukocytes were revealed in the st group. the strong direct relations with segmented neutrophils and the inverse ones with lymphocytes were registered in the nd and rd groups. the average direct correlation with crp was revealed in the rd group. activation of inflammatory process was noted in patients of all groups after operation, and it was already of acute nature in the rd group that allows attributing it to a risk group. the study of expressiveness of inflammatory reaction depending on presence of the ms components allows revealing risk groups among patients. introduction: the soft drink intake has increased worldwide and its high consumption is associated with the development of metabolic syndrome. objective: to estimate the association between the consumption of sugar-sweetened beverages (ssb) and the burden metabolic syndrome diseases (bmsd). a cross-sectional telephone survey was conducted with adults ( . % men and . % women, mean age . years) in the urban area of belo horizonte, brazil. data from the telephone-base brazilian surveillance system for chronic diseases was used (vigitel - / ). burden metabolic syndrome diseases were defined as the self-reported of at least two of the following factors: diabetes, dyslipidemia, hypertension and obesity. the intake of ! days/week soft drinks and artificial juices was assessed. sociodemographic, selfreported health status and lifestyle habits were also used. odds ratios (or) and % confidence intervals were estimated by multivariate logistic regression. results: in this sample, . % of participants consumed ! days/ week sugar-sweetened beverages (ssb). the prevalence of bmsd in the sample was . %. the prevalence of bmsd in people who consumed ssb ( ! days/week) was lower than people didn't consume the beverages (or: . ; % ci: . - . ) five or more days per week. the final model was also adjusted for physical activity, education, marital status, poor self-reported health and poor consumption of fruits and vegetables. obesity is an heterogeneous condition due to fat distribution and storage. the aim of our study was to compare the predicting role of homa index and of bmi on early vascular impairment in morbidly obese subjects (bmi . ae kg/m ) before and after sleeve gastrectomy (sg). glycemia, insulinemia, lipids, flow mediated dilatation (fmd), carotid intima media thickness (imt) and visceral fat area (vfa) by ultrasound were performed in all subjects. patients were divided on the basis of homa-ir median values: ! . group , < . group . group had significantly higher values of bmi (p < . ), waist circumference (p < . ), vfa (p < . ), triglycerides (p < . ), glycemia (p < . ), and lower hdl-c (p < . ) than group ; fmd was significantly lower (p < . ) and imt significantly higher (p < . ) than in the group . the same population divided on bmi median values did not show any difference in lipids, imt and fmd. at stepwise regression analysis vfa was the independent predictor of reduced fmd (β À . , p . ). homa-ir (beta . p < . ) was the independent predictor of imt (beta . , p = . ). in patients, re-evaluated months after sg, bmi, vfa and homa were significantly reduced (p < . ); fmd significantly increased only in the subgroup with homa-ir pre intervention ! . (p . ). bmi, index of overall adiposity, seems less useful in the prediction of early atherosclerosis in morbidly obese; homa-ir, strictly related to visceral fat, is expression of metabolic impairment thus able to predict early vascular damaging. methods: swiss albino mice were given a high fat diet containing lard (h) ( . % wt/wt), supplemented with as or f and in combination alongwith h (f + as + h) for weeks. the control mice (c) were fed with normal diet. after the treatment period the physical, physiological and cellular parameters were evaluated by body weight, liver weight, biochemical estimation, western blot, pcr or ihc. results: the h mice exhibited increased body and liver weight; treatment with f or as and (f + as + h) in the diet significantly counteracted the hfd induced body and liver weight gain, hyperlipidemia; hepatic lipid profile; level of ros; hyperglycemia; hyperinsulinemia; tnf-a, il- level; nuclear translocation of nf-jb; lipid peroxidation. activities of antioxidant enzymes (sod, cat, gsh, frap) were up regulated significantly in f or as and (f + as + h) mice. therefore simultaneous treatment with as or f and their combination protected against hfd induced weight gain and oxidative stress. conclusion: this novel approach of combinatorial preventive medicine is validated not only with the parameters of metabolic syndromes yet it is evidenced with oxidative stress and crucial molecular targets. this study illustrates for the first time that as and f has relatively similar hypolipidemic, antioxidative, anti inflammatory actions and the as + f combination along with hfd has shown prominent preventive effects as compared to other treated groups. s. sivapraksh , i. shabir , n. gupta , j. john , a. ammini aiims, department of endocrinology, aiims, new delhi, india background: insulin resistance/hyperinsulinemia is associated with a variety of reproductive endocrine dysfunction in girls. however, there is a scarcity data regarding hypothalamic pituitary testicular axis functioning among boys with hyper insulinemia. aim: aim of this study was to assess effect of hyper insulinemia on pubertal development in boys. subjects and methods: children of subjects with type diabetes mellitus (t dm) were invited to participate in this study. children and adolescent with any chronic medical condition were excluded. detailed medical history, physical examination including anthropometry, haemogram, liver, renal functions, oral glucose tolerance test (ogtt), insulin, lh, fsh, prolactin and testosterone were done for all subjects. results: seventy-four boys, - years of age participated in this study. results are given in table . thirty boys (all except were overweight) had gynaecomastia. objectives: to find out the prevalence and factors associated with dyslipidemia among adults aged years and above in a resettlement colony located in central delhi. a cross sectional study, that included a random sample of adults, was designed. a study tool based on the world health organisation (who) stepwise approach to surveillance of noncommunicable diseases and their risk factors (steps) questionnaire was used. fasting venous blood sample was collected. criteria based on the third report of the national cholesterol education program expert panel on detection, evaluation and treatment of high blood cholesterol in adults (ncep atp iii), were used to define the cut offs for dyslipidemia. data was analysed using the statistical package for social sciences (spss) version . results: out of a total of study subjects, % had raised cholesterol levels ( ! mg%). thirty-eight percent had raised low density lipoprotein (ldl) levels ( ! mg%), % had raised triglyceride levels (triglycerides ! mg%) and % had low high density lipoprotein (hdl) levels (< mg%). age, hypertension, alcohol consumption and abdominal obesity were found to be associated with increased odds of dyslipidaemia, using the logistic regression model. aim: in the present study we explored whether oral consumption of the probiotic lactobacillus casei shirota bacteria in form of the yakult probiotic drink has any effects on energy metabolism in patients with impaired metabolic functions. a cross-over-study with daily intake of one portion yakult light during weeks was carried out in patients with impaired glucose regulation or metabolic syndrome. fasting blood samples were collected, anthropometric parameters were measured and a frequently sampled oral glucose tolerance test was performed at time points (week , and ). effects on the human gut bacterial communities were studied via t-rflp fingerprinting of s rrna genes amplified from microbial dna preparations from fecal samples. our results reveal a significant increase of total cholesterol (mean increase: . mg/dl; p = . ), triglycerides (mean increase: . mg/dl; p = . ) and a significant decrease of hdl-cholesterol (mean decrease: . mg/dl; p = . ) after weeks of daily intake of yakult. no significant influence of yakult light consumption on indices of insulin sensitivity, hba c and ldl-cholesterol could be demonstrated. a small decrease of fasting glucose levels after yakult consumption was revealed (mean decrease: . mg/dl; p = . ). no consistent changes in the community profiles of the gut microbiota were observed following weeks of yakult light consumption. in mexico, breakfast is one of the most important meals during the day, but changes in food consumption habits, also known as nutritional transition have been associated with a poor food quality intake. scholars, during the recess use to buy some food in internal shops of schools and this food are not generally the healthiest. the aim of this study was to evaluate the quality of the food consumed during the recces by scholars in tepic nayarit, mexico. scholars ( , about - years) from different public schools were evaluated by means of food register questionnaires during days, there has determined the ingestion of nutrients and nourishment healthy index (ias) using the nutrition program dial. anthropometric data were measured for weight and height, and body mass index (bmi) was calculated. the bmi showed that . % of children have low weight for height, . % have normal weight and . % overweight/obesity. twenty percent of scholars declared that they did not take breakfast until the hour of recess. energy intake during recess was on average % of the daily requirement. the foods most frequently consumed were sweetened beverages ( ml) containing g of simple sugars, fried-wheat snacks ( g/ g fat), candies ( g/simple sugars) and some fruit such as mango, apple or watermelon ( g/portion) with chilli. these combinations of foods are risk factors to the development of diabetes in scholars were the prevalence of overweight/obesity is in high levels. introduction: incidence of type , and gestational diabetes mellitus (gdm) are increasing worldwide. given that women with previous gdm have a higher risk of diabetes development later in life compared to women with a physiological pregnancy, the aims of our study were (i) to ascertain a frequency of early postpartum conversion of gdm into permanent diabetes or persistent impaired glucose tolerance and (ii) to find an eventual significant predictive factors from those routinely measured during the gdm follow up. methods: we carried out a retrospective epidemiological analysis of anamnestic, anthropometric, biochemical and clinical data of female patients (n = ) from faculty hospital brno with gdm diagnosis during the - period that underwent repeated ogtt up to year after the delivery. results: any degree of impairment of glucose tolerance postpartum was detected in . % subjects, of those . % had manifest dm ( . % t dm and . % t dm). glycaemia in all three time-points of baseline ogtt, area under the curve (auc ogtt ) and baseline hba c were significantly associated (p < . , mann-whitney) with the postpartum disorder. using regression analysis predictive risk model was developed using these baseline parameters. conclusions: parameters of glucose metabolism measured during - th week of pregnancy fulfilling criteria of gdm diagnosis exhibited highly statistically significant differences between women with and without persistent postpartum glucose metabolism abnormality and conferred significant predictive potential. considering generally lowcompliance of gdm women any more specific assessment of future risk stratifying gdm population could enable more effective screening of postpartum glucose metabolism disorder. institute of molecular biomedicine, comenius university medical faculty, department of health, bratislava self-governing region, regional public health office, bratislava, slovak republic background and aims: in the adults, microalbuminuria is considered as biomarker of present/future cardiovascular and/or renal disease. the roots of these diseases extend back into childhood/adolescence. data on prevalence of microalbuminuria, renal excretion of albumin (albumin/creatinine ratio, acr) and its relationship to obesity and blood pressure in apparently healthy adolescents are scares. methods and results: fourteen to -years-old apparently healthy students of secondary schools in bratislava district were enrolled (n = , boys: %). acr was determined in a spot urine sample. in underaged subjects overweight/obesity was classified according to age-and sex-based slovak population tables from . blood pressure values were recorded. acr (iqr: . - . mg albumin/ mmol creatinine vs. . - . mg albumin/mmol creatinine, p < . ), and the prevalence of microalbuminuria ( . % vs. . %, chi-square: p = . ) were higher in girls than in boys. prevalence of overweight ( . % vs. . %) and obesity ( . % vs. . %), as well as blood pressure values in pre-hypertensive ( . % vs. . %) and hypertensive ( . % vs. . %) ranges were higher in boys if compared with girls. in underweight subjects, particularly boys, acr was significantly higher if compared with the overweight/obese subjects. acr correlated inversely with the markers of peripheral and central obesity. conclusions: our data suggest the need of specific interpretation of data on acr in the adolescents, and the need of further analysis of this (in the adults risk) marker in population of adolescents with regard to other important determinants of acr, such as insulin sensitivity and other metabolic syndrome risk factors. inclusions criteria were bmi between and kg/m , morbidities as diabetes type more than years in oral treatment and without control, hypertension in oral treatment too, moderate or severe liver steatoses diseases and lipid diseases. results: all patients in a both of groups (laparoscopic and robot approach) had a effective loss of weight, with mean about - kg ( - %) after year period. one case of robot approach presented a staple line bleeding at first postoperative day, without transfusion. morbidity rate after rasg was %, but no gastrointestinal leaks occurs. conclusions: rasg can be a safely and feasible tool to the surgical treatment of obese patients and co-morbidities, with good results and satisfactory outcomes. results: patients were nine males and six females with mean age of years (range - ). seven patients were under insulin treatment and with oral medications only. glycemia at months post-surgery ( . ae . mg/dl; n = ) was significantly reduced (p = . ) compared to time ( . ae . mg/dl). the same occurred with hba c at months ( . ae . %; n = ) compared to time ( . ae . %) (p = . ). bmi was also reduced at month ( . ae . ; n = ) compared to time ( . ae . ) and months ( . ae . ; n = ) compared to time ( . ae . ) (p = . ). only one patient remained under insulin after surgery. the procedure was considered safe and significantly improved metabolic control of non-obese t dm patients, although moderate weight loss was also observed. recent studies have shown that the practice of a proper diet provides health benefits. also, it has been observed that the body weight gain is associated with consumption of unbalanced diets. the objective of this study was to evaluate the quality of the diet in adult residents of tehcnological institute of tepic and establish differences for normal weight (nw) and overweight/obesity (ow/ob). forty two adults > years were evaluated, they were taken anthropometric data for weight, height and body mass index (bmi, kg/m ) was calculated. for the diagnosis of nw and ow/ob, were taken established by world health organization (who). it was used a -day dietary record, for diet analysis was used dial software, which contains tables of food composition mexicans. dietary data were adjusted for the degree of discrepancy between energetic intake and energy expenditure obtained estimate. for statistical analysis was used the program rsigma babel and statistical differences were established < . . the caloric profile was unbalanced in % of the study population: a high consumption of fat in detriment of carbohydrates. the difference between groups were not significant (p > . ) in the caloric profile, but nor in lipidic profile. the analysis of the discrepancy intake/energy expenditure describes a probable undervaluing of the diet in both groups, but higher in adults with ow/ob compared to nw ( patients with long standing diabetes had a higher leptin, hsp , hba c and triglyceride than controls. serum leptin levels were significantly lower in patients with newly diagnosed diabetes. women with type diabetes had a higher leptin levels compared to men, both before and after treatment. we showed a positive correlation between leptin-hsp in women with type diabetes. the correlation was highest in women with newly diagnosed diabetes (r = . ) and was attenuated in women who were on treatment (r = . ). the significance of this correlation was only observed in women with type diabetes. there was no correlation between leptin and hsp in men. the positive correlation between leptin and hsp is observed in chronic inflammation such as type diabetes. it could be hypothesized that the observed correlation between serum hsp and leptin imply a higher state of chronic inflammation. materials and methods: carotid atherosclerosis (measurement of intiamedia thickness -imt) and the presence of steatosis were assesed using ultrasonography in subjects ( . % men and . % women, mean age . ae . years), selected from a rural population (were excluded those with known liver disease and those with alcohol consumption > g/day). results: . % of subjects had different degrees of steatosis: . % mild, . % moderate, . % severe. the metabolic syndrome and all its individual traits, were significantly more frequent in nafld patients, especially in those with severe steatosis (p < . ). the mean value for imt was . ae . mm, increasing in parallel with the severity of steatosis. also, subjects with ms had significantly higher imt values than those without ms (p < . ). in the group without ms, imt mean was significantly higher in patients with steatosis than in those without steatosis (p = . ), and in patients with moderate/severe steatosis than in those with mild steatosis (p = . ). by multiple regression analysis, larger waist circumferince (r = . ), increasing alcohol consumption (r = . ) and the presence of steatosis (r = . ), were significant predicting factors for increased imt. conclusions: these data confirm the hypothesis that the presence of steatosis, independently of the ms, is associated with a significant risk for development of atherosclerosis and its detection should be an alert for the existence of an increased cardiovascular risk. the prevalence of the metabolic syndrome (ms), a cluster of central obesity, hyper/dyslipidemia, hyperglycemia, and hypertension is constantly increasing worldwide. although, the exact mechanisms underlying the development of the ms are not completely understood, modern lifestyle of physical inactivity and unhealthy nutrition, obesity, and their interaction with genetic factors are considered largely responsible. this study was carried out to identify the association between physical inactivity and burden metabolic syndrome diseases (bmsd) in an urban brazilian population. a cross-sectional telephone survey was conducted with adults ( . % men and . % women, mean age . years) in the urban area of belo horizonte, brazil. data from the telephone-base brazilian surveillance system for chronic diseases (vigitel - / ) was used. burden metabolic syndrome diseases (bmsd) was defined as the self-reported of at least two of the following factors: diabetes, dyslipidemia, hypertension and obesity. physical activity (pa) indicators were evaluated in free time (leisure), work, home and transportation domains. sociodemographic, health status and lifestyle habits were also used. odds ratios (or) and % confidence intervals were estimated by multivariate logistic regression. in this sample, . % of participants were physically inactive in all domains and the prevalence of bmsd in the sample was . %. physical inactivity was independently associated with bmsd (or = . ; %ci: . - . ), adjusted to age, schooling, poor selfreported health and gender. in this sample, bmsd is a significant public health problem. the evidence from this study shows that physical inactivity was independently associated with proxy of metabolic syndrome. aim: to assess the prevalence of insulin resistance (ir) and glucose homeostasis alterations (gha) in overweight and obese children and the risk factors for ir and gha. method: we collected data from subjects: girls and boys aged . - . years (median: . ). gha was measured by fasting glucose. glucose ! mg/dl was treated as high normal fasting plasma glucose (hnfpg). ir was estimated by homeostasis model assessment (homa-ir), quantitative insulin sensitivity check index (quicki) and fasting glucose/insulin ratio (fgir). we adopted the following cut-off points for diagnosing ir: homa-ir ! . , quicki . and fgir . . results: table . fasting glucose, insulin and ir-indexes. in obese children we observed a significant (p < . ) positive correlation between homa-ir and age (r = . ), bmi (r = . ), fasting insulin (r = . ), triglycerides (r = . ), crp (r = . ) and a negative correlation with birth weight (r = À . ) and hdl the results provide evidence for an association between pd and sm in the adolescent population, which would mean that depression may influence ms in this group that is more vulnerable to pd due to hard changes typical of their life stage. the aim of this study was to evaluate the electrical activity of the pelvic floor muscles (pfm) in women with polycystic ovary syndrome (pcos) diagnostic and insulin resistance (ir). through a crosssectional study, it was recruited women with pcos. the total pcos patients was divided into two groups according to the presence of ri (group a) and without ir (group b). the diagnosis of ri was made through fasting insulin. the muscle tone (mt) and maximal voluntary contraction (mvc) was evaluated by electrical activity, that it was measured by surface electromyography. among the pcos patents, . % had insulin resistence. there was significant difference between the tone (p = . ) and cvm (p = . ) between groups a and b. the correlation test showed a strong negative correlation between muscle tone and fasting insulin levels in group b (r = À . , p = . ). considering the results, it seems that the presence of insulin resistance may adversely affect the electrical capacity of the pelvic floor muscles. central hospital of the army, cpmc, algiers, algeria the polycystic ovary syndrom is a disorder affecting approximatively - % of reproductive age women. hyperinsulinemia and insulinore´sistance are common features of a larger number of patients affected by pcos. objective: the objective of this study was to characterized the prevalence of the insulinore´sistance in a cohort of algerian women with pcos. methods: a total of patients with evidence of pcos defined by the rotterdam consensus were recruted for a prospective study. all women had a standard oral glucose tolerance test with the mesure of glycemia, insulinemia and shbg. the prevalence of insulinore´sistance grows significantly with bmi (p = . ) but didn't change with age (p = . ). the non hyperandrogenic phenotype is less insulinoresistant ( . % vs. . %). conclusion: in our population of pcos near half of them are insulinresistant and need to be treated in order to avoid metabolic features. the aim of this study was to analyze the parameters of glycemic index (ig) in foods intended for feeding patients with impaired glucose metabolism. for this purpose, a new design selected food products, characterized by a higher nutritional value, that pass attempts technological and toxicological studies and have been classified as human food. the food consisted of inulin, buckwheat, pumpkin seeds, buckwheat hulls, the addition of mulberries, kale and beans. the products were characterized by nutritional value and composition. designed food products were the nature of small snacks, designed to supplement the basic diet and enriching it with ingredients desirable from the standpoint of prevention of civilization diseases. characterized by elevated natural origin and health-related properties. the study took part of healthy, non smokers volunteers between and years of age, with proper blood biochemical parameters. the results allow to characterize these foods as relative low glycemic index and possible to use to enrich the diet in the components with pro-health effect. for all the products the dose and single-serving size consumption was described and proposed. the possible potential changes in glucose levels after consumption were characterized. the results are the test pilot study of the project aimed to the creation of the increased food with bioactive healthy properties and are the result of the first stage of the researchclinically-nutritional studies of those products. financial supported by the ue project nr po ig . . . - / . one of the fastest growing trend in food production is designing of health promoting foods, including so-called bioactive food. only food products enriched with bioactive components of natural origin might be perceived as bioactive. it is highly possible that well established technological process of bioactive foods production leads to obtain products useful in prevention and non-pharmacological treatment of metabolic diseases. the project aims to designing these kind of prohealth food, which would simultaneously be organoleptically attractive to the consumer and be an equivalent of conventional, habitually eaten products. the important aspect of bioactive foods is their antioxidant potential, which positive impact on various diseases (obesity, diabetes mellitus and hypertension) is already well known from prior literature. in the studies the antioxidant capacity of the selected bioactive foods designed in the project was assessed. the method used for assessment of antioxidant potential was orac, as the most widely applied and the most reliable one. the analysis included products from three following groups of enriched foods: fruit and vegetable juices, bakery products and confectionery, and meat products, as well as the corresponding placebo products. most of the products enriched in bioactive components was characterized by significantly higher orac values in comparison to placebo correspondents. the results support the correctness of applied production technology and proper selection of bioactive components. based on the antioxidant potential of new products, one can decided which of them should be use for further controlled clinical trial. background: obesity in adolescent tends to persist into adulthood which associated to metabolic disease thereby increasing mortality and morbidity. objective: to investigate the association between central obesity and inflammation marker, insulin resistance and dyslipidemia in adolescent with central obesity. methods: this study was case-control study, compared central obesity adolescent and normal to hscrp, homa-ir, triglyseride, ldlcholesterol, hdl-cholesterol, and sdldl-cholesterol. results: sixty two adolescent were included, were central obesity and were normal. we found that they were with bmi > kg/m had hscrp level higher compared with non obesity, p-value < . (or: . ; % ci: . - . ) and homa ir, p-value < . (or: . ; % ci: . - . ). adolescent with wc ! cm for boys and ! cm for girls, had hscrp levels, homa-ir and hdlcholesterol higher than they were with wc < cm, p-value < . (or: . ; %ci: . - . ), p < . (or: . ; %ci: . - . ) and p-value < . (or . ; %ci: . - . ), respectively. the visceral fat was associated with hscrp levels, p < . (or: . ; %ci: . - . ), and hdl cholesterol p < . (or . ; %ci: . - . ). triglyceride and sdldlcholesterol had not significanty for bmi, wc and visceral fat, however ldl-cholesterol significantly association with visceral fat, p < . (or: . ; %ci: . - . ). conclusion: central obesity adolescents showed increased inflammatory markers and insulin resistance with consequent increased the risk of metabolic diseases so that early intervention in obese adolescents should be done. aims: consumption of high fat diet (hfd) leads to accumulation of intramuscular ceramide (cer). cer is implicated in induction of muscle insulin resistance. the initial step in the de novo cer synthesis is catalyzed by serine palmitoyltransferase (spt). the aim of the present study was to elucidate the role of hfd, myriocin (an spt inhibitor) and metformin on the content of skeletal muscle cer and key proteins implicated in lipid and glucose metabolism in hfd insulin resistant rats. the experiments were performed on male wistar rats, divided into groups: cfed standard rodent chow (control); hfdfed high fat diet; hfd/myrfed hfd and treated with myriocin; hfd/myr/metfed hfd and treated with both the myriocin and metformin. muscle cer and plasma free fatty acids (ffa) were analyzed by lc/ms/ms. content of spt, carnitine palmitoyltransferase (cpt a), fatty acid transporters (cd , fabppm) and glucotransporter (glut ) was measured by wb. results: compared to control values, plasma ffa and muscle cer content and expression of all lipid-related proteins were elevated in hfd group. myriocin decreased muscular cer but increased plasma ffa and the expression of both the spt and cpt a. introducing metformin to hfd/myr group decreased the plasma ffa and muscular cer, lowered the expression of spt, cpt a, cd and fabppm, but increased muscular glut expression as compared to hfd and hfd/myr group. conclusions: simultaneous treatment with myriocin and metformin decreases the plasma ffa and muscular cer and improves glucose tolerance by augmentation of muscle glut expression. internal medicine, new london hospital, new london, nh, usa hyperglycemia, and hyperlipidemia. understanding whether side effect profiles differ between the most commonly prescribed agents could greatly inform prescribing decisions. objectives: to quantify differences in weight gain and metabolic side effects between aripiprazole, quetiapine, and risperidone in adults and children requiring chronic antipsychotic therapy. selection criteria: randomized controlled trials that compared at least two of the three atypical antipsychotics of interest and reported change in weight. all dosing ranges were included and there were no age or diagnosis restrictions. data collection and analysis: two blinded clinicians independently completed data extraction with a piloted, standardized data collection form. study quality was assessed through the cochrane risk of bias tool. we calculated weighted mean differences (wmd) and % confidence intervals (ci) using random effects models on review manager . main results: of studies identified through our search, published trials involving study participants met full inclusion criteria. quetiapine resulted in more weight gain than risperidone and risperidone resulted in more weight gain than aripiprazole). no trials directly compared aripiprazole to quetiapine, but an indirect method of comparison demonstrated that quetiapine causes more weight gain than aripiprazole. similarly, quetiapine led to a greater increase in glucose levels, a greater increase in blood pressure, and a greater increase in total cholesterol than risperidone. non insulin dependent diabetes mellitus (niddm) as a most common form of diabetes is a major public health problem; there is a subgroup of niddm patients which develops the disease at an early age and shows a dominant mode of inheritance. this type is nominates maturity onset diabetes of the young (mody). the prevalence of mody is difficult to access as patients with mody genes mutations are often identified during routine screening for other purposes. mody was linked to mutations in glucokinase gene (gck), and account for - % of mody, with the highest prevalence being found in the southern europe. the aim of this study was to examine the prevalence and nature of mutations in gck gene in iranian paients. we have screened gck mutations by single stranded conformation polymorphism (sscp) technique of polymerase chain reaction (pcr) in iranian families with clinical diagnosis of mody, included patients (eight males and females) and their family members. pcr products with abnormal mobility in denaturing gradient gel electrophoresis (dgge) were directly sequenced. we identified six novel mutations in gck gene in iranian families (corresponding to . % prevalence). our findings and the last study on mody highlight that in addition to gck, other mody genes such as mody and modyx may play a significant role for diabetes characterized by monogenic autosomal dominant transmission. this is clear that the knowledge of the specific defect can be used to pre-symptomatically identify family members at risk for developing mody. background: several epidemiological studies proposed an association between helicobacter pylori (h. pylori) infection with insulin resistance (ir) and metabolic syndrome (mets). however, up to date there is no conclusive evidence regarding this association. objectives: to investigate the prevalence and correlates of h. pylori infection among lebanese adults and to evaluate its association with ir and mets. materials and methods: stored blood samples of adults participating in the national nutrition and non-communicable diseases risk factors survey conducted in lebanon were used for this study (n = ). h. pylori-specific immunoglobulin g antibody titers were measured by elisa. data available included, in addition to anthropometric measurements, sociodemographic and lifestyle characteristics, blood pressure, biochemical indices (serum insulin, hdl, ldl, tag, glucose). a homa -ir level was used to assess insulin resistance. the international diabetes federation criteria were used to classify study participants with mets. results: the prevalence of h. pylori infection in the study sample was % ( % ci: . - . %). a higher crowding index was associated with a % increase in the odds of infection (or: . , ci: . - . ). blood pressure, waist circumference, serum hdl, ldl, tag, and glucose levels were comparable between h. pylori positive and negative subjects. the odds of ir and mets were not significantly different between the two groups. comparable to other developing countries. furthermore, our findings suggested no association of h. pylori infection with ir or mets. eradication of h. pylori infection to prevent ir or mets is not warranted. the economic burden resulting from diabetic neuropathy (dn) consumes a major portion of resources allocated for health-care services. the present study was undertaken to assess the costeffectiveness of medical intervention in patients with dn. two hundred patients with dn were purposively selected from out-patient department of birdem hospital, bangladesh. of them were late in detection of dn (ldn) and were detected early (edn). in ldn group, % had diabetic peripheral neuropathy (dpn), % had diabetic autonomic neuropathy (dan), % had diabetic proximal neuropathy (dpxn) and % had diabetic focal neuropathy (dfn). in edn group, % had dpn and % had dan. the average annual cost of care was us$ (direct us$ and indirect us$ ), with an average us$ per patient. among the average annual cost ldn consumed us$ (us$ per patient) and edn us$ (us$ per patient). the annual medical costs increased with the increased number of complications from us$ to to and to in ldn with one, two, three and more than three complications which is increasing at a rapid rate and us$ to to and to in edn respectively, increasing at a diminishing marginal rate. the regression equation showed that medical cost is significantly related to complications tested in both univariate (p < . ) and multiple linear regression analyses (r = . ; f- . , p < . ). proper management with regular screening substantially reduces the expenditure related to care and complications. a. alizadeasl , z. ojaghi-haghighi , r. azarfarin tabriz university of medical sciences, tabriz, rajaei hospital, tehran, iran background: metabolic syndrome (ms), the combination of hypertension obesity, dyslipidemia, and insulin resistance, is a precursor of diabetes mellitus (dm) and highly prevalent among patients with acute myocardial infarction (ami). diabetes mellitus is associated with larger infarct size and worse outcomes after ami. this study examind the clinical presentation and hospital outcomes among nondiabetic patients with ms following ami. this investigation is prospective analytic study (cohorts type) in consecutive infarct survivors who admitted to our heart centers through years ( ) ( ) ( ) . patients with diabetes (n = ) were excluded. those with ms (n = ) included patients with three or more of the following criteria: hypertension, elevated fasting blood glucose, hypertriglyceridemia, low high-density lipoprotein, and obesity [body mass index (bmi) >or = ]. the control group (n = ) included patients without ms or dm. results: baseline characteristics were similar except for hypertension, bmi, and dyslipidemia, which by study desing were higher in the ms group. the nondiabetic ms group had larger left ventricular dimension (p = . ), left atrium dimension (p = . ) and higher rate of ejection fraction % ( % vs. %, p < . ). also nondiabetic ms patients had higher rates of in-hospital death ( . % vs. . %, p < . ); post infarction angina ( . vs. . , p < . ) and more frequent left main coronary artery or three-vessel disease than the control group ( . % vs. . %, p < . ). conclusion: nondiabetic metabolic syndrome is common in patients with ami and strongly associated with poor outcome of them. background: this study assessed the prevalence of the metabolic syndrome (ms) and its impact on hospital outcomes in patients with acute myocardial infarction (ami) using both ncep atp iii and idf definitions. this investigation is propective analytic study (cohort type) in consecutive ami survivors (mean age: . ae . years; men and women), who admitted to our heart centers through years ( ) ( ) ( ) . results: q-wave myocardial infarction (mi) was present in . % of patients and non-q-wave mi, in . %. the ms was found in . % of the patients and was significantly more common in women than in men ( . % vs. . %, p = . ). one component of the ms was found in . % of patients; two, in . %; and none, in . %. . % of the patients had four or five components. hypertension was the most common component of the ms ( . %). . % of ms patients had triple-vessel disease on coronary angiography in comparing with . % in non-ms, ami patients (p < . ). the ms group had larger infarct size as determind by peak creatine kinase-mb ( . ae . vs. . ae . , p < ). overal inhospital complications (mechanical and electrical) were higher in patients with ms ( . % vs. . %, p = . ). ms is associated with a . -fold increased risk of acute renal failure after mi (p = . ). conclusion: ms in patients with ami is prevalent and associated with larger infarct size, more in-hospital complications, and marked increase of acute renal failure. background and aims: according to current views metabolic syndrome (ms) and obesity, especially with increased amount of visceral fat is characterized by prothrombogenic changes of hemostasis and fibrinolysis. methods: cross-sectional observational study included postmenopausal women (age - ) with ms. coagulant system was assessed by measurement of parameters of plasma haemostasis [activated partial thromboplastin time (aptt), fibrinogen concentration], and the activities of coagulant factors vii (fvii), viii (fviii) and ix (fix) in plasma. in order to investigate the functioning of anticoagulant system the activities of antithrombin iii. also we assessed adiponectin (adp) and homocysteine (hm) concentrations in plasma. results: prothrombotic alterations were observed in . % women. the aptt was decreased in . %, hyperfibrinogenemia was revealed in . %, the increased activity of: fviiin . %, fviiiin . %, fixin . %, and the decreased activity of antithrombin iiiin . %. the hm levels was increased in . %, the adp levels was decreased in . %. there were a significant positive associations between some of revealed prothrombotic alterations (fvii, fviii and fibrinogenemia) and anthropometric markers of visceral obesity and ms (weight, body mass index, and waist circumference). the adp levels were inversely correlated with the hm levels (r = À . , p < . ) and the activity of fvii (r = À . , p < . ). conclusion: results of our study demonstrate high prevalence of various prothrombogenic abnormalities in coagulation and anticoagulation systems in patients with visceral obesity and ms. plasma b-type natriuretic peptide (bnp) and blood urea nitrogen (bun) are elevated in heart failure. renal function is known to be an important factor related to bnp and bun determination. the aim of the present study was to examine whether bnp and bun are associated with left ventricular diastolic dysfunction (lvdd) in patients with type diabetes (t dm) without chronic kidney disease (ckd). the subjects in this study were consecutive patients with t dm [ men ( %); age ae years old (mean ae sd); diabetic duration ae years; hba c . ae . %]. subjects with overt heart failure or nyha class > , history of coronary artery disease, severe valvulopathy, chronic atrial fibrillation, and estimated glomerular filtration rate < ml/min/ . m were excluded from the study. all patients underwent clinical evaluation, laboratory tests including bnp determination, and echocardiographic examination. doppler echocardiographic indices including peak early diastolic mitral annular velocity (e′) and early diastolic myocardial velocity (e) were obtained in each patient. none of the patients exhibited systolic impairment of left ventricular function (ejection fraction > %), whereas lvdd (e/e′ > ) was detected in cases ( . %). e/e′ correlated with age (r = . , p < . ), sex (r = . , p = . ), diabetic retinopathy stage (r = . , p = . ), systolic blood pressure (r = . , p = . ), bnp (r = . , p = . ), and bun (r = . , p = . ). in multiple regression analysis, age (b = . , p = . ), sex (b = . , p = . ), bnp (b = . , p = . ), and bun (b = . , p = . ), correlated independently with e/e′. bnp and bun could be useful tools to screen for preclinical ventricular diastolic dysfunction in patients with t dm without ckd. h. kawano, y. nagayoshi, y. kinoshita objective: this study compared the effects of combination statin and fibrate therapy with either statin or fibrate monotherapy on lipid profiles in patients with impaired glucose tolerance (igt) and a high risk for cardiovascular disease. methods and patients: forty-five patients with igt and dyslipidemia (men , women , mean age . ae . years) were assigned randomly to the three treatment groups for a -month period. results: after months of treatment, low density lipoprotein levels decreased in every group, especially the statin and statin + fibrate groups. triglyceride levels also decreased in all three groups, especially the fibrate and statin + fibrate groups. high density lipoprotein cholesterol and fasting blood glucose levels did not change in any group. the levels of remnant like cholesterol particles decreased in the fibrate and statin + fibrate groups. there was no change during the study in the levels of creatine phosphokinase, lactate dehydrogenase, or creatinine. conclusion: combination statin and fibrate therapy results in greater improvement in lipid profiles than monotherapy with either drug. no marked adverse effects were observed with combination therapy during the study. background: gout is considered a metabolic disease and ranked among the diseases connected with obesity, such as an arterial hypertension, coronary artery disease, stroke, and type diabetes mellitus (who, ) . it has been proven that intake of a considerable quantity of meat products is predictor of acute gouty arthritis. for this reason there is great interest in studying the prevalence of gout among inhabitants of the republic of sakha (yakutia) where a lipid-protein diet prevails. this is a preliminary report on the incidence of gout requiring hospitalization in - . objectives: patients hospitalized in the yakut city hospital with gouty arthritis were studied. methods: patients are being studied by means of a questionnaire developed by the institute of rheumatology (moscow). results: forty-four patients were registered ( men and two women). the majority of patients (n = ) are inhabitants of yakutsk city. median age of the subjects is years, with a range of - years; four patients are over . secondary forms of gout and relapses of disease are common. accompanying pathology includes: ah in patients, cad in seven patient, type dm in four patients, glucose intolerance + obesity in one patient, metabolic syndrome + obesity in one patient, uncomplicated obesity in one patient, metabolic syndrome without obesity in one patient, chronic renal insufficiency in one patient, and cardiovascular accidents in three patients. the research proceeds. results will be used for characterization of the incidence and diagnostic features of gout in yakutia especially among young patients with accompanying metabolic abnormalities. background: the prevalence of obesity, a major public health problem, is rising in many countries including iran. non-drug dependent interventions for obesity management include physical activity, dietary restriction and acupuncture. primary study objective: we examined the effects of body electroacupuncture and low-calorie diet on plasma leptin in obese and overweight individuals with the excess or deficiency pattern (according to chinese medicine). methods/design: the case group received authentic electroacupuncture and the placebo group received sham acupuncture. both groups consumed a low-calorie diet for weeks. settings: this study was conducted in nutritional clinic of ghaem hospital, mashhad, iran. participants: people (n = ), aged between and years with body mass indexes (bmi) between and kg/m were randomized into two groups. interventions: comparison of either real or shame electro acupuncture combined with a low caloric diet was investigated in this trial. primary outcome measures: plasma leptin, body fat mass (bfm), body weight and body mass index were measured before and after treatment. results: in volunteers in the case group with both the excess and the deficiency patterns, we found a significant reduction in plasma leptin ( . %, p = . ) and bfm ( . %, p = . ). in the placebo group, we found a less significant reduction in leptin and bfm. the difference between the two groups was significant for leptin (p = . ) but not for bfm (p = . ). conclusions: body electroacupuncture with a low-calorie diet may reduce plasma leptin concentration; through a mechanism that will require further clarification. m. darbandi , , s. darbandi , , a.a. owji , p. mokarram , m. ghayour mobarhan effects of auricular acupressure combined with low-calorie diet on the leptin hormone level. methods: volunteers (n = ) with body mass indexes (bmi) between and kg/m were randomised into a case (n = ) or a control (n = ) group. the participants in each group received a low-calorie diet for weeks. the case group was treated with auricular acupressure and the control group received a sham procedure. plasma leptin levels, body fat mass, body weight (bw) and bmi were measured before and after treatment. results: participants who received auricular acupressure showed significant reductions in their plasma leptin levels ( . %, p < . ) as well as in their body fat mass ( %, p < . ). these changes were not observed in the control group. the reduction in leptin was significantly greater in the acupressure group than the controls. conclusion: auricular acupressure combined with a low-calorie diet significantly reduced plasma levels of leptin. however, the mechanism of this reduction is not clear. background: premature arteriosclerosis may be one of the mechanisms linking pre-diabetes mellitus (pre-dm) and cardiovascular disease. we assessed premature arteriosclerosis in pre-dm using arterial stiffness indices and analyzed the associated contributors of this process. methods: we collected clinical data of patients without dm, pre-dm patients, and dm patients. both the compliance index (ci) and stiffness index (si) were measured to indicate large and peripheral arterial stiffness. results: patients with pre-dm and dm had lower ci ( . ae . vs. . ae . units; p < . and . ae . vs. . ae . units; p < . , respectively) and higher si ( . ae . vs. . ae . m/s; p < . and . ae . vs. . ae . m/s; p < . , respectively) than patients without dm. both pre-dm and dm patients had higher glucose and hemoglobin a c , higher homa index, higher hscrp, and a lower adiponectin level than patients without dm. using multivariate linear regression analysis, age, heart rate and homa index were independent determinants for si (whole model: r = . , p < . ), whereas male gender, hscrp, and homa index were independent determinants for ci (whole model: r = . , p < . ). conclusions: homa index was an independent determinant for arterial stiffness. increased insulin resistance may associate with increased arterial stiffness both at large and peripheral arteries in pre-dm patients. king's college london, london, uk, uppsala university, regional cancer centre, uppsala, sweden, guy's & st thomas' nhs foundation trust, london, uk, karolinska institute, stockholm, sweden background: impaired glucose metabolism has been linked with increased cancer risk, but the association between serum glucose and cancer risk remains unclear. we used repeated measurements of glucose and fructosamine to get more insight into the association between the glucose metabolism and risk of cancer. methods: we selected , persons (> years old) with four prospectively collected serum glucose and fructosamine measurements from the apolipoprotein mortality risk (amoris) study. multivariate cox proportional hazards regression was used to assess standardized log of overall mean glucose and fructosamine in relation to cancer risk. similar analyses were performed for tertiles of glucose and fructosamine and for different types of cancer. results: a positive trend was observed between standardized log overall mean glucose and overall cancer risk (hr = . ; % ci: . - . ). including standardized log fructosamine in the model resulted in a stronger association between glucose and cancer risk and a statistically significant protective effect of fructosamine (hr = . ; % ci: . - . and hr: . ; % ci: . - . , respectively). the highest risk for cancer was among those in the highest tertile of glucose and lowest tertile of fructosamine. similar findings were observed for prostate, lung, and colorectal cancer. the contrasting effect between glucose, fructosamine, and cancer risk suggests the existence of distinct groups among those with impaired glucose metabolism, resulting in different cancer risks based on individual metabolic profiles. further studies are needed to clarify whether glucose is a proxy of other lifestyle-related or metabolic factors. patients in two groups were compared according to age, parity, prepregnancy weight, family history of diabetes mellitus, history of macrosomia in their previous pregnancies, history of hypertension, previous malformed fetus, history of iufd and abortion. based on the obtained results there was a statistically significant difference between two groups in terms of age (p < . ), parity (p < . ), prepergnancy weight (p < . ), family history of diabetes mellitus (p < . ), previous macrosomia (p < . ), history of hypertension (p < . ), previous malformed fetus (p < . ) and previous iufd (p < . ), but abortion was not significantly different. older age, parity (three or more) obesity, family history of diabetes mellitus, history of macrosomia, hypertension, malformed fetus and also previous iufd are risk factors for gestational diabetes. therefore, these women should be screened and handled for gestational diabetes in their pregnancies, and controlled for possible diabetes mellitus in the future. methods: this family based study was conducted on nuclear families from among tehran lipid and glucose study with two biological parents and at least two offspring ( parents and offspring), aged - years. selected families had at least one person with overweight or obesity. all obesity-related variables (height, weight, hip, waist circumference (wc), body mass index (bmi), body size (bs), resting energy expenditure (ree), waist to hip ratio (whr)) were measured and calculated. the heritability estimate of continuous variables was calculated using a standard quantitative genetic variance-components model which was implemented in the solar software. results: the heritability estimates for obesity-related variables such as height, weight, hip, wc, whr, bmi, bs, and ree, after adjustment for sex, age were %, %, %, %, %, %, %, and %, respectively. the h for the above mentioned variables, expect of bs, after adjustment for sex, age, and body size varied to %, %, %, %, %, %, and %, respectively (p < . ). we clearly demonstrated a significant heritability of obesity-related variables among tlgs families. the results of the present study confirmed the important impress of genetic factors on the obesity-related variables phenotype. method: pwv determined with bpuls apparatus using left external carotid and left dorsalis pedis arteries as "central" and "peripheral" points respectively. pulses picked up by infrared sensors and recorded simultaneously with single lead ecg. time difference between pulses measured. shorter time delay or faster pwv indicates decreased arterial elasticity. materials: nine hundred and fifty-seven asymptomatic filipinos studied. males- , females- . age - years. three hundred and twenty-seven hypertensives. classified into groups according to bmi and wc. average pwv time (adjusted for height) for each group noted. relationship of increased bmi and wc to variations in pwv time determined. results: elevated bmi does not significantly influence pwv time in: all subjects-(p < . ); females-(p < . ); normotensives-(p < . ); and, hypertensives -(< . ). however, for every centimeter increase of wc there is a corresponding decrease of pwv time by: . s (p < . ) in all subjects; . s (p < . ) in females; . s (p < . ) in normotensives; and, . s (p < . ) in hypertensives. discussion: abnormal pwv is a high cvd risk factor. in four groups above, elevated bmi does not significantly influence pwv time. however, in the very same groups, increased wc significantly affects pwv time. this indicates that if we rely solely on bmi to predict cvd we will miss cases which are at high risk as shown by abnormal wc. correlation (r = . ). an increased risk of cvd and cancer was identified with elevated levels of ggt or crp or both markers (ggt-crp score ! ); the greatest risk of cvd and cancer was found when ggt-crp score = (hr: . ( %ci: . - . ) and . ( . - . ) compared to ggt-crp score = , respectively). conclusion: while ggt and crp have been shown to be associated with metabolic abnormalities previously, their association to the components investigated in this study (hyperglycaemia and dyslipidaemia) was limited. results did demonstrate that these markers were predictive of associated diseases, such as cancer and cvd. metabolic syndrome is the aggregation of conditions that together increases the risk of cardiovascular disease and diabetes mellitus in both normal glucose tolerance (ngt) and impaired glucose tolerance (igt) subjects. it is estimated that around - % of the world′s adult population have the metabolic syndrome. over the last years the prevalence of metabolic syndrome has steadily increased in all populations, and making it one of the major global public health challenge. the objective of this study is to estimate the prevalence of metabolic syndrome and cardiovascular risk factors in impaired glucose tolerance (igt) subjects. two hundred and four impaired glucose tolerance and normal glucose tolerance subjects of both genders were selected for the present study according to the american diabetes association ada criteria, on the base of h glucose tolerance test. anthropometric characteristics like waist circumference, bmi, systolic blood pressure, and diastolic blood pressure were measured with standard techniques. biochemical parameters like fasting blood sugar, fasting insulin, cholesterol, triglycerides, hdl-c, and ldl-c were determined by standard techniques, the homa-ir values were calculated with the help of formula. it is concluded from the present study that the prevalence of metabolic syndrome is significantly increased according to aace, atpiii definition criteria's in impaired glucose tolerance subject, the study emphasizes strongly that ms is major factor to enhance the incidence of type diabetes and cardiovascular diseases in impaired glucose tolerance subjects. it is suggested that preventive measures and treatment can reduce incidence of cvd, type diabetes in our population. anthropology, vidyasagar university, midnapore, india waist circumference (wc) and waist-hip ratio (whr) were reported as imperative abdominal obesity related measures having influence on many cardiovascular disease (cvd) risk factors. present study attempts to evaluate the possible association of abdomen circumference (ac) with hypertension and dyslipidaemia among the bhutias, a tribe residing the sub-himalayan state of sikkim, india. five hundred and eleven bhutias of both sexes aged ! years inhabiting gangtok, the state capital and its neighbourhood were systematically selected to participate in the study. after providing informed consent data on blood pressures, blood lipids, anthropometrics and other lifestyle related variables such as perceived stress, diet, energy expenditure, socioeconomic status and so on were collected following standard methods. the results evidently indicate that the ac is the best predictor of the selected cvd risk factors. after log transformation, the effect of age on cvd risk factor variables and anthropometrics was found and regressed out through linear regression. data was pooled for sex as significant sex difference was absent for most of the variables. after adjusting for significant lifestyle related predictors, multiple logistic regression was carried out to evaluate the significant obesity related predictors of hypertension and dyslipidaemia. receiver operating characteristic (roc) curve finally showed ac as the best predictor of hypertension and dyslipidaemia. although wc and whr were found to be important abdominal obesity related predictors of cvd risk factors in many studies, present population based cross sectional study has proved the importance of considering ac as a central obesity related predictor of different cvd risk factors. the achievement of therapeutic goals is of great importance in patients with chronic diseases such as diabetes mellitus (dm), because of its impact on morbidity and mortality. objective: to explore the relationship between therapeutic adherence and metabolic control in patients with dm- , who were seen at a hospital in the city of medellı´n (colombia). methods: cross-sectional study involving patients with the following selection criteria: age ! years, diagnosis of dm- ! months, who signed informed consent. the summary of diabetes self-care activities (sdsca) score was applied for the measurement of therapeutic adherence and duke-unc score for the assessment of perception of social support. glycosylated hemoglobin (hba c) was processed by turbidimetric inhibition immunoassay (tinia) cobas c- equipment. adequate metabolic control was defined as value of hba c %. version . of the spss program was used for the statistical analysis. results: seventy patients studied: % are female, % suffer from hypertension, % have dyslipidemias and % smoke. in addition, % are insulin dependent, % have inadequate glycemic control and % has no social support. items with the highest proportion of adherence were: medication ( %), foot care ( %) and diet ( %). whereas the lowest were: hba c ( %) and exercise ( %). hba c correlated significantly (p < . ) with adherence to diet, blood glucose monitoring, foot care, social support and sex. conclusion: therapeutic adherence was associated with metabolic control in patients with dm- . mellitus. however, it is unclear if severity of dr is associated with lvdd, which is recognized to result in subsequent heart failure. the subjects in this study were consecutive patients with type diabetes mellitus (t dm). all patients underwent clinical evaluation, laboratory tests, and echocardiographic examination. doppler echocardiographic indices including peak early diastolic mitral annular velocity (e′) and early diastolic myocardial velocity (e) were obtained in each patient. the patients were divided into three groups according to presence of dr and its severity: no diabetic retinopathy (n = ), simple retinopathy (n = ), and preproliferative or proliferative retinopathy (n = ). no patients showed systolic impairment of left ventricular ejection fraction (lvef > %), whereas impaired lv diastolic function (e/e′ > ) was detected in cases ( %), furthermore lvdd (e/e′ > ) was detected in cases ( %). e/e′ was correlated with age (r = . , p = . ), sex (r = . , p = . ), diabetic duration (r = . , p = . ), dr stage (r = . , p = . ), systolic blood pressure (r = . , p = . ), and serum creatinine level (r = . , p = . ). in multiple regression analysis, age (b = . , p < . ) and dr stage (b = . , p = . ) were independently correlated with e/e′. in this study, we showed that almost all subjects had asymptomatic lvdd, and severity of dr was associated with lvdd in patients with type diabetes mellitus. objectives: this study explores the contribution of the sasang constitutional types as a risk factor for hypertension by examining the prevalence and risk for hypertension across different constitutional types (se, sy, te, and ty types) and investigating whether certain constitutional types can increase the risk of hypertension in an individual. design: this retrospective chart review evaluated the charts of patients who had visited the clinic for routine physical check-up. subjects: among , visitors, those aged between and , with complete data concerning the past medical and social history, blood pressure and body size measurements, results of blood test, and confirmatory constitutional typing (excluding the ty type) were included in the final analysis group (n = ). results: especially, even after adjusting for the different variables, the odds ratio for hypertension in the te type was found to be . (ci . - . ) (taking the se type as the reference group), indicating that the te constitutional type can act as a risk factor for hypertension. moreover, when comparing the te type to non-te types, the odds ratio was found to be . (ci . - . ), implying a weak but valid contribution of the te constitutional type toward increasing the risk of hypertension. the results of this study show that the prevalence of hypertension differs across different constitutional types, and that the constitutional type (the te type) can act as a risk factor for hypertension independently of other possible variables. a.b. shetty , p.k. roy physical therapy, university of st mary, leavenworth, ks, bon secours hospital, baltimore, md, usa introduction: the purpose of this research was to determine whether habits of individuals contributed to changes in metabolic rate. as the daily physical activity levels increase, there is an increase in the metabolic rate and caloric expenditure. it can be inferred that people who are overweight may not participate in physical activities due to social, psychological, and physical reasons. they may spend more time in less physically demanding activities during their leisure time. hypothesis: it was hypothesized that the individuals who like to read for pleasure during leisure will have higher body-mass-index. subjects: a group of college aged, - , females volunteered to be the subjects for the study. method: each subject's weight and height were collected to determine bmi. the leisure time activities that were included were reading, sleeping, watching television, use of computers, and sports and physical activities. a likert scale questionnaire was developed and had four levels of answers for each of the leisure time activities. a person-product moment correlation was used to determine the relationship between bmi and five leisure time activities. the results indicate that a positive correlation of . between bmi and leisure time reading habits. there is a negative correlation of À . between bmi and sports and physical activities. conclusion: this research demonstrates that the bmi is significantly higher for individuals who like to read during their leisure time activities. therefore, it is also important to develop physical activities as habits during early years that may carry into adulthood. objectives: the main goal of this retrospective cohort study was to compare the incidence of over-all and site-specific cancers among israeli arabs with diabetes mellitus (dm) with that of israeli arabs without dm. methods: a retrospective cohort study was conducted in northern israel, involving all arab subscribers of clalit healthcare services (chs), which is the major hmo service in the region, serving over % of the concerned population. results: during a period of years ( - ) of follow-up, and incident cases of cancer were found among , people with dm and , adults free of dm, respectively. the follow-up time involved , person years. dm was associated with a standard incidence ratio (sir) of . ( %ci: . - . ) and . ( %ci: . - . ) for pancreas cancer in men and women, respectively. a significantly reduced sir was observed for esophageal, stomach and intestine cancer . ( %ci: . - . ) in men. our findings support an association between dm and increased risk cancer of the pancreas in arab men and women. a significantly reduced risk of all other cancers was observed only in arab men. a.e. berezin , o.a. lisovaya methods: seventy-two mild-to-moderate arterial hypertension patients within - weeks after ischemic stroke were enrolled to the scrutiny at baseline. both vegf- and mmp- plasma levels were measured at the study entry and in months after baseline by elisa. we has been assessed all new cardiovascular events including myocardial infarction (mi), unstable angina (ua), recurrence stroke (rs), tia, advance heart failure (hf) during study period. results: analysis of obtained outcomes have been shown that all cases (n = ) of new cardiovascular events identified during first weeks after start of observation are correlated well with vegf- plasma levels (r = À . ; p < . ) measured at baseline. on the other hand, -weeks survival rate was . % and . % respectively for group subjects (p < . ) with top and low quartile of vegf- plasma level at baseline. however, lack of tightly interrelationship between cardiovascular outcomes and vegf- (r = . ; p = . ) in months after study entry. the mean mmp- plasma levels were significantly higher in dead patients in comparison to survival subjects of the study end. both new events associated with rs and tia incidences independently study period are correlated well with vegf- (r = À . ; p < . and r = À . ; p < . respectively) only. we has been proposed that circulating vegf- might have more predicting value in comparison with mmp- concentration among hypertensive patients during early ischemic stroke period. introduction: clinician should change the health care system from on diseases treatment to prevention of diseases. obesity increase mortality, morbidity and psychological problems through life but beneficial effects of risk reduction by changing life style have been documented. objective: sedentary life style is the most important factor for promoting weight gain in people. it's clear that obesity occurs when calorie intake exceeding calorie output. obesity is common in families but seems environmental factors can affect body weight beside genes role. a main factor of life style change is energy balance. we recommend one simple healthy life guideline for managing of environmental factors in obese people that includes a diet and physical activity program. body weight should be reduced - % during first year by following of this guideline and continued until achieving to optimal body weight. obese people are visited and monitored some parameters for program adjusting and changed each item basis on individual response. objective: to assess trend and associations between blood sugar level, blood pressure, overweight/obesity and lifestyle among tribe of northeast india experiencing transition. method: cross-sectional study was carried out among tangkhul nagas, aged between and years. subjects were divided into five decadal age groups to assess age trend in biological and socioeconomic variables. height, weight, waist circumference, hip circumference, random blood sugar level, bp, bmi, wsr and whr were evaluated. result: the prevalence of prediabetes and diabetes were . % and . % respectively. diabetes was found among older age groups only. hypertension was highly prevalent with higher percentage among males ( %) than females ( . %). mean bp was higher among males but sugar level among females, which corresponds to their higher adiposity level. prevalence of overweight/obesity in females was . % while in males, it was . %. sugar level and bp had positive correlation with age, bmi, wsr and whr. the prevalence of hypertension and prediabetes/diabetes were higher among centrally obese subjects. central obesity indices were stronger predictors of diabetes and hypertension than general obesity. odds ratio showed urbanization, higher socioeconomic status and sedentary lifestyle as significant risk factors for development of overweight/obesity, which in turn was risk factor for development of diabetes and hypertension. conclusions: tangkhul nagas has been experiencing socioeconomic and lifestyle change which led to the increasing prevalence of overweight/obesity and cardiometabolic health problems, contributing to the escalating global epidemic of obesity and metabolic syndrome. there was close associations between socioeconomic status, age, overweight/obesity, hypertension and blood sugar level. background and aims: trace elements play an essential role in metabolism of carbohydrates, lipids, etc. these results stipulated the present work. we studied patients (eight females, males, age - years) with type diabetes mellitus. duration of the disease varied from month to years. as a control data the hair composition of practically healthy individuals (n = ) were used. as an analytical method instrumental neutron activation analysis (inaa) was used. results: data obtained shows statistically significant decrease of cu, cr, and zn and increase of na, fe, br, and sb levels in hair in the group with a blood glucose concentration < mmol/l. in the group with a blood glucose concentration more than mmol/l levels of cu and la were decreased and na, fe, co, br, and i levels increased. in the group with a blood glucose concentration more than mmol/l glucose concentration correlates with sc (r = . ), cr (r = À . ), and mn (r = + . ). conclusion: it was found that mn level in blood increases with diabetes. this may be a manifestation of mn metabolism dysfunction in diabetes and excretory role of hair. it is also confirms the important role of some elements, especially cr, in diabetes. concentration of this element significantly decreases especially in the first year of illness. unexpected are correlations for sc. usually sc is considered as an element that has no biological role. these findings are additional reasons to study the biological role of less studied ultra trace elements. objective: investigate the prevalence of hyperglycemia in patients undergoing coronary angiography. methods: six hundered and ninety-five consecutive brazilian subjects undergoing coronary angiography were assessed for fasting plasma glucose and hba c (hplc) levels and for previous history of diabetes mellitus (dm). we classified those without previous diagnosis in three groups according to hba c levels (hplc): normoglycemic (n); hba c -< . %; prediabetes (pd) -hba c . % À . %; and dm (d) -a c ! . %. cad defined by any visible lesion ! %. we also classified glycemic status using fasting glucose levels by ada criteria. results: patients were aged . ae . years, . % male. the group had a high prevalence of cardiovascular risk factors: dyslipidemia - %, hypertension - %, % overweight/obese, metabolic syndrome (idf) in % of subjects. cad was detected in . % of them. dm was newly diagnosed using hba c in . % of the whole sample ( individuals) and pd in ( %). in those without dm according to hba c, ( . %) had glucose levels ! mmol/l and ( . %) had glucose ! . mmol/l. in this particulary population with coronary artery disease and/or cardiovascular risk factors we observed a high prevalence of undiagnosed hyperglycemia -dm or prediabetes ( - %) depending on the criteria used for identification/diagnosis (fasting glucose or hba c). this finding reinforces the importance of implementing a systematic screening for hyperglycemia in this high risk population. national university of singapore, singapore, singapore, university of sydney, sydney, nsw, australia objectives: to evaluate associations between metabolic syndrome (mets) components and mortality and whether these associations change over time. methods: three thousand eighty-six eligible residents aged ! years were prospectively followed in the blue mountains eye study, west of sydney, australia. mets components were measured at baseline ( - ) , and after -years and -years ( - ) . using cox proportional hazards and competing risks models with mets as a time-dependent covariate, we estimated effects of mets on all-cause and cause-specific mortality. receiver operating characteristic (roc) curve analyses were used to identify which individual or combined mets components best predicted mortality. . roc analysis suggested that glucose, body mass index (bmi) and blood pressure (bp) best predicted all-cause and chddeath, bmi and bp best predicted stroke-death and glucose and triglycerides best predicted cancer-death. national university of singapore, singapore, singapore, university of sydney, sydney, nsw, australia objectives: to investigate the effect of metabolic syndrome (mets) and its components on the incidence of different sub-types of cataract (cortical, nuclear and posterior subcapsular cataract (psc)) over years and whether these associations change with time. methods: a prospective cohort of elderly aged ! years were followed up over a period of -years in the blue mountains eye study, west of sydney, australia. mets components were measured at baseline ( - ), -years ( - ) and -years ( ) ( ) ( ) . the incidence of different types of cataract was obtained from standard photographic grading at -and -year (n = ). using random-effect complementary log-log regression model with cataract status as interval-censored data, we estimated the effect of mets on the incidence of different types of cataract at different time-intervals. results: after taking into account the changes in mets (components) and controlling for possible confounders, mets was found to be associated with increased -year incidence of cortical cataract [hazard ratio (hr) . , % confidence interval (ci) . - . ] and psc (hr . , % ci . - . ). amongst the five components of the mets, high glucose and obesity predicted the -year incidence of cortical cataract and at -year, high glucose and low-hdl was associated with increased incidence of psc and cortical cataract, respectively. conclusions: changes in mets predicted the -year incidence of cortical cataract and psc. different mets components predicted the incidence of different sub-types of cataract at varying time-intervals. material and method: this study was a done on a sample of isfahan cohort study (ics) participants. subjects which met atpiii criteria, entered in our study. aobesity indices such as body mass index (bmi), waist circumference (wc), waist to hip ratio (whr) and waist to height ratio (whtr) measurements were done by trained nurses. serum lipids, fasting blood glucose, interleukin- (il- ) and interleukin- (il- ), adiponectin ghrelin, and crp were measured. the mann-whitney u-test was used for comparisons between the level of inflammatory markers in obese subjects with and without mets. then subjects with mets were selected and correlation between inflammation biomarkers and obesity indices correlation coefficients were obtained by pearson correlation test. results: wc and bmi were significantly higher in subjects with mets (p < . ). the median (iqr) of crp was significantly higher in subjects with mets (p < . ). the correlation between inflammatory markers and obesity indices was determined by nonparametric analysis. mets subjects had a significantly positive correlation between il and whtr (r = . , p = . ). no significant relationship found between il- , ghrelin, adiponectin and crp with, bmi, whtr and waist. significant negative correlation was observed for adiponectin and the waist (r = À . , p = . ). negative correlation between adiponectin with whr, whtr and bmi among subjects without mets (r = À . , r = À . and À . respectively). conclusion: present study indicate that the observed inflammatory concentrations cannot be explained by type of obesity. objective: the incretin effect is known to be decreased in type diabetes (t d). however, no study has directly measured the incretin effect in non-caucasian subjects. because asian patients with t d are characterized by decreased insulin secretion, this study set out to examine the incretin effect in korean subjects with normal glucose tolerance (ngt) or t d. research design and methods: we performed g ogtts and corresponding isoglycemic intravenous glucose infusion (iigi) studies in subjects with ngt (n = ) or t d (n = ). the incretin effect was calculated based on the incremental area under the curves (iaucs) of insulin, c-peptide, or insulin secretion rate (isr). the plasma levels of total glucagon-like peptide- (glp- ) and glucosedependent insulinotropic polypeptide (gip) were measured by elisa. results: the incretin effect was not different between the subjects with ngt and t d ( ae % vs. ae %, p = . by insulin; ae % vs. ae %, p = . by c-peptide; ae % vs. ae %, p = . by isr, respectively). however, the gastrointestinally mediated glucose disposal (gigd) was decreased in t d ( . ae . % vs. . ae . %, p < . ). the plasma levels of the total glp- and gip during the ogtts were comparable between the two groups. conclusions: in koreans, the secretion of glp- or gip during ogtts and the incretin effect were comparable between subjects with ngt and t d, whereas the gigd was significantly decreased in patients with t d. a.e. berezin , a.a. kremzer internal medicine, clinical pharmacology, state medical university, zaporozhye, ukraine the aim of this study was to evaluate the interrelation between circulating osteoprotegerin (opg) and coronary vasculature damage in type diabetes mellitus patients. methods: one hundred and twenty-six subjects with stable diabetes mellitus type with previously angiographic documented asymptomatic cad were enrolled to the study. vessel-wall and plaque geometrical and compositional parameters were measured on contrast-enhanced ct angiography. the volume of intramural calcium of > hu in major coronary vessels was measured in coronary segments with a highly standardized method. coronary artery calcification was quantified by calculating the agatston' score index and calcification mass measurement. opg plasma levels were measured with elisa. results: circulating opg level was increase in patients [ pg/ ml [ % confidence interval (ci) = - pg/ml] and was normal in subjects ( pg/ml; % ci = - pg/ml; p < . ). the relationship between coronary artery calcium by agatston' score index and percent atheroma volume (pav) was determined by linear regression. pav and remodeling index were significantly higher in patients with elevation of opg plasma level when compared with those who have normal opg [adjusted odds ratio (or) = . ( % ci = . - . ); p = . ]. there was significant correlation between agatston' score index and pav [r ( ) = . , p = . ]. in conclusion, we demonstrated that opg plasma level can associate with vessel-wall thickening, percent atheroma volume, and agatston' score index value in type diabetes mellitus patients with previously angiographic documented cad. along with the prevalence of diabetes continues to grow, the occurrence of microvascular chronic complications caused by diabetes has increasingly become a serious social problem. diabetic cardiomyopathy, a microvascular disease, results in chronic heart failure and causes a heavy economic burden. endoplasmic reticulum as an intracellular organelle, which occurs the stress leads to cell apoptosis. recent studies indicate that bis(maltolato)oxovanadium can alleviate the endoplasmic reticulum stress to protect cell function. in this study, stz ( mg/kg)-induced diabetic rats were divided into two groups, the diabetic control group, and diabetes + vanadium group; the normal group without diabetes were randomly divided into two groups, normal group and the normal + vanadium group. the bis(maltolato)oxovanadium significantly improve the endoplasmic reticulum stress in stz-induced diabetic rat heart cells and reduce the cardiac damage. in this study, bis(maltolato)oxovanadium can reduce the endoplasmic reticulum stress in diabetic myocardial cells delay the development of diabetic cardiomyopathy. it can be a new way to explain the mechanism in the function of bis(maltolato)oxovanadium. between mets and type diabetes families without diabetic family related. subjects and methodology: forty-three mets subjects with type diabetes parental ( st group), mets subjects without type diabetes parental ( nd group) and no mets subjects but with type diabetes parental ( rd group). this study was conducted over months at diabetologia department hospital. diabetes screening was achieved by oral glucose tolerance testing (ogtt). metabolic parameters were determined by spectrophotometry, insulin by radioimmunoassay. insulin sensitivity was also assessed by the homeostasis model assessment (homa) approach (glucose insulin/ . ). results: in the st and the nd groups there is a significant hyperinsulinemia and to a lesser extent in the rd group ( %, % and %, respectively). the homa model confirms an acute insulin resistance ( %, % and % increase respectively). hypertriglyceridemia was observed only in the nd group. hdl dyslipidaemia has been identified in women of the nd group (< . g/l). our study seems to confirm that type diabetes genetic predisposition is not the only factor, but also environmental factors with or without diabetes family. aims: to examine, the predictors of incident chronic kidney disease (ckd) in a community-based cohort of middle east population, during a mean follow-up of . years. methods: in a sample of non-ckd iranian adults ! years the estimated glomerular filtration rate (egfr) was calculated at baseline and at year intervals during three consecutive phases. the egfr < ml/min/ . m was defined as ckd. multivariate logistic regression analysis was used to determine the independent variables associated with incident ckd. results: the incidence density rates of ckd were . and . per , person-year, among women and men, respectively. female gender per se was associated with higher risk of ckd, compared with males. among women, age, egfr, known diabetes, being single or divorced/widowed, hypertension (marginally significant) and current smoking were independent risk factors for ckd; however the intermediate degree of education and family history of diabetes decreased the risk by % (p < . ). among male subjects, independent predictors of developing ckd included aging and hypertension (with significantly higher risk than in women, p for interaction < . ), egfr, new diagnosed diabetes, high normal blood pressure; abdominal obesity decreased the risk of ckd about % which was marginally significant. in the iranian population, > % of individuals develops ckd each year. our findings confirmed that sex-specific risk predictors should be considered in primary prevention for incident ckd. introduction: obesity is a silent killer and a forerunner of many complications if persists long. various studies with animal model have identified the role of leptin, the hormone of adipose tissue; in obesity and its associated complications like diabetes and atherosclerosis inlater stages. the exact mechanism to know how leptin influences insulin action in body and thereby leading to diabetes or post diabetic atherosclerosis is still not completely evaluated. hypercholesterolemia was only found common to all these three states. aim and objectives: the present study, therefore, evaluated the role of obesity on the expression of ldlr receptor, insulin receptor and leptin receptor. method: receptor expression was done by immunohistochemistry/ western blot. the serum level of lipids were measured by enzyme based kit method. the serum level of insulin and leptin and its soluble receptor were measured by elisa based kit. the blot for insulin expression shows no chamge with body weight; the blot for leptin receptor shows decrease expression with weight gain and blot for ldlr shows decrease expression with weight gain. the serum levels of insulin and leptin are increased with weight gain but soluble receptor for leptin did not change significantly. even the obese group showed decrease tyrosine phosphorylation of insulin receptor. background: visfatin and apelin are two new adipokines that recently gained special interest in diabetes research. however, the relationship between them has not been elucidated and their role in coronary artery disease (cad) complication of diabetes has not been adequately studied. objective: this study was conducted to study the interplay between these two novel adipokines and to study their correlation with other inflammatory and biochemical parameters in type diabetic (t d) postmenopausal women with cad. the levels of visfatin, apelin and other parameters were measured in t d patients without cad, both nonobese and obese t d patients with cad, together with healthy nondiabetic control subjects. visfatin and apelin were measured by enzyme-linked immunoassay (elisa). results: visfatin was found to be significantly higher in the following groups: t d patients without cad, non-obese and obese t d patients with cad, ( . ae . , . ae . and . ae . ng/ml respectively) when compared to control group ( . ae . ng/ml) at p < . . apelin was found to be significantly lower in both non-obese and obese t d patients with cad ( . ae . and . ae . ng/ ml respectively) when compared to control group ( . ae . ng/ml) at p < . . furthermore, visfatin and apelin were found to be significantly associated with each other and with other biochemical parameters in both simple and multiple regression analyses. the current study provides evidence for the novel interplay between visfatin and apelin through the inflammatory milieu characteristic of t d and sheds light on their possible role in the pathogenesis of cad complication of t d. aim: the aim of this study was to investigate the relationship between hscrp, il- , and hcy levels and cardio metabolic risk factors in subjects with and without mets in a sample of tehranian population. in this cross-sectional study, individuals including men and women, aged ! years were selected randomly from among participants of tlgs. the sera of il- , hscrp and hcy were determined using elisa method. results: of the total subjects, aged mean . ae . year, mets was presented in ( . %) individuals. the levels of hscrp, hcy, and il- were higher in subjects with mets compared to normal group. a gradual significant increase just in the level of hscrp with increasing number of mets components was found after adjustment for sex and age. a strong linear augmentation in hscrp levels was observed as the number of mets components increase from to ! with median hscrp levels of . , . , and . (ng/ml) (p trend = À ). also, an increase of . in hscrp levels (ci %: . - . ; p = À ) was observed with an increase in each components of mets in linear regression analysis adjusted for age and sex. the best predictor for hscrp, il- , and hcy, in subjects with mets was hip, whtr, and height, respectively, compared with whtr and wrist which were the best predictors for hscrp and hcy levels in the subjects without mets. conclusion: hip and whtr are significant predictors of the hscrp and il- elevation associated to mets, respectively. methods: in a nested case-control study, conducted on a group selected from participants of the tehran lipid and glucose study, those cases with new diagnosed type diabetes during the . year follow-up ( subjects) were matched to controls for age, sex, body mass index andseason of entrance to study. multivariate conditional logistic regression analysis was used tocalculate the odds ratio (or) with % confidence interval of type diabetes for vitamin dcategories, vs. the first quartile ( . ng/ml) as reference. results: the unadjusted ors of type diabetes were . ( . - . ), . ( . - . ) for the second and third tertiles, respectively. after adjustment for family history of diabetes, systolicblood pressure, triglycerides to high density lipoprotein cholesterol ratio, and fasting plasmaglucose, the corresponding ors were . ( . - . ) and . ( . - . ) for second and third tertiles respectively. multivariate cubic spline modeling analysis indicated that ng/ml hydroxyvitamin d levels was the optimal cut point for distinguishing those who were at risk ofdeveloping diabetes and those who were not. also addition of vitamin d to multivariate model, improved the net reclassification by cut-point based nri of %. discussion: in a prospective cohort study, we demonstrated a nonlinear independent associationof vitamin d with incident diabetes, with prominent increase in risk at a cut-off < ng/ml. research department-ayush projects, svyasa university, bangalore, india type diabetes mellitus (t dm), the seventh leading cause of death, is a biggest challenge for mankind. despite of fascinating advances in pharmaco-therapeutic agents, the prevalence of t dm is growing every year. complementary and alternative medicine (cam) as classified by national centre of cam have documented various positive results of t dm. whole ancient medical systems like ayurveda, siddha, and tcm etc use natural herbs either as a single drug therapy or in the form of formulations, depending upon principles of respective medical system. studies done on various herbs and mind body intervention like, yoga, acupuncture etc are found to be beneficial for t dm. this resulted, large number of physicians either referring to or practicing some of the more prominent and well known forms of cam. the concepts proposed and used by these cam systems (that are kept alive by cam practitioners for thousands of years) appear very mysterious to the present day biomedical practitioners. these models of therapies seem to have evolved through several phases of internal research just like the present day drug trials that go through four phases of intensive statistical evaluation. it appears that today's scientists need to follow the footsteps of research used by the ancient seers of tcm, ayurveda, siddha, yoga or homeopathy to unravel these mysterious theories. this review talks about generating evidence not only for the efficacy of these holistic systems but also in carrying out systematic research by biomedical scientist who have the knowledge of both the western and eastern sciences. background: the epidemic of obesity, over the last two decades, in the middle and high income countries is associated with marked rise in the incidence of metabolic syndrome. objective: to measure the prevalence of metabolic syndrome (ms) and determine its association with ratio of omega- /omega- fatty acids in the diet. design and methods: cross-sectional surveys were conducted in urban streets in the city of moradabad, india. randomly selected subjects with ms aged years and above were evaluated and graded according to omega- /omega- ratio in the diet. physical examination, sphygmomanometer, questionnaire and blood tests were done. results: the overall prevalence of ms was . % (n = ) without any gender difference. the prevalence of ms, type diabetes, cad and hypertension showed a higher rate, in relation to omega- /omega- ratio in the diet. subgroup analysis showed that subjects eating low omega- /omega- ratio (< . ) diets had significantly lower prevalence of ms, and related components compared to higher ratio diets, among both sexes. multivariate logistic regression analysis after adjustment of age showed, that hypertriglyceridemia (odds ratio . in men, . in women) was strongly (p < . ) associated with ms. hypertension, hdl-c, and central obesity were weakly associated with ms in both sexes. hypercholesterolemia was weakly associated with ms only in women. conclusion: ms has become a public health problem in india. higher w- /w- ratio is a major risk factor of ms and cad. it is possible that a low w- /w- ratio in the diet (< . ) may be protective against ms. objective: investigate the differences in clinical and laboratory features (including some adipocytokines) among hyperglycemic patients with or without cad. methods: five hundred and sixty-one consecutive hyperglycemic subjects undergoing coronary angiography. hyperglycemia [diabetes mellitus (dm)/pre-diabetes (pd)] previously known dm or diagnosed at the moment of recruitment by an hba c (hplc) levels-! . - . %-pd, ! . %-dm (ada criteria). cad defined by any lesion ! % on angiography. results: . % were men. age was . ae . (mean ae sd), cad was detected in . % of individuals. patients with cad were older ( ae vs. ae years, p = . ), more often male ( % vs. %, p = . ). additionally, they showed a worse metabolic profile, with higher hba c ( . ae . % vs. . ae . %, p = . ), fasting plasma glucose ( ae vs. ae mg/dl, p = . ), triglyceride [ ( - mg/dl) vs. ( - mg/dl), (p = . )] and plasma visfatin/nampt levels [( . ( . - . ng/ml) vs. . ( . - . ng/ml), (p = . ), median/interquartile range], and lower hdl-cholesterol levels ( ae vs. ae mg/dl, p < . ), even after correction for statin use (except for hdl and visfatin/nampt). diabetic patients with cad had greater diabetes duration than diabetic individuals without cad: . ( . - ) vs. . ( - ) years, median and interquartile range, (p = . ). systolic and diastolic blood pressure, homa%-s, homa-ir, total and high-molecular weight adiponectin levels were similar in both groups. conclusions: patients with hyperglycemia and cad have a worse glycemic and lipid profile and higher visfatin/nampt levels as compared to those without cad. one hundred and sixty-nine patients (p) with the mets were studied to find out the incidence of cardiovascular events, especially myocardial infarction and strokes. the mean age was years. fifty-five percent were males and females. the mean body mass index was kg/m . the mean fasting blood sugar was mg/dl. ninety-seven percent were diabetic type ii and % diabetic type i and the lipid profile was normal. the studied population showed a higher incidence of atrial fibrillation, when compared with a comparison group of diabetics ( % vs. . %) p < . . no ventricular tachycardia was observed. the mets group showed a subnormal ejection fraction ( ae %) when compared with a comparison group ( ae %) p < . . no myocardial infarctions or strokes were detected. coronary angiography was done in % of the (p) all were negative except one. the lower ejection fraction was explained on basis of diabetic cardiomyopathy. the genetics profile of the puertorrican, a hispanic population, is more of an european, indian and african. probably, this produces a culture less sensitive to the atherosclerotic factors, producing a less aggressive mets syndromeless myocardial infarcts or strokes. this suggest that genetics and culture is an important aspect of the expression of mets, especially in the hispanic world. objectives: controversy surrounds the annual progression from prediabetes (impaired glucose regulation) to type diabetes. current uk statistics suggest a % progression rate. our aim was to assess subjects in our locality at high-risk of progression from pre-diabetes to type diabetes within a month period. this will establish whether current recommendations for follow-up of high-risk subjects successfully identify those with pre-diabetes. methods: analysis was performed on data from high-risk subjects who underwent ogtt with baseline clinical and biochemical measurements. the ogtt and biochemical measures were repeated at months. results: of the subjects, ( . %) developed diabetes within the month period, significantly higher than the estimated annual progression rate (p . ). as expected, baseline fasting plasma glucose was higher for subjects that progressed to diabetes (diabetes vs. no diabetes: . ae . vs. . ae . mmol/l; p . ), as was h post-prandial plasma glucose (diabetes vs. no diabetes: . ae . vs. . ae . mmol/l; p . ). additionally, baseline hba c was higher for those that developed diabetes [diabetes vs. no diabetes: . ( . - . ) vs. . ( . - . ) %; p = . ]. interestingly, both sbp and dbp were significantly higher at baseline in those that developed diabetes (sbp: ae . vs. ae . mm hg; p = . ) (dbp: ae . vs. ae . mm hg; p = . ). conclusions: within this cohort, progression to type diabetes was almost twice the current estimated annual rate. fasting, h-glucose, hba c and blood pressure were associated with progression from prediabetes to type diabetes over months. methods: tissue lysates from visceral fat samples of subjects undergoing abdominal surgery (predominantly bariatric and routine non-acute for non-malignant conditions) were collected from subjects categorised as l ( ), o ( ) or odm ( ). a commercially available comet assay (cell biolabs, inc) was used to assess cellular dna damage using a single cell gel electrophoresis method. additionally, results indicate a greater percentage of dna migration from the comet "head" to its "tail" within odm samples (l vs. o vs. odm: . vs. . vs. . %; p = . ). in conclusion, results suggest that visceral fat from obese subjects with type diabetes are subject to higher levels of oxidative burden resulting in a higher proportion of damaged dna. community medicine, faculty of medicine, kuwait university, jabriya, kuwait background: the prevalence of overweight and obesity are high in kuwait. metabolic syndrome is associated with both. it is expected to find the syndrome to higher than in other countries. objective: to assess the prevalence of ms using two different diagnostic criteria, the international diabetes federation (idf) and the national cholesterol education program-third adult treatment panel modified for age (ncep-atp iii). study design: a multi-stage random sample study. methods: the analysis of data for this study was based on a sample of male kuwaiti adolescents, - years of age selected from intermediate and high schools. anthropometric measurements and biochemical tests on blood samples were carried out. the idf criterion requires waist circumference (wc) plus two of the following criteria: triglycerides (tg), high density lipoprotein (hdl), fasting blood sugar (fbs) and blood pressure (pb). the atp iii criterion requires three of the above parameters. the parameters mentioned must show increase in their values except for hdl which must show decrease in either criterion used. results: each of the two criterion revealed that the prevalence of ms was . % and . %, using the idf and the atp iii criteria, respectively. hdl decreased in each of the two diagnostic criteria and the other four parameters increased, satisfying the diagnostic requirements of either criterion. conclusions: significant implications may be drawn from these results, especially when it comes to being at risk of type diabetes (t d) and cardiovascular disease (cvd). m. saghebjoo , j. shabanpour omali , r. fathi university of birjand, birjand, mazandaran university, babolsar, iran background and aims: resistance training has been shown to be beneficial in older adults. however, very little data exist on the effects of resistance training in older diabetics. chemerin is a adipokine that has been shown to induce insulin resistance in skeletal muscles. here we investigate the role of weeks of progressive resistance training (prt) on plasma chemerin levels in older men. methods: a total of sedentary men with type diabetes, aged between and years, were randomized to the weeks supervised prt (n = ) and control (n = ) groups. chemerin, insulin, glycosylated hemoglobin (hba c), and fasting blood glucose (fbg) were measured before and h after the training period. results: plasma chemerin levels decreased significantly (p = . ) in the , and exhibited significant reductions in plasma insulin (p = . ) and fbg (p = . ). fbg decreased by . % in prt group. conclusion: reduced plasma chemerin concentration may contribute to improved insulin sensitivity. these results recognize that increased intensity of exercise may produce greater benefits, but may not be appropriate for some individuals. some studies have demonstrated the presence of metabolic syndrome in children and adolescents, but few have investigated this syndrome in brazilian children. the aim of this study was to investigate the prevalence of metabolic syndrome in children and its association with gender and nutritional status. this transversal epidemiological study involved children of both genders between . and . years old. there were collected sociodemographic, anthropometric, metabolic and hemodynamic data. the nutritional status was obtained according to the body mass index. to diagnose metabolic syndrome was used the criteria proposed by the national cholesterol education program′ s adult treatment panel iii adjusted for age. there were used two separate proposals (cook et al., ; ferranti et al., ) . the prevalence of metabolic syndrome ranged from . % to . %, depending on the criterion. the nutritional status showed . %, . % and . % of children with normal weight, overweight and obesity, respectively. significant association was observed between the metabolic syndrome and nutritional status, but not in relation to gender. metabolic syndrome was present in different nutritional status of children, especially those with excess body weight, thus indicating the importance of early diagnosis and the adoption of primary prevention measures already in pediatric patients. introduction: ifg (fpg . - . mmol/l) is a risk-factor for developing type diabetes and cardiovascular disease. we quantified changes in ifg prevalence (post-hoc analysis) from a double-blind, placebo-controlled trial investigating the effects of liraglutide . mg on maintenance of diet-induced weight loss (primary endpoint). methods: overweight/obese adults ( ! years, bmi ! or ! kg/m with comorbidities) who lost ! % weight after - week run-in with low-calorie diet ( - kcal/day) and exercise were randomised to once-daily subcutaneous liraglutide (n = ) or placebo (n = ), plus kcal/day deficit diet and exercise. the full-analysis-set comprised of randomised individuals [age . ae . years, bmi . ae . kg/m (mean ae sd)]. during run-in, participants lost . ae . kg weight and ifg prevalence decreased from % ( / ) to % ( / ). at week , liraglutide-treated participants lost an additional . kg from randomisation (table ) , whereas placebo-treated participants lost no additional weight [treatment-difference À . kg ( %ci À . ; À . ); p < . ]. moreover, the proportion of participants with ifg at week was lower for liraglutide ( . %) than placebo ( . %; odds-ratio . [ . ; . ]; p < . ). at week , after weeks off treatment, the liraglutide group regained~ kg lost weight and ifg prevalence increased. mean weight loss remained greater for liraglutide vs. placebo [treatment-difference À . kg (À . ; À . ); p < . ] but ifg prevalence did not differ (odds-ratio . [ . ; . ]; p = . ). conclusion: liraglutide decreases ifg prevalence in overweight/obese individuals who have already lost weight by diet and exercise, potentially due to additional weight loss and weight-loss independent mechanisms. objective: we wanted to explore the association between polymorphisms of irs (rs ), tcf l (rs and rs ), adrb (rs ), pparg (rs ), and hhex (rs ) genes with insulin resistance, lipid profile and atherogenic risk in mets patients from the mexican social security institute. methodology and results: four hundred and thirty-one mets patients and controls were selected. the association between the snps and the atherogenic index was evaluated by multiple linear regression and multinomial logistic regression models. adrb c/g were associated with an increase in ldl-c levels (β = . , % ci = . , . p = . ), the hhex t/c variant were statistically associated with an increase in total cholesterol levels (β = . , % ci = . , . p = . ), and with an increase in ldl-c levels (β = . , % ci = . , . p = . ). the adrb gene showed a statistically significant association with high-risk atherogenic index, (or = . , ic % . - . ; p = . ) for the arg/gly variant and for the dominant model (or = . , ic % . - . ; p = . ). conclusions: the arg gly polymorphism of the adrb gene may be a good biological marker to predict the risk of developing cardiovascular diseases given a high-risk atherogenic index. aims: describe the knowledge of major risk factors for type diabetes held by primary health care (phc) nurses involved in the community management of diabetes. methods: random sample ( %) of phc nurses in auckland. information was collected from postal and telephone questionnaires, on education, experience, knowledge and diabetes management practice. results: responses were received from phc nurses ( % response) comprising practice nurses (pns), district or homecare nurses (dns) and specialist nurses (sns). most nurses ( %) were able to identify excess body weight as a major risk factor for type diabetes. only % of sns and a third of pns and dns identified lack of physical activity, and fewer than % of sns and pns, and only % of dns identified hypertension as risk factors. even fewer respondents were able to identify individual lipidsalthough significantly more sns identified elevated triglycerides ( %, p = . ) and reduced high-density-lipoprotein cholesterol ( %, p = . ) as major risk factors compared with only - % of pns and no dns. risk factors for diabetes-related complicationsapart from hyperglycaemia identified by %were not well identified, particularly smoking ( %), hypertension ( %), triglycerides ( %) and reduced high-density-lipoprotein cholesterol ( %). in general, phc nurses had a good knowledge of overweight as a risk factor for type diabetes and hyperglycaemia as a risk factor for diabetes-related complications, but poor knowledge of cardiovascular risk factors, particularly smoking. yoga and life sciences, swami vivekanand yoga anosandhana samsthana (s-vyasa university), bangalore, india metabolic syndrome is clustering of different metabolic abnormalities which encompass central obesity, insulin resistance and hypertension. it is characterized by an overdrive of the sympathetic nervous system, increased oxidative stress, elevated pro-inflammatory enzymes, and impaired circadian cycle. lack of physical exercise, improper eating habits, and psychological stress are also common contributing factors to this condition. thus, life style change which includes adequate exercise, proper diet and stress management are the keys in prevention control and treatment of metabolic syndrome. yoga, one of the ancient sciences on earth, is known to bring balance at all aspects of human existence. its different components like asana (physical postures), pranayama (breathing techniques), meditation and relaxation techniques (yoga nidra) etc have been proven to influence body and the mind towards balance and equanimity. recent scientific studies on yoga have proven its safety and efficacy in the management of many metabolic disorders which includes diabetes mellitus, obesity, hypertension and atherosclerosis. yoga therapy has also caused reduction in the pro-inflammatory cytokines in such conditions. yoga reduces sympathetic tone as well as oxidative stress; it helps in reducing insulin resistance by enhancing secretion of melatonin and hepatic insulin sensitizing substance through bringing the parasympathetic dominancy. thus, we propose that yoga has an important role in prevention and treatment of metabolic syndrome as a complementary or as an alternative to conventional line of treatment. s. debnath , s. addya medical laboratory technology, women's polytechnic, medical officer, government of tripura health services, agartala, india introduction: saliva is an excellent biological matrix that offers several opportunities for scientific inference of diagnostic, toxicological and in forensic importance. numerous salivary metabolites proffer great potential in clinical and epidemiological research. sample collection is non invasive and analysis require simple modifications. establishing good correlates is the need. objective: our objective was to study the association between anthropometric measures (ams) with salivary metabolites in a subsample (n = ) of college women in suburban north east india. method: saliva and blood samples were photometrically analyzed for glucose, protein and urea. ams as bmi and waist circumference (wc) were measured in female students of menstruating age ( - years) following who guidelines. ams were correlated (pearson's correlation, ′r′) to salivary biochemistry. results are reported with intra assay coefficient of variation (cv < % all assays) in the text. ′ four day diet dairy′ was maintained over the period. results: salivary biochemistry found to be significantly correlated to ams in the studied subsample. salivary protein was negatively correlated (′r′ = À . ) with bmi and with wc (′r′ = À . ) whereas salivary glucose (′r′ = . with bmi and ′r′ = . with wc) and urea (′r′ = . with bmi and ′r′ = . with wc) had positive correlation. all assays performed in triplicates .we observed very good repeatability of results. medicine -cardiology, massachusetts general hospital, boston, ma, usa introduction: obesity is an independent risk factor for cardiovascular disease. supine bike stress echocardiography is suggested to be of particular utility for evaluating for coronary artery disease (cad) in obese individuals given the lack of mechanical impact with this modality. database for all recumbent bicycle stress echocardiography examinations performed between january , and july , . all tests performed to evaluate for cad were reviewed. two groups were formedpatients achieving ! % of maximum predicted heart rate (mphr) and those achieving < % mphr. medical records of these patients were then reviewed. comparisons between groups were made using unpaired t-tests and correlations between patient characteristics and hr were assessed using pearson's correlation. results: four hundred and sixty tests were done to evaluate for cad. one hundred and eighty-one ( . %) patients failed to reach % mphr during testing. forty-three percent of patients failing to achieve % mphr were obese (bmi > ) vs. % of all patients referred for stress testing. image quality among obese patients was not notably worse compared to leaner patients. those failing to achieve % mphr had a significantly higher bmi ( . vs. . ; p = . ) than those with adequate hr response. bmi exhibited a negative correlation with percent mphr (r = À . , p = . ). conclusion: obesity is associated with failure to achieve ! % mphr during supine bike stress echocardiography done to evaluate for cad. use of adjunctive pharmacologic agents should be considered when evaluating an obese patient for cad with stress echocardiography. ( ): - ), though the extent to which body weight may act as a confounder or as mediator in this relationship is uncertain. the aim of this study was to analyze whether the association between crf and mets risk is mediated by body mass index (bmi). methods: cross-sectional study including schoolchildren, - years old from the province of cuenca, spain. we measured height, weight and crf ( -m shuttle run test). a validated mets index (diabetes care ; : - ) was estimated by summing standardized z scores of waist circumference, triglyceride-to-hdl-c ratio (tg/hdl-c), mean arterial pressure (map), and fasting insulin. to test whether the association between crf and mets index and its components was mediated by bmi, linear regressions models were estimated according to baron and kenny procedures for mediation analysis (j pers soc psychol. ; : - ) . results: in girls, bmi acts as a fully mediator for the relationship between crf with mets index and all its components, except for tg/ hdl-c ratio. in boys, bmi acts as a fully mediator for the relationship of crf with tg/hdl-c ratio and map; and partial mediator for the relationship between crf with mets index and the rest of components. the obesity mediates the association between crf and mets in schoolchildren. good levels of crf are associated with lower mets risk, but only when accompanied by weight reduction. pre intervention measurement was applied. no statistical differences were found for prediabetes knowledge, physical activity, eating habits, bmi, weight, waist circumference and clinical parameters (glucose, triglycerides and total cholesterol) between both groups in basal measurement. the control group received the usual care from health centers. in the study group, the intervention was developed during months per patient (received usual care plus remote care model′s components). the rct will end at january , and the final results will be presented. chronic conditions. this study compares the prevalence of the metabolic syndrome (mets) between genders in the workplace. methods: as part of the established "prosiect sir gâr" initiative in south wales, uk, female and male employees from either the local steel works or local health board were screened and their data analysed. anthropometric data, blood pressure, self-reported physical activity (gppaq) and smoking status were all recorded. in addition, blood samples were obtained and analysed for high-densitylipoprotein cholesterol (hdl-c). presence of the mets was determined based on the following idf criteria: central obesity (females waist circumference: ! cm; males waist circumference: ! cm), reduced hdl-c levels (females: < . mmol/l; males: < . mmol/l) and either systolic ( ! mmhg) or diastolic ( ! mmhg) hypertension. results: a higher proportion of males were diagnosed with mets than females ( . % vs. . %; p < . ) despite the males being more physically "active" or "moderately active" ( . % vs. . %; p < . ). rates of central obesity and systolic hypertension were comparable between genders (p > . ), however prevalence of diastolic hypertension, reduced hdl-c levels, current smokers and individuals either overweight or obese were higher in the male cohort (p < . ). conclusion: despite being more physically active, males were more susceptible to the mets than females, likely due to a higher percentage of smokers and either overweight or obese. conclusions: the addition of glp analogues to insulin therapy seemed to be superior to the enhancement of insulin therapy regarding to weight loss, decreases of hba c, hypoglycemic episodes and requirements of insulin. it was also observed a significant improvement in insulin sensitivity and in beta cell function. background and aims: type diabetes is often associated with nonalcoholic fatty liver disease (nafld). patients with nafld may be at greater risk for cvd than those without. the relationship between nafld and metabolic syndrome (ms) is very well recognized. the aim: to determine the association of nafld and cvd between type diabetic patients with and without ms. materials and methods: one hundred and thirty type diabetic patients (m: , f: , mean age . + . ), were studied. all subjects were assessed for diabetes duration, the obesity degree, cv risk factors, hba c, c reactive protein and lipid profile. nafld was assessed by patient history and ultrasound. ms was defined based on ncep-atp criteria. the previous and current cvd (myocardial infarction, angina or revascularization) was assessed. we categorized four groups: ms (À) and nafld(+), ms(À) and nafld(À), ms(+) and nafld(+), ms(+) and nafld(À). results: the prevalence of cvd in type diabetic patients with nafld was higher than in those without nafld ( . % vs. . %). the prevalence of chd in type diabetic patients with ms was higher than in those without ( . % vs. . %). the risk of chd in patients with ms was significantly increased by the presence of nafld ( . % vs. . %). in type diabetic patients with ms(+) and nafld(+) the number of components of ms, bmi, and systolic bp were positively associated with chd. conclusions: what this study suggests to us is that the presence of nafld increases the risk of cvd in type diabetic patients with ms. and to determine associations between the levels of fasting blood sugar and its comorbid conditions. this is a retrospective study and uses chart review in the outpatient section of the family medicine clinic. it also uses percentages, means and its standard deviations, and chi square to detect associations. there were patients with impaired fasting glucose aged between and years old (mean age . ae ) and all were of filipino ethnicity. there were more females than males. the mean body mass index was . ae . kg/ m and the mean fasting blood sugar (fbs) was . ae . mg/dl. there was no association between the fbs level and obesity (p > . ) and hypertension (p > . ) in this study. however, fbs > mg/dl was associated with the presence of family history of diabetes in this population (p < . ). it seemed that ifg can occur to young, nonobese patients with family history of diabetes. this study recommends that screening for ifg among filipinos should be done to all patients with a strong family history of diabetes regardless of age, gender, bmi status or presence of hypertension. h. hasan, v.l. raigangar, a.r. abdullah methods: a cross-sectional study of young females (mean age . ae . years. leptin, insulin, high sensitivity c-reactive protein (hs-crp), c-peptide, ua, bg, hdl-cholesterol and triglycerides were estimated from a fasting blood sample. anthropometric parameters (wc, height and weight) and bp were measured. homa-insulin resistance was also calculated. results: mean wc of the studied population was . ae . cm, % (n = ) had wc > cm. for the subjects, all studied parameters were within normal limits except leptin which was high; . ae . ng/ml. ua showed highly significant positive correlation with wc (r = . , p < . ), significant positive correlations with cpeptide, hs-crp and leptin with (r = . , p = . ), (r = . , p = . ) and (r = . , p = . ) respectively. ua demonstrated significant negative correlation with hdl only (r = À . , p = . ). multiple linear regression revealed that wc was the only significant predictor of ua levels (b = . , p = . , ci %: . - . ). conclusion: this study stresses the importance of ua levels in cvd particularly due to its strong association with wc, the main indicator of abdominal obesity in mets that is often missed. ua may hence be considered a valuable biomarker for early prediction/detection of mets in young females. background: adipocyte-secreted cytokines are associated with inflammation and metabolic disturbances but it is unclear how their snps interfere on the response to lifestyle interventions. we assessed associations of selected snps with the changes induced by interventions. methods: this -month intervention on diet and physical activity included brazilians at cardiometabolic risk (prediabetes or metabolic syndrome without diabetes). changes in clinical variables were analyzed according to the presence of the tnfa- g/a, il- - g/c and adipoq t/g snps; individuals with at least one variant allele were grouped and compared with the reference genotype. afterwards, individuals carrying simultaneously the genotypes associated with no glycemic response were grouped and compared to the remainder sample. results: the entire sample ( . ae . years) had lower energy intake, higher physical activity, and improved anthropometric and metabolic variables after intervention. carriers of the tnfa variant allele but not the reference group decreased plasma glucose. il- and adipoq variant allele carriers had worse glucose, lipid and inflammatory responses. grouping the subset of carriers of tnfa- g + il - c + adipoq g, they showed a significant increase in mean fasting glucose after intervention. this increment differ significantly from the behavior of the remainder sample (+ . % vs. À . %, p = . ). the tnfa- g/a but not the adipoq t/g and il- - g/c may predispose a better response of glucose metabolism to a lifestyle intervention. the combination of three worst genotypes can maximize the adverse effect on glucose metabolism in at-risk brazilians. further studies are needed to direct lifestyle interventions to specific subgroups of individuals. obesity is a metabolic disorder, which is associated with an increased risk of various conditions, including sexual dysfunction. objective: to investigate anthropometric indicators of body fat in postmenopausal women influencing their quality of life. material and methods: the study was performed at the scientific and clinical study of endocrinology, uzbekistan public health ministry. a total of women (mean age of years) was examined. bmi, waist circumference and waist to hip ratio were obtained for anthropometric evaluation. lipid specters, glycemia and insulin were the parameters to evaluate. we have used a menopause quality of life questionnaire and female sexual function index questionnaire (fsfi). the quality of life of the obese and overweight patients was compared by age, education, marriage and matched with healthy normal weight controls. results: overweight and obesity were observed in of women. values of wc > cm were above normal levels in %, . %, respectively, and hdl was normal in . %. homa -ir was measured in . % of the women. women with overweight and obesity had worse general health-related quality of menopausal symptoms, life and psychological and sexuality scores than athletic and lean women (bmi ! ). in fsfi it was significant differences in such as scales as desire and orgasmic disorders in women with metabolic syndrome (ms) in comparison with the controls (p < . ). aim: to determinate groups of high cardiovascular risk and start early hypolipidemic therapy due to genetic polymorphism of lipoproteidlipaseone of the main enzymes of lipid metabolism in metabolic syndrome and nafld patients, treating with combined therapy of statins and ursodeoxycholic acid (udca). background: health staff receive more health messages and information in working hours than others. moreover, they are supposed to be healthy models for the community. we conducted a screening of metabolic syndrome on shahid beheshti university health department staff (who are responsible for health affairs of more than million people in tehran province, iran) to assess their health level. we invited all of the health staff for screening on "the world heart day". weight, height, waist circumference, systolic and diastolic blood pressure were measured and a fasting blood sample was taken for lipid and glucose level testing. results: fifty percent of the staff ( person) participated in the screening. the mean age was . ae . years. only % were in normal weight range. overweight, obesity class and class rates were %, . % and . %, respectively. . % of all and . % of normal bmi cases had a high waist circumference. metabolic syndrome was identified in . % of men and . % of women. high blood pressure was detected in . % of the cases. in . % of all and . % of overweight or obese cases fasting blood glucose was elevated. these rates for blood total cholesterol level were . % and . %, for triglyceride were . % and . %, and for ldl were . % and . %, respectively. conclusions: contrary to our expectations, a high rate of metabolic syndrome was identified in this group. it seems that interventional programs targeting nutritional habits and physical activity of the staff are needed along with routine educational programs. introduction: physiologically, brain natriuretic peptides (bnp) and lipolysis are closely linked. obesity is been identified as a major risk factor for the development of cardiovascular diseases (cvd) and has been reported to have an impact on bnp in apparently healthy subjects but also in cvd patients. thus, we speculate that bnp could play an important role in lipid metabolism and may affect the pathophysiology of obesity in cvd patients. methods: serum samples were obtained from cvd elderly patients distributed in two groups: i-non-obese and ii-obese. the plasma mature form of brain natriuretic peptide (nt-probnp) was measured by a sandwich enzyme immunoassay with spectrophotometric detection at nm. conclusion: overall, these data demonstrates that obesity is an important and independent determinant of bnp expression in patients with cvd. inverse relationship between bnp and body mass index may suggest "beneficial" effects of obesity, but clearly lower levels did not confer a more favourable prognosis. the precise mechanisms linking obesity to cvd remain unsolved and may be due either to release attenuation or increases in clearance receptors. these effects should be taken into account for appropriate bnp reference values, so lower cut-points should be used for obese patients and a higher cutpoint for lean patients to increase specificity. v. mladenovic , a. djukic , s. djukic , n. arsenijevic , s. zivancevic simonovic aim: the aim of this study was to investigate dynamic of changes of oxidative stress during acute myocardial infarction depending on development phases of metabolic syndrome x. method: the research included patients; inclusion criteria were diagnosed metabolic syndrome and acute myocardial infarction. according to the movements of glycemia and insulinemia all patients were divided in four development phases of metabolic syndrome x. to evaluate oxidative status we determinated: lipid peroxids (malonyldialdehide), total antioxidative status, as well as oxidative stress coefficient. results: during hospitalisation in patients with acute myocardial infarction concentration of lipid peroxids increased, with maximum in the day th of hospitalisation, mostly in hyperinsulinemic phases of metabolic syndrome. at the st day of myocardial infarction total antioxidant status increased, and decreased during next days. these changes are independent on the phase of metabolic sindrome x. as result of inverse dynamic changes of these parametars, during period of exam came to progressive increase of oxidative stress coefficient, particularly in patients in hyperinsulinemic phase of metabolic syndrome x. conclusion: during first days after acute myocardial infarction lipid peroxids concentration progressively increased, with decrease of total antioxidant status, that results in increase of oxidative stress. these changes are most distinctive in patients with hyperinsulinemic phases of metabolic syndrome x. introduction: glp- (exenatide -lilly) is a good therapy for overweight or obese type diabetic patients, but bid administration might not be effective over h. aim: we intended to evaluate h effectivness of this drug in our outpatients using continuous glucose monitoring (gcm-medtronic). methods: we asked our outpatients to undergo a continuing glucose monitoring for days. twelve of them accepted [ f and mol/l, median age (range - ), median disease lenght years (range - )] and signed an informed consense; they had stable metabolic control with hba c < mmol/mol and had been on therapy with exenatide for months at least. results: glycemic profile demonstrates that no patient had experimented prolonged hypoglycemia and all subjects, expept for one, had mainteined a long period of euglycemia in range - mg/ dl during the blood glucose monitoring. conclusions: it′s our opinion that these data demonstrate exenatide can be surely used in type patients to obtain a good and stable metabolic control during all h inspite of the bid somministration and, moreover, the age or the disease lenght are not to be considered a contraindication to its use. several parameters of vascular function and structure have a predictive value for cardiovascular morbidity-mortality and for the presence of associated target organ damage in diabetic and hypertensive patients. superoxide dismutase (sod) is an intracellular antioxidant defense mechanism, which catalyses the dismutation of superoxide radical into h o and oxygen, and it is easily detectable in human plasma; oxidative stress is associated with cardiac and vascular defects leading to hypertension and atherosclerosis and with diabetic cardiomyopathy. on the other hand, osteoprotegerin (opg) is an indicator of diabetes-associated vascular pathologies as hypertension, endothelial dysfunction and cardiovascular risk. we have assessed the relationship between serum levels of sod, opg and parameters of vascular function and structure as well as cardiovascular risk in type diabetic patients with and without hypertension. there are negative correlations between sod and endothelial dysfunction (evaluated by pressure wave velocity, peripheral and central augmentation index and ambulatory arterial stiffness index), pulse pressure, diastolic and systolic night/day ratio, serum opg and plasma hdl-cholesterol, as well as positive correlations between sod and plasma uric acid, liver enzymes got, gpt and ggt, triglycerides and haemoglobin. on the other hand, serum opg is correlated to endothelial dysfunction, intima media thickness, pulse pressure, systolic night/day ratio and d′agostino cardiovascular risk index. our study shows that both sod and osteoprotegerin plasma levels are indicators of cardiovascular events and target organ damage associated with diabetes and hypertension. objective: we investigated the future coronary artery disease (cad) event rate in diabetic patients with and without chest pain in a prospective cohort study performed in a korean population. we also investigated the impact of chest pain on cad risk according to the presence or absence of diabetes mellitus. research design and methods: the ansung-ansan cohort was established for a prospective large-scale community-based epidemiologic study to investigate chronic diseases in korea. the data from a baseline survey performed from to and two subsequent prospective biennial surveys were analyzed. results: among subjects ( men and women) without a history of cad, . % and . % of non-diabetic and diabetic subjects, respectively, reported newly developed cad events during years of follow-up. diabetic patients had a significantly higher risk of future cad events (age-and sex-adjusted odds ratio, . ; % confidence interval, . - . ; p = . ). although the presence of chest pain at baseline was also significantly associated with an increased risk of cad of more than -fold in both non-diabetic and diabetic subjects (p < . ), the hazard ratio for cvd event in asymptomatic diabetic patients compared to non-diabetic subjects with chest pain was not significantly different from . (hazard ratio, . ; % confidence interval, . - . ). conclusions: diabetes and the presence of chest pain are independently and significantly associated with future cad event risk. asymptomatic subjects with diabetes have a comparable risk of cad events to non-diabetic subjects presenting chest pain. aim: the aim of the study was to select and analyze patients with diabetes mellitus and acute stemi or nstemi myocardial infarction from all patients hospitalized in cardiology department in . results: more patients with nstemi underwent pci in the history than patients with stemi (n = , . % vs. n = , . %); p = . and more pci and cabg (n = ; . % vs. n = ; %); p = . . concentrations of cpk (nstemi vs. stemi) (u/l) ( ae vs. ae ) p < . , ckmb (u/l) ( ae vs. ae ), p < . , glucose on admission (mg/dl) ( ae vs. ae ), p < . . patients with nstemi had less critical changes in the left anterior descending artery (lad) ( . % vs. . %); p = . , less bare metal stents (bms) implanted to the lad ( . % vs. . %one stent), and ( % vs. . %two or more stents), p = . . management of this patients shows figure . patients with stemi require more intensive treatment of more advanced concomitant metabolic disturbances. revascularization should by performed urgently because of higher death rate. during qualification for invasive diagnostic and treatment (pci and/or cabg), not only the risk of death and cardiovascular events should be taken into account, but also a history of revascularization modalities (pci and cabg). methods: a total of diabetic patients both sexes aged . ae . years were studied. the levels of total cholesterol (tc), triglycerides (tg), hdl-cholesterol (hdl-c), ldl-cholesterol (ldl-c), vldl-cholesterol (vldl-c), hba c and renal function tests were assessed. patients were classified as normoalbuminuric (albumin excretion rate < mg/ h, n = ), microalbuminuric (albumin excretion rate - mg/ h, n = ) and proteinuric (albumin excretion rate > mg/ h, n = ). results: the duration of diabetes was . ae . years. the level of tc was significantly highest in proteinuric ( . ae . mmol/l), followed by microalbuminuric ( . ae . mmol/l) and followed by normoalbuminuric ( . ae . mmol/l), (p = . , p = . , respectively). patients with proteinuria had significantly higher level of ldl-c compared to the patients with normoalbuminuria ( . ae . vs. . ae . mmol/l, p = . ). patients with microalbuminuria had significantly higher level of ldl-c compared to the patients with normoalbuminuria ( . ae . vs. . ae . mmol/l, p = . ), as well. the level of hba c in normoalbumiuric patients was significantly lower than in microalbuminuric ( . ae . vs. . ae . %. p = . ). there were no significant differences in levels of tg, hdl-c, vldl-c between patients with normoalbuminuria, microalbuminuria and proteinuria. conclusion: we showed that higher levels of ldl-cholesterol and tg were associated with microalbuminuria and proteinuria in patients with type diabetes. lowering atherogenic lipids may retard nephropathy progression in these patients. s. bonakdaran , b. kharaqani endocrine research center, mashhad university of medical sciences, mashhad, iran background: the relationship between elevated serum uric acid level and metabolic syndrome (ms) has been debated. we aimed to determine the prevalence of hyperuricamia and its association with ms in type diabetes mellitus (dm). methods: this was a cross-sectional study in diabetic patients. hyperuricamia was defined as uric acid ! and ! . mg/dl for men and women respectively. diagnosis of metabolic syndrome was based on atpiii criteria. clinical and biochemical parameters in hyperuricaemic and normouricaemic patients compared with other. results: the prevalence of hyperuricaemia and metabolic syndrome was . % and . % respectively. the prevalence of ms significantly increased in the highest quartile of uric acid levels compared with lowest quartile ( . % vs. . %, p < . ). serum uric acid had positive association with cholesterol, triglyceride, non-hdl cholesterol and a negative association with fasting blood sugar (fbs), glycosylated hemoglobin (hba c) and hdl cholesterol. possible biochemical predictors of hyperuricamia were cholesterol, triglyceride, creatnine and fbs. conclusion: the prevalence of ms and its components increase with increasing levels of uric acid in type diabetes. regular assessment of uric acid could give information for predicting of ms and prevention of atherosclerosis in type diabetes. materials and methods: in subjects (aged . ae . ) who have received recommendations on hypotensive and hypoglycemic therapy at diabetes school. psycho-correctional work has been carried out with people (group ) in order to increase treatment motivation and the work has not been carried out with people (group ). the effect has been evaluated after months according to the results of -h blood pressure monitoring ( -h bpm). results: according to moriski-green test % appear to be nonadherent to treatment. as a result only in group there has been recorded reduction in variability indices sbp (mm hg) at night ( . ae . vs. . ae . ; p = . ), daily index sbp ( . ae . vs. . ae . %; p < . ) and dbp ( . ae . vs. . ae . %; p = . ), rate in morning increase sbp ( . ae . vs. . ae . mm hg; p = . ) and dbp ( . ae . vs. . ae . mm hg; p < . ), which are high risk indicators of cardiocerebral catastrophe. after months of patients have become adherent to treatment in group (p = . ), only patients of in group (p = . ) (moriski-green test). conclusion: psycho-correctional training improves adherence to treatment, which is accompanied by positive dynamics of -h bpm indicators. introduction: quality of life is particular decreased in elderly with diabetes mellitus (dm), even not associated with other chronic illness. the purpose of the study was to analyze the quality of life in a group of elderly diabetic patients without major complications. the study group consisted of patients, males and females, aged over years old [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , diagnosed with type dm. they had no severe dm complication, nor other debilitating chronic diseases. the romanian version of the sf- questionnaire was used to measure quality of life (qol). diabetic subjects were compared with age-and gender-matched controls from a random standard population sample of the romanian population. results: reliability of scales by coefficient alpha cronbach was > . for all scales except social functioning. qol scores for study group were significantly lower compared with controls. there are no significant differences between patients following insulin therapy and patients with other therapeutic protocols. role limitations due to emotional problems correlate with disease duration and female gender. there is a significant correlation between energy/fatigue scores and female gender, hba c, fasting plasma glucose and obesity. there are no other statistically significant correlations between sf- scores and analyzed variables. discussions and conclusions: patients with dm have statistically significant impairment of all aspects of qol. dm put a substantial burden on affected individuals. insulin use didn't seem to have a negative impact upon qol. glycemic control is crucial in preventing long terms complications and provides better qol for diabetic patients. the study involved patients with nstemi and with ua hospitalized in cardiology department in . the data obtained from patients were statistically analyzed to determine the significance of the differences between the groups. results: glucose on admission was lower in patients with ua ( ae mg/dl) than with nstemi ( ae mg/dl), p = . . treatment of dm in patients with nstemi and ua shows figure . patients with nstemi presented lower left ventricular ejection fraction ( ae %) vs. ua ( ae %); p < . and higher mortality during hospitalization. seven patients ( . %) with nstemi died, whereas no patient died in ua group (p = . ). . to determine whether aaa patients found to be at higher risk of osa were also at increased risk for cardiometabolic disease, compared to those at low or no risk of osa. design: the berlin questionnaire to estimate osa was administered to elderly patients with or at increased risk of aaa disease along with several measures of cardiometabolic risk, including the lipid accumulation product (lap), a measure that combines triglyceride levels with central obesity (waist circumference), also known as hypertriglyceridemic waist. results: in this sample (n = ), subjects ( . %) scored clinically positive for risk of osa on the berlin questionnaire. next, individuals were separated into groups based upon the three subclasses of the berlin questionnaire: snore (frequent loud snoring), eds (excessive daytime sleepiness), and htn-bmi (hypertension and high bmi). the combination of snore + eds subclasses, when used to differentiate subject's risk levels for osa, was highly accurate for discriminating low, moderate, and high cardiometabolic risk, based upon significant differences in bmi, insulin (lu/l), waist circumference (cm), waist/hip ratio, low density lipoprotein cholesterol (ldl-c mg/dl), and lap (anova; p < . ). conclusions: these results give credence to the clinical use of the snore + eds portions of the berlin questionnaire to provide simple estimates of increased risk of t dm and cvd and/or need for further evaluation such as polysomnography or oral glucose tolerance. materials and methods: from to , t dm were cumulatively collected for study. accordingly, anthropometric and biochemical data, lifestyle measurements (lifestyle i : no smoking, no alcoholic and regular exercise; lifestyle ii : smoking and/or alcoholic and/or no exercise), total daily caloric intakes and macronutrient consumptions were recorded. the eating habits were classified by fat consumption, high fat diet (fat > %) and low fat diet (fat %). the mets defined was based on the atp iii criteria. patients were obligatorily classified into six groups, mets with waist component, waist required and non-waist required; mets without waist component, with two and more than two components; non-mets with waist and without waist component. each component of mets in these six groups with different combination of lifestyle and eating habit, were presented by case number and percentage distribution. or for the clustering of each metabolic component in these six groups were analyzed. results: the case number, percentage distribution and corresponding or for the clustering of each metabolic component in these six groups were shown in table and . the clustering of metabolic components of tg, hdl-c and bp were significantly higher in lifestyle ii, lifestyle i and high fat diet eaters respectively. objectives: early detection of metabolic syndrome is important in minimizing morbidity and motility. we conducted a study to detect wether serum leptin can be used as a biological marker to detect metabolic syndrome. methods: a group of healthy pre-menopausal females, aged - years was selected from the local community, randomly, stratified according to their bmi. leptin was assessed by the elisa method and, blood pressure was measured using digital blood pressure monitor and chemical analysis for fasting blood, glucose and lipid level were conducted using colorimetric method. body weight and height, hip and waist circumferences were measured, using standard protocols. in subjects with and without metabolic syndrome mean serum leptin values were . (ae . ) and . (ae . ) ng/ml respectively. compared with subjects without metabolic syndrome, subjects with metabolic syndrome had a higher serum leptin level (mean difference À . , and % confidence interval À . to À . , p = . ). conclusion: subjects with metabolic syndrome had a higher serum leptin level in comparison with subjects without metabolic syndrome therefore leptin can be utilized as a surrogate marker to predict metabolic syndrome. conducted a study to detect relationship between serum leptin and cardiovascular risk factors in obese and non obese individuals. methods: a group of healthy pre-menopausal females, aged - years was selected from the local community, randomly, stratified according to their bmi. body weight and height were measured, using standard protocols. serum leptin was assessed by elisa and, blood pressure was measured using digital blood pressure monitor and chemical analysis for fasting blood, glucose and lipid level were conducted using colorimetric method. results: there was a statistically significant inverse correlation between serum leptin level and mean blood pressure in obese (bmi ! ) individuals and subjects with systolic blood pressure > mmhg. corresponding r values were r = À . and r = À . (p < . for both). in subjects with bmi < or in normotensive subjects, there were no statistically significant correlations between serum leptin and mean blood pressure. correlations between serum leptin and total cholesterol, triglycerides, hdl, ldl, cho/hdl and fasting plasma glucose were . , . , . , . , . , . respectively and not statically significant (p . for all). conclusion: due to the presence of inverse correlation between serum leptin and mean blood pressure in obese, and individuals with high systolic blood pressure, it can be concluded that serum leptin may play a different role in pathogenesis of cardiovascular diseases in such individuals. r. irzma nski, j. błaszczyk, l. pawlicki, j. kowalski the aim: the aim of our study was to assess the influence of metabolic syndrome (ms) risk factors on vascular complications in patients with ms. material and methods: the study comprised patients ( women and men, avg. age . ae . years) with ms, which was diagnosed according to idf criteria . results: the prevalence of micro and macrovascular complications was assessed: vascular changes in the fundus of the eye - %, ischaemic heart disease - . %, egfr < ml/min - . %, diabetic foot - . %, cerebro-vascular accident - . % of patients. the negative correlation between hdl concentration, creatinine levels and level of vascular changes in the fundus of the eye was found. moreover the level of obesity and fasting glucose level had positive correlation with the intensitz of vascular changes in the fundus of the eye. objectives: to estimate malnutrition prevalence among newly hospitalized overweight/obese patients; to characterize malnutrition by body weight category; and to assess associations between bmi, duration of hospitalization and in-hospital death in malnourished patients. methods: this cross-sectional survey assessed nutrition status in all adults newly admitted to internal medicine and surgical departments at the e. wolfson medical center, holon, israel. data were recorded during the -week data acquisition period and screening for malnutrition risk was performed using the nrs . an age-adjusted score of ! on the nrs defined malnutrition. malnutrition was compared across body weight categories: underweight (bmi < . kg/m ), normal (bmi . - . kg/m ), overweight (bmi - . kg/m ) and obese (bmi ! kg/m ). overweight/obese subjects were compared by malnutrition status. results: a total of individuals were analyzed, of whom were overweight/obese (bmi ! kg/m ). of these, ( . %) were malnourished. compared to adequately nourished overweight/obese subjects, malnourished overweight/obese patients had significantly prolonged duration of hospitalization: . ae . (median , - days) vs. . ae . (median , - days), (p = . ). in-hospital mortality was . % among malnourished vs. . % among adequately nourished overweight/obese patients, p = . . malnutrition increased duration of hospitalization and in-hospital mortality risk in both overweight/obese and normal weight patients. discussion: malnutrition is a frequent finding in newly hospitalized overweight/obese adults. elevated bmi does not affect duration of hospitalization. in-hospital mortality rates are similar for normal weight and overweight/obese individuals. background: the purpose of this study was to examine differences in rmr in lean and obese subjects and to determine correlation between rmr and cardio metabolic risk factors. methods: ninety nine healthy subjects ( normal; obese and over weights) participated in this case-control study. sex and physical activity were matched. blood pressure, plasma insulin, glucose, homa-index, lipid profile, uric acid and c-reactive protein concentrations, anthropometric measurements, body composition, rmr and macronutrient intake were measured. result: fpg (p = . ), uric acid (p = . ), crp (p = . ), insulin (p < . ), homa index (p < . ), systolic and diastolic blood pressure (p = . ; p = . ), anthropometric measurements (except height and whr) (p < . ) and body composition (p < . ) were significantly higher in case group. there were no significant differences between both groups by the means of dietary intake. in obese and overweight group, rmr was statistically higher than control group (p = . ). there were no significant difference between both groups in adjusted rmr for ffm and fm (p = . ). with multiple linear regression, rmr was significantly associated with ffm (p < . ) and uric acid (p < . ) and negative significant correlation was observed between rmr and waist circumference (p = . ) and hdl (p = . ). the finding of a similarly specific metabolic rate in obese and lean subjects at first sight contradicts the idea that a low rmr is a main cause of obesity. one reason for the undetected association between low rmr and obesity may be that obesity-related metabolic risk factors mask the lower metabolic rate that initially contributed to weight gain. background: pain may cause some patients to avoid self-monitoring, which could impair glucose control. cooling the fingertip prior to puncture may reduce pain. objectives: to examine the efficacy of coolsense, a device designed to cool the fingertip prior to puncture for glucose self monitoring. methods: adults with type diabetes treated at the e. wolfson medical center diabetes unit outpatient clinic were randomized to treatment with the coolsense device or a sham device which appeared identical to the active intervention but did not cool the fingertip. patients completed a demographic and medical history interview and were asked to rate the device for discomfort and satisfaction. results: a total of patients were recruited and randomized to intervention group (coolsense vs. sham, n = in each group). participants were ae . years of age, had been diagnosed with diabetes ae . years prior to study onset and had mean hba c of . ae . %. patients reported performing . ae blood glucose checks per day. the extent to which glucose checking caused pain was rated at . ae . out of a possible five points, one being most severe. the coolsense device was a significant independent predictor of pain reduction, even after controlling for age, sex, hba c, aspirin, neuropathy and baseline rating of pain associated with glucose check. conclusions: cooling the fingertip with the coolsense device significantly reduced pain at the puncture site compared to a sham device. it is possible that this reduction in pain will increase glucose self monitoring events in patients with diabetes. f. saad , , a. yassin , , g. doros results: after years the following changes were observed: weight (kg) decreased by . kg from . introduction: testosterone treatment in hypogonadal men is standard therapy, particularly in younger men with congenital forms of hypogonadism. methods: three hundred thirty-three patients ( with primary hypogonadism including patients with klinefelter's syndrome, with secondary hypogonadism and with late-onset ("mixed" or "metabolic") hypogonadism aged - years (mean ae years) received intramuscular injections of mg of testosterone undecanoate during a maximal treatment time of years, overall corresponding to treatment years. hypogonadism was defined as total testosterone below nmol/l and occurrence of symptoms. physiological functions of bile salts include modulation of cholesterol and triglyceride metabolism, insulin sensitivity, the intestinal endocrine response to meals and energy homeostasis. several of these functions are mediated via the membrane g-protein coupled receptor tgr (also called gpbar and gpr ) which has been shown to promote release of glucagon like peptide- from enteroendocrine cells and increase energy expenditure in brown adipose tissue. methods: based on comprehensive discovery platform developed at satrx several in vivo active tgr inhibitors were discovered. active scaffolds were identified during the high throughput screening campaign of , tgr biased small heterocyclic molecules library that was optimized for medchem parameters and cell permeability. confirmed selective hits were evaluated for functional activity of glp secretion in nci-h endocrine cell line. in vivo activity was confirmed in db/db mice diabetes model. active compounds were administered chronically at doses , and . mg/kg and produced stable and statistically significant anti-diabetic effect. results: the most active compound showed efficacy comparable to mg/kg doses of sitagliptin. the actual activity data and experimental details will be provided. the interaction between excess of body fat (total and abdominal) and increased cardiovascular risk is well established in all age groups [ , ] . however, there are few studies that analyze the pattern of body fat distribution and its association with cardiovascular risk factors (crfs) in a population with more advanced age. objective: to analyze the presence of crfs according to the pattern of body fat distribution, in brazilian aged years or older. methods: one hundred and thriteen subjects, randomly selected, . ae . years, of both sexes. the percentage of total and abdominal body fat, hypertension and lipid profile were used for characterization of crfs. the chi-square test was used to assess proportions of crfs and mann-whitney test was used to compare the results between distributions of adiposity. results: eutrophic subjects showed lower triglycerides (p = . ), total cholesterol (p = . ) and prevalence of hypertension (p = . ) and hypertriglyceridemia (p = . ). subjects with higher abdominal adiposity showed higher total cholesterol (p = . ) and prevalence of hypertriglyceridemia (p = . ) and hypercholesterolemia (p = . ) than no excess of abdominal adiposity. higher value of one outcome already reflects the higher prevalence of hypertension (p = . ) and, the higher values of both outcomes reflect the high values of total cholesterol (p = . ) and triglycerides (p = . ). conclusion: that obesity, whether abdominal or total, is associated, in the same way, with dyslipidemia and hypertension in the subjects aged years. background/aim: there is growing consensus in the literature that inflammation plays a central role in the pathophysiology of obesity and type diabetes mellitus (t dm) and cardiovascular complications. neutrophil-to-lymphocyte ratio (nlr) provides a simple method for assessment of inflammatory status and it is a new, inexpensive marker. the aim of the present study was to investigate the predictive value of preprocedural (before the ogtt) nlr on development of prediabetes (pd) and type diabetes (t dm) in morbid obesity patients (mop). methods: mop and normal weight patients with normal ogtt [fasting plasma glucose (fpg) < mg/dl. two-hour glucose during ogtt < mg/dl] were evaluated in this study. results: the mean ae sd nlr of mop were significantly higher than that of patients with normal weight healthy patients ( . ae . vs. . ae . , p < . , respectively). in receiver operating characteristics curve analysis, nlr > . had % sensitivity and % specificity in predicting pd and nlr > . had % sensitivity and . % sepesifity in predicting t dm. logistic regression analysis showed that elevated nlr (or: . , % ci: . - . , p < . ) was an independent variable for predicting t dm in mop. conclusion: mop have higher nlr than healthy controls. high nlr is a powerful and independent predictor of pd and t dm in mop. elevated nlr levels are usually considered as an inflammatory marker. the results of this study suggested that inflammation plays a role in the pathogenesis of pd and t dm with mop. division of human nutrition, wageningen university, wageningen, general surgery, rijnstate hospital, arnhem, gastroenterology, rijnstate hospital, arnhem, the netherlands objective: endoscopic implantation of a duodenal-jejunal bypass liner (djbl), or endobarrier, is a novel bariatric technique to induce weight loss and remission of type diabetes (t d). placement of the djbl mimics the duodenal-jejunal bypass component of the roux-en-y gastric bypass (rygb) procedure. as gut hormones are known to change substantially after rygb surgery, in our study we now evaluated gut hormone responses after implantation of the djbl. methods: fourteen (eight male, six female) obese t d subjects (bmi . ae . kg/m , duration of type diabetes . ae . years) were selected for implantation of a djbl. fasting plasma levels of glucose, c peptide, hba c and gut hormones ghrelin, gip and glp- were analysed before and at and days after djbl implantation. results: plasma hba c levels were significantly decreased after djbl implantation and a % reduction was found in diabetes medication usage (p < . ). ghrelin was found significantly elevated, with the highest induction in the first days post-implant. although the gip response showed high variation between subjects, gip tended to decrease days after implantation (p = . ). glp- levels showed a significant "dip" at day post-implant, which correlates with the intake of solely pureed/liquid food in the first week post-implant. conclusions: implantation of a djbl results in an early substantial remission of t d, comparable to results seen after rygb surgery. interestingly, in contrast to rygb surgery, implantation of the djbl seems to preserve normal physiological responses of gut hormones that are related to nutritional status. conflicting data exists as to the association between body mass index (bmi) and the rate of chronic kidney disease (ckd). in a cross sectional analysis of database from a screening center in israel we assessed the rate of ckd defined as estimated glomerular filtration rate (egfr) < ml/min per . m in relation to increasing bmi subcategories. the study population included , subjects, % women aged - , out of whom men and women had ckd. subjects with a bmi of - . (kg/m ) compared to subjects with bmi < (kg/m ), had an odds ratio (or) [ % confidence intervals (ci)] for ckd of . ( . - . ) and . ( . - . ) for men and women respectively. for subjects with a bmi of - (kg/m ) the or were . ( . - . ) and . ( . - . ) for men and women respectively. for subjects with bmi > (kg/m ) the or rose to . ( . - . ) and . ( . - . ) for men and women respectively. this association became insignificant in men after multivariate adjustment for age, hypertension and diabetes mellitus but persisted in women even after multivariate adjustment. the correlation between bmi and ckd in women was attributed to the subcategory of severely obese women with bmi above (kg/m ). our study suggests that for both men and women a positive correlation exists between the degree of bmi and the rate of ckd. this correlation persisted in severely obese women even after multivariate adjustment, suggesting that in women, obesity may be an independent risk factor for developing ckd. the enteroendocrine cell line pgip/neo stc- was used to evaluate the effects of gspe on glp- secretion in different nutrient conditions. a cytotoxicity detection kit (ldh) and brdu labelling and detection kit iii (roche) were used to determine cytotoxicity and cell proliferation, respectively. glp- levels in cell culture medium were determined using a glp- (active) elisa kit (millipore). cytotoxicity and proliferation cell assays (n = ) demonstrated that the maximum non-toxic gspe treatment for these cells was mg/l gspe over a period of h. surprisingly, after h of gspe treatment, glp- secretion (n = ) was significantly inhibited. this inhibitory effect was observed at concentrations as low as mg/l. furthermore, inhibition of glp- was also observed when stc- cells were co-incubated gspe and lmol/l dihomo-ϒ linoleic acid. in conclusion, acute gspe incubation decreases glp- secretion in cultured enteroendoncrine cells. interestingly the effect occurs under either on basal or nutrient (fatty acid) stimulated conditions. c. higa , f. novo , m.s. donato , n. rizzo , g. ciambrone , e. korolov , p. comignani coronay unit, hospital aleman, buenos aires, argentina introduction and aim: there is no data available respect of the prognostic value of albumin:creatinin ratio (acr) in non-st-segment elevation acute coronary syndrome (nseacs). the purpose of our study was to evaluate the long term prognostic value of acr in patients with nseacs. methods: we analyzed a prospective cohort of nseacs in whom acr was determined at admission. roc curves were constructed to determine best cut off value associated with primary end-point of death or nonfatal myocardial infarction (d/ami). independent variables for d/ami were assessed by a cox regression model. : seven hundred ten patients with nseacs were analyzed. thirty percent were female and median age was years. median follow up time was months. best cut-off point of acr for primary end point was mg/g. thirty-four percent of patients had acr ! mg/g. acr correlated with higher incidence of primary end point both in diabetics and in non-diabetic patients: or . (ic . - ), p = . and or . (ic % . - ), p = . , respectively. by multivariable cox regression analysis, acr was an independent predictor of d/ami at long-term follow up: hr . (ci % - ), log rank p < . in a model that included age, female gender, diabetes mellitus, serum creatinine, creatinine clearance, glucemia at admission a, elevated cardiac markers and st segment deviations. conclusions: acr was an independent predictor of adverse outcomes in nseacs. this simple and accesible marker should be considered for risk stratification in this high risk setting. aim of the work was to examine possible connection of methabolic syndrome with endothelium dysfunction in pre and postmenopausal women with and without ischemic heart disease (ihd). methods: hundred and eight-nine pre and postmenopausal women with ihd were examined and in same age without ihd. all women were measured arterial pressure using korotkov method (according to jnc- recommendations). vasa regulating function of endothelium examined with ultrasound in triplex scanning using reactive hyperemia probe (method by d. celermajer). willebrant factor determined in blood plasma. results: in group of women with ihd ( %) had arterial hypertension: among them ( %) in pre and ( %) postmenopausal. among women without ihd ( %) had hypertension: ( %) were pre-and ( %) postmenopausal. during reactive hyperemia probe diameter of radial artery was: women with ihd . ae . mm; speed of blood flow . ae . m/s, willebrant factor . ae . ; women without ihd corresponding . ae . mm (p < . ) and . ae . m/s (p < . ), willebrant factor . ae . (p < . ) where there significant difference was noted. findings allows us to suppose, that women with ihd have higher abundance of arterial hypertension, that in connection with other components of metabolic syndrome, specify development of endothelium dysfunction, in comparison with women without ihd, which have arterial hypertension, endothelium dysfunction infrequently. objective: recently, incretin-related drugs are widely used for improving blood glucose level in clinical practices. in this study, we tried to examine the efficacy and safety of these drugs of the japanese approved dose. we compared the efficacy and safety of the human glp- analogue liraglutide (the approved dose . mg) with the dipeptidyl peptidase- (dpp- ) inhibitor sitagliptin (the approved dose mg) once daily in the obese adults with type diabetes, over weeks. methods: japanese obese out-patients whose glycemic control was inadequately controlled with oral hypoglycemic agents received either maximum weeks of treatment with . mg lilaglutide (n = ) or mg sitagliptin (n = ) once daily within the period from march to october , at chubu-rosai hospital. the primary endpoint was change in body weight. other measurements were hba c, lipid profiles, body weight, body mass index, serum creatinine, estimated gfr, and adverse events before and at , , , weeks after liraglutide or sitagliptin administration. results: at the japanese approved dose, the greater reduction of mean body weight was achieved with liraglutide than with sitagliptin (À . kg, p < . , + . kg, p = n.s. vs. baseline). the degrees of lowering hba c (both . % at baseline) were À . % for liraglutide and À . % for sitagliptin (both p < . at baseline). the egfr of the sitagliptin group worsened from . to . ml/min/ . m (p < . at baseline). the most common adverse events were gastrointestinal symptoms ( ( %) patients on . mg liraglutide). conclusion: liraglutide provides greater body weight reduction over weeks even at the japanese approved dose of . mg. objective: to examine prevalence of cardiovascular risk factors in patients with type diabetes and stroke in primary care setting. methods: study was conducted at primary health center tuzla and included all patients with type diabetes and stroke who were registered in one family medicine team. we also calculated absolute cardiovascular risk according to the european guidelines on cardiovascular disease prevention in clinical practice. results: prevalence of stroke in diabetic patients was . %. significantly more women had stroke than men ( . % vs. . %; p = . ). mean age of patients was . ae . years. men were significantly older than women ( . ae . vs. . ae . ; p = . ). majority of participants belonged to age group > years ( . %). mean duration of diabetes was . ae . years. more than half of patients ( %) had diabetes - years, . % had diabetes - years, and . % patients had diabetes > years. family history for diabetes had . % patients. the most prevalent cardiovascular risk factors were hyperlipidemia ( . %) and hypertension ( . %). obesity was present in % patients, and . % patients had family history for premature cardiovascular disease. unhealthy diet had . % patients, . % were physically inactive, and % diabetic patients were smokers. mean absolute cardiovascular risk was . ae . %; . ae . % in men, . ae . % in women. men had significantly higher absolute cardiovascular risk than women (p = . ). conclusion: prevalence of cardiovascular risk factors in patients with type diabetes and stroke were very high. it indicates more effective strategies in primary care setting to reduce risk of macrovascular and microvascular complications. the prevalence of metabolic syndrome was determined as a crosssectional study among healthy saudi adults ( % males and % aged - years) attending national guard clinics using the definition proposed by ncep atpiii. the prevalence of metabolic syndrome was %. only one third of the participants had normal weight (bmi = . - . ). central obesity based on waist circumferences was noted in % of males and % of females. low hdl-c showed the highest prevalence ( %) followed by high tg ( %). about % of participants had impaired fasting blood glucose ( ! mg/dl). only % had high blood pressure ( ! / mmhg). more than three quarters ( . %) of the respondents had ! component of metabolic syndrome. in conclusion, metabolic syndrome needs to be addressed as an important health problem in the gulf region. background/aim: adequate treatment and monitoring of diabetes can significantly improve quality of life and extend life expectancy in diabetic subjects. aim of this study was to examine metabolic control in patients with type diabetes in primary care setting. methods: study was conducted at primary health center tuzla and included randomly selected patients with type diabetes, aged years and over, from one family medicine team. we evaluated parameters of metabolic control in patients with type diabetes according to the european guidelines on cardiovascular disease prevention in clinical practice. results: there were significantly more women than men ( . % vs. . %; p < . ). mean age of patients was . ae . years. mean duration of diabetes was . ae . years. only ( . %) patients had blood glucose < . mmol/l, and ( . %) patients had hba c < . %. controlled blood pressure / mmhg had ( . %) patients. only ( . %) patients had total cholesterol < . mmol/l, while ( . %) patients had triglycerides < . mmol/l. normal body mass index (bmi) < kg/m had ( . %) patients and recommended waist circumference ( . %) patients. mean blood glucose was . l ae . mmol/l, hba c . ae . %, systolic blood pressure . ae . mmhg, diastolic blood pressure . ae . mmhg, total cholesterol . ae . mmol/l, triglyceride . ae . mmol/l, bmi . ae . kg/m , waist circumference . ae . cm. conclusion: metabolic control of type diabetes in family medicine practice was inadequate which indicates more effective interventions in order to achieve appropriate metabolic control of diabetes and reduce risk of complications. aim: the aim of the study was to determine the metabolic responses to two different liquid milk protein diets in prediabetic and healthy volunteers. the diets were composed of . g whey or casein protein, g maltodextrin and g lactulose or . g maltodextrin and g lactulose (control). procedures: fifteen prediabetic and healthy volunteers consumed all liquid test diets with blood sampling over a h time period. blood glucose, incretin hormones, nefas, hydroxybutyric acid and plasma amino acids were analyzed. the feeling of hunger was determined using a visual analog scale. results: in both, prediabetic as well as healthy volunteers, postprandial blood glucose levels were significantly decreased and plasma insulin levels were significantly elevated with the protein diets compared to the control diet. gip and glp- levels also increased after the protein-contaning test-diets. in the prediabetic volunteers, changes in glucose, insulin, amino acids, non-esterified fatty acids and hydroxybutyric acid displayed time delayed changes. a reduced feeling of hunger was reported in the prediabetic compared to the control group. conclusion: both protein components elevate insulin secretion and cause reduced blood glucose auc and these effects are more pronounced in prediabetics. however, despite differences in the amino acid composition, casein and whey protein did not reveal significantly different effects. postprandial changes in plasma metabolites in prediabetics suggest more metabolic pertubations than just impaired glucose disposition. methods: ins- e cells or freshly isolated rat islets were incubated for h in the presence of either leptin or tnf-a at lower ( . nmol/l or ng/ml) or higher concentration ( nmol/l or ng/ml) individually or in combination. proinsulin mrna was detected by real time-pcr, insulin by radioimmunoassay kit, β cell proliferation were tested with mtt assay and β cell apoptosis was determined with annexin v-fitc/pi by fluorescent activated cell sorting. results: higher leptin ( nmol/l) or tnf-a ( ng/ml) significantly suppressed gsis (p < . ) and reduced the intracellular proinsulin mrna level and insulin content (p < . ) in ins- e cells and primary islets. whereas, lower leptin ( . nmol/l) or tnf-a ( ng/ml) did not show such effects. however, the inhibition effects were compromized when two factors were simultaneously administrated in either cultured ins- e cells or pancreatic islets. similarly, higher leptin or tnf-a was able to inhibit ins- e cell proliferation and promote cell apoptosis. again, these effects were alleviated in the presence of both factors. furthermore, western blotting showed that tnf-a inhibited leptin receptor (ob-rb) expression, decreased the phosphorylation of stat . conclusion: tnf-a exerts antagonistic effects on leptin actions in pancreatic β cells by interfering with ob-rb/jak/stat signaling pathway. increased tnf-a level may contribute to the pathogenesis of hyperinsulinemia and disturbed glucose metabolism in people with obesity. aims: identifying socioeconomic factors associated with the metabolic syndrome (mets) is useful to target preventive measures. our objective was to estimate, in france, the prevalence of metabolic syndrome (mets) and to investigate the association between socioeconomic position and mets. methods: the french national nutrition and health survey (enns) cross-sectional national multistage sampling was carried out from february to march . data included waist circumference and blood pressure measurements, blood sample and sociodemographic and medication information. the prevalence of mets was assessed using several definitions, including the most recent joint interim statement (jis). association with sociodemographic covariates was assessed using logistic regression models. results: among the participants - years of age, mets prevalence was found to vary from . % according to the national cholesterol education program definition to . % according to the jis definition, without difference between genders. after adjustment for other covariates, risk of mets increased with age in both men and women (for year: ora = . , p < À and ora = . , p < À ; respectively). in women, mets risk was inversely associated with education level; women with the lowest education level facing a six fold greater risk of mets (ora = . , p < À ). in men, risk of mets was higher in men born outside of france (ora = . , p = . ) than in french-born males. conclusions: mets prevalence is lower in france than in most industrialized countries. lifestyle modifications, targeted to migrants and persons living in low socioeconomic conditions, should contribute to further reducing mets. folate. patients were divided into two groups: group (homocysteine < lmol/l) and group (homocysteine ! lmol/l). results: the mean age was . ae . years. homocysteinemia was . ae . mmol/l. a significant correlation was found between homocysteine levels and the number of criteria for ms (p = . ). besides, a significant decrease of hyperhomocysteinemia (from . % to . %, p = . ), systolic blood pressure (from . ae . mmhg to . ae . mmhg, p = . ), uric acid (from . ae . lmol/l to . ae lmol/l; p < . ) and a significant improvement of hdl levels ( . ae . mmol/l to . ae . mmol/l, p < . ) were reported. a non significant improvement was observed for the other parameters. furthermore, a correlation was noted between the variation of homocysteine and hdl levels (p = . ). the association found between homocysteine and the severity of ms suggests a reflection on the cardiovascular risk caused by such association and on the importance of hyperhomocysteinemia screening in patients with ms. object of study and method: the patients with ms: of them presented with the recurrent form of af, had no arrhythmia. the groups were comparable in terms of age, concomitant disorders, arterial hypertension duration, arterial pressure, and severity of chronic heart failure. patients with permanent af, hemodynamically significant heart disease, myocardial infarction with wave q in the medical history, were excluded from the study. in a review of the diagnostic efficiency parameters showed statistically significant differences in the two groups, with the evaluation of their specificity (se), sensitivity (sp) and or (odds ratio). results: patients with ms having abdominal obesity and arterial hypertension over years (se . ; or . ( % . - . ); x = . ; p = . ); homa ir index more than . (se . ; or . ( % . - . ); x = . ; p < . ); reduced hdl cholesterol level below . mmol/l (se . ; or . ( % . - . ); x = . ; p < . ); left atrial dilation (se . ; or . ( % . - . ); x = . ; p = . ); albuminuria more than mg/day (sp . ; or . ( % . - . ); x = . ; p < . ); waist circumference more than cm (sp . ; or . ( % . - . ); x = . ; p = . ) were at high risk of af. the duration of abdominal obesity and hypertension for years, insulin resistance index > . , reduced hdl < . mmol/l, an increase in albuminuria > mg/day, an increase in waist circumference > cmrisk factors for af in ms. patients and methods: fifty-three patients with ms over , comparable in duration af, comorbidity and treatment. patients with permanent af, hemodynamically significant heart disease, myocardial infarction with wave q in the medical history, were excluded from the study. following a successful cardioversion all patients assigned amiodarone. group (n = ) in the adjuvant therapy prescribed metformin over - mg/day; group (n = ) metformin < mg/day, group (n = ) metformin is not assigned. the observation period is months. results: in group homairind decreased to . ae . (p < . compared with baseline), in the nd to . ae . (p > . ) and rd to . ae . (p > . ) (p - < . ), and improvement of lipid profile and increased gfr ( . ae . (p < . compared with baseline), . ae . and . ae . ml/min, in the st, nd and rd groups, p = . between groups); decreased volume of the left index atria ( . ae . (p < . compared with baseline), . ae . and . ae . ml, in the st, nd and rd); reduction in waist circumference ( . ae . (p < . compared with baseline), . ae . and . ae . cm, in the st, nd and rd). patients in group was maintained sr for much longer ( . ae . days) than in patients of the nd ( . ae . ) and the d group ( . ae . ) (p = . ; p - < . ; p - < . ). aims: metabolic syndrome (mets) is the serious health problem worldwide and is associated with increased risk of cardiovascular disease. mets has a significant genetic component which is estimated on - %. apolipoprotein a (apoa , omim acc. no ) gene and its variants have been associated with the plasma lipids, mainly triglycerides and its role in mets development is recently discussed. we have analyzed, if there is the association between the apoa gene haplotypes (based on the rs and rs variants) and mets in middle european -slavic population. methods: apoa haplotypes based on the presence of either common or at least one minor apoa allele (rs , c- and rs , g ) and the presence of mets were analysed in adults ( males and females, - years old) selected according the monica protocol and examined at / and / . the presence of mets was analysed according the ncep-atp iii criteria. results: in females with at least one minor apoa allele, the prevalence of mets was significantly higher both at / ( . % vs. . %, p < . ) and at / ( . % vs. . %, p < . ). in males, association between apoa gene and mets was not detected neither at / ( . % vs. . %, p = . ) nor at / ( . % vs. . %, p = . ). a. blazquez , o. garcia-sanchez , y. quiros , v. blanco-gozalo , m.j. montero , j.m. lopez-novoa , c. martinez-salgado , f.j. lopez-hernandez universidad de salamanca, ibsal, iecscyl-ibsal-university of salamanca, salamanca, spain diabetes commonly causes a type of chronic nephropathy, namely diabetic nephropathy (dn). diagnosis of dn is presently accomplished late in the course of disease. microalbuminuria anticipates progression towards dn only in a subset of patients. another subset of diabetic, microalbuminuric patients never develop dn. accordingly, new biomarkers are necessary to more accurately identify diabetic patients progressing towards dn. ngal has also been associated to progression to dn. on the other hand, hypertension is a well-known factor of co-morbidity in diabetic nephropathy. we decided to study the capacity of ngal to detect the additive effect of hypertension on progression to diabetic nephropathy. in the present work we aimed at unraveling the origin of the increased urinary ngal. spontaneously hypertensive rats (shr) or normotensive wistar rats were rendered hyperglycemic by a single administration of streptozotocin, or not (as controls). renal function was monitored and ngal was measured in urine, plasma and tissue samples. their kidneys were perfused in situ with krebsdextran solution (containing or not exogenous ngal), and urine was collected. plasma and renal tissue ngal was also measured by western blot, and renal ngal expression was determined by rt-pcr. our results suggest that the urinary ngal is increased by the coexistence of diabetes and hypertension, but not by each of these conditions. ngal excretion results from its altered tubular handling. this subtle and primary renal alteration might be studied further as an early marker of the increased risk of chronic renal disease posed by the co-morbidity of hypertension and diabetes. the increasing prevalence of obesity is a major public health concern. more than . billion adults, and older, were overweight, over million men and nearly million women of whom were obese in . large-scale studies have demonstrated that overweight and obesity increase the risk of developing several forms of cancer, including several that are not classically viewed as hormonedependent. in both men and women, increasing bmi is significantly associated with higher death rates from cancers of the oesophagus, colon and rectum, liver, gall bladder, pancreas and kidney, as well as non-hodgkin lymphoma and multiple myeloma. the associations between obesity and particular maignancies may be affected by body fat distribution, and may result from diverse factors including diet and abnormal levels of hormones and inflammatory cytokines. recently, there is more and more sufficient evidence that excess body weight is an avoidabl e cause of excess cancers including gastrointestinal, endometrial, esophageal adenocarcinoma, colorectal, postmenopausal breast, prostate, and renal cancers. the mechanism that obesity association with cancer is remains not well understood. there are some most studied hypothesized mechanisms such as, high levels of insulin and free levels of insulin-like growth factors (igfs), sex hormones, adipocytokines, inflammatory cytokines, c-myc oncogenic transcription factor, obesity-induced hypoxia and warburg effect, and so on. in the future, the potential mechanisms and conclusions in obesity associated with increased risk for developing cancer, and the underlying cellular and molecular mechanisms will be studied. results: among patients with ms (mean age: years; % male), ( %) had abdominal obesity, ( %) had a c > . %, ( %) had fpg > mg/dl and ( %) had homa > . . if we consider as ir indicators: . presence of prediabetes criteria (fpg > mg/dl and/or a c > . %); and/or . homa > . , patients ( %) met at least one marker of ir, but of them ( %) had homa < . [ ( %) of them were on therapy with metformin, an insulin-sensitivity drug]. in the multivariate analysis, presence of type diabetes (hr . ; p < . ) and presence of prediabetes criteria (hr . ; p < . ) were associated with homa > . discussion: although most of the patients with ms have clinical markers of ir (fpg > mg/dl, a c > . %), only a third part of them have homa levels associated with ir. these observations suggest that: of spilberger's test. from to women were followed for the incidence of ah. results: high level of anxiety (hla) in studied cohort revealed in . % of women. women with hla more often tried unsuccessfully to quit smoking compared to lower levels of anxiety ( . % and . %, respectively; x = . , p < . ). women with hla in twotimes less likely to follow the diet (x = . , p < . ) and assess their physical activity more passive (x = . , p < . ). relative risk (hr) of development of ah in women with hla during the first years of study was in . -fold higher ( . % ci: . - . ; p < . ), over years it was . ( . % ci: . - . ; p < . ) and hr was . ( . % ci: . - . ; p < . ) over years of follow-up compared to those with lower anxiety levels. depending on age groups the risk of ah incidence within years was highest in older group with hla aged - years (hr = . ; . % ci: . - . , p < . ). conclusions: there is high prevalence of hla in russian female population aged - . during years of follow-up women with hla have significantly higher risk of ah especially in older age groups. material and methods: under the third screening of the who "monica-psychosocial" (mopsy) program random representative sample of women aged - years (n = ) were surveyed in novosibirsk. d was measured at the baseline examination by means of test "mmpi". from to women were followed for years for the incidence of ah. results: the prevalence of d in women aged - years was . %. women with major d ( %) significantly extended negative behavioral habits: smoking and unsuccessful attempts to give it up, low physical activity, they were less likely to follow a diet. relative risk (hr) of ah in women with d during the first years of study was higher in . -time compared to women who had no d ( . % ci: . - . ; p < . ). with regard to age groups hr was significant in oldest age category - years (hr = . ; % ci: . - . ; p < . ). hr of incident ah in persons with d within years was . ( . % ci: . - . ; p < . ) and there were no significant differences in age groups. we did not have risk of ah over years of follow-up in women with d (p > . ). the prevalence of d in women aged - years is more than %. women with d had unfavorable lifestyle and higher relative risk of ah over the first - years of the study. purpose: study the association of high level of anxiety (hla) with vntr polymorphisms d and dat genes; determine the relative risk (hr) of arterial hypertension in men with hla. the who " monica-psychosocial" in monica-psychosocial" in , monica-psychosocial" in , surveyed a random representative sample of men aged - years ( men). to assess the level of anxiety was used spielberger's test. cox proportional regression was used for hr assessment. results: the hla in an open population of men aged - years was . %. since hla genotype was significantly associated / drd gene and genotype / gene dat. for years hla maximizes the hr of hypertension in the first years. conclusion: there is high prevalence of hla at male aged - in russian. hla were significantly associated with certain vntr polymorphisms of genes drd , dat; hla increases the hr of hypertension in the first years. inhibiting beta cell proliferation and promoting its apoptosis which concomitantly leads to decreased β cell mass. dermatology, faculty of medicine, cairo university, cairo, egypt background: psoriasis is a disorder with genetic and immunologic background. leptin can regulate the t-helper response. objective: our primary goal is to study the functional polymorphism (g- a) of the leptin (lep) gene in the genetic predisposition of psoriasis, and our secondary goal is to examine factors affecting plasma leptin levels in psoriasis, and to compare patients with and without metabolic syndrome (ms). methods: the study involved psoriatic patients and healthy controls. analysis of g- a polymorphism of the lep gene was made by the pcr and restriction fragment length polymorphism technique. the relationship between lep gene polymorphism and the clinical features of the patients was analyzed. plasma leptin levels and proportions of comorbidities in patients vs. controls were compared. results: in controls the ga, aa and gg frequencies were %, % and % respectively, while in patients the distribution of genotypes was . %, . % and . % respectively, with significant difference (p = . ) between patients and controls. in patients with ms the gg, ga and aa frequencies were . %, . % and . % respectively, while in patients without ms the distribution of genotypes was . %, % and . % respectively, with significant difference (p = . ) between both groups. plasma leptin showed a significant higher levels in the patients vs. the controls (p < . ), and among the different lep genotypes (p < . ) in the patients′ group. conclusion: lep g- a polymorphism could be a predictor for higher plasma leptin and increased risk of psoriasis and could be used as a marker for psoriasis-related comorbidity risk. introduction: contractile dysfunction, associated with disturbances in excitation-contraction coupling, has been widely demonstrated in diabetic heart. aims: the aim of this study was to investigate the pattern of mrna encoding cardiac muscle proteins that are involved in the process of excitation-contraction coupling in early onset type diabetic goto-kakizaki (gk) rat. methods: experiments were performed in gk and wistar control rats aged - weeks. gene expression was assessed in ventricular muscle with real-time rt-pcr, shortening and intracellular ca + were measured in ventricular myocytes with video edge detection and fluorescence photometry, respectively. results: expression of genes encoding some membrane pumps and exchange proteins were unaltered (atp a / , atp b , slc a ) whilst others were either upregulated (atp a ) or downregulated (slc a ) in gk ventricle compared to control. expression of genes encoding some calcium (cacna c/ g, cacna d / d , cacnb /b ), sodium (scn a) and potassium (kcna / , kcnj / / / / , kchip , kcnab , kcnb , kcnd / / , kcne / , kcnq , kcng , kcnh , kcnk , kcnn ) channel proteins were unaltered whilst others were either upregulated (cacna h, scn b, hcn ) or downregulated (hcn , kcna , kcna , kcnj ) in gk ventricle compared to control. the amplitude of ventricular myocyte shortening and intracellular ca + transients were unaltered however, the tpk shortening was prolonged and thalf decay of the ca + transient was shortened in gk myocytes compared to controls. conclusions: early changes in expression of genes encoding various cardiac muscle proteins are associated with disturbances in myocyte shortening and intracellular ca + transport. results: analysing level of tnf-alpha, we found that in group , there were significantly higher values than the control group by . times ( . ae . pg/ml: . ae . pg/ml, respectively), and significantly higher than patients without insulin resistance ( . ae . pg/ml). analyzing level of il- , the presence of ir, level of this cytokine increases by only a factor of ( . ae . pg/ml) relative to that of the control group ( . ae . pg/ml). in the second group, the level of il- ( . ae . pg/ml) was significantly higher than in group and exceeded the performance of control group by . times. analyzing the ratio of the level of tnf-alpha and il- , we have detected a significant increase in the coefficient tnf-alfa/il- in group ( . ae . ) compared with group patients ( . ae . ). that is, ir in chc patients gives a significant shift in balance of cytokines toward proinflammatory interleukins, which can be observed by increase of tnfalfa/il- over . (p < . by mann-whitney). conclusions: progression of ir in patients with chc is accompanied by an increase in ratio tnf-alfa/il- serum. beyond the value of . , chc patients will an require in-depth study for carbohydrate metabolism. cardiovascular medicine, international university of health and welfare sanno hospital, tokyo, japan background: hyperglycemia has been suggested as a significant factor in coronary microangiopathy in patients with type diabetes (t dm), but whether it can be reversed through treatment of hyperglycemia is unknown. aim: to clarify whether glycemic control can improve coronary microangiopathy in t dm. methods: subjects were t dm who underwent coronary angiography and age-matched controls. myocardial segments perfused by angiographically normal coronary arteries were studied. baseline myocardial blood flow (mbf, ml/min/ g) and mbf during dipyridamole administration ( . mg/kg/min) were measured using positron emission tomography (pet). myocardial flow reserve (mfr) was calculated by the ratio of mbf during dipyridamole administration to the baseline mbf. after the first pet study, patients were subdivided into an additional intensive therapy group (atg) and no-additional therapy (natg) group. second pet scan was performed - months later. results: baseline mbf was comparable among the atg ( . ae . ), natg ( . ae . ) and controls ( . ae . ). however, mbf during dipyridamole administration was significantly lower in both the atg ( ae . ) and natg ( ae . ) than in controls ( ae , p < . ) as was the mfr (atg, . ae . ; natg, . ae . ; controls, . ae . ; p < . respectively). mfr was significantly improved in the atg ( . ae . ; p < . ), but not in the natg ( . ae . ; p = ns). there was a significant inverse relationship between percent change in mfr and percent change in glycemic control. however, no significant relationships were seen between the percent change in mfr and percent change in plasma lipid fractions. conclusion: coronary microangiopathy in t dm can be reversed by intensive therapy for hyperglycemia. l. drimba, r. s ari, j. né meth, z. szilv assy, b. peitl background: our aim was to investigate the effect of "sui generis" hyperinsulinaemia on proarrhythmogenic electrophysiological changes and on cardiac arrhythmias. methods: euglycaemic hyperinsulinaemia was induced in chronicallyinstrumented conscious rabbits equipped with a right ventricular pacemaker electrode catheter. hyperinsulinaemia was induced by either or mu/kg/min insulin infusion and a variable rate of glucose infusion ensured the maintenance of euglycaemia ( . ae . mmol/l). the effect of hyperinsulinaemia on cardiac electrophysiological parameters and arrhythmia inducibility was studied by means of -lead surface ecg recording and by programmed right ventricular stimulation (prvs). the role of adrenergic activation was investigated by determination of plasma catecholamine level and by intravenous administration of beta adrenergic blocking agent, propranolol. results: both and mu/kg/min insulin infusion prolonged the pq and the tpeak-tend intervals and shortened the rverp, but no significant changes on other measures of ecg (hr, qt, qtc) were observed. the incidence of prvs-induced ventricular premature beats and non-sustained ventricular tachycardia was higher during euglycaemic hyperinsulinaemia than that of fasting state. we found that higher plasma level of insulin was occurred, the more inducibility of arrhythmias was seen. no change in plasma catecholamine level was observed, but the propranolol restored the prolonged tpeak-tend interval. our results indicate the "sui generis" proarrhythmic effect of hyperinsulinaemia due to reduction of the repolarization reserve in otherwise healthy rabbits. propranolol can be used safely for prevention of arrhythmia in patient with hyperinsulinaemia. euglycaemic hyperinsulinaemia is suitable method to induce acquired long qt syndrome in healthy rabbits. objective: this study investigated the prevalence of metabolic syndrome (mets) and its association with demographic, socioeconomic and behavioral factors in shift workers. a cross-sectional study was conducted on a sample of shift workers of both sexes in a poultry processing plant in southern brazil. the diagnosis of mets was determined according to the recommendations from "harmonizing the metabolic syndrome". the distribution of each of the components of mets was evaluated according to the demographic, socioeconomic and behavioral characteristics of the sample. the multivariate analysis followed a theoretical framework for determining mets on shift workers. the prevalence of mets on the sample was . % (ic % : . - . ). the most frequent altered component was waist circumference (rp . ; ic % . - . ). after adjustment, the prevalence of mets was positively associated with women (rp . ; ic % . - . ), workers of over years of age (rp . ; ic % : . - . ) and those who reported sleeping five or less hours per day (rp . ; ic % : . - . ). on the other hand, mets was negatively associated with higher educational level (rp . ; ic . - . ) and having more than three meals per day (rp . ic % . - . ). in addition, most of the altered components of mets were associated with sociodemographic characteristics, whereas only waist circumference and altered blood pressure were associated with behavioral characteristics. conclusion: sex, age, educational level, eating habits and duration of sleep appeared as independent risk factors for mets. arab world covers a vast geographic area, consists of countries with an approxiimate population of about million people. geographically, arab world is variable ranging from dry desert areas to heavily raining green land. this part of the globe is also unique for its wide cultural, social and ethnic variations. most of the countries are well-heeled with significant natural resources including oil, gas and are benefited from high income. the socio-economic progress has brought benefits in the region such as improved access to health care, education, and safe drinking water. this rapid economical change has also set the scene for the modern lifestyles activities, people are eating more and exercising less. these changes in the lifestyle cause variuos metabolic syndromes including obesity, diabetes mellitus. in spite of marvelous advancement in medical sciences, the most of the metabolic syndromes are still an incurable life-long disease and swiftly increasing in all over the world. presently, six countries including saudi arabia, bahrain, united arab emirates, kuwait, oman and egypt are among the world's highest for the prevalence of metabolic syndromes especially the diabetes mellitus. metabolic syndromes placed a great burden on the public health and clinical practice in the region. v. negrean , o. mislea , i. cheta , t. alexescu , i. chisalita internal medicine, umf iuliu hatieganu cluj-napoca, cluj-napoca, umf 'victor babes' timisoara, timisoara, romania introduction: it is known that type diabetes is a major cardiovascular risk factor, but the relationship between impaired fasting glucose (ifg) and the occurrence of cardiovascular events is still undefined. objectives: to determine whether the ifg is a risk factor for cardiovascular disease. results: twenty-four percent of the patients with ifg progressed to diabetes and % from the control group were diagnosed with this condition. twenty-one percent of the patients with ifg and % from the patients in the control group were diagnosed with hbp. sixty percent from the patients with ifg and % of the patients in the control group were obese, % from the subjects with ifg and % from the subjects in the control group show ischemic heart disease. fifty-five from the patients with ifg and % from the patients in the control group declared that they practice no physical activity. there was a significant correlation between the presence of ifg and the hbp (or = , p < . ), the absence of physical activity (or = , p < . ), obesity (or = , p < . ), ischemic heart disease (or = , p < . ). conclusions: our study shows that ifg is correlated with the cardiovascular risk: patients with ifg have three times higher risk to develop hbp, six times higher risk to be obese and three times higher risk to have ischemic heart diseses. introduction: : the most common investigated factors in chronic inflammation in type diabetes are increased c-reactive protein level, erythrocyte sedimentation rate. the matrix metalloproteinases are a family of proteolytic molecules which contribute to adipose tissue abnormalities. metalloproteinase (mmp- ) has a significant contribution to development of complications of diabetes. aim: : the assessment of the inflammation intensity in patients with type diabetes mellitus and the examination of mixed meal influence on mmp- plasma level. materials and methods: : twenty subjects were qualified to this study. all of them were diabetics on insulin treatment. concentrations of mmp- were estimated at fasting state and after mixed meal challenge (elisa). we also measured body mass, bmi, systolic and diastolic blood pressure and: esr, crp, daily average glucose, hba c. results: : mmp- concentration values were higher in fasting state in comparison to in postprandial state. mmp- correlates with esr, crp, bmi, average daily glucose level and body weight. however, there are no significant correlations between mmp- and hba c. conclusions: : there was a statistically significant positive correlation between serum metalloproteinase and exponents of inflammation, such as erythrocyte sedimentation rate, c-reactive protein. after the mixed meal we observed a significant decrease of metalloproteinase concentration in relation to its concentration in the fasting state. it was shown that the concentration of metalloproteinase depends on short-term metabolic control of type diabetes, not depending on long-term control of the disease. background: several studies suggest increased oxidative stress and reduced endothelial function in obstructive sleep apnoea syndrome (osas). we assessed the association between osas, endothelial dysfunction and oxidative stress. the effect of nasal continuous positive airway pressure (ncpap) on oxidative stress and arterial dysfunction was also evaluated. we studied consecutive patients with heavy snoring. patients underwent overnight home polysomnography. ten patients with severe osas were revaluated after months of ncpap therapy. oxidative stress was assessed by measuring urinary -iso-pgf a and serum levels of soluble nox -derived peptide (snox -dp). serum levels of nitrite/nitrate (nox) were also determined. flow-mediated brachial artery dilation (fmd) was measured to asses endothelial function. results: polysomnographic indices were correlated with the metabolic score, insulin levels and central obesity indices. severe osas had higher urinary -iso-pgf a (p < . ) and serum nox and lower nox. a negative association was observed between fmd and osa severity. apnea/hypopnea index was correlated with urinary isoprostanes (r = . , p < . ). metabolic syndrome (t = À . , p < . ) and urinary -isoprostanes (t = À . , p < . ) were the only independent predictors of fmd. after -months of ncpap treatment, a significant decrease of serum nox , (p < . ) and urinary -iso-pgf a (p < . ) was observed, while serum nox showed only a minor increase. a statistically significant increase of fmd was observed (from . % to . %). conclusions: our study indicates a strong association between osas and metabolic syndrome. patients with osas and cardiometabolic comorbidities have increased oxidative stress and arterial dysfunction that are partially reversed by ncpap treatment. pendyffryn medical group, prestatyn, diabetes centre, royal liverpool university hospital trust, liverpool, uk introduction: metabolic syndrome (mets) and low testosterone levels are independently associated with increased all-cause and cardiovascular mortality. low testosterone levels are associated with obesity, insulin resistance and an adverse lipid profiles in men and the metabolic syndrome and type diabetes have a high prevalence of testicular hypogonadism. the relationship and interaction between these conditions and the potential affect they have on each other is not fully understood. method: this study examined the correlation between testosterone and the criteria of the metabolic syndrome in subjects (age . years, ae . ,( - . ) (mean, sd (range)), total-testosterone . nmol/l, ae . ,( . - ), free-testosterone . nmol/l, ae . , ( . - . ), sex hormone-binding globulin level . nmol/l, ae . , ( - ). correlation and significance statistical testing used the pearson correlation coefficient. results: diabetes was present in . % and a further . %( / ) had the metabolic syndrome. total-testosterone, free-testosterone and shbg had significant and the strongest correlations with age (r = À . , À . . . respectively, p < . ). shbg had the strongest negative correlations with triglycerides (r = À . ), waist circumference (r = À . ) and hba c (r = À . ), (total-testosterone, triglycerides (r = À . ), wc (r = À . )), all significant p < . . there were positive correlations with hdl (r = . shbg, r = . tt, p < . ). there were no significant correlations with blood pressure and free-testosterone had no correlation with mets criteria. conclusion: lower testosterone levels have the greatest correlation with ageing but are also associated with detrimental changes in central adiposity and dyslipidaemia. shbg rises with age, however lower levels have a stronger association with cardiovascular risk. this study suggests that cardiovascular risk and androgen abnormalities might be methods: group (gr ) was composed of normal subjects (age = . ae . ; means ae sem). group (gr ) consisted of non-obese type ii dm pts with hypertriglyceridaemia (type iv hlp) and ath (age = . ae . ). group (gr ) consisted of nonobese type ii dm pts with mixed hyperlipidaemia (type iib hlp) and ath (age = . ae . ). following have been determined in serum, in fasting state: total cholesterol (ch), hdl-cholesterol (hdl-ch), atherogenicity coefficient (hac), triglycerides (tg), lipolytic activity (la), lipoprotein fractions, prostaglandins a and e , prostaglandins f alpha (pgf). following have been determined in plasma, during standard ogtt: glucose, insulin, insulin/glucose index (igi), glucagon, c-peptide, sth, somatostatin, acth, cortisol, aldosterone, beta-endorphin. results: both gr and gr pts, compared to gr , had higher body mass, ch, tg, hac, and lower hdl-ch, la, insulin (at ogtt hour ), igi, sth (hour ), basal aldosterone. gr pts, compared to gr , had lower sth (hours and ). gr pts, compared to gr , had higher glucagon (hour ), somatostatin (hours and ), cortisol (hours and ), pgf, and lowerc-peptide (hour ), sth (hours and ). conclusions: altered hormonal-metabolic patterns have been observed in non-obese type ii dm pts with ath and dyslipidaemias, including decreased sth and elevated cortisol. hyperlipidemia has been indicated as an important factor of contributing to diabetes progression. however, whether native ldl or modified ldl causes dysfunctional effect of insulin secretion in islet cells is still elusive. the present study aims to identify the mechanisms of electronegtive ldl (l ) and l (less electronegtive ldl) acting on the insulin secretion of pancreatic β-cells. rin-m f cells, were cultured in the complete medium with human native l , l , or oxldl. the intracellular concentration of reactive oxygen species (ros) measured by use of dcfhda was significantly increased after loading l ( lg/ml) or oxldl ( lg/ml), but not effected after loading l ( lg/ml). the cell viability assayed by prestoblue tm reagent was suppressed to % after loading l or oxldl; however, l did not inhibit the cell viability. the insulin release of rin-m f cells was determined by elisa kit. our results demonstrated that % decrease of secretion ratio in the phase of high glucose-induced response after the β-cells were exposed in l for h as comparison with in normal medium. we also found that phosphor-c-jun was activated after loading l or oxldl, but not after loading l . the activation of c-jun may modulate the gene expression or the process of insulin secretion. thus we suggest that l , not l , is the main subparticle which induces oxidative stress and then lead to dysfunction of insulin secretion responding to high glucose stimulation in β-cells. target group for diet and physical activity interventions due to their increased risk of post-natal weight gain, type diabetes and related health problems. postpartum weight gain and/or retention, particularly in the first months are commonly due to lack of nutrition knowledge, poor dietary habits and physical inactivity. mothers are also integral to the shaping of attitudes and eating and activity behaviours of their children. the proposed study will evaluate whether an individualized weight management program with nutrition and physical activity advice and support enhances weight loss compared with standard care in overweight and obese women and women with a history of gdm. it is hypothesized that, compared with individuals given standard diet and physical activity advice, overweight and obese women, and women with a history of gdm prescribed exercise energy expenditure targets and using heart rate (hr) and dietary intake monitoring with electronic reminders, are better able to achieve a target weight loss ( % reduction from prepregnancy weight for overweight or obese pregravid ( ! . kg/m ), for overweight women ( . - . kg/m ) to achieve a weight loss that places them in the healthy-weight range, and for women who were in the healthy-weight range pregravid to return to their prepregnancy weight) through changes in eating and activity behaviours. objective: diabetes is associated with moderate cognitive deficits and neurophysiological and structural changes in the brain, a condition that may be referred to as diabetic encephalopathy. we used high-fat and sugar diet and streptozotocin induced diabetic rats to observe the changes of proteins of insulin signaling which closely correlate with learning and memory. we try to illuminate the possible mechanisms of learning and memory decreased in t dm. methods: a total of rats were randomly divided into two groups: control group (c), diabetes mellitus group (dm). after weeks, morris water maze was used to perform training trial and probe trial in order to detect spatial learning and memory abilities. and we detected proteins of insulin signaling such as ir, irs- , akt, p-creb and bcl- in the hippocampus of the rats by western blot and immunohistochemistry staining. results: . water maze experiment: compared with the c group, the escape latency increased significantly in dm from the nd day. in the spatial probe experiment, the first time passing hidden platform prolonged significantly and the distance swimming in the quadrant of hidden platform decreased significantly in the dm. . immunohistochemistry staining: compared with the c group, the positive neurons of ir, irs- , akt, p-creb, bcl- increased in the dm group. . western blot: compared with the c group, the expression of ir, irs- , akt, p-creb, bcl- increased in the dm group. conclusions: the learning and memory ablities decreased, while the expression of ir, irs- , akt, p-creb, bcl- abnormal increased in t dm model rats. the results indicate that insulin signal transduction were impaired in t dm. objectives: niacin, a widely used lipid-modifying drug, is known to induce hyperglycemia during prolonged and high-dose treatments. however, its potential mechanism (s) whereby the islets are involved remains to be determined. we thus aim to investigate the potential role of niacin and its receptor gpr a involved in regulating islet beta-cell function and insulin resistance. methods: hfd-induced obese mice were employed to study the in vivo effects of niacin. blood glucose/serum insulin levels, oral glucose tolerance test (ogtt)/insulin tolerance test (itt), and homeostasis model of assessment-insulin resistance (homa-ir) were performed to assess glucose homeostasis. real-time pcr, western blot and immunefluorescent assays were used to study the expression of genes of interest. cyclic adenosine monophosphate (camp) and glucosestimulated insulin secretion (gsis) from isolated islets and ins- e beta cells were determined. knockdown of the gpr a in ins- e cells was also examined and compared. results: eight-week treatment with niacin increased blood glucose levels by % in hfd-induced obese mice while the areas under curve of ogtt and itt, and homa-ir index were consistently enhanced. in addition, niacin treatment significantly decreased gsis in isolated pancreatic islets. ex vivo and in vitro studies showed niacin decreased gsis, increased mrna expression of ucp and gpr a as well as inhibited intracellular camp accumulation in ins- e cells. in corroboration, the decrease in gsis and camp levels were abolished by the knockdown of gpr a. our data indicate that niacin treatments leads to hyperglycemia and impaired pancreatic islet function, which is probably via the activation of islet niacin receptor gpr a-induced pathway. a once daily glp- analogue, liraglutide, is emerging world-wide as a drug for the treatment of diabetes and also, potentially, obesity. this agent not only acts on glycemic control, but also exerts an effect on body weight control, because liraglutide inhibits gastric emptying, resulting in appetite reduction and lower energy intake. herein, we treated type diabetic obese subjects with . mg/day liraglutide and examined glycemic control and body weight changes over a month period. glycemic control was markedly improved (baseline hba c . ae . %, endpoint hba c . ae . %) with liraglutide. based on subgroup analysis, the good responders to liraglutide were ( ) bmi < . ( ) diabetes duration < years. ( ) postprandial cpr < . ng/ml. while liraglutide-induced gastric symptoms, specifically nausea, occurred in nearly all patients at baseline, it had disappeared in about half by the end of the study. unexpectedly, the hba c improvement was not associated with the presence of nausea. while acute body weight loss ( . ae . kg) was observed at month, there were no significant body weight changes at the end of the study. individual body weight change was associated with the presence or absence of nausea at the end of the study. in conclusion, the effects of liraglutide on body weight loss lasted only a short period and no chronic effects were observed. thus, the hba c lowering effect of liraglutide is not due to reduced energy intake, but rather, to recovery from defects in postprandial insulin secretion. background and aims: durability of good glycaemic control may delay development of diabetic complications. early initiation of combination treatment with oral anti-diabetic drugs (oads) having complementary mechanisms of action may increase durability of glycaemic control compared with stepwise addition of oads. dpp- inhibitors such as vildagliptin are good candidates for early use in combination with metformin as they are weight neutral with no additional risk of hypoglycaemia. materials and methods: about drug-na€ ıve patients with type diabetes mellitus (t dm) with hba c between . and . %, will be randomised in verify, a -year, multinational, double-blind, parallel group study. the study will test the hypothesis whether early combination therapy with vildagliptin/metformin will result in lower treatment failure rate or in lower rate of loss in glycaemic control over time than with metformin alone. other objectives include evaluation of rate of fasting plasma glucose progression, change in hba c over time, time to insulin initiation, development/progression of diabetic complications, changes in weight, changes in homa-β/ir, safety and tolerability. insulin secretion rate and insulin sensitivity will be assessed in annual standard meal-test. patients will also be evaluated for early changes in the vasculature, microalbuminuria and retinal microaneurysms. results and conclusions: verify is the first study to investigate the long-term clinical benefits of early combination treatment vs. the standard-of-care metformin followed by addition of oads. verify will provide valuable data on the durability of glycaemic control, βcell function, insulin resistance, safety and tolerability and explore early changes in the vasculature of patients with t dm. patients with metabolic syndrome are at high risk for developing atherosclerosis. recent studies have suggested glucagon-like peptide- (glp- ) signaling to exert anti-inflammatory effects on endothelial cells, although the precise underlying mechanism remains to be elucidated. on the other hand, pparc activation was demonstrated to inhibit the transcription of factors, such as nfjb, resulting in atherosclerosis prevention via suppression of the expressions of cytokines and adhesion molecules in endothelial cells. we investigated whether pparc activation is involved in the glp- -associated antiinflammatory action in endothelial cells. we constructed an adenovirus expressing the ppre (+)-luc reporter gene for use with the reporter assay system. when we treated huvec cells with . nmol/l exenatide, endogenous pparc translational activity was significantly elevated by % as compared with control cells. the maximum pparc activity enhancing effect of exenatide was observed h after the initiation of exenatide incubation and was approximately % of that induced by lmol/l pioglitazone. when incubated with exenatide and pioglitazone simultaneously, pparc activity was additively promoted, suggesting that these two agents synergistically stimulate pparc activity. as h , a pka inhibitor, abolished glp- induced pparc enhancement, the signaling downstream from glp- cross-talks with pparc activation. in conclusion, our results suggest that glp- has the potential to induce pparc activity, partially explaining the anti-inflammatory effects of glp- on endothelial cells. cross-talk between glp- signaling and pparc activation would confer major impacts on treatment of patients at high risk for cvd events. in the rat hypothalamus by adenovirus-mediated gene transfer and then examined phenotypes of the rats. dnlkb significantly inhibited the thr phosphorylation of ampk alpha subunits, while wtlkb did not alter phosphorylation, suggesting that hypothalamic ampk is activated in basal states and negatively regulated by dnlkb . dnlkb -overexpressing rats exhibited body weight gain and slight insulin resistance as compared with wtlkb -overecpressing or sham operation-rats. taking into consideration that food intakes did not differ among these rats, this effect was probably due to reduced energy expenditure. in fact, the adipose tissue in dnlkb -overexpressing rats produced smaller amounts of pgc alpha and ucp , resulting in increased adipose tissue weights, as compared with wtlkb overexpresing rats. neither hepatic fatty acid synthesis nor gluconeogenesis was significantly altered. the phenotypes observed in dnlkb -overexpressing rats appear to be like those of ampk alpha deficient pomc neuron mice. in conclusion, our findings demonstrated inhibition of hypothalamic lkb to lead to reduced energy expenditure and body weight gain, suggesting that central lkb is involved in bodyweight regulation probably via ampk modification. material and method: anthropometric variables and lipid related factors concentration were measured. pcr and rflp were performed. the distributions of a polymorphic site and its relationship with mentioned factors were examined. result: in normal subjects there wasn't any relationship between these three polymorphism and studied profile, but in females with mets, presence of g allele in rs significantly increase diastolic blood pressure, low density lipoprotein and apolipoprotein a (apo a ) level and the c allele in rs , increase waist circumference, triglyceride and apo a level. while previous studies in adults demonstrated that snps in apoa , have primarily been associated with plasma lipoprotein levels and associated downstream consequences, such as weight gain and heart disease risk, in present study we find that there are some relation between this variation and lipid profile in female with metabolic syndrome and this relationship is sex dependent. tryglicerides mean value was mg/dl and cholesterol mg/dl; the mean value was slightly elevated but inside the lot of the patients the variations were wide probably due to liver inssuficiency (low values) and alcooholic etiology of underlying liver disease (higher values). serum uric acid had a mean value of . mg/dl. no large variations inside the lot. medium level of serum creatinine . mg/dl; higher values in child c cirrhosis and hcc. conclusions: most of the metabolic disturbancies in hcc are correlated with the underlying liver disease. in a few cases of small lesions but mostly in large and complicated hcc these are significant and require specific treatment. background: a significant inter-individual variability in statin treatment efficacy is likely to have a strong genetic background. gene for slco b belongs to the candidates with potential to influence the statin treatment efficacy. slco b codes for solute carrier organic anion transporter, which has been shown to regulate the hepatic uptake of statins and some other drugs. materials and methods: slco b rs (t>c) polymorphism was successfully analysed in the group of patients with dyslipidemia (treated with simvastin or atorvastatin, or mg per day) and healthy normolipidemic controls. the polymorphism was analysed using nested pcr-rflp. lipid values (total-, ldl-and hdl-cholesterol, triglycerides) were analysed before and after - weeks of treatment. results: after treatment, as expected, there was a significant decrease both in total ( . self-care management), were applied to all patients at baseline and month follow-up. t-test and chi-square test were used to analyze the data. after months, (out of ) and (out of ) patients remained in the study. main findings revealed, a significant difference in a c level between the groups (p < . ). the self-care management score increased in both groups, but the increase was significantly higher in the intervention group (p < . methods: after the treatment decision was final, patients were assigned to either vildagliptin or other oads (sulphonylurea, thiazolidinedione, glinide, a-glucosidase inhibitor or metformin except dipeptidyl peptidase- inhibitor or glucagon-like peptide- mimetic/ analogue). demographic data and patient history, especially risk factors and macro-and microvascular complications, were collected and reported by the investigators. results: in total, , patients were enrolled in countries across the world. baseline characteristics are presented in the table. hba c was better controlled in east asia and europe than in india, latin america or middle east. patients in europe had higher bmi and longer duration of diabetes than patients in east asia and india. prevalence of risk factors such as hypertension and lipid disorders was high overall, but particularly higher in europe. macro-and microvascular complications were reported in . % and . % of the overall study population, respectively, and their prevalence was higher in europe. conclusions: data from edge study show that the hba c goal of % as recommended by international guidelines is not achieved worldwide and metabolic control varies remarkably between regions. in addition to the high prevalence of concomitant risk factors, complications were reported already after years of diabetes in a substantial proportion of patients. aim: sudomotor dysfunction due to small fiber neuropathy can be observed very early in pre-diabetes. the aim of this study was to assess the predictive power of ezscan, a non invasive, quick and simple measurement of sudomotor function to identify glucose impairment. research design and methods: the study was performed in german subjects at risk of diabetes. glucose metabolism was assessed by using, oral glucose tolerance test (ogtt) at baseline and after year follow-up. sudomotor function was evaluated by measuring hand and foot electrochemical sweat conductances to calculate a risk score. results: at baseline, patients had normal glucose tolerance (ngt), had pre-diabetes (impaired fasting glucose, ifg and/or impaired glucose tolerance, igt) and four had newly diagnosed type diabetes. the auc values for fpg, h-ogtt glucose, h-ogtt glucose, hba c and ezscan score to predict pre-diabetes were . , . , . , . and . respectively. subjects having a moderate or high ezscan score (> ) at baseline had a substantially increased risk for having ifg and/or igt at follow-up visit presented by an odds ratio of . [ . - . ], the or for having h-ogtt ! . mmol/l at follow-up was . [ . - . ] and for having hba c ! . % was . [ . - . ] compared to subjects with low ezscan risk. conclusions: this preliminary study, which must be confirmed in a larger population, shows that ezscan measurement is associated with diabetes progression which may have implications for prevention and disease management. methods: two groups are involved to the studies -the group of patients with metabolic syndrome (ms) and control group (c)- healthy, age matched volunteers. volunteers were expose to -h ogtt (according to who) and -h oltt (contained g of fat: % saturated, % monounsaturated and % pufa). during both tests the blood glp- , gip, glucose, insulin and free fatty acids (ffa) levels were assessed. results: fasting level of incretins do not statistically differ between ms vs. c participants. only ffas were elevated during whole oltt, when the glucose concentrations decreased in early postprandial period. secretion of gip was activated by ogtt as well as by oltt, however concentration of gip in oltt was higher. output of glp- during whole ogtt was significantly lower in patients with ms. in patients with ms amount of gip released during oltt was lower compared to control patients. conclusion: low level of incretins during oxidative stress connected with fat food intake, may not provide the protective effect for metabolically stressed pancreatic beta-cells. background: who estimates that . million deaths worldwide are due to hypertension, approximately . % of all deaths. this is an important risk factor forcardiovascular disease. argane oil is an integral part of the moroccan diet. several studies showed that an argane oil supplemented diet decreased systolic and diastolic blood pressure measurments in animals and suggested that consumption of argan oil may have a beneficial effect in preventing cardiovascular disease. objective: to study the effect of a regular consumption of argane oil on hypertension in healthy postmenopausal women. methods: seventy-seven postmenopausal women ( . ae . years) were assigned to consume ml of argane oil during weeks of nutritional intervention. anthropometric (weight, height and bmi) and clinical profile (blood pressure) have been determined at and weeks. results: showed that systolic blood pressure was significantly reduced ( . ae . to . ae . mmhg) after weeks (p = . ). diastolic blood pressure underwent a slight decrease ( . ae . to . ae . mmhg) but not significantly (p = . ). conclusion and perspective: these results suggest that consumption of argane oil can be relevant to prevent cardiovascular disease into postmenopausal women and help to decrease cardiovascular risk. the positive impact on blood pressure recorded by a significant decrease in sbp and hypertension is a significant result, however, the mechanisms involved in obtaining this result need to be defined more accurately, focusing mainly on the effects of certain constituents of argane oil as gamma-tocopherol on the mechanisms regulating blood pressure. the epidemic of obesity is associated with multiplication of prediabetic patients. recognition of them is essential as this state is considered to be the last chance to prevent the manifestation of diabetes. our aim was to determine metabolic alterations in healthy men with (dr: n = ) or without (h: n = ) first degree dm relatives. volunteers were adjusted according to age and bmi, insulin resistance was determined with hyperinsulinaemic-normoglycemic clamps and ßsejt function by iv glucose tolerance test. fasting glucose, insulin and ffa values were not different among the groups, but at the and of ivgtt, glucose levels were higher (h: . ae . , vs. dr: . ae . mmol/l, p < . ), injected glucose did not suppressed ffa levels (h: . ae . vs. dr: . ae . mmol/l, p < . ) and first phase insulin secretion was decreased in dr group (h: ae vs. dr: ae ; p < . ). there were no differences among the groups in total body-, muscle and fat tissue glucose disposal, leptin and resistin levels, but the adiponectin levels were significantly lower in dr group (h: . ae . vs. gd: . ae . mg/ml, p < . ) and the ffa/adiponectin ratios were higher (h: . ae . vs. gd: . ae . , p < . ). in conclusion the impairment of insulin secretion and fatty acid metabolism are the earliest sign of diabetes risk in men with first degree dm relatives. the measurement of ffa/ adiponectin ratio could be a simple parameter to screen adult male relatives of diabetic patients for identification of genetic risk of diabetes. the original reaven′s definition from , which has been revised in , missed the abdominal obesity. the definition accepted by who in was not applied due to difficult evidence of the insulin resistance. a new definition of the ms formulated by idf and ead was published in . in this case, the abdominal obesity was the necessary condition of the ms diagnosis. in order to unify the criteria, five essential parameters of the ms were put on the same level by the international medical organizations in . it is not easy to define the ms. it cannot be identified as a single disease, as it consists of a complex of problems. that is why the definitions of the ms were rearranged several times during past years and the used parameters are much stricter. we can assume that in the future this process will proceed. aims: the metabolic syndrome (ms) represents an obesity-related severe health problem, and its prevalence is world-wide increasing in parallel with the growing obesity epidemiology. gwa studies have shown that many single nucleotide polymorphisms (snps) in several genes are involved in common obesity. the aim of this study was to look for associations between snps in the mc r (rs , rs , rs ), sirt (rs , rs , rs , rs , rs ) and fto (rs , rs , rs , rs ) genes and obesity and/or ms in a southern italy population. methods: one-thousand unrelated non diabetic severely obese patients (mean bmi . kg/m , mean age . years) and controls (mean bmi . kg/m , mean age . years) entered the study. mc r, sirt and fto were genotyped by real time taqman assay. anthropometric, clinical and biochemical data were collected for all enrolled subjects. ms was diagnosed according to the american heart association criteria. results: metabolic syndrome was diagnosed in . % of our patients. the four fto snps were significantly associated with the obese phenotype ( . < p < . ). at binomial logistic regression analysis, only snp rs was significantly associated to obesity after correction for sex and age (or/ %ci: . / . - . and . / . - . , for the heterozygous and the homozygous mutated genotypes, respectively) and to ms presence (or/ %ci: . / . - . ) . conclusions: this study confirms that fto is a susceptible gene for obesity risk, and patients bearing the polymorphic allele in the rs snp could be at high risk of ms insurgence, possibly to be addressed toward preventive programs. results: number of patients who achieved hba c goals according age and presence of cvd are shown in table . conclusion: t d patient of middle age reached hba c goals in lowest percentage of cases. among different treatment groups percentage of patients reached hba c goals were the lowest in group treated by insulin with oad. the prevalence of diseases arising mainly due to the bad lifestyle is increasing. it is necessary to find optimal tools to lower the prevalence of the metabolic syndrome (ms). there is no network of institutions that systematically cooperate in the field of education and treatment of the ms. for students and academics the possibility of establishing ( ) and deepening the cooperation in this scientific field is therefore limited. the role of the project is to strengthen relations between the institutions in the form of cooperating network, which will meet the essentials principles of the primary, secondary and tertiary prevention of the metabolic syndrome. the key role of the project is to open an professional discussion and deepen the communication and professional relationship across the cooperating institutions which are realized primarily through internships of students (bachelor and doctoral degree), academic staff, roundtable discussions with experts and partners from the collaborating institutions, organizing workshops and doctoral and scientific conferences. czech society of sports medicine ( cstl) is a professional guarantor of creating a network of cooperating institutions in terms of the objectives and scientific credibility. background and aims: tissue ages accumulation is thought to be a specific marker of long-term glycaemic control, oxidative stress and cardiovascular risk. prediabetes -impaired fasting glucose (ifg) and impaired glucose tolerance (igt), are considered as risk categories for the development of both type diabetes and cardiovascular disease. the aim of the present study was to assess advanced glycation end products (ages) in prediabetes and their relation to anthropometric and glycaemic control parameters. material and methods: subjects (mean age . ae . years, mean bmi . ae . kg/m ) were enrolled. according to glucose tolerance they were divided into two age-matched groups - subjects with ngt and with prediabetes (ifg and igt). glucose tolerance was studied during ogtt applying who criteria. plasma glucose was measured by a hexokinase method, hba c was assessed immuno-turbidimetricaly. tissue ages accumulation was assessed non-invasively measuring the skin fluorescence of ultraviolet light on the ventral side of the lower arm (age-reader-diagnopticstm). antropomethric measurements -weight, height, waist circumference, were performed. visceral fat area was estimated by bioimpedance method (inbody ). results: no significant difference in ages accumulation was found between the groups with prediabetes and ngt. significant positive correlation was observed between ages accumulation, age (r = . ) and visceral fat area (r = . ). the non-invasive assessment of tissue ages accumulation probably is not a sensitive enough method for identifying subjects with prediabetes and increased cardiovascular risk. at the early stages of glucose homeostasis impairment ages accumulation appears to be related to age and visceral obesity rather than to glucose tolerance. this study is an observation study for mild diabetic males with bmi of or higher with subsequent month-follow-up based on single administration of exenatide and dietary and exercise intervention. method: subjects were cases of male patients (age: . ae . , bmi ae . ) with apnea hypopnea index (ahi)≧ /hr and . >hba c> . %. based on polysomnography and measurements of ct abdominal visceral fat area and various biomarkers before and and months after exenatide administration, the observation study was conducted for months. results: decrease in bodyweight was observed by . ae . kg on average during the months with no cases to gain in bodyweight and bmi. ahi was significantly improved from . ae . /h to . ae . /h. improvement was observed in hba c, -ohdg, pro-bnp, high molecular weight adiponectin and visceral fat areas but not in hs-crp and subcutaneous fat area. conclusion: not only diabetes but also sleep apnea syndrome was improved by exenatide administration in japanese mild diabetes patient. weight reduction may have played the primary role. effect of weight reduction provided by the pharmacological property of exenatide is useful to improve sleep apnea syndrome. currently, changes in individual calorie intake and nutrient composition during the study period have been analyzed. [ . - . ], p = . in igt group. no significant association was found between baseline fasting insulin level and progression from either ifg or igt to type diabetes. conclusions: individuals with ifg or igt identified through high-risk strategies in a bulgarian population, have a rather high risk of developing diabetes within year. baseline proinsulin and proinsulin: insulin ratio, known to reflect beta-cell dysfunction, appear to be independent predictors for progression to diabetes in both ifg and igt. introduction: the insulin receptor substrate (irs- ) seems to be an important factor involved in the modulation of insulin signalling in adipose tissue. in this study we want to check the expression of irs- in visceral and subcutaneous adipose tissue, its relationship with insulin resistance and with the metabolic syndrome. material and methods: we measured irs- expression in visceral and subcutaneous adipose tissue from morbidly obese patients. we have determined the level of insulin resistance with the homa-ir index. patients were classified into two groups based on whether or not to have metabolic syndrome (according to the idf criteria) results: irs- expression in subcutaneous adipose tissue is significantly higher than in visceral adipose tissue (p = . ). homa-ir was significantly correlated with the irs- expression in subcutaneous adipose tissue (r = À . , p = . ), but not in visceral adipose tissue (p = . , p = . ). the morbidly obese patients with metabolic syndrome have significantly lower irs- expression levels in subcutaneous adipose tissue than those without metabolic syndrome (p = . ). in visceral adipose tissue, the levels of irs- are lower but not significant (p = . ) in the morbidly obese patients with metabolic syndrome. the presence of metabolic syndrome in morbidly obese patients is associated with a lower irs- expression level in subcutaneous adipose tissue. in the general population and in hiv+ subjects the hypertension is the major risk factor worldwide for cardiovascular morbidity and mortality. this condition has been accompanied by several complication, including dyslipidemia and impaired glucose metabolism. for all these reasons identification of hypertension is of pivotal importance in hiv infected patients. aim of this study was to evaluate the incidence of hypertension and comorbidity in male hiv+ patients. we enrolled only male patients attending two clinics of the infectious diseases in center of italy (chieti and ancona). three hundred and four patients accepted to participate at the study. viroimmunological, lipid and metabolic parameters, including triglycerides, cholesterol, hcv/hbv co-infection, tabacco use were measured at the time of enrollment. the study has shown an incidence of hypertension (esh guidelines) % ( / patients), dyslipidemia % ( / ), diabetes % ( / ), hcv or hbv co-infection % ( / ) and tobacco use % ( / ). patients with hypertension showed dyslipidemia in % of cases ( / )and diabetes in % ( / ). remarkable that only % of patients with hypertension were treated for hypertension. in addition, the average age of the patients in the study was . ae . years. the study has shown a high incidence of hypertension in hiv+ men, even considering the young age of the patients. furthermore, hypertension is associated with a high incidence of co-mobility. hypertension is associated with evidence of under treatment, it showing a poor perception of the problem in this context. method: this study was a -weeks', prospective trial in subjects with metabolic syndrome. metabolic syndrome was defined as the presence of at least three out of five risk factors according to the ncep-atp iii with the asian criteria of abdominal obesity (abdominal circumference; > cm in men, > cm in women). all participants received individualized education by skilled personnel with information about tlc. blood chemistry including lipoprotein profiles and anthropometric data were collected before and after weeks' tlc. result: eighty-six subjects were screened, and subjects with metabolic syndrome were enrolled. body weight was not significantly changed after tlc. fasting blood glucose levels were not significantly changed (from . ae . to . ae . mg/dl, p = ns). therapeutic lifestyle change did not result in significant changes in total cholesterol (from . ae . to . ae . mg/dl, p = ns) and triglyceride (from . ae . to . ae . mg/dl, p = ns). but, weeks' tlc resulted in significant reduction in ldl-cholesterol levels (from . ae . to . ae . mg/dl, p < . ), increase of hdl cholesterol levels (from . ae . to . ae . mg/dl, p = . ). conclusion: four weeks' therapeutic lifestyle change improved lipoprotein profile (especially ldl-c and hdl-c) in metabolic syndrome. our findings indicate that the importance of tlc with education should be emphasized for the control of metabolic syndrome. nutrition, hasanuddin university, school of medicine, makassar, indonesia obesity in major public health and economic problem of global significance. the prevalence of obesity in children has increased significantly, although less rapidly in indonesia. from the public health view, it is disconcerting that the prevalence of adolescent obesity has increased by nearly % in the past two decade. case and control study design was done in makassar, the participant is senior high school students. the study aim to identify the risk factors of adolescent obesity to premetabolic syndrome by measuring body mass index, waist circumference, lipid profile (cholesterol, trigliceride, hdl, ldl and apo b) and fasting oral glucose. data was analyzed using spss program, the relationship among variables was calculated with pearson correlation and regression test. the indicators for obesity using waist circumferences and bmi, energy intake using h food recall and was analysed using wfood . the study showed, a positive correlation between waist circumference and small density ldl, apo b, cholesterol (p < . , p < . , p < . ). student with abnormal waist circumference tend to have abnormal biochemical markers (or . , . , and . ) as a risk premetabolic factors conclusion: nutrition education and food balance diet should be given to adolescent obesity to prevent metabolic syndrome in later of life. l. mundbjerg , g.f. thomsen , r. holst , c. juhl department of endocrinology, department of occupational medicine, hospital of south western denmark, esbjerg, institute of regional health research, region of south denmark, odense, denmark introduction: severe obesity is associated with reduced worker productivity and chronic absence from work. gastric bypass surgery is the most effective treatment of severe obesity. the objective of this study was to measure employment status in danish gastric bypass patients before and after surgery. methods: the study is a nation-wide retrospective case-control register study. data were extracted from three sources: cases were identified in the danish national patient register according to the operational code for laparoscopic gastric bypass surgery and matched on a : basis with respect to age, gender and residence municipality with control subjects. the employment status was calculated from the danish national labour market authority's databasedatabase (dream) which includes information on all public transfer incomes. by linking the databases we achieved a valid measure of the amount of working days. results: the amount of working days was significantly lower in cases compared to controls. there was a significant decline in employment status during the observational period in both groups. this decline corresponded with the timing of the financial crisis (employment data collected over the period january st to december st ). there was no significant difference in the decrease of employment status between groups. conclusion: gastric bypass surgery patients are affected by the economic recession in a similar degree as the general population. thus, the patients do not seem to benefit from the operation nor do they appear particularly vulnerable in periods of recession. excessive accumulation of fatty tissue in obesity associated with fat and glucose metabolism. fish oil contains n- pufas epa and dha had been demonstrated in several studies had effects on the expression of genes ppar-a and srebp- c, the pathomechanism still controversial. this study aims to determine the effect of fish oil on insulin resistance in mice obesity. clinical trials using c bl/ j mice was conducted in animal laboratory medical faculty of hasanuddin university. the mice was giving a normal diet (nd) or high fat diet (hfd) for weeks. mice was divided by four groups; normal diet (nd), high-fat diet (hfd), hfd + g/ g fish oil (hfd-fo), hfd + metformin g/kg diet (hfd-met) as a positive control for weeks. gene expression of ppar-a and srebp- c from the liver were measured by rt-pcr. the study showed, hfd mice had significantly higher body weight compared to nd. hfd-fo have higher blood glucose levels than other groups. ppar-a expression in liver was lower in hfd than nd, but increased in the hfd-fo and hfd-met compared with hfd alone. srebp- c expression decreased in hfd-fo and hfd-met, glucose metabolism of hfd_fo tended to decrease, while the hfd-met is likely to increase. we conclude, fish oil improved insulin resistance, decreased expression of srebp- c and increased expression of ppar-a in the liver tissue through decreasing lipogenesis and increased fat oxidation in the liver. methods: total subjects were divided into two groups having whr > . as obese and whr < . as non-obese. circulating il- and resistin level, fasting blood glucose, insulin and lipid profile were estimated. insulin resistance was calculated by the homeostasis model assessment (homa) index. the genotype and allele frequency of il -g c gene polymorphism was determined by pcr-rflp method in obese and non-obese adult women from north india. results: the genotype distribution of il -g c gene polymorphism was statistically significant in obese women (p = < . ; or = . ; % ci = . - . ) compared to non-obese women. the circulating level of serum resistin was highly significant in obese women ( . ae . vs. . ae . , p = < . ) compared to nonobese. significant association was found with cc + gc genotype of il -g c promoter gene polymorphism in case of waist circumstance, serum triglyceride, homa index and serum resistin level (p = . ; or = . , % ci = . - . ). conclusion: serum resistin is associated with the disorder of metabolism of glucose and lipid in metabolic syndrome. the relationship between this hormone with cc + gc genotype of il -g c promoter gene polymorphism suggests that they may take part in the development of metabolic syndrome in north indian adult women. the comorbidities associated with excessive weight are major causes of morbidity and mortality, thus causing further reduction in quality of life. the dysfunction of excessive fat and its peculiar distribution plays a decisive role in the development of metabolic disorders. the aim of the study was to estimate the prevalence and the correlates of obesity and dysglycemia in a rural community. overweight and obesity were defined according to world health organization criteria, considering both the value of body mass index (bmi) and waist circumference (wc). dysglycemia (impaired fasting glucose -ifg and diabetes) was established based on ada recommendations. the study included people, . % men and . % women, with the mean age of . ae . years. more than half of them ( %) had an excessive weight: . % were overweight and . % were obese. the crude prevalence of overweight and obesity was . % and . % respectively for men, and % and . % respectively for women. the prevalence of diabetes was . % and for ifg of %. the prevalence of dysglycemia increased with the bmi value, with the highest frequency in the grade iii obesity group ( . % prevalence of diabetes, ifg . %). large wc was identified in . % of the studied population ( . % in men, . % women). the individuals with diabetes had a significant higher mean wc ( . cm vs. . cm, p < . ). these results show that excessive weight and abdominal obesity could become a public health problem in romania, thus requiring national screening and educational programs. objective: hyperuricemia is associated with obesity; however, few studies reported the effects of surgery types on uric acid metabolism for severe obesity. the current study was aimed to explore the effects of gene and bariatric surgery on uric acid reduction and to identify the potential pathways. subjects: all participants were han chinese, aged from to years old. a total of severely obese patients with at least body mass index (bmi) of were recruited in the beginning of the study, where cases received laparoscopic adjustable gastric banding (lagb) and cases received laparoscopic mini-gastric bypass (lmgb). a -month follow-up was ensued after surgery to identify the effects of bariatric surgery and estrogen receptor-a (esr ) gene on serum uric acid reduction. results: a tagsnp (rs ) of esr could influence serum uric acid reduction. bariatric surgery effect on serum uric acid reduction was greater in lmgb as compared with lagb at the th month of post-surgery (À . ae . mg/dl vs. À . ae . mg/dl, p = . ). obese patients carrying risk genotype (tt) on rs and exhibiting better glycemic control had a greater serum uric acid reduction at the th month of post-surgery. synergic effect of rs and lmgb exhibited the highest serum uric acid reduction at the th month of post-surgery (À . ae . mg/dl). conclusion: for severely obese han chinese, bariatric surgery appears to reduce serum uric acid levels by mediating different factors, including esr gene and gender, ameliorating glycemic control, and changing dietary patterns. remained significantly lower. compared to mgc, mgr but not mgrc male offspring had higher body fat % and visceral adiposity at months of age. results: the average age of patients was . years, more dominant were females with . %. patients with ms characterizes increased values of bmi ( . kg/m²), which is statistically significantly more that in the control group, where is average value of bmi . kg/m², waist . cm in the study group, and . cm within control group (p < . ), blood pressure . / . mmhg, homa index . , average value of insulinemia . (lu/ml), (within control group homa index was . ), the average value of insulimenia . (lu/ml), average values of: total cholesterol . mmol/l, hdl cholesterol . mmol/l, ldl cholesterol . mmol/l, triglycerides . mmol/l, relation between ldl/hdl . . arterial hypertension was present in . %, hypercholesterolemia in . %, reduced hdl in . %, increased ldl in . %, trigliceridemia in . %. conclusion: abdominal obesity is characterized by manifested insulin resistance and distinct hyperinsulinemia. arterial hypertension as one of the components of metabolic syndrome represents significant cardiovascular risk factor, increased level of triglycerides represents significant risk factor which favors atherosclerosis, in our study the presence of this parameter was . %. introduction: diabetes is the most feared disease because it leads to a variety of complications including end-stage vascular disease, cardiovascular damage and retinal abnormalities. the increased risk of atherosclerotic disease in diabetic subjects may be due to enhanced foam cell formation following an increased susceptibility of low density lipoprotein to oxidative modification. cardiovascular disease (cvd) is the most prevalent complication of diabetes mellitus. methods: the aim of this study was to assess the ldl susceptibility to lipid peroxidation (ldl ox) in two study groups of elderly patients (aged ae years): a group of patients with cardiovascular disease and a group of patient with cardiovascular disease associated with type diabetes mellitus. the ldl susceptibility to in vitro induced lipid peroxidation was evaluated following its incubation with a prooxidant system. : results obtained showed the susceptibility of ldl to in vitro oxidation was increase in diabetic group ( . %) compared with a cardiovascular disease group. conclusion: this study indicates that low-density lipoprotein from diabetic subjects is more susceptible to oxidation. patients with diabetes have a greatly increased relative risk of developing cardiovascular disease when compared with patients without diabetes. much of this risk is related to insulin resistance and is associated with both traditional and nontraditional cardiovascular risk factors. therefore, measurement of ldlox may be helpful for identifying high-risk patients with type diabetes and cvd. janus kinase (jak) and signal transducer and activator of transcription- (stat ) in several cell lines. objective: we sought to determine the role of hypothalamic s pr in the control of jak /stat signaling and food intake in vivo. materials and methods: western blot, immunohistochemistry, gas analyzer, dissection of the hypothalamic nuclei and intrecerebroventricular (icv) infusion of s p ( ng), leptin ( À ) and cucurbitacin ( lmol/l) were combined to evaluate the role of s pr on leptin signaling and on food intake in lean and obese wistar rats and in ob/ob mice. results: high expression of s pr was found in the hypothalamus when compared to other peripheral tissues. s pr is mainly expressed the arcuate nucleus of the hypothalamus, in the same neurons that possess stat . icv infusion of s pr activator, s p, increased jak and stat phosphorylation and the energy expenditure and reduced the food intake in lean rats. in addition, s p potentiated the effects of leptin in the reduction of food intake. conversely, the pharmacological inhibition of stat , blocked the anorectic effect of s p. interestingly, low expression of s pr was observed in the hypothalamus of ob/ob mice and wistar rats fed on high fat diet, whereas, s p infusion reduced the food consumption and increased leptin signaling and action in obese rats. these results indicate that hypothalamic s pr has a key role in the control of leptin signaling and on food intake. aim: the adifit program is an intensive -week multidisciplinary treatment program which promotes weight reduction among obese. during the first weeks behavior change, physical exercise, and nutritional counseling is offered three times a half a day per week, thereafter once a week half a day. the aim was to evaluate efficacy of the adifit program in weight reduction, and its effect on eating behavior, and body image. methods: patients were evaluated at baseline (t ) and after month (t ). bmi was assessed. psychometric instruments such as the german versions of the eating behavior questionnaire (fev), and the body image questionnaire were used at both time points. paired-sample t-test and wilcoxon signed rank test were used for statistical analyses. results: fifty patients participated, % were female. bmi was significantly reduced from t to t (mean ae sd: . ae . vs. . ae . ; t = . , p < . ). results discerned significant improvements from t to t in fkb scale (negative attitudes towards one′s own body) ( . ae . vs. . ae . ; t = À . , p < . ), and scale (restricted body dynamics) ( . ae . vs. . ae . ; t = À . , p < . ). on the other hand, fev scale (cognitive restraint of eating) improved significantly from t to t ( vs. , z = À . , r = À . , p < . ). fev scale (disinhibition) was significantly lower at t ( vs. , z = À . , r = À . , p < . ) as was fev scale (hunger) ( vs. ; z = À . , r = À . , p < . ). after weeks patients showed significant reduction in weight, improvements in body image and eating behavior. metabolic peptides in serum and plasma samples contain status information for diabetes. previously, we have demonstrated that intrinsic protease activity caused instability of plasma and serum peptides. other reports have described that metabolic peptides, including glp- , gip, glucagon, and oxytomodulin, are subject to instability caused by proteolytic and other enzymatic degradation intrinsic to plasma. the variability may result in inaccurate quantitative measurements of the peptides creating challenges when interpreting pharmacokinetic and pharmacodynamic data. using both mass spectrometry and elisa based detection methods; we investigated the instability of metabolic peptides in whole blood, serum, and plasma under a variety of routine clinic conditions. first, the same subjects blood was drawn into different blood collection devices including serum and edta, citrate, heparin, and an edta tube containing enzyme inhibitors. the metabolic peptides of interest were spiked into plasma for time incubation at different temperatures. samples were quenched and processed for both maldi-tof ms and elisa analyses. quantitative analysis of each marker was used to characterize the kinetics of the peptide digestion ie stability (halflife). further a blood collection tube was developed to minimize degradation using enzymatic inhibitors specifically for the stabilization of glp- , gip, glucagon, and oxytomodulin. the addition of specific enzyme inhibitors for stabilization of each peptide reveals more insight regarding enzymatic degradation and stabilization of the peptide biomarkers. our data clearly demonstrates the need of enzymatic inhibitors for peptide stabilization, especially in a clinical setting. ( . ae . mg/dl) . subjects underwent a standardized meal test: g of bread, a boiled egg, g of apple, in the morning after h fasting. venous blood glucose samples:before meal test (sample ), h (sample )and h (sample ) after ingestion of standardized meal. neuropathy (p = . ). women had higher prevalence of neuropathy (p = . ). people with sensory neuropathy had lower weight and bmi than those with autonomic neuropathy and those without neuropathy (p = . ). fasting blood glucose was higher in subjects with neuropathy (p = . ). value of sample was increased in people with neuropathy (p = . ). other parameters cardiometabolic risk factors were not associated with diabetic neuropathy at onset of t d. conclusions: diabetic neuropathy is a frequent complication at diagnosis of t d. people with higher fasting or postprandial glycemia may associate more frequently diabetic neuropathy at onset. m. metalla , m. carcani , g. qirjako , e. demiraj durre regional hospital, endocrinology, durre regional hospital, durres, statistical, mother teresa university hospital center, tirana, internist, durre regional hospital, durres, albania background: metabolic syndrome is a risk factor for cardiovascular diseases and is associated with abnormal cardiac structure and function. the aim of the study: to evaluate the left ventricular structure and function in patients with metabolic syndrome, without installation of diabetes mellitus or arterial hypertension. material and methods: it was analyzed a total of consecutive adults ( -{ %} males and -{ %} females) with metabolic syndrome and healthy ( -males and females) without metabolic syndrome. metabolic syndrome was defined using the atp lll criteria. assessment is done with classic echocardiography, pulsed wave doppler and tissue doppler. results: there was difference in two groups in bmi, in waist circumference, in systolic and diastolic arterial presure in total colesterol, in level of triglicerid and hdl colesterol p < . . there was no diference in age, fasting serum glucose level, lvedd, sw, pw, lvm, lvmi, lav, lvef, early trans mitral inflow (e), late trans mitral inflow (a) and in the rate e/a (p = . ). echokardiografic measurements by tdi in peak mitral anular velocity in early diastole ea were . ae . vs. . ae . cm/sec (p < . ) in the metabolic syndrome and controll grups respectively. average values of sa were significantly lower in the ms than in controll group, . ae . vs. . ae . (p < . ). the ratee/ea mitral was . ae . vs. . ae . (p < . ) in metabolic syndrome and controll group respectivly. the early identification of isolated syndrome in non diabetic, non hypertensive adults may be an indication of an aggressive preventive measure. the fasting glycaemia altered and hyperinsulinemia are strong predicting factors of type dm (dm ) and sedentary habits can lead to this disease, mainly associated with obesity. objectives: verify the influence of physical activity, vo max and anthropometric measurements on glycaemia and insulin fasting in active military over the age of of the brazilian army (ba) serving in rio de janeiro. methods: two hundred and fifty subjects (aged . ae . years), in active duty in the ba, volunteered to participate in the study. the insulin and glycemic levels were measured as well as body mass, stature and waist circumference. body fat (bf) was measured by hydrostatic weighing, when body density was obtained. vo max was measured by maximal cardiopulmonary treadmill exercise test (cpet) using an individualized ramp protocol. oxygen consumption and carbon dioxide production were measured using a cpx-d metabolic cart. results: the prevalence of type dm found was . % and afg was . %. vo max showed an inverse correlation (p < . ) with insulin levels, homa-ir and fasting glycaemia and also with anthropometric measures and %bf. the bmi and %bf presented direct correlation (p < . ) with insulin, homa-ir and fasting glycaemia. subjects in the highest quartiles of vo max and in the lowest quartiles of wc and of %gc also presented lower levels of fasting glycaemia and insulin and homa-ir. the data suggest that vo max was an inverse and nutritional state a direct relationship between glycaemia and fasting insulin. subjects with an active lifestyle have less prevalence of alterations in glycaemia and fasting insulin levels. the increase in prevalence of cardiovascular conditions, and metabolic syndrome (ms) observed in the last decades was accompanied by increase in dietary fructose (fr) consumption (also as sucrose). the aim was to assess the prevalence of fructosemia in cardiovascular patients with or without ms and to investigate the possibility of treatment of hyperfructosemia and other components of ms with oral acarbose. material and methods: fasting serum fr concentration in cardiovascular patients with metabolic syndrome (group ) and in cardiovascular patients without ms (group ) was measured by colorimetric method with commercially available biovision set. patients of the first group were treated with acarbose (glucobay, bayer) increasing the dose from to mg per day to normalize the glucose metabolism. fasting and post oral sucrose load ( g) serum levels of glucose, fr, insulin, nefas and uric acid (ua) were measured at baseline and in days. results: fasting serum fructose concentration varied widely and among patients in both groups, and was significantly higher in group ( . ae . vs. . ae . lmol/l). the data after days and weeks of acarbose use is presented in the conclusions: dyslipidaemia is found to be the risk factor for ischemic stroke in diabetic subjects, with statistically significant differences compared to nondiabetics. hdl-cholesterol was found as a protective factor for haemorhagic stroke in nondiabetic subjects. agave tequilana weber variety azul is an economically important in mexican people because it is the sole plant allowed for tequila production but because it is a potential source of prebiotics, the inulin-type agave are nondigestible/fermentable carbohydrates which are able through the modification of the gut microbiota, the pos content of agave inulin differs from inulin extracted from chicory root. the aim was to assess the efficacy and safety of inulin type agave on lipid profile in dyslipidemic obese subjects. a clinical trial, open was carried out in obese, hypertrygliceridemic and hypercholesterolemic subjects between and years old. all the subjects received g/day of inulin in the morning, during days. biochemical and metabolic profiles before and after pharmacological intervention were performed. after inulin administration, there was a significant reduction of the trygliceride concentrations ( . ae . and . ae . mg/dl; p = . ). glucose serum ( . ae . and . ae . mg/dl; p = . ), and hba c ( . ae . and . ae . % p = . ). there was not a significant reduction of total cholesterol, low density lipoprotein and very low density lipoprotein. anthropometric parameters did not change in the group and soluble fiber intake did not produce any gastrointestinal adverse effect. the increase of fiber intake (inulin type agave) are efficacy and safety to reduced trygliceride concentrations levels in dyslipidemic obese patients. stress and strain have long been associated with the work people do. we aimed to investigate occupational stress index and influence of several different work stressors on cardiometabolic risk factors: diabetes, lipid levels in hypertensive workers in south serbia methods: we studied persons (professional drivers, construction workers, production line workers and bankers): composed group with hypertension ( - years of age, majority males), were age and sex matched controls without hypertension. clinical examination was performed and blood was sampled. we analyzed work stressors by using questioners with different factors and occupational stress index (osi) was calculated with permission of dr belkic. comparison was made regarding total burden and the nature stress burden (underload, high demand, strictness, extrinsic time pressure, aversive/noxious exposures, threat-avoidant vigilance/disaster potential, conflict/uncertainty) results: diabetes was highly present in bankers ( %) and glucose levels were significantly higher in this subgroup. the incidence of diabetes in construction workers was %. total cholesterol, ldl, triglycerides were higher and hdl lower in bankers and contraction workers (p < . ) and linearly correlated with osi (p < . ). previous myocardial infarction suffered . % of bankers. total osi was significantly higher in diabetic hypertensive bankers and construction workers (p < . ), as well as high demand, strictness and extrinsic time pressure (p < . ). conclusion: hypertension appearance in working population is related to high osi, especially when other cardiometabolic risk factors added. further steps are needed to reduce the level of work stressor and provide a better quality of live in individuals. background and aim: plasma levels of adipocytokines in healthy individuals or diabetes mellitus patients have been previously reported as well as salivary levels of many adipocytokines. nevertheless, salivary levels of some adipocytokines in patients with metabolic syndrome have not been investigated. the aim of this study was to evaluate salivary and plasma levels of leptin and adiponectin in patients with metabolic syndrome. results: compared with healthy individuals, leptin levels in patients with metabolic syndrome were significantly increased, both in plasma ( . ae . vs. . ae . ng/ml, p < . ) and in saliva ( . ae . vs. . ae . pg/ml, p = . ). whereas plasma adiponectin levels were decreased significantly in patients with metabolic syndrome ( . ae . vs. . ae . lg/ml, p = . ), salivary adiponectin levels were inversely increased ( . ae . vs. . ae . ng/ml, p = . ). conclusion: this study showed that, similarly to plasma, there was an elevated change in salivary leptin levels in patients with metabolic syndrome compared to healthy individuals. however, for salivary adiponectin levels, the opposite result to plasma adiponectin levels was revealed. replacing saliva to plasma for detecting altered leptin and adiponectin should be concerned in patients with metabolic syndrome. objective: to examine dietary intake in family members with diabetes type (dt ) to identify contributing factors to glycemic control and development dt . design: descriptive and prospective study involving members of families who provided food intake from days, weeks days and weekend day. inclusion criteria were proband member diagnosed with dm with ! siblings and living parents. methods: data were collected at the participants' homes or at the university clinic. the biometric measures were glucose and hemoglobin glucose (hba c). data was entered into nutritional data system to research, the "gold standard" for nutritional analysis. also, the data entry into spss v was done. : of , ( % women, mean age . ae . ; , mean blood glucose . mg/dl ae . ; - and mean (hba c) . % ae . ; . preliminary data indicate intake total fat was higher than the recommendations % of participants, while carbohydrate intake was higher in %. method: this was a retrospective, observational study of consecutive cardiac bypass patients that underwent surgery at sultan qaboos univesity hospital in muscat, oman, between and . analyses were performed using descriptive statistics. the study included a total of cardiac bypass surgery patients with an overall mean age of ae years and % ( / ) were males. mean body mass index was kg/m ranging from to kg/m . twenty-seven percent of the patients were either past or current smokers while % ( / ) had a family history of coronary artery disease. all but of the patients ( %) were on statins pre-op. the most prominent co-morbidities were hypertension ( %), angina ( %), diabetes mellitus ( %), myocardial infarction ( %), and congestive heart failure ( %). the mean average pre-op total cholesterol, low-density lipoprotein cholesterol (ldl-c), high-density lipoprotein cholesterol (hdl-c), triglycerides, apolipoprotein a (apo a ), and apolipoprotein b (apo b) were . ae . mmol/l, . ae . mmol/l, . ae . mmol/l, . ae . mmol/l, . ae . g/l, and . ae . g/l, respectively. eighty-one percent, %, and % of the patients had or or diseased heart vessels, respectively. there was a total of %, %, and % of the patients that had on-pump, off-pump, and on-pump beating coronary artery bypass surgeries, respectively. mortality was recorded in two patients ( %) in an approximately -year period. conclusions: patients undergoing cardiac bypass surgery were observed with a high prevalence of cardio-metabolic risk factors. aim: to evaluate the association between osteocalcin and phenotypic characteristics of metabolic syndrome. material and methods: data of children and adolescents participants of the project "health worker cohort study" was analyzed. to each participant we determined: insulin, glucose, triglycerides, hdl, waist circumference and blood pressure. glucose and insulin were evaluated by glucose-oxidase method and homa. total osteocalcin concentration was determined by chemiluminescence. body mass index (bmi) was evaluated according to cdc chart′s for children and adolescents according to age and sex. using multiple lineal regression and logistic regression we evaluated the association between osteocalcin values and components of metabolic syndrome. results: the proportion of male in the study population was . %. the prevalence of overweigh and obesity was . % and abdominal obesity was . %. the proportion of elevated glucose, hypertriglyceridemia, low levels of hdl, hypertension and metabolic syndrome were . %, . %, . %, . % and . % respectively. difference of medians according to ages groups, was observed for glucose, insulin, homa and osteocalcin (p < . ). the study showed a negative correlation between bmi, fat percentage, waist circumference, glucose levels and crp with ostelcalcin levels (p < . ). conclusions: serum osteocalcin levels were associated with some phenotypic characteristics of metabolic syndrome and measures of adiposity. background: previous studies show that hyperuricemia precede the development of the metabolic syndrome and can be a risk factor to diabetes type , cardiovascular disease and heart failure, independently of obesity. aim: to identify the association between hyperuricemia and cardiovascular risk factors (crf). the study population included adolescents, all of them participants from the "cohort study of health workers". crf were evaluated according to idf pediatrics criteria. the cut-off points for hyperuricemia was levels of uric acid > mg/dl, for hyperinsulinemia > mu/l, insulin resistant (ir) have homa > . . a multivariate regression analyses was used to evaluate the association between hyperuricemia and crf. resultados: the proportion of female in the study population was %. mean age was ae . years, prevalence of bmi >p was %, abdominal obesity ( . %), hypertension ( . %), hyperuricemia ( . %), glucose ! ( . %), hypertrigliceridemia ( %), low levels of hdl ( %), hyperinsulinemia ( %), ir ( %), crp ( . %) and ms ( . %). proportion of hyperuricemia was six times higher in men, ( vs. . , p < . ). the study show association between hyperuricemia and age (or: . ;ic % . - . ), hypertrigliceridemia (or: . ;ic % . - . ) hyperglucemia (or: . ;ic % . - . ), hyperinsulinemia (or: . ;ic % . - . ), ir (or: . ;ic % . - . ), abdominal obesity (or: . ;ic % . - . ) and ms (or: . ;ic % . - . ). conclusions: hyperuricemia is associated to crf. hyperuricemia is not considered for adolescent health diagnostic. however early diagnostic is important for avoid the presence of several crf. method: pancreas of fetuses and offspring from diabetic and nondiabetic sprague-dawley rats were obtained and processed for histological and morphometric studies and for inmunohistochemical analysis of pdx. , insulin and glut . results: fetuses of diabetic mothers, showed a significant delay in the morphogenesis of the islets, with a significant reduction of the diameter, area and beta cell mass and expression of pdx , insulin and glut . these fetal alterations had an impact on postnatal life and offspring of diabetic rats had significantly higher glucose levels. in offspring of days, the alterations persisted and the expression of insulin and glut was significantly lower. at days the islets were mature but the size, beta cell mass and expression of insulin, glut and pdx. were still significantly lower. at days the structure of the islets was normal, but the reduction in size, beta cell mass and expression of glut persisted, but with no significant reduction in the expression of insulin and pdx. conclusions: in utero hyperglycemia induced a delay on the differentiation of beta cells and morphogenesis of islets, a reduction of the beta cell mass and in the expression of insulin, glut and pdx. . these alterations persisted up to adulthood causing hyperglycemia to offspring. g. yoshino , t. an , s. nakano , k. kuboki center for diabetes, shinsuma general hospital, kobe, division of diabetes, metabolism and endocrinology, department of internal medicine, toho university, tokyo, japan background and aim: it has been a matter of debate whether the intervention is necessary even for elderly metabolic syndrome subjects. present study is therefore conducted to explore whether the elderly subjects with metabolic syndrome show increased cad risk measuring plasma small, dense ldl-cholesterol, hs-crp and plaque score of the carotid artery. methods: a total of subjects including male ranging from to years-old, were recruited for this study. they are divided into four groups according to their age (below and above years-old) and an association of metabolic syndrome. blood sampling was done after overnight fast. small, dense ldl-cholesterol was measured employing direct assay method. results: in the non-elderly subjects, plasma triglyceride, small, dense ldl-c, hs-crp and plaque score of carotid artery were all increased in the metabolic syndrome group compared to that of non-metabolic group, while there was no significant difference in either hs-crp or the plaque score between the two groups within elderly subjects. within the elderly metabolic syndrome group, subgroup with type diabetes had higher fasting blood glucose, hs-crp, small, dense ldl-c and plaque score than the subgroup without type diabetes. conclusion: metabolic syndrome is an important factor for progression of subclinical atherosclerosis in the non-elderly subjects, but it cannot be a significant determinant of subclinical atherosclerosis if the subjects are limited within elderly group without type diabetes. thus, intervention for metabolic syndrome may not be obligatory for elderly metabolic syndrome subjects if they are not diabetic. methods: a retrospective cross-sectional study of randomly selected patients on antihypertensive drugs at the outpatient clinic at sultan qaboos university hospital, muscat, oman. the recorded variables included age, gender, history of diabetis mellitus, weight, fasting blood glucose, creatinine level, systolic blood pressures (sbp), diastolic blood pressure (dbp), and type of medication. all parameters were collected of the last two visits from (january and december ) for each patient who had been labeled with persistent hypertension using the hospital information system (his). analyses were conducted using descriptive statistics. results: overall mean age of the cohort was ae years, % were male, % were diabetic, mean sbp ae , dbp ae , weight ae , and fbg . ae . on visit , % were on b-blockers, % patients were on calcium channel blocker, % on angiotensinconverting enzyme inhibitor and % were on diuretics either as a monotherapy or in combination. target bp was attained in . % patients with diabetes mellitus compared to . % in non diabetics after the second visit. the mean body weight in patients with controlled hypertension was . kg compared to . kg in patients with uncontrolled hypertension. the study showed that diabetes mellitus, increased body weight and high fasting blood glucose reduces the attainment of blood pressure goal in patient on antihypertensive therapy. purpose: comparable evaluation of lipid profile and inflammatory markers between patients with stable angina (sa) and patients with sa and diabetes mellitus of type (dm). material and methods: a total of patients with sa (mean age . ae . years) with coronary stenosis < % were examined. group i included patients with sa and dm; group ii - patients with sa without dm. lipid profile parameters; inflammatory markers (hs-crp, tnf-alpha, homocysteine, interleukine β, , ; scd l, mmp- , timp- ); endothelial dysfunction markers (endothelin- , nitrites) were measured initially and in year. results: there were high levels of hs-crp, tnf-alpha, lipoprotein (a), mmp- , triglycerides, and endothelin- in both groups. the level of timp- reduced in both groups. patients in group had significantly elevated levels of total cholesterol, ldl cholesterol, homocysteine, apo-b, apo-b/apo a- ratio, il- β. in group the following positive correlations were found: between glycohemoglobin and apo-b, apo-b/apo a- ratio, homocysteine; il- and hs-crp; homocysteine and ldl cholesterol, mmp- , duration of coronary artery disease; endothelin- and scd l, tnf-alpha. reliable increasing homocysteine, tnf-alpha mmp- , ldl cholesterol were revealed in both groups. conclusions: prospective study showed that both groups had similar blood biochemical abnormalities. however in patients with dm there was an increase in the levels of atherogenic lipid fractions as well as homocysteine, tnf-alpha and mmp- which may indicate a higher risk of developing coronary events even in the absence of significant coronary stenosis. objectives: il- is a pleotropic cytokine and is reported to be involved in various inflammatory and immune-mediated disorders. previous data in apo e-/-mice demonstrated that il- accelerates atherosclerosis via ifn-c and cxcl expression and the effect was independent of t-cells. we therefore investigated whether il- is involved in cholesterol efflux and plaque stability. methods: two groups of chow-diet-fed, male apolipoprotein e-/mice, aged weeks (n = /group) were fed a normal diet and injected intraperitoneally for days with either recombinant il- ( ng/g/ day) or with phosphate buffer saline (pbs). mrna expression of il- , scavenger receptor cd , mmp- and lxr-a genes was determined by real-time pcr. immunohistochemistry was also performed for expression of above genes. results: il- administration led to a significant increase in serum cholesterol and lipoproteins except hdl-c which was decreased. in heart and aortic tissues, expression of il- , scavenger receptor cd and mmp- genes increased . , and fold respectively, whereas expression of lxr-a gene was reduced by . fold. atherosclerotic lesion size was quantified in the ascending aorta and the aortic arch. exogenous il- administration significantly increased frequency of atherosclerotic lesions and lesion area in il- treated mice vs. control animals ( . ae . % vs. . ae . % (p < . ; pbs vs. il- group). the observed data strongly implicates il- as a proatherogenic and proinflammatory molecule which not only enhances inflammation but augments cd and mmp- expression which may lead to enhanced foam cell formation and plaque instability and thereby aggravate atherosclerosis. objective: the present study was attempted to found the association between tnf-a promoter gene g- a polymorphism with metabolic syndrome and insulin resistance. the g- a tnf-a polymorphism has been studied in subject with metabolic syndrome according to ncep atp iii criteria (age . ae . ; bmi . ae . ) and healthy control without metabolic syndrome (age . ae . ; bmi . ae . ). the g- a variant was detected by pcr amplification and nco- digestion. furthermore insulin resistance, serum leptin and tnf-alpha levels were also measured in both the groups. polymorphism was significantly less frequently observed in the control population as compared to study group. furthermore, on dividing the subjects into two groups according to the absence (homozygous for the wild type g allele) (tnf- allele) or presence of the mutant a (tnf- ) allele, significantly high levels of tnf-a (p = . , or = . , % ci = . - . ) and leptin (p = . , or = . , %ci = . - . ) were observed in tnf- group as compared to tnf- group. whereas, there was a non-significant tendency toward insulin resistance in the tnf- group. conclusions: our results suggest that the g- a mutation of the tnf-a gene is likely to play an important role in the development of metabolic syndrome and metabolic abnormalities. metabolic syndrome is associated with residential-area crime rates for men and perceived crime for women: gender differences in social vulnerability to metabolic syndrome introduction: crime rates and perception of crime within neighbourhoods have been linked to residents' cardiometabolic outcomes. men and women vary in their perception of crime but share exposures to residential-area crime. it is unclear whether gender differences exist in the nature of crime-related vulnerability to metabolic syndrome. aim: to assess gender-specific associations between perceived and reported crime, and metabolic syndrome (mets) methods: cross-sectional data from a biomedical cohort study of adults randomly selected from the north-west region of adelaide, south australia, were analysed (n = . ) (mean age = . , standard deviation = . ). clinically measured mets was defined using international diabetes federation criteria. perceived crime was expressed as a standardised factor score reflecting six items related to neighbourhood safety and crime. reported crime rates were obtained from police data, aggregated at the statistical local area level (n = ) and standardised. associations were evaluated using multilevel regression models accounting for area-level clustering and covariates including area-level income and participant sociodemographic factors. results: the prevalence of mets was, for men (n = ), . % ( % ci = . - . ), and for women (n = ), . % ( %ci = . - . ). for men, mets was associated with rates of violent crime (or = . , %ci = . - . ) and total crime (or = . , % ci = . - . ), but not perceived crime. for women, mets was associated with perceived crime (or = . , %ci = . - . ), but not reported crime. conclusions: crime is an adverse social exposure. mets is associated with perceived crime in women and reported crime rates in men. these differentials suggest gender-specific causal pathways by which awareness and perception of adverse social exposures relate to mets independent of socioeconomic factors. background: epidemiological studies suggest that the resting heart rate (rhr) is an independent predictor of cardiovascular and all cause mortality. however, the power of the rhr to predict cardiovascular events in patients with the metabolic syndrome (mets) is not known. methods: we prospectively investigated the relationship between rhr and cardiovascular events in consecutive patients undergoing coronary angiography for the evaluation of coronary artery disease (cad) over a follow-up period of . ae . years. the mets was defined according to ncep-atpiii criteria. results: in the total study population, both all cause and cardiovascular mortality were increased with an increasing rhr (standardised adjusted hrs . [ . - . ]; p = . and . [ . - . ]; p = . , respectively). from our patients, ( . %) had the mets and did not have the mets. among patients without the mets, a higher baseline rhr indicated a significantly higher risk of total mortality (h = . [ - . ], p = . ) and cardiovascular mortality (hr = . [ . - . ], p = . ) after multivariate adjustment. however, the rhr did not significantly affect total mortality (p = . ) or cardiovascular mortality (p = . ) in patients with the mets. interaction terms rhrxmets were significant for both total and cardiovascular mortality (p = . and p = . , respectively), indicating that the respective risks conferred by a high rhr were significantly higher in patients without the mets than in patients with mets. conclusion: we conclude that among angiographically characterized coronary patients, the metabolic syndrome status significantly affects the association of the rhr with total and cardiovascular mortality: rhr is a strong predictor of both total and cardiovascular mortality among subjects without the mets, but not among mets patients. aim: to estimate influence of diet therapy, physiotherapeutic treatment to body mass reduction and prevention of cardiovascular and metabolic risks. patients and methods: were surveyed patients with a metabolic syndrome aged of - years: women ( %) and men ( %): ( %) pts were overweight, ( %) pts had bmi . ae . kg/sq.m, pts ( %) -bmi . ae . kg/sq.m. % pts had hypercholesterolemia, % -glucose intolerance, % -high arterial blood pressure. all patients were undergone by the assessment of nutrition status, biochemical researches. there was executed food allowance correction and added complex of physiotherapeutic treatment. control examination was carried out in weeks by body structure definition by bioimpedance analysis and biochemical blood tests. results: there were noted that level of cholesterol decreased from . ae . mmol/l to . ae . mmol/l (p . ), level of blood glucosefrom . ae . mmol/l to . ae . mmol/l. there was registered decreasing systolic arterial pressure of % of patients to . ae . mmhg (p . ) and diastolic at % pts -to . ae . mmhg (p . ). there were fined reduction of a fatty component on . ae . by kg, with preservation of active cellular weight - . ae . in kg (p < . ) in patients. conclusions: physical exercises, physiotherapeutic procedures jointly balanced food allowance promote more considerable decrease in weight of body and decrease in cardiovascular and metabolic risks. results: after adjustment for sociodemographic and lifestyle factors, the relative risk (rr) of pd comparing subjects with metabolic syndrome to those without it was . and the % confidence interval ( % ci) . - . . this association was especially due to high serum triglyceride levels ( ! . vs. < . mmol/l, rr . , % ci . - . ), and high plasma glucose levels ( ! . vs. < . mmol/l, rr . , % ci . - . ). the results remained after excluding the first years of the follow-up. after this exclusion and further adjustment for other components of the metabolic syndrome, the suggestive association between pd and bmi was strengthened ( ! kg/m vs. < kg/m , rr . , % ci . - . ). conclusions: high serum triglycerides and plasma glucose levels predicted low pd incidence, even after excluding the presumable preclinical disease phase. also, the suggestively increased pd risk in subjects with high bmi varied according to the follow-up time, proposing that an adequate time period should be considered to account for the preclinical disease phase in pd. pancreatic intrinsic nervous system (pins) maturation goes on postnatally and is involved in the control of pulsatility and amplitude of insulin secretion (is), both altered in obese and diabetic patients. the aim of our study was to determine the impact of obesity in infancy on pins maturation and control of is. c bl/ j mice aged weeks received a normal (nd) or a western diet (wd) for weeks. weeks old mice were used as initial controls (t ). after sacrifice, pancreases were placed in organ incubators for h. the impact of pins upon is was studied by adding to the culture the nicotinic receptors agonist dmpp in presence or absence of l-name (inhibitor of nos) or snp (no donor). insulin was assayed in culture supernatants. pins density and phenotype were determined by ihc. pins density was less in nd compared to t mice, whereas there was no difference between wd and t mice. cholinergic innervation significantly increased with age in both wd and nd mice whereas nitrergic innervation increased in nd mice and decreased in wd. pins stimulation by dmpp induced a time-dependent increase in is, significantly larger in nd compared to wd mice. is profile was identical in wd and t mice. addition of l-name inhibited dmppinduced is in nd mice while snp tended to reduce it. neither l-name nor snp altered is in wd mice. our study suggests that wd induces neuroplastic changes in the pins that could be involved in pancreatic dysfunctions observed during obesity. purpose: inflammation drives the progression from central obesity to insulin resistance, metabolic syndrome and hypertension. whether inflammation caused by allergic diseases such as allergic rhinitis can predispose to hypertension is controversial. therefore, we studied the association between hay fever and hypertension in the united states national health and nutrition examination survey (nhanes). we analyzed data on men and women in nhanes nhanes - . we included participants aged years or older who had valid data on hay fever and hypertension. results: . % of the participants had a previous diagnosis of hay fever and . % of them had hypertension. there were ethnic differences in the prevalence of previous hay fever diagnosis (p < . ) and hypertension (p < . ). overall, there was no significant association between previous hay fever diagnosis and hypertension. in women aged - , there was an association between previous hay fever diagnosis and hypertension (or = . , % ci = . - . , p = . ). this association was not diminished after adjustment for age, race and body mass index (or = . , % ci = . - . , p = . ). after further adjustment for physical activity, alcohol consumption, smoking, liver enzymes, c-reactive protein and ige level, the association remained significant (or = . , %ci = . - . , p = . ). conclusions: in this nationally representative population-based survey, previous hay fever diagnosis is not significantly associated with hypertension in adults, except for women aged - . further work is needed to confirm that this is a true association. the university of hong kong, hong kong, hong kong s.a.r. objective: beta- microglobulin (b m) is the light chain of the major histocompatibility complex class molecule. glycation of b m renders it toxic. serum b m level predicts mortality in chronic kidney disease and some malignancies such as multiple myeloma. we hypothesized that it also predicts mortality in people with diabetes. research design and methods: participants of the third national health and nutrition examination survey aged or above who had diabetes or were on medication for diabetes were included in the analysis. results: during a median follow-up of . years (range . - . years) and . person-years, ( . %) and ( . %) participants died from diabetes-related causes and all causes, respectively. tertile of b m was significantly associated with allcause (hazard ratio (hr) = . , % ci: . - . ) and diabetesrelated mortality (hr = . , % ci: . - . ). the association was independent of cardiometabolic risk factors, cancer, microalbuminuria and impaired glomerular filtration rate. conclusions: serum b m level is a novel independent predictor of diabetes and all-cause mortality in people with diabetes. an elevated level is associated with a substantially increased risk of death. metabolic syndrome (ms) refers to a constellation of factors that increase risk of cardiovascular diseases (cvd) and diabetes. insulin resistance and associated abnormalities is considered to be a link between obesity and cvd. our ongoing study investigates relationship of anthropometric, metabolic and cardiovascular parameters in young patients with incipient ms (young lean subjects with essential hypertension; ht) and obese otherwise healthy subjects (ob) in comparison to healthy lean controls (c) similar for age and sex. methods: all subjects underwent the oral glucose tolerance test. the insulin sensitivity index according matsuda (isimat) and ir homa were calculated. fasting serum concentration of total cholesterol (tchol), hdl cholesterol, triglycerides (tg), and uric acid as well as fasting and post load plasma glucose and insulin concentrations were measured. results: young lean ht patients had comparable bmi but higher body fat percentage (p = . ), higher fasting plasma insulin (p = . ), slightly higher uric acid (p = . ), and higher t-chol (p = . ) than c. despite ngt, ht patients had lower isimat (p = . ) and higher ir homa (p = . ) than controls., but these parameters were comparable to the ob group. / of young lean ht patients similarly to ob otherwise healthy subjects exhibited three and or more features of ms. conclusions: young lean patients with hypertension displayed signs of insulin resistance comparable to obese subjects and metabolic abnormalities typical for metabolic syndrome. early life style interventions might prevent theto development of complete ms in these young ht and ob subjects. increased prevalence of overweight in male patients, whereas women had increased prevalence of obesity (grade ii and iii). hypertensive diabetic subjects with other metabolic risk factors are more prone to microvascular and macrovascular complications. methods: eighty-six patients were divided into two groups. the group included subjects (mean age . ae . years) with ah and ao (mass body index (mbi) . ae . kg/m ) and the group - subjects (mean age . ae . years) without metabolic disorders. the parameters of -hour bp monitoring; microalbuminuria and mdrd; total cholesterol, low-density lipoprotein cholesterol, highdensity lipoprotein cholesterol, triglyceride, diene conjugates (dc), malonic dialdehyde (md), catataze and inflammatory markershomocysteine, high-sensitivity c-reactive protein (hs-crp) and fibrinogen were estimated. results: in group there was registered increase in mean -h and daytime systolic bp, time and square indices, in night time systolic and diastolic bp variability. in renal function factors there was registered increase mdrd. in biochemical parameters there was detected increase in total cholesterol, triglyceride level, md and dc level, fibrinogen and hs-crp level; and decrease of catalase level; high density lipoprotein cholesterol compared to group . besides in group positive correlation between lipid and inflammatory markers against each other and with parameters of -h bp monitoring, microalbuminuria, mdrd and mbi was found. conclusion: we revealed relationship between blood pressure profile parameters, renal function parameters, atherogenic lipid profile parameters, inflammatory markers and mbi, that is indicative of development of cardiovascular and cardiorenal risk in patient with ah and ao. there is considerable interindividual variation in therapeutic response to metformin in women with pcos and obesity. genetic factors may play an important role in therapeutic response to metformin and tcf l gene could be one of such factors. tcf l marker is one of the strongest risk factors known for predicting increased likelihood of conversion from prediabetes to t d. tcf l belongs to a subfamily of tcf -like hmg box-containing transcription factors. tcf l is a component of the wnt-signaling pathway and determine the glucoseinduced insulin secretion and regulates the maturation of β-cells of the pancreas from pluripotent stem cells. in addition, this gene plays an important role in adipogenesis and differentiation of adipose tissue. the aim of our study was to evaluate the efficacy of using metformin in patients with pcos and obesity in relation to their rs polymorphism of the tcf l gene. patients with pcos and obesity receiving therapy with metformin were examined. comparative analysis revealed a significant increase in the frequency of genotype c/t (v = . ; p < . ; or = . ; % ci = . - . ) and t/t (v = . ; p < . ; or = . ; % ci = . - . ) in the group of patients with positive dynamics of treatment with metformin compared with the group without positive dynamics of treatment. thus, patients with pcos and obesity who possess the genotype c/t and t/t of the tcf l gene are more likely to have positive therapeutic response to metformin. objective: to investigate the relationship between resistin gene polymorphism with its circulating level, metabolic risk factor and insulin resistance in adult women. design: total healthy subjects were enrolled for the study, (age . ae . years) were with metabolic syndrome and were age matched control (age . ae . years) without metabolic syndrome. circulatory resistin, insulin, plasma glucose and lipid profiles fasting level were estimated along with insulin resistance. resistin-c g promoter region polymorphism were done by rflp method digested with bbsi restriction enzyme. results: homozygous mutant genotype (cc) (cc v/s cg + gg) (p = < . : or = . : % ci = . - . ) of the c/g resistin gene polymorphism was significantly less frequently observed in the control population. on dividing the subjects further in to two groups according to the abscence (resistin- ) and presence (resistin- ) of the mutant g allele, significantly high levels of resistin (p = . , or = . , % ci = . - . ), triglyceride (tg) (p = . ), plasma glucose (p = . ), systolic blood pressure (sbp) (p = . ), diastolic blood pressure (dbp) (p = . ), whr (p = < . ) were observed in resistin- group . conclusion: our results conclude that the c/g mutation of the resistin gene is likely to play an important role in metabolic syndrome and metabolic abnormalities. background: in both obesity and allergy, inflammation occurs. therefore, we examined the association between body mass index (bmi), a measure of general obesity, and serum ige level, a measure of allergy. excluded from this study. using the complex sampling function of spss, the unstandardized regression coefficient, b, for the relationship between bmi and the natural logarithm of ige level was calculated. results: there was a sex difference in ige level (p < . ). before adjustment, ige was associated with bmi in women (b = . , p = . ) and in the overall population (b = . , p = . ). after adjusting for race/ethnicity, age and sex except in sex-specific analysis, the association in women (b = . , p = . ) and the overall population (b = . , p = . ) remained significant. after further adjustments for physical activity, alcohol consumption and smoking, the association was still significant in women (b = . , p = . ) and the overall population (b = . , p = . ). the association was attenuated but remained significant in women (b = . , p = . ) and the overall population (b = . , p = . ) after further adjustment for levels of liver enzymes and c-reactive protein. conclusions: in this nationally representative population-based survey, ige level is associated with bmi. the attenuation in the association after controlling for liver enzymes and c-reactive protein suggests that hepatic inflammation accounts for some of the association. background: janus kinase (jak) is involved in cytokine receptormediated intracellular signal transduction. inhibition of jak protects beta-cells from cytokine toxicity and has been shown to delay the onset of diabetes in the mouse model. the influence of jak single nucleotide polymorphisms (snps) on diabetes risk or on diabetesrelated metabolic traits is unknown. methods: we therefore investigated the association of jak tagging snp rs (c>t) with metabolic phenotypes and type diabetes (t dm) in a cohort of coronary patients including non-diabetic subjects and patients with t dm, totally comprising individuals. results: among non-diabetic subjects snp rs was significantly associated with hba c (cc: . ae . , ct: . ae . , tt: . ae . %; p = . ), fasting glucose (cc: . ae . , ct: . ae . , tt: . ae . mmol/l; p = . ), and hdl-cholesterol (cc: ae , ct: ae , tt: ae mg/dl; p = . ), as well as with total cholesterol (cc: ae , ct: ae , tt: ae mg/dl; p = . ) and ldl-cholesterol (cc: ae , ct: ae , tt: ae mg/dl; p = . ). in patients with t dm, the jak variant was significantly associated with fasting glucose (cc: . ae . , ct: . ae . , tt: . ae . mmol/l; p = . ). the association between snp rs and t dm did not reach statistical significance (allelic odds ratio = . [ . - . ]; p = . ). we conclude that jak tagging snp rs is significantly associated with phenotypes conferring an increased cardiometabolic risk, at least in non-diabetic coronary patients. the association between rs and the risk of t dm warrants further investigation. l. garrido-s anchez , x. escoté , l. coín-aragü ez , j.c. fren andez-garcía , r. el bekay , j. background: munc c is associated to glucose metabolism and could play a relevant role in the insulin resistance. however, little is known on the regulation of munc c expression. we analyze munc c gene expression in human visceral (vat) and subcutaneous adipose tissue (sat) and their relationship with obesity and insulin. we evaluated subjects distributed in non-obese lean subjects, overweight subjects, obese subjects and nondiabetic morbidly obese patients ( with low insulin resistance and with high insulin resistance). results: the lean, overweight and obese persons had a greater munc c expression in adipose tissue than the morbidly obese patients (p < . ). vat and sat munc c correlated negatively with weight (p = . , p = . ) and bmi (p = . , p = . ). vat munc c correlated negatively with glucose (p = . ). sat munc c correlated negatively with insulin (p = . ) and homa-ir (p = . ), and was the main determinant of the improvement in homa-ir index at days after bariatric surgery (b = À . , p = . ). sat explants cultures show that insulin produced a significant down-regulation of munc c expression (p = . ). this decrease is also obtained when explants are incubated with a liver x receptors alpha (lxra agonist, either without (p = . ) or with insulin (p = . ). however, munc c expression is not affected when explants are incubated with insulin plus a sterol regulatory element-binding proteins- c (srebp- c) inhibitor (p = . ). conclusions: munc c gene expression in human adipose tissue is down-regulated in obesity and is inversely associated with insulin resistance. insulin may have an effect on the munc c expression, probably through lxra and srebp- c. lab., faculty of medical technology, endocrin, tripoli-university of medical sciences, biochemstry, cdc, biotechnology, research centre, tripoli, a protective factor for obesity, type- diabetes mellitus (t dm), polycystic ovary (pcos), and lacunars infarction. objectives: the objective of this study was to investigate the association between this polymorphism and t dm, gestational diabetes (gdm), and obesity. methods: genotyping was achieved by pcr-relp in individuals chosen randomly from the out patient's clinics of al-jala maternity hospital of tripoli and gharian hospital, including: t dm patients, gdm patients, obese, healthy control individuals from libyan pregnant women population (north-west region). the results revealed that this polymorphism has no association with t dm, gdm, and obesity in comparison with the control sample. conclusion: t a polymorphism of sorbs gene is not associated with the pathological conditions studied. r. parhimovich, n. konovalova, r. tishenina, n. mylov moscow regional research clinical institute named after m.f. vladimirskiy, moscow, russia area ( . ) of bmi ! . kg/m (bmi ) had significant larger areas than those of wcm ( . ). wci and bmi had good sensitivity ( . % and . %). wci and wci had good specificity ( . % and . %) and classification ( . % and . %). the proposed cutoff values were wci . further cohort study is needed to confirm these values. for national reference, we recommend measuring at umbilical due to its feasibility. servicio de endocrinologia y nutricion, hospital regional universitario carlos haya, ciberdem, servicio de cirugía, hospital regional universitario carlos haya, m alaga, spain introduction: the fndc gene encodes a membrane protein which is proteolytically cleaved, glycosylated and secreted into the blood as irisin. it has been described that causes a significant increase in total body energy expenditure, reduces body weight and improves dietinduced insulin resistance in mice. however, little is known in human. the aim of this study was to analyze the irisin levels in morbidly obese subjects undergoing bariatric surgery at baseline and months after surgery. material and methods: we measured serum irisin levels in morbidly obese subjects undergoing roux-en-y gastric bypass and in healthy controls. we have analyzed anthropometric variables and the level of insulin resistance with the homa-ir index. results: morbidly obese patients have a lower serum irisin levels that control subjects ( . ae . vs. . ae . ng/ml, p = . ). serum irisin levels were similar before and after bariatric surgery in morbidly obese subjects ( . ae . vs. . ae . ng/ml; p = . ). there were no significant differences between morbidly obese subjects according to the homa-ir levels, neither before nor after surgery. irisin levels correlated negatively before surgery with glucose (p = . ), triglycerides (p = . ), cholesterol (p = . ), homa-ir (p = . ) and waist to hip ratio (p = . ). in a multiple lineal regression model, irisin levels were associated with waist to hip ratio (p = . ) after adjusting for fasting glucose, cholesterol, triglycerides, homa-ir and age. no significant correlations were found at months after surgery. conclusions: irisin levels in decreased in morbidly obese subjects and is mainly related to waist to hip ratio. results: the level of uric acid increased with age in women and had a significant difference in women of - years (r = . , p < . ). in men, the maximal level of uric acid was in the group - years. incidence of hyperuricemia among women was %, in men - %. we determined that the highest level of triglyceride, cholesterol, systolic and diastolic pressure was among women and men with hyperuricemia. the higher level of uric acid was found in patients with maximal body mass index (bmi > ). incidence of hyperuricemia among women in the i group was . %, in ii - . %; in iii - . %, in iv - . %. conclusions: it was determined that the level of uric acid was increasing with age and the highest level of some components of metabolic syndrome (triglyceride, cholesterol, systolic and diastolic pressure) was among patients with hyperuricemia. introduction: cushing's disease (cd) is the most common reason of endogenous hypercortisolaemia. the cortisol excess leads to serious metabolic and cardiovascular complications which significantly increase the morbidity and mortality in cd. objective: to assess the prevalence of preoperative glucose homeostasis alterations in cd and their influence on the effectiveness of surgical treatment. material and methods: a prospective study that included patients ( women; six men) with cd. the prevalence of prediabetes (impaired fasting glucose, impaired glucose tolerance) and overt diabetes was assessed. the relationship was evaluated between duration of cd symptoms and the presence of glucose homeostasis alterations as well as their impact on the efficacy of surgical treatment for cd. the proportion in the study group of overt diabetes was . %, whereas the prevalence of prediabetes was . %. . % of patients were obese (bmi ! ) and additional . % were overweight (bmi ! ). there was confirmed the association between duration of cd symptoms and occurrence of diabetes (p < . ) and any type of glucose homeostasis alterations (p = . ). there was no relationship confirmed between the presence of glucose homeostasis alterations and efficacy of transsphenoidal surgery for cushing's disease. conclusion: a longer duration of cd symptoms was associated with greater risk of metabolic complications such as: prediabetes and secondary diabetes. the efficacy of surgical treatment for corticotroph adenoma does not depend directly on the presence of preoperative glucose homeostasis alterations. objective: the study objective was to identify factors associated with depressive symptoms in elderly with metabolic syndrome. material and methods: it was a case-control study to check sociodemographic and lifestyle influencing depressive symptoms in elderly patients with metabolic syndrome. the cases were attended in program family health strategy, classified as having metabolic syndrome and depressive symptoms and the control group consisted of individuals with metabolic syndrome who didn′t have depressive symptoms. it was used as a measure of association, odds ratio (or) with confidence interval of % and p-value, obtained by conditional logistic regression model. conclusions: in the population studied showed that depression was associated with individuals at higher stress levels, those who had shown the mourning, elderly older than years, those with cognitive deficits and negative perception of health. the results reinforce the need to train health professionals so that they can identify and intervene in this population, to improve the quality of life for seniors. introduction: vascular endothelial growth factor (vegf) is said to play key role in pathogenesis of diabetic nephropathy by upregulating the expression of endothelial nitric oxide synthase (enos). human vegf gene, located on chromosome and is highly polymorphic. insertion/deletion (i/d) polymorphism of the bp fragment at position of the promoter region of vegf gene has been implicated in many diseases of angiogenic origin. aim of the study: to investigate i/d polymorphism of vegf gene in patients with type diabetes mellitus and to assess their possible role in diabetic nephropathy. materials and method: fifty subjects with diabetic nephropathy, subjects with diabetes mellitus without nephropathy and normal controls were evaluated for i/d polymorphism of the bp fragment at position of the promoter region of vegf gene by polymerase chain reaction. the frequency of vegf alleles and genotype distribution were compared in diabetic subjects, diabetic nephropathy subject and control groups. results: distribution of vegf genotype was found to be significantly (p < . ) different amongst diabetic nephropathy subjects, diabetic subjects and controls by fisher's exact test and chi square test. statistically significant association (p < . ) of d allele was also found with diabetic nephropathy. conclusion: our study shows that i/d polymorphism of the bp fragment at position of the promoter region of vegf gene is associated with diabetic nephropathy. university of delhi, new delhi, india between bai, bmi and percent body fat (pbf) in an endogamous population of india. design: data was collected on adults with respect to bodyweight, height, skinfolds, hip and waist circumference, and blood pressure. pearson correlations was calculated for bai and bmi with pbf. differences in correlation for baivsbmi were examined using fisher z-tests. receiver operating characteristic (roc) analysis was used to compare the predictive validity, and to determine optimal cut-off values. ors were calculated to assess the risk of having hypertension using the proposed cut-off points. results: the correlation of pbf with bmi (men: r = . ; women: r = . ) were stronger than those with bai (men; r = . ; women: r = . ). the regression model for bai explained . % of the variance in pbf in men and . % in women whereas the corresponding regression model for bmi explained . % variance in men and . % in women. in men, the sensitivity and specificity of bai to predict hypertension was higher than wc, whr and whtr but lower than bmi. in women, the sensitivity of bai was higher than bmi and wc. in men, odds of hypertension on bai were lower than other anthropometric markers while in women, it was higher for other anthropometric markers. conclusions: bai can be used as an additional marker for screening population, however its validity needs to be demonstrated on other populations too. obesity is a multifactorial syndrome characterized by a chronic state of positive energetic balance. the experimental model of treating neonatal rats with monosodium l-glutamate (msg) was used. amino acids, which also participate in the formation of proteins, are precursors of signaling molecules as local hormones and mediators; indeed, glycine can induce catecholamine secretion of adrenal medulla. catecholamines of the adrenal medulla have an important role in the regulation of the metabolism, affecting the mobilization of fats. therefore, abnormalities in catecholamines secretion can contribute for obesity development. thus, the purpose of our work was verify if glycine administration has an inhibitory effect on hypothalamic obesity development. animals were treated with tap water added to glycine ( . g/kg). catecholamine content and secretion from adrenal medulla were measured using the trihydroxyindole fluorescence method. msg treatment induced . % enhancement of perigonadal fat pad when compared to control animals (p < . ). however, glycine treatment caused a reduction of almost % on perigonadal pad in obese group (p < . ); control-glycine group presented a decrease of . % in perigonadal fat pad related to control (p < . ). msg treatment reduced . % basal catecholamine secretion (p < . ). obese animals that received glycine presented an increase in basal catecholamine secretion ( . %, p < . ). in conclusion, we showed that glycine treatment did not inhibit obesity development, but the decrease in adiposity observed in obese and control rats treated with glycine may be consequence, at least in part, of the enhacement in basal catecholamine secretion due to stimulatory effect of the glycine. background: increased high sensitivity c-reactive protein (hscrp) and c-glutamyl transferase (ggt) have been reported to be associated with metabolic syndrome (mets) and its components. the aim of this study is to determine whether these two biomarkers independently predict new occurrences of mets in koreans. methods: on-going prospective cohort study, korea health examinee study (koex), has recruited . individuals since . among them, repeated survey was done in approximately years for individuals. only newly occurring mets cases during follow-up was included in this study. odds ratios (or) and % confidence intervals (ci) for the risk of mets were estimated using multivariate logistic regression analysis. results: three hundred seventy-six newly occurring mets cases were ascertained in the follow-up survey. two years' cumulative incidence of mets was . % and was higher among men than women ( . % vs. . %). after adjustment for potential covariates, an increased risks for newly occurring mets were observed among those with higher hscrp measured at baseline examination in men (or = . , % ci . - . ; ! . (mg/l) vs. < . (mg/l)) and in women (or = . , % ci . - . ; ! . (mg/l) vs. < . (mg/l)). also higher risk was observed in those with higher ggt in women (or = . , % ci . - . ; ! (iu/l) vs. < (iu/l)) and in men (or = . , % ci . - . ; ! (iu/l) vs. < (iu/l)). conclusions: metabolic markers such as hscrp and ggt are clearly predicted new occurrence of mets. clinical usefulness of these markers needs to be more investigated in the extended follow-up study. objective: thyroid dysfunctions are supposed to be implicated in metabolic risk. we assessed the effects of hyper-, hypo-and euthyroidism on patients′ lipid metabolism and oxidative stress from a month follow-up clinical pilot study. methods: a study cohort of probands was grouped into hyper-(n = ), hypo-(n = ) and euthyroid (n = ) patients and healthy controls (n = ). patients received their individual medication and underwent a month follow-up. routine thyroid parameters, inflammatory status, lipid metabolism and oxidative stress were analyzed in patients before and after months of medication and in healthy controls. additionally, we measured the body weight, length, waist and hip circumference, bmi as well as blood pressure (bp). results: analyses of routine thyroid parameters confirmed patient's status. anthropometric baseline characteristics were comparable between groups. bp was significantly higher in all baseline patient groups compared to controls. baseline vs. follow-up analyses revealed that euthyroid follow-ups had a significant increased bmi, waist circumference and waist-to-length ratio. further, euthyroid and hypothyroid follow-ups had a significantly lower bp. observations on lipid metabolism revealed that hypothyroid and euthyroid follow-ups showed declined hdl levels and significant higher hld-ldl ratios compared to their pre-treated state. cholesterin, ldl, tg, oxldl levels and inflammatory markers were comparable in baseline and follow-ups. concerning oxidative stress we found significantly declined asymmetric dimethylarginine (adma) levels in all three follow-up groups. results: in the elderly group without metabolic syndrome, autonomy was associated with increasing age, sedentary behavior, and depressive symptomatology. in the presence of metabolic syndrome, in addition to these factors, the lowest level of education, being insufficiently active in physical activities, and have at least one chronic disease is not transmissible, also correlated with worse autonomy. the strong association between obesity and cardiovascular disease stresses the necessity of elucidation the underlying molecular mechanisms linking these pathologies. adrenergic over-activation can promote cardiac hypertrophy and progression to heart failure. our aim was to evaluate a novel sensor for camp namely epac (exchange protein directly activated by camp) and downstream signalling pathways in the development of cardiac hypertrophy and susceptibility to ischaemia/reperfusion injury in a rat model of obesity-induced insulin resistance. methods: wistar rats on a hyperphagia-inducing diet, hid (supplementing normal rat chow with sucrose and condensed milk) for and weeks were compared to age matched controls. isolated working hearts were subjected to min global ischaemia and functional recovery was measured after min reperfusion. hearts were also freeze-clamped at different time points during ischaemia and reperfusion. epac activation was determined by rap activation kit. nfat, p mapk, erk / , pkb and creb were determined by western blotting using appropriate antibodies. results: the heart weight increased significantly after weeks on hid along with an increase in the hypertrophic marker, nuclear nfat. the weeks hid hearts recovered significantly after ischaemia compared to controls, along with a significant increase in phospho-pkb after min reperfusion, compared to week hid hearts. however, results on epac activation showed variable responses. type diabetes mellitus (t dm) and hypertension (htn), both illnesses share pathogenic mechanisms that predispose to micro/ macrovascular complications. it is well known the role of hyperglycemia and insulin resistance of diabetes in vascular endothelial dysfunction. several studies have shown the association of serum concentrations of osteocalcin (oc) in the metabolism of glucose. oc a marker of bone formation by osteoblasts and produced hormone that regulates energy metabolism, was found recently in arteries with atherosclerosis, suggesting their direct association with vascular disease. we analyzed the relationship between serum oc concentrations and cardiovascular risk factors. a cross-sectional analytical study was carried out in patients with t dm plus htn and healthy subjects (hs). oc serum levels were measured and also statistically correlated with cardiovascular risk parameters. total osteocalcin serum levels in t dm + htn subjects were significantly higher than those in hs (p < . ), whereas the uncarboxylated oc concentrations were lower in t dm + htn subjects than in hs (p < . ). body mass index, waist circumference, fat percentage, fasting plasma glucose, high-density lipoprotein cholesterol, fasting serum insulin, homeostasis model assessment-insulin resistance and high sensitivity-c reactive protein were negatively correlated with uncarboxylated osteocalcin (p < . ). in addition, carboxylated oc was also positively correlated with systolic and diastolic blood pressure (p < . ) and homeostasis model assessment-insulin resistance (p < . ). oc serum concentrations are associated with cardiovascular risk factors in patients with t dm + htn. the oc forms (uncarboxylated/carboxylated) might play different roles in cardiovascular and endocrine physiology and hence be of different value as cardiovascular risk markers. aim: to evaluate the prevalence of ms in a group of medical students from bucharest and their habits related to nutrition and physical activity. cross-sectional study: ms was defined according to international diabetes federation criteria. medical students from bucharest were included in the survey, based on their informed consent. they were examined clinically (weight, height, waist, blood pressure), provided a blood sample (glycaemia, lipids, triglycerides, cholesterol, high and low-density lipoproteins) and answered to block adult questionnaire for food and physical activity. results: students enrolled, . % females. . % of subjects were free of signs of ms, . %, . % and . % met one, two and three criteria for ms diagnosis. the highest prevalence of abnormality was found in waist (above the limit in . % cases), followed by hdl (decreased in . % cases). significant differences among genders were found in waist. food habits: boys were found to eat significantly more calories, fats, carbohydrates and proteins compared to girls. no differences for fibres, transfats, free sugar, fruits and vegetables. physical activity: boys consumed significantly more energy through physical activity, recreational activities and vigorous physical activity compared to girls. only in % of cases the energetic consume was higher than the ingestion (no difference by gender). conclusion: high prevalence of unhealthy habits related to nutrition and physical activity in a particular highly educated young group are concerning for the occurrence of ms in the future. triphala an age old commonly used powered preparation of three medicinal dried plant fruits amla (emblica officinalis), harad (terminalia bellirica) and bahera (terminalia chebula) in equal proportionsis used in indian systems of medicine. present work evaluated the anti-hyperglycemic, anti-hyperlipidemic, and antioxidant potentials of 'triphala' formulation viz., (emblica officinalis: terminalia bellirica: terminalia chebula:: : : ) in subjects with igt and tiidm. the therapeutic effect of 'triphala' administration ( gm bd) in tiidm, igt and healthy individuals was assessed by monitoring blood glucose at days intervals, hba c, lipid profile, oxidative stress markers, and liver & kidney function markers at days intervals. dna damage was assessed by comet assay, flow cytometry and hoechst nuclear stain. molecular markers were determined in the beginning and at the end of therapy. results: 'triphala' ( : : ) administration for year significantly brought down blood glucose levels with a marked improvement in lipid profile in all the groups, this was further supported by increased protein expression of ampk and adiponectin. triphala provided resistance to oxidative stress generated not only by the increasing the antioxidant enzymes activity, but also by shortening comet tail length and number of cells in g phase of cell cycle. our results indicated that diabetes is strongly associated with elevated levels of ar, tnf-a, il- and il- , but triphala down regulated the same, proving its anti-inflammatory potential. conclusion: these observations raise the prospects of using triphala formulation for treatment of diseases associated with oxidative stress and imbalanced cytokine production. introduction: glucoregulation disorders are a state of pre-diabetes increasingly diagnosed in the general population. its association with hypertension, increases the risk of cardiovascular morbimortality objective: identify the blood pressure profile in patients with disorders of carbohydrate. patients and methods: this monocentric study has permitted the prospective recruitment of patients. all had an oral glucose tolerance test (ogtt) with a mesure of plasma glucose level immediately before and h after taking g of glucose. clinical examination with taking blood pressure to two arms and a cardiovascular evaluation were performed. results: the glucoregulation disorders were concerned with patients ( %) with an average age of . years ( - years). sexratio: . . ifg was found in patients. ogtt revealed diabetes, igt. only patients with glucoregulation disorders have normal blood pressure. seventy-two patients have been followed for high blood pressure and five patients are newly diagnosed. more than a half of these hypertensive patients has an igt and a third is diabetic. in the family, the high blood pressure is reported in %, the early cardiovascular events are dominated by myocardial infarction and stroke. in high blood pressure group, patient/ is dyslipidemic and metabolic syndrom, as defined by idf , is concerned with patients/ . as for as cardiovascular events, they are reported in patients/ . (t dm) is an ongoing concern and adequate treatment remains an important issue. thiazolidinediones (tzds) are a class of drugs that initially showed great promise as unique receptor-mediated oral therapy for t dm. the tzds, rosiglitazone (rosi) and pioglitazone (pio) were widely used as hypoglycemic drugs in patients with t dm, but a host of serious side effects, primarily cardiovascular, have limited their use. aim: in the present study we have used a systems biology approach to assess specific gene expression profiles underlying the pathological processes in the heart of pre-diabetic mice treated with rosiglitazone or pioglitazone. results: our data demonstrate that both rosi and pio efficiently decreased high fat diet-induced plasma glucose and insulin levels. analysis of the heart demonstrated that rosi, but not pio, led to an increase in atherosclerotic plaque formation and an increase in heart weight to body weight ratio. a combined transcriptomics and bioinformatics approach revealed specific regulatory pathways that may explain the adverse heart effects associated with rosiglitazone but not pioglitazone treatment. conclusion: our data provide new insights into the mechanisms underlying rosiglitazone and pioglitazone action within the cardiovascular system, including drug efficacy and cardiotoxicity. a. vlassopoulos , m. lean , e. combet human nutrition, school of medicine, university of glasgow, glasgow, uk introduction: the new hba c criteria for diagnosis of pre-diabetes have been criticised for overdiagnosis, because many more people are diagnosed than with the old ogtt criteria. it is possible that some elevation of hba c is not driven by hyperglycaemia. aims: this study assesses associations of hba c, commonly assumed to relate solely to glucose concentration, with, . smoking, a major source of reactive oxygen species (ros) and . fruit & vegetables consumption associated with improved redox status. methods: one-way anova, chi-squared and multivariate linear regressions, adjusted for all known confounders were used to explore associations of hba c with self-reported smoking status and fruit & vegetables consumptions in the scottish health surveys - , among individuals without known diabetes and hba c < Á %. results: compared to non-smokers (n = ), smokers (n = ) were younger, consumed less fruit & vegetables, had lower physical activity levels, lower bmi, higher hba c and crp (p < Á ). hba c was higher in smokers (p < Á ) by two sds ( Á %), and . sds higher ( Á %) in heavy smokers (> cigarettes/day) than nonsmokers. smokers were twice as likely to have hba c in the 'prediabetic' range ( . - . %). pre-diabetes and low grade inflammation did not affect the associations. for every extra g vegetable portion consumed, hba c was . sds ( . %) lower (p = . ), but fruit consumption did not impact on hba c, within the low range of consumptions in this population. conclusion: this study adds evidence for a neglected link between oxidative stress and protein glycation, with implications for individuals exposed to ros and for epidemiological interpretation of hba c. v. aursulesei, i.c. roca, l. mihalache objective: to assess the relation between the traits of metabolic syndrome (ms) and the parameters with independent prognostic significance for cardiovascular risk. material and methods: hundred and forty-three patients were included according to the number of traits of ms ( . % arterial hypertension, . % abdominal obesity, . % low hdl-cholesterol, . % high tryglicerides, . % abnormal oral glucose tolerance). the markers of cardiovascular damage were assessed: pulse wave velocity (pwv -complior method), carotidian intima media thickness (imt), left ventricular hypertrophy (index of mass -lvmi and geometric patterns), flow mediated vasodilation (fmd), microalbuminuria (absent/present), ankle-brachial index (abi). results: in our study the cardiovascular damage is present in . %. pwv values increase with number of traits of ms (t-test) after adjusting for confounders/other cardiovascular risk factors (ancova). decreased abi is related with each of ms traits; the power of correlation depends on criteria association. pwv and abi are both related with postprandial hyperglicaemia and systolic blood pressure (p < . ), while imt is strongly related with hdlcholesterol (r = . , p = . ). lvmi and concentric hypertrophy pattern are also related with systolic blood pressure (r = . , p < . ), while eccentric pattern relates to waist circumference (r = . , p < . ). we cannot establish a relation between traits of ms and fmd or microalbuminuria. conclusions: hyperglicaemia and systolic blood pressure are best related with parameters of cardiovascular risk, but the clustering of ms components may interact to synergistically affect the extent of cardiovascular damage. pwv, abi and left ventricular hypertrophy should be systematically used for defining cardiovascular risk in ms. interleukin- (il- ) is pleiotropic cytokine with a key impact on immunoregulation and nonimmune events. sudies have investigated the role of action/lack of action of il- in the pathogeneses obesity, insulin resistance, type diabetes. aim of the study: to evaluate il- activity in hypertensive patients depend on prediabetes presence. materials and methods: hypertensive patients were examined. common clinical investigations were provided. il- plasma levels were detected using elisa. data is represented as me (q -q ). median test were used, p < . . results: prediabetes was observed in . % of hypertensive patients in % insulin resistance in hypertensive patients with prediabetes vs. % insulin resistance in hypertensive patients were detected. hypertensive patients with prediabetes ( . ( . - . ) %) characterized by significantly higher glycated haemoglobin levels as compared hypertensive patients ( . ( . - . ) %, p < . ). hypertensive patients were characterized by increased il- activity ( . ( . - . ) pg/ml). in hypertensive patients with prediabetes decrease il- activity ( . ( . - . ) pg/ml) were found. conclusion: hypertensive patients were characterized by increased il- adipose tissue is now recognized as a complex organ with a crucial role in energy metabolism and in the development of obesity and metabolic syndrome. modified response and metabolism of hormones has been observed in the visceral adiposity during obesity, specifically related to cortisone. the aim of this study was to assess the response to different concentrations of cortisone in adipocyte cell line t l . the expressions of β-hsd , enzyme responsible for the reduction of cortisone to cortisol, and aqp , involved in glycerol transport, were quantified after treating differentiated cells with cortisone at doses of , . , , and lmol/l during , , , , min, and h. total rna and cdna were obtained from the samples to develop a real time pcr using mnsod as housekeeping gene. results suggest time and dose dependent response of β-hsd and aqp ; increases in the expression were observed during the first min of treatment ( and fold, respectively), followed by expression decrease for both in a min period (p < . ). for the treatment with lmol/l cortisone, both proteins expressions showed quadratic tendencies, β-hsd tendency is described by the equation y = . + . x À . x while aqp tendency is described by y = . À . x + . x . it can be concluded that long term effects of cortisone over adipocyte metabolism may be modulated by the induction or repression of proteins like aqp and should be explored in obese individuals. objective: to present a series of cases of metabolic syndrome patients suffering sleep disorders in which the most relevant metabolic marker is serum tryglicerides levels. it has been considered that the key meatbolic alteration underlying metabolic syndrome is a resitance to insulin action. however, there could be other metabolic abnormalities that may lead to the devleopment of the clinical feautres of this diseasea. materials and methods: patients undergoing a medical check up at medica sur hospital were included. each patient was assesed in order to determine both matabolic syndrome and a current sleep disorder. anthropometric measures were taken, body rates were calculated and blood samples were taken for laboratory tests (serum glucose, tryglicerides and cholesterol levels determination). results were analysed with the spss software. results: fifteen patients meeting the world health organization metabolic syndrome were included, and who referred snoring, difficulties on getting asleep or frequent waking up while sleeping. anthropic measures, and lab results were. discussion: yet, the majority of these patients do not have serum glucose abnormalities, but mainly their weights correspond to overweight and to a phenotype of central adipose tissue distribution. the most significant metabolic alteration, in this set of patients, was hypertigliceridemia. this results suggests that there may be other metabolic pathways leading to the development of this disease. introduction: prediabetes, a condition leading to diabetes and cardiovascular diseases (cvd). in cameroon, few studies have been done about this health indicator. aims: to determine the prevalence of prediabetes and diabetes in cameroon cohort, and to compare metabolic risk factors between normoglyceamia and prediabetes individuals. patients and methods: a sample of cameroonian men and women ( - years) participated in a health survey. statistical analysis of data compared risk factors between three subgroups: normoglyceamia (ng), prediabetes (pd) and diabetes (dt). prediabetes was defined as a glyceamia of - mg/dl. metabolic syndrome (mets) was diagnosed using the national cholesterol education program (ncep) definition. results: the distribution of ng, pd and dt prevalence in the overall sample was . %, . % and . % respectively. the prevalence of mets in those with pd ( . %) was significantly higher than in those with ng ( %). many significant differences between ng and pd subjects were also noticed. conclusion: in this study, approximately % of the population who were found to be diabetic and prediabetic is at risk of cardiovascular diseases. our findings also show that prediabetes individuals are different from those with normal glycaemia in a great number of metabolic abnormalities including a higher prevalence of mets. prevention and control measures should be set urgently. research design and methods: prospective study of the thai comprehensive cirs was further evaluated by multiple logistic regressions. in determine the ability of the thai comprehensive cirs scores in predicting each outcome, the adjusted odds ratio was calculated, and backward stepwise selection was used in the statistical modeling. results: there were also prospective correlations between the baseline thai comprehensive cirs instrument and -month outcomes). total score at baseline emerged as significant predictors of -month qol (r = . - . , p < . ). every subscale of the thai comprehensive cirs was significantly related to patient satisfaction (r = . - . ), with only the neighborhood subscale as a significant predictor for adl (r = . ). the other outcomes (self management behavior, cost of care, and dbp) were not significant concurrent baseline predictors. method: we collected laboratory results of body mass index (bmi), blood pressure, fasting glucose, lipid profiles (total cholesterol, triglycerides, ldl-and hdl-cholesterol level) and visceral fat amount of cancer survivors who visited health promotion center at seoul national university hospital. an age and sex-matched control was selected randomly for each cancer survivor from visitors of this center. we compared blood pressure, fasting glucose, lipid profiles and visceral fat amount between cancer survivors and controls using multiple regression analysis after adjustment for bmi. results: one hundred fifty five cancer survivors and controls were included in statistical analyses. cancer survivors tended to have lower bmi compared to controls ( . ae . kg/m vs. . ae . kg/ m , p = . ) after adjustment for bmi, cancer survivors showed lower fasting glucose level ( . ae . mg/dl vs. . ae . mg/ dl, p = . ). however there were no significant differences of blood pressure, lipid profiles or visceral fat amount. background: both insulin deficiency and resistance are reported in patients with β-thalassemia major (btm). we assessed the ogtt and -h continuous glucose concentration by the continuous glucose monitoring system (cgms) and calculated homeostatic model assessment (homa), and quicki in adolescents with btm on regular blood transfusions and iron-chelation therapy. results: in adolescents with btm (age: . ae years), ogtt, ( %) showed impaired fasting blood (plasma) glucose concentration (bg) (> . mmol/l). two-hour after the glucose load, one of them had bg = . mmol/l (diabetic) and two had igt (bg > . and < . mmol/l). monitoring the maximum (postprandial) bg using cgms, adolescents had diabetes ( %) (bg > . mmol/l) and nine had igt ( %). homa and quicki revealed levels < . ( . ae . ) and > . ( . ae . ), respectively, ruling out significant insulin resistance in these adolescents. neither fasting serum insulin nor c-peptide concentrations were correlated with fasting bg or ferritin levels. the average and maximum blood glucose levels during cgm were significantly correlated with the fasting bg (r = . and . , respectively, with p < . ) and with the bg at -h after oral glucose intake (r = . and . respectively, with p < . ). ferritin concentrations were correlated with the fasting bg and the h blood glucose levels in the ogtt (r = . , and r = . , respectively, p < . ) as well as with the average bg recorded by cgm (r = . , p < . ). conclusion: cgm has proven to be superior to ogtt for the diagnosis of glycemic abnormalities in adolescents with btm. background: in obese children pancreatic beta-cells may not be able to cope with insulin resistance leading to hyperglycemia and type diabetes (t dm). objectives: to assess oral glucose tolerance, -h continuous blood glucose concentrations (cgm) and calculate homeostatic model assessment (homa), and the quantitative insulin sensitivity check index (quicki) in children and adolescents with simple obesity (bmisds = ae . ). results: ogtt performed in obese adolescents ( . ae years) revealed three cases ( %) with ifg (> . mmol/l), four cases ( %) with igt (> . < . mmol/l), and none with diabetes. using the cgms, ift was detected in four cases, the maximum bg ( h or more after meal) was > . and < . mmol/l (igt) in nine children ( %) and > . mmol/l (diabetes) in one case ( . %). five cases had a minimum bg recorded of < . mmol/l (hypoglycemia). no glycemic abnormality was detected using hba c ( . ae . %). / patients had homa values > . and quicki values < . denoting insulin resistance. beta cell mass percent (b %) = ae . % and insulin sensitivity (is) = . ae . % denoting insulin resistance with hyperinsulinaemia and preserved beta cell mass. in obese children and adolescents; cgms is superior to ogtt and hba c in detection of the glycemic abnormalities, which appears to be secondary to insulin resistance. introduction: the aim of this study is to evaluate the effect of vitamin e supplementation on glycemic control, lipid profile, inflammation markers and malondialdehyde level of type diabetic patients. material and method: thirty type diabetic patients were participated in this randomized single blind placebo controlled clinical trial study. fasting blood glucose, serum triglyceride, total cholesterol, ldl, and hdl-cholesterol concentration, malondialdehyde (mda), hs-crp, il- , and insulin level were measured. each subject then given a breakfast that was contained g fat. subjects' post-prandial biochemical measurement was measured as well. patients' then randomly divided in two groups. treatment group received vitamin e ( iu/per day) and control group received placebo for weeks. at the end of weeks baseline procedure was repeated and fasting, and -h postprandial biochemical markers were measured. statistical analysis: data analyzed using mann-whitney u test to compare the mean differences between both groups. basic data expressed as mean ae standard deviation, fasting and postprandial biochemical parameters before and after intervention expressed as median. results: no significant differences were found in fasting and postprandial lipid profile, glucose, insulin and homa-ir after weeks of intervention between two groups. significant decreases in fasting and postprandial serum mda levels in treatment group were recorded. no significant differences were shown in fasting and postprandial inflammatory markers except fasting il- . the result of this study shows that short term supplementation of vitamin e is safe and effective in decrease oxidative stress in type diabetic patients. objective: there is evidence that patients with normal weight and central adiposity (elevated waist circumference and waist-hip index) present a higher cardiovascular and metabolic risk. it has been proven that central adiposity is a risk factor for elevated systolic and diastolic pressure amounts, low hdl cholesterol and altered glucose while fasting. materials and methods: patients treated at the integral diagnosis and treament center of medica sur hosptial were inclued. anthropometric measurments were taken and metabolic (glucose and profile of lipids with ultrasensitive reactive c protein) parameters were analyzed. results: nine hundred and forty patients were included. women with a normal body mass index but with a waist > cm, had metabolic alterations on serum lipids which have a statistical significance when compared with those women with a waist circumference lesser ran cm. an elevated waist circumference diameter, regardless of the bmi, increases the metabolic risk. the measurement of the circumference of the waist and the hip must take place by routine in any medical evaluation. aim of the study: to study the prevalence of prediabetes in elderly age group ( years and above) and to study cardiovascular risk factors in prediabetic group. methodology: study was conducted on patients of age years and above. they were screened for prediabetes as per ada guidelines . such prediabetic study group ( cases) was investigated for cardiovascular risk factors (obesity, hypertension, microalbuminuria, crp, retinopathy, dyslipidemia) along with age matched controls. standard statistical tests were applied for analyzing data. hypertension and retinopathy with the prediabetic state. risk factors are more associated with igt as compared to ifg. conclusion: prediabetes is widely prevalent in the elderly population. it has strong association with metabolic syndrome. prevalence of igt is higher as compared to ifg. similarly, cardiovascular risk factors are widely prevalent in the prediabetic population. dyslipidemia, obesity, microalbuminuria, hypertension and retinopathy share the significant association as risk factors. early identification, of prediabetic state followed by primordial and primary prevention of cardiovascular disease should be the focus of intervention. background: despite commonly using body mass index (bmi) in diagnosing obesity, the accuracy of bmi in detecting adiposity is unknown in korean. we assessed accuracy of bmi in detecting body fat percentage (bf%) defined obesity. methods: this study is a cross-sectional design of subjects (age - . years, men . %) who conducted korean national health and nutrition examination survey (knhanes iv- ) in korea from january to december . we assessed the diagnostic performance of bmi using the who reference standard for obesity of bf% ! % in men and ! % in women, which were measured by dual energy x-ray absorptiometry. we tested the correlation between bmi and bf% by sex and age groups. we defined the bmi cutoff for bf%-defined obesity using roc analysis. results: bmi-defined obesity was present in . % of men and . % of women. according to age and sex, a sensitivity and a specificity of bmi ( ! kg/m²) showed difference. the bmi cutoff value for bf %-defined obesity is . kg/m² (sensitivity %, specificity %). difference between bmi cutoff value of korean and that of american to detecting bf% is about À . kg/m². in korean, bmi showed a limited accuracy to detecting adiposity by age and sex. the difference between bmi cutoff-value of korean and that of american to detecting bf% obesity is smaller than the difference of bmi cutoff-value between the asia-pacific and who criteria. background: the healthkick intervention was developed as part of a study that aimed to address diabetes risk factors in primary schools within low-resource settings in the western cape, south africa. the intervention focused on grade - learners, their parents and the educators. aim: to ascertain the risk of developing diabetes and other noncommunicable diseases among educators. method: educators (n = ) from urban and rural schools, participated in a health check in . measurements included random blood glucose and cholesterol testing, and height, weight, waist circumference and blood pressure (bp) measurements. cut-off values for bp levels in adults years and older of the nhlbi were used for categorising hypertension. results: educators participating in this study were mainly females, with most of them ( %) falling in the age range between and years, and % being older than years. only % of educators had bps in the normal range. half of those on treatment for hypertension had levels above / mmhg, while % with bps above these levels were not on medication. about % of those who said they had diabetes (n = ) knew what treatment they were on. cholesterol levels above mmol/l were seen in %. only % said they smoked cigarettes, whereas % were previous smokers. preliminary results show that most participants had a body mass index > kg/m . conclusions: many of the educators who participated in the healthkick study are possibly at risk for developing cardiovascular and other related non-communicable diseases, such as diabetes. s.k. kota , s. ugale , n. gupta , k.d. modi endocrinology, medwin hospital, laparoscopic surgery, kirolskar hospital, hyderabad, india objective: the objective of the present study was to prospectively evaluate the results of laparoscopic ileal interposition (ii) with diverted sleeve gastrectomy (dsg) for control of type diabetes mellitus (t dm) and related metabolic abnormalities. methods: all patients underwent ii +dsg. they had t dm ! years with poor glycemic control despite adequate dosage of oral hypoglycemic agents (ohas) ae insulin. the primary outcome was remission of diabetes (hba c < . % without ohas/insulin) and secondary outcomes were reduction in antidiabetic agent requirement and components of metabolic syndrome. we report the preliminary postoperative follow-up data of . ae . months (range: - months). there were patients (m: f = : ) with mean age of . ae . (range: - years), duration of diabetes of . ae . years (range: - years), and preoperative body mass index of . ae . kg/m (range: . - . kg/m ). sixteen patients ( %) had hypertension, while dyslipidemia and microalbuminuria was present in patients ( %) each. twenty two patients ( . %) had diabetes remission. fifteen/sixteen ( %) patients had remission in hypertension. all participants had weight loss ranging between % and %. postoperatively statistically significant decline was observed in the glycemic and lipid parameters, microalbuminuria at all intervals (p < . ). patients with postoperative duration > months had better improvement in terms of reduction in glycemic, lipid parameters and microalbuminuria. three patients had vitamin b deficiency year after surgery. conclusion: ileal interposition combined with dsg addresses both foregut and hindgut theories and brings about remissions in t dm patients. background and objective: the objective of this study was to evaluate the screening potential of various anthropometric indices, namely body mass index (bmi), waist circumference (wc), waist-to-hip ratio (whr) and waist-to-height ratio (whtr) in the early detection of dysglycemia among the omani adult population. methods: our study included omani adults ( males and females) who participated in a cross-sectional, community-based study. we defined glycemic status based on american diabetes association (ada) thresholds: < . mmol/l as normal, . - . mmol/l as impaired fasting glucose (ifg) and ! . mmol/l as diabetes mellitus (dm). the cut-off values for the anthropometric indices namely, bmi, wc, whr and whtr were based on the standard definitions. the age adjusted analysis showed that out of the four anthropometric indices, among the males the whtr at the cut-point of . gave relatively higher value of odds ratio with or = . ( % ci: . , . ) and among the females whr at the cut-point of . showed maximum odds ratio with or = . ( % ci: . . . ). the areas under the roc curves, at the cut-point of ifg ! . mmol/l, was more for whtr in case of males and whr in case of females. conclusion: this study shows that out of the four anthropometric indices, there are differences in the predictive values of dysglycemia among the omani males and females. in case of males, the whtr ! . appears to be a better indicator for detecting dysglycemia whereas among the females the whr ( ! . ) is a better indicator. introduction: increased serum ferritin and iron stores are involved in the pathogenesis of insulin-resistance. polycystic ovary syndrome (pcos) is diagnosed by oligomenorrhea and hyperandrogenism. pcos and obesity were associated with elevated serum ferritin levels. the link between obesity and altered iron metabolism was proposed. object: to evaluate the association between serum ferritin levels and insulin resistance and metabolic syndrome in obese and non-obese women. methods: retrospective study. five hundred thirty-nine women, of whom had pcos and of whom did not have pcos, were included in the study. results: serum ferritin correlated with menstrual cycle length, sex hormone-binding globulin, total testosterone, androstenedione, triglyceride, and total cholesterol both in obese and non-obese women. obese women (bmi > ) with high ferritin (ferritin ! . ng/ml, n = ) levels had higher insulin resistance, impaired glucose tolerance, and liver enzymes than obese women with low ferritin levels (ferritin < . ng/ml, n = ). however, among non-obese women, insulin resistance and metabolic disturbances were not significantly different between high and low ferritin groups. women with high ferritin levels had a greater risk of pcos and hyperandrogenism than women with low ferritin levels. independent of obesity, hypertriglyceridemia was the major metabolic disturbance in women with elevated serum ferritin levels. conclusions: the pathogenesis of increased iron stores correlated with insulin resistance and metabolic syndrome among obese and nonobese premenopausal women was different. the hypertriglyceridemia in women with pcos might be associated with iron metabolism. nutrition rehabilitation, unite de dietetique, pegomas, france and yogic counseling for stress management. all subjects underwent a residential program for weeks followed by therapy at home for weeks. results were analyzed using paired 't' test. conclusion: in remote areas organization of screening on base of diabetes bus helps to detect t d and early glucose metabolism disorders in more than % of people with increased risk. findrisk scale is useful screening tool to detect these people. however, in older age groups, percentage of screen-detected t d decreases, which may indicate lower efficiency of findrisk questionnaire at age ! . background and aims: changes in the cellular oxidative status are involved in the pathogenesis of obesity-associated hepatic steatosis. the possibility of gender difference in this process was examined in an experimental model of obesity induced by a western high-fat and highcarbohydrate cafeteria diet. methods: four groups of six swiss cd mice ( day old) received either cafeteria diet (male and female) or balanced diet (male and female) for weeks. hepatic hydrogen peroxide (h o ), thiobarbituric acid reactive substances (tbars), reduced glutathione (gsh) and the activity and/or gene expression of catalase (cat), glutathione peroxidase (gpx), superoxide dismutase (sod), hypoxia inducible factor (hif- -alfa) and nuclear factor (erythroid-derived )like (nrf ) were measured. results: higher levels of tbars and mitochondrial h o were found in livers from cafeteria-fed animals of both genders, with higher levels in females. the level of gsh was lower in cafeteria-fed mice of both gender; females showed higher levels than males (cafeteria or balanced diet). cat and gpx activities were reduced in cafeteria-fed mice of both sexes; the activities in females being lower than those of males. sod activity and the gene expression of cat, gpx and sod were not significantly altered when compared by gender or dietary treatment, but the expression of hif- -alfa and nrf was increased in female cafeteria-fed mice. the female animals exhibited a higher susceptibility to cellular oxidative stress in cafeteria diet-induced obesity in comparison to males. the molecular mechanisms seem to be, in part at least, posttranscriptional. acknowledgements: capes, cnpq, fundac ßa˜o arauc aria. objectives: to investigate the relationship between body fat percentage and body mass index (bmi) among young adults aged - years. methods: young adults aged - years were recruited for study when they took health examination in september in taiwan. all subjects underwent bioelectrical impedance analysis (tanita bc- ) to estimate their body fat percentage. basic demographic data, height, and weight were collected, and bmi was calculated from height and weight. overweight and obesity were identified according to bmi. the correlation between body fat percentage and bmi was analyzed using sas software . . results: a total of male and female participants were enrolled. the mean age was . ae . years old. the mean body mass index was . ae . for men and . ae . for women. the mean body fat percentage was . ae . for men and . ae . for women. categorized by bmi, the mean body fat percentage was . ae . for men and . ae . for women in bmi < . group, . ae . for men and . ae . for women in bmi . - group, and . ae . for men and . ae . for women in bmi - group and . ae . for men and . ae . for women in bmi > group (p < . ). the prevalence of too high or obese body fat percentage among young adults aged - years in taiwan was . % in male and . % in female according to the who and nih recommendations. the cutoff values of healthy body fat percentage for young adults in chinese population ought to be modified. it is estimated that - % of women of reproductive age have polycystic ovarian syndrome (pcos). this article summarizes the recent development and findings in the cardiometabolic abnormalities in patients with pcos. patients with pcos have the clinical features of oligomenorrhoea, hirsutism and infertility; however, they also exhibit hyperinsulinemia, obesity, hypertension, dyslipidemia, and an increased pro-thrombotic state. they have an increased risk of type diabetes and impaired glucose tolerance, and sleep apnea is also found more commonly in this population. however, despite the presence of cardiovascular risk factors and increased surrogate markers of cardiovascular disease it is unclear if they have accelerated atherosclerosis. end point studies are currently lacking and the available evidence are conflicting. this article will address the current evidence for the adverse cardiovascular risk in pcos and the other factors that may be implicated. finally the therapeutic options for treatment will be discussed. conclusion: results suggest that in the fasted condition, when fatty acids levels are elevated, the gluconeogenic flux is higher in cafeteriafed rats, a finding consistent with the higher glycogen levels. the lower production of co indicates a deviation of the citric acid cycle intermediates into the cytosol, a change which may favour the synthesis of fatty acids and triacylglycerols. these liver metabolic disturbances probably contribute to fatty liver diseases, hyperglycemia and dyslipidemia in cafeteria diet-induced obesity. certain cancers. this study aims to evaluate the association between obesity and colorectal cancer risk and also if the association varies with the blood type, age of obesity or cancer subsites. the study was carried out on hospital patients, different ages, diagnosed with colorectal cancer. we determined the blood type, cancer subsites and age of symptoms. we evaluated their family history and their lifestyle in terms of physical activity, smoking and alcohol consumption. results: out of the patients, % had the bmi ! kg/m and all of them showed abdominal obesity. the age of obesity was up to years to % of the subjects and over years for % of them. symptoms were detected over months before diagnosis for % of the individuals and between and months for % of them. in what respects the cancer subsites, % of the cases were located on the descending colon, rectum and sigma. % of the patients had a family history of different types of cancer (colorectal, pulmonary, gastric or breast neoplasia). sixty-five percent of them were smokers, % were alcohol consumers and % carry light or no physical activity. forty-nine percent were blood group a individuals. the study shows that obesity is a statistically significant risk factor for colorectal cancer and the association is stronger for the patients with a higher age of obesity, descending colon and rectum localisation of the neoplasia and blood group a individuals. technical university munich, munich, ikfe institute, mainz, germany purpose: the angiotensin ii receptor antagonist telmisartan (t) has demonstrated bifunctional effects on the hemodynamic, vascular and metabolic features of patients with metabolic syndrome (ms). accordingly, we tested the hypothesis, that antihypertensive therapy with t vs. amlodipine (a) improves diastolic myocardial function, vascular function and metabolic characteristics in ms. methods: this randomised cross-over study investigated ms patients (bmi ae kg/m ) with mild-moderate hypertension before and after months therapy with t vs. a. laboratory and ultrasound data were taken in the fasting state and h after a test meal ( g carbohydrates). cardiac function was assessed by tissue doppler as systolic (s') and diastolic myocardial velocity (e') and vascular function at the common carotid artery as elasticity modulus and pulse wave velocity. results: after months with t, fasting systolic blood pressure was reduced by ae mmhg (p < . ) and postmeal by ae mmhg (p < . ) vs. a ( ae mmhg (p < . ) fasting and insignificant ae mmhg (p < . vs. t) postmeal). with t but not with a, diastolic pressure dropped by ae (p < . ) fasting and postmeal (p < . ). with t but not a, e' increased fasting and postprandially by . ae . (p = . ) and . ae . cm/s (p = . ) and so did s' (p < . and . ), whereas vascular function improved postprandially alone (p < . and p < . ). conclusion: in ms patients, mild to moderate hypertension and without cardiac disease, monotherapy with telmisartan improved diastolic and systolic cardiac function in particular postprandially whereas amlodipine did not. introduction: the metabolic disorders at the tunisian military pilots are more and more frequent affecting more and more young subjects. the expert doctor is in front of a big problem to know the evaluation as well as the control of the evolutionary genius of these disorders to be able to minimize their complications materials and methods: it is about a retrospective study which was interested in the files of the tunisian military pilots followed regularly in the center of expertise of aeronautical medicine since . on these files, we found the various types of metabolic anomalies by referring to the age and the anthropometric characters during their appearance, as well as the evolutionary follow-up of these anomalies with or without treatment results: the metabolic disorders were found at % of the military pilots. these disorders are represented in the order by dyslipide´mies, then disorders of the hepatic metabolism, the hyper urice´mie and finally the not insulin-dependent diabetes. the therapeutic care ways begins with the hygie´no-dietary rules before the passage in the medicinal treatment. the metabolic disorders make the bed of the cardiovascular diseases; their complications particularly at the military navigators are very grave. the correction of these anomalies is imperative to avoid the vascular accidents which can be responsible for a sudden incapacity during flight. comparison to wt controls, and the epididymal fat weighs significantly less in the ko (p = . ; normalized to body weight). the irx ko mice showed increased feed and water intake relative to their body weight compared to wt littermates. moreover, qpcr and western blot analysis indicates differential expression of irx during adipogenesis in t -l cells. our data suggest that irx plays a role in the development of adipose tissue. method: forty-six obese participants (both sexes, age range from to years) group mean ae sd, . ae . years were selected for the study based on a bmi ! kg/m *. the participants were randomized as two groups. all participants were assessed for bmi and lipid profile at the beginning and end of days of the intervention. twenty six participants ( from each group) were assessed for leptin and adiponectin. the yoga group practiced yoga for min two times in a day for days. at the same time of the day the walking group practiced min of walking for two times in day. each day participants were given non calorie restricted diet regulated as kcal/day. data recorded at the beginning and at the end of the intervention were compared by repeated measures analysis of variance using spss version . , followed by post-hoc analysis. results: both groups showed a significant decrease in bmi (p < . ) and in total cholesterol (p < . ). only yoga group showed significant reduction in ldl cholesterol (p < . ) and significant increase in leptin (p < . ). the walking group alone showed a significant reduction in triglycerides (p < . ) and in adiponectin (p < . ). objective: human urotensin ii is the most potent vasoconstrictor identified to data. however, association between urotensin ii and hypertension and whether the association is independent of endothelial function has been controversial. here, we studied the association under adjustment for serum nitric oxide in a case-control study. methods: hundred and ninety-seven hypertensives and age-and sex-matched normotensive controls were studied. plasma urotensin ii, serum nitric oxide and other traditional biomarkers were examined. association between urotensin ii and hypertension was evaluated by multivariate conditional logistic regression analysis. results: hypertensives had higher levels of urotensin ii [median (interquartile rang): . ( . - . ) ng/ml vs. . ( . - . ) ng/ ml] and lower nitric oxide [ . ( . - . ) lmol/l vs. . ( . - . ) lmol/l] than normotensive controls. urotensin ii positively correlated with sbp (r = . , p < . ), dbp (r = . , p = . ) but negatively correlated with nitric oxide (r = À . , p = . ). in multivariate regression analysis, subjects in the highest th percentile of urotensin ii concentration ( ! . ng/ ml) had . times the risk of hypertension than did individuals in the lowest quartile (< . ng/ml) (p = . ). both univariate and multivariate analysis in pairs of serum nitric oxide level-matched cases and controls showed that risk of hypertension significantly and positively increased with levels of urotensin ii (all p < . ). conclusions: urotensin ii was markedly associated with hypertension and the association was independent of endothelial function. this study suggested that urotensin ii may have an etiological role in hypertension. objective: dilated cardiomyopathy (dcm) is the third most common cause of hf. the implication of transcription factors (tfs) in molecular pathways that guide heart development and cardio-specific gene expression has recently been established. however, the role of cardiac specific tfs; myocardin and tbx in the failing heart is unknown. the present study was designed with the aim to determine the expression profile and regulation of these tfs in failing hearts. methods: myocardin and tbx mrna levels were estimated by quantitative rt-pcr (qrt-pcr) in human ventricular biopsies and pbmcs of dcm patients (n = ) and controls (subjects with ventricular septal defect) (n = ). copy number variations in myocardin and tbx were determined by qrt-pcr in dcm patients (n = ) and control (n = ). myocardin and tbx promoter methylation patterns were studied in pbmcs of dcm patients (n = ) and controls (n = ) by methylation specific pcr (msp). results: myocardin and tbx mrna levels were found to be significantly six fold (p . ) and seven fold (p . ) increased in the failing human myocardium as compared to control samples respectively. promoter hypermethylation of myocardin was observed only in patients and none of controls were found to carry methylated alleles for myocardin. we did not observe any significant difference in promoter methylation status of tbx . there was no significant difference observed in the copy number of both the transcription factors; myocardin and tbx between patients and controls. conclusion: our results suggest that epigenetically regulated expression of cardiac specific tfs; myocardin and tbx may contribute to pathophysiology of dcm. introduction: mir- is among the most abundantly expressed and consistently dysregulated mirnas in heart failure and has been implicated in cardiac fibrosis. however, its role in diabetic cardiomyopathy is not known. abstracts of the th international congress on prediabetes and metabolic syndrome normalisation of the majority of indicators of lipid and carbohydrate metabolism. a.g. kistauri , g. devidze , m. jibladze , a.a. kistauri internal medicine, tbilisi state medical university, tbilisi, surgery, kutaisi ortodox christian hospital, kutaisi, georgia, lund university, lund, sweden aims: diabetic foot syndrome is a complex of purulent-necrotic and/ or ostheoarthropatic changes of the foot. in case of purulent-necrotic complications, lethality reaches - %. objectives: optimisation of infected diabetic foot treatment. methods: eight-four patients, suffering from infected diabetic foot. following was used as a material for antibioticogram: soft tissue scraping from the bottom of the injury, purulent discharge, bone biopsy. results: degree of bacterial contamination was high: between and - : anaerobic flora - . %, aerobic flora À . %. bacterial flora in purulent zone (decreased- . % to . %): staphylococcus aureus, saprophyticus, epidermidis, ps. aeruginosa, enterococcus, e. coli. the highest sensibility was shown to the following drugs (decreased- . % to . %): tienam, meronem, amoxiklav, vankomicin, cefepim, ceftriaxon, ciprofloxacin, likacin, klindamicin. less sensitivity was detected to the following drugs ( . - . %): ampicilin, doxaciclin, cefazolin, erythromycin. based on the above, the most appropriate combinations are: ftorchinolines + i-iii generation aminoglycozides (combination i) and/or iii generation cefalosporines + lincosynamides (combination ii). using the first drug combination, infection was stopped in . % and in . % of cases using the second. high amputations were performed in two cases, six more than half of foot. in cases process was stopped and amputation was avoided. conclusions: cause of tissue necrosis during neuropathic form of diabetic foot is infection, during neuroischemiccritical ischemy and infection. neuroischemic infected injury is characterised with much faster course than infected neuropathic ulcer. the most appropriate treatment combination of diabetic foot is fluorcholines + i-iii generation aminoglycozyed and iii generation cefalosporines + lincosomydes. background: continuous glucose-monitoring system (cgms) is a tool for assessment of glycemic excursions. glucose variability is a risk factor independent of glycosylated hemoglobin (hba c) for diabetic complications. aim: to evaluate the prevalence and extent of glycemic excursions & unrecognized hypoglycemia in type diabetic patients. setting and design: the study was carried out in type diabetes patients on oral agents. material and methods: patients underwent continuous glucosemonitoring by cgms for days. number and duration of glycemic excursions, unrecognized hypoglycemia, correlation coefficient (%) between cgms and self-monitoring blood glucose (smbg), mean absolute difference (%mad were analyzed. results: the mean age of patients was . ae . years. the mean hba c was . ae . %. the mean number of glycemic readings was . ae . times. the correlation coefficient was . and the mad was . ae . %, which were considerable. twenty three ( %) patients experienced hypoglycemic events. twenty seven ( %) patients had hyperglycemic events. the hypoglycemic events were found to have significant correlation with the duration of diabetes and inverse correlation with hba c, whereas age was significantly correlated with females diabetics (p < . ). conclusion: this study demonstrated that type diabetic patients have a considerable number of hypoglycemic and hyperglycemia events that may be missed by smbg. internal medicine department, zagazig university, faculty of medicine, university hospital, medical biochemistry, zagazig university, faculty of medicine, zagazig, egypt impaired fibrinolysis increase the risk of cvd in diabetics, it has been found also in igt associating metabolic syndrome but there is no data concerning fibrinolysis in subjects with normal gt that may convert to diabetes. therefore, the aim of work was to study the fibrinolytic activity, as measured by tpa activity and t-pai- antigen as markers of endothelial dysfunction in normal and igt offspring of type diabetes compared to subjects without family history of diabetes. we measured fibrinolytic activity (tpa activity and tpai- antigen) in subjects, healthy volunteers and offspring of type ( normal gt and igt), we measured fasting plasma insulin, lipid profile and insulin resistance. we found that tpa activity was significantly reduced and tpai- was significantly raised in igt group as compared to normal gt. surprisingly tpa activity was also significantly reduced and tpai- was significantly raised in normal gt. also, we found that igt increases the (tpai- antigen and decrease tpa activity in igt by . fold and . respectively than normal gt offspring. we can concluded hypofibrinolysis may aggravate insulin resistance and promote progression of atherosclerosis in those offspring in the future. this may explain the increased prevalence of cardiovascular diseases in early discovered diabetics. moreover, changes of these parameters can be used as a predictor for early detection of prediabetic state even before occurrence of glucose intolerance and the proper correction of this hypofibrinolysis may delay the development of atherosclerosis in diabetic stage. introduction: type diabetes in children is the most common juvenile endocrinopathy. decreased bone mass has been shown to be a common complication of type diabetes. the aim of our study was to evaluate the characteristics of bone mineral density (bmd) in diabetic children and their relationship with the age of diabetes, glycemic control and the biological markers of bone remodeling. with an assay of biological markers of bone turnover were performed for each child. results: sex ratio was . in the diabetic group and . in the control group. the average age of diabetics was . years and that of controls was . years. the two groups were comparable concerning the age, sex, anthropometric parameters and pubertal stage. the only difference found between the two groups concerning calcium intake that was lower in the controls. bone mineral density did not differ significantly between the two study groups. a significant difference was found comparing averages of bone markers (osteocalcin and ctx). the seniority of diabetes was correlated to the bone mineral density only in the diabetic daughter. the glycemic control represented by hba c was inversely correlated to the bone mineral density. conclusion: the prevention of bone damage in the diabetic child must go through adequate calcium intake, a proper sports activity and especially a good control of the disease. background and aims: the aim of the present study was to investigate all-cause mortality in relation to physical inactivity and diabetic status among patients surviving an acute myocardial infarction (ami). we hypothesised that physically inactive patients had a higher mortality risk compared to those who were physically active, regardless of diabetic status. methods: we enrolled n = patients with ami admitted to the coronary care unit of the central hospital in va¨stera˚s, sweden between november and may . all-cause mortality was followed-up until may . the relation between self-reported leisure time physical inactivity during the last year, diabetic status and allcause mortality was analysed univariately using kaplan-meier curves and multivariately using cox regression adjusted for the confounders bmi, prior angina pectoris, prior stroke, smoking, age, sex, education level and immigration status. p-values< . were considered statistically significant. results: a total of n = ( . %) of the ami patients had valid values for diabetics status and leisure time physical inactivity. of these, n = ( . %) died during follow-up. the mortality was significantly different (log-rank test p < . ) between physically active and inactive patients with or without known diabetes (see figure) . notably, physically inactive patients had a higher mortality regardless of diabetic status. after adjusting for confounders, the hazard rate was . (p = . ) for having diabetes and . (p < . ) for being physically inactive. conclusions: physically inactive patients had a higher mortality risk compared to those who were physically active, regardless of diabetic status. medical pharmacology, akdeniz university, antalya, turkey aims: we investigated functional effects of glp- ( - ), glp- ( - ), exendin- ( - ), exendin ( - ) and role (s) of reactive oxygen species (ros) and endothelium-derived hyperpolarizing factor (edhf) in the effects of these agents in small resistance arteries from control and diabetic rats. methods: mesenteric arterial rings were suspended in wire myograph and responses to glp- ( - ) and its analogues were recorded in the absence and presence of ros scavengers; superoxide dismutase (sod, u/ml) and catalase (cat, u/ml). role of edhf in glp- induced responses was investigated in kcl ( mmol/l)-contracted rings following incubation with no synthase inhibitor l-name ( À mol/l) and cyclooxygenase inhibitor indomethacin ( À mol/l). results: glp- ( - ) and glp- ( - ), but not exendin- ( - ) or exendin ( - ) produced concentration-dependent relaxations in mesenteric arteries from control and diabetic rats that were significantly higher in control compared to diabetic rats and in endothelium-intact compared to denuded preparations. incubation of control and diabetic rat mesenteric arteries with cat did not affect responses to glp- ( - ) and glp- ( - ) while, sod caused a significant increase in relaxant responses only in diabetic rats. glp- ( - ) and glp- ( - ) induced relaxations were significantly and similarly blunted by l-name plus indomethacin in control and diabetic rats. we provided evidence about relaxant effect of glp- ( - ) and glp- ( - ) in rat resistance arteries and about the reduced vasorelaxant effect of glp- in diabetic rats. our findings suggested that edhf played a role in glp- -induced relaxations and that increment in certain ros and/or reduction in sod function might play a role in reduced vazorelaxant responses to glp- in diabetic rats. results: significant differences for systolic blood pressure, lipids levels and kidney function between the groups are depicted in table . homa-ir was elevated in both groups, but significantly higher in the diabetic group ( . ae . vs. . ae . ; p < . ). diastolic blood pressure, crp and total cholesterol were not significantly different between the two groups. in the longitudinal group hba c levels decreased dramatically in the diabetes group ( . ae . % vs. . ae . %; p < . ), but less in the normal glucose tolerance test group ( . ae . % vs. . ae . %; p < . ). conclusion: diabetic patients with morbid obesity have a much higher cv risk profile compared with nondiabetic subjects despite presenting with the same bmi and should therefore be the preferred candidates for metabolic surgery since capacities are very limited. objective: morbid obesity (mo) has been shown to be associated with hypothyroid disorders in some patients. we therefore investigated the relationship between thyroid function parameters, bmi and insulin resistance in patients with morbid obesity before and after bariatric surgery. in patients ( . % women) with mo ( ae years; bmi . ae . kg/m ), parameters of thyroid function (tsh, ft , ft ) and homa-ir were determined before and years after bariatric surgery (weight loss À . ae . kg; p < . ). due to the lack of normal distribution, thyroid function parameters were logarithmized for statistical evaluation. results: of the patients, presented with hypothyroidism (tshrange: . - . lu/ml) before surgery, six of them with overt hypotheroidism (ft -range: . - . ng/dl). in the euthyroid patients, tsh decreased from . ae . to . ae . lu/ml (logtsh . ae . vs. . ae . ; p < . ). in the hypothyroid patients, tsh declined from . ae . to . ae . liu/ml (logtsh . ae . vs. . ae . ; p < . ). in the latter, the decline in tsh was more pronounced than in euthyroid patients (p < . ). concordantly, ft concentrations increased by . % (p = . ) and by . % (p < . ) in euthyroid and hypothyroid patients. homa-ir declined from . ae . to . ae . (p < . ) in euthyroid patients and from . ae . to . ae . in hypothyroid patients (p < . ), but did not correlate with the decline in tsh. the improvement of thyroid function after bariatric surgery is not associated with the reduction in insulin resistance. therefore the improvement of thyroid function could independently contribute to the positive long-term effects of this intervention. introduction: some years ago chronic diseases were considered to be a problem of the rich and elderly population. today we know that within high-income countries, poor as well as young and middle-aged people are affected by chronic conditions. for chronic disease, there are a small number of risk factors common to many diseases. the major biological risk factors identified in the world health report are: overweight and obesity, raised blood pressure, raised blood glucose and abnormal blood lipids and its subset raised total cholesterol. objective: was to carry out an epidemiological survey on prevalence of raised fasting blood glucose in kosova. material and methods: according to the who steps methodology the fasting blood glucose in blood sample from finger was measure with accutrend plus on sample of randomly selected participants aged - years. results: according who criteria raised fasting blood glucose is if capillary glucose is more than . mmol/l or more than mg/dl. in kosova, females are in higher risk for diabetes than males (females . % vs. males . %), total . %. prevalence of raised fasting glucose was increased with age. at the age - year the prevalence of raised fasting blood glucose was . %, at age - year . %, at age group - year %, at age group - year was . % and at the age group - year was . %. conclusion: effective preventive interventions are needed, and health systems should prepare to detect and manage diabetes and its sequel. objectives: hypertension and hyperglycemia are features of the metabolic syndrome and diabetes. methylglyoxal (mg), a reactive glucose metabolite, is elevated in diabetic patients. we investigated whether mg induces hypertension and its molecular mechanisms. methods: male week old sprague-dawley rats were treated with mg ( mg/day by continuous infusion with a minipump) for weeks. aortic rings were used for vascular contractility, and other tissues alongwith cultured vascular smooth muscle cells (vsmcs) for molecular studies. hplc, western blotting and q-pcr were used to measure mg, proteins and mrna, respectively. sirna for angiotensinogen and the receptor for advanced glycation endproducts (rage) were used to study mechanisms. results: mg treated rats developed a significant increase in blood pressure, plasma aldosterone, renin, angiotensin (includes precursor and products), norepinephrine, epinephrine and dopamine levels. the aorta showed increased contractility to the a agonist phenylephrine. mg level and protein and mrna for angiotensin, at receptor, a d receptor and renin were significantly increased in the aorta and/or kidney of mg treated rats. treatment of cultured vsmcs with mg or high glucose ( mmol/l) significantly increased cellular mg, and protein and mrna for nf-jb, angiotensin, at and a d receptors, which were prevented by inhibition of nf-jb. silencing of mrna for rage prevented the increase in nf-kb induced by mg. silencing of mrna for angiotensinogen prevented the increase in protein for nf-jb, angiotensin, at and a d receptors. conclusions: mg activates nf-jb through rage and thereby increases activity of the renin angiotensin aldosterone system to cause increased vascular contractility and hypertension. background: guidelines state obesity as an indication for diabetes screening. abdominal obesity is valuable to manifest metabolic risk as much as and may be even more than body mass index (bmi). in this study the answer to "which is a better indicator for diabetes screening; bmi or waist circumference?" has been questioned. method: three hundred people attended to the invitation of diabetes screening in istanbul medeniyet university goztepe research and training hospital outpatient clinics. their demographic characteristics, bmi, waist circumference, fasting blood glucose (fbg), diabetes history and if diagnosed drug regimen were recorded. results: a total of individuals ( women, men) were enrolled. one hundred forty three of ( %) individuals had a bmi ! . among those people ( %) had fbg ! and < mg/dl and (% ) had fbg ! mg/dl (table ) . abdominal obesity was observed in individuals ( women, men). thirty % had known diabetes mellitus (dm). among patients with abdominal obesity and without dm diagnosis, % had dysglycemia (table ) . among obese individuals, % had a history of dm. dysglycemia rate among obese persons without a history of dm, was % (table ) conclusion: abdominal obesity is a strong predictor of diabetes as obesity and its presence should be considered as an indication for screening diabetes. internal medicine and cardiology, expertise centre of aviation medicine of tunis, mhiri, tunisia type diabetes is a rare disease compatible with aviation activity with restrictions and constraints of regular medical checks. this retrospective study was interested in drivers with type diabetes cemeda monitored since until . the aim of this work is to investigate the incidence of diabetes in the tunisian population of seafarers and show the difficulties of management of diabetic driver. sailors have diabetes type (or # %) and three student pilots (two civilians and military) had type diabetes resulting inability final flight. average blood glucose of diabetic patients was . g/l with a range of . and . g/l; glycosylated hemoglobin a c is an average of . % [range: . - . %]. the average age of diabetes is years and mean bmi of kg/m². a mild to moderate hypertension was found in % of diabetics; dyslipidemia was found in two-thirds of diabetics. the treatment of diabetic subjects: rules dietary guidelines were prescribed in only about % of cases. moreover, these measures were associated with treatment with oral antidiabetic (biguanide alone in % of cases; biguanide + pioglitazone in % of cases associated biguanide a sulphonylurea in approximately % of cases. conclusion: : the prevalence of niddm is significantly lower among sailors in the general population. the balance diabetic seafarers is the only guarantor of declining maturity of micro and macrovascular disease and strengthen the doctor′s attitude towards pn medical ethics and flight safety. methods: is a retrospective cohort study that included patients who attended a preventive evaluation unit between and , with at least three visits in that period. results: a total of patients were included, of whom ( %) had nafld at their first visit. the basal variables were similar between groups, with male predominance in the nafld group. high blood pressure and dyslipidemia predominate in the nafld group until visits and respectively. the other cardiovascular risk factors were similar until visit . the study showed a tendency to present high blood pressure, dyslipidemia and gallstones in the nafld group in a shorter period of time than the control group. levels of aspartate aminotransferase raised in a period of . vs. . years in the control group (p = . ). the study was not able to demonstrate a clear difference in the presentation of cardiovascular risk factors and liver function tests in patients with nafld and although there was a higher presentation of gallstones, it requires a larger sample and a longer follow up period to have significant results. objective: to determine the relationship between metabolic syndrome (ms) and exaggerated blood pressure response to exercise (ebp) in adolescents. methods: this cross sectional study was conducted in adolescents ( males, females), randomly selected of high schools, in maracaibo, venezuela. they underwent an exercise treadmill testing. the ms was defined according to the definition of the national cholesterol education program, adult treatment panel iii modified for adolescents. the bp was measured at rest and during the treadmill test (bruce protocol), and it was registered the systolic bp (sbp) in maximal exercise to define adolescents with ebp ( ! mmhg). statistical analysis: chi square test was used to establish associations between ms and ebp. results: the ms prevalence was . % (n = ) in all subjects, . % (n = ) in males and . % (n = ) in females (p: . ). the sbp in maximal exercise values were: . ae in adolescents with ms and . ae in adolescents without ms (p: . ). the prevalence of the ebp was . % (n = ) in all, . % (n = ) and % (n = ) in subjects with ms and without ms, respectively (p: . ). the ms is closely linked to the sbp response to exercise in adolescents. those adolescents with ms are more likely to have exaggerated sbp during exercise, indicating an important information about their cardiovascular risk. background: metabolic syndrome (mets) is a cluster of risk factors that carries a great risk for atherothrombotic events leading to significant morbidity and mortality. few studies evaluated the association between mets and acute stroke. the aim of this work was to study the prevalence of mets and its effect on icu mortality in acute non embolic ischemic stroke patients. patients and methods: we studied patients presented with acute ischemic stroke diagnosed by ct brain in the medical icu, zagazig university hospital for the presence of mets and its relation to age and sex as well as the number of components of mets. we studied also the relative risk of mets with its different components as well as age, sex, glasgow coma scale (gcs) and apache ii score on the mortality in those patients. results: mets was found in . % of patients. it was more prevalent in males ( . %). this prevalence increase progressively in males aged - years then decrease progressively while in females, prevalence increase progressively with age. . % of patients have three components of mets compared to . % with more than three components. the relative risk of mortality was found to be increased with increasing age, male gender, obesity, hyperglycemia, low hdl-c, increased serum triglycerides, lower gcs, increased map, mets per se and higher apache ii score. mets and apache ii score were good predictors of mortality. contrary to the usual approach, we could leave the future open to a bi-therapy associating glp- mimetics and dpp- inhibitors (before the supplementation in metformin and sulfamids or glitazones). case report: diabetes type in balance for years after being treated first with metformin only then added glitazone, to end by glp- mimetics at maximum doses and metformin but still not under control. it was decided to associate glp- mimetics and dpp inhibitor, ending up to a glycemia and insulin . and hba c: . . after stopping the treatment for days we observe: fast glucose , postprandial (on a diabetic diet), relative hypoglycemia generating a multi metabolic syndrome spiral. the increase of the fast glucose being explainable by the non-control of the glucagon produced during the night. pattern proposed: glucagon would not work on demand but time continuously. it has to be inhibited thanks to the glp as soon as the glycemia increases and this would be irrespective of food intake. therefore, there is no reason to use the dpp inhibitors only in case of resistance to endogen glp and let the glp -mimetics being destroyed by the dpp . this would lead to a therapeutic failure or usage of very high doses. we could treat upstream the sequence of energetic metabolism. first of all: glp -mimetics or dpp inhibitors. secondly: glp -mimetics and dpp inhibitors. those steps could be part of tomorrow′s decisional algorithm of type diabetes. abstracts of the th international congress on prediabetes and metabolic syndrome aim: to evaluate the prevalence tipe diabetes mellitus (dm ) and ischemic heart disease (ihd), and diabetogenic/atherogenic factors in patients with newly diagnosed long-term gout material: seventy males - -years (mean ) with untreated tophaceous primary gout - years (mean- ) duration (without renal insufficiency) were studied. uric acid level was fasting serum glucose, insulin (control- - , mean pmol/l), total and hdl cholesterol, triglyceride, bp and ecg monitoring mmol/l, insulin and pmol/l. one more patient, years, with ihd and triglyceride . , cholesterol . mmol/l, insulin pmol/l levels. thus, diabetes was in one and ihd in three patients two patients ( - years) with and years of gout and hyperinsulinemia thus, long-term gout (hyperuricemia) even with concomitant high bmi, insulin, cholesterol and triglyceride levels is not an evident risk factor for diabetes and ihd development. probably, antioxidative effects of uric acid play a role montes claros, brazil background: the leptin receptor is an important regulator of leptin activity and a potential mechanism for the obesity. the polymorphism leprgln arg could be associated with high body fat percentage (bf%) and body mass index (bmi) objective: to investigate the association leprgln arg with obesity indexes we obtained oral swab and anthropometric measures including waist circumference (wc), bmi and bf% for subjects aged ! years. the genotypes were determined by pcr-rflp method. the statistic analyze were carriedout in stata software. results: there were no differences of age average between sex (female . ae . ; male . ae . ). the prevalence of the overweight (bmi > kg/m ) was . %( ), normal, . % ( ) and obesity (bmi > kg/m ) . % ( ). the prevalence of high wc (> cm for women or > cm for men) was . % ( ) and . % ( ) in women and men, respectively (p = . ) and of the high bf% (> % for women and > % for men) was adiposity was not associated with genotypes. the frequencies of overweight were . %, . % and . % and of the obesity were . %, . % and . % in the genotypes aa, ag and gg, respectively. there was not also association for high wc conclusions: these findings suggest that the leprgln arg is not associated with high bf%, bmi or wc in this population hydrogen breath test (bth ), based on lack of source for hydrogen gas in humans other than bacterial metabolism of carbohydrates, is use to detect carbohydrates malabsorption aims: to evaluate the utility of bth in detect carbohydrates malabsorption in overweight-obese subjects. patients and methods: hundred and six consecutive subjects ( overweight, obese; males/ females leptin injection did not suppress ei. importantly, ts treatment reinstalled leptin sensitivity as seeing a significant decrease in ei for h (À %, p = . ) and increase of pstat level (À %, p < . ) in the hypothalamus after i acknowledgements: this work was supported by a grant of the romanian national authority for scientific research, cncs-uefiscdi, project number pn-ii-id-pce- - - ". dr. lixandru, was supported by the postdoctoral program posdru/ / . /s/ , from european social fund. this cluster-randomized controlled trial study aimed to assess the effectiveness of the interactive multi-modality technology (imm) as an intervention to increase self-management among type diabetic patients in a -month period. the imm intervention contained email, short message system (sms), and website with four main functions (i.e., selfregulation, self-monitoring and assessment, social support, and reminder system -linked to email and sms). in this trial, four public offices in bangkok metropolis were recruited and randomly assigned into either the intervention or the control group. one hundred and twenty four thai patients who had met inclusion criteria (hemoglobin a c or a c > . %, no serious illness, and internet and mobile phone accessibility) were subsequently assigned to the intervention (n = ) and the control (n = ) group. patients in the intervention group received the imm intervention. those in the control group received selfmanagement knowledge via email only. outcome measures, a c and behavioral questionnaires (diabetes quality of life, self-efficacy, and division of endocrinology and metabolism, national institute of nutrition, secundrabad, india introduction: we showed earlier that increased visceral adiposity in the offspring of magnesium deficient rats was associated with altered gene expression and increased stress.aim: to assess whether maternal magnesium deficiency modulates the gene expression of adipogenesis and insulin sensitivity in utero due to increased stress.methodology: female weanling wnin rats received for weeks, an ain g diet (control: mgc) or the same with % restriction of magnesium (mgr) and mated with control males. half the pregnant mgr dams were rehabilitated from conception (mgrc) while others continued on magnesium restriction. total rna was isolated from the mgc, mgr and mgrc embryos collected on day of gestation and expression of βhsd , pparc and adiponectin was quantified by real time pcr. body composition was determined in month old offspring by total body electrical conductivity (tobec).results: plasma magnesium levels in mgc and mgr dams before pregnancy; and month old mgc, mgr and mgrc offspring were on expected lines. mgr embryos had significantly higher expression of pparc and βhsd than mgc, whereas adiponectin expression was lower. on the other hand in mgrc th day embryos βhsd and pparc expression was restored to mgc, adiponectin expression introduction: khaya senegalensis is presently used for the treatment of diabetes in some west african countries.objectives: this study was conducted to investigate the anti-diabetic effects of the plant using in vitro and in vivo models.results: ethanolic extract of the root sample of the plant was subjected to solvent solvent fractionation which yielded a butanol fraction that possessed significantly higher (p < . ) anti-oxidative activity as well as a-glucosidase and a-amylase inhibitory activities than other (aqueous, ethyl acetate and dichloromethane) fractions. enzyme kinetic studies indicated that the butanol fraction is a non-competitive inhibitor for a-glucosidase with an inhibition binding constant (ki) of . lg/ml and a competitive inhibitor of a-amylase with a ki of . lg/ml. subsequently, the butanol fraction was subjected to in vivo studies in a type diabetes model of rats. after weeks of intervention, the fraction, at mg/kg bw, was found to improve the feed and fluid intake, body weight gain, blood glucose, glucose tolerance ability, serum insulin concentration and β cell function of diabetic animals. phytochemical analysis of the fraction through repeated column chromatography led to the isolation of bicyclo [ . . ] hexane- , , -triol. the structure of the compound was established through detailed spectroscopic methods including h nmr, c nmr and d nmr (cosy, hsqc and hmbc) experiments.conclusion: data from the study suggests that the butanol fraction of k. senegalensis contains bioactive agents that could be exploited in the management of type diabetes. objective: to determine the progression rate to impaired fasting glucose (ifg), impaired glucose tolerance (igt), and diabetes (dm ) in normal glucose tolerant (ngt) people during years follow up study using who and new criteria of ifg (ifg , -fasting glucose . - . mmol/l).research design and methods: this is an year prospective study in a randomly selected urban population aged ! years living in krakow, poland. persons had ngt. based on who criteria, ( . % of invited, men and women, aged mean . sd = . ) attended the follow-up assessment.. subjects underwent a physical and biochemical examination and questionnaire examination.results: the prevalence of dm , ifg and igt according to who criteria in examined population with baseline ngt was . %, . % and . % respectively. the prevalence of ifg , using new criteria, was . %, lowering cutoff point for ifg caused . % increase in the prevalence of ifg.among people with diagnosed diabetes % had newly diagnosed diabetes during the control study. the prevalence of dm and igt/ ifg was increasing with increasing age and bmi categories (p < . ). the lowest obesity prevalence both baseline and after follow up was found in those who remained ngt.conclusion: in the baseline ngt population high follow-up progression rate to impaired glucose metabolism was found. the implementation of new ifg diagnostic criteria increased the prevalence of ifg by . %. according to our results prevention of diabetes initiatives should focus on normal body weight preservation. results: sbp was found to be elevated in . % subjects whereas dbp was elevated among . % subjects. out of all the subjects, . % were overweight and . % obese. obese subjects were found to be more hypertensive than non-obese subjects (r = . ). sbp had strong correlation with age (r = . ), bmi (r = . ), whr (r = . ), fbs (r = . ), chol (r = . ) and ldl (r = . ) whereas dbp was found to be strongly correlated with same parameters and triglycerides (r = . ) also. no significant correlation was found with hba c levels and hdl-cholesterol. conclusion: hypertension was found to be more prevalent in males as compared to females in this diabetic population. there was an background: the medicine faculty, chiang mai university provided health screening to detect health problem and risk group for high school students who past entrance examination in this academic year . there is no official cutoff value of waist circumference (wc) measured at superior iliac crest level (wci) for overweight and obesity in thai young adolescence. we aimed to determine correlation between wci and to those measured at midpoint between lower costal margin and superior iliac crest (wcm) and to define appropriated wci and body mass index (bmi) cutoff levels for admission students in northern thailand.methods: the admission students had weight (kg), height (cm), wc, and blood pressure measurements.results: there were admission students. . % of them were female. the correlation between wci and wcm was . . for receiver operating characteristics analysis of having high bp (systolic ! mmhg or diastolic ! mmhg.) using wcm of cm in male and cm in female as standard (wcm ), area under curve ( . ) of wci of cm in male and cm in female (wci ) andabstracts of the th international congress on prediabetes and metabolic syndrome all patients were asked to follow a dietary plan for weeks before bth , day before the test, subjects were instructed to take a low fibre diet. bth was carried out both after overnight fasting (t ) and during oral glucose tolerance test (ogtt). hydrogen gas is detected in exhalate, cut-off value was settled at ppm.results: at t bth was positive in % of overweight and % of obese subjects.particularly, bth was positive in % of subjects with ms and in % of those without ms.during ogtt, % of bth results, negative at t , became positive.conclusions: obese subjects with ms had an bth altered value at t suggesting a intestinal dysbiosis.on the basis of our preliminary data, bth at t can be helpful to diagnose gastrointestinal disorders driving the idea of intestinal dysbiosis as a possible cause in pathogenesis of obesity, thus a probiotic supplementation is to be considered as baseline therapy in overweight-obesity. department of clinical physiology and pathology of locomotor apparatus, institute of gerontology ams ukraine, kyiv, ukraine aim of research: to determine uric acid level in blood serum and incidents of hyperuricemia among women and men of different age and their relation with some components of metabolic syndrome.object of research: age of examined patients was from to years old: women (n = ) and men (n = ). they were divided in following groups: i group (bmi = . - . ), ii -(bmi = . - . ), iii -(bmi = . - . ), iv -(bmi > ). average age of examined patients was . ae . years.methods: uric acid level in blood plasma was determined by uricaseperoxidase method. aim: we studied the prevalence and prognostic impact of the metabolic syndrome (ms) in acute myocardial infarction (ami) patients (pts) with normal (ngt) or abnormal glucose tolerance (agt).material and methods: a total of consecutive nondiabetic ami pts performed an oral glucose tolerance test at hospital discharge being categorized using idf/nhlbi/aha ms criteria into four groups (gr): gr. i -ngt no ms (n = ), gr. ii -ngt with ms (n = ), gr. iii -agt no ms (n = ), gr. iv -agt with ms (n = ). clinical characteristics and cv events during . years follow-up were studied.results: ms was diagnosed in % pts, with a higher prevalence in agt vs. ngt subjects (p < . ). ngtms and agtms subjects were more likely to be older (p < . ), women (p < . ), hypertensive (p < . ), have stroke history (p < . ) and hypertriglyceridemia (p < . ) compared to pts without ms. in hospital heart failure rates were higher in gr. ii, iv vs. gr. i, iii (p < . ). agtms subjects showed more often atrial fibrillation and a lower lvef% compared to ngtms (p < . ). cv events incidence during follow-up was similar among groups excepting significantly higher mortality in pts with ms, especially in agtms subjects (rr = . ( % ci . - . ) for ngtms; rr = . ( % ci . - . ) for agtms).conclusions: ms was present in % of nondiabetic ami patients and was associated with high long-term mortality; its incidence and the risk of death increased in the presence of agt. methods: a cross-sectional study was realized in government workers during his medical review, from april to september . the screening included height, weight, waist circumference, blood pressure measurements, plus a blood draw sample to determine glucose, triglycerides, and total cholesterol. body mass index (bmi) was used to diagnose overweight and obesity according to cut-offs proposed by the world health organization ( ). the mets was defined according with aha/nhlbi criteria ( ) . waist circumference (wc) and waist-to-height ratio (whr) were used as fat distribution indexes. all statistical analyses were performed using the spss v .results: in total, workers aged - years, of both sexes ( % males and % females), were included. the overall prevalence of mets was extremely high with % ( % in male, and % in female). abdominal obesity was present in . %, high triglycerides in . %, high-density lipoprotein cholesterol levels in . %, fasting hyperglycemia in . %, and hypertension in . % of the sample. % of the overweight or obese were diagnosed with metabolic syndrome. the prevalence of overweight and obese was extremely high too, according with gender: % in male, and % in female. mets was associated with cigarette smoking, absence of physical activity, a higher bmi and a greater proportion of obesity. the mets prevalence in this sector of mexican government workers is a very serious health problem. it is urgent to develop innovative programs that improve health situation. our rehabilitation department targets obesity and take care of patients a year, either in a outpatient (op, day hospital) or in patient (ip) programme.we focus on therapeutic education, and our approach is medical, nutritional, physical, psychological and social.the aim of our study is to compare the efficiency of the day hospital vs. in patient in the rehabilitation of obesity.two samples of patients who exited our unit months ago were compared.investigated criteria were: loss of weight during the programme, way of life after the programme (physical activities, diet), medical and psychological follow up.the results showed: . a weight loss between the patient admission and the trial date of . kg for in patients vs. . kg for day hospital patients. . the diet prescription is followed by . % of ip patients and by . % of op patients. . the prescription of physical activity was followed by % of ip patients and . % of op patients. . a psychological follow up is done by % of ip patients and % of op patients.the efficiency of the therapeutical education programme is proven in either ip or op patients.the day hospital allows a smooth return to normal life after a nutrition inpatient rehabilitation. research design and methods: a total of asymptomatic t dm subjects ( men and women; mean age: . ae . years) were enrolled. clinical and laboratory parameters, including hba c, glycoalbumin, lipid profile were evaluated and cardiovascular magnetic resonance (cmr) was performed. abnormal findings of cmr were defined as any one of the followings: . silent myocardial infarction. . inducible ischemia. . suspected cad.within days after taking cmr, invasive coronary angiography (ica) was performed in selective patients.results: among patients, a total of patients (silent myocardial infarction (n = ), inducible ischemia (n = ), suspected cad (n = )) had at least one abnormal finding on cmr and ica was recommended. finally, patients underwent ica, and subjects had significant cad (a total of coronary territories assess) overall, in asymptomatic t dm patients, the positive predictive value (ppv) of sp-cmr, cmr-a, c-cmr are %. however, the ppv of each mri to detect signinficant stenosis are %, % and %, respectively. in asymptomatic t dm patients, stress perfusion cmr showed higher ppv than cmr-a. introduction: observational data suggests that low -hyroxyvitamin d is associated with metabolic syndrome in diabetic and non diabetic patients. we examined the difference between components of metabolic syndrome before and after treatment with calcitriol in type diabetic patients with vitamin d deficiency.method and material: a total type diabetic patients were selected. patients had vitamin d deficiency that underwent calcitriol treatment with . lg per day for weeks. in all cases, clinical parameters including weight, systolic and diastolic blood pressure and laboratory parameters including levels of fasting blood glucose, insulin, lipid profile, calcium, phosphorous, hba c and insulin resistance were measured, before and after the treatment period. the two sets of results were then compared with one another.results: following treatment with calcitriol hba c, total cholesterol, ldl, hdl and diastolic blood pressure decreased significantly. (p = . , . , . , . and . respectively). but the changes in other parameters were not significant. subjects and methods: the five components of mets following the criteria of the international diabetes federation (idf) were measured in men (mean age . ae year) and women (mean age . ae . year) participating in the pep family heart study. we determined percentage body fat using skinfold thickness. we defined high %bf > % for females and > % for males and elevated bmi as ! kg/m². spss version was used for the statistical analyses; multiple linear regression models were used. two-tailed p < . was considered significant.results: mean values of wc, blood pressure (bp), fasting plasma glucose (fpg), triglycerides (tg), hdl-cholesterol and bmi were significantly higher in men than in women who had higher %bf ( % vs. %). using multiple linear regression models, we found significant associations with wc, %bf and bmi. bmi had the strongest associations with tg (beta . ; ci % . - . ), hdl-c (À . ; À . to À . ), sbp ( . objective: patients with esrd have an increased risk for cardiovascular morbidity and mortality. metabolic syndrome (metsy) has been implicated in the progression of cardiovascular disease (cvd). this cross sectional study investigated the prevalence of metsy in maintenance hemodialysis (hd) patients using a joint definition for metsy.patients and methods: subjects had to meet at least three of the following five criteria for metsy: elevated waist circumference, elevated triglyceride levels, low hdl cholesterol, elevated blood pressure and elevated fasting serum glucose. demographics, medical history, anthropometric and laboratory data were collected from the medical records. serum chemistries were obtained mid-week and waist circumference was measured twice after a hd session and the mean value was calculated. the study cohort consisted of % male patients with the mean age of . ae . years. hypertension was the leading cause of esrd ( %) followed by diabetic nephropathy ( %). metsy was identified in % of the cohort, with %, % and % having , and risk factors, respectively. the prevalence of metsy was highest amongst patients on hd for > years ( %). for those patients on hd < months, - months and > to < years, metsy was identified in %, % and %, respectively. metabolic syndrome was not associated with gender and age.conclusion: metsy is highly prevalent in hemodialysis patients, which suggests an additional risk for cvd. early screening for metsy may have protective role on cvd morbidity and mortality. department of family medicine, kangwon national university hospital, chuncheon, republic of korea introduction: it was reported decreased relative muscle mass was related with insulin resistance and prediabetes in us. the aim of this study is to investigate the association of relative muscle mass with cardiovascular disease risk factor using the nationally representative sample of korean adults.methods: this is a cross-sectional study using the data of the subjects who participated in the korean national health and nutrition examination survey (knhanes) in - . multiple linear regression analysis for survey design was used to explore the association between relative muscle mass and the factors of metabolic syndrome and homa-ir with adjustment for confounding factors.we also conducted multiple logistic regression analysis for survey design to investigate the relationship of relative muscle mass with metabolic syndrome.results: in comparison with subjects in the first quintile of relative muscle mass, the odds ratio ( % confidence interval) for metabolic syndrome for subjects in the fifth quintile was . ( . , . ) in the age < group and . ( . , . ) in the age ! group respectively after adjusting for confounding variables. relative muscle mass was inversely associated with sbp, dbp, serum tgs, fbs and homa-ir in both age < and age ! group, showing significant liner trend.conclusions: decreased relative muscle mass was inversely associated with the prevalence of metabolic syndrome, and the factors of metabolic syndrome except hdl-c. the causal relationship is not exactly known and would be elucidated through further longitudinal study. endocrinology, moscow regional research clinical institute, moscow, russia background: there has been growth in registered prevalence of type diabetes (t d) in russia. real prevalence of t d is much more higher. new approaches for early detection of glucose metabolism disorders are important.aim: assess effectiveness of new approach to screening of glucose metabolism disorders based on using diabetes bus in remote areas of moscow county. objective: to study the frequency of metabolic syndrome according to the atpiii criteria among elderly people attending the family practice clinic at the jordan university hospital, and to investigate the pattern of antihypertensive medications used for patients with metabolic syndrome.design: a total of elderly people ( males and females) aged years or more attending family practice clinic at jordan university hospital.materials and methods: elderly patients included were studied regarding the frequency of metabolic syndrome and its individual components according to the atpiii criteria. antihypertensive medications used by elderly patients with metabolic syndrome were also investigated.results: the frequency of metabolic syndrome was found to be . %. hypertension was the most frequent risk factor among all patients including males and females ( % in the whole sample, . % in males and . % in females). all risk factors except hypertension were significantly more frequent among patient with metabolic syndrome compared to those with no metabolic syndrome. the most commonly used antihypertensive medications were the angiotensin converting enzyme inhibitors ( . %), followed by beta blockers ( . %), calcium channel blockers ( %), and finally angiotensin receptor blockers and thiazide diuretics (both . %).conclusion: the frequency of metabolic syndrome was relatively high, which highlights the need to take some action to combat the syndrome. hypertension in particular showed the highest frequency among all risk factors. optimum control of hypertension by following the guidelines is essential in this context to better achieve control without adversely affecting the metabolic syndrome out come. introduction: metabolic syndrome is associated with a significantly increased risk of morbidity and mortality.objective: to assess incidence of the metabolic syndrome in patients of the team in the family medicine centre in kalesija through the medical audit.patients and methods: we have analyzed the medical records of all the patients with team with years of age and over ( records).we have used the international diabetes federation and the american heart association (aha) criteria for the definition of metabolic syndrome diagnosis. the analysis is done separately by sex, age and body mass index (bmi). the results of this study shows that ( %) of adults meet the criteria for the metabolic syndrome. of these, ( %) were women and ( %) men. % of patients in age group of - years meets the criteria for the metabolic syndrome. % of patients - years old, and % of patients ages and older, meets the criteria for the metabolic syndrome. out of the total number of female patients who meet the criteria for the metabolic syndrome, % had increased and % had normal bmi. from the male patients who met the criteria for metabolic syndrome, % had increased, and % had normal bmi.conclusion: the incidence of the metabolic syndrome in family medicine is high. metabolic syndrome is prevalent and significantly increased with age and bmi. more effective interventions in primary care are needed in order to reduce cardiovascular morbidity and mortality. methods: after weeks of high-fat diet, dio mice (n = ) were divided into two groups received either intraperitoneal (ip) injection of ts ( mg/kg, daily) or saline for days. another group of mice were fed low-fat diet (lf) as control (n = ). then both dio mice and lf mice were given intracerebroventricular (i.c.v.) injection of leptin or saline. results: ts significantly decreased final body weight gain (À %, p < . ) and average ei (À %, p < . ) in dio mice. ts significantly decreased pro-inflammatory markers (tnf-a, il- , il- β, p-ikk and p-ijba) in epididymal fat, liver and hypothalamus of dio mice. in lf mice, i.c.v. injection of leptin significantly suppressed ei compared to saline injection (À %, p = . ). however, central leptin sensitivity was blunted in dio mice evidenced aim: non-alcoholic fatty liver disease (nafld), which is characterized by the accumulation of fat in the liver in the absence of alcohol intake, strongly linked to metabolic syndrome. recently, proinflammatory cytokines and oxidative stress mechanisms have been implicated in the pathogenesis of psychiatric disorders. in addition, patients with drug-free schizophrenia have significantly higher body mass index than in aged-matched healthy controls. the purpose of the study was to investigate the effects of metabolic syndrome on the apomorphine-induced stereotypy in a rat model of nafld.materials and methods: eighteen male sprague-dawley rats were included in the study. in order to develop nafld model, rats (n = ) were provided with drinking water containing with % fructose for weeks, while control group (n = ) received only tap water. after the verification of fatty liver by ultrasonography, apomorphine-induced stereotypy was investigated as described by kenneth and kenneth ( ) . then, all rats were sacrificed; homovanillic acid (hva), a dopamine metabolite, levels were measured in brain homogenates. prefrontal cortical il- immunoexpression was evaluated by immunohistochemistry and hepatocellular changes were determined histologically.results: histological evaluation of liver sections confirmed macrovesicular steatosis in nafld rats. moreover, the stereotyped behavior scores, brain hva levels and il- expression were found significantly higher in nafld group than in the control group (p < . ). our results suggest that metabolic syndrome and fatty liver significantly induce dopaminergic activity and stereotyped behavior in rats. the neuromodulatory effects of pro-inflammatory cytokines and imbalance between oxidative and anti-oxidative status may underlie these alterations. the classical thinking in type diabetes is that the plasma glucose levels are regulated by interplay between insulin, glucagon and other peripheral mechanisms. a combination of insulin resistance and relative insulin insufficiency is considered to be causal to hyperglycemia. this traditional wisdom is now being challenged and an alternative model is proposed where the central nervous system (cns) plays a vital role in plasma glucose regulation. the role of cns in glucose regulation is well known. for example it has been shown that intracerebroventricular injection of glucose results in a decrease in plasma glucose level in rats. however whether and to what extent the cns has an active role in diabetic hyperglycemia is not known. we make mathematical models of different versions of the peripheral and central mechanisms and make differential correlational predictions which can be tested on oral glucose tolerance test ( background and aims: high calorie diets leads to fat liver and changes in the metabolic pathways. therefore the gluconeogenic capacity of the livers in a condition of high levels of exogenous fatty acids was evaluated in cafeteria-fed rats.methods: two groups of weaned wistar rats received cafeteria or balanced diet during days. the fasted livers were perfused with mmol/l lactate plus . mmol/l pyruvate in absence or in presence of mmol/l stearate plus traces of [ - c]-stearate. measured parameters: glucose, ketone bodies, [ c]co , oxygen uptake, hepatic contents of lipids and glycogen.results: cafeteria-fed rats presented increase in: body and liver weight, fat in the tissues and hepatic glycogen. perfusion experiments revealed that in cafeteria-fed rats the gluconeogenic flux was lower than in the control, but the infusion of stearate, caused a higher stimulus on glucose production. the co and ketone bodies production was reduced during the active gluconeogenesis in cafeteriafed and control rats, being the former less sensitive, whereas no differences were found after stearate infusion. background: despite advances in option of treatement diabetes, optimal glycemic control is not often achieved. glucose homeostasis is dependent on a complex interplay of multiple hormones and glucagon like peptide- (glp- ) receptor agonists are a new class of drug for the treatment of type diabetes. they are not considered as initial therapy for the majority of patient with type diabetes and their clinical use, long-term benefits, risks and their role in combination with other diabetes medication are still under investigation.study: in the retrospective study in we enrolled patients with poorly controlled type diabetes on one or two oral agents, who received additional therapy with glp- receptor agonist: liraglutide or exenatide. we monitored hba c value and body weight before and after modification of therapy.results: fifty-one patients, men, were - years old (mean years). their mean body weight was . kg (sd ae . ) and mean hba c . % (sd ae ). after - months of combined therapy with metformin and/or sulfonylurea and glp- agonist their mean hba c dropped to . % (sd ae . ) and their body weight reduced to . kg (sd ae . ). in patients with type diabetes and suboptimal control on one or two oral agents adding glp- receptor agonist was effective in improving glycemic control and body weight reduction. despite lack of evidence on their clinical use, long-term benefits and side effects these agents have the potential to change the diabetes treatment by replacing traditional secretagogues because of superior control and association with weight loss. objective: the metabolic syndrome (ms) is a particular affection that has been associated with so many factors such as hypertention. both increase cardiovascular diseases. due to the higher prevalence of hypertension in our country, this study aim to determine the frequency of ms in newly diagnosed hypertensive patients in oder to improve the follow -up of these subjets.methodology: over a period of months, we conducted a crosssectional and descriptive study on patients recently diagnosed as hypertensive for < months. the selection of patients was done during external consultation in the cardiology unit at the university teaching hospital of yaounde. it was based on high blood pressure, anthropome´tric parameters such as weight, bmi, waist, abdominal circonference and biological values (lipid profile, blood glucose, uric acid). we identified patients aged between and years, with a mean age of years. people aged more than years were mostly affected. stage was the prominent stage of hypertension.the prevalence of metabolic syndrome was . % with a higher rate in female.the cardiovascular risk factors were obesity, alcoholism, sedentarity and hypo hdlc factors differenciating population with metabolic syndrom was obesity (p = . ), hyperglycemia (p = . ), hypo hdlc (p = . ) while the phenotypes most represented were hyperglycemia, abdominal obesity and hypo hdlc respectively. the metabolic syndrome is frequent in newly diagnosed hypertensive subjects; the females were most affected. metabolic syndrome should be investigated systematically in all hypetensive patients. background: although mainly inhibits osteoclastogenesis, osteoprotegerin is produced by vasculature too. serum opg (sopg) is elevated in both diabetics and patients with coronary artery disease (cad) but there are still insufficient data for its concentrations in impaired glucose tolerance (igt) subjects. aims: to determine sopg in males with igt and concomitant cad and to investigate its relationship with certain glucometabolic parameters.materials and methods: sopg was measured in males with performed percutaneous coronary interventions for cad- with igt and normoglycemic, and in age-and bmi-matched healthy normoglycemic controls. glucose abnormalities were screen-detected using a standard ogtt. mean intima-media thickness (imt) of common carotid arteries was measured by b-mode ultrasonography. opg was measured by elisa.results: sopg was significantly higher in igt patients compared to controls ( . ae . vs. . ae . pmol/l; p = . ) but did not differ between igt and normoglycemic cad patiens ( . ae . vs. . ae . pmol/l, p = . ). in all participants, sopg correlated positively with imt (p . ; pr . ). similarly, in igt males with cad, sopg correlated only with imt (p . ; pr . ). there were no associations with fasting and postchallange plasma glucose, hba c, fasting insulin, homa-ir, lipid parameters, blood pressure, bmi or waist circumference. we found higher sopg in males with igt and cad compared to the controls. opg did not correlate with glucose parameters but rather with markers of atherosclerosis. we speculate in cad patients with igt, the increased sopg might reflect the vascular damage and not glycemic status which requires further investigations. internal medicine, umf iuliu hatieganu cluj-napoca, cluj-napoca, umf 'victor babes' timisoara, timisoara, romania objective: the pro ala polymorphism in the pparg gene (c>g) is associated with less weight loss after treatment for obesity. this study aimed to investigate the association of rs polymorphism with weight loss year after bariatric surgery. the sample was composed of individuals with grade iii obesity undergoing roux-en y gastric bypass. anthropometric data were collected in the preoperative period and year after surgery. genotyping was performed by the method of allelic discrimination in real time pcr (polymerase chain reaction) using the taqman predesigned snp genotyping assays kits (applied biosystems, foster city, ca, usa). individuals with at least one variant allele were grouped and compared with those with the reference genotype.results: subjects ( . % females, mean age . ae . years) participated in the study. genotyping showed % (n = ) of individuals homozygous for the c allele (c/c) and % (n = ) heterozygous (c/g). there was no homozygous mutant (g/g). individuals with the c/c and c/g genotypes respectively showed a loss of . ae . and ae . kg; . ae and . ae . % of initial weight and . ae and . ae . % of excess body weight. there was no difference in weight loss between groups.conclusion: the pparg pro ala genotype seems to have no association with weight loss year after bariatric surgery. objective: evaluated determine the prevalence of ir, ms and associated factors among banking workers in southeastern brazil.methods: out of males and females banking employees, years old were evaluated by cross-sectional study including demographic, biochemical, anthropometric and hemodynamic. the ms was determinate by ncep and idf. the ir was determined by homa-ir, with the cut off > . .results: ( . % % ci . - . ) and ( . % % ci . - . ) of employees with ms, according to the ncep and idf, respectively and ( . %) with ri. the likelihood of developing the syndrome is greater in individuals with high level of education (or . ( % ci . - . ) and among those with overweight and obesity, the possibility of having ms is , ( % ci . - . , p = . ) and . ( % ci . - . , p = . ) times over, respectively. persons who are overweight are at risk of . ( % ci . - . ) times more likely to have elevated homa, and among those who are obese, the risk rises to . ( % ci . - . ).conclusion: this study showed the higher number of employees who have similar characteristics of the total active working, that despite high education, also have ms and ir, and the consequent risk of developing cardiovascular disease. prediabetes is considered as a strong risk factor for type diabetes (dm ). tcf l is a gen involved in dm susceptibility related with glp-l. objective: study the relationship of rs and rs variants of the tcf l gene with insulin levels, c-peptide and glp- in normoglycemia and prediabetes subjects. we included pre-diabetic and normoglycemic subjects. we measure fasting glucose, lipids, insulin, c-peptide and glp- ). insulin resistance and beta-cell function were calculated with the homa model. tcf l polymorphisms rs c/t and rs g/t were determined by pcr-rflp. for analyses two groups were compared: wild-type and carriers of two allele risk. we included a total of subjects aged ae years. weight, bmi, systolic and diastolic blood pressure and triglycerides were significantly lower in the group of healthy subjects. glp- was higher in normoglycemic subjects. the frequency of rs t allele was higher in pre-diabetic subjects, while the allele frequency of rs t was not significantly different between the groups. in carriers of rs t, serum insulin and homa-beta were significantly higher. plasma levels of glp- were lower in prediabetic subjects with and without the risk allele variant. in prediabetic subjects carriers of the rs g/t or tt had also lower levels of serum insulin, homa-ir and homa-beta. the glp- concentrations were lower in both groups.conclusions: in this work the rs polymorphism tcf l gene was associated with prediabetes. the frequency of the rs t allele tcf l gene was not different between groups. objective: determine hba c, igfbp , fgf and other metabolic markers in non-diabetic, prediabetic, type diabetics (t dm) of recent diagnosis. material and methods: a cross-sectional population based study was carried in - years old subjects classified with fasting glucose (fg) and after h g oral glucose load (gt), as normal with impaired fg (ifg), impaired gt (igt), with both alterations (ifg/igt) and dm . after - weeks subjects were re-classified and registration of anthropometric data, food intake and determination of a c, lipids, insulin, fgf and igfbp .results: we found . % for prediabetes and . % for dm (n = ). in the re-classification we classified: normal, ifg, igt, ifg/igt, dm . with anova analysis we found that hba c in dm patients was different from normal, ifg, ifg/igt subjects (p < . , p < . and p < . respectively). fgf levels was different among all groups (p < . ). normoglycemic subjects were better educated and had higher income than the prediabetic and dm subjects. dm subjects reported more screen time. prediabetic subjects had higher hdl-cholesterol. with multiple regression analysis we found igfbp positively correlated with daily caloric intake and triglycerides and negatively with bmi. the fgf correlated positively with insulin. the prevalence of pre-diabetes is more than twice of that of undiagnosed diabetes. we find fgf and insulin related with the metabolic status. igfbp was negatively correlation with bmi finding compatible with an association with insulin resistance. we have previously found that the expressions of several homeobox transcription factors, including irx , were reduced in subcutaneous fat in human obesity. a knock-out (ko) mouse line was acquired for the purpose of investigating the in vivo effects of irx deficiency with the main perspective on how these mice would handle a high-energy dietary intake. though initially undersized, male irx ko mice fed a high-fat ( %) diet approached similar weight and size as their wildtype (wt) littermates. yet, mri show that the irx ko mice have smaller adipose tissue depots and store less fat around organs in aim: to examine the role of mir- in the pathogenesis of diabetic cardiomyopathy.objectives: to study the cardiac expression of mir- and its effect on regulation of genes involved in akt-pkb signalling pathway in animal model of diabetic cardiomyopathy (dcm).methods: type diabetes was induced in adult wistar rats by high fat diet and i.p streptozotocin injections. the animals were sacrificed at weeks and development of cardiomyopathy was confirmed by heart/body weight ratio, histopathological examination, myocardial fibrotic and hypertrophic genes. cardiac tissues were examined for expression of mir- , its target genes by real time pcr.results: myocardial expression of mir- was significantly increased and showed a positive correlation with myocardial mrna levels of fibrotic genes (ctgf, fgf-b & tgf-b) in diabetic rats. myocardial mrna levels of potential targets of mir- , phosphatase and tensin homolog deleted on chromosome (pten) and programmed cell death protein (pdcd- ), were increased and their protein expression was decreased in dcm group and in fibroblasts exposed to high glucose (p < . ). increasing mir- levels promoted, whereas knocking down mir- attenuated, pten, pcdc- activity in cardiac fibroblasts. our results suggest that mir- contributes to cardiac fibrosis in dcm by modulating activity of akt/pkb pathway through pten and pcdc- . objectives: many studies have revealed that prevalence of metabolic syndrome may be related to lifestyle components. the aim of this study was to investigate the influence of dietary patterns on prevalence of metabolic syndrome (mets). the data was based on health and nutrition survey for japanese men and women aged - year. factor analysis was used to obtain dietary patterns applying to intake of food groups. the definition of mets was followed by the modified version of the criteria of idf that is applied to japanese population. values of waist circumference, hdl-cholesterol, blood pressures, and hba c were used to identify mets. logistic regression analysis was used to examine the association between dietary patterns and prevalence of mets.results: three dietary patterns of "fruits", "rice", and "meat" were identified. in males, greater values of "fruits" pattern was associated with a significantly lower prevalence of mets after adjustment for age, physical activity level, smoking and drinking status and other confounding variables (or = . , % ci . - . ).conclusions: fruits consumption was inversely associated with mets and this association may be explained by much intake of mandarin orange specific to this surveyed population. this finding necessitates further investigation on the mechanisms of fruits consumption on health benefits. introduction: the impaired glucose regulation shows a double risk of cardiovascular morbimortality and development of type diabetes, especially in patients with high cardiovascular risk.objective: identify the carbohydrate abnormalities in unknown diabetic patients with high cardiovascular risk.patients and methods: hundred and forty-eight non-diabetic patients were involved in this single-center study, with at least three known vascular risk factors, metabolic syndrome or with known cardiovascular event over months.all had a test load of g oral glucose (ogtt) followed by h after dosing plasma glucose, serum glycated hemoglobin (hba c) and lipid abnormalities exploration. cardiovascular exploration also concerned all patients.results: among these patients, were in primary prevention and in secondary prevention. cardiovascular events were reported to be dominated by myocardial infarction ( . %) and stroke ( . %).dysglucoregulation concerned patients ( %); the sex ratio was . and the average age was , . unknown diabetes, ifg and igt were diagnosed.these glucose abnormalities were found equally in both primary and secondary prevention.in the family, diabetes was concerned with % and cardiovascular events mainly expressed by early myocardial infarction and stroke were observed in %.the vascular risk factors were more present in igt group.hypertension was found in %, followed by dyslipidemia in %; % met metabolic syndrom's criteria (idf ) .conclusion: in primary prevention context, ogtt not only detects unknown diabetics but identifies igt patients who dysplay a high risk of cardiovascular events. the aim was to study some indicators of inflammatory process and oxidative metabolism in the patients arriving for surgical treatment of pathological obesity. laboratory tests have been carried out by conventional methods in patients with pathological obesity of abdominal type with a body mass index > kg/m before and after biliopancreatic shunting operation.rise of blood glucose level up to . % (p < . ), uric acid level up to . % (p < . ), as well as dyslipidemia were determined in patients. the content of malondialdehyde (mda) increased . times, the general antioxidant activity (aoa) decreased . times. concentration of c-reactive protein (crp) exceeded . times the control value. the long-term results in these patients within - months have shown normalisation of level of blood glucose, uric acid, high and very low density lipoprotein cholesterol, a tendency of decrease in the general cholesterol concentration. triglycerides decreased by %, still remaining at sufficiently high level. mda concentration decreased by . %, aoa increased by . %. crp level which was considerably raised before operation decreased within the next months but in months its average value increased five times in relation to normal rate.the obtained results are evidence of the interrelation of inflammation process and oxidative stress in patients with pathological obesity and metabolic syndrome. efficiency of surgical treatment was shown in the insulin resistance syndrome includes well-recognized cardiovascular risk factors such as low hdl levels, hypertension, hypertriglyceridemia, which is highly correlated with small dense ldl and increased lp(a) levels, which is cardiovascular risk factor. we aimed to study dyslipidemia, especially lp(a) level in addition to carotid intima media thickness (ca-imt) as a marker of atherosclerosis in normal and impaired glucose tolerance offspring of type dm. subjects were included and divided into two main groups; group(i) apparently healthy subjects with no family history of diabetes mellitus, as control group, group(iia) non diabetic offspring of type dm with normal glucose tolerance and group(iib) non diabetic offspring of type dm with impaired glucose tolerance. a statistically significant increase in mean ae sd of serum level of lp(a) and ca-imt in non diabetic impaired glucose tolerant offspring of type diabetes as compared to non diabetic normal glucose tolerant group, significant positive correlation between lp(a) and ca-imt vs. each of ldl-ch, triglycerides and cholesterol. also, a significant positive correlation between lp(a) and ca-imt and hdl-ch. in non diabetic impaired glucose tolerant offspring of type diabetes as compared to non diabetic normal glucose tolerant group. in conclusion the increase in serum level of lp(a) and increase of ca-imt in non diabetic offspring of type dm were associated with increasing severity of insulin resistance and increasing the degree of atherosclerosis explaining the high prevalence of cardiovascular diseases in subjects who are genetically prone to the development of diabetes. a. kostrzewa-tarnowska, m. człapka-matyasik, m. fejfer, j. jeszka weight loss can be achieved by any means of energy restriction, but the challenge is to achieve sustainable weight loss and prevent from weight gain without increasing the risk of chronic diseases. conventional high carbohydrate diets, even when based on wholegrain foods, increase insulinemia and may compromise weight control via mechanisms related to appetite stimulation and metabolic rate. the success of low fat diets has given a push for researches on alternative dietary strategies, including high content of bioactive compounds and low glycemic index (gi) diets.the aim of this study was to determine if high content of bioactive compounds using capillary blood sampling lead to any significant difference between the gis of the products mentioned. investigated group consisted of healthy people with normal weight, aged ae years (bmi . ae . kg/m ).foods with a low gi produce a lower peak in postprandial glucose and a less overall blood glucose increase during the first h after consumption compared with foods with a high gi. studies have shown that bioactive products lead to increased satiety, delayed return of hunger, and decreased food intake after ingestion of low-gi compared with high-gi foods.low-gi products may also play an extensive role in weight loss. this strategy can be associated with reducing total energy intake, modifying the macronutrient composition of the diet and lower postprandial glycaemia.research funded within the framework of the project po ig . . . - / . physiology, school of medicine, national university of ireland, galway, ireland introduction: current diagnostic criteria for type diabetes mellitus rely on increased blood glucose concentration following an oral glucose tolerance test (ogtt) or increased glycated haemoglobin. changes in these parameters occur long after insulin resistance manifests as plasma glucose concentration is homeostatically defended. in contrast, glucose oxidation measured by the c-glucose breath test ( c-gbt) is reduced as a direct consequence of insulin resistance. it is important to establish normative data and define the reliability of any diagnostic or scientific test therefore the aim of this study was to determine the reliability of the c-gbt as a diagnostic tool for type diabetes.methods: sixteen apparently-healthy controls { . ( . ) yrs, . ( . ) kg, . ( . ) cm, all data mean (sd)} underwent simultaneous ogtt and c-gbt on two separate occasions following a h overnight fast. mixed capillary blood and breath samples were collected at baseline and every min for h following ingestion of a . g glucose solution (shamrock, ireland) labelled with . g - c glucose.results: mean baseline co was . ae . delta viennapeedeebelemnite (d-vpdb) and peak co was À . ae . d-vpdb. fasting and h mixed capillary glucose concentrations were . ae . mmol/l and . ae . mmol/l respectively. per cent dose recovered c had a cronbach's alpha of . , while fasting and h glucose concentration were . and . respectively. we established normative data for the c-gbt. the c-gbt is a reliable test of whole body glucose oxidation which has the potential to be developed as a diabetes diagnostic test. introduction: outcome studies in morbidly obese patients (mo) have shown that diabetic patients have the highest benefit from bariatric surgery interventions. therefore it was of interest to study a variety of cardiovascular risk factors in a very large group of patients with mo (n = ), who were investigated in our center. we included patients with mo, of whom . % (n = ; mean hba c . ae . %) were diabetic. in a subset (n = ), patients were followed up years after bariatric surgery of whom . % (n = ) were diabetic. all patients without manifest type diabetes underwent a g oral glucose tolerance test, insulin levels were assessed, homa-insulin resistance (ir) was calculated. diabetes was diagnosed after ada criteria. apart from that demographic, cardiovascular risk-markers (blood pressure, lipids) renal and inflammation parameters were assessed. background: obex â is a dietary supplement to help lose weight. in addition, this supplement is specifically made with natural antioxidants molecularly activated to enhance their biological properties without altering their molecular structure.objectives: the purpose of this study was to evaluate the effect of obex â on anthropometric measurements and metabolic disorders in overweight and obese subjects. this was an open label pilot study conducted with overweight and obese adults (bmi > kg/m and < kg/m ), aged between and , who took obex â (without changes in lifestyle), at a dose of two sachets before the two main meals of each day for months. in addition to anthropometric measures and blood pressure, fasting plasma glucose, lipid profile, insulin, creatinine and uric acid were determined. insulin resistance by homa-ir and betacell function by homa-b were assessed. three indirect indexes were used to calculate insulin sensitivity.results: compared to baseline, obex â significantly reduced body weight (p = . ), body mass index, waist circumference, waist/hip ratio, waist/height ratio (p < . , respectively) and conicity index (p = . ). there was also a reduction in fasting glucose levels. compared to baseline, the use of obex â improved insulin secretion (homa-b) and hdl-c concentration (p < . ). no adverse effects were seen in any of the participants during the pilot study.conclusion: short-term treatment with obex â improved visceral and abdominal obesity, as well as ameliorating levels of select markers of metabolic disease risk in overweight and obese adults, indicating that further studies are warranted. methodology: a descriptive cross sectional study was conducted with families. the sample was family members (partner, offspring, blood family members and not family related individuals-all living in the same house). body mass index (bmi), lipid profile and glucose measured. also, the family functionality (ff) and perceived health status (phs). results: age mean was . years (sd, . ); female ( . %) and males ( . %). the rf were analyzed by the role in the family. seventy-five percent of the housewives were overweight, with high levels of glucose ( . %), cholesterol ( . %), triglyceride ( . %) and low hdl ( . %). husbands had overweight ( %), with high levels of glucose ( . %), cholesterol ( . %), and triglyceride ( . %). the children aged between and years, had glucose and cholesterol normal, but were overweight ( . %), and had high level of triglyceride ( . %) as well as low hdl ( . %). additionally, children and parents had only - portions of vegetables intake in - days in week; similarly . , had - portions of fruits or juice, but only - days by month. family functionality was reported with a mean of . (sd, . )- - scale and . (sd, . ) in phs. the family members in the ua are at high risk for developing dt . among them are underscored obesity, high levels of lipids, low consumption of vegetables and fresh fruits. ff and phs are also risk factors in these families. this study designed to compare the effect of three dietary oils: canola, rice bran and grape seed on lipid profile and paraoxanase activity of hyperlipidermic rats. method: hyperlipidemia was induced in wistar male rats by atherogenic diet. once hyperlipidemia was reached, the rats were randomly divided in four groups of animals according to the treatment received. treatment groups were fed canola, rice bran and grape seed oil for weeks. control rats fed regular rat chow diet which contains corn oil. baseline fasting blood lipid profile and paraxonase activity of experimental and control rats were compared at the beginning and at the end of the experiment.result: after -weeks of treatment, a significant decrease was found in serum triglyceride, total cholesterol and ldl-c concentration of rice bran and grape seed oil fed rats (p < . ), serum hdl-c concentration also increased significantly (p < . ). canola oil fed rats showed a significant decrease in total cholesterol, and triglyceride level and an increase in paraoxanase activity (p < . ), however, no significant differences were found in ldl-c and hdl-c concentration. the present study suggest that consumption grape seed, canola and rice bran oil may have beneficial effect on serum lipid profile, but in comparison of the tree dietary oils grape seed oil showed more beneficial effect in reducing hyperlipidemia. key: cord- -si qml authors: li, hai-yan; zhang, hong-lei; zhao, fu-jie; wang, shi-qiong; wang, zhi-xiang; wei, zhan-yong title: modulation of gut microbiota, short-chain fatty acid production, and inflammatory cytokine expression in the cecum of porcine deltacoronavirus-infected chicks date: - - journal: front microbiol doi: . /fmicb. . sha: doc_id: cord_uid: si qml porcine deltacoronavirus (pdcov) is a novel swine enteropathogenic coronavirus that causes watery diarrhea and induces proinflammatory cytokine responses in piglets. our previous research showed that the specific-pathogen-free (spf) chicks exhibited mild diarrhea and low fecal viral shedding, along with cecum lesions after pdcov infection. disturbances in the homeostasis of the gut microbiota have been associated with various diseases. we aimed to explore the effects of pdcov infection on chick gut microbiota, short-chain fatty acid (scfas) production, and inflammatory cytokine expression in chicks, and also to investigate the relationship between gut microbiota and scfas or inflammatory cytokine expression of the pdcov-infected chicks. results obtained using s rrna sequencing showed that infection with pdcov strain hnzk- significantly altered the composition of chick gut microbiota, with the reduced abundance of eisenbergiella and anaerotruncus genera at days post-inoculation (dpi) (p < . ), and an increased abundance of alistipes genus at dpi (p < . ). the production of scfas in the cecum of pdcov hnzk- –infected chicks, including acetic acid, propionic acid, and butyric acid, decreased in all cases. the expression of inflammatory cytokines (interferon-γ, tumor necrosis factor-α, and interleukin- ) was increased in the cecum tissue and serum of the pdcov hnzk- –infected chicks when detected by quantitative real-time polymerase chain reaction and enzyme-linked immunosorbent assay, respectively. further analysis showed significant correlation between bacterial genera and scfas or inflammatory cytokines expression in cecum of the pdcov infected chicks. these findings might provide new insight into the pathology and physiology of pdcov in chicks. porcine deltacoronavirus (pdcov) is an enveloped, positivesense single-stranded rna virus, with a genome length of approximately kb (zhang, ) . this virus was originally found in hong kong in (woo et al., ) , and the first outbreak of pdcov-related diarrhea in swine herds was reported in the united states in (wang et al., ) . as an important enteropathogen in pigs, pdcov can cause acute diarrhea, vomiting, and dehydration in neonatal piglets (chen et al., ; hu et al., ) . moreover, the infected pigs are characterized by thin and transparent intestinal walls and accumulation of large amounts of yellow fluid in the intestinal lumen (jung et al., ; . further, pdcov-infected piglets show signs of proinflammatory cytokine responses during acute infection (jung et al., ) . pdcov has caused huge economic losses for the pig industries. apart from infection of gnotobiotic (gn) and conventional pigs, pdcov was also reported to have limited ability to infect gn calves (jung et al., ) . recent studies showed the susceptibility of specific-pathogen-free (spf) chicks to pdcov infection, with the clinical syndrome of mild diarrhea and slight lesions in cecum, which was weaker than that of piglets infected with pdcov (liang et al., ; boley et al., ) . however, the reason why pdcov infection can cause intestinal damage is still unknown. the chicken gastrointestinal tract is an important site for immune cell development, which not only regulates gut microbiota, but also maintains extraintestinal immunity. intestinal commensal microbes play a crucial role in gut homeostasis through mutually beneficial interactions with the host immune system (deriu et al., ) . once the intestinal mucosal barrier and microbiota are destroyed, intestinal inflammation will occur. in turn, the host's inflammatory response will elicit changes in the microbial community structure (deriu et al., ) . the gut microbiota produces various metabolites, including short-chain fatty acids (scfas), which can regulate the host antiviral immune response (budden et al., ) . propionate and butyrate have also been reported to induce differentiation of t-regulatory cells, assisting in control of intestinal inflammation (donohoe et al., ; louis et al., ) . in chicks, recent studies have emphasized the key roles of intestinal microbiota in shaping immunity against viral diseases, including avian influenza, marek's disease, newcastle disease (nd), and infectious bursal disease (ibd). these studies not only reflected connections between gut microbiota and distal organs in regulatory functions, but also emphasized the interaction between intestinal microbiota and viral infections and their impacts on immune regulations (lillehoj and trout, ; balamurugan and kataria, ; li, ; chen et al., ; yitbarek et al., ) . it was reported that different commensal bacteria had their own unique role against viral infection by modulating diverse immune mechanisms (abt et al., ) . in the h n avian influenza virus infected chicks, increased levels of interferon gamma (ifn-γ). tumor necrosis factor alpha (tnfα), and interleukin- a (il- a) led to intestinal microflora dysbiosis (li h. et al., ) . however, there are no studies emphasizing how pdcov affects the gut microbiota in chicks. thus, in the current study we aimed to observe the intestinal microbiota, scfas, and inflammation responses to pdcov infection in chicks and elucidate the potential associations among them, which will provide the theoretical basis for investigation of the etiology and pathogenesis of pdcov. the virulent pdcov strain-hnzk- (genbank accession number mh ) was isolated and identified by our laboratory and propagated in llc-porcine kidney (llc-pk) cells. passage of this strain was used in current study. virus propagation and virus titers were performed as described previously (liang et al., ) . the spf chicks were purchased from jinan sipafas poultry co. ltd. in jinan, china. twenty-four-day-old spf chicks with similar body weight (about g/chick) were randomly divided into two groups, the control (mock) and pdcov hnzk- infected groups. all chicks were housed in the same facility but in different rooms under biosafety conditions and allowed free access to water and feed during the experiment. feed was formulated to meet or exceed the national research council nutrient requirements for chicks (national research council [nrc] , ; table ). each chick was intragastrically inoculated with pdcov strain hnzk- or eagle's minimum essential medium (mem) with µl/chick ( . log ge/chick) (n = /per group). based on our previous study (liang et al., ) , three chicks in each group were selected randomly for necropsy at and dpi, respectively. the cecal contents were collected for analysis of gut microbiota and scfas. the cecum tissue was collected for inflammatory cytokine mrna measurements. the serum was collected for inflammatory cytokine detection by enzyme-linked immunosorbent assay (elisa). viral rna was extracted from cecal content suspensions using the trizol tm method (invitrogen, carlsbad, ca, united states) according to the manufacturer's instructions. the viral rna was further reverse transcribed into cdna. viral rna titers were determined using quantitative real-time polymerase chain reaction (qrt-pcr) as reported previously (liang et al., ) . the detection limit of the qrt-pcr was . log ge/ml. the scfas in cecum were determined using gas chromatography (gc) according to a previously described method (stewart et al., ) . the samples were placed on a db-wax column ( m long × . mm diameter and . µm film thickness) and were separated by using a trace tm gc with flame ionization detector (fid). the temperature program was • c for . min, then raised to • c at • c/min and held for min, then raised to • c at • c/min and held for min. samples were run with a : split ratio and a . ml/min column flow. high-purity hydrogen was used as the carrier gas. the temperatures of the injector and detector were and • c, respectively. the levels of expression of the inflammatory cytokines (ifn-γ, tnf-α, and il- ) in the cecum of spf chicks were quantified by qrt-pcr. cecum tissue samples were homogenized by the tissuelyser- (jingxin, shanghai, china). total rnas were extracted from the supernatant of the cecum tissue lysate by trizol tm reagent kit (invitrogen, carlsbad, ca, united states) and were quantified by nanodrop spectrophotometer (thermo fisher scientific, waltham, ma, united states), then further reverse transcribed into cdna. the total reaction volume of µl contained . µl of dna, . µl of sybr green qpcr mix (takara bio inc., tokyo, japan), µl of h o, and . µl of each specific primer. primers were synthesized according to previous reports (emami et al., ) and are shown in table . reactions were performed under the following conditions: one cycle of preincubated samples at • c for min and cycles of amplification samples at • c for s, • c for s, • c for s. target gene expression of each sample was normalized using glyceraldehyde -phosphate dehydrogenase (gapdh). the relative expression of the target gene for each sample was calculated using the − ct method (livak and schmittgen, ) . the expression levels of the ifn-γ, tnf-α and il- in serum were detected using elisa kit from nanjing jian cheng biological institute (nanjing, china). serum samples were obtained and measured as previously described (huang et al., ) . absorbance was read at nm using a microplate spectrophotometer. the inflammatory cytokine concentrations were calculated according to a best-fit standard curve. raw fastq files were demultiplexed, quality-filtered by trimmomatic, and merged by flash (magoč and salzberg, ) . sequences with ambiguous bases, shorter than bp, and sequences with an average mass less than were removed. the high-quality reads were clustered into operational taxonomic units (otus) with % similarity cutoff using uparse (version . ) and used for further analysis of the venn diagram, alpha diversity indices (shannon and simpson), and richness estimators (ace and chao). beta diversity measures were based on weighted-unifrac distance analysis and shown by principal coordinate analysis (pcoa), which was conducted to assess the relationships among the different groups. lefse was applied to recognize which bacterial taxa contribute to the differences between the two groups (segata et al., ) , and the minimal threshold of linear discriminant analysis (lda) was set at . . the difference between specific taxa was analyzed using one-way analysis of variance (anova) followed by post hoc t-tests. data analysis of inflammatory cytokines and scfas was performed using graphpad prism (version . , la jolla, ca, united states). a p < . or . was considered statistically significant or highly significant, which is indicated as follows: * p < . , * * p < . . spf chicks, intragastrically inoculated with pdcov hnzk- at days old, showed mild diarrhea at dpi. pdcov rna was detected in the intestinal contents by qrt-pcr at and dpi while non-infected control chicks appeared normal throughout the course of the experiments. pdcov hnzk- infection had the operational taxonomic units (otus) were defined at a % similarity level. the coverage percentage (good's) and richness estimators (ace and chao) and diversity indices (shannon and simpson) were calculated using good's method and the mothur program, respectively. in the same column, values with the same superscript letter are not significantly different (p > . ); those with different superscript letters differ significantly (p < . ). figure | venn map. venn map of shared otus based on the sequences with more than % similarity (n = ). the mock group at dpi (mock- d), the pdcov hnzk- group at dpi (hnzk- - d), the mock at dpi (mock- d), and the pdcov hnzk- group at dpi (hnzk- - d). no effect on feed consumption compared to controls during the whole experimental period. a total of cecal concent samples, the control chicks (n = ), and pdcov hnzk- groups (n = ) at and dpi, respectively, were evaluated using s rrna gene sequencing. a total of , sequences with a median read length of bp (range from to bp) were collected. the total number of unique sequences from the four groups was . the sequence and species-level otus of each group are shown in table . the venn diagram showed that otus of the total gut microbial richness ( ) were shared among all the sequenced samples. two hundred and fifty-nine otus were shared between the samples of the mock and pdcovhnzk- groups with a total of at dpi. three hundred and seventeen otus of the total gut microbial richness ( ) were shared between the samples of mock and pdcov hnzk- groups at dpi (figure ). alpha diversity estimators of community are shown in table . gut microbial richness, according to the ace and chao indexes, was significantly increased in the pdcov hnzk- group when compared with that of the mock group at dpi (p < . ), while there was no significant difference between the two groups at dpi (p > . ). in shannon and simpson alpha diversity indexes, the differences between the pdcov hnzk- and the mock groups at and dpi did not reach statistical significance (p > . ). beta diversity analysis showed that there were some similarities in the microbial composition between the mock and the pdcov hnzk- groups at dpi. however, the microbial composition from chicks with pdcov inoculation and the controls could be divided into two different clusters at dpi, indicating that the cecal microbial community structure and composition in the control group were significantly different from those in the pdcov hnzk- group at dpi (figure ) . to further investigate whether pdcov hnzk- infected chicks experienced any significant alteration in gut microbiota, we analyzed the relative abundance of microbiota at the phylum, family, and genus levels. at dpi, genus level analysis showed the taxonomic abundance was altered in the pdcov hnzk- group, which was characterized by lower abundance of eisenbergiella and anaerotruncus (p < . ). there were no significant differences at the levels of phylum and family between the mock and the pdcov hnzk- groups (figure a) . at dpi, the ratio of firmicutes to bacteroidetes in the pdcov hnzk- group was lower than that of the mock group. at the family level, the proportion of rikenellaceac in the chicks inoculated with pdcov hnzk- significantly increased (p < . ). at the genus level, alistipes and the unclassified f-ruminococcaceae were significantly increased (p < . ), whereas the proportion of ruminococcaceae-ugg- was significantly decreased in the pdcov hnzk- group when compared to that of the mock group at dpi (p < . ) (figure b) . the characteristics of bacterial taxonomic abundant in the collected samples were further analyzed using lefse algorithm (figure ) . lefse analysis revealed that there existed main and discriminative features from phylum to genus (lda score > ) between the mock and the pdcov hnzk- -inoculated chicks at and dpi (figures a,b) , respectively. more specifically, eisenbergiella and anaerotruncus were the most differential microbiota in the mock at dpi. moraxellaceae, acinetobacter, pseudomonadates, eubacterium, and norank-f lachnospiraceae in the pdcov hnzk- group increased when compared to that in the mock group. at dpi, we identified microbial biomarkers from the pdcov hnzk- group, including rikenellaceae, bacteroidia, bacteroidetes, bacteroidales, alistipes, unclassified-f-ruminocococcaceae, sphingomonadaceae, novosphingobium, and lachnoclostridium, figure | beta diversity measures in cecal microbiota of chickens (n = ). the scatterplot of the principal coordinate analysis (pcoa) scores shows four different clusters (weighted-unifrac distance), the blue represents the pdcov hnzk- group at dpi (hnzk- - d), the red represents the mock group at dpi (mock- d), the purple represents the pdcov hnzk- group at dpi (hnzk- - d), and the green represents the mock group at dpi (mock- d). frontiers in microbiology | www.frontiersin.org figure | significant differences analysis in cecal microbiota of chickens. (a) statistical comparison of the relative microbial abundance from phylum to genus between the mock and the pdcov hnzk- groups at dpi (n = ). (b) statistical comparison of the relative microbial abundance from phylum to genus between the mock and the pdcov hnzk- groups at dpi (n = ). **p < . ; *p < . . lefse identifies the taxa with the greatest differences in abundance from phylum to genus between the mock and the pdcov hnzk- groups at dpi (n = ). (b) lefse identifies the taxa with the greatest differences in abundance from phylum to genus between the mock and the pdcov hnzk- groups at dpi (n = ). linear discriminant analysis (lda) effect size (lefse) analysis showing those abundance from phylum to genus between groups; only taxa of an lda significant threshold of . are shown. which could be distinguished from the mock group. clades were more abundant in the mock group than that in the pdcov hnzk- group, including firmicutes, ruminocococaceae-ucg- , clostridia, norank-f-clostridiales-vadinbb -group, clostridiales-vadinbb -group, anaerostipe, eisenbergiella, coriobacteriaceae, coriobacteriales, actinobacteria, and actinobacteria. there were bigger differences on microbiota compositions between the early and later stages of pdcov infection (at and dpi, respectively). compared to the control, there was a decreasing trend in the amounts of acetic acid (aa), propionic acid (pa), and butyric acid (ba) in the pdcov hnzk- group at and dpi. furthermore, pa and aa levels in the pdcov hnzk- group were greatly decreased at and dpi, respectively (p < . ) (figure ). as shown in figure , the expression of ifn-γ (p < . ), tnfα (p < . ) and il- (p < . ) was significantly upregulated at dpi compared with that in the mock chicks (figures a-c) . furthermore, ifn-γ expression was significantly upregulated (figure a ) at dpi (p < . ). to evaluate if pdcov infection could affect ifn-γ, tfn-α, and il- secretion in serum, the concentrations of ifn-γ, tfnα, and il- in serum were tested with elisa kits. our results showed that the changes of the inflammatory cytokines in serum were similar with those in the cecum tissue. the levels of ifnγ and tnf-α were approximately two and three times as high as in the pdcov hnzk- group when compared to that of the mock group at dpi (p < . ). the level of il- in the pdcov infection group was also increased at dpi (p < . ). the serum levels of ifn-γ in the pdcov-infected chicks were higher than in the mock group at dpi (p < . ), and no significant differences were observed for the secretion of tnfα and il- between the mock and the pdcov hnzk- groups at dpi (figures a-c) . spearman's correlation analysis was conducted between the top bacterial genera and the environmental factors (scfas, proinflammatory cytokines), and was directly reflected by a heatmap (figure ) . the threshold | r| > . was considered as having a correlation. the results indicated that eisenbergiella was negatively correlated with tnfα (p < . ) and ifn-γ (p < . ) expression levels, and was positively correlated with pa (p < . ) at dpi ( figure a) . the ruminiclostridium_ also showed a positively correlation with the il- expression (p < . ), while norank_f_ ruminococcaceae was negatively correlated with ba (p < . ). at dpi (figure b) , alistipes and unclassified_f_ ruminococcaceae showed an extremely significant positive correlation with ifn-γ secretion (p < . ), but eisenbergiella and norank_f_clostridiales_vadinbb _group were negatively correlated with it (p < . ). the level of pa was associated with the increase in the abundance of ruminiclostridium_ (p < . ). ruminococcus and eisenbergiella were positively correlated with aa (p < . ), while alistipes showed a negative relationship with it (p < . ). eisenbergiella, unclassified_f_lachnospiraceae, ruminococcaceae_ucg- , norank_f_clostridiales_vadinbb _group, and ruminiclostr idium_ were positively correlated with ba. gut microflora play an important role in shaping immunity against viral diseases in host. disruption of microbial homeostasis is associated with a variety of pathological states, which helps the establishment of acute viral infections in chickens (abaidullah et al., ) . in this study, the infection model of pdcov was developed on spf chicks. our results demonstrated similar clinical diseases, and the dynamics of the virus shedding in cecum were observed in all spf chicks inoculated with the pdcov hnzk- strains when compared with our previous experiment (liang et al., ) . the influence of pdcov infection on cecum microbiota of spf chicken was evaluated, pdcov hnzk- infection significantly altered the gut microbiota composition and decreased scfas products in chicks' cecum. simultaneously, the expression levels of inflammatory cytokines (ifn-γ, il- , and tnf-α) in serum and cecum tissue were significantly increased, resulting in the inflammatory response in the chicken. the analysis showed a significant correlation between bacterial genera and scfas or inflammatory cytokines. the diversity of indigenous intestinal microbiota is one of the key factors in resisting the colonization of invading pathogens (keesing et al., ) . several studies have reported that the diarrhea-relating coronaviruses could influence the intestinal microbiota diversity in pigs (liu et al., ; song et al., ; huang et al., ; tan et al., ) . indeed, many viral agents have been shown to alter the intestinal microbiota in chickens, such as aiv (yitbarek et al., ) , marek's disease virus (mdv) (lillehoj and trout, ) , ndv (li, ) , and ibdv (li l. et al., ) . in pdcov-infected chicks, the species richness indices were increased at dpi, and there were no significant changes in the overall α-diversity of cecal microbiota at dpi. it is possible that the reduced immune response may account for the change of microbial diversity. from the pcoa results, microbiota structure in the pdcov infected group was clearly distinguished from that of the mock group at dpi, which also reflected spf chicks' resistance to pdcov. from microbial community profiling, the difference between the groups was analyzed at the phylum, family, and genus level. eisenbergiella and anaerotruncus genera were significantly decreased in the pdcov hnzk- at dpi, indicating that pdcov hnzk- infection had a marked influence on chicks' cecal microbiota. according to previous studies, the decrease of the ratio of firmicutes-to-bacteroidetes was observed in mice with diabetes (wen et al., ) and in some patients with crohn's disease and ulcerative colitis (frank et al., ) . in our results, a decreased ratio of firmicutes-to-bacteroidetes occurred in the pdcov hnzk- group at dpi. more remarkably, the alistipes, considered an opportunistic pathogen (pandit et al., ; zhang et al., ) , was significantly increased in the pdcov hnzk- group at dpi. we used linear discriminant analysis (lda) of effect size (lefse) to confirm the taxa that most likely explains the differences between the pdcov hnzk- and mock groups. these findings provide compelling evidence that pdcov hnzk- induced microbiota imbalance and showed that recovery was difficult in a short time period after pdcov hnzk- infection. production of scfas, as the end products of protein and carbohydrate fermentation (cummings and macfarlane, ) , can easily be affected by the status of the gut microbiota (lloyd-price et al., ) . studies have shown that lactobacillus salivarius and l. agilis could increase propionate and butyrate contents in cecum of chicks (meimandipour et al., ) . the changes in butyrate and propionate can influence intestinal physiology and immune function, while acetate can alter lipid metabolism (macfarlane and macfarlane, ) . our data showed that the changes of gut microbiota composition contributed to the decreased scfas, which reduced this protective effect of scfa in the cecum. however, the interaction of gut microbiota with scfas to respond to pdcov infection needs further studies. inflammatory immune responses in the gut can alter the gut luminal environment in a way that favors dysbiosis (winter et al., ) . chicks with dysbiosis are more prone to acute viral infection (abaidullah et al., ) , which may in turn further affect the pathogen infectivity. eisenbergiella is strongly correlated with increased levels of tnf-α and ifn-γ, which help in modulating the functional activities of the cells of the immune system (liu et al., ) , and to block virus replication and prevent clinical disease (bradley, ; praveena et al., ) . this may be the reason that eisenbergiella was decreased in the pdcov hnzk- group at dpi. moreover, the observation is similar to the increased proinflammatory (tnf-α) cytokine responses of -day-old gn pigs to acute pdcov infection (jung et al., ) . alistipes was strong positively correlated with ifn-γ levels, and the numbers of ruminococcaceae_ucg- were strong negatively correlated with ifn-γ levels, indicating that these bacteria can be tolerated, with ifn-γ responses benefiting for those genera of bacteria. the anti−inflammation activity could be explained in the study regarding to the administration of norank_f_lachnospiraceae in gut, and was related to the il− cytokine (olszak et al., ) . the results showed the change of microbiota in the cecum was related to intestinal inflammation (directly or indirectly, positively or negatively). in conclusion, the present study revealed that obvious changes were found in the microbial community of chicks infected with pdcov hnzk- . pdcov-inoculated chicks showed a decrease in eisenbergiella and anaerotruncus populations at dpi and an increase in pathogenetic alistipes at dpi with a reduction in scfas production. the changes in the microbial community may be related to changes in inflammatory cytokine expression. these results provide new insights into the pathophysiology of chicks infected with pdcov. the obtained raw sequencing reads have been added to the ncbi sra page (accession number: prjna ). other data generated during the study are included in this article. the experimental procedures were approved by the laboratory animals ethics committee at hennan qixiang biological technology co. ltd. (hnqx- - ) , and all husbandry practices and euthanasia were performed with full consideration of animal welfare. hl and hz performed the experiments. hl, fz, and sw performed statistical analyses and wrote the manuscript. z-xw and z-yw designed the study and revised the manuscript. all authors read and approved the final manuscript. current findings on gut microbiota mediated immune modulation against viral diseases in chicken commensal bacteria calibrate the activation threshold of innate antiviral immunity economically important non-oncogenic immunosuppressive viral diseases of chicken-current status porcine deltacoronavirus infection and transmission in poultry, united states tnf-mediated inflammatory disease emerging pathogenic links between microbiota and the gut-lung axis role of the intestinal microbiota in the immunomodulation of influenza virus infection isolation and characterization of porcine epidemic diarrhea viruses associated with the disease outbreak among swine in the united states the control and consequences of bacterial fermentation in the human colon influenza virus affects intestinal microbiota and secondary salmonella infection in the gut through type i interferons a gnotobiotic mouse model demonstrates that dietary fiber protects against colorectal tumorigenesis in a microbiota-and butyrate-dependent manner necrotic enteritis in broiler chickens: the role of tight junctions and mucosal immune responses in alleviating the effect of the disease molecular-phylogenetic characterization of microbial community imbalances in human inflammatory bowel diseases experimental infection of gnotobiotic pigs with the cell-culture-adapted porcine deltacoronavirus strain oh-fd eimeria maxima microneme protein delivered as dna vaccine and recombinant protein induces immunity against experimental homogenous challenge differences in the intestinal microbiota between uninfected piglets and piglets infected with porcine epidemic diarrhea virus pathogenicity of porcine deltacoronavirus strains in gnotobiotic pigs calves are susceptible to infection with the newly emerged porcine deltacoronavirus, but not with the swine enteric alphacoronavirus, porcine epidemic diarrhea virus susceptibility of porcine ipec-j intestinal epithelial cells to infection with porcine deltacoronavirus (pdcov) and serum cytokine responses of gnotobiotic pigs to acute infection with ipec-j cell culture-passaged pdcov impacts of biodiversity on the emergence and transmission of infectious diseases porcine deltacoronavirus causes diarrhea in various ages of field-infected pigs in china avian influenza virus subtype h n affects intestinal microbiota, barrier structure injury, and inflammatory intestinal disease in the chicken ileum infectious bursal disease virus infection leads to changes in the gut associated-lymphoid tissue and the microbiota composition eric-pcr based fingerprint to analyze the structural features of intestinal microbial communities of chicks infected with salmonella gallinarum, newcastle disease virus and the healthy chicks susceptibility of chickens to porcine deltacoronavirus infection avian gut-associated lymphoid tissues and intestinal immune responses to eimeria parasites comparison of the expression of cytokine genes in the bursal tissues of the chickens following challenge with infectious bursal disease viruses of varying virulence porcine epidemic diarrhea virus infection induced the unbalance of gut microbiota in piglets analysis of relative gene expression data using real-time quantitative pcr and the -ct method multi-omics of the gut microbial ecosystem in inflammatory bowel diseases the gut microbiota, bacterial metabolites and colorectal cancer fermentation in the human large intestine: its physiologic consequences and the potential contribution of prebiotics flash: fast length adjustment of short reads to improve genome assemblies gastrointestinal tract morphological alteration by unpleasant physical treatment and modulating role of lactobacillus in broilers design and experimental application of a novel non-degenerate universal primer set that amplifies prokaryotic s rrna genes with a low possibility to amplify eukaryotic rrna genes nutritional requirements of poultry. th rev protective mucosal immunity mediated by epithelial cd d and il- microbial diversity and community composition of caecal microbiota in commercial and indigenous indian chickens determined using s rdna amplicon sequencing cytokine profiles, apoptosis and pathology of experimental pasteurella multocida serotype a infection in mice metagenomic biomarker discovery and explanation altered gut microbiota profiles in sows and neonatal piglets associated with porcine epidemic diarrhea virus infection evaluation of the effect of four fibers on laxation, gastrointestinal tolerance and serum markers in healthy humans changes in cecal microbiota community of suckling piglets infected with porcine epidemic diarrhea virus detection and genetic characterization of deltacoronavirus in pigs innate immunity and intestinal microbiota in the development of type diabetes the dynamics of gut-associated microbial communities during inflammation discovery of seven novel mammalian and avian coronaviruses in the genus deltacoronavirus supports bat coronaviruses as the gene source of alphacoronavirus and betacoronavirus and avian coronaviruses as the gene source of gammacoronavirus and deltacoronavirus gut microbiota-mediated protection against influenza virus subtype h n in chickens is associated with modulation of the innate responses porcine deltacoronavirus: overview of infection dynamics, diagnostic methods, prevalence and genetic evolution the effect of exposure to high altitude and low oxygen on intestinal microbial communities in mice the authors thank dr. hui hu from henan agricultural university for designing the study and revising the manuscript. key: cord- - dannjjm authors: nan title: research abstract program of the acvim forum denver, colorado, june – , date: - - journal: j vet intern med doi: . /j. - . . .x sha: doc_id: cord_uid: dannjjm nan clinics Ãà also see infectious disease abstracts id- -id- (thursday, june , : pm - : pm) Ãà also see pharmacology abstracts p- -p- (thursday, june , : pm - : pm) Ãà also see gasteroenterology abstracts gi- - june , hypertrophic cardiomyopathy (hcm) is the most commonly observed myocardial disease in cats. beta-blockers and calcium channel inhibitors are frequently administered drugs to cats with preclinical hcm despite the fact that neither drug category has been proven to slow disease progression or improve survival. ivabradine (procorolan s , servier, france) is a novel negative chronotropic agent used in the treatment of ischemic heart disease in people. little is known about its efficacy and safety in cats. the purpose of this study was to determine the short-term effects of ivabradine on heart rate (hr), blood pressure, left ventricular (lv) systolic and diastolic function, left atrial (la) performance, and clinical tolerance in healthy cats after repeated oral doses. ten healthy laboratory cats were involved in the present study. physical examination, systolic blood pressure measurement, and transthoracic echocardiography were performed in all cats at baseline and after oral administration ( weeks each) of ivabradine ( . mg/kg, q h) and atenolol ( . mg/cat, q h; . - . mg/kg) in a prospective, double-blind, randomized, active-control, fully crossed study. a-priori non-inferiority margins for the effects of ivabradine compared to atenolol were set at % (f . ) based on predicted clinical relevance, observer measurement variability, and in agreement with fda guidelines. variables were compared by use of -way repeated measures anova. ivabradine was clinically well tolerated with no adverse events observed. hr (ivabradine, po . ; atenolol, po . ; ivabradine vs. atenolol, p . ) and rate-pressure product (ivabradine, p o . ; atenolol, p . ; ivabradine vs. atenolol, p . ) were not different between treatments. at the dosages used, ivabradine demonstrated more favorable effects than atenolol on echocardiographic indices of left ventricular (lv) systolic and diastolic function and left atrial performance. ivabradine is non-inferior to atenolol with regard to effects on hr, rate-pressure product, lv function, la performance, and clinical tolerance. clinical studies in cats with hcm are needed to validate these findings and further assess safety. the aim of this study was to compare outcome from cpa in dogs following initial administration of either epinephrine or vasopressin during cardiopulmonary resuscitation (cpr). dogs having cpa in the er or icu of a university hospital were randomized to receive either iv epinephrine ( . - . mg/kg) or vasopressin ( . - . u/kg) in a blinded fashion immediately following establishment of iv access and again three minutes later. a standardized cpr protocol was followed. other vasopressors were not permitted during the six minute study period, at the end of the study period additional cpr interventions were at the discretion of the managing clinician. the primary end point was return of spontaneous circulation (rosc) within the study period; secondary end points included rosc at any point, survival to minutes, and survival to one hour. sixty dogs completed the study, received epinephrine and received vasopressin. rosc within six minutes was % ( vasopressin, epinephrine p . ), rosc at any time was % ( vasopressin, epinephrine p . ). survival to minutes was % ( vasopressin, epinephrine p . ), survival to one hour was % ( vasopressin, epinephrine p . ). five dogs survived to hours, one survived to hospital discharge. of animals dying after rosc, / were euthanized and / rearrested. no advantage of routine substitution of vasopressin for epinephrine was seen for rosc, a small survival advantage at one hour was seen in the group receiving epinephrine. the study also demon-strated that prospective clinical cpr research in animals is both possible and practical. three dogs were evaluated in phases. phase- : single-dose diltxr at approximately mg/kg po. phase- : same dose q h for . days. phase- : after a day wash-out the single-dose protocol was repeated using cut tablets to assess affect on extended release properties. blood pressure (bp), -lead ecg, echocardiogram, and h-ambulatory ecg were performed at baseline, and conclusion of phase- . blood samples and bp was obtained , , , , , , and h after final dosing. peak median plasma diltiazem concentrations (mcg/ml) measured by hplc for each phase were . , . , and . respectively. diltiazem concentrations were below the limit of detection in the majority of samples in phase- . median diltiazem concentration reached purported therapeutic concentrations ( . - . mcg/ml) by h post-pill in phase- and h post-pill in phase- . therapeutic concentrations were maintained for h in phase- , but only h in phase- . median bp (mmhg) was . at baseline and . at peak concentration in phase- . median heart rate (bpm) was . at baseline. h-ambulatory ecg analysis revealed the median hourly heart rate was . at baseline and during phase- . median heart rate at peak concentration in phase- was . . lack of detectable plasma diltiazem during phase- may be due to up-regulation of drug metabolism via p-glycoprotein (abcb - ) mutations. ongoing data collection and analysis will include mutation testing. adiponectin (adpn) is a cytokine produced by fat cells which has been shown to be correlated with adverse cardiac conditions in humans. in the heart, adiponectin activates several pro-survival reactions, including the ampk pathway and cox receptors, which protect the heart following ischemic injury. recent studies have shown that higher levels of adpn influence cardiac remodeling signaling, inhibiting protein synthesis and suppressing pathological cardiac growth. in humans, adpn plasma levels rise with decreased activity of the sympathetic nervous system and b-adrenergic agonists inhibit adpn at the level of gene expression. in contrast c-reactive protein (crp), a marker of systemic inflammation is elevated in humans with congestive heart failure (chf) and correlates to the severity of disease. first, we hypothesized that dogs with chf would have reduced adpn and elevated crp compared to normal dogs and that cytokine concentrations would predict severity of chf. second, we hypothesized that adpn receptor- (r ) and adpn protein would be elevated in the myocardium of chf dogs reflecting a compensatory process. we collected serum from dogs ( healthy and chf). circulating adiponectin and crp levels were quantified using a mouse/rat adiponectin elisa and a canine crp elisa. we found lower mean crp concentrations in normal dogs ( . ae . mg/ ml) than dogs with chf ( . ae . mg/ml), however, the results were not statistically significant due to the large variability seen among the chf dogs (p . ). we found greater mean adpn concentrations in normal dogs ( . ae . mg/ml) than chf dogs ( . ae . mg/ml) (p . ). in general, the greater the severity of the heart failure, the lower the level of serum adpn. when the tests the purpose of this study was to determine if there are any clinically important differences between the approaches (including devices) used in non invasive transvascular (interventional) closure of patent ductus arteriosus (pda) in dogs in our institution. initial and follow up records from all dogs (n ) that underwent attempted transvascular pda occlusion from january -december were examined. dogs were placed into groups depending on the device and route of vascular access (transvenous or transarterial). group : amplatz s canine ductal occluder (acdo) (transarterial) - dogs; group : gianturco s or mreye flipper s detachable embolization (flipper) coil (transarterial) - dogs; group : amplatzer s vascular plug (avp) (transarterial) - dogs; group : flipper coil (transvenous) - dogs. statistical comparisons were made using the kruskal-wallis test with mann-whitney tests to compare pairs of groups when significance was detected. p o . was considered significant. there was no significant difference in ages between the groups. there was a significant difference in body weight between groups with dogs receiving a coil either transarterially or transvenously (groups and ) being significantly smaller than dogs receiving an acdo or avp. this was by design since the acdo and avp cannot be used in small dogs. overall, the success rate of the total procedure (including vascular access and satisfactory pda occlusion) was high ( %) with success rates being comparable between groups ( - %). there was a significant difference in complication rate between groups (p o . ) with the acdo group having a markedly lower complication rate than the remaining groups ( % for acdo versus - % for the other groups). total fluoroscopy time ranged from - minutes (median minutes). fluoroscopy time for the transvenous method was significantly longer (median minutes; range - minutes) than in the remaining groups (median minutes; range - minutes) (p o . ). number of dogs with residual flow immediately following the procedure and hrs later was significantly less in the acdo group than in the remaining groups ( dogs from group and from group had moderate persistent flow while dog from group and from group had severe persistent flow hours after the procedure). the acdo appears superior in ease of use, complication rate, completeness of occlusion and fluoroscopy time than other devices. the remaining limiting factor with this device is patient size. until a smaller acdo device is marketed, coils remain the only choice for interventional closure in very small dogs ( o . kg). previously presented at the university of california davis, house officers seminar day. subvalvular aortic stenosis (sas) is one of the most commonly reported canine congenital heart defects and is inherited in newfoundland dogs and human beings. the golden retriever and rottweiler are breeds over-represented in dogs with subvalvular aortic stenosis; however, a genetic cause of this disease in these breeds has not been described. we performed genome wide association analysis in both normal and sas affected rottweilers and golden retrievers to identify chromosomal regions of interest that could implicate a causative mutation by high density single nucleotide polymorphism (snp) array. ( unaffected/ affected) adult golden retrievers and ( unaffected/ affected) adult rottweilers were included in this study. criteria for affected included a subcostal continuous-wave doppler aortic velocity ! . m/s and presence of a left basilar systolic ejection murmur; criteria for unaffected included a doppler aortic velocity . m/s. dna samples were obtained from anticoagulated blood. genotypes were obtained using high density ( , ) snp arrays, and genome wide association with sas was evaluated for each breed. significance cut-off was set at p  À , and all snps meeting this criterion were plotted within each breed and compared across breeds using plink. affected golden retriever data implicate the most significant region of genetic variation on chromosome at location (p .  À ; odds ratio . ) with other significant surrounding snps . affected rottweiler data also implicate the most significant region of genetic variation on chromosome at location (p .  À ; odds ratio . ) with other significant surrounding snps . other regions of statistical significance were on chromosomes and in the golden retriever and and in the rottweiler. genome wide association with subvalvular aortic stenosis in the golden retriever and rottweiler implicate overlapping chromosomal regions of interest for causative mutations on chromosome . the different secondary chromosomal regions of interest (chr , in golden retrievers and , in rottweilers) supports the known familial nature of this disease within different breeds and may suggest the presence of multiple mutations or breed specific disease modifiers. these data highlight the need for candidate gene evaluation on chromosome in golden retrievers and rottweilers with sas. heart valves share developmental signaling pathways with bone and cartilage. degenerative aortic valve disease in humans is characterized by valve stenosis and calcification. recent evidence suggests that degenerative aortic valves are undergoing pathologic processes that mimic osteogenesis. degenerative mitral valves in dogs and humans are characterized by valve regurgitation, and rarely undergo calcification. we tested the hypothesis that canine and human degenerative mitral valves might be undergoing pathologic processes that mimic chondrogenesis. to test this hypothesis, expression of bone morphogenic protein (bmp ), a chondrogenic growth factor; sox , a chondrogenic transcription factor; aggrecan, a proteoglycan abundant in cartilage; and type ii collagen were evaluated utilizing immunohistochemistry. normal canine mitral valves, different stages of canine degenerative mitral valves (early, intermediate, and late), and late-stage human degenerative mitral valves were studied. canine and human degenerative mitral valves showed focal areas that co-expressed all four markers of chondrogenic signaling and phenotype. valve interstitial cells and surrounding extracellular matrix in these focal areas adopted a morphologic appearance reminiscent of cartilage. focal chondrogenesis was present in all stages of canine degenerative mitral valves, but not normal canine mitral valves. focal areas of chondrogenesis did not coincide with nodular areas of glycosaminoglycan accumulation on the leaflet edge, but rather seemed to occur at points of chordae attachment to leaflets. in conclusion, canine and human degenerative mitral valves undergo pathologic processes that mimic chondrogenesis. this finding suggests that mitral valve degeneration may be recapitulating developmental signaling pathways shared by heart valves and cartilage. the triggering events for chondrogenesis in mitral valves remain unknown; as does the reason why aortic and mitral valves appear to be undergoing different pathologic processes. the fact that humans exhibit degeneration of both the aortic and mitral valve, and that dogs commonly exhibit only the latter could eventually provide insight into both processes. arrhythmogenic right ventricular cardiomyopathy (arvc) is a familial cardiomyopathy characterized by right ventricular fibrofatty infiltration and ventricular ectopy of left bundle branch block morphology (vpc) . a deletion in the striatin gene has been associated with arvc in at least some boxer families. syncope and sudden death (sd) occur in some affected dogs, although many affected dogs survive for years. the objective of this study was to define clinical characteristics of arvc in boxers that experienced sd, and compare them to those of a contemporaneous group of arvc boxers that had not died suddenly (nsd). data for both groups were collected from adult boxers enrolled in a long term prospective study of arvc in which echocardiograms and hour ambulatory ecg (aecg) are evaluated annually. aecg are quantitated for vpc numbers and arrhythmia grade ( - ). arvc diagnosis requires at least vpcs/ hours in the absence of other disease. forty three adult boxers that entered the study had died suddenly at the time of analysis (sd defined as the absence of observed clinical signs within hours prior to an unexpected and unexplained death). striatin genotype was available for of the sd dogs ( heterozygotes, homozygotes); were female ( intact) and were male ( intact). sd occurred at a mean age of years (range, - ); sd dogs ( %) had no prior history of syncope. twelve sd dogs ( %) were on antiarrhythmics at the time of death (metop-p oooooooooooprolol ( ), sotalol ( ), amiodarone ( ), procainamide ( ), mexiletine & atenolol ( ), atenolol ( )). eleven sd dogs ( %) had decreased myocardial systolic function defined by a shortening fraction (%fs) o % (range - , mean ) on the most recent echocardiogram prior to sd. median vpcs/ hours on annual aecg was , (range - , ) with a median arrhythmia grade of (range - ). twenty one contemporaneously entered arvc boxers that had survived to at least the median age of the sd group with nsd were available for comparison; / were genotyped ( heterozygous, homozygous, negative), were female ( intact) and male ( intact). twelve nsd dogs ( %) had no prior history of syncope. median nsd group age was years (range, - ); / ( %) were on an antiarrhythmics (sotalol ( ), mexiletine & sotalol ( ), mexiletine & atenolol ( )). one nsd dog had decreased %fs (nsd group %fs range - , mean ). the nsd median number of vpcs was , (range - , ), median arrhythmia grade was (range - ). striatin genotype was significantly associated with sd. no significant differences were found between groups with respect to vpc numbers or arrhythmia grade. shortening fraction was significantly lower in the sd group (p o . ). sd in arvc appears to be associated with the presence of the striatin mutation and reduced % fs, it does not appear to be associated with number of vpcs or arrhythmia grade. coughing in the small breed dog may be related to cardiac causes associated with myxomatous mitral valve degeneration (mmvd) including pulmonary edema and compression of the mainstem bronchus by a severely enlarged left atrium, or due to respiratory causes such as tracheal and/or bronchial collapse or chronic bronchitis. the purpose of this study was to evaluate the association between left atrial enlargement and large airway collapse in dogs with mmvd and chronic cough. we hypothesized that airway collapse was independent of degree of left atrial enlargement. twelve dogs with mmvd and a chronic cough in the absence of congestive heart failure were prospectively evaluated with thoracic and cervical radiography, echocardiography, fluoroscopy, bronchoscopy and bronchoalveolar lavage (bal). group dogs (n ) had moderate to severe left atrial enlargement based on an echocardiographically calculated left atrial:aortic surface area [la:ao(a)] . group dogs (n ) had no to mild left atrial enlargement [la:ao(a) ]. the site and severity of airway collapse was graded on bronchoscopy and bal cytology was assessed for evidence of inflammation or infection. the occurrence of bronchoscopic abnormalities was compared between groups using fisher's exact test. p o . was considered significant. age and body weight did not differ between groups. left atrial size was interpreted radiographically as moderately to severely enlarged in of dogs in group and as moderately enlarged in of dogs in group . fluoroscopy revealed variable degrees of airway collapse during normal respiration and induced cough in both groups. radiography and fluoroscopy were not accurate in identifying site and degree of collapse in either group when compared to bronchoscopy. cervical tracheal collapse was identified during bronchoscopy in both group ( of ) and group ( of ) dogs but was subjectively less severe in group dogs. bronchial collapse % was evident at multiple sites in both groups of dogs with no difference between groups. all dogs had suppurative and/or lymphocytic inflammation on airway cytology. infection was not present in either group of dogs, although non-specific light bacterial growth was detected in of group dogs and of group dogs (p . ). preliminary results failed to identify an association between left atrial enlargement and airway collapse in dogs with mmvd but did suggest that airway inflammation is common in affected dogs. further studies are needed to identify factors contributing to airway collapse in dogs with and without mmvd. atenolol is often used empirically in cats with asymptomatic hcm, even though clinical and experimental evidence of efficacy is lacking. cardiac biomarkers play a critical role in the early detection of subclinical cardiac disease, in the prediction of long-term prognosis, and in monitoring the response to therapy in humans. we hypothesized that serum concentrations of the biomarkers, nterminal pro-brain natriuretic peptide (nt-probnp) and cardiac troponin i (ctni), would improve following the chronic administration of atenolol po to asymptomatic cats with hcm. six maine coon or maine coon cross cats with severe hcm from the research colony at ucdavis were administered atenolol ( . mg po twice a day) for days. no cat had severe left ventricular dynamic outflow tract obstruction due to systolic anterior motion of the mitral valve. the concentrations of nt-probnp and ctni were assayed prior to drug administration and on the last day of drug administration. there was no statistically significant difference identified in nt-probnp [median before: pmol/l (range: - pmol/l), median after: pmol/l (range: - pmol/l); p . ] or ctni [median before: . ng/ml (range: . - . ng/ml), median after: . ng/ml (range: . - . ng/ml); p . ] concentrations before and after drug administration using the wilcoxon matched pairs test. the ctni finding suggests that atenolol does not reduce chronic myocyte death in cats with hcm. the lack of improvement in nt-probnp suggests that atenolol does not improve myocardial wall stress in cats with hcm. a clinical trial is warranted to confirm or refute the findings from this study. therefore, leptin-gene expression was investigated in blood samples of dogs with congestive heart failure (chf; n ) in comparison to dogs presented for cardiac screening (n ) without abnormalities. additionally myocardial samples (interventricular septum, right and left atrium and ventricle) of dogs with no cardiac abnormalities (controls), seven dogs with acquired and three with congenital cardiac diseases were investigated using quantitative rt-pcr. leptin blood levels were significantly higher in dogs with chf in comparison to dogs without diseases (p . ). there was an association with gender with higher myocardial leptin levels in female dogs with cardiac diseases (p . ). differences between cardiac regions were present (p o . ) and cardiac diseases resulted in an increase in atrial leptin levels in both sexes (p . ). interestingly, a significant reduction of myocardial leptin was present in dogs with congenital cardiac diseases (p . ), whereas acquired cardiac diseases resulted in an increase in leptin (p . ) in comparison to controls. these results suggest that the heart might be a target of leptin action in the dog and myocardial leptin production might play a role in regulating cardiac function in an auto-and paracrine manner. predicting risk of chf in asymptomatic dogs with mitral valve disease (mvd) is challenging. we examined ability of nt-probnp to identify asymptomatic dogs at high risk for chf. dogs with isachc- b (la:ao . ) were prospectively recruited; dogs with current or previous chf or diuretic therapy were excluded. physical examination, radiography, echocardiography, and nt-probnp were performed at - mo intervals for dogs (median follow-up d, range, - d). thirty-one patients reached a study endpoint of radiographic pulmonary edema; remained asymptomatic. parameters from the visit immediately previous to onset of chf (future-chf) or prior to the most recent visit without chf (remain-asympt) were analyzed. median nt-probnp of future-chf ( pmol/lpmol/l, iqr - ) was significantly different from remain-asympt ( pmol/l, - ; p . ). median time to chf of future-chf was d (iqr, . groups also differed in median la:ao (future-chf . [ . - . ]; remain-asympt . [ . - . ], p . ); vhs (future- ]; remain-asympt . [ . - . ], p . ); and lvidd:ao ]; remain-asympt . [ . - . ], p . ). roc analysis to predict if chf would occur prior to the next visit yielded auc . ( %ci, . - . ). sensitivity was . % or . % and specificity . % or . % for nt-probnp pmol/l or pmol/l, respectively. mean increase in nt-probnp between penultimate visit and two visits prior to endpoint: future-chf . pmol/l vs. remain-asympt . pmol/l. within mo, . %, . %, . %, and . % of dogs with nt-probnp o , , and pmol/l developed chf. nt-probnp and heart size helped assess risk of chf in asymptomatic mvd. increasing the assay's upper limit of detection would likely improve utility of nt-probnp. piiinp is a serum biomarker of collagen biosynthesis and is described as a marker of myocardial fibrosis in human patients. we hypothesised that piiinp concentrations would vary according to the degree of remodelling demonstrable in dogs with naturallyoccurring myxomatous mitral valve disease (mmvd). serum piiinp concentrations (mg/ml) were measured in dogs with mmvd and healthy controls using a validated commerciallyavailable radioimmunoassay. results are reported as (mean ae sd). non-normally distributed variables were logarithmically transformed. comparisons of continuous variables were made between groups using t-tests and one-way anovas with tukey's post-hoc comparisons. univariable analyses were used to evaluate associations between piiinp and clinical characteristics (age, breed [cavalier king charles spaniel (ckcs) yes/ no], sex, weight, heart rate [measured from ecg], treatment with acei [yes/ no], treatment with diuretics [yes/ no] and echocardiographic measurements [la/ao, lvedd/ lvfwd, lveddn, lvesdn]). multivariable analysis was initially performed with all dogs included and then repeated excluding all dogs receiving therapy. dogs with mmvd were divided into those with no cardiomegaly (nc) (la/ao o . and lveddn o . ), those with cardiomegaly (la/ao ! . and/ or lveddn ! . ) but no clinical signs (c) and those dogs with cardiomegaly requiring treatment for congestive heart failure (chf). one hundred and fifty-four dogs with mmvd and control dogs were studied. there was no difference in age (p . ) or weight (p . ) between the mmvd and control groups. there was a significant difference in serum piiinp (p . ) between normal ( . ae . ), nc ( . ae . ), c ( . ae . ) and chf ( . ae . ) groups. post-hoc comparisons demonstrated a difference between nc and chf groups (p . ). there was no difference in serum piiinp between genders (p . ). in the univariable analysis ckcs (yes/ no) (p . ) was positively associated with serum piiinp. age (p o . ), log (la/ao) (p . ) and lveddn (p . ) were negatively associated with serum piiinp. in the multivariable model including all dogs, lveddn (p o . , b À . ( %ci À . to À . )), age (p . , b À . ( %ci À . to À . )) and ckcs (yes/ no) (p . , b . ( %ci . to . )) were independently associated with serum piiinp. in the multivariable model including only dogs not receiving therapy (n ), lveddn (p . , b À . ( %ci À . to À . )), age (p . , b À . ( %ci À . to À . )) and ckcs (yes/ no) (p . , b . ( %ci . to . )) were independently associated with serum piiinp. in conclusion, serum piiinp decreases with age and with increasing lveddn. ckcs have higher serum piiinp measurements independent of age and lveddn, which may reflect a difference in collagen turnover in this breed. left atrial (la) chamber dilation and congestive heart failure (chf) are common consequences of cardiac conditions in cats. in some cases chf is manifest as right-sided chf (r-chf) or pleural effusion, in other cases chf manifests as left-sided chf (l-chf) or pulmonary edema. it is not always readily apparent as to which cats will develop what form of chf. a general impression has been that la enlargement is associated with the average burden of elevated filling pressures, but little attention has been paid to the function of the la chamber itself. since chf is classically preceded by abnormal atrial chamber dilation and alterations in atrial chamber function, we want to understand how these changes may help us manage or predict chf in the cat. we hypothesized that cats manifesting r-chf have la failure with the la acting primarily as a conduit, resulting in greater pulmonary hypertension, whereas l-chf cats maintain some booster pump and reservoir function. we measured la maximum and minimum areas from right parasternal long axis four-chamber views on d echo, and la m-mode dimensions at maximum, minimum, and beginning of atrial contraction. la area change, fractional shortening, active emptying fraction, and expansion index were calculated from these measurements. right ventricular internal diastolic diameter was also measured on m-mode views. preliminary data revealed that maximum left atrial size is not significantly different between r-chf and l-chf cats on d or m-mode measurements due to high variability. however, total left atrial fractional shortening is significantly reduced in r-chf cats ( . % ae . ) compared to l-chf cats ( . % ae . )(p . ), and r-chf cats have reduced left atrial active emptying fraction ( . % ae . ) as compared to l-chf cats ( . % ae )(p o . ). left atrial expansion ability is poorer in r-chf cats ( . % ae . ) than in l-chf cats ( . % ae )(p . ). these findings may suggest that atrial stiffness and poorer atrial function is associated with a greater degree of pulmonary venous and thus secondary pulmonary arterial hypertension resulting in pleural effusion (r-chf). right ventricular diameter on m-mode was increased in r-chf cats ( . mm ae . ) when compared to l-chf cats ( . mm ae . )(p . ) and normal cats ( . mm ae . )(p . ), which may also be evidence for a greater degree of pulmonary arterial hypertension in these cats. episodic weakness and syncope are common in boxer dogs. reported causes include rapid ventricular tachycardia (vt) and exertion-excitement triggered neurally-mediated bradycardia (nmb) .the purpose of this retrospective study is to describe the features of presumed nmb in boxers. to be included in the study, each dog must have been overtly healthy with a history of exertion-excitement triggered syncope or presyncope; had a normal echocardiogram (ec); had absence of vt and fewer than ventricular premature complexes (vpc) on an initial and subsequent hour holter recordings; and been alive and overtly healthy for at least six months following the initial evaluation. a total of boxers were identified. sixteen were male and were female. most ( %) dogs were either less than or more than years of age. most dogs had multiple, but infrequent, episodes and heart rhythm was documented at the time of an episode in only ( %) and only once (bradycardia) on the first holter recording. owners were instructed to attempt to precipitate episodes. bradycardia related episodes were subsequently recorded in : during the nd ( ), rd ( ) or th ( ) day of hour holter recordings and during the th day of an event recording ( ). collapse and bradycardia were documented during auscultation in additional dogs. the heart rate during syncope was never documented in ( %) dogs. a presumptive diagnosis of nmb was based on the absence of initial and follow-up of ec abnormalities and the presence of no or few vpc during extended ecg monitoring. multiple holter recordings ( - hours) were performed in of ( %) dogs and event monitoring of days ( ) and days ( ) was performed in additional dogs. in conclusion, documentation of the heart rhythm during episodes of collapse was difficult, accomplished in only % and was unlikely during the first holter recording. in boxers with suspected nmb, extended ecg monitoring and implantable loop recorders may be best for hr documentation. arrhythmogenic right ventricular cardiomyopathy (arvc) is an inherited myocardial disease with high prevalence in the boxer dog population, and is associated with sustained monomorphic ventricular tachycardia, sudden cardiac death, and replacement of myocardium with fatty or fibro-fatty tissue. though several genes have been linked to the disease both in humans and in boxers, the etiology of arvc is still unclear. several mechanisms for the development of arvc have been suggested, including dysfunction of the canonical wnt pathway, which results in an arvc phenotype in the mouse. the canonical wnt pathway has been linked to many cellular functions, including growth and differentiation of adipocytes. with the recent discovery that the gene encoding striatin, a protein involved in wnt signaling, may be involved in the development of boxer arvc, we hypothesized that changes in the wnt pathway may also play a role in the etiology. here, we show changes in the localization and decreased amount of proteins affiliated with the canonical wnt pathway. afflicted boxers were identified by -hour holter monitoring and histopathological examination of the heart. samples from the right ventricle rv) of arvc afflicted boxers, and unafflicted dogs ( beagle, mongrels, and german shepherds) were collected, fixed in % formalin, processed, treated with antibodies recognizingcatenin, striatin, and calnexin, and examined using confocal microscopy. western blots were performed on unafflicted rv samples, and arvc afflicted rv samples. frozen tissue samples were homogenized in laemmli buffer, and mg of protein was loaded into each well of a - % gradient gel. -catenin, an integral modulator of the wnt pathway, and striatin were colocalized with the endoplasmic reticulum (er) marker, calnexin. in the unafflicted animals, -catenin localized at sites of cell-to-cell apposition, and striatin localized in a diffuse intracellular pattern, with no detectable localization in the er. in contrast, in the arvc boxers, bothcatenin and striatin were colocalized with calnexin in an er pattern. in the afflicted samples, -catenin and striatin were not visualized to the intercalated disc and intracellular space, respectively. western blots of striatin and -catenin revealed no changes in the amount of protein. interestingly, a western blot for the wnt protein revealed a decrease in the amount of protein in arvc samples, compared to unafflicted samples. our preliminary data suggest that disturbances of the canonical wnt pathway may play an etiological role in the development of arvc in the boxer dog. there are numerous benefits of omega- fatty acid supplementation in human heart disease, including reduction in arrhythmias, decreased incidence of sudden death, and improved survival in heart failure. antithrombotic effects of omega- fatty acids have been demonstrated in people, which may have particular benefit in cats given their risk of thromboembolic complications with cardiac disease. benefits also have been found in canine heart disease, and reduced serum concentrations of the omega- fatty acids, eicosapentaenoic acid (epa) and docosahexaenoic acid (dha) have been found in dogs with congestive heart failure (chf) secondary to dcm. to the authors' knowledge, no studies to date have investigated fatty acid concentrations in cats with cardiomyopathy. the purpose of this study was to measure serum fatty acid concentrations in normal cats and cats with cardiomyopathy. serum fatty acid concentrations were measured in normal cats and cats with cardiomyopathy using gas chromatography. cats with cardiomyopathy and at least mild left atrial (la) enlargement (la to aortic ratio . on two-dimensional echocardiography from a right parasternal short axis view) were candidates for study. normal cats had a normal history, physical examination, echocardiogram, packed cell volume, total solids and platelet count. cats with evidence of other systemic disease or those receiving anticoagulants were excluded from the study. normally distributed and skewed data were compared between the cardiomyopathy and control groups with independent t tests or mann whitney u tests, respectively. statistical significance was set at p o . . thirty cats with cardiomyopathy ( neutered males and neutered females) and healthy controls ( neutered males and neutered females) were enrolled. median age was yr (range, - yr) in the cardiomyopathy group and yr (range, - yr) in the control group (p . ). cats in the cardiomyopathy group were classified in the international small animal cardiac health council stage b (n ), (n ), a (n ) and b (n ). compared to control cats, cardiomyopathic cats had higher concentrations of palmitic acid (p . ) and dha (p o . ), and lower concentrations of linoleic acid (p . ). among cats with cardiomyopathy, there was no significant correlation between any serum fatty acid concentration and left atrial size or age. these findings warrant further investigation into the role of fatty acids in cats with cardiac disease. platelet mapping is an application of thromboelastography that relies on the generation of at least three tracings: ma thrombin (maximum platelet activity),ma fibrin (fibrin activity only), an-dma aa or adp (platelet activity not inhibited by arachidonic acid or adp receptor antagonists, respectively). using these three tracings, the % inhibition of platelets can be calculated. the purpose of this study was to evaluate the platelet mapping assay in normal cats and assess platelet inhibition in cats receiving clopidogrel. employee-owned cats with normal history, physical exam, echocardiogram, thromboelastography, packed cell volume, total solids and platelet count were eligible. clopidogrel ( . mg po q h) was administered for days with platelet mapping performed on days and . platelet mapping values were compared using a paired t test, with significance set at p o . . seven cats ( fs, cm, aged - years) were enrolled. compared to day , ma adp (p o . ) and ma fibrin (p o . ) were lower on day . the latter unexpected result prompted measurement of fibrinogen concentrations at day and in the last of these cats. fibrinogen was not different from day to in these cats. these results suggest that platelet mapping may be a simple, outpatient clinical tool to measure antiplatelet activity in cats receiving clopidogrel. this clopidogrel dose resulted in significant platelet inhibition as measured by ma adp in all cats. further studies correlating antiplatelet effects measured by platelet mapping with clinical outcomes in cats with cardiomyopathy are warranted. this study investigated the hemodynamic effects of application of an itd in a canine model of cardiopulmonary arrest. laboratory beagles which were part of a separate terminal study were anesthetized and instrumented for continuous measurement and recording of right atrial pressure, arterial pressure and carotid blood flow. following euthanasia, cpr was performed for one minute, then a pause of one minute followed by a second one minute period at a compression rate of - /minute, ventilation with % oxygen was delivered at eight breaths/min and ml/kg tidal volume. cpr was performed with the itd in place (itd-cpr) and without the itd (s-cpr) for one period each in a randomized fashion with the rescuer blinded to its application. baseline, s-cpr and itd-cpr data were assessed for normality, a kruskal-wallis one-way anova on ranks was used (baseline v cpr). when appropriate a pairwise multiple comparison procedure (dunn's method) was used. percentage of baseline s-cpr v itd-cpr was assessed using the student t-test. the right atrial diastolic pressure was significantly more negative with the itd attached than without (p . ), the coronary perfusion pressure and carotid blood flow were significantly higher during cpr with the itd than standard cpr (p . , p . ). no significant differences in diastolic, mean or systolic arterial pressure or end tidal co were seen. application of the itd resulted in significantly improved hemodynamics during cpr in dogs. clinical evaluation of the device is warranted to examine whether this translates into improved success in resuscitation and survival. left ventricular (lv) systolic dysfunction is a common problem in dogs and can be due to a variety of etiologies. one potential etiology for systolic dysfunction is persistent or paroxysmal tachyarrhythmias, leading to tachycardia-induced cardiomyopathy (ticm). in humans, ticm carries a relatively good prognosis in that remodeling may be reversible with normalization of heart rate. differentiating between primary and secondary tachyarrhythmias in dogs with systolic dysfunction is critical for prognostic purposes as primary tachyarrhythmias may be associated with a better outcome. the goal of our study was to describe a population of dogs with ticm and to determine if treatment of arrhythmias was associated with reversible cardiac remodeling as indicated by standard echocardiographic parameters. medical records of dogs referred to the cardiology service of ksu vmth from to were reviewed. ticm was defined as the presence of severe tachyarrhythmias that were reversible with treatment, systolic dysfunction or ventricular enlargement that improved with treatment of the arrhythmia, or dogs with severe tachyarrhythmias and systolic dysfunction of breeds with that are atypical for idiopathic dilated cardiomyopathy. exclusion criteria were dogs with congenital heart disease, severe mitral regurgitation, and endocarditis. transthoracic echocardiography, thoracic radiographs and electrocardiography (ecg) were performed in all dogs. ventricular enlargement and systolic dysfunction were defined according to standard echocardiographic parameters. arrhythmias were confirmed with a holter monitor in dogs. a total of dogs were included in the study. mean age was years (range - years) with males ( intact, castrated) and females ( spayed, intact). four dogs had pulmonary venous congestion or pulmonary edema and two dogs had ascites. at initial presentation, the meanaesd values were as follows: heart rate ae bpm, m-mode fractional shortening (fs) . ae . %, ejection fraction (ef) using the area-length method . ae . %, and left atrial to aortic root ratio (la/ao) . ae . . initial meanaesd m-mode derived lv internal dimensions corrected for body weight were as follows: diastolic . ae . and systolic . ae . . at least one of the following tachyarrhythmias were identified in each dog: atrial fibrillation ( ), supraventricular tachycardia ( ), junctional tachycardia ( ), and ventricular arrhythmias ( ). ten dogs were available for follow up. seven dogs improved in at least one of the following parameters: resolution of tachyarrhythmia ( ), improved systolic function ( ) antidiuretic hormone (adh) has been shown to be elevated in humans with congestive heart failure (chf). recently, antidiuretic hormone antagonists were successful during investigational treatment of refractory congestive heart failure in humans. adh levels have been only modestly investigated in dogs with cardiac disease, primarily due to the technical difficulty in measuring adh levels via radioimmunoassay. based on the homologous structure of canine and human adh, we aimed first to determine the feasibility of measuring adh in dog plasma using a human elisa kit, and secondly to investigate the level of adh in dogs with congestive heart failure due to acquired cardiac disease. elisa assay kit validation was performed using six healthy dogs with normal clinical and echocardiographic examinations. pooled canine plasma was spiked with synthetic adh and intra-assay precision, dilutional parallelism, and linearity were assessed. to address the second aim of the study, samples were collected from normal dogs and dogs with heart failure due to one of two types of acquired cardiac disease: chronic degenerative valve disease (cdvd) or dilated cardiomyopathy (dcm). patients underwent clinical, radiographic, and echocardiographic examination to confirm diagnosis, assess severity of disease, and determine presence of pulmonary edema. whole blood was collected into edta tubes containing protease inhibitors, cold centrifuged, and plasma was stored at À until analysis. following ether extraction, plasma adh in each sample was measured in duplicate using a human elisa kit. statistical analysis included a d-agostino and pearson test for normality; group results were compared using a nonparametric mann-whitney test. adh was measured in canine plasma using the human elisa kit with acceptable intra-assay precision, linearity, and dilutional parallelism. intra-assay coefficient of variation was %. twenty-four dogs were recruited for the second phase of the study. six normal dogs and twelve dogs with radiographic evidence of pulmonary edema due to either cdvd or dcm were selected for participation. the remaining six dogs were excluded due to lack of definitive radiographic evidence of congestive heart failure. median adh values were . ae . pg/ml for the normal group (n ) and . ae . pg/ml for the heart failure group (n ). median adh values for the two groups were statistically different (p . ). our preliminary results indicate that measuring canine adh using a human elisa kit is feasible and provides results with an acceptable coefficient of variation. we also showed that dogs with congestive heart failure due to cdvd and dcm have elevated adh levels in comparison to normal dogs. our findings motivate further investigation to assess the degree of plasma adh level elevation and the possible use of adh antagonists as an adjunct treatment for refractory congestive heart failure in dogs. aortic thromboembolism (ate) occurs in both cats and dogs. whereas ate in cats is strongly associated with structural heart disease and typically has an acute catastrophic presentation; the pathogenesis and presentation of ate in dogs is less well known or understood. further, an effective antithrombotic strategy for ate in dogs has not been reported. medical records of dogs diagnosed with ate between and were examined retrospectively. diagnosis of ate was based on ultrasonography, doppler flow studies, and diminished or absent femoral pulses. dogs were treated with various acute and chronic antithrombotic therapies. the severity of ambulatory dysfunction was graded as none, mild, moderate, severe, or non-ambulatory at presentation and after therapy. a cohort of dogs in this study received a standardized protocol of chronic warfarin therapy with or without antiplatelet drugs. target international normalized ratio for warfarin therapy was to . twenty-six dogs were diagnosed with ate. all had an apparent mural aortic thrombus caudal to the renal arteries with most having evidence of embolization to the iliac and femoral arteries. none had structural heart disease at diagnosis. twenty dogs ( %) were still ambulatory at diagnosis. the median duration of ambulatory dysfunction prior to presentation was . weeks (range day - weeks). a majority of dogs ( %) had no concurrent conditions at diagnosis. nine dogs ( %) had protein-losing nephropathy. four dogs ( %) were hypothyroid. fourteen dogs were treated with a standard warfarin protocol for a median period of . months (range . - months). eight dogs were treated concurrently with aspirin, dogs were treated concurrently with clopidogrel, and dogs were treated with warfarin only. ambulatory function improved between and grades in dogs treated with chronic warfarin. the median period until clinical improvement was . days (range - days). two dogs treated with chronic warfarin therapy had documented resolution of ate, and dogs had complete resolution of ambulatory dysfunction. none of the dogs treated with chronic warfarin became nonambulatory, died, or underwent euthanasia because of ate. the median period of freedom from an adverse event was . months. no serious hemorrhagic events were reported. four dogs were treated with tpa. three of these had an unfavorable outcome. two dogs were ambulatory before tpa and become non-ambulatory after treatment. two dogs underwent surgical thrombectomy. one had a favorable outcome until ate recurred months after surgery. in conclusion, the pathogenesis of ate in dogs is not associated with structural heart disease or left atrial thrombus formation. the presentation tends to be for chronic ambulatory dysfunction. most dogs are still ambulatory at presentation. warfarin, with or without concurrent antiplatelet therapy, is an effective antithrombotic treatment strategy for dogs with ate. information is known. through previous work, investigators have encountered norfolk terriers (nt) with echocardiographically apparent dmvd in the absence of a heart murmur. in order to more fully understand dmvd in this breed of dog, we sought to characterize findings from the physical and echocardiographic exam, biochemical, biomarker, and nutritional profile, and select environmental variables from a cohort of apparently healthy nt. overtly healthy nt ! yrs old were recruited by different veterinary hospitals and underwent historical, physical, ecg, and d/color-flow doppler echocardiographic exam. anterior mitral valve length, maximal thickness, area, and prolapse were measured from d images. presence of dmvd was defined as thickened, prolapsing, or flail mitral valve leaflets in the presence of color flow doppler evidence of mitral regurgitation. blood samples were obtained for serum biochemistry and serotonin, plasma nt-probnp, amino acid profile, c-reactive protein, and cardiac troponin-i. forty-eight dogs were entered into the study (median age, yrs iqr [ - ]; gender, f, m; median bcs, ). of the dogs, ( %) had murmurs, ( %) had mid-systolic clicks, ( %) had ecg p-pulmonale, and ( %) were deemed to have echocardiographic evidence of dmvd, including nt without a murmur. seven ( %), ( %), and ( %) dogs were classified as isachc , a, and b, respectively. mean indexed echocardiographic mitral leaflet length (p o . ), thickness (p . ), prolapse (p . ), and la:aod (p . ) were significantly different between isachc a/b vs . between isachc a/ b and , there were no differences in serum amino acids, c-reactive protein, troponin, diet, or environmental factors; however different amino acids (ala, gly, phe, pro, trp, tyr) were significantly higher in isachc b vs. a. median serum serotonin was increased in dogs with a/b vs. (p . ). dogs whose diets contained some canned food (p . ) and dogs residing in suburban environments (p . ) had higher serotonin concentrations. nt-probnp tended (p . ) to be higher in isachc a/ b vs. . dmvd appears to be relatively common in nt and echocardiographic changes consistent with mild dmvd can be seen in dogs without a heart murmur. the results of this study establish a foundation of useful information upon which additional prospective studies can be developed. left ventricle (lv) evaluation is one of the most important contributions of echocardiography in the assessment of cardiac function. however, lv analysis can be made from images obtained by different modes and views of the heart. the aim of this study was to compare lv measurements, shortening fraction (sf) and ejection fraction (ef) obtained from four methods: m mode in short-axis and in long-axis, bidimensional mode in short-axis and in long-axis views of the heart. forty normal adult german shepherds were selected. echocardiographic study of lv of each animal was performed by the four methods described above. ancova test was used to examine the effects of axis, mode, weight and gender over lv measurements. isolated effect of the axis was observed for lv end-diastolic diameter (lvedd), with greater values obtained from short-axis views. there was isolated effect of mode over ef and sf, with greater measurements derived from bidimensional mode methods. weight correlated with all linear lv measures at least in one method, but not with ef and sf. weight had positive effect over lv endsystolic diameter and lv end-diastole posterior wall thickness in all methods, except from m mode in short axis in the last one. gender had isolated effect over lvedd, males showing greater values than females in bidimensional mode in short and long axis. the combined effect of axis, gender and weight was identified in interventricular septal end-diastolic thickness. we concluded that normal reference values obtained by different echocardiographic modes and planes should not be used interchangeably. abstract c- assessment of left ventricular diastolic func-tion by color tissue doppler imaging echo-cardiography in maine coon cats tested for mypbc-ap mutation hypertrophic cardiomyopathy (hcm), characterized by increased cardiac mass and diastolic dysfunction, is the most common feline heart disease. myocardial analysis by color tissue doppler imaging (tdi) is more sensitive than conventional echocardiography. this study evaluated diastolic dysfunction in various stages of feline hcm. maine coon cats (n ) were screened for the mybpc-a p mutation and examined with both echocardiography and tdi. then, were phenotypically classified in: normal (n ), suspects for hcm (n ) and hcm group (n ); and genotypically classified in: negative (n ), heterozygous (n ) and homozygous group (n ). myocardial velocities, measured in the basal and mild ventricular segment of the interventricular septal wall (ivs), left ventricular free wall (lvw) and in radial segment of left ventricular wall, was compared among different groups. a significant decreased (p , ) longitudinal em/am at the basal segment of ivs was observed in hcm cats compared with suspects and normal cats. a significant increased (p , ) longitudinal e/em at the basal segment of ivs was observed in hcm cats compared with suspects and normal cats. and a significant decreased (p , ) longitudinal sm at the basal segment of the lvw was observed in heterozygous cats compared with negative cats, both without hypertrophy. there was a significant positive correlation between summated early and late diastolic velocities (emam) and heart rate (p o , ); and a positive correlation between sm and em velocities and heart rate (p o , ). the mybpc-a p mutation is not consistently associated with ventricular hypertrophy and negatives cats can also develop hcm. the tdi alone is not able to identify cats with mutation before myocardial hypertrophy. diastolic dysfunction occurs in many cats with hypertrophic cardiomyopathy (hcm) but less is known about systolic function in various stages of hcm. myocardial strain analysis by tissue doppler imaging is a noninvasive echocardiographic method to assess systolic function. this study evaluated systolic function in various stages of feline hcm. maine coon cats (n ) were screened for the mybpc-a p mutation an examined with both echocardiography and strain. then, were phenotypically classified in: normal (n ), suspects for hcm (n ) and hcm group (n ); and genotypically classified in: negative (n ), heterozygous (n ) and homozygous group (n ). peak myocardial strain, measured in the basal and mildventricular segment of the interventricular septal wall (ivs), left ventricular free wall (lvw), left ventricular anterior wall (lvaw), left ventricular posterior wall (lvpw) and radial segment of left ventricular wall, was compared among different groups. whereas conventional echocardiography demonstrated an apparently normal contractile state based on fractional shortening, myocardial strain (at mildventricular segment of ivs) in hcm cats was significantly decreased compared with normal group (p , ). myocardial strain (at basal segment of lvaw) also was significantly decreased in heterozygous cats compared with negative group (p , ); and was significantly decreased in heterozygous cats compared with negative group, both without ventricular hypertrophy (p , ). there was a significant negative correlation between strain values and wall thickness (p o , ). this method allows detection of abnormal systolic deformation in maine coons cats with hcm mutation despite apparently normal systolic function. the abnormal systolic deformation already can be present in heterozygous cats without hypertrophy and increased with progressive ventricular hypertrophy. recently, multiple advanced resting electrocardiographic (ecg) techniques have been applied in humans for detection of cardiac autonomic and repolarisation function. this has improved the diagnostic and/or prognostic value of short-time ecg in detection of common human cardiac diseases even before onset of symptoms or changes in the standard ecg. therefore, this study investigates, if advanced ecg can predict the severity of mitral regurgitation (mr) in dogs with myxomatous mitral valve disease (mmvd) and thereby improve the diagnostic value of ecg. the study included privately owned cavalier king charles spaniels (ckcss) (age . ae . years; males and females). all dogs were examined by echocardiography and a short-time ( - min) high-fidelity -lead ecg, with the dog in a resting position and in sinus rhythm. dogs were divided into groups according to the degree of mr estimated as the percentage of the left atrium area using color doppler mapping ( %; % o jet %; % o jet %; jet %; jet % and with clinical signs of congestive heart failure). ecg recordings were evaluated via custom software programs to calculate different parameters, including heart rate variability (hrv), qt variability (qtv), t-wave complexity, wave morphology and -d ecg. one-way anova determined ecg parameters, which were significantly different (p o . ) between the dog groups. principal component factor analysis identified a factor model with . % explained variability. qrs dipolar voltage and two repolarization indices of qtv increased significantly with mr severity, whereas total power of the frequency spectrum of rr interval and the standard deviation of qtv decreased significantly with mr severity. for the selected parameters the prediction of mr jet value was tested by multiple linear regression. a correlation coefficient (r) of . indicated that the prediction value was significant (p o . ). if age was included in the multiple linear regression the prediction value was further increased (r . ). our results indicate that for a cut-off criteria of mr ! % jet the five selected ecg parameters could predict the severity of mr caused by mmvd in ckcss with sinus rhythm with sensitivity % ( % with age inclusion) and specificity % ( % with age inclusion) (p o . ). nt-probnp concentration is increased in canine patients with heart disease. relatively little is known about the stimuli for release of nt-probnp in dogs. physical activity independent of cardiac disease and the stress of being in the hospital could influence nt-probnp release and affect diagnosis and management of patients. we hypothesized that nt-probnp concentration in healthy dogs would not exceed the normal reference value ( pmol/l) following a period of exercise. the goal of this study was to examine whether physical activity could elevate plasma nt-probnp and cause false positive results in healthy dogs. the study population included healthy dogs yr of age without heart murmur or known systemic disease, and normal d/color flow echocardiographic exam. plasma samples for nt-probnp were obtained before, immediately after, and hour after a standardized -minute submaximal exercise regimen. the study included dogs with a median age of . yrs and included females and males. there was no statistical difference in median plasma nt-probnp concentration across the three time points (baseline median, [iqr, immediately post, ; p . ). the average coefficient of variation of nt-probnp concentration across the exercise regimen was . ae . %. in of dogs ( . %), nt-probnp increased from to pmol/l immediately after exercise. the results of this study demonstrate that submaximal exercise does not significantly change median nt-probnp concentration and the incidence of false positive results is low. further studies should investigate effects of exercise on nt-probnp concentrations in dogs with heart disease. obesity is an increasing problem in veterinary medicine. obese human patients are shown to present lower levels of natriuretic peptides, regardless of an increased volume and pressure load, what raises the possibility that the natriuretic response is impaired in these individuals. considering the controversial findings in obese humans, and the lack of studies reported in dogs, this study proposed the evaluation of nt-proanp concentration in obese dogs. nt-proanp concentration was determined prospectively in obese dogs ( females; males; - months) and in non-obese dogs (controls; females; males; - months) from a veterinary hospital population. obesity was determined by body condition score [ ( / ); ( / ); ( / ); ( / ); ( / ); ( / )]. dogs were excluded if they had any primary cardiac disease, renal insufficiency, endocrine disease, or if they were receiving diuretics, vasodilators, antiepileptic drugs or corticosteroids. commercial kits were used (vetsign s canine cardio screen nt-pro-anp vc -guildhay/biomedica). mann whitney test was used for group comparison. results are presented as median; interval; p and p ). nt-proanp was significantly lower in obese dogs [ . fmol/ml ( . - . ); p . ; p . ] than in controls [ . fmol/ml ( . - . ); p . ; p . ]; (p . ). results were similar to what has been found in obese humans. lower levels of natriuretic peptides are also seen in obese heart failure patients. this study provides important information regarding nt-proanp concentration in obese dogs, which should be better explored characterizing the behavior of natriuretic peptides after weight loss, and also in obese dogs with primary heart disease. left-to-right shunting patent ductus arteriosus (pda) is one of the most common canine congenital cardiovascular defects. human studies have shown that bnp and nt-probnp concentrations are elevated in patients with pda, and can be used to detect hemodynamically significant pda. the purpose of this study was to measure nt-probnp concentrations in dogs with pda, and to assess whether additional indicators of hemodynamics correlate with ntprobnp. we hypothesized that nt-probnp will serve as a simple non-invasive marker of hemodynamic significance in dogs with pda prior to and following transcatheter ductal occlusion. nt-probnp was measured in client-owned dogs with echocardiographically normal hearts. ten dogs with pda were initially evaluated with thoracic radiographs, transthoracic and transesophageal echocardiography, pulmonary capillary wedge pressure (pcwp) and nt-probnp. nt-probnp and echocardiography were repeated at day and months following ductal occlusion. pcwp was repeated at months. baseline nt-probnp was significantly higher in pda dogs compared to control ( ae pmol/l (mean ae sd), ae ; p o . ). at day and months following ductal occlusion, nt-probnp was ae and ae , respectively. the following decreased significantly from baseline: pcwp ( . ae . to . ae . mmhg; p . ), and indexed left ventricular internal dimensions in diastole ( . ae . to . ae . ; p . ) but not significantly in systole ( . ae . to . ae . ; p . ). nt-probnp is elevated in dogs with pda and transductal closure is associated with a reduction in nt-probnp, pcwp and left ventricular size. cardiac biomarkers, particularly nt-probnp, are becoming more commonly used in dogs and cats as part of a diagnostic work up. multiple studies already have documented the correlation of this peptide with cardiac disease status and potential clinical implications. in a portion of these reports the manner in which samples were handled was placement of whole blood into an edta tube, followed by centrifugation and decanting of the supernatant that was ultimately stored at À c or À c prior to shipment, either with or without protease inhibition. our objective was to compare the nt-probnp concentrations in feline plasma collected using the previously reported methods to the california animal hospital (cah) collection method using tubes containing a protease inhibitor. this study compared nt-probnp concentrations using the protease inhibitor tubes vs. edta tubes from privately owned feline patients, with confirmed cardiac disease, and control feline patients. for all study participants, we performed a full history and physical examination, a hematology and chemistry panel, thoracic radiographs, ecg, and echocardiogram. in each study participant, at least ml's of whole blood was drawn from a peripheral vein, and transferred to a plastic edta tube. the sample was centrifuged within hour after collection. ml of plasma was then transferred to a tube containing a protease inhibitor, which was stored at c until being shipped within hours of collection. the remaining plasma was placed into separate microtubes, which did not contain a protease inhibitor. one microtube was then stored and shipped as previous studies have reported (À c, styrofoam container, shipment within hours), and the second microtube was frozen at À c. all samples were shipped, received and analyzed within hours of collection. results of this study showed that no difference was found between the frozen sample methods ( pmol/l and pmol/l p . ). it was determined that both frozen methods had lower nt-probnp levels ( and pmol/l) when compared to plasma samples shipped in protease inhibitor tubes ( and pmol/l). the findings of this trial demonstrate that the nt-probnp levels are significantly different between samples placed in edta tubes vs. contain protease inhibitor (p . and p . ). utilizing protease inhibitor tubes allows more accurate measurement of plasma nt-probnp. as for its relevance for future research and publications, authors should take care to investigate the manner in which blood samples were handled and the conclusion/results of these studies should be taken in light of the methodologies used in collecting, storing, shipping and analyzing the samples. degenerative mitral valve disease (dmvd) is one of the most common heart disease and is present approximately % of the canine heart disease. although the high prevalence exists in small dogs, the underlying molecular mechanism of its pathophysiology is rarely known. dmvd is functionally and pathologically similar in humans and dogs, thus, there will be a common pathogenesis in human and dogs with naturally occurring dmvd. serotonin and serotonin-related mechanisms have been implicated as a cause of valvular disease in human and animals, including spontaneous dmvd in dogs. increased circulating ht concentration as a potential source of heightened ht signaling is demonstrated in small dogs with dmvd. the aim of this study was to investigate whether serum ht concentrations were associated with severity of naturally occurring dmvd in small dogs and to investigate potential associations of dog characteristics on serum ht concentrations in our study population. forty-eight dogs were included in this study and were classified into control and dmvd groups according to the results of physical and echocardiographic examinations. based on the la:ao ratio, dogs with dmvd were classified as follow: control (la:ao ratio . and no mr), mild (la:ao ratio . and mr), moderate ( . o la:ao ratio . and mr), severe (la:ao ratio . and mr). serum serotonin concentrations were measured by elisa. an overall significant difference (p o . ) was found among groups and ht concentrations (control, . ng/ml [ . - . dmvd, ). significantly higher ht concentrations were observed in dogs with moderate (p o . ) and severe (p o . ) dmvd, compared with concentration in control group. additionally, ht concentration in dogs with moderate dmvd were significantly higher (p o . ) than concentration in dogs with mild dmvd. also, dogs with severe dmvd had significantly higher ht concentration than dogs with mild (p o . ) and moderate (p o . ) dmvd. there was no significant association of age, platelet, and lvidd, on serum ht concentration, however, weak correlation between serum ht increased significantly and la:ao ratio (r . , p o . ) was observed. the results of this study indicate that serum ht concentrations were higher with increasing severity of spontaneous dmvd, which may be the potential cause to advance the progression of dmvd. further studies should be performed to reveal the role of ht in inducing and accelerating spontaneous dmvd and to investigate if lowering serum ht concentration could alter the progression of dmvd. the objective of this prospective study was to evaluate the utility of cardiac troponin i (ctni) in differentiating between underlying etiologies of pericardial effusion in the canine patient. patients were prospectively recruited at time of diagnosis of novel pericardial effusion. serum samples were collected prior to pericardiocentesis. patients were evaluated by echocardiography and classified with the diagnosis of hemangiosarcoma (hsa), heart base tumor (hbt), or unknown etiology at the initial evaluation based on established characteristic echocardiographic findings. idiopathic pericardial effusion (ipe) was defined by histopathology, echonegative for a mass lesion with no recurrence of pericardial effusion months, or symptom free months from time of enrollment. patients were excluded from analysis if a diagnosis could not be established based on above criteria or concurrent moderate azotemia (creatinine . mg/dl) was present at time of sample collection. serum samples were frozen and analyzed in batches within days of collection by a ctni assay with a . ng/ml lower limit sensitivity. sixty-three patients were recruited over a one year period with patients excluded due to lack of diagnosis ( ) or azotemia ( ). median ctni levels of dogs with hsa (n ), hbt (n ), and ipe (n ) were . ng/dl (interquartile range (iqr) o . - . ), . ng/dl (iqr o . - . ), and o . ng/dl (iqr o . -o . ) respectively. concentrations of ctni differed significantly between dogs with hsa and hbt (p . ) and ipe (p . ). there was no difference between ctni concentrations between hbt and ipe dogs (p . ). receiver operating curve analysis to determine the optimal cutoff for differentiation of dogs affected with hsa and both hbt and ipe revealed a significant (p o . ) area under the curve ( . ). a cut-off point of ctni of . yielded a sensitivity of % ( % ci, - %) and specificity of % ( % ci, - %). utilizing a higher cut-off point of . yielded a lower sensitivity of % ( % ci, - %), but a higher specificity of % ( % ci, - %) which may have more clinical utility given the disparity in prognoses of the etiologies compared. in conclusion, this study supports the diagnostic utility of ctni concentrations to delineate between patients with hsa and other etiologies of pericardial effusion, but does not reliably differentiate between dogs with ipe and other neoplastic etiologies. the pathogenesis of degenerative mitral valve disease (dmvd) in dogs remains to be fully elucidated. the high sheer stress caused by mitral regurgitation damages the endothelial surface of the valve, and a previous study demonstrated increased transcription of intercellular adhesion molecule- (icam- ) and e-selectin in affected mitral leaflet tissue. we hypothesized that this may be responsible for platelet recruitment and adhesion, and initiation of a proliferative cascade, resulting in further myxomatous changes. the goal of this study was to compare plasma levels of icam- and e-selectin in healthy dogs and those with dmvd. the study population included dogs with echocardiographic evidence of dmvd and healthy control dogs year old with no heart murmur or known systemic diseases. dmvd dogs underwent d/color-flow doppler echocardiographic exam. blood samples were obtained for plasma icam- and e-selectin analysis using commercially available elisa kits. the study included dogs, of which had dmvd and were normal. the dmvd group had a median age of . yrs ) and included females and males. two ( %), ( %), ( %) and ( %) dogs were classified as isachc a, b, and a, respectively. of the control dogs, median age was . yrs [ - . ], with females and males. there was no statistical difference in plasma e-selectin between control dogs (median . [ . - . ]) and those with dmvd ( . [ . - . ]); p . . plasma icam- concentrations were higher in dmvd dogs ( . [ . - . ]) than controls (median . [ . - . ], but this difference did not reach statistical significance (p . ). linear regression analysis showed no significant correlation between icam- or e-selectin and serum serotonin level, nt-probnp or echocardiographic measures of dmvd severity (la:ao, lvidd:ao, lvids:ao). the results of this study demonstrate no significant difference in circulating adhesion molecules icam- and e-selectin in dogs with dmvd as compared with healthy controls. further studies investigating adhesion molecules within the mitral valve tissue itself are likely needed if icam- and e-selectin play a role in the pathophysiology of dmvd. the rate of glucose utilization in the heart is greater than in other tissues, and impaired glucose uptake may play a major role in the pathogenesis of heart failure (hf). glucose uptake across the sarcolemma is regulated by a family of membrane proteins called glucose transporters (gluts), which includes glut- , the major cardiac isoform, and glut- , a recently discovered isoform, the role of which is unknown in the heart. in addition, despite the wellknown regional differences in myocardial structure and function, potential regional patterns in glucose transport have not been investigated. thus, we hypothesized that glut- and - protein and gene expression would be chamber specific in healthy dogs and during chronic hf. using a canine model of tachypacing induced chronic hf, glut protein and messenger rna in both ventricles and atria were investigated by immunoblotting and real time pcr. in control dogs, glut- , but not glut- , protein expression were significantly higher in the atria compared to the ventricles, with the highest content in the right atrium (ra, p o . ). glut- and - mrna were homogeneously expressed in all the cardiac chambers. during chronic hf, glut - and - expression was highest in the left ventricle (lv, by . and . fold, respectively, p o . ), with a concomitant increase in glut- and - mrna (p o . ). glut - , but not glut- , was decreased in ra during chronic hf (p . ). our data suggest that glut- protein was differentially expressed across the cardiac chambers in the healthy heart. during chronic hf, lv was the primary site dependent on both glut and glut -mediated glucose transport, which was transcriptionally regulated. in addition, the paradoxical decrease in glut content in ra may induce perturbations in atrial energy production during chronic hf. some obese dogs are suspected to have cardiac disease because they have enlargement of the heart on thoracic radiograph. it has been reported in cats that the fat increases the cardiac silhouette, while echocardiograms revealed normal cardiac dimensions. the purpose of this study was to determine whether obesity overestimates cardiac dimension in radiographs compared to echocardiographic findings in dogs. twenty three obese dogs and controls were included based on a - body condition scoring (bcs). computerized radiography was obtained and vhs measurement was performed as previously described. echocardiographic measurements were interpreted based on reference values according to lean body weight regression equations. results for echo and vhs measurements were classified in scores as normal, mild, moderate or severe increase. student's t test was used for comparison of vhs between groups. mann-whitney rank sum test was used to assess echocardiographic scores between groups. spearman rank order correlation was used to assess relationships between any pairs of variables between echo and vhs scores, echo vs bcs and vhs vs bcs. groups were similar regarding age [obese ( ae ); control ( ae ); p . ], breeds and gender distribution. obese dogs had significantly higher vhs and echo scores compared with controls [vhs: ( . ae . ) vs ( . ae . ); p o . ; echo score: range ( - ) vs ( - ); p . ]. there were no relationships between any pair of variables analyzed. these results show that there are changes both in echo and radiographic appearance of the heart in obese dogs, but vhs overestimates cardiac silhouette compared to echo, probably related to pericardial fat accumulation. heart rate variability (hrv) is an indirect measurement of the autonomic modulation of heart rate (hr). reduced hrv measured from short-time electrocardiography is seen in dogs with heart failure (hf) secondary to myxomatous mitral valve disease (mmvd). however, hrv is suggested to increase with disease severity at early stages of mmvd. the aims of this study were ) to associate hr and hrv with severity of mmvd in cavalier king charles spaniels (ckcs) and ) to compare hr and hrv between ckcs and other dog breeds in a group of dogs in hf secondary to mmvd. one-hundred dogs were examined by echocardiography and hour electrocardiography. the dogs were divided into five groups: ) ckcs with no/minimal mitral regurgitation (mr) (mr jet % of the left atrial area using color doppler mapping) and no murmur, ) ckcs with mild mr ( % o jet %), ) ckcs with moderate/ severe mr (jet %) and no clinical signs of hf, ) ckcs in hf (hf defined as left atrium to aortic root ratio (la/ao) . , clinical signs of hf and furosemide responsiveness) and ) non-ckcs in hf. dogs in hf were allowed hf therapy. both hr and hrv were analyzed over a -hour period, while hrv were also analysed over a -hour nightly period. analyses of variance were performed with hr or hrv as response variables and the explanatory variables dog group and echocardiographic indices of mmvd were included separately. all p-values were bonferroni corrected. minimum-and mean hr were significantly higher in ckcs with moderate/severe mr and in hf compared to ckcs with no/ minimal and mild mr (all p o . ). seven out of hrv variables were significantly decreased in ckcs with moderate/ severe mr and in hf compared to ckcs with no/minimal and mild mr (all p o . ). another hrv variables showed the same groupwise differences (all p o . ), except that the difference between ckcs with mild mr and ckcs with moderate/severe mr did not reach statistical significance. mminimum hr, mean hr and the hrv variables ( and ) differing between dog groups, also consistently decreased with increasing mr, la/ao and the proximal isovelocity surface area in ckcs. non-ckcs in hf had a lower minimum hr compared to ckcs in hf (p . ) and a higher triangular index measured in both periods (all p o . ). in conclusion, hr increased and most hrv variables decreased with increasing severity of mmvd in ckcs, even prior to the development of hf. other breeds in hf secondary to mmvd had lower minimum hr, but higher triangular index compared to ckcs in hf. although the cells in the specialized conduction system in the heart are capable of initiating their own impulse, the rate in which those impulses are generated can be influenced by autonomic nervous system. different types of respiratory patterns can stimulate autonomic nervous system in different manners. thus, non-sedated rabbits were studied during forced respiration aiming to evaluate the influence of this breathing pattern on heart rate. twenty male, one-year-old healthy new zealand rabbits were enrolled in the study. animals were set in right lateral recumbency and maintained that way by physical contention. chemical sedation was not used. partial nasal obstruction by digital compression was applied to those rabbits for five seconds, eliciting a forced inhaling and exhaling against semi closed nostrils. heart rate was obtained by measurement of two consecutives rr intervals in the computerized electrocardiography, recorded continuously prior and during the maneuver. heart rate before the intervention was ae bpm (mean ae standard deviation). all rabbits submitted to the maneuver showed a dramatic reduction in this parameter. after nasal partial obstruction, heart rate was ae bpm. data was submitted to statistical analysis by paired student's t test and a significant difference between the heart rate before and after the maneuver was observed (p o . ). although the exactly mechanism involved in this response was not elucidated, the presented data support the applicability of this maneuver as an efficient method for non-pharmacological heart rate reduction in rabbits. obesity can affect cardiac function due to effects on cardiac rhythm, ventricular volume and blood pressure. the purpose of this study was to determine the effects of obesity and overweight on noninvasive systemic blood pressure and doppler echocardiographic parameters in cats without others causes of cardiac hypertrophy. the study groups comprised fifteen obese cats with mean body score index (bsi) of , , seven overweight cats (bsi , ) and seven cats with ideal bsi ( , ). the blood pressure was measured by doppler method and the doppler echocardiography was performed in conscious animals. the statistical analysis was performed by analysis of variance followed by tukey's test and pearson's correlation. the blood pressure values of the obese cats were superior ( , ae , mmhg, p o , ) than in overweight ( , ae , mmhg) and normal cats ( , ae , mmhg) and % of the obese cats had blood pressure higher than mmhg. there were observed differences on the ratio of early (e) and late (a) left ventricular filling velocity (p , ) of obese animals (e/a , ae , ) compared to overweight ( , ae , ) and normal cats ( , ae , ). seven obese cats ( %) had inversion of e/a compatible with diastolic dysfunction and there were negative correlation (r À , , p , ) between the e/a ratio and blood pressure values. other differences observed were increases in left ventricular septum in diastole (p , ) and in free wall in diastole (p , ) and systole (p , ) of the obese animals compared to overweight and normal cats. these results demonstrate the possibility of cardiovascular effects related to obesity in cats, such as systemic arterial hypertension and secondary diastolic dysfunction. diuretic therapy reduces preload, and relieves congestion secondary to cardiac dysfunction. torsemide (torasemide) is a loop diuretic with longer duration of action, less diuretic resistance, and adjunctive aldosterone antagonism as compared to furosemide. we hypothesized that torsemide was no less effective than furosemide at diuresis, control of clinical signs, and maintenance of quality of life in dogs with congestive heart failure. a double-blinded, randomized, crossover clinical trial was performed in dogs with stable heart failure receiving bid furosemide and adjunctive medications. dogs were randomized to their current furosemide dose or torsemide (calculated as / of the daily furosemide dose divided into bid dosing). crossover occurred at day and the study ended on day . clinical, laboratory, radiographic, and owner-perceived quality of life variables were evaluated on days , and . no dog developed recurrent heart failure during the study. average furosemide dose on day was . mg/kg/day (range, . - . ). following torsemide treatment, blood urea nitrogen (p . ), albumin (p . ), and albumin:globulin ratio (p . ) were significantly increased, and urine specific gravity (p . ) and chloride (p . ) were significantly decreased as compared to baseline and/or furosemide dosing (one-way anova with bonferroni correction). no differences in qol were found. results indicate that torsemide is equivalent to furosemide at controlling clinical heart failure in dogs, and might in fact, achieve greater diuresis vs. furosemide. larger clinical trials evaluating furosemide resistance and/or torsemide as a first-line loop diuretic for congestive heart failure in dogs with heart failure are warranted. the purpose of this study was to investigate the feasibility of speckle tracking echocardiography (ste) in healthy cats and to determine whether or not it can detect myocardial dysfunction in cats with diseased heart. radial and circumferential strain and strain rate were measured by ste using left ventricle short-axis view in clinically healthy cats. eighteen cats with hcm whose lv thickness at end-diastole with mm or more were evaluated with ste analysis, and compared with healthy cats. index of left ventricular synchrony (trs-sd) was also assessed in cats with hcm, and compared to healthy subjects. ste resulted in technically adequate images in % of the cats. fusions of early and late diastolic (e and a) wave in strain rate were seen in of cats. percent errors in analysis with or without simultaneous ecg monitoring were . - . % in all parameters. inter-and intraobserver variability of ste parameters in healthy cats was minimal ( . - . %) except for the systolic circumferential strain rate. sedation using buprenorphine and acepromazine did not affect any ste parameter. e wave in radial and circumferential strain rate of hcm cats was significantly decreased compared with healthy cats. no significant difference was seen in trs-sd. ste analysis was considered clinically feasible to assess cardiac function in cats, and could detect myocardial dysfunction in cats with hcm. further study is warranted to investigate to assess whether or not ste can differentiate the etiology of left ventricular concentric hypertrophy since it is clinically important. carvedilol, a rd generation non-selective beta-blocker with ancillary alpha -blocking and antioxidant properties may have therapeutic implications for multiple diseases in cats; however, pharmacokinetics and bioavailability of commercially prepared oral carvedilol has not been determined. hplc for carvedilol measurement in feline plasma was validated and standardization curves created. the pharmacokinetics (pk) of carvedilol was evaluated in apparently healthy male neutered adult cats (average weight of kg) following single dose intravenous (iv) of . mg/kg and single dose oral administration of . to . mg/kg. concentrations of the active parent compound, carvedilol, were detected in plasma using hplc analysis. lower limit of quantification was ng/ml. the mean peak concentration after iv administration of carvedilol was ng/ml (range, to ), elimination half-life was . hours (range, . to . ), and clearance was . l/hr/kg. the volume of distribution was . l/hr. after a single oral administration of carvedilol, the time to peak plasma concentration was minutes (range, to minutes) and the mean residual time was . hours. the half life was . hours. maximal concentration ng/ ml and the mean bioavailability was . % with a median of . % (range, . % to %). these data demonstrate a low bioavailability of oral carvedilol and a wide variation in cats. all cats tolerated the oral dose of carvedilol with no major adverse effects. also, a mean residual time of . hours would suggest that a more frequent dosing schedule may be required to maintain therapeutic plasma levels. pharmacodynamic studies investigating beta-adrenergic blockade duration may provide a more accurate dosing interval of carvedilol. abstract c- effects of sildenafil citrate on dogs with ei-senmenger's syndrome. k nakamura, m yamasaki, h ohta, m takiguchi. department of veterinary clinical sciences, graduate school of veterinary medicine, hokkaido university, sapporo, hokkaido, japan. sildenafil has shown to be effective for dogs with pulmonary hypertension; however, its efficacy for dogs with eisenmenger's syndrome (es) and secondary erythrocytosis has not yet been determined. the objective of this study is to determine the effect of sildenafil for dogs with eisenmeger's syndrome and secondary erythrocytosis. this was a prospective, single arm, open-label study. five clinical dogs with es and secondary erythrocytosis were included. new york heart association (nyha) functional class, pcv, and pulmonary artery acceleration time to ejection time ratio (pa at : et) were evaluated before and after sildenafil therapy ( . mg/kg, bid). nyha functional class was significantly improved after (median ; range - , p . ) and months (median ; range - , p . ) of sildenafil therapy, compared with the baseline (median , range - ). pcv was significantly decreased after month ( . ae . %, p . ) and months ( . ae . %, p . ) of therapy, compared with the baseline ( . ae . %). at : et was significantly increased after month of therapy ( . ae . , p . ) from the baseline ( . ae . ). sildenafil resolved the clinical signs and secondary erythrocytosis in dogs with es. sildenafil therapy could be the treatment of choice for dogs with es. sepsis is the number one cause of mortality in neonatal foals. the role of the raas and hpaa in systemic inflammation and response to stress is well documented in critically ill human neonates, but limited information exists in foals. we hypothesized that in septic foals the raas and hpaa will be activated by systemic inflammation and hypoperfusion and the degree of activation will be associated with severity of sepsis and mortality. blood samples were collected on admission from septic (sepsis score ), sick non-septic (sns), and healthy foals of o days of age. blood concentrations of corticotropin-releasing hormone (crh), adrenocorticotropin (acth), cortisol, aldosterone, angiotensin-ii (ang-ii), arginine vasopressin (avp) and plasma renin activity were determined by radioimmunoassays. acth, cortisol, aldosterone, ang-ii and avp concentrations were higher while crh was lower in septic and sns foals compared to healthy foals (p o . ). septic non-survivor foals had higher concentrations of aldosterone, cortisol, acth and avp and lower concentrations of ang-ii and crh than survivors. avp was associated with ang-ii in septic, and with acth in septic and sns foals (p o . ). there was no difference in renin activity and ang-ii concentrations among foal groups. septic foals had a higher acth:aldosterone ratio than healthy foals (p o . ). this study shows that in response to sepsis there is raas and hpaa activation in critically ill foals. we propose that in sick foals avp is more important than crh in regulating acth secretion. the increased acth:aldosterone ratio further supports relative adrenal insufficiency in septic foals. this prospective, cohort study aimed to characterize alterations in coagulation and blood-derived inflammatory biomarkers in adult horses that developed diarrhea during hospitalization. physical and hematological parameters were evaluated at times (onset of diarrhea), , , and h, then every h until resolution of diarrhea or death. each hematological analysis included a complete blood count (cbc), thromboelastography (teg), partial-thromboplastin-time (ptt), prothrombin-time (pt), plasma concentrations of lactate, tumor necrosis factor alpha (tnf-a), interleukin (il)- , il- , il- and nt-proc-type-natriuretic peptide (pcnp). horses were categorized into three groups based on the duration of diarrhea and evidence of systemic inflammation. group : diarrhea o h without systemic inflammation (si); group -diarrhea ! h without si; group -diarrhea with si. assessment of vital parameters and cbc established a diagnosis of si as previously described (levy, ) . descriptive and univariate outcome analyses were based on data normality. horses were enrolled, of which ( . %) survived to discharge. the mean age was . /- . years. eight horses ( . %) were categorized as group- , ( . %) as group- and ( . %) as group- . two horses developed thrombophlebitis. based on the results of teg, / ( . %) were normocoagulable, / ( . %) were hypocoagulable and / ( . %) were hypercoagulable, at one or more time points. of these, / ( . %) group- horses were coagulopathic. additionally, group- horses had a significantly lower ma than group- horses at baseline ( . ae . vs. . ae . ) and h ( . ae . vs. . ae . ). biomarker analyses are pending. in conclusion, si was associated with coagulation disorders in horses with hospital acquired diarrhea. clostridium difficile and clostridium perfringens are commonly associated with colitis and diarrhea in equines but asymptomatic carriers exist. reported carrier rates of toxigenic c. difficile and c. perfringens strains in feces range between - % and - % respectively. toxigenic c. difficile has also been isolated from the small intestine of diseased foals and is implicated as etiologic agent of duodenitis/proximal jejunitis in adult horses however scarce information is available on prevalence in gastrointestinal compartments other than feces in healthy horses, and it is unclear whether fecal samples are good predictors of the status of proximal intestinal sites. the objectives of this study were to investigate the presence of c. difficile and c. perfringens in various intestinal compartments of healthy adult horses and to molecularly characterize isolates. intestinal contents were collected from the stomach, duodenum jejunum, ileum, cecum, right dorsal and left ventral colon, small colon and rectum of euthanized horses free of apparent gastrointestinal disease. enrichment culture was performed for c. difficile and c. perfringens and c. difficile isolates were further characterized via toxin gene detection and ribotyping. c. difficile was isolated from / ( %) samples from / ( %) horses. between zero and three sites were positive per horse, and multiple sites were positive in three horses. isolates were recovered from duodenum (n ), right dorsal colon (n ), small colon (n ) and rectum (n ). in one horse, the rectal sample was negative but c. difficile was isolated from a proximal site, all other horses were positive on the rectal sample if a more proximal compartment was positive. in three horses multiple compartments were positive however different strains were always present within the same horse (n ). all isolates possessed genes encoding toxins a and b. five isolates were ribotype and also possessed genes encoding the binary toxin. the other isolates were ribotype and were negative for the genes encoding the binary toxin. despite using a method with a detection level as low as cfu/g of feces, no c. perfringens was recovered. rectal samples were a good predictor of overall c. difficile carrier status ( / horses), however rectal samples were not always representative for the ribotype carried in more proximal compartments. the presence of variable strains within the same horse suggests transient passage of the bacterium through the gastrointestinal system rather than actual colonization although further study testing multiple colonies per site is needed. the predominance of ribotype is consistent with recent emergence of this strain in this region, as earlier studies found other strains ( , ) to be more prevalent and a variety of ribotypes were typically recovered from horses. interestingly ribotype has recently emerged as a hypervirulent strain in humans in our area. clostridium difficile, clostridium perfringens and salmonella are important enteric pathogens in horses, however some healthy animals also harbour these pathogens. point prevalence studies have reported these carriage rates, but there are no data regarding longitudinal prevalence of these enteric bacteria, information that would be useful to better understand the epidemiology of these pathogens. additionally, antimicrobial resistance is a pressing concern. commensal e.coli is often used as an indicator organism to evaluate antimicrobial resistance of enteric bacteria, yet there are limited data from horses on farms. the objectives of this study were to longitudinally investigate the above enteric pathogens over the course of one year, molecularly characterize obtained isolates and determine the antibiotic susceptibility profile for e. coli. fecal samples were collected from adult horses from five farms on a monthly basis over the course of one year. selective cultures were performed for c. difficile, c. perfringens, salmonella and e. coli. c. difficile isolates were characterized via toxin gene pcr and ribotyping. broth microdilution was performed to assess antimicrobial susceptibility profiles of e. coli. clostridium difficile was isolated from / ( . %) samples from / ( %) horses. four horses were positive on more than one occasion, three were positive in two consecutive months. different ribotypes were found in two of the latter horses. most isolates were ribotype (n ) with ribotype (n ) and ribotype c (n ) also identified. ribotypes and c possessed genes encoding toxins a, b and binary toxin, while ribotype only possessed toxin a and b genes. despite a detection threshold of cfu/g feces, c. perfringens was not detected in any samples, nor was salmonella. e coli was isolated from / ( %) samples. resistance to ! antimicrobial was present in only / ( . %) isolates. multidrug resistance (! antibiotics) was present in / ( %). most commonly, isolates were resistant to sulfisoxazole ( / ) and trimethoprim sulfamethoxazole ( / ). the overall detection rate for toxigenic c. difficile in fecal samples of healthy horses was . % which is consistent with previous studies. the cumulative prevalence of % was striking but only one horse shed the same strain for more than one month, indicating c. difficile shedding is a transient and dynamic state. the predominant isolation of ribotype is consistent with the suspicion that this strain has emerged and become widely disseminated in this region in recent years. the low prevalence of c. perfringens and salmonella is in agreement with some other studies. the low prevalence of antibiotic resistance in commensal e. coli was encouraging and suggests that healthy horses on pleasure horse farms are not likely a major reservoir of resistance in enteric bacteria. type polysaccharide storage myopathy (pssm) in horses is associated with a dominant missense mutation (r h) in the skeletal muscle glycogen synthase gene (gys ). since disease severity varies between affected horses, we hypothesised that some clinical variability could be accounted for by the underlying genotype. belgian / percheron horses were genotyped using a validated restriction fragment length polymorphism assay enabling grouping of horses as homozygotes (hh), heterozygotes(hr) or normal (rr). subsequently, semimembranosis muscle samples were biopsied from each of six matched sedentary horses from each group; one sample was formalin-fixed and one fresh frozen. sections were stained using haematoxylin and eosin, periodic acid schiff /diastase. anti-dystrophin, nnos and myosin heavy chain immunohistochemistry was performed to examine sarcolemmal intregrity, there were significant differences in resting ck activity (p . ) (median hh u/l interquartile range(ir) - ; hr u/l ir - ; rr u/l ir - ) and ast activity (p o . ) (ast mean hh u/l sd ; hr u/l sd ; rr u/l sd ) and muscle pathology between the groups, with severity increasing rr o hr o hh. there were significantly more type a (p . ) and fewer type x fibres (p . ) in homozygotes ( a % sd . ; x % sd ) compared with the other groups (hr a % sd . , x % sd . ; rr: a . % sd . x % sd . ). more type a fibres contained polysaccharide inclusions in homozygotes ( % sd . ) than in heterozygotes ( . % sd . ) (p o . ). both dystrophin and nnos expression was normally localised to the sarcolemma in pathologically normal and vacuolated fibres from mutant horses. in conclusion, sedentary homozygotes have more severe skeletal muscle pathology and higher resting plasma ck and ast activities than heterozygotes, and pssm is associated with a fibre type shift towards type a. although subsarcolemmal vacuolation likely disrupts the contractile apparatus's attachment to the sarcolemma, the latter's integrity appeared intact. the recumbent horse presents a logistic, diagnostic, and therapeutic challenge to the equine practitioner. there is currently very little data available on the prognosis and outcome of horses that are recumbent. therefore, the purpose of this study was to investigate the outcome of hospitalized horses that had been recumbent in the field or in the hospital and the factors affecting their survival. records of horses admitted to the school of veterinary medicine, university of california davis from january of to december of with a history of recumbency or horses that became recumbent while hospitalized were evaluated. a horse was defined as recumbent if it was unable to stand on its own. the medical record was examined for the following criteria: history pertaining to the current illness including treatment by the rdvm, breed, age, weight, date of presentation, physical and neurological examination findings, cbc and biochemical profile results, initial drugs administered on arrival, time spent recumbent, time spent in a sling, diagnosis, and hospitalization costs. statistical analysis correlating factors associated with survival was performed using logistic regression. overall there were non survivors and survivors. factors that favored survival included early initiation of treatment in the field by the rdvm, horses that tolerated a sling and spent more time in a sling, increased duration and costs of hospitalization, horses that were recumbent post anesthesia, and those recumbent due to disease of the musculoskeletal system. factors that increased likelihood of non survival included horses that were ataxic on presentation, horses with increased bun, horses that spent more time recumbent, those that did not tolerate a sling, and horses diagnosed with botulism and spinal cord disease. in conclusion, this retrospective study demonstrated that both the cause of recumbency and the ability of horses to tolerate a sling had a direct effect on survival. abstract e- plasma peak and trough gentamicin concentra-tions in hospitalized horses receiving once daily gentamicin. jr read , pa wilkins , rd nolen-walston . university of pennsylvania, new bolton center, kennett square, pa. university of illinois, champaign-urbana, il. gentamicin is often used to provide gram negative antimicrobial coverage in horses at . mg/kg iv every hours. therapeutic drug monitoring in our hospital suggests larger doses are required in many clinical cases to achieve the desired concentration ( -  minimum inhibitory concentration) for common bacterial isolates (peak target range - mg/ml). the aim of this study was to determine the correlation between gentamicin dose and plasma concentration in hospitalized horses receiving gentamicin treatment in order to identify an optimum dose range for this population. review of records ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) identified horses ! months old receiving once-daily gentamicin with peak and trough assays performed (n sets). spearman rank correlation coefficient analysis revealed a weak (r . ) but statistically significant correlation (p . ) between gentamicin dose and peak plasma concentration. horses receiving . - . and . mg/kg gentamicin (groups and ) had higher median peaks ( mg/ml) than horses receiving . - . mg/kg (group ; . mg/ml). higher doses were more likely to result in peaks mg/ml ( and %, groups and respectively) than horses receiving . - . mg/kg (group ; %). all hour post-gentamicin administration trough values were o mg/ml. no correlation was found between dose and change in plasma creatinine during treatment, nor dose and trough level. these data suggest that gentamicin dosage in horses should be individually determined by therapeutic monitoring. additionally, these data support an initial dose of . - . mg/kg iv every hours in order to achieve desired peak concentration and an appropriately low trough concentration. heaves is a common respiratory inflammatory disease, characterized by a pulmonary neutrophilia. this disease is also characterized by an activation of circulating neutrophils after antigen challenge but their specific role in heaves is not well understood. also, there are anecdotal studies concerning heaves-affected horse to be more susceptible to infection. however, to our knowledge, the antibacterial host defense role mediated by circulating neutrophils was not investigated in heaves-affected horses. the objective of this study was to compare phagocytosis activity and bacterial killing by circulating blood neutrophils of heaves-affected and control horses. peripheral neutrophils were isolated from heaves-affected (n ) and control (n ) horses using a density gradient technique. the killing capacity was assessed by incubating neutrophils with streptococcus equi spp equi and spp zooepidemicus. after h of bacterianeutrophil coculture, total viable bacterial cells were measured by quantitative plating. the phagocytosis was evaluated by flow cytometry using fluorescent beads and gfp-transformed streptococcus suis suilysin-negative mutant strain. circulating neutrophils from heaves-affected horses showed a significant decrease in their killing capacity toward s. zooepidemicus (p . ). a reduced, although not significant (p . ), killing capacity of s. equi by these neutrophils was also observed. the phagocytosis activity was not different between groups. this impairment of blood neutrophil bactericidal activity in heaves-affected horses could contribute to an increase susceptibility to infection. obesity is a common disorder of the horse, with current prevalence estimated at %. in people, obesity is associated with dyslipidemia, insulin resistance, mitochondrial dysfunction and downregulation of lipid and glucose metabolic pathways. in the horse, obesity is similarly associated with insulin resistance and alterations in lipid profiles; however, metabolic regulatory gene expression profiles have not been fully characterized. we hypothesized that obese horses have decreased expression of metabolic regulatory genes and decreased mitochondrial content in skeletal muscle compared with non-obese horses. sixteen light breed horses, - years of age were included. body condition score (n ) and neck circumference (n ) were recorded. post-mortem biopsy samples of the semi-membranosus muscle were obtained. dna and rna were isolated. relative expression of the metabolic genes, peroxisome proliferator activated receptor g (pparg), pparg coactivator- a (pgc- a), fatty acid translocase (fat) and estrogen related receptor a (erra) was determined by quantitative polymerase chain reaction (qpcr). mitochondrial content was assessed by determining mitochondrial dna/nuclear dna ratio by qpcr, using nadh-dehydrogenase subunit and cytochrome oxidase subunit as mitochondrial genes and beta actin as the nuclear reference gene. non-normal data was log transformed for analysis and a pearson coefficient of correlation was calculated for relative gene expression, body condition score and neck circumference. a value of p o . was considered significant. body condition score was strongly correlated with neck circumference (n , r . , p . ). relative expression of erra and glut- increased with body condition score (erra: n , r . , p . ; glut- : n , r . , p . ). copy number of the mitochondrial genes (nadh-dh and cox- ) was not related to body condition score or metabolic gene expression. expression of glut- , erra, pparg, and fat were strongly correlated to each other, but not pgc- a. there was a strong trend towards correlation between pparg and pgc- a in horses with body condition score (n , r . , p . ). in this study, there was no change in mitochondrial content in obese horses. assessment of mitochondrial function in obese horses and horses with ems is under way. the strong correlation between pparg and pgc- a observed only in horses with high body condition scores suggests this pathway is activated with obesity. the role of pparg and pgc- a in equine obesity should be further investigated to determine their potential as therapeutic targets. upregulation of erra and glut- in horses with increasing body condition score is unexpected, and may indicate a compensatory response to dysfunction of a downstream pathway. further studies to better define the role of metabolic regulatory gene expression in obese horses and those with ems are ongoing. previously presented at the th annual harold hamm diabetes center research retreat, oklahoma city, ok. inflammatory bowel disease is a cause of weight loss, decreased performance, and colic in horses. this condition is difficult to diagnose and clinicians rely upon absorption tests to document malabsorption. the purpose of this study was to compare glucose and xylose absorption tests in normal horses and determine the repeatability of these procedures. eight horses received mg/kg dextrose or d-xylose powder mixed as a % solution in water or water alone via nasogastric intubation on three different occasions within the same week for three consecutive weeks ( tests/horse). a crossover design was employed and the order of treatments was randomized. blood samples were collected at time , , , , , , and min. data were analyzed by repeated measures anova and t-tests. results showed that the xylose response over time differed significantly from the glucose response over time (test  time; p o . ). mean time to maximum concentration differed (p o . ) between tests (glucose min; xylose min). within-horse area under the curve, maximum concentration, and time to maximum concentration values for dextrose and xylose did not differ significantly when tests were repeated. results indicate that glucose and xylose absorption tests are repeatable within the same horse, but plotted curves differ between tests, with peak concentrations occurring at a later time point for the glucose absorption test. we conclude that both tests provide repeatable measures of intestinal absorption, but glucose and xylose appear to differ in their rates of absorption and clearance. the purpose of this study was to examine the records of a population of thoroughbreds with cervical vertebral malformation (cvm) and to determine which factors have an effect on these horses achieving athletic function. this was a retrospective case study of thoroughbreds with cvm treated medically from to . forty-one were euthanized after diagnosis, while the remaining were discharged for treatment. racing records were reviewed to determine which horses raced after treatment. horses were separated into groups based on whether or not they raced. medical records were reviewed, and results of neurologic examination, radiographic and laboratory findings, treatments, and outcome were assessed and compared between groups. twenty-one of horses treated medically ( %) improved enough to race. median neurologic grade between groups was significantly different (p o . ), with a hind limb grade of . (range - ) for the raced group and . (range . - ) for the unraced. intravertebral sagittal ratios measured from standing lateral cervical radiographs were equivocal between groups. radiographs of all horses were examined for kyphosis, dorsal over-riding arch, caudal epiphysitis, degenerative joint disease, cystic bone lesions, and cranial stenosis of the vertebral canal. horses with kyphosis (p . ), degenerative joint disease (p . ), or cranial stenosis (p . ) at any site were less likely to return to racing. racing prognosis for horses with cvm treated conservatively is equivalent to that of those treated surgically as reported by rush moore et al (javma, ) . radiographic changes and neurologic grade may help serve as indicators for whether a horse will respond to conservative therapy. since pain assessment is vital for management of colic, a valid, reliable and feasible tool for assessing the severity of acute abdominal pain in horses is urgently needed. our aim was to construct and validate a behavior-based pain scale by methodology utilized in construction of pain scales in non-verbal humans. the project consisted of four stages. firstly, behaviors to include in a scale were empirically identified. thirty equine clinicians noted behaviors in each of random film clips of horses with colic using a checklist. nine behaviors (e.g. rolling, pawing, and flank watching) demonstrated good inter-observer agreement without bias (multi-rater kappas: . - . ). secondly, the clinical judgment of experts was utilized to identify and to weight behaviors. six expert clinicians independently expressed opinions as to which of behaviors to include and the severity of pain they indicate. two contending scales (equine acute abdominal pain scales (eaaps) & ) were constructed based on both the empirical and the judgmental approaches. each included identical behaviors with a - point score range; eaaps- with gradations to some of the behaviors and eaaps- without. in the third stage, blood cortisol and lactate levels and heart rate were shown to only approximate pain since they correlate poorly with degree of pain as assessed by visual analog scale (vas) in horses with colic and controls (spearman rho; lactate . ; cortisol . ; heart rate . ). finally, reliability and validity of the pain scales were evaluated including constructs of pain; face validity, convergent and discriminate validity and extreme groups. thirty of films of horses with colic were randomly presented to expert equine clinicians internationally who were randomly allocated into three groups to score pain; one group by both vas and numerical rating scale (nrs)), and two groups, each by one of the two eaaps scales. inter-observer reliability of both eaaps scales was excellent (intraclass correlation . ). intra-observer reliability based on scores given for identical films demonstrated; % and % agreement, kappa . and . , and spearman's rho . and . for eaaps- and , respectively. both scales varied by score between observations. face validity; each group reported their scale to be valid ( % & %). convergent validity; the scales compared favorably with vas/nrs scores (spearman's rho: . - . ). discriminate validity; correlation to heart rate, lactate and cortisol levels was predictably low (rho . - . ). extreme group validity; colic horses scored significantly higher than control horses; scores of . - . in controls versus . - . in cases. in conclusion, methodology established in human medicine but novel in veterinary medicine was used to construct and validate two clinically feasible equine abdominal pain severity scales that showed excellent reliability and validity. further refinement of the eaaps scale is advised prior to introduction into clinical practice. aortic valve prolapse (avp) is a common echocardiographic finding in horses, but when compared with mitral valve prolapse in dogs, little is known about the natural progression of this condition. previously published data has shown that echocardiographic identification of avp in horses is reliable, diagnostic criteria have been established and that development occurs with training. the aims of this study were to evaluate the different rna and protein expressions of smooth muscle actin (sma), transforming growth factor-b (tgf), nitric oxide synthase (nos) and the concentrations of elastin and collagen in normal, prolapsing and diseased cusps to evaluate what structural changes may predispose them to prolapse. valve cusps were harvested and processed from a group of horses at a commercial abattoir following disease classification using echocardiography. horses were aged . ae . years, weighing ae kg and with a median body condition score of / . cusps were collected in rnalater s and stored at À c prior to processing. cdna was produced from half a valve using a standard protocoland qrt-pcr performed to assess relative rna expression of sma, tgfb , endothelial (enos) and inducible nos (inos) and compared with the housekeeping gene s. a quarter of cusp was processed using an adapted commercial protocol to evaluate protein expression of sma, tgf b , enos and compared to vimentin. specific antibody binding was assessed with western blotting and protein expression evaluated using dot blots. the remaining quarter cusp was used to measure soluble collagen and elastin concentrations using commercial assays . statistical analyses included one way anova with post-hoc bonferoni, paired student's t-test, linear and logistic regression. there was no effect of gender or age on any of the measurements. valves from animals with avp had lower expression of sma and elastin compared to normal and diseased valves, increased expression of tgfb and enos, whereas inos expression was greater than normal valves (table ) . collagen content of valves from horses with avp was increased compared to normal but lower than horses with valve disease. prolapsing cusps appear to be a different phenotype from diseased cusps. further studies will help to elucidate the significance of these findings in vivo. a clear association between heart rate (hr) and body mass has been observed across a wide range of mammalian species. furthermore, it is well known that electrocardiographic (ecg) time intervals vary with heart rate and body mass. within the equine species, small breeds are generally thought to have higher heart rates than large breeds. however, despite the large differences in size among different equine breeds, there is little information about normal heart rates and normal ecg time intervals in horses and ponies of different body size. similarly, the relationship between hr and body mass in dogs of various breeds and sizes is still under debate. the goal of this study was to investigate the relationship between heart rate and ecg time intervals to body mass in apparently healthy horses and ponies and to calculate normal ranges for different weight groups. adult horses and ponies at an age of . ( - ) y [median (range)] and a body weight of ( - ) kg were included in the study. all animals were considered clinically healthy based on history and physical examination. a standard base-apex ecg was recorded at a speed of (n ) or mm/s (n ) using a multiparameter monitor (datascope passport). during the procedure, the horses were unsedated, standing quiet in a box stall. mean hr over sec was determined for each recording. the following ecg time intervals were measured in triplicate and averaged for further analyses: pq interval, qrs duration, qt interval, and difference between qt and qrs (qt-qrs duration). the relationship between hr, ecg time intervals, and body mass was assessed using linear regression analyses. normal ranges ( . % to . % percentile) were calculated for different weight groups. the level of significance was p . . heart rate was inversely related to body mass (p o . , r . ). the pq interval (p o . , r . ), qrs duration (p o . , r . ), qt interval (p o . , r . ), and qt-qrs duration (p o . , r . ) were directly related to body mass. normal ranges for hr, pq, qrs, and qt within the different weight groups were - bpm, - ms, - ms, - ms (o kg); - bpm, - ms, - ms, - ms ( - kg); - bpm, - ms, - ms, - ms ( - kg); - bpm, - ms, - ms, - ms ( - kg); and - bpm, - ms, - ms, - ms ( kg). we conclude that in healthy horses there is a significant but weak relationship between body mass and hr and between body mass and ecg time intervals, respectively. this study therefore supports the hypothesis that within the equine species, small breeds have faster heart rates and shorter ecg time intervals than large breeds. therefore, body mass has to be considered when comparing hr and ecg time intervals to normal ranges in horses. horses with pituitary pars intermedia dysfunction (ppid) often have elevated plasma acth concentrations. however, ppidaffected horses rarely have resting serum cortisol levels above the reference range or adrenal hyperplasia. we hypothesized that this apparent dissociation between plasma acth levels and adrenal response in horses with ppid is due to the secretion of acth that is less biologically active than that from normal horses. to test our hypothesis, a bioassay to evaluate acth activity was developed. adrenocortical explants were harvested aseptically from normal horses at euthanasia and stimulated with plasma from healthy (n ) and ppid-affected horses (n ). the assay was performed three times with explants obtained from different horses. cortisol secreted by the explants and plasma acth levels were measured with commercially available radioimmunoassays. cortisol secretion stimulated by each sample was standardized to the respective explant protein concentration. cortisol data was normalized for acth concentration in each plasma sample and expressed as a cortisol:protein:acth ratio. ratios from horses with ppid and normal horses were compared by unpaired t-test. horses with ppid had significantly lower cortisol:protein:acth ratios compared to normal horses. (assay : . ae . vs. . ae . , p o . ; assay : . ae . vs. . ae . , p o . ; assay : . ae . vs. . ae . , p o . ). these results suggest that plasma acth from ppid horses is less biologically active than plasma acth from normal horses. our findings give further insight into the pathophysiology of ppid and may aid in the development of novel diagnostic testing protocols. an online survey was conducted to determine perceived needs of potential employers of new acvim-laim diplomates. the survey was designed as the first step in determining what is needed for success in the various sectors of practice employing acvim-laim diplomates. demographic and background data were collected using questions and drop-down menus on the first page. the survey evaluated skills or concepts in areas of veterinary practice. participants answered questions about each skill or concept using drop-down ranked lists. those participants that had completed an acvim-laim training program were asked additional questions about whether they were taught the skill or concept during their own residency. data were collated and descriptive statistics calculated. the mean scores or frequencies of use for each skills or concepts were ranked to determine which of the skills or concepts were most important for an entry-level diplomate. eighty-eight individuals participated in the survey with respondents being acvim diplomates, respondent was not board-certified and respondent was an act diplomate. nineteen respondents were diplomates of acvim and an additional specialty. eighty-three respondents had completed an acvim residency. the majority of respondents were in academia ( %) with % being in private practice. equine specialists prevailed ( %) followed by mixed large animal ( %) and then food animal only specialists ( %). the distribution of years post-residency was slightly skewed toward younger diplomates, but overall there was a good distribution of diplomates across years of experience. most respondents stated that they did not make hiring decisions in their practice. competency in disciplines other than internal medicine was expected with ultrasonography and radiology being the most desirable followed by theriogenology and lameness. surgical skills, both equine abdominal ( %) and food animal general surgery ( %) were considered important by some respondents. thirty-six per cent of respondents thought that a new diplomate should expect to make o $ , per annum, while only % of respondents thought that a new diplomate should expect to make ! $ , per annum. not all respondents answered questions on all skills or concepts. the mean number of skills or concepts evaluated was (sd ) with only respondents answering all . all skills or concepts evaluated were found to be at least somewhat important, were estimated to be used at least occasionally, were recommended for inclusion in training programs as core or elective, and some level of knowledge was expected. at least some of the respondents were taught each of the skills or concepts during their residency, practiced the skill or concept at least occasionally during their residency, and some degree of competency was expected at the time of completion of their residency. these data will provide a framework for designing future laim residency programs. abstract this study evaluated pharmacokinetics and clinical safety of an oral paste formulation of a commercially available cox -sparing nsaid in clinically healthy pony foals in a randomized controlled clinical trial. values for complete blood count, serum chemistry profile, urinalysis, pharmacokinetic assay, and gastric endoscopy were evaluated in eighteen shetland pony foals treated with firocoxib ( . mg/kg, po, q h) or placebo for days. foals were divided into treatment groups. group and foals received firocoxib while a rd group was administered an oral placebo. gastric endoscopy was performed on group and foals prior to treatment and on days and to monitor for the presence of gastric ulcers. group and foals had blood and urine samples taken sequentially for pharmacokinetic analysis, cbc, serum chemistry evaluation, and urinalysis. physical examinations were performed prior to treatment and daily for days. data were analyzed using anova and paired t-tests (p o . ). none of the foals presented adverse clinical effects. there were no significant changes in cbc, biochemical profiles within groups, or differences between groups. pretreatment gastric endoscopy scores were not significantly different from evaluations at and days. firocoxib was quickly absorbed with an observed maximum concentration at hr, the first sampling interval, for the majority of animals. firocoxib plasma concentrations decreased in a log-linear manner after reaching the maximum concentration and steady state concentrations were achieved by the th dose. based on the sampling times after the final and th dose, an average half life of . days was estimated. administration of firocoxib did not cause any adverse effects on gastrointestinal, or hematological or serum biochemical variables, appears to have been well tolerated, and follows a predictable pharmacokinetic pattern in - week old foals. equine herpesvirus (ehv- ) is highly prevalent in most horse populations. horses are routinely vaccinated against ehv- , and neutralizing antibodies have helped to prevent disease. however, the usda has recently classified ehv- myeloencephalopathy (ehm) as an emerging disease, in response to the apparent increase in incidence, morbidity, and mortality of ehm that suggests a change in virulence of the virus. it has been reported that cellular immune mechanisms, in particular cytotoxic t-cells (ctls), are important in controlling ehv- viremia. interferon-alpha (ifn-a) has a key function in innate immune regulation by inducing the differentiation and maturation of ctls. here, we investigated the influence of abortogenic (racl , ny ) and neuropathogenic (ab ) ehv- virus strains on ifn-a, il- and il- secretion in equine pbmc. equine pbmc were infected with racl , ny or ab ehv- strains or kept in medium for hours. ifn-a, il- and il- secretion was detected in the supernatants by a fluorescent bead-based cytokine assay. the production of ifn-a increased with increasing viral doses and similarly for all three ehv- strains. the production of the antiinflammatory cytokine il- was significantly decreased after ab infection compared to racl and ny strains at viral infection doses of moi . - . at high doses (moi ), il- production was suppressed by all three ehv- strains. the results suggested that abortogenic and neuropathogenic ehv- strains equally induce antiviral ifn-a production in equine pbmc. they also illustrated the differences in the ability of ehv- strains to modulate anti-inflammatory il- . neuropathogenic ab strain had an increased potential to down-regulate il- production suggesting specific viral mechanisms that interfere with the control of inflammation in the host. the variations in innate il- secretion might influence the development of protective immunity and might offer an explanation why neuropathogenic ab induces more severe disease, including myeloencephalopathy, than abortogenic ehv- strains. previously presented at a conference of research workers in animal disease. rhodoccocus equi is the major cause of pneumonia in foals during the first six months and control measures are frequently ineffective. treatment protocols are long, expensive and do not always produce good results. rhodococcosis prevention through immunization of foals using a safe and efficient vaccine is still a challenge. recent studies are based on the use of the virulence associated protein a (vapa) which has been described as an important inducer of immunity against r. equi. the present study evaluated the clinical and immune response of foals vaccinated with an attenuated strain of s. enterica typhimurium expressing vapa antigen (test group) or s. enterica typhimurium without the vapa gene (control group), previous to and following experimental challenge. two experimental phases were established according to the immunization route: intranasal or oral vaccination up to hrs following birth and at days of age. the experimental and control groups were challenged on day with a virulent stain of r. equi. clinical examination, cbc and image complementary exams were used to evaluate the development of clinical signs. immune response patterns were evaluated though immunoglobulin dosage, cytokine expression, lymphocyte proliferation assays, isolation of r. equi and cytological profiles of tbw. clinical manifestation was less intense in the test group during the second experimental phase, and death occurred only in the control group ( / ) and was due to r. equi pneumonia. the test group produced a more intense iggb response when compared to controls however no statistical difference was observed. lymphoproliferation and th cytokine expression were higher in the test group. in contrast, controls produced an il- response. local iga was significantly higher in animals immunized with salmonella carrying vapa. immunization protocols produced no severe toxic effects. the vaccination of neonatal foals with s. enterica typhimurium expressing vapa was considered safe, produced efficient modulation of the immune response and is apparently able to protect against experimental r.equi infection. this study was conducted to test the hypothesis that the kd protein, myristolated alanine-rich c-kinase substrate (marcks), is involved in equine neutrophil migration and adhesion. in other species, marcks phosphorylation and dephosphorylation causes the protein to cycle between the cell membrane and cytosol, respectively. to investigate marcks phosphorylation in horses, neutrophils were isolated from whole blood and stimulated with platelet activating factor (paf), leukotriene b (ltb ) or phorbol myristate acetate (pma). western blot was performed using specific phospho-marcks and total marcks primary antibodies. these results determined marcks phosphorylation is maximal seconds following stimulation and that dephosphorylation occurs within minutes. to investigate the requirement for marcks in equine neutrophil chemotaxis, isolated neutrophils were pre-treated with mans (a cell permeant peptide identical to the n-terminal amino acids of marcks), rns (a control peptide) or vehicle control (vc) prior to a migration assay toward known neutrophil chemoattractants (ltb or paf). pre-treatment of equine neutrophils with mans significantly inhibited migration while rns pre-treatment had no effect. to investigate marcks requirement in equine neutrophil adhesion, mans, rns or vc treated cells were stimulated to adhere to immulon plates coated with % fbs. pre-treatment of equine neutrophils with mans significantly inhibited adhesion while rns pre-treatment had no effect. inhibition of marcks using a cell permeant peptide identical to the protein's n-terminus significantly inhibited equine neutrophil adhesion and migration. these results indicate that marcks is an important regulator of equine neutrophil chemotaxis and represents a potential target for anti-inflammatory therapy. amongst other tests, a thorough neurologic examination of horses may include walking with the head elevated and during blindfolding, in order to help differentiate normal from abnormal and to help with neuroanatomically localising any lesion(s) i.e. in the ataxic horse. consensus amongst equine neurologists suggests that gait abnormalities associated with these specific tests are often exacerbated in horses with underlying proprioceptive deficits however the effect of these tests on temporal gait characteristics in normal horses has not previously been assessed quantitatively. we hypothesized that head elevation or blindfolding, in comparison with walking in a straight line would result in a compensatory decrease in lateral (left front-on to left hind-on and right front-on to right hind-on) and diagonal coupling intervals (left front-on to right hind-on and right front-on to left hind-on) in normal horses. four thoroughbreds without any history or clinical signs suggestive of neurological disease (age range to years) were included in the study. retroreflective markers were applied to the withers, to the sacrum and to left and right tuber coxae; for each limb, lateral fetlock markers and dorsal and lateral hoof wall markers were used. a minimum of trials each with - walk strides for each task were analysed as horses walked across an -force-plate runway i surrounded by a -camera kinematic system. ii force-plate data were processed with semi-automated custom written matlab iii scripts. data were analysed with a mixed model using the statistical software r. there was a significant fixed effect of normal walk on a straight line and head elevation on left and right lateral coupling intervals (p o . ) and of the left and right diagonal coupling intervals (p o . ). there was no significant effect of blindfolding on neither lateral nor diagonal coupling intervals. the random effect of horse had no influence on the coupling intervals. the decrease of the lateral coupling intervals indicates a tendency towards a pacing gait during head elevation. we conclude that there is a significant change in temporal gait characteristics of non-neurologic horses when the head is elevated but not during blindfolding compared to normal walking. current results suggest that pacing and increased variation in foot-placement during head elevation should be interpreted with caution however further work is required to determine whether the change differs between horses with neurological disease and non-neurologic disease. hereditary equine regional dermal asthenia (herda) is an autosomal recessive connective tissue disorder associated with a mutation in cyclophillin b that leads to impaired collagen folding, aberrant wound repair, and corneal abnormalities. it affects young quarter horses, appaloosa, and paints. herda shows similarities to the human hereditary connective tissue syndrome ehlers danlos (eds). many eds patients suffer from joint pain and osteoarthritis (oa) as adults. the similarity between eds and herda raises the question whether horses suffering from herda develop oa. in oa, excess production of inflammatory mediators such as prostaglandin e (pge ) activate enzymes that degrade cartilage as well as impede wound healing. the present study examined articular cartilage from yearling horses afflicted with herda. we hypothesized that chondrocytes from these horses are continually activated to produce inflammatory mediators. to test this hypothesis, articular cartilage from carpal and tarsal joints of herda horses were evaluated using histology. pge production by chondrocyte cultures was measured by elisa and analyzed by one-way anova, tukey post-hoc test, p o . significance. we also determined the antiinflammatory effects of an avocado/soybean unsaponifiables (asu), glucosamine (glu), and chondroitin sulfate (cs) mixture (ingredients found in cosequin s asu) and phenylbutazone (pbz) on chondrocytes. cosequin s asu and pbz are used alone or in combination for the management of oa. chondrocyte cultures were incubated for hrs with control media alone, a clinically relevant concentration of pbz ( mg/ml), or the combination of asu (nmx s , . mg/ml) glu (fchg s , mg/ml) cs (trh s , mg/ml). articular cartilage from joints of five herda-afflicted horses showed gross and histologic evidence of osteoarthritic lesions. chondrocyte cultures from cartilage of horses suffering from herda spontaneously produced greater pge than chondrocytes from normal horses ( -fold). pbz significantly decreased pge production by $ % (p o . ). the combination of asu -glu cs also significantly reduced pge production by $ % (p o . ). the present study supports anecdotal findings that horses suffering from herda are likely to develop oa. the inhibition of pge synthesis by asu glu cs suggests that this combination may be beneficial for the management of oa in herda. research supported by nutramax laboratories, inc. equine inflammatory airway disease (iad) is a common condition often treated empirically with corticosteroids. gene expression analysis in the bronchoalveolar lavage fluid (balf) may help understand the effects of corticosteroids in iad. the first part of the study aimed at identifying reference genes in the balf of iad horses treated with corticosteroids. the second part of the study investigated the effects of dexamethasone and fluticasone propionate treatments on the mrna expression of il- b, il- , il- and il- . the expression stability of seven candidate reference genes was determined in balf taken pre-and post-treatment with dexamethasone and fluticasone propionate in horses with iad. primers' efficiencies were calculated using linregpcr. normfinder, genorm and qbaseplus softwares were used to rank the genes according to their stability. gapdh was the most stably expressed gene whereas b m was the least stable gene. in addition, genorm analysis revealed that the number of genes required for optimal normalization was four (gapdh, sdha, hprt, rpl ). in the second part of the study the mrna expression of il- b, il- , il- and il- was measured in balf samples from seven iad horses treated in a randomized cross-over design with dexamethasone ( . mg/kg sid, days) or inhaled fluticasone propionate ( mcg bid with aerohippus, days). the balf samples were taken at baseline and after each treatment period. there was no significant effect of the corticosteroids treatment on the mrna expression of il- b, il- and il- in the balf. the mrna expression of il- was suppressed by dexamethasone and fluticasone propionate treatments. pneumonia is observed in horses after long distance transportation in association with confinement of horses' head position leading to a reduction in tracheal mucociliary clearance time (tmct). we hypothesize that clenbuterol, a beta- agonist shown to increase tmct in the horse, will ameliorate the affect of a fixed head position on large airway contamination and inflammation in a long-distance shipping model. six adult horses were enrolled in a cross-over design prospective study. horses were housed with their heads in a fixed position for hours to simulate long distance transport, and treated with clenbuterol ( . ug/kg po q h) or a placebo starting hours before simulated shipping. tmct was measured using a charcoal clearance technique. data were collected at baseline and hours, and included tmct, tracheal wash cytology and quantitative culture, rectal temperature, cbc, fibrinogen, and serum tnfa, il- and il- levels. there was a -week washout between study arms, and each horse served as its own control. the data was analyzed using regression analysis and wilcoxon rank-sum tests. no statistically significant difference was seen between treatment and placebo groups for any of the variables investigated. tmct did not differ after treatment ( . ae . cm/min) versus placebo ( . ae . cm/ min; p . ), and intratracheal bacterial counts were similar for treatment (  ae  cfu; p . ) and placebo (  ae  cfu) groups. a reduction of tracheal b hemolytic streptococcus. spp. after clenbuterol versus placebo was also nonsignificant ( % versus %; p . ). in conclusion, treatment with clenbuterol does not appear to combat the deleterious effects of this long-term shipping model. breathing cold air during strenuous exercise is associated with airway inflammation. under these conditions, warming and humidification of inspired air occurs in the lower respiratory tract resulting in mucosal cooling, desiccation, and hyperosmolarity. the purpose of this research was to test the hypothesis that airway hypertonicity causes inflammatory cell migration and alterations in cytokine expression associated with exercise induced airway inflammation. horses (n ) were examined in a randomized crossover design after exposure to hypertonic aerosols ( minute nebulization with solutions of either isotonic or hypertonic mannitol). airway leukocytes were harvested and hours post aerosol challenge via bronchoaveolar lavage, and were used to determine total and differential nucleated cell count and expression of cytokinespecific mrna. hypertonic aerosol challenge resulted in an increase in total number of cells hr after challenge, characterized by increased macrophage (p . ) and neutrophil (p . ) concentrations, but there was no effect on airway leukocyte concentrations hours after nebulization. no significant changes in the relative quantity of mrna for airway cytokines were noted at either time point. these data demonstrate that transient airway hypertonicity can cause airway leukocyte influx and may be responsible for the airway inflammation commonly found in athletes that exercise in cold conditions. however, our data do not support the hypothesis that hypertonicity is the sole initiating cause of changes in cytokine expression secondary to cold weather exercise. it is likely that factors such as airway temperature, shear stress or epithelial damage also play a role in this phenomenon. we studied the importance of abdominal sonograms in neonatal foals suffering from gastrointestinal conditions. we hypothesized that there would be a subgroup of neonates with sonographically detectable pneumatosis intestinalis (pi) as a reflection of a necrotizing component of the disease. records of foals days of age hospitalized between and with signs of gastrointestinal disease were evaluated (n ). the association of sonographic, clinical, pathological and clinicopathological signs with outcome and severity of disease was determined. pneumatosis intestinalis was imaged in foals. twenty-seven foals were classified as having necrotizing gastrointestinal disease based on the presence of gastrointestinal signs (colic, diarrhea, gastric reflux or abdominal distension) and pi detected sonographically ( ), surgical ( ) or pathological ( ) evidence of gastrointestinal necrosis. there was a difference between overall survival rate ( %) and survival rate in foals with necrotizing disease ( %, p . ) or foals with pi detected sonographically ( %, p . ). pneumatosis intestinalis was the only sonographic finding associated with outcome. sonographic abnormalities in peritoneal fluid, stomach, duodenum, jejunum, cecum, umbilicus or the presence of meconium were associated (p o . ) with surrogates of severity of disease (hospitalization cost or days of hospitalization). hypoproteinemia was associated with pi (p . ). the presence of blood in the feces, reflux and abdominal distension was associated with necrotizing gastrointestinal disease (p o . ). abdominal sonograms have prognostic value in neonatal gastrointestinal disease. pneumatosis intestinalis was a common sonographic sign that worsened the prognosis. the therapeutic implications of detecting a necrotizing component of the gastrointestinal disease deserve further study. the interaction of insulin and the microvascular endothelial insulin receptor (irc) plays an important role in the normal and insulin resistant (ir) individual. while endothelial irc signaling is normally vasodilatory, this effect is well-documented to reverse in the ir individual, resulting in vasoconstriction. although vascular dysfunction has been reported in sepsis-associated equine laminitis, the role of the laminar microvasculature in endocrinopathic laminitis remains poorly characterized. the purpose of this study was to characterize the pattern of irc expression in digital laminae in ponies subjected to a dietary carbohydrate challenge that mimicked abrupt exposure to pasture rich in nonstructural carbohydrates (nsc). mixed-breed ponies (body weight . /- . kg) received a diet of hay chop (nsc $ % on a dm basis) for weeks prior to initiation of the experimental feeding protocol. following conditioning, ponies either remained on the control diet (n ) or received the same diet supplemented with sweet feed and oligofructose (total diet $ % nsc; n ) for a period of days. serum insulin concentrations were measured prior to and after completion of the feeding protocol. at the end of the feeding protocol, sections of numerous tissues, including dorsal digital laminae, were collected immediately following euthanasia. the samples were formalin-fixed for hours, transferred to % ethanol, and paraffin-embedded. laminar sections were stained immunohistochemically for irc using a commercially-available antibody (abcam); the number of irc ( ) cells was quantified in x light microscopy fields (n ) for each section. the total number of irc ( ) cells was greater in the laminae of challenged ponies than control ponies (p . ), and there was a significant correlation between the change in serum basal insulin concentration and number of laminar irc ( ) endothelial cells (r . ; p o . ). while the number of irc ( ) endothelial cells was significantly greater in the dermal laminae of challenged ponies (p . ), there was no difference in the number of interstitial irc ( ) cells (p . ). no epithelial irc ( ) cells were observed in any laminar section, and irc ( ) cells were conspicuously absent from the deep dermal tissue (including vessels). up-regulation of irc expression in the laminar vasculature occurs acutely in response to dietary carbohydrate challenge and accompanies hyperinsulinemia in ponies. the dramatic increase in endothelial irc expression in the laminar microvasculature in nutritionally challenged ponies, with no apparent epithelial irc present, suggests that hyperinsulinemia associated with exposure to increased dietary nsc may induce laminar injury by causing a similar vasoconstriction in ir equids as described in the microvasculature of ir humans. glucose transport from the blood stream into cells, the limiting step in whole-body glucose utilization, is regulated by a family of glucose transporter (glut) proteins in insulin-sensitive (i.e., muscle and adipose) tissues. we previously demonstrated that glut , the major isoform, is a key factor in the pathogenesis of equine insulin resistance (ir). while it has been recently demonstrated that glut (a newly discovered isoform) increases insulin-stimulated glucose transport in human muscle, its role in other tissues, particularly in the setting of ir, is not well characterized in any species. in addition, as has recently emerged as a key downstream signaling molecule regulating translocation of glut to the cell surface, the rate-limiting step in glucose uptake. we hypothesized that glut content would be differentially expressed across tissues and that ir would induce alteration in glucose transport by affecting active cell surface glut . biopsies of skeletal muscle, and subcutaneous and visceral adipose tissue were collected from light-breed horses, characterized as either insulin sensitive or compensated ir, based on the results of an insulin-modified frequently-sampled intravenous glucose tolerance test (n /group). we specifically quantified active cell-surface glut in these biopsies, using an innovative exofacial bismannose photolabeled assay, which has not been previously applied to glut . total glut protein expression was measured by western blots, as well as total and phosphorylated (indicating activation of) as . glut was expressed in all the depots with a significant regional effect. total glut protein content was increased (p o . ) in visceral (omental and mesenteric) compared to subcutaneous (nuchal ligament and tailhead) adipose tissue and skeletal muscle of healthy horses. ir did not induce alterations in active cell-surface and total glut content nor in total and phosphorylated as in any of the tissues evaluated. our data suggests that glut is abundant in visceral adipose tissue and is therefore likely to play a substantial role in the regulation of glucose transport. however, neither glut translocation nor as activation are impaired in insulin-sensitive tissues of ir horses. it is concluded that, in contrast with glut , glut does not appear to contribute to glucose transport alterations during naturally-occurring equine ir. insulin resistance (ir), characterized by exaggerated glycemic or insulinemic responses to glucose challenge, is a key metabolic disturbance in horses that develop obesity-associated laminitis. in addition to obesity, diet and age have been demonstrated to affect tissue sensitivity to insulin in other species but these factors have received limited investigation in horses. we hypothesized that there would be greater glycemic and insulinemic responses to a sweet feed meal in aged horses, as compared to adult horses, as well as in horses adapted to a forage-only diet. three diets, grass hay only, grass hay plus sweet feed (starch and sugar-rich, ss), and grass hay plus a fat and fiber (ff) feed, were fed to mares, adult ( - yr) and aged ( yr), for a -week adaptation period in a randomized design. glycemic and insulinemic responses to a standardized meal of sweet feed ( g/kg bw offered for hour) were determined for hours from the onset of feeding. peak glucose and insulin concentrations and areas under the glucose or insulin vs. time curves (auc-g, mg/ dl/ min, and auc-i, mu/ml/ min) were determined and data were analyzed by one-and two-factor repeated measures anova. there were no differences between age groups in glycemic responses to any of the diets. however, in aged horses peak glucose concentration (p o . ) and auc-g (p o . ) were greater after adaptation to the forage-only diet, as compared to the other two diets. in contrast, aged horses had a greater peak insulin concentration (p o . ) and auc-i (p o . ) than adult horses on all diets but no differences in peak insulin concentration or auc-i was found between diets within age groups. as hypothesized, the insulin response, but not the glycemic response, to a sweet feed meal was greater in aged horses, regardless of background diet. further, the glycemic response was greatest after adaptation to a forage-only diet, but this finding was only significant in aged horses. morbidity, mortality, and economic loss to the equine industry. in obese humans and rodent models of nutritional obesity, systemic insulin resistance and hyperinsulinemia are followed temporally in a majority of individuals by decreased glucose tolerance, pancreatic bcell failure, and type ii diabetes mellitus. in stark contrast to humans, obese horses and ponies chronically remain in what is termed a ''prediabetic'' state in human ir, characterized by hyperinsulinemic euglycemia. few data exist describing the biology of the equine endocrine pancreas in the chronically ir animal that may both: ) explain this unique equine endocrine physiology and ) characterize the animal at-risk for hyperinsulinemia-associated laminitis. the purpose of the study reported here was to characterize the morphology and physiology of the equine endocrine pancreas in response to a dietary carbohydrate challenge. twenty-two mixedbreed ponies (body weight . ae . kg) were conditioned to a diet of chopped hay (nsc $ % on dm basis) for weeks; following conditioning, ponies either remained on the control diet (n ), or received the same hay supplemented with sweet feed and oligofructose (total diet $ % nsc; n ) for days. serum insulin concentrations were measured prior to and after completion of the feeding protocol. at the end of the feeding protocol, sections of numerous tissues, including pancreas, were collected immediately following euthanasia. the samples were formalin-fixed for hours, transferred to % ethanol, and paraffin-embedded. immunohistochemistry was performed on pancreas sections using a commerciallyavailable anti-insulin antibody (abcam), and measurements of islet surface area and b-cell surface area were performed (n islets per tissue section) using a commercially-available computer software program (image j). there was a trend for greater total islet surface area in pancreatic tissue from ponies fed the high nsc diet when compared to the ponies on the hay diet (p . ); however, no difference was noted in b-cell surface area between diet treatments (p . ). the change in serum insulin concentration was significantly greater in the high nsc-fed ponies than in controls ( . /- . miu/l vs. . /À . miu/l; p . ); however, this variable was not correlated with total islet surface area (r . ; p . ) or b-cell surface area (r . ; p . ). due to the relatively modest changes in pancreatic islet surface area that accompany marked increases in serum insulin concentrations in ponies fed a high nsc diet, it is important to assess both b-cell function and insulin clearance mechanisms in future studies to delineate the mechanism(s) of hyperinsulinemia in this model. humans that suffer from obesity show exaggerated inflammatory responses and this may be relevant to the association between increased adiposity and laminitis in horses with equine metabolic syndrome (ems). this study was performed to test the hypothesis that inflammatory responses to endotoxemia differ between healthy horses and those affected by ems. six healthy adult mares and horses with ems received an intravenous infusion of lipopolysaccharide (lps; ng/kg in ml sterile saline) or saline alone. a crossover design was employed with a -day washout period. physical examinations were performed hourly for h and whole blood was collected at , , , , , and min for assessment of inflammatory cytokine gene expression. a liver biopsy was performed between and min postinfusion. data were analyzed using mixed model anova. mean rectal temperature, heart rate, and respiratory rate increased following lps infusion (treatment  time; p o . ), with higher heart (group  treatment; p . ) and respiratory rates (group; p . ) detected in ems horses. lipopolysaccharide infusion significantly increased whole blood gene expression of tumor necrosis factor a (tnfa), interleukin (il)- b (p o . ), il- (p o . ), il- (p o . ), and il- (p . ), and hepatic gene expression of il- (p o . ), il- (p o . ), and il- (p . ). inflammatory gene expression did not differ significantly between groups, so our hypothesis was not supported. heart rates tended to be higher when lps was administered to horses with ems. elevated serum concentration of cardiac troponin i (ctni) is a biomarker for myocardial damage in horses. preferred times to test blood for ctni levels following athletic performance or other events that may cause myocardial injury are not yet established and would be affected by time of release from the myocytes, location of release within the myocytes, duration of release and half-life of ctni in the horse. this information would be necessary to more accurately and reliably test horses for myocardial injury. the aim of this study was to determine the elimination half-life (t / ) of equine ctni. to establish the t / of equine ctni in horses, ctni was recombinantly expressed in e.coli. two healthy ponies received intravenous injections of recombinant equine ctni and plasma ctni concentrations were measured with a point-of-care ctni analyzer at multiple time points after injection. standard pharmacokinetic analysis was performed to establish the elimination half-life of ctni. for comparative purposes, data were subjected to pharmacokinetic models describing a single versus biphasic elimination profile. elimination of recombinant equine ctni following intravenous administration exhibits a short half-life. establishing the t / of troponin provides critical information in understanding the clinical application of this cardiac biomarker in clinical practice. this study describes a true biological ctni t / , which has not been documented in any species thus far. stall-side assessment of this cardiac biomarker in horses should enhance the ability of clinicians to detect myocardial damage and aid in the management and treatment of horses with cardiac disease. the objective of the study was to evaluate the between-pony, within-pony, between-analyser and within-analyser variation of flow-mediated vasodilation (fmd) measurement in healthy ponies, to investigate the hypothesis that fmd occurs in healthy ponies. six healthy, native breed, unrelated pony mares of varying weight ( - kg), body condition score ( / - / ) and age ( - years) were used. the median artery was occluded for minutes. twodimensional ( d) ultrasonographic images of the artery were recorded for seconds prior to and for minutes after occlusion. the peak luminal diameter was compared to baseline diameter to calculate the relative percentage increase in luminal size (fmd). images were obtained from six ponies on one occasion and from one pony on six occasions. analysis of images was performed by two independent analysers and by one analyser twice. the mean (sd) fmd in ponies was . % ( . %) and in pony ( occasions) was . % ( . %). coefficients of variation were . % and . % respectively. agreement between analysers was fair (icc . ) and within analyser was poor (icc . ). fmd is used to assess endothelial function in humans and has recently been assessed for its use in canine subjects. fmd occurs and measurement is feasible in ponies. fmd could be used to assess endothelial function, in the context of laminitis or other cardiovascular diseases. current state-of-the-art technique for measuring blood pressure (bp) in the horse is invasive and involves cannulation of the facial artery. indirect techniques, such as oscillometry, have proven useful in the anaesthetised horse, but have not become routine in the standing horse. monitoring bp can be indicated for the diagnosis and treatment of the hypotensive patient (ie. caused by endotoxemia, hypovolemia, systemic inflammatory response syndrome and cardiac failure) or the hypertensive patient (ie. due to equine metabolic syndrome or pain). the objective of this study was therefore to a) describe the methodology for application of oscillometric bp using a cuff applied to the tail in the standing horse and b) and to determine accuracy and precision of this method applied to the normotensive standing horse. the oscillometric method is simple to apply in a clinical setting. a pneumatic cuff is snugly applied to the unclipped tail-base with the cuff bladder centered over the middle coccygeal artery. the tail circumference must match the manufacturers description of the cuffs diameter range. the oscillometric apparatus inflates the cuff and obtain systolic, diastolic and mean arterial bp (sap, dap and map). at least consecutive measurements must be obtained. a correction of . mmhg/cm vertical distance between cuff and heart level is added to the measurement to correct for hydrostatic pressure difference. for determination of accuracy and precision of indirect sap, dap and map, eight healthy horses (age to years), was equipped with an intra-arterial catheter ii in the facial artery and a commercial tail-cuff oscillometric apparatus. i measurements were recorded every minutes for minutes. the data were analysed with the statistical software r using a mixed model with repeated measurements and a bland-altman analysis corrected for repeated measurements. oscillometric bp was accurate and precise for map (mean bias, lower confidence level, upper confidence level, variation in difference, all mmhg) (À . , À . , . , . , respectively) in the conscious horse but not for sap (À . , À . , . , . , respectively) and dap ( . , . , . , , respectively) . there was no significant contribution to the statistical model of either horse or measurement number. all horses tolerated the tail-cuff well and the method was simple to apply. only map could be measured with acceptable accuracy and precision in the normotensive standing horse using the described oscillometric method. reference intervals for thyroid hormone (th) concentrations have not been established for donkeys. therefore, clinicians must use reference ranges from horses, potentially leading to misdiagnosis of thyroid diseases. we hypothesized that th concentrations are different between donkeys and horses. the purposes of this study were: a) to compare th concentrations between donkeys and horses and, b) to determine whether the age may influence th concentrations. thirty-eight healthy donkeys ( . ae . years), mixed breeds, and healthy andalusian horses ( . ae . years) were used. donkeys were divided into three groups: o years (n ), - years (n ), and years (n ). serum concentrations of total triiodothyronine (tt ), free triiodothyronine (ft ), total thyroxine (tt ), free thyroxine (ft ), reverse triiodothyronine (rt ) and thyroid-stimulating hormone (tsh) were quantified by radioimmunoassay. all blood samples were collected the same day. neither horses nor donkeys had received any treatment for days before sampling and both farms had similar production conditions. total t , ft , ft and tt concentrations were higher (p o . ) in donkeys than horses. in contrast, no statistical differences were found for rt and tsh concentrations. young donkeys ( o years) had higher ft , tt and rt concentrations compared to other donkey groups (p o . ). old donkeys ( years) had lower tt and ft concentrations than both younger donkeys groups (p o . ). this study shows that there are differences in th concentrations between donkeys and horses, raising awareness on the possibility of misdiagnosis of thyroid gland dysfunction when using values from horses, being necessary to determine exclusive reference intervals for donkeys. ovariectomy is associated with alterations of responses to many hormones, not just those associated with reproductive function. in humans and rats, ovariectomy leads to insulin resistance, increased adiposity and altered fat mobilization. the effects of ovariectomy on energy metabolism have not been reported in horses. ovariectomized mares have been shown to respond normally to an acth stimulation test, but the response to suppression of the hypothalamo-pituitary-adrenal axis has not been previously described. the aim of this study was to evaluate the effect of ovariectomy on insulin response in mares and to determine if mares exhibit alterations in response to dexamethasone administration after ovariectomy. six healthy mares underwent an intravenous glucose tolerance test (ivgtt), an insulin sensitivity test (ist) and a dexamethasone suppression test (dst) before and weeks after bilateral ovariectomy. body weight, cortisol values at baseline, and hours after dexamethasone injection and acth values at baseline, and hours after dexamethasone injection, basal insulin/glucose ratio, time to reach a % decrease in blood glucose in the ist, time to reach baseline glucose concentration in the ivgtt and area under the curves plotting blood glucose and time to injection of glucose or insulin were compared before and after ovariectomy using a paired t-test or an anova for repeated measures. significance level was p o . . average body weight was decreased after surgery ( kg ). the injection of dexamethasone resulted in a serum cortisol concentration of less than mg/dl in all mares before ovariectomy, whereas after ovariectomy, dexamethasone injection resulted in a serum cortisol concentration of less than mg/dl in out of mares. in all cases, acth concentration was within the reference range ( - pg/ml) before and after ovariectomy. however, acth concentrations at t and at t were significantly higher after ovariectomy. each mare had a normal ivgtt, both before and after ovariectomy. additionally, no significant differences were observed in basal blood glucose ( ae mg/dl before and ae mg/dl after) or in the time to reach glucose baseline ( ae min before and ae min after). serum basal insulin concentration and insulin/glucose ratio was not significantly different before or after ovariectomy ( . ae . miu/ml and . ae . miu/ml and . ae . and . ae . , respectively), nor was the average time to reach a % decrease in blood glucose after insulin injection ( ae min and ae min, respectively). these findings suggest that, as reported in other species, the shortterm effect of ovariectomy may modify dexamethasone response in mares and that, contrary to other species, it may not modify insulin response. equine gastric ulcer syndrome (egus) is a common medical problem in horses. the high prevalence of gastric ulcers, vague clinical signs and negative effect on performance make it a significant clinical and economic problem within the horse industry. current pharmaceutical treatments are expensive and alter the acidic environment of the stomach. berries and pulp from the seabuckthorn plant (hippophae rhamnoides) are a rich source of vitamins, trace minerals, amino acids, antioxidants, and other bioactive substances and have been used successfully to treat stomach ulcers in man and rats. the purpose of this study was to evaluate the efficacy of a commercially sold, liquid extract of seabuckthorn berries (seabuck tm sbt gastro-plus) for treatment and prevention of gastric ulcers in horses. eight thoroughbred and thoroughbred-cross horses ( - years of age, geldings & mares, - kg) were used in a blinded two-period cross-over study. treatments consisted of control (untreated) and treatment (seabuck tm sbt gastro-plus) twice daily mixed with the grain meal. horses were treated for weeks followed by a week alternating feed-deprivation period to induce or worsen existing ulcers. gastroscopies were performed on all horses on day , week , and week (at the end of the alternating feed-deprivation period). gastric juice was aspirated and ph was measured. during gastroscopy, gastric ulcer scores were assigned to each stomach based on lesion number and severity. horses acted as their own controls, and between each treatment period the horses had a -week washout period. data was analyzed by anova for repeated measures via the glm procedure (sas inst. inc., cary, nc). when significant differences (p o . ) were observed, a post-hoc tukey's test was used to determine differences. non-glandular gastric ulcer scores significantly increased in all control and sbt-treated horses from week to week , after the feed-deprivation phase of the study. there was no significant difference in the non-glandular gastric number (p . ) and nonglandular gastric severity (p . ) scores in sbt-treated horses compared to non-treated controls. glandular ulcer number (p . ) and glandular ulcer severity (p . ) was significantly lower in the sbt-treated horses compared to the control horses. there was no significant difference in the ph (p . ) in sbt-treated horses compared to non-treated controls. thus, seabuck tm sbt gastro-plus, mixed in the feed twice daily, may be efficacious in controlling the severity of glandular ulcers in horses during stress, without increasing stomach ph. the availability of rapid and accurate quantitative fibrinogen measurements may be useful for evaluation of hospitalized equine patients. the abaxis vspro analyzer was evaluated for precision using two levels of human fibrinogen controls ( mg/dl and mg/dl), four different vspro machines, and two different lots of cartridges, assessed over subsequent days. the coefficients of variation of the assay ranged from % ( mg/dl) to % ( mg/ dl). we subsequently evaluated the abaxis vspro fibrinogen assay compared to fibrinogen concentration measured using the beckman coulter acl- in equine samples of varying fibrinogen concentrations obtained from horses with gastrointestinal disease. all samples were measured in citrated plasma. fibrinogen samples measured on the acl- ranged from to mg/dl (median mg/dl). vspro samples were run in duplicate, and the mean compared to the acl values. pearson correlation coefficient analysis generated an r value of . (p o . ). duplicate measurements on the vspro were strongly correlated to each other with an r value of . (p o . ). bland-altman analysis of these samples for the vspro compared to the acl- noted a bias of À ae mg/dl the results of this study indicate that the vspro benchtop fibrinogen analyzer provides accurate and precise fibrinogen data compared to the acl- reference analyzer. the immune response of foals to r. equi is incompletely understood and believed to be responsible for clinical disease caused by this pulmonary pathogen. in a recent study foals receiving a large inoculum exhibited th skewing with pneumonia and a small inoculum exhibited th skewing without clinical disease. we hypothesized that cytokine/chemokine production by pulmonary alveolar macrophages, in vitro, would increase with the infective dose and that the magnitude of the response would differ between foals and adults. alveolar macrophages were obtained by bronchoalevolar lavage from healthy mares and their -week-old foals. macrophage cultures were infected with r. equi ( or -) at a multiplicity of infection (moi) of or . total rna was harvested and hours post-infection, reverse transcribed and used as template for quantita-tive pcr. the ddct method was used to calculate relative gene transcripts for il- , il- p , tnfa and cxcl . cellular infections at moi resulted in significantly higher expression of il- , il- p and tnfa mrna transcripts compared to moi . however, the dose-effect was reversed for cxcl with significantly lower expression at the higher moi. there was no difference in magnitude of cytokine/chemokine responses by the alveolar macrophages between adults and foals. dose-dependent responses of alveolar macrophages may represent a novel mechanism by which r. equi could modulate immune responses and therefore disease. significant down-regulation of cxcl mrna transcripts associated with a higher dose is of particular interest as this chemokine plays a role in development of protective th responses. the intent of this study was to develop likelihood ratios (lrs) for infection attributable to corynebacterium pseudotuberculosis in horses based on synergistic hemolysis inhibition (shi) test titers. medical records for horses presented to the uc davis veterinary teaching hospital with serum submitted for shi titer determination were evaluated and cases met study inclusion criteria. these cases were grouped based on evidence of internal and/or external infection attributable to c. pseudotuberculosis and likelihood ratios with % confidence intervals determined. results showed increasing lrs indicating increasing odds for any form of active disease as titer increased with all cases considered. lrs for internal infection were for titers ! overall and for titers with external abscess cases excluded. no difference from (and therefore no significant change in pre-test to post-test odds) was seen in any lrs for internal disease when only cases with external disease were examined (external and internal disease vs. external only). overall, the shi test results showed usefulness in determining internal c. pseudotuberculosis infection in horses with no evidence of external abscessation. overall, however, higher titers were more indicative of active external or internal disease than internal disease specifically in contrast to previous reports. the shi test was unable to distinguish internal infection when external abscesses were present. salmonella enterica is a zoonotic pathogen that has tremendous impact on many different animal production and management systems. rapid detection of s. enterica in fecal samples may facilitate effective infection control practices. current detection methods require - hours (polymerase chain reaction or pcr) or - hours (enriched aerobic culture) to obtain results. alternatives have been developed, lateral flow antigen detection systems (lfads), which are currently marketed for salmonella detection related to food safety microbiology. the objective of this study was to evaluate two commercially available rapid salmonella detection systems in equine feces. fecal samples collected from repeatedly culture-negative horses were inoculated with known concentrations of salmonella enterica serotype typhimurium (five uninoculated control samples, and samples of each -fold dilution [ .  - .  cfu/gram of feces]). all samples were aerobically cultured using a standard enrichment technique. in a blinded fashion, samples were tested using two different lfads as well as plated on agar media for confirmatory testing. at hours of incubation, using bacterial culture as the reference method, test was correctly identify % of samples ( bacterial contamination of stalls with salmonella sp. is a serious problem in equine hospitals. salmonella sp. exposure to horses in the facility can result in nosocomial infections which results in temporary facility closure, until the organism is eradicated. hospital closure can result in loss of revenue, damage to reputation and interference with patient care. the purpose of this study was to evaluate three stall cleaning methods on eradication of salmonella sp. at an equine veterinary teaching hospital (vth). horses admitted to the vth were assigned to salmonella sp.negative stalls within areas of the vth during the study period (september -january . when the horses were discharged stalls were randomly assigned to one of three cleaning methods (pressure-washing only [pw] , pressure washing and hand scrubbing [pws] , or hand scrubbing only [s]) in a single period, non cross-over design. all stalls were stripped of bedding and surfaces sprayed with tap water and cleaned with a disinfectant quaternary-ammonia solution (super hdq neutral, spartan chemical co., inc, maumee, oh). the pressure-washing system (psc cleaning systems, inc., toronto, canada) used, provided a pressure of psi and a temperature range of - f. following cleaning, each stall was allowed to air dry and within hours, stall surfaces were sampled using three  sponges moistened with sterile saline. the person collecting the samples was masked to the method of cleaning. sponges were submitted to the louisiana animal disease diagnostic laboratory (laddl) for culture of salmonella sp. a chi-squared analysis was used to determine significant differences (limit p o . ) between cleaning methods and salmonella sp. isolation. during the study period, stalls (pw [n ]; pws [n ]; s [n ] were included. all stalls had negative environmental salmonella sp. cultures prior to beginning the study. for pw cleaned stalls, / ( . %) were salmonella sp.-positive, for pws cleaned stalls, / ( %) were salmonella sp.-positive, and for s cleaned stalls, / ( . %) were salmonella sp.-positive. although, there were fewer salmonella sp.-positive stalls ( . %) in the handscrubbed stalls, cleaning method did not significantly (p . ) affect the isolation of salmonella sp. from the stall environment. in conclusion, power washing alone, power washing and hand scrubbing, and hand scrubbing alone, using a quaternary-ammonia solution did not significantly affect environmental isolation of salmonella sp. from stalls surfaces in the vth during this study. the objectives of this study were to determine the plasma and pulmonary disposition of gamithromycin in foals and to investigate the in vitro activity of the drug against streptococcus equi subsp. zooepidemicus (s. zooepidemicus) and rhodococcus equi isolates. a single dose of gamithromycin ( mg/kg of body weight) was administered intramuscularly. concentrations of gamithromycin in plasma, pulmonary epithelial lining fluid (pelf), bronchoalveolar lavage (bal) cells, and blood neutrophils were determined using hplc with tandem mass spectrometry detection. the minimum inhibitory concentration of gamithromycin required to inhibit growth of % of r. equi and s. zooepidemicus isolates (mic ) was determined. additionally, the activity of gamithromycin against intracellular r. equi was measured. mean peak gamithromycin concentrations were significantly higher in blood neutrophils ( . ae . g/ml) and bal cells ( . ae . g/ml) compared to pelf ( . ae . g/ml) and plasma ( . ae . g/ml). mean terminal half-lives in neutrophils ( . h), bal cells ( . h), and pelf ( . h) were significantly longer than that of plasma ( . h). the mic of s. zooepidemicus isolates was . g/ml. the mic of gamithromycin for macrolide-resistant r. equi isolates ( g/ml) was significantly higher than that of macrolide-susceptible isolates ( . g/ ml). the activity of gamithromycin against intracellular r. equi was similar to that of azithromycin and erythromycin. intramuscular administration of gamithromycin at a dosage of mg/kg would maintain pelf concentrations above the mic for s. zooepidemicus and phagocytic cell concentrations above the mic for r. equi for approximately days. eight western stock yearling horses were infected with ehv- (ab ) by nasopharyngeal instillation. venous blood samples for collection of plasma were collected in na-citrate tubes on the day prior to infection (d - ) and on d through d . in addition, clinical data, nasal swabs and peripheral blood mononuclear cells (pbmc) for detection of viremia were collected on the day before infection (d - ) and on d through d post-infection. d-dimer concentrations were determined in citrated plasma samples using a latex agglutination test (minutex d-dimer, biopool, ireland). viral load in pbmc was determined using quantitative pcr. all horses showed bi-phasic fevers typical for ehv- infections. one horse developed acute ehm on d and was euthanized after samples were collected. in all horses d-dimers were undetectable on d - and on d , and . in contrast, all horses had increased ddimer concentrations for to consecutive days starting on day post-infection. d-dimer concentrations in horses increased to ug/ml and one of these horses was the horse with acute ehm. interestingly, mean increased d-dimer concentrations showed timely overlap with the mean fever curve and, delayed by day, with the mean viremia curve. because plasma samples for d-dimer measurements were not collected during the first days post-infection, which are typically associated with a primary fever, conclusion on the association of d-dimers with fever of viremia await analysis of a second study currently conducted in our laboratory. in conclusion our data indicates that during ehv- infection with neuropathogenic strains activation of the coagulation cascade and production of cross-linked fibrin is wide-spread; not limited to horses with clinical signs of ehm, and can be expected between days and post-infection. lawsonia intracellularis is an emerging pathogen in horses and the causative agent in equine proliferative enteropathy (epe). the goal of this study was to evaluate the exposure of pre-weanling foals and broodmares to lawsonia intracelluaris on several farms in louisiana with a history of epe and compare the results to several farms with no known clinical cases of epe in foals. an additional goal of the study was to identify whether a relationship exists between lawsonia intracelluaris and other gastrointestinal pathogens in foals. whole blood and fecal samples were collected from mares and foals from four breeding farms in louisiana. farms a and b had no known clinical cases of epe, while farms c and d had previous know cases of epe in . serum samples were examined for the presence of antibodies against lawsonia intracellularis using an immunoperoxidase monolayer assay (ipma). dna was extracted from fecal samples using a commercial dna kit and molecular detection of lawsonia intracelluaris was assayed using real-time pcr. fecal ova were determined using quantitative sucrose floatation. the presence of fecal clostridium difficile toxin was measured using a commercial enzyme linked immunosorbent assay (elisa). three of the farms examined had foals and mares with exposure to l. intracellularis as evidenced by serum antibodies against the organism. of the total population sampled, foals ( . %) and mares ( . %) had evidence of antibodies to l. intracellularis based on serology. three foals ( . %) tested positive for l. intracellularis organism by fecal pcr, and all of these foals were located on farm c. of these, one of the foals was seronegative, while the other two were seropositive. farm c also had the highest percentage of mares ( . %) serologically positive for l. intracellularis, while farm a had the highest percentage of foals ( . %) with antibody titers against l intracellaris. farm c also had the only pairs (n ) of serologically positive mares with seropositive foals. while farm a and b had seropositive mares and/or foals, none of the foals were positive for l. intracellularis fecal shedding by pcr. all serum and fecal samples were negative for evidence of l. intracellaris on farm d. ten foals ( %) had fecal egg counts greater than egg per gram and foals ( %) were positive for c. difficile toxin. this study demonstrated evidence of natural exposure to l intracellularis on farms both with and without a history of epe in louisiana. further, this study failed to establish a relationship between l intracellularis and other gastrointestinal pathogens. the objective of this study was to examine the clinical, hematological, biochemical, and outcome data from equids infected with anaplasma phagocytophilum presented to a primary care field setting in southeastern pennsylvania. computerized medical records from febrile equids with confirmed anaplasma phagocytophilum infection were reviewed. confirmation of anaplasma phagocytophilum was defined by the presence of granular inclusion bodies seen within leukocytes or eosinophils on microscopic blood smear evaluation and/or a positive polymerase chain reaction (pcr) for anaplasma phagocytophilum. horses and donkey presented with a mean fever of . f and mean fever duration of hours. the mean age at presentation was . years and the mean pack cell volume was . %. / cases were diagnosed in the months of may to december. equids ages to years had significantly lower platelet counts. / cases were positive on blood smear for inclusion bodies and / cases were positive for anaplasma phagocytophilum on pcr. treatments included intravenous oxytetracycline, oral doxycycline, or both. mean treatment duration was . days and mean treatment cost was $ . / cases were normothermic within hours. the treatment used in the two remaining cases was changed from oral doxycycline to intravenous oxtetracycline and was successful. this is the first case series of equine granulocytic anaplasmosis in the mid-atlantic states. all cases were examined and treated in the field. in order to make a definitive diagnosis, some cases required pcr. treatment failures were documented with the use of oral doxycycline alone. % of the cases survived. a high incidence of clinical and possibly genetic abnormalities has been reported amongst friesian horses including dwarfism, hydrocephalus, dissecting aortic aneurism and esophageal dysfunction. the purpose of the current study was to develop a new electromyography (emg) method to assess neurophysiological function of the esophagus especially for friesian horses. five friesian horses with esophageal dysfunction were included (ranging in age from . - years and comprising mares and a stallion) and two friesian control horses (a -and -year-old gelding). all five horses with esophageal dysfunction had a history of recurrent esophageal obstruction and were examined histopathologically post-mortem. barium contrast radiography was used as the gold standard to distinguish the diseased from the control horses. an endoscopically-guided percutaneous needle emg procedure (viking quest r ; software version . ) was performed just caudal to the larynx and just cranial to the thoracic inlet (to monitor striated and smooth muscle, respectively) to visualize esophageal motility. esophageal contractility in both control horses was predominantly reflected by interference patterns associated with longer duration and lower amplitude in smooth muscle compared to striated muscle. mean (ae sd) values were . ae . ms and . ae . mv (n readings) and . ae . ms and . ae . mv (n readings), respectively. in diseased horses, aperistalsis in smooth muscle was the most remarkable finding suggesting a loss of inhibitory neurogenic input resulting in aperistalsis and thus esophageal dysfunction. preliminary findings suggest that endoscopically-guided percutaneous needle emg might become a valuable method in elucidating the pathophysiology of dysfunction of esophageal motility especially in friesian horses. lymphoma affects horses of all ages. unlike in humans, no etiologic agent has been discovered. a year old thoroughbred/warmblood cross mare presented with signs of upper and lower respiratory disease and was subsequently diagnosed with lymphoma and equine multinodular pulmonary fibrosis (empf) and was positive for equine herpes virus (ehv- ) in both the pulmonary tissue and the lymph nodes. retrospective polymerase chain reaction (pcr) testing of six lymphoma cases found that of of the cases were positive on pcr for ehv- ( . %, p . , rr . ). electron microscopy was performed on one sample and herpes virus particles were identified. of the samples in which immunohistochemistry was performed ( of ), only t-cell rich b-cell lymphoma was identified. samples of mesenteric or submandibular lymph nodes from clinically healthy horses were submitted for ehv- pcr analysis; % were positive. gamma herpesviruses in humans have been associated with lymphoproliferative diseases such as kaposi's sarcoma and burkitt's lymphoma. equine herpesvirus , also a gamma herpesvirus, is found in association with equine lymphoma; although the exact role this virus plays in the initiation or perpetuation of lymphoproliferative neoplasia remains unknown. pathologic events reported to occur in the digital laminae in early stages of sepsis-related equine laminitis include leukocyte extravasa-tion into the laminar interstitium, pro-inflammatory cytokine expression, and epithelial stress. while these events have been documented early in the disease process at both a developmental stage and at the onset of obel grade (og ) lameness in the carbohydrate overload (cho) model of laminitis, the later events occurring at the onset of obel grade lameness(og , time point at which structural failure of the laminae usually occurs) have not been determined. we hypothesized that the inflammatory events described above are sustained through og lameness, likely playing an injurious role culminating in laminar failure. our objectives were to determine pro-inflammatory gene expression, leukocyte extravasation, and epithelial stress at og induced using the cho model. archived laminar tissue samples (snap frozen and paraffin embedded sections) were used from a previous cho study at louisiana state university (control group [n , water], cho group [n , corn starch]. calprotectin (cp) immunohistochemistry (ihc) was used to assess both laminar myeloid leukocyte numbers and epithelial stress; rt-qpcr was used to assess inflammatory gene expression. minimal inflammatory changes were present at og compared to published values at og stage in the cho lameness model including decreased mrna concentrations of cytokines (i.e. -fold increase in il- at og vs. -fold increase at og , no increase in il- b at og vs. -fold increase at og ), chemokines (no change in mcp- at og vs. fold increase at og , -fold increase in il- at og vs. fold increase at og ) and adhesion molecules (no change in e-selectin at og vs. -fold increase at og ). laminar leukocyte emigration was also decreased at the onset of og lameness compared to previously reported leukocyte infiltration at og . interestingly cox- , underwent a greater increase at og (approx. -fold) compared to that reported at og lameness ( -fold). finally, epithelial stress at og evidenced by cp ihc did not follow the uniform widespread distribution reported at og lameness, but instead was present in focal areas in which secondary epidermal laminae on either side of a common primary dermal vascular supply demonstrated increased cp signal. overall, laminar inflammation appears to be subsiding at og lameness, with epithelial stress possibly more dependent on vascular dysregulation instead of inflammatory events. the sustained increase in cox- , central to the induced production of vasoactive prostanoids in disease processes, may play a role in vascular dysregulation. this study was conducted to characterize clinical, laboratory and postmortem findings associated with oleander toxicosis in equids and to determine factors predictive of survival in these cases. retrospective analysis of medical records from our veterinary medical teaching hospital from january , to july , was completed. records of equids demonstrating detectable oleandrin in serum, plasma, urine or gastrointestinal fluid samples or detectable serum digoxin in the absence of pharmaceutical cardiac glycoside administration were included. descriptive statistics were used to evaluate the history, physical examination, and laboratory and postmortem data of affected individuals. logistic regression analysis was used to detect physical examination and laboratory factors significantly associated with survival. thirty equids met inclusion criteria of the study. three of subjects were dead on arrival or died immediately upon arrival ( %). of the remaining equids, % presented with gastrointestinal abnormalities, % were azotemic and % had cardiac arrhythmias. mortality was % for all subjects and % for those treated. the predominant cause for non-survival was cardiac dysfunction. factors significantly associated with survival included relatively decreased hematocrit and serum glucose, relatively increased serum chloride, absence of cardiac arrhythmias, and increased duration of hospitalization. equids with oleander toxicosis frequently present with gastrointestinal upset and may develop cardiac and renal disturbances. patients with cardiac arrhythmias and relatively increased hematocrit and serum glucose and decreased serum chloride are significantly less likely to survive. oleander intoxication is a differential diagnosis for colic in endemic areas, particularly with concurrent azotemia or cardiac dysrhythmia. the quantitative physicochemical approach emphasizes the importance of strong ions (na, k, cl, lactate), pco , and the plasma protein concentrations in determining plasma ph. serum concentrations of strong ions, proteins, and total co are reported on modern biochemical profiles. we hypothesized that the results of serum biochemical analysis can be used for acid-base interpretation in horses. the objective was to determine whether blood ph, anion gap, and strong ion gap could be quantitatively estimated and clinically used based on the results of serum or plasma biochemical analysis. horses ( adults and foals) presented to the isolation unit of our veterinary teaching hospital for suspected infectious diseases were prospectively enrolled. a venous serum sample was analyzed using a hitachi or copas c automated machine. measured parameters included strong ion difference (sid {na k}-{cl lac-tate}), total protein concentration (tp), and total co (tco ), with lactate being measured by blood gas analyzer. a second venous blood sample was collected into a na-heparin blood gas syringe and analyzed for ph (ph m ), pco and concentrations of na, k, cl, and lactate using a radiometer flex blood gas analyzer; sid was calculated from the measured values, and total solids (ts) were estimated using refractometry. serum/ plasma ph (ph calc ) was calculated using stewart's factor equation from the results of serum or plasma biochemical analysis, assuming pco mmhg for serum and pco accurate for plasma. anion gap (ag) was calculated as: ag (na k)-(cl tco ). strong ion gap (sig) was calculated as: sig . x[total protein, g/l]/ ( {pka-ph} )-ag. linear regression analysis was used to compare ph calc to ph m, as well as ag and sig to blood lactate concentrations. measured ph ranged from . to . ( . ae . ). measured sid from serum biochemistry (sid sb ) ranged from . to . meq/l ( . ae . meq/l) and sid from blood gas analyzer (sid bg ) from . to . meq/l ( . ae . meq/l; r . ; sid bg .  sid sb ). sid sb and sid bg showed small variability in measurements. tp ranged from to g/l ( . ae . g/l) and ts from - ( . ae . g/l; r . ; ts .  tp). using sid sb and tco values with constant pco , ph calc was poorly associated with ph m (r . ; ph calc . . ). in contrast, using sid bg with accurate pco , ph calc was closely associated with ph m (r . ; phcalc . . ) and the equation was not different from the line of identity. anion gap and sig (meq/l) calculated were significantly linearly correlated with lactate concentrations (mmol/l); ag .  [lactate] . (r . ), and sig À .  [lactate] . (r . ). we conclude that ph calc using sid sb , tco and constant pco values is not accurate. however, variability of measured biochemical parameters between machines was small, permitting use of serum biochemistry for clinical metabolic acid-base abnormalities interpretations of patients. these results reemphasize the importance of strong electrolytes and proteins in acid-base balance. metalloproteinases (mmps) are critically important in remodeling processes and in wound healing. however, excessive activation of mmps by pro-inflammatory mediators including cytokines, prostaglandin e , and nitric oxide lead to tissue breakdown. this is observed in osteoarthritis (oa) which is characterized by erosive lesions in articular cartilage. in hereditary equine regional dermal asthenia (herda), afflicted horses exhibit collagen abnormalities and can have associated chronic inflammation and aberrant wound repair. herda affects horses with quarter horse bloodlines and is similar to the human hereditary connective tissue syndrome ehlers danlos (eds). many adult eds patients suffer from joint pain and oa. we hypothesized that chondrocytes from articular cartilage of herda horses have increased activity of mmps. to test this hypothesis, chondrocytes were retrieved from articular cartilage of homozygous herda carpal and hock joints. chondrocytes from normal horses were also obtained for comparison. chondrocytes were seeded at x /ml into -well plates and incubated at c, % co for up to seven days. activity of secreted mmps was determined by zymography using equal amounts of proteins for loading. secreted mmps were analyzed by western blot. zymography showed that normal chondrocytes secreted two major bands with gelatinolytic activity observed at and kda suggestive of the latent form of mmp- and mmp- , respectively. less intense bands of gelatinolytic activity were observed at about and kda suggestive of the active form of mmp- and mmp- . another band of activity was also seen at kda which is suggestive of a dimer of mmp- that has been reported when mmps are in excess of tissue inhibitors of metalloproteinases (timps). chondrocyte cultures from homozygous herda cartilage showed a similar profile but with decreased activity by % at kda and - % increased activity at kda compared to normal chondrocytes. western blot analysis detected mmp- and mmp- immunoreactivity in chondrocyte culture media of herda-afflicted and normal horses. the present study demonstrates for the first time that horses suffering from herda have increased mmp activity which may predispose them to the development of lesions in articular cartilage. research supported by nutramax laboratories, inc. equine polysaccharide storage myopathy (pssm) type is a dominantly inherited glycogenosis caused by a mutation in the gene coding for skeletal muscle glycogen synthase type (gys- ). the disease has been reported to affect the haflinger breed but so far its prevalence is unknown. aim of this preliminary study was to estimate the occurrence of the gys- mutation in austrian haflingers and establish which of the seven haflinger sire lines appear mostly affected. gys- genotyping of randomly chosen haflingers was performed with a validated restriction fragment length polymorphism assay. resting and post-exercise muscle enzyme activities (creatine kinase (ck), aspartate aminotransferase (ast), lacate dehydrogenase (ldh)) and blood lactate concentrations were compared between horses with and without the mutation. among the horses were heterozygous (hr) carrier of the mutation. no homozygotes (hh) were identified. all horses with the gys- mutation were descendents of the a-or w-sire lines. the estimated hr prevalence was % ( % ci: . - . %). ck activity after exercise (p . ) was significantly higher in hr horses compared with horses not carrying the mutation (rr). ast activity was significantly higher in the hr group at rest and after exercise (p o . ). there was no statistically significant difference in resting ck, resting and post exercise ldh activity or blood lactate between hr and rr. results suggest that the prevalence of hr in the austrian haflinger population is higher than in the overall quarter horse population and might be as high as %, similar to some draft horse breeds. further research is needed to establish the prevalence within the different breeding lines. hereditary equine regional dermal asthenia (herda) is an autosomal recessive connective tissue disorder affecting quarter horse lineages. although a mutation in the gene encoding cyclophilin b has been genetically linked to herda, its causal association with the disease is not yet documented. previously, we demonstrated reductions in ultimate tensile strength (uts), modulus of elasticity, and energy to failure (toughness) of skin from many corporal regions of herda animals. given the presumed relationship between her-da and abnormal collagen structure, and the predominance of type i collagen in skin, we hypothesized that altered biomechanical properties would be detected in tendons which are rich in type i collagen. to evaluate this hypothesis we compared the uts, modulus of elasticity, and energy to failure of forelimb deep digital flexor tendons (dft) from six herda horses to six age-matched controls. isolated dft was secured and pulled to failure on an instron s universal testing instrument using purpose-built cryogenic clamps. analysis of variance was executed using sas . proc glimmix program (sas institute, ). p-values . were identified as significant. uts and modulus of elasticity were significantly lower in herda dft when compared with controls (p o . ); energy to failure did not differ between groups. these findings document abnormal biomechanics in herda tendon, leading us to postulate that lower uts and modulus of elasticity associated with the herda defect could convey a competitive advantage in the athletic disciplines in which this defect has segregated. (references on request). a proprietary herbal biocontamination product (bios) approved for cosmetic use in france, inhibits proliferation of medically relevant bacteria, mold, and viruses. these properties make bios potentially useful as a topical wound medication, prompting us to compare bios to silver sulfadiazine (ssd) in a distal extremity wound healing model in horses. using general anesthesia, two . cm wounds were aseptically created on the dorsomedial aspect of all limbs. for the duration of the study, two contralateral limbs were randomly chosen to be bandaged; the other two limbs were un-bandaged -with one limb of each group being treated with % bios and the other with ssd. for each limb the most proximal wound served as an untreated control. every hours wounds were evaluated, digitally photographed, and perimeter and area determined using morphometric software (imagej, nih). analysis of variance did not identify significant differences between ssd or bios treatment for wound perimeter (p . ) or area (p . ). at individual time points the effect of bandaging was significant when area was evaluated (p . ) and trended toward significance for perimeter (p . ) comparisons, substantiating published reports that bandaging modifies wound healing. difference in perimeter and area between control and treatment were highly significant (p o . ), substantiating the importance of topical treatment. over the study duration, effects of bandaging (p o . ) and topical treatment (perimeter p o . ; area p . ) continued to be highly significant. bios performance in the equine distal extremity wound model was equivalent to ssd. both bandaging and topical treatment significantly impacted wound healing. this effect was compounded when both variables were evaluated over time. radiolabeled leukocytes are the only scintigraphic method currently available for identifying sites of infection and/or inflammation in horses; however the clinical applicability of this technique is limited by expense and poor efficacy. this pilot study compares the accumulation of m tc-labeled igg, peg-liposomes and leukocytes in an equine muscle abscess model. three mixed breed adult horses had  cfu s. equi zooepidemicus inoculated into the right semitendonosis to create an abscess. peg-liposomes were prepared via the film hydration method and labeled using mci m tc-hexamethyl-propylene-amine-oxime ( m tc-hmpao). autologous leukocytes were obtained from ml whole blood and labelled using mci m tc-hmpao. commercial equine polyclonal igg was conjugated with the chelator hydrazinonicotinamide (hynic) and labelled with mci m tc. radiopharmaceutical administration was initiated hours after inoculation. horses and received mg m tc-igg, . mmol/kg m tc-liposomes and m tc-leukocytes, with a hour interval between each radiopharmaceutical. horse received only m tc-leukocytes. scintigraphic examinations were performed at and hours post injection (p.i.) with each radiopharmaceutical. after the final study, horses were euthanized and tissue samples collected. the percentage of injected dose per kilogram of tissue (%id/kg) was calculated for the region of the abscess, normal muscle and multiple organs. scintigraphic examinations demonstrated increased radiopharmaceutical in the region of the abscess with all three techniques at both time-points. at hours p.i. abscess-to-background ratio was highest using m tc-igg ( . ae . ). at hours p.i. abscess to background ratio was highest using m tc-liposomes ( . ae ). tissue biodistribution data revealed abscess to muscle ratios of ( m tc-igg), ( m tc-liposomes), and . ( m tc-leukocytes). this preliminary data demonstrates that m tc-liposomes, m tc-igg and m tc-leukocytes exhibit long circulating characteristics and accumulate at inflammatory/infectious foci after intravenous injection in horses. m tc-igg and m tc-liposomes appear to be superior to m tc-labelled leukocytes in this model. due to its low cost and ease of preparation, m tc-igg has great potential for clinical use where identification of infectious or inflammatory foci is necessary. digital hypothermia is used clinically to decrease the incidence of sepsis-related equine laminitis, a disease causing structural failure of digital laminae resulting in crippling lameness. due to the fact that hypothermia was recently reported to effectively decrease laminar expression of inflammatory molecules including pro-inflammatory cytokines, chemokines and cox- in equine laminitis, our laboratory is investigating the effect of hypothermia on central upstream signaling cascades which may induce expression of these diverse inflammatory molecules. the p mapk pathway has recently been reported to be a central component of inflammatory signaling in multiple diseases including human sepsis, and is currently being assessed as a therapeutic target. we thus hypothesized that ) p mapk is upregulated and activated in affected laminae in equine laminitis and ) digital hypothermia inhibits inflammatory mediator expression by blocking p mapk phosphorylation (indicator of p mapk activation). western hybridizations using both a total p mapk and a phospho-p mapk antibody were performed on archived pooled laminar samples from black walnut extract (bwe) model ( control, developmental (dev) groups [ . h & h post bwe administration] and the onset of obel grade lameness (og ) [n each]) and carbohydrate overload (cho) models (con [n ], dev [n ], og [n ]) of laminitis, and individual laminar samples from two groups of horses from a digital hypothermia (dh) study. in the dh study, one forelimb of each horse was kept at approximately c in ice water and the other at ambient temperature following administration of g/kg oligofructose (of). dorsal laminae were harvested for snap freezing at either hours after of administration (dev, n ) or at the onset of lameness (og , n ) using protein extracted from treated and untreated digital laminae of each horse. increased laminar concentrations of phospho-p mapk were present in the developmental periods ( . h and h) in the bwe model, and in both the dev and og periods in the cho laminitis models. however, digital hypothermia had no effect on laminar phospho-p mapk concentrations. thus, p mapk is activated in affected laminae in multiple models of laminitis, but does not appear to be the central signaling cascade through which hypothermia works to block the expression of inflammatory molecules. therefore, p mapk is not likely to be a viable therapeutic target as a sole source for blocking the multiple inflammatory signaling mechanisms inhibited by local hypothermia. abstract e- does cefquinome penetrate the blood brain barrier in the normal horse? hollis ar duggan ve and corley ktt . scott dunn's equine clinic, berkshire, uk; university college dublin, dublin, ireland; anglesey lodge equine hospital, the curragh, ireland. meningitis is a rare but serious condition that occurs in both foals and adult horses. there is currently a restricted choice of antimicrobials that are both safe to use in horses and penetrate the blood brain barrier. cefquinome is a fourth generation cephalosporin that has activity against streptococcus, the most commonly reported causative organism in adult horse meningitis. therefore, if cefquinome were to achieve therapeutic concentrations in cerebrospinal fluid following routine administration, this would be an exciting advance for the treatment of meningitis in the horse. mature, healthy horses were used on separate occasions, seven days apart, in a crossover design. each horse was administered either cefquinome ( mg/kg) or saline (equivalent volume). cerebrospinal fluid was collected via atlanto-occipital puncture under general anaesthesia and hours after administration of cefquinome or saline placebo. blood samples were collected prior to, and and hours after administration of cefquinome or placebo. all samples were analysed for the presence of cefquinome by a laboratory masked to treatments administered. cefquinome was detectable in the cerebrospinal fluid in all horses hours after intravenous administration, and in horses hour after administration. cefquinome penetrates the blood-brain barrier and it is therefore a potential treatment for equine meningitis. further investigation of the pharmacokinetics and pharmacodynamics of cefquinome in the cerebrospinal fluid is warranted to establish the optimum intravenous dose. the purpose of this study was to determine if enrofloxacin alters the pharmacokinetics of firocoxib in the horse. firocoxib is a coxibclass nonsteroidal anti-inflammatory drug (nsaid) approved for use in horses to control pain and inflammation associated with osteoarthritis. dosages of firocoxib are species dependent, with the recommended dose for horses being . mg/kg as an oral paste every h. the main elimination pathway of firocoxib is hepatic; however the effects of concurrent administration of drugs that may inhibit its metabolism have not been evaluated. enrofloxacin is a synthetic antibacterial agent from the flouroquinolone group developed for veterinary use. it is primarily used for gastrointestinal, urogenital, skin and respiratory tract infections in various animals. a well acknowledged problem associated with flouroquinolone usage is their effect on the metabolism of other drugs. co-administration of multiple drugs can result in unpredictable therapeutic outcomes. often it is either diminished therapeutic efficacy or increased toxicity of one or more of the administered drugs. various pharmacokinetic interactions between antimicrobials and nsaids have been described. six healthy, adult mares were administered . mg/kg of firocoxib orally. samples were collected by direct venipuncture of the jugular vein at (control), , , and min, , , , , , , , , and h after administration. after a day washout period the six horses were pretreated days with enrofloxacin mg/kg intravenously every h then on the fourth day given . mg/kg of firocoxib orally. samples were collected at (control), , , and min, , , , , , , , , and h after administration. all samples were stored at À c until analysis using a validated hplc method. the t / , c max , t max , auc - and auc -f after firocoxib administration were . angiotensin converting enzyme (ace) inhibitors improve survival and quality of life in humans and small animals with cardiovascular and renal disease. there is limited information regarding their effects in horses. the purpose of this study was to determine the pharmacokinetics of quinapril and its effects on ace inhibition in horses. six healthy horses were administered quinapril at mg iv, mg po or mg po in a -way crossover design. blood was collected at predetermined times for measurement of quinapril and quinaprilat concentrations using high pressure liquid chromatography, as well as ace concentrations using a radioenzymatic assay. normally distributed data were analyzed with one way repeated measures analysis of variance (rm-anova) and non-normally distributed data were analyzed using friedman rm_anova on ranks. significance was set at p o . . no adverse effects were observed during the study period. plasma quinapril concentrations were low and rapidly declined after iv administration. quinaprilat concentrations were below the limit of quantification ( . mg/ml). ace activity was significantly decreased from baseline at . and hour after iv dosing and at all timepoints after oral dosing. maximum % ace inhibition was , and % with the iv, high and low oral doses, respectively. these results suggest that, despite low plasma concentrations, quinapril has sufficient oral absorption and results in inhibition of ace in healthy horses. controlled studies in clinically affected horses are indicated. this study determined the pharmacokinetic profile of firocoxib in healthy neonatal foals. foals are more sensitive to the side effects of nsaid, primarily due to immature renal clearance mechanisms and ulcerogenic effects on gastric mucosa. firocoxib, a novel, second generation nsaid, is reported to have reduced side effects due to cox- selectivity. the pharmacokinetic profile of firocoxib in neonates has not been established. we hypothesized that firocoxib given po to neonatal foals would achieve therapeutic concentrations in plasma. seven healthy foals of mixed gender were administered . mg/kg firocoxib po q h for nine consecutive days, commencing at h old. blood was collected for firocoxib analysis at (dose # only), . , . , , , , , and h after doses # , and . for all other doses ( , , , , and ) blood was collected immediately prior to the next dose ( h trough). elimination samples were collected after dose # . plasma was stored at À c until analysis. physical examinations were performed on foals daily and body weight obtained every two days during the sampling period. analysis of plasma samples by liquid chromatography-mass spectrometry revealed firocoxib was rapidly absorbed. after the initial dose, a maximum plasma concentration was reached in min, minimal accumulation after repeat dosing occurred and steady state was obtained after approximately four doses. after the final dose, plasma drug concentration decreased in a linear manner with an estimated terminal t / of h. seventy-two hours after the final dose, firocoxib was not detectable (o ng/ml). erythrocytosis is reportedly a rare finding associated with hepatocellular carcinoma in horses. the purpose of this study was to determine the relative frequency of erythrocytosis and the clinicopathologic abnormalities and hepatic histopathology associated with erythrocytosis in horses with liver disease. ninety-seven horses aged ! year with clinicopathologic or clinical signs of liver disease, a complete blood count (cbc), and hepatic histopathology were included. information on cbc, biochemical variables, and hepatic histopathology was collected from records. data from horses with erythrocytosis (packed cell volume %) were compared to those without using the mann-whitney rank sum test with significance set at p o . . there were no differences between groups in white blood cell count, gamma-glutamyl transferase, sorbitol dehydrogenase, aspartate aminotransferase, and alkaline phosphatase activities, total protein, albumin, globulin, blood urea nitrogen, or glucose concentrations. fibrosis ( %), biliary hyperplasia ( %), inflammatory infiltrate ( %), megalocytosis ( %), degeneration ( %), necrosis ( %), cholestasis ( %), anisocytosis and anisokaryosis ( %), and lipidosis ( %) were observed in livers of horses with erythrocytosis. neoplasia ( %) was observed rarely. this study reports a high frequency of erythrocytosis in horses with liver disease. erythrocytosis is associated with higher total bilirubin and serum bile acids concentrations. common histopathologic changes include fibrosis, biliary hyperplasia, and inflammatory infiltrate. hepatic neoplasia was rare. this study was performed to determine if horses diagnosed with equine proliferative enteropathy (epe) from lawsonia intracellularis (li) infection had long term effects from disease based on their sale price as yearlings and race earnings. a retrospective review of medical records of thoroughbred horses that were treated for lawsonia intracellularis infection between january , and january , at hagyard equine medical institute in lexington, kentucky was performed. three criteria were used for inclusion in this study. first, each horse had presumptively been diagnosed with li based on physical examination findings such as ventral edema, diarrhea, lethargy, or poor body condition. second, horses had hypoalbuminemia of less than . mg/dl (normal reference range: . - . mg/dl). third, each horse had a positive fecal polymerase chain reaction (pcr) for li, a positive serum immunoperoxidase monolayer assay (ipma), or both. an ipma titer greater than or equal to was considered positive for disease. horses met the initial criteria. of the horses sold at public auction as yearlings. the sale price of these horses was compared to the average sale price of all yearlings by the same sire as the affected horse (control group). of the horses raced in the united states. their monetary earnings from racing were compared to the average monetary earnings of all progeny by the same sire as the affected horse (control group). earnings of horses that were between and years of age ( / horses) at the conclusion of the study were compared to the lifetime average earnings of the stallion's progeny. earnings from horses that were two years of age ( / ) at the end of the study were compared to the two year old average earnings of the stallion's progeny. monetary earnings from all races prior to december , were included in the study. horses both sold at public auction and raced. as well as being included in the total number of horses that sold and raced, their sale records and monetary earnings were compared to the averages from their respective sire as a separate group. this retrospective study indicated that yearling horses previously infected with li do not sell for as much at public auction as their herdmates, but their monetary earnings from racing are not significantly different from other horses. these results should assist practitioners in guiding owners in determing if treatment of horses with epe is appropriate and it may aid in reassuring owners that despite the poor condition of the horse during and shortly after the course of disease, horse may still have future athletic potential. this abstract was presented at the aaep in december . bronchopneumonia caused by streptococccus equi subsp. zooepidemicus (s. zooepidemicus) is one of the most important causes of morbidity in weanling foals. ceftiofur crystalline free acid (ccfa) is a long acting third-generation cephalosporin antimicrobial recently approved for the treatment of bronchopneumonia associated with s. zooepidemicus in adult horses. the objective of the present study was to determine the disposition of ccfa in plasma and pulmonary epithelial lining fluid (pelf) of weanling foals. six healthy -to month-old weanling foals were administered a single intramuscular injection of ccfa at a dose of . mg/kg of body weight. concentrations of desfuroylceftiofur acetamide (dca) and related metabolites were measured by use of ultra-high performance liquid chromatography and tandem mass spectrometry. following im administration, median time to maximum plasma and pelf concentrations was h ( - h) . mean (ae sd) peak dca concentration in plasma ( . ae . mg/ml) was significantly higher than that in pelf ( . ae . mg/ml). terminal half-life of dca in plasma ( . ae . h) was not significantly different from that of pelf ( . ae . h). time above the therapeutic target of . mg/ml was significantly longer in plasma ( ae h) than in pelf ( ae h). based on the results of the present study, intramuscular administration of ccfa at a dose of . mg/kg would be appropriate for the treatment of bronchopneumonia caused by s. zooepidemicus and other susceptible pathogens in weanling foals. fgf- is secreted by osteocytes and osteoblasts in response to hyperphosphatemia. fgf- enhances phosphaturia and is postulated to have a central role in the development of secondary renal hyperparathyroidism. hyperthyroid cats have elevated plasma phosphate and parathyroid hormone concentrations, which may in part be associated with underlying chronic kidney disease (ckd). the aim of this study was to determine if plasma fgf- concentrations were associated with the presence of underlying ckd in hyperthyroid cats, and to investigate the changes in plasma fgf- concentrations that occur following treatment of hth. hyperthyroid cats were recruited from two london-based first opinion practices between and . cats that were azotemic at diagnosis were excluded. hth was treated with anti-thyroid medication alone or in combination with thyroidectomy. cats were included in the study if they had a plasma total thyroxine concentration o nmol/l documented for a six month period following commencement of treatment. cats were classified as having azotemic ckd if they developed renal azotemia within six months of establishment of euthyroidism. otherwise cats were deemed to have normal renal function. stored edta plasma samples were assayed for fgf- using a recently validated elisa. the mann-whitney u test and the wilcoxon signed rank test were used to compare between the groups and assess the response to treatment respectively. results are reported as median [ th , th percentiles]. correlations were made using spearman's correlation coefficient. thirty one cats with hth ( azotemic and non-azotemic) were included in the study. plasma phosphate concentrations decreased following treatment in cats that did not develop azotemia ( . [ . , . ] mg/dl vs. . [ . , . ] mg/dl; n , p . ) whereas plasma phosphate concentrations did not change significantly following treatment in cats that did develop azotemia ( . [ . , . ] mg/ dl vs. . [ . , . ] mg/dl; n , p . ). plasma fgf- concentrations were significantly higher in cats that developed azotemia than cats that did not at both pre treatment ( . [ . , . ] pg/ml vs. . [ . , . ] pg/ml; p . ) and post treatment ( . [ . , . ] pg/ml vs. . [ . , . ] pg/ml; p . ) timepoints. plasma fgf- concentrations increased following treatment in both azotemic (p . ) and non-azotemic groups (p . ). plasma fgf- concentrations and plasma phosphate concentrations were not correlated at baseline (r s . , p . ) or following treatment (r s . , p . ). plasma fgf- concentrations were higher in pre-azotemic cats than non-azotemic cats and increased following treatment of hth. the reason that fgf- concentrations increased following treatment, particularly in the face of decreasing plasma phosphate concentrations in cats that remain non-azotemic, is unclear but may be related to the decline in glomerular filtration rate. hyperthyroidism is a disorder resulting from the excessive production and secretion of t and t by the thyroid gland. although the disorder and its pathological lesions have been well studied and described the cause remains illusive. whole blood and solid tissue samples from non-diseased, severe disease and mild disease cats based on t levels and thyroid histology were used in this study. whole blood samples from non-disease cats, severe disease cats and mild disease cats as well as solid thyroid tissue samples from non-disease cats, severe disease cats and mild disease cats were collected and processed. the resulting total rna samples were used for genechip analysis using our custom feline gene chip designed by affymetrix. data analysis was performed using the partek s gs software for gene expression data. the robust multichip average algorithm was used for background adjustment, normalization, and probe-level summarization of the raw data. anova analysis was performed to find significant differentially expressed genes with a minimal false discovery rate control of . and a fold change of . in each direction. during the mild disease state, pathways associated with dna damage and apoptosis are most prominent. at later stages when the histopathological disease is more severe in addition to the aforementioned pathways others associated with tgf-beta signaling, cell adhesion and extracellular matrix remodeling take more prominence. the analysis of this unique data set generated from the use of our proprietary genechip revealed molecular mechanisms that are associated with the transition from non-disease, to mild disease to severe disease, in the thyroid tissue as well as the blood. these mechanisms could provide insights into the causes of the disease and identify potential new therapeutic and diagnostic targets. although it is well established that concurrent chronic kidney disease (ckd) develops in about % of hyperthyroid cats, no one has reported the use of the iris staging system for ckd before and after treatment of these hyperthyroid cats. the purpose of this study was to compare the effects of treatment in hyperthyroid cats with known stage and ckd in order to determine the effects of restoring euthyroidism or inducing hypothyroidism has on the iris stage in these cats. we evaluated hyperthyroid cats (median age, years) in this study. one day prior to treatment, serum t concentration, serum chemistry analysis, complete urinalysis, and urine protein-to-creatinine ratio (upc) were measured. all cats were again evaluated with the same parameters again months after treatment with i. prior to treatment, ( %) of the cats had no evidence of azotemia (serum creatinine o . mg/dl), whereas cats ( %) had stage ckd (serum creatinine, . - . mg/dl). in the cats, iris staging revealed proteinuria in cats ( %), with borderline proteinuria (upc, . - . ) and with overt proteinuria (upc . ). hyperthyroidism was cured in all cats (median post-t , . mg/dl). all cats had a good response to treatment; there were no signs of ckd except for polyuria and polydipsia in some cats. a significant (p o . ) increase in median values for both serum urea nitrogen ( mg/dl to mg/dl)) and creatinine ( . to . mg/dl) occurred after treatment. nine of the cats ( . %) classified as nonazotemic or iris stage prior to i progressed to stage ckd after i. all cats with stage ckd before treatment remained azotemic after i, with cats remaining in stage ckd, and cats progressing to stage ckd (serum creatinine, . - . mg/dl). there was a significant inverse relationship (p . ) between pretreatment urine specific gravity (usg) and post-treatment serum creatinine in the cats. of the cats with post-treatment serum creatinine values . mg/dl (stage to ckd), ( %) had pretreatment usg of o . . in contrast, in the cats with post-treatment serum creatinine values o . mg/dl, only ( %) had pretreatment usg of o . . a significant (p o . ) decrease in median upc from . to . occurred after treatment, but there was no relationship between degree of proteinuria and iris stage in these cats. two cats developed iatrogenic hypothyroidism after i, diagnosed by finding low serum t and high ctsh concentrations. both hypothyroid cats had progressed from stage before treatment to stage and ckd, respectively, after i; after thyroxine replacement, serum creatinine decreased to near pretreatment concentrations in both cats. conclusions: ) iris stage ckd is common in untreated hyperthyroid cats. ) progression to next higher iris stage is common after treatment, but most cats with remain relatively asymptomatic for ckd. ) usg may be helpful in predicting which cat's iris stage will progress after i. ) iatrogenic hypothyroidism worsens azotemia, an effect that appears reversible with replacement therapy. home blood glucose monitoring (hbgm) of diabetic pets is likely to result in superior glycaemic control, minimizing episodes and impact of dangerous hypoglycaemia and reducing costs. nevertheless, it has proven difficult to objectively establish a clear benefit of hbgm using biological parameters (clinical signs, blood glucose, fructosamine). the current study aimed to assess the impact of hbgm on owner perceived quality of life (qol) aspects of diabetes mellitus (dm) treatment, using the recently validated psychometric tool diaqol-pet. owners of insulin treated diabetic cats were recruited to complete the -item tool, evaluating areas affecting the cat's and owner's qol, including: worry about pet's dm, hypoglycaemia, costs, owner's desire for autonomous control over the pet's dm, etc. item-weighted-impact-scores (iwis), reflecting frequency and importance ratings of each item, were calculated, as well as averageweighted-impact-scores (awis; average iwis of all items), as an overall measure of diabetes dependent qol. frequencies, iwis and awis were compared between owners practising hbgm and those who did not using mann whitney u test (significance p o . ). two hundred and eleven owners of insulin treated diabetic cats completed the diaqol-pet; owners practised hbgm, whereas the remaining did not practise any form of home monitoring (including urine glucose). iwis for 'excessive drinking' and 'owner wanting more control' were significantly different between the hbgm-group (mean /-standard deviation: À . /À . and À . /À . ) and the non-hbgm-group (À . /À . and À . /À . ). there was no significant difference between the groups with regards to the iwis for other items, including 'worry about hypoglycaemia' or 'worry about pet's dm'. polydipsia was reported significantly more frequently in the non-hbgm-group and this was the reason for the difference between groups in this item's iwis as it was considered of equal importance. frequency and iwis of reported occurrence of hypoglycaemia signs were not significantly different. awis for both groups was not significantly different (hbgm: À . /À . ; non-hbgm: À . /À . ). the current study suggests that hbgm is predominantly practised by owners who desire more autonomous control over their cat's dm. the frequency of polydipsia was lower in the hbgm-group perhaps suggesting superior control. however, hbgm did not detectably affect the impact of the majority of qol-items, nor the frequency of hypoglycaemic episodes. overall diabetes dependent qol of diabetic cat and owner, as measured per diaqol-pet, was unaffected by hbgm. these data argue for the use of hbgm in selected pet-owner combinations rather than as part of a practice's standard dm management protocol, although further studies are indicated. insulin resistance is associated with impaired activation of the insulin signaling pathway in peripheral tissues such as skeletal muscle, visceral and subcutaneous (sc) adipose tissue. high plasma glucose, fatty acid and endotoxin levels are three major causes of insulin resistance in feline and human obesity and in type diabetes mellitus. however, the mechanisms by which these factors influence insulin action are still unclear. therefore, our aim was to investigate the tissue-specific expression of crucial mediators of insulin action such as the insulin-receptor substrate (irs ), the serine/threonine protein kinase b (pkb/akt) and of the principal insulin-dependent glucose transporter protein (glut ) in feline models of hyperglycemia, hyperlipidemia and subacute endotoxemia. healthy cats were infused through the jugular vein with glucose (n ), lipids (n ) or lipopolysaccharide (lps; n ) for days to clamp their blood concentrations at the approximate level found in untreated feline diabetes (glucose: - mmol/l; triglycerides: - mmol/l) or to induce a systemic low-grade inflammation (lps; rectal temperature: . - . c), respectively. healthy control cats were infused with saline (n ). on day , specimens were collected from skeletal muscles, visceral and sc fat and processed for irs mrna expression, total and phosphorylated pkb/akt and glut protein expression. gene transcripts of irs were not different between the groups. compared to controls, skeletal muscle pkb/akt phosphorylation was % lower in cats infused with glucose (p o . ); lipid-infused cats showed a trend for a decrease in pkb/akt phosphorylation ( % lower than saline) and had decreased glut expression (p o . ) in muscle. total (p o . ) and phosphorylated (p o . ) pkb/akt protein expression were decreased in the sc adipose tissue of lps-infused cats compared to controls. in these cats, phosphorylation of pkb/akt protein was also decreased in visceral fat (p o . ). sustained hyperglycemia and, to a lesser extent, hyperlipidemia impaired insulin signaling and glucose transport pathways primarily in skeletal muscle; endotoxemia reduced insulin sensitivity mainly in adipose tissues. thus, the development of insulin resistance in response to hyperglycemia, hyperlipidemia or endotoxemia might be affected by tissue-specific mechanisms in cats. separately used, single photon emission computed tomography (spect) and computed tomography (ct) both lack sensitivity and are additionally hampered by a poor anatomical location capacity and a lack of specificity, respectively. these drawbacks suggest an interest in the fusion of images obtained by the techniques. the aim of this study is to test spect/ct fusion performance in dogs with insulinoma. inclusion criteria were: / a biological diagnosis of insulinoma; / an examination by high resolution ct scan and in-pentetreotide spect followed by spect/ct fusion; / a surgical or post mortem examination completed by histopathological analysis. spect examination showing abnormal foci and ct scan showing pancreas, lymph nodes (ln) or liver abnormalities were considered positive. in case of double positivity, presence (imp ) or absence (imp-) of superimposition of abnormal images was noted. ten dogs were included. in / dogs, superimposition of abnormalities couldn't be tested. ct scan detected abnormal images [ pancreatic nodules (pn), enlarged ln (eln)] while spect failed to show any abnormal uptake. both dogs became euglycemic after removal of pn and ln designed by ct scan. in / , all abnormal images were classified as imp [ pn, eln and diffuse hepatic infiltration (dhi)]. surgery performed on / resulted in euglycemia in ; dog remained hypoglycemic after partial removal of pn. pn localization and dhi were confirmed after necropsy in the th dog. in / dogs imp and imp-images were both recorded. in dog, a dhi was classified as imp but pn localization was imp-: localized in the left lobe by ct scan and in the corpus by spect, the latest localization being confirmed after necropsy. in the other dog pn localization was imp but a diffuse spect signal superimposing to the liver considered as normal on ct scan was noted. hepatic biopsy confirmed spect results. this study confirms an imperfect sensitivity of both ct scan and spect. it confirms that ct scan can be associated with unspecific abnormal images. subject to a confirmation on a larger cohort of dogs, it indicates that imp images provide specific detection and accurate localization of canine insulinomas' primary lesions and metastasis. the majority of dogs with primary hypoadrenocorticism (ph) reveal clinical and laboratory abnormalities of gluco-and mineralocorticoid deficiency. in some of them sodium and potassium levels are normal, a phenomenon currently called atypical addison's. it has been postulated that in those cases adrenal destruction is confined to the zona fasciculata/reticularis, resulting in isolated glucocorticoid deficiency. however, there are no histological studies confirming a normal zona glomerulosa and in most reported cases diagnosis was based solely on low post-acth cortisol levels. the aim of the study was to evaluate aldosterone (aldo) levels in dogs with ph with and without electrolyte abnormalities. seventy dogs with newly diagnosed ph were included. aldo concentrations (ria, coat-a-count s , siemens) were measured before and min after administration of mg synthetic acth (synacthen s , novartis) iv. results were compared to those of healthy dogs and dogs with diseases mimicking ph. to confirm that peak concentrations were not missed aldo was additionally measured , and min after acth in dogs ( with ph, with ph mimicking diseases). results were analysed by means of non-parametric statistical methods (p o . ). post-acth aldo was significantly lower in dogs with ph ( - pg/ml, median pg/ml) than in healthy dogs ( - pg/ml, median pg/ml) and in dogs with ph mimicking diseases ( - pg/ml, median pg/ml). low post-acth aldo was found in / dogs with ph, in / of them levels were below the detection limit of the assay. normal sodium and potassium levels were found in / dogs ( %), / dogs ( %) had hyponatremia and normal potassium, / dogs ( %) had hyponatremia and hyperkalemia. electrolyte abnormalities ranged from mild to severe. there was no correlation between post-acth aldo and sodium and a weak correlation between post-acth aldo and potassium (r À . ). aldo concentrations were not different , and min after acth. the results demonstrate that aldo levels are low in most dogs with ph independent of the degree of electrolyte abnormalities. this implicates that all three zones of the adrenal cortex are compromised and that there are mechanisms which allow maintenance of a normal electrolyte balance without aldo. definitive diagnosis of canine hypoadrenocorticism (ha) is based on inadequate cortisol secretion following adrenocorticotropic hormone (acth) administration. an abnormal serum sodium to potassium (na:k) ratio can be used to determine whether an acth stimulation test is warranted. the aim of this study was to examine the utility of combining the na:k ratio with white blood cell counts to determine whether an acth stimulation test is warranted. a retrospective review of medical records of dogs examined between and was performed. dogs diagnosed with ha and control dogs, in which a diagnosis of ha was excluded during the study period, were included. inclusion criteria for all dogs were hospitalization with intravenous fluid therapy, a complete blood count, and serum na and k measurements at the time of initial examination. dogs were included in the ha group if they also had pre and post acth stimulation serum cortisol concentrations . mg/dl. dogs were included in the control group if they had resting or post acth stimulation serum cortisol concentration . mg/dl. exclusion criteria were recent administration of glucocorticoids, prior treatment of hyperadrenocorticism, or serum cortisol concentration . mg/dl but . mg/dl. continuous variables were compared between groups using the mann-whitney u test. receiver operating characteristic (roc) curves were produced to assess the sensitivity and specificity of detecting ha with various cutoffs for each variable. data is presented with % confidence intervals (ci) and statistical significance was defined as p o . . the na:k ratio, neutrophil count and neutrophil:lymphocyte ratio were significantly lower in dogs with ha than in dogs without ha (p o . for each). lymphocyte and eosinophil counts were significantly higher in dogs with ha compared to dogs without ha (p o . for each). the areas under the curve by roc analysis were largest for na:k ratio ( . , ci: . - . ) and lymphocyte count ( . , ci: . - . ). a na:k ratio . was % sensitive (ci: - %) but only % specific (ci: - %) for detecting ha. a lymphocyte count ! . x cells/ml was % sensitive (ci: - %) and % specific (ci: - %). conversely a na:k ratio . was % sensitive (ci: - %) but % specific (ci: - %) and a lymphocyte count ! .  cells/ml was % sensitive (ci: - %) but % specific (ci: - %). a na:k ratio . was % sensitive (ci: - %) and % specific (ci: - %) for detection of ha and a lymphocyte count ! .  cells/ml was % sensitive (ci: - %) and % specific (ci: - %) for detection of ha. a combination of this na:k ratio ( . ) and lymphocyte count (! .  cells/ml) was % sensitive (ci: - %) and % specific (ci: - %) for detection of ha. these results indicate that the combination of lymphocyte count and na:k ratio results in a better screening test for ha than the use of the na:k ratio alone. pheochromocytoma is a malignant, catecholamine-producing, adrenomedullary tumor. clinical signs resulting from excessive catecholamine secretion are typically non-specific, making differentiation from other adrenal tumors a challenge. elevated plasma concentrations of the catecholamine breakdown products metanephrine (mn) and normetanephrine (nmn) are used to identify pheochromocytoma in humans. this study tested the hypothesis that plasma metanephrine concentrations are greater in dogs with pheochromocytoma than in dogs with other adrenal neoplasms, healthy dogs and dogs with non-adrenal illness. edta plasma was collected from healthy dogs and unwell, hospitalized dogs with non-adrenal illness, pheochromocytoma and cortical tumors between april and october . samples were stored at À c before measurement of free mn and nmn concentrations using high pressure liquid chromatography at the central laboratory for clinical chemistry at the university of groningen ( samples) or the mayo clinic, rochester, minnesota ( samples). kruskal-wallis tests followed by dunn's multiple comparison analysis were used to compare results between groups. significance was set at p o . . results are reported as median [range] . eight dogs with pheochromocytoma, healthy dogs, dogs with non-adrenal illness and dogs with cortical tumors were sampled. pheochromocytoma was diagnosed histologically ( dogs) or cytologically ( dog). cortical tumors were diagnosed histologically ( dogs) or by response to trilostane treatment after obtaining consistent endocrine test results ( dogs occult hyperadrenocorticism (hac) has been theorized to exist in which excess adrenal sex hormone secretion induces the clinical signs and laboratory changes associated with classic hac. however, the ability of sex hormones to cause such alterations has never been closely evaluated. if sex hormones can cause a syndrome similar to classic hac, they should be able to induce expression of classic glucocorticoid-induced genes. the purpose of the study was to determine if in vitro expression of the gene for corticosteroid-induced alp (cialp) could be induced by clinically relevant concentrations of cortisol and sex hormones believed to cause occult hac. canine hepatocytes were purchased from a commercial source (cellzdirect or invitro) in -well plates. upon arrival ( - plates per shipment), the cells were allowed to recover in general media per supplier recommendations. after hrs, media was changed to william's e media (-l-glutamine) containing concentrations of cortisol or sex hormones that have been documented in the literature in dogs with hac or with purported occult hac. each plate was treated with a different hormone (cortisol, -hydroxyprogesterone [ ohp], progesterone, estradiol or androstenedione), and each well contained a different concentration (starting with no hormone added as a negative control) to evaluate a dose response. media was changed daily. after days of hormone exposure, rna was extracted. reverse transcription was performed and the product used for quantitative pcr for cialp and beta-actin (roche lightcycler) using a gene-specific fluorescent probe for detection. standard curves were created for each gene. all samples and standards were run in duplicate. using the lightcycler software (vers . ), cialp expression was normalized to that of beta-actin. fold change in expression was determined relative to the negative control. each sex hormone was used to treat plates; one plate in each shipment was treated with cortisol as a positive control. for cortisol, a dose response was seen in expression of the cialp gene. compared to no cortisol, , , , , and nmol cortisol increased expression . , . , . . . , . and . fold, respectively. a -fold increase is considered significant (j.vandesompele et al genome biol ). expression of cialp was not significantly induced in response to any concentration of ohp ( nm maximum), progesterone ( nm maximum), estradiol (max pm maximum) or androstenedione ( nm maximum). we conclude that in vitro these sex hormones do not induce expression of the cialp gene which is classically induced by cortisol in vivo; indeed, elevated serum cialp activity is a hallmark of classic hac. thus, the ability of the sex hormones to induce the gene in vivo must be questioned and evaluated. measurement of sex hormones has been advocated as an adjunct means for diagnosing typical hyperadrenocorticism (hac), i.e. disease due to excess cortisol secretion, as well as for diagnosis of atypical hac, i.e. disease due to excess adrenal sex hormone secretion. however, measurements in either setting have not been widely studied. therefore, our objectives were: . to determine the sensitivity of -hydroxy-progesterone ( ohp) and estradiol concentrations pre-and post-acth for diagnosis of typical hac. . to determine the specificity of ohp and estradiol concentrations preand post-acth for diagnosis of occult hac. dogs that had pdh (n ), dogs that were suspected to have hac but proven not to (had non-adrenal illness [nai, n ]) or dogs that were healthy (n , used to establish reference ranges [rr]) were enrolled. acth stimulation tests were performed ( mcg/kg cosyntropin iv); blood samples were drawn pre and min post; ohp and estradiol were measured by previously validated radioimmunoassays. a kruskal-wallis rank sum test was used to compare values between the groups. significance was set at p o . . for basal and acth-stimulated ohp concentrations, the rr were determined to be . - . ng/ml (mean ae s.d.; range . - . ) and . - . ng/ml (range . - . ), respectively. in pdh dogs, and had basal and post-acth ohp concentrations above the rr, respectively; in the nai group, and dogs had concentrations above the rr, respectively. thus, the sensitivity of basal and post-acth ohp measurement for diagnosis of hac is % and %, respectively. specificity of diagnosis is % and %, respectively. post-acth ohp concentration was significantly different between groups. for basal and stimulated estradiol concentrations, the rr were determined to be - pg/ml (range - ) and - pg/ml (range - ), respectively. for both basal and stimulated estradiol, pdh dogs (n ) had concentrations above the rr; for those with nai (n ), and had concentrations above the rr, respectively. thus, the sensitivity of estradiol measurement for diagnosis of hac is % for both pre-and post-acth. specificity of estradiol for diagnosis for hac is % and % for pre-and post-acth, respectively. overall, dogs with nai had at least one elevated estradiol concentration (total specificity %). post-acth estradiol concentration was not significantly different between groups. we conclude that use of ohp and estradiol concentrations for diagnosis of hac can be problematic. sensitivity and specificity are relatively low, potentially leading to misdiagnoses. diabetes mellitus is one of the most common feline endocrinopathies and is considered to have a similar pathophysiological basis to human type diabetes. several studies have identified risk factors for development of diabetes mellitus in cats, which include age, obesity, inappropriate diet and physical inactivity. however, to date, no specific genetic risk factors have been identified. genome-wide association studies in humans have identified several genes that predispose to obesity and/or diabetes mellitus, one of which is the melanocortin receptor (mc r) gene. the aim of the current study was to identify polymorphisms (snps) in the feline mc r gene and to use these to perform a case:control study to determine whether these candidate gene snps were associated with diabetes mellitus in cats. genomic dna from cats ( domestic short hair [dsh], burmese) was initially analysed by pcr and direct sequencing using felmc r-specific primers, which identified a missense mutation (mc r:c. c t) in the region encoding the extracellular domain of the receptor protein in dsh cats only. one hundred and nineteen dsh cats were subsequently recruited into the case:control study. fifty nine cats were obese diabetic ( male, female), mean age . years (range - y); mean weight . kg (range . - kg). sixty lean cats were used as controls ( male, female), mean age . years (range - y), mean weight . kg (range . - . kg). the t to c base change alters a restriction site in the sequence recognized by the enzyme bstoi, such that dna from cats with the mutant (c) allele can be cut, whereas that from the wild-type (t) allele cannot. primers were designed that flanked the mutation to allow pcr amplification of this region of mc r from genomic dna obtained from edta blood. the pcr products were purified and subject to restriction fragment length polymorphism (rflp) analysis. bstoi digestion products were then analysed by agarose gel electrophoresis. of the diabetic cats, ( %) were homozygous for the mutation (cc), compared to ( %) of control cats. statistical analysis (two tailed fisher's square test) revealed that this difference between groups was statistically significant (p . ). in conclusion, this pilot study has identified a missense mutation in the coding sequence of mc r. this could be an important predisposing factor for development of diabetes and/or obesity in dsh cats. polymorphisms in a similar region of human mc r predispose to obesity, which in turn is a major risk factor for type diabetes. hyperadrenocorticism (hac) is one of the most common endocrine disorders of dogs. the two most effective medical treatments are trilostane (vetoryl s ) and mitotane (lysodren s ). previous studies evaluating the effect of treatment on aldosterone secretion measured the hormone at min post-acth administration. however, the optimal sampling time would be at the time of maximal secretion, which occurs minutes after the mg/kg dose commonly used for the test (carlson et al, jvim, ). thus, the true effect of either medication on aldosterone secretory capacity is unknown. our objectives were: ) to assess and compare the effect of treatment with trilostane and mitotane in dogs with pituitarydependent hac (pdh) on aldosterone secretory reserve at min post-acth stimulation and ) to determine if changes in aldosterone concentration at that time correlate with changes in serum sodium and potassium concentrations. forty-six dogs being treated for pdh with either mitotane (n ) or trilostane (n ) have been enrolled. the dogs could be treated for any length of time. all had acth stimulation tests performed ( mcg/kg cosyntropin iv); blood samples were drawn before and at and min post-acth for monitoring of cortisol and aldosterone concentration using previously validated radioimmunoassays. ten historical normal controls were also included. serum sodium and potassium concentrations were measured in the basal samples. a kruskal-wallis rank sum test was used to compare values between normal dogs and those treated with mitotane or trilostane. linear regression analysis was used to determine if a correlation existed between electrolyte and aldosterone concentrations or between cortisol and aldosterone concentrations. significance was set at the p o . level. acth-stimulated aldosterone concentrations in mitotane-treated but not trilostane-treated dogs were significantly lower than that in normal dogs at both the and min time points. no difference was detected between aldosterone concentrations at and min after acth injection in either treatment group. a positive correlation existed between the -min cortisol and -min aldosterone concentrations in the trilostane-treated group (r . ), i.e. the peak post-acth concentration for each hormone, but not in dogs treated with mitotane. basal serum sodium and potassium concentrations were not correlated with the basal aldosterone concentration in either treatment group. in conclusion, treatment with mitotane resulted in decreased aldosterone secretory reserve, but this did not correlate with hyperkalemia or hyponatremia. measurement of aldosterone concentrations is not predictive of electrolyte concentrations. previously presented at the auburn university phi zeta research emphasis day, november , . antioxidant depletion is documented in humans with hyperthyroidism, and is reversible with treatment. in addition, antioxidant depletion has been shown to increase the risk of methimazole toxicity in rats. the primary aim of this study was to determine whether deficiencies in glutathione (gsh), ascorbate (aa), or vitamin e, along with increases in urinary -isoprostanes, were present in hyperthyroid cats, and were reversible after radioiodine treatment. a secondary aim was to determine whether antioxidant abnormalities were associated with a prior history of methimazole toxicity. ongoing prospective, controlled, observational study. otherwise healthy client-owned hyperthyroid cats presenting for radioiodine therapy (n to date) and healthy age-matched controls (n to date) were recruited. all cats were screened with cbc, biochemical panel, urinalysis, and t , as well as red blood cell (rbc) gsh, plasma aa, plasma vitamin e, and urinary -isoprostanes. hyperthyroid cats were re-evaluated months after radioiodine treatment. unlike in humans, median blood antioxidants were not significantly different in hyperthyroid cats (gsh . mm; aa . mm, and vitamin e, g/ml) compared to controls (gsh . mm; aa . mm, and vitamin e, g/ml). results for urinary isoprostanes are pending, and associations with methimazole toxicity will be investigated after full recruitment. rbc gsh concentrations did increase significantly (to . mm; p . ) after radioiodine treatment. however, this modest change is unlikely to be clinically significant. preliminary data do not indicate clinically significant blood gsh, ascorbate, or vitamin e deficiencies in hyperthyroid cats. with appropriate insulin therapy and a low carbohydrate diet, up to % of newly diagnosed diabetic cats are eventually able to maintain euglycemia without insulin administration, and these cats are considered to have achieved remission. there are currently no published data reporting the glucose tolerance status of cats classified as being in remission, and it is unknown whether these cats are truly in diabetic remission, or should be classified as non-insulin dependent diabetics, or having impaired glucose tolerance, and/or impaired fasting blood glucose. the aim of this study was to determine fasting blood glucose concentrations and glucose tolerance status of cats in remission. the study was a prospective study in a feline-only clinic. for inclusion, diabetic cats had to have achieved remission through insulin therapy, and insulin withheld for a minimum of two weeks. five diabetic cats in remission and five matched non-diabetic cats were enrolled in the study. blood samples were obtained via the ear vein but where the cat's temperament precluded this, from the jugular.glucose concentration was measured using a meter calibrated for feline blood (abbott alphatrak). a simplified glucose tolerance test was performed after food was withheld for hours. a g catheter was placed in a cephalic vein three hours before the gtt was commenced, to minimize the effects of stress on blood glucose concentration. blood glucose concentration was measured at time and then a g/kg dose of glucose was administered slowly via the intravenous catheter. further blood glucose measurements were made at hours and then hourly until glucose had returned to o mg/dl (o . mmol/l). in the control group, all cats had a fasting blood glucose below mg/dl, and following glucose administration, glucose had returned to o mg/dl by hours. fasting blood glucose in the remission group was o mg/dl ( mmol/l) in all cats except one, which had fasting blood glucose of mg/dl ( . mmol/l). following glucose administration, all five cats in remission had blood glucose above mg/dl ( . mmol/l) at three hours, four were o mg/dl at four hours, and one returned to o mg/dl at five hours. the cat with impaired fasting glucose subsequently became diabetic after steroid administration. the results of this study show that these cats, while no longer diabetic, have mildly impaired glucose tolerance compared to nondiabetic cats, and a minority have impaired fasting glucose. the objective of this study was to determine the role of iodine restriction in the nutritional management of cats with naturally occurring hyperthyroidism. five domestic shorthair cats ranging in age from - years were confirmed to have hyperthyroidism based on persistently increased serum total thyroxine concentrations (tt ), palpable thyroid nodule and weight loss. serum tt concentrations ranged from - nmol/l (reference range - nmol/l). the cats were then fed a low iodine containing food ( . ppm iodine dmb, as measured by epiboron neutron atomic activation). serum tt concentrations were measured every weeks. biochemistry parameters were also evaluated at weeks , and . at weeks, serum tt concentrations had decreased in all cats with of cats ( %) being euthyroid (mean nmol/l; range - nmol/l). the remaining hyperthyroid cat had an initial serum tt of nmol/l, which decreased to nmol/l after being fed the iodine-restricted food. mean decrease in tt for all cats was nmol/l (range - nmol/l). renal parameters remained stable in all cats. these cats along with additional newly diagnosed hyperthyroid cats were transitioned to a similar food that contained less iodine ( . ppm dmb). baseline serum tt concentrations in the new cats ranged from - nmol/l. serum tt and other biochemical parameters were monitored every weeks for weeks, and then every weeks for an additional weeks. with the . ppm iodine food the four new cats became euthyroid with a mean tt concentration of nmol/ (range - nmol/l). the euthyroid cats from the earlier feeding study had a further decrease in tt concentration (mean tt nmol/l, range - nmol/l). the single non-euthyroid cat from the first study had a serum tt concentration of nmol/l, a decrease from the baseline concentration of nmol/l. the average decrease in serum tt for all cats was nmol/l (range - nmol/l). finally, of the cats were fed a third iodine-restricted food ( . ppm dmb) along with one other newly diagnosed hyperthyroid cat ( nmol/l serum tt ) and evaluated every weeks. all cats in this evaluation were euthyroid (mean tt nmol/l; range - nmol/ l). this result included the cat whose serum tt remained in the hyperthyroid range in the first two evaluations. the average decrease in tt was nmol/l (range - nmol/l). biochemical features of renal function remained stable and no other biochemical abnormalities were observed. in summary, the results of these three feeding studies demonstrate that feline hyperthyroidism can be managed effectively with dietary iodine restriction. we have shown previously that restriction of dietary iodine (i) is a safe and effective method for decreasing serum thyroxine concentrations (tt ) in cats with hyperthyroidism. the objective of this study was to determine the maximum level of iodine in a nutritionally balanced feline mature adult food required to maintain normal serum tt concentrations in hyperthyroid cats currently being controlled on a food containing . ppm i (dmb) as measured by epiboron neutron atomic activation. all cats were previously diagnosed at least months prior to the start of the study and their tt concentrations were maintained in the normal range by dietary iodine restriction for a minimum of months (range months- years). serum tt concentrations ranged from - nmol/l (reference range - nmol/l) at the beginning of the study. the cats were divided into two groups each containing cats. groups were similar in age and gender distribution (mean age . years, range - years). one group (group a) was placed on a food that was formulated for mature adult cats containing . ppm i (dmb). the other group (group b) was placed on a similar food that differed only in that it contained . ppm i (dmb). blood was collected from all cats every three weeks and analyzed for serum tt concentration. biochemistry parameters were also evaluated at weeks , and . all group a cats exhibited increases in serum tt concentration (mean increase of nmol/l above baseline, range - nmol/l). seven of the cats remained in the euthyroid range (mean serum tt nmol/l, range- - nmol/l). two cats exceeded the upper limit of the reference range ( and nmol/l respectively). the cats in group b also exhibited increases in serum tt concentration but to a greater degree than the cats in group a (mean increase nmol/l, range - nmol/l). four cats remained in the euthyroid range (mean serum tt , range - nmol/l). the five remaining cats all exceeded the upper limit of the reference range (mean serum tt nmol/l, range- - nmol/l). all cats returned to a euthyroid state within month of being returned to a diet containing . ppm i (dmb). it was determined that serum tt concentrations are not ideally controlled in the normal range in hyperthyroid cats fed a food containing ! . ppm i (dmb). hyperthyroidism is a common disease in old cats. excessive production of thyroid hormones is the hallmark of the disease. three main treatments for feline hyperthyroidism include radioactive iodine, thyroidectomy, and antithyroid drugs such as methimazole. previously we have shown that limiting dietary iodine to or below . ppm induces euthyroidism in cats with hyperthyroidism compared with a similar diet containing . ppm iodine. the objective of this study was to test whether dietary iodine at . ppm would induce euthyroidism in cats with naturally occurring hyperthyroidism. fourteen cats with hyperthyroidism confirmed by serum tt and ft measurements were stratified into two groups based on gender and age. one group (control: males and females, age ranged from to years) was given a positive control dry cat food ( . ppm iodine) while the other group (test: males and females, age ranged from to years) was fed a commercial dry cat food ( . ppm iodine) for at least weeks before the study. afterwards (week ), the control cats continued to receive the same food while cats in the test group were given a test food ( . ppm iodine) for additional weeks. all cats had free access to their food and deionized water during the study. blood samples were collected during weeks , , , and of the study. the control cats maintained euthyroidism during the study. the test food significantly reduced serum tt ( ae , ae à , ae à , ae à nmol/l in weeks , , and , respectively; à : p o . compared with week , dunnett's t test). it also significantly reduced ft at the end of the study ( ae vs. ae pmol, week vs. week ; dunnett's t test, p o . ). serum ft was within the reference range ( - pmol/l) in cats in both groups. serum tt , ft , and tsh were not affected by the test food and were within the reference ranges (tt : . - . nmol/l, ft : . - pmol/l, and tsh: - mu/l) in cats of both groups during the study. this study demonstrates that dietary iodine at or below . ppm provides an effective and inexpensive therapy for cats with naturally occurring hyperthyroidism. radioactive iodine ( i) is a widely used treatment for feline hyperthyroidism. prior to i administration, many cats receive methimazole therapy. it has been suggested that recent withdrawal of methimazole prior to i may increase the risk of hypothyroidism, inhibit the response to therapy, or have no effect. to further address this question, a retrospective medical records search was performed to identify hyperthyroid cats that received i therapy after methimazole treatment. inclusion criteria included documentation of the time interval between discontinuation of methimazole and i administration, and measurement of thyroxine (t ) at - days after i. cats were divided into groups: those receiving i within day of stopping methimazole, and those receiving i treatment or more days after stopping methimazole. sixty cats met the inclusion criteria. forty received i within day of stopping methimazole. of those, ( %) had a low t (o . mcg/dl), ( . %) had a normal t ( . - . mcg/dl), and ( . %) had an elevated t ( . mcg/dl) at - days after i therapy. fourteen cats received i or more days after stopping methimazole: ( %) had a low t , ( %) had a normal t , and ( %) had an elevated t at - days after i therapy. the results were compared with a fisher's exact test and there was no difference between the groups (p . ). these findings indicate that stopping methimazole therapy within day of i therapy does not inhibit the response to therapy. pharmacokinetic studies evaluating synthetic insulin analogs such as glargine necessitate the ability to measure the blood concentrations of glargine without cross-reactivity to endogenous insulin. although the cross-reactivity between endogenous human insulin assays and synthetic analogs is often known for commerciallyavailable assays, the degree of cross-reactivity of human insulin assays with feline insulin is not. the purpose of this study was to evaluate the cross-reactivity of feline insulin with a commerciallyavailable human insulin elisa with known cross reactivity to several synthetic analogs. pre-and post-prandial blood samples were collected from four healthy cats immediately prior to and approximately minutes following a meal, for a total of samples. dextrose was added to the meals given to two of the cats. blood samples were immediately centrifuged and the serum was collected, aliquoted, and stored at À c until analysis. serum insulin levels were determined in parallel with commercially-available feline insulin and human insulin elisas. the elisas were run in duplicate and according to the manufacturer's instructions. concentrations of serum insulin measured by the feline insulin elisa ranged from . ng/l to ng/l. despite the wide range of concentrations of feline insulin, all samples evaluated with the human insulin elisa yielded absorbance readings equal to or lower than the absorbance of the negative control, indicating no crossreactivity between the evaluated human insulin assay and feline insulin. since this assay is reported to cross-react significantly with glargine, it is a great candidate for determination of serum glargine concentrations in cats. the aim of this prospective, controlled study was to compare the efficacy of two trilostane protocols for treatment of canine pituitary-dependent hyperadrenocorticism (pdh). among the client-owned dogs diagnosed with pdh, only the dogs weighing o kg were selected (n ). group a (n ; low-dose treatment group) and group b (n ; high-dose treatment group) received . ae . mg of trilostane/kg orally every hours and mg of trilostane/ body orally every hours, respectively. all of the dogs were reassessed at , , , and weeks after the initiation of treatment. the improvement in post-acth stimulation serum cortisol concentration, as well as clinical signs in group a, required more time than group b; however, of dogs in group b had clinical signs and abnormal laboratory findings consistent with hypoadrenocorticism after treatment for weeks. twenty-four weeks later, all of the dogs of both groups improved the abnormal clinical findings. the present study suggests that twice daily, low-dose administration of trilostane is effective in the management of canine pdh and may be safe without the potential adverse effects of once daily, high-dose treatment. however, because this study involved only a small number of dogs, a population-based control study will be needed to clarify the efficacy of low-compared to high-dose trilostane treatment. cobalamin is essential for a variety of metabolic processes in many tissues and organs, and has effects on cell growth and peripheral and central nervous system function. chronic distal small intestinal disease in humans, cats, and dogs has been shown to cause cobalamin deficiency. an immunoassay for the measurement of serum cobalamin concentration in these species is being used in routine practice for the diagnosis of cobalamin deficiency. in pigs, the role of cobalamin has not yet been extensively investigated. thus, the aim of this study was to analytically validate an immunoassay, labeled for use in humans, for the measurement of cobalamin in porcine serum samples and secondly to determine serum cobalamin concentrations in weaned pigs. for the analytical validation of the assay, serum cobalamin concentrations were measured using the commercially available immulite s cobalamin immunoassay (siemens healthcare diagnostics ltd., deerfield, il, usa) in surplus porcine serum samples from a variety of studies. validation of the assay consisted of determination of dilutional parallelism, spiking recovery, and intra-and inter-assay variability. additional surplus serum samples from piglets from four litters at a texas a&m university farm were obtained. each piglet had been bled twice, the first at weaning ( days of age) and the second one days later. to investigate results in comparison between age groups, serum cobalamin concentrations were compared using a wilcoxon matched pairs test. significance was set at p o . . observed to expected ratios (o/e) for serial dilutions ranged from . to . % (mean ae sd: . ae . %) for four different serum samples at dilutions of : , : , and : , and from . to . % (mean ae sd: . ae . %) for one serum sample at dilutions of : , : , and : . o/e for spiking recovery ranged from . to . % (mean ae sd: . ae . %) for five different porcine serum samples that had been spiked with each other in a : dilution. intraassay coefficients of variation (%cv) for five different serum samples were . , . , . , . , and . %. inter-assay %cvs for five different serum samples were . , . , . , . , and . %. serum cobalamin concentration was significantly lower in piglets post weaning (median: ng/l) compared to those at the time of weaning (median: ng/l; p . ). the immulite s cobalamin immunoassay labeled for use in humans is linear, accurate, precise, and reproducible for measurement of serum cobalamin concentrations in pigs. this study also showed that piglets that differ in age by only days have significantly different serum cobalamin concentrations. further investigations of cobalamin concentrations in both sows and piglets at different stages of weaning are warranted. primigravid dairy heifers can be infected with mastitis pathogens during the periparturient period. the prevalence of intramammary infection (imi) ranges from - % of quarters pre-partum and - % at parturition. some pre-partum infections self-cure before parturition, however a number of these imis persist into early lactation. these imis may impact milk production and quality and may serve as a reservoir for contagious pathogens. no study has specifically investigated the risk of an imi persisting from the prepartum period into early lactation. the objectives of this study were to describe the prevalence of mastitis pathogens in heifers on a grazing dairy before and after parturition and calculate the relative risk (rr) and attributable fraction of population (afp) for the association between a post-partum and pre-partum imi. two-hundred-ninety-four heifers were systematically assigned to of groups: g ) pre-partum secretions from all mammary quarters (n ), g ) no pre-partum secretions collected (n ) and g ) pre-partum secretions from two diagonal quarters (n ). group assignments were designed to assess whether pre-partum sampling increased the likelihood of imi at calving. mammary quarter secretions were collected for bacterial culture approximately weeks prior to expected calving date. quarter milk samples were collected for bacterial culture once weekly during the st -weeks of lactation. bacterial isolates were classified as staphylococci, non-agalactiae streptococci and gram-negatives. mammary quarter samples yielding different bacteria were classified as mixed infections and those yielding ! bacterial types were classified as contaminated. bacterial isolates were speciated using gene sequencing methods and strain-typed using pulse-field-gel-electrophorysis to evaluate the relatedness of bacteria isolated from pre-and post-partum samples from the same mammary quarter. relative risk and afp were calculated using  tables. forty-five percent of mammary quarters had a pre-partum imi. during the st weeks of lactation the mean prevalence of imi was . % of quarters. staphylococci were most frequently isolated bacteria from pre-partum secretions and milk with s. chromogenes and s. aureus being the most common species. using data from mammary quarters, the rr and afp for the association between a post-partum and pre-partum imi were and %, and %, and and % for all staphylococci, s. aureus only and cns only imis, respectively. mammary quarters sampled pre-partum were no more likely to have a post-partum imi than those not sampled (chisquare, p ! . ). these data demonstrate that pre-partum imis persist into early lactation and that pre-partum secretion cultures may be a useful, not only in predicting imi at calving, but also in assessing risk of introducing new contagious mastitis pathogens, e.g., s. aureus, into the lactating herd. despite concerns about antimicrobial resistance and clostridium difficile in food animals, there has been little study of the prevalence or mechanisms of resistance. this study evaluated the impact of tetracycline treatment on c. difficile shedding in veal calves and the impact on resistance. calves arriving on veal farm received oral oxytetracycline for days as per farm protocols. calves were sampled at arrival and days later. selective culture for c. difficile was performed. isolates were ribotyped, and tested for tetracycline susceptibility and the presence of tetracycline resistance genes. multivariable logistic regression models were used to determine the relationship between tetracycline resistance and the presence of tetracycline resistance genes. clostridium difficile was isolated from % ( / ) and % ( / ) calves, at the first and second samples, respectively. the percentage of tetracycline resistant isolates increased from % to %. isolates from the second sample were times more likely to be tetracycline resistant (p . ) and times more likely to possess tet(m) (p . ). tet(m) was detected in % ( / ) and % ( / ), tet(o) in % ( / ) and % ( / ) and tet(w) in % ( / ) and % ( / ) of isolates from first and second samples, respectively. tet(l), tet(k) and tet(s) were not detected. resistant isolates were not carrying any of the genes investigated. routine tetracycline use may have had an impact on both the prevalence of c. difficile, as well as the strain distribution and resistance patterns. this is the first report of presence of tet ( the objectives of this study were to ) estimate the prevalence of antimicrobial resistance in the study population and ) to investigate the associations between exposures to antimicrobial drugs and antimicrobial resistance in fecal non-type specific e. coli (ntsec) recovered from individual feedlot cattle. two-stage random sampling was used to identify cattle for enrollment at western canadian feedlots. a fecal sample was collected per rectum from each individual at arrival and in the middle of the feeding period when cattle were rehandled as part of standard feedlot protocol. from samples collected at this second time point, a total of , ntsec isolates were tested for susceptibility to antimicrobial drugs by disk diffusion. parenteral and in-feed exposures to antimicrobial drugs were recorded for each individual enrolled in the study. the least square means estimates and % confidence intervals for the prevalence of resistance at each time point were modeled using poisson regression. multivariable logistic regression was used to investigate associations between antimicrobial resistance and exposure to antimicrobial drugs. regression models were adjusted for clustering of observations among individuals and pens. the most common resistances identified in arrival samples were sulfisoxazole ( . %; %ci: . - . ), streptomycin ( . %; %ci: . - . ) and tetracycline ( . %; %ci: . - . ). at the second sampling point, resistance prevalence was . % ( %ci: . - . ) for sulfisoxazole, . % ( %ci: . - . ) for streptomycin, and . % ( %ci: . - . ) for tetracycline. logistic regression modeling identified weak associations of exposures to tetracycline and macrolide classes of drugs with antimicrobial resistance at the second time point. abstract fa- premature/dysmature syndrome in cria: a ret-rospective study of cases ( ) ( ) ( ) ( ) ( ) ( ) ( ) . c. gerspach, d. anderson. the ohio state university, columbus oh. prematurity is widely acknowledged as risk factor for subsequent morbidity and mortality in llama and alpaca cria. a review of medical records for premature cria alive at the time of admission to the veterinary teaching hospital between and was performed to determine risk factors of prematurity and to report the outcome and related conditions or diseases in affected cria. medical records for premature or dysmature cria were included in this study. of these cria, were alpaca and llama, were female and were male. reasons for referral were prematurity, failure of passive immunity, dyspnoea, weakness and failure to gain weight. cria were presented at a mean age of . days and were premature by a mean estimated time of . days. overall survival rate was . %, with all llama cria surviving. a multivariate logistic regression model was used to identify risk factors associated with not surviving. cria receiving camelid colostrum had a significant better outcome than cria receiving no colostrum or colostrum from different species. dyspnea and tachypnea was associated with a poor outcome. all cria that were able to nurse, without assistance prior to referral, survived. clinical pathology parameters most commonly associated with death were hyperphosphatemia and acidosis. enrofloxacin is approved for the treatment of swine respiratory disease, however there are no published studies describing the pharmacokinetics of enrofloxacin at the approved dose and route in pigs ( . mg/kg subcutaneously). furthermore no studies have assessed the unbound concentrations of enrofloxacin at its site of action, the extracellular tissue fluid. therefore the objective of this study was to use an in-vivo ultrafiltration method to measure the active fraction of enrofloxacin, and the metabolite ciprofloxacin, at tissue sites relevant to pigs, and to compare these concentrations with plasma concentrations collected at similar time points. six healthy pigs were used in this study. pigs were recently weaned and weighed an average . kg. on the day before the experiment, pigs were anesthetized for the placement of jugular vein sampling catheters and interstitial fluid collection probes. three ultrafiltration probes were placed in each pig in a subcutaneous site near the right shoulder, an intramuscular site along the epaxial muscles, and in the pleural space of the chest cavity. each pig received an injection of enrofloxacin (baytril , bayer animal health) at a dose of . mg/ kg subcutaneously behind the left ear. plasma and interstitial fluid samples were collected at pre-determined time points, and enrofloxacin and ciprofloxacin concentrations were measured using hplc with fluorescence detection. protein binding was determined with a microcentrifugation system. pharmacokinetic data was analyzed using a one compartment model. the analysis of plasma and isf showed that only a small fraction of ciprofloxacin was produced in these pigs, therefore ciprofloxacin concentrations were not used in pharmacokinetic measurements. the plasma half-life (t / ), volume of distribution, clearance, and peak concentration (c max ) for enrofloxacin was . hr (ae . ), . l/kg (ae . ), . l/kg/hr (ae . ), and . mg/ml (ae . ), respectively. the concentrations from each of three tissues were not different in each pig. when pharmacokinetic values from all tissues were combined for the isf, the t / was . hr (ae . ) and the c max was . mg/ml (ae . ). the enrofloxacin plasma protein binding was . % (ae . ) and . % (ae . ) at a high and low concentration, respectively. this study has demonstrated that the concentration of biologically active enrofloxacin in tissues exceeds the concentration predicted by the unbound fraction of enrofloxacin in pig plasma. the half-life of enrofloxacin is longer in tissues and plasma than has been reported in previous studies. the high tissue concentrations and long half-life produce an auc/mic ratio sufficient for the pathogens that cause respiratory infections in pigs. ceftiofur crystalline free acid (ccfa), a long-acting ceftiofur formulation labeled for use in cattle, pigs, and horses for treatment of respiratory disease has been used for treatment of ovine respiratory infections in clinical practice. pharmacokinetic data, however, do not exist for ccfa administered subcutaneously in sheep. the present pharmacokinetic study evaluated the single dose subcutaneous administration of ccfa in sheep (n ) at . mg/kg body weight. concentrations of ceftiofur free acid equivalents (cfae) in plasma were measured by high performance liquid chromatography for days following drug administration. pharmacokinetics of subcutaneous ccfa in sheep were best described using a single compartment model with the following average (ae sd) parameters: area under the concentration time curve ! ( . hÃug/ml ae . ), observed maximum plasma concentration ( . ug/ ml ae . ), and observed time of maximum plasma concentration ( . h ae . ). no significant adverse drug reactions were observed. adequate cfae plasma concentrations were attained to effectively treat respiratory tract pathogens associated with pneumonia in sheep. the purpose of this study was to assess, using thoracic ultrasonography, the prevalence of lung lesions in pre-weaned dairy calves. subsequent aims were to describe ultrasonographic changes within the lung, clinical respiratory score, and treatment of respiratory disease. a longitudinal study was performed using female dairy calves from commercial dairy farms in new york state. calves were enrolled based on age. thoracic ultrasound and clinical respiratory scoring were performed on each calf at time points. a standard mhz linear ultrasound probe was utilized to evaluate intercostal spaces through of each hemi-thorax with the calf in lateral recumbency (us ) or standing (us ). lesion appearance, size, and location were recorded. respiratory score (rs) was assigned based on a previously published protocol incorporating fever, nasal discharge, cough, ocular discharge and ear droop, with a higher numerical score corresponding to more severe disease. abnormal lung on ultrasound was defined as one or more areas of ! cm width or depth of non-aerated lung. farm records were evaluated to identify treated calves. calves were treated for respiratory disease at the farm manager's discretion, not based upon ultrasound findings or rs. non-parametric methods were used to evaluate the data. ninety-one calves were enrolled into the study, with lost to follow-up. an average of minutes was spent performing the rs and ultrasound on each calf. the median ages at first (us ) and second (us ) examination were (interquartile range - ) and (interquartile range - ) days, respectively. the majority of calves had a low rs (o ) and only . % of calves had a rs high enough to warrant treatment based on previous recommendations (rs! ). the prevalence of calves that had abnormal lungs on ultrasound but a low rs (o ) was . % (us ) and . % (us ). the prevalence of calves that had abnormal lungs on ultrasound and a high rs (! ) was % (us ) and . % (us ). of the calves that had abnormal lungs on ultrasound but a low rs, % were treated with antimicrobials within days of examination. none of the calves with high rs and abnormal lungs on ultrasound were treated with antibiotics within days of examination. this study demonstrates a high prevalence of abnormal lungs, as detected by thoracic ultrasonography, without significant clinical signs in pre-weaned dairy calves. the relatively low treatment rate in these calves may suggest an area of opportunity for improvement in calf health, welfare, and herd longevity. further studies and follow up are needed to elucidate the significance of these findings and whether or not treatment is indicated. literature regarding diseases causing lameness in beef cattle is limited. this retrospective study was undertaken to examine beef cattle presented for lameness. medical records of beef cattle having a lameness examination done during the period to were reviewed and descriptive statistics generated. lameness was classified based on clinical diagnosis. the medical records of beef cattle were reviewed of which . % were male and . % were female. beef cattle presented for lameness most often during the summer months ( %) and least during autumn ( %). causes of lameness were categorized as infectious ( . %) or non-infectious ( . %) and infectious lameness subcategorized as either a primary disorder or a secondary infection. all cases of a primary infectious disorder were interdigital phlegmon. secondary infections diseases included sole abscess ( . %), septic arthritis ( . %), tenosynovitis ( . %), and pedal osteitis ( . %). non-infectious lameness included proximal limb lameness ( . %), foot trauma ( . %), hoof horn cracks ( . %), hoof defects ( . %), interdigital fibromas ( . %), overgrown hooves ( . %), sole bruise ( . %), subclinical laminitis ( . %), white line disease ( . %), osteoarthritis ( . %), heel erosion ( . %), sole ulcers ( . %), and sole hemorrhage ( . %). the most frequently affected claw was the lateral digit of the hind limb ( . %), followed by the medial digit of the front limb ( . %), lateral digit of the front limb ( . %), and the medial digit of the hind limb ( . %). the findings of this study suggest significant differences in the frequency of disease causing lameness in beef cattle compared to published reports for dairy cattle. in people, endoscopic ultrasound (eus) has become the technique of choice for assessing pancreatic disease and eus-guided fineneedle aspiration (eus fna) has proven a useful and safe modality for characterizing pancreatic lesions. reported complications include infections, bleeding and acute pancreatitis. in dogs, laparoscopic-assisted pancreatic biopsy has been suggested to be a safe procedure, however eus and eus fna have not been evaluated in dogs so far. thus the aim of the present study was to assess the practicability and safety of eus examination of the abdominal cavity as well as pancreatic eus fna in healthy dogs. this study was approved by the cantonal committee for the authorization of animal experimentation, zurich, switzerland. the study population consisted of healthy beagle dogs with a median bodyweight of . kg ( . - . ). eus was performed with an olympus gf-uc p-echoendoscope and fna were performed using g needles (cook echotipultra). after completion of the eus-examination of the abdominal cavity from the stomach (liver, gallbladder, bile ducts, kidneys, adrenals, pancreas), the scope was advanced into the duodenum and eus fna of the pancreas was performed. fna tissue acquisition was made applying negative pressure and to needle passes were made. all dogs received mg/kg metimazole im after eus fna and were re-checked ultrasonographically minutes post eus fna. postoperative activity was assessed using a standardized scoring system. a cbc, serum biochemistry, urinalysis and spec cpl s were measured before, as well as and h after eus fna. the eus examination was complete in / dogs, the pancreas could not be visualized in dog. the pancreas was hypo-( / ) to isoechoic ( / ) to the surrounding mesenterium in all cases. in / dogs parts of the pancreas presented hyperechoic. the mean measured thickness was . cm. the pancreas was aspirated in dogs using a transgastric approach ( ) or transduodenal approach ( ). duodenal transmural puncture was not accomplished in dog where a re-sterilized needle was used. a minimal amount of peripancreatic fluid was observed in / dogs after eus fna. all dogs recovered uneventfully and required no further analgesia. all laboratory results including the spec cpl s measurements were within reference ranges on all three time points. cytologically, conglomerates of exocrine pancreatic cells were seen in / cases, duodenal villous epithelial cells were seen in / cases. in dog the aspirated pancreatic material was sufficient for a histological assessment. the aspirates with exocrine pancreatic cells on cytology were obtained by transgastric ( ) and transduodenal ( ) aspirations. in conclusion, ( ) eus examination of the abdomen is feasible in medium-sized dogs, ( ) the healthy canine pancreas can be difficult to visualize completely, and ( ) eus-guided pancreatic fna using a g needle is a safe procedure in healthy dogs. studies evaluating its use in dogs with pancreatic disease are warranted to assess its clinical utility. miniature schnauzers have a high prevalence of idiopathic hyperlipidemia, which is characterized by an increased serum triglyceride (tg) concentration, with or without an increased serum cholesterol (chol) concentration. a common initial therapeutic approach for the management of hyperlipidemia is the use of a low-fat diet. also, it is believed that low-fat diets may be beneficial in the treatment of pancreatitis in dogs. however, the efficacy of this approach has not been evaluated for either condition. the aim of the present study was to evaluate the effect of a commercially available low-fat diet on serum concentrations of tg, chol, and canine pancreatic lipase immunoreactivity (cpli; measured as spec cpl s ) in apparently healthy miniature schnauzers with hypertriglyceridemia. blood samples were collected from apparently healthy miniature schnauzers with hypertriglyceridemia (serum triglyceride concentrations mg/dl). common causes of secondary hyperlipidemia were excluded based on historical information, physical examination findings, and the measurement of serum glucose, total t , and free t (by ed) concentrations. the owners of the dogs were asked to switch their dog to the study diet (royal canin gastrointestinal low fat s ; fat content: . g/ , kcal) and have a second blood sample collected weeks after their dog had been on the new diet. all blood samples were collected after food had been withheld for hours. serum tg, chol, and spec cpl concentrations were measured both before and after the diet change. results were compared between the two time-points using the wilcoxon signed rank and fisher's exact tests. serum tg concentrations were significantly higher before (median: mg/dl) than after the diet change (median: mg/dl; p . ). the proportion of dogs with hypertriglyceridemia was significantly higher before ( / ) than after the diet change ( / ; p . ). also, the proportion of dogs with serum tg mg/dl was significantly higher before ( / ) than after the diet change ( / ; p . ). serum chol concentrations were significantly higher before (median: mg/dl) than after the diet change (median: mg/dl; p . ). the proportion of dogs with hypercholesterolemia was significantly higher before ( / ) than after the diet change ( / ; p . ). finally, the difference in serum spec cpl concentrations before (median: mg/l) and after the diet change (median: mg/l) approached but did not reach significance (p . ). also, the proportion of dogs with high serum spec cpl concentrations before ( / ) and after the diet change ( / ) was different, but this difference was not significant (p . ). in summary, a commercially available low-fat diet was effective in reducing serum tg and chol concentrations in miniature schnauzers with hypertriglyceridemia. toll-like receptor (tlr ) is an extracellular pattern recognition receptor which recognizes flagellin present in motile bacteria. we have previously demonstrated a significant association between three non-synonymous single nucleotide polymorphisms (snps) in the tlr gene (g a, c t and t c) and inflammatory bowel disease (ibd) in german shepherd dogs (gsds). recently, we have confirmed that two of these tlr snps (c t and t c) are significantly associated with ibd in other canine breeds. to further substantiate the role of tlr in canine ibd functional analysis of these polymorphisms would be needed. therefore the aim of this study was to determine the functional significance of the tlr snps by transfecting wild-type and mutant receptors in to human embryonic kidney cells (hek) and carrying out nuclear factorkappa b (nf-kb) luciferase assay and il- elisa. the tlr gene containing the risk haplotype for ibd (acc) and wild-type haplotype (gtt) as determined by the case-control analysis in gsds with ibd were cloned into plasmids expressing yellow-fluorescent protein (yfp). these were then stably transfected into hek cells. nf-kb activity was measured by transiently transfecting the cells with nf-kb firefly and hsv-thymidine kinase promoter (prl-tk) renilla plasmids. the cells were then stimulated with various ligands ( . mg/ml flagellin, . mg/ml flagellin, mg/ml lps, mg/ml pam csk and media control). firefly and renilla luciferase activities were measured using the dual-glo luciferase assay system (promega, uk) according to the manufacturer's recommendations. the supernatants were harvested and used in an il- elisa (r&d systems). human tlr transfected hek cells (invivogen) served as positive controls in all experiments. independent t-test was used to determine the significance of relative luciferase activity and il- concentration between wild-type and mutated tlr cells. although there was no significant difference between the wild-type and mutated receptor when they were stimulated with . mg/ml of flagellin (p . ), there was a significant increase when the cells with mutated tlr were stimulated with . mg/ml of flagellin compared to the cells expressing wild-type tlr (p . ). similarly, there was a significant increase in il- concentration in the supernatants in the cells with the mutated tlr receptor when stimulated with . mg/ml flagellin compared to the wild-type (p . -one-tailed, . -two-tailed) but not with . mg/ml flagellin (p . ). we show for the first time that polymorphisms associated with ibd are functionally hyper-responsive to flagellin compared to the wild-type receptor. this suggests that tlr may play a role in canine ibd and that blocking the hyper-responsive receptor found in susceptible dogs with ibd may alleviate the inappropriate inflammation seen in this disease. however, further in-vivo functional analysis of tlr , especially at the intestinal mucosal level would be needed to confirm these findings and predict the usefulness of any future therapeutic interventions. tlr has been shown to play a role in the inappropriate inflammation seen in human inflammatory bowel disease (ibd). similarly, we have recently demonstrated a significant association between three non-synonymous single nucleotide polymorphisms (snps) in the canine tlr gene (g a, c t and t c) and inflammatory bowel disease (ibd) in german shepherd dogs (gsds). therefore the aim of this study was to determine the functional significance of the tlr snps in the breed of gsds. the tlr gene containing the risk haplotype for ibd (acc) and wild-type haplotype (gtt) were stably transfected into hek cells. nf-kb activity was measured by transiently transfecting the cells with nf-kb firefly and hsv-thymidine kinase promoter (prl-tk) renilla plasmids. the cells were stimulated with various tlr ligands ( . mg/ ml flagellin, . mg/ml flagellin, mg/ml lps, mg/ml pam csk and media control). firefly and renilla luciferase activities were measured using the dual-glo luciferase assay system (promega, uk). the supernatants were harvested and used in an il- elisa (r&d systems). peripheral whole blood from dogs carrying the wild type and mutant tlr genes was cultured and stimulated with tlr ligands as above. canine tnf-alpha was measured in the supernatant by commercially available elisa (r&d systems). t-test was used to determine differences of relative luciferase activity, il- concentration and tnf-alpha concentration between wild-type and mutated tlr cells. there was a significant increase in nf-kb activity when the cells with mutated tlr were stimulated with . mg/ml of flagellin compared to the cells expressing wild-type tlr (p . ), which correlated with il- expression in the supernatant (p . ). similarly, in the whole blood assay the tlr risk haplotype for ibd in gsds (acc) was significantly hyperresponsive to flagellin at a concentration of . mg/ml compared to the tlr wild-type haplotype (gtt) (p . ). we show for the first time that polymorphisms associated with canine ibd in gsds are functionally hyper-responsive to flagellin compared to the wild-type receptor. blocking the hyper-responsive receptor found in susceptible dogs with ibd may alleviate the inappropriate inflammation seen in this disease. proton pump inhibitors (ppi) are widely used in human and also veterinary medicine. side-effects of ppi treatment reported in people are atrophic gastritis, gastric and esophageal cancer, and rebound hyperacidity following cessation of treatment, which has been speculated to be due to a sustained increased in circulating gastrin concentration. moreover, long-term ppi treatment has been associated with an increased risk for osteoporosis in people. little is known about the effect of ppi treatment on serum gastrin concentration or calcium metabolism in dogs. eight healthy adult research dogs ( males and females) were enrolled into the study. the dogs received an average dose of . mg/ kg of omeprazole orally twice daily for days. blood samples were collected prior to initiating the treatment and every days during the days of treatment and during the days after discontinuation of treatment for determination of serum gastrin, ionized calcium, pth, and oh vitamin d . gastric fluid was collected via gastroscopy after an overnight fast for measurement of gastric ph prior to, during, and after the omeprazole treatment period. normally distributed data were compared with a repeated measures anova and post hoc dunnett's test. data that were not normally distributed were compared with a friedman's test and a post-hoc dunn's test. gastric fluid ph was significantly higher (p o . ) at the end of the treatment period (median: . ; range: . - . ) when compared to pretreatment values (median: . ; range: . - . ). serum gastrin concentrations increased significantly from a median baseline of . ng/l (range: . - . ) to a maximum median of . ng/l (range: . - . ) at day of treatment (p o . ). serum gastrin remained significantly increased above baseline values from day to day of the treatment, but was not different from pre-treatment values days after the end of the treatment. omeprazole treatment had no effect on ionized calcium or pth for the duration of the study. marginal, but significant changes of oh vitamin d were observed at day (end of the treatment period -increased by . %) and day ( days after the end of the treatment -decreased by . %). this study shows that treatment with omeprazole for weeks results in a profound and sustained increase in serum gastrin concentration in dogs. this effect is rapidly reversible after cessation of the treatment. no effect on calcium metabolism was observed. however, this study documents only the effect of short-term treatment and it is possible that the effects of long-term administration are different. omeprazole treatment has been associated with small intestinal bacterial overgrowth and a higher risk for infectious enteropathies in humans. using a semi-quantitative sequencing approach, we have previously shown that omeprazole treatment may lead to alterations in both duodenal and gastric bacterial populations in healthy dogs (acvim ). however, a sequencing approach can only estimate relative proportions of genomic bacterial targets. therefore, significant changes in the total number of bacteria could not be evaluated. the aim of this study was to quantify gastric and duodenal bacterial populations in dogs undergoing omeprazole treatment. eight month-old healthy research dogs ( males and females) were enrolled. the dogs received an average dose of . mg/kg of omeprazole orally twice a day for days. endoscopic gastric and duodenal biopsies were harvested and days before starting omeprazole treatment, on the last day of treatment (day ), and days after the end of treatment (day ). all biopsies were fixed in % formalin for hours, processed, and embedded in paraffin blocks. fluorescent in situ hybridization was used to quantify mucosa-associated bacteria using fluorescently-labeled probes targeting the s ribosomal rna. statistical analysis aimed to compare changes in helicobacter spp. in gastric biopsies and total bacteria in both gastric and duodenal biopsies using the glimmix and npar way procedures in sas s . . bacteria were counted in , and microscopic fields ( Â) obtained from and gastric and duodenal biopsies, respectively. in the stomach, omeprazole treatment led to a decrease in helicobacter spp. (log of average counts ae standard error: . ae . at day ) when compared to the counts ( . ae . , p . ) and ( . ae . , p . ) days before treatment. after completion of omeprazole treatment, helicobacter spp. increased and returned to baseline counts ( . ae . at day , p . vs day ). also, in the stomach, non-helicobacter spp. bacteria were observed more often during omeprazole treatment (median: , range: - ) than on days (median: , range: - ) and (median: , range: - ) before and days after (median: , range: - ) omeprazole treatment; however, statistical comparison across time points did not reach significance. in the duodenum, while the median number of bacteria for all time points was zero, non-parametric comparison of median scores (number of points above median) revealed significantly higher numbers of bacteria during omeprazole treatment (p . ). our results suggest that omeprazole treatment for weeks leads to a lower abundance of helicobacter spp. organisms in the stomach of healthy dogs. also, this transient decrease in helicobacter spp. was accompanied by a higher abundance of other bacteria in both the stomach and the proximal duodenum. the smartpill ph.p s capsule (the smartpill corporation) is a wireless motility capsule that measures ph, pressure, and temperature as it passes through the gastrointestinal (gi) tract. analysis of this data allows the calculation of gastric emptying time (get), small and large bowel transit time (slbtt), and total gi transit time (tgtt). this study evaluated the variability associated with repeated measurement of gi transit times and the effect of oral administration of ranitidine (zantac s ) on gi transit times in dogs using this system. it was hypothesized that ranitidine would reduce gi transit times. six privately owned healthy adult dogs weighing between . kg and . kg were used. on occasions each dog was fed a standard meal followed by oral administration of a capsule. data were recorded until the capsule had passed in the dog's feces. on a th occasion each dog was given mg of ranitidine po q hrs starting hrs prior to testing. the dogs were then fed the test meal and the capsule was administered as above. ranitidine was given until the capsule had passed in the dog's feces. proprietary smartpill software was used to calculate get, slbtt, tgtt, and the median gastric ph (mgph). mean intra-individual and inter-individual coefficients of variation (cv%) were calculated for get, slbtt, and ttt for the first time points. transit times and gastric ph recorded at all time points were compared using a repeated measures anova. where significant differences were identified, post-hoc testing was performed using a bonferroni's multiple comparisons test. significance was set at p o . . a sharp rise in ph indicating exit of the capsule from the stomach was identified in each experiment. mean (ae sd) get, slbtt, and tgtt without ranitidine were ae , ae , and ae min, respectively. mean get, slbtt, and tgtt during treatment with ranitidine were ae , ae , and ae min, respectively. mean intra-individual cv% before ranitidine for get, slbtt, and tgtt were . , . , and . %, respectively. mean inter-individual cv% before treatment with ranitidine for get, slbtt, and ttt were . , . , and . %, respectively. no significant differences in get, slbtt, or tgtt were found at any of the time points. the mean mgph during treatment with ranitidine (ph . ) was significantly higher than at all other time points (overall mean ph for the time points: . ; p o . ). the smartpill system is an easy to use, ambulatory, non-invasive, non-radioactive method for assessing gi transit times in medium to large breed dogs. measurements of gi transit times, especially slbtt, were subject to considerable intra-individual and interindividual variation. no significant effect of oral ranitidine on gi motility was identified in this group of dogs. however, as expected, oral ranitidine caused a significant increase in gastric ph. the intestinal microbiota has been implicated in the pathogenesis of various gastrointestinal disorders in both humans and dogs. recent metagenomic data suggest that specific bacterial groups, including bacteria within the clostridium clusters iv and xiva (i.e., faecalibacterium spp., ruminococcaceae, and lachnospiraceae) and bifidobacterium spp. are decreased, while proteobacteria are increased in dogs with clinical signs of gastrointestinal disease. the objective of this study was to establish quantitative polymerase chain reaction (qpcr) assays for these specific bacterial groups and evaluate their abundance in healthy dogs and dogs with clinical signs of gastrointestinal disease. fecal samples were collected from healthy dogs ( females and males) and dogs with clinical signs of gastrointestinal disease ( females and males). novel quantitative pcr assays were established for faecalibacterium spp., ruminococcaceae, and lachnospiraceae by aligning respective group specific sequences against canine specific sequences obtained from s rrna gene clone libraries and sequences available from the ribosomal database project. primers for bifidobacterium spp. and proteobacteria were selected from previously published studies. the specificity of the qpcr assays was confirmed by sequencing of obtained qpcr amplicons. the bacterial dna abundance in fecal samples was compared between healthy dogs and dogs with clinical signs of gastrointestinal disease using a mann-whitney u test. significance was set at p o . . a significantly lower abundance of faecalibacterium spp. (p o . ) and ruminococcaceae (p . ) was observed in dogs with clinical signs of gastrointestinal disease when compared to healthy dogs. proteobacteria were more abundant in dogs with clinical signs of gastrointestinal disease, but this difference did not reach statistical significance (p . ). there was no significant difference in the abundance of lachnospiraceae (p . ) and bifidobacterium spp. (p . ) between both groups. in conclusion, we established novel qpcr assays for faecalibacterium spp., ruminococcaceae, and lachnospiraceae. we observed significant decreases in the abundance of faecalibacterium spp. and ruminococcaceae in dogs with clinical signs of gastrointestinal disease. these bacterial groups are considered major short-chain fatty acid producers and studies are warranted to determine if a decrease in these bacterial groups is associated with decreases in short chain fatty acid production. further studies are also needed to determine if these bacterial shifts are associated with specific gastrointestinal disorders. the pathogenesis of chronic enteropathies (ce) in dogs likely involves complex interaction between the mucosal immune system and the intestinal microbiota. while the application of bacterial s rdna sequence-based analysis has shown an association between altered microbial composition and duodenal inflammation in dogs, relatively little is known about alterations in non-invasive mucosal and luminal bacteria seen with diseases involving the ileum and colon. the present study sought to evaluate the relationship of enteric bacteria to type and severity of mucosal inflammation affecting the ileum and colon of dogs with ce. eleven client-owned dogs with ce involving both the small and large intestines were prospectively enrolled. ce was diagnosed on the basis of a history of chronic gastrointestinal signs, exclusion of identifiable underlying disorders, and histopathologic evidence of intestinal inflammation. mucosal bacteria were detected in formalinfixed ileal and colonic tissue sections with fluorescence in situ hybridization (fish) using s rdna-targeted probes directed against all bacteria, enterobacteriaceae, e. coli, eubacterium rectale-clostridium coccoides group, bacteroides/prevotella, and helicobacter spp. sections were examined by epifluorescence microscopy and the number of bacteria and their spatial distribution (luminal, superficial mucus, epithelial adherent, within mucosa) was determined in ten x fields of each section. microbial composition in ce dogs was compared to the ileal/colonic microbiota of healthy control (hc) dogs using a mixed effect anova model. p values o . were considered significant. the final diagnoses for dogs with ce included ibd (n ) and lymphosarcoma (n ). when compared to hc dogs, dogs with ce showed regional (ileum versus colon) imbalances in microbiota composition characterized by selective enrichment of mucosa-associated populations. evaluation of colonic biopsies in dogs with ce showed that the total number of bacteria (p o . ), clostridium (p o . ), enterobacteriaceae (p o . ) and e. coli (p o . ) were increased in the adherent mucus regions of dogs with ibd as compared to hc dogs. total bacteria (p o . ) and e. coli (p o . ) were also more numerous in dogs with lsa versus hc and ibd dogs (p o . for e. coli). ileal biopsies from ce dogs similarly showed variable dysbiosis with increased total bacteria (p o . ) but decreased helicobacter spp (p o . ) and bacteroides (p o . ) observed within inflamed intestines as compared to hc tissues. the spatial distribution of these bacteria was also appreciably different from hc dogs, with higher numbers of bacteria generally found within the adherent mucus compartment as compared to other ileal regions. our data demonstrate that dogs with ce affecting the ileum and colon have altered microbiota composition that may be a cause or consequence of mucosal inflammation. recognition of these microbiota imbalances may provide new opportunities for therapeutic intervention. trichomonads have been rarely reported in the feces of dogs and their pathogenicity remains uncertain. although pentatrichomonas hominis (ph) is considered to be a commensal that may overgrow in dogs with other causes of diarrhea, little is known regarding the history, clinical presentation or prevalence of concurrent gi infections in dogs with trichomonosis. the aim of this study was to determine whether dogs with diarrhea and trichomonosis could be distinguished from dogs having diarrhea without trichomonosis on the basis of clinical signs or presence of concurrent enteric infections. fecal samples from dogs were submitted to ncsu from - for trichomonas spp. pcr testing. dna was extracted using a zr fecal dna mini-prep kit and absence of pcr inhibitors verified by amplification of bacterial s rdna. pcr for ph and tritrichomonas foetus (tf) was performed as well as real-time pcr assays for possible concurrent enteric infectious agents. obtainable medical records were reviewed. all submitted fecal samples were submitted from dogs with diarrhea that was variably described as soft, mucoid, hemorrhagic, or watery. mean age of the dogs was . years (median . ; range: . - months) and represented a total of breeds. ph, tf, or concurrent ph and tf were diagnosed in , , and dogs respectively (group a). the remaining dogs were negative for ph and tf by pcr no dogs were identified as infected with canine distemper virus or parvovirus. five samples from each group had insufficient quantity or quality of dna for concurrent infectious disease testing. in this large study of canine trichomonosis, no differences in age, clinical signs, or prevalence and identity of concurrent enteric infection between diarrheic dogs with or without ph were identified. thus, these findings do not appear to support a primary pathogenic role for ph as a causative agent of diarrhea in dogs. gastrointestinal motility disorders are a common clinical problem in domestic animals. many of the g.i. motility disorders have been treated previously with -ht agonists although limited availability of drugs in this classification have stimulated interest in the use of new (and old) drug therapies. the dopaminergic antagonists are a group of drugs with well-known anti-emetic effects at central dopamine d receptors, and putative gastrointestinal prokinetic effects at peripheral d receptors. domperidone has been shown, for example, to reverse gastric relaxation induced by dopamine infusion in the dog. similar studies have not been reported in the cat or rabbit, two species at risk for distal gastrointestinal motility disorders. our aim was to study the effects, mechanisms, and sites of action of domperidone in feline colonic and rabbit gastrointestinal smooth muscle contraction. portions of stomach (fundus and antrum), intestine (duodenum and ileum), cecum (rabbits only), and colon (ascending and descending) were obtained from healthy cats and rabbits from - months of age. longitudinal and circular smooth muscle strips from each site were suspended in physiologic (hepes) buffer solution, attached to isometric force transducers, and set to optimal muscle length (l o ) using acetylcholine (ach; À m). muscle strips were treated with domperidone (d; À to À m) in the presence or absence of ach ( À to À m), and maximal force output (p max ) was normalized for cross-sectional area (n  newtons/m ). domperidone (d) had a minor direct effect of inducing feline and rabbit gastric, cecal, and colonic smooth muscle contraction. direct effects were similar whether in the longitudinal or circular muscle orientation. the direct effect of domperidone was dose-dependent and maximal (feline colon p max . - . n; rabbit colon p max . - . n) at a dose of À m. domperidone had a much greater indirect effect in augmenting cholinergic (ach; À m) contractions in feline and rabbit gastric, cecal, and colonic smooth muscle. domperidone-augmented cholinergic contractions were - % (feline colon p max . ae . n ach only; feline colon p max . ae . n ach d) of baseline cholinergic contractions. domperidone contractions were of a similar magnitude to those induced by cisapride. domperidone effects were similar in mucosaintact and mucosa-dissected preparations. domperidone contractions were unaffected by prazosin (a receptor antagonist), yohimbine (a receptor antagonist), or terbutaline (b receptor agonist), but were somewhat attenuated by dopamine (d receptor agonist) and a non-specific cholinergic antagonist (atropine). in vitro studies show for the first time that domperidone has minor direct and major indirect effects in augmenting cholinergic contractions of feline and rabbit gastrointestinal (stomach, cecum and colon) smooth muscle. as recognition of acute and chronic pain in dogs has increased, so too has the use of non-steroidal anti-inflammatory drugs (nsaids) often in conjunction with tramadol. in people and rats, co-administration increases the risk of perforation and gastric injury over nsaids alone. using an ex vivo model of acid injury in canine gastric mucosa, we examined the effects of indomethacin and tramadol on gastric permeability and concentrations of gastroprotective prostaglandin e (pge ). mucosa from the gastric antrum was harvested from shelter dogs immediately after euthanasia, and mounted on ussing chambers. the tissues were equilibrated for -minutes prior to addition of acidic ringer's solution (ph, . ). after -minutes of injury, the acid was replaced with neutral ringer's and the tissues were treated with indomethacin, tramadol or both. tissues were maintained for minutes total, during which time permeability was assessed electrically. prostanoid concentrations were quantified using a commercially available elisa. western blots were performed for cox- and À . recovery of gastric barrier function after acid injury was inhibited by co-administration of tramadol and indomethacin ( figure ) but not by tramadol or indomethacin alone (data not shown). prostaglandin e increased with acid injury. the increase in pge was inhibited by co-administration of indomethacin and tramadol (in pg/ml: acid injury . ae . , indo tramadol . ae . ). there was no significant effect of treatment on cox- or À expression. co-administration of tramadol with a non-selective nsaid inhibits the return of gastric mucosal barrier function after acid injury in canine tissue, suggesting that caution is required in prescribing concurrent use of these drugs in dogs at risk for gastric ulcers. these drugs may exert this effect by decreasing levels of gastroprotective prostanoids. further study is needed to understand the mechanism of this drug interaction. an increased intestinal permeability (ip) has been suggested to be both cause and consequence of gastrointestinal (gi) disease, such as inflammatory bowel and celiac disease, in people. a novel tight junction regulator, larazotide acetate (alba therapeutics, baltimore, md) has been shown to significantly decrease ip in rats and in humans with celiac disease. the purpose of this study was to determine if larazotide acetate reduces ip in soft coated wheaten terriers (scwt) and norwegian lundehunds (nl) with chronic gi disease and ameliorates clinical signs. four nl ( females, males; median age: . yrs, range: . - . yrs) and scwt ( females, males; median age: . yrs, range: . - . yrs) were enrolled based on presence of clinical signs of gi disease and hypoalbuminemia, increased fecal alpha proteinase inhibitor (a -pi) concentrations, and/or hypocobalaminemia. scwt with protein-losing nephropathy were excluded. dogs were fed q hrs and received . mg ( nl and scwt) or . mg ( scwt) of larazotide acetate po before each meal for days. prior to start of treatment (day ) and at the end (day ), ip was evaluated by calculating the lactulose/rhamnose (l/r)-ratio in serum samples obtained at , , , and min after oral dosing. also, consecutive fecal samples each were collected prior to day and day for n-methylhistamine (nmh) measurement. pre-and post-treatment data were compared using a wilcoxon signed rank test. the . mg vs. . mg dose groups were compared using a mann-whitney u test. statistical significance was set at p o . . l/r-ratios (medians) for the min sampling time point were significantly lower on day ( . ) than on day ( . ; p . ). dogs treated with . mg q hrs had significantly lower min l/r ratios on day than dogs treated with . mg ( . vs. . ; p . ). no difference was found between breeds. fecal nmh concentrations were not different between time points, treatment groups, or breeds. fecal a -pi concentrations were available for of the dogs and were significantly higher on day compared to day (p . ). no differences were found between pre-and post-treatment serum albumin or cobalamin concentrations. weight gain was seen in all nl. resolution of diarrhea, vomiting, hyporexia, as well as an increased activity was seen in scwt. another scwt had resolution of diarrhea and a decrease in pruritus. no changes in clinical signs were reported in the remaining scwt. this study indicates that larazotide acetate might be able to reduce ip in dogs. this effect may be dose-dependent. however, not all dogs showed an improvement in clinical signs, suggesting that factors other than increased ip might have been responsible for the clinical signs in these dogs. breed-related effects cannot be ruled out, and further studies are warranted to determine the efficacy of larazotide acetate in dogs of other breeds with gi disease. to analyze different biochemical markers, calculate clinical activity scores, and assess survival in dogs with ple and compare them with those in dogs with food-responsive diarrhea (frd) without protein loss. dogs with ple and dogs with frd, referred to the university of bern, ch, were enrolled. selection criteria included a history of chronic diarrhea ( weeks), exclusion of identifiable underlying causes, and histopathologic evidence of intestinal inflammation, but not neoplasia. underlying disorders were excluded based on cbc, chemistry profile, urinalysis, fecal analysis, trypsinlike immunoreactivity, cobalamin, folate, and transabdominal ultrasound. also, canine pancreatic lipase immunoreactivity (spec cpl s ), c-reactive protein (crp), calprotectin and alpha -proteinase inhibitor (a -pi) were measured in serum from dogs and compared with dogs with frd without ple. all dogs were scored using the canine ibd (cibdai) and the canine chronic enteropathy (cce) clinical activity index (ccecai). total protein, albumin ( - . g/l), and total calcium ( . - . mmol/l) were decreased in all dogs. cobalamin was decreased in all but dogs ( o - ng/l). spec cpl was mildly increased in / dogs with ple and normal in / ple and all frd dogs. crp was normal in / dogs with ple ( / frd), mildly increased in / ( / frd), and moderately increased in / ple dogs ( / frd). calprotectin was slightly higher in dogs with ple, but all ple and frd dogs yielded values in the normal range. serum a -pi was significantly lower in dogs with ple than in those with frd (p o . ), with / ple dogs below the reference range ( / frd). cibdai ranged from to and ccecai from to . at the end of the study, / dogs were still alive with survival times between and days. / dogs died with a median survival of days (range - days). dogs with mildly increased crp died earlier than dogs with a normal or moderately increased crp (p . ), whereas albumin, calcium, spec cpl, calprotectin, cibdai, and ccecai had no significant impact on outcome and survival. in conclusion, dogs with ple have a significantly lower a -pi in the serum than dogs with frd. furthermore, most dogs with ple have an increased crp and a decreased cobalamin. a mild increase in crp appears to be a poor prognostic factor. while hypoalbuminemia is a common finding associated with chronic enteropathies, its impact on survival in this population is poorly defined. the aim of this study was to compare dogs with chronic enteropathies on the basis of their serum albumin concentration at the time of presentation. we hypothesized that dogs with a protein losing enteropathy (ple) have a significantly shorter survival time compared to dogs with chronic enteropathies which are not hypoalbuminemic (controls). information obtained from the medical records included signalment, duration and characteristics of clinical signs, physical examination findings, clinicopathologic data and survival time. one hundred seventeen cases fit the inclusion criteria; in the ple group and controls. there was no statistical significance between groups for age (p . ), weight (p . ), weight loss (p . ) and body condition score (p . ). compared to control dogs, ple dogs had decreased serum concentrations of cobalamin (p . ), total calcium (p o . ), globulin (p o . ), cholesterol (p o . ) and ionized calcium (p o . ). survival analysis revealed a significantly decreased survival time for ple dogs (p . ); median survival was days for ple dogs and , days for controls. while the ple group did not survive as long, survival was not directly associated with severity of hypoalbuminemia; patients with albumin concentration o . g/dl survived longer than those with mild hypoalbuminemia ( . - . g/dl). this study supports the observation that chronic enteropathy patients have decreased survival time when presented with hypoalbuminemia; however this study suggests the severity of hypoalbuminemia is not a reliable indicator of survival. cobalamin (vitamin b ) deficiency in the chinese shar pei (shar pei) is suspected to be hereditary. inherited causes of cobalamin deficiency have been reported in humans and may affect absorption, transport, or cellular processing of cobalamin. based on human and veterinary studies, an increased serum methylmalonic acid (mma) concentration has been suggested to reflect cobalamin deficiency at the cellular level. in this context, it has been shown in humans that mma concentrations are higher in patients with genetic disorders affecting intracellular processing than in patients with genetic defects affecting gastrointestinal processing and extracellular transport of cobalamin. therefore, the aim of this study was to evaluate serum mma concentrations in shar peis and dogs of six other breeds with cobalamin deficiency. from in conclusion, serum cobalamin deficient shar peis had a times higher median serum mma concentration compared to cobalamin deficient dogs of six other dog breeds. further studies are needed to investigate the intracellular processing of cobalamin in shar peis with cobalamin deficiency. chinese shar peis (shar peis) have a high prevalence of cobalamin deficiency. two other conditions reported frequently in this breed are shar pei fever and cutaneous mucinosis. shar pei fever is an autoimmune disorder causing periodic flare-ups and is associated with increased serum concentrations of c-reactive protein (crp), a nonspecific marker of inflammation. cutaneous mucinosis is characterized by excessive deposition of mucin in the dermis. also, hyaluronic acid (ha), the main component of mucin, was shown to be significantly higher in serum from shar peis with cutaneous mucinosis than in healthy controls. to date, a possible association between shar pei fever and/or cutaneous mucinosis on one side and cobalamin deficiency on the other has not been investigated in shar peis. thus, the aim of this study was to compare serum concentrations of ha (an indicator of cutaneous mucinosis) and inflammatory markers (crp, calprotectin, and s a ), assumed to be increased in episodes of shar pei fever, in shar peis with and without cobalamin deficiency. serum samples from shar peis, collected from to , were analyzed. serum ha and crp (reference interval (ri): . - . mg/l) were quantified by using commercial elisa kits (echelon biosciences, salt lake city, ut, usa and tridelta, maynooth, ireland; respectively). serum calgranulin concentrations were measured using an in-house elisa (calprotectin; ri: . - . mg/l) and ria (s a ; ri: . - . mg/l), respectively. mann-whitney u tests were used to compare serum ha, crp, calprotectin, and s a concentrations between shar peis with and without cobalamin deficiency. significance was set at p o . . fourteen shar peis were severely cobalamin deficient, defined by an undetectable serum cobalamin concentration ( o ng/l). in the remaining dogs, serum cobalamin concentrations were within the reference interval ( - ng/l). serum concentrations of ha, crp, calprotectin, and s a were not significantly different between cobalamin deficient shar peis (medians: . ng/ml, . . fifty percent of cobalamin deficient shar peis had serum calprotectin concentrations above the upper limit of the reference interval, and % had serum s a concentrations above the suggested upper reference limit. in this study, serum concentrations of ha, crp, and the calgranulins did not differ between cobalamin deficient shar peis and shar peis with a normal serum cobalamin concentration. this finding leads us to speculate that increased ha and/or inflammatory markers are not associated with cobalamin deficiency in shar peis. further studies are needed to investigate serum cobalamin concentrations in patients with shar pei fever or cutaneous mucinosis. cobalamin deficiency (cd) has been associated with gastrointestinal and pancreatic disease in dogs. hereditary cd has been demonstrated in giant schnauzers and single case reports have suggested congenital cd in the border collie (bc) breed. clinicopathologic findings of cd vary and can be unspecific as cobalamin acts as a co-factor for a multitude of enzymatic reactions. the two most important reactions concern the conversion of methylmalonyl-coa to succinyl-coa and the re-methylation of homocysteine (hcy). these two metabolites increase when cobalamin is lacking and act as markers for cobalamin availability on a cellular level. preliminary data from dogs suggested that measurement of methylmalonic acid (mma) may be a better diagnostic test for cd than serum cobalamin concentration. therefore the goals of the study were ( ) to establish reference values for serum cobalamin, urine mma and plasma hcy in healthy pet dogs, ( ) to screen a larger bc population from switzerland for cd, and ( ) to perform genomic analyses on bc with cd. for determination of reference values healthy pet dogs were used. serum cobalamin was measured using an automated chemiluminescence assay (immulite ), urine mma was determined using gas chromatography and expressed as a ratio to urine creatinine and plasma hcy was measured using high pressure liquid chromatography and fluorimetric detection. to calculate reference ranges the th and th percentile were used. data were analyzed using non-parametric tests. reference ranges for cobalamin, hcy, and mma were: cobalamin . - . ng/l; urine mma - . mmol/mol creatinine; and plasma hcy . - . mmol/l. the screened bc population comprised purebred dogs and bc (median . months; range - ) suffering from congenital cd could be identified. clinical signs differed and consisted of tiredness ( ), stunted growth ( ), anemia ( ), dysphagia ( ) and persistent fever ( ). median (ranges) results for healthy bc and bc with cd were: for cobalamin ( - ) and . ( - ) ng/l; for urine mma ( - ) and ( - ) mmol/mol creatinine; for hcy . ( . - . ) and . ( - . ) mmol/l. strikingly, healthy bc with cobalamin concentrations well within the reference range had significantly higher urine mma concentrations compared to control dogs. under the assumption that the four affected bc are inbred to a single founder animal, first results of genotyping on the k illumina canine_hd snp chip suggest that mutations in the cubn and amn gene can be excluded to cause the observed cd in these dogs. we conclude that cd is a rare familial disease in bc with variable clinical signs. to define the genomic region responsible for cd further genetic analysis is in progress. it remains to be determined why some bc have high urine mma concentrations despite a serum cobalamin concentration within the reference range. calprotectin is a protein complex that plays an important role in the innate immune response. preliminary data suggest that canine calprotectin (ccp) is a useful marker for the detection of inflammation in dogs. recently, a radioimmunoassay for the measurement of ccp has been developed and analytically validated, but this test requires the use of a radioactive tracer. therefore, the aim of this study was to develop and analytically validate an enzyme-linked immunosorbent assay (elisa) for the quantification of ccp in serum and fecal specimens from dogs. canine calprotectin (ccp) was purified, antiserum against purified ccp was raised in rabbits, monospecific antibodies were purified by affinity chromatography, and a sandwich-elisa was developed. purified antibodies were used for capturing and, after coupling with horseradish peroxidase (hrp), for reporting. a hrp substrate was used for color development. the assay was analytically validated by determination of analytical sensitivity and specificity, dilutional parallelism, spiking recovery, and intra-and inter-assay variability. control intervals for serum and fecal ccp were established from and healthy pet dogs, respectively, using the central th percentile. sensitivity of the assay for serum samples assayed in a : dilution and for fecal extracts assayed in a : , dilution was . mg/l and . mg/g, respectively. over a wide range of the assay, there was no cross-reactivity with cs a , the closest structural analogue of ccp available. observed to expected ratios (o/e) for serial dilutions ranged from . - . % (mean ae standard deviation [sd]: . ae . %) for four different serum samples, and from . - . % (mean ae sd: . ae . %) for five different fecal extracts. o/e for spiking recovery ranged from . - . % (mean ae sd: . ae . %) for four different serum samples and different spiking concentrations, and from . - . % (mean ae sd: . ae . %) for different fecal extracts and different spiking concentrations. intra-assay coefficients of variation (cv) for different serum samples were . , . , . , and . %, and . , . , . , and . % for different fecal extracts. inter-assay cv for different serum samples were . , . , . , and . %, and . , . , . , and . % for different fecal extracts. the control intervals for serum and fecal ccp were established as . - . mg/l and . - . mg/g, respectively. we conclude that this new elisa for the measurement of ccp is analytically sensitive, linear, accurate, precise, and reproducible, and does not cross-react with canine s a . further studies evaluating the clinical usefulness of measuring serum and/or fecal ccp are currently under way. the syndrome of hemorrhagic gastroenteritis (hge) is characterized by a peracute onset of hemorrhagic diarrhea, vomiting, depression, and anorexia, and can be associated with a high mortality if untreated. the etiology of hge is unknown, but it is speculated that an abnormal response to bacterial endotoxins, bacteria, or dietary components may play a role. hge is characterized by an increased vascular/mucosal permeability, thought to represent a type i-hypersensitivity reaction, whereas inflammation and necrosis appear to be rare. however, markers of gastrointestinal (gi) inflammation and changes in the intestinal microbiota have not been studied extensively in dogs with hge. therefore, the aim of this study was to evaluate fecal canine calprotectin (cp) and s a (a ), a -proteinase inhibitor (a -pi, a marker of gi protein loss), and bacterial groups that have previously been shown to be decreased (i.e., faecalibacterium spp., ruminococcaceae, bifidobacterium spp.) or increased (i.e., proteobacteria) in fecal samples from dogs with hge. fecal samples from consecutive days were collected from dogs with hge. fecal cp, a , and a -pi concentrations were measured by in-house immunoassays. bacterial dna was extracted from each fecal sample and was analyzed for faecalibacterium spp., proteobacteria, rumino-coccaceae, and bifidobacterium spp. using quantitative pcr assays. concentrations of fecal cp, a , and a -pi, and the abundance of bacterial dna were compared using a friedman test with dunn's post-hoc tests. significance was set at p o . . at the time of diagnosis (day ), fecal cp, a , and a -pi were above the suggested reference intervals in , , and of the dogs, respectively. until day , this number decreased to , , and , respectively. decreases in concentrations were significant between days and for a (p . ), and between days and for a -pi (p . ), but not for cp despite a trend (p . ). no differences in the abundance of faecalibacterium spp. (p . ), bifidobacterium spp. (p . ), or proteobacteria (p . ) were observed. however, the abundance of rumino-coccaceae was significantly lower on day when compared to day (p . ). in this study, fecal markers of inflammation and gi protein loss were increased in dogs with hge. although the number of patients was small, following initiation of treatment, two of the markers decreased significantly. these results suggest a loss of protein into the gi tract at the onset of hge. the lack of significant increases of faecalibacterium spp., bifidobacterium spp., and ruminococcaceae, and decreases in proteobacteria may suggest gi dysbiosis. further longitudinal studies are needed and are currently under way to evaluate gi dysbiosis in canine hge patients. the most recent antiemetic approved for use in dogs is maropitant citrate (cerenia s , pfizer animal health). maropitant is a selective nk receptor antagonist that acts by blocking the binding of substance-p within the emetic center and chemoreceptor trigger zone. label dosage recommendations for maropitant citrate are mg/ kg sc or mg/kg orally once daily for up to consecutive days (acute emesis) and mg/kg orally once daily for up to consecutive days (motion sickness). the study objective was to determine when steady-state is reached and the pharmacokinetics of maropitant administered at label oral dosages once daily for consecutive days. two groups of eight healthy beagles were administered maropitant citrate at or mg/kg orally once daily for days. concentrations of maropitant and its metabolite were measured in plasma using a lc-ms/ms assay. pharmacokinetic parameters were estimated using non-compartmental pharmacokinetic techniques and a modeling approach was used to estimate steady-state. the accumulation ratio for maropitant was . (auc - ) and . (cmax) for the mg/kg dose; and . (auc - ) and . (cmax) for the mg/kg dose after days. the model estimate for the number of doses required to reach % of steady-state was . for mg/kg and . for mg/kg. three dogs experienced a single episode of vomiting. dosing maropitant citrate beyond the label duration was well tolerated by healthy dogs. steady-state was reached after approximately doses for daily mg/kg and doses for daily mg/kg oral dosing. previously presented at the veterinary cancer society, november . cobalamin (vitamin b ) is involved in a variety of metabolic processes. altered serum cobalamin concentrations have been observed in dogs with gastrointestinal disorders, such as exocrine pancreatic insufficiency (epi) or severe and longstanding ileal disease. this study was conducted to identify breeds with a higher proportion of a decreased serum cobalamin concentration that were submitted to the gastrointestinal laboratory. the study was also aimed at investigating serum trypsin-like immunoreactivity (tli) concentrations that were diagnostic for epi in the dogs with a decreased serum cobalamin concentration. except for csp, breeds identified here, have not previously been identified to have a higher rate of a decreased serum cobalamin concentration. also, a possible association between an undetectable serum cobalamin and a decreased serum tli in ai needs to be further investigated. calprotectin (cp) is a widely used marker for the diagnosis and monitoring of gastrointestinal (gi) inflammation in humans. studies in humans usually report fecal cp concentrations based on a single stool sample although considerable day-to-day variability of fecal cp was found in patients with gi disease and in healthy controls. intra-individual variation of canine cp (ccp) was also substantial in a small number of healthy dogs but has not been determined in dogs with chronic gi disease. thus, the aim of this study was to compare the day-to-day variation of fecal ccp in dogs with chronic gi disease before and during treatment to that in healthy dogs. we hypothesized that fecal ccp would be less variable in patients with chronic gi disease than in healthy controls, and thus collection of a single fecal sample would be sufficient. fecal samples from consecutive days were prospectively collected from dogs (group a; median age: . years) referred for diagnostic work-up of chronic signs of gi disease, from dogs (group b; median age: . years) with stable gi disease while being treated, and from healthy adult dogs (group c; mean age: . years). fecal samples were extracted and ccp was measured by an in-house immunoassay. mean ccp, standard deviation, coefficient of variation (cv), and difference between maximum and minimum ccp for the -day sample collection period were calculated for each dog and were compared among groups using a kruskal-wallis test. fecal ccp ranged from . - . mg/g (median: . mg/g) in dogs with gi disease (group a), from . - . mg/g (median: . mg/g) in dogs of group b, and from . - . mg/g (median: . mg/g) in healthy controls (group c). cvs were - . % in group a (median: . %), . - . % in group b (median: . %), and - . % in group c (median: . %), respectively. patients in group a appeared to have less variable fecal ccp than dogs in group b and c, but this difference was not significant (p . ). the difference between maximum and minimum ccp for the -day sample collection ranged from - . mg/g in group a (median: . mg/g), from . - . mg/g in group b (median: . mg/g), and from - . mg/g in group c (median: . mg/g), and were not significantly different between any of the groups (p . ). in this study, considerable day-to-day variation of fecal ccp was found in dogs with chronic gi disease (regardless of treatment) and was comparable to that in healthy dogs. results of this study suggest that for evaluating fecal ccp in dogs with clinical signs of gi disease, three consecutive fecal samples rather than a single fecal sample should be analyzed. because we did not intend to evaluate the clinical usefulness of fecal ccp as a marker of gi disease in dogs, disease severity, quality, and location differed among dogs in groups a and b. the diagnostic utility of fecal ccp in dogs with gi disease is currently being investigated. it has been suggested that diagnosis of clostridium perfringens related enteropathy should be based on the detection of the c. perfringens enterotoxin gene (cpe-gene) by pcr and/or c. perfringens enterotoxin (cpe) by elisa in feces. however, the prevalence of the cpe-gene and cpe in dogs and especially cats with gastrointestinal disease has not yet been reported. also, there is limited information about the stability of cpe in fecal samples at various storage conditions. the aim of this study was to evaluate the prevalence of the cpe-gene and cpe and the stability of cpe in fecal samples from dogs and cats. to evaluate the prevalence of the cpe-gene, a total of fecal samples from dogs and cats with clinical signs of gastrointestinal disease ( dogs and cats) and fecal samples from those without such signs ( dogs and cats) were examined using pcr. to evaluate the prevalence of cpe, a total of fecal samples from dogs and cats with clinical signs of gastrointestinal disease ( dogs and cats) and dogs without such signs were evaluated using a commercially available elisa kit (techlab, blacksburg, va). the results were analyzed using a fisher's exact test. significance was set at p o . . to evaluate the stability of cpe, fecal samples from dogs and from cats with clinical signs of gastrointestinal disease that were positive for cpe were examined. also, cpe negative samples from dogs were evaluated as negative controls. each sample was subdivided into aliquots and evaluated on day ; on days , , and after being stored at room temperature (rt) or c; and on day after being stored at À c. the prevalence of the cpe-gene was not significantly different between dogs with signs of gastrointestinal disease ( / ; . %) and dogs without ( / ; . %; p . ). also, the prevalence of the cpe-gene in cats with signs of gastrointestinal disease ( / ; . %) was not significantly different compared to cats without ( / ; . %; p . ). pcr and elisa results were available for samples. of the pcr positive samples, only ( . %) were elisa positive. of the pcr negative samples, only ( . %) was elisa positive. the prevalence of cpe was not significantly different between dogs with clinical signs of gastrointestinal disease ( / ; . %) and those without ( / ; . %; p . ). the prevalence of cpe in cats with signs of gastrointestinal disease was / ( . %), but no samples from cats without such signs were available. when evaluating the stability of cpe, results for all aliquots were consistent with the initial result, except for one sample (on day , stored at rt, which was initially cpe positive). these results indicate that only a small proportion of samples that are pcr positive for the cpe-gene are also positive for cpe. studies are warranted to further compare the prevalence of cpe among animals with gastrointestinal disease and those without. furthermore, the results indicate that cpe is relatively stable in fecal samples at various storage temperatures. clostridium perfringens has been implicated as a cause of diarrhea in dogs. the main study objective was to compare two culture methods for the identification of c. perfringens. a secondary objective was to evaluate c. perfringens toxin genes a, b, b , e, ı and cpe from canine isolates using a multiplex pcr and determine their prevalence in a group of normal and diarrheic dogs. fecal samples were collected from clinically normal (nd, n ) and diarrheic dogs (dd, n ) at a primary care veterinary facility. isolation of c. perfringens was performed using direct inoculation of feces onto % sheep blood agar (sba) as well as enrichment of stool in bhi broth followed by inoculation onto sba. isolates were tested by multiplex pcr for the presence of a, b, b , e, ı and cpe genes. c. perfringens was isolated from % ( / ) of nd fecal samples using direct culture and . % ( / ) with bhi enrichment (p . ). in the dd, corresponding isolation rates were . % and . % (p . ). all isolates possessed a toxin gene. b, b , e, ı and cpe toxin genes were identified in . %, . %, . %, . % and . % of nd isolates, respectively. in the dd group, b and b were identified in %, e and ı were not identified and the cpe gene in . % of isolates. bhi enrichment did not significantly increase the yield of c. perfringens compared to sba but increased time and cost involved. c. perfringens (p . ) and c. perfringens toxin genes were present in equal proportions in nd and dd groups (p ! . ). culture of c. perfringens and pcr for toxin genes are of limited diagnostic utility due to the high prevalence of c.perfringens in normal dogs and the lack of apparent difference in toxin gene distribution between normal and diarrheic dogs. endoscopic biopsies are a relatively convenient, non-invasive test for feline infiltrative intestinal disorders. commonly, only the duodenum is examined due to cost, risks and time required to prepare the colon using lavage solutions, cathartics and/or enemas. the purpose of this study was to evaluate the consistency between endoscopic biopsies of the duodenum and ileum in cats. endoscopic biopsies from cats which had duodenal and ileal tissue specimens were evaluated retrospectively. all slides were randomized and reviewed by a single pathologist (jm) for quality, number of biopsies, and diagnosis according to wsava standards. no information regarding history, clinical signs, endoscopic findings, or previous histological diagnosis was made available to the pathologist. statistical comparison of the diagnosis of sc-lsa and ibd by intestinal location was conducted using fisher's exact test (p o . significant). of cats ( . %) were diagnosed with sc-lsa in the duodenum and/or ileum. of these cats, ( . %) were diagnosed with only duodenal sc-lsa, ( . %) were diagnosed with only ileal sc-lsa, and ( . %) had sc-lsa in both duodenum and ileum. in cats with only ileal sc-lsa, had severe ibd in duodenal biopsies, possibly consistent with early sc-lsa. of these had duodenal biopsies without evidence of sc-lsa. our results suggest there is a population of cats in which diagnosis of sc-lsa may only be found by evaluating ileal biopsies. clinicians should consider performing both upper and lower gi endoscopic biopsies in cats with suspected infiltrative small bowel disease. periodontitis is one of the most common diseases in cats and is mainly due to the presence of plaque and calculus. in this study, we investigated putative correlations between dental tartar and gingivitis and also between gingivitis and subgingival bacteria in cats. twelve cats (median age: years; range: - years; dsh and persians; females and males) were enrolled. dental tartar was obtained during scaling for a dental prophylactic procedure. all cats were negative for felv and fiv infection as assessed by a commercial elisa test (snap s fiv/felv combo test). severity of gingivitis (scores: - ; normal, mild, moderate, and severe) and dental tartar (scores: - ) were scored in each cat. endodontic paper points were applied for collecting a bacterial sample from the subgingival area and transferred to thioglycollate transporting media for bacterial culture. the relationship between gingivitis and tartar thickness scores was analyzed by spearman correlation. a student's t-test was used to compare the mean differences (gingivitis and tartar thickness scores) between upper and lower teeth. the association between severity of gingivitis and bacterial type was tested by chi square test. the spearman correlation coefficient for the average gingivitis score and the average tartar thickness score was . (p o . ). interestingly, the average tartar thickness scores from the upper jaw were significantly higher than those from the lower jaw (p o . ). the highest scores were found for the molar teeth in all cats. bacterial culture revealed . % anaerobic bacteria species (i.e., bacteroides spp., peptostreptococcus anaerobius, and eubacterium aerofaciens) and . % aerobic bacteria species (i.e., pasteurella multocida, streptococcus spp., enterococcus spp., staphylococcus spp., bacillus cereus, escherichia coli, and pseudomonas aeruginosa). anaerobic bacteria were found mostly in cats with higher gingivitis scores ( - ; chi square: p o . ), while pasteurella multocida was found mostly in cats with lower gingivitis scores ( - ; chi square: p o . ). antimicrobial sensitivity testing indicated that all of the anaerobic bacteria were sensitive to clindamycin, chloramphenicol, metronidazole, cefoxitin, or tetracycline, % were sensitive to erythromycin, and % were sensitive to penicillin. the most abundant aerobic bacterial species, pasteurella multocida, was sensitive to cefoxitin in all cases in which it had been cultured. these results suggest that anaerobic bacteria may be associated in the pathogenesis of severe gingivitis. these data warrant further studies of the prophylactic use of antibiotics in cats undergoing dental prophylactic procedures. inflammatory bowel disease is the most common cause of vomiting and diarrhea in dogs. although it can occur in any canine breed, certain breeds are more susceptible. we have previously shown that polymorphisms in the tlr and tlr gene are significantly associated with inflammatory bowel disease (ibd) in the german shepherd dog (gsd), a breed at risk of developing this disease. it would be useful to determine if these polymorphisms are significant in other canine breeds as this may allow the development of novel diagnostics and therapeutics to be applied to all canine breeds with ibd. therefore the aim of this study was to investigate whether polymorphisms in canine tlr and tlr genes are associated with ibd in other non-gsd canine breeds. four non-synonymous snps in the tlr gene; t c, g a, a t and g a and three non-synonymous snps in the tlr gene; g a, c t and t c previously identified in a mutational analysis in gsds with ibd were evaluated in a case-control study using a snapshot multiplex reaction. sequencing information from unrelated dogs with ibd consisting of different non-gsd breeds from the uk were compared to a breed-matched control group consisting of unrelated dogs from patients treated for noninflammatory disease at the royal veterinary college, london, uk. as in the gsd ibd population the two tlr snps; c t and t c were found to be significantly protective for ibd in other breeds included in this study (p . and p . respectively). this study confirms the protective effects of the two tlr snps (c t and t c) in other canine breeds with ibd. this highlights the importance of tlr in the pathogenesis of canine ibd and may represent common pathological pathways of ibd in different canine breeds due to the high degree of haplotype sharing seen among breeds. this may allow for the future expansion of novel diagnostics and therapeutics to be applied to all canine breeds with ibd. further functional studies looking at the role of tlr in the pathogenesis of canine ibd are needed to confirm these findings. toll-like receptor (tlr ) is an extracellular pattern recognition receptor belonging to the innate immune system. we have recently shown that three non-synonymous single nucleotide polymorphisms (snps) in the tlr gene (g a, c t and t c) are significantly associated with inflammatory bowel disease (ibd) in german shepherd dogs. in addition, we confirmed that two of these tlr snps (c t and t c) were significantly associated with ibd in a population consisting of different dog breeds. in order to determine if other novel snps exist in the tlr gene in addition to the ones identified in the gsd population, mutational analysis was carried out in seven boxer dogs with ibd. polymerase chain reaction was carried out to amplify the tlr coding region in the seven dogs with ibd. sequencing was carried out using sequence based typing with the abi prism sequencing kit (applied biosystems, uk) and analyzed using an abi automated sequencer (pe applied biosystems). sequencing information from seven boxer dogs with ibd from the uk were compared to the reference sequence published on the ensemble webserver (www. ensembl.org/canis_familiaris). in addition to the three snps identified previously in the tlr gene, a novel non-synonymous snp; t c was identified in the boxer dog population with ibd. this snp has never been reported before and was present as the homozygote genotype in three dogs with ibd and in one dog as the heterozygote genotype. using the simple modular architecture research tool (smart) web server (http:// smart.embl.de/) we were able to map the t c snp to the leucine rich repeat domain of the tlr protein. the leucine rich repeat domain is involved with ligand binding and therefore a change in the amino acid in this region may affect function, especially as the t c snp results in a change in the amino acid from non-polar to polar. our study further confirms the role of tlr in the pathogenesis of canine ibd. our results suggest that in addition to shared risk polymorphisms amongst breeds, individual breeds may harbor unique snps arising after breed formation which may further affect their susceptibility to this disease. however, a case-control study would be needed in the boxer dog to confirm the significance of the tlr t c snp and further functional data would be needed to elucidate the exact role of this polymorphism in canine ibd. an automated power driver device (oncontrol, vidacare) has recently become available for bone marrow aspiration (bma) and bone marrow biopsy (bmb) in humans. the purpose of our study was to compare this automated technique to the traditional manual technique for bone marrow sampling in cats. twelve healthy research cats were anesthetized using a standardized protocol on different occasions, days apart, to have bmas and bmbs performed by the same operator. on day , half of the cats were randomized to have a bma performed at both the proximal humerus and the iliac crest, and a bmb performed at the iliac wing, using the oncontrol device ( -gauge needle for bma; -gauge needle for bmb). the other half of the cats had the same procedures performed using a manual technique ( -gauge illinois needle for bma; -gauge jamshidi needle for bmb). on day , each cat had bma performed at the opposite humerus and iliac crest, and a bmb performed at the proximal humerus using the opposite technique from day . for each procedure, the operator was given a maximum of attempts to successfully collect a sample. the rate of success, as well as the number of attempts were recorded. the ''ease of use'' of the device was rated by the operator on a -point scale after each procedure. using previously determined criteria, the macroscopic and microscopic qualities of the bma and bmb samples were assessed by a board-certified pathologist, blinded to the technique used. the level of pain experienced by each cat was evaluated , , , , and hours following each set of procedures, using a previously validated pain scoring system. two sample t-tests were used to compare the automated technique to the manual technique and to compare the humerus to the iliac crest site for bmas and the humerus to the iliac wing site for bmbs. for all procedures, at all sites, the ''ease of use'' was better for the automated technique than for the manual technique (p o . ). the duration of the procedure and the number of attempts to collect a sample were significantly lower with the automated technique for bma at the proximal humerus (p o . ). there was no significant difference in the level of pain at any time point following each set of procedures with either technique. performing bma at the proximal humerus was associated with a higher rate of success (p o . ), a lower number of attempts (p o . ), a shorter duration of the procedure (p o . ), a higher-rated ''ease of use'' of the technique (p o . ), and a better quality sample (p o . ) when compared to sampling from the iliac crest, in conclusion, we found the automated bone marrow sampling technique suitable for use in adult cats. this technique was easier to use than the manual technique for both bma and bmb, and reduced the duration of the procedure and the number of attempts for successful bma at the proximal humerus. performing bma at the proximal humerus was faster, easier and allowed collection of better quality samples than at the iliac crest, independently of the technique used. the fractious nature of some feline patients sometimes makes sedation or general anesthesia necessary for routine procedures such as blood collection for hematologic analyses. it has been anecdotally reported that sedation or general anesthesia could induce variations in hematologic parameters in cats, making it important for the clinician to be able to anticipate potential changes on hematologic parameters that could result from chemical restraint. this study evaluated the effects of a standardizecd anesthetic protocol using ketamine ( mg/kg, iv), midazolam ( . mg/kg, iv) and buprenorphine ( mg/kg, im) on the hematologic parameters of healthy adult research cats. each cat had blood samples collected before and after induction of anesthesia on different occasions, days apart. in total, pairs of complete blood counts were obtained. analyses were performed at a certified veterinary laboratory. paired sample t-tests were used to determine whether there were any statistical differences between hematologic parameters before and after induction of general anesthesia, for each cat, on different occasions. compared to preanesthetic values there was a significant decrease in red blood cell count, hemoglobin concentration, hematocrit, lymphocyte count and plasma total protein concentration after induction of anesthesia. there was no significant difference in the segmented or band neutrophil, eosinophil, basophil, monocyte and platelet counts between the samples taken before and after induction of anesthesia. on average, there was a . % decrease in the red blood cell count ( .  /l to .  /l) (p o . ), a % decrease in hemoglobin concentration ( . g/l to . g/ l) (p o . ), a . % decrease in the hematocrit ( . l/l to . l/l) (p o . ), a . % decrease in the lymphocyte count ( .  /l to .  /l) (p . ), and a . % decrease in the plasma total protein concentration ( . g/l to . g/l) (p o . ) when samples taken before and after induction of anesthesia were compared. if only the hematocrit was considered as a marker of anemia, % of the samples from these healthy cats, taken while they were under general anesthesia, would have been misinterpreted as belonging to anemic patients (hematocrit o . l/l), using the reference interval established in our laboratory. none of the cats would have been considered anemic before induction of general anesthesia. in practice, the decrease in lymphocyte count following anesthesia is unlikely to be of clinical relevance, as all the samples except had a lymphocyte count that was within the reference interval for cats established by our laboratory. this study suggests that complete blood counts performed on blood taken under general anesthesia with this combination of anesthetic drugs in cats should be interpreted cautiously in order not to make a false diagnosis of anemia. the mechanism responsible for the decrease in circulating red blood cell mass following anesthesia induction in cats is unknown and requires further investigation. rivaroxaban is an oral inhibitor of activated coagulation factor x (xa). it is expected to have similar coagulation effects as low molecular weight heparin, without the need for injection, making it an attractive alternative for long-term anticoagulant therapy in cats. citrated blood obtained from five healthy adult cats was exposed in vitro to varying concentrations of rivaroxaban, followed by coagulation testing. the rivaroxaban was extracted from commercially available tablets (xarelto s ) and dissolved in dmso prior to addition to the blood. tests performed included kaolin-activated thrombelastography (teg), prothrombin time (pt), dilute pt (dpt), activated partial thromboplastin time (aptt), and anti-factor xa (axa) activity. dose-dependent prolongations were seen in all coagulation parameters. similar to human data, therapeutic axa levels (between . - . axa units) were achieved at in vitro concentrations between and mg/l. at mg/l, dpt measurements were clinically prolonged in all cats ( . ae sec vs. . ae . sec, p . ), while aptt values were only mildly prolonged from baseline ( . ae sec vs. . ae sec, p . ). significant prolongations were seen in dpt at ( . ae ec, p . ). teg r time did not prolong from baseline values until concentrations of mg/l were reached ( . ae min compared to . ae . min, p . ). rivaroxaban has similar coagulation effects in the cat as in other species and may play a role in feline thromboprophylaxis. kaolinactivated teg does not appear to be sensitive to low concentrations of rivaroxaban in the cat. anticoagulated blood is required for platelet function studies. sodium citrate, a calcium chelater, is the most commonly used anticoagulant to measure coagulation parameters including platelet aggregation but it may have a negative effect on platelet responsiveness. dogs are generally considered moderate responders to collagen on platelet aggregation and are notorious for being poor or inconsistent responders to adp-induced platelet aggregation using citrated whole blood. hirudin, a selective thrombin inhibitor, can also be used as an anticoagulant for coagulation assays and is the anticoagulant of choice for certain assays including the multiplate s platelet function analyzer. ten adult healthy dogs were used to compare whole blood platelet aggregation between citrated and hirudinated blood samples. venous blood was collected atraumatically from the external jugular vein directly into tubes containing . % trisodium citrate or hirudin. whole blood platelet aggregation was performed (whole-blood lumi-aggregometer, chrono-log corporation, havertown, pa, usa) with collagen ( mg/ml) and adp ( mm) as agonists. maximal platelet aggregation (ohms) was recorded. there was a significant increase in collagen-induced platelet aggregation from the hirudinated samples compared to the citrated samples ( . ae . vs. . ae . o, p o . ). there was also a significant increase in adp-induced platelet aggregation from the hirudinated samples compared to the citrated samples ( . ae . vs. . ae . o, p . ). the results of this study show a significant difference in platelet responsiveness between citrated and hirudinated whole blood using the chrono-log impedance aggregometer. while both collagen and adp-induced platelet aggregation was attenuated from citrated blood samples, this was most notable for adpinduced aggregation where almost all samples had no objective measurable platelet aggregation. it is suggested from this data that future whole blood platelet aggregation studies performed on the chrono-log impedance aggregometer should use hirudinated blood samples although new reference limits would need to be established. low-molecular-weight heparin (lmwh) is now used to prevent thrombotic complications in dogs. a functional assay such as the calibrated automated thrombogram (cat) may provide a new approach for monitoring lmwh therapy. we hypothesized that cat would detect decreased endogenous thrombin potential (etp) in healthy dogs receiving lmwh (fragmin s ). twenty-four healthy adult beagles were included in this study and divided equally in four groups. one dose of u/kg, u/kg or u/kg of lmwh were given subcutaneously to healthy dogs and compared to a control group. platelet poor plasma (ppp) was collected over a hour period. using a repeated-measure linear model, effect of lmwh on etp was time and dose dependent with a significant interaction (p o . ). compared to control dogs, significant differences were obtained for group u/kg at t (p . ), for group u/kg at t (p . ) and between t -t minutes (p o . ) respectively, and for group u/ at t (p . ), between t -t minutes (p o . ) respectively and at t (p . the cat assay can be employed to measure the effects of lmwh at different doses in healthy dogs, resulting in significant time and dose-dependent decreases in etp and warrants further investigation as a tool for monitoring lmwh therapy in dogs. the purpose of this study was to determine the effects of prednisone and prednisone plus ultralow-dose aspirin on coagulation parameters in healthy dogs, with an emphasis on thromboelastography (teg). this was a prospective, randomized, blinded study utilizing fourteen dogs determined to be healthy based on normal physical examination, complete blood count, biochemistry, urinalysis, and fecal floatation. dogs were evenly divided into either prednisone plus aspirin (pa) or prednisone plus placebo (pp) groups. baseline values for teg parameters (r, k, angle, ma, ly , ly , g, ci) were measured twice two days apart, and thrombin-antithrombin complexes (tat), and traditional coagulation parameters (prothrombin time, activated partial thromboplastin time, d-dimer, antithrombin (at), fibrinogen) were measured once. each dog received mg/kg/ day of prednisone, and either . mg/kg/day of aspirin (pa group) or placebo (pp group) for days. a complete blood count, biochemistry profile, teg, tat, and traditional coagulation parameters were then repeated on each dog. day to day variation was calculated for the teg parameters using the two baseline measurements. the change from baseline between and within each group were compared using t-tests, or wilcoxon sample test where appropriate, for teg, tat, traditional coagulation parameters, and hematocrit. day to day variation in teg was acceptable ( %) for ma, g, and angle, unacceptable ( %) for r, k, ly and ly , and not meaningful for ci. within both groups, ma, g, ci and fibrinogen significantly increased from baseline (p o . ). within both groups, ly and at significantly decreased from baseline (p o . ). for the pp group, ly significantly decreased from baseline (p . ), and approached significance for the pa group (p . ). all other within group changes from baseline were not statistically significant (p-values . ). for all parameters, there was no difference between groups for change from baseline (p values . ). day to day variation in some teg parameters is high and may preclude their clinical utility. prednisone causes hypercoagulability in healthy dogs based on increased g, ma, and ci. the addition of ultra-low dose aspirin to prednisone has no effect on the parameters measured in this study. 'aspirin resistance' has been identified in people and dogs that develop thrombi despite low dose aspirin therapy. variability in platelet cyclooxygenase (cox) isoform expression is one proposed mechanism for aspirin resistance in people. two isoforms (cox- and cox- ) have been identified in canine platelets. high (antiinflammatory) dose aspirin inhibits platelet function and alters expression of both cox isoforms in most dogs. this study evaluated the effects of low dose aspirin on platelet function and cox expression in normal dogs. twenty-five healthy client-owned dogs were evaluated before and at two time points (days and ) during aspirin therapy ( mg/kg po sid). platelet response to aspirin (siemens pfa- s ; collagen/ epinephrine cartridges), was stratified into one of three groups [aspirin responders ( dogs), non-responders ( dogs), or inconsistent responders ( dogs)]. flow cytometry identified platelet cox- and cox- expression. an elisa was used to measure urine -dehydro-thromboxane b ( -dtxb ). there were no significant differences between groups for cox- , cox- or -dtxb at any time point. when all dogs were considered as a single group, there was a significant increase (p o . Ã) in cox- and cox- mean fluorescent intensity (mfi) from baseline to day , . % ae . (mean ae sd) and . % ae . , respectively. there was a significant decrease in mean urine -dtxb :creatinine on day and by . % (p . à ) and % (p o . à ). as with our previous high dose studies, cox- expression was increased with aspirin exposure. however, there was a significant increase in cox- expression with low dose aspirin in contrast to the decrease seen at higher doses. our study suggests that levels of platelet cox- and cox- expression do not influence aspirin response in dogs. although thromboxane levels decreased in most ( of ) dogs on low dose aspirin, platelet function was consistently affected in only % of dogs, suggesting that differences in response to thromboxane may play a role in the variable affects of low dose aspirin on canine platelet function. delayed postoperative bleeding is common in retired racing greyhounds (rrgs), despite normal results of routine hemostasis assays. the excessive postoperative bleeding in the rrgs is not due to primary or secondary hemostatic defects, and may be due to enhanced fibrinolysis or to a clot maintenance dysfunction. providing a method to prevent or minimize the severity of postoperative bleeding in rrgs will not only have major economic impact for owners, but also will markedly decrease the associated complications of minor or major surgeries in the breed. epsilon aminocaproic acid (eaca) is a potent inhibitor of fibrinolysis that also supports clot maintenance due to unknown mechanisms. the objective of this double-blinded, prospective, randomized study was to evaluate the effects of eaca versus placebo on the prevalence of bleeding in rrgs, and to investigate its mechanism of action by using thromboelastography (teg). we compared the effects of eaca and placebo in rrgs that underwent elective ovariohysterectomy or orchiectomy at the veterinary medical center, the ohio state university during years. the main endpoint was bleeding (prevalence and severity); minor endpoints included most teg parameters. thirty percent ( / ) of the rrgs in the placebo group had delayed postoperative bleeding starting to hours after surgery, compared to % ( / ) in the eaca group (p . ). on the teg parameters, the r time (clot formation time) was significantly different between treatment groups (p . ). the postoperative administration of eaca significantly decreased the prevalence of postoperative bleeding in rrgs. thromboembolism associated with protein losing nephropathy (pln) has been long recognized as a serious and unpredictable complication in dogs, however its prevalence remains unknown. in humans, surrogate indicators are frequently used to assess thromboembolic risk. this study aimed to investigate the prevalence of hypercoagulability in pln dogs based on thromboelastography (teg), and to determine whether hypercoagulability in these patients could be predicted by clinical assessments that identify systemic hypertension (systolic blood pressure mmhg), hypoalbuminemia (serum albumin o . mg/dl), antithrombin activity (o %), and degree of proteinuria (urine protein:creatinine ratio [upc] ! ). between march -september , twenty-seven dogs were identified with pln at the animal medical center. the prevalence of hypercoagulability based on a teg g-value . was . %. there was no statistically significant relationship, either categorically or continuously, in univariate as well as multivariate analyses of all variables. univariate logistic regression (odds ratio; lower and upper confidence limit; p value) for hypertension was À . ; . , . ; . ; for albumin - . ; . , . ; . ; and for antithrombin activity - . ; . , . ; . . thus, in this patient population, in the absence of teg, prediction of hypercoagulability using abnormalities in commonly measured clinicopathologic variables was not helpful. however, given the documented high prevalence of hypercoagulability in patients with pln, early institution of prophylactic anti-platelet or anticoagulant therapies should be considered. thromboelastography (teg) is a test of global hemostasis. due to the effects of extrinsic factors on whole blood coagulation, sample collection method (scm) may influence results. the purpose was to determine if scm influenced teg using kaolin-activated citrated whole blood (wb). healthy dogs with normal platelet counts were prospectively enrolled. three wb samples were obtained from each dog at least hours apart from alternating jugular veins in a randomized order of three methods: ) vacutainer s into citrated tube (vac), ) citrated syringe with transfer into plain tube (cit), or ) plain syringe with transfer into citrated tube (plain). draw time was recorded in seconds. kaolin-activated teg was performed, with measurement of reaction time (r), clot formation time (k), maximum amplitude (ma), and alpha angle. eleven dogs were enrolled. there were no significant differences in teg indices between vac samples and either cit or plain samples. cit samples had a significantly higher k value (p . ) and a lower alpha angle (p . ) compared to plain samples. draw times ranged from - seconds. a longer draw time was significantly correlated (p . ; r À . ) with a shorter r time. higher platelet count was significantly correlated (p . ; r . ) with a higher ma. scm did not have a significant effect on teg parameters when comparing vac samples to either cit or plain samples. minimizing sample collection time and trauma during venipuncture may be important in minimizing hypercoagulable changes in teg indices. liquid plasma (lp) is defined as either plasma collected and refrigerated immediately after collection or fresh frozen plasma (ffp) that is thawed and stored refrigerated until use. stability studies in people have shown that adequate clotting factor activity is preserved for at least days. lp is transfused in human level i trauma centers to critically ill people requiring rapid infusion of clotting factors as the time required to defrost ffp is considered prohibitive. the use of lp has not been described in veterinary critical care. the purposes of this study were to ) determine the length of time required in a water bath for a unit of canine ffp to thaw and ) describe the use of lp in a busy university emergency room (er). for part : six units ( ml) of canine ffp were individually thawed in a c water bath. the duration of time (in minutes) to thaw was recorded. for part : the transfusion log was reviewed for dogs receiving lp in the last months. the indications and outcome were recorded. the mean time ae sd thaw time was . ae . minutes. ten units of lp were transfused to critically ill or injured dogs during the study time. indications for lp transfusion included hypovolemic shock due to intra-abdominal hemorrhage in dogs ( traumatic, non-traumatic) and rapid correction of hemorrhage following parenteral tissue plasminogen activator administration in dog. lp volume transfused ranged from . to . ml/kg. no transfusion reactions were identified. effect on coagulation was not consistently evaluated. time required to thaw a unit of ffp is greater than minutes which could be detrimental in a bleeding, coagulopathic dog. lp was transfused without incident to critically ill and injured dogs and represents a potential new addition to the armamentarium of treatments in a veterinary er setting. further investigation of canine lp is warranted including evaluation of in vitro factor stability and in vivo efficacy in correcting coagulopathy. immune mediated thrombocytopenia (imt) is associated with increased morbidity and mortality. large prospective research studies in dog platelet antibodies and clinical utilization of platelet immunoglobulin assays are limited. potential explanations include limited availability and low specificity due to nonspecific binding. the focus of this study is to evaluate optimized direct and indirect platelet surface associated immunoglobulin (psaig) and staining with anti-cd antibodies (cd ab) for the utilization in classifying thrombocytopenic dogs. one hundred clinically ill and apparently healthy dogs were prospectively evaluated. data collected included a history of hemorrhage, physical examination evidence of bleeding, complete blood count, and measurement of psaig and cd ab. the psaig assay utilized polyvalent antibodies with correction for non-specific binding by subtraction of background fluorescence with control antiserum. thrombocytopenia was defined as o , /ml and all dogs were clinically classified into of groups (g): g imt, n , g thrombocytopenia from non-immune mediated diseases, n , g ill with normal platelet counts, n , g healthy dogs, n . median platelet counts, by groups, were g , , ; g , , ; g , , ; and g , , /ml. for the direct and indirect psaigs in dogs with itp (g ), more dogs (n and n ) with clinical evidence of bleeding had antibodies compared to those who were not bleeding (n and n ). considering only direct psaig the sensitivity and specificity was % and %, respectively for the diagnosis of imt. for indirect psaig the sensitivity and specificity was % and %, respectively, for the diagnosis of imt. when considering both direct and indirect psaig together, the sensitivity was % with a specificity of %. in g interference from high control antiserum background staining was noted in . % of dogs and resulted in a negative direct psaig classification. minimal background interference was noted in g , g , or g . the percentage of platelets stained with cd ab was significantly less in g (median , p . ) vs. g (median , p . ) vs. g (median . , p . ) and g (median . ). these findings indicate the optimized platelet surface associated immunoglobulin assay has a high specificity, however poor sensitivity, for the diagnosis of imt. the decreased cd staining in g (imt group) may reflect decreased surface gpiiia expression, blocking by anti-gpiiia antibodies or other proteins, clearance by macrophages, or increased non-platelet debris and has potential applications in the diagnosis and treatment of imt. greyhounds have lower serum concentrations of a-globulin than other breeds, explained by negligible levels of haptoglobin (hp) measured using different methods (colorimetric, immunoturbidimetric and protein electrophoresis). the purpose of the present study was to characterize the hp gene in greyhounds. we isolated dna and rna from blood samples of akc-registered and retired racing greyhounds (akcg, rrg), and a german shepherd dog (gsd). we sequenced the hp exons and splice sites, and conducted array comparative genomic hybridization to identify associated dna structural variation (custom m agilent oligonucleotide array). additionally, we tested for the presence of one or multiple haplotypes spanning hp in greyhounds using a high density snp array ( k illumina hd). sequencing results of hp in both dna and cdna revealed three synonymous snps in the racing greyhound. we did not identify structural variation overlapping or near the hp gene. notably, we detected that the rrg and akcg do not appear to share a specific haplotype spanning hp. despite having low or undetectable serum concentrations of hp, we did find that rrg hp mrna is expressed and lacks amino acid variation. this suggests that the clinical absence of the hp is attributable to post-transcriptional hp effects or to an unknown physiological interaction. finally, given the existence of distinct rrg and akcg haplotypes spanning hp, it is important to characterize serum levels of hp in akcg in follow on studies. we reported that hemoglobin in retired racing greyhounds (rrg) has higher oxygen carrying properties and affinity than other breeds. surprisingly, very little is known about canine hemoglobin genetics. the purpose of this study was to characterize genetics of canine beta globins. using computational blast analysis of the dog genome, we identified five beta globin genes in a single locus: two human hbelike followed by three hbb-like genes. we isolated dna and rna from blood of rrgs, akc registered greyhounds (akcg), and german shepherd dog (gsd). all beta globin exons and splice sites were sequenced, and the beta globin locus was examined by array comparative genomic hybridization (custom m agilent array). additionally, we determined the number of common haplotypes that span this locus in rrgs and akcgs using high density snp array ( k illumina hd). expression and sequence analysis of cdna showed all five beta globin genes are actively expressed in adults. canhbb and were created by relatively recent segmental duplication and have identical protein sequence. canhbb / are abundantly expressed in adults; canhbb is expressed at greatly reduced levels. sequencing results revealed one rare non-synonymous single nucleotide polymorphism (snp) in hbe of rrgs, but no variation that could explain their abnormal hemoglobin. we did not detect structural variation overlapping or near the beta globin locus. notably, rrg and akcg do not share haplotypes spanning the beta globin locus. this is the first characterization of canine hemoglobin genetics, and the first report of canine embryonic hemoglobins and their expression in adults. sampling of the bone marrow in the dog from the costochondral (cc) junction can be performed with minimal to no sedation and readily available equipment but is not in widespread use in the united states. the aim of this study was to compare the number of attempts needed to successfully obtain a sample, the time needed for the procedure, and the sample quality between aspirates obtained from the cc junction and more traditional sites (humerus or femur) in healthy dogs when performed by novice and seasoned practitioners. samples were obtained from healthy anesthetized laboratory reared adult dogs after undergoing terminal endoscopic surgery. paired samples from separate dogs were obtained by each practitioner using either a gauge needle and cc syringe at the cc junction or an gauge rosenthal needle and cc syringe from either the proximal humerus or femur (clinician preference). three small animal veterinary interns, one experienced technician and one boarded internist were monitored for number of attempts to success and length of time needed for success of each procedure. slides were prepared by a single investigator and read by a blinded clinical pathologist. data were compared using the paired t-test for normally distributed data and wilcoxen signed rank test for non-gaussian distributions. five pairs of samples from three dogs were evaluated. two dogs had two pairs drawn from opposite limbs and ribs. mean number of attempts to success for traditional sampling sites ( . /À . ) and time to success ( . minutes /À . ) did not differ significantly from attempts ( . /- . , p . ) or time ( . /- . , . ) needed when aspirating from the cc junction. subjectively, samples were of similar quality with regards to cellularity and number of particles present when compared within practitioners. myeloid: erythroid ratio and percentage of lymphocytes were also not significantly different between sites (m:e ratio p . , lymphocyte % p . ) and were within normal limits. while there were no significant differences between the two sites in terms of number of attempts or time to success, it should be noted that the ''seasoned'' practitioners had never performed an aspirate at the cc site and had an increased number of attempts compared to the traditional sites. if the number of attempts needed for success decreases with experience, it is likely the time required would decrease as well. both subjectively and objectively, there were no significant differences in quality or cell populations between the two sampling sites in healthy dogs. based on this data, bone marrow aspiration from the cc junction appears to be equivalent to more traditional sampling sites in healthy dogs. larger studies in clinically ill dogs should be performed before routinely using the site in the clinical setting. recent research on iron homeostasis has elucidated the tightly controlled intestinal uptake of iron. hepcidin, the major hormone limiting iron absorption and release from macrophages, is downregulated by matriptase- , a transmembrane serine protease (tmprss ) produced by the liver. while iron deficiency is commonly caused by chronic blood loss anemia and rarely dietary deficiency or intestinal disorders in dogs and other species, we report here the clinical to molecular investigations of a dog with iron-refractory iron deficiency anemia (irida) caused by a matriptase- deficiency homologous to a recently described autosomal recessive disorder in humans. the proband, a spayed female cocker spaniel without any clinical signs except for recent occasional idiopathic seizures, exhibited a lifelong history of microcytosis and hypochromasia but not anemia. there was no evidence of any blood loss and the dog was receiving an appropriate meat-based diet. mean values of complete blood cell counts, performed from . - years of age, were: hematocrit % (normal reference range - ); rbc count .  /ml ( . - . x ); mcv fl ( - ); mchc g/dl ( - ). serum iron parameters revealed severe iron deficiency with serum iron mg/dl ( - ); total iron binding capacity mg/dl ( - ); serum iron saturation o % ( - %), and ferritin ng/dl ( - ). prolonged courses of oral ferrous sulfate supplementation and several short courses of intramuscular (dextran) injections and intravenous iron infusions did not result in improvement of any red cell or serum iron parameters. however, this dog was never anemic and the partial seizures could not be directly related to the iron deficiency status. no family members were available for further studies. genomic dna was extracted from the proband's edta blood and the exons of the tmprss gene were amplified with flanking primers and then sequenced. in comparison to the normal canine tmprss sequence and that of a sequenced control dog we found a homozygous missense muation, r h, toward the c-terminal end of the protein in the proband's gene. in conclusion, the severe microcytosis and hypochromasia, low serum iron parameters and lack of a response to oral and parenteral iron therapy led to the diagnosis of irida. the missense mutation in the matriptase- at position from an arginine, which is conserved across all species currently deposited in the genbank, to a histidine is likely the disease-causing mutation. this is the first report of an irida in the dog with features very similar to those observed in humans. dogs with naturally-occurring irida may be helpful in developing and assessing novel therapies. accidental ingestion of copper-coated zinc pennies minted after is the most common causes of zinc toxicity anemia in the dog. zinc toxicity anemia may also be seen with ingestion of zinc from other sources as ingestion of metallic foreign material other than pennies, medicines containing zinc, and zinc supplements. the purpose of this study was to determine if there is a weight below which dogs are more susceptible to zinc toxicity anemia secondary to metallic foreign body ingestion. records of dogs presented to the internal medicine service at the veterinary medical center of long island for metallic foreign body ingestion were reviewed for signalment, weight, presenting pcv, and type of metallic foreign body ingested. eighteen dogs met the inclusion criteria and were compared. of the dogs, there were cases of coin ingestion ( %), with ( %) involving ingestion of or more pennies. the other cases involved ingestion of a metallic object ( ), decorative garland ( ), and bb pellets ( ).of the dogs exposed to zinc, ( %) were less than pounds ( . kgs). of those cases ( %) had ingested one or more pennies. eleven out of the ( %) zinc exposure dogs were anemic at presentation. the average weight of the dogs was . pounds ( kg). this study showed that dogs less than pounds appear to be more susceptible to developing anemia secondary to zinc toxicosis, with the majority of cases due to ingestion of pennies minted after . zinc toxicity anemia secondary to penny ingestion is more commonly seen in small dogs. we suspect larger dogs are able to pass pennies through the pyloric sphincter and thus not develop clinical signs. although thrombocytopenia is common in hospitalized dogs, canine cryopreserved platelet concentrate (pc) is used infrequently. data suggest in vitro efficacy of pc and when administered to research dogs, but efficacy is unknown in clinical patients. study objectives were to determine clinical characteristics of dogs receiving pc as well as safety and efficacy of pc in thrombocytopenic dogs. medical records were evaluated retrospectively to identify dogs that received pc. information evaluated included patient characteristics, platelet count, acute transfusion reactions, and survival. twenty six dogs met study criteria. dogs receiving pc ranged in age from - years (mean . years) and / ( . %) were spayed or intact females. hemorrhage was reported in / dogs ( . %) prior to pc transfusion. platelet counts prior to transfusion ranged from to  /ul (mean . /À .  /ul). change in platelet count was measured in dogs and the mean change was . /À .  /ul. dose of pc administered ranged from . to ml/kg with a mean of . /À . ml/kg. no acute adverse reactions were reported. there was no correlation between transfusion dosage and platelet count change post transfusion. survival to discharge occurred in / ( . %) of dogs. the only variable correlated with survival was age with survivors being younger than non-survivors ( . years-old ae . vs. . years-old ae . .; p . ). efficacy of cryopreserved pc transfusions for improving clinical outcome in dogs with thrombocytopenia is yet to be determined; however, pc is well tolerated in clinical patients. fresh frozen plasma (ffp) is used to treat coagulopathies in dogs. current transfusion guidelines recommend that ffp be administered within hours of thawing to avoid decreasing clotting factor function and bacterial contamination. the purpose of this study was to assess clotting factor activity and bacterial contamination of ffp that had been thawed and refrigerated for days. blood was collected from client-owned healthy dogs with no known history of coagulopathy or of administration of drugs affecting coagulation. plasma was separated from whole blood and frozen (À c) within minutes of collection. thawed plasma was maintained at c ( /À c). aerobic and anaerobic bacterial culture, prothrombin time (pt), activated partial thromboplastin time (ptt), and factor ii, vii, ix, and x analyses were tested at time of whole blood collection, ffp thaw, hours post-thaw, hours post-thaw, and hours post-thaw. there were no statistically significant differences in pt and ptt at any of the measured time points. statistically significant differences occurred between initial measurements of factors ii, vii, ix, and x and subsequent time points, but there was no difference in activity levels of the factors once ffp was thawed. one bacterial colony was grown from each of two samples from post-thaw plasma. thawed plasma protocols do not significantly decrease the function of factors ii, vii, ix, and x or prolong pt and ptt. bacterial contamination of the plasma supply seems unlikely, but strict aseptic technique should be used when obtaining plasma for patient use. erythrocyte pyruvate kinase (pk) deficiency is the first and most common erythroenzymopathy described in dogs, cats, and humans. the pk enzyme plays a crucial role in the erythrocyte energy metabolism and its absence causes severe hemolytic anemia, often misdiagnosed as autoimmune hemolytic anemia. the disease is inherited as an autosomal recessive trait and affected dogs also develop osteosclerosis. in dogs, the enzymatic diagnosis is complicated by the anomalous expression of malfunctioning m -pk expression, but breed-specific r-pk mutation tests have been reported for basenjis, west highland white terriers (whwt), and beagles. we report here on a survey of canine pk deficiency studied at the penngen laboratory. a biased group of samples were received for screening from dog breeds with known mutations as well as from dogs with chronic, prednisone-and antibiotic-resistant hemolytic anemia and their relatives. edta blood samples and/or cheek swabs as well as medical record information were received and genomic dna and/ or enzyme activity testing were performed. among the whwts % and % were found to be homozygous deficient dogs or carriers, respectively, with a mutant allele frequency of . . the average age at the time of diagnosis was . years ranging from months to years of age; some samples came from europe and south america. of the beagles studied, % were affected and % were carriers (mutant allele frequency . ). the average age at the time of diagnosis was years ranging from months to years. surprisingly, very few samples from basenjis were received for screening, and none showed the mutant allele. while pk-deficient basenjis lived o years, whwt and beagles often show milder signs and can reach years of age. several dogs from other breeds were also examined because of chronic regenerative anemia and none had any of the known mutations seen in the other breeds. however, based upon pk enzyme activity studies, chihuahua, dachshund, miniature poodle, spitz, eskimo toy, and labrador retriever dogs were found to be affected; they also had osteosclerosis and at least one labrador retriever developed severe hemochromatosis (hepatic iron , ppm; normal o , ppm, analyzed on a dry weight basis). moreover, sequencing of the r-pk cdna from a pk-deficient labrador retriever revealed a new nonsense mutation in exon . in conclusion, pk deficiency appears to be a common cause for hemolytic anemia in certain breeds, and mutation testing makes screening simple. pk deficiency should also be considered in dogs of other breeds which may require the more cumbersome enzyme testing. studies to identify new mutations will confirm and simplify the diagnosis. supported in part by nih grant rr . immune-mediated hemolytic anemia (imha) is a common hematological condition observed in dogs. the diagnosis is based on clinical history, presenting signs and hematological evidence of imha such as regenerative anemia, leucocytosis and presence of spherocytes. the definitive diagnostic procedure is the coomb's test (direct antiglobulin test, dat) which is known to be highly specific but lacks diagnostic sensitivity. direct flow cytometric assay (fca) for igg, igm or c coated red blood cells (rbcs) detection might be more sensitive and thus could be introduced as an alternative diagnostic tool. to investigate the usefulness of fca for imha diagnosis, evaluation of igg, igm or c coated rbcs was performed from dogs presented at the veterinary hospital at usp that fulfilled clinical and hematological criteria for imha. thirty eight healthy dogs were included as controls. dat was performed with polyvalent and monovalent anti-dog sera with twofold serial dilutions of each one, incubated with % rbcs suspension at c and c. for fca, % rbcs from anemic and healthy dogs were incubated with fitc anti-dog igg, anti-dog igm and anti-dog c and submitted to flow cytometry evaluation. specific software and mann whitney u test were used for data analysis. five dogs showed positive results for dat with polyvalent coombs reagent at c (titer to ) and c (titer to ) but only three of them had agglutination titer for anti-igg at c ( to ) and c ( to ). no positive results were observed for anti-igm and anti-c dat. by fc, percentage of igg, igm and c coated rbcs in normal and anemic dogs were, respectively, , % and , % (p o , ); , % and , % (p o , ); , % and , % (p o , ). igg coated rbcs percentage were higher in dogs showing dat positive results (min. , %; max. , %; median , %). direct flow cytometric erythrocyte immunofluorescence assay is more sensitive than dat for detection of antibodies coated rbc in anemic dogs and may provide quantitative data useful for laboratorial diagnosis of imzha. bone marrow aspirates from cats are typically obtained from the ilium, humerus or femur, but may be difficult to obtain and/or of poor quality. in this study the feasibility, safety, and nature of sternal aspiration in cats was investigated. under general anesthesia, bone marrow aspirates were obtained in a randomized order by a single investigator from the sternum and ilium of healthy cats weighing . - . kg, with body condition scores of - (on a scale of - ). for sternal aspirates, cats were positioned in sternal recumbency and a -inch, - ga hypodermic needle attached to a cc syringe was inserted into the cranial manubrium and directed caudally along the long axis of the sternum. aspirates were also obtained from the right iliac crest using an ga illinois needle attached to a cc syringe. difficulty of site localization, needle insertion and advancement, and specimen aspiration, were scored from (easiest) to (hardest). bone marrow smears were prepared by one investigator and reviewed by a pathologist blinded to aspiration site and cat. sample quality was scored from (no marrow particles) to (excellent) based on the number of wellsmeared marrow particles on the slide. particle cellularity was scored from ( % fat) to (o % fat). post-procedure, cats were treated with tramadol ( - mg/kg, po, q h) for days, and assessed for post-biopsy pain (colorado state university feline acute pain scale, range [no pain] - [maximum]) and site swelling (range [none] - [marked]). data were analyzed by ancova accounting for effects of weight and body condition score. pneumothorax was not identified. it was significantly easier to perform sternal than iliac aspiration, but the quality of the sample was significantly better for iliac than for sternal aspirates. because of limitations due to sample quality, bone marrow morphology in sternal samples could not be compared to iliac samples in all cats. for samples that could be compared, cellularity was identical for sternal and iliac samples from cat but underestimated in the sternal sample from another cat. myeloid:erythroid ratios and lymphocyte numbers were the same for sternal and iliac samples in and cats, respectively. megakaryocyte numbers were the same in one sample, less in sternal samples compared to iliac samples from cats, and overestimated in the sternal sample from cat. bone marrow cell morphology was normal in all acceptable samples. it was concluded that sternal aspiration of bone marrow using a - ga hypodermic needle is ) easier to perform than iliac aspiration; ) safe; but ) provides samples of lower quality than iliac aspiration in cats. the diameter of - ga jamshidi-type needles makes bone marrow core biopsy difficult in cats. in this study, biopsies of the left humeral head were taken under anesthesia using a -inch, ga needle (ez-io s intraosseous infusion system, vidacare) from healthy cats weighing . - . kg with body condition scores of - (on a scale of - ). humeral biopsies were compared to biopsies taken from the left iliac crest using a -inch, ga jamshidi needle. biopsies were performed in randomized order by one investigator. biopsy was repeated to a maximum of attempts until a specimen ! mm long was obtained. difficulty of site localization, needle insertion and needle advancement were scored from (easiest) to (hardest). specimens were wrapped in tissue paper and placed in davidson's fixative for min and then transferred to formalin. biopsy sections were reviewed by a pathologist blinded to biopsy site and cat. biopsy length on the slide was measured, and biopsy quality was scored from (no hematopoietic tissue) to (! intertrabecular spaces free of artifact). post-procedure, cats were treated with tramadol ( - mg/kg, po, q h) for days, and assessed for postbiopsy pain (colorado state university feline acute pain scale, range [no pain] - [maximum]) and swelling of biopsy sites (range [none] - [marked]). data were analyzed by ancova accounting for effects of weight and body condition score. there were no significant differences between ga and ga biopsies except for post-biopsy swelling, and there were no significant effects of body weight and body condition. six ( %) of ga and ( %) of ga biopsies were considered acceptable specimens for assessment of bone marrow architecture and morphology; all intact spaces in these biopsies had normal hematopoiesis and cell morphology. comparison of acceptable ga to ga biopsy specimens from cats showed no significant differences for cell density and lymphocytes/plasma cells, while cellularity, assessed as high in of the ga biopsies, was assessed as medium in corresponding ga biopsies; and megakaryocytes, assessed as - /low-power field in one ga biopsy, were assessed as /low-power field in the ga biopsy. myeloid:erythroid ratios were greater in ga biopsies compared to ga biopsies in cats, and less in the ga biopsy in one cat. discordant results between biopsies were not related to differences in quality. in conclusion, ga bone marrow biopsy of the humerus was as likely to yield a specimen of acceptable quality as was ga biopsy of the ilium, and resulted in less post-biopsy swelling. reports on canine acute liver failure (alf) include individual or small case series of animals with a specific diagnosis. the aim of this study was to describe the clinical course, outcome and etiology of alf in dogs presenting to a referral hospital. medical records ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) were reviewed for a diagnosis of alf (elevated serum bilirubin or icterus with concurrent coagulopathy or hepatic encephalopathy (he)). fifty cases were identified representing breeds: labradors retrievers, golden retrievers, german shepherds, and cocker spaniels. median age was years ( m to humerus, ga . ae . . ae . . ae . . ae . à ( . - . ) ( - ) ( - ) ( - ) ilium, ga . ae . . ae . . ae . . ae . . ae . . ae . à ( . - . ) ( - ) ( - ) ( - ) ( - ) ( - ) yrs). presenting signs included anorexia ( / ), vomiting ( / ), polydipsia ( / ) and neurologic signs ( / granulomatous hepatitis (gh) is a histopathological diagnosis characterized by focal aggregations of activated macrophages mixed with other inflammatory cells that is usually part of a systemic disease process (wsava). published case reports describe many potential infectious causes, but only one retrospective study involving nine dogs with gh has detailed clinically relevant findings. the aims of this study were to describe the clinical and clinicopathologic findings in dogs with a histopathological diagnosis of gh, and to identify infectious agents using differential staining techniques, pcr, and fluorescence in-situ hybridization (fish) in archival paraffin-embedded tissues from dogs with gh. medical records of dogs with a histopathological diagnosis of gh (n ) were reviewed and signalment, historical toxin exposure or evidence of other systemic diseases, clinical signs, physical exam findings, clinicopathologic test results, imaging findings, concurrent diagnoses, treatments administered, and case outcome, when available, were extracted and summarized. twelve archival formalin-fixed, paraffin-embedded hepatic tissue samples were available for special staining and molecular diagnostic testing. two of these samples had sufficient tissue for only pcr. the mean age of dogs with gh was years (median . years; range to years) and included males and females representing different breeds. common presenting complaints included inappetance or anorexia (n ), weight loss (n ), lethargy (n ), fever (n ), and vomiting (n ). high mixed liver enzyme activity ( / ) was the most common clinicopathologic abnormality. leukemia was diagnosed in one dog and copper-associated hepatopathy in dogs. no infectious agents were identified using differential staining techniques. bartonella species dna was not pcr amplified from the extracted archival tissue. furthermore, no bacteria were identified by means of fish using a universal eubacterial probe. these data suggest a possible role for copper accumulation in the genesis of gh in dogs and support further evaluation of dogs with gh for evidence of copper-associated hepatopathy. future studies should include detailed environmental histories, the collection of adequate sample volumes for quantification of hepatic copper content and the examination of frozen tissues using novel molecular diagnostic platforms. hepatocyte copper and iron accumulation contribute to cell loss, inflammation, and fibrosis. the purpose of this study was to compare copper and iron accumulation in feline liver samples with different disease processes. liver biopsies (n ) submitted between july , and june , were evaluated using wsava guidelines and categorized as non-hepatic/normal, congenital, inflammatory/infectious, neoplastic, and other. copper (by rubeanic acid) and iron (by prussian blue) accumulation were graded by increasing amounts ( - ) and location (centrilobular cl, midzonal mz, periportal pp, random r). associations between metal scores and diagnosis category were assessed using the kruskal-wallis test. histologic diagnoses were non-hepatic/normal (n ), congenital (n ), neoplastic (n ), infectious/inflammatory (n ), and other (n ). ninety-two samples were negative for copper; remaining samples were graded (n ), (n ), and (n ). histologic diagnoses (pattern) for positive samples were congenital ( cl), infectious/inflammatory ( : cl, mz, pp, r), neoplastic ( pp), and other ( cl). iron staining was negative in samples; remaining samples were graded (n ), (n ), and (n ). distribution was primarily cl (n ) or r (n ), though mz (n ) and pp (n ) distribution occurred. there were no significant differences by kruskal-wallis analysis for amount or location of hepatocellular iron or copper for the different disease categories. in this study, copper accumulation was rare, had variable distribution and occurred primarily in samples with inflammatory/ infectious disease. in contrast, iron accumulation was common and did not correlate with disease category. further prospective evaluation of copper and iron accumulation in feline liver disease and association with outcome may be warranted. chronic hepatitis (ch) in dogs is a progressive condition without clearly defined treatment. glucocorticoids are commonly used to stop progressive inflammation and fibrosis but are associated with significant side effects including a steroid hepatopathy that complicates enzyme monitoring. cyclosporine is proposed as an alternative therapy, but there are no published reports of its use for canine ch. patient records at the csu veterinary teaching hospital were searched for histologically confirmed cases of ch treated with cyclosporine. data were compiled on cyclosporine dosing, concurrent medications, clinical course and biochemical parameters. patients over a -month period were identified. serum alanine aminotransferase (alt) decreased by an average of % in dogs. the alt normalized completely in of dogs treated for days. in of dogs on mg/kg/day, the alt also normalized. five of the patients that exhibited clinical signs prior to treatment showed measurable improvement (weight gain, fewer gastrointestinal signs). eight patients had hyperbilirubinemia or ascites prior to treatment; these resolved in . post-treatment histopathology, available in one patient, revealed decreased severity of ch. five patients exhibited adverse effects including gastrointestinal signs ( ), gingival hyperplasia ( ), and papillomatosis ( ). cyclosporine was discontinued in dogs with gastrointestinal signs. cyclosporine was an effective therapy for many cases of ch and should be considered for patients who are refractory to or cannot tolerate glucocorticoids. prospective clinical trials with histological documentation are needed to better define cyclosporine's effectiveness in ch. insertion of the veress needle and establishment of pneumoperitoneum is associated with to % of all laparoscopic complications in humans. the purpose of this study was to determine the accuracy of interpretation of tissue impedance measurements for veress needle location. two laparoscopists, blinded to impedance measurements, placed reusable veress needles in cadaverous dogs euthanized for reasons unrelated to the study. placement order was randomized. a third individual evaluated impedance measurements using a handheld device (sensormed, knoxville tn) to determine correct versus incorrect needle placement. veress needle locations were marked using contrasting colors of india ink; tissues were dissected to determine ink locations. impedance measurement interpretation identified / correct and / incorrect placements, respectively. sensitivity, specificity, accuracy, and precision for correct veress needle placement are listed below. agreement was moderate (kappa . , p . ) for placements by operator and very high (kappa . , p o . ) for placements by operator . results for tissue impedance measurement interpretation are superior to published data for currently available tests. impedance measurements accurately detected all incorrect needle placements. comparison of needle placement with and without tissue impedance feedback will be necessary to determine whether it increases operator detection of inappropriate veress needle placement and decreases installment phase complication rates. delayed detection of intestinal perforation during veress needle insertion is associated with high mortality. the purpose of this study was to evaluate the accuracy of tissue impedance measurement interpretation for veress needle location. two laparoscopists, blinded to impedance measurements, placed reusable veress needles in cadaverous cats. placement order was randomized. a third individual evaluated impedance measurements (sensormed, knoxville, tn) to determine placement location. needle locations were marked using india ink; tissues were dissected to determine ink locations. impedance measurement interpretation identified / correct and / incorrect placements. all undetected incorrect placements were located within the retroperitoneal fat pad. sensitivity, specificity, accuracy, and precision for correct veress needle placement are listed below. correlation was absent (kappa À . , p . ) for placements by operator and substantial (kappa . , p o . ) for operator . there was no association between correct or incorrect placement and operator on chi-squared analysis. failure of impedance measurements to identify placement in the retroperitoneal fat pad resulted in poor accuracy and discordant kappa statistics. small cat size limited the number of appropriate placement sites, perhaps resulting in excessively dorsal placement. comparison of needle placement with and without tissue impedance feedback will be necessary to determine whether impedance measurements increase detection of inappropriate veress needle placements or decrease installment phase complication rates. best clinicopathologic tests detecting portosystemic shunting (pss) in dogs remains controversial. this retrospective study examined performance of single random "fasting" and paired serum bile acids (sba; pre-and -hr post-feeding) in a large population of non-icteric dogs with confirmed pss (abdominal ultrasound, colorectal scintigraphy, radiographic or spiral-ct portography, laparotomy, or necropsy). sba were measured by enzymatic colorimetric method with normal o mmol/l. dogs meeting inclusion criteria (n ) included portosystemic vascular anomalies (psva; extrahepatic [e-psva], intrahepatic [i-psva]), and acquired pss (apss). signalment and laboratory parameters were recorded. non-parametric statistical analyses were used, two-tailed p o . applied with bonferroni corrections. median age and weight of breeds were . ( . - ) yrs and . ( . - ) kg, with equal gender distribution. random "fasting" sba detected % psva and % apss, whereas post-feeding sba detected % psva and % apss. low protein-c (o % activity) occurred in % psva and % apss. low mcv and creatinine occurred in % and % of psva dogs, respectively; other tests were less helpful. in apss, post-feeding sba was superior. compared to apss, psva had significantly (p . ) lower mcv, cholesterol, bun, creatinine, glucose, and protein-c. compared to e-psva, i-psva had significantly (p . ) lower post-feeding sba, mcv, albumin, urine specific gravity, and protein-c but higher cholesterol and glucose. post-feeding sba reflect physiologically provoked bile acid challenge and should be the preferred sba test in non-icteric dogs for pss detection. protein-c assists in identifying psva but its utility in apss may be complicated by concurrent coagulopathies and inflammation. this study compared outcomes of treatment with adjunctive nonsteroidal anti-inflammatory drugs (nsaids) or anti-inflammatory glucocorticoids in dogs with severe pulmonary blastomycosis. medical records were reviewed for dogs diagnosed with blastomycosis at the university of illinois veterinary teaching hospital between and . dogs with a presenting pao of mmhg, and clinical or radiographic signs of respiratory blastomycosis were included. all dogs were treated with either itraconazole, fluconazole, amphotericin b, or a combination of these. group (g ) dogs were treated with nsaids and group (g ) dogs were treated with glucocorticoids as anti-inflammatory adjunctive therapy. the following comparisons were made: days of oxygen supplementation, days in hospital, survival to discharge, and long term patient survival. mann-whitney u tests and chi-squared tests were performed on continuous and categorical data, respectively. p o . was considered significant. sixty-eight dogs fit the inclusion criteria. g consisted of dogs and g consisted of dogs. the two groups were found to be similar in weight, age, and sex distribution. there was no significant difference between the two groups with regard to duration of oxygen supplementation, duration of hospitalization, survival to discharge, and patient survival. there does not appear to be a difference between the clinical course or patient outcomes between groups of dogs with severe pulmonary blastomycosis treated with nsaids or anti-inflammatory glucocorticoids. further studies need to be performed to fully evaluate the impact these adjunct treatments have on prevention of ards and additional respiratory complications. diagnosis of feline histoplasma capsulatum infection traditionally relies upon identification of organisms in circulating monocytes or affected organs. in recent years, an antigen assay (aa) was developed for the diagnosis of disseminated histoplasmosis in human patients, but there is little information describing this test in cats. the goal of this study was to determine the sensitivity and specificity of h. capsulatum aa in cats with clinical disorders suggestive of histoplasmosis. urine and serum h. capsulatum aa results for feline patients from veterinary hospitals were evaluated. medical records were reviewed for confirmatory evidence of histoplasmosis (based on cytological or histopathological findings) or an appropriately supported alternate diagnosis. aa results were available for cats; initial testing was performed on urine samples, serum samples, and unspecified sample. of these cats, / had a definitive diagnosis of histoplasmosis based on organism identification, and had a definitive alternate diagnosis (e.g., neoplasia, other infection) based on necropsy findings (n ) or other clinical data (n ). an additional cats had a clinical alternate diagnosis with no cytological or histopathological evidence of histoplasmosis in the affected body system(s). the remaining cats had unverified histoplasmosis (n ) or an open diagnosis (n ). of the cats with confirmed histoplasmosis, were positive on initial urine aa. one cat (with rectal involvement) was negative, indicating a test sensitivity of %. one cat was positive on urine aa but negative on serum aa. all of the cats with definitive or clinical alternate diagnoses had negative results on the aa, suggesting an excellent specificity ( %). however, this result should be interpreted with caution, as the possibility of primary or concurrent histoplasmosis was only definitively excluded in the patients who underwent necropsy examination. these findings suggest that the aa for h. capsulatum is a reliable diagnostic tool in this species. a positive result appears to reliably support the presence of infection, but a small percentage of infected cats may be negative on aa. in addition, tests performed on urine may be more sensitive that those performed on serum. the purpose of this study was to evaluate the sensitivity and specificity of an aspergillus galactomannan antigen enzyme immunoassay (ga-eia) for the diagnosis of canine systemic aspergillosis. serum and urine samples were collected from sick dogs at hospitals (ucd and tamu). group dogs were diagnosed with systemic aspergillosis using culture (sterile site) or microscopy and culture (non-sterile site). group dogs had clinical findings suggestive of aspergillosis but an alternate diagnosis was established. group dogs were not suspected to have aspergillosis. samples were tested using the ga-eia and results expressed as a galactomannan index (gmi). gmis . were considered positive. comparisons were performed using the mann-whitney test. there were dogs in group , in group , and in group . serum was collected from all dogs, and urine from , , and dogs, respectively. serum gmis did not differ from urine gmis across groups. serum gmis of group dogs were higher than those of group and group dogs (p o . ). results from dogs in group did not differ from those in group (p . ). two dogs in group tested negative, but had localized pulmonary infections. one dog in group , which had paecilomycosis, tested positive. two dogs in group tested positive. one was being treated with plasmalyte. the other had a cutaneous opportunistic mycosis. these data support the utility of this assay to aid in the diagnosis of systemic aspergillosis in dogs. anaplasma phagocytophilum, an ixodes tick transmitted rickettsial bacterium has a wide mammalian host range that is not commonly reported in cats. clinical signs in humans, dogs and cats are often vague and include lethargy, anorexia and malaise. the purpose of this retrospective study was to describe the clinical signs, laboratory data and response to treatment in cats that tested positive for a. phagocytophilum on a commercially available pcr of peripheral blood (fastpanel tm ). this study describes and reports the appearance of intracellular morulae in feline neutrophils contributing to the diagnosis of a. phagocytophilum. the a. phagocytophilum real-time pcr (rt pcr) assay consists of four multiplexed primer systems designed to detect a total of three distinct genes. amplicons were confirmed as a. phagocytophilum by dna sequencing. clinicopathologic data was obtained by review of medical records and interview of primary veterinarians. complete blood counts were available from / cats and / blood smears were reviewed. the cats included in this study were all positive for a. phagocytophilum by real-time pcr. the cats ranged from months to years of age with an average age of . years. fifteen of cats had a history of tick exposure and lived in the northeastern region of the us, an ixodes endemic area. all cats presented with lethargy, / were anorexic and / had a fever (temperature o f). other clinical findings included hepatomegaly, splenomegaly, ataxia and ocular changes of conjunctivitis and elevation of the nictitating membrane. hematologic findings included leukopenia ( / ), neutropenia ( / ) and lymphopenia ( / ). thrombocytopenia was not noted in any case. morulae were seen within neutrophils in / cases. all cases in this report responded to treatment with doxycycline. this is the first report of the identification of morulae within neutrophils via peripheral blood smear review in cats confirmed by rt pcr to be infected with anaplasma phagocytophilum in north america. infection with anaplasma phagocytophilum should be considered in a clinically ill cat with tick exposure, living in an ixodes endemic area that presents to a veterinarian for lethargy, anorexia and fever. the spectrum of disease manifestations and the accompanying clinicopathological abnormalities indicative of bartonellosis in dogs have not been thoroughly characterized. the objective of this unmatched case-control study was to compare signalment, clinical and pathologic findings in clinically-ill dogs suspected of a tick-borne disease that were negative for bartonella sp. dna (controls) as were the dogs diagnosed with bartonellosis by pcr amplification, dna sequencing and the bapgm (bartonella alpha proteobacteria growth medium) enrichment culture approach. both groups were tested under the same laboratory conditions and in the same time frame. medical records were reviewed for information regarding signalment, medical history, physical examination findings, clinicopathological abnormalities, microbiological data and treatment. the study population consisted of bartonella-infected dogs and non-infected dogs. healthy dogs with no historical illnesses, such as blood donors, were excluded. the following species were amplified: b. henselae (n , . %), b. vinsonii subsp. berkhoffii (n , . %), b. koehlerae (n , . %), b. volans-like (n , . %), b. bovis (n , . %). nineteen ( . %) bartonella-infected dogs were febrile and lethargic and ten ( . %) had neurological signs. laboratory abnormalities for both groups are summarized below (number of affected dogs provided in parenthesis): multivariate logistic regression using confounding factors was performed to establish potential associations between specific variables and bartonella sp. infection. there were no differences in signalment, age, sex, body weight and duration of clinical signs between the two groups. compared to the control population, infection with the genus bartonella was associated with a diagnosis of endocarditis (p . , or . , %ci . - . ) and hypoglobulinemia (p . , or . , % ci . - . ). controls were more likely to have joint effusion (p . , or . , % ci . - . ) and azotemia (p . , or . , %ci . - . ) than were the bartonella sp. infected dogs. bartonella was detected in dogs with signs such as fever, anemia, thrombocytopenia, hyperglobulinemia and proteinuria that are typically associated with tick-borne diseases. when endocarditis or hypoglobulinemia are detected, testing for bartonella should be prioritized. likewise, the detection of bartonella should prompt further testing for endocarditis, if not already investigated. surveillance studies in other species depend on detection of antibodies to the highly conserved influenza a nucleoprotein (np); however, no such antibody detection assay is approved for canine use in the u.s. the purpose of this study was to determine the diagnostic accuracy of a commercial blocking elisa used for avian species in detecting influenza a np antibody in dogs. since the blocking elisa is not a species-specific or viral subtype-specific format, we hypothesized that it would detect np antibodies in dogs infected by influenza a virus. serum samples from uninfected dogs (n ) and dogs naturally infected with canine influenza h n (n ) were tested using the idexx flockchek blocking elisa for influenza a np antibody according to manufacturer instructions. the sample/negative control (s/n) absorbance ratios for infected dogs ranged from . to . compared to . to . for uninfected dogs. a receiver operating characteristic (roc) curve analysis determined optimum diagnostic sensitivity ( . %) and specificity ( . %) at a s/n cutoff ratio of . . using this cutoff ratio, the overall diagnostic accuracy was . %. coefficients of variation for intra-assay ( . %) and inter-assay ( . %) testing demonstrated good repeatability with canine sera. the excellent diagnostic accuracy of the commercial blocking elisa makes it a suitable tool for large-scale surveillance of influenza a virus exposure in dogs. upper respiratory disease (urd) can affect a majority of cats in shelters and is one of the leading reasons for euthanasia of otherwise adoptable cats. the purpose of this study was to determine prevalence and risk factors for upper respiratory pathogens in four different models for managing unowned cats: short-term animal shelters (shel), long-term sanctuaries (sanc), home-based foster care (fost), and trap-neuter-return (tnr) programs. conjunctival and oropharyngeal swabs were collected from cats, half of which had clinical signs of urd, and tested for feline herpesvirus (fhv), feline calicivirus (fcv), chlamydiophila felis, bordetella bronchiseptica (bb) and mycoplasma felis by real-time pcr. management model, vaccination, sex, age, body condition, and clinical signs were evaluated as risk factors for infection. a majority of cats in all management models carried one or more organisms capable of causing urd. in many cases, prevalence was similar in cats with or without clinical signs. unlike diseases that can be controlled by segregation of symptomatic animals, the lack of strong correlation between the presence of pathogens with the presence of clinical signs suggests that feline urd control should be managed by vaccination before or at the time of intake ,biosecurity protocols that presume all cats may be shedding pathogens, and minimizing stressful conditions that contribute to disease susceptibility. depending on geographical location, sex, age and environment, - % of cats worldwide are infected with the feline immunodeficiency virus (fiv). knowledge of the fiv status of cats is important to limit the spread of disease and to institute appropriate health management. however, like all lentiviruses, fiv is highly variable in nucleotide sequence, and viral load in cats is variable during different disease stages. detection of antibodies is the most widely employed diagnostic approach, but does not distinguish fiv-infected from fiv-vaccinated cats. in this study, samples from fiv-seronegative cats, fivseropositive cats, and fiv-historically seronegative but vaccinated cats, were analyzed by a commercial quantitative pcr (qpcr) assay and virus isolation. replicate blood samples were coded, and then submitted for ) qpcr (idexx); and ) mononuclear cell isolation with -day culture and viral p antigen detection by elisa. for the p antigen elisa, cutoff absorbance values were established from analysis of fiv-negative samples. fiv infection status was pre-determined based on antibody-elisa results and vaccination history. results indicated that qpcr had a sensitivity of % for samples from fiv-seropositive cats, and a specificity of % and . % for samples from fiv-seronegative and fiv-vaccinated cats, respectively. at a cutoff value of standard deviations above the mean absorbance for p antigen elisa, results from fiv-negative samples yielded a sensitivity of . % for samples from fiv-seropositive cats, and a specificity of . % and . % for samples from fiv-seronegative and fiv-vaccinated cats, respectively. conclusions from this study are ) the commercial fiv qpcr assay has high specificity but limited sensitivity for diagnosis of fiv infection; ) -day virus culture has limited sensitivity and specificity. hence, detection of antibodies remains the most reliable test for diagnosis of fiv infection, but qpcr may be suitable to rule out infection. oral disease is an important clinical problem in feline medicine and includes common painful conditions such as oropharyngeal inflammation (formerly known as gingivostomatitis) and tooth resorptive lesions. a number of infectious agents have been associated with private veterinary clinics in the u.s. were recruited to test feline patients presenting with oral disease. presenting cases included cats with plaque, calculus, gingivitis, stomatitis, periodontal disease, tooth resorptive lesions and other oral diseases as defined by the practitioner. all cats were tested using a commercially available point-of-care elisa test (idexx snap combo). confirmatory tests were not performed as part of the study. seroprevalence was calculated as the percentage of positive tests in the study population for each virus. a total of , cats were tested. seroprevalence for felv was . % and for fiv was . %. of these, cats ( . %) were infected with both viruses. seroprevalence was higher in cats with inflammatory oral disease than in cats characterized with other types of oral disease. of , cats with gingivitis, seroprevalence for felv was . % and for fiv was . %, with . % of cats co-infected. of , cats with stomatitis, seroprevalence for felv was . % and for fiv was . %, with . % of cats co-infected. the seroprevalence for felv and fiv reported in this population of cats with oral disease was higher than in a recent large study where samples from u.s. cats not specifically selected for oral disease were tested (felv . %, fiv . %). results of this study indicate that further investigation of the role of retroviruses in cats with oropharyngeal inflammation is warranted. reliable tests and preventive vaccines and medications for feline retroviral and heartworm (hw) infections are available, but compliance with protocols to reduce transmission is unknown. no largescale longitudinal studies evaluating prevalence over time have been reported. the purpose of this study was to determine the prevalence and risk factors for infection compared with a similar study completed for the first time years previously. veterinary clinics and animal shelters in the us and canada submitted results of testing using a point-of-care elisa for felv antigen, fiv antibody, and hw antigen (idexx snap triple) and risk factor information for cats tested during march-september . bivariable and multivariable analyses were used to evaluate risk factors for infections. a total of , cats were tested. only % of owned cats were prescribed hw preventive. risk of retroviral infections was increased by outdoor access, adulthood, and male gender. the most important risk factor associated with all infections was clinical disease; in particular, respiratory and oral diseases and abscesses or bite wounds. multivariate analysis revealed differences among geodivisions and across infection types. feline retroviral and heartworm infections are easily prevented, but difficult to treat. despite availability of effective management protocols, compliance remains inadequate to reduce the prevalence of these infections. improved use of preventive care and testing to identify and segregate contagious cats, particularly those at high-risk, is required to reduce the morbidity of these preventable infections. infectious disease outbreaks are common in animal shelters and are frequently managed by depopulation when risk-assessment tools are not available. during a canine distemper virus (cdv) and parvovirus (cpv) outbreak in sheltered dogs, we used a cdv/cpv point-of-care antibody titer elisa, a cdv quantitative rt-pcr test, and a cpv fecal antigen test as risk assessment tools to guide release of exposed dogs from quarantine and euthanasia of diseased dogs. serum samples (for antibody titers) and swabs of the conjunctiva and upper respiratory tract (for cdv pcr) were collected from asymptomatic dogs starting on day of the outbreak. dogs with positive cdv pcr tests were retested every weeks until euthanized for progressive disease or released following recovery from infection. dogs with clinical signs of parvoviral infection were tested using a cpv fecal antigen test. for dogs ! months old, protective antibody titers correlated with resistance to clinical disease, but % of dogs shed cdv. lack of protective cdv antibody titers correlated with susceptibility to clinical infection, but most dogs recovered. risk assessment and outcome in dogs ! months of age feline herpesvirus (fhv- ) is a common ocular and respiratory pathogen of cats that can have clinical illness exacerbated by stress. cyclosporine (csa) is commonly used for the treatment of a number of inflammatory diseases in cats and can induce immune suppression. a small number of cats administered csa to block renal transplant rejection have developed clinical signs of upper respiratory tract disease that may have been from activated fhv- . in this study, young adult cats experimentally inoculated with fhv- several months previously were divided into three groups and administered methylprednisolone acetate ( cats, mg/kg, im, day and day ), csa ( cats, . mg/kg, po, daily for days), or a placebo ( cats, corn syrup; . ml/kg, po, daily for days). each cat was assigned a daily individual clinical score by a trained, masked observer using a standardized score sheet during the initial pre-treatment time period (day - to day ) and throughout the day treatment period. each individual clinical score (conjunctivitis, blepharospasm, ocular discharge, sneezing, nasal discharge, nasal congestion, and body temperature scores), the total clinical score (sum of all parameters), the total ocular score (sum of conjunctivitis, blepharospasm, ocular discharge), and total respiratory score (sum of ocular discharge, sneezing, nasal discharge, nasal congestion) were analyzed using sas proc glimmix with 'treatment', 'time', and the two-way interaction 'treatment by time' all as fixed effects. statistical significance was defined as p o . . on day of the study, all of the csa treated cats had detectable concentrations of csa in serum (mean . ng/ml; standard deviation . ng/ml; median . ng/ml). when group mean values for clinical signs were compared over time as described, significant differences in individual clinical score measurements, in total score, total ocular score, or total respiratory score were not detected over time among any of the treatment groups. while clinical signs of activated fhv- occurred in some cats administered methylprednisolone or csa, disease was mild and self-limited in most cats and there were no significant csa sideeffects. these results suggest that the csa protocol described here is unlikely to reactivate latent fhv- infection and cause significant clinical illness. the purpose of this study was to determine the prevalence and risk factors for enteropathogens in four different models for managing unowned cats: short-term shelter, long-term sanctuary, home-based foster care, and trap-neuter-return (tnr) programs. fecal samples were collected from cats, half with diarrhea (d) and half with normal feces (n), and tested for a panel of feline and zoonotic enteropathogens by polymerase chain reaction, antigen, and fecal flotation. risk factors for infection evaluated include management practices, fecal consistency, and signalment. a majority of cats had at least one enteropathogen of feline or zoonotic importance, regardless of management model or preventive healthcare protocol. for most enteropathogens, the presence or absence of diarrhea did not correlate with infection, the exceptions being t. foetus in sanctuary cats and fcov in foster cats. prevalence of specific enteropathogens varied between management models, reflecting differences in preventive healthcare and housing conditions. management protocols for unowned cats were inadequate for elimination of infections present at the time of intake and for prevention of transmission of enteropathogens among shelter cats. improved compliance with effective vaccination, deworming, sanitation, and housing protocols is needed to reduce zoonotic and feline health risks. several allergic diseases of cats, including atopy and gingivostomatitis, can be resistant to glucocorticoids but responsive to cyclosporine. toxoplasma gondii infection occurs in approximately % of cats and the effect cyclosporine therapy has on the t. gondii oocyst shedding period is unknown. the objective of this study was to determine whether administration of cyclosporine before or after t. gondii infection influences the oocyst shedding period. the young adult cats were t. gondii seronegative when administered , t. gondii tissue cysts orally on day . group cats (n ) were never administered cyclosporine; group cats (n ) were administered cyclosporine ( . mg/kg, po) daily on days - ; and group cats (n ) were administered cyclosporine ( . mg/kg, po) daily from days - . available feces from individual cages were collected daily and fecal flotation by sugar centrifugation was performed for days after t. gondii inoculation. group shed oocysts for a significantly shorter period than groups or and had a significantly lower oocyst shedding scores than groups and on days - after t. gondii inoculation. group cats had completed the oocyst shedding period prior to being administered cyclosporine and repeat oocyst shedding was not detected during administration of the drug. administration of cyclosporine prior to t. gondii infection lessened oocyst shedding which is likely from the anti-t. gondii effects of the drug. administration of cyclosporine using this protocol is unlikely to induce repeat t. gondii oocyst shedding in client-owned cats. à group with diarrhea significantly different than group with normal feces p o . known about its metabolic pathways or mechanism of pathogenicity and whole genome sequencing of feline hemoplasmas has not yet been reported. the aim of this study was to completely sequence the genome of m. haemofelis to further characterise this important pathogen. mycoplasma haemofelis genomic dna was purified and subjected to whole shotgun roche sequencing. gaps were closed using targeted pcr and amplicon sequencing. ribosomal genes and potential open reading frames (orfs) were predicted in silico. putative orfs were annotated and orthologous groups identified. analysis showed a circular genome of . mbp with a gc content of . %. thirty-one transfer rnas (trnas) were identified, accounting for all amino acids, including a tryptophan trna for the opal codon (uga). of the , putative proteins identified, ( . %) matched to proteins from other bacterial species. in common with the pneumoniae group of mycoplasmas, the closest phylogenetic relatives of the hemoplasmas, genes involved in carbohydrate metabolism were limited to enzymes of the glycolytic pathway, with glucose appearing to be the sole energy source for m. haemofelis. the majority of the pentose phosphate pathway genes present in other cultivatable mycoplasmas appear to be incomplete or absent in m. haemofelis, suggesting an alternative mechanism for sourcing purine and pyramidine bases such as scavenging from the host. a gene encoding a glyceraldehyde- -phosphate dehydrogenase homolog of the immunogenic msg protein of mycoplasma suis was present. of the uncharacterized hypothetical proteins, , were arranged in series of orthologous repeats, or comprised fragments there-of, encoding putative proteins of approximately amino acids. the predicted motifs of the majority of these putative proteins were consistent with these proteins being presented on the cell surface; an n' terminal signal peptide or transmembrane region followed by a non-cytoplasmic tail. these data have provided valuable information as to why this pathogen remains highly fastidious; it lacks some of the metabolic pathways found in cultivatable mycoplasmas. we have also identified a homolog of a known m. suis immunogenic protein, and identified a potential mechanism for host immune system evasion by way of highly repetitive, putatively surface-expressed hypothetical proteins with variable sequences. canine leptospirosis has been recognized as a re-emerging disease in the u.s. over the past years, and several serosurveys of the prevalence of leptospiral antibodies in dogs have been published during that time. the role of cats in the epidemiology of leptospirosis has received little attention. serosurveys of cats for exposure to or infection with leptospires have been published from other geographic areas, but none for cats in the u.s. in the past four decades. the new england states have been found to have a high incidence of canine leptospirosis. the purpose of this pilot study was to determine the prevalence of leptospiral antibodies in a population of feral cats in central massachusetts. blood was collected from sexually intact feral cats presented to a spay and neuter program. microagglutination titers to leptospira serovars autumnalis, hardjo, bratislava, icterohaemorrhagiae, canicola, pomona, and grippotyphosa were determined. three of cats ( . %) had a positive titer to one or more serovars, with autumnalis being the most common. these results are consistent with previously published prevalence rates in feral cats. further studies are required to determine the role of leptosporosis in clinical disease in the domestic cat. since years the rivalta's test is routinely used in several european countries as a tool to diagnose feline infectious peritonitis (fip) in cats with effusion. it is inexpensive and easy to perform in private practice. there is, however, only little information about mode of action or its diagnostic value. the objectives of this study were to evaluate sensitivity, specificity, positive (ppv) and negative predic-tive values of the rivalta's test to diagnosis of fip and to examine if there is a correlation with any effusion or blood parameters. medical records of cats with effusion in which the rivalta's test was performed between and were reviewed concerning diagnosis, blood and effusion parameters, and survival time. effusion and blood parameters were compared between rivalta-positive and -negative effusions using the mann whitney u test. prevalence of fip in cats with effusion was . %. the rivalta's test showed a sensitivity of . %, a specificity of . %, a ppv of . %, and a npv of . % for the diagnosis of fip. the ppv improved, when cats with lymphoma or bacterial infection were excluded (ppv . %) and also, when only cats younger than years (ppv . %) or year (ppv . %) of age were included. the most important significantly different parameters between rivalta-positive and -negative effusions were specific gravity as well as cholesterol, triglyceride, and glucose concentration in the effusion. the rivalta's test in general is a useful tool to diagnose fip, but its sensitivity and specificity are not as high as previously assumed. if the rivalta's test, however, is performed in young cats or if certain diseases have been ruled-out, its diagnostic value is high. effusion total protein is not highly correlated with test outcome. therefore, it is still unclear, which components in the effusion of cats with fip lead to a positive rivalta's test. canine parvovirus (cpv) and canine distemper virus (cdv) infections are relatively common in animal shelters and are important population management issues since the immune status of incoming dogs is usually unknown. our study aimed to determine the antibody protection status of dogs at the time of admission into an animal shelter (pre-vaccination) and over the following weeks after vaccination. serum samples were obtained from incoming shelter dogs aged months and older with no known history of vaccination. immediately following serum collection, the dogs were vaccinated against cpv and cdv using a modified live vaccine (mlv). cpv and cdv antibody protection status was determined using synbiotics titerchek. dogs with unprotective serum antibody levels against cpv and/or cdv were retested at - days post-vaccination and again at - days post-vaccination, if antibody levels were still unprotective against cpv and /or cdv. at the conclusion of the study, stored duplicate sera were submitted for batch 'gold standard' testing to determine canine distemper virus serum neutralization and canine parvovirus hemagglutination inhibition antibody titers. based on the synbiotics titerchek results, / dogs ( . %) were protected against cpv and / ( . %) were protected against cdv at intake. older incoming dogs were more likely to be protected against cpv (p o . ) and cdv (p . ). dogs that were spayed/neutered were more likely to be protected against cpv on intake than intact animals, although this result was not statistically significant (p . ). the number of dogs with protective titers against cpv/cdv was increased at - days post-mlv (cpv - / , . %; cdv - / , . %) and further increased at - days post-mlv (cpv - / , . %; cdv - / , . %). we conclude that incoming shelter dogs often do not have protective antibody titers against cpv and cdv, but older shelter dogs are more likely to be protected against cpv. based on this population, we further conclude that a large percentage of dogs develop protective antibody titers to cpv and cdv within to weeks when vaccinated with a mlv. mycoplasma spp. are common inhabitants of the feline oral cavity and so likely contaminate many cat bite abscesses. mycoplasma spp. are cell-wall deficient and so do not respond to beta-lactam class antibiotics, the class most commonly use for the treatment of cat bite abscesses. the objectives of this study was to determine whether mycoplasma spp. are common contaminants of cat bite abscesses and are associated with beta-lactam resistant clinical disease. privately owned cats with clinical evidence of an acute abscess suspected to be from a cat bite were included in the study. participants were given a free aerobic and anaerobic culture as well as mycoplasma spp. culture and polymerase chain reaction using mycoplasma genus specific primers. mycoplasma spp. amplicons were sequenced to determine the species. all cats were initially treated with appropriate wound management, were administered an antibiotic in the beta lactam class (amoxicillin-clavulanate or cefovicin), and were rechecked in person or by phone days after beginning treatment. of the cats entered into the study to date, mycoplasma spp. were amplified from cats ( . %). of the positive samples with adequate dna for sequencing, one was consistent with m. felis and the other was consistent with m. equigenitalium. of the cats, responded by day to the initial treatment, including of the mycoplasma spp. positive cats. the cat that failed initial treatment was positive for m. equigenitalium on both day and day and ultimately responded to administration of a fluoroquinolone. the results suggest that while mycoplasma spp. commonly contaminate cat bite abscesses, routine wound management and antibiotic therapy is adequate for control. however, as mycoplasma spp. infections do not respond to beta lactam class antibiotic therapy, these organisms should be on the differential list for cats with abscesses that fail treatment with this antibiotic class. molecular diagnostic assays are frequently used in clinical practice to aid in the diagnosis of suspected infectious respiratory diseases in dogs. however, most currently available assays cannot distinguish strains of the organisms used in vaccines from naturally occurring strains. our prior studies demonstrated that previously immune adult dogs are unlikely to shed nucleic acids of vaccine strains of adenovirus , parainfluenza, or bordetella bronchiseptica. however, whether this is true for puppies is unknown. puppies (n ) at a breeding facility were moved into area without other dogs at weeks of age. swabs of the nasal and pharyngeal mucosa were collected prior to vaccination and on days , , , , , , , , , , , , , and after vaccination with an intranasal adenovirus , parainfluenza, and b. bronchiseptica vaccine (intratrac , schering plough). the swabs were shipped on cold packs by overnight express for dna/rna extraction and assay in the fastpanel tm pcr canine respiratory disease profile at antech diagnostics. all puppies were negative for the infectious agents prior to vaccination. after vaccination, positive assay results for parainfluenza and b. bronchiseptica were first detected on day and on day for adenovirus . by day , dna or rna of the agents were amplified from all puppies from both sample sites and most samples were positive for all agents through day . by day , only one dog was still positive for b. bronchiseptica. the results indicate that intranasal administration of adenovirus , parainfluenza, or bordetella bronchiseptica vaccines commonly leads to positive molecular diagnostic assay results for a short time period after primary vaccination. these findings should be considered when assessing the results of these assays in client-owned puppies with respiratory disease. antimicrobial resistance in escherichia coli is an increasing concern in both human and veterinary hospitals' patients. the choice drug for treatment in dogs is enrofloxacin, a second generation fluoroquinolone (fq) whose activity reflects, in part, ciprofloxacin. among the difficulties in effective e. coli treatment is rapid detection of fq resistance. the purpose of this study was to determine the specificity and sensitivity of a fret based assay for the rapid detection of urinary tract infections caused by fq associated multi-drug resistant e.coli. clinical e. coli isolated from canine urine and clinical veterinary urine samples being examined for e. coli were subjected to susceptibility testing for drugs representing drug classes. pure isolates were designated ndr (no drug resistance), sdr (single drug resistance) and mdr (multi-drug resistant) (n mdr, sdr and ndr). minimum inhibitory concentration (mic) for enrofloxacin ranged from . mg/ml to mg/ml, with high mic generally associated with mdr. extracted dna from culture and from urine were subjected to fret-pcr targeting single nucleotide polymorphisms in gyra. the resulting product was sequenced to detect other polymorphisms. further, to determine the level of detection, microbial free canine urine was inoculated with to cfu/ml of isolates characterized by variable susceptibility to enrofloxacin (mic enro . , . , . , , , , mg/ml). of pure isolates, were confirmed positive for enrofloxacin resistance (mic enro mg/ml), of which were positively identified by the fret-pcr assay giving a sensitivity of . %. only isolate that was resistant was not detected (specificity of . %). however, of the isolates expressing high level resistance (mic x breakpoint [ mcg/ml]), and mdr (n ), sensitivity . %. of the urine samples contained e. coli of which determined to be fq-resistant by the assay. colony dilutions of e. coli confirmed the assay able to detect enrofloxacin resistance at as low as cfu/ml. the relationship between cfus and the peak of the -(d/dt) fluorescence of the melting curve was r . . these results conclude that the assay is capable of detecting not only the presence of escherichia coli in clinical samples, but also detecting severity of fluroquinolone resistance and infection. the fluoroquinolones (fqs) are a key class of synthetic antimicrobial agents with an established history in both humans and companion animals of efficacy for treatment of urinary tract infections (utis) caused by e. coli, and fluoroquinolones are common therapy. among the commonly used fqs in dogs and cats are the nd generation drugs, enrofloxacin, marbofloxacin, orbifloxacin (all veterinary approved) and the human drug ciprofloxacin; no rd and th generation fq is routinely used. the purpose of this study was to assess the in vitro activity of different generation fqs toward e.coli uropathogens whose phenotype ranges from no resistance to multidrug resistance. a total number of canine uropathogenic canine or feline e.coli isolates had been subjected to susceptibility testing to drugs classes ( drugs) and phenotyped as to resistance: none (ndr, n ), single (sdr, n ), or multiple, mdr (resistance to - drug classes; n ). mdr included isolates susceptible (enr s -mdr, n ) or resistant (enr r -mdr) to enrofloxacin. the minimum inhibition concentrations (mics) for quinolones ( - st generation, - nd generation, - rd generation and - th generation) were determined for these isolates using broth microdilution methods according to clsi guidelines (e. coli atcc s served as a negative control). mic statistics were generated for each drug among phenotypes. the results showed that companion animal e. coli expressing ndr or sdr are largely susceptible to nd to th generation fqs. however, isolates expressing resistance to st or nd generation quinolone also express high level resistance based on the mic to rd and th generation fqs. the overall potency (mic) for the drugs for isolates not expressing enr resistance (that is, ndr, sdr and enr s -mdr) is gat canine leproid granuloma (clg) was first reported in brazil in . over the past years, cases of clg were diagnosed in sa˜o paulo, brazil, and clinical and epidemiological findings were similar to those reported in australia. all dogs presented with one or more, uni or bilateral, ulcerated or not, papular, nodular or tumoral lesions, mainly observed in the dorsal surface of the ear, site usually more affected. in general, the lesions are painless and confined to the subcutis and skin, and it does not involve regional lymph nodes, nerves or internal organs, and systemic clinical signs frequently are absent. short-coated breeds show a marked predisposition for this disease. the definitive diagnosis of clg was obtained by histological examination of skin biopsies that were stained with acid fast (ziehl-neelsen) and diffquik s . thirty one ( . %) of the dogs were purebred; in this study the breed pattern comprised ( . %) boxers, ( . %) german shepherd and labrador retriever, ( . %) dobermann, ( . %) brazilian terrier, ( . %) golden retriever, ( . %) bulldog, ( . %) american pitbull, ( . %) mastiff, ( . %) fila brasileiro and ( . %) cocker spaniel, ( . %) were of unknown breed. nineteen ( . %) of the thirty seven dogs were males. twenty ( . %) dogs were - years old. in most cases, dogs presented with unilateral or bilateral ear lesions, but rarely thoracic, foot and caudal lesions. the animals were successfully treated by use of rifampicin orally (''the brazilian protocol'') or enrofloxacin orally and topical rifamicin. anaplasma phagocytophilum is being recognized more frequently in dogs in endemic areas. currently, most suspected cases are evaluated for a. phagocytophilum antibodies by immunofluorescence assay (ifa) or elisa. since a. phagocytophilum is an acute disease, detection by antibody measurement may be negative on initial evaluation. it is possible that a. phagocytophilum dna can be amplified from blood or synovial fluid prior to seroconversion. wild caught ixodes scapularis adult ticks from rhode island were allowed to feed on young adult ( - years), mixed sex beagles for up to days. blood (weekly for weeks), serum (weekly for weeks), and synovial fluid (radiocarpal joint; alternating arthrocentesis weekly for weeks) were collected prior to tick attachment and then weekly after tick attachment. joint fluid cytology was performed and total dna was extracted from blood and synovial fluid and assayed in a proprietary real time pcr assay (fastpanel tm ) that amplifies the dna of anaplasma phagocytophilum, a. platys, ehrlichia canis, e. chaffeensis, and e. ewingii. serum was assayed for a. phagocytophilum antibodies by ifa. time to first positive results for serology and pcr were compared by paired student's t test. none of the beagles developed clinical evidence of disease, and no major changes in synovial fluid cytology were detected over time. of the beagles, were positive for a. phagocytophilum dna in blood or synovial fluid or ifa antibodies in at least one sample after tick attachment. antibody titers appeared in of dogs from weeks to (median to st positive weeks ae ). titer magnitude ranged from : to : , . anaplasma phagocytophilum dna was amplified from the blood of of dogs with positive test results ranging from to weeks (median to st positive weeks ae . ). anaplasma phagocytophilum dna was amplified from synovial fluid from of dogs between weeks to (median to st positive weeks ae ). of the dogs, were pcr positive for only one week and dog was pcr positive for two consecutive weeks. of the dogs, were positive for a. phagocytophilum in both blood and joints by dna analysis. anaplasma phagocytophilum dna was amplified from blood more quickly than seroconversion was detected by ifa antibody titer (t À . , p o . ) or dna was amplified from synovial fluid (t . , p o . ). anaplasma phagocytophilum dna can be amplified from the blood prior to development of detectable antibody titers by ifa. amplification of a. phagocytophilum dna from synovial fluid does not occur in all dogs, appears to be transient in most dogs, and a negative test result does not preclude a diagnosis of a. phagocytophilum infection. canine granulocytic anaplasmosis and granulocytic ehrlichiosis are tick-transmitted infections caused by anaplasma phagocytophilum (aph) and ehrlichia ewingii (eew), respectively. both organisms induce an acute clinical disease, frequently accompanied by fever, polyarthropathy and thrombocytopenia. however, aph and eew have different tick vectors, i.e. ixodes scapularis and ambylomma americanum, respectively, with different, but overlapping geographic distributions. in addition, infection outcome may be affected by other regional ticktransmitted pathogens, such as borrelia burgdorferi (mn) or ehrlichia chaffeensis (ar). therefore, we compared serology and pcr results derived from dogs examined at two private practices located in highly endemic areas for either aph or eew. serum collected between april-december, from minnesota dogs (n ) was tested by snap s dx s and whole blood was tested by aph pcr. serum collected from arkansas dogs (n ) for year beginning in august was tested using microtiter plate elisas for antibodies to eew, e. canis, and e. chaffeensis (ech) while whole blood was tested by ehrlichia pcr. comparisons were evaluated using chi square (Ã) and binomial (w) tests with an alpha of %. the above results indicated that dogs are frequently exposed to both aph and bb in mn, whereas ar dogs are often exposed to eew, but less frequently to ech. antibodies to e. canis peptides were found infrequently in both mn and ar with only seroreactive dogs detected in both locations. active eew infection, as determined by pcr, was four times more frequent in ar pet dog seroreactors as compared to active aph infections among aph seroreactors. although both organisms induce acute disease, the number of aph and eew pcr positive dogs that were also seropositive was relatively high suggesting that both organisms induce persistent infections or that dogs are frequently re-infected, despite the presence of a measurable humoral immune response. additional studies are needed to determine regional infection profiles in other areas that are endemic for these pathogens. anaplasma phagocytophilum and ehrlichia canis are two of the most common vector borne disease agents that infect dogs and cats. while pcr assays that amplify the dna of these agents from blood are currently available, there is minimal information concerning the performance of these assays in different commercial laboratories that utilize different techniques. the purpose of this study was to compare the e. canis and a. phagocytophilum results of two different laboratories on the same samples collected from client-owned animals. veterinarians in states (az, md, ct) were recruited to participate in the study based on high prevalence rates for e. canis or a. phagocytophilum infection. blood in edta was collected from dogs or cats with fever, thrombocytopenia, or clinical evidence of polyarthritis and an equal volume of the same blood sample was simultaneously shipped on cold packs by overnight express to colorado state and to antech diagnostics. standard operating procedures at each laboratory were followed for total dna extraction and amplification of gapdh as the dna control. at colorado state university, a previously published pcr assay that amplifies the dna of ehrlichia spp., anaplasma spp., neorickettsia spp., and wolbachia was performed on each sample with positive amplicons sequenced to determine the species. at antech diagnostics, a proprietary real time pcr assay (fastpanel tm ) that amplifies the dna of anaplasma phagocytophilum, a. platys, ehrlichia canis, e. chaffeensis, and e. ewingii was performed. in the study to date, samples from animals ( dogs and cats) have been assayed at both laboratories. dna of a. phagocytophilum ( cats and dogs) and e. canis ( dog) were amplified at both laboratories with a percentage agreement between laboratories of %. the results to date suggest that the assay results of the two laboratories for a. phagocytophilum and e. canis are comparable. ehrlichiosis and bartonellosis are zoonotic diseases caused by extremely small, obligate intracellular bacteria that require a mammalian reservoir and a blood sucking arthropod vector. human ehrlichiosis is present in peru, with a seroprevalence as high as % in the highlands. bartonella species in humans were also identified in peru since (b. bacilliformis). recently, a new species (b. rochalimae) was isolated from an american woman who became febrile after travelling to peru. dogs can become infected with the same ehrlichia species, and the majority of bartonella species that affect human beings. the role of dogs as reservoirs for human infections has not been clearly established, but exposure and/or infection in dogs has been used to monitor human exposure to tick-borne disease (tbd), since they share the same environment. the objective of this study was to determine the serological and molecular prevalence of anaplasmosis, ehrlichiosis and bartonellosis in rural dogs in the highlands of peru. a total of healthy adult dogs were enrolled in this study from four communities in the central highlands of peru: ondores, pachacayo, san juan de pachayo, and canchayllo. edta-blood samples were collected from dogs, whereas serum samples were available from dogs. serum samples were tested for ehrlichia canis, anaplasma, borrelia burgdorferi and dirofilaria immitis infections using a qualitative dot-elisa (snap s dx). the edta-blood samples were screened by conventional pcr for the groel gene of the genus anaplasma and ehrlichia, and for the intergenic transcribed spacer of the genus bartonella. speciation was conducted by nucleotide sequencing. bartonella genus dna was detected from seven of the dogs ( . %) and ehrlichia canis dna was detected and sequenced from one dog ( . %). four of the bartonella positive samples were identified by dna sequencing as b. rochalimae (genbank accession numbers hq and hq ). the other three bartonella positive samples were identified as b. vinsonii subspecies berkhoffii, the causative agent of endocarditis in dogs and humans. no dog was infected with anaplasma species by dna amplification, but one dog was seroreactive for this genus ( . %). no specific antibodies against ehrlichia canis and borrelia burgdorferi and no antigens of dirofilaria immitis were detected. this study expands the current knowledge about tbd in peru and describes for the first time the infection of b. rochalimae in dogs in peru. the results suggest that dogs may play an important role in the epidemiology of this infection in humans, since they can be asymptomatic but bacteremic. bartonella spp. dna is commonly amplified from the blood of cats exposed to ctenocephalides felis. in previous work, it was shown that cats administered imidacloprid and experimentally exposed to b. henselae infected cats and c. felis did not become pcr positive for b. henselae whereas untreated cats all developed infection. the purpose of this study was to determine if administration of imidacloprid to clientowned cats likely to be exposed to bartonella spp. and c. felis in the field lessens prevalence of bartonella spp. infection. veterinary students in tennessee and florida that owned cats that spent at least days per month outside and that were willing to apply imidacloprid to their cats monthly for six months were recruited for the study. blood for bartonella spp. pcr assay was collected from the cats seven months after starting imidacloprid administration and assayed at colorado state university. to serve as a control group that was unlikely to have been administered flea control products in the previous months, blood was collected from feral cats during tnr programs in each of the two cities and assayed for bartonella spp. dna. the bartonella spp. dna prevalence rates between the groups were compared by chi square analysis with significance defined as p o . . the overall prevalence rates for bartonella spp. dna in the blood of veterinary student cats ( . %) and the feral cats ( . %) were significantly different (p o . ). the distribution of results is shown in table . the results suggest that florida feral cats were more commonly exposed to c. felis than tennessee feral cats. while the cats in the groups were not exactly matched, the student cats were allowed outdoors for approximately days per month and lived in the same cities as the feral cats, so c. felis exposure rates were likely similar. as previously shown in experimentally-exposed cats, the use of imidacloprid monthly may influence transmission rates of bartonella spp. amongst naturally-exposed cats. in an endemic area for leishmaniosis and filariosis, coinfection can occur and immunomodulation produced by wolbachia might influence the clinical signs and progression of both diseases. the aims of the present study were ) to determine the prevalence of wolbachia in dogs infected with dirofilaria immitis (di) and other filarial nematodes, ) to evaluate the level of coinfection of leishmaniosis and filariosis by molecular assays and ) to evaluate any associations between leishmania infantum (li) infection, filariosis with or without wolbachia and clinical presentation and outcome. statistical differences between groups were tested for significance by the fisher exact test using spss v. . software (significance: p-value o . ). one-hundred and eighteen owned dogs from southeastern spain presenting for clinical evaluation were included in the study. criteria the results of this study highlight the increased sensitivity of pcr for diagnosis of filariosis, confirm the presence of wolbachia in dogs from the mediterranean basin, show the increased severity of hwd when li-filaria coinfection is present and suggest that wolbachia could play a protective role for leishmaniosis. wolbachia antigens can stimulate a th -type immune response, as has been previously described. however other factors (as treatment with doxycicline) might be responsible for the lower prevalence of wolbachia among filaremic dogs infected with li and further studies must be done to clarify this interaction. the purpose of the present study was investigate the occurrence of leishmaniasis in cats in the municipality of arac¸atuba, sa˜o paulo, brazil, an endemic area for canine visceral leishmaniasis. animals were evaluated by direct parasitological examination of lymphoid organs and serology for visceral leishmaniosis by immunosorbent assay (elisa) and indirect immunofluorescence (ifat). thirteen ( . %) out of cats studied were diagnosed with visceral leishmaniasis; eight ( %) by parasitological diagnosis through cytological examination of lymphoid organs, six ( %) were considered positive by elisa and one ( . %) by ifat. only two ( . %) out of the thirteen infected cats had clinical signs, characterized by the presence of crusty lesions on the dorsal cervical region and hepatosplenomegaly. regarding age five cats ( . %) had between six months and two years, being the others older than years ( . %). only one cat ( . %) was positive for the three employed methods. pcr confirmed leishmania sp infection in nine ( . %) cats, of which six were diagnosed previously by cytological examination, two by elisa and one by the three techniques employed. since its first description in feline leishmaniosis has been reported in several countries. the purpose of this study was to assess the prevalence of leishmania chagasi infection in cats showing dermatologic lesions from an endemic area for visceral leishmaniasis in brazil. animals were evaluated by direct parasitological examination of lymphoid organs, immunohistochemical technique for detection of amastigotes in lesioned skin and serology for visceral leishmaniosis by immunosorbent assay (elisa) and indirect immunofluorescence (ifat). twenty seven ( . %) out of the cats studied were diagnosed with visceral leishmaniosis. twelve ( . %) were positive by parasitological diagnosis; amastigote forms of leishmania sp were identified in lymphoid organs from / ( . %) infected cats, and immunohistochemical technique allowed the identification of nine ( . %) positive animals. the seroprevalence of leishmaniosis was . % ( / ) by elisa and . % ( / ) by ifat. fiv specific antibodies were found in / cats ( . %), of which / ( . %) had leishmaniosis. real time pcr confirmed leishmania chagasi infection in three cats. based on the evidence of the high occurrence of leishmaniosis in cats in this study, this disease should be included in the differential diagnosis of skin diseases of felines living in endemic areas. blastomyces dermatiditis is a dimorphic fungus that commonly affects large-breed hunting dogs. a recent advancement in diagnosis has come with the advent of a urine antigen screening test that has both high sensitivity and moderately high specificity. therapy for the disease involves use of antifungal agents, usually itraconazole, and length of treatment is based chiefly on resolution of clinical and radiologic signs. with the new urine antigen test, however, a noninvasive route of monitoring treatment progress is available and could be an adjunct device utilized to determine treatment efficacy and may even reveal a need for prolonged treatment. therefore, the purpose of this study was to determine if monitoring the blastomyces urine antigen test and comparing to pulmonary radiographic signs would elucidate the necessity for prolonged antifungal therapy, even after resolution of radiologic signs. to this end, a retrospective case review was performed that identified a series of client-owned animals with naturally occurring blastomycosis. the inclusion criteria were radiographic pulmonary parenchymal signs consistent with fungal disease and urine antigenconfirmed blastomycosis with repeated testing of both radiographs and urine antigen quantification as monitoring parameters until negative results achieved in each. ideally, intervals between testing dates would be between two and five months. radiographs were considered negative if all radiographic changes had resolved or if repeated radiographs separated by at least one month were considered static after documented improvement had occurred from original diagnostic radiographs (suspected scarring). urine antigen testing was considered negative if concentrations were less than . enzyme immunoassay units, a reference interval set by the testing laboratory. preliminary data analysis reveals resolution of radiographic signs of blastomycosis occurred earlier in many of the cases presented than did attaining a negative urine antigen concentration. ceasing treatment month after radiographic resolution of signs as has been recommended in the past might have resulted in premature discontinuation of therapy in many of the cases. monitoring of urine antigen concentrations may be of additional clinical use for determining when cessation of treatment should occur in cases of blastomycosis. persistent elevation of urine antigen concentrations after radiographic resolution of infection may account for apparent recrudescence of blastomycosis after suspected clinical resolution. giardia spp. and cryptosporidium spp. are both known to cause infections in dogs and humans in the united states. nevertheless, prevalence rates for dual infection in dogs had not been widely reported. in this study, fecal samples from dogs housed in a northern colorado animal shelter (n ), dogs owned by veterinary students in northern colorado (n ), and dogs from the pine ridge reservation in south dakota (n ) were collected. each sample was assayed with a commercially available fluorescent antibody assay that detects giardia spp. cysts and cryptosporidium spp. oocysts. those samples that were positive for giardia spp. or cryptosporidium spp. with adequate dna available for sequencing were genotyped by the glutamate dehydrogenase [gdh] and by the heat shock protein- [hsp- ] genes, respectively. overall, ( . %) of the dogs had current evidence of a protozoal infection ( table ). the dogs from pine ridge reservation had the highest prevalence rates for giardia infection and also for dual infections. from the student dogs, sequencing was successful for the three giardia isolates (assemblage d from dogs; assemblage c from one dog) and one cryptosporidium isolate (c. canis). from the reservation dogs, sequencing was successful for nine giardia isolates (assemblage d from dogs; assemblage c from dogs) and one cryptosporidium isolate (c. canis). cryptosporidium and giardia co-infections are commonly detected in dogs; in this study dual infections were more common than cryptosporidium infections alone. further studies will be required to determine the clinical importance of this finding. although the giardia and cryptosporidium isolates that were sequenced were the dog specific assemblages/genotypes, more samples should be analyzed in order to assess the potential for zoonotic transmission of either parasite. the current study was conducted to determine the prevalence of intestinal parasites in dogs visiting the veterinary teaching hospital, chiang mai university, northern thailand. fecal samples (n ) were collected and submitted by owners between august to february . demographic and geographic data were recorded. intestinal parasitic infection was diagnosed by both microscopic examination after zinc sulfate centrifugation flotation and commercially available ifa for giardia spp. and cryptosporidium spp. polymerase chain reaction and dna sequencing were performed on all giardia and cryptosporidium positive samples to provide genotyic information. overall prevalence of intestinal parasitic infection in dogs in chiang mai was . %. the most prevalent parasite was giardia spp. ( . %) followed by ancylostoma spp. ( . %), cryptosporidium spp. ( . %), cystoisospora spp. ( . %), toxocara canis ( . %), trichuris vulpis ( . %), coccidian-like ( . %), toxascaris leonina ( . %), and strongyloides spp. ( . %). the prevalence of having at least one parasite in dogs o year, - years, and years were . %, . %, and . %, respectively. of these infected dogs, . %, . %, . %, and . % were infected with one, two, three, and four organisms, respectively. available dna sequences from giardia spp. positive samples were shown to be dog specific. only one adequate dna sequence was available for cryptosporidium spp., which was shown to be c. canis. the findings suggested that intestinal parasitic infection was common in dogs in chiang mai, thailand. dogs could be potential source for zoonotic intestinal parasitic infection since dogs in this area are allowed for free roaming. regular deworming program is indicated to prevent not only transmission among dogs but also to human. a retrospective study was conducted on parasite positive fecal specimens consisting of canine, feline, equine and from other host species, comparing recovery of eggs, protozoan cysts and coccidian oocysts using standardized methods of parasite concentration: the formalin/ethyl acetate (f/ea) sedimentation concentration and the commercial fecalyzer (flotation) kit procedures. specimens were processed by each technique either according to manufacturer's instructions or according to standard laboratory procedures. formalin/ethyl acetate concentrations used at a ratio of ml normal saline to ml ethyl acetate for extraction of lipophilic material from pelleted stool samples, previously fixed in sodium acetate/acetic/acid/formalin (saf) solution. flotations with the fecalyzer kit were performed with concentrated zinc sulfate solution (s. g. . ) . the range of parasites recovered from these specimens included flagellate cysts ( total), coccidian oocysts ( total), ova and larvae of nematodes ( total), and ova of trematodes ( total) , and cestodes ( total). recovery rates by fecalyzer flotation were good for protozoan cysts, coccidian oocysts and nematode eggs and larvae, but very poor for cestode and trematode eggs. formalin/ethyl acetate concentration showed excellent recovery of all parasites and consistently outperformed fecalyzer in recovery rates. recoveries by f/ea concentrations were higher by . % for giardia, by . % for coccidia and by . % for nematode eggs and larvae. with the exception of coccidian oocysts, based on z-test analyses, recovery rates were significantly higher, at a confidence level of at least %, for all parasites, using formalin/ethyl acetate sedimentation concentration. although capc recommends the use of flotation with centrifugation methods for standard fecal ova and parasite examination for veterinary patients, sedimentation concentration methods are widely and effectively used in human diagnostic parasitology laboratories. these results provide good evidence for the use of f/ea concentration as a preferred method to flotation procedures for stool ova and parasite examinations in veterinary laboratories. cyclosporine and glucocorticoids are powerful immunosuppressive agents used to treat many inflammatory diseases. cyclosporine inhibits calcineurin-dependent pathways of t-cell activation and the resultant cytokine production, and glucocorticoids directly inhibit genes coding for cytokines. little work has been done comparing the effects of these agents on cytokine production in dogs. our study assessed these effects by measuring t-cell cytokine production using flow cytometry, and cytokine gene expression using quantitative reverse transcriptase polymerase chain reaction (qrt-pcr) in activated canine t-cells treated with cyclosporine and dexamethasone. for flow cytometric assays, peripheral blood mononuclear cells were separated using density gradients and cultured for hours in the presence of cyclosporine ( , , or ng/ml), dexamethasone ( À , À , À m), or cyclosporine plus dexamethasone. for qrt-pcr, whole blood was cultured for hours with the same drugs at the same concentrations, and rna was then extracted from leukocytes. expression of cytokines il- and ifn-g was analyzed in pma/ionomycinactivated t-cells by flow cytometry, and gene expression for il- and ifn-g in activated t-cell populations was assessed via qrt-pcr. flow cytometry and qrt-pcr both demonstrated inhibition of il- and ifn-g that was generally dose-dependent in response to both cyclosporine and dexamethasone. flow cytometry results from the average of samples collected from different dogs are shown in figure a . similar results were achieved using qrt-pcr ( figure b ). suppression of il- and ifn-g in activated t-cells has potential as an indicator of the efficacy of cyclosporine and glucocorticoids in suppressing canine t-cell function in vivo, and may therefore be of value for characterizing the immunosuppression induced by these drugs in clinical patients. idiopathic eosinophilic diseases are described in several breeds, but are over represented in rottweilers. the immunopathogenesis of idiopathic eosinophilic disorders is poorly characterised. studies in people highlight the importance of cytokines, particularly interleukin- (il- ), in mediating eosinophil maturation, differentiation, egress from the bone marrow, migration and polyclonal expansion. eotaxin- and eotaxin- also appear important for induction of chemotaxis and release of reactive oxygen species from eosinophils. the aim of the current study was to establish whether definable differences in specific cytokines associated with mediation of eosinophil production and survival are present between healthy rottweilers, non-rottweilers and rottweilers with non-parasitic eosinophilia. secondly, by evaluating cytokine profiles the study aimed to improve understanding of the pathophysiology of eosinophilia therefore assisting development of potential molecular treatment options. quantitative real-time reverse transcriptase polymerase chain reaction (qrt-pcr) assays were used to quantify messenger rna (mrna) encoding cytokines il- , il- , il- , il- p , il- p , il- p , il- , interferon gamma (ifn-g) and chemokines eotaxin- and eotaxin- from peripheral blood mononuclear cell (pmbc) samples obtained from healthy non-rottweiler dogs with normal eosinophil counts (n ) and rottweilers with normal (n ), mildly increased (n ) and high (n ) eosinophil counts. quantification of serum ifn-g was also performed using a commercially available canine-specific elisa. all samples were positive for housekeeping genes and all cytokines could be quantified with the exception of eotaxin- and - . results were normalised using three stably expressed housekeeper genes (rpl a, sdha and ywaz) and a relative copy number was calculated for each sample with the sample with the fewest copies given a value of . no significant differences were found between groups but there was a tendency for ifn-g mrna expression to be lower in the rottweilers with moderate to severe eosinophilia versus control dogs (p . ). this trend was not seen in the concentration of serum ifn-g quantified by elisa as there were no significant differences between normal and diseased animals. in conclusion, there were no significant differences in cytokine mrna profiles between normal dogs and rottweilers with varying degrees of eosinophilia. additional studies including larger numbers of affected dogs are warranted before any accurate conclusions can be made. the presence of large amount of antibody on erythrocyte membrane can accelerate red blood cell (rbc) removal process by the mononuclear phagocyte system. an antigenic stimulus such as the one promoted by vaccines, for example, can induce hypersensitivity reactions and may accelerate rbc destruction. the study objective was to evaluate the erythrocytic membrane potential in inducing lymphocyte proliferative response of recently immunized dogs. healthy adult dogs (n ) were immunized with multiple antigens (commercial vaccine with eight antigens: distemper virus, parvovirus, coronavirus, parainfluenza virus, adenovirus, infectious hepatitis virus and leptospire; and anti-rabies). blood samples from each animal were collected into edta tubes in two moments: pre (immediately before vaccination) and pos ( to days after vaccination). mononuclear cells were separated by gradient, marked with cfse-fitc and cultured. the stimuli for lymphocyte proliferation used were autologous erythrocytic membrane (aem) and concanavalin a (cona). aem was obtained by hypotonic lysis and tested in two concentrations (m : . ug/ ul; m : . ug/ ul). the proliferation assay was evaluated by flow cytometry and analyzed with specific software. the proliferation index (pi) was calculated dividing the fluorescence intensity of the basal sample by the stimulated one. statistical analysis was performed using paired t-test for parametric samples and wilcoxon test for non-parametric samples (a . ). the for the tested concentrations, autologous erythrocytic membrane does not constitute a stimulus for lymphocyte proliferation in vitro, either before or after vaccination procedure. additionally, there was no evidence of self-reagent lymphocytes to erythrocyte membrane after vaccination. e. coli is a common cause of canine urinary tract infection. current treatment emphasizes eradication of established infection rather than infection prevention but increased antibiotic resistance necessitates strategies to prevent infection. proanthocyanidins found in cranberry juice inhibit e. coli attachment to human uroepithelial cells, impairing bacterial adherence and colonization. we hypothesized that purified cranberry extract (ce) inhibits bacterial adhesion to canine uroepithelial cells. five healthy female dogs received an oral ce supplement (vetoquinol; mg ce/tablet) according to body weight for days. voided urine collected from each dog before (pre) and after ( -day) completion of the protocol was membrane filtered ( mm) and stored frozen (- c). bacterial adhesion was determined using an in vitro assay. briefly, urine samples were incubated with an uropathogenic e. coli strain that had been subcultured to promote fimbriae expression. urine samples containing e. coli were next incubated in -well plates containing methanol-fixed madin-darby canine kidney (mdck) cells for -hr ( c) to permit bacterial attachment. after incubation, plates were washed to remove nonadherent bacteria and fresh media added. plates were incubated ( c) for -hr to grow attached bacteria to detection level. bacterial concentration in each well was determined using a spectrophotometer ( nm). results were analyzed using the chi-square test. ce significantly reduced bacterial adhesion by % (n ; p . ) in -day urine samples compared with pre samples. the results show that ce supplementation can reduce adhesion of uropathogenic e. coli to canine uroepithelium and suggests one mechanism by which ce might improve urinary tract health. the purpose of this study was to determine prevalence of urovirulence factors (uvfs) and antimicrobial resistance in canine uropathogenic e. coli (upec) and to evaluate associations between uvfs and antimicrobial resistance. two hundred and twenty-one upec isolates from samples collected from different canine patients submitted to the university of tennessee microbiology laboratory in were evaluated. a multiplex pcr assay was used to detect cnf, hlyd, sfa/foc, and papgiii in dna lysate. in vitro susceptibility was evaluated and if the isolate was resistant to any antimicrobial in a class, it was considered resistant to that class. of the samples, the number of uvf expressed per isolate was: / ( %), / ( %), / ( %), - / ( %), and / ( %). expression of uvf was sfa ( %), hly ( %), cnf ( %), and pap ( %). presence of uvfs was associated with less resistance (p o . ). the combination of hly, cnf, and sfa was associated with less resistance (p o . ). when sfa was present alone, resistance was less (p o . ). average resistance to antimicrobial class by number of uvfexpressed was: uvf . ae . classes, uvf . ae . classes, uvf . ae . classes, uvf . ae . classes, and uvf . ae . classes. urovirulence factors were present in a moderate number of upec and correlated negatively with resistance. neither individual nor combinations of uvfs were associated with increased resistance. obesity is associated with several comorbidities in dogs including pancreatitis, osteoarthritis, oral disease, neoplasia, and lower urinary tract disease. investigator observations led to the hypothesis that morbidly obese dogs are more likely to have asymptomatic bacterial urinary tract infections (abuti) than overweight and moderately obese dogs. therefore, a pilot study was conducted to screen for abuti in obese dogs. urinalysis with urine culture and dual energy x-ray absorptiometry (dxa) were performed on fortythree dogs with body fat (bf) percentages ranging from to %. following dxa, subjects were categorized as obese (o)(bf - %, n ) and morbidly obese (mo)(bf %, n ). no dogs had owner-reported symptoms indicative of uti. the prevalence of abuti in o dogs was % (n ) and % (n ) in mo dogs. the dog in the o group with abuti was close to being mo with a bf equaling . %. of the nine dogs with positive cultures, were neutered males and were spayed females. the prevalence ratio of abuti in mo dogs was . , indicating dogs with % or greater bf are . times more likely to have the condition then dogs o % bf. the results of this pilot study coincide with other surveillance data describing an increased prevalence of lower urinary tract disease in obese dogs. in conclusion, dogs with body fat percentages greater than % are at risk for abuti, and veterinarians should consider screening all morbidly obese patients for urinary tract infections. calcium carbonate (cac) is recommended to decrease phosphate intake in chronic kidney disease. however, its effect is poorly documented in dogs. our objectives were to assess within-day, postprandial and cac effects on phosphatemia variations in healthy dogs. phosphatemia was measured every hours for hours in eight adult healthy beagle dogs in i) fasted condition and ii) a  crossover design. one group received cac mixed with maintenance diet ( . % phosphorus), while the second group received the diet alone. after a -week wash-out period, groups were switched. a general linear model was used to test the period, sequence, treatment, dog and time effects on phosphatemia and the area under the phosphatemia versus time curve (auc - ). a significant (p o . ) circadian variation existed in fasted dogs. the maximum difference (mean: À . mg/dl; % c.i.: À . mg/dl; À . mg/dl) was observed between a.m. and midnight. the auc - with cac ( ae mg.min/dl) was mildly but significantly lower (p . ) than without cac ( ae mg.min/dl). however, it was similar to the auc - in fasted conditions. feeding, with and without cac, has minor effect on phosphatemia. however, circadian variation of fasted phosphatemia might affect its interpretation. gfr measurement permits diagnosis of kidney injury prior to development of azotemia, and is the gold standard for kidney function assessment. accurate and rapid (o min) gfr measurement has been performed in rats by simultaneous transcutaneous assay of two intravascular fluorescently-labeled markers. a recently developed analyzer assays fluorescence via a fiberoptic cable introduced through a peripheral catheter, and thus should also allow rapid gfr determination in larger species. the purpose of this study was to determine correlation and agreement between fluorescent ratiometry (fr) and iohexol plasma clearance (ipc) in dogs over a range of gfrs. acute kidney injury (aki) was induced in female hound-type dogs ( mg/kg gentamicin iv q h), and fr and ipc gfr were simulta-neously determined on days , , and . a -sample, -hr protocol was used for ipc; fr was determined following bolus injection of a dextran conjugate mixture ( -sulfohexamine rhodamine-carboxymethyl kd dextran, -aminofluorescein-carboxymethyl kd dextran) with fluorescence measured over min. gfr was calculated using -compartment model concentration-vs.-time curves for both techniques. correlation was determined via spearman's rho; agreement was analyzed via bland-altman plots. ipc gfr and serum creatinine confirmed progressive aki in all dogs. correlation between fr and ipc was . (p o . ). bland-altman plots confirmed good agreement between techniques with slight underestimation of gfr by fr across most observed values. these results suggest fr is suitable for gfr determination in dogs with aki. importantly, the portable analyzer allowed for point-of-care gfr determination in o min using a peripheral vein. previously presented at the american society of nephrology renal week (related but not identical abstract). dogs with protein-losing nephropathy (pln) are at risk of thromboembolic disease, but the mechanism of hypercoagulability and the population of dogs at risk are unknown. the purpose of this study was to characterize thromboelastography (teg) in dogs with pln. twenty-eight client-owned dogs with pln (urine protein:creatinine ratio (upc) . ) and control dogs were enrolled. teg parameters, antithrombin activity, serum biochemical profiles, and upc were measured. teg analyses were run in duplicate with kaolin activation; reaction time (r), clot formation time (k), maximal amplitude (ma), and g (global clot strength) were analyzed. a wilcoxon sum rank test was used to evaluate differences between groups. twelve pln dogs ( . %) were azotemic. nineteen pln dogs ( . %) were hypoalbuminemic [serum albumin (salb) o . g/dl]; had salb o . g/dl. dogs with pln had higher k (p o . ), ma (p o . ) and g (p o . ) than controls. r was similar between the two groups. pln dogs with salb o . g/dl had higher g (p o . ) values than dogs with salb . g/dl; however, even pln dogs with normal salb ( . g/dl) had significantly higher g values than controls (p o . ). no significant relationship between upc and g, salb and g, antithrombin and g, or salb and antithrombin was noted using linear regression analysis. these results indicate that antithrombin, salb, and upc cannot be used alone to predict hypercoagulability as assessed by teg in dogs with pln. a comprehensive evaluation of the coagulation system in individual patients may be necessary to predict the point at which to initiate anti-thrombotic therapy. cystinuria is a hereditary renal tubular reabsorption defect of cystine, ornithine, lysine and arginine (collectively, cola). the low solubility of cystine in acidic urine predisposes to the formation of uroliths. type i cystinuria in newfoundland and labrador retriever dogs is an autosomal recessive trait caused by mutations in the slc a gene, whereas in other breeds, the cause of cystinuria has not yet been determined. we report here on the clinical, biochemical and molecular features of cystinuria in irish terriers. urine and edta blood were collected from irish terriers from europe and australia. a nitroprusside screening test was used to identify increased cystine in urine. urinary amino acid concentrations were determined by high-pressure liquid chromatography. cystinuric dogs were defined as having cystine calculi, a positive nitroprusside result, urinary cystine ( mmol/g creatinine) and/ or a cola concentration of mmol/g creatinine. all females tested nitroprusside negative and had normal urinary cystine (o mmol/g creatinine) and cola (o mmol/g creatinine) concentrations. the intact males that formed calculi as adults exhibited cystine concentrations ranging from - and cola from - mmol/g creatinine. an additional males had similarly high cola values with cystine levels from - mmol/g creatinine. among the affecteds tested, % were nitroprusside positive. the negative nitroprusside results and/or low urinary cystine levels of affecteds may be due to precipitation of cystine in acidic urine. sequencing the coding regions of the slc a and slc a genes from edta blood identified no mutations. the mode of inheritance remains undetermined. however, castration appears to lower the urinary cystine and cola concentrations and to prevent cystine calculi formation, while diet changes have lesser effects. in conclusion, non-type i cystinuria in irish terriers (and several other breeds like mastiffs and scottish deerhounds) is a unique form characterized by increased aminoaciduria only in males, with lower cystine and cola excretion and fewer and later urolith formation compared to type i cystinuria. castrating cystinuric irish terriers lowers their cystine and cola excretion and thus their risk for calculi formation. cats and dogs that are diagnosed with acute kidney injury (aki) and resultant uremia that is not responsive to standard medical therapy are likely to benefit from renal replacement therapies, such as intermittent hemodialysis (ihd). the purpose of this study was to evaluate the long-term outcome of patients with aki treated with ihd, and to establish whether renal function, as determined by serum or plasma creatinine concentrations, is associated with longterm survival. medical records of cats and dogs that were diagnosed with aki, treated with ihd, and survived longer than days following the last ihd treatment were retrospectively analyzed. standard methods of survival analysis using kaplan-meier product limit curves and the log-rank test were performed. for all-cause mortality, the median survival time was days ( % confidence interval: , ) for cats and days ( % confidence interval: , ) for dogs. when only renal-related causes of death were taken into account, the median survival time was not reached for cats or dogs. survival time for all-cause mortality was inversely associated with the lowest creatinine concentration within the to day period following the last ihd treatment (p o . for cats, p o . for dogs). this study demonstrates that veterinary patients that are diagnosed with aki, treated with ihd, and survive greater than days after the last ihd treatment have a good longterm prognosis and frequently die from causes that are unrelated to renal impairment. renal fine-needle aspiration (r-fna) is oftentimes attempted during evaluation of dogs and cats with renomegaly, mass lesions, or suspected infiltrative processes. diagnostic utility of fna is dependent upon the organ being sampled; additionally, in some organs, certain diagnostic imaging findings are associated with improved concordance of fna with final diagnosis. objectives of this study were to evaluate the diagnostic utility of r-fna and determine whether concordance with final diagnosis is associated with specific clinicopathologic or diagnostic imaging findings. we hypothesized that r-fna is most useful in patients with diagnostic imaging results suggestive of renal neoplasia (i.e. masses or suspected infiltrative processes). dogs and cats that had undergone r-fna from jan , to dec , were identified by database search. patient signalment, serum creatinine and blood urea nitrogen concentration, urine specific gravity, dipstick protein, r-fna result, and final diagnosis were recorded. patients were excluded if abdominal radiographs or sonographic images were not available for review, or if diagnostic test results were insufficient for determination of final diagnosis. a single coauthor blinded to final diagnoses interpreted all abdominal images using a pre-set list of descriptors and grading criteria. radiographic kidney shape, margin distortion, and ventrodorsal kidney-to-l ratio were evaluated. sonographic kidney margin distortion, cortical echogenicity, and corticomedullary junction distinction were described, and presence of nodules or masses, peri-renal effusion, or a peripheral sonolucent rim was noted. concordance of r-fna and final diagnosis was determined, and the chi-squared or fisher's exact test were used to determine association of concordance with the above variables; p o . was considered significant. dogs and cats ( animals) met all inclusion criteria. r-fna results were concordant with the final diagnosis in ( . %) patients, discordant in ( . %) patients, and inadequate for cytologic interpretation in ( . %) patients. neoplasia or fip were the final diagnoses in of ( . %) and of ( . %) patients with concordant results, respectively. renal lymphoma (p . ), renal carcinoma (p . ), and renal neoplasia in general (p . ) were not associated with a higher likelihood of r-fna and final diagnosis concordance. there was no association noted between likelihood of r-fna and final diagnosis concordance when patients were stratified by species, serum creatinine or blood urea nitrogen concentration, urine specific gravity, dipstick proteinuria, or any diagnostic imaging variables. this study failed to identify concurrent clinicopathologic or diagnostic imaging findings that enhanced the diagnostic utility of r-fna. future studies should use standardized criteria to prospectively identify patients in which r-fna will be performed, evaluate additional variables that may be associated with increased r-fna diagnostic utility, and directly compare the utility of r-fna with that of other diagnostic techniques. feline lower urinary tract disease (flutd) is a disease with increasing prevalence in private practices and veterinary teaching hospitals. although several underlying causes can cause the obstructive form in male cats, the idiopathic form (feline interstitial cystitis) often is diagnosed as underlying reason in cats o years. the goal of this retrospective study was to identify possible predisposing factors in order to optimize the therapy of these patients. as a study group, cats hospitalized with obstructive flutd at the veterinary university of vienna were examined during a year period ( ) ( ) ( ) . as a control group cats presented for other reasons were randomly chosen during the same time period. the data were examined concerning the signalment and history. furthermore, the long-term outcome was evaluated with a questionnaire. based on assumptions a student's t-test or a chi-square test was used. there were no significant differences in age and breed. the body weight was significant higher in the flutd group than in the control group (p o . ). we could observe a significant risk for the disease of a weight of kg (p o . ). there were significant less cat toilets in the flutd group compared to the control group (p o . ). furthermore we could observe that in the households of flutd cats there was significant less than one toilet per cat (p o . ) and more cats diseased on flutd lived strictly indoor than outdoor (p . ).there were no significant differences at the time of hospitalization in age, breed, number of cats per household or season of the year between the two groups. in summary, we could observe that cats over kg body weight kept indoor with less than one toilet per cat have a significant higher possibility to be affected by obstructive flutd. further studies with an extensive history of animal husbandry are needed to identify risks predispoing cats to this frequent and cost-intensive disease. although purine uroliths (ammonium urate, sodium urate, xanthine, uric acid, etc.) represent the third most common stone type in cats, purine uroliths have the highest rate of recurrence ( % in months). in dogs, mutation of the urate transporter (slc a ) and portovascular anomalies are common risk factors. however the underlying cause(s) for purine urolith formation in cats is unknown. the purpose of this study was to test the hypothesis that hyperuricosuria without alterations in liver function is common in cats with urate uroliths. urine concentrations of purine metabolites were measured by high-performance liquid chromatography in cats with ammonium uroliths (cases), clinically healthy, breed and gender matched cats (negative controls), and cats with naturally occurring xanthine uroliths (positive controls). prior to urine collection, all cats were fed a standard maintenance food (protein g/ kcal) for weeks. urinary xanthine, uric acid, and allantoin concentrations and concentration to creatinine ratios were calculated and compared between groups. also, serum pre-and post-prandial bile acid concentrations were measured. when compared to control cats, urinary uric acid concentration was significantly higher in case cats (p . ). xanthine was not detected in the urine of cases or negative controls. a significant difference in fasted and post-prandial serum bile acid concentrations was not detected in cases or controls (p . , . ).hyperuricosuria without increased concentrations of urinary xanthine or allantoin appears to be a risk factor for ammonium urate urolith formation in cats. an association between portovascular shunts and purine urolithiasis was not observed in this population of cats. studies indicate that proteinuria is predictive, on a population basis, of those cats at risk of developing azotemia. seldi-tof-ms is a sensitive, high-throughput, proteomic technique utilising chromatographic surfaces to facilitate separation and detection of proteins and peptides within biological fluids such as urine. individual low molecular weight (lmw) urinary proteins have been considered as potential biomarkers for renal damage but provide only a limited representation of the urinary proteome; seldi-tof-ms may provide a more global assessment. normotensive, non-azotemic geriatric cats ( years) were recruited prospectively from two first-opinion clinics for routine health screening. at entry cats received a full physical examination, plasma biochemistry, evaluation of total t concentration and urinalysis including urine protein to creatinine ratio. re-examination was offered at and months. cats were divided into two groups based on clinical status at the month re-examination (azotemic; creatinine concentration ! . mg/dl and non-azotemic). optimisation studies were performed to facilitate the automated preparation (biomek ) of cm (weak cation exchange) arrays for seldi-tof-ms analysis (ciphergen enterprise ) of urine samples from cats at entry to the study. results are reported as median [ th , th percentile]. mann whitney u-test and wilcoxon signed rank test were used to compare variables between groups and between timepoints, respectively. ciphergen express ( . ) software was used to analyse spectral data and a mann whitney u-test was used to identify clusters which differed significantly between groups (p o . ) at entry to the study. twenty non-azotemic cats were recruited, of which cats developed azotemia by months. no significant differences in age, body weight, biochemical or urinalysis variables were identified between groups at entry to the study. as might be expected creatinine increased significantly ( . mg/dl [ . , . ], . [ . , . ], p . ) between study entry and months in the cats that developed azotaemia and there was a commensurate increase in phosphate concentration ( . mg/dl [ . , . ], . [ . , . ], p . ). creatinine and phosphorus did not change significantly over time in the cats that did not develop azotaemia. seven clusters with m/z values of , , , , , were found to differ significantly between groups at entry to the study. the low protein concentration of feline urine makes the use of proteomic techniques challenging. however, this pilot study indicates that seldi-tof-ms can be utilised to examine the feline urinary proteome and that differences in low molecular weight protein patterns may be useful to differentiate those cats which are at risk of the development of azotemia. further work is necessary to identify these proteins/peptides. fibroblastic growth factor (fgf- ) is a phosphotonin with an important physiological role in the regulation of phosphorous and vitamin d metabolism, and may therefore play a part in the development of renal secondary hyperparathyroidism. previous studies in cats have shown parathyroid hormone (pth) to be elevated prior to the development of azotemia. the study objectives were to explore the hypothesis that fgf- is a mediator of the development of renal secondary hyperparathyroidism in the nonazotemic stages of feline ckd. healthy, non-azotemic (plasma creatinine concentrations (cr) o . mg/dl) geriatric cats were recruited into the study prospectively and followed for months. at the study end point cats were categorised into the following groups: group (n )-cr . mg/dl, group (n )-cr ! . mg/dl but did not meet the criteria for group and group (n )-cr . mg/dl in association with reduced urine concentrating ability (usg o . ) or demonstration of persistent azotemia (cr . mg/dl). plasma samples were subjected to routine biochemical analysis, intact pth, calcitriol and intact fgf- assay. variables were compared between the groups at the baseline time point. gfr was measured in an additional group of cats ( non-azotemic, iris stage ii, iris stage iii) using a corrected slope-intercept iohexol clearance method. relationships were explored using linear regression analysis and determining the coefficient of determination (r ). results are presented as median [range] . at the baseline time point fgf- concentrations were significantly higher in group ( . [ . - . ], p . ) and group ( . [ . - . ], p . ) compared to group ( . [ . - . ] ). weak positive relationships were identified between fgf- and pth (r . , p . , n ) and fgf- and cr (r . , p . , n ). however, the positive relationships between fgf- and phosphate (r . , p . , n ) and fgf- and calcitriol (r . , p . , n ) were not significant. the additional group of cats in which gfr measurement was performed there was an inverse relationship between fgf- and gfr (r . , p . ). in conclusion, fgf- was elevated in cats prior to the development of azotemia. the role of fgf- in the development of feline renal secondary hyperparathyroidism remains to be determined and should be explored through interventional studies. however, considering the relationship between fgf- and gfr, it cannot be excluded that the phosphotonin is simply a marker of reduced filtration. chronic kidney disease (ckd) is common in geriatric cats and hypoxia might contribute to the progression of this disease. the aim of this study was to evaluate urinary vascular endothelial growth factor (vegf) as a marker of renal hypoxia. cats were recruited through geriatric clinics held at two first opinion london practices. vegf was measured in stored samples using a canine elisa kit validated for use on feline urine and indexed to creatinine concentration to yield a vegf to creatinine ratio (vcr). two studies were undertaken -firstly a cross-sectional analysis of clinical variables associated with vcr in cats with ckd. diagnosis of ckd was based on concurrent findings of plasma creatinine ! mg/dl and usg . , with persistence of azotemia for ! weeks. only patients receiving no medical therapies were included. normotensive and (pre-treatment) hypertensive cats were included, but borderline cases (mean systolic blood pressure - mmhg on the date of sampling) were not. hyperthyroid cats were also excluded from this cross-sectional study. associations between vcr and clinical data were initially assessed using the spearman's coefficient and mann whitney test. linear regression was then used for multivariate analysis. the second study used samples from a trial in which hypertensive cats that had been treated with amlodipine for at least months were entered into a randomised cross-over study where they received placebo or benazepril ( . to mg/kg daily) for weeks in turn. vcr on placebo was compared with that on benazepril using the wilcoxon signed ranks test. cats with well controlled hyperthyroidism were included in this intervention study. results are reported as median [ th, th percentile]. vcr was higher ( . [ . , . ] vs. . [ . , . ] fg/g, p . ) in untreated hypertensives (n ) than normotensives (n ). vcr was correlated with pcv (r À . , p . , n ), upc (r . , p o . , n ), plasma phosphate (r . , p . , n ), and usg (r À . , p . , n ), but not plasma creatinine concentration. in the best multivariate model, pcv was associated with vcr independently of upc (r . , n ). vcr was significantly reduced by benazepril therapy ( . [ . , . ] fg/g) compared with placebo ( . [ . , . ] fg/g; p . , n ) with a reduction seen in % of cases. these results suggest urinary vegf excretion is associated with proteinuria in cats with ckd and might be a marker of renal hypoxia induced by low pcv. ace inhibitor therapy might reduce urinary vegf excretion because angiotensin ii causes constriction on efferent arterioles resulting in tubular hypoxia. fgf- is a phosphaturic hormone. fgf- concentrations increase with declining renal function in humans. the objectives of this study were to validate a method for fgf- quantification in feline plasma and to assess the association between fgf- concentration and plasma creatinine or phosphate concentration in cats with chronic kidney disease (ckd). non-azotemic and azotemic (plasma creatinine concentration (cr) . mg/dl) geriatric ( yrs) cats were recruited into the cross-sectional study from two london first opinion practices. cats were excluded from the study if they were fed a phosphate restricted diet, or had evidence of concurrent disease. the cats were categorized, using a modified iris staging system, into the following four groups: group (cr . mg/dl), group (cr . - . mg/dl), group (cr . - . mg/dl), group (cr . mg/dl). groups and were further subdivided based on the iris targets for plasma phosphate concentration (po ): group a (po . mg/dl), group b (po . mg/dl), group a (po mg/dl), group b (po mg/dl). fgf- concentrations were measured in feline edta plasma using a human intact fgf- elisa, validated by intraand inter-assay variability and assessment of dilutional parallelism. comparisons between groups were made using the kruskal-wallis test and mann-whitney u test, with statistical significance defined as p o . . bonferroni correction was applied where appropriate (statistical significance then determined as p o . ). results are reported as median [ th, th percentiles]. fgf- concentrations ! pg/ml (upper limit of quantification) were assigned the value of pg/ml. intra-and inter-assay variability of fgf- measurements were o . % and dilutional parallelism between feline samples and the calibration curve were demonstrated. plasma fgf- concentrations increased with increasing creatinine concentrations (group : [ , ] , n , group : [ , ] , n , group : [ , ], n , group : [ , ], n ). fgf- measurements were significantly different between all groups (p . to o . ) except between groups and (p . ). fgf- concentrations were significantly higher in cats with higher plasma phosphate concentrations (group a: [ , ] , n vs. group b: [ , ], n ; p . ) and (group a: [ , ] , n vs. group b: [ , ], n ; p . ). in conclusion, fgf- concentrations were higher in cats with more severe ckd or higher plasma phosphate concentrations as would be predicted from its known biological actions. further work is warranted to explore the role of fgf- in the development of renal secondary hyperparathyroidism by measuring parathyroid hormone (pth) and calcitriol in cats at different stages of ckd. progressive non-cardiogenic edema and lung dysfunction are common complications of acute kidney injury (aki) in people. pulmonary abnormalities have not been systematically reviewed in dogs with renal azotemia, but anecdotal reports of dogs with aki and concurrent non-cardiogenic pulmonary edema are suggestive of uremic pneumonopathy (up), a centrally-distributed pulmonary edema syndrome associated with kidney disease in people. we therefore hypothesized that pulmonary-associated clinical signs or thoracic radiograph abnormalities are more common in dogs with renal azotemia than in non-azotemic dogs, and that this association is more likely in dogs with aki than dogs with chronic renal failure (crf). our study objectives were ) to describe thoracic radiograph and lung histopathologic abnormalities in dogs with renal azotemia, ) to compare the occurrence of these findings in dogs with aki, crf, or non-systemic illness, and ) to determine if these abnormalities are associated with shorter survival times. records of dogs with renal azotemia evaluated from / / to / / were reviewed; dogs which could be classified as having aki or crf and which had complete thoracic radiograph studies available for review were included. dogs with primary intracranial disease and normal serum creatinine and a complete thoracic radiograph study were selected as controls. signalment, weight, presence of pulmonary-related clinical signs, azotemia duration and severity at time of radiography, and leptospirosis antibody titer were noted. alveolar, bronchial, interstitial, or nodular lesions were described using a -point scale, and lung tissue collected at time of necropsy was reviewed; both the radiologist and pathologist were blinded to final diagnoses. significance was p o . for all analyses. the final study population included aki, crf, and control dogs. crf dogs were older (p o . ) than aki and control dogs. pulmonary-related clinical signs were more commonly diagnosed at first evaluation in aki dogs ( / dogs, . %) than in crf ( / , . %; p . ) or control dogs ( / , . %; p o . ). presence of an alveolar pattern was the only radiographic finding which differed amongst groups (more common in aki [n , . %, p . ] and crf [n , %, p . ] dogs than in control dogs [n , . %]). there was no association between presence of an alveolar pattern and any other variable. alveolar mineralization was the most common lesion in aki dogs ( / dogs; . %), with concurrent alveolar space concretions or mineralization of vessels or bronchioles noted in dog each. necropsies had not been performed in any of the crf dogs, but mineralization was not seen in lung tissues from any control dogs (n ). neither pulmonary-associated clinical signs nor alveolar pattern were associated with median number of days from discharge until death in dogs with aki (p . and . , respectively) or crf (p . and . , respectively). in this group of dogs, presence and type of radiographic pulmonary abnormalities were associated with renal azotemia but not with median time until death. the association between and clinical relevance of alveolar mineralization in aki dogs were not determined, but both the radiographic and histopathologic abnormalities reported here differ from up in people. chronic kidney disease (ckd) is a common cause of morbidity and mortality in cats. the purpose of this study was to investigate the effects of chinese rhubarb (rheum officinale) supplementation on the progression of feline ckd. cats with stable iris stage ii or iii ckd and without comorbidity were included in the study. cats were divided into treatment groups and administered rhubarb extract (group , rubenal s , vetoquinol, mg tablet po q h), benazepril as a positive control (group , . mg/kg po q h), or both (group ). cats were fed a commercial renal specific diet and enteric phosphate binder as appropriate. body weight, laboratory data, and blood pressure were recorded every months for up to months. variables between groups at enrollment and within groups over visits were compared with anova and repeated measures ano-va, respectively. a treatment by visit interaction term was included in all repeated measures models. significance was set at p . . except for body weight there was no significant differences between treatment groups at enrollment. there was no significant change in body weight, hematocrit (hct), upc, or creatinine over time as compared to baseline within any group. there was no significant difference between groups over time in regards to change in weight, hct, upc, or creatinine. the treatment by time interaction was non-significant in all models. although there was no benefit associated with combination treatment, the results for rhubarb treatment alone were not different from benazepril treatment. azodyl, an encapsulated, enteric-coated probiotic/prebiotic nutraceutical, is marketed for reduction of azotemia (bun & creatinine) in dogs and cats. cat owners often sprinkle contents onto cat food to facilitate administration. however, exposure to air and stomach acid are thought to inactivate the lyophilized bacteria within the product. therefore, we examined the ability of foodsprinkled azodyl to reduce azotemia in cats with ckd. cats with ckd were enrolled in the study and randomized receive azodyl or placebo. owners were provided with - capsules of azodyl prior to enrollment to ensure compliance with administration. baseline blood samples were obtained month apart, and then & months after beginning therapy. clinicians and owners were masked as to medication assignment. we hypothesized that a % decrease in bun and/or creat in the azodyl group would be significant, and set a . . in order to maximize the probability of detecting a difference, we determined the % change as being the difference between the maximal baseline analyte concentration and minimal therapeutic concentration. we compared the % change between groups by mann-whitney u test. bun and creatinine did not differ between groups. based on these results, azodyl, applied by sprinkling onto food fails to reduce azotemia in cats with ckd. whether intact capsule administration reduces azotemia in cats with ckd remains unknown. lower urinary tract disease (lutd) occurs commonly in cats, and idiopathic cystitis (fic) and urolithiasis account for over % of cases in cats less than years of age. although several strategies have been recommended, a common recommendation is to induce dilute urine resulting in more frequent urination and to dilute calculogenic constituents. in addition to conventional therapy using modified diets, traditional chinese and western herbs have been recommended, although only one, chorieto, has published data. we evaluated commonly used herbal treatments recommended for use in cats with lutd including ( ) san ren tang, ( ) wei ling tang, and ( ) alisma. we hypothesized that these chinese herbal preparations would induce increased urine volume and decreased urine saturation for calcium oxalate and struvite. six healthy, spayed female, adult cats were evaluated in a placebocontrolled, randomized, cross-over design study. cats were randomized to of treatments including placebo (p), san ren tang (srt), wei ling tang (wlt), or alisma (a). treatment was for weeks each with a week washout period between treatments. at end of each treatment period, a -hour urine sample was collected using modified litter boxes. urine volume and biochemistries were measured, and urine saturation for struvite and calcium oxalate was estimated using equil . b. analysis of variance (anova) was used to analyze data statistically if distributed normally and kruskal-wallis was used to analyze data statistically if data were not distributed normally. a p o . was considered significant. body weights were not different between treatments. no differences were found in -hour urinary analyte excretions, -hour urine volume, urine ph, or -hour urinary saturation for calcium oxalate or struvite between treatments (table) . urolithiasis is a multifactorial disease, frequent and recurrent in dogs in the worldwide, in which breed, sex, age, diet, some anatomical abnormalities, urinary tract infection, urine ph and some geographical and hereditary features in the populations studied have been implicated as risk factors. the effective long-term management of urolithiasis depends on identification and control of the pathophysiological mechanisms involved, which, in turn, depend on accurate knowledge of the mineral composition of the uroliths. the aim of this study was to determine for first occasion the main epidemiological data of canine urolithiasis in mexico. this study was developed with dogs with urolithiasis from of the states of the country. chemical composition of the uroliths was determined by stereoscopic microscopy, infrared spectroscopy, scanning electron microscopy and x-ray microanalysis. urolithiasis affected nearly the same number of males and females; with ages ranging from two months to years with a median age of years. adult animals were the most affected. breeds more affected were schnauzer miniature, poodle, dalmatian, yorkshire terrier, scottish terrier, chihuahua and bichon frisee´. uroliths were found in the lower urinary tract in . % of the cases. mineral composition of the uroliths was: struvite . %, followed by calcium oxalate . %, purines . %, silicate . %, others . %, mixed . % and compound uroliths . %. struvite uroliths affected females in most cases, whereas calcium oxalate, purines and silicate uroliths, were mainly observed in males. our results are similar to studies developed in other countries and continents, though we found a higher frequency of uroliths containing silicate, either pure, mixed or compounds uroliths ( . %); in mexico city the frequency reached %. this high frequency may be due to high consumption of silicate in home-made food or in the groundwater derived from aquifers. acknowledgments: this work has been partially supported by a project of waltham foundation in mexico and the consejo nacional de ciencia y tecnologı´a (conacyt) of mexico. voiding urohydropropulsion is a non-invasive method for removing small urocystoliths from the dog, most commonly used in females due to the relatively wider and shorter urethra. this procedure is typically performed under general anesthesia to allow complete relaxation of the urethra, however, anesthesia results in longer procedure times and difficult endotracheal tube stabilization due to the vertical positioning of animals, especially in larger dogs. the aim of this study was to devise a novel injectable sedation protocol for urohydropropulsion when cystoscopy was not concurrently required. an intravenous catheter was placed, and a combination of medetomidine ( to mg/kg iv) and hydromorphone ( . to . mg/kg iv) was administered, with the addition of ketamine ( mg/ kg iv) in fractious animals; atipamezole (double volume of medetomidine, administered im) was used as a reversal agent upon procedure completion. this protocol was considered in cardiovascularly healthy, non-diabetic dogs without evidence of urinary obstruction. monitoring equipment included electrocardiography, blood pressure measurement, and pulse oximetry, and supplemental flowby oxygen was provided. two dogs received the proposed sedation protocol in order to perform urohydropropulsion. dog one was a year old female spayed shih tzu cross, and dog was a year old female spayed standard poodle. ultrasonography revealed a moderate number of urocystoliths present in both dogs, measuring up to mm in dog and . mm in dog . urohydropropulsion was performed and resulted in retrieval of urocystoliths in dog , and approximately urocystoliths in dog . repeat ultrasonography revealed no uroliths present after urohydropropulsion in both dogs. the time from administration of sedation to administration of reversal agent was minutes for dog , and . minutes for dog . records were obtained from dogs that had traditional general anesthetic protocols for urohydropropulsion with cystoscopy for confirmation of urocystolith removal, performed within the last years, and the average anesthetic time was minutes. subsequent to the use of medetomine-based sedation protocols for the above dogs, cystoscopy was performed in a year old neutered male golden retriever with prostatomegaly. medetomidine ( ug/kg iv) and butorphanol ( . mg/kg iv) were administered; atipamezole (double volume of medetomidine, administered im) was used as a reversal agent upon procedure completion. this sedation allowed adequate immobilization for cystoscopy of the urethra and urinary bladder, and endoscopic biopsying of the prostatic urethra and urinary bladder. the time from administration of sedation to administration of reversal agent was minutes for this dog. in conclusion, a novel sedative protocol for urohydropropulsion is proposed which allows for an appropriate level of sedation along with a short procedure time and rapid recovery. this sedation protocol may also be useful for certain cystoscopic procedures. analysis may be delayed for a variety of reasons, including the need for sample batching within the laboratory or shipping to an outsourced location. therefore, it is important to know how storage of the sample may affect enzyme activity. we hypothesized that urinary nag and ggt activity would be affected differently in samples stored by refrigeration vs. freezing. thirty-four canine urine samples submitted to the clinical pathology laboratory at kansas state university were included. samples were collected from clinical patients with a variety of medical/surgical disorders and were selected based on the day of the week and a minimum volume of ml. a complete urinalysis was performed on each sample; however there were no exclusion criteria based on urinalysis results. nag and ggt activity in the urine supernatant was assessed by colorimetric assay. aliquots of each supernatant were refrigerated for days and frozen at À c for and days at which time enzyme activity was re-assessed. compared to baseline values, enzyme activity for both nag and ggt were stable after days of refrigeration, however there were significant (p o . ) declines in ggt and nag activity when urine supernatants were frozen for and days. treatment for canine urinary tract infections (uti) typically consists of - days of antimicrobial drugs in primary care veterinary practice. compliance with this drug regimen can be difficult for some clients. enrofloxacin is a veterinary approved fluoroquinolone antimicrobial and is useful for treatment of canine uti. fluoroquinolones are often used in human medicine to treat uncomplicated utis in women and can be prescribed for as little as days. the primary objective of this study was to determine if dogs with naturally occurring uncomplicated uti have equivalent microbiologic cure with a high dose short duration protocol of enrofloxacin, compared to a standard antimicrobial protocol. client-owned adult dogs with naturally occurring, uncomplicated uti were prospectively enrolled in a multi-center clinical trial and assigned to of groups in a randomized blinded manner. group received treatment with - mg/kg oral enrofloxacin once daily for consecutive days. group dogs were treated with . - mg/kg oral amoxicillin-clavulante twice daily for days. both groups had urinalyses and urine cultures submitted on day , , and . at the time of this interim analysis, thirty-six dogs have completed the trial. bacteriological cure was achieved in dogs ( %) treated with enrofloxacin and dogs ( %) treated with amoxicillinclavulante, respectively. these data suggest that the high-dose, short-duration enrofloxacin protocol was equally effective to the standard protocol in treating uncomplicated canine uti in the sample patient population. and may represent a viable alternative therapeutic regimen for similar patients. azotemia is frequent in dogs with dmvd (nicolle et al; jvim ; : - ) and could result from renal hemodynamic alterations. renal resistive index (ri) allows assessment of renal vascular resistance. the aim of this prospective study was to assess ri in dogs with different dmvd stages. fifty-five dogs with dvmd were used (isachc class (n ), (n ), and (n )). physical examination, renal ultrasonography and echo-doppler examinations were performed in awake dogs by trained observers. plasma creatinine, urea and nt-probnp were measured. statistical analyses were performed using a general linear model. whereas ri of renal and arcuate arteries were unaffected by isachc class, left interlobar ri increased (p o . ) from . ae . (mean ae sd) in class to . ae . in class . left interlobar ri was also higher (p o . ) in azotemic ( . ae . ) than in non azotemic ( . ae . ) dogs. similar findings were observed for right interlobar ri. a positive effect of nt-probnp (p . ), urea (p o . ), creatinine (p . ), urea-to-creatinine ratio (p o . ), left atrium-to-aorta ratio (p o . ), regurgitation fraction (p . ), systolic pulmonary arterial pressure (p o . ) and shortening fraction (p . ) on ri was also observed. in conclusion, interlobar ri increases with the severity of dmvd and azotemia. a cause-effect relationship remains however to be established. antibodies against alpha-enolase are associated with immunemediated nephritis in people. it was previously shown that vaccinated cats commonly develop antibodies against alpha-enolase. the purpose of this study was to assess for associations between alphaenolase antibodies and azotemia in privately-owned cats. clinically stable privately owned cats ! years of age, with and without azotemia (creatinine mg/dl), and with an available vaccine history for ! years were recruited for the study. sera were assayed for creatinine concentrations and alpha-enolase antibodies by use of previously validated techniques. results from cats with and without azotemia were compared by student's -tailed t test or fisher's exact test with significance defined as p o . . median ages were years (range: - ) and years (range: - ) for cats with (n ) and without azotemia (n ), respectively. there was no significant difference in vaccine events (number, type, or route of administration) between groups. azotemic cats ( . %) were more likely than normal cats ( . %) to be positive for antibodies against alpha-enolase (p . ). in addition, alpha-enolase antibody concentrations were greater (p . ) in azotemic cats (mean % elisa . %) than cats with normal creatinine concentrations (mean %elisa . %). results of this study suggest that antibodies against alpha-enolase in cats may be associated with renal disease. additional prospective evaluation in a larger number of cats is indicated. aki is used in human medicine as a predictor of mortality based on the akin (acute kidney injury network) scoring system which utilizes relative increases in creatinine to determine stage. with this scheme, mortality has been shown to increase as the stage of kidney injury (indicated by akin score) increases. accordingly, we hypothesized that this system would improve predicting prognosis in dogs and cats. we retrospectively evaluated dogs and cats ( ) ( ) ) that had ! creatinine measurements within days, and whose first creatinine was o . mg/dl. patients were categorized as: level (no aki); level (second creatinine value o . mg/dl, but creatinine increased ! . mg/dl); or level (second creatinine . mg/dl with a creatinine increase ! . mg/dl). thirty and day survival for each level was compared to level . adjusted odds ratio (or) in dogs for day survival was . for level (ci %, . - . ) and . (ci %, . - . ) for level ; or for day survival was . for level (ci %, . - . ) and . (ci %, . - . ) for level . for cats, or at days was . (ci %, . - . ) for level and . (ci %, . - . ) for level ; or for day survival was . (ci %, . - . ) for level and . (ci %, . - . ) for level . thus, detecting increasing stage of aki helps predict mortality in dogs and cats. abstract n/u- feline urate urolithiasis: cases ( - . j dear , r shiraki , a ruby , j westropp . william r pritchard veterinary medical teaching hospital, university of california, davis, ca, gerald v. ling urinary stone analysis laboratory, university of california, davis, ca and the department of veterinary medicine and epidemiology, university of california, davis, ca. feline urate urolithiasis accounts for % of the feline stones our laboratory analyzes each year; little information is known about this disease, particularly the incidence of those cats with hepatopathies. the objective of the study was to characterize the signalment, clinicopathologic data, and diagnostic imaging of cats with this disease as well as the salts of uric acid present. a retrospective analysis of feline urate uroliths submitted to the stone lab between january -december were included. from these data, primary veterinarians were solicited to submit records. furthermore, all records from cats with urate uroliths from the vmth were analyzed separately. records were received from the primary care veterinarians. sixteen cases were identified from the vmth. median values for the cbc and chemistry panels available were within the reference ranges provided, with only a few outliers present. of the cats with radiographic reports, ( %) had visible evidence of uroliths. two external cases had confirmed pss; five cases from the vmth had a pss. cats with urate uroliths and pss were younger than cats without a documented hepatopathy ( years vs. years). the siamese breed was overrepresented. all stones were ammonium hydrogen urate. the pathogensis of urate uroliths in cats is poorly understood. most cats were not completely evaluated for pss, however, there were few clinicopathologic parameters which indicated hepatopathies were present. further studies are warranted to evaluate genetics and purine metabolism in cats with urate uroliths to help tailor proper management and breeding strategies. -indoxyl and p-cresyl sulfate (is, and cs, respectively), small protein-bound molecules derived from gastrointestinal protein metabolism, are among the most important uremic solutes affecting morbidity and mortality in human chronic kidney disease (ckd). in the blood stream, these compounds are predominantly bound to protein, but their debilitating effects on prognosis and quality of life in ckd appear to be driven by the free fraction. the objectives of the present study were to assess the normal, physiological levels of is and cs in healthy cats and to evaluate the correlation of the respective free and protein-bound levels. blood samples were taken from clinically healthy adult cats enrolled at five participating veterinary practices in germany. after centrifugation, the serum was deep frozen until transport on dry ice to the analytical laboratory. serum creatinine and urea levels were quantified by vettest s (idexx laboratories, inc.). total and free is and cs, respectively, were quantified by turbulent flow chromatography coupled with a tandem mass spectrometry detector. statistical analysis of the results comprised i) a descriptive report of the median with upper and lower bounds of the % confidence interval for reference values of is and cs, ii) a calculation of various pearson correlation coefficients r, also tested with reference to the null hypothesis of no relationship, and iii) wilcoxon-mann-whitney utest for an estimation of the effect of hemolysis on serum is or cs levels. six animals with serum creatinine or urea levels outside the reference range were excluded from the calculation of reference values. median levels of is in cat serum were . mg/l with upper and lower bound % confidence intervals at . and . mg/l, respectively. the corresponding median levels of cs were . mg/l (median) and . vs . mg/l (upper vs lower bound levels, respectively). these values showed a low, non-significant correlation with serum creatinine or urea levels. however, is and cs serum levels were moderately correlated (total levels r . , p o ). their respective free levels constituted about % of the total serum levels (r ! . , p o . ). non-hemolytic samples tended to yield lower values than hemolytic samples. due to the low number of hemolytic samples (n ) , the group difference could, however, not be statistically confirmed. the results indicate that it is sufficient to determine total levels of either is or cs in serum while studying the effects of therapeutic or dietetic interventions on the evolution of these parameters in feline ckd. reference values are provided for orientation towards clinically relevant changes. disrupted urothelial differentiation has been implicated in the pathogenesis of feline idiopathic cystitis (fic). studies of cultured human urothelium have shown that abnormalities in urothelial differentiation and repair may be mediated by persistent -hydroxy-prostaglandin dehydrogenase (pgdh) activity and subsequent metabolism of cytoprotective prostaglandins. the goal of this study was to confirm persistent pgdh expression in fic bladders compared to desmoplakin i ii expression, a marker of urothelial differentiation. urinary bladder biopsy specimens were obtained by cystotomy from symptomatic cats with chronic fic. cats with a history of another major disease, previous cystotomy, or recent treatment with corticosteroids, nsaids, antihistamines, antidepressants, or glycosaminoglycans were excluded. urinary bladder tissue specimens were also obtained from untreated clinically normal specific-pathogen-free cats. tissue specimens were fixed in buffered % formalin and embedded in paraffin. tissue sections were deparaffinized and subjected to citrate buffer microwave antigen retrieval. tissues were stained for pgdh using a rabbit anti-pgdh antibody, an isotype negative control or goat anti-desmoplakin i ii and developed using the avidin-biotin peroxidase complex method. all fic ( / ) and normal ( / ) cat bladder samples showed similar staining of urothelial cytoplasm for pgdh. however, desmoplakin i ii staining, found on the luminal cell surface in / normal tissues, was disrupted in / fic bladder samples. desmoplakin i ii staining confirmed altered urothelial differentiation in fic cats. however, pgdh expression remained intact in fic samples. we hypothesize that pgdh expression in fic may contribute to its pathophysiology due to breakdown of prostaglandins essential for urothelial healing. additional studies will explore this hypothesis. the university of tennessee college of veterinary medicine's picture archiving and communication system was searched over a month period for cats that had undergone both abdominal radiographs and ultrasound during the same visit. one hundred and three cats were identified (age range o to yrs; median yrs). kidney size was determined based on radiographic and ultrasound findings. of the included cats, . % had two normal sized kidneys, . % had one small and one normal, . % had one large and one normal, . % had two small, . % had two large, and . % had one small and one large kidney. the presence of mineralization, uroliths and hydronephrosis was also noted. medical records were reviewed for clinical chemistry data and historical information concerning previous urinary disease. no significant differences were found between kidney size and renal function, kidney size and the presence of uroliths, renal mineralization and function or the presence of uroliths and function. the presence of uroliths was significantly associated with hydronephrosis. of the cats with at least one large kidney, ( %) had hydronephrosis. of the cats with current or previously diagnosed uroliths, urinary tract infections or other uropathies, ( . %) had at least one small kidney. small kidneys were commonly found in older cats, however, this correlation was not statistically significant. based on these findings, small kidneys are more likely to be the result of urinary disease as opposed to being either congenital or due to aging. this study aimed to evaluate ife, which has been advocated for treatment of lipid-soluble drug intoxication, in the treatment of clinically-occurring canine ivermectin toxicosis. one australian shepherd and two miniature australian shepherds were included. all three dogs were homozygous for the mdr- gene mutation. two dogs roamed on horse ranches where ivermectin-based deworming products had recently been used. ivermectin was administered to the third dog ( mg/kg po). all three dogs exhibited tremors, ptyalism, and cns depression, which progressed over several hours to stupor in two dogs, and to a comatose state requiring mechanical ventilation in the remaining dog. a % formulation of ife (liposyn ii, hospira) was administered as a bolus ( . ml/kg) followed by a slow iv infusion ( . - ml/kg over minutes). no change was observed in the neurologic status of any patient. lipemia visible upon blood sampling persisted for hours in one dog. no other adverse effects were noted. serum ivermectin levels confirmed ivermectin exposure in each case. in this study, ife administration did not result in clinical benefit in cases of ivermectin toxicosis. brain ivermectin concentrations in mdr mutant/mutant genotype dogs may be too high to be overcome by ife. additionally, these dogs may lack p-glycoprotein-mediated biliary clearance mechanisms needed for optimal ife function. further investigation is needed to determine the utility and optimal dosing of ife in canine toxicoses, to characterize its safety, and to determine how mdr- status may alter the efficacy of ife in treatment of canine ivermectin intoxication. rufinamide is a recently approved antiepileptic drug used for the treatment of seizure disorders in human patients. rufinamide is administered at a dose of mg/kg divided twice daily to achieve therapeutic concentrations of mg/ml. the objective of this study was to determine the pharmacokinetic properties and short-term adverse effects of single-dose oral rufinamide in healthy dogs in preparation for a possible clinical trial evaluating the efficacy of rufinamide in the treatment of canine epilepsy. six healthy adult dogs were included. the pharmacokinetics of rufinamide were calculated following administration of a single mean oral dose of . mg/kg (range . - . mg/kg), extrapolated from the dose used in human patients. dogs were monitored by repeat physical examinations, electrocardiograms and blood pressure assessments during the course of the study. plasma rufinamide concentrations were determined using high-performance liquid chromatography. pharmacokinetic data were analyzed using winnonlin version . . no adverse effects were observed. the mean terminal half-life was . /À . hours. the mean maximum plasma concentration was . /À . mg/ml and the mean time to maximum plasma concentration was . /À . hours. mean clearance was . /À . l/hr. auc inf was . /À . mgÃh/ml. results of this study suggest that rufinamide given orally at mg/ kg twice daily in healthy dogs should result in a plasma concentration and half-life sufficient to achieve the therapeutic level extrapolated from humans without short-term adverse effects. further investigation into the efficacy and long-term safety of rufinamide in the treatment of canine epilepsy is warranted. the aims of this study were to investigate the abg for (i) the prevalence of skull abnormalities; (ii) the prevalence of sm; (iii) an association between lateral ventricular size, cerebellar size and sm; and (iv) associations between sm, skull abnormalities, csf pleocytosis and clinical signs. seventy-six abgs, recruited as part of a larger epidemiological and genetic study, underwent brain and spinal mri evaluation ( . t general electric signa hdx, milwaukee, wi). all dogs were evaluated neurologically, recording deficits and the presence of spinal pain. sequences acquired included t w, t w pre-and postcontrast, and t w flair, sagittal and transverse. cervical spinal cord central canal (cc) and or syrinx size and its percent area of spinal cord was measured using osirix s . the presence of chari-like malformation (cm) was assessed by recording the presence of caudal cerebellar deviation and/or foramenal vermal herniation. lateral ventricle and cerebellar volume was expressed as a percent of the cerebrum and intracranial volume qa respectively. forty-five dogs underwent atlanto-occipital cerebrospinal fluid tap at the time of mri and the white blood cell (wbc) count was recorded. student's t-tests were used to compare the measured variables between groups with and without skull abnormalities, spinal pain and neurological signs. the mean age of the males ( intact) and the females ( intact) was . months (range - ; median months). neurological deficits and neck pain were noted in ( %) and ( . %) of dogs respectively; dogs ( . %) exhibited both. cerebellar deviation and vermal herniation were present in ( . %) and ( . %) dogs respectively; twenty-three dogs ( . %) had both. mean height of the cc was . mm ( - . mm). forty ( . %) ccs were greater than mm in height; the mean length of these lesions was . vertebrae ( . - ). mean csf wbc count was . /ml ( - ). syrinx height and extent were significantly higher in dogs with neurological signs (size p . ; extent p . ). there were no significant differences in syrinx sizes and extent in dogs with or without skull abnormalities or spinal pain. there were no associations of syrinx height or extent with csf wbc count or age of dog. intact females had a significantly lower syrinx extent than intact males (p . ). there were no significant differences in presence of spinal pain or neurological signs between dogs with or without skull abnormalities. there was a significant negative association of ventricular percentage and cerebellar percentage (p o . ). there was a significant association of ventricular percentage with syrinx percentage (p . ) and height (p . ). this study suggests that sm and cm are prevalent in abgs. syrinx size and extent are associated with neurological signs and ventriculomegaly is associated with both small cerebellar size and large syrinx size. however, sm may not be associated with cm as defined by cerebellar herniation and deviation and is not associated with csf inflammation. the power tissue resection device (ptrd) is a hand-piece comprised of an outer cannula with motor driven vacuum-assisted inner cutting blade. this device was designed and is marketed for human neurosurgical brain/spinal cord tumor resection. the purpose of this study is to describe the use of the ptrd for intervertebral disc fenestration and to compare the effectiveness of manual fenestration to that of the ptrd. fifteen cadaveric lumbar spines were randomly placed into three study groups: group was the control group on which no fenestrations were performed, group was the manual fenestration group and group was the ptrd fenestration group. the effectiveness of fenestration via both manual and ptrd was assessed by calculating the ratio of remaining nuclear weight post fenestration to total nuclear volume. discs with lower ratios were more effectively fenestrated. results showed a smaller ratio of post fenestration remaining nuclear weight to nuclear volume following fenestration with the ptrd ( . ae . ) as compared to manual fenestration ( . ae . ). these results did not show statistical significance. when fenestrated samples were compared to control samples ( . ae . ), there was a statistically significant reduction in ratios. in conclusion, the ptrd is easy to use and is as effective as the manual technique for canine intervertebral disc fenestration. according to the human who classification gliomatosis cerebri (gc) is a rare astrocytic tumor affecting at least three lobes of the brain with extensive infiltration, but relative preservation of brain architecture. gc has not been reported to occur as a hereditary disease, neither in man nor in animals. here, we report the temporally clustered occurrence of gc in a family of bearded collies. a years old female bearded collie with forebrain signs was presented. differentials included inflammatory/ infectious, metabolic/ toxic, and neoplastic diseases. within a time period of months, offspring of this bitch were presented with similar clinical signs. two dogs were full siblings ( males). the remaining female dog originated from a match with a different male dog. mri was performed in all dogs and revealed a diffuse and extensive intra-axial lesion with moderate mass effect and midline shift. the ill defined lesion showed mainly a white matter distribution with hyperintense signal in t -w and flair images and iso-to hypointense signal in t -w images without contrast enhancement. the lesion was bilateral in all cases, continued along the white matter extending partially into the gray matter with contact to the brain surface. neuropathology revealed a diffuse and extensive infiltration of the brain and spinal cord by a neoplastic glial cell population involving white and gray matter of both hemispheres, thalamus, brainstem and cerebellum in all dogs. based on the cell morphology and immunoexpression of glial fibrillary astrocytic protein by neoplastic cells diagnosis of gc was made. this is the first report of familial occurrence of gc, which is likely the result of a germ-line mutation. several human hereditary cancer syndromes are associated with cns tumors including amongst others the li-fraumeni cancer family syndrome (p mutation), neurofibromatosis (type and ) (neurofibromin, merlin mutation), and tuberous sclerosis (hamartin, tuberin mutation). furthermore, familial clustering of human gliomas unassociated to the known inherited cancer syndromes has been described. in the dog, hereditary cns tumors are not known. the exact mode of inheritance and putative gene mutations of gc in this bearded collie family are currently under investigation. preliminary results are consistent with a monogenic autosomal dominant mode of inheritance, although a recessive inheritance cannot be completely ruled out at this time. mutations in the tp gene were not found following amplification and sequencing of exons - in affected dogs. previously presented at the ecvn annual meeting in cambridge, uk. the gm gangliosidoses are characterized by a deficiency of bhexosaminidase. there are two isoforms: hex a composed of an a and b subunit encoded by hexa and hexb genes respectively and hex b with two b subunits. hex a requires an activator encoded by gm a. two japanese chin dogs with confirmed gm gangliosidosis showed elevated total hexosaminidase and normal hexosaminidase a activity, a pattern associated with the ab variant in humans and consistent with prior reports in the breed. this study was performed to identify the mutation responsible using resequencing with an applied biosystems xl dna analyzer as previously described (awano ). mutations in gm a cause the ab variant in humans, but resequencing gm a revealed no mutation that could account for the disease. resequencing hexa and hexb revealed a c. g a mutation in hexa which was homozygous in both affected dogs. sixty-five normal japanese chin dogs were screened for the mutant allele; were homozygous for the ancestral allele and heterozygous. this mutation predicts a p. e k substitution affecting one of two primary active-site amino acids that participate in the hydrolysis of gm ganglioside. substitution of a lysine residue at this site is likely to eliminate subunit a enzymatic activity. the apparently normal levels of hexosaminidase a activity in affected dog samples may be a result of b subunit overexpression. human hex b possesses low levels activity against the artificial substrate used to assess hex a activity, but specificity of activity of the canine enzyme is not known. previously presented at the american society for neurochemistry: additional data in this abstract. phenytoin (pht) is the intravenous drug of choice in humans for seizure emergencies following benzodiazapines. iv fosphenytoin (fos) is a pht pro-drug which causes less administration related adverse events. while the short half-life of pht is not suitable for chronic oral therapy in dogs, iv fos has not been studied. two dogs received mg/kg phenytoin equivalent (pe) and two dogs received mg/kg pe of fosphenytoin intravenously at a rate of mg pe/min. blood for plasma levels were drawn at time-points over hours; total and unbound drug levels were measured by hplc. vital signs including ekg, blood pressure, and neurological examination were monitored. the half-life of metabolism of fos to pht was $ min, with % of fos metabolized to pht by minutes. eighty to % of pht was protein-bound during the first minutes after dosing, compared to - % in humans. the elimination half-life for total pht ranged from . - . hours and for unbound pht ranged from . - . hours. dogs receiving mg/kg pe intravenously achieved unbound pht plasma maximum concentrations of . - . ug/ml at minutes, consistent with human loading dose levels. adverse events observed in some dogs included vomiting, mild ataxia, and short lived tremors, the severity of which appeared dose dependent. all dogs were clinically normal within minutes of all doses. a mg/kg pe dose of iv fos appears adequate for production of pht levels predicted to be effective for the treatment of canine seizure emergencies. further studies in clinical canine patients are warranted. acquired myasthenia gravis (mg) is caused by antibodymediated inactivation of the acetylcholine receptor on the neuromuscular endplate causing focal, regional or generalized muscle weakness. many medical treatments have been reported; however, responses to therapy and outcomes are unpredictable and death often results from aspiration pneumonia. therapeutic apheresis is an extracorporeal procedure that separates blood into its components for removal or specific alteration prior to return to the patient. therapeutic plasma exchange (tpe) is an apheresis treatment in which plasma (containing pathologic antibodies) is removed and exchanged with donor plasma. tpe is used routinely to treat mg in human patients with severe disease or disease unresponsive to conventional therapy. we report the successful use of tpe to treat large breed dogs with confirmed mg (aceytlcholine receptor antibody concentration: . and . nm/l, respectively; normal concentration: o . nm/ l) that was severe and not adequately responsive to traditional therapies. both dogs were non-ambulatory, recumbent, and demonstrated megaesophagus and aspiration pneumonia. three tpe treatments ( plasma exchange each) were performed over and days, respectively, in each dog without complication. both dogs became ambulatory within days of starting tpe treatment with subsequent resolution of regurgitation and megaesophagus. pyridostigmine was continued during tpe sessions and discontinued in both dogs within - months. both dogs remain asymptomatic and have had no recurrence of mg during and months of follow-up, respectively. tpe is a viable treatment option for dogs with mg that have severe disease, life-threatening complications or that remain unresponsive to traditional therapies. tpe may alleviate clinical signs more rapidly, and improve long-term outcomes when compared to historical experiences in patients with comparable disease. clinical findings, clinicopathologic data, imaging features, and treatment of canine spinal meningiomas have been described in the veterinary literature, but histological characteristics and tumor grading have less commonly been reported. the aims of this retrospective case series were to describe the clinical, imaging, and histologic features of seven canine spinal meningiomas including a cervical spinal cystic meningioma that had imaging and intraoperative features of a subarachnoid cyst. medical records from dogs with a histopathological diagnosis of spinal cord meningioma presented to the veterinary teaching hospital between and were reviewed. signalment, presenting clinical signs, physical and neurologic examination, clinicopathologic data, surgery reports and available images were reviewed. all meningiomas were histologically classified and graded following the international who human classification for cns tumors. seven dogs were included, males and females. median age at presentation was . years (range, . - . years), and median weight was kg (range, - kg) . median time between onset of clinical signs and diagnosis was days (range, days - year). cerebrospinal fluid (csf) analysis was performed in dogs, showing increased protein concentration in cases, and being normal in the other . spinal radiographs revealed vertebral canal widening in one case. myelography ( / ) showed intradural/extramedullary lesions in three cases, one of them consistent with a csf-filled subarachnoid cavity, and an extradural lesion in one case. magnetic resonance imaging (mri) was performed in all cases and revealed mild to marked hyperintensity on t w and precontrast t w images and homogeneous contrast enhancing (ce) intradural/extramedullary masses ( cervical and thoracic) in six cases, with one of these showing an additional intramedullary ce pattern. a dural tail was identified in two dogs. one dog had a fluid-filled subarachnoid enlargement located dorsally to the spinal cord. this lesion was hyperintense on t w, hypointense on t w and flair images, and did not enhance. it was diagnosed as a spinal subarachnoid cyst, but the histopathological study of the surgically resected mass revealed a grade i cystic meningioma. five other cases underwent cytoreductive surgery, two transitional meningiomas (grade i) that survived (alive at the time of writing) and months; and three anaplastic meningiomas (grade iii) that survived - . months before neurological deterioration and euthanasia. another anaplastic meningioma was euthanized right after diagnosis. there are few reports grading canine spinal meningiomas, with most being grade i or ii. of the few grade iii tumors reported, only one had been treated surgically and was euthanized days later because of neurological deterioration. we report four grade iii (anaplastic) meningiomas, three of which surgically treated and with longer survival times. finally, cystic meningioma should be considered in the differential diagnosis of cases with imaging features consistent with arachnoid cyst because of their similar appearance, making histopathological analysis essential for a definitive diagnosis. head trauma is a common veterinary emergency, but few prognostic indicators have been studied in dogs, making it challenging for clinicians to counsel clients about the odds of recovery. a recent meta-analysis showed that higher plasma glucose, lower plasma ph and lower hemoglobin at admission were associated with increased risk of death in human head trauma. the goal of this retrospective study was to investigate the association between admission point of care blood gas parameters and survival to discharge in dogs with head trauma. fifty one dogs presenting to the cornell university hospital for animals with head trauma from to that had a blood gas analysis done within hour of presentation were eligible for inclusion. parameters assessed included glucose, base excess (be), anion gap (ag), ph, hemoglobin, and sodium. biochemical data were found to be normally distributed using the kolmogorov-smirnov test. t-tests or welch tests were used to compare parameters between survivors (s,n ) and non-survivors (ns, n ). of glucose, be, ag, ph, hemoglobin, and sodium, only mean glucose (s mg/dl, ns . mg/dl, p . ) was significantly different between groups, although there was a trend for a difference in mean be (s À . , ns À , , p . ). logistic regression analysis showed that of the parameters, only be was independently associated with outcome (odds ratio . , % ci . - . , p . ). these results suggest that two easily measured biochemical parameters (glucose and be) may yield useful prognostic information in dogs with head trauma, but further studies are needed to further elucidate these findings. type i intervertebral disc disease (ivdd) commonly affects chondrodystrophic dogs. neurological recovery and outcome following surgical decompression may be unpredictable due to suspected ischemic neuronal injury. hyperlactatemia has been associated with spinal cord injury in humans and experimental animals. the purpose of the study was ) to determine the relationship between serum and csf lactate levels and ) to compare lactate levels with neurological outcome following decompressive surgery in dogs with ivdd. healthy, chondrodystrophic dogs diagnosed with ivdd localized to the t -l spinal cord were included. serum lactate levels were obtained at: anaesthetic induction, skin incision, muscle dissection, and extubation. in patients with hyperlacatemia at extubation, additional samples were obtained. csf was analyzed for lactate concentration. neurological status was recorded at presentation and multiple times during the recovery period. dogs were included in the study ( - years old). / dogs had normal lactate levels throughout the study. / dogs had serum hyperlactatemia prior to anaesthetic induction; / dogs returned to normal during anaesthesia and / dogs had continued hyperlactatemia until the end of the observation period. neurological status of the dogs varied similarly between all groups. in / dogs where csf lactate levels were measured, initial serum levels were lower than csf lactate levels; in / dogs where csf and serum were collected simultaneously, serum lactate concentration was consistently lower than csf lactate. no association between presenting neurological status or neurological outcome and serum or csf lactate concentration was made. neither serum nor csf lactate concentration is useful for predicting neurological outcome in dogs with ivdd. chiari-like malformation (cm) has been associated with syringomyelia (sm) in cavalier king charles spaniel (ckcs) and is postulated to result from a mismatch between the volume of the caudal cranial fossa and the brain parenchyma contained within. the objective of this study was to assess the role of cerebellar volume in caudal cranial fossa overcrowding and syringomyelia. three dimensional models were created using t -weighted transverse magnetic resonance images in the commercial software package mimics s . volumes of cerebellar parenchyma were analyzed as percentages of caudal cranial fossa volume (cerebellar caudal cranial fossa percentage) and total brain parenchyma volume (cerebellar brain percentage). data was assessed for normality and the appropriate statistical test was used to compare means/medians between groups. forty-five small breed dogs (sb), ckcs and labradors (ld) were compared. as sm is thought to be a late onset disease process, two subgroups were formed for comparison: ckcs younger than years with sm (group ) and ckcs older than years without sm (group ). ckcs had a larger cerebellar caudal cranial fossa percentage than the other groups . %] vs. sb . % [ . - . %] and ld . % [ . - . %]; p o . ). the cerebellar brain percentage was also larger in ckcs compared to the other groups (ckcs . % [ . - . %] vs. sb . % [ . - . %] and ld . % [ . - . %]; p o . ). group had a significantly larger cerebellar caudal cranial fossa percentage than group ( . % ae . vs. . % ae . , p . ) and a significantly larger cerebellar brain percentage ( . % ae . vs. . % ae . , p . ). our findings show that the ckcs has a relatively larger cerebellum than small breed dogs and labradors and there is an association between increased cerebellar volume and sm in ckcs. chiari-like malformation (cm) is nearly omnipresent in the cavalier king charles spaniel (ckcs) breed. the mis-match of the caudal cranial fossa and the parenchyma within is thought to lead to syringomyelia (sm). there is currently a lack of information if the morphological changes seen in ckcs with cm are progressive or non-progressive. in this retrospective study we used established measurements of cerebral volumes, foramen magnum height and cerebellar herniation length to assess if there is a significant difference between subsequent magnetic resonance (mr) imaging of the brain of the same dog. electronic patient records were reviewed for ckcs with cm which had two separate mri scans, which were a minimum of months apart. ckcs with diseases affecting measurements were excluded. for the volumetric measurements three-dimensional models were created using t -weighted transverse mr images in the medical imaging software (mimics v . , materialise n.v, ) . volumes of the caudal cranial fossa parenchyma were analyzed as percentages of caudal cranial fossa volume and caudal cranial fossa volume was analyzed as a percentage of total cranial cavity volume. the volume of the ventricular system was recorded as a percentage of total parenchymal volume. data was assessed for normality and the appropriate statistical test was used to compare means/medians. twelve ckcs were included with a median scan interval of . months ( - months). the size of the foramen magnum increased significantly between the first and second scan ( . ae . cm vs. . ae . cm; p . ), as did the length of cerebellar herniation ( . ae . cm vs. . ae . cm; p . ) and the caudal cranial fossa percentage ( . % [ . - . %] vs. . % [ . - . %]; p . ). there was no significant difference noted between the two time points in any of the other volumetric measurements ( this work could suggest that overcrowding of the caudal cranial fossa in conjunction with the movements of cerebrospinal fluid and cerebellar tissue secondary to pulse pressures created during the cardiac cycle causes pressures on the occipital bone. this leads to a resorption of the bone and therefore an increase in caudal cranial fossa and foramen magnum size allowing cerebellar herniation length to increase. the cord dorsum potential (cdp) is a stationary potential arising in dorsal horn interneurons after stimulation of sensory nerves. cdps have been recorded in normal anesthetized dogs previously, and normal latency values have been determined for tibial and radial nerves. this study was undertaken to determine whether cdps could be reliably recorded from the caudal nerves in normal dogs, thus allowing electrophysiological assessment of the cauda equina, and whether neuromuscular blockade improved recording quality. ten adult dogs weighing from . to . kg were anesthetized and cord dorsum recordings were compared before and after administration of atracurium. recording needles were placed onto the dorsal lamina at intervertebral sites from l /s to l / . stimulations were made on the lateral aspect of the caudal vertebrae approximately - cm from the tail base. recordings from stimulations were averaged. cdps were recorded successfully in all dogs. onset latency varied from . to . ms. the cdp was largest when recorded closest to the site of entry of the stimulated nerve into the cord, as determined by post-mortem examination immediately after testing in dogs. administration of atracurium did decrease muscle artifact, and in some cases helped isolate the origin of the cdp. these data show that cdps can be readily assessed from the caudal nerves of anesthetized dogs, with or without atracurium. cord dorsum potentials from caudal nerves may add important information about the integrity of the cauda equina in dogs with suspected degenerative lumbosacral stenosis. canine intracranial glial tumors and many human brain tumors express heat shock proteins (hsps) associated with their degree of malignancy. the up-regulation of hsps during tumor cell growth helps keep tumor proteins stable and therefore makes them a reasonable target for therapy. ki expression and ec have been strong indicators of cell proliferation and dedifferentiation, respectively.the aims of this study were to determine (i) if canine meningiomas express hsp and/or hsp ; (ii) whether the expression of the hsps was associated with ki and/or e-cadherin (ec) expression; and (iii) whether peritumoral edema was associated with hsp, ki and/or ec expression. forty-one formalin-fixed, paraffin-embedded canine intracranial meningiomas underwent immunohistochemical staining using anti-hsp , or antibodies. these tumor samples were also immunohistochemically stained for ki and ec expression. canine mammary carcinoma and squamous cell carcinoma tissues served as the control samples, as both have previously been shown to express hsps. skin was used as control for ki and ec. four non-overlapping high power fields of each stained sample were selected and cell staining was analyzed using a semi-quantitative method for hsps and ki ; a qualitative assessment was used for ec. all analyses were performed using sas v . (cary, nc). descriptive statistics of staining percentages were calculated for all tumors tested. simple pearson's correlation was used to test for correlations of ec area with hsp areas and ki- percent positive cells and of ec intensity with hsp intensities and ki- percent positive cells. all hypothesis tests were sided and the significance level was a . . thirteen meningiomas had mr images quantitatively evaluated for peritumoral edema using t flair sequences. the edema index (ei) was evaluated for an association with hsp , hsp , ec and ki expression. hsp was expressed in % (mean . % of cells; range - %), hsp in % (mean . % of cells; range - %) and ec in % of meningiomas. there was no association demonstrated between either hsp expression variable and ec or ki- expression. there was also no association between the ec expression variables and ki- . however, there was a significant negative association between hsp extent (p . ) and area (p . ) with ei. in conclusion, hsp and expression was demonstrated in canine intracranial meningiomas but was not associated with ki- or ec expression. this study suggests that hsps may not have a significant role in the maintenance of canine meningiomas and so do not represent a novel treatment target for this group of tumors unlike canine glial cell tumors. however, hsp may be involved in the pathogenesis of peritumoral edema in meningiomas and warrants further investigation. an extended release (xr) formulation of levetiracetam, a second generation antiepileptic drug, was recently approved for human use on a once daily basis. although levetiracetam is clinically effective for seizure control in dogs, it requires a three times daily administration. the potential benefits of the xr formulation include reduced daily dosing leading to improved compliance and relatively constant plasma concentrations. the aim of this study was to compare the pharmacokinetics of levetiracetam xr tablets with immediate release (ir) tablets following single dosing in dogs. five clinically and neurologically normal mixed breed dogs were used in a cross-over design. all dogs (mean body weight . kg; range . - . ) had normal hematology, serum chemistry and urinalyses. following a hour fast, each dog was administered oral ir levetiracetam ( mg; mean dose . mg/kg; range . - . ). heparinized blood for drug analysis was taken from each dog prior to administration and . , . , . , , , and hours after. blood was immediately centrifuged and supernatant plasma was stored at À c until analysis. after a day wash-out period, each dog was administered mg oral xr levetiracetam and blood samples were taken at identical timings. plasma samples were thawed at room temperature before preparation by solid phase extraction for hplc analysis. reverse phase chromatographic separation was performed. levetiracetam and an internal standard were detected using ultraviolet spectroscopy at nm. concentrations of levetiracetam were determined by peak area comparison to the internal standard. mean data were fit to a one compartment pharmacokinetic model with first order elimination and absorption and included a lag-phase for xr formulation. no adverse clinical effects were noted in any of the dogs. the auc associated with xr was hr ug/ml, a . fold increase over that with ir ( . hr ug/ml). the absorption half-life was . hr with xr and . hr with ir, a . fold difference. the elimination halflife was . hr with xr and . hr with ir, a . fold difference. the tmax associated with xr . hr and . hr with ir, a . fold difference. the cmax associated with xr was . mg/ml and . mg/ml with ir, a . fold difference. the plasma concentration of ir levetiracetam was not detectable at hr after administration whereas it was greater than mg/ml at hr after xr administration. based on the auc data, there is an approximately fold increase in bioavailability of the xr compared to the ir formulation. the cmax was approximately times greater following xr administration and a high plasma level in excess of the suggested canine therapeutic concentration ( mg/ml) for at least hours. although specific dosing recommendations cannot be made from this data, the favorable pharmacokinetics of xr over ir suggests that single, daily administration could be efficacious. thoracic and lumbar vertebrae are frequently affected by fractures and or luxations in dogs following trauma. surgical repair is part of the emergency treatment described for this disorder but does not guarantee improvement of the associated clinical signs. multiple surgical repair techniques have been described but have not been compared in terms of their success and the factors associated with a positive outcome. the aims of this study were to retrospectively evaluate the effect of different types of vertebral repair, injury type and injury location on outcome in dogs with thoracolumbar (tl) and lumbosacral (ls) spinal trauma. medical records were searched for dogs with radiographic evidence of a tl or ls vertebral fracture and or luxation ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ; signalment, body weight and duration of disease were recorded. dogs were retrospectively scored neurologically ( - ; normal to plegic with absent pain perception) on admission and at re-evaluation following surgery. lesion location was classed as t -l and l -s ; dogs were evaluated as one group and as two separate groups with respect to outcome. a subset of lesions were classed as cord compression or not based on advanced imaging. three repair techniques were evaluated (i) pins and polymethylmethacrylate (pmma); (ii) screws and pmma; and (iii) spinal stapling. regression analysis was applied to test for an association between the type of surgery and a successful outcome (non-painful and ambulatory). simple bivariate analyses were performed to investigate for variables predictive of a successful outcome. fifty-nine dogs were included. twenty-eight dogs were classed as t -l and were l -s . there were dogs with fractures and with luxations; dogs had both. thirty-one of dogs evaluated had spinal cord compression. ten dogs were repaired with im pins and pmma, dogs with screws and pmma and dogs with spinal stapling. overall, there was a . % success rate; there was no significant difference in outcome between the anatomic sites (p . ). all dogs initially graded as - pre-operation were classed as a successful outcome after at least one week following surgery; % of dogs initially graded as (plegic with pain perception) were classed as successful recovery. one dog ( . %) initially as graded as (plegic with no pain perception) had a successful outcome. a low admission score was statistically predictive of a successful outcome (p o . ). surgery type was not associated with a successful recovery (p . ). signalment, body weight, location of injury, injury type (fracture, luxation or both), presence of compression, and duration of disease did not predict outcome. from this study, the successful recovery of dogs following surgical fixation is high and is only dependent on the neurological score at the time of admission. the choice of surgical technique does not seem to influence outcome although a prospective study comparing two surgery types is warranted to further investigate this issue the results of which can be confounded by surgeon experience and variable follow-up. cranial thoracic intervertebral disc disease (ivdd) is extremely rare due to the presence of the intercapital ligament, although anecdotic data suggest german shepherd dogs (gsd) can share some predisposition for this disorder. the objective of the study was to retrospectively evaluate through mri if cranial thoracic ivdd is significantly more common in gsd compare to other large breed dogs. a search was done through database of the ontario veterinary college. any gsd were a spinal mri including t -t spine was performed was recruited. a group of large-breed non-gsd was used as a control. in the midsaggital t wi plane, three variables were assessed and graded for each intervertebral disc space t -t : spinal cord compression (scc), disc degeneration (dd), and herniation. wilcoxon sign rank test was used to assess if scores were different between groups. exact conditional logistic regression was used to determine whether any intervertebral disc space was a risk factor. gsd and large breed non-gsds were recruited. the gsd group had significantly higher scores than the non-gsd for scc, and herniation. regarding the individual intervertebral discs, in the gsd group t - , t - , t - discs had significantly an increased risk for scc, and t - for herniation. the results of this study show that gsd have a higher risk of cranial thoracic disc ivdd than other large breed dogs. that risk was higher in discs t -t , t - , and t - , particularly in t - . genetic and/or conformational factors, such as weakness of the intercapital ligament, may predispose gsd to this lesion. diskospondylitis is a common disease of the canine spine; however, few reports of mr imaging findings in dogs are available. the purpose of this study was to describe the signalment, clinical and mr imaging features in affected dogs. twenty-three dogs with a diagnosis of diskospondylitis based on clinical signs, mr imaging, and urine, blood, csf and/or intervertebral disk cultures were included. large breed dogs ( kg) accounted for of the cases. the mean age was . years with males and females equally represented. most dogs ( / ) were ambulatory with varying degrees of pain and paresis. mr imaging characteristics of sites were reviewed. on t w images, vertebral endplates were of mixed signal intensity ( / ) while the vertebral body was hypointense ( / ). the intervertebral disk space was hyperintense on t w ( / ) and stir ( / ) images and mixed signal intensity ( / ) on t w images. paravertebral soft tissue hyperintensities were noted on / t w and / stir images. contrast enhancement occurred at / endplates and / intervertebral disk spaces. only / vertebral bodies and / parvertebral soft tissues contrast enhanced. intramedullary spinal cord t w hyperintensity was noted at / sites. spinal cord or cauda equina compression occurred at / sites. based on the spearman correlation coefficient, a significant direct correlation was found between the degree of spinal cord or cauda equina compression and the patient's neurologic status (p . ). the incidence and severity of spinal cord compression in canine diskospondylitis may have prognostic value and may have been previously underestimated using other imaging modalities. hemilaminectomy and pediculectomy are both well described and commonly utilized techniques to access the spinal canal. these procedures are most often performed to approach a compressive lesion, such as intervertebral disc disease and neoplasia, the goal being adequate visualization of the spinal canal and access to the offending lesion. a proposed benefit of pediculectomy is preservation of the articular facets and thus better maintaining stability of the vertebral column, but at the cost of reduced access to the spinal canal. the purpose of this study was to describe standardized anatomical limits of each technique and report any observed differences that could be considered during presurgical planning. ten canine cadavers had both procedures performed on opposite sides to access the t - , t -l , and l - spinal canal. measurements were obtained after performing a computed tomography study of the spine and recorded from the transverse slice most representative of the defect. the surgical technique, vertebral site, and side of vertebral column were compared with the mean spinal canal and defect height using a covariate model. dorsal and ventral remnant lamina heights were also compared. the height of the defect relative to the spinal canal was - % with hemilaminectomy and - % with pediculectomy. the observed difference in defect height of - % (p o . ) and varied with spinal canal height. dorsal remnant lamina height was . - . % of spinal canal height with hemilaminectomy and - % with pediculectomy. ventral remnant lamina height ranged from - % and . - . %, respectively, though the difference was not statistically significant. while a larger defect is expected with a hemilaminectomy procedure, our results demonstrate that this difference increases with increasing spinal canal height. interestingly, the proportion of exposed spinal canal decreases with increasing canal height for both procedures. the difference in defect height between techniques was due to greater removal of the dorsal spinal canal, possibly making the hemilaminectomy technique better suited for more dorsal lesions, while no statistically difference in access to the ventral canal is observed. no effect of vertebral site was detected. of note was the involvement of articular facets in half of the pediculectomy defects, involving an average of % of the articular facet height. this result questions the suggested benefit for the vertebral stability, but further biomechanical studies would be required. low level laser therapy (lllt) is a treatment used in human and veterinary medicine for a variety of clinical syndromes. some uses in human medicine include acute pain associated with osteoarthritis, rheumatoid arthritis, tendonitis, tmj disorders, chronic joint disorders, and wound healing. research is currently on-going to determine the adequate wavelengths to promote effective treatment results with lllt in these conditions. it is purported that lllt acts via the mitochondria to increase cellular metabolism promoting wound healing and a decrease in pain and inflammation. in this study, we hypothesized that dogs treated with lllt in conjunction with hemilaminectomy would display quicker recovery times regardless of the presence or absence of deep pain sensation. seventeen dogs ( dachshunds, chihuahuas, french bulldogs, lhasa ahpsos, and each of a pembroke welsch corgi, and a miniature poodle) were selected and divided into two groups. the dogs ranged in age from to years old, weighed between and pounds, and underwent hemilaminectamies after acute onset of paraplegia secondary to intervertebral disc disease (surgically confirmed). one group received laser treatments on days through of hospitalization. the second group did not receive lllt, but followed the same peri-operative medication protocol. the laser used in this study was an erchonia laser model pl ( nm). the hertz setting was similar for each patient using the previously established protocol for intervertebral disc disease (ivdd) with pulse rate ranging from hz to hz. all dogs received advanced imaging pre-operatively with myelogram or mri. results of the study revealed that treatment with lllt of nm wavelength did not shorten or improve recovery times for dogs with acute onset paraplegia secondary to ivdd after hemilaminectomy procedures. dogs that showed recovery to ambulation at the two week recheck were consistently dogs that were deep pain positive on presentation. a lengthened recovery time or no recovery was seen in the majority of those dogs with absent deep pain on presentation as has been revealed historically in past studies. lllt did not appear to have an effect on this result. however, there are few data describing normal glucose uptake of the canine brain for comparison with suspected or confirmed disease. thus the purpose of this study was to assess the normal distribution of fdg uptake of canine brain structures using a high-resolution research tomography-pet and t-magnetic resonance imaging (mri) fusion system. fdg-pet and t -weighted mr imaging of the brain were performed on healthy laboratory beagle dogs. acquired pet and mr images were automatically co-registered by the image analysis software. on mr images, regions of interest (roi) were manually drawn over intracranial structures, including gross structures (whole brain, telencephalon, diencephalon, mesencephalon, dorsal metencephalon, ventral metencephalon and myelencephalon). a standard uptake value (suv) and relative suv ratio (rsuv suv of roi/suv of whole brain) were calculated for each roi. t-mr images compensated the low anatomical resolution of pet qj;by proving good spatial and contrast resolution for the identification of the clinically relevant brain anatomy. among gross structures, mesencephalon and ventral metencephalon had the highest (suv: . ae . ; rsuv: . ae . ) and the lowest (suv: . ae . ; rsuv: . ae . ) fdg uptake respectively. when suvs were calculated on detailed regions, rostral colliculus and corpus callosum had the highest (suv: . ae . ; rsuv: . ae . ) and the lowest (suv: . ae . ; rsuv: . ae . ) value respectively. these data acquired from normal dog brain will be used in clinical neurology to investigate various intracranial diseases such as inflammation, neoplasm and behavioral disorders. degenerative lumbosacral stenosis (dlss) is a multifactorial condition affecting predominantly large breed dogs. the combination of stenosis and compressive neuropathy cause lumbar pain, lameness and neurologic dysfunction. previous reports describe urinary and fecal incontinence in severely affected dogs. the objectives of this retrospective case series were to describe the clinical signs associated with dysuria and eventual diagnosis of dlss in dogs, and to describe factors associated with regained micturition following prompt diagnosis and treatment. medical records from the university of georgia and the university of missouri between and of dogs were reviewed. inclusion required observation of dysuria, urine retention, absence of structural lower urinary tract disease and concurrent presumptive diagnosis of dlss. dysuria was defined as inability to initiate or sustain a urine stream. urine residual volume was evaluated postvoiding. dysuria was further evaluated using urethral contrast studies, urodynamic testing (urethral profilometry ( ) and cystometry ( )), ultrasonography ( ), and urine culture ( ). presumptive diagnosis of dlss was based on imaging using plain radiography and epidurography ( ), computed tomography ( ) or magnetic resonance imaging ( ). breeds represented included the german shepherd dog (n ), golden retriever (n ), burnese mountain dog (n ), and each labrador retriever, weimaraner, rottweiler and mixed-breed. all dogs were male. were intact at onset of clinical signs. median body weight was . kg (range . - ) and median age was years (range - ). median duration of clinical signs prior to admission was months (range . - ). other pertinent presenting clinical signs included dyschezia ( ), fecal incontinence ( ), general proprioceptive ataxia ( ), weakness ( ), and difficulty rising ( ). physical examination findings included pelvic limb muscle atrophy ( ) and prostatomegaly ( ). abnormal neurologic examination findings included postural reaction deficits ( ), hyporeflexia ( ), decreased tail tone ( ) and lumbosacral hyperesthesia ( ). neurologic examination was normal in dogs. dorsal laminectomy was performed and diagnosis confirmed in dogs; recovery was monitored for a median of . months (range . - ). three of the dogs ( %) regained normal micturition within . - . months of surgery. though not statistically significant, dogs that regained micturition tended to have a shorter duration of clinical signs (median . months, range . - ) versus dogs that remained dysuric (median months, range - ). two of the dogs that regained micturition were neutered at the onset of clinical signs, but only of dogs that remained dysuric was neutered. signs improved in all dogs with postural reaction deficits and decreased tail tone. hyperesthesia resolved in of dogs ( %) and fecal continence returned in of dogs ( %). these findings suggest that following prompt diagnosis and surgical decompression, normal micturition could be regained in dlss affected dogs presenting with signs of dysuria. glycogen storage disease type ia (gsdia; von gierke disease) is an inherited metabolic disorder resulting from a deficiency of glucose -phosphatase-a (g pase). previous reports indicate that clinical manifestations of gsdia occur only in individuals with homozygous expression of a p.i l mutation. heterozygote dogs (het) have been previously reported to exhibit an overall normal outward phenotype. the purpose of this report is to briefly describe some differences that have been observed between het and homozygous wild type (wt) dogs. a colony of dogs at the university of florida contains a mix of affected, wt, and het individuals. in the course of studies designed to determine the effectiveness of gene therapy for correction of gsdia in dogs, both wt and het dogs have been utilized as controls. available information about body weights, clinical pathology tests, fasting studies, and liver biopsies was retrieved from records for both wt and het dogs and compared. although birth weights are similar, het dogs have a slower average rate of weight gain than wt dogs and this difference is especially prominent during the first few months of life (figure ) . in contrast to affected dogs, both wt and het dogs are able to maintain normal blood glucose concentrations for up to - hours of fasting, however, after longer fasts of - hours, het dogs have lower glucose and higher lactate concentrations (table ). in addition, liver biopsy samples from het dogs had greater apparent levels of glycogen suggested by pas staining than did samples from wt dogs, and this correlated with the results of proton magnetic resonance spectroscopy which demonstrated . times greater glycogen content in a liver biopsy sample from a het dog compared to a sample from a wt dog. together, these findings suggest that the level of g pase activity in heterozygote dogs does not provide a completely normal physiological, biochemical, or histological phenotype as previously reported. the glucokinase gene (gck) encodes an enzyme involved in cellular glucose-sensing mechanisms in pancreatic beta cells and hepatocytes. gck mrna is present in feline pancreas but the gene is not expressed in feline liver. hepatic gck expression is abundant in omnivores so its absence may reflect an evolutionary adaptation of strict carnivores, like feline species. we hypothesized speciesspecific features in the gck hepatic promoter may underlie the gene expression pattern observed in cats. the putative feline gck (fgck) promoter region was located using bioinformatic software to identify homology with human gck (hgck). genomic dna from a dsh cat was subjected to direct sequencing using a series of pcr reactions with speciesspecific primers. dna clones thus obtained were aligned to generate the feline sequence. direct sequencing yielded . kb of genomic dna sequence with high homology with sequences (acbe , acbe ) archived in the feline genome project. the feline sequence had six regions homologous with non-coding regions of hgck; four of these conserved regions are upstream of the putative fgck start. a . kb segment immediately upstream of feline hepatic exon is not present in hgck. the . kb insert is the reverse complement of a conserved sequence located downstream of exon in feline and human sequences. in conclusion, the putative hepatic promoter of fgck shares extensive homology with the hgck promoter but contains a . kb insert not found in hgck. functional studies are needed to confirm the role of the unique insert in regulation of fgck gene expression. deuterium oxide (d o) dilution has been proposed for quantifying body water content, but remains difficult to perform routinely. the objective of this study was to assess if the volume of distribution (vd) of creatinine could be proposed as an alternative in dogs for such a measurement. creatinine and d o vd were measured before (c) and after induction (o) of obesity (by giving an hypercaloric diet ( kcal/ kg) for months) in six healthy adult beagle dogs. creatinine ( mg/kg) and d o ( mg/kg) were simultaneously injected by bolus iv. blood was collected before administration and then at , , , , , , , , and min post-injection (creatinine), and , , , , , , and min (d o) . plasma concentrations of both markers were determined. vd was calculated using pharmacokinetic equations. the body weight increased from . ae . (c) (mean ae sd) to . ae . kg (o). d o vd decreased from ae (c) to ae (o) ml/kg. similarly, creatinine vd decreased from ae (c) to ae (o) ml/kg. the individual difference between creatinine and d o vd (expressed in % of d o vd) ranged from À . to . % (c) and from À . to À . % (o). in conclusion, creatinine vd provides a good estimate of d o vd in both normal and obese conditions. a wk double blinded study was conducted comparing the affect of two foods on mobility in dogs. all work was approved by an iacuc. healthy beagle dogs ( - years old, mixed gender) were used. affected (a) and non-affected (na) dogs were identified based on orthopedic examination and radiography as having or not having evidence of naturally occurring joint pathology (presence of osteophytes, dysplasia, effusion, pain on manipulation etc) in one or more joints. a and na dogs were evenly distributed between two locations. foods had nutrient profiles adequate for maintenance according to the aafco official publication. the test food contained greater amounts of methionine, manganese, carnitine, vit. e,, vit. c, alpha linolenic acid (ala), and eicosapentaenoic (epa) acid: the food provided mg n fatty acids and mg n fatty acids per kcal. all dogs were fed the control food for wks followed by a wk feeding period where a and na dogs consumed the test food and a and na dogs the control. blood and urine were collected at weeks , , and and analyzed for serum fatty acids and urine thromboxane:creatinine ratios were determined. evaluators in this study were different than those making the original diagnosis and so were blinded as to treatment and diagnosis. orthopedic exams were performed by two veterinary surgeons at each site on weeks , , and . the same two evaluators examined the same dogs throughout. the data was evaluated for the difference between a and na dogs and between foods with age, gender and location as covariates. body weight, disease status, age and gender were blocked. analysis included anova repeated measures mixed procedure (sas version . ) to determine treatment effects over time.serum epa was greater and arachidonic acid lower at weeks , and in the test food fed dogs (p o . ). urine thromboxane:creatinine ratios were decreased in the a dogs fed the test food compared to the a dogs fed the control food at wks (p o . ). lameness score was significantly improved (p o . ) within and between groups of dogs fed the test food. a significantly greater proportion of a dogs fed the test food had improvement in total het (n ) blood glucose (mg/dl) (ae ) (ae ) blood lactate (mmol/l) . (ae . ) . (ae . ) joint score, lameness, functional disability and overall assessment score at wks compared to a dogs fed the control food. % of a dogs had an improved overall assessment score on the test food after wks and at wks compared to % at wks and % at wks of a dogs consuming the control food. this study shows that a food with moderate amounts of added linolenic acid and epa can have a positive impact on systemic inflammation and mobility in - weeks. a similar abstract will be presented at the orthopedic research society meeting in january to an audience largely of orthopedic researchers interested in human orthopedics. fat is an important dietary component, serving both as a source of energy and as a supplier of essential fatty acids (fa). medium-chain triglycerides (mct) contain intermediate length fa that do not rely on l-carnitine for transport across the inner mitochondrial membrane, bypassing this rate-limiting step in fa oxidation. longchain (n- ) polyunsaturated fatty acids (pufa) from fish oil (fo), and in particular eicosanoids derived from eicosapentaenoic acid (epa), may protect against excessive inflammatory reactions, which may be exacerbated by eicosanoids derived from (n- ) arachidonic acid (aa). this study investigated the effects of adding mct:fo and l-carnitine to a control diet (prescription diet s k/d s ) on lean body mass, and serum fa and metabolites. forty healthy beagles ( . to . y) were fed one of three foods (n to dogs each) for mo. the study protocol was reviewed and approved by iacuc, hill's pet nutrition, inc. all foods were complete, balanced, and sufficient for maintenance of adult dogs; and had similar concentrations of moisture, protein, and fat (approx. . %, . %, . %, respectively). composition of serum fa was determined by gas chromatography of fa methyl esters. metabolomic profiles of serum samples were determined from extracted supernatants that were split and run on gc/ms and lc/ ms/ms platforms, for identification and relative quantification of small metabolites. body composition was determined by dual energy x-ray absorptiometry. serum concentrations of lauric and myristic fa increased; epa and dha increased in a dose-dependent manner; and aa decreased in dogs fed treatment food (proc-mixed procedure in sas; all p . ) when compared to dogs fed treatment foods or . serum concentrations of acetylcarnitine and succinylcarnitine increased, indicating lcarnitine incorporation, in dogs fed treatment foods and . thus, a diet enriched with mct:fo significantly altered serum fa composition, enriching (n- ) pufa and lowering aa concentrations. there was no change in lean body mass for any of the diets compared to baseline values, and no difference between treatments, showing that all three treatment foods met protein requirements. ten owned dogs, obese for more than months (body condition score [bcs] of ; fat mass [fm] . ae . %) were studied. these dogs had their weight reduced by % (bcs ; fm . ae . %; p o . ) being designated weight reduced (wr) group and then were fed to maintain constant body weight during days (bcs . ; p . ), designated maintenance (main) group. a control (ct) group of beagles was also included (bcs . ; fm . ae . %; p o . ). in all groups the glucose postprandial response test was performed after hours of fasting. blood samples were taken prefeeding and after , , , , , , , , , and minutes of the consumption of cooked rice enough to the ingestion of g of starch/kg body weight. tnf-a and il- were dosed in milliplex tm map panel, insulin and leptin by radioimmunoassay. statistical analysis included paired or non-paired t-tests and wilcoxon (p o . ). the regimen normalized meal glucose response, the area under the curve (auc) of glucose for wr was lower than for obese (p o . ) and similar to main and ct (p . ). insulin secretion did not normalize immediately, as obese and wr exhibited similar auc of insulin and higher values than for ct (p o . ). main, however, presented similar auc of insulin than ct, with lower values than obese and wr (p o . ), suggesting that dogs require some time to adapt their metabolism. leptin, tnf-a, and il- presented significant reductions after weight loss (p o . ), without differences between wr, main and ct (p . ), suggesting an improvement of the pro-inflammatory state consequent to obesity. studying food base excess (be) modification, methionine intoxication was described. in a basal kibble dog diet (be meq/kg; . g/kg of s) two dosages of ammonium sulphate and methionine was added, resulting in diets with be of meq/kg ( . g/kg of s) and À meq/kg ( . g/kg of s), or be of meq/kg ( . g/kg of s) and meq/kg ( . g/kg of s), respectively. a  factorial plus a control diet design, resulting in five treatments, and adult health beagle dogs were used, in a completed randomized design with six dogs per diet. a -d adaptation phase followed -d of total urine collection (in bottles with mg of thymol). urine were pooled by dog and analyzed for density, volume and ph. food macroelements were determined by standards methods (aoac, ) and used for be calculation. dog's acid-basic status was studied by blood gas analysis of venous blood, at : h (pre feeding) and hours after meal. a dose-dependent reduction of urinary ph was verified for both compounds (p o . ). blood bicarbonate (r . ; p o . ), and blood base excess (r . ; p o . ) were highly correlated with food be. acidemia and reduced blood be were verified in diets with be close to zero (higher dose of both compounds, or . g/kg of s), resulting in daily or each other day vomiting episodes in the dogs. ataxia, seizures, and vomiting were previously describe in dogs fed g/kg of methionine, but our results suggest that a much lower value ( . g/kg) was toxic and that the safe upper limit should be between this value and . g/kg (the lower evaluated dose). in people with chronic kidney disease and heart failure, obesity is associated with longer survival times. this association, called the "obesity paradox," also has been recognized in dogs and cats with heart failure. excess weight appears to modulate the serious deleterious effects of muscle loss in these diseases. the purpose of this study was to determine the effects of body condition and body weight changes in dogs with naturally-occurring chronic kidney disease (ckd). dogs diagnosed with ! iris stage ii ckd between and at iowa state university and tufts cummings school of veterinary medicine were eligible for the study. dogs o year of age and those with acute renal failure or suspected congenital renal diseases were excluded. medical records were reviewed using a standardized data form, and data were collected for initial body weight and body condition score (bcs, - scale), clinicopathologic values, changes in body weight and bcs, comorbidities, and treatments. dogs were classified as underweight (bcs - ), moderate weight (bcs - ), or overweight (bcs - ). a change in body weight was defined as . kg. survival times were determined for all dogs that were discharged from the hospital and lived day. associations between survival and bcs or body weight changes were analyzed using cox proportional hazards models. one hundred two dogs were enrolled in the study. at the time of diagnosis, dogs were classified as iris stage ii, dogs were stage iii and dogs were stage iv. median body weight at baseline was . kg (range, . - . kg). for dogs with body condition scores recorded (n ), were underweight ( %), were moderate ( %), and were overweight ( %). for dogs that had at least two body weights recorded over the course of their disease, gained weight, lost weight, and had no change in weight. changes in body weight were not associated with survival; however, bcs at the time of diagnosis was significantly associated with survival. dogs classified as underweight had a significantly shorter survival time compared to both moderate (p o . ) and overweight dogs (p o . ). these results suggest that body condition is an important consideration in dogs with acquired chronic kidney disease. further studies are warranted to evaluate the relationship between obesity and longer survival in dogs with ckd. protein restriction is the cornerstone of dietary management of kidney disease. the national research council recommends % crude protein and the american association of feed control officials (aafco) recommends a minimum of % crude protein for maintenance for healthy adult cats. protein requirement is unknown for adult cats with kidney disease. most commercially produced cat foods for adult maintenance contains % or more crude protein on a dry matter basis. a typical therapeutic food for cats with kidney disease contains about % crude protein. the objective of the present study was to investigate whether dietary crude protein at . % would be adequate for the maintenance for adult cats with impaired kidney function. seven adult cats, female and male, with age ranging from to . years old (mean: . years) were used in the study. all cats had elevated serum creatinine concentration ( . mg/dl, range: . - . mg/dl) and reduced glomerula filtration rate (mean: % reduction; range: - % reduction) during the study. they did not have other systematic diseases, e.g., hyperthyroidism, at the beginning of the study. cats were fed an expanded dry food made with ingredients commonly used in commercial dry cat foods. the food contained . % crude protein (chemical analysis) and kcal/kg (calculated) on a dry matter basis, or . g protein/ kcal. each essential amino acid in the food was at least % of that recommended by aafco. other nutrients in the food also exceeded aafco's recommendations for maintenance for adult cats. cats were fed the food for weeks. lean body mass (dual x-ray absorptionmetry; hologic, hologic, inc, ma) and serum albumin concentration were measured periodically to monitor protein status of cats. the average lean body mass (mean ae sd) was . ae . kg, . ae . kg, . ae . kg, and . ae . kg in weeks , , , and of the study, respectively. paired t-test did not detect statistical difference (p . ) when comparing the lean body mass in weeks versus weeks , , and , respectively. serum albumin concentration were within the normal reference range during the study (mean ae sd: . ae . %, . ae . %, . ae . %, and . ae . % in weeks , , , and , respectively) . these data show that . % dietary crude protein in a dry food with kcal/kg on a dry matter basis, or . g protein/ kcal, is adequate for maintenance for cats with impaired kidney function. in humans, several disease conditions exist that involve abnormal patterns of polyunsaturated fatty acids and similar abnormalities may be present in companion animals. indeed there have been reports of decreased plasma arachidonic acid and reduced delta- desaturase activities in dogs with atopy and other skin disorders. the present study investigated serum fatty acid profiles in dogs and cats presented to the texas a&m university veterinary teaching hospital, clinical pathology laboratory over the past one year period. results were compared with normative data generated among dogs and cats from earlier feeding studies. sera used were residual samples submitted to the laboratory for other diagnostic procedures and stored frozen for no more than months after collection. the samples were grouped according to presenting disorders involving liver, kidney, digestive, and cardiac diseases. total lipids were extracted using chloroform:methanol ( : v/v) and fatty acid methyl esters were prepared for capillary gas chromatography. relative percentage distribution of individual serum fatty acids for each animal were then compared with average normative serum phospholipid fatty acid values (dogs, n ; cats, n ) by calculating the ratio of the value in the diseased individual to the normal mean value and used as an index of normalcy. normalcy ratios were then plotted on a logarithmic scale with normal at . . the ratio was then compared to changes greater than , and standard deviations of the normal mean values. in this way a graphical presentation of resultant values was obtained. although the animals had been fed various commercial diets and some home-prepared foods, a number of noteworthy patterns emerged from this analysis. dogs showed increased linoleic acid, decreased arachidonic acid, increased total monounsaturated and decreased saturated fatty acids at p o . ; oleic acid was increased at p o . . remarkably, these findings were similar for all canine disease categories evaluated (n , heart; n , kidney; n , liver, and n digestive disorders). in cats, a slight decrease in arachidonic acid and large decrease in : was observed but only in heart disorders. by contrast, modest elevations of arachidonate were observed in kidney, liver, and digestive disease groups but at p o . . sample sizes of the feline sera were considerably smaller (range of - per group). a limitation of this analysis is that variability of normal data may exist depending on diet fed making comparisons less reliable however, these preliminary data suggest that metabolic diseases of dogs may depress plasma arachidonic acid independent of diet fed suggesting either reduced conversion from linoleic acid or increased utilization of arachidonate for eicosanoid production during times of metabolic stress. conversely, in cats, increases in arachidonic acid may be associated with diet arachidonate or other mechanisms. additional studies to verify these findings are warranted. the objective of this study was to determine whether or not lalanyl-l-glutamine (ala-gln) supplementation in dogs with parvoviral enteritis improves the survival rate and ameliorates clinical signs without side effects. this randomized, double-blinded, placebo-controlled clinical trial included client-owned dogs. the dogs were randomly assigned into two groups and administered ala-gln solution (dipeptiven; . g/kg) or an equivalent volume of placebo orally twice a day. all of the dogs (ala-gln group [n ] and placebo group [n ]) received standard treatment while hospitalized and were monitored daily according to a clinical scoring system and diagnostic evaluation for days. among the dogs, (ala-gln-treated group [n ] and placebo group [n ]) were vaccinated and (ala-gln-treated group [n ] and placebo group [n ]) were not vaccinated. the population consisted of purebreds and mixed breed dogs, with a mean age of . ae . weeks. the survival data were compared statistically by means of a log-rank test for the kaplan-meier survival curves. the clinical scores of ala-gln-treated dogs improved significantly relative to the placebo group. there was a significant difference between the two groups in the survival distribution (p . ); specifically, of the ala-gln-treated dogs ( . %) died, whereas of the dogs in the placebo group ( . %) died. no side effects were associated with the administration of ala-gln. these results suggest that the oral administration of ala-gln is effective in improving clinical signs and survival rate in dogs with parvoviral enteritis. bleeding disorders, thrombocytopenia and alterations in platelet function have been documented in humans receiving lipid-containing parenteral nutrition formulations. despite a lack of evidence in the veterinary literature, it is believed that parenteral lipids are contraindicated in critical illness when the development of bleeding disorders is likely. the objective of this study was to determine if there is an in vitro effect on platelet function and thromboelastography (teg) in normal dogs with varying concentrations of a % soybean oil emulsion (intralipid s ). twelve clinically healthy dogs were used for this study. whole blood platelet aggregation, using adp and collagen agonists, was measured using multiple electrode aggregometry in hirudinated blood with final lipid concentrations of , , , and mg/ml. the teg parameters r, k, a-angle, and maximum amplitude (ma) were evaluated from citrated whole blood with equivalent final lipid concentrations as platelet aggregation. there was no significant difference between groups with collageninduced platelet aggregation. there was a significant increase in the area under the curve (auc) with adp-induced aggregation at a lipid concentration of mg/ml (p . ). the ma was significantly reduced at both the mg/ml (p o . ) and mg/ml (p o . ) lipid concentration. there was no statistical difference between groups evaluating the other teg parameters. while platelet aggregation appeared enhanced at the highest concentration evaluated, this concentration is not clinically relevant. the reduction in ma seems discordant but both fibrinogen and platelets contribute to the ma. therefore the higher lipid concentrations may be interfering with fibrinogen kinetics or fibrinogenplatelet interaction. in vivo studies are indicated to determine if any of these changes are clinically significant. rosiglitazone is a peroxisome proliferator-activated receptor gamma (pparg) agonist and an fda-approved anti-diabetic agent in humans that has been investigated for its ability to reduce tumor cell growth. specifically, the combination of rosiglitazone and carboplatin has demonstrated enhanced tumor control. the purpose of this study was to determine the peak plasma concentrations and side effect profile of rosiglitazone after oral administration in dogs with spontaneously occurring cancer. all dogs received carboplatin intravenously concurrently with oral rosiglitazone. ten cancer-bearing dogs with normal pre-treatment hepatic and renal function were enrolled. complete pre-treatment hematological and biochemical parameters were available in ten dogs and post-treatment parameters in nine dogs. peak plasma concentrations varied with dose and ranged from . - . ng/ml and occurred between minutes and hours post administration and rapidly declined after the peak. the dose limiting toxicity was hepatic at a dose of mg/m . there was one grade iii, two grade i alt, and one grade iii ast elevations noted. no changes in total bilirubin, alkaline phosphatase, or ggt values were noted. blood glucose values remained within normal limits. mild, self-limiting gastrointestinal and hematologic toxicities were observed when rosiglitazone was administered in combination with carboplatin. based on this study, the recommended dose of rosiglitazone in cancer-bearing dogs with normal hepatic function is mg/m orally once daily. side effects of the combination appear similar to side effects noted with carboplatin alone. further study is needed to determine efficacy of this combination and if more frequent dosing is required to maintain plasma concentrations. carboplatin has shown little activity as a single agent for the treatment of canine transitional cell carcinoma (tcc). however, gemcitabine has shown synergism with carboplatin in human cell lines. the purpose of this study was to evaluate the activity of gemcitabine against canine tcc cell lines alone or in combination with carboplatin. we hypothesized that gemcitabine in combination with carboplatin would have synergistic effects in vitro. the results of this study could provide a rationale for treatment of canine tcc with the combination of these drugs. tcc cell lines tcc-kiss, tcc-knapp-js, tcc-axa, tcc-hxc, and tcc-sh were treated with gemcitabine, carboplatin, or the combination. cell proliferation was assessed using cyquant assay, cell cycle was evaluated using propidium iodide staining, and apoptosis was assessed by measuring caspase- / activation. synergy was quantified by combination index analysis using compusyn software. treatment of canine tcc cell lines with carboplatin or gemcitabine decreased cell proliferation, induced cell cycle arrest, and apoptosis. when tcc cell lines were treated with gemcitabine and carboplatin in combination at a therapeutically relevant concentration (gemcitabine o um, carboplatin o um), a significant decrease in cell proliferation was observed compared to gemcitabine or carboplatin alone, and the drug combination was synergistic in of cell lines, and additive in the remaining lines. gemcitabine exhibits biologic activity against canine tcc cell lines and carboplatin combined with gemcitabine exhibits synergistic activity at biologically relevant concentrations. our results support further evaluation of these drugs in dogs with tcc to determine the clinical efficacy of this combination. metronomic chemotherapy has been shown in murine models and humans to improve tumor control by inhibiting tumor angiogenesis and suppressing regulatory t cells (treg). treg are a subset of t lymphocytes demonstrated to be increased in humans and dogs with cancer and are thought to suppress cellular immune responses against tumors. the purpose of this study was to determine whether metronomic cyclophosphamide therapy depletes treg and/or exhibits antiangiogenic activity in dogs with soft tissue sarcoma. client owned dogs with histologically confirmed grade i or ii soft tissue sarcoma were administered cyclophosphamide at . mg/m or mg/m orally once daily for days. whole blood and tumor biopsies were obtained on days , , and . flow cytometric analysis of blood was performed to assess changes in t lymphocyte subsets, including cd and cd cells as well as cd foxp treg. tumor microvessel density (mvd) was assessed by performing immunohistochemistry for cd . five dogs were enrolled in the . mg/m /day dose cohort and six dogs were enrolled in the . mg/m /day dose cohort. in patients that received cyclophosphamide at . mg/m /day, the mean number of treg decreased from day to but there was no change in the mean percentage of treg or mvd. for patients that received . mg/m /day, both the mean number and percent of treg as well as mvd decreased over the day time period. cyclophosphamide at . mg/m /day or greater selectively depletes treg and inhibits angiogenesis in dogs with soft tissue sarcoma. arsenic trioxide (ato) is used to treat leukemias, multiple myeloma, and relapsed lymphoid malignancies in humans; its use has not been explored in veterinary oncology. prior therapy with glucocorticoids decreases likelihood and duration of remission for dogs with lymphoma treated with chemotherapy. we hypothesized that ato will re-sensitize glucocorticoid-resistant canine lymphoma cells to glucocorticoid-induced apoptotic death. the osw canine lymphoma cell line was cultured with um dexamethasone. remaining viable dividing cells were considered resistant. resistant cells were exposed to . um and . um of ato without dexamethasone, after which cells were washed and re-exposed to um dexamethasone. after , and hours of dexamethasone exposure, cells were counted using trypan blue stain. apoptosis was assessed by tunel assays on cytospin preparations collected at , , and hours from ato-exposed and control groups. statistical analysis was performed using way anova and tukey's test. the proportion of dead cells increased over time in both . um and . um ato exposed groups. the proportion of dead cells was greater for . um ato (p o . ) and . um (p o . ) groups compared to control. apoptosis increased with increasing ato concentration and duration of dexamethasone exposure compared to control. these results support the effectiveness of ato at re-sensitizing glucocorticoid-resistant canine lymphoma cells to apoptotic death following re-exposure to glucocorticoids. ongoing gene expression studies aim to elucidate this mechanism. additional studies to determine if this effect is seen with other chemotherapeutic agents are warranted. lymphoma is the most common hematopoietic tumor of dogs. protein disturbances may be associated with this disease including monoclonal gammopathies in a low percentage of cases. serum protein electrophoresis (spe) is routinely used to aid diagnosis of various canine diseases including lymphoma when total protein concentration is elevated. the purpose of this study was to compare spe changes in lymphoma patients without elevated total proteins with a population of healthy dogs. agarose gel electrophoresis was performed on residual serum from healthy control dogs and untreated dogs with multicentric lymphoma (stage iii -v) after measuring total protein (tp) using the biuret method. densitometric traces of the protein bands were obtained using computer software (totallab ) and the albumin, alpha- , alpha- , beta- and gamma globulin subfractions were identified by visual inspection. the total protein concentration, the number of subfractions and the relative and absolute protein subfraction concentrations were then compared statistically between the two populations. in lymphoma dogs, tp, absolute albumin, beta- and gamma globulin concentrations and both relative and absolute concentrations of the alpha- globulins were significantly lower however relative and absolute alpha- globulin concentrations were significantly elevated. no monoclonal gammopathies were identified in any of the dogs and not every patient with lymphoma had the above changes in their electrophoretogram. this study has demonstrated that significant changes occur in the albumin and globulin fractions of canine lymphoma patients despite no obvious increase in tp. further investigation is required to identify the proteins responsible for these changes. it is well known that immunophenotype has a prognostic value for the outcome of canine lymphoma, with t-cell lymphomas having a worse prognosis than b-cell lymphomas. the recent advent of flowcytometric techniques allowed easy detection of many different markers on lymphoma cells and therefore, not only distinguish between t and b cells, but also estimate possible aberration on immunophenotype. in human oncology, although some controversy persists, it seems that non-hodgkins lymphoma and acute leukemia carrying aberrations have a worse prognosis. the aim of this study was to evaluate the role of immunophenotype aberration in canine high-grade lymphoma considering outcome and time span to achieve complete response under chemotherapy. samples of bone marrow, blood and lymph node suspensions from twentythree dogs were evaluated with flow-cytometry. eleven dogs had aberrant expression of neoplastic lymphocytes and twelve were non-aberrant. the most common aberrations found were: positivity to cd , biphenotypes, double expression of tantigens (cd , cd ), diminished expression of cd . all dogs were treated with a chop-based protocol. there was a significant difference for the time to achieve response to chemotherapy (partial or complete). / non aberrant lymphomas went into cr or pr after the first treatment (l-asparaginase), while aberrant lympho-mas needed more than treatment to reach cr or pr. there was a trend for a prolonged disease free interval with non-aberrant versus aberrant, although it was not statistically significant. aberration of immunophenotype may be a prognostic factor for canine lymphomas, but further studies with larger groups are needed. class ii major histocompatibility expression is a significant and independent predictor of prognosis in human b cell lymphoma. low class ii mhc is consistently associated with poorer outcome. the mechanism underlying this relationship is not clear, but one hypothesis is that high class ii mhc allows for better antigen presentation and tumor-specific immune responses. in the this study, we investigated whether that class ii mhc expression in canine b cell lymphoma was associated with remission and survival times. a total of patients were categorized by level of class ii mhc,expression of cd and cell size for on neoplastic b cells. multivariable cox-proportional hazard analysis was used investigate this research question using a randomly selected subset of the data, and the predictive ability of this model was validated on the remaining / of patient data. results suggested that low class ii mhc expression was associated with decreased times to relapse and death as is seen in human b cell lymphoma, and that large neoplastic cells were associated with decreased survival time. cd expression was not associated with patient outcomes. these findings have implications for the use of dogs to model human lymphomas, for the study of tumor vaccines, and for prediction of mortality in dogs with b cell lymphoma with a high level of specificity. one of the reasons for the failure of canine lymphoma treatment is related to the resistance of tumor cells against chemotherapy drugs. the major form of this resistance is provide by multidrug resistance abc transporters. abc transporters proteins comprise a large superfamily of transmembrane proteins, atp-dependent, that extrude a large variety of drugs from the cells. multidrug resistance phenotype in cancer cells is associated with overexpression of these transmembrane proteins. abcg , also known as bcrp, is a residue half-transporter protein that protect hematopoetic stem cells against toxic compounds. the aim of this study was to investigate the expression of bcrp (abcg ) in canine multicentric lymphoma. samples were collected by fine needle aspiration of an enlarged lymph nodes, from dogs with multicentric lymphoma (stage iii to v) at diagnosis, and normal lymph nodes (control). dogs that were previously treated with prednisone or chemotherapy were excluded from the study. quantitative rt-pcr was used to measure the mrna expression level of bcrp and flnb expression as a endogenous reference canine gene. a widely range expression value for abcg expression was found for canine multicentric lymphoma. high gene expression was observed in % ( / ) canine lymphoma, but % of dogs had a lower expression when compared with normal lymph node. gene expression was not associated with clinical staging, complete or partial remission, relapse and survival time. in conclusion, abcg was expressed in canine lymph node and canine multicentric lymphoma at the diagnosis, and it was not correlated with clinical response. osteosarcoma (osa), the most frequent primary malignant bone tumor of dogs, is both locally aggressive and highly metastatic. prognostic factors for canine osa include tumor location, distant metastatic disease, and serum alkaline phosphatase (alp) concentration. an increased serum alp concentration is associated with poor prognosis; however the mechanisms underlying this phenomenon are currently unclear. during normal bone development alp may be used as a marker for osteoblasts. additionally, alp is a downstream target of activated canonical wnt/b-catenin signaling. therefore, we hypothesized that increased serum alp would be associated with increased expression of b-catenin in canine osa. the goals of this study were: ( ) characterize and compare cellular alp expression in osa tissue from patients with normal and high serum alp; and ( ) assess b-catenin expression in those same patient populations. we used frozen osa samples collected from patients with either high alp (n ) or normal alp (n ). total rna was isolated from the frozen tissue, converted to cdna, and analyzed using quantitative reverse-transcriptase polymerase chain reaction (qrt-pcr) with either target gene alp (aim ), or target gene b-catenin (aim ). additionally, b-catenin expression was analyzed by western blot. qpcr data for bcatenin and alp expression were normalized to s, and relative expression was calculated by the ddct method. the relative expression of cellular alp was higher in high serum alp samples compared to normal serum alp samples: . ae . (mean relative expression ae standard deviation; p o . ). further, the relative expression of b-catenin was also increased; b-catenin expression of high serum alp samples relative to low serum alp samples was . ae . (p o . ), which is also seen by western blot. this study begins to clarify the mechanism behind high serum alp in canine osa, and suggests the wnt signaling pathway may be active in this population of patients. further work will focus on elucidating the role active wnt signaling plays in the biology of osa. in the future, serum alp status of osa patients may help identify patients that would benefit from therapies targeting this pathway. accurate assessment of abdominal lymph node status is of vital importance for appropriate treatment planning and determining prognosis in dogs with apocrine gland adenocarcinoma of the anal sac (agaas). pretreatment knowledge of lymph node status is helpful for determining prognosis and planning the optimal extent of lymphadenectomy. in addition, pretreatment knowledge of lymph node status may help in selecting patients who might benefit from adjuvant chemotherapy and radiation therapy. abdominal ultrasound is currently the most commonly employed test to screen for abdominal lymphadenopathy in dogs with agaas. imaging studies in people indicate that magnetic resonance imaging ( to determine and compare the plasma concentration of cyclophosphamide and its metabolite -ohcp, within the plasma of lymphoma bearing dogs being treated with either oral or intravenous cyclophosphamide. in this prospective study, patients were randomly assigned to either receive oral or intravenous cyclophosphamide, at a dose of mg/m . based on a priori power calculation eight patients per treatment group were enrolled. plasma was obtained at times , , , minutes, and then at , , , , hours post administration for evaluation of -ohcp concentrations by liquid chromatography-dual mass spectrometry (lc/ms/ms). average values were obtained for both cyclophosphamide and -ohcp concentrations within the plasma of both groups. the following values were obtained, half life (hl), time to maximum concentration (tmax), maximum concentration (cmax), and area under the curve (auc). the mann-whitney statistical test was used to compare the groups. the auc for cyclophosphamide was statistically significant (p o . ) when compared between the two groups. the auc for -ohcp was not statistically significant between the groups. the difference between cmax for cyclophosphamide and -ohcp was statistically significantly (p o . ) between the groups. although the auc for cyclophosphamide was statistically significant between the two groups, the auc for the active metabolite -ohcp was not different when administered intravenously or orally. thus drug exposure to the active metabolite of cyclophosphamide is the same when administered intravenously or orally. previously the percentage of successful intraosseous (io) catheter insertions, insertion times, and ''ease of use'' scores using the ez-io g power driver by a wide spectrum of novice participants in feline cadavers were evaluated. novice users' mean io catheter insertion time using the ez-io g driver was also compared to the mean iv catheter insertion time in normovolemic feline and canine patients presented to the western college of veterinary medicine (wcvm) small animal hospital. novice users included wcvm personnel ( technicians, veterinary students, interns, residents, clinicians). after watching a -minute ez-io g training video, each participant inserted io catheters using the ez-io g driver. site (proximal humerus or trochanteric fossa of the femur) and side of cat (right or left) were randomized for each attempt for each participant. a gauge x mm long needle and a gauge x mm needle were used for io catheter insertion in the humerus and femur, respectively. participants then graded the ''ease of use'' of the ez-io g device on a visual analog scale (vas) that was converted to a -point scale. twenty-six iv catheter insertions in normovolemic feline and canine patients performed by wcvm small animal hospital personnel ( technicians, veterinary students, intern, resident, clinicians) were then timed and compared to the mean io catheter insertion time in feline cadavers by study participants using the ez-io g device. the io catheter was inserted correctly on every attempt by % ( / ) of participants. no difference was found between participant groups for mean io catheter placement confirmation percentage (p . ). percentage of io catheter ''slippage off the bone'' at the time of placement did not vary across participant groups (p . ). mean io catheter insertion times were all less than seconds and did not differ significantly as a function of attempt number (p . ) or as a function of participant group (p . ). participants rated the ez-io g 's ''ease of use'' favorably and subjective scores did not differ across participant groups with varying levels of clinical experience (p . ). compared to the mean insertion time for iv catheterization ( sec), mean io catheter insertion by participants using the ez-io g ( sec) was significantly faster (p . ). regardless of their level of clinical experience, participants rated the ez-io g device favorably in terms of its ''ease of use'' and their willingness to use the device in the future. regardless of their level of clinical experience, study participants successfully placed io catheters using the ez-io g device and did so significantly faster than the reported iv catheter insertion time in normovolemic feline and canine patients in the wcvm small animal hospital. intraosseous catheterization using the ez-io g has the potential to provide very rapid vascular access and is a skill that can be easily learned. previously presented at the western college of veterinary medicine undergraduate poster competition. multicavitary effusion is a common cause of presentation for dogs to emergency medical centers. the goal of this study was to identify common underlying causes of multicavitary effusion as well as determine their relative importance. a retrospective analysis of cases of multicavitary effusion admitted to the icu of a tertiary referral center (ontario veterinary college) from to was performed. twenty-three different breeds, with golden and labrador retrievers ( . % and %, respectively) being most commonly seen, were included in the study. ages ranged from to years with a median age of years and a mean of . years. . % of cases were males ( / cases). most common presenting signs included lethargy ( . %), anorexia ( . %), vomiting ( %) and dyspnea ( %). cavitary effusion was detected by either ultrasonography (pericardial, pleural or abdominal) or radiographs (pleural). bicavitary effusion was present in cases ( . %) whereas cases ( . %) had tricavitary effusion. neoplasia was found to be the most common underlying cause overall ( . %), with hemangiosarcoma being the leading type ( . % of neoplasia cases), followed by congestive heart failure ( . %), gastrointestinal lymphangectasia ( . %), peritonitis/pancreatitis ( . %), cirrhotic liver disease ( . %) and acute renal failure ( . %). in cases ( . %), no underlying cause could be found. of these, ( . % of all cases) were diagnosed as having idiopathic pericardial effusion. taken together, these findings suggest a strong association between multicavitary effusion and diseases carrying a guarded prognosis in dogs. infection control practices in veterinary clinics and hospitals are becoming increasingly important, with rising client expectations, growing concern about the spread of antimicrobial-resistant pathogens, and the potential for zoonotic transmission of disease. surgical patients are at increased risk of developing infections, and can serve as sources of these pathogens for other animals and people with whom they have contact within and outside the clinic. taking all reasonable precautions to reduce the risk of surgical site infections, beginning with preoperative preparation of the surgeon and patient, is therefore an important part of any infection control program. while guidelines are available for preoperative preparation procedures, there has been no objective investigation of compliance with these guidelines in veterinary practices. the objectives of this pilot study were to describe a range of preoperative hand scrub and surgical site preparation practices in veterinary clinics, and to determine if there were any areas that consistently require improvement. observation of preparation practices was performed in each of ten clinics over - days using - small wireless surveillance cameras. data was coded for surgical patients, and surgeons performing a total of hand scrubs. patient hair removal was most commonly performed after induction of the animal ( / , %) and using clippers ( / , %) . steps in surgical site aseptic preparation ranged from - . contact time with soap ranged from - s (mean s, median s), and with alcohol from - s (mean s, median . s). application of alcohol or antiseptic using a ''cleanest to dirtiest'' pattern was infrequent ( / ( %) and / ( %), respectively). potential contamination of the surgical site occurred most frequently when the animal was moved to the surgery table after initial preparation ( / , %). preoperative alcohol hand rub was used in / facilities, but soap and water hand scrub was still more commonly used even at these clinics. proximal-to-distal scrubbing was noted in / ( %) of soap and water scrubs. contact time during surgeon hand preparation ranged from - s (mean s, median s) for soap and water and from - s (mean s, median s) for alcohol-based hand rub. approximately % of the variation in contact time was due to inter-surgeon variation. no significant changes in practices were identified over the course of the observation period. some preoperative preparation practices were fairly consistent between clinics in this study, while others varied considerably. contact times with preparatory solutions were often far shorter than recommended, and there was a high frequency of non-sterile contact with the surgical site during movement of patients to the surgical suite. the camera system used to perform this study did not have a significant time-dependent effect on the behavior of participants, and could be useful for performing similar field-based observational studies in the future. this prospective randomized study compared the percentage of successful intraosseous (io) catheter insertions, insertion times, and ''ease of use'' scores using the ez-io g power driver to manual io catheterization in feline cadavers. the io catheter insertion time in cadavers using the ez-io g device was also compared to iv catheter insertion time in normovolemic feline and canine patients. after a purposely limited training period, a preclinical veterinary student was timed and video-recorded as she performed io catheter placements in feline cadavers ( io insertions by placing an illinois needle manually and io insertions using the ez-io g ). order of technique (manual or ez-io g ), site of io placement (proximal humerus or trochanteric fossa of the femur), and side of cat (right or left) were randomized for each attempt. when using the ez-io g , a gauge x mm long needle and a gauge x mm needle were used for io catheter insertion in the humerus and femur, respectively. after each attempt, the student graded the ''ease of use'' of each technique on a visual analog scale (vas) that was converted to a -point scale. twenty-six iv catheter insertions in normovolemic feline and canine patients performed by western college of veterinary medicine (wcvm) small animal hospital personnel ( technicians, veterinary students, intern, resident, clinicians) were then timed and compared to the student's mean io catheter insertion time using the ez-io g .median io catheter insertion times for the techniques were significantly different (manual io technique sec; ez-io g sec) (p o . ); the manual method took seconds longer ( % confidence interval of to seconds) than the ez-io g method. insertion time was more variable for the manual technique than for the ez-io g . percentage of catheter ''slippage off the bone'' and extravasation around the inserted catheter were significantly higher for placement of the manual io catheter compared with placement of the ez-io g catheter (p o . ). student's subjective ratings were more favorable and more consistent for the ez-io g technique compared to the manual technique for io catheter insertion. compared to the mean insertion time for iv catheterization in the wcvm small animal hospital, io catheter insertion by the student using the ez-io g was significantly faster (iv catheter sec; ez-io g io catheter sec) (p o . ). intraosseous catheter insertion using the ez-io g can be said to be significantly faster, less traumatic, more user-friendly, and as effective as io catheter placement using the manual technique. vascular access via io catheter insertion using the ez-io g device may be suggested to be faster than iv catheter insertion. previously presented at the western college of veterinary medicine undergraduate poster competition. computed tomography (ct) has been widely investigated and applied as a means for non-invasive quantitative bone mineral determination in human medicine. the aim of this study was to assess age-related changes and anatomic variation in bone mineral density (bmd) using quantitative ct in normal cats. seventeen normal cats were included in this study and divided into the following age groups: o year (n ); - years (n ); and years (n ). a computed tomographic scan of each vertebra from the th thoracic to the th lumbar spine, and the pelvis, was performed with a bone-density phantom ( , , and mg/cm , calcium hydroxyapatite, cirs phantom s ). on the central transverse section, the elliptical region of interest (roi) was drawn to measure the mean hounsfield unit value. those values were converted to equivalent bmd by use of the bone-density phantom and linear regression analysis (r . ). the mean bmd value of the thoracic vertebrae ( . ae . mg/cm ) was significantly higher than of the lumbar vertebrae ( ae . mg/cm ). the maximum bmd occurred at the t , t , and l levels in all age groups. there was a statistically significant difference in the mean bmd value among the age groups at the t (p o . ), t (p o . ), and l levels (p . ), respectively. in addition, there was no significant difference between the mean bmd value of the left and right iliac bodies ( . ae . mg/cm and . ae . mg/cm , respectively). the present study suggests that age-related changes and anatomic variation in bmd values should be considered when assessing bmd using quantitative ct in cats with bone disorders. dynamic contrast-enhanced computed tomography (dce-ct) is a rapid and widely available method of cerebral perfusion imaging. however, there is no established reference value of cerebral blood flow (cbf) measured by dce-ct according to a dog's age. the purpose of this study was to identify the correlation between regional cbf and aging in clinically normal dogs using dce-ct. fourteen dogs with no evidence of hemodynamic disorders and central nervous system dysfunction were included in this study. dogs were assigned to the following age groups: o year (group ); - years (group ); and o years (group ). dce-ct scans were performed at the level of the third ventricle and mesencephalic aqueduct. cbf in the gray and white matter was calculated using stroketool-ct s software. the overall mean ae standard deviation quantitative estimate for regional cbf in clinically normal dogs was . ae . ml/min/ g, . ae . ml/min/ g, and . ae . ml/min/ g in groups , , and , respectively. there was no significant regional cbf difference between the right and left sides of the brain in each group. also, a statistically significant difference in the regional cbf was observed between groups and (p o . ). thus, aging affects the regional cbf in normal dogs and the values should be considered assessing the results of dce-ct. according to several clinical behavior guidelines, ''toileting'' type inappropriate urination (i.e. large amounts of urine deposited in horizontal surfaces) can arise in cats suffering from a medical problem (typically lower urinary tract disease). by contrast, ''spraying'' type behaviour (i.e. possibly smaller amounts of urine deposited on vertical areas) is more typically associated with anxiety brought about by a threat to local resources, arising from either a change in the physical environment or threat to these resources from another cat. however, there is some evidence that ''sprayers'' may also be presented with a medical problem, which might be linked to the disease (e.g. painful voiding associated with crystalluria may lead to a standing posture being adopted and small amounts eliminated at a given time). this might be associated with an apprehensive state or simply a co-morbid state. as part of a larger research project aimed at investigating behavioral and physical aspects of cats presented with inappropriate urination, owners of ''spraying'' and ''toileting'' cats with appropriate control subjects from the same households were recruited throughout local media coverage and the internet. the case-control dyads were brought by the owners to the veterinary hospital of the university of sa˜o paulo, at the same time, for a medical work-up (i.e. physical examination, complete blood count, biochemical profile, urinalysis, urine culture and abdominal ultrasound). no significant differences between the ''sprayers'' and ''toileters'' regarding the occurrence of medical problems were found. both groups had a similar proportion of cats affected by medical illnesses (sprayers: . %, toileters: . %; chi , p . ), directly or indirectly relating to the urinary system (e.g. diabetes, chronic kidney disease). in both groups, control cats also had a relatively high occurrence of medical concerns ( . % and . %, respectively for each control group). these results emphasize the importance of careful medical evaluation of cats presented for a urinary housesoiling problem. the relatively high prevalence of medical concerns among apparently healthy cats in multi-cat households may have arisen, at least in part, as a result of an inability/failure of owners to monitor individuals, thus allowing some early signs to pass unnoticed. the way in which medical and behavioral elements are linked (if at all) remain unknown but deserve further investigation. considered as a semi-social species, domestic cats appear to be highly sensitive to the effects of social stress, especially when living in high density populations. cats are capable of adapting to live ingroup; nonetheless, they do not appreciate living in close proximity with others as result of an environment lacking of great opportunities of escaping and hiding. this study aimed at testing the following hypotheses: (a) owners' perceived quality of life affects cats' global levels of stress; (b) cats' global levels of stress are influenced by cats' personality; (c) cats' living style (single housing versus large group housing) does affect stress levels in cats. to our knowledge, this is the first study investigating stress levels of domestic owned cats, under natural conditions, throughout measurement of faecal glucocorticoids metabolites concentration, and taking into consideration cat personality, cat living style and owner's subjective life quality. in this study, adrenocortical activity, as a valuable physiological indicator of emotional stress, was evaluated throughout the measurement of faecal glucocorticoids metabolites in fourteen single and sixteen in-group housed cats. cat personality as well as owners life quality was evaluated by self reported questionnaires given to the owners to answer. significant differences in mean glucocorticoids metabolites concentrations (mgcm) between the two populations (i.e. single versus in-group cats) were not detected (random effect model, p . ). however, when mgcm were taken as a function of cat personality, there were differences regarding single catstimid cats showed higher levels in comparison to easy-going (random effect model, p . ) and bossy (random effect model, p . ) cats. as to owner subjective life quality, a direct association between the scores given by the owners to the social dimension and mgcm was found for single cats only (i.e. the better the owner felt itself social wise the higher the mgcm of the cat; random effect model, p . ). social stratification may compensate the stress resulting from spatial restriction in large in-group living cats. other underexplored factors such as feline personality and owner life style seem to play an equally important role in domestic cats' day to day levels of stress, especially in the cats kept as single pets. in dogs, raas activation is a major feature of congestive heart failure (chf). benazepril (fortekor s ) is a potent ace inhibitor with well-documented effectiveness in canine chf. although ace activity (ace a ) has been used in preclinical studies as a surrogate marker of efficacy, some authors have reported a poor correlation between plasma ace a and changes in angiotensin ii (aii) or aldosterone (al). the purpose of this study was to investigate the effect of benazepril on canine plasma renin activity/concentration (pra/prc), angiotensin i (ai), aii, al, and fractional excretion of potassium (ufek), sodium (ufena) and aldosterone (ufeal). sixteen beagle dogs were fed a low-sodium diet and dosed with placebo or benazepril tablets ( mg po, q h) for days. blood and urine samples were collected on day (d ) and day (d ) over -hour periods. data were analyzed by repeated measures anova of baseline corrected values, and anova of auc hours . compared with placebo, benazepril induced a significant increase in pra and ai at d (p-value [pra] : . , p-value [ai] : . ) and d (p-value [pra] : . , p-value [ai] o . ). no differences in prc were noticed. based on auc hours, aii levels were % lower in the benazepril group at d (p-value [aii] : . ). ufeal and al decreased by up to % and % at d and d , respectively, though differences did not reach statistical significance. benazepril markedly influences raas dynamics in dogs. decreased exposure to aii and al are likely to be the key events required to counteract pathological remodeling of the heart in chf. this study compared two intravenous anesthetic agents, alfaxalone (alf) (alfaxan s , jurox pty. ltd.) and propofol (ppf) (rapinovet s , schering plough animal health) and their effects on spontaneous ventilation after induction of anesthesia in dogs at various doses. this randomized, crossover, dose-escalation study used six dogs in weight and gender-matched pairs ( m- f). for each drug, each dog was dosed incrementally at , , , and times the labeled anesthetic induction dose rate (alf mg/kg, ppf . mg/kg) or until a dose was reached that rendered the dog apneic. a minimum of three days was allowed between doses. for each dose administration, the entire calculated dose was delivered constantly over min. the primary variable was apnea, defined as an absence of spontaneous ventilation for minute. apneic dogs were manually ventilated with oxygen until they resumed adequate spontaneous ventilation. once the apneic dose was determined for an individual dog for one drug, the dog began incremental doses with the alternate drug. for each anesthetic episode times were recorded from completion of induction dose to; removal of endotracheal tube, dog lifting head, dog attaining sternal recumbency and dog standing. pulse rate, respiratory rate, spo and etco were each measured every min. within-dog comparisons were made using the paired student's t-test. for both alf and ppf all dogs respired voluntarily at the labeled ( x) dose. for ppf at and x doses, and dogs respired voluntarily respectively. for alf at , and x doses, all , and dog respired voluntarily respectively. for all six dogs to become apneic required x dose of ppf and x dose of alf. the mean no observable adverse effect dose (noael) expressed as a multiple of the labeled dose was higher for alf ( . x) than for ppf ( . x) (p . ). there were no significant differences between times to extubation, head lift or attaining sternal recumbency after alf and ppf at , and x doses. at the x dose, dogs took longer to stand after alf ( . ae . min) than ppf ( . ae . min). we concluded that based on anaesthetic duration, the manufacturer's labeled dose rates of mg/kg for alf and . mg/kg for ppf were equivalent. however, based on the dose escalation, the number of dogs becoming apneic at each dose-multiple is consistent with ppf having a narrower safety margin, i.e., ppf caused more respiratory depression than alf. parenteral levetiracetam (lev) has been shown to rapidly attain therapeutic levels in dogs when given iv or im, and has been used offlabel for the treatment of seizure emergencies. the purpose of this study was to determine the safety and pharmacokinetics of subcutaneously administered levetiracetam in healthy dogs. potential application of these results would be use of sq lev instead of or in addition to rectal diazepam for the treatment of cluster seizures at home. lev was administered sq between the shoulder blades to healthy, purpose-bred hound dogs, at a dose of mg/kg (undiluted). blood samples were collected at , and minutes after lev administration via jugular venipuncture. plasma lev concentrations were measured by high pressure liquid chromatography. none of the dogs became sedated, nor was there pain evident on palpation of the injection site. mean (standard deviation) lev concentration was . ( . ), . ( . ) and . ( . ) mg/ml at , and minutes, respectively. administration of sq lev was well tolerated, and exceeded the suggested therapeutic range ( - mg/ml) within minutes of administration, and remained above the range for at least hours. these data indicate that sq lev administration may be an alternative for the at-home treatment of cluster seizures in dogs, and prospective studies in epileptic dogs are warranted. the purpose of this study was to assess the effects of cyp inhibitors (ketoconazole, chloramphenicol, fluoxetine, trimethoprim, cimetidine, and medetomidine) in varying combinations on the bioavailability of oral methadone in healthy greyhound dogs. the iacuc approved this study. cyp inhibitors were administered po for hours prior to methadone administration. methadone hydrochloride was administered po at a targeted dose of mg/kg. blood was obtained for the determination of methadone plasma concentrations by mass spectrometry. the area under the curve (auc) of methadone for each treatment group was compared statistically to the auc of methadone administered without inhibitors using the mann-whitney rank sum test. significant increases (p o . ) in the methadone auc occurred in all treatment groups which included chloramphenicol, including chloramphenicol as the only inhibitor. the magnitude of increase was at least fold. mean concentrations of methadone exceeded ng/ml for at least hours in all groups administered concurrent chloramphenicol. no significant increases in the auc occurred in any of the groups which did not include chloramphenicol. in conclusion, chloramphenicol significantly inhibits the metabolism of methadone in greyhound dogs. as a result, the oral bioavailability of methadone is significantly increased and plasma concentrations are achieved that are reported to be effective in humans for - hours after a single oral administration. doxycycline hyclate is used frequently in small animals, horses and exotic animals for treatment of a wide variety of infections. because doxycycline hyclate tablets may not be suitable for oral administration in some animals, particularly horses and cats, it has been compounded into liquid suspensions. the commercially available doxycycline calcium mg/ml oral suspension, vibramycin s (pfizer) is not suitable for use in animals due to its low concentration and flavoring that animals find unpalatable. because of the known inherent instability of doxycline in aqueous vehicles under storage, this study was conducted to determine the potency of two formulations stored in dark and light conditions. a high pressure liquid chromatography (hplc) assay with uv absorption at nm was developed for analyzing doxycycline in formulations, in comparison to a reference standard from the united states pharmacopeia (usp). doxycycline hyclate mg tablets were first tested for potency. the tablets were then crushed and mixed with a pharmaceutical vehicle to make two concentrations: . mg/ml and . mg/ml. the vehicle used was a : mixture of a vehicle for oral solution (ora-sweet, usp-nf) and vehicle for oral suspension (ora-plus, usp-nf). the suspensions were prepared in replicates of . each replicate was divided, with one aliquot stored at room temperature in lighted conditions, and the other aliquot stored at room temperature in the dark. doxycycline was extracted from the formulations and measured by hplc at day , , , , , , and . each replicate was tested and the potency reported as the percent doxycycline relative to the usp reference standard. on day , , , and , the potency of each formulation was within - % of the reference standard (range . - %). this value is within the accepted range cited in usp o on pharmaceutical compounding-non-sterile preparations. however, starting at day , the potency declined dramatically and remained low for the tests performed on day and . the potency on day , , and was below % of the reference standard (range - %). there was also a noticeable change in the quality of the formulation starting on day , and a change in the color of the formulation to a dark brown. these results indicate that when doxycycline hyclate tablets are compounded as a suspension in an aqueous vehicle as described in this study, at . and . mg/ml under the storage conditions used in this study, potency of the formulation cannot be assured beyond days. we recommend a beyond-use-day (bud) of days for formulations prepared and stored at room temperature in light or dark conditions. therapeutic options for multidrug resistance (mdr) escherichia coli urinary tract infections (uti) are limited. fosfomycin (fos) tromethamine is an oral, broad-spectrum, cell-wall active, bactericidal drug approved for treatment of uncomplicated uti in humans. the purpose of this study was to determine time dependency of fos and the disposition of fos tromethamine in dogs. using a randomized, double crossover design, client-owned dogs received fos sodium iv ( mg/kg) and fos tromethamine (po, mg/kg) either with (n ) or without food (n ). serum and urine were collected for hr; fos was quantitated with a bioassay (atcc e. coli , serum or atcc proteus vulgaris , urine). in-vitro killing curves (cell counts through hours) were performed at (control), . , , , , and x mic for mdr e. coli canine fos susceptible (e-test s ) uropathogens. killing curves indicated fos to be time dependent. after iv administration, clearance (mlÃkg/hr), volume of distribution (l/kg), elimination half-life (hl; hr) and mean residence time (mrt, hr) were (mean ae sd): ae , . ae . , . ae . , . ae . and . ae . , respectively. for po, c max , hl and mrt were ae , . ae . and . ae . , respectively. serum fos exceeded the mic reported for multidrug resistant (mdr) e. coli ( . mg/ml) for hr (iv; . mg/ml) and hr (po, mg/ml diminazene is an aromatic diamidine, anti-protozoal drug that has shown promise in a small number of cases of cytauxzoonosis. in a noncontrolled case series, of cats with clinical cytauxzoonosis given mg/ kg of diminazene aceturate survived infection. dosage frequency was two intramuscular injections given one week apart. commercial formulations contain the diminazene diaceturate salt. the active base is diminazene with the salt consisting of two aceturate molecules. currently there is no data available on the pharmacokinetics of either diminazene compound in cats. the objective of this study was to determine the pharmacokinetics of diminazene diaceturate in healthy cats. four purpose bred cats with normal physical examination, cbc, chemistry and urinalysis were used. a powdered commercial drug formulation (veriben s , ceva sanet animale) was freshly reconstituted with sterile water to a concentration of mg/ml prior to administration and sterile filtered solution. heparinized blood samples were collected just before (hour ) or . , , , , , , , , , , , , and hours after intramuscular administration of mg/kg ( . mg/kg of diminazene base) diminazene diaceturate. the plasma was separated by centrifugation within minutes of collection and frozen (À c) until analysis. concentrations of diminazene were measured by hplc analysis using uv absorption and ion-pairing conditions. the pharmacokinetic profile was analyzed using a simple one-compartment model. in these cats, diminazene had a mean terminal half life (t / ) of . ( /- . ) hrs and mean peak plasma concentration (c max ) . ( /À . ) mg/ml. the mean residence time (mrt) of diminazene was . hrs ( /À . ). systemic clearance (cl/f) was . ( /À . ) l/kg/hr. the volume of distribution per fraction absorbed (vd/f) was . ( /À . ) l/kg. a single intramuscular dose of diminazene diaceturate was well tolerated by all cats. without knowing the concentration required to inhibit or kill cytauxzoon felis, it is not yet possible to make suggestions regarding optimum dosing schedules for this drug. additional toxicology data and studies to assess clinical efficacy for the treatment of cytauxzoonosis are indicated before routine clinical use can be considered. meloxicam has been shown to accumulate in areas of inflammation in both the rat and human. the objective of this study was to investigate the concentration of meloxicam in synovial fluid of inflamed joints versus that of non-inflamed joints in dogs. eight male dogs were treated with . mg/kg of meloxicam on day one and . mg/kg of meloxicam on day two. all treatments were administered orally. on day three reversible acute synovitis was induced in one stifle by aseptic, intra-articular administration of ml sodium urate crystal suspension ( mg/ml). in four dogs synovitis was induced in the l stifle and in four dogs the same procedure was used in the r stifle. in each dog the stifle without induction of synovitis served as the ''normal'' joint sample. a synovial fluid sample was collected from both the r and l stifle of each dog. sample collection occurred eight hours after administration of sodium urate and twenty four hours after the last administration of meloxicam. synovial meloxicam concentration was analysed using high performance liquid chromatography-mass spectrometry (hplc/ ms-ms). the concentration of meloxicam in the inflamed versus non-inflamed joint in each dog was compared using the paired t-test. the results indicate that meloxicam preferentially accumulates in inflamed joints in the dog as meloxicam concentrations are statistically significantly higher in inflamed joints than in non-inflamed joints. no national surveillance system exists for monitoring emergent resistance in companion animals. however, e. coli resistance is an increasing therapeutic and public health concern in these in dogs and cats. the purpose of this study was to describe current resistance patterns of canine and feline pathogenic e. coli throughout the united states and identify risk factors of antimicrobial resistance. isolates (n ) of clinical e. coli collected from dogs or cats from may through may located in different regions. susceptibility was determined to drugs ( drug classes) by broth microdilution methods. pharmacodyamaic statistics were described regionally. phenotypes were determined and type of resistance was based on the number of drug classes to which resistance was expressed: none (ndr), single (sdr) and multi (mdr). the majority of isolates were from urinary tract ( . %) and dogs ( . %). the proportion of resistance type for each drug was: ndr ( . %), sdr ( . %) and mdr ( . %). the proportion of mdr was greatest in the southwest ( . %) and least in the northwest ( . %) (p o . ). for all regions, the proportion of resistance was: cephalothin (cph, . %) amoxicillin-clavulanic acid (amx, . %), ampicillin (amp, . %), tricarcillin-clavulanic acid (tcx, . %), doxycyline (dxy, . %) cefoxitin (cfx, . %), cefpodoxime (cpx, . %), chloramphenicol (chp, . %), enrofloxacin (enr, . %) , ciprofloxacin (cif, . %), trimethoprim-sulfamethoxazole (tmx, . %), ceftazidime(cfz, . %), gentamicin (gtm, . %), cefotaxime (cft, . %) meropenem ( . %) (p o . ). the mic exceeded the resistant breakpoint for amp, amx, cpx, cph, cif, cfx, dxy and enr whereas mic did not surpass the susceptible breakpoint. beta-lactams ( . %) was the most and aminoglycosides the least ( . %) sdr. the drug class most frequently involved in mdr was beta-lactams ( . %) and least, gen ( . %). resistance differs regionally, being greatest in the southwest. cph is the most and meropenam is the drug least associated with resistance; these patterns are consistent with current drugs used by veterinarians. the fluoroquinolones (fqs) are common choices for treatment of e. coli urinary tract infections (utis) in animals and humans. nd generation drugs approved in animals include enrofloxacin (enr), marbofloxacin (mar), orbifloxacin (orb); human drugs include ciprofloxacin (cip). rd and th generation fq for humans include moxifloxacin (mox), gatifloxacin (gat) and ofloxacin, (ofl]), its lisoform levofloxacin (lev). for animals, pradofloxacin (pra) is approved for use in europe. the purpose of this study was to assess the in vitro activity of st (naladixic acid [nal] through th generation fqs (n ) toward dog or cat e.coli uropathogens (n ). isolates were subjected to susceptibility testing to drugs classes ( drugs). isolate phenotypes included no (ndr; n ), single (sdr; n ) or multidrug (to more than drug classes; mdr; n ) resistance (including enr resistant [enr r -mdr; n ] or enr susceptible (enr s -mdr, n ). the minimum inhibition concentrations (mics) were determined for each isolates using broth microdilution (e. coli atcc s served as a negative control). mic statistics were generated for each drug among phenotypes. the overall potency (mic ) for all enr susceptible isolates (ndr, sdr and enr s -mdr) was gat pra, mox, mar, lev, cip sar, orb, ofl enr nal. each e. coli isolate expressing ndr or sdr was susceptible to all fq. however, isolates expressing resistance to st or nd generation fq were also resistance to later generation drugs. glucocorticoids (gc) are standard therapy for allergic asthma but do not reverse the underlying type i hypersensitivity. allergenspecific immunotherapy (asit), a process of ''desensitization'', is potentially curative but requires identification of offending allergens. the purpose of this study was to determine if oral or inhaled gc administered at routinely used dosages would interfere with allergen identification. we hypothesized that oral but not inhaled gc would interfere with accurate identification of allergen-specific ige using skin and serum testing in experimentally asthmatic cats. asthma was induced in eighteen cats using bermuda grass allergen (bga). cats (n /group) were randomized to receive oral gc ( mg prednisolone q hr po), inhaled gc ( ug budesonide q hr) or placebo (gelatin capsule q hr po) for one month. intradermal skin testing (idst) and bga-specific ige amounts were measured prior to, during (weeks one and four) and every two weeks after treatment until both tests were positive. a paired t test was used to compare serum ige among groups pre-and post-treatment (p o . significant). idst reactivity was eliminated in / cats on oral gc, / on inhaled gc, and / placebo-treated cats. within two weeks after stopping treatment, idst was again positive in all cats. contrary to our hypothesis, serum ige reactivity to bga was not significantly diminished by any treatment. in conclusion, a two week withdrawal from gcs is adequate for idst identification of allergen but no withdrawal is required prior to serum ige testing to identify the sensitizing allergens. previously in people, increasing severity of asthma is associated with low serum concentrations of -hydroxyvitamin d ( -oh-d). -oh-d is thought to ameliorate lower airway inflammation primarily by decreasing the production of pro-inflammatory mediators, and by increasing the production of the anti-inflammatory cytokine il- . in people, serum -oh-d concentration is associated with sunlight exposure as well as dietary intake. cats do not rely on sunlight for vitamin d synthesis; all vitamin d comes from dietary intake. cats have a naturally occurring lower airway disease syndrome (lad) that shares many features with human asthma. the goal of this study was to evaluate serum -oh-d concentrations in cats with lad. cats with naturally developing lad were enrolled. criteria for a diagnosis of lad included a history of cough, wheeze or respiratory distress, radiographic evidence of a bronchial pattern and hyperinflation, negative heartworm antigen and antibody test, and a resolution of clinical signs in response to glucocorticoids. dietary history was obtained. -oh-d concentrations were determined on serum samples by a commercial laboratory. twelve cats with lad were enrolled. all cats ate commercial cat food. the median -oh-d concentration was nmol/l with a range of - nmol/l which is within the reported reference range of - nmol/l. in contrast to human asthma, lower airway disease in cats is not associated with low serum concentrations of -oh-d. interstitial lung diseases (ild) are uncommon in dogs, with the most commonly recognized ild idiopathic pulmonary fibrosis (''westie fibrosis''). in human medicine, ild represent a large umbrella of pulmonary diseases, with ipf only a subset. other, more treatable, ilds are also identified, and may respond to either the removal of a stimulus (hypersensitivity) or steroid therapy. the goal of this report is to describe the clinical course, including outcome, computed tomography and histopathology of dogs affected with an ild. the computed tomography (ct) log was reviewed for dogs that underwent thoracic ct scanning for evaluation of respiratory signs, and had changes consistent with ild as the primary abnormality, including the presence of diffuse disease in all lobes, and at least of the following: reticulation, ground glass opacity, consolidation, or traction bronchiectasis. survival time from ct date was calculated. the presence of moderate pulmonary hypertension [phtn] ( mmhg) as estimated by tricuspid regurgitant jet, was also reported and survival times were compared with a mann-whitney rank sum with p o . considered significant. thirteen dogs were identified. terriers and chihuahuas were the most commonly affected breeds. two dogs were adolescents, the remaining dogs ranged from - years, with a median of years. histopathology results (n ), including moderate to severe interstitial fibrosis ( ) alveolar proteinosis with fibrosis ( ), and interstitial eosinophilic pneumonia ( ). one had suspected cryptogenic organizing pneumonia and had a good response to glucocorticoids. eight dogs died of respiratory failure, with a median post ct survival time of days (range - ), two dogs died of non-pulmonary disease, dogs had severe lower respiratory infections as puppies with persistent respiratory signs, and both are still alive at years since diagnosis, terrier is alive at months and was lost to follow up. dogs had phtn, with a median survival of days ( - ), while the dogs without had a survival of days (range - ), [p . ]. interstitial lung disease in dogs is not just idiopathic pulmonary fibrosis. following respiratory infection, young dogs may develop an ild with a relatively indolent course and rare ild is steroid responsive. ct is useful to identify ild but further research correlated with echocardiography and histopathology is advised to use it to prognosticate. idiopathic pulmonary fibrosis (ipf) is an interstitial pulmonary disease, mainly described in west highland white terriers (whwt). identification of molecular pathways important in the pathogenesis of ipf would improve our understanding of this disease and may help identify therapeutic targets. the aim of the present study was to investigate gene expression in lungs of whwt with ipf using oligonucleotide microarray. total rna was extracted from post-mortem pulmonary samples from five whwt with ipf and five control dogs (ctrl) without pulmonary disease. the rna was pooled from each group (ipf and ctrl) and analysed using the canine specific affymetrix microarray technology. genes with a minimum of a two-fold difference in expression between the two groups were selected for further analysis. the most significant biological functions for these genes were identified using ingenuity pathways analysis. more than genes were identified as having greater than twofold difference in expression. the significant biological functions associated with these genes were related to cellular movement, cellular proliferation and apoptosis. most notable among these were genes encoding the leukocyte chemotactic proteins: ccl (fold change . ), ccl ( . ) and il ( . ); the proteins involved in fibroblast migration; and the matrix metalloproteinases (mmps) involved in matrix degradation: mmp (À . ), mmp (- . ), mmp (À . ). this study has identified genes which may be important in pathogenesis of ipf, e.g. proteins involved in leukocytes chemotaxis, fibroblast recruitment and activation, regulation of apoptosis, and extracellular-matrix turn-over. however, real-time quantitative rt-pcr studies are needed to confirm these results before any definitive conclusions can be drawn. idiopathic pulmonary fibrosis (ipf) is an interstitial disease, mainly described in west highland white terriers (whwt). defini-tive diagnosis ultimately relies on lung histopathology. identification of specific biomarkers would be very helpful. expression microarray is a powerful screening tool to study local gene expression in a disease state. the aim of the present study was to measure gene expression profiles in lungs of whwt with ipf to identify potential blood or bronchoalveolar lavage fluid (balf) biomarkers. total rna was extracted from post-mortem pulmonary samples from five whwt with histopathologically confirmed ipf and five control dogs (ctrl) without pulmonary disease. the rna was pooled from each group (ipf and ctrl) and analysed using the canine specific affymetrix microarray technology. ipa-biomarkers analysis (ingenuity system) was used to filter and prioritize biomarkers candidates using the three following criteria: a minimum of a two-fold difference in expression between ipf and ctrl; expression of the gene in lung tissue; possible detection of the protein in blood or in balf. fifty-four molecules met all the criteria. based on difference in expression, promising proteins included ccl (fold change . ), a -actinin ( . ), ccl ( . ), serum amyloid a ( . ), il ( . ), plunc (À . ), mmp (À . ). some are well-known biomarkers of ipf in humans either for diagnosis (mmp , il ) or prognosis (ccl ). these results provide novel potential biomarkers of canine ipf. measurement of these proteins in blood and balf of healthy dogs, dogs with ipf and with other respiratory diseases is needed to assess their use as biomarkers of canine ipf. heliox is a mixture of helium and oxygen that has been used therapeutically in human medicine for treatment of airway obstruction. helium's low density and other physical properties have been shown to reduce the work of breathing by limiting turbulence. the purpose of this study was, therefore, to evaluate respiratory parameters in response to inhaled heliox in dogs with meso-and brachycephalic conformation. eleven healthy dogs were recruited, five were mesocephalic and six were brachycephalic. flow-volume loops were collected using commercial software (buxcor) while breathing : helium: oxygen (heliox) and : nitrogen:oxygen (nitrox) in a randomized order via a low dead-space face mask. due to the intrinsic gas properties, gas flow rates and volumes were corrected in-vitro by a conversion factor for the effect of helium on the pneumotachograph. respiratory rate, tidal volume (ml), minute ventilation (l), inspiratory time (ti), expiratory time (te), peak inspiratory flow (pif) and peak expiratory flow (pef) were recorded while breathing heliox or nitrox. values were compared using a paired sample t-test, with p o . considered significant. all dogs cooperated with testing. there was no significant difference in respiratory rate, tidal volume, minute ventilation, inspiratory or expiratory times, or peak inspiratory flow. peak expiratory flow was significantly higher (p . ) while breathing heliox than when breathing nitrox in brachycephalics but not in mesocephalics (p . ). heliox is well-tolerated in healthy dogs and results in an increased expiratory flow rate in brachycephalic dogs. further investigation of heliox is warranted in dogs with airway obstruction. of this prospective multicentric study is to assess the effects that surgical correction has on the severity of clinical signs and levels of acute phase proteins (c-reactive protein [crp] , haptoglobin [hp]) and cardiac troponin i (ctni). thirty three brachycephalic dogs with boas were included and evaluated before and, approximately two months, after surgical correction. the most common components of boas found were elongated soft palate ( / ; %), stenotic nares ( / ; %) and everted laryngeal saccules ( / ; . %). staphylectomy was performed by means of two different surgical techniques: laser (n ) or electrical scalpel (n ). there were significant differences between dogs depending on the surgical technique used, with a higher reduction of respiratory signs (p o . ) and a better postsurgical improvement (p o . ) with the use of laser. the levels of crp, hp and ctni were categorized into normal or elevated. before surgical treatment three ( . %), six ( . %) and thirteen ( . %) dogs had elevated values of crp, hp and ctni, respectively. two months after surgical correction, five ( . %), eleven ( . %) and fourteen ( . %) dogs had elevated values of crp, hp and ctni, respectively. there were no statistical differences between values of crp and ctni before and after surgical correction but the levels of hp increased significantly after surgical treatment (p o . ), probably due to postsurgical treatment with corticosteroids. as previously suggested by others, there was a statistically significant reduction of respiratory and gastrointestinal signs in dogs with boas submitted to surgical correction (p o , ). according to the results obtained in the present study, the determination of crp, hp and ctni before and two months after surgical treatment do not have a prognostic value in dogs with boas. even though, near half of the dogs studied had elevated levels of ctni ( . %) that persisted after surgical treatment ( . %), suggesting some degree of myocardial damage is present. further studies are needed considering the influence of breed and age. to the authors' knowledge, this is the first description of crp, hp and ctni determination in dogs with boas. overweight and obesity are common conditions that lead to alterations in respiratory mechanics, airway resistance, pattern of breathing and gas exchange in humans. the objective of the present study was to investigate if there are significant differences on respiratory parameters and arterial gas analysis of obese and overweight cats, in conscious state and under general anesthesia. twenty nine adult cats were arranged in three groups: obese (n ), overweight (n ) and with ideal body score index (bsi) (n ). mean of bsi in the groups were: , (obese), , (overweight) and , (ideal bsi). cats did not had respiratory, cardiac or others systemic diseases. the respiratory parameters were evaluated with a ventilometer equipment coupled to facemasks in conscious cats and directly to the endotracheal tube in anesthetized cats under spontaneous respiration. the anesthesia was performed with propofol ( ae , ml/kg) and the cats were maintained in the same anesthetic plan. the three groups were compared by analysis of variance followed by tukey's test and conscious and anesthetized cats were compared by student's t test, with a % significance level. there were not observed differences on the respiratory parameters evaluated on ventilometry (tidal volume, expiratory and inspiratory times and peak pressures, respiratory rate and partial pressure of end tidal co (petco )) and on arterial gas parameters (pao e paco ) in the three groups. the pao of cats with ideal bsi was , ae , mmhg, although was not significantly different (p , ) from overweight ( , ae , mmhg) and obese cats ( , ae , mmhg). comparison of anesthetized to conscious cats, it was detected decreases in tidal volume, expiratory and inspiratory times and peak pressures and increase in petco in respiratory rate in the anesthetized cats. only petco , inspiratory time and respiratory rate in overweight cats did not differ in anesthetized cats. these results suggest that obesity and overweight did not result in impairment of respiratory function in cats and propofol induced respiratory depression. osteosarcoma (osa) is the most common bone tumor in dogs, however, little is known regarding the mechanisms underlying malignant transformation in these tumors. breeds such as rottweilers and greyhounds are at higher risk for developing osa, suggesting that heritable factors play a role in this disease. mirnas have tumor/tissue specific roles in regulating gene expression and dysregulated mirna expression is found frequently in cancer. we hypothesize that canine osa is characterized by a unique mirna expression profile(s) with dysregulation of some mirnas being associated with specific breeds. mirna expression profiling of primary osa tumors from greyhounds and rottweilers was performed using the nanostring technologies ncounter mirna expression assay kit, interrogating the mirna expression profile of human mirnas, of whose mature sequences are % conserved between human and dog. mirnas were differentially expressed in greyhound versus rottweiler tumors (p o . ), suggesting that breed-specific dysregulation of mirnas may contribute to the development and progression of spontaneous osa. hierarchical clustering revealed distinct mirna expression signatures in greyhound osa tumors as compared to rottweilers. based on these preliminary results, we are evaluating a larger cohort of osa tumor samples including greyhounds, rottweilers, golden retrievers, and a mixed population of other breeds. statistical analysis will be performed to determine the association of mirna transcript levels with specific breeds and overall outcome. characterization of mirna expression in canine osa will facilitate our understanding the biology of this disease and has the potential to identify targets for therapeutic intervention. originally combination therapies using drugs with documented single-agent activity and lack of overlapping toxicities could potentially improve outcome. the hypothesis intended to be tested is that palladia s can be safely administered concurrently with a standard weekly protocol of vinblastine (vbl), at dosages known to have activity against mast cell tumors. dogs with histologically confirmed measurable mast cell tumors were evaluated for eligibility to enter a standard phase i dose-finding trial ( cohort), at a starting dose of . mg/m iv vbl (weekly for a total of treatments) and . mg/kg po palladia s eod, concurrently. dose escalation of palladia s was scheduled in . mg/kg increments until mtd was established or fda label dose completed ( . mg/kg). safety evaluation was performed weekly throughout the week study period. dose-limiting toxicities were described following established vcog-ctcae(v . ) criteria. while antitumor response is not a primary endpoint of phase i trials, activity was documented prior to vbl treatments - , and monthly thereafter, based on recist criteria. nine dogs have been enrolled; cohort is filled and approaching completion of the evaluation period. hematologic dose limiting toxicity led to de-escalations of vbl. the current safe combination appears to include vbl at . mg/m every other week and palladia s at . mg/kg eod. response was seen in all but one dog. without head to head trials comparing efficacy of bi-weekly vbl combined with palladia s and vbl alone, choice of therapy should remain at the clinician's discretion. originally prostate specific membrane antigen (psma) is a transmembrane protein expressed by tumor-associated neovasculature, but not normal blood vessels. based upon its selective expression in endothelial cells associated with cancer, psma may serve as a conserved angiogenic target shared by macroscopic solid tumors of various histologies. to investigate the feasibility of targeting a homogenous population of psma-expressing endothelial cells as a novel anticancer strategy, we have investigated psma expression in several canine hemangiosarcoma (chsa) cell lines, and subsequently developed self-assembling nanoparticles containing diagnostic (near infrared dyes) and therapeutic (doxorubicin) cargo which selectively bind to psma by means of the a aptamer, a commercially-available oligonucleotide. the expression of psma by chsa cells was confirmed transcriptionally and translationally by real time pcr and immunohistochemistry, respectively. selective binding and endocytosis of a decorated nanoparticles was studied by fluorescent microscopy. the ability of a decorated nanoparticles encapsulating doxorubicin to exert in vitro cytotoxic effects in chsa cells was assessed by colony forming assays. using a chsa xenograft murine tumor model, clinically-relevant anticancer effects of a decorated nanoparticles encapsulating doxorubicin were tested. all chsa cell lines expressed psma mrna and protein. a decorated nanoparticles were selectively endocytosed by psma-expressing cells, and when these nanoparticles encapsulated doxorubicin, significant cytotoxic effects were exerted in vitro. finally, a decorated nanoparticles encapsulating doxorubicin significantly reduced the size of macroscopic chsa tumor burdens in transplanted mice. diagnostic and therapeutic nanoparticles can be targeted to psma-expressing endothelial cells, and chsa provides a comparative model for the future study of nanoparticle therapeutics. canine transitional cell carcinoma (tcc) is the most common tumor of the urinary tract, and is similar to human invasive tcc in histopathologic characteristics, molecular features, sites of metastasis, and response to medical therapy. prevalence is increasing, and novel therapies and strategies are needed to effectively treat this aggressive form of cancer in both species. personalized medicine techniques intend to improve treatment outcome by using patient tumor profiling to identify potential and individualized therapeutic targets. a genomic algorithm has been developed termed ''coexpression extrapolation'', or coxen, that aims to use expression microarray data to predict drug activity in patient tcc samples. the utility of this predictive methodology has been established in other types of cancer in vitro, however its clinical utility has not yet been determined. validation studies of coxen in canine tcc cell lines were conducted. the goal was to determine the value of coxen in predicting baseline sensitivity of canine tcc to chemotherapy agents (gemcitabine, mitoxantrone, carboplatin, vinblastine and cisplatin) that would then be used in a proposed clinical trial. additionally, expression data from canine treatment-naı¨ve primary tumor samples were generated on an affymetrix array platform (canine genome v . ). both the expression data and tcc cell line data (antiproliferative effects, % growth inhibition or gc ) were used to establish a canine specific predictive coxen algorithm. coxen scores for canine tcc cell-line drug activity were then analyzed. scores predicted the activity of cisplatin, gemcitibine, and mitoxantrone in all cell lines, and of carboplatin in cell lines. because all of the cell lines were sensitive to vinblastine (gi o . mm), the coxen score was not predictive of its potency. interestingly, coxen fails to predict vinblastine response in human tcc cell line data as well. in concurrent work, comparative genomic studies to define and compare the gene expression signatures of tcc in dogs and humans provides further evidence that canine tcc is a valuable genomic model of the human disease. current studies involve testing the chemo-predictivity of this derived canine coxen algorithm in additional canine tcc cell lines. canine tcc offers an excellent model for in vitro and in vivo studies of the coxen approach. this preclinical work will be used to guide the feasibility of future coxen clinical trials in dogs and humans with tcc. a small molecule complex (aminoact) isolated from bovine milk is a natural peptide mixture with multi-kinase inhibitory effects against epidermal growth factor receptor (egfr) and insulin-like growth factor receptor- (igfr- ). ingestion of aminoact in people with cancer results in lower serum tnf-alpha, an increase in antioxidant superoxide dismutase (sod) enzyme activity, and subjects' blood serum causes apopsotis in cancer cell lines. this study was designed to first assess safety and secondly the efficacy of three dosage levels of ax- in sustaining progression free survival (pfs) for dogs with refractory advanced and/or metastatic cancer. the prospective, open label study included dogs of different breeds with naturally occurring histologically confirmed malignancies. the first dogs received aminoact at g/m ; the second group of dogs subsequently received the same dosage mg of aminoact; and the third group of dogs subsequently received g/ m . each dog was treated orally daily for six weeks along with mg betaine hcl, that aids in peptide absorption. all patients were evaluated for toxicity using the vcog-ctcae and efficacy using the recist criteria via assessment of clinical parameters, blood work and client questionnaires. no toxicity other than mild, transient (grade i) nausea was noted, nor were there any changes in hemograms or biochemical profiles in any patient. dogs with tumors that were confirmed as responders ( % reduction in size) include pulmonary adenocarcinoma, mast cell tumor, trichoepithelioma and soft tissue sarcoma. it appears in limited studies that the response rate may be more durable at higher dosages. the response to aminoact is dose dependent and only transient mild toxicity was observed, which suggest the maximum effective dosage has not been reached. further clinical studies will be valuable in determining the effective dosage and response duration. treating cancer in dogs with aminoact offers a unique opportunity as a model for human cancer biology and translational cancer therapeutics. stereotactic radiation therapy (srt) combines patient immobilization, image guidance, and intensity modulated delivery to achieve ablative radiation doses within the tumor, while preferentially sparing surrounding normal tissues. the purpose of this study was to evaluate the efficacy of srt as a means of achieving local tumor control for canine nasal tumors. retrospective analysis was performed on dogs with a nasal tumor confirmed by histopathology and computed tomography, no previous surgical or radiation therapy, at least six months of follow-up, and completion of three fractions of srt at csu.srt was administered via the varian trilogy linear accelerator once daily for three consecutive days. the varian eclipse treatment planwas reviewed to determine the planned target volume (ptv) and dose to % of the ptv. kaplan-meir survival analysis was performed for disease free interval (dfi) and overall survival (os). sixteen patients with nasal tumors ( adenocarcinoma/carcinomas, squamous cell carcinomas, chondrosarcomas, osteosarcomas, and undifferentiated sarcoma) were treated with srt. a median dose of . gy was administered to % ptv with a median ptv of . cc. srt was well tolerated by the normal tissues with minimal, manageable side effects. to date, the median dfi is days, while the median os is days. based upon the initial clinical experience, stereotactic radiation therapy is an emerging modality in the management of canine nasal tumors. canine leptospirosis can vary from subclinical infection to illness that ranges from mild to severe, including death, depending on the susceptibility of the dog, virulence of the organism, and route and degree of infection. the objective of this study was to evaluate the ability of a canine leptospira bacterin to prevent infection and disease following challenge with virulent leptospira canicola, l. pomona, l. grippotyphosa, or l. icterohaemorrhagiae. groups of week-old beagles were vaccinated (day ) and boosted (day ) with placebo (n ) or the -way bacterin (n ! ) and subsequently challenged with each serovar. the results demonstrated that blood and various tissue samples from placebo-recipients became reliably infected, and the dogs developed typical clinical signs of leptospirosis including loss of appetite, ocular congestion, depression, dehydration, jaundice, hematuria, melena, vomiting, petechiae, and death. in addition, placebo-recipients developed kidney and liver dysfunction. in contrast, some vaccine-recipients became infected, but the organisms were cleared quickly from the blood. vaccinated dogs failed to develop severe clinical disease requiring medical intervention, and no animals died (p ! . ). a few of the vaccinated dogs developed clinical abnormalities, but the clinical signs remained mild and were self-limiting (p o . for each serovar). administration of the bacterin also prevented thrombocytopenia ( ciprofloxacin, a synthetic fluoroquinolone antimicrobic, is not fda-approved for veterinary use. however, due to recent availability of less expensive generic formulations, extra-label use of ciprofloxacin by veterinarians appears more common. although ciprofloxacin crystalluria and uroliths have been reported in humans, we are unaware of any published reports in dogs. this is surprising since mean urine ciprofloxacin concentration ( . mg/ml) in dogs following a modest iv dose ( mg/kg) was times higher than the solubility of ciprofloxacin in water ( . mg/ml). to identify the occurrence of ciprofloxacin uroliths in dogs, records from the minnesota urolith center were reviewed. between january and december , ciprofloxacin was identified in uroliths from dogs; uroliths were composed of % ciprofloxacin in , mixed uroliths containing ciprofloxacin were identified in , a shell of ciprofloxacin was observed in , and ciprofloxacin surface crystals were identified in . based on an experimental study in which % of human volunteers consuming mg of ciprofloxacin with nahco exhibited ciprofloxacin crystalluria (urine ph . ), while no volunteers consuming mg of ciprofloxacin and nh cl to acidify urine formed crystals; we postulated that ciprofloxacin uroliths could be dissolved in acidic urine. to test this hypothesis, canine uroliths composed of % ciprofloxacin from a single source ( -yr-old male, english bulldog receiving mg/kg of ciprofloxacin po, q hr to manage superficial pyoderma; turbulent flow chromatography/tandem mass spectrometry detected mg of ciprofloxacin/g of urolith) were incubated in urine at selected ph's and monitored for dissolution. urine obtained from multiple dogs not receiving fluoroquinolones, was pooled and divided into aliquots. aliquots were adjusted with hcl or naoh to a ph of , , , , or . aliquots were capped and preserved by refrigeration; ph was monitored and readjusted weekly. ten uroliths of approximately equal weight were randomly assigned to individual flasks containing mls of urine. flasks were constantly agitated and maintained at c. every hours, urine was discarded and replaced with mls of urine of identical ph until stone dissolution was complete. ciprofloxacin urolith dissolution times at each urine ph are reported below. ciprofloxacin uroliths are a newly recognized disease and a potential adverse effect of ciprofloxacin administration in dogs. in vitro dissolution of ciprofloxacin uroliths was achieved in canine urine, supporting the premise that in vivo dissolution is possible. urolith dissolution times were shortest at lower and higher ph's, which is consistent with the pka ( . and . ) of this amphiprotic antimicrobic (more soluble at ph below the acidic pka and above the alkaline pka). foods designed to promote struvite urolith dissolution may be designed for short term feeding facilitating rapid dissolution or may be formulated with a more moderate target urine ph to allow for dissolution and then life-long maintenance feeding minimizing recurrence. the purpose of this study was to compare the efficacy and rate of dissolution of a maintenance food with a struvite dissolution food. sixteen client-owned adult cats ( fs, mc) with naturally occurring struvite urocystoliths (mineral composition based on history, radiographs, urinalysis, urine culture and physical examination) were randomized to either a dry maintenance food (test) or a dry food known to dissolve struvite uroliths (control). the clinical care team and owner were blinded to treatment assignment. the test food was formulated to provide . % mg (dm), . % p, % protein, and a calculated target urine ph value (uph) of . - . . the control food was formulated to provide . % mg (dm), . % p, % protein, and a targeted urine ph of . - . . owners were advised to feed the assigned diet exclusively in an amount to maintain body condition. after diet assignment radiographs were performed at eight weekly intervals until there was no evidence of uroliths or until there was evidence that the uroliths were the same size or larger. a physical examination, complete blood count, serum chemistry profile, urinalysis and urine culture were repeated at the conclusion of the study. statistical analysis was by anova. all uroliths dissolved in all cats and both foods were palatable. radiographs of cats fed the control food indicated the uroliths dissolved in a significantly shorter time (mean ae std dev of . ae . weeks) compared to cats consuming the test food (mean . ae weeks; po . ).). cats in the control group finished the study at (n ), (n ) and weeks. cats in the test group finished the study , , (n ), , , , and weeks. all the minnesota urolith center occasionally receives uroliths for analysis that are immersed in formalin. results of quantitative analysis of these uroliths revealed that some submitted in formalin consisted of newberyite (magnesium hydrogen phosphate trihydrate). because newberyite is uncommonly found in uroliths formed by cats and dogs, we hypothesized that this mineral was an in vitro artifact caused by exposure of struvite (magnesium ammonium phosphate hexahydrate) to formalin. the purpose of this study was to determine if formalin alters the mineral composition of uroliths. urolith submissions containing stones of either % struvite (n dogs and cats), % calcium oxalate (n dogs and cats), % calcium phosphate apatite (n dogs and cats), % cystine (n dogs and cats), % ammonium urate (n dogs and cats), and % silica (n dogs) preserved by only air drying were tested. one urolith from each submission was quantitatively analyzed by polarized light microscopy or infrared spectroscopy. a subsequent urolith from the same submission was immersed in ml of % buffered formalin for hours at room temperature. uroliths were then air dried for minutes and the analysis was repeated. after exposure to formalin, portions of all struvite uroliths were transformed into newberyite. three ( dog and cats) of ammonium urate uroliths were completely dissolved. newberyite was not detected in any of the remaining uroliths. likewise quantitative mineral analysis of non-struvite uroliths remained unchanged. to avoid misdiagnosis of mineral composition, uroliths should not be immersed in formalin prior to analysis. we previously reported that transfusion to normal dogs of autologous erythrocyte concentrates (prbcs) that had been stored for days causes a profound inflammatory response ( x increase in leucocyte count and fibrinogen, x increase in c-reactive protein). we speculated that inflammation was due to cytokines produced during the storage period, and hypothesized that transfusion of fresh (f) prbcs would elicit less inflammation than would stored (s) prbcs. a whole blood unit was collected from healthy dogs (n ) for prbcs on day , then again on day . on day dogs received an autologous transfusion of prbcs stored for either days (s, n ) or days (f, n ). cbcs and in-tem thromboelastometry (ct:coagulation time, cft:clot formation time, a:alpha, mcf:maximum clot firmness) were evaluated on blood samples collected at (pre) and , , , , and hours after transfusion. fresh prbcs did not elicit any change in leucocytes, platelets, or thromboelastometry. stored prbcs elicited a degenerative left shift ( hr) followed by a regenerative left shift ( - hr), thrombocytopenia ( % decrease at hr), and marked hypocoagulability characterized by prolonged ct ( , , hr) and cft ( , hr), and decreased a ( , hr) and mcf ( , , hr). data are mean(sd). a: p o . between groups f and s by t test. b: p o . compared to '' '' by rm anova. transfusion of autologous stored prbcs elicits a greater inflammatory response than fresh prbcs, and results in hypocoagulability on thromboelastometry. clopidogrel is a potent antiplatelet drug that is gaining popularity in veterinary medicine for antithrombotic therapy. the parent molecule is an inactive prodrug that must be converted by hepatic isozymes to an active metabolite. the majority of the parent molecule is directed to the formation of inactive metabolites with only an extremely small proportion of parent molecule directed to the formation of the active metabolite. there are multiple hepatic isozymes responsible for the formation of the active metabolite. a non-specific hepatic isozyme inducer such as rifampin could increase the formation of the active metabolite of clopidogrel thereby increasing the pharmacodynamic response which may allow a reduced drug dose to achieve a clinical effect. we have previously presented data supporting the increased pharmacodynamic response of clopdiogrel after rifampin therapy. the goal of this study was to demonstrate an increased pharmacokinetic response of clopidogrel after rifampin induction of hepatic isozymes. six healthy, purpose-bred dogs were used for this study. the pharmacokinetics of clopidogrel were determined by measuring the parent molecule, primary inactive metabolite and active metabolite through lc/ms/ms. the pharmacodynamics of clopidogrel were determined by measuring collagen-induced whole blood aggregation. blood samples were collected prior to clopidogrel administration (baseline), after days of mg/kg clopidogrel po q hrs, and after days of mg/kg clopidogrel po q hrs mg/ kg po q hrs rifampin. given the absence of a known standard for the active metabolite, only a semi-quantitative assessment of active metabolite concentration can be made. there was no identifiable active metabolite peak noted at baseline or after clopidogrel treatment. however, with clopidogrel and rifampin combined administration there was an active metabolite peak identified in all dogs with a mean area of . ae . . the development of the active metabolite peak was associated with an increase in the pharmacodyamic response of clopidogrel in the dogs. this is the first study in any species to document the increased formation of the active metabolite of clopidogrel in response to a strong, non-specific hepatic isozyme inducer. this increased pharmacokinetic response was associated with an increased pharmacodynamic response of clopidogrel. this data provides supportive evidence to develop therapeutic protocols to improve the pharmacodynamic response to clopidogrel in dogs that may reduce dosing requirements or correct subtherapeutic pharmacodynamic response. critical illness-related corticosteroid insufficiency (circi) has been identified in humans, foals, dogs and cats with lower-thanexpected circulating cortisol concentrations, and/or by a blunted cortisol response to acth stimulation. our purpose was to determine if circi exists in critically ill horses. endogenous plasma acth and serum cortisol concentrations, and cortisol at t and t min after . mg/kg cosyntropin, were measured by radioimmunoassay from horses with colic or systemic illness on admission, and days , and of hospitilization. horses were divided into mild, moderate, or severe illness groups based on clinicopathologic data. inappropriately low cortisol was defined as endogenous cortisol o mean- sd achieved after administration of . mg/kg cosyntropin to normal horses ( o nmol/l). inadequate delta cortisol was defined as o mean delta cortisol in normal horses after . mg/kg cosyntropin ( o nmol/l). cortisol, acth and delta cortisol were compared using anova between groups, with p o . considered significant. fifty-eight horses classified as having mild ( ), moderate ( ) and severe ( ) disease at admission had survival rates of %, % and % respectively. admission acth and cortisol concentrations were highest in severely ill horses ( ae pg/ml, ae nmol/l) compared to moderate ( ae , ae ) and mildly ill horses ( . ae . , ae ). admission cortisol concentrations were higher overall in severely ill horses (p . ), but were low in % ( / ). admission delta cortisol was low in % ( / ) of severely ill horses, and was associated with marked adrenal hemorrhage in non-survivors. severely ill horses have high cortisol and acth, but low cortisol and delta cortisol may indicate circi secondary to adrenal hemorrhage. equine pituitary pars intermedia dysfunction (ppid) is a common endocrinopathy of aged horses that results from neurodegeneration of the dopaminergic periventricular neurons that innervate the intermediate lobe of the pituitary. factors that initiate spontaneous dopaminergic neurodegenerative disease remain elusive, however accumulation of misfolded a-synuclein protein and dysfunctional protein clearance have been implicated. misfolded protein accumulation occurs due to increased protein production or decreased clearance of damaged macromolecules through the process of autophagy. while have previously demonstrated that horses with ppid have increased asynuclein in the periventricular neurons compared to controls, it remains unknown whether the protein accumulates due to increased production or decreased clearance. we hypothesized that autophagy is decreased in the pituitary neurointermediate lobe from horses with ppid compared to controls. neurointermediate lobe pituitary tissue was from collected from horses with ppid (n ) and healthy horses (n , - years). realtime pcr was used to determine the relative expression of autophagy genes (mtor, beclin , atg , atg , atg , pink, lamp ) and a-synuclein relative gene expression from horses with ppid were compared to healthy horses by t-test following log transformation. a pearson coefficient of correlation was calculated comparing a-synuclein expression with autophagy gene expression. the expression of a-synuclein, autophagy-related genes (atg , beclin, lamp ), and mtor was greater in horses with ppid than in healthy horses. age was not correlated to a-synuclein or autophagy gene expression. there was a significant positive correlation between expression of a-synuclein and beclin , atg , atg , atg , and pink, but not mtor expression. accumulation of a-synuclein protein in horses with ppid may result from increased a-synuclein expression. autophagy genes are upregulated in horses with ppid, suggesting a compensatory response, although these findings need to be confirmed by demonstrating an increased functional response. asynuclein expression was positively correlated to expression of autophagy genes except mtor, suggesting a-synuclein may stimulate autophagy in an mtor independent manner. acvim forum session a efficacy of delayed antiviral therapy against ehv- challenge. lk maxwell , ll gilliam , n pusterla , r carmichael , rw eberle , jw ritchey , tc holbrook , t gull , gb rezabek , d mcfarlane , cg macallister . oklahoma state university, stillwater, ok. university of california, davis, ca. equine herpes virus type- (ehv- ) outbreaks are often not recognized until exposed horses are at immediate risk for developing equine herpes myeloencephalopathy (ehm). the objective of this study was to determine whether delayed therapy with the antiviral drugs valacyclovir or ganciclovir could protect those horses most at risk for ehm. eighteen aged ( years) mares were randomized to treatment: no therapy (control), oral valacyclovir therapy, or intravenous ganciclovir therapy. drug administration was initiated at the onset of the second febrile phase, between days - after ehv- inoculation (pi), and continued for one week. neurological examinations were performed prior to the study and for three weeks pi. one horse was excluded from the study for failure to become febrile. body temperature was significantly lower in the ganciclovirtherapy horses as compared to control horses on days - pi (p o . ), whereas valacyclovir-therapy horses did not differ from control horses. viremia in whole blood, as determined by pcr, was also lower in the ganciclovir-therapy horses on days - pi and on day pi in the valacyclovir-therapy horses (p o . ). although antiviral drug administration did not reduce the risk of ataxia (p . ) or nasal shedding, ganciclovir therapy did decrease the severity of ataxia (p o . ) as compared to valacyclovir-therapy and control horses, where / , / , and / horses, respectively, developed at least a two grade change in ataxia. in summary, ganciclovir administration provided better protection against ehm than did valacyclovir when therapy was initiated just prior to the onset of neurological disease. equine vaccination is amongst the most important method of prophylaxis against equine influenza virus (eiv), a pathogen in which continuous antigenic drift can lead to vaccine failure. a month duration of immunity (doi) challenge infection study was conducted using commercial inactivated vaccines containing different strains of a/equine/ /influenza virus's, including innovator tm , containing kentucky/ (pfizer animal health, new york, ny), and calvenza, containing a combination of ohio/ , kentucky/ , and newmarket (boehringer ingelheim vetmedica, st. joseph, ms) . the challenge virus strain was colorado/ , the most contemporary challenge strain currently in use. the study design was a blinded, randomized challenge trial. three groups of yearling ponies, with no history or serological evidence of eiv infection were established. each group received one of three treatments: vaccination with innovator tm ; vaccination with calvenza tm ; or injection with a saline placebo. each treatment was administered times, at intervals of month between the first two treatments, and months between the second and third treatments. all ponies were challenged by nasal nebulization of x eid influenza virus a/eq/ /colorado/ months after the third treatment. clinical signs of disease, including rectal temperature, nasal discharge, anorexia, coughing, and depression, were recorded daily for days prior to challenge infection, and days post-challenge. nasal shedding of eiv was measured on the same days, using a realtime pcr test procedure. eiv-specific antibody responses were measured by elisa. differences between groups were analyzed by non-parametric repeated measures anova, and differences were declared significant when p o . . all control group ponies demonstrated clinical signs of disease consistent with eiv infection post-challenge infection, including pyrexia, nasal discharge, inappetance and partial anorexia. these signs were significantly lower in both vaccine groups; mean body temperature was elevated ( . f) for days in controls, but only days in vaccine groups. nasal shedding of eiv was detected in all ponies in all groups: over the duration of the study the calvenza group shed significantly less virus than innovator and control. over time antibody titers were significantly higher in the calvenza than the innovator group, and both were significantly greater than controls. this study demonstrated that both current commercial inactivated eiv vaccines have a duration of clinical protection of at least months after a highly pathogenic challenge with a recent eiv isolate. both antibody responses and virological protection differed between the vaccines. formulation difference between the vaccines, including the eiv antigens employed, may have contributed to this performance difference. degenerative myelopathy (dm) may be homologous to a form of amyotrophic lateral sclerosis in humans which has excitotoxic and immunologic pathogeneses described. the aims of this study were to determine (i) presence or absence of abnormalities in concentrations of csf amino acid (aa) neurotransmitters (glutamate, glycine and gÀaminobutyric acid (gaba)) and cytokines in dogs with dm and if present (ii) investigate associations with disease severity. twenty-two dogs histopathologically confirmed for dm and dogs with suspected dm based on thorough diagnostic investigations and clinically normal age-matched control dogs were included in the study. the neurological severity of the dm dogs was graded ( - ) using an established scale. csf was evaluated for presence of glutamate, glycine and gaba by high performance liquid chromatography and for gm-csf, ifn-g, il- , il- , il- , il- , il- , il- , il- , il- , ip- , kc (keratinocyte chemoattractant), mcp- (monocyte chemotactic protein- ) and tnf-a using a commercially available, canine multiplex immunoassay (millipore, billerica, ma). all data analyses were performed using sas v . (cary, nc). analyte levels were compared between dm confirmed, dm suspected and control dogs by an analysis of variance (anova). spearman correlation was used to test for correlations of analyte levels and neurological grades. all hypothesis tests were -sided with a . . there were no significant differences between individual csf analytes in dm confirmed and dm suspected dogs. glutamate levels were not significantly different between dm affected (mean . mg/ ml; range . - . ; sd . ) and control dogs (mean . mg/ ml; range . - . ; sd . ). control dogs (mean . mg/ml; range . - . ; sd . ) had significantly higher levels of gaba (p o . ) than dm dogs (mean . mg/ml; range . - . ; sd . ). control dogs (mean . mg/ml; range . - . ; sd . ) also had significantly higher glycine concentrations (p o . ) than dm dogs (mean . mg/ml; range . - . ; sd . ). dm-affected dogs also had significantly higher levels of il- (p . ), kc (p o . ) and mcp- (p . ) than control dogs. neurotransmitter levels were not significantly associated with neurological grade. kc levels were significantly higher in the least affected dogs (p . ). there were no associations with disease severity and analyte concentrations. dm affected dogs have an imbalance of csf aa concentrations creating a relatively excitotoxic environment. reports in human als confirm an imbalance between csf excitatory and inhibitory aas suggesting a pathogenic role for excitotoxicity in als. it also appears that dm affected dogs have increases in csf cytokines and chemokines suggestive of an immunologic component to the pathogenesis as is similar to als. further prospective analysis of dm is warranted to evaluate the role of treatment on csf variables. the pathogenesis of neuropathic pain (np) and syringomyelia (sm) in association with chiari-like malformation (clm) in dogs has focused on the anatomical anomalies and secondary cerebrospinal fluid (csf) flow abnormalities. neuropathic pain in humans has been associated with abnormalities of neurotransmitters such as glutamate and serotonin as well as immunologic mechanisms. the aim of this study was to investigate the csf neurotransmitter and cytokine levels in brussels griffon dogs (bgs) with clm, sm and np. as part of an mri study investigating the prevalence of sm in bgs, atlanto-occipital csf was acquired from dogs and stored at - c until analysis. all dogs underwent a neurologic exam prior to mri; osirix s software was used to measure sm and the presence of cerebellar herniation and deviation were recorded. deproteinized csf samples were analysed for presence of serotonin (ng/ml), glutamate, glycine and gaba (mg/ml) by high performance liquid chromatography. all csf samples were evaluated simultaneously for gm-csf, ifn-g, il- , il- , il- , il- , il- , il- , il- , il- , ip- , kc, mcp- and tnf-a. a commercially available, canine multiplex immunoassay (millipore, billerica, ma) was used for the cytokine analysis (pg/ml). student's t-tests were used to compare the means of neurotransmitter and cytokine values between groups with and without skull abnormalities or spinal pain. simple pearson's correlation was used to test for correlations of neurotransmitter and cytokine values with syrinx dimensions and correlations of neurotransmitter with cytokine values. all hypothesis tests were -sided and the significance level was a . . np was detected in dogs ( %); sm was present dogs ( %); and cm was detected in dogs ( %). ifn-g levels were significantly lower in dogs with np than without (p . ). there were significant positive correlations between syrinx size and il- (p . ), kc (p . ) and mcp- (p . ). there were significant negative correlations between ifn-g and syrinx height (p . ) and extent (p . ). there was a significant negative correlation between il- and syrinx height (p . ). neurotransmitter levels were not associated with skull abnormalities or spinal pain, but there was a positive correlation of glycine with il- (p . ) and mcp- with glutamate (p . ) and serotonin (p . ). the size of the syrinx in bgs with sm is associated with several cytokine elevations but only a decrease of ifn-g was associated with np. based on this study it does not appear that excitotoxicity plays a role in either sm development or np. further work is justified on the role of the immune system in cm, sm and np. current knowledge about the conservative management of disk associated cervical spondylomyelopathy (da-csm) is rather limited and mainly based on retrospectively retrieved data. the goals of this study were to prospectively evaluate the evolution of clinical signs in dogs treated conservatively for da-csm. additionally, several potential prognostic parameters and the correlation of initial clinical signs with magnetic resonance imaging (mri) and transcranial magnetic stimulation (tms) were investigated. twenty-one dogs were included. after neurological evaluation, neurological status was graded from ( normal) to ( tetraplegia). all animals underwent low-field mri and tms with measurement of onset latencies and peak-to-peak amplitudes from the extensor carpi radialis and cranial tibial muscles. from the mr images, the following dimensions were calculated: remaining spinal cord area; compression ratio; vertebral occupying ratio of the spinal cord; canal height to body height ratio (cbr); canal height to body length ratio (cblr); and the canal compromise ratio. intraparenchymal intensity (isi) changes were graded from to . all dogs were reevaluated by the same person after , , , , and months. eight of dogs ( %) experienced a positive clinical evolution with improvement of clinical signs or stabilization of mild clinical signs. all dogs with a negative clinical evolution month after diagnosis experienced a further progression of clinical signs resulting in a poor outcome. the opposite was true for all dogs with a positive clinical evolution after month. outcome was further significantly associated by the remaining spinal cord area and the vertebral canal compromise ratio. prognosis was not significantly affected by clinical presentation or tms. progression of clinical signs, in unsuccessfully treated dogs, was generally characterized by a rapid and dramatic deterioration of neurological status. there were no significant correlations between clinical presentation, mri and tms. two dogs underwent necropsy and histopathological examination. this revealed in both cases chronic wallerian degeneration and segmental myelomalacia. the results of this study suggest that conservative treatment of da-csm is associated with a rather guarded prognosis. clinical evolution month after diagnosis and selected mri parameters can be considered as prognostic indicators. the lack of correlation between clinical presentation and outcome, medical imaging and electrophysiological evaluation is disturbing and warrants further investigation. a mri-guided stereotactic brain biopsy system has not been clinically evaluated in dogs. the purpose of this study was to determine the ability of the brainsight tm system to obtain histologically diagnostic samples and access the impact of this procedure on neurologic status for hours after the biopsy. five dogs with mri definable lesions in the brain have been enrolled. breeds included a pitbull mix, pembroke welsh corgi, french bulldog, border terrier and west highland white terrier. age ranged from - years. weight ranged from . - . kg.dogs presented with seizures (n ), ambulatory paresis(n ), unilateral blindness(n ) and head tilt(n ). one dog had a normal neurologic exam. lesions chosen for biopsy were in the olfactory and/or frontal lobes (n ), parietal lobe(n ), and pyriform lobe(n ). lesions were between - mm in diameter. all lesions were well-circumscribed and contrast enhancing except for one. histologic diagnosis of meningioma(n ) and granulomatous meningoencephalitis(n ) were made. the poorly-circumscribed, non-contrast enhancing frontal mass yielded non-specific necrosis. following biopsy, three dogs returned to pre-biopsy neurologic status within hours. the french bulldog took hours to return to previous neurologic status due to brachycephalic syndrome that required oxygen support. one dog had acute respiratory arrest hours post-biopsy. necropsy is pending. these results suggest that this mri-guided biopsy system can provide an accurate histologic diagnosis of brain lesions. biopsies of poorly-circumscribed and non-contrast enhancing brain lesions may be less diagnostic. further evaluation is on-going to determine the true diagnostic yield and complication rate of this procedure. concurrent malformations of the craniocervical junction are commonly identified in humans with chiari type i malformation. recent evidence suggests such craniocervical junction abnormalities (cjas) also occur in dogs suspected of having chiari-like malformation (clm). the purpose of this study was to objectively describe morphometric features of the craniocervical junction region of dogs with suspected clm and to investigate for associations between these features and the occurrence of other malformations in this region. magnetic resonance (mr) and computed tomographic (ct) images from dogs with clm were evaluated. three regions of neural tissue compression were assessed: cerebellar compression (cc); ventral compression at the c /c articulation, termed ''medullary kinking'' (mk); and dorsal compression (dc) at the c /c articulation. a compression index (ci) was calculated for all abnormal regions for each dog. multiple logistic regression analysis was performed (p o . ) to ascertain whether ci values for the different regions of compression were associated with the incidence of other craniocervical junction abnormalities. % of dogs had mk and % of dogs had dc. % of dogs also had evidence of atlanto-occipital overlapping (aoo medical infrared imaging (mii) is a non-invasive diagnostic imaging technique that measures skin surface temperature and generates thermal pattern maps based on predetermined color scales. because skin temperature, dependent on regional perfusion, is under direct control of the sympathetic nervous system, mii provides information about the function of the autonomic nervous system. because of recent advances in technology and lack of sedation needed to image patients, mii has potential use as a screening test for a variety of conditions that may result in autonomic dysregulation like chiari-like malformation in dogs (clm). the purposes of this study were to establish a mii protocol for dogs suspected of having clm, to identify thermal imaging patterns for various regions of interest (roi), to evaluate changes in thermal patterns and compare the results to those of mri findings, considered the standard for diagnosing clm in dogs. one hundred and five cavalier king charles spaniel dogs with clinical signs attributable to clm and confirmed clm with mri were evaluated with a complete blood count and chemistry profile, examination by a board certified surgeon/neurologist, multidetector ct scan of the craniocervical junction, whole body mri and mii. the protocol for thermal imaging included cranial and caudal views of the body, full lateral right and left body views, dorsal views of the head and body, and right and left lateral views of the head. thermal patterns were assessed with custom image recognition software. after each dog was imaged awake, general anesthesia was administered and the dogs re-imaged using the same protocol. mri findings in dogs with severe or moderate cerebellar compression and cerebellar herniation were compared with mii results. the top of head and front of head roi were . % and . % successful in identifying dogs with clm. based on these preliminary findings, mii may be a viable screening tool to detect clm in dogs. medical infrared imaging (mii) is an imaging technique that measures skin surface temperature derived from cutaneous perfusion and generates thermal pattern maps based on color scales. mii has been used as a test for a variety of conditions that cause autonomic dysregulation resulting in altered cutaneous perfusion. acute thoracolumbar intervertebral disk disease (tlivdd) is common in dogs. the purpose of this study was to: ) determine the success of mii in identifying dogs with tlivdd, ) compare the mii localization with mri results and surgical findings ) determine if the mii pattern returns to that of normal dogs following decompression surgery. small breed chondodystrophic dogs with tlivdd confirmed with mri and dogs with no tlivdd were evaluated with mri and mii. regions correlating with the intervertebral disk spaces were analyzed for average temperatures and thermographic patterns. thermal patterns were assessed with computer recognition pattern analysis (crpa) software. dogs were re-evaluated weeks after surgery using the same protocol. when analyzing temperature averages over a region, no significant difference was found between control and affected dogs. crpa was % successful in differentiating normal from affected dogs. crpa was % successful in identifying the intervertebral disk space when compared with mri and surgical findings. based on these findings, mii may be a viable screening tool to detect tlivdd in dogs. microglia physiologically shows regional topographical differences in immunophenotype and function within the central nervous system indicating the endowment for a prompt response to pathological stimuli such as trauma. spinal cord injuries (sci) consist of a primary injury encompassing the mechanical impact and the ''secondary wave'' of injury occurring minutes to weeks later and comprising various consecutive effects such as increased production of free radicals, excessive release of excitatory neurotransmitters and inflammatory reactions. activated microglia has the potential to perform some of these reactions, their contribution to the secondary wave is therefore controversially discussed. it has to be considered a double-edged sword as both, beneficial and deleterious effects have been attributed to these cells. the purpose of the presented study was to assess microglial involvement, particularly in the ''secondary wave'' following sci. microglia from dogs with sci was isolated and characterized ex vivo in terms of morphology, immunophenotype, and function by flow cytometry. the results were compared to region-specific findings obtained from healthy control dogs (n ). the histopathological exam confirmed the diagnosis of sci in the cervical (n ) and thoracolumbar (n ) spinal cord, and revealed a significant activation of microglia/ macrophages and upregulation of myelinophagia in dogs with sci days or longer prior to euthanasia. microglial ex vivo examination showed significantly increased expressions of b - , b - , mhc ii, cd c, icam- , cd , cd , and cd , and significantly enhanced phagocytosis and generation of reactive oxygen species (ros) in sci compared to healthy controls. microglial cells seem to be highly activated following sci with an immunophenotype indicating their active role in co-stimulation of t cells, in leukocyte adhesion and aggregation, and in lipid and glycolipid presentation. microglial phagocytosis might play a pivotal role in removal of injured or damaged cells and initialize subsequent healing processes. however, as ros can be directly neurotoxic an enhanced microglial generation might lead to bystander damage of the traumatized spinal cord and might therefore add to the deleterious effects of the secondary wave. modulating the microglial response in sci might be a valuable novel therapeutic strategy alleviating further damage to the spinal cord. thymidine kinase (tk) is a soluble biomarker present in s-phase of a salvage pathway for dna synthesis, and can be measured in serum. tk activity correlates with stage, prognosis, and relapse in canine and human lymphoma. we previously reported the results of a pilot study evaluating tk activity in archived canine osteosarcoma, transitional cell carcinoma, and hemangiosarcoma (hsa) sera, and found elevated tk activity in % of canine hsa sera evaluated. the purpose of this study was to prospectively evaluate serum tk activity in a large number of dogs presenting to emergency clinics with hemoabdomen and a splenic mass, to determine if tk activity could be used as a noninvasive means to distinguish hsa versus benign conditions in this population. dogs presenting with hemoabdomen and a splenic mass identified on ultrasound examination were studied. serum was collected prior to anesthesia, euthanasia or surgical intervention and frozen until batch analysis. tissue from all patients was evaluated histologically by a single pathologist. sera from age-matched normal dogs comprised a control population. an elisa using azidothymidine as a tk substrate was used. comparisons between groups were made using -tailed student t-tests, and receiver-operator characteristic (roc) curves were generated. sixty-two patients and normal controls were studied. there were dogs with hsa, dogs with other splenic neoplasia, and dogs with benign diseases. using a training set of normal dogs, a cutoff of . u/l was established from the roc curve. tk activity was significantly higher (p o . ) in dogs with hsa than in the validation set of normal dogs (mean /Àsd . /À . and . /À . respectively), but not between dogs with hsa and benign splenic disease (mean /Àsd . /À . , p . ). using a cutoff of . u/l, tk activity demonstrated a sensitivity of . , specificity of . , positive predictive value of . and negative predictive value of . for distinguishing hsa versus benign splenic disease. when interval thresholds of o . and . u/l were used together, diagnostic utility was markedly increased for distinguishing both hsa versus normal and hsa versus benign disease. in conclusion, serum tk evaluation may assist in detection of canine hsa, and may also discriminate between benign disease and hsa in dogs with hemoabdomen and a splenic mass. t cell chronic lymphocytic leukemia (cll) is a heterogeneous disease that affects a number of dog breeds. cll patients have variable disease outcomes. the objectives of this study were to use gene expression profiling of cd t cell leukemias with variable outcomes in order to identify markers that can be used in routine diagnostic tests to distinguish good from poor prognosis disease, and to identify potential targets for novel therapy. gene expression profiling of cd t cell leukemias ( good, poor prognosis) was conducted. samples from normal dogs were also profiled. several differentially expressed genes were found including cd , cd , and cd . these were selected for further study using flow cytometry to determine expression of protein on the cell surface. seventy nine cases of cd t cell leukemia were screened for cd expression. forty seven had associated outcome information. based on analysis to date, cd expression as assessed by flow cytometry does not appear to provide prognostic information. a monoclonal antibody to cd was recently made available. to date patients with cd t cell leukemia have been profiled. cd is variably expressed on t cell leukemias compared to normal cd t cells. cd is the receptor for interleukin . cyclosporin, a commonly used immunosuppressive drug, inhibits il- production, and has been used to treat a subset of t cell leukemias in people. thus, the finding that cd is up regulated on t cell leukemias compared with normal t cells suggests a possible new therapeutic avenue. recent molecular studies have revealed a highly complex bacterial microbiota in the intestine of dogs. there is mounting evidence that microbes play an important role in the pathogenesis of acute and chronic enteropathies of dogs, including idiopathic inflammatory bowel disease (ibd). similarly, compositional changes of the intestinal bacterial ecosystem have been associated with ibd in humans. the aim of this study was to characterize the bacterial microbiota in dogs with various gastrointestinal disorders using a next generation sequencing technique. fecal samples were obtained from healthy dogs (n ), dogs with acute uncomplicated diarrhea (n ), dogs with acute hemorrhagic diarrhea (ahd; n ), and dogs with active (n ) and therapeutically controlled ibd (n ). the bacterial composition was analyzed by massive parallel s rrna gene -pyrosequencing. differences between groups were analyzed using mann-whitney u tests and kruskal-wallis tests followed by dunn's multiple comparison tests. statistical significance was set at p o . . significant differences in the proportions of several bacterial groups were identified between healthy and diseased dogs. dogs with gastrointestinal disease had significantly higher proportions of proteobacteria (p o . ). proportions of firmicutes were lower in diseased dogs, but this difference did not reach significance (p . ). within the firmicutes the most notable findings were decreases in bacterial groups belonging to clostridium clusters iv and xiva (i.e., ruminococcus, dorea, and faecalibacterium spp.; p o . for all). dogs with ahd had the most profound changes of the microbiota, followed by dogs with acute uncomplicated diarrhea, and dogs with active ibd. faecalibacterium spp. was the bacterial group most prominently depleted in dogs with active ibd, but was not significantly different between healthy dogs and dogs with therapeutically controlled ibd (p . ). results of this study revealed bacterial dysbiosis in fecal samples of dogs with various gi disorders. bacterial changes were more profound in dogs with severe disease, but were not identified in dogs with therapeutically controlled ibd, suggesting that the microbiota is stable in non-active disease. the bacterial groups identified are considered to be important short chain fatty acid producers and may serve as candidates for the diagnosis or therapeutic monitoring of gi disease. future studies are necessary to determine if these microbial changes correlate with functional changes in the intestinal microbiota. ciprofloxacin oral tablets, available in a generic formulation for people, are widely used for treatment in dogs. oral absorption data for ciprofloxacin in dogs has been variable, and too limited to guide accurate dosing. subsequently, published doses for dogs in veterinary formularies have varied from to mg/kg. this study was undertaken to explore the factors that may affect oral absorption of generic ciprofloxacin in dogs, and to derive a pharmacokinetic-based dose for treating susceptible bacteria. six healthy adult beagle dogs were used for the study ( . kg mean weight). after placing jugular vein catheters for collecting blood samples, these dogs were administered either a single oral dose of ciprofloxacin ( mg tablet; mean dose mg/kg), or an intravenous (iv) dose ( mg/kg; mg/ml solution). a randomized crossover design was used with a washout time between treatments. blood was collected for plasma drug analysis for hours. ciprofloxacin concentration in plasma was analyzed using high pressure liquid chromatography (hplc) and pharmacokinetics analyzed using a computer program. oral absorption was also evaluated via deconvolution analysis. the oral dose was well-tolerated, but the iv dose produced transient vomiting and depression in some dogs. after the oral dose, the peak plasma concentration (c max ) was . mg/ ml (cv . %), terminal half-life (t / ) . hr (cv . %), auc . mg Á hr/ml (cv . %), and systemic absorption (f) . % (cv . %). after the iv dose, the t / was . hr (cv . %), systemic clearance . l/kg/hr (cv . %), and volume of distribution . l/kg (cv . %). after examining the pharmacokinetic results from the oral dose, it was apparent that oral ciprofloxacin was absorbed well in some dogs (approximately %), but poorly in others (approximately %). to explore the factors that may have affected oral absorption, two high absorbers and two low absorbers were administered an additional oral dose as a mg/ml solution ( mg total dose) via gastric tube. after administration of the oral solution, the plasma concentrations were more uniform and consistent among dogs. absorption of the oral solution of ciprofloxacin was . % (cv %) with a t / of . (cv . %) hr and c max of . mg/ml (cv . %). therefore, it appears that inconsistent oral absorption of ciprofloxacin in some dogs may be formulation-dependent, and affected by tablet dissolution in the canine small intestine. doses were calculated using the data for oral tablets in these dogs. the pharmacokinetic-pharmacodynamic (pk-pd) target was an auc/ mic ratio of . because of the wide range in oral absorption of tablets, a dose to reach the pk-pd target ranged from canine distemper (cd) is a highly contagious, acute or subacute systemic viral disease of dogs and other carnivores which can be controlled efficiently by the use of modified live-virus (mlv) vaccines. however, mlv strains do cross-react with molecular diagnostic tests and cause significant confusion for clinicians. the purpose of this study was to use quantitative real-time pcr viral load information to differentiate between vaccine virus used in mlv vaccines and wildtype infections in dogs. a real-time pcr test for cd virus (cdv) based on the p gene for phosphoprotein was used to determine viral loads in vaccinated and wildtype infected animals. a total of respiratory mucosal swab samples from mlv vaccinated and asymptomatic dogs were obtained within the first weeks after mlv vaccination. based on the viral load in vaccinated animals, a cutoff value was established for the differentiation of dogs with clinical signs of respiratory distress and presumably infected with a wildtype strain of cdv. two hundred clinical cases with known clinical and vaccination histories were analyzed to validate the cutoff value. the cdv real-time pcr proved to be of high analytical and diagnostic sensitivity: a standard curve was established using known numbers of cdv molecules to allow absolute quantitative cdv viral load data. the limit of detection was in the single molecule range while the limit of quantitation was established at around molecules per pcr reaction. a comparison to ifa showed real-time pcr to be % more sensitive. the cdv viral load in vaccinated animals averaged , viral particles per swab. a cutoff value of , viral particles was calculated by adding standard deviations to the average value. this cutoff value correctly detected . % of the vaccinated samples. acutely infected dogs with cdv compatible clinical signs have high viral loads normally several logs higher than the cutoff value. in dogs with clinical distress, recent cdv mlv vaccination but viral loads below the cutoff value, other infectious agents were detected by using a panel of real-time pcr tests. testing additional infectious agents in clinical settings is important in order to explain clinical signs when viral loads below cutoff values indicate that cdv is not the cause of clinical signs. in conclusion, quantitative real-time pcr is a sensitive, rapid and reliable test regardless of recent vaccination. the use of a cutoff value will be of significant help to discriminate between vaccine interference and wildtype infection in clinical settings. feline ureteral obstructions are a common urinary dilemma and traditional therapy is associated with substantial morbidity/mortality. feline nephrostomy tubes are reported as being effective when pelvic drainage is required. the biggest limitation is externalized drainage, requiring careful management to prevent infection/dislodgement. the development of an indwelling ureteral bypass using a combination locking-loop nephrostomy/cystostomy tube was modified from humans, resulting in permanent indwelling drainage, reduced complications, and improved quality of life. the objective is to describe the technical and clinical outcome using a novel device called a subcutaneous ureteral bypass (sub) in cats with ureteral obstructions. fifteen cats ( kidneys) had a sub placed for: ureterolithiasis ( ), ureteral stricture ( /À stones) ( ), and ureteral stent rejection ( ). the median pre-and post-procedure creatinine was mg/dl (range: . - ) and . mg/dl (range: . - ), respectively. the median pelvis diameter pre and post-procedure were (range: - ) and mm (range . - ), respectively. six french tubes were placed in , and fr. in . the bypass remained indwelling for a median of days (range - ). there were major complications resulting in nephrostomy tube dislodgement ( ) and port leakage ( ) days after surgery. one patient with severe coagulopathy developed a clot which resolved with tpa infusion through the port. no sub got occluded/obstructed long-term. overall, the use of a sub for cats with ureteral obstructions can be considered a functional option when other therapies have failed or are contraindicated, but shtime. oxidative stress is considered central to the pathogenesis of many systemic diseases. in humans, biomarkers of oxidative stress, antioxidant depletion and lipid peroxidation, have been correlated with disease severity and associated with poor clinical outcomes. therapeutic antioxidant supplementation with nac in glutathione (gsh)-deficient patients has shown clinical benefits, including repletion of intracellular gsh levels. we have shown that clinically ill dogs are gsh-deficient, and that gsh deficiency correlates with mortality, but it is not clear whether there are direct benefits of antioxidant intervention in these patients. the purpose of this randomized, investigator-blinded, placebo-controlled, prospective study was to evaluate the effect of nac to normalize blood antioxidants (rbc reduced gsh (rbc gsh), plasma cysteine (cys), serum vitamin e (vit e), and whole blood selenium (se)), reduce lipid peroxidation (urine isoprostane/creatinine ratio (u i/ c)), and improve illness scores (spi ) and outcome (survival to discharge) in clinically ill dogs. clinically ill client-owned dogs, admitted to the uw veterinary medical teaching hospital that did not receive blood transfusions, tpn, vitamins, or antioxidants were eligible for the study. dogs enrolled in the study were randomized to receive iv infusions q. h. of either nac (  mg/kg and  mg/kg) or equal volumes of % dextrose (placebo) over hours. at the time of enrollment, and hours following the final hour infusion, blood and urine were collected to quantify rbc gsh, cys, vit e, and se concentrations; u i/c ratios; and calculate spi scores. rbc gsh and cys concentrations were quantified by hplc. commercially available hplc, atomic absorption spectroscopy, and eia were used to quantify vit e, se, and u i/c ratios, respectively. nonparametric statistical analyses were used, with results reported as medians and p o . considered significant. sixty-one ill dogs were randomized to either nac (n ) or placebo (n ). overall this group of ill dogs had significantly decreased rbc gsh ( . vs. . mm; p . ), vit e ( vs. mg/ml; p . ), and se ( . vs. . mg/ml; p . ) levels and elevated u i/c ratios ( vs. pg/mg; p . ) in comparison to healthy control dogs. dogs in the placebo group showed a significant further decrease in rbc gsh over the next hours ( . to . ; p . ). nac supplementation significantly increased plasma cys levels ( . to . mm; p o . ), and prevented a further decline in rbc gsh ( . to . mm; p . ). however, serum vit e ( vs. mg/ml), se ( . vs. . mg/ ml), u i/c ratios ( vs. pg/mg), spi scores ( . vs. . ), and outcome ( % vs. %) were not significantly different between the nac and placebo groups after treatment. the results of this study further support that clinically ill dogs experience oxidative stress, and suggest that antioxidant supplementation with nac within the first hours of hospitalization prevents further rbc gsh depletion. further studies are necessary to investigate whether longer duration or combined antioxidant supplementation normalizes the redox state and impacts long-term outcome. diabetes mellitus in cats is very similar to type ii diabetes in humans, preceded by a period of insulin resistance. evaluating insulin resistance in a cat is a time consuming, expensive, and difficult procedure. there is a need for a simple biomarker based test predictive of insulin resistance. there is a biomarker based assay predicative of insulin resistance in humans. the purpose of this study was to evaluate the utility of this assay in overweight cats and show improvement in insulin sensitivity following weight loss and weight maintenance. the insulin resistance assay is based on the quantitative analysis of metabolites ( -hydroxybuterate, creatine, palmitate, decanoylcarnitine, and oleoyl-lpc). a proprietary algorithm (metabolon, inc, durham nc) was used to generate a predictive rd (rate of disposal) value (normal range in cats . - . ). individuals with an rd value less than will have a greater than % chance of being insulin resistant and an rd value less than will have a greater than % chance of being insulin resistant. initial studies demonstrated that the rd values indicating insulin resistance in cats correlated with age, obesity and severity of diabetes as determined by histopathology and blood glucose levels. in a feeding study of cats ( % vs. o % body fat) rd values improved from . ae . to . . (p . ). during weight maintenance, % body fat for months, further improvement was observed (rd, . . (p . e- )). these results demonstrate that long term weight maintenance following weight loss is critical for increasing insulin sensitivity in cats. the use of monoclonal antibodies and antibody fragments to directly target tumor antigens and neutralize their growth factors has shown promising results in human clinical trials. however, these targeted approaches have not been possible in dogs since specific tumor antigens have not been identified, monoclonal antibodies of canine origin are not available and the efficacy of xenogeneic antibodies in the dog is limited by neutralizing antibody responses. to overcome these obstacles, we have generated canine antibody phage display libraries from canine splenocytes. these libraries consist of single chain variable fragments (scfv) comprised of canine variable heavy (vh) and variable light (vl) immunoglobulin chains displayed on the surface of bacteriophage (fig. ) . the antigen specificity within these libraries is diverse and recapitulates the antigen-experienced immunoglobulin repertoire of the dog. we can now use simple panning techniques to isolate scfv of canine origin that bind to either known targets or unknown targets which can then be identified using standard molecular techniques. canine hsa is a highly aggressive malignancy of vascular endothelial cells that affects large breed dogs. although there are no confirmed immunological targets for hsa, serum levels of vascular endothelial growth factor (vegf) are elevated in these patients and, as in many human cancers, vegf may represent an important therapeutic target for neutralization. we used simple panning techniques to screen canine scfv libraries generated from the spleens of dogs with hsa against canine vegf and successfully isolated scfv clones that bind and neutralize canine vegf in vitro. these scfvs are now being taken into a murine model of canine hsa to determine whether they can inhibit tumor growth and metastases. in addition, we have panned the same antigen-experienced scfv phage display libraries against allogeneic primary canine hsa cells of low passage number to isolate canine-derived antibody fragments that can target malignant endothelial cell surface molecules. early results demonstrate enrichment of scfv phage libraries for malignant endothelial cell binders. these scfv can be readily linked to chemotherapeutic agents or other toxins and used to deliver high doses directly to the malignant cell. this novel approach aims to reduce side effects of systemic chemotherapy and augment therapeutic response. calcitriol, (vitamin d ), has antineoplastic activity and acts synergistically to potentiate the antitumor activity of a diverse array of chemotherapeutics. ccnu, vinblastine, corticosteroids, and tyrosine kinase inhibitors, are used to treat canine mast cell tumors (mct). vitamin d receptor is expressed in the majority of canine mcts, suggesting a role for calcitriol in the management of dogs with these tumors. the purpose of our study was to examine the in vitro effects of calcitriol in combination with ccnu, vinblastine, imatinib, or toceranib on canine mastocytoma c cells. also, we evaluated the antitumor activity of dn , a highly concentrated oral formulation of calcitriol, as single-agent treatment in dogs with naturally occurring mcts. c cells were incubated with serial dilutions of calcitriol ( . - nm). twenty-four hours later, cells were then treated with vehicle control or serial dilutions of ccnu ( . - um), vinblastine ( . - nm), imatinib ( . - . nm), or toceranib ( . - nm). cell viability was assessed with an mtt assay after hours and data was used to derive a combination index (ci: values o , , indicate synergism, additivity, antagonism, respectively). in the phase ii clinical trial, dogs were eligible if they had at least measurable, histologically confirmed, mct. calcitriol was administered orally. recist criteria were used to assess tumor response. calcitriol, ccnu, vinblastine, imatinib, and toceranib each suppressed c cell viability in a dose-dependent manner. ci values o were obtained for calcitriol ( . - . nm) combined with ccnu ( and um), vinblastine ( . and nm), imatinib ( . - . nm) and toceranib ( . - . nm). due to the occurrence of toxicity (vomiting, anorexia, hypercalcemia), the phase ii trial was terminated early; only of planned patients were treated. one dog with a metastatic muzzle mct had a complete response that lasted days. three dogs achieved partial response lasting from - days. in summary, our in vitro data demonstrate that calcitriol combined with ccnu, vinblastine, imatinib or toceranib has synergistic effects on c mastocytoma cells. antitumor responses were observed in dogs with spontaneously occurring mcts treated orally with single-agent calcitriol, but the frequency of adverse effects was high. together these results suggest calcitriol combination therapies might have significant clinical utility in the treatment of canine mcts but refinement of the calcitriol-dosing regimen must be done. cyclosporine is a potent immunosuppressive agent used to treat many canine inflammatory and immune-mediated diseases. cyclosporine has gained popularity as an immunosuppressive agent because of a favorable toxicity profile compared to many other immunosuppressive agents. optimal dosing regimens for cyclosporine in the dog remain unclear, primarily because standard methods that monitor effectiveness of immunosuppression have not been established. pharmacokinetic testing is currently used during treatment with oral cyclosporine to adjust doses based on measurement of blood drug levels. individual patients, however, often demonstrate marked variations in blood drug levels while on similar oral doses of cyclosporine, and can also demonstrate different clinical responses even at comparable drug levels, making correlation of blood cyclosporine levels and degree of disease control extremely difficult. pharmacodynamic testing offers an alternative method for regulating cyclosporine dosing by objectively measuring the effects of cyclosporine on t-cells, the drug's main cellular target in the body. our acvim foundation-funded research has focused on developing and evaluating a comprehensive panel of biomarkers of immunosuppression that can be utilized for pharmacodynamic monitoring during treatment with cyclosporine and other immunosuppressive agents that affect t-cell function. we have completed several studies using flow cytometry to evaluate activated t-cell expression of surface molecules (cd & cd ) and cytokines (il- , ifn-g & il- ) as potential biomarkers. our first study was an in vitro study evaluating expression of surface molecules and cytokines in canine t-cells exposed to varying concentrations of cyclosporine. this study established consistent drug-associated suppression of the cytokines il- , ifn-g and il- . our second study was an in vivo study in normal dogs evaluating the effects of two doses of oral cyclosporine, a high dose considered to be reliably immunosuppressive (starting dose mg/kg bid, titrated upwards as needed to attain trough drug blood levels of at least ng/ml) and a lower dose used to treat atopy ( mg/kg sid), on t-cell expression of these three cytokines. significant suppression of il- and ifn-g expression was seen at the high cyclosporine dose, while at the lower dose only ifn-g expression was suppressed. because tcell expression of il- was not significantly suppressed at the high cyclosporine dose, il- was not evaluated at the lower drug dose. because of specialized sample handling requirements, flow cytometry is not as practitioner friendly as other assays (such as pcr) for routine use in pharmacodynamic testing. we have therefore conducted an in vitro study comparing the effects of cyclosporine on activated t-cell expression of il- and ifn-g using flow cytometry and qrt-pcr, and demonstrated dose dependent and comparable suppression of il- and ifn-g using either methodology. we are currently evaluating, using qrt-pcr, the effects of oral cyclosporine on t-cell expression of il- and ifn-g in normal dogs prior to moving on to pharmacodynamic trials in our clinic patients. effect of hypothyroidism on reproduction in bitches. dl panciera , bj purswell , ka kolster , sr werre . departments of small animal clinical sciences, large animal clinical sciences, and laboratory for study design and data analysis, virginia-maryland regional college of veterinary medicine, virginia tech, blacksburg, va. numerous reproductive abnormalities, including irregular interestrous period, anestrus, and infertility have been attributed to hypothyroidism. we previously documented reduced fertility and lower birth weight and increased periparturient mortality in pups born to bitches with experimentally-induced hypothyroidism for a median duration of weeks. the purpose of this study was to evaluate reproductive function in these same bitches after hypothyroidism was treated with a replacement dose of levothyroxine. twelve multiparous bitches were studied. hypothyroidism was induced in dogs by administration of mci/kg i. hypothyroidism was confirmed by finding serum t concentrations before and hours after iv administration of human recombinant tsh that were o nmol/l. levothyroxine ( . mg/kd q h) was administered to all hypothyroid bitches. six bitches served as euthyroid, untreated controls. dogs were evaluated daily for signs of estrus and were bred by of males when serum progesterone was ! ng/ml. interestrous interval, gestation length, strength and duration of contractions during whelping, time between pups, number of live pups and stillbirths, viability of pups at birth, weight of pups, and periparturient mortality were recorded. the student's t-test and anova were used to compare differences between control and hypothyroid bitches for continuous, normally distributed data. the wilcoxon rank sum test was used to analyze data between groups that was not normally distributed. the mean duration of hypothyroidism prior to levothyroxine administration was ae . weeks. breeding took place after levothyroxine treatment for ae . weeks in the hypothyroid group. all dogs in the hypothyroid group and / control dogs were pregnant, while / hypothyroid and all control bitches became pregnant prior to levothyroxine administration. no difference in interestrus interval or gestation length was noted between groups. during whelping, no difference in strength of contractions, contraction duration, interval between pups, or viability scores of pups was found between groups. litter size, birth weight and peirparturient mortality were similar between groups. levothyroxine administration reverses the detrimental effects of hypothyroidism on fertility and neonatal health. racing sled dogs have a high prevalence of exercise-induced gastric erosions/ulcers, with reports ranging from - % of dogs running at least miles in a day or less. omeprazole reduces the severity of, but does not completely prevent, gastritis under racing conditions, and can be difficult to administer under these conditions. famotidine can be administered in food, but has only demonstrated efficacy under less intense training conditions. the purpose of these studies was to evaluate different acid suppression strategies under racing conditions for the prevention of exercise-induced gastritis. experiment # was a randomized placebo-controlled study using sled dogs ( - years) competing in a mile race over - h. treatment groups were famotidine (approx mg/kg qd) or no treatment, beginning days prior to the start of the race and proceeding until gastroscopy was performed h after the race. experiment # was a randomized positive-control study using sled dogs ( - years) running a mock race of miles in h. dogs were divided into omeprazole (approx mg/kg qd, administered min prior to a meal) or famotidine (approx mg/kg bid) groups beginning days prior to the exercise challenge and continuing for h after completion. gastroscopy was performed immediately prior to the start of dosing and h after completion of the exercise. in all cases, mucosal appearance during gastroscopy was blindly scored using previously described scoring system. famotidine ( mg/kg qd) reduced the prevalence of clinicallyrelevant, exercise-induced gastric lesions compared to no treatment ( / vs / , p . ). compared to famotidine at mg/kg bid, omeprazole significantly decreased the severity ( . vs . , p . ) and prevalence ( / vs / , p . ) of gastric lesions. although famotidine provides some benefit in the prevention of exercise-induced gastric lesions, neither the recommended dose nor the higher dose were considered acceptable in the prevention of exerciseinduced gastritis as between - % of the dogs receiving famotidine had clinically significant lesions. a previous study examining omeprazole under racing conditions, but without careful administration on an empty stomach, resulted in a % prevalence of clinically significant gastric lesions. however, the bioavailability of omeprazole is reduced in the presence of food, and when the daily administration of the drug is carefully scheduled to coincide with an empty stomach, the resulting prevalence of clinically significant lesions induced by racing-intensity exercise is reduced to just over %. the conclusions of these studies are that omeprazole is superior to famotidine in preventing gastritis in racing sled dogs during competition. routine administration of omeprazole is recommended to prevent stress-associated gastric disease in exercising and racing alaskan sled dogs. mares may be an important source of environmental contamination with rhodococcus equi on breeding farms. attempts to reduce fecal shedding of r equi by the mare and the effects of the mare's fecal r equi concentration on airborne concentrations in the foaling stall have not been previously reported. twenty-one arabian mares were treated daily with either oral gallium nitrate or placebo in a randomized double-blind study. fecal samples were collected at day of gestation (time ), the week before foaling (time ), and the week after foaling (time ). airborne concentration of r equi were measured in the stall within hours post foaling using a microbial air sampling system into which standard ( -mm) culture plates with a media selective for r. equi have been loaded. concentration of total r equi were determined by morphological characteristics. the concentration of virulent r equi was determined using a modified colony immunoblot method. concentrations of total and virulent r equi were compared among mares to examine effects of treatment, time, and treatment by time interaction. there were significant (p o . ) effects of treatment that depended on time of sample collection. at sample times and there were no significant differences between groups in the fecal concentration of virulent r equi. at time concentrations of virulent r equi were significantly lower among mares in the treatment group (p o . ) compared to control. effects of time depended significantly on groups: for the control group, there were no significant effects of time. for the treatment group, concentrations tended to decrease over time, and concentrations at time were significantly (p o . ) lower than those at time . no other differences among times for concentrations in the treatment group were statistically significant. there were no significant effects of treatment, sample time, or their interaction on the concentration of total r equi between groups; however, the pattern for these data was similar to that observed for the virulent isolates. no significant differences were determined between treatment groups for airborne concentrations of virulent or total r equi. treatment of mares with oral gallium nitrate significantly reduced the fecal concentrations of virulent r equi over time, but had no impact on the airborne concentration of r equi shortly after foaling. the purpose of this study was to evaluate the protein profile of bronchoalveolar lavage fluid (balf) in horses affected with recurrent airway obstruction (rao) and in control horses using proteomics and western blot techniques. rao-affected (n ) and control horses (n ) were subjected to an experimental exposure trial; when the rao-affected horses showed clinical signs of disease, balf was collected from all horses. balf was also collected from client-owned rao-affected horses (n ) with naturally-occurring clinical signs of disease and client-owned control horses (n ) from the same environments. the balf from the experimental exposure trial horses was subjected to trypsin digestion and proteomics analysis with mass spectrometry (ms). peaks detected with ms were identified using tandem ms analysis and database searches. western blot was used to confirm the identity and expression levels of two proteins identified using proteomics techniques in the balf of all horses. data from ms experiments were analyzed with the student's t-test to compare peak intensity between rao-affected and control horses. western blot band density data was analyzed with the kruskal-wallis anova for comparison between groups of horses. significance level was set at p o . . with ms proteomic analysis of the balf from the experimental exposure trial horses, total peaks (peptides) were identified. of these peaks, were differentially expressed between the rao-affected ( over-expressed) and control horses ( over-expressed). identifications were made for balf proteins. transferrin and secretoglobin were chosen for validation with western blot. proteomics indicated that secretoglobin was not differentially expressed between the experimental exposure trial group; this was confirmed with western blot analysis. western blot also showed that clientowned rao-affected horses had lower secretoglobin expression than client-owned control horses and control horses before experimental exposure. according to the proteomics data, transferrin was over-expressed in control horses after experimental exposure compared to rao-affected horses. while the western blot analysis did not show a statistically significant difference in this comparison, transferrin was significantly over-expressed in control horses before experimental exposure compared to client-owned rao-affected horses. in addition, both secretoglobin and transferrin band densities on western blot were negatively correlated with airway obstruction and neutrophilic pulmonary inflammation. this study demonstrates that proteomics techniques can be used in the investigation of equine balf proteins. the proteins identified as differentially expressed between rao-affected and control horses in this study including, but not limited to, secretoglobin and transferrin should undergo further evaluation for their use as biomarkers of rao, and as potential targets of new therapeutic agents for rao. cardiotoxic effects of rattlesnake venom in the horse are not well defined. the first aim of this study was to document cardiac damage in naturally envenomated horses. twenty horses with clinical diagnosis of snake bite were included. a snake venom elisa was utilized to confirm envenomation when possible. serum and plasma were collected at selected intervals. plasma was assayed for cardiac troponin i (ctni) using a flurometric assay (stratus cs s , dade behring). holter monitors (zymed s , philips) were placed at admission, week and month post presentation. echocardiography was performed on available horses - months after envenomation. the second aim of this study was to investigate potential mechanisms of the cardiac damage. serum samples were assayed for tnfalpha using a commercial assay (endogen). antibody titers to crotalus atrox venom were measured at admission, week and month after natural envenomation and compared to titers in vaccinated horses (crotalus atrox toxoid, red rock biologics). a significant number of horses showed elevations in ctni (p o . ) at one or more time point indicating myocardial damage. holter readings revealed the presence of arrhythmias or persistent tachycardia in horses. five of twenty horses were available for echocardiography; no abnormalities were noted. horses with increased ctni tended to have greater tnfalpha concentrations compared with horses without increased ctni. peak venom titers in bitten horses were significantly higher than peak titers in vaccinated horses (p o . ). rattlesnake envenomation was associated with evidence of cardiac damage in a significant proportion of bitten horses. further studies are needed to determine the cause as well as mechanisms to treat and/or prevent its occurrence. little is known about the gastric mucosal flora in healthy horses and its role in gastric disease has not been critically examined. our laboratory previously reported that a diverse microbial flora with a predominance of streptococcus spp. and lactobacillus spp. exists in healthy horses using fluorescence in situ hybridization (fish). the present study sought to further characterize the gastric mucosal flora of healthy horses using massive parallel srrna bacterial tag encoded flx-titanium amplicon pyrosequencing (btefap). biopsies of the squamous, glandular, antral and any ulcerated mucosa were obtained from healthy horses via gastroscopy after a -hour fast and horses immediately post-mortem. dna was extracted from the mucosal biopsies and btefap and data processing was performed. hierarchical cluster analysis based on relative abundance data on the genus level were performed to look for trends in bacterial diversity among the individual horses. pyrosequencing yielded between , and , reads per horse with , , reads in the antrum, squamous and glandular regions, respectively. the microbiome segregated into two distinct clusters: cluster comprised of horses that were stabled, fed hay and sampled at post-mortem and cluster consisted of horses that were pastured on grass, fed hay and biopsied gastroscopically after a -hour fast. samples from different antomic regions clustered by horse rather than region. despite being very similar at the higher taxonomic level (phyla) differences in the distribution of bacteria were seen at the genus and species level. the dominant bacteria in cluster horses were firmicutes ( % reads/sample) consisting of mainly streptococcus spp., lactobacillus jensenii, l. fornicalis and sarcina maxima. cluster had more diversity with a predominance of proteobacteria, bacteroidetes and firmicutes and genera identified such as streptococcus spp., moraxella spp., actinobacillus spp., and others. though the relative abundance of the individual taxonomic groups was significantly different between individual horses, no significant differences in the overall diversity could be found (as assesed by shanon weaver, ace and choa i diversity indices). helicobacter spp. sequences were not identified in any sample (out of , reads). the ulcerated mucosa from horse (group ) had lower diversity and higher numbers of bacteria predominated by lactobacillus equigenerosi. this data shows that the equine gastric mucosa harbors an abundant and diverse microbiome which is unique to each individual and differs by sampling method, fasting prior to sampling and diet. seasonal pasture myopathy (spm; atypical myopathy [am] in europe), typified by nonexertional rhabdomyolysis, occurs in pastured horses during autumn or spring. clinical signs rapidly progress from muscular weakness to recumbency and frequently death. extensive myonecrosis and intramyofiber lipid storage occur in highly oxidative respiratory and postural muscles. recently, a defect of lipid metabolism called madd has been identified in european horses with am. this report documents the first cases of equine madd in the united states. six midwestern us horses suspected of having spm in the spring or fall of were evaluated for madd by urine organic acids, plasma acylcarnitines and/or muscle carnitine and histopathology. five horses had clinical signs and clinicopathologic data consistent with severe rhabdomyolysis. one horse was found dead on pasture after days of rear limb stiffness and inappetance. urinary organic acid profiles revealed markedly elevated ethylmalonic and methylsuccinic acids, butyrylglycine, isovalerylglycine, and hexanoylglycine, consistent with equine madd. plasma acylcarnitine profiles from horses had marked elevations of short chain acylcarnitines, while the third horse and only survivor had minor elevations of short chain acylcarnitines. affected muscle showed extensive degeneration with intramyofiber lipid accumulation, a marked decrease in free carnitine, and high levels of carnitine esters. spm appears to be a highly fatal emerging disease of pastured horses in the us characterized by weakness, colic-like signs and myoglobinuria. the disease is associated with a defect in muscular lipid metabolism that can be diagnosed by performing lipid staining of muscle samples and urine organic acid profiles. candidatus mycoplasma haemolamae (cmhl) is a common red blood cell parasite of new world camelids. the high degree of parasitemia that develops in an infected splenectomized animal allows for the efficient collection of parasitic dna. this dna can then be used in the development of genetically-derived tools such as pcr and in-situ hybridization. thus, one splenectomized animal can replace many immunologically intact animals within a research setting. the purpose of this study was to track the natural progression of cmhl parasitemia and associated clinical signs in a splenectomized alpaca. an intact, -month-old, . kg male alpaca was used in this study. he had tested positive via pcr for cmhl on three different occasions, although no organisms were seen on peripheral blood smears. the alpaca was placed under general anesthesia and a ventral midline incision was made. the spleen was located, the vessels ligated, and the organ removed. buprenorphine and flunixin meglumine were given for and days after surgery respectively. body weight, attitude, rectal temperature, blood glucose, and pcv were recorded daily. in addition, a peripheral blood smear was examined daily and the percent of red blood cells that were infected with mycoplasma organisms was determined. the alpaca was not parasitemic prior to surgery. one percent of the rbc's contained mycoplasma on days and after splenectomy. parasitic bloom developed on day with % of the red blood cells infected, and over % containing or more organisms. the alpaca was treated with mg/kg oxytetracycline i.v. on day . on postoperative day no parasites were seen in the peripheral blood. the peripheral blood remained free of parasites for days. on the morning of the th day, % of the peripheral red blood cells contained mycoplasma. by late that afternoon, % of the observed rbc's contained - organisms. the alpaca again received oxytetracycline. there were no more parasites observed from that time until the alpaca was euthanized days later. the alpaca lost . kg between days À and after surgery. his weight fluctuated between . and . kg for the remainder of the study period. blood glucose ranged between and mg/dl there was no major change in pcv (range - %), a finding that was expected as the spleen was not available to remove infected red blood cells. body temperature ranged between . and degrees celsius except for days and when more than % of red blood cells contained parasites. on those days rectal temperature reached . and . degrees respectively. this study confirmed that a non-parasitemic, yet pcr positive alpaca did indeed harbor cmhl. the time from splenectomy to parasitic bloom was shorter, and the length of oxytetracycline suppression longer than has been observed in other species. gastro-intestinal (gi) disease frequently results in increased wall thickness in many species. identification of changes in gi wall thickness using ultrasound has proved to be a useful diagnostic tool and is widely used in human patients, small animals and horses. although gi motility has been evaluated in cattle, normal reference ranges for wall thickness has not been reported in ruminants. the aims of this study were to report normal values for wall thickness of various gi structures and to assess the repeatability of this technique in adult dairy cows, sheep and goats. eight healthy adult holstein friesian (hf) cattle ( ae kg), eight jersey (j) cattle ( ae kg), thirteen adult sheep ( ae kg) and eleven adult goats ( . ae kg) were recruited and examined on three consecutive days. ultrasonographic images were optimised for the structure of interest. structures were identified based upon appearance and anatomical position. a minimum of three cineloops were obtained of the abdominal organs per intercostal space (ics) and three along the ventral midline in each ics; images were analysed offline. data were analysed using anova and post-hoc bonferoni, student's ttest and intra-class correlation coefficients. each structure was measured per ics per species; if no differences were noted for structures in different ics, then measurements were pooled. no differences were noted between hf and j cattle so data were pooled. data are displayed in table . good repeatability (icc . ) was obtained for all measurements and no differences were noted between animals of the same species or between days. these measurements for assessment of normal gi thickness are repeatable and may allow valuable additional information to be gained from ruminants with gi disease. ocular infections with the infectious bovine keratoconjunctivitis (ibk) agent moraxella bovis (m. bovis) are associated with significant economic loss in the cattle industry.although antibiotic therapy is the treatment of choice for ibk, treatment failures are common and current vaccines are not optimally effective mainly due to antigenic variation. as a result, our laboratory has been actively investigating the therapeutic potential of bdellovibrio bacteriovorus j (b. bacteriovorus); a predatory bacterium capable of attacking and inducing lysis of gram-negative bacteria, as a new treatment for ibk. we have previously shown that b. bacteriovorus can reduce the number of m. bovis attached to bovine epithelial cells in an in vitro model of ibk and that b. bacteriovorus can be trained to kill m. bovis as effectively as e. coli using serial passages. in this study, we hypothesized that b. bacteriovorus can remain viable in bovine tears without its prey for up to hours. this hypothesis was addressed by incubating inocula of active b. bacteriovorus in its preferred media peptone yeast extract (pye) and comparing b. bacteriovorus viability in bovine tears or phosphate buffered saline (pbs) at time , , , , and hours. using a plaque assay to quantify the mean amount of plaque forming units (pfus) of b. bacteriovorus exposed to each treatment, it was determined that viability of b. bacteriovorus over time was comparable between treatment groups. overall, the results supported that b. bacteriovorus can remain viable in tears for up to hours in the absence of prey bacteria. further studies are needed to determine the therapeutic potential of b. bacteriovorus in an in vivo model of ibk. correction of the measured ionized calcium concentration (cca ) to a ph . is routinely applied in experimental studies in order to assist in the interpretation of measured values relative to a reference range. the equation most commonly used for ph correction in bovine plasma is: cca ph . cca  (- . Â{ . -ph}) . the validity of this equation for bovine plasma is unknown. accordingly, our first objective was to characterize the in vitro relationship between cca and ph for bovine plasma. feeding rations with a low dietary cation-anion difference (dcad) during late gestation mitigates periparturient hypocalcemia in dairy cows, particularly when chloride containing acidodgenic salts are fed. the mechanism for this beneficial effect remains unclear. our second objective was to determine whether hyperchloremia displaces calcium from binding sites to albumin, thereby increasing cca . the in vitro relationship between plasma log(cca ) and ph in was investigated using lithium heparin anticoagulated blood from healthy holstein-friesian calves. plasma was harvested and tonometered with co at c over a ph range of . - . . plasma chloride concentration (ccl -) was altered by equivolume dilution of plasma with electrolyte solutions of varying ccl -( ae , ae , and ae meq/l; mean ae sd). the slope of the linear regression equation relating log(cca ) to ph for tonometered plasma samples from the calves was - . ae . at normal values for cca ( . ae . meq/l), albumin concentration ( . ae . g/l), and ccl -( . ae . meq/l). the experimentally-determined value for the slope for bovine plasma was identical to that determined previously for human plasma. the formula for correcting cca in bovine plasma for change in ph from . is therefore: cca ph . cca  (À .  { . -ph}) . this equation is only valid at normal concentrations of albumin and chloride in plasma. equivolume dilution of plasma by electrolyte solutions of varying cclindicated that cca ph . increased by . meq for every meq/l increase in ccl -. in other words, plasma cca at a given ph increases directly in response to an increase in plasma ccl -, presumably because the additional chloride displaces calcium that is electrostatically bound to albumin. furthermore, the increase in cca is independent to the change in plasma ph induced by an increase in ccland decrease in plasma strong ion difference. our finding that hyperchloremia directly increases plasma cca provides an additional mechanism by which ingestion of high chloride (acidogenic) rations prevents the clinical signs of periparturient paresis. our finding is consistent with the results of other studies that indicate acidogenic salts that contain chloride as the predominant anion (ie, nh cl, cacl ) are more effective in increasing cca than equimolar quantities of acidogenic salts such as mgso . coagulase negative staphylococci (cns) are among the most common bacteria isolated from the bovine mammary gland. historically, these bacteria were lumped together as minor mastitis pathogens. modern molecular techniques have allowed accurate speciation and fingerprinting of the cns species. these methodologies have recently been applied to the study of cns in bovine mastitis. the aim of the studies presented here was to evaluate the role of individual cns species on milk somatic cell count (scc) and duration of intramammary infection (imi). in the first study, mammary quarter foremilk samples were aseptically collected from all lactating cattle ($ head) at the university of missouri dairy research center once monthly for months for bacterial culture and milk scc. staphylococcal isolates were speciated by sequencing the rpob gene and strain-typed using pulsed-field gel electrophoresis (pfge). using species and fingerprint data along with published definitions for staphylococcal imi, cns imis were identified. overall, species of cns were identified with staphylococcus chromogenes, s. cohnii, s. epidermidis, and s. simulans being most prevalent. duration of imi and scc data were analyzed using regression models accounting for repeated measures. mean milk scc and duration of imi were found to differ between cns species (p o . ). although most imis were of short duration ( month), staphylococcus capitis and s. chromogenes imis had longer mean durations of infection than or more of the other species isolated. mean sccs were under , cells/ml in most cases. however, staphylococcus simulans and s. xylosus imis were more inflammatory (mean , cells/ml) and had a higher mean scc than s. cohnii, s. epidermidis, and s. haemolyticus. to examine the relationship between cns imi and milk scc in a larger population of cattle, cns isolates from the canadian bovine mastitis research network (cbmrn) culture collection were obtained for speciation. speciation and fingerprinting were performed as above. isolates were from subclinical imi from before and after the dry period and from subclinical imi during lactation. data associated with each isolate were obtained from the cbmrn database. nine-hundred-thirty-eight isolates from mammary quarters in herds were successfully speciated. twenty-two different species of cns were identified. staphylococcus chromogenes was the most frequent species identified accounting for % of the infections. three species, s. chromogenes, s. xylosus, and s. simulans accounted for % of all infections. data were analyzed using a linear hierarchical repeated measures mixed model. differences in mean scc were found between some cns species and culture negative control quarters and also between different species of cns (p o . ). overall, our data demonstrate potential differences in pathogenicity between strains of cns that cause bovine mastitis. passive transfer of maternally derived antibodies via ingestion of good-quality colostrum within the first hours of life is crucial for the health and future productivity of dairy calves. however, infectious diseases can be transmitted via colostrum feeding, which may require use of a colostrum replacement product or pasteurization to decrease disease transmission. while pasteurization of colostrum is effective for sterilization, heating during pasteurization can alter the viscosity of colostrum, destroys important nutritional biomolecules, and has been shown to decrease colostral igg concentrations. the purpose of this study was to investigate the effect of high pressure processing (hpp) on the viscosity, igg concentration, and bacterial contamination of bovine colostrum. first milking colostrum samples were collected from cows from different farms, and ml aliquots of each sample were pooled for analysis. pooled colostrum was processed in triplicate using an isostatic press at mpa ( , psig) for , , , , and minutes. samples were tested for the effects of hpp on the viscosity, bacterial load (cfu/ml), and igg concentration. there was a significant decrease (p o . ) in bacterial load at each time point when compared to time . no significant difference in igg concentration was found between any time points. subjectively, the colostrum viscosity appeared to increase with the processing time, though the rheologic assessment has not been completed at this time. hpp appears to be an effective method to decrease bacterial contamination of colostrum while maintaining appropriate igg concentrations. minimizing the processing time or pressure may be necessary to maintain an acceptable viscosity of the colostrum. based on these results, additional studies are justified in order to determine the optimum combination of processing time and pressure and the effect of hpp on specific bovine pathogens. the heme-associated iron-binding apoprotein lactoferrin (lf) is known for its, anti-inflammatory, anti-parasitic, antimicrobial and bactericidal effects. lactoferrin demonstrates ubiquity throughout mammalian host biological fluids: saliva; tears; mammary secretions, as well as at mucosal surfaces. it is also released from immune cells under pathogenic stimulation. the purpose of this study which has been approved by western university's institutional animal care and use committee is to further characterize the mechanisms through which lf modulates inflammation in the face of bacterial endotoxin. it was hypothesized that lf would inhibit p phosphorylation. numerous studies speak to the ability of lf to alter leukocyte function, inhibit cytokine production, and bind lipopolysaccharide (lps); mechanisms through which it is believed to achieve its anti-inflammatory effects. recently, investigators demonstrated its ability to interact with host dna while others describe regulation of granulocyte adhesion and motility; elucidating its roles in the apoptotic signaling. in earlier studies, dawes me, et al. demonstrated lactoferrin's ability to limit the expression of inducible cyclooxygenase- and the gelatinase, matrix metalloproteinase - by lps-induced macrophages. the generation of these inflammatory mediators is modulated by pro-inflammatory cytokines such as interleukin- b (il- b) and tumor necrosis factor-alpha (tnf-a), the production of both being dependent on signaling through the p mitogenactivated protein kinase (mapk) pathway. peripheral mononuclear cells (  )isolated from buffy coat cells of healthy neonatal to -month old holstein calves were cultured in the presence and absence of lf ( ng/ml), lps ( mg/ml), anisomycin ( mg/ml), a known p activator -the positive control, and mm of sb , a known p inhibitor -the negative control. sample lysates obtained post culture was subjected to immunoprecipitation and kinase reactions. reactions were terminated under reducing conditions and evaluated using western immunoblotting. phosphorylation of activated transcription factor- (atf- ) by phosphorylated p served as the marker of investigation. immunologically reactive atf- expression by lps and anisomycin-treated cells was compatible with a prominent band at kd. evidence of lf-induced inhibition of lps-induced p- activation was observed in lanes representative of co-cultures of lf lps; lf anisomycin; and anisomycin sb , which was demonstrated by decreased immunological reactivity at kd. the findings here, suggest that lf interferes with lps-induced p- activation of transcription factor atf- , in vitro. this serves as additional proof of its potential use in attenuating the systemic effects of lps. six ( ) clinically normal, purpose-bred cats of similar age and body condition were imaged with [ f] fluorodeoxyglucose ([ f]fdg) and [ f]ftha by using dynamic cardiac-gated fused pet/ct for kinetic assessment of myocardial glucose and fatty acid uptake and metabolism, respectively. kinetic tracer uptake within the myocardium was achieved by initiating image data acquisition simultaneously with tracer injection. pet data were acquired over a hour period with the heart in the center of the scanner field of view. regions of interest were drawn in the left ventricular wall and thoracic aorta for the purpose of measuring the kinetics of tracer redistribution. serial blood samples were also taken during pet imaging for comparison with image data. the equilibrium biodistribution of both tracers was documented hour post-injection in a whole body pet/ct image. standard echocardiographic examination of cardiac structures was also performed. both radiotracers remained in the plasma fraction; however, [ f]ftha was cleared from the more rapidly than [ f]fdg (t / $ and $ min, respectively). the tracers were readily visualized within the feline myocardium in dynamic pet images and analysis of the blood pool clearance from the kinetic image data agreed with blood sampling data. myocardial uptake of each tracer was best described by a double exponential analysis and was rapid but variable among animals (range - bq/cc/min), although blood glucose levels were similar in all cats during image acquisition. physiologic [ f]fdg was observed in the brain, salivary tissue, gastrointestinal tract, renal pelves and urinary bladder, with [ f]ftha seen in the myocardium, liver and renal cortex. all cats were normotensive with normal echocardiographic parameters. this study demonstrates the utility of kinetic imaging using the left ventricle (lv) shape has been suggested to change from elliptical to more globular in response to chronic volume overload. real-time three-dimensional echocardiography (rt de) offers new modalities for lv assessment. the aim of the study was to investigate left ventricular changes in shape and volume occurring in response to different severities of naturally acquired myxomatous mitral valve disease (mmvd) in dogs using rt de. privately owned dogs were classified by standard echocardiography into: healthy ( ), mild ( ), moderate ( ) and severe mmvd ( ). a lv cast was obtained using semi-automated endocardial border tracking from rt de dataset, from which global and regional (automatically acquired basal, mid, and apical segments based on lv long-axis dimension) end-diastolic (edv) and endsystolic volumes (esv), lv long-axis dimension and rt de sphericity index, were derived. global and regional edv and esv increased significantly with increasing mmvd severity, assessed by mmvd group-wise comparisons and linear regression analyses using left atrial to aortic root ratio, and lv end-diastolic and end-systolic dimensions. all three segments contributed to the overall increased global volumes, but the mid edv segment was strongest associated with increasing lv end diastolic dimension (p . ). furthermore, lv long axis distance and lv sphericity index increased with increasing mmvd severity. the basal and apical edv segments were strongest associated with sphericity index (p o . ). in conclusion, this rt de study showed that increased lv edv, primarily in the mid segment, leads to rounding of lv apical and basal segments in response to increasing mmvd severity in dogs. dogs from shelters in florida with naturally acquired di infection were euthanized and necropsied. all adult di in each dog were sexed using morphological features. total worm burdens and numbers of males and females were recorded. no other information was available for any dog. all data, raw and transformed, were examined visually and descriptively. raw numerical data were further examined by a paired t-test; log-odds transformed data were examined by logistic regression. we also conducted a binomial distribution goodness of fit analysis assuming a null hypothesis of a m:f . . worm intensities ranged from to di per dog. eight dogs had unisex infections: / had all-female infections. dogs with lowintensity dual-sex infections were more likely to have greater numbers of female di. overall, sex ratios were equal (paired t-test, p . ). however, logistic regression demonstrated that the probability of being female is strongly affected by the total worm intensity, with lower intensities increasing the probability of having a predominance of female worms. our data show that di sex ratios in naturally-infected dogs equal when examining the entire dog population, but deviate to favor female worms at low worm intensities. these data could impact adulticide treatment strategies. the reasons for sex ratio distortion in di are unknown. we evaluated cardiac reverse remodeling after mitral valve repair under cardiopulmonary bypass (cpb) for mitral regurgitation in small breed dogs. fifty dogs (body weight . - . kg, age - years) with mitral regurgitation were treated between august and november . the cardiac murmur was grade / - / . the preoperative chest x-rays showed cardiac enlargement (vertebral heart scale (vhs) . - . ). echocardiography showed severe mitral regurgitation and left atrium enlargement (la/ao . - . ). after inducing anesthesia, a thoracotomy was performed in the fifth intercostal space. cpb was started by using a cpb circuit connected to carotid artery and jugular vein catheters. after inducing cardiac arrest, the left atrium was sectioned and chordae tendineae rupture confirmed. the chordae tendineae were replaced with expanded polytetrafluoroethylene. a mitral annulus plasty was also done, and the left atrium was closed. after de-clamping for restarting the heart, the chest was closed. heart rate decreased from - bpm to - bpm. the grade of cardiac murmur was reduced to / - / three months postoperatively, and the heart shadow was reduced (vhs . - . ) in the chest x-rays. echocardiography confirmed the marked reduction in mitral regurgitation and the left atrial dimensions (la/ao . - . ). mitral valve repair reduced enlarged cardiac size by reduction of regurgitant rate. pulmonary arterial hypertension (pah) is a well recognized condition in dogs leading to considerable morbidity and mortality. the majority of therapeutics has focused on endothelial dysfunction causing reduced production of vasodilators, such as nitric oxide and prostacyclin, coupled with overproduction of vasoconstrictors, such as endothelin- . more recently, it has been shown that the mitochondria play an important role in the development of pah as oxygen sensors and regulators of cellular proliferation. in pah, pulmonary artery smooth muscle cells undergo a metabolic shift from oxidative phosphorylation in the mitochondria to glycolysis in the cytoplasm as the major energy source and this leads to suppression of apoptosis and increased proliferation. dichloroacetate (dca) inhibits pyruvate dehydrogenase kinase to activate pyruvate dehydrogenase which catalyzes the rate limiting step for entry of pyruvate into the krebs cycle, thus increasing mitochondrial respiration. in three different rat models of pah, dca has been shown prevent and reverse pah by normalizing molecular pathology, stimulating apoptosis of pulmonary artery smooth muscle cells, and reducing pulmonary artery hypertrophy. dca has known toxic effects, including reversible hepatotoxicity and peripheral neuropathy, and has not been studied in any species with naturally occurring pah. the objective of this open label pilot study is to evaluate the therapeutic and toxic effects of dca in naturally occurring canine pah. three dogs with pah diagnosed by doppler echocardiography and no correctable underlying cause are enrolled in the study. dogs are orally administered mg/kg of dca divided daily for weeks, and then . mg/kg of dca divided daily for the remainder of the study. at baseline, , , , and weeks, an echocardiogram, cbc, serum chemistry profile, urinalysis, nt-probnp, blood uric acid, blood lactate, noninvasive blood pressure, nerve conduction study, and trough dca level ( hr post-dose) are obtained. the measured echocardiographic parameters include peak and mean tricuspid regurgitant flow velocity and pressure gradient, peak and enddiastolic pulmonary regurgitant flow velocity and pressure gradient, pulmonary valve flow velocity acceleration time and ejection time, pulmonary valve flow velocity time integral, right ventricular myocardial performance index, tricuspid annular plane systolic excursion, and systolic tricuspid annular tissue velocity. variables are inspected for normalcy and equality of variances and a two-sided paired t-test is used to compare the variables before and after treatment at each evaluation time. the basis for the role of the mitochondria in pah and the results of this pilot study will be presented to determine if dca warrants further study as a therapy for dogs with pah. study produced the strongest associations between the ncl phenotype and cfa markers. all ncl-affected tibetan terriers were homozygous for the same haplotype which extended for consecutive snps spanning . mb. none of the annotated genes within this target region had previously been associated with human or rodent ncl. we used dna from ncl-affected tibetan terriers to resequence the coding regions and intron-exon borders of several genes harbored within the target region and found a single base pair deletion, c. delg, in exon of positional candidate atp a . this deletion produces a frame shift and a predicted premature termination codon. we genotyped all tibetan terrier dna samples in our collection and found all ncl-affected tibetan terriers to be homozygous for the c. delg allele. eleven additional c. delg homozygotes were either less than years old, or lost to follow up. there were no known cases of ncl in the remaining tibetan terriers which were either heterozygous (n ) or homozygous for the ancestral allele (n ). atp a is a member of group of ion transport genes and has been associated with lysosomes. mutations in human atp a cause kufor-rakeb syndrome (krs), a rare neurodegenerative disorder with clinical features that include parkinsonism plus spasticity, supranuclear upgaze paresis, and dementia. post-mortem findings in krs have not been reported. we conclude that ncl in tibetan terriers is caused by a mutation in atp a . our results suggest that krs may be a form of adult onset ncl in humans. niemann-pick type c (npc) disease is a progressive neurological disorder characterized by dementia and ataxia, hepatic and pulmonary disease, and death typically within the first or second decade. despite the identification of causative mutations, the pathogenesis is not clear and therapies to successfully treat npc disease have been ineffective to date. the recent use of intravenously administered -hydroxypropylbeta-cyclodextrin (hpbcd), an fda-designated orphan drug (may ), in a small number of children with npc disease is based on favorable treatment outcome data in subcutaneously treated mouse and cat models. to rigorously evaluate the mechanistic, pharmacologic, and toxicity issues associated with hpbcd therapy in npc disease, we have utilized the spontaneous feline npc model harboring a missense mutation in npc (pc s), orthologous to the most common mutation in juvenile-onset patients. the feline npc model has clinical, neuropathological and biochemical abnormalities similar to those present in juvenile-onset patients making this model homologous to the most common disease form seen in human patients. we identified that intrathecal administration of hpbcd ameliorated all clinical aspects of neurological disease at least up to weeks of age (an age when untreated cats die) but had no effect on hepatic disease. we identified that while subcutaneous therapy with hpbcd at all doses ameliorated liver disease, only mg/kg substantially affected neurological disease but also resulted in early death due to pulmonary toxicity. finally, we identified a dose-related toxic effect of hpbcd on hearing function that had not been described in any other species. leukodystrophies are disorders of myelin synthesis and maintenance that affect cns myelin. they are subdivided as leukodystrophies, hypomyelinating disorders and spongy degenerations. although infrequently seen, several forms have been described in various dog breeds. we present a novel form of complex leukodystrophy consisting of hypomyelination and spongy degeneration that presents primarily with hind end tremors in border terrier puppies. three border terriers from two different litters (and lineages) are described here that presented with a history of shaking movements. the youngest dog was a -week old male. it was the only dog affected in the litter. the other two dogs were -week old female littermates. there were two unaffected males in the same litter. physical examination revealed no abnormalities. on neurological examination, the affected dogs displayed severe hind end tremors, with a characteristic swinging side-to-side movement (best described as ''rumpshaker''). the tremors also involved the head and thoracic limbs but to a lesser degree, and disappeared when the dogs were asleep or at rest. severe cerebellar ataxia was observed when the dogs ambulated. proprioceptive positioning was delayed in the pelvic limbs of all dogs. spinal reflexes and nociception appeared normal. necropsy was performed in all puppies. no macroscopic changes were observed. histologic evaluation of the cns revealed spongy degeneration and hypomyelination in all funiculi of the cervical and thoracic spinal cord. white matter of the frontal, temporal and parietal cortices had mild multifocal spongy degeneration and hypomyelination, whereas white matter of the cerebellum, medulla and pons showed severe diffuse spongy degeneration and hypomyelination with gliosis. the combination of reduced myelin formation combined with spongiform white matter changes in the absence of microglial responses suggest a complex pathogenesis affecting both oligodendrocytes' capacity to synthesize myelin and the stability of the myelin that was formed. the number of oligodendrocytes and axons appeared subjectively normal indicating a primarily hypomyelinating process. the clinical and pathological features of this disease have not been described in any other canine leukodystrophy. the primary and most striking clinical feature is the presence of severe tremors in the hind end, causing the ''rumpshaker'' pheynotype. genetic studies are underway to determine if the disease is inherited and the inheritance mode. a syndrome of border collie collapse (bcc) appears to be common in dogs used for working stock. this syndrome has also been called malignant hyperthermia, heat intolerance, exerciseinduced collapse and ''wobbles''. a presumptive diagnosis of bcc can only be made by eliminating other causes of exercise intolerance and weakness. the purpose of this study was to describe the clinical features of collapse in affected dogs and determine if there were characteristic clinical or laboratory features at rest or after exercise that could aid in diagnosis. seven adult border collies with a history of collapse during sheep herding (affected) and adult border collies regularly used for sheep herding but showing no signs of exercise intolerance (normal) were evaluated before and after participating in a videotaped minute exercise protocol consisting ofa series of continuous short outruns and fetches of three sheep in an outdoor pen. exercise was halted at minutes or earlier if there were signs of gait or mentation abnormalities. pre-exercise evaluation included physical examination, orthopedic and neurological exam. pre and immediate post exercise rectal temperature, pulse and respiration, patellar reflexes, ecg, cbc, serum biochemistry profile, cortisol, arterial blood gas and plasma lactate and pyruvate concentrations were measured. clinical parameters (gait, temperature, reflexes) and lactate and pyruvate concentrations were evaluated at intervals up to minutes after exercise. additional testing in affected dogs included measurement of acetylcholine receptor antibodies (achrab) and dna testing for dynamin-associated exercise induced collapse (deic) and the ryanodine receptor mutation associated with canine malignant hyperthermia(mh). one week after exercise affected dogs had thoracic radiographs and echocardiography performed and were anesthetized for emg and muscle biopsies. there were no significant differences in temperature, pulse, respiration, or any laboratory parameter at any time point between normal and affected dogs. no arrhythmias were detected. affected dogs were negative for the dna mutations tested and for achr ab. thoracic radiographs, echocardiograms, emgs and muscle biopsies were normal. the normal dogs had no alterations in mentation or gait during or after exercise. three of the affected dogs had exercise halted early ( min- min) because of altered gait or mentation. all of the affected dogs were abnormal in the minutes following exercise. abnormalities seen in all dogs included disorientation, dull mentation, swaying, falling to the side, exaggerated lifting of limbs each step, choppy gait, delayed limb protraction, scuffing of rear and/or forelegs, and crossing legs when turning. all dogs returned to normal by minutes. bcc appears to be an episodic nervous system disorder that can be triggered by exercise. genetic testing excluded deic and the described canine mh mutation. common causes of exercise intolerance were eliminated, but the cause of collapse in bcc was not determined and no clinical or biochemical marker to aid diagnosis was established. equine cushing's disease (ecd) is common in older horses. the purpose of this study was to determine the frequency of diagnosis, identify prognostic factors and assess owner satisfaction with treatment. the study was a retrospective cohort design evaluating equine accessions reported to the veterinary medical data base (vmdb) and the ohio state university from - . proportional accessions, annual incidence and demographic characteristics of horses with ecd were compared with all accessions in the vmdb. medical records for a subset of horses were extracted and owners contacted to obtain long-term follow up information. two hundred seventeen new cases of ecd were reported to the vmdb. incidence increased from . / , in to . / , in . eighty-one percent of horses were ! years of age. average delay from onset of signs to diagnosis was days (range to , days). hirsutism ( %) and laminitis ( %) were the most common clinical signs. improvement in one or more signs months after diagnosis was reported by / ( %) of horse owners. none of the clinical or laboratory data were associated with survival and, % of horses were alive, . years after diagnosis. / ( %) of horses were euthanatized and / ( %) were euthanatized due to conditions associated with ecd. twenty-eight of ( %) of horse owners said they would treat a second horse for ecd. ecd is becoming a more frequent diagnosis. fifty percent of horses survived . years after diagnosis and owners were satisfied with the horse's quality of life. supported by centers of excellence in livestock diseases and human health, college of veterinary medicine, university of tennessee. the role of the hypothalamic-pituitary-adrenal (hpa) axis in sepsis has been a subject of a great deal of research. the role that the somatogenic axis plays in sepsis is less well understood and how these two axes interact during critical illness is not clear. the purpose of this study was to assess inter-relationships of adrenocorticotropin (acth), cortisol, and insulin-like growth factor-i (igf-i), in septic and non-septic term foals. blood samples were obtained from term septic foals less than days of age (n ) admitted to texas a&m university veterinary medical teaching hospital or mid-atlantic equine hospital. the foals were classified as septic by a sepsis score ! and/ or a positive blood culture. non-septic term foals less than days of age (n ) and having a sepsis score o and a negative blood culture, were obtained from texas a&m university veterinary medical teaching hospital and mid-atlantic equine hospital. plasma and serum were processed from whole blood collected by jugular venipuncture upon admission, at hours post admission and at days post admission or at the time of discharge. plasma concentrations of acth, and serum concentrations of cortisol and igf-i were determined by specific rias. data were analyzed using linear mixed-effects modeling with foal modeled as a random effect and day of admission modeled as an ordered categorical variable; post-hoc testing of pair-wise comparisons was made using the method of sidak. significance was set at p o . , and analyses were performed using s-plus software (tibco, inc., seattle, wa). plasma concentrations of acth were not significantly different between septic and non-septic foals whereas septic foals had greater serum cortisol ( ae ng/ml vs ae ng/ml) but lower serum igf-i ( ae ng/ml vs ae ng/ml) relative to non-septic foals pooled overall sampling times. the positive association of the peripheral blood concentrations of acth and cortisol depended on disease status of the foals. specifically, cortisol and acth were positively correlated for the septic foals (p . ) but not significantly correlated in the non-septic foals. peripheral concentrations of acth and igf-i were not significantly correlated whether data were pooled overall or stratified by sepsis status. however, peripheral concentrations of cortisol and igf-i were negatively associated (p . ); disease status did not influence this association, although it appeared to be a stronger association for the septic than the non-septic foals. the negative correlation between serum concentrations of the adrenal axis steroid cortisol and the somatogenic axis peptide igf-i may reflect interactions of these homeorhetic hormones. further studies of these and other metabolic hormones in a greater number of foals are warranted to better understand how these factors contribute to survival or non-survival of critically ill foals. botulism is a potentially fatal paralytic disorder which definitive diagnosis is difficult. the purpose of this study was to investigate if repetitive stimulation of the common peroneal nerve will aid in the diagnosis of suspected botulism in foals. four healthy foals were used for its comparison with foals with suspected botulism. controls were anesthetized and affected foals were sedated to avoid risks of anesthesia. the common peroneal nerve was chosen for its superficial location and easy access. stimulating electrodes were placed along the common peroneal nerve. for recording, the active and reference electrodes were positioned over the midpoint and distal end of the extensor digitorum longus muscle, respectively. repeated supramaximal stimulation of the nerve was performed utilizing a range of frequencies ( to hz). amplitude, area under the curve and percentages of decrement or increment for each m wave over subsequent potentials for each set of stimuli were analyzed. baseline m waves were decreased in affected foals compared to controls. a decremental response was seen at all frequencies in control foals. decremental responses were also observed in affected foals at low frequencies. however, an incremental response in amplitude and area under the curve was seen in all affected foals at hz. reduced baseline m waves with incremental responses at high rates are supportive of a presynaptic neuromuscular disorder which botulism was the most likely cause in these foals. repetitive nerve stimulation is a safe, simple, fast, and non-invasive technique that can aid in the diagnosis of suspected botulism in foals. this study examined the frequency with which dogs are exposed to e. chaffeensis and e. ewingii relative to e. canis, which is transmitted by the more ubiquitously distributed brown dog tick (rhipicephalus sanguineus). a total of , canine serum samples, ranging from to from each of the participating institutions, collected at random from clinical accessions, diagnostic laboratories and/or shelters were evaluated. all serum samples were tested by three microtiter plate elisas using species-specific peptides for antibodies to e. canis, e. chaffeensis and e. ewingii. zip code information for sample origin was provided by the collaborator and was used to assess seroprevalence by region. comparisons were evaluated using the chi-square test. seroreactivity for at least of ehrlichia spp was found in samples from every institution both mississippi and oklahoma had greater than a % samples from ohio had the lowest aggregate seroprevalence ( . %) with only dogs e. canis seropositive, one e. ewingii seropositive and no e. chaffeensis seroreactors. the geospatial pattern of e. chaffeensis and e. ewingii seropositive samples was similar to that previously reported based on modeling seroreactivity to e. chaffeensis in white-tailed deer as well as the distribution of human monocytic ehrlichiosis (hme) cases reported by the cdc. this study provides the first large scale regional documentation of canine exposure to these three ehrlichia spp., highlighting where infections most commonly occur and thus identifying areas where heightened awareness about these emerging vector urinary incontinence (ui) occurs in approximately % of spayed female dogs. the most common cause is urethral sphincter mechanism incompetency (usmi). pharmacological agents are effective, however, not all dogs respond, and dogs may become refractory to treatment over time. urethral bulking, where a compound is injected submucosally in the urethra, has been used in women and in female dogs with urinary incontinence. new synthetic compounds have been used in human medicine; the most promising is polydimethylsiloxane (pdms), which has been shown to be more effective than glutaraldehyde cross-linked collagen. the purpose of this descriptive clinical trial is to evaluate the safety and effectiveness of pdms urethral bulking agent (pdms uba) in client-owned, spayed female dogs with naturally-occurring ui due to usmi.twenty-two, spayed female dogs were included. dogs had a median age of years ( to years). eighteen dog breeds were represented, and dogs weighed a median of . kg ( . to . kg). average length of time of ui was . ae . years; / dogs had been treated medically, of which / were continent, / were improved, and / had no improvement. dogs were deemed healthy based on results of physical examination, complete blood cell counts, plasma biochemical analysis, and urinalysis; urine cultures were negative.dogs were anesthetized, positioned in dorsal recumbency, and cystoscopy performed using a . mm, -or -degree, cm rigid cystoscope. urethral bulking was performed with pdms uba. on average, . ae . ml were injected in to locations approximately to . cm distal to the trigone submucosally in the proximal urethra. good coaptation was achieved in all dogs. the procedure took on average . ae . minutes. one dog experienced urethral obstruction after the procedure; a foley catheter was inserted for approximately hours and removed at which time she urinated normally and was continent. three dogs experienced an acute allergic reaction characterized by blepharedema and urticaria treated successfully with diphenhydramine. dogs were discharged on day of procedure except for the one dog that experienced urethral obstruction. all dogs were treated with meloxicam ( . mg/kg po q h for days).owners were contacted on day after discharge and / dogs were continent; / dogs was improved. dogs were re-evaluated week after discharge and / dogs were continent and / dogs polyneuropathy in large breed dogs is a relatively common clinical problem for which the genetic basis is generally unknown. the first cases of polyneuropathy in the leonberger breed (leonberger polyneuropathy or lpn) were identified in by one of the authors (gds) and a report published in (musclenerve : - ) . in this report a spontaneous, distal and symmetrical polyneuropathy with onset between to years of age was described and characterized clinically, electrophysiologically, histologically and morphometrically. there were striking similarities between lpn and the charcot-marie-tooth group of human inherited sensory and motor polyneuropathies, which have many known genetic mutations.a genome-wide case-control association study for lpn was performed with cases and controls on high-density k canine snp arrays and revealed a significantly associated region on cfa (p raw .  À p genome .  À ). a clear association of an approximately mb cfa haplotype with cases (p .  À ) was observed, particularly with those cases that were affected more severely and at a younger age (p .  À ). a positional candidate gene, arhgef , which has previously been associated with peripheral nerve abnormalities in humans, was sequenced, revealing a deletion that results in a frame shift and premature stop codon. of all leonbergers with young onset lpn (before years), . % ( of ) have two copies of this deletion, and, of all young onset leonbergers that are nerve biopsy positive for lpn, . % ( of ) have two copies of this deletion. importantly, nearly all dogs carrying two copies of the deletion ( of or . %) are affected with lpn by the age of years.the leonberger breed was generated from crossing several breeds, including the st. bernard, and a polyneuropathy clinically and histologically similar to lpn occurs in this breed. to determine if the arhgef mutation was associated with polyneuropathy in the st. bernard, dna was extracted from archived frozen muscle biopsy specimens from clinical cases (n ). the identical arhgef startle disease or hyperekplexia is caused by defects in mammalian glycinergic neurotransmission resulting in an exaggerated startle reflex and extensor hypertonia triggered by noise or touch. in humans and animals, startle disease is typically caused by mutations in one of three genes (glra , glrb, and slc a ) encoding postsynaptic glycine receptor subunits (a and b) or a presynaptic glycine transporter (glyt ). a litter of seven irish wolfhounds was recently identified in which two puppies developed muscle stiffness and tremor beginning at - days of age post-partum. signs were dramatic when the puppies were handled and resolved when the puppies were relaxed or sleeping. both puppies were euthanized due to ongoing stiffness, tremor and breathing difficulties. necropsies were performed, but no microscopic pathological abnormalities were identified in the peripheral or central nervous system.based on the clinical signs, exons from the three candidate genes were amplified from genomic dna isolated using pcr and directly sequenced. no deleterious polymorphisms were identified in either glra or glrb. however, difficulties were experienced in amplifying slc a exons and from affected animals, although control samples were positive, suggesting that the pcr primer designs and conditions were not at fault. further pcrs revealed that the reason for this anomaly was the presence of a homozygous . kb deletion encompassing exons and of the glyt gene in both affected animals. this deletion is predicted to result in the loss of part of the large cytoplasmic n-terminus that is vital for trafficking of glyt to synaptic sites, and a loss of all subsequent transmembrane domains via a frameshift. this genetic lesion was confirmed by defining the deletion breakpoint, southern blotting and multiplex ligationdependent probe amplification (mlpa). this analysis enabled the development of a rapid genotyping test that revealed heterozygosity for the deletion in the dam and sire and three other siblings, suggesting recessive inheritance of this disorder. wider testing of related animals has identified a total of carriers of the slc a deletion and enabled the identification of non-carrier animals to guide future breeding strategies. insulin resistance (ir), obesity, and type diabetes affect glucagon-like peptide (glp- ) concentrations in humans and rodents, but this incretin hormone has not been examined in horses. we therefore hypothesized that glp- concentrations would change in horses as obesity and ir were induced or exacerbated by overfeeding. six horses previously diagnosed with equine metabolic syndrome were provided with twice the amount of digestible energy required for maintenance as sweet feed and hay for weeks. intravenous and oral glucose tolerance tests (ogtts) were performed at and weeks. effects of time and period ( and weeks) were assessed by repeated measures anova.mean body weight increased from ae kg (range, to kg) to ae kg (range, to kg) over weeks, with individual horse weight gain varying from to %. mean body condition score increased (p . ) from ae (range, to . ) to ae (range, to ). three horses developed mild laminitis. glucagon-like peptide concentrations increased over time during ogtts (p . ), but the period  time effect was not significant (p . ). area under the glp- curve remained unaffected by weight gain, whereas area under the insulin curve increased (p . ) over time, indicating a reduction in insulin sensitivity. obesity and ir were induced or exacerbated when horses previously diagnosed with ems were overfed, but glp- concentrations did not change as a result. hypertonic saline solution ( . %) (hss) is an intravenous fluid used for the emergency treatment of intravascular volume deficits. the use of this fluid in horses with severe dehydration is controversial. the purpose of this study was to compare the use of hss and isotonic saline solution ( . %) (iss) for the emergency treatment of endurance horses.endurance horses eliminated from competition and requiring intravenous fluid therapy were eligible for enrollment in the study. twenty-two horses were randomly assigned to receive ml/kg of either hss or iss along with l lactate ringer's solution (lrs). following this bolus, all horses were treated with an additional l of lrs. blood and urine samples were collected before, during and after treatment. data was compared using two-way anova with repeated measures.as compared to iss, hss horses showed a greater decrease in pcv (p . ), total protein (p . ), albumin (p . ), and globulin (p . ). hss horses showed a greater increase in sodium and chloride (p o . ) as compared to iss horses. horses receiving hss had a shorter time to urination (p . ) and lower specific gravity (p o . ) than those receiving iss.results of this study indicate that hss may provide faster restoration of intravascular volume deficits than iss in endurance horses receiving emergency medical treatment. more profound electrolyte changes should be expected with hss however. b -adrenergic receptor agonists have been shown to increase erythrocyte carbonic anhydrase activity, which may stimulate the jacobs-stewart cycle and increase pulmonary circulation transvascular fluid fluxes during exercise. increase in pulmonary transvascular fluid fluxes (j v-a ) and consequent increase in the pulmonary interstitial fluid would be detrimental for alveolar o exchange during the fast erythrocyte transition time across the pulmonary capillaries. therefore, we hypothesised that treatment with inhaled b -adrenergic receptor agonist will increase j v-a and the alveolar-arterial po difference (aado ) during exercise.six stb horses were exercised on a high-speed treadmill at % vo peak until fatigue. horses were randomly assigned to treatment with salbutamol (sal: mcg) or placebo (control: con) inhalation via aeromask à min prior to exercise, with cross over treatment used at the repeated exercise test ( days later). arterial and mixedvenous blood, as well as co elimination and o uptake, were sampled simultaneously at rest, during exercise at sec intervals until fatigue, and into recovery. blood gases were analyzed. aado was calculated using the inspired po ( mmhg), and blood partial pressure of o and co . blood volume (%) changes across the lung were calculated from changes in hemoglobin and hematocrit values in venous and arterial blood. cardiac output (q) was calculated using the fick equation. j v-a was calculated using q and blood volume changes across the lung. variables were analyzed using two-way repeated-measures anova (p o . ).the duration of exercise to fatigue was . ae . min and . ae . min in both con and sal, respectively. at rest sal had no effect on j v-a , oxygen consumption (vo ), blood oxygen saturation (so ) or aado (p . ). at the onset of exercise j v-a increased in con and sal (p o . ) and at fatigue reached . ae . l/min and . ae . l/min, respectively. treatment with sal had no effect on j v-a during exercise (p . ). at the onset of exercise so and vo increased in con and sal (p o . ). treatment with sal had no effect on so or vo during exercise (p . ). aado increased during exercise in con and sal (p o . ) and at fatigue reached . ae . mmhg and . ae . mmhg, respectively. treatment with sal had no effect on aado during exercise (p . ).inhaled b -adrenergic receptor agonist salbutamol at the dose of mcg given min before exercise did not affect the duration of exercise to fatigue, j v-a , vo , so or aado . therefore, it had no detrimental effect on alveolar-capillary diffusion distance and the ventilation/perfusion mismatch in exercising horses. inflammatory airway disease (iad) and recurrent airway obstruction (rao) represent two classes of equine lung inflammatory diseases that may share some similar immunologic mechanisms. there is evidence that th cytokines and il- play some role in rao. iad is a common condition in horses, but its pathophysiology is still not understood. the aim of the present study was therefore to determine the mrna expression of th , th and th inflammatory cytokines, to understand the immunological mechanisms of iad.the mrna expression of ten inflammatory cytokines and chemokines was measured in the bronchoalveolar fluid (balf) of seventeen horses with iad and compared with ten control horses. the horses were selected based on -their clinical signs, -the inflammatory cells count in the balf, -their physical examination and -their medical history. the mrna expression of il- , il- b, il- , il- and il- was significantly up-regulated in balf from horses with iad.furthermore, the balf samples were subdivided in two groups based on the differential cells count -balf with increased mast cells (iad-mast) and -balf with increased neutrophils (iad-neutro). il- was significantly down-regulated in the iad-neutro group compared to the iad-mast group. il- , il- and il- were significantly up-regulated in the iad-neutro group compared to the iad-mast group.the present study shows that iad in horses is characterized by a th and a th mrna inflammatory expression profile and that different immunological mechanisms are involved in mast cells or neutrophils accumulation in the balf of horses with iad. b -adrenoreceptor (b -ar) agonists are a class of medications that promote smooth muscle relaxation and bronchodilation in horses and humans with airway disease. activated human peripheral blood lymphocytes (pbls) also respond to b -ar agonist stimulation by attenuating the production of cytokines associated with the pathogenesis of asthma and recurrent airway obstruction (rao). the aim of this study was to develop an in vitro technique for measuring the response of equine pbls to stimulation with salbutamol, a b -ar agonist. this method was then used to compare the response of pbls from rao-affected and non-affected horses to b -ar agonist stimulation. pbls from rao and nonaffected horses were cultured ( x /ml) in rpmi complete media with concanavalin a (cona, ug/ cells) for , , or days then stimulated with salbutamol ( minutes). using flow cytometric techniques, response was measured by detecting protein kinase a phosphorylation of vasodilator stimulated phosphoprotein (vasp). results were verified by western blot analysis. activated pbls were then incubated with cona for one day were pre-incubated with b or b-adrenoreceptor antagonist (ici , , sigma s ; atenolol, sigma s ) for minutes, followed by minutes salbutamol ( nm) stimulation. results were analyzed by anova or ancova and differences were considered significant when p o . .response to b-antagonist was only observed in activated pbls (pre-cultured with con a) and was greater in cells from rao horses as compared to cells from non-affected horses. the addition of b-antagonist attenuated the response of pbls to salbutamol while the addition of a b -antagonist had no effect. these findings indicate that activated pbls from rao-affected horses have a greater response to salbutamol as compared to pbls from non-affected horses, and this response is mediated mainly through the b -ar.human b -ar are known be polymorphic and this polymorphism results in a variable response to b -agonist binding that affects long term outcome in human asthmatics. further studies are required to determine if the difference in response of pbls from rao affected as compared to non-affected horses is due to genetic polymorphism in the equine b -ar, and whether this difference is associated with a propensity for horses to develop equine rao. key: cord- -f oz zyz authors: pastakia, sonak d.; braitstein, paula; galárraga, omar; genberg, becky; said, jamil; vedanthan, rajesh; wachira, juddy; hogan, joseph w. title: preserving decades of healthcare gains for africa in the coronavirus disease era date: - - journal: aids doi: . /qad. sha: doc_id: cord_uid: f oz zyz as coronavirus disease (covid- ) restrictions upend the community bonds that have enabled african communities to thrive in the face of numerous challenges, it is vital that the gains made in community-based healthcare are preserved by adapting our approaches. instead of reversing the many gains made through locally driven development partnerships with international funding agencies for other viral diseases like hiv, we must use this opportunity to adapt the many lessons learned to address the burden of covid- . programs like the academic model providing access to healthcare are currently leveraging widely available technologies in africa to prevent patients from experiencing significant interruptions in care as the healthcare system adjusts to the challenges presented by covid- . these approaches are designed to preserve social contact while incorporating physical distancing. the gains and successes made through approaches like group-based medical care must not only continue but can help expand upon the extraordinary success of programs like president's emergency plan for aids relief. as the coronavirus disease (covid- ) pandemic continues its march to all corners of the world, there is urgent concern about the risks a novel, highly contagious, and deadly virus poses for africa. although the pandemic presents a universal health threat to all populations, the economically disadvantaged are at the greatest risk of short-term and long-term consequences as covid- restrictions upend all aspects of daily living and threatens already fragile livelihoods. patients with chronic conditions -including hiv, hypertension, diabetes, and cancer -are at even higher risk of suffering adverse health outcomes associated with complications of covid- itself and more generally from inevitable interruptions to healthcare throughout all phases of the pandemic. the remarkable improvements to healthcare infrastructure, delivery, and outcomes, facilitated in part through assistance from programs like the president's emergency plan for aids relief (pepfar) and developed over decades through local partnerships, are at risk to be significantly reversed as patients face potential interruptions in care in trying to adhere to social distancing restrictions. in the absence of a specific plan and coordinated effort for implementation, the investment of tens of billions of dollars by development organizations, and the gains in population health that have resulted, are at risk of facing significant losses. fortunately, these investments and partnerships have generated evidence-based and field-tested innovations for delivery of healthcare. many of them were developed to overcome the challenges of responding to the hiv pandemic; they may now be the key to overcoming the daunting challenges presented by coronavirus. one example of these successful partnerships is the academic model providing access to healthcare (ampath), which is a consortium of north american and kenyan universities who work side-by-side with partners from the kenyan government to serve over million people across western kenya. through direct partnership with local governmental and academic partners, ampath has established itself as a leader in developing and implementing innovative solutions to address the needs of vulnerable populations suffering from chronic conditions like hiv, hypertension, and diabetes [ ] . these initiatives are characterized by geographic decentralization, task redistribution, reliable access to medications, community engagement, community health worker involvement, group-based care outside of traditional health facilities, and initiatives designed to address social determinants of health alongside clinical care services. a specific example is the integration of group medical visits into culturally appropriate microfinance groups which rely heavily on strong traditions of social connectedness. within these microfinance groups, community members meet on a weekly or monthly basis to pool their savings and distribute interest-generating microloans that provide community members with liquid assets to help alleviate their economic challenges. across africa, group medical care has been deployed in a variety of different fashions, including formation of patient groups to promote medication adherence and group-based health education sessions [ ] . in a study conducted by our group, we compared communitycentered group-based care delivery with standard strategies based on receiving care at a health facility [ ] . patients with hypertension and diabetes received group medical visits comprising microfinance, group health education, personalized clinical consultation, laboratory tests, and medications from clinicians who travel to the group meetings. the combined interventions: first, increased their rate of linkage to care from to percentage; second, increased retention in care from to percentage; and had greater reductions in sbp ( . vs. . mmhg) [ , ] . similarly substantial improvements in adherence, retention, and viral suppression have been realized in settings that incorporate group-based microfinance activities into hiv care delivery [ ] . in addition to their superior effectiveness in care delivery and health outcomes, the community-based group care model decongests crowded clinics and provides more convenient care for stable patients in locations near their homes. on the contrary, patients who have benefited from group-based interventions and community-centric approaches are disproportionately at risk, given current guidance and instructions to remain physically distanced in their homes and avoid in-person gatherings. for instance, in-person home visits by community health workers and in-person group medical visits would not be feasible in the current context. although challenging, these new restrictions have presented an opportunity for us to develop novel ways to respect physical distancing requirements while preserving community connectedness in a culturally appropriate manner. instead of completely abandoning the social connectedness that has made these past interventions impactful, it is crucial that readily available technologies are adapted to promote physical distancing while preserving social contact. ampath is accomplishing this by leveraging the ubiquity of mobile phones in africa to digitize group-based microfinancing activities through mobile money applications, replacing in-person communication with digital communication, promoting further integration of point-of-care electronic medical records, and using text messaging to coordinate medication drop-offs to safe and convenient delivery points. although these initiatives represent significant departures from our successful in-person community-centric approaches, the increased trust that group-based care has fostered between our providers and the community potentially eases the adoption of new models of care delivery. although covid- has threatened the important social fabric that has enabled communities to withstand many past challenges, we hope to use this opportunity to create a viable and durable option for healthcare delivery that could serve as a model for other chronic disease programs worldwide. while respecting the need for physical distancing, we aim to use the proven effectiveness and viability of group-based care delivery to preserve social bonds by increasing our communication with the community and creating alternate strategies for community members to communicate with each other. in the face of the urgent need to preserve not only effective delivery of care for chronic conditions, but also the health and economic gains demonstrated through group-based care approaches, we are establishing both the framework and evidence for charting a way forward. the gains and successes made through approaches like group-based medical care must not only continue but can help expand upon the extraordinary success of programs like pepfar. there is surely more to be done, but we remain committed to ensuring that the multinational partnerships and locally driven innovations will continue to thrive during and after the covid- pandemic. we have an opportunity to use group-based care, in combination with mobile money and communication advances, to maintain and even improve upon the remarkable gains in healthcare delivery and outcomes realized during the past two decades. leveraging the power of partnerships: spreading the vision for a population health care delivery model in western kenya models of integration of hiv and noncommunicable disease care in sub-saharan africa: lessons learned and evidence gaps impact of bridging income generation with group integrated care (bigpic) on hypertension and diabetes in rural western kenya community health workers improve linkage to hypertension care in western kenya microfinance interventions and hiv treatment outcomes: a synthesizing conceptual framework and systematic review we thank the harambee team (funded by nih: mh ), bigpic study groups (funded by nih: hl ), and the front-line healthcare workers who tirelessly care for hundreds of thousands of patients throughout western kenya.the work described in this perspective was supported in part by the president's emergency plan for aids relief through the us agency for international development under the terms of cooperative agreement no. aid- -a- - . the contents of this article are the sole responsbility of the authors and do not necessarily reflect the views of usaid or the us government. there are no conflicts of interest. key: cord- -p d t v authors: nan title: neocore conference abstracts date: - - journal: indian j pediatr doi: . /s - - -y sha: doc_id: cord_uid: p d t v nan neonatal conference on research and expert talks (neocore) is an annual conference jointly organized by departments of neonatology of sri ramachandra institute of higher education and research (sriher), chennai; christian medical college (cmc), vellore; and jawaharlal institute of postgraduate medical education and research (jipmer), puducherry. there had been three successful conferences conducted in turns since , with good response every time. the fourth annual conference 'neocore ' was conducted by sriher from march - , at chennai. the main objective of the conference is to encourage high-quality research in neonatology in india. the conference serves as a platform to present research works in neonatology to eminent faculty for critical appraisal. there was a total of abstracts for podium presentations, submitted by delegates from leading institutions across the country. gold medal and cash awards were given to the best five papers, that were selected based on the combined score from the evaluations based on a pre-defined scoring system of the blinded manuscript prior to the conference and podium presentation during the conference. in addition, there were expert talks by pioneer neonatologists from all over india. this included the 'dr r shanmugasundaram oration' on "traversing the journey from evidence to clinical practice" delivered by renowned neonatologist, professor siddharth ramji from maulana azad medical college, new delhi. there were expert talks and one debate. the audience were neonatology residents doing dm, dnb or fellowship, as well as practicing neonatologists. in view of travel restrictions due to covid- , two sessions were conducted using an online platform and they were attended online by many neonatologists across the country, in addition to the delegates of the conference. two pre-conference workshops were also conducted. one was 'research methodology and biostatistics -basic and advanced' with professor sourabh dutta, pgimer, chandigarh as the lead instructor. the second was an innovative workshop on 'next-gen learning', first of its kind in a medical conference, in which the delegates were taught advanced functions of basic softwares such as microsoft word, powerpoint and excel, research related softwares such as zotero and spss, online teaching platforms such as kahoot and moodle and search strategy for evidence. the lead instructors for the latter workshop were professor prakash, sriher, chennai, and dr nishad plakkal, jipmer, puducherry. over the years, we envisage neocore to serve as a desired platform for researchers in neonatology to look forward for presenting their high-quality research and to have expert talks based on the expert's own research. it gives us immense pleasure to announce the grand success of neocore under the patronage of professor vishnu bhat and professor binu ninan. we take this opportunity to invite you to participate in the fifth annual conference 'neocore ' to be held in cmc, vellore. it is a great honour and privilege to publish the abstracts of research papers presented in neocore in 'indian journal of pediatrics' and we extend our sincere thanks to the ijp publishers. papers awarded gold medal . comparison of the effect of non-nutritive sucking and cold compression on pain during heel stick procedure among preterm neonates-a randomized controlled trial soumi pal , sivam thanigainathan , vetriselvi p college of nursing, department of neonatology, jawaharlal institute of postgraduate medical education and research, puducherry corresponding author: sivam thanigainathan email: thanigaipaeds@yahoo.com importance: effective pharmacological and non-pharmacological methods are available to control pain. non-nutritive sucking is one of the non-pharmacological methods used widely in reducing pain but this method requires extra manpower in addition to the person doing the procedure. objective: to compare the effect of non-nutritive sucking (nns) and cold compression (cc) in reducing pain during heel prick in preterm neonates. design, setting and participants: this was an unblinded parallel randomized controlled trial, done in tertiary care neonatal unit. the authors recruited preterm infants ( in each group) ≥ wk gestational age, admitted in nicu. methods: after getting written consent from the parents, babies were assigned to either of two groups. for group babies (nns), mothers were instructed to wash their hands and to start non-nutritive sucking before min of the heel prick using her little finger. for group babies (cc), the cold compression was given to the baby using x cm size ice cubes covered by thin cling wrap sheet and was kept for s over the lateral aspect of the sole. physiological parameters and pain score using nips pain scale were measured before, during, after one minute, after two minutes and after min of the heel prick for both groups. results: group and group had equal distribution of gender, birth weight and gestational age. there was no difference in the severity of pain perception during and one minute after the prick (p . and . respectively) between two groups. but, mild to moderate pain persisted till min after the heel prick for group babies than group babies ( . % vs. . % respectively, p . ). after min of prick, no baby was in pain. conclusions and relevance: more babies perceived pain for more than two minutes after heel prick in cold compression group than in nns group. hence, non-nutritive sucking was more effective in reducing the pain due to heel prick than cold compression. objective: to compare the incidence and severity of nasal injury at the removal of cpap in the two groups (hudson prong and ram cannula). patients and methods: neonates with gestational age between - wk and birth weight ≥ g and with respiratory distress needing nasal cpap were enrolled. enrolled infants were randomly allocated to either cpap with hudson prongs or with ram cannula using computer generated random numbers. appropriately sized prongs were used in both the groups. cannula id was used for creating zero leak at nostril in the ram group. all enrolled infants were monitored and assessed for nasal injury using a standard nasal injury score every hourly. relevant infant data was collected prospectively from admission till discharge. results: two hundred twenty nine infants were enrolled. of these, infants were randomized to ram cannula and infants to hudson prongs. both groups were comparable for all the baseline characteristics. any nasal injury at cpap removal was significantly lower in the ram cannula group [n= ( . %) vs. n= ( . %), p= . ]. moderate nasal injury was present in ( . %) infants in the hudson prongs group. none of the study infants had severe nasal injury. any nasal injury at discharge was lower in ram group [n= ( %) vs. n= ( . %) p= . ]. need for mechanical ventilation in the first h was similar between the two groups [ram cannula . % vs. hudson prongs . % p= . ]. nasal interface was changed in infants in hudson prongs and in infant in the ram group. the median duration of cpap was higher in the ram group, p= . . conclusions: for preterm infants supported with nasal cpap, any nasal injury was significantly lower in infants with ram cannula compared to hudson prongs. objective: to study the effect of prophylactic % oral dextrose gel on prevention of neonatal hypoglycemia in infants of diabetic mothers (idm) compared to the standard of care (early, prolonged and frequent breastfeeding with strict thermoregulation). this was an open label, parallel design, randomized controlled trial, done in a tertiary care neonatal unit. infants of diabetic mothers born in authors' unit with > wk and > kg and not requiring admission were enrolled in this study. total babies were randomized to either the study group or the standard of care group. after randomization, mg/kg of % oral dextrose gel was applied to the buccal mucosa of infants in the study group. the standard of care including breastfeeding within - min of birth, prolonged as well as frequent breastfeeding, and strict thermoregulation were followed in both the groups. blood sugars were checked as per unit protocol till h of life. infants with symptomatic, severe or recurrent hypoglycemia were admitted to nicu and the same treatment protocol was followed for both the groups. results: incidence of hypoglycemia in study group and control group were % and % respectively (p . ). there was no difference in neonatal admission due to hypoglycemia, incidence of recurrent and severe hypoglycemia between two groups. incidence of hyperglycemia was more in the study group (p . ) conclusions: prophylactic use of oral % dextrose gel is not superior to standard of care in reducing the incidence of hypoglycemia in idm infants. *** background: among term and late preterm infants, hypoxic ischemic encephalopathy (hie) contributes to % of all neonatal deaths in india. objectives: the primary objective was to study the incidence of survival to discharge among late preterm and term infants with moderate or severe hie. secondary objectives were to explore variation in hie across participating sites and to identify the predictors of survival. methods: it was a retrospective cohort from innc database. survival to discharge was estimated for the whole cohort and individual centers. a multivariable logistic regression model was constructed to identify the predictors of survival. p < . was considered significant. results: of term ( - wk) and late preterm ( - wk) infants with moderate or severe hie from - , % survived to discharge. % of these infants received therapeutic hypothermia (th). phase change material based devices were most commonly used for th. after adjusting for confounders, severe hie (aor . ; % ci . - . ) and pphn (aor . ; % ci . - . ) were independently associated with decreased odds of survival to discharge. objective: family-centered care (fcc) in the neonatal intensive care unit (nicu) facilitates mother-infant bonding with potential benefit for the parents and infants. in this quality improvement initiative (qi), authors planned to effectively implement fcc (defined as proportion of eligible infants receiving fcc on a daily basis) from a baseline of % to % among stable infants admitted in level- nicu over a period of mo through parental education and parental capacity building. methods: this qi is based on a model for improvement and done in three phases; baseline ( mo), intervention (three months) and post-intervention period ( mo) from august to january . neonates admitted in level- nicu were eligible for fcc if they had at least one female family member willing to allocate h a day for neonatal care. neonates with major malformations, hemodynamic instability and those requiring respiratory support were excluded. in pdsa cycle- authors created educational videos for parents in tamil language familiarizing them with nicu, preparing them for entry to nicu and how they could contribute to their infant's care. this was reinforced with one-to-one training by the bed-side nurse on general care, feeding and kangaroo care. in pdsa cycle- , authors identified fcc champions among mothers and facilitated peer teaching and motivation. the primary outcome was the proportion of eligible neonates receiving fcc. results: the proportion of eligible mother-infant dyads involved in fcc increased from a mean of % in baseline phase to % during intervention phase and further to % in post intervention period. the authors did not observe an increase in culture positive sepsis ( per nicu admissions at baseline) or any inadvertent event during the study period. feed interruptions may result in extra uterine growth retardation-a known risk factor for poor neurodevelopmental outcome, especially in vlbw babies. in view of this, a team was assembled and a qi project was initiated with the primary objective being reduction in unnecessary feed interruptions objectives: the primary objective was reduction in unnecessary feed interruptions as part of a quality improvement initiative. the secondary objective was to develop and maintain a written feeding policy to ensure sustained compliance. methods: this project was undertaken in a level iii nicu, catering exclusively to outborn neonates. a qi team was assembled and after a fishbone analysis of problems were identified, a written feeding policy was developed. after three pdsa cycles and looking at run charts for feedback, feed interruption rates were recorded post intervention. results: post intervention, the total feed interruptions reduced from a baseline to . the total rate expressed as a percentage of interruption hours and feed hours reduced from a baseline % to %. conclusions: the implementation of the qi initiative significantly decreased the feed interruption rates from % to %. *** . assessment of age of achievement of full oral feeding and its associated factors among very preterm neonates -a prospective observational study saswati bhowmick , p. vetriselvi , sindhu sivanandan department of nursing and neonatology, jipmer, puducherry corresponding author: sindhu sivanandan email:drsindhusivanandan@gmail.com importance: competency at oral feeding is a must for hospital discharge among preterm neonates admitted to nicu. they are at risk of various morbidities during hospital stay that influences achieving feeding milestones. objectives: this study aimed to assess the progression of feeding milestones and factors influencing the age of achievement of full oral feeding in very preterm neonates ( - wk of birth ga) admitted to nicu. methods: this prospective observational study included very preterm neonates admitted in nicu during august and september . the authors used a convenient sampling technique that enrolled neonates tolerating any volume of milk for three consecutive days. they excluded neonates with major congenital malformations, craniofacial anomalies, surgical conditions of gastrointestinal tract and death during hospitalization. the authors collected data on demographics, morbidities and feeding milestones during hospital stay after obtaining informed parental consent. the feeding milestones assessed were, age at first enteral feeding, full enteral feeding, first oral feeding, and full oral feeding. results: fifty six neonates belonged to - wk ga category and to - wk ga category. the pma of initiation and achievement of full oral feeding were (mean ± sd) . ± . and . ± . wk respectively. infants belonging to the - wk ga category required gavage feeding for a longer duration compared to those belonging to the - wk ga category ( . ± . vs. . ± . d). however, both the ga categories achieved full oral feeds at similar pma ( . ± . wk compared to . ± . wk). conclusions: in this study, the age of achievement of full oral feeding among very preterm neonates was wk. although the duration of gavage feeding was greater among - wk category, this group also achieved full oral feeding at wk pma despite being at higher risk of morbidities. *** . a quality improvement project to improve functioning of donor human milk bank sylvia jabakani, divya p, krishma k, vijaya calevanane, bethou adhisivam, sindhu sivanandan department of neonatology, jipmer, puducherry corresponding author: sindhu sivanandan email: drsindhusivanandan@gmail.com background: mother's milk is the ideal food for a neonate. when mother's milk is unavailable for any reason, pasteurized donor human milk is the next best option. objective: this quality improvement project evaluated the effect of a multipronged intervention for improving voluntary donation in a public human milk bank (hmb) in south india. methods: between january and june , the hmb received an average of l of donor milk per month ( . l/d). the aim was to increase voluntary milk donation by % from baseline over a period of mo using qi methods. two pdsa cycles were done during the intervention period ( mo). in cycle- , multiple micro teams were formed in all the postnatal wards to promote exclusive breastfeeding, troubleshoot breastfeeding issues and to form a liaison with the core qi team. a whatsapp group was used for networking among the teams. a separate milk expression area was created in the postnatal ward. in cycle- authors focused on counselling postnatal mothers for milk donation and addressed supply chain issues like sterile pumping accessories. the qi efforts were sustained in the post intervention phase ( mo) by monthly staff appraisal and feedback. results: the average daily donation to hmb increased from . l/d in the baseline phase to . and . l per day in the intervention and postintervention phases. the volume of pasteurized donor milk disbursed from hmb increased from . ( . ) l/mo to . ( . ) l/mo; p= . after qi. the number of mothers donating milk per month did not change significantly during the study period. background: postnatal growth failure (pgf) is a major morbidity of vlbw infants, which can have long term effects. objective: the primary objective was to reduce the pgf rate of vlbw infants by %. methods: this was a quality improvement project in a tertiary care nicu. the authors included all inborn vlbw infants not having major congenital anomaly or genetic and metabolic disorders. baseline phase was november and december of and intervention phase was between january and july. interventions included introduction of new feeding protocol, feedback for the stakeholders in person or via messages, education of mothers for breastfeeding and kangaroo mother care, peer group teaching by mothers and providing tags for adequately growing babies. progress was plotted in run charts. spss and ms excel were used for the analysis. results: study sample included infants ( . % males) in baseline phase and infants ( . % males) in the intervention phase and infants in sustenance phase ( . % males). the mean gestation was . , . and wk during the baseline, intervention and sustenance phase respectively. pgf decreased from . %to % and sustained at %. time to first feed decreased by h and mean age at reaching ml/kg/d of feeds decreased by d and time to regain birth weight decreased by d. incidence of mortality, nec, anemia requiring transfusion, pda and metabolic bone disease did not change significantly during the study. conclusions: pgf can be reduced by systematic feeding protocol and by quality improvement methods. *** background: among term and late preterm infants, hypoxic ischemic encephalopathy (hie) contributes to % of all neonatal deaths in india. therapeutic hypothermia is the standard of care in term infants with hie but has been shown to provide up to % neuroprotection in moderate to severe hie. additional neuroprotection may be achieved by using concomitant pharmacological neuroprotective agents. the neuroprotective role for the magnesium sulfate therapy given to at-risk mothers for preterm birth for the preterm fetus is well established now. objectives: primary objective: to compare the composite outcome of neonatal mortality or abnormal neurodevelopmental outcome ( y of age) among term infants with hie treated with magnesium sulfate and therapeutic hypothermia (group a) and therapeutic hypothermia alone (group b). secondary objectives were to compare the neonatal mortality, neurodevelopmental disability at y of age, hospital course and adverse effects of magnesium sulfate. methods/design: parallel group randomized controlled trial. results: the baseline characteristics were comparable between the intervention and comparator group. a total of infants died or had abnormal neurodevelopmental outcomes at y of age in the magnesium and therapeutic hypothermia group as compared to infants in the therapeutic hypothermia alone group. however the difference was not statistically significant (p value . ; relative risk . ; % confidence interval . - . ). conclusions: the combination of magnesium sulfate and therapeutic hypothermia did not improve the composite outcome of neonatal mortality and neurodevelopmental outcome at mo of age. the dose of mg/kg/dose once every h for d did not result in the adverse effects like hypotension or respiratory depression requiring assisted ventilation, however, it caused hypermagnesemia in the intervention group. *** . d speckle tracking echocardiography derived deformation imaging in very preterm neonates-a prospective exploratory study sreedhara ms, prakash a, umamaheswari b, ashok c department of neonatology, sri ramachandra institute of higher education and research, chennai corresponding author: prakash a email: draprakash @gmail.com background: deformation imaging by d speckle tracking echocardiography is a promising tool for cardiac assessment of preterm neonates. objectives: to assess the . feasibility and reproducibility of deformation imaging . normal pattern of global longitudinal strain (gls) . usefulness of gls in predicting the need for pda treatment and development of bpd. methods: very preterm neonates were recruited prospectively. echocardiography was performed by a single investigator at - , - & - d of life and at wk pma or before discharge using philips cx machine. strain quantification in apical -chamber loops was done using q lab tm software. reproducibility was evaluated by repeating the analysis on % of images by the primary investigator and a cardiologist. . ( . ), . ( . ), . ( . ) respectively at predefined time points. repeated measures of anova did not show any change in gls over time. icc for intra-observer and inter-observer agreement for gls-lv and gls-rv were . , . , . and . respectively. gls-lv at - d predicted pda treatment (p= . ) and gls-rv at - d (p= . ) and at - d ( . ) predicted bpd by multivariate analysis. conclusions: deformation imaging is feasible in very preterm neonates with good reproducibility. lv-gls and rv-gls within h predict pda treatment and bpd respectively. *** . non-invasive bilirubin sensor for continuous monitoring and automatic control of phototherapy for infant jaundice treatment akshaya j , k ragadeepthi , vijitha venugopal , prakash amboiram , angeline kirubha sp biomedical engineering, srm institute of science and technology, chennai; department of neonatology, sri ramachandra institute of higher education and research, chennai corresponding author: angeline kirubha sp email: angeline.sp@ktr.srmuniv.ac.in abstract: measurement of bilirubin content in neonates at an early stage is important to prevent any serious illness such as jaundice. jaundice meter that can determine bilirubin count is widely used as a diagnosis procedure and the treatment procedure includes phototherapy, which uses blue light to break down the bilirubin by isomerization. both the diagnosing and treatment procedures are manual methods which require external assessment. in order to make both the procedures automatic, the non-invasive bilirubin sensor has been designed which is compact for continuous monitoring of bilirubin values. based on bilirubin value measured by sensor, light intensity of phototherapy setup can be altered using machine learning and iot technology. the non-invasive bilirubin sensor follows spectro-photometry principle. a machine learning algorithm is developed in order to provide high speed optimization and control of the overall application. various aspects like the bilirubin count, severity of fever, saturation of skin pigment, etc. will be used as a predetermine input for the ml algorithm, based on which, the measures for various treating parameters will be controlled. the microprocessor will offer the system to run as a standalone application and aids to update the results to a cloudbased server-client (iot) system for the hospital to maintain and organize patient records. *** . cerebroplacental ratio percentile -a predictor of adverse pregnancy outcome sunantha perumal, chitra andrew division of fetal medicine, department of obstetrics & gynecology, sri ramachandra institute of higher education and research, chennai corresponding author: chitra andrew email: chitraandrew@gmail.com aim: to evaluate the predictive efficacy of cerebroplacental ratio (cpr) percentile in third trimester to identify fetuses at risk of adverse pregnancy outcome and to compare with the conventional parameters estimated fetal weight, umbilical artery pulsatility index and cerebroplacental ratio (cutoff < ). methods: this was a retrospective cohort study done between september and september , at fetal medicine unit, sri ramachandra medical centre. following approval from the ethics committee, women with a single non-anomalous fetus, delivered within wk of fetal doppler study in the third trimester were included in the study. the parameters efw (< th centile), ua-pi (> th centile) and cpr (< th centile) were calculated. perinatal outcomes assessed were intrapartum ctg abnormalities, operative delivery for fetal distress, preterm delivery, low birth-weight (bw) centiles, and a composite neonatal outcome. statistical indices calculation and results analysis was done using spss software version . results: cpr (< th centile) had a sensitivity of %. when all parameters were normal, pregnancies had adverse outcomes. cpr percentile values were abnormal in of them ( %). combination of cpr and efw had high specificity of . % and positive predictive value of . %. conclusions: comparatively, cpr percentile is a better predictor of adverse outcome and can be affected earlier in fetal hypoxia, than other parameters. the addition of cpr percentile to efw improves the positive predictive value of the test which can be used to optimize the perinatal outcome without increasing unnecessary interventions. *** . effect of hydrocolloid dressing on nasal injury among preterm neonates on nasal continuous positive airway pressure (ncpap): a randomized controlled trial takhelmayum bideshwori , nishad plakkal , p vetriselvi college of nursing, jipmer; department of neonatology, paediatric c.o.n, jipmer corresponding author: nishad plakkal email: plakkal@gmail.com importance: nasal continuous positive airway pressure (ncpap) is widely used in management of respiratory distress. preterms are at high risk for nasal injury during ncpap. objectives: to assess the effect of hydrocolloid dressing, when compared to petrolatum jelly (vaseline®) application, on nasal injury among preterm neonates on ncpap and to identify the association of nasal injury with their clinical characteristics. design, setting and participants: this randomized controlled trial was conducted at nicu, jipmer. seventy-eight preterm neonates with gestational age - wk receiving ncpap > h were consecutively enrolled and randomly allocated to treatment (hydrocolloid, n= ) or control group (vaseline, n= ). methods: in group , hydrocolloid dressing was cut to a length of - cm with two holes applied around the nostril before ncpap was connected. in group , vaseline was smeared around the nostril before ncpap was connected. assessment was done at baseline and once daily, until wk of age or when ncpap was discontinued, whichever was earlier. the dressing in group was changed daily; petrolatum was applied during assessment as per standard practice. the skin, nasal septum and nostrils were examined, and findings were recorded, along with a clinical photograph. results: fourteen preterm neonates (hydrocolloid= and control= ) developed nasal injury. the difference was not statistically significant [in group , normal= ( . %) and mild= ( . %); in group , normal= ( . %), mild= ( . %) and moderate= ( . %)]. no infant in the study had severe injury. an association between the level of nasal injury and duration of ncpap (p < . ) in the hydrocolloid group was noted. conclusions: although not statistically significant, there was a reduction in each level of nasal injury and overall incidence with the use of hydrocolloid dressing. objectives: to determine the effect of time to reach full feeds ( ml/ kg/d) on mortality and morbidity among preterm neonates and factors influencing the time to reach full feeds. methods: this prospective observational study was conducted in a level iii nicu, department of neonatology, iog from july to january , and included preterms - wk. results: out of the preterms, babies were started exclusive enteral feeding on day reaching full feeds within h with . % survival, mortality being significantly less (p < . ). the incidence of culture positive sepsis was less in babies reaching full feeds within h ( . %) with a significant less usage of antibiotics [median duration of ( , ) d] vs. babies taking > d [ . %culture positive sepsis, ( . , ) d of iv abx.]. the incidence of pda ( . %), ivh ( . %), rop ( . %), bpd ( %), nec ( %) & inotropic requirement ( . %) was significant less in the babies reaching full feeds earlier whereas the same being %, %, %, %, % & % respectively for babies reaching full feeds > d; the duration of nicu stay & ventilation being significantly shorter in babies reaching full feeds earlier. doppler abnormality, sga < rd centile, steroid coverage and hie had no influence on time to reach full feeds. conclusions: early attainment of full enteral feeds reduces the mortality, culture positive sepsis, nec, pda, ivh, rop, bpd, inotropic requirement, duration of ventilation, iv antibiotics and hospitalization. *** . what are the factors associated with necrotizing enterocolitis in a developing country? a multicenter collaborative study gokuldas punnadan koroth , nivedita mondal , sreekumaran nair , nishad plakkal department of neonatology and medical biometrics and informatics, jipmer, puducherry corresponding author: nishad plakkal email: plakkal@gmail.com background: necrotizing enterocolitis (nec) is a serious morbidity of preterm infants. objective: the primary objective was to identify the incidence of nec in infants < wk or with very low birth weight (bw < g). design/methods: setting: the indian neonatal collaborative (innc) is a network of neonatal units in india. design: retrospective cohort; infants born at < wk or bw < g in - were included. analysis: after descriptive statistics, multivariate logistic regression model was constructed to identify potential predictors. stata was used for analysis. results: two thousand six hundred thirty two infants from centers were included ( . % males). the mean gestation was . wk (iqr - wk) and mean birth weight was g. seventy six infants developed nec (incidence . %). among infants with nec, mean gestational age was . wk and mean bw was g. mortality was . % in infants with nec, compared to . % in infants without nec. among sites, the incidence of nec varied from % to . %. after adjusting for potential confounders in the regression model, antenatal doppler abnormalities (aor . ; % ci . - . ) and neonatal sepsis (aor . ; % ci . - . ) were independently associated with increased odds of nec, and higher bw was associated with lower odds (aor . ; % ci . - . ). conclusions: the incidence of nec in this cohort of infants was . %. nec increased with sepsis, antenatal doppler abnormalities and lower birth weight. large inter-center variation in nec was noted. *** outcomes such as cognitive, language, gross and fine motor development, behavioral and emotional regulation. programs that are culturally appropriate, independent of literacy, easily understood and implemented are lacking in our population. objectives: to develop an educational-behavioral program on early intervention for parents of preterm infants admitted in the neonatal icu. also to evaluate the effectiveness of this program in reducing maternal stress, anxiety and improving parent-infant bonding. study design: prospective phase lag interventional cohort trial methodology: this is a preliminary report. mothers of preterm infants (≤ wk and birth weight < g) with working knowledge of english or tamil were recruited. a wk pictorial educational behavioral program was developed entitled "parent administered neuro-developmental activities (nicu-panda)". mothers attended sessions of min each in addition to standard care. pre and post tests were done at recruitment and after wk using the state-trait anxiety inventory (stai), parental stress scale (pss-nicu) and postpartum bonding questionnaire (pbq). results: twenty-three mothers completed the intervention program. there was a significant reduction in the mean anxiety (p < . ), stress (p < . ) and improved postpartum bonding (p < . ) between the pre and post-test scores using stai, pss-nicu and pbq respectively. the post-test scores were not associated with any maternal or infant demographic variables except length of hospital stay. conclusions: the parent-mediated early intervention program which was developed was found effective in reducing anxiety, stress and improving postpartum bonding for the mothers of preterm infants in nicu. *** . effect of early sodium supplementation in preterm neonates between and weeks of gestational age on postnatal weight gain: a double blinded randomized controlled trial anvesh amiti, prakash a, umamaheswari b, usha devi r, abdhul gani department of neonatology, sri ramachandra institute of higher education and research, chennai corresponding author: prakash a email: draprakash @gmail.com objectives: to compare velocity of weight gain (g/kg/d) at wk pma in neonates born between + and + wk of ga with early sodium supplementation vs. placebo. methods: this double blinded rct was conducted in a level iii tertiary nicu and included neonates + to + wk ga who had reached minimum of ml/kg/d feeds and between and dol and with serum sodium < mmol/l. neonates with major malformations incompatible with life, gastrointestinal anomalies, npo and renal insufficiency were excluded. intervention group received enteral meq/kg/d of % sodium chloride equally distributed in all feeds and control group received . % saline of similar volume. weekly growth velocities of weight, length and hc were taken. results: interim analysis was done for this study. total neonates were eligible for the study; parents were not given consent, neonates did not reach feed volume ml/kg/d, neonates had sodium > and hence were excluded. so, the authors enrolled neonates for the study. out of them, currently the study is ongoing on neonates. finally, total neonates ( -intervention, -study group) were included for analysis. there was no statistical difference in baseline variables except for mode of delivery. median weight gain velocity (g/kg/d) was higher in intervention group . (iqr: . - . ) compared to control group . (iqr: . - . ) and it was statistically significant (p value- . ). no difference was found in other secondary outcomes like weekly length and hc velocities, duration of ventilation, bpd, rop, ivh, and days to reach birth weight. conclusions: early sodium supplementation improves short term weight gain at wk of pma. larger studies are required to see long term outcomes and adverse effects. *** background: most neonatal intensive care units (nicus) use fortified human milk but specifics of timing, composition, and advancement of feeds vary. as per the evidence available, early fortification of human milk improves postnatal growth, improves protein, calorie and mineral intake without any significant issues of nec and feed intolerance. however, data regarding long term growth and neurodevelopment remains inconclusive. objectives: to study the efficacy of early vs. delayed human milk fortification in very low birth infants and its effect on anthropometry and morbidities. methods: very low birth weight preterm babies (n = ) were prospectively randomized to early fortification (ef) (beginning at a feeding volume of ml/kg/d) or delayed fortification (at a feeding volume of ml/kg/d). the authors employed a standardized feeding protocol and parenteral nutrition guidelines for the nutritional management of all study infants. results: the median duration of tpn was equivalent in the groups ( vs. . d; p= . ). no significant difference was observed in the total number of episodes of feeding intolerance and necrotizing enterocolitis. median ofc gain velocity (cm/wk) was significantly higher in ef group introduction: surfactant is essential to normal lung function in babies. policy of early rescue should be standard i.e., within h of birth. it is commonly seen that there is a delay in administering surfactant. objective: the authors aimed to identify the reason of delayed dosing and clinical implications of the same by an observational study. materials and methods: all babies who received surfactant over a year were included in the study. babies with congenital anomalies were excluded. quantitative data was expressed in percentage and central tendency was expressed in median. mann whitney test was done for evaluation of difference in outcome. p less than . was considered significant. results: total neonates received surfactant; % received delayed surfactant. median gestational age for early group was wk and late group was wk respectively. primary respiratory support was cpap in . % babies, intubation in . % babies and oxyhood in . % babies who eventually received surfactant. mann whitney test was done to find the difference in duration of respiratory support, which was found to be statistically significant (p= . ). main cause of delayed surfactant in inborns was due to persistent / progressing distress on cpap ( . % of inborn babies who received late) and in outborns due to delay in transport from referral hospital ( . %) and no cpap ( . %) as initial respiratory support. conclusions: clinicians must be aware of early use of cpap and early transport to facilitate early surfactant. one must also be aware on use of surfactant in view of persistent or worsening distress and not just fio requirement to give surfactant. objective: to analyze the perinatal outcome of antenatally detected fetal intra-abdominal cysts. methods: this was a retrospective study of fetuses with intra-abdominal cysts on antenatal scans done between january and december at sri ramachandra medical centre. data was collected from the ultrasound database. maternal, fetal, and neonatal characteristics were retrieved from the electronic patient records and through telephonic enquiry. results: a total of fetuses were diagnosed with intraabdominal cysts antenatally; mostly in third trimester. of these, there was one ongoing pregnancy, two lost to follow up, three pregnancy losses and live births. isolated cysts were seen in ( %) fetuses and five ( %) had associated abnormalities. cyst regression was observed in utero in two ( %) and postnatally in cases. postnatal diagnosis was not made in ten cases. there were more girls than boys ( girls and boys) in this study. ovarian cysts were diagnosed in % of cases with persistent cysts. most pregnancies ( %) were managed conservatively and % underwent surgical management. conclusions: isolated cysts have good outcome. those with associated abnormalities are likely to have poor prognosis. cysts are common in girls and are usually ovarian cysts, which can regress in utero or postnatally. gastrointestinal tract abnormalities are mostly observed in boys and are likely to have good outcome following surgical management in the immediate postnatal period. antenatal detection of intra-abdominal cystic lesion helps to offer appropriate antenatal and postnatal follow up and management. *** received nephrotoxic drugs (p < . ). duration of hospital stay (days) in aki group was . ( . ) compared to non aki group, . ( . ), p= . . on logistic regression, use of nephrotoxic drug was found to be the single most risk factor with or . ( % ci: . - . ). conclusions: male sex, sepsis and nephrotoxic medications are independent risk factors for aki. use of nephrotoxic medication is the single most important risk factor for aki. *** . knowledge, attitude and practices in breastfeeding among health care professionals in a tertiary care centre ajinkya wazurkar, nalini, neelam sundara raghupathy department of pediatrics, avmch puducherry, vinayaka mission's research foundation university, salem corresponding author: nalini email: nallu_ @yahoo.co.in importance: mothers should be instructed about baby's hunger cues, proper positioning and attachment, feeding frequency and counselling regarding problems faced during breastfeeding. health care professionals can play an important role in this aspect. objective: to assess knowledge attitude and practices of health care professionals in breastfeeding through a pre-validated questionnaire in avmch, puducherry. methods: pre validated open ended questionnaire was given to all the participants comprising faculty, postgraduates, staff nurses, interns, final year mbbs and nursing students. results: out of participants, mean knowledge score was highest among faculties which was . % (range . to . %) and mean practice score was . % ( . to %) and lowest among bsc final year nursing students where mean knowledge score was . % ( . to %) and mean practice score was . % ( . to . %). there was a statistical difference (p value < . ) between combined knowledge and practice scores of interns, final year mbbs and nursing students. participants were having lack of knowledge especially about contraindication of breastfeeding among nursing final year students ( . % score), staff nurses ( . %) and mbbs students ( . %). attitude had been assessed by likert scale, where faculty and postgraduates were having good attitude regarding all questions asked, whereas among other participants some lack of attitude was observed. conclusions: in this study, gaps in knowledge and practices among health care workers was identified. in professional students it is evident that there should be improvement in knowledge through proper teaching and they should be taught skills for practices, for example, proper positioning and attachment for breastfeeding. counselling efforts were lacking. *** . effect of antenatal corticosteroids (acs) in neonatal mortality and morbidity in preterm - weeks small for gestational age (sga) infants when compared to non-sga infants: a retrospective single centre cohort study p ajai kumar, mangalabharathi sundaram, prakash vinayagam department of neonatology, institute of obstetrics and gynecology, madras medical college, chennai corresponding author: mangalabharathi sundaram email: drmangalabharathi@gmail.com introduction: maternal antenatal corticosteroid (acs) administration in preterm labor reduces the incidence of neonatal respiratory distress syndrome (rds) and neonatal mortality. acs usage is the most effective intervention for these risks associated with preterm birth but current recommendations for acs use do not differentiate between sga and non-sga fetuses. objectives: to analyze neonatal outcomes in sga and non-sga preterm infants with acs usage. methods: a retrospective database analysis was performed for preterm infants ( - completed wk) born in july -september . clinical details, weight for gestational age, mortality and major adverse events were noted. analysis was done with chi square, fischer's and t-test. results: one hundred ninety six preterm infants were included in the study. there were non-sga infants and sga infants, with acs usage of and respectively. there was no difference in mortality between sga and non-sga with acs usage (or . , %ci . to . p= . ) there were no significant differences in incidence of rds (or . , %ci . to . ), nec, pda, rop and ivh. conclusions: usage of acs in sga fetuses at risk of preterm delivery does not lead to worse perinatal outcome. *** validation of winrop for prediction of severe retinopathy of prematurity among preterm less than weeks-a diagnostic study . follow-up rates in a three-year longitudinal study of neurodevelopmental outcomes of a preterm cohort in south india acute kidney injury in neonates in level nicu-a matched case control study methods: children (n= ) born ≤ wk ga or between - wk with significant risk factors, enrolled in a child development unit formed the sampling frame. families were contacted over the phone for enrollment and follow-up. field and research assistants conducted developmental screening and assessments respectively at -, -and -mo. appointments were rescheduled as needed and reasons for missing appointments were documented. home visits were made for families who consented to participate but were unable to visit the clinic. results: among the children enrolled at -mo ca, ( %) and ( %) children completed participation at -and -mo respectively. follow-up rate at the clinic was % and % respectively. the reasons for home-visits and loss to follow-up differed at different timepoints. families with twins/ triplets requested home visits at enrollment. subsequent pregnancy of the mother and child going to school/presence of a younger sibling at home were reasons for the inability to visit the clinic at -and -mo respectively. timely scheduling, multiple reminders and rescheduling facilitated follow-up clinical and investigation data were extracted from medical records. risk factors were analyzed using multivariate logistic regression. results: total cases and controls were enrolled for the study. incidence of aki was . %. among aki patients, ( . %) were males. mean birth weight (sd) in kilograms of aki group was . ( . ) and . ( . ) among non-aki group. the incidence of aki was higher in those who received nephrotoxic drugs background: poor postnatal weight is a risk factor for rop. winrop (weight, igf , neonatal rop) algorithm is an online tool which predicts the risk for severe rop (type ) based on gestational age, birthweight and weekly weight gain. objective: to validate the diagnostic accuracy of the winrop (https:// winrop.com/) in predicting type i rop. methods: diagnostic study design was conducted among babies < wk gestation born between jan and dec with weekly weight and final rop status available. based on weekly weight, algorithm signaled an alarm to indicate high risk for type rop. from rop requiring treatment, sensitivity, specificity, ppv and npv were calculated. results: a total of babies were included with a mean gestational age of ± . wk and mean birth weight of ± g. sixty three ( %) developed type rop and ( %) developed type rop. the median time from birth to alarm was wk (iqr - wk) and alarm to treatment was . d (iqr . - . ). overall sensitivity of winrop for type rop was %, specificity %, ppv %, npv . %, lhr (+) was . . among less than wk, sensitivity was % and npv . %. conclusions: winrop is a useful non-invasive tool for screening, particularly in babies less than wk in early identification of type rop. *** . follow-up rates in a three-year longitudinal study of neurodevelopmental outcomes of a preterm cohort in south india lakshmi venkatesh , adhirai garibaldi , roopa nagarajan , binu ninan , udayakumar narasimhan , prakash boominathan key: cord- -bq h authors: romano, mario r.; ferrara, mariantonia; rocha-de-lossada, carlos; angi, martina; govetto, andrea; mastropasqua, rodolfo; romano, vito title: active e-learning in ophthalmology through live webinars: back to the theatre date: - - journal: eye (lond) doi: . /s - - - sha: doc_id: cord_uid: bq h nan we read with interest the article titled "transforming ophthalmic education into virtual learning during covid- pandemic: a global perspective" by chatziralli et al. [ ] . they highlighted the need of the continuity of ophthalmology education and the crucial role that e-learning may have during pandemic [ ] . in a previous survey-based study assessing the impact of pandemic on training, we outlined that the long-term reorganization of ophthalmology education can significantly benefit from technology-based teaching tools [ ] . moreover, educational activities involving learners' active participation and promoting interaction (active learning) are known to be superior to passive lecturing in terms of teaching effectiveness [ ] . in this regard, we describe, for the first time, an innovative model of active e-learning in a web-based course in vitreoretinal surgery, held at humanitas university, milan, italy. the course was entirely broadcast online and structured using webinars and active learning techniques (casebased discussion, pause procedures, commitment activities, open discussion) ( table ) . ninety-nine participants (ophthalmology trainees and specialists) attended the course, of which (group a) at the venue and (group b) via live streaming. lecture and surgery webinars were followed via live streaming by both groups, whereas formal lectures, case-based and open discussion sessions were attended at the venue by group a and via live streaming by group b. a course evaluation survey was conducted using a five-point scale ranging from (very poor) to (excellent). overall, the participants were highly satisfied with the course ( . ± . in group a, . ± . in group b) and teaching effectiveness ( . ± . and . ± . in group a and b, respectively). the interaction level was highly rated regardless of attendance modality ( . ± . in group a, . ± . in group b). both groups strongly appreciated lecture and surgery webinars ( . ± . and . ± . in group a, . ± . and . ± . in group b, respectively). mean scores did not significantly differ for all the items between the groups ( table ) . ophthalmology active e-learning may be a promising teaching format, preserve interaction and audience engagement and, thus, improve ophthalmology education, ensuring the continuity of learning beyond any situational barriers. transforming ophthalmic education into virtual learning during covid- pandemic: a global perspective reshaping ophthalmology training after covid- pandemic novel educational approach for medical students: improved retention rates using interactive medical software compared with traditional lecture-based format acknowledgements the authors thank hannah levis for proofreading this manuscript. conflict of interest the authors declare that they have no conflict of interest.publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- - sr djft authors: mentus, cassidy; romeo, martin; dipaola, christian title: analysis and applications of adaptive group testing methods for covid- date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: sr djft abstract testing strategies for covid- to maximize number of people tested is urgently needed. recently, it has been demonstrated that rt-pcr has the sensitivity to detect one positive case in a mixed sample cases [ ]. in this paper we propose non-adaptive and adaptive group testing strategies based on generalized binary splitting (gbs) [ ] where we restrict the group test to the largest group that can be used. the method starts by choosing a group from the population to be tested, performing a test on the combined sample from the entire group and progressively splitting the group further into subgroups. compared to individual testing at % prevalence we save % at % we save % and at % we save % of tests. we analyze the number of times each sample is used and show the method is still efficient if we resort to testing a case individually if the sample is running low. abstract in addition we recommend clinical screening to filter out individuals with symptoms and show this leaves us with a population with lower prevalence. our approach is particularly applicable to vulnerable confined populations such as nursing homes, prisons, military ships and cruise ships. testing capacity for covid- is still too scarce to meet the needs to meet global health needs. conned are at particular risk for rapid contagion. they may include those who reside in facilities such as prisons, ships, military units and nursing homes. the goal of this paper is to increase the capacity to identify asymptomatic carriers of covid- by applying group testing methods. current practice typically involves a one-patient-one-test strategy. recently the potential to detect covid- rna in a mixture of samples from individuals has been validated [ ] using rt-pcr. the method was rst devised in during world war ii to test large groups of us servicemen for syphillis prior to deployment [ ] . now, just as in the wwii era, large scale testing is necessary. covid- is a highly contagious disease that can lead to pneumonia, acute respiratory distress syndrome (ards) and death. clinical symptoms and phyiscal exam features may include fever, cough, shortness of breath, malaise, lethargy, ageusia, anosmia and gastrointestinal (gi) symptoms. besides this diseases potential lethality, it is highly contagious. with the demonstrated success of group testing using rt-pcr for nding sars-cov- rna [ ] , there is a renewed interest in the practical applications of mathematical group testing algorithms. in [ ] a nonadaptive group testing method and practical applications are explored. we describe both non-adaptive and adaptive group testing based on generalized binary splitting (gsb) [ ] . the adaptive approach optimizes group size according to the prevalence. we provide an algorithmic specication for subdividing groups and account for the limited test accuracy and the possibility that the an individual's sample size constrains the number of tests. we explain how prescreening symptomatic cases and separately testing them ca dramatically improves the performance. pre-screening reduces the prevalence in the test groups, this approach is relevant for large scale populations and particularly for conned groups. figure . : (image credit: matthew heidemann) our group testing method consists of rst clinically screening out symptomatic individuals. this will lower the prevalence in the test population. our group testing is especially eective when we can assume the prevalence is uniform over the whole population. therefore, it is especially applicable to conned or cohesive populations. we split the asymptomatic individuals up into groups for which we mix the samples from each individual and test them. a negative result will conrm many negative cases. we subsequently divide groups and test the mixtures of samples for positive results. this we show, conserves the number of tests and, as a result, the time spent testing. using numerical experiments, we also show that our methods can be performed without running out of samples from passing through too many rounds. this application utilizes a primary clinical screening step to ensure that the tested population is composed of asymptomatic covid- (-) and (+) patients. this ensures the lowest prevalence of disease in the population and enhances the ecacy of the method. clinical screening should rst take place in the selected population to screen out as many potential positive patients as possible before administering the test. all patients with history of cough, shortness of breath, nausea, gastrointestinal symptoms, fever, malaise, lethargy, recent contact with positive covid- patients, have physical exam consistent with those ndings should be segregated out of the population. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint clinical screening will decrease the prevalence of covid- carriers in the test population if the probability of being asymptomatic given covid- (+) is less than the proportion of the population that is asymptomatic (regardless of covid- (+) or (-)). we demonstrate this by proving the following claim. claim. the sub-population not showing any symptoms will have a lower proportion of symptomatic carriers when the proportion of people not showing any symptoms in our group is less than the estimated proportion of covid- carriers who are asymptomatic. we can prove this through a couple of applications of bayes' theorem. we refer to the event that an individual does not show symptoms as no symptoms. the event that an individual has symptoms that are signs of covid- is referred to as symptoms regardless of whether they carry the disease. we denote the event of carrying the covid- virus as covid- . then an asymptomatic carrier is referred to as no symptoms and covid- . let p (a) denote the probability of an event a occuring. written in terms of probabilities, screening will help when p (covid- |no symptoms) < p (covid- ). re-writing the left side of the inequality, we get p (covid- |no symptoms) = p (covid- and no symptoms) p (no symptoms) = p (no symptoms|covid- ) p (no symptoms) p (covid- ). . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint therefore it is necessary and sucient for p (no p (no symptoms) < , which is the same as p (no symptoms|covid- ) < p (no symptoms). this is the probability of being asymptomatic given that they have covid- for the population we are testing. if a population has a low prevalence of covid- then it is likely for groups of individuals to not have any positive cases. therefore it is often the case that one test of the mixture of their samples is all that is needed to determine that they are all negative. in this example cases are conrmed either (+) or (-) using tests. some cases are left un-determined for future rounds of testing. otherwise, a positive result on the combined samples indicates that there are some positive cases. we are therefore able to design a strategy to use less tests to determine whether each individual is positive or negative for the disease by testing mixtures of samples from groups. to suciently identify negative cases and positve cases the groups must be large enough to balance nding many negative cases with one test, and locating some positive cases. step one of the group test method is: . a group size is chosen so that the frequency that a group has only (-) cases (gure . ) is roughly equal to the probability we nd at least one (+) case in the group. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint table . : group size specied for the divide and test method. by dtg we mean to apply divide and test, using the minimum of g and the group size for divide and test (e.g. dt will use a group of size if dt uses a group of size ). we study limited group sizes to explore how many tests can be saved depending on the limitations of the instruments. if the test of the group's combined samples is positive, indicating that one of the individuals in the group is positive, apply a routine of repeatedly dividing the group into subgroups applying tests to the subgroups until a positive individual is identied. this is step two of the group test method. . if the rst test is (+), divide the group into two subgroups of equal size. test the combined sample from individuals in one subgroup to determine which halve contains some positive individuals. repeat this step on the subgroup that contains the positive cases. this routine is referred to as binary search. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint when the test result of the group's samples is (+) we split the group into two equally sized subgroups testing one of them to decide if it contains some positive cases or if it consists entirely of negative cases. in the second situation, the second half must contain positive cases. continue the search on the subgroup with positive cases in the same way dividing it into two halves test- . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint ing the mixed samples from one of the half-subgroups. repeating this step we are able to nd one positive case. along the way many groups of several individual are likely to be conrmed negative with a relatively small number of tests. any subgroup that was not tested retains its undetermined status and is returned to the general set of samples to be conrmed positive or negative. . repeat the procedure starting with . on the individuals in the population for which whether they carry the disease has yet to be determined. in this paper we consider group testing methods that follow two dierent interpretations of step in the procedure above: methods with a xed group size and methods where the group size changes based on the results of previous tests. each type of method uses a slightly dierent denition of prevalence. prevalence is dened as the probability p an individual in the population has covid- . for each level of prevalence we specify a xed number of individuals to test their combined samples, performing binary search if it is positive. the xed group size method we analyze in this paper is divide and test (dt). we also consider dorfman's method as a method to compare the methods against, as well as a simpler alternative that only ever uses an individuals samples for a maximum of two tets. prevalence is dened as the count of positive cases in the test population. as testing is carried out, the conrmed positive and negative cases are set aside are both removed from the undetermined test population. therefore, the population and the prevalence changes during the testing process. the group size depends on both the population and the prevalence. the adaptive group testing method presented in this paper is generalized binary splitting (gbs). in addition to studying these two classes of methods, we make modications to the methods to take into account limitations of the devices and techniques used to test samples for covid- rna. specically, we study methods with limited group sizes. these are dt and gbs with maximum group g (dtg and gbsg). they are dened so that any time either dt or gbs species a group size over the capped limit g we take the group size to be g. to cover a wide range of limits of detection we consider groups of sizes , , , and . non-adaptive group testing method: divide and test (dt) this method is can be thought of as a xed group size version of the generalized binary splitting method [ ] . . if p > . then test each member of the population individually. otherwise, let α = log p − . select a group of individuals g with |g| = α and apply one test to g. if it is negative, then we conclude that the result of each case in g is negative. . if g is positive we use binary search to nd exactly one case that we can deduce is positive. . repeat the method starting with step . on the yet to be conrmed portion of the population. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint adaptive testing method: hwang's generalized binary splitting (gbs) the group testing methods suggested in this paper are based on hwang's generalized binary splitting method. in [ ] gsb is designed to nd up to d (+) cases in a population containing n individuals. it is described as follows: take g a group of cases such that |g| = α and apply one test to g. if it is negative, then we conclude that the result of each case in g is negative. . if g is positive we use binary search to nd exactly one case that we can deduce is positive. . set the population to the set of individuals not determined (+) or (-). we set n to be the new population size. if we have found a positive case in the last two steps, we take d − to be the new number of positives in the un-tested population. this method is extended to populations with a random number of (+) cases by setting the upper limit on positive cases according a chosen condence level (i.e. the probability that the number of (+) exceeds this is very small). in probability terms, if the number of positive cases d is generated acccording to a probability distribution, and we assume probability c that will identify every positive case, then let d c be such that p (d ≤ d c ) < c. generalized binary splitting is then applied to nd at most d c positive cases in the population. the setting of hwang's paper is group testing for general purposes, including identifying defective parts or products in addition to determining individuals with a disease. it is an ethical requirement to determine if each person is (+) or (-) if they are tested for covid- . therefore gsb is appplied for an upper bound d c of positive cases at a xed level of condence c. if exactly d c positive cases are found, then there with non-zero probability there are some cases that have not been determined. otherwise if < d c positives are identied, then we are certain we have found them all and it will also happen that a positive or negative conrmation was given to each individual by the end of the testing process. in the case where there could be more positive cases, we repeat gsb with the same level of condence c on the remaining population. rather than considering the application of a level of condence as an idiosyncracy of the method, it is actually a fundamental property of identifying asymptomatic covid- carriers. asymptomatic positives cannot be identied without testing them, we can only pick an upper bound on the cases with a high level of certainty. it might seem preferable to then choose a method that instead prescribes a group-size for each level of prevalence, such as dorfman's method or divide and test, but for those methods the possibility that we have misjudged the prevalence still needs to be factored in! condence bounds on group testing methods we will apply dt and gbs with groups capped at , , , and samples using two dierent levels of condence. • gbsg with d . (i.e. p (d ≤ d . ) = . ). we repeat gbsg at this level of condence if there are undetermined cases remaining. • we apply dtg with the group size log( p − ) . • gbsg with d . . for a population generated by a prevalence level p, this will perform worse on average than the application with d . , but level of eciency theoretically guarenteed for gsb [ ] will hold with % condence. therefore, we can be more condent of the algorithms performance. • for populations of size n generated with prevalence p, we apply dtg at the actual prevalence level of the population with % condence. that is, we apply dtg with the group size (with ceiling g) corresponding to p . = d. n . . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint for small to medium sized populations, the % condence upper bound is very dierent from the mean. the dierent condence levels are very close for large n for a constant probability of having covid- . how condent we are needs to be taken into account in this scenario as well because assuming a uniform probability of having the disease is likely to be too broad of an assumption. there are many dierent factors that lead to sub-populations having distinct frequencies of carrying covid- and the certainty about the prevalence varies as well. dorfman's method [ ] we compare the results from dt and gbs methods to dorfman's method. dorfman's method is as follows: . for a the optimal group size b (dened below), apply one test to a group of b cases. if the result is negative, then conclude that every case in the group is negative. if the test result is negative then one test was used for b cases. if it is positive, then b+ tests were used. the quantity b is chosen to minimize the expected number of tests used to determine the result of one individual case, we will use this formulat to compute the expected proportion of tests saved for several dierent levels of prevalence to compare to the successor binary search based methods we choose study. to evaluate and analyze the performance we assume that the populations are sequences of randomly generated i.i.d. variables representing cases with the probability of having the disease p. the population is then modeled by probability distribution with the following parameters. • n -the size of the population/number of cases • pthe probability that a case is positive. we refer to this as the prevalence. • a case is then a bernoulli random variable that is positive with probability p and negative with probability − p. • the number of positive cases is then a binomial random variable with n samples and probability p of a success, we write this as binomial(n, p). in the section we analyze the performance of the group testing methods at a selection of prevalences for populations of size and . in section we analyze the performance at the . condence upper bound. this can be thought of as overestimating the prevalence by a large enough amount so that we are % sure that the actual number of positive cases falls at or below this level. in section we analyze the number of rounds of testing each sample goes through. our results suggest that not only do group testing methods save tests and time, but they can be done within the realistically expected amount of usage for each test. an analysis of the histograms of the number of tests per case from which we compute the average performances is in the numerical results section after the bibliography (section ). please visit https://github.com/cmentus/group-testing/ to nd the jupyter notebook for all numerical experiments. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint performance of group testing methods at dierent prevalences for our performance analysis, we sample populations of sizes n = , at prevelance levels p = . , . , . , . , . , . , . , . , . , and . . we present the mean of samples and present them in the table below. for dtg results, some of the entries are left empty. this is because the xed group size is less than the capped group size so it would be redundant to list it, and for the performance refer to the nearest entry to the left. we do not do this for gbs because the group size is adaptive and there is nothing restricting it from becoming small. in each table we list the percentage of tests saved from employing the group test methods. . we analyze the eect of picking the prescribed method for a conservatively large estimate on the prevalence. a larger estimate on the prevalence will still take advantage of the frequent occurence of many consecutive negative cases. the overestimate we use corresponds to a probability of having less positive cases of . . we sample the populations at least times and take the mean of the proportion of tests saved over all samples. specically for dtg applied to populations of and we generated samples. for gsbg we applied to populations of size we sampled times except for gsb . for gsbg applied to populations of size we sampled times except for gsb we sampled times. the dierences in number of samples . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint are due to the overall computational expensiveness of simulating gsb and dt. the mean savings of each numerical experiment are presented in the following and various prevalences at the . condence level d . . note that d . is closer to d . for higher populations (that is d. d. is closer to ). therefore the performance is closer to the results depicted in the previous section. although demonstrated to be more ecient in test usage, generalized binary splitting requires some samples to be used at least as many times as the logarithm of initial group size. for maximum group sizes of and this implies that positive cases will be tested at least or times. as is demonstrated by gures . and . it is possible for tests to be used more than twice as many times. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint figure . : for gbs we sample a population of size , and record the number of times each case is tested. note that for prevalence of p = . % a case at most times in the population. in gure . where we perform the same experiment we nd cases that are tested up to times. we apply gbs to nd at most d . (see section ??) we see in gure . that the proportion of cases that are tested many times (more than ) is very low. this is evidence that testing the cases indivually when we are running low (if we are limited to uses) adds up to less than % extra tests. if we are able to test a sample more than this many times, individually testing when we are about to run out eects the eciency negligibly. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint we plot the histograms of the number of times postive results and negative results are tested given that they are tested more than once. interestingly, sometimes the number of times negative cases are tested seems to have a larger maximum. gaining knowledge of covid positive status in asymptomatic carriers is of prime importance in the ght to contain and eliminate the disease. the group testing strategy will generate certainty and a margin of safety in conned populations and may be useful in detection of disease burden in geographically dispersed populations as a mode of surveillance. a key factor in our strategy is the two phase approach that we propose. clinical screening of symptomatic patients cuts down the prevalence of covid- in the chosen asymptomatic test populations. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint rapid, large scale testing is urgently needed for naval ships and military bases. a recent outbreak upon the uss roosevelt has brought this concern to the forefront of military proporities [ ] . recently italian prisoners have rioted rioting due to lack of testing [ ] . prisoners have been released from nyc prisons due to concern for spread of coronavirus [ ] . nursing homes have been sites of extensive outbreaks [ ] . screening an asymptomatic population is challenging but important. sensitivity of tests is paramount but also utilization of resources must be ecient. this study proposes a statistically valid mathematical model to optimize number of tests performed on chosen populations. the future direction of our work will require clinical validation with real world application of this group testing strategy. the clinical screening of symptomatic patients out of our population is helpful but it will also make detecting virus in asymptomatic people potentially tougher because of the chosen viral load. current rt-pcr methods are standard but have a concerning false negative rate in symptomatic patients [ ] . this may be further exacerbated in asymptomatic patients. future studies may explore or consider the use of more sensitive techniques including ddpcr and addition of other sampling techniques such as fecal specimens and perhaps advanced imaging such as chest ct scan. based on the above evidence it is clear that a comprehensive strategy is necessary to test all asymptomatic people. this strategy will uncover the hidden silent carriers of disease. group testing has the chance for saving tests, while giving an exit to revert to individual testing if there are more cases than estimated. these strategies are not necessarily the theoretical optimums. nevertheless, by our calculation and numerical simulations they have the power to cut down the number of tests used. the group testing method is applicable to conned populations from both a clinical and mathematical stand point. we can clinically screen conned groups to decrease the prevalence in a predictable way. this method allows each patient in the population to get a test result. we explore adaptive and non-adaptive strategies for group testing for covid- , therefore we add adaptive and binary search based non-adaptive strategies. both perform well even when we restrict the size of the group based on the sensitivity of rt-pcr. we test the performance of two algorithms: divide and test and generalized binary splitting. for populations of size and with each case being positive independent of one another with probability p, we nd that both methods save many tests. in fact, even when we restrict the size of the groups they make substantial savings. for example at prevalence . and group sizes capped at , both dt and gsb are capable of outperforming dorfman's method, that requires a group size of for optimal performance. for a population of and condence level . , the dt and gbs also have a similar performance to dorfman's method at . where dorfman's method is chosen as if we knew the exact prevalence. we nd that dt outperforms gsb on average even though gsb in theory uses close to optimal number of tests for a known xed number of (+) cases (bounded above by #tests − + information lower bound). this indicates that non-adaptive binary search methods have the potential to save many tests. it is possible that gsb is more generally applicable to populations that cannot be thought of as being generated since samples can be divided frozen and stored for continuous use we mathematically analyze how many divisions we have to use for each sample. we nd that testing individually when the sample is about to run out does not subtract substantially from the savings. we demonstrate that for a group size of the generalized binary search on cases uses the same sample more than times for < % of all cases. therefore, applying a test individually to samples when they are running low is a viable way to save many tests while not depleting material from one person's sample. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint for both gbs and dt. the maximum group size is . for gsb we sampled populations, for dt we sampled populations. note that the spread of the dt algorithm is much wider and has many cases that need a much lower number of tests than gsb. the small bars in gsb are caused by the % chance of not identifying all of the cases in one run and so repeating the process on the rest of the population. . cc-by-nc-nd . international license it is made available under a author/funder, who has granted medrxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint correlation of chest ct and rt-pcr testing in coronavirus disease (covid- ) in china: a report of cases the detection of defective members of large populations a method for detecting all defective members in a population by group testing evaluation of group testing for sars-cov- rna. medrxiv italian coronavirus prison riot six dead coronavirus new york update: mayor announces immediate release of prisoners convicted for non-violent oenses all residents of new jersey nursing home presumed positive for coronavirus evaluation of covid- rt-qpcr test in multi-sample pools. medrxiv we thank martin douglas for interesting and useful discussions about group testing methods using binary search. we are also grateful to matthew heidemann, blake elias, kevin schallert, gary chizever, michael wells, olga buchel and patrick o'neill for contributing ideas and useful feedback.we are indebted to yaneer bar-yam for important recommendations that greatly improved the ideas, clarity and organization of the paper. we thank matthew heidemann for the diagram at the beginning of the paper that skillfully explains our process. thank you to david f. schaeer, marcel dvorak, julia naso and marthe kenny charles for discussions about the limit of detection for sars-cov- rna by rt-pcr and recommendations that lead us to simulate group tests with maximum sizes , and .we thank endcoronavirus.org and the new england complexity institute for giving us the platform to meet and collaborate as a team and meet great people with diverse backgrounds and skillsets united in the cause to ght the current pandemic. key: cord- - lp v i authors: vahedi, ensieh; ghanei, mostafa; ghazvini, ali; azadi, hossein; izadi, morteza; panahi, yunes; fathi, saeid; salesi, mahmood; saadat, seyed hassan; ghazale, amir hossein; rezapour, mohammad; mozafari, abolfazl; zand, nahid; parsaei, mohammadreza raesi; ranjkesh, mohammad hossein; jafari, ramezan; movaseghi, fatemeh; darabi, enayat title: the clinical value of two combination regimens in the management of patients suffering from covid- pneumonia: a single centered, retrospective, observational study date: - - journal: daru doi: . /s - - -w sha: doc_id: cord_uid: lp v i background: there is no identified pharmacological therapy for covid- patients, where potential therapeutic strategies are underway to determine effective therapy under such unprecedented pandemic. therefore, combination therapies may have the potential of alleviating the patient’s outcome. this study aimed at comparing the efficacy of two different combination regimens in improving outcomes of patients infected by novel coronavirus (covid- ). methods: this is a single centered, retrospective, observational study of laboratory-confirmed covid- positive inpatients (≥ years old) at two wards of the baqiyatallah hospital, tehran, iran. patient’s data including clinical and laboratory parameters were recorded. according to the drug regimen, the patients were divided into two groups; group i who received regimen i consisting azithromycin, prednisolone, naproxen, and lopinavir/ritonavir and group ii who received regimen ii including meropenem, levofloxacin, vancomycin, hydroxychloroquine, and oseltamivir. results: the oxygen saturation (spo ) and temperature were positively changed in patients receiving regimen i compared to regimen ii (p = . and p = . , respectively). the serum level of c-reactive protein (crp) changed positively in group i (p < . ). although there was a significant difference in platelets between both groups ( . vs . , p < . ), their change did not clinically differ between two groups. the findings indicated a significant difference of the average length of stay in hospitals (alos) between two groups, where the patients under regimen i showed a shorter alos ( . vs . , p = . ). conclusion: this study revealed the beneficial effect of the short-term use of low-dose prednisolone in combination with azithromycin, naproxen and lopinavir/ritonavir (regimen i), in decreasing alos compared to regimen ii. since there is still lack of evidence for safety of this regimen, further investigation in our ongoing follow-up to deal with covid- pneumonia is underway. [figure: see text] coronavirus disease (covid- ) is a viral disease caused by the novel coronavirus (ncov- ) , which is known as a positive-sense single-strand rna segment with an approximate weight of - kb, belonging to a unique clade of the betacoronaviruses [ , ] . the world health organization (who) stated a public health emergency of international concern after the rapid spread of the covid- on january , , and it was presented as a pandemic on march , as many regions of the world had been affected by then. covid- infection also spread across iran with an increasing pace [ ] , where has affected a large population. so far, there has been no international complete consensus or guideline on any specific anti-covid- treatments. for the diagnosis of covid- , chest computed tomography (ct) has been suggested as a sensitive imaging technique for early diagnosis of covid- pneumonia in combination with patients' clinical symptoms and laboratory findings [ , ] . the association of pathophysiology of human coronavirus infection with inflammatory reactions and the consequent cytokine storm has previously been described [ , ] . furthermore, dyspnea and hypoxemia suggest occurrence of a severe pneumonia [ ] , leading to acute respiratory distress syndrome (ards) [ ] . accumulative evidence has revealed organizing pneumonia patterns based on chest ct scans and pathological findings in some patients with covid- [ , , ] . it is suggested that covid- induces diverse pathophysiological processes in two-phase immune response including immune defense-based protective phase (non-severe stage) and the second inflammation-driven damaging phase [ ] ; thus tailored therapeutic strategies need to be recommended. a growing body of evidence has indicated presence of a cytokine storm syndrome in patients suffering from severe covid- [ ] , in which good general health may not be beneficial [ ] . in cytokine storm syndrome a series of immune responses are generated resulting in alteration of peripheral white blood cells (wbcs) and immune cells (e.g., t and b lymphocyte, macrophage, etc.) [ ] , which lead to the secretion of proinflammatory cytokines and the consequent severe lung injury. therefore, expeditious anti-inflammatory treatment in an early phase might be effective in controlling the disease among selective patients [ ] . there is active controversy on the use of corticosteroids in the second phase that is not routinely considered as a therapeutic approach in such conditions (i.e., spo < %) and covid- lung injuries [ ] [ ] [ ] , but their timely prescription at a proper dose may inhibit disease progression or deterioration [ ] . immunomodulation therapy has been considered as a therapeutic strategy for treatment of hyperinflammation which may reduce the mortality rate [ ] . a retrospective, multicenter study in wuhan, china demonstrated that mortality rate of covid- could be probably linked to virally-driven hyperinflammation [ ] , indicating efficacy of corticosteroids in reducing hyperinflammation and immunosuppression [ ] . hypothetically, use of a combination regimen of off-label medications (i.e., azithromycin, low-dose prednisolone, naproxen, and lopinavir/ritonavir (kaletra) may be effective in the management and control of the disease. macrolides are indicated for different respiratory infectious diseases, and so azithromycin may be beneficial in fighting covid- with its therapeutic value (e.g., antiviral effect) [ ] . in addition, corticosteroids as a double-edged sword (i.e., the effect of prednisolone on -lipoxygenase activity) are considered to have anti-inflammatory properties and nonsteroidal anti-inflammatory drugs (nsaids; e.g., naproxen) also used for their antipyretic, analgesic and anti-inflammatory effects. from the other point of view, low-dose, short-term administration of prednisolone may be capable of reducing potential risks of corticosteroid therapy [ ] . although there seems to exist no strong evidence of any specific treatment strategy for covid- infection, immune-boosting therapies (e.g., antisera or pegylated ifnα, etc.) may be of great importance in the initial phase as well as an appropriate general health and genetic background (e.g., hla) that may be implicated in the specific endogenous antiviral immunity; also, immunosuppressive and antiviral strategies may be applicable in the inflammatory phase [ ] . currently, there is limited evidence for effective therapeutic strategies and the comprehensive data on clinical randomized trials are lacking and most of the medications are used as off-label or compassionate use. the physicians may indicate a medication or a combination of medications as clinical practice and based on their responsibility or may investigate on potential off-label medications [ ] . thus, rcts are ongoing all over the world for many therapeutic agents and strategies such as remdesivir, chloroquine, hydroxychloroquine, favipiravir, and corticosteroids, as well as convalescent plasma transfusion, etc. based on hospital data repository, and according to the guideline issued by the iranian ministry of health and medical education [ ] , in which a three-drug regimen including oseltamivir, hydroxychloroquine, and lopinavir/ ritonavir were recommended for inpatients, some patients in baqiyatallah hospital received azithromycin, prednisolone, naproxen, and lopinavir/ritonavir and we assigned them to group i and the other patients received oseltamivir, and hydroxychloroquine and we assigned them to group ii. it is noteworthy that two different drug regimens were used at two different wards of hospital as prescribed by two groups of pulmonologist and infectious disease specialists. therefore, the present study aimed to evaluate short-term effects of regimen i (azithromycin, prednisolone, naproxen, and lopinavir/ritonavir) in group i patients in comparison to regimen ii (meropenem, levofloxacin, vancomycin, hydroxychloroquine, and oseltamivir) in group ii patients in the treatment of covid- infection. we conducted a single centered, retrospective, observational studybetween february , and march , at two wards of baqiyatallah hospital, tehran, iran, where two different drug regimens were used by infectious disease specialists and pulmonologists for the treatment of patients suffering from covid- the laboratory-confirmed covid- inpatients (≥ years old) with moderate disease who admitted in two wards of baqiyatallah hospital, retrospectively enrolled in the study. this hospital was one of the hospitals dedicated to covid- patients in tehran, iran. our study was designed according to the national and international ethical guidelines and was approved by the ethics committee of baqiyatallah university of medical sciences with the code of ir.bmsu.rec. . the informed consent was obtained from the patients for using their medical records. additionally, patient confidentiality was considered by protecting the electronic data in computer. the patients' medical information including demographic data, covid- test using a real-time rt-pcr via throatswab specimens, clinical features, routine laboratory tests, chest ct scans (before and after discharge) according to the who interim guidance [ ] , treatment measures, comorbidities and data on the outcomes were extracted independently by two physicians through a standard case record form provided by the hospital. it should be noted that laboratory tests were requested based on the physicians order including c-reactive protein (crp) concentration and complete blood count as the time-series data before and after the treatment depending on the duration of hospitalization. daily vital signs monitoring, including body temperature, heart rate, respiratory rate, blood pressure, and spo , were also recorded from patients medical information. the records indicate that other supportive measures including active control over high fever (paracetamol) and supplemental oxygen have been considered for all patients if necessary. the patient's definitions of clinical outcomes including moderate disease (having fever, respiratory symptoms, radiological sign of mild pneumonia, no complications and severe conditions) and severe disease (having respiratory distress, resting spo < , and rapid disease progression on ct scan) were also extracted. improved outcomes were defined as subsided fever, improved covid- pneumonia (confirmed via ct scans), as well as improvements in symptoms of the upper respiratory system, while failed outcomes of the patients were determined as progression toward a critical condition or death. finally, data adjudication was performed by a pulmonologist. according to the hospital data, two diabetic inpatients received treatment at two wards of hospital after adjusting their drug doses for controlling their diabetes (in both groups i and ii). descriptive statistics were reported as frequencies and percentages or as the mean ± standard deviation or confidence interval % (ci %). the t-test and mann-whitney u were used for normally-distributed variables (evaluated by the one-sample kolmogrov smirnov test) and non-normally distributed variables, respectively. in addition, the chi-square test was used to compare the difference between the percentages of variables between the two groups. the generalized estimating equations (gee) regression was applied for analyzing repeated measures. the probability value of . or less (p ≤ . ) was set to determine the significance level. by march , , laboratory-confirmed covid- inpatients were enrolled in the study. the demographic data and base line variables are presented in table . the mean age of the patients was . years (sd = . ) in group i and . years (sd = . ) in group ii. furthermore, the study included ( . %) males and ( . %) females, and two patients with underlying diseases, (diabetes), in group i and ii ( . %) were treated after adjusting their drug doses for control of diabetes. the most common symptoms on admission were recorded as fever, dry cough, myalgia or fatigue and shortness of breath. two-thirds of the patients experienced anorexia and headaches as mentioned in their medical records. the main clinical parameters are presented herein. the patients' body temperature was recorded, followed by their resting oxygen saturation (spo ), respiratory rate (rr), pulse rate (pr), systolic blood pressure (sbp), and diastolic blood pressure (dbp). the body temperature showed a statistically significant change in group i in day compared to baseline (p < . ; table ), while the change was not significant in group ii ( . - . vs . - . ). our results showed that the mean change of rr and pr exhibited no significant change in both groups compared to baseline (table ) . additionally, the changes of sbp and dbp were not found to be statistically significant in both groups (table ) . furthermore, the mean change of spo was significantly noticeable in patients receiving regimen i compared to regimen ii (p = . vs p = . )( table ). on admission, white blood cells (wbcs) were reported to be lower than the normal range in ( %) patients (wbcs less than × /l) and above the normal range in ( %) patients. lymphocytes (lyms) were found to be lower than the normal range in % of patients ( patients; lymphopenia) on admission time and above the borderline or normal range in % of patients ( patients). additionally, the hematologic assessment of patients revealed highly decreased platelets (plts) for patients ( . %) on admission. the mean change of laboratory parameters including wbcs, lyms, plts and crp are presented in table . of patients enrolled in this study, the mean concentration of crp was significantly decreased in group i compared to group ii (p< . ) ( table ) . additionally, platelet counts increased relatively in both groups, but the changes were relatively distinctive for group i patients in comparison to group ii, where a statistically significant difference was observed between the two groups (p < . ) ( table ) . there was also no statistically significant difference in the wbcs between groups (p = . ) and the mean circulating lyms did not vary significantly between the groups after the treatment (p = . ) ( table ). the patients in group i responded more effectively to the fourdrug combination regimen i compared to group ii, as manifested by alos in group i, . days (sd = . ) compared to group ii with mean alos of . days (sd = . ) (p = . ). in other words, alos was significantly lower in the (table ) . additionally, the median time from admission to discharge was and days for regimens i and ii, respectively (iqr = - . vs - ). no patient was admitted to the intensive care unit (icu), but an years old female patient in group ii died of respiratory failure. the researchers carefully assessed the ct findings of the enrolled patients before and after the treatment. depending on their hospitalization time, abnormal chest ct scan features were observed in all patients on admission. on admission, chest ct images of inpatients showed bilateral lung involvement representing diffuse lesions, bilateral ground-glass opacity appearance, and subsegmental areas of consolidative opacities ( fig. a; fig. a and c) . however, complete resolution of opacities was recorded for these patients days after the treatment with regimen i, suggesting a dramatic response to the treatment without complications (fig. b; fig. b and d) . in group ii, small patchy ground glass opacities on both lungs fields were observed on the admission day ( fig. a and b) , followed by multifocal bilateral consolidation and severe lung involvement (fig. c and d) . this report is an observational study of hospitalized patients with covid- and aimed to compare short-term effects of two combination regimens i and ii according to hospital data. based on the hospital data, azithromycin, prednisolone, naproxen, and lopinavir/ritonavir (regimen i) have been considered by physicians for blocking the inflammatory cascade and combating virus in early infection detection based on the two-phase immune responses, because a combination therapy may be capable of halting the pathologic process. from the point of view of anti-inflammatory treatment, immunosuppressive strategies [ ] or symptomatic management should be considered for suppressing inflammation in inflammation-driven damaging phase coupled with antiviral therapies. furthermore, higher viral loads in asymptomatic and paucisymptomatic (minimally symptomatic) patients (over the first days) has been detected in the upper respiratory tract of covid- patients [ , ] , except for the patients with critical disease as having different viral kinetics (a persistent and high viral excretion), [ ] , suggesting their role in disseminating the disease and difference in viral shedding pattern or viral loads [ , ] in comparison with sars-cov [ ] . this evidence may affect not only control measures, but also therapeutic strategies. it has been reported that low-dose short-term administration of prednisolone may be capable of reducing potential risks of corticosteroid therapy [ ] . there are some evidence showing some degrees of effectiveness of short-term low-tomoderate-dose corticosteroids therapy in combination with immunoglobulin in decreasing lung injury, normalizing body temperature, crp levels, lymphocyte counts, and spo levels, leading to inhibition of inflammation [ ] , which is more or less in agreement with our findings revealed by immunomodulatory theraphy (regimen i). short-term and lowdose administration of corticosteroids has been prudently recommended for critically ill patients suffering from covid- (e.g., ards, refractory septic shock, and chronic obstructive pulmonary disease, etc.) [ ] . while corticosteroids were not routinely recommended for treatment of covid- patients, a retrospective cohort study of covid- in wuhan, china reported the benefits of methylprednisolone by decreasing the risk of death due to covid- in patients who developed ards [ ] . in contrast, corticosteroid use was found to be linked to risk of death, secondary bacterial infections and longer alos, as reveled by meta-analysis [ , ] . the efficacy and duration of corticosteroid use in covid- patients requires further investigation by retrospective studies and rcts as conflicting results have been reported due to heterogeneity of studies and timings of use, etc. numerous rcts such as fig. axial non-contrast ct scan in a -year-old female with covid- pneumonia a: patchy consolidative opacities in both lungs are indicated; b: ten day later nearly complete resolution of opacities and dramatic response to regimen i treatment was revealed for patient. chictr , nct , chictr , and chictr in covid- are underway to determine the clinical value of corticosteroid therapy for preventing hyperinflammation, and decreasing the risks of secondary bacterial infections, etc. likewise, blocking il- , il- , tnf and cytokine licensed-mesenchymal stem cell therapies are among other strategies that may be beneficial for treatment of covid- patients [ , ] . lopinavir/ritonavir and arbidol have also been reported to be beneficial in treatment of covid- patients [ ] . while lopinavir/ritonavir use was not associated with clinical improvement beyond standard care in patients suffering from severe covid- [ ] due to particularly challenging population and/or lack of lopinavir potency against covid- , its beneficial effect for some secondary endpoints was revealed, where the safety of this therapeutic approach was achieved fig. axial non contrast ct scan of two -year-old women with covid- pneumonia. a: patchy ground glass opacities; b: significant resolution of ground glass opacities is notable ten-day after treatment with regimen i fig. axial chest ct scan images without contrast (a year-old women). small patchy ground glass opacities on both lungs field on the admission day (a-b), and eleven day later multifocal bilateral consolidation and sever lung involvement (c-d) is noted in patient receiving regimen ii [ ] . furthermore, the secondary endpoints provided both lower number of death (hope) and lack of discernible effect on viral shedding (discouragement) [ ] . therefore, further studies are needed to evaluate lopinavir/ritonavir as monotherapy or combination therapy for clinical improvement. there is no conclusive evidence that nsaids are certainly contraindicated for covid- , while naproxen, with its wellknown anti-inflammatory, ant-influenza [ ] and antiplatelet properties in combination with antiviral agents may be potentially useful; however, no conclusive evidence demonstrated its risk for covid- patients in clinical trial (ct ) or other respiratory infections [ ] . empirical use of broad-spectrum antibiotics requires urgent de-escalation, but difficulties in differentiating bacterial and viral pneumonias and time-consuming laboratory tests have led to their empirical use in the critical conditions. the use of therapeutic combination regimen including meropenem, levofloxacin, vancomycin, hydroxychloroquine, and oseltamivir could be hypothetically capable of fighting covid- , especially in the case of antiviral effect of oseltamivir and the immunomodulatory effect of hydroxychloroquine. currently, there is no strong evidence for the use of oseltamivir and accumulating evidence does not considerably support the clinical benefit of hydroxychloroquine in covid- patients, while mobile cardiac outpatient telemetry is recommended due to cardiovascular risks of this antimalarial drug [ ] . therefore, the optimal therapeutic use of this medication has yet to be clarified by clinical trials. clinical manifestation of the disease was found to be more effectively resolved in group i patients who received the combination regimen i compared to group ii patients who received the combination regimen ii. our data revealed that the spo had a relative increased pattern in group i patients receiving regimen i in comparison to those in group ii, indicating that regimen i had a positive significant impact on improvement of spo , while the patients in group ii did not show clinical significant improvement. it should be taken into account that the mean changes of spo for the third, fourth, and fifth days of admission were noticeable for regimen i. the differences in daily body temperature between the groups were found to be significant; but the relative drop in fever in group i, may be attributable partly to nsaid use (naproxen). the mean changes of rr, pr, and blood pressure (sbp and dbp) did not vary between two groups after the treatment, but relatively (not statistically significant) rapid improvement of respiratory rate was seen in group i patients compared to group ii. the laboratory findings showed an increased level of crp concentration on admission in patients with covid- , as previously reported for betacoronavirus infections [ , , ] . furthermore, persistently increased crp level is a strong index for the continuation of inflammation, suggesting provision of additional therapeutic interventions [ ] . a declining trend in crp values was detected days after starting the treatment, when a reduction in fever was also observed. laboratory tests indicated that the mean concentration of crp significantly decreased in group i compared to group ii. decreased total lyms and decreasing trend in lyms until death was found to be the most common laboratory findings on admission time, indicating the probability of the association between covid- and cellular immune deficiency and presence of persistent lymphopenia [ ] . covid- is more likely to affect t lymphocytes (cd and cd cell depletion), as does severe acute respiratory syndrome-related coronavirus (sars-cov) [ ] . inaddition, decrease in cd , cd , and cd t cells have also been observed from the early phases of covid- to the recovery [ ] as demonstrated for sars-cov in the peripheral blood [ , ] . t cell responses are capable of suppressing the overactivation of innate immunity [ ] and gradual elevation of lymphocyte responses may be of great importance for effective immunity responses against covid- [ ] . in this study, no statistically significant difference was found in mean changes of wbcs count between both groups. as decreased platelet count is used for screening of hyperinflammation along with other laboratory tests (e.g., a rise in ferritin as an acute phase reactant, h score for secondary hlh and esr), may be important to identify subgroup of severe covid- patients who may benefit from immunosuppression (i.e., improvements in mortality rate) [ ] . on admission, depressed platelet counts were detected in covid- patients, while both combination regimens relatively revived platelet counts; however, no significant clinical difference was found between two groups compared to the baseline data. regimen i proved efficient in improving the clinical outcomes of covid- patients by addressing a shorter patient's hospital stay in our patients in group i. furthermore, we observed the beneficial effects of regimen i on ct scan of the patients by comparing before and after results. it seems to us that the capacity of the four drugs regimen including azithromycin, naproxen, prednisolone and lopinavir/ritonavir could be effectively considered for the management of covid- pneumonia, regarding overall cost savings due to reduced alos and decrease in antibiotic use. in the next step, we recommend further studies to focus on the problems of widespread ineffective antiviral use by physicians for management of the patients. therapeutic options such as steroids are in need of further elucidation for covid- -induced lung injuries. additionally, the evidence for potential harm or benefit (i.e., safety and efficacy) of azithromycin and naproxen in the case of covid- seems to be of paramount clinical importance. therefore, an ongoing follow-up of adverse post-treatment outcomes is underway to provide sufficient evidence for the overall harm or benefit of the current combination therapies. in conclusion, we assume that the patients exhibited better outcomes in the four-drug combination (regimen i) than the regimen ii in parallel, in terms of decrease in crp, increase in platelet counts, and improvement of spo . this effect was due to immunomodulatory properties, antibiotic with triple effects (azithromycin) and antiviral effects in patients without comorbidity conditions, except for one diabetic patients, in the second inflammation-driven damaging phase as rescue protocol; however, those changes were not clinically significant despite their statistically significant difference, compared to base line. a significant decrease in aols in group i patients is of utmost importance. the present study has some limitations. first, this singlecentered, retrospective, observational study should be considered with caution owing to the relatively small sample size and associated residual confounding. second, a number of outcomes were not well-delineated due to unavailability of some laboratory data or incomplete profiles in medical records resulted from the fact that laboratory tests are requested at the discretion of the physicians. third, only patients with moderate disease were admitted in these two wards of the hospital during this period and enrolled in the study. hence, rcts are needed to confirm these findings. origin and evolution of pathogenic coronaviruses a novel coronavirus from patients with pneumonia in china coronavirus disease (covid- ): situation report clinical features of patients infected with novel coronavirus in wuhan. china the lancet radiological findings from patients with covid- pneumonia in wuhan, china: a descriptive study pathological findings of covid- associated with acute respiratory distress syndrome pathogenic human coronavirus infections: causes and consequences of cytokine storm and immunopathology therapeutic and triage strategies for novel coronavirus disease in fever clinics clinical course and outcomes of critically ill patients with sars-cov- pneumonia in wuhan, china: a single-centered, retrospective, observational study risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease pneumonia in wuhan, china covid- infection: the perspectives on immune responses covid- : consider cytokine storm syndromes and immunosuppression epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study potential effect of blood purification therapy in reducing cytokine storm as a late complication of severe covid- a new coronavirus associated with human respiratory disease in china treatment of severe acute respiratory syndrome with glucosteroids: the guangzhou experience clinical evidence does not support corticosteroid treatment for -ncov lung injury clinical predictors of mortality due to covid- based on an analysis of data of patients from wuhan, china potential use of hydroxychloroquine, ivermectin and azithromycin drugs in fighting covid- : trends, scope and relevance risk-adapted treatment strategy for covid- patients covid- and off label use of drugs: an ethical viewpoint iranian ministry of health and medical education, diagnostic and therapeutic flowchart of covid disease at the outpatient and inpatient service levels. national guidelines for novel corona virus world health organization (who. a. clinical management of severe acute respiratory infection when novel coronavirus (ncov) infection is suspected: interim guidance cytokine storm intervention in the early stages of covid- pneumonia clinical and virological data of the first cases of covid- in europe: a case series sars-cov- viral load in upper respiratory specimens of infected patients viral shedding patterns of coronavirus in patients with probable severe acute respiratory syndrome short-term moderate-dose corticosteroid plus immunoglobulin effectively reverses covid- patients who have failed low-dose therapy. preprints (www.preprints.org) on the use of corticosteroids for -ncov pneumonia impact of corticosteroid therapy on outcomes of persons with sars-cov- , sars-cov, or mers-cov infection: a systematic review and meta-analysis the effect of corticosteroid treatment on patients with coronavirus infection: a systematic review and meta-analysis mesenchymal stem cell therapy for covid- : present or future a trial of lopinavir-ritonavir in adults hospitalized with severe covid- lopinavir-ritonavir in severe covid- covid- -the search for effective therapy structure-based discovery of the novel antiviral properties of naproxen against the nucleoprotein of influenza a virus non-steroidal anti-inflammatory drugs, pharmacology, and covid- infection inpatient use of mobile continuous telemetry for covid- patients treated with hydroxychloroquine and azithromycin epidemiological, demographic, and clinical characteristics of cases of middle east respiratory syndrome coronavirus disease from saudi arabia: a descriptive study a major outbreak of severe acute respiratory syndrome in hong kong erythrocyte sedimentation rate and creactive protein: how best to use them in clinical practice clinical characteristics and therapeutic procedure for four cases with novel coronavirus pneumonia receiving combined chinese and western medicine treatment ni a-p. expression of lymphocytes and lymphocyte subsets in patients with severe acute respiratory syndrome significant changes of peripheral t lymphocyte subsets in patients with severe acute respiratory syndrome adaptive immune cells temper initial innate responses publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements the authors would like to thank the baqiyatallah university of medical science for the facilities offered during study. authors appreciate dr. pooneh salari's valuable help in review and direct editing of the article. we would also like to thank vice presidency for science and technology and iranian deputy of research and technology, ministry of health and medical education for their supports. conflict of interest the authors declare no conflict of interest. key: cord- -ak pq authors: nan title: th european congress of intensive care medicine athens - greece, october – , abstracts date: journal: intensive care med doi: . /bf sha: doc_id: cord_uid: ak pq nan objectives: evaluate the levels of tnf, il- and pai-i in different moments of the ards and the possible relationships among them. methods: septic patients with ards were studied. also significant differences for: tnf, pai-i and il- in septic patients and both evaluations of ards with control gropup; pai- between septics and nd evaluation in ards, and between the ist and nd evaluation in ards; il- between septics and both evaluations in ards; and il-~ in both evaluations in ards patients in relation to mortality. conclusions: i) elevations of tnf, pai-i and il- , with clinical signs, are suggestive of infection; ) the persistent and progressive elevation of pai-i with any clinical criteria may suggest evolution to ards; ) due to its own kynetics, il- takes part later in the acute phase, its levels being related to the magnitude of the injury in the tissues. objectives: the influence of long-term volume therapy with different solutions on plasma levels of circulating adhesion molecules was studied. methods: according to a randomized sequence, patients with sepsis secondary to major surgery exclusively received either hydroxyethylstarch solution ( % hes, mean molecular weight (mw) , daltons, degree of substitution (ds) . ) or human albumin % (ha) for volume therapy for days. plasma levels of circulating (soluble) adhesion molecules (endothelial leukocyte adhesion melecule- [selam -i] , intercellular adhesion molecule- [sicam -i] , vascular cell adhesion molecule- [svcam -i] , and p-selectin ) were serially measured on the day of admission to the intensive care unit (='baseline ' value) and during the next days. results: selam-i, sicam-i, and svcam-i plasma levels were markedly higher than normal at baseline in both groups. in the hes-patients, selam-j decreased to normal range, whereas it further increased in the ha-group (from • to • during the study period, sicam-i and svcam-i plasma levels remained unchanged in the hes-patients, but further increased in the ha-group (from • to , • sgmp- increased significatly only in the ha-group ( • to • only pao /fio was significantly correlated to plasma levels of adhesion molecules. conclusions: sepsis is associated with markedly elevated plasma levels of adhesion molecules indicating endothelial activation or damage. by long-term volume therapy with hes, these levels remained unchanged or even decreased, whereas volume therapy with human albumin did not have any beneficial effects on soluble adhesion. central venous catheters are frequently used in the care of the critically ill patient. the incidence of catheter related sepsis varies in the literature. we investigated the occurrence of contamination and sepsis compared to results of the epic study as part of quality assesment in our intensive care unit. from january until august all removed central venous catheters were examined for microbiological culture. the patients who showed signs of sepsis were also registered. the results of the contaminated catheters and septic patients were compared with results from the epic study. during the month period , patients were hospitalized on our intensive care unit. central venous catheters were examined for microbiological culture. specimens appeared to be possitive ( %). patients showed clinical signs of sepsis. the incidence of sepsis due to contaminated central venous catheters was / ( %). the incidence of sepsis due to the presence of all central venous lines was / ( %). the microorganisms responsible for the sepsis syndrom were : stapylococcus aureus (n= ), escherichia colt (n= ), others (n= ). in the epic study the percentage for sepsis on the icu was . % for the netherlands and . % for europe. despite a high number of positive culture from removed intravascular lines, a low percentage of sepsis was seen compared to results of the epic study. we recommend routine bacteriological culture of all removed central venous lines and recommend to look at colonization and sepsis due to intravascular lines as a measure of quality control in the intensive care unit. objectives: prognostic assessment of simplified acute physiology score (saps) in granulocytopenie patients with septic shock (ss). methods: the medical records of admissions to an intensive care unit (icu) of granuloeytopenic patients with ss are reviewed. fiftytwo patients had haematological malignancies. seven patients had aplastie anaemia. patients were categorised as survivors (discharged from icl and non-survivors (died in the icu). saps index was calculated for patients daily during their stay in icu. all patients were severe granulocytopenic (total white cell count less than , ] ] ). results: five patients ( , %) were discharged from icu. fifty-four patients died in icu. non-survivors had saps on admission higher than survivors ( . + . and . + . , respectively, p< , , mann-whitney u test). no patient with a saps greater than survived. mortality among the patients with saps from to was , %o. the evolution of ss was rapid. the mean stay in icu among non-survivors was only hours. an analysis of the saps index on admission of non-survivors showed an inverse correlation with the duration of their stay in icu (r=- , , p= . ). all survivors recovered from granulocytopenia. they had normal white cell counts at the time of discharge from icu. there was inverse correlation in survivors between saps and white cell counts, when these parameters were evaluated daily. however, the saps index alone cannot be considered to be on individual predictor factor of mortality. patients who had failure of the malignancy to respond to chemotherapy and who had persistent granuloeytopenia died in icu despite saps index on admission and recovery from ss. conclusion: saps index greater than , failure of the malignancy to respond to chemotherapy and persistent leueopenia all point to a poor outcome of granulocytopenie patients with ss. introduction: antipyretics sometimes are used for fever control in febrile neutropenic patients with hematological malignancies(hm). we observed a dramatic fall of blood pressure(bp) and development of septic shock(ss) in some of the patients who received antipyretics. aim: to clarify can antipyretics provoke ss in neutropenic patients with infection. methods: retrospective review of medicat records of neutropenic(wbc < , / )patients with hm, admitted to the intensive care unit for ss, was performed. there was selected group of patients receiving antipyretics shortly before a fall of bp. results: there was a definite causal relationship between receiving antipyretics and fall of bp in from patients. all patients had fever due to infection and had normal level of bp before receiving antipyretics. hypotension developed within minutes up to , hours after administration of antipyretics. three patients received , g of metamisol and one , g ofparacetamol per os. in all cases we observed dramatic diaphoresis and the temperature fall to subnormal level ( . + . ~ accompanied'by hypotension. but in - hours the fever was coming back without blood pressure elevation. the fluid replacement was controlled by central venous or wedge pressures. there were required + ml colloid and cristalloid solutions for volume loading. in spite of fluid administration the hypotension persisted and all patients required inotropic therapy. only one patient survived and is alive now. conclusion: it seems to us that our data offer to state that antipyretics administration can initiate ss in febrile neutropeuic patients with infection. objectives: to assess the agreement between cardiac output (co) measured by odm t and by other methods used in icu patients. methods: we prospectively studied adu t patients requiring hemodynamic monitoring with a pulmonary artery catheter. an esophageal doppler monitor provided measurements of co (odm), stroke volume and flow time (ft) used as an indirect evaluation of patient's volume status. patient hemodynamic status was evaluated by a modified fast response pulmonary artery catheter (baxter health care corporation, santa ana, ca), allowing co measurements by thermodilution "d) and an evaluation of right ventricular ejection fraction and end diastolic volume (rvef and rv-edv). in the last six patients co was measured by transthoracic echocardiography (echo) and oxygen consumption was measured by a deltatrack ii metabolic monitor (datex) allowing co calculation according to the fick formula (fick). the agreement between methods measuring co and their reproducibility, were evaluated by bland and altman analysis. results: agreement between co measurements is expressed as bias (d) and % limits of agreement (l of a = d_+ sd . td-fick - . - . to . fick-echo . - . to . there was no correlation between ft and rv-edv. conclusions: although co measurements by odmil had the best reproducibility, the limits of agreement between the four methods tested were unacceptable for clinical purposes. further investigation is required in order to improve the accuracy of co measurement in the icu. phd, a. paltzev, v.bajbikov, b.dobryakov d.sc., a.ostanin phd, o.leplifia phd, h.chernykh phd munieip. hosp. n l, n ; inst. of clin. immunol., novosibirsk, russia objectivies: efficiency of native cytokines used in the treatment of patients with severe surgical infections has been studied. methods: for two years patients were treated with cytokine mixture (ssp) obtained by arterio-venous perfusion of swine spleen and contained the following cytokines: il- , il- , il- , tnfa, ifny, gm-csf. results: ssp intravenous infusions were shown to accompany with mortality decrease from . % to . % in patients with abscessed pneumonia and lung abscesses and from % to % if disease course was complicated with sepsis. in patients with purulent peritonitis and sepsis efficiency of ssp was decreased due to endotoxieosis. thus, we used adoptive immunotherapy with mnc activated in vitro with ssp or recombinant il- . intravenous infusions of such cells resulted in transformation of a pathologic process from destructive into productive one. moreover, clinical manifestations of sepsis were controlled in % and mortality was decreased from % to %. conclusions: the use of eytokines themselves as well as cytokine-treated lymphoeytes permits to control the disease and leads to the mortnlity decrease owing to stimulation of host defence mechanisms. background: although red blood cell transfusions (rbct) are used to increase oxygen availability in septic patients, several lines of evidence suggest that rbct may actually worsen tissue hypoxia. thus, rbct may negatively influence outcome of septic patients. objectives: to determine the association of ) rbct ; ) number of units transfused; and ) mean age of the units transfused on the first day of transfusion with mortality of critically ill septic patients. methods: we prospectively identified patients who met strict criteria for sepsis syndrome (ss) seen in the icu of st. paul's hospital from to and excluded patients who died in the first days after the onset of sepsis. we recorded clinical characteristics, multiple system organ failure score, and apache ii at onset of sepsis. then, we retrospectively recorded the total number and age of rbc units transfused during the first days after onset of sepsis. overall -day mortality was %. results: the main results are shown in the table. the mortality of patients who received rbct was nearly double the mortality of those who did not receive rbct even after adjusting for severity of illness using apache ii. objectives: gastric mucosal acidosis is frequently observed in patients with sepsis. the aim of this study was to determine whether volume infusion using pentaspan| decreases abnormal gastric mucosal pco (pico ) in patients who have sepsis syndrome (ss) who have already been resuscitated using clinical endpoints. methods: we prospectively identified patients who met strict criteria for ss, had a pulmonary artery catheter and a gastric tonometer in place, and pico > mmhg. pentaspan| ( ml) was infused in rain. measurements of hemodynamics, hemoglobin, arterial lactate, blood gas analysis, and pico were performed before and repeated miff and hr after pentaspun| infusion. we calculated the pico -arterial pco' difference (pico -paco ) and phi (using henderson-hasselbach equation). anova was used to assess statistical significance. results: all patients werereceiving adrenergie drugs. map was : : mmhg and lactate . : : . mmol/l. pentaspan| increased ci by % (p< . ) but did not change pico ( and increase m oxygen o* wery were simimny achieved in both groups. nevertheless, epinephrine was associated with a lactic acidosis and increased laetate/pyruvatemia ratio (l/p) that evoke a dysoxia rather than a metabolic effect. an higher gastric mucosal pco in the ep group compared to nor-rob suggests the hypothesis of an anaerobic production of co in favor of a splanchnic hypoxia. in both group, arterial ketone body ratio that reflects hepatic mitochondrial redox state, compared to a control group without shock was decreased but increased between and hours after restoration of arterial pressure. the association norepinephrine-dobutamine seems to be better for splanehnic circulation than epinephrine and should be used for dopamine resistant septic shock. moreover, the increase in arterial pressure with nor-dob improved gastric mueosal ph and hepatic mitochondrial redox state and argue to reconsider arterial pressure as a significant goal for resuscitation in septic shock. conclusion: significantly higher malondialdehyde and ghitathione levels and glutathione-peroxidase activity in group ns at the end of icu stay were related to mortality these findings indicate an increased generation of free oxygen radicals together with increased anfioxidant activity in this group and sapport the employment of antioxidant interventions in critically ill patients. oblecfives: to determine the role of nitric oxide (no) in the mechanism of septic shock induced by isolated limb perfuslen with recombinant tnfcr methods: we have measured tnfr~ and metebo~ites of no in patients with signs ot septic shock following treatment with isolated limb perfusion for nonresectable soft tissue tumors and melanomas of a limb. perfuslen was carried out with melphalan (burroughs wellcome) and recombinant tnfcr (boehringer). tnfc~ was determined by specific radiometric assay (medgenix diagnostics), nitrate and nitrite were measured with a modification of the guess reaction ~. results: results are shown in the table. conclusions: during isolated limb pedusion with recombinant tnf~ very high levels of tnfcr were measured in arterial blood in patients. they all showed signs of severe sepsis syndrome with shock from vasodilafion, probably due to leak of recombinant tnft~ from the peduslen circuit to the systemic circulation. tnfc~-induced vasodilation was not accompanied by a rise in serum no-metsbolites. our findings do not confirm the widely accepted theory, mainly based on animal experiments, that genera• of no is the key pathogenefic mechanism in septic vasodilafion , nor that tnfrt invariably induces forreafion of no. the precise mechanism of shock in these patients remains to be elucidated. references: . moshage h, kok b, huizenga jr, jansen plm nitrite and nitrate determinaiions in plasma: a critical evaluation. clin chem : / . . moncada s, higgs a. the l-argioine-nitrio oxide pathway. n engl j med ; : - ec is a commonly used for prolonged, stable animal anesthesia. noting that the hypotension after iv lps was attenuated by ec, we hypothesized ec also protects against lps toxicity. sprague-dawley rats received ip saline (s), thiobutabarbita mg/kg (tb), or varied doses of ec, followed hours later by bolus mg/kg iv lps. -day survival is shown below: group: s tb ec( . gmikgi ec( .sgm/kg) ec(i. gm/kg) alive (n) t ~ total (n) s s "signiflcant;y different from all other groups, p< . s / rats given lps followed hours later by ec ( . gm/kg) also died. additional rats were treated with s (n= ) or gm/kg ec (n= ) followed by mg/kg lps, then sacrificed at hours. blood glucose (bg, mg/dl),.hematocrit (hct), leukocyte count (wsc/mm~ platelet count (pltxl ~/mm ), bicarbonate (hco, mg/dl), gross bowel hemorrhage (bh, - scale) and lung myeioperoxidase activity (mpo, ~vmirvgm wet lung) are shown below ( we conclude that ec reduces the lethality and multiple organ toxit;~ty of lps. its diverse effects suggest asite of activity upstream from the cytokine cascade. these results are important for studies of lps which may use ec anesthesia and may have potential in the therapy of septic shock. [zo = hz impedance (z; {dyn.sec.cm " }); zl = first harmonic z; zc = characteristic z; z ph. = t'trst harmonic phase angle {radians}; f, #, * at least p < . between fio . and . , fio . and fio . &no - . _+ . - . _+ . # - . + . m - . + . * - . + . * - . + . * - . _+ . * in hyperoxia, compared to dogs at the same q, minipigs had a higher ppa ( + rnmhg versus + mmhg; p < . ). hypoxia increased (ppa-ppao) at all levels of q by an average of mmi-ig in minipigs and mmhg in dogs. inhaled no inhibited hypoxia-induced (ppao-ppa)/q changes in both species. conclusions: we conclude ~ that the minipig is an animal model of elevated pulmonary vascular resistance and impedance, and ~ that hypoxia-induced alterations in pvz spectrum are due to changes of resistance in small arteries. objectives: ) to determine the toxicity of ng-monomethyi-larginine (nma) administered by intravenous bolus to patients with refractory septic shock. ) to investigate the biologic activity of nitric oxide synthase inhibitors in septic shock. methods: from august to january , thirteen patients with vasopressor refractory septic shock received nma intravenously in escalating doses from to mg/kg. results: no hepatic, renal, gastrointestinal, or hematologic toxicity was observed at doses of nma as high as mg/kg. significant biological activity was observed at all dose levels consisting of increased blood pressure (systolic blood pressure from . mm hg + . to . _+ . s.e.m., p= . , systemic vascular resistance ( + to + dyne.sec/ cm s, p=. ), and a decrease in vasopressor requirements. the magnitude and duration of these effect were dose dependent. decreased cardiac output ( . _+ . to . _+ . i/min p=. ) and increased pulmonary artery pressure ( . _+ . to . _+ . mm hg; p=. ) were also observed. no significant effects on heart rate, pulmonary capillary wedge pressure, or central venous pressure were observed. four of patients survived for more than days, patients died of cancer complications (all patients had maintained blood pressure for h on nma) and patients died of complication attributable to septic shock (mods, ards, dic, refractory hypotension), and patient was unevaluable. conclusions: no adverse clinical effects have been observed in patients receiving bolus doses of nma as high as mg/kg. the increased pulmonary artery pressures observed in septic shock patients is further augmented by nma and may limit the dose which can be administered by intravenous bolus. other schedules of drug dosing may attenuate this effect. glucose-insulin-potassium (gik) solutions have been shown to improve cardiac contractility and increase oxygen availability in experimental and clinical settings of septic shock. several mechanisms have been proposed to explain these effects including a direct improvemeut of the energy balance by glucose, a direct influence of insulin on cardiac performance or an increase in intravascular volume due to the hyperosmolarity of the solution. to explore the role of hyperosmolapity, we compared the effects of gik to those of a isoosmolar hypertonic saliue solutiou in endotoxin shock in dogs. methods : the study included mongrel dogs ( • pentobarbitalanesthetized aud mechanically ventilated with air. thirty minutes after the intravenotls administration of mg/kg of e. coli endotoxin, the dogs were randomized to receive a ml/kg infusion in rain of a hypertonic ( mosm]l) solution iucludiug either a mixture of glucose % with u insulin and meq kcl/l (glk-group ) or hydroxyethyl starch . % in naci . % (hes-group ). in each dog, a . % saline infi~sion was continued to maintain the puhnonary arlery occluded pressure at baseline level. hemodynamic, blood gas aualysis and laboratory data were collecled at baseline and miu, rain, rain, and nunutes later.. results : eudotoxin administration was followed by a fall in mean arterial pressure (map) aud cardiac index (ci) and a rise in blood lactate levels. resuscitation with either gik or hes hypertoaic solutions resulted in similm increases in map, ci, oxygen delivery and left ventricular stroke index (table ) . we conclude that during resuscitation from endotoxic shock the use of gik solutions is not superior to hypertouic hes solutions. the higher blood lactate levels observed in the dogs receiving gik can be attributed to the glucose metabolism. , for group , for group ) were drawn and immediately analysed at ~ using the abl radiometer for po , pco and ph, and the osm radiometer for hbo %, hbco% and methb%. psost (i.e. the ps at ph= . , pco = mmhg and temperature at ~ c) was calculated automatically by the instruments on mixed venous blood, as was the ps "in vivo" (i.e. the ps at the patient's value of ph, pcoz and temperature), using siggaard-andersen's algorithm. the data were compared by the one-way anova test and by the t-test for paired and unpaired samples. results: the mean resulting values (in mmhg) with the statistical differences are shown in table i. in addition, the time series analysis shows the mean ps~st values as statistically below the psin vivo" in the septic patients while the opposite is shown for the cardiac patients. no differences in the time analysis are demonstrated for the second group. a possible clinical significance may be drawn from these different behaviours. objectives:toxemia degree and humoral immunity condition have been studied in patients aged from to with progressive course of sepsis and polyorganic insufficience. methods: such toxemia and humoral immunity findings as lencositlcindex of toxication (lii), level of oligopeptides of the middle molecular mass registered at the wave length of nm(mmi) & nm (mm ), distribution index (id), immunoglobulins a,m,g, concentration of circulating immunocomplexes (cici & cic ) and also some clinical and biochemical findings on the , , day after the operation serve as criteria for treatment effect. results: it was founded that in intensive therapy and detoxication, level of lii is successively decreased from . ~ . to . +. on the -th day after the operation. true decrease of the level mm from . ~. to . +. un & optimal density and increase of distribution index from . to . are argued. conclusions: in studlng the dynamics of the immunoglobulin's spectrum and the true increase of immunoglobulin g level from . +. g/i to i . +. g/i on the -th day after the operation simultaneously with the decrease of cic from . ~ to . ~ . (p . ) were founded. some stages of the investigation true increase of lymphocytes from . + . % to . + . % was noted and it appeared to be a favourable prognosis finding for disease outcome. high correlation dependence between bacillus-and segmentonuclear neutrophils and immunoglobullns g & m (r=. -. in p<. ) was discovered and it also showed positive dynamics of the course of the disease. a year old male patient was admitted to the icu with severe paraquat poisoning. treatment consisted of gastic lavage and oral administration of fullers earth. because of very high plasma levels hemodialysis together with charcoal hemoperfusion was started within one hour after admission. this treatment was further continued by continuous veno-venous hemofiltration in order to remove the circulating paraquat and also circulating cytokines. nevertheless patient s condition worsened necessitating artificial. ventilation and hemodynamic support. patient died hours after admission of acute multiple organ failure due to paraquat poisoning. serum levels of paraquat were determined by colorimetric method (table) . levels of interleukin (il ) and (il ), tumor necrosis factor (tnf-alpha), interleukin i receptor antagonist (il ra) were determined both in plasma and ultrafiltrate ( q~!ectives : evaluate in critically ill patients the effects of tow-dose dopamine on gastric mucosal blood flow (gmbf) using laser-doppler flowmetry, a continuous non invasive method of assessing microcirculation. methods : patients requiring both mechanical ventilation and pulmonary artery catheterization for multiple trauma (n= ), ards (n= ) and pancreatitis (n=l) were included. in each patient, the laser-doppler (ld) probe was inserted through a naso-gastric tube. the ld signal is proportional to the number of red blood cells moving in the measuring volume and the mean velocity of these cells. when the ld signal was satisfactory, an aspiration was created into a catheter which was fixed in parallel to the ld probe, to maintain the tip of the probe against the gastric wall at the site of measurement. data (systemic hemodynamic parameters and gmbf) were obtained at the end of a rain resting period (baseline), then min after dopamine ( mcg/kg/min) infusion, and finally rain after the end of dopamine infusion (recovery gmbf _+ (perfusion units) gmbf ~a% vs baseline) * p < . vs "baseline" and "recovery". conclusions : ) despite a slight increase in co (+ %), the dramatical increase in gmbf (+ %) with dopamine, strongly suggests a selective vasodilator effect of low-dose dopamine on gasaic mucosal perfusion. ) laser-doppler flowmetry appears a promising method to assess gastric microcircalation in critically ill patients. increasing evidence suggests that the activation of inos is the final common pathway for vasodilation in human sepsis associated with endotoxic shock. activation of the cellular immune system induces the excessive release of the pteridines neopterin (n) and , -dihydroneopterin (nh ) by human macrophages/monocytes. besides the well established diagnostic value of pteridines in several inflammatory diseases, it is speculated that these substances per se exhibit biochemical functions. thus we hypothesize that pteridines can modulate inos gene expression in vascular smooth muscle cells (vsmc) in vilro. cdtured rat aortic vsmc from female wistar kyoto rats were incubated with n ( pm), nh ( ilm), lipopolysaccharide (lps, ~g/ml), and interferone-~/(ifn-~/, u/ml) for h, respectively, inos gene expression was measured by competitive reverse transcription polymerase chain reaction. the results are summarized in the table. the present study demonstxates a neopterin induced increase in inos mrna expression at the transcriptional level in vsmc. while coincuhation of cells with n + lps resulted in an additive effect on inos gene expression, n + ifn- seem to have a more than additive effect nh did not alter inos mrna synthesis, but it suppresses the lps as well as the ifn-yinduced augmentation of inos gene expression. we speculate that this pteridine-mediated modulation of inos gene expression is involved in the regulation of the vascular tone in endotoxic septic shock. the relationship of sepsis and coagulation abnormalities is well known, mainly in severe sepsis and septic shock. still farther, the extreme expression of hemostasis abnormalities (disseminated intravascular coagulation) in sepsis, has been extensively described. we studied the changes in several coagulation and fibrinolysis markers in septic patients, trying to correlate them with the evolution of the sepsis phenomenon, with an emphasis in its early stages, where therapeutic intervention might be more drastic. in patients, with sepsis, with severe sepsis and with septic shock, as well as in healthy volunteers (control group) we measured : platelet (ptl), coagulation markers [fxii, fvii, fviii, fvw, fibrinogen (fibr) we conclude that all parts of the coagulation system are gradually changed during the evolution of sepsis phenomenon , even in the earliest stage of sepsis. the expression of an inducible nitric oxide (no) synthase (inos) plays a major role in the pathophysiology of septic shock (ss). inhibition of inos could therefore be of therapeutic value. however, such an inhibition has been shown to be detrimental, increasing tissue anoxia (and end-organ damage), possibly through the simultaneous blockade of constitutive nos (cnos). thus, selective inhibition of inos might be more suitable. we evaluated the effects of l-canavanine (can), a more potent inhibitor of inos than cnos, in an animal model of ss. method: in anesthetized rats, catheters were placed in the femoral vein and artery. rats were given an iv bolus of lipopolysaccharide (lps, mg/kg), at baseline (to). after h (t ), rats received at random an infusion of either can ( mg/kg/h; can group, n=l ) or an equivalent volume of . % naci ( cc/kg/h; nac group, n= ), giyen over h (t -t ). a third group (sham group, n= ) received . % nac in place of lps, and then was treated like the nac group. mean blood pressure (mbp), blood lactate and nitrates (no ) were measured each h. glucose, creatinine and asat were also measured in rats (n= in each group). the can _+ * + "t . + . "~ . +_ . "t + " + " *p< . can vs naci ?p< . vs sham can suppressed the hypotension, reduced the hypoglycemia and hyperlactatemia, and attenuated the biological signs of renal and hepatic dysfunction induced by endotoxemia. these effects were associated with a lesser elevation of blood no , confirming a partial inhibition of inos. conclusion: l-canavanine attenuates the hemodynamic and metabolic consequences of endotoxemia in the rat. these effects may be related to a partial inhibition of inos. they contrast with the deleterious effects described with non selective inhibitors of nos. l-canavanine could become a new tool for the treatment of septic shock. rocalc tonin :marker of sepsis, ii~flammaiiur% t~ boifi .cheval*~ jf.timsit*, m.assicot**, b.misset*,/.carlet*, c.bohuon** saint joseph heap, paris**biochemistry institut g roussy, villejuif, ce bi~)l~i~ttectives_: high serum levels of procalcitoaln (proct) have been shown to be ~ss-ocinted with bacterial infection. however, few data exist about the ability of proct to differenciate septic shock and shock from other origin in which an activation of intlmmamtory mediators has been also demonstrated. methods: thirteen patients with bacterial septic shock (ss), patients with non septic shock (nss), patients with bacterial infection without shock ( nf) and icu patients without shock and without infection (control) were compared for proct levels at dayl, , , , . patients were classified blindly and independently fi'om proct results. twelve patients were excluded because any classification was impossible due to mixed pathology. proct was measured with ebemoluminescenee (brahms diagnostica-berlin). results: dayl, proct levels are significantly different between the four groups. dayl proct levels are correlated with saps (p= . ), infection ( . +_ vs _+ ,p= . ), shock ( _+ vs +.- ,p= . ), death at day ( _+ vs _+ ,p= . ). when shock and infection are introduced in multifactor &nov& only infection remains correlated with day proct levels ( = . ) in patients with shock, dayl proct levels are correlated with saps, infection and death at day , but not with arterial lactate levels (p= . ), white blood calls (p= . ) or fever (p= . ). proct levels remain higher i~i septic shock patients at day , and ( figure) . i c edpsion: procalcitonin levels in the first three days of shock are differen[" between septic and non septic shock patients. in patients with diseases known to induce acute an inflammatory process, procaldtonin seems to be a marker o~ infection. obiectives-to evaluate the effect of endotoxic shock on the distribution of blood flow between the mucosal and the muscular layer of the intestinal wall. methods: in fasted pigs, mean aortic pressure (map, mm hg), cardiac output (co, ml/min-kg),superior mesenteric artery flow (q sma, ml/min.kg), and phi, where measured before (control) and after i.v. endotoxin ( gg/kg). the blood flow to the mucosal and the muscular layer was measured in regions (proximal jejunum (pj), mid-small intestine (mi) and terminal ileum (ti)) by colored microspheres, using adjacent samples in each region. the muscular layer was separated from the mucosa by blunt dissection, and the flow determined independently in each layer. results: endotoxin with fluid resuscitation induced the expected decrease in map ( . _+ . vs . -+ . , p< . ), and phi ( . !-_ . vs . _+ . , p< . ), with a constant co ( _+ vs _+ , p= . ) and qst, aa ( . _+ . vs . _+ . , p= . ). the results of regional pertusion are presented in the table. (flow in ml/rain g of tissue; mean _+ sem ; * p< . vs control by two-way anova) conclusions-these data indicate that the mucosal flow increased during septic shock. they suggest that a decrease in phi may be due to hypoper~usion of the muscular layer or to metabolic alterations within the mucosa, despite a % increase in flow. acute increase in wbc count (from a mean of lo.oo mm a to o /mm~), between the rd and the th day of therapy. there was a decline of the wbc count to an average of about . mm a after decreasing the daily dose of the medication to mcg there was no increase in tile absolute number of the eosinophils during the whole course of the medication. there was a slight decrease in the c complement between . to . g/i. normal values . to . g/i there was no change in c values. conclusions : an early increase in wbc count was observed ( rd day) without subsequent increase in the number of immature types from bone marrow, probably due to the mobilization of wbc from the periphery and this increase was dose dependent. there was a slight decrease in c fraction of complement, probably due to the consumption of this fraction in the process of opsonization. no adverse effects of the medication were observed, during the treatment with the above dose. these data sugest that cm csf may be a useful complement to tile main antimlcrobial treat,nent ~ of septic [cu patients. objectives: as part of a large multicentric, placebo-controlled, randomized clinical trial investigating the effects of interleukin- receptor antagonist (ii-lra) in the treatment of severe sepsis and septic shock, this substudy evaluated in dem.il the acute hemodynamic effects of ii-lra in patients who were invasively monitored. methods: in a total of evaluable patients in whom vasoactive support was little altered, hemodynamic measurements were performed at baseline (twice), and i hour, h, h, h, h, and h after the administration of mg/kg (n= ) or mg/kg (n= ) of i - ra or the corresponding placebo (n = ). / patients ( %) were treated with adrenergie agents and / ( %) with mechanical ventilation. data were analyzed by a kruskal-wallis test. results: during the study, there was no significant difference with time or between groups in arterial pressure, cardiac filling pressures, cardiac index or left ventricular stroke work (figure). burmester, "~ man and h. djonlagic medical university (internal medicine, "cardiology, *'microbiology) and "**southern city hospital, lfibeck, germany obiectives: evaluation of the incidence of bacteremia and sepsis in patients with nontyphoidal salmonella (s.) infections, specification of risk factors, need of icu treatment, clinical course, and mortality in the group of the patients who developed septic complications. methods: data of all patients with microbiologically proven s. infections hospitalized in the medical university of lobeck and in the southern city hospital of l beck from to . results: within the observation period s. was isolated from the stool cultures of patients. in patients (g m, f, median age yrs) s. could be detected in blood cultures ( s. enteritidis, s. typhimurium). in addition, in of these patients s. was also isolated from other specimens (urine, liquor, and tissue fluids derived from abscess punctures). in all patients with positive blood cultures the clinical course of s, infection was complicated: ? patients developed mof (acute renal failure, ards, hemodynamic instability, dic) and required icu treatment for at least up to days, of the patients died. the predisposing disorders in the patients with s. bacteremia were (n=): aids ( ), immunosuppressive drugs ( ), chronic alcoholism ( ), malignancies ( ), none ( ). septic complications in patients with nontyphoidal s, infections are relatively rare (in this study < % of all hospitalized patients with microbiologically proven salmonellosis) but severe (mortality of approx. %). patients at risk for a complicated clinical course are predominantly those with predisposing disorders but occasionally also patients without evidence for an underlying disease. age (yr) + + death (n) duration of shock (h) + + noradrenaline (rag/h) , _+ + temperature (~ , + , + pvr (dynxsecxcm - ) + + co (ljmin) , _+ , , + , lactate (mmol/l) + , , + interleukin- (pg/ml) _+ + interleukin- (pg/ml) , _+ , , + , tnf-alpha (pg/ml) , + , + neopterin (nmol/l) , + , + crp (rag/l) _+ +_ pro-ct (ng/ml) , + , , + there was no positive correlation between serum lactate levels, degree of shock, hypoxemia and pro-ct positivity. pts with septic shock of bacterial origin entirely developed hyperprocalcitoninemia, whereas pts with cardiogenic shock, who expired within h did not. however, in late cardiogenic shock (> h) all pts developed fever of unknown origin and consecutive hyperprocalcitoninemia. these data suggest bacterial inflammation and/or mucosal translocation of bacterial products in pts with prolonged cardiogenic shock. the use of a loading dose of quinine ( . mg/kg base in h) is recommended in previously untreated patients (pts) with sfm, particularly in multi-drug resistance areas. this protocol is difficult to validate, since the viability of microorganisms is not assessed routinely in parasitology laboratories. objectives: to examine the evolution of parasite viability during the early phase of therapy of sfm. methods: from / to / , pts with sfm (who ) treated with iv quinine for less than h were included prospectively. blood samples were collected at o, , , , , and h viability was assessed by culturing parasitized red blood cells in the presence of h-hypoxanthine, and radioactivity was determined at h by scintillation counting. viability was expressed as the percentage of radioactivity compared to the initial sample. plasma quinine was determined by liquid chromatography. tile ratio plasma quinine (pmol/ )xlo /icso for quinine (nmo]/]) was called the parasiticida/ index. results: pts were included, • saps . -+ . . the initial parasitemia was t. + . %. complications of malaria were coma ( pts), shock ( pts), renal failure ( pts) and acute lung injury ( pts). all strains were sensitive to quinine (icso -- nmol/ ). in pts who were not given a loading dose, parasite viability increased by and %, with concomitantly low quinine levels ( and #mow] at h); pt died. in pts that received a loading dose (serum quinine at h = . -- . ~mol/]) a marked decrease of parasite viability (by +_ % at h) was shown. viability was inversely correlated with plasma quinine (r=. , p-.o ) and parasiticidal index (r=. , p-.o ). conclusions: even with fully sensitive strains, the use of a loading dose of quinine seems warranted in severe falciparum malaria in order to reach rapidly adequate plasma quinine ]evels, necessary to inhibit significantly parasite viability. l nkka, e ruokonell j takala. critical care research program, department of intensive care, kuopio univ hospital, finland objective: to determine the incidence of positive blood cultures, their microbial subgroups and to evaluate the outcome of icu patients with different bacleremias. material and methods: we analysed all positive blood cultures in consecutive admission to a university hospital icu in - and the icu and hospital survival of the bacteremia patients. during these years patients had positive blood cultures that were considered as clinically relevant, excluding colonizations or contanfinations. results: patients with positive blood cultures had an icu survival of . % (vs. , % in all icu patients) and six month survival of . % (vs. . % in all icu patients). the most common bacteria were enterobacteriaceae ( , %), staphylococcus aureus ( , %) , coagulase negative staphylococci ( . %), pseudomonas ( . %) and slieptococci ( . %). obiectives: to evaluate prognostic factors and mortality in consecutive patients (pts) with hiv infection and septic shock. methods: from - to - , records of consecutivepts with septic shock (crit care med , : - ) admitted to the icu were reviewed retrospectively. results: among pts with septic shock admitted during the study period, had hiv infection- of whom had aids-(gr. i) and were hiv-negative (gr. ill. ten gr. ii pts ( %) were irnmunosuppressed because of neoplastic or immune dlsease. mechanica] ventilation was required in % gr. i and % gr. ii pts in gr . i pts ( %) a multivariate analysis demonstrated that hiv infection and sap i were independently predictive of death in pts with septic shock. ~onclusions: evidence of increased mortality, number of organ failures and higher severity scores (saps i does not take into account immunosuppression) is demonstrated in hi v-positive pts, infection with hiv appears to be an independent prognostic factor in pts with septic shock. the frequency of opportunistic infections (often responsible for delayed diagnosis and treatment) may contribute to the poor prognosis in this population. obiectives: to determine interleukin (il)-i levels in plasma of patients with sepsis and septic shock. to analyze the relationship between plasma il- and the proinflammatory mediators, tumor necrosis factor-aifa (tnf) and il- , the underlying severity of the disease and the evolution of patients with sepsis. methods: we studied critically ill patients ( men, women; - years old) in three diferents groups. group i: patients without evidence of infection, group i : patients with sepsis and with septic shock (group iii). we measured plasma il-lo, tnf and il- levels in the first hours of diagnosis. severity of illness was estimated with the acute physiology and chronic health evaluation (apache ii) scoring sytem. results: plasma levels of il- were higher in group iii (median, pg/ml; range, - pg/ml) than in group ii (median, pg/ml; range, - pg/ml; p <. ) and group i (median, pg/ml; range, - pg/ml; p <. ). median il- concentrations did not differ among patients who survived (median pg/ml; range, - pg/ml) and those who died during the overall follow-up period ( days) (median, ; range, - pg/ml); but patients who died in short-term (< hours) with catecholamine-refractory hypotension showed the highest concentrations of il-io (median, pg/ml; range, - pg/ml). in patients with bacteriemia ( %), levels of il- were higher (median, pg/ml; range, - pg/ml) than in those with negative blood culture (median, , pg/ml; range - . pg/ml; p< . ). there was a good correlation between plasma il-io concentration and levels of tnf (r= . ; p < . ) and il- (r= . ; p < . ). the correlation between levels of il- and the apache ii score was significant only in the septic shock group (r= . ; p <. ). conclusions: in septic shock, il-io and proinflammatory citokines are released in high concentrations. the significant correlation observed in patients with septic shock between il- levels and apache ii, short-term death and bacteriemia can possibly be explained by the massive inflammatory response in septic shock with fulminant course. intensive care department -calmette hospital - lille -france. in septic shock, inadequate splanchnic blood flow may play a prominent role in the pathogenesis of multiple organ failure. measurement of gastric phi has been propose to evaluate tissue oxygenation in splanchnic organs. objectives: to compare gastric phi values with hepatic icg clearance, an index of liver blood flow and function ; to determine if one of these two methods could be proposed to assess the entire splanctmic peffusion in septic shock. methods : patients (age : • years ; saps ii : • were prospectively investigated (septic shock : bone criteria). following parameters were collected during hours : systemic hemodynamic parameters (swan ganz catheter a h -ref computer -baxter lab.), calculated systemic oxygen transport (do ), oxygen consumption (vo ) by indirect calorimetry (deltatrac datex lab.), gastric intramucosal pco (pco ss) and phi (trip -ngs catheter -tonometrics lab.) and plasma disappearance rate of icg (pdr dye) (femoral artery fiberoptic/thermistor catheter , cold z computer -pulsian medizintechnik, germany). correlations were performed using a linear regression. elevated in all days with the highest value in second and third days of treatment. nonsurvivors had higher values of these parameters than survivors but differences did not reach statistical significance. another trend of changes were observed in selectin p (gmp- ) concentration. in all patients concentrations measured were elevated but in survivors after not significant decrease this parameter in second day another one had simmilar values. in patients who died we noted significant decrease in third day (p < . ) whereafter prominent increase, significant after seventh day, in comparison to third day value and value in survivors group. icam- concentrations in all patients reached high levels and in nonsurvivors after four day of treatment significant increase in comparison to survivors we found. conclusions: multiple trauma complicated with sepsis induce rapid elevation of concentrations of il- , il- and increased expressior of adhession molecules (selectin e, p, icam- ) measure of icam- and selectin p concentration determine lung injury severity and prognosis as to health and life. (clp) .pathophysiology of cip is unclear, but changes in regional bloodflow may be a ~ignificant factor. nerve blood flow (nbf)is reduced in rat models of hemorrhagic shock (g),but no information is available in sepsis. we studied the comparative effect of acute endotoxemic shock {etx)& h on perfusion of rat sciatic nerve. methods: male sprague-dawley rats were anesthetized with pentobarbital (ip), instrumented with a tracheostomy, carotid arterial & venous catheters and mechanically ventilated (fi = . ). the left sciatic nerve was surgically exposed. monitored variables included: a) mean arterial pressure (map,mmhg) ,b) nbf (ml/ o g/min) by laser doppler flow meter,c) nerve internal arterial diameter (id ~ m) by video image shearing and splitting method. after stable baseline measurements were obtained, acute hypotension was induced by randomly assigning the rats to etx ( . b , difco) in saline at mg/kg or h. both interventions produced % reduction in map within min., which recovered to baseline values spontaneously in etx group, & by reinfusion of heparinized withdrawn blood in m. data were analyzed by linear regression, two-way repeated measures analysis of variance followed by bonferroni-t method. experimental stages were:( )baseline, ( ) mid-point of map reduction; ( ) nadir of hypotension, ( )midpoint of map recovery, & ( ) after stable recovery of map. both etx & h induced shock result in similar reduction in nbf consistent with lack of autoregulation in peripheral nerve vessels independent of etiology. since cip is primarily associated with sepsis, it is not likely that acute reduction in nbf alone causes cip. direct & indirect neurotoxic effects of mediators of sepsis need to be evaluated. .':_.~::::o o:oc ., objectives : evaluate the relationship between il- , a cytokine which inhibits tnf, production and protects mice from endotoxin toxicity, and the other proinflammatory cylokines, tnf~, il and ils in severe sepsis and septic shock. methods : twenty-eight icu patients ( m, f, mean age + y) were studied as soon as they developped a severe sepsis (n = ) or a septic shock episode (n= ) as defined by a conference consensus in ( ). tnf~, il , il s and il- plasma levels were measured by immuno-radiometrie assays from medgenix (fleurus, belgium). lc mean and range. results : the comparisons between cytokine levels in severe sepsis versus septic shock were made using the logarithm of the value in order to normalize the distribution of data, and student test. il- plasma levels were higher in patients with septic shock than in patients in severe sepsis. there was a significant correlation (p < . ) between il- and tnf a (r= . ), il- and il~ (r = . ) and il- and il s (r = . ) as well as between il- and apache n score (r= . ). patients who died (n = ) had il- levels higher than patients who survived but this difference was not statistically significant ( pg/ml vs . pg/ml; p> . ). conclusions : during severe sepsis and sepsis shock, il- seems at least to follow the same evolution (increase in plasmatic level) with the severity of sepsis as the other cytokines. reference : ( ) crit care med ; : - . objectives: to evaluate the effects of steroids on hemodynamics and mortality in septic patients with konwn levels of cortisol concentration. methods: retrospectively we analyzed data ofpatients with documented septic shock who received steroids after assessment of adrenal function. in all patients hemodynamic parameters as well as the necessary vasoactive medication were assessed, before and hours after corticosteroid medication. immediately before administration of corticosteroids adrenal function was evaluated with cortisol levels before and after synthetic corticotropin ( . mg). finally we studied mortality. we defined a positive respons on corticosteroids as an elevation of map of at least mmhg and/or a decrease in the necessary vasoactive medication of at least % within hours. adrenal insufficiency was defined as a cortisol level after stimulation of less than nmol/l. results: of patients were found to respond to steroid medication, did not. mean cortisol levels before and after corticotropin were • and • nmol/l in the responder group (rg) and • and • nmol/l in the non responder group (nrg). in the rg out of ( %) were found to have an adrenal insufficiency, in the nrg out of ( %). in the rg -weeks mortality was . % (l out of ), the overall mortality % ( out of ). mortality in the nrg was % ( out of ) (p < . ) and % ( out of ) (p < . ) respectively. conclusions: in patients in septic shock there is a beneficial effect of steroids in case of adrenal insufficiency, but also in a subgroup with normal adrenal f{unction. obiectives: intercellular adhesion is a critical step in the accumulation of leukocytes. postischemic cardiac lymph has the capacity to stimulate icam-i. in the coronary microcirculation neutrophils can be trapped and in many cases obstruct capillaries, previously we found that troponin t (s-tnt) a marker for myocardial iechemia, was increased in septic patients. the aim of the study was to follow slcam- and s-tnt levels continuously starting at the beginning of sepsis. methods: patients were ingluded in this institutionally approved study after relatives had given their informed consent. all patients were included within hrs following the beginning of sepsis. blood was drawn every hrs in the first ;~ hrs, after hrs, followed once per day for days. s-tnt, icam- , elam (elisa's, boehringer mannheim inc, r&d systems ltd.) arterial and venous blood gases were determined, an ecg and a complete hemedynamir measurement including cardiac output were obtained. all patients received adequate volume and catecholamine therapy (norepinephrine, dopamine, dobutamine; median (range) . ( . - . ), . ( . - ), . ( . - . ) pg/kg/min, respectively). statistical analysis: wileoxon signed rank-sum test. . ( . - . ) . patients had s-tnt levels > . pg/l. of these died, whereas only of patients died with s-tnt values < . pg/l (p= . ). all patients that died had elevated sjcam- levels ( ilg/l:cut-off ) whereas in the survivor group only % had elevated icam- levels (p= , ). conclusions: increased slcam- and s-tnt levels were found during early sepsis in the majority of patients, a high sicam- and s-tnt value was associated with a higher mortality. the research of the noninvasive haemodynamic monitoring accelerated recently all over the world. the aim of our study was to test whether the changes of the haemodynamk parameters measured by impedance cardiography (icg) were corresponded to clinical changes in septic patients. investigations were performed on critically ill postoperative septic patients (their multiple organ failure score was - /with icg monitor. in cases the investigation~ were performed in septic shock. the measured parameters were: heart rate (hr), mean arterial pressure (map), cardiac output (co), peripherial resistance (svr),preejection period (pep), and ventricular ejection time (vet). these parameters were measured during - hours in every minutes, depending on the patients cl~tnical condition. results: at the septic patients the hr and the co ]~reased. in septic shock the co was significantly higher the svr lower than in the septic group. in the hr there was no difference between the two groups. in septic shock noradrenalin influenced more effectively the measured parameters than dobutamin. conclusion: the trend of the measured icg parameters correlated with the clinical changes of septic patient's state. the noninvasive haemodynamic monitoring by impedance cardiography helps the planning and leading the adequate intensive therapy of these critically ill septic patients. to evaluate the development of sirs, sepsis and septic shock in hospitalized patients with fever, a prospective study was performed on patients using previously defined criteria. methods: normotensive patients with fever (temperature > . ~ axillary), admitted to the department of internal medicine were evaluated for the existence of sirs during the first three days of the study and sepsis at inclusion. during a follow-up period of days the patients were daily evaluated for the development of sepsis or septic shock. results: most patients ( %) had or developed sirs within the first three days, patients ( %) did not. sepsis was present in % at inclusion. in patients with sirs, % did not progress to sepsis or septic shock, % progressed to sepsis (mean interval . • . days), and patient (< %) directly progressed from sirs to septic shock. in patients with sepsis, % progressed to septic shock (mean interval . • . days). sepsis was preceded by sirs in %. septic shock was preceded by sepsis in % and by sirs in %. conclusions: % of patients with fever in an internal medicine department develop sirs, or sepsis. furthermore, progression from sirs to sepsis or septic shock is poorly predicted by fever or sirs. nevertheless, all patients with septic shock were preceded bysirs or sepsis. taken together, this may indicate a severity hierarchy of the syndromes. however, fever, sirs and sepsis are relatively poor indicators of development of septic shock. this supports further research on additional predictors of septic shock. b. m.manuylov, v.b.skobelsky (moscow) in recent years sodium hypochlorite (sh) has been successfully used to eliminate pyo-septic complications. moreover, the mechanism of the sh effect on the immune system has not been sufficiently studied. the aim of the present investigation was to study the mechanism of sh effect in inflammatory pulmonary diseases. patients with double pneumonia were subjected to the evaluation. sh in the concentration of mg/l in the volume of - m / hours was administered by drop infusion into the central vein. to evaluate one of the defence systems the leukocytes activity by the chemoluminescence technique was studied. in all the patients baseline secondary immunodeficiency which was indicated by the decrease in the luminescence level was established. even hour after the sh administration the leukocytes activation exp-ressed by the enhancement of their chemoluminescence . - times was observed. this supports the available findings that accumulation and liberation of the oxygen active forms (ol'oh, ' , h ) are accompanied by the increased phagocytosis, i,e. the signs of "the oxydation explosion" testify to the favourable sh effect on the course of inflammation processes. the use of sh permitted to decrease the percentage of lethality in double pneumonia by % in the intensive care unit over the year. at the same time, excessive activation of free radical oxygen may be a damaging factor. therefore, precise individual control over the choice of concentration, dosage and the preparation administration rate is required. prospective, double-blind, placebo-controlled, trial of atiii substitution in sepsis r. a. balk objective: pilot study to evaluate the efficacy and safety of atiii substimtion therapy in patients with sepsis. efficacy assessed using change in mortality or organ failure/dysfunction. adult patients meeting a definition of sepsis and cared for in a tertiary care academic medical center in chicago were identified and prospectively randomied to receive either atiii (kybernin p) or placebo in a double-blind treatment protocol. all other therapy and patient management were under the direction of the patient's attending physician. all patient's were followed for days and the organ dysfunction/failure were scored using published scoring systems (jordan et al crit. care med. , goris et al arch. surg. , kuaus et al ann. surg. colldusions:wha~ we met the shomaeker objectiv% the mortality and the pro~os[s were i~ttc*. those criteria were obtained with file tradititmal t~ctor likr doht~mme, hut c.~vh ~,as ca in~aertam measure. they ac~s smxergically in the optimizatic~l of the fell vmtrictdar work index, tad fimdameatally cavh seox~s to have an impo.aat role in the better respiratory ev-altmtioa, leaving yet the possibility to coltrol the flui& r althou~l eomproved it's not aec~pt~xl file importmlce h* the diminution, of the sepsis modiat~lrs llke fnt and il- with h~wmotiltrafi(al, stopphlg the evolution to nmltiorganic failure mid de~easethe mortality. with ours clhlicals results, we could saythat cavii in multiol~atlie disfut~oa septic patieats, se~r~ to be an c xilna] supoa or troatmeat maesure. of anaesthesia and intensive therapy, medical university of prcs, p~csf hungary. objectives: since some biological effects of bacterial endotoxin require an interaction between the lps molecule and a serum factor(s), we hypothesized that lps-induced no production and cgmp accumulation in vascular smooth muscle cells (vsmc), a mechanism ~thought to underlie cardiovascular collapse associated with septic shock, is modulated by serum factor(s). methods: cultured vsmc from rat aorta were challenged with e. coli lps for - hours either in the presence or absence of fetal calf serum (fbs), and no production was monitored by radioimmunoassay determination of cgmp content of hci extracts. results: in the absence of serum, o ng/ml lps was required to increase cgmp levels, whereas the presence of % fbs shifted the lps concentration curve i times to the left. similarly to fbs, human serum also potentiated lps-induced cgmp accumulation. in contrast to lps, serum had no effect on cgmp accumulation elicited by sodium nitroprusside, a no releasing agent, suggesting that the sensitivity of vsmc to generate cgmp in response to exogenous no is not modulated by serum. heat inactivation (> ~ min) but not removal of small molecules (< , d) from the serum by dialysis, reduced the potentiation of cgmp accumulation by serum. time course studied indicated that serum is required within the first min of lps exposure to increase cgmp levels. to investigate whether the effect of serum is specific for lps, we treated the cells with increasing concentration of interleukin -~ (il-i). % fbs shifted the il-iinduced cgmp responses five times to the left. conclusions: our study suggests that lower concentrations of e. cell lps and il-i require a heat labile macromolecule in the serum in order to elicit no production. this factor is present in the human serum and it may play a potentially important role during no synthesis induction in vsmc. objective: to evaluate the factors of acquisition and the outcome of methicillin resistant staphylococcus aureus (mrsa) bacteremia in an intensive care unit (icu). methods: all patients in which bacterermia due to staphylococcus aureus developed > hours following admission to our icu, during a year period ( january through january ) were reviewed. patients (pts) were included, mean age , y (sd , ), saps , (sd , ), mac cabe ( and ) %, mortality directly due to sepsis %. pts had mrsa bacteremia and methicillin susceptible staph. aureus (mssa) . both groups were compared using the chi square (with correction of yates), fisher's exact, student's t or wilcoxon test. results: there was no statistically significant difference between mrssa and mssa regarding at age ( , + , vs , + , ) , saps ( , + , vs , + , ), use of vancomycin ( % vs %), mechanical ventilation ( % vs %), number of days (d) before the drawing of the first positive blood culture (median d, range - d vs median d, range - d). more mrsa than mssa pts had previous use of nonsteroidal anti-inflammatory drugs (nsaid) ( % vs % p< , ), central venous catheter infection due to staph.aureus ( , % vs % p< , ), but previous use of antibiotics was not significantly different ( , % vs %). the outcome of the bacteremic pts was not statistically different: saps at the first day of bacteremia ( , +_. , vs , + , ), severe sepsis and septic shock ( % vs %), persistence of the bacteremia ( % vs %), mortality directly due to bacteremia ( % vs %). conclusion: previous use of nsaid, infection of venous central catheter are more frequently associated with mrsa bacteremia. thus, similar to others studies (hershow infect control hosp epidemio ; : - ) , these results do not indicate that mrsa is associated with increased virulence. objectives: to closer definition of mosf formation mechanismes in nosocomial sepsis (ns) the complex clinicobiochemical, microbiological, immunological, functional exaroination of cases with ns had been done. methods: examination of cellular and humoral immunity, nonspecific immunologic reactivity, systemic and hepatic circulation, microbiological examination of blood,electro-and echocardiography, sonography and computer tomography of chest and abdomen organs were obligatory. autopsy findings of dead cases had been analized. results: in cases ( , %) opportunistic pathogen microscopic flora ( staphylococcus anreus,staphylococcus epidermidis, staphylococcus saprophyticus) had been found out in blood inoculations. in cases ( %) side by side with destructive process in lungs the bacterial endo-and myocarditis with blood circulation failure had been determined.in cases ( %) simultanious lesion of three organs (heart,lungs,liver) had been found. morphologic examinations of dead cases ( %) internal revealed involvement of them in mosf-syndrome.hyperplasia of adenohypophysis;sclerosis of adrenal glands cortical layer;perivascular brain oedema,paralysis of brain capillaries and plasmorrhagia, cerebral thrombosis and cerebral abscess,necrobiosis of epithelium tubules of the kidney,pletora of hepar, fatty and granular degeneration of hepatocytes had been found.atrophy of white pulp and hyperplasia of red pulp, supress of lymphoid tissue, plethora and formation of infarctious had been found in spleen. mentioned changes in spleen were indispensable in ns. conclusion: in ns spleen can not secure it functions to support and appropriate detoxication potencial of organism,elimination of microbes,toxines,antoallergenes. insolvency of immunological link of antimicrobic defence is the starting mechanism of mosf developmentin ns. %neviere, jl. chagnon, b. vallet, d. mathieu, n lebleu, f. wattel ] ept of intensive care, hop calmette, lille, france ~everal studies have described tiypoperfusion of intestine during sepsis. owever, it is unknow whether the mesenteric blood flow is associated with nucosal hypoperfusion. additionally, the effects of resuscitation on the ntestinal microcirculation remain controversial. bjectives : to describe the effects of endotoxin in a porcine model during ~hock and resuscitation. ~ethods : ten pigs ( kg) were anesthetized and instrumented for "neasurement of cardiovascular variables. gastric and gut oxygenation vere assessed by intra-mucosal ph and microvascular laser doppler lowmetry. after baseline data collection, a minute intravenous infusion )f escherichia colt (serotype h , sigma, st. louis, mo) was begun ~t a rate of pg/kg. an infusion of either saline at . ml/kg/min (group ; n= ) or saline and dobutamine at a rate of pg/kg/min (group ii; n= ) vas begun mn after the end of the endotoxin infusion. tesults : to td t ~ fl w fluid ioadin,q alone sfyras d, k perreas, e douzinas, k spanou, m pitaridis and c roussos critical care dpt, evangelismos hosp., athens univ, school of medicine. obiectives: much controversy exists concerning the beneficial effects of cvvh on sepsis. we studied the effects of cvvh application on septic patients with reference to the following parameters: i) survival rate ii) cytokines' removal and iii) timing of cwh onset. methods: patients with sepsis (criteria according to accp/sccm, ) underwent cvvh as soon as they developed renal failure or dysfunction (urinary output< ml/ h, cr> . mg/dl and bun> mgd'dl ). specimens were collected: blood samples before cvvh and therafter both blood and ultrafiltrate (uf) samples on , and hours. cytokines tnfa, i - and ii- were measured by the immunoassay method in all specimens (uf and plasma -p) and sieving coefficient ([uf]/[p]) and h solute mass transfer of tnf and i - were calculated (v h x [uf] ). the apache ii score before cvvh onset, the duration of icu stay and the timing of cwh application related to the sepsis onset in days (ta) were recorded.with respect the mortality two groups were formed, i.e. group a (survivors) and group b (non-survivors) . the morbidity period in days of those septic patients who died in the past year and were not subjected to cwh (group c) was compared to that of group b. results: group a included pts and group b pts with mean+sd age ( _+ vs _+ , ns) and apache scores( _+ vs -+ . , ns). the mean ta-+ sd was . + vs -+ , p< . . the mean_+se morbidity period of group b vs group c was _+ vs _+ . p< . . the mean values of cytokines are presented in the following figures. the sieving coefficient for tnf was . and for i - was . . the solute mass tranfer was -fold the actual plasma content at a given time. . o conclusions: i) early application of cvvh seems to favourably affect the outcome of septic patients, ii) cytokine plasma levels do not decrease although cytokine removal is substantial, iii) it seems that cwh application in sepsis of any stage helps to buy time for further treatment. the most commonly monitored variables in shock stages idclude : arterial pressure, heart rate, central venous pressure, pulmonary artery wedge pressure and cardiac index. with vigorous therapy it is possible to bring these values back into the normal range in both survivors and nonsurvivors. therapeutic goal in septic shock stages is to maximize the values of cardiac index, delivery (do ) and consumption (c ). objectives: the main purpose of this article is to determine the relationship betwee~ delivery an consumption as a sign of hypoxia. fifteen patitents with septic shock were treated with intention to maximize the value of ci,d and v . we compared the levels of these parameters between the survivors and nonsurvivors and found no significant differences after hours. high levels of do and v may not guarantee against tissue hypoxia in early stage of septic shock. zjar~iic, dj janjic, lj. gvozdenovic, a.komareevic. t.petrovic, &marjanovic, institute of surgery, novi sad, yugoslavia objectives: evaluation and mutual comparison of clinical signs, laboratory data and microbiological monitoring in the patients with burn sepsis. method: retrospective analysis of the recorded data of all burn patients treated in our department between january and december . specially attentions were given to data considering wound infection, positive haemocultures, positive urinocultures and characteristics of septic state. results: out of patient there were ( , ~) adults and ( , ( ~) children. almost two thirds of the patients ( - , ~) were males. the predominantly cause ( , ~) of children's burns was scalding b~y hot liquids and flame burns ~ , ~) in adult patients. the most frequdntly species isolated from surface swat~ were pseudomonas aeruginosa ( " in adult patients) and staphyloccocus epidermidis ( , % in children). in only five patients ( , ~ the haenmcultures were positive -pseudomonas aeruginosa was isolated in three and staphyloccocus aureus in two patients. urine infection was diagnosed in , % of all patients. the treatment protocol included use of imipenem and polyvalent pseudomonas vaccine again~ pseudomonas aeruginosa and vancomycin and aminoglycosides against staphylococcus aureus. total mortality rate in this group of burned patients was , ~, but the mortality rate caused of sepsis was low (i %) . conclusions: early detection of any signs of wound infection and symptoms of septic state is a foundation for prevention and treatment of burn sepsis. the burn sepsis could be reliable detected by continuously monitoring the patient's status and by systematic microbacteriological monitoring of the burned patients. hyperdynamic vasoplegic septic shock p.f. laterre, p. goffette, j. roeseler, j.p, fauville, a. poncelet, p. lonneux, m.s. l~eynaert. dept. of intensive care, st. luc univ. hospital, brussels, belgium. splanchnic ischemia is described as a common feature of septic shock and could determine the development of msof. therapy such as noradrenaline (na) aiming at improving blood pressure is expected to worsen splanchnic ischemia by its vasoconstrictive effect and subsequent reduction in intestinal blood flow. ob[ective: evaluate the effect of na on splanchnic blood flow. material and method : in a patient admitted for variceal bleeding, ards and sepsis with positive blood culture, a fiberoptie catheter was positionned in the portal vein after recanalisation of its portosystemic stent shunt. blood pressure (bp-mmhg) , ci, svr, do (vigilance ~ baxter), v (indirect colorimetry), arterial, mixed venous and portal vein blood gases, phi were determined before (to) and during (t ) na infusion ( , to , hcg/kg/min.) . changes in splanchnic flow were assessed by changes in portal oxygen saturation (sp ) and arterio-portal oxygen saturation gradient (sao, -spoe laterre, ,lp. pedgrim, th. dugernier, v. delrue, ph. hantson, p. mahieu, m.s. reynaert. dept. of intensive care, st. luc univ. hospital, brussels, belgium. aim of the study : prospective determination of plasma levels of in patients with ss and their correlation with the type of microorganism and outcome. material and methods : in patients (pts) with ss and severe sepsis, plasma levels of tnfti, ill-b, il and il were determined every hours for days and on day after fulfilling the criteria of ss and severe sepsis. results : in pts, sepsis was caused by a gram (-) microorganism, in pts by a gram (+) and in pts no microorganism was identified. there were survivors ( %) (s) and non-survivors ( %) (ns) . cytokines profiles and levels were not different between gram (+) and gram (-) sepsis. ill-b levels were seldom elevated whatever the group studied. tnfot and il- were significantly higher in ns than in s ( objective: to evaluate the effects on the nitric oxide synthase inhibitor l-n~ hcl ( c ) on myocardial performance in human septic shock. method: septic shock was defined as severe sepsis with either persistent hypotension (mean arterial pressure; map< mmhg) or the requirement for a noradrenaline (na) infusion >_ .i ]tg/kg/min with a map _< mmhg. cardiovascular support was limited to na _+ dobutamine (db), c was administered for up to h at a fixed dose-rate of either , . , , or mg/kg/h iv. during c infusion, na was to be reduced and if possible withdrawn, whilst maintaining map above mmhg and the cardiac index (ci) as clinically appropriate. assessments were made at baseline (t = ); at i h from the start of treatment (t = ); and at the end of treatment (t = ) with c . conclusions: c can restore systemic vascular tone in patients with septic shock enabling na therapy to be reduced and/or removed. the ci tends to fall whilst lv performance is sustained over time. c is a novel vasoacfive agent for the treatment of septic shock, which is undergoing further clinical evaluation. laterre, f. thys, e. danse, j.p. pelgrim, e. florence, z roeseler, m.s. r eynaert. dept, of intensive care, st. luc univ, hospital, brussels, belgium. therapy aiming at improving blood pressure and cardiac index in septic shock (ss) might have deleterious effects on regional blood flow. objectives : compare the influence of volume loading (vl), dobutamine (dobu) and noradrenaline (na) on sushepatic oxygen saturation (shoe) and svoe-sho, gradient in treated ss. material and methods : in patients with ss, ci (thermodilution) , doe, svo,. sho,, svoe-sho e gradient and lactate (l) were determined before (to) and after (t ); vl, dobu and na. results: in patients with treated ss, tests were performed (vl n= ; dobu n= ; na n= method: septic shock was defined as severe sepsis with either persistent hypotension (mean arterial pressure; map< mmhg) or the requirement for a noradrenaline (na) infusion ~> . ~g/kg/min with a map _< mmhg. cardiovascular support was limited to na + dobutamine (db), c was administered for up to h at a fixed dose-rate of either i, . , , or mg/kg/h iv. during c infusion, na was to be reduced and if possible withdrawn, whilst maintaining map above mmhg and the cardiac index (ci) as clinically appropriate. assessments were made at baseline (t = ); at h from the start of treatment (t = ); and at the end of treatment (t - ) with c . conclusions: c is a novel vasoactive agent that can sustain map in patients with septic shock, enabling na support to he reduced and/or removed. there is a tendency for the ci to fall during treatment, which may be reflex in response to the increase in systemic vascular tone. c is a promising new therapy for septic shock, which will now be evaluated in a randomised, placebo-controlled safety and efficacy study. k. guntupalli objective: to evaluate the acute effects of the nitric oxide synthase inhibitor l-n~ hc ( c ) on selected indices of organ function in patients with septic shock. method: septic shock was defined as severe sepsis with either persistent hypotension (mean arterial pressure; map < mmhg) or the requirement for a noradrenaline (na) infusion --> . [xg/kg/ min with a map _< mmirlg. cardiovascular support was limited to na + dobutamine. c was given for up to h at a fixed dose-rate of either , . , , or mg/kg/h iv. during c infusion, na was to be reduced and if possible withdrawn, whilst maintaining map above mmhg and the cardiac index (ci) as clinically appropriate. indices of organ function were assessed at baseline (t = ); at the end of treatment (t = ); and h after treatment (t = ) with c . results. -median values (* assessment made at h or when c discontinued). conclusions: there was no appareut dose-dependent adverse effect on these indices of organ function either during or after exposure to c . the plmelet count tended to fall whilst creadnine appeared to increase over time in all dose cohorts. this novel and promising therapy for septic shock will now be evaluated in a randomised, placebo-controlled safety and efficacy sludy. pharmacokinetics of c in patients with septic shock preliminary results z. hussein, b. jordan, c. fook-sheung, k. guntupalli objective: to evaluate the pharmacokinetics of the nitric oxide synthase inhibitor l-n~ hc ( cg ) given by continuous infusion for h in patients with septic shock. method: septic shock was defined as severe sepsis with either persistent hypotension (mean arterial pressure; map < mmhg) or the requirement for a noradrenaline (na) infusion --> . ~tg/kg/min with a map _< mmhg. cardiovascular support was limited to na • dobutamine. c was administered for up to h at a fixed dose-rate of either , . , , or mg/kg/h iv. plasma was collected from each patient over a h period and analysed for c . pharmacokinetic parameters were derived from plasma concentration-time profiles using non-compartmental pharmacokinetic analysis. results: the (cm~ -maximum plasma concentration; auc -area under curve; cl -plasma clearance; v,, s -steady state volume of distribution; t'/ -plasma elimination halflife). conclusion: the pharmacokinetics of c in patients with septic shock are dose-independent at infusion rates up to . mg/kg/h. at higher rates, clearance of c decreases without any marked change in volume of distribution. c metabolism may be partially saturable at dose-rates above . mg/kg/h. obiectives: investigate the effect of the no synthase inhibitor, l-nt-methylarginine hc ( c ) on the haemodynamics and survival rate in a conscious mouse model of endotoxin shock. methods: female cd- mice ( - g) were instrumented under gaseous anaesthesia (isofluorane, %) and connected to a swivel tether system for continuous monitoring of blood pressure and drug administration. results: after h recovery, endotoxin administration (e. col• :b , - . mgkg - i.v.) elevated the plasma concentration of nitrite/nitrate (nox) and caused a progressive fall in mean arterial pressure (map) from + to + mmhg (n= , p< . ) at h, with a survival rate at h, h and h of %, % and % respectively. c administered as a h continuous infusion ( mgkg-th -t i.v., n= ), h after endotoxin, inhibited the elevation of plasma nox and attenuated the fall in map from + to + mmhg (n= ) at h, with an improved survival rate at h, h and h of %, % and % respectively. conclusions: this study suggests that overproduction of no is involved in the hypotension and mortality characteristic of septic shock. inhibition of no synthase using c represents a novel and promising treatment for septic shock. cultures of e.coli ( , %) and candida( , %) were olso received from autopsy material of children;p.aeruginosa,unspored anaerobes,proteus sp.,s.aureus,b.pneumonia were found in the few cases. in adults the spectrum of bacterioflora was mo~ re limited speaking about the number of species and cultures. in generalized forms of bacterial pyo-septic pathology a wider specific spectrum of causative agents was revealed usua fly with associations. e.coli and k.pneumonia played the leading role in children as well as in adults. in general,k.pneumonia ( , %cultures) and common e.coli( , %)prevailed according to the date of microbiological investigations of authopsy material in pyo-septfc pathology in . objectives: .in spite of all clinical exertion sepsis is still the reason for high clinica! lethality. this study is characterizing the group of patients which survived a septi~ shock. methods: during a period of months all surgical patients on icu were registrated prospectively, more than parameters for each of them were documented'daily in a paradox file. results (see table ): of patients fulfilled the criterion of a septic shock (r. bone, ) , of them died at the lth day, while the surviving group of patients stayed almost days at icu. obiectives: to compare the effects of and % pentastarch solutions to a human albumin solution on oxygen delivery (do ) in septic patients. methods: this stud}, included septic patients with fever (t > ~ tachycardia flqr > /rain), tachypnea (rr > /min) or mechanical ventilation, leukocytosis (wbc> /mm ) or leukopcnla (wbc< ()/mm ) and a clinical source of infection, who required a fluid challenge. in each patient the pulmonary arterial occlusion pressure (paop) was < mmhg. patients were randomized to receive ml of % albunun (n:i ), hydroxyethyl starch (hes -mw /d.s. . ) % (n: ) or t % (n=i ); patients were also treated with adrenergic agents. results cardiac index (c ) increased significantly only in % lies (table) hemoglobin (hb) decreased significantly at min in the same group. there was not significant change in oxygen delivery ( do ). baseline ci alb . :: . (l'min/m ) hes % . = . hes % . polyneuropathy of the critically ill (pci ) is a well recognized complication, acquired in the course of severe illness. we undertook a prospective study, to estimate the severity, extension and time of onset of pci in a selected group of patient with established septic shock ( bone's criteria ). all patients received inotropic circulatory support and were mechanically ventilated. none received relaxants or aminoglycosides. pci was diagnose<by clinical investigation and by emg, and repeated weekly ( axonal degeneration ). after days ( day = onset of septic shock ) in % of the patients pci was demonstrable. after days % of the patients had pci. there was a strong correlation between pci and other mof and between pci and encephalopathy ( eeg ). we conclude that i. pci is a common complication after septic shock. . pci develops early in the course of illness ( % after days ). . pci can be considered as a part of mof, suggesting a common pathogenesis. objectives: we addressed two questions: ) can serial measurements of vapco and avph also reflect the onset of tissue hypoxia during endotoxemia? ) are whole body changes in vapco and avph associated with parallel changes in regional circulation? methods: in anesthetized, mechanically ventilated dogs exhaled gases were sampled for determination of oxygen consumption (vo ). a catheter was positioned into the pericardial cavity to induce cardiac tamponade. ultrasonic flow probes were placed around superior mesenteric, left renal and left femoral arteries, and the corresponding veins were cannulated. group l served as control (n= ), group (n-- ) received mg/kg of endotoxin. thirty min later, tamponade was induced to gradually reduce do . results: systemic do crit was higher ( . _+ . vs . + . ml/kg.min, p < . ) and critical oxygen extraction ratio (o ererit) was lower ( . +_ . vs . +_ . %, p< . ) in the endotoxie than in the control group. meslenteric and femoral do crit were higher in the endotoxic than in the control group ( . _+ . vs . _+ . mlll g tissue.min and . _+ . vs . _+ . ml/min, respectively, both p< . ). regional o ercrit were lower in we endotoxic than in the control group (mesenteric: . _+ . vs .i_+ . %, renal: . + . vs . -+ . % and femorah . -+ . vs . _+ . %, all p< . ). vapco and avph followed a similar pattern in both groups, increasing slightly before do crit was reached, but dramatically wh,en do fell below do crit. in the presence like in the absence of endotoxin, systemic and regional do crit calculated from vo , from vapco , or from avph were similar; do crit was also significantly higher in the mesenteric and the femoral beds of the endotoxic than the control dogs. systemic and regional do crit could be calculated from the blood lactate levels only in the control group. conclusions: during an acute reduction in blood flow i) vapco and avph can reflect hypoxic threshold in the presence like in the absence of endotoxemia. ) alterations in organ oxygen extraction capabilities induced by endotoxin can be reflected by regional changes in vapco and avph. objectives: enhanced nitric oxide (no) release has been incriminated in the vasodilation and myocardial depression characterizing septic shock, but the administration of no blockers has yielded equivocal results. the present study explored the systemic and regional effects of a no donor linsidomine (sin-i) during endotoxic shock. methods: anesthetized dogs received endotoxin ( mg/kg iv), followed min later by a saline infusion to keep cardiac filling pressures constant. oxygen uptake (vo ) was derived from the expired gas analysis. regional blood flow was measured by an ultrasonic flowmeter (transonic). results: the control endotoxie group (n= ) maintained low arterial pressure and systemic vascular resistance. the dogs receiving a continuous infusion of , , ~ug/kg.min of sin- starting min following initial fluid resuscitation (each dose for h), had a higher cardiac index ( . -+ . vs . _+ . l/min.kg, p< . ) and lower systemic and pulmonary vascular resistance than the control group ( -+ vs -+ and -+ vs -+ dyne.sec/cm , respectively, both p< . ). arterial pressure and pulmonary artery pressure were not influenced. sin- significantly increased the mesenteric blood flow from -+ to + % of baseline levels and renal blood flow from -+ to -+ % (both p< . ) but did not influence femoral blood flow. the relative blood flow was increased in the mesenteric bed (at all doses), and reduced in the femoral bed (at highest dose). systemic oxygen delivery, vo , oxygen extraction and blood lactate levels had similar course in the two groups. conclusions: in fluid-resuscitated endotoxic shock dogs, the no donor sin- increased cardiac index without deleterious effects on arterial pressure, and increased splanchnic blood fl w. objectives: sepsis syndrome is associated with the release of a variety of inflammatory mediators, such as interleukins, tumor necrosis factor and platelet-activating factor (paf). administration of paf, a naturally occuring phospolipid, to laboratory animals has been demonstrated to resullt in pathological changes that closely resemble those found in sepsis. in addition, paf antagonists of various origins have been demonstrated to attenuate cardiovascular collaps and to protect against lethality in endotoxemia. in the present study the efficacy and safety of the paf-antagonist tcv- g was investigated in sepsis syndrome patients. in addition, the putative inflammatory parameters tumor necrosis factor (tnf), interleukin il) - il- , and soluble (s) e-selectin were measured in both tcv- and placebo treated patients. metho.~a randomized, double-biind, multi-center study was undertaken to compare the safety and efficacy of intravenously administered tcv versus placebo (takeda chemical industries ltd., osaka, japan). tcv- was used as add-on to conventional therapy in the treatment of patients with severe sepsis and septic shock ( . mg/kg body weight intravenously over hrs, twice a day for one week). day mortality was registered, as well as vital signs, laboratory parameters, hemodynamic parameters, apache ii score and mof score. plasma samples for the determination of inflammatory parameters were collected twice a day for one week. the study was approved by each institutional review board and written informed consent was obtained for each patient. results: a total of patients were included in the study. one patient had to be excluded as a result of protocol violation of the remaining patients patients were randomised to receive tcv- and to be treated with placebo. there were no significant differences between the treatment group with respect to age. gender, and apache i~ score on admission. however, admission levels of il- and il- , considered to reflect severity of disease, tended to be higher in tcv treated patients: . . vs . ng/ml for il- (p. ) and . vs . ng/ml for il- (p. ) in tcv- and placebo treated patients, respectively. a remarkable difference in survival, however not significant, was observed at day i.e. the end of tcv treatment (mortality: out of in the tcv group and out of patients in the placebo group). the inc;dence ui ~-,~verse events, 'n both treatment groups were comparable. plasma il- and plasma il- levels tended to decrease more rapidly in tcv treated patients compared to controls (p=. and p=. , for il- and /l- respectively) conclusions: tcv- is safe as add-on treatment in sepsis syndrome patients. the data presented indicate that tcv- may enhance survival of sepsis syndrome which will be assessed in a phase ill study. objective: oxidation of lipids by free oxygen radicals playes an important role in sepsis. an important source of oxygen radicals is the respiratory burst of phagocytic leukocytes, especially~ polymorphonuclear leukocytes. clinically the hallmark of sepsis is the capillary leak, which is mediated in part by oxyradicals. the adult respiratory distress syndrom (ands} represents the most studied capillary leak phenomenon in sepsis. methods: in ii patients (df,~m, aged - y.) with verified septicemia had been included in this study. beginning from day oxidisable lipidautoantibodies (club), ~opterin and crp were determined in the patients serum and compared against the apache ii score during the days - . patients, f and m died @u= ring their stay at the icu, of them in less than h~urs: after admission. at the begin surviving patients showed olab values between - %, non-survivors between - %, com= pared to neopterin values of - m~ol/l in survivors and - ~mol/l in non-survivors. apache ii score didn t show any difference. during the following days olab sbowed an in= crease in survivors, while in non-survivors olab stayed equal or showed a decrease. no difference between both groups was found in neopterin, crp and apache ii score. as result we conclude, tbat lipidperoxidation playes an important role during septicemia. olab as a marker of this process are predictive for the outcome of patients. obiectives : to evaluate the influence of cardiopulmonary bypass ongastrointestinal transit. meth~xls; gastrocoecal transit time (gtt) in consecutive children on day after uncomplicated open heart surgery was compared to gtt in children after closed heart thoracic surgery and to healthy controls. gtt was measured by hydrogen breath testing, using lactulose (o, g/kg in a % aequous solution) as nonabsorbable marker. exspiratory hydrogen content was measured using a electrochemical system (stimotron). patients in both groups had continuous infusion of morphine and midazolam and were comparable in respect to catecholamine dose. children with a history of toddler's diarrhoea and children with elevated central venous pressure were excluded. results: gastrocoecal transit was delayed in all patients after cpb, no transit was achieved within minutes in / . after closed heart surgery gtt was delayed (+- ) min vs. (+- ) compared to controls, but transit was achieved in all aptients within rain. mean dopamine dose was , mcg/kgmin after cpb and , meg after closed heart surgery.. conclusions: after uncomplicated cpb gastmcoecal transit is extremely delayed. the degree of delay is not explained neither by the use of analgetic and sedative drugs neither by the use of catecholamines. factors directly related to cpb (e.g. low flow perfusion, hypothe,mia) may be responsible. these findings are of limited clinical relevance in ancomplicated cases. in critically ill patients delayed enteral feeding may contribute to infectious complications. studies of therapentic measures to accelerate gastrointestinal transit therefore are warranted. neonatal ecmo -czech experience. nekvasil r., penkova z, vasek l., plier p., bobula a novotna e., pavlicek v., hnilicka m. nicu and ecmo center brno and dept. pediatric surge ', children's hospital brno, czech republic. introduction. in spite of the fact that neonatal ecmo has been gradually considered a standard method of solving uncontrollable respiratol t failure in newborns in most countries of the western europe, the introduction of this sophisticated method in countries of the former communist block meets a lot of problem. material methods. in the course of two years, only newborns, b.w. - g, were reffered to neonatal ecmo because of uncontrollable respiratow failure. at the admission the average values of oxygenation index were + , and aado , -+ , kpa. results. newborns ( %) died shortly alter" admission or during transport without possibity to further is newborns ( , %) were treated using high-frequency ventilation (hfo or hfjv), one for conspicuous airway resistance paradoxically with low-frequency ippb. all ventilated newborns survived. ecmo was applied in newborns ( , %) and of them survived the mortality rate of group mentioned was %. conclusion. the fact that in the czech republic ( mil. population with natality rate of about . newborns/year) only small part of patients was reffered to neonatal ecmo has a number of causes. the most important are: unacquaintance of prognostic and indication criteria at forwarding workplaces and the aversion of neonatologist to all new.therapeutic interventions. last but not least, a negative role is also played by current change of health service systems when, under the influence of health-service insurance companies a newborn in serious condition given only a standard intensive care in primary and secondary nicu is literally "the golden calf", and therefore these workplaces either do not send him or send him too iate ~o an ecmo center. stndy aim: urfactant, which is being applied into the lungs for treatment of respiratory distress syndrome, can reach the circulatory blood system by absorption. it refinances local fimctiun of macrophages and lymphocytes and increases the accumulation of nentrophils into the hmgs this eunld influence the local acute phase reactiml in the hmgs after surfactant application. "ilia aim of the stud), was to investigate the influence of oatural and artificial surfactaat onto the acute phase reaction and the blood elottiog system. material :and methods: a) measurement of tnf-a, - , ltb and thromboxane b release in whole blood: each of . ml hepariaised blood of healthy adult volunteers was iucubated lbr hears with eillier ill ug/ml lps, mg/ml b&,ine smfactant (alveulhct/themae), rag/nil artificial surfactant (exosurf/wellcome), og lps + i mg/ml bovine surfactant or i ug lps + i mghal artificial sorfactant, tleparinised bhx-,d without additions was used for controls. ' e concentration of e)lokines and eicosanoids ".van measured semiquantilatively by eijsa or eia (dimmva/hamburg) after ceatrifagalion, b) measurement of platelet aggregation: each of . ml haparinised hltxxl of healthy adult vohmteers was inculmled lbr hours with eilher aghnl i,ps, i mg/ml bovine surfactant (alveafact/thomae), i mg/ml artificial snrlhctant (exosurf/wellcotne), it} ug lps + i mghnl bovine snrfactant or ug lps + i mg/ml artificial surfaetant, tlepminised blood withont additions was nsed for controls. platelet aggregation in whole blood was measured by impedance in the aggregometer (g~nstaedt). c) measurement of the dotting activity: citrated bleed of healthy adult w~lunlccrs was mixed with difl'ereul couccalrations of imvine or artificial snrfactant fad then prolhrombiu tiaras and imrlial thrmnlx~plaslia filues were ineasnrcd. for measurement of the prokoagulatioo acfivily the reagent in the qnick test was replaced by surfaclant. results: dependmlt on the dose both surfactants stimulated the release of - but not or tnf-a io wlmle blood. "illere was no suppression of the lps-indaeed eytokine-release. both surfaclants did not directly influence the extrinsic blood coagulation system, while both activated the inniasie activity dependant on the dose. platelat aggregatiun was slightly stimulated by bovine snrfactunt and strongly inhibited by by artificial surthctant. in comhinafion with . ~ both factors showed no difft.'renca to lps ahme.'fhe reltu.tse of eiconasnid~." was stimolated more by artificial surfactant then by bovine surfilctant with regard to the cyehmxygelmse (thromboxsne b ) and the lipooxygenase (lencotrieae b ) pathways. conclusion: we cooclude: ) i:lovine as well as artificial surfaelant stimulate the cellular inmnn]e response. ) bovine as well as artificial surfnctant activate the intrinsic ctmgnlation cascade. ) bovine surlilctant stimulates platelet aggregation, artificial sar-fijctant inhibits platelet aggregation.. introduction: although the use of modem noninvasive methods like measurement of tope , tcpco or san leeds to an carly infonnation about pathologic alterations of the gas exdmage of ventilated patients, these methods cannot replace invasive bloodgas analysis. a new noninvasive method to monitor the capillary gas exchange is the reflection spectrophotometry. to record reflection spectra with a ldgh sensitivity on the surface of tissue we eonstnmted a special mierolightgnide photospectronmter (empito). this spectrometer enables the investigation of local helerogenities of llbo and lb content, capillary flow rate and oxygen uptake rate. aim of the study: ) to compare the sousitivity and specifity ofthe empilo with other non-invasive method~ of monitoring the gas exchange in neonatal intensive care patients. ) to investigate the possibility of obtainiug infonnations about the local nptake and the venous as well as arterial satnration. patients and methods:we investigaled non-selected patients of oar pediatric intensive care unit. for coulinnons monitoring we conslracted a special sappert to fix file end nf the microlightguide+ during the investigation tope , tcpco and san were measured by standard methods. "fo investigate the local tisslm oxygen uptake we recorded spectres within minutes by moving the lightgnide over an described area of the skin of the patient. 'lhe reselting i(gx) l ibo vahms were sorted by a software package. on the assumption that the low values correspond to the tibo value of the veaons ends of the capillaries and the high values to those of the arterial ends we ) it is possible to gel infonnations about the local o -uptake and arterial saturation ia the peripheral tissue by photoslg'ctroscopy. ) in combination with noninvasive pl i-measorement it seems possible to reduce withdrawal of blood for invasivn bhmd gas analysis. objectives:improve ventilation,tissue oxygenation and acid base balance among extremly low birth weightand premature infants. methods: fourteen cases were s~udied,their gestational age ranged from( - )ws.continnous positive air way pressure was applied to six cases at peep level from ( - )cm h o through nasal pronge,(group i),the other cases were managed as routine,(group ii).blood gases, tcpo ,tcco ,resp.rate,depth and pattern were monitored for assessment of tissue oxygenation and ventilation, results: our rasults showed that early application of cpap improve ventilation among ( . %)of cases,while ( . %)of cases need imv.the cases of group ii need imv among ( %)of the studied cases during the second or the third day of life. conclusions:-this preliminary study showed the import-............ ance of early application of cpap before the onset of respiratory distress syndrom to improve spontaneous ve ventilation,tissue oxygenation and to gecrease the risk of intubation. comparative assessment of pediatric intensive care; a national multicenfre siudy. reinoud j.b.j. gemkc, gouke j. bonsel , the dutch picasso (pediatric intensive care assessment of outcome) study group. twilbelmina children's hospital and utrecht university, utrecht department of clinical epidemiology, academic medical center, : amsterdam, the netherlands the performance of all ( ) pediatric intensive care units (icus) in the netherlands ( tertairy and non-tertiary) was analyzed in an open prospective muiticenter study. effectiveness of care was defined as the ratio of observed to prism-score derived expected mortality aenee, standardized mortality rate). efficiency was determined by objective criteria (mortality risk > % or administration of at least icu-dependent therapy)'. consecutive admissions aged < years old were included. overall, observed and expected mortality were in good agreement (p > . ). between hospitals, crude mortality showed wide variations (mean . %, range - %). however, in each center, observed and expected mortality were similar (mean ratio . , range . - . ). in tertiary care centres, severity of illness corrected mortality in high-risk patients was less than in non-tertiary care centres; paradoxically, in low-risk patients the opposite was found. probably the large proportion of low-risk tertiary care patients suffering from severe, incurable chronic disease, explains the higher mortality in this group. this indicates that simultaneous assessment of circumstances of dying and of long term morbidity in similar future studies is imperative. the average proportion of efficient icu days was %, however large variations between units were found (range: - %). in conclusion differences in mortality rates among pediatric icus were explained by differences in severity of illness. high efficiency rates in combination with adequate effectiveness, found in several centres suggest that admission and discharge decisions might be improved by a better selection of high risk patients requiring icu-dependent therapies, especially in less efficient centres. objectives: previously published studies showed that serum lactate levels correlated with outcome of severe ill adult, 'we hypothesized that critically ill newborns are often incurred hypopeffusion manifested by elevated lactate levels. these initial blood lactate levels should be related to nicu outcome. design: prospective study with ethical comfnittee approval. setting: the -bed neonatal intensive care unit of a university hospital material and method: a total of consecutive outbem newborns admitted to nlod from , . to ., . were enrolled to the study. babies who died or were discharged from the unit within hours of treatment were excluded from the study, mean birth weight was g (+/- r), mean gestatational age was weeks (+/- . wks), mean age at the admission was h (+/- hi. multiple (~_ j organ system failure occurred jn . % of babies at the admission./~tertal lactates were measure/at the admission, among - hour and - hour of n[c'lj therapy. outcome was defined as a mortality and length of nicu stay. results" survival rate was . %, mean length of nicu stay for survivors was . days (+/- . day). we found high lactate levels at the admission in . % babies (~ . % with levels above . retool/i). the mean arterial lactate concentrations for nonsurvivors were signiftcahtly higher than for survivors durin~ consecutive da~ as follows: objectives: the purpose of our research was to analyze the frequency of bronchial asthma (b.a.) exacerbations in pregnant women and health status of infants. methods: the research was based on the epidemiological investigation and prolonged observation of pregnant women with b.a. during the gestation period. remission of b.a. before the pregnancy in excess of years was recorded in patients ( . %), patients ( . %) reported a - year remission and patients ( . %) had a remission lasting less than months before they became pregnant. results: seven patients ( . %) developed medium attacks in the second half of pregnancy, four patients ( . %) experienced light attacks of b.a. asthma attacks were most frequently caused by acute respiratory diseases and stress factors. in two cases with grave manifestation of b.a., the pregnancy ended in abortion within the first - weeks due to the frequent and heavy choking attacks. to fight b.a. attacks, five patients used adrenomimetics (salbutamol, becotid) in sprays, six women were administered theophyllinum and salbutamol in the form of tablets during - weeks. a significant portion of pregnant women with b.a. ( %) exhibited frequent complications during pregnancy (toxemia, late gestosis, threat of miscarriage). our findings prove that babies born from women with b.a. of domestic and pollen origin had a low body weight ( - gr), functional immaturity and chronic antenatal and intranatal hypoxia twice as often as the infants born from healthy women without allergic background. conclusions: preventive treatment of women with b.a. prior to pregnancy is required to maintain a stable remission of the disease, which is a key to having healthy children delivered by mothers suffering from b.a. introduction. intracerebral hemorrhage (ich) is a common event in human prematudty, affecting about % of newborns weighing below g who are born before weeks of gestation, however, little is known about the pathogenesis of ich with exception of the prematurity of the brain itself, (birth) trauma, and asphyxia. the postischemic production of oxygen free radicals (ofr) dudng reoxygenation as a cause of brain damage has been demonstrated in animal research. since almost all preventive antioxidant activity of plasma is associated with ceruloplasmin and transferdn we investigated the association of such iron-oxidizing resp. iron-binding proteins and ich. we could demonstrate significantly reduced levels of both, iron-oxidizing and iron-binding proteins, in premature asphyxiated newboms pdor to development of ich. an increase of suparoxide after hypoxia in the presence of iron ions facilitates the formation ofthe highly reactive hydroxyl radicals. our data support the theory that ich may be caused by ofr, which can damage any sensitive tissue including growing endothelial cells. the estimation of transferrin-saturation and measurement of ceruleplesmin levels might help to identify an infant at dsk before the onset of ich. with the new medos | hia-vad | cardiac assist system the missing tool in the armamentarium of cardiac surgeons is available in two pediatric sizes: i -ml and -ml pump volume. the right sided pumps are % smaller for biventricular use. between february and may we implanted this assist system in children. the indications and demographics are indicated in the following table (left ventricular assist device-lvad, right vad-rvad univentricular vad-uvad, post cardiotomy cardiac failure-pcf, dilated cardiomyopathy-cmr bland white garland syndrome-bwg, tetralogy of fallot-tof, hypoplastic left heart syndrome-hlhs). objectives: evaluate tile effeci'of inhaled nitric oxide (no) as puhnona] t vasodilating agent ill tile posloperalivc period after correclion of congenital heart defects in infant. patient n.l: kg, lnonlhs, down syndrome undenvcnl rep~fir of atrioventricular septal defect (avsd). after surgery the puhnonary arlcry pressure (pap) slowly rose to tile syslemic dcspilc tnaximal eonvcnlional fllerapy (fentanyl mcg/kg/h, hypocapnia of mmhg and metabolic alcalinization). no was delivered into tile inspiratory branch of!be breathing circuit at ppm, and the gas aoalyser for no and no (polylron dmger) were situated at the espiratory branch, a rapid dccrcasc of pap io i/ of systemic was obtained with a dramalic improvement. no was continued at ppm for six days and the baby was exlnbated if! days after surgery and discharged from the icu days after. patient n. : . kg, monlhs, onderwen! repair of avsd. the day after surgery the systemic oxygen salnralion was % wilh a pap at % of systemic. two hours of c wenlional therapy failed o improve ihc patient and no administration was slarled at ppm. so dramatically incrcased to %, but the pap dropped only to % of syslemic. nevertheless ihe clinical conditions improved and the no administration could be reduced at ppm in the following days. she was extubaled days after surgery and discharged from the icu days after. patient n. : kg, 'ears. underwen| hearl tral~splantalion for congenital heart disease with moderate hypoplasia of pulmonary arlcrics. at the end of cardiopulmonary bypass the transpnlnlonary al~erio-venoas gradient yeas higher than mnfflg and we speculaled !hat w'ls due to a degree of puhnonary vasocostrictiont. the nsnal dose of no was otilised, however no significant modilicalion of pulmonary pressure or systemic oxygen saluralion was noled, and after h no was discontinned. tile palienl was carried io the icu with maximal inotropic support, extubated after d;b's and disclmrged from the icu after days. in all patient no major adverse effect relaled to no admilfistration ",','as holed. conclusion: in our experience no ms a pulmonary vasodilaling agent is effective and easily adjustable to tile palienls requiemenls, however its use remains limited ill those palienl ill whoin tile alnonll! of fixed inlllllojliify vascular resistance is predominanl. we report the use of ecmo support in two unusual cases of severe tracheal disruption in which it had become impossible to achieve adequate ventilation. case : severe tracheal laceration due to aspiration of a share forelan bodv: a previously healthy month old toddler was referred for ecmo following aspiration of a porcelain foreign body (with razor sharp edges) which had become embedded in the right mainstem bronchus with massive extrusion of air. this was removed on veno-arteda[ ecmo support, as the patient was unventilatable prior to bronchoscopy due to ongoing airieak. ecmg was continued after bronchoscopy to permit airway healing without the presence of an endotracheal tube. unfortunately, an extensive pulmonary haemorrhage on day of ecmo necessited re-exploration of the airway. this revealed a posterior tracheal tear from the cricoid to the middle of the right lower lobe. following repair the patient was left on ecmo support together with high frequency oscillation ventilation (hfov), the latter being used to minimise potential aideak and maximise alveoli recruitment. ecmo was weaned after days ( hours) -the patient was extubated weeks later. case : tracheal wound dehiscence due to seosls -tracheal transelant on ecmo: a month old infant with a c[inically significant congenital long segment tracheal stenosis and left pulmonary artery sling underwent resection of the stenosis, followed by primary reanastomosis. this was complicated, days later, by severe mediastinitis and complete dehiscence of the anastomosis. an autologous pericardial patch was used to repair this, however, the tracheal wound again dehisced days later making mechanical ventilation impossible. in view of ongoing sepsis and a severely disrupted trachea ecmo was the only possible form of support. following resolution of the local sepsis ( days) a definitive procedure in the form of a tracheal homograft (transplant) was undertaken on ecmo. the patient was managed on ecmo and hfov for a further days, the hfov being used to optimize rapid lung inflation. unfortunately this patient died months after weaning from ecmo due to complete disintegration of the homograft, which was not deemed reparable. conclusions: ) ecmo can be used in the acute management of oxygenation when there is major airway disruption making mechanical ventilation impossible. ) hfov was a useful adjunct in aiding recruitment of lung volume on ecmo in these two patients. backoreund: persistent pulmonary hypertension of the newborn (pphn) consists of a heterogenous group of diseases ranging from transient reversibte pulmonary hypertension to fixed primary malformations of the lung (primary pulmonary dyspfasia-ppd). inhaled nitric oxide (ino), a selective pulmonary vasodilator, has been proposed as a treatment for severe pphn. obiective and methods: ino was administered to near term neonates with severe persistent pphn, oxygenation index > and echocardiogrephic evidence of pulmonary hypertension, in order to further determine the clinical role of ino in the treatment of pphn. the response to ino was also analysed retrospectively to examine whether this could be of diagnostic value in differentiating at an early stage patients with reversible from fixed causes of pphn results: twenty one of the patients studied responded to the initial trial of no ( ppm x minutes), as defined by a greater than percent improvement in pad as well as a fall in the el to < . these patients were continued on ino therapy, with patterns of response emerging: pattern babies (n= ) continued to show a sustained response to ino and were successfully weaned from it within days -all survived. pattern babies (n= ) failed to sustain their response to ino over hours, as definded by a rise in the el > . six survived, five with ecmo. pattern babies (n= ) had a sustained dependence on ino for - weeks. all three died and lung histology revealed severe primary pulmonary dysplasia (ppd). patients with ppd (pattern ) not only required ino for longer periods of time than did the sustained responders (pattern ), but also required significantly higher doses of ino we report on the air transport of paediatric intensive care patients. these transports fall into three categories: ) retrieval of critically ill neonates and paediatdc patients referred for either ecmo or inhaled nitric oxide (ino) (n = ). one patient was transferred on ind. mean transfer time . hours (se + . hrs). ) long distance international transport using chartered aircraft (n = ). the indications for these transfers included both urgent retrievals for cardiac surgery and semi-elective transfer of stable patients back to their referring unit following treatment in tertiary centres. mean transfer time . hours (se + . hrs) ) long distance international transport using commercial aircraft (n = ). indications for transfer were either semi-elective retrieval for tertiary treatment or the return of stable chronically ventilated patients to their referring hospitals. mean transfer time hours (se _+ .fhrs, longest hrs). the transport team consisted of a paediatric intensive care doctor of at least registrar grade and a registered sick chidrens nurse with intensive care experience. the administrative components of the transfer (ambulances, airlines, customs) were managed in collaboration with companies specializing in air ambulance transfers. outcome: all the patients were safely transported to their destination without mortality or morbidity. complications durino transfer ir~lv~; ) patient complications -semielective endotracheal tube change and central access needed in the only patient brought to the commercial aircraft by the referring hospital (all others retrieved directly from referral hospital), seizure in patient with known encephalopathy, severe cyanotic spells in patient with fallots tetralogy who was retrieved for urgent surgery for this indication ) mechanical compfications -ventilator failure, incubator battery failure, oxygen regulator failure -all occurred with equipment sent from referral hospital, this was unfamiliar and unchecked by our transport team -it was not the decision of the transfer team to use this equipment on this single occassion. ) administrative complications -confiscation of incubator battery by airport security police, excessive delay by custom officials ( hours) in the airport. the incidence of such problems were felt to be low and unpredictable. in conclusion: mechanically ventilated paediatric patients can be safely transported on both chartered and commercial airlines. these transports are best accomplished by trained intensive care medical and nursing staff with the backing of an air ambulance organization competent in arranging the necessary administrative details. it is essential to use your own equipment and to retrieve the patient _directly from the referrin(] hospital to minimise ootential complications. our experience with anaesthesia for paediatric electromyography _w_._pla_ti_k_a_n_o_v, r.eousseff, k.pavlova, d.marinova dpts. of anaesthesiology and int. care and clinika] neurophysiology, med. university, pleven, bulgaria ~)_b_j#~ti_v~. to t~st a " heavv sedation " regimen of anaest-es~a for the purpose of paediatric electromyography d#s~gil~ non-randomized,non-blinded human trial in the seting of an uriiversity hospetal. _m_a_t_eri_a_is_a_nd_ m_e_th_od_s_. children,asa i-if,median age years,range - who undervent eleetrcmyography required anaesthesia. they recieved low-dose ketamine + i~iazepam or midazolam via musculary route( children,age - yrs,ketamine , mg/kg, diazepam - mg total dose ) or per os ( children,ketamine - mg/kg,diazepam , mg/kg or midazclam , - , mg/kg ) _resu_l_t_s. - minutes after medication a state of heavy sedation with weak spontaneos and stimuli-provoked movements was achieved in all children, that lasted - minutes and allowed adequate needle emg and nerve conduction investigation. children recieved additional , - , vol.% halothane during the placement of the needle. non -invasive blood pressure , breath and heart sounds and hb sad by pulse oxymetry were monitored.none of the older children disclosed memories of pain when asked after they regained adequate verbal contact.no complicationes were observed. antenatal maternal steroids reduce the risk of periventricular-intraventricular hemorrhage in very premature neonates treated with natural surfactants. i.apostolidou, c.papagaroufalis, g.touloumi, m.xanthou, n.kalpoyannis a' and b" neonatal icu "ag. sophia" children" s hosp. athens, greece. dept of hygiene and epidemiology, athens university, greece. obiectives: the aim of the study was to evaluate the association of periventricular-intraventricular hemorrhage (p-ivh) in surfactanl treated premature neonates with pre-and postnatal variables. methods: the population of the study was neonates admitted during the years to , with gestational age _< weeks and severe respiratory distress syndrome (rds) (mechanical ventilation and arterialalveolar oxygen tension ratio (ajapo ) < . ), who received rescue therapy of at least two doses of natural surfactants (alveofact or curosurf) and examined with ultrasound and/or autopsy for the presence of p-ivh (papile's classification). the examined factors in each neonate were the following: gestational age, birth weight, sex, multiple pregnancy, antenatal maternal steroids (complete and incomplete course of betamethasone), a/apo before the administration of the st dose of surfeclant, delivery, apgar score at min, type of surfactant, pneumothorax and patent ductus arteriosus. the statistical methods used were x and one-way analyses of variance followed by logistic regression medels, results: the incidence ot p-ivh was . %. three factors were found to have an independent relation to p-ivh (final logistic regression model): gestalional age, a/apo before surfactant administration, and antenatal administration of maternal steroids (complete and incomplete courses). for every weeks of lower gestational age the neonates had an almost doubled associated risk of p-ivh (or: . , % c : . , . ). for every . on average decrease of a/apo before surfactant administration the risk of p-ivh in the neonates was . times higher ( % ci: . , . ). the neonates whose mothers received antenatally steroids had only one tenth of the risk of p-ivh of the neonates whose mothers had not (or: . , % ci: . , . ). conclusions: our results suggest that the antenatal administration of maternal steroids, even less than hours before delivery, reduce the risk of pqvh in very premature neonates treated with natural surfactants, whereas the small gestational age and the lung immaturity still remain the main risk factors tor the development of p-ivh. we analysed retrospectively the management of ( boys, girls) accidental ingestions of foreign bodies in children (mean age : . years, range : months- years). no child had ingested more than foreign object. the majority of the ingested foreign bodies were : coins (n : ), toy parts (n : ), jewellery (n : ), batteries (n : ), "sharp" materials such as needles and pins (n : ), "large" amounts of food (n : ). impaction of food occurs more frequently in children after oesophageal reconstruction in cases of oesophageal atresia. although according to literature "coca-cola" is reported to be effective, this was not seen in our experience. / patients had minor transient symptoms at the moment of ingestion, such as retrosternal pain. only children experienced severe manifestations (cyanosis, dysphagia). in these children, endoscopy revealed oesophageal and gastric erosions. children were seen at the emergency ward within a few hours after the accident ( mean : hours, range min. - hours). chest and/or abdominal x-ray was performed as first-line investigation ( / objects were radio-opaque), and revealed an (unexpected) oeeophageal impaction in children. in / the foreign body was in the stomach. batteries, sharp objects and objects trapped in the oesophagus were removed, either by endoscopy or by magnet-extraction whenever possible. the outcome of the patients was excellent. no complications were observed. extraction is recommended in symptomatic patients, and whenever the foreign body is trapped in the oesophagus, or if the foreign object is "sharp" or a battery. objectives: two strategies were used for management of malignant diphtheria in children aged from . to years. methods: protocol n consisted of intravenous administration of diphtheria antitoxic serum, prednisolone ( mg/kg bw/day), plasmapheresis and supportive care. protocol n included the use of antitoxic serum against the background of high-dose dexasone ( - mg/kg bw/day), hemocarioperfusion and a preventive use (before the clinical manifestation of myocardial damage) of inotropic medications, inhibitors of angiotensin-converting enzyme and pentoxyphylline. each of protocols included the monitoring of serum toxin (diphtherin) levels. results: the group of patients treated according to the protocol n consisted of children with malignant diphtheria, of them with severe malignant diphtheria (grade and ). all patients exhibited the circulation of toxin during at least three days after the start of treatment. all patients with severe grade of disease demonstrated heavy cardiovascular disturbances associated with malignant diphtheria. of the children in the group died seven. the children of the second group were treated according to the protocol n . out of total of patients of this group. patients had severe malignant diphtheria. in all children a significant reduction in serum toxin level was revealed after hemocarboperfusion. in all but one case the satisfactory control of cardiovascular function on was achieved. of children admitted to the trial survived, one child with malignant diphtheria of grade and congenital filbroelastosys of the left ventriculum died. the severity of neurological complications was similar in each of groups. conclusions: the use of hemocarboperfusion, high-dose dexasone and early prevention of heart failure as a adjunct to the standart treatment has been shown to be of benefit in the management of malignant diphtheria. t. schaible, i. reiss, j. m er, l. gortner med. university of lqbeck, children's hospital, kahlhorststr. - , l~beck, germany surfactant therapy seems a promising approach for the treatment of the biochemical and biophysical abnormalities of the pulmonary surfactant system in severe ards. patients and methods: over a months period non-neonatal pediatric ards patients (age - months) in a "pre-ecmo"-situation (oi over h) were treated with bovine surfactant (alveofact| the underlying conditions-of ards were pneumonia ( ), sepsis ( ), immunosuppression ( ), near drowning ( ), neurogenous ards ( ). a total of - mg/kg b.w. was applied in several fractions. before surfactant therapy, we first tried different ventilation (best peep-finding, inversed i/e-ratio, hfo-ventilation) while monitoring the pulmonary mechanics. for hemodynamic stabilisation both norepinephrine and epoprostenol were used to optimize pulmonary perfusion for max. hrs. if there was no improvement of the oi by at least , further treatment with surfactant was initiated. in addition to surfactant all patients received a treatment with dexamethasone of mg/kg in doses. patients with no benefit (oi remained unchanged or increased within the max. - hrs) were taken on ecmo. results: nine patients improved within hours after surfactant therapy: the oi decreased from a level of (mean, range - ) before our treatment to a level of (mean, range - ) thereafter. in patients we were able to continue the positive effects of our treatment and they could be weaned of the respirator within - days. the other patients got worse despite respiratory improvement, they suffered of multiorgan failure of more than organ systems. the last patient did not benefit from surfactant, he had to be put on ecmo, but died because of a complication (hemopericard)after days. the autopsy of the ecmo-patient showed a pulmonary fibrosis, but the other death were not due to pulmonary failure. conclusion: a different sequential ards treatment integrating surfactant therapy can reduce the number of patients requiring ecmo. but ecmo as a therapeutic tool should be available in centers involved in ards treatment. l.blindl, t.p.le, h.weinzheimer, centre for paediatrics, university of bonn, germany selective reduction of elevated pulmonary vascular resistance by inhaled prostacycliu (pgi) has been reported in adults with acute lung injury, neonates with persistent pulmonary hypertension and in one infant with idiopathic pulmonary hypertension. we report on the effect of aerosolized prostacyclin in two children with secondary pulmonary hypertension. patient : in a boy with down's syndrome an avsd had been surgically corrected at month of age. at , yr of age a catheter examination revealed a pulmonary vascular resistance of % of systemic vascular resistance in room air and at an fin of . . prostacyclin ( . mcg/ml) was administered with a jet nebulizer at an fin of . . pvr declined to . systemic vascular resistance and returned to baseline after stopping pgi-inhalation. subsequent intravenous infusion ( ng/kg rain) had to be stopped after minutes because of systemic arterial hypotension. patient : a month old male infant with bronchopulmonary dysplasia developed suprasystemic right ventricular pressure inspire of therapy with oxygen and nifedipin. while he was spontaneously breathing % oxygen via face mask pao was mmhg, arterial ph was . . systolic arterial pressure was mmhg, a rv-ra gradient of mmhg was measured by cw-doppler. while fio was maintained aerosolized prostacyclin was administered over minutes. rv-ra gradient was mmhg, systemic blood pressure mmhg, pao mmhg. two hours later nitric oxide ( ppm) was inhaled at an fio of ( , . rv-ra gradient declined from to mmhg, systemic systolic blood pressure remained stable at mlnhg. discussion: sporadic experience shows that aerosolized prostacyclin selectively reduces elevated pulmonary vascular resistance in some patients. in patient the poor response to inhaled pgi compared to inhaled nitric oxide may be explained by the fact that the action of pgi is not independent from endothelial function, limiting it's effect in severe vascular disease. during the last two years ( - ), infants weighing less than gr. admitted to our referral unit. thirty four of them ( %) survived, ( % of infants weighing - g and % of infants weighing - gr survived) for the years - - the survival of these infants was % and for the years - - , % (p< . ). we analyzed the perinatal and neonatal factors influencing the outcome of these infants. the comparison among neonatal survivors ( ) to neonatal deaths ( ) shows: gestational age: . w ( ) to . w ( ) (s). birth weight: . g ( ) to . ( ) (s). apgar score: , ( ) to . ( ) (ns). presentation and mode of delivery: breech presentation is associated with higher incidence of neonatal deaths. i.v.h. (at the age of weeks): no one of the survival infants had evidence of i.v.h. respiratory problems: intubation, at the admittance of the infants . ",,( ) to % ( ) (s) use of surfactant: % ( ) to % ( ). bpd observed in % of the babies and only one was dependent on oxygen at home. antenatal betamethasone was given in % of the mothers. in conclusion: ) a great improvement in the survival rate observed in these infants the last years in our unit. ) factors with positive effect are increasing gestational age and birth weight, the absence of i.v.h. and the use of surfactant. the breech presentation and the severe respiratory problems increase the incidence of death. animal experiments demonstrated, that brain temperature determines the amount of neuronal damage caused by hypoxia and that mild hypothermia may have a protective effect. until now there is no method described and evaluated to measure brain temperature in neonatal intensive care units. we non-invasively measured brain temperature analogues, nasopharyngeal (tnasoph) and zero-heat-flux temperature (zht) at the temple whereby under zero heat flux surface temperature represents deep head and thus brain temperature. the aim of our study was to investigate the practicability of the method, the relationship of the two brain temperature analogues to rectal temperature (trect) and their dependence on insulation, thermal environment, body activity and time course. we investigated healthy preterms less then weeks postnatal age (gestational age +_ . wks; x + sd, weight +_ g) in an incubator. tnasoph was measured by a thermistor within a feeding tube, advanced to the nasopharynx, zht temple by a thermistor and a heat flux transducers both covered by an insulating pad, and trect thermal environment was characterised by operant temperature (tair . . + twall . ). body activity was video taped. measurements were performed during the following interventions: i/ insulation increased by turning the temple with sensors onto the mattress ( rain). ii) insulation increased by a cap ( min), iii) min after its removal, iiii) increased operant temperature by . + . ~ ( min). results: seven children with ea had a gasless abdomen, the endoscopic procedure excluded ( ) or diagnosticated an upper pouch fistula ( ). in patients who suspected "h" fistula ( ) broncoscopy has strong advocated method to make diagnosis and established cervical approach. from july newborns with ea and lower pouch tef received a selective transtracheal incannulation. we were not able to proceed just in case with congenital subglottie stenosis. in these patients we provided gastric drainage by radiopaque and flexible - french catheter. the knowledge of the precise anatomic position of tef consent to adjust the tip of the endotracheal tube in order to achieve best ventilation. the presence of the catheter through the fistula helps the surgeon to identify, it quickly. no complications were correlated to the procedure and no babies had early pneumonia. alimentary continuity was achieved in all patients ( primary anastomosis, resections of tef, oesophagocoloplasty and died with gastrooesofagostomy). the late mortality . % ( ) was only directly related to the severity of associated malformations. conclusion: the advantages of this technical approach are unquestionable for the anaesthesiologist and the surgeon. in our experienc e the procedure improves perioperative management of babies and appears to be safe. relation between cytokines, prethrombotic markers and endotelial injury markers in children with septic shock objectives: to establish the relationship between cytokines (tnf, il- , il- ) prethrombotic markers (d.d., pcam) and endothelial injury markers (tm, uwf) in pediatric patients with sepsis and bacteriemia without shock, and patients with septic shock. design and methods: prospective study, children ( months- years) were admitted in our picu in with the following diagnosis: bacteriemia ( ) sepsis ( ) and septic shock ( ) according to jacob's r f criteria. measurements: il- , il- , tnf, tm, vnf, d.d. pcam and routine laboratory data on admision, , , hours and on discharge. the prism (pediatric risk of mortality score) was also recorded. results and conclusions: two patients in the septic shock group died. significant differences were found between non-shock and septic shock patients in relation to tm, dd, pcam, il- , il- and tne high levels of tnf and il- are closely associated with the severity of septic shock with purpura in children. low levels of pcam on admission were associated with severe shock. who underwent open hea~nt surgery, hypervotaemia with or without oliguria was the most frequent reason to start pd ( %). in patients pd lasted less then one week and there were no complications; in patients it lasted - days (one child had a peritonitis). instillation of dialysis fluid into the peritoneal cavity was associated with a significant increase in central venous pressure. there were no significant changes in cardiac output or arterial oxygeu saturation. in all patients pd dhnjnished fluid overload or improved the metabolic status. patients ( %) survived the postoperative course and all had complete reintegration of renal function. conclusion: pd is a useful method to treat the fluid overload and acute renal failure in paediatric patients following open heart surgery with file effects of little importance on the cardiovascular fimction. obieetives: with the marketing of computerised systems for lung function testing in newborns, there has been an increasing interest in clinical approaches. percentile curves of pulmonary parameters permit an appropriate and clinically useful interpretation. however, the manual evaluation of the results using different curves is an impractical technique. therefoi'e a computer programme was developed. methods: the percentiles ( %, %, ~ %, %) of the most important pulmonary parameters were determined non-parametrically in weight-classes. for the calculation we have taken results of our own as well as other laboratories using a meta-analysis of reference studies. in all, individual data of - healthy newborns ageing between - days were collated. using these percentiles, for every parameter in relation to the body-weight the cumulative distribution was calculated approximately using piecewise linear and exponential functions. as shown in the figure the results of computing are represented numerically as well as graphically and can be included in the patient report. conelusions: clinic~d experiences with the programme have shown that representation of all measured parameters on standardised % scales allows an easy interpretation at first sight and improves the detection of pathologic patterns in the parameters. ")supported by bmft, fp "risikoneugeborene" prism (pediatric risk of mortality) score is a well known, already validated scoring system that quantifies severity of illness based on routinely clinical and laboratory variables measuring physiological instability. once computed the score by summing up the weights corresponding to the most abnormal value recorded during the first hours, the overall risk of mortality can be predicted by using the coefficients estimated by a logistic regression where prism score is the main independent variable. (pollack mm et al, -pediatric risk of mortality (prism) score. crit. care med. ; : - . to assess the applicability and validity of prism in the italian setting we launched out a prospective data collection in a sample of pediatric icus. measures of calibration (goodness of fit statistics) and discrimination (receiver operating characteristics and area under the roc curve) are planned to be adopted in the cohort of patients recruited during year period. as the validation study started on july , data collection is still on going and validation analyses will be carried out on july . up to now centers recruited cases. at present, characteristics of the sample recruited are the following: most of the patients were male ( %); the mean age is years with % of patiens having less than days; more than half were medical cases ( %) admitted from emergency room or from hospital floor ( %); % cases were admitted with an organ failure while % to be intensively monitored. icu-mortality was l %. the paper will present final results of calibration and discrimination analyses that will be carried out in the whole sample and across subgroups known to differ in terms of clinical relevance and prognosis. if calibration and discrimination assessment will produce not satisfactoty findings, a customization of the current coefficients will be made allowing a formal comparision of previous and new parameters. jf riera-faneao, m wells, j lipman. baragwanath intensive care unit, university of the witwatarsrand, south africa. [background the prism score is designed to assess the likelihood of death in ipaediatdc icu patients, using only acute physiological disturbances, age and [operative status to predict mortality. there is no evaluation of chronic health status, [including malnutrition. this may significantly affect its ability to accurately predict outcome in a population where malnutdtion is common. aim to determine the influence of nutritional insufficiency, as indicated by a low weight-for-age on outcome prediction by prism. patients & methods we analysed prism, weight and demographic data co ected prospectively from consecutive paediatdc icu admissions over a year pedod. a proportional weight (pwt) was calculated as a percentage from the th centile of the who weight-for-age growth charts. the pwt was compared for survivors and nonsurvivors, and mortality compared for pwt categodes nho wellcome classification). multivariate statistical techniques were used to identity associations with non-survival and to develop a modified logistic regression equation including a measure of i nutdtional status. receiver operating characteristic (roc) analysis was performed including and excluding patients with low pwt for the odginal and modified equations. results non-survivors had a lower weight than survivors ( . kg and . kg medians p = ) a lower pwt ( % and % medians p = . " . the incidence of malnutdtion , in our icu population was %. the mortality of manoudshed patients was' significantly increased (p = . ), with a good correlation with the degree of malnutrition. the accuracy of prism was significantly improved when malnourished patients were excluded from the analysis (roc value increased from . to . ). ! logistic regression and discriminant analysis identified a significant association between prism, pwt and outcome; age and operative status were not significantly related to mortality. the use of a modified equation including the raw prism score, pwt category and age can significantly improve the discriminatory power (az dm/elopmental sample . , az validation sample . ). the modified formula is: legit = - . + . *prism score - . *age + . *weight category, where the probability of mortality is exp(iog/t)/ + exp(iogio. discussion although we can improve the prediction of mortality by a modified or recelibrated formula, this still does not compare with the reference prism population. the need for validation of the score itself, in the association with outcome of the acute physiological variables themselves, is thus apparent. we conclude that while the odginal prism formula can be improved significantly, a modification of the basic variables in this and other third wodd populations may be essential. a high incidence of malnutrition is an independent risk factor of mortality, and an important cause of the poor discriminatory performance of prism. in order to improve the accuracy of prism, nutritional status should be taken into account. objectives: to assess the value of inhaled no to differentiate between pulmonary vascular constriction or fixed anatomical obstruction. methods: we assessed the response to ppm inhaled no in patients( m, f, median age . months, range day to years) with signs of increased pulmonary vascular resistance, there were pre and postoperative patients. patients were divided into responders(+) or non-responders(-). a positive response was defined as a % reduction in pulmonary arterial pressure and pulmonary vascular resistance(pvr) or in the presence of a left to right shunt, a fall in pvr accompanied by increasing pulmonary blood flow. left atrioventricular valve atresia + mustard pat: pulmonary atresia vsd: ventricular septal defect asd: atrial septal defect pda: patent ductus arteriosus tapvc: total anomalous pulmonary venous connection the responders( / ) were characterised by left to right shunts or pulmonary venous hypertension( / ). patient# was weaned from ecmo with inhaled no. patient# , without congenital heart disease, underwent a lung biopsy which confirmed reversible pulmonary vascular changes. patient# had a pulmonary hypertensive crisis which responded to no. all non-responders( / ) had evidence of anatomic obstruction to pulmonary blood flow (# , , )or a low pvr(# ) on subsequent cardiac catheterisation. in patient # , lung biopsy confirmed severe obliterative vascular disease. conclusions: inhaled no appears to be an effective pulmonary vasodilator. a failed response may be evidence of either irreversible pulmonary vascular disease or a residual anatomical obstruction which may be surgically remediable in the postoperative cardiac patient. therefore, inhalation of no may be a useful diagnostic test to differentiate between fixed anatomical obstruction and reversible vasoconstriction. results: during these years, the incidence of sdra was . % of the total of admissions. the most common etiology was meningococcic septic shock. since , there is a decrease of its incidence. (from % to %) and an increase of pneumonia and immtmodeficiencies. mean age of our patients was , years ( % males, % females), total mortality by sdra was % and there is an increase up to % since mean time of stay of the dead was , days and , days those who survived. although during the late years we offer in the picu a better attendance quality to the patients with sdra and the mean stay is longer, both for those who die and for those who survive, mortality of patients with sdra have increased. the incidence of sdra secondary to the septic shock of a meningococcic etiology have decreased. on the contrary, the sdra secondary to infections by opportunistic germs in patients with congenital inmmunodeficiencies or acquired immuodeficiencies have a tendency to increase. in our series, this change of aetiology is the responsible for the increase in mortality. hospital infantil unlversitario "virgen de roclo". sevilla. espalqa aims:to assess the incidence, etiology, clinical course, sequelae and mortality of the patients admitted to a paedfiatic intensive care unit with the diagnosis of severe traumatism. material and method: cases of severe traumatism in children admitted to our icu in the period from january to june were reviewed. age of patient ranged from months to years, % were males. in our series, % of cases suffered traumatism due to a traffic collision and % had a fall from a considerable height. only in one case was traumatism due to violence to the child. we assessed the first assistance received in % of cases: where was it performed, interval of time since the accident, and steps taken. these data were also studied in relation to the latter evolution. results: % of our patients suffered cranioencephalic traumadsm (ct); in % it was an isolated picture and in % of cases was associated to other lesions. there was participation of thoracic and/or abdominal organs in % of cases. % of cases presented important maxillofacial involvement. only one case presented serious cervical medullar lesion. mortality in our series was . %. in . % important sequelae remained. all of these patients presented tepas on admission equal or lower than . % of those with traumatises had slight sequelae. . % of the total evolve towards healing. a polytraumatized child is a patient that benefits considerably of it admission in a paedriatic !cu. the rapidity in receiving first aid and its quality are essential to avoid sequelae and to make mortality decrease. after unilateral lungtransplantation % of the patients develop a lung failure with decrease of perfusion and increase of pulmonary blood pressure in the transplantated lung. the improvement of perfusion is an importent task in the postoperative period. case report: a year old girl with idiopathic pulmonary fibrosis received a left sided single lung transplantation. during the early postoperative period occured a higtter demand of oxygen and an increasment of the pulmonary vascular resistence in the left lung. the pulmonary ventilation and perfusion scintigraphy indicated in comparison with the right lung a reduced perfusion of only % in spite of a ventilation of % of the transplanted lung. to improve the perfusion of the transplant we administrated per inhalation prostacyclin in a maximal dose of ng/kg/min. the arterial blood pressure decreased but the perfusion continued nearly at the same level. during the following administration of ppm no in the respiratory air we achieved a significant reduction of the respiration pressure f~m to nun h and of the pulmonary arterial pressure. the perfusion in the transplanted lung increased to ca/of the total pulmonary perfusion. after days of administration with no we were able to withdraw the axtifical respiration without any following complications. conclusions: the perfusion of transplanted lungs is a major proble_r~ in the postoperative period. this case demonstrated the advantage of no towards the inhalativ application of prostacyclin. no showed a significant improvement of perfusion in the transplanted lung of a year old girl. results: a total of children with ards were treated with bovine surfactant (alveofact| cases were evalable. the median age was . years (range weeks to , years). in six cases ards was associated with pneumonia, in two cases with lung hemorrhage; in one case isolated ards followed hemihepatectomy. the first surfactant application was performed with a median latency of clays (range - days) after first symptoms of ards witha median doseof mg/ kg (range - mg/kg). in patients doses of surfactant were applied. during the hour before therapy, the median pao / fio -ratio was - . within min. after application of exogenous surfactant the pao / fio -ratio increased to with successive decrease over a period of hours to . accordingly, an increase in pao and oxygen saturation and (less significant) a decrease in ventilation parameters could be observed. analysis of broncho-alveolar lavage before surfactant application in children receiving repeated doses revealed in most examined cases either clear surfactant deficiency or pathological function. of treated patients survived ( of the , respectively). of the surfactant doses were applied in the surviving patients.conclusions: the application of exogenous surfactant in children with ards caused a significant increase in oxygenation, which declined over a period of - hours. the effect often could repeatedly reproduced, in one case after applications. the increase in oxygenation often allowed the reduction of fio and/or the inspiratory pressure. no side effects were observed after exogenous surfactant application.in many cases the application of surfactant wag too late after first symptoms of disease (median latency days). ards mostly due to pneumonia seemed to respond to surfactant therapy less well or not at all. permanent junctional reciprocating tachycardia (pjrt) is the most common incesant supraventricular tachycardia (svt) in children. it is usually drug resistant and its onset in early life has been associated with dilated eardiomyopathy. we report our clinical experience with patients detected antenatally and another diagnosed at months of age. method.diagnosis: negative p waves were detected in leads ii,iii and f, p'r > rp" and there was not warm-up at tachycardia onset.clinical records, ekg,x-rays, echo and holter were reviewed. ep studies were undertaken only with therapeutic purposes. results. in a year period patients under y of age fullfilled diagnostic criteria; were detected prenatally ( - weeks) and one was diagnosed at age mo. the fetuses had intermitent svt during gestation. all of them had pjrt in the first month of life at rates between and bpm. they were admitted to the icu but did not develop signs of heart failure. they were controlled with digoxine (d); d and quinidine; d and propafenone in to days. one was in sinus rhytm until age y; he then showed persistent pjrt over % of the day on repeated holters and underwent successful radiofrecuency catheter ablation (rfca).the other two patients showed initially a lowering of tachycardia rate followed by sinus rhytm for over % of the day (follow-up ran and y). the mo. old infant was admitted to the icu in severe cardiac failure. echocardiogram showed marked systolic dysfunction (shortening fraction %) treatment with digoxine, amiodarone and propafenone were unsuccessful despite lowering heart rate to ; rfca was performed at m. of age with restoration of sinus rhytm and rapid recovery of contractility. all patients were given atp at admission with transient ( to see) recovery of sinus rhytm. ff,s clinical course of pjrt is variable. atp is useful only as a diagnostic tool. initial treatment with digoxine + amiodarone or propafenone is adviced. rfca is a very useful therapeutic modality and can also be performed in young infants twelve patients ( %) died. these were meningitis, head injury, sub-arachnoid bleeds, status epileptieus, leukaemie, drowning, and multiple trauma. calculated from the a admission day p edialric risk of mortality score (prism), the probability of death (p) ranged from - %. of the deaths, i were predicted by prism analysis except for the leukaemie patient (p i%) who died from haematological complications following chemotherapy. two children predicted to die (p % & %) survived. the median length of stay was days (range - days). patlents( %) received ventilatn~ support and patienta( %) were transferred to specialist units ( neurosciences, liver, cardiac, bums). this data supports the view that many paediatric patients are being adequately treated in a dgh icu. meningitis and other neurological illness caused the majority of deaths and respiratory problems caused most admissions. most deaths ( of ) occurred within a few hours of admission. ectopic junctional tachycardia (ejt) is one of the most dangerous arrhythmias in the postoperative setting of congenital heart defects since it does not respond to antiarrhythmics or defibrilation. the object of this presentation is to report on two patients who presented f_jt in the early postoperative period and developed intense congestive heart failure which could be controlled after treatment with moderate topical hypothermia. two patients, m and y, diagnosed of atdoventficular septal defect and tetralogy of fallot developed intense heart failure in the early postoperative period. taehyeardia rate was and bpm. medical drug therapy included weaning from vasoactive drugs, iv digitalization and iv amiodarone treatment. there was not response. they were both surfaced cooled by placing plastic bags filled with cold water over the patient's chest and abdomen. temperature was monitored to obtain a central temperature of ~ there was a gradual decrease in heart rate in the following hours ( - bpm) paralel to the degree of surface cooling and clinical course estabilized.both recovered normal sinus rhytm in to hours. there were not significant arrhytmias after the procedure and postop, was uneventful. conclusions. moderate hypothermia is a very useful manuever for the treatment of drug resistant ejt. since it lacks side effects of other antiarrthymics we beleave it should be the treatment of choice for the treatment of ejt in the postoperative patient. present understanding of the pathogenesis of sepsis, based on the theory of systemic inflammatory reaction, has risen new interest in the more invasive methods of treatment, like plasmapheresis, leucapheresis and exchange transfusion (et). obiectives: evaluate the effect of et in the treatment of neonatal sepsis. material and methods: from september to december , a prospective study was carried out, where the severest cases of bacteriologically proven neonatal sepsis (n= ) were treated with et. in total newborns were treated for culture positive sepsis in the intensive care unit during this study period. diagnosis of sepsis was based on the clinical criteria of suspected neonatal sepsis, used by mc harris et al., laboratory data and positive blood culture. newborns with severe congenital malformations were excluded. et was carried out with fresh (less than hours old) adsol-conserved erythrocytes, from which buffy coat had been removed, and same donors plasma, using a slow continuous two-site technique. the mean volume of et was . ml/kg. the effect of et was assessed as a change in the score for acute neonatal physiology (snap), general treatment results were compared with a historical control group of newborns, treated for culture-positive sepsis in the same icu during the first eight months in . students ttest and chi-square test were used in statistical analysis of the data. results: with the use of el a significant decrease in mortality was achieved: death of cases during the study period, compared to deaths among the controls (p< . ). no baby, receiving et, died. the incidence of severe complications did not differ in the two groups. the snap-score showed quick improvement by the first post-transfusion day (p<o. ) and the effect persisted during the five following days. conclusions: we conclude, that the use of et in the treatment of critical cases may help to lower the mortality of neonatal sepsis. it provides a quick improvement in the clinical condition of septic neonates. the granulocyte-colony stimulating factor (g-csf) is largely employed in granulocytopenic patients. experimental studies have' demonstrated the effectiveness and safety of the therapeutic use, nevertheless the human employ is reported almost exclusively in neoplastic patients submitted to chemotherapy and in patients with fungal or pseudomona~ spp infections. the authors report the data concerning three non granulocytopenic children: in the first, o girl years old, affected by pseudomomm aerug/n~a pyeionephritis, the antibiotic therapy was not tolerated in consequence of renal and hepatic failure. the second patient, an infant months old, has been treated with salbactam-ampiciilin, ceftriaxone and chioramphenicol because of haemepldlw iafluem~ meningitis; a late neurological aggravation required the antibiotic therapy recommencement the last, a years old insulin dependent diabetic boy, was affected by cared/do spp systemic infection; the antifungnl therapy w~ not practicable in consequence of renal and hepatic involvement in all the g-csf was administred subcutaneously at the'dose of $ u for days. a significant increase of granulocytes was ever noted already after the second administration until hours after the last dose. clinical signs, fever and biochemical values are promptly influenced positively and all patients are restored to health. no side affects were noted. the granulocyte colony stimulating factor, at indicated doses, can prove of great help in critical patients, in who the antibiotic or antifangal therapies can result toxye or cannot be tolerated. the ~reptococcas p~, among the gram pmltlve~ represents the main causative organism of bacterial meningitis in children, with the majority of deaths occurring within hours of admission, the third generation cepohlosporim were indicated as antibiotic of first choice, and some literature reports have demonstrated no significant dlffereuces in dinical course of patients treated with ce~rlaxoae and of those treated with ampieibin and chlornmphenicol. the authors report the ease of on infant, male, months old, submitted to a neurosurgical interventiol after days the infant became febrile and lethargic and a bacterial meningitis by ~trepmcecctz ~ was diagnosed, in spite of he was given the eoftriaxone therapy.. an amelioration was found only when a systemic treatment with vaucomyein was added. after days an intrathecal administration of vancomyein m~day was started: the norbmlization of the spinal fluid profile was uoted two days later and the infant receve~d progressively. the follow-up after eight months doem't evidentiate motosensorini sequelae-the individuation' of ~cscc~ pmmmsm/ae strains heta-loctam antibiotics resistant requires alternative therapeutic regimens: the k~terity quead vitam and quoad valetudinem of these infections justifies an intrathecal therapy, especially failing o prompt answer to the systemic treatment objectives: to evaluate the incidence of the burnout (bo) of the staff in a picu in a university hospital. the bo is a syndrome charactedzed by many factors like emotional stress, lack of personality and reduced work ability. this syndrome represents a kind of abnormal response in the working habitat, above all, where psychological and personal characters are mostly involved. the symptoms of bo are represented by demoralisation, demotivation, incapability, boredom, isolation up to organic disturbances, like migraine, insomnia, dizziness and gastrointestinal disturbances. the major incidence of this syndrome was found in the hospital staff, especially among the nurses, working in an atmospher of high emotional dsk, just like in an intensive care unit. methods: from january ' till april ' , all the staff of the picu of the a. gemelli hospital of rome, underwent a test to evaluate the bo. the test used was taken from the book "bumout: from tedium to personal growth", by pines and aronson. twenty seven people were studied ( females, males)i out of which doctors, residents and nurses. it was considered sign!ficant as mild bo, a score between - and as severe, the score of bo >. . results: subjects ( %) resulted positive for bo, out of which were females ( %) and were males ( %). the subjects with mild bo were / : was a doctor, residents and nurses. the subjects with severe bo were / , out of which resident and nurses. conclusion: the results obtained show that bo is a condition well represented in the staff of our picu. the category most at dsk seem to be the nurses ( subjects), as well as residents ( subjects), as in literature, which shows a major incidence of the syndrome in younger subjects and having a limited partecipation of functional decision. the results obtained obliged us to start a programme of serial controls so that the subjects most exposed can have a necessary psychological support to react adequately to this condition. the term systemic inflammatory response syndrome (sirs) was adopted by the consensus conference to denote a type of systemic response to severe infection or otherinsults in critically ill patients. when sirs occurs from infection it is called sepsis. sepsis occurs more frequently in persons with perexisting illness or severe trauma. there has been tremendous advances in prophylaxis, diagnosis, and treatment of sepsis. a comprehensive model of the disease progression from sirs to mods should be developed giving priority to severity of illness scoring system and other predictive methods. some recommendations for future clinical trials include: trials should not start with humans. before proceeding to human trials, animal studies should indicate an acceptable risk/benefit ratio. appropriate patient populations must be defined and treatment protocols should be standardized. full and rapid reporting of all results should be mandatory and a central repository of published and unpublished study results could be helpful. accrual at each center should be of sufficient size, and should include the number of patients accrued, mortality rates, and patient characteristics. pivotal trial should be preceded by sufficient pilot or phase ii studies. correct drug dosage and usage should be delineated in pilot studies. large, multicenter, trials should be used to enhance the unversality of trial results. analyses should be planned a priori. definitions for the target population should be explicit, reproducible, and include illness severity scores. outcomes should be relevant reproducible and include both measures of benefit and harm. mods and its reversal should be considered as an endpoint. quality of life should also be considered as an endpoint. the estimators of overall treatment effects should be controlled for base-line prognostic factors and subgroup anaiysis should only be used for hypothesis generation and not to modify the conclusoin of the trial. economic analysis should be included as part of clinical design. evaluatin of source control should be a critical component of any study. standardized clinical mediator assays should be pursued. placebo patients in clinical trials should be studied for a better understanding of the pathogenesis and epidemiology of sirs, evidence based medicine should be used to evaluate the validity of clinical. introduction: use of inhaled nitric oxide (no) as a modulator for optimizing ventilation-perfusion or lowering pulmonary artery pressure is becoming increasingly common. no is a free radical but little toxicological research has been published. clearance of nebulized mtc-dtpa is known to be, a sensitive indicator for early function impaimaent of the alveolocapillary barrier. we investigated whether exposure to no increased clearance of ~tc-dtpa from the lung. methods: three groups of white sealand rabbits (bw . kg) were anesthetized, tracheotomized and paralyzed. groups were ventilated for six hours at pressure regulated volume control, set to deliver ml/kg with a frequency of /rain, i/e ratio = : and peep = cm hzo using a modified servo ventilator (siemens, solna, sweden) with computerized no delivery system. gas mixture per group was either / or / [no (ppm) / fioz]. after six hours of ventilation in these groups and immediately after anesthesia in group (control), ~tc-dtpa was nebulized into the inspiratory line of the breathing circuit and administered as a fine aerosol. gamma counting was measured for minutes, monoexponential curves were fitted to the data and the clearance half-time (t was calculated. the t~/ mean • sd of the different groups were: t~a (mean -sd) h"e,i witl~ arf : di.ff:erent kinds, aged .q-ore mon't.hes to [ gears o : (bodi weight .~rom ., to kg), is presen .... "ed ( i,,~u::trl:e i:ibstraclive d:lse~se... ~ .ards'- ; :~,;,,arf o~ ::entral genes:i s .- , ,~ :inc lud ing men ingeenceph it :is- ~ reye ' s ~yrtdro~e-..#~,bri~:ln pes~.re~nimatior~ disease.." ). int:lrl~]. pa-. "iiulle'i,~s ariel regymes o+ l;mv,l;i"t"v were cle'l'.ermllled by ba- 'i~ier was. about . tuber,, dopamin tiara-:. t.io; was ~.".,,'.r:~r~led. cmv,cppv d~.!"~tion raniled -~rom f to dayns.,~ < .-:in , "t -irl lo;and> davs'-in 'l~atierr~{s i'i"ai s:ltiol~ o ; patterers to imv, simv modee was per.r:)rmed, ~herl pif:' decrease.d to - ml~ar, fi ~ecreased to , . lind less with a = /,,. i:lesq.lts:{ in pat:i.ents e{ group :l, who were tre,~d.ed w&th f'f'v, teoph :i. : . l:i.r~ (is- .mg/kg/day), g lucecdr t icostei~oids ( .... :~;mg/kg/day), when r exceeded in , -.];, times normal va i tea the e aqes/,'!:l"oln ~j,, ite :i.~;::.!;, ~ml"lrj), it was possible 't'(' ce 'e~ e aad]t:..~rom ! . '.' i', to !..'; , - , mml-lg in ~}.. :~.[~ houi,!; ~d'l(:i to ru:}l",g'd!~l:i. e i::h,:~e,'~c['el';i.stil obieetives : this chapter will describe what is knovca of the psychlogical responses of infant and children to hospiuiisation and attendant procedures. the factors which may modify these responses will he discussed and important considemtiorts will be outlined for optimal anaesthetic management and postoperative period of infants and children which will minimised the rise of emotional upset. methods : in this paper the autors will discttssed the probl of: . health children (asa i, ii) facing single uncomplicated surgical elective procedures . various abnormal situations including neurotic children, children facing repeted operations, chronically ill, buaaes and tsaumatically impired ones . unfortunate young patient facing and often expoclting fatal outcome from le "ul'ukaemia, tumors, cystic fibroses or otheq" disease. : management of each child must vary greatly, ifi general the phases of emotional conditioning include home and preadmissiun preparation, admitiun preoperated and operative care and postoperative period. the authors would be happy if the child passes all stages without any trauma which could be prolonged in the future life. introduction ino is used to selectively reduce pulmonary vascular resistan(~e. we applied ino in the postoperative intensive care of patients with pulmonary hypertension and the risk of right ventricular failure after surgical correction of a congenital cardiac defect. methods - ppm no were added to the ventilatory gas mixture using a specially designed equipment (messer-griesheim, germany/austria). indications for application included pulmonary artery pressure > % systemic pressure, critically depressed right, ventricular function or an oxygenation index > . assessment of n oefficiacy consisted of on-off-on measurements according to the clinical stability of the patient including hemodynamic parameters, pulmonary gas exchange, continuous monitoring of ventitatory function and transesophageal echocardiography of the right heart. results in situations ( patients, age days- , years), ino was applied - h postoperatively. oxygenation was improved in situations from _+ to + mmhg pc ; pulmonary pressure was reduced in situations from -* % to _+ % of systemic pressure. in situations, no reduction of pulmonary pressure was present, but measurement of cardiac output or echocardiographic analysis indicated an improvement of right ventricular function (right ventricular stroke volume + -* %, cardiac output + -* %). in situations (immediately postoperativ with suprasystemic pulmonary artery pressures [n= ], multi-organ-failure [n= ]), no response to ino could be determined. conclusions for a special group of patients, the selective reduction of pulmonary vascular resistance by ino has become an important part of postoperative therapy. using this selective afterload reduction, postoperatively depressed right ventricular function can be improved. this effect of ino seems to be the most important one in the postoperative period. thus, ino appears justified to be appfleo when impaired right ventdcular function could be improved even when pulmonary artery pressure is not raised or remains unchanged. obiectives : premature infant are exposed to danger of apaea due to anaesthesia during their tirst months of life. it is yet unknown whether prematurity is corelated to any other kind of reslgratory disorder due to anaesthesia within the tirst year of life. methods : we theretbre researched retrospectively for respiratory disorders in all infants under months of life belonging to asa group . they all had been anaesthetised in . in our clinic for the following surgical reasons: ingvinal haemia, umbilical haemia, hydrocelae testis and phymosis. results : in cases we tbund: lafingospasm during induction in anaesthesia ( , %), bronchospasm during induction in anaesthesia ( , %), impaired intubation ( , ~ postanaesthetic laringospasm ( , %), supposed aspiration ( , %),postanaesthetic inspiratory stridor ( , %), postinductional inngoedema ( , %), death after months in consequative of infection pneumonie ( , %), none of these disorders was correlated the prematurity, infants suffered of post anaesthetic apnea, of them had premature medical history. concludions : prematurity does not enhance the risk of respiratory disorders due to anaesthesia within the first year of life, except the danger of postanaesthetic almea needs spetial cosideration. it could be demonstrated that aepgi lowers pulmonary vascular resistance and indirectly improves cardiac function. this effect seemed to be selective, and was comparable to ino in the doses we have examined. therefore, aepgi could represent a clinically useful alternate to inc. however, further research is necessary to work up the benefits of either therapeutic strategy. objectives: heat and moisture exchange filtem (hme) are used as artificial noses for intubated patients to prevent tracheo-bronchial or pulmonary damage resulting from dry and cold inspired gases. furthermore they are used for the prevention of bacterial contamination of the anesthetic apparatus by the patient's exspired air. so they are considered as a time-and money-saving device in anesthesia. filters are mounted directly on the tracheal tube, where they collect a large fraction of the heat and moisture of the exspired air, adding this to the subsequent inspired breath. the effective performance depends on the water-and bacteria-retention capacity of the filter. this study evaluates the efficiency of four different filters under clinical conditions. methods: four different types of filters ( dar hygrobac, gibeck humidvent, medisize hygrevent and pall bb ) were investigated dudng mechanical ventilation over a pedod of hours. minipigs with hemorrhagic shock were intubated and ventilated for days in an animal intensive care unit (icu). after hours of mechanical ventilation the filter was randomly replaced maintaining the individual ventilatory conditions. the weight of the filter was determined before use and after removal after hours. the airway pressure was monitored online to record changes during use. tracheal secretions and both sides of the filter were microbiolologically tested to see whether bacteria of the animal's respiratory system could be found on the patient's side of the filter or if they even would have penetrated the barrier. results and discussion: over a pedod of hours of types of filters showed an increase in weight of + % and airway pressure. bactedal celonisation ccured in nearly all fillers ( of ) on the patient's side, whereas only three of four types of filters showed identical bacterial colonisation on both sides. the only filter that did not show bacterial penetration, increase in weight or airway pressure was the pall-hme, a condensation humidifier without hygroscopic salts for moisture retention. with respect to our data one should use a condensation humidifier if airway conditions should remain stable dudng mechanical ventilation and desinfection of the anesthetic apparatus should be avoided after each patient. aim: to assess the clinical uses of, and experiences with, the hayek oscillator. this is a non-invasive device capable ef delivering not only continuous negative pressure (cnp) but also external oscillatory ventilation around a negative baseline (eov-nb) using an external cuirass. this type of ventilation avoids the need for intubation and intermittent positive pressure ventilation (ippv) and facilitates weaning in ventilator dependent patients. patients and methods: patients in respiratory failure, age range weeks to years in a total of patient episodes were treated using either cnp or eov-nb mode. duration of treatment varied from hours to days. indications for use ef the device were: ) to facilitate weaning from ippv ) prevent reintubation of patients following unsuccessful extubation, and ) avoid intubation and ippv altogether using the hayek oscillator as the on[y means of respiratory support. results: there was an increase in pao :fio ratio after cnp and eov-nb (p < . , and p= . respectively, wilcoxon signed rank test). patients who were in respiratory failure with hypercapnia showed a statistically significant reduction in paco both with eov-nb and cnp (p= . and p= . respectively) but the magnitude of change was individually greater in the patients who were treated with eov-nb. all patients, however, showed a fall in respiratory rate (p< . ) after the application of the cuirass in cnp mode. there was no physiological deterioration related to the application of external extrathoracic negative pressure in either cnp or eov-nb modes. conclusion: the improvement in pao :fio , the fall in paco and respiratory rate were indicators of an improvement in ventilation. the proposed mechanisms include improvement in frc, recruitment of additional alveolar units, and improvement in secretion clearance resulting in reduction in the work of breathing. meek to ~ month of the lifo,the bemodyuanicfacls were defined uitb the help of tetropolar reography method!. the excretion of !he catbocholauines fcfi] mith the urine gas detertend by taylor ll,laoorsy ~ iacg/dayl. hsaltl in the hypercuagulation stage of bic we deflorteeed the acliuutiun of the tbrubio and plasiin syaet~ mitb the increase of the inhihitnrs, in this case we registered in full uahe dot this process coabined uitb the dayl~ excreliou with lho urine epinopbr ne e], nor~pinopbr no tel and dophanine io], lbat shod the inlensificatiou of the s~nthosis prnoe-s~es and the release of ea in blood fron hissue deport the actffat on of the svnpathadrenui systen ]sfisl assisted to furl the b?perd~nanical rosins of the eircuidion and increase the ,icrocirculatinn, the klinicai sings of the insufissieutly of the circulalion have not defined,that has been associated the conpensatury character uf the ehan~es of ~ and heludy~enic status, t~e uun~u|p-lion ceugulupatby bus been donoustraled in the hypocougulatien stage ~bat man xauifosted b the exhaust of lhe confulalion nod oessel-platel heuostasis, the consuxptton of cnnpononts tbronbln ,plnstin, kallek~eiu-kinln s~slots and the forniration eat in fell canoe clot uas accoqaued bs docrea,e of fl,nfl,o, the products of the xotabolisx of c~ and the activation of xonoaninoxydasu. the decrease of the extoll'on g and the exhaust deport co indicahd about t!e ]ou fund/anal reserve of ~fl~. it was one of the lain reason of ~bo heiod~uanic disbroed iheat insnfissient]~] and the uicrncireulaflion lintestinal codeme with the low effectife periferal flow] and nul[iplay organ failure,the distrued deport of sos mitb throubocytupenin no; be one of the nechanisn the dislrood of uessej-plalol heioshasis, the correlation bolueeo changes of boiostosis c~ and circulation ore reguired aduinistration nedidns, thai reslore the love s of c~ in the blood, prevent uulliplay organ failure and hetorrnge in children with sepsis, ~b~ectives: multi-measured correlative analysis of the most number of non-invasive indices of the cardiorespiratory system function was made to determine the structure of their interrelation and the ways of their adequate and effective correction. hethods: spiremetry, capno~raphy, oxygenography, indirect fick method at recurrent respiration, plethysmography, integral rheography -in all indices were used. the received data were processed on a computer by a standard package of statistical bmdp programs. results: women with ~h-gestosis (i group) and somatically healthy pregnant women (ii group) were studied. cluster analysis has shown that the rate of the mean correlation connection between ventilation indices was % in the ist group and % in the iind group; gaseous metabolism - % and %, respectively; central hemodynamics was ~ in both groups. conclusion: cluster interpretation allowed to suggest that an increase of the rate of the mean correlation connection between the indices was characteristic of effective adaptation as the system was multi-component and well-regulated. on the contrary, the increase of the rate of strong correlation connection between the indices reveals the rigidity of the system and the tensity of adaptation mschaniams, i.e. the proximity to decompensation. it follows from this that in cases of eph-gestgsis, the reliability of regulating ventilation and gaseous metabolism decreases. seve/e hypoxemia in non intubated patients represents a major contraindicafion to fiberoptic bronehoscopy (fob) and bronehoalveolar levage (bal), but these procedures are often required for a correct diagnosis of the causative agent of pneumonia. aim of this investigation was to veaify the safety and efficacy of bronehoseopic procedures during pressure support ventilation administered through facial mask (fm-psv). five intensive care patients, all immunoeompromised, ( males and females; mean age . • were enrolled in the study. all patients presented criteria for pneumonia with pao /fio ratio ~ and were responders to fm-psv. fob and bal were performed afte~ topical anesthesia with fm-psv ( ps = em h ; peep = emh ; trigger = -lemh ) continuously admires" tered ( ' before fob fio = . ; during fob, fio = and for ' alter fob, fio = . ). pao /fio ratio as well as saturation (sat) did not show signifteative changes during the procodure (fig.l) . no complication was observed and hemodynamic conditions were stable for all patients. cmv, pnenmoeystiis ( ), legionella and mycobaetermm tuberculosis were identified from bal allowmg a prompt and targeted therapy. we concluded that mask psv can represent an excellea~ technique to pexform fob and bal in severely hypoxemic patients without deterioration of gas exchanges and avoiding endotraoheal intubation. intensive care unit, hospital general of albacete, albacet~ spain. objective: to analyze the current incidence and epidemiology of total parenteral nutrition (tpn) among critically ill patients placed on mechanical ventilation. design: prospective observational study. setting: medical intensive care unit in a tertiary hospital. patients: a total of consecutive l'ritically ill patients with non-coronary related disease needing mechanical ventilation admitted in our icu during a months period. measurements: data of sex, age, diagnosis, and outcome were recorded. severity of illness and therapeutic effort in the first hours were measured using acute physiology score and chronic health evaluation (apache ii) and therapeutic intervention scoring system (ties). r~ults: mechanically ventilated patients, male and female, were studied. only ten patients needed tpn and their main diagnoses were: five cases of multiple organ failure secondary to pneumonia ( ), ards ( ) and septic shock ( ); two eases of acute panereatitis; and one mesenteric throngmsis, one status epilepticas, and one ,prolonged cholinergic crisis b~ suicidal organophnsphate insecticide subcutaneous injection. no statistically significant differences between both tpn and non-tpn groups were found: objectives: evaluate the efficacy of prone position in ards and determine its importance in the therapeutic algorithm. methods: consecutive patients with severe ards (murray-score > , ; pao / fit < mmhg; male, female, mean age years) were conventionally ventilated (pcv, peep - mbar, i:e=i:i, ppeak < mbar). if after hours pulmonary function did not improve patients were placed in prone position. change from prone to supine position was done every hours. beside ultimate survival, parameters investigated were aado , pao /fio , and venous admixture (qs/qt). results: during the first hours in prone position of patients showed a significant decrease in qs/qt ( . % vs. . %) and aado ( vs. mmhg), and an increase in pao /fio ( vs. mmttg). changes were most pronounced in patients with high qs/qt, and in patients with an onset of ards less than hours before first application of prone position. after an average of position changes ( to ) of patients could be weaned from the ventilator. patient could leave tile hospital. i the later course letality was primarily determined by additional organ failures and by the severity of the underlying disease. negative side effects were minor, including slight cardio-vascular depression and increase in p~co , and never posed a limitation to continuation of prone position. especially in patients with septic shock skin lesions in exposed areas could not always be prevented, prone position could easily be combined with all ventilation modes and with all intensive care interventions. also immediately after major surgery and in patients with open packing prone position was possible. conclusions: in this investigation prone position proved to be an efficient and safe method in the treatment of severe ards. patients with a pronounced ventilation/ perfusion mismatch and patients in the early stages of ards appear to profit most from prone position. though the immediate effect on oxygenation is striking, still more the % of all patients die from multi organ failure and underlying diseases. a proposed therapeutic algorithm for ards is as follows: if under conservative ventilation (pcv, peep < mbar, ppeak < mbar) pulmonary function does not improve within - hours prone position should be applied. when after - position changes no lasting effect can be achieved further ventilation modes (e.g. pc-irv, aprv, no, etc.) should be used in addition to prone position. standard intensive care principles, such as fluid restriction and optimization of circulation, apply also to patients in prone position. objectives: nitric oxide reacts with superoxide to form peroxynitrite, an extremely reactive and toxic species. we quantified the presence nitrotyrosine, the stable product of the interaction ' of peroxynitrite with tyrosine residues in the lungs of pediatric patients that died with respiratory distress syndrome (rds). methods: paraffin embedded lung sections, obtained at autopsy, were incubated with a polyclonal antibody raised against nitretyrosine, followed by a secondary fluorescent antibody. alveolar structure-associated fluorescence was quantified using existing methods. results: tissue sections from patients who died with rds exhibited significant specific immunostaining which was uniformly distributed across the blood-gas barrier. in contrast only background levels of fluorescence were seen in the lungs of patients who died from non-pulmonary causes. intense staining was also seen in the lungs of rats that breathed % for h, a condition known to result in rds-type illness; no immunostaining was observed in air-breathing rats. conclusions: significant levels of peroxynitrite may be formed in the lungs of patients with acute lung injury. peroxynitrite may be contributing to the pathology of rds by damaging key components of the alveolar epithelium including the pulmonary surfactant system. mechanical ventilation time was prolonged ,g • days in patients with ardsvs , _+ l, days in control . mean staylcuwas lg _+ ,g days in the ards group vs , • , days in control group postoperative mortality rate was % in ards patients vs , % in those without respiratory failure. -ards incidence in liver transplantation is low ( , % in our sene) but it causes high mortality ( %) page, gas ventilation of the perfluorocarbon-f'dled lung, supports gas exchange and circulation in small animals (< kg) with lung disease. we hypothesized that large animals could be supported by page without adverse effects on bemodynamics. we first elucidated the determinants of gas exchange in normal sheep, and applied them to a model of adult respkatory distress syndrome (ards). methods: using the ventilator settings determined to be optimal in our pilot study (fio of . , peep of cm h , imv of bpm, it of %, and tv of ml/kg), sheep weighing . ~ . ) kg had lung injury induced by instilling ml/kg of . n hc into the trachea. ten minutes after injury, sheep with pao < ton" were randomized to continue gas ventilation (control, n= ) or to institute page (n= ). page was instituted by instilling . l of unoxygenated pefflubron into the trachea and resuming gas ventilation at the previous settings. abg's were drawn at baseline, minutes after injury, minutes after injury, and then every minutes for hours. objectives: inhaled nitric oxide (no) can improve oxygenation and decrease mean pulmonary artery pressure (papm) in hypoxemic patients with ards. in severe hypoxemic copd patients, it is not known whether inhaled no can exert a similar effect on hemodynamics and gas exchange. therefore, we investigated die response of inhaled no in hypoxemic copd patients and the results compared with those obtained in a group of ards patients. methods: ten copd patients (age _+ y;fev~ . _+ . l) and ards patients (age _+ ; lis . _+ . ) mechanically ventilated were studied. hemodynamic parameters were measured using a swan ganz catheter. arterial and mixed venous blood gas determinations, sao , svo , hb and methb were measured (abl ,osm ). mean intratracheal concentrations of no and no were continuously monitored using a chemiluminescence analyzer (nox ) . during the study the ventilatory pattern and fioz were kept constant. the protocol was for ards group: basalt, no loppm, basal~; copd group: basalz, no lo ppm, no ppm, no ppm and basal . after a steady state of rain hemodynamic and gas exchange measurements were performed. a positive noresponse was defined as a % increment in pao . results: papm was similar in both groups and decreased significantly after no (ards, basal . _+ . mmhg, no . + . mmhg, p < . ) (copd, basal . _+ . mmhg, no- . _+ . nrmhg, p< . ). all other hemodynamic variables remained unchanged after no. basal oxygenation was higher in copd group (paojfio _+ mmhg) vs ards group (paojfio _+ mmhg)(p< . ). after no- , pao increased ( _+ mmhg to _+ mmhg, p< . ) and qs/qt decreased ( + % to _+ %, p< . ) only in ards group. in both groups, significant correlations between basal papm and inhaled no-induced decrease in papm were found. inhaled no-induced increase in pao /fio was not correlated with basal paoflfio . no responders were / ( %) in ards group and / ( %) in copd group (p< . ). conclusions. in hypoxemic ards and copd patients, inhaled no decreased mean pulmonary artery pressure. however, oxygenation only ameliorated in ards group because die number of responders to inhaled no were higher in ards group and this effect seems not to be related to the basal hypoxemia. these results might be explained by the v/q abnormalities present in copd patients. grant fis / . objectives: it has been recently reported that expired con slope as a function of time is modulated by total respiratory system resistance (rrs) in critically ill patients (chest ; : - ) . in this study, we analyze the relative contribution of disease (dis), endotracheal tube resistance (rtube), airway resistance (rmin), additional resistance (~rrs), autopeep (peepi) and dylmmic/static elastance (ed/es) to the co elimination in different clinical conditions. methods: we have studied adult patients ( controls, acute respiratory failure, severe ards and copd) mechalfically ventilated (servo and c, siemens) without peep. we recorded tracheal pressure, airflow and capnograms. signals were analogic to digital converted for posterior data analysis. objectives: alveolar ejection volume (van) can be defined as the fraction of tidal volume (vt) with minimal dead space (vd) contamination. according to the classical paradigm: limvd_~ [vco /vt] =facoz, vco vs vt relationship tends asyntotically to a constant slope when approaches end-tidal volume. we have defined van as the volume that defines this relationship until a limit of % variation. methods: six subjects with normal respiratory mechanics were studied during anesthesia for minor surgery. two subjects, otherwise normals but having high values of total resistance and dynamic compliance, were also studied. capnograms were recorded in steady-state at levels of vt ( . , . and . l) and four levels of peep ( , , and cmh objectives: patients with ards presented lung abnormalities which originate an increase in airway resistance (rmin), in additional resistance (~rrs) and in static elastance (ers). application of peep further increases ~rrs. capnographic indexes reflect lung ventilation]per fusion inhomogeneities. in these conditions, the effects of peep on lung mechanics could be better understood by simultaneous measurement of capnographic indexes. methods: we studied groups of subjects. n: normal subjects scheduled for minor surgery; arf: critically ill patients with mild acute respiratory failure; ards: patients with early ards (< h). we recorded tracheal pressure, airflow and capnograms. signals were analogic to digital converted for posterior data analysis. respiratory system mechanics was assessed by constant end-inspiratory and end-expiratory occlusions technique. at equal tidal volmne ( . l) a peep level of , , and cmh was applied in all patients. we calculated ers (cmh /l), rmin, c~rrs (cmh /l/s) and autopeep. capnographic indexes were alveolar ejection volume (vae)/vt ratio and expired co slope beyond vae (sipco in contrast to synthetic surfactant natural suffactants (alveofact| are able to inhibit pmn-activation. after incubation of activated neutrophils with surfactant, l-selectin expression is decreased. these effects depends on which preparation is used. we conclude, that natural surfactant (aveofact| can perhaps influence early recruitment (,,rolling") of pmn in patients with respiratory failure like ards. with ards hormann cb, baum m, putensen c, knapp r, lingnau w, putz g . clinic for anesthesia and general lntensiv care medicine, university of lnnsbruck, anichstrabe , innsbruck objectives: in thoracic ct scans of patients with severe ards atelectasis and pleural effusion can be found in the dependent lung regions. by rotating these patients from left lateral position to right lateral position a redistribution of the ct densities, a recruitment of atelectasis and therefore an improvement of gasexchange is possible within a few days ( , ). the objective of this study was to find out the mechanism of alveolar recruitment during lateral positioning by ct scanning in left and right lateral position. methodes: after approvel by the local institutional reviewboard we investigated ventilated patients with severe ards (entry criterias: murray score > , ) in the ct scann of the university hospital. after a stabilisation period of minutes in supine position a thoracic ct scan slice cm above diaphragm was taken. then two different positions of the patients were studied in a randomized order: a) degree of left lateral position, b) degree of right lateral position. each lateral position was held for minutes. at the end of each of these periods a thoracic ct scan slice cm above diaphragm was taken. quantitative analysis of ct scan data was based on the frequency distribution of the ct numbers. to quantify the alveolar recruitment during lateral positioning by means of ct scan we defined compartments within the lungs: a) normaly inflated lung, b) poorly inflated lung, c) noninflated lung ( = atelectases) ( ). results: independant of the side of lateral positioning (l) in the non-dependent upper lung a significant increase of the normaly inflated compartment (s: %; l: %) as well as a significant decrease of the noninflated compartment (s: %, l: %) was observed in comparison to supine position (s). in the dependant lower lung the normaly inflated compartment decreased significantly (s: %, l: %) whereas the noninflated compartment increased significantly (s: %, l: %). throughout the whole studyperiode we did not observe any significant change regarding gasexchange and hemodynamic parameters. conclusions: in lateral position the non-dependent upper lung is decompressed. therefore a significant recruitment of atelectases is observed in the upper lung within minutes. on the other hand the dependent lung is compressed by the weight of the upper lung and the mediastinum. a great amount of the alveoli of the dependant lung collapse in this short time intervall. therefore the net effect of recruitment of one positioning maneuver is very small. when positioning patients one should be aware, that the patient is kept in each lateral position long enough to clean up the atelectases in the non-dependant lung and short enough to compress less lung tissue in the dependant lung. objective: to analyze effects of low-dose no inhalation ia patients with severe aeut~ respiratory distress syndrome (ards) over five days. methods: we prospectively studied patients ( men, woman) with severe ards admitted to our icu between may and may who required no inhalation with a dose of ppm for at least days. entry criteria for no injaalafioa were murray score >i . aud pat/fie < nun hg with peep >~ em i~o for at least hours. all patients were sedated, intubated and mechanicauy vantil~ed with volume assist-control ventilation, and had indwelling arterial catheters (pulmonary artery, and radial or femoral artery) to measure cardiac output (by thermodilufion) and relevant intravaseular pressures, and to calculate derived parameters. no was administered between y piece of the ventilator and endotraeheal tube and flow was adjusted to obtain ppm no in the inhaled gas. the no, no and no x concentrations were continuously measured at the distal end of the endouacheal tube by the chemiluminiscence method (nox , see-seres, france). metahemoglobinemia levels were mesured daily. no inhalation was manteined if paojfio ~ improved at least % and was stopped when the change in pao /fio ~ was below % or when the patient presented a paojf > mm hg a~er minutes without no inhalation. every day we made an on-off test to determine if no inhalation improved pao /fio ~. statistics: analysis of vmiance. data: mean + standard deviation. results: the mean age was . +_ . years and mean lung injury score was . • . . mortality was % ( / ), metahemoglobinemia . • . %, and no concentrations zero. paojf~o always improved significantly al~er ppm no inhalation (see :~ conclusions: reintubation in salf-extubated patients strongly depends on the type of meehamcal venfilatory support: the probability of needing a reintabation ff ese occurs during fult vontilatory support is higher than ff ese occurs during weaning. these data suggest that some patients may remain under weaning from mechanical ventilation for unnecessarily prolonged periods of time. objective: the aim of this study was to evaluate the acute effects on gas exehonge and hemodynamics due to positional changes from supine (sp) to prone (pp) in patients with severe acute respiratory distress syndrome (ards). methods: nine intubated, sedated, paralyzed and mechanically ventilated patients with severe ards were prospectively studied. all had a murray score > . , and a pao /f~o < with peep ~ cm h for at least h. all patients had indwelling arterial catheters in the pulmonary artery as well as in the radial or femoral artery in order to measure cardiac output (by thermodilution) mad relevont pressures, and to withdraw blood samples. arterial blood gases and hemodynamie parameters were measured first in sp, and then in pp after minutes of stabilization. vontilatoly parameters remaing unchanged during all the study. statistical analysis was done by the non parametric wdeoxon test. data are expressed as mean ~= sd. results: there were men and women with a mean age of . years ( - ) and mortality was % ( / ). main results are shown below: objective: to describe and compare a new method for obtaining p-v loops (p-vcv) by using a two-way collins valve (twv) with thosu obtained by the supersyringe method (p-vss). methodology: we prospectively studied patients who had an aeute lung injury and were intubated, sedated and paralyzed, and mechanieany ventilated. we performed the p-vev loops and p-vss loops in random order, and the static inflation pressure was limited to emh with both methods. pressure (p) was measured at the airway opening by means of a differential p transducer, and volume was obtained from flow (measured with a pneumotacograph) integration. the p-vse method has already been described (h~trf a,et al.bepr ; : - ) . the p-vev method consists in the following: the inlet of a twv is connected to the ventilator's y-piece, and both outlets are couneeted to the endotraeheal tube by means of an additional y-piece; one of this outlets has a one-way rudolph valve in order to allow inspiration but not expiration during the inflation maneuver. changing the twv tap position allows basal ventilation or progressiveinflation of the respiratory system. this maneuver is as follows: during an end-expiratory occlusion, the ventilatory settings are adjusted to deliver a ml v r with a respiratory rate of /min and i/e ratio : ; at the same time the twv tap is ehonged in order to divert flow through the one-way valve. inflation then begins alter releasing the expiratory oonlusion. pressure and flow signals were digitized and acquired by a computer for subsequent data analysis. we analyzed the following parameters: inflation compllonee ( objective: to analyze the variables which eventually may differentiate ards patients who do and do not respond to low doses of inhaled no. we prospectively studied patients ( men, woman) with severe ards admitted to our icu between may and may who were treated with no ( ppm). the onta'y criteria for no inhalation were murray score >/ . and paojfo z < mm fig and peep >/ cm i~o for at least hours. all patients were sedated, intubated and mechanically ventilated with volume assist-control ventilation. tidal volume was between and ml&g, with constant inspiratory flow, respiratory rate was - /rain, and i/e ratio between : to : . all patients had indwelling arterial catheters (pulmonary artery, and radial or femoral artery) in order to measure cardiac output (by thermodiintion) and relevant intravascular pressures, and to calculate derived parameters. no was administered between y piece of the ventilator and ondotracheal tube, and flow was adjusted to obi~a ppm no in the inhaled gas. the no, no and no x concentrations were continuously measured at the distal end of the endotracheal tube by the chemilumiinscenee method (nox , see-seres, france). metahemogtobinemia levels were measured daily. we considered a response to no inhalation when an improvement in paoz/fo above % was observed after the inhalation of ppm no (group r) . when the cha~age in paojfi z was below % it was considered a lack of response (group non-r small airways functional abnormalities have been recognized as a common feature of lung pathology. however peripheral airways contribute relatively little (~ %) resistance to flow and there disturbances can not be adequately estimated by conventional measurements of respiratory mechanics. the purpose of the study was to evaluate the relationship between raw and small airways conductance following weaning from ventilator methods. patients (age: - years; males) with no serious complications al~er mitral or multiple valves replacements and with more than hrs on mechanical ventilation have been enrolled in this study. the modified flow interrupter technique (ptg "gould" with fleish head # ; differential pressure transducer pm- -tc "statham" w amplifier "kistler ") and flow-volume recording of forced expiration (fleish head # ) have been applied before surgery and following operation on mechanical ventilation (my), after extubation (t:xtijb), on ( nay) and ( day) days. airways specific conductance (sg aw) has been calculated as a mean of - consequent measurements in each patient at each stage. the sac was estimated by max expiratory flow at and % of vc on - f-v curves (mef .~ , mef ) all the data were statistically analyzed with t-test introduction : noninvasive ventilation (niv) reduces the need for endotracheal intubation, the length of stay in icu and the mortality rate in acute exacerbation of copd. however, some patients failed to be ventilated with niv. .objectives...; to further delineate patients who failed to be ventilated with niv and to obtain predicted factors of failure. patients : a cohort of patients ( • years) presenting with acute exacerbation of copd (fevi: • ml, paco : • , ph: . • . ) and nonmvasively ventilated (pressure support through a full-face mask) between april and may twenty-seven ( %) were successfully ventilated with niv (discharged alive without the need for endotracheal intubation) while ( %) failed, requiring endotracheal intubation. .methods : patients successfully ventilated and those who failed were compared according to respiratory and nonrespiratory variables univariate analysis (wilcoxon rank-sum test and fisher-exact test) was performed to select variables included in a multivariate analysis by stepwise logistic regression. results : underlying disease assessed by the simplified acute physiologic score ( • vs • , p = . ), creatinine serum concentration ( • vs • gm/l, p = . ), blood urea nitrogen (bun : • vs mm/l, p = . ), age ( • vs • , p = . ) were higher and encephalopathy ( vs %, p = . ) more frequent in patients who failed. multivariate analysis showed that encephalopathic patients (or (odd ratio) = , p = . ) older than years (or = , p = . ) and presenting with bun >_ mmyl (or = , p = . ) failed to be ventilated with niv. variables related to the respiratory" status (i.e. paco , pao , fev ) were unable to predict tile failure of niv. conclusion : copd patients older than years, presenting with acute exacerbation, encephalopathy and bun > ram/l, should be carefully monitored because of high probability of failure with niv. methods:from february to december we studied pa_ timnts, males and females(mean age +/- ); of the se had emphysema,lo chronic bronchitis, dilatative car diomyopatia,with tracheostomy and emphysema.mean pac at admission in icu was +/- mmhg,while when weaningbegan, +/- .mean autopeep was cmh ( - ).all patients were ventilated in crpv as long as four hours to calculate st tic and dynamic cmpliance and autopeep.then the ventila tion was continued with psv+cpap(peep cmh objectives: analysis of the incidence of neurogenic pulmonary edema (npe) in a population of headtrauma patients with acute respiratory failure (arf). npe can occur after a central nervous system insult. differential diagnosis: cardiogenic pulmonary edema and other forms of non eardiogenic pulmonary edema. true incidence and pathophysiohigy remain poorly defined, however the role of catecholamines seems undeniable. early onset npe (within h after trauma) is characterised by hypoxemia, transient pulmonary hypertension and bilateral central fluffy infiltrates on chestx-ray. characteristics of cardiogenic edema or pneumonia are absent. late onset npe, (beyond hours after trauma), is more insidious. the clinical and radiographic picture has to clear within to hours. ( ) methods: all headtrauma patients admitted from january to december , in a nearotrauma icu setting were retrospectively analyzed for arf with as sole criterinm a pao -fio ratio < . results: neurotrauma patients were admitted during . patients ( %) presented with severe head injury (gcs< ), patients ( . %) with moderate (gcs - ) and patients ( . %) with minor head injury (gcs - ). overall mortulity was . % early (within h. after trauma) and delayed onset respiratory incidents were distinguished, counting for ( . %), respectively patients ( . %), patients ( . %) had early and late respiratory complications. early respiratory insufficiency was caused in patients ( . %) by aspiration, in patients ( . %) by lung contusion, in patient ( . %) by fat embolism and in patients ( %) by npe. in the late onset group patients ( . %) presented with pneumonia, ( . %) with fat embolism and ( . %) with npe. the npe group, patients, presented as follows: patients ( . %) developed early npe, and ( . %) delayed onset npe. patients ( %) died within the first days after admission, showing high mortality. gcs was less than in patients ( . %), indicating severity of head injuries. conclusions: high incidence of arf with various etiology ( , ~ was found in this population. in about % of all admitted hcadtrauma patients ( , % of arf) npe was causing attetial hypoxemia. occurrence of npe seems to be related to the severity of the brain injury and thus to outcome. these data call for extreme vigilance in respect of the insidious occurrence of npe. were included if recovering from respiratory failure and if in the opinion of the primary physician were ready for extubation. patients were excluded if undergoing compassionate withdrawal of support or had tracheostomies. the attending physicians were blinded to the measurements. included patients were placed on pressure support (ps) of em h with demand-flow continuous positive airway pressure (cpap) cm h . after a minimum of minutes on the above sehiogs: gastric intramucosai pc'o , abg, and a p . were measured. the padents were then disconnected from the ventilator for a period of one minute and the patients" respiratory rate and minute ventilation were measured using a wrights respirometer to calculate the frequency to tidal volume ratio (f/vt). patients were then extubated. extubafion failure was defined as the inability to maintain spontaneous ventilation for hours for any reason. results: twenty patients met criteria and were studied over one month period in october . six of the twenty patients ( %) failed weaning. the mean and standard deviation is outlined in failure . +/- . . +/- . . +/- . . +/- . comparison between roc areas shows phi and p . to each show a statistically significant difference from an area of . (p<o. ). the area at which the test has no discriminative value. this is not the case for either the integrative index or the f/vt ratio. the differences between areas for each curve is not statistically significant. the area's for each roc curve is shown in table #' . results. of the newborns referred to us for ecmo-therapy developed barotrauma, of the required ecmo and one of the three other patients who did not recieve ecmo-therapy died. to determine the correlation between the risk factor barotrauma and the severity of the pulmonary situation, we determined the oxygenation index of each patient referred to us for ecmo-therapy . the table demonstrates , d- giessen, frg. inhalation of nitric oxide (no) and aerosulizatiun of prostaglandin (pg) i: have been suggested to achieve selective pulmonary vasodilation and improvement of arterial oxygenation in patients with acute respiratory distress syndrome (ards). we directly compared these two modes of transbronchial vasodilator therapy in ards patients mechanically ventilated for - h (mean murray lung injury score [ ] . + . ). patients were randomized to receive either first no and then pgi (n= ), or vice versa (n= ), with an intermediate baseline period. each drug was titrated individually to find the lowest effective dose for maximum improvement of arterial oxygenation. gas exchange variables, including data from the multiple inert gas elimination technique (miget), and hemodymmaics under application of no/pgi were compared to pro-and past-challenge values. no (mean dose . + . ppm) increased the mean oxygenation index (pao /fio ) from + to + mmi-ig (p < . ) and reduced the shunt-flow from . + . to . : . % (p < . ). aernselized pgi (mean dose . + . " ng/kg rain) augmented pao /fio from + to + mmhg (p < . ), and decreased shunt from . + . to . + . % (p < . ). the miget analysis showed predominant redistribution of blood-flow from shunt areas to regions with normal ventilation-perfusion ratios in response to both agents. in patients, both no and pgi caused an increase in pao /fio by at least rnmhg. two further patients displayed a corresponding improvement of arterial oxygenation in response to either no or pgiz. the mean pulmonary artery pressure decreased from . : . to . : . mmhg in response to no, and from . : . to . : . mmhg (p < . ) in response to pgi . cardiac output, systemic arterial pressure, and right and left heart filling pressures were not affected by either agent. we r that individually titrated doses of inhaled no and aerosolized pgi~ effect selective pulmonary vasodilation and redistribute blood-flow from shunt-areas to weu-ventilated regions with nearly identical efficacy profiles. obieetives: the use of extraeorporeal bypass systems for oxygenation and co -removal is performed in patients with acute respiratory distress syndrome (ards) to reduce mortality and to improve restitution of pulmonary functions. high-dose heparin -commonly used in such patients to prevent thrombotic complications -might cause incurable bleadings as a major risk. this lead to the development of heparinized bypass systems; results of animal and first clinical studies proposed that such systems might run with low-dose heparin or even without any systemic anticoagulation. methods: since , patients with severe ards were treated with extracorporeal lung assist (ela) using heparin-coated systems (type maxima, medtronic, carmeda coating) in our icu. they received a moderate systemic heparinization. standard clotting assays (act, aptt, tt, ptt, at-ill, fbg, fsp) as well as special tests (tat, r~-tg, pf , pal-l, d-dimers, protein c, cl-inhibitor) were performed. results: covalent heparin-eoating of the ela-systems combined with lowdose heparinization could not prevent major changes in coagulation: ) in mean, platelets dropped from /nl to /nl within h after onset of ela. ) tat levels were already elevated before ela start ( ug/]) and demonstrated an additional peak h after onset of ela (up to ug/[). ) in parallel, there was a transient peak of pai-i levels (from to au/ml} h after onset of ela. ) in mean, fibrinogen levels dropped from to mg/ ml within h after onset of ela. ) in mean, cl-inhibitor levels dropped significantly from % to % after onset of ela and reached the initial levels within h. ) after membrane change, there were significant changes for c -inhibitor, fibrin-d-dimers and tt. ) global clotting tests such as aptt, ptt and tt were within normal range. conclusions: patients with severe ards develop a prethrombotic state already before they get connected to the ela bypass system. after onset of ela, they experience additional involvement of procoagulant, anticoagulant, fibrinolytic, and complement systems. in parallel to laboratory findings, clinical data suggest that the use of heparin-coated systems with accompanying systemic low-dose heparinization does not avoid thrombembolic and hemorrhagic complications in tong-term ela patients. thus, at the present, higher dosed individually adjusted heparin treatment has to be recommended. thereby, standard clotting monitoring is not sufficient. objective: poor muscle performance contributes to prolonged dependence on mechanical ventilation. longitudinal data on muscle function in icu patients is scarce. we evaluated changes in inspiratory and peripheral muscle performance during prolonged intensive care in patients with acute respiratory failure. methods: patients requiring intensive care for more than one week were studied. maximum inspiratory pressure (pimax) was measured twice a week for a maximum of three weeks. handgrip power (dynamometer) and subjective fatigue (keldet score) were obtained in survivors only. one measurement was done on the date of extubation. pimax pressure was obtained by occluding the airway for seconds or at least five inspiratory breath attempts. obiectives -measurement of peep-induced changes in lung volume helps to assess respiratory mechanics in acute lung injury (ali). we evaluated the accuracy and stability of a new respiratory inductive plethysmograph (rip), in the measurement of peep induced changes in end-expiratory lung volume (eelv) and tidal volume (vt) against volume reference, pneumotachograph (pnt), methods -two hours periods of basal ventilation and stepwise increases and reductions of peep ( - - - - cm h ) were recorded in patients with all. in addition, the new rip device (respitrace plus tm) was compared to an older rip (respigraph tm, nims, fl, usa) to determine its thermal stability using cold and warm devices and a ventilated lung model. results -the difference between the new rip and pnt in the measurement of vt was - _+ mi (x _+ se) or a - . _+ . % error. increasing peep from to cm h induced a + ml change in eelv. a difference of + ml ( . % of max. eelv change) (ns) was found between rip and pnt eelv readings. during controlled ventilation with constant settings the mean change in eelv was _+ ml/ min (fig.i) . validation of calibration showed a mean error of -+ . % after rain. the new rip had a higher drift when cold (cold + ml/ min vs warm _+ ml/ min), whereas the old rip was thermally stable (cold - + ml/ rain vs warm i + ml/ min). trauma icu, hospital traumatologia y rehabilitacidn. vall d'rebron. barcelona. spain. recent data suggest that the proportion of patients with relevant discrepancies between two jugular bulb (jb) oxygen saturation (sjo ) values is higher than suspected. objectives: determine the incidence, the significance and the pro nosis value of those differences,if they exist,in severe head injured-patients. material and methods: severe head-injured patients, coma glasgow scale (gcs) , with diffuse brain injury according to marshall criteria in the first ct scan, icp recorded, with an interval from accident-double jb monitoring < than hours, were studied. data from bilateral sjo were obtained simultaneously, every hours. discrepancies were considered significant, when differences in sjo were > %. no chan es in treatment protocol (hyperventilation, man• etc) were carried out due to this study. results: men and women were studied, aged • yrs. at arrival at hospital, gcs were < in and ) in to. the incidence of high icp() mmhg) were sz at the entry. the mean therapy index level required to control lop was ~l all patients required vasopressor therapy to maintain upp over ds mmhg. in patients a s.s f swan-ganz fiberoptic catheter was used to obtain a continuous recording of sjo . in the others , sj were intermittently controhed.the mean time of monitoring were d. • days. ten patients died within this period. a total of . blood samples were analized. at arrival, sjo discrepancies were found in patients, b %. at hours, the incidence were lower, / , . %. at th day, were h/ , z and at day , when the catheters were retired, ii[ , z showed discrepancies. the ct showed new injuries in g z of patients with differences > ~ in sd values throughout treatment period. none of those were considered for neurosurgical treatment. no correlation was found between iop and sjo values and sjo differences. conclusions: the incidence of discrepancies between sjo was higher than expected in severe head-injured patients. these situation could reflect disturbances between demands. when differences are known, and those lend to change, the ct scan, nearly always, will show new injuries. platelet-activating factor (paf) is an inflamatory mediator implicated in the pathogenesis of bronchial asthma and acute respiratory distress syndrome (ards). its inhalation in healthy subjects produces transient bronchoconstriction and mild ventilation-perfusion mismatch, together with peripheral leukopenia as a result of intrapulmonary neutrophil (pmn) sequestration. likewise our group has shown in healthy subjects and asthmatic patients that aaibutamol (s) inhibits both pulmonary and systemic effects of paf, suggesting that s may inhibit paf-induced venoconstriction in pulmonary microoirculation. the aim of the present study was to investigate if s inhalation decreases pmn by lung sequestration induced by paf. we studied healthy, non-atop• nonsmoking subjects ( m/ f, + yr), which were pre-treated with s ( ,ug) or placebo, with a randomized, double-blind, crossover, design, before paf ( ,ug) inhalation. we measured the respiratory system resistance (rrs) by forced oscillation, arterial btood gases and both total white cell and pmn count every min over a min. period. simultaneously, we recorded continuously the lung dynamics of inm-neutrophil and tc m-erythrocytes activity, with a gammacamara. after placebo, paf inhalation decreased white cells (from to x /l), and pmn(from to _+ x /l), and increased aapo (from . _+ . to . + . mmhg, p<o. ) and rrs(from . . to . . cmh .s.i q ) (p < . each). the fall in total white cell count correlated with the intrapulmonary pmn retention (r = . , p < . ). by contrast, after s, paf did not induce any change in white ceil count (from to + x /i), pmn count (from to x /i), aapo (from . to . + . mmhg), and rrs (from . . to . . cmh .s.i ). compared with placebo, after s there was a lower ~lln-pmn lung activity ( . . vs . . cts/mci/pixel, p<o. ), lower intrapulmonary pmn retention ( . . vs . . %, p=o, ), and a faster washout ( . . vs . . s ~, p= , ). our results indicate that s inhibits paf-induced intrapulmonary pmn sequestration, being consistent with the hypothesis that s may offset the venoconstriction of pulmonary microcirculadon caused by this mediator. supported inpiratory muscle fatigue with failure of force generation as def'med by a tensiontime index (tti)> . - . has been shown to occur in normal volunteers and in stable copd patients with a specific imposed breathing pattern. its role, however, in hypercapnic respiratory failure is less certain. we studied failed weaning trials in copd patients in which breathing pattern, tension-time index (tti) of inspimtory muscles, dynamic peepi, dynamic lung elastance, lung resistance, and arterial paco and ph were measured at the beginning and end of a t-piece weaning trial. in addition, the change in esophageal pressure during a mueller maneuver (apes max) was measured. a weaning trail has been prospectively defined to have failed if one of the following criteria was met: a rise in pco > mmhg from baseline accompanied by a fall in ph< . ; a respiratory frequency (f) > /min; excessive accessory inspiratory muscle recruitment; and a marked increase in dyspnea. values are expressed as mean • se. weaning failure was characterized by a more rapid, shallow breathing pattern, worsened mechanics, hypercapnia and respiratory acidemia despite an unchanged tri and pes max. we conclude that in this setting hypercapnic respiratory failure is not a consequence of inspiratory muscle fatigue. rather the adopted breathing strategy and resultant hypercapnia may represent an adaptation to forestall the onset of muscle fatigue. concerning the investigated elf-par~eters, no stadstically signhqcant differences were detected between the pgi and the control group. histopathologlcal changes occured in both groups and consisted in rare focal flaaaning f tracheal epithelium with loss of cilia and slight inflammatory cell infiltration, as well as slight swelling of alveolar typo pneumoeytes. sections of generation , and from bronchial tree were free of pathological changes. conclusion: alter h inhalation of p~ji no signs of respiratory-lract tissue damage caused by the aerosol could be detected. the minor pathological findings in the trachea are most likely due to mechanical irritation by bronchoscopy, changes of the alveolar epithelium are known for long-term mechanical ventilation . objectives: the aim of this study was to evaluate of efficiacy of ganglion stetlate blockade in patients with respiratory failure. methods: two groups of patients were investigated: group i (n = ) trauma patients with acute lung injury (ali), group if (n = ) patients with asthmatic status. in all cases continuous mandatory ventilation (cmv) was used with bennett ae. in both groups bilateral ganglion stellate blockade with antero-lateral approach was performed, using . % marcain. the following parameters were analysed: pao , sao , paco~, pip and c~t~t. results: in trauma patients with aij after bilateral ganglion stellate blockade short -lived and slight improvement of pao and sao , decrease of pacoz and pir and increase of static compliance of respiratory system were found. in second group bilateral ganglion stellate blockade interrupted the asthmatic status and significant statistical improvement of parameters of oxygenation, ventilation and respiratory system mechanics were observed. conclusions: we suggest that the bilateral ganglion stellate blockade is a very useful method in treatment of patients with obstructive respiratory insufficiency. the aim of the study was to analyse whether there exists serum and urine electrolyte disorder in patients(pts.) with acute respiratory insufficiency(ari). the study included t pts. with ari (pao : , @ , kpa. paco : , i- , kpa, ph: ~: , , hco : , :~ , mmol/ , sao : , ~- , %) who were hospitally treated due to pneumonia( pts.),emboly of the pulmonary artery( pts.) and severe attack of bronchial asthma ( pts). among tham there were ( , %) males and ( , %) females, average age , ~: , years, otherwise previously healthy. electrolyte concentracions were measured at the onset of the disease in serum and urine collected during hours (sodium-na,potassium-k, chlorine-c , calcium-ca,magnesium-mgand phosphorus-p). the measured serum and urine electrolyte concentrations were compared with respective referent values (rv). by serum electrolyte analysis, the following average velues were obtained: na:l o, the object of our investigation was a group of pts with massive pneumonias, males ( . %), females ( . %),mean age yrs.thirteen ( %) of them were smokers, ( %) nonsmokers. only pt ( . %) had pre-existing chronic respiratory disease, and ( . %) were admitted for the first lime,with no previous respiratory anamnesis. diagnose was based on anamnestic data of productive cough in pts( . %),physicaly ~onchial breathing in i~s ( . %),white cell count onder x /l in pts( . %). radiographicly, bilateral massive homogeneous shadows were found in pts ( . %), onilateral in pts( . %),pleural effusion in pts ( . %). abnormal renal function was found in pts ( . %). sputum culture was positive in pts ( %): slr.pneumoniae, str.pyogenes, pse'udomonas aerug, in , , cases respectively. all patients had remarcable hypoxernia (pao range from , to , kpa) without hypercalmea. all patients needed oxygenotherapy together with antibiotics and other .symptomatic therapy. nineteen pts had anaelioration of general condition and normalization of blood gas analyses, while pts with the lowest hypoxcmia died.in conclusion, massive pneumonias are frequently followed by respiratory insufficiency which is one of the markers of pneumonia severity. as existing hypoxemia complicates the course of the disease,prolonges the recovery, makes therapy more complexe and may be cause of death , frequent blood gas measurement is recomanded. we studied the effects of bosentan (bos), an eta and etb receptor antagonist, to examine if endogenous et mediates pulmonary hypertension in anesthetized and ventilated dogs with acute lung injury due to oleic acid (oa). the gradient between pulmonary artery pressure (ppa) and occluded ppa (ppao), and gas exchange (evaluated by arterial blood gases and sf intrapulmonary shunt) were measured at controlled flow. in dogs (treatment), data were collected at baseline, during long injury (obtained rain after intravenous administration of oa . ml/kg), and again after bos ( mg/kg intravenously). in dogs (pretreatment), data were obtained at baseline, after bos and then after oa. in treated dogs, oa increased (ppa-ppao, mmhg, table, means + sem, * p < . vs base) and deteriorated gas exchange. after oa, bos did not affect pulmonary vascular tone nor gas exchange. in pretreated dogs, bos had no effect on baseline pulmonary vascular tone but prevented the increase in (ppa-ppao) after oa. the deterioration in gas exchange after oa was not influenced by bos pretreatment. objectives: the alveolar tension is measured by the application of the alveolar air equation in which the arterial pco is used or by the simplified form of this equation in which the respiratory exchange ratio is taken at the value of . . the purpose of this study was to estimate the effective alveolar tension (pao eff) during spontaneous breathing with a new bedside technique which is simple non-invasive in normal subjects and patients with chronic bronchitis-emphysema. we also compared these values with the ideal alveolar po (pao (i)), measured from the alveolar air equation in which paco was substituted by the effective alveolar pco (paco eff) and with the alveolar po measured from the simplified alveolar air equation (pa ). this study is complemantary to previous work for the estimation of paco eff. methods: the subjects breathed quietly through the equipment assembly (mouthpiece monitoring ring, fleisch transducer head) connected to a pneumotachograph and a fast response and co analyzer. the method is a computerised calculation of the effective alveolar po quite similar to that of paco eff, obtained from the simultaneously recorded at the mouth expiratory flow, and co concentration versus time curves. results: the results showed a mean difference (pao eff-pa (i)) of - . kpa in normal subjects and - , in patients. the mean of the difference (pao eff-paq ) and (pad (i]-pao z) was much greater than . in all subjects. the limits of agreement for the difference (paozeff-pa (i))were - . to . kpa in normal subjects and - . to . in patients, while those for the differences (pao eff-pad ) and (pao (i)-pad ) were very large ( > - . to > . ) in all subjects. conclusions: the effective alveolar po is very close to the ideal one in normal subjects, tn patients pao eff may excessively deviate from pa (i) due to the observed significant difference between the alveolar/tidal volume ratio for o and that for co . the alveolar po measured from the simplified alveolar air equation (pao ) differed substantially from pao eff and pad (i) in all subjects. the essential role of glucoprotein hormone erythropoietin is to control red cell production. hypoxemia, reduced blood -carrying capacity and increased affinity of hemoglobin for are the primary stimuli for erythropoietin production. both anemia and hypoxemia induce rapidly erythropoietin secretion. kidney erythropoietin rna levels correlate inversely with hematocrit and directly with plasma erythropoietin level. similarly, hypoxemia increases kidney erythropoietin rna and plasma erythropoietin. the effect of hyperoxemia (pa >lo mmhg) on erythropoietin secretion isn't very well understood. the purpose of this study was first to evaluate the erythropoietin secretion in patients with acute respiratory failure and second to determine the effect of hyperoxemia on erythropoietin secretion in patients with and without anemia. sixteen patients with acute or acute on chronic respiratory failure needed mechanical ventilation were included in this study. these patient were divided in two groups. the patient who developed anemia were included in group i and the patients without anemia in group i . erythropoietin was estimated in venous blood in three stages. the first sample was taken during hypoxemia, the second during hyperoxemia and third during normoxemia. all the patients had high erythropoietin level during the hypoxemia period (mean value • mu/ml). during hyperoxemia etythropoietin levels were reduced in both groups ( mean value . + . mu/ml in group i, . • mu/ml in group ii). in normoxemia stage, erythropoietin increased again in anemic patients, and decreased more in the patients of group i . we conclude that hyperroxemia inhibit erythropoietin secretion in spite of anemia and tow arterial oxygen content. hyperoxemia may be a factor of the insisted anemia in with oxygen treated icu patients. the purpose of this study was to determine the relationship between clinical features of acute lung injury (all) and parameters like total proteins, total and individual phospholipids, the presence of paf, and acetylhydrolase activity in bal of mechanically ventillated patients. acetylhydrolase catalyses the cleavage of acetyl-group from the second position of the glycerylether backbone of paf, leading to its inactivation. mechanically ventillated patients were divided to three groups. group i includes patients without all; group ii, comprisespatients with moderate degree all, ( . <g-i < . ); and group iii comprises patients with severe ards (all score > . ). broncoalveolar lavage (bal) was obtained after infusion of normal saline at ~ to intubated patients and cooled immediately. cells were removed after mild centrifugation ( x g, min, oc). aliquots from the supernatant were used for total protein, phospholipid and paf analysis and determination. acetylhydrolase activity was assessed after incubation of bal with h-paf labelled on the acetyl group. released label was measured by liquid scintillation counter in the supernatant after trichloroacetic acid precipitation of the non-reacted substrate. kinetic characteristics of the enzymes were also studied. total phospholipids appear reduced in bal of patients with all, while total proteins increase. these factors appear to correlate with the severity of all. paf was not present in bal samples pretreatad with equal volume of % acetic acid to denaturate acetylhydrolase. detection limit for paf under our experimental conditions: pg paf/ml bal. instead, acetylhydrolase activity was detected in amounts increasing with the total protein content. background: intubated patients without lung injury or impaired breathing control normally display an inspiratory peak flow of below l/s. the aim of our study was to investigate the inspiratory peak flow generated by patients with acute respiratory insufficiency (ari). we had to take into account that both an inspiratory pressure support (ips) and the resistance of the endotracheal tube considerably influence the flow pattern generated by the patient. patients and methods: to investigate the non-influenced flow pattern we developed a new ventilatory mode which automatically compensates for the flow-dependent resistance of the endotracheal tube (automatic tube compensation, atc). furthermore, the mode maintains a constant tracheal pressure in inspiration and expiratio n . consequently, the measured flow pattern exactly corresponds to the flow pattern generated by the patient except that the ventilator modified for this mode (evita, driiger liibeck, germany) was not able to deliver a gas flow of more than l]s. we have investigated patients with ari arising from different reasons. results: the inspiratory peak flow measured in the atc-mode was . l/s _+ . l/s. the maximal deliverable flow of l/s was obtained in of patients. the figure shows the flow pattern under atc and ips in [~s] oi:) one of these patients. conclusions: patients with ari display a highly increased inspiratory peak flow. ventilators used for spontaneous breathing should therefore be able to deliver a gas flow of more than l/s. an overproduction of no and reactive oxygen species (ros) has been demonstratred in septic shock. ros and nitric oxide (.no) are free radicals which are known to react together leading to peroxynitrite anions that can decompose to form nitrogen dioxide (no ) and hydroxyl radical (oh~ thus, no has been reported to have a dual effect on lipid peroxidation (prooxydant via the peroxinitrite or antioxidant via the chelation of ros). in the present study we have investigated in different models the in vitro and in vivo action of no on lipid peroxidation. copper-induced ldl oxidation was used as an in vitro model of lipid peroxidation. ldl ( ~g apob/ml) was incubated with cu + ( , ~tm) in presence or absence of no donor (sodium nitroprussiate or glutathione-no) from to ~m. oxidation of ldl was monitored continuously with conjugated diene formation ( nm) and hydroxy nonenal accumulation (hne). exogenous no prevents in a dose dependent maner the progress of copperinduced oxidation. ischaemia-reperfusion injury (i/r), characterized by an overproduction of ros, is used as an in vivo model. anaesthetized rats were submitted to hour renal isehaemia following by hours of reperfusion. sham operated rats (sop) were used as control. lipid peroxidation was evaluated by measuring the hne accumulated in rat kidneys in presence or absence of l-arginine or d-arginine infusion. l-arginine, but not darginine, enhances hne accumulation in i/r but not in sop (< . nmol/g tissue in sop versus . nmol/g tissue in i/r), showing that in this experimental conditions, no produced from l-arginine, enhances the toxicity of ros. this study shows that the pro-or antioxydant effects of no are different in vivo and in vitro and could be driven by environemental conditions such as ph, relative concentration of no and ros, ferryl species...these conditions are impaired in circulatory shock. methods:" the diagnostic and therapeutic approach was standardized so that data collected over a -year period were comparable. a progressive deterioration of clinical conditions and/or pulmonary gas exchanges was considered as indication for my. variables potentially predicting the need for hv were derived from clinical and arterial gas data, extrapulmonary diseases, use of drugs, chest x-ray and ecg abnormalities. results: rv, performed with external and/or internal ventilators, was necessary in patients ( %). at the hospital admission, pac was higher and ph was lower in patients requiring rv ( pneumomediastinum, pneumothorax, ateleetasis and myocardial infarction are rarely seen in bronchial asthma. these complications occur as a result of the severe asthma.the aim of our retrospective study was to analyse the complications seen in acute asthma attacks. during the years through , patients were admitted to hospital in acute asthma episode. there were ( , %) pts with complications; mean age of yrs; females ( %). clinical history, ecg and chest radiogr~hs were analysed. the mean duration of bronchial asthma was yrs (range from months to yrs), all patients were atopics. there were four ex-smokem and one smoker. the worsening of asthma symptoms begun two days before the admission (range from to days). on ecg all patients had tschycardia. rightward shift of the qrs axis and st-t changes indicative of right ventrieutur strain were found in three pts. these were the transient fmdings that improved after curing the acute asthma attack. non-q myocardial infarction oeeured in one patlent and resulted from the hypoxaemia of asthma. hyperinfl~ion was the usual finding on the chest radiograpk pneumomediastinum and subcutaneous emphysema were apparent in five pts and required no additional treatment unilateral pneumothoraccs were present in two pts and needed eontimous intrapleural drainage; one of these patienst died in eardiorespiratory insufficiency. ateleetasis of right upper lobe was present in one patient. it oceured due to inspissated secretions and needed no additional treatment all these patients, except one who died, improved on lreaanent with oxygcr~ steroids, beta-two agonists, theophylline and antibiotics. in conclusion, complications occur in acute asthma episodes as a result of the severe asthma mediastir,*l emphysema and atelectasis are not serious complications. pneumothorax and myocardial infarction are very serious life-treatening complications and always have to i:m considered in taati~ts with sev~ asthma. acute bronchial asthmatic episodes represent one of the most common respiratory mnergendes, its maximmum expression "status asthmatiens" is one entity of low incidence, still it is a risk to the physical integrity of the patient. during a total of patients with diagnosis of status asthmabcas were hospitalized. out of these palients six had a near-fatsl asthma and they were subjected to a complex examination. near-fatal asthma was defined as either respiratory arrest or acute asttuua with paco greater than , kpa and/or an altered state of consciousness. mean age was , -d: , yrs, four male and two female sex. at presentation two patients suffered from coma, others were confused. they exh'bited severe dystmoes, diffieul~ speaking, used accessory muscles of respiration, increased whee~tg while two cases had silent chest on auscultation. cyanosis indicated a very severe asthma attack in all six patients. mean respiratory rate was ~ /min and puts rate .d: bts/imn. arterial blood gases revealed a pao of , ~ , kpa, paco of , • kpa and ph of , -+- , . area-careful evaluation they received conventional therapy (immediately continuous oxygen, impelled nebulization with high doses of betatwo agonists and ipmtropium bromide, intmvanous st~oids and theophylline). in two eases signs and symptoms of deteriorating airflow and respiratory muscle fatigue determined the need for mechanical ventilation. out of six near-fatal attacks aggressive lrealanent was suscessfull in four patients and fatal in two eases. one patient admittcxl in coma died in severe hypoxae~a upon one hour and one mechanicaly ventilated died from cardiac arrhythmia. life-threatening attacks in asthmatics in our group developed gradual worsening despite neatment which r symptoms in most other patients. one patient had "brittle asthma", other long-standing acute episodes ireated with systemic steroids. conclusions: idantitiechon of fatality prone subjects may lead to fttrther muetion of seveze episodes. respiratory affest and coma upon admission, severe dyspnoca with silent chest on ausouhation, oyanusis and use of accessory muscles of respiration constitute the basic cfinieal picture. hypoxasmia must be immediately eon'ected.the patients and physicians should be able to assess the severity of asthma, a major factor in near-fatal and fatal asthma attacks. objectives :our purpose was to asses if the evolution of patients with a adult respiratory distress syndrome (ards) ,shows any relation to the pulmonary or systemic origin of the disease and whether or not there were differences in the frequency of the syndrome in both groups. methods : randomized prospective study in multidisciplinary icu. one hundred and sixteen patients with a high risk developing ards were distributed into two groups. one was named systemic origin group(so) and the other pulmonary origth group (po).ai patients only showed one cause (pulmonary or systemic) with potential risk of ards.the patient's hemodynamic and respiratory status was evaluated every hours the first day and every hours the second and third day. at the end of hours the patients were diagnosed as ards or non-ards. measurements and main results : of the total patients, were finally included in the so group and in the po group.patients in so group and po group had comparable ages (p<. ).peep in both groups was comparable (=. ) at the mmnent of admission to the study. there were no statistically significant differences for cardiac index and systemic vascular resistances. the pulmonary vascular resistances (pvr) showed significant differences at h.(p<. ) and h. (p<. ).the oxygen comsumption (vo) in patients of the so group showed statistically significant differences at h. (p<. ) with respect to initial values.fifteen cases of ards ( . %) in the so group and twenty five cases ( . %) in the po group were identified. the time of onset of ards was _+ hours in the so group and + b hours in the po group.the final outcome was very similar th both groups : mortality of % in the so group versus % in the pc group. conclusions : the pathogenesis of ards depends on whether the lesion is originated at or outside the lung. the po group showed a sborter thne of onset of ards, a faster and more severe increase of pulmonary shunt and a higher percentage of patients developing ards compared with patients of the so group.the so group showed a higher and faster increase in puhnonary resitances tbat po group and a decrease th oxygen comsumption earlier and more severe than in the po group. these data thus seem to show that there could be two mechanisms involved in the genesis of ards depending on the cause. the fact that the ards genesis is shorter in the cases of pulmonary etiology with faster impairment of pulmonary shunt, and a slower increase in pulmonary resistances in this pulmonary group, would indicate that the underlying mechanisms responsible for the hypoxemia are different to those which thitiate the increase in pulmonary resistances. finally, the exclusive inapairinent of oxygen consumption, which appears earlier than the onset of ards in the systemic origth group, could show the generalized character of the process in this group. perfusion of prostacyclin (pgi ) to treat pulmonary hypertension in adult respiratory distress syndrome (ards) worse pulmonary gas exchange due to a marked impairement of ventilation/perfusion mismatch. recently has been shown that if prostacyclin is given by aerosol instead of intravenous the net effect is an improvement of arterial oxigenation due to a redistribution of blood flow to well ventilated areas. objectives: to asses the effects of inhaled proatacyclin on pulmonary haemodynamics and gas exchange in patients with severe ards. methods : two patients with severe ards (murray score > ) recived inhaled pgi at - ng.kg.min " using an ultrasonic nebulizer. haemodynamic measurements, arterial and mixed venous blood gas analysis were performed before and after rain of pgi inhalation. results: short-terro p~i inhalation improved pulmonary g-~ e-'~hange in both patients. arterial oxygen partial pressure (pao ) increased from to mmhg in patient and from to in patient , the ratio pao to the fraction of inspired oxygen increased from to (patient ) and from to (patient ). venous admixture decreased from % to % and from % to % in patient and respectively. mean pulmonary artery pressure decreased slightly from to mmhg in patient and from to mmhg in patient . no effects on systemic haemodynamics were observed in any patient. conclusions: pgi inhalation improves gas exchange and produces selective pulmonary vaaodilation, thus can be an alternative therapy for the treatment of pulmonary hypertension and hypexemia in patients with severe respiratory falllure. methods: we treated ards-patients (age yr ( - ) mean, range) during - . the lowest pao /fio -ratio was ( - ), the worst murray score . ( . - . ), icu-stay ( - ) days and hospital mortality %. the costs of intensive care were calculated according to intensivity of patient care as assessed by tiss-scoring (therapeutic intervention scoring system). the more intensive the care, the higher are the costs. costs per year of life saved (=life-year" in us $) were compaired by other medical treatments ( - ). it is assumed that the mean expected length of remaining life in ards-survivors after intensive care is years. treatment life-year ($) ' bone marrow transplantation (acute leukemia) lowering cholesterol using iovastatin treating hypertension using nifedipine heart transplantation intensive care of ards-patients conclusions: intensive care of patients with severe ards is highly more cost-effective as compared with many other routinely used medical treatment strategies, the usually good recovery and the reasonable quality of life in survivors justifies investments to care of these patients ( ). there is a close correlation between these two methods of measuring evlw. however there is an underestimation of . % in this kind of pulmonary edema ( oleie acid induced ) with the double dilution method. although the size of the sample is small, in normal lungs there appear not to be this underestimation. the effect of peep on evlw has been studied with contradictory results, probably as a consequence oft differences in methods of measuring evlw, variations in the type and severity of lung injury, and different timings of peep application. objective= ) to analyse the effect of different levels of peep ( , and omh ) on evlw during hpe; ) to establish whether increases in intrathoracic pressure due to high peep levels can obstruct lymphatic drainage. material and methodet hpe was provoked in groups of dogs by inflating a foley catheter in left auricular to a pressure of - r~uhg. peep levels of , i or m~hg were applied. resultst objective: to assess the effect on extravascular lung water (evlw) of the application of peep and the reduction of vt in an oleic acid pulmonary edema model in pigs, using three ventila~ary strategies. material and methods: twelve adolescent pigs (weighing over kg) were randomly divided in three gmups immediately alter infusing via a central vein . ml/kg of oleic acid to produce a permeability pulmonary edema. the ventilatory parameters for each group were as follows: group i (n= ) : vt: - ml/kg; zeep. group :(n= ) : vt: - ml/kg; peep: cm h . group :(n= ) : vt: - ml/kg; peep: emil . (resulting in permissive hypereapnla) after a four-hour period of ventilation the animals were killed and the lungs excised to calculate gravimetrically the extravascular lung water using a standardized procedure ( hemoglobin content method ). ill evlw (ml/kg) group obiective: in the postoperative period, maintenance of adeguate arterial oxygen tension is a major problem in morbidly obese patients probably because of a large reduction in functional residual capacity (frc). the aim of this study was to evaluate the effects of peep on respiratory mechamcs and gas exchange in this kind of patients. methods: in nine postoperative mechanically ventilated morbidly obese patients (bmi> kg/m ) we partitioned the total respiratory system mechanics into its lung ( ) and chest wall (w) components using the airway occlusion technique associated with the esophageal balloon, during constant flow inflation (jap ; : ) . at three different levels of peep ( , , cmh ) we measured: compliance (cst), airway (rim) and "additional" (dr) resistance, frc and gas exchange. obiectives. to describe the use of prone position in our icu we analyzed the clinical records of all patients admitted in - , selecting adult patients with arf defined as: intubation and pao /fio < mmhg plus an fio > . or peep> cm i . results. patients met the arf criteria: of them ( . %) underwent prone positioning (p+). prone position use began in the early phase of arf ( . • days from the beginning, range - , median ). out of p+ pts were treated with controlled ventilation (cppv or pcv), while were on assisted ventilation (simv+ps) and on spontaneous breathing (cpap). only pts were awake when turned prone, while pts required adjuncts of sedation to tolerate the change of position. the duration of prone positioning was variable (average lenght . • h, range . - h). only minor side effects were observed (eyelids and facial edema, chest and facial pressure bruises). we consider responders (r+) those patients presenting at least . mmhg increase in pao /fio : / patients ( . %.) were responders when first pruned. the pao /fio changes induced by prone position are reported in the figure. pao /fio increased when patients were pruned (*p< . ) and remained higher than baseline values when returning supine(*p< . ). paco remained unchanged. prone positioning was used at least twice in / ( conclusions. this retrospective analysis confirms that prone positioning improves oxtgenation in the majorib' of arf patients. altough we have no available criteria to discriminate in advance r+ from r-pts, we now routinely consider the use of prone position in the treatment of severe arf. palo a, otivei m*, galbusera c, veronesi r, sala gallini g, zanierato m, iotti g, braschi a.servizio anest. e rianim. i, *laboratorio biotecnologie e tecnologie biomediche irccs s. matteo, pavia, italy inhaled no can improve arterial oxygenation and reduce pulmonary hypertension in ards patients; little information is, however, available about the dose-response curves. methods seven ards patients (lis . +. ) submitted to mechanical ventilation randomly received inhaled no doses in increasing or decreasing sequence: . , , , , , and ppm. reference measurements were obtained before and after the entire period of no inhalation. hemodynamic parameters and blood gases were measured after min in each condition. cmv was administered under sedation and paralysis, with constant ventilation, peep (lol-_ cmh ) and fit (. +. ). the changes in vt and fit due to the no ( ppm in n ) injection in the ventilator external circuit were compensated for. results . the dose of . ppm, ineffective on papm, significantly improved oxygenation. the increase of pat and the decrease of q'va/q' and papm were nearly maximal at - ppm. no deterioration of arterial oxygenation was observed at no doses as high as ppm. co exchange was not influenced by no inhalation. systemic hemodynamic variables did not change throughout the study. these results suggest that a concentration around ppm is adequate for obtaining maximum effects on hypoxemia and pulmonary hypertension in patients with ards. low-dose inhaled nitric oxide (no) induces redistribution of pulmonary perfusion in patients with severe ards and causes improvement of oxygenation [ ] . however, addition of exogenous lowdose no in the inspiratory gas mixture might be only a replacement of missing atmospheric no ( - ppb) in hospital central-supplied medical air. [ ] we have realised nitric oxide measurements in ten healthy volunteers, ( smokers and non-smokers) breathing with a mouthpiece and occluded nostrils through a ventilator circuit, with separation of inhaled and exhaled gases by a valve. no concentration was measured with a double-chamber chemiluminometer (environnement sa, france) and with charcoal/silicate purified compressed air. there was no nitric oxide detectable in the inspirat ry limb of the ventilator. unfiltered central supply medical air contained : - ppb of no and - ppb of no , whereas central supplied oxygen was no/no free. samples were taken after equilibration periods of minutes, with increasing fit levels of . , . and . for subsequent minutes periods; paired values were recorded every s. the mean no value was . ppb (sd . ) and n o significant differences were found for different fit levels both in smokers and non-smokers. these data suggest that the no concentration of pulmonary origin in the exhaled air of' healthy volunteers is probably lower than that reported by other authors [ ] and that, previously reported, differences between smokers and non-smokers are not always striking [ ] . we suggest the use of activated charcoal/silicate filters for clinical trials in order to achieve standard conditions. [ objective: to compare efficacy and safety of two doses of salbutamol. methods: sixteen adults who had severe acute a~hma were randomly assigned to receive either rag (n= ) or rag (n= ) of nebulized sulbutamol. both groups were similar with respect to age, duration of a~hma, duration of attack before arrival at the hospital and severity of a~hma according to baseline measurements (table) . evaluation was performed , , and rain after the start of nebulization. results: compared with mg regimen, mg regimen resulted in the same improvement in peak-flow and fischl index (figure). the changes in heart rate, respiratory rate and pace did not differ significantly between both groups. the incidence of side effects, which included tremor, palpitations, cardiac arrythmlas and other symptoms, was not sj~ificanfly different in the two populations. conclusion:the results of this study suggest that nebulization of ng of salbutamol is not more effective than rag in the initial treatment of acute severe asthma in adult patients. the prognostic factors of neutropenic patients admitted to the icu remain poorly known. the aim of this study was to determine the respective weight of underlying malignancy and organ system failures on the outcome of these patients. patients and methods: the charts of neutropenic patients (wbc < /mm and/or pmn < /ram ), admitted to the icu between and , were retrospectively reviewed. the characteristics of the neoplastic disease (h~emopathy or solid tumor, tumoral evolution, duration of cancer disease and of neutropenia), the mac cabe's score, the organ system (respiratory, hemodynamic, renal, neurologic, hepatic) failures and the severity scores (saps, saps ii ,osf) were registred within the st day in the icu. when discharged from the icu, the patients were classified as alive or dead. results: fifty-seven patients ( . %) had a h~ematologic malignancy, and ( . %) a solid tumor. fifty-nine of the patients died ( . %); the mortality rate did not differ between both groups ( . and % respectively, p = . ). with univariate analysis, none of the tumoral features is linked to the prognosis; only the respiratory (p < - ) and cardiovascular (p < - ) failures, and the number of organ system failures (p < - ) are associated to the risk of death. the saps (p < - ) and saps ii scores (p < - ) were higher in patients who died. with multivariate analysis (logistic regression), only the respiratory failure is correlated to the risk of death (p = - ); neither the features of the underlying malignancy (p > . ), nor the duration of neutropenia before admission in icu (p = . ), nor the severity scores figs ii: p = . ) are linked to the outcome. conclusions: the tumoral characteristics do not modify the prognosis after admission to the icu. they should not influence the decision to admit or refuse a cancer patient in the icu. respiratory failure at icu admission has the predominent weight on the risk of death in the icu. patients with respiratory acidosis due to asthma occasionally require levels of mechanical ventilation that place them at risk for barotrauma. a few case reports have described the use of an extra-corporeal membrane oxygenator(ecmo) circuit as an alternative means of co removal. generally, this has been used for short periods of time (< h) without serious complications and with low blood flows through the extra-corporeal circuit. we report a case of refractory asthma who could not tolerate even small-volume breaths from a mechanical ventilator due to severe bilateral airleak. ecmo therapy was initiated at the referring hospital prior to helicoptor transport. high blood flows were used ( % of the patient's cardiac output), sufficient to achieve both co removal and oxygenation. satisfactory gas-exchanged was accomplished (pco = - mmhg) with nearly total lung rest for a prolonged period ( h). however, the long ecmo duration was associated with two severe complica-ti ns: ) bilateral hemothoraces due to anticoagu!ation in the extra-corporeal circuit, and ) prolonged weakness as a result of neuromuscular blockade for six days. the patient was discharged from the hospital in good condition. we present the respiratory and hemodynamic features of this case aw well as the potential complications of ecmo therapy in asthma. objectives: parameters derived from tidal expiratory flow ~e) and volume (vt) can be used to detect airflow obstruction in copd patients who might be unable to perform forced spirometry (e.g., icu). however, indices such as ave/v t and at/re are highly variable (thorax, : ; ) . methods: we investigated whether the standardized for v m effective time (teff~) of a tidal breath, which is derived by asimple mathematical procedure (teff,= j'vdt/vt ), is a more reproducible and sensitive detector of airways obstruction, we studied nine normal subjects ( male, -+ yr) and copd patients ( male, -+ yr) in the seated position, with a noseclip on. they breathed quietly, through a pneumotashograph to measure flow (v). volume was obtained by numerical integration of thellow signal. each subject had an initial - min trial run, in order to become accustomed to the apparatus and procedure. when regular breathing had been achieved, all breaths over a min time interval were recorded. the mean value of six consecutive breaths (ers criteria) for each subject was used for analysis under the condition that within session variation of tidal volume (vt) was < %. lung function tests were: in normals (mean-sd), fevl%pred = • fevl/fvc%= -+ % , and in copd patients, fev~%pred= __. and fevi/fvc%= --. %. results: values are shown as mean-..+-sd in the following a su~ve~ os literature sources p~oves that t~aditlona], i.e. medicinal medication and physiothe~apeutic methods os t~eatment often p~ove to be insufficientl~ effective both currently and in the ~emote future. the goal of this study was to investigate the efficacy os t~eatment of b~onchial asti~ma patients by means os speleo-and artificial sp~ay therapy. speleotherapy t~eatment was conducted in the conditions os mic~oclimate os salt mine in solotvino hospital. a~tis sp~ay the-~apy was conducted by means os a self-made device. ou~ method is based on the p~inci-~ le os using the majo~ facto~ of speleo-he~apy -highly dispe~sed sp~ay s sodium chloride. the obtained ~esults ~e~e analyzed in five g~adations. at the end os the speleothe~apy improvement and considerable improvement was observed in , ~ os patients; inconsiderable improvement -in , ~ os patients. having evaluated the e~s os t~eatment using a~tis sp~ay therapy the indices a~e , h and , ~ ~espectively. remote ~esults of t~eatment a~e an important index os t~eatment, the ~esult os ~hich ~e~e studied by means s a ~uestionnaive-method. patients ~ho had been t~eated by speleothe~apy mo~e f~eguently ~e-po~ted a ~elapse in disease ust afte~ the course o~ t~eatment ( , h). ho~eve~, in a ]ate~ phase the ~emission ~ould last ]on-~e~ (s months in , ~ os patients, till one yea~ in ~ ~). in , ~ os patients who passed the co~se os a~tificial sp~ay therapy a ~elapse was ~egiste~ed immediately as the co~se os t~eatment. then thei~ condition stabilized ~hile in , ~ os patients a period os ~emission lasted s ha]s a yea~. , ~ of patients dida't ~epo~t a ~elapse of the disease du~in~ one yea~. evangelismos hospital, critical care department, athens, greece method#: mechanically ventilated patients ( copd, ards, other pulmonary diseases) were studied in two phases: ) during the acute phase of respiratory failure; ) during recovery - days later. we measured mip and monitored the pattern of breathing while the patients were breathing spontaneously through the respirator (pressure support mode with - cmh ) until either the point they were unable to sustain spontaneous breathing (sb) any longer (phase ) or for two hours when they could sustain sb indefinitely (phase ). subsequently the patients were sedated, paralyzed and mechanically ventilated. then we simulated the pattern of sb at the end of the sb trial by manipulating the variables of the ventilator and assessed respiratory mechanics b y the end-inspiratory and end-expiratory occlusion technique. . during recovery, a combination of reduced inspiratory load and increased venfilatory capability makes a patient previously unable to sustain sb to breathe spontaneously. . inspiratory load is reduced during recovery, mainly because both intrinsic peep and breathing frequency are diminished. obiectives: although elevated concentrations of a few cytokines have been shown to be present in the bronchoalveolar lavage (bal) fluid (balf) of patients with the adult (acute) respiratory distress syndrome (ards), the pethogenesis of ards is largely unknown. leukemia inhibitory factor (lif), a growth factor recently recognised as a polyfunctional cytokine integrated in cytokine networks was measured in unconcentrated balf of patients from different patient groups. methods: lif was measured in balf by means of a specific and sensitive elisa (detection limit pg/ml)in balf (lavage of x ml in the right middle lobe). results: lif was not detected in the balf of healthy control patients and in only one ( pg/ml) out of patients at risk for ards (after cadiopulmonary bypass surgery) who underwent bal h after the end of the extracorporeal circulation. high and detectable levels were found in the unconcentrated balf of out of patients with full-blown ards ( + , mean + sem, range - pg/ml). there was a good correlation between the level of lif in the balf and a number of markers of inflammation: neutrophils/ml (r: . , p= . ), albumin ( r: . , p= . ) and protein level (r: . , p= . ). conclusions:the biological role of lif in these balfs is not readily explained by its currently known actions and it is unkwon whether lif contributes to or is a response to local tissue damage. our results indicate that this cytokine with lots of interesting _functions is a pert of the inflammatory cytokine cascade in ards. background and obiective : we recently demonstrated that cisapride -a new prokinetic drug -enhanced enteral feeding in a heter genoas group of ventilated icu patients by significantly accelerating their gastric clearance (crit care meal, ; : - ) . it remains unknown, however, whether certain subgroups of patients might benefit more from adding cisapfide to their enteral nutrition regimen than others. patients with chronic obstructive pulmonary disease (copd) might represent such a subgroup since their illness and its specific treatment put them at risk for gastric emptying disorders. design and setting : prospective, consecutive sample study in an adult medical intensive care unit in a university hospital. patients : mechanically ventilated and hemodynamically stable copd patients. interventions : gastric emptying was evaluated by bedside scintigraphy and expressed as the time at which % of a tcg~-labelled test meal was eliminated from the stomach (t / ). baseline data (do) were recorded after enteral nutrition reached to ml daily. scintigraphic measurements were repeated days after cisapride ( ml orally, q.i.d) had been added to this regimen (d ). patients were considered cisapride responders when gastric clearance improved by more than % from baseline. results : normal values for the test meal and for scintigraphic acquisitions obtained in the supine position were found to be + min. in healthy volunteers (crit care med, ; : - ) . five patients responded to cisapride (t / : + rain vs. + min at do and d , respectively) and five did not (t / : + min vs. _+ rain at do and d , respectively). in contrast with non-responders, all five responders had clinically significant maldigestion at baseline (excessive (> ml) gastric residues, vomiting (> times/day and abdominal distension) which disappeared in of them after the administration of cisapride. conclusion : copd patients who tolerate enteral nutrition well have basal gastric emptying times which are comparable with those of healthy volunteers and are not influenced by cisapride. however, cisapride treatment provides both scintigraphic and clinical improvement in those copd patients who exhibit clinically obvious gastric emptying disorders. cernv v., dostal p., zivny p., zabka l. dept. of anesth. and critical care, charles university, faculty hospital, i-irade~ kralove , czech republic objective: the aim of the study was to evaluate the effect of early entera nutrition started within hours of injury on the incidence of multiple orgar failure (mof) in trauma patients requiring vantilatory support. methods: after institutional approval patients were enrolled in the study enteral feeding was begun within hours of injury in trauma patients (en group) admitted to icu. nasuenteric tube was placed as soon as possible after admission into the distal duodenum under endoscopy. additional parenteral nutrition was used to meet patients energy and protein requirements. the control group (pn) consisted of patients fed during this period paretuerally. severity score apache ii, trauma score, cumulative balance of nitrogen (g), incidence of mof (three and more organs) and length of ventilatury support (days) were calculated. values are expressed as mean + sd. results: tab introduction : parenteral nutrition (pn) is an important aspect in the optimal treatment of patients on gastroenterology or intensive care. the aim of this bi-center study in patients has been to assess tolerence and efficacy of a new protein-lipid mixture for pn from a simple preparation. patients and m~hods : patients were selected in two hospitals (tenon and saint-lazare, paris) and were divided into two groups : group a (gastroenterology~ l short bowel syndrome) and group b (intensive care, surgical patients). all patients likely to require pig for a period of days (group a) or days (group b) were studied. the pn regimens administered were the following : combination with g of mct/lct fat emulsion end , g of nitrogen, in liter end glucose requirements were met by imfizsion of l liter of glucose - % via a "y " connection. lipid thus provided % of the non introgen calories. total daily calorie intake was to ] kced. this study monitored, before and at the end of infusions, the sennn albumin (alb), preaiburtun (prealb), triglycendes (tg), cholesterol (cs), and the serum ammotransferases (sgot and sgpt) end alkaline phosphatase (alp) activities. statistical significances were calculated using the wilcoxon-tost. introduction: many cu patients present a catabolic illness in response to inflammation and infection, characterized by a rapid loss in skeletal-muscle mass despite optimal nutritional support. growth hormone (gh) is responsible for a rise of lipolysis, enhancing the energetic balance, and of protein synthesis. recombinant human gh (rhgh) is nowaday available for clinical use, but its cost is very high. therefore, rhgh should only be prescribed to icu patients when its efficacy can reasonably be anticipated (ie. when the patients are catabolic or stressed, but in order to avoid overprescription for unstressed patients and for those who are overly catabolic). hence, we, as others, recently demonstrated that rhgh had no favorable effect in highly stressed icu patients. objective: to detect on a clinical basis, low (ls), mild (ms) and severe stress (ss) states in icu patients and validate this clinical judgement by objective metabolic mesurements, in order to select early those icu patients potentially able to benefit from rhgh therapy. methods: consecutive icu patients were prospectively stratified as ls, ms and ss by two experienced icu senior consultants (temperature; agitation; heart rate; arterial blood pressure; presence of an infection; respiratory rate; exogenous catecholamines). anabolic (insulin, igf- , gh) and catabolic (cortisol, ghicagon) hormones, and nitrogen balance were determined for each patient within hours after admission in the icu. metabolic and clinical data were then compared. the clinical stress states determined by icu physicians correlate with an objective metabolic assessment. therefore, the patients who will more likely benefit from adjuvant rhgh therapy can be detected simply and early. a prospective study on rhgh therapy in ms icu patients is in progress. berger mm md , chiolero r md , pannatier a phd , berger l , cayeux c , voirol p , hurni m md . surgical icu, pharmacy, and cardiac surgery, chu vaudois, ch-iotl lausanne, switzerland objective. nutrition of the compromised cardiac surgical patient is challenging. numerous factors influence the gastrointestinal (gi) absorption function, among which gut perfusion, which depends largely on the systemic hemodynamic status. patients in hemodynamic failure are prone to organ failure, and may benefit from an early jejunal feeding. the study was designed to assess the absorption function after cardiac surgery in patients with adequate and altered hemodynamic status, using paracetamol as tracer of gi absorption. methods. after cardiac surgery, patients, aged _+ years (mean_+sd) were assigned to groups (anaesthesia: fentanyl gg/kg + midazolam): group (n= ): reference group, with normal hemodynamic status, easy recovery. group ('n= ): patients in low output syndrome, cardiac index < . i/m on day (d ) after surgery, requiring prolonged intensive care, mechanical ventilation + nutritional support. paracetamol g, was given intragastrically on d + d : plasma levels measured (h.p.l.c), at administration (to), t - - - - - and rain. hemodynamic status assessed with pulmonary artery catheter. healthy subjects served as controls. results. compared to healthy controls, absorption was strongly reduced on d in all patients (no difference between groups). on d , peak paracetamol level was significantly lower in group (low cardiac output): in group the area under the curve on d and d were similar. there was a large inter-patient variability, reflecting the hemodynamic status. conclusion. gi absorption was decreased on d in all patients, and reverted to normal between d and d in case of normal cardiac function, but not in case of low output syndrome. the decrease on d can be attributed to fentanyl, known to slow down the gi transit. in patients with cardiac failure, correction of altered absorption was correlated with the hemodynamic status, suggesting that gi absorption is dependent on adequate splanchnic perfusion. the aim of the work was to define specific significance and evaluate efficiency of enteral component of infusion therapy in the intensive care of gastroenterotogic patients of surgical profile with pyo-septic complecations. there were used the methods of radial diagnostics and polyelectrography; the laboratory control on oxygen-transporting function, volumetric and hemodynamic state, changes in metabolic, hormonal and immunologic status was conducted. from january, [ till november, there was carried out the randomized study of patients with general purulent peritonitis; among them persons constituted the control group and -the main one. in the main g~oup the intestinal lavage, enterosorption, enteral introduction of nutrient solutions with gradual turn to enteral nutrition by equalized mixture "ovolaet" were started from the first hours after operation. the data obtained allowed to define the specifity of the program of artificial medical nutrition in the group of examined patients, based on necessity of individual selection of media for enteral introduction depending on the stages of intestinal insufficiency syndrome. it was shown that inclusion of enteral component into the program of infusion therapy during early periods stabilized circulation in the regime of moderate hyperdynamia, considerably decreases the deficiency of circulating blood volume, normalizes the values of oxygen transport, consumption an}d extraction, provides the optimal level of mycardial adaptive possibilities without tension of its compensatory functions and pulmonary circulation overload. due to combined application of parenteral and enteral nutrition the metabolic processes are shifted towards anabolism. this is supported by decrease to normal values in the contents of blood aggresive hormones (acth,hydrocortisone) and increase in somatotrophic hormone. the complete parenteral-andenteral nutrition influences positively on restoration of cellular and tumoral immunity, activates the factors of organism nonspecific protection and recovery from immunodepression, prevents the development of immunodeficiency. impact tm vs control. s atkinson, n maynard, r grover, e sieffert, r mason, m smithies, d bihari departments of surgery and intensive care, guy's hospital, london, u.k objectives: comparison of the effect of an immunonutrient enteral feed versus a control on the outcome of a mixed intensive care unit (icu) population. methods: admissions to this multidisciplinary adu)t icu thought likely to stay more than three days and with tube access to the gi tract ~r randomised to receive either impact tm, a feed with supplemental arginine, dietary nucleotides and omega- fatty acids, or an isocaloric and isonitrogenous control feed. study end points included mortality and icu stay. approval was obtained from the hospital ethics committee. rosults: patients were entered into the trial. the two groups were well matched for age, sex, and admission apache ii with an overall mean admission risk of death of . (std. dev. -+ . ). on an intention to treat basis, there was a no significant difference in icu mortality, icu stay or standardised mortality ratio (s.m.r.) between the two groups (see table) . similarly, there were no differences after stratification for patients receiving or more litres of feed. conclusion: there is no evidence of an effect of impact@, an enteral immunonutrient feed, on pre-determined end-points (icu mortality, icu stay or standardised mortality ratio) in a mixed intensive care unit population over that of an isocaloric, isonitrogenous control feed. objeeflves: evaluate changes of blood laatate levels according to patient medical status after cvvhd initj,~ion using dialysate solution containing lactate. method: review of medioal records of consecutive patients ~eated by cvvhd (dialysate solution hmnosol lg , hospal,uk, lactate concentration retool/l). date obtained hr before and - hrs at~er cvvhd initiation were analysed. results: all data are presented as mean + sem. in one patient, pre end post filter lactate levds were measured during standard cvvhd setting (blood flow ml/mlu, dialysate solution flow i /hr), and approximate daily lactate flux into the patient was calculated to be as high as mmol/d. lactate leveh measured after cvvhd initiation increased significenfly compared to baseline levels ( . + . axtd . + . ,respectively; p< . ,paired t-test). when patiente with increased basal lactete (~- ) were compared to paliente with normal basal values (n= ), no difference in laotete increase was fmmd (p= . , manova). patiente with severe liver dysfunction ( points in mop scomlg, n= ) had higher basal laotate levels than patiente with normal or slightly abnormal liver teste ( or point in mof scoring, n=ll), rite values being . + . and . + . , respectively (p< . , student t-test). increase in blood lactate did not differ between these two groups after cvvhd was stetted (p= . , manova). in pafiente with invasive hemedynamio mo~, no oorrelation batween changes in lactate levels and eitlm" changes in oxygen ddivery (t =o.ol; p--o. ) or oxygen consumption (reversed fie, k) (r -q).o ;p-- . ) were found after cvvhd initiation. conclusion: blood lactate increases on cvvhd with dialysate soh~on rich in lactate. this increase is predominantly caused by influx of lactate into the blood via the filter end does not seem to depend on the liver fimotion and/or oxygen metabolism changes. objectives: the study was designed in order to determine the effect on plasmatic proteins, of two types of aminoacids solutions of parenteral nutrition (pn) adapted to stress, having different concentration of branched chain aminoacids (bcaa), when applying to politraumatized critical patients. methods: a prospective study was performed using a randomized double blind design of polytraumafized patients, split in two groups of ten patients each, with mean ages of _+ an -+ years. due to their condition, all patients required p.n. for at least days. both groups were subjected to isocalorie and isonitrogenous solutions ( ci/kg/ day and . g of nitrogen/ks/day), varying only in the concentration of bcaa; solution a having a % concentration and solution b %. blood samples determinations during days , , , after the beginning of treatment with p.n. were total proteins., albumin, trandferrine, protein binding retinol; prealbumine and fibronectine. the anova test (one and two way) was used to compare the values between the two groups. results: the administration of solution a, showed statistically significant increases in the determinations of the values of protein binding retino] (p < . ) and prealbumin (p < . ). no significant increases were observed in the values of total protein, albumin, transferrine and fibronectin. solution b produced statistically significant increases only in the values of total proteins (p < . ). the remaining proteins did not changed from their control values during the whole period of pn administration. comparing both groups, no statistically significant differences were observed related to the type of diet. nevertheless, differences were found in total proteins, albumin, protein binding retinoi, fibronectin (p< . ) and prealbumin (p < . ) in relation to the time course of pn therapy. only the albumin values showed significant differences (p < . ) when considering the interaction of both the type of diet and the time course of pn. conclusions: . solutions of pn adapted to stress, can maintain the control values of slow turnover proteins and improve the values of rapid turnover proteins. . no significant differences on plasma proteins were found between the two solutions having % or % concentration of branched chain aminoaeids. &determination of rapid turnover proteins does not seems useful for discriminating different solutions of bcaa during pn. obiectives; the hormonal changes in the post-traumatic situation often leads to an elevated blood glucose and a negative nitrogen balance. to reduce the elevated glucose production by aminoacids the apprication of xylitol may be an alternative energy source. in a double-blind randomized study we investigated the effects of a xylitol/glucose solution (group a: aminoacids g/i; glucose/xylito g/ g/l) on metabolism and particularly on pancreatic and liver enzymes compared to a glucose based nutrition solution regimen (group b: aminoacids g/i; glucose g/i). methods: the clinical trial was carried out after the approval by the local ethical committee on patients with severe brain injury. there was no difference in body mass index bmi (group a: . +/- . kg/m and group b: . +/- . kg/m=), age, and sex. daily individual energy expenditure was measured by indirect calorimetry (deltetrac "~). nutrition was started - hours after trauma or surgery with carbohydrates and aminoacids. fat was added h after nutrition had started. to analyze the effects on pancreatic and liver enzymes we investigated the following parameters for days: blood gtucose, serum lipase, serum amylase, asat, alat, ~gt, ap, and serum cholinesterase (che). results: due to the daily indirect calorimetric measurements energy requirements were satisfied. there was no difference in blood glucose concentration and cumulative nitrogen balance between the two groups. neither were there any significant changes in asat, alat, ap, and che for days in both groups. serum tipase steadily rose to lull in group a and . lull in group b, respectively. conclusions: there was no measurable influence of either nutrition solution on liver enzymes. the xylitol/glucose nutrition regimen does not have any advantage over the glucose based nutrition solution concerning blood glucose level or nitrogen balance. the elevation of serum lipase to a -fold level in either group needs further investigation on trauma patients. the effects of fat emulsions in lung function, particularly in lungdamaged patients, have been attributed to alterations in pulmonary vascular tone caused by eicosanoid production modificatione. as the eicosanoid production may depend on the fatty acid profiles of the intravenous fat emulsion, haemodynamic, pulmonary gas exchange and plasma levels of prostanoids were investigated in acute respiratory distress syndrome (ards) patients, during different intravenous lipid emulsions (providing different prostanoid precursors). we studied in a randomized double-blind design groups (n= each) with ards. group i (lct) received a fat emulsion with long chain triglycerids (lct- %), group ii (mct) an emulsion containing a mixture of medium and long chain triglycerids (mct/lct / - %) and group iii placebo (control), during h ( mg/kg/min each). we measured before, at the end of h infusion, and h after the end of the infusion: lipaemia, arterial and venous blood gases, pulmonary and systemic haemodynamics, and plasmatic levels (arterial and in mixed venous sample) of eicosanoids (txb=, -keto pgf~,, and ltb ). at the end of the fat emulsion, groups (i and il) to , • to , • mmol/i), the paoz/fio z remained unchanged in the three groups; no changes in intrapulmonary shunt (qs/qt) were shown; neither in the mean pulmonary artery pressure. in contrast, only in the lct group: cardiac output and oxygen consumption increased significantly ( . % and %) (p< . ). eicosanoids were increased at baseline compared to reference values (p< , ). a decrease (p<o, l in the arterio-venous difference of the vasodilatador prostanoid ( -keto pgf~=) was shown in lct group. our results indicate that fat emulsions in ards patient do not influence pulmonary gas exchange, provided that the perfusion rate were keept at mg/kg/min. the present study was designed to evaluate the metabolic changes of a carbohydrate-based diet versus a fat-based diet on oxidation rate of substrates and energy muscle metabolism in patients with an acute exacerbation of chronic obstructive lung disease. patients were mechanically ventilated with a volume-cycled respirator. after an overnight fast, patients were randomnly treated with a continuous enteral feeding over a nasogastrie tube with a carbohydrate/fat ratio of / in group i (n= ) , and a carbohydrate/fat ratio of / in group i] (n = ) during consecutive days. indirect calorimetry was set at baseline and hours later the enteral feeding was started. muscular quadriceps biopsy was performed on baseline and on day of enteral feeding. urine was collected during hours and was used to measure h urea nitrogen production. the caloric intake was set according to the measured resting energy expenditure. respiratory gas exchange rate were measured using a computerized open-circuit indirect calorimeter. quadficeps femoral muscle samples were obtained by muscular biopsy after local anesthesia. analyses of glycogen, glucose -phosphate, lactate, phosphocreatine and adenosine triphosphate (atp) and enzymes (glycogen synthase and glycogen phosphorylase) were determined. after h of nutrition patients in group i showed an increase in carbohydrate oxidation (from . % to . %, p= . ), and in group ii a decrease in protein oxidation (from % to %, p= . ). after days of enteral feeding a tendency to increase in glycogen concentration (group i, p= . ; and group ii,p= . ) was observed. while patients in group i showed a tendency (p= . ) to decrease glycogen phosphorylase, patients in group ii maintained these enzymatic levels. the increased in glycogen was correlated in group li with degradation enzyme (p = . ). in group i, the pao /fio ratio increased after days of treatment (from . to . ; p= . ), but no changes in days of mechanically ventilation, length of stay in icu, or mortality rate was evidenced between groups. it is concluded that the oxidation rate of substrates used for energy production varies according to the caloric sources administered. with nutritional therapy muscle glycogen concentration increases in both diets, with different enzymatic influence. more studies are warranted to further assess the clinical implications of the different pathophysiologic behavior of the two diets. under certain experimental and human conditions (radiation and/or thermal injury) the gi mucosa is unable to perform this protective function and could play an important role in the pathophysiology of the syndrome of multiple organ failure (smof). the objective of the present multicenter study was to know the gi mucosal permeability in critically ill patients and the relationship with their outcome. the method used to assess the integrity of the gi mucosal barrier measured mucosal permeability to various hydrophilic compounds. specifically, we measured the urinary excretion ratio (uer) of two sugars (lactulose and mannitol) that had been previously administered through a nasogastric tube. urinary excretion rate was measured in healthy humans (control) and in patients admitted to the intensive care unit (icu) at days , and . the apache ii of the patients studied was _+ . there was an increase of uer in the critically ill patients compared with controls (o. _+ . vs . _+ . ) (p< . ). in contrast, no changes in uer between days , and were observed ( . -+ . . significant changes were also established in the different groups: major and minor surgery, general and epidural anaesthesia , transfused and non transfused patients except for iron and ferritin plasma levels which didn't change significantly in patients who had received blood. a positive significant correlation was established between crp and ferritin (r= . ) for patients under general anaesthesia, but not on epidural, regardless of the type of surgery. conclusions: iron and transferrin plasma levels fell acutely in surgical patients while ferritin and crp rose. transfusion implied an acute iron load.the established correlation between cpr and ferritin in patients on general anaesthesia suggests that ferritin behave as an acute phase reactant in that setting, while epidural anaesthesia may ameliorate the inflammatory response. objectives: to analize the effect of gastrointestinal complicacions (gic) related to the enteral nutrition (en) in the real volume of diet administered to icu adult patients. a prospective multicenter study was designed (comgine study) in wich en application, gic definition and his management were defined by collaborative consensus.patients treated with en in one month pedod were included. in each case, daily volume of diet prescribed (pv) and administered (av) was recorded and the volume ratio calculated (vr=pvxl /av). patients were divided for days of en according to the presence (group ) or absence (group ) of gic (abdominal distension, increase of gastdc residuals,vomits or regurgitation, diarrhea,constipation and bronchoaspiration). differences between groups were analized by anova and mann-whitney u test with p< . for statistical significance. (vr%) group (vr%) tolerance to the enteral nutrition (en) has been related to the severity of illness in icu patients. the aim of this study was to evaluate this relationship. methods. a prospective, multicenter, study was performed (comgine study) in wich en application and related gastrointestinal complications (gic) were defined by collaborative consensus. adult icu patients treated with en in one month pedod were included. gic were classified as: ) abdominal distension (abd), ) increase of gastdc residuals (igr), ) vomits (vom), ) diet regurgitation (reg), ) diarrhea (dia) and ) constipation (con). patients were divided in two groups: group a: patients with gic dudng their evolution. group b: patients without gic. differences between groups were analized for apache ii admission score or evolutive variables ( carbon dioxide production is a major determent of work of breathing. increase in co production during nutritional support may precipitate ventilatory failure and difficulty in weaning from mechanical ventilation. in the present study, co output was calculated while passive mechanically ventilated patient were fed with different amount of calories and different proportion of protein, carbohydrate and fat. four clinical stable and mechanically ventilated patients were studied. carbon dioxide was calculated while patients were paralyzed, sedated and mechanically ventilated. six nutritional regimens were used: a) no calories, b) t gr glucose/ h, c) calories equal to rest energy expenditure in special formula with low carbohydrates and high fat (pulmocare) d) calories equal to rest energy expenditure in standard formula (nutdson) e) calories double to rest energy expenditure in standard formula (nutrison) and f) calories equal to rest energy expenditure parenterel (tpn). carbon dioxide output was low while no calories and/or only gr/ h glucose was provided, the mean values of vco output were _+_ and !-_ ml/min respectively. there was no difference in vco output between with low carbohydrates and high fat regimen and standard regimen, mean values were t . -+ and _+ respectively.the high calories regimen and tpn resulted in higher vco output, mean values _+ and • respectively. we conclude that the special with low carbohydrates and high fat regimen did not reduce vco output, in the contrary, high calories intake as well as tpn increased vco output under tested conditions. klouche k., cristol j.p., vela c., canaud b., b raud j.j. m tabolic intensive care unit and nephrology department. lapeyronie hospital. montpeuier france. predictive factors for rhabdomyolysis (rh) -induced acute renal failure (arf) were studied in a retrospective study from january to january . patients (pts) (male: , female:lo; mean age: + y.o.) were admitted with rh defined as cpk> iu/ . etiologies were: traumatic and ischaemic , infectious , toxic , excess activity . factors studied were: simplified acute physiologic score (saps: . + . ), organ systemic failure (osf: . _-!- . ), diagnosis delay (d: +_ h), clinical parameters (sepsis, dehydration), blood chemistry data (cpk, bun, creatinine, potassium, phosphorus, calcium, proteins, hematocrit) and urinary ph. severity of rh was estimated by ward score determined according to phosphorus, albumin, potassium, cpk, dehydration and sepsis. urea appearance rate (uar) and creatinine index (ci*) were determined over a hours period. arf was observed in pts. in non-arf and arf groups respectively, saps ( . _+ . vs . + . ), deshydratation ( vs ), sepsis ( vs ), phosphorus ( . + . vs . -+ . ), calcium ( . + . vs . _+ . ), ward score ( _+ . vs . + . ) were significantly different. however, no significance was observed in uar ( -+ vs -+ ) and ci ( _+ vs _+ ). patients required hemodialysis (hd) ( : sessions) and remained dialysis free. only osf ( . _+ . vs . -+ . ), ward score ( . _-/- . vs . _+ . ) and ci ( +_ vs -+ ) appeared significantly higher in pts requiring hd. pts died from associated disease. all patients suffering from arf recovered a normal renal function. we confwmed that an elevated ward score (over ) is a good predictive index of arf. in addition we found that ci is a severity factor for arf requiring hd. thus, patients suffering for rh with elevated ward score and ci, have a fair chance of dialysis and should be treated more intensively. * ci (expressed in mg/kg) = (car + feces creatinine) / weight. where car: creatinine appearance rate; feces cr~t..= mean plasmatic creatinine x . . tr~er k., cetin t.e., tugtekin i., georgieff m., ensinger h. universit~tsklinik flir an~sthesiologie, uim, germany introduction: endogenous as well as exogenous adrenergic agonists have a profound effect on carbohydrate metabolism in human critical illness. in this study the effects of noradrenaline (nor) and dobutamine (dob) on carbohydrate metabolism during a hr infusion were investigated. methods: after approval by the local ethic committee healthy volunteers were studied. hepatic glucose production (hgp [mg/kg/min]), using , -d glucose as stable isotope tracer, as well as plasma concentrations of glucose (glc [mmol/i]) and lactate (lac [mmol/i]) were measured prior and during infusion of nor ( . pg/kg/min) and dob ( pg/kg/min). blood samples were drawn before and during the agonist infusion. results: no major changes in insulin and gtucagon plasma concentrations could be found during the study period. ::i:::: :iiiii~ ~ i ::i: ~:: : :: i:ii. mean-+sd are shown. # p< . , anova for repeated measurments. conclusions: the effect of nor on hgp and glc were smaller as compared to adrenaline (i) with a similar time course. in contrast to the effects of adrenaline and nor, dob had a different effect on carbohydrate metabolism: a decrease in hcp and glc, which is uncommon for a / -adrenoceptor agonist. since hgp is an energy consuming process that might deteriorate hepatic oxygen balance in critical illness, the differential effects of adrenergic agonists may be of importance and need further clarification. the nutritional insufficiency often accompanies post-operative hypercaloric states, inanition, serious infections and weakening chronic illnesses. that is why the early nutritional support, sufficient and appropriate for each individual base, is a fundamental component of intensive care unit as an indispensable factor for recovery. per this reason, our unit, developed a software for the implementation and nutritional control of t~e assisted patients. this software is incorporated is an expert system called ~i~su, designed and developed by the computational division of our unit. this system arrives to inferred diagnoses such as : respiratory, hepatic, renal(with and without dialysis) dysfunctions, pancreatitis, ards, decrease of consciousness, diabetes. according to these data objectives: to compare the effect of short term enteral feeding versus parenteral nutrition, when a isonitrogenous and isocaloric feeding solution is administered by either mute. methods: in a prospective controlled clinical trial patients were studied; all exhibited moderate degree of malnutrition, normal liver and kidneys, and a functi ning gastrointestinal tract. the patients were randomized to receive a free amino acid and small peptide diet ( patients) or an isonitrogenous isocaloric parenteral support (tpn) ( patients) (total energy: kcal, nitrogen: . g, carbohydrates: g, fat: g, n/non protein calories: / ) at least for days. results: there were no significant changes in anthropometric parameters within either group. nitrogen equilibrium was aqhieved by day in the tpn group and by day in the enteral group ( . % of the enterally fed patients and % of the tpn patients maintained in positive balance the day of the study). there were no significant changes in serum albumin within either group. serum level of transferrin reached a significant increase in both groups (p= . ). thyroxine-binding prealbnmin rose significantly in both groups as well (p= . and . respectively). statistically significant rises in lymphocyte counts (p= . and . respectively), in levels of c (p= . and . ) respectively), iga (p= . ), igg (p= . and . respectively) and igm (p= . ) occurred in either treatment group. there was a high incidence of negative skin tests at the start of the study in the enteral group ( . %) and the tpn group ( %). by the end of the study the incidence of negative responsiveness was . % and . % respectively. despite maintenance of similar glucose levels in both groups, tpn led to significantly higher serum insulin levels. the serum insulin increased almost linearly over the study period and eventually prevented fat mobilization and lipolysis, so that free fatty acid levels had fallen significantly. a significant elevation of the liver enzymes over the study period occurred in . % of the tpn group, but not in the enterany fed patients. conclusions: the present findings provide no evidence that enteral diets containing free amino acids and small peptides, as their nitrogen sources, are in any way inferior to isonitrogenous isoealoric regimes parenterally given. aim: the aim of this study is to describe and explore the expectations of the functions of the critical care nurse to enable the formulation of guidelines for the scope of practice for the critical care nurse with a south african context, methods: phase i was to determine the expectations of the critical care nurse, the nursing service managers and the doctors with regard to the functions of the critical care nurse. a focus group interview was held with a group of experts in the field of critical care. the results were used to compile a questionnaire. this questionnaire was sent to the critical care nurses, the nursing service managers and the doctors in south africa for completion. from these results the functions of the critical care nurse were determined. phase ii was to formulate guidelines for the scope of practice for the critical care nurse within a south african context. through usage of the date (phase i) the scope of practice was formulated. guidelines were formulated for the practise, education and research regarding the limitations of the professional-ethical authoration and the implementation of the scope of practice for the critical care nurse. objectives : high output gastric aspirates arc occasionally observed during fasting in critically ill paticnts, preventing any attempt of feeding via the enteral route. although these patients are often said to suffer from "gastroparesia", the motor correlates of this condition arc lurgcly unknown. in this stud?', wc recorded the gastrointestinal motility of critically ill patients with abundant (> ml/ hours) fasting gastric aspirates. methods : antral ( sites separated each other from . cm), duodenal ( site) and jejunal ( site) contractions were recorded simultaneously by ~eans of a multihimen tube assembly positioned trader fluoroscopic control (perfused catheter technique). tracings from prolonged recordings were obtained on a multichannel recorder ( a recorder, hewlett-packard) then anal) ,ed visually, with a special attention for the following abnormalities which are characteristic of intcstinal pseudoobstmctiou: l) absence or aberrant propagation of the migrating motor complex (mmc), ) presence of bursts (> min) of nonpropagated phasic pressure and ) presence of sustained (> min) uncnardinate pressure activity. patients with a volume of gastric aspirates of • (sd) [median ml/ hrs were investigated for - [median minutes. results : only one patient had no detectable motor abnormality. mmcs were either absent (n= ) or migrated abnormally (retrograde propagation : n= ; retrograde and stationnary : n= ) in pts. bursts of nonpropagated phasic pressure activity were present in the duodenum in pts and sustained uncoordinate pressure activity was found in pts. additional abnormalities included episodes of prominent pyloric activity. (n=l) and sustained antral pressure activity (n= }. conclusion : critically ill patients with large volume of gastric aspirates have manometric evidence of intestinal pseudoobstruction. prokinetic therapy in these patients should thus focus not only on enhancing gastric motility, but also on restoring a normal propagative contractile activity in the intestine. this prospective, open-label, randomized placebo-controlled study included patients with hypokalemia in whom rapid potassium replacement ( meq kci in h) was performed: patients received mg sulfate ( g in hours) and patients received a corresponding saline infusion. measurements were made at time , + , + and + hours results: k levels increased more in mg treated patients than in the patients who received saline infusion at time and h (p < . -students-newman-keuls). (table ). introduction. dual lumen uaso-gastrojcjunal tubes are a major ads'ance in nutritional therapy of mechanically ventilated critically ill patients since the " authorizc jejunal feeding with concurrent gastric decompression, there,, reducing the risk for aspiration. unfortunately, placcmem of these tubes in the jejunum regularly dictates to resort to endoscopy in order to facilitate pyloric intubation. recently, the remarkable gastrokinetic properties of the well known macrolide antibiotic er}lhromycin have been demonstrated in gastroparetic critically ill patients . aim. in the presem stu~,, we evaluated the feasibility of placing dual lumen naso-gastrojcjunal feeding tubes at the bedside without endoscopy, using edthromycin to help iranspy'loric migration of the tube under fluoroscopic control. methnd each patient admitted in our icu during a months period and requiring artificial ventilation and enteral nutrition for a period of at least days was included in the study.. after inserting the tube (stayput| sandoz, usa) in the gastric anmnn, e.rythromycin ( rag) was aduunistored intravenously, to help fluoroscopic positioning of the tube into the jejunum. the total duration of the procedure (from nasal intabatiun to jejunal placement), as well as the duration of ftuoroscopy were recorded in each patient. results. patients (male/female : / : mean age : . + . years; mean apacbell score : .t • . ) wore enrolled into the study.the procedure was performed within the dab,s following institution of mechanical ventilation. jejunal access was obtained in all patients without resort to enduscopy in , • . min.(total duration of the procedure). mean duration of fluoroscopy was . + . rain. conclusion. we conclude that placement of dual lmnen naso-gastrojejunal tubes can be obtained in mechanically ventilated critically ill patients without resort to endoscopy., provided that e rythromycin is used as gastrokinetic agent to help pyloric intubation. the following ad and dis parameters were considered in all patients: -mid arm circumference, triceps skinfold thickness, serum transferrin, albumine and lymphoeites and urinary creatinine/height index. patients whose results were bellow % of normal values in or more of the above criteria were considered undernourished (und).statistical analysis was performed using % analysis.statistical significance was established at p<o.o . results: a total of patients( female, male) -with a mortality rate (~) of , % -were studied, aged -+ years and a median ]enght of stay of days. -nourished (nou) at ad and at dis - ; ~ %; -nou at ad and und at dis - ; ) , % ; -und at ad and und at dis - ; ~ . %; -und at ad and nou at dis - ; ~ , %. we observed a p< . when we compared groups and (p= . ), and groups and (p= . ). variation in nutritional status and longht of stay: -nou at ad and nou at dis = > median lenght of stay days; und at ad and und at dis = > median lengbt of stay days; nutritional status and age at admission: -age > = years : nou ( ) , und ( ) -age < years: nou ( ), und ( ) nutritional status and age at discharge: -age > = years : nou ( ) , und ( ) -age < years: nou ( ), und ( ) we observed a p<o. when we compared groups and (p=o. ) and groups and (p = . ) conclusion: such study permits to conclude that most of our patients ( . %), staying in icu for more than days, were und, namely the elder. we observed that this kind ef patient had a longer median length of stay in icu, associated with higher mortality rate. in conclusion, the nutritional management is an essential element in suportive care of critical)y ill patients. ohiectives: sirs is associated with hypercataholisnl and resistance to nutritional support, despite raised circu&ting levels of growth hormone and insulin. serum igf- levels however are low; thercti~re rhigf-i administration might produce nsefnl anabolic effects. the pharmacokinetics of exogenously administration rhlge-i in such patients are likely to differ from that seen in the less seriously ill due to changes in circulating blood volume, increased capillary permeability, poor nutritional stares, and alterations in binding proteins. the ol jective of this study was to determine the clearance, apparent vohnne (if distribution (vd), time to peak concentration (tmax) and elimination half-like (tia) of a single subctkaneous il~ieetion of rhlgf-i in patients with sirs on the intensive care unit (icu). methods: icu patients with sirs were entered into the study, which had been approved by the ethics comjnittee. in each patient baseline hlood samples for circulating gf-i were obtained over a hour period, prior to il!iection of p.g/kg of rhlgf- subcutaneously. a further l samples were taken fi'om each subject over the next hours. circulating ige-i was measured in serum at each time point by radioimmtme assay, and the area under the curve tbllowing administration of rhlgf-i was derived tbr individual patients fixm~ baseline a~!justed igf-i levels. clearance values were caietdated by dividing the administered dose of rh[ge-[ by the total area under the etnve. vd and tv were calculated by regression analysis of the terminal part nf the log sertnn concentration time profiles. results: results are expressed as median (range). age ( - ) years, apache ii score ( - ), and length of icu stay ( - ) days. baseiine circulating igf- levels were low ( < - ) ng/ml reaching a peak of only ( < - ) ng/ml. of the patients had basal levels predmnhaantly below the inwel-limit of detection of the assay, and showed no appreciable rise in serum igf-[ levels tbllowing rhigf-i injection. parmacokinetic variables could not therefi)re be determined in these two patients. following rhlgf-i injection in the remaining patients tmax was at ( - ) hours, clearance was ( - ) ml/min, vd was . ( . - . ) l/kg, and tia . ( . - . ) honrs. conchlsions: there was marked patient wu-iability in response to rhlgf-i administration. vd was similar to that seen in poshq~erative maior surgery patients ( . vs . l/kg), but clearance was greater ( vs ml/min), tmax earlier ( vs hours) and t~a shorter ( . vs i . homts). if riaigp-i is to be administered to dtically ill patients the dose should he nlodified m the light of these findings. baekgronnd: acute bacterial endoearditis continues to be a condition with high morbidity and mortality. the majority of patients are treated with high dose antibiotics, but a patient group requires surgical treatment. methods and results: from january to march , patients underwent surgery for acute bacterial endocarditis: had native valve endocarditis and had prosthetic valve endocarditis. there were men and women. streptococcus viridans was the predominant infecting agent in native ~alve endocarditis and staphylococcus epidermidis in prosthetic valve endocarditis. progressive congestive failure, uncontrolled sepsis and peripheral emboli were the most common indication for surgery. although the mitral valve is more commonly involved in acute bacterial endocarditis, the aortic valve most often requires surgical inlervetion. the postoperative bleeding in the no-aprotinin group was + cc and in the aprotinin was :t: (p < , ). the mortality in icu was , %, the staphyloccocical endoearditis mortality was , % and the no-staphyloccocical endocarditis mortality was , % (p< , ). conclusions: the early surgery is indicated if endocarditis has no response with medical treatment. the mortality of staphyloceocical endoearditis involving left valves was higher than caused by other infecting agents. aprotinin treatment improved prosta#andin metabolism and preserved pletelet function during open heart surgery and could be useful in this type of interventions. urgent surgery had a high mortality ( %). selective digestive decontamination (sdd) has increasingly become the subject of critical discussion sine~ the development of multiresistant organisms has become an issue. moreover, a selection of gram-positive pathogens must also be taken into account when using the sdd regimen, which is primarily directed at the gramnegative bacterial specumn, with the methicillin-resistant staphylococcus aureus strains (mrsa) being of particular importance. the objective of our study was to determine the extent to which colonization with mrsa strains is promoted by sdd. method: patients (ventilation period > days) were randomized and allocated to the sdd group (n= ) or the control group (n= ). in their general intensive care theraw, there were no differences between the groups. the sdd regimen consisted of the four times daily administration of rag polymi~ mg tobramycin and mg amphotericin b in the nesc, mnoth and stomach. systemic prophylactic ~dmini~/rution of antibiotics was not part of the sdd regimen. smears were taken from the nose and the rectum twice wceldy and from the pharynx and trachea once wceldy, and tested for mrsa. further samples were taken as clinically reqnircr results: smears were examined in the sdd group. mrsa strains were detected in samples ( . %) from patients, and in patients they were detected for a period of up to weeks. the positive smears were districted as follows: tracheal / ( . %), nasal / ( . %), pharyngeal / ( . %) and rectal ( . %). severe mrsa-induced infections were observed in patients (infection rate . % of the colonized sdd patients). smears were examined in the control group. ivlrsa swains were r in samples ( . %) from patients, but only repeatedly over a period of up to days in patients. the po~tive snmars were distributed as follows: traclmal / ( . %), nasal / ( . %), pharyngeal / ( . %) and rectal / ( . %). there were no mrsa infections in the control group. conclusion: the data collected support the view that the use of sdd promotes a selection and persistence of mrsa strains. longer-term colonization with mrsa and sovere systemic inf~ons were only found in the sdd group. although the clinical and epidemiological impact of resistance develol~ng when sdd is applied ~maine unclear, this question should be given close scrutiny. tazobactam/piperacillin (taz/p p) is a new broad spectrum antibiotic, in which the acylaminopenicillin piperaeillin is protected by the betatactamase inhibitor tazobactam from hydrolization by bacterial enzymes. taz/pip has shown to possess a high antibacterial activity against almost all clinically relevant bacteria and is a registered drug in germany. obiectives: purpose of this investigation was to evaluate, whether faz/pip . g is suited for efficient antibacterial monotherapy of severe infections and what influence dosage frequency reveals on clinical efficacy. methods: hospitalized patients have been documented in this multicenter trial during a year period. as this investigation should reflect the usual clinical treatment, the only criteria for enrolment were the typical signs of infection as e.g. temperature > ~ leucocytosis or an isolated pathogen. exclusion criteria did not exist and the patients were treated in accordance to the severeness of infection, underlying diseases, risk factors etc. with taz/pip . g t.i.d, or b.i.d. results: patients suffered in most cases from infections of the lower respiratory tract (n= ), followed by intraabdominal (n= ) and skin and soft tissue infections (n= ). % of the lrtis wvre nosocomial acquired and in % the treatment was conducted as monotherapy. in % the lrti was treated with taz/pip b.i.d, and in % t.i.d. pseudomonas spp. (n= ) and staph..aureus (n= ) were the most isolated pathogens pretrcatment. the clinical response rates (cured/improved) after treatment with taz/pip . g b.i.d, and t.i.d, were % and % respectively. results for intraabdominal-and skin and soft tissue infections will be presented. conclusions: in hospitalized patients with severe infections successful treatment with taz/pip in monotherapy is possible. in this population a reduction of the dosage frequency to . g b.i.d, revealed equivalent clinical response rates. objectives. retrospective evaluation of cases of severe generalized tetanus (sgt), treated in our icu the last years. we review cases of sgt ( m, f), mean age . years. in eases the entry site of c.tetanus was a skin laceration, in case it proved to be the external genitalia, while in the rest no portal of entry could be determined. in the first cases incubation period was short ( - days) and so was the period of onset ( - days). all patients needed mechanical ventilation (range - days), initally through an orotracheal tube,and later through a tracheostomy, performed • days after admission. clinical manifestations of sgt included muscle rigidity and i generalized spasms, persisting for up to weeks in the most severe cases. significant autonomic nervous system dysfunction was present in cases occurring - days after the admission and following the time course of generalized spasm. besides general supportive measures, specific treatment included passive +active immunization, penicillin g, magnesium sulphate and sedation in a variety of regimens. neuromuscular blockade was required in cases. nosocomial infections occurred in eases, with sepsis and mof in one. average stay in the icu was - days. one patient died with severe septic complications and one was discharged with severe disability due to anoxaemie ancephalopathy, after a cardiac arrest on admission. ~ disinfectant in suspension test, without presence of organic load, disinfectants showed efficacy on lm. in the carrier test, in the presence of organic load, out of examined disinfectants did not exposed efficacy on lm. the results of examinations clearly showed that evaluation of disinfectant's efficacy partly depend on the used test method. antun basi , intensive care unit, kb firule split spin~ideva ! jugoslavia bacteremia and sepsis are frequent complications encouuntered in severe icu patients.microorganism identification with hemoculture presents the basis for adequate and successful antibiotic treatment.in many patients damage and vulnerability of the peripheral veins presents an obstacle for obtaining the blood culture from the central venous (cv) catheter sample could be also used. material and methods blood cultures were perfomed in lo patients on blood samples simultaneously obtained from the peripheral vein and cv catheter three times in a -hour period.criteria for the suspected bacteremia were body temperature above c and leucocytosis above ioooo leucocytes/dl. the site for venipuncture and the cv catheter stopcock port were cleansed with povidon iodine.after the initial ml of blood were discarded,lo ml were used for the blood culture.standard laboratory technique for blood cultures was used. results and discussion in ( %) patients hemocultures was negative at both sites,whereas in the remaining ( %) they were positive.for twentyone ( ~ of the positive patients the same results were obtained at both sites (peripheral vein and cv catheter),whereas in ( . %) patients the blood culture were positive only for the cv catheter samples.the cv catheters were in place for less than days in patients and for more than days in patients.from patients with positive blood culture from the cv catheter,one patient had the catheter for three days,whereas the other had the catheter from - o days. we neither found significant differences in hemodynamic dates : objectives: , to count and evaluate bacteria isolated from endotracheal (et) suctiori samples (with and without saline). . to establish the exogenous source(s) of pathogens isolated from carer's hands and the equipment involved in sampling in order to reduce the incidence of contamination and infection. method~: this prospective study included consecutive ventilated patients ( male and female, _ + yr; apache ii score -+ ) over a period of months. et aspirated samples with and without saline were taken daily from day of intubation until pathogen~ were presented in counts of _> per ml. at the same time, samples from both carer's hands were taken before and after et suction and a swab from the ventilator tube. results: the overall length of intubation varied between to days. bacterial transfer between staff and patients was noted in % of patients until day of intubation. there was no significant correlation between severity score and appearance of colonization. the incidence of pneumonia in studied patients was % with an overall mortality rate of %. acinetobacter anitratas (no ), staphylococcus aureus (no. ), klebsiella pna~moniae (no. ) and pscudomonas aeruginosa (no. ) isolates predominated in all our specimens. we noticed increased resistance to most antibiotics with the exception of imipenem for gram (-) bacteria and vancornycin for gram (+) bacteria. conclusions: i. tracheobronchial colonization appears directly in the maiority of intubated patients. . there is a close relationship between the microflora of personnel, patients and equipment. . bacteria transfer was noted both to and from patients. . strict hand disinfection policy remains an important measure for the proper care of mechanically ventilated patients to reduce respiratory infections. nnseeomial pneumonia is the most common nnsocomiai infection in the icu-settiag, reported in up to % of patients admitted to the icu following surgery. it is associated with significant mortality that ranges from ~ to %. enteric gram-negative bacilli have been implicated in % to % of ventilntor-associated pneumonias and pseudomonas aeruginosa accounts for % to % of these pneumonias. importantly, epidemics of/ - actamnse-pruducing enterobacter spp or klebsiella spp that are resistant to extended spectrum cephalosporins or penicillins, pose serious obstacles to effective antibiotic choices. carbapenems provide in ~tro activity against a wide range of enterobacteriaceaeand other gramnegative aerobic bacteria, except steaotrophomonns maltophilia. in vitro meropcnem is more active against pseudomonas spp than imipanem (especially p. aeruginosa and p. cepacia), imipenem and meropenem are effective against more than % of strains responsible for nnsocomial infections. all major pathogens associated with lrti are usually covered by the carbapenems, exceptions are pathogens involved in so-called atypical pneuomouia like mycoplasma, chlamydia and legionella. carbapenems are highly stable in the presence of most chromsomal and plasmid-mediated blactumases and usually offer a postantibiotie effect lasting for three hours against most of the enterubacteriaceae. reeent studies comparing imipenem/cilastatin with other ~-lactams and fluoroquinolones in severe lrti in icu patients resulted in favourable clinical cure rates and good tolerance, but development of resistance in p. aeruginosa and ;. aureus during treatment were of some concern. meropenem offers the advantage of greater stability against enzymatic degradation, so no concomitant administration of an enzyme inhibitor is necessary, and meropenem appears to be associated with a lower risk of seizures, particularly when used at high doses. results from studies with meropenem in lrti, especially in critically ill patients with acute exacerbations of chronic bronchitis, demonstrated excellent cure rates and better gastrointestinal tolerance of this new carbapenem. both earbapenems are effective candidates for use as empiric monotherapy in nosucominl infections of critically ill patients. qbl~ctives a favourable effect of iv immunoglobulins in septic surgical patients has been reported, but not sufficiently validated. we conducted this study on trauma patients to: i) investigate the effect of ivig on septic complications and il) quantify this effect by means of serum bactericidai activity (sba) assessment and iii) to explore the effect of temperature increase (from to ~ c) on the sba methods: twenty trauma patierits matched on admission for age, sex, inju~ severity score and glasgow coma scale, were allocated to receive either wig (ivig group; i patients) or equal volumes of human albumin % (control group; patients). wig (sandoglobulin) was administered in a total dose of g/kg divided in a four time regimen on days , , and post-admission. three blood collections were performe& before the first dose (day ) and hours after the third and the fourth dose (days and respectively). complement, lgg fractions, the sba at ~ and at o c and clinical parameters were recorded. results-similar lgg and igg] serum levels were found in groups ivig and control on day ( +_ vs • ns and + vs + , ns), whereas they were significantly higher (p< ) in the v g group on days ( _+_ vs + , p< ) and ( _+ vs +i , p< . ). the various complement-fractions increased in both groups without inter-group differences the mean (• sbas ( ~ c) at rain in ivig group vs control group were: - _+ vs - • ns for day , _+ vs - _+ p< for day and _+ vs - + p< for day . the mean (+sd) sbas ( ~ c) at rain presented a significant improvement over those of ~ c but for the control group remained negative a~d were respectively as following: -~ • vs - + , ns for day , +_ vs - _+ , p< . for day and _+ vs - _+ , p< . for day . the increase of temperature induced a -fold improvement of sba in iv g group and -fold ofcontrol-~oup positive blood cultures, and the product of the infectious episodes number multiplied by days of occurence, were significantly lower (p< ) in the ivig group than in the control ( vs , and vs , respectively). conclusions: our study shows a significantly favourable effect of ivig administration on septic complications and on sba of trauma patients. the increase of temperature results in a significant improvement of sba of patients that received ivig, which theoretically means a farther prevention of infection in the febrile state. pharmaceutical microbiology, university of bonn, meckanheimer aune , d- bonn, germany infectious diseases in intensive care patients are common in comparison to patients on other wards and out-patients. the main difference is that intensive care patients are much more sensitive even to less virulent bacteria. thus, the spectrum of infecting organisms is different. strains often regarded as pathogens with low virulence cause serious infections in these patients. strains such as serratia, however, have intrinsic resistance to most commonly used agents such as rd generation eephalosporins. furthermore, the common pathogens like staphylococci, psoudomonas aeruginosu, enterocneei and gram-negative bacteria, enterobacteriaeceae as well as the non-fermenters are less sensitive if isolated from intensive care patients. it is difficult to generalize on intensive care units as different patient groups are in different icus aud there are great changes from one hospital to another and from one country to another. if we take s. aurens strains from one study from the'overall resistance in intensive care units towards oftoxacin was %, whereas in other hospital wards the percentage of resistance was . %, in out-patients, however, only .$ %. the same trend was true for entercnecus faecnlis, coagulase-negntive staphylococci, and other bacteria as well as other drugs. one most striking difference was found with klebsialla pneumoniae and gantamycin resistance, which was $ times higher in intensive care units as compared with outpatients, whereas in the same species no difference was to be seen with the resistance towards carbapenems. however, differences between countries seem to be even more striking, as example gantamycin resistance and staph. anrens is given. the extreme difference is more than fold. thus, it is evident that there is a general trend towards higher resistance in intensive care units, but no generalizatiouis possible. therefore, surveillance studies in intensive care units are needed and the antibiotic policy has to be adapted to the specific needs of the unit. in the icu setting the most potent antimicrobial agents are required to address problem organisms including those resistant to penicillins, cephalosporins and aminoglycosides. carbapanems would appear to present a useful option in this setting. objectives of this study was the evaluation of systemic candid• in postoperative cardiac surgery patients (pts) with prolonged icu stay. methods: out of postoperative adults pts of mean age . + . years old, with a mean icu stay of . _+ . days, following an open heart surgery from july to april , pts ( %) remained in icu for more than days because of severe perioperative complications. patients were included in the protocol if they had clinical signs of infection or sepsis, and fungi isolated in blood culture or in culture from at least three different sites. the patients who developed systemic candidiasis received iv fluconazole ( mg/day) ( patients) or amphotericin-b for at least four weeks, and then they were closely monitored. results: out of postoperative pts with prolonged jcu stay, pts ( . %) developed systemic candid• usually after the th postoperative day. they were males and females of mean age +_ . years old. this group of pts had prolonged bypass and aortic cross-clamp time compared to control group ( min vs , and vs min). all these pts received inotropes per• (mean value= . ). during their icu stay, pts developed sepsis of bacterial origin, while the other two severe infection, and received antibiotic regimens for prolonged period. the patients were submitted to mechanical ventilation for a median period of days. the median icu and hospital stay was and days respectively. all pts have been improved and finally negative cultures were obtained. conclusions: . a significant percentage of patients who remained in the postoperative icu for more than days developed systemic candidiasis. . all patients who developed systemic candidiasis had received antibiotics because of sepsis or severe infection, for prolonged period. . fluconazole seems to be a very good alternative to amphotericin-b. . fluconazole is a safe antifungal agent with few side effects. botulism is the most severe and an odd food poisoning. although it is more commonly related to preserved meat derivatives, preserved fish and vegetables are also responsible for a number of cases. obiectives: to evaluate four familiar outbreaks of botulism . methods: we study the patients that were admitted in our hospital because of botulism from may to february . results: the thirteen pacients involved had a previous history of home preserved beans ingestion. after a -hours incubation period, gastrointestinal symptoms (abdominal pain, vomits, constipation) appeared and lead them to hospital consultation in the th to th day after ingestion. two patients died (acute respiratory failure before admission), seven were admitted in icu, two in ward and two of them were discharged from emergency room. clinical symptoms and the previous history of the ingestion established the diagnosis, that was emg confirmed. in all cases, symptoms were consistent with b-toxin botulism. b-toxin was isolated in serum and food proceeding from the third outbreak, and the serum was negative in the other ones. neurological symptoms were predominant: midriasis ( %), dry mouth ( %), dysfagia ( %), asthenia ( %), palpebral ptosis ( %), accomodation paralisis ( %) and urinary retention ( %). muscle weakness lead to acute respiratory failure in three patients (one of them required mechanical ventilation). four patiens developed infections (respiratory, urinary and phlebitis). both died patients and one another presented severe hypertension. all admitted patients were treated with polivalent anti-toxin. the two patients who underwent a more severe muscle weakness received also guanidine hydrochloride, with no answer in one case and provoquing a cholinergic crisis in the other one. icu length of stay was days. at hospital discharge, patients continued symptomatic, mainly with dry mouth, disfagia and impaired vision. conclusions: although botulism is a serious illness, the pronostic seems favorable if treatment and support measures are avaible. usually neurological symptoms we predominant and at discharge some of them could still persist. the arrow "hands-off" (aho) thermodilution catheter (tc) is completely shielded during balloon testing, preparation, and the insertion procedure. in order to assess the value of the aho thermodilution catheter in the prevention of systemic infections associated with pulmonary artery catheterization (siapa), we conducted a randomized prospective study over an -month period. methods : the patients (pts) were randomly assigned to two groups : group i for a standard tc customarily used in the department, versus group for the aho thermodilution catheter. the diagnosis of siapa was determined on the basis of a positive culture of tc and bacteremia with the same organism, with out any other nearby focus, in association with regression or disappearance of the clinical signs of infection after removal of the thermodilution catheter. results ( objectives: the mortality rate (mr) of tb requiring mechanical ventilation (mv) is high ( - %). the aim of the study was to evaluate mr, associated factors, and prognostic significance of mv and hemodynamic disorders from tb in icu in patients with tb. methods: clinical parameters on admission, and complications in icu were related by univariate analysis to icu, hospital, and month outcome. patients required mv; were immunocompromised (ic) including hiv. tb was pleuropulmonary in , disseminated in and meningeal in . results: mr was % in icu, % in hospital and % at month. / ( %) < . mortality was associated with a high saps score, initial shock, mv and nosocomial septicemia. the mr dramatically increased when ards occurred during illness, despite the lack of correlation between mr and initial po /fio ratio or initial murray score. the site of infection did not influence the mr. surprisingly, the mean therapy delay was shorter for non survivors. mr was not related to ic status, nor hivstatus, but was only related to previous steroid therapy. conclusion: mr of tb requiring icu is high ( % at month). need for mv increased mortality ( % vs %). general severity and respiratory dysfunction seem to be major prognostic factors in icu rather than tb per se or than therapy delay. in spite of the improvement in the prognosis of pneumococcal meningitis (pm) with third generation cephalosporins (tgc), this infection still presents a great mortality which could be increased with the appearance of antibiotic resistant streptococcus pneumoniae. objectives: to asses intensive care mortality and morbidity of pm and to define patients (pts) at risk of complicated evolution. patients and methods: a retrospective evaluation of pm cases (all diagnosed by csf culture) admitted in our icu from january tit march . in all pts we analized: demographic data, underlying disease, apache ii score, clinical symtomps, treatment, complications and outcome. statistical analysis was done using bmdp sofware package. results:a total f pts were studied, males; mean age , _+ ( - ); apache ii score , + , ; glasgow coma scale (gcs) at admission , _+ , ; ( %) pts suffer from cronic pathology; ( %) pts diabetes mellitus (dm), ( , %) pts had had a previous cranial traumatism. in cases the source of infection was otic and also in ( %) episodes of pm there were bacteriemia. in out of ( %) pts that ct was performed no radiologic abnormalities were shown, of them presented cerebral oedema and pts a cerebral abscess. twenty-eight percent presented seixures, % hemiparesia, , % respiratory failure, , % shock, i % renal failure, , % multiple organ failure (mof). as for treatment refers , % pts recieved only penicillin, , % pts only tcg, , % pts tcg followed by penicillin and , % pts tcg+vancomycin. seventy-five percelat of pts recieved corticosteroids and , % vasoaetive drugs. the mean icu stay was , : days ( - ). twelve ( , %) pts died, two of them presented pm relapse (resistant streptococcus pneumoniae) and another two pts developed neurological sequelae. factors associated statistically with bad prognosis were dm, the use of vasoactive drugs, shock, mof, the apache ii score at admission, the gcs at the and hours from admission in the icu but not the gcs at admission. didn't resulted statistiealy signifcative age, previous eronie pathology, seizures, baeteriemia, renal failure and coagulation disorders. conclusions: mortality was high and associated to apache ii score at admission, to gcs at and hours after admission, shock, vasoaetive drugs and mof. objectives:the aim of the study was to analyse some of significant immunologycai changes in surgical patients,requiring intensive health care,and to determinate the possibility for evaluation,dynamical examination and importance of immunologycal problems for treatment. methodes:the study concerns a number of patients with expanded surgical intervention or serious postoperative complications.the results has been carried out with fiowcytometryc analyses of lymphocytic suhpopulations and routins methods for investigation of humeral immunity.the"panel" for evaluation of (} immunologycal parameters has been offered:t-calls total/cd +/;t-helper/cd +/;t-supressor/cd +/ th/ts ratio;b-cells/cd +/;naturai kilier/nk/cells;skin test for cellular immune function;phagocytic and oxidative activity;serum levels of immunogiobulins-g ,a,m;protease inhibitors;c-reactive protein.all patients have been studied during suffering and after surgical procedures dynamicaly. results:there have been estimated significant changes in immunologycal parameters especially:decrease of t-cells: cd +mean= . %/ . %- . %/and cd +mean= . %/ % - . %/;inverted th/ts ratio ,mean=o. / . - , /;reduced or negative skin teste;reduced phagocytic and oxidative activity before septic complications. conclusions:dynamical examination of immunologycal parameters shows,that the prolonged t-total,t-helper lymphocytopenia with functional deficience of ceils-mediated immunity correlates with the stage of clinical condition of the patients and has prognostic importance.it's clear,that immunologycal monitoring gives a possibility for immunecorrection. patients (pts) with the human tmunodeficiency virus (hiv) infection have a decreased immune response and are particularly susceptible to infectious endocarditis (ie). the aim of our study was to analyze the prevalence of ie, its clinical and therapeutic implications in a hiv population we prospectively studied pts, . % ( / -group ie+) with ie during the clinical course of this disease. we analyzed the following parameters: age, gender, race, type of hiv, cdc classification, number of t and t type cell population and its ratio, therapeutic with azt, type and number of opportunist infections (inf, mycobacteriosis (mb), neoplasm's (nee) the echocardiographic parameters were lv internal diastolic and systolic diameters, lv percentage of fractional shortening, interventricular and posterior wall thickness, the degree of valvular regurgitations and the presence of pericardial effusion. el was located at the mv in . %, tv in . %, av in % and pv in . ~ and was multiple in . %. hiv el+ pts had larger lv diameters and more frequent significant valvular regurgitations ( % tr, pe %, mortality %). these two groups differed significantly in the following clinical parameters: the typical symptoms were watery diarrhea, high fever, tachycardia,luekocytopenia and oligouria within th postoperative days. the patients with mrsa enterocolitis had positive mrsa culture from the many materials except feces.mesa strains frequently had coagulase type ,enterotoxin a and toxic shock syndrome toxin- .eight of patients had postoperative organ failure.most of the mrsa strains in japan were similar in coagulase type to our hospital and our department.all of mesa strains were susceptible to vancomycin and arbekacin,tbough most of them showed resistant to many other antibiotics.we have employed guidelines for therapies such as oral or enteral administration of vancomycin and correction of the hemodynamics for dehydration and circulatory failure due to diarrhea from .futhermore we have placed colonized or infected patients in private room,worn gown and mask,and carefully washed our hands from . these countermeasures for prevention of nosocomial infections after significantly reduced the incidence of mrsa enterocolitis. conclusions:earlier diagnosis and treatment, and distric prophylactic measureres against mrsa infections are very important. -- cdo ivda leptespiresls affects all the organs with widespread hemorrhage that is more prominent in skin, mucosa, skeletat muscles, liver and kidneys. lung involvement is usually mild and less common. suli, it is very uncommon acute respiratory failure to be the pr sontirlg symptom. a case with leptosplrosl..,s which was presenting with acute respiratory failure is described. a year-old man admitted to icu becauso of fever, myaigla, aevere c~, hemopty~s. his blood gases showed: pao : mmhg with fio : . , pco : mmhg, ph: . , hco : mecl chest x-ray film demonstrated diffuse bilateral alveolar pattern occupying beth lung / ). trarmamlnase, bllllrubln, ~ and esr were elevated, wbc was . mm , platelet: . ram , hematesrlt: %, hemoglobin: .sgrldl=. there was no clinical or ecttlographlc evidence of left heart failure.patient fulfilled the criteria for diagnosis ards he was found to have an ~lutinatlon tlter for leptoq~lral antigens(indirect he~lutlnatlon atomy, ilia} very high ( / , negative<ill ) and iglm antibodies also very high (elisa, a= . , negative< . ) strongly suggesting leptospirosls. treatment with tetracycline and non-tnvaslve mechanical ventilation by nasal mask were started. pre~jre support mode and cpap was usod. the following days the clinical picture,the oxygenation and the chest x-ray of the patients were improved, and patient dl~herged from the icu. the control of leptosplremlc phase as well as his good cooperation during nipsv contributed to rapid recovery and excellent outcome in hiv infections, pneumonias (pnm), mainly due to pne~ mocystis carinii (pc) have an outstanding place in pu ! monary complications. the aim of this work was to compare two group> of patients admitted with pnm in our icu during the same period ( - ): group a, patients hiv+, and group b, patients hiv-. apache ii was identical in the groups (p=ns). group a required more often mechanical ventilation (p= ,o ), had a higher p(a-a)o (p= , ) and metabolic acidosis was more frequent (p= , ). regarding laboratorial parameters group a had a lower no. of linfocytes (p= , ), a higher ldh (p= , ) and a more marked hypoalbuminemia (p=o, ). mortality was higer in group a ( , %) than in group b ( , %), (p= , ). analysing the a group patients, we found no significant differences between alive and deceased patients, with exception for albuminemia, which was lower in the deceased patients (p= , ). in conclusion, the hiv+ patient's pnm have a more agres sive behavior when compared with community acquired hiv-patient's pnm. the prognosis was not influenced by the apache ii. perhaps other parameters such as p(a-a)o , metabolic acidosis, linfocytes, ldh and albumin shoud be more evaluated as possible predictive indices. some prognostic factors, usually accepted as predictive in the analysis of hiv+ patients do not seem to be worth in the late stages of aids, mainly when they reqquire intensive care. intensive care unit, onassis cardiac surgery center, athens, greece. objectives of this study was the comparison of two different antibiotic regimens as prophylaxis in cardiac surgery patients. methods: in a prospective randomised comparative study, two different forms of antibiotic regimens were investigated : a single dose of cefuroxime (zinacef, gr) (group a) given during the induction of anaesthesia, versus a four days combination of amoxiculine (amoxil, gr tid) plus netilmicin (netromycin, mg bid) (group b). a total of patients (pts) ( males and females, of mean age . + . years old) were included in the study over a period of one year; in group a and in the group b. patients were checked for the occurrence of infection during the first postoperative month. results: the total rate of infection in cardiac surgery pts was . %; . % in group a and . % in group b (p=ns). pts ( . %) developed infection following cabg, pts ( . %) following valve replacement and pts ( . %) after other cardiac surgery. they were males ( . %) and females ( . %). endocarditis has occurred . % in group a and . % in group b. severe wound infection was recorded in . % in group a and in . % in group b. one case of sepsis ( . %) in group a and in group b ( . %). respiratory infection occurred in pts of group a ( . %) and in pts of group b ( . %). two cases of urinary tract infection was in group a and one in group b. catheterrelated infection was occurred in ( . %) in group a and ( . %) pts in group b. pts ( . %) had fever of unclear aetiology in group b. conclusions: there was no statistically significant difference regarding the rate of infection in both groups. a single dose administration of cefuroxime is accordingly just as effective as a four days regimen of amoxicilline plus netiimicin. legionella pneumophila is a common bacteria of the environment, and it is an agent responsible for severe community acquired pneumonia (cap). we analyzed the patients with lpp admitted in our icu during the last years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . they represented . % of cap. seven patients were males and female, with mean age . + . years. tiss was . + . and apache ii . + . . all, but patient, were under mechanical yen tilation (mv) during a mean period of . • (min-l, max- ) days. two pneumonias occurred beyond the season, while patients had an epidemiological history. only patient had no risk factor. in all the others tobacco smoking and alcohol abuse was quite frequent. diagnosis was based on serologic test and culture or direct fluorescent antibody staining of bronchial secretions. seven patients had a multisystemic disease with hepatic dysfunction in , renal failure in (due to rhabdomy~ lysis in ). one patient had a prosthetic valve endocarditis and another developped ards. nosocomial septicaemie occurred in patients. mortality rate was %. deceased patients had initially higher apache ii, (a-a) , and lower natriemia. comparing lpp with the other cap (n= ), both submitted to mv, mortality rate was similar ( , % versus . %). in conclusion lpp can occur all over the year. there was a high incidence of severe complications and outcome was similar to the other cap when requiring mv. prospective specimen brash (psb) with culture > cfu cfu/ml. broncho-alv~lat lavage (bal) ~= c'fu/rnl or positive blood culture. were excluded for rapture of treatment ; were analysed (shift with oral antibiotic : ; prohibited antibiotics associations : ; resistant germ : ). clinical data : age , • , ; saps • , ; mac cabe i : , % -ii : , % -iii : , . , % of the patients were intubated and under mechanical ventilation. the pneumoaiae were : primitive in ( , %), copd ( , %), aspiration pneumonia ( , %). germs were isolated (psb , bal , blood culture ) : s. pneumoniac ( , %), h. influeazae ( , %), sttep~:occns ( , %), saar ns ( , %), enterobaetdrindr ( , %), mosexella catarrhalis ( , %), othem . / ( , %) were sensitive to freatment. the ltentment was mg/kg/d of ampiclllin and mg/kg/d of sulbactam in continuous iv adminisu'ation during at least days. clinical eff~ienev : success ( %), failures ( %) with superinfeetion , worsening or relapse , dead , side effects . there was no difference between etiologies : primiti~;e~ , %, copd , %, aspiration pneamoniae , %. the bacteriological effieieacy was evaluated only for patients with eradication ( , %), eradication but super~ection ( , %) : with pseadomoaas a&ogiuosa , eater~ac~ ; beeteriological failure ( , %). in conclusion, the aasor ampicillin -sulbactam is effective for the i~eatment of severe acquired community pneumonise. objectives : to assess the efficacy of chlorhexidine (cl) gel or suspension applied in the nose and in the op for the prevention of the tmcheobronchial colonization. methods : thirty-seven patients expected to be intubated for > h were randomized to received topical application oga cl suspension ( %) qshrs, a cl gel ( %) q hrs or a placebo. in addition all vpts received a nasal and a op spray ( %) of either cl or placebo administrated according to the same schedule. semi-quantitative cultures of the anterior nares, the oropharynx (op) and the trachea were obtained on admission and once a day until extubation (just before the next application). the results were assessed according to the following criteria: success = no acquisition of gnb in the trachea ; failure = acquisition of gnb in the trachea. acquisition was defined by a follow-up culture positive for a gnb not present in the trachea on admission. results : success failure nosocomialpneumonia overall morality clsusp. placebo clgel placebo n= n= n= n= / / / * / / / / * / / / / / / / / / i *p = , byfisher'sexacttest conclusions : these results suggest that topical cl gel administered q hrs may prevent tracheal colonization by gnb. f. daumal*, m. daumal**, c. plot**, v. vurmmen ~ e.colpurt**, b. manonry** * hygiene hospitali&e, ** service de r enmmtion, * service des admissiens-urgeuces centre hospitalier g- ndral - saint-quentin -france obiectives: evaluate the nosocemial risk due to peripheral venous inserted short catheters, and the quality of care. patients-methods: the intensive tare unit (i.c.u.) is a beds unit. the prospective study includes all the patients comn~ in from / / to / / . the recruitemont uses an evaluation schedule of local clinical signs. the nurses aimed to create this evaluation data which includes the place of entry site, the duration of catheterization and the cause ot withdrawal. only patients staying longer than days in the i.c.u. are accounted for. the diagnosis of uosoenmial infection is assured by the physician taking care of the patient and by the hospital epidemiologist on the next signs: evident pus at the catheter entry site, positive culture of the strain, with or without the same pathogen in the blood sla'uam,the patient having no other distant source of infection. analyses were performed on epi/nfo. results: the occurrence of nosoeomjal inthrtions: i abcess and bacteremia during the first part of the study lent the medical staff to modify the protocol of insertion end survey of the device. so we analysed different periods: period ( / / to / / ) and period ( / / to / / ) for all .e peripheral catheters inserted in the i.c.u. period , % , % en infection due to peripheral venous device is a daily threat. the severity of some clinical situations requiring admission in icu proves it. the motivation of nurses for rigid adherence to established protocol, the daily survey of the entry site, the withdrawal of the peripheral catheter every hours aimed to reduce significantly the local signs of inflammation end infection of peripheral catheters inserted inside the i.c.u. objectives: to investigate the use of a new metabolic monitoring device for different ips levels by comparing oxygen consumption (vo ) to measurements of the mechanical work of breathing (web) and p . . methods: the study was approved by the institutiotml ethics committee. eight patients were investigated during weaning after prolonged mechanical ventilation ( - days) for various diagnoses when the clinical physician judged the patient to be ready fur weainag. ips was setto , , , mbar far rain periods each. all patients had a peep between - mbar.. respiratory frequency (f), tidal volume (tv), minute ventilation (ve) were read from the ventilator display ( ae, puritan bennett, carlsbad, usa). flow and airway pressure were measured at the endotracheal tube site. esophageal pressure was measured using an esophageal balloon catheter (fa. ruesch, frg). web was determined as the area subtended by the pleural-pressure-vohime curve. p . was determined by using standard occlusion technique and graphical analysis of the airway pressure tracing. vo and vco were measured using the pb metabolic monitor (puritan bennett, carlsbad, usa) connected to the pb ae ventilator. all data are given as mean• deviation for each ips level. comparison between the different ips levels was performed using anova for repeated measurements. significance was considered at p< . , compared to ips mbar. results: the values for breathing pattern, web, p . , vo and vco are given in the table for the different ips levels; significance is indicated by ~. objectives: fluidized beds are often used in the management of critically ill mechanically ventilated patients. critically ill patients are increasingly colonized with resistent pathogens [ie: p. aeruginosa, methicillinresistent s. aureus (mrsa), extended spectrum i~-iactamase producing enterobacteriaceae ] that can ultimately cause nosocomial infection. methods: we prospectively monitored bacterial colonization of mechanically ventilated patients and of the fluidized bed (clinitron) inwhich they were treated. multiple samples for quantitative bacterial cultures were taken from oropharynx, trachea, feces and bedsores. samples of ceramic beads from the bed were also taken both during and after patient stay (after bed operation in the absence of patient). re,~ults: episodes in consecutive patients (mean age: . years) were analyzed. all had bedsores and/or urinary catheters and fecal incontinence, patients had nosocomial pneumonia, had urinary tract infection [ with extended spectrum imactamase producing k/ebsie//a pneumoniae (ki~lse)], one had positive blood cultures with mrsa, and one patient had a ki~lse found in high concentrations ( - s cfu/ml) in occasions in feces. patients were heavily colonized: the , samples from ceramic beads showed no growth or became sterile without any sterilisation procedure (even in one case of presence of kf~lse) during the patient stay. conclusions: fluidized beds do not put patients at high risk of acquiring nosocomin pathogens, and cross-contamination between patients seems unlikely, even when multiple resistent organisms were initially present. the recommandation from some manufacturers to undergo extensive sterilization of fluidized beds after use does not seem warranted, at least with the bed used in this study. ant. koutsoukou, a, tahmitzi, p. kithreotis, m. koutonlidou, k. stavrakaki, kainis e, g. vlahogiorgos and e. eliopoulos icu-centre for respiratory failure -chest diseases hospital of athens. the cost-effectiveness issue is becoming vital in modern medicine and may lead to moral dilemmas since sometimes certain groups of patients may not have access to highly specialised modalifies. objective: our study compared the mean daily cost for antimicrobial medication in copd patients treated in icu versus all other patients in the context of relevant epidemiological, prognostic and outcome data. methods: age, sex apache ii score, length of icu stay (los) and in -icu fatality were retrieved from the files of all icu admissions over . mean daily cost for antimicrobial therapy per patient (dcat) was estimated. these variables were statistically compared between copd and non-copd patients. significance was assumed at p< . results: of the total admissions were fully evaluable. of them ( %) were copd patients. data (m---sd) results for statistical test are given in table i . copd patients were significantly older spent more time in the icu and presented with significantly higher apache ii scores. outcome and dcat were comparable in the two groups. objectives: the use of heat and moisture exchangers (hmes) during long term mechanical ventilation (mv) is increasing. in icu patients, they are routinely changed every day, according to the recommendations of the manufacturers, but the clinical basis for such a daily practice is lacking. we therefore prospectively assessed whether changing hmes (dar hygrobac, spa, mirandola, italy) every h only would affect their clinical and bacteriological efficiency. methods: two consecutive groups of patients requiring mv for > h were compared: group = hme replaced every day, n= episodes of mv in patients; group = hme changed every h, n= episodes in patients. tubings were not changed in the same patient during the whole length of ventilatory support. diagnosis of nosocomial pneumonia (np) was based on a positive quantitative culture (~ cfu/ml) of a protected specimen brush in patients with clinical signs of pneumonia. quantitative cultures of pharynx, trachea and y-cannector were performed every h. results: the groups were similar in terms of age, indication for and overall duration of mv ( +_ . vs +_ days, p= . ), and severity of illness (saps: --- . vs . +_ . , p= . ). the maximal values for peak airway pressure were identical in both groups ( . -+ . vs . • cmh , p= . ). obstruction of the tracheal tube was observed in only one instance in a group patient who had tracheal bleeding. circuit colonization was very rare, and of low grade in both groups. the level of patient colonization and the type of organisms were identical in both groups. more importantly, the incidence of np was the same ( / vs / , p= . ), as was duration of mv before the occurence of pneumonia ( • vs . +_ . , p= . ) and overall mortality rate ( vs , p= . ). conclusions: the clinical efficiency of this hme does not seem altered after days of use. indeed, replacing this hme every h only neither affect circuit and patient bacterial colonization nor the incidence of np. therefore, substantial savings could be obtained changing hmes every other day only. obiectives: to evaluate the usefulness of different paraclinical investigations for the diagnosis and prognosis of acute viral encephalitis in icu patients. methods: we reviewed patients (pts) admitted to our icu from july to december with the diagnosis of acute viral encephalitis. all were in coma and were initially treated as presumed herpes simplex virus (hsv) encephalitis. the causative agents were: hsv ( cases), herpes zoster varicellae ( ), measle ( ), rabies ( ), unidentified ( ). eleven pts survived and three presented neurologic sequelae. twelve pts were investigated by mri, and eleven also by spect and multi-modality eps. including brainstem auditory eps (baeps). these investigations were obtained as soon as possible following admission and were repeated during icu stay when possible. the clinical outcome was noted. results: six pts ( / ) had an abnormal mri. among them, pts made a complete recovery, in comparison with / pts with a normal mri. in one hsv infected patient, mri remained normal despite clinical deterioration and bad outcome. when repeated, mri became abnormal in cases (with poor outcome in one) and was improved in one. spect was found abnormal in / pts (among them, pts had thus a normal mr/). the correlation regarding the topography of brain lesions was poor between mri and spect. the findings of spect could not be correlated with a poor outcome. the baeps confmned in % of the pts the clinical diagnosis of brainstem involvement. changes in visual and somatosensory eps were mild in all the pts and were not helpful for the prognosis. eps were otherwise interesting for the follow-up of the coma in these sedated and ventilated pts. conclusions: the value of mri and eps for the diagnosis of acute viral encephalitis is of limited interest. spect seems to show early modifications, even in pts with a normal mri, but this test is poorly specific and does not correlate with mri changes when present. concerning the prognosis, larger studies should probably confmn that a normal mri could usually result in a good outcome. this serie illustrates also that hsv encephalitis could be demonstrated only in a small number of cases and that the prognosis of non hsv encephalitis is not easily assessed. objectives: to study the influence of gram (-) bacterial lung infections on liver function i~ mv icu pts. pts and methods: we studied pts, # ( , %), ( , %). hean age: , • years ( - ). mean stay in icu: , • days ( - ). they were divided in groups: a( pts) who did not suffer from pneumonia and b ( pts) who developed a gram(-) bacterial pneumonia. both groups were consisted of pts with same age, sex and disease distribution and same systemic failures. we measured sgot, sgpt, total bilirubin(tb), direct bilirubin (db), alk.phosphatase (al.ph.), v-gt and albumin (alb.) times: on days o, and of the pneumonia for group b and respectively for g~oup a. conclusions: ) in elderly intubated pts of an icu, kp is isolated more frequently than in icu pts< years (p<o, ). ) the frequency of isolation of kp in icu pts during - was - %, but now ( - ) kp becomes more and more rare ( - %) and is isolated especially in elderly pts. ) its sensibility to antibiotics remains always the same. ) the prognosis of np in our study was independent from age (p<o, ), sex, presence of bacteremia (p< , ) and type of invading microorganism. gram neg bacteria and renal failure (rf) from aminoglycoside toxicity are common and serious complications in critically ill patients. the aim of this prospective, pilot study was to compare the safety and adequancy of the endotrecheal (et) vs the intravenous (iv) administration of aminoglycosides. were measured in the plasma and the bronchial secretions at and hours after the iv (bolus) or the et (nebulized) administration of mg of gm in seven criticcally ill patients ( with established renal failure). safety was defined as peak and trough plasma gm levels _< than and ijg/ml respectively and adequancy as gm levels in bronchial secretions _> , ijg/ml. results: gentamicin was administered by the et and iv routes in and separate sessions respectively. a total of samples were assayed, in bronchial secretions (bs) and in serum. the et route resulted in higher gm levels in the bronchial secretions compared to the iv route ( , + , vs , _+ , pg/ml respectively, p = ns ). adequate bronchial gm levels were achieved in % of patients after et administration, compared to % after iv aaministretion. the blood levels of gm were significahtly lower after the et vs the iv route ( , + , vs , • , pg/ml respectively, p _< . ). the et administration resulted in toxic bronchia~ gm levels in % of the specimens. % of these samples were from patients with renal failure, however toxic blood levels were reached in only % of these. gentamicin seems to be a safe and adequate alternative route of treatment for the lrti. however, in patients with renal failure the et administration of the aminoglycosides should also be modified and continuously monitored. in order to evaluate the pathogenic role of anaerobes in nosocomial pneumonia (np), we investigated the systemic humoral response in patients who developed a np with anaerobic bacteria, especially prevotella species. methods: blood samples from groups of patients were tested. group i: patients with a np in which prevotella spp. was isolated from protected specimen brush (psb), group ih a control group of patients with a np without anaerobic bacteria, group ill: a control group of patients with dental stumps but without pulmonary infection, group iv: a control group of healthy voluntary people with prevotella spp. isolated from the dental plaque. an elisa was used to evaluate the total antibodies level against a mixture of four prevotella strains and a western-blot method was done to identify the antigenic proteins. results: data are expressed as means .+ sd. the antibody levels in patients of group i ( • was statistically higher (p=o.o ) than in the control groups (respectively: + , _+ , _+ ). using western-blot method, the intensity of the response was roughly superposable to levels obtained by elisa and the profiles were different according to the prevotella species. the occurence of a np with anaerobic bacteria (prevotella species) isolated from psb leads to an antibody response which seems specific of the prevotella species isolated. fever is common in the intensive care unit, but is not always related to an infection. we sought to define the epidemiology of febrile patients in a general medical/surgical icu. methods: we prospectively analysed the source of fever (t > . ~ c) in all adult patients admitted for >- hours in the icu during a two month period. these patients were studied for consecutive days. and werc classified in groups according to the evidence of infection (center for disease control criteria) after complete evaluation: documented infection: cdc criteria + isolation of pathogen (d); possible infectron: cdc criteria without isolation of pathogen (p); unlikely infection: patients who did nol meet the cdc criteria (u). results: of a total of patients studied, dec'eloped fever ( %). including (after complete evaluation) d, p and u palients. both the highest temperature in tile first day of fever and the maximal temperature were higher in d than in u ( . • versus . • and . -~ . ~ versus . - . , respectively p= . and p= . ). most common sources of infection in d were the lungs in patients ( %) and urina .ry tract in ( %). of these patients had positive blood cultures ( %). the overall mortality was % ( % in d, % in p and % in u. differences ns). antibiotics were given in % of d, % of p and % of u ( patients). in p there was a non significant lower mortality." in patients who received antibiotics ( / ( %) versus / ( %) patients, respectively). conclusions: in febrile icu patients both the highest first day" temperaturc and maximal temperature are significantly higher in infected than in non infected patients, but the differences are too small to be useful clinicall). mortality rate is not significantly influenced either by the presence of an infection or by the administration of antibiotics, obiective: retrospective study to determine the influence of candida infection on icu outcome. methods: patieet with a stay of more than days in inteaasive care were screened for candida infection. patients were treated with antifungal therapy due to either an increased antigen titre of -> : or clinical evidence of candida colonization. serological candida-antigens (ramco, pastorex) and antibody titres (hemagglutination, lgg-, igm-elisa) were examined routinely. seroconversion was defined as a threefold increase of antibody titre or a titre of : or higher. results: the median length of stay was (ranging from to ) days, the mean apache ii score on admission was (+_ . sd) points. of patients patients died ( . %). in the group treated with antifungnls ( patients) patients died ( . %). although of the patients only ( . %) developed a candida infection as defined above the mortality in the group that showed signs of infection was significantly higher ( . % vs. . %, p < . [chi-square-test]). in patients an antigen concentration-> : was measured. seroconversion was found in patients. the most common fungus was candida albicans ( . %). furtberm re, candida glabrata was found in . %. most of the patients were treated with x mg fluconazole ( patients). in patients therapy was changed to amphotericin b/flucytosine. in patients therapy was started with amphotericine b and flucytosine. in patients a threefold decrease of candida antigen titre was found. patients showed a decrease of candida antibody titre. conclusions: meticulous screening for eandida infection seems to be necessary since the number of patients with fatal outcome is significantly higher in the group with signs of fungal infections and thus requires immediate antifungal treatment. objective: early diagnosis of patients with ventilator-associated pneumonia (vap), and subsequent identification of causative microorganism, and selection of the appropriate therapy are critical important points that affect morbidity and mortality. the results of the quantitative bacterial cultures are not available for at least hours, while a two hours period, since the specimen are obtained is enough to know the gram stain results. the aim of this study is to determine the usefulness of gram stain in specimens obtained by bronchoaiveelar lavage (bal), through the bronchoscope. material and methods: we studied patients ( males and females, age + ) with suspected ventilator-associated pneumonia. the bal gram stain was considered positive when the specimen after a centrifugation at rpm for min revealed: i) more than leukocytes per optic field, ii) squamous epithelial cell less than percent and iii) one or more microorganisms per optic field on magnification. all patients had been receiving antibiotics, with no change during the last days, prior to bronchoscopy. results: patients had vap and patients did not. in cases the bal specimens (quantitative bacterial cultures) established the diagnosis of vap in the remaining three patients the vap diagnosis was established by other procedures (blood or pleural fluid culture, clinical outcome, autopsy). apache fl score in patients with vap was , -+ , , while in patients without vap was , + , . there was a significantly higher incidence of vap in patients who had i) coma (gcs < ) and ii) been receiving neuromuscular blockade (p< . ) . the sensitivity of the gram stain for vap diagnosis was %, the specificity , %, the positive predictive value %, and the negative predictive value , %. conclusion: our data indicate that the gram stain of bal specimens is useful for the early diagnosis of vap and the subsequent administration of the appropriate treatment. the role of anaerobes in mechanically ventilated patients with pneumonia (mvp) have been poorly investigated aim of the study : analyse the prevalence of anaerobic isolation in mvp. methods : between october and february all suspected mvp were investigated using protected specimen brush (psb) technique. brushes were rapidly transported in shaedler broth to laboratory. a special care was tooken for anaerobic isolation. results : among the psb performed for suspected mvp ( nosocomial and community-acquired pneumonia), yielded at least one micro-organism (positive psb : %). of positive psb demonstrated only aerobic bacteria and ( %) yielded with anaerobes. in out patients, anaerobes were associated with aerobic bacteria. anaerobes were mostly isolated in nosocomial pneumonia ( / positive psb). strains of anaerobes were isolated. prevotella species represent out these strains ( %) the most frequent anaerobic species were prevotella oralis ( ) p. intermedia ( ) and p. buccae ( ). comments:using adequate methods, anaerobic bacteria are frequently isolated in mvp. it could be off importance to take in account anaerobes in the choice of empirical antibiotic therapy in mvp. objectives: the majority of patients with multiple trauma are considered immunocompromised. the aim of this study was to identify risk factors of pneumonia in mechanically ventilated patients with multiple trauma or after surgery. methods: in this prospective study we studied multi-trauma patients (mean age + years, apache ii . + ), admitted to a general intensive care unit (icu). all patients were intubated and mechanically ventilated. we were considered that a patient had ventilator associated pneumonia (vap) when the specimens of bronchoalveolar lavage (bal) or protected specimen brush (psi?,), ebb'ned through the bronchoscope, had one or more microorganisms in concentrations greater than and cfu/ml respectively. all patients had been receiving antibiotics, with no change during the last days, prior to bronchoscopy. results: patients had vap, and patients didn't. in the bivariate analysis, the glasgow coma scale (gcs)< (x = . , p< . ), the administration of neuromuscular blockade (x = . , p< . ), the duration of mechanical ventilation to be greater than days (x = . , p< . ), the flail chest (x = . , p< . ), the parenteral nutrition (x = . , p< . ), the ards (x = . , p< . ), the abbreviated injury scale (ais) of more than for thorax (:,: = . , p< . ), the pneumothorax (x = . , p< . ) were statistically significant related to development of vap. in multivariate regression analysis, using the stepwise technique, three of the seventeen studied factors showed to have an indepantent association with the development of vap:the administration of neuromuscular blockade (f: . , p< . ), flail chest (f: . , p= . ), and gcs (< ) (f: . , p= . ). conclusions: in patients admitted to icu for multiple trauma or major surgery, the administration of neuromuscular blockade, the flail chest, and the gcs (< ), in the population under study, were the indepedent risk factors for vap. mof is a sereous complication of differem states: infection, sterile inflamation, extensive fissure injure, intoxication, ets. there is close correlation between extension of mof and death, developement of nasocomial infection. immunologic disfunction. in order to prgnose probability of risk of mof development among the patients with sepsis and septic shock, we achived an eqation, allowing to recive a coeficient, closely connected with this probabiliti. we have used retrospective analisis of cases of sepsis. diagnosis of sepsis was based according to bone's criterions of sepsis. mof was assessed as disfunction of or more systems according to bone's classification of mof. having used correlation analisis we have estimated factors which have had high correlation coeficient with the probability of development of mof. there were: apache-ii score points, evidenceof septic shock, endocrinopathy. with the help of multyple regression analisis we acheved next equation: y= , + , x~ + , x + , x , were x i-apache-ii score points, x -evidence of septic shock, x -endocrinopathy. the explanatory power of this quation was evidenced by roc of . , se (v - . introduction: the presence of liver dysfunction in the process of multiple organ failure is associated with an adverse outcome, particularly when it becomes progressive to liver failure. disturbances of liver function may occur early and their detection may be of significant importance for the further development of organ failure. routinely used liver function tests appear to be inconsistent indicators of hepatic damage. in this study, we used p_lasma disappearance rate (pdr) of indocyanin-green dye (icg) as an early estimate of liver function. methods: we serially evaluated pdr and routine liver function tests (serum bilirubin, sgot, sgpt), as well as acute phase and non-acute phase proteins (crp, transferrin) in patients during the first week after trauma or the onset of sepsis. patients: group : (n = ) multiple trauma iss > , group : (n = ): abdominal sepsis, acute necrotizing pancreatitis (anp) grade iii. patients were selected on the basis of clin cal estimates that these patients would require continued icu observation. pdr was determined by means of a fiberoptic catheter and a computerized system (cold z- , pulsion), which permits repeated bedside measurements. the initial values of pdr, serum bilirubin and transaminases were not significantly different in trauma, sepsis and anp. in trauma patients pdr improved during the first week. in patients with sepsis and anp pdr remained low and worsened with time. the decrease in pdr preceeded an increase in biochemical liver function tests in these patients. + . &-_ ( - ) discussion: routinely available blood tests of liver function are usually altered several days after injury. however, they are generally non-specific indicators and they are influenced by extrahepatic factors. pdr seems to be useful to evaluate impaired liver function early after the onset of sepsis and trauma. objectives: to study frequency of organ system failure (osf) and it's influence on outcome in granulocytopenic patients with hematological malignancies and septic shock(ss). materials and method: retrospective review of medical records of granulocytopenie(wbc< , xl ) patients with hematological malignancies and ss, who were admitted to the intensive care unit (icu). frequency of osf before and after ss was analysed. the patisnts were categorised on survival and non-survival. results: signs of osf were observed in . % of patients before ss and in all patients after ss. only patients presented with hypotension refractory to inotropic therapy. nevertheless there was a significant increase of frequency of acute respiratory failure (arf), acute renal failure (arenf) and liver injury (li) after ss occurred(showed on the figure). only frequency of organ failure before and after objectives: statusmetria allows to define the effective level of oxygen status and accordance to it means of carbon dioxide and elec-trolyte in critical care. the conception of syndrome int~ive care (sic) is exhausted itself and invariable outcomes of sic of multiergan system failure (mosf) confirms that. therefore, an alternative to sic should be advanced. methods: efficlenoy of treatment has been asscsaed in patients with mosf using value of metabolic rate and ability of an organism to cover it by oxygen and substrate supply. oxygen pulse (op) and index of efficacy of oxygen transport (ieto ) was monitored. ~lt~.lntenaive care is considered to be homeostasis-securing therapy (hst) if energostructure deficit is eliminated and necessary for recovery regeneration rate is .restored. op in patients with mosf was . mt-m " , and le,~ and ie'i~ w~ . units in sic. we managed to maintain op of . - . ml.m " and ieto of . - . units in hst. patients from with mosf survived in sic and patients from survived in hst. efficiency of hst appeared to be two times as much as efficiency of sic. cr of homeostasia-se-'uring therapy is advancing. the conception provides restoration of regeneration rate due to effective then in sic elimination of en=gostructure deficit. the conception may be a basis of new technology for treatment of mosf. helen f goode phd, nigel r webster phd. anaesthesia & intensive care, university of aberdeen, ab zd, uk. objectives: xanthine dehydmgenase is converted under conditions of ischemia, reperfusion and endothelial damage to xanthine oxidase, with superoxide anion as a co-product of its catalytic activity. multiorgan dysfunction syndrome is associated with splanchnic vasoconstriction resulting in significant and prolonged gut ischaemia. aggressive volume resuscitation with prompt restoration of blood flow results in reperfusion of the tissue and is likely to cause xanthine oxidase-mediated release of oxygen-derived radicals. this study investigates xanthine oxidase activation and oxygen-derived free radical-mediated damage in such patients. methods: fourteen consecutive patients on itu who met established criteria for septic shock and secondary organ dysfunction were studied. serum xanthine oxidase activity was measured using oxidation of a chromagen in a dual enzyme system and plasma malondialdehyde was measured using a specific spectrephctometdc assay. apache ii scores, blood pressure, svr, cardiac output and day survival were also recorded. biochemical data were compared with results from healthy subjects. results: xanthine oxidase activity was . + . units/i in patients (mean :t: sem) and . + . units/i in controls (p<o. , mann whitney u test), and was highest in the patients who survived (p< . ). malondialdehyde concentrations were elevated ( . • . prnol/i compared with . • . pmol/i in controls, p< . ). xanthine oxidase activity did not relate to apache score or any of the cardiovascular parameters recorded, and was not influenced by the degree of organ dysfunction. conclusions: patients with sepsis and secondary organ dysfunction have xanthine oxidase activation and evidence of free radical damage. the finding that activity was highest in those patients who survived suggests that reperfusion was incomplete in patients who died, with decreased tissue xanthine oxidase ~tash out' into the circulation. influence objective : evaluation of the feasibility of measuring the intragastrie partial pr~sure of carbon dioxide (pco ) using a chemilumin~nt optode and fibre~ptics originally developed for intrav~cular blood gas monitorlng(p ) methods the pco electrode w~ calibrated i~-vitro according to the m~ufaeturers instructions the sensor w~ then stripped of its outer c~ing and threaded down the pile tube of a g~ c enema e (gt) so ha he ens ng portion sat well within the balloon. the modified gt was inserted n~og~trically after induction of anesthesia in ten patients undergoing c~diopuimonary byp~s throughout results: according to the datas of integral rheography % of patients were revealed to have hypodynamic type of blood circulation (cardiac output was decreased on - % and general peripheral resistance increased on - %). it was effective to use complamin (xantinoli nicotinas) in the complex therapy of su~h patients. the dosage was - mg/kg during - days. as a result of such therapy was also the oliguric stage shortening (ac n ).in , % of the cases unsatisfactory datas of central hemodynamic,combined with high (more than cm h ) venous pressure,lung oedema.then nanipruss ( , - , mkg/kg/min) was succesfutly used in complex with routine therapy.in the patients with low cardiac output and low general peripheral resistance mesaton ( , - , mg/kg) and dopamine ( - mkg/kg/min) were effective.change for the worse in the hemodynamics datas, inspire of therapy during - days,was prognostically unfavourable. conclusions:we consider early diagnostic of hemodynamic disorders and adequate correction of them is one of the most important factors, determined the outcome and prognosis in arf patients. obiective: to evaluate the results of renal replacement therapy (rrt) in surgical icu patients with acute renal failure (arf). arf in icu patients is associated with high mortality rates. we investigated the relation between mortality and organ failure in different categories of surgical icu patients receiving renal replacement therapy (rrt) for arf. methods: the records of surgical icu patients with arf requiring rri-(haemodialysis or cavhd) were examined. five different patient categories were defined; .ruptured aneurysm of the abdominal aorta (raaa) n = .elective vascular surgery (evs) n = .abdominal sepsis n - .trauma n = .others ( e.g. malignancy, obstetric emergencies) n- seven organ systems (cns,circulatory,respiratory,hepatic,renal,digestive,haematologic) were scored for possible failure using the mof score. results: mortality was as follows: all patients % , group % , group % , group % , group % , group % . mortality increased with the number of failing organ systems; mortality for all patients with > failing organsysterns was % the only exception being the subgroup of trauma patients where mortality under these circumstances was o% conclusions: mortality in surgical icu patients receiving rrt for arf is high. no significant difference in mortality is found between raaa and evs. mortality increases with the number of failing organ systems. the subgroup trauma patients shows a lower mortality compared to the group as a whole, even with > failing organ systems. to look for the most accurate scoring system to measure the severity of the complications occuring in the early phase ( first day) of kidney transplantation and to asses their prognostic value. methods: in our retrospective study we applied the apache li and the goris scoring system for the kidney recipients who developed multiple organ failure (mof) as a consequence of their pulmonary and. cardiovascular complications following kidney transplantation. we evaluated the recipients the distribution of the women and men ( % ~ % ) was the same as in the kidney recipients. applying the apache ii system most of the patients had their score between and , and the function of , or organs were affected at the time of the onset of mof. the apache ii system gave adequeate information about the disturbance of the function of other organs beside the kidney failure even at the time of the transplantation. the scores and the number of the affected organs correlated with the condition of the patients in the goris scoring system but not as sensitively as in the apache ii scoring system. conclusions: both the goris and the apache ii scoring system can be applied to measure the severity of the multiple organ failure occuring during the early phase of kidney transplantation. however the apache ii system is more suitable to follow not only the stateof the patients at the time of the admission but also the changes occuring in their condition during the complication. v.v.erofeev, v.v.ivleva scientific research institute for general reanimatulogy russian amsci, moscow, russia objectives: the analysis of ssc and results of their treatment in patients following critical states showed the necessity of developing a combined antibacterial therapy. methods: according to the protocol patients ( - years old) with combined trauma and massive hemorrhagy following vast aml traumatic operations were examined. microflora's composition and resistence to up-to-date antibiotics was studied using the anaiyser iems reader by "labsisteme"(finland). general clinical, bacteriological, immunological indices, as weil as the duration of the treatment and recovering rate served as criteria of the combined antibacterial therapy effectiveness. results: it was proved expedient to administer antibiotics in staphylococcus infection in the following combinations: riphampizin with fluoroquinolones; i-ii degeneration, cephalosporins with aminoglycosides; cephalosporins with fluoroquinolones. in case of singling out the exciters of the euterobacteriaceae family, including the pseudomonas aereginosa, -fluoroquinolones combined with modern amynoglycosides; fluuroquinolones with ureidopenicillines; ureidopenicillines with amynoglycosides; amynoglycosides with the ii-iii generation cephalosporins; cephalosporins with fluoroquinolones. in severe ssc caused by combined infection (including anaerobes) clindamicin with modern amynoglycosides was prescribed. conclusion: the combined antibacterial therapy allows: ) to increase the effect on microbic agents and the efficacy of treatment in combined infections; ) to lessen the possibility of the exciters'resistence to antibiotics; ) to prevent the development of superinfection: ) to decrease the doses of medicine and its toxic effect. objectives: two methods of blood volume measurement in a group of critically ill patients were compared to investigate the practical possibilities of a new easy to use method based on carbon monoxide (co) uptake. methods: all patients had multi-organ failure and haemodynamic monitoring with a swan-ganz catheter. mean apache ii score was ( - ). when indicated, patients had blood volume measurements simultaneously based on the techniques of, i) dilution of ~cr labelled red cells, and ii) inhalation of carbon monoxide gas with measurement of the rise of carboxyhaemoglobin produced. the co was administered via a newly designed, ventilator driven, fully closed circle system ensuring co retention and co removal with automatic addition of oxygen to m}ttch patient uptake. a portable computer performed all necessary calculations. results: volumes obtained by co uptake were compared with the "gold standard" radiolabelling method. mean blood volume determined by the co method was ml ( - ml) compared with ml( - ml) with slcr labelled red cells (r= . ). regression analysis produced an intercept at ml. the slope of the regression line was . ( . - . , % confidence limits). discussion: the co method produces volumes in excess of the radiolabelling method. there appears to be a systematic error, and one possible explanation is co binding to substances other than haemoglobin. conclusion: the co method is easier to use than radiolabelling and of the lower cost, since cohb measurement only is required. aceuraey is sufficient for clinical use and our preliminary findings suggest this system will meet the requirements. objectives: this study was conducted to determine the role of nitric oxide (no) in the pathophysiologic alterations and multiple organ damage, and the possible effects of " " " (l-n -monomethyl-l-arglnlne nmma) on hemodynamics and mortality in rats caused by a prolonged hypovolemic insult. methods: a prolonged hemorrhagic shock ( - mmhg for rain) was induced in anesthetized rats followed by adequate resuscitation. l-nmma was administered intravenously at doses of . mg/kg or . mg/kg at the end of resuscitation. results: infusion of . mg/kg l-nmma diminished the fall in mean arterial pressure, significantly increased the cardiac index (ci) and stroke volume (sv), together with remarkable protection from multiple organ damage compared to the controls. the h survival rate was significantly improved from . % in the control group to . % in the treatment group (p< . ). in contrast, the high dose of . mg/kg l-nmma resulted in a strong blood pressure response but a marked reduction in ci and sv concomitant with an increased total peripheral resistance index within the observation period, and caused severe damage to various organs at h after treatment. in addition, marked elevation in both endotoxin and tnf levels were observed in animals subjected to shock insult. conclusions: these results suggest that no induced by hemorrhagic shock in rats is an important mediator for pathophysiologic alterations associating with cardiovascular abnormalities, multiple organ dysfunction, and even lethality. thus, regulation of no generation and use of no inhibitors might provide new aspects in the treatment of hemorrhage related disorders, and the use of l-nmma would be either deleterious or salutary in a dose dependent manner. (hebert, chest- ) . the purpose of this study was to assess the risk factors for hepatic dysfunction in mosf. methods: patients have been hospitalized in our icu from january to may . , ( %) with mosf. among mosf pati~ts, ( %) have had hepatic dysfunction defined according to hebert (bilirubin ~ ttmop , chest ). thirty six of these patients acquired hepatic dysfunction after admission in the icu. these patients were compared with mosf patients without hepatic dysfunction selected blindly. chrorfic diseases, severity scores, eanse of admission, clinico-biologieal and hemodyunrrfic parameters, use of vesopressors, use of hepaiotoxic drugs, use of nutritional support and mortality were compared for hepatic failare and non hepatic failure groups.twenty nine patients had postmortem hepatic histologic examination, results: univaciate analysis: only parameters with p _< . are pre~nted. including these paramet~'rs in a multivariate analysis, anly c~hosis and vascular surgery remain independent risk factors for hepatic dysfunction. in particular, pao /fio , arterial lactate, do were not different between the two groups, some de~'ee of histological abnormalities was found in all liver samples, despite a normal bilirubin level in % of the cases conclusions: in our patients, conu'ary to previous studies, hypoxic and hemody~anfic parameters were not independent risk factors for hepatic dysfantion. this might be due to the inadequacy of the usual biologic definition of hepatic dysfunction as well as to the poor sensitivity of general hamodynamic parameters. critical states of various origin are complicated with the mldtiorgan farm (moi~ oceuzr~ce. due to their and functional features the lungs become the primmy damage target in various critical.states. ard that occurs in such states is associated with pulmonary edema development because of capillary permeability increase mediated by humeral and cenular responses to amag/~ factors exposure. r nmst be emphasized that mediators and effecto~rs of this respo~e affect not only puknonary capillaries, but other organs capiu~es as wellenhancing their permeability. orsans edema is a conmm~ finding at the autopsy of patients died from mof.clinical and radiolosial findings allow to have a diagnosis of pulmonmy edema before ~mi!ar lesions in other organs occm. additionally, there are some techniques that permit quantitative assessment of pulmonary edema flv.id (evlw) volume. in conclusion, we suggest that evlw changes in .dyn~rmcs in patients with mof are considered as a critical state severity measure which reflects indirectly the edema in other organs. objectives: we compared three different dialysis membranes to find out whether or not there were differences between their clearance characteristics on substances such as inuline, creatinine, urea, and phosphate to be eliminated in acute renal failure (arf). moreover, if a loss of clearance did occur we were interested in whether this was due to heparinization and a high production of the thrombine-anti-thrombine-complex (tat). methods: we carried out a randomized controlled study on consecutive critically ill patients presenting with arf, most of them in association with multi-organ failure, to be treated by continuous pump-driven arterio-venous renal replacement therapy on continuous low-dose heparinization. three different types of high-flux filter membranes (f tm [fresenius] , ct tm [baxter] , and filtra tm [hospal]) were assessed. each filter was changed intentionally after a hours" use. together the data of filters were evaluated, each at three different times (immediately after its onset [ hi, after h, and after h). the clearances of creatinine, urea, phosphate, and inuline were measured. results: there were some significant differences in clearance characteristics of inuline, creatinine, urea and phosphate between the filters (p< , ) showing the f tm membrane excelling filtra mand ct tm the more. the loss of inuline clearance ( mi/min/m ) after h, however, was insignificant for all filter types. a continuous low-dose heparinization scheme was applied without any relevant prolongation of the aptt. even lower losses were noted for the clearances of creatinine, urea, and phosphate. we found the tat-producfion increased after h (p< , ), but it did not rise any further. conclusions: as we could demonstrate in our study the clearance data of different types of filter membranes applied during continuous renal replacement therapy do show significant differences. on the other side, no relevant loss of clearance occurs during a hours" period indicating a high efficiency over time. to consider commercial aspects as well it shows that inexpensive conventional filter membranes can successfully be applied even for a longer renal replacement period, if needed. a retrospective study was performed on patients with acute renal failure (arf). we analysed survival in continuous (cd) and intermittent dialysis (hi)). mean age of the patients was years (y), patients ( % ) were < y, patients ( %) were >= y. the incidence of dialysed arf in our mixed intensive care departement is %/admission/y. statistics: fischer's exact test, mann-whitney-u test. efioloev: the contribution sepsis, cardiac failure and aminnglycosidcs was respectively %, % and %. treatment: cavh (cd) or cvvh (cd) was used in patients ( %), hemedialysis (hd) was used in patients ( %). data: mean apache scores were the same for cd and hd ( for both groups), patients treated with continuous dialysis techniques had significantly (p<o, ) more need for ventilation ( % vs %), elevated bilirubin ( % vs %) and a higher vasopresser need ( % vs %@ than patients treated with hemedialysis. there was a trend towards more sepsis ( % vs %; p= . ) mad coaguiation disorders ( % vs %; p= . ) in cd. taere were sign/ficantly more younger patients (< y) treated with cd ( % vs %, p< .os). mean apache score was significantly lower in patiants< y than as patienta>= y ( vs ; p< . ). patients< y had significantly (i}< . ) more coagulation disorders ( % vs %) and elevated bilirabin ( % vs %). there was no significant difference in vasopressur need and ventihatio~ between age groups. outcome:. hi) had a better sr compared to cd ( % vs ~ p< . ). patiants>= y had a comparable sr vs patients< y ( ") */e vs %; p----a.s.). tha global survival rate (sr) was % ( patients). conclusions : diaiysed arf has a well known lowsurvival rate ( %): hc~raedialysed patients had a better survival rate than patients treated with continuous dialysis. this can be explained by the fact that the latter were in a worse condition considering organ failure (more vantilatian, elevated bflirubin and need for vasepressurs), apache score couldn't illustrate that. patient~ y with arf have the same survival rate as patients< y: although patients >=- y have a higher apache score they have less organ faille. the avacbe score is not a good oredictor of survival in p with organ failure. departments of surgery and intensive care, guy's hospital, london, u.g-obiectives: a randomised controlled trial of a management protocol utilising the regular measurement of gastric intramucosal ph (phim) to control the administration of dopexamine. methods: patients admitted to a multidisciplinary teaching hospital intensive care unit (icu) undergoing insertion of a pulmonary artery catheter were managed according to a resuscitation protocol. randomisation was to either the protocol alone or to insertion of a nasogastric tonometer and subsequent management guided by phim. phim < . initiated volume and inotrope resuscitation and, if unsuccessful in elevating phim, dopexamine was commenced. approval was obtained from the hospital ethics committee. results: patients were considered for analysis and the two groups were well matched for age and sex. overall, there was a high hospital mortality of . %. there was no difference in icu or hospital mortality between the two groups (see table) . objectives: to compare cardiac output (co) measurements between continuous termodilution (cco) by thermal wire on pulmonary artery catheter (cco/svo vigilance. baxter critical care), and co measurement using a trans-esophageal doppler (dco) ultrasound system (odm ii, abbott laboratories), in the immediate postoperative period of cardiac surgery. methods: patients undergoing myocardial revascularization were monitored with cco by a swan-ganz catheter and an intra-esophageal dco probe, after induction of anesthesia. exclusion criteria were: aortic valve disfunction, previous valvular surgery esophageal disease, absense of sinus cardiac rhythm, and need of ventricular or intraaortic assistance. hemodynamic parameters, co by both cco and dco, svo . sao , diuresis, pha, and hemoglobin were repeatedly registered during the first hours after surgery, as the patients were kept under sedation and mechanical ventilation. results were compared using the method described by bland and altman. results: measurements of co were obtained, ranging . objectives: a decreased tissue oxygen delivery is responsible for a higher morbi-mortality rate among surgical patients; this diminished oxygen delivery/consumption rate (dojvo ) may origin the lactic acidosis observed in the gastrointestinal tract, reported in patients undergoing hypothermic cardiopulmonary extra corporeal surgery, and can be registered by tonometry as result of the gastric mucose ph. the purpose of this study is to evaluate the reliability of the intramucosal ph (phi) measurement by a nasogastric catheter as indicator of the do /vo > its co> relation to other parameters of do /vo disturbance, and with postoperative complications and clinical course. methods: patients ( male, female) undergoing cardiac surgical procedures were included ( myocardiai revascularizations, valvular substitutions, constrictive pericarditis). mean age was + years, mean weight _+ kg. a nasogastric probe (trie tonometrics) was placed after anesthesia induction; phi values were registered in the postoperative period ( ', ', ", ' and h after surgery end). the corresponding hemodynamic parameters, venous oxygen saturation (svo ), diuresis and arterial ph (pha) were also recorded. results: phi values ranged . to . (mean . ( . ); the mean values of clinical evolution were: extubation time, _+ hr.; discharge from postoperative care unit, - hr.; and hospital total postoperative time, _+ . days. complications registered were: perioperative acute myocardial infarctions, cases of respiratory insufficiency, occlusion of coronary bypass, an ease of hyperamilasemia. all patients with severe complications needing specific treatment showed either a low phi value, or a considerable descent in comparison with the initial register. statistic correlation between low phi and presence of complications was found; the low significance (p > . ) degree may be due to the low population size. conclusions: phi measurement in cardiac surgery patients is a non invasive, uncomplicated method for prediction of doz/vo disturbances, thus reflecting risk of increased major complications, and may precede changes in other usual indicators (svo , pha, cardiac output, ...). work-in-progress with a greater population size may offer more significant results. references: ( ) gutidrrez g: lancet ; : - . ( ) landow i: acta anaesthesiol scand ; : - . the haemoglobin-level (hb) is besides the arterial oxygen saturation and the cardiac index one of the relevant parameters of oxygen supply to the tissue. in contrast to otherwise healthy patients, there is no agreement on tile so-called transfusion-trigger in critically ill patients. in i?ont of this background the question arises, whether and to what extent blood transfusion in critically ill patients improves oxygen supply io tile tissue. this study was performed in critically ill/septic patients in the postoperative period alier an inlcclive/scptie revision operation of the hip or knee joint. on cardiac/seplic reasons monitoring consisted beside other measures of a pulmonary arlery catheter and of an indwelling arterial line li~r measurering/calculating standard haem~dynamic as well as systentic oxygen parameters. the indication for blood transfusion was given by hb together with the cliuical slatus of thc patienl (asa-scorc and multiple organ dysfunction (moi))). statistical analysis w~ks performed by mann-whitney-u-test. by fisher's exact-test and by wii.coxon-test: statistical significance was set with p< . . according tu the pretransfusion value of hb and of lactate (lac) palicnts ;,,'ere divided into groups as follows: a: hb< and b: >sg/dl: i: ac< . and ii: > .smm. in either group blood transfusion results in zt significant increase in hb (a: . _+ . to . + . g/dl; b: .(~ . tt, . + . g/dl; i: . -+ . to . -+ . jdl; i : . -+ . to . + . g/dl). wlailc, however, haemodynamic parameters do not difl)r significantly from each other before and alter blood transfusion, oxygen delivery (do, -ml/min x m-') increases significantly hi either group studied (a: -+ to -+ ; b: + to + ; : -+ to -+ ; i : -+ to -+ ), in contrast oxygen consumption (vo~ -ml/min x m e) does not change significantly in either group (a: i -+ to -+ ; b: -+ to -+ ; i: -+ tu -+ ; : -+ to +_ ); oxygen exlraction ratio decreases. this study in critically ill/septic patients demonstrates, that in this group of patients studied blood transfusion at a base-line-value of > . -+ . g/dl expectedly rises do~, however, it does not improve vo=; even not in septic patients with elevated lac-values. paclitaxel in a new anticancer agent, extract from the bark of the yew tree (taxus brevifolia), employed against breast and ovarian cancers resistant to chemotherapy. it promotes the polymerization of tubuline, and disrupts the normal microtubule dynamics. hematologic toxicity, hypersensitivity reactions (bronchospasm, urticaria and hypotension), and peripheral neuropathy are the main reported toxic effects. cardiac side effects are rare: atrioventricular blocks of higher degree are reported in . % of patients; congestive cardiotoxicity was discussed only in one trial in patients treated with paclitaxel and doxorubicin. we describe the history of a -years-old worn an with a breast cancer, diagnosed in , initial staging t nim , treated with mastectomy, axillary lymphadenectomy, andchemotherapy with a cumulative dose of anthracyclines of mg/m until august . the patient complained of dyspnea and severe hypotension immediately after an intravenous infusion of mg paclitaxel, given over hour for the treatment of bilateral, malignant pleural effusion. at echocardiography die left ventricular ejection fraction was reduced to %. she died days later because of a severe cardiac low output with hepatic and renal failure; an impressive hepatic cytolysis was observed. the post mortem examination confirmed the dilatation of the cardiac cavities, especially of the right ventricle, bilateral pleural fluid, and ascites. the histology was suggestive for a cardiomyopathy secondary to anthracyclines. the electron microscopy revealed a deposition of an unusual pathological pigment in the myocytes; subsarcolemmal deposition or membranous were absent. we hypothesize that paclitaxel was the cause of a major hypersensitivity reaction with shock and severe hepatic cytolysis, worsening the myocardial damage induced by anthracyclines. the possibility that a low doge of paclitaxel could directly increase anthracyclines cardiotoxicity -as decribed in the medical literature -will be discussed. objectives: activated endothelial cells release soluble intercellular adhesion molecule- (sicam- ), vascular cell adhesion molecule- (svcam- ), and e-selectin (selam- ). sicam- , svcam- , selam- , and inflammatory cytokines were determined. methods: sicam- , svcam- , and selam- were determined by elisa. tnf-a, il- , and il- were also measured by elisa. endotoxin was measured by an endotoxin-specific endospecy test after pretreatment of new pea method. results: the sicam- and s vcam-i levels were significantly higher in the septic multiple organ failure (mof) and sepsis groups than in the non-septic mof group. the selam- level was slightly higher in the septic mof group than in the sepsis withut mof group and non-septic mof group. the increases of soluble adhesion molecules were not in agreement with changes of plasma endotoxin level. levels of soluble adhesion molecules were correlated with the levels of plasma tnf-a and il- , but the level of il- . discussion and conclusion: the slcam- and svcam- levels in septic patients closely reflected the severity of the pathophysiological conditon. it was possible that the release of sluble adhesion molecules were not stimulated by plasma endotoxin, but endotoxin in the local infectious region. tnf-c~ and il- also were suggested to be involved in the release of these soluble adhesion molecules. obiectives: cardiopulmonary bypass (cpb) surgery is associated with a systemic inflammatory response attributable to the release of various inflammatory mediators and the activation of complement or coagulofibrinolytic system. in addition, adhesion molecules, such as icam- , elam- , and vcam- , appear to be of central importance in the inflammatory process following cpb surgery. we previously reported the effects of a synthetic protease inhibitor, fut- , reduced release of inflammatory cytokines (tnf, il-lg, il- ), activation of complement (c a, c a) or coagulofibrinolytic system (tat, pic, fpa) and protected platelet function (gpib, gpiib/llla) following cpb surgery. methods: in this study, we analyzed fut- on soluble adhesion molecules following cpb surgery. patients undergoing cpb surgery were divided into two groups, group a consisted of patients who received omg of fut- in priming solution, followed by a continuous infusion at mg/kg/hr during cpb in addition to initial heparin dose of mg/kg. group b, a control group, included patients who were injected with heparin only. the plasma slcam- , selam- , and svcam- concentration was measured by elisa. results: every soluble adhesion molecules decreased during cpb in both groups, and rose after cpb. selam- and slcam- reached their peaks on hours after cpb and on pod respectively in both groups, but they remained lower in group a (selam-i: . + . vs. . • ng/ml, p< . , slcam-i: • vs. • ng/ml, p< . ), svcam- , in both groups, remained lower than preoperative levels, but did much lower in group a. conclusions: fut- reduced adhesion molecules and suggested to be the effect on postoperative organ dysfunction. in the last few :,'ears the conditions of treatment in continuous hemofiltration/hemodiafiltration were discussed controversially. a significant removal of tnf-alpha and il-i could be demonstrated in cvvhd. the aim of our study was to investigate the elimination of tnf-alpha, l- , il- , il- , s-cd- and ifn-gamma in cvvh by measurement in plasma and hemofiltrate of critically ill patients with an acute renal failure. the patients of our study were treated with a continuous veno-venous-hemofiltration (polysulfone-filter, blood flow: - ml/h, filtration rate ml/h). the samples, hemofiltrate and plasma, were taken one hour after the start of treatment. the patients suffered from septic shock ( ), the so called hepatorenal s~aldrome ( ) and a severe pancreatitis ( ). the cytokine concentrations were measured with elisa-method. in contrast to elevated concentrations in plasma for tnf-alpha ( cases), scd ( cases), il- (l case) and il- ( cases), hemofiltrates contained no activities. only il- was removed in significant amounts with even higher levels in hemofiltrate than in plasma. this phenomenon was described so far for tnf-alpha and il- and may be due to the absence of metabolic properties (possibily enz~natic) in hemofiltrate. it can be shown, that tnfalpha, il- , il- could not be eliminated in cvvh with a filtration rate to ml/h. in contrast to findings of other investigators with a higher filtration rate (> ml/h), we found no significant concentrations of tnf-alpha and il in hemofiltrate. we conclude, that for a significant removal of important cytokines higher filtration rates (> ml/h) are necessary. objectives: multiple organ dysfunction syndrome including liver and renal impairment is a fatal complication in patients with the diagnosis of sever sepsis. this study focused to the effects of removing toxic substances from inflamnatory tissue by hemodiafiltration. ~ ethods: eleven patients were admitted to the icu in emergency center and met the criteria of systemic inflammatory response syndrome in association with infection. all patients developed liver and renal dysfunction and were treated by hemodiafiltration with high flux membranes (fb-u:nipro). the hemodiafiltration were performed times using nafamostat mesilate as an anticoagulant in hours with l of substitution fluid (hf-b:fuso). the serdm levels of endotoxin, cytokines, endothelin-i (et-]), human neutrophil elastase ~ -proteinase inhibitor complex (hne-pi), fibronectin (fn), lactate, and amino acids were measured before and after the hemodiafiltration. the hemodiafiltration would be effective to renal dysfunction by reducing endothelin and beneficial to tissue metabolism represented in fisher's ratio, but might be harmful to respiratory function by activating neutropila in patients of severe sepsss. background : intermittent hd may be poorly tolerated in the early phase of arf in hemodynamically unstable patients (pts). this technic may fail to achieve steady state urea low levels in hypercatabolic pts. method : nt = consecutive pts treated with hd; n = consecutive pts treated with cvvhf. hemodynamic unstability is defined by arterial hypotension and requirement of inotropie support despite adequate filling. rate of change in urea (u), ereatinin (cr), k + , ph were computed from a linear regression .analysis of data vs time in each treatment group during the first days of application of the two technics (anova). dally worst values were recorded. results : hd-group : apach% score = _+ ; mean number of organ system failure (osf) = . -+ ; mean blood pressure (mbp) = • mmhg (first day of application of hd). cvvhf-group : apachen score : + ; osf = -+ ; mbp = + mmhg (first day of application of cwhf discussion : during the first days of application of hd/cvvhf, u and cr decreased much more rapidly in the cwhf-group. k* and ph were maintained within normal range in the two groups. initial mbp which was much lower in the cwhf-group significantly improved during the application of cvvhf while mbp remained unchanged in the hd-group. conclusion : despite higher severity of disease in cvvhf group (apachen score, osf, lower initial mbp), we obtained a better performanco with cvvhf regarding the decrease of u and cr and the improvement of mbp. in relation to the different and continuous renal replacement techniques, the continuous venovenous one is the alternative method to continuous arteriovenous for critical patients with acute renal failure (arf). we present you our experience with cvvh in patients with mof. in our intensive care unit (icu) patients with mof were treated with cvvh in the period between january in to march in . the mean (• age of our patient population was , • years, being % male and % female the whole patient population was with mof iust at the moment the technique was accomplished; % was in mechanical ventilation, % needed vasopressor support and % required both of them (mechanical ventilation and vasopressor support) apache ii score mean of the patient population was , ~: , (range - ) and ati of them were with arf oligoanudc. technique: cvvh was accomplished using a single-d~al iumen catheter, ptaced in either a temoral or subclavian vein by the stand ard seld{nger technique. pol{sultone hemofitiers were also used, and the extracerporeal circuit used standard arterial-venous blcod tubing. blood flow and hence oltrafiltration pressure, within the circuit was generated by a roller blood pump. the modulus has a roller pump, a pressure transducer connected in an arterious and venous line, such as an air-transducer which is adapted to a drip-chamber in the return way. the replacement used was a peritoneal dialysis solution. medicine , st. george's hospital medical school, london. england. hepatic sinusoidal endothelium shows a major inflammatory response in porcine sepsis that can be attenuated by the administration of dopexamine hydrochloride. dopexamine is a beta and dopaminergic receptor agonist. the specific beta adrenoceptor antagonist ici has been shown to reduce the protective effects of dopexamine. we investigated the effect of this antagonist on hepatic ultrastructure in porcine sepsis. six pigs ( - kg) divided into groups were anaesthetised and intubated. cardiac output and portal blood flow were measured using standard techniques. the groups were; placebo, (peritonitis induced); blocker, (peritonitis induced and pg/kg ici bolus infused then given hourly). caecal content was aspirated and peritonitis induced. colloid was infused to maintain pawp at - mm hg for eight hours the animals culled, hepatic tissue removed and prepared for electron microscopy. in the placebo group hepatic endothelium was swollen and the sinusoids occluded by wbc. but in the ici blocker group, much of the sinusoidal endothelium was absent and there where large extra sinusoidal spaces among the hepatocytes. an assessment of the two groups showed worse hepatic architecture in the blocker group. the b antagonist blocked any protective effect of endogenous beta adrenoceptor agonist (adrenaline) on hepatic endothelium in porcine sepsis. george's hospital medical school, london. england. dopexamine hydr chloride, a beta and dopaminergic receptor agonist reduces hepatic damage in porcine sepsis. we tested dopexamine's effect on cerebral oedema. the beta adrenoceptor antagonist ici was infused to block any protective effect of dopexamine. nine anaesthetised pigs ( - kg) were randomised into groups; placebo, (peritonitis induced); dopexamine, (peritonitis induced and ~tg/kgdar of dopexamine infused); blocker, (as in dopexamine group but in addition pg/kg ici bolus given then infused at that rate hourly). caecal peritoneum was induced and colloid infused to maintain pawp at - mmhg for eight hours when the animals were culled, cerebral tissue removed, prepared for electron microscopy and digitisation. digitisation of the area of oedema surrounding the blood vessel and expressed as a percentage of the micrograph. . _+ . , dopexamine . + . ", blocker . + . . data expressed as mean + sd. significance p< . . * dopexamine compared to placebo and blocker. in the dopexamine group the area of tissue oedema was significantly lower than either the placebo or blocker groups. there were no significant differences between the placebo or blocker groups. the antagonist completely blocked the protective effect of the drug on cerebral oedema in porcine sepsis. beta adrenoceptor stimulation is protective of cerebral oedema in porcine sepsis. objectives: the hemodynamie~ of hepatic circulation during multiple organ failure (mof) have not been suffleienly studied. we investigated liver hemodynamics in two subgroups of patients with mof, those with either liver or lungs as the main organ of involvement. methods: three groups of patients were created: i) mof-hepatic involvement (mof-hi) ( patients) with bilirubin > . mg/dl and lung injury score < . , it) mof-ards ( patients) with respective values < . and > , iii) patients with head injury with respective values < and < , served as group control. all patients were in haemodynamieally stable state with an oxygen delivery index > ml/min/m prior to measurements. two swan-ganz catheters 'were inserted, one in the hepatic veins and one in pulmonary artery and the following measurements were determined: the hepatic vein free pressure (hvfp), the hepatic vein wedge pressure (hvwp), cvp, paop and co. the gradient of hvwp-hvfp represents liver perfusion pressures. by injecting contrast media at dose of iml/lokg with the balloon inflated to achieve sinusoidai image, the hepatic blood flow (hbf) was concluded by the time in seconds of media removal after balloon deflation. results: the co, cwp and cvp were comparable to all three groups. namely, for mof-hi, mof-ards and control groups the mean (+sd) value of co was . _+ . vs . _+ . (ns) and . _+ . respectively, of the paop was . +_ . vs +: (ns) and . + . respectively and of the cvp was .+. . vs . + . (ns) and . respectively. in contrast the two mof groups were different after the cut-offinclusion criteria ie the mean (+sd) value for bilirubin was . + . vs . + . ( < . ) and . _+ . respectively and lung injury score was . objectives: oxygen delivery (do ) and oxygen consumption (vo ) are increasingly monitored parameters in the icu. there still remain controversies about an oxygen supply dependency in critical illness particularly with respect to vo determination by either indirect calorimetry (vo m) or tick calculation (vo c). the purpose of this study was to investigate the changes in vo m and vo c following do increase. methods: the relatives of critically ill patients (mean age years, mean apache ii , mean mof-score ) gave their written informed consent to participate in this institutionally approved, prospective study. do was increased by fluid loading (hydroxyethylstarch %: mean volmne ml, mean duration of infusion min) and catecholamine support (dobutamine: mean dose , ~g/kg/min). changes in vo m and v c were recorded sinmltaneously before, during and following interventions. calorimetry was obtained with the metabolic monitor integrated in the ventilator (puritan bennett, carlsbad, ca adaptive endocrine response of organism to septic shock consisting in activation of the production of adrenal hormons, renin -angiotensin -aldosterone system (raas) and other hormonal systems has an influence over microvascular changes in these states and for development of multiple organ failure (mof). in patients with peritonitis of different origins ( nonsurvivors and survivors) were followed the changes in cortisol level and raas by radioimmunological methods and many variables for evaluation of respiratory, renal, hepatic function, coagulation etc. as a signs of mof. it was observed significant increase of the level of cortisol ( +_ , nmol/ i), aldosterone ( , • , nmol/i). by factorial statistical analysis we found significantly high correlations between hormonal changes and respiratory function (for example r=- , , p < , between cortisol and pao ; r = , , p < , between cortisol and d (a-v) ; olso renin -cao r=- , , p < , , renin d ~,vl o r = , , p < , ). such significant correlations was found and for raas with respiratory, renal function, byproducts of arachidonic acid thromboxan b and p fla, soluble fibrine degradation products etc. these correlations between the degree of endocrine changes and multiple organ failure in patients with septic shock produced by peritonitis suggest that their effects upon peripheral vascular resistance and constriction of the splanchnic, splenic, renal and other organ vasculatures are not always with physiologic expediency and there are perhaps the possibilities of therapeutic influence. intredu~on : dopexamlne has previously been shown to control hyperkalaemia ia patients with acdto renal failure (arf), however effects on the subsequent course of art are undomunente~ ob_iectlv~ : to evaluate clinical progress in patients with acute renal failure (arf) in an intensive care unit (icu) with regard to biochemical control, need for -and time to -dialysis, and outcome in patients receiving dopexamine. m~ods : consecutive patients meeting standard criteria for diagnosis of arf were included in the study. full cardiovas~dar, biechemical and intervention/outcome details were recorded. dopex.~min~ was infilsed at a dose of pg/kg/min in conjunction with a regimen of inotropir support and blood volume optimization. resn]~ : following the intzoduetion of dopc',~mine ilrinr vohlmes increased slightly over the next hrs fzom + ml/ hrs to + ml/ hrs (ns). data expres,uxl as mean + sem. three patients ( %) became polyuric with urine output > ml/hr within days and did not need dialysis. in the remaining patients the time to dialysis (to correct acid-base deficits or volume overload) was . + . days. serum potassium levels were well controlled. day or immediate pre-dialysis levels were . + . mmol/l compared with pre-lreatment . + . mmol/l overall mortality in this series was / ( %). duration of acute dialysis in survivors with renal recovery was . +_ . days. patients ( %) progressed into chronic renal failure and needed continuing renal replacement therapy. no adverse cardiovascular altects were seen at this low dopoxami~ dose although its competitive inhibition to adrenergic reuptake mechanisms meant that doses of pressor agents could often be reduced. : dopcx:~minr nsed in conjunction with inotropic support and blood volume oplimitntion, can safely postpone, or even avoid, the necessity for acute haemodialysis in icu patients. no evidence of tachyphylaxis to the effect on serum potassium levels was seen over the duration of the study. hen'era m., suarez g., dagn d., varela a., ramos j., garoia jm, aragdm c, jurado l, medina a. icu. hospital regional. malaga. spain. objective: to evaluate the haemodinamic tolerance to the veno-venous continuous hemefiltration (vvchf) system in patients with systemic inflammatory response sindrome (sirs), and the possible beneficial effect of this technique on the haemodinamics in these patients. material: patient admitted to the icu, with diagnosis of sirs and monitored with a pulmonary artery catheter at the beginning of wchf. we performed a complete haemodinamic study to all these patients (cardiac output, vascular resistanoss, ph and co in arterial and mixed venous blood samples, saturation of pulmonary mixed venous blood, do and vo calculations and temperature) and determined the respiratory mechanics (compliance and pao /fie relatinship) before starting the procedure, after minutes operating with the ultraflltrate branch closed (without filtered fluid production), afler and minutes of zero fluid balance bemofiltration and after minutes of filtration with negative balanos adjusted to the patients conditions. for the statistical analisis we have performed the anova test over the mentioned variables. results: we have not detected statisticaly significant differences of the analyzed variables before the beginning after operating the pun'@ for minutes without filtered fluid production and after minutes of zero fluid balance hf. only temperature shows a meaningful decrease in time. objectives: among many organs, playing the important role in pathogenesis of multiple organ failure, the particular place is taken by the intestine. ~ethods: the study was carried out in dogs !~n"~h pi was modelled by severe operative trauma (ot). the dcm was estimated by the indices values of work time (wt), contraction frequency (cf), mean amplitude of contractions (~ac) and motility index (mi) measured by method of tensography. "sl", created on the basis of sorbit and sodium lactate ( mosm/l), was injected in the dose of .o ml/ kg into v. cephalica antebrachii after hrs of ot. the results of the present study are the evidence of "sl" stimulative action on dcm and are experimental ground for "sl" using in complex therapy of pi in clinic. with splanchnic venous blood pc p.f. laterre p. goffette, j.p. fauville, a. poncelet, p. loneux, m.s. reynaert. intensive care unit, st. luc univ. hospital, brussels, belgium. determination of gastric intramucosal ph (phi) by gastric tonometry using the henderson-hasselback equation is expected to allow the detection of splanchnic ischemia in critically ill patients. because of bicarbonate concentration and acidbase balance influences on the calculation of phi, it has been proposed to use arterio-gastric pco,_ gradient [p(gast-a)co,] to assess splanchnic perfusion. htpothesis : pcoz in the gastric mucosa is in equilibrium with intraluminal co z and with co, in the blood leaving the stomach (mesenteric and portal blood). objective: mesure pco; and ph in portal vein blood and compare its value with pco and phi obtained simultaneously by gastric tonometry. material and method : in a patient ( y.), a fiberoptic catheter (baxter r) was positionned in the portal vein after transhepatic stent shunt repermeabilisation. hemodynamic parameters, do, (vigilance n baxter), gastric co and phi (tonometrics baxter) and portal blood gas were determined at regular intervals. results : sets of data were obtained and are expressed in mean + sd. gastric pco z was , + compared to , + . mmhg for portal pco . phi was . +._ , vs . +._o, for portal ph. no correlation was found for these parameters. p (gast-a) c was . + mm hg vs + . mm hg for p (portal-a) coz (no correlation). there was a good correlation between do e and p (portal-a) co z (r = , ) [figure] but no correlation with p (gast-a) c . obiectives: desaturation is a common finding during haemodialysis (hd). pulmonary oedema might be one cause for impaired gas exchange ( ). the aim of this study was to quantitate the amount of extravascular lung water (evlw) and gasexchange in chronic renal failure patients during and after a regular hemodialysis session. methods: chronic renal failure patients without symptoms or diagnosis of cardiac or respiratory disease were studied at the start (i), at the end (ii) and two hours after (iii) a regular bicarbonate hemodialysis session. the double-indicator dilution method, with indocyanine green and the stable isotope h as tracers, was used to measure evlw ( ). arterial bloodgases and endtidal co were registered. evlw data was compared to a group of renal healthy patients ( ). dcp n evlw, ml -pao , mmhg h~o +, nmol/l control group - -- l _+ "* -+ _+ crfgroup ii -+ ~ +- ns -+ "(" iii +- t _+ ns -+ t ** p < . dcp i from dcp , t p < . dcp li or i from dcp i, :~ p < . dcp ii from dcp i the evlw at the start of dialysis was larger in the crf group than in the control group. the evlw decreased significantly to a level not different from the control group in response to the reduction in weight after hd. pao~ was normal at the start of hd and showed a nun-signficant reduction after hd. paco ( . + . kpa) and etco ( . + . kpa) were unchanged while h o+ decreased and bicarbonate increased significantly. conclusions: the elevated level of evlw at the start of hd did not impair gasexchange. the decrease in evlw did not inhibit the decrease in pao . the reduction in h + followed by a fall in alveolar vantilation is the most plausible cause for the decrease in pao in bicarbonate dialysis. . prezant lung ; : - . . wallin j appl physio ; : - . a. dona~ d. battis& l col~ r danieli, d. achill~ l viglienz;~ c. giov-anaini, p. piaropao~ oblectives: to verify if intraoperative modifications of mtramucosal gastric ph (phi) below the normal lowest value . , can be predictive for important complications, as perforation, sepsis, mof or death. methocls: we have considered patients who andenvent major abdominal surgery. all patients received the same drugs in pre-anaesthasia, the same type of anaesthesia (balanced anaesthesia) and the same treatment with h -bloekers. after the induction of anaesthesia a gastric tonometer was positioned and a catheter was positioned in the radial artery. during the operation, every minutes, the following parameters were measured at the same time: phi, arterial ph (pha), blood lactate, mean arterial pressure. in follow up we considered death and complications happened during the hospital stay, in relation to intraoperative phi falls below . . results: among the patients, had a drop of phi below . during surgery. in three of them this fall was a single episode and happened within the first hour after the begiluting of the operation. after that phi rose to nomml values until the end of the operation these patients had a normal post-operative period, without complications, the other patients had a fall of phi during the demolitive manoeuvres. two paticots of them died. the first had a lowest phi= . and the second . . the first one ~zs operated on for hepatic istiecitoma, suffered a complete del'dseenco of the surgical wound on the th day after operation and died on the th day, the second one was operated on for a hepatic carcinoma had an intraoperative haemorrhage and died ~vo hours after the end of the operation. the other patients with a fall of phi had a lowest phi= . . . . . . . respectively.the first patient,operated onfor sigmoid carcinoma, underwent on a second operation for a transmural necrosis of the colic segment on the th day; the second one, operated for carcinoma of the right colon, had a cardiac ischelnia on the th pest-operative day and a dehiscence of the surgical wound on the th day: the third one, operated on for a sigmoid carcinoma, had melena in h post~ operative da b, and finally the fonrth patient, operated on for carcinoma of the tight colon, suffered a fistula of the surgical enteral anastomosis.all these patients were discharged alive from the hospital. the other patients, who had not reductions of phi ditring the operation, had a normal pest-operative period, without complications. conclusion: phi was able to predict the arising of some complications, probably due to intraoperative ischemic events. we can say that gastric tenometry, for its low invasivi.ty, can be included among the intraoperative monitoring in patients that tmdenvent on major abdominal surgery. (ttd),t"ea~rrerj.~ of hours duraticn. all l:atients nm.'-~ms_(~lly va~ ated in eantrol wcde ard_ la':'ad a a,~m--ganz catheter, with optic fibers for contirums mmsuremmt of svo mic studies were performed, c~e before the hegir~ of hd, c~e rain after the ~, ~ne at the middle, ~ne rain before lhe erd ard one rain after the erd of hd. paired t test ~as used far slatistical eval~ti~n. results: daring i~d there was a significant'reductton (p<o.~) of: c~tr~ venc~s eres~.re ( ve)emm to . ~ ~, ) ~arn'~w capil~ ~f~e pressure (i<~p) fr~n to ~mg hg, ) i~ from to . mmg hg. ~here was also a less pmnameed bat also-slatistics/ly significant r~ucticn (p<o. ) of: i) s~o~ from to patients undergoing surgical reconstruction of the aorta due to anenrysms of its abdominal part may develop transient and sometimes sustained episodes of dysoxia despite the conventional appeoreneas of being adequately resuscitated. indirect masurement of gastric mussel ph (phi) is being widely evaluated as a minimally invasive and sensitive means of assessing the adequaey of tissue oxygenation in these circumstances. the duration end degree of gastric intramucosal acidosis are related to the risk developing injured gastrointestinal tract end its putative consequences, i.e. translceation, cytokine release, organ dysfunction end failure, sepsis end death. measurement of phi is obtained indirectly by measuring pc in the lumen of the stomach with a silicone balloon tonometer (tonometrics, inc., worcester, ma, usa) and the bicarbonate concentration in arlz,,rial blood, end substituting these two values in the henderson-hasselbalch equation. objectives: to evaluate whether perioperative phi changes are predictive of complications end outcome end how they compare to standard haemodyuamic and oxygen trensport parameters. methods: patients ( males and female) urtderwent surgical replacement of abdominal aortic anonrysm with the aortic simple or bifurcated grail. patients were operated on eleetively, had an emergency surgery for raptured enentysm. haemodynamic, arterial ph and bicarbonate concentration measurements were taken before and after induction of anaesthesia, after cross-clamping and declamping of the aorta end at admission to itu. phi calculations ware done at the sime time except before induction, as tonometers were inserted after patient had been asleep. we used pulmonary utilizing a computer billing survey as well as hospital service transfer data from a month period ( / - / ), all obstetric patients that were transferred to the med/surg icu were identified, as well as their diagnoses and procedures. twenty-eight obstetric patients were transferred to the med/surg icu, compared to , deliveries occurring during that time period for a . % rate. the following procedural indications for icu transfer occured: insertions of endotracheal tubes, arterial catheterizations, temporary tracheostumy, and venous catheter. the following medical diagnoses were found: hypertensive/eclamptic episodes, hypotensive episodes, pulmonary embolism, mitral stenosis, and coagulation deficiency. there were four episodes of respiratory failure ( %). the historical rates of respiratory failure from the medical literature seen at a university hospital ore higher than those at our community hospital despite comparable icu transfer rates for critically ill ob patients. objectives: to evaluate the usefulness of several isss used in order to predict risk of death (rd). design: prospective data collection for months in a multidisciplinary -bed icu. methods: data from consecutive patients admitted to the icu from / / to / / were studied. all the necessary informations were stored in a computer using special software for every day computation of three isss (saps, saps ii, apache ii) and of the rd predicted by saps ii, mpm , mpm and odin. data from days of hospitalisation were used for comparative evaluation of isss and rd, while sensitivity and specificity in death prediction (cut off point of rd = %) were evaluated from data collected during the day of admission (saps ii, rpm , odin) or after hrs (mpm ). agreement between rd predictions was evaluated by bland and altman analysis. results:our results were the following: objectives: a) to create and validate software specially designed for the collection of demographic data and estimation of illness severity and predicted rd and b) to provide data necessary for the evaluation of the effectiveness and the efficiency of our icu. design: prospective data collection in a multidisciplinary -bed icu. methods: prospective data on specific physiological variables, selected demographic characteristics, comorbidity and the reason for icu admission were recorded every day for consecutive patients admitted to the icu from / / to / / . data were entered into a portable computer using specially designed software allowing the calculation of usual illness severity scoring systems (isss) and the corresponding predicted rd. results: we studied men and women, with a mean age of years. we conclude that, although observed mortality was higher than predicted rd, this difference was not statistically significant. the fact that the sd of predicted rd was too large, limits the usefulness of isss predictions for a comparative evaluation of different icus. objectives :the importance of objective evaluation of patients prognosis at their admission to an emergency department is clear. the aim of this study was to appreciate the prognosis of patients with the simplified acute physiology score ii (saps ii), and correlate this score to the prognosis and orientations of patients. methods : the score which is a reduced form of saps ii was calculated from clinical variables and laboratory items for patients. sensibili}y (se), specificity (sp) and accuracy (ac) were calculated to evaluate the performances of saps i . thresholds were calculated with the youden's test (se+sp- ). results : patients were admitted in the intensive care unit (icu)and patients in medical units; patients died. the saps ii was higher in patients which died than the survivors ( , + , vs. , + , , p< , ; respectively), the best threshold was , se was de %, sp was %, the ac was / . thus for patients admitted in icu than in medical unit ( , : : , vs. , + , , p< , ; respectively); the best threshold was , se was %, the sp was %, the ac was %. conclusions : these preliminary results suggest that saps ii can be used to determine the short term prognosis and the destination of patients seen in an emergency department. design: data was collected on all admissions over a six month period. all patients had a screening hiv elisa test. confirmatory ifa tests, western blot and flow cytometry were performed on hiv positive patients. the institutional ethics committee considered the major clinical impact of the study sufficient cause to waive the patient's right to informed consent, icu staff and patients were blinded to hiv results. following discharge patients were given the option of being advised of their hiv status. setting: the study was conducted in a bedded surgical icu at a tertiary care teaching hospital. patients, participants: all patients admitted during the period in question were included. interventions: "all patients were treated according to standard icu protocols. there were no interventions. results: most patients were admitted following trauma. there were no patients with aids, hiv positive and hiv negative patients. with respect to the latter two groups, the mean age and sex distribution was similar, there was a significant difference in organ failure ( % versus %, p < . ) and septic shock ( % versus %, p , : ) but no difference in icu/hosp[tal mortality or duration of icu/hospital stay. flow cytometry changes in hiv positive patients were consistent with the quiescent phase of hiv infection. conclusion: while morbidity is higher in hiv positive patients, there is no difference in mortality. hiv status should, therefore, not be an exclusion criterion for icu admission in this patient population. , n= ) and january-march (period , n= ) were studied. interventions: a resident micu team led by a trained intensivist took over the medical care from the primary physicians when the patients were admitted to the micu. the intensivist also vetted micu admissions and decided on micu discharge. in addition, there was a resident respiratory therapist to attend to vendlatory care during office hours. after office hours, the care of the micu was delegated to the on-call team on a rotational basis among the medical departments. results: the patients in the two groups were similar with respect to age, sex, race, source of admission and apache scores. the icu and hospital mortalities decreased from . % to . % (p=ns) and . % and . % (p=ns) respectively in period . the mean icu and hospital stay was also decreased from . __+ . to . + . days (p=ns) and . __+ to . • . days (p=ns) respectively. the improved micu length of stay for survivors in period was statistically significant ( . • . days vs . • . days = . ). there was no significant differences in the vse of peritoneal dialysis ( . % vs . %) and mechanical ventilation ( . % vs . %). however, utilisation of intra-arterial lines and pulmonary artery catheters increased from % in both to . % and . % respectively in period . conclusion: the duration of critical illness was reduced in period . hence, we believe that the closed |cu which was staffed by an intensivist and had the services of a respiratory therapist was beneficial for the care of the critically ill. the intensivist, was also more likely to utilise invasive monitoring. in the absence of liver transplantation, intensive care for patients with acute hepatic decompensation arising from alcoholic liver disease (ald) is indicated only for those who are likely to benefit from conventional means of organ support. we have attempted to elucidate potential risk factors and the efficacy of organ support in relation both to hospital outcome and icu costs so as to allow the earlier identification of relatively futile intensive care in this group of patients. methods: over a period of one year, ald patients ( males; females; median age years, median apache ii score ; hospital mortality %)with severe complications ( [ %] with bleeding oesophageal varices, [ %] with hepatorenel failure, [ %] with respiratory failure, [ %] with septic shock, and [ %] others) were studied in our liver icu. organ system failure, daily therapeutic interventions and icu costs were assessed using a patient management system (riyadh intensive care program). results: whilst survivors had a significantly lower admission apache ii score compared with non survivors (medians and , p< . ), or more organ systems in failure in the first hours of icu admission was associated with a % ( ) mortality. mortality was also related to child's grading and the numbers of organs supported. of the patients who received more than one form of organ support only one survived. organs supported mortality a (n= ) % none / ; % b (n= ) . % one / ; % c (n= ) . % two or more / ; % the icu costs for the patients were only s but s ( %, patient days) was utilised by the patients who died, giving an effective cost per survivor (ecps) of s . although the cost of treating the patients with or more organ systems in failure on the day of admission was s ( % of the budget) the ecps was s . conclusion patients with ald who have or more organ systems in failure early in their icu course have a poor prognosis and in the absence of liver transplantation, traditional strategies of organ support are ineffective. this begs the question whether such costly care is appropriate as although the ecps in this sub group is comparable with other patient groups with multiple organ failure, their outcome is considerably worse. objectives: to evaluate the economic impact to the healthcare sector of using dopexamine hydrochloride infusions to deliberately increase perioperative oxygen delivery in high-risk patients. methods: effectiveness data were obtained from a controlled clinical trial in which surgical patients were randomly assigned to either a control group (n = to receive best standard optimal fluid resuscitation perioperatively, or a protocol group (n = ) to receive, in addition, an infusion of dopexamine hydrochloride to increase the perioperative oxygen delivery index to greater than ml/min per square metre. resources consumed by patients during treatment were recorded prospectively and costs of resources at / prices were obtained retrospectively. cost-effectiveness ratios were estimated by dividing the total cost for each treatment group by the total number of patients in each group and by the clinical outcome of mortality days postoperatively. results: in the protocol group, there was a % reduction in mortality days postoperatively (p = . ), a significant reduction in the number of complications (p = . ) and a reduction in length of stay in the icu and surgical ward. the average cost per protocol patient to achieve a . % survival rate days postoperatively was s , , resulting in an average cost of s , per surviving protocol patient. the average cost of a control patient was s , to achieve a . % survival rate days postoperatively, resulting in an average cost of s , per surviving control patient. the use of dopexamine to deliberately increase oxygen delivery perioperatively generated a cost saving to the nhs of s , per patient together with a % reduction in mortality at days postoperatively. hence, the cost per surviving protocol patient was s . less than the cost of a surviving control patient. conclusion: the additional cost of dopexamine in protocol patients was offset by a lower incidence of complications and a shorter stay in the icu and on the surgical ward. hence, increasing oxygen delivery perioperatively in high-risk surgical patients saves both money and lives. objective: although king's college criteria are widely used, indication and timing for liver transplantation in acute liver failure is still far from certain. long-latency sensory evoked potentials -a proven measure of metabolic brain dysfunction (grimm et al. lancet ; : - ; madl et al. lancet ; : - ) -are markedly affected in patients with acute liver failure. serial sensory evoked potential recording should provide very useful information for the management of patients with acute liver failure. methods: recordings of standard bilateral sensory evoked potentials were performed in patients with acute liver failure. findings were focused on cortical n peak -a stable negative deflection occuring • ms after median nerve stimulation in healthy subjects, which can be recorded by skull electrodes over the sensory cortex. results: nine patients recovered spontaneously, patients were referred to emergency liver transplantation, and patients died. in all patients who recovered spontaneously, n peak was detectable between and ms. all patients who were referred to liver transplantation and of patients who died, developed a loss of a prior detectable n peak during the course of acute liver failure. objective: to determine high risk arid low risk patient groups in a medical intensive care unit regarding short term and long term outcome. methods: data on all admissions of the year were collected prospectively. according to their mode of admission patients were classified as admissions by the physician staffed ambulance service (as), admissions through the emergency department (ed)i referrals from non-intensive care wards (ni), and secondary referrals from other hospitals (oth). outcome was assessed in terms of in-unit mortality, in-hospital mortality, and long time mortality. patient groups were compared using the \ -test. life table analysis were per{ormed by kaplan-meier method comparing patient groups by log-rank test. the software spss for windows . . was used for statistical calculations. results: in-unit mortality: / patients ( . %) --oth . % > as . %> ni . % > ed . %; p = . . in-hospital mortality: / patients ( . %) --oth . % > ni . % > as . % > ed . %; p = , . mean survival time in days after discharge: as < ni < oth < ed ; p = . . conclusions: despite an excess in-unit mortality of secondary referrals from other hospitals the iongtime course of this special patient group is not different to others. solsuam, j, marrugat*, g, mirs, j, nolla, a, vazqu~z-sanchez, l alvamz, ~ioio s xndioina i~siw. ir~itate l(~icipal da l~sti~isn l~di~*, ~ospits dal objective: to study the influence of modifiable variables (complications derived from therapeutic activities) on the prognosis of ~atients admitted to the icu indapemently on thn severity of illnsss. patients am methods: between january asd ]lay data from , patients over years of aqe who retained in the icu for mare than hours ~ere pr~pectively regiatered. a cohort st~ly with follo~-~ nf patients durin~ ~eir stey in the hospital was deni~.el in all patients, reasons for a~issien, principal diagnosis sad severity of illn~s moasared by the saps scare vare recorded. fastens affecting patients' outcome that my be proventsd or modified included technical :omplisafioss, heapital-acqnired infections and in~pro~riate therapeutic decisions. a logistic regression model was used to assess the relative risk (l~} for in-heapital mortality adjusted for each variable. results: ic~ mortality ~s . % and in-hospitul mortality . %. patients who died showed a higher spas score then survivors ( , ~ i ,i). after adjusting hy severity of illness, co~;licetices that statistically increased the risk of in-hospital death were septic shock secomery to hoapitul-acqdired infection ( ~ . ; % el, . to . ), pmo~othor~x related to mocasnical ventilation (@ . ; % cl, . to . ) and delay in the insertion of a fln~-quidod catheter (ii~ . ; % ic, i.i to . ). col~lusien: registration of complicaticas derived from therapeutic activities is a valuable tool far quality central in the icu. g, ~i~ , j.l mle~ma, j, ~amqat*, j..~lla, a, vazquez-saltemz, f, alvamz , servioia de nndicina l~siu. i~stitutu ~icipal de ln~sti~acidn ~ i:a*, hospital dsl objective: to dstsr~ine the incidence of self-extebatien and its effect on ~ortality. patients and ]~etheds: betveen january and april , all i~tiente in whom selfextubatien w~s registered were inclnded in a prospective study. patients were divided into @nee who needed r~intabatinn within hoers and those who did not. in all patients, dsmoqraphie and ciinical data were recorded as well as icii mortality, in-hoapital mrtality and severity of illness according to saps score. eta were analyzed usi~ the cbj-square test for cathgorical verinbls, the analysis of varianc~ (anva) for aontinuc~ ~ria~les and a leqi tic regression anal~is to estimate the relative risk (iiii) for mortality as result of celt-nxtt~ation after adjusting for severity of illness. results: a total of intnmtsd patients amre stndied. self-extu~atien occurred in ( . %) patients and . % required reintuhot~pn. when a co,arise was made between patients who did not required reint@atinn and patien~.s who did, statistically significant differences in eqe ( . v_s . years, p = .~ ), ~verity of illness ( . ~ . spas score, p = . ), dia~isstia category ( s. % v_s . % of patients with res~iratury conditiono, p = , } and mean length of stay ( , ~ , days~ p = . ) were fo~m, a~ter ad~sti~ for severity, patients with self-ext@atinn who did not reqnired reintalatien showed a . iir for mortality ( % ci, .i to . ) as co~arod with patients in when self-ext@ation did mot occur. conclnsien: self-~extamtice that does not require reint@ation is associated with a isamr in-hospital natality probably dt~ to a prolonged period of weaming. patients' admissions to ices am often delayed doe to the shortage of beds available. @ile amaltieq icu admission, these patients are treated in observation nits of @e emergency services which bare ,either tile structure nor the trained ~reomenl that are available in leb~. objective: to daterdno the effect on the patient's proqusis of a delay in tile admission to the icu when criteria for icij admission are fulfilled. ~terials and methods: between jme am l?ece~ber all patients who fulfilled criteria to be almittod to the ic who for waste~r reason retained in tile observation unit for more than hours were included in a prospective stedy. in all patients, des~raphic end clinical dabs amre recorded as well as severity of illness aencrdi~j to saps score. a cesucontrol dasi~ was eend with a total ss~ln of , patients who suffered no delay is admission to icii over a period of years. data wen analyzed using the chl.-squ~re test (to aeons the association hetwenn in-patienty mortality end categorical vari~lns) and a maltipln logistic reqression model to sstimta odds ratio for) for in-hospital mortality as result of delay in icy admission as compared with early ad~issi| after adjusting for severity of illness end use of assisted mchenical ventilation. ~ &ults: a total of patients remained in the observation nit for more than hours with a del w in igd admission of . _+ . hoers. assisted mechanical ventilation was requited in % of patients and only monitericatien in %. itsse patients were cspared with ntients from the tet~l sample ratchod by age, sp~ score and rennoss of admission. in-hospital mortality for cases warn % as compared with . % for controls (p = s). after adjamtilg fen spas, age and mobamioal ventihtien, no statistically significant differences between both ~renpa were foam, altho~b there was a tendency towards a higher mortality amen@ patients with delay in icu admission (or = . ; % ci, , to , ). conclnnien: ~se findings suggest that prognosis of critically-ill patients is no worse as a result of admission to the loll being deln~d for borers. all data appropriate for the calculation of the apache ii score (aps) together wi'th other specific cardiac details relevant to these .patients were collected daily, verified and enter~ into a computer database. results: patients were studied. six patients died and five of thee underwent cardiac surgery. the mean aps was for survivors and t for non-survivors (p < . ). the mortality ratio was . and the major markers of mortality were apache ![ score, presence of chronic ill health, mean duration of ventiiation, mean length of icu stay and need for emergen~ surgery. sixteen percent ( ) of icu bed days were occupied by % of patients (non-sarvivors) which resulted in cancellation of cardiac sot#cat sessions in momhs. conclusions: this study concludes that apache t could be used as an audit tool in a cardiac surgical icu and demonstrates the severe compromis~don of cardiac surgical throughput by a few non-survivors, organ to determine the number of organ failure free days (offd) in a cohort of survivors and non-survivors with sepsis syndrome followed over a day period. ) to determine sample size requirements for clinical trials utilizing a increase in the number of organ failure free days as the primary outcome as opposed to mortality. methods: beginning december through to april , patients who met inclusion criteria of the "cardiopulmonary effects of ibuprofen in sepsis syndrome" and who did not have hiv/aids. brain death or moribund state were prospectively identified. presence or absence of failure of organ systems (pulmonary, cvs, renal, hepatic, gi, hematologic, & cns) was recorded daily until death or until days. a score of one was assigned to each organ system free of organ failure in patients still alive, ie, maximum daily off score= , maximum day off scorn= , sample size estimations were performed for variable detectable differences in off scores (delta). alpha was set at . (two-sided), with n/group = [(z a +z b ) o conclusions: a clinically relevant increase in off days may be detected with as small a sample size as to patients per group. this represents a significantly smaller sample size than needed to detect a change in mortality from % to % ( % relative risk reduction) where the n/group= . scoring patients in this manner prevents a lethal inte~entien from providing an improved organ failure score. in addition, an intervention that prolongs survival must also provide greater organ failure free days in order to be counted by this scoring method. survival as an outcome provides no information about the quality of that survival. off days provides a measurement of burden of illness. interventions which lessens this burden may be just as valuable as those that decrease mortality by providing a measure of the quality of survival and by decreasing costs of care. they may also prove to be an accurate surrogate marker of mortality. the advantage of this approach is that the event rote is much higher and sample size requirements are subsequently smaller. this would mean that clinical trials can be completed faster and at lower cost. outcomes such as mortality could then be assessed at a later date utilizing recta-analysis. we suggest that the use of off days is a valid outcome measure that may be utilized in clihieal trials of sepsis syndrome. the icu is perceived by many as being a stressful environment for both patients and staff. stress has been defined in three ways: a stimulus producing a particular response; the physiological and psychological response to a stimulus; an interaction butwom an individual and their environment. stress is currently thought to be a dynamic system of stimulus and. response which takes into account the individual's perception of the stimulus and their ability to respond effectively. stress may, therefore, be positive and allow personal development but an individual unable to respond effectively to a stimulus will experience negative effects or strain. critical illness is an intense stimulus to which the body needs to respond effectively. physiological responses are vital and most of intensive care involves supporting these. alternatively, blocking them, for instance with atom(date, increases mortality. psyehological responses are also vital but often poorly appreciated because of communication problems. many of the problems patients experience in an icu are evidence of psychological strain. this can be exhibited in various ways, for instance, anxiety, depression, passivity and confusion. dealing with critically ill patients is perceived as stressful. we recently studied occupational stress in our icu. most aspects of intensive care were not generally perceived as stressful indicating a self-selectien of icu staff. the most stressful aspects of icu work for nursing staff were the structure of the organization and career opportunities. medical and nursing staff had different stressors and different coping strategies. support for occupational stress, therefore, should focus on the individual and concentrate on information and communication. atmosphere, and especially at intensive care units, we face up to daily decision making. in most cases these are taken on the basis of personal opinion and the processing of a very limited amount of information. rising need to optimize the results of medical attendance becomes necessary to set structured system of d@cision making in which ethical basis have a sp@dial significance in view of next considerations: -we live into a pluralist society in which the importance of values is different. -most persons consider health as the first value only in the event of illness. -medical resources available are limited, whereas medical, attendance demand from population increases in a way many people consider it unlimited. in consequence, it becomes necessary to set up priorities in patients treatment. ehtical basis that rule decision making are essentially these ones: i. beneficence: to provide the patient that is being treated the highest profit. . non maleficence: it is our first duty to avoid hurting or damaging the patient."primum non nocere" . autonomy: in every particular medical attendance, the patient has ability to decide by himself. . justice: as equity: to provide the same treatment for those who have the same pathology, ignoring another factors such as age, sex or race. severe application of these principles can cause difficulty, which resolution requires a systematization of decision making. ( - ) . the lenght of stay between survivors and non survivors didn "t show statistical significance (p = . ). the mean aiii score when considering all admissions was , ( - ) . the initial score between survivors and non survivors showed ststistical difference ( . vs . ) respectively (p < . ). univariate logistic regresion analysis demostrated a % increment in death probability for every points augmentation in the aiii score with a sensitlbity of . % and specificity of . %, the roc curve showed that the best cut off point for death prediction was points with a sensitivity of . % and specificity of . %. if a patient is classified as high risk (> ) the bayesian analysis showed a . probability of death and for one class(fed as low risk (< ) a death probability < %. conclusions: the first day aiii score in this population showed to be a good discriminator between survivors and non survivors, and the risk of death augments as the aiii does. in this population an aiii score > points is asociated with a greater risk of death. using the aiii score in conjuntion with the clinical judgement will help clinicians reducing uncertainty in the every day decision making and better predict outcome, the results from this study should been taken with caution because the data were obtained from a small sample. objective: the quality of life has been considered a "uniquely personal perception" resulting from a mixture of health related factors and social circumstances [t. m. gill, jama , : ] . the aim of this study was to evaluate two measures of pqol in intensive care unit (icu) admitted patients. patients and methods: during icu stay and six-months after hospital discharge, co-operative icu admitted patients were directly interviewed about their pqol. we administered ftrstly the uniscale (pqolu) [sage et al crit. care med. , : - ] and then a step verbal scale (pqolv): best, good, fair, poor, worst. of the studied patients, at the first interview, were able to use both scales, but ( . %) understood only the verbal one. at the second interview, patients were not able to answer, used both scales and only pqolv. statistical analysis was performed using wilcoxon signed ranks, spearman rank correlation, student's t and chi square tests. results: of all cardiac surgery pts, pts ( . %) died in icu. they were males ( . %) and females ( . %). their mean age was (+ ) years and mean ef was . (+ . ). nineteen pts ( %) had low (< . ) preoperative ef. mortality was . % in the coronary artery bypass grafting (cabg) group (n= ) and . % in the valve replacement (vr) group (n= ). in the cabg +vr group, mortality was . % (n= ), and . % in the remaining pts (n= ). cardiogenic shock was the sole cause of death in pts ( %), septic shock in pts, whereas sepsis in combination with ards in pts, sepsis and stroke in two pts. in addition, pts died from cerebrovascular accidents, one from ards and one from pulmonary embolism. the pts who died in the icu had a significantly longer bypass and aortic cross clamp time and received more blood transfusions (p< . ) than a matched control group that survived to icu discharge. the duration of mechanical ventilation and length of icu stay were greater in the pts who died in the icu than in the control group. conclusions: . although cardiogenic shock is the main cause of death ( %)in cardiac surgery pts, sepsis and cerebrovascular accident are relatively frequent causes. . patients who died in the icu had longer bypass and aortic cross clamp time and received more transfusions, compared with the control group. . although renal or hepatic failure contributed to death in some pts, they were not the primary cause of death in any patient. objectives: evaluate the acute and follow-up outcome of patients (pts) treated with primary ptca (without prior thrombolysis) in acute myocardial infarction (ami) after and up to hours after onset of typical thoracic pain ("late" primary-ptca). methods and patients characteristics: from / to / consecutive pts with ami were treated by primary ptca in the wuppertal heart center pts ( , %) were admitted to our hospital > hours and < hours after symptom onset with ongoing chest pain and typical ecg-changes.mean age was years ( - ). pts were male, four female. % had an anterior wall myocardial infarction, % suffered an inferior/postero-lateral wall myocardial infarction.two pts were in cardiogenic shock at admission. singlevessel-disease was documented in . %, multi-vessel-disease in . %. average time of onset of pain to recanalisation was min ( - ). angiography revealed timi-flow in . % of the pts, timi-flow i in . %, timi-flow ii in . %. average follow-up (fu) period was months ( - months). timi iii lv-ef ~ -day major late re-late flow p.i.* aeute/fu mortality bleeds infarction mortality . % %/ % . % . % . % % early mortality occured in the two pts, who were in cardiogenic shock at admission no pt required emergency coronary artery bypass grafting.restenosis > % was seen in % of the pts. conclusions: "late" primary ptca achieves a favourable high recanalisation rate of about % (timi ill-flow) in our study group. additionally, there seems to be a trend for lv-ef improvement in follow-up. early high mortality is influenced by the patients admitted in cardiogenic shock. there might be a trend for increased major bleeding complications. objective: to assess the validity of saps ii (new simplified acute physiology score), comparing it with the previous version, (saps), in a sample of patients recruited by giviti, a network of icu's representative of the italian icu system methods: measures of calibration (goodness-of-fit statistics) and discrimination (receiver operating characteristics curve and area under the curve) were adopted in the whole sample and across subgroups differing in relevant prognostic characteristics. of the patients recruited during one month period, a total of patients were included in this study. for the purpose of the comparison of the two scores, patients with less than years, or having cardiac surgery or staying in the icu less than hours were excluded. vital status at icu discharge in the whole sample and at hospital discharge in half cases wher adopted as outcome measure. re$ ~: saps ii fits the data equally well compared to the older version (goodness-of-fit p= . and in the new and old versions, respectively) but its performance is somewhat better in terms of capability to distinguish patients who live from patients who die (areas under the curve . and . , respectively). furthermore, saps ii is better in terms of uniformity of fit across relevant subgroups, although substantial over prediction of mortality was observed in trauma patients and in patients admitted without organ failure to be intensively monitored. saps ii performed very wet] also in the subsample where hospital mortality was the dependent variable.satisfactory measures of calibration (goodness-of-fit p-- . ) and discrimination (receiver operating characteristics area= . ) were observed. c nr saps ii, a multipurpose scoring system developed in an international study, retains its validity in this independent sample of patients recruited in a large network of italian icus. although it has shown a good performance when adopted to predict icu and hospital mortality in the entire sample, further investigations are warranted. the observed over prediction of mortality in a few subgroups indeed call for a through assessment of the impact of confounders and biases on model performance when saps ii is adopted in samples that do not reflect the "average" icu patient. objectives: ) assess the effectiveness in a group of intensive care units by means of a quality performance index (qpi); ) assess the efficiency by means of a resource use index (rui); ) evaluate the performance of individual icus with respect to both indices (clinical and economical) while controlling for severity of illness. critical from ucis in catalonia patients alearic islands have been included in the study. inhospital mortality and weighted hospital lenght-of-stay (los) have been considered the outcome variables. severity of illness has been measured with the mpm ii at admission. in each icu, expected mortality has been obtained adding the probabilities of dying for its patients. expected los has been estimated adjusting a second order polynomial to the severity of illness. performance indices have been obtained by dividing the observed by the expected outcomes. re~ult~: the overall qpi was . and it ranged from . to . in the icus. the overall rui was and it ranged l~ont . to . . there was not a trade-offpattern between clinical performance and resource use. objectives: teaching hospitals often provide [cu care across a variety of specialized services. overall, this approach appears to result in the best risk adjusted survival rates, but at the highest cost (critical care medicine ; : - ): recently, there has been increasing focus on markers of overall hospital performance. however, in large teaching institutions, such markers may fail to detect intra-institntional variation at a large tertiary care medical center. methods: first intensive care unit (icu) day, acute physiology and chronic health evaluation iii (apache iii) and active therapeutic intervention scoring system (tiss) data were collected on random admissions to specialty icus with beds (range - ) between february i and december l, . post-operative solid organ transplant recipients were excluded. units included general medical, general surgical, and trauma, neurosurgery, cardio-thoracic surgery, and coronary care units. data were analyzed for risk adjusted outcomes: icu and hospital mortality and length ef stay (los); risk of requiring active cu treatment; and icu readmissinn using apache iii risk prediction models. results: the study icus cared for a diverse group of patients. mean apache iii scores ranged from . - . ; predicted risk of hospital death ranged from . - . %. standardized mortality ratios ranged from . to . with icus performing significantly better and performing worse than predicted (p< , ). los ratios and icu readmission rates ranged from . to . (ns) and . to . % respectively. patients predicted at low risk of requiring active icu treatment ranged from , to . % conclusions: there was wide variation in the mean level of patient severity between icus. after controlling for this severity, outcomes also varied widely. no clear pattern of overall institutional performance was evident. these data suggest that efforts to assess performance, improve quality, and maximize efficiency must be focused within individual units. programmatic evaluation of outcome allows for focused review of the processes of care contributing to good outcome (best practices) and where to focus ongoing quality improvement and cost reduction activities. background and method : we compared icu mortality in different age groups presenting with the same severity of disease. we assessed severity of illness by the physiological day -apache~ (physio-aa) score (thus excluding the age related points). for each of the following physio-a n score intervals ( - ; - ; - ; - ; > ) , we compared tcu mortality within age intervals (< ; - ; - ; - ; - ; > years - , - , - ) . in these groups mortality may be twice higher in the > years patients than in the _< years. mortality does not vary with age in low (physio a n = - ) and high (physio a n = > ) risk groups. in the low risk group, mortality is low in all the age intervals because of the begninity of illness. in the high risk group, extreme severity of disease probably blunts the impact of age and leads to high mortality rates in all age intervals. introduction: to access the actual social/clinical outcome of the patients who undenvent intensive care therapy oct) is rather difficult, quality of lilr is not easih.' defined and ohserver subjectivity is a prime factor in the evaluation. mortality ratio after discharge must be established and its causes understood. obieetives: the propose of this stud)-is to look into the mortality ratio that occurred on a series of patients that undorwent ict at our unit from of the ~iew point of severity of the original illness and the diagnostic groups. material and methods: during the period of one )-ear ( ), patients were treated at the unit, of them died, and ~ere not matched in our series because os incumpletc records. thirteen patients died in hospital after their reference to other departments, twelve patients were lost after discharge. thus. at the end. only patients were evaluated on the fu. the, were classified into the follov ng three groups: acute medical, elective surge d and acute and emergency postoperative. the patients were seen at , and months after discharge. the, were evaluated in accordance to their abili~, to being self supported in their daily life and capecity to fully return and hold to their pre~ ous jobs. apache scores were evaluated for each of the three groups and correlated to the icu dead, hospital dead, and mortality after hospital discharge, spss package was used for statistical analysis. remlts/conclasions: data shows that / patients died after discharge from the hospital, of ~itch nine died in the first three months. seventy-eight per cent of the patients were fully self supported in their daily life and % showed some kind of handicap. fosty-nine per cent of the patients wore on retirement either due to age or some form of chronic disease, when admilled to our unit. thirty-two peg cent had not been able to return to work, because the" were incapacitated on discharge. only % had return to their fully jobs but the period of the stu~, is not enough for all of them to be fully physically recovered. preliminmy statistical analysis shows us significant differences among groups. the aim of the present study is to compare the prognostic performance of five general severity indices ou coronary patienta and to find out if a proper ntatistical hundling of these indices could provide better results in these patients. methods: saps ii, mpm ii (mpm ii i mpmp ii ), apach ii end gaprik were evaluated o~ patients with acute myocardial infurction admitted to intensive care units from catulunye. calibration and discrimination were calculated for each index. calibration was calculated by th bosmer-lemeshow test. discrimination was evaluated by the area under the relative operating characteristic (roc)curve. if a model did not show a good performance it was customized using multiple logistic regression. finally, tworeduced models were developed, one fro~ the mpm series (mpm ii cor) and one from the group apache-saps (sapsiicor).their performances were again evaluated. results: discrimination was high enough for all models. neverthelees, oelibration of apache ii, saps ii and mpm was not satisfactory. thus,mpm ii , saps ii and gaprik were customized for coronary patients using the logits of both models, and obtaining good calibrations. mpm ii , and apache-saps were adapted and reduced to (mpm ii cor) end to variables (sapsiicor), respectively . both models showed better oalibrutions end discriminations than the original models. conolusion| models developed for multidisciplinary patients show a good discrimination when applied on aoronar i patients, but some needed customization in order to improve calibration. the number of variables of the principal model can be reduced (even to or variables) without loosing prognostic accuracy. objective: to compare the ability of two methods to predict outcome for intensive care patients. methods: we included consecutive intensive therapy unit (itu) admissions with an itu stay> hrs in a month prospective study (exclusion criteria: burn injury and age < yrs). data were couectsd applying the criteria described by the developers [ , ] . the definition of coma (mpm ii) was modified and the best assessment within in's, rather than the admission score, was used. statistical analysis included classification tables and receiver operaung characteristics (roc) curves to assess discriminative power, and lemeshaw-hosmer statistics and calibration curves to test accuracy of prediction. results~ average abe was yrs (ranse: - ) with a male:female ratio of . : . the actual hospital mortality was . %, mean predicted death rates were . % (mpmz ii) and . % (ap hi). non-survivors had siguitlcanfly higher predicted risks than survivors applying both methods (p< . l, t-test). the total correct classification rates (tccr) for apache iii were bett~r for all decision criteria applied (tccr, decision criterion %: apache ]/i . %, mpm ii . %). the area under the roc curve was . (ap iii) and . (mpm ii) confirming the better discrimination of apache ill. accuracy of risk prediction was similar for both models (ap nl ~ - , mpm b ;( - , lemeslmw-hosmer). showing some fluctuation, calibration curves lay close to the ideal line for predicted risks -< % with increasing deviation for higher risk groups (s. figure) . apache iii underestimated the risks of hospital death for almost all risk groups (curve above diagonal), whereas considerable overestimation for predicted risks > % ceenred with mpm~ii. objective: to assess the goodness-of-fit of the apache iii model for british itu patients. methods: we prospectively studied a cohort of adult patients consecutively admitted to a medical-surgical itu over a period of months. patients with burn injury, age < yrs and itu stay < hrs were excluded. using a eomputerlsed database, we routinely recorded hrs apache ill scores. predicted risks of hospital death were computed by critical audit ltd, london. accuracy of risk prediefion was assessed by hosmer-lemeshaw chi square (;( ) statistics and calibration curves [ ]. discrimination was tested employing classification tables and receiver operating characteristics curves (roc). restths: the mean age of the male and female patients was yrs (range: - yrs). of these patients, % were medical admissions, % were admired after emergency and % after elective surgery. the observed hospital mortality was . %, the overall mean predicted death rate was . %. mean predicted risks were siguifieanfiy greater for nonsurvivors ( . %o) than for survivors ( . %, p< . l, t-test). apache iii showed good calibration (z -~ , lemeshaw-hosmer). however, the calibration curve lay above the diagonal for almost all risk groups reflecting the tendency to underestimate actual mortality (s. figure) . the best total correct classification rate (tccr) was . % (decision criterion: %). the area under the roc curve was . % confirming the good discriminative ability of the model. objectives: the aim of this study is to point out the discrepancies between needs and actual treatment of less severely ili patients admitted in italian intensive cam units (icus) requiring only intensive monitoring, and verify the substantial likelihood of data comparing those collected from a national short term study with a regional long ternl use. ~: less severely ill patients ("observed patients") were only monitored; they did not require intubation, even if for a short period (less than houm) or major cardioeiranlatory supports, and were neurologically normal. epidemiologieal national data were obtained from giviti group (gruppo italiano valutazione interventi in terapia intensiva); this cohort study, collected patients, in two months in summer in all over italy. regional data were echieved in a three years entlection ( -i ) in lombardia' icus from archidia group (arehivio diagnostieo), including patients. mortality, severity score, diagnostic category and some typical intensive procedures were analysed and compared in both studies. patients' disgunstie categories were defined as surgical, medical and trauma, according to the main diagnosis and the presence/absence of surgical procedures. rr observed patients account for . % and % of all icu's patients respectively in national and regional data. very tow mortality rate was found in national data ( . %) and extremely low mortality in regional data ( . %). in both studies mortality, s.a.p.s. and length of stay were much lowor in "observed patients" than in general icu's population (mortality: . % and . %; .a.p.s. score: . and ; iength of stay: % and ). homologous distribution of patients in the two studies was noted for what concern their diagnostic category, aside from a slight prevalence of tranmatised patients in the giviti study. in the two groups the surgical patients were respectively % vs. %, medical patients were % vs. % and traumatised were % vs. %. % of "observed patients" in national study and % in the regional did not received any intensive procedure. only a minority of these patients availed haemodynamie eonu'ol with swan-ganz or renal haemofiltration. conclusions: these results underline that about one fourth patients admitted in italian icus benefit an oversized slructure i, relation to the real needs of their pathology. in hot more than % did non received any advanced treatment and mortality and s.a.p.s. score were substantially lower respect to general population. the results obtained from these two studies are similar, suggesting an uniform distribution of the case mix in italy, even if a different recruitment period and a different gengraphieal distribution were used. some discrepancies in the two studies were found in the diagnostic categories moreover regarding the tranmatised patients ( % vs. %); this can be explained from the seasonal (summer) characteristic of the national study. mutuality, yet very low, is different in the two groups, but these data do not allow any definite explanation. finally these epidemiologieal survey suggest need of further studies settling more strict criteria of admission in icu. this study aims to evaluate patients outcome, quality of care and effectivity of therapy in our intensive care unit. the main goal was to indentify factors that the most influence that outcome. during . the authors collected data of patients outcome and predictor variables. overall mortality rate was , %. the most common causes of death were infection. the diagnosis of sistemic inflammatory response syndrome (sirs) and multiple organ dysfunction syndrome (muds) significantly correlate with death ( %). average length of stay was . days ~. % patients died in the first ten hosiptal days and only % after days. age was directly correlated with death % of dead were older then sixty years. an analysis of physiological variables showed that serum levels of gl~cose ( %) and natrium ( %) were in optimal physiological values. serum proteins ( %) and haemoglobin ( %) levels were inversely related to death. multivariate showed that alveolo-arterio difference in content was the most informative of all mortality predictors (mean value , mmhg in % patients io>mrnhg). factor that most influence the patients outcome was infection (sepsis) and muds. use of predictive indicators of outcome in critically ill patients may help to assess treatment regimens and to compare patient groups. acute physiology and chronic health evaluation (apache if) score (crit. care had. ; : - ) and the sepsis score of elebute and stoner (br. h surg. ; : - ) have been used, objectives: to compare sepsis score and apache ii score in predicting outcome of critically ill patients. methods: overall survival during the past years for patients in our icu was calculated = % (prior probability). the outcome of patients who were admitted to our icu for > hours was observed. apache ii score on admission, patient predicted risk of death (apache ii risk) and the sepsis score on the first day of antibiotic course were prospectively recorded. discriminant function analysis of the scores in relation to outcome was performed. results: apache ii and sepsis scores in the survivors were significantly lower than in those who died ( . i . v~s . • . and . • v's . • . respectively p < . ). correct prediction of outcome by each score is shown in discussion and conclusions: although both scores have been previously evaluated in predicting outcome of icu patients, studies of the sepsis score were conducted in small numbers of patients or involved additional measurements not routinely available. this study demonstrates that the sepsis score alone or in combination with apache ii score is more effective than apache ii score in predicting outcome. objective to test the hypothesis that resuscitation titrated against gastric intramucosal ph (phi) improves survival in critically ill patients as suggested by gutierrez et al~. method emergency admissions to the intensive care unit were randomized into control and intervention groups. in the control group phi was measured at , and h while in the intervention group phi measurements were made hourly for h. both groups were managed according to the same guidelines to achieve the following targets: mean arterial pressure > mmhg, systolic arterial pressure > mmhg, urine output > . /ml/kg, haemoglobin > g/dl, blood glucose < mmol/ , arterial oxygen saturation > % and correction of uncompensated respiratory acidosis. if the phi was < . after achieving these targets, or after maximal therapy to achieve the targets, patients in the intervention group were given fluid to ensure an adequate cardiac preload and then dobutamine at then mcg/kg/h, titrated against phi. this additional therapy was continued until h after entry into the study. in each year patients were subdivided in two series with random selection, so that the st series contained abeat / and the nd / of the patients. the st series of all the years constituted the devdoping data set and the nd series the validation data set. with data of the st series ( patients), we created the predictive model, using stepwise logistic regression (bmdp, usa). each patient has been evaluated in die st, th, th and th day, calculating for each lime the apache ii score (for a total of records), independent variables were, besides time and apache ii of the time ( michaloudia g,, melissaki a., alexias g., gogafi c., kolotoura a., krimpeni g., pamouktaoglou f, filias n. objectives: to determine the medical staff's attitude towards various ethical issues methods : between january and february , anonymous questionnaires were sent to intensive care units, all over greece. results : questionnaires ( , %) were replied and returned back. of them , % were answered by male and , % by female. the doctors replied in the following rate : , % aged up to , % aged between and , % aged over . questions were answered and were divided into main topics, as following: . admission criteria: limited bed availability was the main cause for refusing admission in , % of icu's. , % evaluated each case's viability and only , % used some prognostic score system. , % of icu's accepted all cases and a significant percentage ( %) gave in to pressure coming from their colleagues ( , % female and , % male). . informing the patient/relatives: only , % was willing to tell the whole truth, while , % had given selective information.. in the case of iatrogenic incident, , % withheld it, because either they feared legal implications ( , %), or lost of trust ( , %). doctors are asking consent from the patient and/or his family, in order to include him/her in research protocols, in a rate of , %, while only , % found informed consent necessary for the proposed treatment procedure. . withdrawal of therapy/dnr orders/organ donation: , % were willing to withdraw complex treatment in patients with short life expectancy, except of administi'ating intravenous fluids, feeding and analgesics. in , % such a decis~n was unanimous, while the percentage of those carrying it out was , % ( , % female, , % male). in case of brain stem death , % ( , % female, , % male) withdrew any life support. , % would like therapy withdrawal to be legally established, while only , % would perform euthanasia, if there was substantial legal cover. for these cases, relatives' consent was considered to be necessary from a percentage of only , %. , % considered organ donation to be a necessary proposal, while , % refused to ask the patients' relatives for an organ donation, either because they didn't have the psychological strength for it ( , %), or because they doubted the procedures' objectivity ( , %). note: in greece, icu beds are less than % from the total number of hospital beds available. only a percentage of - % of these admissions comes from the same hospital, with a potentially direct evaluation. usually an icu doctor has to be informed through the telephone. finally, employment conditions in greece are such that any changes of the medical and nursing staffare limited. conclusions: the mathematical model we found has been validated also in the second series and the discrimination capability increases with time. using this model we can evaluate the probability of survive at every, time. its application at different times permits a better evaluation of haemodinamically instable patient trend. introduction: the feasibility to assess pulmonary capillary pressure (pcap) offers the opportunity to determine the longitudinal distribution of pulmonary vascular resistance (pvr). the purpose of this study was to measure pcap and to calculate pvr to determine whether relevant shifts in the distribution of pvr could be expected after routine cardiac surgery. methods: the study population consisted of consecutively admitted patients after cardiac surgery. surgical procedures included coronary artery bypass graft (cabg) (n= ) and mitral valve replacement (mvr) (n=t ). pcap was estimated by analysis of the pressure decay tracing after pulmonary artery occlusion. after estimation of pcap precapillary (ra) and postcapillary resistance (rv) was calculated. a complete set of hemodynamic variables was obtained at hour and at hours after operation. results: there were no significant hemodynamic changes during the first hours after surgery. the mvr group maintained pulmonary hypertension and higher levels of pcap. ra/rv, reflecting the longitudinal distribution of resistances, remained unchanged. however, rv predominated ra during the postoperative period in both groups. objectives: evaluation of the influence of long-term continuous i.v. administration of the ace-inhibitor enalaprilat on regulators of circulatory homeostasis. methods: t trauma and sepsis patients randomly received either . mg/h (group i, n= ) or . mg/h (group , n= ) of enalaprilat i.v. or saline solution (control, n= ) as placebo for days. plasma levels of endothelin- (et), atrial natriuretic peptide (anp), renin, vasopressin, angiotensin-ii, and catecholamines were measured before injection of enalaprilat (='baseline' values) and during the next days. results: except for et, plasma levels of all vasoactive substances exceeded normal range at baseline. angiotensin-ii significantly decreased during enalaprilat infusion ( . mg/h: from . • to . • pg/ml; . mg/h: . • to . • whereas it remained significantly elevated in the untreated control patients. vasopressin increased only in the control group (p< . ) and decreased after . mg/h of enalaprilat. et remained almostunchanged in group , whereas et increased significantly in the control patients (from . • to .t• on the th day). catecholamine plasma levels (epinephrine, norepinephrine) markedly increased in the control group (p< . ), but they did not change significantly throughout the study period in both enalaprilat groups. conclusions: continuous i.v. administration of the angiotensin-converting enzyme inhibitor enalaprilat beneficially influenced systemic and local vasoactive regulators of the circulation, which are normally increased in the critically ill. thus patients at risk of (micro-) circulatory abnormalities may profit from enalaprilat infusion. objectives: to determine the time taken for hemodynamic and gas exchange variables to a reach stady-state after a change from supine to trendelenburg position (trp). methods: we prospectively studied adult patients with severe sepsis or septic shock requiring hemodynamic monitoring. usual cardiorespiratory parameters were measured at baseline, min after the patient was placed in a trp and again min after the return to a supine position. a fiberoptic pulmonary artery catheter (svo~ oximetrix, abbott) allowing continuous svo monitoring wa~used. during the protocol we also continuously measured sao~ by pulse oximetry and vco~ and vo by monitoring partial concentration of o and co ir~ inspiratory and expiratory gases (deltatrac metabolic monitor, datex). therefore, we were able to monitor cardiac output variations by dividing vo~ with arteriovenous difference according to the fick equation (co-fick). results: no significant difference in hemodynamic status was observed min after the patients were placed in trp. despite the fact that no significant change was observed in co and vo~ estimated by thermodilution, co-fick had a tendency to dedrease continuously in trp and then to return to its initial value when patients regained supine position. respiratory gas analysis showed a small but persistent continuous increase in vco without a similar trend in vo values. conclusions: we conclude that no significant hemodynamic effect was detected in our patients after min in trp. evaluation of vo from respiratory gases analysis after a change in body's position should be interpreted with caution, since the patient may not yet have reached a stady-state after rain. since vo did not change, vco~ increase was probably due to position related changes in-pulmonary gas exchange and not to a change in patient's metabolic status. objectives: to determine whether changes in svo and/or other hemodynamic parameters during weaning trials could be used to predict successful weaning. methods: we prospectively studied adult patients with a history or clinical evidence of cardiovascular dysfunction, who were unable to tolerate spontaneous breathing (sb) for hours. for all these patients right heart catheterisation was considered necessary in order to detect hemodynamic alterations during weaning. a fiberoptic pulmonary artery catheter (svo ximetrix, abbott) allowing continuous svo monitoring was sod. hemodynamic status was evaluated ~t baseline and after one hour of spontaneous breathing through a t-piece. patients were assigned to one of two groups depending on whether they tolerated sb for hours. data were analysed by analysis of variance and unpaired student's t-test we also used multiple linear regression analysis to determine which hemodynamic variables were correlated with the magnitude of svo~ change and multiple discriminant analysis to determine if asy of the above variables were associated with toleration of sb for hours and/or successful weaning (s-w). (j physiol ; ." - ) . we tested the hypothesis that the ventilatory stimulation by dead space (vd) loading and % co inhalation is accompanied by a proportionate cardiovascular change. methods: six healthy subjects, mean age, year, performed three incremental exercise tests in a randomized order: ) inspiring air without vd (air control, ac); ) inspiring air with vd of ml (avd); ) inspiring % co ; % oxygen, balance nitrogen. the ventilatory responses were examined at matched heart rate (hr) equivalent to % peak hr. results: ventilation (vi) was significantly greater (p< . ) during the avd and co tests than during the ac test at the same work rates. end-tidal co (petco ) and estimated arterial co (paco ) were significantly greater (p< . ) at w and w. oxygen saturation was significantly lower (p< . ) during the avd test than during the ac and % co exerdse. at matched hrequivalent to % peak hr, vi was significantly greater (p< . ) during the avd and % co tests than during the ac exerdse ( l, l, and /). conclusion: we conclude that the increase in xri and petco due to vd loading and % co inhalation is not associated with an acceleration in hr. sup.ported by mrc (canada). objeetlve: the production of large amounts of oxygen radicals from the onset of ~en may be responsible, st least in part, for peroxidative damage to myocardial tissue. the aim of this study was to evaluate the time dependence of plasma tbars in patients with am] receiving thrombolytie therapy (tt). patients and m~hods: filiy eight patients admitted in icu ( men and women; mean age . - . years) rec~ving systemic tt for possible am] were ~died. all patients received recorabinant haman tissue-type plasminogen activator (r-tpa). the mean time fi'om the onset of symptoms and the be~nning of tt was . - . hours. peripheral veao~s blood samples were obtained fi'om each patient before and serially after tt ( , , and hours). tbars levels woe determined by using a spectrophotometrie technique. rq~r fusion was identified by the timing of ereatine phosphate kkmse (cpk) peak (< hours). table i list the variation of plasma eoneenlrations of tbars (mean -sd) in groups (a,b, and c) as a function of time from the beginning of tr. co,arisen oftbe time cuncentzatiens reveal a difference p<o. between group ami (a and b) versus group c. the between-groups (a-c) comparison showed significant differences (p<~). ) at , and hours fi-om de begin~g of'it. comparison ofthe , and hours eonocnlratiens did not reveafl any difference becween n~ (group b) and angor (group c). condmien: we have observed a maintenance of high level of tbars in reperfused patients enly. these results suggest that the increase of tbars levels may be due to phospholipid derangament of reperfused myocytes. objective: to detemline if tbars levels may be an early index reflecting peroxidative damage in ami patients. patients and methods: by using a spectrophotometric teclmiqtm, based on a modificatien oftbe buege and aust method, tbars levels ware determined in healthy subjects (group i) , patients with several risk factors of ischaemic cardiopathy (group if) and icu patients with possible aim ( were confirmed ami (group ma) and were angor (group iiib)). peripheral blood was obtained at the time of the icu admission in the group i . electrecardiographic data and eehocardiographic wall motion were used to identify ami location (anterior, inferoposterinr and indeterminate). statistical analysis was made with a standard statistical package (rsigma, horus hardware). , h , s, , h statistically significative increase of ' ix~e/ea.ee x~* tbars levels (p< . ) only in pstients with con/tuned ami (group ilia) . no differences were found between the rest of the groups. the figure shows the relationship between the tbars values and the time from the onset of the aim's symptoms. conclusion: we have found that in am/patients the tbars levels can be used as an early index reflecting peroxidative damage occurring to ischemie tissues. perioperative risk in patients with ischemic heart disease. the protective role of diltiazem. lg. hatziantoniou, p. tassiopoulos, c. fakiolas, ! g. foussas~ m. lycourinas perioperatlve morbidity and mortality are mainly of cardiac origin, particularly among elderly patients (pts) ~ith ischemic heart disease. we performed a randomized trial, in order to investigate the possible protective activity of diltiazem (d). methods: pts (aged zo• with a history of coronary insufficiency were subjected to major urological operations. they were randomized to two groups: group i ( pts) -p:ithout d and group ii ( pts) -d ~as administered . mg/kg iv bolus hours prior to anesthesia and . mg/kg/h upon the end of operation and for at least hours post-operatively. iv was substituted by oval administration of x mg starting the next day and for the rest of hospital stay. all pts underwent daily clinical, electrocardiographic and laboratory (ck-mb) control. results: are shown in the following interactions between the heart-lung unit and a cardiac assist device are the crucial issues for successful outcome of patients under mechanical circulatory support. several factors have been indicated and we can diffrentiate between anatomical and hemodynamic interactions. especially right heart failure and pulmonary hypertension have been proven to limit left ventricutar assist device (lvad) performance. in order to study the effects of right heart failure (rhf) and pulmonary hypertension (pht) on mechanical circulatory support, we designed an experimental study in dogs and combined in six groups left heart failure (lhf) and rhf and pht, respectively. in the control group we induced lhf with subsequent occlusions of lad and cx followed by reperfusion: in the next group we supported with an lvad during minutes starting minutes after cx occlusion (group if). in the next group we added right ventricular ischemia by occluding the rca simultaneously to the cx (group iii). these both groups we repeated only with pre-existing acute pht induced by the injection of o fm glass beads (groups vi and v). a last group was similar to group v (lhf and rhf and pht), but instead of a lvad, we used bvad support. in i and v no animal survived the second perfusion period ( hours). in ii and iii (no pht), all dogs survived in stable conditions. in iv (lvf, pht), % survived, the remainder died of incomplete recovery. in vi with bvad, only % survived. in iii and v, during occlusion of the rca, the right ventricle stopped contracting and right atrial pressure and mean pulmonary pressure equalized. this lead to a significant drop in inflow on the left heart side, which still provided sufficient lvad performance in case of absent pht (iii) and lead to death due to "low lvad output" syndrome in v. this "low lvad output" snydrome could be partly overcome by bvad support. we conclude that heart-lung interactions play a major role in lvad performance. by optimizing the perioperative management, they all can be overcome, except the occurrence of alveolar leakage syndrome. obiectives : we propose a new approach of transmural pulmtmary artery occlusion pressure (paoptm), in presence ef peep, from the folluwing hypothesis : if respiratory swings of paop are compared to those of alveolar pressure (apalv = plateau pressure -total peep), an index of transmission of airway pressures to pulmonary vessels is obtained (i t = apaop/apalv). the value of the product of it by peep can be substracted from end-expiratery paop (paopee) to obtain a calculated paoptm (paoptrnc). thus paoftmc = paopee -(apaop/apalv x peep). methods : we tested this hypothesis in patients by comparing paopee, paoptmc, and paopnadir obtained within the first seconds after disconnection from the ventilator, value of reference of paoptm in absence of intrinsic peep (peepi). at zeep, peepi was absent in patients (group a) but present in others (group b). patients were studied under the peep level chosen by the attending physician-(gr a : +_ ; gr b : _+ cmh ). results : l. gr a : paopee ( _+ mmhg) differed (p < - ) from paopnadir ( • mmhg) and paoptmc ( _+ mrahg). gr b : paopee, paopnadir, paoptmc differed between themselves ( " - , + , + mmhg respectively). . good correlatkm (r - (i. ) and agreement between paopnadir and paoptm were found in gr a, while there was no agreement in gr b (bland and altman analysis). . lung compliance (v t/bpah,) correlated well with i t in both groups (r - . ), suggesting that our hypt)thesis was strtmg even in patients with peepi. conclusions : paoptm under peep ventilation can be obtained, even in patients with peepi, from parameters easily measured at the bedside. introduction: cardiopulmonary bypass (cpb) may cause ischemia in several organ systems like the heart, brain and kidneys. reactive oxygen species (ros) are formed by subsequent reperfusion and stimulation of neutrophils by cpb. ros are harmful to biological systems e.g. cellular membranes, enzymes~ dna. many natural antioxidant systems protect against the effect of ros. in patients undergoing cabg we evaluated the production of ros by total plasma antioxidant status (tas) and lipid peroxidation measured by lipofuscin flip). methods: tas (randox, uk) and concentrations ofllp (tsuchida et al.) were measured in consecutive patients undergoing cabg. all the patients had a normal serum creatinine clearance (> ml/min). serum samples were obtained a) before operation, b) after removal of the aortic crossclamp, c) at admission to the icu, d) hours after operation, e) hours after operation. results: tas was significantly decreased after removal of the aortic crosselamp ( b, c and d lower than a), followed by a subsequent significant increase of lip ( c and d higher than b). the levels of tas and lip returned to baseline hours after operation. methods: patients with preoperative lvef< % undergoing coronary artery bypass grafting were studied. after surgery, a f femoral artery catheter was inserted and connoted to a fiberoptic monitoring system (cold z- t; pulsion medizintechnik, germany); this allows, with a double-indicator dilution technique, the calculation of cardiac index (ci,l/min/m ), intrathoracic bood volume (itbv,ml/m ), pulmonary blood volume (pbv,ml/m ) and extravascular lung water (evlw,ml/kg). with a f pulmonary artery catheter, wedge (w,nunhg) and central venous pressure (cvp,mmhg) were measured, while extraction ratio (o exr,%) and oxygen delivery (do ,ml/min/m ) was calculed. peak inspiratory pressure (pawp,cmh ) and mean airway pressure (mawp,cmh ) were measured with a varflex flow transducer (bicore,sensormedics,us). the patients were studied after minutes (to) of volume controlled standard ratio ventilation (vc), and after minutes (ti) of stabilisation period of pcirv ( % inspiratory time, % pause). vt,ve and total peep were held constant in every mode of ventilation. +_ . " *'p < , versus to conclusions: these data show that pcirv : is a safe ventilatory support also in cardiac patients with impaired ventricular function, and monitoring of itbv is more reliable to measure and optimise circulatory volume status, than w and cvp. c.ledeki-,g.rldisis,s.karotzai,c.micheilidis,m.agioutantb, g.beltapaulos. objeolivee:to evaluate the influence of lvswl on the well known correlation of sr and svo . paw eight patients ( melee end females) were included in this study regerdlen of the icu ~h"niseion couse. all paints were ,'~theta~ with e fiboroptir pulmonary artery catheter connected with an oxymetfir (r)~ so /co abbot computer.for any pulmonary artery catheter insertion, two pain= of sr and svo were obtained, one dudng inserlion and one during taking the catheter out. for any pair obtained, we eleo collected the deta concemig with the pedient's hemodynamir and oxygenation end we calculated the lvswi. were significantly (p<o. ) higher in group i. conclusion: breathing room air, the less hypoxemic patients had a rather satidactory do and tissue oxygenation (pro ) because they had properly adapted their ci. the absence of this mechanism (right heart impairement ?) in the hypoxemic patients, in spite of higher blood ne and e, was responsible for the poor do and pro . objectives: acute massive pulmonary embolism (pe) increases pulmonary artery pressure (pap) and dght ventdcular aftedoad, which may lead to dght ventdcular failure. inhaled nitdc oxide (no) selectively dilates pulmonary vessels. thus, inhaled no may be of potential therapeutic value in the management of the acute phase of pe. methods: following institutional approval, ten piglets (body weight + kg) were anaesthetised (midazolam/piritramide) and ventilated using a modified servo ventilator (siemens elema, sweden; fio . ). the following variables were obtained: systolic pap (spap), mean pap (mpap), diastolic pap (dpap), mean artedal pressure (map), central venous pressure (cvp), pulmonary capillary wedge pressure (pcwp), cardiac output (co), and artedal (pao ) and mixed venous (pvo ) oxygen saturation. pulmonary vascular resistance (pvr) was calculated. to induce pe, pm microspheres (sephadex g coarse, pharmacia biotech, freiburg, germany) were injected in an amount sufficient to increase mpap to mmhg initially. rain after embolisation when haemodynamics were in a steady state (control ), inhaled no was administered. further measurements were taken min after ppm no (no ), min after ppm no (no ), and min after discontinuation of no administration (control ). the administration of inhaled no resulted in a significant decrease in spap, mpap, and pvr. the cessation of no inhalation led to a complete return to pretreatment control values (table) . co, map, cvp, pcwp, pao?, and pv~ remained unchan no administration. objectivss:evsluate the yield of recombinant tissue plasminogen activater(rt-pa, actiiyse ~ oehringer ingelheim) as a thrombolytic agent ie pulmonary embolism ie .kr~auma patients. methods: in five patients with diagnosed pulmonary embolism(blood gases, chest x-ray, echocardiography, perlesion lung scans) were given rag of actij.yse as ~ hrs infusion, followed by heparin~single j. ihjaction snd iefusion ie doses - j./kg/day).the effectiveness of rt-pg thrembo].ytic sctier~ was svaluated im . . hrs(blood gases) amd on the third dayafter t~eat-,ment(~chocardiography and lung scan). results: three hrs after actilyse was given we observed significant clinical imprevemeet,confirmed by elevation of pao and sao in dlood.echocardiegr~m on the third day showed regression of pulmonary hypertension and lung scans showed % improvement in total lung perfusien. except slight bleeding from the site of injection nc~ more thromboiytic complicatioos were observed. conclusiens: actilyse used in five hrauma patients with pulmonary embol.ism was a very effsctive and safe thrombolytic agerlt, inducing rapid and evident clinical improvement. intermittent positive pressure ventilation ( ppv) by increasing pleural pressure, decreases the pressure gradients for systemic venous return and left ventricular (lv) ejection. we have previously shown that when inspiration is synchronized with systole using synchfjv in patients with severe cardiomyopathy, that cardiac output (co) was increased relative to both ippv and non-synchronized hfjv ( ). however, it is not known if similar effects could be realized in ventilatordependent patients with lesser degrees of lv dysfunction and fluid overload. we thus compared synci-ifjv to ippv in stable patients following coronary artery bypas grafting. methods: normothermic who were stable (< % variance/h.) were studied following admission to the sicu. heart rate (hr), mean arterial (pa), pulmonary artery occlusion pressure(ppao), co by continuous thermodilutiun (vigilance, baxter, usa), mixed venous saturation (svoz) and arterial blood gases (abg) were measured after rain. of each step. ippv was simv adjusted for a rate, tidal volume and fit to insure both normal abg and a peak airway pressure < cm h,o. syncfifjv was delivered by a hfjv ventilator (acutronic) during systole with ventilator parameters adjusted to optimize abg. protocol: patients received three ippv runs (ippvi. , ) with synchfjv runs interposed (hfjvz ). statistics: anova for repeat measures and paired t-test were used to compareruns and demonstrate variability. results:no significant difference in any of the measured hemodynamic variables were seen among the ippv and synchfjv runs (table) . post hoc separation of patients by preoperative ejection fraction (ef; ef > % ; n= and < %; n= ) did not alter these results. back~ound: in man, vascular endothelium-bound ace is expressed in concentrations greater than x that in serum and is believed to be the site of synthesis of circulating angioteusin il it is unclear whether ace inlubitors interact similarly with ace in different vascular beds. coronary vessels possess all the components of the renin-angiotensin system, including ace which may be involved in normalcardiac homeostasis, as well as in the pathogenesis of various cardiomyopathies. obiecfive: to develop a method for assaying the interaction of ace inkibitors with coronary endothelium-bunnd ace in man, methods: ace a~aty was meas~ed in five patients undergoing cabg surgery, from the transeuronary hydrolysis of the synthetic ace substrate h-bpap. trace mnou~ of ~fi-bpap ( gci) were injec~d as a bolus in the root of the aorta and simultaneously blood was withdrawn from a coronary sinus catheter into a syringe containing protease inhibitors which prevented the convession of umeaet~ ai-i-bpap by blood ace. the sample was later centrifuged to separate cells from plasma and the radioactivities due to formed product (~rl-bphe) and total sh were astimated in a [b-counter. two additional such determinations of ace activity were perform~ the second in the presence of . pg/kg e (coinjected with ~-i-bpap) and the third ten minutes after e. results: all subjects were hemodynamically stable throughout the course of the there were no noticeable hemodynamic effects of e. control transcorunary metabolism of~-bpap averaged g -a: %, in agreement with previously reported data. in the presence of e, % metabolism of ~-bpap was reduced to • reflecting a • inhibition of normal ace activity. ten minutes after e, ~ri-bfap metabolism had partially recovered to :l: %, representing a -a: % inhibition of control ace activity. from this data, the dissociation constant of e for coronary ace in vivo was estimated as . x " sec "l. conclusions: we have demonstrated the feasibility of repeated, reproducible measures of coronary endothelium-bound ace activity and of its inhibition by e. this procedure is safe and can be used to study the role of ace in normal cardiac function and in card pathologies. objectives. primary pulmonary hypertension (pph) is a progressive fatal disease of unlmown origin, with median life expectancy of less than three years after diagnosis. the responsiveness of pulmonary hypertension to a variety of vasodilator agents led to the speculation that, concomitant with vascular renmdelling processes, persistent vasoconstriction is an important feature of the disease. long term use of ca-channel blockers and intravenous pgiz may improve mortality in certain populations of pph patients, but both of these treatments lack selectivity for tire lung vasculature. the aim of this study was to test the efficacy of aerosolised prostacyclin and its stable analogue, [loprost for selective pulmonary vasodilatation in pph. methods: in three patients with pph, we compared aerosolisation of prostaglandin iz (pgi ) and iloprost to a battery of vasodilatory agents (diltiazem, nifedipin, inhaled nitric oxide, intravenous pgiz). results: nebulisation of pgi and iloprost tumed out to be most favourable for achieving effective and selective pulmonary vasodilatation. pulmonary vascular resistance decreased from + to -+ dyn*s*cm (p< . ) and pulmonary artery pressure from . + . to + . mmhg (p < . ), cardiac output increased from . + . to . _+ . i/rain (p < . ), mixed venous oxygen saturation from . _+ . to . + . % (p < . ) and arterial oxygen saturation from . + . to . _+ . % (mean _+ sem of trials in patients). -month iloprost nebulisation in one patient ( gg/day in six aerosol doses) demonstrated sustained efficacy of the vasodilator r~men. conclusion: aerosolation of pgi or its stable analogue may offer as new strategy for selective pulmonary vasodilatation in pph. endothelial adhesion molecules may play an important role in the pathogenesis of myocardial cell damage, and may contribute to the progression of heart failure. we measured the plasma soluble intercellular adhesion molecule- (sicam- ), vascular cell adhesion molecule- (svcam- ), and e-selecfin (selam- ) levels in patients with acute myocardial infarction admitted within hours after onset. peripheral venous plasma-samples were collected at the time of admission, , , , , and hours after onset. plasma soluble adhesion molecule concentrations were determined by elisa. patients were divided into groups as follows: group ; killip's class (k) and without thrombolytie therapy, group ; k and with thrombolytic therapy and group ; k and . both plasma sicam- and svcam- concentrations in group and were elevated rapidly and significantly and maintained at a high level during the first days. plasma selam- level did not change in any of the groups. these results suggest that the adhesion molecules icam- and vcam- may play a role in the pathogenesis of myocardial reperfusion injury and may indicate its severity in myocardial infarction. objectives: nitric oxide (no) is known to exert cytotoxic and negative inotropic effects on cardiomyocytes. no synthase activity has been reported to be increased in infarcted area in animal model of myocardial infarction. these findings suggest that no may be an important regulator for myocardial damage and cardiac function after myocardial infarction. we measured plasma no no -(nox) levels and estimated serial changes in acute phase of myocardial infarction. methods: subjects were patients admitted within hours after onset. venous blood samples were collected at -hour intervals on the first day, -bour intervals on the nd day and -hour intervals on the rd day and th days after onset. plasma nox concentrations were determined by griess method. results: the time course of the plasma nox levels (mea~+sem) displayed a tendency to gradually increase and to make a biphasic pattern with two peaks about hours and - days after onset (basal level; . _+ . , first peak; . !-_ . , second peak; . + . ram/l). plasma nox concentration was not influenced by the thrombolytic therapy, and nox values at the time of hours after onset were significantly correlated with maximal plasma creatine kinase level (r= . , p< . ). the levels of plasma nox in the early stage of myocardial infarction (from admission to the th day after onset) did not correlate significantly with the hemodynamic parameters (left ventricular ejection fraction, pulmonary capillary wedge pressure). conclusion: the early and late increase in no production after myocardial infarction may be implicated in the deterioration of myocardial contractility and induction of myocardial damage in the early phase of myocardial infarction. range - ) fullfilling the high risk criteria of shoemaker (colectomy , gastrectomy , pancreaticoduodenectomy , others ). patients were admitted to the icu preoperatively. arterial and pulmonary artery catheters were inserted and hemodynamics and oxygen transport were measured at admission and after stabilization to predetermined physiological end points. patients were considered stable when ci > . l/min/m , pcwp > mmhg, hb > g/l, sat >. . objectives: evaluate the acute effects of , mg ipratropium bromide and , mg fenoterol (ibf) inhaled dose on pulmonary function in nonsmocers (nb:m) and smocers (s) with sever (new york heart association class ii-iii), stabile congestive heart failure(chf) and healthy subjects. methods: pulmonary function tests were performed < h postprandial. the tests consisted el arterial blood gas aspiration followed by routine spirometry and pletismography, and single-breath gas analysis. after performance of these maneuvers, the patients was administred puffs-ipratropium bromide ( , rag) and fenoterol ( , rag). for , h, spirometry was repeated. results: in resting, pulmonary abnormalities observer in the s group were more severe then abnormalities observere in the nsm group. after treatment with ibf the improvement in pulmonary function was even more marked in patients who had smoked. the mean changes by forced expiratory volume in second(eevt) was , % (p< , t) improvement and , % (p< ,ob), forced expiratory flow betwen % and % of the forced vital capacity (fef . ) was , % (p< , ) and , % (p< , ) and maxamal voluntary ventilation (mw) was , % (p< , ) and , % (p<o, ) improvement. the mean changes in normal subjects were mild (fev increased by , %,fef - by , % and mvv by , %). we observed no adverse heamodinamie conseevence and no arrthytmogenicity. conclusion." in patients with chf the airway response to ibf is highly significant. further study is needed to determine whether therapy with ibf will load to improvement quality of life in patients with chf with dearly documented venti/atory defects. compared with unilateral ima grafts, usage of bilateral ima grafts in cabg patients causes greater thoracic trauma and further reduces blood supply to the sternum and intercostal muscles. these effects may be associated with increased postoperative respiratory complications obiectives: to study the effects of bilateral ima grafts on postoperative respiratory morbidity in cabg patients. methods: two groups of patients undergoing cabg were prospectively studied: group (n= ) received both imas as grafts and group (n= ) received only the left ima. the two groups were matched for age, smoking habits, total number of grafts and preoperative ejection fraction. pao /fio ratio was measured in all patients in the icu, at , , minutes on mechanical ventilation (mv), at , , minutes after extubation (ex) and on postoperative day (pod) . in addition, radiografic scores of atelectasis and pleural effusion were assessed postoperatively. results: group had significantly longer bypass ( _+ vs + . p< , ) and aortic cross clamp time ( +- vs + , p= , ). pao /fi ratio was significantly higher in group only at minutes after extubation (table) . there was no difference in the incidence or severity of atelectasis or pleural effusion between the two groups. the duration of mv was longer in group ( +_ vs _+ , p= , ), but the length of icu stay and hospitalization were similar. there was one case of pneumothorax in group and one case of pulmonary infection in each group. after extubation m[n min min min* rain min pod ' _+ _+ + -+ - -+ _+ _+ _+ _+ -+ _+ _+ -+ mean_+sd, *p=o, o conclusions: compared with unilateral ima grafts, the usage of bilateral ima grafts in cabg patients is not associated with increased postoperative respiratory morbidity. the diagnosis of rv ischaemia is difficult in the critical care setting. the purpose of this study was to determine the ability of rv endomyocardial and interstitial ph electrodes to detect rv ischaemia in an animal model of rv infarction produced by fight coronary artery ligation. we hypothesized that changes in transmural and interstitial ph would accompany the induced tissue hypoperfusion. rv interstitial (phint) and transmural endomyocardial ph (phendo) were measured in adult anaesthetized pigs before and serially after coronary ligation. phendo and phint fell progressively and significantly following coronary occlusion. this was accompanied by ischaemic ekg changes. the absolute and relative rates of change were greater for phendo compared to phint, particularly after minutes of ischaemia, ph was unchanged in control experiments when the electrode was placed within the fight atrial or ventricular chambers, as well as when coronary ligation was not performed. these data suggest that rv myocardial ph measurements reflect coronary ligation induced rv ischaemia, ph recorded from an electrode placed against the rv endomyocardial wall via a central vein was as useful as an interstitial measurement that required a thoracotomy. this newly described technique may be helpful in clinical settings where differentiation between ischaemic and nonisehaemic causes of rv dysfunction is important. centre. depts of cardiac surgery and anesthesiology, university of bari, italy. lung injury secondary to cardiopulmonary bypass (cpb) is well recognized. nevertheless, mechanical respiratory changes after cpb have been poorly investigated. aim of the study was to evaluate the effects of cpb on respiratory mechanics. elastance of the lung (est l), chest wall (est cw), and total respiratory system (est rs) were measured in patients without previous pulmonary disease undergoing elective cardiac surgery. there were males and females; no pleurotomy was done. cpb was carried out with membrane oxygenator. mean cpb and cross clamping times were _. and • min. flow (pneumothacograph), airway opening and esophageal pressures (pressure transducers and esophageal balloon) were measured on patients sedated and paralysed. measurements were obtained before sternotomy, at the end of cpb after chest closure, four and seven hours later. est rs, est l and est cw, were measured by occluding the airways and the end of a tidal breath. before end cpb- h after h after stemotomy closed chest cpb cpb estrs (cmh /l) . + . . - . " . _+ . * . - . * est cw " . _+ . . • . + . . -+ . est l " . -- . . - . " . -_ . " . _+ . " x + sd. * p < . : anova vs "before sternotomy". our data show that cpb induces increase in est l, whereas est cw remains unchanged despite sternotomy. impairment in est l after cpb evolves within the first hours and stabilizes hours later. during the clinical course of human imunodeficiency virus infection (hiv), patients (lots) can develop congestive and dilated cardiomyopathy syndrome (dcm). the aim of our study was to analyze the prevalence of dcm among an hiv population, its clinical and echocardiographic changes under a long term follow-up and therapy with an ace-inhibitor agent (captopril). we prospectively studied pts, % ( / ) developed dcm during the follow-up study. among this group % ( / pts) were in class i and ii and % ( / pts) in class iii and iv of the nyha classification. we divided this population in a acei+ ( pts) and acei-( pts), according to the administration of captopril. we analyzed the following parameters: age, gender, race, ivda, type of hiv, cdc classification, number of t and t type cell population and its t /t ratio, therapeutic with acei, type and number of opportunist infections, mycobacteriosis and neoplasm's. we analyzed several echocardiographic parameters, which included the initial (i), final (f) and variation (a) of the lv internal diastolic (lvdd/mm) and systolic (lvsdimm) diameters, lv % of fractional shortening (lv%fs/%), ivs and posterior wall thickness and lv mass (lvm/g). the two groups differed significantly in the following parameters: left ventricular functional indices of patients (pts) with iscjhemic dilated cardiomyopathy (idcm) have a critical value in terms of clinical prognosis of this disease. three-dimensional echocardiography ( -de) is a recently developed method that gives a better evaluation of lv morphology and function. the purpose of our prospective study was to assess the clinical applicability of this new -de method in a population with ischemic dcm diagnosis and calculate its lv indices of global and regional function. we studied a group of idcm pts, mean age _+ yrs, % male gender, using a combined -de tee approach. all pts were in class ill/iv of the nyha classification. first, ekg gated images were acquired through a mechanical pullback of the tee probe, and each set of data was transferred to a conventional ibm-pc system using a dedicated -de software. computer processing and analysis of the tee images led to a -de reconstruction matrix and off-line calculation of several lv global and regional indices. in all idcm lots the lv cavity was clearly reconstructed and end-systole and diastole in several orthogonat projections, out in multiple planes and its function quantitated using -de derived indices. mean values of -de lvesv= -+ ml, lvedv= _+ ml, lvstv= _+ ml and lvef= -+ % were obtained. for all these -de parameters, good correlations were observed with -de lv measurements obtained through biplane tee analysis of the lv cavity (r>. ; p<. ) as well as regional analysis of sequential -de cut planes. conclusion: in our group of patients with the diagnosis of ischemic dilated cardiomyopathy, this new -de method could be applied. our results show that this method allows a better assessment of the lv morphology and spatial geometry, with the calculation of global and regional indices with critical clinical and prognostic value in this particular cardiovascular pathology. simultaneous left atrial (la) and left ventricle (lv) inflow analysis assessed by pulsed doppler tee illustrate the loading conditions and reflect the hemodynamics of the left heart. we performed a prospective tee pulsed doppler study with recordings of the transmitral lv filling and pulmonary venous (pv) flow drainage in a group of patients with dilated cardiomyopathy (dcm). a group of dcm patients, mean age _+ yrs, % male were studied. this population was divided according to tee severe lv dysfunction (group slvd+ % pts; group slvd- % pts) in each pt we measured the peak velocities (vel/m/sec) and time velocity integrals (vti/m) of the transmitral early (e) and late (a) filing waves, the vel and vti of the pv systolic (s), diastolic (d) and atrial contraction (c) reversal flows. -de tee evaluation of the lved, lves, lvst volumes and lvef were obtained. we calculated other parameters, such as e/a, s/d and a/c ratios and the sum of c+a vel, that refelect la systolic function and lv compliance. + -_ . simultaneous and quantitative analytical approach of the pulmonary venous and transmitral flows and ventricular volumes improve the non invasive assessment and understanding of left ventricular diastolic function and cardiac performance in dilated cardiomyopathy patients. objectives : to assess the hemodynamic effects of fluid loading (fl) in acute circulatory failure (acf) due to acute massive pulmonary embolism. methods : hemodynamic measurements (fast-response thermistor pulmonary artery catheter) were performed at baseline (baseline) and after a rapid fluid loading with (fl ) and (fl ) ml of dextl'an (rhemacrodex| in patients free of previous cardiopulmonary disease ( • yrs) with acf (ci < . l/rain/m ) due to angiographicalty proven mpe (miller score > ) . results : are expressed as mean _+ sem and compared by anova. a significant negative correlation (r = . ) was observed between baseline rvedv[ and the effects of fl on ci. such correlation was not observed between baseline rap and the fl induced increased in ci. conclusion : fusibmificantly increases ci in acf due to mpe. however, the simultaneous decrease of arterial content due to hemodilution, limits the benefits expected from improved ci on peripheral oxygenation. obiective: to examine the hemodynamic effects of external positive endexpiratory pressure (peep) on right ventricular (rv) function in acute respiratory failure (arf) patients. methods: incremental levels of peep ( - - - cmh ) were applied and rv hemodynamics were studied by a swan-ganz catheter with a fast response thermistor for right ventrieular ejection fraction (rvef) measurement in mechanically ventilated arf patients (lis = . ~- . sd). according to the response to peep , two groups of patients were defined: group a ( pts.) with unchanged or increased rv end diastolic volume index (rvedvi) and group b (h pts) with decreased rvedvi. results: in the whole sample cardiac index (ci) and stroke index (sj) decreased at all levels of peep, while rvedvi , rv end systolic volume index (rvesvi) and rvef remained anchange d. at zeep the hemodynamic parameters of the two groups did not differ. in group a, ci decreased at peep , rvef decreased at peep (~ . %)~ rvesvi increased only at peep (+ . %) and rvedv[ reded unchanged. in group b, ci and rvedvi started to decrease at peep , 'rvesvi decreased only at peep (- . %), anf rvef was unchanged. individual behaviors of the hemodynamic parameters at the levels& peep were studied. rvedvi and ci were significantly correlated in out of:l patients in group b, and in no patient of group a. on the contrary, mpap and rvesvi were significantly correlated in out of patients in group a, and in no patient of group b. the slope of the relationship between rvedvi and rv stroke work index (rvswi) expresses rv myocardial performance. this relationship was significant (no change in rv contractitity)in patients of group b and in patients of group a. in some patients of group a, increments of peep shifted the rvswi/rvedvi ratio rightward inthe plot (rv function decrease). conclusions: in arf patients peep causes more often a preload decrease with unclmnged rv conctraetility. on the contrary, the finding of increased rv volumes during the application of peep is related to a decrease in rv myocardial performance. thus, these data suggest that application of peep might be considered as a stress test to assess rv function. right introduction: after heart transplant (ht), the right ventricle can be subject to an acute pressure overload, especially in cases where there is a preexisting severe pulmonary hypertension. this provokes right ventricular failure and, occasionally, circulatory collapse in intensive care unit. desire the advances that have been made in systems for preserving the donor heart and in post-surgical management, we have failed in our attempts to totally avoid this problem. the right ventricular function, although it usually remains within tolerable limits in these patients during the post surgery period, represents a factor which limits the results achievable in clinical transplant programmes. objectives: to determine the maximum tolerance of the right ventricle (mxtrv) when faced with acute pressure overload. to study the function of both ventricles of the healthy heart (donor) when faced with different degrees of pulmonary hypertension. to detect possible interactions between the ventricles in the absence of the pericardium to approximate the experimental model to the clinical model of ht. materials and methods: the pulmonary artery is progressively constrained in an experimental model until biventricniar failure is detected. this experiment is performed in two diffferent situations: with and without pericardial integrity. results: when pericardial integrity is maintained the mxtrv faced with a pressure overload is . + . nun hg. when this pressure is exceeded there is a circulatory collapse with a sharp fall in the cardiac output and in the aortic pressure. however, when pericardectomy is performed (model similar to ht), only • . nun hg is tolerated (p < . ). conclusions: with the pericardium open, as in heart transplant, the maximum pressure that the right ventricle can support is significantly less than with the pericardium closed. the pericardium has a positive effect in protecting the systolic ventricular interaction. it is, therefore, advisable to close the pericardium after heart transplant. jb prrez-bernal, a ordrfiez, a. heroandez, jm borrego, map camacho, c cruz, mac s~nchez, j monterrubio, c garcia, e. gonz~lez. hospital uulversitario " virgen del rocio ". sevilla. espaiqa. introduction: nowadays cardiomyoplasty isused incases of cardiac insufficiency as an alternative to cardiac transplant. after surgery the patients show a noteable improvement with the aid of this "biological circulatory assistance". some researchers suspect that the improvement could also be due to the formation of new blood vessels from the muscle that wraps the heart, nourishing the ischemic myocardium. objectives: our cardiovascular research group has proposed as an objective, the detection of any possible myocardial neovascularization through the muscle used for cardiomyoplasty. in the case that there are new blood vessels to the diseased myocardium through the wide dorsal muscle in which it is wrapped and which aids it mechanically, it would be possible to confirm the worldng hypothesis that cardiomyoplasty not only improves the cardiocirculatory funcfinn mechanically but also by facilitating a better blood flow to the ischemic myocardium. materials and methods: the cardiomyoplasty technique is described using an experimental model of myocardial ischemia. the vascular cast is achieved by injecting methacrylate simulataneously into both the coronary tree and the wide dorsal muscle, in five experiments the connections between the coronary vascular system and the vascular structure of the wide dorsal muscle are demonstrated, conclusions: we have demonstrated that cardiomyoplasty, as well as improving ventricular function, favours the revascularization of the myocardium. cardiomyoplasty could be indicated for cases of ischemic cardiopathy in patients in whom it is not possible to perform direct revacularization using conventional methods. a the therapeutic cardiological manouevres necessary in cases of ischeima reperfusion have increased considerably: fibrinolysis, transluminal angioplasty, coronary revascnlarization surgery and cardiac transplant. the appearance of a specific pathology ht acute reperfusion has been related to free oxygen radicals (for) generated by oxidative damage. objectives: to evaluate the appearance of for during a conti-olled process of ischemia-reperfusion in an experimental biological model and compare it with that in clinical cases. materials and methods: transitory cardiac ischemia was performed in five rabbits by reversible surgical ligation of the descending anterior coronary artery. after minutes coronary reperfusion was performed. blood samples were taken in the basal situation, at the end of ischemia and at , and minutes after the start of reperfusion. malondialdehyde (mda) was measured to evaluate the degree of lipid peroxidation (oxidative damage to the membrane). in ten patients undergoing conventional cardiac surgery the production of for was measured after aortic clamping. results: we observed that after minutes of reperfusion there was a highly significant increase (p < . ) in the mda values (mean = . /zmols/l). these returned to basal levels after and minutes of reperfusion. conclusions: an "explosion" of oxygen free radicals was detected very quicldy, just a few minutes after post-ischemia reperfusion. thus, if antioxidant agents are to be used to reduce the toxic effects of the for, these will ordy have a therapeutic effect if they are administered in the early phases of reperfusion. introduction: aortic connterpulsation is a ventricular assistance widely used in intensive care units in patients with cardiogenic shock as a provisional ventricular assistance. paraaortic or external aortic counterpnlsation is been investigated as a definitive veutricular assistance in those cases of terminal congestive heart failure and when heart transplantation is counterindicated. aims: to assess the haemodynamic effects of an aortomyoplasty in a biological model of congestive heart failure. material and method: as specimens, we used "large white" pigs. mean weight was kg. after the administration of conventional anaesthesia, dissection of the ladssimns dorsi muscle was performed on the samples at the laboratory of experimental surgery of our hospital. then we performed a thoracotomy at the level of the fourth intercostal space to reach the thoracic aorta. the aorta is dissecated centimetres from the exit of the subclavia and it is wrapped by the dissecated muscle. a cardiomyostimulator is provided in order to allow the synchronization between the diastole and the muscle contraction. the model of heart failure was provoked using verapamil plus propanolol i.v.. results: a significant increase of the aortic diastolic pressures and a significant decrease of the left ventricle telediastolic pressures were observed. this improvement in the parameters (dpti/tti) implies an increase of the coronary perfusion in a model of heart failure. conclusions: using the external aortic counterpulsation, the aortomyoplasty improves the coronary perfnsion and the heart efficiency in patients with heart failure in whom no conventional therapeutic action is possible. the permanent character of the paraaortic counterpulsation is it main advantage. the appearance of specific pathologies as a resuk of myocardial reperfasion has been related to the oxidative damage secondary to the release of oxygen derived free radicals (ofr). during the myocardial ischemia induced during heart surgery with extraeorporeal circulation, severalsubproducts of the oxygen are produced that shall cause toxic effects after the reperfusion which could be counteracted by the physiological antioxidant systems and/or provided by the medication. aims: to asses the ofr during heart surgery. to check whether an antioxidant treatment administered in the preoperative period make decrease the levels of ofr before and after the myocardial reperfusion and to verify whether its administration have any beneficial effect on the intra and extraoperative management. material and method: the study comprehends patients studied as two groups of individuals each (a and b). all patients underwent conventional heart surgery of valvniar substitmion or myocardial revaseularization. group a patients were administered rag/ hours of vitamin e (tocopherol acetate) hours prior to the intervention as antioxidant treatment. group b patient were not administered vitamin e. we assessed the quantity of malondialdehido (mda) to assess the degree of lipidic peroxidation or oxidative damage of the membrane during the myocardial ischemia and nm after the reperfusion. conclusion: patients who underwent heart surgery and were treated with tecopherol acetate in the preoperative period presented levels of rlo significantly lower than those who were not administered the drug, both during the intraoperative period and after myocardial reperfusion. we detected in these patients a need for antiarrhythmicals and pharmacoiogical support with catecholaminas, although not significant, both in the introaperative period and the immediate postoperative period. recommendations for the treatment of pulmonary embolism (pe) in the presence of right atrial thrombus (at) are conflicting. because of a significantly higher mortality rate due to fulminam or recurrent pe, there is a necessity to treat patients (pts) with mobile type a thrombi compared to pts with adherent type b thrombi. therapeutic strategies include anticoagulation, thrombolysis (t) or surgical thrombembolectomy. combination thrombolysis (cot), predominantly used for the treatment of acute myocardial infarction proved to prevent reocclusion of the infarct related artery at a comparable rate of hemorrhagia. benefit has been related to the alteration of hemostatic proteins by non-fibrinspecific thrombolytic s. administration of cot in pe has been performed sporadically. in the present case, a -year old male with no history of prior cardiovascular disease developed acute dyspnea which was related to pe in the presence of deep vein thrombosis of the left femoral vein. therapeutic anticoagulation was installed for a couple of days until there were several bouts of deterioration. biplane transesophageal echocardiography (tee) was performed and revealed a large, wormlike, hypermobile thrombus within the right atrium. computer tomography (ct) of the chest detected a saddle embolus in the bifurcation of the pulmonary tmnk almost occluding the entire left pulmonary artery (pa) and parts of the right pat consisted of mg frontloaded rt-pa and the subsequent continuous administration of urokinase in a dosis of . u/hr for hrs followed by therapeutic anticoagulation. symptoms, blood gases and ecg improved steadily during infusion, no adverse effects, i.e. minor or major hemorragia were registered. follow-up ct promptly after termination of t showed almost complete resolution of the saddle embelus, whereas tee showed complete dissolution of the at. ' finally, the patient was switched to oral anticoagulants and had an uneventful clinical course until he was discharged. conclusion: in the present case, cot was effective for the treatment of a complicated pe without any adverse effect. introduction: nowadays we can assist hearts with problems of insufficiency by techniques other than transplant. many researchers believe that the best way of assisting insufficient heart muscle is with another muscle from the patient. this technique of ventficular assistance is known as cardiomyoplasty. we describe the surgical technique of cardiomyoplasty using a biological model. the transformed skeletal muscle is transferred to the thoracic cavity where it wraps the heart and assists it. the choice and preparation of this muscle is currently under investigation. our group has focussed on the development of protocols for electrical stimulation to transform a skeletal muscle into a muscle which resists fatigue and which is functionally similar to the myocardium. we detect the optimum time at which this muscle has been transformed, by studying the transmembrane action potentials using intracellular electrodes. when the action potential of the trained muscle behaves like cardiac muscle we consider it ready for cardiomyoplasty. conclusions: cardiomyoplasty is an alternative surgical technique to cardiac transplant, which has a great future in the treatment of patients with advanced cardiac insufficiency. we describe methodology which, by intracellular techniques, allows selection of the optimum moment of transformation of a skeletal muscle trained to perform,like cardiac muscle, without suffering fatigue. purulent pericarditis is a rare disease. its treatment associate systemic antibiotics and drainage of the pericardium. we report a ease of purulent constrictive pericarditis in which intraperieardial fibrinolysis was use. a years old patient admitted in our icu for a constrictive pericarditis as a complication of a purulent pericarditis diagnosed seventeen days before. he had also an aehalasia and the o'esogastric endoscopy had found an oesophageal neoplasm. a fistula was not seen, indeed pericardial of flora was the same that oropharyngeal. hemodynamie and echographic study had confirmed a constrictive pericarditis. because of the poor state of the patient an intraperieardial fibrinolysis was prescribed ( . ui of streptokinase on days , , , ). fluid drainage was improved and cardiac output was also improved (day : . .min "i, day : . l.min'l). no change ofhemostasis was noted. a pericardeetomy and an oesophagectomy were performed after days of evolution. eighteen months latter the patient was still alive. intraperieardial fibrinolysis seems an interesting therapeutic way if rapidly prescribed in the purulent pericarditis course. the decrease in the systolic pressure following a mechanical breath, termed ddown (delta down), has been shown to be a sensitive indicator of preload ( , ) . however, the clinical use of this method necessitates the introduction of a short apnea. we have therefore developed a respiratory systolic variation test (rsvt) which obviates the need for apnea. the test is based on the delivery of successive breaths of increasing magnitude ( , , , and ml/kg). a line of best fit is drawn between the minimal systolic values (one after each breath) and the downslope calculated as the decrease in blond pressure for each increase in airway pressure ( mmhg / cmh ). in mechanically ventilated patients the rsvt was performed during controlled mechanical ventilation under sedation. the test was repeated after the administration of ml/kg of plasma expander. the initial mean downslope of the rsvt was -. + . mmhg/cmh . following volume loading the downslope decreased to -. + . (ns). at the same time, cardiac output (co) increased by . + . l/min (p<. ), end-diastolic area (determined by tee) increased from . + . to . + . cm (ns), and paop increased from + to + mmhg ( p < . ). the preinfusion downslope value of the rsvt correlated significantly with the increase in the co (r = . ) and the eda (r = . ). methods: an expert system has been constructed running on a multimedia computer with the two objectives in mind, viz training of inexperienced staff, and protocol guidance with treatment regimes for all staff. the system is based on experience gained from two previous systems, the one for dealing with acid-base and electrolyte problems in icu patients; the second for stabilisation of patients with heart rate and blood pressure abnormalities. the training section takes the form of a stage-by-stage account of the insertion of the pac and displays of correct waveforms, coupled with indications of possible incorrect placements, and guidance when failing to achieve the perfect positioning. the treatment protocol section extends an existing protocol for correcting abnormalities in heart-rate and blood-pressure, and now takes account of all the indices as measured by the pac. the system will suggest treatment to correct such things as abnormal wedge pressures concomitant with parameter values throughout the rest of the cardiovascular system. the type of patient eg post-operative cardiothoracic or i. c. u. trauma, will be taken into account when recognising abnormal parameter values and when prescribing treatment. results: a working system which will be improved by the finetuning being carried out. the results and lessons learnt will be presented at the conference. method: septic shock was defined as severe sepsis with either persistent hypotension (mean arterial pressure; map < mmhg) or the requirement for a noradrenaline (na) infusion ~ . g/kg/ rain with a map --< mmhg. cardiovascular support was limited to na + dobutamine (db). c was given for up to h at a fixed dose-rate of either , . , , or mg/kg/h iv. during c infusion, na was to be reduced and if possible withdrawn, whilst maintaining map above mmhg and the cardiac index (ci) as clinically appropriate. assessments were made at baseline (t = ); at i h from the start of treatment (t - ); and at the end of treatment (t - ) with c . conclusions: c does not appear to increase mpap or worsen pulmonary gas exchange in patients with septic shock, when given by infusion for up to h. c is a novel vasoactive agent for the treatment of septic shock which will now he evaluated in a randomised, placebo-controlled safety and efficacy study. objectives : to compare cardiac output (q) data obtained for thermal indicators in pulmonary artery (qtpa) and aorta (qtao) and for the stable isotope hzo in aorta (q v~ o) with indocyanine green (icg) in aorta (qicg) as reference. methods : an indicator solution of ice cold h ( . ml), h ( . ml) and icg ( mg) was injected as bolus via the injection port of a swan-ganz catheter. qlco and qzmo was measured using a dual optical system (penn lab instruments, philadephia, pa, usa). qtpa and qtao was measured using a in contrast to the recoveries of thermal indicator in pa and h in aorta the :~covery of thermal indicator in aorta was significantly increased in group ii (n= boluses) over group i (n= boluses) ( . <- . vs. . +- . , p= . ). conclusions: the "overrecovery" of thermal indicator in aorta is in agreement with " biscks deconvolution study (i) and results in erroneous values for q. the most pausible explanation is the distortion of the thermal curve caused by the slow response time of the thermal detection instrument as shown by ganz ( ) objectives: to compare data obtained with the double indicator dilution method using indocyanine green (icg) and the stable isotope h for the estimation of extravascular lung water (evlw hzo) to gravimetriu lungwater data (evlwg~). methods: an indicator solution oflcg ( rag) and h ( . ml) was injected as bolus via the injection port of a swan-ganz catheter. dilution curves for icg and zh was registered in aorta with a dual optical system (penn lab instruments, philadephia, pa, usa). cardiac output and mean tranist time was measured for both tracers (qico, tlco, q n o, t o) ( ). data analysis: evlwg~av was reference for evlwzhzo calculated as q hzo times the difference in mean transit time between t nzo and rico (atm n). as reference for atzn o evlwg~,v was divided by q~cg to obtain atg~,. a reference distribution volume for h was calculated as the sum of central blood volume and evlwg=v. boluses were administrated in a group (i) of anaesthetized pulmonary healthy sheep while q was altered. another boluses were administrated in a group (ii) of anaesthetized sheep with stable oleic acid induced pulmonary oedema. evlwg~v measurement was performed postmortem. results: for boluses h parameters were not significantly different from their respective reference parameter: at vao . +_ . s vs. atg~, . + . s, evlwzh o -+ ml vs. evlwg~,~ + ml. in group i the ratio between hzo parameters and respective reference parameters (n= ) were independent of qlco from . to . l/min. obiectives: to assess the thermo dye method using indocyanine green (icg) and thermal indicator for the estimation of lung water (evlwt). methods: ice cold indicator solution of icg ( mg) in water ( ml the aim of the study was to assess left and right ventricular function in the early postoperative period after orthotopic heart transplantation to elaborate therapeutic approaches of heart function abnormalities correction. mathefial and methods. haemodynamic monitoring data of twenty one patients ( men, women ) age from to were studied. cardiac output, pulmonary artery, right atrium and pulmonary wedged pressure were measured with swan-gans catheter. central haemodynamic indices were calculated with the help of computer-based monitoring system. relations of ventricular stroke work index to it's end-diastolic pressure were used for ventficular function assessment. results. in most cases right ventricular disfunction was the main problem. isolated fight ventficular failure with high pulmonary vascular resistance (pvr) was observed in % ( pts), without high pvr-in % opts) and with left ventricular failure-in % ( pts). one of the most important reasons for fight ventricular failure was the time of heart ischemia more than min, which is of great importance in the ease of distance harvesting. the most effective treatment for cardiac failure was combination of dobutamine with i oprotherenol, atrial pacing and vasodilatators in case of right ventfieular disfunction. all cases with isolated right ventricular failure were treated sucsessfully. biventricular heart failure was a sighn of bad prognosis and the reason of death in cases. conclusion. right ventfieular disfunetion is the main problem during transplanted heart adaptation in the early postoperative period. optimal therapeutic management of cardiac disfunction includes infusion of dobutamine in combination with isoprotherenol, atrial pacing and vasodilatators. cardiology-department of clinical centre-kragujevac institution for occupational health "zastava"-kragujevac, sr yugoslavia the aim of the investigate is analisis five years survives patients with a.i.m.in dependence of locality and risk-factors. we ana~sed- ~-pat~e~ts ( males and woman), average , years. for statistic evaluation we used life-table slstem in oder to estimate prognostic determinants. patients with respkatory muscle paralysis may benefit from respiratory assistance by abdomino-diaphragmatie pneumatic belt. we used a non invasive technique, m-mode sonography, to assess the effect of this device on diaphragmatic excursion. we measured the amplitude of right diaphragm motion in seven patients with duehenne muscular dysl~ophy in supine position with various thoracic posture ( ~ ~ ~ without and during pneumatic belt respiratory assistance. without respiratory assistance, the thoracic posture had no significant consequence on the amplitude of diapttragm motion, either in quiet or deep breathing. the pneumatic belt increased the diaphragm motion amplitude from . +__ . mm to . +_ . ram (p = . ) at ~ tilt angle, and from . + . mm to . + . mm (p = . ) at " tilt angle. the tidal volume increased from + to + rut a * tilt angle, and from + to + ml at * tilt angle (p = . ). two patients could not bear the horizontal position ( ' tilt). in the five other patients, the pneumatic belt increased but not significantly the amplitude of diaphragm motion ( . + . mm to . + . ram). after an overnight respiratory assistance, pao increased from . +_. . to + . mmhg ( = . ), sao increased from . + . % to . +_. % (p = . ), and paco decreased from + . to . +_. mmhg (p = . ) according to the ventilatory pattern result, m-mode sonography allows to measure non invasively the improvement of diaphragm kinetics obtained by pneumatic belt respiratory assistance, and may be helpful for its adjustment. objective: to study the effect of flow triggering (flow sensitivity and l/min) vs pressure triggering (-lcmh ) on inspiratory effort during pressure support ventilation (psv) and assited/controlled mode (a/c) in stable copd patients non-invasively ventilated with a full face mask. methods: the patients were studied during randomized min. runs using a bird st ventilator at zero peep (zeep). trigger values for pressure (-lcmh ) and flow ( l/rain) were the lowest allowed by this ventilator. the transdiaphragmatic pressure time product per breath (ptpdi), dynamic intrinsic peep (peepi,dyn), maximal airway pressure drop during inspiration (apaw) andl ventilatory variables (ti,te,ttot,rr,vt and minute ventilation) were measured. results: no major problems due to airleaks or to auto-triggeriffg phenomena were observed in the patients, so that all of them were able to perform all the protocol runs. minute ventilation and respiratory pattern were not different using the two triggering systems. the ptpdi was significantly higher during both psv ( . + . cmh: x sec) and a/c ( . + . ) with pressure triggering, as respect to psv ( . + . , p< . ) and a/c ( . + . , p< . ) with flow triggering ( l!m). no differences were observed between and l/min flow triggers. apaw was also significantly larger during pressure triggering; peepi,dyn was reduced during flow triggering being . + . cmh (psv flow trigger) vs . + . (psv pressure trigger) and . +_ . (a/c flow trigger) vs'f~ +l (atc pressure trigger). conclusions: in stable copd patients non-invasively ventilated, flow triggering reduces the respiratory effort during both psv and aic mode as compared to pressure triggering. this may be partly due to a decrease in peepi,dyn using a flow-by system. objective. cardiac output is higher during alternating ventilation (av) (i.e. differential ventilation of the lungs with a phase shift of half a ventilatory cycle) than during synchronous ventilation (sv) of both lungs . we verified the hypothesis that the higher cardiac output depended on a lower central venous pressure and intrathoracic pressure, due to a lower mean lung volume, which we attributed to part of the expansion of the inflated lung at the expense of the expiring, opposite lung . we studied this interaction between the lungs during one-sided inflation, which we called cross-talk. method. in anaesthetized and paralyzed piglets we applied short periods ( s) of one-sided ventilation ( breaths per rain, bpm), while the other lung was open to the ambient air. the air flow into the non-ventilated lung during expiration of the ventilated lung was integrated to volume. we studied -to-r and r-to-i cross-talk at ventilatory rates of , and bpm. the amount of cross-talk was the volume displacement in the non-ventilated lung. results. during bpm the r-to-i crosstalk was _+ . % (mean +__ sd) of the tidal volume to the right lung and the -to-r crosstalk _ . % of the left tidal volume. both values increased at bpm to _ . % (p < . ) and _ . % (p < . ) respectively. the values at bpm were in between., conclusion. we concluded that the lower mean lung volume and lower thoracic expansion during av compared to sv depends on partial expansion of the inflated lung into the non-inflated lung, resulting in a lower mean intrathoracic pressure as the main reason for the higher cardiac output during av. obiective: natural surfactant given for rds in premature infants leads to a rapid improvement in oxygenation, but lung compliance did not improve in most studies. however, acute effects on lung mechanics during and immediately after surfactant administration have not been studied before. methods: a total of administrations of bovine surfactant in recommended doses was given via a small catheter into the distal endotracheal tube either as a bolus (n = ) or as a slow infusion (n = ) in infants with established rds. static compliance (c), resistance (r) and time constant (tc = cxr) of the lung were measured every minutes with a lung function cart (sensormedics ) without interrupting ventilation. infants receiving synthetic surfactant were studied as controls. results: after surfactant as a bolus or during infusion c first decreased but then increased, whereas r increased immediately with great fluctuations but did not return to baseline. this pattern was more pronounced in infusion than in bolus administration. change of c and r varied greatly in the individual case, maximum c was > %, maximum r > % of baseline value. retreatment was followed by an increase in r in all patients, but c increased only in the one who was responder. patients receiving synthetic surfactant had no change of c or r and were non-responders. ob~i ctives= acute lung injury (ali} sometimes induces severe hypoxernla which may be refractory to conventional modes of mechanical ventilation (mv). the elm of this study was to observe some cardio-pulmonary effects of an alternative method of ventilatory management of severe ali. five patients with severe ali (murray scores > ) requiring mv were studied. protocol inclusion was considered when a control-mode of mv (with a pzo~=l. and a peep level < cme=o} was not able to get either a p.ojf=o= ratio > or a s.o= > %. patients were sedated, paralyzed, and a ventilator (serve c) was used for pressuz'e-control ventilation (pcv). fio= was maintained at . and peep removed. continuous gas flow ( • ml/kg] was humidified and jet delivered through a tube ( ram id, ml capacity, . ml/cm h=o compllancel ended in a nozzle ( . mm is) attached to the endotracheal tube connector. a thermodilution flcw-dlrected catheter was inserted in pulmonary artery. following variables were recorded minutes before and after protocol started: tidal volume (vt), minute ventilation (vz), intratracheal pressures (p~w), wedge pulmonary artery pressure (wp), central venous pressure (cvp), mean arterial pressure (map), cardiac index (ci), arterial and mixed venous oxyhemoglobin saturation (sao=, svoa) , oxygen delivery (do~) , oxygen consumption (vo ) , intrapulmonary shunting (q./qt) , and oxygen extraction ratio (ero). this observation suggests that hfpv could allow to ventilate at lower fin and improve blood oxygenation during the acute phase after inhalation injury reducing toxicity risk related to high fin . further studies are necessary to confima these results and evaluate the possible implications on mortality alter smoke inhalation and for other icu pts. objectives: to design a system for volume controlled high frequency ventilation (hfv) and to estimate the dependence of the tidal volume (vt) on frequency (f) in normocapnic ventilation in rats at frequencies - hz. methods: a new system for volume controlled hfv was devised consisting of the generator of the constant flow during inspirium and the constant pressure during expirium. the ventilator allows ventilation at frequencies - hz with the relative inspiratory time (ti) . - . . the airway pressure was measured at the proximal port of tracheostomic cannula , at the same site inspiratory and expiratory flow was measured using modified lilly-type of pressure-differential flow sensor. non-linearity of flow sensor was compensated on line by derived equation based on calibration at static and dynamic conditions. flow and pressure data were evaluated on line using original software. value of the positive end expiratory pressure (peep) was serve-regulated by analogous feed-back. in animal experiments white wistar rats ( - g) narcotized with ketamine/xylazine with cannulated carotid and femoral arteries were kept at the rectal temperature ~ the arterial pressure was monitored. after traeheotomy the metal cannula ( mm [.d.) was inserted, animals were curarized and ventilated at the following condition: peep = . kpa, ti = . . the dead space of ventilator including canula was . ml. the initial frequency was hz and rain after each change of the ventitatory regimen the blood gases analysis was performed. the frequency was changed according to the following schedule : hz--> hz--> hz--> hz--> hz--> hz--~ hz--> hz. vt for each frequency was regulated to maintain normocapnie ventilation with arterial pco = + mm hg. the arterial po was always above mm hg. results: for normocapnie ventilation in rats the following tidal volumes vt [ ml/kg] were found : vt = . --+ . ml/kg for ft = hz, vt = . + . mukg for fz = hz, vt = . +_ . ml/kg forf = hz, vm = . + . ml/kg forf = hz andvmt= . + . mukg for fs = hz (presented as mean values _+ s.d., n = ). the regression analysis using the mean values resulted in the equation for normocapnic vt in rats in our experiments : vtn = . * f-e. . conclusions: the described system allowing ventilation in a wide frequency range - hz with accurate measurements of airway pressures and vt might be useful for optimisation of artificial ventilation in new-barns with different lung pathologies. supported by grants iga mz cr nr - and gacr nr . s intensive care unit. university. hospital of south manchester, uk. methods: measurements were conducted on ventilated patients (puritan bennett ac with metabolic monitor pb set to measure end tidal co ). all measurements were repeated with the patient stabilised at cm. cm and cm peep. inclusion criteria were: ) haemedynamic stab(l( .ty for hr; ) pulmonad" anon" flotation catheter in situ: ) volume control ventilation with plateau of . s: ) fio ~ > . to maintain pao~. > kpa with em peep: ) qs/ot > %; ) pao /fio ratio < . measured variab!es included: r minute volume: plateau ainvay pressure: applied and intrinsic peep: fractional end tidal co ; arterial and mixed venous blood gases and hacmod).ttamic variables. results: statistical analysis was performed using repeated measures anova. significant decreases in cardiac index (ch p< . ), compliance (p<t). ) and o,'gcn deliver, index (do , p< . ) occurred with increasing peep (table ) . no other variable showed any significant change. methods : all consecutive patients orally intubated in the micu between january to april were studied. etts were positioned according to the reference marks mentioned above (measurements from upper incisors). the position of the ett tip in relation to the carina was measured on the chest radiograph done with the patient's head in neutral position. results : a total of men and women were studied (n= ). the mean distance of ett tip to carina was . cm. using the reference markings, cases ( . %) had the ett tip < cm from the carina and cases ( . %) > cm. one case resulted in an endobronchial intubation. the mean height of all patients were cm ( - ) for males and cm ( - ) for females. of the patients with ett tip < cm from carina, the mean height was cm and cm respectively. ~ onclusion : adopting the above quoted reference marks did not result in ideal positioning of the ett in a significant proportion of cases ( . %). we postulate that [s because our asian population is generally shorter than those in previous studies. objectives: to measure the changes of pulmonary mechanics before and after tracheostomy in patients with prolonged mechanical ventilation and to determine factors that predict the outcome of liberation from mechanical ventilation. design: prospective. setting: respiratory intensive care unit (ricu) in a tertiary hospital. patients: twenty patients with chronic lung disease requiring long-term mechanical ventilation. tracheostomy is indicated for further care. intervention: tracheostomy. measurements and results: pulmonary mechanics including respiratory rate (rr), tidal volume (vt), peak inspiratory pressure (pip), intrinsic positive end ex~ piratory pressure (peepi), lung compliance (cld), mean airway resistance (rawm), work of breathing (wob), pressure time product (ptp) by bicore cp- pulmonary monitor were recorded hours before and after tracheotomy. ventilator setting parameters remained the same during surgical intervention and were also recorded for comparison. generally, the mechanics including pir wob, raw~x and ptp showed improvment after tracheostomy. but only pip was significantly reduced (pre . _+ . to post . _+ . , p < . ). changes of wobp showed significant correlation with pre-operation rr, minute volume (mv), wobp, and peep(. changes of raw m were also significantly correlated with pre-operation peep, vt, and raw m. the patients were divided into two groups according to their outcome after two week follow-up. group included eight patients who were completely weaned from ventilator; group included twelve patients who still remained ventilator-dependent or were mortality. there was no difference in age, duration of mechanical ventilation, pro, post or changes of several lung mechanics between the groups of patients. pre-tracheostomy peep i and cld showed significant difference between these two groups ( . _+ . vs . + . in peepi; . _+ . vs . _+ . in cld, p < . ). pre-tracheostomy ventilator setting in mode of assist/control also showed significant higher percentage in group ( % % in group vs . % in group ). conclusion: in prolonged mechanical ventilation patients with chronic lung disease, tracheostomy will significantly improve pip and slightly reduce wobp, raw m and ptr patients who used pressure support mode before tracheostomy had better underlying lung conditions (lower lung compliance and auto-peep) will have better chance to wean from mechanical ventilation. forty-eight infants with congenital diaphragmatic hernia presenting within the first hours of life, who underwent surgical rapair,were analysed prospectively in order to produce a reliable inde x of severity of disease that would reliably predict eventual outcome. there were survivors and deaths in this series (mortality %).using arterialpco values measured hours after surgical repairand correlating them with an index of mechanical ventilation,we have been able to clearly define two groups of diaphragmatic hernia based on their response to hyperventilation. the first group, with co retention and severe preductal shunting,was unresponsive to hyperventilation with high rates and pressures the mortality was %. the second group responded well to hyperventilation and demonstrated reversable ductal shunting only. survival in this group was %. arterial co accurately reflects the degree of lung development in this disease and separates those patients with severe pulmonary hypoplasia where the outcome is invariably fatal, from those with a well developed contralateral lung where there is excellent potential for survival. respiratory failure unit, dpt medicine, univ. thessaloniki, thessaloniki, greece the variability of arterial blood gases (po , pc ) and the ph (abg) was examined in stable icu patients, few hours before a successful weaning from the ventilator. all patients were lightly sedated and the ventgatory conti~ons were pressure support (ps) for and ps plus intermitted mantatory ventilation in ii. [n each patient, speciments of abg were measured at min intervals during a - study period. at the same time with abg the arterial blood pressure (bp), the heart rate (cf), the tidal volume (tv) and the respiratory rate (n r were measured. for all the patients, the mean coefficient of variation (c) was . percent for po , . percent for pco and . percent for hco . the average sd for ph was . , the corresponding c for systolic bp, diastolic bp, cf, tv, rf were . , . , . , . , . percent. we conclude that the spontaneous variability of arterial blood gases in icu patients is not substantial ~hen they have stable the heamodynamic and the ventilatory parameters. deptx?fa'aaesthesioiogy and reanimation, rhe sechenov medical academy, moscow, russia objective: ~he prevention and treatment of hypoxia in the critical patiems. methods: i~fusions of perphtoran -a blood substitute with gas-transporting fimclion based on perphtorhydrocarbon -in patients with acute hypovolemia, microcirculatory distnrbance~ tissue gas exchange and metabolism; pulmonary iavage in ; iongterm extrapulmonary oxigenation with tleoroearboa oxygenator in combination whb ~trafiltra!ion, hemosorption and hemodialysis -in patients. results: pe~htoran increases blood volume, co,sv, decreases svr, improves capillary blood flow, increases the blood oxygen capacity, tissue oxygen tension, del, vo by improving the rheologic properties of blood and plasma, normalizes ext., prevents and eliminates fat embolisation and ards. decreases the need for blood transfusions and infusions of plasma expanders by . - . limes. alveolar venti!ation-perfusion ratio remains unchanged with its increased effective utilization. there was no surfactant destruction during lavage. extrapulmonary oxygenation of small volumes of venous blood eliminates venous destruction and then arterial hypoxia and increases pulmonary oxygenation. the use of lluorocarbon cxygenators during hemosorption and hcmodialysis provides the atraumatic and iongterm oxygenation of arterial blood and increases elimination of co which prevents the development of hypoxic complications. conclusions: perphtoran and fluorocarb~n oxygenators are effective in the correction of hypoxia in the criticat patients. objeqtives: to determine if there are differences in oxygen consumption (vo ) during weaning from mechanical ventilation (during total ventilatory support and spontaneous ventilation with cpap), and to compare different predictive parameters of weaning in predicting success of weaning. methods; prospective study in critically ill patients treated with mechanical ventilation for at least h, who fulfilled at least of standard weaning criteria (vt> ml/kg; respiratory frecuency (f) < ; pimax > cm h ; pao /fio > ). baseline measurements: t, vt, p . , pimax, f/vt, p . *(f/vt), p . /pimax. study protocol: measurement of vo , vco (medgraphics), vt, f, ve, and arterial blood gases during total ventilatory support (cmv), and after and minutes of spontaneous ventilation with cpap cm h . the weaning trial was stopped, failure to wean diagnosed, and mv resumed it a patient presented significant tachypnea, tachycardia, bradycardia, cardiac rythm disturbances, hypertension, hypotension, hypoxemia or hypercapnia. results: four patients did not complete the weaning trial, were extubatad, and of them had to be reintubated before h, being considered also weaning failures. during cmv, vo /kg was . + . ml/kg/min, and . _+ . mlo- /kg/min after ' on cpap cm h (p < , ). of patients ( %) with standard criteria were extubated, while only of ( %) with criteria (p< , ). next objectives: compare the extent and distribution of lung injury in dogs preinjured with oleic acid (oa) and ventilated with high tpp and adequate peep in the prone and supine position. methods: lung injury was induced with oa ( . - . ml/kg) in anesthetized, paralyzed, and intubated dogs (n= ) during volume controlled ventilation: rate= /min, peep= cmh , ti/ttot= . , fio = . , vt= ml/kg. animals were rotated during the oa infusion and the following minute stabilization period to assure uniform injury. in the supine position, peep was set - cmh above the lower inflection point (as determined by the pressure-volume curve), and vt was set to obtain a tpp of cmh : animals were ventilated in either the prone (n= ) or supine (n= ) position for four hours. pulmonary artery occlusion pressure was maintained constant ( - mmhg) with saline infusion. at the end of the protocol the lungs were removed and divided by template into dependent (d) and nondependent (nd) sections for wet weight/dry weight (v~n/dw) and grading of nstologic lung injury (hli; scale - ). oseillatron | is a pneumatic device that generates high frequency, oscillation by means of a reciprocating system in the form of a membrane. it generates sinusoidai wave form at ( to ( cycles/rain. the system does not deliver gas but must be adapted to the proximal respiratory, circuit of a conventional ventilator, resulting in ci-ifo. it was developed to enhance intrapnlmona~ diffusion during mechanical ventilation and to mobilise endebronchial secretions. methods. we measured arterial blood gases and haemedynamics during a first period of conventional ventilation (cppv) followed by. two rain periods of chfo (sequences : ( and ) c/rain : group l, n = l: and c/rain : group , n = ). measurements were made at the end of each period. cardiac output was measured using thermedilution method: flu and peep were kept unchanged throughout the study. intrinsic peep was also evaluated by, means of an occlusive valve. results. pa is not significantly modified during chfo at or c/rain. paco is slightly decreased at c/rain (p = .( ). however, intrinsic peep remains unchanged. there is no sequential effect (gr. l vs gr. ). there is no more effect of chfo for patieets who are at a flu higher than . (n = ). no changes in haemodynurmcs are observed except a slight increase in central venous pressure (cvp) during ci-ifo (p < .ol). obiectives: to examine the effects of inspiratory muscles unloading on neuromuscular output at controlled levels of chemical stimuli. methods: the ventilatory response to co was examined in ten normal subjects using rebreathing method. ventilation ~) and respiratory muscle pressure output (pmus) at the same end-tidal partial pressure of co (petco~) were compared with and without combined flow and volumeproportional pressure assist in two protocols (a and b). protocol a (n = ): two levels of assist were studied; flow assist (fa) of cmh /i/sec and volume assist (va) of cmh /i (assist ), and fa of cmh /i/sec and va of cmh /i (assist ). all conditions were applied randomly. v~, tidal volume (vt) and breathing frequency (f) were measured breath by breath and plotted as a function of petco~. protocol b: in subjects, in addition to above measurements, esophageal (pes) and gastric (pg) pressures were measured and the time courses of transdiaphragmatic pressure (pdi) and pmus were calculated. one level of assist (assist ) was studied in this protocol. results: in both protocols inspiratory muscle unloading did not change the f response to c%. compared to control, with assist v t response was displaced upwards; at petco of mmhg v t was increased significantly by . + . i and . + . i in protocol a with assist end , respectively, and by . _+ . i in protocol b with assist (p< . ). ~/~ responses showed similar changes as vtresponses. in both protocols the slope of v~ response (s did not change significantly with unloading. at low petco~ ( mmhg), pdi and pmus waveforms did not differ with and without assist. with unloading, at high petco ( mmhg), pdi and pmus at the end of neural inspiration decreased by . -+ . % and . + . %, respectively, from control values. neither change was significant (p> . ). by theoretical analysis we estimated the expected changes in vt and ~/~ when the levels of assist used in both protocols were applied in the absence of : any change in neural output response to co z. the predicted response was similar to that observed, indicating that the small difference in pdi and pmus between control and unloading runs was due to intrinsic properties of respiratory muscles end respiratory system. conclusions: these results suggest that when chemical stimulus is controlled, respiratory motor output is not downregulated with unloading. the determinants of the response of the respiratory output to inspiratory flow rates (v~) were examined in awake normal subjects. subjects were connected to a volume-cycle ventilator in the assist/control mode and v~ was increased in steps from to i/min and then back to i/min. v~ pattern was square, and all breaths were subject-triggered. in six subjects the effects of breathing route (nasal or mouth) and temperature and volume of inspired gas (protocol a) and in subjects the effects of airway anesthesia (upper and lower airways, protocol b) on the response of respiratory output to varying v~ were studied. in protocol b, in order to calculate muscle pressure during inspiration (pmus), respiratory system mechanics were measured using the interrupter method at end-inspiration. independent of conditions studied breathing frequency increased . significantly and end-tidal concentration of c% decreased as v~ increased. the response was graded and reversible and not affected by breathing route, temperature and volume of inspired gas and airway anesthesia. with and without airway anesthesia (protocol ) neural inspiratory and expiratory time and neural duty cycle, estimated from pmus waveform, decreased significantly as v~ increased. at all conditions studied the rate of change in airway pressure prior to triggering the ventilator tended to increase as v~ increased. the changes in timing and drive were nearly complete within the first two breaths after transition with no evidence of adaptation during a given ~/~ period. we conclude that v~ exerts an excitatory effect on respiratory output which is independent of breathing route, temperature and volume of inspirate and airway anesthesia. the response most likely is neu~'al in origin, mediated through receptors not accessible to anesthesia such as those located in chest wall or below the airway mucosa. it has been shown, in mechanically ventilated awake normal humans, that increasing inspiratory flow rate (~/~) exerts an excitatory effect on respiratory output. it is not known if this effect persists during sleep. to test this seven normal adults were studied during wakefulness and nrem sleep. subjects were connected through a nose-mask to a volume-cycled ventilator in the assist/control mode and ~/t was increased in steps ( - breaths each) from to i/min and then back to i/min. v~ pattern was square, and all breaths were subject-triggered. forty-one trials during nrem sleep and during wakefulness were analyzed. both during sleep and wakefulness minute ventilation increased and total breath duration (ttot) decreased significantly in a graded and reversible manner as ~' increased. these changes were complete in the first breath after v{ transition. the response was significantly less during sleep than during wakefulness (p< . ); at i/min ttot, expressed as % of that at i/rain, was . +_ . % during sleep and . +_ . % during wakefulness. during wakefulness, at i/min, the rate of change in airway pressure prior to triggering the ventilator, an index of respiratory drive, was % of that at i/min (p< . ). the corresponding value during sleep, was % (p> . ). in four sleeping subjects the increase in v~ was sustained for . - min. there was no evidence for adaptation of the response; tro t, averaged over the last three breaths, did not differ from that obtained when vj was sustained for only - breaths. we conclude that ) vt exerts an excitatory effect on respiratory output, mediated by a reflex neural mechanism and ) the gain of this reflex is attenuated by sleep. chest radiographs is a common complementary technique for patients in critical care units, with a low cost and easily available. however, it has certain well-known limits in diagnosis, the most important derived from the low quality of some pictures. in this paper we make a general review of some new technical approaches developed for improving the quality of the images, and so incrensing the diagnostic value of conventional radiology. we begin deaeng with the correct positioning of the patient, trough the filtering techniques, the synchronization of radiology and ventilation, and we make reference to the new computerized systems for digital image processing. conclusions: the portable radiographic system is a device that probably with maintain for many years in critical care units as a basic non-invasive diagnostic tool. but we need an increase in the efficiency of it, applying means as simple as a correct positioning of the patient, or the use of fitlers or synchronizers. thus we should improve the general standards of portable radiography. "are circular circuits safe? quantifying undelivered tidal volume in pediatrics patients". objectives: to evaluate the overall influence of internal compliance of circular circuits on delivered tidad volume (vt). methods: we studied prospectively asa i pediatrics patients ( to yr. old) scheduled for elective general surgery. mechanical ventilation was supplied by an ohmeda excel (circular circuit). the internal compliance of the circuit (cc)-anesthesia machine plus external circuit-was determined by the supersyringe method: corrugated dar tubes of mm. id and . m. long (children < kg), and a corrugated dar set of mm. id and . m. long (children > kg) were respectively used for ccl an cc values of . and . ml/cm h . a vtof mlg/kg and respiratory frequency was adjusted for an end-tidal co (etpco ) between mmhg. tidal volumes (measured by spirometry) and airway pressure (paw) data were recorded every ten minutes. volumes and thorax-lung compliances were calculated as follows: (vt delivered = vtadjusted-vol compressible, being vol. compressible = co x ppeak (aw). apparent compliance (ca) = vt adjusted/pplateau(aw), and true compliance (ct) = =vt delivered/pplatean(aw)). comparative statistics were separately designed between calculated compliance data and tidal volumes on a paired sample ~test basis. results: calculated values for volumes and thorax-lung compliances were: conclusions: due to the elevated internal compliance of the circular circuit there is a remarkable dilference between adjusted and delivered vt: mean undelivered vt was . % and reached as high as . %. teere is also a significative error in calculating true thorax-lung compliance: its overestimation can be as high as . %. circular circuits are considered safe and cost-saving for anesthetical practice. nevertheless we conclude that anesthetists should bearin mind vt losses when using circular circuits, due to compressible volume. tracheal stenosis is one of the most serious complications of patients submitted to prolonged endotracheal intubation, in which the decrease in inner diameter of upper airway makes it very difficult to achieve a correct ventilation. objectives: compare the results of applying high frequency jet ventilation (hfjv) to some of these patients with conventional controlled ventilation (cmv). methods: we used a prototype of high frequency jet ventilator (santiago- ) developed in our university, and we developed a tracheal tube in wich we modified the distal tip (conic tip). we applied this system to two patients which were initially ventilated in the operating room with usuai controlled mecanical ventilation (cmv) following the standards of our department, and then intubated with the special endotracheal tube and ventilated with hfjv. results: we could verify a proper ventilation of both patients with cmv and hfjv. during hfjv, the airway pressures were lower than those recorded during cmv. a lower airway pressure prevents lesions due to high pressures. conclusions: hfjv is a good method of ventilation for patients with significative stenosis of the trachea, not only during surgical procedures, but also during ventilation for long periods in critically patients. the ventilatory setting is pressure support mode. the pressure level and fit were kept constant during h/d. arterial blood gas, wbc count, and mean bp was checked according to the schedule: '(immediately before h/d), ', ', ', ', ', '. respiratory drive (represented by poa), tidal volume(ti) and minute ventilation(ve) were continuously recorded by pulmonary mechanics monitor (bicore cp- ). the mean value of the breaths minutes before blood sampling were used to represent the ventilatory status of that period. anova test is used for comparison between groups. for poa, hierarchical cluster method is applied to divide the cases into two groups of similar change. conclusions: our data suggest that pl is very useful, non invasive and low-expensive emergenc e support for arf, expecially in the elderly with severe chronic pulmonary disease and relative controindications to eti. pl seems to be an effective alternative when it is not immediatly possible to perform etl. the multiple inert gas elimination technique (miget) can be used to assess the effects of any given mode of mechanical ventilation on the pulmonary and systemic factors determining arterial po and pco> however, a potential problem in mechanically ventilated patients is that the l mixing box (mb- l) placed in series in the expiratory side of the circuit of the ventilator to sample mixed expired gas may provoke substantial discrepancies between the tidal votume set in the ventilator and the effective tidal volume delivered to the patient, due to the increase in the compression volume (vc) of the circuit. the effects of the mb- l on the v c were compared with those produced by a new l mixing box (mb- l) specifically designed to produce adequate gas mixing and to prevent loss of the two most soluble gases (ether and acetone) used in the miget. at any given peak cycling pressure (p~ak, cm h~o), the v c (ml) provoked by the mb- l was substantially higher (vc= . *ppeak) than that provoked by the new mb- l (vc= . *ppeak). at a ppeak = cm h ~ the v c were ml (mb- l) and m{ (mb- l), respectively (p< . ). in a group of subjects ( m/ f, _+ years), for each of six the gases used in the miget, the regression line between the mixed expired partial pressures simultaneously obtained from mb- l and mb- l fell on the identity line. it is concluded that the new mb- l allows adequate assessment of the effect of different modalities of mechanical ventilatory support on pulmonary gas exchange, with less potential for gas compression and thus hypoventilation. objectives evaluate the influence of different pressure support ventilation (psv) levels on cardiovascular and respiratory funcion in icu polytrauma patients. metbed&we studied polytrauma icu patients , who were in weaning process , after long term mechanical ventilation for acute respiratory failure . mean age ( - ) yrs . they all were connected to servo ventilators siemens c , and all were in stable condition , without sedation , inotropes or diuretics. the hemodynamic studies were done with continuous svo , swan ganz catheter (oximetrix, abbott). they all were in spontanuous mode (spent) with cm h cpap for at least one hour. we turned them to psv with inspiratory assistance (psv cm h ) and after rain we applied psv cm h , and after min psv cm h . hemodynamlo and respiratory measurements were done before and after the application of insiratory assistance. the results were statistically analyzed with anova. resets . respiratory variables . no significant changes in minute volume (ve). tidal volume (vt) and mean airway pressure (mpaw) increased statistically significant (p< . ) . respiratory rate (rr) decreased significantly (p< . ) . blood gase showed no difference . cardiovascular variables. cardiac output (co) decreased ns , heart rate (hr) had no change , central venous pressure (cvp) , mean pulmonary artery pressure (mpap) , pulmonary capillary wedge pressure (pcwp) , increased ns , oxygen delivery (do ) decreased ns, oxygen consumption (vo ) decreased ns. conclusions. psv is a very useful respiratory mode helping patients to be weaned from long term mechanical ventilation . it has beneficial effects on respiratory function and oxygen consumption without affecting seriously the hemodynamic parameters, possibly due to a decrease of the work of breathing. a. michalopoulos, a. anthi, k. rellos, j. kriaras, s. geroulanos intensive care unit, onassis cardiac center, athens. objectives of this study was to examine the effect of different levels of peep on postoperative svo and pvo values in a group of patients, following open heart surgery. methods: upon transfer to icu, patients ( males and females) of mean age _-+ years, were randomly assigned to receive (n= ), (n= ), or cm of peep (n= ). there were no statistically significant differences in demographic data or preoperative respiratory status among the three groups. all patients were ventilated on the assist control mode with a tidal volume of ml/kg. the fraction of inspired oxygen (fio ) was adjusted to keep a pao around mmhg. mixed venous po and svo were measured at min, and hours after application of mechanical ventilation in the icu, just before extubation (be), half hour after extubation (ae), and at hours post-extubation. differences at each study time were analysed by anova. results: mean svo and pvo values among the three groups, for all study intervals, are presented in the table. conclusion: we found no differences (p=ns) in tissue oxygenation (expressed by svo and pvo ) among the three groups, at any study interval, in the early postoperative course of patients following open heart surgery. intrinsic peep (peepi), and high elastance and resistance increase inspiratory work load in copd. cpap reduces work of breathing by counterbalancing peepi. pav provides flow (fa) and volume (va) assistance proportionally to patient resistance and elastance and inspiratory effort. we studied the effects of partitioned support (cpap-fa-va) on breathing pattern and inspiratory effort in five copd patients on pav compared to spontaneous ventilation (sv) and full support (fs: cpap+fa+va). flow, volume, minute ventilation (ve) respiratory rate (rr), inspiratory swing in esophageal pressure (apes), and its integral per breath (pti/b) and per minute (pti/m) were measured. objectives: to evaluate airway pressure fluctuation (apf) during spontaneous breathing in a high compliance cpap system. methods: the cpap system consisted of two l weighted balloons in a wedge shaped holder. ventilating gas flowed from one balloon through a low resistance one way valve into a tracheal tube (ett) provided with a pycor co sensor to monitor rebreathing. the ett was connected to a piston drive mechanical lung. expired gas flowed through a low resistance valve into a second weighted balloon, from where it was exhausted through a peep valve connected in parallel with the second weighted balloon. we evaluated system performance at v r from to ml, at rr from to bpm, while closely monitoring cpap airway pressure swings. at v v of and ml the rr was limited to bpm. for comparison we explored aps of a one l balloon cpap system, the cpap mode of the puritan bennett , and siemens ventilators, when connected to a healthy adult volunteer breathing through an ett. results: the compliance (cpl.) of one l balloon system was linear over a range from . to . l, with a cpl. of . l/em h .the cpl. of the l balloon ( . l/em h ) was linear between a volume of and . l. apf of the weighted balloon system was under em h at all v r (except at a v r of ml aps was . em h ), while the apf in the l balloon was up to em h . apf witli human volunteers with the two commercially available ventilators in the cpap mode was about cm h ; while under identical conditions apf in the l balloon system was . emhzo; and in the two l balloon system was below lcm h . conelusions: cpap using the two balloon system exhibits lower airway pressure fluctuations than a single balloon system; and is substantially lower than found in the two commercially available ventilators when used in the cpap mode. objective: to perform independent lung ventilation (ilv) with individual tidal volume (vt) set at a value generating a plateau airway pressure (pplat) < crnh~o and to evaluate the usefulness of the continuous monitoring of endtidal co (etco ) as a guide to titrate individual lung vt during ilv and for the weaning from ilv. methods: in seven patients, ilv was performed with ttvo ventilators set with the same fio: and respiratory rate. each lung was ventilated with a vt that developed a pplat < cmh~o. this setting led to a lower vt on pathological lung (pl). vt was increased in pl following etco~ and paco -etco variations. ilv was discontinuated when etco~., vt and statical compliance (cst) were similar in both lungs. results: one hour after starting ilv (ti), pl mean vt was significantly lower than in normal lungs (nl) ( + ml vs + ml, p< ) two individual behaviours were observed on tl in pl: four patients presented low etco: (range - mmhg)and normal pacoz (range - mmhg), while three patients had normal etco (range - mmhg) with high pac (range - mmhg). one hour before stopping ilv (t ), vt, etc and paco were the same in each lung. the pao /fio: ratio improved in all patients from the beginning ofllv cst of pl was + % of the normal lungs' cst on ti and improved to . + % ofnl's cst on t (p< . vs conclusions: setting vt of pl to a value not overcoming a pplat threshold does not impair oxygenation and is helpful in avoiding barotraumatism. measurements of differential etco and of the differential paco -etco gradient can be used to titrate vt allocation during ilv and as a guide for the weaning from ilv. total respiratory resistance in mechanically ventilated patients exceeds values obtained in normal subjects, due to the added and highly flow dependent resistance of the endotracheal tube (rett). this can adversely effect the efficacy of pressure regulated modes of assisted ventilation, such as pressure support (psv) and proportional assist ventilation (pav). recent work demonstrates that the influence of rett during psv can be overcome by using tracheal (ptr) rather than airway opening (pao) pressure to regulate the pressure applied (intensive care med :$ , ) . the purpose of this study was to see if this approach would also be effective during pav. flow, volume, pao, ptr, and transdiaphragmatic pressure (pdi) were measured in intubated patients in which either pao or ptt were used to regulate the pressure applied during pav where volume assistance was varied from to % of respiratory elastance. representative results (mean + se) are shown below. compared to spontaneous breathing (pav %), pav increased tidal volume (vt) while reducing respiratory rate (rr) so that minute ventilation ('~e) also rose. this was associated with a reduction in inspiratory effort, as reflected by a decrease in the pressure-time integral ( [ p) of pes and pdi both per minute and per liter ~re. the effects on breathing pattern were similar for pao and ptr regulated pav. in contrast, the reduction in inspiratory effort was always greater for ptr regulated pav. in conclusion, the volume assistance provided by pav is more effective when ptr rather than pao is used to regulate the pressure applied. pav methods: retrospective data analysis of adult patients with normal pulmonary function before operation and uneventful course following coronary artery bypass graft surgery over an month period. we compared assist/controlled mandatory ventilation (s-cmv, patients), synchronized intermittent mandatory ventilation with inspiratory pressure support (s-imv/psv, patients) and biphasic positive airway pressure ventilation (bipap, patients). results: patients ventilated with bipap had a significantly shorter mean duration of intubation ( . h, p< . ) than patients treated with s-imv/-psv ( . h) and s-cmv ( . hi. with s-cmv . % of the patients required single or multiple doses of midazolam but only . % in the s-imv-/psv group and . % in the btpap group. the mean total amount of midazolam of these patients was significantly higher in the s-cmv group ( . mg) than in the s-imv/psv group ( . mg, p< . ) and in the bipap group ( . mg, p< . ). the consumption of pethidine and piritramide did not differ between s-cmv and s-imv/psv but was significantly lower during bipap (p< . ). after extubation the paco patients was highest in the s-cmv group. conclusion: ventilatory support with bipap reduces the consumption of analgesics and sedatives and duration of intubation. unrestricted spontaneous breathing as well as fully ventilatory support allow adequate adaptation to the patients requirements. bipap seems to be an alternative to s-cmv and sqmv/psv ventilation not only in patients with severe ards but also in short term ventilated patients. _objectitives: after end-inspiratory airway occlusion we examined the ensuing gradual decrease in tracheal pressure (ptr) with the following equations proposed by bates et al. and hildebrandt: pv = p'v e'~cccl~ +pst, rs (bates) [ ] where p'tr is tracheal pressure immediately after occlusion, to= is occlusion time, "r is viscoelastic time constant of respiratory system, and p t is static elastic recoil pressure of respiratory system. p~(t) = h -h log t (hildebrandt) [ ] where h~ and h are parameters depending on lung volume, and initial time is s for analytical reasons. materials & methods: we studied healthy patients intubated, anestethized with propofol, paralyzed with vecuronium, and mechanically ventilated with constant flow ( . i/s) at zeep for minor surgery. pressure was measured in the trachea. flow was measured with a pneumotachograph and volume was obtained by numerical integration. the rapid occlusions were produced by an external valve. the signals were sampled at a frequency of hz and processed on a pc. the influence of the cardiac artifacts during the occlusion time ( s) was reduced by a software low-pass filter kaiser finite duration impulse response of elevated order. results: the mean (+ sd) coefficient of correlation using eq. was , -+ . , and using eq. was . + . . the values ofz~ (eq. ), however, decreased with increasing the tidal volume (vt) according to the following equation: "~ = . - . v t, similary, the values of h~ and h increased with increasing v t according to the following functions: h~ = . + v i and h = . + . v t. conclusions: the behaviour of "% of eq. suggests that the linear viscoelastic model is not sufficient to further describe the mechanical properties of the respiratory system over the vt range ( - ml/kg) in ventilated patients. infect this model predicts that "c is constant and independent of tidal volume. on the other hand the plastoelastic model is not sufficient to further describe the mechanical properties of the respiratory system. in fact "r obtained by fitting an exponential for data of eq. , is determined by the time of endinspiratory airway occlusion. obiectives: according to the viscoelastic model, the viscoelastic pressure of the respiratory system pv=rs during lung inflation with constant flow e~ is t/ r wh t lsms ira tlmeand r given by:pv~c.~ = d~( -'e-~ )[ ] ere " ' p" tory " and "r are resistance and time constant of viscoelastic unit. in the past, the viscoaletic constants were determinated by performing a series of occlusions at different lung volumes, or a sedes of occlusions at a fixed lung volume achieved with various inflation flows. in the present study we have developed a new method for determining "c and r which requires a single constant flow inflation. our method is based on determination of pv~r, during a single breath constant flow inflation, and of z during the ensuing end-inspiratory airway occiusion. dudng the occlusion the tracheal pressure p~, declines according the following function: ptr = p'lr e " too= " z + e~t.r= [ ] where p'~r is tracheal pressure immediately after occlusion, toc c is occlusion time, p,i.rs is static elastic recoil pressure of respiratory system, and ~ is viscoelastic time constant. we first determinated "~ by analyzing the time-course of ptr according to eq and next determining r according to eq. , using the expedmental values of p,i=~, ~ and ti, as well as "~ obtained with eq. . materials & methods: we studied healthy patients intubated, anestethized with propofol, paralyzed with vecurenium, and mechanically ventilated with constant flow ( . i/s) at zeep for minor surgery. pres-sure was measured in the trachea. flow was measured with a pneumniachograph and volume was obtained by numerical integration. the rapid occlusions were produced by an external valve. the signals were sampled at a fi'equency of hz and processed on a pc. the influence of the cardiac artifacts dudng the occlusion time ( s) was reduced by a software low-pass filter kaiser finite duration impulse response of elevated order. results: the mean coefficient of correlation with eq. was . . with v t of ml/kg, the mean values (+ sd) of ': and r of the subjects amounted to . • . s and . • . cmh i "~ s. with the traditional multi breath method the corresponding values were . + . s and . _+ . cmh i " s, respectively. with the t-test the difference between new and traditional "~ was statistically significant, between new and traditional r was not significant. conclusions: with the single breath method it is possible to compute ': and r . the mean values of r with v t of nd/kg, however, was slighuy different than those obtained with the traditional multi breath method. the application of modem principles of respiratory care and mechanical ventilation in icus has resulted in increased survival of critically ill individuals with neuromuscular, skeletal and irrevers~le pulmonary diseases. in these chronically ill individunts mechanical ventilation, long term therapy (ltot) and continuous home care is considered a chronic life supporltng technique that can not be withdrawn after their discharge from an icu. the aim of this study was to present the results of a rehabilitation programme and home care that runs in our ward. twenw three patients were referred to our clinic f~om icus during - . a specific rehabilitation programme designed according to individual's needs was performed. patients that benefitted from this programme were grouped into the following disorders. ) post tb respiratow failure ( %) ) neuromuscular diseases, ( %) } undiagnosed sas { %) ) cope) ( %) ( patients had a overlap syndrom). the programme consists of : ) assessment and mechanical support ff needed of the respiratonj system with non invasive methods (nasal or via tracheostomy). ) group and individual respiratory therapy ) mobilization ) nutritional support ) educational classes for the members of the family. three from the patients passed away (during the year), are under nippv during night with or without supply, pts recieve ltot. conclusion: the development of a programme for chronically ill individuals in especially designed wards in hospitals and the overall care at home is considered necessary at least in hospitals with icus. a rehabilitation programme and home care permits the fast but safe discharge of these patients from units of acute medicine that the cost of treatment is high and besides permits beds that are invaluable. we considered that the rehabilitation prod'amine and home care in our ward is the first performed in greek chronically ill pts and even though there is no special administxative support we think that the results are quite saltsfactory. objective: we postulated that the product of the respiratory frequency (f) and the ratio of inspiratory pressure (ip) to maximal inspiratory pressure (mip) would predict the weaning outcome in deeompensated copd patients better than either variable alone or other indices previously proposed. methods: in decompensated copd patients with difficult weaning, we measured, daily, respiratory mechanics data both during mechanical ventilation and after ten minutes of spontaneous breathing. then we calculated weaning indices reported in literature and some new integrated indices. according to the results of the discriminant analysis, we considered the integrative index crop (acronym of compliance, rate, oxygenation and pressure), the rapid shallow breathing index f/vt, the load/capacity ratio ip/mip, and the following new index: f x ip/mip. we used receiver-operatingcharacteristic (roc) analysis by calculating the area under the curve considered as the overall probability of correct classification. results: main results are reported in the following objective: to evaluate the reliability of some indices of endurance in predicting the weaning outcome of decompensated copd patients. methods: in decompensated copd patients with difficult weaning from mechanical ventilation (mv) we measured, daily, blood gas analysis, ventilatory and airway pressure pattern during mv, breathing pattern (frequency (f) and tidal, volume (v~)), inspiratory pressure (ip), and maximal ip (mip) during spontaneous breathing (sb). thereafter we calculated the following weaning indices: crop (compliance * mip * (pao /pao ) / f), flvt, ip/mip. data obtained the day at which the patient was considered ready for a trial of sb on clinical grounds but weaning failed (wf) and those obtained the day of the successful weaning (ws) were compared statistically through the wilcoxon rank-sum pair analysis. in order to quantify the predictive accuracy for each index with respect to successful weaning we calculated sensitivity, specificity, and diagnostic accuracy according with the standard formulas. methods : five patients ( + yrs) suffering from ards (lung injury score > . ) for hours or less entered into the study. irv (volume controlled, decelerating flow, % inspiratory pause, lie = / ) was compared to conventional ventilation (cv) (volume controlled, constant flow, no inspiratory pause, iie= / ). these two modes were applied for hours in a randomized order, with the same levels of total peep (peept = peep + peepi), tidal volume ( . • . ml/kg), respiratory rate ( • "bpm) mad fit ( • %). measurements (respiratory mechanics, hemodynamics, arterial and mixed venous blood gases) were performed after , , and hours of application of each mode. rvsuils : are expressed as mean + sem and compared by anova. backeround and methods: periodic breathing (pb) is characterized by repetitive cyclic variation in minute ventilation. pb is considewxl to be provoked by an instability in the respiratory control. inintubated, spontaneously breathing patients conventional modes of pressure support ventilation, i.e., triggered inspiratory pressure support ps), do not allow patients to breathe with theirinherent breathing pattern. therefore, pb, if existing, will appear mainiy after extubation. since our new mode of pressure support ventilation" automatic tube compensation" (atc) continuonsly corrects for the flow-dependent tube resistance during insnmdon and expiration ("electronic" extubatim), it pemaits patients to maintain their own inherent breathing pattern. then, ff necessary, tracheal pressure can be additionally supported by volume-proportioead and/or by flow-proportional pressure support (proportional assist ventilation, pav). (~as~: we report the case of a -year-old male patient who was intubated due to acute respiratory insufficiency after acute myocardial infarction with left ventricular dysfunction. during ips of mbar the patient showed a regular breathing pattem which became periodic during atc. in addition, proportional assist ventilation of mbar/l increased periodic breathing in such a way that the typical cheyne-stokes breathing pattem occurred (see figure) . baqkground: the hering-breuer reflex (hbr) is characterized by an inhibition of inspiration during lung inflation. this response has been recognized as an important vagally mediated mechanism for regulating the rate and depth of respiration in newborn mammals. in adult man the hbr is considered to be active only at lung volumes well above functional residual capacity, i.e., at tidal volumes above ml. assessment of the hbr requires specialized methods such as single breath or multiple occlusion technique. methods; in the presence of desynchronization between ventilator and patient, which frequently occurs during triggered inspiratory pressure support ventilation (ips)(see figure) , prolongation of the interval between inspiratory efforts (indicated by negative deflection of the esophageal pressure) due to lung inflation exposes an active hbr. we examined the occurrence of hbr in intubated critically ill patients. strength of hbr was assessed by the formula: prolongation [%] = ((inspiratory interval of interest -preceding inspiratory interval)/preceding inspiratory interval) * ( . rr of patients examined showed moderate to severe desynchronization. in of these patients a (re)activation of the hbr was found. the strength of hbr amounted to + %. there was a significant correlation between tidal volume and strength of hbr. in contrast to previous reports, an active hbr was shown during lung inflation well below ml. b pck~round: triggered inspiratory pressure support ventilation (ips) is commonly used to support inspiration in intubated spontaneously breathing patients. despite its usefulness ips shows some disadvantages which can be deleterious in crificauy ill patients: -additional work of breathing to be performed by the patient due to the flow-dependent tube resistance -desynchronization between patient and ventilator due to inherent triggering failures of the ips mode suppression of the patient's inherent breathing pattern -inability to predict successful extubation in difficult-to-wean patients methods: based on the known flow-dependent tube resistance our new mode "automatic tube compensation" (atc) compensates for the pressure drop across the endotracheal tube ("electronic" extubation). then, if necessary, tracheal pressure can be supported by volume-proportional pressure support (vpps) and/or by flow-proportional pressure support (fpps). results: hitherto, we have examined patients after open-heart surgery and patients with acute respiratory insufficiency (ari) or ards using atc with/without vpps/fpps. preliminary results suggest that the new mode avoids additional work of breathing due to accurate compensation of the pressure drop across the endotracheal tube during in-/expiration prevents desynchronization between patient and ventilator allows patients to breathe with their inherent breathing pattern accurately predicts the outcome of extubation even in difficult-to-wean patients due to "electronic" extubation conclusions: the new mode atc with/without vpps/fpps allows to support ventilation in a more physiologic manner and overcomes the disadvantages of conventional modes of pressure support in intubated patients. backgound: cheyne-stokes respiration (cs) is characterized by regula]; recurring periods of hyperpnea and apnea. in normal subjects, cs may occur after hyperventilation, after arrival in high altitude, or during sleep. it has also been observed in patients with prolonged circulation time due to congestive heart failure, as well as in some neurological patients. there is no report about the influence of sedative drugs on periodic breathing (pb) and cs. methods: in intubated patients conventional modes of pressure support do not allow patients to breathe with their inherent breathing pattem. therefore, periodic breathing and cs are rarely seen. since our new mode of pressure support ventilation "automatic tube compensation" (atc) continuously corrects for the flow-dependent tube resistance during inspiration and expiration ("electronic" extubation) it permits patients to maintain their own inherent breathing pattem even if pathological, e.g., periodic. results: using this new mode of pressure support ventilation, periodic breathing was unmasked in of intubated patients, of which showed cs. in of these patients the occurrence of cs was linked to impaired left ventricular function with increased circulation time. normal left ventricular and neurologic function was found in the remaining patients. in of these patients cs disappeared after intravenous administration of the benzo-diazepine antagonist flumazenil (figure). consequently, in this patient cs was induced by benzodiazepine sedation. objecti',~s: in contrast to conventional rhodes for pressure supported spontaneous breathing, our newly developed ventilatow mode ,,automatic tube compensation" (atc) completely compensates for the flow-depandant pressure drop tlpm-r across endotracheal ttlbe (ett). in the atc mode, the ventilator supplies a flow v' in order to maintain a constant tracheal pressure p~,,~. to this end, pk,,= has to be oontinuousiy determined. since continued measurement of p,,~ by introducing a catheter via the ett is not reliable, we opted for its continuous calculation socordng to the following equation: p~ = p,,, -aperr, pw being the continuously measured airway pressure. this also requires the continual measurement .of flow v' to calculata apm-r using the non-fineer approximation: aport = kvv' + k .w. the constant tube coefficients k~ and k are mathematically determined by mesns of a least-squares-fit procadum based on laboratory investigations. tracheal secretions, however, reduca the omss-saction of the ett. consequently, ~ values of ki end k are changed rendering the p~,ch calculations inaccurate. therefore, k and ~ have to be pedodcally updated to ensure an a~urete monitoring of pn,~ and a complete tube compensation under atc at any time. background: one of the first steps in weaning patients from controlled mechanical ventilation is to stop muscle relaxation and to reduce sedation. it can take several hours, however, until the patient is able to trigger the ventilator and to breathe spontaneously. during this period, many patients display a sudden increase in peak airway pressure of up to %. patients and methods: to investigate the reason for this potentially dangerous effect, we continuously measured lung and chest wall mechanics in post-operatively ventilated patients. lung mechanics (airway resistance and lung compliance) was measured using the esophageal balloon technique as described in [ ] . chest wall mechanics (tissue resistance and chest wall compliance) was calculated from lung mechanics and total respiratory system mechanics as described in [ ] . results: we found a decrease of chest wall compliance (cw) to be the main reason for episodes of sudden airway pressure increase while lung compliance (cl) remained unchanged. the decrease of c w can be inter- gil cano a, san pedro jm ~, sandar d, herntndez . , carrizosa f, , herrero a. emergency and intensive care department, hospital of jerez, spain objective: ) to determine the incidence of hypoteasion (h) associated with emergency intabatian of mechanical ventilation, and ) to establish its relauonship with respiratory mechanics (rm) and arterial blood gases. mechanical ventilation performed in the emergency room, in a prospective eans~eative manner, were evaluated. data collected included patient demographics, diagnoses, blood pressure and arterial blood gas levels before and at~er intabatian, and p_m, including calculated pulmonary end-inspiratory volume above functional residual capacity (veic) and calculated dynamic hypetinflatien (dhc). all patients received midazolen and awaanrinm to facilitate tracheal intubatien and rm measurement. hypotension was defined as a decrease in systolic pressure higher than mmhg or an absolute decrease in systolic blood pressure below to mhg within hour of intabatian. patients were excluded because met at least one of the following exclusion criteria: preexisting shock or h ( ), cardiac arrest ( ) . there weren't any association between peepi or other airway pressures (paw) and h, but calculated pulmonary volitmes had tendency to be larger in patients with h (p < . ). high paco before lrasheal intubatian ( . - mmhg) with a quickly decrease alter starting mechanical ventilation was a usual finding (p < . ) in patients who developed h. paw. ) thexe was a good relatienship between h and high arterial paco before traqueal intahatian and its fast "washing" with mechanical ventilation. ) because cao patients had the highest incidence of h, controned mechanicel hypoventilatien driven by paco changes and pulmonary volumes monitoring instead paw, should be attempted in these patients to avoid this cemplication after tracheal intubatiert. introduction: the endotracheal tube (ett) and demand valve devices cause an added work of breathing (wobadd), which is the work necessary to overcome the resistive load of the ett and the breathing circuit ( ). application of ips has been shown to partly compensate this added work ( ). since tbe amount of wobadd is flow dependent, a fixed ips is not adequate to completly compensate the wobadd ( ). therefore, atc has been developed as a new form of assisted spontaneous breathing ( ), which provides a flow-dependent pressure support. thereby, it theoretically should compensate all the wobadd due to the tube. the purpose of this study was to evaluate the reduction of wobadd with ips and atc for different ett. methods: a mechanical lung model (ls , dr*alger, liibeck, frg) was used to generate a constant spontaneous breathing pattern. the ls was connected to an artificial trachea (at, cm long, mm id). the at was intubated with three different tubes of . , . , . mm id and connected to an evita ventilator modified to provide atc as an option (dfager, liibeck, frg). flow and airway pressure were measured between the y-piece and the ett for four different modes of ventilation: cpap, ips of and cm i and atc all with a peep of cm h . the tracheal pressure (ptrach) was measured in the at. total wobadd was calculated as the area subtended by the ptrach-volume curve below peep. results: the results for total wobadd in nd/ are shown in the figure for the three different ett: breath/mln, s=success, f=failur% *~p<. , **-p< , ns = non significant, f versus s neveltheless, in / patients, invasive ventilation was necessary in mean . _+ hours after beginning of fmpsv. there was no significant difference between the two groups (success, failure) in following parameters : sex, age, previous histoly, medical treatment, saps & , clinical signs (rr, spo , heart rate, blood pressure, glasgow score...), radiological and echocardiographic findings and standard biological parameters. only two parameters were related with failure : .a low value of pac on admission until the patients were intubated. . an increased level of cpk in relation with an acute myocardial infarction ( / cases in the failure group, vs / cases in the success group, x~(with continuity correction) : p<. ). conclusion : fmpsv is a noninvasive, safe, rapidly effective method of treatment in acpe, which may avoid tracheal intubation. further studies are necessary to precise if association of arf and low paco (< mmhg) and/er acute myocardial infarction represents an indication of immediate invasive ventilation. introduction: since the added work of breathing (wobadd) imposed by the endotracheal tube (ets and the breathing circuit is regarded as an important contribution to the total work of breathing, considerable effort has been tmdettaken to compensate for this added work. ips has been fotmd to decrease the wobadd imposed by different ventilators ( , ). because of the flow dependent pressure drop across the etf the tracheal pressure (ptr) should be measured to estimate the total imposed wobadd (wobtut) ( , ). the aim of this study was to assess the circuit imposed work (wobcirc) and wobtot (including ett) for different demand valve ventilators during cpap and/ps. methods: a mechanical lung model (ls , driiger, lfibeck, frg) generated a constant spontaneuus breathing pattern. the ls was connected to an artificial trachea (at), intubated with an . nun et]', end connected to one of four ventilators (servo c and servo , siemens,-elema, sweden; evita , driiges, liibeck, frg; pb ae, puritan bennett, carlsbad, usa). three different modes of ventilator settings were tested (cpap, ips and mbar; trigger set at maximal sensitivity, peep always mbar). flow and airway pressure (paw) were measured between the y-piece and the etr; tracheal pressure (ptr) was measured in the at. wobtot was calculated as the area under the ptr-volume curve below peep, wobcirc was calculated as the area under the paw-volume curve below peep. results: in the foti g., patroniti n., cereda m., sparacino me., giacemini m., pesenti a. inst.of anesth.and intensive care-univ.of milan -sgh monza i aim of the study was to assess cpl,rs measurement obtained by the airway occlusion method during psv. we therefore studied paralyzed cppv ventilated ali patients (lung injury score = . • that were weaned to psv. we performed end inspiratory and end expiratory airway occlusions using the hold function of the ventilator (siemens serve c), first during cppv and then within the th psv hour. airway pressure and flow signals were recorded (cpi bicore) for subsequent analysis. an airway pressure plateau was defined as a flow tracing in which airway pressure was stable for at least . sec. end inspiratory (pel,rsi) and end expiratory (pel,rse) recoil pressures were then measured as the mean airway pressure during plateaus. cpl,rs was computed as tv/ (pel,rsi-pel,rse i) cpl,rs can be adequately estimated during psv using the airway occlusion method; ) during psv inspiratory plateaus are longer than the expiratory ones; ) the length of plateaus is negatively affected by the respiratory drive. foti g., de marchi l., *tagliabue m., gilardi p., giacomini m., sparacino me., pesenti a. inst.of anesth.and intensive care,-univ.of milan *dept.of radiology-sgh monza i we retrospectively compared ct scan and gas exchange findings between a group of patients successfully weaned from vcv to psv (group s = ii patients) and a group who failed the weaning (group f = patients). we selected ali patients (lis= . • in vcv mode who had available a chest ct scan performed within days from the weaning trial. a psv trial was began as soon as the patient reached hemodynamic stability and a pao > mmhg, irrespective of fie (peep < cmh ). maximum psv level was < (pel,rs-peep) measured during vcv, where pel,rs was the respiratory system elastic recoil pressure at end inspiration. psv ventilation was considered successful if a respiratory rate < bpm, an increase in fie lower than . compared to vcv, a pace increase < % of vcv value and hemodynamic stability were maintained during the next hours of psv. if any of these conditions was not met the trial was declared a failure. interdisciplinary critical care unit, regional hospital lugano-ch *surgical critical care unit, university hospital, geneva-ch objective: to assess the degree of correlation of cardiac output measured by thoracic electrical bioimpedance and thermodilution in mechanically ventilated patients with different levels of positive end-expiratory pressure (peep). methods: prospective study with ventilated patients, after head injury and with postoperative sepsis, with normal cardiac output: simultaneous determination of cardiac output by thermodilution and thoracic electrical bioimpedance performed with different levels of peep ( - - cm h ). results: cardiac output measured by thermodilution during sequential increment of peep did not vary: . + . for peep , . + . for peep and . + . l/rain for peep . simultaneously the bioimpedance device recorded a significant increase in cardiac output from . + . for peep to . + . l/mi for peep . (p < , ). conclusion: cardiac output measured by bioimpedance cannot replace the invasive thermodilution methods of cardiac measurement output during mechanical ventilation with peep. we also isolated a subset (h) of patients who had been hypercapnic (paco > mmhg) for at least days (range to days) before the end of cv. the psv trial was started as soon as pao was > mmhg, irrespective of fie and with peep < cmh and the psv level had to be < (pplateau-peep) as measured during cv. pace , pha, base excess (be) were collected before discontinuation of cv and on the ist day of psv: ) . ) weaning is more difficult in pts with head injury(p<o, ) and iss> (p<o,ol), in elderly(p<o, ) and in pts who need fi > , (p<o, ) and peep>io cm h (p<o, ). ) pts with iss> need longer duration of mv (p<o,ol). ) the mortality rate is higher in pts with iss> (p<o,o ), with head injury (p<o,ol) and in elderly (p<o, ). ) paradoxally, compliance was found to be higher in pts> years than in pts< years (p<o, ). s. crotti, p.pelosi, d.mascheroni, m.cerisara, a.lissoni, l.gattinoni. istituto di anestesia e rianimazione -irccs, milano, italia. obiectives. we investigated by ct scan the effects of extrinsic peep (peepe) on lung inflation, tidal volume distribution and regional compliance in sedated, paralyzed chronic obstructive pulmonary disease (copd) patients with dynamic hyperinflation (peep• methods. two ct section (end expiration, end inspiration) were obtained at lung base level in patients (individual analysis for each of the eight lungs) at peepe levels: peepe = cmh (zeep) and peepe amounting to %, % and % of the peep• at zeep ( . • cmh ). tidal volume was kept constant ( • . ml/kg). each lung section was divided into zones equally spaced along the vertical axis: upper (the most ventral), middle and lower (the most dorsal) zone. for each zone we computed: gas volume at end expiration (gase) and at end inspiration (gas• tidal volume (dgas=gasi-gase) and compliance (cpl=dgas/dp;.dp=plateau pressureactual peep• we also computed the lung inflation as the entire ct section gas volume at end expiration (total gase). results. at each peep level both gase and gas• were higher in the upper than in the lower zone ( we cone!ude that in copd patients with dynamic hyperinflation only the application of peepe higher than peepi produces a further increase of lung inflation, decreasing cpl of the upper zone (the more expanded one) probably by stretching phenomena, and causing dgas redistribution from the non dependent to the dependent lung zones. i. ravagnan, p. vicardi, f. valenza, d. tubiolo. p. pelosi l. gattinoni. st . anestesia e rianimazione, universita' di milano, ospedale maggiore -irccs, italy objectives: to investigate the effects of peep and ps on respiratory. pattern and inspiratory effort during ps ventilation in patients with acute lung injury or acute exacerbation of chronic lung disease. methods: pts with acute (a) (paco = • mmhg, pao /pao = . • and pts with chronic (c)(paco = • mmhg, pao /pao = . : . ) lung disease were studied in ps ventilation during the weaning phase. measuring airway pressure, esophageal pressure and gas flow we computed respiratory rate (ril bpm), tidal volume (tv, ml) and pressure time product (ptp, cmh *s/min), which is an index of oxygen muscle consumption. measurements were collected, after rain of stabilization, at and cmh ps and at two different peep levels ( and cndd conclusions: during psv: ) breathing pattern and ptp are different between a and c; ) in both groups peep does not modify breathing pattern; ) peep reduces ptp in c but not in a; ) ps modifies breathing pattern and reduces ptp in c but not in a. to test the performance of a new heat and moisture exchanger (hme): twistair, baxter. this is a hydrophobic-hydrophilic hme without hygroscopic salts. method: we evaluated the hme performance with a previously described method (i); it consists of a "lung simulator" connected to a mechanical ventilator and a flow divider, with a dry and a wet thermal probe inserted into inspiratory and expiratory limbs. on average ps level changes were associate( with opposed changes in both p . and rr. changes in p . were remarkable, homogeneous and highly significant (p<. ), while changes in rr were less pronounced, inhomogeneous and less significant (p<. ). it seems therefore that p . is a better index than rr for estimating a change in load for the respiratory muscles. recently, the lsf method has been described as an interesitng alternative to conventional tecniques used to measure total respiratory mechanics, providing, over these latter, advantages such as no need for hold maneuvers and no need for particular flow patterns. data on the reliability of the lsf method, however, are still few. methods. sets of measurements were obtained in each of ards patients, paralyzed and ventilated in cmv with constant inspiratory flow and an end-inspiratory pause equal to % of ttot. the lsf method provided data for total compliance (ctotlsf) and total resistance (rtotlsf) by multiple linear regression analysis of airway pressure, flow and volume change, applied over the entire breath. the lsf measurements were automatic and continuous, and each value used for analysis was the average of consecutive cycles. conventional measurements of dynamic.compliance (cdyn), quasistatic compliance (cqs), minimum inspiratory resistance (rmin) and maximum inspiratory resistance (rmax) were obtained by the constant flow, end-inspiratory occlusion method, each value being the average of measuremts. ctotlsf was compared with cdyn and cqs, while rtotlsf was compared with rmin and rmax. results. ctotlsf showed a high correlation both with cdyn (cdyn=. .ctotlsf+l. , r =. ), and with cqs (cqs =. .ctotlsf + . , r =. ). the average difference between ctotlsf and cqs, yet, was much lower (+. + . ml/cmh ) than the one between ctotlsf and cdyn (+ . + . ml/cmh ). rtotlsf correlated much better with rmax (rmax=. *rtotlso+. , r =. ) than with rmin (rmin =. .rtotlsf +. . , r =. ). the average difference between rtotlsf and rmin was + . + . cmh / /s, while the one between rtotlsf and rmax was +. + . , confirming the better agreement between rtotlsf and rrnax. conclusion.the agreement between rtotlsf and rmax suggests that rtotlsf takes into account both the airway and the tissue components of resistance, unlike rmin which only expresses airway resistance. the agreement between ctotlsf and cqs indicates that ctotlsf expresses the pure elastic components of the respiratory system. in the paralyzed patient, the expiratory time constant (rce) of the unit represented by total respiratory system and ventilator can be calculated from the slope of the expiratory flow-volume curve. recently it has been suggested that an estimate of this slope is provided by the ve/v'epeak ratio, ve being the exaled tidal volume and v'epeak the peak expiratory flow.the reliability of this method is still little known. methods. sets of measurements were obtained in mechanically ventilated ards patients during paralysis and cmv. measurements of ventilator expiratory resistance (rext) and of total respiratory mechanics were performed in order to calculate these reference measurements for ve/v'epeak: rcdyn=(rmin+rext)ocdyn, rcstat=(rmax+rext)ocqs, rclsf=(rlsf+rext)~ cdyn (dynamic compliance), cqs (quasistatic compliance), rmin (minimum inspiratory resistance), rmax (maximum inspiratory resistance) were obtained by the constant flow, end-inspiratory occlusion method. clsf and rlsf respectively corresponded to measurements of total respiratory system compliance and resistance by the least squares fitting method. ve/v'epeak showed a high correlation with all reference measurements, rcdyn (ve/v'epeak= . orcdyn-. , r =. ), rcstat (ve/v'epeak = . rcstat -. , r = . ), and especially rclsf (see fig the static pressure volume curve of the respiratory system (p/vst) provides valuable information, but the extensive data analysis prevents its use in clinical routine. dynamic p/vcurves are simpler to record. the objective of this study was to develop an automated method to obtain quasi-static p/v-curves (p/vqs) during low flow inflation as well as to measure resistance. preliminary tests were done in normal subjects and subjects with varying degree of lung disease. methods: a computer/ventilator interface (cvl) was constructed for control of a servo ventilator c during an automatic sequence: a) a normal breath, b) a prolonged expiration at zero peep, c) a low flow inflation of a predetermined volume, d) analysis of ventilator pressure and flow. pressure was corrected for tube resistance. airway resistance was calculated from a) and used to derive p/vqs from c). as reference, p/vst was obtained by the occlusion method. results: in non-obstructive diseases the method performed well at volume and pressure controlled ventilation. static and quasistatic compliance were virtually identical. p/vqs clearly reflected the lower inflection point and, when present, the upper inflection point (uip). in some patients uip was more evident in p/vqs, especially at an increased inflation flow rate. in obstructive diseases, the method for subtraction of resistive pressure was inadequate. conclusions: the system for automated computer controlled studies of lung mechanics based on a standard ventilator provides comprehensive information. differences between p/vst and p/vqs imply that the latter reflects also other factors than p/vst that contribute to impedance at hyperdistension. the clinical significance of the two curves remains to be shown. obiective: to evaluate the effect of combined high frequency jet ventilation (chfjv) in patients with severe respiratory insufficiency (sri). methods: in a retrospective study of the period - we analyzed patients suffering from sri who were refractory to conventional mechanical ventilation and were treated with combined high-frequency jet ventilation (chfjv). refractory to conventional mechanical ventilation was defined as a pao /fio < , despite maximal ventilator settings: peep > cm hz , fit > . . a total of patients matched these criteria, males and females with a median age of ( - ) years. seventeen suffered from severe trauma. chfjv was started following a median period of ( - ) days of conventional mechanical ventilation. prior to chfjv ventilation parameters expressed as median were the following: fit . , pao /fio , peep cm h peak airway pressure (pap) cm h . chfjv consisted of high frequency jet ventilation with a frequency of to breaths/minute, driving pressure of . to . arm, and inspiration time of to percent, superimposed on the whole cycle of conventional mechanical ventilation with a frequency of l to breaths/minute and tidal volumes of to ml. results: following two days of chfjv of patients showed an improvement of ventilatory parameters; peep could be reduced to < cm h in patients, the pap was decreased with > cm h:o in patients, fio could be reduced to < . in patients and finally the median pao /fio ratio changed from to . during chfjv patients died, of respiratory failure and due to multiple organ failure, died within two days of chfjv. the median duration of chfjv in survivors and nonsurvivors was days in both groups. conclusions: our data show that with chfjv in the majority of patients with sri who are refractory to conventional mechanical ventilatior" the ventilatory parameters can be improved. backeround and obiectives: although ventilation with peep above the inflection point (pinf) has been shown to reduce lung injury by recruiting previously closed alveolar regions, it carries the risk of hyperinflating the lungs. in the present study we set out to develop a new strategy to recruit the lung during ventilation with small vt, while maintaining peep levels as low as possible. we hypothesized that if the lung was recruited with a sustained inflation (si) to total lung capacity, recruitment would be maintained as long as the peep level was higher than the critical closing pressure of the lung, as observed on the deflation limb of the pv curve (ajrccm ; ( ) :a ). the purpose of this study was to examine the hypothesis that a strategy using si and a peep<pinf would induce less lung injury during small tidal ventilation than ventilation at the same low peep level without using a recmitment strategy in a model of respiratory distress syndrome. methods: we used a randomized protocol with groups to ventilate nonperfused, lavaged rat lungs with small vt ( to ml/kg) for hours and studied the effect on compliance and lung injury. group : peep>ping group : peep<pin f with an si, inflation to on h over sec, to recruit volume; group : peep<pinf without si; group : control group, lungs were inflated at peep<pin f, but not ventilated. results: in group and group static compliance did not change after ventilation (table) . in group static compliance fell significantly. group showed significant changes in the pv curve, which were less severe than in group . results from morphological examination are pending but preliminary results showed less lung injury in group , compared to group . conclusions: small tidal ventilation following a recruitment manoeuvre in a model of respiratory distress syndrome allows ventilation on the deflation limb of the pv curve at a peep below pinf. this strategy ( ) minimizes lung injury as well as, or better than using peep above pint" and ( ) ensures a lower peep to minimize the detrimental consequences of high lung volume ventilation. i~peep>pin~ _objectives-this report is presenting the results of the clinical study for using eeg examination as a method of the evaluation of patients ability for weaning. methods: the study inclljqles eeg examinations with fourier spectral analysis' of patients ~vith respiratory insufficiency and prolonged control mechanical ventilation (cmv). all patients have had a-rhythm of eeg before weaning. we have followed respiratory rate, tidal volume, respiratory pa{tern, end-tidal co and blood gases during weaning. results: patients had invariable eeg activity or short -waves period (till one hour). the weaning of this patients was fast arid sucsessful. other patients have had a decreasing of a-activity, an appearence of -waves for an hour and more, a short episodes of a-and e-activity. after that this patients had gas exchange and respiratory disorders with regression of the weaning right up to cmv. conclusion: eeg could be used as a method of the evaluation of patients ability for weaning from cmv. some eeg signs shows the overstrain of compensatory systems before the change to the worse of gas exchange and respiratory pattern. s. elatrous, p. aslanian, d. touchard, d. corsi, h. lorino, l. brochard. medical intensive care unit, inserm u , hopital henri mender, cr~teil, france. in vitro comparison of flow triggering (ft) systems demonstrated advantages compared to pressure triggering (pt) systems for some ventilators (puritan bennett ) but not others (siemens serve ). we studied the two types of systems in two groups of patients mechanically assisted with pressure support ventilation ( + cmh ). in the first group (pb ) the effort of breathing, assessed by the esophageal pressure time index, was significantly lower with the ft than with the pt ( + cmh .s/min - vs + , p< . ). by contrast no significant difference appeared in the second group (serve ), as predicted by the bench study despite marked interindividual differences ( + cmh .s/min - vs + , p = . ). we conclude that ) rigorously performed bench studies can predict in vivo effects, ) mild advantages can be found for the new triggering systems on some ventilators. objectives: pressore-volume curves (pv) of the respiratory system is of interest for the determination static compliance (cs , lower (lip) and upper (uip) inflection points which indicate zones of airway recruitment and overdistension. this study aimed to compare an "automated low flow inflation" method (alfi) to the reference occlusion (oc) method. the ability of the former method to identify cst, lip and uip was tested in icu patients. me,otis: ( arf and ards) sedated paralysed patients were studied using a serve c ventilator linked to a computer which automatically forced the ventilator to insufflate at a low constant flow a velum up to - ml or a maximum paw of cm h (alfi). the quasistatic elastic pressure (pel,qs was obtained by subtraction of the resistive pressure of tubing and patient and related to volume for calculation of compliance cqst. for oc tidal volumes (v from up to - ml were followed by a s post-inspiratury pause for determination of static pal (pel,st) in relation to volume. compliance was defined from the linear part of the p/v curves. lip and uip were defined from the consistent deviation of p/v data from extrapolated the linear part. ~,~ i~: in ards, mean cst was . + . and cqst . + . ml/cm h (us), lipst . + . and lipqst . + . cm h (us), uipst . + . and uipqst . + ~ cm h (us). nosocomial pneumonias (np) are frequent and often unsuspected during ards (bell, ! ). in the present study, we evaluated prospectively the onset of np during severe ards (group b of the european study). patients and methods: the charts of patients with severe ards have been prospectively recorded. a plugged telescopic catheter (ptc) specimen has been systematically performed every hours, for quantitative bacteriological analysis. the diagnosis of np was defined by a number > colony forming units / ml. results: for the patients studied, the mean saps score (+ sd) was +_ , the initial pao /fio ratio was -&-_ , the duration of mechanical ventilation (mv) was + days. the mean delay before the onset of the first np was . + . days ( - ), and the mean pao /fio ratio was +- . respiratory symptoms (purulent aspirates, new pulmonary infiltrates, or gazometric changes) were present in % of the patients studied. alteration of gas exchange was present in of the patients ( np) . a new pulmonary infiltrate was present in only np ( %). an increase of fever was noted in patients, an increase of leukocytosis > % in patients, an increase of volume and purulence of sputum in of the patients with np. the degree ofgazometric worsening (pao /fio before np minus pao /fio during np) during the first episode of np was + mmhg. excluding the bacteriological criteria of np, the number of criterias of np present was in / patients, ( / ), ( / ) or ( / ). two patients only had a pulmonary colonization (ptc: < cfu / ml) before the first episode of np. the incidence of np is high ( %) during severe ards. the first episode occurs in average:at the th day, and is the cause of a severe hypoxemia (pao /fio ) . the onset of a np may contribute to the high mortality rate observed in our patients ( %). each worsening of hypoxemia during severe ards should induce to suspect a np. respiratory system during mechanical ventilation. the me~hod quantifies the dissipative energy consumption of the respiratory system in terms of energy loss aek, inefficiency ~k~ and respiratory dissipative resistance rk~ over a given partition of the tidal volume. the method can be applied in intensive care units with no interference to ventilatory support. it allows for monitoring the combined effects of inhomogeneities, non-linearities and visco-elastic effects, that are subject to change in the respiratory system. the method is studied on pigs~ in the presence of a log-dose response curve of methacholine (mch) induced disease. in healthy pigs~ we find a mean value of energy loss, ae, of . • j/l, a mean value of inefflency, ~ of . ~= . and a mean value of resistance, ~, of . • cm h s/ . the respiratory resistance, rk, shows a variation over the partition of tidal volume with armax ---- . • . cm h s/l. during methacholine provocation~ ae rises more than five-fold up to . • j/l~ doubles to . • and t~ increases to a maximum of • cm h s/l, with armax : . • . cm h s/ . the variation in rk becomes more pronounced with higher doses of methacholine. methods: ards patients were prospectively studied. initially they were ventilated in the amv (assist mechanical ventilation) mode with the settings prescribed by their primary physician. after stabilization, ventilatory gas exchange and hemodynamic variables were determined. patients were then ventilated in the mrv (mandatory rate ventilation) mode with breaths as the target rate. in mrv the target rate is set and the ventilator autoregulates the pressure support level delivered ~o achieve this rate. after stabilization, the measurements done on amv were repeated. finally, patients were sedated and paralyzed and ventilated in cmv (control mechanical ventilation) with the ventilatory variables they had during mrv. measurements done in amv and mrv were repeated and respiratory mechanics were assessed with the constant flow end inspiratory occlusion method. results: two groups were recognized based on their response to mrv. tn group patients responded to mrv by decreasing their v and increasing the t/t t ratio. ve, vo , and aado decreased while paco increased and tda vo ume and co remained unchanged. on the contrary, in group v, vr and ve increased; ppeak and trr t remained unchanged, paco~ decreased while vo and aado increased with constant co, the pressure support level needed to achieve the target rate was much lower in group than in group ( , -+ . vs . _+ . ). obiectives : in the newly developed mode of ventilatory support ,,automatic tube compensation" (atc) the ventilator compensates for the flow-dependent pressure drop across the endetracheat tube (ett) thus allowing ,,e]ectronic extubation". the aim of the study is to investigate whether healthy subjects perceive atc in inspiration (atc-in) and in expiration (atc-in-ex) and whether atc provides an increase in subjective comfort compared with the conventional assisted spontaneous breathing mode (asb). methods : healthy volunteers (no preceding lung disease, non-smokers, male, - years)breathed spontaneously through an uncut ett of . mm id via a mouthpiece. the ett was connected with a prototype ventilator evita modified by the manufacturer (drfiger, lebeck) for atc. flow and airway pressure were measured at the outer end of the ett. three ventilatory modes, ( ) asb ( mbarover mbar peep), ( ) atcin, ( ) atc-in-ex were selected in random order. immediately following the transition from one mode to another the volunteers answered by hand sign how they perceived the new mode compared with the preceding mode: ,,better" (+ ), ,,equal" ( ) or ,,worse" (- ). inspiration and expiration were investigated separately by presenting mode transitions (in total; including ,,placebo" transitions). results : the difference between atc and conventional asb is perceived in inspiration and in expiration. atc is positively judged; asb is nega ively judged. the diagrams show mean values _+ sd of five volunteers investigated up to now. the new mode atc is perceived as an increase in subjective comfort. our explanation is that atc preserves the natural breathing pattern better than conventional asb. objectives: to determine the role of cerebral vasoconstriction in the delayed hypoperfusion phase in comatose patients after cardiac arrest. to correlate the results with indices of cerebral oxygenation and the levels of several vasoactive hormones in the jugular bulb. methods: in comatose patients after cardiac arrest we measured the pulsatility index (pi) of the medial cerebral artery by transcranial doppler sonography. the pi is a reliable indicator of cerebral vascular resistance. we also sampled blood from the jugular bulb and measured cerebral oxygen extraction ratio and jugular bulb levels of endothelin, nitrate and cgmp. the first measurement was done within hours after cardiac arrest and repeated , , , , and hours later. results: we studied patients, females, mean age , + , years. the pi decreased s!gnificantly between th~ first and the last measurement from . _+ . to . + . (p = . ). cerebral oxygen extraction ratio decreased also from . + . to . + . (.p = . ). endothelin levels were high, but didn't change during the studied period. nitrate levels varied in a wide range, but didn't change significantly. however, cgmp levels increased significantly from very low levels in the first measurement to very high levels hours later, rasp. . pmol/ml (median; th . - th . ) and . pmol/ml (median; th . - th . ) (p = . ). eighteen and hours after the first measurement we found a strong correlation between pi and cerebral oxygen extraction ratio ( r = . , p = . and r = . , p = . ). we.also found hours after the first measurement a significant correlation between pi and cgmp levels ( r = . , p = . ). we found no correlation between pi and endothelin or nitrate levels. conclusion.~; our results show a high cerebral vascular resistance in the first few hours after cardiac arrest, gradually decreasing during the next hours. this is accompanied by an initially high cerebral oxygen extraction ratio and low cgmp levels, suggesting that the cerebral vascular resistance is induced by active vasoconstriction because of insufficient cgmp levels, leading to a decrease in cerebral blood flow and a compensatory ~ncrease in cerebral oxygen extraction. objectives: sudden cardiac arrest is a major cause of mortality in western countries accounting for over half of all cardiovascular deaths. in most cases the mechanism of death is prolonged cardio-circulatory arrest due to ver:tricular fibrillation (vf) preceding final asystole. recurrent syncopes due to idiopathic vf with good neurological prognosis have been reported in patients with and without cardiac etiology ( , ). in the past measurements of cerebral hemodynamics have been repeatedly done in humans during cpr, but until today no studies of cerebral blood flow velocity (cbfv) have been reported during controlled cardiac arrest in humans not under-going cpr. it was the purpose of our study to evaluate the acute hemodynamic effects of untreated vf on cbfv. methods: after approval by the local university ethics comittee, five male patients aged - years without evidence of cerebral disease were investigated during vf while undergoing implantation of a pacer cardioverter defibrillator system (model d; medtronic| a standard anaesthetic regimen was used (propofol, fentanyl). after implantation of the automated cardiac defibrillator vf was induced by electrical countershock to test effective sensing, pacing, and defibrillation. to measure cerebral blood flow velocities (cbfvmca) the doppler probe was placed above the zygomatic arch between the lateral margin of the orbit and the ear and directed towards the m segment of the middle cerebral artery (mca). results: a total of phases of vf were investigated. duration of vf ranged from to seconds, with cbfvmc a (mean_+sd, cm sec - ) flow pattern changing from pulsatile to laminar flow immediately after onset of vf. conclusions: the underlying mechanism of the laminar cerebral blood flow observed during vf in our patients is uncertain, but it may provide insight into the prognosis of patients with idiopathic vf. theoretically, the laminar cerebral blood flow observed in our pulseless patients may provide a substantial amount of cerebral perfusion even during clinical cardiocirculatory arrest objective: to investigate whether the intensive care nursing staff can inflate more accurately a specific air volume with the laerdal resuscitation bag when they receive feedback after each inflation about the delivered volume compared to no feedback. method: icu nurses were asked to inflate a testlung model times with a specific air volume ( ml, ,ml or ml) under three different conditions (normal, decreased compliance and increased resistance) without and with feedback. we measured the mean absolute difference from the specific airvolume after each ten inflations. results: the largest absolute difference was found when icu nurses inflated ml ( ml). the mean inflated volume for this group was ml. when the icu nurses had to inflate ml the mean absolute volume difference was ml with a mean inflated volume of ml. inflating ml produced an absolute volume difference of ml with an mean inflated volume of ml. the absolute volume difference decreased when the compliance of the testlung was decreased and even more when the resistance of the used endotracheal tube was increased. when the icu nursing staff received volume feedback after each inflation the mean absolute volume difference was reduced between the ml and ml for all specific air volumes. % of the last inflations with feedback were significantly smaller than ml from the specific air volume (p < . ). conclusion: the majority of nurses overinflated the specific air volumes. the largest over inflation occurred when ml and the smallest when inflating ml. when nurses were provided with volume feedback the performed significantly better. we concluded that icu nurses are not able to inflate a specific air volume with the laerdal resuscitation bag without receiving volume feedback. feedback is desirable in order to reduce the volume trauma. objectives: a pro_found impairment in systolic and diastolic myocardial function following successful cardiopulmonary resuscitation (cpr) has been demonstrated by using langerdorff method in rats. in the present study we have investigated post resuscitation myocardial dysfunction in a porcine model of cpr. methods: ventricular fibrillation (vf) was electrically induced by alternating current applied to the ep{cardium of the right ventricle in domestic pigs. following rain of untreated vf, precordial compression and mechanical ventilation was initiated and maintained for min. electrical defibrillation was then attempted and of animals were successfully resuscitated. results: following successful cardiac resuscitation, stroke volume index (svi) decreased from prearrest value of . ml/kg to . ml/kg (p< . ), and left ventricular stroke work index (lvswi) from . to . mmhg,ml/kg (p< . ). both svi and lvswi remained depressed for another hours. these decreases were associated with increases in heart rate from bpm to bpm (p< . ). no significant changes from baseline in mean arterial pressure, mean pulmonary pressure, right atrial pressure and pulmonary artery wedge pressure were observed. prehospital resuscitation efforts c. k ppel. g. fahron, h. lufft, a. kruger, c. th(jrk, f. bertschat, f. martens dept, of nephrology add medical intensive care, virchow-klinikum, humboldt-universit~t, d- bedin, germany obiective: the success rate of prehospital resuscitation in patients with cardiocirculatory arrest in an emergency medical system (ems) may reach - % depending on the time of calling the ems, the distance to cover by the emergency ambulance and the training of the emergency physician and his staff. in the berlin ems, which is associated with the berlin fire brigade, the time between alarm and arrival at the scene ranges from - min, mean min. resuscftation is based on the advanced cardiac life support (acls) according to the guidelines of the american heart association. if resuscitation efforts fail to restore circulation, they are terminated after - min, depending on duration of cardiocirculatory arrest, pre-existing disease, age, absence of an even transient response to cpr. however, there is a lack of practical criteria for termination of cpr in individual decision making. patients: we report cases of prehospital cpr with primary asystolia terminated after - rain of frustraneous cpr efforts including highdose epinephrine and dopamine. results: after termination of cpr, the ecg monitor remained connected and showed permanent asystolia in all patients while the emergency physician completed his records. spontaneous resumption of respiration and circulation was observed in these patients after - min and cpr efforts were immediately resumed, nevertheless, of the patients died at the scene, while could be hospitalized with stable circulation. one of them died hours after admission to the icu, the other survived for weeks in a vegetative state. spontaneous resumption of circulation and respiration is most likely due to the development of extreme hypercapnia and acidosis, which -at least in some patients -seems to be a stronger stimulant of the circulatory and respiratory brainstem centers than cpr with high-dose catecholamines, conclusion: because of the legal and ethical implications of this rare phenomenon, emergency physicians should continue ecg monitoring for at least rain. after termination of cpr efforts. pulmonary artery catheterezation is used for patient's monitoring [ ]. we reported our results on such monitoring in [f.coaobbeb,r.fe enb~-kap~monorm~, ,n ,p. - ] .however not all of the received criteria assessments meet demands that are necessary for early diagnosis of critical states. here we report the data on po ,pco (mm rg),so ,ph levels in femoral [af) and pulmonary (ap) arteries blood, as well as on summary gas pressure (sgp) calculated from pe=(po +pco ) in mm hg in ap blood. these data were derived from:i) subjects free of cardiovascular pathology according to catheterization data during their spontaneous air breathing (n group in ap blood appears to be a measure of adequacy ratio between pc and sgp in ap blood during air breathing; partly its characteristics and variations ranges are presented earlier [ j. in control group it is equal to , • mm hg. tests on sgp neither exclude nor substitute conventional (pc and pco ) tests, but rather include them as a part choosing only additive characteristic -pressure. they appear to be a part of general system of human metabolism regulation by pressure (arterial,venous,intracardiac, tissue,liquor,onco-osmotic,etc ietraabdeminal pressure produces perturbations of cardiac, pulmonary, and renal physiology. this most often occurs fonowing eeliotomy for peritonitis or intestinal obstruction; bowel edema and distention prevent wound closure without unacceptable compromise of blood pressure or pulmonary compliance. a variety of temporizing measures have been reported for managing wounds that cannot be closed: ) using towel clips to reapproximate skin only, )i sewing silastic, marlex or other prosthetic grafts to the fascia to "enlarge" the peritoneal cavity, ) using loosely tied retention sutures for partial closure, ) simply packing the wound without attempts at c~osure. these techniques either traumatize the abdominal wall (complicating definitive closure), expose the bowel to damage, or allow excessive loss of fluid and heat. since we have evolved a suturelees technique which permits the abdomen to be partially closed in a quick, safe, sterile, sealed, atraumatic fashion -while providin! decompression of unphysiologic intraabdominal pressure. methods: whenever possible omentum is interposed between bowel and the open incision. viscera are covered by a layer of sterile, non-reactive plastic, placed deep to the fascia and extending we~t beneath the edges. sump tubes are placed above the plastic and covered in turn by two layers of an adhesive plastic drape which sticks to the skin and seals the wound in all directions, the patients remain intubated and paralyzed. results: we have used this technique in a total of patients, four of whom suffered from compartment syndrome. all of the latter were males and ranged in age from to . all four showed immediate physiologic improvement. all four incisions were eventually closed without complication. one compartment syndrome patient died t days later of multiple organ failure. there were no complications related to the closure technique in any of the patients. conclusions; . selected patients with abdominal compartment syndrome will benefit from decompression using this temporary sutureless technique. the technique a) is quick, safe, sterile, sealed, and atraumatic, b) minimizes loss of fluid and heat, c) facilitates eventual definitive abdomina| closure. although m. brunner m. mitllncr objectives: to determine incidence and predisposing factors for cardiac arrest occurring during the first hours after open heart surgery. methods: the study included patients who, following open heart surgery, had adequate cardiac function and in whom cardiac arrest was not anticipated. all data were prospectively recorded and analyzed. results: from / through / , pts underwent open heart surgery at our hospital. of th~se, pts ( %) (age _+ yrs) had a cardiac arrest during the first hours after transfer to icu. they were operated on for coronary artery bypass grafting (cabg) ( pts), valve replacement (vr) ( pts), cabg and vr ( pts) and aortic aneurysm ( pt). the preoperative ejection fraction was _+ % whereas bypass and aortic cross-clamp time were + and + rain, respectively. prior to arrest, they had a cardiac index of . _+ . l/min/m and were receiving . + inotropes. arrythmias leading to cardiac arrest were ventricular tachycardia/fibrilation ( pts) and bradyarrythmia ( pts). closed-chest cpr was initially performed on all pts and was followed by open-chest cpr in pts. eighteen pts ( %) survived to icu discharge. causes of arrest included perioperative myocardial infarct (t pts, %), tamponade ( pts, %), rupture of the proximal vein gra& anastomosis ( pt, %), graft occlusion ( pts, %); no cause was found in pts ( %). conclusions: postoperative cardiac arrest in stable cardiac surgery pts is relatively infrequent (- % incidence) and is associated with a high survival rate following successful cpr. perioperative myocardial infarct is the most common predisposing factor. group ~deptof anaesthesia and intensive care, semmelweis univ. medical school, buda military hospital intensive care unit, budapest background: when a cardiac arrest occurs in-hospital, the outcome can be improved by a higher quality of basic life support provided by the witnessing health care workers until the code team arrives. this basic life ~pport (bls) should include the best available method for airway management as well. since not all medical staff are ready for carrying out endatracheal intnbation, we investigated the effieacy of the use of different airway management methods during bls. methods: we have investigated the efficacy of airway management of doctors and nurses from different hospital wards: internal medicine, department of surgery, trauma, urology and gynaecolagy. comparing the bag-valve-mask, laryngeal mask and the endotracheal intubafion, we have measured the following parameters: time needs for correct application (sec.), number of incorrect applications (out of ten trial), efficacy of artificial ventilation provided by the device. we used a computerised als trainer manikin for the evaluation of the performance. total performance score was created after the measurement between - . after the first screening we held a x hours training. doctors and nurses were trained for the endotracheal intubation (group it , t ) , doctors and nurses were trained to use the laryngeal mask (group lm , lm ) . all respondent were trained to use the bag-valve-mask device. day, month and month after the training we have carried out retention study using the same method. results: we have found that the efficacy of the artificial ventilation using the above mentioned devices were poor before the training. the average after-training performance scores of the groups are presented in the table below. (bls) should be initiated by the witnessing health care professional. the cpr study introduced a multi level code system, which means bls included sophisticated airway management, early defibrillation and early epinephrine administration provided before the code team arrives. our previous studies confirmed a poor level of cpr performance and a high demand for cpr training among health care professionals. method: we established a cpr training course centre, where doctors and nurses are being trained for in-huspital basic and advanced life support. x hours of training were held. after the theoretical introduction a step-by-step training method ws used for trainees to be familiar with all sequences of basic and advanced life support. then we synthetised all separated sequences. afterwards, a r e play of rescue groups was taken in simulated situations. we also trained the multi level alarm system fur the in-hospital resuscitations. after the training all respondents had to sit for examination. the quality of performance was scored and compared to our previous results. semi-structured interviews were carried out before and aider the training among all respondents to collect information about the course. results: we have found a remarkably high interest among doctors and nurses in our cpr training courses. it was very important to use proper equipment for the training: audio-visual training facilities, computerised als trainer manikin, manual and automatic defibrillator units. the evaluation of the examination held immediately a~er the training course showed a significant higher quality of performance than before the training. the self.-eonfidence of the trainees for initiating and carrying out resuscitation had increased. their overall feeling about the course was positive and % responded the course "very useful". . % of doctors and . % of nurses claimed fur regular training facilities with als trainers, conclusion: the cpr training for health care werkers is mandatory including the training of sophisticated airway management and use of elad~l~ills~tt~r wlaa ~en ~r a~ti~atir ~nel r rm~a'*h*nr m~thnd for training will improve the efficacy, the satisfaction of trainees, therefore their compliance for further co-operation will also increase. s objectives: the effect of reinfusion in emergency surgery and gynecology. methods: we had an experience of autologous blood transfusion in patients whom was produce t an emergency surgical or gynecological interventions in occasion with break tubal pregnancies ( . %), penetrating abdominal wounds with injuries of mesenterial vessels ( . %), injuries of the liver ( . %), blunt abdominal trauma with lien ruption ( . %). in . % patients had the previous somatic pathology. blood loss volume was - ml, & the reihfuside blood volume was - ml, consisting - % of blood loss. it was needn't to fransuse donor blood in . % in further but - ml of contanined erythrocytes were frasfused for supporting of hb concentration on the g/l ( g/dl) rate at the other patients with isovolemie hemodiluttion. results: the arterial blood pressure fast stabilisation on the perfusion level had noted after reinfusion, excluding the case, when the volume of reinfused blood had conisted just % of blood loss at the patient with massive blood loss. complications have noted in two cases. one patient with slash wound, injury of arteria gastrica dextra and total blood loss of ml, has an episode of asystoly, dic (disseminated intravascular coagulation) syndrome, acute renal failure, and acute pancreatitis that we haven't connected to reinfusion. all the complications were successfully corrected and at thirty first day patient with subcapsular wound of the lien that has happened days before complicated with external rupture of the capsull & massive intraabdominal bleeding, has the hemolytical shock, dic syndrome, acute renal failure developed after reinfusion. he was died. all another have no complications. posthemorrhagic anemia had corrected rapidly than in case when hemorrange corrected exclusively by donor blood. conclusions: we consider that simplicity, accessibility, high effectiveness, quite well further results of blood reinfusion, except the case of blood reinfusing that was for time-expired out of blood vessels (more than days in our case) will promote to the wide spreading of this method, especially in emergency surgery, in massive injuries, & in disarters, all the cases of insufficiently of time for selection of lot of donor blood. objectives: study of a reaction of the oardioreepiratory system of pregnant women to i/v microperfusion of clophelinum which is known to eliminate hemodynsmic and endocrine nociceptive reactions and can be used for treating hypertensive syndrome in pregnancy and labor. methods: the following non-invasive methods were used: capnography, spirometry, oxygenography, indirect fick principle based on the circle breathing, plethysmography and integral rheography~ functional indices of cardiorespiratory function were evaluated. results: pregnant women with ~h-gestosis were examined before and after i/v infusion of i ml of . % clophelin solution, . mg/kg/hour. before the treatment intensification of carbohydrate metabolism, hyperventilation with moderate hypooapnia and complete respiratory compensation of metabolic acidosis~ increased alveolar ventilation, decreased alveolar volume, predomination of perfusion over ventilation, hypokinetio type of circulation with dominated load by peripheral vascular resistance to the blood flow was observed in this group of patients. microperfusion of clophelin imp~-oved the ventilation/perfusion ratio, ventilatory and gaseous exchange efficiency, resulted in a decrease of congestion in the pulmonary circulation, possibly owing to a decrease of peripheral vascular resistance by %, of the heart rate by io. %, of the oardial output index by . %. conclusionm: the resulted type of circulation with a decreased load on the heart both by resistance and volume allowed to improve the cardioreepiratory system function in pregnant patients. objectives: the injury severity score is a measure of severity of anatomic injuries. iss is a sum of squares of the highest degrees of the abbreviated injury scale (ais) for each of three most severity injured regions. the purpose of the study is to establish correlation between the iss values and mortality rate in older, polytraumatized patients. methods and results: iss was determined for patients. the mean iss value was . + . while the median value was . minor injuries were present in ( %) patients with iss less than , while ( %) patients with iss more than had severe injuries. increased mortality of the older patients was noted in the range - . all patients older than died while % of patients below yrs of age survived, indicationg correlation between iss and mortality rate in polytraumatized patients above yrs of age. conclusions: this mode of evaluating severity of injuries may help in triage, determining appropriate level of care and as an indicator of future outcome of polytraumatized patients. objectives : tissue hypoxia is a non exclusive cause of hyperlactatemia. other serious medical situations induce hyperlactatemia. therefore, lactatemia could be a non specific indicator of severity in patients admitted in emergency unit. the aims of this study were to examine the correlations between lactatemia with the short term survival course prognosis and the unit of hospitalisation; intensive care unit (icu) or medicine unit, in patients admitted in our emergency department. methods -lactatemia was measured as soon as the admittance, in arterial blood sample of patients which needed arterial blond gas. sixty-one patients were included during months. to assess the statistical performances of lactatemia, sensitivity (se), specificity (sp) and accuracy (ac) were calculated for the threshold determined by the youden's test (se+sp- ). results : fifteen patients were admitted in icu and in a medical unit. fifteen patients died. a group of patients had a lactatemia up to mmol.l" . in this group of patients, had acidocetosis, had asthma, had cerebral vascular ischemia, had neoplasia, had cardiogenic shock, was epileptic, had congestive heart failure, had acute respiratory failure, had septicaemia, had hyperosmolar status finally had medicinal intoxication. lactatemia was significantly higher in non survivor than survivor ( . • vs. . + . , p<o.oool, respectively), the cut point of lactatemia was . mmoll" se was %, sp was % and the accuracy was %. on the other hand lactatemia was higher in patients admitted in icu than in medical unit ( . + . vs. . • p<o. , respectively). conclusions : this preliminary results suggest that lactatemia is a good indicator of the short term survival course in patients admitted in an emergency unit. furthermore, hyperlaotemia is present in several pathology seen in emergency. objective: to determine the pattern of injury, total peripheral white cell, neutrophil, and lymphocyte responses, and the outcome of trauma patients who are leucopaenic on admission to the icu. design: prospective, descriptive study of consecutive admissions over months. setting: a -bed surgical intensive care in a teaching hospital. patients: thirty consecutive adults admitted to the icu following trauma. leucopaenia was defined as a total peripheral white cell count of < x , neulropaenia < x , and lymphopaenia < . x ~ cells per litre. measurement and results: the total peripheral white cell count was documented daily and the neurtophil and lymphocyte counts and differential percentages on days , , and . the incidence of leucopaenia was significanfiy higher in patients with gunshot wounds (p < . ) and hollow visceral intra-abdominal injury (p < . ). eight ( %) patients died. no significant differences were found in the initial mean total white cell, neutrophil, or lymphocyte counts nor in the differential percentages between survivors and non-survivors. the total peripheral white cell count increased significantly in survivors compared to those who died (p < . ) and significant differences were found in absolute neutrophil counts (p < . ) and differential percentages (p < . ) on days and . no significant differences were found in lymphocyte counts or differential percentages. conclusions: there is a signficant association between leucopaenia, neutrepaenia, and intra-abdominal hollow visceral injury and peritoneal contamination. survival is related significantly to resolution of these white cell deficiencies. these findings suggest a possible role of granulocyte colony stimulating factor in the trauma patient with intra-abdominal infection and persistent neutropaenia. amelioration of organization emergency care team in order to improve caring for urgent cases. objectives: emergency care team (ect), as integral part of health, respectively as activity of primary health protection care all acute difficult conditions which vitaly danger patients and distressed. the aim of our investigations was to indicate on the possibilities of amelioration of organization ect in order to improve caring for urgent cases. methods: in our investigations we used epidemiologicai and statistical metods all informations and matherials from terrain ects. results: the number of traumatized in traffic accidents etc. have a epidemic character. it is well known that . % traumatized died in first two hours. ect isn't enough qualified to care a traumatized on the place of accident and during transport. because that medical personnel must have an education with solid qualities. conclusions: . besides a physician specialized (vii --+ vii -~ viii gradus) in urgent medicine, it's necessary to introduce two ( ) medical technicians instead of one as is existing now ( ~ ). .the medical technicians can drive cars and one of them always, drives the ambulance car ("b" category). .the technicians have been specially educated for urgent cases (iv ~ v ~ vi). . such a new team structure should be more capable in professional sense. .we can see an importance of team-work in ects. . such teams should also be more economic in comparison with existing one. . we think, that on the general medical studies need to include a new discipline-urgent medicine! objectives: to detoxicate an organism since we have used biological sorbents: isolated from liver and spleen of human or animal cells or tissue fragments. methods: cellular dialysis ( dialyses) in patients with an acute hepatic insufficiency poisoning by hepatotropic poisons: cc , dichloethane, mushrooms -were conducted using "artificial kidney" apparatus, by means of arteriovenous shunt, formed at forearm with disposable dialyzers. hepatocytes suspension was poured into dializing circuit of dialyzer at - mg of cells per i kg of patients weight. dialysis was performed during - hrs. patients with purulent-septic states were treated as for hemoperfusion through prepared sorptional column: . ml of hemosorbent and . ml of fragmented spleen or hepatocytes suspension with the help of roller pump with the rate of - ml/min, during - min. average volume of hemoperfusion made . . conclusions: in all cases we used both native and cryopreserved biomaterial. analysis of the dynamics of clinical, biochemical, scintigraphic and us-investigastions allows to conclude that application of cellular-sorptional method of detoxication enable to prolong life and reduce lethal outcome in some severe category of patients with endotoxicosis. after infusion of diazepam ( . mg/kg),thiopentone ( mg/ kg) and vecuronium (lmg/kg),patient was intubated and mechanical ventilation was adjusted to mantain normoca= pnia. ct scan showed left parieto-occipital hypodensity with brain swelling. after admission in neurological icu,dexamethasone ( mg/ kg/die),mannitol ( .smg/kg) and diphenylydantoin ( mg/ kg/die) were administred. two hours later neurological status of the patien~ was normal and she was extubated. the risks of stereotactie radiosnkgety are related to: hemorrhgge during the latency interval;transient radia= tion effects;permanent radiatio~einduced complications; radiation induced neoplasia. no epilepsy is reported in pts with avm and no seizure before radiosurgery. in c nclusion, epilepsy can be a posmib~e delayed eompli c~t~n, ~fe~r rgdi surgery for cerebral avm. serum potassium deficiency is a frequently reported finding in the time course of acute myocardial infarction (ami). if this is also correct for patients with ami undergoing primary percutaneous transluminal coronary angioplasty (ptca) is unknown.for that reason we analysed in patients ( m., f., + y.) serum potassium concentrations on ad ,mission and directly after ptca.the reference intervall for potassium in our clinical laboratory is , - , mmol/l. although more than % of the patients with ami undergoing ptca showed normal potassium serum concentrations on admission a measurable decrease of potassium could be found in % of patients ( ) after ptca.therefore for the majority of patients with ami potassium supplementation prior to ptca can be justified to avoid electrolyte disturbances as a possible trigger factor for cardiac arrhythmias in the setting of ami and acute reperfusion due to primary ptca. objectives: diagnostic procedures are very important in the management of abdominal injures in trauma. the aim of this paper is to present our experience with peritoneal lavage as diagnostic procedure in abdominal injury. methods: we analyzed patients to whom peritoneal lavage was applied in the surgical emergency from st of january till st of december . results; in this four years period there were abdominal injures. there were blunt injures. among them in patients peritoneal lavage was applied. results were positive in patients and negative in patients. false positive finding were in patients and false negative in two patients. in patients with positive lavage there were more than , /mm red blood cells, more than , /mm white blood cells and the level of amylase was up to u/i. the gall, urine and stool were positive as well. in patients with negative lavage there were less than , /mm red blood cells, less than /mm white blood ceils and amylase were negative. conclusion: peritoneal lavage is useful and important diagnostic procedure in the management of abdominal injures in trauma. our experience with urgent surgical management of the acute gastric and duodenal bleeding s.se en md, z.milo~evi md, *s.srdi md, k.sar ev md. clinic for abdominal and endocrine surgery, institute for surgery; *clinic for cardiology, institute for cardiovascular diseases; school for medicine novi sad, university of novi sad, yugoslavia objectives: acute gastric and duodenal bleeding are very common complication of gastric and duodenal ulcer. the aim of this paper is to present efficiency of our surgical management of these acute conditions. methods: in this paper results of surgical management of patients with acute gastric and duodenal bleeding, treated in our clinic from the st of january till st of december , are presented. results: among operated patients there were females ( . %) and males ( . %). there were patients ( . %) with gastric bleeding and patients ( . %) with duodenal bleeding. bleeding from gastric ulcer were treated with the following methods: excision of ulcer with suture in patients ( . %), ulcer suture in patients ( . %), billroth i in patients ( . %) and billroth ii in patients ( . %). heinecke-mikulicz-weinberger pyloroplastica was the most frequently used in the treatment of the duodenal ulcer bleeding. bilateral truncal vagotomy was done in patients ( %), duodenotomy with ulcer suture was done in three patients ( . %) and three patients underwent billroth ii operation. we had three complicationsduodenal dehiscence in pyloroplasty. there were no lethal complications. conclusions: based on our own experience we conclude that acute bleeding from gastric and duodenal ulcer can be safely managed with urgent and modern operative techniques. dept. of anaesthesiology. emergency center of serbia, belgrade, srj b ectives and methods: cardiac contusion was evaluated by serial determination of cpk-mb fraction and co using non-invasive doppler technique in patients with blunt trauma of the chest. results: miooardial contusion was diagnosed in ( %) patients, while in ( %) it appeared unaffected. cpk-mb of % and more in comparison to total cpkwas . + , % in patients, and , + , % in pts (p< . ).c of . + . l/min in patients with cardiac contusion, measured hrs after admission at the latest, was significantly lower than in group of patients with co of . + . l/min (p< . ). conclusions: co values were significantly lower in patients with cardiac contusion and correlated with pathological values of cpk-mb fraction. objectives: extracorporal plasmophoresis (pph) was implemented by non-stop method in patients with obstructive jaundice. methods: changes of serotonin (s) and histamine (n) in arterial (ab) and venous (vb) blood were investigated before and after one-time session of pph. s and h in blood serum were determined with fluoremetric method. results: before pph the average s contents in ab and vb did not differ. after one-time pph session s in the blood outflowing lungs was % lower than in the blood inflowing. hours after extracorporal detoxication implemented the indices kept the same level. similar dynamics after pph was observed in h. before the session h contens was equal both in the blood inflowing and in the blood outflowing lunge. after pph h contents in ab was % lower compared to the vb and did not change for hours. conclusions: dynamics of changes of biogene amines shows that under the influence of pph there takes place not only mechanical removal of their surpluses together with plasm, but there sharply grows inactivating role of lungs towards ba substances, which is confirmed by reduction of their concentration in the blood outflowing lungs. this effect is probably connected with the "deplasmation" of the lung cellular elements. simultaneously lungs' cells are freed not only from plasm but from toxic adsorbents on their surface. as a result the lung cells activate absorption of the surplus number of amines from the vessel channel. it is not excluded that s inactivation is due to growing activity of monoaminooxidase resulting in deminishing of intoxication. acute pulmonary embolism: thrombolytic therapy or pulmonary embolectomy? i.lodiena md, phd, s.shevchenko md, pphd., medical university, kharkov, ukraine objectives: pulmonary embolism (pe) remains a challenging problem for diagnosis and management for the emergency physician. the aim of this work is to identify the best treatment for massive pulmonary thromboembolism. methods: during recent years patients with symptomatic acute serious pe were reffered to our observations. selective pulmonary arteriography confirmed this diagnosis in all cases. ( . %) underwent urgent surgery, of them ( . %) with cardiogenic shock and ( . %) with massive pulmonary embolism. patients ( . %) underwent thrombolytic therapy. results: in the patients who received thrombolytic therapy successful results were achieved in cases ( . %), in ( . %) patients subsequent pulmonary embolectomy was performed. mortality rate was ( . %) in the patients who underwent pulmonary embolectomy after unsuccessful thrombolytic therapy and ( %) in the patients with cardiogenic shock and massive pe. lower extremity deep venous thrombosis caused pe in % patients. pe mortality rate is repoted to be %, but all patients with cardiogenic shock and massive pe died. this very high mortality rate related to the clinical status of the patients whose condition became worse despite intensive treatment. conclusions: the results of this study show that in most cases thrombolytic therapy is an effective rapid method of treating pe. however, surgical treatment is preferable when the patients reveal adverse effects to drug therapy, when medical therapy is unsuccessful or when the patients are seriously ill with reccurent cardiac arrest. high-quality pulmonary angiography remains the most accurate and reliable means of diagnosing pe. this prospective study was conducted to investigate the serum thyroid hormone levels in traumatized critical ill patients. serum thyroid stimulating hormene(tsh),total thyroxine(tr ),free thyroxine(ft ),total tri-iodothyronine(tr ),free tri-iodothyronine (ff ) levels were measured within hr.of intensive care unit admission(first day) in multiple tratmmtized male patients(injury severity score higher than ). in fifth day the same hormone levels were repeated. tsh,et ,ft ,tr and ft levels were determined by radioimmueoassay(ria). the levels of 'i~sh,xt ,fr ,et and ft in survivors and nonsurvivors were compared with first and fifth days (table) . in conclusion, we are convinced that there was a high correlation between low ser~n thyroid hormone levels and mortality, serum thyroid hormone levels are prognostic value in traumatized critical ill patients. objectives: glucagon improves myokardium contractility, intensifies kidney blood flow, stops bronchospasm ( ), these were the reasons of investigating its effect on hemodynamics and metabolism in hypovolemic shock expermentally and in clinic. methods : in experiments on white rats with traumatic shock glucagon (novo nordisk) was injected intraperitoneally in dose rocg/kg. patients with hypovolemic shock (trauma, hemorrage) were injected glucagon intravenously in dose mg on the background of infusion therapy. results : glucagon hightened recovery indexes of glucose in rats and patients with shock, whereas in groups without glucagon hyperglycemia developed. rats with glucagon injection had double times urea content than the norm ( , + , mmol& norm - , + , mmol/i ), whereas rats without glucagon had urea content , + , mmol/ ( p < , ). osmolarity of blood plasma in rats having glucagon injections was , + , mosm/kg h , without the drug - , + , mosm/kg h ( p < , ), ldh activity - , + . and , + , ( p < , ) mcmol cec- accordingly. lethality in the group of rats without glucagon was % /n= /, with glucagon - (n = ). in patients with hypovolemic shock in minutes after glucagon administration stroke volume increased to % (sv), miocardium contractility -to % (mc), peripheral resistance of vessels ( vr ) decreased to %. in - , hrs sv increased to %, mc-to %, pvr -decreased to %. conclusion : the study provides the evidence that glucagon has an anti-shock effect, improves hemodynamics and metabolism indexes in cases of hypovolemic shock. reference : picazo j. glucagon in acute medicine : pharmacological, clinical and therapeutic implications (norwell, mass:kluwer publishing, ), p. n, vasina (t) ,n.sebbota hph ( ). dept; of acute endotoxicosis, n.v. s~lifosovslay scientific research institute of ermergency ltealth care, boscow, lk'ussia (i}. institute for problems of cryobiology and cryouledicine of the national academy of sciences of the f/maine, kl'k r-key, [ maine ( ), objectives: the investigation of isolated hepatocytes using's efficacy in patients with acute hepatic fai lln-e. methods: native and crioconsrved allo-and xeno-!mmatocztes fixed on semi;ermeable ~mbr~s were used. results: the artificial supporting system with isolated hepatocttes as metabolic ~its was. ap-plied in patients. during tl~ treatmen~ with this cytotherapz an improvement of clinic state and biochemical rates were observed even inthe first we~s. for instance, the kncreasing of glutamin acid's level in blood up to normal value and decreasing of ammontes -concentration from i ~ mmol/l down to # mol/l were discovered. ~ae diminution of ence,%halo;athy was noted too. general lethality was' equal z, there of i z concerned acute hepatic failure (/k~). conclusions: the using of sum~rting hepatic system is able to cope the ~nenomenon of ~i~. objectives: fat embolism (ee) is an important and insufficiently studied problem of the intensive care medicine. fe is clinically diagnosed in % and morphologically in - % of the victims with severe multiple skeletal injury that is accompanied by the shock. methods: during the last years patients with the cerebropulmonary form of fe were treated in the icu. the prognosis of the probability of fe development was done using the computer system "cite-prognosis" in which the triss-method, dynamic and statistical prognosis of the injury outcome~ and the values of the most severe injury in points were realized. the treatment consisted of the surgical stabilization of the fractures with the authors' design of the rod apparatus in the acute period, long-term mechanical ventilation with peep via tracheostomy, complex fluid therapy using perfluorochemical emulsions (pe), and electrochemically active solution of na hypochlorite (snh) via the central vein. results: the treatment of patients with fe gave a good result that was manifested by the complete regression of psychoneurologic and respiratory disorders. conclusions~taking into account the prognostic data~ it is necessary to provide early complex of intensive care to the polytraumatized patients. it includes the surgical stabilization of fractures, fluid therapy using pe and snh~ early long-term mechanical ventilation. dr. alexandr e. poladko, station of medical aid. kiev ukraine. objectives: the reason of investigation is to prove the necessity of beginning of the intravenous infusion of nitroglycerin before the hospitalisation. methods: from january i to june protocols of treatment myocardial infarction patients in kiev medical aid station. results: the results of treatment are better if infusion began early or prolonged during hospitalisation. conclusions: there were patients with acute myocardial infarction treated before hospital by the cardiological groups. patients were treated with the early infusion of nitroglycerin and without. the results of treatment were: in the group with infusion: mortality in the first hours % the full disappear of pain % in the group without infusions mortality in the first hours % the full disappear of pain % that's why our opinion is that infusion of n. is necessary in the treatment of the patients with myocardial infarction from the first minutes of illness. dr. gennady d. kyrzhner, station of medical aid, kiev, ukraine. object: looking for safe medication which is good for the treatment of arterial hypertension and is simple for use. we inspected the effect of prazosin in the conditions of the cail during the year. method: we used mg prazosin tablets sub lingua and measured blood pressure ones during hours. the parameters were registrated in protocol. result." one hundred patients took part in investigation. the middle age of patients was . the reason of hypertension was not taken into consideration. in two hours after beginning of the treatment we caught the reliable lowering of blood pressure in % of patients. the general condition of patients became better in - min. it was only one accident of complication during the treatment -the orthostatic hypoter~sion, conclusion: prazosin hydrochloride in the dose mg sub lingua is safe and simple for use in the urgent situations. objectives: hypomagnesemia is frequently observed in severely burned patients during the early period after injury. increased urinary excretion is insufficient to explain the magnitude of the magnesium (mg) depletion. the possibility of exudative cutaneous mg losses has been proposed, but not yet demonstrated. the study aimed at measuring the mg content of the cutaneous exudates and urine during the first week after major burns. methods: patients, aged _+ years (mean _+ sd), and burnt _+ % of body surface, were studied from day (d ) to d . serum samples were collected at do, serum and urine from d to d , and on dio, d , d . cutaneous exudates were extracted from the textiles surrounding the patients, collected over h periods from d to d , using bidistilled acidified water. mg supplements ( . to mmol/ h) were prescribed from d to dio according to the severity of hypomg (serum mg < . mmol/i). results: mg serum levels decreased below reference ranges in patients between d and d , and normalised thereafter during supplementation. urinary mg excretion was increased in patients, mean excretion being . _+ . mmol/ h until d . mean daily mg cutaneous losses, were mmol/ h, i.e. mmo; in days. large inter-& intra-patient variability: the daily exudative losses ranged from to mmol/ h. conclusions: the mean daily mg cutaneous losses after burns were larger than the urinary losses, and equivalent to the recommended intakes for mg; the addition of the exudative and urinary losses largely explained the increased mg requirements after burns. complex immunologic alterations occur following thermal injury. the activation and consumption of the complement and dotting systems are suggested to play an important role in the development of the capillary leak syndrome, tn burned patients, a generalized inflammatory reaction as well as the impairment of the host defense are considered to be the major reasons for complications, such as sepsis and multiple organ failure. in a pig model we investigated a possible protective effect of cl-inhibitor (berinert, behring). before conducting the animal experiments the human cl-inhibitor concentrate was analyzed for its inhibitory capacity on purified pig cls and its pharmacoldnetic behaviour in pigs (t / ,id ). pigs received anesthesia and analgesia and arterial, venous and pulmonary (swan ganz) katheters were placed into the carotis and jugular veins. the pigs were scalded for seconds with ~ hot water to achieve a % tbs partial-thickness burn. blood samples were taken prior and after surgery as well as , minutes, , , and every further hours after thermal trauma. two control groups (each n= ) included animals which were either scalded or not scalded and treated only by resuscitation of ringers lactat solution. besides various parameters blood samples were analyzed for complement. the pigs (n= ) received c -inhibitor concentrate at an initial dose of u/kg body weight either immediately or hours after thermal trauma (n- ), followed by three further applications (of reduced amounts) every hours. the clinical outcome as indicated by vital parameters and as well as demonstrated by reduced edema and inflammatory tissue destruction suggested a protective effect of cl-inhibitor. complement analysis revealed a faster recovery of the alternative and classical pathway activities in cl-inhibitor treated pigs as compared to the control group but only if the regulator was given immediately after thermal trauma. from these results a protective function of c -inhibitor on thermal trauma can be assumed. objectives: the aim of study was to characterise the pattern of secretion of interleukin- (il- ) and tumor necrosis factor alpha (tnf alpha) in multiply injured or not injured critically ill patients and to relate these results to their outcome. methods: blood samples of multiply injured ( ( ) ( ) ( ) il- (nis) ( ) ( ) ( ) il- (nin) ( ) ( ) ( ) conclusions: this data suggest tnf alpha is a better prognostic marker in patients with multiple injury, than in critically ill patients without injury. il- is not significantly higher in nonsurvivors of both groups. sepsis is associated with an increased production of nitric oxide (no), as reflected by a rise in plasma levels of nitrites (no ) and nitrates (no ). severe bum injury is associated with similar symptoms of inflammation like hypotension, high cardiac output low vascular resistance and increased vascular permeability so that an increased no production may be involved. the present study included patients admitted to the intensive care unit of the burn center of brussels (age : - years; burned surfaee area - %), and control (non-septic) patients hospitalized in the neurological rehabilitation unit of the erasme hospital (age - years). the patients in both groups were fed enterally with to kcal/kg/day of a standard solution. in the burn group, daring the study period, patients were mechanically ventilated, required vasopressor (dopamine) therapy, and received antibiotics; patients were discharged alive from the intensive care unit, and no patient died during the study period. plasma was sampled for no /no determinations (griess reaction) daily from day to day (n=ll) or to discharge (day , n= ; day , n= ) in the burn group, and once the control group. in the burn group, no /no levels were elevated at day ( _+ #moles/i), reached a maximal value on day ( - p.moles/l) and progressively decreased to day (fig). these values were higher than in the control group ( . :t: . #moles/l, all differences p< . ). however, no correlation was found between the plasma no /no levels and the age of the patient or the total burned surface area; burned patients who became infected tended to have higher plasma no /no levels than those who did not ( + vs - #moles/i, ns). the present study indicates that burn noa/noa (llmol**/l) injury is associated with increasedloo] [__ ] ~ no /no plasma levels, which are ao so consistent with an enhanced no pro- o duction, ao obiectives:urapidil has been recommanded for therapy of hypotension in neurosurgical patients, because it was found not to increase intracranial pressure in patients with compromised intracranial dynamics ( ). in contrast several authors reported an increase of icp after urapidil administration in patients with head injury ( ). our study was designed to determin the influence of urapidil on mean lumbar cerebrospinal fluid pressure (csfp) in awake humans with uncompromised intracranial compliance. methods: after approval by the local university ethics comittee, six volunteers (asa , male, female) were studied in the lateral decubitusposition with the vertebral column positioned horizontally. a gauge needle was inserted into the lumbar subarachnoid space at level l /l and connected to a trancducer (mx | medex inc.) for csfp measurements. the volunteers were advised to keep respiratory rate and etco constant. after a resting period of minutes basline measurements were performed including csfp, cvp, map, hr, etco (cardiocap | datex). then the volunteers were given urapidil . mg/kg over a period of minute. minutes later measurements were repeated. results: statistics: wilcoxon signed rank test, p< . significant; values: mean_+sd, si = mmhg. - _ " _+ * _+ * - _+ " _+ csfp: cerebrospinal fluid pressure, cpp: mean cerebral perfusion pressure. conclusions: during normoventilation urapidil leads to a decrease in map parallel by an increase in csfp and therefore in icp, most likley mediated by an autoregulatory dilatation of cerebral vessels. if this cerebrovascular response is suppressed by hyperventilation, no increase in icp is found despite a uredipil induced drop in map ( ). after longterm hyperventilation cerebralbloodflow is normalized. this might be the reason why the drop in bloodpressure following urapidil administration again led to an increase in icp ( background and objectives: the intestine is one of the most sensitive tissues to ischemia-reperfusion injury. reperfusion of the intestine is often associated with increase in mucosal permeability and ulceration. d(-)-iactate is produced by indigenous bacteria found in the gastrointestinal tract and mammals do not possess the enzyme systems to rapidly metabolize it. the present study was designed to determine the kinetics of plasma d(-)-iactate alteration in rats paused by acute intestinal ischemia-reperfusion injury. methods: following the anesthesia, the superior mesentcric artery (sma) was exposed and it was occluded by a micro-bulldog clamp applied at its origin from the aorta. after min of occlusion, the arterial clamp was removed and the supply area of the sma was allowed to be reperfused ( h). plasma d(-)lactate levels were measured by an enzymatic spectrophotometric assay. the endotoxin content of plasma sample was assayed by the limulus amebocyte lysate test with a kinetic modification of the test kit procedure. results: intestinal ischemia for min resulted in a significant increase in d(-)-lactate levels within the portal vein as compared to sham-operated animals. plasma d(-)-lactate levels had a tendency to further increase after reperfusion up to h. it was showed that significant elevation of endotoxin concentrations in portal vein was alread~r detected at the end of -min ischemia, reaching peak at . h post-reperfusion and decreasing gradually throughout the study period. at the end of ischemia, marked mncosai damaged such as edema, hemorrhage and necrosis was observed. there was evidence of injury to ti, e muscuiaris propria together with diffuse mucosal damage and destruction following reperfusion, particular at h postreperfusion. in addition, penetration of bacteria was commonly found in the intestinal wall at various time points following ischemia/reperfusion injury. conclusions: these data suggest that acute intestinal ischemia is associated with permeability change of mucosal barrier resulting in increased plasma d(-)qactate, which is also remarkably influenced by subsequent reperfusion. plasma d(-)-lactate may be a useful marker of intestinal injury following both ischemia and reperfusion insult. objective: to assess the clinical usefulness of two methods of intracranial pressatre (icp) monitoring: intraparonquimatous recording (icpc) and epidural recording (icpe), versus intraventricular icp (icpv) as a gold standard. we prospectively studied patients with severe head injury (glasgow coma score < ) admitted to our icu between fobmaly and december . icpv was monitored in all pativrats by means of a multipzffolated catheter connected to a water coinnm. six of patients were additionally icpc monitored by a fiber optic transducer (comma r~), and seven of patients were icpe monitored by a couplvd fluid system (plastimedr). icpc was placed homolatetal to the focal, lesion m two cases and contralateral in three; icpe was placed homolateral to the focal lesiou in two cases and contralateral in three. all three systems were calibrated at the ear level. stali~cs: correlation coefficient and lineal regression were done between icpe and icpv, and between icpe and icpv with the hourly p~rs of values obtained dttting assistontial period. results: of the six icpc -icpv studied pa~onts, we observed a correlation coef~cieut r = . (p < . ) with a regres~on line y = . + . x. four of ~hx lcpc -icpv patients had r > . when correlaliou eoet~dent was obtained indixddually. of the seven icpe -]cpv studied patients, we observed a cortelafiau ooeffioiont r = . (p < . ) with a regression line y = . + . x. corralalmu eoetfieiont was inwer than . in all seven patients. corrdation eoelfieients for levals of icpv > man hg, > mm hg and > tuna hg with icpe showed r = . , r = . and r = . respectively; and with icpe r = . , r = . and r = . . the obtained values did not change during the study. conclusdns: in our study icpe was considered a good type of icp monitoring. /cpe signiticantly infravalorates icp values. we observed a good correlatinn between icpc and icpv values in patients with high inttacramal presanre. objective: midazolam is a benzodiazepine agonist widely used for sedation in emergency medicine. few studies in animals and humans point to a direct analgesic effect of midazolam probably mediated by spinal antinociceptive receptors and/or peripheral benzodiazepine receptors ( , ). in our experience in the berlin emergency medical system (unpublished results) with anecdotal cases of extreme chest pain due to binge drinking but no evidence of acute myocardial infarction or extreme abdominal pain due to peritonitis, acute intermittent porphyria, peutz-jeghers syndrome or testicular torsion, we found that small doses of midazolam ( - mg i.v.) were much more effective in relieving pain than repeated administration of high doses of buprenorphine or morphine, which may be associated with a considerable respiratory depressant effect. the dose of midazolam required for pain relief in these patients is non-narcotic and allowed further communication on the character and localization of' the residual pain, which might be very important for the further diagnostic procedure. patients: ten patients with abdominal pain due to acute gastrointestinal bleeding, suspected pancreatitis, suspected acute porphyria, and chest pain with no evidence of acute myocardial infarction received first-line midazolam i.v. at an initial dose of mg and were asked how it affected the intensity and character of pain. results: at the chosen dose of midazolam ( - mg), all patients were responsive to detailed questioning on basic orientation, the character, intensity and localization of the pain, and medical history. none of the patients required an additional opiate. all patients stated that the pain was tolerable after midazolam alone. conclusion: our preliminary clinical observations suggest that low-dose midazolam might be an alternative to opiates in extreme pain of presumably visceral odgin. objectives: it is known that severe head injury in elderly patients is associated with higher mortality than in younger patients. it remains however to be clarified whether the preinjury pathology which is frequent among these patients, affects the outcome. methods: in an attempt to investigate this hypothesis, patients aged over years suffering from head injury, with glasgow coma scale (gcs) of or less, were studied retrospectively. twenty-six patients ( . %) had preinjury pathology i.e. diabetes mellitus, arterial hypertension, heart failure, alcoholism, parkinson's disease etc. (group a) and fifty-three ( . %) did not (group b). the following data were recorded: mortality in the i.c.u., duration of hospitalisation, incidence of infective complications and neurologic status at discharge. results: groups were comparable in terms of mean gcs ( . vs. . ) and median age ( . vs. ). the incidence of brain pathology in the two groups was the following: epidural haematoma . % vs. . %, acute subdural! haematoma . % vs. . %, intracerebral haematoma . % vs. . %, subarachnoid haemorrhage . % vs. . %, diffuse haemorrhage . % vs. . %, contusion . % vs. . % and non-visible pathology (normal ct) . % vs. . %. unilateral pupilary dilatation was found to be . % in group a and , % in group b. the mortality during hospitalisation in the i.c.u. was almost the same: % iu group a and . % in group b patients. however, group a patients had significantly more infective complications, required longer hospitalisation and had lower gcs at discharge. conclusions: the results show that the existence of preinjury pathology does not seem to affect the short-term outcome of elderly patients with severe head injury. it has however an impact on morbidity and perhaps long-term survival of these patients. the assessment of clinical development in intensive care patients with severe head injury still remains a problem. to optimize the monitoring of intracraniel prassure (icp) we rautlr~dly implant an eplduml measuring device in our hospital. the aim of this study was to prove the correlation of the icp-values with ct findings and clinical development. during a month period ( - r the icp was monitored in p~,tients ( male, female) with severe head injury by an eplclural measuring device (epldyn~/$plegelberg| the mean age was . years ( - ). the glasgow coma scale at admission was . ( - ). in all cases the device was placed wfihln the first hours after admission. the tcp was compared with physical examination, radioidglcal or intraoperatlve findings and cunlca! outcome. the average time of measuring was . days ( - ) . the traatment depended on the !cp values recorded. rising icp-valuea ~ed to radlologlcal c ntra!s by ct-scan. in case an intracranlai hemorrhage was detected and drained. the overall survival rate was . %. showed a complete resolutl n, in other . % psychological residuals like decreased mentatlon, in . % sensomotorlc residuals like cerebral nerve dysfunction and aphasia, and . % of the injured remained in a comatous status. in % of our cases the measured values correlated with clinical course and management. in cases ( . %) we observed a displacement of the icp-pevice. there was no icp induced infecllon. istituto di anestesiologia e rianimazione, universit& ,,la sapienza", rome, italy * istituto superiore di sanit& -servizio di epidemiologia e biostatistica, rome, italy objectives: acute renal failure (arf) can be a severe complication of trauma. the current incidence of post-traumatic arf is associated with high mortality . identification of risk factors and prevention of this complication could improve the outcome of trauma patients. methods: one hundred fifty three consecutive trauma patients (age . _+ . , injury severity score . + . ) admitted to icu were studied. incidence of arf was . % ( / ). arf was defined as persisteat plasma creatinine > mg/dl with or without oligoanuria . arf was defined as early when occurring within the first hours (earf) and late when the onset was after the first four days (larf). results: earf occurred in patients while larf developed in patients. age, iss, and incidence of rhabdomyolysis and acute respiratory failure were not different in the two groups. an higher incidence of multiple organ failure (mof) and sepsis ( . % for both) were observed in larf group, when compared to earf ( % and % respectively). abdominal trauma was more frequent in earf group ( % vs %). the gs for earf and larf were respectively _+ . and _+ . while in the group who not developed arf (narf) the gs was . • conclusions: gs score difference seems suggestive and can be that an abnormal cerebral activity (hipofisary hormones?) may play a crucial role on onset of arf in these patients. moreover the frequency of acute respiratory failure in the group of arf was higher ( . versus . ) than narf group. the early ipoxia in the early phase of trauma, then, may be another crucial point for development organ failure. these are preliminary data. a more exact statistical analysis must be perform to have definitive conclusions. to compare the active compression-decompression cardiopulmonary resuscitation (acd-cpr) with the standard cardiopulmonary resuscitation (s-cpr) in out of hospital cardiac arrest patients. is a controlled, randomized study. two groups of patients with cardiac arrest out of the hospitalwere formed. group i, (acd-cpr) and group ii (s-cpr). for the acd-cpr groupweusedthecardiopumpdeviceofambulnternational. asfortherest, the erc ( ) algorithms for acls were followed. the utstein style (for out of hospitat cardiac errest) was used for listing and evaluating all cases of the study. the cpr was contucted by the crew and the doctors of our mobile intensive care units (micu). we studied consequitive patients ( in group i) and ( in .group ii). demographics pre-cpr characteristics (e.g. ecg form of cardiac arrest) and procedures (eg bystanders or second tiers crew cpr, defibrillation, drugs) were quite similar for both groups. the mean arrival time of micu was min. in group i we recorded r.o.s.c. (return of spontaneous circulation) , %, death %, continuation of cpr efforts , %. while in group ii, %, %, and , % respectively (recorded percentage until the admission to the hospital). no significant difference was found in anyofthe short term outcome parameters. no complications related to the acd-cpr technique, were noted. not any significant difference between the two methods was proven (from this small evaluated sample). the results of previous clinical studies are controversial (i) . more sophisticated studies proved the superiority, in a certain number of parameters (e.g pressures, flow, etc) of the new technique although there are many difficulties for establishing clinical results. in the pre-hospital setting that is related to many parameters (speed of the intervention, effectiveness of bystanders cpr, education ofparamedics, etc.)the evaluation is even harder. the superiority ofthe acd-cpr can be proven when it is performed in almost times increased number of studied patients as w~ll as improvement of the technique could lead us to more established results. objectives; infectious morbidity is the major cause of mortality after burn injury, and is due to multiple factors. trace elements (te), which are involved in both humeral and cellular immunity, exhibit severely altered status after burns. te supplementation has been shown to be associated with increased leukocyte counts and shortened hospital stay. the trial aimed at studying the immune responses in severely burnt patients receiving normal te supplies or early large supplements. methods: patients, aged _+ yrs (mean_+sd), with burns covering + % of body surface were studied from day (d ) to d post-injury, were randomised in groups (g): g -control receiving recommended te supplies + placebo; g -receiving in addition large supplements of cu, se and zn from d to d . enteral nutrition was started within hours of injury in all patients. immunological parameters: peripheral leukocyte counts, proliferation of mononuclear cells to mitogens, cell surface molecule expression, and neutrophil chemotaxis at d and d . infectious episodes and micro-organisms were monitored until d . results: the patients' characteristics were similar g & g . the total leukocyte counts were higher in g between d and d , due to increased neutrophils (significant from d to d ). total cd + and cdlg+ cells did not differ, whereas cd + (monocytes) were significantly increased at d . proliferation to mitogens was significantly depressed in all patients. chimiotactism was not altered. the number of infectious episodes was significantly decreased in g with a mean of . _+ . infections during the first days versus . _+ . in the control group (p < . ). conclusions: the large te supplements for days was associated with a significant decrease of the number of infectious episodes. supplementation was associated with increases in total leukocyte, monoeyte and neutrophit numbers. further studies are required to determine the precise mechanism underlying the improved immune defences. objectives: evaluate the efficiency of local adsorption (la) with the use of carbon adsorbents in case of severe burns in expertment and clinic. methods: experimental studies on la were performed on a model of % body surface area iiib-iv burn in rats. a burn eschar was excised on the rd day after burn, the wounds were dressed with the gauze bandages (control) or with adsorptive dressings (la), dressings were regularly changed. clinical investigations were carried out in the course treatment of patients with severe thermal and radiation ilia-iv burn. in the dynamics of bum disease some indices of proteometabolism and intoyacation criteria were evaluated. results: the experiments have demonstrated that the application of la after early excision of a burn eschar exerts a pronounced normalizing effect on a protein electrophoregram and the activity of proteases and their inhibitors in burned tissues preserving vitality. thus, by the th day after burn infliction the activity of cathepsin d in injm'ed muscles is times lower under an adsorptive dressing than under a gauze bandage (control) (p< , ), the activity of trypsin-like proteases is . - . times lower and the antitryptie activity does not differ significantly from the normal level. the cytotoxicity of extracts of burned tissues after the adsorptive dressing application fn vivo and adsorption in vitro is - % and - %, respectively, of the toxicity of control extracts. a similar normalizing effect of la is ok~rved for an intact muscular tissue and blood serum. the dectron-spin-resonance studies have demonstrated that la allows to normalize antitoxic activity of liver and functional activity of kidneys. the application of la in the treatment of patients with severe burns have been shown to localize a region of irreversible tissue changes, accelerate rejection of a burn eschar, attenuate an endogenous intoxication level and, as a result, shorten the time for grafting of a burn wound and accelerate wound heating. conclusions: proceeding from the obtained results, we can consider la as an effective method of localization of a region of irreversible tissue changes as well as of correction of local and general metabolism failures and overcoming burn autointoxication during burn disease. c de deyne, t vandekerckhove*, j. decruyenaere, b. vaganee, v vandewalle*, f colardyn depts of intensive care and neurosurgery*-university hospital gent-belgium. jugular bulb oximetry is the first bedside available cerebral monitoring technique providing an estimation of the adequacy of cerebral perfusion. its routine use in all patients suffering from severe head injury admitted to our ic unit enabled an extensive analysis of all very early cerebral perfusion data in order to evaluate the incidence of abnormal sjo~ data (and their possible causes) in this very eady period after traumatic insult and to search for possible implications as to the emergency management. these very early data were defined as the first hours icu data and icu admission had to occur within h of traumatic insult. over the last years, pts with severe head injury (gcs< ) were monitored by jugular bulb oximetry, starting immediately after their arrival at the icu (mean of . h after trauma, range between - h). in a total of pts (= . %), jugular bulb desaturatiens (< %) were noticed during this early h period. in pts (= %), jugular bulb saturations higher than % were observed, whereas pts (= . %) revealed no abnormal sjo data ( - %) during these first h. concerning the periods with too low jugular bulb saturations (n: ), we found the following correlation ; in pts (= . %) cerebral perfusion pressure (cpp) was below mmng, in pts (= . %) paco~ was below mmhg and finally in pts (= %) we found primary intracranial hypertension. for the high jugular saturations (n: ) we found a primary intracraniaf hypertension in f pts (= %), and a pace level above mmhg in pts (= %). in all patients we could restore jugular bulb saturation within normal range ( - %) with the correct!on of the presumed causative factor. we can conclude that ultra early jugular bulb saturation data revealed a high incidence of abnormal values, with a predominance of jugular bulb desaturations, confirming once again the high incidence of disturbed and too low cerebral perfusion within the first hours after severe head injury. these jugular bulb desaturations were especially correlated to systemic causes, as a too low cpp (caused in the vast majority by primary map insufficiency, and not by intracranial hypertension) and hyperventilation were the major causes of the desaturation periods. as jugular bulb desaturatione are known to be significantly correlated to a worse neurological outcome after severe head injury, one might improve outcome by an emergency management avoiding these possible causes of jugular desaturation. therefore, extreme attention should be paid to the maintenance of an adequate mean arterial blood pressure (above mmhg?) even duhng the few time spent at the emergency department. one should be as attentive to the maintenance of normoventilation during this very early period of admission and hyperventilation without any knowledge of icp or sjo should be abandonned. recently, indomethacine has been proposed for the treatment of therapy refractory intracranial hypertension in pts suffedng from severe head injury ( ). indomethacine, a cyclo-oxygenase inhibitor, gives rise to a significant fall in cerebral blood flow by inducing cerebral vasoconstriction. therefore, its use could result in a drastic lowering of the intraeranial pressure (;cp) in pts suffering from intracranial hypertension secondary to cerebral hyperaemia and in whom the use of other cerebral vasoconstrictive drugs (barbiturates or hyperventilation) appears insufficient to control icp. for the last months, we included the use of indomethacine in our therapeutic flow chart for severe head injury management. pts revealing intracranial hypertension (icp> mmhg) and cerebral hyperaemia (sjo~> %) and in whom icp was not efficiently controlled by the combined use of hyperventilation and barbiturates were given indomethacine in a trial to control icp. a total of head injured pts received treatment for intracranial hypertension over the last months. six of them met the criteria set for the administration of indomethacine. in pts, no decrease in icp or in sjo was observed and both pts died due to therapy refractory intracranial hypertension. in the other pts, a significant fall in icp and in sjo was observed shortly after indomethacine administration. in pts we observed a catastrophic fall of sjo= even below %, indicating an extreme cerebral vasoconstriction with the possible risk of inducing cerebral ischaemia. in one of the pts, icp remained under control without further administration of indomethadne, but he died days later in multiple organ failure. the other pts, needed multiple indomethacine administrations (for pt even during consecutive days) to finally control icp. in all pts, icp was finally controlled, but only pt survived. both other pts died from systemic causes (multiple organ failure in pt, massive gut infarction in the other tat, possibly due to the systemic vasoconsttictive effects of the indomethacine administration). in conclusion, indornethacine might have a role in the treatment of intraoranial hypertension, especially when caused by cerebral hyperaemia. we observed however a poor final outcome and a threatening high incidence of systemic events (multiple organ failure, gut infarction) in those pts receiving indomethacine for icp control. therefore, indomethacine in the treatment of intracranial hypertension should be reevaluated in controlled study settings, before its routine use can be considered. untill recently, intracranial hypertension (ich) in pts suffering from severe head injury was managed in a staircase approach, with csf drainage as first therapeutic step, mannitol as second step, hyperventilation as third step, and finally, barbiturates as the last rescue step for therapy refractory ich. this staircase approach for the treatment of tch was only guided by the intracraniat pressure, and not by other parameters such as e.g. the actual state of cerebral perfusion of the concerned pt. jugular bulb oximetry provides us with the first, bedside and continuous available, estimation of cerebral perfueion. its implementation in a rigourous flow chart, based on as well icp-as jugular bulb oximetry-data might result in an altered strategy for ich management. we adopted a '~ugular bulb saturation (sjo~)-guided approach" for ich management in consecutive pts, suffering from severe head injury (gcs< ). we maintained csf drainage as first therapeutic step, but the decision for the second step was guided by sjo information. pts revealing ich and sjo=values above %, were treated with hyperventilation, and did not receive mannitol. if ich persisted, barbiturates were added as a third step. on the other hand, pts with ich and sjo= vales less than %, received mannitol administration as second step. hyperventilation and/or barbiturates were only added if ich persisted and if no cerebral hypoperfusion was discerned (sjo=> %). our objectives were to prospectively analyze this new therapeuticstrategy, as compared to the formerly used staircase approach of ich. we managed pts with ich, with an overall mortality of . % due to therapy refractory ich. all pts received standard primary care with head elevation, full sedation and normovenfilation. fer pts, csf drainage alone was sufficient to control ice of the remaining pts, pts received mannitol and pts were hyperventilated as second approach. in the third line, pts were managed with barbiturates, with mannitol and pts with hyperventilation. finally, barbiturates were used as the final rescue in pts. these results reveal a less frequent use of mannitol as only pts received mannitol, compared to the pts that would have received mannitol using the former staircase approach. hyperventilalien was used much earlier in the treatment course, as lots were already hyperventilated in the second line approach, were this was formerly exclusively reserved for the third line approach. finally, also barbiturates were used much eadier ( pts received barbiturates as third approach). we may therefore conclude to a important change in the management of ich, induced by a sjo -guided flowchart. however, future studies will have to elucidate if this new strategy for the intensive care management of severe head injury will also result in an improved outcome. obsectives: in a first series of experimental brain injury we investigated the course of brain po , icp and cerebral blood flow after traumatic brain injury (tbi), whilst accordingly there are very few data available and the mechanisms leading to secondary brain damage are poorly understood. methods: in piglets ( days old, , - kg) of either sex we produced a moderate brain injury ( , arm., msec.) using a lateral fluid percussion {fp) device. complete measurements were made before and min. after brain trauma and after , and hours including blood gases, cardiac output (htermodilution), heart rate, eeg, laser doppler flow probe (ldf} and icp values (camino), brain temp., po by a clake type oxygen electrode (licox) and coloured microspheres for regional blood flow. results: immediately after the trauma a typical "cushing"response to the icp peak up to mm hg being highly significant (before mean i mm hg, range - mm hg) could be observed: mean arterial blood pressure rose from appr. mm hg to ii mm hg for - min. in two animals this was followed by an ischemic period lasting min. accordingly icp values gradually returned to starting measures within hours; in the ischemic animals they remained at a level of about mm hg.-no secondary increase of icp could be observed, once icp dropped to starting values within hours. cerebral blood flow (ldf) fell from mean values being i before trauma to appr. zero and recovered to around . brain po started at mean values of mm hg (range - mm hg) and fell to around zero depending upon the severity of the ischemic reaction. on average values of mm hg were reached over the time course. conclusions: with our fp trauma model we can reproduce the well known "cushing"-response after brain injury; secondary icp elevations cannot be achieved, although local edema is observed. direct brain po measurement seems to be a very sensitive variable for detection of cerebral ischemia and anticipates eventually following icp elevations by far. pulmonary aspiration s,traoaras. v. sgountzos, p. agouridakis, m eforakopoulou, e. ioannidou. intensive care unit (tcu) of "kat" hospital, athens, greece ob!e=ives: the reported mortality rate after pulmonary aspiration is variable in several series. the purpose of this study was to find out the influence of preexisting disease or situation on morbidity and mortality of intensive care unit (icu) patients with pulmonary aspiration. methods: patients who were treated in icu and had pulmonary aspiration, were studied, entrance's criteria in the study, all of them obliged, were: ) suction of gastric contents from trachea during intubation, ) presense of a predisposing factor, e.g. coma. ) recent hypoxaemia or new infiltrates in xray. preexisting disease was recorded and correlated with complications and outcome. patients with glasgow coma scale , because of cerebral injury, and patients who died within days from cause other than aspiration, were excluded from the study. method of statistical analysis: chi-square test, results: one hundred forty five patients were studied. the trauma patients were and the non trauma patients . from the trauma patients, had cerebral injury and were polytreumatized without cerebral damage. from the non trauma patients, had malignant neoplasms, neurological diseases in terminal stage, old age, drug overdose, and several diseases. eighty seven from trauma patients ( %) and from non trauma patients ( %) manifested several complications (pneumonia, ards, etc), so there was no statistical difference in complications' frequency between the groups (p> , ). the severity of complications was also proportional in the groups. eighteen deaths were recorded in the trauma patients (mortality %). only deaths correlated directly or indirectly with the aspiration ( %). in non trauma patients, deaths were recorded ( %). twelve deaths were recorded in patients with neoplasms, deaths in patients with neurological diseases, deaths in aged patients, death in drug overdose patients, and death in patients with several diseases, the mortality difference in trauma and non trauma patients was statistically significant (p< , ). in patients with drug overdose the mortality was significantly lower from the other non trauma patients and the difference was statistically significant (p< , ). conclusion: the preexisting disease or situation plays a major role in the outcome of the patients with pulmonary aspiration. the mortality of patients with aspiration seems to be caused by severe preexisting situations rather, that lead to death, than from the pulmonary aspiration per se, which may be a final happening in a predetermined course. obiectives; the purpose of this study was to compare fluconazole and amfotericin-b in the treatment of fungal infections in severe trauma patients. methods: thirty five severe trauma patients who were treated in intensive care unit (icu), were studied prospectively. they all developed fungal infections, prooved with blood positive cultures and at least one of the following: fever, positive urine or bronchial secretions cultures, infiltrates in xrays. the patients were separated randomly in groups. the patients of group a ( patients) received fluconazole rag/day for days. and the patients of group ( patients) amfotericin-b rag/day for also days. compaiison's criteria were the clinical responce to treatment (fever etc), the fungal elimination (blood and other cultures), the relapses of the disease, the side effects of drug, and the outcome of the patients. as method of statistical analysis was used the chi-square test. results: nine patients from of the group a ( %), and from of the group b ( %), presented remission of fever (patients of group b had better clinical responce than patients of group a, and the difference was statistically significant, p< , ). all the patients before treatment had positive for fungi blood cultures. after days of treatment, patients of group a and none of group b had positive cultures. eight patients (from who had positive cultures of bronchial secretions before treatment) of group a. and (from ) of group . had positive cuttures of bronchial secretions after days of treatment, so positive bronchial secretions were fewer in group b than in group a, but this difference wasn't statistically significant, (p< , and p> , ): ten patients (from ) of group a and patients (from ) of group b had positive urine cultures, after days of treatment (positive urine cultures were fewer in group b than in group a and this difference was statistically significant. (p< , ). two patients of group a and none of group b had a relapse of fungal disease. in group a, no side effects were obsepced, while in group b were observed only minor side effects (small increase of serum creatinine in patients, chills and fever during infusion in patients, and hypokalemia in patients). three patients of group a and patient of group b died, because of sepsis. conclusion: amfotericin-b (even i~ short regimen of days), is superior to fluconazole in the clinical and laboratory responce and also in the relapse of fungal disease, fluconazole is superior to amfotericin-b as it has no side effects. ob!ectives: flail chest after thoracic trauma is a serious injury. it is controversial if flail chest by itself orthe concomitant intrathoracic injuries e.g. pulmonary contusion, is the cause of the reported significant morbidity and mortality. in this study we searched the influence of concomitant thoracic injuries in the course and outcome of patients with flail chest. methods: eighty five patients with flail chest after isolated chest injuries were studied, for the purpose of analysis, we separated the patients into groups, patients with isolated flail chest were included in group a, patients with flail chest and hemo-pneumothorax in group b, patients with flail chest and pulmonary contusion in group c, and patients with flail chest and hemo-pneumothorax and pulmonary contusion in group d. complications from the chest, duration of mechanical ventilation and mortality were compared in the groups. statistical comparison of results belween groups was made using chi-square and t-studend tests. results: the patients were . all patients received mechanical ventilation, twenty eight patients were ihcluded in group a, in group b, in group c. and in group d. seventy three patients manifested complications from the chest, especially pulmonary infections. there was no statistical difference among the groups as to number of complications ( twenty four patients had chest complications in group a, in group b, in group c, and in group d. p> , }. the duration of mechanical ventilation was not statistically different among the groups (the mean duration was , days in group a, , in group b, , in group c, and , in group d, p> , ). there was also no statistical difference in mortality among the groups (six patients died in group a. in group b, in group c, and in group d, p> , ). conclusion: flail chest by itself is a serious thoracic damage with many complications, regardless of the presense of other thoracic injuries, which don't contribute to greater morbidity and mortality. the present study investigated the correlation between blood lactate mortality and organ failure in trauma patients admitting between december , and july , in the icu. road traffic accidents were the most common cause of trauma in this studded population. brain damage was the main cause of mortality .nevertheless, of patients died from sepsis and multiple organ failure without significant brain damage and these deaths were potentially preventable. respiratory failure was the most common complication and was developed in ( %) of survivors and in ( %) of non survivors .we noted low fncidence of renal failure may be do to the early and aggressive ittv'asive hemodynamic monitoring and cardiopulmonary support. as part of our routine case protocol serial blood lactate levels were measured in each patient at least times a day until the valses returned within the normal range or until death. we analysed the blood lactate levels on admission, the highest value and the number of days until the first normal value (<l.smeq/i). initial lactate and highest lactate levels were significantly higher in patients with than without organ failure.( . vs . , . vs . meq/l, p< . )the duration of hyperlactemia also was higher in the patients with organ complications. ( . vs . days, p< . ). both initial lactate and highest lactate levels were higher in the non survivors than in the survivors.( . vs . , . vs . meq/l, p< . ) the present study demonstrated that not only the degree but also the duration of hyperlactemia can be related to the development of posttraumatic complications. serial blood lactate measurements are reliable indicators of morbidity and mortality following trauma. s current evidence suggest that peep only affects intracrenisl pressure (zcp)when it interferes with systemic arterial pressure, although the effects of peep over cerebral oxygenation remains unknown. objective: determine the effects of peep over icp and cerebral metabolism measured by sj , kjdo and ceo in severe head injured patients. meterial ~ methgds: patients with glasgow coma scale l at arrival, with difusse brain injury in the first gt, according to marshall criteria,lop and jo monitored, under analgesia and sedation, normoventilated with zeep, without mannitol treatment in the previous hours, normal x ray chest and within the first hours from injury, were considered candidates. peep value where increased fro~ zero to cmh , in three different steps, each one with min of duration. all date were analized on line, pmax p'p ..... p.._, from the ventilator, systemlc haemodynem]c data, cerebra perfuslon pressure (cpp), icp and sjo , in the case of hemodynamic deterioration, during the study, ppc ommhg, extra-volume were administered. if persistence, dopamine were begun or increased dosage. if no good response were obtained, patients were retired from the study. results. patients were candidates, of them were exc;uded due to haemodynamic instability, k total of completed all steps and were e~amined, men and women, age ! . yrs. at hospite; arrival, glasgow were < in patients, and > in the rest . patients mmhg at the beginning. zeep ob/ectives. critically ill patients are transpoded to an intensive care unit(icu), under conditions, which have not been systematically evaluated. therefore, we set suite investigate transportation and admission condition of these patients to our department. methods. we studied patients( females), aged (mean-..+-sd) . _ . yrs, which were consecutively (from august to march ) admitted to the icu, through the greek national emergency transporta~on service. apache ii severity score upon admission was . -+ . (range - ). the following data were evaluated: ) number of medical departments, where health care was provided until final admission to the icu, ) ambulance transportation conditions, ) catheters and tubes inserted before admission, ) vital signs upon admission ) information provided by referring physician (scored on a to scale: history, electrocardiogram, chest x-ray, laboratory data, drug therapy already administered), ) comparison of the state of the patient described by referring physicians, to the actual state u pen admission. resu/ts. one to four medical departments had provided health care before the palient was admitted the icu ( : . %, : . %, : . %, : %). thirty/ ( . %) patients were escorted by a physician. twenty-six/ ( . %) were transported on oxyge n, fio (mean__.sd): -+ %, pao : . -+ . mmhg. five of the remaining , for whom no oxygen was provided, had pao : . -+ mmhg. twelve/ ( . %) were intubated and ventilated during transportation. thirtyfour/ had a peripheral venous line, / had an arterial line, / had a nasogastdc tube, / had a urinary catheter. eleven/ were sedated and / were paralysed. three/ were on inotropes. vital signs upon admission were: arterial blood pressure, systolic . -+ mmhg, diastolic -+ mmhg, heart rate -+ bpm, temperature . -+ cc. patient information score was --. . . the actual state upon admission was found substantially different, as compared to the description of the referring physician, in / ( . %) patients. conclusions. we conclude that several aspects of the greek national emergency transportation service to an icu should be reevaluated and further improved, i. e. ventilatory support, adequacy of information provided and accuracy of prior description of the patient's state. a new perspective must be applied for critically ill patients transportation since . % of the patients were evaluated and treated in more than one, medical departments, mostly primary care, before they were finally admitted to our icu. dclhb is a human derived hemoglobin molecule that has been cross-linked to stabilize and permit heat pasteurization to remove residual proteins and inactivate viruses. dclhb is mixed with a lactated electrolyte solution to yield a total hemoglobin concentration of log/dl objective: to present an overview of four recently completed clinical safety studies of dclhb in the u.s. and europe, and to discuss the properties, actions and potential indications for dclhb. method: patient populations in the four studies included males and females ranging in age from to years. dosing ranged from mglkg to mg/kg. the controlled randomized safety studies were conducted in chronic renal failure patients, surgical patients undergoing total hip replacement or abdominal aorta repair and in hemorrhagic hypovolemic shock patients. these very diverse patient populations allowed safety evaluation of the product in patients who were generally elderly, often hypertensive with some degree of cardiovascular disease, and receiving medications for treatment of other conditions. results: over patients received dclhb in the four:studies. no product related sarious adverse events occurred during the clinical trials. conclusion: results from phase itll safety studies of dclhb in patients undergoing chronic renal dialysis, abdominal aorta repair, or total hip replacement and in patients in hemorrhagic hypovolemic shock, indicate that the product was well tolerated in these distinct populations. although these studies were designed to evaluate safety, the data suggest clinical benefit. follow-up efficacy trials are indicated. prehospital emergency services represent the extension of emergency care into the community and constitutes the manpower, communications, transportations and facilities used to provide care for patients outside hospital. one of the main points of the system is how to decide the hospitalization of patients and what kind of facilities to provide : emergency medical service, fire brigade, locat general praclitionner or ambulance officers. objectives : to realize guidelines for using the prehospital emergency medical service in case of patient'calls outside hospital. methods : from st june to july , all the calls for emergency care were analysed using a questionnaire of items (origin of the call, responses to the questions of an emergency practitionner, kind of emergency service provided and the issue of the patient). after taking account of the appropriatness of the decision, statistical method used was a logistic regression. results : calls were analysed. the criteria, for prehospital emergency medical service using, given by the logistic regression were as following : existence of a call for emergency, thoracic pain, dyspnea, seizures, cyanosis, drug intoxication, fall of the patient, fracture, age, the state of consciousness and the neurologic reactivity. the minimal and maximal predictive values of the model given by the logistic regression are respectively % and %. the performance of the model is %. conclusion : it seems possible to help medical decision of emergency medicine by using only some easy criteria and a predictive model. (italy) objective: to evaluate the incidence of blunt carotideal injury (bci) in patients admitted to our icu after head injury. methods: we reviewed the medical records of all patients diagnosed to have a bci. at admission, the severity of trauma was assessed either with glasgow coma scale (gcs) and with ct scan. bci was demostrated by doppler ultrasography (us) and by angiography (ang). results:since may to april , patients were admitted to our icu with bci ( m, f, age + ). a history of direct trauma was present in patients. admission gcs was in all patients, and was associated with hemiparesis in of them; the last became paretic hours thereafter. two patients had concomitant injuries (a homoiateral clavicular and a controlateral zygomatic fracture, respectively). the initial ct scan was negative in every patient, and showed signs of ischemia after a variable timespan ( - days) after the onset of the symptoms. the bci was diagnosed with us and ang, which demonstrated a thrombosis of the internal carotid artery (ic). in two patients, an intimai dissection was also present. three patients were treated with heparin associated with antiaggregating agents and were discharged alive. the last patient was referred to our icu after the development of a massive hemispheric infarction, and died three days after the admission. at necropsy, the ic thrombosis was associated to an extensive homolateral extra and intracranial venous thrombosis. conclusions:the presence of focal neurological signs despite a negative ct scan should address the diagnosis toward a bci, thus implementing the diagnostic workup with us and/or ang. tab i: distribution of l~tients (%) in the groups the outcome were monitorett results were sabmitted to statistical analysis using a continence table x in z test. res.cl~s: of patients were submitted to thrombolysts and died. the higher incidence of bracb, ar~lhmias (ii degree gg p t e and av block. i degree av block. avsb . <ii. sinus arrest) that requited the insertion of avsc . <cl temporar~ pace-maker was recorded in group a b vs c . ns in % of the cas ~. the rapid recognition of life tab li:;~ test. threatening conditions suggests the monitoring of v r-lead r b' in the course of inferior ami. the authors report their own expirience in application of ringer lact.(rl)and , %nacl/ %dextran . methods:in polytraumatized patients with developed hae morrhagic shock,injures of the chest(qg)and abdomen(q ) prevalid.replacement of the volume loss egan in institutions of general medicine,frequently by rl and dextran or haemaccel.after receiving necessary medical aid,polytraumatized patients wer transported to mma by helicopter,continuing replacing of circulation volume by the same solution. results:average quantities of the solution dministered ~o the injured wer~ - ml.a group of the inoured which,after the admission to mma was resuscitated by adml nistration of the , %nacl/ %dextran @(groupii)( -sml/kg observed to the final surgical management,had statistically higher map(increase of % in relation to admission), cvp(average increase of , cmh~o),diuresis(averagely omi after min.),better gas ~nalyses and acid-base status in relation to the group which was administered only rl(groupi)(increase of the map of q %,average increase c~ of cvp , cmh and average diuresis oml after omin). total quantity of the administered solutions was significantly smaller in the groupii( ml: ml).the only ob served complication was hyperhatr~f~a::and~moderat~hyper osmolerity of plasma which disappeared within hours. the quantity of replaced blodd was considerably smaller in the groupii(qooofnl: ooml).in the group i interstitial pulmonary oedema was observed in two patients(qo%),while: in the group ii no complication was observed.coagulation i disorder and hypotension were not recorded because of the fast infusion of hypertonic/hyperoncotic solution in the groupil as the infusion of , %nacl/ %dextran lasted minutes. w.scherzer(l~,k.lechner( ),r.simon( ). ll)dept.anaesthesiology,trauma hospital,vienna-meidlin !( )neurotraum.rehabilitation center,vienna-meidling both austrian workers'compensation board,vienna,austria what we usually call"unconcious" means only that the patient is not able to interact in any kind of way.experiences in intensive care medicine (robinson, ) ,in general anaesthesia (bennet, ) and with evoked potentials show,that unconcious patients are not automatically unhble to process and recall information.this implicates a challenge to start the efforts to restore the traumatica-!ly desintegrated brain function as early as possible in the acute phase ia (zieger, ) .we present a method to ~repare the patient for the rehabilitation goals of the postacute phase ib,the phase of stabilisation ii and of rehabilitation iii within one concept. to achieve sensory stimulation in phase la we use: attempt at some kind of dialogue by speaking to and tou-ching the patient,to make him experience his body limits, ~acio-oral therapy by ice application,tast and smell pro vocations and trials of feeding,early adaption to circadian rhythm and guiding the patient in every-day-life-ac-tivities e.g.:in the brushing of teeth,washing etc. to achieve motor stimulation and orientation in terms of ~-ace,time and gravity in phase la we use: avoidance of perceptual impairment as produced by air-:sack-beds or habituation to supine position,using method~ according to affolter( ) ,basal stimulation (bienstein, ) , bobath-therapy( ) and facilitation of a physiological moving pattern(pnf)according to knott( ) . conclusions: by integrating all these measures in the ~herapy and nursing even in the acute phase la one prei ares the comatose patient for multisensory stimulation nd motor training and all other rehabilitation activities in the following phases of therapy. s objectives." measurement of cardiac output (co) and stroke volume (sv) requires insertion of a central venous catheter and is associated with a considerable risk for complications. non-invasive methods for determination of hemodynamic parameters have been introduced recently. one of these methods is the aortic modelflow program, which provides co and sv continously using a three-element windkessel model. the aim of the study was to evaluate the accuracy of the aortic modelflow program in critically ill patients. methods: patients (mean age: ) admitted to the emergency department after cardiopuimonary resuscitation (n=ll) and for myocardial infaction (n= ), acute congestive heart failure (n= ) and anaphylactic shock (n=l) were included to the study protocol. after stabilization all patients received a swan-ganz catheter (baxter~; edwards swan-g-anz) via a central vein. co and sv were measured by the use of a cardiac output catheter and injection of rrd ice-cold glucose % non-invasive cardiac output measurement was done by using the continuous cardiac output software package modelflow (tno; portapres| results: overall, paired measurements were used for the evaluation of the accuracy of non-invasive obstained sv and co. mean values, standard deviation and range of co and sv evaluated by invasive and non-invasive methods are summarized in the aortic modelflow provides reliable hemodynamic data in critically ill patients. it may be a useful alternative due to its non-invasive approach and continous measurement. objectives: to determine the feasability and accuracy of a rapid urine screening test (triage tm, merck-diagnostika) in an emergency department. methods: prospective analysis of the triage tm testkit (tt) in patients admitted because of suspected drug abuse during an observational period of months. the tt is a eompetitve immunoassay which gives qualitative results within i minutes for methadone, benzodiazepines, cocaine, amphetamine, opiates, barbiturates and cannabis. urine samples were analysed with the tt and compared to the results of a enzyme-lihked tmmuno-assay (el.a) in our labratory (gold standard). results: during the study patients were enrolled, in of these patients substance abuse was proven by tt and verified by eia. we recorded no false positive or false negative results for benzodiazepines, barbiturates, opiates, cocaine and cannabis. two results were false positive and one false negative for methadone; one result was false negative for amphetamines. the triage-testldt had an overall sensitivity of . and specificity of . . conclusions: the triage tm testkit seems to be a a useful rapid test device in addition to quantitative tests for drugs of abuse in an emergency department. objectives: the purpose of this study was to evaluate the influence of several factors of the renin-angiotensin-aldosterone system on blood pressure response in patients with hypertensive crises. methods: patients with systolic blood pressure > rorohg and diastolic blood pressure > nunllg were included into the study. prior to treatment blood samples for determination of plasma renin activity (pra), angiotensin converting enzyme (ace), angiotensin ii (ang ii) and aldosterone (aldo) were collected. all patients received rog enalaprilat intravenously. success of treatroent was defined as a reduction of systolic blood pressure below mmi-ig and diastolic blood pressure below mmi-ig within minutes after start of treatment. results: patients were included in our study, ( %) patients responded successfully to treatment. mean arterial pressure decreased in responders by . mmhg and in non-respenders by . mmhg (p< . ). responders and non-respenders differed signii'icantly concerning pra (p= . ), ace (p= . ) and ang ii (p= . ). . . the extent of blood pressure reduction correlated positively with the pretreatment pra and ang ii concentrations (correlation coefficient for pra: r= . ; ang ii: r= . ). conclusion: our data confirm that in patients with hypertensive crises blood pressure response to ace inhibition is mainly determined by circulatory pra, ace and ang ii. as the extent of blood pressure reduction correlates with pra, ace-inhibitors in patients with suspected high renin status cannot be recommended, as excessive blood pressure reduction, which carries a considerable risk for further organ damage, may occur. f. staikowsky, n. grillon, f.pevirieri, c.jedrecy, c. zanker, f. michard, a. haft medical emergency department. hospital bichat, paris epidemiology of acute intentional self medications-poisoning (smp) in france is especially known by data of poison control centei,s and intensive care units (icu). the purpose of this study is pro~,ided characteristics of this problem in a med for adults. method: july to june , files of patients consulting to the ed for smp have been retrospectively analyzed. results: patients, women and men, . + years old (range - ) have been admitted for episodes of smp ( % of all consultations) whose relapses during the period of study. psychiatric disorders, drug addiction or hiv patients was found for respectively . %, . % and , % of patients. the interval of time between the ingestion and emergency consultation was noted for % of smp ( + min, ranges - ). the involved products name was known in totality in % of cases with an average number by episode of . + drugs (ranges - ). the most often, ( %) or ( %) different products were interfered. the nonbarbiturate psychotropic drugs accounted for . % of the products (benzodiazepines %, antidepressants . %, neuroleptics %, carbamates . %, imidazopyridines . %, cyclqpyrrol nes . %). analgesics and nonsteroidal antiinflammatories represented . % of all drugs, anticonvulsants . %, cardiovascular drugs %, antiinfective agents . %, drugs against cough . %, muscle relaxants . % and antihistamines h . %. the benzodiaz pines were present in episodes, alone in episodes. in . % of cases, there was a simultaneous intoxication with alcohol. the processing consisted of gastric lavage in . % of cases, activated charcoal in . % of cases, flumazenil in . % of cases, naloxone and acetylcysteine in . % of cases; orotracheal intubation was performed in patients. admission in hospital was effective for patients, in medical ward (n = ), psychiatry (n = ) or icu (n = ); no fatal case was recorded. conelusion: smp to ed are often benign. the benzodiaz pines are the most often incriminated but the new anxiolytics and hypnotics (imidazopyridines and cyclopyrrolones) take a growing place. the latsion burn center of athens. its planning constructive and functional refinements j. ioannovich, a. petalas-vourekus, d~ serbetis, h. carsin a bed burns unit is under construction following a donation to the general hospital of athens. the plan of the unit, covering a surface of approximately . m is based on the principle of three identical bed satelites which may function totally independent from each other. in the center of the unit the common facilities are installed, like operation theatres, storage rooms etc. this new modification in the plan of a burn unit is presented in this paper. the advantages from the fucntional, administrative and medical point of view are discussed. tiffs anisotropic conduodon could favour the ocenrence of a circular movement of the impulse that leads to tachyeardias by reentry. purposes of this work were to study, with the help of epicardial mapping, the influence of a trieyclie antidepressant, clomipramine (c), on the conduction velocity longitudinal (vl) and transverse (vt) to myocardial fiber orientation and on anisotropy (a = ratio vl/vt), and their modificutions by the sodium bicarbonate ( ). method: a plaque of electrodes, positioned on the left anterior ventricular wall of anesthetized dogs, allowed to deliver, thanks to central electrodes, programmed electrical stimulations inducing vcuttienlar complexes, and to collect them. each entailed unipolar dectrogram was processed by a computer system that drew the isochrones and a map of activation allowing the calculation of v. the c was infused ( . mg/kg/min iv) during rain; at t , dogs received the b until the retuni of qrs to its initial value fro). a lengthening of qrs of at least % of its value at to was demanded before the administration of b. results: dog was excluded because of an.~nsufficient prolongation of qrs before the administration of b. all values (map : mean arterial pressure, i-ir : heart rate, qrs andqt intervals, v) differed significatively ( < . ) compared to values control fro)except qrs at t . the b ( + ml/kg; ranges . and . ml/kg) modified no studied dements outside of the ( }rs. to ti t t t t t a , + , , + , , + , , + , , + , , + , , +- ,~ conclusion : the c slowed v l and v t without modify the anisotropy. the b did not modify the v of~conduction while the qrs prolongation was corrected. the c acts as a class i antiarrythmie drug on the inward sodium current during the phase of action potential; the gap junctions have shown to be important in the conduction and an action on the gap junctions such as a modulation of the junctional resistivity, can not be rule out. is the doctor a heroe ? p. t.schies~.he, t. bauer, m. seyr dept. of anaesthesiology and intensive care, aokh krems, austria objectives: helicopter emergency services (hes) are getting popular more and more. the results concerning outcome are encouraging. however, some recent accidents with dead or badly wounded hescrew-members have shown the relatively high risk for the crews. therefore we were interested to eval ate the motivation of physicians to participate in a hes. this survey was designed to investigate current concerns about safety and motivation of doctors on emergency call. methods: a questionnaire was sent to doctors of the austrian emergency system. the survey consisted of multiple choice questions and subjective scoring tables from (--full agreement) to (=disagreement). overall, "/. of the active emergency physicians participated in the survey. results: . % of the doctors assume the system is basically safe, experienced doctors tended to have less trust in safety. only % would not hesitate to go into action by dark. . % stdctly refuse night flights to accidents outdoors. although defibrillations are assumed to be safe dudng flight, only % would do it. . % of the doctors would rather stop flying. the most common reasons for ,uitting were wish of family and fear of an accident. . % conclusioq: short transportation times help to avoid trauma related stress, pain and shock-induced organ complications. therefore the physiologic and economic advantages of hes are undebatable. however, the survey data indicate a considerable concern about safety of the medical personal in a hes. crash landings within less than years with deadcases and badly wounded crew members in a small country like austda make desire for safe flying conditions understandable. obiectives: to evaluate the clinical usefulness of trachlight. methods: trachlight is a new device facilitating endotracheal intubation. a stylet with a lightprobe is inserted into the endotracheal tube. intubation is guided by the light glowing through the neck tissues, thus rendering direct laryngoscopy unnecessary. intubation using trachlight was studied in patients (age - years). the indication for intubation was elective surgery in patients (asa i-ii) and emergency intubation in patients. in the elective patients, anaesthesia was induced with thiopentone supplemented with fentanyl, and intubation was facilitated with vecuronium. the cause for intubation in the emergency patients was dyspnea in , cardiac arrest in , trauma in, and unconsciousness due to drug overdose or seizures in patients. intubation was facilitated with medication in patients. results: of the elective patients, ( %) were successfully intubated. six patients ( %) needed two attempts before successful intubation. the duration of intubation exceeded seconds in patients ( %). of the emergency patients, ( %) were successfully intubated. six patients ( %) needed two attempts, and the duration of intubation was more than seconds in patients ( %). in % of all patients, intubation was assessed as easy. no or insufficient glow, prolonging intubation or necessitating two attempts, was noted in patients ( %). oesophageal intubation occurred in patients. conclusions: trachlight may be a valuable adjunct for intubation in varoius settings provided that adequate training is provided. a learning curve was found to exist. objectives: to compare enoxaparin and standard heparin in cavhd and calculate the value of laboratory controls in the treaanent. patients and methods: twenty patients needing dialysis for acute renal failure participated in the study. the main exclusion criteria were massive bleeding or a thrombocyte level < x e /i. in each treatment the same type (av- , fresenius ag, germany) of a polysulfone capillary haemofilter was used. the study scheme consisted of two consecutive four-day cavhd treatments, one course for each type of heparin. the order of heparin administration was counterbalanced between patients. the standard heparin was given as a continuous infusion aiming at an activated coagulation time between and s. the initial enoxaparin dose was rag every :th hour intravenously, but was modified by any signs of coagulation in the dialysis blood lines or bleeding complications. results: the dialysis treatment was adequate in both treatment modes, with mean blood urea levels . and . mmol/l respectively (ns). the bleeding complications were moderate and similar in both treatment modes. the mean life-span of haemofilter using enoxaparin as an anticoagulant was some longer than using heparin ( . + . h versus . + h, ns). the mean aptt-levcl during heparin treatment was s and during enoxaparin treatment s (ref. - s). the mean daily dose of heparin was nag, that of enoxaparin lg mg. the mean anti-xa activities were . u/mi and . u/mi, respectively, reflecting a better bioavallability of enoxaparin. conclusions: both anticoagniation modes were equally effective and well tolerated. the amount of enoxaparin needed for a proper anticoagulation was, however, less than half of that of standard heparin. the changes in aptt level were too slight to make its use possible in controliing the dose of enoxaparin. the use of enoxaparin seems to be rather safe in cavhd even without laboratory controls. the adv~ucea in the management of computerized data of an intensive care unit have been petalled to the clinical advauces and the increasing sophistication of methods of diagnosis fop the clinical application an therapy. this has led our unit to design and develop a computational system called timbu which is used to help physicians assist patients. among its various uses, this system has a software for the hemodynsmic control of a critic patient. this program was carried out to get as fast as possible the hemodynamic data of the patients in an intensive care unit. as an example, we can mention that when we load data obtained through direct measurement from the monitors and the lab, the program calculates parameters that guide, intelligently, to the diagnosis and therapeutic behaviour of the hemodynamic problem through screen messages. the validation of this program in the unit of intensive care has demonstrated that its use allows a more efficient handling of the patient with serious hemodynamics and respiratory disorders. ohieetlve: traema is a heterogeneotm 'disease' that ecatr~ a~"o~s all age ~oupe with v~ying degrees of severity. this imerogeneity has made the di~e, trmma, diflkaflt to r the ehn of this stady wa~ to assr the fitaen of saps in ibis popeleties. methode: in order to compute the ~ probability, a model derived from logistic regression w~ developed. meam'e of calibration (goodaess-of-fit stetislj.r and di~'riminafion (roc ou~e) were adopted in developmm~ and validetlon set randomly taken from a database of pts eeeseemivety admitted in icu (arohidia). ~ witho= salm, p~ yom~ am is yam, with los ~horter thma hotam wore exr fa'om thi~ mmly~ir thi~ model v~s then evahmed on the ~per ~mbgro~ (i.e., trmma pts). if'it did t~t fit the data well ~, new model wm developed rer the logit only on trm=~apm. reims: data were availabte for pts during aperiod of three .y~m , treama pts were . %), teats of calibration iadioaled probability model did mot provide m adequate refle~on of the mortality ezperieace in pm with ireutae, being the observed mortality lower flma the expected (figm'o). a aew model was then variable. this oastomized model fit~ the de~t of trmara pts very well (g =- a p> . ; roc = , ). the di:lferencea between the two modele were evident. conclusion: this ltudy shows that mortality in iramna pts is over wcfe~d when ~se~ed by menm of saps. however the r mode! meets high standmcd in terms of calibration mid dil~'iminat'~o~ ']"he advaatage of ~imd models meaas the colleotion of the ~ set of variables for all pm admitted in icu e~einat the ase of diasma specific ~oring syatex~. ("sl"): effects on cardiovascular and hemostasis systems (cvs, hss) a.oborin~ph, ~.~yndiuk~ph, b.kondratsky ~pt. of'""su~gery and transfusiology, research institute of hematology, lvov, ukraine objectives: great interest has been shown recently in the use of hoss for the initial resuscitation of hypovolemic shock. methods: the study was carried out in dogs -~h hs was induced by jet momentary hemorrhage (h) from a. femoralls (the bloodloss volume made . + . ml/kg). the treatment was begun after .u+o. hrs of h. "sl", created on the basis of-sorblt and natrium lactate ( mosm/l) was injected into v. femofalls at the dose of io. ml/kg. results: it is established that before treatmen-~rterial blood and central venous pressures (abp, cvp) diminished to . mm hg and - . + . cm h (p .o ), while heart rate (hr)-increased to . + . per min (p<.o ). by this the indices of ~latelet counts (pic) and plasma fibrinogen (pf) lowered by . % (p<.i) and . % (p~. ), while fibrin degradation products (fdp) enlarged by . % (p~ . ). after - min of treatment termination abp and cvp increased to . + . mmhg and . +o. cm h (p<.o ), and ~[r diminished to t . + . per min (p>. ). at the same time the indtces of pic and pf enlarged by . % and . % (p>.i), while fdp diminished by . % (p>.i). one of dogs survived. life duration of the other dogs was . + . hrs. conclusions: the obtained data are ~he evidence of normalizing influence of "sl" on cvs and hss, and allow to recommend it as a mean of initial resuscitation of hs in clinic. oblectives: we prospectively studied icu patients with severe head injury (hi), which cerebral lesions monitorized with sjo through opljcal fiber and the cerebral flux with tcd. methods: since january until june , we collected ht admitted to the icu, and of them monitorized with optical fiber in the right jugular bulb and tcd. all patients needed mechanical ventilation related to gcs <__ , with ct in admission (classifing lesions according to marshall and al.) . we related the final results to the evolution of sjo and tcd, with other monitorizing methods like gcs, ct and icp. ~sults: conclusions: in patients with gcs _< , sjo is useful to evaluate the evolution towards vegetative state, still more in cases with ct type ii in admission and higher apache ill. elevation of icp implies an evolutive nsk to brain death and data of tcd is a good indicator of brain death, the complete monitorization of these patients can improve the therapeutic control of this neurologic problem, , ( m, f) , (m. age: + years), divided in two groups (a and b) under specific criteria(tremor and/or fever during admission in i.c.u., or not). the injury severity score was > in all studied patients. tbe group a ( m, ") had no tremor and/or fever on admisskm, while em group b (tin, the above criteria were ix)sitive. bhx~d samplings were taken - hours after accident and - rain. after admisskm in i.c.u. micro-eli~ method was used for measuring cytokinc-levcls. statistic analysis was performed by studcnt-t test. as control group, healthy people were examined. _resu!_ts-il-lct, il-ii~, il- and tnf-tt levels were similar to control group levels in both groups a and b. i!,- and g-csf levels were found increased in both groups (p< jxjl), while il- levels were statistically significant comparing to group a. in con_tin_skin, during immediate post raumatic period,proinflamatory cylokines il-i~, il-i~ and tnf.-ct, produced in an earlier stage than ,. , cannot be detected,whereas .- was increased significantly, especially in group b. g-csf was fimnd in increawal levels in both gr(mps, without statistically significant difference between gnmps a and i|. objectives-l~valantc proteolitic activity, disorders in" eariy, period after combined trauma and p(~.ssibilit, i' of their correction by injection of proteo[ysis inhibitors contrycal and s-fto~:nracil in combination with driving an isotonic snlu~ion of sodlum chloride and polig[ucine. methods: biochemicai studies of proteolitic activity in dogs with limited deep burn and acute bloodloss, . result:s: in case of deep % burn, cornplicated by bloodshed the of blood grows at - times. it; is the restdt of the pancreas glandischemi demage, caused by the centralised circulation of blood and intensifies the deviations of haemodiaamics and albumin exchange. the degree of endogene intoxication by mean mofecular peptides which are the products of albumin decay reses to %, and % in hours. in hours after the trauma the-process is accompanied b ! , % lower inhibitory activity of blood, where as at the peak of the trauma it was , ~ higher. that proves the nnfavuurahle process of the shock in case a combined trauma. conclusion: the vein injection of 'proteolysis inhihitotz cnntrycal and -fforuraei[ in cumbination with driving an isotonic solution of sodium chloride and p.dligh]cine to refill lhe loss of blood helps to lower at times the profeolitic activity of blood. but it still remains above the initial level. the degree of endogene intoxication lowers at times; [ emodinamics aml albumin exchange stahilised. objectives: nimodipine, a known calcium antagonist, has been shown to dispose a beneficial effect on patients with subarachnoid hemorrhage, but its efficacy on traumatic or spontaneous intracerebral hematoma has not been justified. therefore, we studied the effect of nimodipine on the histopathological changes following an experimental intracerebral haematoma in rabbits. methods: twenty-three new zealand albin rabbits of both sexes, weighing - , kgr and at age of - months were anesthetized and a small burr hold in the left parietal aerea was carried out under aseptic conditions. the dura was opened and . ml (this volume assuring a normal incranial pressure after kaufman ) of autologous blood was injected into a depth of mm via a needle of . mm bore. the wound was closed and the animals were left to recover. nimodipine, of , mg/kgr of by weight per day was given via a nasogastric tube to fifteen animals for a period of time of fifteen days (group b). six rabbits were given water and served as control (group a). both groups of animals weie sacrified on the fifteenth day, their brains were removed and immersed into % formalin solution. tissue sections of ~ were embedded into paraphin and stained with haematoxyline and eosin, mason and gfap stain for gliac cells. results: two animals died after the surgical procedure, because they developed large intracerebral bematoma. no animal developed neurological deficit except one of group a which manifested a right side hemiparesis. the results of the bistopathological changes are the following: i) the mean -+ sd diameter of the lesions in the group a was --. ~t while that of group b was + ~t (p< , ) ii) secondary ischaemic neural tissue changes, characterized by the extravasatlon of red cells, the presence of haemosiderin-containing macrophages and signs of low grade inflammation zpredominated in the specimens of group a and were totaly absent from those of group b. iii) a ring of gliac hyperplasia and a low grade local fibrosis was found, encircling the lesions in the specimens of group a in contrast to those of group b. conclusions: nimodipine when administered in rabbits following the development of a non increasing the icp experimental intracerebral haematoma, prevents the extention and the severity of the lesion. objectives: to study the efficacy and side effects of adding intramuscular clonidine (clophelinum) to analgesic regimen in early management of patients with serious burn injury. methods: pts with - % bsa second to third degree flame burns (respiratory tact injury excluded) to yrs of age were randomised to study (n= ) and control (n= ) groups. burn shock was treated with hypertonic saline -bicarbonate solutions ( mmol/l na +) ml/kg/%bsa for the first hours and ml/kg/%bsa for second day. analgesia in control group for the first hours was provided by regular hourly intramuscular administration of mg of morphine sulphate and mg of analgesic -antipyretic analgin with mg of diphenhydramine (dimedrol). from the rd day regular administration of morphine was finished. in the study group ixg of clonidine was added -hourly for hours and dose of morphine halved. vas, verbal rating scale for sedation (vrs, - ), sleeping time, spo , hr, bp, diuresis, vomiting and other complications were comparatively evaluated during patients' stay in icu. results: addition of ~g of intramuscular clonidine daily allowed to achieve better analgesia and sedation with halved consumption of morphine. mean vrs in study group for the first days was . - . vs . - . in control group with twice longer sleeping time. there was significantly less tachycardia in study group; dynamics of bp for the first hours did not differ considerably; later, there, was tendency for hypotension in study group without adverse effects on diuresis or other indices of tissue perfusion. because of high incidence of chronic ethanol abuse among study population pts of control group suffered from psychomotor agitation or delirium, probably as a sign of alcohol withdrawal syndrome (aws). this made regular evaluation of vas impossible. in the study group only pt showed sign of aws. mean vas score was in . - . range for first postburn days. pts appeared excessively drowsy due to clonidine, but it had no adverse effect on their overall clinical course. mean spo values in study group were in - % range, among controls - %; vomiting was absent in. cionidine group vs cases among controls conclusions: clonidine could be a valuable addition to analgesic -sedative regimen in burns, especially for prevention of aws and deserves further study in this regard. hemodialysis -hemoflltration modifications and/or intratracheal gas insuflation have been recently used for blood gas exchange in several models of respiratory failure. objectives: evaluate the combination of cavh-m and igi for respiratory support in experimental acute lung injury. methods: five mongrel dogs ( -+ kgr) were mechanically ventilated inroom air, paralysed, heparinized, connected with a cavh-m system (diafilter- polysulphone membrane) and remained stable for one hour (pao~= . • peco = -+ mmhg, ph= . -+ . , bp= -+ mmhg and pap= -+ mmhg). all was induced two hours after oleic acid infusion ( . ml/kgr) into the pulmonary artery (poo~= . _+ -p< . , paco~- . _+ -p< . , ph= . -+ . -p< . , bp= -+ -p=ns, and pap= _+ -p< . ). fio % for the next minutes did not significantly altered the b ood gas abnormalities. afterwards, pure oxygen applied simultaneously a) through the inlet of the filtrate's compartment of the hemofilter ( l/min) while filtrate and gas were removed from the outlet port (bypass flow ml/min) b) through a thin intratracheal catheter positioned cm above the carina ( l/min). the fio given through the ventilator readjusted to %. results replacement fluids/filtrate during the next four hours were not exceed . l/hour, whilst the blood gases and pressures were improved as follow: cavh-inlet:pao.= . objective. to compare the changes in humoral immunity in trauma patients following massive transfusion of autologous and homologous blood. methods. we studied randomised clinical groups of patients each containing patients with trauma and operation of large arterial vessels. the amount of autologous or homologous blood transfused to the patients was exceeding ml, while the patients in the control group did not recieve blood or blood products. results. we recorded most pronounced and characteristic changes on the -st and on the -th day in the group of patients recieving homologous blood transfusion, i.e. decreased amount of igg,iga,igm,c and c fractions of the complement system, haptoglobin and significant and sustained rise of circulating immune complexes up to the end of the study period. in the control group of patients the decrease was weaker and lasted only during the -st post-operative day; the dynamics of the circulating immune complexes level were almost the same as in the first group of patients. in the group of patients recieving autologous blood transfusion, the parameter values did not change significantly from preexisting levels after the -st day, while on the -th and on the -th day showed a tendency towards aslight rise. conclusions. autologous blood has a favourable effect upon humoral immunity and should be the transfusion medium of choice in cases where autologous blood reinfusion is technically possible. ivan petkov, m.d., rumen farashev, m.d. and dimitar terziiski, m. d. medicine, military medical academy, g. sofiiski str., sofia, bulgaria objective. the amount of blood lost during trauma and operation could hardly be forseen and donor blood supplies are not always available in sufficient amounts. rare blood group types and/or unexpected haemorrhage pose a great challenge to the transfusion therapy and the methods of intraoperative autologous blood transfusion. methods. we report a case of a -year old male patient with extremely massive intraabdominal haemorrhage ( m( blood loss ) during an abdominal aorta reconstruction following a traumatic injury of the abdominal aorta. we achieved a successful reinfusion of ml of autologous blood using an original autotransfusion system developed by us ( pat. no / . . ) . results and conclusions. the autotogous blood in the case reported here was the only and the most suitable transfusion medium for the rapid intraoperative compensation of the acute haemorrhage and the favourable outcome of the patient. the post-operative period was smooth and no significant disorders in the clinical course as well as in the laboratory tests ( morphological,biochemical,coagulation and immunological) were recorded. there were no complications during the postoperative period despite the fact that the amount of blood reinfused to the patient was slightly exceeding his own volume of circulating blood. objective. the haemoglobin concentration and the perfusion pressure value could not be the only criteria for the early signs of tissue and organ dysfunction. because of this, we employed the extensive monitoring of oxygen transport during severe trauma in order to. achieve dynamic evaluation of physiologic compensatory mechanisms and to assess the efficacy of intensive care management. methods. we conducted a prospective controlled trial on the blood oxygenation, oxygen transport and tissue perfusion during the first days after the trauma in patients with polytrauma. we used a swan -ganz pulmonary artery catheter (beckton -dickinson, u.s.a.), deseret cardiac output computer (medical inc., u.s.a.) and hewlett -packard monitor (hewlett -packard, germany) to measure and calculate all the parameter values. the severity of the injury was assessed using the apache ii score system. all the patients had scores over . results. the results show a significant decrease in the arterial blood oxygen content and in the arterio-venous difference, as well as an increase in alveolo-arterial oxygen difference and in the transpulmonary right-to-left shunt. the tissue oxygen supply and the tissue oxygen consumption reveal a tendency towards a decrease below the physiologic minimum of adeqate values. the erythrocyte current velocity and the ratio between oxygen transport and erythrocyte current velocity also decrease inspite of the optimal blood rheology. conclusions. the dynamics in the parameters values are most pronounced between the -nd and the -th hr after trauma, which predisposes patients to the risk of developing stable hypoxemia and characterizes this period as the most critical for tissue metabolism and organ dysfunction. posttraumatic changes in immune mechanisms in lung compartment in trauma were analyzed in ao and da inbred strains of rats which differ in their immunological reactivity: the former being low responder and lat-~er hiperresponsive. methods: the levels of tnf-alpha activity in the supernatants of cultured lung lobes and dynamics of cells migration from tissue explants in h lung cultures were assessed in ao and da rats subject ted to severe burn trauma. results: increased levels of tnf activity ( + pg/ml compared to + . pg/ml in control) were found od day following trauma in lung sups of ao rats while no changes in the levels of activity of this cytokine were found in lung-sups od da rats more pronounced extent and dynamics of cell emigration were noted in da rats, while almost unchanged in ao rats sharp rise in pmn percentages h following trauma ( - % compared to rare pmns in control), followed by increase in lymphocyte numbers at later time points among lung cell emigrants was detected in ao rats. slower but persistent increase ( %, h following trauma and % and % on days and after trauma infliction, respectively) in pmn numbers among da lung cell emigrants was detected, which appeared to be activated, as judged by their nbt reduction capacity. increased percentages of peripheral blood pmns and increased state of leukocyte aggregation/adhesion were detected in both strains, but different levels of plasma tnf: increased levels in ao rats on days and following trauma, and initially but persistently high levels of plasma tnf alpha in da rats ( - fold higher compared to initial levels in ao rats). conclusions:different patterns of local (lung) and systemic changes in cell numbers and cytokine levels implicate differential posttraumatic migratory capacity of pmns vs. lymphocytes in lungs in ao and da rats. early diagnosis of acute intestinal ischemia by color doppler sonography e. danse, b.van beers, p.goffette, f.hammer,aav.dardenne, f.thys, p-f.laterre, m,s. reynaert, .lpringot dept of radiology (profb.maldague) and dept of intensive care ( prof m,s.reynaert), st.luc univ.hospital, brussels, belgium ob emergeny medical squad service is the most important segment in the process of saving the people, in the cases of mass accidents, like industrial accidents caused by the: explosion, fire, chemical poisoning, traffic accident, elemental catastrophes and the war. because of that, each emergency medical squad service needs to have in its motor-pool vehicle for the mass accidents/ for provoding at least people, wounded as well as the people became ill/. objectives: presentation of such special vehicle, produced by "zastava-kamioni" and it's medical-technical equipment. methods: descriptive and comparative analysis of the medical and technical characteristics, based on the actual norms/din, , iso , yus.../ results: on the base of doctrinaired requirements of the emergency medical squad in the case of mass accidents, our researches resulted in the following medical and technical characteristics -the vehicles for mass accidents are gvw/with a payload off cca - t, with the fixed, closed body, type: universal van, -technical equipment aggregates, stretches, anti-fire device, equipment for pitching the tent and for maintaing technical conditions of the work -medical equipment: linen bags with complete sets of bandage material, means for the reanimation and immobilization, for the infusion, medical instruments and remedies as well as the tent for lodging at least wounded and sik people. in federal republic yugoslavia, it was proposed such vehicles for the emergency medical squad needs. conclusion: we suggest to introduce this vehicle in the production range of the ambulance vehicles for saving, especially in the circles where can occur serious accidents. introduction : carbon monoxide (co) poisoning commonly generates central nervous system abnormalities though an important cardiac morbidity and mortality must be considered. long-term exposure to co with cohb levels < % may be more dangerous than short-term levels of - %. we report a case of an adolescent who after prolonged exposure to co developed a severe reversible cardiac dysfunction with low levels of bloed cohe c a.ase history : a year old boy was found comatose at home. his mother in the neighbouring bathroom died severn hours earlier of what was later proven to be a co intoxication. on arrival the gcs was / and the patient was breathing spontaneously. a postictal status with eventual postanoxic encephalopathy was suspected. a coh'b level of % was objectivated. the cardiorespiratory situation quickly deteriorated requiring mechanical ventilation. chest x-ray showed diffuse bilateral patchy infiltrates. ecg revealed signs of ischemia. severe left ventricular dysfunction was evidenced by pulmonary artery catheterisation and echecardiography and later by isotopic angiography (lvef %). treatment was intensified with inotropic support, intta-aortic balloon counterpulsation and oxygen therapy. the clinical course was further complicated by a crush syndrome and renal failure. the patient's condition gradually improved and he fully recovered without any residual lesions (lwf %) conclusion : even after prolonged exposure cohb levels can be misleadingly low. high tissue levels of accumulated co can be associated with coma and fulminant cardiorespiratory failure requiring advanced life support facilities. introduction : both neuroleptics (nlp) and tricyclic antidepressive agents (tca) can induce arrhythmias, prolongation of the qt segment and the pr interval and hypotension. we report a case illustrating that combined overdose of these agents increases the toxicity of each compound and the risk for adverse cardiac events. .c, gse history : a year old male ingested mg doxepin (sinequanr), a tca and mg prothipendyl (dominalr), a potent nlp in an attempted suicide. upon arrival in the emergency department the patient was unconscious (gcs / ), breathing superficially, and presenting signs of recent vomiting. physical examination revealed a taehycardia of b.p.m., an arterial blood pressure of / mmh g. ecg showed a brood qrs complex tachycardia. a chest x-ray revealed the presence of an aspiration pneumonia. laboratory investigation demonstrated increased levels of crcatine phosphokinase, lactate dehydrogenase and aspartate transaminase ; hyperglycemia and leucocytosis were present. the plasma concentrations of doxepin and prothipendyl were respectively gg/l (toxic level #g/l) and i.tg/l (no reference). treatment consisted of mechanical ventilation, gaslric lavage and administration of activated charcoal and iv fluids and antibiotics. a hemodynamically well tolerated veatricular tachycardia developed / h later. nahco ( meq/ h) was administrated inducing an ectopic atrial tachycardia with a normal qrs complex and prolonged qt. h after admission a normal sinus rhythm was present; the prolongation of the qt segment persisted for days. the patient fully recovered. conclusion : the treatment with nahco~, alkalizing the blood and thus increasing the protein binding of the tricyclic antidepressant molecule, can readily correct the potentially life-threatening cardiac arrhythmias and therefore should be part of the routine treatment of combined tca-nlp overdose. ob/ectives: the development of diabetes insipidus (di) in patients with brain injury is a known negative prognostic sign. the aim of this study was to investigate whether this is also a reliable early prognostic sign of brain death. methods: this is a retrospective study of patients treated" during a two year period ( - - to - - ) in our i.c.u who meeted the following criteria: ( ) coma score _< gcs within the first hours, ( ) positive brain ct scan on admission classified according to marshall's diagnostic classification (classes - ), ( ) normal renal function during the entire icu stay. for the definition of di were used the usual di criteria plus hypematriaemia (serum na" >_ meq/l). survival was defined up to the th postadmission day. conclusions: according to the findings of this study, the development of diabetes insipidus in brain injured patients seems to be a highly specific index for brain death (positive predictive value = . ). however, further prospective studies are needed for the definitive evaluation of these findings in such patients. emergency care in italy, despite all efforts, is still lacking a nationwide organized prehospital care system and, until today, there are only different regional solutions. the majority of these realities imply rather simple ambulance first-aid services without attending emergency physicians and without resuscitation equipment. the emergency medical service (ems) system in falconara m., italy, was implemented in august by a collaboration between the school of anesthesiology and intensive care of the university of ancona and the, already existing, volunteer rescuer organisation "yellow cross". according to the guidelines pubblished in [ ] the pre-existing equipment of the volunteers was completed with type a ambulances and special equiped motorcar (patient monitor, defibrillator) for ambulance indipendent physician transpur[. a special data collecting schedule was created to memorise every emergency intervention in a computerised data-base. the intraining members of the school of anesthesiology and intensive care provide hour ready intervention. in this report the authors describe their experience concerning primary firstaid medical interventions. for a preliminary evaluation we considered, retrospectively, consecutive emergency interventions in the time period from novembre , to april , . the emergency physicians treated male ( %) and female ( %) patients, patients died before hospital admission and patients ( %) were treated at home by the ambulance indipendent physician and did not need any further medical treatment. in the same time period year earlier (november to april ) without attending physician the volunteer rescuers transferred all first-aid interventions to near-by hospitals. we conclude that the presence of an attending, iudipendently motorised physician in emergency interventions is essential for the establishment of precise priorities and may be helpful to reduce hospital admissions by ambulance intervention, though reducing primary" health care costs. we have developed the method of liquor filtration which allows to purify the cerebrospinal liquor from blood and its decay products in the subarachnoid bloodstroke. the hemipermeable dialysis membrane was used as a filter, which lets only in water, electrolytes and substances with small molecular weight. the liquor filtration was used for the treatment of patients with the subarachnoid bloodstrokes of different etiology. the perfusion of liquor was performed at the rate ml/min in the recirculatory mode. its duration was - min depending on the bloodstroke intensity. the filtration makes possible the most completely purifying of the hemorragic liquor, the reducing of the content of blood ceils and its decay products - times as less. the monitoring of the patient's state during the perfusion didn't revealed the departure from the norm of the main vital part. the liquor filtration technique compares favo-~ rsbly with the routine method of cleaning by the absence of toxical effect of heterogenous solutions on the central nervous system. the filtrstion of the cerebrospinal liquor in the subarachnoid bloodstroke sllows to provide the the early cleaning of liqour, the regression of meningeal syndrome and to improve the patient's state of health. e tabli~mczr bd ~ of rei~idnal medical first-aid zhoulittoing, ed., tan zi, m.d. dept. of sargery, the first teaching t[ospitat, yejin-l)a-l)ao, wuhan fltlna objectives: the medical first-aid is the most important task of the public hc atth department. in general, single hospital model couldn't fatty, effective ly rescue mony severe patients who need mergant treatment in the scene. bub establishing the medical first-aid network, the severe patients can be given the most timely und the most scientific emergent treatment. so that, the suc cessfut rate of the saving wilt be greatly increased. methods..; our hospital is a general big hospital. through developing and cons tructlng for more than ten years, the medical first-aid network distributed art over the area under our jurisdiction has been set up. it consists of thr ee units: the medical first-aid unib center comartd and mnagment unit, co m~nlcation and tiaison unit. the principle of the network operation is with oat having to far to mergoncy, specialized emergency and the best merge acy. results: the results of the network operation were notable. cmpari~ the to tat successful rate of the saving ( . ~), the successful rate of saving tra ma ( .~), the suscessfut rate of saving shock ( .~) and the successful rate of cardioputmonary resuscitation ( . ~) daring the three years after t he network operated with these before ( . ~), ( ]. ~), ( . ~) and ( ft. ~), the successful rates after operating were remrk~iy higher ( p<i).o ). conctusions~ the above results showed estabiishmnt and mena emont of region at medical first-aid network had very si~nificont action during mergentty s avin the severe patients. moreover, the regi~at medical first-aid network atso take an important part in prevention and health protection of the mass. objectives: se related mortality is due to the occurrence of both rv and lv dysfunction evoking cardiogenic shock and pulmonary edema (f. abroug, intensive care med ; s. nouira. chest ) . prospective evaluation of scorpion antivenon (sav), the only available specific treatment, is lacking. the aim of this study is to assess the effects of sav on the basis of a case-control study. methods:among consecutive victims of se presenting to the emergency department, were managed using sav (group sav+). these patients were matched to envenomated patients who did not receive sav (group sav- chest injuries are the cause of death in % of trauma fatalities and a major contributing factor in an additional %. pneumothorax is a major complication of chest injuries and can be initially overlooked bringing to additional morbidity and mortality especially in patients who require mechanical ventilation. the real incidence of pneumothorax in severe blunt chest trauma hasn't yet been established, as many pneumothorax can be missed on the initial chest x-ray (cxr) and computed tomography (ct) has not been routinely used. to evaluate the incidence of pneumothorax in patients with severe blunt chest trauma. methods: a prospective study. from january to december , all trauma patients with one of the followings conditions: fractures of four or more ribs, signs of lung contusion on the initial cxr or presenting a severe hypoxemia on admission (pao /fio < ) in the absence of pre-existing pathologies, were evaluated by initial cxr and subsequently submitted routinely to a ct. results: severe trauma patients were considered. of them, presenting a severe hypoxemia on admission, had no evidence of major chest trauma (ais< ). hypoxemia was the consequence of severe trauma in other districts; these patients were therefore excluded. patients with severe thoracic trauma (ais>= ) were admitted into the study. the mean iss was . ( - ). thirty-six patients required artificial ventilation for at least hours during the icu slay. three of them, who had a tension pneumothorax, were submitted to an emergency thoracic decompression on the field by the emergency helicopter team. in cases pneumothorax was diagnosed an the initial cxr more patients had a pnx which was identified only on the ct. in cases a large pnx with lung collapse was missed on the cxr. in our group of severe blunt trauma patients, % ( / ) presented a pnx that required the insertion of a thoracic drainage. only one third ( / ) of the pneumothorax could be recognised on the initial cxr, while other were decompressed before performing the cxr. as many as % of the cases of clinically significant pnx were missed on the cxr, and a ct performed soon after admission allowed an early diagnosis bringing to changes in the treatment. (as the patients were mechanically ventilated a chest tube was inserted in all these cases). in cases, the initial cxr overlooked a huge tended pnx which was the cause of hemodynamie instability. conclusion: in patients with severe blunt chest trauma even large pnx can be missed on the initial cxr. moreover due to the non compliant compressible lung, a % pneumothorax which can be recegnised only on a ct, can bring to high intrapleural pressure altering eardiopulmonary function. n. andoeli , .~osid, m.zesevid, m.risovid, d.stepi , d.djokid b~rga~yc~qterclinicalcaqterafserbia, belgrade cb~ctives:~lis study ~ the use of ~rq]ofol earbired with k~t~ine (aq a~sjgh~ic s@~qt widn inirjrsic armlgesic pro~mities) or with fsqtmtyl,with psrtial azgmsis an hgenxlyn-a~ic ~ durirg ~ ~ re:~ver~ f~m ~ in hxh ~ of ~ti~. ~: yali~mial and ~bod: a~it p~tie~ts a~ i-ii were included in ibis shxly. patients were rsrd]nly dieided in two ~ns. all d~tie~ts ~me given - prcpofol bolus doses (o, ~gkg) for ird~iqn of ~. ~ia ~s m~sjn~ with an infusion ~ ~ropafol. as sdflitianal were given fan-i~l (o, n]g) ~tely before ~ anj trad~e~ irfojoation followad by feasted bolus of o,i mg in ~ro o l.patients in gr~ o received i~ (an initial bolus dose of rg slowly intcavax~ rd mg as infusion over ~ rain) .infusions of pro~fol or imcpofol with kg~mine ~ stopfsj - rain ]:~o~ extuhation.arterial blood ~ (sistolic arterial blood preassu-re~zap,mean ~rterial blood pr~,d~lic arterial preassure-[zp a~ h~art rate-~) ~ m~ before induction of a~ io, snd rain aftem ~ intutation. results: arterial blood preasstre ~s decreases duri~ irn~ction of sn~wd~sia in hy~ ~n~s,tnt mare in th~ ~ who r~eived fsqtanyl.~ere w~s statisticslly sifnific~ntly difemerme dmir~ m~ of an~ia. arterial blood r~easatre and heart rate were stable in the t-..e~min -~a ~. all th~,fl-e keta'nire grcqo hsd e~rly :~e~y time. ctrmlusi~s: ~e ombiretion of protxfol wilh keta/ne for irduorion a~d ~ of sn~sd~esis w~s yell accept~ by p~tierfcs anj coald he ~ as an alterrstive ~o ccnva~icrsl a~es -d~sia. objectives : assess the relation between cytokine or endotoxin release and indices of splanchnic malperfasion after hemorragic shock in multiple trauma patients. ]~r study was approved by the local ethical committee. trauma patients admitted to the emergency room who met the entrance criteria of more than hour map < mmhg or use of vasoactive agents or blood lactates > mmol/ were selected for study. a nasogastric tonometer (tonometrics, inc, plastimed, france) and a swan ganz catheter were placed on admission. phi, lactates, hemodynamics, plasma cytokine and endotoxin concentrations were measured on admission and at . , , , hrs. an immunoradiometric assay was used to determine plasma concentrations of il (n< . ng/ml) and tnfc~ (n< pg/ml). plasma endotoxin concentrations were measured using a chromogenic limulus assay (n< . eu/ml)( endotoxine unit= pg). results : severe multiple trauma patients (age = _+ yrs, iss = -!-_ , saps = +'~, mean-+sd) were studied. they received + packed red cells during the first h. mean duration of collapsus before inclusion was . _+ . hrs. death occm'red in ~tients. ~ pglml, *: ng/ml, etox : endotoxin(eu/ml), lact: lactate (retool/l) a significant correlation between initial il level and saps was observed. in the early post-injury period phi, sao , svo , vo were significantly associated with ;il release (p< . at ho, h , h ). later a significant correlation existed between lactates and ii (h , h ). a peak of tnf was detected at and hrs. it was associated with low phi and low arterial ph of the early post-injury period (p< . iat ho, h , h ,h , h ) and with high lactate levels of later period (_>h ). only the late release of endotoxins (i{ ) was correlated significantly with initial !oxygea-delivered parameters. iconclusion : there was a marked increase in il in the early phase of trauma . i and tnf release after major trauma iwith hemorragic shock is associated with splanchnic malperfusion, as assess by the ivery low values of phi. lactates seem to be a later indice. toxic effects are a well-known complication of an overdosage of prescription theophylline. what is less known is that over-the-counter (otc) asthma medications contain theophylline, and that in some cases this might cause toxic effects. a case seen by us involved toxic effects from theophylline in an otc medication and to date is the only published case in the english literaturet the rationale for this study was to delineate the otc products containing theophylline from whatever data sources available. hyperthermia frequently occurs in intensive care treated patients and intentional application of whole body hyperthermia together with chemotherapy is a therapeutical access to treatment of malignant disorders. anaesthetic support is required in either condition. due to the marked decrease in systemic vascular resistance seen in hyperthermia an additional vasodilatory effect of the anaesthetic is unwanted. the vascular effects of anaesthetics in hypertherm organisms is not known in detail. therefore, we performed an experimental study to detect the effects of inhalational anaesthetics in whole body hyperthermia. in sprague-dawley-rats katheters were inserted into trachea, jugular vein, and carotid artery. for continuous monitoring of cardiac output a flow probe was placed around the aortic arch. the rats were mechanically ventilated with different concentrations of inhalational agents in oxygen. we compared the effects of enflurane, isoflurane, and halothane in stepwise increased body temperature by submerging in a temperature controlled water bath. results: isoflurane lowers arterial pressure more than halothane or enflurane. the inhalational anaesthetics lower the cardiac output similarily and independently of temperature. isoflurane decreases systemic vascular resistance independently of core temperature and the decreasing effect of halothane on the resistance is completely abolished in hyperthermia. conclusions: the influence of hyperthermia on the systemic vascular resistance is dangerous. this allows no additional effect of the anaesthetic management. in spite of the vasodilating effect of inhalational agents in normotherm subjects, this effect is abolished in hypertherms using halothane. the condition of management of analgosedation in hyperthermia is different from normothermia. objectives: to evaluate a bedside computer processed cerebral function monitor for assessment of brain wave activity when clinical/visual clues are not present. methods: ten icu patients undergoing neuromuscular blockade monitored with the aspect brain wave monitor from january to june , . results: time to onset and depth of sedation were readily apparent to icu physicians not specifically trained in eeg reading. objectives: to determine whether non-depolarising neuromuscular blockade reduces oxygen consumption (vo ) in sedated, apnoeic patients. methods: haemedynamic. metabolic and oxygen transport variables were determined in sedated, apnoeic patients with severe acute lung injury. all patients were ventilated using a puritan-bennett ae ventilator with integrated metabolic monitor. inclusion criteria were; ) stable cardiorespirator s" status; ) systemic and pulmonary artery catheters already in situ; ) inspired oxygen < %. patients were sedated with midazolam or propofol to abolish response to verbal stimuli, and sufficient morphine or alfentanil to abolish all spontaneous respiratory efforts. following baseline measurements, neuromuscular blockade was induced with intravenous vecuronium, ug/kg, followed by an infusion of ug/kg/h to maintain the train-of-four ratio at . a further four sets of measured and calculated variables were obtained at min intervals. results: statistical analysis was by repeated measures anova. there were no significant changes in any variable over time. the changes in calculated oxygen consumption (vo fick) , and measured oxygen consumption (vo gas), and in energy expenditure (ee), are shown in the table. objetive: to study the effects on coronary hemodyrtamics and myocardiai metabolism of administering propofol during postoperation sedation of patients with normal coronary circulation and good ventricular function undergoing cardiac surgery. patients and methods: patients ( women and men) undergoing aortic and/or mi~-a/ valvular cardiac surgery were selected, with an ejection fraction greater than . and normal coronary circulation. for postoperation sedation propofol was administered in . mg/kg i.v. bolus, followed by a . mg/kgth perfusion. all data were registered before administering propofol and after minutes, the patients being hemodynamically stable and a rectal temperature of _+ . -~ systemic and pulmonary hemodynamics, and global, as well as regional myocardial blood flow, and metabofic variables were measured. results: the patients studied were about years old, and the average period of aortic cross-clamp was . min. the adminstering of propofol caused a decrease in the coronary blood flow (- %), great curonary vein flow (- %), myocardial oxygen consumption (- %), regional myocardial oxygen constanption (- %), myocardial oxygen extraction (- %), regional myocardial ooxygen extraction (- %), while coronary vascular resistances and global coronary vascular resistances did not change. oxygen saturation increased in the coronary sinus (+ %) as well as in the great cardiac vein (+ %). in no patient were significant changes suggestive of myocardial ischemia objectified. there was also found a decrease in systolic (- %), diastolic (- %) and mean (- %) arterial pressure, systemic vascular resistance (- %), and cardiac output (- %). conclusions: in accordance with the clinical conditions of this study, the administering of propofol is not likely to cause changes in coronary autoregulation, oxygenation and myocardial metabolism. obietive: analyse the effects of . % "end tidal" isoflurane (sedative dosage) on the metabolism and coronary hemodynamics during the postoperation period of patients undergoing cardiac surgery. patients and methods: patients ( women and men) undergoing aortic and/or mitral valvular cardiac surgery, with an ejection fraction greater than . and normal coronary anatomy, were selected. after the surgical operation, . "end tidal" isoflurane was administered for postoperadon sedation. the determination of variables to be studied was carried out before and minutes after administering isoflurane, die patients being hemodynamically stable and a rectal temperature of _+ . -+c. systemic and pulmonary hemodynamics, and global, as well as regional myocardial blood flow, and metabolic variables were measured. results: the average age of the patients studied was -+ . years. during surgical operation the period of aortic cross-clamp was . _+ . rain. the administering of isoflurane was followed by a statistically significant drop in coronary perfusion pressure (- %), coronary vascular resistance (- %), regional coronary vascular resistance (- %), regional myocardial oxygen consumption (- %), regional myocardial oxygen extraction (- %) and accompanied by a significant rise in oxygen saturation in the coronary sinus (+ %) and in the great cardiac vein (+ %). myocardial oxygen consumption, myocardial exu'action of lactate and regional myocardial lactate extraction did not change. in no patient were enzyme or electrocardiograph changes objectified. systolic (- %), diastolic (- %), mean (- % ) arterial pressure, and systemic vascular resistances (- %) decreased, while cardiac output did not. discussion: the administering of . % "end ddal" isoflurane, in the clinical conditions of this study, produced a decrease in systemic arterial pressure due to a reduction of systemic vascular resistance without deteriorate cardiac output. at coronary circulation level, has and effect on coronary autoregulation but had no effect on oxygenation and myocardial metabolism. the idea of tiva implies the realisation of major anesthesia components (los of consciousness, neurovegetative inhibition, analgesia, myorelaxatiou, providing the adequate gas-exchange) through i.v. introduction of drugs exclasively. aim: providing for the main tiva components with minimal side effects of the drugs used, taking into consideration the patients characteristics and the surgery specific character. methods: anaesthesias have been conducted in patients aged years ( females, males), undergoing planned and urgent operations with the pathology of lower, extremities, perinaeum, small pelvis, hypogastrium and with reserved spontaneus respiration against a background of % insnffladon through mask. operations lasted from . - . h. anaesthesia adequacy was assested by constant monitoring: "cardiocap" (nibr hr, rr, sao , t), through glykhaemia level and mimicry reactions. standart premedicatioo of m-cholinolytics ( . mg/kg) and h -blockers ( . mg/kg) on the operational table was sumplemented by administration of . - . mg/kg of lidocaine, . . mkg/kg of clonidine, . - . mg/kg of pentamidine by the tachifilaxia method. the premedication adequacy was assessed through haemodynamics characteristics. sedation: . - . mg/kg of droperidoi, .l- . mglkg of diazepam and analgesia: - mkg/kg of phentanyl, . -- . mg/kg of ketamine were introduced fractionally according to indications. infusion rate of ringer-lactat solution was - ml/kg/h and depended on the intraoperational blood loss volume and on the patients preoperational condition. the duration of postoperative analgesia was registered. results: clinical assessment of analgesia according to this techniques allowed to decrease the anaigetics dosage to the subauaesthetic levels. smooth stabilisation of haemodynamics (bp) at proper age norms in patients with the initial hypertension by the -th min. of anaesthesia as well as the absence of its increase in response to the additional introduction of anaesthetic have been achieved. (hr) had no abrupt changes and remained in the range of - per rain. adequate external breathing: decrease (rr) by - per rain., with sao increase from % to - %. hypoventilation was avoided by respirate ventilator. according to unauthentic data the glykhaemia level had been lowered by -t % to the end of the operation with the initial moderate hyperglykhaemia of up to mmol/l the cutaneous covering grew warm and got pink colouring. no mimicry reactions. in the postoperative period patients were in the superficial sleep state ( - ) and analgesia lasted - b. there were no complications due to anaesthesia. conclusion: combined using of bz, opiates, neuroleptics potentiate the i.v. anaesthetics effects allowing lowering of each tiva component dosage and, as a consequence avoiding their negative influence on respiratory and heart vascular systems. complex application of adrenergetics (therapeutic doses of cionidine and pentamini with using of taehfilaxy effects) permitted to provide for analgetic and neurovegetative components of general anaesthesia under subanacsthetic doses of tiva main components, and manifestation of hyperdynamic reactions of haemodynamics decreased while using of lidocaine -the economicai activity of heart-vascular system. good level of muscle relaxation was achieved allowing for widening of surgical intervention extent without respirator ventilators and inhalation anaesthetics application. anaesthesia is easily controlled due to fractional introduction of drugs with quick recovery of cns functions after anaesthesia. postanaesthetic analgesia is increased while concurrent opiates doses are decreased. absence of marced haemodynamic, endocrine and metabolic reactions during the operation and after it resulted in shortening the period of patients staying in hospital. a yo white man was admitted to hospital for dyspnea and a productive cough. he had cabg in past, but no recent cardiac ischemia. physical exam: decreased breath sounds over right lung. chest xray: consolidation of right lung. admission medications included diltiazem, furosemide (both were continued) and trazodone (which was discontinued). admission ecg: sinus rhythm, qt . /qtc . sec, with st and t wave abnormalities similar to prior tracings. he required intubation and mechanical ventilation for progressive hypoventilation and hypoxemia. between icu days and he received haloperidol, - mg/d (cumulative dose rag) for agitation and delirium. icu day : qt . /qtc . sec. icu day : for better control of delirium, trazodone " mg q hs was added. icu day : he developed frequent nonsustained ventdcular ectopy. icu day : qt . /qtc . sec, pha . , paco mm hg, pao mm hg, k . meq/l, mg . meq/l. later in icu day the patient had brief episodes of torsades de pointes, each responding to precordial thump, and finally rhythm stabilized with i.v. lidocaine and magnesium. haloperidor and trazodone were discontinued. ecg was unchanged and myocardial infarction was ruled out. next day, icu day : qt . /qtc . sec. torsades de pointes, a form of ventricular tachycardia characterized by a twisting qrs axis, is commonly associated with qt prolongation. haloperidol is used frequently in icu for control of agitation and delirium, with reported doses up to mg/day. over past decade, cases of torsades de pointes with prolonged qt related to haloperidol have been reported. trazodone may also prolong qt and cause ventricular arrhythmias, especially in patients with pre-existing cardiac disease. in this patient, trazodone likely exacerbated qt prolongation from halopeddol leading to torsades de pointes. critical care physicians must be aware of this interaction. it is imperative to follow the qt interval for patients receiving halopeddol, especially when another drug also known to prolong qt is added. one must consider discontinuing the drug when qt/qtc becomes prolonged. objectives: analgesics and intravenous anesthetic drugs are routinely used in critically fll patients, who often suffer from a secondary impairment of the immune system. previous in vitro studies have demonstrated inhibitory effects of these drugs on polymorpho nuclear cells (pmn). the potentially important role of endothelial cells (ec), however, was not investigated, since suitable test systems were not available until recently. therefore a physiologically more relevant in vitro migration assay through cultured human endothelial cell monolayers (ecm) we established. using this assay system, the comparative effects of fenlanyl, sufentanil, propofol and the known pmn inhibitor thiopontal were tested. methods: human umbilical vein endothelial cells (huvec) were isolated and cultured on microporous membranes (cyclopererm) until an ecm was grown. pmn from male and female volunteers were separated by standard procedures. ecm and pmn were preincubated with clinically relevant concentratious of thiopental ( m), propofol ( p_g/ml), the solvent of propoful (intralipid), fentanyl ( ng/ml) and sufentanil (sng/ml). after preincubatiun (ecm minutes, pmn minutes) with the reslx~tive drug, leukocyte migration towards the chemoatfractant fmlp ( o - m) was measured in a two chamber well system for hours. the migration rate of untreated (untr.) and treated (treat.) pmn through untreated and treated ecm were determined. as a control untreated pmn and untreated ecm were used. results are given as means from independent duplicate determinations and expressed as a percentage of control (table) . statistical analysis was done with student's t-test. results: clinical concentrations of fentanyl, sufentanil and prupofol showed similar inhibitor~ effects as the known pivin inhibitor thit e ). % conclusions: for the first time we could show that analgesics and anesthetics exert their inhibitory effects not only on pmn, but mainly on the interaction of pmn with endothelial cells. moreover, we could shmv a significant suppressive effect of the opinids fentanyl and sufentanil on both ec and pmn. the known inhibitory effect of thiopental obtained in ec-free test systems were also confirmed in our physiologically more relevant assay system. objectives: to investigate when and how sedation is used in a consecutive cohort of patients admitted in a large sample of italian intensive care units (icus), gathered in a network named giviti, representative of the italian icus system. methods; the study called for a recruitment period of one month, from january to february , , data collection included age and other demographic variables, acute diagnostic broad profiles, severity of illness scores, treatments, lenght of stay and vital status at icu discharge. as concerned sedation, each patient was observed until discharge or for a maximum period of seven days. information on all the drugs used for analgesia/sedation, the route and modalities of administration, the timing, dosages and purpose of the administration have been recorded. results: the study involved the cooperation of icus, of which enrolled at least one case. the total sample included patients. overall, . % of patients analyzed (t / ) received at least one prescription of sedative during their stay. globally, at least one sedative drug was prescribed to these patients in days in icu. although over drugs were reported to be used, pharmacological principles accounted alone for % of all prescriptions. opioids were actually used in % of prescriptions; propofol in % and benzodiazepine in . %. as regards the way of administration, intravenous administration was applied in % of cases and, followed by intramuscular in . %. moreover, non-steroidal anti-inflammatory drugs (nsald) were used in % of patients and neuromuscular blockade agents (nmba) in %. detailed analysis on certain subgroups (surgical, trauma, ventilated patients etc.) have been also carried out in order to describe the practice of sedation in these peculiar subgroups. findings will be widely discussed during the presentation. conclusions: these results should be interpreted keeping in mind how peculiar is the intensive care setting compared to many other less complex settings of hospital care. in conclusion we thought it was important to present the data currently available in the most neutral form, to start moving in a direction which will enable us -by means of more specific and detailed studies, and with the cooperation and involvement of all those participating in the project -to shed light on one of the many aspects of medical practice in the field of intensive care which deserve closer attention. introduction: the aged run perilously high risks in cardiac surgery: among others, of haemodynamic fluctuations, respiratory depresskm and organ failure. response to anaesthetics is a crucial determinant for post<)perative complications, none the less being reintubation due to mechanical ventilation difficulties which increase morbidity, mortality and intensive cdre unit (icu) stay. objective: we wanted to assess our a,aesthesia window (selection, and a view of the induction -extubation period) for predicting safe and swift awaking, thus: icu dismissal for the aged. methods: in , selected patients (pts) (> y, f) followed a regular elective cardiac surgery protocol (propofol given at precisely designated time intervals). upon cu arrival, they were subjected to an admission protocol. our predictive criteria for early extubation at h included: a) alertness and ready response to commands; b) adequate gag reflex and sufficient protection for respirak)ry tract; c) pao > mmhg with flu < . ; d) stable ph> . with spontaneous respiration; d) stable haemodynamics without dysrhythmias; e) adequate perfusion and diuresis (> .(i ml/kg/h); f) mediastinal bfeeding< ml/h for at least h; g) normothermia (core temp> ~ and no shivering). subsequent reintubation was for: ) rr> /min; ) spontancx)us ventilation for rain with paco > mmhg; ) pao < mmhg with fio > . ; ) ph> . ; ) heart rate>] bm; and/or ) non mental alertness; and ) other medical disorders, after which adequate weaning therapy was necessary. then, successful weaning after h was considered: ) spontaneous breathing without any forrn of mechanical assistance; ) stability in haemodynamics; and ) elimination of fever threat. results: pts ( %) were extubated at h without complication; other pts ( %) at h but had to be reintubated because they were hypoxic and began weaning therapy; finally, they were all re-extubated by h. only pts ( %) proved problematic. conclusion: a,aesthesia wimhlw options (selectkm, extubation, reintubation and weaning) predicted quick (times propofol administration) and safe (rigid criteria) extubation ( %= h and %= h), exempting pts with developed post-operative complications ( %=extubation< h) unrelated to al~aesthesia window or icu protocol. dismissal and recovery then became an abbreviated question of time. fifisetll p, domeneg~i ~, sforzini i., veronesi i~, maconi a.g. *, breg~ massone p.p h [] ic+pca request conclusions:using e~aprenorphine, a synthetic,long-acting, ago-antagemist opinid drug as analgesic, in the major surgery we obtained the best clinic results with association of conttheus infusion of haft dose drug with bohts of pca in the first - hours and just pca in the secmad day after surgery when the patient is less sleepy. in this way we dent have a great sav~g of suppled drug but the major well-belng of patient without ~erious side-effects and quick mobilization; the dosage used don't compromise a good awake of patient: all patients are sleepy but ready for answer, no allueinatian, bradipnea but not less than b/m without ipoxia. also the patient proffered this kind of truit meut than the traditional at demand. the ward staff feel it useful] and rehabl~ the negative feed-back technology of the electronic infuser system makes possible to use it safe in the ward with high drug's concentration too. the infusion rate of low dose of drug assure a continuative analgesic covering ~n the first postoperative periad; the pca mode involves the patient him-self in the managemenl of therapy and enables him to choose the best way to confront the dll~icuity of postoperative period without call medical stall using pca-device we have had no probicm~ no accident. analgesia during extracorporeal shook wave lithot ripsy a .levit, b.grinbezg regional hospital, ekaterinbu~g, russia b~ectives: our task was to compare ~he analgetic effect of norphin and tramel. methods: study was made of two groups of uro-li~patients aged - . group a ( patients) received baprenorphine hydrochloride (norphin) at dosages of #. • mg/kg. group b ( patients) received tramadel hydrochloride (t~aasl) st dosages of . z . mg/kg. before the procedure diazepam was administrated i.v. ( . ! . mg/kg). blood saturation (spoz), hemodynamics incides (bp, hr,sv,co,sap,svr) were examined and the patients' subjective assessments of snsesthesis quality were analyzed. the hospital ethics committee approved the investigation. results: when using norphin hr increased by . % on the onset of the procedure while sap and sv decreased by .%% and . %, respectively (p< . ). however, there were no reliable co chsnges. spoz ~educed by @. % (p< . ) and remained lower than the initial one after the procedure was oyez. when administrating tramsl min. after ste~ting the procedure sap and svr increased by ~ . % and . % respectively. sv and co decreased insignificantly. nine patients in group b saffeting some dlscomfo~t needed additional tm~msl in~ection. in the course of the whole p~oced~e spo, was constant and was highez than that in ~he case of nozphin (p<o. ). conclusion: respiratory suppression by no~phin can limit its use in case of lithotzip@y while the advantages of tremsl a~e: lack of dyspnoe and good contact with the patti-b_ the role of uncommon agents of antinociception, placed epidurally, in the control of pain transmission in the spinal cord is well documented. somatostatin as an inhibitory agent is found in the dorsal horn of the gray matter of spinal cord. the effects of somatostatin is similar to the opiates if injected into the epidural space (ref. i, , , ) . the aim of the present study is to present the clinical effect of above mentioned palliative therapy in the case of cancer and non cancer pain. informed consent had been obtained from every patient before treatment was initiated under the legalisation of the local ethics committee. using the permanent epidural catheter and continuous infusion pump, we administer somatostatin in the dose of up to microgram per hour for one up to three days. the patients paln feeling was evaluated using a vas (visual analogue scale). we found that the opiate resistant pain level decreased by %. the rest pain could be controlled by pereral opiate analgetics or by combination of somatostatin and an opiate plus a local anaesthetic agent epidurally. theoretically, it seems that epidural administration of somatostatin and local anaesthetic agent is useful in the control of acute pancreatic pain and systemic effect of somatostatin is beneficial in the treatment of acute pancreatitis. few studies have been performed in the critically ill (ci) and because of the complex pharmacodynamic and pharmacokinetic changes that occur, it is difficult to predict accurately drug responses and interactions in individual patients. midazolam (m) is a watersoluble benzodiazepine with a rapid onset and short duration of action in normal individuals; however its metabolism is decreased in the ci. critical care physicians every day experience suggest that among the ci there is a different pattern of response to m; here it is hypothized that such a response could be due to different metabolic behaviours of ci. m (i.v.infusion rate - rag/h) and antipyrine ( rag p.o.) were infused to ci with ( patients -group ) and without ( patientsgroup ) endotracheal intubation. blood samples were collected at fixed times during and after m infusion. total urine nitrogen and antipyrine elimination half-life demonstrated different metabolic characteristics in group chypermetabolizer") as compared to group chypometabolizer"). results follow. the results of our study are preliminary and more kinetic data in critically ill patients are needed to statistically confirm our approach of "hypometabolizer" and "hypermetabolizer". objectives: some clinieai and experimental studies suggest that propofol decreases myocardial contractility in coronary artery bypass grafting (cabg) patients. the intrinsic negative inotropic action of the drug may be independent from changes of preload and afterload, whereas the myocardial depression induced by propofol may depend on changes in ca ++ ious availability. aim of this study was to verify the hemodynamic effects of propofoi in a group of cabg patients with uneompromised contractile function and to minimize myocardial depression, during induction of anesthesia, choosing to associate calcium chloride (cac ) in an other group and to define its role in producing this effect. methods: fourty patients, randomly divided in two groups ( pts a and pts b), undergone elective cabg, were enrolled in this study. anesthesia was induced by senior anesthetist in both groups by means of fentanyl mg• kg < in ", pancuronium . mg x kg - and propofol mg • kg - in ". a blind investigator administered via another venous way at same speed ( ") saline in patients of group a and mg x kg - cac in patients of group b. hemodynamic data (heart rate hr, mean arterial pressure map, mean pulmonary artery pressure pap, pulmonary capillary wedge pressure pcwp, central venous pressure cvp, cardiac index ci, stroke volume index svi, systemic and pulmonary vascular resistances indexed svri and pvri) were obtained at baseline (to), ' after anesthesia induction (t ) and " after tracheal intubation (t ). results: hr decreased moderately in both groups (p = ns). map decreased as well, more markeatly in group a at ti and t . this trend was statistical significant (p < . ) in both groups. pap, pcwp and cvp unchanged following induction in any of two groups. ci decreased in group a (p < . ) dramatically dropping at t , while in group b it showed a negligible decrease at t (p = ns) and value similar to baseline at t . svri and pvri did not exhibit statistically significant changes. conclusions: the use of propofol as a starter of anesthesia in cabg patients allows to reduce total dose of fentanyi, dramatically reducing post-operative intubation time. propofol-fentanyl association prevented the hyperdynamic response to stress (i. e. laryngoscopy, intubation) but severely depressed ci and svi. cac simoultaneous administration effectively minimized the negative inotropic effect of propofol. moreover no unwanted side-effects due to cac were observed. diseoordinated labor activity (dla) is one of most serious in obstetric pathology.medication sleep effect to a woman in birth is of limitation of pathologic impulsation from the central nervous system, but it does not influence processes resulting in and supporting dla on the organ level. constant discoordinated uterine contractions during medication sleep (ms) imerease disturbances of uterine blood flow, organ hepoxemia connected with hyperergia of vascular wall and myometrium to catecholamines, that reduces efficiency of anesthesiologic protection. we applied hexoprenalin in complex with ms to primaparas. efficiency control was being accomlished through hysterograms, grade scale of analgetic effect where hemodynamics reaction to pain, significance of emotional reactions and their vegetative manifestations before and during ms were registered, and also through hydrocortisone level in plasma before and during ms. the examined women's average duration of ms was hours more than in control and made hours, though their average labor duration and in control was the same and made hours. % of the examined women experienced independant labor, as for the control group -only %. supplementary methods of anesthesia were required in % in control,that increased medicamentous depression of the fetus, but for the examined group -only in %. the examinees's newborns experienced favourable terminations, in control newborns were in state of light rate asphixia. analgetic effect was complete in control just in i %, and of examinees -in %. on the women's hysterogrnms before ms discoordinated contractions were registered on the background of increased tonus. during ms in control similar uterine contractions were constantly registered, but for the examinees they were not marked at all or had the proper character. the examinees' hydrocortisone level was reduced for % and in control only for %. the study has allowed to make a conclusion that hexoprenalin applications in complex with ms in case of dla make anesthesiologic care safer and more effective, promote simultaneous removal of patholgic processes in the central nervous system and uterus, which lead to dla development. objectives: the aim of report is to present a clinical study results for the evaluation of anesthesia for a patients in unconscious states by eeg examination: methods: the study was conducted on patients after a severe abdominal operations on stomach and intestine and on one patient after traumaticat exarticulation of upper extremity. all patients have different unconscious state levels from somnolence to coma ]. also thay hav~ had respiratory insufficiency and control mandatory ventilation have been used. we were used intrave,~ous injections of morphine hydrochloride from initial dose of mg. than we were increased the dose to mg i.v. by drops with an accompanying eeg monitoring and fourier spectral analysis. initially all patients have had -rhythm with slow and a-activity. an c~-activity index have been lower than %. results: after anesthesia the o-and a-activity have disappeared. the or-activity index have increased to %. also we have noted decreasing of the unconscious state levels to a possibility of a verbal contacts ( - points gcs). conclusion: the quality of anesthesia could be evaluated by eeg monitoring. a regaining consciousness afte~ the injections of high doses of morphine, probably, may be a result of an opiate deficiency (full or partial). anesthesia with the following drugs: clonidine, l-arginine, l-n-arginine-methyl-ester (l-name), and their combinations. tail-flick latency (tfl) was determined at time zero and min after each treatment. clonidine (i- ~g/mouse) prolonged tfl in a dose-dependent manner. at a clonidine concentration of gg/mouse, tfl increased . -fold compared to time zero. l-arginine increased tfl at a high concentration (i gg/mouse). l-name suppressed tfl . -fold compared to time zero at a concentration of gg/mouse. conclusion: we have found that no is involved in clonidine spinal analgesia. studies are currently being undertaken to assess the effect of combination treatment of the above drugs on clonidine supraspinal analgesia. objectives: hemodynamic changes ussualy accompany laryngoscopy and tracheal intubation.the aim of this prospective study vas tu present the effectivness sufentanil in preventing reflex circulatory respone of laryngoscopy and tracheal intubation and provides stable hemodynamio condition for induction of balanced anaesthesia. methods: adult asa i-ii patients sheduled for elective surgery.they were allocated randomly and divided into two groups:fifteen patients received single bolus of placebo prior to laryngoscopy.and tracheal intubation. anaesthesia induction was then performed with thiopental (smg/kg) and atracurium ( , mg/kg), followed by neurolept anaesthesia. mean arterial preassure (map) and heart rate (hr) were measured before, during and min after intubation. althought ecg was recorded at the same time intervals. results: the groups were compared with regard to the changes in arterial blood pressure,heart rate and electrocardiogram. mean arterial preassure and heart rate were incresed significantly during and after laryngoscopy and tracheal intubation in control group but remained unohange the baselin values in the group who received sufentanil. control group ecg suggested more changes than sufentanil group. conclusions: the results indicated that , mg/kg sufentanil for anaesthesia induction reducing the pressor response to laryngoscopy and tracheal intubation. obiective: the aim of this experimental study was to evaluate morphologically the influence of anesthesia in liver as well as in isolated hepatocytes (hc). methods: a total of female swine ( - kg) were used as liver donors and were randomly assigned to one of two groups regarding anesthesia protocol: group a (n= ): induction with intravenous sodium thiopental in a dose of mg/kg, group b (n= ): propophol in a dose of mg/kg for induction'and mg/kg/h for maintainance of general anesthesia. both groups were under the same preanesthetic regimen (diazepam, ketalar and atropin) and received standarised doses of fentanyl and pancuronium during anesthesia. in beth groups total hepatectomy was performed and the liver was perfused with - it of cold ( oc) university of wisconsin solution for a period of hours before hepatocyte isolation. liver tissue samples were fixed in formalin for the morphological study and stained with hematoxylin-eosin and pas. for hc isolation collagenase solution (type v, sigma, c- , . mg/ml) was infused via portal vein and the liver was incubated at oc for rain. cells were filtered and then washed in cold hanks' solution. isolated hc were fixed and prepared for staining or simply cryopreserved (- oc). results: histology was completed in / experiments ( in group a and in group b). mononuclear infiltration (halothane type injury) was found in all specimens ( / ). focal zonal necrosis and acidophilic bodies were found in specimens from group a ( / and / respectively) while portal inflammation with piece meal necrosis was found in one specimen from group b ( / ). smears of hepatocytes -beth formalin fixed and cryopreserved at - oc -were stained with hematoxylin-eosin and showed morphologically intact hepatocytes. conclusion: pre[imineq~' study of our material reveals mote frequent livet injury in the thiopental group, but this finding has yet to be established by increasing the number of observations. objectives: in this paper we present our experience and point out the importance of sedation of those patients who suffered severe head injuries/contusic cerebri with signs of decelebration/and who were put on ventilatory machine to obtain better mechanical ventilation in neurosurgical intensive care unit of emergency center in belgrade. methods: patients were treated from jan. till dec. results: in patients we successed to reduce agitation and decelebration. conclusions: the major demand of sedation in neurosurgical patients are that the patient should be calm, comfortable and painless. references we compared three analogous groups of patients in each, with orthopedic operations on lower extremities. in each group we applied different kind of analgesia: first group rece-ned local anesthetic ( ml . ~ bupivacaine) when analgesia was first demanded; second group received ml fentanyl via peridurai catheter when analgesia was first demanded, and third group received m] fentanyi intravenously on demand for analgesia. we used visual analog scale (vas) for estimation of pain intensity and success of applied therapy. statistical data analysis was performed using student's t-test. tha best vas had group in which local anesthetic was applied periduraly. second was the group with periduraly applied fentanyl, and third was the group with intravenously applied fentanyl the longest duration of the effect of analgesia ~/as in the second group. there were no adverse effects and complications, apart from mild sedation in the third group. for orthopedic operations on lower extremities, application of peridural catheter for anesthesia and successful postoperative analgesia with local anesthetic, or opioid analgesics is acceptable. background and obiective : tympanic temperature measurement (ttm) is a relatively new procedure which provides accurate estimates of core temperature in stable postoperative patients and in patients admitted to the emergency ward. however, experience with this technique in hemodynamically unstable adult icu patients is limited. design : prospective study with patients serving as their own control. se:ttijlg : adult medico-surgical icu in a tertiary care hospital. patients : consecutively enrolled patients with thermodilution catheters in place and without contraindieation for rectal temperature measurement and without hypothermia (core temperature < ~ interventions : tympanic temperature, measured by a commercialized tympanic thermometer (genius a first temp) was compared with pulmonary artery (pat) and rectal temperature (rt). within minutes, core temperature was assessed in each patient by the same trained individual using the three techniques in random order. measurements and main results : mean bias (ix~ and its variability (sdr of method comparison pairs were calculated using the methods comparison analysis as described by bland and alunan (lancet, ; i : - objective: to measure the prevalence of pressure sores on the intensive care unit and the effect of risk calculation on pressure score prevalence and pressure score severity. method:in during a period of months a series of prevalence studies was carried out on the sicu to investigate how many patient days with pressure sores were taken care for by the icu nursing staff, what kind of preventive interventions were done and what the patient risk was on developing a pressure score. results: on average there was a prevalence of pressure sores on the buttocks of . % on the short stay unit and . % on the long stay unit; preventive interventions increased when the pressure score was visible for the nurse and the majority of patients had a high risk or extra high risk for developing pressure sores according the pressure score risk calculator. as a result of these findings the nursing management decided in that nurses had to complete daily on every patient the pressure score risk assessment in order to be able to take adequate preventive interventions. when the results of the two studies were compared, the most important results were that: ) there is no indication of a reduction in patient days with pressure sores (short stay unit: %, long stay unit: %); ) there is a reduction in severity of pressure sores (grade iv decreased from . % to . %) because adequate preventive measurements are initiated by icu nurses in an earlier stage. possible explanations for the increase of patient days with pressure sores on the long stay unit are that the average pressure score risk score was increased from . to . and the mean frequency of nursing patients on alternate sides decreased from . to . times each day. conclusion: daily assessment of the individual patient risk on developing pressure sores does not decrease development but reduces the severity of the developed pressure sores. method: the conventional woundcare method of patients with an open abdomen is to change frequently the saline soaked ribbon gauze pads ( - times each day). this method is labour intensive for the itu nursing staff and rather uncomfortable for the patient. problems that often occur are: insufficient hygiene, frequent nursing interventions, a progressive risk for deterioration of the skin and underlying tissues, difficult to measure abdominal output and in case of bowel fistulas enteral feeding is hardly possible. in using the new method, stomahesive is applied on the skin surrounding the wound. a large size of surgical film dressing, opsite | is applied over the abdomen. two or more foley ~ catheters ch are inserted through an opening in the surgical filmdressing. the application of several lateral openings in the catheters is advised. the drains are held firmly in place between two layers of sterile opsite | "flexigrid ~'' x with the so called bookend method and are connected to a low vacuum suction system ( - kph) results: we studied the frequency of dressings changes on patients in the itu. in total they had days with an open abdomen. during this period there were dressing changes. this means one dressing change every days. further advantages of the new method are; more hygiene in patient care, no maceration and irritation of the skin, nursing on alternate sides is possible, output can be measured, in case of bowl fistula, enteral feeding is possible and an abdominal lavage is possible on the sicu by opening the opsite | conclusion: this new method of woundcare management is more patient friendly, prevents several nursing complications and decreases the work load for the nursing staff. objective: to investigate the interaction between the ventilator and the closed suction system related to possible induced negative pressure by this sytem. method: we studied in a testlung model what the effect was of the different ventilators (evita: dr~iger; servo c: siemens), ventilation modes ppv, simv) and ventilator settings (tv, trigger level, frequency, peep level) on the induced negative pressure by the closed suction system during suctioning. results: when using the evita the magnitude of the negative pressure increased when the ventilation frequency and tv decreased.. the largest negative pressure (- cm h ) was produced with a tv of ml and a frequency of /min in the ippv mode with trigger level on - cm h and a peep level of + cm h . the servo c showed a complete different pattern. the largest negative pressures were measured when no trigger level was set ( cm h ), the induced negative pressure was not depended on the tv or ventilation frequency but more depending on the ventilator mode. the simv mode produced the smallest negative pressures ( - cm h ) and the ippv mode the largest ( - cm h ). conclusion: the effectiveness of the closed suction system is very much depending on the kind of ventilator, ventilator mode and ventilator setting that is used. if the interaction with the used ventilator is not known by the icu nurse this piece of equipment can cause damage to the patient by inducing large negative pressure in the comprimised lung and there fore creating the possibility of alveolar collaps and atelectasis or oedema. introduction : ethical problems are daily and disturbing preoccupations for the icu staff. objectives : improving ethical management in icu by creation of an intelprofessional group of ethical reflexion ( iger ). methods : existing was evaluated by a preliminary formulated series of questions sended to the whole staff (q , n = , items) after two training sessions (laws, deontology, professional values, culture, norms of quality) followed by persons ( %) and directed by an external chairman, satisfaction and needs of the staff were evaluated by a second series of questions (q , n = , items). at the issue, iger was created. results : q : responders ( %). law's misinformation : to %, disagreement for limitation of intensive cares : %, hope to improve collective decisions and creation of iger : % q : responders ( %) : satisfied by the training sessions : %, non satisfied : %, want to continue the project : %, refuse : %. iger was constitute by physicians, nurses, secretary, dietetic (n = ). the first working theme was {< therapeutic's withholding and withdrawing decisions in icu ~>. four subgroups of iger's members (having access to an ethical library) worked independautly and submitted their reflexions in a tdmestrial plenary session of iger in the presence of an external chairman, allowing a synthesis. at the issue a report was writted to be used as a reference for bedside and individual decisions. conclusions : constitution of iger seems to improve ethical management in icu. the first result of iger is that it is now possible to began collectively a reflexion concerning therapeutic's withholding and withdrawing in icu. the work is going on and further subjects will be studied. objectives: ) to compare the value of heat-moisture exchangers with bacterial filters (hmef) and without bacterial filters (hme) in the prevention of colonization of ventilator tubing and ventilator-associated respiratory infections. ) to asses the temperature and relative humidity of inspired all using both types of heat-moisture exchangers. methods: mechanically ventilated patients were randomized, to either hmef or hme. endotraeheal aspirates, pharyngeal swabs and samples from tubing were collected for bacterial cultures on the st, nd day mechanically ventilation and weekly thereafter. temperature and relative humidity were measured in patients ( hmef and hme) h and h after placing the hme or the hmef. results: both groups were comparable as regards age, mechanical ventilation period, severity score (saps ii), leukocyte count, and number of patients with prior antibiotic treatment. from the hmef group, ( %) ventilator tubing yielded microorganisms in, at least, one sample as compared to ( %) of the hme group; p=ns. the incidence of respiratory infection was similar in both groups ( % vs %, p:ns, for hmef and hme respectively). among the bacterial species isolated from ventilator tubing in the hmef group, ( %) were not isolated from pharyngeal swabs. a similar ratio was shown in the hme group ( / , %). both heat-moisture exchangers were efficacious in keeping a good relative humidity of inspired air ( % • vs % • .%; p=ns, for hmef and hme respectively). relative humidity was significantly higher after h of mechanical ventilation in the hme group as compared to hme group ( . % • vs . % • %; p= . ). conclusions: both types of heat-moisture exchangers have the same effect on the prevention of colonization of ventilator tubing. similar relative humidities are achieved when using either type of heat-moisture exchanger. results: tumor and nontumer enhrgements of the thyroidea were present in ~ of the operated, surgicel adrenal disease in io!, hyperplssle or persthyroid gland tumor in ~ end endocrine pancreatic tumors in %. in the intensive oere unit, these patients wore screened by noninwsive monitoring in ~ of cases: and invasive monitoring was applied in % of ceses.the basic noninvesive methods included: electrocardiogram with standard end precerdial leeds, percutaneous eutomotlc measurement of systolic, diastolic and mean arterial pressure, measurement of hourly diuresis and body temperature, frequency, hearing capacity and rhythm of one s own breathbng bs well as pulse oxymetry. a special plece in monitoring and control of vital parameters in postoperative period belonged to the nurse, thoroughly trained for enelysis end interpretation of the observed parameters which would be discussed in the paper. it has been believed that the leader sits at the pinnacle of power. over the years, this has proven to produce frustruation and anguish instead of the expected results. leaders have not been able to produce the changes they know are essential to their organization's survival with this command-and-control paradigm. through literature reviews and evaluating leadership styles, one can clearly see the most effective form is that of empowering people to a new level of performance -not ordering it. changing the leadership paradigm to a manner/style that has been shown to be effective and one of people empowerment shifts the focus to personal responsibility for performance. removing obstae}es~ stimulating self-directed actions, and determining focus and direction are just a few elements used to create the successful environment of empowerment. with increasing pressure in the health care arena, it becomes critical that a leader's job is to get the people to be responsible for their own performance. developing ownership, creating an environment where people want to be responsible, being a mentor or coach, and learning faster while encouraging others to do so demonstrates the commitment to effective leadership. this presentation will illustrate the critical components that are achieved when every person in the institution is empowered to perform at a level that is directed toward positive, effective results. herrera m. (md) . icu. hospital regional. malaga. spain. the systems of veno-vanous continuous haemofiltration (wchf) have a high cost and a limited life span. in an attempt of lengthening their mean life it has been proposed to accomplish programmed washes of the ~-stems. this practice supposes an increase in nursing workload. in order to evaluate the real efficiency of this practice we have accomplished this study. material: prospective randomized study of all the filters of vvchf used during the last year in our icu. we have determined two groups of filters, in the first (group a) we accomplished washed in a programmed way, and in the other (group b) only when the alarms of the system suggested a clotting of the filter. for the statistical analysis we used the kaplan-meier test for survival analysis. results: we have studied a total of patient submitted to wchf during the last year. we used a total of filters with this results. objectives. sounding out the nurses about the need to inform patients" relatives and the rigth kind of such information, like a preliminary approach to an information cuality assessment, methods: we inquired all the nurses of the intensive care unit of an regional hospital by an semiestructurated questionary which included personal data: age, sex, contractual relation, professional experience.., and opinion data: do you think to inform relatives is a nurse task?. which of the next informafions do you think is more important?, please, write others topics about information you think are relevant. we process the data on epi-info estatistical program and use x test to compare the results. results" from nurses of staff refused to flu the quetionary, and were not available. of the remaining, %were v~men and % men. the mean age were . % had an svable contract and ( eventual, the mean professional experience were of years and % worked in the unit since more than years. the % answered that offer information to relatives is part of the nurse activities. we did not find differences with nurses who answered negatively comparing by sex, age, contractual relation or proffesional experience. the three information topics found out like more important were: ) to inform about patient mood. ) to inform about happenings from the last visit. ) to inform about dressing instrument required by the patient, nurses who answered negatively think that to inform is a doctors task or that nurses are not competent. conclusion~ intensive care unit teams (nurses, doctors and auxiliar personnel) should get accord on who and how to inform relatives, we consider the nurses' role on information as unquestionable. objective: investigate the respiratory and cardiovascular response after discontinuing oxygen therapy durir~ intr~/]o~pital transport. desiqn: fifty-one patients ( male and female, aged + , and , , years respectively, ~+sym) being on therapy were studied prospectively in two consecutive intrahospital transports. oxygen therapy was continued in the first transport while the second one was performed as usually, i,e, without . during transport each patient was monitored by pulse oxymeter and holter whereas arterlal blood gases were tested just before a~xl aft~-trar~portation. results: compared to daseline, pa and sa were signif~canthy decreased in the case of oxygen discontinuation (p< , i). paco was significantly inur~ds~i only in the subgroup of patients with obstructive lun[ disease (p< , ) . heart rate increased in all phases of the transport when administratlon was discontinued. blood pressure remained stable in either case. the percentage of supraventricu!ar extrasysto!es, ectopic v~r[hicui~r contractions and st-s ~ment depression was progressively increasing and became very high at the end of transport in the case of therapy discontinuation. other arrhythmias did not change significantly. conclusion: discontinuation of oxygen therapy during intrahospital transport causes severe drop of pao and sa , increases the heart rate and contributes to the appearance of arrhythmias which were not present before. methods:for evaluation of the functional state of brain the complex of methods was used,whieh included electro encephalngraphy ( brain mapping ), rheoencephalography, tetrapolar transtorax rheography. for the estimation of humoral status the level of histamine and serotonine, products of free-radical oxidation,enzimatic markers of ishemic damage of brain and of endogenous intoxication was investigated. results: patients with encephalopathies after resuscitation were observed.asystolia was as a result of:shock, trauma, asphyxia,poisonings,appiication of drugs, eclamp sia,injury of the heart,diseases of fhe cardiac vessels. all patients with postasystolic syndrome entranced in comafose condition.in the group (reconvalescents) the depth of coma by glasgo~ pittsburg"s scale was , +- , . the duration of coma was from rain. to hour,average , +- ,sh.ln the group (the deads) the depth of come was , +- , .the artificial lung ventilation was used in all patients:in the group , +- , days,in the ~ , +- , days.apallish syndrome developed in cases,in patients diagnozed <<brain death~. the th degree encephalopathy (coma) was found to be associated with disorganized eeg-pattern with predomi nant alpha-( group) and slow ( group) activity. the relative power of delta-and theta-ranges was about - per cent.the patients with apallich syndrome demonstrated greatly elevated theta-range power, that of beta -range was essentially decreased. the degree of disturbances of circulation in the both groups was different.cardiac index (ci) and stroke index (si) in the group decreased on , % and , z, in the -on , % and (; , %.general peripheral resistance (gpr) increased in the group on , %,in the -on (; , %.in the group brain blood flow was increased, in the -decreased on , n.in the group there was the normotonic type of reg-curve,in the -atonic or hypotonic type (without reaction on pharmacologic influ ence).disturbances of permeability of cellular membranes (enhanced free-radical oxidation with an increase in di enic conjugates on and n) and vascular ones (an increase of serotonin concentration on and %, hi stamine content on and %) resulted in hyperfermentia (an increase of concentration of creaune phosphoki nase in the group on %,in the - %.the level of middle molecules (mm) increased in the group on , %, in the -on , %,of polyamines (p) (spermidin,spermin,putrescin).coefficient of correlation between mm and p was , . immediate correction of neurocyte metabolism is impossible due to marked brain oedemaswelling,severe dis ordes of cerebral circulation, disturbances of membrane permeability.thus,the following treatment algorythm might be advisable: . protective inhibition of brain and reduction of its energy requirements. . recovery of cell and vascular membrane fuoctions. .recovery of blood circulatiom .oxygenation of nervous tissue and drainage of brain disintegration products.in patientshbo carried out. .active methods of detoxication (homo-and enterosorption). .correction of cerebral metabolism. . dehydrative therapy must be very cautious. conclusion: the activation of energetic metabolism in neurocytes must be carred out only under neurophysiolngical control and after definite preparation. ( ). the clinical estimation of acute cerebral failure carried out by olasgo-pittsburg"s classification of coma. we studied such groups of patients: poisoning co ( ), asystolia ( ), eclampsia ( ), acute renal failure ( ), control group ( ). methods: electroeneephalngraphy (brain mapping) was fulfilled by means of encephalograph <,medicor ~ in monopolar channels. the estimation of eeg patterns by zhirmunskaya method ( ) was carried out. there were analyzed and changes of eegb by results of rapid transformation furie after rhythmical photostimulation(phts) , , , hz. we studied also the figures of absolute and relative power in such diapason : delta ( - hz), theta ( - hz), alpha ( - hz), betal( - hz), beta ( hz and more). results: all eeo changes were divided into following types: -organized ( , groups); iii -asynehronic ( group); iv -disorganized with prevalence of alpha-waves ( , , groups); v -disorganized with prevalence of delta-and theta activity ( , , ; , groups) akkording to our model of hormonal-metabolic disbalance in pregnancy , one of the main reason of destosis is hypoergos , reesults in endotoxemia and neuro-endokrine disregulation. so, stady of central nervous system function give us the information about adaptation processes. the aim of our work is to study the degree of neurologikal deficit in destosis when olifen and lipin were used. there were studied pregnants with different severe forms of gestosis. the degree of neurologikal deficit was valued by datas of neurologikal status . eeg with ,~brain mappinng~, , electrikal resistance of the skin. the komplex inteensive therapy with applikation of olifen and lipin allowed to improve the patient,s condition , decrease the degree of neurolodikal deficit and mortality . kostenko v.phd,kabanko t.,phd,galalu s.md,beliavtseva n. ,shramenko k. phd intensive care department,donetsk medical university, donetsk, ukraine plasmapheresis (pph),as other extracorporal methods of detoxicatin,has a great importance in contemporary medicine. the role of pph is special,because of its simplicity, effectiveness, atraumatic.we incalcated pph in obstetrical clinic. there are rough changes in agregate condition of blood in more of pregnants.these changes lead to disturbances of central,organ and peripheral hemodynamic.the therapeutic effect of pph is due to influence on agregate condition of blood. we considered that application of pph is very effective in pregnants with:bronchial asthma, severe forms of diabet, psorias, gestosis, allergic diseases. we used the membrane pph in pregnants: apparatus-,,hemos-pf>,, plasmofllter pmf- ,with effective area- cm,the volume of extracorporal contour- ml.such pph has no the ~ agressive effect,,, as in cases of application another extracorporal methods. this method was incalcated in our practice recently, so results will be reported in further publications. ( ). post-operative cerebral neoplasm ( ), post-operative subdural hematoma ( ). icp was monitored via a catheter inserted in the lateral ventricle and values were continuously digitally recorded by means of a bedside computer data acquisition system (maclab). the fiberoptic tracheobroucosenpe, which guided the procedure, was passed between the nasotracheal tube and the trachea in order to avoid hypoventilalion. the patients had stable baseline hemodynaimcs. propofol infusion and fentanyl boli were administered to mantain stable mean arterial pressure values. peak (mean(sd)) icp duping the minutes pre-ciaglia procedure (baseline values) were compared with values during ciaglia procedure, and the minutes p st-ciaglia procedure. data were compared with repeated measures anova. results: ciaglia procedure duration was (mean(sd)) ( ) objectives: transient global amnesia (tga) is a syndrome caracterized by impairment of short-term memory, inability to form new memories, retrograde amnesia and repetitive queries, without other neurological signs and symptoms. the pathophysiology of tga is unknown; thromboembolic, epileptic, migrainous and metabolic mechanisms have been suggested. to address some of these issues, we undertook a study of cases of tga in whom we examined clinical, laboratory data, electroencephalogram, ct of the head, ultrasonography ecodoppler. methods: patients were included in this study: men and women. the mean age was years. all cases underwent a standard clinical examination, electrocardiogram, routinary humoral tests and x-ray, electroencephalogram (eeg), ct scan of the head, ultrasonography ecodoppler. results': the mean duration of amnesia was h. m. +/- h. m. hypertension was found in patients ( %), ischemic heart disease in patients ( %), hypercholesterolemia in patients ( %), hypertrigliceridemia in patients ( %), smoking in patients ( %), atrial fibrillation in patient ( %), history of epilepsy in patient ( %), migraine history was not recorded. ct scans of the head showed multiple small deep infarcts in patients ( %), a single hypodense lesion in patients ( %). in patients electroencephalogram was normal ( %), in patients there were widespread nonspecific electrical changes ( %), in patients there were focal nonspecific eeg abnormalities ( %). conclusion: in our study tga was more common in women ( %). we showed a prevalence of hypertension, hypercholesterolemia and cerebral infarcts compared to normal controls. we have demonstrated a higher incidence of nonspecific electrical changes in tga of lower length, while ischemic lesions in ct of the head were more frequent in tga of greater length. these data seem to be in agreement with the hypothesis that tga is a heterogeneous clinical syndrome, consisting of pure, epileptic, and ischemic types. however we did not find any correlation useful in discriminating pure from associated tga forms. from our study it is tempting to speculate that pure tga is a rare event, underlying still unknown mechanisms wich differ from ischemic, epileptic, migraineous causes. objectives: aneurysmal subarachnoid haemorrhage (sah) is special condition increasing intracranial pressure (icp) in various ways. at the other hand cerebral vasospasm and related delayed ischaemic deficit (did) could answer for the poor outcome. triple h therapy seems today a basic option to prevent did, but it may increase the icp worsening the altered intracranial pressure condition and thereby the cerebral perfusion pressure (cpp). is there any way to individualise the triple h therapy when it is necessary? methods: between sept. march thirty-seven patients with intracranial aneurysms were operated on within hours following sah. five patients were in hunt-hess iv at admission. all patients received triple h therapy in a preventive fashion following surgery and were monitored by daily transcranial doppler ultrasonography (tcd). icp and cpp was measured in twenty-four cases. twenty-two of them received lumbar liquor drainage (lld) and nineteen were administered induced hypertension. the other group was treated by basic triple h therapy. results: in group with monitored icp the outcome was twenty-one excellent, one poor, two died (one of them died from extracranial decease). in the other group four had excellent, six moderate, two poor outcome, and one died. conclusion: according to our recent observation the patients can be divided into two groups of therapy. in group i, the patients with elevated tcd values and either low or high icp reacted to lld. we are concerned that haemodilution and slight hypervolaemia should dominate in the triple h therapy. in group ii patients having high icp with tcd and/or symptomatic vasospasm should be managed by the induced hypertensionhypervolaemia dominated therapy focusing on cpp (icp) and focal neurological signs. air emboli were detected in lo% (n= ) of natients undergoing coronary srtery bypass craftin~ (cabg). central nervous system ~ysfunction occured in ~$ of the nstients with air embnli and in none of those ~ithhout air embo!i. hvtothermia is the classic form of oro-tect~on used dur~nc ~"~" " ~ ~ ca~.,~modu] :r, on~_,_. bj/oass. the surf~eon sho,;,ed thorough!~: evecnnte air from the heart, but the onesthesio!o[[ist can signifieamt!y influence the outcome by emt!oyin ~ methods to detect and treat air emboli. the changes in head rate are primarily due to alterations of autonomic tone. the heart rate variability (hrv), that express the degree of heart rate fluctuation around the mean heart rate, reflects somehow the condition of central nervous system. hrv may be measured by a number of techniques. short-term time-domain variables of hrv are reflect generally the vegal activity. in this study the changes in hrv variables of patients with brain damage, and in addition the changes in hrv measurements in comparison with the clinical evolution were evaluated. eight patient with brain damage and six normal individuals as control group were studied. a elecrocardiographer with availability of computation the sequence of beat-to-beat intervals for one minute was used. the following variables of hrv were measured: ) standard deviation (sd) of beat to beat r-r interval differences that reflects the respiratory control, )the maximum/minimum (max/rain) interval that reflect variability related to baroreflex and thermoregulation and ) the coel~cient of variation (cv), the results are shown in the in the patients with brain death and in vegetate state there were virtually no hrv. increased hrv pattern was found with clinical improvement, the changes of hrv precede of the changes of gcs, we conclude that time-domain hrv could reflects the degree of brain damage, it is good prognostic index of the brain damage and may change earlier than the gcs. objectives: cerebral co vasoreactivity is an important determinant of cerebral blood flow (cbf) and has been shown to be of prognostic value in head trauma (acta anaesthesiol. scand. ; : - ) . we wondered whether co vasoreactivity could be selectively altered in one hemisphere in comatose patients. methods: patients ( m/ f, age - yrs, glasgow - ) in coma due an acute brain lesion (trauma, hemorrhage, or infection) were studied. cbf was measured bilaterally using jugular thermodilution at paco , , , and mmhg by increasing pico with mechanical ventilation kept constant. normal co vasoreactivity was defined as an increase in cbf of at least i ml/min. g per mmhg paco . results: patients had normal co vasoreactivity bilaterally, patients had altered co vasoreactivity at both sides, and patients had a normal response at one side (left or right) with an altered response on the other side (dght or left). for the patients left cbf was in mean ! ml/min. g lower than right cbf (figure methods: following institutional approval piglets (body weight :tl . ) were anaesthetized by % fluothane. a catheter was placed in the right femoral artery for blood pressure monitoring and a fiberoptic catheter (oxymetncs- abbott) was advanced via the right internal jugular vein to the jugular bulb for sjo determinations. another catheter with a balloon on the tip was advanced in the right atrium via the right femoral vein. a mean arterial pressure (bp) at mmhg was achieved by appropriate balloon inflation for rain and two groups were cleated: i) the hypoxemic group by respirator disconnection (*) and it) the hyperoxemic group by fio =l on respirator (o). samples were obtained at time ( ), ' min at hypoperfusion ( ) arid at reperfijsion at ' ( ), ' ( ) and ' ( ). pao , pjo and oxidative brain stress evaluation was performed from jugular bulb blood. the latter included: i) no synthase (nos) and xanthine oxidase (xo) activities by a method based on the oxidation of scopoletin detected fluorometrically, it) no levels estimated as onoo-by luminol enhanced chemiluminescence in the presence of ~tm hydrogen peroxide (h ). resul'~s: the mean pao was mmt-ig for group i and methods: we retrospectively reviewed all upper gi-endoscopies, performed in the period january -july in patients ( men and women) admitted at the icu's of our hospital. results: it concerned surgical, medical, eardiological and neurological patients with a mean age of . yrs (range: - ). in %, the endoscopy was performed at the icu and in % at the endoscopy department. in % of the cases, the endoscopy was primarily diagnostic, of which % was performed for localization of upper gi blood loss. in % the endoscopy was primarily thempentic, of which % was performed for placement of a duodenal feeding canula. location of the upper gi bleeding was: variees ( %), duodenal ulcer ( %), oesophagitis ( %), gastric ulcer ( %), others ( %) and none ( %). as coincidental findings were noted: cesophagitis ( %), gastritis ( %), gastric deer ( %), duodenal ulcer ( %), duodenitis ( %), oesophageal ulcer ( %) and others ( %). conclusions: there were marked differences in indications and findings of endoscopy at the different icu's. these differences reflect an admission bias and differences in populations and treatment preferences. compared with cardiological and neurological icu's, substantially more endoscopies were performed at surgical and medical icu's. in a considerable number of cases, no source of upper gi blood loss could be found endoscopicaiiy. when upper gi blood loss was the icu admission diagnosis, the main cause was needing varices, which could be controlled endoscopically in the vast majority of cases. when upper gi blood loss was ndt the icu admission diagnosis, peigie ulcer and oesophagifis were the main causes of bleeding. because of the considerable number of coincidental almom~adities found at endoscopy, there is still room for debate whether antacid medication and/or motility stimulating agents should be given prophylactically at icu's. many studies have shown that blood lactate levels in survivors and nonsmvivors of traumatic and septic shock are significantly different. the degree of multiple organ failure is related to the duration of lactic acidosis ( ). the aim of this study was to evaluate blood lactate level as a prognostic marker of high risk postoperative patients who may benefit from invasive hemodynamic monitoring and aggressive fluids administration and early inotropic support based on oxygen transport parameters. methods: patients undergoing elective long term vascular and abdominal surgery (asa i-bi) were studied. blood lactate levels were measured after icu admission. in the case of blood lactate level above mmoltl, measurement was repeated every hours for hours or until normaiisation (blood lactate level less than mmol/ ). type of surgery, length of surgery, amount of fluids delivered intraoperatively and postoperatively, hemoglobin levels, hemodynamic variables, diuresis, postoperative complications, length of icu stay and clinical outcome were recorded. because no attempts were made to randomisr therapy or change our standard therapy protocol institutional approval was not required. rebuts: the frequency of postoperative complications was , % and mortafity was , % in a group of patients with blood lactate level less than , mmol/l (n = ). frequency of complications ( , %) was significantly increased in a group of patients with blood lactate levels , - mmol/l (n = ), mortality was , %. mortality ( %) and frequency of complications ( %) were significantly increased in a group of patients with blood lactate levels above mmol/l (n = ). conclusion: blood lactate levels can serve as early marker of high risk postoperalivr patients and may predict increased risk of postoperative complications mad ~e death. objective.~: investigated practicability and clinical value of the routine measurement of hepatic venous oxygen saturation (shvo ) after major liver surgery, as shvo is considered an indirect parameter for splanchthc and hepatic blood flow. methods: consecutive patients were included in this study after liver resections for primary or secondary liver tumors. patients suffered from liver cirrhosis (childs a). immediately after post-operative admission on the icu a pa-catheter ,was inserted under fluoroscopy via the right jugular internal vein into the hepatic vein contralateral to the resection area. hepatic venous and arterial blood samples were drawn every two hours. shvo was correlated to the clinical course, macro hemedynamics, abgs aug other established lab parameters. results: in out of attempts the catheter could be placed correctly. in four cases after right hemihepatectomy the left hepatic vein could not be intubated due to a dorso-lateral tilting of the left liver. this is also reflected in a significantly longer time of fluoroscopy for catheterization of the left hepatic vein ( . _+ % rain vs. . + . rain; p < . ). the procedure requires a total of between and minutes. relevant clinical complications were not observed except for short term supraventricular arrhythmias during passage of the catheter through the right atrium. hemodynamics and pulmonary function could be considered normal in all individuals at time of measurement. shvo showed a span from . % to . % with a mean of . % -+ . %. the following statistically significant findings could be obtained: (a) patients with liver cirrhosis showed a significantly lower shvq than patients without ( . % • . % vs. . % • . %; p < . ). (b) a negative correlation between shvo immediately after operation and the duration of intraoperative hepatic vascular occlusion could be observed (r = - . ; p < . ). this correlation could also be seen for the first post-operative hours (r = - . ; p < . ). (c) a negative correlation between shvo and the difference between arterial and hepatic venous lactate levels was found (r = - . ; p < . ). conclusions: the routine measurement of shvo appears to be a promising extension of post-operative monitoring after major liver surgery. it is a safe method easily feasible on any major surgical icu though relatively time consuming. a further validation of this method is necessary in larger studies. therapeutic recommendations on the basis of shvo findings cannot be given yet. methods: in cases after major liver resection, in which abnormally low readings of shvo suggested an impaired hepatic blood flow, pgi was applied at a dose rate of ng/kg/min. as shvo can be considered an indirect parameter for hepatic blood flow, the effect of pgi infusion on shvo was measured. moreover, the changes of macro hemodynamics and pulmonary function were monitored. results: before the application of pgi z mean shvo for all patients .was . % ( - - - ). in three cases without major structural alteration of the remaining liver tissue the continuous intravenous administration of pgi lead to a sustained increase of shvo z to an average of . % ( . - , ). the postoperative course in these three cases was uneventful. in two cases with compensated liver cirrhosis after hepatitis c no change in shvoz under pgi infusion could be observed. both patients died and days respectively after operation in protracted liver failure. side effects of pgi included a slight decrease of systemic and pulmonary vascular resistances. consequently map decreased by up to % as did intrapuimonary right-left shunt increase. in none of the observed patients did these side effects posed a limitation of continuous application of pgi z. conclusions: in patients without structural alteration of the liver the systemic application of prostacyclin at a dose rate of ng/kg/min could significantly increase an abnormally low hepatic venous oxygen saturation after major liver resections, tn two cases of severe liver cirrhosis a similar increase could not be observed. after first clinical investigations and with the results of recent studies in animal further controlled clinical studies of prostacyclin in the postoperative management after liver surgery appear justified. any delay in gastric emptying can promote micro-aspiration and give rise to ventilator associated nosoarnnial pneumonia. h -receptor antagonists have been suspected of promoting pneumonia by changing the gastric ph. in a few tri',ds on humans ranitidine was noted to delay gastric emptying. the aim of this prospective, randomised, blinded study was to evaluate in a ventilated icu population if there was a difference between cimetidine (c) and ranitidine (r) on the gastric filling index (gfi conclusion: in this population there was no difference in gfi between c and r; however the age and creatinine were significantly different and could have favoured the c group. also the very long t/ could have hidden smaller differences between c and r as has been described in volunteers. between april , and april , , patients with severe acute pancreatitis were admitted to participating hospitals. patients were entered into the study if severe acute pancreatitis was indicated, on admission, by multiple laboratory criteria (imrie score >_ ) and/or computed tomography criteria (balthazar grade d or e). patients were randomly assigned to receive standard treatment (control group) or standard treatment plus selective decontamination (norfloxacin, colistin, amphotericin; selective decontamination group). all patients received furl supportive treatment, and surveillance cultures were taken in both groups. results: fifty patients were assigned to the selective decontamination group and were assigned to the control group. there were deaths in the control group ( %), compared with deaths ( %) in the selective decontamination group. (adjusted for imrie score and balthazar grade: p = . ). this difference was mainly caused by a reduction of late mortality (> weeks) due to significant reduction of gram-negative panreatic infection (p = . ). the average number of laparotomies per patient was reduced in patients treated with selective decontamination (p < . ). failure of selective decontamination to prevent secondary gram-negative pancreatic infection with subsequent death was seen in only three patients ( %) and transient gramnegative pancreatic infection was seen in one ( %). in both groups of patients, all gram-negative aerobic pancreatic infection was preceded by colonization of the digestive tract by the same bacteria. reduction of gram-negative colonization of the digestive tract, preventing subsequent pancreatic infection by means of selective decontamination, significantly reduces morbidity and mortality in patients with severe acute necrotizing pancreatitis. ieco by sodium hypochlorite (nacio) infusion is considered to be a model of microsomal oxidation in liver on cytochrome p- . active c provides oxidation of toxic metabolic products in the blood and exfused during plasmapheresis plasma, and also hydrophobic to hydrofilic transformation of substanses. sterile nacio in necessery concentrations was obtained by electrolysis of saline ( , - , % naci solution) in electrochemical set e~io- (russin,moscow). methods: . the nacio in concentration ragfl ( - ml/ h ) was administred into central veins in patients with extensive peritonitis and endotoxicosis - /t. erytrocytes resistance to nacio, circulating blood volume glycemia and hemostasis were initially estimated. . after plasmapheresis exfused toxic plasma was mixed with nacio conccantration of i mg/t in : ratio in sterile "hemacons".the effectiveness of plasma detoxication and possibility of its reinfusion were evaluated by determination of albumin effective concentration (eca g/l), the concanlration of medium molecular oligopeptides (mm , ) and other biochemical tests (bilimbin, creatinine, carbomide and so on). results: . the intravenous administration of nac excels detoxicative effect of hemosortion by - % provides effictive presentation of protein components and blood cells and improves the transport function of albumin by %. . the return of exfused plasma after its purification ieco was - %. only the remaning - % of deficient plasma were compensated by fresh cryoplasma and albumin solutions. ischemic hepatitis (ih) is a severe complication in critically ill patients. acute circulatory failure of multiple etiology can lead to splachnic hypoperfusion and cause acute and reversible anoxic damage. over a period of mos pts, m and f, mean age + . yrs developed liver disease compatible with ih. eight pts had a documented hypotensive episode (six pts with septic shock and two hypovolemic shock), while cardiogenic pulmonary edema in the absence of hypotension was responsible for ih in the remaining four pts. all the pts had a rapid striking elevation of ast, &lt and ldh with equally rapid resolution of these parameters to near normal wimin days (mean . ). the mean peak level of ast, alt and ldh was iu/l (range to ), iu/l (range to ) and iu/l (range to ) respectively. serum total bilirubin levels rose transiently with a moan t:eak level of . mg/dl (range . to . ), while altered coagulation paran-,ete's (pt> . times normal) was observed in four pts and clinically significant coagulopathy with fibrin degradation products occurred in one pt ( . %). renal impairment (cr> . mg/dl) was manifest in all pts; six pts developed non-oliguric renal failure ( %) while two pts required hemodialysis. ten lots required vasoconstrictor inotropes [dobutamine (range - pg/kg/min) and dopamine (range - pg/kg/min), while replacement of circulatory blood volume was performed in two pts with hypovolemic shock. eight lots expired ( . %), but none died as a direct result of hepatic damage. the mortality rate was higher among pts with concurrent renal failure ( %). it is concluded that: ) ih is not uncommon complication in the icu with the prognosis depending on the underlying disease. ) clinically significant coagulopathy is uncommon complication of ih. ) titration of inotropes is required to obtain optimal cardiac output support and subsequently liver blood flow. it is difficult to ascertain the perfusion of free flaps such as jejunal loops after surgery. objectives: to assess ischaemia as evidenced by intramural ph of jejunal free flaps used for reconstructive surgery following total pharyngolaryngectomy. methods: the sigmoid ph tonometer ( tonometrics inc.,usa ) was used to monitor intramural ph of the jejunal free microvascular flaps ( phig ) in patients who underwent total pharyngolaryngectomy. a standard general anaesthetic was given and all patients were admitted to the icu for controlled ventilation and monitoring. all had similar postoperative care. phig was measured pre, post-revascularization of the flap and on icu admission, , and hours postrevascularization. objectives: to classificate the wide spectrum of itc of anp into distinct pathophysiological patterns according to presentation and course. patients (pts) and methods: pts, ~( , %), ( , %) were admitted in the icu because of anp and acute respiratory failure(arf), ilean age: , • years. hean stay in icu: , • days. pts were operated, of them twice. hean value of ranson's scale: , • ( - ). we analyzed hemodynamic measurements,arterial blood gases(abg), x-ray findings(xrf), ct-scans and operative records. results: patterns of pleuropulmonary complications were identified: a)early hypoxia without xrf - pts. b)early ards with typical xrf - pts( died), c)early arf with xrf(atelectasis,infiltrates)- pts( died). d)late ards with typical xrf- pts( died), e)pleural effusions in various combinations with the above patterns - pts. overall mortality rate: / = , %. conclusions: l)frequent x-rays and abg are important for the classification of itc of anp. )even though patterns of classification in anp are not clearly distinguishable,they facilitate an anticipatory management. )deterioration of abg and xrf indicates that preventive measures for arf must be intensified and agressive surgical therapy is required. )delay of surgical therapy is related to worse prognosis(p<o, ) and prolonged hospitalisation time(p<o,ol). in the contrary, the early timing of the operation before infection and extrapancreatic necrosis is essential for a better prognosis (p<o, ). objectives: the development of cholestasis during intensive care treatment is allied with an inferior prognosis. this study investigates the sensivity, specification and also the positive and negative forecast of patients survival -exemplary for bilirubine. methods: during a period of months all surgical patients on icu were registrated prospectively (n = ). for documentation of disease development a standard foldcrform based on a computer-data-system was used. the results of this kind of documentation showed aapprax. , m!ll. of single patient informatioas. results: of patients didn't suffer from liver disease or have any operation on liver or bile tract. of them have had a normal scale of bilimbine in the postoperative period, a higher scale of bilirabine was regisu'atcd by patients. at a ,,cut-off" of rag% (total-bilirubine) the sensitivity was , , specivity , , positive predicive level , , negative predictive level , for survival criteria of a patient. the max. reached level of bilirubine, also the daily increase turned out almost the same results as they were found for other parameters nf cholcstasis like ap or gamma-gt. objective: the aim of this experimental protocol was to evaluate the morphological and functional parameters of isolated pig liver grafts, perfused in an extracorporeal liver support system. methods: the system consists of the graft liver, a membrane oxygenator (oxygenation surface . cm z, flow= itlmin), a heater, a centrifuge pump and a fluid reservoir. twenty pig livers, mean weight gr (min , max gr) were obtained and after a mean cold ischemia time of min were perfused fo} a mean of . h (min . , max h). perfusion solution consisted of r/l and hemacell. inflow to the graft liver was performed through the portal vein at a mean pressure of ( - ) mmhg at ~ while outflow was secured through the suprahepatic inferior vena cava. during perfusion the following parameters were evaluated through pre-and posthepatic hourly (to-t ) sampling: po , " + + " pco , ph, hco -, na , k , ca , osmolality, glucose, lactate, ast, alt, alp, u bilirubin and coagulation factors i, v and viii. biopsies were obtained periodicallty. b_p_~: results were as follows: mean ph fell from . at t o to . at t while mean output po fell from at t o to at t . mean output ast values increased from at t o to > at t while mean output alp values increased from . at t o to at t . mean output k + values increased from . at t o to > at t . histology revealed lesions of ischemic necrosis, more prominent after t . conclusion: results show that the isolated liver graft presents satisfactory function and morphology at least for a five hour perfusion period in the described extracorporeal circuit. correction of ph contributed to an increase in bile flow. between and the practice of transplantation has changed drasticaily in switzerland -besides kidneys also hearts, heart and lung, lung, iiver and pancreas transplantation has started in several centers. major information efforts have been made, organ exchange rules were set up and a national coordination center was initiated. the aim of this retrospective single center study was to assess the influence of transplantation on organ donation. in the past eleven years organs were donated from potential donors i single, multi organ donations) analysis of refusal was evaluated categorized into medical and/or familiar reasons. the number of potential donors increased from ( ) ,to ( ) with a concomitant drastic reduction of donations from % in to % in ; amounting to a net unchanged number of donations over the last years ( = ; = ) . the import and export of donor organs was balanced since the introduction of the national coordination center. in contrast multi organ donation increased from % in to % in despite of the more stringeant selection criteria, in conc]usion the introduction of a full range of transplantation procedures at several new university programs and the increase of multi organ donation has not had the forecasted impact on organ donation despite a sustained informative and promotional campaign, objective: monitoring hepatic venous oxygen saturation (svho ) provides online information about hepatic-splanchnic oxygen supply-demand ratio [ ]. previously, x~ reported hepatic venous catheterization in patients undergoing orthotopic liver traru~lantation (olt) [ ] . in the present study, we assessed the effects of nitroglycerin (ng), a vasudilator that affects the venous capacitance vessels more than arterial vessels and prostaeyclin (pgi , flolan r~, wellcome, uk), an arterial and splanchnic vasodilator on hemodynamies and hepatic venous oxygen saturation (svho ) in human liver transplantation. methods: with institutional approval and informed consent, consecutive patients, mean age - -_ years, were studied following olt. postoperatively, fiberoptic pulmonary artery catheter was inserted into the right hepatic vein. timed infusions of ng at a rate of . gg/kg/min and pgi at ng/kg/min were initiated for a rain period. each sequence was followed by baseline therapy for rain. results are expressed as mean=tsd. statistical analysis was performed using friedman's-two-way-anova-test, significance was accepted at p< , . results: ng at . gg/kg/min induced a decrease of mean arterial pressure (map) ( _ [baseline] vs. + mmhg) and pulmonary artery wedge pressure (pcwp) ( j: [baseline] vs. : mmhg). cardiac index (ci) ( - vs. + l/rain/m ), oxygen delivery index (do i) ( -+ vs. + mgnfin) and svho ( _~ vs. -l-_ %) were decreased (p< . ). pgi at ng/kg/min induced a reduction in map ( • nm~. _g) and pcwp ( + mmhg). ci ( _+ l/rain/m ), do i ( : ml/min) and svhoz ( + %) were increased (!o< . ). vasedilatation induced by ng decreased systemic oxygen supply and impaired splanclmie oxygenation. pgi increased systemic oxygen delivery in parallel with svho , suggesting a corresponding improvement of hepatic-splanchnic okygenation. thus, if vasedilator therapy is indicated in th orient receiving liver grafting, pgi appears to be advantageous. however, due to its platelct aggregation inhibiting properties, the usefulness and safety of pgi in olt patients has still to be determined. objectives: to analyze the effect of steroid treatment given to donor on the early function of transplanted kidney. methods: from january, until now donors were involved into this prospective study. every other donor was treated with mg/kg solu-medrol one hour before organ retrieval. according to the steroid treatment of the donor the recipients were divided into two groups: group -steroid pretreatment goup (y~= ), and group -control group (n= ). the donors and the recipients were treated using the same kidney transplantation protocol onl~r the adults, and the first cadaver kidney transplanted patients were involved into the study. the daily routine parameters were analyzed pre-and intraoperafive, and on the - th, th and th postoperative days. results: we could not show any clinically important differences between the two groups in respect of donor parameters. preoperative, the patients in group had slightly lower ereatinin level ( -+ g.,non vs. -+ gmol/ ) which persisted into the early postoperative phase. the values of the other examined pre-and intmoperativc parameters were almost the same. during the first postoperative days the patients in group i needed less diuretics (furosemide and renal dose of dopamine) and their sodium excretion was closer to the physiological range than in group . the other parameters did not differ significantly. the less furosemide need in group ! pe~isted to the end of the first month. conclusions: according to our data the steroid treatment of the donors improves the early function of the transplanted kidney in some respects. to prove the real benefit of the donor steroid treatment needs more data and further analysis. objectives: severe infections may compromize the outcome of liver transplantation..determination of new parameters may increase the knowledge of pathophysiologic mechanisms and may lead to changes in postoperative therapeutic management of patients at risk. methods: between august and september , patients with transplants were monitored for cytokines and extracellular matrix pammeters on a daily basis. serious infections (n= ) included microbiologic evidence and more than secondary organ failures. patients with cholangitis (n=ll) or uneventful postoperative course (n= ) referred as control groups. results: -year patient survival was . % ( / ): patients died due to serious infections, while died for other reasons. mean bilimbin, stnf-rii-, ifn- -, il- -, il- -, il- -, laminin-and neopterin levels were significantly elevated in patients with serious infections compared with patients experiencing mild cholangitis or with an uneventful postoperative course. a further increase of all parameters was observed in patients who subsequently died; tnf-ri/: _+ pg/ml vs • pg/ml; ifn- : _+ pg/ml vs . -+ . pg/ml; il- : -+ pg/ml vs -+ pg/ml; il- : -+ pg/ml vs _+ pg/ml; il- : _+ pg/ml vs • pg/ml; laminin: -+ ng/ml vs -+ ng/ml; neopterin: _+ nmol/ vs _+ nmolb for non surviving vs-surviving patients. a significant decrease of sialic acid yeas observed in patients with serious infections; and a further decrease occurred in patients who subsequently died: -+ mg/l vs • mg/ . conclusions: the increase or decrease of various cytokines and extracellular matrix parameters may be indicative for severity of infectiolx routine monitoring of these parameters may improve current diagnostic tools and poss~ly lead to changes in therapeutic management of patients at ~k. objectives: evaluation of the cytokine network after liver transplantation may give some insight in pathophysiologic mechanisms of rejection and may lead to detection of patients at high risk. methods: patients with transplants were monitored for various cytokines on a daily basis between august and september . rejection was assessed by histology in combination with clinical signs of rejection and laboratory investigations. results: during the first postoperative month, patients ( . %) developed rejection; patients were successfully treated with methylprednisolone (steroid-sensible rejection), while further patients required additional treatment with fk or okt (steroid-resistant rejection). patients subsequently developed chronic rejection. mean levels of various cytokines and extracellular matrix parameters including tnf-rii, ifn- , il-ib, il- r, il- , il- , il- , hyaluronic acid and neopterin were significantly higher in patients with steroid-resistant than in patients with steroid-sensible rejection. a further increase of some parameters was observed in patients who subsequently developed chronic rejection; bilirubin: . -+ . mg/dl vs . -+ . rag/all; tnf-rii: -+ pg/ml vs _+ pg/ml; il- : +- pg/ml vs -+ pg/ml; neopterin _+ nmol/ vs -+ nmol/ ; hyaluronic acid: _+ ~tg/l vs _+ ~tg/l for patients with chronic versus patients with acute steroid-resistant ~ejection. sialic acid levels decreased in patients with acute steroidresistant rejection; and a further decrease was observed in patients who tieveloped chronic rejection: _+ mg/l vs _+ mg/ . ~onclusions: various cytokines and extraeeuular matrix parameters were indicative of severity of rejction. the extensive increase of bilirubin, tnf-ii, il- , hyaluronic acid and neopterin may indicate subsequent chronic ection. monitoring of these parameters may, therefore, lead to changes in immunologic management after liver transplantation. background : combined kidney and pancreatic transplantation is being performed with increasing frequency in patients with diabetes mellitus and renal failure, as it offers more chances of success and better results than kidney transplantation alone. mycotic arterial aneurysm constitutes a devastating complication following pancreatic transplantation. all cases of mycotic arterial aneurysms have been however reported with exocrine pancreatic drainage into the gastrointestinal tract. intervention : we describe a series of consecutive whole kidney-pancreas transplantation performed at the university of geneva hospitals ( beds) between december and may . exocrine pancreatic drainage into the bladder (epdb) was performed to improve early detection of rejection episodes. epdb was hypothesized to reduce the risk of contamination from the gastrointestinal tract and the subsequent possible occurrence of potentially fatal infectious complication. in all patients the dual transplantation was performed through a median incision according to the procedure described by nghiem. results : two out of the patients who received kidney-pancreatic transplant developed arterial mycotic aneurysms and days following surgery. aneurysms developed at the site of the arterial anastomosis used to rearterialize the homograft. both patients had peritonitis caused by candida albicans requiring surgical drainage and intravenous antifungal therapy. rupture with hemorragic shock occured in both patients leading to graft removal in one patient, and three episodes of lffetreateniug hemorragic shock followed by graft failure and removal days after transplantation in the other. conclusion : arterial mycotic aneurysm constitutes an early, lifetreatening complication of kidney-pancreatic transplantation; it mandates graft removal. although exocrine pancreatic drainage into the bladder consitutes a definitive advantage for caller diagnosis of graft rejection, it does not eliminate the risk for retrograde colonization and subsequent severe infection in our experience. s. bocharov, i. teterina, regional clinical hospital, irkutsk, russia acute profound loss of blood can result from the very different injuries and hepato-pancreato-duodenai operations enter such a rank. ill-timed and inadeguate correction of operation hemorrage is one of the reasons for postoperation complications, including polyorganic insufficiency. the pathogenesis seems to be very complex. in early stages of bleeding the liquid enters the vessel bed, followed by hypoproteinosis and hematocrit fall. however, as decompensation develops, the fluid leaves the vessel system in the result of increasing postcapillary resistance and lowering col-ioidnooncotic blood pressure (cop). the resulting hypovolemia causes primarily acute disturbance of central hemodynamics and then of microcirculations and transcapillary exchange. central hemodynamic failure after acute loss of blood manifests itself through cardiac output lowering and capillary blood flow deceleration. taking into consideration, that % is critical value for cpv loss and for cev it is %, we consider arising the level of cop to the immediate task. cop raising allows to normalize transcapillary exchange, which we assess through cop and mcp (mean capilary pressure) gradient. the next task is to make up for globular volume till homeostasis providing level. considerable attention is given to catabolism inhibition and maximum possible enegry provision. control over high proteolitic activity of blood and callicreinkinin system activity implies direct proteases inhibitors. reologic, membrane stabilizing, antihypoxanthine and anticoagulant therapies are obligatory. virehow clinic, dept. of surgery, humboldt university berlin, germany regarding a high mortality up to % of fulminant hepatic failure orthotopic liver transplantation seems to be the only promising therapeutic approach in many cases. this study shows experiences from a transplantation center. between june and april patients suffering fulminant hepatic failure were admitted to our surgical intensive care unit all patients showed severe liver dysfunction with grade ii to iv encephalopathy. after a period of diagnostics and conservative treatment ranging from few hours to days (mean . days) we reported of these patients as possible organ recipients to eurotransplant. all of these patients were transplanted within hours, ( %) of them even within hours. the principal aetiologies were hepatitis b ( ), hepatitis c ( ), nanb hepatitis ( ), mushroom poisoning (amanita phalloides ). after transplantation patients suffered from initial-non-function and underwent re-transplantation. the one-year-survival rate was %, patients died within months after transplantation due to various reasons. patients were not referred for liver transplantation. of them never met transplantation criteria, improved by conventional therapy and could finally be discharged from hospital. the known reasons for liver failure in this group were mushroom poisoning ( ), paracetamol intoxication ( ) and fulminant hepatitis a ( ). patients suffering from fulminant hepatitis ( ) or intoxication ( ) were excluded from emergency liver transplantation for various contraindications. of these patients ( %) died despite conventional intensive care. we don't know if some of the patients in the transplantation group would have survived without transplantation, because whenever we decided on transplantation we could perform the operation within hours. but the good survival rate in the transplantation group ( %) the % recovery rate in the group, where there was no transplant-indication in our opinion and the fatal outcome ( % mortality) in patients with contraindications are an encouraging proof of a successful therapeutic strategy in acute liver failure. these results are based on a close cooperation between experienced transplant surgeons, hepatologists and intensive care doctors, using sophisticated laboratory and imaging techniques in a specialized center. introduction: during brain death patients suffer from multiple endocrinologic disturbances. one of the most important are those related with thyroidal axis. it is well described the euthyroid sick syndrome whose more frequent pattern consist of decreased triiodothyronine (t ), increased reverse t (rt ) with normal levels of tetraiodothyronine ( " ) and tsh, this lacking in " " levels lead to a change from aerobic to anaerobic metabolism which results in tissular damage. objective: .to study thyroidal pattern in brain death patients potential organ donors. .to avoid organ impairment by administration of t . .to study the hemodynamic and hormonal changes after the administration of t in these patients. material and methods:population: brain death patients of any etiology potential organ donors admitted to the intensive care unit. patients were classified in hemodynamically stable (group ) and unstable (group ). group received a bolus of . p.gr/kg. and a perfusion at a dose of - . p.gr]h of t . hormonal assays: total t (tt ), total " (tt ), tsh. fxee t (ft ), free " (ft ) and rt were determine at the moment of clinical brain death ( hrs) and in group two these assays were repeted at hours , and . results: patients ( male) with a mean age of years (range to yrs.) were studied. the clinical brain death was confirm later with other explorations (eeg, doppler). there were patients in group ( , %) and patients in group ( , %). hormonal pattern: at the moment of brain death tt was normal in cases ( , %) and decreased in i ( , %); tt was normal in patients ( , %) and decreased in ( , %); ft was normal in cases (i , %), decreased in ( , %); fl' was normal in patients ( , %) , decreased in ( , %) .rt was normal in cases ( , %) and increased in cases ( , %). there were no statistically significant differences in hormonal pattern between the two groups. only t levels at hours , and were significant in group . in the cases with ft decreased, the tt was normal in ( %) and decreased in ( %), tt was decreased in ( , %) and normal in ( , %), tsh was decreased in i ( , %), normal in ( , %) and increased in i( , %) and ft decreased in ( , %) and normal in ( , %) and rt was normal in ( , %) and increased in ( , %). there were no statistically significant differences in cardiac index, vascular resistances and pulmonary shunt before and after the administration ef t . conclusions: . the hormonal pattern most often find in brain death patients was: normal tt , decreased tt , normal tsh, decreased ft , normal fr and normal rt . . there were discrepancies in the values of ft and tt . there were no statistically significant differences in hemodynamic and pulmonary parameters. objectives: magnetic resonance angiographie (mra), a non-invasive procedure, provides flow-related information additionly to the anatomy of the vascular system. measurement of signal intensity and edge detection of vessel structures permits to calculate blood flow velocity and vascular diameters. we examined whether cerebral hemodynamic changes by altering the arterial pressure of carbon dioxid (pace ) could be detected by mra. methods: following institutional approval and informed consent, mechanically ventilated patients without elevated intracraltial pressure underwent mra with defined periods of hyper-, hypo-and normoventilation (pace : , , mmhg; arterial blood gas probes; avl). mra was performed with a . tesla magnetom (vision, siemens). two different mra techniques were used: a conventional time-of-flight- d-angiography (tr: ms; te: ms; fl: deg; slab: mm) for vessel diameter detection and a flash- d-gradient-echo-sequence (tr: ms; te: ms; fl: dog) for measurements of blood flow velocity. an axial view parallel to the ac-pc-iine (anteriorposterior-commissur-line) was used for repeated imaging of identical regions of interest toi) of the proximal part of the internal carotid (ica) and middle cerebral artery (mca) as well as of peripheral branches of the mca and the posterior cerebral artery (pca). results: changes of pace correlated with changing signal intensities, whereby under hyperventilation a decrease of , % (p . ) and under hypoventilation an increase of . % (p . ) was observed compared with normoventilation. blood pressures were stable throughout the whole study period, pace dependent changes in vessel diameters were more pronounced in peripheral branches of mca and pca. a change from normo-to hyperventilation produced a decrease in proximal vessel diameter of - . % (p _< . ) and in peripheral diameter of - . % (p _< , ). a change from normo-to hypoventilation produced an increase in proximal diameter of + . % (p < . ) and of + . % (p -< . ) in peripheral diameter. conclusions: pace related changes of cerebral vessel diameter can be easily detected by mra without injecting a contrast agent. the results confirm that co -reactivity is more pronounced in peripheral cerebral vessels, which are subjected to greater changes in diameter than major basal arteries. hyperventilation leads to a decrease and hypoventilation to an increase in signal intensity thus reflecting the corresponding changes in blood flow velocity, intensive care unit (icu) of "kat" hospital, athens, greece, ob!ective$; the value of bronchoscopy in pulmonary atelectasis of icu patients is under question the presence of an air bronchogram sign in xrays, which is considered as evidence of central bronchus patency, is referred in several studies as a negative criterion for bronchoscopy, whereas its absence as a positive one. it is also referred that air bronchogram sign correlates with delayed resolution of atelectasis, probably because of obstruction of many periferal airways (not central). the purpose of this prospective study was the evaluation of the air bronchogram sign on frontal chest film as a negative criterion for bronchoscopy and as criterion of delayed resolution of atetectasis, methods: icu patients with atelectasis were studied prospectively. they underwent bronchoscopy, bronchoscopic findings, presense of air bronchogram sign, and outcome of atelectasis were recorded, correlations were made, between: ) bronchoscopic potency of airways and air bronchogram sign } resolution time of atelectasis and broncoscopic potency of airways. ) resolution time'of atelectasis and air bronchogram sign, methods of statistical analysis were the t-student test and the chi square test, results:the patients were , men women , seventeen patients had atelectasis of whole lung, of upper lobe, and of lower lobe. ten patients had atelectasis in right and in left lung. eight from patients had air bronchogram sign in x-ray, there was no statistical correlation between air bronchogram sign and bronchoscopic potency of airways [ from patients with air bronchogram sign ( %) and from without air bronchogram sign ( %), had bronchoscopic potency of airways, p> . ], resolution time of atelectasis didn't correlate statistically with bronchoscopic potency of airways (mean resolution time in patients with bronchoscopic potency , days and in bronchoscopically closed bronchi , days, p> , ). there was also not a statistical correlation between resolution time of atelectasis and air bronchogram sign (mean resolution time in patients with air bronchogram sign , days, and without air bronchogram sign , days. p> ). conclusion~i; the presense of an air bronchogram sign in x-ray of icu patients with atelectasis, does not coexist obligatorily with bronchoscopic patency of airways and cannot be used as a negative criterion for bronchoscopy, neither as a criterion of delayed resolution of atelectasis. th. wertgen chest sonography (cs) is routinely used in our department to examine icu patients with clinical symptoms of pulmonary embolism, pneumonia, pleural effusion or unclear chest pain. we perform cs with a sector transducer ( . mhz) and a linear transducer ( . mhz) using acuson xp/ c. the sonographic signs of pulmonary embolism and infarction are most well demarcated, mainly wedge shaped and triangular pleural based lesions, more roughly structured, observed with a hyperechoic reflex in the center corresponding to the bronchitic (fig. ) . pneumonia is characterized by homogenously hypoechoic, wedge shaped parenchymal lesions, containing air or fluid bronchograms; they move with respiration (fig. ) . pleural effusions are spaces of various echogenicities, from anechoic to homogeneously echogenic, which may contain floating strands or complex septa, located between visceral and parietal pleuras (fig. ) . from march to april we did examinations by cs in icu patients ( male, female; age from - ). patients examinations pulmonary embolism pneumonia pleural effusion us-guided thoracic punctions were performed in patients. in two patients we found pneumonia or pleural effusion caused by a lung carcinoma. another two patients showed a normal cs (diagnosis: inflammation of the gall bladder, inflammation of the myocardium). conclusion: cs is a very useful method for icu patients with chest diseases. it takes less time and is less expensive than ctand sometimes of a higher diagnostic value than x-ray. last but not least cs is invaluable for the icu patient, because the examination is done save and quickly at bed side and the results of cs are very helpful in diagnoses and treatment. results : inter-observer reliability was evaluated as an % concordance. results of the tee classification were : class : n = ( %) ; class : n = ( %) ; class : n = ( %) ; class : n = ( %) class : n = ( %). therapeutic implications of tee in class patients were : cardiac surgery in patients (two cases of acute mitral regurgitation, two valvular abscesses and one hematoma compressing the left atrium), discontinuation of peep in one ventilated patient with an atrial septal defect, weaning of mechanical ventilation in one patient with an atrial septal defect, prescription of antimicrobial therapy in patients with endocarditis and prescription of anticoagulant therapy in patients with left atrial thrombus. the only noteworthy complication was a case of spontaneously resolving supraventrieular tachycardia. conclusion : tee is safe and well tolerated, and is useful in the management of icu patients with shock, unexplained and severe hypoxemia or suspected endecarditis. the aim of this study was to determine whether ultrasound guidance can help interns to improve the results of jugular vein access in icu. methods : in a prospective and randomized study, we compared, in patients admitted to the icu, an ultrasound-guided method (ultrasound group : patients) with an external landmark guided technique (control group : patients). all jugular vein accesses were performed by young interns with an experience of < procedures. results : internal jugular cannulatian vein was aci~ieved in all patients in the ultrasound group and in patients ( p.cent) in the control group (p < . ). average access time was longer in the control group ( • sec. vs • see. ; p = . ) and puncture of the carotid artery occurred in patients in each group (p = . ). patients ( p.cent) in the ultrasound group and patients ( p.cent) ia the control group (p < . ) were cannulated in rain. or less. the cannula was therefore unabie to be inserted within minutes in patients in the control group, with failure of eannulation in of these patients ( p.cent). failure was due to thrombosis (n = ), small calibre of the internal jugular vein (< ram) (n = ), abnormal vascular relations (n = ) or cervical irridation (n = ). among the primary failures of cannulation, an internal jugular vein catheter was able to be inserted in cases by an experienced physician on the side initially selected and with ultrasound guidance in cases. the catheter was inserted into the contralateral internal jugular vein under ultrasound guidance in the remaining cases. jugular cannulation was obtained at the first attempt in p.cent in the control group and p.cent in the ultrasound group. conclusion : ultrasound guidance improved the success rate of jugular vein cannulation by inexperienced operators in icu patients. when the internal jugular vein has not been successfully eannulated within minutes by the external landmark guided technique, the authors recommend the use of the ultrasound guidance. in the majority of cases right atrial or ventricular thrombi represent pulmonary emboli in transit. these may be fatal in patients (pts) treated conservatively with anticoagulation only. in literature the incidence of right heart thrombi in pts with proven pulmonary embolism (pe) is said to be in the range of - %. extremely mobile, long, worm-shaped masses in the right heart cavities carry an especially high early thrombus-related mortality rate which ranges from - %. current therapeutic strategies favour fibrinolytic therapy with consecutive anticoagulation. we report five cases ( male, i female, - years) of right heart and pulmonary thromboembolism. in these pts diagnosis and regression of thromboemboli following systemic intravenous lysis therapy with recombinant tissue-type plasminogen activator (rt-pa) was documented by transesophageal echocardiography (tee). a submassive pe occured in pts, a massive pe in pts. one patient (pt) had a cardiac arrest. in all cases tee clearly identified the extensive thrombns formation in the right-sided cavities of the heart and in the central pulmonary artery in cases. all pts were treated with mg rt-pa, pts in a front-loaded regimen over minutes, pt over minutes, and, due to the life threatening situation, in one case a bolus injection as ultima ratio was performed with no intracerebral bleeding complication. regression of thromboembolic masses after fibrinolytic therapy was demonstrated by transthoracic and transesophageal echocardingraphy after to hours. all pts survived and were put on coumadine, pt developed an intracerebral bleeding with persistent hemiplegia. conclusions: the use of thrombolytic therapy is highly efficacious for the therapy of pts with pe and concomitant right or ventricular thrombus formation. transthoracic and especially transesophageal echocardiography are powerful bed-side diagnostic tools for the immediate diagnosis and follow-up of successful treatment in this life-threatening condition. although widely used, catheterisation of the femoral vein in the groin using "landmark" technique is frequently complicated by accidental arterial puncture. suboptimal hygiene and patient discomfort are also associated with this technique. with regard to these last two factors cannulation of the femoral vein - cm below the inguinal ligament would seem an attractive alternative. as "landmark" technique is not possible for the cannulation of the femoral vein in this part of the thigh, ultrasound was used to locate the vessel and the results of this technique were evaluated. methods: a portable compact ultrasound device (site rite,dymax corp.) featuring a . mhz transducer (ultrasound depth - cm) fitted with a needle guide and a cm screen was used by residents with no previous experience in ultrasound guided cannulation. patients consisted of a surgical icu population. results: in patients catheters were introduced.in cases more than one ( - ) attempt was made and in patients the procedure was unsuccesfull due to the fact that the vessel was situated out of reach of the ultrasound (vessel depth > - cm), during the procedures one accidental arterial punction was registered. the catheters remained in situ for a mean of days (range - ) and were used for volume suppletion, medication, parenteral nutrition and haemodialysis.co-ionisation rates compared to those of subclavian catheters in our icu. in the first patients cases of asymptomatic thrombosis of the femoral vein were seer on ct-scans performed for other indications, in the following patients duplex scanning performed after removal of the catheter yielded another cases of asymptomatic femoral vein thrombosis. conclusions: ultrasound guided femoral vein catheterisation - cm below the inguinal ligament is a safe and simple technique that can easily be performed by residents without prior experience. the incidence and impact of thrombo-embolic complications associated with this technique are still subject to further investigation. objectives: to estimate the cost of antibiotherapy (ab-cost) in a multidisciplinary -bed greek icu and to correlate ab-cost with total cost of drugs and consumables and with patient's outcome, severity of illness and type of admission. methods: prospective data from consecutive patients admitted to the icu from / / to / / were studied. a tick chart was designed to record all drugs, materials and consumables regularly used for icu patients, but did not include low price drugs and consumables, which are provided from hospital's pharmacy as stock and were included in a fixed icu cost calculated for a month period. the chart also contained demographic details and data necessary for the calculation of several illness severity scoring systems. obiectives: over years evaluate the necessary efforts and expenses to implement a cis in the routine of a -bed stcu. methods: in june a commercially available, unix-based cis was installed on a -bed surgical icu. the goal was a paperless documentation at the bedside. after more than years clinical experience two aspects were investigated: what effort is necessary to install and support a cis, and what is the benefit for patients and personnel on the icu? results: the installation and support of a full-fledged cis requires a considerable effort: (a) the conceptual framework for the cis has to be defined. this includes the definition of documentation standards, as well as nursing and therapeutic standards, which is the essential basis for the configuration of any cis. (b) configuring a cis, i.e. "fine-tuning" it to the user's specific needs, is always a laborious task. moreover, constant maintenance is necessary. these tasks require the following personnel: experienced health care professionals for defining the conceptual framework, - trained health care professionals for configuration, system administrator. on a single icu ( - beds) these are not considered full-time jobs. (c) training is best done employing the "train-the-trainers" approach. (d) beside the necessary amount of man power and money to install and purchase a cis, administrative and mis support is needed, especially when interfaces to the hospital and laboratory information systems have to be set up. in general, a cis needs the commitment of all people involved. without a really professional approach with a longterm goal any major cis can turn into an unnecessary but inevitable night mare. after years clinical use and a thorough implementation of a cis on a major sicu it can be said that full-fledged cis offers an opportunity to dramatically improve the working environment on an icu. moreover, it adds to patient safety, quality of care and cost efficiency in one of the most advanced and expensive areas of medicine. conclusion: a major investment in man power and money is necessary to install and maintain a full-fledged cis. a sincere professional commitment to the goals of a cis is necessary. in exchange, a well configured and well maintained cis dramatically improves the quality of therapy and care on the icu. even return of investment and financial profitability of a cis seem feasible todayl from the clinical perspective it appears that the users themselves are the central determinant whether a cis makes a dream come tree or turns into a night mare. objectives: to establish a relationship between the activities of the staff and the occurrence of auditory alarms on the i. c.u. ard to evaluate confusion between auditory alarms. methods: laboratory based studies which investigated aspects of confusion between alarms in current use on the i. c. u. the observational studies were conducted over an month period and examined the frequency and duration of alarms together with the concurrent activites being undertaken by staff on the unit. the laboratory based studies showed that there were enduring confusions between the alarms on various items of medical equipment, for example a ventilator alarm and an e. c. g. monitor alarm. the results of the observation studies demonstrated that alarms are activated when specific activities are being undertaken by staff. sounds could be used in future recommendations for alarms on medical equipment. suggestions are also discussed for improving and rationalising auditory warnings in the i. c. u. obiectives: we investigated inferior petrosal sinus (ips), the lowest affluent to jugular bulb (jb), as a possible source of contamination of samples in jb for monitoring oxyhemogiobin saturation (sjbo ). pulling back the catheter the oxyhemoglobin saturation usually rises indicating extracerebral contamination (jakobs en met al: j cereb blood flow metab ; : ). methods: the study was carried out on patients undergoing ips sampling to differentiate cushing disease from ectopic acth syndrome and to lateralize any resulting pituitary lesion. we studied the value of oxyhemogiobkn saturation high in jb (sjbo ), at ips (sipso ) and at mid jugular vein ( th cervical vertebra) (smj ) bilaterally. results: we found significant differences between right sjbo and both right sipso (p= . ) and right smjo ( p= , ) and between left sjbo and both left sipso (p= . ) and left smjo (p= . ) we did not fred any difference bilaterally. objectives: we studied various methods of receiving and editing of clinical datas in critically ill patients (different ethiology). patients were investigated in regional intensive care center. methods : the following datas were studied : anamnesis, status praesens objectivus ( organs and systems ) ,. clinical and biochemical markers of critical condition , datas of eeg ,rheography . the medical information complex contained : channel electroencephalograph, -channel roencephalograph, ad-converter ( analog inputs, bit resolution, k hz), ibm dx , software includes set of routines for spectral eeg analysis, eeg-mapping, correlative analysis, and brain bloodstream reg-monitoring (written in turbo pascal . ), expert programs for estimation objective and humoral patient status (written in clipper . ) and statistics. there were used following programme-language instruments : borland c++ . , nantucket clipper . , ca-clipper tools ii. as the methods of statistical processing of dates were used: t-students criterion , fisher criterion, methods of correlation analisis, calculation of the regression levels, dispersion analysis, results : there was created the optimal structure of hard and sofware complex of search steady objective regularity in dynamic of critically ill patients condition. conclusion : the created system allowed to value effectiveness of intensive care and give us new opportunities in study pathogenesis of systems disorders in critical condition . over a five year period a patient data management system has been installed which allows individualised patient data to be accurately collected. using this data a costing system has been developed which ascribes costs thus: . direct costs -drugs, fluids, consumables, interventions. these are ascribed to individual patients, according to data collected from the pdms. . indirect costs -energy, depreciation, admm costs, maintenance etc. these are summed for the year and ascribed as an overhead per patient day. n.b staffcusts contain art element of both cost types the aim is to make as many costs as possibie 'direct', hence 'activity costs' have been calculated winch comprise staff time, drugs and consumables -these are direct costs. these costs of patient care are then searnlessly integrated into the financial and budget management of the icu environment. it was found that by calculating costs in this manner % of the total cost of icu are captured within the 'direct' element, and so are able to be ascribed to individual patients. this is much more accurate than simply dividing the total costs of ~cu by the number of patient days. temporal costs (variations during patient stay) and cross sectional costs (cost differences between admitting specialities) were also noted with interest. results of the initial analysis of data captured by the system will be presented. little is known about the resource costs (not simply cash costs) of icu. even less is known about individual patient costs, with previous estimates of these costs varying widely. however, if cost effectiveness studies are to be undertaken accurate calculation of individual, group and total icu cost is an essential, prerequisite, which, via this system of costing, is now achievable. information about intensive care of cancer patients is limited in the literature, despite the increasing use of such facilities in oncology over the two last decades. in order to determine if and how critical care facilities can be used specifically for these patients, we performed a world-wide inquiry in anticancer centers selecting the hospitals by using the international directory of cancer institutes and organizations. we mailed a questionnaire to centers and we received responses ( . %). there was at least one uncological (i.e. with > % of cancer patients) icu in (% % an -year old woman with graves disease presents with sore throat, vomiting, diarrhea, sinus tachycardia at /minute and a temperature of ~ several weeks before, treatment with propylthiouraeil had been stopped (rash and fever) and replaced by methimazole and ledide prior to a minor surgery. however, both drugs were discontinued by the patient two weeks before admission. shortly after arrival in hospital, patient's condition progressed to respiratory failure (upper airway edema), delirium and shock requiring icu admission, intubation and resuscitation with fluids and vasopressors. white blood count was /mm ~ with neutrophils. patient's hemodynamic data showed initial hyperdynamic profile followed by low output state with decreased sv ( %) (n - %) and cardiac index ( , ) (n , - ). echocardiogram confirmed cardiac chambers dilation as previously described in thyroid storm. lithium carbonate, corticosteroids, antibiotics and beta-blocker perfusion were given. plasmapheresis was started. free t& (n= , - pmo/l) went from , to , after the first two pheresis. after a remarkable clinical recovery, sub-total thyroideetomy was done i days after admission. in life-threatening thyroid storm, plasmapheresis is a very effective therapy when anti-thyroid drugs are counterindicated. purpose: to compare the reliability of prognostic indexes in crhically iu patients admitted in an intesive care unit (icu) who had acute renal failure (arfi and were treated with different dialytic techniques. material and methods: patients were included in a prospective study from june to november . patients presented arf defined by creatinin serum leve(s greater than pmol/l and previous normal levels. patients were divided in three groups. group i (control) : patients with arf who did not receive substitutive techniques. group ih patients under intermittent hemodialysis (hd) or peritoneal dialysis (pd). group ii : patients under continuous hemodiafiltrstion (hf). the statistical analysis was chi-square test and analysis of variance. results: the table shows the results we obtained, we did not find any significant difference betwen the two groups of patients undergoing dialysis. d(fferences were observed only between group i and the other groups as shown below. we did not find any significant association between the theoretical mortality predicted and the observed mortality according to saps in the three groups. due to exposure to a wide variety of unpleasant stimuli, for example, tracheal suctioning, venipuneture and physiotherapy, most pataents admitted to the icu will require some form of sedation. this review will describe the suggested properties of an ideal sedative agent for use in the icu and review the current limitations of some of the available agents from this perspactive. methods used to quantify the level of sedation, such as the ramsay score, glasgow coma score, newcastle sedation score and visual analogue scores, and their deficiencies will be examined. consideration will be given to defining the optimal level of sedation and the circumstances under which sedation might be varied over the icu course will be discussed. preliminary results from an ongoing study examining the role of light versus heavy sedation and ischaemia in a cardiac surgical icu population will be presented. the pharmacceconomics of icu sedation will be briefly addressed. finally, the role that sedation may play in increasing morbidity, pastieuiarly nosocomial pneumonia, in the icu will be discussed. objectives : therapy cost(tc) in icu patients is a substantial component of total hospital care cost. estimation of tc during this year, partitioning to various groups of drugs used and attempt to minimise it, were considered practically useful. methods : in collaboration with the hospital pharmacy we were able to have a complete report of au drugs used for icu patients (including enteral and parenteral nutrition). mean apache ii severity score upon admission was . and mean length of tcu stay was . days. price per drug unit and cost per group of drugs were also available drugs were divided into two groups: antibiotics ( ) cardiovascular drugs ( ), gastrointestinal system drugs ( ), enteral and parenteral nutrition ( ), respiratory system drugs ( ), sedative, analgesics and paralysing agents ( ), parenteral solutions with electrolytes, vitamins and trace elements ( ), anti-inflammatory agents ( ), protein substitutes and immunomodulation agents ( ), anticoagulative agents ( ). antibiotics were further subdivided into those "freely" prescribed (a) and those whose prescription and administration requires filling of a relevant form (b). results : !) tc for icu patients/day was . drs ($ ). total tc/patient was . drs ($ . . ). ii) partitioning total tc per group of drugs reveals : ( ) %, ( ) . %, ( ) . %, ( ) . %, ( ) . %, ( ) . %, ( ) . %, ( ) . %, ( ) . %, ( ) . %. t ) concerning antibiotics which consist the major cost component, group a and group b contributed by . % and . % to the total icu tc respectively. group b were administered to . % of all icu patients. conclusions : i) for the above studied patient population antibiotics consist almost half of total tc followed by protein substitutes and immunomodulation agents. ii) if tc control could be attempted in the icu, prescription of beth groups must be reviewed. appropriate treatment should be prescribed and readily provided to any patient. clinical significance of routine protein substitution, currently controversial, should be re-evaluated. new antibiotics (third & fourth generation cephalosporins, quinolones, carbaponems) should be prescribed on the basis of strict diagnostic procedures using modern technology available. rationalisetion of antibiotic therapy will lead to cost control, redistribution of icu expenses and substantial contribution to infection policy in our country. objectives: i -to investigate the clinic efficiency of the monitoring of the rso cerebral, in relationship to the stroke prevention, in patient undergoing carotid surgery. -to determinate the variations of the rso during the different surgical and anesthetic procedures in these patients methods: ten patients undergoing carotid endarterectomy. precise neurological exploration previously to the surgery and in the immediate postoperative period. angiography evaluation to the extend of carotid artery disease. invasive blood pressure, ecg, pulse-oximetry ( pso ) and rso were collected previousty to the induction of anesthesia. the premedication was administered intravenously -midazolam ( mcgr/kg) and fentanyl (i rncgr/kg) -. thiopental ( mg/kg),fentanyl ( mcgr/kg) and atracnrium ( , mg/kg) have been used for induction of anesthesia. co te is monitoring al~er the orotraqueal intubation ! the anesthetic maintenance is accomplished with lsofluorane ( , - , %) and bolus of atracurium and fentanyh the surgical procedure is standard (without arterial shunt during the carotid cross-clamping). we register each minutes: blood pressure, cardiac frequency, pso , co te and rso . the rso cerebral variate in relation with: the anesthetic induction, blood ~ressure, co te, cross-ulampping carotid and with the modifications of the head position. the maximum decrease of rso cerebral was in relation with the :ross-clampping carotid ( minimal value: ). no patient had neurologic complications and postoperative stroke after carotid endarterectomy were not observed. objectives: there are more than anesthesia in chelyabinsk emergency hospital every year. to % patients of it emergency anesthesia is applied. more than patients have ishemie heart disease (ihd), hypertansion (hp) and previos miocardial infarction (pmi). more than % of all patients are old patients (op). the resalts deep noninvasive bioimpedance monitoring (nbm) in surgical patients have been studied by us. methods: our nbm system "kentavr" includes parameters of cardiac and vessels function. it is realised by monitors in operation theatres and computer network. moreover we are able to examine surgery patients before anesthesia and perioperatively by using special computers system for cardiovascular reflex control by fast fourie transform (fft) of parameters simultaneously. results: pathients extremly needed peryoperative monitoring of hemodinamics. from these patients more % had stroke volume (sv) less than ml, n -co less than . /mim/m , % -ejection fraction (ef) less than n and % -puls bioimpedans microvessels (pbm) less than morn. patient had intensive care in special department. out of died. comparing with survived with these patients before operation hr was larger, sv, co,ef, pbm and puls bioimpedance aortha was smaller. much more of these patients were with ihd, pmi, hd, op. even with survived patients these parameters decreased the towards the end of operation. surgery patients had different variability of basic hemodinamical parameters with common tendency to increase power amplitude in low frequency by fft. conclusions: using of bioimpedanee noninvasive parameters allows to have criteria for corrections (infusies, vasodilatators, inotrops and others) and then us the final goal, to have more sucssesful surgery. with survived patients was perioperatively and postoperatively care more intensive. obiectives: the aim of the study was to compare the phi with the hemodynamically derived tissue oxygenation indexes as: oxygen delivery (do ), oxygen consumption (vo ), cardiac index (el), and arteriovenous difference in oxygen [(a-v)do ]. methods: patients ( males and females) with major trauma or major abdominal surgery were studied. on admission, a nasogastric tube allowing phi measurement was introduced and a pulmonary artery catheter was inserted for optimal hemodynamic management. each phi measurement was accompanied with a complete hemodynamic study comprising systemic and pulmonary artery pressures, blood gases, and cardiac output measurements with the thermodilution method. derived parameters vo , do , ci, (a-v)do were measured according to the standard formula. hemodynamic parameters were opt• as soon as possible with fluids, inotrepes, and vasopressors according to repetitive hemodynamic measurements. all patients were under mechanical ventilation. after hemodynamic stabilisation phi and hemodynamic measurements were repeated every eight hours, during a -hour study period. a total number of measurements were obtained and compared. statistics: results are presented as means + sd, correlations were performed between phi and the hemodynamically derived oxygenation parameters. a p< . value was considered as significant. results: mean values were phi= . + . , do = + , vo = + , c. = . + . , (a-v)do = . + . . no correlation was found between phi and do , phi and vo , phi and c.i, phi and (a-v)do . on the contrary in patients phi remained below . for more than hours despite adequate hemodynamically derived tissue oxygenation parameters. mortality in this group of patients was very high ( %). conclusion: no correlation was found between phi and the hemodynamically derived tissue oxygenation parameters our data suggest that phi is a better oxygenation indicator than the hemodynamically derived tissue oxygenation parameters, because it is closely related to the patient's outcome. objectives: the pathogenesis of septic shock and multiorgan failure is believed to be related to tissue hypoxia of the gastrointestinal tract. therefore new monitoring techniques, preferably organ specific, are required to establish the adequacy of tissue oxygenation. peep is used to reduce pulmonary shunt volume and improve blood oxygenation, but is accused to impair splanchnic perfusion. we studied mucosal oxygenation and perfusion on the capillary level in the stomach and the duodenum. methods: we used the erlangen microlightguide spectrophotometer (empho ll) together with a specifically designed fibre probe (bodenseewerk ger~tetechnik, berlingen) in combination with a standard gastroscope. measurements were performed on ventilated, traumatized patients (ages - years), with no evidence of shock or severe infection, after informed consent was obtained from the relatives. all patients were hemodynamically stable without inotropic support. an area of cm was analysed in the gastric corpus, the antrum and in the duodenum. in three patients we simultaneously measured the muc sal blood flow using a laser doppler flowmeter ( objectives: to investigate the influence of hb-o affinity in the monitoring of svo~ during improvement of cardiac index (ci) in cardiogenic shock. design: to state whether changes in svo: were associated in changes in actual pso (p~ ) and standard p~ (ps st) consecutive measurements of artero-venous bga, before an.d after therapy-induced changes in ci, were evaluated in patients (mean age -* y) suffering from cardiogenie shock, all under mechanical ventilation in psv modality. methods: together the hemodynamic measures, m~xed venous samples were analysed at ~ c using the abl radiometer for po , pco: and ph, and the osm radiometer for hbo %, hbco% and methb%. psost (i.e. the p~ at ph= . , pco:= mmhg and temperature at ~ c) was calculated automatically by the instruments on mixed venous blood as was the ps "in vivo" (i.e. the pso at the patient's value of ph, pco and temperature), using siggaard-andersen's computerizated algorithm. mean time between paired measurements was . -* . houm. the data were compared by anova test for linear regression and t-test for paired samples. results: a dose linear relationship was found between svo and oxygen extraction ratio (oer), r= . ,p= . . the improvement of ci ( . -* . to . + . l/min/m , p< . ) induced a significant increase in svo~ ( . -* . to . • . %, p<. ). a significant decrease in p ( . • . to . • . mmhg, p< . ) without any significant change in p~ st ( . • . to . • . mmhg, p=ns) was also found. these data show that either oer or the shift to the left of the oxygen dissociation curve account for increase in svo occurring with restoration of systemic blood flow. the program is intended to help the intensive care unit interne providing him with a practical tool when making decisions concerning patients in a critical condition. in his daily practice in intensive care unit, in this case the interne of the unit, uses this program for each patient as follows: on the first stage of data collection he should complete the following modules: ( )personal data ( )patient's pathology ( ) laboratory and~ monitor lug data ( )drugs prescribed or toxic elements ingested. in this way, the system allows optionally the consult with a computerized data base about the drugs prescribed, standardized parameters and techinques performed by the central laboratory. ( )reference to an antibiotics guide regarding becterian sensitivety in our unit, whitch ee checked every six month ( ) access to de questionnaired apache ii to load up new data. ( ) statistcs about patient's admission and discharge. results: once all data collection is finished the system performs the followin duties: ( )detailed drugs interactions, including toxic elements ( )diagnosis starting from the clinical, laboratory and monitoring data. in some cases, it also establishes therapeutic strategies, e.g. a coagulopathy ( ) give the l~narmacological incompatibilities between the drugs p~escribed and %he diagnosis established, and ( )perform dosage adjustments based upon the personal and pathological data. objeatve: to assess the power of diseri~,~ion ofa multiperpose severity score (sai~) when applied to subgroups ofpatieals (pta) according to their lemg~ of ~ay (los) in icu. design: in order to compute the saps probability, a model derived fi~m legible regression was developed. meaumree of calibration (goodmem..of.fit statistics) end discrimination (roc cm've and relative area under the cm've) were adopted in develotammtul asd validation set. the whole databue was ~ati~ed in five gronps reeked on los as follows: los = days, los = - days, los = - da~, los = - days, los > day~. area under the carve (auc) was ud~ninted for each ro~. s~ing: imlimlcus. patents: of ~ pts comec~ively admired ~ a period of three yeet~ ( ) ( ) ( ) , a total of was i~leded in this study. pts without saps, p~ yolmger them yearn, p~ with los shorter ~ hom'~ were excluded from this maly~is. iaterventinns: nose mema'onm~ end result: the logistic model developed gave good remits in terns of calibration md discrimin~on, both in developmental set (do.s g : . , p > . ; auc = . i- . ) and in validation ~t (g.o.g g : . , p > . ; auc = . ..+ . ). auc of each grottp showed a loss in di~zimination (i.e., prediaton) closely related with los, being . i- . in pts with los = days el . ~. ia tm with los > da~ (figure). following the present guidelines of integral management, in order to achieve optimization of sanitary resources and better use of facilities, we feel that the setting up of objetives is a key factor in the continuous process of improvement of quality care. postsurgical intensive care services maintain an interdepent relationship with other hospital services. within the general plan of the hospital it's of the utmost importance to delegate autonomy to the various depertments and service units in determining and achieving objetives. it's also necessary to establish mechanism for coordination of the activities in order to assure the succes of the program. the objetives cannot be improvised, they must be carried out in a specific manner in the following stages: .-analysis of the present situation (starting point). where are we?. defining objetives and making explicit the activities and methods to achieve them is to anticipate the future; it is of the utmost importance to comunicate said plans to all whom affect by encouraging them to attain the desired results. in the present paper we intend to show the guidelines to follow in carrying out a course of objetives. introduction:we presents results related to the quality of life (qol)of critical patients, from paeec project data. material and methods: the paeec project is a multicentre study define the type of patients cared for in spanish icus, and the therapeutic activity provided. ninety-five icus from spain are taking part. this study analyzes the qol of critical patients prior to their icu admission.for the evaluation of qol a questionnaire designed by our team for critical patients was used, with items grouped in sub-scales: physiological functions ( items); functional capacity ( items) and subjective aspects ( items). qol is classified in levels: normality ( points); slight deterioration ( - points);moderate deterioration ( - points); significant deterioration (>i points). the we present results related to therapeutic activity in critical patients and their age, from the paeec project. material and methods: the paeec project is a multicentre study to define the type of patients in spanish icus, and the therapeutic activity provided. ninetyfive icus from spain are participating. this study analyzes therapeutic activity in the first hours as evaluated by tiss, and related factors. results: the sample was , patients, sge . ~ . years. severity by apache ii system was . • points. the tiss score was . • points, distributed as follows: i (<i points): %; ii (i - points): %; iii ( - points): %; iv (> points): %.there is a positive correlation between the level of therapeutic activity and severity by apache ii (r = . , p < . ), and a very weak but negative correlation between tiss and age (r = - . , p < . ), so that an increase in age corresponds to a lower level of therapeutic activity.patients the multivariate analysis of the relationship between tiss and age took into account: severity, existence of previous history, need for mechanical ventilation, size of hospital, diagnosis and mortality. it indicated that there continued to be a relationship between therapeutic activity and age, so that as age increased, therapeutic activity diminished. conclusions: therapeutic activity performed on critical patients is less in the oldest patients, in whom excessively aggressive procedures are limited. a relational data base management system in the icu. c. kotsavassiloglou*, d.matamis, g. dadoudis, j. kioumis, d. riggos. icu dep., g. papanicolaou gen. hosp., exohl, thessaloniki, and * a' neurological clinic of aristotelian university, thessaloniki, greece. objectives: the introduction of the information technology in the i. c. u seems to be unavoidable because of the large amount of produced data and the need for their systematic analysis. such an information system should be a) easy to use, b) friendly to the user, c) powerful and d) modular. on that basis, we created a patient data management system (pdms) according to the expectations of the medical staff of an eighteen bed multidisciplinary icu. methods: we selected paradox for windows v . for the implementation of a relational data base because this program meets the above mentioned criteria. informations regarding the patients include a) demographic data, b) previous medical history, c)diseases upon admission, d)complications during hospitalization and e) outcome data. the diseases' registration consists of items classified in categories upon the principal system affected. specific informations about the need and duration of mechanical ventilation, nutrition, renal replacement, right heart catheterization and icp monitoring are also available. an extension was added concerning icu infections and related informations about antibiotic-resistant pathogens. all icu pathogens can be matched to their resistance or sensitivity and cost of antibiotics. the program can perform queries and various statistical analyses based on complex criteria. new modules can be added later according to the future needs and remarks of the users. results: the program was well accepted by the medical staff and patients were registered as a test. the first analysis of the data related a) observed mortality versus the apache ii predicted mortality, b) mortality according to the age, gender, pathology aud duration of icu stay and c) pathology upon admission and icu related complications. conclusions: the long term use of this pdms can be an efficacious research tool. it can be used in retrospective or prospective studies by addition of necessary modules. the first data analysis revealed the iack of an international diseases' classification system. the development of a worldwide common classification system is essential for the compatibility of the data analysis among various icus. this will allow the realization of multicenter trials on a large scale. s. nanas= n. sphiris, a. precates, a. lymberis, m. pirounaki, and ch. roussos dept. of critical care, university of athens, athens, greece the complexity of the cases submitted to an icu, the variety of underline disease, tbe severity, as well as the large number of substances administered to each patient constitute obvious the need of support with an easy available dss. this system will assure the safety of the administered treatment will help to adjust the dose according to the situation of each patient and it will screen for possible interaction and incompatibilities between the administered drugs. the goal of the present effort is the design and development of a software system acting as a decision support tool to physicians of icu. the application is organised around a relation database management system (rdbms) that consist of: a) all available substances ( . ), b) all generic names of medications available in our country for each substance, c) incompatibilities ( . cases) and d) interactions with other substances ( . cases). the following figure shows the structure of the rdbms. y ta~ortato~ [ c~rs using the stored parameters for each patient the dose and the rate of administration of selected substances will be possible to calculate. the continuous monitoring of the treatment for each patient supports the medical staff to make the necessary changes of the prescriptions. the application is currently developing in wireless pen based computer systems which place patients at the centre of "islands of information" located throughout icu. in conclusion this dss is a powerful and useful tool for icu staff because it provides without additionai work to the routine of daily practice, the currently available information for each order concerning drug interaction and incompatibilities as well as treatment monitoring is to obsea~ among critically ill pfdieats, stdjdivided following the diagn~s at the adn~ssio~ the diffmeax:es in the ~ and oxyplx~efic l~mmems bawe~ strvwors [s] and non sumvors ins] and to test the pc~'bih'ty to have soar survival criteria, as earliest as tx~able. method~ :we made a ~ study on consexa~e ~ilically ill paliffas, subdivided in series following the diastases at the admission: medical pafiea~ ( s and ns), surgical patients ( s and ns), a~d poliwauntas ( s and ns). follow up was done at d,.ays from the admission in ice. all the patienls were ramitored with a ~ c~eter and laeno:lymmi. "c and o .x.xyphorefic txuamaers va:~e couected at fin~es (t): at fiae ~draission (t ), at x~ars from t (t ), at (f ), (y ), (t ), % (t ) and horus from t cf ). in~,h ~ies, for ~y ~ a all the lin'~ n~an and sandaid d~viation was ~ tx~h for s and for ns. th~ betw~ s and ns tl~ roeaas of ~h porarneter ~e ccmpared tt~ng t-lest and p < . w~ considered ska~ significant in each series in the t wheae the mast significative diffemx:as ~goeamd bet~en s and ns, we made a txedictive criterion, asamting as predictive indices for stnvival the i:r values, higher or lower than flae treans of the ~rar~ers of au flae patients, axx)rdhlg to those ones t~iatistically diff~'e~ betw~m s and ns. fhmlly xse co:weatxt onaong the series the nrametees of the st~rs with the analysis of variance, to daserve the lxjsable differealt irea~ of sty hflices, following the diagn~s of admission: :nedkal, angical patient or poll~tam results: we c~ld not find ~ predictive criterion for politraonaas, perhaps ixx:ause of the few ntanber of l~fients. for high ri~ saw~cal patieras the following criterion at t has a sensitivi .ly of ~ ,and a ~ecificity of . %: sv > . nffmin/n~, map> mmhg, pmap< nmalqg cvp<i nunhg will nmah& lvswi> g m/m , sxo > ~ do > mlhnin/m , o er< %. for lx~dical l~tienls at t the following criteric~a has a ser~tivi.ty of % and a ~zificity of . ~ cvp< . mn~g, sao > %, s,g) > ~ vo i< ml/nfin/m , o er< %, shunt< % survlvops' data of the series ~ signitic~atly differenl~ both for the t~mody~nic a~ for fl~e ox rphomfic lxlmn~s; moreover we ~ that the vatt~ of hemodynamic mad ox.~ho~tic indices were higher in politrautms. conclus'ions: acx~ording to the fftffe~mt patho!o~es, the ~ rnelabo~c needs are diffeten~ so that it is juslified to mash ~ the~alceutic goals, following the type oflmthology. hen~ we foru~d for high ~k mrgical pmka~ and for medical patier~s assme, ff mllslied, a good prognosis while, if n [ ntljsfled~ the plinsliclioil ofdl~tth is no[ g(ioct finally, ab~ high iis~ supgical palieaats, according to what other atmhors say, txatws sh ~'n~ers ' therapeutic goalsvvould seem inadeqt~te, bec~jse they need a gear physiologic and themtx~ic elth~ in rdation to the rretabolic needs. figure ) . thus, the smaller european nations had a greater participation than ~e larger ones, with the exception of norway. a similar result was evidenced for contributions to intensive care medicine (figure ). these findings can be explained by different submission policies and language banners. however, there was no significant correlation with the gross national product of each country. conclusion: we conclude that the smaller european countries generally contribute more to international intensive care journals than the larger ones. objectives: to evaluate the agreement between a new and three old methods measuring ctp and to assess their reproducibility. methods: we studied patients ventilated with a siemens c respirator. we measured ctp by dividing the tidal volume with the increase in airway pressure (paw), either with the respirator setting used (ca) or with a fixed setting (cf). by modifing the inspiratory time (ti) without changing inspiratory flow, we were able to deliver two series of inflations ( , ,... ml) before and after curarisation of the patient. the same volumes were also inflated in paralysed patients with a super syringe. at the end of each inflation a plateau of sec was performed and paw was recorded. the above three sets of pressure-volume (pv) points were used to reconstruct the corresponding pv-curves (( , c , c the new method for ctp measurement without a super-syringe had the best reproducibility in paralysed patients and gave similar results without curarisation in the majority of them. however, agreement between the methods tested was unacceptable for clinical purposes. further investigation is required in order to improve the accuracy of ctp measurement in icu patients. m kunert, r.sorgenicht, l.scheuble, k.emmerich, h.g ker med.clinic b (dept.of cardiology) i heart center of wuppertal/university witten-herdecke,germany objective to determine the accuracy of activated partial thromboplastin time (apl-l) and activated clotting time (act) studies when samples are drawn through heparinized central venous catheters (cvc). methods a total sample of paired act/p't-/" values was analysed in patients ( m., f., + y.) for monitoring heparin therapy.all patients had a cvc (certofix trio,braun,frg) in the internal jugular vein receiving a continous infusion of . u heparin via the central catheter.act (hr-act, hemotec,usa) and ap'i-f (neothromtin, behring,frg) samples were drawn from the cvc using the double syringe technique (removing and discarding ml blood before drawing the sample). these blood samples were compared to act/ap'cf blood samples obtained by venipuncture (v.fem.) at the same time, act values were analysed directly in the intensive care unit (icu),api-i samples were measured in the hospital laboratory within minutes. results ac-i -~ pi-f~ cact/~pi r = , ) cvc samples + + . v.femoralis samples " + + p-value n.s. n.s. conclusion there is no difference in heparin anticoagulation studies drawn from heparinized central venous catheters compared to those obtained by femoral venipuncture,withdrawing ml blood prior to obtaining the blood specimen is a safe way for eliminating heparin contamination.not only the aptt test but also the act test is a useful method for heparin anticoagulation assessment in the icu. objectives: evaluation of the delicate balance between filter-coagulation and patient-hemorrhage using heparin as anticoagulant in continuous renal replacement procedures. methods: from january through august , we studied filter surviva[ and hemorrhagic complications during filter periods in critically d[ patients, treated with continuous arterio-venous hemo(dia)filtration, with special emphasis on the heparin dose, concurrent use of coumarins, systemic activated partial thromboplastin tirne(aptr), platelet count, mean arterial bloodpressure and the type of filter used. results: filters ( %) were disconnected because of coagulation. mean survival of multiflow an filters was twofold shorter compared to survival of fh gambm filters. a total of hemorrhagic complications occurred of which three patients died at aptt values of respectively , and seconds. after adjustment for mean arterial bloodpressure, platelet count and the type of the filter, the risk for filter-coagulation decreased % (relative risk . , %c . - . ) for each ten seconds increase in aptt. the risk for patient-hemorrhage increased % (relative risk . , %ci . - . ) at an aptt-increase of ten seconds. the occurrence of filter-coagulation and patienthemorrhage was not correlated with the administered dose of heparin. concurrent use of cournarines had a positive effect on filter-survival, without increasing the overall incidence rate of patient-hemorrhage. conclusions: the systemic apt]" is a good predictor of the risk for filtercoagulation and patient-hemorrhage. heparine therapy seems optimal at an aptt between and seconds, although one should realize that fatal hemorrhagic complications still can occur. objectives: the alterations in vascular tone which are primarily regulated by adreno-sympathetic tone(ast) are compensatory responses in hemorrhagic patients. this study was designed to evaluate the correlation between vascular tone and ast in patients with hemorrhage, methods: the vascular tone was expressed by volume elastic modulus (ev) that is defined as; ev = ap/(av/v) (ap; the arterial pulse pressure, av/v; the volume change ratio). ev was measured using a non-invasive transmittance infrared photoelectric plethysmography (tipp) and a volume oscillometric sphygmomanometer . we prospectively studied patients with hemorrhage. the initial ev measurement was performed on arrival and repeated for a hours duration. as a parameters of ast, serum concentrations of adrenalin (ad), noradrenalin (nor), plasma renin activity(pra) were measured simultaneously. we analyzed the correlation of ev and conventional parameters to ast by multivariate statistical analysis. results: ev values at transmural pressure mmhg on admission and hours later were respectively . + . mmhg, . +_ . mmhg (mean + sd). systolic pressure(pas) and serum hormones on arrival and hours later were respectively, pas; . _+ . , + . mmhg, ad; . _+ . , . _+ . ng/ml, nor; . _+ . , . + . ng/ml, pra; . _+ . , . _+ . ng/ml/hr. the ev values correlated significantly with ad (r= . , p= . , n= ), nor (r= . , p= . , n= ), pra (r= . , p= . , n= ). by multivariate statistical analysis, ev correlated more significantly with ad and nor and pra (p= . ) than the conventional parameters such as pas, heart rate and pulse pressure. conclusions: the alterations of ev correlates closely with ast. the compensatory mechanism in hemorrhagic patients can be detected noninvasively by ev monitoring. obiectives and method: autologous oxygenator blood was processed at the end of cardiopulmonary bypass (cpb) by either hemofiltration (hf , , m , fresenius) or by cell washing with a onntinous autologous transfusion system (cats, fresenius). prospectively the blood of patients for each group was processed and then retransfused intravenously to the patient. besides, volume and time requirements, standard hematologic chemistry, coagulation and complement activation were measured. results (mean values for oxygenator blood at the end of cpb, and results of concentrate after processing by filtration or washing): both processing techniques show excellent hemoconcentration of the diluted cpb blood with a good transfusion effect for the patient. filtration retains all plasma proteins and large molecular weight plasma bound waste products. in contrast, cell washing with cats significantly depletes plasma proteins and waste products. the newely developped cats machine gives eonsisinnt laboratory result in a fully automatic continuous processing mode. in conclusion, both filtration and washing are effective for processing cpb blood. filtra tion yields a highly concentrated whole blood, whereas cats washing produces a high quality autologous erythrocyte concentrate. soluble fibrin has during the last years gained interest as a marker for the activation of the coagulation in connection with various clinical conditions, e.g. disseminated intravascular coagulation, deep venous thrombosis and myocardial infarction. elevated levels of soluble fibrin in plasma can be detected by the chromogenic assay coaset fibrin monomer, relying on the ability of fibrin to enhance the tpa-catalyzed conversion of plasminogen to ,plasmin. using this test, it has been shown that the level of soluble fibrin can be correlated to severeness of illness in critically ill intensive care unit patients. a revision of the coaset fibrin monomer kit has now been made and the new product, coatest soluble fibrin, is considerably more convenient to handle and gives higher resolution at low fibrin levels. the test is performed by the addition of a buffer dilution of the plasma sample to a microstrip well containing the colyophilized mixture of tpa, plasminogen and the plasmin specific cbromogenic substrate s- . the reaction is allowed to proceed at,. room temperature for minutes before discontinuation. the absorbance at nm, measured in a microplate reader, is proportional to the content of soluble fibrin in the sample. the assay is carefully standardized and calibration curves are provided in the kit. the convenient and rapid assay procedure makes the coatest soluble fibrin test well suited for single test analysis in acute situations. objectives : blood coagulation abnormalities have been reported in the systemic blood of patients with cerebral lesions. the physiopathology of such events is not yet completely understood. we compare the coagulation profile of blood from the right jugular bulb with systemic blood of patients with head injury. methods: we studied patients, who were admitted to our neurosurgical intensive care unit between january and march with head injury and no other associated pathology (age - yrs), a glasgow coma score <= g, no abnormality in baseline coagulation profile and no history of coagulopaties. the patients did not undergo angiography. a one-way gauge certofix catheter was inserted through the right internal jugular vein up to the jugular bulb. an identical catheter was inserted through a subclavian vein. blood was sampled from either catheter (a=atrial; j=jugular) - hours after trauma (t ) and t hours later (t the inddence dpontolx'rative thmmhi~e and haumord~gic complieatiom were assessed in padents treated with indobefen, heparin calcine caeca), low mollecolar weight heparin (lmwh) (f.nosheparin) and undergoing hemodiludun, blood predeposhing, intra mad postoperative blood saving. ]'he indolmfon tempota~.norks platelet aggregation through ,,elective inhibition of the cyclatygenasis and thus atacbldonicadd( ).tbe n'mimum effect occurs after hours from the fast administration and is still present after hours. ~- patients, mean age --- yrs., weight --- kg were studied. ( . %) were male and ( . %) female. onderwent hip prosthesis ( previously plate and screw removal) hip revim'un ( stem, cop and stem + cop), tutal knee prosthesis, in the st anaesthesidogy depl from - to - - . as for antithromboembolic ptephylam, apart from hemodihitiun pts were with treated indobufen ndo), with heparin ealdum caeca) and with low mo!lecular weight hepam (lwr, ). as the slightest clinical and/or imtmmental suspidon of deep vein thrombosis (dv'i') or polmonary umbolism(pe), a phlebogram or sdndgram were respectively carried out. -the inddence of homologom transhisiom was significandy lower (p= . l) in the padeats treated with indobufen ( . ) compared .'ith heca ( . %). the con~gency table shows statistical signifleance for the use of heca in patients with vein deficiency in the lower limbs, past dvr and/or pe, coronary heart disease (cdh'), while there is no correlation for renal, cardiac or liver defidency, obesity, systemic hypertemion, atrhythmy, diabetes, chronic bronchitis and rheumatoid arthritis. by comparing the postoperative cumplications with the risk factors, there ks a highly significant correlation (p= . l) between cdh and thrombotic and humord~agic complieatiom (pe, death, he~atoma, die use of hum_ologous blood). thee data show that hep~in, preferred in patients with c'dh, roost likely for leagal-tuedical reasons, did not have the de~'ed effect. conclusions -the stastisfical aar~ais shows ~nifieanfly different efflea~ (pro . ) between the therapies (see table) : it can be seen that in patients undergoing autotramfusiun and hemedihidon, indobufen produo~ a lower incidence of haemotrhagic complieatiens compared to heca and lmwh and is more effective in the prevention d ~c complications at clinical e~idence. the duration of i~toperadve hospital stay is signi~cantlylonger for patients transfused with homologous red ceils and treated with hec, .a ( . -+ . days) and lmwh ( . +- a days) compared with indo(ll. _+ a days). one of the main causes for postoperative complications in major orthopaedic surgery is postopemtive bleeding with local effects in the operation site (hematomata, pain and delayed mobilization) and/or systemic and subsequent cardiodrculamry repercussions that are sometimes severe. the aim of this study is to assess the possibility to apply a new system of monitoring, control and saving postopemtive blood loss from the drainage. the bt recovery dideco (marandola, modena-italy) ~ used since it is the only apparatus capable of doing this. the apparatus consists of a pressure transducer, adjustable from - a + mmhg, which activates a peristaltic pump connected m drainage robes. the bt recovery display shows hourly bleeding in the first hours, total bleeding, time passed since the start of monito~g and subsequent salvage and the aspimtioo pressure on the drainage robes; the latter is inserted at - mmhg and then modified according to bleeding/minute, g bt recovery also has an alarm that sounds automatically if.' blood loss is more than ml/hour; air is in the circuit; the batteries are running low. materials and methods: pts were studied ( m and ~), aged . -+ .lyears, basal hemoglobin . -+ (range . - . )g/all, treated from st january, to mst december, in the st service of anesthesia and intensive care unit of our hospital. the patients underwent the following surgical treatment: total hip revision ( pts), cup revision (~ipts), stem revision ( pts), total knee revision ( pts). the average dumtion of the operations was -+ min. intranpemtive monitoring and blood salvage was applied to all patients. genera! anesthesia was used on pts. and integrated (epidural analgesia + light general) on the remaining t . anttthromboembolic prophylaxis consisted of external pressure bandage, isovolemic hemodilution with iodobufen in ( . %)pts., calalc heparin in ( . %)pts., low molecular weight heparin in ( . %)pts.; pt did not give a predepoalt of blood, gave unit, pts units, pts units, pts units. the data obtained was statistically analysed using contingency tables and anova. results: average intmop salvage was -+ ml, average postop salvage was -+ mi the average intra+postop +- ml. average postop loss was -+ ml. the global incidence of postop complications was: h~natomata . %, dvt . %, pulmonary thromboembolism , , myocardiac ischemia . %, acute myocardic infarction . %, respiratory deflciecy . %, arrhythmia %, cystitis . % there were nn complications in . % of pts. postop bleeding over ml in under minutes (with bleeding alarm activation) occurred in pts ( . %). this sta~tically correlates only with the type of operation performed (more frequently in total hip revision p= . ) and with a significant decrease (p~ . ) in the pruthrombic activity detected about hours after the operation. this bleeding, also made the alarm sound, calling the attention of staff who could act accordingly, by making the drainage pressure positive and incre~sthg the tension of the external pressure bandage. conclusions postop monitoring, control and blood loss salvage combined with predepoalting and intmop salvage has enabled allogenic transfusions in % of cases to be avoided in operations with high postop blood loss like hip or knee revision. the usefulness of the system can be seen by the fact that in the patients with so much bleeding to set off the alarm, there was no significant difference in the incidence of allotransfusions and complications. references )borghi b., bassi a., de simone n., laguardia am., fonnaro g. an injury of the brain may result in various disorders of hemostasis caused by the release of • into the circulation through a damaged blood-brain bar tier. disseminated intravascular coagulation(dic) is one of these disorders. it is a freguent but relatively rare ly diagnosed complication of subaraohnoidal haemorrhage. the aim of this study was to evaluate some parameters of both blood coagulation and fibrynolisis in patients with sah.in addition one wanted to find out wh~ther potential changes correlated with the pa• condition in the acute phase of sah and whether they influenced the course of this disease. patients with sah were studied. in of them sah was due to closed eraniocerebral injury and in the rema ining resulted from vascular malformation. the following parameters were evaluated:the prothrombine time,the activated partial thromboplastin time, the thrombine time,level of factor v,fibrinogen degrada tion products and fibrin monomers. the results let us show the presence of oic in patients with closed craniocerebral injury and in with vas. cular malformation despite the lack of clinical symptoms the tests in posttraumatic patients and in patients from second group showed incomplete dic.on admission patients with such changes in measured parameters were in poor condition.the course of the disease and the effe cts of treatment were also worse in these patients. the results showed ihal in patients with sah complex disorders of both coagulation and fibrynolisis occur, and they depend on clinical condition of the patient. they also influence the course of the disease. methods : charts of all patients admitted with d.i.c. over a ten year period ( - ) were reviewed. diagnosis of dic was based on the association of fibrinogen < g/ -platelets < / -fpd > ~tg/ml in the hours of the admission. results : patients -mean age + y -saps +_ -gestanional age _+ weeks -the two first conditions associated with d.i.c. were placental abruption ( %) and preeclampsia or eclampsia ( , %). bleeding episode was present in pts ( %) and surgical treatment has always been necessary. pts ( %) were given packed red ceils ( + u) and fresh frozen plasma ( + u). patients were given platelets packs. heparin was never administered. pts required mechanical ventilation and two patients hemodialysis. all the patients survived. correction of prothrombin time (p.t.) and fibrinogen (f) was quick (p.t. at t h ~ % -f at t h , + , g/i). but platelets count remained low (plat. at t h + / ) -no difference was observed in patients who received platelets. conclusion : prognosis of critically ill o.p. is good. blood loss is the main complication. correction of hypovolemia and anemia with concomitant surgical treatment are essential. the administration of coagulation factors or platelets is still under discussion. objectives: to evaluate the effects of antithrombin iii i at-iii) and a protease inhibitor, gabexate mesilate foy), on the coagulation and fibrinolysis in disseminated intravascular coagulation (dic). methods: after the approval of our institution and consent from patient's family, patients with a dic score ( , japan) more than points (dic or having a risk for dic) entered this study. they were randomly divided into two groups, foy (i- mg/kg/h for days or more) treated group and no foy group, each of patients. platelet count (plt), fibrinogen (fen), at-iii fibrin degradation product (fdp), d-dimer (do), fibrin monomer (fm), thrombin-antithrombin complex (tat), plasmin-plasmin inhibitor complex (pic), and prothrombin time ratio (ptr) were measured before the start of treatment (at admission) and i, , and days after the admission. at-iii at units for days was administered if the at-iii at admission was less than %. finally the patients were divided into four groups: group a, foy (+) and the at-iii ~ %; group b, foy (+) and the at-iii < %" group c, foy (-) and the at-iii %; group d, foy (~) anffthe at-iii < %, each of patients, to match the patients for backsrounds. all parameters, dic score and survival rate in a month following treatment were compared among the four groups. results: the at-iii and plt from day to were significantly higher in groups a and c than in groups b and d. the fdp, dd, tat, and pic after treatment decreased significantly from the baselines in groups a and c but not in groups b and d. the fgn and fm were not significantly different among the four groups. the ptr decreased in groups c and d but increased in group b. the dic score decreased significantly in groups a and c than in groups b and d. survival rates were %, %, % and % in groups a, b, c and d, respectively, although not significantly different. conclusions: in patients with dic or a risk for dic, foy had no expected effects but at-iii had suppressive effects on the coagulation and fibrinolysis mechanisms. a prognostic factor ? carbon monoxyde intoxication is a classical complication of inhalation injury. carbon monoxyda is also physiologically produced during the heme metabolism: heme is conversed to bi]irubin by the hemeoxygenase which is an intracellular stress protein. icu patients (pts) were studied prospectively for apache ii score and carboxyhemnglobin (hbco) arterial level to assess if hbco level could be correlated with the severity of the pts. objective: to evaluate a new technique of non-surgical tracheotomy. patients: adults, mean age years and children, mean age months ( me.- yrs). method: through a needle inserted in the trachea, a guide wire is retmgradely pushed out of the mouth and attached to a special device formed by a flexible plastic cone with pointed metal tip joined to an armoured tracheal cannula. this device is then pulled back through the oral cavity, larynx and trachea, and outwards across the neck wall by applying traction on the wire with one hand and counterpressure on the neck wall with the fingers of the operator's other hand. when the cone and / of the eannula have emerged, the cannula is cut off from the cone, straightened perpendicular to the skin, rotated and advanced caudally to its final position. results: endoscopic control facilitates and improves the safety of all manoeuvres. the pointed cone easily pierces the tissues, and the cannula is extracted without difficulty since it has the same outer diameter as the cone. tissue adherence around the cannula is absolute thus preventing local inflammation. the time in apnea required for dilation and cannula placement does not exceed see., and it is well tolerated because within safety limits in patients hyperventilated with oxygen. only one case of bleeding occured in a patient on dialysis with severe coagulopathy. autoptic findings in subjects who died due to progression of primary disease showed a very regular stoma with an almost complete lack of hematic and flogistie infiltration in recent tracheotomies. .conclusions: translaryngeal tracheotomy (tlt), by virtue of its greater inherent safety and lower tissue trauma than percutaneous techniques, can also be carded out in infants and children, a severe test bench for any tracbeotomy technique. further specific indications are recently stemotomized patients, since tlt is associated with a low rate of infection, and short term tracheotomies after laryngeal surgery, to prevent obstructive complications. references: fantoni a., translaryngeal tracheotomy, apice, ed. gullo, trieste, , . background: inhalation of no has been shown to reverse hypoxic pulmonary vasoconstriction , to reduce pulmonary pressure in pulmonary hypertension of different origin and to improve gas exchange. in putmoflary embolism, pulmonary hypertension is caused by mechanical vascutar obstruction and by reactive vasoconstriction. the effects of inhaled no in putmonary embofism has been partiatly studied' the purpose of this study was to investigate and determine the effects of no inhalation on pulmonary hemodinamica and gas exchange in a hypoxic canine model of pulmonary embolism. methods: two groups of adult mongrel dogs were studied: group (control} dogs and group (no inhaled) dogs. both groups were anestesized with tiopental, mechanically normoventilated with an hypoxjc mixture of and n~ (f[q , ) and instrumented (swang-ganz catheter, femoral artery catheter) pulmonary embolism (pe) was induced by fisher's method s. no inhalation ( ppm) in group was started rain. pdor to pe and kept constant throughout the experiment. no inhaled concentration was analyzecf by chemiluminiscence technique. pulmonary artery pressure (pap), central venous pressure and sistemic arterial pressure were continuosly recorded. cardiac output, artedat po~ (pan ) and mixed venous po~ were measured in both groups under hypo)dr conditions, before pe and , , and rain. after pe. pulmonary vascular resistance (pvr) and gas exchange (pao fio:~ ratio), were calculate using standard formulas. data were process and analyzed with non pararnetdc test, and reported as mean -so and statistical significance was considered if p < , . : no produced an increase in arterial oxigenation (pao /fio~ ratio) and reduced pap before pe induction in group . after pe we found no significant difference with .respect to the time eour.se of pap, pvr and gas exchange between beth groups throughout the experiment. probably, the severe mechanical obstruction produced in pulmonary embolism masked the small effects of no inhaled. obiectives: blood volume measurement would be useful in critically ill patient management if it were easy to perform. this is not the ease and current methods are based on radiolabelled red cell dilution. inhalation and uptake of a known mass of carbon monoxide (co) gas and measurement of earboxyhaemoglobin increase can give results accurate enough for clinical use. this requires a rebreathing system providing oxygenation and carbon dioxide removal, yet complete retention of all carbon monoxide administer&l, and so most authors hand ventilate with a bag and waters soda-lime canister, adding oxygen as necessary. we aim to popularise this method by; i)design of an automatic co administration system driven by the itu ventilator and ii)writing of software for a portable computer to perform all necessary calculations method: we show the computer is use estimating the co dose required and later estimating the blood volume. we also show the new gas administration system. this is a fully closed circle attached to a "bag in bottle", driven by the ventilator. the novel feature is the mechanism by winch driving gas (set to % ) spills automatically into the circle, balancing o uptake by the patient, yet allowing no co loss. conclusions: this equipment is easy to use, reduces human error and allows optimum ventilator settings to remain. the operator merely administers the volume of co determined by the computer and takes blood on two occasions. carboxyhaemoglobin measurement is easy to perform, thus there is a cost saving also. with our modifications use of this technique may potentially become more widespread, the video demonstrates the method in use in our itu. - ( %) underwent conventional surgical therapeutics. " ( %) with resection of tracheal stenosis with end-to-end anastomosis(rts). i ( %) with broncoscopic dilatation. one patient died and the others still have stable patency(sp) without continued treatment. - ( , %) have received endoscopic laser ablation with or without calibration tubes. of them ( , %) are receiving continued endotracheal treatment until now. ( , %) have sp wihout continued treatment. -i ( , %) endoscopic laser therapeutic case turned to rts and is having sp. conclusion: conventional surgical aproach has been progressively replaced in our hospital by endoscopic laser ablation and silicone calibration tubes. this study suggests that these technics are effective and could be the elective treatment for iatrogenic stenosis. obiectives: hemorrhagic disorders due to thrombocytopenia and thrombocyiopathia remain one of the most serious complications during long-term extracorporeal membrane oxygenation (ecmo) in patients with severe acute respiratory distress ~drome (ards). in the presented study, nitric oxide (no), kwown as a potent endogenous platelet antiadhesive, disaggregating and antiaggregating compound, was evaluated for its possible antagonistic effect on platelet trapping when added to the gas compartment of membrane oxygenators (mo). meti~ods: two parallel separated extracorporeal circuits, consisting of heparin bonded hollow fiber oxygenators (minimax, medtronic, carmeda eioactive surface), tubing systems, low pressure reservoirs, and roller pumps were prepared. for each measurement, a pair of circuits was simultaneously filled blood from the same volunteer. low-heparinized fresh warm blood was obtained from four healthy volunteers, who had no drugs for at least two weeks. the gas inlets of both oxygenators received dry gas ( % oxxygen, % carbon dioxide, % nitrogen); gaseous no ( ppm) was added to the gas of one of the oxygenators (no-mo), whereas the other one (mo) was used as control. after minutes no gas was switched off, so that the no-mo received no more no, and no was added to the gas inlet of the membrane, which had no no before_ to assure iutracircnit volume stability, drawn blood for measurements was replaced with saline, and platelet counts were corrected for dilution by hemoglobin values. the mean of four platelet counts (coulter counter) of each timepoint (start, , , , , , , , and minutes) was used for statistical analysis (paired sample t-test). results: in the no-mo platelets remained at + , % (percentage of baseline value, mean -+ sd) until min. in contrast, platelets of the mo continuously decreased after start and were significantly lower after minutes ( , + , % vs _+ , %(p< . ); min. , -+ , %vs , _+ , %(p< . ); min. , _+ , % ( p < . ). after switching of no gas to the mo, further decrease of plateleta was stopped and platelets remained at , +_ , % until termination of circulation. platelets of the former no-mo decreased slightly after cessation of no gas to , _+ , %. conclusions: these data indicate that gaseous no significantly attenuates platelet trapping in hollow fiber oxygenators, when added to the gas compartment. this might be a new therapeutical approach for membrane oxygenator induced thrombocytopenia during long-term ecmd. objectives: nitric oxide (no) plays a pivotal role in regulation of vascular hemostasis. several studies elucidated the antiadhesive, antiaggregating, and disaggregating properties of endothelially synthesized no to platelets. additionally, agonist-induced no production in platelets by the l-arginine-no pathway was found as a negative feedback mechanism after platelet activation. although noplatelet interactions were intensively studied by several investigators, no data exist, about changes in platelet surface molecule expression in no-modulated platelets measured by flow cytometry using monoclonal antibodies (moabs). methods: p-selectin (alpha-granule-membrane protein, gmp- , cd p) and glycoproteiu (gp , lysosomal protein, cd ) are expressed only after platelet activation and degranulation. activation was quantified in thrombin ( . u/ml) and adp ( . ram) stimulated platelet rich plasma samples (prp). blood was obtained from healthy volunteers (n= ), who had no drugs for at least days. for evahiation of no-modulated activation, the spontaneously noreleasing compound sin-i ( . mm) ( -morpholino-syndonimin-hydrochlorid) was added in parallel prepared samples prior to the addition of agonist. platelet surface molecule expression was evaluated with moabs directed against cd a (gpilbliia, fibrinogen-receptor, phycoerythrin(pe)-conjugated), cd p (fitcconjugated), and cd (fitc). only cd a-positive signals were gated in sideangled light scatter, and assayed for activation marker expression (defined as percent of gated population). results: basal p-selectin expression was . + . %, and increased to . _+ . % after thrembin-activation, and to . + . % in adp-stimulated samples. addition of sin- attenuated p-selectin expression to . - - % in thrombin (p<. , two-tailed paired t-test), and . + . % (p<. ) in adpactivated platelets. basal gp expression was . _+ . % and increased to . + . % in thrombin, and to . _+ . % in adp-stimulated samples. with sin-l, gp expression decreased to _+ . % (p<. ) in thrombin, and . : . (p . ) in adp-stimulated samples. conclusions: these data implicate, that no leads to a significantly reduced activation of surface molecule expression in thrombin and adp-stimulated platelets. in addition, flow cytometry might be a useful tool for studying modulation of platelet activation by no or no-releasing compounds. introduction: acute cadmium poisoning is very rare. on initial presentation may mimic metal-fume fever, but acute inhalation cadmium toxicity may produce fatal chemical pneumonitis. case report: we present a case of acute fatal respiratory failure secondary to cadmium-fume irthalation. a year old patient was trasferred from another hospital with acute respiratory failure presumably due to pneumonia. the last days before he had had commom cold symptoms. he had been cutting with a welder during one hour without any respiratory protective measure. three hours after exposure he developed progressive dispnea and was admitted to hospital. with presumtive diagnosis of respiratory infection, antibiotics were begun, however be failed to improve. all microbiological studies were negative. chest x-ray showed bilateral diffuse infiltrates. on seventh day he needed intubation and mechanical ventilation and on th he was admitted to our icu. antibiotics were stopped and new microbiological studies were performed including brochoalveolar lavage and virologic studies. all results were negative. he developed progressive hipoxemia and hipercapmia and finally, multiorganic disfunction syndrome. he died days after exposure. the metal he had been working with was a % cadmium alleation. blood cadmilam concentration days after exposure was . mcg cd/g cr, and urine cadmium concentration was . mcg/l. on postmortem examination, tissue cadmium concentrations were: blood ng/ml, liver ng/g, kidney ng/g and lung ng/g. these values confirm that cadmium was the cause of the fatal respiratory illness in this patient. conclusion: this case evidences the considerable hazard of acute poisoning after inhalation of eadmium-fume and stresses the need of appropiated safety measures against metal-fume poisoning. aim : lactic acidosis is considered the hallmark of cyanide poisonirig. however, the relationship between plasma lactate and blood cyanide levels has not been determined. the aim of this study was to determine the significance of plasma lactate concentration (plc) during the course of cyanide poisonings. methods : the patients were included according to the clinical suspicion of pure cyanide poisoning at the time of presentation. fire victims were excluded. serial blood samples were collected before and after intravenous hydroxocobalamin (hoco). blood cyanide concentration (bcc) was measured colorimetrically. plc was measured enzymatically. results : patients were studied. on admission, plc ranged from . to mmol/l, and bcc from . to gmol/l. mean systolic blood pressure was • mm hg, mean arterial ph . • . , mean anion gap was . + . mmol/l and mean pao . • . kpa. three patients died. before antidotal treatment, there was a significant correlation between plc and arterial ph (p = . ), anion gap (p = . ) and bcc (p = . ) but not with heart rate, pao , paco and blood glucose, or blood pressure. during the whole course of the poisoning, a plc _> retool/ was a sensitive and specific indicator of a blood cyanide concentration > ~tmol/ . sustained catecholamine administration reduces the correlation coefficient. conclusion : baseline measurement of plc allows assessment of severity of acute cyanide poisoning. thereafter, plc may be used to assess the adequacy of antidotal treatment, more especially in patients not requiring sustained infusion of catecholamines. aim: the aim of this case report was [o study the correlation between the plasma lactate levels and several clinical, biological, and toxicological parameters serially measured during the course of a cyanide poisoning treated with a high dose of hydroxocobalamin. a -year-old male ingested potassium cyanide leading to cardiac arrest. cpr was performed prior to hospital arrival where the patient received g hydroxocobalamin. sbp rapidly returned to normal allowing withdrawal of epinephrine. the patient remained comatose and died from brain injury days after the ingestion. methods plasma lactate and blood cyanide levels were measured serially. blood cyanide levels were measured using a colorimetric method.~ plasma lactate levels were measured using an enzymatic method. for correlation spearman rank correlation test was used. results. initial plasma lactate and blood cyanide levels were mmol/l and gmol/l, respectively. there was no overall correlation between sbp and either blood cyanide or plasma lactate levels. similarly, there was no overall correlation between arterialvenous oxygen saturation difference with either blood cyanide or plasma lactate levels. in contrast there was a strong correlation between blood cyanide and plasma lactate levels (r= . , p< . ). the time-course of the blood cyanide concentrations was described by a mono-exponentiai decay (r = . ) with a blood half-life of . h. similarly, the time-course of plasma lactate levels was described by a mono-exponential decay (r = . ) with a blood half-life of . h. discussion. in this case of acute human poisoning, sbp was a much poorer indicator of continuing cyanide effect both before and after antidotal treatment, than was lactate production. this suggests a potential clinical role for following serial plasma lactate levels as a marker of the evolution of cyanide toxicity. aim : cyanide (cn) poisoning in fire victims is frequent and rapidly fatal. in a prospective study we tried to assess the clinical tolerance of a high dose of hydroxocobalamin (hoco) administered at the scene of the fire in fire victims suspected of cn poisoning. methods : inclusion criteria : soot in mouth or sputum ~ any degree of neurological impairment. exclusion criteria : children, pregnant women, burns of total surface body area > %, multiple trauma. protocol desigrl following examination and the collection of a blood sample in dry heparin, a g dose of hoco ( g in case of cardiovascular collapse) was administered intravenously over min. the systolic blood pressure was monitored before and after the administration of hoco, and one hour later. results : there were females and males. the mean blood cn concentration was • pmol/ . the mean blood carbon monoxide was . • . mmol/ . nineteen fire victims eventually died. among the non-cn-intoxicated patients (blood cn < ~mol/ ), there was no significant change in arterial blood pressure. in the cn-intoxicated patients (blood cn > gmol/ ) a significant increase in blood pressure was observed both immediately (p < . ) and hour later (p < . ) after the admistration of hoco. no allergic reactions were observed. conclusions : in fire victims with cyanide poisoning, the administration of a high dose of hydroxocobalamin was associated with an improvement in systolic blood pressure. hydroxocobalamin is well tolerated in fire victims without cn poisoning. objectives: tricyclic antidepressant (tca) overdose can lead to serious complications including cardiac arrhythmias [ ] . because of the known risk of early deterioration and the implication for management, emergent evaluation is essential. we determined the diagnostic usefulness of the electrocardiogram (ecg) in tca poisoning. methods: retrospective study of all patients with tca intoxication (pos. ,toxicology screening in urine and/or pos. history) in a -beduniversity hospital from through . the severity was graded with mild= no symptoms or agitation; medium= disorientation, somnolence, tachycardia, or convulsions; and sever~ coma, significant arrhythmias or death. we analysed the first ecg after admission with a special emphasis on qrs-and qtc-intervals and the terminal ms frontal plane qrs-vector (tqrs), which, was reported to lie typically between + and * + + • the best correlation with severity grade was found with qrs-and qtc-duration (p= . ), the tca-dose (p= . ) and hf (p= . ); tqrs did not correlate. patients died ( . %). conclusion: qrs-and qtc-prolongation in the admission ecg, and the reported dose of ingested drugs are useful predictors for severity of poisoning due to tricyclic antidepressants. we did not find additional benefit in determining the terminal ms frontal plane qrs-vector. objectives: since treatment of amphetamine poisoning is usually symptomatic and often associated with a fatal outcome, a search for specific drugs to help the amphetamine-intoxicated victim is sorely needed. methods: we report a case of a suicidal ingestion of large amounts of the amphetamine-derivative , -methylenedioxy-ethamphetamine (mdea) and heroin (diacetylmorphine) and present the hypothesis that the two drugs produce opposing clinical effects. results: a year old caucasian male was admitted to the emergency ward because of acute-onset confusion. at presentation, he was agitated and showed increased muscular rigidity. he had taken tablets of "eve" (mdea, approx. g) and g of "smack" (heroin) by oral route approximately h before admission. because of rapidly progressive tachypnea and exhaustion, the patient was intubated and ventilated. the serum concentration of "eve" on admission was ng/ml (lethal range - ng/ml). trace amounts of cocaine and substantial amounts of heroin ( ngtml; mean value in heroin-related deaths: ng/ml) were also found in the serum. the patient was successfully weaned from the ventilator by day and recovered without persistent neurobehavioral disturbance. despite high serum levels of both drugs, the patient did not present with the classic signs and symptoms normally seen during intoxication with these drugs. amphetamines in general, and mdea in particular, have opposite clinical effects to heroin or diacetylmorphine. none of these were however present in the case presented despite the high ingested doses and the serum levels in the lethal range. conclusions: the fascinating fact that, apart from the respiratory depression, none of the clinical signs reported after massive overdose with these two drugs were present, might be attributed to the opposite pharmacological effects of mdea and heroin. we believe that the patient unwittingly saved his own life by the oral coingestion of both mdea and heroin. our clinical data raise an interesting point about the pharmacological treatment of acute poisoning with amphetaminederivatives. introduction: the acute attack of aip still carries a significant risk of mortality of around %. a succesful outcome depends on early diagnosis, removal of pricipitating factors and provision of intensive supportive therapy. objectives: twenty one patients ( females, male) with documented aip were seen over a -year period in the university hospital. patient was in clinical remission and were with the acute attack of aip, among them with respiratory paralysis were required artificial lung ventilation and -assistant ventilation with peee pathologic treatment during the attack was normosany, adenil, androgenes, glueosa, riboxin parenteral and enteral nutrition via nasogastric tube. symtomatic treatment -pethidine, propranoton, antibiotics, bronchoscopia. methods: intermittent phasmapheresis was performed on patients. the following measurements were peformed: level of porphobilinogen (pbg) in the wire and delta-aminolevulinic acid in the blood. hematological and routine chemical evaluations, hepatic, hemodynamic and respiratory function. results: after plasmapheresis the median pbg excretion (normal range - mkg per/ kgr creatinine) fill from mkg on admission . mkg, then on - day raise to mkg and then during treatment with normosong and prasmapheresis lowest level was . mgk. fatalities occured in two females during attacks with proforma cerebral involvement and patients attained clinical remission. conclusion: after therapy with plasmapheresis normosong we found that there was consistently reduce the urinary excretion of pbg and shortening the duration of the acute attack. objectives: pigs has been reported to present with a higher pulmonary arterial pressure (ppa) and stronger pulmonary vascular reactivity than many other species, including man. aim of the present study was to compare pulmonary vascular impedance (pvz) before and after embolisation in weight-matched adult dogs and minipigs. methods: we investigated pvz spectra in anaesthetized and ventilated (fio . ) minipigs and dogs. after baseline measurements the animals were embolised with autologous blood clots to reach a ppa above mmhg. results: flow ( and ppa matched pvz data (mean-+sem) are shown in the table. [zo = hz impedance (z; {dyn.sec_em- }); zl = first harmonic z; zc = characteristic z; z phase = first harmonic phase a@e {radians}; fmin = frequency of pvz the first m{n~mam; *, f p at least < . between dog and minipig, and before v~. after embolisation respectively]. before case report: a -yr-o]d woman affected by legs recurrent thmmbophlebitis, was admired in medmine department for tach.~pnea, chest pain, tachycardia and cyanosis. before starting two-dimensional transesophageal echocardiography (tee) to confirm the suspicion of pulmonary embolism, she suddenly had ventricular fibrillation. resuscitation and defibrillation were readily performed. when sinus rhythm was reinstituted she was in superficial coma with preserved corneal and light reflexes: right hemiplegia, poor perfusion and h~posphygrma of the left arm. tee showed dilation of rigth ventricle (rv), incomplete occlusion of pulmonary arter~ (pal at it~ hifurcation, severe tigth-to-left shunt through a patent foramen ovate, paradoxical embolism with incomplete occlusion of left subclavian artery mechanically ventilated with vt= ml, rr= /mm, fio =l, the patient had ph= . , pao = mmhg and paco = . systemic bp was / mmhg and hr= b/min with low dose epinephrine ( . g/kg/min) a thrombolytic infusion (rtpa: mg/ h) through a peripheral vein was started tee imaging and clinical status hours later were unmodified. a new rtpa infusion was performed through the pulmonary hole of a swan-ganz catheter with the tip close to the embolus. one hour later pa pressure decreased from / mmhg to / mmhg, etco increased from to mmhg and sao improved from % to % three days later the parietal, spontaneously breathing and with normalized tee scans of rv and pa, was transferred to rehabilitation service to perform physical therapy. conclusions: massive pulmonary embolism in a patient with patent foremen ovale, paradoxical embolism and refractory hypoxaemia was unaffected by systemic rtpa infusion, while intrapulmonary rtpa administration dramatically improved gas-exchange, hemodinamics and the general conditions of the patient. the presence of a large rigth-to-left _atrial shunt and the rapid rtpa metabolism could likely explain the effectiveness of its intrapulmonary administration in front of failure of systemic thrombolysis. introduction. cardiogenic shock during massive pulmonary embolism (blpe) is due to an acute increase of right ventricle (rv) afterload and possibly rv ischemia causing a failure of rv pump function. the rec~;mmended therapeutic strategies are: xoiume augmentation ~n ~rder m }ncrease rv pre-h~ad, adrenergic drugs to increase t'ontractillly and maybe coronary perfusion, fibrinolytic drugs to delermine clot lysis. there have been several reports of noradrenaline (na) as a useful drug in this setting for its sluing ~z, but also ~, properties. case report.an obese },ears old woman was transferred to our icu for tetanus. she was given the usual antibiotic and immunoglobuline therapy. l'wo thoracic epidural catheters were put in place at different levels and replenished with marcaine qid. a continous infusion of sedation (diazepam § was started together with mechanical ventilation. curarization ~,as given occasionally. fraxiparine . /die was used for prophylaxis of thrombotic disease, on day th at . a.m. she started to be hypoxic (sa %), tach ,tardic l l(i b/rain.), her blood pressure(rp) dropped frum norma~ values to r mm/hg, the central venous pressure (cvp) raised [rom lb to mm/hg and the end tidal co was mm/hg lower than one hour before. the physical examination of the chest revealed a clear bilateral ventilation and the chest x-ray was normal apart from an elevation of the :tiaphragm as compared to the previous. an e.c.g. showed sinus tachycardia, right bundle branch block and a possible inferior necrosis (which was already present on admission). a trans-thoracic echozardiography was performed which showed "an acute overload of the right centricle wilh remarkable dilatation. tricuspidal regurgitation ++. paradoxical movement of septum. small left ventricle with normal wall kinetics". the cardiac enzymes were later shown to be normal. an acute massive pulmonary embolization was assumed m be present.. a bolus of streptokinase x i(i u. was given fonowed by a continous infusion . two liters of colloids were also given in a sh~rt time, two hours later the patient was still deeply hypotensive, hypoxemic and anurir(bp / mm/hg, cvs mm/hg, spo %) despite a cominnus infusion of dobutamine fag/kg/min and adrenaline . ~tg/kg/min. at this stage a bolus of aoradrenaline ,g was given followed by a cnntinous infusion of . !*g/kg/min. an immediate improvement of the hemodynamics was noticed and one hour later the bp was / mmhg, the cvp mm/hg, the sao % and a brisk diuresis started. the hemodynamics kept stable and weaning from vasoactive drugs was achieved within two days. one month iater the patient was discharged home in good conditions.. con c i u sio n.ne administration may help to restore rv coronary flow and ;~ump function during mpe. aeute putmonary t~omboembo~sm [ffe) cou be mamfeslated with either respiratory or cardiovascular syndromes or both. the arm of the study was to establish leading respn'atory symptoms, frequency and form of the roendganographic (rig) changes as well as blood gas disturbance degree in acute pte with dommam respiratory disease appearance. the study includes retrospeotive analysis of i pte patients (pts), males (average age , yrs) and .q females (average age , yrs). they were admitted at university, olinie" with suspection ofpleuropnlmonary disease, including pte. final diagnosis of pte was based o~ evident risk factors in , % of the eases (deep venous thrombosis, surgery, trauma, imobilisation, malignancy ere), acceptable clinical, rtg, sdntigraphic and laboratory findings, as well as deep veins examination by dopple~-sonographie and radioisotopic -~enogmphy. respiratory symptoms appeared in all cases: sudden pleural pain ( %), dyspnea ( %), hemoptysis ( %), cough ( %) with association of two or more symptoms in %. chest xrays findings were abnormal in % with diaphragmal elevation ( , ~ lung opaeilies ( , %), atelectasis ( , %), plemal effusion ( , %), main pulmonary brancah asimetry ( , ~ oligemia ( %), heart shadow changes ( , %) and pulmonary arteries "cut off' ( , %). the association of two or more abnormalities was found in , % while normal chest x-rot was found in ~ of the cases. hypoxemia with pao < , kpa was found in , % followed with hypocapnia and respiratory alealosis in , % in , % of the gas exchage analysis were within normal limits. among cardiovascular symptoms short syn~cpa appeared in i , %, ecg changes-st q t type in "~ , %. results show high frequency of positive ~g findings in pte pts that is opposite to oppinion that chest x-ray in acute fie is the most ofran normal. leading symptoms are pleural pain and dyspnea, while hemoptysis were found in a half of the study group. blood gas changes were present in two thirds of the cases. kakkar, in his classic work ,clearly demonstrated the efficiency of low doses of heparin in prevention of deep vein thrombosis (lancet : , ) .after this first study the application of heparin prophylaxis became more and more diffused until to be considered a routine in many surgical departement.actually application of blood saving technique induces postoperative hemodilution effect. in that condition prophylaxis routinely applied seems a nonsense and can be at risk for postoperative hemorrhage. methods: to analize this problem we compared patients arrived in our intensive care unit (i.c.u.) in. : (group a) with arrived in : (group b) .every patient was operated for major abdominal surgery.in each one we considered the hemoglobin (hb) value,hematocrit(hct), and coagulation pattern (c.p.) at the arrive in i.c.u. and hours later. the patients was also divided in those receiving heparin prophylaxis (i) from not treated patients (ii) results:the application of blood saving technique clearly appears from the hb and hct level wich have a mean value of , +/- , (hb) and +/- (hct) in group a while in group b mean value are , -/- , (hb) and +/- (hct).patients of group a (ii) are the only one where a pathologycal c.p. with statistical significance has been demonstrated.in this goup we got four cases of evidence of venous thrombosis and one of pulmonary embolism.in patients of group b(i) we encontered the incidence of two cases of severe hemorrhage despite the absence of statistical significance in c.p.modifications. oxygen desaturation during broncho-alveolar lavage: role of oxygen saturation monitoring in prevention of acute respiratory insufficiency g. galluccio, b. valeri, s.batzella, m. di lazzaro*, servizio di endoscopia toracica, ospedale forlanini, rome, italy * servizio die anestesia a rianimazione, osp. forlanini the broncho-alveolar iavage is a diagnostic procedure employed in interstitial diseases of the lung. it requests the introduction through the working channel of a fiberoptic bronchoscope, after occlusion of a segmentary bronchus, of aliquots of saline solution at c, subsequently gently reaspired, in order to remove cells and proteins from elf (endoalveolar lining fluid), which is related to interstitial medium. bronchoalveolar lavage induces deep effects on pulmonary function: -lowering of the alveolar surface of exchange; -shunt effect, depending on the perfusion of non-ventilated districts; -increased pulmonary arterial pressure, due to hypoxic vasoconstriction; -decrease of lung compliance. in this report the authors present the result of oxygen saturation monitoring in a group of patients with interstitial lung disease, who underwent diagnostic broncho-alveolar lavage. in most patients with severe interstitial involvement, the lavage performed without supplement of oxygen induced a severe fall in the oxygen saturation during the late phase of the procedure. if supplementary oxygen was delivered during bronchoscopy, since its beginning, only slight modifications of the curve were detected. in patients without thickening of interstitium, in whom the lavage was performed in order to obtain material for bacterial or cytologic examination, no modification of oxygen saturation was observed in standard procedure. as conclusion the authors strongly reccomend monitoring oxygen saturation in patients with radiologic evidence of interstitial involvement also in patients with no evidence of dyspnoea. g. galluccio, b.valeri, s.batzella, m. di lazzaro*, servizio di endoscopia toracica, ospedale forlanini, rome, italy * servizio die anestesia a rianimazione, osp. forlanini the treatment of choice in patients with alveolar proteinosis consists of pulmonary lavage. this procedure requests the introduction, through the working channel of a fiberoptic bronchoscope, segment by segment, of aliquots of saline solution at c, subsequently gently reaspired, in order to remove the proteins deposited in the alveolar spaces. the method is very similar to that used in bronchoalveolar iavage, a diagnostic procedure used to obtain cells and substances from elf (endoalveolar lining fluid), which is related to interstitial medium. as known, bronchoalveolar lavage induces oxygen desaturation, because of shunt effect. understandably, one lung lavage has remarkably more deep effects on pulmonary function than bronchoalveolar lavage, for the amount of fluid introduced, the length of the procedure and the conditions of controlaterai lung. in this report the authors present the result of oxygen saturation monitoring in a patient who underwent pulmonary lavage for alveolar proteinosis. in the lavage performed without supplement of oxygen a severe fall in the oxygen saturation was observed during the late phase of the procedure. if supplementary oxygen was delivered during bronchoscopy, since its beginning, only slight modifications of the curve were detected. as conclusion the authors strongly reccomend the subministration of supplementary oxygen in pulmonary lavages, also in patients with excellent respiratory conditions. a. b. dublisky prof., m. r. isaakjan ass., v. a. zasukha, s. m. vinichuk prof., v. p. tserty ass. prof., chair of anaesthesiology, resuccitation and medicine of catastrophes, neurology of ukrainian state medical university, kiev, ukraine. objectives: detection of plasmophoresis's influence of results in treatment of ishemic insult. methods: we ve investigate patients with ishemic insult, treated with reverse plasmopheresis in complex treatment. after primary infusive therapy we took ml of patients' blood and separated it within min with rotation frequensy of /rain. after separation of erythrocytes from plasma, the latter has been returned to patients. we made - procedures during - days. hemoglobin, hematokrit, time of blood coagulation were determinated. the brain blood flow in internal carotid arteries, regional volum brain blood flow and total brain biood flow were evaluated with tetrapotar chest rheography and tetrapolar rheoencephalography. obtained date were comparised with control group after traditional treatment. results: it was found that after reverse plasmopheresis the hemoglobin and hematokrit levels decreased significantly in studied patients' plasma (from + . g/l to _+ . g/ and from + . % to _+ . % respectively). the time of blood coagulation by lee-white has increased by - . times (up to - rain). the level of brain blood flow has been increased significantly after reverse plasmopheresis in comparison with control group. the following tests of brain blood flow have been increased: a) the total volume brain blood flow from . + . ml/min to . _+ . ml/min (p < . ); b) the regional brain blood flow from . _+ . ml/min to . + . ml/min (p < . ); c) the brain blood flow in internal carotid arteries from . _+ . ml/min to . + . ml/min (p < . ). conclusions: the use of reverse plasmopheresis in complex treatment of patients with ishemic insult aiiows to improve rheological blood patterns, helps to increase volume brain blood flow. it results in quicer reparation of neurological functions. objectives: a prospective evaluation of the efficacy of continuous infusion of verapamil in reducing the incidence of postoperative atrial fibrillation after pulmonary surgery. methods: a total of consecutive patients, on verapamil, on placebo was included after lobectomy or pneumouectomy. a loading bolus of verapamil ( mg over minutes) was followed by a rapid loading infusion ( . mg/min) for minutes and finally a maintenance infusion ( . rag/rain) for hours. results: a mean plasma level of verapamil of ng/ml was obtained only after more than hours. atrial fibrillation occurred in five out of patients who tolerated the verapamil infusion, and in out of patients on placebo (p = . ). verapamil infusion was not tolerated in patients because of hypotension or a heart rate of less than /min, within hours of the start of the therapy. when atrial fibrillation occurred, the ventricular response, mean _+ sd, was not significantly slower during verapamil infusion ( + ) compared to placebo ( + ). conclusions: because of its frequent side effects and the only modest efficacy verapamil should not be considered for prophylactic therapy of atrial fibrillation after pulmonary surgery, and is probably not a good first choice for slowing the heart rate in case of rapid ventricular response once atrial fibrillation has occurred in these patients. results: study of haemostasis in these patients has showed deep disturbances of blood coagulation. fibrogen level has reduced to . + . g/l, fibrinogen and/or fibrine degradation products concentration have enhanced to . _+ . g/l, monofibrin soluble complex concentration to . -+ . g/l, blood plasmin level was enhanced to . + . mmol/ , plasminogen proactivator level was also enhanced to . + . ram, plateletes aggregation has decreased to %. after plasmopheresis aggregation was decreased in . times. it has been connected with decrease of fibrin and/or fibrinogen degradation products level and level plasmin in . times, and plasminogtnt activator level in . times. at the same time we have observed increase in total antifibrinalitic activity of blood in . times. activity of activators plasmine and plasminogene proactivators has decreased in . times and in the same time activity of activation inhibitors and antiplasmines has increased in times. conclusions: plasmapheresis leads to considerable improvement of a general condition and reduction of the haemorrhagic syndrom's sings (controlling of gastrointestinal haemorrage, reduction of intensity of subcutaneons haematoma). evaluation of continuous cardiac output (cc ) monitoring based on thermodilution technique in critically ill patients. methods: cardiac output (co) was monitored continuously using a modified pulmonary artery (pa) catheter, on which a heating filament is located and by which energy is transmitted to the circulating blood. a microprocessor calculated co by a new algorithm. standard bolus thermodilution technique ( ml of ice-cold saline solution) was used to compare cc with intermittent bolus cardiac output (ic ) measurements. the following subgroups were prospectively studied: i. heart rate (hr) > beats/min, . cardiac output > i/min . cardiac output < . i/min, . rectal temperature > . ~ and . pa catheter was inserted for more than days. results: a total of pairs of ic and cc measurements were obtained from the patients. bias (ico measurement minus cc measurement) of all measurements were . • i/min and the % confidence limits (mean difference• were - . / . i/min. also in the subgroups, cc measurement agreed closely with ico measurement (c > i/min: bias= . • i/min; co < . i/min: bias=- . • i/mln). elevated temperature and prolonged lay-days of the pa catheter did influence agreement of cc measurement with ic measurement neither (> ~ bias= . • i/min). conclusions: monitoring of cc using a modified pulmonary artery catheter with a heated filament has proven to be accurate and precise also in the critically ill when compared with "standard" intermittent bolus thermodilution technique. this method enhances our armamentarium for more intensive monitoring of these patients under various circumstances. background: the number of patients who need coronary artery surgery was) grows every year. most of these surgical operations are with extrar eircuiation (ecc). since january , this surgery is made without ecc in selected patients in our hospital. this technique is exceptional in spain. this type of surgery has proved useful in patients requiring revascularization of the left anterior descending, eireunflex or right coronary artery (not for grafting the pos~tefio~r descending branch}. blethods and results: since , patients aged to years (mean years) underwent cas without ecc. the mortality in programmed surgery was %. no patient was reexplored for hemorrhage. the mean values of some clinics parameters v~ere: a) blood requeriments: units per patient, b) need of mechanical ~entilation: i , hours, c) postoperative bleeding: cc, d) days at icui , . we used the student % t test or fisber~s exact test to compare these results with the mean values of surgery with ecc: a) blood requeriments per patient (p< , ), b) need of mechanical ventilation: hours (p< , ), c) postoperative bleeding: cc (p< , ), d) days at icu: (p< , ), e) programmed surgery mortality: % (p< , ). conclusion: our limited experience shows that this surgery is an alternative in the treatment of coronary disease, especially for aged patients with associated pathology and in jehova's witness. the need of mechanical ventilation, days at icu, blood requeriments and morbi-mortality were fewer than surgery with ecc. to study the hemodynamic and antiarrhythmic influence of ace-inhibitor enalapril in acute myocardial infarction (mi). methods: holter ecg monitoring, heart rate variability analysis, echocardiography ( and l days after beginning of the treatment), stress-echocardiography and stress ecg ( - -th day after the onset of mi). enalapril was included into the treatment of pts with mi (study group), with normal or increased blood pressure, from the -st day of the disease. the data were compared with pts treated without enalapril (control group). results: silent ischemia during stress-test was registered in pts of the study group and of control group, the arrhythmia episodes during stress test -in and pts and episodes of silent nocturnal isehemia -in and pts correspondingly. enalapril importantly attenuated the hypertensi~re re~aetioh % stress test. in pts of the study group the number of perifocal hypokinesis zones decreased; in the control group it didn't change. the quantity of ventricular extrasystoles in the patients of the study group decreased by %; the heart rate variability indices improved as well; in the control group the character of ventrieulir arrhythmias, heart rate and its va]~i~bili%y didn't change significantly. conclusions: the inclusion of enalapril into the treatment of mi is a useful t ol to improve hemodynamie parameters and decrease the incidence of ventricular arrhythmias. objectives: to study left ventricular (lv) systolic function in the patients with acute myocardial infarction (ami) before and after peroral captopril test. methods: the original echocardiographic parameter of lv contractility, "coefficient of effective systolic function" (cesf), was proposed in the study. cesf is calculated from lv stroke volume (sv), obtained from doppler aortic flow in lv outflow tract and lv end-diastolic diameter (edd): cesf =sv/edd. the study included patients with ami, who had local lv dyskinesia and global lv systolic dysfunction (ef< %). besides cesf, the ejection fraction was calculated before and after administration of mg eaptopril (on the fifth day of ami) by methods of bullet and simpson. results: the dynamics of these parameters, as well as heart rate (hr) and mean blood pressure (bp), is shown in the tabte. before cal~topril ef (bullet) . • . ef (simpson) . introduction: the cold system is a monitoring system for measurement of right (copa) and left (coart) ventricular cardiac output, cardiac function index (cfi), fight ventricular ejection fraction crvef), fight ventricular cnddiastolic volume (rvedv), intrathoracic blood volume (!tbv), global enddiastolic volume (gedv), lung water (etv) and excretory liver function (pdr). patients and methods: pts have been monitored by the cold system. above mentioned parameters are measured by thermal dye dilution and a fiheroptic femoral artery catheter. copa, rvef and rvedv measurements additionally were compared to measurements by the baxter explorer. :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ;;;k;;;;i cov (%) explorer ! ! [ gedv, itbv and pdr showed a significant decrease dufing the first - h after the operation, cfi and rvef si~canfly improved after k wheras etv showed a i~ in the early postoperative phase and fell to normal ranges at h. comparison of cold/explorer m~ements sb wed good correlations. discussion: concerning m ~toring of ri,ght ventric~ar function cold and explorer can he seen as equal. rvef gives an ar report about the performance of the right ventricle without use o f echocardiography. measuring itbv and gedv ~ improve ~gement and con~ol of th.e volume status, monitoring etv helps preventing lung edema. pdr shows good corre|ati n to liver blood chemistry and is bedside avai|ab|e. thus the cold system offers additional parameters for comprehensive m~nitofing of pts. ~e~ ~c surgery. obiectives: to evaluate the influence of an a!'~ered cardiac function on the cardiovascular response to the increase in oxygen demand induced by an increase in core temperature. methods: this preliminary study included adult critica!ly ill patients monitored by arterial and pulmonary artery catheters in whom thermodilution cardiac index {ci) and arteria! and mixed-vef)ous blood gases measurements could be obtained before and after an acute change in core temperature of at least . ~ (max rain apartl the patients were separated in two groups according to their cardiac function: patients had an impaired cardiac function as defined by a history of cardiac disease and an ejection fraction below % and patients had normal cardiac function. results: individual data are shown in the figure. in contrast to the control group (continuous line) in which c! increased without changes in oxygen extraction ( er), the q er in patients with impaired cardiac function (dottled line) increased without changes in ci. conclusions: the increase in oxygen demand associated with changes in temperature is met by an increase in c! in patients with unaltered cardiac function and in an increase in o er in patients with altered cardiac function. temperature should be taken into account in the assessment of the adequacy of cardiac output in patients with impaired cardiac function. objectives: to define the hemedynamic and metabolic response to physical therapy(pt) in relation to the type/level of sedation and the cardiac status in icu patients. methods: we studied mechanically ventilated icu patients ( • years) in stable hemodynamic status (no change in vasoactive treatment for at least hours), separated in groups: group = deep sedation, cardiac dysfunction required dobutamine (n= )r group = deep sedation (barbiturates), unaltered cardiac function (h=lo), group = moderate sedation, altered cardiac function (h= ) and group = moderate sedation, unaltered cardiac function (n= ). complete hemodynamic data, arterial and mixed venous blood gases, respiratory gas analysis (metabolic cart ccm, medgraphics) were obtained at baseline ( x) and twice (q. min) during leg mobilization. data were analyzed by anova. calcium channel blockers were used in complex preoperative preparation of hypertensive surgical patients. patients were allotted to groups based on their hemodynamic profile: hypokinetic: ejection fraction (ef)< . , patients; eukinetic (ef> . ),i patients and hyperkinetic (ef> . ),i patients. the most noticable change in hemodynamics was in the hypokinetic group: ef and cardiac output (co) were significantly decreased (p< . ) while systolic arterial pressure (sap) (p< . ) and peripheral resistance (pr) (p< . ) were elevated. the results showed that in hypokinetic patients on nifedipine ef (p< . t) stroke volume (sv) (p< . l) and co (p< . ) were increased while pr(p< . t), sap(p< . ) and diastolic arterial pressure(p< . ) were decreased. eukinetic type patients also showed an increase in ef,albiet to a lesser extent,than in the hypokinetic group. increased sv and co(p< . ) were observed in eukinetic patients though this was to a lesser extent than in the hyperkinetic group. in the hyperkinetic group of patients nifedipine had no effect on the aforementioned parameters except for a decrease in sap(p< . i). nifedipine increased ef in all hypokinetic patients. comparative results show that isoptin was less effective than nifedipine in decreasing peripl~eral vascular resistance and had a depressive effect on the myocardium. it can be concluded that the action of calcium channel blockers normalizing the circulation in the hypertensive surgical patient depends on: the condition of myocardium, the patients hemodynamic profile and their pharmacological properties. they were most effective in the hypokinetic group. zalo/nthinos e., daniil z. zakynthinos s., armaganidis a., kotanidou a., nikolaou ch..,roussos ch. critical care department, university of.athens, evangelismos hospital, athens, greece. introduction : surgical is the optimal treatrnent for ioculated effusions and the preferable procedure when multiple bands are seen in the pericardial sac by echo. patients : palients, post cardiac surgery, uremic ( men, women) with large pericardial effusion and clinical or echocardiographic findings of tamponade or both. these particular patients displayed numerous linear echo-dense bands and s~'ands crossing the pericardial space (in one of them a ioculated effusion compressed the left ventricule). one had aptt increased, four were mechanically ventilated. technklue : a fr polyurethane catheter with end and multiple side holes over ga needle was echo-guided to the ideal site (fluid abundant and closest to the transducer). the catheter was attached to a close system with a heimlich valve for continuous drainage (pneumothorax kit). subcostal entry was selected in one patient and chest wall in five. the patient's position was changed every hour at least. (we believe that the small changes in the position of the catheter and the mechanical breaking of the bands in relation with the movement of the heart assist the pericardial fluid to remove). results : in all cases only a small quantity of fluid was withdrawn in the first minutes( - ml) with some clinical and echo-findings improvement. the fluid was bloody or serosanuginous with high protein content (ht= % ,protein , gr/dl) in all cases. in first hours the mean volume of fluid removed was ml ( to ml). in that period echo showed no residual fluid. the catheter remained within the pericardium to days .. no complications are mentioned. conclusion : cardiac tamponade due to hemorrhagic high protein pericardial effusion in uremic and postcardiac surgery patients,, as it is revealed by echo dense bands, can be faced by -d echo guided perieardiocentesis. a -fr polyurethane catheter with multiple side holes, attached to a heimlich valve was effective to evacuate the pericardial fluid. no catheter was occluded though heparin infusions were not used. multiple changes of the patient's position may be fundamental. this -d echo guided pericardiocentesis performed in in~nsive care unit seems to be useful , safe and quick technique. determining the best inotropic drug represents a very serious problems. the use of more selective and potential inotropic and vasodilatative drugs does not always lead to improvement of hemodynamic parameters in patients with low cardiac output syndrome. this paper presents patients with acbp who need an inotropie support after extracorporeal circulation in first hours. the patients were divided into dobutamin et dopamine groups. the heart rate (hr). mean sistemic arterial pressure [map), central venous pressure (cvp). and termodilution cardiac index (ci) were measured. the measurements were without using inotropic drugs, and then using them after rain, min, and finally with one hour rate, within first hours. the statistical analysis shows that both drugs lead to an increase in hr in the first hour of the application. the final effect of dobutamine is no change in hr, whereas the effect of dopanime is very significant increase in hr. thus. an absence of taehyeardie response selects the dobutamine as a better choice. backeround: pulmonary vascular eadothelium possesses major metabolic functions, which when altered contribute to the development of serious pathologies such as ards. one such function is the conversion of angiotensin i to angiotensin ii, catalyzed by angiotensin converting enzyme (ace), located on the luminal surface of the endothelial cells. ace activity has been extensively studied in animals in vivo, by means of indicator-dilution techniques, providing: i) under toxic conditions, an early index of lung injury, and it) under normal conditions, estimations of dynamically perfused capillary surface area (pcsa). objectives: to validate the use of these techniques in matt: i) for pulmonary endothelial function assessment, and it) for pcsa estimation. methods: ace activity was estimated in ten adult haman volunteers, with no pulmonary medical history and normal pulmonary artery pressures, undergoing cardiac catheterization for coronary artery disease assessment. single-pass traspulmonary hydrolysis of the specific ace substrate hbenzoyl-phe-ala-pro (bpap; p.ci) was measured by means of indicatordilution techniques, and expressed as %metabolism (%m) and v=-hi( -m). bpap was injected as a bolus i) into a main pulmonary artery, and it) inside the right atrium, to assess ace activity in one and both lungs. we also calculated a,~,/i~, an index of pcsa. pulmonary plasma flow (fv) was determined by thermodilution. fp in one lung was estimated as . xf v. results: similar values of %m ( . + . vs . • and v ( . • vs . • were observed in both and one lung respectively. a~k~ decreased from • ml/min (both ltmgs) to :~ (one lung). conclusions: i) pulmonary endothelial ace activity and thus pulmonary endothelial function may be assessed in humans by means of indicator-dilution techniques, it) our data denote homogeneous pulmonary capillary ace coneentratious and capillary transit times in both haman lungs, iii) the % reduction of a=~/k~ in one lung suggests that this procedure can be used to quantify pcsa in man. (supported by the fonds de la recherche en saute du quebec and the national health system of greece). objective: verify whether antioxidant activity is higher in reperfused than in no-reflow myocardium after i.v. thrombolysis for acute myocardial infarction (ami). methods: patients with ami were included. blood for estimation of catalase (cat), glutathione peroxidase (gpx) and mn-superoxide dismutase (sod) was drawn before initiation of i. the mechanism of myocardial cell defence against free radicals is probably identical in both reperfusion and no-reflow phenomena. therefore, antioxidants cannot be used as reperfusion markers. objectives_ to evaluate the precipitating factors of hypothermic phrenic nerve injury following cabg with lima. methods: fifty two consecutive patients ( females), with a mean age of + (mean +sd) years were studied. during the ischemic arrest time topical hypothermia was obtained in al~ patients wffh ice slush and no cardiac insulation pad was used. all patients received a lima graft, with or whithout additional vein grafts. supramaximai, bilateral phrenic nerve stimulation was performed percutaneously preoperatively and whithin hours postoperatively. square wave stimuli of . msec duration were applied at the posterior border of the sternomastoid muscle. the compound muscle action potential of the diaphragm was recorded, using surface electrodes on the anterior chest wall. the time interval from the application of stimulus to the onset of diaphragmatic activity, phrenic nerve conduction time (pnct), was measured. values exceeding . msec were considered as abnormal. besults: preoperatively, all patients had normal (mean+sd) pnct, . • msec for the left nerve and . • mseo for the right nerve. on the first postoperative day, right pnct was normal in atl patients ( . • msec) , whereas left pnct was normal in patients ( . • msec) and abnormal in patients (incidence . %). in patients the left phrenic nerve was inexcitable and in patient left pnct was prolonged ( . msec). comparing patients with normal and abnormal pnct there was no difference in age, gender, number of grafts used, aortic cross-clamp and bypass time. however, patients with abnormal pnct had a lower preoperative ejection fraction ( • vs • p= . ). moreover, in all of them lima was dissected from its origin ligating all upper arterial branches, which provide the blood supply to the left phrenic nerve, whereas in those with normal pnct the small vessels originating from the upper to cm of lima were preserved (p= . ). conclusiojel~ a hypoperfused left phrenic nerve seems to be more susceptible to hypothermic injury during cabg with a lima conduit. objectives: to test if necessary interventions on systemic vascular resistance (svr) along with preset pump flew (q) during cpb could adversely affect autoregulatory response and cause vo shifts. methods: we studied males ( - yrs) who underwent cpb for cardiac surgery. at o oesophageal temperature - c we set pump flow at . i.m~ .min - . when map was higher than mmhg we calculated vo by using fick equation. then we infused sodium nitropruaside (sn) to control map at - mmhg for min and we calculated vq . without changing the sn infusion rate we set q at . i.m' .min " . ten min later we measured vo . we took vo changes into consideration if greater than %. statistical analysis using students-t-test for paired data and analysis of variance was used as appropriate. results: depending on the biphasic vo response to sn infusion during low and high q we classified pts in four groups (table). i. vo increases with sn and increases further during high q unmasking hypoperfusion and supply dependency. ii. vo increases with sn but the addition of high q results in systemic shunt. iii. vo increase during high q proves that vasodilatation can turn flow insufficient. iv. vo does not change with any intervention. the small number of pts and the wide standard deviation did not allow any statistical significance. conclusions: cpb is an interesting model for the behavior of microcirculation. intervention on svr and q can improve or impair effective regional oxygen delivery, resulting in either better perfusion or systemic shunt. vo monitoring seems necessary during cpb. preoperative cardiovascular optimization (opt) to ci > . l/min/m , _< paop < mm hg,and svri __< mmhg/ll/min/m decreases cardiac events (events) and mortality (mort) in peripheral vascular surgery patients (pvs). objectives: to determine if opt to the same endpeints decreases events in patients undergoing abdominal aortic aneurysm repair (aaar) and to study the r predictive value in pvs patients. methods: aaar patients and pvs patients were admitted to the s cu monitored with e pa and arterial catheters and treated to achieve opt. patients underwent surgery independent of success of opt data included demograph cs, incremental risk factors, laboratory and hemodynamic data pre, intra, a~nd postoperatively events, and mort. events included arrhythmias requiring treatment or prolonging the sicu stay > hours, a st depression > !mm or t wave inversion, an acute mr defined by a new q wave > . sec or cpk-mb > %. results are presented as means _ -. sd. opt was achieved in of ( %) and in of ( %) in the pvs and aaar group, respectively. events did nat differ between groups of ( , %) and of ( , %) in the pvs and aaar group, respectively (p>o. ). mort was of ( %) and of ( . %) in the pvs and aaar group, respectively (p > . ), while there was no difference in endpoints of opt between patients with and with.out events in the aaar group, there was a significant difference in ci between patients with and without events in the pvs group. of note, of ( %) patients who developed events in the pvs group had a ci < . in contrast to of ( %)in the aaar group. the positive and negative predictive value were % and % in the pvs and % and % in the aaar group. conciusione: f. the endpoints of opt used for pvs patients cannot be ~sed to reduce events in aaar patients; . pvs patients who have net achieved opt are at extraordinary risk of perioperative events; . preoperative card ovascu ar opt in aaar patients makes no difference in cardiac related events, background : comparison of the right and left filling pressures (cvp/pcwp ratio) is considered as a useful diagnostic clue : the normal ratio is _< . ; ratio >_ . may suggest right ventricul~ infarction while equalization of the cvp and pewp is a classic sign of tamponade ( ). however after cardiac surgery, many conditions (diastolic dysfunction, pulmonary hypertension, positive pressure ventilation) are susceptible to modify the '*normal" cvp/pcwp ratio. material and method : we determined cvp/pewp ratio in consecutive patients (pts) after uncomplicated cardiac surgery ( coronary artery bypass grafts; valvular replacements) measurements were made before and after tracheal axtubation. results :cardiac index : . _+ . /minlm~; laotate: + rag/i; cvp range : - rnmhg; pewp range : - mmhg. mean cvp/pcwp ratio before extubation is . ( % confidence imerval : . - . ) and after extubation, . ( % confidence interval : . -. . ), (ns, paired t-test). in % of the pts, cvp was higher than pewp. there are no correlation between the cvp/pcwp ratio and c! before (r = - . ) and after extubation (r = - . ) nor between the cvp/pcwp ratio and mean pulmonary arterial pressure (mpap), before (r = . ) and after extubation (r = - . ), discussion : cardiac performance is adequate according to ci and lactate. however the cvp/pcwp ratio is markedly higher than the "normal" (_< . ) ratio. this difference is not related to mechanical ventilation because the ratio is similar before and after extubation, nor to pulmonary hypetaension because of absence of any correlation with mpap, post-cpb diastolic dysfunction of the right ventricle could be an alternative explanation. in this group of pts, increased cvp/pewp is not associated with any impairment of cardiac performance (absence of correlation with ci), conclusions : cvp/pcwp ratio as high as within a large range of cvp ( - mmhg) and pcwp ( - mmhg) may still be considered as normal after cardiac surgery. this emphasizes the limitations of the hemodynamic monitoring after cardiac surgery (in comparison with echographic technics). careful analysis of the morphology of the cvp and right ventricular pressure curves (x descent, y descent, dip-plateau) is mandatory rather than relying on the quantitative assessment alone. reference : ( ) ntensive care.-university hospital -m~laga (spaink introduction. fibrinolitic treatment (ft) permits the treatment of acute myocardial infarction (ami) addressing the etiology, thereby eading to mproved ventncular function and a marked reduction m mortality. the main clinical oroblem is the reduced time of application. delay in hospitalization, which can be from to minutes, is potentially the most avoidable delay. method. to reduce delays in hospitalization, the following was carried out in two chases. audit: analysis of the time lapse from onset of symptoms to start of ft. showed that during "(he period june to december , patients with chest paros were treated within a eriod varying from minutes to hours from onset of symtoms. ages ranged from to (average , ), oelng males and females. they were glved initial ecgs to determine st mcreases suggesting ami. median t~me for this orocedure was l m.. potentia ami patients were then admitted to the coronary unit, [)atients, under age with no contraindications received ft the median time apse from admission to corona-y care and administration of ft was minutes ( . ), -he total median delay was minutes ~ -i h. min,~ delays n start of this procedure are grouped as follows: extra-hosdita delays (from onset of symtoms to arrival at hospital) diagnostic delays (from hospital arrival to ecg). treatment delays (from diagnosis to ft). objectives: protocol of procedure to implement a fast-track method. a protoco was drawn up with the object of reducing diagnostic delays to -i minutes and treatment delays to less than i minutes results. following rmplementatlon of this protocol in january , fts were glven, with an over all average delay of minutes. this fast-track method did not reveal any inappropnate ft or any increase m complications, conclusions: detailed study of the various times taken for diagnosis ane treatment of ami patients, showed up weaknesses in the system and improvements througn the protocol based on performence orocedures which led to a % reduction in the start of ft background: the importance of the early use of thrombo!ytic agents in acute myocardial infarction (ami) is based in the better remaining ventrictjlar function and smaller mortality rate because of the greater reperfusion and sma!ler infarction size, therefore, it is very impodant to apply this treatment to the maximum number of patients without thrombolytic contraindicati n, and within the minimun period of time. the "thrombolytic fast track" implementation allows to optimize the time to administrate thrombelytic agents avoiding multiple delays~ methodology: we anal!ze the application of thromboly c agents to patients with suspect of ami from the begin!ng of september until the end of february . in this time there are two different periods, during the first months thrombolytic agent were admin!strated at intensive care unit (icu), and during the second period we carried out a protocol of quick detection and thrombolysis therapy in susceptible patients at the emergency room in order to reduce the time to treatment. ma!n results are shown in the faffewins de ay h=hours m=minutes the implementation of the fast track does not need supplementary personal or equipment but a protocelized approach and training of the personal involved the main problem detected was the usual attendance overload of the emergency department that makes difficult to follow many structurated actions. conclusions: pratocqlized changes in the management of ami can significantly reduce the detay in the administration ef thrombolytic agents. it is not necessary to eomplet the procedure iq the emergency department, as the use of bolus schedules allows to begin the treatment in this area and to transfer the patient to icu afterwards. elective cardiac surgery. b calvet, f ryckwaert, p trinh duc, p colson. anesthesia -reanimation, hopital arnaud de villeneuve, montpellier, france. obhectives: the study was aimed at analysing the incidence of renal dysfunction following cardiac surgery and its prognosis (acute renal failure, post-operative morbidity and mortality). methods: two hundred and thirty seven patients (aged from to ) were consecutively operated on for elective cardiac surgery and retrospectively included in the study. patients with preoperative infections and operated on in emergency were excluded. each patient had preoperative invasive cardiac investigation with angiography and calculated ejection fraction (ef). anaesthesia, cardiopulmonary bypass (cpb) and cardiac arrest management were similar in all patients. general body temperature was reduced to - ~ c. renal dysfunction was defined as a % increase from baseline of serum creatinine. demographic data, asa, treatments, pre-operative creaunine level, cpb and clamping (axc) times, intra and postoperative use of inotrope, serum lactate level before surgery, at the end of cpb, at the time of admission in intensive care unit (icu) and on post operative day one and apache score were compared in patients with or without renal dysfunction using anova test for repeated mesures and x when appropriate. data are expressed as mean +__sd. p value less than . was considered statistically significant. results: thirtytwo patients ( , %) suffered from renal dysfunction. age, serum lactate level at the end of cpb, at admission in icu, at pod and apache level at admission in icu, intra-operative use of inotropes were statistically different in patients with or without renal dysfunction (p< , ). mortality rate was statistically different in patients with or without renal dysfunction(~, , % and %, respectively, p= , ). incidence of acute renal failure following renal dysfunction was , % ( patients required hemodialysis). conclusions: although our cdteria for defining renal dysfunction were very sensitive, the incidence of renal dysfunction following elective cardiac surgery was lower than communly accepted in the litterature ( ). however renal dysfunction appeared significantly associated with a poor prognosis. reference: -settergren g, ohqvist g current opinion in anaesthesiology , : - r ; , tzelepis, g. , , late complications were observed in % of cannulations: local infection in (i, %), catheter displacement by the patient in cases ( , %), catheter displacement during nursing care in ( , %) and malfunction in cases ( , %). conclusions: central venous catheterizations are followed by immediate and late complications in almost the same percentage acute poisoning with amphetamines (mdea) and heroin: antagonistic effects between the two drugs methods: after institutional approval and informed consent, selected patients ( _+ years) undergoing peripheral vascular surgery (n= ) or carotid endarterectomy (n= ) were investigated. patients included had either documented cad (n= ) or two or more (n= ) dsk factors (age > years, smoking, diabetes meltitus, hypertension, hypercholesterolaemia > mg/dl). -lead ecg recordings were carded out preoperatively, on ardval in the postanaesthetic care unit, and h, h, h, and h postoperatively. ecg recordings were analysed by an independent blinded cardiologist for signs of pmi (new st segment depression > . mv and/or new t inversion). in addition results: of the patients investigated developed ecg-documented pmi, % occurdng in the immediate postoperative phase. troponin i levels > . ng/ml were found in of these patients thus, comparing a cardiac troponin i cut-off level of ng/ml with intermittent -lead ecg recordings, we found a sensitivity of % and a specificity of % methods: demographic, clinical and ecg data were analyzed. . % of patients were male; . % female. cad was the most common underlying cardiac disease ( . %) and . % underwent open heart surgery. % received proeainamide for supraventricular and % for ven~cular arrhythmias. % received a loading dose. maintenance was provided by iv route in . % and by po in . % ( . %sr end . % ir). . % of patients were obese right ventricular function following cardiopulmonary bypass: is important the mode of myocardial protection we underwent this study in order to examine its safety and usefulness in pts with trustable coronary conditions (unstable angina ua the mean age for group a was • years, for group b • years, and for group c • years. a history of previous myocardial infarction was present in pts of group a, in of group b and in of group c. three pts in group a, in group b and in group c had previous coronary artery bypass grafting. the median time between the onset of symptoms and a was days ( - ) for group a we used a continuous fixed intravenous a infusion at a dose of the sn was % in groups a and b, % in c, and sp % for group a, (fixed defects included) and % for groups b and c. there was no difference of side effects among groups: chest pain (i pt -group a, pts -group b, and pts -group c), transient hypotension ( pt -group c), headache ( pts, group c), dyspnea ( pt -group a), while st depression was seen in pts of group b and in pts in group c. the rate of a infusion was decreased to /kgr/min in one group b pt due to development of chest pain s five year follow up of humoral immunity in paced patients athens polyclinic hospital, department of cardiology athens, greece author index a abiad ch bertschat, e betbes blanch, l del nogal saez e -meneza nolla, j. nolla-salas pilz~ u puig de la bellacasa e scarpa, n. van de wetering objectives: only % of patients suffering from acute guillain-barr@ syndrome (gbs) respond promptly to established therapies like plasma exchange or intravenous immunoglobulines. in contrast to serum, cerebrospinal fluid (csf) of gbs and ctdp patients contains enriched portions of antiexcitatory factors(i) and cytokines ( ) able to induce pronounced conduction block ( ). to reduce or remove such pathologic factors we introduced a technique with direct access to the subarachnoid space. methods: with informed consent we lumbally inserted g catheters in gbs-and cidp -patients under sterile conditions. some of them had not responded very well to established therapies. - ml of csf were withdrawn and retransfused by a bidirectional pump (flofors) after passing newly developed filters (pall). daily filtrations with several cycles were performed ( - ml) over one week. results: the gbs patients improved after days (median) for one grade (according to the gbs-scale from the gbs study group) . the ventilator dependent patients were weaned after days (median). patients not at all treated before ( / ) responded better than patients that had been pretreated ( / ) with plasmaexchange or intravenous immunoglobulines. / cidp patients drew benefit from treatment, stabilized iongterm. conclusions: csf-filtration is a relatively save and well tolerated additional procedure. the costs are considerably lower ( / ) than those for plasmaexchange or intravenous immunoglobulines. references:( )wsrz aet al: csf and serum from patients with inflammatory polyradiculopathy have opposite effects on sodium channels. muscle nerve ( ) . ( ) clinical observations were made in patients admitted to the clinic. they were in coma associated with acute alcohol intoxication.standard evaluations (ecg-monitoring, electrocardiography, neuromonitoring, studies of acid-alkali condition, biochemical and toxicologic investigation of blood and urine) prior to and following the treatment conducted were undertaken in all the patients.to correct irreversible impairement of functions twofold laser blood irradiation by means of alok- apparatus, the exposure within minutes, was carried out.the data obtained confirm more rapid coma withdrawal of the patients, reconstruction of the heart and central nervous system electrophysiologic indeces, reliable reduction in complications compared with the control group. objective: to know the actual incidence of the critical illness polyneuropathy(cip). setting: fourteen intensive/critical care unit beds, in bed university hospital, covering . inhabitants (majority rural area). the icu patients are medical, surgical and coronary, excluded the neurotrauma and neurosurgical. design: a conseculive and prospective study. all the patients admitted during three months, from january lth to march th , were eligible (patients with admittance diagnosis of polyneuropathy were excluded ). methods: patients with apache ii score > , at the admission and six days after admissions were included into the study protocol. diagnosis of sepsis, mof, and all the drugs administered days before were recorded. a complete neurological exam, by a neurologist, in absence of ssdatives and muscles reliant ( th, ~ and th days after icu admittance) was made. we evaluated the nerve and muscles function with and electromyography study in all patients, at same days. in some paeents with cip we performed a nerve biopsy. results: from patients ( apache ii score: . ) admitted in the icu, ( . %) enter the study protocol. seven ( , %) had an axonal polyneuropathy(cip), three very severe. only four of the patients with cip had pathologic clinical exam. apache ii score: cip vs non-cip was . vs . . the incidence of cip by diagnosis (cip/diagnosis) was: sepsis, / and mof, / . conclusions: . -we think that it is necessary to define the "critically ill" for some score, before designing a study to know the incidence of this syndrome. . -we think that the incidence of the cip is lower that the latest papers say. objectives:acute pancreatitis(ap)is becoming a more important problem among the elderly as the population ages. the increasing presence of gallstone disease,as well as the use of certain drugs,may also contribute to the occurrence of pancreatitis. methods:all patients(> years)admitted to our medical department over an eight year period were included.pancreatitis was confirmed by biochemical tests and imaging techniques.scores were developed using ranson's criteria and a multiple organ system failure(mosf)index . overall, patients were evaluated; ( %)had pancreatitis of unknown etiology . results:( )patients with pancreatitis of ~nlqnown etiology were sicker and had greater morbidity( % vs %),mortality( % vs %),and longer hospital stays than p~tierf~ with pancreatitis of known cause.( )the best predicto~of severity and outcome was the mosf index and not ranson's criteria;the higher the score,the greater the associated disease,the worse the outcome.( )curlously,no difference existed in associated medical conditions between patierts withknown and ur ~own causes of pancreatitis. conclusions:greater organ dysfunction exists in patients with pancreatitis of unknown etiology, even though age and associated medical conditions do not differ . the application of the total enteral nutrition in the burns disease has minimized the complication rate and consequently increased the survival rate of children and adults. time of initiation, composition, duration and way of administration are very important in obtaining the optimum beneficial effect from the treatment and diminishing the complication rate and side effects. the above features will be discussed in view of our experience in cases. ta buckle?,, ra freebalm, c gomersall g joynt, r young. tg short. department of anaesthesia and intensive cm+e, prince of wales hospital. the chinese university of hong kong, shatin, hong kong introduction: gastric mucosal ph (phi) monitoring has been proposed as a relatively noninvasive index of the adequacy of aerobic metabolism in the gut. to examine the accuracy of gastric intramucosal pit measurements as a function of time and as a function of the catheter itself to determine whether the measurement error between catheters is clinically acceptable. patients with a gastric tonometer (trip tm, tonometrics, worcester. ma) insitu for > days were studied. following informed consent two new tonometers were inserted equidistantly & correct position was confirmed radiographically. measurements of intramucosal gastric ph were then performed over a hr period. eight -ten measurements were made in each of ten critically ill patients.percent differences between the two new catheters were . % ie at ph . _+ . ( % limits) and between old & new catheters were . %, ie ph j _+ . ( % limits). conclusions: the results suggest that the function of the tonometer deteriorates over time and that the absolute values of phi m~ not ~ufficiently accurate. however as a trend monitor phi may be useful in the clinical setting. despite a continuous decline both in li'equency and severity of gastro-intestinal stress-lesion/-bleeding (gisb) due to both improvement in preclinical support and in intensive care medicine, patients with cerebral lesion are still considered at high risk for developing gis . therefore the question arises, whether m> specific (}lsb-prophylaxis besides general and neurological intensive care, specific pharlnaeothcrapy or even the combination of two specific drugs reveals any protective efli~ct on frequency and severity of gisb.this pntspcclive randomized study has been perfornted in patients snfrering t'rttna head-injury/cerebral lesion and with a glasgow-coma-scale on admission (gcs:,)of < . according to randomization the patients have been grouped as tbllows: h analgesia/sedation (n= ); ih analgesiajsedation plus pirenzepine mg/day (n= ); .[ih anatgcsia/sedalkm plus sncraltate x [ g/day (n= ); iv: analgesidsedatkm plus pirenzcpine mghlay plus sucralfate x e/day (n= ). slalislical analysis has been performed by chl:*tt~sl. rank correlatinn and unpaired t-test; statistical significance has been set with p < . . / patients ( . %) developed gisb. although the mean gcs~-value (x -+ sd) did not reach significance between patients with and without gisb ( . + . vs . -+ . ). a significant inverse correlation between gcs:, and the incidence of gtsb (rs~ = . ) has been shown. the frequency of gisb among the groups is as follows: h . %; lh . %; llh . %; iv: . % (ch -~ = . ; not signilicant). no gisb-induced blood translusion or mortality, respectively, could be demonstrated. survival rate between the groups did not differ significantly (chi-" = . ; p= . ) and reached an overall-value of . %.drug-specific glsb-prophylaxis -administered either as monotherapy (pirenzepine, sueralfate) or in combination of these two specific-drugs -reveals no additional significant influence on the incidence of gisb in patients with cerebral lesion compared to no specific prophylaxis besides the general trauma-/disease-specific intensive care measures. critical care dpt, evangelismos hospital, athens university scho~" of medicine objectives: the correlation of longterm presence of nasogastric tube (ngt) to gastroesophageal reflux (ger) is still in question. in case of positive correlation, peg should represent an alternative to tube feeding in patients unable to be fed orally. therefore, we investigated: i) the correlation between ng and ger and ii) the effect of peg on ger. methods: a -h esophageal ph-metry was performed in patients in recumbent position at ~ who had a ngt for more than days and were on sucralfate for gastric mucosal protection. the tip of the ph-probe was lied cm over the esophagogasttie junction, confirmed by x-rays. patients who presented a percentage of ger-total (i.e. with a ph less or more than ) (ger-t) more than %, underwent ~t peg. the presence of a creseent-notch on the esophagogastric junction persisting on inspiration and the grade os endoseopic and histologic esophagitis (scale= - ) was noted. two ph-metrles repeated on h and on days post-peg were compared to the pre-peg one, with the followin~ parameters taken in consideration: i) % ger-t, ii) number of ger-total per hour (no/h ger-t) and iii) the duration that ph was less than (tph< ). in case ot ger persistence at the ph-metry on ?th day post-peg (group ii) another endoscopy was performed, while patients with reduced ger (group i) were considered as esophagifis-free.results: out of patients presented a ger-t> %. eleven out of group i group (n= ) i ( objectives: the aim of the present study was to compare the performance of a specially modified version of a photo-and magnetoacoustic (pa/ma) gas analyzer (br~)el & kjaer, denmark) with a conventional quadrupole mass spectrometer (ms) (innovision, denmark) in inert gas rebreathing (rb) tests such as determination of functional residual capacity (frc), pulmonary capillary blood flow (pcbf) and lung tissue volume (vtc). methods : from simultaneous readings of inert gas concentrations with the ms and the pa/ma analyzer during rb experiments a comparison was made of the pcbf, vtc and frc values. the rb tests were performed during rest and exercise ( , and w) in ten healthy subjects. results: the differences (mean +/-sd) between simultaneous estimates of rebreathing parameters were the following (pa/ma -ms) for pooled data, pcbf: . +/- . i/min, vtc: - +/- ml and frc: . +/- . liters. conclusions: smell but significant differences were found between the estimates of pcbf, vtc and frc using the ms and pa/ma, respectively. reference: p. clemensen, p. christensen, p. norsk, and j. gr~nlund. a modified photo-and magnetoacoustic multigas analyzer aplied in gas exchange measurements. j appl physiol ; : - . objectives: because transcranial doppler (tcd) has been proposed to explore cerebral co vasoreactivity in brain injury (stroke ; : - ), we compared this technique with the kety-schmidt reference method to assess cerebral vasoreactivity in comatose patients. methods: mechanically ventilated patients (age - yrs, glasgow - ) in coma due to acute brain injury were investigated during stepwise changes in paco ( , , , and mmhg) by increasing inspired pco . middle cerebral artery velocity (vm) was measured by tcd. after insertion of a catheter in the ipsilateral jugular bulb, cerebral blood flow (cbf) was determined by the kety-schmidt method, using the inhalation of % n through the inspiratory line of the ventilator. for each patient a cerebral co~ vasoreactivity index was calculated as the slope of linear relationship between vm or cbf and paco . objectives: after cardiac surgery the fluid shill, between interstitial and intravasal space may be marked. this is due either to the intraoperative volume loading by the extracorporeal circulation or the increased postoperative diuresis. therefore, infusion of a large amount &fluids is necessary during the first postoperative hours. it still remains unclear which of the substances at disposal is the best for this purpose. aim of the present study was to compare the different fluids with special regard to postoperative bleeding and rheological behaviour. methods: patients undergoing cabg-surgery were investigated and randomizedly distributed to three different groups of postoperative volume replacement to stabilize the mean arterial pressure at mm hg. . ringer's solution, . . % gelatine solution, . % hydroxyaethylstarch (mean m.w. . ). we evaluated the following parameters within intervals of min: arterial and central venous pressure, heart rate, postoperative bleeding, urinary output, volume replacement. results: there was no statistically significant difference between the groups with regard to urinary output and bleeding. in spite of larger amounts of fluids necessary in the ringer treated group patients of this group showed symptoms of hypovolemia. hematocrit was increased in the ringer patients. this was statistically significant. introduction: pulmonary wedge pressure (pcwp) and central venous pressure (cvp) are frequently used as parameters for cardiac preload, although it is known that both are poorly correlated to the cardiac index (ci). it has been claimed that intrathoracic blood volume (itbv) measured with the thermal dye dilution method reflects cardiac preload better than pcwp and cvp. we studied the correlation between itbv and ci in a mixed population of critically ill patients. methods: in consecutive patients ( sepsis/sirs, acute heart failure, ards, transjugular intrahepatic portosystemic shunt) monitored with a pulmonary artery catheter, itbv was measured on regular intervals using the pulsion cold z- system (pulsion, munich, germany). ci, pcwp, and cvp were recorded simultaneously. results: a total of ol measurements was made. pcwp and cvp did not correlate to ci, nor did apcwp or acvp correlate to aci. itbv was correlated to ci in a non-linear fashion (f - , df = , p < . , (figure) ). aitbv was correlated to ac in a linear fashion (r = . , f = , df = , p < .o ). a rapid and efficient circulatory support system may save a patient in cardiogenic shock. left heart bypass with percutaneous and transseptal placement of the aspiration canuia simplifies the circuit and avoids the need for an oxygenator. we assessed this preclinical set-up in anaesthetized pigs using a centrifugal pump with a f arterial catheter and a f left atrial aspiration line. animals were supported for two hours at a mean flow of . liter ( ' rpm), a mean hematocrit of % and low heparinisetion (act double baseline). hemodynamic and laboratory samples were taken at baseline (a), minutes (b), one hour ( pulmonary hypertension (ph) usually involves obliteration and loss of functional pulmonary microvasculature. the microvaseular endothelium normally acts as a major metabolic organ, converting angiotensin i to angiotensin ii via the angiotensin-converting ectoenzyme (ace). it is unknown whether the loss of functional vasculature and altered pulmonary blood flow seen in ph will affect lung ace metabolic activity. we therefore estimated pulmonary vascular ace activity in patients with ph of various causes: primary; post atrial septal defect closure (asd); chronic thromboembolic (te); anorexigen; iv drugs; collagen disease. single-pass transpulmonary hydrolysis of the specific ace substrate h-benzoyl-pbe-ala-pro (bpap) was measured and expressed as % metabolism (%me . we also calculated an index of peffused functional capillary surface area (amax/km). all patients with ph had an abnormality of %met or amax/km, or both. as compared to control humans (mean %met = . % _+ . % s.d.), the mean %met in ph patients was . % _+ %. the %met in ph patients correlated inversely with cardiac output (r= . ), possibly reflecting more complete bpap hydrolysis with longer pulmonary transit times. amax/km was markedly decreased in ph ( + ml/min) as compared to controls ( _+ ml]min), consistent with a significant loss of functional capillary surface area. patients with collagen disease, asd and anorexigen-induced ph had the most marked abnormalities. in conclusion, patients with pulmonary hypertension have decreased pulmonary endothelial angiotensin converting enzyme activity, likely due to a loss of functional or perfused pulmonary microvaseulature. supported by the funds de la recherche en same du quebec and the national health system of greece. objective: to investigate adrenocortical function in patients with ruptured aneurysm of the abdominal aorta (raaa). studies investigating adrenocortical insufficiency in critically ill patients report an incidence ranging from % to less than %. this may in part be explained by difference in methods used (single cortisol measurement vs short acth stimulation test) and populations studied (heterogenous groups of patients with great individual variation in underlying disease as well as duration and severity of illness). methods: we investigated the adrenocortical function in patients with (raaa).a short acth stimulation test (synacthen test; ug - acth iv) was performed at hrs within hrs of admission. plasma cortisol was measured before (cort basal) and after stimulation (cort stim). a plasma cortisol level > . umol\l before or after stimulation was considered normal, severity of illness was assessed using apache ii. results: of the patients investigated died and survived. mean cort basal in nonsurvivors was significantly (p< .o ) higher than in survivors; . (range . - . ) vs . (range . - , ). this difference between nonsurvivors and survivors was also present for cort stim but lacked significance; . (range . - . ) vs . (range . - . ). while patients showed a cort basal < . , no cort stim < . was found. there was no significant difference in mean age or apache ii score between survivors and nonsurvivors; vs and vs . conclusions: single plasma cortisol levels were inadequate to assess the adrenocortical function in the patients studied, judged by a short acth stimulation test, our investigation in patients with raaa showed no adrenocortical insufficiency. mortality in raaa is associated with elevated plasma cortisol levels. obiectives: mortality in acute myocardial infarction (ami) prinicipally depends on hemedynamic impairment. thus, patients (pts) with elevated pulmonary wedge pressure (pwp) present high in-hospital mortality. however, the complete right heart catheterization is laborious, so the central venous pressure (cvp) alone is frequently used to assess the severity of ami. the accuracy of cvp in estimating pts with ami was tested in this retrospective study. methods: pts. aged + years, admitted to our ccu from to with their first ami, were inctuded in this study. all had undergone right heart catheterization because of overt or suspected heart failure. swan-ganz catheters ( f, cm, abbott, il, usa) had been used, every treatment had been temporarily interrupted l h before the calheferization. based on ecg findings the pts were retrospectively divided into groups. in group a we included pts with anterior ami, in group b, pts with inferior ami, and in group c, pts with inferior and right ventricular ami. the initial values of cvp and pwp were considered for the linear regression of the pwp variable on cvp and p< . was accepted as statistically significant.results: in g~oup a, the cvp and pwp vaiues were + mmhg and _+ mmhg respectively. despite the signifanf correlation (p< . ) between the two variables, it was not possible fo predict the exact value of pwp based on cvp value, pts ( %) presented cvp> mrnhg and of these ( %) had pwp_> mmhg. in group , the cvp was _+ mmhg and the pwp, _+ mmhg. significant correlation (p< . ) between the two variables also existed, however it was impossible to predict the pwp value. pts ( %) had cvp> mmhg but only of these ( %) had pwp> mmhg, similar was the relation between cvp and pwp in group c (p< . ). cvp averaged + mmhg, and pwp, _+ mmhg. pts ( %) had cvp> mmhg and from these ( %) presented pwp> mmhg,conclusions: a single measurement of cvp in ami does not ensure an accurate assessment of pwp. because every pt with ami needs optimal values of pwp in order to prevent pulmonary congestion or manifestations of low preload, the significance of complete right heart catheterization becomes apparent. in patients (pts) with advanced hf the need and the prognosis for heart transplantation (ht) can be predicted from vo= max. indirect measure of functional capacity with the six-minute walk test can also predict smvival in moderate hf. to predict vos max from indirect astinmtions of functional capadty such as - ~q~/, pulmonary and heart function tests, and to assess the prediddve value of the above parameters in hf pts survival. we evaluated pts (age + yeats nyha class: ii, hi, iv) with hf for pit. they underwent a pmgmmive exercise test on cycle ergometer for vo max determination, a -mw, a right heart catheterization and a spirometry and dlco estimation. introduction: brain death causes myocardial impairment by mechanisms that are not well understood yet. the aim of this work was to assess the echocardiographic features found in these patients from the clinical onset of brain death to somatic death, methods: seven brain dead patients were studied (patients" relatives refused to allow them to be used as donors). mean age was . ( - ) years old. four of the patients were female, none of the patients had any history of cardiac disease. transthoracic echocardiogram (echo) and electrocardiogram (ecg) were obtained at the onset of clinical brain death and were repeated every hours until somatic death. we we detected severe diffuse hypokinesia (ef< %) in patients and mild hypokinesia in others (ef - %). systolic function was strictly normal in only patients. corrected qt interval (qtc) in ecg was . _+ . msec (normal range - msec) just before somatic death (b). conclusion: in patients with brain death we observed a significant increase of left ventricular mass due mainly to ivs "hypertrophy" without any important change in the dimensions of the left ventricle. to our knowledge, this finding has never been reported before and its importantance in heart transplantations may be of particular interest. predict right ventricular outcome. l. jacquet, r. dion, p. noirhomme. m. van dijck. m. goenen cardiothoracic intensive care unit, st-luc univ. hospital(ucl) we have registred: heart rate (hr), blood pressure (bp), pulmonary artery pressures (pap), central venous pressure (cvp), pulmonary capillary wedge pressure (pcwp), pulmonary and systemic vascular resistances (pvr, svr), right ventricle end-diastolic end end-systolic volume (redv, resv), right ejection fraction (ref), right sistolyc ventricular work (rsvw) and cardiac output (co) using a thermodilution thechnique and a microprocessor (model ref- ; baxter-edwards laboratory); duration of cpb and aortic clamping, and the requirements of haemodynamic support after cpb.results: in the c group an increase post-cpb of the fc ( + . + . , p < . ) was produced without significantly changes in the redv, resv, ref, rsvw neither co. in the w group, hr increased from . + . to . + . (p < . ); redv was reduced from . -+ to . _+ . (p < . ); resv was reduced from • . to + . (p < . ). there were not changes in the other haemodynamyc parameters. there was a trend (no significantly) to an increase of ref in the w group ( . + . |• . ) compared with the c"group ( • . ($ . • . ) post-cpb. the need for haemodynamic support was similar in both groups.conclusions: the warm, continuous, anterograde-retrogade myocardial protection has obtained a decrease of preload, hr, and a trend to an increase in the ref, making an improvement in the right ventricular global performance when is compared with the classic form of cold myocardial protection. objective: to evaluate the effect of dobutamine on gastric mucosal ph (phi) after coronaly artery bypass surgery. design: prospective study in a university hospital intensive care unit (icu). subjects: elective cardiac surgery patients. interventions: dobutamine was infused at ug/kg/min for hours immediately after admission to the icu. hemodynamics were measured every minute periods until hours and again hours after stopping dobutamine. results: there were no significant differences in mean gastric phi between the groups but mean phi decreased in both groups during the study period. oxygen delivery and consumption both increased during dobutamine infusion but decreased to the control group level after stopping the dobutamine infusion. lactate levels did not change. baseline objectives: the aim of the study was to evaluate the usefulness of a low dobutamine dose in conjunction with intraaortic balloon pumping and mechanical ventilation in cardiogenic shock. we studied patients . -+ t . years of age suffered of post infarction cardiogenic shock characterized by a systolic arterial pressure< mmhg, urine output< ml/h and mental confusion or purpueral signs of low output, non responded to dobutamine infusion up to pg/kg/min. all patients underwent mechanical assistance by the intra-aortic balloon pump (iabp). five patients were additionally placed on mechanical ventilation due to blood gases disturbances. the end points in our study were: reversion of cardiogenic shock, improvement of patients survival or both on the th post infarction day and months later. results: three patients refused iabp treatment and / survived on the th day. on the th day / supported by the iabp and / that underwent mechanical ventilation plus iabp were alive (p < . ). on the th month / supported by the iabp and / that underwent mechanical ventilation plus iabp were alive (p< . ). conclusions: in conclusion, the combined use of mechanical ventilation and iabp assistance in severe cardiogenic shock might improve survival. obiectives: the study was aimed at analysing predictive factors of swan ganz pulmonary catheter (pc) requiremen t during elective cardiac surgery according to the need of sustained inotropic support after surgery. methods: three hundred patients (aged from to ; females and males)were consecutively operated on for elective coronary artery bypass surgery (cabg, n= ), valvular replacement (vr, n= ), combination of both (vr-cabg, n= ), or others (n= ) and retrospectively included in the study. each patient had preoperative invasive cardiac investigation with calculated ejection fraction (ee). anaesthesia, cardiopulmonary bypass (cpb) and cardiac arrest managements were similar in all patients. pc requirement was estimated from the need of either dobutamine, adrenaline, dopamine or enoximone use during the first hours after cardiac surgery. demographic data, asa and nyha classifications, preoperative ef and treatments, type of surgery, cpb and aortic cross clamping (axc) times, and postoperative incidence of complications were compared in patients with or without inotropic support using either student's t test or x with continuity correction when appropriate. results: seventy hree patients ( . %) required inotropic support after surgery. axc .and cpb times, mean stay in icu were significantly longer in patients with inotropie support (p< . ). type of surgery, preoperative ef, and nyha classification are the first significant factors related to inotropic support (p< . ). most patients operated on for double-vr or vr=cabg required inotropic support ( and %, respectively). postoperative mortality was higher in patients receiving inotropic support ( , % vs , % 'overall mortality, p= . ). conclusions: since pc insertion is most.often justified because inotropes are required, these results suggest that elective rather than routine systemic pc insertion could be helped by considering several but selected preoperative factors. background: cardiovascular depression due to anaesthesia, old age and major gastrointestinal surgery is becoming an increasingly frequent challenge .to the anaesthesia-surgory team. deliberate preoperative manipulation of haemodynamics and oxygen transport parametres towards prede~t~mined optimal values may prove to be effective "in reducing morbidity ~nd mortality in high risk surgical patients,. a new concept of using conlimaous perioperative measurement of cardiac'output to obtain and maintain supranormal oxygen delivery (do i) is presented. methods: continuous measurement of cardiac output is a relatively new form of on-line monitoring, in which trains of impulses are emitted from a thermal filament mounted on a pulmonary artery catheter. computer software recognizes patterns generated by minute changes in blood temperature and ealoalates cardiac output every - seconds. cardiac output and mixed venous blood oxygen saturation are displayed graphically on line. in tins tm study cardiac output was measured continuously by vigilance cardiac outpu t compl/ter (baxter). preoperative haemodynamic optimization was performed with the goal of increa- sing do i to at least ml/min/m accordfing to shoemaker's algorithm . this was.done by infusing colloids (albumin or hydroxy ethyl starch (haes-steril| until the desired do was reached. infusion was stopped if cardiac output ceased to increase with infusion, if there were signs of pulmonary oedema or if wedge pressure reached mmhg. vasoactive or inotropic drugs were infused if the desired do was not reached by infusion alone. anaesthetic technique included continuous thoracic epidural and isoflourane anaesthesia. expected mol:bidity and mortality rates were calculated by the "possum" score aasing preoperative clinical and paradinical estimates of organ function as well as surgery characteristics . materials: asa group ill-iv patients with a mean age of years (range - ) and a mean weight of kg (range - )) scheduled for major abdominal surgery were included. results: patients were excluded because do i could not be raised at all. mean do i was increased from ml/min/m (range - ) to ml/min/m (range - ). mean volume of preoperativdy infused colloid was ml (range - ). during surgery ml (range ) of colloid was infused. mean length of surgery was minutes (range - ). mean blood loss was ml (range ). expected mortality and morbidity rates ("possum") were % and %, respectively, whereas patient follow up upon discharge or at death revealed mortality and morbidity rates of % and %, respectively. conclusion: based on experience from the present study, continuous measurement of cardiac output has proved to be a valuable tool for perioperative optimization of do in asa group ili and iv patients during major surgery. however further studies including a greater number of patients are necessary to confirm the promising preliminary findings. we studied the hemodyn~c effects of three different combinations of positiv inotropic .agents, vasodilators, diuretics and av-filtration (av) in patients (pts) with severe left heart faille (left veutrieul x filling pressure (lvfp) > mmhg) due to acute myocardial infarction. hemodynamic measurements (intravascular pressures (lvfp), thermodilution (cardiac index (ci)) were made before (control) and after each therapy. in furosemide (f) + d butamin (d) + nitroglycerin (ni) reduced lvfp and a small increase of ci occurred. in of these pts :(group a) nitroprusside (hip) instead of ni increased ci significantly, in the other pts adding of amrinone (a) resulted in a pronounced increase of ci. group c (n= ): the combination of ni and av reduced lvfp but did not increase ci which was achieved by av+d+ni. in order to optimize the treatment of acute heart failure a combination of inotropic agents, vasodilators, diuretics and av-filtration should he used guided by hemodynamic monitoring. arias jr, miragaya d, sandard, san pedro dm ~, herndndez d, valenzuela . objectives: to evaluate the variation in nomdrenaline (na) plasma concentrations in patients with acute myocardial infarction (am ) after thrombolytic therapy with noniltvasive reperfusion criteria (clinical, electrocardiographic and enzymatic), in relation to infarct size and location.methods: consecutive patiens with ami, from october , to february , , admitted within hours alter onset of symptoms, undergone successfull systemic thrombolysis. of them were anterior (group a) and inferior (group b) . noradrenaline plasma levels at (na ), (na ) and (na ) minutes after admission were compared with ck-peak plasma levels by linear regression. differences were tested for significance by student-t-test for paired and unpaired values. na plasma concentration was measured by high-presssure liquid chromatography. p< ns . ns means -sem (normal limit for our laboratory: na < / pg/ml; ck < u/i ) conclusions: . the na plasma levels at admission (nai) are more increased in anterior than inferior amis, probably in relation to infarct size. . the decrease in na is more evidence in amis with anterior location. . this decrease is probably due to the major efficacy of thrombolytic therapy in amis with anterior location. arias jd, miragaya (group b) , probably due to certain degree of t~cg'rfueion. . there is not significant variation in na in conventional treated ami (group c). v.suchanov, a.levit, p.trofimov, icu, regional hospital, ekaterinburg, russiaobjectives: our task was to improve the technique of preservation of platelet rich plasma. methods: patients scheduled for multiple cardiac valve replacement in were divided into two groups: group i ( patients) -without pp; group ii ( patients) -pp was performed preoperatively. the first pp was made ten days and the second - days before the operation. prp was preserved by cryoconservation. our technique of cryoconservation is distinguished by the speed of freezing ( - ~ and absence of dmso. this made it possible to preserve % functionally active platelets during days. the prp was transfused back after heparin neutralization. the hospital ethics committee approved the investigation.results: the blood loss through the st p. o. d. was significantly greatest in the group i ( _+ ml) and all the patients required transfusion of the donor blood ( + ml) whereas the blood loss in group ii was +_ ml and olny patients required the donor blood. the number of platelets on the st p.o.d, was _+ . /l (group i) and + . /l (group ii), p < . .conclusions: our technique of prp cryoconservation makes it possible to avoid the crystallization phase during freezing of prr thus the infusion of prp may improve hemostasis after open heart surgery and limit the use of the donor blood. in-hospital outcome of women suffering an ami is generally considered worse than that of men, but it is still debated whether female sex is per sea negative prognostic factor or is merely associated with other negative determinants of prognosis. the purpose of the present study is to evaluate the independence of the association between female sex and mortality (in the patients of the swiss centers) and in the patients randomized in the isis- trail mortality rate in women was . % ( / ) compared to . % ( / ) in men; in switzerland: in-hospital mortality for women was . % ( / ), for men . % ( / ).the table shows the results of isis- in terms of odds ratios and their % confidence intervals either after unadjusted analysis or after adjustment for age, known to be the major confounding variable when prognosis of women after myocardial infarction is considered, and for all the available clinical and epidemiological characteristics collected at trial entry: these observations suggest that there is a small but independent effect of female sex on short-term mortality after acute myocardial infarction. ( ) and bubble ( ) oxygenators a, ere used. anaesthesia was balanced and pts were extubated to hrs after cpb. pts were monitored with swan-ganz catheters (sgc) for hrs after cpb. at that time qs/qt was calculate( according to )be standard shunt equation. after the sgc had been removed, an estimated shunt was calculated. measurements of qs/qt were performed: before induction of anaesthesia ( ), after induction of anaesthesia (i[), mins after cpb (iii) (iv) and (v) hrs afiter cpb, rains after extubation (vi), hrs after cpb (v[ ) and on the nd, rd, th, th and tb postoperative day (pd) (viii, x, x, xi, xi , respectively). analysis of data was performed by two-way analysis of variance, p < . being regard as significant.results: the figure shows the values for qs/qt expressed as means + sd. there was a significant increase in qs/qt above b~setine throughoul the whole investigated period except on the th pd. qs/qt reached maximum at rains after extubation (vi). objectives: many stndies have shown advantages of membrane oxygenalors over ubbie type oxygenators. the aim of this study was to evaluate the influence of x 'genator type on pulmonary shunt (as/at) after coronary surgery. methods: patients (pts) gave their informed consent to the study which was approved by the university ttuman research committee. pts were divided into two groups: a (n = ) with a membrane o~genator and a (n = ) with a bubble oxygenalor used during cardiopulmonary bypass (cpb). ths were monitored with swan-ganz catheters (sgc) for hrs after cpb. at that tfme os/ot was calculated according to the standard shunt equation. alter the sgc had been removed, an estimated shunt was calculated..measurements of os/qt were performed: betore induction of anaesthesia (i), mins after extubation ( ), hrs alter cpb ( ) and on the nd, rd, th, th and th postoperative day (iv, v, vi, vii> viii, respectively). analysis of data was performed by one-way analysis of variance, p < . being regarded as significant.results: the figure shows the values for qs/qt expressed as means _+ sd. os/qt was significantly greater at rains after extubation (ii) in a group. the difl'ereuce between the two groups was no more significant from hrs after cpb (iii) to the end of the investigated period. ! i * p < a. s betw~n ~o~ conclusions: membrane ox 'genation during cpb is accomplished by reduction in blood cellular destruction and less alteration in blood. the results of our study show the influence of oxygenator type on value of qs/ot only after extubation ( to hrs after cpb). the difference in qs/qt disappeared his after cpb and since that time the oxygenator type had no influence on qs/qt. it may be of particular importance in patients with severe forms of cardiopulmonary disease who are at risk of higher postoperative morbidity and mortality. objectives: hypomagnesemia has been reported with a variable prevalence ( to % ) in icu patients. magnesium deficiency can induce a number of climcal symptoms (primarily cardiovascular and neuropsychiatric) but can also be clinically silent ( - % are asymptomadc), methods: we measured whole blood ionized magnesium (lmg++) in patients on admission to the icu, using a nova electrolyte analyzer (nova biomedical), containing an img++ electrode. blood was collected in syringes with dry heparin (radiometer qs ). normal range of img++ was found between . - . mmot/l (healthy volunteers). results: for the entire population, we found a % prevalence ( / ) of hypomagnesemia (figure ) . among the surgical patients, the prevalence was highest after cardiac surgery ( %) and after thoracic surgery ( %) and was lowest after neurosurgery ( %). hypomagnesemia was also common in patients after liver transplantation (lvtx) or with hepatic failure ( % for both groups). conclusion: our findings confirm that hypomagnesemia is common in acutely ill patients, especially in those after cardiothoracic surgery or those with liver disease. nevertheless. it is difficult to define the associated factors with sufficient specificity, so that measurements of img++ are warranted to diagnose hypomagnesemia. hepariu influences platelet function and may lead to thrombocytopenia called heparin-associated thrombocytopenia (hat) regardless of the dose and route of administration. additinnal venous and/or arterial thrombosis may lead to life-threatening complications. the incidence of so-calied heparin-associated thrombocytopenia and thrombosis (hatt) ranges between i- %. hatt is confirmed by a heparin induced platelet activation assay (hipa). results: from / to / consecutive patients of our icu were reviewed retrospectively. all patients were treated with heparim the incidence of hatt was % ( ). in all cases diagnosis was proven by a positive hipa. / patients died. in / hatt could be confirmed before severe thromboembolic complications occured. / patients developed a deep vein thrombosis (dvt), / dvt and pulmonary embolism (pe), / dvt, pe and arterial thrombosis (at) and / a dvt, pe~ at and a sinus thrombosis. conclusion: the incidence of hatt in a r series of pts. is %. presence of thrombocytopenia and thrombosis of the great 'vessels is associated with a significant mortality ( / ). computed tom graphy (ct) and transthoracic/transesophageal echocardiography (tte/tee) are important tools in diagnosing and monitoring the extent of cenlrai venous and arterial thrombosis. a. cabral md, m. shahla md c. meneses-oliveira md and jl vincenl md.phd. department of intensive care. erasme university hospital, brussels, belgium objective: to determine extreme hemodynanuc patterns in cardiogenic shock. although ~.~xdiogenic shock is characterized by a low cardiac index (ci), high systemic w~,scular resistance index (svri), and high cardiac filling pressures, some patients may develop art atypical pattern. we reviewed the hemodyuamic pattern of patients with cardiogenic shock, as defined by an initial ct below . l/rain/m: in the presence of myocardial dysfimction attributed to ischemic heart disease (n= ), heart failure (n= ), valvulopathy (n= ) or recent cardiac surgery (n= ). after exclusion of patients with concurrently suspected/documented infection, this study included patients, of whom ( . %) survived. treatment of shock included dopamine (n= ), dobutamine (n= ), norepinephrine (n= ) and epinephrine (n= ). patients with arterial hypertension (ah) and initially law plasnla renin activity (pra) had been studied. in all patient changes of arterial pressure (ap) after single administration of enap was studied. nypotensive reaction wiht deereasin e of average ap about - mm hg ayter single drug administration observed only in patients. ezap monotherapy accomplished during one week with mg daily dose. hypotensive effect observed in patients including ones which were susceptible to single enap administration. after that first stage of therapy all patints began to combinate enap with hypothyazid in dose of mg per day~ after week of treatment such drugs combination lead to veritable ap lowering in addition patients. in the remaining resistant to such drug combination patients was add corinfar in daily dose of mg. this new drug combination permits to lower ap in patients. subsequent discontinuation of enap administration to such patients aid not connected with increasing of again.therefore the most of the patients with ah and law pra( , %)did not susceptible to enap therapy and enap and hypothyazid combination. on the contrary-combination of corinfar with hipothyazid was effective in % patients with ah and low pra. methods: in patients with cardiogenic shock due to ischemic heart disease (n= ), heart failure (n= ) and valvulopathy (n= ), hemod aamic data including measures of intravascular pressures, cardiac output and mixed venous gases were collected at regular times intervals, at least times a da?. all measurements were obtamed in a relative steady state and in the absence of severe anemia or hypoxemia. treatment of shock included dobutamine (n= ), dopamine (n= ), norepinephrine (n=i ) and epinephrine (n= objective: based on our previous studies of the function of isolated liver grafts, this experimental protocol aims at developing a novel extracorporeal liver support circuit, with an incorporated pig liver. methods:the graft liver was obtained from pigs weighing - kg. under general anesthesia the aqimals underwent total hepatectomy,following cannulation of the portal vein, the infrarenal aorta and the infrahapatic vena cava and peffusion wit h it of heparinised r/l solution at ~ the circuit consisted of the graft liver connected to a fluid reservoir and a centrifuge pump. ten healthy pigs weighing - kgr were connected to the circuit as follows: the rt carotid artery was connected to the portal vein of the graft and the rt jugular vein was connected to the fluid reservoir, through the centrifuge pump. the fluid reservoir collected the outflow from the graft's suprahepatic inferior vena cava. the cystic duct of the graft was ligated and the bile.duct cannulated for bile collection and measurement. bridges were adapted to the circuit to bypass the graft liver when necessary, in cases of by pass blood perfusing the graft was oxygenated through a bubble oxygenator. mean total priming volume of the circuit was ml. temperature was maintained at ~ and portal vein pressure at ( - ) mmhg. the flow was . - . ml/gr of graft liver mass per minute. observation period was hours (t ). results: results of the hemadynamic and metabolic monitoring of the recipients [map (t = mmhg , t = mmhg), hr (t = , t = ), rap (t = mmhg , t = mmhg), pap (t = mmhg, t = mmhg), pcwp (t = mmhg, t = ~mhg), svr (t = dyn'sec/cm ' , t = dyn'seclcm~ pvr (t = dyn.sec/cm o, t = dyn.sec/cm ,'~), co (t = . t/min, t = . t/min), do (t = ml/min, t = . ml/min), vo (t = ml/min, t = ml/min), o er (t = . %, t = . % ), ph (to= . , t = . ), po (t = mmhg, t = mmhg), pco (t = mmhg, t = mmhg), pvo (t = mmhg, t = mmhg), svo (t = %, t = %), be, na, k, ca ++, lactate, osmolality, ast, alt, pt, aptt, revealed hemodynamic and metabolic stability of the animal. consumption, co production and tissue oxygenation of the graft were also studied. conclusion; the described circuit proved to be safe and well tolerated by healthy animals but its value for temporary liver support is currently being estimated, in a surgically induced experimental fulminant hepatic failure modal. introduction: prosthetic materials like silikone, dacron, teflon e.tc. produce auto immune responses and may even trigger clinical syndromes like scleroderma, sjogren, sle el.c. in our study we followed the evolution of humorial immunity parametrs for up to five years in a cohort of paced pts with implanted metallic and silicone materials. method: paced pts (mean age +- yrs) without clinical or laboratory findings of malignancy or immune disorders were included. we measured the immunoglobulins, the complement, the auto antibodies and the proteins involved in inflammatory reactions every months. the initial and final mean values are shown in the obiectives: hsp, a systemic leucocytoclastic vasculitis and anaphylactoid purpura can be accompanied by abdominal pain and life-threatening intestinal bleeding. recently we could disclose, that these patients develop severe fxiii-deficiency and immense haemorrhagic oedema of the intestinal wall. by the following case report we will demonstrate and discuss the importance of fxiiideficiency for pathogenesis, therapy and outcome in hsp. case report: a year old man developed typical skin manifestations of hsp following an episode of severe (biliary ?) pancreatitis and percutaneous draining of a pancreatic pseudocyst. two days later he had a paralytic "ileus with immense hemorrhagic wall-oedema and massive dilatation of the small bowel. he got fever up to . ~ and developed severe gastrointestinal haemorrhage (blood transfusions necessary). the coagulation data disclosed a severe fxhi-deficiency (activity %), whereas quickvalues, platelet count and atiii-level were found to be within the normal range. elastase was markedly elevated. substitution of fxiii to normal levels leeds to the cessation of bleeding symptoms and abdominal pain, later resulting in a restitutio ad integrum. conclusions: hsp with intestinal involvement is a life-threatening vasculitis, in which careful and frequent examinations of the coagulation system, especially of fxiii are necessary. detailed analysis of the coagulation data suggest, that the severe fxiiideficiency is due to a specific degradation by proteolytic enzymes (like elastase) as well as consumption within the immense haemorrhagic oedema of the intestinal wall. knowing these facts, even most severe cases of hsp with intestinal involvement can be successfully treated by substitution of fxih. a -year-old woman presented a year history of occasional self-limited episodes of weakness, generalized edema and o!!~aria. the immunologic testing showed no~nnai levels of complements, clq inhibitor, and serum chemistry values, between or during a attack, she was not treated. she was a~mitted to the hospital with symptoms including nausea, vomiting, weakness and ol!guria. on examination, the patient presented facial and g~neralized edema. the systolic blood pressure was mm hg, pulse beats/mir~ute, hematocrit . , seln~n protein /i, and se~um albumin q/l. an leg-kappa pa[apfotein was demostrated ( . g/l) and urine was neaative for puotein. c~'stalloid and colloid don't increased the blaod pressure but resulted in anasarca, with a total of ii lit[as of in~ravenous fluids. therapy wink flozen plasma, . units of clq inhibitor, cortlcosteroids, annihistwnines and antifibrinolytic agents was uns~iccessfull. the a~minist~ation of dopamine, norepineph~ne and epinephrine was inefective. the patient died at the bores, only a few cases have been reported, all had igg paraprotein, the pathophysio!o~] is urd~no~n% but is possible that the paraprotein may be zesponsib!e for the increased capillary pe~leabilityo despite efforts to res~scinate the patients during an acute attack, the syndrome is often fatal. the variable course of systemic uapiliary leak syndrome and the unpredictability and self-limited nature of attacks cloud assessment of therapeutic inte~-vention. the purpose of the present work is to provide some information about the nursing care and results from our experience in continous arteriovenus hemofiltration (cavh).cavh is an extracorporeal technique, especially applicable in the critically ill patients, for disturbances, and for the control of azotemia.we used this method in critically ill patients men and women ages from - who had sepsis -arf congestive heart failure postoperative multiple organ failure and polytrauma .this method was applied to these patients from to hours. % of the patients recovered completely their kidney function, % improved their kidney function and % died.we concluded therefore that this method was very effective for the critically ill patients to whom it was applied, but it requires excellent and continuous nursing care; under the above mentioned circumstances the method works effectivelly. an animal model with rats undergoing a dialysis procedure was designed to test the hypothesis that recovery from ischemic acute renal failure (airf) may be affected by the type of membrane used in hemodialysis. male sprague dawley rats were allocated to groups: in group i, (n= ) airf was inducted by bilateral renal artery clamping for rain. group h (n= ) rats underwent a sham procedure. in each group, rats were dialyzed twice ( th and th day) with either a cuprophan (cupro), a hemophan (hemo) or a pan (an ) minidialyscr or stayed nondialyzed (no hi)). renal function was monitored daily by measuring urea and creatinine values and by two single shot inulin clearances on the days following dialysis. additionally hemolytical activity of complement was determined. inulin clearance on day was reduced significantly but there was no difference in the degree of decrement in glomular filtration rate (gfr) between dialyzed and undialyzed rats, nor between the dialyzed animals with different membranes (gfr: no hi): . _+ . ; cupro: . _+ . ; hemo: . _+ . ; an : . _+ . ). the evaluation of renal function by day nine revealed significant recovery for all airf-groups compared to day (p< . ), irrespective of wether they underwent dialysis or not, or the type of dialysis membrane. complement activation could be detected in all dialyzed groups but no statistical differences between the animal groups dialyzed with different membranes were noticed. our findings refute the hypothesis that in airf exposure to complement-activating cellulosic membranes impairs the recovery of renal function in rats. changes patients: patients who underwent first cadaver kidney transplantation in our unit between january and december in were involved. the recipients were divided into groups: group i." non functioning graft (n= ); group ii: delayed graft function (n= ), group ili: good graft function (n= ). the grouping criteria were: a/haemodialysis in the fii~t postoperative days, b/diuresis in the i st postoperative day, c,' scram crcatininc difference between the st postoperative day and the preoperative level. all of the parameters were involved into the exarainatio, which we measllre in our every, day practice. results: the preoperative haematocrit level differed significantly between group i. ( . ) and croup ii. and iii. ( . and . , p< . ). intmo! emtive significant differences were found between the different groups in systolic blood pressure (group i. hgrmn, group ii. hgnnn, group iii. hgmm, p< . ), mean arterial pressure (group i. hgmm, vs. group ii. hgnun p< . , vs. group iii. hgmm p< . ), and pulse-amplitude and rate-pressure product too. the second warm ishaemic time in group iii. was significantly shorter than in the other two groups (group iii. inin. vs. group ii. rain. p< . , vs. group i. rain. p< . !). the rejection rate was higher in the first days in the patients with non-functioning grafts (group i. % and group ii. % vs. group iii. %) . the other examined parameters have not differed significantly. conclusion: according to our results the success of the kidney transplantation is mnitifactorial. the most important factors of this relationship are: the perioperative fluid-balance, the maintenance of adequate perfusion blood pressure during the operation, good surgical technique and immunological problems. key: cord- - ai xgy authors: paddon, laura isobel title: therapeutic or detrimental mobilities? walking groups for older adults date: - - journal: health place doi: . /j.healthplace. . sha: doc_id: cord_uid: ai xgy the health benefits of walking through greenspace have earned widespread academic attention in recent years and have been termed ‘therapeutic mobilities’. as a result, walking groups are actively encouraged by health professionals as a way to promote ‘healthy ageing’. this paper examines whether the promotion of community-led walking groups relies upon overly optimistic understandings that portray walking in greenspace as an inherently therapeutic practice. accordingly, this paper introduces the concept of ‘detrimental mobilities’ to explore how the shared movement promoted via walking groups may not always be inherently therapeutic and may have some detrimental impacts on the individuals who take part in these activities. drawing on findings from in-depth walking interviews with older members of the ‘walking for health’ scheme in southampton, england, this paper examines how mobilities have the potential to disable, as much as they enable, health and wellbeing. the concept of therapeutic mobilities, coined by gatrell ( ), has grown out of a development of research within health geography into therapeutic landscapes; places that are seen to contribute to improved health and wellbeing. literature on therapeutic landscapes has enriched understandings of the health impacts of places, with detailed descriptions of the healing benefits of iconic sites, such as the (laumann et al, ) and gardens (pitt, ) . however, the recent 'mobilities turn' has helped develop research that moves from a focus on fixed sites, towards the role of everyday movements through places that can contribute to wellbeing (doughty, ) . this emerging body of research focuses largely on the restorative power of mobility to convey the idea that mobility, as well as place, can contribute to improved health and wellbeing. studies have examined the downsides to walking, for instance when it is stressful or burdensome when walking with small children (bostock, ) or in unsafe neighbourhoods (green, ). yet, further research that explores the unfavourable qualities of shared walking is required to examine the downsides of shared walking in different contexts (hanson et al, ) . this paper explores how group walking may negatively influence wellbeing in later life, and contributes to a richer understanding of the relationship between the two. in literature that focuses on places and landscapes, scholars such as conradson ( ) and cummins et al ( ) have critiqued the assumption that certain environments create an inherently therapeutic experience and argue for a relational approach to place and wellbeing. as conradson ( , p, ) states, 'individuals clearly experience even scenic environments in quite different ways, in terms ranging from enjoyment through to ambivalence and even anxiety'. in this study, i argue that presumptions that group walking has intrinsically beneficial influences on wellbeing requires a relational approach that emphasises subjective experience. ). healthy ageing refers to 'optimising opportunities for good health, so that older people can take an active part in society and enjoy an independent and high quality of life' (healthy ageing eu, , p, ). older adults are encouraged to 'age healthily' by taking responsibility for their health through activities that contribute to wellbeing, such as walking groups. however, endorsements of healthy ageing can create a pressure among older people and can be exclusionary to people who cannot, for various reasons, maintain a certain standard of health (stephens et al, ) . particularly in older age, group walking in various places has been found to increase fitness, reduce blood pressure and improve mental health (hanson and jones, ) . nevertheless, the widespread promotion of walking groups for older people downplays the possible detrimental impacts of shared walking to health and wellbeing and thus portrays a largely romanticised view of group walking. walking groups are often prescribed as a way to improve health, without considering the individual issues of older adults, and shared walking in older age is rarely spatially nor relationally understood. for instance, health professionals may not appreciate where people walk and the impacts of this on a person's wellbeing, as well as who they walk with or encounter and how this impacts on their wellbeing. in the current climate of austerity in the uk , walking groups are increasingly promoted by health professionals because they are usually free for members to join and are volunteer-led, so do not incur costs to the government or local authorities. the austerity measures of the uk government, as well as the previous 'big society' agenda, has seen responsibility for health and wellbeing shift from local authorities to communities and individuals (lowndes and pratchett, ). cuts to government funding have resulted in the closure or reduction of many public services for older people, such as day centres, meals-on-wheels and home-care support (age uk, ) , therefore older adults are being encouraged to take a greater responsibility for their health and wellbeing to ensure they are leading active and healthy lives (kuh et al, ) . this promotion and increase of self-responsibility for older people may mean that the detrimental qualities of physical activities are overlooked. furthermore, there is a need to examine whether older individuals are reaping the benefits that they are assumed to gain from walking groups. in this paper i am not seeking to challenge the idea that shared walking has many health benefits. rather, i question the assumption that shared movement is inherently therapeutic or indeed inherently disabling. through an in-depth ethnographic study of a walking group, i explore how the same form of mobility can be both beneficial and damaging in different ways to different people. i aim to encourage a shift from romanticised accounts of shared walking to consider both the positive and negative influences of shared walking on health and wellbeing. in doing so, i introduce the concept of 'detrimental mobilities' and argue that this concept needs to be considered when exploring the wellbeing implications of shared walking. the concept of detrimental mobilities conveys the idea that shared mobility and movement are not imbued with intrinsic beneficial properties but can actually result in unintended, unfavourable impacts to wellbeing for some people. were to take part. the groups consisted mainly of white older women, thus the study's participants reflected the overall group membership. i then joined each walking group on their walk, and it was during these walks that ten of the members expressed their willingness to be part of the study. all ten interviews were walking interviews and participants chose to either undertake the walking interview at the same time as one of the walking groups -but walking further behind the group -or on a different day altogether. five of the participants decided to arrange their walking interview for the same time and route as the walking group, thus i was also involved in participating in the walking groups, which allowed for a deeper ethnographic understanding of how these groups function. each interview lasted approximately thirty to fifty minutes and was audio-recorded. participants were asked questions about how and why they came to join the walking group, the benefits they gain from the walking group and any issues they have with the walking group. before the data collection period, ethical approval was gained from the university of southampton's ethics committee. small-scale, purposively selected samples are generally used for exploratory qualitative research because it favours depth of illustration over representation (ritchie et al, ) . i had approached both walking groups and ten members agreed to take part in the study. i analysed the data throughout the data collection period, and data saturation, defined as the 'point at which no new themes or codes emerge from the data' (clarke and braun, , p, ) was reached by the tenth interview. robinson ( ) argues that this commonality of experiences between the participants could be because of the lack of heterogeneity within the study sample and therefore the walking groups as a whole, because the participants' characteristics reflected the overall makeup of the walking groups. although the sample size is small, the depth of the narrative data i uncovered satisfied my study's aims and as a lone . walking interviews the study of walking and use of walking interviews is a burgeoning field within social sciences (carpiano, to respond accurately about their experiences. in this study, participants were interviewed individually and the route of the walking interviews were chosen beforehand by each participant, so that they could decide how far and over which terrain they would prefer to walk. this paper argues that the wellbeing implications of walking groups are often over-romanticised, with shared walking presumed to be fundamentally therapeutic. likewise, i do not wish to romanticise the walking interview as a way to somehow gather more 'accurate' research data. accordingly, the benefits of walking interviews should not be over-emphasised or thought to be without problems, an assumption firstly, i transcribed the data verbatim and familiarised myself with the data through re-reading. after, i created initial codes from the data using nvivo version software. these were codes that were interesting and meaningful to my research aims (braun and clarke, ) . the codes were then collated into potential themes which i reviewed, and i produced a thematic map which best represented the data and was supported by codes and the relationships between them (clarke and braun, ) . at this stage, some themes, such as 'importance of nature' and 'healthy ageing' remained closely related to the therapeutic landscapes and therapeutic mobilities literatures. however, my thematic map also included many interpretive themes, such as 'lack of integration' and 'personal comparisons' that had been inductively generated. thus, the focus on detrimental mobilities emerged more inductively during the data collection, analysis and as the study unfolded. i decided to focus this paper on the themes which showed the detrimental aspects of the walking groups because these were more interesting, meaningful group'. these participants find that despite the shifts in who is walking (or sitting) with whom, the same members generally stick together in a clique that is exclusionary to others. nevertheless, not all participants had issues with the cliques of the walking groups. wendy, aged , has been attending both walking groups for six years. wendy joined the waking groups with a friend who shares her passion for walking and being out in nature. as well as being a member of wfh, wendy takes part in ramblers walks and feels such walking groups provide her with both exercise and friends. unlike some of the other participants, wendy has no issue with the cliques of the walking group, one of which she is included in: "we tend to have our little groups. so, there's a group that i am part of if you like and we do tend to integration between some group members. during the interview, she described some spin-off activities, such as trips to cafés and to the cinema, which were generated from the walking group. however, it was clear that these trips were only welcome to certain people, possibly those who were part of her clique. that is not to say that shared walking cannot produce therapeutic landscapes that can have healing benefits for those involved. doris, aged , describes how the conversations she has with other walkers helps to reduce the stress she feels in her daily life and other participants spoke of the intimate conversations they have had with other walkers, such as when ada's mother passed away. nevertheless, interaction, suggests that social wellbeing is not necessarily gained by being part of a walking group and thus shared mobility is not inherently therapeutic. the social aspect of these groups can create anxiety and exclusion for some, and while other research into walking groups has explained this anxiety as something newer members feel about joining group activities (hanson et al, ) , here, some participants who have been attending for some time are still feeling excluded from the group. moreover, while sociality is important in the creating of therapeutic mobilities (doughty, ), lack of sociality is also important in creating detrimental mobilities. likewise, just as engaging in supportive social environments is beneficial for combatting social isolation, engaging in unsupportive social environments, and feeling excluded or rejected, is damaging for social wellbeing. furthermore, it is important to note that this research did not include the voices of those who perhaps feel so excluded that they no longer attend the walking groups or feel so excluded that they have not terrains of southampton common, such as the rough grassland or the woodland, she would often head straight to the café to wait for the other walkers to finish the walk, rather than walking with them. actually hinder the benefits gained by group members who cannot cope with these changes as much as the other members. these narratives thus suggest, perhaps unsurprisingly, that walking groups can be exclusive to people whose physical ability falls below a certain level. during the walks, walk leaders stop at regular intervals to ensure that members at the back of the group can catch up with those at the front, which allows a few moment's rest for many walkers. yet, for those at the back of the group, who perhaps, like eileen, cannot walk as fast, these built-in halts do not provide any rest and could in fact pressure some members into walking faster in order to catch up. eileen's story highlights an issue of universally prescribing walking groups with the view that they are inherently restorative and relaxing in the same ways for all (carpenter, ) . the pressure that members feel to maintain the pace of the group could also have relevance to other group activities, such as cycling groups, long-distance swimmers or park- runners, where the therapeutic experience depends on one keeping pace with a group. therefore, assuming that shared mobility is valuable to people in the same ways overlooks the nuances between mobility and wellbeing, and the diverse ways in which shared walking is experienced by individuals. what these participant's narratives also show is that detrimental and therapeutic mobilities may not instantly impact on one's wellbeing or always have the same impact. for instance, eileen was no slower or less able to walk on uneven surfaces than other members when she joined the group eight years ago, healthy ageing discourse, as well as funding cuts to social and physical activity services for older people, mean that walking groups are increasingly promoted by health professionals as a means of improving the wellbeing of older adults. this paper has introduced the concept of detrimental mobilities to highlight that shared mobility is not always inherently beneficial for all individuals, thus promoters of walking groups should avoid romanticising their benefits. taken together, the findings from this study complicate the boundaries between positive and negative therapeutic experiences and the assumption that membership in a walking group is entirely advantageous. these participants are members of the same walking group, therefore health professionals may presume that they each experience the walking group in a similar way and that they all draw the same healing benefits from each walk (carpenter, ). their experiences emphasise the importance of examining mobilities at an individual level, and with a relational approach that recognises the interplay of people and place. the findings promote need for a shift in thinking from walking groups as homogenously beneficial for all members, to also understand the unintended, detrimental impacts of shared walking in older age. this paper has the potential to enrich the understanding of wellbeing as an intersubjective and fluctuating experience, which will open up ideas surrounding how wellbeing is influenced by shared movement. this study also has implications for research into therapeutic mobilities and contributes to a richer understanding of the relationship between mobility, old age, and health and wellbeing. the focus of this paper has only been on shared walking as a form of mobility and the findings are based on a small self-selected sample, thus they cannot represent the experiences of all older adults in walking groups. this paper does not seek to disregard the notion that shared walking through greenspace is therapeutic or beneficial to health, but instead seeks to emphasise that shared mobility also has the potential to be briefing: the health and care of older people in england talking whilst walking: a geographical archaeology of knowledge ageism: a threat to "aging well" in the st century the health benefits of walking in greenspaces of high natural and heritage value pathways of disadvantage? walking as a mode of transport among low-income mothers using thematic analysis in psychology healthy ageing' policies and anti-ageing ideologies and practices: on the exercise of responsibility from 'healthful exercise' to 'nature on prescription': the politics of urban green spaces and walking for health is there evidence that walking groups have health benefits? a systematic review and meta-analysis a spatial equity analysis of a public health intervention: a case study of an outdoor walking group provider within local authorities in england. international journal for equity in health walking groups in socioeconomically deprived communities: a qualitative study using photo elicitation. health & place doing" gardening and "being" at the allotment site: exploring the benefits of allotment gardening for stress reduction and healthy aging healthy ageing inside-out: analysis of the insider-outsider concept as a heuristic device to develop reflexivity in students doing qualitative research walking groups for women with breast cancer: mobilising therapeutic assemblages of walk, talk and place using templates in the thematic analysis of text a life-course approach to healthy ageing: maintaining physical capability hermeneutic phenomenology and phenomenology: a comparison of historical and methodological considerations rating scale measures of restorative components of environments how phenomenology can help us learn from the experiences of others social exclusion and community in an urban retirement village walking methods: research on the move neighbourhood blue space, health and wellbeing: the mediating role of different types of physical activity beyond "move more": feeling the rhythms of physical activity in mid and later-life therapeutic experiences of community gardens: putting flow in its place. health & place qualitative research practice: a guide for social science students and researchers sampling in interview-based qualitative research: a theoretical and practical guide encountering place: a psychoanalytic approach for understanding how therapeutic landscapes benefit health and wellbeing. health & place indices of multiple deprivation healthy ageing from the perspective of older people: a capability approach to resilience walking for health walking for health programme overview we estimate that landscape perception and environmental psychology highlights: • 'detrimental mobilities' refers to negative impacts of shared mobility on wellbeing • walking groups can result in unfavourable impacts to the wellbeing of individuals • shared movement can be exclusionary in terms of sociality and physical ability • there is a need to question romanticised accounts of shared walking in older age acknowledgements: many thanks to all the participants of this study. thank you to dr eleanor wilkinson for her advice and support, to dr andrew power and dr ros edwards for their comments and my sister zoe elmore for help with proof-reading. the transient nature of the walking groups helps participants to open up and permits an ease in the key: cord- -nu q ddu authors: saitoh, masayuki; tsuchida, masanori; koike, terumoto; satoh, koichi; haga, manabu; aoki, tadashi; toyabe, shin-ichi; hayashi, jun-ichi title: ultrafiltration attenuates cardiopulmonary bypass–induced acute lung injury in a canine model of single-lung transplantation date: - - journal: the journal of thoracic and cardiovascular surgery doi: . /j.jtcvs. . . sha: doc_id: cord_uid: nu q ddu objective the purpose of this study was to investigate the effects of cardiopulmonary bypass and ultrafiltration on graft function in a canine single-lung transplantation model. methods fifteen left single-lung transplantations were done in weight-mismatched canine pairs. the animals were divided into groups: group , in which transplantation was done without cardiopulmonary bypass; group , in which transplantation was done with cardiopulmonary bypass and in which the cardiopulmonary bypass flow was decreased slowly with controlled pulmonary artery pressure; and group , in which transplantation was done with cardiopulmonary bypass and ultrafiltration. hemodynamic parameters and lung function were monitored for hours after reperfusion. the grafts were harvested for histologic studies, myeloperoxidase assay, and real-time quantitive reverse transcription–polymerase chain reaction of mrna encoding interleukin . results the hemodynamic parameters were similar among the groups. in group pao and alveolar to arterial gradient for o levels were excellent throughout the -hour observation period, but in group they progressively deteriorated. however, ultrafiltration significantly (p = . ) improved the pao level in group . on histology, interstitial edema and polynuclear cell infiltration were most marked in group and significantly worse than in groups and . myeloperoxidase assay and real-time quantitative reverse transcription–polymerase chain reaction showed increased myeloperoxidase activity and interleukin gene expression in group grafts compared with group grafts. myeloperoxidase activity and interleukin gene expression were suppressed with ultrafiltration. conclusions cardiopulmonary bypass had negative effects on the graft, but ultrafiltration attenuated acute lung dysfunction by reducing the inflammatory response. t he use of cardiopulmonary bypass (cpb) is limited to a minority of lung transplant recipients because cpb has been associated with inferior early graft function and clinical outcome. several reports have found that the mortality and morbidity of recipients requiring cpb is higher than that of recipients not requiring cpb. [ ] [ ] [ ] one of the reasons for these findings could be that cpb evokes an inflammatory response that leads to organ failure, including respiratory distress syndrome. [ ] [ ] [ ] in cardiac surgery cpb is well recognized to cause a systemic inflammatory response syndrome that can progress to acute lung inflammation known as postperfusion syndrome. on the other hand, triantafillou and colleagues reported that cpb has no deleterious effect on early graft function. in pediatric transplantation most operations are performed with cpb, and good results have been reported. in fact, the harefield group recommends the routine use of cpb in lung transplantation. furthermore, szeto and associates have found that cpb had minimal deleterious effects on graft function in a homogeneous population of patients with chronic obstructive pulmonary disease. thus the use of cpb in lung transplantation is controversial. the reason for a lack of consensus is partially due to the fact that clinical studies can be biased because patients who require cpb have more severe disease. in particular, cpb is mostly needed in patients with pulmonary hypertension, and this group of patients has the highest risk of all patients undergoing transplantation. there have been no randomized controlled studies to address the effects of cpb on the outcomes of lung transplantation, and few experimental studies have specifically examined the effects of cpb on graft function. theoretically, cpb has potential benefits, such as providing hemodynamic stability during surgical intervention and preventing the sudden increase of pulmonary flow during the reperfusion period. thus controlling graft flow with cpb might protect the graft from high-pressure reperfusion injury. halldorsson and coworkers , reported that decreasing the reperfusion pressure prevents pulmonary injury in a piglet model. on the other hand, the pittsburgh group reported that the use of cpb is associated with early graft dysfunction in a canine experiment. fullerton and colleagues reported that lung transplantation with cpb exaggerates pulmonary vasomotor dysfunction. however, in their experiment the animals were quickly weaned off cpb, and the potential benefit of cpb was not examined. we hypothesized that the effect of cpb on lung function depends on the balance between its deleterious effects caused by an inflammatory response and its beneficial effects caused by decreasing pulmonary flow. to examine the beneficial effects of cpb on graft function, we performed canine single-lung transplantations with cpb, and graft flow was controlled during the early reperfusion period. in addition, we examined whether conventional ultrafiltration (cuf) during cpb attenuates graft dysfunction because it has recently been suggested that ultrafiltration is effective in eliminating the inflammatory mediators responsible for the cytokine syndrome. fifteen left single-lung transplantations were done in weightmismatched pairs of adult mongrel dogs. dogs weighing from to kg were used as donors, and smaller dogs weighing from to . kg were used as recipients. the donor/recipient body weight ratio ranged from . to . . weight-mismatched pairs of dogs were used because fujita and associates found that the donor/recipient body ratio had an important effect on early graft function; a donor/recipient body weight ratio of . or greater was associated with stable graft function. the animals were divided into groups: group , in which transplantation was done without cpb; group , in which transplantation was done with cpb and cpb flow was decreased slowly with controlled pulmonary artery pressure; and group , in which transplantation was done with cpb and ultrafiltration was used until the termination of cpb. anesthesia was induced with intramuscular ketamine hydrochloride ( mg/kg) and atropine ( . mg/kg). intravenous thiopental sodium ( . mg/kg) and pancuronium bromide ( . mg/kg) were used to facilitate endotracheal intubation. the animals were ventilated at a tidal volume of ml/kg at a rate of breaths/min by using a volume-limited ventilator (servo b, siemens-elmer). positive end-expiratory pressure was controlled at cm h o; the inspired oxygen fraction was . . anesthesia was maintained with inhalation of % to % halothane, and muscular relaxation was obtained with additional pancuronium bromide at a dose of . mg/kg. an arterial line was inserted into the right femoral artery to monitor blood pressure and arterial blood gases. a venous line was inserted into the right femoral vein to allow infusion of solutions. a left thoracotomy was performed at the fifth intercostal space. the left and right pulmonary arteries, pulmonary vein, and left main bronchus were isolated. sodium heparin ( u/kg) was administered through the venous line. a purse-string suture with - prolene was placed on the proximal site of the left pulmonary artery, and a catheter was inserted. a vascular clamp was placed on the left atrium, and an incision was made for decompression. after left pulmonary artery clamping, the left lung was selectively flushed with cold modified euro-collins solution ( ml/kg). during this period, the lung was ventilated with % oxygen. after flushing was completed, the left main bronchus was stapled, leaving the lung well inflated with % oxygen. the left lung was then excised and stored in °c euro-collins solution until transplantation. during pulmonary artery flushing, donor blood for the recipients' transfusion was collected into packs containing citratephosphate-dextrose solution from the venous line. after harvesting the left lung, the animals were killed by means of an intravenous injection with an overdose of potassium chloride and thiopental sodium. recipient dogs were anesthetized and ventilated, and catheters were inserted as in the donors. a pulmonary artery catheter ( f swan-ganz catheter) was placed in the main pulmonary artery with the animals in the right decubitus position, a left thoracotomy was done through the fifth intercostal space. the right pulmonary artery and the right main bronchus were encircled by - silk strings. sodium heparin ( u/kg) was administered systemically, and the activated clotting time was confirmed to be longer than seconds. a catheter was placed into the left atrium through the right accessory pulmonary vein to monitor left atrial pressure (lap). in group a left pneumonectomy was performed, and then the donor left lung was orthotopically transplanted. in groups and a pediatric arterial cannula was inserted in the distal part of the ascending aorta, and a -stage wire-reinforced venous cannula ( f, f) was placed in the right atrium by opening the pericardium through a left thoracotomy. the arterial and venous cannulas were connected to the bypass circuits, which consisted of a roller pump, a -ml venous reservoir, ⁄ -inch tubing, a -m arterial filter, a polystan oxygenator (safe mini, polycare ltd), and a heat exchanger. the bypass circuit was primed with ml of lactate ringer's solution, % mannitol, and sodium bicarbonate. cpb was initiated and maintained at a flow rate of to ml/kg for hours, and rectal temperature was maintained at °c. during cpb, the respiration rate was decreased to breaths/min. the left pneumonectomy and lung transplantation were done in the same manner as in group . when the animals were weaned off cpb, the cpb flow was decreased slowly so that the newly transplanted lungs were reperfused with a controlled pulmonary artery pressure over a -minute period. in all groups transplantation involved about hours of ischemic time. all animals were transfused with donor blood if the hematocrit level decreased to less than %. the donor blood was endotoxin free and a negative cross-match. in all groups protamine was administered to neutralize heparin, and the activated clotting time was normalized. after minutes of reperfusion, the native right pulmonary artery and right main bronchus were ligated to ensure dependence on the transplanted lung. the lungs were ventilated with a tidal volume of ml/kg, a positive end-expiratory pressure of cm h o, and an inspired oxygen fraction of . at a rate of breaths/min. the skin was closed, and the recipient dogs were observed for hours, during which time aortic pressure, pulmonary artery pressure, cvp, and lap values were continuously monitored. measurement of co, arterial blood gas analysis, and blood sampling was done at , , , , , and minutes after ligation of the right pulmonary artery and the right bronchus. co was measured by means of the thermodilution technique with a -ml bolus injection of % glucose at °c. arterial gas was analyzed with the i-stat portable clinical analyzer (heska corp). bronchoalveolar lavage (bal) was done twice by means of flexible bronchoscopy, once before transplantation and again minutes after ligation of the right pulmonary artery and the right bronchus. the bronchoscope was wedged in the lingular segment of the left upper lobe. the bal fluid was collected by flushing the distal airways with ϫ ml of normal saline and consequent intermittent suctioning. after hours of observation, the animals were killed with an intravenous injection of an overdose of potassium chloride and thiopental sodium. in group the ultrafiltration circuit was arranged as follows. one of the outlet ports of the arterial line was connected to a hemoconcentrator (capiox cx-hc s, terumo corp) through a small roller pump. a polysulfon fiber with a surface of . m , a priming volume of ml, and a maximal transmembranous gradient of mm hg was used. ultrafiltration was performed at ml/ min, and the blood was returned to the venous reservoir after filtration. ultrafiltration was started minutes before the reperfusion of the transplanted lung and continued until the termination of cpb. a total of ml of normal saline was infused into the venous reservoir, and the priming volume, including the additional infusion, was completely removed. all animals received humane care in compliance with the "principles of laboratory animal care" formulated by the national society of medical research and the "guide for the care and use of laboratory animals" prepared by the institute of laboratory animal resources, national research council, and published by the national academy press, revised . the institutional review committee approved the study protocol. the left upper and lower lobes were used to measure the wet/dry weight (w/d) ratio. the lungs were weighed and then dried in an oven at a constant temperature of °c for hours. the w/d ratio was obtained by dividing the wet weight by the final dry weight. lung specimens harvested at the time of animal death were fixed with % formalin. the tissues, cut into -m sections, were stained with hematoxylin and eosin and with naphthol as-d chloroacetate esterase. polymorphonuclear neutrophils (pmns) were identified by means of positive staining and were counted at ϫ magnification by investigators who were blind to the specimens. the data were expressed as pmns per alveolus. the recipient lung samples were frozen in liquid nitrogen and stored at Ϫ °c until assay. quantitative myeloperoxidase (mpo) activity was determined as previously described. results were expressed as mpo per minute per mg of tissue corrected for dry weight (change in optical density per minute per milligram). data were expressed as means Ϯ standard deviation. data for multiple observations over time were analyzed by means of -way analysis of variance (anova) with repeated measures for overall treatment effect. one-way anova was used to test for differences among treatment groups. when anova showed significance, the tukey test was used for post-hoc multiple comparisons between treatment groups. all analyses were performed with spss . j (spss japan inc) and sas . (sas institute inc) software. there were no differences among the groups with respect to donor/recipient body weight ratio, cold ischemic time, warm ischemic time, implantation time, body temperature, and the amount of heparin and protamine used ( table ) . all recipient animals survived the -hour observation period. a comparison of the groups and the differences among the groups for every measurement of arterial oxygen and alveolar to arterial gradient for o are shown in figure . the pao level was excellent in the animals undergoing transplantation without cpb during the -hour observation period. however, in animals undergoing transplantation with cpb, the pao level progressively deteriorated, and significant differences were found among the groups (overall group effect, p ϭ . ; group vs group , p ϭ . ; group vs group , p ϭ . ). the pao level of the animals undergoing transplantation with cpb was better with the use of ultrafiltration during the early reperfusion period. the alveolar to arterial gradient for o of the animals undergoing transplantation without cpb was significantly better than that of the animals undergoing transplantation with cpb (overall group effect, p ϭ . ; group vs group , p ϭ . ; group vs group , not significant). the hemodynamic data of the recipients during the -hour observation period are shown in table . all groups had similar mean aortic pressure, cvp, lap, and co values. the animals undergoing transplantation with cpb and ultrafiltration had significantly lower mean pulmonary artery pressures than the animals undergoing transplantation without cpb (overall group effect, p ϭ . ; group vs group , p ϭ . ). although the p value of the overall group effect for pvr was not significant (p ϭ . ), the pvr of animals undergoing transplantation with cpb and ultrafiltration was lower than that of animals undergoing transplantation without cpb at and hours after ligation of the right pulmonary artery and bronchus. regarding aerodynamic parameters, peak airway pressure was essentially the same among the groups. the microscopic findings for each group are shown in figure . neutrophil infiltration into the interstitial and alveolar spaces was observed in all groups. these changes were most marked in the animals undergoing transplantation with cpb. the mean pmn infiltration number per alveolus was . Ϯ . in group , . Ϯ in group , and . Ϯ . in group . pmn infiltration was significantly higher in group than in the other groups (p Ͻ . ). severe perivascular hemorrhage, in addition to alveolar exudates and hemorrhage, was seen in animals undergoing transplantation with cpb. ultrafiltration attenuated these histologic changes. is shown. each group consisted of animals. significant differences in pao levels were observed among the groups (overall group effect, p ‫؍‬ . , group vs group , p ‫؍‬ . ; group vs group , p ‫؍‬ . ). significant differences in a-ado values were observed among the groups (overall group effect, p ‫; .؍‬ group vs group , p ‫؍‬ . ). the mpo activity of the graft was . Ϯ . min/mg for animals undergoing transplantation without cpb, . Ϯ . min/mg for animals undergoing transplantation with cpb, and . Ϯ . min/mg for animals undergoing transplantation with cpb and ultrafiltration. the mpo activity of the lungs transplanted with cpb was higher than that of the lungs transplanted without cpb (p ϭ . ). simultaneous use of cpb and ultrafiltration significantly suppressed mpo activity (p ϭ . ). the w/d ratio of the transplanted lung after hours was . Ϯ . for animals undergoing transplantation without cpb, . Ϯ . for animals undergoing transplantation with cpb, and . Ϯ . for animals undergoing transplantation with cpb and ultrafiltration. there were no significant differences with respect to the w/d lung weight ratio among the groups. there were no statistically significant differences among the groups in recovery rates and total cell numbers in the bal fluid. the protein concentration of the bal fluid obtained hours after reperfusion was . Ϯ . mg/dl for animals undergoing transplantation without cpb, . Ϯ . mg/dl for animals undergoing transplantation with cpb, and . Ϯ . mg/dl for animals undergoing transplantation with cpb and ultrafiltration. the protein level of the animals undergoing transplantation with cpb and ultrafiltration was lower than that of the animals undergoing transplantation with cpb (p ϭ . ), whereas the serum protein levels of the groups were essentially the same ( . Ϯ . mg/dl for group , . Ϯ . mg/dl for group , and . Ϯ . mg/dl for group ). interleukin (il- ) mrna expression in the lung is discussed in appendix e and figure e . the use of cpb in lung transplantation remains controversial because clinical and experimental studies have reported different conclusions. [ ] [ ] [ ] [ ] , , , cpb is known to stimulate and release several mediators, including complement factors. [ ] [ ] [ ] at the time of reperfusion, the blood activated by cpb goes into the newly transplanted lung, and reperfusion injury could be more severely accelerated compared with cases in which the blood is not activated. on the other hand, cpb has a beneficial effect in that the transplanted lungs can be reperfused with controlled pulmonary artery pressure. several studies have demonstrated that decreasing the reperfusion pressure reduces lung injury after lung ischemia. , therefore one could expect that cpb should have beneficial effects by preventing high pulmonary flow during reperfusion of the transplanted lung. in the present experiment all animals survived the -hour observation period, which is in contrast to other reports in which animals could not tolerate contralateral pulmonary artery clamping for longer than hours. the reason for the differences in survival could be the different reperfusion methods. in previous canine experiments the animals were quickly weaned off cpb, and the potential benefit of cpb was not fully examined. we believe that that the decreasing of the pulmonary pressure in our model ameliorated graft function to some extent. however, our data indicated that even if pulmonary flow was controlled during reperfusion, pulmonary function eventually deteriorated over the -hour observation period, and the graft was not permanently protected from the adverse effects of cpb. our study has several limitations. first, the animals underwent transplantation with unilateral lungs and vascular beds that were smaller than in bilateral lung transplantation. however, a donor/recipient body weight ratio of . or greater was used in this study. second, canines are thought to be more susceptible to cpb than human subjects. third, most of the animals undergoing transplantation with cpb required blood transfusion, whereas the animals undergoing transplantation without cpb did not. this might have accelerated the worsening of graft function. halldorsson and coworkers , reported that controlled reperfusion prevents pulmonary injury after hours of lung preservation. in their experiment white blood cells were depleted through a leukocyte-depleting filter. bando and associates reported similar results in lung injury associated with cpb. they showed that leukocyte depletion improves lung injury after cpb. in our experiment leukocyte depletion was not ap- plied; this could explain why there was graft dysfunction despite the prevention of high-flow vascular injury. in fact, the changes observed on histology and the mpo assay were not those of simple lung edema but the result of accumulation of pmns into the alveolar space. these changes are compatible with those found in lungs after cardiac surgery with cpb. it is well known that there is an inflammatory reaction to cpb with neutrophil sequestration in the lungs, contributing to microvascular injury and postoperative pulmonary dysfunction. therefore in our model reperfusion pulmonary injury of the transplanted lung might have been further enhanced by the adverse effect of cpb. recently, ultrafiltration techniques have been shown to improve postoperative respiratory and cardiac functions after heart surgery. furthermore, ultrafiltration has been investigated as a potential therapy for severe acute respiratory syndrome because it removes inflammatory mediators and excess free water. thus we hypothesized that ultrafiltration could reduce inflammatory mediators and be beneficial for graft function in lung transplantation with cpb. cuf is applied during the rewarming phase of cpb, and modified ultrafiltration (muf) is performed immediately after cessation of cpb; both methods are used in cardiac surgery. [ ] [ ] [ ] berdat and associates reported that in pediatric cardiac surgery both cuf and muf could remove inflammatory mediators. they reported that of the cytokines, il- was removed most effectively and that il- was removed to a greater extent with cuf than with muf. il- is known to be the key cytokine associated with sequestration of neutrophils in the lung. il- stimulates neutrophilia and thrombopoiesis and induces the synthesis of acute-phase proteins. [ ] [ ] [ ] sustained increased of il- in the plasma and bal fluid of patients with adult respiratory distress syndrome have been demonstrated and are negatively correlated with disease outcome and patient survival. in this experiment we used the cuf method. we were not able to show whether the improvement of graft function was brought about by the reduction of il- levels in the present study because the specific cytokine kit for canine il- is not yet commercially available. therefore instead of measuring serum cytokine levels, we showed that il- mrna was reduced in canines with ultrafiltration by using real-time reverse transcription-polymerase chain reaction (see appendix e and figure e ). another possible mechanism by which ultrafiltration could improve graft function might be due to the reduction of adhesion molecules on recipients' blood lymphocytes. it is well known that some adhesion molecules are upregulated during cpb and have been associated with the adverse effects of cpb. grunenfelder and associates reported that ultrafiltration led to a significant reduction in not only cytokines but also adhesion molecules, such as soluble e-selectin and intercellular adhesion molecule . both molecules are responsible for the primary adhesion of neutrophils to the endothelium of the vessels. thus several mechanisms might contribute to the changes observed in grafts treated with cuf. given our results, further study to determine the optimal ultrafiltration method for patients undergoing lung transplantation with cpb is warranted. in conclusion, despite controlling pulmonary flow during the reperfusion period, cpb has deleterious effects on the graft in a canine single-lung transplantation model. ultrafiltration applied during termination of cpb might improve graft function by reducing the inflammatory response through several mechanisms. to assure fairness to authors submitting work for consideration in the journal of thoracic and cardiovascular surgery, a mechanism exists for managing conflicts of interest. the editor and each of the section editors complete a "conflict of interest" form that identifies any and all relationships with commercial and other academic entities. when the editor has a potential conflict because of a relationship with another entity or author, the editor appoints an alternate editor from among the section editors or editorial board members who assumes the entire responsibility for final decisions on the manuscript in question. the editor does not read the reviews that are submitted nor engage in discussing the manuscript prior to the final decision. when the conflict of interest involves a section editor, a "guest section editor" is appointed who fills the role normally played by the conflicted section editor. all members of the editorial board and reviewers are asked to indicate any conflict of interest when they agree to review a manuscript. cardiopulmonary bypass is associated with early allograft dysfunction but not death after double-lung transplantation effect of cardiopulmonary bypass on early graft dysfunction in clinical lung transplantation con: lung transplantation should not be routinely performed with cardiopulmonary bypass lung injury and acute respiratory distress syndrome after cardiopulmonary bypass inflammatory response to cardiopulmonary bypass effect of cardiopulmonary bypass on systemic release of neutrophil elastase and tumor necrosis factor predictors, frequency, and indications for cardiopulmonary bypass during lung transplantation in adults pro: lung transplantation should be routinely performed with cardiopulmonary bypass cardiopulmonary bypass for bilateral sequential lung transplantation in patients with chronic obstructive pulmonary disease without adverse effect on lung function or clinical outcome controlled reperfusion prevents pulmonary injury after hours of lung preservation lowering reperfusion pressure reduces the injury after pulmonary ischemia deleterious effect of cardiopulmonary bypass on early graft function after single lung allotransplantaiton: evaluation of a heparin-coated bypass circuit lung transplantation with cardiopulmonary bypass exaggerates pulmonary vasomotor dysfunction in the transplanted lung effect of continuous hemofiltration on hemodynamics, lung inflammation and pulmonary edema in a canine model of acute lung injury experimental study on size matching in a canine living-donor lobar lung transplantation quantitative assay for acute intestinal inflammation based on myeloperoxidase activity. assessment of inflammation in rat and hamster models leukocyte depletion ameliorates free radical-mediated lung injury after cardiopulmonary bypass neutrophil sequestration and pulmonary dysfunction in a canine model of open heart surgery with cardiopulmonary bypass effect of ultrafiltration during cardiopulmonary bypass for pediatric cardiac surgery elimination of proinflammatory cytokines in pediatric cardiac surgery: analysis of ultrafiltration method and filter type modified ultrafiltration lowers adhesion molecule and cytokine levels after cardiopulmonary bypass without clinical relevance in adults the biology of interleukin- interleukin- and its receptor in autoimmunity impaired neutrophil response and cd ϩ t helper cell development in interleukin -deficient mice infected with candida albicans persistent elevation of inflammatory cytokines predicts a poor outcome in ards. plasma il- beta and il- levels are consistent and efficient predictors of outcome over time neutrophil adhesion molecule expression and serum concentration of soluble adhesion molecules during and after pediatric cardiovascular surgery with or without cardiopulmonary bypass modified ultrafiltration lowers adhesion molecules and cytokine levels after cardiopulmonary bypass without clinical relevance in adults we gratefully acknowledge the expert technical assistance of jyu-ichi higuchi with the surgical preparation of the dogs. lung tissue was collected in tubes containing trizol reagent (invitrogen japan k.k.) and stored at Ϫ °c until analysis to isolate total rna from the lungs. samples were incubated for minutes at °c to permit complete tissue dissociation. samples were mixed with . ml of chloroform per ml of trizol and were centrifuged at , g for minutes at °c. the aqueous phase was collected and transferred to fresh tubes. the rna was precipitated by mixing with isopropyl alcohol. after incubation for minutes at °c, samples were centrifuged at , g for minutes. the supernatant was removed, and % ethanol was added to the rna pellet, which was then mixed by vortexing and centrifuged at g for minutes at °c. finally, the dried rna was isolated. reverse transcription was done with l of hotdenatured dna-free rna, pmol of random hexamer primers (pd [n ], amersham pharmacia biotech), and u of superscript ii reverse transcriptase (roche diagnostics). the reaction mixture was incubated for minutes at °c, minutes at °c, and minutes at °c. products were precipitated with naoac ( . m, ph ) and . volumes of ethanol ( %). they were then resuspended in l of diethylpyrocarbonate-water and stored at Ϫ °c. cdna was diluted -fold with dnase-free water in a siliconized tube (which had ng/l ms rna to prevent adherence to the tube wall), and l was then used for real-time pcr. real-time reverse transcription-polymerase chain reaction on the lightcycler (roche diagnostics) was done with a total volume of l in the presence of l of ϫ reaction buffer (taq polymerase, deoxyribonucleoside triphosphates, mgcl , sybr green, roche diagnostics) and l of cdna (or water as a negative control, which was always included). mgcl was added to a final concentration of mm, and . pmol of each oligonucleotide primer (actin-lf: cccaaggccaaccgcgagaa-gat, product size, bp; actin-lr: gtcccggccagccag-gtccag; il -lf: aaggggcatctccaacatcatcat, bp; il -lr: ctcctgccaagctgaacccaagac) was added. real-time pcr was performed in glass capillaries with an initial denaturation step of seconds at °c, followed by cycles of seconds at °c, seconds at annealing temperature (␤-actin, °c; il- , °c), and (product length [bp]/ ) seconds at °c. at the end of each cycle, the fluorescence emitted by the sybr green was measured. after completion of the cycling process, samples were subjected to a temperature ramp (from °c above annealing temperature to °c at °c/s) with continuous fluorescence monitoring for the melting curve analysis. the relative quantification analyses the actual amount of a particular target transcript relative to an internal standard (a housekeeping gene) in the same sample. results were expressed as the target/internal standard concentration ratio of the sample divided by the target/ internal standard concentration ratio of the calibrator.the average and standard deviation of relative gene expression of il- of normal lungs and the experimental groups' lungs are shown in figure e .expression of il- was significantly increased in group over that in group (p ϭ . ). simultaneous use of ultrafiltration suppressed il- (p ϭ . , group vs group ). key: cord- - bzxdh authors: gånheim, charina; alenius, stefan; persson waller, karin title: acute phase proteins as indicators of calf herd health date: - - journal: vet j doi: . /j.tvjl. . . sha: doc_id: cord_uid: bzxdh the potential for using acute phase proteins (apps) in the assessment of herd health was studied by examining the levels of serum haptoglobin, serum amyloid a (saa) and plasma fibrinogen in relation to clinical findings and leukocyte counts in calves. two groups of calves from conventional dairy farms were studied. the animals were examined times during the first six weeks after introduction into a new environment. haptoglobin, saa and fibrinogen were analysed and weight gain, disease symptoms and treatments were recorded. analysis of antibodies against viral infections was performed. an acute phase reaction (apr) score was established at each sampling by combining the app results and total leukocyte counts. the health status differed between the two groups, although no manipulation of health had been performed, except that the group with a higher incidence of disease had a concurrent experimental infection with lungworm as part of another study. in the group with a higher incidence of disease, the mean weight gain was significantly lower, and the number of sampling days with elevated serum concentrations of apps, and the mean maximum concentrations of haptoglobin and fibrinogen were significantly higher compared to the healthier group. the apr score was significantly higher at days and of the study in the group with a higher incidence of disease. the results indicate that measurement of apps could be a useful tool for evaluation of health in calf herds. an important contributor to beef production is the specialised rearing of dairy calves for slaughter. this production system comprises transportation of young calves from their birth farms to specialised units, and mixing of individuals from several different breeders. stress due to transportation and mixing, in combination with exposure to a variety of microorganisms often leads to outbreaks of infection such as respiratory disease (dyer, ) . important microorganisms include bovine respiratory syncytial virus (brsv), bovine corona virus (bcv), bovine virus diarrhoea virus (bvdv), bovine parainfluenza virus type (piv- ), bovine adenovirus (bav), and certain bacteria, e.g., mannheimia haemolytica and pasteurella multocida (ames, ; bengtsson and viring, ; tråvén et al., ) . disease outbreaks can cause substantial costs for the farmer and result in serious animal welfare problemsan important consideration given the rising concern about animal welfare and food safety. tools for surveillance of herd health status could be a useful component of a quality assurance programme and there is a need to identify new indicators of health and disease. the acute phase response (apr) is a non-specific reaction by an individual to different kinds of tissue damage such as infection, neoplasia or trauma . the tissue damage induces a cascade of events that leads to the production of acute phase proteins (app) in the liver. haptoglobin and serum amyloid a (saa) are important bovine apps, which increase in serum for example during viral and bacterial diseases (murata et al., ; petersen et al., ) , but are absent, or present in very low levels, in healthy animals (godson et al., ; heegaard et al., ; gånheim et al., ) . moreover, sub-clinical inflammatory disorders can induce increase in app concentrations (karreman et al., ) . the concentration of fibrinogen, another app, is increased in the plasma of animals with inflammatory disorders (mcsherry et al., ) and has been used for many years to evaluate inflammatory disease in cattle (eckersall and conner, ) . lungworm infection (gånheim et al., ) , and stress due to poor housing (alsemgeest et al., ) , weaning, transportation and mixing (arthington et al., ) , can also result in increased app concentrations in cattle. apps have been considered both as potential indicators of disease and well-being in individual animals and as indicators of herd health (alsemgeest et al., ; murata et al., ; petersen et al., ) . studies show that saa (karreman et al., ) and haptoglobin (saini et al., ) have been found useful in herd screenings to identify cows with inflammatory diseases. apps may also be an important tool at the slaughterhouse to improve food safety (saini et al., ) . the aim of this study was to further evaluate the potential of using serum apps in the assessment of overall calf herd health by examining the levels of haptoglobin, saa and fibrinogen in relation to clinical findings and leukocyte counts in calves in farms specialised for beef production. two groups of calves differing in clinical health status were studied. the hypothesis was that analysis of one or several app may be used as an objective tool to evaluate animal health and management on this type of farm. two groups of male calves were used, groups a and b. all calves were of the dairy breeds swedish red and white, or swedish holstein, or of crosses between these two breeds. the calves were obtained from different conventional dairy farms, mediated through the swedish meats organization for purchase of live animals. group a consisted of calves from eight different farms. the age of the calves at the start of the study ranged from to weeks (mean weeks, sd . ). at a private commercial farm specialising in beef production, the calves were housed in a stable that had been cleaned and empty for more than two months before their arrival. the calves, weighing - kg, were kept in large boxes on straw bedding. milk replacer was offered via an automated feeder for the first two weeks after arrival. hay and concentrates were fed according to swedish recommendations during the study period of six weeks. group b consisted of calves from eight farms, different from those from which group a calves were selected. the age of the calves at the start of the study varied between and weeks (mean weeks, sd . ) and their weight ranged from to kg. the animals were weaned either before or on arrival at the division of ruminant medicine, department of clinical sciences, swedish university of agricultural sciences. the calves were housed in large boxes on straw bedding in a stable that had been cleaned and empty for more than four weeks before the experiment started. the animals were fed hay and concentrate according to swedish recommendations during the study period of six weeks. these animals were also part of another study, in which they were inoculated orally with lungworm (dictyocaulus viviparus) ( l ) on days and . however, the infection did not induce a patent infection with larvae present in faeces, probably because the larvae were not sufficiently viable. the study protocol was approved by the swedish national board for laboratory animals, uppsala, sweden. jugular blood samples were taken twice weekly from each calf, during the first four weeks following arrival and once weekly for the following two weeks. venoject tubes with edta and without additive (terumo europe n.v.) were used. clinical observations of the calves were performed at the same time, including recordings of any coughing and/or diarrhoea. the farm personnel decided which individuals were to be examined by the herd veterinarian for possible treatment during the observation period. the weight of the calves in both groups was recorded on arrival and again at the end of the study using heart girth measurement in group a, and a scale in group b. within a few hours of sampling, edta-blood was analysed for total and differential leukocyte counts and fibrinogen at the division of diagnostic imaging and clinical pathology, department of biomedical sciences and veterinary public health, swedish university of agricultural sciences. the leukocyte counts were performed using cell-dyn (abbot diagnostic division), and fibrinogen was analysed according to becker et al. ( ) using an automated analyser (konelab , konelab corporation). samples without additive were centrifuged ( g, min) and the serum was frozen at À °c until analysed for haptoglobin, saa, and viral antibodies. analysis of serum haptoglobin and saa was performed using the tridelta phase range haptoglobin assay and saa assay (tridelta development limited), respectively; the working range for the haptoglobin assay was . - g/l, and the intra-and inter-assay coefficients of variation were % at the concentration . g/l . the saa assay had been slightly modified by adding extra standard points. the working range was . - mg/l with samples diluted : . in this range, the intra-and inter-assay coefficients of variation were < %. serum antibody titres against bovine respiratory syncytial virus (brsv), bovine corona virus (bcv), parainfluenza virus type (piv- ), bovine virus diarrhoea virus (bvdv) and bovine adenovirus type (bav- ) were analysed on three occasions per group, i.e. days , and , using elisas (svanova biotech ab for brsv, bcv, piv- and bvdv, bio-x diagnostics for bav- ) and all analyses were performed according to the manufacturer's instructions. seroconversion was defined as a negative optical density value in the first or second sample, converting to a positive value in either the second or the third sample in paired sera. a total scoring of the results from the different apr parameters was calculated. where above normal values of saa, haptoglobin, fibrinogen or total leukocyte count occurred, one point was allocated for each. the sum of the points was calculated for each individual and sampling occasion as well as the mean (sd) value for each group. previously established (gånheim et al., ) basal app threshold levels differing between healthy and diseased animals were used, namely, . g/l for haptoglobin, . mg/l for saa, and . g/l for fibrinogen. a total leukocyte count > . · /l was considered above normal (jain, ) . leukocyte counts, app concentrations, numbers of sampling days with above normal app values and apr scores in groups a and b, were compared using student's t tests. the bonferroni correction was used to avoid mass significances. a p value < . was considered significant. in group a, . % and . % of the calves had signs of respiratory disease and diarrhoea, respectively, on at least one of the observation points (table ) . some calves had both respiratory symptoms and diarrhoea, but not on the same occasion. during the study period, three calves with respiratory disease were treated with antibiotics (benzylpenicillin procaine, ethacilin vet, intervet), based on evaluation of the farm veterinarian (table ) . in group b, all calves showed signs of respiratory disease on at least one of the sampling days, and % of the calves also had diarrhoea at the same time as respiratory symptoms (table ) . almost half of the calves were treated with antibiotics for respiratory disease as described for group a (table ). the proportions of calves in the two groups having respiratory symptoms or diarrhoea, at each sampling occasion, are given in fig. . the proportion was very low in group a, while a higher proportion of sick calves, especially with respiratory symptoms, was obvious in group b during the first two to three weeks after arrival. the average (sd) daily weight gain of the calves in group a was . ( . ) kg during the study period. in group b, the average (sd) daily weight gain for the calves ( . [ . ] kg) was significantly lower. none of the calves in group a seroconverted against brsv, bcv, bvdv, or piv- , during the study period, but % of the animals seroconverted against bav- (table ) . all calves had elevated antibody titres against one or several viruses at the beginning of the study. table numbers (%) of calves with respiratory symptoms (resp), or diarrhoea (diar), or being treated for respiratory disease (treat), or seroconverting against brsv, bcv, bvdv, piv- , bav- , in two groups a (n = ) and b (n = ) of calves over a period of six weeks after housing in group b, one-quarter of the calves had seroconverted against bcv between the first and second sampling, while the remainder of the calves already had high antibody titres against bcv at the start of the study (table ) . a majority of the calves also seroconverted against bav- , while the rest of the group had such antibodies from the beginning of the study (table ) . there were no seroconversions against brsv, bvdv and piv- during the study, but most calves had antibodies against one or several of these viruses on arrival. the total leukocyte counts, and the numbers of neutrophils, lymphocytes and eosinophils for groups a and b are given in fig. . the mean number of monocytes was constantly close to . · /l in both groups throughout the study (data not shown). the proportions of animals with above normal total leukocyte counts were low in both groups (fig. ) . no significant differences between the groups were observed in total leukocyte counts, or in numbers of lymphocytes and neutrophils. however, the eosinophil numbers were significantly higher in group b than in group a on days , and . out of calves in group a, ( %), ( %) and ( %) calves had above normal values of saa, haptoglobin and fibrinogen, respectively, at least once during the study period. in group b, all calves had above normal values of all three app on at least one occasion. the proportions of calves having above normal concentrations of saa, haptoglobin and fibrinogen were numerically higher in group b than in group a at most sampling occasions (fig. ) . in group a, the mean maximum concentration per calf was . g/l (sd . , range . - . g/l), . mg/l (sd . , range . - . mg/l) and . g/l (sd . , range . - . g/l) for haptoglobin, saa and fibrinogen, respectively. in group b, the mean maximum concentrations of haptoglobin ( . g/l [sd . , range . - . g/l]), and fibrinogen ( . g/l [sd . ], range . - . g/l) were significantly higher than in group a. the mean maximum concentration of saa ( . mg/l [sd . ], range . - . mg/l) was numerically higher, but not significantly different, from in group a. the mean numbers of sampling days per calf with above normal saa, haptoglobin and fibrinogen concentrations in groups a and b are presented in table . the numbers were significantly higher in group b than in group a for all three app. the mean apr scores for the two groups are given in fig. . the scores were significantly higher in group b than in group a on days and after arrival. a large proportion of calves in both groups had elevated concentrations of one or more apps at one or several occasions during the study. this is consistent with the expectation that many animals would experience infection after transportation and mixing with animals from other farms. some also had elevated antibody levels against the viruses of interest. the disease and treatment incidences were considerably higher in group b than in group a, as was the proportion of animals with above normal values of apps, and the apr score. however, also in group a, where the health status was considered to be good, many calves had elevated app-values, indicating sub-clinical disease. the mean number of sampling days per calf with above normal app-values was well correlated with the clinical findings in the groups. the difference between the groups was most obvious for haptoglobin, indicating that this may be the most useful predictive app and is in agreement with carter et al. ( ) who concluded that analysis of serum haptoglobin was a better tool for discrimination between calves that became ill and those that did not, compared to other apps. saa is reported to be more sensitive to stimulation (horadagoda et al., ; heegaard et al., ) , and as an increase can be induced also by other factors than disease, such as stress (alsemgeest et al., ) it may be less suitable as an indicator of health problems. the treatment incidence also differed between the two groups. in group b, almost half of the calves were treated with antibiotics, while only / calves was treated in group a. the difference may not only reflect the health status in the groups, but could also be due to different evaluations by the persons handling the animals. however, no deaths occurred in group a, suggesting that all animals in need of treatment received it. the mean weight gain differed significantly between the groups, with the healthier group a having the greatest weight gain. different methods were used in the groups for evaluating weight, indicating these results must be interpreted with care. however, heinrich et al. ( ) demonstrated that, among the different body measures, heart girth is the best estimate for body weight, and sørensen and foldager ( ) and andersson ( ) showed a good correlation between the heart girth and body weight. the total leukocyte counts exceeded normal values for calves of this age (jain, ) only on a few occasions and in a few individuals. the results did not differ between groups indicating that an above normal leukocyte count alone is not a good indicator of disease. the significantly higher number of eosinophils in group b was probably due to the experimental inoculation with lungworm, as eosinophilia is a rather consistent finding during lungworm infection (radostits, ) . this result was table mean (sd) number of sampling days per calf with levels of serum haptoglobin, serum amyloid a (saa) and plasma fibrinogen values above basal levels a in two groups (a and b) of calves sampled on ten occasions during the six week period after housing surprising as none of the animals had a patent infection with the presence of larvae in faeces. however, the eosinophilia indicates that the immune system of the calves had responded to the parasites. thus, the lungworm infection may be one factor responsible for the elevated app levels observed in group b, as lungworm infection can induce production of app (gånheim et al., ) . the seroconversion against bcv and bav- in group b indicates that these infections were probably the main reason for the disease symptoms in this group. it is likely that some calves brought the infection from the farm of origin and spread it in the new group. the four calves that seroconverted against bcv reacted with increases in haptoglobin and fibrinogen and three of them also reacted with an increase in saa. however, as indicated above, the lungworm infection may also have affected the clinical outcome; mixed infections are likely to result in more severe symptoms as was shown when combining viral and bacterial infections (gånheim et al., ) . there may also have been other infectious agents circulating in the group, such as other serotypes of adenovirus or secondary bacterial infections, e.g., with m. haemolytica, or other opportunistic invaders, but other viral or bacteriological examinations were not performed in this study. the apr score, combining the results of the three apps and the total leukocyte counts, was created to give a better overview of the reactions in the groups. other researchers have reported that measurement of a single app is not reliable for health evaluation and recommend a combined analysis of several parameters (toussaint et al., ; young et al., ) . in our study, differences in clinical health status between groups a and b, were consistent with the differences in the apr score. however, the results need to be interpreted with care, as the experimental infection with lungworm may have been partly responsible for the app elevation. the results of the present study support the usefulness of app measurement in monitoring animal health, and supports the proposals made by other authors (alsemgeest et al., ; murata et al., ; petersen et al., ) . at present, routine use of app analyses at the herd level is not realistic because of the high costs involved. however, pooling of serum from several animals in a herd may offer a way to minimize the costs. if less expensive analytical methods become available, the calculation of mean apr scores could be a useful tool for the evaluation of herd health. however, to provide the best evaluation of health status in a herd, or in a group of animals, frequent samplings during the whole rearing period should be made and again this is probably not a realistic approach as it would be too expensive. sampling during the first weeks after arrival in the herd would give an indication of the pressure of infections and/or stress during transportation and mixing and so may not give a fair picture of the management conditions of the actual farm. in our opinion, samplings at, for example, monthly intervals during the middle and later stages of the rearing period may be more relevant if the main interest is to evaluate the animal health conditions of a specific farm. the establishment of suitable app or apr score thresholds for herd health would require analysis of a much larger number of herds. the diagnostic value of acute phase proteins in bovine clinical chemistry. in: blood concentrations of acute-phase proteins in cattle as markers for disease influence of physical stress on the plasma concentration of serum amyloid a (saa) and haptoglobin (hp) in calves dairy calf pneumonia. the veterinary clinics of north america rekryteringskvigor fö r mjö lkproduktionuppfö dningsmodellens betydelse fö r produktionen effect of transportation and co-mingling on the acute phase protein response, growth, and feed intake of newly weaned beef calves respiratory infections -project, panorama and treatment strategies a functional photometric assay for plasma fibrinogen relationship of vitamin e supplementation and antimicrobial treatment with acute-phase protein responses in cattle affected by naturally acquired respiratory tract disease the bovine respiratory disease complex: a complex interaction of host, environmental, and infectious factors bovine and canine acute phase proteins serum haptoglobin as an indicator of the acute phase response in bovine respiratory disease diagnostic significance of the major acute phase proteins in veterinary clinical chemistry: a review the acute phase response in calves experimentally infected with bovine viral diarrhoea virus and/or mannheimia haemolytica the acute phase response of haptoglobin and serum amyloid a (saa) in cattle undergoing experimental infection with bovine respiratory syncytial virus predicting body weight and height in holstein heifers using body measurements acute phase proteins in cattle: discrimination between acute and chronic inflammation hematology of cattle using serum amyloid a to screen dairy cows for sub-clinical inflammation plasma fibrinogen levels in normal and sick cows current research on acute phase proteins in veterinary diagnosis: an overview application of acute phase proteins in veterinary clinical chemistry lungworm infestation in cattle (bovine verminous bronchitis) development of a simple enzyme immunoassay for blood haptoglobin concentration in cattle and its application in improving food safety effect of breed and plane nutrition on the estimation of live weight by heart girth in dual purpose heifers implication of clinical pathology in assessment of animal health and in animal production and meat inspection experimental reproduction of winter dysentery in lactating cows using bcv -comparison with bcv infection in milk-fed calves serum haptoglobin concentrations in a population of feedlot cattle the authors thank the swedish council for forestry and agricultural research for financial support and the staff at the clinic of the division of ruminant medicine and epidemiology for looking after the calves well. key: cord- -qxn td authors: ibfelt, t.; engelund, e.h.; schultz, a.c.; andersen, l.p. title: effect of cleaning and disinfection of toys on infectious diseases and micro-organisms in daycare nurseries date: - - journal: j hosp infect doi: . /j.jhin. . . sha: doc_id: cord_uid: qxn td background: the rising number of children in daycare nurseries increases opportunities for the transmission of infectious diseases. pathogens may be transmitted directly from child to child via sneezing, coughing and touching, or indirectly via the environment. toys are among the fomites with the highest pathogen load, but their role in disease transmission is unknown. aim: to determine if washing and disinfection of toys can reduce sickness absence and microbial pathogen load in the nursery environment. methods: twelve nurseries (caring for children) were randomized to intervention and control groups. the intervention consisted of washing and disinfection of toys and linen every two weeks for three months by a commercial cleaning company. the extent and causes of sickness absence among the children were recorded in both groups before and after introduction of the intervention. ten sampling points in each nursery were examined for bacteria and respiratory viruses. results: the presence of respiratory virus dna/rna was widespread, but very few pathogenic bacteria were found in the environment. the intervention reduced the presence of adenovirus [odds ratio (or) . , % confidence interval (ci) . – . ], rhinovirus (or . , % ci . – . ) and respiratory syncytial virus (or . , % ci . – . ) compared with the control group, but the intervention had no effect on sickness absence or disease patterns in the nurseries. conclusion: although cleaning and disinfection of toys every two weeks can decrease the microbial load in nurseries, it does not appear to reduce sickness absence among nursery children. children, especially children aged three years and under, have a high frequency of infectious disease episodes. children in daycare nurseries have more infections than children cared for elsewhere, e mainly because of direct transmission between children, contact or respiratory droplet transmission, and inadequate hand hygiene. although indirect transmission of infection via the nursery environment has not been studied extensively, it is likely to play a role. previous research on bacteria in the nursery environment has shown positive cultures in e % of samples, depending on location, but almost all bacteria isolated were of low pathogenicity. e quantitative polymerase chain reaction (pcr) to determine the diversity of bacteria in the nurseries has shown that the most common bacteria in the nursery environment are coagulase-negative staphylococci (cons), bacillus spp. and pseudomonas-like bacteria, all of which rarely cause disease in healthy children. less is known about viruses in the nursery environment in spite of the frequency of viral respiratory infections caused by rhinovirus, bocavirus, adenovirus and respiratory syncytial virus (rsv). e in a study of the prevalence of different respiratory viruses on surfaces in nurseries during the winter of e , using the same technique as in this study, respiratory viruses were found to be widespread in the environment, especially on toys (publication pending). this study found that toys were not washed or disinfected systematically. the danish health board recommends monthly cleaning, but it is not known whether regular cleaning of toys in nurseries can affect the pathogen load and reduce infection. the aim of this study was to determine whether regular systematic cleaning and disinfection of toys would decrease the prevalence of bacteria and respiratory viruses in the nursery environment, and reduce sickness absence in danish nurseries. twelve nurseries from the municipality of copenhagen were recruited in autumn . the number of divisions in each nursery ranged from two to six, and the number of children ranged from to . the total number of children was , and their ages ranged from six months to three years. nurseries were questioned about their policies and procedures for hygiene and cleaning of toys before commencement of the study, and randomized to intervention (n ¼ ) and control (n ¼ ) groups. the intervention took place from january to march . a commercial cleaning company (berendsen a/s, søborg, denmark) collected toys and linen every two weeks from nurseries in the intervention group for cleaning in their industrial cleaning facility. linen and toys suitable for washing machines were washed at c and subsequently disinfected with turbo oxysan (ecolab, valby, denmark). toys that were not suitable for washing machines were either immersed in a disinfectant [sirafan m, ecolab ( e % benzalkonium chloride, e % didecyldimethylammonium chloride and e % alcohol ethoxylates)] or cleaned manually with a microfibre cloth using the same disinfectant (sirafan m, ecolab). the toys were subsequently rinsed with water, air dried and returned to the nurseries. cleaning of toys was staggered to ensure that the children had some toys to play with while others were being cleaned. absence data and disease patterns were recorded for each child on a daily basis from december to march . the number of absent children and the reason for absence (as reported by the parents) was recorded by the staff within the following categories: respiratory infections, gastrointestinal infections, other illnesses, or day off. sampling was performed before and after the intervention in december and april . ten predefined sampling points (seven in the playroom and three in the toilet area) were sampled in each of the nurseries. the playroom sampling points were undersides of tables, plastic toys, wooden toys, food toys, teddy bears, pillows and sofas. the toilet sampling points were toilet seats, changing mats and basin taps. the sampling area for most sampling points was  cm, but where it was not possible to sample a  cm square (e.g. on smaller toys), the whole object was swabbed. sampling was performed using: ( ) a dry, sterile, cotton-tipped swab, immersed in ox serum broth after sampling (department of clinical microbiology, herlev hospital, herlev, denmark); and ( ) a double-sided dipslide (  mm) with tryptic soy agar (tsa) agar on one side and violet red bile glucose agar on the other side, with both sides containing a neutralizer against disinfectants (model no. dpsldtv, m, copenhagen, denmark). the dipslides were incubated for h and the ox serum broth was incubated for seven days at e c. following incubation, the ox serum broth was plated on to a blood agar plate (item no. , ssi-diagnostika, copenhagen, denmark) and a lactose agar plate (item no. , ssi) and incubated for h. total bacteria count was determined using the tsa side of the dipslide and the supplied key from the manufacturer, and reported as colonyforming units (cfu)/cm . the different species from both dipslides and the ox serum broth were identified using conventional identification and matrix-assisted laser desorption/ ionization-time of flight (maldi-tof) (bruker daltonics scandinavia ab, frederikssund, denmark). maldi-tof was only used for potential pathogens (all faecal bacteria, staphylococcus aureus and nasopharyngeal bacteria). bacteria (and fungi) were divided into four groups: skin bacteria (cons, micrococcus spp., poprionibacterium spp. and s. aureus), water and soil bacteria and fungi (acinetobacter spp., pseudomonas-like spp., aeromonas spp., comamonas spp., bacillus spp. and moulds), nasopharyngeal bacteria (streptococcus pneumoniae, moraxella spp. and non-haemolytic streptococci) and intestinal bacteria (all enterobactereaceae and enterococcus spp.). escherichia coli and enterococcus spp. were used as indicators of faecal contamination. respiratory viruses were sampled from the same sampling points as the bacterial samples. each point of  cm was sampled using a  mm polyester foam swab (model - , vwr, herlev, denmark). swabs were immersed in sterile rnase-free water before sampling. after sampling, each swab was placed in a -ml sterile plastic container with ml nuclisens lysis buffer (biomérieux, marcy l'etoile, france). on arrival at the laboratory, the tubes were placed on a shaking table for min and the lysis buffer was transferred to a . -ml cryotube and stored at À c until analysis. virus dna and rna from the sample were extracted using a minimag apparatus and nuclisens extraction reagents (biomérieux). the purified dna/ rna, eluted in ml of elution buffer (biomérieux), was stored at À c until quantitative pcr amplification and analysis. selected and bocavirus. quantitative pcr was performed using ml of extracted nucleic acids and the ftd respiratory pathogens plus multiplex pcr kit (fast track diagnostics, junglinster, luxembourg) with the recommended enzyme kit (agpath-id one-step rt-pcr reagents, life technologies, naerum, denmark). pcr amplification and reading was performed using rotorgene q (qiagen inc., venlo, the netherlands) and analysis was performed using rotorgene software. total bacterial growth was read from the tsa side of the dipslide and calculated in cfu/cm . results from the dipslides and the ox serum broth were pooled for each sample point, and given as binary results depending on the presence or absence of the target organisms. the same binary method was used for respiratory virus detection. logistic regression models were used to examine the odds of bacterial and viral presence before and after the intervention. differences in total growth were analysed using student's t-test. differences in sickness absence between groups were analysed using a modified chi-squared test. all calculations were performed using statistical package for the social sciences version (ibm corp., armonk, ny, usa). p . was considered to indicate significance. no difference in hygiene standards was found between the control group and the intervention group. no nurseries in either group had a scheduled plan for cleaning toys or washed the toys systematically. very few potentially pathogenic bacteria were found in the samples. out of samples, there were potential pathogens ( %) in the pre-intervention samples (six in the control group and nine in the intervention group) and ( %) potential pathogens in the post-intervention samples (eight in the control group and three in the intervention group). these were bacteria of low pathogenicity such as enterobacter spp., e. coli and nonhaemolytic streptococci. the highest prevalence was found on pillows and sofas, followed by changing mats and various toys. mean (ae standard error) bacterial growth was . ae . cfu/ cm . highest bacterial growth was found on teddy bears ( . ae . cfu/cm ), followed by sofas ( . ae . cfu/cm ), pillows ( . ae . cfu/cm ), toilet seats ( . ae . cfu/cm ), plastic toys ( . ae . cfu/cm ), wooden toys ( . ae . cfu/ cm ), playroom tables ( . ae . cfu/cm ), changing mats ( . ae . cfu/cm ), food toys ( . ae . cfu/cm ) and basin taps ( . ae . cfu/cm ). no difference in total growth or potential pathogen presence was found between the intervention group and the control group. a mean of three different respiratory viruses was found at each sampling point. the prevalence rates for the different respiratory viruses are listed in table i on the other hand, metapneumovirus was found significantly less often in the control group than in the intervention group. the intervention had no effect on the detection of other viruses. the fomites with the highest presence of respiratory virus were pillows and sofas, followed by toys and playroom tables. when looking at the samples from the toys alone, there was a significant decrease following the intervention in the intervention group compared with the control group for rhinovirus (or . , % ci . e . ; p ¼ . ) and rsv (or . , % ci . e . ; p ¼ . ), but not adenovirus. as in all samples, the presence of metapneumovirus was significantly decreased in the control group compared with the intervention group. no differences were found for the other viruses on the toys. the prevalence rates of the four most prevalent viruses on the toys are shown in figure . the proportion of healthy children in the control group decreased from % to % in the post-intervention period, whereas it was unchanged in the intervention group; however, the difference between the groups was not significant. mean absence (ae standard error) due to respiratory infections decreased after the intervention in both the intervention and control groups (from . % ae . % to . % ae . % in the intervention group and from . % ae . % to . % ae . % in the control group). however, gastrointestinal infections increased after the intervention (from . % ae . % to . % ae . % in the intervention group and from . % ae . % to . % ae . % in the control group). other illnesses also increased in both groups after the intervention (from . % ae . % to . % ae . % in the intervention group and from . % ae . % to . % ae . % in the control group). no significant differences in any of the disease categories were found between the groups. when looking at the timeline of infectious diseases in the two groups before and after the intervention, there is no striking effect of the intervention on total sickness absence, respiratory infections or gastrointestinal infections (figures e ). there was a significant difference (p ¼ . ) in total sickness absence between the groups, but the control group had the lowest sickness absence ( . % vs . % in the intervention group). no difference was found between the groups when analysing respiratory or gastrointestinal infections in the pre-and postintervention periods. the bacteria found in this study were mainly nonpathogenic; only % of the bacteria were potential pathogens. this is in accordance with a study by lee et al., who investigated the bacterial diversity in a nursery through a combination of cultures and s rrna sequencing. prevalent bacteria cultured were bacillus spp., staphylococcus spp. and pseudomonas spp., while s sequencing analysis was dominated by pseudomonas spp. and oxalobacteria spp. the present study found a very low prevalence of potential pathogens ( %), and this was lower than reported in many other studies; for example, laborde et al. reported faecal coliform rates of e % on toys, sinks and tables in toddlers' classrooms; and ekanem et al. reported a faecal coliform rate of % on classroom objects. the discrepancies may be due to different sampling techniques, different sampling points and different sampling areas. it may be more efficient to sample larger areas using cloths in order to maximize the chances of finding pathogenic bacteria present in the environment. respiratory virus rna/dna was widespread in the environment, especially for viruses causing the common cold, such as rhinovirus, adenovirus, coronavirus and bocavirus. other studies have found similar pathogens in the throats of children with respiratory infections. , , these studies found rhinovirus, rsv, coronavirus and adenovirus to be the most prevalent viruses. this corresponds well with the present results, where bocavirus was the most prevalent virus, followed by coronavirus, adenovirus and rhinovirus. rsv detection was lower, but this may have been because the severity of rsv infection keeps children away from nurseries. the similarity between the present findings in the environment and findings in children's throats indicates that viruses are transmitted to the environment. the weakness of the pcr technique is that viral nucleic acid is detected rather than 'live' viruses, and the prevalence of infectious viruses may be overestimated. to assess this, the viruses would have to be grown in cell cultures. this was not possible due to time and economic constraints. moreover, some viruses, such as norovirus, cannot be cultured. the main endpoint in this study was the number of days of absence due to sickness. this study did not find a decrease in total sickness absence or in sickness absence due to respiratory infection. to the authors' knowledge, this is the first study to measure the isolated effect of cleaning toys on infectious diseases in nurseries. however, a few studies have 'touched upon' the subject. krilov et al. showed a significant decrease in the number of infections in a specialized preschool following the implementation of an infection control programme. this programme included cleaning toys, but this was combined with other measures such as hand hygiene and environmental cleaning. numerous studies have shown the presence of coliforms and different pathogenic bacteria and viruses on toys in hospitals and other clinical settings. e consequently, the general recommendations to date have been that toys should be cleaned regularly in order to prevent infections. the data from this study, however, do not support these recommendations. possible reasons for failure to observe an effect of cleaning toys include: too great an interval between washes; not washing all toys at the same time; and the effect of person-to-person transmission overshadowing the effect of cleaning. this raises the question of whether commercial cleaning of toys is costeffective. it is likely that the most effective ways to prevent infections in daycare nurseries are rigorous hand hygiene and other well-established infection control measures, or simply to keep the children at home for longer when they are ill. e the latter is confirmed by the absence timelines in this study (figures e ) , which included the period before and after the christmas holiday in december. during this holiday, the nurseries were closed for two weeks. there was a marked decrease in sickness absence after the holiday in both groups, with the percentage of children with respiratory infection decreasing from . % to . % in the intervention group and from . % to . % in the control group. if feasible, absence from nurseries might be the best way to reduce the spread of infection in children. in conclusion, this study showed that respiratory virus dna and rna are widespread in the nursery environment. fortnightly cleaning and disinfection of toys reduced the frequency of detection of some respiratory viruses, but not the bacterial load, and did not reduce the number of days of absence due to respiratory infection or sickness as a whole. as this is the first study of its kind, further studies are needed to confirm or refute the findings. studies over a longer period of time may be necessary to control for seasonal fluctuation in infection rate and virus types. acute respiratory infections in day care diarrheal illness among infants and toddlers in day care centers. ii. comparison with day care homes and households forms of care and children's infections. . occurrence and causal factors childhood upper respiratory tract infections: to what degree is incidence affected by day-care attendance? microbiological analysis of food contact surfaces in child care centers effect of fecal contamination on diarrheal illness rates in day-care centers microbial evaluation of foodservice surfaces in texas child-care centers culture-independent analysis of bacterial diversity in a child-care facility epidemiology of multiple respiratory viruses in childcare attendees presence of viral and bacterial pathogens in the nasopharynx of otitis-prone children a prospective study epidemiology of viral respiratory tract infections in a prospective cohort of infants and toddlers attending daycare the occurrence of influenza a virus on household and day care center fomites prevalence of rotavirus on high-risk fomites in day-care facilities survival and detection of rotaviruses on environmental surfaces in day care centers the frequency, level, and distribution of fecal contamination in daycare center classrooms transmission dynamics of enteric bacteria in day-care centers frequent respiratory pathogens of respiratory tract infections in children attending daycare centers impact of an infection control program in a specialized preschool viral contamination of environmental surfaces on a general paediatric ward and playroom in a major referral centre in riyadh toys in a pediatric hospital: are they a bacterial source? bacterial colonization of toys in neonatal intensive care cots toys e friend or foe? a study of infection risk in a paediatric intensive care unit the impact of selected environmental factors on the morbidity of children in day care centers a review of enteric outbreaks in child care centers: effective infection control recommendations a randomized, controlled trial of a multifaceted intervention including alcohol-based hand sanitizer and hand-hygiene education to reduce illness transmission in the home an open randomized controlled trial of infection prevention in child day-care centers mandatory handwashing in elementary schools reduces absenteeism due to infectious illness among pupils: a pilot intervention study the authors wish to thank charlotte foged (rigshospitalet) and resadije idrizi (dtu food) for excellent technical assistance, and ecolab denmark, berendsen denmark and m denmark for the free supply of materials and cleaning. ecolab denmark, berendsen denmark and m denmark supplied materials and cleaning free of charge, but had no influence on the analysis of the data or the writing of the manuscript. key: cord- -tvegf kt authors: brook, judy; leanne aitken; maclaren, dr julie; debra salmon title: co-production of an intervention to increase retention of early career nurses: acceptability and feasibility date: - - journal: nurse educ pract doi: . /j.nepr. . sha: doc_id: cord_uid: tvegf kt co-production is a process employed to solve complex issues, recognising the expertise of all stakeholders. this paper reports on co-production undertaken by nursing students, early career nurses and researchers as part of a larger study to design an intervention to increase retention of early career nurses. mixed methods were used to evaluate the acceptability and feasibility of the co-production process in a uk university. data were collected prospectively, concurrently and retrospectively via interview and questionnaire, between april and january . twelve co-production group members completed the questionnaire and six group members and facilitators were interviewed. students and early career nurses reported personal benefit from participating; they developed and practised transferrable communication and problem-solving skills, believed they were able to make a difference, enjoyed contributing, found benefit from using the group as a reflective space and considered that co-production produced a credible intervention. findings indicated co-production equipped participants to function more effectively in their nursing roles; incorporating co-production into the development of future interventions may prove beneficial. the relative novelty of this approach, and the potential application of the findings to a diverse range of geographical and organisational settings, add to the utility of the findings. the nursing workforce is a national and global priority, highlighting the importance of identifying reliable ways to encourage nurses to remain in their role and in the profession. the extent and impact of nurse turnover has been discussed extensively in the nursing literature as it affects many countries' ability to fight disease and improve health. in england, more than in registered nursing posts in the nhs are vacant (beech et al., ) , and international research indicates that on average % of the nursing workforce seriously considers leaving either their current role or the profession (heinen, et al., ) . the issue of retention is particularly topical in the wake of the covid- pandemic, which has shone a spotlight on the importance of a sufficient and robust nursing workforce. although current nurse workforce issues are particularly acute, this is not a new concern and the international nursing literature is replete with examples of initiatives to reduce turnover and increase retention in high and medium-income economies. a large systematic review (brook, et al., ) explored interventions to increase retention and decrease turnover of early career nurses in a range of settings. whilst a wide range of interventions were reviewed, many studies showed limited and inconsistent benefits. the review highlighted a paucity of evidence relating to the explicit participatory nature of work to design interventions to increase retention of nurses. what was missing from these studies was the voice of students and early career nurses regarding potentially beneficial solutions. the increasingly popular approach of co-production is one way to access and incorporate those voices. traditionally developed in relation to service improvement (osbourne, et al., ) , coproduction has been embraced as the cornerstone of public policy reform (horne and shirley, ) and is now referenced prolifically in grey, policy-orientated literature. in particular, the value of service user involvement in creating health services that are fit for purpose is increasingly recognised in uk policy (potter, et al., ) and mirrored in expectations of higher education institution healthcare programme development and delivery (quality assurance agency for higher education, ; nursing and midwifery council, ) . the underpinning premise of co-production is that working in partnership results in more relevant, appropriate and sensitive outputs (latif, et al., ) . working with nurses and students to develop an intervention that aims to increase retention of nurses is more likely to result in a pragmatic and credible intervention (henshall, et al., ) , that may also be more effective. this paper reports on a co-production process undertaken by nursing students, early career nurses and researchers as part of a larger study to design an intervention to increase retention and decrease burnout of early career nurses. those individuals potentially impacted by attrition from the nursing profession were key to the process, offering greater understanding of the value of coproduction in similar future intervention development. the co-production approach used to design the intervention spanned both healthcare and higher education contexts. the relative novelty of this approach, and the potential application of the findings to a diverse range of geographical and organisational settings, add to the utility of the findings. there is no consistent definition in the literature but durose, et al., ( , p ) describe coproduction as 'joint working between people or groups who have traditionally been separated into categories of user and producer'. co-production originated in public service administration, with recognition that drawing on the expertise of a plurality of actors was a practical and reinvigorating solution to complex problems (sorrentino, et al., ) . whilst the construct of co-production is continually evolving (sorrentino, et al., ) , the benefits outlined in the wider literature such as more sustainable change, greater translation of knowledge into practice and closing the theory-practice gap (durose, et al., ) , are of relevance to clinical and higher education contexts. although there is an inevitable blurring of boundaries, co-production differs from participatory research, which often seeks to disrupt the traditional power relationships and distinction between researcher and the researched (higginbottom and liamputtong, ) . co-production focuses on a commitment to working together, recognising the equity of all forms of knowledge, and the social capital of the participants (voorberg, et al., ) . participants in co-production recognise that although different parties may require different outcomes from the process, undertaking the journey together will result in a jointly owned product (hickey, ) . the shared experience may also leave a more enduring and beneficial legacy than traditional forms of service development. whilst co-production is a relatively new phenomenon in health education contexts, it promises to allow students as co-production group members to evolve beyond passive receivers of knowledge. a recognised challenge is the paradigm shift that students must undertake to see themselves as coproducers rather than participants (vargo and lush ) and acknowledge the capital they bring in terms of experience and perspective . despite the importance that policy makers attach to co-production, a systematic review (voorberg, et al., ) identified a dearth of studies that addressed the outcomes and concluded that the process is primarily seen as a virtue in itself, with few external objectives given to legitimise the choice of process. potential achievable objectives included increased effectiveness, efficiency, and service user satisfaction. challenges included lack of awareness about co-production, preconceptions about service users' ability to co-produce, service and time constraints, and developing, managing and utilising sometimes tense partnerships (holland-hart, et al., ) . ultimately, knowledge is scarce about how co-production works in practice, in what context it is best utilised, or whether it is a superior approach to alternatives (oliver, et al., ) . this study evaluates the feasibility and acceptability of the co-production process, in order to gain insight into the value and utility of the process of co-production to the stakeholders and project objectives. the co-production group was facilitated by two researchers employed by a uk university and six group meetings were held in the university during spring . the established coproduction toolkit, experience based co-design (ebcd), was used to guide the process (point of care foundation, ). the toolkit consists of specified exercises and steps, which were implemented as described in table . the aim of the study was to implement and evaluate the co-production of an intervention to increase retention of early career nurses. the focus of the evaluation was to explore the experiences of the co-production group members and facilitators, their perceptions of the acceptability of co-production as a process, and the feasibility and value of co-production within the context of nursing and education. design: using an overall evaluation research methodology, an explanatory sequential design was undertaken using mixed methods to provide a comprehensive view of the co-production process. a questionnaire was used to collect data on acceptability of the co-production process, followed by semi structured interviews with group members and facilitators, and reflective field notes, to explain and add context to the questionnaire data. sample/participants: a purposive sample of all members and facilitators of the co-production group were invited to participate in the study. this included students undertaking adult or child pre-j o u r n a l p r e -p r o o f registration nursing programmes at a uk university, who were completing their placements at a specific partner nhs organisation, and early career nurses (within their first year following registration) working at the collaborating nhs organisation. students were recruited to the coproduction group from existing pre-registration nursing programmes and the early career nurses were identified through the preceptorship programme at the nhs organisation. all participants attended at least one co-production group session. the two facilitators were employed by the university as researchers, one was jointly employed by the nhs organisation as an early career nurse. the mixed methods approach incorporated three data collection methods: questionnaire data collection, semi structured interviews and reflective field notes. questionnaire data: acceptability questionnaires based on the theoretical framework of acceptability (tfa) of healthcare interventions (sekhon, et al. ) were developed. the tfa comprises of seven constructs (figure ). to evaluate acceptability, questions related to the seven constructs in the model and used a likert-type scale to collect data. questionnaires were completed between april and june , to explore changes over the duration of the co-production process. question phrasing was changed for each data collection point to reflect the temporal nature of the process. the complete questionnaire is available as supplementary table and explored experience of the process, including the challenges, benefits, and perceived effectiveness as a method for developing an intervention to increase nurse retention. interviews with the co-production group members were conducted by telephone by a female academic researcher (jb) independent to the co-production process but integral to the larger project. interviews with facilitators were conducted face-to-face by another independent female researcher (gl), who had no prior relationship with the facilitators or project. questionnaire data: descriptive statistics were reported as frequency of response choice for each question. semi-structured interview data and reflective field notes: thematic analysis followed the six phases outlined by braun and clarke, . the field notes and interview were integrated during analysis. reflective field notes, facilitator and group member interview data were given equal weighting during analysis. validity and reliability/rigour: the questionnaire was based on the tfa. the multi-component framework allows identification of the source of an acceptability issue and easier refinement of the co-production process (sekhon, et al., ). the questions were tested for both content and construct validity and amended to improve clarity and validity. social desirability bias was mitigated through self-administration of the questionnaire and reassurance that answers would be kept confidential. the interview guide was formulated following analysis of questionnaire data and decisions about which aspects required further explanation. one interviewer was a nurse (jb) and therefore had insight into the professional context of the group members, and one (gl) was an experienced social researcher and educator. although there are some limitations to telephone interviews, such as not being able to read visual cues through body language, they were used as a pragmatic solution to contacting the geographically dispersed group members. the research team were reassured that the interviews elicited rich descriptions of the participants' experiences. quantitative data analysis was conducted using spss version . qualitative data analysis was conducted by two researchers independent to the co-production group. each researcher analysed the qualitative data independently, themes and ideas were discussed, agreed and presented to one early career nurse from the co-production group for comment, who attended a steering group j o u r n a l p r e -p r o o f meeting for the wider project, and who agreed that the findings represented their experience of the process. the co-production group consisted of members, two male and female. two members were early career nurses and were student nurses; in the first year of their programme, in the second year and in the final year. the co-production group met times with an average attendance of members (maximum , minimum ). first and second year students attended only the first meeting. twenty-three acceptability questionnaires were completed, at the beginning, at mid-point and at end point (table ) . participants were generally positive about the co-production process. greatest change over time related to the constructs of burden (q ) and opportunity costs (q ) with respondents anticipating that participating in the co-production group would take effort and would interfere with other priorities. by the final session, participants indicated they disagreed or strongly disagreed that coproduction required effort or interfered with their other priorities. participants increased their agreement over time that the co-production process was enjoyable (q ), an effective way to develop the intervention (q ), a process they personally valued (q ), they were confident they could contribute (q ), and they understood the process (q ). the semi-structured interviews were used to explore the acceptability in greater depth, particularly around the constructs of affective attitude, burden and effectiveness of co-production. telephone interviews were carried out with co-production group members; early career nurse and final-year students, who had qualified as nurses subsequent to the co-production group meetings. face-to-face interviews were conducted with the group facilitators. thematic analysis of the interviews and the reflective field notes of the facilitators identified two overarching themes: co-production as a framework or philosophy; and the added value of coproduction. the relationship between themes and subthemes is illustrated in figure . co-production as a framework or philosophy j o u r n a l p r e -p r o o f data relating to co-production as a framework or philosophy included three subthemes: the effectiveness of co-production, being heard and being valued, and the influence of the higher education setting. the effectiveness of co-production: facilitators and group members were unanimous in their belief in co-production as an effective method of designing an intervention. participants saw the strength of co-production as the integrity of the end product, derived from the ideas and experiences of the group: 'yeah, definitely because it keeps it realistic and you're able to actually gather real opinions in order to help other people because then we've been through it and so we understand so we're able to …form a realistic intervention.' (participant ) the facilitators highlighted that co-production encouraged group members to be proactive; they were stimulated to think in a different way to develop the intervention. one group member suggested that co-production could be more effective if decision makers from partner organisations were also present as group members: 'i think if you were to bring in people with a bit more of a status in the degree programme itself, the students will be thinking, you know what this is the opportunity. they are going to be sitting across the table from me, let me just shoot them a couple of questions.' (participant ) group members and facilitators both stated that they would engage with the process again and would consider incorporating a co-production element into future research, although facilitators recognised it as a resource intensive process that may not be feasible in every research project. being heard and being valued: the facilitators were aware of the potential power differences between themselves as researchers, the qualified nurses and the students. attempting to flatten this hierarchy, they integrated into the group: 'and i just felt like one of them if that makes sense which is, the main point of the coproduction is that we're on the same level and there isn't any hierarchy. and i really did feel i wanted to really have a bit of a gossip with them because that was because i'd experienced it as well.' (facilitator ) to a large extent this was effective, with participants reporting that they were able to talk freely, that their ideas or suggestions were welcomed and that their voices were being heard: only one group member reported that they felt their opinions were not valued by the facilitators and stopped attending the group meetings. this group member was experiencing significant problems in clinical placement and felt it would be useful to share with the group, however the facilitators, conscious of time pressure, guided the conversation to areas they felt were more relevant to the project: 'so, my voice was being, yeah, it was being heard but when it was not being valued was when i was a bit frustrated, but yeah it was being heard.' (participant ) 'eventually and after treading carefully so as not to upset anyone, we offered that we would hang around after the session to have a moan about placements but if we could focus on solutions and interventions for now as we didn't want to run over time. ' (field notes . . ) the facilitators acknowledged the process would have been very different had they not felt the need to focus on outputs, and this brought into sharp focus conversations that were perceived as not solution focused, inefficient, or going off topic. not being in a position to 'fix' the issues in the way they would in their roles as academic or nurse, was one of the most difficult aspects of coproduction. the influence of the higher education setting: the facilitators attempted to minimise the impact of the higher education context on the process but acknowledged that as the meetings took place in a university, inevitably, the students associated them with learning. both facilitators were tempted to resort to established techniques when working with the group members and language closely related to academic roles rather than co-production was evident in their interviews: by the final group meeting the facilitators found a balance between their academic style and the philosophy underpinning co-production, encouraging group members to leave their desks, accepting the free-flow nature of the discussions and abandoning any attempts to encourage written exercises. participants felt there were unanticipated benefits to participating in a co-production group, both for the facilitators and the group members. these benefits were founded in their experience, specifically being part of a group and making a difference, developing transferrable skills, and enhanced health and wellbeing. this led to the conclusion that co-production was a salutogenic model, an approach that supports the relationship between health, stress and coping. making a difference: this was key to both facilitator and group member experience, as three of the group members also identified that helping the next generation of nurses was both a motivation to take part and a positive outcome of co-production: the co-production meetings were mutually beneficial; students learned from early career nurses and early career nurses enjoyed the opportunity to reconnect with the students. attending the group meetings was not perceived to be onerous, but were positive and enjoyable; participants cited interest in hearing other people's opinions and the outcome of the intervention implementation. transferrable skills: both facilitators and group members reported that they had developed new skills during the co-production process. facilitators enhanced their group work skills, gaining confidence in working closely with students, and facilitating co-production: the group members identified that they had developed skills that they could use in their clinical roles, such as problem solving or thinking outside the box. they appreciated others' opinions and the value of sharing ideas to reach a consensus or solution. in particular several group members identified enhanced communication skills allowing them to relate more effectively to patients: salutogenesis: comments from participants indicated that the experience of participating in a coproduction process may in itself support psychological health and wellbeing, which is the essence of the concept of salutogenesis. they identified the value of sharing issues from clinical placement, validating their feelings and being reassured they were not alone with their experiences. the j o u r n a l p r e -p r o o f opportunity to voice their concerns and hear them interpreted from alternative perspectives was cathartic. one group member felt strongly that sharing personal challenges in clinical placement was central to the group's remit: 'it was just i was going through personal issues within my placement, like i said, and i thought … if i voiced them in the coproduction, it could have been something that can help other people.' (participant ) the facilitators were challenged by the use of the group as a therapeutic space, acutely feeling the tension between the welfare of the group members and the remit of the project. they reported regularly guiding the focus of the group back to the narrow parameters of the terms of reference, possibly in juxtaposition to the collaborative nature of co-production: 'but that was probably the worst part was saying, no we can't do that sorry…yeah, that was horrible to do because you know that they want to talk about some things and sometimes they just want to rant about certain things.' (facilitator ) the benefit to the group members of being able to discuss their current issues with empathetic and compassionately critical colleagues was not lost on the facilitators and the difficulty associated with interjecting was the issue raised most frequently by both of them. the questionnaire data indicated that co-production was a generally acceptable process. perceptions changed positively over time about effort, enjoyment and opportunity costs related to co-production. as understanding about the process increased, so did the confidence of the participants that they could contribute and the process was effective. the qualitative data was a rich source of insight into the influences at each of the temporal assessments of acceptability. the perception that the process was effective developed in parallel with participants recognising their developing skills and appreciating the opportunity to help future generations of nurses. those interviewed explained how they came to understand the coproduction process, value their own and others' contributions over time, and took the opportunity to gain personally from the experience, which impacted on their perception of opportunity costs. their comments identified that they enjoyed hearing other's experiences and this increased their self-efficacy as they gained confidence with their own practice. the interview data also gave context to the challenges the facilitators faced trying to balance the needs of the group members with the needs of the project, how this may not always have been possible or desirable but ultimately influenced the experience of the group members. j o u r n a l p r e -p r o o f discussion engaging service users, students or public in the design of services or education intuitively has value, but co-production has been described as weakly conceptualised with little consensus about why we do it, what effects are being sought, or achieved (oliver, et al., ) . this argument is compounded by the longstanding debate about the nature of knowledge and expertise (durose, et al., ) . this study was designed to explore the experiences and perceptions of co-production group members with regard to acceptability and feasibility of the co-production process. the findings raised key points for discussion: first, the co-production process was generally acceptable and group members were unanimous in the opinion that they would like to participate in co-production again. second, co-production in a higher education setting presented challenges related to group members' perceptions and relationships that impacted on the feasibility of co-production to design an intervention. third, co-production has the potential to offer unanticipated added value beyond that of the design of an intervention, both for group members and facilitators and for the integrity of the output. evaluation of acceptability identified practical challenges to participating in the co-production process. resources and time restraints are recognised barriers to co-production (holland-hart, et al., ; oliver, et al., ) and all data sets revealed concern about competing priorities. once group members understood the concept of coproduction, the level of burden was perceived to be more acceptable and group members found ways to overcome the practical barriers to engagement. this suggests that clearer explanation, with examples of similar processes, at an earlier point would enhance the process. the academic setting for meetings may have been an additional constraint to achieving the full potential of the process. the high value placed on academic knowledge influences both the degree of control taken by academics in collaborative partnerships and the likelihood of challenge to that decision-making offered by other stakeholders (mccabe, et al., ) , exacerbated in this case by the traditional student-academic hierarchy. potentially, respectful relationships masked the limitations this imposed. incongruence between the social boundaries of academic/researcher/facilitator, early career nurse and student in an academic institution may in reality prevent the blurring of boundaries that is espoused as key to the co-production process (kirkegaard and anderson ) . the distribution of knowledge and expertise across organisations and the significance of context in co-production is key (ledger and slade ) . the facilitators struggled with the tension between allowing the group members time to benefit from the process and meeting the aim of the project. co-production is not without cost; it is emotionally demanding and subject to competing demands and expectations. the skills required to manage co-production group dynamics may differ from those traditionally required or rewarded by higher education institutions (flinders, et al., ) . ideally, co-production offers equality and lack of hierarchy but in reality the demands of different stakeholders impact on the ability of the facilitators to value all contributions equally or to invest time in relationships and conversations that may not have guaranteed output (oliver, et al ) . these findings indicate that the pressure to design an intervention weighed heavily on the facilitators, potentially exacerbated by their awareness of and engagement in the evaluation of the co-production process. they juggled ethical and political complexity and tried to design an intervention that was 'right' for all stakeholders but found it impossible to utilise all the ideas from the group. in one instance this resulted in a group member feeling undervalued and unrepresented, a recognised potential cost to co-production (boaz, et al., ) . one explanation for the enthusiastic response from those interviewed may be their perceived personal gain from the process; an increased sense of self-efficacy and self-worth because at the end of the process they believed they were able to make a difference, help future generations of nurses, and develop communication and problem-solving skills useful for clinical practice. crucially, they also understood the capital that they brought to co-production. the salutogenic nature of coproduction is echoed in studies considering the benefits for service user involvement in participatory nursing research, with key contributory factors being the leadership of the process, clarification about their role, the structure of the meetings and being a member of a team (mjøsund, et al., ) . the appreciation group members had of the facilitators' styles justifies their commitment to respectful engagement (flicker and nixon, ) and genuine respect for group member opinions (simpson et al., ) . given that the co-production process was implemented to design an intervention that would support newly qualified nurses, the benefit of using a salutogenic approach, maximising the potential of the relationship between health, stress and coping, was not lost. this approach has potential to be of particular value during periods of increased demand such as the current covid- pandemic. in england, nursing student experience has been impacted considerably by their early incorporation into the nursing workforce and will influence their experiences as newly qualified nurses. the strength of this study lies in the novel approach to co-production, spanning boundaries between nursing practice and higher education. to our knowledge this is the first use of co-production to design this type of intervention making the findings relevant to a range of settings. the study represented all participant voices, offering a comprehensive perspective. the mixed methods, explanatory sequential design further strengthens the credibility of the findings as the interview data contextualises the questionnaire data. we saw from the questionnaire data that the process became more acceptable to group members over time but that attendance was challenging. the use of interviews allowed us to triangulate with the questionnaire data and explore the context, which added significant value to the evaluation of the process. providing opportunities for the facilitators and group members to reflect both during and after the process aligned with the principles of co-production, which advocate hearing and valuing multiple voices. a potential limitation to the co-production process and the evaluation is the small number of participants. although all group members attending the initial, mid-point and final group sessions completed the acceptability questionnaire, fewer attended the final group meeting. those who found participation difficult may have decided not to continue to attend and may have had different views of acceptability of the co-production process than those who did attend, however, the interview data helped to explain the context of the lower attendance. ultimately, we were interested in the potential of co-production as an effective process at the interface between clinical and higher education settings. our findings were limited by the scope of the study, as we are unable to report on the legacy of participants' experience in relation to their professional practice. we would recommend further research to explore this area. co-production is a technique that attempts to include individuals not traditionally seen as 'experts' in the development of services or products. our evaluation of this co-production process highlighted the potential for greater use of the strategy in the context of higher education and clinical nursing practice. not only was an intervention designed using co-production, but the individual nurses and students who participated gained personally from the process and saw the end product as more credible. they developed and practised communication and problem-solving skills that transferred effectively to the clinical environment. they recognised and enjoyed being able to make a difference and found benefit from using the group as a reflective space. this added value of co-production has equipped and motivated the group members to function more effectively in their j o u r n a l p r e -p r o o f participants were asked to circle or underline the answer that best suited their opinion from the following options: no opinion agree strongly agree questions asked: . i felt it was acceptable for me to take part in the co-production process. . i enjoyed taking part in the co-production group meetings. . it required effort for me to take part in the co-production group sessions. . the co-production process was effective to design an intervention to help retain early career nurses. . participating in this co-production group interfered with my other priorities. . i am confident that i was able to contribute to the co-production process. j o u r n a l p r e -p r o o f closing the gap: key areas for action on the health and care workforce. the health foundation how to engage stakeholders in research: design principles to support improvement using thematic analysis in psychology characteristics of successful interventions to reduce turnover and increase retention of early career nurses: a systematic review towards co-production in research with communities generating 'good enough' evidence for coproduction the depict model for participatory qualitative health promotion research analysis piloted in canada, zambia and south africa the politics of co-production: risks, limits and pollution the potential for coproduction to add value to research health expectations what is participatory research? why do it? in: participatory qualitative research methodologies in health nurses' intention to leave their profession: a cross sectional observational study in european countries improving the quality and content of midwives' discussions with low-risk women about their options for place of birth: coproduction and evaluation of an intervention package coproduction and health: public and clinicians' perceptions of the barriers and facilitators, health expectations co-production in public services. london: cabinet office co-production in community mental health services: blurred boundaries or a game of pretend? co-producing a digital educational programme for registered children's nurses to improve care of children and young people admitted with self-harm coproduction without experts: a study of people involved in community health and well-being service delivery the ceiling to coproduction in university-industry research collaboration salutogenic service user involvement in nursing research: a case study standards framework for nursing and midwifery education the dark side of coproduction: do the costs outweigh the benefits for health research? co-production and the co-creation of value in public services: a suitable case for treatment a qualitative study analysing the journey towards an embedded approach to service user involvement the uk quality code for higher education acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework adding sugar: collaborating with service users and carers in mental health nursing research understanding co-production as a new public governance tool health care co-production: co-creation of value in flexible boundary spheres nurse retention: a review of strategies to create and enhance positive practice environments in clinical settings evolving to a new dominant logic for marketing a systematic review of co-creation and coproduction: embarking on the social innovation journey we would like to acknowledge the generosity of the participants who shared their ideas and gave their time to the research study. we would alos like to thank grace lucas for contributing to the data collection and analysis. j o u r n a l p r e -p r o o f (sekhon et al, ) , adapted to illustrate the seven constructs in relation to coproduction how an individual feels about the co-production process the perceived amount of effort that is required to participate in the co-production process the extent to which coproduction process has good fit with an individual's value system the extent to which the participant understands the co-production process and how it works the extent to which benefits, profits or values must be given up to engage in the co-production process the extent to which the coproduction process is perceived as likely to achieve its purpose the participant's confidence that they can perform the behaviour(s) required to participate in the co-production process prior to participating in co-production whilst participating in co-production after participating in co-production acceptability as defined by sekhon et al : a multi faceted construct that reflects the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate, based on anticipated or experiential cognitive and emotional responses to the intervention.j o u r n a l p r e -p r o o f key: cord- -mkfg nar authors: ren, zhigang; luo, hong; yu, zujiang; song, jingchao; liang, lan; wang, ling; wang, haiyu; cui, guangying; liu, yong; wang, jin; li, qingquan; zeng, zhaohai; yang, shengkun; pei, guangzhong; zhu, yonghui; song, wenbin; yu, wenquan; song, chuanjun; dong, lihong; hu, chuansong; du, jinfa; chang, junbiao title: a randomized, open‐label, controlled clinical trial of azvudine tablets in the treatment of mild and common covid‐ , a pilot study date: - - journal: adv sci (weinh) doi: . /advs. sha: doc_id: cord_uid: mkfg nar coronavirus disease (covid‐ ) has spread worldwide. to date, no specific drug for covid‐ has been developed. thus we performed this randomized, open‐label, controlled clinical trial (chictr ) in china. a total of mild and common covid‐ patients were enrolled and randomly assigned to receive azvudine and symptomatic treatment (fnc group), or standard antiviral and symptomatic treatments (control group). the mean times of the first nucleic acid negative conversion (nanc) of patients in the fnc group and patients in the control group were . (sd . ; range – ) days and . (sd . ; range – ) days, respectively (p = . ). the mean times of the first nanc of newly diagnosed subjects in the fnc group and subjects in the control group were . (sd . ; range – ) days and . (sd . ; range – ) days, respectively (starting from the initial treatment) (p = . ). no adverse events occurred in the fnc group, while adverse events occurred in the control group (p = . ). the preliminary results showed that fnc treatment in the mild and common covid‐ may shorten the nanc time versus standard antiviral treatment. therefore, clinical trials of fnc treating covid‐ with larger sample size are warranted. in december , severe acute respiratory syndrome coronavirus (sars-cov- ) broke out in wuhan, hubei, china. [ ] as of july , , more than million patients have been confirmed, and over half of a million have died worldwide. [ ] moreover, the number of confirmed and fatal cases continues to increase. however, at present, there is no specific drug for treating coronavirus disease (covid- ), and many critically ill patients have died without effective treatment. thus, it is urgent to rapidly develop direct antiviral drugs to treat covid- . sars-cov- is a typically enveloped, single-stranded positive rna virus belonging to the betacoronavirus genus, the coronaviridae family and the nidovirales order. rna synthesis requires nucleosides and nucleotides as the raw materials. [ ] therefore, in view of this characteristic, the nucleoside antiviral drugs most widely used in the clinic may have an anti-sars-cov- effect. nucleoside antiviral drugs are synthetic and chemically modified nucleoside analogs that can enter host cells by imitating natural nucleosides. after entering the host cells, the nucleoside analogs are transformed into an active compound through the catalysis of kinase. the active compound was nucleoside triphosphate, which is embedded in viral dna or rna during viral dna or rna synthesis, leading to the termination of viral dna or rna chain synthesis and inhibition of viral replication. [ ] in addition, nucleoside antiviral drugs can also inhibit the activity of virus dna-dependent dna polymerases (dddps), rna-dependent dna polymerases (rddps) and rna-dependent rna polymerases (rdrps), which can lead to the inhibition of viral replication. nucleoside antiviral drugs are characterized by a high antiviral efficacy and a high drug resistance barrier. remdesivir, an unlisted nucleoside antiviral drug used abroad, has been tested in vitro to directly inhibit the activity of sars-cov- [ ] and completed the phase iii clinical trial for the covid- treatment. although a recent report about the compassionate use of remdesivir for patients with severe covid- showed that clinical improvement was observed in of patients ( %), [ ] its phase iii clinical trial result was unsatisfactory. however, at present, covid- is spreading rapidly around the world and has become a major threat to human health. therefore, it is urgent to find more safe and effective nucleoside drugs against covid- as soon as possible. azvudine (fnc) is the first double-target nucleoside drug that has demonstrated significant and broad-spectrum in vitro antiviral effects against targets such as hiv [ ] , hcv [ ] , ev [ ] , and hbv [ ] . recently, azvudine showed potent antiviral activity against hcov-oc and sars-cov- in vitro (unpublished results). the result from phase ii clinical trial (gq-fnc- ) of treating hiv infection with azvudine showed that the drug had excellent efficacy and safety. [ ] therefore, we speculate that azvudine has an anti-covid- effect. under the condition of covid- defined as public health emergency of international concern, we conducted this prospective, randomized, open-label, controlled clinical trial to make a preliminary exploration of the efficacy and safety of azvudine tablets in the treatment of covid- . [ ] methods study design. we performed this prospective, randomized, open-label, controlled clinical trial at guangshan county people's hospital in china. this trial was approved by the institutional review board of the first affiliated hospital of zhengzhou university ( -ky- ) and guangshan county people's hospital ( - ) in accordance with the good clinical practice guidelines of the international conference on harmonisation and the declaration of helsinki. the study was registered on chictr.org.cn with the number chictr . all enrolled participants provided written informed consent. patients. patients meeting the following criteria were enrolled in the study: ) age and over, regardless of gender; ) respiratory or blood samples that were tested positive for sars-cov- nucleic acid by real-time reverse transcriptase polymerase chain reaction (rt-pcr), or respiratory or blood samples that were tested highly homologous with the known sars-cov- by viral gene sequencing; ) the confimation of covid- according to the diagnostic criteria of "the latest clinical guidelines for novel coronavirus" issued by the world health organization (who) on january , , and the diagnostic criteria from the "diagnosis and treatment program trial version (or ) guidelines" issued by the national health commission of the people's republic of china. all enrolled patients signed informed consent forms. exclusion criteria included ) known or suspected allergy to the composition of azvudine tablets; ) patients with malabsorption syndrome or any other condition that affects gastrointestinal absorption, the need for intravenous nutrition or an inability to take oral medication; ) patients on anti-hiv treatment; ) patients with one of the following conditions: respiratory failure and the need for mechanical ventilation; shock; intensive care unit (icu) monitoring and treatment for other organ failures; ) pregnant women or those who were lactating or may have a birth plan during the trial period and within months after the end of the trial; ) patients participating in other clinical trials or using experimental drugs within weeks before administration; and ) patients with other conditions that were not suitable for participating in this experiment according to the judgment of the researcher. the definition of mild covid- was patients with mild clinical symptoms and without signs of pneumonia in imaging; the definition of common covid- was patients with fever, respiratory, or other related symptoms, and with signs of pneumonia in imaging. enrollment. the isolation ward is divided into two areas in hospital, one for suspected patients ward and the other for confirmed patients ward. patients with fever, cough or other related symptoms, or clinical confirmed covid- were admitted to suspected patients ward. after hospitalization, the throat swab specimens were collected for nucleic acid testing by rt-pcr the next day. patients were transferred to confirmed patients ward if the nucleic acid testing was positive. then our researcher evaluated the patient whether meeting our criteria and enrolled eligible patients after signing written informed consents. patients with exposure to confirmed patients or wuhan, but without symptoms, were isolated outside the hospital and collected throat swab specimens. patients were admitted to hospital and transferred to confirmed patients ward if the result of nucleic acid testing was positive. then researchers screened and enrolled eligible patients. a total of mild and common covid- patients were screened and patients were enrolled, without severe patients, because none of severe patients were admitted to hospital during the study. randomization. patients were randomly assigned in a : ratio to the fnc group or control group. randomization was accomplished by using a random table that was generated in sas software at : . each enrolled subject (meeting all the inclusion criteria and not meeting any of the exclusion criteria) was given a number, randomly assigned to the fnc group and guidelines. on february , , which overlapped with the study period, the "diagnosis and treatment program trial version guidelines" was updated to the sixth edition, and subsequent participants were given routine treatment according to the sixth edition treatment program. the drug was administered daily until the patient was discharged from the hospital or transferred to the corresponding department for the treatment of other diseases or death. during the treatment, no anti-hiv drugs other than azvudine were used, and if there were patients with liver damage (the normal phenomenon of antiviral therapy), liver protection was provided in time. according to the diagnosis and treatment program trial version guidelines, the criteria for release and discharge were as follows: body temperature returned to normal for more than days, respiratory symptoms showing obvious improvement, pulmonary imaging showing that the inflammation was obviously absorbed, and negative respiratory pathogenic nucleic acid testing for two consecutive assessments (with a sampling interval of at least day). these criteria were not updated in the sixth edition. we monitored the patient's vital signs, oxygen (via finger pulse oximetry), and respiratory symptoms and signs every day. on odd days and the discharge day, we monitored the patient's routine blood, erythrocyte sedimentation rate (esr), c-reactive protein, blood biochemistry, blood coagulation, myocardial markers, procalcitonin, myocardial zymogram, and arterial blood gas. we monitored the pneumonia change by chest computed tomography (ct) images. patients were taken ct scan once at the enrollment, every days during the treatment, and at discharge. we began to test sars-cov- nucleic acids by rt-pcr after the patients began taking their drugs. the time of nucleic acid detection was determined by researchers based on the patient's condition and testing results. outcomes. the primary outcomes were the rate of nucleic acid negativity conversion of sars-cov- and the negativity conversion time. nucleic acid conversion rate was defined as the ratio of patients with negativity nucleic acid testing in fnc group to all patients in fnc group at a certain point in the follow-up process. secondary outcomes were the improvement rate of chest ct images, the time required for the body temperature returning to normal and the improvement in respiratory symptoms and signs. the improvement of chest ct images was defined as a significant reduction in the range of lesions and inflammation. the results for this outcome were double-checked by two radiologists. safety was regularly assessed by monitoring vital signs (heart rate, respiratory rate, systolic pressure, diastolic pressure), changes in laboratory values (liver function, renal function), and adverse events (including type, incidence, severity, time and drug correlation, and assessment of severity according to the national cancer institute common terminology criteria for adverse events [nci ctcae], version . ). continuous variables were presented with the form of mean (standard deviation) or median (interquartile range). categorical variables were presented with the form of percentage. differences between subjects in fnc group (n= , n= , or n= ) and control group (n= or n= ) were analyzed by using student's t-test for normal continuous variables, wilcoxon rank-sum test for non-normal continuous variables, and fisher's exact test for categorical variables. statistical analysis was performed using sas software, version . . statistical significance was defined by p< . (two-tailed), without post-analysis and α adjustment. data transformation, normalization, evaluation of outliers were not used in our study. from february , , to february , , a total of mild and common covid- patients were screened and only mild and common covid- patients were eligible for enrollment in guangshan county people's hospital. then patients were sequentially randomly assigned into the fnc group (n= ) and the control group (n= ) to receive therapy. all patients were cured and discharged before march (figure ) . the demographic and baseline characteristics of the patients were well matched between fnc group and control group at enrollment ( table ). the median age was years (iqr - ), and ( %) subjects had been exposed to confirmed patients or had returned from none of the patients reported diarrhea at the onset of the illness. the mean time from illness to hospitalization was days (iqr - ), and the mean total length of stay in the hospital was . days (iqr - ). (supplementary table s ). there was no difference in laboratory test results and ct images during the screening between the fnc group and the control group. the mean blood cell counts were normal in the fnc group and control group, including white blood cells table s ). during the screening, all patients underwent chest ct images. among them, patients ( %) had single-side lung invasion, and patients ( %) had bilateral lung invasion ( table ) . twelve patients ( %) had received routine treatment according to the "diagnosis and treatment program trial version guidelines" before enrollment. among them, treated subjects were in the control group ( %), and were in the fnc group ( %). after enrollment, all patients received antiviral therapy. two patients in the fnc group ( %) and patients in the control group ( %) received antibiotic therapy. three patients in the fnc group ( %) and patients in the control group ( %) received traditional chinese medicine. five patients in the fnc group ( %) and patients in the control group ( %) received adjuvant medication. a total of patients received oxygen support, in the fnc group ( %) and in the control group ( %) ( table ) . expect for fnc treatment and standard antiviral therapy, other treatments were symptomatic treatment according to the "diagnosis and treatment program trial version (or ) guidelines", and without additional treatments. the rate of first negative conversion of nucleic acid after days of treatment was % in the fnc group and only % in the control group (figure a) . the kaplan-meier curves indicated the significant difference between two groups (p= . ). the rate of nucleic acid negative conversion after days of treatment was % in the fnc group and % in the control group (figure b) , with a significant difference (p= . ). the mean times of the first nucleic acid negative conversion of the patients in the fnc group and the patients in the control group were . (sd . ; range - ) days and . (sd . ; range - ) days, respectively (difference, - . days; % confidence interval [ci], - . ~ . ; p= . ). the mean times of the confirmation of nucleic acid negative conversion were . (sd . ; range - ) days and . (sd . ; range - ) days, respectively (difference, - . days; % ci, - . ~ . ; p= . ) (figure a) . to eliminate the influence of grouping cut points on the treatment outcome, we analyzed the whole negative conversion time for the use of fnc alone. the mean times of the first nucleic acid negative conversion were . (sd . ; range - ) days for the newly diagnosed patients in the fnc group and . (sd . ; range - ) days for subjects in the control group (starting from the initial treatment) (difference, - . days; % ci, - . ~ - . ; p= . ). the mean times of the confirmation of nucleic acid negativity conversion were . (sd . ; range - ) days and . (sd . ; range - ) days, respectively (difference, - . days; % ci, - . ~ - . ; p= . ) (figure b) . the average lengths of stay in the hospital were . (sd . ; range - ) days and (sd . ; range - ) days. considering that patients in each group had received standard antiviral treatment and symptomatic treatment before enrollment, we carried out a stratified analysis to understand the efficacy of fnc in treatment of previously treated covid- patients. the results are described as follows: the mean times of the first nucleic acid negative conversion of the treated patients in the during the screening, the pulmonary ct of patients ( , , , , , , , ) in the fnc group and patients ( , , , , , , , ) in the control group showed abnormalities, including patchy blurred shadow, cord shadow, nodular shadow, or density shadow (supplementary figure s ) . after enrollment and receiving fnc or routine treatment, the lungs in the subjects were improved (focus shrinking/absorption/no obvious abnormality). the pneumonia improvement rate was % after days of treatment in the fnc group and % after days of treatment in the control group. the pneumonia improvement time were shortened in the fnc group versus control group (p= . ) (figure a) . during the screening, the pulmonary ct of patients ( , ) in the fnc group showed no obvious abnormalities. after enrollment, they received fnc treatment and maintained normal. the pulmonary ct images of patients ( , ) in the control group were missing. during the study, we monitored the body temperature of the participants every day. due to the participants in the fnc and control groups receiving symptomatic treatment during the screening, their average body temperatures were basically normal. after enrollment and receiving fnc or routine treatment, the average body temperature remained normal, in the range of . to . °c (figure b) . a total of subjects in both the fnc and control groups showed mild and occasional cough (slightly accompanied by pharyngeal discomfort or expectoration). after treatment, subjects returned to normality and remained normal until discharge. only one subject in the control group ( ) was transferred to another hospital to receive routine treatment on the ninth day after treatment due to epidemic management. the respiratory symptoms and signs of this subject had been improved, and his nucleic acid testing reached negativity on the th day. the vital signs in the fnc group and control group, including heart rate, respiratory rate, systolic pressure, and diastolic pressure, were in the normal range during the treatment (figure a-d) . the liver function in the fnc group and control group, including aspartate aminotransferase, alanine aminotransferase, glutamyl transpeptidase, and total bilirubin, were normal and did not significantly change during the treatment (figure e-h) . the kidney function in the fnc group and control group, including blood urea nitrogen and creatinine, were also normal during the treatment (figure i-j) . during the study, no adverse events occurred in the fnc group, while adverse events occurred in the control group, with an incidence of % ( / ) (p= . ) (figure k) . these adverse events were determined to be possibly related to the chloroquine phosphate treatment: one patient had anorexia, epigastric discomfort, nausea, abdominal distension without vomiting and abdominal pain; one patient developed chest tightness with limb tremor; and one patient had nausea and vomiting (stomach contents). the severity of the adverse events was grade and disappeared after follow-up. during the study, there were no serious adverse events, serious adverse reactions, important adverse events, deaths and so on. this pilot study is a randomized, open, controlled clinical trial to evaluate the efficacy and safety of azvudine tablets in the treatment of covid- . our trial found that azvudine may shorten the time of nucleic acid negativity conversion of persistent mild and common covid- patient versus standard antiviral therapy. compared with a previous randomized clinical trial of using hydroxychloroquine in patients with mainly mild to moderate covid- , our results is encouraging. [ ] the rate of nucleic acid negative conversion after fnc treatment is higher than hydroxychloroquine treatment ( % after days treatment vs % after days treatment). however, our sample size is smaller than hydroxychloroquine clinical trial, which may reduce the persuasion of our results. we found that regardless of whether the patients were newly diagnosed or had previously received routine treatment, the time of nucleic acid negative conversion may be shortened with fnc versus standard antiviral therapy ( . days vs . days). moreover, it was also found that although patients had received other treatment regimens, they did not affect the benefits of fnc treatment. in addition, fnc treatment can not only accelerate the elimination of the virus but also improve the lung function of patients, and maintain their vital signs. patients in our study are all persistently mild and common patients, with a median days from illness to hospitalization, thus our results about the efficacy of fnc in treating covid- are applicable only to persistently mild and common patients. although it is reported that covid- is basically a self-limiting viral infection, and it resolves gradually over time, especially for mild and common cases, the most proportion of covid- patients, [ ] it does not mean that these patients do not need to receive treatment. on the contrary, these mild and common cases are the most proportion of covid- , the major source of covid- transmission. these patients will recover faster after treatment compared with no medical treatment, and they just need fewer medical resources if receiving specific antiviral drugs timely. however, due to the lack of specific antiviral drug, the pandemic was not under the control and spread rapidly, which caused a large cumulative expense of medical resources. fortunately, azvudine could reduce treatment time of mild and common patients and save a lot of medical resources. therefore, azvudine may bring the hope for treating covid- and a larger controlled, randomized clinical trials are required to confirmed or contradict our findings. the frequency of nucleic acid testing is not completely uniform for each subject, due to the difficulty of nucleic acid test during the pandemic. the testing time was determined by researchers based on the patient's condition and testing results. moreover, all throat swab specimens were sent to the local center for disease control (cdc) for nucleic acid testing by rt-pcr. cdc determined whether to feed back the results on the day or the next day based on the received sample size and the submission time. these factors delayed the next sample collection. however, the first result of two consecutive nucleic acid negative conversion could reflect the efficacy of drugs. in addition, although the mean time from enrollment to the first nucleic acid testing was longer in the control group than that in the fnc group, it did not influence our results because the first testing result did not reach the real nucleic acid negativity conversion in patients who had longer testing interval time. fnc in our study was given at a dose of mg daily. the dose was determined according to the previous phase i and ii clinical trials of fnc in the hiv treatment. in the phase i clinical trial, the climbing testings showed that mg of fnc was still a safe dose for humans. moreover, in the phase ii clinical trial, no severe adverse event was associated with the fnc in the mg group, mg group, and mg group. given to the pandemic belonging to the public health emergency, we decided to use a dose with a better therapeutic effect and within a safe range. thus, we used mg fnc in this pilot study to make a preliminary exploration of the efficacy and safety of azvudine tablets in the treatment of covid- . in our study, fnc treatment was well tolerated for patients. the vital signs, liver function and kidney function in both groups were normal. moreover, three secondary adverse events were observed in the control group. it was confirmed that the adverse events were caused by chloroquine phosphate, which is consistent with other clinical trial data. [ ] there were no adverse events in the fnc group. given to the short treatment time in fnc group, we will follow these patients to surveil and evaluate their prognosis. under the condition of covid- defined as public health emergency of international concern, we conducted this prospective, randomized, open-label, controlled clinical trial to make a preliminary exploration of the efficacy and safety of azvudine tablets in the treatment of covid- . it is inevitable that some disadvantages may exist in this study during the pandemic. firstly, the sample size of the groups were small, with only people enrolled in this study owing to limited number of available patients. our further recruitment was precluded by the rapid decline of new covid- cases due to successful restraint of covid- in early march in china, especially in xinyang. however, our trial is a pilot study, in which sample size does not need to be calculated, aiming to make a preliminary exploration of the efficacy and safety. secondly, the design of open-label but not doubleblind, maybe influence the clinical decision-making due to the knowledge of the treatment assignment. thirdly, there was no difference in demographic and baseline characteristics of the patients between two groups, but we did not test and compare the throat viral loads between two groups. higher throat viral loads may raise more viral replication and delay the time of nucleic acid negativity conversion. finally, the efficacy and safety of azvudine tablets in the treatment of severe and critically ill covid- was not acquired due to none of severe covid- patients admitted to hospital. nevertheless, the results of randomized clinical trials of remdesivir [ ] and lopinavir-ritonavir [ ] in adults with severe covid- showed that no benefit was observed with remdesivir or lopi-navir-ritonavir treatment. therefore, trials with larger sample sizes are needed to confirm the efficacy and safety of fnc treatment for severe and critically ill covid- patients. in summary, the present preliminary clinical trial results showed that the fnc treatment of liang and ling wang contributed equally to this work. competing interests: all authors declare that they have no competing interests. we thank all the generous volunteer subjects who enrolled in the study. we thank bo feng, ranran sun, changyue guo, and binyuan he for their support and revision of the article. no individual data is reported in this article. data are shown for patients assigned to fnc group and assigned to control group. data are percentage (%). the differences between groups were using log-rank (mantel-cox) test. on the fourth day after treatment, the rate of first negative conversion of nucleic acid achieved % in patients from the fnc group and % in patients from the control group. the kaplan-meier curves indicate the significant difference (p= . ). on the sixth day, the rate of second nucleic acid negative conversion achieved % in patients from the fnc group and % in patients from the control group. the kaplan-meier curves indicate the significant difference (p= . ). nat, nucleic acid testing. data are mean (sd). the differences between groups were analyzed using student's t-test. * p < . , ** p< . , and *** p< . . fnc, azvudine; first neg, first nucleic acid testing negativity; second neg, second nucleic acid testing negativity. (k) comparison of adverse events incidence of patients in the fnc group and patients in the control group. data are percentages (%). the adverse events incidence was decreased in the fnc group ( %) versus the control group ( %) (p= . ). azvudine treatment in the persistently mild and common covid- patients may shorten the nucleic acid negative conversion time versus standard antiviral treatment, regardless of whether the patients are newly diagnosed or have previously received routine treatment. azvudine treatment could improve the lung function of patients. moreover, the adverse events is not observed in patients receiving azvudine. coronavirus disease (covid- ): situation report- the lancet key: cord- -aizjzglo authors: guo, tingting; liu, xiaoming; xu, cihao; wang, jiazheng; yang, lian; shi, heshui; dai, meng title: fangcang shelter hospital in wuhan: a radiographic report on a cohort of covid- patients date: - - journal: int j med sci doi: . /ijms. sha: doc_id: cord_uid: aizjzglo objectives: to present the temporal changes of ct manifestations in covid- patients from a single fangcang shelter hospital and to facilitate the understanding of the disease course. materials and methods: this retrospective study included patients (males: females, : , mean year, ± years) with confirmed covid- at jianghan fangcang shelter hospital admitted between feb , , and feb , , who had initial chest cts at our hospital. radiographic features and ct scores were analyzed. results: a total of ct scans of patients were evaluated. our study showed a high median total ct score of within the first week from symptom onset, peaked in the (nd) week at , followed by persistently high levels of ct score with . , and for the week , , and > , respectively, and a prolonged median disease course ( days, the median interval between the onset of initial symptoms and discharge). ground-glass opacity (ggo) ( %, / ) was the earliest and most frequent finding in week . consolidation ( %, / ) and mixed pattern ( %, / ) were predominant patterns in (nd) week. ggo and reticular were the main patterns of later phase ct scans in patients with relatively advanced diseases who had longer illness duration (≥ weeks). among the ct abnormalities obtained within days from the twice rt-pcr test turned negative, the mixed pattern was mainly presented in patients with disease duration of - weeks, for ggo and reticular were common during the whole course. conclusion: discharged patients from fangcang shelter hospital demonstrated a high extent of lung abnormalities on ct within the first week from symptom onset, peaked at (nd) week, followed by persistence of high levels and a prolonged median disease course. ggo was the predominant pattern in week , consolidation and mixed pattern in (nd) week, whereas ggo and reticular patterns in later stages (≥ weeks). since the outbreak of coronavirus disease in wuhan in december , it has spread worldwide and infected more than people by may [ ] . with the high rate of human transmission and a mortality rate of . % in hubei province compared to that of . % outside of the region [ ] , the disease has been recognized as a pandemic by the who on mar , [ ] . in wuhan, fangcang shelter hospitals have been built-up to hospitalize, treat and monitor the patients with confirmed covid- , such that the limited medical resources could distribute for mildtype, common-type, severe-type, and fatal severe-type patients. by march , more than , patients [ ] had been treated uniformly according to the standard protocols [ ] , and all the fangcang shelter hospitals in ivyspring international publisher wuhan had been closed due to the recent relief of the epidemics. previous studies have revealed the typical radiological imaging features of covid- [ ] [ ] [ ] [ ] [ ] [ ] [ ] . however, it remains understudied how the chest ct manifestations evolve in the patients of fangcang shelter hospitals, who were hospitalized according to uniform criteria [ ] and who went through more regular examinations and uniform treatments [ ] . in the meanwhile, as will be introduced below, the medical intervention in the fangcang shelter hospitals could be potentially practiced in a self-isolation environment such as at home. therefore, the purpose of this study was to determine the temporal patterns of ct manifestations in covid- patients from a single fangcang shelter hospital and to facilitate the understanding of the disease course. the jianghan fangcang shelter hospital in this study was operated by our hospital. this retrospective study was approved by the ethics of committees of our hospital. only the anonymous data was collected, and informed consent for this retrospective study was waived. the admission criteria for fangcang shelter hospitals were [ ] : ) patients with confirmed covid- ; ) clinical classifications were mild-type (clinical symptoms without ct abnormity) or common-type (clinical symptoms with ct abnormity); ) no respiratory, cardio, or mental diseases, no other basic diseases; ) - years old with self-care ability; ) negative test results of influenza virus assays. the treatment protocol and discharge criteria followed 'the th edition of pneumonia diagnosis and treatment plan for new coronavirus infection' formulated by national health commission of the people's republic of china [ ] . for treatment: ) oseltamivir: mg/tablet, tablets each time, times a day, less than days; ) abidor [ ] : mg for adults, times a day, less than days; ) moxifloxacin: . g for adults, once a day, less than days; ) lianhua qingwen formular: . g each time, three times a day, less than days. for discharge: ) afebrile for more than days; ) respiratory symptoms markedly improved; ) improvement in the radiological abnormalities on chest ct (reduction in density and range of lesions); ) two successive negative pcr tests with at least h interval. we retrospectively reviewed the clinical records of patients for jianghan fangcang shelter hospital who were admitted between february , , and february , , and the initial symptoms and symptom onset time were recorded. the inclusion criteria were: ) patients had initial chest ct at our hospital (hence the integrity of the clinical and imaging records) were included in the study; ) patients had been discharged from jianghan fangcang shelter hospital by the censored date (march , ). to minimize motion artifacts, patients were instructed on breath-holding in the supine position. all chest ct scans were performed within a single inspiratory phase on two commercial multi-detector ct scanners (uct , shanghai, china, shanghai united imaging healthcare; aquilion -slice, toshiba medical systems, tochigi, japan). for ct acquisition, the tube voltage was fixed at kvp, the pitch of . , scanning interval of . mm, rotation time of . s, and collimator width of mm. low-dose scanning mode with an automatic tube current of mas and dose level at was performed to reduce the radiation risk of the patients. ct images were reconstructed with a matrix size of × (thickness of . mm and increment of . mm) in transverse slice orientation. the images were acquired for lung (window width, , - , hu; window level, - hu) and mediastinal (window width, hu; window level, - hu) settings. image analysis was reviewed by three radiologists (h. s, l. y, and m. d who had , and years of experience in thoracic radiology, respectively), using the institutional digital database system (vue pacs, version . . . , carestream health, canada). decisions were reached by consensus when there was a disagreement between the three radiologists. depending on the time between symptoms onset and the ct scan, all the ct scans were divided into groups: group (scans obtained the first week from symptom onset), group ( nd week), group ( rd week), group ( th week), and group (>week ). predominantly ct pattern, including groundglass opacity (ggo), consolidation pattern, reticular pattern, and the mixed pattern (the combination of ggo, consolidation, and reticulation) [ , , , ] . distribution of abnormal opacities was recorded mainly as three types: subpleural (involving mainly the peripheral one-third of the lung), random (without predilection for subpleural or central regions), and diffuse (continuous involvement without respect to lung segments) [ ] . additionally, the presence of pleura effusion, mediastinal lymphadenopathy (axil diameter > . cm) was also noted. a total score of - was obtained as the summation of lobes (score - for each lobe: score , no involvement; score , < % involvement; score , %- % involvement; score , %- % involvement; score , %- % involvement; score , > % involvement) [ ] . the median values of total ct scores were plotted against time since symptom onset. the temporal changes in ct abnormity patterns and the distribution of lung abnormalities were analyzed. manne-whitney u test was used for the difference between the median values of ct lung quantification in different groups, and the chi-square test was applied to compare the frequency of ct patterns in different groups. a p-value of < . was considered statistically significant. statistical analysis was performed by using statistical software (spss version , ibm, new york, usa). between february , , and february , , a total of patients for jianghan fangcang shelter hospital who performed the initial ct scans in our hospital were conducted. another patients were excluded because they were transferred to designated hospitals due to failure to meet discharge criteria. the remaining patients ( males and females) with confirmed covid- were included in this study, all of whom had been discharged by the censored date. the mean age of the patients was ± years old (range - years). the most common symptoms at the onset of illness were fever ( %) and cough ( %). most fever patients had either low-grade ( %, . - °c) or moderate fever ( %, . - . °c). all patients were discharged with a median hospitalized period of (interquartile range: - ) days, range - days. median time from symptom onset to discharge was (interquartile range: - ) days, range - days. the demographic characteristics, initial symptoms, and clinical records were summarized in table . among the patients, had twice ct scans, had three ct scans, and the other had four ct scans. a total of ct scans was acquired and evaluated. group (n= ), group (n= ), group (n= ), group (n= ), and group (n= ). for group , the predominant demonstrations were subpleural ( %, / patients) and diffuse ( %, / ) lung abnormalities. lung abnormalities tended to be most diffuse ( %, / ) in group (fig. ) . bilateral lung involvement was commonly observed during the whole course of the disease (lung involvement %- %) with the highest percentage of % ( / patients) in group ( table ). ( , ) the interval between the onset of initial symptoms and discharge (d) note: quantitative data were presented as mean ± standard deviation (minimum-maximum), while the counting data were presented as count (percentage of the total). the hospitalized period and the interval between the onset of initial symptoms and discharge were presented as median ( %, %). ct scores peaked at nd week of illness, with a platform period after that and slow decline substantial scores after the rd week. the median score between group and , group , and were statistically significant, respectively (p= . , p= . ). the median values of total ct score were (interquartile range: - ) for the first week (group ), higher than reported in the literatures ( , , ), which slowly increased to a peak value of (interquartile range: - , p< . , compared to that of within the first week) at the second week (group ) and started to decrease substantially afterward. the median values of total ct scores were . ( , ) , ( , ), and ( , ) for the groups , , and , respectively. radiological improvement occurs after the third week, with a statistically significant decrease in median scores between group and group (p= . ) (table , fig. ). predominant ct image patterns changed over time as the disease progressed. within the first week (group ) after symptom onset, the ggo pattern was the earliest and most common imaging finding ( %, / patients). in the second week (group ), consolidation and mixed pattern developed to the predominant patterns with demonstration frequencies of % ( / ) and % ( / ). in the third week of illness (group ), imaging patterns became more diverse, including ggo ( %, / patients), reticular pattern ( %, / ), and mixed pattern ( %, / ). ggo and reticular patterns were the main imaging patterns in group ( th week) and group (> weeks) (table , fig. ) . (fig. ) , reticular pattern [ patients, ( , ) ] and mixed pattern [ patients, ( , ) ]. noticeably, the median ct score of patients with the final reticular pattern was higher than that of patients with final ggo (p= . ). among the patients with initial predominant ggo, had final ct scan at discharge also demonstrated predominant ggo, while the median ct scores had significant differences between the initial [median ct score: ( , ) ] and final cts [median ct score: ( , )] (p= . ). on the other hand, of the patients had their initial predominant ggo turned to the reticular pattern in the final scans, for whom no significant differences were observed between the initial [median (table ) . out of patients had their last ct scans obtained within days from the twice pcr test that turned negative. the last ct scans were obtained more than days from the pcr turning negative for the other patients. among the last ct scans for these patients, the mixed pattern was mainly presented in patients with a disease duration of - weeks, for whom ggo and reticular were consistently the most common ct abnormalities during the whole course. complete lesion absorption was observed for ( / ) patients only. substantial residual lesions (median ct score ≥ ) mainly existed in patients with the disease course of greater than weeks (table ). week (n= ) week (n= ) week (n= ) > week (n= ) no lesion ( %) ( %) ( %) ( %) ( %) patterns ggo ( %) ( %) ( %) ( %) ( %) consolidation ( %) ( %) ( %) ( %) ( %) reticular ( %) ( %) ( %) ( %) ( %) mixed ( %) ( %) ( %) ( %) ( %) total scores ( %) ( %) ( , ) ( , ) ( , ) note: the counting data were presented as count (percentage of the total). total scores were presented as median ( %, %). four of the patients ( %) developed mild unilateral ( / patients) and bilateral ( / ) pleural effusion at , , , and days since symptom onset. mediastinal lymphadenopathy was not observed in our study. in this study, serial ct scans obtained in the cohort of jianghan fangcang shelter hospital were analyzed to explore the temporal imaging changes from symptom onset. lung injury in ct demonstrations developed remarkably after symptom onset and peaked in the second week, followed by a slow decrease of total ct scores. remarkably, the median ct score in the st week from symptom onset was higher than those reported previously for covid- patients [ , ] and even sars [ ] patients. the peak of the ct score appeared in the nd week since symptom onset in our cohort, which was consistent with - days reported by pan et al. [ ] and wang et al. [ ] with covid- patients and the nd week reported by ooi et al. [ ] for sars patients, and which was, however, controversial to the rapid lung injury as presented for sars and mers [ , ] . the high median ct score in the st week from symptom onset in our cohort was accompanied by longer median disease duration of ( , ) days and hospitalized ( , ) days, in contrast to the median disease duration of ( , ) days and hospitalized period of ( , ) days reported by wang et al. [ ] and the mean disease duration of ± days and hospitalized period of ± days as reported in pan et al. [ ] . these observations of high initial ct score and longer disease duration might be attributed to the older cohort in our study ( ± years) as compared to the cohort ages of ± years in pan et al. [ ] and ± years in wang et al. [ , ] . the patients reported in sars [ ] and mers [ ] studies were . ± . years old and . ± . years old, respectively, which might have led to a shorter disease course and, hence, the earlier ct score peak when compared to the cases in our cohort. the differences in treatments may be another cause of varying disease course. oral antiviral agents, complaint management and symptomatic treatment were the main treatments in fangcang shelter hospitals [ ] , while oxygen treatment/high-flow nasal cannula, mechanical ventilation, glucocorticoids therapy and emergency extracorporeal membrane oxygenation (ecmo) were commonly used for severe patients in designated hospitals [ , ] . therefore, the similar peak time, despite the higher initial ct score, when compared to the previous reports might have revealed the progressive nature of the disease at the absence of complicated treatments in the fangcang shelter hospitals, which was also evidenced by the slow decrease and persistent high ct scores after the nd week in our study that was suggestive of the slow absorption of the covid- lung lesions. to confirm this speculation, we will review the data from multiple fangcang shelter hospitals for larger sample size and extended monitoring. in this work, predominant ggo was the commonest and earliest imaging finding within the first week after symptom onset, while consolidation became predominant in the second week. predominant ggo and consolidation have also been widely reported in previous studies as the common lung abnormalities within the first weeks after symptom onset in covid- , sars or mers [ , - , , , ] . a recent postmortem pathology study [ ] for a patient with a -day disease course revealed the exudative change in the lung and the absence of severe fibrosis, suggesting diffuse alveolar damage in response to acute lung injury, which was supportive to the observed ct manifestations in the first weeks. the severity and distribution of gray-white patch lesions in the lung in the pathology had explained the predominant ggo in the early stage. the eventual consolidation was considered a result of cellular fibro-myxoid exudates in alveoli [ ] . radiological improvement occurred after the third week. for later stages (≥ weeks), predominant ggo and reticular pattern became common findings, inconsistency with the ct demonstrations of sars [ , , ] or ards [ ] . however, wang et al. [ ] indicated ggo and mixed pattern were the common findings in the later stage of covid- pneumonia, the cause of this difference remaining unclear. particularly, the reticular pattern experienced a persistent increase since the nd week in our study, and the lung involvement of ggo had an obvious decrease in the second week and increased after that. besides, ggo and reticular were the main patterns of later phase ct scans in patients with relatively advanced diseases who had longer illness duration (≥ weeks). elevation of ggo in later stages had also been reported before for both covid- [ ] and sars [ ] . noticeably, patients with predominant reticular pattern in the late stages had significantly higher late-stage ct scores than those with late-stage predominant ggo, implying the appearance of ggo in later stage suggestive of better recovery of the illness [ , ] . in contrast, substantial residual reticular pattern in later stage might indicate the possible development of fibrosis [ ] or secondary organizing pneumonia [ ] . irreversible fibrosis might be too early to label due to uncharted nature history [ ] . our observation raised the necessity of long-term follow-up in chest ct and concomitant functional tests to determine the long-term pulmonary sequelae of covid- [ ] . although all the patients in this cohort matched with the discharge criteria by the end of the study, varying residual lesions were still observed via ct. in light of a recent report of discharged patients with recurrent positive rt-pcr results [ ] , follow up of these patients is also necessary from the perspective of epidemic prevention. the current study was mainly limited as no severe patients were included. in conclusion, our study showed a high median total ct score of within the first week from symptom onset, peaked at nd week, followed by persistence of high levels and a prolonged median disease course. ggo was the predominant pattern in week , consolidation and mixed pattern in nd week, whereas ggo and reticular patterns in later stages (≥ weeks). • a high median total ct score of within the first week from symptom onset, peaked at nd week, followed by persistence of high levels and a prolonged median disease course; • ground-glass opacity (ggo) was the earliest and most frequent finding in week . consolidation and mixed pattern were predominant patterns in nd week. ggo and reticular were the main patterns in the later stages of the disease; • among the patients with ct abnormities obtained within days from the twice rt-pcr test turned negative, ggo and reticular were common during the whole course. covid- : coronavirus disease ; sars-cov- : severe acute respiratory syndrome corona- ; sars: severe acute respiratory syndrome mers: the middle east respiratory syndrome; ggo: ground-glass opacity covid- ) situation reports- care for critically ill patients with covid- world health organization website. who director-general's opening remarks at the media briefing on covid- - china national health commission website national health commission of the people's republic of china. the guidelines for the diagnosis and treatment of -ncov pneumonia severe acute respiratory syndrome: temporal lung changes at thin-section ct in patients coronavirus disease (covid- ): a perspective from china chest ct manifestations of new coronavirus disease (covid- ): a pictorial review radiological findings from patients with covid- pneumonia in wuhan, china: a descriptive study. the lancet infectious diseases temporal changes of ct findings in patients with covid- pneumonia: a longitudinal study novel coronavirus ( -ncov) pneumonia chest ct findings in coronavirus disease- (covid- ): relationship to duration of infection management rules of mobile cabin hospitals therapeutic and triage strategies for novel coronavirus disease in fever clinics. the lancet respiratory medicine fleischner society: glossary of terms for thoracic imaging time course of lung changes on chest ct during recovery from novel coronavirus (covid- ) pneumonia. radiology ct correlation with outcomes in patients with acute middle east respiratory syndrome coronavirus preparing for the most critically ill patients with covid- : the potential role of extracorporeal membrane oxygenation thin-section ct of severe acute respiratory syndrome: evaluation of patients exposed to or with the disease autopsy report in a dead patient with covid- pathological findings of covid- associated with acute respiratory distress syndrome. the lancet respiratory medicine pulmonary sequelae in convalescent patients after severe acute respiratory syndrome: evaluation with thin-section ct high-resolution ct findings of severe acute respiratory syndrome at presentation and after admission acute respiratory distress syndrome: ct abnormalities at long-term follow-up importance of ground-glass attenuation in chronic diffuse infiltrative lung disease: pathologic-ct correlation middle east respiratory syndrome coronavirus (mers-cov) infection: chest ct findings positive rt-pcr test results in patients recovered from covid- the authors have declared that no competing interest exists. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. key: cord- -wadf c i authors: li, yan; yang, zhenlu; ai, tao; wu, shandong; xia, liming title: association of “initial ct” findings with mortality in older patients with coronavirus disease (covid- ) date: - - journal: eur radiol doi: . /s - - - sha: doc_id: cord_uid: wadf c i objectives: to investigate the association of chest ct findings with mortality in clinical management of older patients. methods: from january to february , , older patients (≥ years) who had undergone chest ct scans (“initial ct”) on admission were enrolled. manifestation and ct score were compared between the death group and the survival group. in each group, patients were sub-grouped based on the time interval between symptom onset and the “initial ct” scan: subgroup (interval ≤ days), subgroup (interval between and days), and subgroup (interval > days). adjusted roc curve after adjustment for age and gender was applied. results: consolidations on ct images were more common in the death group (n = ) than in the survival group (n = ) ( . % vs . %, p < . ). for subgroup and subgroup , a higher mean ct score was found for the death group ( . ± . vs . ± . , p < . ; . ± . vs . ± . , p = . , respectively) and no significant difference of ct score was identified with respect to subgroup (p = . ). in subgroup , ct score of . with a sensitivity of . % and a specificity of . % for the prediction of mortality was an optimal cutoff value, with an adjusted auc of . . in subgroup , ct score of . with a sensitivity of . % and a specificity of . % for the prediction of mortality was an optimal cutoff value, with an adjusted auc of . . conclusions: “initial ct” scores may be useful to speculate prognosis and stratify patients. severe manifestation on ct at an early stage may indicate poor prognosis for older patients with covid- . key points: • severe manifestation on ct at an early stage may indicate poor prognosis for older patients with covid- . • radiologists should pay attention to the time interval between symptom onsets and ct scans of patients with covid- . • consolidations on ct images were more common in death patients than in survival patients. the novel coronavirus infection initially breaks out in wuhan, china, and, as of april , has spread to more than countries and regions in the whole world. the disease caused by the novel coronavirus (sars-cov- ) is now named coronavirus disease (covid- ) by the world health organization (who). as of april , , there are accumulative , , confirmed cases and , deaths in the whole world, with an average mortality of about . % [ ] , which is lower than that of severe acute respiratory syndrome (sars) [ ] and middle east respiratory syndrome (mers) [ ] . however, the mortality is extremely high in critically ill patients with covid- ( %) [ ] , and older patients with comorbidities are at increased risk of developing critical illness and death [ ] [ ] [ ] . the severity of covid- poses great strain on critical care resources in hospitals, especially when they are not adequately staffed or resourced [ ] . therefore, stratifying the severity of older patients with or without comorbidities on admission is beneficial to allocate medical resources accordingly. during the outbreak of covid- , in clinical practice, auscultation is limited to identify pulmonary lesions due to the isolation of protective clothing. although radiation dose [ , ] needs to be considered, chest ct as reported previously plays an important role in disease diagnosis, monitoring, severity stratification, and evaluation of treatment response in patients with covid- [ , ] , which goes beyond the ability of reverse transcription polymerase chain reaction (rt-pcr). in this single-center study, aiming to further identify the value of chest ct in clinical management of covid- , we evaluated the association of initial chest ct findings obtained at admission with severity and clinical outcomes in older patients with covid- . this retrospective single-center study was approved by the ethics commission of tongji hospital and written informed consent was waived due to emergence of epidemic outbreak. tongji hospital is the largest general hospital in wuhan and has been designated to take care the treatment of severe covid- patients by the chinese government since late january . we retrospectively reviewed older (≥ years old) patients with confirmed infection of sars-cov- and admitted to tongji hospital between january and february , . all patients were confirmed with positive results of rt-pcr in throat swab specimens. of the patients, as of march , , died of covid- , recovered and were discharged from the hospital, and other patients were still in hospitalization. we finally enrolled patients ( died patients and survival patients) who had undergone chest ct scans before admitting to the hospital or within h of admission (fig. ) . we defined these ct scans as "initial ct" scans. the survival patients were discharged before march , , based on the criterion of the diagnosis and treatment program (trial th version) published by the national health commission of the people's republic of china [ ] . the clinical characteristics of the older patients were collected from electronic medical records. a ct score was calculated using chest ct for each patient. according to the prognosis, we divided the patients into a survival group and a death group, and the ct scores were compared between the two groups. chest ct images were obtained using the protocol described in a previously reported study [ ] . two certified radiologists (with and years of experience in interpreting thoracic imaging, respectively) were blinded to patient outcomes and reviewed all chest ct images by consensus. ct findings were graded on a -point scale focused on predominant ct patterns and based on the classification system as previously described [ ] : , normal attenuation; , ground-glass opacity (ggo); , consolidation. because this study was focused on evaluating the association between early ct features corresponding to diffuse alveolar damage at early stage and prognosis, ichikado k's scale points , , and [ ] , which are associated with the late proliferative or fibrotic phase, were not used. ggo was defined as increasing density of attenuation that did not conceal the underlying vessels. consolidation was defined as increasing density of attenuation that concealed vessels. in addition, the severity of each lung lobe (left upper/lower lobe and right upper/middle/lower lobe) was scored on the basis of predominant lesion extent in the corresponding lobe, as ( %), ( - %), ( - %), ( - %), and ( - %) [ ] . the -point scale of severity of lung lobe was multiplied by the -point scale of ct findings, generating an overall score termed as "ct score." the ct score of each lobe ranged from to , and the finally obtained total cumulative score values of all lung lobes ranged from to . in the survival (n = ) and death (n = ) groups, the patients were sub-grouped based on the time interval between symptom onset and the "initial ct" scan: subgroup (interval ≤ days), subgroup (interval between and days), and subgroup (interval > days). the software spss (ibm spss statistics, version . . ), graphpad prism (version . ), and r (rstudio, version . . ) were used for statistical analysis. continuous variables were expressed as mean ± standard deviation (sd) or median and interquartile range (iqr). categorical variables were reported as counts and frequencies in each category. the proportion rates of clinical characteristics in the two groups were compared by the chi-square test. the mean ct scores of the "initial ct" on admission between the survival group and death group in total, and on the basis of each subgroup, were compared by student's t test. a receiver operating characteristic (roc) curve with an area under the roc curve (auc) was used to analyze the performance of "initial ct" in predicting outcomes, and an optimal cutoff value with maximum sensitivity and specificity was obtained. adjusted roc curve was applied to exclude the influence of confounding factors of age and gender. p value less than . (two-tailed) was considered statistically significant. epidemiologically, in our retrospective cohort, all patients (mean age, . ± . years old; . % are men) were local residents of wuhan city; patients acknowledged a history of contact with wuhan's huanan seafood market; patients had familial cluster exposure; and patient was a medical staff. there was no significant difference in age distribution between the death group and survival group ( . ± . vs . ± . , p = . ). the proportion of men was significantly higher in the death group than the survival group ( . % vs . %, p = . ) ( table ). in total, / ( . %) patients were having comorbidities and / ( . %) suffered from hypertension. in reviewed comorbidities, the proportion rate of chronic renal disease in the death group was statistically higher (p = . ) than that in the survival group. the median time interval of symptom onset to "initial ct" scan was days (iqr, . - ). there was no significant difference (p = . ) in the time interval of symptom onset and "initial ct" scan on admission between the two groups. the median hospital stay in the survival group was significantly longer than that in the death group ( days vs . days, p < . ). the most common clinical manifestations of patients in this study were fever ( / [ . %]) and cough ( / [ . %]). the proportion of dyspnea in the death group was significantly higher than that in the survival group (p = . ). there was no significant difference for other symptoms like fever, cough, chest tightness, weakness, and diarrhea. all patients received isolation and antiviral agents and oxygen therapy (including nasal oxygen breath and mask oxygen inhalation). most patients ( %) were empirically treated with antibiotics and glucocorticoids. some patients ( %) also received immunoglobulin treatment. in the death group, / ( . %) of patients required non-invasive mechanical ventilation, / ( . %) patients required invasive mechanical ventilation, and patient required extracorporeal membrane oxygenation (ecmo) treatment. in the survival group, patient required non-invasive mechanical ventilation, and no patients received invasive mechanical ventilation or ecmo. of the patients, underwent chest ct scans before admission, and underwent ct scans within h after admission. according to the subgrouping rules mentioned earlier, in the death group, there were patients in subgroup , patients in subgroup , and patients in subgroup . in the survival group, there were patients in subgroup , patients in subgroup , and patients in subgroup . ggo and consolidation are two main signs of covid- lesions on chest ct images with or without vascular enlargement, interlobular septal thickening, air bronchogram sign, and air trapping, and the lesions were predominantly peripheral and subpleural. on ct images, of the total lobes were not involved in patients of the survival group, and of the total lobes were not involved in patients of the death group. a total of . % ( / ) lobes involved in the death group and % ( / ) lobes involved in the survival group showed predominantly consolidation. consolidations on ct images were more common in the death group than in the survival group (p < . ) (figs. and ) . pleural effusion was found in ct images of patients in the death group. no mediastinal lymphadenopathy was seen on chest ct images. the mean ct score was significantly higher in the death group than in the survival group ( . ± . vs . ± . , p < . ). for subgroup and subgroup , a higher mean ct score was found for the death group ( . ± . vs . ± . , p < . ; . ± . vs . ± . , p = . , respectively) and no significant difference of ct score was identified with respect to subgroup ( . ± . vs . ± . , p = . ) (fig. ) . from roc curve analysis, in subgroup , ct score of . with a sensitivity of . % and a specificity of . % for the prediction of mortality was an optimal cutoff value, with an area under the curve (auc) of . ( % ci . - . ) and adjusted auc of . ( % ci . - . ). in subgroup , ct score of . with a sensitivity of . % and a specificity of . % for the prediction of mortality was an optimal cutoff value, with an auc of . ( % ci . - . ) and adjusted auc of . ( % ci . - . ) (fig. ). in clinical practice, clinicians with isolation of protective clothing cannot auscultate and no frequent ct scans are performed for patients with covid- . thus, using information of "initial ct" scan on admission to assess and predict severity of the disease is useful and valuable for planning treatment strategies and evaluating prognosis. in this study, the ct score calculated from the "initial ct" scan can effectively predict mortality in older patients with covid- , showing a sensitivity of . %, a specificity of . %, and an adjusted auc value of . (cutoff is . ), when the "initial ct" scans were done within days after symptom onsets; the corresponding performance changes to a sensitivity of . %, a specificity of . %, and an adjusted auc of . (cutoff is . ) when the time interval was to days between symptom onsets and ct scan. from previous studies, it has been shown that older age, gender of male, and co-existing comorbidities might be risk factors for the poor prognosis of covid- patients [ ] [ ] [ ] ] . in this single-center study on older patients, the proportion of men was significantly higher in the death group than in the survival group (p = . ), which was consistent with what was observed in a previous study [ ] . however, it is important to notice that there was no significant difference in age distribution between the death group and survival group. in total, the proportion of severe symptom onsets (dyspnea) and co-existence with chronic renal disease was higher in the death group than in the survival group. two main ct signs of covid- lesions are ggo and consolidation, which are similar to the ct features for sars and mers, and the lesions were predominantly peripheral and subpleural, consistent with previous studies [ , , , , , ] . consolidations were more common in the death group than in the survival group. these ct findings may correspond to viscous secretions seeping through the pulmonary alveoli described in the autopsy report [ ] and suggest acute respiratory distress syndrome (ards). ards characterized by an acute, diffuse, inflammatory lung injury, leading to an increased alveolar capillary permeability, is a strong predictor of mortality, reflecting the severity of respiratory failures [ ] . our results supported the investigation that chest ct is possible to predict clinical course of ards [ , ] . in this study, the overall ct score was based on the severity of air-space abnormality and its distribution. the mean ct score of chest ct images in the death group was significantly higher than that in the survival group. however, as previously reported [ ] , serial ct showed disease changes, and the most common pattern of evolution was initial progression to a peak level, followed by improvement. our results showed that the "initial ct" score changes with respect to different time intervals between symptom onsets and ct scans. in subgroup and subgroup , patients underwent ct scans within days after symptom onsets, where the mean score of "initial ct" was statistically higher in the death group than in the survival group. this suggests that severe manifestation on ct at an early stage may indicate poor prognosis. in subgroup , the time interval between symptom onsets and "initial ct" was longer than days, where no significant difference was identified between the death group and survival group. according to fig. , in either the death or survival group, ct score of chest ct in subgroup was higher (though not statistically significant) than that in sub-group and subgroup . this may indicate a progression course of - days after symptom onsets. however, this finding needs further evaluation. this study had several limitations. first, we compared the scores of "initial ct" between the death and survival groups in terms of subgroups, which does not account for individual variations. second, due to the popularity of rt-pcr, many patients would not undergo ct scans for diagnosis before admission; thus, our study only included a relatively small number of cases who had initial ct scans acquired. third, the ct scores were evaluated on the consensus of two readers rather than an independent reading, and there was a lack of assessment on the interobserver agreement. fourth, because of the retrospective nature of the study, there is an inclusion bias, though we tried to avoid and such inclusion bias is inevitable, and our results should be carefully interpreted. in summary, in this single-center study, we observed the prognosis implication of chest ct scores calculated by determining the extents of ggo and consolidation. we found that "initial ct" scores may be useful to stratify patients, which has a potentially important utility in the current global medical situation, especially for rational allocation of medical resources. however, a clear identification of the time interval between symptom onsets and "initial ct" is crucial. further studies may include evaluation on a larger cohort and exploring the effects of this semi-quantitative method in monitoring disease progression and in assessing treatment responses. (in the survival or death group, patients were sub-grouped based on the interval time between symptom onset and the initial ct scan: subgroup (interval ≤ days after symptom onset), subgroup (interval between and days), and subgroup (interval > days) funding information the authors state that this work has not received any funding. guarantor the scientific guarantor of this publication is prof. liming xia. the authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. no complex statistical methods were necessary for this paper. informed consent written informed consent was waived by the institutional review board. ethical approval institutional review board approval was obtained. study subjects or cohorts overlap no study subjects or cohorts have been previously reported before. • retrospective • diagnostic or prognostic study • performed at one institution world health organization website ( ) coronavirus disease (covid- ) situation reports. world health organization summary of probable sars cases with onset of illness from roc curve analysis of the ct scores including crude roc curve and adjusted roc curve after the adjustment for age and gender in the full cohort and in subgroup , subgroup , and subgroup for prediction of mortality middle east respiratory syndrome coronavirus (mers-cov). world health organization clinical course and outcomes of critically ill patients with sars-cov- pneumonia in wuhan, china: a single-centered, retrospective, observational study epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study evaluating the accuracy of different respiratory specimens in the laboratory diagnosis and monitoring the viral shedding of -ncov infections the role of ct for covid- patient's management remains poorly defined recommendation of low-dose ct in the detection and management of covid- correlation of chest ct and rt-pcr testing in coronavirus disease (covid- ) in china: a report of cases coronavirus disease (covid- ): role of chest ct in diagnosis and management national health commission of the people's republic of china website ( ) diagnosis and treatment of novel coronavirus infection (trial version ). national health commission of the people's republic of china prediction of prognosis for acute respiratory distress syndrome with thin-section ct: validation in cases ct imaging features of novel coronavirus ( -ncov). radiology radiological findings from patients with covid- pneumonia in wuhan, china: a descriptive study clinical features of patients infected with novel coronavirus in wuhan initial ct findings and temporal changes in patients with the novel coronavirus pneumonia ( -ncov): a study of patients in wuhan, china imaging and clinical features of patients with novel coronavirus sars-cov- autopsy report of patients with novel coronavirus pneumonia acute respiratory distress syndrome: advances in diagnosis and treatment a predictive factor for patients with acute respiratory distress syndrome: ct lung volumetry of the well-aerated region as an automated method publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -jton oig authors: jové-blanco, a.; solís-garcía, g.; torres-soblechero, l.; escobar-castellanos, m.; mora-capín, a.; rivas-garcía, a.; castro-rodríguez, c.; marañón, r. title: video discharge instructions for pediatric gastroenteritis in an emergency department: a randomized, controlled trial date: - - journal: eur j pediatr doi: . /s - - -w sha: doc_id: cord_uid: jton oig the aim was to evaluate if the addition of video discharge instructions (vdis) to usual verbal information improved the comprehension of information provided to caregivers of patients who consult for acute gastroenteritis (age). we conducted an open-label, parallel, randomized trial, enrolling patients who consulted for age at a tertiary hospital. first, caregivers answered a written test concerning age characteristics and management. they were randomly allocated to a control group, which received the usual verbal instructions, or to an intervention group, which additionally received vdi. after discharge, caregivers were contacted by telephone and answered the same test, satisfaction questions, and follow-up information. from september to march , patients were randomized, completed follow-up. the mean score was . (sd . ) over points in the initial test and . (sd . ) in the follow-up test. patients in the intervention group had a greater improvement ( . points, sd . ) than those in the control group ( . points, sd . , p < . ). in the follow-up test, . % in the intervention group and . % in the control group answered all questions correctly (p < . ). there were no significant differences in return visits. caregivers gave high satisfaction scores regardless of the allocation group. conclusion: video instructions improve caregivers’ understanding of discharge information. trial registration: [nct , retrospectively registered july , ]. electronic supplementary material: the online version of this article ( . /s - - -w) contains supplementary material, which is available to authorized users. acute gastroenteritis (age) is a frequent cause of consultation in the pediatric emergency department (ped) with a subsequent high healthcare spending [ ] . age has usually a selflimited and favorable course; therefore, it is essential to provide adequate discharge instructions in order to improve treatment adherence and avoid unnecessary return visits. however, providing effective discharge information in the ped can be a challenging task due to the hurried environment [ ] . discharge instructions are a key element in patients' ped aftercare management. both patients and caregivers must understand the diagnosis, the treatment received, and when and why they should be reevaluated in order to diminish unnecessary return visits and improve caregivers' satisfaction [ ] . poor comprehension of discharge instructions leads to incorrect treatment after discharge, increased ped readmissions, and a reduction of caregivers' satisfaction. patient-centered care is based on effective communication, which is often overestimated by healthcare providers [ ] . comprehension of discharge instructions depends on caregivers' health literacy level, complexity of the instructions given, time constraints in ped or the communication skills of the healthcare provider [ , ] . improving the comprehension of discharge information has been the subject of multiple studies, concluding that simple, straightforward, short, and standardized instructions improve caregivers' comprehension [ ] [ ] [ ] . different strategies have been used to ameliorate discharge instructions. the most common formats are verbal, written, and video instructions. one of the disadvantages of verbal instructions is that information can be incomplete and that in this case comprehension depends mostly on the healthcare provider communication skills [ , ] . instead, written instructions are frequently left unread by caregivers [ ] and mostly overestimate the caregivers' health literacy level [ ] . the use of video discharge instructions (vdis) has proved to be a useful strategy to provide clear, simple, and concise information independently of the patients' health literacy level or communication skills of the healthcare provider [ , , ] . demonstrations and illustrations can be included, being effective tools in patient education [ ] . vdi must provide key points which tackle diagnosis, management, and follow-up information. in order to keep caregivers' and patients' focus and attention, the video's length must be short (less than min) [ ] . previous studies [ , ] suggest that the use of visual aid could be incorporated to clinical practice as a communication and educational element. this study was designed to evaluate if the addition of vdi to usual verbal information improved the comprehension of the information provided to caregivers of patients who consult in ped for acute gastroenteritis. as secondary objectives, we aimed to evaluate if video instructions improved satisfaction with the information received and decreased return visits. the study was an open-label, parallel, randomized trial which took place between june and march in the ped of a third-level spanish hospital which receives , emergencies annually. up to eligible patients were enrolled every shift when one of the main investigators was present. simple, : randomization was performed using r software [ ] . patients were randomly assigned to a group by opening sequentially numbered paper envelopes which contained the group in which the patient would be allocated, ensuring thus allocation concealment. we enrolled patients from month to years who met espghan criteria for age: decreased stool consistency and/or increased evacuation frequency during a period < days, associated or not to fever or vomiting [ ] . patients were eligible if they were accompanied by a usual caregiver; if two caregivers were present, they could decide who would participate. we excluded patients with severe dehydration, chronic comorbidities needing special instructions (i.e., neurologic, respiratory, or cardiologic), those whose caregivers were not able to communicate in spanish, and those who were admitted for hospitalization. written informed consent was provided before trial enrollment. the trial was developed in three steps: an initial written test, an information phase, and a second follow-up test after discharge. . first step. after enrollment, all patients filled-in a written test before discharge, which consisted of questions about age: etiology, treatment, dehydration signs, after-care diet, and reasons to reconsult (appendix i). each correct answer scored point. in addition, demographic and clinical characteristics of the age episode were collected: gender and age of the patient, siblings, previous age episodes, age symptoms (fever, diarrhea, and vomiting), gorelick score [ ] , caregiver filling in the questionnaire and academic level, as well as length of stay in the ped. academic level was categorized as primary education, secondary education, technical qualification, and university studies. length of stay in the ped included both waiting time and time consumed by the verbal and video instructions. . second step. enrolled subjects were randomly assigned to the control or intervention group. in the first group of subjects (control group), caregivers received, after completing the test and prior to discharge, the usual verbal information and recommendations about age following the guidelines of the spanish society of pediatric emergencies [ ] . in the second group (intervention group), patients were shown a short -min video providing the same information about age, in addition to verbal instructions. in both groups, instructions were given by one of the main investigators in order to provide homogeneous and consistent information. both sets of instructions explicitly included the information that had been previously asked in the test. all patients additionally received a discharge report which included instructions concerning aftercare treatment. . third step. after discharge, all caregivers were contacted by telephone and were asked the same questions from the initial test. the questionnaire had to be completed by the same caregiver as in step . this test also included questions about subsequent visits to either emergency units or outpatient pediatric clinics, satisfaction with the information (caregivers were asked to evaluate information in a score - ) and a question about whether they perceived video instructions as potentially useful tool or not. all questions were asked to all patients independently of the group they had been allocated to. the first telephonic contact was established h after discharge. if investigators were not able to contact them at first, telephonic contact would be repeated every - days up to a total of days before excluding them and considering them as lost in follow-up. the primary efficacy endpoint was the difference between the score obtained in the initial test and the follow-up test. secondary efficacy assessments included the number of caregivers who got a % score in the follow-up test, the rate of return visits and caregivers' satisfaction. no post hoc analysis were made. the trial was approved by the hospital's institutional review board and registered at clinicaltrials.gov database as nct . no financial aid was involved in the study. no changes were made in the protocol after the start of the study. all authors are responsible for adherence to the protocol and veracity of the data. the sample size was calculated to provide a statistical power of % at an alpha level of % to detect a two-tailed difference of . points between the two groups. we calculated that with an estimated loss rate of % of patients between randomization and follow-up test, assuming a -point variance in test results based on previous studies [ ] , this statistical power would be reached by enrolling patients in each group. all randomized patients who completed both tests were included in the primary endpoint analysis as part of the group in which they were randomized, following intention-to-treat principle. patients lost before completion of the second test were not included as it was not possible to calculate the primary endpoints. the differences in test points and satisfaction between groups were analyzed using student's t test, and the differences in proportions were analyzed using chi-square test. statistical significance was set at p < . . analysis was performed using rv . . and spss. statistical software. from september to march , patients with age were assessed for eligibility. of the patients included in the study, patients were randomized to the standard verbal information group (control group) and patients to the video instructions group (intervention group) (fig. ) . after discharge, patients ( %) in the control group and patients ( %) in the intervention group were contacted by telephone and were included in the follow-up analysis. the baseline characteristics of each group are provided in table . median age was years (iqr - ) and patients were male ( . %). only patients ( . %) presented with dehydration. of these dehydrations, ( . %) were mild (gorelick < ) and ( %) were moderate (gorelick - ). the median global score in the pre-allocation written test was . over the -total score (sd . ). the mean time elapse from discharge to step was . days (sd . ) without differences between groups (p = . ). analyzing the difference in scores obtained in step and step , patients in the intervention group had a greater improvement ( . points, sd . ) than those in the control group ( . points, sd . ,p < . ). scores for both groups in each test are summarized in fig. . in step , there was a difference of . points between allocation groups in favor of the intervention group, which was not statistically significant. the mean score for all patients was . (sd . ) over a total score of points in step and . (sd . ) in step . globally, only caregivers ( . %, one of each group) answered over questions correctly in step . in the followup test, up to caregivers ( . %) answered all questions correctly: caregivers ( . %) belonged to the intervention group and caregivers ( . %) to the control group (p < . ). there were no differences in the test scores in relation to previous age episodes (p = . ), patients' sex (p = . ) or age (p = . ), caregivers' educational level (p = . ), or to whether the mother, father, or grandparent was participating in the study (p = . ). the question that most caregivers failed to get right, in both moments of the study and both allocation groups, was "what kind of diet should children with age receive?" the frequency of return visits was . % ( ) in the control group. of these patients, revisited ped and were attended in a primary healthcare center. the frequency of return visits in the intervention group was . % ( ): six patients were attended in ped and patients in a primary healthcare center. of them, patients (one in each group) needed intravenous fluid rehydration and (in the control group) needed oral rehydration treatment. only one patient (in the intervention group) needed subsequent admission, but the cause was not age but an accidental intake of a caustic agent. there was no significant difference in the frequency of return visits, globally (p = . ) nor specifically emergency visits (p = . ). regarding caregivers' perceived satisfaction level with information, caregivers gave high scores regardless of the allocation group (control group . , sd . , vs intervention group . , sd . ,p = . ). more caregivers thought that video instructions could be useful in the video instructions group than in the standard verbal information group: caregivers ( . %) in the intervention group considered that videos could be useful while only caregivers in the control group considered so ( . %, p = . ). the present study analyzes the effect of the addition of discharge video instructions to verbal information in ped. we observed that when caregivers received vdi in addition to verbal instructions, their performance in a test that measured age knowledge improved with respect to those who only received verbal instructions. these results are consistent to those obtained by bloch [ ] , where the addition of video instructions about age, fever, and asthma symptoms improved caregivers' knowledge after fig. flow diagram discharge. the use vdi has been extended to other aspects such as providing information about appropriate antibiotic use [ ] , fever and head injuries [ ] , or sprains and lacerations [ ] , improving the comprehension of discharge information in the short and long term as well as caregivers' satisfaction with the information. alternatively, wood [ ] pointed out that the benefit of vdi depends on the disease, observing a greater improvement in caregivers' knowledge when they received vdi for gastroenteritis than for fever/bronchiolitis. although a single clinical trial regarding acute media otitis found no differences between paper and video instructions [ ] , most studies [ , [ ] [ ] [ ] agree that vdi minimize factors [ ] . therefore, the use of short vdi seems a useful strategy to provide clear and standardized discharge instructions in ped, which has been highlighted as a key path to improve quality of care for children and caregivers [ ] . interestingly, ismail et al. observed that families with lower educational level (less than high school education) could be most benefitted by the addition of vdi to standardized verbal instructions [ ] . we did not find such differences, probably due to having a small percentage of caregivers with low educational level. a previous systematic review also found no differences in ped outcomes and costs depending on health literacy [ ] . as a secondary endpoint, we aimed to compare the frequency of return visits between groups. we did not find differences, probably due to the sample size not being calculated for this outcome: in order to find a difference between and % rates of return visits, we would have needed to randomize patients, more than three times more the sample size we used for our primary outcome. a previous before-and-after study [ ] found that implementing a set of clinical practices which included standardized (but not video) instructions would reduce subsequent visits to ped. however, this study included more measures such as identification of risk factors, management plans, feedback systems, and planned visits to clinics. alternatively, a similar before-and-after study found no differences in return visits in the period after computergenerated discharge instructions were implemented [ ] so the direct effect of these instructions cannot be inferred. we also aimed to measure caregivers perceived satisfaction with the information received. previous studies comparing video instructions to usual information show that vdi may be perceived as more helpful [ ] . in our study, we did not find significant satisfaction differences, with very high satisfaction in both groups. however, we found that caregivers who received video instructions were more likely to think that vdi could be helpful in the understanding of their children's disease. this may be a sign of lack of familiarity with video instructions from the parents allocated to the control group. given the high satisfaction with video instructions in the intervention group, as a future quality improvement project they will be available in the hospital's web page for all caregivers to watch at home. our study has some limitations. it is a single-center design, and we only enrolled patients who consulted during working shifts of one of the investigators; although this included patients in different morning, evening and night shifts as well as those who attended ped in working days and holidays, it may have led to selection bias. when both caregivers were present, it is probable that the most qualified of them was the one who decided to participate. due to coronavirus pandemic situation and the reorganization of patient care [ ] , we were forced to stop patients' recruitment, hence the smaller sample analyzed. even though the allocation was random, there was a difference of . point between the scores obtained in step in favor of the control group. in step , we did not find differences between the scores obtained by each group, probably due to these differences found in step . finally, we did not enroll any patients with severe dehydration, which could be the one of the populations whose caregivers are most benefited by detailed information. as a conclusion, we have found that in our population of pediatric patients with acute gastroenteritis, short video instructions improve caregiver understanding of the information given. satisfaction with the information provided is high and return visits are not frequent. author contributions ajb, gsg, and rm were responsible for the trial design and wrote the trial protocol. ajb, gsg, lts, and mec enrolled the patients and collected the data. gsg analyzed the data. ajb, gsg, lts, and ccr wrote the draft of the manuscript, which was critically revised by rm, mec, arg, and amc. the manuscript has not been published nor is under consideration for publication in any other journal. gastroenteritis aguda: coste de una causa de ingreso potencialmente evitable mobile and web-based education: delivering emergency department discharge and aftercare instructions using video discharge instructions as an adjunct to standard written instructions improved caregivers' understanding of their child's emergency department visit, plan, and follow-up: a randomized controlled trial reading ability of parents compared with reading level of pediatric patient education materials emergency department patient literacy and the readability of patient-directed materials emergency department discharge instructions and patient literacy: a problem of disparity role of diagnosis-specific information sheets in parents' understanding of emergency department discharge instructions standardized instructions: do they improve communication of discharge information from the emergency department? do parents of discharged pediatric emergency department patients read discharge instructions? evidence-based practice: video-discharge instructions in the pediatric emergency department the effectiveness of mobile discharge instruction videos (mdivs) in communicating discharge instructions to patients with lacerations or sprains animated video vs pamphlet: comparing the success of educating parents about proper antibiotic use randomizr: easy-to-use tools for common forms of random assignment and sampling european society for pediatric gastroenterology, hepatology, and nutrition, european society for pediatric infectious diseases ( ) european society for pediatric gastroenterology, hepatology, and nutrition/european society for pediatric infectious diseases evidence-based guidelines for the management of acute gastroenteritis in children in europe: update validity and reliability of clinical signs in the diagnosis of dehydration in children. pediatrics. :e . sociedad española de urgencias de pediatría. hojas informativas para padres, gastroenteritis aguda impact of video discharge instructions for pediatric fever and closed head injury from the emergency department video discharge instructions for acute otitis media in children: a randomized controlled open-label trial a framework of pediatric hospital discharge care informed by legislation, research, and practice health literacy and emergency department outcomes: a systematic review implementation of clinical practices to reduce return visits within h to a paediatric emergency department the effect of diagnosis-specific computerized discharge instructions on -hour return visits to the pediatric emergency department children's healthcare during corona virus disease pandemic: the italian experience conflict of interest the authors declare that they have no conflict of interest.informed consent informed consent was obtained from all individual participants included in the study. key: cord- - qn d authors: snyder, n.l.; seeberger, p.h.; mukosera, g.t.; held, e.m.k. title: . technology-enabled synthesis of carbohydrates date: - - journal: comprehensive organic synthesis ii doi: . /b - - - - . - sha: doc_id: cord_uid: qn d automated solid-phase oligosaccharide synthesis has revolutionized the emerging field of glycomics. the automation process, in which selectively functionalized monosaccharide building blocks are added sequentially to a growing oligosaccharide chain connected via an inert linker to a solid support, has been used to prepare a number of biologically relevant oligosaccharide-based constructs in record time and on scales that would have been impossible using standard solution-phase synthetic techniques. this review highlights recent developments in automated solid-phase oligosaccharide synthesis including engineering advancements that have led to the design of a fully automated platform, new and improved linker strategies that have broadened the scope of the chemical reactions that can be used in automation, and recent developments in the synthesis of functionalized monosaccharide building blocks. the automated solid-phase synthesis of biologically relevant carbohydrate constructs including bacterial and viral antigens, cancer antigens, vaccine candidates, and n-linked core oligosaccharides is also presented. nucleic acids, proteins, and glycoconjugates play critical roles in a number of important signal transduction pathways. the development of rapid and efficient automated platforms for the synthesis of nucleic acids and peptides from their monomeric building blocks (figure (a) and (b) ) has led to a better understanding of the fundamental interactions these biomolecules play in important biological processes. as a result, the fields of genomics and proteomics have grown exponentially with the development of new therapeutic strategies for disease prevention and treatment. until recently, the lack of a general and accessible approach for the construction of oligosaccharides meant that only specialized research laboratories were capable of accessing defined glycoconjugates. this has slowed the pace of research in this area and in turn, our understanding of the diverse roles of these compounds in nature. the major challenge with developing a general and accessible approach for the synthesis of oligosaccharides is inherent in the reaction products. the linear phosphodiester and amide bond linkages required for nucleic acid and peptide synthesis are easier to generate because the individual building blocks lack significant steric hindrance and the newly formed bonds are nonstereogenic. in contrast, the synthesis of oligosaccharides, which can be linear or branched, often involves more sterically encumbered building blocks and the newly formed bond is part of a stereogenic center. in order to be useful the reaction must generate the desired linkage with high selectivity. the development of a first-generation automated solid-phase oligosaccharide synthesizer by seeberger and coworkers led to the first reported automated synthesis of three linear , -a-linked mannan oligosaccharides and a branched phytoalexin elicitor b-glucan ( figure ). the synthesis of these glycoconjugates, which play important roles in the immune response to pathogenic fungi such as candida albicans, began what would become a new chapter in the preparation of glycoconjugates for biological evaluation. since then, automation has proven to be vastly beneficial. additional bacterial antigens, cancer antigens, vaccine candidates, and n-linked core oligosaccharides are just a few of the glycoconjugates that have been rapidly synthesized using automation. moreover, these glycoconjugates have been synthesized on scales that would have been impossible using standard solution-phase synthetic techniques. the goal of this chapter is to review the historical aspects of solid-phase oligosaccharide synthesis as well as recent developments including engineering advancements that have recently led to the design of a fully automated platform, and new and improved chemistries that have broadened the scope of the reactions that can be used in automation. the automated solid-phase synthesis of several carbohydrate constructs including bacterial and viral antigens, cancer antigens, vaccine candidates, and n-linked core oligosaccharides is also presented. automated solid-phase oligosaccharide synthesis uses an automated synthesizer to make glycosidic linkages in an analogous process to the way dna synthesizers generate phosphodiester linkages and peptide synthesizers generate peptide linkages. the general process is illustrated in figure . selectively functionalized monosaccharide building blocks containing temporary and permanent protecting groups (commonly referred to as donors) serve as electrophiles and are added sequentially to a growing oligosaccharide chain, which serves as a nucleophile (or acceptor). the acceptor is connected via an inert linker to a solid support that is generally insoluble in organic solvents. each glycosidic linkage is made by activating the appropriately functionalized monosaccharide building block (donor) in the presence of the growing nucleophilic oligosaccharide (acceptor) to couple to the two molecules. after each glycosylation reaction, the growing oligosaccharide is washed, the appropriate temporary protecting groups are removed to expose the next functional group for coupling, and the process is repeated until the desired oligosaccharide has been synthesized. the oligosaccharide is then removed from the solid support, purified if necessary, and the remaining temporary and permanent protecting groups are removed. the oligosaccharide can then be functionalized for further study. the key features of the automated process, shown in figure , include the automation platform, an insoluble solid support, an inert linker, and selectively functionalized carbohydrate building blocks containing temporary and permanent protecting groups. developments in each of these areas have had a significant impact on the evolution of automated solid-phase oligosaccharide synthesis. the first automated synthetic platform for automated solid-phase oligosaccharide synthesis was developed by seeberger and coworkers and based on a modified applied biosystems peptide synthesizer, the abi . this system was chosen as a prototype because it was affordable and commercially available, it could accommodate up to nine different reagents/building blocks at one time, and required minimal modifications, namely a custom made jacketed reaction vessel connected to a variable cryostat to allow for controlled cooling of the reaction mixture. as a prototype, the abi synthesizer played a critical role in the development of automated oligosaccharide synthesis. the synthesizer was reliable, and solvent delivery and waste removal were relatively efficient. in addition, reaction mixing, which was achieved by agitation of the reaction vessel, was effective in producing a uniform heterogeneous solution. however, the instrument, which was designed for peptide synthesis, had several shortcomings. reagent delivery, which was achieved via solenoid valves, was imprecise. therefore, the delivery of small reagent volumes or the delivery of reagents at a controlled delivery rate was difficult to achieve. in addition, the system could not be modified to accommodate additional reagents limiting the number of different glycosylation reactions that could be performed in a single run. finally, temperature control required manual adjustment of the cryostat therefore, necessitating the continuous presence of an operator. for these reasons, the seeberger group focused their efforts on the development of a new fully automated solid-phase oligosaccharide synthesizer. in order to provide a more efficient platform for automated solid-phase oligosaccharide synthesis, seeberger and coworkers collaborated with ancora pharmaceuticals to develop the first fully automated solid-phase oligosaccharide synthesizer. the new design, introduced in , addressed the shortcomings of the modified abi peptide synthesizer. syringe pump technology for precise reagent delivery was combined with solenoid valves for rapid pressure-driven washing steps. the system also included vessels capable of delivering up to reagents building blocks at one time. in addition, a mechanical controller was designed to serve as an interface between the instrument and a personal computer, which provided full control of the system including temperature modulation. the instrument is capable of reaching temperatures as low as À c via adjustable cryostat and as high as c via heating block. demchenko and co-workers recently reported on the first modified hplc for automated solid-phase oligosaccharide synthesis. their experimental setup, which includes an unmodified three-headed pump hplc system and an onboard variable range uv detector, uses a standard chromatography column packed with preswelled polymer resin. the benefit of this system is that it employs a commercially available hplc found in almost any synthetic or analytical laboratory, and the programming can be accomplished using standard hplc operating software. demchenko's hplc-based solid-phase oligosaccharide synthesizer is the first automated system that uses real-time uv-vis reaction monitoring and shows significant promise as an emerging technology. however, one significant disadvantage is the limited number of reagents/building blocks the system can accommodate without significant modification or the continuous presence of an operator. commercially available nonsoluble polystyrene solid supports such as merrifield resin and tentagel ( figure ) are most commonly employed in automated solid-phase oligosaccharide synthesis. these resins generally exhibit high loading, are chemically inert to most of the reaction conditions required for glycosylation, and can be easily filtered from the reaction solution. the only disadvantage is that they require swelling to expose the reactive sites of the resin. incomplete swelling can lead to incomplete reactions and deletion sequences. controlled pore glass (cpg), which is a rigid, mechanically robust material that does not shrink or swell in the presence of solvents, has been used with high success for the synthesis of oligonucleotides; however, it has not attracted much attention for automated oligosaccharides synthesis for two major reasons. first, cpg loading, which is approximately . - . mmol g À , is generally lower than merrifield and tentagel ( . - . mmol g À ). second, the growing oligosaccharide has been shown to eventually block the glass pores reducing diffusion of the reagents to the reactive sites. cpg with larger pore sizes has been used with some success, although the resin tends to be significantly more fragile. the majority of the automated solid-phase oligosaccharide syntheses reported to date have made use of merrifield resin, a chloromethylated polystyrene resin that has been widely employed in peptide synthesis. in addition to high loading, merrifield resin is relatively inert under the acidic and basic conditions used in the automation process. one significant disadvantage in comparison to the cpg used in dna synthesis is the number of washing steps required to completely remove excess reagents and byproducts from the porous polystyrene matrix. in addition, the reactive sites of the resin are only exposed in the presence of a swelling solvents such as dichloromethane, tetrahydrofuran, and toluene, prohibiting the use of nonswelling solvents such as hexane and methanol. tentagel has also been used in the automated solid-phase synthesis of oligosaccharides. tentagel consists of polyethylene glycol cross-linked to polystyrene via an ether linkage. tentagel combines the benefits of a soluble polyethylene glycol support with the insolubility and handling characteristics of a polystyrene bead. tentagel also displays relatively uniform swelling in a variety of solvents from medium to high polarity ranging from toluene to water. one significant disadvantage in comparison to merrifield resin is that the hydrophilic nature of the resin can make the removal of residual water difficult, leading to reduced yields during glycosylation. the linker connects the first unit of the growing oligosaccharide chain to the solid support. to be effective the linker must remain intact during synthesis, and be selectively cleavable under relatively mild conditions at the end of the synthesis. optimally, the cleaved linker should have a functional handle for attachment to a protein carrier, chip, or other surface. to date, four linkers have been commonly employed in automated oligosaccharide synthesis ( figure ): alkene-diol (octenediol or butenediol) linkers, a bifunctional linker, and a succinamic linker. merrified octenediol and butenediol linkers, which contain a single double bond, fit the requirements for a suitable linker for automated solid-phase oligosaccharide synthesis. these linkers are generally connected to the solid support via an ether or ester linkage. after synthesis, the linker is cleaved by cross-metathesis (or base hydrolysis then cross-metathesis) using grubbs' first-generation catalyst (grubbs' i) in the presence of ethylene. the resulting fully protected n-pentenyl glycoside (octenediol) or allyl glycoside (butenediol) can be hydrolyzed to the free reducing sugar or activated and then glycosylated. the carbon-carbon double bond can also be modified to produce a handle with a nucleophile suitable for conjugation. there are three major disadvantages to the use of the octenediol and butenediol linkers. the first is that the alkene prohibits the use of electrophiles, such as those required for the activation of thioglycosides, during the automated process. the second is that the grubbs' catalyst required for cleavage from the resin is expensive and often difficult to remove from the final reaction products. finally, the alkene handle requires further functionalization to be useful for conjugation and biological evaluation; such transformations can reduce the overall yield of the final oligosaccharide product. the bifunctional linker was prepared to address the issues associated with the octenediol and butenediol linkers. the bifunctional linker, which is connected to the solid support via an ester linkage, is fully compatible with most common glycosylation conditions, including the electrophilic conditions required for the activation of thioglycosides. cleavage of the ester using basecatalyzed hydrolysis is inexpensive and accomplished under mild conditions. after purification, hydrogenolysis of the remaining carbamate reveals a c linker with a terminal amine suitable for conjugation. the main disadvantage with the bifunctional linker is that it's use limits the types of temporary protecting groups that can be used; acetate groups can no longer serve as temporary protecting groups since the reaction conditions required to remove them would also result in the cleavage of the oligosaccharide from the resin. a succinamic linker was recently reported for use in automated solid-phase oligosaccharide synthesis. this linker, which is connected to the solid support (tentagel) via an amide linkage, can also be cleaved using base-catalyzed hydrolysis. the succinamic linker offers similar advantages to the bifunctional linker, and in principle could support the electrophilic conditions required for thioglycoside activation. the main disadvantage with the succinamic linker is that the alcohol handle produced on hydrolysis from the resin must be further functionalized for conjugation. the identification and synthesis of the building blocks required to construct the oligosaccharides is the most laborious and timeconsuming task of the automated process. protecting group patterns must be designed to achieve the desired connectivity and stereoselectivity in high yield. in addition, the nature of the protecting group can directly influence the reactivity of the building block, affecting reaction times and yield. the basic features of a building block are highlighted in figure and include the anomeric leaving group (lg), a participating group (for , -trans linkages) or nonparticipating group (for , -cis linkages) at the c position (r ), temporary protecting groups that are stable under glycosylation conditions but readily removed for the next glycosylation reaction (r ) and permanent protecting groups that remain intact until the final global deprotection step (r ). mammalian carbohydrates are commonly comprised of ten monosaccharides: glucose, galactose, mannose, sialic acid, n-acetlyglucosamine, n-acetylgalactosamine, fucose, glucuronic acid, iduronic acid, and xylose ( figure ). in principle, each carbohydrate residue can be linked through any of its different functional groups and each linkage generates a new stereocenter. the potential diversity is significant. for example, the number of theoretical structures possible for a hexasaccharide comprised from any one of the ten mammalian monosaccharides is approximately billion! it has been estimated that building blocks would be required to assemble any given mammalian oligosaccharide. however, recent studies have suggested that only building blocks would be required to access approximately % of all known mammalian oligosaccharides due to significant overlaps in common connectivities. thirty of these building blocks are shown in figure and are ranked by relative abundance in mammalian oligosaccharides. the type ii lewis blood group oligosaccharide le y -le x (nonasaccharide) provides a good example of the number and types of carbohydrate linkages that can be made. as illustrated in figure , the le y -le x molecule is comprised of four b-linked sugar residues: glucose, galactose, n-acetylglucosamine, and fucose. individual differences in the connectivities of these four sugars require that five differentially functionalized building blocks from figure would be required to synthesize le y -le x molecule. in automated solid-phase oligosaccharide synthesis, the mono-or disaccharide with the lg, which serves as a glycosyl donor or electrophile, is activated in the presence of a nucleophile. there are three common lgs employed in automated solid-phase oligosaccharide synthesis ( figure ): phosphates, imidates, and thiols. historically, glycosyl phosphates and imidates have played the most important roles in automated solid-phase oligosaccharide synthesis. however, a number of automated solid-phase oligosaccharide syntheses employing thioglycosides have been reported recently in the literature. the accepted mechanism for glycosidic bond formation using glycosyl phosphates, imidiates, and thiols under standard glycosylation conditions is illustrated in scheme . nucleophilic displacement (s n ) results in a glycosidic bond with the c position playing a role in the resulting stereochemistry of the products. for this reason, the stereochemistry of the lg generally has little impact on the stereochemical outcome of the reaction. however, it has been demonstrated that in some cases anomers may have different chemical properties resulting in enhanced or reduced reactivity. glycosyl phosphates can be synthesized from lactols, glycosyl bromides, acetates, trichloracetimidates, nitrates, thioglycosides, -pentenyl and -buten- -yl glycosides, glycals, , -orthoesters, and oxazolines. dibutylphosphate is most commonly employed in automated solid-phase oligosaccharide synthesis, and it is generally activated with a stoichiometric amount of a lewis acid, most often trimethylsilyl trifluoromethanesulfonate (tmsotf), at temperatures approximately À c in the presence of a nucleophile (scheme ). glycosyl imidates are generally prepared from their corresponding lactols. in general, glycosyl imidates are advantageous in comparison to glycosyl phosphates because the conditions required to activate them (catalytic tmsotf or trifluoromethanesulfonic acid (tfoh)) are generally milder. glycosyl trichloroacetimidates and n-phenyl trifluoroacetimidates are generally activated at temperatures between À c and À c (scheme ). glycosyl phosphates and imidates have been shown to be reasonably stable for over a year at À c. lg = leaving group r = participating or nonparticipating group (can be temporary or permanent) r = temporary protecting group r = permanent protecting group lg phosphate imidate n-phenyl trifluoroacetimidate lg building blocks required for the synthesis of approximately % of all known mammalian oligosaccharides. lg scheme activation conditions for glycosyl phosphates, imidates and thioglycosides. more recently, thioglycosides have been shown to be effective lgs in automated oligosaccharide synthesis. thioglycosides can be prepared from a number of sources. the most common include lactols, glycosyl halides, and peracetylated or -acylated sugars. in automated solid-phase oligosaccharide synthesis, thioglycosides are activated using either an n-iodosuccinimide (nis)/ tmsotf or nis/tfoh promoter system (scheme ) at temperatures approximately À c. the major advantage to using thioglycosides in automated solid-phase oligosaccharide synthesis is their shelf stability. they generally remain stable, even at room temperature, for extended periods. in addition, thioglycosides can be used to access the other donors; phosphates can be accessed directly from thioglycosides, or the thioglycoside can be hydrolyzed to the lactol and then converted to the imidate in two steps. . . . temporary protecting groups -fluorenyl carboxymethyl (fmoc), levulinoyl (lev) and silyl-protecting groups (scheme ) have proven to be effective temporary protecting groups in automation. the -fluorenylcarboxyl group is generally installed using fmoccl in the presence of a pyridine in high yield. in automated solid-phase oligosaccharide synthesis, the fmoc group is readily removed by treatment with a solution of piperidine in dimethyl formamide (dmf) to give a fulvene byproduct (which can be used to monitor the progression of the reaction) and the free alcohol, which serves as a nucleophile in the next glycosylation reaction (scheme ). lg scheme effects of the c position on glycosylation. the levulinoyl (lev) ester group is generally installed using levulinic acid, n n -dicyclohexylcarbodiimide (dcc), and dimethylaminopyridine (dmap) at room temperature. the lev group is generally removed in automated solid-phase oligosaccharide synthesis using a . mol l À solution of hydrazine in a mixture of pyridine and acetic acid to give the desired alcohol (scheme ). these conditions do not affect normal esters such as acetates, benzoates, or pivaloates. although less common, silyl-protecting groups are gaining importance in automated solid-phase oligosaccharide synthesis. the most commonly employed silyl-protecting group, tert-butyldimethylsilyl ether (tbs or tbdms) is commonly installed using tbdmscl and imidazole in dmf. removal of the tbdms group in automation is accomplished using tetrabutyl ammonium fluoride to give the free alcohol (scheme ). permanent protecting groups used in automated solid-phase oligosaccharide synthesis include benzyl groups (bn), pivaloyl (piv) and benzoyl (bz) esters, azides (n ), and n-trichloroacetyl (tca) groups (scheme ). these groups are generally removed after the newly oligosaccharide has been cleaved from the resin and purified. benzyl groups (bn) are the most common permanent protecting groups used in automation due to their stability under relatively acidic and basic conditions. they are generally installed via treatment of the corresponding alcohol with benzyl bromide and sodium hydride in dmf and are removed using standard hydrogenolysis (scheme ). azides (n ) are generally employed as nonparticipating protecting groups for the synthesis of -amino sugars. azides are commonly introduced by nucleophilic substitution of sugar derived tosylates, , , mesylates, and epoxides. azides can also be installed by treating the corresponding amino sugar with sodium azide and triflic anhydride or triflate azide in copper sulfate. , azides are most commonly reduced by hydrogenolyisis to the corresponding amine (scheme ). pivaloyl (piv), benzoyl (bz) esters, and n-trichloroacetamides (tca) are more stable than acetates and do not hydrolyze readily under the standard reaction conditions used for automated solid-phase oligosaccharide synthesis. these groups are generally prepared by treating the free alcohol (piv or bz ) or amine (tca ) with the corresponding acyl chloride in the presence of a base. piv and bz groups are readily hydrolyzed by treatment with strong base. n-trichloroacetyl (tca) groups are generally reduced to the corresponding n-acetyl groups using tributyltin hydride in refluxing xylene. acetyl esters (ac) can serve as temporary or permanent protecting groups depending on the linker chosen for automation. acetates are most commonly prepared by treatment of the free alcohol with acetic anhydride in pyridine, , and they are hydrolyzed using a solution of sodium methoxide in methanol (zemplén conditions). octenediol and butenediol inkers are unaffected by these conditions, but the bifunctional and succinamic linkers are readily cleaved. when these linkers are employed, acetate serves as a permanent protecting group. lg scheme temporary protecting group deprotection strategies. the nature of the protecting groups can also affect the general reactivity profile of an individual monosaccharide. with regards to glycosyl donors, electron-donating groups stabilize acyloxonium/oxocarbenium ion intermediates by donating electron density to this intermediate via induction. these groups tend to enhance the rate of the glycosylation reaction. in contrast, electronwithdrawing groups destabilize acyloxonium/oxocarbenium ion intermediates by withdrawing electron density from the reactive site. this can have the affect of decreasing the reaction rate, and in extreme cases can impede reactivity altogether. this stabilizing/ destabilizing based on electron donation or withdraw is known as the 'armed-disarmed' concept, where electron-donating groups 'arm' the donor, whereas electron-withdrawing groups 'disarm' the donor. , , when considering the electronics of glycosyl acceptors, electron-donating groups near the nucleophilic hydroxyl group may enhance nucleophilicity. this can lead to faster reaction rates. electron-withdrawing groups near the nucleophilic hydroxyl group, which remove electron density through induction, can diminish the overall rate of the reaction. the first automated solid-phase oligosaccharide syntheses reported by seeberger and co-workers began a revolution in the preparation of glycoconjugates for biological evaluation. since their initial report, automation has been used by scientists around lg scheme permanent protecting group deprotection strategies. the world to synthesize more than complex oligosaccharides including bacterial antigens, cancer antigens, vaccine candidates, and n-linked core oligosaccharides. the syntheses of several of these oligosaccharides are presented in sections . . . - . . . . examples were chosen for historical purposes as well as to highlight the challenges and complexities of the oligosaccharides prepared using the automation solid-phase oligosaccharide process. the majority of the oligosaccharides synthesized via automated oligosaccharide syntheses were synthesized using either the first-or second-generation automated solid-phase oligosaccharide synthesizer. in most cases merrified resin was used as the solidsupport. glycosylation reactions typically employ a 'double-coupling' (figure ) or 'triple coupling' strategy which involves activating to equivalents of glycosyl donor two or three times with a washing step (to remove unreacted donor and reaction byproducts) in between. this process is employed to ensure complete reaction thereby minimizing deletion sequences which can have a negative impact on the purification of the desired oligosaccharide. a-mannan and b-glucans are known to play important roles in the pathogenesis of certain fungi. the first automated solid-phase oligosaccharide syntheses of a-mannan and b-glucan oligosaccharides were reported in by seeberger and co-workers using the first-generation automated solid-phase oligosaccharide synthesizer. the syntheses of these compounds provided proof of principle that linear and branched oligosaccharides could be made in automation in high yield using standard lgs such as glycosyl imidates and phosphates. the synthesis of a- , linked penta-, hepta-, and deca-a-mannans was accomplished using the first-generation solid-phase oligosaccharide synthesizer. octenediol-functionalized merrifield resin was repeatedly glycosylated with mannosyl imidate using a double coupling approach ( equivalents) per cycle in the presence of a catalytic amount of tmsotf (scheme ). the c ac served as both a directing group (for anchimeric assistance) and a temporary protecting group, which could be hydrolyzed under zemplén conditions. the pentasaccharide (n ¼ ) was generated in % yield demonstrating approximately % coupling efficiency at each step. the heptasaccharide (n ¼ ) and decasaccharide (n ¼ ) were produced % and % yields, respectively, demonstrating approximately % coupling efficiency at each step. two selectively functionalized glucose building blocks were used to generate a phytoalexin elicitor b-glucan (scheme ) as the first example of a branching glycan synthesized by automated solid-phase oligosaccharide synthesis. octenediol-functionalized merrifield resin was coupled with two glycosyl phosphate building blocks, monosaccharide , and , -linked disaccharide , containing c piv participating groups. each iterative 'double coupling' required equivalents of the desired phosphate building block ( or ) and a stoichiometric amount of tmsotf. after each glycosylation, the lev ester of the growing oligosaccharide chain was removed using hydrazine/pyridine/acetic acid solution to furnish a nucleophile for the next glycosylation reaction. after four glycosylation reactions, the oligosaccharide was cleaved from the resin using grubbs' catalyst under an ethylene atmosphere to produce the final protected phytoalexin elicitor b-glucan in % yield over five steps. leishmania, which is transmitted to humans via the sand fly, affects millions of people worldwide. automated solid-phase oligosaccharide synthesis was used to synthesize the tetrasaccharide cap of the antigenic glycosylphosphatidylinositol (gpi) found on the surface of the leishmania parasite, providing the first example of the automated solid-phase synthesis of a branching glycan using functionalized monosaccharide building blocks with different lgs. octenediol-functionalized merrifield resin and three building blocks ( , , and , scheme ) containing c participating groups were employed in the synthesis of the tetrasaccharide cap. mannosyl imidate was glycosylated on to the linker using a catalytic amount of tmsotf. removal of the lev group using hydrazine, followed by glycosylation with galactosyl phosphate using a stoichiometric amount of tmsotf gave the desired disaccharide. hydrolysis of the c ac under zemplén conditions, followed by glycosylation with mannosyl imidate gave the desired trisaccharide. a second hydrolysis and glycosylation with , followed by cleavage with grubbs' catalyst under an ethylene atmosphere gave the desired tetrasaccharide in % yield with approximately % coupling efficiency at each step. malaria is caused by the parasite plasmodium, which is transmitted by the mosquito. in , approximately million cases of malaria were recorded worldwide with more than deaths reported (data obtained from the world health organization). in , a gpi toxin responsible for the pathogenesis of the parasite was identified and targeted for vaccine development. shortly thereafter, the first automated solid-phase synthesis was reported. four selectively functionalized imidate building blocks, , , , and , were required for this synthesis (scheme ). the use of acetates as temporary protecting groups and the need to install a second mannose residue at the c position of the reducing sugar required that imidate , with a nonparticipating group at c , be employed for this synthesis. glycosylation of mannosyl imidate on to the octenediol-functionalized merrifield resin using the 'double coupling' strategy and stoichiometric amount of tmsotf led to a mixture of a and b anomers. this mixture was inconsequential since later steps in the synthesis of the vaccine candidate required hydrolysis of the pentenyl tether and refunctionalization of the reducing sugar. methanolysis of the c ac to the corresponding hydroxyl group using zemplén conditions provided the corresponding nucleophile required for extension. subsequent glycosylation/hydrolysis cycles with imidates , , and gave the final tetrasaccharide in % yield after cleavage from the resin (approximately % coupling efficiency at each step). it is worth noting that the employment of building block represented the first use of a silyl-protecting group in automated oligosaccharide synthesis. reported in . an initial solution-phase screening led to the use of glucosylamine phosphate building block functionalized with a participating phthalimido group (nphth) at c and a temporary lev group at c . a 'double coupling' strategy was employed on the first-generation automated solid-phase oligosaccharide synthesizer. glycosylation of the first building block with octenediol-functionalized merrifield resin followed by removal of the lev protecting group using a hydrazine/pyridine/acetic acid solution gave the free c hydroxy methyl group for extension. two additional glycosylation/deprotection steps were required to access the final trisaccharide in % yield ( % coupling efficiency) after cleavage from the resin using grubbs' i catalyst in the presence of ethylene (scheme ). the lower yield is likely due to the steric hindrance and conformational constraints of the participating phthalimido group. development of the bifunctional linker and the second-generation automated solid-phase oligosaccharide synthesizer permitted the use of thioglycosides in the automated synthesis of b-( - ) oligoglucosamines (scheme ). for this synthesis a 'double coupling' strategy was employed. activation of glucosylamine thioglycoside functionalized with a trichloroacetamide (tca) participating group at the c amine and fmoc group at c with a promoter system consisting of n-iodosuccinimide (nis) and triflic acid (tfoh) in the presence of the bifunctional linker led to the initial monosaccharide bifunctional linkerfunctionalized resin. hydrolysis of the fmoc group using a solution of piperdine in dmf provided a free alcohol for extension. subsequent glycosylation/deprotection cycles followed by base-mediated hydrolysis from the resin and reduction of the tca groups led to the production of the hexasaccharide (five additional cycles) or the dodecasaccharide ( additional cycles) in % yield with % coupling efficiency and % yield with close to % coupling efficiency, respectively. this synthesis indicated a marked improvement over the initial trisaccharide synthesis (scheme ). a similar strategy employing thioglycoside building block with a participating tca group at c and an fmoc group at c was used to synthesize a b- ( ) ( ) ( ) ( ) yield (not shown). the reduced yield for the b-( - ) hexasaccharide is presumably due to the increased steric encumbrance of the nucleophile. . . . core n-linked glycan n-linked glycans play critical roles in cell-cell recognition and communication in mammals. n-linked glycans have also been implicated in tumor progression and metastasis, and the pathogenesis of viruses such as hiv, ebola, and some coronaviruses. the pentasaccharide core of n-linked glycans, which consists of chitobiose (two b-( - ) linked glucosamine residues) followed by a c /c branching b-( - ) linked mannose residue, presents a significant challenge due to the b-( - )mannosidic linkage to the chitobiose disaccharide. the first automated solid-phase synthesis of the core n-linked glycan by seeberger and co-workers in employed the firstgeneration automated solid-phase oligosaccharide synthesizer, octenediol-functionalized merrifield resin and a 'double coupling' strategy using three selectively functionalized imidates (scheme ). the reducing glucosamine residue of the core chitobiose disaccharide was installed using imidate donor functionalized with a participating tca group at the c amine and a temporary ac protecting group at c under standard conditions. hydrolysis of the c ac using zemplén conditions provided a nucleophile for subsequent glycosylation. in this synthesis, installation of the difficult b-mannosidic linkage was avoided by using disaccharide building block with a participating tca group at the c position and temporary acetate groups at the c and c positions. hydrolysis of the acetates at c and c followed by double glycosylation with mannosyl imidate gave the core pentasaccharide in % yield with approximately % coupling efficiency after cleavage from the resin using grubbs' catalyst. the development of the second-generation solid-phase oligosaccharide synthesizer, the bifunctional linker and advances in the synthesis of b-mannosidic linkages encouraged seeberger and co-workers to revisit the synthesis of the n-linked glycan in . their new approach is illustrated in scheme . the chitobiose core was installed using a 'double coupling' strategy with glucosylamine thioglyoside building block functionalized with a tca participating group at the c amine and a temporary fmoc group on c . two glycosylation cycles were performed using an nis/tfoh promoter system. removal of the fmoc group was accomplished between each cycle using piperidine to expose the next acceptor. the b-mannosidic linkage was then formed using mannosyl ocb building block consisting of a nonparticipating benzylate at the c position, a temporary benzylidene acetal installed at the c and c positions, and a temporary silyl-protecting group at the c position, marking the first use of a benzylidene acetal and an ocb donor in automation. glycosylation of the chitobiose disaccharide with using triflic anhydride (tf o) and di-tert-butyl- -methylpyridine (dtbmp), followed by removal of the silyl ether at c with tbaf and selective ring opening of the benzylidiene acetal using diborane and dibutylboron triflate (bu botf), gave the core n-linked trisaccharide which underwent subsequent glycosylation with mannosyl imidate . the final assembly of the core n-linked glycan was completed in . % yield after cleavage from the resin under zemplén conditions; the b-mannosidic linkage was installed with an a/b ratio of : . although the yields were far lower than the original synthesis of the core n-linked glycan, this work represents the first example of the direct generation of a beta-mannosidic linkage using an automated solid-phase platform. the cancer antigen glycosphingolipids gb- (scheme ) and globo-h (scheme ) are of interests for vaccine development. in addition, gb- has recently been shown to play a role in hiv infectivity. gb- and globo-h were synthesized in record time using an automated solid-phase approach employing the first-generation automated oligosaccharide synthesizer. a cis agalactosidic linkage linked to the axial c hydroxyl group of a second galactose residue is common motif to both glycans and presents a significant challenge in solution and in automation. after careful screening, it was determined that galactosyl imidate (gb- ) or galactosyl phosphate (globo-h), both containing a nonparticipating benzyl group at c , could be used to selectively install this linkage efficiently. the protected oligosaccharides were subsequently assembled using octenediolfunctionalized merrifield resin under standard glycosylation conditions. functionalized monosaccharides through were used to synthesize the gb- trisaccharide (scheme ) in % yield with % coupling efficiency. globo-h hexasaccharide was synthesized from building block , and building blocks through in h (scheme ) and % yield with a coupling efficiency of % per step. the development of the second-generation automated solid-phase oligosaccharide synthesizer and the bifunctional linker led to the first automated synthesis of iso gb- (scheme ), a glycan of biological interest due to its homology with gb- . the synthesis of iso gb- marked the first automated solid-phase oligosaccharide synthesis using a 'double coupling' strategy employing only differentially functionalized thioglycoside building blocks. the first glucose residue was installed by glycosylation of glucosyl thioglycoside building block , functionalized with a permanent participating c piv group and a temporary fmoc group at c with bifunctional linker-functionalized merrifield resin using an nis/tfoh promoter system. after hydrolysis of the fmoc group using piperdine, subsequent glycosylation/deprotection cycles, first with galactosyl thioglycoside building block with a participating pivaloate c protecting group and a temporary fmoc group at c , followed by glycosylation with galactosyl thioglycoside building block with a nonparticipating c bn group provided the desired glycan in % yield ( % yield coupling efficiency) after cleavage from the resin using zemplén conditions. the installation of the nonreducing terminal galactose building block represented the greatest challenge. the type ii lewis blood group oligosaccharides le y (hexasaccharide) and le y -le x (nonasaccharide) are of interest as potential cancer vaccines. their complexity, including the number and different types of carbohydrate residues and challenging linkages, render them significant challenges for automated solid-phase oligosaccharide synthesis. the first automated synthesis of le y and le y -le x employed the first-generation automated oligosaccharide synthesizer, an ester-linked octenediol-functionalized linker, and five differentially functionalized phosphate building blocks: , , , , and , under standard glycosylation conditions. fmoc and lev groups were used as temporary protecting groups whereas piv and tca groups were used as c directing groups with the exceptions of galactose building block , which used a c fmoc group as both a temporary protecting and directing group, and fucose building block , which required a nonparticipating group to install the desired cis linkage. the synthesis of le y is shown in scheme . successive 'double coupling' of building blocks , , , , , and gave the desired hexasaccharide in % yield after cleavage from the resin using zemplén conditions. after each double coupling, the fmoc or lev protecting group was removed using piperdine or hydrazine, respectively. the le y -le x nonasaccharide was synthesized using a similar protocol (scheme ) to produce the desired product in . % yield after cleavage from the resin. sialic acid containing glycans mediate pathogen invasion and modulate important roles in cellular communication. despite their significance, the chemical synthesis of these glycans has been limited by the challenging installation of the sialic acid residue, which is often accomplished in low yield and limited selectivity. the automated solid-phase oligosaccharide synthesis of sialyl lewis x (sle x ), a tetrasaccharide involved in inflammation and metastasis, demonstrated that sialic acid residues could be installed in automation. the second-generation automated oligosaccharide synthesizer, bifunctional linker-functionalized merrifield resin and a 'double coupling' strategy employing three building blocks: glucosylamine thioglyoside with a tca participating group at c and temporary fmoc and lev protecting groups at c and c ; disaccharide imidate containing an acetate participating group at c ; and fucosyl imidate with a nonparticipating bn group at c were required to complete the synthesis of sle x in just over % yield ( % coupling efficiency). the key to the success of this synthesis was the preparation of the disaccharide building block incorporating the sialic acid residue. this method was applied to several sialyl lactose and sialyl lactosamine derivatives in excellent yields (scheme ). an hplc-based automated oligosaccharide synthesizer was recently employed by demchenko and co-workers in the generation of several b-( - ) linked oligosaccharides. the initial glucose residue containing a participating bz group at c and a temporary trityl group at c was coupled to tentagel resin using edc and dmap on column and then detritylated with wet tfa to expose hyaluronic acids are glycosylaminoglycans composed of repeating units of glucuronic acid and n-acetylglucosamine monosaccharides. hyaluronic acids function as molecular lubricants and have also been shown to play important roles in the inflammatory response, cell proliferation, recognition, migration, and adhesion. the first automated solid-phase synthesis of well-defined hyaluronic acids employed the second-generation automated synthesizer. butenediol-functionalized merrifield resin and a 'triple coupling' strategy using equivalents of two di-tert-butylsilylidene-protected imidate building blocks and (scheme ) incorporating c participating groups (tca for building block and bz for building block ) and lev groups as temporary protecting groups. activation of glucosylamine imidate using tfoh, which was demonstrated to be more efficient than tmsotf, followed by hydrolysis of the lev protecting group with hydrazine and iterative glycosylation reactions with disaccharide gave the desired glycans in - % yield (n ¼ , , or ) after cross-metathesis from the resin. interestingly, the authors demonstrated that direct glycosylation of disaccharide to the linker was unsuccessful, necessitating the synthesis of building block . in addition, removal of the glycan from the resin using cross-metathesis using grubbs' catalyst proved challenging due to the partial dechlorination of the tca group. the use of a decoy substrate, trichloracetamide, was used to circumvent this unwanted reaction. . . . b-mannuronic acids alginates b-mannuronic acid alginates are major components of the cell wall of algae. they are also major constituents of the exopolysaccharides of pseudomonas aerigunosa, an opportunistic, nonsocomial gram-negative bacterium. the automated synthesis of tetra-, octa-, and dodeca-b-mannuronic acid alginates via automated solid-phase oligosaccharide synthesis was recently reported using the second-generation automated oligosaccharide synthesizer, butenediol-functionalized merrified resin, and a mannuronic imidate building block functionalized with a nonparticipating bn at c and a temporary lev protecting group at c (scheme ). the major challenge with this synthesis was the selective installation of each b-mannosidic residue. tfoh was found to be the most effective promoter and the reaction was found to be completely selective at temperatures near the decomposition of the donor ( À c). each glycosylation cycle required hydrolysis of the lev group using hydrazine. the first oligosaccharide synthesized, a tetrasaccharide, was prepared using four glycosylation/deprotection cycles in % yield with approximately % coupling efficiency. the octasaccharide and dodecasaccharides were synthesized with % coupling efficiency at each step providing the final products in % and %, respectively. . . . . oligoarabinofuranosides the first automated solid-phase oligosaccharide synthesis of oligoarabinofuranosides was recently reported. oligoarabinofuranosides and their analogs are the major components of mycobacterial cell envelopes and play important roles in a number of critical aspects of the life cycle of the mycobacterium. [ ] [ ] [ ] the versatility of the second-generation synthesizer combined with the use of the bifunctional linker provided for the synthesis of a series of linear and branched oliogarabinofuranosides from the sequential 'double coupling' of two thiofuranosides and , both of which contained a bz participating group at c and temporary f-moc protecting groups at c ( ) or c and c ( ) . the use of nis/tfoh as a promoter system was shown to provide the best yields and selectivites. piperdine was used to remove the fmoc protecting groups in between coupling cycles. overall, this process was shown to be efficient and rapid -the hexasaccharide in scheme was prepared with % yield and % coupling efficiency in h. fully automated solid-phase synthetic oligosaccharide platforms and new linker strategies have streamlined access to a host of carbohydrate constructs including bacterial and viral antigens, cancer antigens, vaccine candidates, and n-linked oligosaccharides. this has led to an increase in the general understating of the fundamental roles of these oligosaccharides in a number of biological processes. current research is directed at identifying monosaccharide building blocks that can be used to access the major glycoconjugate classes including n-linked, o-linked, glycolipids, and glycosylaminoglycans. these oligosaccharides will be used to study important carbohydrate-protein, carbohydrate-nucleic acid, and carbohydrate-carbohydrate interactions involved in normal and abnormal cellular processes. the development of rapid and efficient synthetic protocols for commercialization of these building blocks is the next critical step for expanding the automated solid-phase platform for oligosaccharide synthesis. phosphites and other o-p derivatives. in handbook of chemical glycosylation glycoside synthesis from -oxygen-substituted glycosyl imidates. in handbook of chemical glycosylation glycoside synthesis from -sulfur/selenium-substituted derivatives. in handbook of chemical glycosylation proc. natl. acad. sci proc. natl. acad. sci proteoglycans and sulfated glycosaminoglycans key: cord- -t b h authors: duijker, g.; bertsias, a.; symvoulakis, e. k.; moschandreas, j.; malliaraki, n.; derdas, s. p.; tsikalas, g. k.; katerinopoulos, h. e.; pirintsos, s. a.; sourvinos, g.; castanas, e.; lionis, c. title: reporting effectiveness of an extract of three traditional cretan herbs on upper respiratory tract infection: results from a double-blind randomized controlled trial date: - - journal: journal of ethnopharmacology doi: . /j.jep. . . sha: doc_id: cord_uid: t b h abstract ethnopharmacological relevance observations from the island of crete, greece suggest that infusions of traditional cretan aromatic plants, well known for their ethnopharmacological use in eastern mediterranean region and near east, could be effective in the prevention and treatment of upper respiratory tract infections, including viral-induced infections. the aim of this study was to report the effectiveness of an essential-oil extract of three cretan aromatic plants in the treatment of cases with an upper respiratory tract infection. materials and methods a double blind randomized controlled trial was implemented between october and february . an essential-oil extract of cretan aromatic plants in olive oil (total volume of ml of essential oil per litre of olive oil) was administered as . ml soft gel capsules, twice a day, for days. placebo treatment was . ml olive oil in soft gel capsules. eligible patients were those presenting for clinical examination in the selected setting with signs and symptoms of upper respiratory tract infection that had begun within the previous hours. real-time polymerase chain reaction (pcr) was used for the detection of respiratory viruses. the primary outcome was the severity and duration of symptoms of upper respiratory tract infection, assessed using the wisconsin upper respiratory system survey (wurss- ) questionnaire. a secondary outcome of interest was the change in c-reactive protein (crp) status. results one hundred and five patients completed the study: in the placebo group, and in the intervention (treated) group. baseline characteristics were similar in the two groups. no statistically significant differences were found in symptom duration or severity between the two groups, although small and clinically favorable effects were observed. when the analysis was restricted to subjects with a laboratory-documented viral infection, the percentage of patients with cessation of symptoms after days of treatment was % in the intervention group and % in the control group (p= . ). at baseline, one third of the patients in each group had elevated crp levels. at follow-up, the respective proportions were % in the intervention group and % in the placebo group (p= . ). the data were also in a favorable direction when % and % symptom reduction points were considered for specific virus types. conclusions compared with placebo the essential-oil extract of three cretan aromatic plants provided no detectable statistically significant benefit or harm in the patients with upper respiratory illness, although descriptive differences were identified in favorable direction mainly in the virus-positive population. novel h n , referred also as "swine flu", as well as other viral agents involved in common cold infections, compose a public health problem, accountable for many visits to primary and secondary health care services and hospital admissions; additionally, a considerable number of deaths is likewise documented, especially in vulnerable people. these infections are easily transmitted by exposure to infected droplets expelled by coughing or sneezing that can be inhaled, or contaminated hands or surfaces. symptoms include fever, cough, headache, muscle and joint pain, sore throat and runny nose, and sometimes vomiting and diarrhea. the new influenza a (h n ) appears to be as contagious as seasonal influenza, and spreads rapidly, particularly amongst young people. the severity of the disease ranges from very mild symptoms to serious illness and occasionally even death. the majority of people who contract the virus experience mild disease and recover without antiviral treatment or medical care. additionally, more than % of serious hospitalized cases have underlying health conditions or impaired immune function. antiviral drugs may reduce the symptoms and duration of illness and may also contribute to preventing severe disease and death. however, the effectiveness and cost of administered therapy remains an interesting topic for further investigation, as a recent cochrane meta-analysis, although contested, reported a limited effect of oseltamivir (tamiflu s ), a classical antiviral drug (jefferson et al., ) , mainly related to the time-limited and usual self-healing nature of the disease. much discussion has been dedicated to the use of herbal medicine for the common cold. a randomised controlled trial (rct) has reported on the effects of so-cheoug-ryong-tang (ko et al., ) and yeon-gyopae-dok-san on the common cold (byun et al., ) . the use of herbs as ailments in the island of crete has been mentioned since the bronze age (arnott, ) . herbal medicine also has a long history in ancient greece. popular medical handbooks from the byzantine era forward incorporated material rooted in ancient medicine and routinely claimed hippocrates and galen (among others) as sources (clark, ) . in current times, the antioxidant activity of herbs in rural crete has been investigated and it has been shown that herbal extracts decrease lipid peroxidation in cultured lung cells exposed to iron or ozone (lionis et al., ) . previous ethnobotanical field studies have revealed the existence of an indigenous knowledge system in rural crete and certain combinations of different aromatic plants in rural areas of crete have been used for the prevention and cure of the common cold and influenza (lionis et al., ) . the biological effects and bioactivity of essential oils and as well as their antibacterial properties have been reported in the literature (cowan, ; burt, ; bakkali et al., ; koroch et al., ) . similarly, the antiviral potential of medicinal plants has been discussed as well (jassim and naji, ; mukhtar et al., ) . it is also exciting that even though the term "virus" is a very recent term in modern medicine (silverstein, ) , these rural societies, without any prior knowledge of the term and in the absence of any immunologic knowledge, were protecting the population using traditional and folkmedicine. as stated above, it was interesting to study to what extent this ethnopharmacological knowledge is evidence-based and effective in virus-induced diseases. to that effort we have also taken into account certain cretan history and archeological elements, as well as their ethnopharmacological uses in the eastern mediterranean and near east regions, suggesting a beneficial action of such a combination in upper respiratory viral infections (dafni et al., ; honda et al., ; lev and amar, ; said et al., ; hanlidou et al., ; lardos, ; hudaib et al., ) . as stated above, this study reports the results of the effectiveness of an extract based on three cretan aromatic plants in the reduction of duration and severity of symptoms of patients with upper respiratory tract infections, utilizing a standardized questionnaire, physical examination measurements and the decrease of inflammation assayed by c-reactive protein [crp] levels. plant material has been identified by one of the authors (sp) and voucher specimens of the three species have been deposited at the herbarium tau of the aristotle university of thessaloniki (uocsp - , uocsp - , and uocsp - ). formulation of the essential oil extracts was provided by the authors and prepared by olvos sa, according to the patents and patent applications related to the subject (wo gb ; gb ; ep ; cn ) of thyme or spanish oregano (coridothymus capitatus (l.) rchb. f. synonym of thymbra capitata (l.) cav.), dictamnus or cretan dittany (origanum dictamnus l.) and sage (salvia fruticosa mill., salvia pomifera l.) extracts through steam distillation. analysis of essential oils was performed by gas chromatography-mass spectroscopy, in a gc-ms, shimadzu, qp a apparatus. gc was equipped with mdn- column (length m, film thickness . mm, diameter . mm, max. useable temperature c) and a quadrupole mass spectrometer as detector. mdn- column temperature was initially c for min. it was then gradually increased to c at c/min and kept for min, and finally increased to c at c/min and held for min. the carrier gas was helium, the flow rate . ml/min. μl was used as an injection volume. the sample was measured in a split mode procedure with a split ratio : . injector and detector were maintained at and c, respectively. for gs-ms detection an electron ionization system was used with ionization energy at ev. the chemical and percentage composition of specific constituents in each essential oil (adams, ) is shown in supplemental tables - . essential oils (at a dilution of ml/l) in extra virgin olive oil (used as a vehicle) were formulated as . ml soft-gel capsules, for a daily dose of two capsules. this dose has been based on anthropological reports of fieldwork work studies carried on crete (lionis et al. ) and corresponds to two cups of infusion of the aforementioned aromatic plants. placebo capsules contained only extra-virgin oil, equally formulated as . ml soft-gel capsules. gc-ms chemical and percentage composition of the formulated mixture (adams, ) are shown in supplemental table . participants were recruited from october th, to february th, . eligible subjects were patients aged years or older, presenting at their local health centre of harakas in the prefecture of heraklion, in rural crete, greece, with symptoms of upper respiratory tract infection, initiated within the previous h. the jackson criteria were used in order to identify patients suffering from common cold (jackson et al., ) . these criteria consist of sneezing, nasal discharge, nasal obstruction, sore throat, cough, headache, malaise and chilliness. a patient was considered as eligible for participation when the jackson score was greater or equal than two (with at least one of the first four 'cold-specific' symptoms present). patients on a daily dosage of acetylsalicylic acid greater than mg were excluded from the study. further criteria for exclusion were the presence of malignancy, immunosuppression and pregnancy. harakas health center serves a population of , , in rural crete. of the general practitioners (gps) practicing at the centre, agreed to participate. eligible patients were informed about the study and enrolled after providing written consent. a randomized placebo-controlled, double-blind, parallel group design was used and the consort herbal medicinal interventions guidelines were followed (gagnier et al., ) . stratified randomization using a varying block size ( or ) was implemented using the statistical environment r, version . (〈http://www.r-project.org〉, package blockrand); stratification was by sex and age (cut-off taken at years). the packages containing the capsules were stored at the health centre and were identical in appearance but with differing id labels, corresponding to specific patients. enrolled patients received either the cretan aromatic plants product or the placebo. both gps and patients were blind to treatment group, as were the study coordinators, clinical chemistry and immunology diagnostic laboratories and other participating personnel. patients were examined at the gp's office on the day of presentation and at follow-up ( days later) and were contacted by telephone on a daily basis by their gps between their initial and final visits, for the completion of the daily questionnaire (see below, section . ). this study received approval by the commission of bioethics of the university general hospital of heraklion (no , - - ) . a written, fully informed consent was obtained from all patients enrolled in the study. the trial was registered in the international standard randomised controlled trial number register (〈http://www. isrctn.org〉) (isrctn number: isrctn ). after appropriate permission, the validated -item wisconsin upper respiratory system survey (wurss- ) instrument, translated in greek, was used to quantify symptoms' severity and duration (barrett et al., ). the wurss- is an evaluative illness-specific quality of life instrument, designed to assess the negative impact of acute upper respiratory infection. daily wurss summary scores are calculated by summing scores of individual items. the first and last of the items are not included in the summation as they have categorically different reference domains (〈http://www.fammed.wisc.edu/ research/external-funded/wurss〉, accessed on august ). higher scores indicate more severe symptoms (the theoretical maximum score being ) whilst a score of indicates the complete absence of symptoms. the questionnaire was completed on a daily basis, seven times in total. initially (day one) and at final follow-up (day seven) it was completed by the patient at the gp's office and in between, completion was undertaken by their gp, using telephone interviews. during the initial visit, information was also obtained on participant gender, date of birth, self-reported weight and height, smoking history (number of cigarettes per day, years of smoking, year started, year quitted), alcohol consumption (type of drink, milligrams per day), medical history (chronic illnesses, type of drugs provided, drug dosage), vaccinations (against streptococcus pneumoniae and influenza) and hospitalization history. each subject underwent a clinical examination, including the following: systolic blood pressure (sbp, mmhg), diastolic blood pressure (dbp, mmhg), o saturation (%), pulse (beats per minute), body temperature (degrees celsius) and respiratory rate (breaths per minute). these measurements were repeated at day , at the follow-up visit to the gp's office. blood was drawn on days one and seven, for the following tests: erythrocyte count (rbc, /μl), hemoglobin (g/dl), hematocrit (%), white blood cell count (wbc, / l), neutrophil (%), lymphocytes (%), monocytes (%), thrombocytes (%), alanine aminotransferase (alat or sgpt, u/l), aspartate aminotransferase (asat or sgot, u/l), alkaline phosphatase (alp, u/l), creatinine (mg/dl) and c-reactive protein (crp, mg/dl). all assays were performed at the university hospital of heraklion, after a specific agreement, with routine standard methods (number of protocol: / - - ). real-time pcr assays . . . dna/rna extraction nucleic acids were extracted from nasopharyngeal swabs, using a commercial purification kit (purelink viral dna/rna kit, invitrogen), suitable for viral dna/rna extraction, according to the manufacturer's instructions. all samples were quantified spectrophotometrically and normalized aliquots were produced for each sample. dna/rna isolation was performed in a separate area of the laboratory distant from the polymerase chain reaction (pcr) area. meticulous care was taken to avoid cross-contamination of the dna/rna. one hundred swabs were taken. six swabs were used as internal controls, resulting in available samples. the detection of respiratory viruses was carried out using two commercial kits, by real time pcr. the first kit allowed the multiplex real-time pcr detection and identification of human respiratory viruses, namely human respiratory syncytial virus (hrsv) rna, human metapneumovirus (hmpv) rna, human parainfluenza virus- - (hpiv) rna, ОС , Е , nl and hkui human coronavirus (hcov) rna, human rhinovirus (hrv) rna, human b, c and e adenovirus (hadv) dna as well as human bocavirus (hbov) dna (cat no tv - frt, sacacce). in addition, a second commercial kit was also employed for the simultaneous detection of pandemic h , influenza a virus and influenza b virus (anyplex™ flua/b typing real-time detection (v . ), seegene). real-time pcr reactions were set up according to the manufacturers' protocols, following the amplification conditions recommended and data were collected during annealing (two measurements) and at all times during melt curve analysis. experiments were conducted on an abi fast system real-time pcr thermal cycler, using software version v. . . (applied biosystems). the quality control of the dna/rna samples was accomplished by checking for the successful amplification of beta- microglobulin gene. the primary outcomes of interest were the duration of symptoms and changes in the severity of symptoms over the study period. duration of symptoms was assessed as the number of days from enrollment, before the participant reported "not sick" to the question "how sick do you feel today?" i.e. a response of on a likert scale of - . symptom severity was assessed by the outcome of wurss- questionnaires. a secondary outcome of interest was the normalization (crpo . mg/dl) of crp positive subjects, at day . the number needed to treat (nnt) that indicates the number of patients we need to treat to benefit one was also calculated in order to measure the study's effect. an overall sample size of ( in each group) was calculated to be necessary to detect a medium-large effect size ( . ) with power % at a significance level of % (comparison of means), using gpower . . (faul et al., ) . general characteristics of the patients in each group at baseline were summarized using descriptive statistics. univariate comparisons of patient characteristics between the two study groups were performed using pearson's chi-square test of independence (for categorical data), the independent samples t-test (for normally distributed variables) and the non-parametric the mann-whitney test (for not normally distributed variable). severity of symptoms over the study period was compared between intervention and control groups, using the -item wurss- scores, with both univariate techniques and multiple linear regression models, adjusting for age, sex, initial crp level, body mass index (bmi) and the presence of chronic diseases. severity was assessed in three ways: (a) firstly, the average total wurss- score over the time period was compared between groups (i.e. the sum of daily wurss- scores). (b) differences between the groups were assessed by calculating the area under the time-severity curve (the y-axis being the wurss- score). the area under the curve (auc) was calculated using a trapezoidal approximation. (c) finally, the average maximum wurss score (for each subject) was compared between groups. the percentage of missing values for the daily wurss- scores ranged from . % (n¼ out of at baseline) to . % (n¼ out of on day three). confidence intervals for median daily scores were calculated using a binomial method (the centile command in stata ). multiple linear regression models were applied, with dependent variable the natural logarithm of the auc [ln(auc)] and independent variables the treatment (intervention/placebo), age (in years), bmi (kg/m ), gender (male/female), presence of chronic illnesses (yes/no) and crp-level upon presentation (z . mg/dl vs r . mg/dl). discrete-time survival analysis was used to assess possible differences in time to symptom cessation (i.e. symptom duration) between groups. symptoms were considered absent on the first day in which the wurss score dropped to zero. an intention-totreat approach was used. a complementary log-log model (a discrete time proportional hazards model) was also applied to our data. the model was estimated by maximum likelihood adjusting for age and sex (stata command cloglog). the proportions of initially crp-positive subjects who were crp-negative at the end of the study were compared between groups. in addition, within-group comparisons of crp changes were made using mcnemar's test. at randomization, all diagnosed upper respiratory tract infections were presumed to be of viral etiology. respiratory viruses were only detected, however, in ( %) of the patients tested. the statistical methods described above were initially applied to the total sample and the analyses were subsequently repeated using data only from the subsample of virus-positive patients. the significance level was set to % and the statistical software used was spss version (for univariate analysis) and stata version (for the survival analysis). results are presented below by outcome, for the complete sample and for the sample of virus-positive patients. a total of patients with signs and/or symptoms of upper respiratory tract infection visited the health centre of charakas over the month time-period, ( . %) females and ( . %) males. one hundred and thirty five ( . %) did not meet eligibility criteria ( females, males); subjects ( %) because they presented to their doctor more than h after their symptoms had begun. other reasons for exclusion included pregnancy (n¼ , . %), treatment with acetylsalicylic acid with a daily dose mg (n¼ , . %) and malignancy or immunosuppression (n¼ , . %). fifty-four ( ) out of the eligible patients ( . %) did not agree to participate in the study. the most common reason stated was lack of time/inability for follow-up (n¼ , . %). four patients ( %) were not willing to participate in a clinical trial. fourteen of the patients ( . %) did not provide details, while ( . %) denied for various other reasons. comparison between patients willing to participate and those who were not did not produce significant results in terms of gender distribution. those who were willing to participate were significantly older than those who were not (mean age versus years; % ci for the difference from . to . years). one hundred and eight ( ) patients were enrolled in this study; however, three ( ) patients ( . %) did not complete it (two in the placebo group and one in the intervention group). one patient developed pneumonia, one patient reported being unable to swallow the pills and one patient was lost to follow-up after the initial examination (fig. ) . intervention (n¼ ) and control (n¼ ) group patients had similar demographic characteristics (gender, age, bmi, smoking habit, alcohol consumption) and vaccination pattern against streptococcus pneumoniae and influenza (supplemental table ). in each group, about half of the patients reported suffering from at least one chronic illness. most frequent chronic illnesses were heart diseases (n¼ , %), metabolic diseases (n¼ , %) followed by respiratory and musculoskeletal diseases (n¼ , %). clinical examination characteristics (which included systolic and diastolic blood pressure, oxygen saturation, pulses per minute, respiratory rate and temperature) were also similar in both groups (supplemental table ). finally, hematological (rbc, hemoglobin, hematocrit, wbc, neutrophils, lymphocytes, monocytes, thrombocytes), biochemical (sgpt, sgot, alp and creatinine) and immunological (crp) parameters were sim-ilar in both groups of patients (supplemental table ). the median lymphocyte count was not increased in either group, suggestive of the very initial phase of the respiratory infection. the median wurss- score at baseline was (lower quartile q ¼ , upper quartile q ¼ ) in the placebo group and (q ¼ , q ¼ ) in the intervention group (supplemental table ). there was one missing bmi measurement ( . %), two missing values for pack-years of smoking ( . %), one for pneumococcal vaccination ( . %) and two regarding previous hospitalization of patients ( . %). there were no missing measurements regarding presence of chronic diseases, vaccination against influenza and alcohol consumption. forty eight out of patients that were tested ( %) were found to be positive for at least one viral strain (fig. ) , assayed by specific rt-qpcr. the distributions of the demographic, hematological and biochemical variables appeared similar when the analysis was restricted to virus-positive patients (supplemental tables and ) with the possible exception of exception of lymphocyte count, which appeared somewhat higher at baseline in the intervention group (p¼ . ). interestingly, in % (n¼ ) of positive patients human rhinovirus (hrv) was detected ( % in the intervention group, % in the control group), while h n influenza, human metapneumonovirus (hmpv) and human coronavirus strain nl were identified in $ % (n¼ ) of virus-positive patients. the severity of symptoms at baseline, as assayed by the wurss- score, appeared highest in h n -positive patients (p¼ . , supplemental table ). the severity of symptoms for the total duration of the study was assessed using the wurss- score. the auc, the maximum wurss- score and the sum of the daily wurss- scores were calculated per individual to estimate the severity of symptoms over the followup period. using data from all participants, average auc values and total wurss- score appeared lower in the intervention compared to the placebo group but not to a statistically significant extent (with respective medians of cf. , p¼ . , and cf. , p¼ . ). average maximum wurss- scores were (min , max ) and (min max ) in intervention and control groups respectively (p¼ . ). boxplots of total wurss- score by day and group are presented in fig. a for all subjects and in fig. b for symptomatic patients only. no statistically significant differences in comparisons of daily scores between placebo and intervention groups were observed. using multiple linear regression of log-transformed auc on treatment and other possible predictor variables, treatment was not found to significantly affect ln(auc) (b¼ . ; % ci from À . to . ) adjusting for age (b¼ . ; % ci from . to . ), bmi (b¼ . ; % ci from À . to . ), gender (b¼ À . ; % ci from À . to . ), presence of chronic illnesses (b¼ À . ; % ci from À . to . ) and baseline crp-level (b¼ . ; % ci from À . to . ). no treatment-viral status interaction was found. the distributions of the daily wurss- scores in virus-positive intervention and control group patients are depicted in fig. c . administration of the cretan aromatic plants extract in virus-positive patients did not modify the total wurss- score to a statistically significant extent, although lower scores were identified in the intervention group compared to placebo group: median (min , max ) cf. (min max ), p¼ . . the average auc scores were also not found to differ to a statistically significant extent, although again lower scores were seen in the intervention group (median ) compared to the control group (median , p¼ . ). average maximum wurss- scores (out of a possible ) were (min , max ) and (min , max ) in intervention and control groups respectively (p¼ . ). using discrete-time hazard modeling with the complete data set, the "risk" of symptom cessation appeared % higher in the intervention group (hazard ratio, hr . , % ci . - . ), adjusting for age and gender. similar results were found when the analysis was restricted to virus-positive patients only: hr . , % ci . - . .the probability of cessation of symptoms per day is presented in fig. a and b for the total sample and the viruspositive patients respectively. a trend towards a higher, albeit nonstatistically significant, probability of symptom cessation in the intervention group can be seen. seventy percent of patients in the placebo group had a cessation of symptoms at the time of their final consultation, while the respective proportion in intervention group was . % (p¼ . ). finally, symptom amelioration was considered per virus infection (fig. a-d) . fitting the curves with a logistic equation (fig. e ) permitted us to evaluate the time (in days) of a % and an % amelioration of symptoms, as quantified by the wurss- questionnaire. despite the small number of patients, it becomes evident that a significant amelioration ( days) was observed in the % decrease of objective symptoms of the disease in patients with h n . at baseline, the proportion of patients with elevated crp levels was similar in both groups ( % and % in intervention and placebo groups respectively). at follow-up, the respective proportions were % in the intervention group and % in the placebo group (p¼ . ). in the intervention group, out of patients with initially elevated crp levels had low crp levels at follow-up ( %) as compared to out of patients in the placebo group ( %). a % ci for the percentage unit difference in favor of the intervention treatment was calculated as À % to %. within group changes in the proportion of patients with consistently elevated crp were statistically significant (po . and p¼ . for intervention and placebo groups respectively). details are presented in supplemental table , fig. . in the virus-positive group, normalization of crp values also occurred preferentially in the intervention group (fig. , supplemental table ). at baseline, the proportion of patients with elevated crp levels was identical in both groups. at follow-up, the respective proportions were % in the intervention group and % in the placebo group (p¼ . ). when the analysis was restricted within each study group, a statistically significant reduction of the number and proportion of patients with consistently elevated crp level was found only within the intervention group (p¼ . ). from the calculation of the number needed to treat (nnt), we found that we have to treat subjects from the whole group to see one with symptoms being ceased on the th day of the followup. the corresponding numbers of the ntt when we analyze the data in virus-positive subjects were on the th day. on the final day of their participation, all patients were asked to report on any possible adverse effect. six out of the that completed the study reported adverse effects; three of them had received the cretan aromatic plants (intervention) treatment. all three participants were females and their respective age was , and years old. one of them reported frequent urination, the second reported mild abdominal pain in the left upper quadrant (for one day), and the third participant reported rash on her arms which was present for three days. no change in hepatic or renal function was observed, as evidenced by sgot-sgpt and creatinine levels respectively. it is therefore concluded that the administration of the herbal extract, at least for the duration of our intervention, is safe. there is much research on the anti-viral and especially the antiinfluenza activity of a variety of medicinal plants worldwide, either in vitro by reporting the reduction of the viral cytopathic effect or in vivo. the main country in which such in vivo research has been conducted is china, where more than chinese patented medicinal recipes have been reported in (tang et al., ) . an interest in the effectiveness of herbal remedies in treating or preventing influenza or influenza-like illness has been acknowledged; however, a systematic review performed in databases until reported table presented in (e) shows the time in days at which half ( %) and % of wurss- encoded symptoms were relieved in the control and the intervention group, according to the virus found at day . data were calculated through a logistic fit of curves presented in a-d. rcts and concludes that the majority of performed studies concern small groups, assayed with questionable methodologies or they report clinically irrelevant effects (guo et al., ) . another systematic review (wu et al., ) , searching the evidence from cochrane systematic reviews, about the effectiveness of traditional chinese medicinal herbs in treating acute respiratory infections, came to similar conclusions. the authors also reported lack of quality in the researched trials and the presence of certain biases that have an impact on study validity (wu et al., ) . a recent chinese rct (wang et al., ) described the mean symptom population scores, as well as the number of recovered patients, as primary endpoints for treating influenza patients while one of the secondary endpoints included the time required to alleviate both fever and the severity of clinical symptoms (wang et al., ) . in our randomized clinical trial, we have compared the essentialoil extract of three cretan aromatic plants with placebo; our main finding is that the plant extract did not show a statistically significant benefit or harm in patients with upper respiratory illness of any cause, although a slight albeit non-significant amelioration of symptoms was detected in the treated patients. this is further more evident in virus-positive patients. in details, the following primary or secondary endpoints of the trial are: (a) the proportion of patients who presented symptom-free on day seven is higher in the intervention ( %) than in the control group ( %), a result close to statistical significance. interestingly, and in spite of the small number of patients, a favorable effect was found in the subgroup of h n influenza-infected patients. (b) the proportion of patients whose crp levels were normalized by the end of the follow-up period is significant in the intervention (p¼ . ), but not within the placebo group (p¼ . ). in addition, we found a number needed to treat (nnt) of in the total population decreasing to in the virus-positive population, meaning that at least one out of six virus-positive patients received the beneficial effect of our preparation. two key issues should be taken into consideration, prior to any safe conclusions on the effectiveness of the cretan extracts in our population: ( ) the definition of common cold that in our study was based on the jackson score is based on a subjective assessment and could have potentially introduced selection bias. we are not certain to what extent non-infectious diseases have been included in the study sample. this may explain the high number of patients without a virus-infection (resulting in a sample size far lower than that required to detect a medium-large effect size-see methods). the possible inclusion of non-infectious diseases could seriously have affected the design of the study that assumed a high proportion of patients with virus infection. ( ) the primary endpoint of this trial was also based on self-reported symptoms and it is known that subjective self-assessment might also be another potential source of bias. furthermore, the self-healing nature of the disease and the small duration of the symptoms presents additional difficulties in the exploitation of the data. in this report, we provide only clinical data, without any attempt to decipher underlying mechanisms of action, explaining the anti-viral properties of our preparation. however, preliminary data suggest a direct in vitro anti-viral action of our preparation. in a recent review it was highlighted that the use of certain herbal extracts rich in polyphenols could play an important role in controlling virus outbreaks and alleviating their symptoms (hudson, ) . actually, we are in the process of further delineating the direct anti-viral action of our preparation, as well as of some of its specific constituents, detected after an nmr analysis, although we strongly believe that the beneficial effect might be attributed to a combined effect of more than one constituent, as we have previously reported in the case of wine extracts kampa et al., ) . the present study is the first rct on the subject. randomization was successful in creating comparable baseline groups in terms of other disease prevalence, demographic, anthropometric and laboratory (biochemical, hematological and immunological) data. in addition, the proportion of patients completing the study was very high. however, there are certain limitations that need to be considered in the interpretation of results. our sample is limited in size ($ participants) and becomes even smaller when focussing on patients with a documented viral infection. even in the sub-sample of virus positive patients, our sample was very heterogeneous as several types of viruses were identified. however, the effect of our extract might be underestimated, since a sample of subjects with a virus-documented infection does not provide enough statistical power, to respond to the question of the potency of our preparation in a large spectrum of common cold and influenza viruses. this can only be addressed through laboratory estimation of the potency of our preparation on virallyinfected cells (which is under investigation) and through a larger analysis, permitting the collection of a significantly higher number of virus-infected patients. the use of herbs is extensively diffused among local cultures and it represents a time-line between ancient and modern traditions. tradition and culture can further create ideal synergies in engaging the pharmaceutical industry towards innovative herbal-oriented research and possibly new products. however, our main intention was to introduce and promote research based on indigenous knowledge of the european regional flora, especially from the island of crete, considered as a herbarium of the mediterranean flora. we do not, of course, suggest to the health practitioners that they replace existing guidelines about the use of anti-viral treatment in influenza virus, although the use of specific anti-viral agents has been recently criticized, nor we suggest the combined use of anti-viral drugs and herbal extracts, which may lead to unwanted drug-herb interactions (yang et al., ) . the study findings arrive on a time where much criticism has been published on the effectiveness of the neuraminidase inhibitors (jefferson et al., ) . very few adverse effects were reported in our study group. indeed, our current laboratory data suggest that our preparation is effective in a broad spectrum of viruses, at doses similar or higher to those reported here. compared with placebo the essential-oil extract of three cretan aromatic plants provided no detectable statistically significant benefit or harm in the patients with upper respiratory illness, although descriptive differences were identified in favorable direction mainly in the virus-positive population. in general, our rct study provides promising new data in the field of the use of aromatic plants and their therapeutic potential as anti-viral therapeutics, and calls for additional basic and interventional research either for prevention or treatment of common cold and influenza in larger group of patients. this study was supported by an unrestricted grant (grant no. -olv-herb- ) from olvos sa. the company did not interfere to the design and execution of the study, and the results presented represent the opinion of the authors. the established standards were strictly followed with the university of crete's special account for research (elke). identification of essential oil components by gas chromatography/mass spectorscopy healing and medicine in the aegean bronze age biological effects of essential oils-a review validation of a short form wisconsin upper respiratory symptom survey (wurss- ) essential oils: their antibacterial properties and potential applications in foods-a review effects of so-cheong-ryong-tang and yeon-gyo-pae-dok-san on the common cold: randomized, double blind, placebo controlled trial landscape, memories, and medicine: traditional healing in amari plant products as antimicrobial agents ethnobotanical survey of medicinal plants in northern israel potent inhibitory action of red wine polyphenols on human breast cancer cells g n power : a flexible statistical power analysis program for the social, behavioral, and biomedical sciences recommendations for reporting randomized controlled trials of herbal interventions: explanation and elaboration complementary medicine for treating or preventing influenza or influenza-like illness the herbal market of thessaloniki (n greece) and its relation to the ethnobotanical tradition traditional medicine in turkey. vi. folk medicine in west anatolia ethnopharmacological survey of medicinal plants in jordan, mujib nature reserve and surrounding area the use of herbal extracts in the control of influenza transmission of the common cold to volunteers under controlled conditions: i. the common cold as a clinical entity novel antiviral agents: a medicinal plant perspective neuraminidase inhibitors for preventing and treating influenza in healthy adults and children wine antioxidant polyphenols inhibit the proliferation of human prostate cancer cell lines so-cheong-ryong-tang, tradititional korean medicine, suppresses th lineage development bioactivity of essential oils and their components the botanical materia medica of the iatrosophikon-a collection of prescriptions from a monastery in cyprus ethnopharmacological survey of traditional drugs sold in the kingdom of jordan antioxidant effects of herbs in crete the relevance of anthropology to medical practice: comparative studies of illness behaviour in rural crete antiviral potentials of medicinal plants ethnopharmacological survey of medicinal herbs in israel, the golan heights and the west bank region theories of acquired immunity research on component law of chinese patent medicine for antiinfluenza and development of new recipes for anti-influenza by unsupervised data mining methods chinese herbs in treatment of influenza: a randomized, double-blind, placebo-controlled trial traditional chinese medicine in the treatment of acute respiratory tract infections interaction between oseltamivir and herbal medicines used for treating avian influenza. hong kong medical journal ¼xianggang yi xue za zhi/hong kong academy of medicine the authors thank all participating primary care physicians who were responsible for the enrollment and clinical examination of eligible patients: nikolaos drakonakis, despoina chatzisymeon, vasiliki lemonomichelaki, dimitrios brimis, emmanouel doulgerakis, eva ladoukaki, anastasia stefanaki, irene stefanaki, georgios papadopoulos, and zoe troulaki. we also express our gratitude to maria dagianta who worked as the health centre coordinator.all authors would like to thank the team members from the clinic of social and family medicine, school of medicine, university of crete for their assistance: myron galenianos, irene vasilaki, and vasiliki-irene chatzea. the authors also appreciate the assistance of maria titaki and maria kouroupi in the implementation of the project. cl, sp and ec conceived and shaped the idea. ab, jm, cl, and eks prepared the first draft of the manuscript. jm was responsible for designing the randomization procedure. ab participated in the study, and was responsible for data entry and data analysis under the supervision of jm. gd participated in the study as coordinator and reviewed the manuscript. nm, spd, and gs were responsible for the biochemical and immunological analysis. gkt and hek were responsible for gc-ms analyses of specimens. cl provided clinical details and technical input, revised the manuscript and performed editing and format changes throughout the manuscript. all authors read and approved the final manuscript. supplemetary data (supplemental tables) associated with this article can be found in the online version at http://dx.doi.org/ . /j.jep. . . . key: cord- -cfbvka authors: zhang, shi-jin; chen, zhuo; li, guo-wen; wang, bo-liang title: effect of the haoqinqingdan decoction on damp-heat syndrome in rats with influenza viral pneumonia date: - - journal: asian pacific journal of tropical medicine doi: . /s - ( ) - sha: doc_id: cord_uid: cfbvka abstract objective to investigate the effect of chinese medicine prescription-haoqinqingdan decoction on damp-heat syndrome in rats with influenza viral pneumonia and its influence on the immune function. methods a total of wistar rats were randomly divided into the normal control group, the damp-heat syndrome model group, the haoqinqingdan decoction group (high, medium and low dose group) and the ribavirin group. the body temperature and weight of rats in each group were recorded after modeling. after treatment for d, the concentration of t lymphocyte subgroup (cd +cd +, cd +cd +) was determined by flow cytometry. the od value of ifn-γ/il- was detected by double-antibody sandwich elisa method, and its concentration was acquired through conversion. results after modeling, the temperature and weight of rats in each modeling group showed the increasing trend (p< . ). from the second day of treatment, there was significant difference in the body mass between groups, and the rat weight of the control group was higher than in the modeling group (p< . or . ). with the advances of treatment, only the temperature in the medium and high dose haoqinqingdan decoction groups declined significantly (p< . ). after treatment, the cd +/cd + ratio of the damp-heat syndrome model group decreased more significantly compared with the control group. elevated cd + cd + percentages and declined cd +/cd + ratios can be observed in the low dose group and ribavirin group (p< . ). moreover, the cd + cd + percentage of ribavirin group was lower than in the control group (p< . ). after treatment, the ifn-γ and ifn-γ/ il- levels in the peripheral blood of rats in the damp-heat syndrome group were obviously higher than in the control group (p< . ). conclusions compared with ribavirin, the high dose haoqinqingdan decoction can improve the ratio of t lymphocyte subgroup and th /th cell balance more effectively. sourced from "renewed popular treatise on febrile diseases" haoqinqingdan decoction is a famous prescription founded by gen-chu yu, a famous doctor in qing dynasty [ ] . this prescription was designed originally for shaoyang damp-heat syndrome and proved to have good efficacy in clinical practice [ ] . the damp-heat syndrome is an acute exogenous febrile disease caused by pathogenic dampness. the causes of damp-heat syndrome are multifactorial, including not only environmental factors, but also autoimmune function and pathogenic microorganism [ ] . viral infection is one of the common causes of dampheat syndrome. it was found that people tend to have viral damp-heat syndrome in hot and humid environment, and objective: to investigate the effect of chinese medicine prescription-haoqinqingdan decoction on damp-heat syndrome in rats with influenza viral pneumonia and its influence on the immune function. methods: a total of wistar rats were randomly divided into the normal control group, the damp-heat syndrome model group, the haoqinqingdan decoction group (high, medium and low dose group) and the ribavirin group. the body temperature and weight of rats in each group were recorded after modeling. after treatment for d, the concentration of t lymphocyte subgroup (cd + cd + , cd + cd + ) was determined by flow cytometry. the od value of ifn-毭/il- was detected by double-antibody sandwich elisa method, and its concentration was acquired through conversion. results: after modeling, the temperature and weight of rats in each modeling group showed the increasing trend (p< . ). from the second day of treatment, there was significant difference in the body mass between groups, and the rat weight of the control group was higher than in the modeling group (p< . or . ). with the advances of treatment, only the temperature in the medium and high dose haoqinqingdan decoction groups declined significantly (p< . ). after treatment, the cd + /cd + ratio of the damp-heat syndrome model group decreased more significantly compared with the control group. elevated cd + cd + percentages and declined cd + /cd + ratios can be observed in the low dose group and ribavirin group (p< . ). moreover, the cd + cd + percentage of ribavirin group was lower than in the control group (p< . ). after treatment, the ifn-毭 and ifn-毭/ il- levels in the peripheral blood of rats in the dampheat syndrome group were obviously higher than in the control group (p< . ). conclusions: compared with ribavirin, the high dose haoqinqingdan decoction can improve the ratio of t lymphocyte subgroup and th /th cell balance more effectively. influenza virus infection is most common [ ] . due to the limitation of western medicine and the hysteresis of vaccine development, the treatment of this disease is not satisfactory. however, traditional chinese medicine shows its unique advantages in the treatment of this disease. a study found that haoqinqingdan decoction can decrease the mrna level of nf-毷 b and the percentage of th /th through decreasing the expression of tlr , decrease lung index and improve pathological change [ ] . on the basis of related studies, we illustrated the advantages of haoqinqingdan decoction in treating this disease and its role in regulating immunity through the comparison between the high, medium and low dose haoqinqingdan decoction groups and the ribavirin group, which would provide basis for differential traditional chinese medicine treatment of upper respiratory viral infection [ ] . experimental animals and strains: wistar rats in spf grade with the weight of - g; the influenza virus a (h n ) fm strains were provided by the national institute for the control of pharmaceutical and biological products). medicine: haoqinqngdan decoction. composition: g artemisia annua l, g baical skullcap root, g tangerine peel, g rhizoma pinelliae praeparatum, g fructus aurantii, g bambusae caulis im taeniam, g talcum, g folium isatidis and g glycyrrhiza uralensis. the decoction method referred to the great dictionary of tcm formulas. the medicine was concentrated to g/ml and saved in the refrigerator at 曟 . positive control medicine: ribavirin purchased from the department of pharmacy of zhengzhou central hospital. according to the method reported in the study [ ] , rats were randomly divided into groups with rats in each group, namely, the normal control group, the damp-heat syndrome model group, the high, medium and low dose haoqinqngdan decoction groups (the high, medium and low dose groups for short) and the ribavirin group. the modeling started after d adaptive feeding. the modeling groups were raised by high-fat diet every day, while the normal group was given normal diet. on the tenth day of modeling, the rats in the modeling groups were infected by the h n virus through nasal drip. h after viral infection, the rats in modeling groups were put into the artificial temperature chamber at ( 依 . ) 曟 , %- % air humidity for h. these rats were exposed in this environment for h every other day with a total heat exposure for three times. the normal control group and modeling group were raised separately. the body weight and temperature of rats were measured at am every day after modeling. on the th day after modeling, intragastric administration once a day was performed for each treatment group (high, medium and low dose groups and ribavirin group). the dosage of haoqinqingdan decoction was calculated according to the body surface area of human and rat. the doses of high, medium and low groups were . mg/ kg/d, . mg/kg/d and . mg/kg/d, respectively. the ribavirin dose was mg/kg/d. the normal control group and damp-heat syndrome model group were intragastrically administrated by normal saline. after medication for d, eyeballs were extracted for blood, and food and water were prohibited h before the blood extraction. a total of . ml blood was added into the anticoagulant tube and fully mixed. detection of t lymphocyte subgroup was finished in the same day. the serum was separated after blood standing and then was used for cytokine detection. detection of t lymphocyte subgroup: . ml heart blood was taken from the rats. the number and percentage of each t lymphocyte subgroup was measured by flow cytometry using three kinds of antibodies labeled by different fluorescent dyes. the operative procedures were strictly in accordance with the instruction. detection of the cytokine level (ifn-毭/il- ): about ml supernatant was taken from rats. double-antibody sandwich elisa method was used to detect the concentration of cytokine. the curve was drawn using the concentration of the standard preparation as the x-axis and od value as the y-axis. the concentration of the specimen can be found in the curve by its od value. il- /ifn-毭 = concentration in the standard curve 暳 dilution multiple. anova and t test were used for experimental data. multigroup comparisons used one-way anova. results were considered to be statistically significant when p< . . spss . software was used for statistical analysis. from the first day to the th day after modeling, the weight of rats in each experimental group and control group increased significantly (p< . ), but the rat weight difference among groups was not significant at the same time (p> . ). changes of body temperature: from the first day to the th day after modeling, the temperature change of the control group was not significant (p> . ), but the rat temperature of the modeling groups (the damp-heat syndrome model group, the haoqinqingdan decoction groups and the ribavirin group) showed the trend of increasing (p< . ), and the temperature comparison at the same time showed that the temperature of rats in the modeling groups was significantly higher than in the control group on the th day of modeling (p< . , table , ). the th day after modeling was regarded as the first day of treatment. the intragastric administration was given table body weight changes of rats in each group after modeling ( mean 暲 sd, g). table temperature changes of rats in each group after modeling ( mean 暲 sd, 曟 table weight changes of rats in each group after treatment ( mean 暲 sd, g). table temperature changes of rats in each group after treatment ( mean 暲 sd, 曟 to the haoqinqingdan decoction group and the ribavirin group, while the normal control group and the damp-heat syndrome model group were intragastricly administrated by normal saline. the results indicated that the weight of rats in each modeling group slowly increased, but not obviously. the group comparison indicated that from the second day of treatment, the weight difference among each group was significant, and the body weight of rats in the control group was obviously higher than in the modeling groups (p< . or . ). with the advances of treatment, obvious temperature decrease can only be observed in the medium and high dose haoqinqingdan decoction groups (p< . , table , ). after treatment for days, the cd + cd + percentage and cd + /cd + ratio in the damp-heat syndrome model obviously decreased compared with the normal control group, but the percentage of cd + cd + increased (p< . ). increased cd + cd + percentage and decreased cd + /cd + ratio can be observed in the low dose group and ribavirin group (p< . ). moreover, the cd + cd + percentage of the ribavirin group was lower than in the control group (p< . , table ). the ifn-毭 and ifn-毭/il- levels in the peripheral blood of rats in the damp-heat syndrome model was obviously higher than in the control group (p< . , table ). table comparison of t lymphocyte subgroup in each group (mean 依 sd). in modern medicine, respirovirus is a kind of virus invading into the human body through respiratory tract and causing respiratory tract and/or systemic infection. in most circumstances, this kind of virus would infect host cell and induce immune response after entering human body through respiratory tract [ ] . due to the high mutation rate, this kind of virus (such as influenza virus, parainfluenze virus, coronavirus and some enteric viruses) often brings great difficulty to clinical diagnosis and treatment in clinical practice [ , ] . the treatment of this kind of virus is mainly symptomatic treatment in modern medicine. despite of the occurrence of many broad-spectrum antivirus agents and vaccine, this kind of infection can hardly be radically cured for the high variability and drug resistance of virus [ ] [ ] [ ] [ ] . in the treatment of these diseases, traditional chinese medicine focuses on the relationship between virus, organism and medicine rather than the virus itself. respiratory viral infection and its pathogenesis are closely related to the immune state of organism. this kind of infection belongs to the damp-heat febrile disease, because its clinical manifestation and occurrence season and region are very similar to the defensive qi & body surface and qiphase syndrome of febrile disease [ ] . having the function of qingdan dampness, and regulating stomach and dissipating phlegm, haoqinqingdan decoction is a representative prescription for clearing heat and eliminating dampness. febrile disease theory holds that clearing heat and eliminating dampness method has the function of guiding qi downward, activating spleen, regulating stomach, promoting diuresis, clearing heat and dissipating dampness, which is suitable for damp-heat febrile disease [ ] . the experimental results of our study indicated that haoqinqingdan decoction can reverse the decline tendency of cd + /cd + ratio caused by the synthetic action of damp-heat environment and viral infection, making the cd + /cd + ratio close to the normal control group. in the comparison of th /th cytokine (ifn-毭/il- ) level, after treated by haoqinqingdan decoction for days, the ifn-毭 and ifn-毭/il- levels in the peripheral blood of rats in the damp-heat syndrome model group was obviously higher than in the control group, while the ifn-毭/il- levels of the other modeling groups were close to the control group. these results indicated that haoqinqingdan decoction can strengthen the effect of rat helper t cell, regulate the balance of t lymphocyte subsets and the balance of th / th and strengthen the anti-virus immune function of organism [ ] , and the efficacy of high dose drugs was lower than the low dose. the possible mechanism of the antiviral immune injury of haoqinqingdan decoction is up-regulating cellular immune function, re-balancing the cd + /cd + and th /th and lightening the stress state [ ] . in the improvement of rat temperature, obvious decline of temperature can only be observed in the medium and high dose haoqinqingdan decoction groups (p< . ), and the effect of decreasing rat temperature was not obvious in low dose haoqinqingdan decoction group and the ribavirin group (p> . ), which indicated that the therapeutic effect of haoqinqingdan decoction on fever caused by influenza virus was notable [ ] [ ] [ ] . in the aspect of weight, although the immune state and temperature of rats in each treatment group were improved, the body weight did not significantly increase after treatment (p> . ). this indicated that dampheat syndrome had great impact on the dietary intake and metabolism of rats, and this impact can hardly recovered in a short time. it was also found that in regulation of the balance of t cell subset (cd + /cd + ), the therapeutic effect of ribavirin was poorer than the medium and high dose haoqinqingdan decoction, but was close to the low dose haoqinqingdan decoction, which indicated that ribavirin has a certain effect on the treatment of damp-heat syndrome caused by influenza virus, but is not superior to haoqinqingdan decoction. experimental study on the inhibiting flu virus action of haoqinqingdan decoction on new application of ancient prescriptions starting with clinical and experimental research of haoqinqingdan decoction observation of the curative effect of qingchanghuashi recipe for treating active ulcerative colitis of inner-accumulation of damp-heat syndrome study on the differential gene expressions of chronic hepatitis b patients of gan depression pi deficiency syndrome and pi-wei damp-heat syndrome the mechanism of signal extension in haoqinqingdan dection immunity activity in damp-heat syndrome of pneumonia disease infected by influenza virus immunomodulatory effects of a traditional chinese medicine with poteintial antiviral activity: a self-control study effects of hao qin qing dan decotion and jade screen powder on changes of t-lumphocyte subsets and serum th /th cell factors in mouse with damp-heat syndrome infected by influenza virus serum amyloid p is a sialylated glycoprotein inhibitor of influenza a viruses virological and clinical characterizations of respiratory infections in hospitalized children glycomic analysis of human respiratory tract tissues and correlation with influenza virus infection vaccines for preventing influenza in people with asthma decline in influenza vaccine effectiveness with time after vaccination genetic analysis of polymerase complex (pa, pb and pb ) genes of h n avian influenza viruses from iran pathogenicity of avian influenza virus h n isolates from pakistan curative effect and mechanism of wormwood and scutellaria gallbladder clearing decoction cured viral upper respiratory tract infection pharmacology of traditional chinese medical formulae antagonism effects and signal transduction path of hao qin qing dan decotion on damp-heat syndrome of pneumonia disease infected by influenza virus cases of exogenous fever treated by haoqin qingdan decoction with addition and subtraction method cases of viral fever treated by haoqin qingdan decoction therapeutic effect of haoqin qingdan decoction combined with tanreqing on influenza virus fever we declare that we have no conflict of interest. key: cord- -die jmbv authors: chabre, yoann m.; roy, rené title: design and creativity in synthesis of multivalent neoglycoconjugates date: - - journal: adv carbohydr chem biochem doi: . /s - ( ) - sha: doc_id: cord_uid: die jmbv from the authors' opinion, this chapter constitutes a modest extension of the seminal and inspiring contribution of stowell and lee on neoglycoconjugates published in this series [c. p. stowell and y. c. lee, adv. carbohydr. chem. biochem., ( ) – ]. the outstanding progresses achieved since then in the field of the “glycoside cluster effect” has witnessed considerable creativity in the design and synthetic strategies toward a vast array of novel carbohydrate structures and reflects the dynamic activity in the field even since the recent chapter by the nicotra group in this series [f. nicotra, l. cipolla, f. peri, b. la ferla, and c. radaelli, adv. carbohydr. chem. biochem., ( ) – ]. beyond the more classical neoglycoproteins and glycopolymers (not covered in this work) a wide range of unprecedented and often artistically beautiful multivalent and monodisperse nanostructures, termed glycodendrimers for the first time in , has been created. this chapter briefly surveys the concept of multivalency involved in carbohydrate–protein interactions. the topic is also discussed in regard to recent steps undertaken in glycobiology toward identification of lead candidates using microarrays and modern analytical tools. a systematic description of glycocluster and glycodendrimer synthesis follows, starting from the simplest architectures and ending in the most complex ones. presentation of multivalent glycostructures of intermediate size and comprising, calix[n]arene, porphyrin, cyclodextrin, peptide, and carbohydrate scaffolds, has also been intercalated to better appreciate the growing synthetic complexity involved. a subsection describing novel all-carbon-based glycoconjugates such as fullerenes and carbon nanotubes is inserted, followed by a promising strategy involving dendrons self-assembling around metal chelates. the chapter then ends with those glycodendrimers that have been prepared using commercially available dendrimers possessing varied functionalities, or systematically synthesized using either divergent or convergent strategies. pap-a-glc, poly(p-n-acryloylamidophenyl) a-glucopyranoside; pbs, phosphate buffered saline; pepo, pentaerythrityl phosphodiester oligomer; pet, photoinduced electron transfer; pitc, phenylisothiocyanate; pdt, photodynamic therapy; poss, polyhedral oligosilsesquioxane; pmbc, peripheral blood mononuclear cells; ppi, polypropyleneimine; ps, photosensitizer; pvk, poly(methyl vinyl ketone); pybop, benzotriazol- -yl-oxytripyrrolidinophosphonium hexafluorophosphate; qsar, quantitative structure-activity relationship; rca , ricinus communis agglutinin; rgp, radial growth polymerization; scvcp, self-condensing vinyl copolymerization; sem, scanning electron microscopy; shc, sonogashira-heck-cassar cross coupling reactions; slt, shiga-like toxin; slt-iie, shiga-like toxin ii edema variant; spg-lac, schizophyllan bearing lactosides; spr, surface plasmon resonance; sps, solid-phase synthesis; stec, shiga toxigenic group of escherichia coli; stx, shiga toxin; swnt, single-walled nanotube; tbaf, tetra-n-butylammonium fluoride; tbah, tetra-n-butylammonium hydroxide; tbtu, -( h-benzotriazole- -yl)- , , , -tetramethyluronium tetrafluoroborate; tem, transmission electron microscopy; tempo, , , , -tetramethylpiperidine- -oxyl; tf, thomsen-friedenreich antigen; tfa, trifluoroacetic acid; tga, thermogravimetric analysis; thf, tetrahydrofuran; tris, tris(hydroxymethyl)aminomethane; vaa, viscum album agglutinin; vt, verotoxin; vv-hrp, horseradish peroxidase-labeled plant lectin v. villosa; vva, v. villosa plant lectin; wga, wheat germ agglutinin; yds, yolk decasaccharide i. introduction generally, the valency of a particle (namely a small molecule, oligosaccharide, protein, nucleic acid, lipid or aggregate of these molecules, a virus, bacterium, or cell) can be defined as the number of separate structural units of the same kind that can interact with other particles through ligand-receptor interactions. thus, one can consider that a molecule having two tethered and identical copies of binding components can be classified as a divalent entity. similarly, multivalent or polyvalent interactions can be defined as specific simultaneous associations of multiple ligands (or epitopes) present on a molecular construct or biological surface that binds in a cooperative way to multiple receptors expressed on a complementary entity. the ubiquity of these multivalent interactions at different levels in several biological mechanisms testifies to their essential role. in fact, multivalency in nature is very often expressed by fractal or ''dendritic'' architectures that represent perhaps the most pervasive topologies observed in vegetal and animal kingdoms. typical examples of these patterns may be found at different scales of dimensional length (meters to microns), and typical examples can be observed in abiotic systems (such as snow crystals, fractal erosions, manganese dendrites in rock) or in the biological world. the reasons for such extensive mimicry of these dendritic topologies at virtually all scales of dimensional length are not entirely clear. however, one might speculate that these evolutionary architectures have been optimized over the past several billion years to provide structures manifesting maximum interfaces for optimum energy extraction/distribution, nutrient extraction/distribution, information storage/retrieval, and adhesive processes. for example, trees use fractal dendritic patterns above and beneath the ground in order to enhance the exposure of their leaves to sunlight to harvest light and maximize the photosynthesis process, and of their roots to collect water from the soil. most notable natural examples of this architecture at the molecular level are probably the glycogen and amylopectin hyperbranched structures that nature uses for energy storage. presumably, the many chain ends that decorate these macromolecules facilitate enzymatic access to glucose for high-demand bioenergy events. another nanoscale example of dendritic architecture in biological systems is found in proteoglycans. these macromolecules appear to provide energy-absorbing, cushioning properties and determine the viscoelastic properties of connective tissues. in addition, the tremendously complex dendritic respiratory network is composed of bronchioles and alveoli to give the maximum surface for efficient transfer of oxygen into the bloodstream. the arterial and central nervous system networks, together with the kidneys and lung structures also consist of a great number of cells growing into dendritic structures in order to gain the largest exchange of material or information with the surrounding tissues. recently, the implication of dendritic patterns observed under the feet of the gecko has also been clarified to explain the exceptional ability of these animals to climb rapidly up smooth vertical surfaces. microscopic examinations have shown that a gecko's foot has nearly five hundred thousand keratinous hairs or setae, each composed of an impressive dendritic network of tiny foot hairs ''spatulae.'' measurements have revealed that one seta is times more effective at adhesion than predicted from maximal estimates on whole animals. values of the adhesive force support the hypothesis that individual setae operate by weak attractive quantum chemical forces from molecules in each foot-hair interacting through van der waals forces with molecules of the surface. finally, a very striking example is also afforded by nature, particularly in exposing a wide array of complex dendritic glycoconjugates on mammalian and hiv- cell surfaces. these carbohydrate structures play critical roles in multiple key cellular events, such as cellular adhesion and recognition, regulation of physiological functions, and pathogenic infections. for hiv- , several hypothesis have been formulated concerning their role in infection process, and it has been speculated that the n-linked hyperbranched high mannose oligosaccharide (man glcnac ), exposed at the exterior envelope glycoprotein gp , helps the ''hidden'' virus to escape neutralizing antibodies. indeed, these glycans are produced by the host cell, and are largely unrecognized by the immune system machinery. although carbohydrates and their corresponding conjugated glycoforms have long been regarded as only space-filling matrices or post-transcriptional accessory elements in glycoproteins serving to protect them from premature degradation, it has become apparent that such glycoconjugates as glycolipids or glycosaminoglycans exhibit a broad variety of additional biological functions. indeed, carbohydrates are expressed on the majority of mammalian cell surfaces, and are bound to proteins, glycoproteins, and glycolipids, or conjugated to such cellular constituents as proteoglycans that are entangled in the cell membrane and clustered in multiantennary configurations. in other terms, these oligosaccharides constitute signal transductors between extra-and intracellular media. [ ] [ ] [ ] hence, these glycosylated structures are responsible for the presentation of target structures for microorganisms, toxins and antibodies, control the half-life of proteins, modulation of protein function, or provision of ligands for specific binding events. in addition, they have recently emerged as antigenic determinants in cell-cell recognition, signaling events, and as ligands for bacterial and viral infections. , as such, they constitute the first line of contact for the adhesion and tissue colonization by several pathogens expressing carbohydratebinding proteins (lectins). conversely, several infectious microorganisms use or escape the immune defense mechanisms by masking important receptors or antigenic determinants by exposing self-carbohydrate structures. as mentioned earlier, the consequences of these ''masking'' events are that the bacterial or viral pathogens are transported to target tissues by self cellular systems. despite their critical importance, carbohydrate-protein interactions are paradoxically characterized by rather weak association constants (millimicromolar), with limited specificity and selectivity on a per-saccharide basis. , nature usually compensates for this situation by exposing numerous copies of the same carbohydrate ligands on the extracellular domains of the cells. consequently, these interactions are transformed into very potent attractive forces, dramatically and naturally reinforced, when multiple ligand copies are presented to similarly clustered receptors. this phenomenon, resulting from a synergic and cooperative effect, is known as the ''glycocluster or dendritic effect,'' and has been initially observed with asialoglycoprotein receptors found on hepatocytes. in its widespread version, it is usually assumed that this effect has its source in the enhanced affinity of a given multivalent glycoside toward a crd (carbohydrate-recognition domain) by fully occupying one active site at a time.the phenomenon is now widely accepted of having its basis in stabilization by macroscopic ''crosslinking glycocluster effects.'' it has thus come well established that multivalency may offer numerous benefits in terms of affinity and receptor selectivity versus monovalent interaction, and can induce particular clustering organization on the cell surface, notably to provide a strategy for controlling signal transduction pathways within cells. surprisingly, however, mammals utilize only nine different monosaccharides, which are organized in a massive amount of structural diversity. the variations of anomeric configurations and linkage positioning between saccharides are thus responsible for unraveling several distinctive ''glycocodes.'' as a consequence, the different architectures and topological expressions that result are at the origin of the required high affinity and selectivity for a particular tailored recognition event. interestingly, even such complex multiantennary glycans as man glcnac are only partly involved in these binding processes and often, but not unexpectedly, only the peripheral groups are bound in the receptors' active sites. hence, multivalent interactions are now understood to be a ubiquitous strategy that has evolved in nature for a wide range of functions, and which provide numerous benefits and unique roles not achievable with monovalent interactions. consequently, from a simplistic point of view, most multiantennary glycans may be regarded as polyvalent neoglycoconjugates of well-defined architectures and multivalency, designed to mimic the complexity of the multiantennary oligosaccharide structures while emphasizing the recognition of the sole surface. as mentioned before, multivalent carbohydrate-protein interactions mediate many important physiological and pathophysiological processes. however, their thorough understanding suffers from the natural complexity of the carbohydrates resulting from incomplete biosynthesis or subtle attachment of other functionalities at specific positions along the oligosaccharide sequences. numerous key functions of carbohydrates depend on the observed microheterogeneity, added to well-defined cluster organization. in order to study, characterize, understand, and manipulate these critical interactions, striking advances have been made in isolation, purification, structural analyses, and partial or selective degradation processes. alternatively, chemical or chemoenzymatic synthesis of multivalent carbohydrate ligands is, however, likely to remain the method of choice to afford tailored multivalent architectures developed as effectors or inhibitors of biological mechanisms. accordingly, it is highly desirable to tackle the inherent problem of high specificity and increased affinity by simultaneously optimizing factors involved in both multivalency and intrinsic fine tuning of a ligand toward individually targeted carbohydrate-binding protein interactions. to achieve these goals, glycochemists are actively pursuing an approach that can be summarized in fig. . the steps to be undertaken may be expressed as follows. after assessing the bacterial/viral genomes, proteomic analysis, and search for carbohydrate-binding protein homology through bioinformatics, the presence of a carbohydrate-binding protein is then confirmed. for bacterial or viral lectins, the isolated proteins can be labeled with fluorogenic probes. the ligand-binding specificity of the fluorescent lectins is then determined by glycan microarrays such as the one freely accessible from the consortium for functional glycomics (or the like) to identify the best oligosaccharide ''lead.'' the most recent microarrays are usually constituted of approximately natural and synthetic glycans (version . ). [ ] [ ] [ ] [ ] [ ] once essential carbohydrate residues (epitopes) responsible for the biological activity of interest are identified, the lead candidates are then validated by using a range of binding assays such as elisa (enzyme-linked immunosorbent assay), ella (enzyme-linked lectin assay), itc (isothermal titration calorimetry), spr (surface plasmon resonance), fret (fluorescence resonance energy transfer), x-ray crystallography, and analogous techniques. the relative binding affinities of confirmed oligosaccharide ligands are next evaluated with a panel of simpler oligosaccharides with, ideally, a monosaccharide as the simplest target to ease potential manufacturing purposes and lead optimization that can be obtained by classical qsar (quantitative structure-activity relationship). the resulting ''glycomimetics'' are further transformed into multivalent architectures such as glycodendrimers that should also undergo iterative scaffold optimization. in this context, ''artificial glycoforms'' have played crucial roles in our understanding of multivalent interactions, which encompass chelation, receptor clustering and steric stabilization, subsite binding, and statistical rebinding phenomena. hence, research on synthetic multivalent macromolecules has intensified, giving rise to a myriad of original glycoconjugate structures which constitute high-affinity multivalent ligands that target surface receptors (namely enzymes, lectins, toxins, and such pathogens as viruses or bacteria). these novel nanometersize structures have thereupon shown great potential as potent effectors or inhibitors of surface-surface interactions, including cell-cell and cell-pathogen interactions that occur in biological systems. the following sections illustrate synthetic creativity recently devoted to generating a plethora of multivalent structures used in the biomedical field and with therapeutic goals in particular. synthetic neoglycoconjugates in which carbohydrate residues are attached to carriers thus present numerous advantages in terms of characterization, structural uniformity, and availability. hence, presentation of the sugar epitopes as multiple copies on an appropriate scaffold (molecular, dendritic, polymeric) creates a multivalent display that can efficiently mimic the natural mode of affinity enhancement that arises from multiple interactions between the binding proteins and the carbohydrate ligands. in general, the carbohydrate ligands are usually found at the periphery of these macromolecules. efficient conjugation reactions are required for complete substitution and the structural integrities of the multivalent glycoconjugates are evaluated by such conventional techniques as nmr spectroscopy and mass spectrometry. progress encountered in terms of their synthetic accessibility and efficiency has allowed optimization of their modulation and activity. these factors remain necessary for investigating how these multivalent structures can best influence the targeted binding activity. these investigations are critical for highlighting the potential of multivalent carbohydrate inhibitors as high-affinity ligands or as effectors capable of clustering cell-surface receptors, and may permit generation of structures having tailored biological activities. in addition to useful but polydisperse multivalent glycomimetics of prominent components at the surfaces of mammalian cells [such as neoglycoproteins, , neoglycopeptides, [ ] [ ] [ ] neoglycolipids (or glycoliposomes), , glycopolymers, [ ] [ ] [ ] [ ] or glyconoparticles, [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] new synthetic families of well-defined and monodisperse glycosylated macromolecules have recently emerged, including glycoclusters, such glycosylated nanomaterials as glycofullerenes and glyconanotubes, glycosylated architectures from supramolecular assembly processes, and finally glycodendrimers. the uniformity of these multivalent neoglycoconjugates is ensured by the controlled arrangement of the constitutional building blocks. to this end, a large panel of linkage functions have been used, but the ones most frequently used are amides, thioureas, and recently , , -triazoles obtained via dipolar cycloadditions of alkyne and azide precursors through a process now termed ''click chemistry.'' [ ] [ ] [ ] [ ] the required functionalities are installed with equal success on either the sugars or on the scaffolds. this particular application has become widely used, since the sugar attachment can be effected with both protected or free sugars. the protecting groups most repeatedly employed on the sugars have been esters because it is usually more difficult to remove large number of ether or acetal-protected sugars (for example, benzyl ethers). moreover, the lectin-binding efficiency and specificity of multivalent glycoconjugates have been found to be dependent not only on the epitope density but also on the nature of the core and the geometrical characteristics of the multivalent assembly. the main goal of this chapter consists in the description of the most recently conceived multivalent neoglycoconjugates, emphasizing the synthetic strategy required to afford well-defined glycoclusters, glycofullerenes, glyconanotubes, glycosylated self-assembled systems, and glycodendrimers, together with discussions concerning their respective relevant uses and perspectives in biomedical applications. ''glycoclusters'' (or ''cluster glycosides'') can be structurally considered as mimics of oligoantennary oligosaccharides of naturally occurring glycoconjugates. arbitrarily, this chapter considers these clustered structures as multivalent glycoconjugates, regardless of the number of peripheral saccharides and they are built from ''home-made'' or commercially available scaffolds that do not contain repetitive units. these structural characteristics allow distinction between these generally rather low-valency architectures and the ''true'' multigeneration glycodendrimers that are presented in later sections. because of the straightforward synthetic access to such rather small structures, a large variety of glycoclusters, based on multivalent scaffolds and illustrated in fig. , have been described in the past few years. hence, branched aliphatic or aromatic scaffolds, calixarenes, porphyrins and derivatives, cyclic peptides, carbohydrates and cyclodextrins, or more exotic central cores have been efficiently used as core molecules, to afford small multivalent glycoconjugates having greatly enhanced avidity compared to corresponding monovalent carbohydrates. in particular, the design of such systems, including the valency, the introduction of suitable functions and flexible linkers with optimal lengths, has been tailored. thus, their optimization has rapidly led to the dramatic enhancement of neoglycoconjugate-protein interactions, and has been useful for determining such critical parameters as optimal association geometries, including optimal distances between saccharide epitopes. it is noteworthy that the majority of these scaffolds have also been used for constructing more complex multigeneration glycodendrimers, in particular orthogonally derivatized ab x systems, such as tris or gallic acid derivatives. (continued) since a large panel of multivalent scaffolds has recently been reviewed by roy et al. [ ] [ ] [ ] and extensively detailed by the group of santoyo-gonzález for ''click chemistry,'' , this section is dedicated to describing the synthesis of optimized glycoclusters, notably highlighting more recent synthetic advances that have led to multivalent candidates that are strikingly biologically relevant. in order to synthesize the target complex glycoclusters, several commercially available or readily derivatized aliphatic scaffolds constituting small multifunctional building blocks have been used to permit rapid access to these multivalent structures (fig. ) . historically, one of the first branched glycoside clusters was based on a readily available ab building block, tris(hydroxymethyl)aminomethane ( , tris), used by lee in the late s. owing to the synthetic advantages in terms of symmetry that ensure orthogonal and rapid functionalization, this building block constitutes an ideal candidate for clustering of saccharides. hence, and its derivatives have been extensively used by several groups for direct glycoside attachment on hydroxyl groups to generate trivalent clusters. however, although the chemistry of glycocluster synthesis was established, the first such glycoconjugates were generally subject to unfavorable steric factors upon binding to proteins. in this context, kötter et al. used extended tris derivatives, such as -( -hydroxypropyl)- -nitroheptane- , -diol ( ) to prepare highly branched glycomimetics (fig. ) . based on these trivalent building block and peptide-coupling methodologies, the rapid synthesis of tri- ( , ) and nonavalent mannosylated clusters ( , ) varying in the chemical characteristics of their spacer moieties and lengths was accomplished. the c- -linked trimannosylated cluster displayed the highest binding potency toward the type- fimbrial lectin from escherichia coli (fimh), as tested by inhibition of agglutination and elisa, for which showed an ic of mm. unfortunately, the corresponding nonavalent dendrons and presented only very poor or no inhibitory potencies. to explain these a priori unexpected results, it has been postulated that the cluster did not present enough hydroxyl groups for efficient interactions with the lectin surface, or did not present hydroxyl or other functional groups in the appropriate orientation for lectin binding. alternatively, it is well known that the fimh binds mannosides from the nonreducing end. by virtue of promising preliminary biological results indicating that tri-and tetravalent glycoclusters constitute potent inhibitors of bacterial binding, which fitted particularly well into the crd of bacterial lectins (especially for mannose-specific adhesion) straightforward syntheses of low-valency glycoclusters were initiated. in this context, preparation of glycosylamines by direct condensation of amines with reducing sugars could be an appealing strategy. the direct conjugation of reducing sugars with diethylenetriamine ( ) has been previously reported as allowing efficient and rapid access to divalent carbohydrate derivatives in excellent yields. a few years later, hayes et al. extended this strategy, describing an elegant one-pot methodology that allowed synthesis of higher valent derivatives through reaction of more-highly functionalized amine clusters with unprotected d-mannose ( ) and dimannosides (scheme ). several linkers of different lengths, flexibility, and valency, including di-, tri-, and tetra-valent amines, were readily incorporated to generate multivalent targets in good yields. notably, tris( -aminoethyl)amine ( ) and pentaerythrityl tetraamine ( ) , [prepared from tetrabromide ( ) via azide substitution to followed by reduction to with hydrogen on % pd/c], gave the corresponding tri-and tetra-mannoside clusters and , respectively, using the free reducing sugar d-mannose ( ) . c -symmetrical glycoclusters, based on a trivalent central core, and exhibiting three and six peripheral mannosides have similarly been prepared by dubber and lindhorst, who examined the potential of reductive amination for introducing an aldehyde group of a d-mannose derivative as the carbohydrate ligand on tris( aminoethyl)amine ( ) as the branching core. to this end, the glycoclusters were synthesized from ( -mannosyloxy)ethanal ( ) , which was obtained by ozonolysis of fig. . early mannoside clusters used as ligands for e. coli fimh. , acetylated allyl a-d-mannopyranoside ( ) , followed by treatment with sodium triacetoxyborohydride nabh(oac) (scheme ). however, the instability of the trivalent conjugate arising from autocatalytic deacetylation led the authors to use an excess of aldehyde to ensure complete double n-alkylation. in more-complex carbohydratebased multivalent architectures, this situation may afford undesired partial structures. scheme . reductive amination leading to tri-and tetravalent mannosylated clusters. another example has been described by li et al., which proposed an efficient convergent one-pot synthesis of a trivalent mannoside cluster using a ugi fourcomponent reaction, involving the use of -carboxyethyl , , , -tetra-o-acetyl-a-dmannopyranoside, benzaldehyde, methyl isocyanoacetate and the tris( -aminoethyl) amine core in methanol. biological investigations by ella assays indicated efficient inhibition of binding of yeast mannan to the phytohemagglutinin concanavalin a (con a) with all the synthesized ligands, with notably an ic of . mm for the trivalent derivative, corresponding to about a -fold enhancement after valency correction as compared to a methyl a-d-mannopyranoside standard. as previously mentioned, pentaerythritol and its derivatives constitute another widely used family of aliphatic cores, allowing the construction of multivalent and branched structures via the attachment of four similar or different groups, two pairs of which are tilted at . accordingly, this tetravalent compound has received considerable interest as an orthogonally protected handle useful for the generation of combinatorial libraries, and as a building block that fits well into the general structure of oligonucleotides and peptides, providing additional functionalities. hence, through the years, pentaerythritol-based multiantennary glycoclusters, exhibiting such relevant carbohydrates as b-d-galactopyranosides, galili antigen, , lactosides, galabiosides, a-d-mannopyranosides or sialic acids, were efficiently prepared. these three last examples that furnished promising antiadhesins toward pathogenic infections will be described in more detail in the following section. historically, one of the first example of a glycocluster based on pentaerythritol was furnished in the late s by hanessian et al., who described the synthesis of di-and tri-haptenic clusters composed of the tn (galnac) and the tf [b-d-gal-( ! )-galnac] antigens elongated with serine and glycolic acid spacers and attached through amide bonds to pentaerythritol amino derivatives (fig. ) . a few years later, hansen et al. proposed the first biological evaluation of galabioside clusters built around thiolated scaffolds with different valencies, including pentaerythrityl derivatives (scheme ). efficient inhibition of hemagglutination (hai) by the gram-positive bacterium streptococcus suis at nanomolar concentration was achieved with these constructs. synthesis of the most potent tetravalent soluble inhibitors started with -bromoethyl galabioside ( ) , which was treated with sodium azide followed by o-deacetylation under zemplén conditions and hydrogenolysis to afford -aminoethyl galabioside ( ) in % overall yield. concerning the central core, the commercially available pentaerythritol tetrabromide was treated with methyl -mercaptopropanoate and cesium carbonate to give tetraester , which upon hydrolysis led to the corresponding tetraacid in excellent yield. carboxylic acid activation via formation of a pentafluorophenyl ester, using pentafluorophenol and diisopropylcarbodiimide (dic) and subsequent peptide coupling in the presence of amine , allowed the synthesis in % yield of the desired deprotected glycocluster containing four galabioside residues. biological studies indicated, through the series of multivalent conjugates, a clear connection between inhibitory efficacy, the number of galabiose units present on the potential inhibitor, and the flexibility of the structures. interestingly, the tetravalent galabioside was several hundred times more efficient than the monomeric galabioside in inhibiting the agglutination of human erythrocytes by the s. suis bacterium, resulting in complete inhibition at a concentration as low as nm. inhibition of bacterial adhesion of fimbriated e. coli to pentaerythritol-based clusters bearing peripheral a-d-mannopyranoside residues has also been often addressed, albeit without systematic structure-activity relationships. in this context, lindhorst et al. proposed biological investigations of pentaerythritol-based mannoside clusters to test their capacity to block the binding of e. coli to yeast mannan in vitro. in all of the proposed structures, and according to a rational approach, pentaerythritol itself, as well as the included c spacers, were used as structural components for substituting the inner regions of the monosaccharide moieties (scheme ). the tetravalent cluster has been efficiently synthesized according to two different synthetic pathways. in the first route, a c hydroxy linker was introduced within the aglycone moiety of , and a williamson ether synthesis with pentaerythritol tetrabromide ( ) led to a mixture of mono-, di-, tri-, and tetra-dentate ( ) conjugates, even when an eightfold excess of the corresponding alcohol and forcing reaction conditions were used. in the best case, the protected tetravalent cluster was isolated in % yield. to circumvent these difficulties, an alternative strategy was investigated, involving the use of a modified pentaerythritol derivative to serve as a longer spacer-equipped tetraol ( ) for the subsequent glycosylation step, using imidate . to this end, pentaerythritol was initially perallylated and the extended tetraol was obtained by an hydroboration-oxidation sequence on the double bond in the presence of -bbn, naoh, and h o . then, the perbenzoylated mannosyl trichloroacetimidate was used as the glycosyl donor for the lewis acidassisted mannosylation reaction. deprotection of the resulting tetramer under zemplén conditions afforded the desired cluster in excellent yield. evaluation of antiadhesive properties of the mannosylated clusters was assessed using elisa inhibition assays, in comparison to the monovalent reference methyl a-d-mannopyranoside (meaman). results indicated that tetravalent cluster was more than times more potent (thus . times on a valency-corrected basis) in inhibiting mannose-specific adhesion than meaman, with an ic of . mm. the observed inhibition of bacterial adhesion was most probably explained by the binding of cluster glycosides to single crds, which are distributed along type- fimbriae, rather than by multivalent binding, which would reflect interaction of the sugar clusters with more than one crd. subsequently, touaibia et al. described the efficient and systematic synthesis of a family of mannoside clusters built on pentaerythritol and dipentaerythritol scaffolds using regioselective cu(i)-catalyzed azide-alkyne [ , ] -dipolar cycloaddition (cuaac) (''click chemistry''). [ ] [ ] [ ] the synthetic strategy first involved the use of tetrazide derivative with prop- -ynyl a-d-mannopyranoside ( ) under click chemistry conditions, thus providing tetramer in good yield after o-deacetylation (scheme ).the conditions under which the cu(i) catalyst was generated in situ from copper(ii) sulfate and sodium ascorbate as the reducing agent generally provided slightly better yields than that using the cu(i) species (cui) directly. the second cluster was obtained by the treatment of tetrakis( -propynyloxymethyl)methane ( ), prepared via nucleophilic substitution of the corresponding pertosylated pentaerythritol and propargyl alkoxide, with -azidoethyl , , , -tetra-o-acetyl-a-d-mannopyranoside ( ) under the same conditions already described. an excellent yield of the extended cluster was similarly obtained after acetyl-group deprotection. the tetramannoside analogue , bearing a more rigid aromatic spacer, was likewise obtained from the tyramine mannoside derivative and the tetrapropargylated core . interestingly, the presence of the hydrophobic residue in the mannoside aglycone (triazole) was considered to play an important role for an adequate fit into the e. coli fimh crd active site near tyrosine- and tyrosine- . further, dendritic growths with new multiarmed clusters having more flexibility and various geometries have also been considered by the authors. thus, the hexatosylated dipentaerythritol was converted into hexaazide , which upon treatment with propargylated mannoside under standard conditions of click chemistry and subsequent o-deacetylation afforded the hexavalent cluster in good ( %) yield over two steps (scheme ). the elongated analogues and were then synthesized by the reaction of triazide and ditosylates and under basic conditions (koh, me so) (scheme ). the resulting hexakisazido pentaerythritol scaffolds (n ¼ , ) were then independently ''clicked'' in the presence of prop- -ynyl a-d-mannopyranoside ( ) , affording hexavalent clusters in % yields. deprotection under zemplén conditions furnished the corresponding conjugates and having respectively a distance of and Å between each the tripodal mannoside moieties. preliminary biological data on this series of mannosylated clusters indicated interesting potency in the inhibition of agglutination of e. coli x by baker's yeast, with approximately a hundred times improved efficiency than those obtained with monomeric d-mannose. the pioneering observations of sharon, who first demonstrated the binding preferences of type- fimbriated e. coli to mannopyrannosides bearing aromatic aglycones, led to the hypothesis for the existence of ''subsite-assisted aglycone binding.'' based on these premises, the group of roy et al. pursued their investigations to enlarge the panel of mannopyranoside clusters via single-step multiple sonogashira coupling. the necessary carbohydrate precursors were built with either p-iodophenyl, propargyl, or -azidoethyl aglycones, whereas the central cores consisted of (di)pentaerythritol-based azide or propargyl derivatives. the first target tetramer ( ) was synthesized from p-iodophenyl a-d-mannopyranoside , previously prepared from peracetylated a,b-d-mannopyranose by glycosidation with triflic acid as a promoter. then, sonogashira coupling between tetrakis( -propynyloxymethyl)methane ( ) and , followed by subsequent o-acetyl deprotection of provided the key tetravalent cluster in good yield (scheme ). noteworthy is the fact that those transition metal-catalyzed cross-couplings have been optimized during this study, recommending the use of mol% pd(pph ) cl in the presence of mol% cu(i) catalyst, piperidine as a base in tetrahydrofuran (thf) or n,n-dimethylformamide (dmf), with slow addition of the tetrakis alkyne to prevent homocoupling and degradation. alternatively, tetramer , possessing the reversed linkage functionality, that is, the propargyl group installed on the mannoside residue and the aryl iodide on the pentaerythritol scaffold, was also similarly prepared to investigate the effect of the aryl pharmacophore positioning on binding. in this context, the central tetrakis[( iodophenyloxy)methyl]methane was efficiently elaborated by nucleophilic substitution of pentaerythritol tetrabromide using p-iodophenol under basic conditions in % yield. treatment of with prop- -ynyl a-d-mannopyranoside under the optimized sonogashira coupling conditions just described provided tetramer , which upon further o-deacetylation gave unprotected tetramer in % yield over two steps. according to the same strategy, but using et n in dmf at c instead of the foregoing sonogashira cross-coupling conditions, the corresponding hexavalent cluster was efficiently obtained, using dipentaerythritol derivative and mannoside after conventional zemplén deprotection of . three different types of biological assays were put in place to evaluate the relative binding properties of these tetra-and hexa-valent mannosylated clusters. initially, the cross-linking abilities of these molecules were investigated by using a kinetic turbidimetric assay (nephelometry), with the tetrameric phytohemagglutinin con a from canavalia ensiformis as a model. significant activity of the glycoclusters was observed when they were used as ligands in interactions with protein receptors, with the rapid formation of cross-linked lattices toward con a, especially for tetramer . in fact, this last example was the best candidate, and it induced an almost quantitative precipitation of the lectin within min. obviously, clusters having the scheme . alternative strategy toward the synthesis of hexakis mannopyranosides. alternative triazole heterocycles or the extended series from the sonogashira coupling were less efficient. these results were rationalized by the authors on the basis of the relative stability of the resulting insoluble complexes, with molecular modeling of tetramer showing that each mannopyranoside residue was at the apex of a tetrahedron in which they were . and . Å apart. this distance could easily accommodate the clustering of four different tetrameric con a lectins. each compound was then evaluated for its relative binding affinity by spr measurements. the affinity of the lectin domain of isolated fimh of e. coli k toward clusters was obtained by competitive experiments between an immobilized anti-fimh antibody ( c ) and free mannosylated clusters. according to this study, tetramer was designated as the best ligand known, with a k d of . nm ( . nm/man) in the subnanomolar range, corresponding to -fold and -fold enhancement over the reference monomer methyl a-d-mannopyranoside and the strongest monosaccharide ligand known (heptaman), respectively. once again, the position of the phenyl ring appeared to be rather important with regard to modulating the activity of tetravalent conjugate (k d ¼ nm), which differed from only by the inverted alkyne-phenyl ring sequence. these results thus further demonstrated that clusters possessing an aryl moiety in the vicinity of the anomeric oxygen atom showed the best overall qualifications. conjugates obtained by the click chemistry already described have also been studied. spatial rearrangement of the hexamer having the triazole rings appeared to be a determinant for affinity, as was nearly five times better than the analogous tetramer (k d of and nm, respectively), thus illustrating the influence of multivalency on this scaffold. the distance between the anomeric oxygen atom and the triazole ring was also a critical factor for affinity. on the other hand, the introduction of four or six mannopyranoside moieties using extended precursors and sonogashira coupling had only a minor effect on the relative affinity. finally, the clusters were tested as inhibitors of hemagglutination of pig and rabbit erythrocytes by type- piliated uti clinical isolate e. coli. the inhibition titer (it), that is, the lowest concentration of the inhibitor at which no agglutination occurs, showed tetramer to be the best inhibitor of hemagglutination, with an it of about mm, or a factor of as compared to its affinity, and corresponding to -fold better inhibition than that induced by d-mannose. overall, tetravalent cluster was the best noncovalent cross-linker of con a and the best ligand known to e. coli k fimh. extended biological investigations concerning structure-function studies were further initiated to evaluate the abilities of these clusters to inhibit con a-induced membrane type- -matrix metalloproteinase (mt -mmp)-mediated pro-mmp- activation, cell death, and antiproliferative property in mesenchymal stromal cells (msc). mobilization of mscs and recruitment by experimental vascularizing tumors involves mt -mmp functions. given that the mannose-specific lectin con a induces mt -mmp expression and mimics biological lectin-carbohydrate interactions, these clusters were tested to evaluate their potential to block con a activities on msc. the results indicated that specific tetra-and hexavalent mannoside clusters, especially , , and , reversed con a-mediated changes in msc morphology, and antagonized con a-induced caspase- activity and prommp- activation. they also inhibited con a, but not the cytoskeleton-disrupting agent cytochalasin-d-induced mt -mmp cell-surface proteolytic processing mechanisms, and effects on cell-cycle phase progression. the antiproliferative and proapoptotic impact of con a on the mt -mmp-glucose- -phosphate transporter signaling axis was also reversed by these mannosides. in conclusion, this family of mannosylated clusters very effectively inhibited a spectrum of mt -mmp-mediated cell responses that could be potentially transposed to target tumor-promoting processes. in addition, their noncytotoxicity allowed their use in vivo against experimentally implanted tumors. recently, gouin et al. have designed a tetravalent cluster ( ) based on a potent e. coli fimh ligand heptyl a-d-mannoside ( ) that has been preliminarily recognized as a strong binder to fimh, with a k d of nm, as determined by spr measurements (fig. ) type- -piliated e. coli on a bladder cell line and biofilm formation in vitro, and also decreases bacterial levels in a murine cystitis model. suitably functionalized and flexible ethylene glycol linkers were used to tether moieties in order to ensure water solubility and efficient conjugation on a pentaerythritol core via ''click chemistry'' to afford neoglycoconjugate . binding affinities of the new flexible synthetic glycocluster toward type- -piliated e. coli were evaluated by hai and bladder-binding assay (bba). the results indicated that, with an inhibition of bacterial bladder-cell binding at nm ($ -and -fold lower than mannose and , respectively), the tetravalent compound is currently one of the most promising antiadhesive drugs under development for the treatment of urinary tract infections. pentaerythritol-based glycoclusters have also been investigated as potential neuraminidase inhibitors. in this context, linhardt's group has described a straightforward approach to generate clustered nonnatural n-glycosylamines of a-sialic acid, which are known to be resistant to neuraminidase-catalyzed hydrolysis as opposed to the natural o-glycosides. influenza viruses use their hemagglutinin to bind to sialic acid residues located on the surface of the host cell and gain entry into the cell. once the cell is infected, the new virions use their neuraminidases (or sialidases) to escape from the infected cells. thus, these neuraminidases have been targeted to stop viral infection by blocking the virus inside the infected cells. to this end, a small library of mono-and divalent , , -triazole-linked sialic acids has been constructed via click chemistry, together with corresponding tetravalent cluster, generated from tetrapropargylated core and a-sialic acid azide. preliminary neuraminidase-inhibition assays, involving fluorescence measurements induced by the release of -methylumbelliferone produced by the hydrolysis of the substrate [ -( -methylumbelliferyl) n-acetyla-neuraminic acid] by the enzyme [neuraminidase from clostridium perfringens (clostridium welchii)], have been addressed. the results indicated micromolar ic values, notably for the tetramer with an ic of mm, comparable to the known sialidase inhibitor neu ac en ( mm). inasmuch as only a few of the carbohydrate residues contained in large oligosaccharides can be involved in several binding-recognition process to trigger or inhibit various biological phenomena, it has been assumed that the roles of the remaining sugars within the polymer were limited to a structural matrix, acting simply as spacers maintaining the epitopes at the proper distances to ensure optimal interaction with the receptor-binding sites. based on these preliminary assumptions, structural analogues of elicitors could result from molecules containing an aromatic core supporting pendant sugar epitopes. by substitution of structural sugar components with benzenoid groups, the rigidity of the polymeric matrix would be preserved with only minimal distortion to the three-dimensional framework. the first and closest analogy to such ''aromatic core'' harboring cluster glycosides was provided by yariv et al. who first described phloroglucinol-based ''artificial antigens'' , with the general formula , , -tris-(p-glycosyloxyphenylazo)- , , -trihydroxybenzene. these early multivalent models had the ability to form brightly colored, cross-linked precipitates with antibodies directed against the appropriate and homologous carbohydrate determinants (fig. ). through the years, the development of transition metal-catalyzed methodologies, notably involving cyclotrimerization and sonogashira or heck cross coupling, has paved the way for rapid and efficient access to aryl glycoclusters with desired and controlled valency. a. glycoclusters from intermolecular cyclotrimerization.-in , kaufman and sidhu described the one-step synthesis of aromatic cluster glycosides via metalcatalyzed cyclotrimerization of appropriate acetylenic sugar precursors. feasibility of this type of benzannulation approach in glycochemistry. treatment of acetylenic precursors ( , , ) with the conventional cyclotrimerization catalyst, dicobalt octacarbonyl, co (co) , gave a mixture of the corresponding regioisomeric trimeric glycosides and (scheme ). although the reaction appears to be quite general, the yields, ranging from % to %, tend to be markedly influenced by the nature of the starting material, and the thio analogues afforded poor yields, undoubtedly due to poisoning of the cobalt catalyst. in the same study, the authors also proceeded to the construction of original ''octopus-like'' hexakis glycosides, readily accessible from the corresponding bis (glycoside) monomers (scheme ). thus, cyclotrimerization of -butyn- , -diyl bis-(b-d-glucopyranoside) octaacetate ( ) gave benzenehexaylhexamethylene hexakis-(b-d-glucopyranoside) tetraeicoacetate in an excellent yield of %. the corresponding thio derivative ( ) was also prepared according to similar conditions, but in lower yield ( %). hexavalent glycocluster , organized around a hexaphenylbenzene core, has also been obtained via a synthetic strategy involving diphenol , which was coupled with tetra-o-acetyl-a-d-glucopyranosyl bromide ( ) using stannate methodology to furnish divalent glycoconjugate in moderate yield. its cyclotrimerization under the standard cobalt-catalyzed conditions gave the desired glucosylated cluster in % yield. however, these elegant glycosylated nanostructures displayed only weak biological activity relative to their native glucan elicitor counterparts. nevertheless, such glycoclusters provided unique environments for host-guest chemistry of amphipathic molecules owing to their lipophilic core surrounded by a hydrophilic periphery. subsequently, roy et al. improved the methodology to provide hexavalent mannopyranosides via [ þ þ ]-cycloadditions in the presence of the dicobalt octacarbonyl catalyst by refluxing in , -dioxane for only h (as compared to days for the mannoside cluster obtained in the previous example). regioisomeric mixtures of , , -and , , -isomeric clusters were obtained in % yield and in : molar ratio. interestingly, the reaction was general and could be equally applied to several other saccharides. prompted by the success of the dicobalt octacarbonyl-catalyzed cyclotrimerization, the same group attempted similar reactions with symmetrical and mannosylated disubstituted alkynes. under identical conditions as just described, the corresponding hexamer was obtained in % yield. the resulting deprotected cluster, obtained quantitatively under zemplén o-deacetylation conditions, was water soluble and showed excellent cross-linking abilities with tetrameric plant lectins, indicating that the spatial orientation and rigidity provided by the extended inner aryl core offers great potential as neoglycoconjugates. a few years later, the same group extended this strategy in order to access metabolically stable c-glycosyl clusters containing long-arm spacers via a sequence of transition metal-catalyzed transformations (scheme ). scheme . ''molecular-asterisk'' bearing the hydrolytically stable c-galactosyl group as synthesized by roy et al. mannopyranosides, in ratios similar to those observed with the dicobalt octacarbonylmediated benzannulation but with decreased reaction time and much improved yields. therefore, -propynyl glycosides, including the acetylated a-d-mannopyranoside, b-d-galactopyranoside, and lactoside were treated with grubbs' catalyst ( mol%) in dry dichloromethane at room temperature for h. the desired trisubstituted benzene derivatives were isolated as typical mixtures of , , -and , , regioisomers ( : ) in - % yields. by contrast, the access to corresponding hexavalent analogue via cyclotrimerization of disubstituted symmetrical alkynes was not successful, perhaps because of steric hindrance. b. glycoclusters from cross-coupling reactions.-earlier work in the mid s by several research groups highlighted the formation of cross-linked lattices induced when multivalent protein receptors were admixed with synthetic carbohydrate multimers, including dimers. , all of the reported evidence supported the notion that small-rigidified carbohydrate clusters bearing hydrophobic residues would form stable complexes. the result of the synthetic efforts as presented here was inevitably the formation of glycoside clusters wherein the sugar moieties were linked to the side arms emerging from the central platform through o-, s-, or c-glycosidic linkages. based on these observations, roy et al. proposed efficient synthesis of oligomeric carbohydrate clusters, named ''sugar-rods,'' by using sonogashira-heck-cassar (shc) cross coupling reactions. , in this context, dimeric conjugates of constrained conformational flexibility, incorporating central hydrophobic aryl residues, were obtained under standard sonogashira cross-coupling conditions. hence, heating a mixture of protected propynyl glycosides with a p-diiodobenzene core in the presence of catalytic tetrakis(triphenylphosphine)palladium( ) in a : mixture of dmf-et n quantitatively afforded the corresponding glycosylated bisethynylene derivative. it is worth noting that the reaction was effected in the absence of cu(i) as cocatalyst, thus preventing the undesired oxidative homodimerization of the propynyl starting material (glaser reaction). this general strategy, compatible with various glycosides and the usual acetate protecting groups, has also been applied toward the efficient synthesis of divalent ''rod-like'' thioglycosides, which represent potential enzyme inhibitors because of their resistance to enzymatic hydrolysis. sengupta and sadhukhan adapted this one-step pd-catalyzed methodology to triand tetra-valent aromatic cores in order to generate multiantennary glycoclusters (scheme ). a threefold sonogashira cross-coupling reaction of propargyl b-dglucoside with , , -tribromobenzene ( ) in the presence of pd(dba) , pph , in a : mixture of et n and dmf at c smoothly gave rise to the centrally planar triantennary glycocluster in % isolated yield. the authors also presented an example wherein multivalent glycoclusters could be rapidly assembled via a multiple heck reaction strategy. for this purpose, -o-acryloyl- , : , -di-o-isopropylidenea-d-glucofuranose ( ), derived from alcohol , was used with the centrally tetrahedral core tetra(p-iodopenyl)methane ( ) under phase-transfer-catalyzed conditions (pd(oac) , bu nbr, nahco , dmf) at c. the resulting tetrahedral glycocluster was obtained in % yield. a few years later, dondoni et al. extended the pd-catalyzed cross-coupling strategy to c-glycosyl compounds, resistant to enzymatic degradation. dense c-glycosylated clusters built around benzene as a rigid platform were thereby synthesized via multiple shc cross-coupling reactions, using various ethynyl c-glycosyl derivatives and polyiodinated benzenes. the limit of this type of conjugation was tested by the use of such crowded systems as those represented by vicinal polyiodobenzenes and short-arm sugar acetylenes. the study elegantly and efficiently afforded di-and tri-valent conjugates from p-diiodobenzene and sym-triiodobenzene, respectively, involving the use of diversely protected ethynyl glycosides (acetylated or benzylated). in addition, the deprotection via hydrogenolysis of the clusters generated from the conjugation of benzylated saccharides afforded the corresponding ethylene-bridged systems, since the triple bonds were also reduced through this operation. as the use of benzylprotected ethynyl c-glycosyl derivatives turned out to be inefficient as reaction partner in the shc with the tetraiodobenzene, the desired tetravalent neoglycoconjugate was biological investigations of these rigid clusters were addressed by andré et al., who described the preparation of lactoside-bearing glycotope bioisosteres having strong binding affinities to lectins (fig. ) . according to the optimized sonogashira conditions already described, and using the required di-and tri-iodinated benzene cores and per-o-acetylated -propynyl lactoside, they obtained divalent ( ) and trivalent ( ) glycosides in yields of % and %, respectively. complete o-deacetylation resulted in freely water-soluble clusters in almost quantitative yields. the relative affinities of these lactoclusters were evaluated in a competitive solidphase binding assay, using different labeled sugar receptor as probes, notably the b-trefoil mistltoe lectin (viscum album agglutinin, vaa) and three mammalian galectins having different modes of presentation of their respective crds. preliminary results indicated that glycoclusters could well surpass the inhibitory capacity of lactose. of note is the fact that binding of the two homodimeric proto-type galectins- and - was not effectively influenced by the presence of multivalent compounds. fig. . di-and tri-valent rigidified lactoside clusters having strong affinity to v. album lectin. in fact, only a few of them manifested inhibitory capacity in the range of free lactose, demonstrating cases of negative correlation between carrier-dependent presentation of lactose and inhibitory efficiency. however, the trivalent cluster induced the strongest cluster effect with the chimeric-type galectin- , with an ic of . mm ( mm for free lactose) in contrast to the corresponding divalent lactoside . its efficiency was independently confirmed by hemagglutination and by in vitro cytofluorometric tumor-cell binding analysis. the trivalent compound was a potent inhibitor of galectin- , blocking its binding to native cell surfaces. finally, these data underlined the feasibility of galectin-type target selectivity by compound design, despite the use of an identical headgroup for the synthesis. c. persulfurated glycoclusters.-recently, two research groups have independently described the synthesis of persulfurated glycoclusters, organized around an aromatic core, that showed interesting lectin-binding activities. in an ongoing research program to study mannose-binding proteins (mbps) by the systematic syntheses and biological evaluation of multivalent glycomimetic inhibitors against bacterial adhesion, chabre et al. have described the synthesis via ''click chemistry'' of dense sulfurated glycoclusters containing up to peripheral a-d-mannopyranoside residues (scheme ). the synthetic strategy employed hexavalent sulfurated scaffolds , initially obtained by thioacetylation of a commercial hexabromomethylated precursor with potassium thioacetate, which was further functionalized with tris derivatives -bromoacetamido-tris[propargyloxy)methyl]aminomethane ( ) . this trivalent moiety was synthesized in an efficient three-step sequence using boc n-protection of tris, followed by propargylation under basic conditions. quantitative removal of the boc protecting group under acidic conditions and reaction with bromoacetyl chloride led to precursor , which was then treated with hexathioacetate under basic and reductive conditions to afford the octadecapropargylated dendritic scaffold in excellent yield. its treatment with -azidoethyl tetra-o-acetyl-a-d-mannopyranoside ( ) using ''click chemistry,'' and subsequent deprotection under standard zemplén conditions provided the densely packed cluster containing peripheral mannoside residues. initial evaluation against the bcla lectin from burkholderia cenocepacia by itc revealed promising candidate ligands having strong affinities (chabre et al., unpublished results). the second example has been furnished by sleiman et al., who proposed a new class of persulfurated, semirigid, radial, and low-valent glycosylated ''molecular-asterisks'' possessing dual function as ligands and as probes by virtue of the conjugated electronic system. moreover, these glyco-asterisks could exhibit conformational preferences for alternating up-and-down patterns around the central core by exposing the phenylthio groups above and below the plane of the benzene ring, which could be thf/h o, % . these glycoclusters were obtained from the hexaamino persulfurated benzene precursor , readily accessible on a multigram scale by coupling sodium -acetamidothiophenolate with commercial hexachlorobenzene in , -dimethyl- -imidazolidinone (dmi) and subsequent deprotection in concentrated hydrochloric acid. various protected carbohydrates containing terminal carboxylic acid function ( ) ( ) ( ) were then introduced onto the multivalent amino-scaffold, using -ethoxy- -ethoxycarbonyl- , -dihydroquinoline (eedq) as the coupling agent, in yields ranging from % to %. o-deacetylation under zemplén conditions occurred uneventfully to provide the hexavalent clusters and . in order to assess their biological activity, the authors investigated their ability to inhibit the hemagglutination of rabbit erythrocytes by con a. results indicated that the a-glucose asterisk efficiently inhibited hemagglutination at mm, corresponding to a -fold enhancement per sugar relative to methyl a-d-glucopyranoside. a more significant impact was recorded for the a-d-mannoside , which showed one of the best inhibitory potencies reported at a minimum concentration of nm, and hence a greater than -fold increase in relative activity per sugar compared to methyl a-d-mannopyranoside. control experiments proved that nonspecific interactions of the scaffold were not responsible for the observed inhibition effects, which were more probably induced by a powerful cross-linking phenomenon. in addition, the authors observed a -fold amplification of selectivity between the mannose and the glucose clusters relative to the monovalent compounds. meona, meoh quant. con a by the mannoside cluster at concentrations slightly above the nanomolar range, according to a mannose-dependent and partially reversible process. finally, these results suggested that, rather than an increased avidity for con a, the unusual potency of these molecular glycoasterisks was due to an efficient and kinetically controlled macromolecular assembly that strongly amplified the effect of these low-valency ligands. d. glycoclusters with a calixarene core.-cyclic polyaromatic calix[n]arenes, owing to their oligomeric nature and shapes that can be tailored by the size of the macrocycle ring and by the nature of the substituents on the lower rim, are attractive multivalent scaffolds with controllable valency. hence, they constitute valuable candidates onto which glycosides can be exposed at the periphery. more particularly and analogously to cds, calix [ ] arenes blocked in the cone conformation can, to some extent, mimic a small portion of the multiantennary cell surface, presenting a series of glycosylated residues on the exterior of a lipophilic cavity. moreover, the cavity and the spacers between the upper rim of the calix[n]arenes and the sugar units can be useful for cooperatively binding molecules in a host-guest chemistry process. in this way, the inclusion complexes could be directed toward selected biological targets which specifically recognize the carbohydrate units, with the glycocalix[n]arenes acting as novel types of site-directed molecular delivery systems. they thus provide a versatile platform of well-defined shape for the construction of more-sophisticated structures, including neoglycoconjugates that may be named ''calyx sugars.'' furthermore, because of their low cytotoxicity, calixarene derivatives have found wide applications in the biomedical field as enzyme inhibitors, anticoagulant and antithrombotic agents, antiangiogenic and anticancer, antiviral, antimicrobial, and antifungal products. since the first examples of lower and upper rim glycocalixarenes were obtained in by marra et al., employing the mitsunobu reaction or copper(ii)-catalyzed glycosylation, the development of efficient synthetic methodologies has allowed the emergence of several examples of o-, n-, or c-glycosyl calix[n]arenes, and these have recently been reviewed ( - , fig. ). , severe drawbacks resulting from the absence of suitable spacer arms and low water solubility recorded for the first calix[n]arene-glycoconjugates have been overcome during subsequent years with the use of adapted chemical ligations and suitably derivatized carbohydrates. as example, -thio-a-sialosides have been efficiently conjugated to a calix [ ] arene scaffold via nucleophilic substitution, providing extended and water-soluble clusters that may exhibit up to dense clustered epitopes. wittig olefination, , pd-catalyzed sonogashira cross coupling, click chemistry, , and azide-nitrile cycloaddition [ ] [ ] [ ] [ ] (which can act as hydrogen-bonding groups) have been described and have afforded elongated nanostructures with tailored spacer arms. these have shown promising applications as drug delivery systems via host-guest supramolecular chemistry. initial exploratory investigations, addressed by dondoni et al. in the late s, have highlighted the ability of calyx sugar to recognize such neutral and charged molecules as d-glucosamine hydrochloride and tetrabutylammonium dihydrogenphosphate, and showing interesting potential as receptors of phosphate or phosphonate-bearing molecules of biological relevance. the same group then synthesized thiourea-linked upper rim calix [ ] arene glycoconjugates with exposed two or four glucose, galactose, and lactose units, and they further investigated the recognition properties of these glycocalixarenes, together with their interactions with specific lectins. solution h nmr and electrospray ionization-mass spectrometry (esi-ms) experiments demonstrated their anion-recognition properties, enhanced with the presence of an aromatic ring in the guest, whereas turbidimetric analysis indicated the ability of the glycoclusters bearing four peripheral glucosides and galactosides to interact with con a and with peanut lectin, respectively. these combined features made these new glycoclusters attractive as possible site-specific molecular delivery systems. higher valency analogues, such as glucosylthioureidocalix [ ] -and calix [ ] arenes were further investigated. supramolecular studies suggested the formation of self-assembled small discoid-like particles in water ( - nm in size), in equilibrium with the monomeric macrocycle, which ideally could exhibit a working valency much higher than when compared with that of the monomeric species. turbidimetric measurements and atomic force microscopy (afm) assays indicated strong interactions with con a, especially for the octameric glycoconjugate, causing agglutination with the formation of large supramolecular entities, which progressively evolved toward precipitation because of the extensive lectin cross-linking. besides these preliminary studies that have demonstrated the interesting potential of these calyx sugars, recent applications have afforded striking and concrete results. in , elegant work disclosed from combined efforts of the ungaro and bernardi groups has described the synthesis of a divalent cholera toxin (ct) glycocalix [ ] arene ligand ( ) having higher affinity than the natural gm oligosaccharide (fig. ). the bacterial ct is produced by toxicogenic strains of the gram-negative bacillus vibrio cholerae, the causative agent of cholera, the life-threatening acute diarrhea, that mainly affects third-world populations. this heterohexameric ab complex is composed of structurally independent, catalytically active heterodimeric a (ct-a, enzymatic) and homopentameric b (ct-b, targeting) subunits. this last moiety effects recognition and anchoring to the cell membrane. with % sequence homology in common with the heat-labile enterotoxin secreted by some strains of the e. coli bacterium (lt), their mode of action remain similar: both toxins exploit the intrinsic complicated trafficking mechanisms of the host cells to gain access to the cytosol, where they exert their detrimental activity. as a prelude to the infection, once in the lumen of the gastrointestinal tract of the human host, the toxins recognize the receptor ganglioside gm [bgal ! bgalnac ! (aneu ac ! )bgal( ! )b glc ! cer] ( with an ic of nm for ct)) on the surface of epithelial cells through the b subunits arranged in a pentameric pattern which trigger endocytosis. acute structural studies and biochemical data concerning the fundamental interaction of gm with ct demonstrate the critical role of the two sugars at the nonreducing end of gm , namely galactose and sialic acid. taking these specific structural properties into consideration, the rational design of artificial receptors for the toxin as monovalent or multivalent ligands has been envisaged. while preparation of the ganglioside gm represents a tedious synthetic challenge, one of the strategies of impeding ct-b/gm interactions concerns the design and synthesis of functional and structural in this context, divalent presentation of this promising candidate has been investigated by the authors using the fixed cone conformation of calix [ ] arene to allow introduction of the molecules onto the upper rim, and their projection into the same portion of space, thus mimicking, to some extent, a small portion of the natural cellsurface ganglioside. the synthesis of the divalent neoglycoconjugate was based on initial functionalization of the corresponding diacid with an aminated spacer and further introduction of squaric acid moieties. the interaction of the deprotected cluster with ct was studied by fluorescence spectroscopy, which indicated that, together with elisa assays, the ligand displayed a higher affinity for ct (ic ¼ nm) than the natural gm oligosaccharide under the same conditions (ic ¼ nm). an exceptionally high-affinity enhancement relative to that for the monovalent ligand was thereby obtained, roughly fold (namely per sugar mimic). although complementary detailed thermodynamic analysis is needed to determine the precise role of multivalency in this particular system, the result constituted another striking example highlighting the advantageous utilization of calixarene scaffolds together with the use of a glycomimetic. subsequently, křenek et al. proposed a series of calixarenes substituted with acetamido- -deoxy-b-d-glucopyranose (glcnac) directly linked by a thiourea spacer, and tested their binding activity to heterogeneously expressed activation of c-type lectin-like receptors of the rat natural killer (nk) cells nkr-p , and the receptor cd (human nk cells, macrophage). nk cells are important components of the innate immune response against tumors and early protection against viruses and other intracellular pathogens. interestingly, high-affinity carbohydrate ligands for both major activating receptors, nkr-p and cd , have been found. more particularly, glcnac was recognized as a high-affinity receptor in this study. furthermore, multivalency through multiantennary, branched glcnac-containing structures was found to be crucial for a highly specific recognition and binding event to nkr-p and cd receptors in vitro. hence, this study was initiated to determine differences in the binding capability of calix [ ] arene-based glycoconjugates to recombinant receptors, as well as their effects on proliferation and cytotoxic cell-effector function. results indicated that, in the case of nkr-p , the binding affinity of b-d-glcnac-substituted calixarenes carrying two or four sugar units was comparable to that observed with known linear chitooligomers. the influence of glcnac substitution of the calixarene skeleton on binding affinity for cd receptor was more profound, and the corresponding tetravalent cluster containing thiourea functionalities displayed very potent inhibitory activity, with -logic as high as . , making it one of the best ligands for this receptor. the use of glycoconjugates with lower valency led to a dramatic decrease of the binding activity. in addition, the immunostimulating activity of the tetravalent glycoconjugate indicated a proliferation and stimulation of natural cytotoxicity of human peripheral blood mononuclear cells (pbmc) at concentrations of À and À m, as observed for lipopolysaccharide. moreover, at these concentrations, it induced an increase in the spontaneous death of tumor targets. generally, calyx sugar derivatives were superior to the corresponding dendritic pamam-glcnac analogues (see next). the synthesis of a novel anticancer vaccine candidate built on a nonpeptidic scaffold, in which a cluster of four s-linked tn antigen glycomimetics (s-tn) was conjugated to an immunoadjuvant moiety, trihexadecanoyl-s-glycerylcysteinyl-serine (p cs), through a calix [ ] arene scaffold has been described. the glycomimetic s-tn antigen was chosen as antigenic determinant because of its higher metabolic stability and capability to determine the maximal immunostimulating activity of a construct at lower doses with respect to the natural o-tn analogue. preparation of the calix [ ] arene platform started from disymmetrical , , -tripropoxy- -hydroxy-p-tert-butylcalix [ ] arene ( ) , which reacted with ethyl bromoacetate in the presence of nah to furnish ester quantitatively (scheme ). direct replacement of the tert-butyl groups via aromatic nitration afforded the nitrocalixarene derivative which, upon subsequent reduction with h at atmospheric pressure using pd-c catalyst, afforded the amino analogue . afterwards, four boc-glycine spacers were efficiently introduced into the upper rim of the macrocycle, via standard amide coupling in the presence of pybop and dipea. saponification (aq. koh, thf) of the ester group led to intermediate , containing a single carboxylic acid functionality in the macrocycle lower rim, for amidation to the p cs immunoadjuvant unit leading to . removal of the boc group with tfa and coupling of the s-tn acid derivative with hoat/edc in dry dmf allowed the formation of the targeted conjugate . thus, in the designed construct, the four s-tn antigen units were linked covalently through the glycine spacers of the calix [ ] arene. three propyloxy groups and one pendant p cs unit at the narrow rim block the synthetic core in a rigid cone-shaped conformation, ensuring the preorientation of the antigenic units on the same side with respect to the median plane of the macrocycle. the all-syn orientation of tn antigens was crucial for better mimicking of the cancer cell surface, while the presence of a glycine spacer should avoid steric hindrance and ensure flexibility, both advantageous in the antigen-immune system interaction. the authors evaluated the immunogenicity of the tetra-tn construct in mice by using a monovalent glycoconjugate as reference compound. the aim was to investigate the role of the cluster effect in amplifying the antibody production with respect to a single presentation of the tn antigen unit. in the serum-dilution range considered, mice immunized with tetramer showed a substantial and significant production of antibodies. even when the concentration of monovalent compound was increased fourfold with respect to the parent monovalent derivative , the reactivity elicited by the clustered construct was significantly higher. these data clearly showed that a cluster effect provoked the higher immunostimulating activity of the tetravalent cluster as compared to the monovalent analogue. the authors thus presented still further convincing evidence for a vaccine candidate built on a nonpeptidic platform that induces a more-effective immune response due to the cluster effect and presentation in an optimized arrangement of tn antigens. the rigid calix [ ] arene scaffold was claimed to properly mimic the mucine surface encountered in vivo. in a later investigation, a set of calix[n]arenes (n ¼ , , or ) having thiourealinked galactose or lactose moieties were prepared to analyze their reactivity toward the reference plant lectin from vaa relative to three human galectins (galectins- , - , and - ). despite their high degree of flexibility, the calix [ , ] arenes generally proved especially effective for the plant ab-toxin. in the solid-phase model system involving vaa lectin and using the absorbed glycoprotein asialofetuin (asf), the inhibitory potency of the hexa-and octavalent galactoside clusters were and mm, respectively, corresponding roughly to a -fold enhancement as compared to free galactose. as demonstrated with solid-phase and cell-binding assays, clustering on macrocycles was also particularly effective toward galectin- . in fact, among the human lectins, different response patterns were registered, the tandem-repeat-type galectin- reacted very sensitively to the presence of these test compounds. the ic value for the lactoside cluster was lowered by a factor of -fold relative to the free sugar, when calculating the sugar concentration in the assay. these bioassays underlined clear intergalectin differences and dependence of inhibition on the conformational properties of the calix [n]arenes scaffold, as well as on the shape and valency of the glycoclusters. e. glycoclusters with porphyrin cores.-the attachment of saccharide components to porphyrin macrocycles gives rise to various derivatives termed glycoporphyrins, which might become of great importance for medicinal and other applications, such as catalysis and molecular recognition. since the pioneering synthesis of this type of glycoconjugate first described by maillard et al. in the late s via condensation of -formylphenyl tetra-o-acetyl-b-d-glucopyranoside with pyrrole, improved synthetic methodologies have generated highly promising water-soluble glycoconjugates showing potential as photosensitizers (pss) in photodynamic therapy (pdt), or as antibiotics, antiviral agents, and drug sensors. interestingly, despite the fact that carbohydrate and porphyrin derivatives constitute two groups of naturally occurring compounds of great significance to all existing organisms, only a few examples of natural glycoporphyrins are known. tolyporphin a , isolated from the blue-green alga tolypothrix nodosa, whose total synthesis has been reported, , and the chlorophyll c -monogalactosyldiacylglyceride , a derivative isolated from emiliana huxleyi, are two examples of natural glycoporphyrin-like derivatives (fig. ) . the biological significance of glycoporphyrins, their limited natural occurrence, and their widespread applications have made the availability of such compounds a scientific challenge for several research groups. synthetic approaches have consisted in the direct glycosylation of prefunctionalized porphyrins or chemical synthesis from suitable glycoconjugates precursors. two general approaches have thus been used to access glycoporphyrins. the first is based on lindsey's method involving the coupling of pyrroles or dipyrromethanes with glycoaldehydes species through acid-catalyzed condensations, followed by oxidation of the reaction mixture, for instance with , -dichloro- , -dicyanobenzoquinone (ddq) (fig. ). by this strategy, o-, , c-, and s-linked glycosyl compounds can be obtained, and have been examined in detail. interestingly, higher valency glycoporphyrins can be obtained by following the pyrrole-aldehyde condensation strategy, generating o-glycosylated porphyrin dimers possessing ether linkages. the second methodology involves direct introduction of glycosylated moieties onto a suitably functionalized meso-arylporphyrin scaffold, accessible from a natural source (protoporphyrin-ix) or by total synthesis. several o-, , , s-, and n-glycoporphyrins ( ) ( ) ( ) ( ) ( ) have thus been prepared (fig. ) . moreover, in order to explore the influence of the clustered peripheral saccharides around the porphyrin scaffolds, and to evaluate their photophysical properties, the synthesis of dodecavalent porphyrins bearing four trivalent glycodendrons via amide ligation ( ) has been achieved. pdt is certainly the most promising application for this kind of neoglycocluster. its concept is based on the concentration of ps in target cells and upon subsequent irradiation with visible light in the presence of oxygen, leading to specific destruction of the target cells or tissues. there is general agreement that the principal mechanism whereby cell destruction occurs involves the disruption of the cellular, mitochondrial, or nuclear membranes by singlet oxygen ( o ) generated by the action of the ps. photofrin , the first pdt formulation introduced, has been approved in several countries including usa, canada, netherlands, france, germany, and japan for treatment of bladder, esophageal, gastric, cervical, and lung cancers, and several other diseases. although photofrin is effective against a number of malignancies, it is not an ideal ps because of the lack of a well-defined structure, its weak absorbance in the red region of the visible spectrum and the long-lasting skin photosensitivity induced. mainly because of these drawbacks, several other derivatives have been synthesized with the required peripheral substituents, such as carbohydrate residues to control water solubility, biodistribution, pharmacokinetics, and affinity-selectivity for cancer cells. five novel diethylene glycol (deg)-linked o-and s-galacto or manno-conjugated m-tetraphenyl porphyrins have been prepared and their biological and photobiological properties investigated in vitro against a human retinoblastoma cell line (y ). preliminary studies established that human retinoblastoma cells express sugar receptors that exhibit a preferential affinity for galactose and mannose residues. the precursor , , -m-tri(p-phenol)- -phenylporphyrin ( ) was used for synthesis of all of the glycoconjugates studied (scheme ). the trivalent o-glycosylated deg porphyrins a (b-gal), b (a-gal), and c (a-man) were obtained by treating with the requisite bromo-substituted glycosides ( ), followed by deprotection under zemplén conditions, with yields ranging from % to % over two steps. the corresponding thioglycosylated porphyrin analogues d (b-gal) and e (a-man) were obtained according to a slightly modified strategy involving the preliminary synthesis of the bromo-substituted porphyrin glycol via standard williamson etherification and final introduction of peracetylated -thioglycopyranoses under basic conditions, with improved overall yields of - %. the amount of ps taken up by the y retinoblastoma cells was first determined by fluorescence intensity measurements (reflecting the internalized drug concentration) scheme . galacto-and manno-substituted tetraphenyl porphyrins used for pdt against human retinoblastomas. using flow cytometry. the results indicated efficient internalization of the glycoconjugates, preferentially in the membranes of all cytoplasmic organelles, with the extent of uptake dependent upon the nature of the sugar component, its anomeric configuration, and the linker used. an increase in the spacer length linking the tetrapyrrolic ring and the sugar moiety resulted in higher cellular uptake in the case of a (o-b-gal), d (s-b-gal), and c (o-a-man), while a considerable decrease in drug internalization was observed for b (o-a-gal). hence, these results highlighted the importance of the amphiphilic/lipophilic character of these clusters, indicating that high lipophilicity led to low cellular uptake. the binding affinity toward the sugar-specific receptors on y cells has also been investigated by examining a possible competition effect between the glycoporphyrins and the corresponding glycosylated albumin, indicating inhibition of uptake values of - %, possibly due to cell-sugar-receptor saturation. in addition, their phototoxicity in darkness, evaluated by measurements of the cell survival fraction, was found to be negligible in all cases. high photoactivity was observed for the two a-galacto-manno porphyrins b and c (ld ¼ . and . mm, respectively) at nm and low fluence ( j/cm ). in addition, glycoporphyrins can also exhibit possible cell-membrane interactions that can affect, for instance, the plasma lifetime of a particular drug. promising results have been obtained for both compounds b and c since each one showed high in vitro photobiological activity in human retinoblastoma cells. very low doses of the drug associated with low light intensities were sufficient to observe a marked effect. moreover, both compounds undergo only very limited cellular metabolic degradation. the same group further investigated the in vitro phototoxicity in order to determine the influence of different structural parameters. despite lower photodynamic activity than that observed for hydroxylated pss (in particular the common foscan or temoporphyn ), glycoconjugates displayed phototoxicity against y cells having significant intrinsic cytotoxicity. these results confirmed that the photoactivity could be strongly modulated by the presence of a deg spacer between the chromophore and the glycoside, and by the anomeric configuration of the sugar. trivalent a-o-galactosylated porphyrin b was determined to be a better candidate than foscan in the clinical application of pdt for conservative therapy of retinoblastomas. a second example has been addressed in which the synthesis and potential application of a series of neutral o-glycosylated porphyrin dimers and two original o-glycosyl cationic dimers were examined in pdt. in order to understand the influence of the number of glycosyl moieties, the spatial geometry and the ionic character on their photodynamic activity was evaluated. the in vitro results concerning their photocytoxicity against k human chronic leukemia cells compared favorably with those of the common ps photoprin ii . two strategies for preparation of neutral and monocationic porphyrin models were used. the presence of a spacer arm directly attached to the meso phenyl position of the porphyrins gave access to a series of dimers with different substituents on the meso position and with different geometries. neutral bisporphyrins were synthesized according to lindsey's methodology, namely the coupling of pyrrole with p-formylphenyl , , , -tetra-o-acetyl-b-d-glucopyranoside and o-or p-hydroxybenzaldehyde with controlled stoichiometry and in the presence of bf .et o as catalyst (scheme ). subsequent oxidation of the porphyrinogen intermediates with p-chloranil gave porphyrins a and b in % and % yields, respectively. treatment of a or b with an excess of , diiodopropane (k co , dmf, reflux) afforded derivatives a or b in - % yields, respectively. dimers a and b were formed by the reaction of a or b with the monohydroxylated precursors a or b via nucleophilic substitution, followed by o-deacetylation under modified zemplén conditions. the analogous triglycosylated bisporphyrin was similarly obtained from -( -hydroxyphenyl)- , , tristolylporphyrin ( ). an elegant synthesis of a monomeric porphyrin intermediate bearing one pyridyl and three glycosyl units, precursor of cationic dimers, has also been described (scheme ). the authors first determined the partition coefficients of the deprotected bisporphyrin conjugates in order to evaluate their lipophilic character. both triglycosylated conjugates and were found to be more lipophilic than a,b and . next, studies concerning their photosensitizing properties, consisting in trapping reactions of o with ergosterol acetate, indicated production of o in very high yield, comparable to the reference hematoporphyrin (hp). their in vitro photocytotoxicity was then evaluated against the k leukemia cell line. the amphiphilic character was found to be an essential factor for efficient pdt, since the amphiphilic triglycosylated dimers and more particularly neutral , were found to be more active, with a quasi-similar activity to photofrin for after min of irradiation, inducing - % cellular death, probably through apoptosis. in addition, it has been shown that the presence of the glucosyl residues on the same side of the dimer conjugates was crucial for optimal activity. a final illustration of the biological potential of glycoporphyrins has been provided by ballut scheme . synthesis of glucosylated porphyrins bearing cationic head-groups. (dmpc) liposome membrane and measured the interaction of the resulting conjugates with con a lectin. in this context, the authors designed a new family of glycoconjugated pss bearing only one glycodendron moiety, with variable length for the spacer linking the carbohydrates to the porphyrin scaffold, on the para position of one mesophenyl group (fig. ) . briefly, the cbz-glycine spacer was introduced via peptide coupling onto the amino function of a trivalent precursor, followed by deprotection of the three terminal carboxylic acid functions of the scaffold and subsequent introduction of aminoethyl a-d-mannopyrannoside derivative through amide ligation. the suitably functionalized aminodendron (after cbz-hydrogenolysis) was then coupled to -benzoic acid- , , -triphenyl porphyrin through an amide linkage, which after standard odeacetylation afforded the trivalent glycoporphyrins and in good overall yields. in order to evaluate the conditions of incorporation of compounds and into a liposome membrane, the two derivatives were mixed with dmpc in a : ratio and the mixtures were spread at the air-water interface. interestingly, incorporation of the elongated conjugate in dmpc induced the formation of larger vesicles than the phospholipid ones (diameter of vs. nm) while compound mixed poorly, leading to smaller and less stable vesicles probably because of repulsive interaction between sugar moieties in the vicinity of the phospholipid headgroups. moreover, h of contact between the mixed liposome containing and con a, led to a dramatic increase of the vesicle diameter (up to nm) and polydispersity was observed. these striking results were postulated to originate from the long spacer, which would increase the mobility of the mannoside moieties and thus facilitate their interactions with the lectin. in addition, the existence of con a dimers and tetramers at the ph studied, allowed lectin interaction with more than one porphyrin molecules possibly borne by different liposomes. such multiple interactions would lead to the formation of a network of vesicles bridged by con a molecules, resulting in a dramatic increase f. other aromatic glycoclusters.-clearly, access to other type of clusters has also been addressed, for instance, by using more conventional glycosylation strategy. in this context, the synthesis of trivalent b-d-galactoside using stereoselective lewis acid-catalyzed tris-glycosylation of , , -benzenetrimethanol ( ) with galactal derived from has been described (fig. ) . a second example concerned the synthesis of trivalent clusters ( ) containing such disaccharides as lactoside as ligands for galectin- and - , or the more-complex a-l-fucp-( ! )b-d-glcnac for the inhibition of binding of paii-l lectin from pseudomonas aeruginosa, generated by click chemistry between an aromatic tripropargylated core (derived from trimesyl chloride), and the corresponding glycoside azide. inhibitory properties of mm against galectin- were observed for the conjugate in hai assays. this comprises a -fold enhancement as compared to free lactose, and . fold on a per-saccharide corrected basis. in addition, more-unusual macrocyclic scaffolds, such as phthalocyanine ( ) have recently emerged to afford dense glycoclusters for which biological relevance remains to be determined. , structurally, carbohydrate derivatives are interesting polyfunctional platforms for the synthesis of oligosaccharide mimetics or glycoclusters. the possibility of selective functionalization of the various hydroxyl groups by well-established methodologies, and control of the relative orientation of the branches by configurational and conformational bias, makes these ''full-carbohydrate glycoclusters'' ideally suited for mapping the geometrical requirements for efficient lectin binding. in this context, several synthetic strategies for efficient derivatization of various carbohydrate scaffolds have been described, notably including perallylation of nonreducing mono-or di-saccharides and subsequent ligation of s-glycosides by thioether linkages through photochemically promoted radical addition. controlled introduction of such desired functionalities as hydroxyl or amino from terminal allyl functions can also permit the construction of glycoclusters through ether, or thiourea linkages ( - , fig. ). , systematic studies aimed at evaluating their biological properties against uropathogenic e. coli have been initially addressed by measuring the relative affinities of con a towards d-glucose-centered mannosylated clusters a and b and their corresponding analogues, , , and by a competitive ella assay. hence, the known allyl , , , -tetra-o-allyl-a-and b-d-glucopyranosides were chosen as the core building-blocks for the preparation of pseudosymmetric pentabranched derivatives. the versatile reactivity of the terminal alkene has been exploited in different ways to produce glycoclusters exhibiting a variety of linking functional groups, such as thioether, ether, and thiourea. with this strategy, the higher-valent d-glucose-centered glycocluster [ ] [ ] [ ] has also been obtained. the ic values of the pentavalent clusters a and b ( and mm, respectively) were indicative of strong con a affinity relative to the reference methyl a-d-mannopyranoside, corresponding to a . and . -fold enhancement on a per mannoside basis. a tetravalent analogue ( ) containing an aglyconic oxygen atom presented identical avidity, indicating that multivalent presentation through four branches is sufficient to elicit a cluster effect. in sharp contrast, replacement of the -thiomannose wedges with a-d-mannopyranosylthioureido units virtually abolished any multivalent or statistic effects, along with a dramatic decrease of binding affinity. alternatively, the -valent ligand , possessing classical o-glycosidic linkages, was a very efficient inhibitor of the con a-yeast mannan association (ic of . mm). however, the valency-corrected relative potency was about one-half that of the pentavalent derivatives. those results illustrated the potential of carbohydrates as multivalent scaffolds for glycocluster synthesis and underlined the importance of careful design of the overall architecture in optimizing glycocluster recognition by specific lectins. as mentioned in the introduction, the tris scaffold is not optimized for simultaneous binding without the utilization of elongated spacers that allow several lectins to bind the maximum accessible sugar ligands. in contemporary studies, several others multimannoside glycoconjugates based on carbohydrate scaffolds have been similarly constructed using ''click chemistry.'' the construction of these multivalent glycoclusters involves first the introduction of propargyl or azide functionalities on such mono-or oligo-saccharides as maltoside or maltotrioside as central cores and subsequent reaction with glycosylated ligands containing the complementary functionality ( - , fig. ). , a remarkable example of a biologically relevant d-glucose-centered glycocluster has been achieved by kitov et al., who designed an oligovalent, water-soluble carbohydrate ligand named starfish having subnanomolar inhibitory activity toward shiga-like toxin i (slt-i). shiga toxin (stx) and shiga-like toxins (slts or vts (verotoxins) are ribosome-inactivating proteins that act as n-glycosylases, cleaving several nucleobases from the rna, and thereby halting eukaryotic protein biosynthesis. infection by bacteria that produce slts results in serious gastrointestinal and urinary tract disorders, and is known to cause a potentially lethal disease, the hemolytic uremic syndrome (hus), that may result in kidney failure. stx is produced by shigella dysenteria, whereas slts are produced by the shiga toxigenic group of e. coli (stec), including serotype o :h and enterohemorrhagic e. coli (ehec). the e. coli toxins can be further divided into slt-i and slt-ii having conserved structures in the binding sites, and the slt-ii edema variant (slt-iie). like ct, slts belong to a family of bacterial enterotoxins harboring a hexameric ab structure, where a denotes a cytotoxic enzyme located above the center of one face of the b -subunit, which represents a symmetrical homopentameric lectin-like carbohydrate-recognizing complex having a doughnut shape that facilitates delivery and entry of the a component into the cell of the host. the slt-i is virtually identical both in structure and mechanism of action to the toxin expressed by s. dysenteria, having similar b-subunits and differing only in one residue (ser vs. thr ) in their a-subunits. the in vivo receptor of stx and slts is the trisaccharide portion (p k ) of the neutral glycolipid, globotriosylceramide (gbose or gb , agal-( - )bgal( - ) bglc( - )ceramide), present in greater amounts on the surfaces of kidney glomerular endothelial cells, to which the renal toxicity of stx may be attributed (fig. ) . when the crystallographic structures of the protein or carbohydrate-ligated proteins are known, it is possible to model multivalent oligosaccharide inhibitors. as mentioned, the slts possess five noncovalent b-subunits per molecule and each subunit presents three carbohydrate-binding domains. therefore, oligovalency ''tailored'' to the structure of the b-subunit pentamer offers the best opportunity for designing higher affinity inhibitors, as binding sites are symmetrically arranged across the toxin surface that engages the cell membrane. thus, highly selective, potent binding of slts to gb is mainly attributed to the multiple interaction of the b-subunit pentamer with the trisaccharide moiety on gb . on the basis of these facts, several slts antagonists in which this trisaccharide moiety was combined using various dendritic core structures have been reported. among these, the foregoing study in synthesis of multivalent neoglycoconjugates particular afforded spectacular results and effectiveness in neutralizing slts infection. hence, the use of the crystal structure of the b subunit of e. coli :h slt-ib in conjunction with an analogue of its carbohydrate receptor allowed the design of tailored multivalent glycocluster bearing peripheral functionalized p k residues. structurally, this decavalent cluster, named starfish, comprised a radially symmetrical star-shaped carbohydrate backbone (d-glucose) with pairs of gb trisaccharides at the tip of each arm, ideally spaced and oriented to be simultaneously engaged by each the b-subunits and thus to permit pentavalent interaction with slts. to achieve this display of tethered ligands, a glucose molecule was chosen as the central core for adequate pentavalent presentation, via its derivatization as pentaallyl ethers, free-radical reaction with thioglycolic acid, and subsequent chain elongation of the radial arms. each of them was designed to span $ Å from the central core of the toxin and the tether was adapted to bridge binding sites and on each b-subunit. elisa and solid-phase inhibition assays indicated the highest molar activity of any inhibitor reported, with subnanomolar inhibitory activity against stl-i and ii (ic of . and nm, respectively), thus being - -million-fold higher than that of monovalent ligand. furthermore, the ability of the inhibitors to protect host cells against a lethal dose of slt-i in culture could be determined by using vero cells. cytotoxicity assays indicated that starfish inhibitor provided effective protection of vero cells cultured in the presence of slt-i (ic of . mm) and slt-ii (ic of . mm), even over a -day coincubation period. interestingly, the crystal structure showed that one starfish molecule bound to not just one but to two b-subunit pentamers. instead of binding sites and , the tethered p k -trisaccharides of star-fish bound to two b-subunit monomers from separate toxin molecules. as, in the experiment, the concentration of starfish was sufficient to form a : complex, it was suggested that the formation of a : sandwich must be thermodynamically favored, as for the ct. extended investigations have been made by the same group in order to circumvent the differentiation of slt-i and slt-ii during biological studies. in fact, starfish protected mice when it was injected subcutaneously in admixture with a lethal dose of slt-i but not slt-ii, and it also reduced the distribution of i-stl-i but not i-stl-ii to the murine kidney and brain. modification of the nature and length on the linkage between the oligosaccharide component and the backbone (thereby increasing the flexibility of the tether) was then necessary to protect against the more-toxic slt-ii. despite a considerable decrease in its inhibitory activity in the solid-phase inhibition assays (with an ic of nm, corresponding to a $ -fold increase compared with ), an equivalent decrease in performance of the so-called daisy ( ) in the more challenging slt-i and slt-ii verocytotoxicity-neutralization assays was not apparent (fig. ). subcutaneous injection of protected mice against oral challenge with slt-i and also stl-ii-producing stec. interestingly, did not interfere with the ability of the murine immune system to produce slts-specific protective antibodies. the class of well-defined biocompatible cds also provides an interesting alternative for construction of carbohydrate-centered clusters. this nonimmunogenic scaffold combines unique structural features, such as high symmetry and a truncated cone-shaped hydrophobic cavity, which can be exploited for efficient and radial epitope presentation, together with complexation of hydrophobic drugs in their cavities for targeted drug delivery. more particularly, perglycosylated cds showed much improved ability to form stable complexes with an antitumor fig. . a variant of the starfish -mer in which the p k antigen is linked to the central glucose core at the anomeric position. reagent as compared with the cd itself and they provide one of the most potent candidates among specific carriers toward drug-delivery systems. in order to introduce peripheral carbohydrates on these macrocyclic scaffolds, a variety of selectively functionalized derivatives has been described, often generated without need for hydroxyl-group protection. since the first synthesis of perthioglucosylated derivatives of b-cd in , several other groups have described alternative synthetic pathways for the multifunctionalization of cds, either on their primary faces or on both faces simultaneously. those methodologies, involving well-documented photoaddition of thioglycosides to polyallylated b-cd ethers in an anti-markovnikov fashion, followed by selective introduction of such reactive functionalities at the primary positions as iodine, , amine, and chloroacetamide, gave rise to a panel of neoglycoconjugates named ''glycocds.'' these can exhibit simple b-d-glucosides ( and ) or n-acetyl-d-glucosamines ( ) through ether, thiourea, or amide linkages, or more-sophisticated carbohydrate appendages, such as elongated sialic acids ( ) or sialyl lewis x ( ) via thioether functions (fig. ). concerning the general biological relevance of glycocds, it was demonstrated that these systems often showed amplified inhibitory effects as compared to their monovalent analogues. for instance, the roy group synthesized a small library comprising b-d-glucosylated, b-d-galactosylated, a-d-mannosylated, and n-acetyl-b-d-glucosaminated cds. they evaluated their relative binding properties toward different natural carbohydrate-binding plant lectins, using both microtiter plate competitiveinhibition experiments, double-sandwich assays using horseradish peroxidase (hrpo)-labeled lectins, and turbidimetric assays. in general, all persubstituted b-cds showed good to excellent inhibitory properties, together with abilities to crosslink their analogous plant lectins. their capacity to anchor both microtiter plate-coated lectins and their corresponding peroxidase-labeled derivatives further confirmed the usefulness of these multivalent neoglycoconjugates in bioanalytical assays. another example has been provided by furuike et al. who proposed an efficient practical synthesis of cd-scaffolded glycoclusters via standard nucleophilic substitution of iodide from a heptakis( -deoxy- -iodo-b-cyclodextrin) precursor by various unprotected sodium thiolates derived from -( -acetylthiopropanamido)propyl glycosides (fig. ) . hence, novel glycocds having d-galactose ( ) , n-acetyl-dglucosamine ( ), lactose ( ) , and n-acetyllactosamine ( ) residues were obtained in high yields ranging from % to %. in order to evaluate the effect of clustering on the biological potency of these four glycoclusters, the hemagglutination inhibitory activities were examined by means of wheat germ agglutinin (wga) from triticum vulgaris and erythrina corallodendron lectin (ecorl), which are known as n-acetyl-d-glucosamine-and n-acetyllactosamine-specific lectins. as anticipated, heptavalent glcnac-cd ( ) showed drastically enhanced affinity against wga in comparison with the monovalent analogue, corresponding to a -fold enhancement of the inhibitory effect. similarly, the three other glycoconjugates efficiently inhibited hemagglutination induced by ecorl, notably compound bearing nacetyllactosamine residues, which showed the lowest inhibitory concentration (mic of . mm). finally, another remarkable example has been designed in which a variety of glycocds bearing clustered mannosyl ligands were prepared and investigated for binding toward the tetrameric plant lectin con a. , in this context, the key template was a i -amino- i -deoxy-b-cyclodextrin, the modified , , -triaminopropane branching component, and an isothiocyanato-functionalized a-d-mannopyranosyl cluster prepared from tris. coupling of the isothiocyanate derivative and the amine-functionalized trimannoside and the branching component gave the thioureabridged glycodendrimer-cd conjugates . the monosubstituted hexavalent b-cd mannocluster showed a strong cluster effect in the inhibition of con a binding to yeast mannan, with an ic of mm that constituted up to a -fold increase on a molar basis as compared to monovalent derivative. in addition, the cd derivatives exhibited extremely high water solubility, more than -fold higher as compared to the parent cd ( mm). furthermore, the potential utility of such systems in active sugar-directed drug delivery to specific saccharide receptors on biological surfaces has been investigated. thus, the cavity of b-cd was used to carry the anticancer drug taxotere, for which the water solubility was greatly improved by the construct. up to . and . g/l of taxotere was solubilized in mm aqueous solutions of a trivalent mannocyclodextrin derivative at c, corresponding to more than a -fold solubility enhancement as compared to the water solubility of the isolated drug ( . g/l). the class of peptide-based glycoclusters constitutes a valuable addition to the arsenal of glycoconjugates serving as important tools in glycobiology. their structural properties allow them to act as mimetics of glycocalyx constituents and permit presentation of the glycans in particular and optimized orientations. ideally, an unnatural peptide scaffold, cyclic or not, might provide much greater design flexibility than one afforded by the natural sequence. in general, manipulation of the length and nature of the amino acid sequence of the cyclic peptide provides opportunities for designing multivalent ligands that are suitable for different geometric requirements. moreover, variation in the number of glycan attachments, as well as the distances between glycans, together with subsequent introduction of a suitable chemical handle for conjugation to a carrier protein constitute parameters that could be readily tailored during the scaffold synthesis. although standard chemical processes have been used to access linear bioactive glycopeptides, - solid-phase synthesis (sps) constitutes one of the most appealing synthetic methodologies and has led to a large variety of well-defined glycoclusters grafted onto synthetic peptide platforms. the numerous successes encountered in the sps of various peptide-based conjugates, coupled to the ease of preparation and purification of complex derivatives, have motivated chemists to apply this methodology to synthesis of peptide glycoclusters. hence, linear peptides containing a glycocluster head group ( , ) , multivalent cyclic neoglycopeptides including, for instance, three n-acetylglucosamine residues ( ), and multitopic biotinylated glycoclusters build on a topological cyclodecapeptide template ( ) ( ) ( ) ( ) ( ) represent remarkable illustrations of this powerful and straightforward methodology (fig. ) . concerning biological investigations, zhang et al. described the sps of a pentavalent ligand having a cyclic decapeptide scaffold with built-in linkers in order to create efficient inhibitors for the ct b pentamer. varying the nature of the flexible amino acids lacking side chains (such as lysine, g-aminobutanoic acid, and e-aminohexanoic acid) allowed the authors to achieve the desired ring-size variations and to increase the likelihood that the peptides might adopt expanded conformations in solution (fig. ). the synthetic peptide-core ( ) bearing five galactosylamine residues were assayed for their ability to block ct b pentamer binding to ganglioside-coated plates. interestingly, ligands having longer or shorter linkers than optimal exhibited a loss in inhibitory power, demonstrating that when a ligand's effective dimension is not matching that of its target, there is a decrease in the ligand's affinity. submicromolar ic values were obtained for the best derived ligand ( ) , depending on the core size, which ranged from . to Å . the resulting glycoclusters presented a more than -fold increase over monovalent galactose, which had an ic of $ mm in the same receptor-binding inhibitory assay. several glycopeptides, particularly those having mannosides or complex oligomannoside end-groups, have the potential to become entirely synthetic vaccines. more notable are the following examples directed at raising the protective immune response against hiv- infection. noteworthy is the fact that several infectious microorganisms use or escape the immune defense mechanisms by masking important receptors or antigenic determinants through exposing self-carbohydrate structures. the consequences of these ''masking'' events are that the bacterial or viral pathogens are transported to target tissues by self cellular systems. an emerging example of this irregular situation is the recognition, binding, and transport of the hyperbranched high-mannose oligosaccharide (man glcnac ) present on hiv gp by dendritic cells, with the ensuing transport of the ''hidden'' virus particles to lymph nodes. danishefsky's group using -residue cyclic peptides bearing b-turns provided by two d-pro-l-pro sequences appended at the extremity of the scaffolds ( ), elegantly constructed the potent hiv-gp carbohydrate antigen , which was strongly recognized by the human swapped and protective igg g antibody (fig. ). the cyclic peptide containing two or three handles for glycan attachment, together with a single cysteine residue for further carrier protein or biological marker conjugation, was built on a prolinated trityl resin using solid-phase peptide chemistry, while the synthetic oligosaccharide man glcnac -nh , prepared by amination of the reducing sugar, was attached to the aspartic acid residues properly positioned onto the cyclic peptides a or b using the lansbury aspartylation procedure, thus providing dimer and trimer ( ) , respectively. studies with spr indicated that the control peptide lacking the saccharide portion, as well as the monovalent glycopeptides, showed no measurable response, thus confirming the importance of multivalent binding event in this critical recognition process. the corresponding divalent and trivalent glycopeptides proved to be strong ligands against the g bound surface, indicating topographical homology with the natural gp structure. with the confirmed antigenicity of both glycopeptides, the authors then used the sulfhydryl anchor of the divalent antigen for its attachment to the highly immunogenic, maleimido-derived outer membrane protein complex (ompc) carrier from neisseria meningitidis. the conjugate addition, performed at near-neutral ph, afforded a vaccine candidate bearing $ copies of the carbohydrate antigen which was also recognized by g antibody in an elisa assay using b x = asp, r = ch co h a x = ala, r = me either gp or the glycoconjugate as coating antigens. horse radish peroxidaseconjugated antihuman igg (hrp-igg) evidenced detection of the binding event. the results indicated that, while both antigens could bind to the g antibody, the natural gp bound more efficiently. the immunological properties of the semisynthetic vaccine are presently under investigation. an analogous example has been provided for the construction of a tetrameric gp glycan epitope ( ) by using the determined shortest version derived from the d arm of the man glcnac ( ) , and prepared as an extended azide-bearing aglycone (fig. ) . the cyclic peptide scaffold was built with lysine, glycine, and proline residues. four of the lysine e-amino groups were acylated with propynoic acid for glycan attachment by ''click chemistry,'' and the remaining two e-amines were coupled to the universal t cell epitope derived from tetanus toxoid -mer peptide tt - to afford a fully synthetic vaccine candidate . the binding of vaccine candidate to the human antibody g was analyzed by spr technology. while a synthetic monomeric oligosaccharide such as as well as the natural high-mannose type n-glycan man glcnac asn ( ) four units of the d arm tetrasaccharide have demonstrated affinity to this antibody. furthermore, results suggested that an appropriate spatial orientation of the sugar chains in the cluster was crucial for high-affinity binding to antibody g , and that the introduction of the t-helper epitopes onto the cyclic decapeptide template did not affect the structural integrity of the oligosaccharide cluster formed at the other face of the template. therefore, compound constitutes a valuable immunogen that might also be able to raise carbohydrate-specific neutralizing antibodies against hiv- . to better understand the critical role of oligosaccharide-receptor interactions and their molecular mechanisms through the cluster-effect, and thus access optimized synthetic ligands, several research groups have shown creativity in proposing original multivalent platforms that could allow for tailored valencies, dimensions, and epitope orientations. for instance, burke et al. investigated a templated ligand array based on a conformationally defined macrocyclic scaffold on which three mannoside residues, appended through a solubilizing linker, were displayed (fig. ) . the c -symmetric hydropyran cyclooligolide core was previously obtained according to an iterative multistep synthetic sequence notably involving key-step macrolactonization under keck-steglich high dilution conditions. in particular, the template rigidity conferred a specific orientation of saccharide residues such that they emanate from a single face. in addition, molecular-modeling studies predicted a maximum separation between mannose residues of approximately Å . given that the binding sites within the con a tetramer are separated by - Å , the trivalent ligand could not simultaneously occupy two mannose-binding sites within the tetrameric lectin. therefore, it could be used to explore mechanisms of multivalent ligand binding in the absence of the chelate effect. spr competition-binding assay with con a indicated the absence of nonspecific interactions induced by the template, and highlighted the fact that promoted rather than inhibited binding of con a to the mannosesubstituted lipid surface. the data suggested that the glycocluster was able to bind two or three con a tetramers simultaneously and to form soluble clusters with high avidity for immobilized ligands. assay by fret showed the reversibility of the phenomenon, and corroborated the fact that clustering of con a by did not depend on subsequent precipitation or cluster binding to a surface. in addition, this synergistic interaction favored the formation of a con a cluster rather than the formation of a one-to-one complex of con a and the trivalent ligand. another striking example has been provided which exploited cucurbit[n]urils (cb [n], n ¼ - ) ( ), a family of macrocyclic cavitands comprising n glycoluril units as multivalent scaffolds for carbohydrates. they possess a hydrophobic cavity accessible through two identical carbonyl-fringed portals, and can form stable host-guest complexes with a wide range of guest molecules. hence, cb[ ]-based clusters a-c, presenting an average of carbohydrate moieties attached to the periphery ( a, b-glucose; b, b-galactose; and c a-mannose, respectively) were prepared via photoreaction of (allyloxy) cb [ ] ( ) with corresponding acetylthioglycosides, followed by standard o-deacetylation (fig. ). in particular, the mannoside cluster c presented strong avidity for con a and a -fold excess of me-aman was necessary for the disruption of its cross-linking interaction with the lectin. itc confirmed this affinity and indicated that c behaved predominantly as a trivalent ligand to the lectin with a binding constant k ¼ ( . ae . ) À m À , which was times higher than that for me-aman. the authors further exploited the cavity provided by such conjugates to incorporate, through host-guest interactions, the fluorescein isothiocyanate (fitc)-spermine conjugate in order to estimate their potential as drug-delivery vehicles. targeted delivery experiments in vitro were thus carried out with the (fitc)-spermine derivative as a fluorescent probe as well as a drug model, and the hepg hepatocellular carcinoma cells that overexpressed galactose receptors as target cells. intracellular translocation has been estimated by confocal microscopy, and the results confirmed internalization of the cb[ ]-galactose-(fitc)-spermine complex b via galactose-mediated endocytosis. this study demonstrated the potential of glyco-cucurbituryl derivatives as targeted drug-delivery system and paved the way to other interesting therapeutic applications. touaibia and roy have used biodegradable and biocompatible cyclophosphazene derivatives as multivalent platforms to afford densely functionalized a-d-mannoside clusters (fig. ) . use of a short and efficient strategy based on single-step sonogashira and ''click chemistry'' has afforded a variety of glycoclusters around cyclotriphosphazene with different valencies, spacers, and epitope spatial arrangements. hexavalent derivatives a- d were obtained from commercial hexachlorocyclotriphosphazene (p n cl ) onto which various phenol derivatives had been conjugated via nucleophilic substitution. direct ligation of a-d-mannoside containing the adequate complementary function via optimized pd-catalyzed cross-coupling or ''click chemistry'' and subsequent deprotection under zemplén conditions afforded hexavalent conjugates in excellent yields. higher valency glycoclusters were also obtained by reaction of the hexabromomethylated p n scaffold derivative with di-or triazide building blocks containing a hydroxy anchoring function (fig. ). corresponding deprotected dodeca-and octadeca-mannoside clusters and were thereby isolated following click chemistry and o-deacetylation. similarly, decamannoside has been obtained from a dimer bearing an n p cl fragment prepared from the double monosubstitution of hexachlorocyclotriphosphazene with bisphenol a, using n-buli as a base and appropriate stoichiometry. subsequent replacement of the remaining chlorides by iodoaryl groups allowed the preparation of the sonogashira adduct . to evaluate the influence of structural parameters governed by the cyclophosphazene core concerning the valency and the spatial orientation of epitopes, as well as the nature of linkers directly related to the ligation technique used for the mannoside incorporation, the authors performed preliminary kinetic turbidimetric assays with con a. insoluble crosslinked complexes formed rapidly for all compounds, without marked difference for the hexavalent analogues. on the other hand, the incorporation of additional mannosyl units led merely to statistical binding-affinity enhancements, notably for the less-dense decamer , which presents favorable extended intersugar distances. the class of azamacrocycles also constitutes an interesting platform for controlled multivalent presentation of epitopes (fig. ) . although examples are quite scarce, their use has generated biologically relevant glycoclusters. for instance, the tetravalent a-mannosyl clusters scaffolded on , , , -tetraazacyclotetradecane (cyclam) have been described and showed interesting inhibitory properties in the adhesion of type- fimbriated e. coli to guinea pig erythrocytes or binding properties toward con a ( , ) . (fig. ) . the modular design of multivalent antagonists (antiadhesins) targeting members of the ab bacterial-toxin family has been achieved, including ct and e. coli heat-labile enterotoxin (lt). the strategy exploited the fivefold symmetry of the binding sites on the toxins b pentamer. this synthetic plan was based on difficulties in distinguishing ligand-mediated aggregation of the protein from an actual gain in effective affinity when highly multimeric ligands were studied. in this context, the authors expected substantial enhancement in affinity by using multivalent systems that allowed geometrically restrained presentation of the exposed ligands to match the specific arrangement of the target protein's binding sites. with this in mind, synthesis of various pentavalent derivatives and containing three distinct modules has been achieved. a semirigid core, having ''fingers'' projecting outward in the direction of the receptor's binding sites and fitting perfectly into the active site have been assembled. a study describing the syntheses of b-d-galactosylated pentavalent ligands built around a pentacyclen core and adopting a fivefold symmetry, and the systematic effects of flexible linkers has been published (fig. ) . preliminary results detailed the affinity for lt, and the best pentavalent ligand (r ¼ r with n ¼ ) showed an ic that was -fold higher than galactose. a few years later, the same group optimized the structure, incorporating five copies of the more potent m-nitrophenyl a-d-galactoside (mnpg) derivatives rather than five copies of b-d-galactose. the $ -fold higher single-site affinity enhancement of mnpg for the binding site of the toxin relative to galactose was found to yield a proportionate increase in the affinity and ic measured for the respective pentavalent constructs. indeed, elisa experiments involving ctb pentamer revealed an ic of . mm for (r ¼ r ), corresponding to about an -fold affinity enhancement over (r ¼ r ). these results demonstrated that improved affinity for a single-site ligand confers a parallel improvement in the affinity of a pentavalent construct presenting five copies of the same ligand. furthermore, from dls studies and crystallographic data, it resulted that a : ctb/ complex was the major mode of association in solution between the ligand and the toxin. the lead structure was then affined with the incorporation of guanidine-bridged poly(ethylene glycol)s of various lengths, in order to enhance its water solubility. thus, compound (r ¼ r ) having an optimized effective fig. . the best ligands against e. coli heat-labile enterotoxin. [ ] [ ] [ ] [ ] dimension for strong affinity, displayed an ic of nm, being lower than that of the natural receptor gm , and which represented the first multivalent ligand based on a simple galactoside having nanomolar affinity against ctb. during parallel investigations, spectacular improvement has been observed with the construction of a family of complex ligands having five flexible arms, each ending with a bivalent ligand (r ¼ r ). elisa tests revealed that the improved decavalent derivatives were significantly more potent, showing affinities for ctb an order of magnitude better than the corresponding nonbranched ligands. more precisely, a more than -fold enhancement in inhibitory power over the monovalent ligand was achieved with the best decavalent candidate (with n ¼ ) with an ic of nm, a value that lies in the same range as the ic of the natural receptor ( nm). dynamic lightscattering studies demonstrated the formation of concentration-dependent unique : and : ligand-toxin discrete complexes in solution, with no sign of formation of large aggregates. crystallographic studies confirmed that the decavalent inhibitor resulted in a ''sandwich arrangement'' of two b pentamers facing each other and bridged by the ligand. the improvement in ic displayed by the decavalent ligands might be attributed to a substantial difference in affinity between the galactose fragment within the pentavalent ligand and the rather short, nonspanning bivalent galactose moiety present in the decavalent ligand. finally, two other exotic scaffolds has been described that can be added to the large panel of glycoclusters described so far. the first consists in linear pentaerythrityl phosphodiester oligomers (pepos) onto which galactosyl clusters were attached via combinatorial and automated synthesis on a solid support (fig. ). the propargylated scaffold was synthesized by standard dna solid-phase supported phosphoramidite chemistry, and azido-galactoside residues were conjugated by ''click chemistry.'' microwave-assisted acceleration of the reaction time afforded the corresponding multivalent clusters a,b with controlled length and valency. the elongated fucosylated analogues have also been described by the same authors, and showed increased affinity in ella competition assay for p. aeruginosa lectin (pa-iil), with ic values - times higher than the monovalent l-fucose but corresponding to only a modest twofold increase on a per saccharide basis. the second one concerns polyhedral oligosilsesquioxanes (poss) that have been functionalized with carbohydrate moieties - via standard amide bonds or more efficiently via photolytic thiol addition from a perallylated precursor. biological evaluation of the octavalent poss-glycocluster exhibiting elongated lactoside residues was investigated by measuring the inhibitory effect on the binding of asialo-oligosaccharides from human a -acid glycoprotein (agp) by rca (a b-galactose specific lectin), using capillary-affinity electrophoresis. the first results indicated strong inhibition, $ times higher than that induced by free lactose and being thus attributable to the cluster effect. the past few years have witnessed the discovery, development and, in some cases, large-scale production and manufacturing of novel materials that lie within the nanometer size scale. more particularly, the incorporation of nanotechnologies in earlystage development of new drugs, diagnostics, or therapeutics constitutes a powerful addition to the arsenal of classical macromolecular structures. consequently, this strategy opens new avenues for the original and efficient designs of adapted nanomedicine. in this context and owing to their three-dimensional architectures, the fullerenes and nanotubes (both carbon-based nanomaterials), constitute promising candidates for novel nanometric constructs having biological properties and offering challenging scaffolds toward multivalent presentation of saccharide units. fullerenes, the third allotropic form of carbon along with graphite and diamond, are a novel class of spheroidally shaped molecules made exclusively of carbon atoms. they have generated much enthusiasm and numerous research efforts during the past few years. hence, the chemical and physical features of c , also named buckminsterfullerene, the most representative example among the fullerenes, have been extensively explored. their intrinsic properties such as their size, hydrophobicity, threedimensionality, and electronic properties have made them extremely promising nanostructures, offering interesting features at the interface of various scientific disciplines, ranging from material sciences to biological and medicinal chemistry. [ ] [ ] [ ] in order to demonstrate and illustrate their attractive potential in the foregoing applications, an array of studies has been recorded, including cytotoxicity investigations on both unmodified and functionalized fullerenes. initial results have indicated that these novel and fascinating architectures were not carcinogenic when applied to the skin, nor did they affect the proliferation and the viability of cells when they are internalized. hence, despite an observed dose-dependent toxicity phenomenon reported for certain related derivatives, the early observations indicate great promise for applications in dna cleavage, pdt, enzymatic inhibition, antiviral, antibacterial, and antiapoptotic activity. [ ] [ ] [ ] however, the total lack of solubility in aqueous or physiological media is a severe drawback for their quick and efficient development as suitable carriers. in order to circumvent the natural repulsion of fullerenes for water, several methodologies have been adopted, including their entrapment into tailored microcapsules, their suspension with the help of cosolvents, and their chemical derivatization, notably their introduction onto peripheral solubilizing appendages. furthermore, it has been shown that the multivalent presentation of polar groups around the fullerene spheres can prevent clustering phenomena in reasonably dilute solutions and consequently increase the hydrosolubility of the resulting conjugates. in this context, a variety of chemical functionalities have been utilized to increase both the hydrophilicity (with groups such as oh, co h, nh , quaternary ammonium, and cd) and to prepare novel compounds possessing biological and pharmacological activity. among the panel of known fullerene derivatives, the fulleroglycoconjugates (also termed glycofullerenes) exhibit a combination of interesting properties related to water solubility and biological relevance. spherical topology of the fullerenes has furnished suitable scaffolds for multivalent presentation of peripheral carbohydrate residues, and chemistry has been adapted for their efficient and controlled conjugation. the first examples of glycofullerenes were monovalent conjugates which were subsequently tailored and optimized to generate multivalent glyconanostructures based on c where biological properties were enhanced by taking advantage of the ''glycoside cluster effect.'' a. monovalent structures.-in the early s, vasella et al. reported the first synthesis of a monoglycosylated fullerene, introducing one carbohydrate residue on c via the nucleophilic glycosylidene carbene precursors and generating the enantiomerically pure spiro c-linked glycosyl-c derivatives (scheme ). another approach permitted synthesis of fullerene glycoconjugates via the thermal cycloaddition of the per-o-acetyl glycosyl azides in boiling chlorobenzene. although this methodology generated a mixture of two inseparable stereoisomers of n-b-glycopyranosyl [ , ] azafulleroids in relatively poor yields ( - %), the generality of the reaction has been demonstrated with a series of mono-( , d-glucopyranose and , d-galactopyranose), di-( , lactose and , maltose), and trisaccharide ( ) conjugates to c . soon afterwards, dondoni et al. developed a three-component approach involving c , a carbohydrate aldehyde ( ) , and n-methylglycine (sarcosine) leading to the formation of glycofulleropyrrolidine monocycloadducts ( ) in poor yields ( - %), via , -dipolar cycloaddition reaction of the intermediate azomethine ylide to c . the feasibility has nevertheless been demonstrated with the use of a series of -deoxy- -c-formyl derivatives of galactopyranose, glucopyranose, and mannofuranose. moreover, this methodology has been advantageously adapted for synthesis of c derivatives containing a -(b-d-glycopyranosylamino)pyrimidin- -one unit. alternative strategies utilizing the initial introduction of suitable chemical functionality onto the fullerene have been adopted by several research groups, allowing conjugation of the saccharides with complementary functions in the final synthetic steps. this approach has led to improved flexibility with the chemical functions on the carbohydrate moieties, especially the anchoring ones, and a better control on the number of attached saccharide residues. another example has been provided by ito et al., who described the use of methanofullerene derivatives as powerful and stable precursors for glycofullerenes. their study was based on the use of [ ] fullerenoacetyl chloride ( ), obtained from the tert-butyl [ ] fullerenoacetate derivative , which had been prepared in % yield by treatment of corresponding stabilized sulfonium ylides with c . subsequent transformation with p-tsoh in toluene gave [ ] fullerenoacetic acid, which was directly converted into the corresponding acyl chloride by using thionyl chloride. standard ester formation with methyl , , -tetra-obenzyl-b-d-glucopyranoside ( ) an additional study investigated the dna-and protein-degradation properties of the novel glycofullerene derivative . its synthesis was based on a diels-alder reaction of -trimethylsilyloxy- , -butadiene with c , followed by the reduction of the cyclohexanone derivative with dibal-h in toluene to afford the corresponding racemic cyclohexanol in excellent yield. glycosylation with glycosyl bromide in the presence of agclo , caco , and caso in toluene and subsequent deprotection under zemplén conditions gave the desired glycofullerene , which was shown to effect selective degradation of the hiv-protease by photoirradiation. synthetic aspects for access to monovalent fullerene-carbohydrate hybrids were highlighted, but only a few biological applications were mentioned. in contrast, multivalent presentation of saccharides by multiple anchorages to the same structure, or their presentation as antennary glycodendrons, has generated promising results. b. multivalent structures.-divalent hybrid glyconanostructures have been prepared via the [ þ ]-cycloaddition reaction between -azidoethyl glycopyranoside derivatives and c . the first example described a strategy for synthesis of [ ] fullerenols carrying mono-and bis-a-d-mannopyranosides (scheme ). the methodology was based on initial thermal coupling of -azidoethyl mannopyranoside ( ) and an equimolar amount of c in chlorobenzene, giving a mixture of two isomeric monoadducts (a-d-mannosyl [ , ] -azafulleroid, a, and a-d-mannosyl [ , ]-aziridinofullerene, b) and a bismannosylated adduct . subsequent simultaneous deacetylation and polyhydroxylation were then conducted in the presence of tetra-nbutylammonium hydroxide (tbah) in aqueous naoh, to afford deprotected mono- ( ) and bisfullerenols ( ) with an average of heterogeneously distributed oh groups per c . biological evaluations, notably involving lectin-induced hai assay with an a-d-mannoside-specific lectin (con a), revealed that mono-and bis-mannosyl fullerenols exhibited diminished activity for both binding to con a and aggregating erythrocytes as compared to the activity of mannosylated neoglycopolymers. a few years later, a similar grafting methodology was used to generate a series of mono-and bis-sugar-pendant [ ] fullerene derivatives prepared from a variety of carbohydratelinked azides. the phototoxicity of the corresponding deprotected glycoconjugates was evaluated for potential applications in pdt. substantial production of singlet oxygen ( o ) under laser irradiation ( nm) was observed for both adducts, notably for the monosugar derivatives, which shown a better photosensitizing ability. in addition, in vitro studies involving hela cells confirmed their photocytotoxicity and indicated a carbohydrate-dependent efficiency. in line with previous work, another application has been proposed which described the formation of stable selfassembling structures in aqueous solvents from the deprotected bis(a-d-mannopyranosyl)- [ ] fullerene conjugate . the diameters of the resulting large aggregates ( - nm), resembling bilayer vesicles or unadulterated liposomes, were determined by dls and afm. these supramolecular structures were able to encapsulate ba þ ions and such organic molecules as acridine red, constituting for instance, promising candidates for slow drug delivery. the ability of these mannofullerenes to bind to a mannoside-recognizing lectin (con a) was also investigated. colloidal suspensions of the stable self-assembling structure presented higher blocking activity than the two monoadducts, with an interesting submicromolar mic (minimum inhibitory concentration) value in a lectin-induced hemagglutination assay. this strong protein-binding activity has been rationalized by the authors by the fact that the fullerene scaffold allowed a spatial arrangement of the bis(mannopyranoside) moiety that could mimic , -branched a-d-trimannoside, a natural ligand of con a. unfortunately, this methodology often generates mixture of diversely substituted adducts, difficult to separate, in rather low yields and presenting only very limited solubility in water. an alternative synthetic approach, first developed by bingel allowed the efficient nucleophilic cyclopropanation of fullerenes via their reaction with bromomalonate derivatives in the presence of base. this approach, the most reliable method for the synthesis of functionalized methanofullerenes, combined the advantages of mild reaction conditions, good yields, and exclusive formation of [ , ] -bridged adducts. furthermore, the degree of functionalization could be controlled by the stoichiometry of the malonate derivatives for access to higher adducts in one step (bis up to hexakis). this methodology suffers, however, from the complexity of preparing the bromomalonates, often generating mixtures of mono-and di-bromo derivatives with similar chromatographic properties. an optimized methodology has then been proposed by camp and hirsch that avoids the use of bromomalonates by direct treatment of the fullerene with malonates in the presence of cbr (or i ) and dbu ( , -diazabicyclo-[ . . ]undec- -ene). it has been exploited in collaborative work describing the synthesis of amphiphilic glycofullerodendrimers and their incorporation into langmuir and langmuir-blodgett films (scheme ). the synthesis of the first c -dendrimer conjugate containing one glycodendron headgroup started from the treatment of c with diethyl malonate ( ) in the presence of cbr and dbu to furnish the monoadduct a in % yield (scheme ). a clean formation of b from its diester a was accomplished in toluene with a -fold molar excess of nah at c. the resulting bismalonate derivative was then engaged in double-bingel macrocyclization with c to afford the c s -symmetrical cis- bisadduct in % yield. subsequent selective cleavage of the tert-butyl ester under acidic conditions provided the desired diacid core , which was finally treated with the glycodendron under the foregoing conditions to yield glycofullerodendrimer exhibiting six peripherally protected glucopyranoside residues. with this work, the authors highlighted the preponderant role of the bulky glycodendron headgroups on c that formed a compact insulating layer around the carbon sphere, avoiding the general propensity of amphipilic fullerene derivatives to aggregate irreversibly. hence, both amphiphilic fullerenes and were able to form stable, ordered monomolecular langmuir layers at the air-water interface and showed reversible behavior in successive compression-expansion cycles. in addition, the monolayers were transferred successfully as x-type langmuir-blodgett films onto quartz slides for anticipated applications as biosensors. the group of hirsch has reported the synthesis of ''sugar balls'' according to the two distinct methodologies already mentioned, but involving the direct grafting of glycosylated dendrons onto c (scheme ). they also described their supramolecular assembly in aqueous solution. in this context, bis(a-d-mannopyranosyl)fullerene ( ) has been synthesized by a sequence involving the bis-(a-d-mannopyranosylated malonate) . this resulted from a peptide-coupling reaction between the corresponding -aminoethyl , , , -tetra-o-acetyl-a-d-mannopyranoside, quantitatively obtained from corrersponding azide derivative after staudinger reduction, and malonic acid, in % yield. the subsequent nucleophilic cyclopropanation of c with under typical bingel-hirsch conditions, followed by o-deacetylation of under zemplén conditions afforded fully deprotected [ , ] -monoadduct in an overall isolated yield of $ %. it is noteworthy that the protected architecture, presenting robust amide linkages around the malonate anchor points, tolerated basic cleavage of the acetyl protecting groups without side reactions or decomposition of the fullereno sugar. scheme . synthesis of a bismannoside-c adduct using the bingel-hirsch procedure. unfortunately, its relatively low solubility in aqueous media compelled the authors to enhance the number of peripheral saccharidic units. toward this goal, they developed fullerene glycoconjugate , where two dendritic branches terminated by six deprotected a-d-mannopyranosyl building blocks were connected through two adjacent imino bridges to the all-carbon framework (scheme ). moreover, in this type of c adduct, which constitutes a , -dihydro- a-aza- ( )a-homo(c -i h ) [ , ] fullerene derivative, the entire -p-electron system of the fullerene core was retained. for its preparation, ab glycosylated dendritic building blocks were first synthesized by preliminary protection of newkome's dendron with benzyl chloroformate (cbzcl), then treatment with formic acid for orthogonal and quantitative cleavage of the tert-butyl ester to give triacid upon which, peptide coupling with -aminoethyl , , , -tetra-o-acetyl-a-d-mannopyranoside provided trimannoside in % yield. selective removal of the cbz protecting group by hydrogenolysis gave the corresponding amine in quantitative yield, which was engaged without further purification with a suitable linker bearing a terminal azide group, namely -[ -( azidoethoxy) ethoxy]acetyl fluoride ( ) , in the presence of dmap in ch cl to provide the azido oligo(ethylene glycol)-terminated glycodendron in % yield. its subsequent thermal coupling with c in toluene afforded a mixture of mono-and bisglycodendron adducts. separation and purification by column chromatography gave regioselectively the twofold cluster-opened diazabishomofullerene adduct , scheme . direct anchoring of azide-bearing mannosylated dendrons onto c . but in only % yield. finally, quantitative deprotection under standard zemplén conditions provided . this c glycoconjugates having six peripheral mannoside residues is the most water-soluble fullereno sugar (> mg/ml) known. its amphiphilic nature, with a cone-shaped structure, triggered the formation of small supramolecular aggregates in aqueous solutions (observed in dosy nmr and corroborated by tem investigations), as uniform spherical micelles with an extremely narrow size distribution. these micellar sugar balls, with a diameter below nm, furnish an original arrangement of saccharides that opens the gate to new biomedical applications. another fruitful methodology, initially developed by nakamura's group allowed the introduction of five carbohydrate moieties onto a c scaffold using the efficient synthesis of c symmetric fullerene derivatives (scheme ). a thiolate-alkyl halide coupling reaction in aqueous basic media provided their one-step synthesis in good yields, taking advantage of the high nucleophilicity of the thiolate anions generated. synthesis of the key fulleropentathiol intermediate involved the fivefold addition reaction of the copper derivative , prepared in situ from the corresponding grignard reagent and cubr . sme . the desired fullerene cyclopentadiene bearing tetrahydropyranyl-protected thiophenol moieties ( ) % yield. subsequent installation of five saccharide moieties via a nucleophilic substitution reaction in aqueous thf with equivalents of sodium hydroxide and -bromoethyl glycopyranosides a-c afforded the fullerene glycoconjugates a-dmannoside , b-d-glucoside , and b-d-galactoside , in %, %, and % yields, respectively. despite the generality of this methodology for simple carbohydrate derivatives, its application for introduction of larger oligosaccharides via direct nucleophilic substitution produced side products and led to lower yields. to circumvent this situation, the same authors described the optimization and adaptation of this methodology for the quantitative synthesis of fullerenes bearing five saccharides, such as the glucose a, maltotriose b, and globotriaosylceramide gb -p k trisaccharide c derivative (scheme ). hence, more-sophisticated nanometer-scale pentavalent molecular architectures could be readily prepared by use of the key pentaalkynylfullerene intermediate obtained directly by the derivatization of fulleropentathiol with -bromohept- -yne in % yield under the foregoing conditions. click chemistry allowed efficient conjugation of the functionalized saccharide moieties with a terminal complementary azide function ( a-c) on the pentaalkynylated core under mild conditions. hence, in the typical presence of cubr.sme and dipea in me so, deprotected fullero-derivatives a-c were obtained in nearly quantitative yields through optimized conditions involving controlled heating or microwave irradiation. similarly to the starfish design already described (fig. ) , the peripheral and radial presentation of five p k -trisaccharide residues presenting tailored spacers could scheme . alkylation of fulleropentathiol by an alkyne spacer followed by ''click chemistry'' with various azido sugars, including the p k trisaccharide. furnish adapted structures for efficient and specific interactions with slts. in line with promising results obtained with the functionalization of fullerenes, several research groups have recently described the derivatization of carbon nanotubes (cnts) with biologically relevant carbohydrates. cnts are members of the fullerene structural family and consist exclusively of carbon atoms arranged in a series of condensed benzene rings, organized in graphitic sheets that are rolled up into a tubular structure. cnts made up of a single graphene layer wrapped into a cylindrical structure constitute single-walled cnts (''swnts''), whereas multiwalled cnts (''mwnts'') are generated from a central tubule of nanometric diameter and surrounded by several graphitic layers spaced by a distance of about . nm. most commonly, the diameter range of cnts varies between . and nm for swnts and between . and nm for mwnts, while their length is in the range of micrometers (up to nm). moreover, cnts typically form bundles that are entangled together in the solid state, giving rise to a highly complex ''spaghetti'' network. intrinsically, cnts possess very interesting and unique physicochemical properties such as: high surface area, ordered structure with a high aspect ratio, ultralight weight, excellent chemical stability, high electrical conductivity, high thermal conductivity, and metallic or semiconducting behavior according to the arrangement of the hexagon rings along the tubular surface. for these reasons, these nano-objects have raised great enthusiasm and expectations in many different applications, including material, biological, and medical sciences. more particularly, their intriguing structures and properties have led to the emergence of functionalized cnts as new biologically relevant alternatives for therapeutic and diagnostic applications, including their use as vectors for delivery of therapeutic molecules (plasmid gene delivery, peptides/proteins, and antibiotics ). indeed, prior to become viable and effective nanomedicines, the toxicological and pharmacological profiles of cnts had been determined by several research groups and reviewed by lacerda et al. as with biological studies on fullerenes, functionalized cnts offer potential as nanomedicines, whereas nonfunctionalized cnts usually contain amorphous carbon, carbon nanoparticles, and residues from metal catalysts, regardless of the procedures for their production. indeed, their inherent hydrophobic properties, associated with their innate propensity to form bundles via aggregation through van der waals forces, constitute major technical barriers for their utilization in medicinal applications. to overcome these drawbacks, modification of their surface is typically achieved by adsorption, electrostatic interaction, or covalent bonding of different molecules and chemical procedures that render them more soluble in biological media. such modifications generally improve the water solubility of cnts, decrease the aggregation phenomenon, and transform their biocompatibility and biodistribution profiles. it has been shown experimentally that such bioactive proteins, nucleic acids, genes, and more particularly carbohydrates can be successfully conjugated to cnts. in particular, because of versatile modes of chemical modification and solubilization, the one-dimensional nanostructure of swnts, with high surface area-to-weight ratio and some structural flexibility, can be exploited as platforms for multivalent carbohydrate arrays under physiological conditions. the resulting densely attached sugars, as pendant groups on the cnt hybrids, serve as multivalent carbohydrate ligands and show potential biological activities as well as behaving as glycoconjugate polymers. multivalent presentation of saccharidic residues has been realized via noncovalent stabilization processes through favorable hydrophobic, p-p stacking or electrostatic interactions, or via sidewall-or defect-targeted covalent functionalization. several groups have reported multivalent carbohydrate-cnts conjugates, such schizophyllan polysaccharides, lipid-terminated glycopolymers, and carbohydrate ligands toward bacterial toxins and viral proteins. a. glyconanotubes from noncovalent interactions.-the initial challenge of obtaining swnts soluble in organic or aqueous media by a supramolecular approach was motivated by the necessity for retaining their intrinsic physical properties without affecting the all-carbon scaffold. the first successful example was realized through noncovalent functionalization by wrapping synthetic and biocompatible water-soluble polymers around the swnts. the formation of supramolecular complexes in solution between swnts and the preformed helical structure of starch (a polymer composed of the linear amylose and branched amylopectin) has been investigated. the enhanced water solubility of the supramolecular complexes was significant, and further investigations suggested that the presence of the preformed helical structures of amylose may not be required. other studies examplifying complexation of the swnts with cds have also yielded some interesting results. as a natural extension of these preliminary studies, promising applications in the area of glyconanotechnology have been directed toward artificial glycoconjugates carrying bioactive carbohydrates, densely distributed onto cnt platforms, to mimic cell-surface oligosaccharides. a striking example describes a biomimetic surface modification of cnts, using glycosylated polymers designed to mimic cell-surface mucins (scheme ). these high molecular weight glycoproteins are involved in specific molecular cell-cell recognition processes. additionally, the dense clusters of o-linked glycans confer rigidity, provide strong hydration and passivation against biofouling (cell adhesions), thus ensuring protection of structural functions against nonspecific biomolecular interactions. it has been demonstrated that, in native mucins, the clustered n-acetyl-a-d-galactosamine (a-galnac) residues proximal to the peptide were the major contributors to the rigidification of peptide backbones. based on these observations, the authors prepared synthetically tractable mucin mimic (mm) in which a-galnac residues were linked through an oxime bond to a poly(methyl vinyl ketone) (pvk) lipid-teminated backbone. its preparation started with the initial introduction of a c scheme . noncovalent functionalization of swnts by using an amphiphilic glycopolymer, ending with a lipid tail for mucin mimicry. fully solubilized, suggesting the formation of hydrophilic surface coating through the self-assembly of the terminal lipid chains on the nanotubes via hydrophobic interactions, affording glycoconjugates c -a-mm-swnts ( ) . evidence for mucin mimetic coating was provided by three different imaging techniques, namely afm, scanning electron microscopy (sem), and transmission electron microscopy (tem). as anticipated, substantial enhancement of water solubility was observed and the previously entangled swnt bundles dissociated to form much finer bundles, stable in aqueous solution for several months. despite the inherent difficulties from the imaging technique conditions, the formation of individual nanotubes with fairly uniform diameters of - nm was observed. the recognition and resistance properties of these nanotube-mucin mimetics were investigated with the use of helix pomatia agglutinin (hpa). incubation of with a solution of hpa conjugated with fluorescein isothiocyanate (hpa-fitc), and appropriate subsequent treatment led to significant fluorescence that was attributed to a dependent receptor-ligand interaction. moreover, studies under similar conditions but involving glycoconjugates bearing the b anomer of galnac manifested no significant fluorescence labeling. hence, the lectin did not interact with the coated nanotubes in the absence of its favored ligand. these results clearly demonstrated that swnts coated with a mm could engage in specific molecular recognition with protein receptors and resist nonspecific protein binding. a few years later, the same group extended studies with functionalized cnts-cell interactions. in order to exploit their ability to interact with cells, the advantage of the hexavalency of hpa and its capability to cross-link cells and glycoproteins was explored. two parallel experiments were conducted, on one hand involving the preformed complex of hpa-fitc with c -a-mm-coated cnts incubated with chinese hamster ovary (cho) cells, and on the other the preincubation of cho cells with unmodified hpa and subsequent treatment with modified c -a-mmcoated cnts containing the fluorescent dye texas red. in both instances, analysis by fluorescence microscopy and flow cytometry suggested the formation of the tricomponent a-galnac-hpa-cnt-cell surfaces complex, and with a dose-and precomplexation-dependent labeling for the second study. control cnts modified with c -b-mm-cnts indicated no significant fluorescent labeling at low concentration. in conclusion, demonstration that lipid-terminated poly(mvk)-based glycopolymers could coat cnt surfaces and promote their binding to cells through receptor-ligand interactions has been demonstrated. modified cnts were nontoxic to cultured cells (cho and jurkat cells), but irregular surface and nonuniform thickness of the cnts coating might be explained by the high polydispersities (> . ) of the polymers employed. the surface heterogeneity generated could constitute a drawback to the systematic use in a reproducible way of glycopolymercoated cnts as sensors of protein binding. in immobilized rca lectin (ricinus communis agglutinin, b-lac-specific) on gold surfaces, and the results indicated highly specific affinity toward the lectin. this specificity was also confirmed by confocal laser-scanning microscopic (cslm) observations using fitc-labeled rca . promising applications as swnts-based sensory systems have been demonstrated by the authors, who succeeded in constructing a layer-by-layer structure composed of the spg-lac-swnts composite and rca . by the same methodology, an individual dispersion of water-soluble swnts randomly wrapped by a helical glycoconjugate polymer (poly(p-n-acryloylamidophenyl)a-d-glucopyranoside, pap-a-glc, ) has been obtained. the characteristic sharp photoluminescence signal observed by near-infrared fluorescence spectroscopy, associated with the multivalent presentation of peripheral carbohydrates, made this system promising as new sensing approach for detecting carbohydrate-recognition proteins. the preparation of biocompatible swnts, noncovalently functionalized with bioactive glycodendrimers, has been reported (scheme ). a bifunctional dendritic scaffold was built using the , -bis(hydroxymethyl)propanoic acid as a building block , which was linked to an azidopyrene tail ( ) scheme . syntheses of glycodendrons with hydrophobic and fluorescent pyrene head-groups for p-p stacking to swnts. of swnts through p-p interactions. the orthogonal synthetic approach was based on sequential condensation of the dendrititic polyol with , -bis(hydroxymethyl)propanoic anhydride ( ) . at the desired generation, azide-functionalized pyrene was chemoselectively ligated to the propargylated and hydroxylated dendritic scaffold by cuaac methodology. a panel of deprotected -azidoethyl mono-or disaccharides ( a, a-mannoside; b, b-galactoside; and c, b-lactoside) were then efficiently grafted onto the multivalent dendrimer by click chemistry. the unifornity and purity of the resulting amphiphilic glycodendrimers a-c were confirmed by nmr spectroscopy and maldi-tof mass spectrometry. the glycodendrimers were then adsorbed onto swnts by ultrasonication in aqueous solution. analysis groups as suitable anchoring sites constitutes the favored covalent methodology for installing suitable functional group that render the cnt soluble in appropriate solvents. typically, carboxylic acid functions are generated on cnts through the oxidation of surface defects, by suspending the cnts in m hno , and then treatment with aqueous hcl (scheme ). as already presented in this chapter, in addition to their biological relevance, the conjugation of unprotected carbohydrates onto all-carbon scaffolds can solve the problem of their intrinsic low solubility. one of the first examples of a water-soluble swnts glycoconjugate was obtained by covalent grafting of glucosamine via amide bonds. the carboxylic acid functions of were first converted into the corresponding acyl chlorides by suspending the functionalized swnts in a solution of thionyl chloride (socl ) in dmf. the resulting solid was then mixed with an anhydrous solution of glucosamine in thf at reflux to afford glucosamine grafted-swnts. the new glycoconjugates were characterized by uv-vis and afm analysis, and their solubility in water ranged from . to . mg/ml, depending on the temperature. the synthesis of the first b-d-galactoside-modified swnt (gal-swnt, ) with high water solubility has been described, along with its interactions with galactosespecific lectins that formed supramolecular junctions at the surface of the glycocoated swnts (fig. ) . using a similar strategy, analogous man-swnts conjugates ( ) effective in the capturing of pathogenic e. coli under physiological solution was also synthesized. the synthesis was based on the use of -aminoethyl b-d-galactopyranoside ( a) grafted onto swnt-bound carboxylic acids ( ) under sonication conditions, through carbodiimide-activated amidation with -ethyl- -( -dimethylaminopropyl)carbodiimide (edac) in aqueous kh po buffer. complete instrumental characterization included solution-phase nmr, sem and tem, raman, and near-ir spectroscopy, optical absorption, thermogravimetry, and spectrophotometry. the resulting galactosylated-swnts ( ) were exfoliated and well dispersed, and presented a total sugar content of $ %. the high sugar ratio and large surface area of the covalently galactosylated swnts permitted the display of abundant sugar arrays implicated in their strong binding interaction with receptors on pathogenic e. coli :h cells. significant cell agglutination was observed by sem, with multiple nanotubes binding to one cell and some nanotubes ''bridging'' adjacent cells. the same research group went further into detail concerning the antimicrobial properties of monosaccharide-coated swnts, advantageously exploiting their application for efficient and specific recognition of a nonvirulent strain of bacillus anthracis. in this context, similar nanostructures containing a large number of monosaccharides (mannose or galactose) have been synthesized by conjugation of the corresponding -aminoethyl glycopyranosides ( a,b) onto through amidation. the resulting water-soluble conjugates both strongly bound to b. anthracis spores, leading to significant aggregation with the mediation of the ca þ divalent cation. this binding phenomenon was unique to the nanotube-displayed monosaccharide molecules, and was not available with other displaying platforms such as polymeric nanoparticles (polystyrene nanobeads for instance), indicating specific arrangements of the carbohydrate ligands on the nanotube scaffolds. furthermore, the associated substantial reduction in colony-forming units (cfu) could potentially find valuable applications in efforts for detection and decontamination. another series of hydrophilic glycodendron-functionalized swnts was also synthesized and the lectin-binding interactions studied. it was assumed that the limited defect sites on the original nanotube surface could generate only a limited number of carboxylic acid functions. the desired dense population of multivalent ligands could therefore be reached by covalently grafting sugar dendrons containing a suitable anchoring functionality. toward this goal, b-d-galactopyranoside dendrons gal -nh ( a), gal -nh ( a), and their analogous a-d-mannopyranoside dendrons man -nh ( b), and man -nh ( b) were efficiently prepared by a systematic synthetic sequence based on the use of trisubstituted benzene cores (scheme ). divalent a,b and tetravalent glycodendrons a,b were obtained from brominated derivatives a,b and a,b, respectively. synthesis of the required dendritic building blocks was initiated with the trisubstituted benzene core a, from which t-butyl ester removal with tfa afforded brominated precursors b. the tetravalent bromine-ending analogue ( ) was synthesized by selective etherification of , -dihydroxybenzyl alcohol with a in order to double the surface functionalities, followed by the introduction of bromine function with the pph /nbs tandem. the acetylated amine-tethered monosaccharides a,b were then conjugated to b or by carbodiimide-activated amidation yielding protected glycodendrons a,b and a,b in % and % yields, respectively. finally the amine-ending glycodendrons were prepared by a common synthetic protocol involving treatment with nan , o-deacetylation under zemplén conditions, and subsequent hydrogenolysis with h on pd/c. the amine-derivatized glyco wedges were finally used for the functionalization of swnt acids by peptide coupling as before, to afford - (fig. ) . the resulting larger number of displayed ligands per swnt was responsible for the significant increase of water solubility, increasing with the functionalization, and the enhancement of biocompatibility. in addition, they enabled more quantitative characterization, permitting a better understanding of the structural details of swnts exhibiting multivalent carbohydrate ligands. solution and gel-phase nmr studies, sem, raman, optical absorption studies, spectrophotometry, and thermogravimetric analysis (tga) have all been employed in order to determine the morphology, the arrangement of glycodendrons around the swnt scaffolds, and the sugar content. no meaningful differences in sample composition between the gal-( ) and man-( ), gal -( ) and man -( ), gal -( ), and man -( ) glyconanotubes as functional moieties were observed. more sugar residues were displayed on the same amount of swnts for the divalent conjugates than for the monovalent ones. furthermore, and interestingly, the electronic properties of the cnts were largely preserved during the functionalization. these carbohydrate-functionalized swnts were evaluated in binding assays with pathogenic e. coli and with bacillus subtilis (a nonvirulent form of b. anthracis or anthrax). as compared with the binding properties of gal-swnt ( ) to e. coli o :h and the induced decrease of cfu evoked earlier, considerable improvements were recorded with divalent gal -swnt ( ) . in the presence of the same e. coli strain, the amount of recovered cellular aggregates was clearly larger, and with a more significant reduction of cfu. this more favorable binding process by ii ) . m, naome/meoh, quant. iii ) pd/c, h , meoh, quant. ) nai, acetone, quant. gal -swnts ( ) seemed to suggest that the paired b-d-galactosides are more effective in the specific interactions. moreover, man -swnts ( ) and man -swnts ( ) were both capable of binding and aggregating b. subtilis spores in the presence of calcium cations. despite preliminary encouraging observations, quantitative evaluations of the foregoing binding assays were complex: a lack of major tendencies and inconsistent results over a same series rendered the interpretation difficult and inaccurate. finally, a subsequent study furnished a clear demonstration that cnts could provide suitable support for rapid and efficient polymeric growth for the synthesis of novel and biocompatible linear and hyperbranched glycopolymers by the ''grafting from'' strategy, with good and high reproducibility (fig. ). the successful and controlled linear glucopyranoside-polymer grafting onto mwnts was achieved by atom-transfer radical polymerization (atrp), while hyperbranched glycopolymers were introduced by self-condensing vinyl copolymerization (scvcp) of the corresponding functionalized , : , -di-o-isopropylidene- -o-methacryloyl-d-glucofuranose ( ) and inimer -( -bromoisobutyryloxy)ethyl methacrylate ( ) via atrp. the mwnt-co h precursor was generated by oxidation of the crude mwnt with % hno , and then modified with ethylene glycol, generating mwnt-oh. the cnt-based macroinitiator mwnt-br ( ) for atrp was formed by treating mwnt-oh with -bromo- -methylpropanoyl bromide. the morphology and nanostructures of the resulting multihydroxylated conjugates and were observed by sem, tem, and sfm, indicating the formation of nanotube-supported polymer brushes for linear polymers and a polymer layer in a core-shell structure for hyperbranched structures, implying their uniform growth on the surfaces of the mwnts. these original water-soluble glycopolymer-grafted cnts offer promise in the fields of tissue engineering and bionanomaterials. in conclusion, such three-dimensional carbon-based nanostructures as fullerenes and nanotubes constitute scaffolds whose efficient functionalization and derivatization has been developed in recent years. accurate control of the introduction of biologically relevant moieties has been achieved, giving rise to original nanostructures with intriguing and promising properties. in particular, monovalent carbohydrates, more complex oligosaccharides, or glycodendrons have been successfully anchored at the surfaces, through covalent or noncovalent methodologies. although practical applications remain as yet limited, preliminary results suggest that these nanomaterials offer unique and favorable arrangements of multivalent carbohydrate arrays that are not readily available with other displaying platforms. to enhance the number of saccharidic units exhibited, construction of multivalent scaffolds through supramolecular chemistry provides an interesting alternative for the rapid synthesis of glycodendrimers. dynamic and reversible self-assembly process consisting in coordinating metal-assisted association of ligands is one of the most striking examples of supramolecular organization. over the years, optical and electrochemical properties of various complexes have been widely studied and exploited in different domains for material and biological applications. , to target specific biological events, cells or tissues, the introduction of relevant recognition molecules such as carbohydrates have been investigated during recent years. in this context, metalloglycoclusters-initiated self-assembly of ligands containing simple saccharides or more dense glycodendrons around a coordinating metal has contributed valuable additions of original and promising structures to the range of available multivalent glycoconjugates. it is rather surprising that only a few examples have been described, because the metal-assisted association of carbohydrate components offers a straightforward access to carbohydrate clusters in which the number and the relative orientation of the carbohydrate residues can be modulated almost at will by changing the structure of the ligand and the nature of the metal. in addition, the intrinsic photophysical properties of the metal complexes can be advantageously exploited, for instance to create efficient biosensors. furthermore, a second example of multivalent presentation of carbohydrates through self-organization process resulting from lipophilic cores has been furnished through the aggregation of glycodendrimers in aqueous solution, allowing the homogenous and controlled formation of hypervalent structures with distinct recognition properties as compared to the individual precursors. historically, the first multivalent glycoconjugate obtained by metal-assisted selfassembly was described in by sakai and sasaki (fig. ) . the methodology was based on the trimerization of unsymmetrical bipy-galnac ( ) induced by the presence of fe(ii) salts, to give the tridentate fe ii (bipy-galnac) cluster as a mixture of four diastereomeric isomers (l-fac, d-fac, l-mer, and d-mer). a comparative study involving bipy-galnac ( ), fe ii (bipy-galnac) dendrimer ( ), and asialoglycophorin a using the galnac-specific plant lectin, vicia villosa b , has been assessed by the authors to determine and compare their relative binding potential. better binding affinities were observed for the trivalent complex over the monovalent precursor , indicating the role played by the cluster formation of galnac residues around the metal template. more interestingly, the similar strong binding affinities observed for asialoglycophorin a, a natural glycoprotein containing several repeating units of galnac linked to ser or thr residues, and fe ii (bipy-galnac) were attributed to the adapted organization of galnac residues in the complex with adequate intercarbohydrate distances. a few years later, the same group proposed further investigations to explain the strong binding affinities earlier observed with the self-assembled complex, describing the dynamic molecular recognition of their synthetic ligands by lectins. studies involving v. villosa b lectin and the complex highlighted the fact that the ratio of the four diastereoisomers gradually changed during the binding experiment. after h at room temperature, the authors recorded enrichment in the l-mer isomer, which in the end comprised % of the total isomers (vs. % in the native mixture). these experimental observations suggested that the dynamic equilibrium seen at room temperature allowed the spatial arrangement of the three galnac residues to selfadjust in order to provide a better complementarity to the multivalent carbohydratebinding sites of the lectin. this tendency was confirmed with studies involving other galnac-specific lectins, such as glycine max, specific for a terminal a-d-galnac residue attached to the -oh group of galactose. selective enrichment of other diastereoisomers has been observed, indicating the adaptability of the process for lectins presenting different shape and functionnalities in their carbohydratebinding pockets. the intramolecular lectin's binding sites, being too distant from one another to be reached by the close galnac residues, strongly suggest a dynamic cross-linking process. kobayashi et al. employed hexavalent metal complexes based on the self-assembly of three symmetric , -bipyridine ligands tethering two functionalized glycopyranosides around ruthenium(iii) or iron(ii) as the core component (fig. ). they undertook complete comparative studies involving glycosylated tris-bypyridine iron and ruthenium complexes in order to develop robust biosensors for monitoring saccharide-binding phenomena. synthesis of the ligands was based on the use of a , -bipyridine- , -dicarboxylic acid core onto which amino glycopyranoside derivatives were conjugated via amide functions. hence, self-assembled glycoclusters fig. . self-assembled glycodendrimers using chelating metal cations and divalent bipyridine scaffolds. , consisted of direct n-linked glycosylamine appendages to the complex, or through a o-linked p-butanamidophenyl spacer, were produced. three equivalents of the resulting conjugates were then treated with rucl or fecl in a minimum amount of boiling water-alcohol mixture to afford the corresponding tris-bipyridineruthenium and iron complexes as mixtures of separable diastereoisomers. to determine the importance of the structural parameters, the first study involved ferrous o- ( ) ( ) ( ) ( ) and n-( - ) glycoclusters. in this context, the influence of the spacers on the lectin affinity was investigated. their relative binding properties to specific lectins were evaluated by a hai assay and by spr, using a-glucosideand a-mannoside-specific cona and b-galactoside-specific rca lectins. lectin affinities observed for the n-linked-glycoclusters - were low, but high affinities (ic in the micromolar range) were recorded for the elongated conjugates, thus highlighting the importance of the flexibility and the density of the carbohydrate scaffolds. flexibility seemed essential for reaching high and specific lectin-recognition, and this was probably induced through optimized conformational organization of the epitopes to fit the binding sites of the lectins. on the other hand, strong binding avidities to lectins were not observed, because of the lability of the iron complexes, which readily dissociated in dilute aqueous solution (< À m). for this reason, the authors further investigated more stable elongated ruthenium o-linked glycoclusters, and showed their avidity to the corresponding lectin to be enhanced, reaching ic in the nanomolar range, comparable to known potent glycopolymers. the results indicated that dense saccharide clusters played essantial roles in their specific and strong binding, as compared to monovalent precursors. furthermore, the complexes exhibited intense emission spectra after excitation of the metalto-ligand charge transfer (mlct) band in water, as compared to nonglycosylated ruthenium complex. the strong luminescence was attributed to the peripheral carbohydrate shell caused by closely packed saccharide clusters, which could possibly isolate the luminescent core from that lost to the outer aqueous environment. the structures were considered by the authors to resemble natural proteins having redox and luminescent cores embedded in the polypeptide shells. interestingly, binding of lectin to these glycoconjugates decreases their luminescence by disrupting their outer carbohydrate shell structure. in , combined efforts of the two research groups just mentioned developed a one-pot transglycosylation strategy for the construction of complex-type disialooligosaccharides starting from an a-d-glucopyranoside residue self-assembled onto a tris-bipyridineruthenium complex d[ru(a-glc- -bpy) ]cl ( ) (scheme ). they succeeded in this commendable chemoenzymatic one-pot transformation by using endo-b-d-glcnac-ase from mucor hiemalis (endo m), which effectively catalyzed transfer of the egg-yolk decasaccharide (yds) from the asparagine-bonded complex-type disialooligosaccharide (yds-asn) onto the -oh position of a a-dglucoside unit of . therefore, a mixture of two separable products, consisting of mono-(yds -dru) ( ) and bisadducts ( ), was obtained in % and % yields, respectively. the binding properties of and in the presence of influenza type-a viruses (a/memphis/ / ) were evaluated, using an inhibition test with virus-infected mdck cells. the results revealed that, despite their small molecular weight, the yds-adducts and more especially , exhibited strong inhibitory potency, with an ic of . mm, being values of two orders of magnitude higher than that of the parent yds-asn. the origin of this excellent virus affinity was unknown, but speculations concerning favorable electrostatic and hydrophobic interactions between the cationic and aromatic-rich complex center and certain amino acid residues of the hemagglutinin have been formulated. in addition, and exhibited strong luminescence at nm, the intensity of which increased with the number of yds residues. as evoked in the earlier work, this enhancement was attributable to the bulky oligosaccharides spanning around the luminescent core. interestingly, the addition of influenza type-a viruses to the and in pbs resulted in luminescence quenching, probably caused by disruption of the saccharide shell and the resulting exposure of the luminescent core to the aqueous environment. although the exact mechanism was not clear, this strategy could allow for the construction of robust and efficient sensitive biosensors for various toxins, viruses, and bacteria. scheme . enzymatic transglycosylation of a preformed bisglucobipyridine core self-assembled as a hexavalent cluster around a ruthenium cation. this strategy constitutes an extension of the work of constable et al. who initially described the self-assembly of peripheral saccharides covalently linked to terpyridine moieties. divalent iron(ii) and ruthenium(ii) complexes bearing functionalized b-d-glucopyranosides or b-d-galactopyranosides have been efficiently prepared by this approach (scheme ). the peracetylated glucosylated terpyridine ligand was obtained under phase-transfer conditions involving the reaction between the nucleophilic -hydroxy- : , -terpyridine and tetra-o-acetyl-a-d-glucopyranosyl bromide ( ) . the elongated analogue was synthesized by simple nucleophilic substitution using k co , ki, and -bromoethyl tetra-oacetyl-b-d-glucopyranoside ( ). , : , -di-o-isopropylidene- -o-tosyl-a-d-galactopyranose ( ) was similarly treated with , using sodium hydride in thf to afford . divalent complexes ( , , and ) were typically formed by treating their terpyridine intermediates with [nh ]fe(so ) . h o in acetonitrile or ethanol and precipitation with ammonium hexafluorophosphate. subsequent deprotection of the saccharide portions with aqueous methanolic k co or trifluoroacetic acid in water, respectively, afforded the glycoadducts , , and . the authors conducted preliminary biological investigation on these complexes, studying their stability toward enzymatic hydrolysis. interestingly, the glucoside residue was not released from the complexes under the action almond b-glucosidase, scheme . self-assembled glycoclusters using a monosubstituted terpyridine ligand. while free ligands were hydrolyzed under similar conditions. the precise molecular origin of these effects was, however, not determined. later, the same group attempted to improve the efficiency of coupling of the carbohydrates onto the terpyridine scaffold by introducing a reactive pentaflurophenyl group onto the -position ( ) with the use of simple alcohols or saccharides (scheme ). somewhat surprisingly, it appeared that the nucleophilic s n aryl substitution could not deliver the expected conjugates. they then relied on an alternative strategy using a -tetrafluorophenoxy spacer ( ) , which allowed synthesis of the intermediate , via attack of the electrophilic sugar . complex formation between with ferrous chloride furnished the divalent iron complex in good yield. the lengthy synthetic sequence, together with the modest yields obtained for the starting materials, rendered the strategy unsuitable for further development. in order to prove the generality of the concept and enhance the stability of the resulting complexes, several research groups investigated the use of various ligands or coordinating metals. with this concept in mind, a versatile synthetic methodology leading to the self-assembly of galactose-oligopyridine conjugates around various metal cores has been disclosed. the simple and successful strategy allowed structural variation in the components and linkers, generating multivalent adducts of different sizes, shapes, valencies, and conformational mobilities. the synthesis of the necessary galactosylated precursors started from tetra-o-acetyl-b-d- complexations of the bipyridine ligands with cuotf and terpyridine ligand with zn(otf) , afforded the corresponding : ( ) and : ( ) complexes, respectively, as single species (fig. ) . depending on the metal ligands, spectroscopic evidence indicated the formation of tetrahedral structures in the cu complexes, regardless of the length or the nature of the spacers, while a trigonal-bipyramidal geometry was observed for the self-assembled glycoconjugates resulting from the scheme . synthesis of b-d-galactopyranoside precursors, bearing amine, alcohol, and iodide as anchoring functionalities, for metal-based self-assembly. zn metal. in addition, unprotected bipyridine-cu(i) complexes were obtained via o-deacetylation under zemplén conditions, in contrast to the terpyridine-zn(ii) adduct, where the complex decomposed. a later investigation describes the attachment of different -thiosaccharides to , substituted bipyridines to obtain biologically stable ligands and radiolabelled metal complexes of re and tc (scheme ). the novel ligands were obtained by coupling , -dibromomethyl- , -bipyridine with , , , -tetra-o-acetyl- -thio-b-d-glucopyranose ( ), , , , -tetra-o-acetyl- -thio-b-d-galactopyranose ( ), and , , , tetra-o-acetyl- -s-acetyl- -thio-a-d-mannopyranose ( ) , under basic conditions. the ensuing thioglycosidically linked bipyridine derivatives were o-deacetylated under standard zemplén conditions to afford the water-soluble ligands - . luminescent rhenium complexes ( ) ( ) ( ) were formed by refluxing a methanolic suspension of the corresponding ligand with rhenium pentacarbonyl chloride [re(co) cl]. new glycoconjugated complexes of the general formula [re(l)(co) cl], considered as luminescent probes, were characterized by mass spectrometry, elemental analysis, h and c nmr, ir, uv-vis, and fluorescence spectroscopy. one of the structures was unequivocally characterized by x-ray crystallography, indicating a surprising nonsymmetric metallocomplex architecture. in addition, the rather stable radiolabelled m tc in order to increase the complexity of the peripheral epitopes resulting from the self-assembly process, glycodendrons have been successfully grafted onto various ligands, allowing the formation of dense glycocomplexes. indeed, in most of the examples, branching of the dendrimers produces a microenvironment that scheme . preparation of luminescent re and m tc glycoclusters obtained by self-assembly. encapsulates the coordinating metal core and can drastically modify its photochemical and electrochemical properties, and these can be modulated at will for suitable applications. the first such example was proposed by roy and kim who described the synthesis and the relative lectin-binding properties of square planar complexes organized around a cu(ii) coordinating core, and glycodendrons containing four or eight peripheral tn-antigen units (a-galnac known as a cancer marker), covalently linked to a bipyridine core (scheme ). -aminoethyl -acetamido- , , -tri-oacetyl- -deoxy-a-d-glucopyranoside ( ) and its analogue containing an elongated linker (obtained by peptide coupling with n-boc-protected -aminohexanoic acid followed by acid deprotection with tfa, ch cl , %) were used for anchoring. compounds and were then coupled with , -bipyridine- , -dicarboxylic acid chloride ( ) to provide divalent tn antigens and , respectively, after zemplén deprotection. in order to provide access to self-assembling structures of increasing carbohydrate valencies, the authors described a convergent strategy for dimeric galnac building blocks having both short-and long-space arms. thus, aminated derivatives and the preformed dendrons , , and were clustered around copper(ii) (cuso h o) in aqueous media to provide efficiently the symmetric and hydroxylated glycoclusters and glycodendrimers - (fig. ) , respectively, exhibiting four and eight galnac residues. these metallated a-d-galnac-bearing glycodendrimers were fully characterized by standard spectrometric analyses, h and c nmr, maldi-tof mass spectrometry, and uv-vis spectroscopy. the potential of these self-assembled complexes to cross-link and to precipitate horseradish peroxidase-labeled plant lectin v. villosa (vva-hrp) was confirmed by a solid-phase competitive inhibition assay (ella) with the use of asialoglycophorin as coating material. all of the neoglycoconjugates, including simple divalent and tetravalent ligands, inhibited the binding of asiaglycophorin to vva-hrp with greater efficacy than the monomeric standard inhibitor allyl a-d-galnac (ic of . mm). as anticipated, the elongated dimeric analogue was the most potent (ic of . mm) and the tetravalent ligand showed less potency (ic of . mm), probably because of the shorter intrasugar distances between each of the branches. as compared to their nonmetal complexes, the metallic clusters clearly exhibited enhanced inhibitory potencies following the expected ''cluster effect.'' indeed, the cu(ii)-(bipy-galnac) tetramers, and were -and -fold, respectively, more potent than the monovalent control, while octamer exhibited a -fold enhanced avidity. interestingly, the best binding affinity was recorded for the tetramer cu(ii) nucleated derivative ( scheme . other elongated tn-antigen (a-d-galnac) clusters for self-assembly. the longest intersugar distances. these results clearly demonstrate that the structural arrangement and flexibility of the molecules play crucial roles in their relative binding affinities. this work confirmed that the aglycone spacer and valency enhancement of sugar residues in neoglycoconjugates were responsible for an increase in binding affinity in carbohydrate-protein interactions. this supramolecular assembly process has also been directed toward the synthesis of metallic and fluorescent glycodendritic architectures. thus, homogenous fluorescent and sugar-functionalized metallic dendrimers, containing various numbers and types of monosaccharides have been prepared. the chelation of transition or lanthanide metals was ensured by the presence of -hydroxyquinoline (scheme ). metallic glycodendrimers containing up to peripheral mannoside residues have been prepared starting from n-(tris[( -cyanoethoxy)methyl])methylamine ( ) , which was treated with concentrated hcl in ethanol to yield triester . successive peptide couplings with boc-b-alanine and then with -o-benzylquinoline- -carboxylic acid ( ) yielded the functionalized tripod , which after hydrolysis and further coupling with pentafluorophenol afforded the active triester in % yield. tetraacetylated mannose containing an anomeric -aminoethoxy linker ( b) was then coupled to to generate the trivalent neoglycoconjugate . o-deacetylation and further hydrogenolysis afforded the corresponding complex precursor in % yield over two steps. second-generation mannosylated dendrons were synthesized by the process employed for , starting with the introduction of boc-b-alanine on triester to provide in % yield. saponification and coupling with pentafluorophenol under standard conditions afforded triester . the -aminoethyl mannoside b was then coupled to to give . in situ removal of the n-boc-protecting group (tfa) and treatment with afforded, after deprotection, the nonavalent glycodendron in fig. . a-d-galnac , -bipyridine oligomers self-assembled around a copper(ii) salt. % yield over four steps. finally, treatment of the foregoing precursors under appropriate stoichiometry with zn(oac) , [or al(oac) or gdcl for lower generation] in hot methanol afforded the self-assembled complexes and in - % yields, containing either or peripheral mannopyranosylated residues (fig. ) . after assessing the interesting optical properties of the complexes, specific protein interactions with cona as a model lectin were investigated in preliminary scheme . mannosylated dendrons having an -hydroxyquinoline ligand at the focal point for selfassembly. turbidimetry assays. initial results indicated that metallic second-generation glycodendrimer induced strong binding because of the large and dense glycocluster at the surface, and was a highly efficient lectin sensor. this approach to lanthanideglycodendrimers [for instance with gd(iii)] might thus provide tunable fluorescent or mri reagents for imaging. the same research group extended their studies, proposing a systematic investigation of the core activities for different carbohydrate densities during biosensing processes. three new mannosylated dendrimers with a ru(bipy) core unit were synthesized, and the influence of the number and size of dendritic branches on the rate of electron and energy transfer, as well as the lectin-biosensing abilities (scheme ), were investigated. mannose-capped dendrimers , , and were prepared using glycosylated bipyridine precursors by treatment with rucl or cis-ru-(bipy) cl . a first-generation dendron ( ) was prepared in modest yield ( %) via the previous strategy, by removal of the n-boc protecting group of and subsequent peptide coupling with , -bipyridine- , -dicarboxylic acyl chloride ( ) . a second-generation dendron, containing nine saccharidic units (not shown), was synthesized in % yield by the introduction of an amine derived from and coupling to . following n-boc deprotection (tfa) and subsequent peptide coupling with bipyridine derivative gave in % yield over two steps. boiling the first-and second-generation glycodendrons and in ethanol in the presence of cis-ru(bipy) cl or rucl followed by o-deacetylation under zemplén conditions yielded dendritic complexes - (scheme ) containing or peripheral mannopyranosides, respectively. scheme . mannosylated glycodendrimers on a bipyridine core for ruthenium complexation. the rate of electron transfer within the complexes was investigated by photoinduced electron transfer (pet) between photoexcited ru(ii)-templates and a suitable quencher (n, n - , -bis(benzyl- -boronic acid)bipyridinium dibromide, bbv) having high affinity for sugar. as expected, all compounds exhibited different extents of quenching, depending on the degree of peripheral carbohydrate density that efficiently insulated the core properties. the rate of energy transfer induced by photoexcitation of the complexes was also evaluated by quantification of molecular oxygen in the singlet state trapped by a quencher (tempo). the rate of appearance of the generated stable species (tempo) decreased from to , thus supporting the notion that dense carbohydrate insulation of the ru(ii) template presents a shield that stopped effective energy transfer to dissolved oxygen. in addition, the selectivity and sensitivity of these processes have been studied by use of complexes as lectin biosensors. cona and galanthus nivilis agglutinin (gna), both tetramers that contain one and three mannose-binding sites per subunit, respectively, were selected for these investigations. the concept was based on the reconstitution of the fluorescent signal when preliminary complexes between the bbv quencher and mannosylated-complexes were disrupted in favor of the tight interactions that take place between glycodendrimers and lectins. a spontaneous gain in fluoresecence was observed with the addition of nm of cona to the initial mixture of hexavalent complex and bbv. in contrast, more modest gains in fluorescence were obtained for dendrimers containing mannosides under the same conditions, but a steady and linear increment continued at higher concentrations of cona. similar experiments with the higher valency lectin gna induced the same tendency. based on these results, detection limits for each ru-complex were evaluated and compared, indicating that hexavalent glycoconjugate was the most sensitive; whereas a higher detection limit was determined for and which exhibited a broader limited range of linear response. in conclusion, although complex represented the best compromise between encapsulation and efficient quenching properties for sensitive lectin sensing, glycodendrimers and were also suitable sensitive biomarkers to study lectin-carbohydrate interactions, owing to their high quantum yield and excellent lectin-affinity through their high carbohydrate density. in the early s, thoma et al. presented an alternative concept for the polyvalent presentation of ligands, based on the supramolecular chemistry of rather small molecules that fulfill single-molecule entity criteria. they described the noncovalent and dynamic self-assembly of original and functionalized dendrons capped with carbohydrate ligands in aqueous solution, generating polyvalent glyconanoparticles. dendritic scaffolds were prepared by a convergent ''outside-in'' approach. this iterative methodology was based on a single building block ( ) obtained by the coupling of methyl , -diaminobenzoate and -(tert-boc-aminomethyl)benzoic acid. selective cleavage of the methyl ester group to give , and subsequent removal of the n-boc group liberated , comprising the g( ) dendrimer generation with two amine end groups. its coupling with , followed by orthogonal methyl ester cleavage furnished , a g( ) dendrimer generation containing four terminal anchorage functions. the third-generation dendrimer, with eight end groups, was obtained by treatment of with . the same procedure was repetitively applied to yield dendrimers with up to end groups, corresponding to the sixth generation. the peripheral amines of the glycodendrons of each generation were isolated as tfa salts and further transformed by introduction of chloroacetamide groups, using a large excess of chloroacetic anhydride in dmf, leading to complete conversion. subsequent introduction of thiolated oligosaccharides such as (galili antigen) and (lac-sh) onto the dendritic cores was realized in the final step of the synthetic sequence in the presence of dbu, to afford water-soluble glycodendrimers , , a, and b (not shown; sixth generation) presenting a controlled number of peripheral oligosaccharidic residues based on the generation (scheme ). , aggregation of all glycodendrimers in water was observed by h nmr and quantified by using multiangle light scattering (mals). measurements indicated the formation of small aggregates of kda for the first generation ( ) whereas the tetravalent analogue formed large particles of kda, corresponding to the aggregation of more than individual molecules per particle. surprisingly, the particle weight obtained with higher generation dendrimers decreased with increasing mass of the individual molecule. furthermore, the third-generation glycodendrimers , containing eight (rs-or r s-) residues, exhibited similar size and weight, indicating that particle structure depended primarily on the dendritic core architecture, and less on the size and the nature of the carbohydrate group. the synthesis of several dendritic cores containing more branched aliphatic components in their structures, such as cyclohexyl rings, linear alkyl chains, or methylated amides demonstrated that only highly aromatic architectures induced aggregation as a result of p-stacking, hydrophobic interactions, and rigidity. the authors assumed that intramolecular p-stacking led to preorganization, allowing efficient core-core contacts. an optimal core-core interaction was recorded for the second generation, whereas the lowest generation dendrimer was too small and the largest ones were too shielded by the dense carbohydrates. in addition, both the shape and the size of these homogenous nanoparticles (within a factor of ) was investigated by afm, indicating a disk-like morphology, having average diameters decreasing with increasing mass of the individual molecule, thus resembling their tendency in solution. the biological activity of these noncovalent multivalent ligands was investigated via the inhibition of decavalent igms directed against the agal (galili) xenoantigen. to assess the compounds as polyvalent igm ligands, the authors employed two in vitro assays in which the inhibition of both the anti-agal igm binding to the xenoantigen and the agal-mediated lysis of pig erythrocytes were measured. in agreement with previous results, monomeric agal was inactive at mm in both assays. whereas no activity was observed for the divalent conjugate, the second-and third-generation dendrimers and were highly potent in both assays ( . , . mm and . , . mm, respectively). the fourth-generation analogue, containing peripheral agal residues, also showed high potency in the binding assay ( . mm) but was significantly less potent in the hemolysis assay ( . mm). generally, potency decreased drastically for the larger dendrimers which did not induce aggregation. the avidity thus correlated with the size of the aggregates, but not with the size of the individual particles. preliminary in vitro results highlighted the involvment of polyvalent aggregates in antibody binding, without nonspecific interactions of the dendrimer backbone. the most potent compound ( ) bearing eight trisaccharidic epitopes, was selected for in vivo profiling in cynomolgus monkeys. within min after injection, the anti-agal igms detected by elisa were diminished to % of the initial value determined prior to the administration, and remained at low levels for more than h. most importantly, anti-agal antibody-mediated hemolytic activity was completely eliminated. even though examples remain rather scarce, the preparation of multivalent structures via supramolecular chemistry involving the self-organization of ligands around a coordinating core has afforded glycoconjugates in which the valency, the size, and the structures can be efficiently tailored with the nature of the coordinating metal and the chemical composition of the ligand. in most instances, the stable complexes generated constitute promising organizations with enhanced biological properties as compared to the corresponding monomeric ligand. moreover, this noncovalent, dynamic, and reversible self-assembly process can, ideally, allow the utilization of the polyvalent receptor (lectin) as a template to optimize its own polyvalent inhibitor with the organization of carbohydrate moieties to fit perfectly into the recognition sites. this adaptability has also been emphasized by the significant improvement of biological activities as compared to those of individual species that has been observed for homogenous noncovalent glycoparticles that self-assembled in aqueous media via a similar dynamic equilibrium process. in the light of promising applications offered by these supramolecular glycoconjugate structures, notably for the intrinsic optical and electrochemical properties of metal complexes, this underexploited research area is undoubtedly in its infancy and holds promise for such systems as biomarkers or sensitive biosensors. . introduction a. definition and history.-a dendrimer is a synthetic highly branched monodisperse and polyfunctional macromolecule, constituted by repetitive units (so-called ''generations'') that are chemically bound to each other by an arborescent process around a multifunctional central core. , thus, as opposed to traditional polymers, which often have poorly defined molecular structures that are clearly an important drawback for medical application in terms of product characteristics, dendrimers are structurally well defined and can be synthesized from a fully controlled iterative approach. although differences exist in terms of rigidity and compaction, dendrimers are often compared to ''artificial proteins'' with their semiglobular or globular structures, mostly with a high density of peripheral functionalities and a small molecular ''volume.'' , it is now accepted that dendritic polymers are the fourth major class of polymeric architecture, consisting of three subsets that are based on the degree of structural control, namely: (a) random hyperbranched polymers, (b) dendrigraft polymers, and (c) dendrimers. the concept of repetitive and controlled synthetic growth with branching was first reported by vögtle, who achieved the construction of a low molecular weight ''cascade'' polyamine. however, it was not until that the groups of newkome and tomalia independently described a divergent macromolecular synthesis, giving birth to the first well-characterized true dendrimers, named ''arborols'' and ''pamam'' [poly(amidoamine)] dendrimers, respectively. their strategy thus efficiently avoided problems of low yields, purity, or purification encountered by vögtle in his cascade synthesis. in their chapter, tomalia et al. paved the way to dendritic structures: their definition and construction, and introducing for the first time the term ''dendrimer,'' which arises from the greek dendron meaning ''tree'' or ''branch,'' and meros meaning ''part.'' their original and efficient methodology still constitutes the preferred commercial route to the trademarked starburst dendrimer family, with molecular weights ranging from several hundred to over million daltons (namely, generations - ). until the mid- s, the synthetic challenge of such aesthetic structures stimulated numerous research groups to investigate intensively a range of synthetic strategies. these efforts gave rise to original dendritic structures emerging from two main synthetic strategies used to construct perfectly branched dendrimers: the divergent and the convergent approach. over time, an accelerated version of the convergent strategy has been developed in order to increase its throughput and efficiency by using clever adaptations of cores or dendrons. initial efforts gave rise to well-characterized dendritic macromolecules, but applications remained limited because of the lack of specific functionalities. an exponential increase of publication volume observed for about years testified the growing interest for dendrimers and has led to versatile and powerful iterative methodologies for systematically and expeditiously accessing complex dendritic structures. the perfect control of tridimensional parameters (size, shape, geometry) and the covalent introduction of functionalities in the core, the branches, or the high number extremities, or by physical encapsulation in the microenvironment created by cavities confer such desired properties as solubility, and hydrophilic/hydrophobic balance. thus, creativity has allowed these structures to become integrated with nearly all contemporary scientific disciplines. undoubtedly, biology and nanomedecine, more particularly biomedical and therapeutic applications, are the domains that have generated the highest infatuation for these architectures. however, the complexity of mechanisms involved in biological processes presents an important challenge for efficient structure design. in fact, historically, problems concerning toxicity, hydrosolubility, degradability, targeting specificity, pharmacokinetic, and biodistribution profiles for this kind of applications have been recurrent when using monomeric systems. application of polymeric systems has been exploited advantageously to enhance hydrosolubility, biocompatibility, lack of toxicity, immunogenicity in order to improve drug stability, and selectivity toward malignant tissues. this enhancement of therapeutic properties observed with the use of ''prodrugs'' has been explained by the physical properties of these polymeric structures, presenting high hydrodynamic volumes that facilitate blood persistence and accumulation in tumoral tissues in particular.this phenomenon, called the ''epr effect'' (i.e., enhanced permeation retention), may be roughly explained by physiological and biochemical differences observed between tumoral and healthy tissues. in fact, tumor tissues present specific vascularization with a defective lymphatic drainage system that allows macromolecules (with molecular weight ! kda) permeability, retention, and accumulation. however, a high polydispersity index and low drugs loading are often responsible for critical lack of reproducibility and efficiency. dendrimers, combining several of the advantages described for polymers, along with monodispersity and a high density of functionalities with a small molecular volume, have been exploited for about years to surpass the problems usually encountered. thus, their particularly unique structures and properties have motivated their use in numerous applications as drug or gene delivery devices in anticancer therapy, and as antibacterial, antiviral, or antitumoral agents. the use of dendrimers in biological systems, and also systematic studies of the most common dendritic scaffolds to determinate their biocompatibility, such as in vitro and in vivo cytotoxicity, their biostability or immunogenicity have been extensively reviewed. , one typical example concerns the use of dendrimers as ''glycocarriers'' for the control of multimeric presentation of biologically relevant carbohydrate moieties that are useful for targeting modified tissue in malignant diseases for diagnostic and therapeutic purposes. in such molecules, termed ''glycodendrimers,'' the saccharide portions are conjugated according to the principles of dendritic growth or are ligated to preexisting highly functionalized and repetitive dendritic scaffolds having varied molecular weights and structures. since they first appeared in the literature in , glycodendrimers and related glycodendrons, with their spheroidal or dendritic wedge structures, have been initially designed as bioisosteres of cell-surface multiantennary glycans that stimulated wide interests within the scientific community. [ ] [ ] [ ] [ ] [ ] [ ] as with conventional dendritic structures, glycodendrimers can be obtained as dendrons, spherical or as globular architectures, or ''hybrid dendronized polymers'' according to divergent, convergent, or accelerated approaches. all of these original synthetic clusters were constructed in such a way that their valencies, shapes, and carbohydrate contents could be varied at will with a controlled integration of dendritic building blocks. hence, recent progresses in synthesis of dendritic structure can allow easier optimization, to afford tailored glycoconjugates with biologically adapted and optimized properties. b. glycodendrimer syntheses.-historically, the divergent strategy was used to prepare the first dendritic structures. dendrimers are built iteratively out from a central core, layer by layer, requiring activation/addition steps to afford the desired dendritic structures: the focal and multifunctional molecules are systematically expanded outward using various chemical linkages. the first-generation dendrimer is simply formed by attaching branching units to the core molecules. to form the second-generation dendrimer, the peripheral functional groups then react with a complementary chemical function presented on the branched building blocks. to avoid hyperbranched polymerization, this step has to be carefully controlled by using protected (or inert) groups on the building blocks. activation (deprotection or chemical transformation) of the newly attached surface groups leads to the second-generation dendrimer. the generation growth quickly allows exponential multiplication of active terminal functions, and the process is repeated until the required degree of branching is obtained. for glycodendrimers, the sugars are then appended at the periphery of the molecules. although this approach is conceptually straightforward, synthetic problems are sometimes encountered, involving the use of very large excess of reagent (or monomer) in each synthetic step to ensure complete functionalization and the necessity of efficient coupling in regard to the exponentially increasing number of functions. to accentuate the difficulty, and although monomers are generally easy to remove, separation of the required dendrimer from the structurally flawed by-products usually remains challenging, because of their mass, size, and general properties that are very close to the perfect dendrimer. for the sake of simplicity and diminished cost, the inner scaffold portion of the glycodendrimer can be either synthesized by a one-pot procedure using hyperbranched polymer methodologies, or purchased directly. indeed, several dendrimers having various surface functionalities and building blocks are commercially available: polyamidoamine dendrimers (pamam, starburst , dendritic nanotechnologies), polypropyleneimine (ppi, astramol , dsm fine chemicals), polyglycerol dendrimers, and hyperbranched dendritic polymers (boltorn ), are most commonly used as multibranched dendritic core or glycodendron precursors, and most of them are known to be nontoxic and nonimmunogenic. an alternative and more efficacious convergent strategy was reported in by hawker and fréchet, using the symmetrical nature of these structures, in order to overcome some of the synthetic and purification problems associated with the divergent methodology. it involves the preliminary synthesis of peripheral branched dendritic arms, named ''dendrons'' or ''glycodendrons,'' from the ''outside-in.'' this concept can be described by envisaging the attachment of x terminal units containing one reactive group to one polyfunctional monomer possessing orthogonally protected functionalities, resulting in the first-generation dendron. transformation of the unique focal site, followed by treatment with / x equivalent of the protected monomer or a polyfunctional central core affords the next higher generation dendron or a dendrimer. the advantages of the convergent strategy lie with the diminished number of reactions carried out in each step. moreover, purification of the desired dendrimer becomes less problematic than in the divergent case, fewer by-products are generated and they are structurally very different from the perfect target dendrimer. however, the fact that the focal functionalities of the wedge may be sterically inaccessible from within the infrastructure (depending on the generation) causes difficulties toward subsequent linkage to the core, thus resulting in slower and less efficient reactions as the generation grows. nevertheless, it is now well established that a large number of surface glycan moieties impede accessibility of the carbohydrate by carbohydrate-binding receptors. considering these synthetic advantages, this methodology has been used successfully for access to dissymmetric dendritic structures. cumbersome purifications and synthetic disadvantages observed with both iterative approaches have motivated investigations toward accelerated synthetic methodologies. to improve synthesis efficacy and limit synthetic steps, while preserving monodispersity and functionalization versatility, new strategies have been successfully addressed. these include the development of larger building blocks involved in ''multigeneration'' coupling, as largely described by fréchet et al. in this way, high molecular weight dendrimers and dendrons have been synthesized using highly polyfunctional dendritic cores (''hypercores''), and high-generation dendrons for subsequent coupling reaction (''hypermonomers''), which can also be obtained by an orthogonal protected functions approach (''double exponential growth strategies''). an elegant application has been described based on this design to allow for more rapid dendritic construction, starting with small glycoclusters, which are attached to branching units to form glycosylated hypermonomers and then finally to a suitable central part. more recently, another clever strategy based on ''orthogonal monomer systems'' has been designed. , the judicious use of functionalized building blocks that are coupled together without need of protection/deprotection steps has allowed rapid and easy access to homogeneous and heterogeneous dendrimers. the convergent alternative for the synthesis of glycodendrimers is attractive, since early synthesized glyco-coated molecular wedges present readily available and interesting multivalent candidates for biological investigations. obviously, by analogy to classical synthesis of globular structures, their growth can emanate from the controlled succession of suitable functionalized building blocks provided by standard ab or ab systems. a. ab systems.-aromatic ab dendritic building blocks have been widely used to construct glycodendrons possessing interesting biological activities. one of their first applications was to prevent tissue infection by the pentameric bacterial toxin from v. cholerae. the approach for preventing binding of ct-gm consisted in considering the terminal galactose residue (fig. ) as the anchoring fragment, to which various pharmacophores could be attached to provide optimized small-molecule antagonists against ct. this strategy was based on the fact that this galactose residue bound very specifically at a buried pocket of the receptor-binding site. however, the rest of the binding site is very shallow and lacks well-defined hydrophobic pockets that can be exploited using traditional structure-based drug design to arrive at potent inhibitors. initial studies were made by screening commercially available galactose derivatives. using elisa, it resulted that m-nitrophenyl a-dgalactopyranoside (mnpg) was the best inhibitor identified, with an ic of mm, corresponding to a -fold better affinity for ct than that of the ''lead'' galactoside. in addition, a small library of antagonists showing up to -fold improvement as compared to the best mnpg candidate was designed. the library consisted of , -disubstituted phenyl galactosides (as a/b anomeric mixtures), in which a hydrophobic ring-system was linked via a short, flexible aliphatic linker through an amide linkage at the remaining meta position of the mnpg core. further improvements were obtained by using a simplified strategy based on the use of relatively simple lactose derivatives (fig. ) . fig. . simple lactoside analogues as surrogates for the more complex gm oligosaccharide ligand against the pentameric bacterial toxin from vibrio cholerae. inhibitor ( ) for ct was developed and had a k d of mm from a direct fluorescence-binding assay. this rather low value was attributed to the presence of the thiourea moiety, and the aryl group that seemed to contribute to the -fold binding enhancement as compared to unsubstituted lactose (k d ¼ mm). an improvement in binding affinity was further observed by the same group with a new lactose -aminothiazoline conjugate ( ) , formed by a cyclization of the thiourea sulfur atom onto a triple bond and containing a more rigid spacer between the sugar and the aryl group. fluorescence studies revealed one order of magnitude enhancement in its affinity (k d ¼ mm) for the ctb subunit, as compared with that of thiourea derivative. in order to improve their respective inhibitory potencies against ct, the optimized monovalent inhibitors just described were linked to various ab building blocks, thus adding the concept of multivalency. therefore, an improvement in receptor-binding activity was expected with the use of the glycodendron approach, taking advantage of the symmetrical arrangement of five identical binding sites on the toxin b pentamer, as mentioned in earlier sections. this context allowed the synthesis of generation , , and of lactosylated dendrons based on a , -bis( -aminoethoxy)benzoic acid repeating unit and containing ( ), ( ) , and peripheral lactoside residues ( ) , respectively, bound to the dendritic scaffold via thiourea linkages (fig. ) . binding affinities with the ct subunit were determined by fluorescence assay (fret) and ranged from mm for lactose to mm for the octavalent glycodendron . this value corresponded to an eightfold enhancement as compared to corresponding monovalent lactoside derivative under the same conditions. however, an increase in the branching of the dendron (namely valency) provided only a modest increase in the potency of the ligand, corresponding to a rather constant relative potency per lactose, regardless of the number of peripheral epitopes. to further advance the effectiveness of such glycodendrimers, the same group incorporated two modifications to the system. the first alteration implicated glycodendrons having a slightly modified scaffold, outfitted with elongated arms, and peripheral attachment of the gm mimics proposed earlier by bernardi et al. using the modified gm analogue (fig. ) . unlike gm , the modified derivative was obtained on a gram scale and the synthetic sequence was adapted to achieve differentiation of the carboxyl group in the cyclohexanediol moiety to allow further functionalization. using the spr inhibition assay, the products showed good inhibition, with ic of mm for the divalent and . mm for the tetravalent , corresponding to a -fold improvement over its monovalent counterpart. the octavalent analog was the most potent compound, as determined using an elisa assay. in ongoing efforts, highly effective ct inhibitors were obtained by using similar architectures with a combination of several critical factors in their design: the use of authentic or modified gm oligosaccharide sequences as the optimal monovalent ligand ( - ), bound to multivalent dendritic scaffolds presenting elongated spacer arms of optimal length (fig. ) . compound and its galacto-modified analogue , each bearing an azido group, can be conjugated to polyalkynic dendritic scaffold by ''click chemistry.'' to evaluate the potency of the inhibitors and and their corresponding di-, tetra-, and octavalent derivatives, an elisa assay was used which indicated unprecedented affinities and potencies, notably for octavalent , which exhibited a very low ic (around pm), meaning that each gm os moiety bound , -fold more strongly than the corresponding monovalent . di-and tetravalent gm os systems had ic values roughly - orders of magnitude lower than the octamer. in the agalacto dendrimer series related to , the octavalent was a weaker inhibitor than its tetravalent counterpart, having an ic of . mm. further studies concerning the activity of glycodendrons containing two or four peripheral gm os against the e. coli heat-labile toxin (ltbh) b-pentamer have been similarly described (fig. ). fig. . octameric glycodendrons bearing gm analogues. [ ] [ ] [ ] analytical ultracentrifugation and dls have been used to demonstrate that the multivalent inhibitors induced protein aggregation and the formation of space-filling networks. this aggregation process appeared to take place when using ligands that did not match the valency of the protein receptor. interestingly, the valency of the inhibitor had a dramatic effect on the mechanism of aggregation, influencing both the kinetics of aggregation and the stability of intermediate protein complexes. in addition, structural studies employing afm have revealed that a divalent inhibitor induced head-to-head dimerization of the protein toxin, which either prevented the ltbh pentamer from sitting flat on the surface, or gave rise to a protein bilayer. considering that tetravalent structures were shown to be more potent inhibitors than pentavalent analogues of similar size, the development of a strategy based on the use of mismatched valencies may provide more relevant multivalent therapeutics against pentameric bacterial toxins, thus adding to the arsenal of multivalent strategies. to avoid the tedious preparation of gm derivatives, the direct and efficient preparation of dendritic inhibitors based on a simple galactoside was also proposed by the same group. hence, a simple b-d-galactopyranoside bearing a poly(ethylene glycol) unit, crudely mimicking the other sugar rings of gm os and ending with a lipophilic part having a terminal azido function, was attached to keep this factor the same as in the systems just mentioned. the compounds of highest valency ( ) and the corresponding tetravalent system showed ic s in the same range as the gm os derivative . the multivalency effect, as expressed by the relative potency per sugar, still increased from di-to tetra-valent ( vs. ), while remaining basically the same for the octavalent analogue ( ). although results obtained with dendrimers coated with a sole galactoside residue were less spectacular than those observed with the agalacto-gm os derivatives, they again constituted an important step toward potent ligands against ct of low cost and ready availability. parallel investigations by the same group described the construction of new and rigidified multivalent structures bearing up to four lactose- -aminothiazoline units at the periphery. the synthesis of the dendritic scaffold started with aromatic diiodide , which was treated with boc-protected propargylamine under modified sonogashira coupling conditions, to yield the branching unit , fully orthogonally protected as the key building block (scheme ). part of this material was exposed to a ch cl -tfa mixture to afford quantitatively the n-deprotected compound . the other part was smoothly hydrolyzed with tesser's base to lead to carboxylic acid derivative . the two fragments were then coupled under standard peptide conditions and subsequently treated with tfa to yield the tetraamino compound . coupling di- ( ) and tetraamines ( ) to the lactosyl b-isothiocyanate ( ) in the presence of ipr net and subsequent acid treatments to facilitate formation of the aminothiazole afforded the glycoclusters in moderate yields of % and %, respectively (fig. ) . standard deacetylation under zemplén conditions yielded di- ( ) and tetra-valent dendrons ( ) . the deprotected lactosides were evaluated as inhibitors against lectin binding in a solid-phase inhibition assay with immobilized asf on the surface of microtiter plate wells, mimicking cell-surface presentation, while mammalian galectins- , - , and - were in solution. strong multivalency effects and selectivity were observed for the tetravalent lactoside in the inhibition of galectin- binding, even better than for asf, with an ic of nm, corresponding to a -fold enhancement compared to lactose (thus a factor of in the relative potency of each lactose unit). on the other hand, although rigidified glycodendrons generally generated more interesting results than the corresponding analogues and , no marked multivalency effects in the inherent binding affinities to galectin- were observed by fluorescence spectroscopy with all components in solution. a biotinylated glycopeptide dendron, based on a dendritic l-lysine scaffold and bearing four t-antigen tumor markers [b-gal-( ! )-agalnac, t-ag ] (fig. ) , was first proposed by baek and roy in . the doubly associative binding interactions between the heterobifunctional biosensor and the coating streptavidin, together with mouse t-ag monoclonal antibody, were demonstrating using conventional solid-phase double sandwich elisa. hence, the virtue of the t-ag glycodendrimer used as coating agent was a very effective anchoring motif of high avidity (nanomolar coating), and constituted an efficient cell-surface model. using analogous aromatic ab building blocks, a modular approach leading to glycoconjugates with multiple copies of gb analogues that can induce differentiation between structurally homologous shiga (stx ) and shiga (stx ) toxins from complex samples has been developed. to this end, divalent systems bearing gb (fig. ) analogues, or those of a neutralizing polysaccharide corresponding to serogroup o (o lps, ) , have been constructed (fig. ) . interestingly, o lps resembles gb , but there are significant structural differences since gb has a terminal a-( ! )-digalactoside moiety, whereas the neutralizing polysaccharide has a modified terminal digalactose moiety possessing a bulky n-acetyl group at each -position. in contrast to gb , which binds to both stx and stx , o lps was not able to bind stx or to neutralize its effect on vero cells, suggesting that the nacetyl group sufficiently modifies the binding specificity toward stx . tailored biantennary glycoconjugates ( ) ( ) ( ) consisting of three structural components including peripheral carbohydrate-recognition components, flexible aliphatic spacers, and a biotinylated dimer have been synthesized with varied n-acetylation patterns. biotin was used because it afforded ready access to multivalency as one streptavidin tetramer binds to four biotin molecules, and it can be conjugated to commercial streptavidin matrices for toxin capture. molecules were designed such that the biotin and, hence, streptavidin were attached to the opposite end of the rigid scaffold to minimize interference by biotin in the binding event. binding of stx , stx , and stx c, a variant found in human clinical samples, was assessed by elisa analysis. results indicated that stx bound to the di-and mono-nacetyl-substituted galactosamine and , respectively, whereas stx failed to bind to either compound. more precisely, appeared to be a better substrate for stx than . in contrast and surprisingly, , constructed with the gb analogue, bound exclusively to stx , probably due to the biantennary architecture with a short spacer that constrained binding to stx . finally, the authors proved the ability of to capture stx in clinical applications, without any interference from a complex sample, indicating the feasibility of highly selective and sensitive synthetic glycoconjugate-based detection reagents for stx by introducing simple manipulations in the structure of known saccharide receptors. using the same versatile modular synthetic strategy, the same group developed biotinylated bi- ( ) and tetra-antennary ( ) mannosylated glycoconjugates to capture and detect e. coli cells, and compared the relative capturing ability of these molecules to commercial polyclonal antibodies (fig. ) . instead of aliphatic spacers, tetraethylene glycol linkers were used to diminish nonspecific binding and to impart flexibility for a better fit in the active sites. biotinylated glycoconjugates or antibodies were grafted on commercial streptavidin-coated magnetic beads and the resulting material was used to capture, isolate, and quantify bacterial recovery by using a luminescence assay. in this context, ''glycomagnetic'' beads completely covered with glycans were incubated with two isogenic strains of e. coli, orn and orn . the orn e. coli bears numerous fimbrial adhesins (fimh) possessing binding preferences to a-mannosides. the second strain is a mutant lacking pilus expression. in initial experiments, strain orn mediated the aggregation of beads coated with mannose-bearing divalent compound within minutes of addition to the beads, whereas strain orn did not. bacterial aggregation has been shown to be dependent on multivalency, and these results suggested that a single bacterium could bind to multiple beads. moreover, at higher concentrations of e. coli, the tetravalent conjugate was responsible for an increase in capture effectiveness. the authors further compared their competence relative to standard antibody-coated beads for the capture of bacteria. the results indicated that the glycoconjugate-coated magnetic beads outperformed traditional antibody-coated magnetic beads in sensivity and selectivity when compared under identical experimental conditions. in addition, these systems could capture e. coli from environmental samples of stagnant water, with the possibility for targeting specific pathogenic bacteria modulating the nature of the carbohydrate recognition component. these experiments thus clearly revealed the power of glycans in biosensing, and demonstrated that these stable and inexpensive glycomagnetic beads could be used for capture and isolation of pathogens from other complex matrices. in , saladapure and lindhorst reported the synthesis of glycopeptide dendrons in which the peptide coupling of orthogonally protected ab -type carbohydrate units formed the basis for an iterative sequence leading to the various generations of glycodendrons in either a divergent or convergent manner. the synthetic strategy was based on the use of efficient peptide chemistry in the linking step, avoiding sophisticated glycosylation techniques for each coupling step, and allowing possible adaptation to solid-phase chemistry (scheme ). the key ab -type glucoside building block was used for the preparation of multigeneration glycopeptide dendrons from its orthogonal deprotection, to yield complementary building blocks and . hence, mildly alkaline hydrolysis of the methyl ester groups led to dicarboxylic acid , whereas removal of the n-boc protecting group with a tfa-dimethyl sulfide mixture afforded amino-functionalized glucoside . hatu-mediated peptide coupling, together with dipea gave protected first-generation glycodendron in % yield. using the n-boc-deprotection and peptide-coupling reaction sequence, the synthesis of higher generations of glycopeptide dendrons was carried out convergently. hence, was converted into its amine derivative , whose coupling with led to protected g( ) glycopeptide dendron in % yield. the same convergent strategy was applied for the construction of the third-generation glycodendron containing eight peripheral glucoside units, via peptide coupling between dendron and . although no biological investigation was proposed by the authors, the stability of o-deacetylated g( ) glycodendron against b-glycosidases from almonds was evaluated and no degradation was observed over several hours. four years later, nelson and stoddart designed di-and tetra-valent lactosylated dendrons according to a convergent pathway and under mild and chemoselective conditions (scheme ). the strategy was based on the photochemical addition of hepta-o-acetyl- -thio-b-lactose ( ) zemplén o-deacetylation followed by cleavage of the acetal protecting groups with aqueous tfa afforded g( ) dendron , whose reducing end was reductively aminated with bismethylamino trisaccharide using cyanoborohydride in : meoh-h o to furnish the g( ) dendron in % yield. in , heidecke and lindhorst detailed an original approach toward glycodendron synthesis using a , -diallylated precursor serving as an ab system, and in which a hydroboration-oxidation sequence or radical addition of mercaptoethanol as an activating step, and subsequent glycosylation with branched or unbranched sugar trichloroacetimidates constituted key steps toward dendritic growth (fig. ) . a collection of six new hyperbranched mannosylated glycodendrons ( - ) was thereby prepared, and tested using elisa for their potential as inhibitors of type- fimbriae-mediated bacterial adhesion of e. coli to yeast mannan polysaccharide from saccharomyces cerevisiae. the branched oligomannosides differed with regard to both their carbohydrate content and to their spacer characteristics. binding data to e. coli indicated that all these glycodendrons performed better than the monovalent meaman, exceeding its inhibitory potency by one or two orders of magnitude. the small conjugate , consisting of three a-d-mannosyl moieties, presented the weakest inhibition (ic . mmol). its extended analogue , in which two a-d-mannoside units were tethered on thiahexyl spacers, performed unexpectedly well. for instance, it showed average inhibitory potency ( mm) exceeding that of the larger glycodendron (ic of . mmol) in which the carbohydrate moieties were spacered by propyl units. thus, with regard to the influence of the spacer characteristics, it was concluded that conformationally flexible glycodendrons containing four peripheral mannosyl units and the longer thiahexyl spacers (such as and , ic of and mmol, respectively) showed increased inhibitory potencies relative to their counterparts bearing propyl spacers (such as , the shorter analogue of ). furthermore, oxidation of the sulfide groups of , providing sulfone , had a pronounced negative effect on its inhibitory potency, indicating that the lipophilic properties of the spacers might also promote the affinity of a given glycoconjugate, as previously concluded. finally, a polyether ab system, initially developed by jayaraman et al. have been used for the synthesis of di-and tetravalent clusters decorated with b-d-galactoside moieties (scheme ). in addition, the convergent construction allowed the preparation of more complex systems consisting of ''mixed'' glycodendrons carrying both galactoside and mannoside moieties as biologically important ligands. this strategy involved a sequence of repetitive simple or double williamson etherifications with methallyl dichloride ( ), followed by generation of alcohols and via toward better mimetics of highly complex natural oligosaccharides, the authors also embarked on the synthesis of ''mixed'' glycodendrons bearing carbohydrate moieties of different kinds, employing two different routes. the first one involved the bisgalactose-substituted alcohol with an equimolar amount of to allow the synthesis of chloride in % yield. subsequent etherification with bismannosemodified alcohol furnished which after acidic deprotection provided an example of a mixed-type polyether glycodendron. the second way was based on the preliminary desymmetrization of with one of the saccharides, followed by attachment of the other one on the remaining reactive function. generation of the alcohol group from the double bond and subsequent williamson etherification on afforded, after tfa-water deprotection, the second ''mixed'' glycodendron . c. ab systems.-among the most widely used ab dendritic building blocks, derivatives of the aliphatic tris and of the aromatic , , -trihydroxybenzoic acid (gallic acid) provide systems of choice for constructing dense glycodendrons according to an iterative and orthogonal synthetic strategy. since the pioneering work of newkome and coworkers in the early s describing the synthesis of ''arborols,'' the widespread use of tris and its derivatives has afforded highly functionalized structures. , tris thus offers synthetic advantages in terms of symmetry for ensuring an accelerated dendritic growth: the amine can serve as an anchoring function and the hydroxyl groups can allow efficient tris-functionalization. for instance, tris-based glycodendrons have recently been designed by the group of wong, based on an efficient synthesis of structures displaying multivalent oligomannosides in high density, notably to mimic the glycans on hiv- gp (fig. ) . their interaction with the antibody g and dc-sign lectin has been characterized by a glycan microarray binding assay. an ab type dendritic skeleton (functionalized tris) was chosen as a precursor for constructing densely packed glycodendrons that were achieved in a few generations. the versatile ligation was ensured by the use of catalyzed alkyne-azide , -dipolar cycloaddition reaction (cuaac) to conjugate the sterically demanding azido oligomannosides and , designated as man and man , respectively, to the polypropargylated dendrons (scheme ). a convergent approach was also designed to facilitate the homogeneity of the dendritic scaffolds, using an iterative sequence based on n-boc removal and subsequent edc-hobt-mediated peptide coupling on tricarboxylic acid derivative , to afford polypropargylated compounds - for the first, second, and third generations, respectively. interesting results from biological studies indicated that g( )-man appeared to be an effective mimic of the hiv- gp surface glycan, suitable for conjugation to a carrier protein as a vaccine candidate. furthermore, evaluation of inhibition of dc-sign with was studied via gp /fc-dc-sign elisa tests. excellent inhibition activity in the nanomolar range was demonstrated, in contrast to the millimolar range from the reference mannoside. in these experiments, no inhibition was observed for the corresponding nonglycosylated alkynyl dendron (up to . mm), indicating that the multivalent oligomannose residues were responsible for dc-sign binding. the inhibition of glycodendrons interacting with antibody g and dc-sign indicated that these dendritic architectures, especially for g( )-man glycodendron , had the potential for use in the development of both carbohydrate vaccine candidates and as antiviral agents. oligomannoside-ending azides used in ''click-chemistry'' toward hiv- gp mimetics recognized by human antibody g and dc-sign. as with tris, the commercially available gallic acid constitutes an ideal candidate as branching unit for rapid dendritic growth. it allows dendron and dendrimer scaffolding to reach n surface groups at the nth generation. thus, gallic acid and its derivatives can afford highly functionalized glycosylated structures, taking advantage of its geometry for orthogonal transformation. it was initially used by roy et al. for the construction of hyperbranched dendritic lactosides presenting up to nine peripheral saccharide residues (scheme ). the convergent strategy described relied on the synthesis of a thiolated lactoside derivative , to be added to a preformed gallic acid derivative containing g( ) or g( ) dendrons ( ) capped with functionalized tetra(ethylene)glycol, to afford such glycodendrons as . the hydrophilic spacer was chosen to ensure advantageous water solubility of the resulting dendrimer and to counteract the hydrophobic effect of the aromatic gallic acid. two years later, the same group described the synthesis of hyperbranched glycodendrimers containing sialic acid residues, according to a similar strategy involving gallic acid derivatives and oligo(ethylene)glycol as dendritic backbones. the foregoing conditions were used to conjugate a-thiosialosides onto an n-chloroacetylated dendritic precursor ( for instance) by nucleophilic substitution, affording the anticipated sialodendrimers in high yields. interestingly, turbidimetric analysis confirmed the strong potential of g( ) sialodendrimers having nine readily accessible sialic acid residues to efficiently bind, cross-link, and precipitate two different lectins: the wheat-germ agglutinin wga and the lectin from the slug limax flavus (lfa). similar structures were later employed to create original dendronized polymers and , based on a chitosan backbone and using such sialodendrons as (fig. ) . chitosan itself is nontoxic, biodegradable, and has widespread biological activities, but major intrinsic drawbacks such as low solubility in both organic solvents and water have hampered its development as a bioactive polymer. thus, the synthesis of water-soluble dendronized chitosan-sialic acid hybrids was successfully achieved, using gallic acid as focal point and tri(ethylene)glycol as hydrophilic spacer arm, in order to investigate their potential to inhibit viral pathogens, including the flu virus. sialodendrons bearing a focal aldehyde end-group ( , for a trivalent dendron) were synthesized by a reiterative amide-bond strategy, based on the use of polyamineending trivalent or nonavalent dendritic scaffolds having gallic acid as the branching unit and capped with an acetal as a precursor for the aldehyde function. sialic acid p-phenylisothiocyanate (pitc) derivative was conjugated via thiourea linkages, followed by hydrolysis of the resulting aldehyde acetal with tfa to provide aldehyde . the same procedures were followed efficiently to access the next generation of dendrimers. finally, the focal aldehyde sialodendrons were grafted convergently onto the chitosan polysaccharide backbone by reductive amination in good yields, with the degrees of substitution indicated in fig. . the water solubility of these original hybrids was further enhanced when unmodified amino groups of the chitosan backbone were succinylated with an excess of succinic anhydride. an improved strategy using microwave-assisted synthesis, involving a gallic acid core and copper-catalyzed [ þ ] cycloaddition (cuaac), afforded a series of glycodendrons. fig. . polysialic acid dendronized chitosan. achieved in high yields, starting from azido sugar derivatives ( - ) and their subsequent cu(i)-catalyzed cycloaddition with acetylene-bearing dendrimers and (fig. ). this strategy allowed the rapid preparation of triazole glycodendrimers up to the nonavalent level and the successfull use of unprotected carbohydrates. the direct introduction of unprotected carbohydrates provides an interesting approach, avoiding tedious final deprotection steps and allowing, for steric reasons, more efficient couplings. an additional example provided by fernandez-megia et al. describes a quick, efficient, and reliable multivalent conjugation of unprotected alkyne-derived carbohydrates to three generations of azido-terminated gallic acid-triethylene glycol dendrons (fig. ) . in this work, azide-terminated dendrons were favored over those incorporating terminal alkynes because of the potential bias of the latter to cu(ii)catalyzed intradendritic oxidative coupling. under aqueous conditions and employing typical ''click chemistry,'' glycodendrimers containing up to [g( ) ] unprotected fucose ( a), mannose ( b), and lactose ( c) residues were efficiently isolated in high yields, after practical purification of the reaction mixture by ultrafiltration. further investigations by the same group led to the synthesis of three generations of a new family of block copolymers peg-(r)-saccharide a, b, and c with very good to excellent yields. interestingly, an nmr relaxation study of the azido-terminated peg-dendritic block copolymer precursors revealed a radial decrease of density from the core to the periphery, becoming more intense on increasing the generation of the dendritic block. furthermore, the resulting pegylated and mannosylated glycodendrimers demonstrated an increased capacity to aggregate lectins with increasing generation. a. glycopeptide dendrimers.-as stated earlier, the first glycopeptide dendrimers were described in the literature in . they were built using divergent solid-phase peptide fmoc-chemistry and l-lysine as a repeating amino acid on a wang resin. the initial sugar attached was sialic acid, which was introduced to confer strong inhibitory properties against flu virus hemagglutinin, a lectin-like protein recognizing a-sialosides on respiratory mucins. this early hyperbranched l-lysine scaffold was elongated with n-chloroacetylglycylglycine and efficiently coupled to a peracetylated a-thiosialoside. using dendrons bearing eight surface a-thiosialosides, roy et al. demonstrated that each saccharide moiety was a -fold better, on a per saccharide basis, than the corresponding monomer, while being stable to viral neuraminidase. these interesting architectures were, however, not as potent as sialopolymers since they could not properly cover the entire surfaces of the spherical virions, a property well exploited by random-coiled polymers. , it was later argued that dendronized polymers had improved potencies in this respect (see following pamam section). when the same poly-l-lysine scaffold was utilized with mannoside residues bearing an optimized arylated aglycon, the resulting -and mer glycodendrons showed , -fold increased inhibitory potency against fimbriated e. coli k on a per mannoside basis. the structure of the -mer mannosylated dendrimer ( ) is illustrated in fig. . the octameric aminophenyl a-d-mannopyranoside had an ic of . nm ( . nm/man). it was found that a competitive binding assay measuring the binding of i-labeled, highly mannosylated neoglycoprotein (bsa) to type- fimbriated e. coli (k ) strain in suspension gave much lower ic values than the equivalent values obtained by hemagglutination or in assays that involved microplate immobilization. two key features strongly influencing the affinity to e. coli adhesin were: ( ) the presence of an a-oriented aglycone bearing a hydrophobic group, and ( ) the presence of multiple mannoside residues that can span a distance of nm or longer. the two best inhibitors were a highly mannosylated neoglycoprotein with the longest linking arm between a mannose and protein amino group, and the -mer mannosylated dendrimer (fourth generation), with an ic of . nm ( . nm/man). first described and patented by denkewalter et al. in the late s, dendronized lysine is one of the most widely used core structures in dendrimer and glycodendrimer synthesis. an excellent series of reviews by the group of ježek on the synthesis and biological applications of lysine-based glycodendrimers has been published. [ ] [ ] [ ] [ ] such glycosylated lysine dendrimers have been prepared both on solid supports [ ] [ ] [ ] and in solution. [ ] [ ] [ ] reaction of the peripheral amino groups with a variety of electrophiles carrying pendant sugar residues (such as isothiocyanates, carboxylic acid, and reducing sugars) have lead to glycodendrimer thioureas, amides, and amines, respectively. sugars bearing activated ester groups have also been coupled to dendritic lysines to provide galactoside-and n-acetylglucosamine-capped glycoclusters, , including the important thomsen friedenreich (tf) disaccharide antigen [b-d-gal( ! )-a-d-galnac] known as a breast cancer marker and against which monoclonal antibodies were raised (see, for instance, fig. ). , the corresponding tf-bearing glycodendrimers bound to the antibodies, and were shown to be adsorbed strongly onto the surface of microtiter plates. the analogous b-d-glcnac glycodendrimer was also further elaborated as the lewis x tetrasaccharide antigens , using multiple chemoenzymatic processes (fig. ) . analogous mannosylated architectures have also been proposed. mbp acting as receptors can mediate uptake and internalization of both soluble and particulate glycoconjugates, and as such they take part in innate immunity. , the broad pattern-recognition displayed by mannose receptors, together with their implication in adaptive immunity, has stimulated considerable efforts toward the selective delivery of enzymes, , drugs, [ ] [ ] [ ] oligonucleotides or genes, [ ] [ ] [ ] [ ] and antigens [ ] [ ] [ ] to cells expressing them, for therapeutic and vaccine strategies. another important mannose receptor is a membrane-associated protein restricted on sinusoidal liver cells, peripheral and bone marrow macrophages, and dendritic cells. it also recognizes and internalizes mannosylated glycoconjugates from pathological microorganisms, tumor and yeast cells, such glycoproteins as type-i procollagen, tissue-type plasminogen activator, or various lysosomal enzymes. as such, this mannose receptor contributes to the nonimmune host-defense system. in addition, the macrophage receptor is implicated in major histocompatability complex-mediated antigen (mhc) presentation by dendritic cells (dc-sign) (dendritic cell-specific icam- grabbing nonintegrin) (icam- ¼ intercellular adhesion molecule). dc-sign also belongs to the family of c-type lectins able to bind high-mannose glycoproteins of hiv-gp , ebola-gp , or dengue-gp e. dc-sign is also known to oligomerize, and it is therefore particularly important to understand the intrinsic binding and multivalent binding requirements of this lectin. in this context, biessen et al. conceived oligomeric linear l-lysine mannosides bearing the same arylated aglycone just described for . its associated p-isothiocyanatophenyl a-d-mannopyranoside was coupled to the poly-l-lysine backbone through an isothiourea linkage. the structure of the -mer is illustrated in fig. . the affinity of these mannoclusters toward the mannose receptor increased steadily from - mm (dimer) to . - . nm ( -mer). as a consequence of its high affinity, is a promising targeting device for cell-specific genes and delivery of drugs to liver endothelial cells or macrophages in bone marrow, lungs, spleen, and atherosclerotic plaques. another investigation targeting the mannose receptor expressed by the human dendritic cell (dc-sign) has been presented by grandjean et al. but adding carbohydrate mimicry to the multivalent concept. , as with the strategy just described, quinic and shikimic acid derivatives used as mannose bioisosteres have been linked to dendritic l-lysine scaffolds to afford novel hyperbranched glycomimetics (fig. ) . fluorescein-labeled pseudoglycodendrimers with valencies of two to eight were tested by competitive-inhibition assays with mannan, which was evaluated by confocal microscopy using mannose receptors expressed in transfected cos- -cells. cells expressing mannose receptor-mediated uptake were assayed on monocyte-derived human dendritic cells by cytofluorometric analysis. the synthetic clusters were shown to be effective ligands against the dendritic cells, with an optimum affinity , toward clusters having a valency of four ( ). however, the glycomimetics as well as the natural mannosides did not perform , although the results indicated that the mannose receptor could accommodate structures that diverged significantly from previously identified natural ligands and which could be further optimized using qsar. , additionally, monodisperse lysine dendrimers capped with - mono-, di-, and tri-a-d-mannopyranosyl residues did not induce dendritic cell maturation. as stated, dc-sign is a key mannoside receptor for exogenous pathogens that is used by viruses for entry into the lymph nodes. the inhibition of this process has thus been sought as an interesting strategy for blocking viral adhesion. consequently, a series of mannosylated boltorn dendrimers was prepared (see later section) that were rather efficient in this respect. an interesting extension of this strategy was proposed using various fluorescent probes: fluorescein, rhodamine, pyrene, and dansyl groups ( , fig. ). they were incorporated onto mannosylated dendrons prepared entirely by spps (fmoc-chemistry) and used for the imaging studies of mannose receptor-mediated entry into dendritic cells by confocal fluorescence microscopy. after pathogen capture, internalization, and digestion, peptide fragments were expressed on mhc molecules. a t cell-specific immune response was thereby initiated. this sequence of biological events was exploited for vaccine design (see next). the heterobifunctional, high-affinity multivalent ligand was assembled on nontoxic, nonimmunogenic poly-l-lysine dendrimers to which the required number of mannosyl residues can be attached simultaneously via a -hydroxybutanoic acid linker, a substance occurring naturally in mammals. the synthesis of the model poly-l-lysine dendrons was initially performed on a commercial tentagel resin preloaded with fmoc-sieber amide linker. the low loading level of the commercial resin ( . mmol/g) ensured that sufficient space was allowed for the large fourth and fifth-generation dendrons to be assembled without problems of steric hindrance. at the same time, the mild cleavage conditions required for this type of resin did not cause significant acidpromoted glycoside hydrolysis. the -(mannopyranosyloxy)butanoic acid was then introduced by classical peptide-coupling reagents. the established protocol was next applied toward the fluorescently labeled analogues by introducing at the focal point a lysine residue possessing the acid-labile -methyltrityl (mtt) protecting-group. the side chain of the focal e-amine, protected by the mtt group, was used for labeling, in conjunction with the considerably less acid-labile commercial rink amide linker for maximum versatility. thus, the rink amide tentagel resin was loaded with fmoc-lys(mtt)-oh and the n-terminal fmoc group was removed by classical treatment with % piperidine in dmf. after the reiterative insertion of bis-fmoc lysine was terminated, the mtt group was removed at low tfa concentrations with minimal losses of the dendron, and the newly freed amine was directly labeled onto the resin. accordingly, treatment of the polymersupported g( ) dendron with % tfa in ch cl led to complete removal of the mtt group within a short time. lower concentrations of tfa were inefficient. the free amine group of the glycodendrons was then treated with the appropriate fluorescent probes to provide desired mannosylated glycodendrons such as (fig. ) . spherical and hemispherical glycodendrimers containing a polylysine scaffold have been elaborated (fig. ) . , third-generation polylysine dendrimer was prepared as a tfa salt from tris( -ethylamino)amine ( ) as a trivalent core and the stepwise condensation of diboc-lysine, according to a published strategy. the n-boc-protecting group was removed using standard conditions ( m tfa) to provide the free polyamine. the polylysine dendrimer , having terminal amino groups on the surface, was then treated with the peracetylated cellobioside , using bopmediated peptide coupling. deprotection of the crude peracetylated glycodendrimer was achieved (zemplén conditions: naome, meoh, h), and the free dendritic glycopeptide was obtained in % yield and fully characterized by cellobiosyl glycopeptide dendrimer would show key biological activities such as anti-hiv and blood anticoagulant activities. solid-phase combinatorial synthesis furnished a large ( , -members) neoglycopeptide dendrimer library ending with c-fucoside derivatives. a tetravalent dendrimer (fig. ) showed the strongest binding affinity (ic of . mm) against the p. aeruginosa pa-iil lectin, a virulence factor in cystic fibrosis (cf) patients. the optimized ligand combined multivalency with the presence of positive guanidine charges in proximity to the carbohydrate residues, and which happen to be better in comparison to a divalent analogue lacking the n-terminal lysine residues (ic of . mm). an improved , -membered peptide dendrimer library was prepared analogously. dendrimer (a-fuc-ch co-lys-pro-leu) (lys-phe-lys-ile) lys-his-ile-nh was the most potent ligand against the model plant lectin ulex europaeus (uea-i), with an ic of mm and the bacterial lectin pa-iil from p. aeruginosa (ic of . mm). glycopeptide libraries have also been synthesized with divalent carbohydrate structures to optimize multivalent carbohydrate-binding protein interactions at subsite at the vicinity of the carbohydrate-recognition domain (crd). as stated earlier, dendritic cells and macrophages are valuable antigen-presenting cells (apcs). these cells express mbps and, as such, they constitute important entry mechanisms for vaccine targeting. thus, instead of linking short peptide antigens to , classical immunogenic protein carriers, such as keyhole limpet hemocyanin (klh) or tetanus toxoid and the like, a study was evaluated toward the possibility of using mannoside-capped polylysine glycodendrimers ( ) constructed at the n-terminal of several immunogenic peptides (fig. ) . peptide sequences from hiv- gp protein ( - bearing the llsgiv motif capable of inhibiting viral fusion, - ), sars-cov s ( - , - ) , and influenza hemagglutinin ha were built on a rink amide resin. the lysine moieties were then introduced as a g( ) lysine dendron followed by mannosylation, using -(mannopyranosyloxy)butanoic acid ( ) at the terminal (e) amino groups of the lysyl-peptide dendrimer ( ). preliminary data from the resulting vaccine candidate , containing the llsgiv motif, demonstrated that it could elicit a polyclonal antibody response in rabbit much stronger than the klh constructs. it was concluded that the mannosylated dendron was stabilizing the peptide from proteolysis. n-terminally mannosylated peptides carrying one to six mannose residues were also shown by koning and coworkers to elicit an immune response, with efficiency up to -fold greater than peptide antigens alone. the capture of antigenic determinants by apcs that will ultimately appear in mhcs for t helper cell stimulation depends on several factors. if apcs are represented by b cells, multivalency becomes an issue, because both the recognition and the binding events are triggered by cell-surface immunoglobulins. a classical example of successful applications in this regard is presented by the high immunogenicity of bacterial capsular polysaccharides (cps) which, on their own, can elicit protective antibodies. , however, the resulting antibodies are usually limited to low-affinity igms, and the immune responses lack memory effects because of the absence of t fig. . entirely synthetic anti-hiv vaccine candidate capable of apcs uptake. , cell-dependent antigens normally associated to peptides. cps are thus said to be t independent antigens. alternatively, if the b cell antigens are not multivalent, such as those found in small peptides or oligosaccharides, they will greatly benefit from being mounted on dendritic scaffolds. moreover, the key t cell epitopes, needed in the context of mhc complexes, can be typically short -mer peptides and yet, be too small for efficient uptake by apcs. consequently, the design of dendritic glycoconjugates bearing multiples copies of both oligosaccharides (b cell epitopes) and short peptides (t cell epitopes) has been proposed as entirely synthetic vaccine candidates ( ) (fig. ) . a few elegant applications of this principle have been recently proposed for triggering neutralizing antibodies against the v- loop glycoprotein of gp from hiv- isolates that recognize and bind to the high mannose oligosaccharide epitope man glcnac (fig. ) that is present in numerous copies on gp . the proposal was based on the observation that a swapped human antibody, named g , was identified in a patient that successfully mounted a protective anti-hiv immune response (fig. ) . besides glycoclusters based on a central peptide, earlier presented in section ii. , the group of kunz was the first to fully demonstrate the feasibility and efficacy of eliciting complete immune responses with memory effects, using carbohydrate cancer antigens built on multiple antigen glycopeptide scaffolds. , thus, the immunogenicity of synthetic multiple antigenic glycopeptides (mags) displaying four clustered t n -epitopes anchored to an oligomeric branched lysine core was examined (fig. ) . conventional sps of the peptidic structure was performed by fmoc-methodology on wang resin. the dendritic immunogen , containing clusters of three consecutive t n -epitopes linked to the poliovirus t cell epitope klfavwkitykdt, was tested in mice as both a prophylactic and as a therapeutic cancer vaccine. as the analogous mag , harboring only four monomeric t n -antigens that have been shown to increase the survival of tumor-bearing mice, added results indicated that showed high immunogenicity and good protection against the development of t n -expressing tumor cells. poliovirus t cell epitopes capped with monomeric ( ) and trimeric t n -antigens ( ) that confered high murine immunogenicity. , the n-linked pentasaccharide core man (glcnac) glycopeptide bearing the extracellular mmp inducer sequence (emmprin - ) has been successfully linked to g( ) pamam aminodendrimer by thioester activation (fig. ) . the resulting octameric kda construct was obtained in low yield, but was purified by preparative electrophoresis and fully characterized by maldi-tof mass spectrometry. the multivalent architecture was built to evaluate the requirement of emmprin multimerization for inducing mmp expression. the numerous successes achieved in the solid-phase syntheses (sps) of glycopeptides dendrimers, coupled to their ease of preparation and purification, has also triggered chemists to apply the sps nucleotide chemistry toward the synthesis of phosphodiester-linked glycodendrimers. as mentioned earlier in the glycoclusters section, the chemistry and geometry of phosphodiesters and triesters are obviously appealing factors for their use as glycodendrimer scaffolds. the following strategy was based on the synthesis of key phosphoramidite building blocks bearing either n-chloroacetyl or alcohol end groups for further branching. deg spacers were initially transformed into the mono tert-butyldiphenylsilyl derivative which upon treatment with n,n-diisopropylphosphoramidous dichloride (cl p-n-(ipr) , dipea, ch cl ), provided the essential building block n,n-diisopropyldiphosphoramidite ( ) in % yield (fig. ) . alternatively, the mono n-chloroacetylated deg derivative , prepared from commercially available -( -aminoethoxy)ethanol (clch co h, eedq, c, h, %) was similarly treated to provide phosphoramidite ( %). further couplings of or with alcohols or in the presence of h-tetrazole gave the corresponding phosphotriesters or after oxidation with t-butyl peroxide ( - %). coupling tris(n-chloroacetyl) derivative (meoh, et n) with the thiolated n-acetylgalactosaminide afforded a firstgeneration phosphoglycodendrimer ( %) having three a-d-galnac moieties (not shown). thiol was prepared from allyl n-acetyl-a-d-galactosaminide by reaction with thioacetic acid (hsac, meoh, aibn, reflux, h, %) followed by zemplén s-deacetylation. tert-butyldiphenylsilyl-protected phosphotriester was deprotected by fluoride anion (bu nf, thf, %) to give a triol , which was further branched with building block as before to provide a second-generation phosphotriester ( %) having six nchloroacetyl residues after oxidation of the phosphite. nucleophilic displacement of the hexavalent n-chloroacetylated precursor by as before, provided hexavalent dendrimer ( %). further processing of the synthetic sequence, coupled with tethering strategies with various spacers, gave access to a family of dendrimers having many different valencies. all of the galnac-bearing phosphodendrimers thus produced were tested as inhibitors of the plant lectin v. villosa binding to asialoglycophorin, a natural ligand for hepatocytes receptors. the results indicated a - -fold (hexamer) enhanced affinity over the monovalent ligand, thus supporting once again the glycoside cluster effect. interestingly, sugar is part of a key determinant known as the tf-antigen overlay expressed on breast cancer tissues and other melanoma cancers. its structure and higher oligosaccharide homologues have formed the basis for the dendritic glycopeptides vaccines already described. additional examples of dendritic phosphodiesters have been highlighted by dubber and fréchet with mannoside and galactoside oligonucleotide conjugates, using a dna synthesizer (fig. ) . the sps of multivalent glycoconjugates enables the custom tailoring within hours of their valency and structural requirements toward the biological targets, as opposed to more cumbersome traditional approaches. a tetrameric mannoside ( ) was thus prepared from simple precursors - , using phosphoramidite chemistry. a glycodendron was built with a fluorescein probe and another one with a thiolated oligonucleotide coded for the antisense inhibition of inducible nitric oxide synthase. once again, the constructs, prepared on a mmol scale, were satisfactorily characterized by standard h nmr and maldi-tof ms. b. commercial dendritic scaffolds.-(i) pamam dendrimers. several dendrimer scaffolds having various surface functionalities and valencies, constructed from diverse building blocks and according to both general synthetic strategies (fig. , see also section v. ones are illustrated in fig. . among these readily available and widely used dendritic scaffolds, poly(amidoamine) dendrimers (pamam, dendritic nanotechnologies) constitute candidates of choice that have been extensively exploited by many groups of glycochemists, notably for the rapid synthesis of highly branched glycodendrimers. since the pioneering synthesis of poly(amidoamine) dendrimers proposed by tomalia et al. using a divergent growth procedure, these attractive molecules have constituted an exciting new class of macromolecular and highly branched architectures with well-defined size, shape, and geometry. they have drawn much interest in several research areas. , accordingly, pamam-based dendrimers, having built-in surface amine functionalities, have been the first and most frequently used scaffolds for attachment of sugars. the very first example of saccharide-substituted pamam dendrimers was proposed by okada and coworkers, who described the synthesis of ''sugar balls'' via amide bond formation, starting from sugar lactones ( ). although this process is a straightforward manipulation, it suffered from the disadvantage of sacrificing the reducing sugars, which alternatively served as extended linkers (scheme ). several other strategies have been used to adequately functionalize pamam dendrimers with carbohydrates, involving: (a) introduction of thiourea linkages formed by treating amino dendrimers with isothiocyanated saccharide derivatives, (b) direct amide linkages with sugar-bearing carboxylated or activated ester derivatives, (c) reductive amination, or (d) incorporation of chloro-or bromo-acetamido groups onto pamam dendrimers or saccaharides, to afford highly electrophilic species that can for instance react with thio or amino derivatives. all of these synthetic approaches are illustrated in the following section. thiourea linkages. attachment of saccharide units to the surface of pamam through thiourea linkages offers one of the most efficient ways to develop multivalent ligands quickly and efficiently for the study of protein-carbohydrate interactions. historically, lindhorst and kieburg first published the simple and efficient coupling of different low-generation polyamine scaffolds, including pamam, to b-d-gluco-, aand b-d-manno-, b-d-galacto-, b-cellobio-, and b-lacto-configured glycosyl isothiocyanates. an improved version, using a hydrophobic aryl aglycone, later permitted the syntheses of the first four generations of monodispersed neoglycoconjugates having up to mannoside units ( ). p-isothiocyanatophenyl a-d-mannopyranoside was used as key precursor (scheme ). the resulting glycodendrimers were evaluated as ligands for the phytohemagglutinins from con a and pisum sativum (pea lectin), using ella and turbidimetric analyses. the relative binding data indicated that incorporation of terminal a-substituted mannoside residues furnished glycodendrimers showing an up to -fold increase in binding capacities. moreover, their ability to bind and form insoluble carbohydrate-lectin complexes was also demonstrated by radial double immunodiffusion and turbidimetric assays, and their capacity to precipitate selectively their homologous protein receptors from crude lectin mixtures made them convenient tools for the rapid and simple isolation of proteins. the same procedure was successfully adapted by the same group a few years later, allowing the introduction of p-isothiocyanatophenyl b-d-lactoside onto pamam scaffolds to study their relative binding behavior toward the family of galectins, the influence of the generation, and the binding-site orientation of receptors. in , a similar but simplified procedure, involving aqueous solutions that and avoiding protecting groups, for the synthesis, from methylthiourylene a-d-mannopyranoside or the aromatic derivative, of a g( ) pamam dendrimer containing up to six peripheral mannosyl residues was proposed. , parallel investigations by thompson and schengrund involved the synthesis of glycodendrimers from poly(propylene)imine and starburst (pamam) dendritic scaffolds, and provided potent inhibitors of ct. using the pitc derivative of oligo-gm . the ic s values were determined for the oligo-gm -pitc dendrimers, native gm , and the oligosaccharide moiety of gm (oligo-gm ), and studies revealed that the glycodendrimers inhibited binding of the ct to gm -coated wells at molar concentrations -to -fold lower than native gm and more than -fold lower than that of the free oligosaccharide. g( ) and g( ) sialic acid-containing pamam glycoconjugates with p-isothiocyanatophenyl a-sialoside ( ) (fig. ) as precursor have also been described by zanini and roy, and their lectin-binding properties evaluated. preliminary turbidimetric studies with g( ) and g( ) a-thiosialodendrimers, presenting and peripheral sugar units, respectively, demonstrated their ability to bind the slug lectin from lfa, showing well-organized precipitation patterns. furthermore, their relative efficiency to inhibit the binding of hrpo-labeled lfa to human agp (orosomucoid) was determined by a competitive ella. interestingly, an increase in multivalency resulted in a steady increase of inhibitory potential, with ic values in the nanomolar range ( . and . for g( ) and g( ), respectively) corresponding to an $ -fold jump in inhibitory potential over the monomeric analogue. subsequently, baker and coworkers evaluated similar sialic acid-conjugated g( ) pamam structures as a mean of preventing adhesion of three influenza a virus subtypes, and furnished one of the first documentations of the function of dendrimer conjugates as antiinfective agents in vivo. hai in vitro showed the glycodendrimers to inhibit some specific influenza subtype strains at concentrations - times lower than those of sialic acid monomers. the in vivo studies also demonstrated the ability of the glycodendrimers to protect against experimental infection by influenza a x- h n virus in mice. in , woller and cloninger described the largest glycodendrimer then built, prepared on generation g( )-pamam dendrimer and containing mannoside residues. when compared to methyl a-d-mannoside taken as the monomeric control, dendrimers g( ) and g( ) did not show any increase in activity toward the phytohemagglutinin con a, and the g( ) dendrimer bound roughly one order of magnitude better than g( ), g( ), or methyl mannoside. this was suggestive of a glycoside cluster-effect (enhanced local concentration). as with g( ) and g( ) glycodendrimers, g( ) was too small for multivalent binding to occur (chelate effect). dendrimers g( ) to g( ) showed a two orders of magnitude increase in activity against the tetrameric con a, indicating that multivalent binding was occurring. it is also possible that the change in shape from circular [g( )-to g( )-pamam] to spherical [g( ) to g( )] caused the observed binding enhancement. further studies led the same group to the efficient incorporation of more complex saccharide units such as aman-( ! )man disaccharide , manifesting the fact that dimannose functionalized g( ) and g( )-pamam dendrimers , having an average of and peripheral groups were very competent for the recruitment of cyanovirin-n (cv-n), an hiv-inactivating protein that blocks virus-to-cell fusion through high mannose-mediated interactions (scheme ). finally, a subsequent investigation provided the first example of the use of glycodendrimers as model systems for studying carbohydrate-carbohydrate interactions (cci). more particularly, lactosylated pamam dendrimers with various peripheral carbohydrate numbers, depending on the generation, were synthesized to examine the cci of lactose with mixed langmuir monolayers containing gm and dipalmitoyl phosphatidylcholine (dppc). thiourea ligation between glycosyl isothiocyanate derivatives and the aminated dendritic core, following standard protocols afforded glycodendrimers containing appropriate amounts of lactose, which were further capped with poly(ethylene)glycol chains or other carbohydrates. the results corroborated the concept that lactosyl dendrimers were engaged in a cci with gm in a langmuir monolayer. this cci was dependent on both the carbohydrate density and the density of glycolipid within the monolayer. moreover, a specific cci was observed only in the presence of calcium ions and when at least one-fifth of the monolayer was composed of gm . amide linkages. strategies based on the direct formation of amide bonds via carboxylic acid or activated ester-containing saccharides and pamam dendrimers have afforded sophisticated dendritic architectures having promising biological properties. for instance, using a similar approach to the one just described, aoi et al. described the synthesis of dendrimer-based star polymers (''oligoglycopeptide sugar balls'') by the original macromolecular design of living polymerization. the actual dendritic oligoglycopeptides were thus synthesized by living oligomerization of glyco-n-carboxy anhydrides (glyco-ncas) with poly(amidoamine) (pamam) dendrimer as a multifunctional macro initiator. this polymerization system was termed as ''radial-growth polymerization (rgp),'' since dendrimer-based living polymerizations offered highly ordered star-shaped macromolecules with a number of arms, which should be different from conventional star polymers. the resulting sugar balls in this study are dendritic nanocapsules surrounded radially by oligoglycopeptide chains. roy et al. described the systematic preparation and biological evaluation of gly-copamams containing up to tf-antigen units [bgal-( ! )-agalnac], known to be a cancer-related epitope and as an important antigen for the detection and immunotherapy of carcinomas, particularly relevant in breast cancer patients. , , the synthetic sequence was based on the efficient acid functionalization of the allyled tf-antigen derivative , accomplished using -mercaptopropanoic acid, to provide acid in % yield. glycopamams , presenting up to peripheral tf-antigens, were prepared by direct amide bond formation between unprotected and pamam, using the efficient tbtu coupling reagent ( -( h-benzotriazole- -yl)- , , , -tetramethyluronium tetrafluoroborate) and dipea as a base (scheme ). the protein-binding properties of these glycodendrimers were evaluated using peanut lectin from arachis hypogaea and a mouse monoclonal igg antibody. based on bulk conjugates, the glycopamams with the highest carbohydrate density exhibited the strongest inhibitions, clearly indicating a cluster effect. all of these conjugates were antigenetically active and their ic values of . , . , . , and . nmol, respectively, for g( ) to g( ) correspond to inhibitor abilities , , , and times higher than that of the monomer toward antibody-coating antigen interactions. based on an identical approach, mannosylated pamam dendrimers were constructed in order to evaluate their relative inhibitory properties against the type- fimbriated uropathogenic e. coli. as an alternative to the synthetic strategy just described, the authors chose -aminopropyl a-d-mannopyranoside ( ) pretreated with diglycolic anhydride. the resulting extended acid derivative was then coupled to peripheral pamam amino groups with typical peptide coupling reagents such as bop (benzotriazole- -yloxy-tris(dimethylamino)phosphonium hexafluorophosphate) or tbtu (scheme ). the deprotected glycodendrimers were tested using a newly developed elisabased inhibition assay for their ability to inhibit the binding of recombinant type- fimbriated e. coli (fimh) to a monolayer of t cell lines derived from human urinary bladder epithelium. the pamam mannodendrimers displayed potent affinity toward the target fimh, with ic of and mm for g( ) and g( ), respectively, although their relative potency per mannose was rather low. the synthesis of mannose -phosphate-functionalized pamam dendrimers was also investigated and studied for their ability to bind goat-liver mannose- -phopshate receptor (mpr ). the preparation of these glycodendrimers was achieved by the initial preparation of the amine-tethered man- -p derivative . since the amino function was present on the saccharide residue, the authors used preformed halfgeneration g( . ) to g( . ) pamam dendrimers exhibiting , , , and carboxylic acid groups, respectively. the resulting dendritic conjugates were obtained by direct amide bond formation, using dic-hobt ( -hydroxybenzotriazole) or edc ( -ethyl- -( -dimethylaminopropyl)carbodiimide)-nhs (n-hydroxysuccinimide) as coupling reagents (scheme ). preliminary biological studies suggested that the newly synthesized man- -phosphate-containing dendrimers could act as adsorbents in related affinity chromatography, with an interesting potential to bind the purified goat-liver mannose- -phopshate receptor (mpr ) protein. additional conjugation of various nonprotected glycosides has been similarly described using p-nitrophenyl activated saccharide esters to conjugate disaccharides or sialic acid components onto pamam scaffolds. reductive amination. sashiwa et al. have used reductive amination to provide dendronized chitosan-sialic acid hybrids containing different spacers (scheme ). [ ] [ ] [ ] the sialic acid residues were successfully attached to each pamam dendrimer by reductive n-alkylation with p-formylphenyl a-sialoside , using nabh cn in meoh, to furnish hybrid chitosans . however, since an excess of aldehyde must be used for high incorporation of sialic acid, the procedure also gave rise to double n-alkylation. the reaction thus gave complex sialic acid constituents, affording undesired mixed structures. to circumvent these drawbacks, n-methylamino derivatives (see scheme ) have been subsequently used for the reductive amination, and sialodendrimers have been prepared to target the immunoglobulin exposed siglecs. nucleophilic substitution via incorporation of haloacetamido groups. in , zanini and roy described the design and synthesis of a novel family of symmetrical dendrimers presenting even valencies between and residues, based on a , iminobis(propylamine). the synthetic approach was based on convergent assembly of suitable multibranched dendrimers containing n-chloroacetylated end groups to provide electrophilic species that could readily react with thiolated carbohydrate derivatives. many synthetic benefits emanated from this strategy. first, the method was general, high-yielding, and readily amenable to such existing commercially available amine-terminated dendrimers as pamam that could be similarly treated with chloroacetic anhydride. second, the synthesis of this dendritic family presented a viable alternative to pamam dendrimers, avoiding the need for large excesses of the reagents commonly used to ensure complete conversion. more importantly, these scheme . synthesis of dendronized chitosan-sialic acid hybrids. [ ] [ ] [ ] structures are not susceptible to base-catalyzed retro-michael degradations, in contrast to classical pamams, since the substituents are not b-carbonyl positioned. the authors thus accomplished the efficient preparation of dendritic a-thiosialosides - , starting from the ab -type core , -iminobis(propylamine) ( ), which was subsequently transformed to afford various symmetrical n-chloroacetylated dendrons, such as tetramer (scheme ). a slight excess of thiosialoside allowed the synthesis of glycodendrimers under mild conditions. they were deprotected to afford the dendritic architectures containing between four ( , scheme ) and up to sialoside residues ( , fig. ), respectively. the same group conducted a systematic study of similar but tethered sialodendrimers with even valencies between and ( ), based on the same ab core , and according to the same synthetic strategy. the potential of these sialodendrimers to cross-link and precipitate lfa was confirmed by preliminary turbidimetric analysis. when tested in enzyme-linked lectin inhibition assays using human agp (orosomucoid) as coating antigen, and hrpo-labeled lfa for detection, tetravalent dendron showed ic values of . nm, while presented a higher value of nm. on the other hand, these assays indicated that for the corresponding tethered dendrimers, the inhibitory potency increased with a corresponding increase in valency. the highest ic value was obtained for ( . nm) and constituted a -fold increases in inhibitory potential over the monovalent -acetamido- -deoxy-d-glycero-a-d-galacto- -nonulopyranosyl azide used as standard (ic of nm). the same group then extended this approach using solid-phase chemistry. despite the demonstration that pamam dendrimers can exhibit up to functionalized scaffolds are not always the ones with the highest protein-binding activity. in fact, less-functionalized ligands may often present optimal potencies. a plausible explanation for this phenomenon has been suggested and highlights the fact that at high loading, the peripheral saccharide portions might become less accessible to proteins because of an increase in steric hindrance. another hypothesis is based on the drawbacks of using large dendrimers bearing aromatic aglycones, which can intramolecularly undergo p-stacking, thus further tightening the saccharide units at the dendrimer surface. furthermore, solubility problems are often encountered with pamam dendrimers bearing more than arylated mannoside moieties. straightforward solutions to this problem have been addressed in the following publications describing the synthesis of sialoside dendrimers , where the glycans are interspaced by tris residues used as ''dummy'' functionalities ( fig. ) . aiming to validate these concepts, wolfenden and cloninger conducted the controlled preparation of a series of heterobifunctionalized mannoside and hydroxyl-g( ) to g( )-pamam dendrimers (fig. ) . , a systematic study was addressed of the effect of carbohydrate loading on the activity of the dendrimer for a lectin and the influence of the conjugates' size. the degree of functionalization of mannose-hydroxyl groups via thiourea linkages was controlled by the stoichiometric amount of isothiocyanate derivatives of comparable reactivity. ms data allowed determination of the average number of mannose surface residues for each dendrimer generation. hemagglutination assays were performed by adding rabbit erythrocytes to preincubated solutions of con a and varying the concentrations of deprotected dendrimers. comparison of the fourth through sixth pamam generations with different loading of surface mannose residues suggested that the binding efficiency was the highest for all generations at % to % loading. the most interesting observation was that the highest activity did not correlate with the maximum sugar loading, but rather occurred at slightly closer packing of the sugars as the generation increased, suggesting that unfavorable steric interactions precluded optimal binding at high carbohydrate density. a follow-up investigation described the simultaneous anchoring of various sugars, such as mannose, galactose, and glucose residues via thiourea linkages, in order to quantify the effect that functionalization of dendrimers with monomers of varying affinities would have on its multivalent activity with lectins ( ).as mentioned in earlier work, maldi-tof ms was used to determine the exact number of carbohydrate residues of each type on the resulting glycodendrimers. both the change in mw after each sequential addition and the change in molecular weight after deacetylation were used for accurate measurement of the extent of functionalization. the association of the corresponding deprotected dendrimers with con a was studied by precipitation and hemagglutination assays. as expected, increasing the number of mannose residues, while decreasing the number of glucose residues, caused an increase in the relative affinity toward con a. as with the dendrimers bearing % mannose: glucose loading, a linear relationship between man:glc loading and assay activity was observed for compounds of generations - . however, the relative binding differences between mannosylated dendrimers and glucosylated dendrimers varied from one generation to another. alternatively, the g( )-mannosylated pamam had a fivefold higher relative affinity toward con a compared to the glucose-functionalized analogues. in summary, the reported results suggested that multivalency can be influenced in fig. . modified pamam scaffold bearing inter-spacing tris residues to promote better accessibility to surface saccharides. predictable and therefore tunable ways. monovalent differences are amplified by multivalent associations, and mixtures of low-and high-affinity ligands can be used to attenuate multivalent binding activities. given their commercial accessibility, pamams have been the scaffold most widely used in modern investigations. they have been modified with a large variety of sugar derivatives and with varied sugar densities (fig. ) . they have been used for several important binding phenomena and represent the most deeply studied scaffold for toxicity evaluations. in addition, scaffolded glycodendrimers were shown to be nonimmunogenic, a key property if they are to be used as bacterial or viral antiadhesins. b. ppi dendrimers.-a convenient reaction sequence for large-scale synthesis of ppi dendrimers [poly(propyleneimine) or dab-dendr-(nh ) x ] (fig. ) has been described by meijer's group, who nicely adapted the original strategy proposed earlier by vögtle's group (which suffered from cumbersome purifications). , by a repetition of double michael addition of acrylonitrile into primary amines, followed by metal-catalyzed hydrogenation, the preparation of well-defined dab-dendr-(nh ) x containing up to primary amine surface groups was efficiently achieved. as with pamam dendrimers, this family of commercial dendritic scaffolds has been widely functionalized. obviously, saccharide-based ppi dendrimers have also been synthesized. the first example of glycodendrimers using ppi scaffolds was proposed by ashton et al. who described their use for the rapid and facile construction of high molecular weight g( ) to g( ) carbohydrate-coated dendrimers. a divergent approach was followed and glycodendrimers containing, respectively, , , , , and d-galactose and lactose peripheral groups, were efficiently synthesized. the saccharide residues were attached to the aminated dendritic scaffold was by amide in continuing efforts, the same authors constructed tris(galactoside)-modified dab dendrimers by the accelerated convergent strategy. in this particular approach, the saccharides were connected first to a small tris branching derivative to form a cluster which served as a building block, once suitably functionalized. n-succinimidyl-activated ester was then coupled onto g( ) and g ( ) the same group modified the linker by using different numbers of carbon atoms ( , , ) to afford variations of the local saccharide concentrations at the dendrimer surface. this study was aimed to determine the influence of this linker parameter on the glycodendrimer-protein interactions, the relationship between structure and water solubility, and to investigate amphiphilic properties. in , additional poly(sulfogalactosylated) dendrimers based on dab scaffolds were investigated to study their antagonist properties against hiv- infection. first, to assess the interaction of hiv- gp with its reported alternative glycolipid receptors, a series of glycodendrimers built from mimics of galactosyl ceramide (galcer ) and its sulfated derivatives were synthesized, analyzed by spr as ligands for rgp iiib, and evaluated for their ability to inhibit hiv- infection on cxcr -and ccr -expressing indicator cells. the synthesis was based on direct amine bond formation with carboxylated galactoside residues or and g( ) to g( ) dab-dendrimer (scheme ), and afforded compounds and . polysulfated dendrimers were obtained by random sulfation of , and the average number of sulfates was determinated by maldi-tof ms analysis. the in vitro studies of their effectiveness at inhibiting infection of u -magi-ccr cells by hiv- ba-l indicated that the sulfated glycodendrimers were better inhibitors than those of the nonsulfated compounds, but not as effective as the sulfated dextran control . further investigations led the same group to increase the degree of sulfation on galactosylated dendrimers, based on the hypothesis that glycosphingolipid sgalcer was the best ligand for both recombinant and virus-associated gp . therefore, the synthesis of g( ) dab-dendrimer , containing up to peripheral galactoside groups and with an average of two sulfate groups per galactose residues (versus about . for the first example) was performed. the ability of to inhibit infection of cultured indicator cells by hiv- was compared to that of dextran . the results showed that inhibited hiv- iiib as well as dextran sulfate (a known potent inhibitor of hiv- infectivity) with ec values in the nanomolar range, and both were comparable in their ability to inhibit hiv infection of both x and r indicator cells. furthermore, cytotoxicity studies revealed that neither the glycodendrimer nor were toxic to the cells at the highest concentration ( mg/ml) tested. critical parameters such as the number and the position of sulfate groups (especially at c- ), which may constitute a key structural component of an efficient inhibitor, were clarified by this study. an interesting application against hiv was developed, using g( )-mannosylated ppi dendrimers (mppi) as carriers for the controlled and targeted delivery of antiretroviral nonnucleoside reverse-transcriptase inhibitors, such as lamivudine ( tc) and efavirenz (efv). , numerous benefits over the standard treatment based on the free drug or its ppi-encapsulated version, were demonstrated in vitro. these nanocontainers ensured efficient entrapment of the bioactive drugs ($ %), which allowed their prolonged release profile for up to h (vs. h with ppi). the toxicity of these systems was generally found negligble. in cellular-uptake experiments, mppi interacted with the lectin receptors present on the surface of mt cells or monocytes/macrophages, leading to cellular uptake of drugs times higher than that of the free drugs. furthermore, this phenomenon may be responsible for the significant, but preliminary anti-hiv activity displayed by mppi. despite these promising results, further studies are needed to consider those encapsulated systems as potent carriers for efficient control and targeting the delivery of anti-hiv drugs. c. hyperbranched boltorn dendrimers.-hyperbranched dendritic boltorn polymers (perstorp speciality chemicals) are also useful scaffolds, which have been used for the multivalent presentation of various functional groups. their selection is based on the fact that second, third, and fourth generation polymers (h , h , and h , respectively) are commercially available at a low cost since they are prepared in bulk quantities by polymerization. they are, however, polydisperse. , nevertheless, they can also be synthesized by a simple and iterative approach, using pentaerythritol ( ) as the central core and , -bis(hydroxymethyl)propanoic anhydride (bis-mpa anhydride, ) (scheme ). deprotection in acidic media furnished g ( )-boltorn polymer ( ) to mimic the natural organization of high-mannose structures notably present in pathogens, mannosylated glycodendrimers obtained from these multivalent scaffolds have been synthesized. the commercial hyperbranched polymers of the second, third, and fourth generations were first functionalized with succinic anhydride ( ) to furnish poly(acid) , which was then capped with -aminoethyl a-d-mannopyranoside to give mannosylated dendrimers of various generations [ for g( ) (fig. ) ]. preliminary studies of these glycodendrimers, perfectly soluble under physiological conditions and nontoxic against several cell lines, evaluated their interactions with lens culinaris lectin (lca). the same group demonstrated that these mannodendrimers block the interaction between dc-sign and ebola virus envelope glycoprotein. interestingly, dendrimer , containing an average of peripheral mannosides, was able to inhibit selectively the dc-sign-mediated ebola infection in an efficient dose-dependent manner (ic of nm), and showed no inhibitory effect in infection experiments using dc-sign-negative cell lines. these results showed that was a potent inhibitor of ebola infection mediated by dc-sign both in cis and trans (intra-and inter-cellular) presumably via the same inhibition mechanisms involving the interaction between the lectin and the viral envelope. in addition, a carbohydrate-dependent inhibitory effect was confirmed and a multivalent effect of two orders of magnitude demonstrated, since the monovalent manoside was able to inhibit this interaction at only millimolar concentrations. a related application used ''click chemistry'' for synthesis of azido-functionalized boltorn dendrimer (bh ) (touaibia and roy, unpublished data). dendrimer was obtained by treatment of hexadecahydroxylated bh (on average) with azidoacetic anhydride ( ). ir analysis demonstrated complete hydroxyl-group transformation and introduction of azide function. the ''clicked'' hyperbranched dendrimer was obtained under typical reaction conditions (cuso and sodium ascorbate) using nonprotected propargyl a-d-mannoside (scheme ). the relative inhibitory potency of the mannosylated dendrimer for the inhibition of agglutination of e. coli by yeast mannan was approximately times higher than that of the respective methyl mannoside (benhamioud and roy, unpublished data). for most practical and biological applications of glycodendrimers, three functional units are usually required: a targeting moiety, a biologically active agent, and a probe. a general and facile strategy for functional-group introduction at defined positions on dendrimers is best achieved when dendrimers are synthesized stepwise. from this perspective, sharpless, hawker, and their group have provided an example of sophisticated, multifunctional materials that can be constructed in a stepwise, yet facile manner, using the efficient ''click'' methodology, and with a fashion-controlled strategy toward unsymmetrical glycodendrimers in which two distinct moieties (targeting and detection probe) were placed at the chain ends. dendritic block copolymers up to the fourth generation were coupled via the key step of cu(i)-catalyzed azide-alkyne cycloaddition to prepare rapidly these dual-purpose and multifunctional materials without use of protecting groups. the orthogonal synthetic approach was based on , -bis(hydroxymethyl)propanoic acid (bis-mpa), which constitute the main building block in synthesis of the commercial boltorn dendrimers. the corresponding bis-mpa anhydride ( ) provided access to alkyne ester and azide ester by condensation with the appropriate alcohol (scheme ). removal of the protecting groups and subsequent condensation by ''click chemistry'' allowed the generation growth of the core and afforded the asymmetrical structure having a diol as the focal point. two molecules of the functionalized coumarin-type fluorescent dye were then introduced by esterification of the two free hydroxyl groups of with pent- -ynoic anhydride , followed by the [ þ ] cycloaddition. acetal hydrolysis and subsequent introduction of the alkynes via esterification, followed by [ þ ] cycloaddition with an unprotected -azidoethyl a-d-mannopyranoside ( a) in thf-h o furnished the asymmetrical heterobifunctional dendrimer . the performance of the resulting mannosylated dendrimer was investigated in a standard hemagglutination assay using the mbp con a and rabbit red-blood cells. when compared to the activity of a single mannose, exhibited -fold greater potency, corresponding to a relative activity of per sugar moiety, thus demonstrating the synergistic benefit provided by the multivalent dendritic array of sugar groups. d. ab and ab subunit-containing glycodendrimers.-(i) aromatic ab systems. as mentioned earlier, aromatic ab building blocks constitute privileged components for rapid design of highly branched glycodendrimers possessing biological potential. as well as examples presented earlier, the approach has involved the design and synthesis of g( ) and g( ) glycodendrimers containing building blocks of , -dihydroxybenzoic acid. homo-and heterobifunctional glycodendrimers ending with up to fucoside and/or galactoside residues, installed via the ''click'' , -dipolar cycloaddition, were synthesized via an ''outside in strategy,'' scheme . synthesis of bifunctional glycodendrons with two distinct moieties containing targeting and detection probes. from a diazide derivative of methyl , -dihydroxybenzoate (fig. ) and alkynefunctionalized carbohydrates. the saccharides were selected based on the fact that the bacterium p. aeruginosa (responsible for chronic lung colonization and the major cause of morbidity and mortality in cf patients), expresses two lectins, pa-il (leca) and pa-iil (lecb) specific for d-galactose and l-fucose residues, respectively. polyazido dendritic scaffolds - , containing up to peripheral azido functions were synthesized by successive formation of amide linkages between dendritic subunits. the polyazides were then totally functionalized with l-fucoside units to give - (fig. ) while the heterobifunctionalized dendrimer bearing both d-galactoside and l-fucoside residues was also prepared, providing binding access to either pa-il and pa-iil, simultaneously. the sugar heterogeneity was incorporated in order to increase the biological activities of the dendritic architecture and afford potent new antiadhesin agents against p. aeruginosa. turbidimetric assays indicated that glycodendrimers possessing a minimum of four fucoside residues on the same side showed rapid cross-linking abilities with tetrameric p. aeruginosa pa-iil lectin, by forming insoluble complexes. as expected, heterodendrimer containing fucosides and galactosides had the ability to recognize both binding-site domains of pa-il and pa-iil. (ii) ab systems. one of the first examples of glycodendrimers based on ab building blocks was proposed by stoddart et al. who designed dense multivalent neoglycoconjugates in which the carbohydrates were located at the periphery of short peptidic chains emanating from an aromatic central core and tris-containing branching system. the convergent approach was adopted, with preliminary construction of dendrons based on initial glycosylation of the three hydroxylmethyl groups of tris ( ) with glucose (scheme ). the availability of the single free amino group in following deprotection enabled further elaboration through formation of amide bond. this could be accomplished directly with triacid or, preferably, to avoid steric problems through the intermediacy of the , -iminodipropanoic acid-derived dendron . the glycine-derived glucosylated dendron was thus connected with trifunctional scaffold to afford glycodendrimer decorated with up to peripheral glucosides in a single step. scheme . convergent strategy for the construction of glucosylated dendrimers using tris as the branching component. the authors then prepared even larger dendritic derivatives employing two different, yet closely related, convergent accelerated strategies. the resulting d-glycopyranoside-containing glycodendrimers ( ), bearing up to saccharide residues, were obtained in good yields by a so-called  reaction sequence, involving three equivalents of dendritic wedge ( -mer) and one equivalent of the trifunctional core (scheme ). this advanced strategy circumvented the problem of incomplete dendrimer formation arising from limited reactivity of the core and accessibility impeded by the decreased interstitial space around it. high-generation glycodendrimers were thus obtained with very precise molecular sizes and shapes, and were completly monodisperse, despite the densely packed surface groups. furthermore, to avoid the anticipated limitation upon the growth of this type of dendrimer, common when saccharides contain protecting groups, jayaraman and stoddart focused on synthesis of glycodendrimers wherein the saccharides were totally unprotected during construction. e. carbosilane glycodendrimers. dendrimers. as well as an efficient methodology for constructing multivalent carbosilane scaffolds, the authors simultaneously developed a general synthetic strategy for the attachment of the carbohydrate moieties, employing an efficient sn substitution of an alkyl halide by the highly reactive thiolate anion. in addition to typical advantages encountered for dendrimers, multivalent carbosilane architectures offered (i) synthetic simplicity to extend the generation at will and thus provide access to derivatives of definite molecular weight and number of terminal functions, (ii) the neutral nature of dendritic scaffolds having chemical and biochemical stabilty, and (iii) biological inertness. these dendrimers ( - ), displaying unique shapes (fan-shape, ball-shape, and dumbbell-shape, respectively) were called ''super twigs'' and are presented in fig. . the same group studied these ''super twigs'' as therapeutic agents for treatment of infections by stx-producing e. coli o :h , and demonstrated their inhibition potential. spr studies showed that dendrimers and presented very low k d values of . and . mm, respectively, for stl-i, while the value for was times higher. this indicated that ''super twigs'' and bound directly with high affinity to the stl-i b-subunit. in addition, six trisaccharides situated at an appropriate distance (span of $ Å from the central silicon core) in one molecule allowed full embrace of the predicted gb -binding sites (cbps and notably) and were sufficient for high-affinity binding. furthermore, in vivo inhibitory effects of the ''super twigs'' on the lethality of intravenously administred slt-ii in mice, indicated that was a better candidate than for this specific application. slt-ii was used in this study because it is more toxic than slt-i both in vitro and in vivo, and clinically more significant. the assays indicated that completely supressed the lethal effect of stl-ii when administrated along with the toxin: treated mice survived more than months without any pathological symptoms, whereas % of nontreated mice died within days. the biological results suggested that suppressed the lethality of slt-ii by diminishing the deposition of slt-ii in the brain and consequent fatal damage. also, protected mice from a challenge with a fatal dose of e. coli o :h , even when administrated after establishment of the infection. in the light of these results, a unique dual mechanism of action was proposed to explain this spectacular efficiency: (i) bound to slts with high affinity and inhibited its gb -dependent incorporation into target cells; (ii) it induced active uptake and subsequent degradation of slts by macrophages present in the reticuloendothelium. a few years later, the same group identified the optimal dendritic structure, namely optimal valency and shape, required for slts neutralization. they identified the -mer as another potent slts neutralizer, functioning in vivo. examination of additional structural features allowed the identification of crucial structural parameters. a dumbbell-shaped structure in which two clusters of trisaccharides, symmetrically located through their hydrophobic core and having an optimal length of at least Å was first required. this indicated that grouping of the trisaccharides was more important than the number of trisaccharides. in the dumbbell shape, at least six trisaccharides needed to be involved for in vivo activity, and terminal trisaccharides with spacers had to be branched from the same terminal silicon atom to be clustered in high density. these structural requirements were essential for the appropriate induction of macrophage-dependent incorporation and degradation of slt-ii, further supporting the pivotal role for this mechanism in the in vivo slts-neutralizing activity of ''super twigs'' having optimal structure. interestingly, the data demonstrated the crucial implication of the cbp present on the slt-ii b-subunit, and showed that it was an essential and sufficient site for high-affinity binding of . in addition, the core length was a major structural parameter for perfectly embracing the three sites in a multiple way and, consequently, to provide an adequate hydrophobic volume for recognition by macrophages. considering the fact that galabiose is also known to bind slts with high affinity, matsuoka et al. considered that enhancement of the binding ability by the clustering of galabiose would be advantageous as compared to clustering of globotriaose, both in terms of synthetic accessibility, and from the viewpoint of practical use for slts neutralization. according to the synthetic strategy just described, a series of water-soluble carbosilane dendrimers were made, bearing peripheral galabiose trimers interspaced by Å , adjusted to the binding-site distances (fig. ) . the binding affinity to slt-i and slt-ii b subunits were determined by scatchard plot analysis. hexavalent compound showed k d values of . and . mm for slt-i and slt-ii, respectively, constituting one-tenth of the potency of the homologous . triand tetravalent analogues and , respectively, also presented weaker affinities ($ and mm, respectively, for both slts). on the other hand, further evaluations with i-labeled slts binding and cytotoxic assays showed that multivalent - inhibited the binding of i-labeled slts to vero cells, and presented very weak inhibitory effects in the cytotoxic assay as compared to the best dumbbell . in summary, results of in vivo experiments showed the effectiveness of carbosilane dendrimers having clustered p k carbohydrate moieties, and the complete neutralization potency against stl-ii was discovered when dumbbell-shaped dendrimers were identified as potent candidate inibitors. although the precise mechanism of action remains to be elucidated, this type of inhibitor provided a new strategy for the detoxification of slts present in circulation. the same research group further reported synthesis of asialyl-( ! )-lactosyl moieties [aneu ac-( ! )-bgal-( ! )-bglc-( !] using a series of carbosilane dendrimer scaffolds and the products had interesting biological activities against various such human influenza virus strains as a/pr/ / (h n ) and a/aich/ / (h n ). these dendrimers were thus uniformly functionalized with asialyl-( ! )lactose residues, with different degrees of freedom of the sugar moities depending on the spacer length and core shape, and thus being responsible for a variety of d structures (fig. ) . the inhibitory activity against the hemagglutination of influenza viruses to erythrocytes suggested that dumbbell amide , having the longest spacer-arms and most carbohydrate epitopes, possessed the highest activity of the glycolibrary (ic s < mm for both h n and h n viruses). following this initiative, other complex glycosylylated architectures have been designed, finishing a series of large multigeneration glycodendrimers (fig. ) . characterization by h-and c nmr, elemental analysis, and ir spectroscopy confirmed their low polydispersity ( . - . ). the growth in size of the dendrimer from g( )- to g( )- and also upon functionalization within each generation, was shown by diffusion light scattering (dsl), dosy nmr, and size exclusion chromatography (sec), all of which satisfactorilly agreed with the expected size of the nanostructures. f. other glycodendrimers.-several other types of glycodendrimers have been synthesized from a wide variety of multivalent scaffolds. three of the most relevant exampes as described in the following sections. another interesting example illustrates the use of scyllo-inositol, the all-equatorial stereoisomer of myo-inositol. it has also been added to the growing selection of suitable scaffolds for synthesis of multivalent neoglycoconjugates. the n-bocprotected amino scyllo-inositol scaffold constituted the key intermediate for subsequent glycosylation, as well as for chain elongation and multiplication directed toward the next dendrimeric generation (scheme ). hence, conjugate , -addition between triamine and excess methyl acrylate, followed by amidation of the resulting esters with ethylenediamine afforded an amidoamine dendrimer under conditions previously seen for the synthesis of pamam dendrimers. reiteration of this two-step sequence successfully doubled peripheral amino functionalities toward a g( )-dendrimer . glycoconjugation of the dendrimers was then achieved by the thiourea linkages discussed previously based on mannosyl isothiocyanate . another, architecture as yet exotic, has been proposed by sakamoto and müllen, who designed original glycodendrimers based on shape-persistent polyphenylenes building ( and , fig. ). both convergent and divergent routes were used to allow for sugar installation on not only the dendrimer surface but also within the hydrophobic internal scaffold, employing successive schmidt glycosylation and the diels-alder reaction. all of the described glycodendrimers exhibited good solubility in weakly acidic aqueous solutions, and those possessing interior sugar moieties (reminescent of an active center situated inside a hydrophobic pocket of natural enzymes) were identified as interesting candidates for host-guest molecular recognition. finally, the group of majoral prepared additional phosphorus-based glycodendrimers involving hydrazone groups, derived from d-xylose and containing up to peripheral epitopes, in excellent yields and through very simple precipitation-based purification processes (fig. ). such multivalent derivatives were obtained via substitution of the chloride atoms of terminal -p(s)cl groups with a triacetylated phenolic derivative of d-xylose under basic conditions [cs co ( eq./cl atom)]. consequently, g( ) to g( ) glycodendrimers, containing , , and xyloside residues, respectively, were readily purified through filtration and extraction steps, and their uniformity was confirmed, notably by p nmr spectroscopy. controlled zemplén o-deacetylation allowed full deprotection to furnish such valuable amphiphilic glycodendrimers as without decomposition. this chapter has highlighted different strategies leading to a vast range of neoglycoconjugate architectures. of glycodendrimers has matured and expanded to unpredicted levels. the synthetic strategies leading to these nanostructures have also witnessed considerable progress, that including organometallic chemistry, chemoenzymatic build-up, silicon chemistry, and self-assembly. most of the initial challenges in complete substitution by the carbohydrate, and structure determination, have been resolved. undoubtedly, a fundamental contribution toward this goal has been the utilization of classical [ , ] -dipolar cycloaddition, using the soft and efficient copper-catalyzed, coupling reaction of azide to alkyne. this method, extensively used in this field, has proven extremely versatile. an additional enhancement has been ''accelerated convergent strategies,'' offering clear synthetic advantages and ease of purification. an important addition to the arsenal of sophisticated glycodendrimer methodologies is the recognition that most complex carbohydrate epitopes can be advantageously replaced by simpler saccharides, and most importantly by glycomimetics. in this way, by combining the multivalent scaffolding of carbohydrate ligands, together with their replacement by simpler but higher affinity mimetics, the research community has delivered very potent antiadhesin candidates against viral and bacterial infections, including hiv and ebola viruses. key to these discoveries and applications, glycodendrimers have permitted a better understanding and appreciation of the very complex nature of multivalent carbohydrate-protein interactions. the upcoming challenges must address the issues of fine-tuned specificity faced by numerous families of carbohydrate-binding proteins having common and conserved crds, such as those identified for instance in galectins and mbps. another challenge will be to determine the toxicities of glycodendrimers to allow development of safe therapeutic agents. polyvalent interactions in biological systems: implications for design and use of multivalent ligands and inhibitors on growth and form review of medical physiology, th edn adhesive force of a single gecko foot-hair glycosylation of hiv- gp v loop: towards the rational design of a synthetic carbohydrate vaccine glycobiology: toward understanding the function of sugars essentials of glycobiology biological roles of oligosaccharides: all of the theories are correct biological importance of glycosylation probing low affinity and multivalent interactions with surface plasmon resonance: ligands for concanavalin a thermodynamic binding parameters of individual epitopes of multivalent carbohydrates to concanavalin a as determined by ''reverse'' isothermal titration microcalorimetry the cluster glycoside effect carbohydrate-protein interactions: basis of glycobiology synthetic multivalent molecules: concepts and biomedical applications chemical biology of the sugar code glycomimetics and glycodendrimers as high affinity microbial anti-adhesins carbohydrate microarrays-a new set of technologies at the frontiers of glycomics carbohydrate microarrays: an advanced technology for functional studies of glycans recent advances in carbohydrate microarrays carbohydrate microarrays as tools in hiv glycobiology the use of carbohydrate microarrays to study carbohydrate-cell interactions and to detect pathogens shiga-like toxins are neutralized by tailored multivalent carbohydrate ligands effective inhibitors of hemagglutination by influenza virus synthesized from polymers having active ester groups. insight into mechanisms of inhibition stochastic detection of monovalent and bivalent protein-ligand interactions maximising multivalency effects in protein-carbohydrate interactions exploring and exploiting the therapeutic potential of glycoconjugates synthesis of glycoproteins enzymatic synthesis of oligosaccharides and neoglycoconjugates synthesis of glycopeptides containing carbohydrate and peptide recognition motifs synthesis and application of glycopeptide and glycoprotein mimetics a synthetic conjugate polysaccharide vaccine against haemophilus influenzae type b self-assembly in glycolipids potential of polysaccharide anchored liposomes in drug delivery, targeting and immunization design and synthesis of glycoconjugates drug delivery systems using carbohydrate recognition polymer immobilized carbohydrate ligands versatile chemical tools for biochemistry and medical science recent advances in the synthesis of well-defined glycopolymers gold glyconanoparticles as water-soluble polyvalent models to study carbohydrate interactions a model system mimicking glycosphingolipid clusters to quantify carbohydrate selfinteractions by surface plasmon resonance gold glyconanoparticles: synthetic polyvalent ligands mimicking glycocalyxlike surfaces as tools for glycobiological studies quantitative and reversible lectin-induced association of gold nanoparticles modified with a-lactosylo-mercapto-poly(ethyleneglycol) selective binding of mannose-encapsulated gold nanoparticles to type pili in escherichia coli synthesis of gold glyconanoparticles and biological evaluation of recombinant gp interactions gold glyconanoparticles as probes to explore the carbohydrate-mediated self-recognition of marine sponge cells facile in situ preparation of biologically active multivalent glyconanoparticles glyconanoparticles: types, synthesis and applications in glycoscience, biomedicine and material science in vitro and in vivo liver targeting with carbohydrate capped quantum dots bacterial detection using carbohydrate-functionalised cds quantum dots: a model study exploiting e. coli recognition of mannosides cu-catalyzed azide-alkyne cycloaddition azide-alkyne , -dipolar cycloadditions: a valuable tool in carbohydrate chemistry recent applications of the cui-catalysed huisgen azide-alkyne , -dipolar cycloaddition reaction in carbohydrate chemistry application of the , -dipolar cycloaddition reaction in chemical biology: approaches toward multivalent carbohydrates and peptides and peptide-based polymers a decade of glycodendrimer chemistry application of multivalent mannosylated dendrimers in glycobiology recent trends in glycodendrimer syntheses and applications click multivalent homogeneous neoglycoconjugates-synthesis and evaluation of their binding affinities click multivalent heterogeneous neoglycoconjugates-modular synthesis and evaluation of their binding affinities synthesis of some cluster glycosides suitable for attachment to proteins or solid matrices trivalent a-dmannoside clusters as inhibitors of type- fimbriae-mediated adhesion of escherichia coli: structural variation and biotinylation multivalent ligands for the mannose-specific lectin on type fimbriae of escherichia coli: syntheses and testing of trivalent a-d-mannoside clusters multivalent glycomimetics: synthesis of nonavalent mannoside clusters with variation of spacer properties stereospecific synthesis and characterization of aminoglycoside ligands from diethylenetriamine one-pot synthesis of multivalent arrays of mannose mono-and disaccharides exploration of reductive amination for the synthesis of cluster glycosides synthesis of cluster mannosides via a ugi four-component reaction and their inhibition against the binding of yeast mannan to concanavalin a facile synthesis of glycotope bioisosteres bearing b-dgalactoside moieties synthesis of clustered xenotransplantation antagonists using palladium-catalyzed cross-coupling of prop- -ynyl a-d-galactopyranoside olefin self-metathesis as a new entry into xenotransplantation antagonists bearing the galili antigen first demonstration of differential inhibition of lectin binding by synthetic tri-and tetravalent glycoclusters from cross-coupling of rigidified -propynyl lactoside synthesis of clustered d-galnac (tn) and d-galb( ! )galnac (t) antigenic motifs using a pentaerythritol scaffold di-, tri-, and tetravalent dendritic galabiosides that inhibit hemagglutination by streptococcus suis at nanomolar concentration assembly of dendritic glycoclusters from monomeric mannose building blocks synthesis of a nonavalent mannoside glycodendrimer based on pentaerythritol cluster mannosides as inhibitors of type fimbriae-mediated adhesion of escherichia coli: pentaerythritol derivatives as scaffolds tri-and hexavalent mannoside clusters as potential inhibitors of type fimbriated bacteria using pentaerythritol and triazole linkages copper(i)-catalyzed synthesis of azoles. dft study predicts unprecedented reactivity and intermediates a stepwise huisgen cycloaddition process: copper(i)-catalyzed regioselective ''ligation'' of azides and terminal alkynes efficiency and fidelity in a click-chemistry route to triazole dendrimers by the copper(i)-catalyzed ligation of azides and alkynes bacterial lectins, cell-cell recognition and infectious disease diversity of c-linked neoglycopeptides for the exploration of subsiteassisted carbohydrate binding interactions mannosylated g( ) dendrimers with nanomolar affinities to escherichia coli fimh tetra-and hexavalent mannosides inhibit the pro-apoptotic, antiproliferative and cell surface clustering effects of concanavalin a: impact on mt -mmp functions in marrow-derived mesenchymal stromal cells synthetic multimeric heptyl mannosides as potent antiadhesives of uropathogenic escherichia coli receptor binding studies disclose a novel class of highaffinity inhibitors of the escherichia coli fimh adhesin intervening with urinary tract infections using anti-adhesives based on the crystal structure of the fimh-oligomannose- complex synthesis and biological evaluation of non-hydrolyzable , , -triazole-linked sialic acid derivatives as neuramidase inhibitors host-pathogen interactions in plants-plants, when exposed to oligosaccharides of fungal origin, defend themselves by accumulating antibiotics the interaction of glycosides and saccharides with antibody to the corresponding phenylazo glycosides synthesis of aryl cluster glycosides by cyclotrimerization of -propynyl carbohydrate derivatives transition metal catalyzed neoglycoconjugate syntheses effects of linker rigidity and orientation of mannoside clusters for multivalent interactions with proteins synthesis of ''molecular asterisks'' via sequential cross-metathesis sonogashira and cyclotrimerization reactions stereoselective synthesis of a-c-allyl-glycopyranosides mild ruthenium-catalyzed intermolecular alkyne cyclotrimerization synthesis of divalent a-d-mannopyranosylated clusters having enhanced binding affinities towards concanavalin a and pea lectins synthesis and application of a-d-mannosyl clusters as photoaffinity ligands for mannose-binding proteins: concanavalin a as a model receptor synthesis of ''sugar-rods'' with phytohemagglutinin cross-linking properties by using the palladium-catalyzed sonogashira reaction transition metal-catalyzed syntheses of ''rod-like'' thioglycoside dimers synthetic studies on dendritic glycoclusters: a convergent palladium-catalyzed strategy synthesis of all carbon linked glycoside clusters round benzene scaffold via sonogashira-heck-cassar cross coupling of iodobenzenes with ethynyl c-glycosides first demonstration of differential inhibition of lectin binding by synthetic tri-and tetravalent glycoclusters from cross-coupling of rigidified -propynyl lactoside expeditive synthesis of glycodendrimer scaffolds based on versatile tris and mannoside derivatives glycosylated asterisks are among the most potent low valency inducers of concanavalin a aggregation biopharmaceutical application of calixarenes sugar calixarenes: preparation of calix[ ]arenes substituted at the lower and upper rims with o-glycosyl groups neoglycoconjugates based on cyclodextrins and calixarenes peptido-and glycocalixarenes: playing with hydrogen bonds around hydrophobic cavities polysialosides scaffolded on p-tert-butylcalix[ ] arene amphiphilic p-tert-butylcalix[ ]arene scaffolds containing exposed carbohydrate dendrons the assembly of carbon-linked calixarene-carbohydrate structures (c-calixsugars) by multiple wittig olefination glycoside-clustering round calixarenes toward the development of multivalent carbohydrate ligands. synthesis and conformational analysis of calix[ ]arene o-and c-glycoconjugates synthesis of deeper calix-sugarbased on the sonogashira reaction c-glycoside clustering on calix[ ]arene, adamantane, and benzene scaffolds through , , -triazole linkers microwaveenhanced ionothermal cuaac for the synthesis of glycoclusters on a calix[ ] arene platform addressing the scope of the azide-nitrile cycloaddition in glycoconjugate chemistry. the assembly of c-glycoclusters on a calix[ ] arene scaffold through tetrazole spacers synthesis of upper rim calix [ ]arene divalent glycoclusters via amide bond conjugation synthesis of bridged thiourea calix-sugar calix[ ]arenebased glycoconjugates as multivalent carbohydrate-presenting systems synthesis of thiourea-bridged cluster glycoside calixarenes synthesis and lectin binding ability of glycosamino acid-calixarenes exposing glcnac clusters synthesis and properties of o-glycosyl calix[ ]arenes (calixsugars) thiourea-linked upper rim calix[ ]arene neoglycoconjugates: synthesis, conformations and binding properties conformationally mobile glucosylthioureidocalix[ ]-and calix[ ]arenes: synthesis, aggregation and lectin binding a synthetic divalent cholera toxin glycocalix[ ] arene ligand having higher affinity than natural gm oligosaccharide vibrio cholerae: cholera toxin natural and synthetic cholera toxin antagonists second generation mimics of ganglioside gm as artificial receptors for cholera toxin: replacement of the sialic acid moiety n-acetyl-d-glucosamine substituted calix[ ]arenes as stimulators of nk cell-mediated antitumor immune response calix[ ]arene decorated with four tn antigen glycomimetic units and p cs immunoadjuvant: synthesis, characterization, and anticancer immunological evaluation calix[n]arene-based glycoclusters: bioactivity of thiourea-linked galactose/lactose moieties as inhibitors of binding of medically relevant lectins to a glycoprotein and cell-surface glycoconjugates and selectivity among human adhesion/growth-regulatory galectins glycoconjugated tetrapyrrolic macrocycles photodynamic efficiency of diethylene glycol-linked glycoconjugated porphyrins in human retinoblastoma cells nitroglycosylated meso-arylporphyrins as photoinhibitors of gram positive bacteria synthesis of glycoporphyrin derivatives and their antiviral activity against herpes simplex virus types and amperometric metronidazole sensor based on the supramolecular recognition by metalloporphyrin incorporated in carbon paste electrode total synthesis of the proposed structure of (þ)-tolyporphyn a o,o-diacetate revised structure of tolyporphyn a synthesis of glycoporphyrins glycoconjugated porphyrins. . synthesis of flat amphiphilic mixed meso-(glycosylated aryl)arylporphyrins and mixed meso-(glycosylated aryl)alkylporphyrins bearing some mono-and disaccharide groups sugar-dependent photocytotoxic property of tetra-and octa-glycoconjugated tetraphenylporphyrins synthesis of hydrolytically stable porphyrin c-and s-glycoconjugates in high yields conjugates of porphyrins with carbohydrates glycosyl bis-porphyrin conjugates: synthesis and potential application in pdt water-soluble porphyrin diglycosides with photosensitizing properties sol-gel polycondensation of tetraethyl orthosilicate (teos) in sugar-based porphyrin organogels: inorganic conversion of a sugar-directed porphyrinic fiber library through sol-gel transcription processes efficient synthesis and photodynamic activity of porphyrin-saccharide conjugates: targeting and incapacitating cancer cells construction of glycosylated myoglobin by reconstitutional method porphyrin-containing glycodendrimers chemical aspects of photodynamic therapy, gordon and breach science endogenous sugar receptor (lectin) profiles of human retinoblastoma and retinoblast cell lines analyzed by cytological markers, affinity chromatography and neoglycoprotein-targeted photolysis in vitro phototoxicity of glycoconjugated porphyrins and chlorins in colorectal adenocarcinoma (ht ) and retinoblastoma (y ) cell lines the synthesis of some substituted tetraarylporphyrins new strategy for targeting of photosensitizers. synthesis of glycodendrimeric phenylporphyrins, incorporation into a liposome membrane and interaction with a specific lectin multivalent templated saccharides: convenient syntheses of spacer-linked , -bis -and , , -tris-b-glycosides by the glycal epoxide glycosidation method carbohydrate triazoles and isoxazoles as inhibitors of galectins- and - synthesis and binding properties of divalent and trivalent clusters of the lewis a disaccharide moiety to pseudomonas aeruginosa lectin pa-iil synthesis of water-soluble phthalocyanines bearing four or eight d-galactose units synthesis of an octasubstituted galactose zinc(ii) phthalocyanine garcía fernández, functional evaluation of carbohydrate-centred glycoclusters by enzymelinked lectin assay: ligands for concanavalin a synthesis of carbohydrate-centered oligosaccharide mimetics equipped with a functionalized tether trehalose-based octopus glycosides for the synthesis of carbohydrate-centered pamam dendrimers and thiourea-bridged glycoclusters click multivalent neoglycoconjugates as synthetic activators in cell adhesion and stimulation of monocyte/macrophage cell lines multi-mannosides based on a carbohydrate scaffold: synthesis, force field development, molecular dynamics studies, and binding affinities for lectin con a ab toxins assessment in mice of the therapeutic potential of tailored, multivalent shiga toxin carbohydrate ligands biotechnological applications of cyclodextrins inclusion and solubilisation properties of -s-glycosyl- -thio-derivatives of b-cyclodextrin an efficient synthesis of cyclodextrin-based carbohydrate cluster compounds chemical and enzymatic synthesis of glycocluster having seven sialyl lewis x arrays using b-cyclodextrin as a key scaffold material synthesis of cluster n-glycosides based on a b-cyclodextrin core cyclodextrin-scaffolded glycoclusters synthesis of persialylated b-cyclodextrins synthesis of per-glycosylated b-cyclodextrins having enhanced lectin binding affinity a highly practical synthesis of cyclodextrin-based glycoclusters having enhanced affinity with lectins optimizing saccharide-directed molecular delivery to biological receptors: design, synthesis, and biological evaluation of glycodendrimer-cyclodextrin conjugates multivalent cyclooligosaccharides: versatile carbohydrate clusters with dual role as molecular receptors and lectin ligands synthesis and comparative lectin-binding affinity of mannosyl-coated b-cyclodextrin-dendrimer constructs convenient and simplified approaches to n-monoprotected triaminopropane derivatives. key intermediates for bifunctional chelating agent synthesis search and discovery of new antitumour compounds synthesis of multivalent aminoglycoside mimics via the ugi multicomponent reaction synthesis of new peptidic glycoclusters derived from b-alanine: di-and trimerized glycoclusters and glycoclusterclusters a lysoganglioside/poly-l-glutamic acid conjugate as a picomolar inhibitor of influenza hemagglutinin synthesis of glycocluster peptides combinatorial solid-phase synthesis of multivalent cyclic neoglycopeptides a fully solid-phase synthesis of biotinylated glycoclusters large cyclic peptides as cores of multivalent ligands: application to inhibitors of receptor binding by cholera toxin fully synthetic carbohydrate hiv antigens designed on the logic of the g antibody a new simple synthesis of amino sugar b -d-glycosylamines a practical, convergent method for glycopeptide synthesis novel template-assembled oligosaccharide clusters as epitope mimics for hiv-neutralizing antibody g . design, synthesis, and antibody binding study synergistic formation of soluble lectin clusters by a templated multivalent saccharide ligand synthesis and study of c -symmetric hydropyran cyclooligolides with oriented aryl and alcohol appendages at Å spacing carbohydrate wheels: cucurbituril-based carbohydrate clusters first synthesis of ''majoral-type'' glycodendrimers bearing covalently bound a-d-mannopyranoside residues onto a hexachlorocyclotriphosphazene core lindhorst, a-mannosyl clusters scaffolded on azamacrocycles: synthesis and inhibitory properties in the adhesion of type fimbriated escherichia coli to guinea pig erythrocytes carbohydratation of , , , -tetraazacyclotetradecane (cyclam): synthesis and binding properties toward concanavalin a high-affinity pentavalent ligands of escherichia coli heat-labile enterotoxin by modular structure-based design characterization and crystal structure of a high-affinity pentavalent receptorbinding inhibitor for cholera toxin and e. coli heat-labile enterotoxin solution-and solid-phase syntheses of guanidine-bridged, water-soluble linkers for multivalent ligand design solution and crystallographic studies of branched multivalent ligands that inhibit the receptor-binding of cholera toxin combinatorial and automated synthesis of phosphodiester galactosyl cluster on solid support by click chemistry assisted by microwaves fucosylated pentaerythrityl phosphodiester oligomers (pepos): automated synthesis of dna-based glycoclusters and binding to pseudomonas aeruginosa lectin (pa-iil) synthesis, characterization and lectin binding study of carbohydrate functionalized silsesquioxanes efficient preparation of glycoclusters from silsesquioxanes fullerene polymers: synthesis and properties biological applications of fullerenes medicinal chemistry with fullerenes and fullerene derivatives fullerene derivatives: an attractive tool for biological applications anti-hiv properties of cationic fullerene derivatives fullerene sugars: preparation of enantiomerically pure, spiro linked c-glycosides of c fullerene glycoconjugates: a general synthetic approach via cycloaddition of per-oacetyl glycosyl azides to [ ]fullerene synthesis of [ ]fulleropyrrolidine glycoconjugates using , -dipolar cycloaddition with c-glycosyl azomethine ylides fullerenoacetyl chloride as a versatile precursor for fullerene derivatives: efficient ester formation with various alcohols a superior synthesis of [ , ]-methanofullerenes: the reaction of sulfonium ylides with c targetselective photo-degradation of hiv- protease by a fullerene-sugar hybrid sequence-specific modification of guanosine in dna by a c -linked deoxyoligonucleotide: evidence for a non-singlet oxygen mechanism syntheses and biological evaluations of a-d-mannosyl [ ]fullerenols stereo-and biochemical profiles of the - -and - -junction isomers of a-d-mannosyl [ ]fullerenes detection of nm emission from singlet oxygen and photocytotoxic property of sugar-pendant [ ]fullerene preparation and supramolecular properties of unadulterated glycosyl liposomes from a bis(a-d-mannopyranosyl)-[ ]fullerene conjugate cyclopropanierung von fullerenen efficient cyclopropanation of c starting from malonates stable langmuir and langmuir-blodgett films of fullerene-glycodendron conjugates water-soluble malonic acid derivatives of c with a defined three-dimensional structure a convergent synthesis of carbohydrate-containing dendrimers macrocyclization on the fulleren core: direct regio-and diasterodelective multi-functionalization of [ ]fullerene, and synthesis of fullerene-dendrimer derivatives sugar balls: synthesis and supramolecular assembly of [ ]fullerene glycoconjugates cascade polymers: syntheses and characterization of one-directional arborols based on adamantane the first pentahaptofullerene metal complexes synthesis of fullerene glycoconjugates through sulfide connection in aqueous media synthesis of fullerene glycoconjugates via a copper-catalyzed huisgen cycloaddition reaction chemistry of carbon nanotubes applications of carbon nanotubes in drug delivery the emerging field of nanotube biotechnology functionalized carbon nanotubes in drug design and discovery functionalized carbon nanotubes: towards the delivery of therapeutic molecules functionalized carbon nanotubes for plasmid dna gene delivery nanotube molecular transporters: internalization of carbon nanotube-protein conjugates into mammalian cells biomedical applications of functionalised carbon nanotubes carbon nanotubes as nanomedicines: from toxicology to pharmacology advances toward bioapplications of carbon nanotubes starched carbon nanotubes solubilization of single-wall carbon nanotubes by supramolecular encapsulation of helical amylose water solubilization, determination of the number of different types of single-wall carbon nanotubes and their partial separation with respect to diameters by complexation with -cyclodextrin biomimetic engineering of carbon nanotubes by using cell surface mucin mimics interfacing carbon nanotubes with living cells single-walled carbon nanotubes acquire a specific lectin-affinity through supramolecular wrapping with lactose-appended schizophyllan synthesis and spectroscopic characterization of single-wall carbon nanotubes wrapped by glycoconjugate polymer with bioactive sugars biocompatible carbon nanotubes generated by functionalization with glycodendrimers multivalent, bifunctional dendrimers prepared by click chemistry chemistry of single-walled carbon nanotubes dissolution of full-length single-walled carbon nanotubes fullerene pipes water solubilization of single-walled carbon nanotubes by functionalization with glucosamine lectin-mediated supramolecular junctions of galactose-derivatized single-walled carbon nanotubes single-walled carbon nanotubes displaying multivalent ligands for capturing pathogens unique aggregation of anthrax (bacillus anthracis) spores by sugarcoated single-walled carbon nanotubes single-walled carbon nanotubes as a unique scaffold for the multivalent display of sugars linear and hyperbranched glycopolymer-functionalized carbon nanotubes: synthesis, kinetics and characterization toward self-organization and complex matter metallasupramolecular architectures, an overview of functional properties and applications development of a coordination chemistry-based approach for functional supramolecular structures multivalent carbohydrate ligands assembled on a metal template a self-adjusting carbohydrate ligand for galnac specific lectins iron(ii)-assisted assembly of trivalent galnac clusters and their interactions with galnac-specific lectins tris-bipyridine ruthenium complex-based glyco-clusters: amplified luminescence and enhanced lectin affinities artificial metalloglycoclusters: compact saccharide shell to induce high lectin affinity as well as strong luminescence ruthenium complexes carrying a disialo complex-type oligosaccharide: enzymatic synthesis and its application to a luminescent probe to detect influenza viruses metal-ion control of molecular recognitionsugar-functionalised new approaches to sugarfunctionalised , : , -terpyridines based upon tetrafluorophenoxy spacers synthesis of some oligopyridine-galactose conjugates and their metal complexes: a simple entry to multivalent sugar ligands synthesis and structure of novel sugar-substituted bipyridine complexes of rhenium and m-technetium cu(ii)-self-assembling bipyridyl-glycoclusters and dendrimers bearing the tn-antigen cancer marker: syntheses and lectin binding properties supramolecular one-pot approach to fluorescent glycodendrimers ru(ii)-carbohydrate dendrimers as photoinduced electron transfer lectin biosensors novel glycodendrimers self-assemble to nanoparticles which function as polyvalent ligands in vitro and in vivo non-covalent polyvalent ligands by self-assembly of small glycodendrimers: a novel concept for the inhibition of polyvalent carbohydrate-protein interactions in vitro and in vivo dendrimers and dendrons: concepts, synthesis, applications dendrimers and other dendritic polymers poly(amidoamine) (pamam) dendrimers: from biomimicry to drug delivery and biomedical applications starburst dendrimersmolecular level control of size, shape, surface chemistry, topology, and flexibility from atoms to macroscopic matter cascade''-and ''nonskid-chain-like'' syntheses of molecular cavity topologies micelles. part . cascade molecules: a new approach to micelles. a [ ]-arborol a new class of polymers: starburst-dendritic macromolecules polymer therapeutics: concepts and applications dendrimer biocompatibility and toxicity dendrimers in medicine and biotechnology: new molecular tools solid phase synthesis of dendritic sialoside inhibitors of influenza a virus haemagglutinin biological applications of dendrimers design, functional evaluation and biomedical applications of carbohydrate dendrimers (glycodendrimers ) design and synthesis of glycodendrimers glycodendrimers: chemical aspects design, synthesis and potent pharmaceutical applications of glycodendrimers: a mini review preparation of polymers with controlled molecular architecture. a new convergent approach to dendritic macromolecules unimolecular micelles and globular amphiphiles: dendritic macromolecules as novel recyclable solubilization agents hyperbranched macromolecules via a novel double-stage convergent growth approach a ''branched-monomer approach'' for the rapid synthesis of dendrimers double-stage convergent approach for the synthesis of functionalized dendritic aliphatic polyesters based on , -bis(hydroxymethyl)propionic acid a convergent synthesis of a carbohydrate-containing dendrimer rapid synthesis of dendrimers by an orthogonal coupling strategy a chemoselective approach for the accelerated synthesis of well-defined dendritic architectures structure-based exploration of the ganglioside gm binding sites of escherichia coli heat-labile enterotoxin and cholera toxin for the discovery of receptor anatgonists anchor-based design of improved cholera toxin and e. coli heat-labile enterotoxin receptor binding antagonists that display multiple binding modes synthesis of lactose dendrimers and multivalency effects in binding to the cholera toxin b subunit synthesis and cholera toxin binding properties of a lactose- -aminothiazoline conjugate synthesis and cholera toxin binding properties of multivalent gm mimics strong inhibition of cholera toxin by multivalent gm derivatives the influence of ligand valency on aggregation mechanisms for inhibiting bacterial toxins strong inhibition of cholera toxin binding by galactose dendrimers rigidified multivalent lactose molecules and their interactions with mammalian galectins: a route to selective inhibitors simultaneous binding of mouse monoclonal antibody and streptavidin to heterobifunctional dendritic l-lysine core bearing t-antigen tumor marker and biotin differentiation between structurally homologous shiga and shiga toxins by using synthetic glycoconjugates biotinylated bi-and tetraantennary glycoconjugates for escherichia coli detection a general entry into glycopeptide ''dendrons synthesis of lactoside glycodendrons using photoaddition and reductive amination methodologies iterative synthesis of spacered glycodendrons as oligomannoside mimetics and evaluation of their antiadhesive properties a convergent route to novel aliphatic polyether dendrimers synthesis of new polyether glycodendrons as oligosaccharide mimetics chemistry of micelles series. part . cascade molecules. synthesis and characterization of a benzene [ ] -arborol targeting the carbohydrates on hiv- : interaction of oligomannose dendrons with human monoclonal antibody g and dc-sign synthesis of hyperbranched dendritic lactosides synthesis of hyperbranched glycodendrimers incorporating a-thiosialosides based on a gallic acid core chemical modification of chitosan. . . synthesis of dendronized chitosan-sialic acid acid hybrid using convergent grafting of preassembled dendrons built on gallic acid and tri(ethylene glycol) backbone high-yielding microwave-assisted synthesis of triazole-linked glycodendrimers by coppercatalyzed [ þ ] cycloaddition a click approach to unprotected glycodendrimers clickable'' peg-dendritic block copolymers syntheses and antigenic properties of sialic acid-based dendrimers dependence of effective molarity on linker length for an intramolecular protein-ligand system multivalency in ligand design inhibition of viral adhesion and infection by sialic-acid-conjugated dendritic polymers inhibition of adhesion of type fimbriated escherichia coli to highly mannosylated ligands macromolecular highly branched homogeneous compound based on lysine units peptide and amide bond-containing dendrimers peptide dendrimers glycopeptide dendrimers. part i glycopeptide dendrimers. part ii glycopeptide dendrimers, part iii-a review: use of glycopeptide dendrimers in immunotherapy and diagnosis of cancer and viral diseases solid-phase synthesis of lysinebased cluster galactosides with high affinity for the asialoglycoprotein receptor convergent synthesis of fluorescein-labelled lysine-based cluster glycosides solid phase synthesis of glycopeptide dendrimers with tn antigenic structure and their biological activities. part i oligolysine-based oligosaccharide clusters: selective recognition and endocytosis by the mannose receptor and dendritic cell-specific intercellular adhesion molecule (icam- )-grabbing nonintegrin synthesis of sphere-type monodispersed oligosaccharide-polypeptide dendrimers, macromolecules the synthesis and immune stimulating action of mannose-capped lysine-based dendrimers chemoenzymatic synthesis and lectin binding properties of dendritic n-acetyllactosamine synthesis of n,n -bis(acrylamido)acetic acid base-t antigen glycodendrimers and their mouse monoclonal igg antibody binding properties glycodendrimers: novel glycotope isosteres unmasking sugar coding. case study with t-antigen markers from breast cancer muc glycoprotein chemoenzymatic synthesis of dendritic sialyl lewis x binding of tissue-type plasminogen activator by the mannose receptor the serum mannose-binding protein and the macrophage mannose receptor are pattern recognition molecules that link innate and adaptive immunity quantitative analysis of the targeting of mannose-terminal glucocerebrosidase. predominant uptake by liver endothelial cells comparison of the pharmacological properties of carbohydrate remodeled recombinant and placental-derived b-glucocerebrosidase: implications for clinical efficacy in treatment of gaucher disease use of mannosylated liposomes for in vivo targeting of a macrophage activator and control of artificial pulmonary metastases synthesis, characterization and in vivo behavior of a norfloxacin-poly(l-lysine citramide imide) conjugate bearing mannosyl residues neoglycoproteins as carriers for receptor-mediated drug targeting in the treatment of experimental visceral leishmaniasis oligonucleotide targeting to alveolar macrophages by mannose receptormediated endocytosis transfer of the human a-antitrypsin gene into pulmonary macrophages in vivo efficient gene delivery into human dendritic cells by adenovirus polyethylenimine and mannose polyethylenimine transfection pharmacokinetics and in vivo gene transfer of plasmid dna complexed with mannosylated poly(l-lysine) in mice get into the groove! targeting antigens to mhc class ii liposome oligomannose-coated with neoglycolipid, a new candidate for a safe adjuvant for induction of cd þ cytotoxic t lymphocytes ex vivo targeting of the macrophage mannose receptor generates anti-tumor ctl responses lysinebased cluster mannosides that inhibit ligand binding to the human mannose receptor at nanomolar concentration novel hyperbranched glycomimetics recognized by the human mannose receptor: quinic or shikimic acid derivatives as mannose bioisosteres parallel synthesis of glycomimetic libraries: targeting a c-type lectin non-carbohydrate inhibitors of the lectin dc-sign direct solid-phase synthesis and fluorescence labeling of large, monodisperse mannosylated dendrons in a peptide synthesizer synthesis of new spherical and hemispherical oligosaccharides with polylysine core scaffold synthesis of a new polylysine-dendritic oligosaccharide with alkyl spacer having peptide linkage combinatorial variation of branching length and multivalency in a large ( , member) glycopeptide dendrimer library: ligands for fucose-specific lectins neoglycopeptide dendrimer libraries as a source of lectin binding ligands direct fmoc/tert-bu solid phase synthesis of octamannosyl polylysine dendrimer-peptide conjugates peptides corresponding to a predictive a-helical domain of human immunodeficiency virus type gp are potent inhibitors of virus infection mannose receptor-mediated uptake of antigens strongly enhances hla class ii-restricted antigen presentation by cultured dendritic cells new trends in carbohydrate-based vaccines carbohydrate-based vaccines crystal structure of a neutralizing human igg against hiv- : a template for vaccine design synthesis of tumor-associated glycopeptides antigens synthesis of tumor-associated glycopeptides antigens for the development of tumor-selective vaccines synthesis of glycopeptide dendrimer by a convergent method recent development in the rational design of multivalent glycoconjugates solid-phase synthesis of multivalent glycoconjugates on a dna synthesizer globular carbohydrate macromolecules ''sugar balls'' synthesis of novel sugar-persubstituted poly(amido amine) dendrimers glycocoating of oligovalent amines: synthesis of thiourea-bridged cluster glycosides from glycosyl isothiocyanates synthesis and biological properties of mannosylated starburst poly(amidoamine) dendrimers glycodendrimers as novel biochromatography adsorbents lactosecontaining starburst dendrimers: influence of dendrimer generation and binding-site orientation of receptors (plant/animal lectins and immunoglobulins) on binding properties glycodendrimer synthesis without using protecting groups inhibition of the type fimbriae-mediated adhesion of escherichia coli to erythrocytes by multiantennary a-mannosyl clusters: the effect of multivalency oligosaccharide-derivatized dendrimers: defined multivalent inhibitors of the adherence of the cholera toxin b subunit and the heat labile enterotoxin of e. coli to gm practical synthesis of starburst pamam a-thiosialodendrimers for probing multivalent carbohydrate-lectin binding properties prevention of influenza pneumonitis by sialic acid-conjugated dendritic polymers mannose functionalization of a sixth generation dendrimer the lectin-binding properties of six generations of mannose-functionalized dendrimers cyanovirin-n binding to mana - man functionalized dendrimers probing the lactose . gm carbohydrate-carbohydrate interaction with glycodendrimers radial-growth polymerization'' of sugarsubstituted a-amino acid n-carboxyanhydrides (glyco-ncas) with a dendritic initiator synthesis and protein binding properties of t-antigen containing glycopamam dendrimers synthesis and antibody binding properties of glycodendrimers bearing the tumor related t-antigen novel multivalent mannose compounds and their inhibition of the adhesion of type fimbriated uropathogenic e. coli synthesis and biological evaluation of mannose- -phosphate-coated multivalent dendritic cluster glycosides neoglycoconjugates based on dendrimer poly(aminoamides) chemical modification of chitosan. . hyperbranched chitosan-sialic acid dendrimer hybrid with tetraethylene glycol spacer highly convergent synthesis of dendrimerized chitosan-sialic acid hybrid chitosan-dendrimer hybrid chemically defined sialoside scaffolds for investigation of multivalent interactions with sialic acid binding proteins novel dendritic a-sialosides: synthesis of glycodendrimers based on a , '-iminobis(propylamine) core synthesis of new a-thiosialodendrimers and their binding properties to the sialic acid specific lectin from limax flavus multivalent neoglycoconjugates: solid-phase synthesis of n-linked a-sialodendrimers mannose/glucose-functionalized dendrimers to investigate the predictable tunability of multivalent interactions carbohydrate-functionalized dendrimers to investigate the predictable tunability of multivalent interactions poly(propylene imine) dendrimers: large-scale synthesis by hetereogeneously catalyzed hydrogenations synthesis of glycodendrimers by modification of poly(propyleneimine) dendrimers synthesis of spacer-armed glucodendrimers based on the modification of poly(propylene imine) dendrimers synthesis of novel, multivalent glycodendrimers as ligands for hiv- gp novel polysulfated galactose-derivatized dendrimers as binding antagonists of human immunodeficiency virus type infection poly(propyleneimine) dendrimer based nanocontainers for targeting of efavirenz to human monocytes/macrophages in vitro targeting potential and anti-hiv activity of lamivudine loaded mannosylated poly(propyleneimine) dendrimer structure builup in hyperbranched polymers from , -bis(hydroxymethyl)propionic acid hyperbranched polymers glycodendritic structures based on boltorn hyperbranched polymers and their interactions with lens culinaris lectin mannosyl glycodendritic structure inhibits dc-sign-mediated ebola virus infection in cis and in trans synthesis of glycodendrimers containing both fucoside and galactoside residues and their binding properties to pa-il and pa-iil lectins from pseudomonas aeruginosa synthesis of carbohydrate-containing dendrimers. . preparation of dendrimers using unprotected carbohydrates synthetic assembly of trisaccharide moieties of globotriaosyl ceramide using carbosilane dendrimers as cores. a new type of functional glyco-material a therapeutic agent with oriented carbohydrates for treatment of infections by shiga toxin-producing escherichia coli o :h identification of the optimal structure required for a shiga toxin neutralizer with oriented carbohydrates to function in the circulation syntheses and vero toxin-binding activities of carbosilane sialyl a( ! ) lactose clusters using carbosilane dendrimer core scaffolds as influenza hemagglutinin blockers click glycodendrimers containing , , and modified xylopyranoside termini architectonic neoglycoconjugates: effects of shapes and valencies in multiple carbohydrate-protein interactions syntheses of glycodendrimers having scyllo-inositol as the scaffold sugars within a hydrophobic scaffold: glycodendrimers from polyphenylenes first phosphorus d-xylose-derived glycodendrimers neoglycoproteins. the preparation and application of synthetic glycoproteins chemoselective neoglycosylation key: cord- -q tlj jd authors: lu, jingjing; yin, qi; li, quan; fu, gang; hu, xueping; huang, jianhao; chen, lin; li, qiang; guo, zhongliang title: clinical characteristics and factors affecting the duration of positive nucleic acid test for patients of covid‐ in xinyu, china date: - - journal: j clin lab anal doi: . /jcla. sha: doc_id: cord_uid: q tlj jd background: the outbreak of a new coronavirus, covid‐ , which was earliest reported in wuhan, china, is now transmitting throughout the world. the aim of this study was to articulate the clinical characteristics of covid‐ and to reveal possible factors that may affect the persistent time of positive sars‐cov‐ nucleic acid test, so as to identify which patients may deteriorate or have poor prognoses as early as possible. methods: retrospective cohort study was carried out on patients with confirmed covid‐ infection admitted to xinyu people's hospital of jiangxi province. epidemiological, demographic, clinical, laboratorial, management, treatment, and outcome data were also collected and analyzed. results: in this study, patients were divided into two groups based on whether their sars‐cov‐ nucleic acid tests in respiratory specimens turn negative within (group rapid or group r) or over (group slow or group s) a week. there was no significant difference in age, sex, travel or exposure history, and smoking history between the two groups. forty‐two patients had been observed with comorbidities. similar clinical manifestations, for instance fever, cough, sputum, and fatigue, have been observed among patients in both groups, except that patients in group s were obviously more likely to get fatigue than patients in group r. both groups had shown decrease in white blood cell or lymphocyte counts. chest x‐ray or computed tomography scan showed unilateral or bilateral infiltrates. high proportion in both groups has used nasal cannula ( . % vs. . %) to inhale oxygen. . % of group s have applied high‐flow nasal cannula, while group r used none. the current treatment is mainly antibiotics, antiviral, and traditional chinese medicine, while a couple of patients has used methylprednisolone. only patient out of both groups got even worse despite this active treatment. conclusion: clinical characteristics of covid‐ include the exposure history and typical systemic symptoms such as fever, cough, fatigue, decreased wbc and lymphocyte counts, and infiltration in both lower lobes on ct imaging. among them, fatigue appears to be an important factor that affects the duration of positive sars‐cov‐ nucleic acid test in respiratory specimens. in december , a group of pneumonia patients with unknown pathogeny was found in wuhan, hubei province, china. the clinical manifestation of such pneumonia is very similar to that of viral pneumonia, nats in respiratory specimens were taken after - hours of treatment. clinical data were sampled only on patients whose nats show negative in at least two successive tests between which the time interval is at least over one day. written informed consent was waived for the retrospective case series, and this study has involved no potential risk to any patient. descriptive analyses of the variables were expressed as median (interquartile range [iqr]) or number (%). differences in distributions of patient characteristics by subgroups are reported using differences with % cis. all analyses were performed with spss version . , and p value <. was considered statistically significant. a total of patients, among which ( . %) were female, were involved in this study (table ) . aged from to , the median age of the patients is years old. epidemiological data showed that patient had been traveling to hubei province, and patients had been exposed to positive infections of covid- ( . %), including family members and colleagues. forty-two patients had comorbidities, including hypertension (n = , . %), diabetes (n = , . %), coronary heart disease (n = , . %), and chronic obstructive lung disease (n = , . %). the proportion of patients having underlying diseases seems to be higher in group s than in group r. in addition, in both groups most patients were non-smokers. used methylprednisolone. only patient out of both groups got even worse despite this active treatment. clinical characteristics of covid- include the exposure history and typical systemic symptoms such as fever, cough, fatigue, decreased wbc and lymphocyte counts, and infiltration in both lower lobes on ct imaging. among them, fatigue appears to be an important factor that affects the duration of positive sars-cov- nucleic acid test in respiratory specimens. clinical characteristics, coronavirus disease, covid- , fatigue, sars-cov- in this study, patients were divided into two groups based on whether their sars-cov- nats in respiratory specimens turns negative within (group rapid, or group r) or over (group slow, or group s) one week. there were no significant differences in age, gender, travel or exposure history, or smoking history between the two groups of patients ( note: except where indicated, data = n/n (%), n is number of patients, where n is the total number of patients with available data. *p < . . in order to detect covid- , sars-cov- nucleic acid assay played a vital role in testing oropharyngeal swabs samples and provided a standard and critical condition for confirming recovering and approving discharge. negative sars-cov- nat in respiratory specimens has been believed to indicate viral shedding in respiratory specimens, which allows shorter hospital stay and implies better prognosis. in this study, patients were divided into two groups based on whether or not the nat turns negative within one week. we thank dr gang fu from xinyu people's hospital for supporting the clinical data of the patients. the authors declared that they have no conflicts of interest to this work. we declare that we do not have any commercial or associative interest that represents a conflict of interest in connection with the work submitted. all the data supporting used in this work were publicly available. zhongliang guo https://orcid.org/ - - - x a novel coronavirus from patients with pneumonia in china genomic characterization and epidemiology of novel coronavirus: implications of virus origins and receptor binding clinical management of severe acute respiratory infection when novel coronavirus (ncov) infection is suspected: interim guidance clinicopathologic, immunohistochemical, and ultrastructural findings of a fatal case of middle east respiratory syndrome coronavirus infection in the united arab emirates epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia analysis of clinical features and outcomes of patients with severe and critical covid- : a multicenter descriptive study elevated serum aspartate aminotransferase level identifies patients with coronavirus disease and predicts the length of hospital stay targeting metabolic reprogramming by influenza infection for therapeutic intervention naive t cell maintenance and function in human aging significant changes of peripheral t lymphocyte subsets in patients with severe acute respiratory syndrome expression of lymphocytes and lymphocyte subsets in patients with severe acute respiratory syndrome ct imaging features of novel coronavirus ( -ncov) clinical features of covid- convalescent patients with re-positive nucleic acid detection novel coronavirus (covid- ) pneumonia clinical features of patients infected with novel coronavirus in wuhan advances in critical care for the nephrologist: acute lung injury/ards risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease pneumonia in wuhan, china key: cord- -xr v n authors: van aalst, jan title: distinguishing knowledge-sharing, knowledge-construction, and knowledge-creation discourses date: - - journal: int j comput support collab learn doi: . /s - - - sha: doc_id: cord_uid: xr v n the study reported here sought to obtain the clear articulation of asynchronous computer-mediated discourse needed for carl bereiter and marlene scardamalia’s knowledge-creation model. distinctions were set up between three modes of discourse: knowledge sharing, knowledge construction, and knowledge creation. these were applied to the asynchronous online discourses of four groups of secondary school students ( students in total) who studied aspects of an outbreak of severe acute respiratory syndrome (sars) and related topics. the participants completed a pretest of relevant knowledge and a collaborative summary note in knowledge forum, in which they self-assessed their collective knowledge advances. a coding scheme was then developed and applied to the group discourses to obtain a possible explanation of the between-group differences in the performance of the summary notes and examine the discourses as examples of the three modes. the findings indicate that the group with the best summary note was involved in a threshold knowledge-creation discourse. of the other groups, one engaged in a knowledge-sharing discourse and the discourses of other two groups were hybrids of all three modes. several strategies for cultivating knowledge-creation discourse are proposed. for two decades, carl bereiter and marlene scardamalia have been developing an educational model intended to make the processes experts use to advance the state of knowledge in their fields more common in education. the model was initially called "intentional learning" to emphasize that learning needs to be an intended goal rather than the by-product of activities (bereiter and scardamalia ) and then "knowledge building," suggesting that knowledge is the product of a constructive process (bereiter and scardamalia ) . but as constructivism has gained wide receiver if they comprehend its content and significance. examples are providing factual information to answer a query or uploading various kinds of information to an intranet. one thing that makes such interactions effective is that the receiver has already identified a need for the information. for example, someone new to editing digital video may need to be shown how to add music to the video, which will address an already meaningful goal. as a social practice, knowledge sharing is an accomplishment, especially in competitive environments; people are not naturally inclined to share what they know unless doing so is likely to enhance their own social position. the management literature indicates that knowledge-sharing practices can make organizations more effective, but they need to be cultivated (lencioni ) . in a community engaged in collaborative inquiry, knowledgesharing practices involve the introduction of information and ideas without paying extensive attention to their interpretation, evaluation, and development. the perceived lack of a need for interpretation and evaluation can be related to naïve realism, an epistemic position according to which data speak for themselves (science council of canada ) . a related epistemic belief is "quick learning," which has been linked to overconfidence in knowledge (schommer ). the ideas shared are not modified by the sharing interaction (bereiter and scardamalia ; pea ) , and knowledge sharing is not reflective. knowledge construction refers to the processes by which students solve problems and construct understanding of concepts, phenomena, and situations, considered within cognitive psychology. it is effortful, situated, and reflective, and can be individual or social (sullivan palincsar ) . the basic assumption of constructivism is that the student must make ideas meaningful in relation to his or her prior knowledge and to the situation in which the need for ideas arises (von glasersfeld ) . the cognitive processes are "situated" because they are mediated (enabled) by social interactions within the particular group that is working together and by the particular technologies used (brown et al. ; hutchins ) . knowledge construction is often associated with deep learning, which involves "qualitative changes in the complexity of students' thinking about and conceptualization of context-specific subject matter" (moore , p. ; also see biggs ) . dole and sinatra ( ) conceptualize the effort students invest in information processing as "engagement," ranging from simple processing that leads to assimilation (low), to deeper processing and some reflection that leads to knowledge restructuring (moderate), and on to substantially metacognitive processing (high). at moderate to high levels of engagement, knowledge construction can lead to the substantial restructuring of knowledge, which may include the invention of new concepts and enhanced meta-conceptual knowledge (e.g., knowledge about the hierarchical nature of networks of concepts). for example, students may initially consider the motion of an apple that falls from a tree to be unrelated to the motion of the earth in its orbit around the sun, but then come to realize that both can be described using the universal law of gravitation. this change would imply deeper insight into the nature of gravity and would lead to a restructuring of knowledge; the resulting knowledge structure would explain a greater range of observations and require fewer assumptions. more generally, synthesis that results in understanding phenomena on a higher plane and the creation of new concepts is an important form of knowledge advancement. for example, mendeleev's introduction of the periodic table of the elements accelerated progress in chemistry by predicting the existence of unobserved elements and the creation of new concepts to explain the partially observed patterns. scardamalia ( ) conceptualizes such advances as "rise-above," which she described as "working toward more inclusive principles and higher-level formulations of problems. it means learning to work with diversity, complexity and messiness, and out of that achieve new syntheses. by moving to higher planes of understanding knowledge [creators] transcend trivialities and oversimplifications and move beyond current best practices" (p. ). although scardamalia proposes rise-above as a knowledge-creation principle, i regard it as a cognitive act whereby students articulate higher levels of understanding and not merely reorganize knowledge (gil-perez et al. ) ; nevertheless, the need for rise-above is greater when the need for synthesis is greater. knowledge construction involves a range of cognitive processes, including the use of explanation-seeking questions and problems, interpreting and evaluating new information, sharing, critiquing, and testing ideas at different levels (e.g., conjectures versus explanations that refer to concepts and/or causal mechanisms), and efforts to rise above current levels of explanation, including summarization, synthesis, and the creation of new concepts. however, educational approaches vary considerably in the extent to which they make it possible for students to engage in these processes. although most emphasize working with information and ideas (e.g. goldberg and bendall ; hunt and minstrell ; linn et al. ) , there may be limited opportunities for students to pursue problems they have identified themselves or to synthesize ideas and formulate new concepts. for example, in problem-based learning (hmelo-silver and barrows ), students are provided problems, although these are ill-structured and need considerable articulation. in other approaches, students may collaborate in small groups on relatively simple tasks that require little synthesis and reflection on progress. in the vast majority of approaches, knowledgeconstruction processes are directed at acquiring the reliable knowledge of a field (edelson et al. ; kolodner et al. ; krajcik et al. ) . knowledge construction, with its emphasis on building on students' prior ideas, concepts and explanations, and their metacognition, produces deeper knowledge in complex domains than does knowledge sharing (bransford et al. ; hmelo-silver et al. ). the term "knowledge creation" is used in the literature on expertise and innovation to describe how companies, organizations, and academic fields develop the ideas needed to sustain innovation (e.g. engeström ; gundling ; nonaka and takeuchi ) . knowledge creation depends on conditions in which creative work on ideas is valued and there are mechanisms for choosing the most promising ideas for further development, and rewarding creativity. these elements need to work together to create what gundling ( ) has called an "ecology of innovation" that produces "a dazzling variety of new products each year" (p. ). at one level, knowledge-creation discourse involves the design and improvement of intellectual artifacts such as theories, explanations, and proofs (bereiter ) . drawing from popper's theory of objective knowledge, bereiter considers ideas to be real objects similar to bicycles or telephones. we may ask how a bicycle can be improved, and we can ask the same of an idea. this aspect of the discourse is known as "design-mode" (bereiter and scardamalia ) , with an emphasis on explanations, casual mechanisms, and the coordination of claims and evidence. however, knowledge creation is not just a rational effort. for example, the community periodically needs discourse to identify priorities and long-term goals, decide how to mentor newcomers, and evaluate knowledge advances. as studies of scientific practice have shown, the associated discourse tends to be more argumentative (feyerabend ; kuhn ; lakatos ; latour ) . to mention just a few examples, in science, good problems may not be investigated because they are not currently considered important (latour ) . researchers promote their own work and that of close colleagues by alerting the community to recent findings, and may ignore important new findings that they do not find appealing (reeves ) . other researchers may not make their insights public, for fear of attracting criticism (e.g., madame curie's reluctance to make public the health hazards associated with radium, see quinn ) . in other words, belief-mode discourse also plays an important role in knowledge creation. despite individual idiosyncrasies, members of a scientific field share a goal of innovation and the advancement of knowledge. commitment to shared goals within a team is also important in a variety of other innovative contexts (gundling ; lencioni ; nonaka and takeuchi ) . in bereiter and scardamalia's knowledge-creation model (bereiter ; bereiter and scardamalia ; scardamalia ; scardamalia and bereiter ) , a class of students is considered a community that shares a commitment to creative work on ideas and advancement of the state of knowledge in that community. ideas are considered intellectual artifacts of the community; they reside in the community's discourse rather than in people's minds. the community needs to be able to identify gaps in its collective knowledge, map out ways to fill those gaps, design and manage inquiries, manage social processes, and evaluate progress. thus, the community's goals are emergent. students are expected to make "constructive use of authoritative sources" (scardamalia ) such as books, websites, and experiments, treating them as potentially useful for informing their work. they are also expected to engage in progressive problem solving, reinvesting cognitive resources to deepen their understanding of problems and taking on more difficult problems over time (bereiter and scardamalia ) . one of the most important roles of the teacher in this process is to facilitate the development of an innovation ecology. important progress has been made in this direction by the development of a system of principles that describe the socio-cognitive and socio-technological dynamics of knowledge creation, including collective cognitive responsibility for knowledge advancement, real ideas/authentic problems, epistemic agency, improvable ideas, rise-above, and constructive use of authoritative sources (scardamalia ) . these principles provide a technical vocabulary that students, teachers, and researchers can use to reflect on the extent to which there is evidence of a knowledge-creation discourse. initial studies show that elementary and secondary school students are capable of engaging in the dynamics described by these principles (niu and van aalst in press; zhang et al. zhang et al. , ). however, more work is needed to characterize the innovation ecology, such as by determining the social practices that make collaboration possible, the overall school culture, and the community's experience at knowledge creation and its long-term goals (bielaczyc ; truong ) . knowledge creation requires discourse for maintaining social relations, setting goals, deepening inquiry, and lending support to ideas that are already understood by some in the community. for example, van aalst ( ) discusses how a grade student referred to the scientist francis bacon to support an explanation he had proposed earlier that had not been accepted by the community. this move was directed less at improving understanding than at improving the impact of the student's own ideas. similarly, students who wish to further a line of inquiry need the ability to argue the case for doing so. these types of moves cannot be understood by examining short-term goals such as the problem students are currently attempting to understand, but require the consideration of higher level and longer term goals such as the diffusion of new insight throughout the community and progressive problem solving (hmelo-silver ) . in groups that work together for short periods, there is less need for such moves. there are important theoretical differences between knowledge construction and knowledge creation, although they involve similar processes such as posing questions, formulating conjectures and explanations, summarizing progress, and proposing rise-above ideas. these processes are interpreted within different psychological perspectives. knowledge construction corresponds to cognitive psychology, in which improved understanding is regarded as the emergence of more complex cognitive structures and schemata (novak and gowin ) . such views have been criticized for their cartesian split between the knower and what is known, and for treating knowledge as residing in the mind. proponents of sociocultural theories posit knowing as the ability to participate in cultural practices (lave and wenger ; roth and tobin ) . for example, roth and tobin argue that "knowing physics … means to participate in talking about relevant objects and events in the ways physicists do, using acknowledged words, sentences, gestures, inscriptions, and so forth …" (p. ). these developments have given rise to a division between learning as the acquisition of mental representations and learning as participation; sfard ( ) argues that both views are needed for a complete understanding of learning. brownell and sims propose a pragmatic and relational view of understanding implied by the ability to "act, feel, or think intelligently with respect to a situation" ( ( , quoted in bereiter , which bereiter uses to argue that understanding is always mediated by the object to be understood. accordingly, understanding has an "out-in-the-world" character. drawing from bereiter's analysis and work on expansive learning and knowledge-creating companies (engeström ; nonaka and takeuchi ) , paavola et al. ( ) propose a "knowledge creation metaphor" that further articulates this view. thus, understanding and knowing are mediated by the objects that a community creates and shares, and the cartesian split appears to be avoided. rather than residing inside individual minds, ideas are regarded as cultural objects (or artifacts) that mediate knowing and understanding. in summary, knowledge sharing, knowledge construction, and knowledge creation correspond to different theoretical perspectives. however, this does not mean that a community will use a single mode of discourse. for example, we would expect students to use a knowledge-sharing discourse when it meets their needs, and for there to be individual differences in epistemic beliefs and conceptions of learning that make the identification of a single discourse mode difficult. nevertheless, we can examine which discourse mode, in the balance, is most consistent with the observed discourse. the three modes of discourse can be supported by a wide variety of educational tools and activity structures, including online discussion forums (synchronous and asynchronous), mobile devices, face-to-face conversations, and lessons. this paper focuses on the use of an online discourse environment, knowledge forum. from a cognitive perspective, knowledge forum is designed to support knowledge construction through the use of scaffolds, which are sentence starters such as "my theory" that keep the writer and reader focused on cognitive processes. knowledge forum also has a variety of features that support working with ideas after they have been posted including: (a) the ability to revise notes; (b) the ability to add a note as a reference to another note; (c) the ability to reuse a note introduced in one workspace in a later workspace created for a different purpose (a workspace in knowledge forum is called a view for "point of view"); and (d) the ability to create rise-above notes, which have a special icon and are used to take the discourse to a higher conceptual plane. the ability to link notes is useful for making visually evident the connections between ideas. knowledge forum also makes it possible to objectify ideasto share them and then allow the community to work on them. the above-mentioned features then support the work of improving such objects, reviewing progress, and synthesis. the remainder of this paper reports a case study of asynchronous online discourse in knowledge forum using a coding scheme based on the distinctions between the three discourse modes. the data are drawn from a design experiment (brown ; collins et al. ) in which the researcher and teacher collaborated to achieve two goals: to achieve a fuller implementation of the knowledge-creation model than in previous iterations, and to test a new assessment strategy (van aalst et al. ) . the assessment task was designed to extend our previous work on portfolio notes, in which students had used concepts describing collective aspects of knowledge creation individually (lee et al. ; van aalst and chan ) . the new task was intended to underscore that knowledge advancements are collective achievements in a knowledge-creation community; it asked students to collaborate to review whether knowledge advances had been made on the problems they investigated and, if so, to coauthor a collaborative summary note with all who had contributed to the collective advance. while the work students did together throughout the project involved both the division of labor (cooperation) and joint activity to understand the same problems and ideas (collaboration), the word "collaborative" in the name of the task signified that students were to work together to review and create these notes (for details see van aalst et al. ) . the study evaluated performance on the collaborative summary notes and related that to what students were doing in knowledge forum. the unit of analysis was a group of students that worked together in the same workspaces (views) in knowledge forum; there were four such groups in the study (groups a-d). the analysis proceeded in five parts: ( ) several relevant independent variables were examined to check whether the groups could be considered to be equivalent. ( ) two dependent measures, knowledge quality and significance of findings, based on the collaborative summary notes, were measured to assess advances in collective knowledge made by the groups. ( ) to identify mechanisms that could explain observed between-group differences in the dependent variables, the group discourses (all the notes written by each group) were coded and analyzed using a new coding scheme with main codes and subcodes. statistical analysis was then performed on the main code frequencies to determine which main codes provided the greatest group separation. ( ) the results were used to select several main codes for qualitative analysis to further elucidate what the groups were doing differently. ( ) the observed patterns in the subcode frequencies were used to examine the fit of the four group discourses to the knowledge-sharing, knowledge-construction, and knowledge-creation discourse modes. the participants were two classes of secondary school students, from a grade course on career preparation and inquiry (n= ) and a grade course focusing on computers and their impact on "global society" (n= ). the courses were taught concurrently by the same teacher at an inner city school in western canada. approximately % of the students had some experience with knowledge forum in previous grades, such as in discussing "problems of the week" in mathematics. however, these experiences did not last more than one or weeks and were not integrated into a pedagogical approach based on knowledge-creation principles. the teacher had years of experience teaching secondary school mathematics. he had recently completed a master's degree focusing on cognitive strategy instruction and was in his third year of using knowledge forum. the researcher and teacher met several times at the beginning of the school year to plan the project, deciding that the then recent outbreaks of severe acute respiratory syndrome (sars) and avian flu in and could provide a suitable area of inquiry for secondary school students. for example, students could build on their knowledge of science to study what was known about these phenomena, critique media attention, examine the economic impact, or form a position on how governments should have responded to the outbreaks. the grade course provided a promising context for integrating a focus on such questions into the curriculum, as one of its main goals was learning how to conduct research. the grade course also provided a good opportunity to engage in knowledge creation, as one of its main goals was for students to learn how information and communication technology could be utilized for learning in global societies. the second main topic on the grade course syllabus was "computer viruses," which was added to sars and avian flu as a third main topic for inquiry with the aim of having the students examine the nature of viruses in both biological and non-biological systems and identify patterns across them. (however, the topic only accounted for . % of the coded notes.) the two classes shared a knowledge forum database and worked on the same topics. to limit the number of notes they would encounter, the students were divided into four groups. each group had students from both classes, with an equal number of students from each class; the students could choose their own groups but the teacher made some minor changes. each group had its own views on knowledge forum and the groups were not expected to interact with each other during the inquiry. in the week before the project commenced, all students responded to an icebreaker topic. the researcher then introduced both classes to knowledge-creation principles, and students were reminded of these by means of posters in their classrooms. both classes had daily access to a computer lab ( -minute periods), but students had a number of other assignments to complete. during typical periods, the teacher would spend to min interacting with the whole class, and the students would then work on one of their assignments. most of the students worked on knowledge forum during class a few times per week, and after school hours. the teacher discussed the students' work in knowledge forum with them from time to time, but he only read % of their notes and posted of his own. the researcher visited the classes four times, and occasionally the teacher emailed the researcher to ask for advice on issues that arose during conversations with the students. because the teacher and students had little experience with extended and collaborative inquiry, a three-phase inquiry model was employed. phase developed a focus, phase was the main inquiry phase, and phase involved the students evaluating what they had learned. the researcher provided extensive instructions for the three phases as outlined below. phase : orientation ( weeks) the goal of the first phase was to enable the students to identify problems and select the most promising inquiry foci. research into inquiry-based learning has shown that the nature of students' own questions constrains student-led inquiry (krajcik et al. ; lipponen ; polman ) . the students were thus asked to read widely and post notes in their group's view, summarizing the main points and raising questions and ideas. toward the end of phase , they were asked to propose problems of understanding, using a research question note format stating the question, its background (relation to earlier notes), and ideas for studying the question. finally, they were asked to select a few of the most promising problems for further research, considering: (a) the extent to which a question might lend itself to inquiry worth several weeks of effort, (b) whether they had ideas or resources for researching the question, and (c) the coherence among the questions that were under consideration. the researcher explained the rationale for these processes and related it to knowledge-creation principles. phase : research ( weeks) the students were asked to create a view in knowledge forum for each research question. they were then expected to work within their groups to research their problems by reading additional information on the internet and from other sources. the students were encouraged to evaluate the credibility of the sources (e.g., the world health organization website would be a more trustworthy source than writing by a person who did not declare his or her credentials), and to examine the evidence used to support the claims made in the sources. they were encouraged to extend their inquiries after they developed preliminary answers to deepen their understanding. the researcher and teacher were less involved in scaffolding the inquiry than in phase . phase : evaluation of learning ( weeks) as knowledge advancement is an important outcome of knowledge creation, each group was asked to create a collaborative summary note for the problems on which progress had been made by the end of phase . the students began their review face-to-face within their own group and class, and then created coauthored notes in knowledge forum; in the best examples, the coauthors then edited the notes to gradually improve them. the note format was similar to a brief scientific research report, with the groups asked to (a) state the problem on which they were reporting, (b) explain the problem's background, with links to their work in phase , (c) describe what they did to investigate the problem, (d) report the main findings, and (e) explain the significance of the findings and outline opportunities for further inquiry. the instructions also indicated that a student could be coauthor of several summary notes. the notes were designed as self-assessments of group accomplishment but were not used by the teacher for formal assessment. to guide their work, the students were provided a rubric showing several dimensions of the task (writing quality, identification of collaborators, organization, findings, and implications) with levels of performance for each (van aalst et al. ) . the following baseline data were collected to examine the extent to which the groups could be considered equivalent in terms of their opportunities to create knowledge: prior knowledge relevant to the inquiry topics, general indexes of participation in knowledge forum, and the research questions proposed. a short test with eight questions was administered at the beginning of the project to assess existing knowledge of sars and avian flu. the questions asked students to describe their knowledge of sars, the corona virus, and what measures had been taken to control it; one asked whether a nurse should enter a hospital ward with sars patients, and another asked what students knew about avian flu. each question was scored on a - scale, ranging from "no domain knowledge evident" to "at least two relevant points." for example, in a response that received a score of " " for knowledge of avian flu, a student stated that "it was the same thing as bird flu," which she further explained as follows: "the birds get the flu because they have to live in small spaces where bacteria grow and become more dangerous." the scores were added to create a scale with a range from to points. the papers were scored by the researcher; % of the papers were also scored independently by a research assistant resulting in an inter-rater reliability of . (pearson correlation). general indexes of participation in knowledge forum-notes created, percentage of notes read, and percentage of notes linked-were obtained using the analytic toolkit (atk) for knowledge forum; these kinds of measures have been used in many studies of online discourse (guzdial and turns ; hsi and hoadley ; lee et al. ; van aalst and chan ; zhang et al. ) . while high values of all three measures are not necessarily indicative of knowledge construction or knowledge creation, the measures can be informative. for example, a low percentage of notes read would suggest a low level of awareness of ideas in the database. conversely, a high percentage of linked notes could indicate attempts to synthesize and integrate contributions. these measures are correlated with both performance on self-assessment tasks and knowledge advancement, although such effects are contingent on the discourse being explanation-driven (niu and van aalst in press). the potential for knowledge advancement is also influenced by the nature of the research questions posed. do they require explanations or will descriptive information suffice? do the students have relevant knowledge that they can apply? the research question notes posed in phase were thus checked to determine whether all groups posed some explanation-seeking questions and questions that related to prior learning. two dependent variables were derived from the collaborative summary notes. the knowledge quality scale measured: (a) an epistemic position ranging from knowledge as a single factual claim to a fully integrated explanation in which several concepts and/or causal mechanisms were invoked (hakkarainen et al. ) ; and (b) the extent and correctness of knowledge from a single finding, possibly with evidence of misconceptions, to at least three findings without evidence of misconceptions. the significance of findings scale was intended to measure the students' ability to identify the significance of what they had learned, ranging from a brief restatement of their findings to a clear explanation of the significance, limitations, and potential for further inquiry. self-assessment of the significance of learning is a metacognitive ability needed for knowledge construction and knowledge creation, especially for setting new learning goals. the descriptors for each point on these two scales are shown in table . all summary notes were scored independently by the researcher and a research assistant who had completed a course on knowledge creation but was not familiar with the database. the inter-rater reliability was . for knowledge quality and . for implications of findings (pearson correlation coefficients). a coding scheme was developed for analyzing the group discourses during phase and phase . the goal of the analysis was to identify mechanisms that could explain betweengroup differences in the dependent variables. the scheme was intended to be general enough for use in analyzing discourse from a variety of perspectives within the computersupported collaborative learning field, particularly knowledge sharing, knowledge construction, and knowledge creation. it includes seven main codes: community, ideas, questions, information, links, agency, and meta-discourse. the community code describes the extent to which the social interactions within a group suggest a "sense of community," in which "people feel they will be treated sympathetically by their fellows, seems to be a first necessary step for collaborative learning" (wegeriff , as quoted in kirschner and kreijns , p. ). indicators of a sense of community include commitment to shared goals, appreciation for the work of group members, identification with the group, and ways of getting things done that are specific to the group (wenger ) . discourse that involves risk-taking requires a stronger sense of community than other types of discourse (e.g., improving ideas versus only sharing them). although the knowledge-creation model refers to communities, the discussion in its literature has been limited to the socio-cognitive features of those communities. the next five main codes-ideas, questions, information, links, and agency-are based on research into a wide variety of cognitively oriented inquiry approaches (chan ; hakkarainen ; hakkarainen et al. ; hmelo-silver ; kolodner et al. ; linn et al. ) . this body of work has shown that a focus on explanation is more likely to lead to knowledge advancement than answering fact-seeking questions (hakkarainen ) . the idea code captures the ways in which students contribute to and work on ideas (e.g., opinions, conjectures, and explanations), with its focus on the nature of those ideas. in contrast, the information code focuses on the extent to which students interpret or evaluate the information they introduce. the agency code is intended to describe the ways in which students selfregulate their inquiries; the subcodes emphasize planning and reflection relating to logistics and the epistemic features of their inquiries. in terms of these codes, we would expect informationsharing discourse to be characterized by fact-seeking questions and limited evidence of ideation, interpretation of information, synthesis, and planning and reflection. in contrast, both knowledge construction and knowledge creation would be characterized by stronger evidence in these areas, with minor differences between the two modes of discourse. for example, although rise-above should occur in knowledge construction, it should occur more often in knowledge creation, which takes place over a longer period and has greater need for synthesis. the final main code, meta-discourse, describes a level of discourse beyond maintaining social relations and building understanding, and relates to the existence of long-range goals in a knowledge-creation community. scardamalia and bereiter ( ) suggest that this feature is lacking in most online discussions. examples of meta-discourse would be reviews of the state of knowledge in the community, work aimed at helping new insights diffuse through the community, making arguments for a new phase of inquiry, and establishing more difficult goals over time. although evidence of meta-discourse may not be strong in an inquiry of weeks, there should be some examples. to capture the different ways the seven codes could be exemplified, subcodes were identified and their relevance to each of the discourse modes estimated (see table in the "results" section). for these estimates, a three-point rating scale was used (low, medium, high). for example, the subcode fact (under ideas) was rated high for knowledge sharing and low for both knowledge construction and knowledge creation. in this example, knowledge construction and knowledge creation are called degenerate to indicate that the scale for this code does not differentiate between them. major review (under meta-discourse) was rated low for knowledge sharing, medium for knowledge construction, and high for knowledge creation on the assumption that knowledge creation is generally more complex and requires more time than knowledge construction, so the need for major review is greater. all ratings were completed independently by the researcher and an independent second rater, leading to an inter-rater reliability of . (cohen kappa). the computer notes were entered into atlas-ti® qualitative data analysis (qda) software for coding; notes were coded (approximately , words). each view in knowledge forum was entered separately, beginning with the first view of group a and ending with the last view of group d. most of the development of the coding scheme was done using the data from groups a and b. the researcher started with a small set of codes based on knowledgecreation principles and prior research into asynchronous discourse, and gradually expanded the set. he started by focusing on the text, and applied each code that seemed relevant to a given text segment; the amount of text varied from a sentence to a few notes depending on the code (hmelo-silver ). the process was then repeated focusing on the codes and working through the corpus checking for potential examples for small groups of codes. the researcher began by coding data from groups a and b, and reflexively improved both the code definitions and coding procedures. it soon became clear that coding was needed for both the nature of the idea (e.g., conjecture or explanation) and the extent to which the students processed new information. after three rounds of improving the code definitions and procedures in groups a and b, the codes were organized into main codes and subcodes and the remaining data were coded. as employing a second coder was not possible, to further ensure the accuracy of the coding the researcher returned to it after an absence of approximately months. the qda software was then used to check the consistency of subcode allocations, with % of the quotes needing to be recoded. most changes were between subcodes of the same main code (e.g., switching from "opinion" to "conjecture"). the coding results were analyzed in three ways. first, a frequency analysis was conducted to examine the extent to which each main code could be used to separate the four groups. the goal of this analysis was to identify potential mechanisms that could explain betweengroup differences for knowledge quality and implications of findings. next, several of the main codes were selected for qualitative analysis to further elucidate what students were doing in knowledge forum. main codes were selected for this analysis based on the amount of group separation. finally, the alignment of the subcodes with the three discourse modes allowed the mapping of the four group discourses onto those modes. the goal of the first analysis was to determine whether the four groups could be considered equivalent in subsequent analyses. table shows the results for the knowledge pretest and atk indexes. the pretest results show that prior content knowledge was not extensive and varied very little between the four groups; the group means varied from . % (group c) to . % (group b). the majority of students ( %) stated at least two substantive points about sars, but % stated they knew nothing about the corona virus, and % stated they knew nothing about avian flu. between-group differences were also relatively minor for the atk indexes, the most noticeable being that the students in groups c and d read fewer notes. overall, the amounts of note writing and reading were consistent with those in other studies of online discourse (guzdial and turns ; hsi and hoadley ) . in contrast, the amount of linking ( . % to . %) was less than in other studies using knowledge forum, in which it reached % (lee et al. ; yoon ) . each group posted approximately research question notes, although group c required days longer than the others to reach this point. each group's output included some explanation-seeking questions, such as "why is it children are less likely to develop sars?" there were, however, important differences in the extent to which the questions allowed the students to build on prior knowledge. for example, while discussing the question about sars and children, the students used their knowledge of viruses and infection, but in discussing "is killing chickens the only way to end avian flu" they resorted to exchanging opinions. in sum, these data suggest that the four groups were similar in terms of prior knowledge about the main inquiry topics, the extent to which they used knowledge forum, and their ability to formulate research questions. however, group c had fallen behind the other groups by the time it had generated its research questions, and the research questions varied in their potential for knowledge creation. the goal of the second analysis was to evaluate the advances in collective knowledge reported by those students who collaborated on summary notes. the students collectively submitted summary notes; . % of grade students and . % of grade students were coauthors of at least one note. all of the summary notes were assessed for knowledge quality and implications of findings with the scales shown in table . table shows the group means and standard errors for knowledge quality and significance of findings for the summary notes. some students did not realize that a group was required to write only one note on a given research question, resulting in duplicate notes for some questions; in such cases, only the best note from the group was considered in the calculation of group means. group a had a higher mean score than the other groups for knowledge quality (effect sizes ≥ . , cohen's d); for most groups. the knowledge gained was factual and did not reach the level needed for a or on the scale. group c had the lowest mean knowledge quality score; its small number of notes is understandable because it needed more time to articulate its focus. the goal of the third analysis was to identify possible mechanisms for the between-group differences in the dependent variables by coding the group discourses leading up to the creation of the summary notes. the code and subcode frequencies are shown in table . the total frequencies for all subcodes associated with a main code are shown in the first row of each section. before examining intergroup variation, it will be useful to consider the total frequencies over all groups (last column). in descending order of total frequency, the following patterns can be observed. first, although there were many linkages (f= ), there were few examples ( ) in which features of knowledge forum such as adding a note as a reference to another note were used; the majority of links were to web pages ( ), although some groups did link their ideas verbally to earlier contributions in knowledge forum ( ). this finding suggests that the level of competence with features of knowledge forum designed to support linking ideas was low, and may explain the lower than expected atk index for linking (table ) . second, although there were many instances of working with ideas ( ) and information ( ), the subcodes suggest that information sharing was a significant aspect of all group discourses. third, there were few instances of two codes: questions and meta-discourse (both ). group a had substantially more code instances than the other groups ( , compared with , , and ) reflecting that it invested more effort into the processes measured by the coding scheme, which may explain the better performance on the summary notes to some extent. however, a more interesting question is what group a did differently, controlling for the difference in overall effort. thus, a two-way analysis of the main code frequencies (code × group) was conducted. the results are shown in table ; cohen's guidelines regarding effect sizes were used to arrange the codes in three groups from large to small effect size. accordingly, community and questions were very effective in separating the groups-especially group a from the other groups. the next two codes (ideas, information) provided statistically significant but more moderate separation. the last three codes (linking, agency, meta-discourse) provided limited or non-significant group separation. the relatively low frequencies for these codes indicate that these aspects of the discourse were generally not well developed. to gain additional understanding of the nature of the group discourses, three sets of main codes were selected for qualitative analysis based on the group separations shown in table : community (large), ideas/information (moderate), and agency/argument (non-significant). in the knowledge-creation model students contribute ideas, on which the community works and which thus become its "intellectual artifacts" (bereiter ) . at the same time, students continue to own their ideas, and whether their ideas are appreciated and taken up by the community is important to the formation of students' identities as community members (wenger ) . the coding revealed between-group differences relating to aspects of this issue. for example, group a encouraged its members more often than the other groups (table ): i think your ideas for groups are good … it would mean that we could get a start on all the topics right away. good job of actually getting things going! i really like [s's] idea of setting ourselves little mini-deadlines so that everybody will stay on task and finish the job more efficiently. there were also examples in which additional views were sought from students who had not yet contributed ideas. some students also felt a responsibility toward the group and apologized for failing to contribute to the discourse: sorry i've been away at a tournament for quite a while, so i'm just trying to get caught up. i don't know how much work you've all got done already, but the groups etc. sound pretty good ... i'll get onto researching as soon as i'm sure what's going on. another way in which group a promoted a sense that students belonged to a community was by instituting a democratic voting scheme for prioritizing research questions ( of code instances). while taking a vote can be a superficial process, it was accompanied in this group by considerable ideation, information processing, and linking. the voting process was also present in group c but was absent from groups b and d. group b appeared to harbor some tension between the grade and students arising from miscommunication. one student in the grade class wrote: as of now, we have less than week left and because your class have not been very active in this final phase, we've decided to go with these two questions above because we've a student from the grade class responded as follows: yeah, alright. if the rest of our group wants to do it then i guess that's what's being done since "we have not been very active." i thought we were only supposed to research our own questions first. are those the only questions that we are doing then? we are sorry that you are not satisfied with the level of our commitment on kf. we weren't aware that we needed to pick from your questions as well as ours. sorry for the inconvenience. in summary, group a had a shared commitment to the task, a sense of belonging to the group, and an appreciation for all group members' contributions, all of which are indicators of communities (wenger ) . these social processes were also present to some extent in group c, but they may have had less effect. group a's discourse had most of the kinds of idea units needed for knowledge construction, particularly concepts and explanations; only . % were coded as facts or opinions. however, only . % of its idea units were classified as rise-above, suggesting that the discourse was not yet a well-developed example of knowledge creation. all of the other groups' discourses were more fact oriented, with percentages of idea units coded as facts or opinions ranging from . % (group b) to . % (group d). nevertheless, in group b, there were some examples of concepts and explanations, and group c had explanations and a few rise-above units. this mix of conceptual and factual contributions is the main reason for the idea code providing only moderate group separation ( table ). the information code revealed a tendency toward knowledge sharing in all groups: the many instances where information was presented without interpretation or evaluation (group c, . %; group d, . %; group a, . %, group b, . %). this prevalence of information sharing may be related to an epistemological understanding of inquiry as asking questions, finding answers, and reporting them, with information assumed to be self-explanatory (a realist position). instead of describing information, students need to be developing explanations and using information to support them. the difference is illustrated below: i found this information on: [web link]. "thailand, the world's seventh largest poultry producer, will suffer only 'modest losses' to its economy due to the h n strain of the avian virus, it says. a 'complete decimation' of thailand's poultry industry would this note describes information but does not interpret or evaluate it. in contrast, in the following note, the student is providing an explanation and uses the web link at the end of the first paragraph as a reference for further information; in the second paragraph, the description of the second web link is integrated into the explanation. first off, let's look at the very definition of 'quarantine.' we're not talking maybe putting up some red tape around affected farms here, we're talking the slaughter and elimination of literally millions of chickens in the us, canada, and asian nations including vietnam and china. the most recent outbreak, in hong kong, resulted in the slaughter of about , poultry; the birds were killed, then bagged for dumping in landfills. this outbreak alone cost the poultry industry the equivalent of us $ . million. [web link] the short-term costs incurred may seem rather drastic, but if the flu can be contained now, by eliminating all possibly infected birds, it will cost far less than trying to contain it later on if there are more outbreaks. i found the following website had some really valuable information concerning avian flu outbreaks in the past-there have been large-scale epidemics all over the world, ranging from australia to pakistan, and this site talks about the economic impact of each-for example, "the pennsylvania (usa) outbreak took years to control. some million birds were destroyed at a direct cost of us$ million. indirect costs have been estimated at more than us$ million." [web link] neither agency nor meta-discourse provided statistically significant group separation. the agency code looked separately at planning and reflection relating to epistemic aspects of the inquiry and the completion of the project. there were not many instances of agency relating to the inquiry ( ). reflection on learning is an important aspect of knowledge construction and knowledge creation, and the lack of reflection in the discourses provides separate evidence that most groups treated information as unproblematic. another important finding from the agency code is the many instances of project planning from group c, suggesting that it had considerable difficulty in self-directing its inquiry. project planning is an important aspect of knowledge-creation discourse, but it should not dominate the cognitive features. the meta-discourse code is conspicuous because it occurred infrequently, but there were attempts by all groups. for example, a group b student attempted to advance the inquiry to a new stage by suggesting a new question: … i guess the question now is how can we make the chickens less likely to develop serious symptoms, and to become more like the wild poultry. and maybe an effective method of keeping the chickens from getting sick and to stop the spread of the avian flu is by doing something to the wild fowl to make them unable to carry the virus. it raises some interesting questions that can probably be analyzed further! perhaps the suggestion came too late, but it was not taken up by the group. relating the group discourses to the discourse modes the goal of the fourth analysis was to map the group discourses onto the three modes of discourse. first, the subcode frequencies were classified as small ( to instances), moderate ( to ), and large (greater than ). the results were then compared to the relevance ratings of the subcodes (table ) to predict the discourse modes. for example, group a had explanation-seeking questions (large), which corresponds to knowledgecreation discourse. group c had two instances of fact-seeking questions (small), which is consistent with knowledge-construction and knowledge-creation discourses (a degenerate prediction). group b had nine instances of opinion (moderate), which did not correctly predict any discourse mode. to sample the main codes evenly, the two subcodes that predicted the most complex discourse mode were selected for creating profiles. figure shows the number of correct predictions of each discourse mode for the four groups. perfect agreement with a discourse mode would include predictions of that mode; however, because there are many degenerate predictions, these would be accompanied by some predictions of the other modes. the profile of group a is most consistent with knowledge creation: it includes nine predictions of that mode, of which only one is degenerate. it also includes two predictions of knowledge sharing. the overall fit of the predictions to the discourse mode is best for this group. the profile of group d is almost the reverse: it has nine predictions of knowledge sharing (seven nondegenerate) but includes more predictions of the other modes than the group a profile. the profiles of groups b and c are more difficult to interpret because they include nearly equal numbers of predictions of all three of the discourse types. this could be caused by a variety of factors including the existence of smaller units of social organization that approach the discourse differently and contextual dependencies that cause the discourse on one problem to be qualitatively different from that on another. this possibility was explored for group b using inquiry thread analysis. (group b was chosen for this because we already know that group c fell behind in phase and had less time for its inquiry in phase .) fig. number of correct predictions of discourse types from sub-code frequencies. two sub-codes from each main code were used, leading to at most correct predictions per group. however, because some subcodes did not uniquely predict a single discourse type and some did not correctly predict any type the number of predictions per group is generally different from an inquiry thread is a temporally ordered sequence of notes on the same problem or topic. the notes need not be hyperlinked to be part of the same inquiry thread, and it also is possible that notes that are hyperlinked are not part of the same inquiry thread (for details on the method see zhang et al. ). nine inquiry threads were identified, of which six were active for more than a month. the longest thread ( notes, authors, and readers) was active throughout the entire project and examined scientific mechanisms by which avian flu infection occurs; it included relatively many of the instances of concept, explanation, and deepening inquiry identified in the coding. a similar inquiry thread, but of shorter duration, began in the second half of phase , and focused on a causal explanation of why children may be less susceptible to sars ( notes, authors, readers). threads that were more descriptive were general explorations of sars and avian flu in the first weeks of the project, and somewhat argumentative discussions of how the media had handled the sars outbreak, the disposal of chickens infected by avian flu, and the prevention of avian flu. although deeper analysis would be useful, these results generally support the context-dependence hypothesis. group b engaged in more explanation-oriented discourse when relevant concepts were available, and less when exploring sars and avian flu in general and when concepts were not available. this paper seeks a clearer articulation of the nature of computer-mediated discourse needed for bereiter and scardmalia's knowledge-creation model. its main contributions are the conceptual framework for distinguishing between knowledge-sharing, knowledgeconstruction, and knowledge-creation discourses, an accompanying coding scheme, and the application of both to an evaluation of discourse in knowledge forum. this section reviews what has been accomplished, suggests several strategies for improving the alignment of online discourse to the knowledge-creation model, and outlines further development of the coding scheme. conceptual framework i have argued for a conceptual framework that contrasts three modes of discourse, which can be associated with different theoretical perspectives (transmission/naïve realism, cognitive psychology, and interactive learning mediated by shared objects). knowledge sharing is included because it remains a common discourse mode and is useful in some situations; knowledge construction is included because it is what knowledge creation needs to be distinguished from most. knowledge creation is not a new example of constructivism (in the cognitive paradigm), but an example that reifies a new theory of mind that does not depend on a notion of the mind as a container (bereiter ) . however, due to the incommensurability of the underlying theories, i do not regard the discourse modes as stages in the development of a community's discourse, as gunawardena et al. ( ) have suggested for knowledge sharing and knowledge construction. the framework extends the distinction between learning and knowledge creation (bereiter and scardamalia ) by differentiating between learning by knowledge sharing and learning by knowledge construction. this differentiation makes it possible to bring into focus both differences and similarities between knowledge construction and knowledge creation. the treatment of the knowledge-creation model in the framework marks a departure from the extant literature. bereiter and scardamalia focus on ideas as improvable objects and the socio-cognitive and epistemic dynamics of improving them, as though that could happen without regard for the social context (bereiter and scardamalia ; scardamalia ; scardamalia and bereiter ). in the framework described here, the recommended use of design-mode discourse over belief-mode discourse, a distinction valid for the epistemic work of improving ideas but not for the additional work needed to prioritize goals, ensures that new ideas diffuse throughout the community and possible advances in knowledge are evaluated. one of the most apparent differences between examples of knowledge construction and knowledge creation is the discourse by which this additional work is achieved. paying more attention to the social context in which knowledge creation occurs is not only important for an adequate portrayal of knowledge creation for students, but it also reflects the conditions in classrooms. recently, interest in these aspects of knowledge creation has been mounting. bielaczyc ( ) develops a social infrastructure framework that emphasizes culture and practices, and hakkarainen ( ) introduces the notion of "knowledge practices" to combine epistemic and social practice elements of knowledge creation. it is hoped that the framework described here will stimulate further research to clarify the relationship between explanationoriented discourse, argumentation, and the advancement of collective knowledge. group a's discourse was identified as knowledge creation, providing the strongest evidence of a sense of community, explanation-seeking inquiry, interpreting and evaluating information, knowledge advancement, and insight into these processes. from the analysis of frequencies in table , we know that the leading factor differentiating group a from the others was its sense of community, but it is likely that all of the observed effects are necessary. the relatively clear identification of knowledge-creation discourse and better knowledge advances are encouraging because they suggest that knowledge creation is feasible for secondary school settings. however, there is a need for caution because there was little evidence of rising above, meta-discourse, and use of the advanced features of knowledge forum, and there was still too much evidence of knowledge sharing. the relatively clear identification of group d's discourse as knowledge sharing is more disconcerting in a classroom generally oriented toward student centered and constructivist learning. nevertheless, my work with many teachers in the last decade suggests it is a common occurrence. perhaps in this case context dependence mattered less, and the results may point to deeply held beliefs such as quick learning (schommer ) and achievement motivation. indeed, group d's results on the summary notes were second to group a's. group c was also problematic. like group a, it expended much effort on maintaining its sense of community, but was relatively inactive in posing questions and working with information (see table ), and created fewer summary notes. we also know the group had less time for its inquiry than the others because coming up with research questions took longer than planned. although motivation could have been a factor, this was probably an example of an inadequate level of guidance (hmelo-silver et al. ). nevertheless, cases like this, in which students are unable to manage inquiries very well, are also common in project-based science (krajcik et al. ; polman ) . cultivating an innovation ecology as the study described here was a case study, its claims pertain to the observed groups only. further studies investigating the phenomena using different methods and in different settings would lead to a fuller understanding of the generality of the claims (yin ) . nevertheless, some cautious recommendations for encouraging an innovation ecology can be made based on the findings. this subsection examines several conditions that constrain or enable knowledge creation-the nature of the task, the sense of community, idea-centered discourse, the use of technology, and meta-discourse-and discusses how they can be optimized. a common reason for the failure of efforts at knowledge creation in school is their lack of authentic problems (bereiter and scardamalia ) . asking students to investigate what interested them about sars and avian flu held some attraction from this point of view because there was a lack of knowledge, the topics were discussed in society, and students could pursue their own questions. these are considered good things by proponents of socio-scientific issues in teaching (walker and zeidler ). yet, the students' interests frequently took them into areas where they could not build on their initial knowledge. it is possible that the extensive reliance on knowledge sharing resulted in part from a general lack of knowledge that led the students to explore opinions and "chart the territory," and from a lack of concepts and perspectives that could be used to question sources. some students seemed to suggest that what they were doing lacked authenticity as schoolwork because the depth of knowledge was inferior to what was normally expected of them: it is important to understand that there is not one answer to this question. i am limited in my understanding because i get my information from news sources that may be biased. i can also not understand how sars spreads scientifically because i am not a scientist or a doctor. i am like the rest of the public that gets information from news sources. (group d summary note) these considerations have important implications for developing an innovation ecology. in school, it is important that students develop academic knowledge: for example, concepts, explanations, explanatory principles, inquiry methods, and meta-conceptual knowledge. social norms are needed in the classroom to keep these things in focus as students engage in knowledge creation. in other words, in getting a knowledge-creation experience started, the curriculum, students' prior academic knowledge, and their interests should be explored together to forge a closer connection to the curriculum and assess the potential of ideas for inquiry. in the study, students did explore the potential of their ideas but did so independently in their own groups, and the social norms were not developed. a closer connection to the curriculum would also be needed for scaling up knowledge creation in schools. many other researchers link inquiry to the attainment of national educational standards (krajcik et al. ) but do this in ways that undermine key goals of knowledge creation (e.g., epistemic agency, adding to the intellectual heritage of a community). further research into how knowledge-creation experiences can be integrated into the curriculum is much needed. the study identified social processes that constitute a sense of community (such as encouragement, giving credit, drawing in participants, and apologizing) as the distinction between group discourses. these processes have been studied extensively in education and social psychology (e.g. johnson and johnson ; slavin ) but have received little attention in computer-supported collaborative learning research, where social interactions tend to be studied in the context of problem solving from the perspectives of cognitive theory (de laat et al. ; roschelle ; suthers et al. ), intersubjective meaningmaking (koschmann and lebaron ; stahl ) , or are dismissed as off-task behavior (meier et al. ). the social interactions identified in the study were neither part of problem-solving sessions nor irrelevant, but were directed at maintaining and improving how the groups worked. cultivating the social dynamics identified in the study would be important for creating a safe environment for knowledge creation, and thus an important aspect of an innovation ecology. the considerable differences in how the groups functioned socially provide reasons for reexamining the social organization of the class for its knowledge creation. in the assessment literature, the inequities of group work have been noted (webb et al. ). if students work together for several months, inequities arising from individual differences in motivation, effort, and ability could lead to substantial disadvantages for some students. using flexible and opportunistic groups, in which students join a group for a short time to accomplish specific goals, would make students less susceptible to the potential inequities and would help them learn and work with many different students. recently, zhang et al. ( ) used social network analysis to compare three social configurations-fixed groups, interacting groups, and opportunistic groups-and found that opportunistic groups best diffused new knowledge. in the present study, the decision to form fixed groups was intended to limit the number of notes students would need to deal with, but this problem could also be addressed by encouraging more reflective discourse with greater attention paid to synthesis and rise-above ( van aalst ) . one thing that this cognitively demanding work does is slow down the growth of the database. the importance of idea-centered discourse is so well established in the literature that it does not require further amplification (e.g. bereiter ; hakkarainen ; scardamalia ) . nevertheless, in the study students frequently introduced information without generating ideas or questions. if this kind of discourse is widespread and consistent within a community, it may suggest naïve epistemic beliefs (schommer ). deeper reflection on what makes a valuable contribution to knowledge forum may lead students to interpret and evaluate information, and to elaborate by providing examples and counterexamples. students could do this even when exploring a new content area, provided that they have concepts that can provide a lens for interpretation. social norms about the quality of knowledge to be created could also help students to focus on developing explanations. to facilitate developing a set of coherent explanations, it seems important to cultivate rise-above as a prominent dynamic of the discourse. although it can be used late in an inquiry to articulate what has been learned, it may also be useful for scaffolding the discourse, suggesting how students can contribute next. in studies of portfolio notes in knowledge forum, the reflections needed to prepare the portfolio notes have also had such a scaffolding function (lee et al. ; van aalst and chan ) . rise-above can produce incomplete explanatory frameworks, which may lead to predictions and new inquiry goals. thus, rise-above needs to be a social norm that is in focus throughout the inquiry. this would allow an approach whereby students contribute new information and ideas and regularly look for opportunities to review progress and identify more new ideas and lines of inquiry. the approach taken to the use of technology was typical of what i have seen in work with many teachers. the basic features (creating and responding to notes) were demonstrated at the beginning of the project, and instructions for creating links between notes were given with the instructions for phase . that was not sufficient. we made an implicit assumption that learning about knowledge forum would not occupy very much instructional time-it was just "a tool." to the contrary, the use of knowledge forum needs to mediate the social and cognitive work of creation (cole and engeström ; hakkarainen ); students need to learn to coordinate use of its features with use of the concepts of the knowledge-creation model. for example, rise-above involves important social skills because the ideas contributed by different students are combined and the authors may disagree with how their ideas are used. technical skills such as the ability to create a private view (accessible to a subgroup) and annotations can be helpful for temporarily storing copies of notes that are being considered, as well as draft ideas and notes before the final result is made public. thus, rise-above is a social practice that can exist only because the technology makes it possible, and it is a practice that needs to be developed. it is also worth considering whether knowledge forum provides the best medium for creating knowledge. at least one group had difficulties using it to reach a consensus about priorities and goal setting in phase , and talking face-to-face may have been more effective. while asynchronous writing can support reflective thought, reading and writing notes is time consuming and should only be used when it provides advantages over more social ways of interacting. some researchers and teachers have developed practices such as poster presentations, gallery walks, and whole-class talk, whereby students report and discuss the ideas, questions, and challenges they are considering within their groups (kolodner et al. ; zhang et al. ). according to kolodner and colleagues, such practices become routines and rituals within the community, and students come to see why they are necessary. zhang et al. ( ) found that students requested "kb talks" to discuss the database with each other. these practices provide opportunities for students to be aware of their progress, suggest ways of addressing problems, and identify learning needs not otherwise recognized. in their absence, work on knowledge forum is disconnected from the educational culture of the class and feels like a special project. however, research into the role of the social infrastructure that supports knowledge creation is still in an early phase (bielaczyc ; truong ; zhang et al. ). the evidence of meta-discourse in the groups was limited, partly due to the short duration of the project but also because it was an intervention. had we not intended to study their work, the students would have been completing individual inquiries. when knowledge creation pervades the general approach students take to their schoolwork, long-range effects may become more evident. for example, students may discuss how to improve on previous efforts or evaluate the evolution of ideas over a substantial period such as an entire school year. before this can happen, their inquiries need to be connected more deeply to the curriculum, and the use of technology woven into a set of coherent practices aimed at knowledge creation. the study provides a coding scheme for analyzing asynchronous discourse, extending earlier schemes that emphasized the socio-cognitive aspects of online discourse and drawing from previous work on rating scales on levels of questioning and explanations (chan ; hakkarainen et al. ) . the main codes can serve as a general framework for coding to facilitate comparisons across studies of computer-supported collaborative learning. however, if the subcodes are considered as indicators of the phenomena intended with the main codes, further research is needed to improve and expand the current set. for example, it would be useful to add further subcodes for questioning, agency, and meta-discourse to provide more balance among the main codes and improve the usability of the coding scheme for a wider range of research questions. the currently limited set of subcodes for some main codes reflects the overall limited evidence of the underlying phenomena (i.e., additional subcodes could have been induced from the data had the evidence of these main codes been stronger). while it is not my intention to fully map the codes onto the knowledge-creation principles, the coding scheme may provide a complementary framework useful for elaborating several principles. for example, information is intended to describe different levels of information processing, ranging from uncritical sharing to evaluation of a collection of sources in the context of the problems under investigation. if one correlates frequencies for this code with those relating to working with ideas, a fuller understanding of the principle of the constructive use of authoritative sources could be achieved. this paper has elaborated distinctions between three modes of online discourse-knowledge sharing, knowledge construction, and knowledge creation-which correspond to theories of transmission/naïve realism, cognitive psychology, and interactive learning using shared mediating objects. the framework was applied to a case study of four groups of students who used knowledge forum as part of an attempt to create knowledge about sars and avian flu. through the use of a new coding scheme, one group discourse was indentified as a threshold case of knowledge creation, one as knowledge sharing, and two as hybrids of all three modes. the study revealed the importance of the social interactions needed for a sense of community as one of the leading factors separating the group discourses. education and mind in the knowledge age the psychology of written composition knowing, learning and instruction: essays in honour of robert glaser surpassing ourselves: an inquiry into the nature and implications of expertise the handbook of education and human development: new models of learning, teaching and schooling learning to work creatively with knowledge designing social infrastructure: critical issues in creating learningenvironments with technology student approaches to learning and studying how people learn: brain, mind, experience and school design experiments: theoretical and methodological challenges for creating complex interventions in classroom settings situated cognition and the culture of learning peer collaboration and discourse patterns in processing incompatible information distributed cognitions: psychological and educational considerations design research: theoretical and methodological issues investigating patterns of interaction in networked learning and computer-supported collaborative learning: a role for social network analysis reconceptualizing change in the cognitive construction of knowledge addressing the challenges of inquiry-based learning through technology and curriculum design expansive learning at work: toward activity-theoretical reconceptualization against method: outline of an anarchistic theory of knowledge: humanities defending constructivismin science education making the invisible visible: a teaching/learning environment that builds on a new view of the physics learner interaction analysis of a global on-line debate and the development of a constructivist interaction analysis model for computer conferencing the m way to innovation: balancing people and profit effective discussion through a computer-mediated anchored forum emergence of progressive-inquiry culture in computer-supported collaborative learning a knowledge-practice perspective on technology-mediated learning epistemology of inquiry and computer-supported collaborative learning analyzing collaborative knowledge construction: multiple methods for integrated understanding problem-based learning: what and how do students learn? facilitating collaborative knowledge building scaffolding and achievement in problem-based and inquiry learning: a response to kirschner productive discussion in science: gender equity through electronic discourse a cognitive approach to the teaching of physics cognition in the wild cooperation and competition: theory and research enhancing sociability of computer-supported collaborative learning environments problem-based learning meets case-based reasoning in the middle-school science classroom: putting learning by design into practice learner articulation as interactional achievement: studying the conversation of gesture inquiry in projectbased science classrooms: initial attempts by middle school students learning-goals-driven design model: developing curriculum materials that align with national standards and incorporate project-based pedagogy the structure of scientific revolutions falsification and the methodology of scientific research programmes science in action: how to follow scientists and engineers through society situated learning: legitimate peripheral participation students assessing their own collaborative knowlegde building the five dysfunctions of a team wise design for knowledge integration towards knowledge building: from facts to explanations in primary students' computer mediated discourse a rating scheme for assessing the quality of computersupported collaboration processes understanding learning in a postmodern world: reconsidering the perry scheme of intellectual and ethical development participation in knowledge-building discourse: an analysis of online discussions in mainstream and honours social studies courses the knowledge creating company: how japanese companies create the dynamics of innovation learning how to learn models of innovative knowledge communities and three metaphors of learning seeing what we build together: distributed multimedia learning environments for transformative communities designing project-based science: connecting learners through guided inquiry marie curie, a life in science a force of nature: the frontier nature of ernest rutherford learning by collaborating: convergent conceptual change college physics teaching: from boundary work to border crossing and community building collective cognitive responsibility for the advancement of knowledge knowledge building environments: extending the limits of the possible in education and knowledge work knowledge building: theory, pedagogy, and technology effects of beliefs about the nature of knowledge on comprehension epistemology and the teaching of science. ottawa, canada: science council of canada on two metaphors for learning and the dangers of choosing one cooperative learning: theory, research and practice group cognition: computer support for building collaborative knowledge social constructivist perspectives on teaching and learning beyond threaded discussion: representational guidance in asynchronous collaborative learning environments exploring social practices that support knowledge building in a primary school student-directed assessment of knowledge building using electronic portfolios exploring collective aspects of knowledge building through assessment radical constructivism a way of knowing and learning promoting discourse about socioscientific issues through scaffolded inquiry equity issues in collaborative group assessment: group composition and performance communities of practice, meaning, and identity case study research: design and methods an evolutionary approach to harnessing complex systems thinking in the science and technology classroom socio-cognitive dynamics of knowledge building in the work of -and -year-olds designs for collective cogniitve responsibility in knowledge-building communities acknowledgments the classroom work of this study was completed while i was at simon fraser university; it was supported by a discovery parks grant from that university and the social sciences and humanities research council of canada. i thank the students and teacher for their work. preliminary findings from the summary note task were reported at the cscl conference held in taipei, taiwan. i thank cindy hmelo-silver, jianwei zhang, carol chan, and three anonymous reviewers for their comments on a draft of the paper.open access this article is distributed under the terms of the creative commons attribution noncommercial license which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. key: cord- -pby i wq authors: deng, yan; liu, wei; liu, kui; fang, yuan-yuan; shang, jin; zhou, ling; wang, ke; leng, fan; wei, shuang; chen, lei; liu, hui-guo title: clinical characteristics of fatal and recovered cases of coronavirus disease in wuhan, china: a retrospective study date: - - journal: chin med j (engl) doi: . /cm . sha: doc_id: cord_uid: pby i wq background: the novel coronavirus has caused the outbreak of the acute respiratory disease in wuhan, hubei province of china since december . this study was performed to analyze the clinical characteristics of patients who succumbed to and who recovered from novel coronavirus disease (covid- ). methods: clinical data were collected from two tertiary hospitals in wuhan. a retrospective investigation was conducted to analyze the clinical characteristics of fatal cases of covid- (death group) and we compare them with recovered patients (recovered group). continuous variables were analyzed using the mann-whitney u test. categorical variables were analyzed by χ( ) test or fisher exact test as appropriate. results: our study enrolled covid- patients who died during hospitalization and recovered patients. the median age of the death group was older than the recovered group ( [ , ] vs. [ , ] years, z = . , p < . ). more patients in the death group had underlying diseases ( . % vs. . %, χ( ) = . , p < . ). patients in the death group had a significantly longer time of illness onset to hospitalization ( . [ . , . ] vs. . [ . , . ] days, z = . , p = . ). on admission, the proportions of patients with symptoms of dyspnea ( . % vs. . %, χ( ) = . , p < . ) and expectoration ( . % vs. . %, χ( ) = . , p < . ) were significantly higher in the death group. the blood oxygen saturation was significantly lower in the death group ( [ , ]% vs. [ , ]%, z = . , p < . ). the white blood cell (wbc) in death group was significantly higher on admission ( . [ . , . ] vs. . [ . , . ] × ( )/l, z = . , p < . ). patients in the death group exhibited significantly lower lymphocyte count ( . [ . , . ] vs. . [ . , . ] × ( )/l, z = . , p < . ) and lymphocyte percentage ( . [ . , . ]% vs. . [ . , . ]%, z = . , p < . ) on admission, and the lymphocyte percentage continued to decrease during hospitalization ( . [ . , . ]% vs. . [ . , . ]%, z = . , p < . ). alanine transaminase ( . [ . , . ] vs. . [ . , . ] u/l, z = . , p = . ), aspartate transaminase ( . [ . , . ] vs. . [ . , . ] u/l, z = . , p < . ), and creatinine levels ( . [ . , . ] vs. . [ . , . ] μmol/l, z = . , p < . ) were significantly higher in the death group than those in the recovered group. c-reactive protein (crp) levels were also significantly higher in the death group on admission ( . [ . , . ] vs. . [ . , . ] mg/l, z = . , p < . ) and showed no significant improvement after treatment ( . [ . , . ] vs. . [ . , . ] mg/l, z = . , p = . ). the patients in the death group had more complications such as acute respiratory distress syndrome (ards) ( . % vs. . %, χ( ) = . , p < . ), acute cardiac injury ( . % vs. . %, χ( ) = . , p < . ), acute kidney injury ( . % vs. %, χ( ) = . , p < . ), shock ( . % vs. %, χ( ) = . , p < . ), and disseminated intravascular coagulation (dic) ( . % vs. %, χ( ) = . , p = . ). conclusions: compared to the recovered group, more patients in the death group exhibited characteristics of advanced age, pre-existing comorbidities, dyspnea, oxygen saturation decrease, increased wbc count, decreased lymphocytes, and elevated crp levels. more patients in the death group had complications such as ards, acute cardiac injury, acute kidney injury, shock, and dic. the novel coronavirus ( -ncov) is the pathogen responsible for the outbreak of the acute respiratory disease in wuhan, hubei province of china in december . [ ] although a high proportion of infected individuals only develop mild symptoms, some cases can progress to pneumonia, multi-organ failure or even death. in this study, we performed a retrospective research focusing on clinical characteristics, laboratory findings, and the treatment regimens of the fatal and recovered coronavirus disease cases with an aim to investigate the characteristics of dead patients and thereby provide some insights into the treatment of this disease. this study was conducted in accordance with the declaration of helsinki and was approved by the medical ethics committee of tongji hospital, tongji medical college, huazhong university of science and technology (no. tj-irb ). written informed consent was waived due to the rapid emergence of this infectious disease. a retrospective study focusing on patients who died due to confirmed covid- during hospitalization (death group) was conducted in two tertiary hospitals in wuhan (hankou and caidian branch of tongji hospital, tongji medical college, huazhong university of science & technology, and hankou branch of the central hospital of wuhan) from january , to february , . recovered patients who were discharged from the same inpatient ward during the same period were also enrolled. patients were diagnosed according to the diagnosis and treatment protocol for novel coronavirus pneumonia (trial version ), national health commission of the people's republic of china. [ ] the severe cases are defined as patients with one of the following symptoms: respiratory rate ≥ breaths/min, finger oxygen saturation % at rest, and arterial partial pressure of oxygen/fraction of inspired oxygen mmhg. [ ] the criteria for discharge are: ( ) throat swab specimens collected h apart were negative for tests of -ncov; ( ) body temperature was normal for three consecutive days; ( ) symptoms of covid- were resolved; ( ) the chest computed tomography manifestations of covid- significantly improved. [ ] laboratory confirmation throat swab specimens were tested by real-time reverse transcription polymerase chain reactions for laboratory confirmation of -ncov infection as recently reported. [ ] the following primers and probe were used. the forward primer was -tcagaatgccaatctccccaac- , and the reverse primer was -aaaggtccacccgata-cattga- , while the probe was cy -ctagttacac-tagccatccttactgc- bhq . the amplification conditions were °c for min and °c for min, followed by cycles of °c for s and °c for s. basic information such as age, gender, underlying diseases, clinical presentations, and complications was collected from clinical charts and nursing records of each patient. laboratory tests were conducted at admission and after treatment, including blood cell count, alanine transaminase (alt), aspartate transaminase (ast), creatinine, and creactive protein (crp). the treatment regimens including intravenous corticosteroids, intravenous gammaglobulin, anti-viral drugs, antibiotics, anti-fungal drugs, and respiratory supports were also collected from medical records. the spss statistics . software (spss inc., chicago, il, usa) was used to perform statistical analysis of the data. continuous variables were presented as median (interquartile range) (distribution of normality was checked by kolmogorov-smirnov test) and analyzed using the mann-whitney u test. categorical variables were presented as counts and percentages, and analyzed by x test or fisher exact test as appropriate. a value of p < . was considered to be statistically significant. one hundred and nine fatal and recovered cases out of covid- patients admitted to two tertiary hospitals in wuhan were enrolled in our study. the general information of the two groups was shown in the . %, x = . , p < . ), and heart disease ( . % vs. . %, x = . , p = . ) [ table ]. figure showed the distribution of hypertension, lung disease, diabetes, heart disease, and malignancy in the two groups of covid- patients [ figure ]. more patients in the death group had more than one comorbidity. the baseline signs and symptoms of covid- patients in the death group and the recovered group were shown in table . there was no significant difference in the proportion of patients with fever, myalgia or fatigue, headache, cough, hemoptysis, diarrhea, and heart palpitations at the time of admission between two groups (all p > . ). however, the proportions of patients with dyspnea ( . % vs. . %, x = . , p < . ) and expectoration ( . % vs. . %, x = . , p < . ) were significantly higher in the death group as compared with the recovered group. the blood oxygen saturation when the patients were admitted to the hospital was significantly lower in the death group as compared with the recovered group ( [ , ]% vs. [ , ]%, z = . , p < . ). at the time of admission, patients in the death group and nine patients in the recovered group were considered as severely ill patients. the proportion of severely ill patients was significantly higher in the death group than in the recovered group ( . % vs. . %, x = . , p < . ). the median time from illness onset to hospitalization was . ( . , . ) days in the death group as compared with . ( . , . ) days in the recovered group (z = . , p = . ) [ table ]. patients in the death group exhibited significantly higher white blood cell (wbc) count ( [ , ] vs. [ , ] days, z = . , p < . ) [ table ]. coronaviruses are enveloped rna viruses that could affect birds, humans, and other mammals, leading to respiratory, digestive, hepatic, and nervous system disorders. [ , ] among the six coronaviruses known to infect humans, two of them can cause ards, which are the severe acute respiratory syndrome coronavirus (sars-cov) that caused an outbreak in in china, and the middle east respiratory syndrome coronavirus (mers-cov) that caused an outbreak in the middle east in . [ ] -ncov is also a beta coronavirus that causes ards and can be transmitted between humans. [ ] similar to sars-cov, the -ncov is speculated to use the angiotensin-converting enzyme (ace) as a receptor for cell invasion. [ ] similar to the patients infected with sars-cov, some of the -ncov patients showed rapid progression of lung lesions, which might lead to death. in data were shown as median (q , q ). the pre-treatment parameters were tested on the day of admission, and the post-treatment parameters were tested within days before discharge or death. * p < . , compared with the recovered group before treatment. † p < . , compared with the death group before treatment. ‡ p < . , compared with the death group before treatment. chinese medical journal ; ( ) www.cmj.org this study, we analyzed the clinical characteristics of the fatal cases and recovered cases collected from two tertiary hospitals in wuhan while most patients were still hospitalized. therefore, it is possible that more patients in the death group and fewer patients in the recovered group were severely ill patients at admission. differences may exist in the initial conditions of the two groups in our study. a recent study showed that -ncov mainly infects middle-aged and elderly people. [ ] similar to that study, most of the patients in the current study were middle-aged and elderly people. the median age of the deceased patients was ( , ) years in our study. a previous study which enrolled patients reported the median age of sars non-survivors was ( , ) years and age (per -year increase) is a risk factor for death. [ ] another study showed that the median age of mers non-survivors was ( , ) years, older than the survivors [ ( , ) years]. [ ] one of the possible reasons for this phenomenon might be that the lung aging is associated with an inability of lung cells and multiple structural and functional changes in the respiratory tract, giving rise to decreased lung function, altered pulmonary remodeling, diminished regeneration, and enhanced susceptibility to pulmonary disease. [ ] it is also reported that the older patients have a higher risk of ards development. [ ] the comorbidities, particularly the cardiovascular diseases and chronic pulmonary diseases, were reported to be important to predict the in-hospital mortality in critically ill patients. [ ] in our study, more patients in the death group had underlying diseases, especially hypertension, lung disease, and heart disease. besides, more patients in the death group had more than one comorbidity. it is thought that diabetes may increase the risk of infection and can delay the recovery of the infectious illnesses. in our study, we found no significant difference between the death and recovered group in the percentage of patients complicated with diabetes. recent studies also showed that diabetes has no significant correlation with the initiation, progression, and prognosis of ards. [ , ] a hypothesis is that there are more hypertensive patients who developed the -ncov infection, which is related to the ace inhibitors used in these patients. ace inhibitors could indirectly increase the cellular ace receptors, which may be the receptors for -ncov. we found more patients in the death group had hypertension. however, the exact roles that age and underlying diseases played in the development and progression of novel coronavirus pneumonia require further investigation. furthermore, time from illness onset to hospitalization was longer in the death group. the patients in the death group tended to have a delayed medical care compared with the recovered group. our study found that the proportion of patients with dyspnea was significantly higher in the death group compared to the recovered group, and initial blood oxygen saturation was lower in the death group compared to the recovered group. it is easy to understand that the progressive hypoxemia often suggests poor prognosis in pulmonary diseases and the indicators for hypoxemia are already used to evaluate the severity of the covid- . [ ] our study found that the wbc count increased in the death group during hospitalization, suggesting that comorbid bacterial or fungal infection might have occurred in these deceased patients. however, most of the patients in this study received broad-spectrum antimicrobial drug treatment, and no etiological evidence of infection was obtained from them. previous studies found chinese medical journal ; ( ) www.cmj.org that during the acute phase of sars-cov infection in humans, the blood lymphocyte counts, particularly cd + and cd + t cell counts, were decreased. [ ] [ ] [ ] another study suggested that lymphocyte cells, especially cd + and cd + t cells may play protective roles in coronavirus infection. [ ] similar to previous studies, our study found that patients in the death group had lower lymphocyte count and lymphocyte percentage. during hospitalization, the lymphocyte count and lymphocyte percentage decreased in the deceased patients. this may be because the viral infection causes persistent consumption and/or insufficient regeneration of lymphocytes. alt, ast, and creatinine levels were higher in the death group as compared to the recovered group. previous studies also showed that the transaminases were elevated in the mers and sars patients. [ ] [ ] [ ] [ ] a recent study showed that elderly patients infected with -ncov have higher crp levels. [ ] moreover, crp was considered to be a significant predictor for disease severity in sars. [ , ] similar to previous studies, our study found that the crp levels were higher in the death group compared to the recovered group at the time of admission, and the crp levels remained high during the progression of the disease. patients in the death group had more complications such as ards, acute cardiac injury, acute kidney injury, shock, and dic, which was consistent with the previous study of covid- . [ ] it is noteworthy that patients in the death group had a shorter length of hospital stay compared with the recovered group. this difference probably caused by the rapid progression of covid- in the death group. the patients in the death group were empirically given more corticosteroids, more anti-fungal drugs, and better antibiotics without solid evidence. a limitation of our study is that the initial conditions of the two groups differed. therefore, these results do not provide conclusive data on the effects of different treatments. more researches are required on the necessity of prophylactically using antibiotics and the time to use them in viral pneumonia patients. previous studies in corticosteroid therapy suggest that high doses of corticosteroids do not diminish the mortality rate for sars but tend to result in severe adverse reactions. [ , ] further research is required to investigate the necessity, dose, and timing of corticosteroid therapy in -ncov infection. furthermore, it is found that % of patients showed signs of pulmonary fibrosis within one month after being infected with sars-cov. [ ] another study found lung fibrosis in % of patients who have recovered from mers-cov. [ ] it is possible that pulmonary fibrosis will become one of the serious complications in patients with -ncov infection. [ ] drugs for the treatment of idiopathic pulmonary fibrosis such as pirfenidone and nintedanib might be useful in preventing and treating pulmonary fibrosis in patients with -ncov infection. in summary, we studied the clinical data of patients who died from -ncov infection and patients who recovered. patients in the death group exhibited characteristics of advanced age, more pre-existing comorbidities, dyspnea, oxygen saturation decrease, increased wbc count, decreased lymphocytes, and elevated crp levels. we hope our study could offer some suggestions to the understanding of this disease. national health commission of the people's republic of china. diagnosis and treatment protocol for novel coronavirus pneumonia (trial version ) clinical features of patients infected with novel coronavirus in wuhan, china coronavirus pathogenesis fatal swine acute diarrhoea syndrome caused by an hku -related coronavirus of bat origin a novel coronavirus from patients with pneumonia in china a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster receptor recognition by novel coronavirus from wuhan: an analysis based on decade-long structural studies of sars acute respiratory distress syndrome in critically ill patients with severe acute respiratory syndrome critically ill patients with the middle east respiratory syndrome: a multicenter retrospective cohort study aging and lung disease recovery rate and prognosis in older persons who develop acute lung injury and the acute respiratory distress syndrome the deyo-charlson and elixhauser-van walraven comorbidity indices as predictors of mortality in critically ill patients identifying associations between diabetes and acute respiratory distress syndrome in patients with acute hypoxemic respiratory failure: an analysis of the lung safe database the effect of diabetes on the risk and mortality of acute lung injury/acute respiratory distress syndrome: a meta-analysis haematological manifestations in patients with severe acute respiratory syndrome: retrospective analysis expression of lymphocytes and lymphocyte subsets in patients with severe acute respiratory syndrome significant changes of peripheral t lymphocyte subsets in patients with severe acute respiratory syndrome t cell-mediated immune response to respiratory coronaviruses epidemiological, demographic, and clinical characteristics of cases of middle east respiratory syndrome coronavirus disease from saudi arabia: a descriptive study serum hepatic enzyme manifestations in patients with severe acute respiratory syndrome: retrospective analysis severe acute respiratory syndrome in taiwan: analysis of epidemiological characteristics in cases sequential changes of serum aminotransferase levels in patients with severe acute respiratory syndrome sars in singapore-predictors of disease severity clinical course and outcomes of critically ill patients with sars-cov- pneumonia in china: a single-centered, retrospective, observational study clinical issues and research in respiratory failure from severe acute respiratory syndrome osteonecrosis of hip and knee in patients with severe acute respiratory syndrome treated with steroids follow-up study on pulmonary function and lung radiographic changes in rehabilitating severe acute respiratory syndrome patients after discharge follow-up chest radiographic findings in patients with mers-cov after recovery clinical characteristics of hospitalized patients with sars-cov- infection: a single arm meta-analysis clinical characteristics of fatal and recovered cases of coronavirus disease in wuhan, china: a retrospective study none. key: cord- -vyo w a authors: albertini, laetitia; soletchnik, mickael; razurel, anais; cohen, johana; bidegain, frédéric; fauvelle, francis; safrano, geoffroy; piquet, jacques; maurer, cyril; goldgran-toledano, dany title: observational study on off-label use of tocilizumab in patients with severe covid- date: - - journal: eur j hosp pharm doi: . /ejhpharm- - sha: doc_id: cord_uid: vyo w a background: in december a novel coronavirus designated sars-cov- was identified, and the disease covid- has caused many deaths. sars-cov- infection has been associated with the development of cytokine storm (including interleukin (il- )), which can cause lung damage and lack of oxygen. tocilizumab (tcz) inhibits ligand binding to the il- receptor and may be a potential treatment for the hyperinflammation symptoms of covid- . however, data regarding the efficacy of tcz in covid- are lacking. the rapid spread of the pandemic in france, especially in the paris region, constrained us to the off-label use of tcz in patients with severe clinical conditions. methods: a single-centre observational cohort study of patients infected with covid- was carried out between april and april in groupe hospitalier intercommunal le raincy-montfermeil (ghilrm). twenty-two patients diagnosed with covid- were treated with tcz and were compared with patients not treated with tcz matched for age, gender and length of hospital stay for covid- . respiratory rate and oxygen supplementation as well as laboratory parameters (such as c-reactive protein (crp), aspartate aminotransferase and alanine aminotransferase) were collected at baseline and during days of follow-up. our primary objective was to assess the efficacy of tcz on respiratory clinical conditions. findings: the average respiratory rate was lower in the tcz group than in the control group ( . vs . breaths/min at day , % ci − . to − . ; p= . ). treated patients tended to be intubated less during the course of the disease ( / vs / , % ci − . to . ; p= . ). in each group, patients no longer required oxygen therapy. we found a significant decrease in crp in treated patients on day (p= . ). tcz caused cytolysis in more than half ( / ) of the patients but without clinical impact. interpretation: there was a significant difference in the respiratory rate on day of follow-up, with a greater decrease observed in the treated group. fewer patients required mechanical ventilation in the tcz group, especially among patients with more extensive ct lung damage, than in the control group. the same number of patients were weaned off oxygen on day in the two groups, while the patients in the tcz group had more severe impairment at inclusion. we consider that tcz showed significant control of the biological inflammatory syndrome, suggesting that it may limit the effect of the cytokine storm. our study seems to indicate the efficacy of tcz, particularly in patients with severe initial pulmonary impairment. selecting the best candidates and the best timing for tcz therapy needs to be determined in randomised clinical trials. in december the wuhan municipal health committee identified an outbreak of viral pneumonia cases of unknown cause. a novel coronavirus has been designated sars-cov- , and the disease caused by this virus has been designated covid- . this novel coronavirus spread in months to all continents. the infection was declared a pandemic by the world health organization on march . in mild cases the infection causes fever, dry cough and asthenia. ageusia and anosmia also appear to be frequent clinical features in patients with covid- . however, some patients ( %) suddenly deteriorate - days after the appearance of the symptoms and develop severe pneumonia and acute respiratory distress syndrome (ards). there is growing evidence that virally-induced pro-inflammatory cytokines lead to hyperinflammation. an acute severe systemic inflammatory response known as cytokine storm leads to severe and critical disease. one of the cytokines involved is interleukin (il- ), which is considered to be a key mediator of the cytokine storm causing the deterioration. raised il- levels have been reported in patients with covid- and are sometimes associated with disease severity. currently, there is no proven treatment for patients with this novel infection. in the context of the covid- pandemic and growing tensions worldwide regarding healthcare facilities, there is an urgent need for effective treatments. many different molecules are being considered as possible treatments for covid- , but none have so far been found to be really effective. tocilizumab (tcz) is a humanised anti-human il- receptor monoclonal antibody, which may be a possible strategy for patients with cytokine storm. data on this off-label use of tcz in the treatment of covid- are still preliminary. it is currently unclear which patients may benefit from tcz. preliminary results from clinical trials are expected to be available soon. in march and april we used tcz off-label in patients with severe covid- based on its hypothetical benefit, and report on the experience of our general hospital. this is a single-centre observational cohort study of patients infected with covid- and treated with tcz between april and april at our general hospital. we recorded several data original research every day from admission to days after injection of tcz. clinical parameters such as respiratory rate and oxygen supplementation were measured daily. laboratory parameters (c-reactive protein (crp), lymphocytes, aspartate aminotransferase (ast) and alanine aminotransferase (alt)) were measured at the clinician's discretion and collected from baseline to day . due to high costs, lack of knowledge and safety risks, a multidisciplinary ethics committee validated the use of tcz for each patient . patient consent was requested and marked in the patients' records. patients received tcz after agreement by the multidisciplinary ethics committee. the criteria for receiving tcz were: ► hospitalised patients with a positive diagnosis of covid- (by real-time pcr on nasopharyngeal swabs) ► extensive bilateral lesions in the lungs ► severe respiratory insufficiency needing oxygen supplementation (≥ l) ► clinical aggravation ► increased crp level ► no major contraindications to the drug. research of infections including tuberculosis was performed before tcz use by a test to detect the production of gamma interferon (interferon-γ release assays; quantiferon). we compared the parameters of hospitalised patients with a positive diagnosis of covid- with a group of patients withf the same sex ratio, comparable age and with relatively similar impairment who had not been treated with tcz. patients were compared at similar times of disease progression compared with onset of symptoms. however, as our study was an observational study and not a clinical trial, all patients with severe disease and without contraindications were treated. patients in the control group therefore necessarily had more moderate impairment than the group of treated patients, although their profile was similar. this allowed us to compare the effect of tcz versus control. the comparison with untreated patients also makes it possible to assess the events linked to the sars-cov infection itself. tcz was prescribed at a fixed dose of mg for patients < kg and mg for those > kg. these fixed doses were determined on the basis of mg/kg but with a rounding which allowed the use of whole vials (roactemra mg and mg). given the high cost and the quota of this drug, this enabled us not to waste the product (opened vials are not sufficiently stable and patients are not always treated on the same day). there was no need to adjust the dose in patients with renal insufficiency. the dose was diluted to ml with . % sodium chloride and the intravenous infusion time was more than hour. a second dose (same dose as the first injection) was given after hours in cases with insufficient response to the treatment. descriptive statistics were used for demographic, laboratory and clinical data. continuous variables were expressed as mean (sd) and compared using the anova test. categorical variables were expressed as number and compared between the two groups by the student t-test. a p value of < • was considered significant. the online test biostatgv (inserm) was used. statistical analysis was also performed using microsoft excel and rstudio team (integrated development for r, rstudio, boston, massachusetts, usa). data were collected from patients, receiving tcz and not receiving tcz. the characteristics of the patients are shown in table . the study population consisted of men and women with a median age of years (range - ). the mean body mass index (bmi) was kg/m (range - ). in the tcz group the mean age was years (range - ), with a male/ female ratio of / and a mean bmi of kg/m (range - ). in the control group the mean age was years (range - ), with a male/female ratio of / and a mean bmi of kg/m (range - ). the groups were comparable with regard to age ( % ci − . to . ) (p= . ) and bmi ( % ci − . to . ) (p= . ). the most commonly reported symptoms were fever ( / patients, %), dyspnoea ( / , %), asthenia ( / , %) and cough ( / , %). some patients had diarrhoea ( / , %), body aches ( / ), anosmia ( / ), ageusia ( / ) and rhinitis ( / ). the mean duration between the onset of the first symptoms and hospitalisation in the tcz and control groups was days and . days, respectively. twenty patients had hypertension. some of the patients were overweight ( / ) or obese ( / ). ten patients had cardiovascular comorbidities (heart failure or atrial fibrillation) and seven patients had diabetes mellitus. in the tcz group, hypertension ( / ) and obesity ( / ) were the most common comorbid conditions. other cardiovascular disease (heart failure or atrial fibrillation) occurred in seven patients. three patients had diabetes mellitus and two had no known comorbidities. in the control group, hypertension was the principal comorbidity ( / ). the patients in this group had slightly lower bmi (three obese (bmi > )). four patients had other cardiovascular diseases, three patients had diabetes mellitus and three had no known comorbidities. in the tcz group the severity of lung damage on ct scanning was worse than in the control group, varying from < % ( / ) to > % ( / ) and > % ( / ). four patients had less than % of lung damage on the first ct scan and one patient did not have a ct scan. in the control group most patients had less lung damage. six patients had - % lung damage on the first ct scan, four had more limited involvement (< %), two had < % lung damage and three were not evaluated by ct. the lung damage was more severe in seven patients (six had - % and one had > %). the average length of stay for treated and untreated patients with covid- was and days, respectively. in the tcz group, two patients had received hydroxychloroquine and azithromycin prior to treatment with tcz and four patients had received azithromycin monotherapy. in the control group, three patients had received hydroxychloroquine and azithromycin. the majority of patients therefore did not receive any other treatment. no difference was noticed between the groups. twenty patients received two tcz administrations and two patients received one (one patient died and the other patient could not receive the second injection because of several complications which contraindicated a further injection (myocardial infarction)). on average, patients received the first injection of tcz days after the onset of symptoms (range - days). we did not notice any difference in response according to the time of injection. on admission to hospital all the patients in the tcz group had tachypnoea and the average respiratory rate was . breaths/ min. in the control group patients had tachypnoea when they arrived at hospital with an average respiratory rate of . breaths/min ( % ci − . to . ) (p= . ). we calculated the average respiratory rate in the two groups in patients on spontaneous ventilation (excluding intubated patients) on days and of follow-up to analyse the variation in respiratory rate in the two groups. in the tcz group the average respiratory rate on day was . breaths/min compared with . breaths/min in the control group ( % ci − . to . ) (p= • ) and on day the average respiratory rate was . breaths/min in the tcz group and . breaths/ min in the control group ( % ci − . to − . ) (p= . ). we compared the two groups according to the ventilatory parameters on days and of follow-up. on day , four patients in the tcz group and five patients in the control group required mechanical ventilation. one patient in each group was on high flow nasal oxygen therapy (optiflow). thirteen patients in the tcz group required oxygen therapy compared with nine in the control group. on day , fewer patients required oxygen in the control group (two patients in the tcz group were oxygen-free compared with seven patients in the control group). the average oxygen flow rate was calculated from the flow rates required for each patient; the average oxygen flow rate of the tcz group on day was . l/min compared with . l/min in the control group. at day , in the tcz group three patients required mechanical ventilation and six in the control group. one patient in the control group was on high flow nasal oxygen therapy but none in the treated group. six patients in the tcz group required oxygen therapy compared with three in the control group. in each group, patients no longer required oxygen therapy. however, there was a difference in the average oxygen flow between the two groups at this stage; the average oxygen flow rate was . l/min in the tcz group and . l/min in the control group ( % ci − . to . ) (p= . ). the average duration for oxygen withdrawal was . days for the tcz group and . days for the control group ( % ci − . to − . ) (p= • ). half of the patients in the tcz group (n= ) were weaned off oxygen in days (or less) and in the control group patients needed no oxygen after days (or less). four patients were receiving invasive mechanical ventilation in the treated group versus six in the control group. we analysed the patients according to their degree of involvement on the chest ct scan performed at the start of each patient's hospitalisation. we were interested in patients with > % ct damage according to the recommendations of the european radiology society. on admission, patients in the tcz group had > % involvement compared with seven in the control group ( % ci − . to . ) (p= . ). on day , in the tcz group two patients required invasive ventilation compared with six in the control group ( % ci − . to . ) (p= . ) (figure ). one death occurred in the treated group and none in the control group. three patients in the tcz group were still requiring oxygen with an average flow of l/min versus one patient in the control group with a flow of l/min ( % ci − . to . ) (p= . ). five patients in the tcz group were no longer oxygen-dependent compared with none in the control group (figure ). in the tcz group patients were found to be lymphopenic on arrival with an average lymphocyte count of . g/l (range . - . ) compared with seven patients in the control group with an average count of . g/l (range . - . ) ( % ci − . to . ) (p= . ). all patients had hyperinflammation with raised crp levels when they were admitted to hospital (median value of mg/l in the control group and . mg/l in the tcz group). the crp levels decreased significantly in patients treated with tcz from mg/l (median) to mg/l in days. in the days following the injection of tcz we noted that the treated patients had lower crp values than the untreated patients (median mg/l in the tcz group vs mg/l in the control group at day ) ( % ci − . to . ) (p= . ). at day the difference was significant with a median of . mg/l in the tcz group and . mg/l in the control group ( % ci − . to − . ) (p= . ), and this was even more marked in the following days. the crp value in the treated patients returned to the normal or near normal range within days but, in the control patients, the crp was not negative within days (figure ). fourteen of the patients ( %) in the tcz group developed cytolysis on days or . the median ast level rose from iu/l to iu/l in days in the tcz group while, in the control group, the median level was iu/l at admission and iu/l at day (p< • ). the values returned to normal in the tcz group at day . given the chronology of occurrence and the difference between the two groups, this hepatic toxicity is attributed to tcz and not to sars-cov- (figure ). no infusion reactions were observed. an increased risk for infection due to tcz is an expected adverse effect, but no nosocomial infection was reported. the occurrence of secondary infection does not seem to be frequent with short-term treatment. twenty patients returned home, from each group. five patients died, three in the treated group and two in the control group. two patients were transferred to another hospital to have extracorporeal membrane oxygenation (ecmo), one from each group. five patients in the control group were transferred for continuation of medical care in another establishment. the remaining patients are still hospitalised at the time of writing this article. in this study we examined the effect of tcz treatment of patients with covid- in real life in our general hospital. the chinese health commission included tcz in its seventh edition of covid- therapy national guidelines. in italy, in case of rapid worsening, the national guidelines of the italian medicines agency (aifa) also support the use of tcz. in most uses of tcz in covid- the dose is that approved to manage cytokine release syndrome (crs) in car t-cell recipients-that is, mg/kg up to a maximum dose of mg. some give a smaller fixed dose of mg. however, reid et al in illinois proposed that potentially lower doses may be sufficient. to evaluate this hypothesis they performed a -person trial in april named covidose, which involves patients hospitalised with covid- but not yet in need of mechanical ventilation. the patients received mg or mg of tcz, depending on their risk of complications. this lower-dose strategy, if proven effective, could help address any shortages of tcz that arise as the covid- pandemic continues and could minimise the cost of the treatment. luo et al reported that repeated doses of tcz might improve the condition of critically ill patients. they also conclude the possible effectiveness of a small dose. in another study, sciascia et al used intravenous tcz ( mg/kg) or subcutaneous tcz ( mg). this is the only study to report the subcutaneous route. no differences were observed between the route of administration in terms of mortality. the use of subcutaneous tcz could therefore be considered. we chose to use a fixed dose of mg for patients under kg and mg for patients over kg. dose-banding studies have shown that the administration of a fixed dose for antibodies does not increase the interindividual variability of the response compared with a dose calculated according to a morphological parameter. the aim of dose-banding is to provide a single dose per weight interval. this helps limit costs and optimise the use of the number of vials, which is particularly important since tcz is expensive and the quantities available are limited. our study shows that a smaller proportion of patients required the use of mechanical ventilation in the tcz group, especially in patients with more extensive ct damage. indeed, on day of follow-up, two patients in the tcz group required invasive ventilation compared with six in the control group. yuan et al showed that the severity of the ct scan was a predictor of mortality from covid- infection. by comparing patients according to their degree of severity on the ct scan, we can objectify a clear improvement in the group who have received tcz compared with the control group concerning the evolution of the ventilatory parameters. it may therefore be reasonable to think that the administration of tcz in patients with severe disease (ie, with ct lesions > %) would allow clinical improvement to be faster and more effective. roumier et al reported their experience with tcz in selected patients ( % in icu). they also observed that tcz significantly reduced the requirement for mechanical ventilation and the risk of subsequent icu admission. this results in a shorter hospital stay and therefore a lower risk of a nosocomial event and a lower cost for society. in the same way, a french retrospective study collected data from patients with severe covid- compared with control patients. they showed a significant difference in mortality and hospitalisation in icu between the two groups, with % mortality or admission to resuscitation in the control group compared with % in the group treated with tcz. in the same way, in each group in our study patients no longer required oxygen therapy. however, there was a difference in the average oxygen flow between the two groups with an average oxygen flow rate of . l/min in the tcz group and . l/min in the control group ( % ci − . to . ) on day (p= . ). the need for oxygen was reduced in the tcz group despite the fact that this group had more severe clinical and radiological impairment of covid- at the beginning of the study. in italy, toniati et al concluded that the response to tcz in patients with covid- pneumonia and ards was rapid and associated with significant clinical improvement. in their study, overall at days they reported improvement or stabilisation in % of patients, of whom were discharged from hospital. the respiratory condition worsened in % of patients, % of whom died. in our study we found a significant difference in the respiratory rate on day of follow-up, with a greater decrease in the treated group. this coincides with the first report from china of severe or critical patients treated with tcz. the results showed that patients had lowered their oxygen intake within days after treatment with tcz without control. in another study in doha, alattar et al original research who were on invasive ventilation decreased from % at the time of initiation of tcz therapy to % at day and % at day . we observed that the crp levels were far above the normal range in all patients before the start of tcz therapy. during the study a significant difference was seen in the crp level. patients in the tcz group had lower crp levels than those in the control group from day after the injection ( . mg/l in the tcz group vs . mg/l in the control group). our results are in agreement with the study led by xu et al, which reported that crp decreased significantly and returned to normal in . % of patients after treatment on the fifth day. cytokine levels would be interesting biomarkers. however, we did not have the possibility of dosing il- at the beginning of the study. il- measurement may be a biomarker for risk stratification and for effectiveness of tcz. our findings seem to support the effectiveness of tcz in the control of cytokine storms induced by covid- in patients with > % ct lung damage. these results are in agreement with those of xu et al. they report reduced lung complications, reduction of oxygen requirement, reduction of crp levels and average hospitalisation length of stay of . days. our results are also in accordance with the preliminary data of fu et al collected from patients who received one or two doses ( mg/dose) of tcz for ards induced by sars-cov . fifteen patients experienced clinical improvement requiring less oxygen. they also observed a decrease in crp levels. increased transaminase levels with tcz are frequent, but rates of severe hepatic adverse events are low. initiating tcz treatment is associated with early increases in serum liver enzyme levels, which often rose to - times the upper limit of normal weeks after each infusion, but decreased towards baseline by the time of the next -weekly administration. clinical consequences have not been evident in clinical practice to date (according to drug labelling). in our study we observed an increase in cytolysis in the treated patients. the median ast rose from iu/l to iu/l in days in the tcz group and from iu/l to iu/l in the control group (p< . ). this difference, as well as the kinetics of appearance, allows us to attribute this side effect to tcz and not to the virus itself. however, no clinical consequences were observed and this effect was reversible within days of the injection. we did not observe any nosocomial infections, which could be explained by the short and non-chronic use of tcz. in the beginning of this unique pandemic situation, global recommendations for covid- were being made based on unpowered studies, and because of the chaotic urgency of the situation, drugs were prescribed off-label given the severity of the disease and the risk-benefit balance. our study is observational and not a clinical trial. hyperinflammation in covid- looks like crs, which suggests that therapies targeting il- like tcz commonly used to treat crs can be used in the severe and inflammatory forms of covid- . this study presents the first conclusions regarding the use of tcz in covid- . it appears to be effective in decreasing oxygen withdrawal time, respiratory failure symptoms, avoiding mechanical ventilation and stopping the biological inflammatory process of covid- pneumonia in hospitalised patients, especially in those with > % of initial lung lesions on ct scan. randomised controlled clinical trials are needed to confirm the efficacy of tcz in covid- . contributors la and ms had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. jc, fb, gs, jp, dg-t, cm and ms carried out the medical care of the patients. la and ms realized the data collection and performed data analysis. la, ms and ar drafted and revised the paper. dg-t, cm and ff revised the paper. all authors approved the final draft of the manuscript for publication. the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. ► fifteen percent of covid- patients who suddenly deteriorate or days after the appearance of the symptoms develop acute respiratory distress syndrome. ► an acute severe systemic inflammatory response known as cytokine storm leads to critical disease. ► tcz is an il- receptor monoclonal antibody which seems to be a possible strategy for patients with cytokine storm. ► in the context of the covid- pandemic, there was an urgent need for effective treatments. ► we used tcz off-label in patients with severe covid- in march and april based on its hypothetical benefit and report the experience of our general hospital. effective treatment of severe covid- patients with tocilizumab anosmia and ageusia: common findings in covid- patients clinical presentation and initial management critically ill patients with severe acute respiratory syndrome coronavirus (sars-cov- ) infection in brescia, italy clinical features of patients infected with novel coronavirus in wuhan, china rational use of tocilizumab in the treatment of novel coronavirus pneumonia off-label use of tocilizumab in patients with sars-cov- infection clinical features of patients infected with novel coronavirus in wuhan, china use of tocilizumab for covid- -induced cytokine release syndrome: a cautionary case report tocilizumab to prevent clinical decompensation in hospitalized, non-critically ill patients with covid- pneumonitis (covidose) clinical trial tocilizumab treatment in covid- : a single center experience pilot prospective open, single-arm multicentre study on off-label use of tocilizumab in patients with severe covid- association of radiologic findings with mortality of patients infected with novel coronavirus in wuhan, china interleukin- blockade for severe covid- tocilizumab therapy reduced intensive care unit admissions and/or mortality in covid- patients tocilizumab for the treatment of severe covid- pneumonia with hyperinflammatory syndrome and acute respiratory failure: a single center study of patients in tocilizumab for the treatment of severe covid why tocilizumab could be an effective treatment for severe covid- ? transaminase levels and hepatic events during tocilizumab treatment: pooled analysis of long-term clinical trial safety data in rheumatoid arthritis provenance and peer review not commissioned; internally peer reviewed. all data relevant to the study are included in the article or uploaded as supplementary information. the data are available on request to the authors: albertini. laetitia@ gmail. com; mickael. soletchnik@ gmail. com.this article is made freely available for use in accordance with bmj's website terms and conditions for the duration of the covid- pandemic or until otherwise determined by bmj. you may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained. laetitia albertini http:// orcid. org/ - - - key: cord- - j jkfn authors: zhu, h.; qu, g.; yu, h.; huang, g.; chen, l.; zhang, m.; wan, s.; pei, b. title: features of alpha-hbdh in covid- patients with different ages,outcomes and clinical types: a cohort study date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: j jkfn background: coronavirus disease- (covid- ) has spread all over the world and brought extremely huge losses. at present, there is no study to systematically analyse the features of hydroxybutyrate dehydrogenase (alpha-hbdh) in covid- patients with different ages, clinical types and outcomes. methods: electronic medical records including demographics, clinical manifestation, alpha-hbdh test results and outcomes of hospitalized covid- patients, with confirmed result of severe acute respiratory syndrome coronavirus (sars-cov- ) viral infection, were extracted and analyzed. results: the alpha-hbdh value in greater than or equal to years old group, severe group and critical group, death group all increased at first and then decreased, while no obvious changes were observed in other groups. and there were significant differences of the alpha-hbdh value among different age groups, clinical type groups and outcome groups. the optimal scale regression model showed that alpha-hbdh value and age were related to clinical type. conclusions: alpha-hbdh value increases in some covid- patients, obviously in greater than or equal to years old, death and critical group, indicating that patients in these three groups suffer from more serious tissues and organs damage, higher alpha-hbdh value and risk of death. the obvious difference between death and survival group in early stage may provide a approach to judge the prognosis. the accuracy of the model to distinguish severe/critical type and other types is . %, suggesting that alpha-hbdh could judge the clinical type of covid- patients accurately. in brief, alpha-hbdh is an important indicator to judge the severity and prognosis of covid- . since the outbreak of covid- in december , caused by severe acute respiratory syndrome coronavirus (sars-cov- ), it has spread rapidly around the world. sars-cov- has attracted the attention of the global because of its high transmission ability, morbidity and mortality [ ] [ ] [ ] [ ] . on january , the world health organization (who) identified covid- as a public health emergency of international concern [ ] . as of july , , the number of confirmed cases of covid- worldwide has reached , and the number of deaths has reached [ ] . lactate dehydrogenase (ldh) is one of the important enzymes in glycolysis and gluconeogenesis. it mainly catalyzes the transformation between lactic acid and pyruvate. its enzymatic reaction is: pyruvate + nadh+h + ⇌ lactic acid + nad + . ldh consists of five isozymes composed of different combinations of h and m subunits: ldh (h ), ldh (h m), ldh (h m ), ldh (hm ) and ldh (m ). α-hbdh is tested by the α-ketoacid, a substrate, to determine the ldh activity. additionally, the activity of ldh and ldh with more h subunits is described by α-hbdh activity because of the high affinity for this substrate to the h subunit in ldh. α-hbdh mainly distributed in the heart, brain, kidney and red blood cells, and the activity of the enzyme in the heart is more than half of the total enzyme activity. α-hbdh level increased in the progression of cor pulmonale, leukemia and tumor. moreover, the extents of the increase and the tissue and organ injury were closely related, which can be used as an auxiliary diagnostic index [ ] [ ] [ ] [ ] [ ] . compared with other pneumonia types, the α-hbdh level in covid- patients was significantly higher, and the α-hbdh value of severe group was higher than that of non-severe group [ , ] . when complicated with cardiovascular disease or gastrointestinal symptoms, the increase of α-hbdh in covid- patients was much more significant as well [ , ] . cen y et al. observed mild and moderate . cc-by-nc-nd . international license it is made available under a who has granted medrxiv a license to display the preprint in perpetuity. is the author/funder, (which was not certified by peer review) the copyright holder for this preprint this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint covid- patients for days. it was found that the higher the α-hbdh value, the greater the risk of progression to severe or critical type [ ] . zhang gemin et al. divided covid- patients into four groups according to their α-hbdh level on admission. they found that the higher the α-hbdh value, the greater the proportion of severe cases, and the higher the risk of death or need for mechanical ventilation for patients, showing that the high α-hbdh level indicates an increased risk of further aggravation of the disease [ ] . in this study, we analyzed the changes of α-hbdh values of covid- patients with different ages, clinical types and outcomes. the effects of α-hbdh, age and gender on the clinical type of covid- patients were quantified by the optimal scale regression model, so as to achieve the purpose of early judging the severity of the disease. our study included individuals with complete examination data, years old or above, who were hospitalized in xiangyang no. people's hospital with a diagnosis of covid- . in the end, we included a total of patients. this research project was a bidirectional observational cohort study. according to the diagnosis and treatment guidelines [ ] , the patients were divided into mild group, moderate group, severe group and critical group. according to their age, the patients were divided into ≤ years old group, - years old group and ≥ years old group. according to the outcome, the patients were divided into death group and survival group. the distributions of α-hbdh median value were plotted with an -days interval (t , t , t …tn represented the time unit successively). the symptom onset data was designed as the first day of disease, the abnormal percentage, median and quartile interval of α-hbdh in different ages, outcomes and clinical types were calculated. . cc-by-nc-nd . international license it is made available under a who has granted medrxiv a license to display the preprint in perpetuity. is the author/funder, (which was not certified by peer review) the copyright holder for this preprint this version posted november , . two groups (two researchers per group) extracted the data from hospital information system through a consistent data collection protocol and cross-checked. gender, age, all α-hbdh test results, disease onset date, outcome, death date, etc. were collected. two respiratory physicians classified the clinical types and then cross-checked the results. a third expert was involved when there was disagreement. the data were traced back to january and followed up to march, . all statistical analyses were performed by spss . . continuous data in accordance with normality were represented by means and standard deviations, otherwise median (interquartile, iqr) was applied. categorical data were described as frequency (%). the chi-square test was conducted to assess significance between groups. t-test was used to compare the quantitative data of normal distribution between the two groups, and the comparison of the quantitative data of non-normal distribution between the two groups was analyzed using mann-whitney u test. the correlation between two variables was tested by spearman correlation test. the maximum α-hbdh value in the first days, age and gender were regarded as independent variables and clinical types were regarded as dependent variables to build the optimal scale regression model. . cc-by-nc-nd . international license it is made available under a who has granted medrxiv a license to display the preprint in perpetuity. is the author/funder, (which was not certified by peer review) the copyright holder for this preprint this version posted november , . ; https://doi.org/ . / . in ≤ years old group, - years old group and ≥ years old group, the α-hbdh median value was . and . %, respectively. the changes indicated that the α-hbdh median value in ≤ years old group increased during t -t and decreased after t , and the normal range was t to t ; in - years old group, the α-hbdh median value decreased during t -t , and was in the normal range from t to t ; in ≥ years old group, the α-hbdh median value increased during t -t and decreased after t , and the abnormal time interval was t -t (figure , table ). there were significant differences of the α-hbdh value in the first days among the three age groups. significant differences were observed in the α-hbdh value between ≤ years old group and - years old group during t -t , between ≤ years old group and ≥ years old group during t -t , and between - years old group and ≥ years old group during t -t . differences were also significant in the α-hbdh value abnormal percentage among the three age groups (p< . ). the age was correlated with α-hbdh value according to the spearman correlation test (p< . ), and the coefficient was . . . cc-by-nc-nd . international license it is made available under a who has granted medrxiv a license to display the preprint in perpetuity. is the author/funder, (which was not certified by peer review) the copyright holder for this preprint this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint in survival group and death group, the α-hbdh median value was . ( . - . ) u/l and . ( . - . ) u/l, respectively, and the α-hbdh value abnormal percentage was . % and . %, respectively. the changes indicated that the α-hbdh median value in survival group increased during t -t , decreased after t , and was in the normal range during t -t ; while in death group, the α-hbdh median value increased during t -t and decreased after t , and the abnormal time interval was t -t (figure , table ). there were significant differences of the α-hbdh in the first days and every time unit during t -t . differences were also significant in the α-hbdh value abnormal percentage among the two outcome groups (p< . ). spearman correlation test showed that there was a correlation between outcome groups and the α-hbdh value (p< . ), and the correlation was . . increased during t -t and decreased after t , and was in the normal range during t -t ; in the severe group, the α-hbdh median value increased during t -t and decreased after t , and the abnormal time interval was t -t ; in the critical group, the α-hbdh median value increased during t -t and decreased after t , and the abnormal time interval was t -t (figure , table ) . however, the mild group was excluded in statistical analysis for the reason that it only contained cases. there were significant differences of the α-hbdh value in the first days among the three clinical type groups. significant differences were observed in the α-hbdh value between moderate type group and severe type group during t -t , between moderate type group and . cc-by-nc-nd . international license it is made available under a who has granted medrxiv a license to display the preprint in perpetuity. is the author/funder, (which was not certified by peer review) the copyright holder for this preprint this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint critical type group during t -t , and between severe type group and critical type group during t -t . gender, respectively). the comparison between the output type and the actual type quantification score was shown in the figure . according to the model, the output accuracy of moderate, severe and critical types was . %. in order to discriminate moderate type and severe/critical type, the severe type and critical type were combined to the same category, and the accuracy was . %. discussion α-hbdh is one of the important enzymes in the process of glucose metabolism, which is widely distributed in various tissues and organs, especially in the heart, brain, kidney and red blood cells. covid- mainly induces lung injury and causes damage to the heart and other tissues and organs, which results in the release of α-hbdh and the increase of α-hbdh in blood terminally [ ] . the α-hbdh value in covid- patients changed, it increased or significantly increased in some patients (figure ). in different age groups, outcome groups and clinical type groups, there were significant differences in the distribution and abnormal percentage of α-hbdh. age and outcome were significantly correlated with α-hbdh. moreover, α-hbdh value may be related to the severity of covid- . in ≥ years old group and death group, the α-hbdh median value increased from t , and reached a single peak in t ( . u/l) and t ( . u/l), respectively, which was significantly different from that in ≤ years old group (peak value was . u/l ), - years old . cc-by-nc-nd . international license it is made available under a who has granted medrxiv a license to display the preprint in perpetuity. is the author/funder, (which was not certified by peer review) the copyright holder for this preprint this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint group (peak value was . u/l) and survival group (peak value was . u/l). the abnormal interval of α-hbdh median value in ≥ years old group and death group was t -t , t -t respectively, which was significantly different from that in ≤ years old group, - years old group and survival group, in which α-hbdh median value were all in the normal range. it shows that the older the age, the worse the outcome, the higher the α-hbdh value, and the longer the abnormal interval. the α-hbdh value in ≥ years old group and death group was higher than that in other groups, indicating that the injury of heart, brain, kidney and other tissues and organs is more serious in elderly and death patients, which was consistent with previous study [ ] . this may be related to the poor function of the immune system and being more sensitive the α-hbdh median value of the mild group was in the normal range, without obvious change, indicating that the injury of tissue and organ injury in this type was slight. the same as mild group, α-hbdh median value in moderate group also distributed in the normal range. it increased firstly, and reached a peak ( . u/l) in t , indicating that tissue and organ injury occurred immediately after the symptom onset in spite of the slight degree, and mainly occurred in the first days. the changes of α-hbdh median value of severe group was similar to that of critical group, which increased during t -t and decreased after t . their peak value was . u/l and . u/l appearing in t , and recovered to normal range in t and t , respectively. it shows that the more serious the illness, the higher the α-hbdh median value and peak . cc-by-nc-nd . international license it is made available under a who has granted medrxiv a license to display the preprint in perpetuity. is the author/funder, (which was not certified by peer review) the copyright holder for this preprint this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint value, the longer the abnormal interval, which may be related to the serious virus-induced acute lung injury, tissues and organs damage in severe and critical type groups. these characteristics are of great significance for us to judge the severity of the disease by α-hbdh. the maximum α-hbdh value in the first days, age and gender of all patients were selected to build the optimal scale regression model. α-hbdh < . u/l and aged < years old was associated with moderate type, α-hbdh between . - . u/l and aged between - years old was associated with severe type, α-hbdh > . u/l and aged > years old was associated with critical type. in this model, the output accuracy for clinical type was over %, which indicated that the model could distinguish the clinical classification based on our data well. α-hbdh and age could be used to discriminate the clinical type of covid- patients if further verified by other data, which could help us to grasp the opportunity of treatment and reduce the risk of progression to severe and critical type in early stage. however, this study has several limitations. all the patients in the study come from the single hospital, and the sample size is small. this study is a retrospective cohort study, which fails to detect and analyze the daily α-hbdh in patients and may lose some information. α-hbdh value increases in some covid- patients, obviously in ≥ years old, death and critical group, indicating that patients in these three groups suffer from more serious tissues and organs damage, higher α -hbdh value and risk of death. the obvious difference between death and survival group in early stage may provide a approach to judge the prognosis. the accuracy of the model to distinguish severe/critical type and other types is . %, suggesting that α-hbdh could judge the clinical type of covid- patients accurately. in brief, α-hbdh is an important indicator to judge the severity and prognosis of covid- . . cc-by-nc-nd . international license it is made available under a who has granted medrxiv a license to display the preprint in perpetuity. is the author/funder, (which was not certified by peer review) the copyright holder for this preprint this version posted november , . . cc-by-nc-nd . international license it is made available under a who has granted medrxiv a license to display the preprint in perpetuity. is the author/funder, (which was not certified by peer review) the copyright holder for this preprint this version posted november , . score: quantitative score in optimal scale regression model . cc-by-nc-nd . international license it is made available under a who has granted medrxiv a license to display the preprint in perpetuity. is the author/funder, (which was not certified by peer review) the copyright holder for this preprint this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nc-nd . international license it is made available under a who has granted medrxiv a license to display the preprint in perpetuity. is the author/funder, (which was not certified by peer review) the copyright holder for this preprint this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint figure . comparison between the output type and the actual type quantification score in the model . cc-by-nc-nd . international license it is made available under a who has granted medrxiv a license to display the preprint in perpetuity. is the author/funder, (which was not certified by peer review) the copyright holder for this preprint this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nc-nd . international license it is made available under a who has granted medrxiv a license to display the preprint in perpetuity. is the author/funder, (which was not certified by peer review) the copyright holder for this preprint this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint clinical features of patients infected with novel coronavirus in wuhan epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study the novel coronavirus originating in wuhan, china: challenges for global health governance early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia novel coronavirus( -ncov) situation report- novel coronavirus( -ncov) situation report- prognostic value of c-reactive protein and cardiac troponin i in primary percutaneous interventions for st-elevation myocardial infarction estimation of enzymatic infarct size: direct comparison of the marker enzymes creatine kinase and alpha-hydroxybuty rate dehydrogenase biochemical markers of myocardial injury serum alpha-hydroxybutyrate dehydrogenase levels in children with sickle cell disease. the american journal of pediatric hematology/oncology acute changes of serum markers for tissue damage after eswl of kidney stones a comparative study on the clinical features of coronavirus (covid- ) pneumonia with other pneumonias clinical characteristics of coronavirus disease (covid- ) patients with gastrointestinal symptoms: a report of case s. dig liver dis risk factors for disease progression in patients with mild to moderate coronavirus disease -a multi-centre observational study analysis of clinical characteristics and laboratory findings of cases of novel coronavirus pneumonia in wu han, china: a retrospective analysis nationan health commissiom of the people's republic of china. diagnosis and treatment of corona virous disease- clinical characteristics of patients infected with sars-cov- in wuhan key: cord- -fka svzu authors: gerber, michael a. title: diagnosis and treatment of pharyngitis in children date: - - journal: pediatr clin north am doi: . /j.pcl. . . sha: doc_id: cord_uid: fka svzu acute pharyngitis is one of the most common illnesses for which children visit primary care physicians. most cases of acute pharyngitis in children are caused by viruses and are benign and self-limited. group a beta-hemolytic streptococcus is the most important of the bacterial causes of acute pharyngitis. strategies for diagnosis and treatment of acute pharyngitis are directed at distinguishing children with viral pharyngitis, who would not benefit from antimicrobial therapy, from children with group a beta-hemolytic streptococcal pharyngitis, for whom antimicrobial therapy would be beneficial. making this distinction is crucial in attempting to minimize the unnecessary use of antimicrobial agents in children. coronavirus, adenovirus, and respiratory syncytial virus, are frequent causes of acute pharyngitis. other viral causes of acute pharyngitis include coxsackievirus, echovirus, and herpes simplex virus. epstein-barr virus is a frequent cause of acute pharyngitis that is often accompanied by other clinical findings of infectious mononucleosis (eg, splenomegaly, generalized lymphadenopathy). systemic infections with other viral agents, including cytomegalovirus, rubella virus, and measles virus, may be associated with acute pharyngitis. gas is the most common bacterial cause of acute pharyngitis, accounting for % to % of cases of acute pharyngitis in children. other bacteria also can cause acute pharyngitis, however, including groups c and g beta-hemolytic streptococci and corynebacterium diphtheriae. arcanobacterium haemolyticum is a rare cause of acute pharyngitis, particularly in teenagers, and neisseria gonorrhoeae occasionally can cause acute pharyngitis in sexually active adolescents. other bacteria, such as francisella tularensis and yersinia enterocolitica, and mixed infections with anaerobic bacteria (eg, vincent's angina) are rare causes of acute pharyngitis. chlamydia pneumoniae and mycoplasma pneumoniae have been implicated as causes of acute pharyngitis, particularly in adults. although other bacteria, such as staphylococcus aureus, haemophilus influenzae, and streptococcus pneumoniae, are cultured frequently from the throats of children with acute pharyngitis, their etiologic role in this disease has not been established. most cases of pharyngitis occur during the colder months of the year, when respiratory viruses (eg, rhinovirus, coronavirus, influenza virus, and adenovirus) are prevalent. spread among family members in the home is a prominent feature of the epidemiology of most of these agents, with children being the major reservoir of infection. group a beta-hemolytic streptococcal pharyngitis is primarily a disease of children age to . in temperate climates, it usually occurs in the winter and early spring. the incidence of gonococcal pharyngitis is highest among older adolescents and young adults. the usual route of infection is orogenital sexual contact with an infected sexual partner. sexual abuse must be strongly considered if n. gonorrhoeae is isolated from the pharynx of a prepubertal child. widespread immunization with diphtheria toxoid has made diphtheria a rare disease in the united states, with fewer than five cases reported annually in recent years. groups c and g beta-hemolytic streptococci can cause acute pharyngitis with clinical features similar to those of group a beta-hemolytic streptococcal pharyngitis. group c streptococcus is a relatively common cause of acute pharyngitis among college students and adults evaluated in emergency departments [ , ] . group c streptococcus also can cause epidemic food-borne pharyngitis; family and school outbreaks of group c streptococcal pharyngitis related to ingestion of contaminated food products, such as unpasteurized cow's milk, have been described [ ] . although there have been several well-documented food-borne outbreaks of group g streptococcal pharyngitis, the etiologic role of group g streptococcus in acute, endemic pharyngitis is unclear. a community-wide, respiratory outbreak of group g streptococcal pharyngitis in a pediatric population was described in which group g streptococcus was isolated from of ( %) consecutive children with acute pharyngitis seen in a private pediatric office [ ] . results of dna fingerprinting of the group g streptococcus isolates suggested that % of them were the same strain. the role of groups c and g streptococci in acute pharyngitis may be underestimated for several reasons. anaerobic incubation increases the yield of these organisms, but many laboratories do not use anaerobic incubation routinely for throat cultures. in addition, because many groups c and g streptococci are bacitracin resistant, and laboratories may report only bacitracin-sensitive streptococci (consistent with gas), many groups c and g streptococci would be missed. finally, many clinicians no longer perform throat cultures, but instead rely solely on rapid antigen detection tests (radts), and groups c and g streptococci would not be identified by a radt for gas [ ] . acute group a beta-hemolytic streptococcal pharyngitis has certain clinical characteristics and epidemiologic patterns ( table ) . patients with group a betahemolytic streptococcal pharyngitis commonly present with sore throat (generally of sudden onset), severe pain on swallowing, and fever. headache, nausea, vomiting, and abdominal pain also may be present. on examination, patients typically have tonsillopharyngeal erythema with or without exudates and tender, enlarged anterior cervical lymph nodes. other findings include a beefy, red, swollen uvula; petechiae on the palate; excoriated nares (especially in infants); and a scarlitiniform rash. none of these findings is specific for group a betahemolytic streptococcal pharyngitis. many patients with streptococcal pharyngitis exhibit signs and symptoms that are milder than a ''classic'' case of this illness. some of these patients have bona fide group a beta-hemolytic streptococcal pharyngitis, whereas others are merely colonized with gas and have pharyngitis resulting from an intercurrent viral illness. scarlet fever is an upper respiratory tract infection associated with a characteristic rash, which is caused by an infection with pyrogenic exotoxin (erythrogenic toxin)-producing gas in individuals who do not have antitoxin antibodies. scarlet fever is encountered less commonly and is less virulent than in the past, but the incidence is cyclical, depending on the prevalence of toxinproducing strains and the immune status of the population. the modes of trans- the rash of scarlet fever appears within to hours after the onset of symptoms, although it may appear with the first signs of illness. the rash often begins around the neck and spreads over the trunk and extremities. it is a diffuse, finely papular, erythematous eruption producing a bright red discoloration of the skin, which blanches on pressure. involvement is often more intense along the creases of the elbows, axillae, and groin. the involved skin has a goose-pimple appearance and feels rough. the face is usually spared, although the cheeks may be erythematous with pallor around the mouth. after to days, the rash begins to fade and is followed by desquamation, first on the face, progressing downward, and often resembling that seen after a mild sunburn. occasionally, sheetlike desquamation may occur around the free margins of the fingernails, palms, and soles. examination of the pharynx of a patient with scarlet fever reveals essentially the same findings as with group a beta-hemolytic streptococcal pharyngitis. in addition, the tongue usually is coated, and the papillae are swollen. after desquamation, the reddened papillae are prominent, giving the tongue a strawberry appearance. the absence of fever or the presence of clinical features such as conjunctivitis, cough, hoarseness, coryza, anterior stomatitis, discrete ulcerative lesions, viral exanthem, and diarrhea suggests a viral etiology rather than gas. acute pharyngitis caused by adenovirus typically is associated with fever, erythema of the pharynx, enlarged tonsils with exudate, and enlarged cervical lymph nodes. adenoviral pharyngitis may be associated with conjunctivitis, and, when it is, it is referred to as pharyngoconjunctival fever. the pharyngitis of pharyngoconjunctival fever can persist for days, the conjunctivitis can persist for days, and both resolve spontaneously. outbreaks of pharyngoconjunctival fever have been associated with transmission in swimming pools; widespread epidemics and sporadic cases also occur. enteroviruses (coxsackievirus, echovirus, and newer enteroviruses) can cause acute pharyngitis, especially during the summer and early fall. the pharynx may be erythematous, but tonsillar exudate and cervical adenopathy are unusual. fever may be prominent. resolution usually occurs within a few days. herpangina is a specific syndrome caused by coxsackievirus a or b or echoviruses and is characterized by fever and painful, discrete, gray-white papulovesicular lesions on an erythematous base in the posterior oropharynx. these lesions become ulcerative and usually resolve within days. hand-foot-mouth disease is a specific syndrome caused by coxsackievirus a . it is characterized by painful vesicles and ulcers throughout the oropharynx associated with vesicles on the palms, soles, and sometimes on the trunk or extremities. these lesions usually resolve within days. primary oral herpes simplex virus infections usually occur in young children and typically produce acute gingivostomatitis associated with ulcerating vesicular lesions throughout the anterior mouth, including the lips, but sparing the posterior pharynx. the gingivostomatitis can last weeks and often is associated with high fever. the pain may be intense, and the oral intake of fluids may be impaired, leading to dehydration. herpes simplex virus also can produce a mild pharyngitis in adolescents and adults that may or may not be associated with typical ulcerating vesicular lesions. acute pharyngitis is a common finding in adolescents and young adults with infectious mononucleosis caused by epstein-barr virus. the pharyngitis of infectious mononucleosis can be severe with clinical findings virtually identical to those of group a beta-hemolytic streptococcal pharyngitis. generalized lymphadenopathy and hepatosplenomegaly also may be present, however. fever and pharyngitis typically last to weeks; the lymphadenopathy and hepatosplenomegaly resolve over to weeks. laboratory findings include the presence of atypical lymphocytosis, heterphil antibody, and specific antibodies to epstein-barr virus antigens. the acute pharyngitis caused by a. haemolyticum may closely resemble group a beta-hemolytic streptococcal pharyngitis, including the presence of a scarlitiniform rash in many patients. in rare cases, a. haemolyticum can produce a membranous pharyngitis that can be confused with diphtheria. pharyngeal diphtheria is characterized by a grayish brown pseudomembrane that may be limited to one or both tonsils or may extend widely to involve the nares, uvula, soft palate, pharynx, larynx, and tracheobronchial tree. involvement of the tracheobronchial tree may lead to life-threatening respiratory obstruction. soft tissue edema and prominent cervical and submental lymphadenopathy may create a bull-neck appearance. the decision to perform a microbiologic test on a patient presenting with acute pharyngitis should be based on the clinical and epidemiologic characteristics of the illness (see table ). a history of close contact with a welldocumented case of group a beta-hemolytic streptococcal pharyngitis or a high prevalence of group a beta-hemolytic streptococcal infections in the community also may be helpful. testing usually does not need to be performed on patients with acute pharyngitis whose clinical and epidemiologic features do not suggest gas as the etiology. selective use of diagnostic studies for gas not only increases the proportion of positive test results, but also the percentage of patients with positive tests who are truly infected rather than merely gas carriers. efforts have been made to incorporate clinical and epidemiologic features of acute pharyngitis into scoring systems that attempt to predict the probability that a particular illness is caused by gas [ ] [ ] [ ] . these clinical scoring systems are helpful in identifying patients at such low risk of infection with gas that a throat culture or radt is usually unnecessary. the signs and symptoms of group a beta-hemolytic streptococcal and non-group a beta-hemolytic streptococcal pharyngitis overlap too broadly, however, and the clinical diagnosis of group a beta-hemolytic streptococcal pharyngitis cannot be made with accuracy even by gerber the most experienced physicians. guidelines from the infectious diseases society of america (idsa) [ ] , american academy of pediatrics [ ] , and american heart association [ ] indicate that microbiologic confirmation (with a throat culture or radt) is required for the diagnosis of group a beta-hemolytic streptococcal pharyngitis. new practice guidelines from the centers for disease control and prevention (cdc), american academy of family physicians (aafp), and american college of physicians-american society of internal medicine (acp-asim) recommend the use of a clinical algorithm without microbiologic confirmation as an acceptable approach to the diagnosis of group a beta-hemolytic streptococcal pharyngitis in adults only [ , ] . although the goal of this algorithm-based strategy was to reduce the inappropriate use of antibiotics in adults with pharyngitis, there was concern that their use would result in the administration of antimicrobial treatment to an unacceptably large number of adults with nongroup a beta-hemolytic streptococcal pharyngitis [ ] . the authors of the cdc/aafp/acp-asim guidelines suggested that prospective studies should be conducted to compare this particular strategy with other strategies in terms of relevant patient outcomes and cost. mcisaac et al [ ] performed a retrospective analysis to assess the impact of six different guidelines (including the idsa and cdc/aafp/acip-asim guidelines) on identification and treatment of group a beta-hemolytic streptococcal pharyngitis in children and adults. guidelines that recommend selective use of radts or throat cultures and treatment based only on positive test results significantly reduced the inappropriate use of antibiotics in adults. in contrast, the empirical strategy proposed in the cdc/aafp/acip-asim guidelines resulted in the administration of unnecessary antibiotics to an unacceptably large number of adults. before abandoning the concept of treatment only after laboratory confirmation of gas in adults with pharyngitis (idsa guideline), additional prospective studies need to be performed to compare empirical and laboratory-based strategies in terms of relevant patient outcomes and cost. culture of a specimen obtained by throat swab on a sheep blood agar plate is the standard laboratory procedure for the microbiologic confirmation of the clinical diagnosis of acute group a beta-hemolytic streptococcal pharyngitis [ ] . if performed correctly, a single throat swab has a sensitivity of % to % in detecting the presence of gas in the pharynx [ ] . several variables may affect the accuracy of the throat culture results. one of the most important is the manner in which the swab is obtained [ , ] . throat swab specimens should be obtained from the surface of both tonsils (or tonsillar fossae) and the posterior pharyngeal wall. other areas of the pharynx and mouth are not acceptable sites and should not be touched during the culturing procedure. even with an appropriately collected specimen, false-negative results may be obtained if the patient has received antibiotics before the throat swab is taken. anaerobic incubation and the use of selective culture media have been reported to increase the sensitivity of throat cultures [ , ] . the data regarding the impact of the atmosphere of incubation and the culture media conflict, however, and, in the absence of definite benefit, the increased cost and effort associated with anaerobic incubation and selective culture media are difficult to justify, particularly for physicians processing throat cultures in their own offices [ ] [ ] [ ] . duration of incubation is another variable that can affect the yield of throat cultures. when plated, cultures should be incubated at c to c for to hours before reading. an additional overnight incubation at room temperature would identify a considerable number of positive throat cultures, however, that would not otherwise have been identified. armengol et al [ ] found that more than % of the positive confirmatory throat cultures obtained on patients with pharyngitis and negative radts were negative after hours of incubation, but positive after hours. although initial therapeutic decisions may be made on the basis of an overnight culture, it is advisable to examine plates that are negative at hours again at hours. the clinical significance of the number of colonies of gas present on the throat culture plate is controversial. patients with bona fide acute group a beta-hemolytic streptococcal pharyngitis are likely to have more colonies of gas on their culture plates than patients who are gas carriers. there is too much overlap in the colony count, however, between patients acutely infected with gas and gas carriers to permit differentiation on the basis of degree of positivity [ ] . probably the most widely used test for differentiation of gas from other beta-hemolytic streptococci in physicians' offices is the bacitracin disk test. this test provides a presumptive identification based on the observation that greater than % of gas show a zone of inhibition around a disk containing . units of bacitracin, whereas % to % of non-gas are not inhibited by bacitracin [ ] . an alternative and highly specific method for the differentiation of gas from other beta-hemolytic streptococci is the detection of the group-specific cell wall carbohydrate antigen directly on isolated bacterial colonies. commercial kits employing group-specific antisera are available for this purpose. such tests are appropriate for use by clinical microbiology laboratories, but most physicians performing throat cultures would find it difficult to justify the additional expense for the minimal improvement in accuracy that serogrouping of beta-hemolytic streptococci would provide over the bacitracin disk test [ ] . the major disadvantage of culturing a specimen obtained by throat swab on blood agar plates is the delay in obtaining culture results. radts have been developed for the identification of gas directly from throat swabs. although radts are more expensive than blood agar plate cultures, the advantage they offer over the traditional procedure is the speed with which they can provide gerber results. rapid identification and treatment of patients with group a betahemolytic streptococcal pharyngitis can reduce the risk of the spread of gas, allow the patient to return to school or work sooner, and speed clinical improvement [ , ] . in addition, in certain environments (eg, emergency departments), the use of radts has been shown to increase significantly the number of patients appropriately treated for group a beta-hemolytic streptococcal pharyngitis compared with the use of throat cultures [ ] . most currently available radts have specificities of % or greater compared with blood agar plate cultures [ ] . false-positive test results are unusual, and therapeutic decisions can be made with confidence on the basis of a positive radt result. the sensitivity of most radts is % to % [ ] . although it has been suggested that many false-negative radt results occur in patients who are gas carriers, it has been shown that a large proportion of patients with falsenegative radt results are truly infected with gas [ ] . the first radts used latex agglutination methodology, were relatively insensitive, and had unclear end points [ ] . subsequent tests based on enzyme immunoassay techniques had a more sharply defined end point and increased sensitivity. more recently, radts using optical immunoassay and chemiluminescent dna probes have been developed [ ] . these tests may be more sensitive than other radts and perhaps even as sensitive as blood agar plate cultures [ ] . because of conflicting and limited data about the optical immunoassay [ ] and other commercially available radts, however, advisory groups recommend that physicians electing to use any radt in children and adolescents without culture backup of negative results should do so only after showing in their own practice that the radt is as sensitive as throat culture [ , ] . currently, two of the most important issues regarding the use of radts for the diagnosis of group a beta-hemolytic streptococcal pharyngitis are the relative sensitivities of the different tests and whether any radts are sensitive enough to mitigate against the need to perform throat cultures in patients with negative test results. most studies that have evaluated the sensitivities of radts have compared the performance of a single type of radt with a standard culture. because of considerable variability in study designs and culture techniques, it is difficult to compare the sensitivity of a radt as determined in one study with the sensitivity of another radt as determined in a different study [ ] . the relative sensitivities of different radts can be determined only by direct comparisons. there have been to date only four direct comparisons of different radts reported in the english literature (one of which was a letter to the editor) [ ] [ ] [ ] [ ] . the relative sensitivities of different radts have not been established. few studies have investigated the performance of the radts currently being used in clinical practice [ , [ ] [ ] [ ] [ ] [ ] . armengol et al [ ] attempted to validate the sensitivity of the specific radt being used in their practice before abandoning confirmatory throat cultures for negative radt results [ , ] . in this study performed over three winter seasons and using the on-site physician office laboratory at the pediatric group practice, they found that the radt had a sensitivity of approximately % compared with a single blood agar plate culture. the investigators concluded that the sensitivity of this particular radt was too low for them to consider abandoning the confirmatory throat culture in their practice. in contrast, mayes and pichichero [ ] reviewed the experience with radts in a different pediatric group practice between january and june . during this period, , radts were performed, and ( . %) were negative. a confirmatory blood agar plate culture was performed for ( . %) of these negative tests. of these, ( . %) were determined to have been negative radt results with a positive throat culture. a cost analysis showed that elimination of confirmatory throat cultures for negative radt results could produce substantial saving to a practice and to patients. the investigators concluded that culture confirmation of negative radt results may not be necessary in all circumstances [ ] . neither the blood agar plate culture nor the radt can differentiate accurately individuals with bona fide group a beta-hemolytic streptococcal pharyngitis from asymptomatic gas carriers with intercurrent viral pharyngitis. they do facilitate, however, the withholding of antibiotics from most patients with sore throats, whose cultures or radts are negative, and this is extremely important. there are an estimated . million visits to primary care providers by adults who complain of sore throat each year in the united states, and antibiotics are prescribed at % of these visits [ ] . although more recent trends suggest a decline in the use of antibiotics in children and adolescents with pharyngitis, in - , . % of children and adolescents who were seen by their primary care provider for pharyngitis received a prescription for antibiotics [ ] . antistreptococcal antibody titers reflect past and not present immunologic events and are of no value in the diagnosis of acute group a beta-hemolytic streptococcal pharyngitis. they are valuable for confirmation of prior group a beta-hemolytic streptococcal infections in patients suspected of having acute rheumatic fever or poststreptococcal acute glomerulonephritis. antistreptococcal antibody titers also are helpful in prospective epidemiologic studies in trying to differentiate patients with acute group a beta-hemolytic streptococcal infections from patients who are gas carriers. most asymptomatic patients who have confirmed positive throat cultures after completing a course of appropriate antimicrobial therapy are gas carriers [ ] . follow-up throat cultures (or radts) are not routinely indicated for asymptomatic patients who have completed a course of antibiotic therapy for gas. there are specific situations, however, when follow-up throat cultures (or radts) on asymptomatic individuals should be performed. patients with a history of rheumatic fever should have routine follow-up testing. such testing also should be considered in patients who develop acute pharyngitis during outbreaks of either acute rheumatic fever or poststreptococcal acute glomeru-gerber lonephritis and during outbreaks of group a beta-hemolytic streptococcal pharyngitis in closed or semiclosed communities [ ] . antimicrobial therapy is indicated for individuals with symptomatic pharyngitis after the presence of gas in the throat has been confirmed by either throat culture or radt. in situations in which the clinical and epidemiologic evidence results in a high index of suspicion, antimicrobial therapy can be initiated while awaiting laboratory confirmation, provided that such therapy is discontinued if the diagnosis of group a beta-hemolytic streptococcal pharyngitis is not confirmed by a laboratory test. early initiation of antimicrobial therapy for group a betahemolytic streptococcal pharyngitis results in a shortening of the clinical course of the illness [ ] . group a beta-hemolytic streptococcal pharyngitis is usually a self-limited disease, however, and most signs and symptoms resolve spontaneously within or days of onset even without antimicrobial therapy [ ] . in addition, the initiation of antimicrobial therapy can be delayed for days after the onset of symptoms and still prevent the occurrence of acute rheumatic fever [ ] . there can be flexibility in initiating antimicrobial therapy during the evaluation of an individual patient with presumed group a beta-hemolytic streptococcal pharyngitis. numerous antimicrobial agents have been shown to be effective in the treatment of group a beta-hemolytic streptococcal pharyngitis, including penicillin and its congeners (eg, ampicillin and amoxicillin) and numerous cephalosporins, macrolides, and clindamycin. when selecting an antimicrobial for the treatment of group a beta-hemolytic streptococcal pharyngitis, it is important to consider efficacy, safety, antimicrobial spectrum (narrow versus broad), dosing schedules, compliance, and cost. based on such considerations, several advisory bodies recommend penicillin as the treatment of choice for this infection [ ] [ ] [ ] . although the problem of increasing antimicrobial resistance among bacteria is one of the most important current infectious disease issues, gas has never developed resistance to any of the penicillins or cephalosporins or shown any increase in penicillin minimal inhibitory concentrations over at least decades [ ] . amoxicillin often is used in place of oral penicillin v in young children; the efficacy appears equal. this choice is related primarily to acceptance of the taste of amoxicillin suspension. orally administered erythromycin is indicated for patients allergic to penicillin. other macrolides, such as clarithromycin or azithromycin, also are effective. first-generation cephalosporins also are acceptable in penicillin-allergic patients who do not manifest immediate-type hypersensitivity to b-lactam antibiotics. casey and pichichero [ ] presented a meta-analysis of clinical trials performed between and in which a cephalosporin was compared with penicillin for the treatment of group a beta-hemolytic streptococcal pharyngitis. based on this analysis, they concluded that cephalosporins should be added ''as a treatment of choice for [group a beta-hemolytic streptococcal] tonsillopharyngitis. . ..'' this report has several major flaws, however, that make it impossible to accept the validity of this conclusion [ ] . although the use of cephalosporins for group a beta-hemolytic streptococcal pharyngitis could reduce the number of patients (most merely chronic carriers) who continue to harbor the organism in their throats after completing therapy, the economic and ecologic costs involved would make this a pyrrhic victory for those who advocate the use a cephalosporin as the drug of choice for streptococcal pharyngitis. penicillin has stood, the test of time satisfactorily for decades, and there are compelling reasons (eg, its narrow antimicrobial spectrum, inexpensive cost, and impressive safety profile) to continue to recommend it as the drug of choice. most oral antibiotics must be administered for days to achieve maximal pharyngeal eradication rates of gas. it has been reported that several antimicrobial agents, including clarithromycin, cefuroxime, cefixime, ceftibuten, cefdinir, cefpodoxime, and azithromycin, are effective in eradication of gas from the pharynx when administered for or fewer days [ , ] . many of the studies of short-course therapy have serious methodologic flaws, however, that raise questions about the validity of their conclusions. in addition, the spectra of these antibiotics are much broader than that of penicillin, and even when they are administered for short courses, they are more expensive [ ] . additional studies are needed before these short-course regimens can be recommended [ , ] . attempts to treat group a beta-hemolytic streptococcal pharyngitis with a single daily dose of penicillin have been unsuccessful [ ] . in recent years, investigators have shown that several antimicrobial agents, including azithromycin, cefadroxil, cefixime, ceftibuten, cefpodoxime, cefprozil, and cefdinir, are effective in eradicating pharyngeal streptococci when given as a single daily dose [ , ] . these agents are expensive, however, and have broad spectra of activity compared with penicillin. preliminary investigations have shown that once-daily amoxicillin therapy is effective in the treatment of group a beta-hemolytic streptococcal pharyngitis [ , ] . if confirmed by additional investigations, oncedaily amoxicillin therapy, because of its low cost and relatively narrow spectrum, could become an alternative regimen for the treatment of group a beta-hemolytic streptococcal pharyngitis. antimicrobial therapy for group a beta-hemolytic streptococcal pharyngitis may be given orally or parenterally. table gives recommendations for several antimicrobials proved to be effective for the treatment of group a beta-hemolytic streptococcal pharyngitis [ ] . intramuscular benzathine penicillin g is preferred in patients who are unlikely to complete a full -day course of oral therapy. antimicrobial resistance has not been a significant issue in the treatment of group a beta-hemolytic streptococcal pharyngitis in the united states [ ] . there has never been a clinical isolate of gas documented to be resistant to penicillin anywhere in the world. although there have been geographic areas with relatively high levels of resistance to macrolide antibiotics [ , ] , the rate gerber of macrolide resistance among isolates of gas in the united states generally has remained low at less than %. in an investigation of antibiotic resistance patterns of pharyngeal isolates and invasive isolates of gas obtained between and from states and the district of columbia, only ( . %) of the isolates were determined to be macrolide resistant [ ] . higher resistance rates occasionally have been reported, however. nine percent of pharyngeal and % of invasive gas strains collected in san francisco during - were reported to be macrolide resistant [ ] . martin et al [ ] , during a longitudinal investigation of group a beta-hemolytic streptococcal disease in a single elementary school in pittsburgh, pennsylvania, found that % of the isolates of gas collected between october and may were resistant to erythromycin. none were resistant to clindamycin. molecular typing indicated that this outbreak was due to a single strain of gas. in addition, of randomly selected isolates of gas obtained from the community between april and june , ( %) were resistant to erythromycin [ ] . tanz et al [ ] reported the results of a prospective, multicenter, communitybased surveillance of pharyngeal isolates of gas recovered from children to years old during three successive respiratory seasons between and . during this -year period, the macrolide resistance rate among pharyngeal gas in the united states was less than %, and it was stable. clindamycin resistance was found in . % of isolates over the -year study period and did not vary by study year. there was no evidence of wide dissemination of spe- cific macrolide-resistance clones, increasing clindamycin resistance, or increasing erythromycin minimal inhibitory concentrations over the -year study period. there was, however, considerable geographic variability in macrolide resistance rates in each study year and year-to-year variability at individual study sites [ ] . although these results are reassuring, clinicians need to be aware of local resistance rates. in the future, if there are significant increases in rates of macrolide resistance among gas strains, it may be necessary to reconsider recommendations for treatment of group a beta-hemolytic streptococcal pharyngitis in penicillin-allergic patients. the primary reason to identify either group c or group g streptococcus as the cause of acute pharyngitis is to initiate antimicrobial therapy that may mitigate the clinical course of the infection. there is currently no convincing evidence, however, from controlled studies of clinical response to antimicrobial therapy in patients with acute pharyngitis and either group c or group g streptococcus isolated from their pharynx. if one elects to treat either group c or group g streptococcal pharyngitis, the treatment should be similar to that for group a beta-hemolytic streptococcal pharyngitis with penicillin as the antimicrobial agent of choice [ ] . group a beta-hemolytic streptococcal pharyngitis can be associated with suppurative and nonsuppurative complications. suppurative complications result from the spread of gas to adjacent structures and include peritonsillar abscess, retropharyngeal abscess, cervical lymphadenitis, sinusitis, otitis media, and mastoiditis. before antimicrobial agents were available, suppurative complications of group a beta-hemolytic streptococcal pharyngitis were common; however, antimicrobial therapy has reduced greatly the frequency of such complications. acute rheumatic fever, acute poststreptococcal glomerulonephritis, and poststreptococcal reactive arthritis are recognized nonsuppurative sequelae of group a beta-hemolytic streptococcal pharyngitis. acute rheumatic fever occurs after an episode of group a beta-hemolytic streptococcal pharyngitis (usually after a -to -week latent period) and not after group a beta-hemolytic streptococcal infections of the skin. appropriate antimicrobial therapy begun within days of the onset of pharyngitis can prevent this complication. in contrast to acute rheumatic fever, acute poststreptococcal glomerulonephritis can occur after a group a beta-hemolytic streptococcal infection of either the pharynx or skin and does not seem to be prevented by antimicrobial therapy of the antecedent group a beta-hemolytic streptococcal infection. the latent period for glomerulonephritis is about weeks after a skin infection and days after an upper respiratory tract infection. poststreptococcal reactive arthritis is similar to other postinfectious arthritides. the relationship of this entity to acute rheumatic fever is still unclear. gerber acute glomerulonephritis has been reported as an extremely unusual complication of group c streptococcal pharyngitis, but a causal relationship between group g streptococcal pharyngitis and acute glomerulonephritis has not been established. acute rheumatic fever has not been described as a complication of either group c or group g streptococcal pharyngitis [ ] . antimicrobial treatment failures with group a beta-hemolytic streptococcal pharyngitis traditionally have been classified as either clinical or bacteriologic failures. the significance of clinical treatment failures (usually defined as persistent or recurrent signs or symptoms suggesting group a beta-hemolytic streptococcal pharyngitis) is difficult to determine, however, because group a beta-hemolytic streptococcal pharyngitis is a self-limited illness even without antimicrobial therapy [ ] . in addition, without the repeat isolation of the infecting strain of gas (ie, true bacteriologic treatment failure), it is particularly difficult to determine the clinical significance of persistent or recurrent signs or symptoms suggesting group a beta-hemolytic streptococcal pharyngitis. bacteriologic treatment failures can be classified as either true or apparent failures. true bacteriologic failure refers to the inability to eradicate the specific strain of gas causing an acute episode of pharyngitis with a complete course of appropriate antimicrobial therapy. apparent bacteriologic treatment failure reflects a variety of circumstances. most apparent bacteriologic treatment failures are patients who are gas carriers (ie, patients with gas in the upper respiratory tract, but without illness or immunologic response). gas carriers are unlikely to spread gas to their close contacts and are at low, if any risk, for developing suppurative or nonsuppurative complications [ ] . during the winter and spring in temperate climates, % of asymptomatic school-age children are gas carriers [ ] . apparent bacteriologic failure also can occur when newly acquired gas isolates are mistaken for the original infecting strain of gas, when the infecting strain of gas is eradicated but then rapidly reacquired, or when compliance with antimicrobial therapy is poor. although the specific reasons for true bacteriologic treatment failures have not been determined, several explanations have been proposed. it has been suggested that gas may have become more resistant to penicillin; however, there is no evidence to support this hypothesis [ ] , and no penicillin-resistant strains of gas have been identified. it also has been suggested that some strains of gas have developed penicillin tolerance (ie, a discordance between the concentration of penicillin required to inhibit and to kill the organisms); however, the role of penicillin tolerance in true bacteriologic treatment failures has never been established [ , ] . it also has been suggested that other species of bacteria present in the normal pharyngeal flora contribute to true bacteriologic failures either by enhancing the colonization and growth of gas in the upper respiratory tract or by producing b-lactamases that inactivate penicillin. the precise role, if any, of these other organisms has not been determined yet, however [ ] . routine throat cultures (or radts) for asymptomatic individuals after completion of antibiotic therapy for group a beta-hemolytic streptococcal pharyngitis are generally not indicated. the interpretation of a positive throat culture (radt) after a course of treatment may be difficult even if the patient remains symptomatic because it is not possible to distinguish persistent carriage from persistent or recurrent infection. under these circumstances, many clinicians elect to administer a second course of antimicrobials. when the physician suspects ''ping pong'' spread to be associated with multiple repeated episodes of group a beta-hemolytic streptococcal infections in a family, simultaneous cultures of all family contacts and treatment of persons whose cultures are positive may be helpful. there is no credible evidence that family pets are reservoirs for gas, and they do not contribute to familial spread. a patient with repeated episodes of acute pharyngitis associated with a positive throat culture (or radt) is a common and difficult problem for the practicing physician. the fundamental question that must be addressed is whether this patient is experiencing repeated episodes of bona fide group a betahemolytic streptococcal pharyngitis or is a gas carrier experiencing repeated episodes of viral pharyngitis. the latter situation is considerably more common than the former. such a patient is likely to be a gas carrier if ( ) the clinical and epidemiologic findings suggest a viral etiology, ( ) there is little clinical response to appropriate antimicrobial therapy, ( ) throat cultures (or radts) are also positive between episodes of pharyngitis, and ( ) there is no serologic response to gas extracellular antigen (eg, antistreptolysin o, anti-dnase b). in contrast, a patient with repeated episodes of acute pharyngitis associated with positive throat cultures (or radts) for gas is likely to be experiencing repeated episodes of bona fide group a beta-hemolytic streptococcal pharyngitis if ( ) the clinical and epidermiologic findings suggest group a beta-hemolytic streptococcal pharyngitis as the etiology, ( ) there is a demonstrable clinical response to appropriate antimicrobial therapy, ( ) throat cultures (or radts) are negative between episodes of pharyngitis, and ( ) there is a serologic response to gas extracellular antigens. when it has been determined that the patient is experiencing repeated episodes of bona fide group a beta-hemolytic streptococcal pharyngitis, some have suggested prophylactic oral penicillin v. the efficacy of this regimen has never been proved, however, and antimicrobial prophylaxis is not recommended except to prevent recurrences of rheumatic fever in patients who have experienced a previous episode of rheumatic fever. tonsillectomy may be considered in a rare patient whose symptomatic episodes do not diminish in frequency over time and in whom no alternative explanation for the recurrent group a beta-hemolytic streptococcal pharyngitis is evident. tonsillectomy has been shown to be beneficial for a relatively small group of these patients, however, and any benefit can be expected to be relatively shortlived [ ] [ ] [ ] . office visits to pediatric specialists: . advance data from vital and health statistics clinical and microbiological evidence for endemic pharyngitis among adults due to group c streptococci epidemiologic evidence for lancefield group c betahemolytic streptococci as a cause of exudative pharyngitis in college students group c beta-hemolytic streptococcal infections in children: nine pediatric cases and review community wide outbreak of group g streptococcal pharyngitis group a, group c, and group g beta-hemolytic streptooccal infections the diagnosis of strep throat in adults in the emergency room a streptococcal score card revisited performance of a predictive model for streptococcal pharyngitis in children practice guidelines for the diagnosis and management of group a streptococcal pharyngitis american academy of pediatrics committee on infectious diseases. red book: report of the committee on infectious diseases principles of appropriate antibiotic use of acute pharyngitis in adults principles of appropriate antibiotic use for acute pharyngitis in adults: background diagnosis of strep throat in adults: are clinical criteria really good enough? empirical validation of guidelines for the management of pharyngitis in children and adults the accuracy of diagnosis of beta-streptococcal infections on clinical grounds comparison of throat cultures and rapid strep tests for diagnosis of streptococcal pharyngitis streptococcal pharyngitis: optimal site for throat culture cultures of streptococcus pyogenes from the oropharynx effect of atmosphere of incubation on the isolation of group a streptococci from throat cultures effect of atmosphere and duration of incubation on primary isolation of group a streptococci from throat cultures effect of atmosphere of incubation on the isolation of group a streptococci from throat cultures comparison of throat culture methods for the recovery of group a streptococci in a pediatric office setting pharyngitis: management in an era of declining rheumatic fever sensitivity of a rapid antigen detection test for group a streptococci in a private pediatric office setting: answersing the red book's request for validation effect of antibiotic therapy on the clinical course of streptococcal pharyngitis clinical evaluation of a latex agglutination test for streptococcal pharyngitis: performance and impact on treatment rates rapid diagnosis of pharyngitis caused by group a streptococci antigen detection test for streptococcal pharyngitis: evaluation of sensitivity with respect to true infections comparison of biostar strep a oia optical immunoassay, abbott test pack plus strep a, and culture with selective media for diagnosis of group a streptococcal pharyngitis critical evaluation of a clia-waived streptococcal antigen detection test in the emergency department comparison of two rapid streptococcus pyogenes diagnostic tests with a rigorous culture standard evaluation of rapid streptococcal detection tests are current rapid detection tests for group a streptococci sensitive enough? evaluating the american academy of pediatrics diagnostic standard for streptococcus pyogenes pharyngitis: backup culture versus repeat rapid antigen testing are follow-up throat cultures necessary when rapid antigen detection tests are negative for group a streptococci? trends in antimicrobial prescribing rates for children and adolescents treatment failures and carriers: perception or problems? effect of penicillin and aureomycin on the natural course of streptococcal tonsillitis and pharyngitis the role of streptococcus in the pathogenesis of rheumatic fever susceptibility of group a beta-hemolytic streptococci to thirteen antibiotics: examination of strains isolated in the united states between meta-analysis of cephalosporin versus penicillin treatment of group a streptococcal tonsillopharyngitis in children so what's wrong with penicillin for strep throat? new approaches to the treatment of group a streptococcal pharyngitis failure of once-daily penicillin v therapy for streptococcal pharyngitis treatment of streptococcal pharyngitis with amoxycillin once a day once-daily therapy for streptococcal pharyngitis with amoxicillin antibiotic resistance: relationship to persistence of group a streptococci in the upper respiratory tract resistance of streptococcus pyogenes to erythromycin and related antibiotics in italy the effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group a streptococci in finland characterization of antimicrobial resistance in streptococcus pyogenes isolates from the san francisco bay area of northern california erthromycin-resistant group a streptococci in school children in pittsburgh community-based surveillance in the united states of macrolide-resistant pediatric pharyngeal group a streptococci during respiratory disease seasons the group a streptococcal carrier state: an enigma efficacy of beta-lactamase-resistant penicillin and influence of penicillin tolerance in eradicating streptococci from the pharynx after failure of penicillin therapy for group a streptococcal pharyngitis association of penicillin tolerance with failure to eradicate group a streptococci from patients with pharyngitis efficacy of tonsillectomy for recurrent throat infection in severely affected children tonsillectomy and adenoidectomy for recurrent throat infection in moderately affected children infection indications for tonsillectomy key: cord- -jwlc fxj authors: vagni, monia; maiorano, tiziana; giostra, valeria; pajardi, daniela title: coping with covid- : emergency stress, secondary trauma and self-efficacy in healthcare and emergency workers in italy date: - - journal: front psychol doi: . /fpsyg. . sha: doc_id: cord_uid: jwlc fxj coping with the coronavirus disease (covid- ) is a significant risk factor for the psychological distress of health workers. hence, this study explores the relationship between coping strategies used by healthcare and emergency workers in italy to manage the stress factors related to the covid- emergency, which may result in the risk of developing secondary trauma. we study differences between healthcare (n = ) and emergency workers (n = ) in terms of their coping strategies, emergency stress, and secondary trauma, as well as the relationships of these differences to demographic variables and other stress factors (instructions and equipment). for this purpose, we collected data from participants through the following questionnaires online: secondary traumatic stress scale – italian version, the coping self-efficacy scale – short form, an original questionnaire on stressors, and the emergency stress questionnaire (to assess organizational–relational, physical, decisional inefficacy, emotional, cognitive, and covid- stress). we performed a t-test, correlational analysis, and hierarchical regression. the analyses reveal that compared with the emergency worker group, the health worker group has greater levels of emergency stress and arousal and is more willing to use problem-focused coping. healthcare workers involved in the treatment of covid- are exposed to a large degree of stress and could experience secondary trauma; hence, it is essential to plan prevention strategies for future pandemic situations. moreover, individual efficacy in stopping negative emotions and thoughts could be a protective strategy against stress and secondary trauma. the coronavirus disease , or the acute respiratory disease caused by severe acute respiratory syndrome coronavirus (sars-cov- ), began spreading in china at the end of and, to date, represents an international health emergency without precedents in terms of its health, economic, and organizational effects on people's lives (world health organization, ) . after china, italy was the first country to be affected by this epidemic, with the first deaths on february , , and a rapid increase in the spread of infection and mortality. covid- was first detected in northern italy, and it then spread, although at different rates of incidence, to the other regions. it was immediately evident that healthcare and emergency workers were at great risk of contagion and that protection and intervention protocols needed to be introduced in the absence of adequate points of reference because of the exceptional nature of the epidemic, the rate of spread of the infection, the seriousness of patients' health condition, and the mortality index. the extreme conditions in which health workers have had to work, especially in the most affected regions in northern italy, are indicated by the following data from the italian national institute of health ( ): over doctors died and , other health workers were infected within the general context of the population of , deaths and , infections in a span of weeks. it was also clear that the medical staff would experience serious psychological repercussions because of the working conditions as well as the difficulty of having scientific points of reference on care and intervention procedures. to this must be added the increase in workload, the extension of working hours and, for health workers, the frequent exposure to the suffering and death of their patients. therefore, healthcare and emergency workers were subjected to serious psychological as well as physical stress. hence, the aim of this study, which was also the aim of a previous study (vagni et al., ) , is to focus on the similarities and the differences in the stress management of two professional groups-healthcare and emergency workersduring the acute phase of the pandemic. both groups have had to deal with covid patients as frontline responders and have been exposed to the related risks of infection and psychological consequences, which, to date, have not been examined in detail through a comparative analysis. as regards the stress that they experience, the literature clearly explains that healthcare and emergency workers who intervene in emergency situations are exposed to the risk of developing dysfunctional reactions that can be identified at different levelsphysical and/or physiological (e.g., psychosomatic disorders, sleep/wake cycle alterations, and sense of tiredness); emotional (e.g., irritability, nervousness, agitation, anger, low self-esteem, and guilt); cognitive (e.g., distractibility, sense of ineffectiveness, and negative anticipation of events); and relational (e.g., increase in conflicts within emergency teams and/or with their organization/institution, and social withdrawal)-and may also develop reactions from secondary trauma (del missier et al., ; sbattella, ; argentero and setti, ; fraccaroli and balducci, ; bellelli and di schiena, ; walton et al., ) . faced with stressful events regarding which they lack previous experience and specific, necessary knowledge, and which cause tension owing to the need for rapid decision timings and a sense of responsibility, emergency workers may experience a sense of decision ineffectiveness. in fact, emergency situations are characterized by high levels of decisional and operational uncertainty with associated regret and guilt (del missier et al., ) . several studies have highlighted that insufficient instructions and a lack of personal protective equipment (ppe) are important predictors of stress for healthcare and emergency workers in large-scale emergencies (oh et al., ; du et al., ; el-hage et al., ; walton et al., ) . oh et al. ( ) highlighted that nurses involved in managing the middle east respiratory syndrome (mers) experienced lower levels of stress when the levels of goods supply and hospital training were higher. some studies have highlighted that frontline healthcare workers had lower secondary traumatization scores than non-frontline health workers and the general public in contrast to the findings of previous research on the sars outbreak in the same area in singapore (chan and huak, ) . according to barleycorn ( ) and tan et al. ( ) , these results may be due to the dedicated training and psychological support given to healthcare workers after the sars outbreak and demonstrate the validity of policy strategies for prevention of stress in the psychological health field. an analysis of studies published from january to march aimed at investigating the stress experience of healthcare workers in facing covid- shows that health workers experienced symptoms of depression and anxiety related to this stressful experience. moreover, the severity of their symptoms was influenced by their age, gender, role, specialization, type of activity performed, and exposure to patients with covid- ; however, prevention, resilience, and social support interventions mediated their response to stress (bohlken et al., ) . in a review of the literature, spoorthy ( ) underlined that sociodemographic variables, such as age, gender, profession, and workplace, and psychological variables, such as poor social support and self-efficacy, affect the stress level experienced by health workers. in addition, covid- emerged as an independent stress risk factor. xiao et al. ( ) found that social support plays a role in reducing the anxiety levels in medical staff and increases their sense of self-efficacy. according to walton et al. ( ) , the specific stressors that health workers face in the covid- emergency are related to the organizational context. the challenges for medical staff include not only an increased workload but also a fear of infection, the need to work with new protocols that change frequently, and the use of ppe. in uncontrollable situations such as a pandemic, when specific action protocols are absent and limited resources are available, health workers must make individual decisions with a heavy burden of responsibility that may be contrary to their moral principles. for example, in the case of covid- , they may have to choose which patients to save because only a few places are available in intensive care. in this regard, cai et al. ( ) showed that for a sample of healthcare professionals who worked closely with covid- patients in hubei, the most stressful factors were the lack of protocols for the treatment of covid- , the scarcity of ppe, the exhausting work shifts, their concern about the risk of infection, and their exposure to the death and suffering of their patients. they also found that the support of superiors proved to be one of the most important motivational factors for medical staff, and the presence of clear guidelines and effective safety protocols were protective factors against the development of stress, in particular, for females. further, walton et al. ( ) identified the organizational stressors as the changes in work shifts, the prevalence of night shifts, an excessive workload, staff roles, autonomy, the lack of support from superiors, and the absence of adequate information and clear instructions. on the basis of these stressors, they estimated that % of the medical staff working on the front line of this pandemic are at risk of developing posttraumatic stress disorder (ptsd). in addition, limited resources, longer shifts, decreased hours of rest, and the occupational risks associated with covid- exposure have increased the physical and mental fatigue, stress, anxiety, and burnout of these staff members (sasangohar et al., ) . the loss of a social support network, which can be an important resilience factor, is another risk factor (ozbay et al., ) . in the covid- emergency, healthcare and emergency workers have often experienced a separation from their affective links, either because of the restrictions on social contacts imposed by the lockdown or the fear of spreading the infection to their family members. to this must be added that although, at first, health workers received unanimous encouragement from the population, later, they also experienced demonstrations of stigma and isolation. some studies have shown that being able to resort to their own social support network is a significant protective factor for health workers dealing with this emergency . as favretto ( ) stated, when individuals experience situations that go beyond their coping strategies, their vulnerability to, and risk of developing, psychopathological reactions increases. studies conducted during previous epidemics, such as the sars, mers, and ebola epidemics, converge in detecting how healthcare and emergency workers may experience extremely high levels of stress and even develop secondary traumatic stress or vicarious trauma. this trauma is defined as an experience of symptoms similar to those found in people with ptsd, such as in emergency nurses working with traumatized patients (beck, ) . figley ( ) defined it as a form of stress that derives from the feelings of empathy experienced when helping traumatized people. the symptoms may include intrusive recurring thoughts, disturbed sleep, fatigue, physical symptoms, hyperarousal, increased stress response, anxiety, depression, and feeling emotional (adriaenssens et al., ) . wolf et al. ( ) described how nurses may feel "overwhelmed, " and this condition becomes a source of moral distress that triggers feelings of powerlessness, guilt, fear, anger, and frustration. the sense of frustration and impotence felt by nurses when they are unable to treat and save a patient has been highlighted as a risk factor for secondary traumatic stress in several studies (missouridou, ) . avoidance and emotional numbing can become tools for self-protection from intrusive symptoms that exceed the personal tolerance level (coetzee and klopper, ; mealer and jones, ) . their frustration obviously intensifies on a patient's death. the onset of ptsd in the health workers involved in treating mers was also detected after the acute phase of the emergency was over, highlighting a risk not only in the immediate period but also in the medium-term period (lee et al., ) . in reference to covid- , updated studies conducted on chinese health workers have already highlighted the strong impact of the epidemic on the psychological health of doctors and nurses. some studies have found that healthcare workers have high levels of anxiety, depression, insomnia, and distress (lai et al., ; li et al., ; zhu et al., ) . in particular, female professionals with more than years of experience and previous psychiatric pathology present more risk factors of developing the symptoms of stress, anxiety, and depression (lai et al., ; zhu et al., ) . huang j. z. et al. ( ) studied stress levels during the covid- emergency in a sample of medical staff. they found that females showed higher levels of anxiety and ptsd than males did and that the levels were higher for nurses than for doctors. moreover, li et al. ( ) found that nurses had developed higher levels of vicarious trauma than those of the general population and that nurses who did not work closely with covid- patients showed a more severe symptomatology, both physical and psychological, compared with their colleagues working on the frontline emergency services. in italy, a study conducted on healthcare workers found that doctors and nurses developed high levels of stress and anxiety, greater than those developed by the general population, and that healthcare workers operating in the north, the area of italy most affected by the virus, showed a more severe symptomatology (simione and gnagnarella, ) . this study also confirmed that females tend to have a greater perception of the risk of infection, which increases their risk of developing the symptoms of anxiety and distress. because of their long, intense exposure to various stressors, it is important to note the nature of the coping strategies used by these healthcare and emergency workers in these situations and their effectiveness in terms of reducing and effectively coping with stress. indeed, the effective management of stress levels in the acute/emergency phase could reduce the risk of developing long-term ptsd or other pathologies, such as anxiety and depression (fullerton et al., ; slottje et al., ; argentero and setti, ; sakuma et al., ; birinci and erden, ; li et al., ) . coping may be defined as a series of cognitive and behavioral efforts to manage specific internal or external issues that test or exceed individual resources (lazarus and folkman, ) . a distinction can be made between problem-focused and emotion-focused coping strategies. the former is aimed at modifying and solving the stressful situation through active interventions. by contrast, emotion-focused coping is aimed at managing the emotions connected to the stressful event and regulating affective reactions, such as anxiety and the tension of response to stress, for example, by trying to avoid the threat (denial) or re-evaluating it (reappraisal). the choice of coping strategies is influenced by the individual's cognitive evaluation of the event, termed secondary evaluation, which involves estimating the resources available and the most effective strategies to deal with the situation (lazarus and folkman, ) . a key element of this assessment is the extent to which the individual can maintain control over the outcome of the situation. the literature indicates that individuals apply dysfunctional coping when they face an uncontrollable event by responding primarily with a coping strategy focused on the problem, and conversely, when they face a controllable situation, they respond with coping strategies focused on emotions (strentz and auerbach, ; vitaliano et al., ) . a coping strategy may be defined as adaptive when the controllability of the stressful event corresponds with the choice of coping strategy: in this case, the subject will experience fewer symptoms related to stress (park et al., ) . the strategies used to cope with trauma may differ among individuals, but they can also vary according to the profession and the features of the traumatic event (nydegger et al., ) . individuals differ in their choice of coping strategies (connor-smith and flachsbart, ) , and factors related to the situation can also have a decisive influence on such choice (brown et al., ) . a few studies have considered the ways in which gender influences the perception of stress in emergency situations and the choice of coping strategy. these studies highlight that females tend to perceive events as more negative and uncontrollable and to resort more to coping strategies focused on emotions and avoidance, whereas males tend to resort more to applying problem-focused coping and to inhibiting emotions (matud, ; matud et al., ; matud and garcia, ) . the literature on the relationship between coping strategies and the stress levels of emergency workers has shown that the use of coping strategies focused on the problem usually tends to correlate with lower stress levels, both in healthcare workers (watson et al., ; howlett et al., ) and in other emergency workers, such as firefighters (brown et al., ) . however, a coping strategy frequently used by emergency workers is that of avoidance and minimization, and this strategy is associated with higher levels of stress (brown et al., ; chang et al., ; kerai et al., ; witt et al., ; theleritis et al., ) . loo et al. ( ) found that in a group of emergency workers, avoidance as well as coping strategies focused on emotions were associated with the development of post-traumatic symptomatology. rodríguez-rey et al. ( ) revealed that among health workers working in a pediatric emergency department, approximately % of the variance in ptsd was explained by the frequent use of coping strategies focused on emotions and the infrequent use of those focused on the problem. in addition, kucmin et al. ( ) , who considered a sample of paramedics, highlighted that the risk of developing ptsd symptoms was predicted by the use of coping strategies focused on emotions. however, the literature does not offer unanimous results. chamberlin and green ( ) found that in a group of firefighters, all coping strategies actually correlated with high levels of stress: the authors explained this finding by suggesting that it is not the individual coping strategies that are maladaptive in themselves, but that greater effort is needed to adjust in stressful situations. by contrast, young et al. ( ) indicated that firefighters use problem-focused coping strategies more often at the beginning of the operation and emotion-focused coping strategies more commonly in the phase of breakdown and fatigue. however, after the incident, they use both strategies (young et al., ) . a meta-analysis by shin et al. ( ) highlighted that different coping strategies have different effects on work burnout: in particular, emotional stress and depersonalization are associated with the use of emotion-focused coping strategies, whereas professional ineffectiveness is associated with the use of problem-focused strategies. further, a few studies have investigated the coping strategies that emergency workers can use during health emergencies similar to covid- . maunder et al. ( ) revealed that healthcare professionals who tended to apply dysfunctional coping strategies, based on avoidance, hostile comparison, or self-blame, tended to develop higher stress levels. wong et al. ( ) highlighted that during the sars epidemic, doctors and nurses tended to use different coping strategies. the doctors tended to turn more to action planning, but this strategy did not affect their stress level. instead, their stress level was positively correlated with their use of coping strategies based on emotional outlets. by contrast, the nursing staff tended to resort more to behavioral disengagement and distraction strategies, which, however, correlated with higher levels of stress among them. in this regard, during the mers epidemic, hospital staff tended to adopt coping strategies related to the use of ppe and the adoption of all prevention measures, as well as social support, whereas the coping strategy that they adopted the least was that based on an emotional outlet (khalid et al., ) . a recent study on healthcare workers in hubei, china, during the covid- epidemic , yielded similar results: to reduce stress, the medical staff tended to rely on active coping strategies, such as using security protocols, practicing social isolation measures, and seeking support from family and friends, but they did not find it necessary to discuss their emotions with a professional. huang l. et al. ( ) found that a sample of nurses working during the covid- emergency presented greater emotional reactions and turned more to problem-focused coping compared with university nursing students. emergency workers must have sufficient self-efficacy in terms of their coping skills to be able to manage and cope with stress levels. self-efficacy in coping appears to be an effective protective factor in relation to stress levels and maladaptive responses (chesney et al., ) . self-efficacy to cope with traumatic events has been effective in reducing the risk of developing ptsd (bosmans et al., ) . the main objective of this study is to identify the coping strategies activated by healthcare and emergency workers to deal with stress factors related to the covid- emergency that may be associated with the risk of developing vicarious or secondary trauma. few studies have considered both groups simultaneously when analyzing the strategies they have adopted to manage stress during the covid- emergency. hence, in this study, we are interested in detecting the similarities and differences in the approaches they adopted to manage their stress during the acute phase of the current pandemic according to walton et al. ( ) , the main acute stress reactions of emergency workers to emergency medical situations are emotional, cognitive, physical, and social reactions. therefore, these factors were included in the questionnaire used in the present study. moreover, reactions linked to stress factors for difficulties due to ineffective decision-making and dealing with stress were also considered (chesney et al., ) . in addition, fears regarding contracting the virus and infecting their own families because of covid- were specifically considered (du et al., ; huang j. z. et al., ; ornell et al., ; walton et al., ) . based on results found in the literature, the specific objectives of this study are as follows: ( ) to examine the relationships between coping strategies, emergency stress, and secondary trauma in healthcare and emergency workers. ( ) to identify significant differences in stress factors, coping strategies, and secondary trauma between two groupshealth workers and emergency workers. participants were selected on a voluntary basis through a trasversal sampling in order to take a picture of the situation caused by the pandemic emergency. we used an internet platform to conduct the study and approached the participants using social media, dedicated mailing lists, and forums. participants from all italian regions completed the questionnaire online. the sample consists of participants- males ( . %) and females ( . %)-whose average age was . years (sd = . ; min -max ). further, . % of the sample were married, . % were separated, and the remaining . % were single. we selected various professional figures who had directly worked in various sectors during the covid- emergency and who could be divided into two main groups. the first, the "health group, " consists of participants ( . %) who were healthcare workers: doctors ( %), nurses ( . %), psychologists ( . %), and seven healthcare assistants ( . %). their average age was . years (sd = . ), and their average years of active professional service was . (sd = . ). the second, the "emergency group, " consists of participants ( . %): emergency workers ( . %), firefighters ( . %), and civil protection staff ( . %), whose average age was . years (sd = . ) and average years of service was . (sd = . ). there was an age difference between the two groups (t = − . ; p < . ), and the distribution of the gender variable differed between the two groups, with males and females in the health group and males and females in the emergency group (χ . ; p < . ). the study involved participants from the entire national territory, and their workplace could be divided as follows: , , and % were from north, central, and south italy, respectively. further, % of the sample worked directly with covid- patients and . % worked in specific covid- departments. among the healthcare workers, % had worked in direct contact with covid- patients, whereas among the emergency workers, only % had assisted these patients (χ . ; p < . ). in the present study, we included two variables, lack of necessary instructions and lack of ppe, in accordance with the findings in the literature on their impact on the stress reactions of healthcare and emergency workers during the covid- pandemic. among the participants, and % of healthcare and emergency workers, respectively, did not have sufficient instructions to intervene (χ . ; p n.s.), and and % of healthcare and emergency workers, respectively, lacked adequate ppe when working (χ . ; p n.s.). this study used an online questionnaire and was conducted during the lockdown period owing to the covid- pandemic. the questionnaire had three parts: one each to collect online informed consent and baseline sociodemographic information, and one with an online series of questionnaires, as described in the next section. participants' anonymity was maintained in collecting the data. the institutional ethics committee approved all the procedures. we administered a series of questionnaires to evaluate the psychological stress and coping style of each participant. we included the following questionnaires. in detail, the arousal items describe situations characterized by anxiety, confusion, physical and psychological complaints, and agitation. intrusion refers to the re-experiencing of the traumatic event-even if not directly suffered-through internal images and memories. instructions for the stss-i indicated that respondents should specify how frequently an item was true for them in the previous weeks. the statements are evaluated on a -point scale ( = never; = very often) that provides scores for intrusion (example items: "i thought about my work with victims when i didn't intend to"; "reminders of my work with clients upset me") and arousal (example items: "i had trouble concentrating"; "i was easily annoyed"; "i expected something bad to happen"; "i felt jumpy"). the reliability coefficients of the instrument are . and . for arousal and intrusion, respectively. the coping self-efficacy scale -short form (cses-sf; chesney et al., ) this is a -item measure of perceived self-efficacy for coping with challenges and threats. this measure focuses on the changes in individuals' confidence in their ability to cope effectively, based on the self-efficacy theory (bandura, ; chesney et al., ) . participants were asked, "when things aren't going well for you, or when you're having problems, how confident or certain are you that you can do the following." then, they were asked to rate on an -point scale the extent to which they believed they could perform important behaviors for adaptive coping. the instrument yields three subscale scores: "problem-focused coping" (α = . ), "stop unpleasant emotions and thoughts" (α = . ), and "support" (α = . ). anchor points on the scale are ("cannot do at all"), ("moderately certain can do"), and ("certain can do"). we constructed an ad hoc -item questionnaire that included yes/no questions to detect stress factors identified by the literature, such as the availability of suitable equipment and the receipt of clear instructions during the covid- coping experience. in this study, we present the results related to two of these items: "instructions, " which refers to having received the necessary instructions to intervene, and "equipment, " which refers to having ppe. predictions of these factors have also been made in other studies (du et al., ; walton et al., ) . in light of the relevance and specificity of the lack of clear information or instructions and adequate ppe in the management of covid- in the italian context, as well as the findings in other studies, we decided to focus attention on these two risk factors. our analysis of the literature revealed that in situations in which they have to cope with a pandemic, several factors may affect the stress of medical staff and emergency healthcare workers and that covid- represents an independent specific stressor (spoorthy, ) . these stress factors have been identified as frequently affecting healthcare and emergency workers in emergency situations and leading to physical, emotional, cognitive, decision-making, relational, and organizational stress (del missier et al., ; sbattella, ; argentero and setti, ; fraccaroli and balducci, ; bellelli and di schiena, ; du et al., ; walton et al., ) . focusing on the specificity of the covid- epidemic, items have been constructed regarding the fears of contracting the infection and of infecting colleagues or family members (walton et al., ) , since covid- represents a factor of independent stress (spoorthy, ) that has great impact (huang j. z. et al., ) . consequently, we constructed the esq consisting of items assessed on a point likert scale, with scores ranging from (not at all) to (very much), grouped into six scales. the participants were asked to indicate how often they experienced certain emotions and thoughts while performing intervention and emergency activities during the covid- pandemic. the scales correspond to the factors identified and confirmed by factorial analysis through an analysis of the main components with orthogonal rotation of factors (varimax). the number of factors to be extracted was initially verified through the unit's largest eigenvalue criterion and, subsequently, by the scree test. the esq is based on six scales: ( ) organizational-relational stress: measures the stress levels related to the organizational context, relationships with colleagues, and social support (consisting of eight items: , , , , , , , and ); ( ) physical stress: composed of five items describing symptoms of physical fatigue ( , , , , and ); ( ) inefficacy decisional stress: consists of five items that analyze decision-making aspects and the possibility to act, which are related to the level of self-efficacy ( , , , , and ); ( ) emotional stress: comprises six items that indicate the participant's emotional reactions ( , , , , , and ); ( ) cognitive stress: consists of four items on the cognitive aspects of stress ( , , , and ); ( ) covid- stress: comprises five items regarding worries related to the covid- emergency ( , , , , and ) . first, we performed pearson's correlation analyses to identify the associations between the variables for the two groups that we considered in this study. subsequently, we checked for significant differences between the two groups as their stress levels, coping strategies, and secondary trauma. we used hierarchical linear regression models to verify the predictive effect of the risk factors (lack of adequate information and ppe) on the different stress levels (in step ). then, we verified the protective effect of the coping strategies (in step ). the models were controlled for age, gender, and group. lastly, we used hierarchical regression models to verify the predictive effect of stress factors on the components of secondary trauma. the models were controlled for age, gender, and group. first, we conducted correlational analyses and comparisons of averages on the reference sample. table shows the correlations between the scales of the esq and the other instruments. preliminary comparisons were made through the student's t-test between the health group and the emergency group in relation to the esq, cses-sf, and stss-i scores. table shows the comparison between the two groups. as shown in table , significant differences emerged between the two groups in relation to their stress and arousal levels. the results indicate higher levels of both for the health group, and that emergency workers turn more to the stop unpleasant emotions and thoughts strategy. further, we performed comparisons with reference to the gender variable to detect differences in the levels of stress factors, coping strategies, and secondary trauma. the emergency group, there were no differences in levels of stress and secondary trauma or coping strategies. moreover, we found similar correlations between the two groups for the stop unpleasant emotions and thoughts strategy and the stress factors, whereas for the other two coping strategies, we found a different association, particularly for the emergency group. however, the t-test comparisons highlight differences only at the level of the stop unpleasant emotions and thoughts strategy. given the findings of the preliminary analyses, we considered it necessary to include the age, gender, and group variables to test the predictiveness of the coping strategies on the participants' stress levels. to test the predictive effect of the coping strategies on various levels of stress, hierarchical regression was conducted. considering the age and gender differences within the groups, we included these variables in all models together with the group variable (health vs. emergency) and the "instructions" and "equipment" variables. the models generated by assuming the esq scales as dependent variables are shown in table . regarding the coping strategies, we observed an important effect of the stop unpleasant emotions and thoughts coping strategy on all the stress scales, except for physical stress where the effect of the focused problem coping strategy is recorded. as shown in table , significant negative associations between stressors and secondary trauma were found for both groups. the hierarchical regression models of stress scales were analyzed for the arousal and intrusion levels of secondary trauma. the models included the age, gender, health/emergency group variables, and the esq scales. the results are shown in table . . *** f = . *** f = . *** f = . *** f = . *** f = . *** *p < . , **p < . , ***p < . ; gender ( = male; = female); instructions ( = yes; = no); equipment ( = yes; = no); cses-sf scales, focused problem; stop emotion_thought; support. the same regression models were generated by including coping strategies as predictors and were analyzed by age, gender, and health/emergency group. compared with arousal, the results of this study show that healthcare and emergency workers both experienced high stressors during the covid- epidemic, exposing them to the risk of developing secondary trauma (dominguez-gomez and rutledge, ; argentero and setti, ; adriaenssens et al., ; duffy et al., ; aisling et al., ; morrison and joy, ; wolf et al., ; roden-foreman et al., ; lai et al., ; li et al., ; zhu et al., ) . we found significant differences between the two groups regarding their reactions and their levels of organizational, physical, and relational stress, their sense of decision-making, and their emotional and cognitive ineffectiveness. compared with emergency workers, healthcare workers had higher stress levels, leading them to perceive more serious tensions and difficulties in teamwork, physical fatigue, somatic illnesses, irritability, and difficulty in maintaining control over the situation, in taking decisions, and in predicting the consequences of their actions. higher levels of stress have been reported related to the fears of contracting covid- and of infecting family members. in line with other studies, we found that the covid- emergency led health workers, in particular, to perceive specific stress factors that affected the organizational area, with consequences in terms of tension in teamwork and a sense of ineffectiveness since they had to intervene without sufficient tools and resources. they also experienced deep emotional reactions of anger, powerlessness, and frustration with inevitable cognitive stress, in terms of increased arousal levels. many of the healthcare workers also developed physical stress, due not only to the lack of sleep but also to the possible forms of somatization of the psychoemotional tension they perceived (sasangohar et al., ; walton et al., ) . the differences recorded between the two groups in stress levels may be explained by taking into account, for example, the fact that the emergency group perceived their intervention with a greater sense of continuity in their usual procedures compared with the health group. the former performed their usual activities on the organizational, cognitive, and procedural levels, although with greater levels of safety and self-protection and a greater frequency of interventions. conversely, the health group had to reorganize aspects such as departments, teams, and shifts to cope with the emergency, which thus involved making radical changes. in addition, the health group helplessly witnessed a large number of deaths of their patients and had to make decisions in conflict with their moral sense and in situations of insecurity and unpredictability regarding the consequences of their actions walton et al., ) . however, in terms of physical stress, there was no predictive effect of the group, which indicates that the health and emergency groups were both exposed to very similar physical stressors. it is important to consider the significant impact of the gender variable. according to other studies, females developed a greater reaction of physical and emotional stress and the sense of decision-making ineffectiveness than did males (lai et al., ; zhu et al., ) . in fact, females apparently tend to perceive events as more negative and uncontrollable, and thus suffer higher levels of stress. further, females tend to resort to coping strategies focused on emotions, which tend to be less effective in emergency situations (matud, ; matud et al., ; matud and garcia, ) . however, in the present study, these gender differences did not have an impact in terms of psychopathological or specific maladaptive consequences, and coping strategies. in fact, females and males perceived a similar sense of efficacy/ineffectiveness in dealing with stressful situations and had similar scores on the secondary trauma scale. the results shown in table also indicate that predictive impact is also assumed by the lack of adequate instructions and knowledge about the emergency and the lack of necessary ppe. in particular, for the health group, the lack of necessary instructions on how to conduct quick interventions affected almost all stressors, leading to tensions or conflicts within the team, difficulty in making decisions, irritability, anger, and frustration. above all, the lack of ppe affected the sense of making the right decisions, the emotional sphere and, most importantly, the fear of contracting the virus or of transmitting it to their families. these results converge with those of other studies that have highlighted that the lack of adequate and specific information and of equipment for healthcare staff in dealing with covid- affected their self-efficacy and the factors protecting them from stress, thus increasing their fear of contracting an infectious disease and causing them greater emotional, decisional, and physical stress. conversely, the professionals who were provided with the necessary knowledge and equipment were more resilient during the emergency response (du et al., ; huang j. z. et al., ; ornell et al., ; walton et al., ) . the lack of specific equipment and instruments in emergency situations along with the risk of infection increases the feeling of poor control, leading to cognitive and emotional stress and a sense of ineffectiveness (placentino and scarcella, ; walton et al., ) . higher levels of stress were found in the health group than in the emergency group because of the absence of ppe, the risk of infection from the virus, and the lack of necessary instructions or prompt information . the incidence of these variables is contained and limited by the use of coping strategies. the coping strategy that assumes a predictive effect, reducing stress levels, is to block those negative or unpleasant emotions and thoughts associated with the risk of developing secondary trauma. in fact, the use of the stop unpleasant emotions and thoughts strategy reduces the arousal and intrusion levels of the secondary trauma. the effectiveness of this strategy in reducing the arousal levels appeared to be greater in the health group. as fraccaroli and balducci ( ) suggested, in situations of high emergency stress, healthcare workers and emergency workers may have a deficit in the cognitive process of emotions, thus failing to identify their emotional reactions, which tends to be associated with maladaptive behaviors. the lack of a complete recognition of one's unpleasant emotions, which tends to be denied and dismissed as a coping strategy, would explain the greater predictive impact of cognitive stress and physical stress on post-traumatic arousal compared with emotional stress. further, the results of this study highlight that the stop unpleasant emotions and thoughts strategy has an inhibitory and therefore effective and highly significant impact on the stress levels and the components of secondary trauma, unlike the problem-focused and social support strategies. the literature points out that the avoidant matrix coping strategies tend to present themselves when healthcare and emergency workers experience a condition of fatigue and exhaustion, and this would explain the presence of the greater acute stress responses in healthcare workers (maunder et al., ; young et al., ) . the results of this study show that the problem-focused coping strategy (the strategy most frequently used in the health group in line with the finding of huang l. et al., ) in this emergency situation did not appear to demonstrate protective efficacy. this is likely to be because the workers were dealing with an emergency that was not yet fully understood and the therapeutic and treatment procedures were not fully known. moreover, the supply of ppe was scarce, especially in the first few weeks of the covid- emergency in italy, in all hospitals (e.g., a lack of respirators and insufficient number of resuscitation beds), which meant that the level of protective efficacy of this strategy may have been lower than the stress levels. in other words, emergency workers, although task-oriented, were faced with a problem that was not fully understood, and in the absence of ppe, perceived poor self-efficacy in terms of trust and belief in their ability to organize and make effective decisions. the strategy that ensured optimal levels of self-efficacy was the one that allowed negative thoughts and emotions associated with the epidemic to be removed from consciousness, which was also found to have a protective function against the risk of developing traumatic symptoms. the government lockdown and the consequent restriction of visits outside the working environment limited the use of coping strategies involving social support, family, and friends, implying a greater use of emotional and cognitive avoidance methods to deal with anguished thoughts, intrusive memories, and the constant vision of corpses or the seriously ill. in this regard, the health group appears to have developed a greater secondary trauma arousal than the emergency group. by contrast, the latter appears to have developed more aspects of intrusiveness related to secondary or vicarious trauma than the health group (see table ). since they were interviewed during the covid- emergency, the healthcare and emergency workers who participated in the present study do not appear to have developed a complete secondary trauma. this may explain the prediction of the stress factors on arousal and not on intrusion. in other words, these individuals were interviewed while the emergency was still in the acute phase and before a structuring of answers in a psychopathological sense could be performed. therefore, performing a follow-up study would be interesting. ptsd can take several months to fully emerge, and its stabilization can depend on the individual's internal as well as external factors. because they blocked negative emotions and unpleasant memories, the healthcare and emergency workers' arousal appears to be mainly due to, at least in the full phase during the epidemiological emergency, the factors of a cognitive matrix, linked with the difficulty of focusing on and identifying the most appropriate intervention strategies, leading them to experience regret, disappointment, and both physical and relational tension. the health workers apparently blocked the emotional aspects related to pain, impotence, and guilt, which allowed them to continue their work. in an emergency phase that is still active, and a few weeks after the start of the pandemic, it is possible to detect high arousal and a lower level of intrusiveness of stressful or traumatic events. this condition may be more likely if the blocking of negative emotions and intrusive thoughts linked to one's personal experience intervenes as a coping strategy. low perceptions of self-efficacy regarding coping has been found to be a predictor of ptsd in other studies (benight and harper, ; bosmans et al., ) . in emergency situations, high stress can cause emergency workers to experience impotence, breathlessness, cognitive difficulties, and difficulties in decision-making and managing emotional reactions along with a prevalence of feelings of anger, as recorded in this study. if the lack of adequate knowledge and of ppe are added to these factors, even professional experts may perceive a loss of self-efficacy in coping and, simultaneously, experience an inability to orient their skills more effectively, thus developing maladaptive responses. this study has several limitations. the first is the limited sample size. the second is that our study involved participants in the very midst of the covid- emergency, which means that the level of stress in healthcare workers may have been more severe and acute. moreover, the long-term psychological implications for the healthcare and emergency population should be investigated for the presence of a full secondary trauma. therefore, a large-sized longitudinal study is called for to further explore the pathogenesis of vicarious traumatization. the third is that participants were not selected based on whether they had existing psychological problems. in proposing the hypothesis of this study, we anticipated that we would be able to discover the relationships between coping strategies, emergency-related stress, and secondary trauma in healthcare and emergency workers and commenced our investigation by assuming that the impact of stress can provoke psychological consequences in emergency situations. in future work, this assumption could be tested to verify whether an emergency situation has a different impact on workers who have already experienced psychological problems. the raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher. the studies involving human participants were reviewed and approved by comitato etico per la sperimentazione umana -cesu of the university of urbino. the patients/participants provided their written informed consent to participate in this study. mv, tm, vg, and dp: conceptualization, writing -original draft preparation, and writing -review and editing. mv, tm, and vg: methodology and investigation. mv and tm: formal analysis and data curation. tm and vg: visualization. mv, tm, and dp: project administration. all authors contributed to the article and approved the submitted version. we would like to thank all the participants involved for the contribution they made to this study during this serious emergency. the impact of traumatic events on emergency room nurses: findings from a questionnaire survey an assessment of psychological need in emergency medical staff in the northern health and social care trust area diagnostic and statistical manual of mental disorders (dsm- ) engagement and vicarious traumatization in rescue workers self-efficacy: the exercise of control awareness of secondary traumatic stress in emergency nursing secondary traumatic stress in nurses: a systematic review emozioni e decisioni. come la psicologia spiega il conflitto tra ragione e sentiment coping self-efficacy perceptions as a mediator between acute stress response and long-term distress following natural disasters yardım çalışanlarında üstlenilmiş travma, ikincil travmatik stres ve tükenmişligin degerlendirilmesi [evaluation of vicarious trauma, secondary traumatic stress and burnout in aid workers covid- -pandemie: belastungen des medizinischen personals [covid- pandemic: stress experience of healthcare workers -a short current review coping with burns: the role of coping self-efficacy in the recovery from traumatic stress following burn injuries incident-related stressors, locus of control, coping, and psychological distress among firefighters in northern ireland psychological impact and coping strategies of frontline medical staff in hunan between stress and coping strategies among firefighters and recruits psychological impact of the severe acute respiratory syndrome outbreak on healthcare workers in a medium size regional general hospital in singapore posttraumatic distress and coping strategies among rescue workers after an earthquake a validity and reliability study of the coping self-efficacy scale compassion fatigue within nursing practice: a concept analysis relations between personality and coping: a meta-analysis psicologia del giudizio e della decisione prevalence of secondary traumatic stress among emergency nurses psychological symptoms among frontline healthcare workers during covid- outbreak in wuhan secondary traumatic stress among emergency nurses: a cross-sectional study health professionals facing the coronavirus disease (covid- ) pandemic: what are the mental health risks? le forme del mobbing compassion fatigue as secondary traumatic stress disorder: an overview stress e rischi psicosociali nelle organizzazioni acute stress disorder, posttraumatic stress disorder, and depression in disaster or rescue workers burnout in emergency department healthcare professionals is associated with coping style: a cross-sectional survey emotional responses and coping strategies of nurses and nursing college students during covid- outbreak mental health survey of medical staff in a tertiary infectious disease hospital for covid- post-traumatic stress disorder and its predictors in emergency medical service personnel: a cross-sectional study from karachi healthcare workers emotions, perceived stressors and coping strategies during a mers-cov outbreak coping styles and dispositional optimism as predictors of post-traumatic stress disorder (ptsd) symptoms intensity in paramedics factors associated with mental health outcomes among healthcare workers exposed to coronavirus disease stress, appraisal, and coping psychological impact of the mers outbreak on hospital workers and quarantined hemodialysis patients moderating effects of coping on work stress and job performance for nurses in tertiary hospitals: a cross-sectional survey in china vicarious traumatization in the general public, members, and non-members of medical teams aiding in covid- control coping behavior and risk of post-traumatic stress disorder among federal disaster responders gender differences in stress and coping styles gender differences in psychological distress in spain psychological distress and social functioning in elderly spanish people: a gender analysis long-term psychological and occupational effects of providing hospital healthcare during sars outbreak posttraumatic stress disorder in the nursing population: a concept analysis secondary posttraumatic stress and nurses' emotional responses to patient's trauma secondary traumatic stress in the emergency department post-traumatic stress disorder and coping among career professional firefighters exploring nursing intention, stress, and professionalism in response to infectious disease emergencies: the experience of local public hospital nurses during the mers outbreak in south korea the impact of the covid- pandemic on the mental health of healthcare professionals social support and resilience to stress: from neurobiology to clinical practice appraisals of controllability and coping in caregivers and hiv+ men: testing the goodness-of-fit hypothesis secondary traumatic stress in emergency medicine clinicians burnout and posttraumatic stress in paediatric critical care personnel: prediction from resilience and coping styles post-traumatic stress disorder and depression prevalence and associated risk factors among local disaster relief and reconstruction workers fourteen months after the great east japan earthquake: a cross-sectional study provider burnout and fatigue during the covid- pandemic: lessons learned from a high-volume intensive care unit manuale di psicologia dell'emergenza vicarious trauma: a contribution to the italian adaptation of the secondary traumatic stress scale in a sample of ambulance operators relationships between coping strategies and burnout symptoms: a metaanalytic approach differences between health workers and general population in risk perception, behaviors, and psychological distress related to covid- spread in italy epidemiological study air disaster in amsterdam (esada): study design mental health problems faced by healthcare workers due to the covid- pandemic: a review adjustment to the stress of simulated captivity: effects of emotion-focused versus problem-focused preparation on hostages differing in locus of control psychological impact of the covid- pandemic on healthcare workers in singapore coping and its relation to ptsd in greek firefighters hardiness, stress and secondary trauma in italian healthcare and emergency workers during the covid- pandemic appraised changeability of a stressor as a modifier of the relationship between coping and depression: a test of the hypothesis of fit mental health care for medical staff and affiliated healthcare workers during the covid- pandemic a study of stress and burnout in nursing students in hong kong: a questionnaire survey stress coping styles in firemen exposed to severe stress it's a burden you carry": describing moral distress in emergency nursing the psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope the effects of social support on sleep quality of medical staff treating patients with coronavirus disease (covid- ) in january and february in china stressors and coping strategies of u.k. firefighters during on-duty incidents covid- in wuhan: immediate psychological impact on health workers key: cord- -n se ajb authors: stańdo, mirella; piatek, paweł; namiecinska, magdalena; lewkowicz, przemysław; lewkowicz, natalia title: omega- polyunsaturated fatty acids epa and dha as an adjunct to non-surgical treatment of periodontitis: a randomized clinical trial date: - - journal: nutrients doi: . /nu sha: doc_id: cord_uid: n se ajb periodontitis is a chronic multifactorial inflammatory disease that leads to the loss of supportive tissues around the teeth with gradual deterioration of masticatory function and esthetics, resulting eventually in the decrease of the life quality. host immune response triggered by bacterial biofilm is responsible for the chronic periodontal inflammation and ongoing tissue loss. omega- polyunsaturated fatty acids (pufa) such as eicosapentaenoic acid (epa) and docosahexaenoic acid (dha) have anti-inflammatory properties, thus may be used for the treatment of chronic inflammatory diseases. in this study, we aimed to evaluate the effect of dietary supplementation with omega- pufa in the patients with stage iii and iv periodontitis. thirty otherwise healthy patients were treated with scaling and root planning (srp). in the test group (n = ), patients were additionally supplemented with . g of epa and . g of dha. in the control group (n = ), patients received only srp. periodontal examination was performed at baseline and three months following initial therapy. salivary samples were taken twice at baseline and at the end of the experiment. we found that there was a statistically significant reduction in the bleeding on probing (bop) and improvement of clinical attachment loss (cal) at three months in the test group compared to the control group. moreover, a statistically significant higher percentage of closed pockets (probing depth ≤ mm without bop) was achieved in the test group vs. control group after three months of treatment. accordingly, the levels of pro-inflammatory cytokines/chemokines interleukin (il)- and il- were markedly lower, while the level of anti-inflammatory il- was significantly higher in the salivary samples of the patients supplemented with omega- pufa at three months in comparison to the patients treated with srp alone. our findings demonstrate that dietary intervention with high-dose of omega- pufa during non-surgical therapy may have potential benefits in the management of periodontitis. periodontitis is a highly prevalent oral disease in humans, affecting nearly % of the population worldwide [ ] . the global burden of disease study conducted by kassebaum et al. revealed that the severe form of periodontitis affects . % of the world's population and it is the sixth most common human disease [ ] . periodontitis is a multifactorial disease individually accelerated or decelerated by different factors. one of them, a bacterial biofilm, leads to dysbiosis and an increase periodontology and oral diseases, medical university of lodz. after the nature of the study was clearly explained to participants, they signed the consent form for participation. forty patients aged - years ( females, males, mean age . ± . ) with generalized stage iii and iv periodontitis were selected for this study. the criteria of the classification of periodontal and peri-implant diseases and conditions [ ] were used for periodontitis staging. stage iii periodontitis was diagnosed when the following criteria were met: interproximal clinical attachment level (cal) ≥ mm in at least two non-adjacent teeth, probing depth (pd) ≥ mm and radiographic bone loss beyond one-third coronal part of the root. stage iv periodontitis was diagnosed when, in addition to the clinical parameters of stage iii, tooth loss ≥ teeth with an impairment of occlusion and masticatory function were found. the inclusion criteria were the following: at least scorable teeth (not including third molars), ≥ teeth with pd ≥ mm, cal ≥ mm, radiographic evidence of bone loss more than one-third of the root length and no periodontal treatment performed within last six months. the exclusion criteria were the following: smoking, history of diabetes or chronic inflammatory disease, any diseases that compromise wound healing, history of radio-or chemotherapy, history of nonsteroidal anti-inflammatory drug (nsaids) intake > days and use of antibiotics or corticosteroids three months prior to the study. all assessments and treatments were carried out at the department of periodontology and oral diseases, medical university of lodz over a two-year period (from october to june ). at the beginning, patients filled in the questionnaire about their general health and diet, followed by the assessment of clinical and radiological periodontal status. following screening, patients were invited to participate in the study. all subjects were randomly assigned to one of the two treatment groups by using a website (www.randomization.com). the test group consisted of patients ( males, females, mean age . ± . ) and the control group consisted of patients ( males, females, mean age . ± . ). all participants received non-surgical periodontal therapy. srp was performed using ultrasonic (piezon master , ems) and hand (mini five gracey curette, hu-friedy) instrumentation under a local anesthesia if necessary. the number of srp sessions varied from to depending on the extent and severity of periodontitis. all patients were instructed about etiology and consequences of periodontal disease and received individual oral hygiene instructions. srp was repeated at the follow-up visit at three months only at the sites with pd ≥ mm positive for bleeding on probing (bop). furthermore, to ensure adequate oral hygiene performance, patients appeared to the recall visit at week after completion of initial srp sessions. oral hygiene was reevaluated by dental plaque disclosing (hurriview ii, beutlich lp, bunnell, fl, usa), and toothbrushing technique and the use of interdental cleaning devices (interdental toothbrushes or dental floss) were checked and reinforced. in the control group, patients received srp only. in the test group, srp was supplemented with the dietary fish oil (fo) rich in omega- pufa epa and dha for three months. fish oil (biomarine medical, liquid, uprp patent # p. ), derived from centroscymnus crepitater, etmopterus granulosus, deania colceai, centrophorus scalpratus, sardinops sagax, scomber scombrus and gadus morhua species, was administered twice a day at a dose of ml. daily dose of ml provided . g of epa, . g of dha, . g of alkylglycerols, . g of squalene, µg of vitamin a and µg of vitamin d . patients were required to fill in a diet diary documenting the daily consumption of fish oil and complaints about its consumption. the compliance with fish oil intake was monitored by calling the patients every four weeks during the medication period to check the bottles back for any possible remaining oil. then, patients received required bottles of the fish oil for subsequent four weeks. periodontal charting was performed by a periodontist (n.l.) blinded to the study allocation of participants. all treatments were performed by m.s. who knows the study allocation of the patients. both charting and treatments were done under magnification (perioptix ttl ready-made . × or . × loups). clinical parameters were evaluated at two time points: at baseline and three months. the following clinical parameters were assessed: full mouth plaque index (fmpi), bop, pd and gingival recession (rec). cal was calculated as a sum of pd and rec at respective sites. all measurements were carried out using an unc- periodontal probe (hu-friedy) and recorded at six sites (buccal, lingual, mesio-lingual, mesio-buccal, disto-lingual and disto-buccal) for each tooth with exclusion of the third molars. a trained and calibrated examiner (n.l.) performed all assessments at baseline and at follow-up. the study examiner (n.l.) participated in a calibration exercise and the standard error of measurement was calculated. the examiner reliability was high with agreement in assessment on all clinical parameters of above % (icc > . ). saliva collection was completed before clinical periodontal measurements and any periodontal intervention. patients were advised not to chew gum, eat or drink anything except water h before sampling. salivary samples were taken from all individuals at baseline and after three months. a total of ml of unstimulated saliva was collected in an empty -ml falcon tube before clinical measurements. patients were asked to lean their heads forward and kept their mouths slightly open with minimal head movement to allow passive drainage of saliva into the test tube. the samples were centrifuged at rpm ( , g) for min at • c degrees. subsequently, the supernatants were collected at . ml eppendorf tubes and frozen at − • c. concentrations of fifty-four cytokines, chemokines and growth factors in saliva supernatants were measured using bio-plex pro™ human chemokine assays (bio-rad laboratories) and bio-plex pro tm human cytokine -plex assay. standards and samples were diluted ( : ) in sample diluent and transferred to the plate containing magnetic beads for h at rt. next, the plate was washed ( ×) and detection antibody was added for min on a shaker ( rpm) at rt. after that, the plate was washed ( ×) and streptavidin-pe solution was added for min. subsequently, the plate was washed ( ×) and samples were re-suspended in µl of assay buffer and analyzed within min. all samples were analyzed at the same time in duplicates. all reagents and technology were provided by bio-rad laboratories (bio-plex ). sample size was estimated based on the primary outcome parameter (mean pd) from a study employing mg of n- pufa during non-surgical periodontal treatment [ ] . the study was powered at % to detect a mean pd difference of . mm (sd ± . ) between test and control groups at three months. the minimum required sample size was calculated to be patients for each group; to compensate for potential dropouts, patients were recruited for each group. the statistical unit was the patient, and all sites with pd ≥ mm at baseline were considered for the statistical analyses. the primary outcome variable was the percent of closed pockets (pd ≤ mm and bop) at three months in relation to baseline. secondary variables were average changes in pd, cal, rec, bop, fmpi, number of sites with pd ≥ mm and concentrations of cytokines/chemokines/growth factors. additionally, for clinical parameters, changes (∆) from baseline to three months were calculated at subject level. following calculation of the mean ± sd of each parameter for both groups, statistical comparison of differences within the groups at two time points were determined by the paired t-test, and the comparisons between the test and control groups were performed using the unpaired students t-test. the verification of normal distribution and analysis of variances were made using the kolmogorov-smirnov test and the fisher's test. changes (∆) from baseline to three months between the groups were analyzed using mann-whitney u test. p < . was considered as the significant difference. forty patients meeting inclusion criteria were included in the study. ten subjects were lost during follow-up because of the following reasons: antibiotic or nsaids intake for other medical reasons (n = ), severe acute respiratory syndrome coronavirus (sars-cov- ) pandemic-related lockdown (n = ) and moving to another country (n = ). thus, per protocol, analyses included only thirty patients aged - years (mean age: . ± . years old) ( figure ). between the groups were analyzed using mann-whitney u test. p < . was considered as the significant difference. forty patients meeting inclusion criteria were included in the study. ten subjects were lost during follow-up because of the following reasons: antibiotic or nsaids intake for other medical reasons (n = ), severe acute respiratory syndrome coronavirus (sars-cov- ) pandemic-related lockdown (n = ) and moving to another country (n = ). thus, per protocol, analyses included only thirty patients aged - years (mean age: . ± . years old) ( figure ). according to the new classification of periodontal diseases [ ] , all the patients presented generalized periodontitis stage iii or iv. the demographic distribution revealed statistical difference regarding age between the test and control groups (table ). according to the new classification of periodontal diseases [ ] , all the patients presented generalized periodontitis stage iii or iv. the demographic distribution revealed statistical difference regarding age between the test and control groups (table ) . no adverse events or anomalies were observed in oral soft and hard tissue examinations. in the intervention group, six subjects reported nausea and irritating fish-scented halitosis as adverse effects that were not strong enough to stop the treatment regimen. no other adverse events were reported. baseline periodontal parameters did not differ between the groups, except for fmpi (table ) . throughout the study, plaque accumulation was markedly reduced in both groups; however, fmpi remained significantly higher in the control group at three months. bop scores showed higher reduction at three months in the patients receiving omega- pufa compared to the control group (p < . ). in both groups, the number of pockets and pd reduced after three months compared to the baseline but there were no statistically significant differences between the groups (p > . ). there was a statistically significant improvement of cal and rec mean values in the test group vs. control group after three months following treatment. moreover, a statistically significant higher percentage of closed pockets (pd ≤ mm without bop) was achieved in the test group vs. control group at three months ( table ). taken together, the patients receiving omega- pufa demonstrated better improvement in resolution of inflammation (greater reduction of bop) and higher gain of cal compared to the patients treated with srp alone. to address whether clinical improvement in the test group in comparison with the control group was accompanied by the appropriate changes in the pro-and anti-inflammatory mediators, we compared salivary levels of fifty-four cytokines/chemokines/growth factors using multielisa. at baseline, no differences in the mean concentrations of cytokines/chemokines/growth factors between the test and control groups were detected. conversely, at three months, we found that mean concentrations of pro-inflammatory il- and il- were markedly lower, and the concentration of anti-inflammatory il- was significantly higher in the salivary samples of the patients who received omega- pufa in comparison to the patients treated with srp alone (table ) . moreover, il- level was increased at three months in both tested groups in comparison to the baseline, suggesting reestablishing the balance between t helper (th) -and th -type immune response towards th . this increase was significantly higher in the test group (p = . ). we also detected different pattern of chemokine release in the patients receiving fo in comparison to the control group. at three months, we detected significant increase of chemokine (c-c motif) ligand (ccl) , ccl , ccl , ccl and chemokine (c-x -c motif) ligand (cx cl) and decrease of ccl , ccl , ccl , chemokine (c-x-c motif) ligand (cxcl) , cxcl and cxcl in the test group (table ) . these changes may reflect cell signaling during tissue healing and repair [ ] . further, we found a significantly higher concentration of fibroblast growth factor (fgf) in saliva in the test group vs. control group at three months. this was a result of a statistically insignificant increase of fgf in the test group (p = . ) and its unchanged level in the control group (p = . ) after treatment (table ) . fgf is a multipotent factor responsible for angiogenesis, keratinocyte organization and wound healing processes. finally, we detected different tendency in granulocyte-colony stimulating factor (g-csf) concentrations between the groups. in the test group, g-csf decreased at three months (p = . ), whereas, in the control group, it increased, but the change was statistically insignificant (p = . ) ( table ) . collectively, we demonstrated regulatory effects of high-dose omega- pufa on mediators of periodontal inflammation and healing. this shift of immune response promoted better resolution of inflammation detected clinically as reduced rates of bop and improved healing detected clinically as cal improvement and better rates of closed periodontal pockets. * statistically significant differences to srp alone; † statistically significant differences between baseline and three months; nd, non detectable; green font-proinflammatory cytokines; pink font-anti-inflammatory cytokines; red font-cxc type chemokines (associated with recruitment of neutrophils and lymphocytes); blue font-cc type chemokines (associated with recruitment of lymphocytes, monocytes, mast cells and eosinophils); black font-growth factors. abbreviations: interleukin- receptor antagonist (il- ra), interferon (ifn), macrophage migration inhibitory factor (mif), granulocyte-macrophage colony-stimulating factor (gm-csf), platelet-derived growth factor bb (pdgf-bb), vascular endothelial growth factor (vegf). the present study showed that supplementation with high-dose omega- pufa as an adjunct to non-surgical treatment of periodontitis can be helpful in management of periodontal disease. it is well recognized that mechanical debridement is a key element in the treatment of periodontal inflammation, with srp being a gold standard of non-surgical treatment. as expected, the improvement of clinical parameters was demonstrated at three months in comparison with baseline in both the study and control groups. we found, however, a statistically significant better improvement in bop and cal at three months in the patients receiving omega- pufa in comparison with srp alone. these parameters are sensitive indicators of resolution of inflammation and tissue healing that both are crucial in preserving healthy and stable dentition for a long period of time in patients with periodontitis. we confirmed that epa and dha can soothe the ongoing inflammation in periodontitis and can be used as hmt non-surgical treatment. our results are in accordance with the study of deore et al. demonstrating that dietary supplementation of omega- pufa with non-surgical periodontal treatment had significant effect on clinical parameters such as gingival index (gi), bop, pd and cal, but no effect on serum c-reactive protein (crp) level [ ] . in contrast, other studies showed that using omega- pufa during non-surgical periodontal treatment had no effect on clinical parameters [ , ] . these differences can result from much lower doses of omega- pufa than used in our study. keskiner et al. showed that daily dietary supplementation with low-dose omega- pufa ( . mg epa and . mg dha) for six months may reduce salivary tnf-α, however no significant impact on clinical parameters was gained [ ] . it was concluded that the effect of omega- pufa could be cumulative and time-dependent. in another study, the effect of daily consumption of mg epa and mg dha for months was analyzed. a significant increase of epa level and decrease of the arachidonic acid/epa serum ratio (mean levels of : ) was achieved [ ] . earlier studies suggested that optimal omega- /omega- ratio should be approximately : - : , and not exceeding : , to maintain health [ ] [ ] [ ] . this suggests that higher intake of omega- pufa for a longer period can result in better outcome. therefore, in our study, we decided to use high-dose omega- pufa ( . g of epa and . g of dha). this is in line with the studies demonstrating beneficial effects of omega- pufa supplementation in other chronic inflammatory diseases such as rheumatoid arthritis ( . g of omega- pufa per day) or crohn's disease ( . g of omega- pufa per day) [ ] . to our surprise, the clinical effects of . g of epa and . g of dha in our study were clearly detectable at three months, thus dietary intervention with high-dose omega- pufa seems to provide rapid anti-inflammatory effect detectable at the clinical level. moreover, omega- and omega- pufa are essential because of the inability of humans, and all mammals alike, to synthesize them. therefore, they must be obtained from properly balanced diet. it has been estimated that current western diet is deficient in omega- pufa with a ratio of omega- to omega- of - / . today, industrialized societies can be characterized by an increased intake of saturated fat, omega- fatty acids and trans fatty acids and a decreased consumption of omega- fatty acids [ , ] . the effects of omega- pufa were also tested in the patients with gingivitis. similar to the results of our study, the decrease of bop was demonstrated in the patients that received omega- pufa in addition to the scaling and oral hygiene instructions versus control group, thus anti-inflammatory properties of epa and dha were also clinically detectable at the less advanced stages of periodontal inflammation [ , ] . some studies employed acetylsalicylic acid together with omega- pufa [ , , , ] . simultaneous administration of omega- pufa and low-dose aspirin resulted in a synergistic interaction of both compounds in resolution of inflammation. elwakeel and hazaa revealed in the patients with diabetes mellitus a significant improvement in clinical parameters plaque index (pi), gi, pd and cal in the test group versus control group, and a highly significant reduction in the il- β level in the gingivocrevicular fluid (gcf) in the experimental group [ ] . another study demonstrated a significant reduction in pd and cal in the group receiving omega- pufa plus aspirin during non-surgical periodontal treatment compared to the control group, with significantly reduced levels of salivary rankl and matrix metalloproteinase (mmp) in the test group [ ] . one study tried to determine whether low-dose of mg of acetylsalicylic acid in combination with a total daily dose of approximately g of dha without mechanical debridement would be beneficial in the treatment of periodontitis versus control group where only mg of aspirin + corn/soy oil capsules was administered. in the intervention group with dha, decreases in pd and gi and no changes in pi and bop were demonstrated with the reduced levels of crp and il -β in gcf. moreover, when acetylsalicylic acid was used alone, no beneficial effect on periodontal inflammation was noted [ ] . although the results of the above-mentioned studies are favorable, it should be kept in mind that providing patients with low-dose aspirin as an adjunct to non-surgical treatment might be questionable. firstly, long-term intake of aspirin is mainly recommended in patients as a primary and secondary prevention of cardiovascular events, where possible adverse effects are less dangerous than the progression of cardiovascular disease [ ] . secondly, acetylsalicylic acid taken for a long period of time inhibits constitutive cyclooxygenase- , which is involved in maintaining physiological homeostasis [ ] . another goal of our study was to determine the effect of omega- pufa on the inflammatory mediators released during periodontal inflammation. the levels of cytokines/chemokines/growth factors were analyzed in the salivary samples at three months. saliva is a good medium for detection of soluble mediators released during periodontal inflammation into gingivocrevicular fluid and subsequently to the saliva. we decided to investigate salivary samples because of the simplicity of the methodology in comparison with gcf collection and analysis [ , ] . saliva as a non-invasive diagnostic fluid was previously used for determining the inflammatory status of periodontal patients with good results [ , ] . it is generally agreed that non-surgical periodontal treatment can result in downregulation of pro-inflammatory cytokines associated with bone connective tissue and bone metabolism. the majority of studies demonstrated significant reduction of salivary concentrations of il- β, il- , il- , tnf-α and gm-csf, as well as increases in il- and il- [ ] [ ] [ ] [ ] [ ] . however, some studies failed to show the same pattern pointing to quite high variability of salivary cytokine levels in the patients with periodontitis [ , ] . in our study at three months after srp, the reduction of il- β was statistically significant in the control group, while the reductions of il- , il- , il- , tnf, ccl , ccl , ccl , cxcl , cxcl , cxcl and g-csf were significant in the test group. when comparing the effect of fish oil on the inflammatory mediators, we found that the levels of proinflammatory il- and il- were markedly lower, and the level of anti-inflammatory il- was significantly higher in the salivary samples of the patients that received omega- pufa in comparison with the patients treated srp alone. both il- and il- are known for neutrophil recruitment, and an important role of il- signaling in tissue damage during periodontal inflammation was recently described [ ] . resolvin d (rvd ), a product of dha metabolism, was shown to prevent alveolar bone loss in porphyromonas gingivalis-induced experimental periodontitis by inhibiting th /th polarization [ ] . moreover, in the mouse model of periodontitis, it was demonstrated that il- plays a protective role by dampening an excessive il- -mediated inflammatory response majorly through innate immune cells [ ] . in line with these findings, we previously reported that il- may induce a population of il- -producing neutrophils in periodontitis [ ] . we also detected an increased salivary concentration of il- in the test group after treatment. il- induces th cell differentiation from naive t cells and their subsequent ifn-γ production. previous studies showed that il- and ifn-γ did not have a major effect on the pathogenesis of infection-stimulated bone resorption in vivo [ ] , and short-term non-surgical therapy resulted in a significant improvement in periodontal indices and a marked increase in the salivary il- levels [ ] . however, an osteolytic role of il- in the pathogenesis of periodontitis was also suggested [ ] . interestingly, ifn-γ, a th -type cytokine that was increased in the saliva of the test group seems to act antagonistically on th differentiation [ ] and osteoclastogenesis [ ] . in this study, we also found that an intake of fish oil rich in omega- pufa slightly promoted an increase of salivary concentrations of fgf that was previously shown to promote bone formation through accelerating the differentiation of osteoprogenitor cells and to stimulate proliferation and migration of periodontal ligament cells [ ] . host modulatory therapy is one of the main focuses of interest for many of the investigators and currently considered a promising treatment approach. many medications were proposed in this context such as non-steroidal anti-inflammatory drugs, tetracyclines or bisphosphonates which may be delivered locally or systemically [ , , ] . however, those pharmacological substances can be used only to a limited extent and have undesirable effects. thereby, our attention was focused on safer, naturally derived pufa epa and dha. although the studies analyzing omega- pufa in the treatment of periodontitis are limited, and the study design differed in the aspects such as epa and dha dose, duration of study, number of participants and inclusion criteria, a general conclusion can be drawn that this approach provides favorable clinical outcomes. we need to emphasize that non-surgical periodontal treatment is required for the patients in terms of cooperation and proper regimen. in particular, adequate daily oral hygiene and controlling the risk factors, such as smoking habit or diabetes, may be crucial in the long-term maintenance of disease remission. keeping in mind the systemic effects of untreated periodontal inflammation on general health, introduction of the natural and safe dietary supplementation during treatment of periodontitis may have additional beneficial effects. in this context, omega- pufa seem to be particularly beneficial in the patients with hypercholesterolemia/cardiovascular diseases and periodontitis [ ] . our study has a few limitations. one of them is the baseline difference between the test and control groups in terms of age and fmpi. this was a result of a relatively high dropout rate, mainly due to sars-cov- epidemic-related lockdown. when we took into account the baseline data of all forty patients that were recruited, no differences between the groups in the age and fmpi were noted. although both groups at baseline have comparable advancement of periodontitis, we need to bear in mind that age and plaque accumulation are the risk factors of periodontitis and may lead to the worse treatment response [ ] . however, it has been suggested that the increased level of periodontal destruction observed with aging is the result of cumulative damage rather than a result of its increased rates [ ] . thus, aging is not a risk factor per se. there are very limited data on periodontal healing in older individuals showing both delayed [ ] and normal healing after periodontal treatment of people with moderate-to-advanced forms of periodontitis [ ] . in general, aging is not perceived as a negative predictor for unfavorable treatment response and risk factor for disease progression [ ] . another limitation of the study is the use of fish-derived oil mixture instead of isolated epa and dha. natural fish oil was chosen to mimic dietary conditions where a range of essential oils is consumed. however, we cannot rule out that other components of the fish oil affected the outcome of our study. specifically, squalene and alkylglycerols present in the fish oil may affect inflammatory immune response activating th -type il- and ifn-γ cytokine production and increasing total antioxidant status of serum [ , ] . because of the choice of fish oil as a source of epa and dha, no placebo was employed in our study and patients were aware of the treatment allocation. in our experience, the taste of fish oil cannot be masked, even when it is taken in capsules (as a result of belching). future research with a larger sample size and long-term observation are warranted to validate the usage of omega- pufa as an adjunctive dietary therapy option to treat periodontitis. in conclusion, the results obtained in this study suggest that daily dietary supplementation with high-dose omega- pufa can be used as an adjunct to non-surgical treatment of periodontist as host modulatory therapy. no adverse events were recorded during omega- pufa treatment. omega- pufa had favorable effects on resolution of inflammation and tissue regeneration in the patients with periodontitis. our research showed significant improvement of clinical parameters accompanied by the reduction of salivary levels of pro-inflammatory cytokines/chemokines in favor of higher level of anti-inflammatory il- and pro-regenerative fgf . biomarine medical fish oil composition is restricted by patent no. uprp p. . assessing the role of porphyromonas gingivalis in periodontitis to determine a causative relationship with alzheimer's disease global, regional, and national prevalence, incidence, and disability-adjusted life years for oral conditions for countries, - : a systematic analysis for the global burden of diseases, injuries, and risk factors clinical study laser supported reduction of specific microorganisms in the periodontal pocket with the aid of an er clinical improvement following therapy for periodontitis: association with a decrease in il- and il- bone versus immune system modulation of host pge secretion as a determinant of periodontal disease expression periodontal host modulation with antiproteinase, anti-inflammatory, and bone-sparing agents. a systematic review new directions in host modulation for the management of periodontal disease: commentary host response modulation in the management of periodontal diseases dietary supplementation with low-dose omega- fatty acids reduces salivary tumor necrosis factor-α levels in patients with chronic periodontitis: a randomized controlled clinical study effect of omega fatty acids plus low-dose aspirin on both clinical and biochemical profiles of patients with chronic periodontitis and type diabetes: a randomized double blind placebo-controlled study omega fatty acids as a host modulator in chronic periodontitis patients: a randomised, double-blind, palcebo-controlled, clinical trial serum level changes of long chain-polyunsaturated fatty acids in patients undergoing periodontal therapy combined with one year of omega- supplementation: a pilot randomized clinical trial the efficacy of host response modulation therapy (omega- plus low-dose aspirin) as an adjunctive treatment of chronic periodontitis (clinical and biochemical study) docosahexaenoic acid and periodontitis in adults: a randomized controlled trial fatty acids from fish: the anti-inflammatory potential of long-chain omega- fatty acids omega- polyunsaturated fatty acids as an adjunct to non-surgical treatment of periodontitis resolving inflammation: dual anti-inflammatory and pro-resolution lipid mediators staging and grading of periodontitis: framework and proposal of a new classification and case definition chemokine changes during oral wound healing omega- /omega- essential fatty acids: biological effects dietary n- and n- polyunsaturated fatty acids: from biochemistry to clinical implications in cardiovascular prevention importance of a balanced omega /omega ratio for the maintenance of health. nutritional recommendations therapeutic potential of n- polyunsaturated fatty acids in disease the importance of the omega- /omega- fatty acid ratio in cardiovascular disease and other chronic diseases omega- fatty acids in inflammation and autoimmune diseases mechanism of action of aspirin-like drugs effect of periodontal surgery on osteoprotegerin levels in gingival crevicular fluid, saliva, and gingival tissues of chronic periodontitis patients adjunctive treatment of chronic periodontitis with daily dietary supplementation with omega- fatty acids and low-dose aspirin recent trends in the prevalence of low-dose aspirin use for primary and secondary prevention of cardiovascular disease in the united states human saliva as a diagnostic material the clinical value of salivary biomarkers for periodontal disease the influence of vitamin d supplementation on local and systemic inflammatory markers in periodontitis patients: a pilot study non-surgical periodontal therapy reduces saliva adipokine and matrix metalloproteinase levels in periodontitis impact of non-surgical periodontal treatment on salivary expression of cytokines related to bone metabolism interleukin- levels in gingival crevicular fluid and saliva of patients with chronic periodontitis after periodontal treatment comparative evaluation of cytokines in gingival crevicular fluid and saliva of patients with aggressive periodontitis the effect of scaling and root planning on salivary tnf-α and il- α concentrations in patients with chronic periodontitis. open dent evaluation of salivary biomarker profiles following non-surgical management of chronic periodontitis antagonistic effects of il- and d-resolvins on endothelial del- expression through a gsk- β-cebpβ pathway resolvin d restrains th immunity and prevents alveolar bone loss in murine periodontitis il- dampens an il- -mediated periodontitis-associated inflammatory network induction of human il- -producing neutrophils by lps-stimulated treg cells and il- gamma interferon (ifn-γ) and ifn-γ-inducing cytokines interleukin- (il- ) and il- do not augment infection-stimulated bone resorption in vivo effect of periodontal therapy on salivary interleukin- levels in chronic periodontitis interleukin- induces receptor activator of nuclear factor-kappa b ligand expression by human periodontal ligament cells th cells in human disease t-cell-mediated regulation of osteoclastogenesis by signalling cross-talk between rankl and ifn-γ evaluation of recombinant human fgf- and pdgf-bb in periodontal regeneration: a systematic review and meta pharmacotherapy for host modulation in periodontal disease: a review fitoterapia marine omega- fatty acids in the prevention of cardiovascular disease risk factors for periodontitis current view of risk factors for periodontal diseases wound healing in the gingiva of young and old individuals effect of age on healing following periodontal therapy effect of high doses of shark liver oil supplementation on t cell polarization and peripheral blood polymorphonuclear cell function an update on the therapeutic role of alkylglycerols key: cord- -y vkpuv authors: nan title: global initiative for chronic obstructive lung disease strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease: an asia–pacific perspective date: - - journal: respirology doi: . /j. - . . .x sha: doc_id: cord_uid: y vkpuv abstract: chronic obstructive pulmonary disease (copd) is a major public health problem and its prevalence and mortality are increasing throughout the world, including the asia–pacific region. to arrest these worldwide trends, the global initiative for chronic obstructive lung disease (gold) expert panel's global strategy for the diagnosis, management, and prevention of copd was published in . based on recently published clinical trials, the gold statement was updated in . the asia–pacific copd roundtable group, a taskforce of expert respirologists from the asia–pacific region, has recently formulated a consensus statement on implementation of the gold strategy for copd in the asia–pacific region. the key issues identified by the copd roundtable group for comment are: (i) where there is no access to spirometry, diagnosis of copd could be suspected on the basis of history, symptoms and physical signs; (ii) inhaled bronchodilators are the preferred regular treatment for copd in the region, but oral bronchodilators may be considered if the cost of inhaled bronchodilators is a barrier to treatment; (iii) the use of an metered dose inhaler with spacer in place of a nebulizer is recommended in the treatment of acute airflow obstruction in patients with copd; (iv) influenza vaccination is recommended for all patients with copd in communities where there is a high likelihood of severe acute respitory syndrome; and (v) simplified pulmonary rehabilitation programmes should be established in areas where comprehensive programmes are unavailable. physical exercise training and education on smoking cessation should be core elements of any rehabilitation program. in summary, the copd roundtable group supports implementation of the gold strategy for the diagnosis, management and prevention of copd in the asia–pacific region, subject to the additions and modifications to the guidelines suggested above. chronic obstructive pulmonary disease (copd) is a major public health problem throughout the world. a world health organization (who)/world bank study estimated the worldwide prevalence of copd in to be . / in men and . / in women. , copd was estimated to be the sixth most common cause of death globally, and the twelfth most common cause of burden of disease worldwide. furthermore, copd is expected to increase in prevalence and mortality over the coming decades. for example, of the four leading causes of death in the usa, copd is the only one that continues to increase in prevalence. copd is also projected to be the fifth greatest cause of worldwide burden of disease in , and the third most common cause of death internationally. copd is associated with huge economic costs. in the uk for example, copd accounts for % of all working days lost, and in the usa, the estimated annual cost of copd is over us$ billion. relatively little is known about the prevalence, morbidity and mortality of copd in developing countries, including those in the asia-pacific region. a recent study in thailand estimated the prevalence of copd in to be per people at risk (smokers aged ≥ years), but this estimate is based on the number of people hospitalized with copd and, therefore, represents only the prevalence of moderate to severe disease. a who/world bank study, , which estimated the prevalence of copd in different areas of the world (using informed expert opinion or extrapolations from comparable regions where published data were lacking), suggested that the prevalence of copd in china in was . / in males and . / in females. these estimates have been challenged by recent reports of an overall copd prevalence of . % ( per people aged ≥ years) in three regions of china. the who/world bank study also estimated a copd prevalence of . / in males and . / in females in for 'other asia and islands' (an amalgam of countries and island states in the asia-pacific region). , furthermore, data from that study were used to extrapolate a copd prevalence figure of . % ( per people) for the entire asian population. these estimates, which are not necessarily based on actual epidemiological data, do not provide reliable information about the precise prevalence of copd in the asia-pacific region. this in turn means that governments are unaware of the regional economic and human impact of copd, and are, therefore, unable to plan effective strategies for reducing the burden of disease. large-scale, population-based, epidemiological studies are logistically difficult and expensive to conduct. an alternative method for assessing copd prevalence that makes use of a well-validated computerized tool for predicting prevalence on the basis of local copd risk factor data (prevalence of smoking, exposure to biomass fuel, air pollution, high-risk occupations etc.) has shown that the overall pre-valence of clinically significant copd amongst adults ≥ years old in the asia-pacific region is approximately . %. these data suggest that copd is a more significant problem in the region than has been previously realised. furthermore, trends in risk factors (increased incidence of smoking, greater longevity with associated increased risk of succumbing to chronic diseases such as copd, and increased exposure to environmental pollution) suggest that the prevalence of copd in the asia-pacific region is likely to increase over coming years. in , an international group of copd experts met to discuss the development of a global initiative for chronic obstructive lung disease (gold). cosponsored by the us national institutes of health (heart, lung, and blood institute (nhlbi)) and who, the gold expert panel consisted of health professionals from around the world with expertise in respiratory medicine, epidemiology, socioeconomics, public health, and health education. the model for this initiative was the global initiative for asthma (gina), an international strategy for developing comprehensive evidence-based guidelines on asthma control and management, using a committee of experts. the gold expert panel agreed that the objectives of gold should be to increase awareness of copd (amongst governments, public health officials, healthcare workers, and the general public), improve prevention and management of the disease, decrease copd morbidity and mortality, and encourage new research into the disease. in , the gold expert panel conducted a workshop to review existing copd guidelines and advances in understanding of the disease, the ultimate aim being to prepare a consensus guidelines document/global strategy for the diagnosis, management, and prevention of copd. this was published, in both full workshop report and executive summary forms, early in . updated gold guidelines, , based on clinical research published from june to march that has had an impact on the management of copd, were published in july . these reports present evidence-based guidelines on copd diagnosis and management, and, importantly, include grades (a, b or c) for the weight of scientific evidence supporting each recommendation. the gold strategy presents a copd management plan divided into four components: (i) assessment and monitoring of disease; (ii) reduction of risk factors; (iii) management of stable copd; and (iv) management of exacerbations. information and recommendations presented in the gold report are based on 'best-validated current concepts of copd pathogenesis and the available evidence on the most appropriate management and prevention strategies'. the content of the report was developed by experts in copd research and clinical management, then extensively reviewed by other experts, scientific societies, the nhlbi and who, before publication. gold guidelines are to be audited after implementation to assess the impact of the programme on outcomes. the updated gold guidelines include the following changes: (i) the classification system has been modified to: i = mild, ii = moderate, iii = severe, iv = very severe; (ii) for moderate to very severe copd, the use of regular treatment with long-acting bronchodilators, including tiotropium, rather than short-acting bronchodilators is recommended (evidence level a); (iii) inhaled glucocorticosteroids are recommended only in patients with copd of severity iii and frequent exacerbations (evidence level a); (iv) rehabilitation programmes should be ≥ months in duration (evidence level b); and (v) nurse-administered home care represents an effective and practical alternative to hospitalization in selected patients with exacerbations of copd without acidotic respiratory failure. while the gold recommendations are intended to have universal applicability, the expert panel drew attention to some possible difficulties in the implementation of gold recommendations in developing countries. thus, the gold expert panel noted: that 'reproducible and inexpensive exercise-testing methodologies . . . suitable for use in developing countries need to be evaluated and their use encouraged'; that 'spirometers need to be developed that can ensure economical and accurate performance when a relatively untrained operator administers the test'; and that 'methods and strategies for implementation of copd management programs in developing countries will require special attention'. thus, the gold expert panel acknowledged that some aspects of the gold guidelines may require amendments to ensure their relevance, applicability and usefulness in developing countries. in the asia-pacific region, this task has been taken up by the asia-pacific copd roundtable group. the copd roundtable group is a taskforce of expert respirologists from the asia-pacific region that has met - times per year since july . the copd roundtable group has the support of the asia-pacific society of respirology (apsr) and is supported by an educational grant from boehringer ingelheim and pfizer. the main objectives of the copd roundtable group are to: (i) increase awareness of copd in the region; (ii) assess the regional relevance and applicability of the gold guidelines and facilitate their implementation; (iii) identify copd-related problems specific to the region for discussion and resolution; (iv) stimulate regional collaborative research into copd. as noted above, however, one of the main reasons for the establishment of the copd roundtable group was to facilitate regional implementation of gold guidelines; to this end, the roundtable group has developed a consensus statement on the implementation of the gold strategy for copd in the asia-pacific region. the relevance and practicality of the gold recommendations for the region were considered by the copd roundtable group at several meetings. during this review process, roundtable members focused on the implications of implementing the gold strategy in their own countries, taking into account both local published data and members' experience of copd diagnosis, management and prevention in the region. on the basis of these deliberations, the copd roundtable group concluded that implementation of gold recommendations would be very useful in the asia-pacific region. particular strengths of the gold strategy identified by the roundtable included: (i) the emphasis on the need for spirometry in the diagnosis and assessment of copd; and (ii) the inclusion of a disease severity classification which recognized the importance of intervention at a presymptomatic disease stage. the copd roundtable group also endorses the gold guidelines on smoking cessation and in view of the immense burden of smokingrelated copd in the asia-pacific region believes that greater efforts to achieve smoking prevention and cessation should be encouraged in this part of the world. in addition, the copd roundtable group identified that some aspects of the gold guidelines require amendment to suit the needs of the region. these amendments are discussed below. the gold document unequivocally identifies spirometry as the gold standard for the diagnosis and assessment of copd because it is the most reproducible, standardized, and objective way of measuring airflow limitation. specifically, a fev to fvc ratio of < %, together with a postbronchodilator fev of < % predicted, confirms the presence of an airflow limitation that is not fully reversible. gold also states that 'health care workers involved in the diagnosis and management of copd patients should have access to spirometry'. , the copd roundtable group fully supports this recommendation and encourages the use of spirometry for the diagnosis and assessment of copd patients in the asia-pacific region. however, the roundtable group also notes that, for a number of reasons (e.g. costs, inaccessibility, lack of awareness, lack of technical knowledge etc.), spirometry is unavailable to large numbers of patients in many asian countries. the gold guidelines state: 'where spirometry is unavailable, the diagnosis of copd should be made using all available tools'. therefore, for the asia-pacific region, the copd roundtable group recommends addition of the following statement to the gold guidelines relating to the diagnosis and assessment of copd. where there is no access to spirometry, the diagnosis of copd could be suspected on the basis of history, symptoms and physical signs. if spirometry is not available, peak flow measurements can be used to exclude asthma but not to diagnose copd. a forced expiratory time (fet, which is the time taken for an individual to forcefully exhale through an open mouth, from total lung capacity until airflow becomes inaudible. the time taken to exhale should be recorded with a stopwatch; ≥ s is abnormally prolonged) † > s is a good guide to the presence of an fev /fvc ratio < % (i.e. obstructive disease). while chest x-rays are not recommended for diagnosing copd, they can be useful for excluding other common diseases that can give rise to airway obstruction (e.g. tuberculosis, bronchiectasis, lung cancer etc.). because there is very little correlation between peak flow measurement and symptoms in longitudinal studies of copd patients and copd patients can have improvements in symptoms and quality of life without improvements in lung function, the group does not recommend the use of serial measurements of peak flow to assess or monitor any response to therapy. the mrc dyspnoea scale, while not used for diagnosis of copd, is a functional scale that is useful for assessing shortness of breath and disability, and can assist in the evaluation of disease severity. gold recommends inhaled bronchodilators as the preferred option for symptomatic management in stable copd, either as regular treatment or on an asneeded basis. , bronchodilator therapy prevents symptoms or reduces their severity, but does not modify the decline in lung function in copd. inhaled bronchodilator therapy is preferred over oral therapy because lower doses are needed to achieve a therapeutic response, and because adverse effects are less likely to occur, and resolve more rapidly after treatment withdrawal. the copd roundtable group supports the promotion of inhaled therapy as the preferred route of bronchodilator delivery for copd patients in the region. however, the roundtable group also notes that, in some asia-pacific settings, where the cost of therapy is not reimbursed and the patient has limited financial resources, oral bronchodilator treatment may be less expensive and is, therefore, an appropriate alternative to inhaled therapy. while emphasising that inhaled bronchodilators remain the preferred option (as stated in gold), the copd roundtable group recommends addition of the following statement to the gold guidelines relating to use of bronchodilators in the treatment of stable copd. wherever possible, copd patients should receive bronchodilator therapy via the inhaled route. however, oral bronchodilators ( b -agonists, theophylline) may be appropriate if the cost of inhaled bronchodilators is a barrier to treatment. the gold report notes: when treatment is given by the inhaled route, attention to effective drug delivery and training in inhaler technique is essential. copd patients may have more problems in effective coordination and find it harder to use a simple metered dose inhaler (mdi) than do healthy volunteers or younger asthmatics. it is essential to ensure that inhaler technique is correct and to recheck this at each visit. patients who have been prescribed drugs using mdi and have trouble mastering inhaler technique should attempt to use a spacer with the mdi. the copd roundtable group notes that use of spacers results in more efficient delivery of bronchodilator to the lungs compared to use of the mdi alone, particularly in patients who have not mastered the correct inhaler technique. furthermore, this approach is as effective as nebulized drug delivery in patients who have been taught how to use a spacer plus a mdi correctly. in these patients, alternative inhaler devices may also be tried to optimize the benefits of inhaled therapy. for example, dry powder inhalers (dpi) are breath activated and do not require the same level of hand-and-mouth coordination as mdi, so some copd patients may find these easier to use. for these reasons, the copd roundtable group recommends addition of the following statements to the gold guidelines relating to use of bronchodilators in the treatment of stable copd. patients who have difficulty mastering inhaler technique with the mdi should try the use of a spacer with the mdi. different types of spacers and inhaler devices should be experimented with in an attempt to identify a device that the patient can use easily and effectively. as with inhaler technique, patients require training in how to use a spacer effectively. this approach is more convenient than recommending treatment with a nebulizer. nebulizers may not be available for many copd patients in the asia-pacific region because they are expensive, require set-up, a power source and filling with a nebulizer solution. furthermore, in areas that are affected by severe acute respiratory syndrome (sars), it is thought that the risk of transmission of the virus may be reduced by the use of spacer devices. the asia-pacific region was severely affected by an epidemic of sars caused by a new coronavirus, with far-reaching health, societal and economic costs. the epidemic peaked in february to may . while the epidemic of sars has now been brought under control, the who warns that in the absence of a vaccine and a cure the possibility of a seasonal recurrence cannot be ruled out. it is important that sars is differentiated from other respiratory diseases, particularly from the 'triggers or mimics' of an acute exacerbation of copd. currently, there is no gold standard for diagnosis, which usually encompasses suspicion, isolation and then empirical use of antibiotics and supportive treatment. sars is thought to be transmitted via droplets and close contacts. however, airborne and other modes of transmission cannot be excluded. for this reason it is recommended that nebulized treatment in patients with copd be avoided. the use of spacer devices may help to reduce this risk. the use of an mdi with spacer in place of a nebulizer is recommended in the treatment of acute airflow obstruction in patients with copd in an attempt to reduce the risk of droplet transmission of respiratory infection such as sars. sars should be considered in the differential diagnosis of an acute exacerbation of copd and if sars is suspected the patient should be triaged accordingly. it is recommended that bronchodilator treatment should not be delayed or denied in patients with copd. in treating patients who are experiencing an acute exacerbation it is important to ensure that the bronchodilator dosage is adequate and titrated at frequent intervals based on patient response, when using a spacer instead of a nebulizer. it is recommended that appropriate ventilatory support should not be delayed or denied in patients with copd. the burden of suspected sars should be reduced by influenza vaccination of copd patients. the gold expert panel cites category a evidence that influenza vaccination can reduce serious illness and death in copd patients by approximately %. in light of this evidence, gold recommends vaccination against influenza for all patients with copd. vaccines that contain killed or live, inactivated viruses should be used since these have been shown to be more effective in elderly patients with copd. the gold guidelines add that influenza strains are adjusted annually for appropriate effectiveness and should be given once (in autumn) or twice (in autumn and winter) each year. , the copd roundtable group notes that influenza vaccination is not routinely offered to copd patients in asia, but is given by some pulmonologists or in response to patient requests. furthermore, a review of the literature shows that there is a knowledge gap with respect to use of influenza vaccination in the region, particularly in patients with copd. in early deliberations there were some reservations regarding vaccination of copd patients. however, this has been reevaluated in the context of new information from recent clinical trials of the efficacy of influenza vaccination and the sars epidemic within the asia-pacific region. [ ] [ ] [ ] with these considerations in mind, the copd roundtable group recommends addition of the following statements to the gold guidelines relating to influenza vaccination in patients with copd. influenza vaccination is highly recommended for all copd patients within the asia-pacific region where there could be a recurrence of sars which mimics the clinical presentation of influenza. patients should be vaccinated - months prior to the anticipated peak incidence of influenza. while the copd roundtable group recommends vaccination of all patients with copd in communities where there is a high likelihood of sars, there remain some issues regarding the implementation of influenza vaccination for copd patients in the asia-pacific region, for the following reasons: (i) low surveillance data from tropical countries; (ii) apparent lack of bimodal seasonality in tropical countries; (iii) uncertainty of appropriate frequency or timing of vaccines; (iv) the presence of two potential vaccine formulations to coincide with influenza strains emerging in february and september; (v) limited efficacy data on vaccination in tropical countries; and (vi) lack of cost-effectiveness and cost-savings studies. in countries with bimodal peaks or a relative lack of seasonality of influenza infection, the choice of when to vaccinate is left to physicians. gold lists the main goals of pulmonary rehabilitation programmes in patients with copd as reduction of symptoms, improved quality of life, and increased physical and emotional participation in everyday activities. these goals are achieved by attending to problems such as exercise deconditioning, social isolation, depression/other mood disturbances, muscle wasting, and weight loss. since these problems particularly affect patients with stage ii (moderate), stage iii (severe) or stage iv (very severe) copd, gold recommends that patients in these subgroups should be enrolled in pulmonary rehabilitation programmes. , however, the gold guidelines also point out that category a evidence indicates that copd patients at all stages of disease benefit (in terms of exercise tolerance and symptoms of dyspnoea and fatigue) from exercise training programmes. , as noted in the gold document, pulmonary rehabilitation has been carefully evaluated in a large number of clinical trials. these have yielded category a evidence that pulmonary rehabilitation improves exercise capacity, reduces perceived intensity of breathlessness, improves health-related quality of life, reduces the number of hospitalizations and days in hospital, and reduces anxiety and depression associated with copd. there is also category b evidence that pulmonary rehabilitation improves arm function with strength and endurance training of the upper limbs, provides benefits that extend well beyond the immediate period of training (provided home exercise training is continued after the programme ends), and improves survival in patients with copd. the gold guidelines also note that pulmonary rehabilitation programmes ideally involve several types of health professionals. however, significant benefits can also be attained by more limited personnel, so long as the healthcare professionals concerned are aware of the needs of individual patients. the updated gold guidelines recommend a duration of ≥ months for pulmonary rehabilitation. a comprehensive pulmonary rehabilitation programme includes: exercise training : as assessed by to -min sessions of bicycle ergometry, treadmill exercise, walking tests etc., at up to % peak oxygen consumption or until symptoms intervene, on a daily to weekly basis. nutrition counselling : nutritional state is an important determinant of symptoms, disability and prognosis in copd, with both overweight and underweight patients potentially having problems. how-ever, nutritional therapy without an accompanying exercise regimen may not be helpful. education : while education of the patient is a component of most pulmonary rehabilitation programmes, its specific contribution to the improvements seen after pulmonary rehabilitation remain unclear. the gold guidelines also emphasize that baseline and outcome assessments should be made for each participant in a pulmonary rehabilitation programme so that individual gains can be quantified and appropriate areas targeted for improvement. assessments should include history and physical examination, pre-and post-bronchodilator spirometry, exercise capacity, health status and the impact of breathlessness, inspiratory and expiratory muscle strength, and possibly lower limb strength in patients with muscle wasting. the copd roundtable group recognizes that pulmonary rehabilitation is one of the most effective management strategies for patients with copd. therefore, its use and benefits should be promoted to copd patients, healthcare professionals, funding agencies, and governments in the region. unfortunately, comprehensive pulmonary rehabilitation programmes, as described in gold, are beyond the means of many asian healthcare systems and, therefore, unavailable to most patients in the region. indeed, the difficulties of providing pulmonary rehabilitation programmes in developing countries, with reduced resources available for healthcare, may be better appreciated when it is considered that in a developed country such as canada, < % of the copd population per annum has access to pulmonary rehabilitation programmes. physicians in the asia-pacific region who are unable to refer copd patients to established pulmonary rehabilitation programmes are unlikely to be able to organize the complex, multidisciplinary types of programmes described in the literature. however, they may be able to organize the 'next best' alternative, that is, less complicated programmes which include only the most important components of pulmonary rehabilitation. minimum elements of pulmonary rehabilitation which could be made available in simplified programmes involving limited numbers and types of healthcare professionals include: (i) basic exercise tests, for example, -min walking distance tests; (ii) regular (daily if possible) exercise, for example, walking to a symptom-limited maximum, then resting, then continuing to walk until min of exercise has been completed; and (iii) educating patients about how to minimize exposure to other copd risk factors, such as smoking, indoor air pollution due to biomass fuels and occupational hazards. the above measures, which could be included in simplified pulmonary rehabilitation programmes, would be expected to benefit copd patients who do not have access to more intensive and complete programmes. on this point, it is pertinent to note that pulmonary rehabilitation programmes conducted in the home have been associated with benefits for copd patients. , with the above considerations in mind, the copd roundtable group recommends addition of the following statements to the gold guidelines relating to pulmonary rehabilitation in patients with copd. although there is limited evidence within the region, simplified pulmonary rehabilitation programs which include the crucial elements of regular exercise training and patient education have been found to be workable and are recommended. exercise training programs involving simple, structured elements (a baseline -min walking test to determine workload requirements, followed by regular sessions of walking for min and, ideally, upper limb exercises) are pivotal to the success of a pulmonary rehabilitation program. patient education initiatives may be undertaken by trained physiotherapists to improve patient awareness of the importance of smoking cessation in the management of copd. such initiatives will aid in enhancing patient co-operation and improving rapport between the patient and physiotherapist. the gold strategy for the diagnosis, management and prevention of copd is an important initiative which is relevant and useful for the asia-pacific region. the copd roundtable group agrees with the content and recommendations of the gold strategy, and supports implementation of the programme as a means of helping to prevent copd and improving diagnosis and management of the disease in the region. the only respects in which the views of the copd roundtable group diverge from those of the gold guidelines are expressed in the specific modifications outlined in the text above. as noted, the copd roundtable group statement on the gold guidelines represents the consensus view of members of the group. before publication, however, the statement was presented as a 'working document' for discussion/feedback at the october meeting of apsr in taipei. clarification of some of the key messages articulated by the copd roundtable group may be warranted to avoid misinterpretation. with regard to spirometry, the roundtable group is keen to emphasize both the key role of this tool for diagnosing and assessing copd, and the pressing need for greater availability of spirometers in the region. the roundtable group urges that the gold recommendations on this issue be used to mount pressure not only on regional governments and health funding agencies to finance wider access to spirometry in the region, but also on manufacturers to provide cheap but efficient spirometers. however, economic considerations are not the only barriers to use of spirometry in asian countries; others include lack of demand for/recognition of the need for spirometric testing (by patients, healthcare professionals, and health administrators/ policymakers), lack of technical knowledge and expertise in the use of spirometers, and inappropriate emphasis on reporting, diagnosing and managing symptoms (as opposed to lung function) in patients with copd. for these reasons, it is vital to note that the copd roundtable group recommends that a diagnosis of copd can be suspected on the basis of symptoms, physical signs and history only when spirometry is unavailable. the other important implication of this statement is that diagnosis of copd by repeat peak expiratory flow measurements or chest x-ray appearances in these circumstances is not recommended. similarly, none of the other recommendations made by the copd roundtable group should be interpreted as contravening gold recommendations. the roundtable group notes that the inhaled route is the preferred means of bronchodilator delivery for copd patients. oral bronchodilators should only be used when there is no affordable inhaled alternative for the patient. similarly, the roundtable group agrees that enrolment of copd patients in 'standard' pulmonary rehabilitation programmes is the preferred option, and one which should be promoted as much as possible, but suggests that participation in a simplified programme is better than no pulmonary rehabilitation at all. with respect to experimenting with spacers before using nebulizers, this is also consistent with the discussion of bronchodilator therapy presented in the full workshop report of the gold strategy. this approach should be tried in patients who are unable to master inhaler technique with a mdi. health professionals caring for copd patients should take the time to educate patients about correct inhaler technique and to check on correct technique during follow-up consultations. in some countries such as the philippines, there is a high rate of nebulizer use, and this has prompted the copd roundtable group to include a specific endorsement of the use of spacer devices before resorting to nebulization. finally, gold recommends influenza vaccination for all patients with copd, and in light of the recent sars epidemic the copd roundtable group supports this recommendation. however, because of limited evidence regarding influenza vaccination within the asia-pacific region, the roundtable group suggests that in countries which lack seasonality of influenza, the choice of vaccination should be left to physicians. adherence to copd guidelines has been shown to not only improve clinical outcomes but also to lower healthcare costs in a us teaching hospital setting. while findings from studies conducted in developed countries cannot automatically be extrapolated to healthcare systems in developing countries, the copd roundtable group considers that implementation of the gold strategy for prevention, diagnosis and management of copd in the asia-pacific region would confer similar types of clinical and economic benefits. it is hoped that the additions and modifications to the gold guidelines suggested by the copd roundtable group will further enhance the applicability and usefulness of these guidelines in the region. finally, the copd roundtable group acknowledges that there is a need for regional studies evaluating these consensus recommendations. clinical data, for example, on the efficacy of pulmonary rehabilitation programmes and the diagnosis of copd with or without spirometry, will lend support to and enable further refinement of this consensus statement. evidence-based health policylessons from the global burden of disease study the global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in and projected to global mortality, disability, and the contribution of risk factors: global burden of disease study economic burden of chronic obstructive pulmonary disease. impact of new treatment options chronic obstructive pulmonary disease: new opportunities for drug development american lung association fact sheet: chronic obstructive pulmonary disease (copd) chronic obstructive pulmonary diseases in thailand: incidence, prevalence, present status and future trends the impact of tobacco on lung health in china chronic obstructive pulmonary disease: a prevalence estimation model asia-pacific countries and regions: projections based on the copd prevalence estimation model global initiative for asthma. global strategy for asthma management and prevention. nhlbi/who workshop report. national institutes of health. national heart, lung and blood institute, publication no. - global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease hurd ss for the gold scientific committee. global strategy for the diagnosis, management and prevention of copd update global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease canadian thoracic society copd guidelines: summary of highlights for family doctors comparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literature overview on sars in asia and the world who says sars outbreak is over, but fight should go on sars: hospital infection control and admission strategies evidence-based to acute exacerbations of copd influenza vaccination for the - season: recommendations in the context of concern about sars update : preparing for the next influenza season in a world altered by sars acute respiratory illness in patients with copd and the effectiveness of influenza vaccination: a randomized controlled study pulmonary rehabilitation programs in canada: national survey a simple pulmonary rehabilitation program improves health outcomes and reduces hospital utilization in patients with copd unconditional educational grants from boehringer ingelheim and pfizer covered the costs of the group's meetings and the writing of the consensus statement. the deliberations of the group were free of any influence from the funding companies. members of the asia pacific copd roundtable group have acted as consultants for several pharmaceutical companies, including boehringer ingelheim and pfizer, and have spoken at meetings sponsored by pharmaceutical companies, including boehringer ingelheim and pfizer. key: cord- -orlga qf authors: gomes da silva, j.; sofia silva, c.; alexandre, b.; morgado, p. title: health literacy of inland population in the mitigation phase . . of covid- 's pandemic in portugal - a descriptive cohort study date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: orlga qf background: covid- is a respiratory disease transmitted through respiratory droplets with a high transmission rate. there's still no effective and approved antiretroviral treatment or vaccine, thus, preventive measures are the main key to contain this pandemic. portugal is now in phase . of the mitigation of covid- , being imperative to understand the health literacy of our country and how to prevent the lack of information, through community empowerment. material and methods: a cross-sectional study with a cohort from a primary care facility was conducted. we collected demographic and epidemiological data and carried out a questionnaire by phone call. descriptive statistics and nonparametric tests were used to assess associations between the independent variables and the level of health literacy. the level of significance was set at p< . . results: our cohort includes subjects (median age: years old), mostly females ( ), undergraduate ( ) and with at least one risk factor for covid- ( ). globally, younger individuals, females, graduates and the non-risk group appear to have higher levels of health literacy, with some exceptions to this pattern. conclusions: we observe a well-informed population. however, being a pandemic situation, we intend to identify and correct outliers/misconceptions. this work allows a perspective of the current state/pattern of health literacy as well as its possible predictors. furthermore, this study makes aware of how relevant the specific communication approaches are. further studies to understand the predictors of health literacy are necessary. key-words: covid- , pandemic, sars-cov , portugal, health literacy. in december , an outbreak of pneumonia with unknown etiology began to arise in the city of wuhan, china and the diagnosis of influenza and other coronaviruses (such as mers and sars) were considered but later excluded by laboratory tests , . on th of january, , china announced that the cause of that epidemic was a new coronavirus strain, later designated sars-cov- and proven to be present in wild bats , , . the transmission mode of sars-ncov- is through respiratory droplets, and they are either a source of direct or indirect contamination , . this strain presented a basic reproduction number (r ) within a range from . to . : the highest infection rates in the elderly or in people with underlying pathologies , . therefore, this means that this strain of virus has a high rate of human-to-human transmission and a person is much more contagious as more symptomatic , . the median age of the symptomatic patients seems to be between - years even though it can affect individuals of all ages . the clinical presentation of covid- has a wide spectrum that ranges from assymptomatic or slightly upper respiratory infection to septic shock , , . the cardinal symptoms described by the world health organization and later integrated in the flowcharts issued by the direção geral de saúde (dgs) are "cough", "fever" and "dyspnea". however, other studies report myalgia, fatigue, headache and gastrointestinal symptoms as other symptoms to be taken into account , , . in a study involving laboratory confirmed cases, zhong et al described that the most common clinical manifestations were fever ( . %), cough ( . %) and fatigue ( . %), with sputum, dyspnea, sore throat and headache also being highly reported by the patients . this study also mentions that there was a minor percentage of patients who showed gastrointestinal symptoms such as vomiting and diarrhea. despite the broad spectrum of the disease, huang et al described that the elderly or those with underlying pathologies such as hypertension, chronic obstructive pulmonary disease, diabetes mellitus and cardiovascular diseases had a faster progression of the disease, with a higher rate of acute respiratory distress syndrome, consequent multiorgan failure and higher rate of death , . these pathologies, considered as risk factors for covid- , were later included in the "norma de orientação clínica / " of dgs, as patients with a particular risk of infection and with higher care needs. at the moment, there is no effective and approved antiretroviral treatment or vaccine targeting sars-cov- , with the treatment being mainly symptomatic and organ support , . therefore, in the absence of effective specific treatment, there is a range of preventive measures to be taken, such as a correct handwashing, respiratory etiquette, disinfection of surfaces and social isolation and/or social distancing (> meters) , , , . these measures are assumed as vital in the control of the mitigation of the pandemic , . to raise public awareness of these measures and health promotion, community empowerment is necessary and the main key for this public health problem. this empowerment through health literacy programs and official campaigns using television, radio and other media has a positive impact, especially in this actual context -outbreaks and/or pandemics - . on the th of march, , the state of emergency was decreed in portugal, with a law decree regulating preventive measures to contain the pandemic mitigation in portugal. on the th of march, , phase . of the mitigation of covid- 's pandemic in portugal was declared, e.g., chains of community transmission of the virus in the national territory. thereupon, it arose the need for tighter control and application of preventive measures. regarding the positive impact of official campaigns and community empowerment with a strong health literacy, we considered it extremely important to study the health literacy of the population in this mitigation phase, in order to understand the flaws that may still exist as well as identifying possible predictors of health literacy concerning this matter. thus, and since as far as we're concerned this is the first study focusing on this subject, it will be possible to rectify possible wrong ideas through specific intervention strategies aimed at different populations. also, we hope that this study helps to identify possible errors/flaws of health literacy in a pandemic situation and to avoid them at the early beginning of a possible future pandemic. we conducted this cross-sectional study with a cohort of subjects, with an age greater or equal to years old -to avoid a misunderstanding bias of our questionnaire -covid- 's questionnaire (supplementary information). we excluded subjects codified with the icp- codes for "dementia", "mental retardation" or "presbycusis", -to exclude the inherent misunderstanding bias. we selected a cohort: individuals with a scheduled medical appointment in a primary care facility of unidade local de saúde de nordeste between st and th of april. we collected the demographic and epidemiological data (age, gender, education level and risk factor(s) for covid- codified by icp- ) and carried out covid- 's questionnaire by phone call with simultaneous registration of the data, between march and april . for statistical analysis, we regarded "age" as a continuous variable. concerning the other variables, we categorized subjects according to their "gender" ("female" and "male"); education ("undergraduate group" -< years of schooling; , , or years of schooling; "graduate group" -graduate, master's degree and/or doctorate); "risk factor(s) for covid- codified by icp- " ("risk group" -presence -and "non-risk group" -absence -as described in "norma de orientação clínica / " by direção geral de saúde (dgs) such as chronic obstructive pulmonary disease, asthma, cardiac insufficiency, diabetes mellitus, chronic liver disease, chronic renal disease, ative malignant neoplasm or immunosuppression state). we performed the statistical analysis of the collected data using microsoft office excel ® (microsoft, redmond, washington, usa) and the spss ® statistical package (standard version . ; spss, chicago, il, usa). exploratory analysis was conducted to demographically characterize our cohort as well as for the answers given for each question of our questionnaire. we used non-parametric tests (kruskal wallis h and fisher's exact test) to test whether significant associations between the variables and the answers given were observed or not, except for the last question. the level of significance for all statistical tests was set at p< . , with a % confidence interval. this study was submitted for approval and approved by the direction of department of primary health care of unidade local de saúde do nordeste, according to the declaration of helsinki of the world medical association. the confidentiality of the data was guaranteed, only accessible by the main investigator and the respective authors. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . this study comprises a cohort of subjects, with an age range - years old and a median age of years old. the majority registered an undergraduate level of education and had at least one risk factor for covid- codified by icp- (table ) . globally, younger individuals, females, graduates and the non-risk group presented higher relative frequencies of the correct answer along covid- 's questionnaire. however, three exceptions were observed: the undergraduate group and the risk-group had a high relative frequency stating that covid- has a cure and in mentioning "social isolation" as an important preventive measure to adopt when compared to the graduate group and the non-risk group, respectively. males have higher relative frequency in answering the correct number of sns and in stating that children can get sick and transmit the infection by sars-cov- when compared to females ( table -supplementary information). the use of non-parametric tests (kruskal wallis h and fisher's exact test) demonstrated several statistically significant associations between our variables and the answers given along covid- 's questionnaire (table ) . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . when questioned about the symptomatology of covid- , . % of individuals stated that they know the symptoms of covid- . indeed , analysing only the individuals who answered "yes" in the first . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . question, we observe that most of the individuals stated the cardinal symptoms of covid- described in several "normas de orientação clínica" from dgs (e.g. "fever", "cough" and "dyspnea") in relative frequencies > . % and that . % stated "other" symptoms such as "myalgia", "headache" and "loss of smell and taste". nonparametric tests denote statistically significant associations: "other" reveal a significant association with "education", with individuals of graduate group stating more often other symptoms of the disease; "cough" reveal a significant association with "risk factor", with individuals from non-risk group stating more often this symptom. when questioned whether covid- only affects old people or not, . % of individuals answered the correct answer. nonparametric tests reveal a statistically significant association regarding variable "gender", with females answering more often the correct answer. regarding the two questions about children, there's a good level of health literacy among our cohort. when questioned if children can get sick, there's a major dominance of the answer "yes" ( . %). nonparametric tests reveal a statistically significant association regarding variable "risk factor", with individuals from "non-risk group" stating more often the correct answer. when we questioned about the possibility of children transmitting the disease, . % of individuals answered "yes". no statistically significant associations were observed. regarding the question about the cure of covid- , we found a great dispersion of the answers: . % of the subjects refer that covid- has a cure, . % deny it and . % refer that they don't know whereas this disease has a cure or not. nonparametric tests reveal a statistically significant association regarding variable "education" and "risk factor", with individuals from "undergraduate group" and "risk group" stating more often the correct answer. when questioned about the correct procedure in case they have symptoms compatible with covid- , . % stated they should "stay home and call sns ". nonparametric tests reveal a statistically significant association regarding variable "age", "gender" and "risk factor", with younger individuals, females and individuals from risk-group stating more often the correct answer. regarding the number of sns , only . % of subjects knew the correct number. nonparametric tests reveal a statistically significant association regarding variable "gender" and "risk factor", with males and individuals from non-risk group answering the correct number. when questioned about the preventive measures to adopt, . % of individuals stated "social isolation", . % stated "other" preventive measures (e.g., the use of gloves, the use of mask, distance > meters from other people, leaving shoes at front door,...), . % of individuals refer "washing hands" and lastly, only subjects ( . %) of all subjects mention "respiratory etiquette" as an important measure to adopt. nonparametric tests demonstrate several statistically significant associations: "other" has a statistically significant association with variable "risk factor" -individuals from "non-risk group" state this symptom more often -and "social isolation" has a statistically significant association with "education" and "risk factor" -individuals from "graduate group" and "risk group" state this preventive measure more often. regarding the use of gloves, a great dispersion of answers was observed, with . % of individuals referring that the use of gloves does not always prevent the infection by the new coronavirus, . % affirming "i don't know" and . % answering "yes". nonparametric tests demonstrate that variables "gender" and "risk factor" have a statistically significant association with the answers given, with females and individuals from "non-risk group" answering correctly more often. regarding the use of masks, a great dispersion of answers was observed, with . % of individuals referring that the use of gloves does not always prevent the infection by the new coronavirus, . % affirming "i don't know" and . % answering "yes". nonparametric tests show a statistically significant . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint association between variables "risk factor" for this question, with individuals from "non-risk group" answering correctly more often. when we questioned our subjects about the possibility of visits of friends and/or family during social isolation, . % stated "no", . % stated "yes" and . % affirmed "i don't know". nonparametric tests show no statistically significant associations. regarding the final question, and even though we have a slight dispersion of frequencies of answers, it is obvious that the major source of information about covid- is the television, with . % of individuals reporting that fact. after television, the social networks ( . %) and other ( . %) -such as official websites (who, dgs and cdc), employers, town hall and guarda nacional republicana -have an important role in informing the population about the actual public health problem (fig. ) . according to portugal's censuses, the population of our cohort comprises citizens, with a proportion > female per male and as well as an undergraduate and older population , . the characterization of our cohort is compatible with these data. globally, our results demonstrate a relatively well informed population. furthermore, females, younger individuals, the "graduate" and the non-risk groups presented higher relative frequencies of the correct answer throughout our questionnaire. there are some exceptions to this pattern, which we are going to discuss later on this section. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . in the literature, several studies support our results, reporting age, gender and education as predictors of health literacy. indeed, sørensen et al in their comparative study of the results of european health literacy survey (hls-eu) reported education, age and gender as predictors of low health literacy, along with social status and financial privation. according to their findings, males and older individuals tend to have slightly lower health literacy, while a higher level of education is a strong positive predictor of health literacy . besides, regarding health literacy, several other studies state these gender, age and education significant differences, reporting that an increase in age, being male and lower levels of education usually implies a decrease in health literacy , [ ] [ ] [ ] [ ] [ ] [ ] [ ] . regarding the presence/absence of risk factors for covid- as far as we're concerned, there's no literature available to support the results found in our study. however, we do know that the median age of the risk group is higher than the median age of the non-risk group and these differences stated in non-parametric tests along this study may be a consequence of an age bias. concerning the symptomatology, most of the population knows the cardinal symptoms of covid- related by dgs (high relative frequencies > . %). curiously, even though not being reported by dgs, there's a significant percentage of subjects relating. "other" symptoms such as "myalgia", "headache" and "loss of taste and smell", described in several articles , , , , . this fact may suggest that people do not obtain their information by a single source of information and that they try to search for relevant information. the third question was thus constructed to capture the discord underlying the definition of "cure". according to portuguese lexicon, "cure" is defined as "act or effect of self-healing or healing somebody" or "health recovery" and "healing" being described as "restore health". however, the answers given along the phone calls highlighted the uncertainty in this definition, emphasizing the insecurity in answering this question. indeed, throughout this study, most of the people who answered "no", justified using sentences such as "there's no vaccine" or "there's not a medication targeting the virus". these findings underline some incongruences and misconceptions. a vaccine is a tertiary preventive measure administered in an individual to confer immunity to a certain infectious disease, which enables an asymptomatic/mild clinical manifestation of it, useful in controlling epidemics [ ] [ ] [ ] . therefore, it is necessary to demystify the idea that a vaccine is a cure for an infectious disease. even though there's not a specific antiretroviral targeting sars-cov- efficiently approved, there are several reported cases of healed patients, matching with the portuguese definition of "cure" , , , . interestingly, the undergraduate group presents a higher relative frequency of the answer "yes", yet, it wasn't possible to find any information in literature supporting this finding. regarding the preventive measures to adopt face to covid- , overall, the subjects in our study were able to mention them, with the exception of respiratory etiquette. in the literature there are several studies that report the importance of handwashing, respiratory etiquette and social isolation in containing epidemics and in controlling sars-cov- transmission , . indeed, even though chao yang reports that there's no proven efficacy of handwashing in controlling sars-cov- transmission , there are several findings that report the opposite. qing-xia et al , in a study involving countries, alert to the fact that handwashing significantly slows the exponential spread of sars-cov- and several other studies showed that a correct handwashing is useful in controlling epidemics as well as sars transmission , , . even though handwashing is an important preventive measure to adopt face to covid- , unfortunately, there are findings that show that the correct procedure -as recommended by who -isn't always applied and that some mistakes are observed, as such low frequency in washing hands and not washing hands the enough time , . also, zhang et al conducted a study in beijing's population as a post-pandemic assessment and verified that even though people knew the importance of handwashing, they did not apply it . in their study, fung et al also observed a decline of practice of this preventive measure . therefore, in order to avoid this decline and errors, we must implement methods to successfully achieve a correct preventive handwashing . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . as well as for other respiratory viruses, respiratory etiquette has a preponderant role in controlling the transmission of an infectious respiratory disease [ ] [ ] [ ] . looking at the numbers in our study, the absolute and relative frequencies of subjects who mentioned it as a necessary preventive measure was disappointingly low. thus, this must be a point to improve in health literacy. concerning "social isolation", being sars-cov- an extremely high contagious virus, an effective and important preventive measure to adopt and to contain the pandemic is social isolation , . interestingly and contrary to the other questions, in this question the risk group has a higher relative frequency of the preventive measure "social isolation'' than the non-risk group. this fact may be explained by the fact that non-risk group is a younger group. thus, younger people belong to the proletariat more than older people, having the necessity to leave home for work, which can be a justification to this finding. regarding the answers obtained in question , there are still cases of people who believe it is possible to receive or visit family and/or friends at home. since this idea may promote the creation of new transmission chains, it is necessary to demystify it, across every single outlier. regarding the right procedure in case of having symptoms, most of the subjects stated that they must stay at home and call sns , as recommended by dgs. concerning the number of sns , interestingly, males report higher relative frequency of the right answer. this may be explained by the fact that in our population, males have higher rates of education with more educational opportunities . recalling that the graduate group has a higher relative frequency of correct answers, this difference between females and males may be explained by this bias. also, along the phone calls, individuals that belong to the risk group -overall, older individuals -referred that they didn't know the number by heart because their caregivers knew or they had it pointed on a paper. besides suggesting the lower capacity of older people to memorize numbers, this draws our attention for the important role that caregivers may have in transmitting the proper information to older people. regarding the questions about the epidemiology of covid- , there's a major consensus that this disease affects the elderly and that children either transmit and can get sick. indeed, concerning all the information already mentioned, the literature states that sars-cov- may infect individuals of all age ranges, with a more severe clinical manifestation in the elderly and/or people with underlying pathologies , , . also, concerning the clinical manifestation and transmission in children, throughout this study, some people reported that "children can transmit the virus, that's why grandchildren and grandparents cannot be together". indeed, children can get sick and are an important vector of transmission of sars-cov- , . this fact is especially because if infected they are mainly asymptomatic and have more difficulties in applying the correct procedures of the hygiene measures correctly , . interestingly, males reported higher relative frequencies than females in stating that children can get sick and transmit sars-cov- . however, there's no literature supporting this finding. regarding the use of gloves and/or masks, it is visible a certain hesitation and some myths associated with them, which may be explained by the quantity of contradictory information transmitted concerning these equipment . the use of gloves is recommended during procedures associated with aerosol production, in a clinical context . regarding the global use of gloves, its general use is not recommended by who, cdc and dgs and may even constitute a false security if people don't discard them regarding the proper procedure . the use of masks has been under constant study since the beginning of this pandemic, in order to understand whether it prevents the infection by sars-cov- or not and the literature regarding this matter is very controversial. however, in a recent study, greenhalgh et al advocate the general use of the mask, regardless of their material, even stating that a simple cotton mask will reduce the amount of transmitted virus by times . indeed, masks are gaining a major role as a community preventive measure and not as an individual preventive measure , , , , . concluding, even though we observe a relatively well informed population, this is a pandemic of a virus with an elevated transmission rate. thus, biological characteristics as well as individual and communitary behaviours have an impact in its course , , and even a single error/mistake may have a . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . negative impact, creating new transmission chains that could have been prevented , , , , . following this thought, we are looking for the outliers of wrong answers/unfamiliarity of a concept and in order to promote a fruitful health literacy, towards an informed population and avoid an overwhelming unjustified panic, which may lead to more mistakes , , . to pursue this objective, we must take in account the major sources of information and adapt our communication, creating programs/methods in order to reach each specific population . this adjustment to different realities has a positive impact on the population and their behaviour, by promoting community empowerment . on a final note, we safeguard that a correct health literacy does not always mean a correct behaviour and that some mistakes can still prevail , . health literacy is nowadays a critical issue and has an impact in controlling epidemics and pandemics , , . in portugal we are now in phase . of mitigation of covid- 's pandemic and, even though we have a relatively well informed population, there seems to be some misconceptions of the guidelines . as the actual public health situation is a pandemic by a highly infectious virus, every single deviant compliance matters and must be prevented. thus, our goals were to characterize the population regarding their covid- 's health literacy, in order to help create specific intervention strategies aimed at populations with different levels of health literacy. although our cohort has a small dimension, it highlights some aspects that can bridge gaps that still remain. we believe it also provides support for future studies and alerts to the necessity of new approaches of communication in order to control not only this pandemic but also possible future pandemics with human-to-human transmission. the main limitation of this work was the size of the database. also, besides comparison between groups, other tests or applying metrics could have been used, e.g., correlation coefficients such as spearman's rank and pearson's. also, a multinomial regression could have been carried out in order to predict the health literacy for an individual. likewise, a new index variable representing health literacy could have been created, in order to state the level of health literacy of an individual. in further studies, this new variable can be created based on who and dgs information, enabling a comparative study of various coefficients, considering criteria and quality adjustment metrics. all data confidentiality was guaranteed. all authors report no conflict of interest. no financial support was obtained for this study. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint report : estimating the potential total number of novel coronavirus cases in wuhan city the origin, transmission and clinical therapies on coronavirus disease (covid- ) outbreak -an update on the status rolling updates on coronavirus (covid- ) disease. accessed on return of the coronavirus: ncov emergencies preparedness, response. pneumonia of unknown origin -china. disease outbreak news novel coronavirus (covid- ) outbreak: a review of the current literature the reproductive number of covid- is higher compared to sars coronavirus transmission of -ncov infection from an asymptomatic contact in germany epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study clinical features of patients infected with novel coronavirus in wuhan a novel coronavirus from patients with pneumonia in china identification of severe acute respiratory syndrome in canada clinical characteristics of coronavirus disease in china post-pandemic assessment of public knowledge, behavior, and skill on influenza prevention among the general population of beijing, china a cross-sectional study of pandemic influenza health literacy and the effect of a public health campaign diagnóstico e plano municipal para a igualdade health literacy in europe: comparative results of the european health literacy survey (hls-eu) how often do you wash your hands? a review of studies of hand-washing practices in the community during and after the sars outbreak in gender differences in the impact of cognitive function on health literacy among older adults with heart failure a life course approach to health literacy: the role of gender, educational attainment and lifetime cognitive capability age differences in health literacy: do younger korean adults have a higher level of health literacy than older korean adults health literacy among different age groups in germany: results of a cross-sectional survey the relationship between health, education, and health literacy: results from the dutch adult literacy and life skills survey an international comparison of the association among literacy, education, and health across the united states a review of coronavirus disease- (covid- ) case-control vaccine effectiveness studies: data collection, analysis and reporting results controlling epidemics with transmissible vaccines sars-cov- : what do we know so far health security capacities in the context of covid- outbreak: an analysis of international health regulations annual report data from countries does hand hygiene reduce sars-cov- transmission? potential utilities of mask-wearing and instant hand hygiene for fighting sars-cov- inadequate handwashing practices in childcare facilities handwashing improvement project-a resident run success predictors of respiratory hygiene/cough etiquette in a large community in korea: a descriptive study influenza in children respiratory viruses in returning hajj & umrah pilgrims with acute respiratory illness in - updated understanding of the outbreak of novel coronavirus ( -ncov) in wuhan covid- through the lens of gerontology the different clinical characteristics of corona virus disease cases between children and their families in china -the character of children with covid- sars: diagnosis, therapy, and especially prevention how to apply and remove medical gloves face masks against covid- : an evidence review face masks for the public during the covid- crisis will covid- generate global preparedness? a tale of two epidemics communication of scientific uncertainty about a novel pandemic health threat: ambiguity aversion and its mechanisms a cross-sectional study of pandemic influenza health literacy and the effect of a public health campaign community matters -why outbreak responses need to integrate health promotion fair allocation of scarce medical resources in the time of covid- how will country-based mitigation measures influence the course of the covid- epidemic? at the epicenter of the covid- pandemic and humanitarian crises in italy: changing perspectives on preparation and mitigation key: cord- - cd dolj authors: mishra, anurag; bains, lovenish; jesudin, gnanaraj; aruparayil, noel; singh, rajdeep; shashi title: evaluation of gasless laparoscopy as a tool for minimal access surgery in low- to middle-income countries: a phase ii non-inferiority randomized controlled study date: - - journal: j am coll surg doi: . /j.jamcollsurg. . . sha: doc_id: cord_uid: cd dolj background: minimal access surgery [mas] is not available to most people in the rural areas of low middle-income countries [lmic]. this leads to an increase in the morbidity and the economic loss to the poor and the marginalized. the gasless laparoscopic surgeries [gal] are possible in rural areas as they could be carried out under spinal-anaesthesia. in most cases, it does not require the logistics of providing gases for pneumoperitoneum and general anaesthesia. the current study compares gal with conventional laparoscopic surgeries [col] for general surgical procedures methods: a single-centre, non-blinded randomized control trial [rct] was conducted to evaluate non - inferiority of gal versus col at a teaching hospital in new delhi. patients were allocated into two groups and underwent mas (cholecystectomies and appendectomies). the procedure was carried out by two surgeons by randomly choosing between gal and col. the data was collected by postgraduates and analyzed by a biostatistician. results: patients who met the inclusion criteria were allocated into two groups. no significant difference was observed in the mean operating time between gal group ( . min) vs col group ( minutes) [p= . ]. the intraoperative vital signs were better in the gal group [p < . ]. the postoperative pain score was slightly higher in the gal group [p = . ]; however, it did not require additional analgesics. conclusions: no significant differences were found between the two groups. gal can be classed as non-inferior compared to col and has the potential to be adopted in low resource settings. the invention of laparoscopy in the late th century revolutionized the way surgery is performed. it indeed is a significant milestone invention which transformed surgical practice. however, the benefits of minimal access surgery (mas) are not available to the majority of the rural population in india and similar low and middle-income countries (lmics). although no formal access to care study is available for india, it is estimated that only % population in lmic can access affordable mas services [ , price] . open surgery is the first line of treatment for conditions like the acute abdomen, gall stone disease, appendicitis. lack of any access to surgery leads to prolonged illness, deaths and loss of livelihood for poor people [ dare ] . hence, mas has the potential to provide better access to surgery in such settings. the recurring cost of expensive laparoscopic instruments, logistics of providing medicalgrade gases in remote areas and non-availability of general anaesthesia (ga) [ , rosenbaum] make it difficult to adopt mas in low resource settings. the gas insufflation less laparoscopic surgeries [gal] offers a solution to the challenges associated with conventional laparoscopy [col] . it mechanically elevates the abdominal wall and allows laparoscopic visualization through a single incision, providing diagnostic and therapeutic procedures. ideally, for low resource settings, the ideal comparison should be between open surgery and gal. however, considering the ethical issues, we planned a non-inferiority study to compare gal using stan laparoscopy positioner device [slp] (fig ) with conventional laparoscopy (col) for general surgical procedures. the study was conducted as a single centre, non-blinded non-inferiority, randomized controlled study. ethical clearance was granted by the institutional ethical committee on j o u r n a l p r e -p r o o f the chosen sample size of was more than the calculated sample size of using operative time as the primary parameter (power %, α . , σ , sampling ratio ). [ , ge b] . a non-inferiority margin of % (+ min, assuming average operative time as minutes) was chosen. the primary outcome was to compare operative times for gal and col. the secondary outcomes of interest were: intraoperative vital signs, postoperative pain and surgeon satisfaction for cholecystectomy, diagnostic laparoscopy and appendectomy. the patients were randomly allocated using computer generated random numbers and sealed envelopes to conventional laparoscopy (col) or gasless laparoscopy (gal). cases were grouped according to diagnosis to avoid unequal distribution in the two groups. the surgeries were performed by two proficient laparoscopic surgeons (authors) with more than five years of experience. surgeons underwent one month of training and familiarization of the technique and equipment. general anaesthesia was used for all cases as the standard operating technique practised in the institute. the only variation was the creation of intraperitoneal space. standard -port technique was used for col group [ , olsen] . for gal the peritoneal cavity was accessed through a two-centimetre infra-umbilical midline incision. after entering the peritoneal cavity, a finger sweep was done to rule out any adhesions to the anterior abdominal wall and creating safe space for the ring of slp device [ , who compendium]. in a paper form, data was recorded on demographics, clinical profile, operative times, vital signs, use of analgesia, efficiency, procedure safety, patient and surgeon satisfaction. for gal group, the operating surgeon was asked to rate their satisfaction score on a likert scale of to , being satisfied. all recorded data was transferred to microsoft excel file and was analyzed using descriptive statistics. chi-square test and student's t-test was used in ibm spss version . strict safety monitoring framework was adopted to ensure no harm is done to participating patients. critical red flag events were identified at the beginning of and were adhered to during the whole period of study. out of patients screened, were excluded due to the exclusion criteria, and did not consent. those who met inclusion criteria were randomized into two groups. (see figure ). the groups matched in terms of their demographic and base surgical characteristics, as shown in table . the mean time for setting up gal was . minutes ( - , . ) which was statistically similar to that of the conventional procedure with a mean of . ( - , . ) minutes. the mean operating time from incision to closure was less in the gal group ( . ) compared to the col group ( minutes), but this was not statistically significant [p= . ] ( table ) . conversion: in gal group, three cases of cholecystectomy were converted to standard [col] due to inadequate operative space in one case and complicated anatomy in the other two cases. one of the latter cases were subsequently converted to an open procedure. there were no cases of conversion in appendectomy or diagnostic laparoscopy cases. in col group, the three cases were converted to an open procedure due to technical difficulties. the vital signs were comparatively more stable in the gal group. the average maximum heart rates recorded were . beats/minute in the gal group and . beats/minute in the col group. the range between the highest and lowest recorded heart rates was better in the gal group [ . vs . ] (p . ) ( figure ). (table ) the gal group had a lower variation in blood pressures [ table . overall, in either group, the pain was not severe (> ) at any time. the average pain recorded six hours after surgery was around the umbilicus - . on the vas pain scale (range - , sd j o u r n a l p r e -p r o o f . ). the vas pain scores were recorded below by the second day. the pain at hrs and hrs was found to be higher in the gal group. a mild shoulder tip pain which was found to be higher in the col group. (figure ) seventy-three of total patients did not require additional analgesia after the first dose as per protocol (table ) . during the entire hospital stay, a similar analgesic was required - . mg and mg in gal and col groups, respectively (p . ). no significant difference was noted for postoperative recovery and hospital stay ( table ). no intraoperative complications or mortality was experienced in either group during the study and follow up period of days. the overall incidence of ssi and delayed wound healing was and per cent, respectively, with no difference between the two groups. most of these complications were mild, and it healed without any interventions. average surgeon satisfaction score with gal was found to be . . the score gradually improved as the number of cases increased, forming a linear relation (fig ) . the score for st case and nd cases was . and . , respectively. adverse effects of mas are known and related to the use of carbon dioxide gas under pressure causing increased intraabdominal pressure and hypercarbia and subsequent acidosis. other risks include gas embolism, hypothermia if the gas is not pre-conditioned and by convection effects, oliguria, decrease in gut perfusion, subcutaneous emphysema, pneumothorax, pneumomediastinum, fogging issues, desiccation of peritoneum by dry gas, loss of space issues, and increased likelihood of dvt due to pooling of blood. [ whelan, gutt.] in low resource setting in lmics, there is a lack of trained anaesthesiologists, logistics of a constant supply of gases and lack of sophisticated monitoring equipment. [ , ren] in another meta-analysis on gasless laparoscopic cholecystectomy, liu et al. concluded that surgeries using abdominal wall lifts appear to decrease respiratory and cardiovascular complications of laparoscopy as compared to conventional. [ , liu] yet another study by ge b et al. found that gasless and conventional approaches are comparable in terms of operative duration, complications, and total hospital stay for j o u r n a l p r e -p r o o f laparoscopic appendectomy and the former may have an advantage due to reduced hospital cost and reduced need for analgesia. [ge b et al. ] despite the many advantages gal did not become popular due to the suboptimal exposure due to tenting and difficulty in handling the instruments and longer operating time [ , ren] . our study found that the operating time is similar to gal and col, the time lost with setting up is recovered with maintained operating space as there is no gas loss and quick specimen extraction we found that the gal group experienced marginally higher pain score. however, it did not require additional analgesics. anaesthesiologists preferred the lesser fluctuations in the vital signs like including heart rate, blood pressure and etco . the haemodynamic stability observed during gal could encourage more surgeons to take up laparoscopic surgeries in low resource settings. the urban centres can also consider using the technique for patients with asa iii-iv. however, further studies are required to understand safety in this patient group. as there is no issue around the gas leak and loss of operative space in gal, the procedure can be easily performed without sophisticated ports. one can introduce camera and instruments without need of any port, still to avoid repeated injury and soiling of the laparoscope on entry. we recommend the use of valve-less sleeve made of abdominal drains/ reusable metal sleeve as the port. they are readily available and a cost-effective alternative to commercially available ports. it makes it extremely convenient for a surgeon who is providing services in a resource-constrained area. also, because there is no gas insufflation, cost-effectiveness is another added benefit while using the gasless technique. though it was not evaluated in this study, it was highly indicative that we did not require new and costly access ports. we could work with cheaper alternatives like a basic sleeve and cut drain pieces. the cost of saved gas and monitoring equipment makes a strong case to promote gasless surgeries. during this covid- pandemic, various guidelines are issuing caution for the use of highpressure gas in laparoscopic surgeries as it may increase chances of cross-infection due to aerosol formation. use of gasless has the potential to decrease the viral spread as it prevents the use of gas under pressure. this role can be a topic for further research. the study was not blinded, so subjective outcomes such as pain may have reporting bias. operating surgeons are co-authors of the study, which introduces bias. our hospital is a tertiary teaching hospital in the metropolis and does not simulate a rural resource-limited setting. results may not be directly applicable to this setting. still, it may offer insights into the potential benefits for use in limited resource settings. the current study included patients with a maximum of bmi kg/m . further study with higher bmi patients is needed to evaluate the safety and advocate its wider use. improving surgical care in mongolia: a model for sustainable development deaths from acute abdominal conditions and geographical access to surgical care in india: a nationally representative spatial analysis improving access to laparoscopy in low-resource settings a randomized comparison of gasless laparoscopic appendectomy and conventional laparoscopic appendectomy single incision gasless laparoscopy surgical equipment. prototype product. who compendium of innovative health technologies for low resource settings the sages manual. perioperative care in minimally invasive surgery circulatory and respiratory complications of carbon dioxide insufflation laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study gasless laparoscopic hysterectomy: a comparative study with total abdominal hysterectomy a randomized comparison of gasless laparoscopy and co pneumoperitoneum prospective trial of gasless laparoscopic burch colposuspension using conventional surgical instruments gasless laparoendoscopic single-site surgery with abdominal wall lift in general surgery: initial experience gasless laparoscopy-assisted versus open resection for gastrointestinal stromal tumors of the upper stomach: preliminary results gasless laparoscopy-assisted versus open resection of small bowel lesions gasless laparoscopy-assisted colorectal surgery gasless laparoscopic assisted surgery for abdominal trauma gasless laparoscopic cholecystectomy: comparison of postoperative recovery with conventional technique abdominal wall-lifting versus co pneumoperitoneum in laparoscopy: a review and meta-analysis meta-analysis of the clinical application on gasless laparoscopic cholecystectomy in china precis gasless laparoscopy, being non-inferior to standard minimal access surgery, has the potential to extend the benefits of minimal access surgery to low resource settings in low the authors would like to thank the team of pgssc harvard medical school for their assistance during the study.j o u r n a l p r e -p r o o f key: cord- -weptfpa authors: halvachizadeh, sascha; teuben, michel; berk, till; neuhaus, valentin; pape, hans-christoph; pfeifer, roman title: the impact of sars-cov- (covid- ) pandemic on trauma bay management and guideline adherence in a european level-one-trauma centre date: - - journal: int orthop doi: . /s - - - sha: doc_id: cord_uid: weptfpa purpose: sars cov- (covid- ) represents a pandemic that has led to adjustments of routine clinical practices. the initial management in the trauma bay follows detailed international valid algorithms. this study aims to work out potential adjustments of trauma bay algorithms during a global pandemic in order to reduce contamination and to increase safety for patients and medical personnel. methods: this retrospective cohort study compared patients admitted to the trauma bay of one academic level-one trauma centre in march and april with patients admitted in march and april . based on these datasets, possible adjustments of the current international guidelines of trauma bay management were discussed. results: group pan ( , n = ) included two-thirds the number of patients compared with group ref ( , n = ). the number of severely injured patients comparable amongst these groups: mean injury severity score (iss) was significantly lower in group pan ( . ± . points) compared with group ref ( . ± . points, p = . ). duration from admission to whole-body ct was significantly higher in group pan ( . ± . min) compared with group ref ( . ± . min, p = . ). number of trauma bay admissions decreased, as did the injury severity for patients admitted in march and april . in order to contain spreading of sars cov- , the suggested recommendations of adjusting trauma bay protocols for severely injured patients include ( ) minimizing trauma bay team members with direct contact to the patient; ( ) reducing repeated examination as much as possible, with rationalized use of protective equipment; and ( ) preventing potential secondary inflammatory insults. conclusion: appropriate adjustments of trauma bay protocols during pandemics should improve safety for both patients and medical personnel while guaranteeing the optimal treatment quality. the above-mentioned proposals have the potential to improve safety during trauma bay management in a time of a global pandemic. trauma is amongst the top ten causes of death worldwide [ ] . numerous international guidelines have been introduced worldwide in order to standardize the treatment of severely injured patients and to improve their survival [ ] [ ] [ ] . these guidelines include recommendations for the minimum number of required medical professionals in the trauma bay (e.g., anesthesiologists, traumatologist, neurosurgeons, nurses, technicians etc..), initial assessments according to advanced trauma life support (e.g., blood pressure measurements, respiratory rate, auscultation and examination of body regions, etc.), and settings around the trauma bay management, such as operation room or computer tomography availability [ , ] . sars cov- , a rapidly spreading pandemic, has led to increasing infection and mortality rates which threatens to overwhelm the critical care infrastructure [ ] . several measures have recently been implemented in order to optimize treatment and outcomes of covid- patients. both intramural (mandated quarantine of medical personnel, novel isolation wards, involvement of other physicians from other specialties in daily covid- care) and extramural (businesses have been closed, social distancing, isolation) measures have been introduced. reports documenting infections have shown symptoms or even mortalities of medical personnel (nurses and doctors) and healthcare workers exacerbating the crisis [ ] . additional stresses include the increased need for medical protective equipment and medical supplies. without a doubt, the increased spread of the covid- over the population and lower capacities in critical care infrastructure directly affects the management and strategies in treatment of severely injured patients. this study aims to analyze the impact of the global sars cov- pandemic on the treatment of patients in the trauma bay in a level-one trauma center. based on the challenges brought by sars cov- , this study further discusses potential adjustments of trauma bay guidelines: . how to comply with international recommendations and guidelines and reduce risks of infections in medical personal (surgeons, nurses, emergency practitioners) involved in trauma management. . how to maintain the quality of trauma management without being contaminated or spreading the virus throughout the hospital. . how to protect of critical care infrastructure from becoming overwhelmed. the local institutional review board and the cantonal ethics committee received a detailed study protocol and waved the requirement for ethical approval to conduct this study (nr. - ). this retrospective cohort study was conducted under adherence to the strobe guidelines [ ] . data from patients who were treated in the trauma bay of one academic level-one trauma center was extracted from the electronic patient charts. for the purpose of the study, two study groups were composed based on admission data: exclusion criteria were death in the trauma bay, secondary admissions to the trauma from other hospitals, or international repatriations. this study compared patients treated in the same month to increase seasonal comparability and to reduce selection bias. the patients included were treated for the following reason: the swiss federal department of health recommended in march behavioral changes of the population to reduce the spreading of sars cov- . these recommendations included social distancing of m ( ft), staying at home as much as possible, and short-time contact to other persons ( min). in addition, non-essential businesses have been closed. for clinical personnel, wearing of personal protective equipment, such as gloves, masks, coats, and glasses has been introduced. the injury severity score (iss) was calculated based on information found on the discharge paper in common manner [ ] . severely injured patients were defined as iss ≥ points [ ] . total duration in the trauma bay indicates the time from admission to the trauma bay to the time of discharge to either the operating room (or), intensive care unit (icu), or the ward. the time from admission to whole-body ct scan (wbct) represents the delivery procedure, an initial assessment, and the preparation of the trauma team and the patient for wbct. life-saving interventions included emergency intubation, placement of a chest tube, laparotomy, craniotomy, thoracotomy, external fixation of pelvic fracture, and other interventions to stop major bleedings in the trauma bay. injury mechanisms included fall from any height, motor vehicle accidents (mvas), blunt trauma from other causes (violent attacks), penetrating injuries, or suicide attempts. treatment and diagnostics as well as trauma team members followed the local and international guidelines for trauma resuscitation [ ] . collected variables included patient demographics (age, gender), iss, total duration spent in the trauma bay, duration from admission wbct, number of severely injured patients, and life-saving interventions performed in the trauma bay. continuous variables were summarized as mean ± standard deviation and discrete variables as a number and percentage. group comparison was performed using student's t test on continuous and pearson's chi-square test on discrete variable with % confidence interval (ci) in case of normal distribution. skewed distributed variables were compared using mann-whitney u test. a p value of below . was considered statistically significant. all statistical analyses were performed using r (r core team ( ). r: a language and environment for statistical computing. r foundation for statistical computing, vienna, austria. url https://www.rproject.org/). a total of patients were initially identified. one patient was excluded in each study group, due to death before finishing trauma bay diagnostics. in group ref, one patient died after a self-inflicted gunshot to the head, and in group pan, one patient died due to brain herniation after suicidal hanging. the final cohort included patients, mean age . years (± . ), with a majority being male (n = , . %) ( table ) . group ref included ( . %) patients, while group pan included ( . %) patients. demographic variables including age and gender distribution were comparable amongst these groups. table ). the total duration in the trauma bay for group ref was . ± . minutes while in group pan, the total duration was . ± . min. this difference was statistically significant ( % ci − . to − . , . ). the duration from admission to wbct for group ref was . ± . minutes. this was found to be significantly lower when compared with group pan ( . ± . minutes, % ci − . to − . , p = . ). the sars cov- pandemic challenges routine clinical care and more specifically largely interferes with trauma care. in order to optimize planning of trauma care in the near future, there is a need to define specific alterations and to identify practical pitfalls. to do so, the current study aimed to compare trauma bay characteristics under covid- pandemic conditions and during a corresponding time period under regular circumstances (prior to covid- pandemic). the following differences were identified: & during the pandemic, there were . % less patients treated in the trauma bay & despite a comparable number of severely injured patients, the injury severity score was significantly lower during the pandemic & both the total duration in the trauma bay and the duration from admission to wbct were significantly higher during the pandemic the observed decrease in trauma bay admissions during the covid- pandemic is likely associated with the restrictions introduced by the federal health department. individuals were recommended to avoid unnecessary movements and expected to stay at home, as much as possible. furthermore, nonessential businesses have been closed. consequently, frequencies of both labor-related injuries, violence, and traffic incidents were likely lower than during normal conditions. it is assumed that admission rates of trauma patients have been influenced by patients avoiding trauma submissions. the data collected in this study revealed that "group pan" had significantly lower iss, compared to the reference group from the year "group ref." it is tempting to hypothesize that increased awareness and alertness of the general population might have affected behaviors towards high-risk sports or driving habits. however, the number of severely injured patients was comparable between the groups, indicating the necessity of maintaining the same quality of care despite the decrease of iss. even with a reduced injury severity, an increased duration from admission to ct scan was observed. these changes are difficult to explain; however, they might be a result of increased alertness of medical personnel, associated with increased hygiene recommendations and personal protection measures. the increased caution of self-exposure towards potentially infected people during daily living might also have affected medical personnel during their routine clinical treatment. based on these changes and the developments during the sars cov- crisis, the following points should be discussed regarding potential adjustments to existing trauma bay guidelines (table ) : recent guidelines (level guidelines on the treatment on patients with severe/multiple injuries by european society of trauma and emergency surgery (estes)) indicate that the basic trauma team must consist of at least three physicians ( surgeons and anesthesiologist) [ , ] . local conditions of the trauma system in each region usually define which specialties are primarily present in the emergency department. other disciplines, such as neurosurgeons or/and radiologist, and nurses/technicians from each department are frequently present in emergency department during the initial assessment of the patient in the trauma bay. in the time of pandemics, such as covid- , where there is a high infection rate, all patients need to be initially treated as infected until proven otherwise [ ] . the number of medical personnel with direct contact to the patient needs to be decreased during such pandemics in order to increase patient and medical personnel safety [ ] . moreover, the trauma team needs appropriate training in the safe use of personal protective equipment (ppe) [ ] . in order to avoid cross-contamination, the exact roles in trauma bay need to be adjusted for pandemics such as covid- [ ] . physicians with direct contact to the patient (e.g., anesthesiologists and surgeons) may be defined as the "hands-on" team, whom perform the line placement, blood collection, and clinical examination or emergency interventions (fig. ) . depending on the injury pattern or severity, the initial team can be supplemented (hands-off team) with additional colleagues (e.g. neurosurgeons, vascular surgeons, thoracic surgeons etc.) (fig. ) . the function and the role of a "trauma leader" stays unaffected according to each system and organization. especially, if the treatment of more than one severely injured patients simultaneously requires a clear definition of teams and consideration of hygiene standards. moreover, the above-mentioned strategies lead to a rationalized use of personal protective equipment, such as gloves, masks, and glasses. severely injured patients are frequently subjected to different diagnostic modalities to identify life-threatening injuries and patterns. chest and pelvis x-rays, sonography, whole-body computed tomography (wbct), and angiography are commonly used diagnostic procedures in trauma bay. the evaluation of the trauma patient should not be delayed, and appropriate precautions should be taken. when possible, diagnostic procedures are performed at sites with less traffic of outpatients to avoid secondary exposure of patients and medical staff. when possible, covid- patients should be placed in a separate location from non-covid- patients; however, optimal injury care should be a priority [ ] . transportation of trauma patients through the hospital should be avoided. therefore, whenever possible, the use of portable imaging, such as portable x-rays and sonography, is recommended. every patient is assumed to be infected; therefore, adequate decontamination of imaging equipment and any surface is necessary. when possible, repeated examinations should be reduced or entirely avoided with initial adequate diagnostics. the number of patient transfers to imaging facilities can be reduced by performing all imaging directly upon admission. in order to increase capacity, non-urgent imaging can be delayed or postponed. discussions of imaging referrals during face-to-face consultations have a potential risk of contamination, and it is recommended that this is done over the phone. recent publications indicate that a relevant number of sars-cov- -infected patients may develop severe inflammatory complications with diffuse pulmonary inflammation and alveolar damage [ , ] . some reports even document the presence of a cytokine storm in the infected patients leading to altered cellular and humoral immune responses [ ] [ ] [ ] , similar to post-traumatic acute lung injuries (alis) induced by both direct and non-direct pulmonary insults [ , ] . besides the assessment of the overall conditions of trauma patients (age, injury severity, pattern, physiological response), the presence of bilateral opacities in chest imaging may influence the decision-making in trauma bay, as well. the surgical fig. the whole treatment team could be grouped in two teams: handson and hands-off teams. the hands-on team has a direct contact with the patient and performs clinical examination and emergency interventions. the hands-off team avoids the direct contact with the patient and contaminated materials management should be based on minimizing the "secondary hit" phenomena to the immune response [ , ] . in addition, lung-protective ventilation protocols may prevent barotrauma. mechanical ventilation can exacerbate lung damage by causing a secondary induced lung injury when used improperly [ ] . the prevention of secondary infections is also stressed in order to prevent additional infectious insults and inflammatory exaggerations. moreover, recent publications indicate high rates of thromboembolic complications in covid- infected patients [ ] . therefore, adequate anticoagulation is recommended according to patient conditions. the worldwide covid- pandemic has had an immense impact on the day life and clinical practices. the number of patients admitted to the trauma bay has decreased; however, the number of severely injured trauma victims was unchanged. in order to maintain the quality standards, adjustment to the current trauma guidelines for pandemic situations is needed. patient and personnel safety should be the number one priority in such situations. moreover, the abovementioned strategies could also lead to improved and sustainable use of personal protective equipment. hans-christoph pape: interpretation of data and statistics, critical revision of the manuscript, supervision of the study. roman pfeifer: analysis and interpretation of data, statistics, critical revision of the manuscript, data collection, development and supervision of the study, searched literature. all the authors read and approved the final manuscript. sh developed the study protocol, collected and analyzed the data, interpretation of the data, writing the original manuscript, and revisions; mt interpreted the data and revised the manuscript; tb interpreted the data, revised the manuscript; vn interpreted data, revised the manuscript, and developed the study idea; hcp interpreted the data, provided the infrastructure, revised the manuscript, developed the study idea, and supervised the project; rp developed the study idea, collected and interpreted the data, revised the manuscript, supervised the project, and wrote the original article. funding information open access funding provided by university of zurich. data availability all data and material are available upon request from the corresponding author. the datasets generated during and/or analyzed during the current study are available in the figshare repository https://doi.org/ . /m . figshare. ethical approval and consent to participate, consent for publication the local institutional review board and the cantonal ethics committee received a detailed study protocol and waved the requirement for ethical approval to conduct this study (nr. - ). the study protocol and the study were approved by the local institutional review board (irb) (nr. - ). consent to participate the requirement for additional consent to participate was waived by the local irb (nr. - ). the authors declare that they have no conflict of interest. open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/ . /. the top causes of death polytrauma managementtreatment of severely injured patients in er and or an evidence based blunt trauma protocol the european guideline on management of major bleeding and coagulopathy following trauma: fourth edition emergency room management of multiple trauma : atls(r) and s guidelines the updated german "polytraumaguideline": an extensive literature evaluation and treatment recommendation for the care of the critically injured patient tracking covid- in europe: an infodemiology study covid- : protecting health-care workers the strengthening the reporting of observational studies in epidemiology (strobe) statement: guidelines for reporting observational studies the injury severity score revisited level guideline on the treatment of patients with severe/multiple injuries abstracts covid- infection in a paucisymptomatic infant: raising the index of suspicion in epidemic settings high contagiousness and rapid spread of severe acute respiratory syndrome coronavirus precautions for operating room team members during the covid- pandemic environmental contamination and viral shedding in mers patients during mers-cov outbreak in south korea american college of surgeons f maintaining trauma center access & care during the covid- pandemic: guidance document for trauma medical directors clinical course and outcomes of critically ill patients with sars-cov- pneumonia in wuhan, china: a single-centered, retrospective, observational study temporal changes in cytokine/chemokine profiles and pulmonary involvement in severe acute respiratory syndrome analysis of serum cytokines in patients with severe acute respiratory syndrome reduction and functional exhaustion of t cells in patients early decreased tlr expression on monocytes is associated with their reduced phagocytic activity and impaired maturation in a porcine polytrauma model lung repair and regeneration in ards: role of pecam and wnt signaling impact of intramedullary instrumentation versus damage control for femoral fractures on immunoinflammatory parameters: prospective randomized analysis by the epoff study group femoral nailing-related coagulopathy determined by first-hit magnitude -an animal study preemptive mechanical ventilation based on dynamic physiology in the alveolar microenvironment: novel considerations of timedependent properties of the respiratory system incidence of thrombotic complications in critically ill icu patients with covid- key: cord- -hc yo authors: muthanna, abdulrahman; salim, hani syahida; hamat, rukman awang; shamsuddin, nurainul hana; zakariah, siti zulaikha title: clinical screening tools to diagnose group a streptococcal pharyngotonsillitis in primary care clinics to improve prescribing habits date: - - journal: malays j med sci doi: . /mjms . . . sha: doc_id: cord_uid: hc yo this review highlights the clinical scoring tools used for the management of acute pharyngotonsillitis in primary care clinics. it will include the prevalence of group a pharyngotonsillitis among children and adults worldwide and the selective tests employed for diagnosing group a streptococcal pharyngotonsillitis. pharyngotonsillitis is one of the common reasons for visits to primary care clinics worldwide, and physicians tend to prescribe antibiotics according to the clinical symptoms, which leads to overprescribing antibiotics. this in turn may lead to serious health impacts and severe reactions and may promote antibiotic resistance. these significantly add on to the health care costs. the available information from health organisations and previous studies has indicated the need to manage the diagnosis of pharyngotonsillitis to improve prescribing habits in primary care clinics. acute pharyngotonsillitis is the second most commonly diagnosed pediatric illness, with sporadic cases among adults ( ) . group a streptococcal (gas) infection frequently causes significant morbidity and is associated with significant mortality rates worldwide. around the world, more than million cases annually have been diagnosed as pharyngotonsillitis ( ) . serious complications of pharyngotonsillitis caused by streptococcus pyogenes (also known as group a streptococcus) are rheumatic fever, scarlet fever, toxic shock syndrome, and acute glomerulonephritis ( ) . streptococcus pyogenes is responsible for about %- % and about %- % of acute pharyngotonsillitis cases in children and adults, respectively ( ) . clinical signs and symptoms alone cannot be used to rule out or diagnose pharyngotonsillitis, as it can mimic other types of diagnosed infections ( ) . thus, diagnosis of pharyngotonsillitis has always been delayed. ideally, the diagnosis of gas pharyngotonsillitis should be confirmed by throat swab culture, which usually takes two to three days for the bacterial growth to be identified. during this period, the illness might be resolved, or patients might experience several complications ( ) . viral pharyngotonsillitis is treated by a symptomatic relief, whereas gas pharyngotonsillitis may require the prescription of antibiotics such as penicillin, clindamycin, or erythromycin. a specific treatment might be required if complications occur ( , ) . in general, . what are the clinical scoring tools to diagnose group a streptococcal pharyngotonsillitis? . what are the sensitivity and specificity of the centor scoring system? . what are the treatment and diagnosis of group a streptococcal pharyngotonsillitis in primary care practice? pharyngotonsillitis (pharyngitis or tonsillopharyngitis) is one of most common upper respiratory tract infections ( ) . it is an inflammation involving both the pharynx and tonsils most commonly caused by viral or bacterial infection. pharyngotonsillitis can be classified as acute or chronic depending on the causative agent and the patient's immune system efficiency ( ) . the typical symptoms of pharyngotonsillitis are a sore throat, red and swollen tonsils, white or yellow patches on the tonsils, and fever ( ) . the patient's temperature rises to above °c in group a streptococcal pharyngitis ( ) . cough and nasal discharge are more symptomatic of viral infections than bacterial infections. other symptoms may include swollen anterior cervical lymph nodes, headache, painful or difficult swallowing (dysphagia), loss of voice or changes in the voice, abdominal pain in children, and bad breath. symptoms usually begin one to three days after exposure (table ) ( ) . antibiotics are safe but should be prescribed by a physician after a careful clinical assessment. however, antibiotics that are taken unnecessarily may contribute to the development of antibiotic resistance ( ) . the excessive use of antibiotics and an unnecessary antibiotic prescription add an economic burden to the health care system worldwide, as well as to patients and their families ( ) . studies have shown trends of inappropriate prescribing of antibiotics for upper respiratory tract infection (urti) in malaysian primary care, where antibiotic prescribing rates for urti were . % in malaysian primary care settings, and these rates exceed the expected prevalence of group a streptococcus among adults and children ( ) . previous studies have shown that clinical scoring tools have an acceptable specificity and can limit the overprescribing of antibiotics, thereby reducing the emergence of antibiotic resistance and the cost of health care ( , ) . this review has gathered information relevant to pharyngotonsillitis. the sources of the information provided are reliable to an extent owing to the references that have been cited. recent literature has been used, and very few sources of old literature have been used where necessary. in writing this review, answers to the following questions are sought: . what is the prevalence of group a streptococcal pharyngotonsillitis among children and adults worldwide? . what is the principle of management for antibiotic prescription in primary care clinics? and about %- % of acute pharyngotonsillitis cases in children and adults, respectively. it is characterised by inflammation, exudates, fever, leukocytosis and tender cervical lymph nodes ( , ) . groups c and g beta-hemolytic streptococci are a normal flora of the human upper airway, but they can cause pharyngotonsillitis ( ) . occasionally groups b, and f betahemolytic streptococci are responsible for pharyngotonsillitis. haemophilus influenzae cause pharyngotonsillitis in children less than five years old. others bacteria such as moraxella, chlamydia pneumoniae, mycoplasma pneumoniae, corynebacterium diphtheriae, and neisseria gonorrhoeae cause pharyngotonsillitis, rarely ( , ) . candida albicans rarely cause pharyngitis when the normal flora is killed through antibiotics therapy or when the individual is immunosuppressed by disease or drugs ( table ) ( ) . table shows the prevalence of group a pharyngotonsillitis among children and adults. the studies included developing and developed countries around the world. the prevalence of group a pharyngotonsillitis around the world varies from % to . %. most cases of pharyngotonsillitis are caused by viruses and sometimes occur as a part of the common cold or influenza syndromes ( ). the most common viruses that cause uncomplicated pharyngitis are adenoviruses, especially in children ( ) . rhinoviruses cause about % of pharyngitis cases, and there are more than serotypes of rhinovirus ( ) . in addition, pharyngotonsillitis is common in patients with influenza a and constitutes about % of the cases, whereas the proportion is lower in patients with influenza b ( ) . the epstein-barr virus is responsible for % of pharyngotonsillitis cases and usually spreads from adults to infants ( ) . moreover, coxsackieviruses and echoviruses are common enteroviruses that cause pharyngitis ( ) . cytomegalovirus, parainfluenza viruses, coronaviruses, and the measles virus may cause pharyngotonsillitis ( , ) . bacteria cause about %- % of pharyngotonsillitis cases ( ) . the most common and important bacteria that cause acute pharyngotonsillitis belong to streptococcus pyogenes (group a beta-hemolytic streptococcus). streptococcus pyogenes is responsible for about %- % that weaken the immune system, such as diabetes, organ transplant, chemotherapy, and aids ( ) . all racial and ethnic groups are affected by pharyngotonsillitis worldwide and the infection can affect both male and female genders ( ). appearance of streptococcus pyogenes produces a zone of β hemolytic around the colonies and it is sensitive to bacitracin disc on the blood agar, following h of incubation under anaerobic conditions figure shows the wide variation in prevalence of group a pharyngotonsillitis around the world. the highest prevalence of group a pharyngotonsillitis was recorded in the middle east, while the studies in the southeast asian countries has reported the lowest the prevalence. the rate of infection was higher among children than adults. these variations in the prevalence of group a pharyngotonsillitis between the different countries due to several factors such as the study design, sampling technique, cultural, ecological, and others ( ) . furthermore, the incidence pharyngotonsillitis is more common in children, especially in school age because they are in close contact with the pathogens, where infection spreads through close contact with an infected child, when a person inhale droplets of respiratory secretions from the air when an infected person breathes, coughs, or sneezes ( ) . an environment, polluting the environment and the lack of ventilation and air pollution, all of these environmental factors reinforce the spread of infection ( ) . in addition, the peak incidences of pharyngotonsillitis occur in the winter and spring with sporadic cases throughout the year ( ) . other risk factors for pharyngotonsillitis are sickle cell anemia, sinusitis, smoking or exposure to secondary smoke, and any condition s o u t h a f r i c a s a u d i a r a b i a e g y p t i r a n p a k i s t a n a u s t r a l i a j a p a n t h a i l a n d s i n g a p o r e i n d o n e s i a i n d i a y e m e n e t h i o p i a s e r b i a t u r k e y f r a n c e u k u s a c a n a d a b r a z i l a r g e n t i n a ( ) . according to previous studies, rapid antigen detection test has been hindered because it has low sensitivity ( ) . therefore, the centres for disease control and prevention (cdc) and american academy of family physicians (aafp) guidelines have recommended that the negative radt results should be backed up by a swab throat culture to increase the accuracy of the diagnosis ( ). however, radt has a high specificity, this means that the positive radt results do not require to be backed up by a swab throat culture ( ) . more recently, molecular based techniques, such as dna probes and polymerase chain reaction (pcr) have been developed to identify the pathogens that cause pharyngitis. it is a sensitive, and specific method, but it is not used routinely in most of the countries around the world, and usually it is used in epidemiological studies ( ) . anti-streptolysin-o (aso) test is a rapid latex agglutination test to determine antistreptolysin-o antibodies in patient's serum who had a recent β-haemolytic streptococci infection. the titer increases after days of infection and reach the peak after to weeks ( ). clinical tools are a guideline for a quick diagnosis and treatment of group a streptococcal pharyngotonsillitis in patients with complaints of sore throat ( ) . it is a screening method to help physicians determine if the patient needs testing (throat culture or rapid antigen detection test) or not and if the patient needs empiric antibiotic therapy ( ) . all the studies that reported the clinical prediction rules for diagnosing group a streptococcal pharyngotonsillitis among adults and children were eligible to inclusion for the purpose of this review. the clinical prediction rules were defined as a decision-making tool that included two or more variables obtained from the physical examination or the history of the patients. all studies that updated by the original authors only was included ( table ). most of these tools are clinical scores based on the clinical findings which is associated with group a streptococcal infection. previous studies regarding to the accuracy of diagnosis of group a streptococcal pharyngotonsillitis by using these tools have shown that, most of these strategies did not show sufficient accuracy, and were majority of physicians depends on the clinical findings to diagnose pharyngotonsillitis but cannot distinguish between streptococcal from non-streptococcal infections according to the clinical findings ( , ) . in addition, signs and symptoms of pharyngotonsillitis overlay extensively with other infectious, making the diagnosis according only to the clinical findings is inaccurate ( ) . pharyngotonsillitis is manifested by white or gray patches on the tonsils, swelling of the tonsils, and redness, and inflammation of pharyngeal wall. usually there will be swollen anterior lymph nodes in the sides of the neck with group a streptococcus pharyngotonsillitis. in addition, ear and nose inflammation might be occurred where pharyngotonsillitis conferred an increase conferred an increase of ear and nose infections. spreading of bacterial infections from pharynx to the nose and middle ear because they are located in the same cavity might be an explanation of this association ( ) . the gold standard laboratory diagnosis of streptococcal pharyngotonsillitis is culture of throat swab. culture of throat swab is a laboratory diagnostic test to evaluate the presence of a streptococcal infection in the throat ( ) . the sample is collected from the tonsils and the wall of pharynx by swab. presence of streptococcus pyogenes onto blood agar confirm the streptococcal pharyngotonsillitis ( figure ). the results are further identified based on biochemical test such as gram stain and pyrrolidonyl arylamidase test ( ) . the sensitivity and specificity of the throat swab cultures ( . %, and . %, respectively) are more than the sensitivity and specificity of the rapid antigen detection test ( . %, and . %, respectively) ( ) . however, the throat swabs culture is not effective enough because of the relatively long time (two to three days) for the bacterial growth to be identified ( ) . rapid antigen detection test (radt) can be an appropriate alternative test to identify group a streptococcus directly from throat swabs because it is a rapid test and takes few minutes in providing results as compared to throat swab culture. therefore, the physician can make a decision about the therapy at in , centor et al. ( ) have developed set of four criteria which might be used to identify the likelihood of group a streptococcal infection in adult patients complaining of a sore unable to identify patients in a low or high-risk case. however, several studies have shown that centor and macisaac scoring have a sensitivity more than % and a specificity more than % ( , ) . of two or three is require testing by using rapid antigen detection test or throat culture, because the chance of streptococcal infection is around %- % and require anti-microbial therapy only if the result is positive. however, a patient with a score of four should be tested by using rapid antigen detection test or throat culture, and empiric antibiotic therapy is required due to chance of streptococcal infection is high between % and % ( figure ) ( ). previous studies about the accuracy of centor criteria have shown that, the sensitivity of absence of cough and swollen anterior cervical lymph nodes was higher than the specificity (sensitivity %, specificity % and sensitivity %, specificity %, respectively), while the specificity of the presence of fever (≥ °c) and tonsillar exudates was higher than sensitivity (sensitivity %, specificity % and sensitivity % and specificity %, respectively throat. centor criteria including the presence of fever equal to or more than °c, absence of cough, swollen anterior cervical lymph nodes, and tonsillar exudates or swelling, one point is added for each criterion. the centor scores might range from - (table ) ( ). bacterial pharyngotonsillitis is treated by anti-microbials. penicillin, a course of oral penicillin v for days or a single dose of parenteral penicillin g are the best choice to treat group a streptococcal pharyngitis. however, amoxicillin can be used. in penicillin allergic patients, cephalosporins, clindamycin, erythromycin or azithromycin are an acceptable alternative ( ) . in addition, group c and g streptococcal pharyngitis are usually treated with antibiotics, although it lacks the clinical trials ( , ) . to help physicians to prescribe the appropriate antibiotics for children and adults with streptococcus pharyngitis, centres for disease control and prevention (cdc), american academy of family physicians (aafp), and the institute for medical research (imr) have developed the clinical practice guidelines for respiratory tract infections ( , , ) . moreover, the guidelines were compiled by the leading medical organisations ( , ) . according to the cdc, aafp guidelines, and the national antibiotic guideline in malaysia, antibiotics should be prescribed only to patients with group a streptococcal infection (streptococcus pyogenes) which group a streptococcus usually cause symptoms including sore throat, fever more than °c, exudates, nausea, vomiting, headache, stiff and swollen neck, abdominal pain, and tender enlarged cervical lymph nodes. however, cough, nasal discharge, conjunctivitis, and diarrhea are more symptomatic of viral infections than group a streptococcal infections and the viral infections do not treat with antibiotics. the diagnosis must be confirmed by throat culture or rapid antigen detection test ( , , ) . cdc and aafp guidelines recommended antibiotics for patients with sore if the patient is younger than months, diagnosis certain, or in severe illness ( ) . the first-line of antibiotics to treat group a streptococcal infection in children and adults are oral penicillin v for days or a single dose of parenteral penicillin g; however, the alternative therapy for children are amoxicillin, oral cephalosporins, clindamycin, and macrolides. amoxicillin, macrolides, erythromycin, oral cephalosporins, clindamycin in adult patients allergic to penicillin for days. ( ) . in addition, the positive likelihood ratio (lr) of tonsillar exudates was the highest positive likelihood ratio equal . , suggesting it raises the probability of having group a pharyngotonsillitis between % and %, while the positive likelihood ratio (lr) of fever (≥ °c) was . and it raises the probability of having group a pharyngotonsillitis between % and % when present. absence of cough and swollen anterior cervical lymph nodes both decrease the likelihood of having group a pharyngotonsillitis between % and % when absent ( ) . the presence of all four criteria have a positive predictive value between % and % for group a streptococcal pharyngotonsillitis. however, the absence of all criteria have a negative predictive value more than %. therefore, these studies have suggested that the presence of all four criteria discriminates group a streptococcal pharyngotonsillitis from other etiology in patients with sore throat ( ) . furthermore, studies have shown that the centor score has an acceptable sensitivity and specificity (sensitivity %, and specificity %, respectively) in predicting likelihood of group a streptococcal pharyngotonsillitis. applying this to prescribing decision, can limit the over prescription of antibiotics, thus will reduce the emergence of antibiotic resistance as well as the cost of health care but should be used in primary care clinics. however, laboratory confirmation is the gold standard in making an accurate diagnosis ( ) . in addition, centor scoring provides quick diagnosis of group a streptococcal pharyngotonsillitis in adult patients, unlike the tests to confirm a diagnosis of streptococcal pharyngotonsillitis, such as a culture which takes two to three days for the results in order to avoid any complications ( ) . macisaac score are similar to centor score, but it adds one extra point for patient less than years old, because this age group is more susceptible to streptococcal pharyngotonsillitis and subtract one point if the patient age years old or more. therefore, the score might range from − to . a low score on macisaac criteria help to exclude streptococcal pharyngotonsillitis, and higher scores require testing by using rapid antigen detection test or throat culture, and empiric antibiotic therapy ( , ) . with sore throat ( ) . a study that carried out in jordan among patients with sore throat has reported that antibiotics were prescribed for . % of patients with sore throat ( ) . another study done by lauri et al. in the united states of america has reported that the rate of prescribed antibiotics to adults with sore throat was . % ( ) . the centres for disease control and prevention (cdc), american academy of family physicians (aafp), and the national antibiotic guideline in malaysia strongly recommend the strategies of centor scoring to select patients need for antibiotic therapy. the goal of the strategies is to limit unnecessary antibiotic prescribing. these strategies are expected to limit the antibiotic prescribing rates between % and %, lower than current rates which is more than %. in addition, the strategies are expected to administer appropriate analgesics, anti-pyretics and supportive care of patients with pharyngotonsillitis ( , ) . the infectious diseases society of america (idsa) and american college of physicians (acp) guidelines, conversely, have recommended that the diagnostic testing is required (radt or throat culture in all patients at risk) and cannot depend on the clinical diagnosis of gas pharyngotonsillitis alone. idsa and acp guidelines recommend confirmatory for negative radt by throat swab culture in children ( ) . in addition, according to the united kingdom national health service (uknhs), the antibiotic is prescribed only to high-risk and very ill patients ( ) . group a streptococcus (streptococcus pyogenes) and other beta haemolytic streptococci are sensitive to penicillin and cephalosporin as well as rifampin and vancomycin. however, some strains of the bacterium have been found to be resistant to macrolides, tetracycline, and clindamycin ( ) . the excessive take of unnecessary antibiotics led to increase and spread the resistant of anti-microbial in communities around the world. the increasing of antimicrobial resistance has been attributed to combinations of microbial characteristics, selective pressures of anti-microbial use, and societal and technological changes that enhance the transmission of drug-resistant organisms analgesics and antipyretics such as ibuprofen or acetaminophen can be used to reduce the pain ( ) . the national antibiotic guideline in malaysia has recommended amoxicillin mg or phenoxymethylpenicillin mg for days to treat pharyngotonsillitis that are caused by group a streptococcus; however, the alternative therapy is a single dose of benzathine penicillin, azithromycin mg for days or clindamycin mg- mg for days to patients who allergic to penicillin ( ). viral pharyngotonsillitis is treated by a symptomatic relief, such as soothing fluids, aspirin, paracetamol, soothing gargle, and rest with drinking an adequate water and hot fluid ( ) . tonsillectomy or surgery to remove the tonsils is indicated when complications of pharyngotonsillitis (repeated occurrence of acute tonsillitis, peritonsillar abscess or obstruction of the nasal airway) ( ) . antiinflammatory medications such as aspirin for pain or corticosteroids might be required if the complications of group a streptococcal pharyngotonsillitis such as rheumatic fever occur ( ). anti-microbial resistance is driven by many factors, the most significant of which is inappropriate prescribing. this is when patients get a prescription for an antibiotic that they don't really need, or get a prescription for the wrong antibiotic, the wrong dose or the wrong duration. typically, antibiotics are prescribed by physicians to the patients based on clinical symptoms. there are reasons for inappropriate prescriptions are very difficult to curb, including the difficulty of diagnosis of whether a viral or bacterial infection to determine the appropriate treatment and it is known antibiotics can only be given to patients with bacterial infection ( ) . patients play an important role in that issue, because most of the patients insist that physicians to prescribe the antibiotic and that increase demand for a group of antibiotics speeds up the resistance of antibiotics and it becomes useless ( ) . the antibiotic prescription rate in a study at public primary care clinics which was carried out in malaysia was . % among patients . % compared to . % in . for group b streptococci, the resistance to tetracycline, co-trimoxazole and clindamycin have increased in compared to . ceftriaxone resistance was less in ( . %) compared to . % in ( ). the above review has documented that the over prescribing of antibiotics is a global problem. since pharyngotonsillitis is one of the common reasons for visiting care clinics worldwide, over-prescription of antibiotics reason to occur the anti-microbial resistance. although, there is a lack of the data on the above matters, the available studies indicated that, there is an urgent need to reduce the overprescription of antibiotics in the health care centres and clinics. one of the solutions is to follow the strategies that help to diagnose group a streptococcal infection. according to previous studies, the clinical rules for triaging patients who should undergo group a streptococcal testing was poor, however, centor and macisaac scoring have shown high sensitivity and acceptable specificity. further validation studies about the clinical prediction rules are needed to ensure the accuracy and update the clinical strategies. future studies should also aim to detect the accuracy of diagnosis using the rapid antigen detection testing and the gold standard to diagnose group a streptococcal pharyngotonsillitis. none. none. none. none. ( ) . furthermore, the resistance of antimicrobial lead to increase the morbidity and mortality since resistance increases the risk of inappropriate therapy. the risk is that the patients who do not receive appropriate therapy will have a longer period of disease or fatal effect; moreover, morbidity and transmission of the microorganism will increase due to the patients remain infectious for a long period. increased morbidity and mortality was documented in several cases including streptococcal infection ( ). a study in france has estimated that , infections due to multidrug-resistant microorganisms occurred in , including , deaths were associated with these infections ( ). in addition, another study in european countries has reported that , infections due to multidrug-resistant microorganisms were associated with , deaths ( ) . in term of cost, the cost of the consequences of anti-microbial resistance might include hospitalisation for long period, costs of additional laboratory testing and including full health care costs. the costs of antibiotic therapy depend on the dose and duration of treatment and often are expensive due to there are few antibiotics available to treat the multidrugresistant bacteria. in addition to this costs, the costs of the efforts and studies to eradicate the anti-microbial resistance from health care centres. the costs of morbidity and mortality has indirect effects and are not easy to be measured and economically evaluated due to a number of effects such as extension of resistant genes between different species and strains ( ) . however, the morbidity, mortality and economic impact of streptococcal infection has not been elucidated ( , ) . previous studies have shown that there was a high rate of resistance among group a streptococcus and other beta haemolytic streptococci to antibiotics β-lactam, but they were highly susceptible to penicillin vancomycin, ofloxacin, cephalosporin, and clindamycin ( ) . in addition, another study in south korea have reported that the resistance to erythromycin and clindamycin has markedly increased during the period to ( ) . in malaysia, according to the institute for medical research (imr), for group a streptococcus, erythromycin resistance was . % in and has decreased to . % in . the resistant to clindamycin has increased to . % in compared to . % in . tetracycline resistance in has increased to antibiotics for urti and uti prescribing in malaysian primary care settings large-scale validation of the centor and mcisaac scores to predict group a streptococcal pharyngitis predicting streptococcal pharyngitis in adults in primary care: a systematic review of the diagnostic accuracy of symptoms and signs and validation of the centor score appraisal of clinical practice guideline for the diagnosis and management of group a streptococcal pharyngitis: update by the infectious diseases society of america etiology of acute pharyngotonsillitis in children: the presence of viruses and bacteria. pediatr infect vaccine viral and atypical bacterial etiology of acute respiratory infections in children under years old living in a rural tropical area of madagascar rapid antigen detection test for group a streptococcus in children with pharyngitis (review) group c and group g streptococcal infection environmental and non-infectious factors in the aetiology of pharyngitis (sore throat) streptococcal acute pharyngitis serious group a streptococcal infection impact of the rapid antigen detection test in diagnosis and treatment of acute pharyngo-tonsillitis in a pediatric emergency room primary prevention of acute rheumatic fever and rheumatic heart disease with penicillin in south african different antibiotic treatments for group a streptococcal pharyngitis (review) distribution of emm types among group a streptococcal isolates from serbia prevalence of group a β-haemolytic streptococcus among children with pharyngitis in jimma town, southwest ethiopia group a streptococcal emm type prevalence among symptomatic children in cape town and potential vaccine coverage prevalence of group a beta-haemolytic streptococcus isolated from children with acute pharyngotonsillitis in a study of group a streptococcal bacteria isolation from children less than years with acute tonsillitis, pharyngitis and healthy primary school children group a beta-hemolytic streptococcal pharyngitis and carriage rate among egyptian children: a case-control study isolation of streptococcus pyogenes from children with pharyngitis and emm type analysis pakistan prevalence survey in acute pharyngitis prevalence of beta-hemolytic streptococci groups a, c, and g in patients with acute pharyngitis prediction of bacterial pharyngitis in children using clinical features prevalence of streptococcal pharyngitis and streptococcal carriage in children: a meta-analysis high incidence of invasive group a streptococcal infection in remote indigenous communities in northwestern ontario factors associated with group a streptococcus emm type diversification in a large urban setting in brazil: a cross-sectional study throat carriage rate and antimicrobial resistance of streptococcus pyogenes in rural children in argentina surgery of the nose and paranasal sinuses: principles and concepts, an issue of oral and maxillofacial surgery clinics e-book comparative epidemiology of streptococcus pyogenes emm-types causing invasive and noninvasive infections in french children by use of high-resolution meltingpolymerase chain reaction prevalence of group a streptococcal carriers in asymptomatic children and clonal relatedness among isolates in malatya, turkey currently neglected, physical examination maintains its clinical relevance comparison of illumigene group a streptococcus assay with culture of throat swabs from children with sore throats in the new zealand school-based rheumatic fever prevention program a comparison between the strep a rapid test device and conventional culture for the diagnosis of streptococcal pharyngitis rapid diagnostic tests for group a streptococcal pharyngitis: a metaanalysis sensitivity and specificity of rapid antigen detection testing for diagnosing pharyngitis in the emergency department excessive antibiotic prescribing for sore throat and acute bronchitis remains common rapid antigen group a streptococcus test to diagnose pharyngitis: a systematic review and meta-analysis molecular and clinical diagnosis of group a streptococcal pharyngitis in children clinical predictors of childhood streptococcal pharyngitis acute respiratory symptoms in adults in general practice upper respiratory tract infection in thai adults: prevalence and prediction of bacterial causes, and effectiveness of using clinical practice guidelines epidemiological survey of β-hemolytic streptococci isolated from acute pharyngitis in a private pediatric practice low rates of streptococcal pharyngitis and high rates of pyoderma in australian aboriginal communities where acute rheumatic fever is hyperendemic diagnosis of acute tonsillopharyngitis in primary care: a new approach for low-resource settings incidence and microbiology of peritonsillar abscess: the influence of season, age, and gender group a streptococcal pharyngitis and immune-mediated complications: from diagnosis to management clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of prism (primary care streptococcal management) a scoring system for management of acute pharyngo-tonsillitis in adults pharyngitis management: defining the controversy adolescent and adult pharyngitis: more than "strep throat": comment on "large-scale validation of the centor and mcisaac scores to predict group a streptococcal pharyngitis identifying and treating group a streptococcal pharyngitis in children principles of judicious antibiotic prescribing for upper respiratory tract infections in pediatrics ministry of health malaysia. national antibiotic guideline nudging guidelineconcordant antibiotic prescribing: a randomized clinical trial effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices diagnosis and treatment of streptococcal pharyngitis control of pain after tonsillectomy in children aso tire in acute rheumatic fever/rheumatic heart disease in pediatric age group diagnosis and management of group a beta-hemolytic streptococcal pharyngitis clinical practice guideline for the diagnosis and management of group a streptococcal pharyngitis over prescription of antibiotics for adult pharyngitis is prevalent in developing countries but can be reduced using mcisaac modification of centor scores: a cross-sectional study selective utilization of clinical diagnosis in treatment of pharyngitis the diagnosis of strep throat in adults in the emergency room streptococcal pharyngitis in a paediatric emergency department a clinical score to reduce unnecessary antibiotic use in patients with sore throat performance of a predictive model for streptococcal pharyngitis in children pragmatic scoring system for pharyngitis in lowresource settings mechanisms and consequences of bacterial resistance to antimicrobial peptides antibiotic resistance threats in the united states mortality and hospital stay associated with resistant staphylococcus aureus and escherichia coli bacteremia: estimating the burden of antibiotic resistance in europe the threat of antimicrobial resistance in developing countries: causes and control strategies epidemiology and antibiotic resistance of group a streptococci isolated from health schoolchildren in korea to fight antibiotic resistance, we need to fight bad prescribing habits the effect of profiling report on antibiotic prescription for upper respiratory tract infection antibiotic prescribing for acute respiratory infections in children in jordan us outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in practice guidelines for the diagnosis and management of group a streptococcal pharyngitis macrolide and clindamycin resistance in group a streptococci isolated from children with pharyngitis key: cord- -by albr authors: van ginkel, frederik w.; padgett, justin; martinez-romero, gisela; miller, matthew s.; joiner, kellye s.; gulley, stephen l. title: age-dependent immune responses and immune protection after avian coronavirus vaccination date: - - journal: vaccine doi: . /j.vaccine. . . sha: doc_id: cord_uid: by albr infectious bronchitis virus (ibv) is an endemic disease of chickens and a major contributor to economic losses for the poultry industry despite vaccination. recent observations indicated that chicks may have an immature immune system immediately after hatching when vaccinated for ibv. therefore we hypothesized that early ibv vaccination will generate an immature, poorly protective ibv-specific immune response contributing to immune escape and persistence of ibv. to test this hypothesis the ibv-specific immune response and immune protection were measured in chicks vaccinated at different ages. this demonstrated a delayed production of igg and iga plasma antibodies in the , and -day-old vaccination groups and also lower iga antibody levels were observed in plasma of the -day-old group. similar observations were made for antibodies in tears. in addition, igg antibodies from the -day-old group had lower avidity indices than day vaccinated birds. the delayed and/or lower antibody response combined with lower igg avidity indices coincided with increased tracheal inflammation and depletion of tracheal epithelia cells and goblet cells upon ibv field strain challenge. the lack of vaccine-mediated protection was most pronounced in the -day-old vaccination group and to a lesser extent the -day-old group, while the -day-old and older chickens were protected. these data strongly support ibv vaccination after day post hatch. ibv is endemic and currently one of the most important causes of economic losses for the poultry industry and represents a continuous threat for this industry. in the past, it was estimated that with the best possible management of flocks ibv infection will reduce income by approximately % when compared to an ibv-free flock [ ] . there is approximately a % vaccine failure for arkansas (ark) serotype of ibv [ ] , the most prevalent vaccine serotype used in the usa. symptoms of ibv infection include, but are not limited to, wet eyes, swollen face, tracheal and kidney lesions, respiratory disease, reduced weight gain in broilers, decreasing and poor egg quality in layers [ , ] . the existence of various ibv serotypes as abbreviations: ark dpi, arkansas delmarva poultry industry; calt, conjunctivaassociated lymphoid tissue; elispot, enzyme-linked immunospot; hg, harderian gland; halt, head-associated lymphoid tissues; hrp, horseradish peroxidase; ibv, infectious bronchitis virus; eid , median embryo infectious dose; tlr, toll-like receptor. * corresponding author. well as antigenic variants [ ] complicates vaccination programs. since immunity induced by vaccination against a single serotype generally provides insufficient protection against other serotypes [ , ] . mucosal immunity plays a role in the control of ibv in chickens as was demonstrated using ibv-resistant and ibv-susceptible inbred chicken lines [ ] . this combined with the finding of gelb et al. [ ] , in which ocular immunization with the massachusetts connaught strain of ibv only on day or on day plus day followed by challenge with massachusetts provided protection of % and % of the chickens, respectively, while the same spf white leghorns only ocularly immunized on day were % protected [ ] . bsa immunization of , and day old broiler chickens obtained very similar results [ ] . this raises questions pertaining the maturity of the immune system and in particular the mucosal immune system, and the ability of chicks to generate a protective immune response when vaccinated at a very young age. conjunctiva-associated lymphoid tissue (calt) and harderian glands do not fully mature as a lymphoid organ until weeks after hatching [ , , [ ] [ ] [ ] . this combined with the practice of immunizing and boosting for ibv early after hatching may set up the immune http://dx.doi.org/ . /j.vaccine. . . - x/© elsevier ltd. all rights reserved. response for failure to protect. the second ibv immunization on day of age, which by itself is fully protective, does not completely compensate for the premature priming on day [ ] . field studies by de wit et al. [ ] demonstrated a lack of protective immunity when birds were boosted between day through day of age. the percentage of birds in a commercial flock positive for ibvspecific igm antibodies was correlated with vaccine protection and increased with the age of boosting. this data supports the notion that early vaccination and boosting of the ibv immune response may limit induction of protective immune responses to ibv. unlike the study by gelb et al. [ ] , the de wit et al. [ ] study can also be interpreted that maternal antibodies interfere with vaccine delivery during the first weeks of life [ ] . further evidence that the immune response may be limited during the first weeks of life comes from the observation that iga levels are undetectable in plasma the first week of life and igm levels are low [ ] . this indicates that immunoglobulin class switching and production of antibodies is very limited during the first week post hatch and therefore chicks are highly dependent on maternal igy antibodies for protection against ibv, which drops ∼ % during the first week of life [ ] . besides diminished b cell response after vaccination, splenic t cells from one week old chickens are also less responsive to polyclonal activation than that of older chickens. the splenic t cells from day old chicks even produce inhibitory factors for proliferation of mature t cells in vitro [ ] . furthermore, splenic lymphocytes of day old chicken displayed better antigen specific proliferation after oral salmonella exposure than day old chicken [ ] . when measuring gene expression in lung and trachea in and week old birds after avian influenza exposure a reduced expression of immune-related genes was shown and included innate immune response genes in the younger birds [ ] . additional evidence that innate immune mechanisms are diminished in young chickens was demonstrated by a lower salmonella phagocytic index of heterophils during the first few days of life [ ] . thus, early exposure to pathogens or vaccines may induce suboptimal innate and adaptive immune responses. based on these observations we hypothesized that early ibv vaccination, i.e., within the first week after hatching, will generate an immature, poorly protective ibv-specific immune response contributing to ibv immune escape and persistence. therefore, the ability of spf chickens of different age to induce an ibv-specific antibody response and protect against challenge with an ibv field strain was measured. our data indicate that early vaccination is suboptimal for induction of ibv-specific immune responses and immune protection. chickens: specific-pathogen-free (spf) white leghorn eggs were obtained from sunrise farms, inc., catskill, ny, hatched and used in all experiments. all hatched chickens were used for the below outlined experiments regardless of sex. chickens were housed in cages in bsl facilities for the duration of the experiment. food and water were provided ad libitum. all experimental procedures and animal care were performed in compliance with all applicable federal and institutional animal use guidelines. auburn university college of veterinary medicine is an association for assessment and accreditation of laboratory animal care (aaalac)-accredited institution. ibv-vaccination and challenge: spf chickens were ocularly vaccinated with × % embryo infectious doses (eid ) of a live attenuated arkdpi ibv vaccine strain (zoetis, new york, ny) in l pbs, which was expanded in our laboratory. chickens were vaccinated day of age and , , or weeks of age. all groups were challenged ocularly with . × eid of the al/ / ibv field strain days after vaccination sample collection: tears were collected as previously described [ ] . blood samples were obtained by puncturing the brachial vein with a sterile g needle into kendall monoject, edta containing, blood collection tubes (tyco healthcare group lp, mansfield, ma) and incubated on ice. blood samples were centrifuged at × g for min. plasma was collected and stored at − • c until tested. ibv propagation and purification for elisa: ibv was propagated in spf white leghorn embryonated chicken eggs (sunrise farms, inc., catskills, ny) by inoculation on day of embryonation as previously reported [ ] . supernatants were titrated for the ibv virus using the reed and muench method [ ] . ibv was treated with . % ␤-propriolactone for min at • c [ ] . inactivation of the virus was confirmed by injection into embryonated eggs. the inactivated ibv was purified based on a previously published protocol [ ] . the virus was then stored at − • c until used. in order to measure igg (igy), iga and igm antibody levels in plasma and tears of chicken, an ibv-specific enzyme-linked immunosorbent assay (elisa) was developed as previously described [ ] . in brief, elisa plates were coated with ␤propriolactone killed, purified ibv at g/ml in carbonate buffer. the plates were blocked with pbs-bsa ( %) after which the samples were loaded at two-fold dilutions. binding of chicken antibodies was detected using biotinylated anti-chicken-igg, -iga and -igm monoclonal antibodies (southern biotechnology associates, inc., birmingham, al) followed by streptavidin-horseradish peroxidase. the plates were developed using tmb ( , , , -tetramethylbensidine; invitrogen corp., frederick, md) substrate. the highest sample dilution with at least an optical density of . above background level at nm was defined as the endpointtiter. ten to thirteen chickens were analyzed per group. the control group consisted out chicken from each age group for iga and igg, which were pooled in one group of since no differences were observed between the controls. for igm levels in plasma the controls (each group containing chickens except day which had ) were displayed separate for each age group. this was done because significant differences were observed between control igm levels to ibv in different age groups. the avidity index was determined as previously described [ , ] using the above described ibv-specific elisa. plasma and tears were diluted : in elisa buffer and were loaded on ␤propiolactone killed ibv coated elisa plates ( g/ml) [ ] . after overnight incubation of these samples at • c, l of increasing concentrations of potassium thiocyanate ( . , . , . , . , . , . , . m kscn) were loaded into the wells and incubated for min at room temperature. after washing the plates, the detection of ibv-specific antibodies was accomplished as previously reported [ ] . the data were normalized to percent inhibition relative to samples not exposed to kscn. the concentration of kscn to inhibit % of the reactivity of the elisa was defined as the avidity index [ , ] . the od read-out for the kscn inhibition data was curve-fitted using -order polynomial regression analyses in microsoft office excell program. the excell provided formula for the inhibition curve was used to determine the x values of y = . , which are the concentrations of kscn inhibiting % of the elisa reactivity, representing the avidity indices of those samples. all samples were analyzed in triplicates and - samples were analyzed per group. the cranial / of tracheae was collected days after ibv challenge with . × eid of al/ / ibv field strain. the tracheae were formalin-fixed and embedded in paraffin. longitudinal m sections were made and were hematoxylin and eosin (h&e) stained and analyzed for mucosal thickness using aperio scan scope and the image j morphometry program (rsb.info.nih.gov/ij/download.html). to measure the mucosal thickness measurements were made at regular intervals on one tracheal ring (see supplemental fig. ). as stated above, histopathology was analyzed in h&e stained tracheal slides days after ibv challenge. besides mucosal thickness (see supplemental fig. ), deciliation (see supplemental fig. ), goblet cells (see supplemental fig. ) and lymphocytes scores (see supplemental fig. ) of the tracheal mucosa were evaluated blindly and scored through based on severity (i.e., normal, mild, moderate, marked, severe). five chickens were used as positive and negative controls, i.e., one of each age group, and - chickens were analyzed for each age group. a visual depiction of the scoring of these parameters is provided in the supplemental data (supplemental figs. - ) . statistical analysis: data were analyzed using a one-way anova test with newman-keuls multi-comparison test or the t-test using graphpad prism software. groups were considered significantly different when p < . . to determine whether age of ibv vaccination affected the humoral immune response, plasma samples were collected and days and tears days after vaccination with × eid of a live-attenuated arkdpi ibv vaccine strain on , , or days of age. the ibv-specific igg endpoint titers in plasma days after vaccination are significantly lower for day vaccinated birds with a mean of . ± . when compared to day , and vaccinated birds, which means vary between . - . . the -day-old group does not differ significantly from day or later vaccinated bird (fig. a) . the igg ibv-specific plasma levels days after vaccination demonstrate, that the day and old vaccination groups chickens were vaccinated at day , , , or of age. unvaccinated chickens of the different age groups served as negative control. the data was analyzed by one way anova with the newman-keuls post-test. the control group contains data points for each age group, which were pooled in one group (n = ). all vaccinated age groups contained between and chickens for igg and iga. a significant difference is observed at p < . and is indicated by different letters. igm levels in ibv vaccinated birds are depicted by squares (n = ) and the controls by circles (n = , d group n = ). for the igm controls the different age groups are shown separately since significant differences were observed between them. a significant increase (p < . ) of igm levels in ibv vaccinated birds over their control group is indicated by a (*). stayed the same, while igg antibody titers in groups vaccinated on day , and still increased (fig. c) . this shows that early vaccination causes a delay in the ibv-specific igg antibody kinetics. the ibv-specific iga plasma antibody titers are not significantly different between groups, although the day vaccinated group mean antibody titer is the lowest of all groups (fig. b) and at least -fold lower than the next lowest group. unlike the igg antibody titers only the day vaccination group increases in mean iga plasma titer on day post vaccination, while day group stays the same and the day , and groups decline in mean iga titer. thus, only the day group increases antibody titers on day when compared to older birds. thus, the day group displays a delayed response in antibody production compared to older birds. the day and day groups have plasma iga titers to ibv that are comparable to, or higher than, the day and groups on day of the response. unlike the day and day vaccination groups the day and groups are declining on day of the response compared to the immune response on day . this indicates that they are past their peak response on day and possibly even on day based on previous observations [ ] . these data are consistent with a delay in the iga plasma response to ibv in birds vaccinated at a younger age and a non-significant decline in mean iga titers in the -day-old group. ibv-specific igm antibody titers were measured in plasma. the plasma samples analyzed were collected on day post vaccination. this time point was selected based on the literature in which the peak igm response was observed between - days after virus challenge or live virus vaccination [ ] [ ] [ ] . due to the variability of ibv-reactive igm in the controls between different age groups, independent controls were included for each age group. the igm levels in the controls decreased considerably by ∼ week of age after ( days after the day old chick vaccination) which increased one week later and stabilized in older age control groups (fig. e) . the day through day control igm levels were significantly higher than in the day and day age group controls. and the day control was significantly lower than the day control igm levels. all igm titers from the ibv vaccinated age groups were significantly higher when compared to their controls (p < . ) with exception of the day age groups (p = . ). this was due to higher control values, which were ∼ . fold higher than in the age or days old groups. this may reflect an initial peak of natural antibodies induced to ibv before stabilizing. the ibv vaccinated age groups did not differ significantly in igm antibody levels to ibv with exception of the day ibv vaccinated group, which mean ± se was . ± . had significantly lower ibv-specific igm levels in plasma than the day ( . ± . ) day ( . ± . ) and day ( . ± . ) vaccinated birds but did not differ significantly from the day ( . ± . ) vaccinated birds (fig. e) . the day igm antibody titers were also significantly lower than those in the day vaccination group but not compared to the other age groups. in tears the ibv-specific igg response is significantly higher in the day and vaccinated groups than in the day and vaccinated chickens for day of the immune response ( fig. a) . the igg endpoint titer in the day immunized group is even significantly lower than the day immunized group, while the day immunized group is intermediate between the day group and chickens vaccinated at an older age. thus, a correlation between age of vaccination and the magnitude of the ibv-specific igg response in tears is observed on day of the ibv-specific immune response. the day and groups have significantly higher iga anti-ibv responses in tears on day after vaccination compared to the day group. the day group is not significantly different from the day and vaccination groups. the day group is also significantly lower than the day and groups (fig. b) . this is likely due to the day group displaying faster kinetics for iga antibody levels in tears after vaccination, rather than a lower response [ ] . the day group iga response is significantly higher than the day and day groups consistent with a delay or deficiency in the mucosal antibody response when vaccinated at an earlier age. our data indicate there is a delay in antibody production when vaccinated at a younger age. the day vaccination group not only displays a delay but also lower levels of antibody production. to determine whether there are not only quantitative differences between antibodies produced when vaccinated on day but also qualitative differences we compared avidity indices for igg and iga antibodies from plasma and tears generated in day old versus fully matured day old birds days after ibv vaccination. as is illustrated in fig. a ,b a significantly higher avidity index is observed for igg plasma antibodies for the day vaccination group when compared to the day vaccinated birds, while no significant difference is observed for iga plasma antibodies. the same observations are also made for tear igg and iga antibodies (fig. c,d) . ciliated cells and goblet cells are the primary target of ibv in the respiratory tract [ ] . fig. displays the deciliation (fig. a ) and goblet cell (fig. b ) scores days after ibv challenge. ibv challenge decreased ciliated epithelial cells and goblet cell score. ciliated cells were fully protected when vaccinated on day of age or later but not when vaccinated on day of age (fig. a) . the protection of goblet cells increases with the age of vaccination and were fully protected when vaccinated on day of age or older (fig. b) . the lymphocytes score and mucosal thickness were also measured in tracheal samples on day post al/ / ibv field strain challenge as indicators of inflammation. as is illustrated in fig. a , a significant decrease in lymphocyte score was observed in the day and vaccination groups when compared to the day group. the day vaccination group did not significantly differ from the day fig. . the ibv-specific igg and iga response in tears. endpoint titers of ibv-specific igg (a) and iga (b) on day of the immune response were measured by elisa. chickens were vaccinated on day , , , or of age. unvaccinated chickens of the different age groups served as negative control. depicted are the means and standard error of each age group and the control group, and different age groups are as described in fig. (n = - per group) . the data was analyzed by one way anova with the newman-keuls post-test. differences were considered significant at p < . and are indicated by different letters. fig. . tracheal deciliation and goblet cell depletion after ibv challenge. to measure the degree of protection against ibv challenge after vaccination tracheal deciliation and goblet cell depletion were measured. chickens were vaccinated at day , , , or of age and challenged days later. unvaccinated/unchallenged chickens of all age groups served as negative control and unvaccinated/ibv challenge chickens as positive control. trachea were collected days post challenge. depicted are the mean and one standard error. for the negative and positive controls n = for the different age groups n = - . the data were analyzed by one way anova with the newman-keuls post-test. significant difference was observed at p < . and are indicated by different letters. and vaccination groups due to a small increase in lymphocyte score in the latter two groups (fig. a) . the day group displayed the highest lymphocytes score from all vaccination groups, which is consistent with the highest inflammatory response to ibv challenge. this was also supported by a significant increase in mucosal thickness in the day vaccinated group when compared with the day , and groups but not day group, which was intermediate between the day and groups vaccinated at an older age (fig. b ). based on our data, the hypothesis that early ibv vaccination will generate an immature, poorly protective ibv-specific immune response, is confirmed. ibv vaccination on day of age, which is routinely performed in the poultry industry, will not be fully protective and as a consequence the chicks remain vulnerable to ibv exposure. thus, early vaccination perpetuates the ibv problems and is a factor in the estimated $ million or more annual loss to the poultry industry due to ibv infection [ ] . our measurements of mucosal and systemic antibody levels demonstrates a delayed production of igg and iga plasma antibodies in the day , day and of age vaccination groups. iga antibody levels in the day group, unlike igg antibodies, do not recover later in the response. besides delayed igg kinetics, the day group displays also a lower avidity index than the day vaccinated group. lower avidity index is not observed in iga antibodies. the delayed and/or lower antibody response and lower igg avidity index translated in increased tracheal inflammation and depletion of tracheal epithelia cells and goblet cells upon ibv challenge when compared to chicks vaccinated later in life. a lack of vaccine-mediated protection is most noticeable in the day of age vaccination group and to a lesser extend the day vaccination group, while the day and older vaccinated chickens are protected. the igm antibodies specific for ibv were significantly elevated above controls on days of the ibv immune response in all age groups except the day group. the day group was not quite significant (p = . ) because of higher igm levels in the control group. this could be due to an initial surge of natural igm antibodies to ibv in this age group. a significant decline in the day old group is observed when comparing the igm antibody levels to ibv in the control day group. this would be consistent with a drop of presumably natural maternal ibv-specific igm antibodies in these spf chickens in the day control age group. these igm antibodies rapidly increases in the day group after which they stabilize in the older age groups. this indicates that a considerable portion of igm antibodies in plasma from the older vaccination groups reacts with ibv without seeing the virus, indicating these are natural antibodies to ibv, which only increase after day of age. bacterial colonization of the intestinal tract of chickens is established during the first two weeks post-hatch [ ] . this, combined with the observation that probiotics enhance natural antibodies in chicken [ ] , indicates that ibv-specific natural igm antibodies to ibv are possibly generated following intestinal colonization presumably by stimulating b cells, which are the main producers of natural igm antibodies in sera of mammals [ ] . in the ibv vaccinated groups we see a steadily incline of igm ibv-specific antibodies in plasma with age as has been reported by de wit et al. [ ] . only the day age group displays significantly lower igm antibody levels when compared with the day - age groups but not with the day age group. this is consistent with an early in life deficiency or delay in the igm response. the lower avidity index for the igg antibodies in -day-old chicks is an important factor contributing to decreased protection to ibv challenge. increased antibody affinity maturation to virus vaccines strongly correlated with better protection [ , ] . a lack of antibody affinity maturation observed following vaccination against respiratory syncytial virus was due to a lack of tlr stimulation [ ] . this indicates that -day-old birds may be deficient in tlr expression. evidence that this is the case comes from a recent publication [ ] demonstrating, that significantly lower levels of tlr expression in spleen and small intestines were observed when comparing -day-old chicks with -to -week-old chickens. inclusion of tlr activating adjuvants could alleviate the problems of early vaccination by boosting antibody production and affinity maturation in -day-old chicks. neither monomeric plasma nor dimeric tears-derived iga [ ] displays this drop in avidity index for the day vaccinated group (fig. b,d) . although there is a lower level of iga antibodies produced by the day vaccinated birds compared to the older groups, which is consistent with a delay in class-switching in the day old group, it is not clear why the lack of a mature mucosal immune system in the -day-old group [ , , [ ] [ ] [ ] did not result in lower affinity maturation of mucosal iga antibodies compared to the -week-old group. another factor influencing early vaccination is the level of maternal antibodies, an issue not addressed in this study. there exists a linear relationship with the hens' plasma antibody levels and transfer of igy to the chicks' circulation [ ] . chicks were over % protected against ibv challenge on day if they had high levels of maternal antibodies but less than % protected when challenged on day . this protection correlated with local respiratory antibodies and not serum antibodies [ ] . ibv-specific maternal antibodies decreased the induction of neutralizing antibodies following boosting [ ] . despite this inhibition by maternal antibodies of the memory response, low or erratic maternal antibody titers to ibv in broiler flocks are associated with ibv-induced economic losses [ ] . this further supports that protection by maternal antibodies, which are predominantly of the igg isotype, is important to prevent activation of an immature immune system that is not capable generating a fully protective immune response early in life. in several studies ibv vaccination was effective against ibv challenge in both spf chickens and commercial broilers when the initial vaccination was performed on day [ ] [ ] [ ] . however, in these studies day vaccination was followed with a second vaccination two weeks later for optimal protection against challenge, which would have masked the relative poor ibv-specific immune responses after the day immunization. extensive immunization on the day of hatch containing three different live attenuated viruses, which caused severe vaccine symptoms, provided similar protection as two single live attenuated ibv virus vaccines on day of hatch and day of age when challenged with a heterologous virus [ ] . this seems to indicate that induction of cross-protective immunity may be less impaired when vaccinated early in life. however, no direct comparison of the same vaccination protocol was analyzed between these two challenge groups, which makes this data harder to interpret in the context of age-dependent immune responses. a decreased humoral immune response to vaccines early in life as seen in chickens is also observed in humans. neonates are highly dependent upon passively acquired maternal antibodies, since their humoral immune system remains underdeveloped [ ] . these passively obtained antibodies in infants can alter humoral and antibody-dependent immune responses to vaccines [ , ] . in broiler chicks maternal antibodies to pathogens persisted only for ∼ days [ ] . in our study interference of maternal antibodies was excluded. the observation that -day-old and -day-old birds are not fully protected when vaccinated are confirming the importance of pathogen-specific maternal antibodies during this period. in summary we can say that ibv vaccination of chickens on day of age contribute to the ibv problem in the poultry industry by inducing lower levels and/or slower kinetics of antibody production as well as lower avidity igg antibodies. this results in a poorly protective immune response as is demonstrated by subsequent ibv field strain challenge. therefore, it is advisable for the poultry industry based on our data to change their practice from vaccinating chicks on day of age to vaccinating after day of age. infectious bronchitis infectious bronchitis virus field vaccination coverage and persistence of arkansas-type viruses in commercial broilers efficacy of infectious bronchitis virus vaccinations in the field: association between the alpha-ibv igm response, protection and vaccine application parameters coronavirus ibv: removal of spike glycopolypeptide s by urea abolishes infectivity and haemagglutination but not attachment to cells delineation of b and t lymphoid cells in the chicken the harderian gland of the domestic fowl. i. histology, with reference to the genesis of plasma cells and russell bodies the secretory antibody response of inbred lines of chicken to avian infectious bronchitis virus infection infectious bronchitis virus antibodies in tears and their relationship to immunity development of immunocompetence of broiler chickens b cells and t-lymphocyte subsets of the headassociated lymphoid tissues of the chicken quantification of particle uptake by conjunctiva-associated lymphoid tissue (calt) in chickens immunoglobulin production in chicken harderian glands the avian antibody response maternal antibody transfer from dams to their egg yolks, egg whites, and chicks in meat lines of chickens development of t cell immune responsiveness in the chicken a strong antigenspecific t cell response is associated with age and genetically dependent resistance to avian enteric salmonellosis early host responses to avian influenza a virus are prolonged and enhanced at transcriptional level depending on maturation of the immune system age-dependent phagocytosis and bactericidal activities of the chicken heterophil transfer of igg from serum to lachrymal fluid in chickens iga as an early humoral responder after mucosal avian coronavirus vaccination a simple method of estimating fifty percent endpoints evaluation of different methods of inactivation of newcastle disease virus and avian influenza virus in egg fluids and serum purification of infectious bronchitis virus propagated in embryonated chicken eggs and its confirmation by rt-pcr estimating the relative avidity of mucosal iga for antigen the measurement of relative antibody affinity by elisa using thiocyanate elution local and systemic antibody class responses to an infectious laryngotracheitic virus vaccine strain the immunoglobulin m response in chicken serum to infectious bursal disease virus development of monoclonal antibodies against chicken igm and its application in immunity studies comparative analysis of the sialic acid binding activity and the tropism for the respiratory epithelium of four different strains of avian infectious bronchitis virus the economic and social impact of the institute for animal health's work on avian diseases. in: dtz institute for animal health report. dtz institute microflora ecology of the chicken intestine using s ribosomal dna primers probiotics stimulate production of natural antibodies in chickens origins and functions of b cells with notes on the role of cd h n-terminal sheet promotes oligomerization of h -ha that induces better antibody affinity maturation and enhanced protection against h n and h n viruses compared to inactivated influenza vaccine lack of antibody affinity maturation due to poor toll-like receptor stimulation leads to enhanced respiratory syncytial virus disease chicken tlr acts as a functional homologue to mammalian tlr in the recognition of cpg oligonucleotides induction of mucosal immunity in the avian harderian gland with a replication deficient ad- vector expressing avian influenza h hemagglutinin maternal antibody to infectious bronchitis virus: its role in protection against infection and development of active immunity to vaccine infectious bronchitis serology in broilers and broiler breeders: correlations between antibody titers and performance in vaccinated flocks breadth of protection of the respiratory tract provided by different live-attenuated infectious bronchitis vaccines against challenge with infectious bronchitis viruses of heterologous serotypes pathogenicity of a qx strain of infectious bronchitis virus in specific pathogen free and commercial broiler chickens, and evaluation of protection induced by vaccination programme based on the ma and / serotypes induction of cystic oviducts and protection against early challenge with infectious bronchitis virus serotype d (genotype qx) by maternally derived antibodies and by early vaccination the maturing immune system: implications for development and testing hiv- vaccines for children and adolescents determinants of infant responses to vaccines in presence of maternal antibodies decay of maternal antibodies in broiler chickens we thank the alabama agricultural experiment station for funding this research ala - - . supplementary material related to this article can be found, in the online version, at http://dx.doi.org/ . /j.vaccine. . . key: cord- - uw xcxw authors: sugiarto, sarah; spiri, andrea m.; riond, barbara; novacco, marilisa; oestmann, angelina; de miranda, luisa h. monteiro; meli, marina l.; boretti, felicitas s.; hofmann-lehmann, regina; willi, barbara title: passive immunization does not provide protection against experimental infection with mycoplasma haemofelis date: - - journal: vet res doi: . /s - - -x sha: doc_id: cord_uid: uw xcxw mycoplasma haemofelis (mhf) is the most pathogenic feline hemotropic mycoplasma. cats infected with mhf that clear bacteremia are protected from mhf reinfection, but the mechanisms of protective immunity are unresolved. in the present study we investigated whether the passive transfer of antibodies from mhf-recovered cats to naïve recipient cats provided protection against bacteremia and clinical disease following homologous challenge with mhf; moreover, we characterized the immune response in the recipient cats. ten specified pathogen-free (spf) cats were transfused with pooled plasma from cats that had cleared mhf bacteremia; five control cats received plasma from naïve spf cats. after homologous challenge with mhf, cats were monitored for days using quantitative pcr, hematology, blood biochemistry, coombs testing, flow cytometry, dnak elisa, and red blood cell (rbc) osmotic fragility (of) measurement. passively immunized cats were not protected against mhf infection but, compared to control cats, showed significantly higher rbc of and b lymphocyte (cd r/b (+)) counts and occasionally higher lymphocyte, monocyte and activated cd (+) t lymphocyte (cd (+)cd (+)) counts; they also showed higher bilirubin, total protein and globulin levels compared to those of control cats. at times of peak bacteremia, a decrease in eosinophils and lymphocytes, as well as subsets thereof (b lymphocytes and cd (+), cd (+) and cd (+) t lymphocytes), and an increase in monocytes were particularly significant in the passively immunized cats. in conclusion, passive immunization does not prevent bacteremia and clinical disease following homologous challenge with mhf, but enhances rbc osmotic fragility and induces a pronounced immune response. electronic supplementary material: the online version of this article (doi: . /s - - -x) contains supplementary material, which is available to authorized users. hemotropic mycoplasmas (hemoplasmas) are noncultivable epierythrocytic bacteria that infect a variety of mammalian species worldwide [ ] . in recent years, hemoplasmas have attracted scientific attention due to their host diversity and pathogenic potential [ ] . the main pathogenic feature of hemoplasmas is hemolysis, and clinical signs such as lethargy, anorexia, pale mucosal membranes, pyrexia, jaundice and pigmenturia may be present in severely affected animals [ ] . reports of hemoplasma infections in humans emphasize the need to characterize these agents in more detail [ ] [ ] [ ] [ ] [ ] [ ] . feline hemoplasmas can thereby serve as a model because of their extensive molecular and clinical characterization within this group of organisms. feline hemoplasmas comprise at least three different species: mycoplasma haemofelis (mhf), "candidatus mycoplasma haemominutum" (cmhm) and "candidatus mycoplasma turicensis" (cmt) [ ] [ ] [ ] . concurrent infections with two or three hemoplasma species have been documented [ ] [ ] [ ] [ ] , suggesting that no immunological cross-protection exists between the feline hemoplasmas, which has recently been experimentally confirmed [ ] . mhf is the most pathogenic of the three feline hemoplasma species and can induce severe hemolytic anemia, which is potentially fatal if left untreated. in contrast, the other two feline hemoplasmas may induce mild anemia, and the infection often remains subclinical [ ] . the natural route of hemoplasma transmission between cats is still unresolved, but aggressive interactions and blood-sucking arthropods have mainly been implicated [ ] [ ] [ ] . for experimental transmission, the intraperitoneal, intravenous or subcutaneous inoculation of hemoplasma-containing blood has been successful [ , [ ] [ ] [ ] . recently, a low-dose infection model for mhf that aimed to more accurately mirror the natural transmission of hemoplasmas was developed [ ] . different antibiotic regimens reduce hemoplasma blood loads and alleviate clinical signs but, so far, no treatment protocol has successfully and consistently cleared feline hemoplasma infections [ , [ ] [ ] [ ] [ ] . this limitation emphasizes the need to further investigate protective immune mechanisms against these agents. recently, cats that were experimentally infected with mhf or cmt and overcame bacteremia were shown to be protected from reinfection with the same hemoplasma species [ , ] . a study by novacco et al. [ ] suggested a significant role for the humoral immune response in protecting against cmt reinfection: nine out of the ten cats that were protected from reinfection showed intermediate to high antibody levels against cmt before challenge. furthermore, a transient decrease in antibody levels was observed in the protected cats immediately after attempted reinfection, which could be due to the binding of antibodies to the inoculated antigens. in the early phase after re-challenge, compared with the control group, the protected cats exhibited significantly higher il- /il- ratios and cd + t lymphocyte counts and a pronounced eosinophilia. therefore, the authors concluded that an early th immune response, prior to the onset of bacteremia, is beneficial for protection against cmt reinfection [ ] . this result was not found in the study by hicks et al. [ ] , where an early increase in the pro-inflammatory cytokines tumor necrosis factor-α (tnf-α) and interleukin- (il- ) was observed in cats protected from mhf reinfection. furthermore, the immune response seemed to be skewed towards a th response after primary mhf infection, whereas a switch from an initial th to a delayed th response was observed after primary cmt infection [ , ] . these results suggest that cats respond to infection by different feline hemoplasma species with different immune mechanisms. important data on the immune response elicited by hemoplasma infection have been provided by previous studies [ , ] , but the mechanisms that confer protection against re-infection have yet to be clarified. passive immunization transfers humoral immunity to a nonimmune individual in the form of antibodies and allows the protective role of antibodies in the absence of cellular immune mechanisms to be assessed. the present study aimed to investigate whether the passive transfer of antibodies from mhf-recovered to naïve recipient cats induced partial or complete protection against bacteremia and clinical disease following homologous challenge with mhf. different parameters addressing the humoral and cellular immune response were monitored in passively immunized and control cats. in the main experiment, -month-old male specified pathogen-free (spf) cats from liberty research, inc. (waverly, new york, usa) were used as recipient cats. five adult spf cats served as blood donors: three of these cats had overcome a previous mhf infection (hbu , hbz and hcd ) [ ] , while two cats were naïve adult spf cats (gcn and jcr ). moreover, in a pre-experiment, a -year-old male castrated spf cat (hcc ) was used. all cats were housed in groups in a confined university facility under ethologically and hygienically ideal conditions [ ] . all experiments were approved by the veterinary office of the canton of zurich (tvb / ) and were conducted in accordance with swiss laws. fifty days prior to plasma transfusion and experimental infection, the spf status of all the cats was confirmed by testing for the absence of infection with feline hemoplasmas, feline calicivirus, feline herpesvirus- , feline coronavirus, feline leukemia and feline immunodeficiency virus, as well as bartonella henselae and chlamydia felis, as recently described [ , ] ; the absence of mhf infection was again confirmed by real-time taqman ® quantitative (q)pcr [ ] on day prior to plasma transfusion and mhf inoculation. all donor cats and the cat from the preexperiment were blood-typed using a commercial immunochromatography technique (feline lab test a + b, alvedia, france). the recipient cats had been bloodtyped by liberty research, inc. (waverly). a standard saline-agglutination cross-matching procedure was performed to ascertain the compatibility of transfusion [ ] . for passive immunization, a total of ml of plasma was collected from the three cats that had overcome previous mhf infection (hbu , hbz and hcd ) [ ] . the plasma was collected from these cats on day post mhf inoculation. hbu had cleared the infection without treatment, whereas hbz and hcd had received antibiotic treatment to clear the infection (hbz : mg/kg/day doxycycline for days; hcd : mg/ kg/day doxycycline for days, followed by mg/kg/ day marbofloxacin for days); in the latter two cats, antibiotic treatment was stopped - days prior to plasma collection. all cats tested negative for mhf for at least eight consecutive weeks following antibiotic treatment and prior to the plasma collection, as determined using weekly collected blood samples that were analyzed in triplicate with a mhf-specific qpcr assay [ ] . for plasma transfusion of the control cats, a total of ml of plasma from two adult naïve spf cats (gcn and jcr ) was collected. prior to plasma collection, the two cats were confirmed to be negative for all three feline hemoplasmas using qpcr [ ] and to be free from all commonly known feline pathogens, as described [ ] . for plasma preparation, whole blood was collected from the donor cats from the jugular vein under shortduration general anesthesia ( mg/kg ketamine, narketan ® , vétoquinol ag, belp, switzerland; . mg/kg midazolam, dormicum ® , roche pharma ag, reinach, switzerland); the blood was anti-coagulated with acidcitrate-dextrose (acd) to a final concentration of . %. plasma was separated from rbcs by centrifugation at g for min and stored at − °c until use. prior to transfusion, the plasma was thawed, pooled (pool a: plasma from the mhf-recovered cats hbu , hbz and hcd ; pool b: plasma from the naïve spf cats gcn and jcr ), and filtered through a . µm pore-size filter (jet biofil, madrid, spain), and ml aliquots were prepared. before freezing and after thawing and filtration, the plasma was tested in triplicate with a mhf-specific qpcr assay for the absence of mhf organisms [ ] . for the plasma transfusion, all recipient cats were put under short-duration general anesthesia ( mg/kg ketamine, narketan ® , vétoquinol ag; . mg/kg midazolam, dormicum ® , roche pharma ag) and ml of whole blood was collected for baseline analysis and to prevent circulatory volume overload. the plasma was prewarmed to °c and intravenously administered over a duration of min using standard blood transfusion sets (hemo-nate ® , micron, utah medical products, inc., utah, usa). during transfusion, the cats were closely monitored for transfusion reactions. in the pre-experiment, an adult naïve spf cat (hcc ) was intravenously transfused with a ml aliquot of plasma pool a that was later used for the passive immunization of the cats in group a. after the transfusion, weekly blood samples were collected from the cat for weeks and analyzed using mhf-specific qpcr [ ] . for the main experiment, the recipient cats were assigned to two groups: group a (n = , passive immunization, cats dhr , dhr , jhw , jhw , jhw , jhw , jhx , jhx , jhz and jic ) and group b (n = , control group, cats dhp , dht , jhv , jhw and jic ). the cats of each group were housed together during and after the end of the study period. on day , plasma transfusion was performed, and the cats were experimentally inoculated with mhf. for the passive immunization, each cat in group a was transfused with a ml aliquot of plasma pool a. each cat in group b was transfused with a ml aliquot of plasma pool b. ten minutes after the completion of the transfusion, all cats in groups a and b were inoculated with mhf by a subcutaneous injection of µl of % dimethyl sulfoxide (dmso)-preserved blood containing copies of mhf diluted with µl of phosphatebuffered saline (pbs), as previously described [ ] . an aliquot of the same mhf inoculum was used to infect the recipient cats in this study that had been used to infect the plasma donor cats (hbu , hbz and hcd ) in a previous study [ ] . clinical condition, body temperature and body weight were recorded, and blood samples collected prior to plasma transfusion and mhf inoculation (day ), twice weekly post inoculation (pi) until week and weekly thereafter up to day pi.; an additional blood collection to measure red blood cell (rbc) osmotic fragility (of) was performed on day pi because rbc of was still increased compared with baseline values in several cats of group a and b at day pi. all samples were collected without anesthesia, with the exception of the samples collected at day . samples for pcr analysis and serology were stored at − °c until analysis. flow cytometry, hematology, blood biochemistry, coombs tests and rbc of assays were carried out within h of blood collection. hematological parameters were determined on day , twice weekly pi until week and weekly thereafter up to day pi on a sysmex xt- iv instrument (sysmex corporation, kobe, japan), as previously described [ ] . white blood cell differential analysis was confirmed using manual evaluation of wright-giemsa stained blood smears. severity of anemia was defined as mild ( - %), moderate ( - %) and severe (< %). bilirubin, total protein and albumin concentrations were measured on day , on days and pi and weekly thereafter until day pi using a cobas integra system (roche diagnostics, rotkreuz, switzerland). globulin values were calculated by subtracting the albumin value from the total protein concentration. reference intervals (mean ± standard deviation, sd) for pcv and total protein concentrations for kittens of and weeks of age were obtained from the literature [ ] . because bilirubin concentrations reach adult values after week of age [ ] , the laboratory's device-specific reference interval was used for this parameter. rbc of was determined on day and on days , and pi using a published protocol [ ] . the reference interval was determined in nine healthy cats during a previous study ( % hemolysis in nacl . - . % w/v) [ ] . direct coombs tests were performed on day and on days and pi. rbcs from edta-anticoagulated blood samples were washed, diluted in nacl . % w/v solution and incubated for h at °c with feline antiglobulin reagent (mp biomedicals, llc., solon, ohio, usa) in dilutions ranging from : to : , as described [ ] . agglutination in dilutions of ≥ : was defined as positive. quantification of mhf blood loads by qpcr was performed on day , twice weekly pi until week and weekly thereafter up to day pi. total nucleic acid (tna) was extracted from μl of edta anti-coagulated blood using the magna pure lc (roche diagnostics ag, rotkreuz, switzerland) and the magna pure lc tna isolation kit (roche diagnostics) following the manufacturer's instructions. tna was eluted in µl elution buffer and stored at − °c until use. with each batch of extraction, a negative control consisting of µl of phosphate-buffered saline (pbs) was used to monitor for cross-contamination. all tna samples were tested with a mhf-specific qpcr assay to detect and quantify mhf as previously described [ ] . for absolute quantification, tenfold serial dilutions of a standard plasmid were used as described [ ] . positive and negative controls were included in each pcr run. antibodies against the recombinant dnak protein of mhf were measured on day , on days and pi and weekly thereafter until day pi using a previously described elisa [ ] . the serum was diluted : , and ng of recombinant protein per well was used as described [ ] . all samples collected from one cat were measured on the same plate, and all plates were antigen coated within the same batch. absorbance was measured at a wavelength of nm (od ) using a spectramax plus microplate spectrophotometer (molecular devices, sunnyvale, ca, usa). an od ≤ . was defined as negative based on dnak elisa results obtained from spf cats, as described [ ] . flow cytometric analysis was performed on day and on days , , , , , , , and pi. three different staining combinations of primary antibodies were used: ( ) fluorescein isothiocyanate (fitc)-conjugated mouse anti-feline cd antibody (f , southern biotech, allschwil, switzerland); ( ) an r-phycoerythrin (rpe)conjugated mouse anti-feline cd antibody (vpg , abd serotec, puchheim, germany) and a fitc-conjugated mouse anti-feline cd antibody; and ( ) a fitc-conjugated mouse anti-feline cd antibody (fcd , southern biotech) and a rpe-conjugated rat anti-mouse cd r/ b antibody (ra - b , abd serotec). cd is a marker for feline t lymphocytes [ ] , and cd + -and cd +positive t lymphocytes represent helper and cytotoxic t lymphocytes, respectively [ ] . cd + cd + t lymphocytes represent activated cd + t lymphocytes, and cd r/b antibody was used to identify b lymphocytes [ , ] . prior to the start of the experiment, the antibodies were titrated for optimal dilution as follows: cd and cd , : dilution; cd and cd , : dilution; and cd r/b , undiluted. a µl aliquot of edta anticoagulated blood was incubated with µl of the aforementioned antibodies. to rule out non-specific binding, isotype control antibodies (rpe-conjugated mouse igg and fitc-conjugated mouse igg , abd serotec) and unstained blood samples from each cat were used as negative controls. blood samples were stained according to published protocols [ , ] . flow cytometry was performed using a guava easy-cyte ™ ht flow cytometer (millipore, darmstadt, germany) using the guavasoft . software. gates representing the lymphocyte population were set based on forward and side scatter, and events were acquired for each sample. the absolute number of each lymphocyte subset was calculated by multiplying the absolute lymphocyte number from hematology by the subset percentage as previously published [ ] . up to different parameters per cat were statistically analyzed using analyse-it ® for microsoft excel version . . . (analyse-it software, ltd., leeds, uk) and graph-pad prism . (graphpad software, inc., ca, usa). the mann-whitney u test (p mwu ) was used to compare the two groups a and b at each time point. one cat (jhw ) in group b stayed pcr-negative and seronegative throughout the -day study period. to investigate whether significant differences observed between groups a and b were related to the inclusion of this cat, the mann-whitney u tests were repeated without the data of this cat for all significant parameters. the results from these analyses were reported if they differed from the original results including cat jhw . friedman's test (p f ) followed by dunn's post test (p d ) was used to analyze the parameters over time when more than two time points were considered. multiplicity adjusted p values for each comparison in a family of comparisons were computed. fisher's exact test was used to determine significant differences of proportions. p values < . were considered significant. all donor cats, the cat from the pre-experiment and all recipient cats were confirmed to be blood type a. crossmatching revealed no incompatibilities between the donor cats, the cat of the pre-experiment and the recipient cats. all plasma samples used for transfusion tested mhf pcr-negative. the adult cat (hcc ) transfused with an aliquot of plasma pool a during the pre-experiment tested mhf pcr-negative in each of the samples collected during the weeks after the transfusion (data not shown). the cat stayed clinically healthy throughout the entire experiment. prior to plasma transfusion and experimental infection (day ), all cats in both groups tested mhf pcr-negative. all cats in groups a and b became mhf pcr-positive within - days and - days pi, respectively ( figures a and b) , except for one cat (jhw ) in group b. cat jhw remained pcr-negative throughout the -day follow-up period ( figure b ) but became mhf pcr-positive after the end of the experiment (day pi, data not shown). peak hemoplasma loads (group a: . × - . × copies/ml blood; group b . × - . × copies/ml blood) were reached between days and pi in group a and days and pi in group b. there was no significant difference in mhf blood loads between the two groups during the -day follow-up period, except for day pi, when group a showed significantly higher mhf blood loads (p mwu = . ; figure c ); this difference was not significant when the pcr-negative cat jhw in group b was excluded from the analysis (p mwu = . ). the cats in both groups tested negative in the dnak elisa (defined as an od ≤ . ) prior to the plasma transfusion (figures a and b) . after passive immunization and subsequent infection, group a cats showed slightly but significantly higher dnak elisa od values at days , and pi compared with the od values of cats in group b (p mwu < . ; figure c ). from day until day pi, no significant difference in the dnak elisa od values was evident between the two groups. when cat jhw was excluded from the analyses, the anti-dnak antibody level in cats in group a was still significantly higher early after passive immunization (days and pi, p mwu < . ), but not at day pi and thereafter until day pi when compared to cats in group b. there was no significant difference in the time of seroconversion (od > . ) between the two groups; cats in both groups, a and b, seroconverted between days and pi, with the exception of cat jhw (group b), which did not develop anti-mhf dnak antibodies throughout the study ( figure b ). two other cats (jhw , group a, and jhv , group b) were seronegative (od ≤ . ) by the end of the experiment ( figure b ); one of these cats (jhw ) was treated with doxycycline between days to pi because of a pronounced decrease in packed cell volume (pcv) to % (day pi, see below). seven out of ten cats in group a became moderately anemic (pcv between and %) at days to pi ( figure a ). in group b, one cat showed moderate anemia (pcv %) and one cat severe anemia (pcv %) at days and pi, respectively ( figure b ). the lowest pcv observed during the study was found for cat dht (pcv %, days pi) in group b. there was no significant difference in the mean pcv values between the two groups ( figure c ). there was a significant change in pcv over time for both groups (group a, p f < . ; group b, p f = . ); pcv values of the cats were higher towards the end of the study period when compared to the first weeks pi (figures a and b) . this finding may be attributed to the increasing age of the cats; reference intervals of pcv (±sd, %) were reported to increase from the age of weeks ( . ± . ) to weeks ( . ± . ) [ ] . three cats in group a (cats jhw , jhw and jhz ) and two cats in group b (cats dht and jhv ) developed elevated body temperature > . °c during the course of the experiment: jhv at day pi, jhw at day pi, dht at day pi, jhw at day pi and jhz at day pi. in addition, apathy, anorexia and weakness were observed in three cats in group a (jhw and jic at day pi; and jhx at day pi) and in one cat in group b (dht at day pi). three cats necessitated oral antibiotic treatment with doxycycline ( mg/kg/day, supracycline, grünenthal gmbh, mitlödi, switzerland) for - days. the decision to treat the cats was based on the presence of severe anemia (group a: dht , pcv of %, day pi) or a pronounced decrease in pcv within h (jhw , pcv of %, day pi; jhx , pcv of %, day pi). all three cats showed clinical signs (apathy, anorexia, weakness and fever) when the treatment was initiated. at day , rbc of was significantly lower in cats in group a when compared to cats in group b (p mwu = . ), but mean rbc of of both groups remained within the reference interval (group a and b, % hemolysis in nacl . and . % w/v, respectively; reference interval, % hemolysis in nacl . - . % w/v, figure c ). thereafter, at days and pi, rbc of was significantly higher in cats in group a compared to cats in group b (p mwu < . ; figure c ). when cat jhw was excluded from the analyses, there was no longer a significant difference between the groups on day pi. remarkably, compared with baseline values, rbc of was still increased in several cats in groups a and b at day pi (figures a and b ) ; therefore, one further measurement was obtained at day pi. rbc of significantly changed during the course of infection only in cats in group a (p f = . , figure a ). the rbc of reached maximal values at day pi in eight out of ten animals in group a (range, % hemolysis in nacl . - . % w/v) and at day pi in cat jhz ( % hemolysis in nacl . % w/v) and at day pi in cat jhw ( % hemolysis in nacl . % w/v; figure a ). cat jhw in group b, which turned mhf pcr-positive only after the end of the experiment (day pi), showed a pronounced increase in relative rbc of at the time of mhf bacteremia ( % hemolysis in nacl . % w/v, day pi; reference interval, % hemolysis in nacl . - . % w/v; figure b ). all cats in both groups tested negative in the direct coombs test at all time points (data not shown). cats in both groups showed an increase in leukocyte counts immediately after infection, followed by a significant decrease, with the nadir being reached three to four weeks pi (data not shown). there was no significant difference in leukocyte counts between the two groups during the -day follow-up period. the lymphocyte cell counts showed an initial increase followed by a significant decrease, with the nadir reached at day pi, coinciding with the onset of peak bacteremia in cats in group a (p f < . , figure a ); this pattern was less pronounced in cats in group b (p f = . , figure a ). furthermore, compared with cats in group b, cats in group a had significantly higher blood lymphocyte counts at days and pi (p mwu < . ), as well as a tendency for higher counts at day pi (p mwu = . , figure a ). when cat jhw was excluded from the analyses, the lymphocyte cell counts tended to be mhf at day . significant differences between groups are indicated with asterisks (p mwu < . ). the reference interval for rbc of based on measurements in nine healthy cats is shaded grey ( % hemolysis in nacl . - . % w/v) [ ] . rbc of significantly changed during the course of infection in cats in group a (p f = . , significantly higher levels at days and pi compared with day pre-inoculation, p d < . ), but not in cats in group b. higher in group a compared to group b during the study period, but significance was not achieved. the eosinophils showed a similar pattern to the lymphocyte counts in cats in group a, but the decrease in cell counts was delayed, and the nadir was reached at weeks pi (p f < . , figure b ); again, this pattern was less pronounced in cats in group b (p f = . , figure b ). in contrast, the monocyte counts increased after infection in cats in group a, with maximal values reached at day pi (p f < . , figure c ); again, this pattern was less pronounced in cats in group b (p f = . , figure c ). when compared to the counts in group b, the monocyte counts in group a were higher at most of the time points pi, with significance reached at days , , , and pi (p mwu < . , figure c ). the monocyte cell counts were higher in group a compared to group b at most time points pi when cat jhw was excluded, with significance reached at days and pi (p mwu < . ). the neutrophils significantly changed over time only in cats in group a (p f = . , figure d ). there were no significant differences in the neutrophil counts between the two groups. when the course of the different white blood cell subsets was compared with the course of pcv and mhf bacteremia, most cats showed a decrease in the leukocyte, lymphocyte, and neutrophil cell counts just prior to the decrease in pcv and the onset of maximal mhf blood loads (data not shown). a similar pattern was also observed for the eosinophils, whereas the monocyte counts peaked at the onset of maximal anemia in most of the cats (data not shown). in the passively immunized cats, all analyzed lymphocyte subsets [cd + , cd + and cd + t lymphocytes, activated cd + t lymphocytes (cd + cd + ) and b lymphocytes (cd r/b + )], showed a significant change over time (p f < . ). in the control cats, a significant change during the course of infection was only observed for the activated cd + t lymphocyte subset (p f < . ). specifically, cats in group a showed a significant decrease in the cd + , cd + and cd + t lymphocyte counts, with the nadir reached at days , and pi, respectively, coinciding with the onset of peak bacteremia (cd + , p f = . ; cd + , p f = . ; cd + , p f < . , figures a-c) . the cd + /cd + ratio was significantly increased at - weeks pi in the passively immunized cats (p f = . , figure d ). cats in group a showed a significant decrease in their b lymphocyte counts during maximal bacteremia, with the nadir reached at day pi (p f = . , figure e ), and the b lymphocyte counts were significantly higher at days , , and pi compared with cats in group b (p mwu < . ; figure e ). when cat jhw was excluded from the analyses, the b lymphocyte counts were also higher in cats in group a compared to cats in group b, with significance reached at days and pi (p mwu < . ). the activated cd + t lymphocyte subsets showed a somewhat different pattern than the other lymphocyte subsets in group a. the activated cd + t lymphocyte counts increased early during the course of infection into the onset of pcrpositivity and peak bacteremia, and then, they markedly decreased and reached a nadir at day pi (p f < . ); this pattern was also present but less pronounced in group b (p f = . , figure f ). furthermore, compared with cats in group b, cats in group a showed significantly higher activated cd + t lymphocyte counts at day pi (p mwu = . ) and significantly lower levels at day pi (p mwu = . ; figure f ). when cat jhw was excluded from the analyses, a tendency for higher activated cd + t lymphocyte counts in cats in group a compared to group b was found at day pi (p mwu = . ); the difference at day pi was still significant (lower counts in cats in group a when compared to cats in group b; p mwu = . ). bilirubin concentrations significantly increased in both groups during the course of the experiment and peaked at day pi (group a, p f < . ; group b, p f = . ; additional file a). bilirubin concentrations were lower in group a than in group b at days and pi (p mwu = . ) but tended to be higher from day until the end of the experiment, with significance reached at day pi (p mwu = . ; additional file a). the mean bilirubin concentrations in both groups remained within the reference interval (bilirubin concentration < . μmol/l) throughout the study period; bilirubin concentrations exceeding the reference interval were observed in three cats in group a (dhr , day pi, jhw , day pi; jhw , day pi, bilirubin concentrations, range . - . μmol/l). the total protein concentrations significantly changed over time in groups a (p f < . ) and b (p f = . ; additional file b) and peaked at days and pi, respectively. higher total protein concentrations were observed in cats in group a compared to cats in group b, with significance reached at days , and pi (p mwu = . ; additional file b). when cat jhw was excluded from the analyses, total protein concentrations of group a were also higher compared to cats in group b with significance reached at days , and pi (p mwu < . ). the mean total protein concentrations of both groups remained within the reference interval (total protein, reference interval for - weeks of age, - g/l) throughout the study period; total protein concentrations above the reference interval were observed in two cats in group a and one cat in group b (total protein concentrations between . - . g/l). the globulin concentrations significantly increased over time only in group a (p f < . ; additional file c). compared with cats in group b, cats in group a showed significantly higher globulin concentrations at days and pi (p mwu < . ; additional file c). this is the first study to investigate the protective role of the humoral immune response against hemoplasma infection using a passive immunization experiment. our study demonstrated that the passive transfer of antibodies from mhf-recovered to naïve spf cats does not prevent infection, high bacterial loads and the development of clinical signs following homologous challenge with mhf. the passively immunized and control cats showed no differences in the onset and extent of bacteremia and anemia during the course of mhf infection. hicks et al. [ ] recently documented that mhf-recovered cats were protected from reinfection following re-challenge with a homologous mhf isolate. our study indicates that the presence of antibodies to mhf cannot mediate protection against homologous challenge, but that cellular or innate immune mechanisms may be necessary to provide protection against mhf infection. this is also in line with the study by hicks et al. [ ] , which reported protection from mhf reinfection in the absence of a pronounced th -type response in the cats after re-challenge. in the latter study, the protected cats showed no increase in anti-dnak antibody and il- mrna levels following mhf re-challenge. the anti-dnak antibody levels in the passively immunized cats were only higher in the first weeks after transfusion than in the control cats, and they remained below the threshold for seropositivity up to day pi. it is possible that the level of antibodies in the passively immunized cats following transfusion was not sufficiently high to prevent bacteremia. however, hicks et al. [ ] documented protection from mhf although the antibody levels to dnak did not rise after mhf challenge infection and remained at rather low levels (mean log-transformed relative antibody level (ral) < . ) when compared to the control cats with de novo mhf infection (peak mean ral > . ). they concluded that if mhf-specific antibodies had been responsible for immune protection in these cats, then low levels of anti-dnak antibodies could be sufficient to provide protection against mhf infection. because the assay and the calculations used to quantify anti-dnak antibodies in that study were different from those used in the present study, a direct comparison of antibody titers was not possible. furthermore, it needs to be considered that antibodies with different epitope specificities that are not detected with current dnak elisa could mediate immune protection. however, assays to measure such antibodies are not available. infection enhancement, i.e. earlier onset of bacteremia and anemia, was recently documented in cats that had recovered from cmt infection and were re-challenged with mhf [ ] . all cmt-recovered cats were serologically positive before mhf inoculation. the study suggested that the pre-existing antibodies against cmt might have had enhanced infection kinetics in the cmt-recovered cats [ ] . although infection kinetics were not different between the passively immunized and control cats in this study, our results still suggest that the transfer of antibodies from mhf-recovered cats could potentially be harmful. the passively immunized cats showed a significant increase in rbc of during the course of infection. this effect was not observed in the control cats, indicating that the increase was not simply due to a non-specific effect of plasma transfusion on rbc fragility. it can be hypothesized that the antibodies bound to the mhf organisms attached to rbcs. rbc-bound antibodies have been found after primary mhf infection [ , , ] and can induce receptor-mediated rbc phagocytosis or the activation of the complement system [ ] . in the present study, rbcbound antibodies were not detected in the cats by coombs test, but the sensitivity of this assay may be limited [ ] . the bilirubin concentrations were also higher in the passively immunized versus control cats at some time points during infection. rbc destruction leads to the formation of free hemoglobin, which is processed by the mononuclear phagocytic system. during this process, bilirubin is formed, released in the blood stream and further metabolized and excreted by the liver. during pronounced rbc destruction, the capacity of the liver to metabolize bilirubin is overwhelmed, and hyperbilirubinemia occurs. hyperbilirubinemia was observed in three cats of group a, although mean bilirubin concentrations in both groups remained within the reference interval. nevertheless, the higher rbc of values and occasionally higher bilirubin concentrations could point towards a more pronounced rbc destruction in the passively immunized cats following subsequent mhf challenge exposure. the passively immunized cats showed signs of a more pronounced immune response when compared to control cats. cats of group a showed higher lymphocyte, monocyte and b lymphocyte counts and higher total protein and globulin concentrations than the control cats at several time points during the experiment. furthermore, peak globulin concentrations coincided with peak anti-dnak antibody levels in both groups. this result was also found in our recent study, where we documented polyclonal hypergammaglobulinemia during mhf infection coinciding with high anti-dnak antibodies [ ] . we speculated that a large portion of the immune globulin pool was not hemoplasma-specific and was potentially due to a polyclonal b lymphocyte activation. the induction of autoreactive antibodies has recently been reported for the porcine hemoplasma mycoplasma suis and is thought to be caused by the upregulation of b lymphocytes in response to changes to the rbc surface of the infected host [ ] . it could be argued that the use of the homologous mhf isolate for experimental challenge of the recipient cats that had been used to infect the plasma donor cats contributed to the more pronounced immune response in the passively immunized cats. this has been reported for other feline pathogens, i.e. feline coronavirus (fcov) which can cause feline infectious peritonitis (fip) [ ] . during the pathogenesis of fip, the virus targets macrophages and infection of these cells can be enhanced in the presence of antibodies (antibody-dependent enhancement, ade) [ ] . takano et al. [ ] showed that cats passively immunized with antibodies to serotype i fcov showed an enhanced onset of disease following inoculation with the homologous serotype; this was not found when cats passively immunized with antibodies to serotype ii fcov were challenged with serotype i. the authors concluded that fcov re-infection with the same serotype might induce ade and could advance the development of fip. although ade has also been suspected in bacterial infection [ ] , it is unknown whether it might play a role in the pathogenesis of feline hemoplasma infections [ ] . signs of infection enhancement have recently been documented in "candidatus m. turicensis"-recovered, seropositive cats following a challenge with mhf [ ] . the study suggested that the presence of antibodies directed against cmt could enhance mhf infection. however, to the best of our knowledge, disease enhancement after rechallenge with the same feline hemoplasma species has not been documented. in contrast, two studies showed that cats that had recovered from mhf or cmt infection were protected from re-infection following re-challenge with the same hemoplasma species, respectively [ , ] . both studies had used an aliquot of the same mhf or cmt isolate for re-infection that had been used for primary infection of the cats (personal communication, rhl). the passively immunized cats showed a significant decrease in lymphocyte counts near the onset of peak bacteremia (around weeks pi). this comprised decreases in absolute counts of cd + t lymphocytes, cd + t lymphocytes and b lymphocytes around three to weeks pi, and was followed by an increase of the lymphocyte subsets until the end of the study. in two recent studies we reported a very similar pattern in the lymphocyte subsets following mhf infection of naïve and cmt-recovered cats. the decrease was explained by the migration of the cells from the peripheral blood to the draining lymph nodes, where they become activated and proliferate [ , ] . in the individual cats, the decrease in leukocyte, lymphocyte and neutrophil counts occurred just prior to the development of anemia and the onset of peak bacteremia. a similar pattern was also observed for the eosinophils, whereas the monocyte counts peaked at the onset of maximal anemia. a decrease in leukocyte and neutrophil counts could be caused by the increased consumption of these cells, which are involved in bacterial killing or, less likely, by reduced production due to undefined inhibitory factors [ ] . monocytosis could be found due to hemolysis [ ] and was shown to be associated with mhf infection in naturally infected cats [ ] . we documented leukopenia and neutropenia, as well as decreased eosinophils, lymphocytes and increased monocytes, at times of peak mhf bacteremia also in a recent study [ ] . it is difficult to judge whether the decrease in the white blood cell subsets was due to bacterial replication and cell consumption or, conversely, whether the decrease in white blood cells facilitated bacterial replication. interestingly, one cat in group b (jhw ) stayed pcrnegative and seronegative during the -day follow-up period, but it developed bacteremia and seroconverted days after mhf inoculation. although low-level bacteremia, below the detection limit of the pcr assay, cannot be completely excluded in this cat, we would expect a productive infection to result in seroconversion [ , ] . because all cats in this study were kept under strictly controlled hygienic conditions, vector-borne transmission between the cats can be excluded. however, all cats of group b were housed together and four out of five cats in group b tested mhf pcr-positive at the time that bacteremia and seroconversion occurred in cat jhw . therefore, direct transmission between the cats, i.e., by aggressive interactions, seems most likely, although no obvious clinical signs of aggressive interactions were observed in the cats in this study at any time during the experiment. a direct transmission of mhf through saliva seems unlikely because only low hemoplasma loads can be detected in saliva of mhf-infected cats [ ] and transmission by oral or subcutaneous inoculation of saliva has not been successful for another feline hemoplasma species, cmt [ ] . the present study had some limitations. no masking was used during data collection and analysis. furthermore, the relatively small groups size used in this study for animal welfare reasons could have masked significant differences between the passively immunized and control cats. however, as no protection but rather signs of infection enhancement were found in the passively immunized cats, the limited group size should not have affected the principal hypothesis addressed in this study. the present study used an experimental set-up to address the protective role of passively transferred antibodies in mhf infection. experimental infection studies do have some inherent limitations when results are generalized to natural infections. however, to mirror the natural transmission of hemoplasmas most accurately, a published low-dose infection model was applied in this study [ ] . the inoculated dose contained only copies of mhf, which corresponds to approximately . μl of infectious blood from a naturally infected cat [ ] . this small blood volume can easily be transmitted by bloodsucking arthropods or via aggressive interaction between cats-both of the latter transmission routes are assumed to be natural ways of transmission for feline hemoplasmas [ ] [ ] [ ] . therefore, the infectious dose applied to the cats should not be the reason for the lack of protection in the passively immunized cats. several measures were undertaken to ensure that the plasma used for passive immunization did not contain viable mhf organisms that could transmit infection. the donor cats were tested weekly for at least eight consecutive weeks before the plasma was collected. all these samples and the plasma pool itself were tested in triplicate with a highly sensitive mhf-specific qpcr assay [ ] and revealed pcr-negative results. furthermore, an aliquot of the plasma pool used for passive immunization was transfused into an adult spf, the cat was followed for weeks after transfusion and stayed pcr-negative. in conclusion, passive immunization did not provide protection against experimental infection with mhf but instead enhanced rbc fragility and was associated with a more pronounced immune response after infection. this result suggests that a humoral immune response in the absence of cellular immune mechanisms is insufficient to provide protection from mhf infection. potential vaccine candidates should include the induction of a cellular immune response against mhf. and the plasma transfusions. fsb was responsible for the clinical aspects of the study and supported the plasma transfusions of the cats. rhl supported the statistical analyses. ss and bw drafted the manuscript. bw and rhl edited the manuscript. all authors read and approved the final manuscript. hemotrophic mycoplasmas (hemoplasmas): a review and new insights into pathogenic potential hemoplasma infection in hiv-positive patient a novel hemotropic mycoplasma (hemoplasma) in a patient with hemolytic anemia and pyrexia investigation of human haemotropic mycoplasma infections using a novel generic haemoplasma qpcr assay on blood samples and blood smears human coinfection with bartonella henselae and two hemotropic mycoplasma variants resembling mycoplasma ovis outbreaks of hemotrophic mycoplasma infections in china prevalence of mycoplasma suis (eperythrozoon suis) infection in swine and swine-farm workers in use of a polymerase chain reaction assay to detect and differentiate two strains of haemobartonella felis in naturally infected cats candidatus mycoplasma haemominutum' , a low-virulence epierythrocytic parasite of cats identification, molecular characterization, and experimental transmission of a new hemoplasma isolate from a cat with hemolytic anemia in switzerland worldwide occurrence of feline hemoplasma infections in wild felid species prevalence, risk factor analysis, and follow-up of infections caused by three feline hemoplasma species in cats in switzerland hemoplasma prevalence and hematological abnormalities associated with infection in three different cat populations from southern brazil prevalences of various hemoplasma species among cats in the united states with possible hemoplasmosis lack of cross-protection against mycoplasma haemofelis infection and signs of enhancement in "candidatus mycoplasma turicensis"-recovered cats description of outcomes of experimental infection with feline haemoplasmas: copy numbers, haematology, coombs' testing and blood glucose concentrations evaluation of experimental transmission of candidatus mycoplasma haemominutum and mycoplasma haemofelis by ctenocephalides felis to cats attempted transmission of candidatus mycoplasma haemominutum and mycoplasma haemofelis by feeding cats infected ctenocephalides felis in vivo transmission studies of 'candidatus mycoplasma turicensis' in the domestic cat identification, characterization, and application of a recombinant antigen for the serological investigation of feline hemotropic mycoplasma infections effect of chronic feline immunodeficiency infection, and efficacy of marbofloxacin treatment, on 'candidatus mycoplasma haemominutum' infection establishment and characterization of a low-dose mycoplasma haemofelis infection model effect of chronic fiv infection, and efficacy of marbofloxacin treatment, on mycoplasma haemofelis infection detection of haemobartonella felis in cats with experimentally induced acute and chronic infections, using a polymerase chain reaction assay use of enrofloxacin for treatment of large-form haemobartonella felis in experimentally infected cats use of pradofloxacin to treat experimentally induced mycoplasma hemofelis infection in cats protection from reinfection in "candidatus mycoplasma turicensis"-infected cats and characterization of the immune response protective immunity against infection with mycoplasma haemofelis housing and care of laboratory cats: from requirements to practice retroviral dna-the silent winner: blood transfusion containing latent feline leukemia provirus causes infection and disease in naive recipient cats clinical blood typing and cross-matching evaluation of a novel haematology analyser for use with feline blood pediatric clinical pathology characterization of a feline t-cell-specific monoclonal antibody reactive with a cd -like molecule identification of a cd homologue in the cat identification of monoclonal antibodies for immunohistochemical staining of feline b lymphocytes in frozen and formalin-fixed paraffin-embedded tissues the role of cd +cd + regulatory t cells in viral infections the role of in vitro-induced lymphocyte apoptosis in feline immunodeficiency virus infection: correlation with different markers of disease progression cold agglutinins in cats with haemobartonellosis western immunoblot analysis of the antigens of haemobartonella felis with sera from experimentally infected cats immune-mediated anemias in the cat the coombs' test in veterinary medicine: past, present, future pathobiology of mycoplasma suis antibodydependent enhancement occurs upon re-infection with the identical serotype virus in feline infectious peritonitis virus infection an update on feline infectious peritonitis: virology and immunopathogenesis antibody-dependent enhancement of infection: bacteria do it too molecular biology and pathogenicity of mycoplasmas interpreting absolute wbc counts diagnosis of feline haemoplasma infection using a real-time pcr assay detection of humoral response using a recombinant heat shock protein , dnak, of mycoplasma haemofelis in experimentally and naturally hemoplasma-infected cats the mouse anti-feline cd antibody was kindly provided by m. b. tompkins, north carolina state university, nc, and g. dean, colorado state university, co, usa. the authors thank e. gönczi, t. meili, b. weibel and the technicians of the clinical laboratory, vetsuisse faculty, for excellent laboratory assistance, as well as m. stirn, v. cattori, c. asquith and k. helfer-hungerbühler for helpful assistance in laboratory work and analyses. the authors also thank s. hartnack for helpful discussion and the animal caretakers m. zihlmann and f. dreier for the dedicated animal care. the laboratory work was performed with logistical support from the center for clinical studies at the vetsuisse faculty, university of zurich. ams was supported by a research grant (forschungskredit, fk- - - ) from the university of zurich. the study was supported by the kids and career program of the vetsuisse faculty, university of zurich. this study was the doctoral thesis of s. sugiarto. the authors declare that they have no competing interests.authors' contributions bw, rhl and fsb conceived and coordinated the study. ss was responsible for the training and clinical care of the cats and the sample and data collection. ams and ao were involved in sample collection and cat training. mn and lhm supported the flow cytometric analyses. mlm was responsible for the molecular analyses. br was responsible for the management of the spf cat facility and animal welfare, the clinical pathology data, the plasma collection • we accept pre-submission inquiries • our selector tool helps you to find the most relevant journal submit your next manuscript to biomed central and we will help you at every step: key: cord- - elfpx e authors: abbaspour kasgari, hamideh; moradi, siavash; shabani, amir mohammad; babamahmoodi, farhang; davoudi badabi, ali reza; davoudi, lotfollah; alikhani, ahmad; hedayatizadeh omran, akbar; saeedi, majid; merat, shahin; wentzel, hannah; garratt, anna; levi, jacob; simmons, bryony; hill, andrew; tirgar fakheri, hafez title: evaluation of the efficacy of sofosbuvir plus daclatasvir in combination with ribavirin for hospitalized covid- patients with moderate disease compared with standard care: a single-centre, randomized controlled trial date: - - journal: j antimicrob chemother doi: . /jac/dkaa sha: doc_id: cord_uid: elfpx e background: new therapeutic options are urgently needed to tackle the novel coronavirus disease (covid- ). repurposing existing pharmaceuticals provides an immediate treatment opportunity. we assessed the efficacy of sofosbuvir and daclatasvir with ribavirin for treating patients with covid- . methods: this was a single-centre, randomized controlled trial in adults with moderate covid- admitted to the ghaem shahr razi hospital in mazandaran province, iran. patients were randomly assigned to mg sofosbuvir, mg daclatasvir and mg ribavirin (intervention group) or to standard care (control group). the primary endpoint of this study was length of hospital stay. this study is registered by irct.ir under the id: irct n . results: between march and april , patients were recruited; patients were randomly assigned to the intervention group and to the control group. the median duration of hospital stay was days in both groups (p = . ). the number of icu admissions in the sofosbuvir/daclatasvir/ribavirin group was not significantly lower than the control group ( versus , p = . ). there was no difference in the number of deaths between the groups ( versus , p = . ). the cumulative incidence of recovery was higher in the sofosbuvir/daclatasvir/ribavirin arm (gray’s p = . ). conclusions: this randomized trial was too small to make definitive conclusions. there were trends in favour of the sofosbuvir/daclatasvir/ribavirin arm for recovery and lower death rates. however, there was an imbalance in the baseline characteristics between the arms. larger randomized trials should be conducted to investigate this treatment further. the novel coronavirus (covid- ) epidemic, which began in early december in wuhan, china, , has spread to most countries in the world and has led to a catastrophic burden on healthcare systems. the first confirmed case of the disease in iran was reported from qom city on february and the disease has now been confirmed in all provinces of the country. according to the who, confirmed cases to date ( may ) exceeded in iran, with more than deaths. unfortunately, therapeutic options thought to be effective have been proven otherwise one by one. [ ] [ ] [ ] [ ] new options are needed urgently, but require time to develop. repurposing existing pharmaceuticals provides an immediate treatment opportunity. current trials include remdesivir, hydroxychloroquine, chloroquine, favipiravir, lopinavir/ ritonavir and nitazoxanide; however, with the possible exception of remdesivir, , these drugs have not shown efficacy in treating patients with covid- . the once-daily combination of sofosbuvir and daclatasvir has demonstrated success as treatment for hcv. , the combination has since been added to the essential medicines list in and has been made accessible worldwide in generic formulations. a generic fixed dose combination of sofosbuvir and daclatasvir ( / mg, respectively) is used to treat hcv in iran and therefore is a pragmatic candidate for trial against covid- . sofosbuvir has a broad antiviral spectrum including other members of the flaviviridae and togaviridae families including yellow fever, zika, dengue and chikungunya viruses. covid- is caused by the severe acute respiratory syndrome coronavirus (sars-cov- ), a positive-sense rna virus. sars-cov- shares a similar replication mechanism with other rna viruses, requiring enzymes including rna-dependent polymerase (rdrp), main protease (m pro ), helicase and other non-structural proteins, which therefore act as attractive targets to model antiviral drugs against. in silico studies have predicted that sofosbuvir, daclatasvir and ribavirin may bind with high energy to the sars-cov- rdrp enzyme and m pro and inhibit their function. [ ] [ ] [ ] [ ] [ ] [ ] [ ] some in vitro studies did not find sofosbuvir or ribavirin to be effective at reducing sars-cov- -induced cellular death at feasible concentrations. , however, in a more recent in vitro study, the effects of sofosbuvir, daclatasvir and ribavirin in inhibiting replication of infectious sars-cov- virus particles were studied in three different cell lines. daclatasvir was consistently able to inhibit the virus in all tested cell lines whilst sofosbuvir and ribavirin were less effective and only worked in certain cell lines. sofosbuvir and daclatasvir have demonstrated good safety profiles with minimal drug interactions , and may be an affordable and widely available treatment option for covid- . we therefore conducted a randomized controlled trial in adult patients hospitalized with covid- in ghaem shahr razi hospital to evaluate the efficacy and safety of sofosbuvir and daclatasvir in combination with ribavirin compared with standard care. this study was a single-centre, randomized clinical trial to evaluate the effectiveness of sofosbuvir/daclatasvir with ribavirin against controls who received standard of care for covid- at the time of the study. the study population were patients suspected of having covid- who were referred to ghaem shahr razi hospital in mazandaran province between march and april . patients with initial symptoms of fever (oral temperature . c at least once before enrolment) and/or cough, shortness of breath and gastrointestinal symptoms were considered to be suspected of having covid- . to confirm covid- infection, a positive qualitative rt-pcr for sars-cov- and/or features consistent with covid- on a chest ct scan was required. cases of confirmed covid- in the age group of - years were included. only patients with moderate disease on admission were included, which was defined as respiratory rate of < /min, arterial o saturation of > % and symptom onset days prior to admission, together with compatible findings in a chest ct scan. patients with multiorgan failure, active cancer, renal insufficiency (creatine clearance less than ml/min/ . m ), anaemia (haemoglobin less than g/dl), pregnant women or men with a pregnant wife, and patients treated with amiodarone, phenytoin, phenobarbital, rifabutin or carbamazepine were excluded. all patients were required to provide written informed consent prior to participation in the study. once patients fulfilled inclusion and exclusion criteria and signed the consent form, they were randomly assigned to each treatment arm in a : ratio by block randomization and a block size of . sealed envelope online software was used to randomize patients to the intervention and control groups. the study was open label and patients and managing physicians were not blind to patient allocation. after randomization, the intervention group received the combined singlepill once-daily regimen of sofosbuvir/daclatasvir at a dose of / mg (sovodak, fanavaran rojan mohaghegh daru co, tehran, iran) and ribavirin mg twice daily. the control group received hydroxychloroquine ( mg single dose) and lopinavir/ritonavir ( / mg twice daily), with or without ribavirin ( mg twice daily), according to the national recommendation at the time of the study. demographic, clinical, radiological and laboratory data of patients were collected at baseline. the primary outcome of the study was length of hospital stay. secondary outcomes included the frequency of icu admission, invasive mechanical ventilation, duration of icu admission, mechanical ventilation and, finally, the frequency and time to recovery, defined as hospital discharge alive. reducing the length of hospital stay by days was considered to be the desired outcome of this study. at % power and a day difference in hospitalization length between the two groups, the calculated sample size equalled in each group (corrected for % attrition rate). the outcomes of this study were analysed in the itt population of randomized patients. comparison between the two groups was performed by a mann-whitney u-test for continuous outcomes and fisher's exact test for categorical outcomes. time to recovery was compared by graphically plotting the cause-specific cumulative incidence functions (cifs) by treatment group; difference between groups was evaluated by gray's test for the equality of cifs. adjustment for baseline characteristics was carried out using cox proportional hazards and competing risks regression models [see table s (available as supplementary data at jac online)]. a p value was considered statistically significant at the p < . threshold. statistical analysis was performed using stata (version . ; statacorp) and r software (version . . ; r foundation). the study protocol was approved by the institutional review board and ethics committee of mazandaran university of medical sciences (approval abbaspour kasgari et al. between march and april , patients were screened and patients met the enrolment criteria and were recruited and randomized to the intervention arm (n = ) or the control arm (n = , figure ). the median age (years) of participants in the sofosbuvir/daclatasvir group was (iqr - ) and in the control group was (iqr - ). a total of patients were men ( %) versus ( %) women (table ) . overall, patients ( %) had existing comorbidities, which were most commonly diabetes and hypertension. the median time to admission from symptom onset was days for both groups (iqr - ). the age, sex and baseline characteristics were generally similar between the two groups (table ) ; however, the control arm was on average years older (p = . ) and had higher rates of diabetes (p = . ) and slightly higher rates of hypertension (p = . ). two of the control subjects received hydroxychloroquine alone; the others received lopinavir/ritonavir either alone or in combination with hydroxychloroquine and, in one case, ribavirin. the median length of hospitalization in the intervention group and control group was the same ( days). no patients in the intervention group were admitted to icu or required invasive mechanical ventilation compared with four individuals in the control group. no patients in the intervention group died compared with three in the control group; however, these differences were not significant ( table ). the cif for recovery by treatment arm is shown in figure . median time to recovery was days in both groups; however, the difference between the groups was significant (gray's test p = . ). after adjustment for potential baseline confounders, the association between treatment group and time to recovery was not significant (table s ). this randomized trial found that the combination of sofosbuvir/ daclatasvir/ribavirin compared with standard care showed limited clinical improvement in moderate covid- patients. jac sofosbuvir/daclatasvir/ribavirin did not reduce the duration of hospitalization, but cumulative incidence of recovery was higher in the sofosbuvir/daclatasvir/ribavirin group compared with the control group. fewer icu admissions and deaths were observed in the sofosbuvir/daclatasvir/ribavirin arm; however, these differences were not significant. to our knowledge, this is the first clinical trial of sofosbuvir/ daclatasvir/ribavirin in covid- patients; however, there are limitations to our study. the median age was higher in the control arm and there were more patients with diabetes in the control arm. in a sensitivity analysis, we adjusted our results for observed baseline imbalance; however, the interpretation of these models is limited due to the small sample size and possible error margin. most importantly, the number of patients was not high enough to identify probable beneficial effects on survival. a larger study would be required in order to prove such an effect. we also another limitation of our study is lack of blinding. unfortunately, due to the urgent situation imposed by covid- , it was not possible to prepare a suitable placebo in time. whilst we found clinical improvement benefits, we were not able to analyse biological markers of improvement as we did not measure viral decay nor serological inflammatory markers over time, which would both be helpful data to demonstrate effective antiviral therapy. in this trial of patients per arm, there was no statistically significant difference in length of hospital stay between the arms. however, the sample size could be too small to make reliable conclusions. we are also not able to clearly identify from this study whether the benefits found in terms of clinical improvement and cumulative incidence of recovery were directly from the effects of sofosbuvir or daclatasvir or ribavirin or due to a synergistic effect of the combination of all three antivirals. in vitro models have shown a synergistic effect when combining other antivirals against covid- . another study in china has shown that the combination of ribavirin with lopinavir/ritonavir and interferon b- together is superior to lopinavir/ritonavir alone in covid- . there are seven more trials registered in https://www.irct.ir/ working on sofosbuvir-containing regimens in covid- and various others studies around the world include ribavirin-containing regimens. we are aware that in at least five of these sofosbuvircontaining trials in iran, data collection has finished. if the cumulative results of these trials indicate beneficial effect, it is well advised that a larger trial be performed on this subject. a large trial could identify the effects on mild, moderate and severe cases in elderly patients and the effects on survival and hospital stay. if sofosbuvir/daclatasvir is proven to be effective against covid- , given that both are widely available in generic formulations, costing an estimated $ per day course or only $ . per day as a combination, sofosbuvir/daclatasvir may be an affordable and accessible treatment option for covid- . the promising results of this small sample warrant further trials into the effectiveness of sofosbuvir and daclatasvir for the treatment of covid- . this study was funded by mazandaran university of medical sciences. s. merat has received travel grants from and is a stockholder of fanavaran rojan mohaghegh daru co. all other authors: none to declare. clinical features of patients infected with novel coronavirus in wuhan, china a systematic review of covid- epidemiology based on current evidence coronavirus disease (covid- ) outbreak in iran: actions and problems who. who covid- data explorer observational study of hydroxychloroquine in hospitalized patients with covid- a trial of lopinavir-ritonavir in adults hospitalized with severe covid- hydroxychloroquine in patients with mainly mild to moderate coronavirus disease : open label, randomised controlled trial remdesivir in adults with severe covid- : a randomised, double-blind, placebo-controlled, multicentre trial pharmacologic treatments for coronavirus disease (covid- ): a review remdesivir for the treatment of covid- -preliminary report hepatitis c guidance: aasld-idsa recommendations for testing, managing, and treating adults infected with hepatitis c virus sd : high sustained viral response rate in patients with hepatitis c genotypes , , , and using a lowcost, fixed-dose combination tablet of generic sofosbuvir and daclatasvir: a multicenter, phase iii clinical trial th who model list of essential medicines yellow fever virus is susceptible to sofosbuvir both in vitro and in vivo the fda-approved drug sofosbuvir inhibits zika virus infection sofosbuvir as treatment against dengue? beyond members of the flaviviridae family, sofosbuvir also inhibits chikungunya virus replication emerging coronaviruses: genome structure, replication, and pathogenesis nucleotide analogues as inhibitors of sars-cov- polymerase quantitative structure-activity relationship and molecular docking revealed a potency of anti-hepatitis c virus drugs against human corona viruses advanced bioinformatics rapidly identifies existing therapeutics for patients with coronavirus disease- (covid- ) ribavirin, remdesivir, sofosbuvir, galidesivir, and tenofovir against sars-cov- rna dependent rna polymerase (rdrp): a molecular docking study in silico study of various antiviral drugs, vitamins, and natural substances as potential binding compounds with sars-cov- main protease simeprevir suppresses sars-cov- replication and synergizes with remdesivir the in vitro antiviral activity of the anti-hepatitis c virus (hcv) drugs daclatasvir and sofosbuvir against sars-cov- evaluation of antiviral drugs against sars-cov- infection sofosbuvir) tablets, for oral use daclatasvir) tablets, for oral use minimum costs to manufacture new treatments for covid- radiologic management of covid- : preliminary experience of the iranian society of radiology covid- consultant group (isrcc) triple combination of interferon b- b, lopinavir-ritonavir, and ribavirin in the treatment of patients admitted to hospital with covid- : an open-label, randomised, phase trial key: cord- - uf hj a authors: nalbantoglu, ozkan ufuk title: group testing performance evaluation for sars-cov- massive scale screening and testing date: - - journal: bmc med res methodol doi: . /s - - - sha: doc_id: cord_uid: uf hj a background: the capacity of the current molecular testing convention does not allow high-throughput and community level scans of covid- infections. the diameter in the current paradigm of shallow tracing is unlikely to reach the silent clusters that might be as important as the symptomatic cases in the spread of the disease. group testing is a feasible and promising approach when the resources are scarce and when a relatively low prevalence regime is observed on the population. methods: we employed group testing with a sparse random pooling scheme and conventional group test decoding algorithms both for exact and inexact recovery. results: our simulations showed that significant reduction in per case test numbers (or expansion in total test numbers preserving the number of actual tests conducted) for very sparse prevalence regimes is available. currently proposed covid- group testing schemes offer a gain up to x- x scale-up. there is a good probability that the required scale up to achieve massive scale testing might be greater in certain scenarios. we investigated if further improvement is available, especially in sparse prevalence occurrence where outbreaks are needed to be avoided by population scans. conclusion: our simulations show that sparse random pooling can provide improved efficiency gains compared to conventional group testing or reed-solomon error correcting codes. therefore, we propose that special designs for different scenarios could be available and it is possible to scale up testing capabilities significantly. administrative borders, asynchronously experience epidemic growths. while social distancing and quarantine measures have been the primary factor to contain sars-cov- , widespread testing and aggressive contact tracing are observed to be effective to isolate the spreaders from vulnerable populations. according to this, widespread scanning of populations or subpopulations is crucial to locate and isolate epidemic clusters, especially by detecting asymptomatic carriers. excessive numbers of asymptomatic carriers appear to be especially important as they might be the most important factor in the difficulty of lowering the reproductive numbers. unbiased estimation of the ratio of asymptomatic or presymptomatic spread-ers might be difficult to assess. yet, statistics from small or medium-sized cohorts and case studies indicate that they might be as abundant as %- % [ , ] . these ratios possess special importance regarding the case studies observing that asymptomatic/presymptomatic carriers are likely to infect their contacts [ , ] . currently, pcr-based molecular testing primarily serves as the standard diagnostics in the majority of health systems. since the infrastructure and financial limitations dictate the allocation of resources for higher priority cases, the capacity of the current molecular testing convention does not allow high-throughput and community level scans. therefore, the focus of testing is on hospitalized symptomatic cases and subsets of their contacts reached via tracing. the diameter in the current paradigm of shallow tracing is unlikely to reach the silent clusters that might be as important as the symptomatic cases in the spread of the disease. group testing is a feasible approach when the resources are scarce and when a relatively low prevalence regime is observed on the population [ ] . it allows scanning large populations by pooling samples and conducting orders of magnitude lower number of tests while being able to locate the positive cases. starting from its initial practical use in us army in the s [ ] , screening recruits for syphilis, group testing has been popularly employed in several different fields where pooling/mixing and testing was available to detect the defective elements. in general, group testing algorithms seek for t = o(k log n) measurements in order to correctly detect k positive cases in n testing samples. here, o(.) denotes that the measurements are in the order of magnitude of the argument. practical algorithms are shown to achieve t ≈ . α −α ln n k while k scales sublinearly as k = o (n α ) [ ] . with an assumption that early phases of epidemic waves or screening of asymptotic carriers would form populations of relatively low prevalence, conventional group testing schemes can potentially provide significant gains in testing capability. complying with the idea of employing group testing in sars-cov- screening, sinnott-armstrong et al. [ ] recently proposed an adaptive scheme, pooling rows and columns of pcr well-plates, and they showed that up to x efficiency gain could be achieved in . %- % prevalence band. eberhardt et al. [ ] used multistage group testing with two or three rounds. their results imply even greater efficiency gains of x- x around low prevalence bounds. while these are very practical and simple schemes eliminating the requirements of robotic pipetting needs and reducing the pipetting errors, more sophisticated pooling schemes that can improve the efficiency gains are available. indeed, shental et al. [ ] used sampling pools out of well-plate by reed-solomon coding, and showed x efficiency gain around the band of % prevalence. these schemes offer very significant scaleups in testing capacity, especially around mid-scale sparsity bands (i.e. %- % prevalence). however, in potential scenarios of achieving wide-spread or community level scans with lower expected prevalence, further efficiency gains would be required. therefore, designing group testing schemes aiming sparsity is beneficial to explore the practical capabilities. we employed group testing with a sparse random pooling scheme and conventional group test decoding algorithms both for exact and inexact recovery. our simulations showed that significant reduction in per case test numbers (or expansion in total test numbers preserving the number of actual tests conducted) for very sparse prevalence regimes is available. we designed a random-pooling based group testing scheme for different laboratory setups including -, -, and -well plate options. two different approaches were considered i) two-pass adaptive testing for exact recovery. ii) single-pass non-adaptive testing for approximate recovery of test results. for both approaches, we use the same random pooling design. random pooling procedure samples a pooling procedure from the space of m pools out of n samples by adding each sample exactly to k pools. the distribution to pools is selected without replicating the same pattern to be able to distinguish samples. also, the sampled pooling matrices are intended to have low coherence, as low coherence improves the rate (i.e. efficiency gain in this setting) in sparse recovery problems [ ] . the coherence of a measurement matrix denotes the maximum inner product of its column vector pairs, and it is associated with the maximum number of pools a couple of samples coexist in our case. we achieve low coherence by metropolis sampling algorithm [ ] with a modification that acceptance is driven by coherence, rather than density. according to that, the pooling matrix is iteratively perturbed via changing the pools that a given sample is contributing to, with a small probability p. perturbed matrices are accepted with a probability proportional to the decrease in coherence as suggested by metropolis sampling. this monte-carlo random walk in the pooling matrix space is expected to design low coherence random pooling procedures. the random pooling algorithm is provided below, where m by n denotes the binary pooling matrix. (i,j) indicates inclusion of sample j in the i th pool. (:,i) denotes the i th column of and α is inversely related to the coherence of (i.e. it attains k in minimum coherence and in maximum coherence). algorithm : random pooling. a pooling matrix is randomly initialized (step ), randomly perturbed ensuring no two samples are pooled identically (steps [ ] [ ] [ ] [ ] [ ] [ ] , and the new pooling is accepted/rejected according to metropolis sampling. (steps - ) input: = , α = , n, m, k, p : ← for each sample i pick k random pools out of m to set a distribution column, set the corresponding rows of (:,i) to : while iteration_no < max_iteration do : while i ≤ n do this scheme concentrates on two rounds of testing. the first test round employs random pooling and testing of pooled samples. confidently negative samples are eliminated using a possible positive detection algorithm. at this point, a subset of the samples is determined as possible positives for further testing, and no false negatives are eliminated. testing the possible positives directly for eliminating the false positives concludes the testing process without false calls. note that, perfect recovery in this sense assumes single tests are accurate. we have employed the straightforward "definite defectives" algorithm [ ] to detect the possible positives in the first round. once the possible positives are subject to the second round, the remaining procedure includes the conventional "one test-one sample" approach. the procedure is given as follows. here, we refer to the binary vector y as the pooled test results where s are the positive and s are the negative pool results. row i represents the support set of the i th row in pooling matrix determined by random pooling scheme, and t sets represent the set of positive candidates. single-pass testing includes only the approximate decoding of pooled samples in one round. we considered sequential combinatorial orthogonal matching pursuit (comp) algorithm [ ] for decoding. according to this, among the set of possible defectives, the minimal set explaining the pooling test results is considered using a greedy forward addition. this set is the predicted positives for the entire test population. unlike the previous approach, single-pass testing is vulnerable to false positives and negatives, whenever the pooling scheme is underpowered to explain the actual population uniquely. here, similarly, we refer to the binary vector y as the pooled test results. ω y represents the support set of y, row i represents the support set of i th row in , col i represents the support set of i th column in , and t sets represent the set of positive candidates. since the pooling matrix design procedure is stochastic, it is possible to design several different pooling schemes. the decoding algorithms are driven by pooling matrices, therefore two-pass and single-pass testing instances may vary physically. performed with p = . perturbation probability applied to each sample-pool pairing independently for . iterations. for each pooling setup, sample sets were simulated assuming a bernoulli process where the probability of a positive sample draw was estimated to be the prevalence. for two-pass testing, the mean efficiency gain is reported at each prevalence sampled over a number of independent simulations. in order to attain the detection performance of single-pass testing, the number of pools were incremented with new pooling designs until the perfect recovery of single tests was achieved at each prevalence instance. similarly, the mean performances of a number of simulations were reported. in order to observe the performance of group testing under different regimes, simulations under bernoulli sampling were repeated and reported. the prevalence range between . and . was chosen as the simulation operating region. efficiency gain, defined as the ratio of tested subjects to the number of actual tests performed in pools was used as the performance metric. three pooling strategies, each corresponding to a different plate operation were considered: -well plate, -well plate, and -well plate. in case of exact recovery of one sample-one test naive testing, which would fix the sensitivity and specificity of group testing approximately to that of pcr technical limitations, the two-pass procedure explained in the methods, referred to as "definitive defectives" was considered. for -well plate set up, pools are considered for the first round group testing and each sample is represented exactly in three different pools. the preferred number of pools was with each sample being distributed to exactly pools for -well plate setting, also pools with each sample being distributed to exactly different pools were considered for -well plate set up. the corresponding random pooling strategies construct sparse mixing matrices which are expected to result in good performance of decoding algorithms (i.e. detecting a small number of possible positives with ideal specificity). consequently, greater efficiency gain values are expected compared to conventional grouping. in order to observe how this pooling strategy scales for low prevalence scenarios compared to previously proposed techniques, we considered the group testing scheme suggested by sinnott-armstrong et al. (which we refer to as "row-column grouping") for the same setup. multistage testing strategy proposed by eberhardt et al. [ ] was also implemented in the same setup. from several two-or three-stage testing schemes, pools of with three stages (named as "multistage p s ") and pools of with two stages (named as "multistage p s ") were observed to be the most efficient strategies throughout the prevalence spectrum. therefore, we included these two in our comparison. finally, a well-known group testing strategy proposed by phatarfod and sudbury [ ] , which is an adaptive version of "row-column grouping" was considered as a reference. while underperforming in the small plate setup ( -well plate), the proposed group testing resulted in higher efficiency in sparse prevalence regimes (i.e. < . %) for medium ( -well plate) and large plate ( -well plate) setups (fig. ) . especially, for the large plate setting, the efficiency gain was observed to achieve more than twice the rates of other schemes. each observed value is the recorded mean of independent simulations. this came with the trade-off of underperforming in denser areas ( . % to % regions). we have considered the scenarios in which the preservation of naive test accuracy is not the primary concern. a widespread scanning concept might be focusing on determining the hot-spots within a population rather than diagnosing each individual for covid- . in such a case, test accuracy could be traded off in return of gains in testing capacity. since single-pass group testing schemes are underdetermined systems analogous to compressed sensing, reduction in the number of pools to be tested will translate to reduction in testing accuracy, which corresponds to the trade-off operation between efficiency gain and test accuracy. to observe these characteristics we conducted the simulations in similar prevalence ranges as the two-pass process. however, in this case, random pools were decoded to sample test results in a single pass using scomp decoding as described in the methods section. the accuracy increase was recorded with respect to increasing number of random pools at each prevalence instance. starting from the same setting with two-pass testing pooling scheme, new pooling procedures were sampled at each pooling expansion. the parameter k, which corresponds to the number of pools that a sample contributes to, was incremented by one at the introduction of every new pools. as the performance metric, we chose sensitivity to reflect the operation success of group testing scheme. as expected, the specificity measures were close to throughout the operational regions (fig. ) . figure shows the efficiency gain operations, indicating operation at each sensitivity level as separate contours. following similar characteristics with two-pass testing, pooling from larger well plates yields greater gains, especially for very sparse regimes. typically, the trend of equal-sensitivity contours exhibits greater slopes as the prevalence gets smaller, indicating better efficiency gain boosts for lower sensitivity trade-off. sequential comp decoding employed for single-pass decoding of group testing by random pooling operates on a greedy algorithm, selecting a suboptimal minimal subset satisfying the pooled test results. clearly, the solutions are not unique, and in case several linear combinations cover the same support set of pools, the decoding is vulnerable to errors. lowering the number of random pools drives the system to be more underdetermined, expecting a greater number of errors on average. this can be observed from our simulations. observing the empirical results, the specificity has never been experienced to be lower than . , which is expected since the negative/positive distribution is unbalanced. this is also an indication that the decoding is not overexploring the positives. a more rigorous or liberal decoding scheme, allowing relaxations such as linear programming might be further investigated to observe if any improvement in decoding accuracy is achievable empirically. although single-pass and two-pass schemes presented are not directly comparable since the former is a partial recovery method and the latter is an exact recovery method, it is interesting to compare their efficiency gains where single-pass testing performs close to exact recovery. according to our simulations, operation characteristics of single-pass testing converges to row-column group testing as the prevalence increases, and it operates close to the proposed two-pass testing in low-prevalence regions ) . it might be possible to perform single-pass testing with appropriate random pooling schemes even in high prevalence regimes. figure provides the mean efficiency gain performance of the two proposed schemes. roughly, the single pass scheme approximates the gains of random pooling and row-column pooling schemes at both sides of the prevalence spectrum. the single pass scheme appears to perform similar to two-pass complete recovery around near errorless operation (e.g. sensitivity > . ). while this is practically preferable, as single-pass testing requires only one round of testing being more efficient in time requirements, it might be more difficult to design a single-pass test. it should be noted that each efficiency gain requires different random pooling numbers for different prevalence regimes and a correct guess of prevalence should be predicted beforehand. in case prevalence distribution attains high variance, two-pass testing might be a safer approach. figure depicts the expansion rates, showing how many folds the testing capacity can be expanded to include presumably negative dominant scan population (e.g. extending the tracing to not only symptomatic but also to asymptomatic contacts) conducting the same number of tests. as expected, it would be possible to achieve larger expansions at low prevalences, especially with large plate setups. on the other hand, still, room for a few-fold expansion seems to be achievable around relatively large prevalences such as %. this might be an indicator that group testing could be a feasible operation at a large spectrum. single-pass testing vs. p-best testing p-best testing was shown to perform accurately around the band . %- . % with x efficiency gain. while p-best incorporates a specific reed-solomon errorcorrecting code scheme for pooling, we ran simulations around this band with similar aspects (i.e. each sample contributes to exactly pools in -well plate setting) fig. efficiency gains of single-pass group testing. decoding performed using sequential comp for different number of pools were simulated for -, -, and -well plate setups at a range of prevalence scenarios. as the number of pools reduces and the efficiency gain increases, the sensitivity of the test reduces. equal-sensitivity contours are shown in different color codings to observe the efficiency gain rates around perfect recovery operating points. according to the averages over simulations, random pooling performs similarly around % prevalence ( table ). note that this observation is not based on practical experiments neglecting any physical noise source. in order to validate the results and draw a confident conclusion, further studies and wet-lab experiments are needed. conducting an effective test, trace & isolate solution might be the key for containing sars-cov- and an elemental part of fighting against the current covid- pandemic. perhaps the most significant and challenging issue is performing massive-scale tests. asymptomatic cases, being the possible silent culprits of undetected infection clusters, are off the radar of conventional testing procedures. in order to expand the radius of contact tracing to subpopulation scan level or performing community scans, given the current testing infrastructures and resources, efficient group testing strategies are needed. currently proposed covid- group testing schemes offer a gain up to no more than x and x scale-up for medium ( . %- %) and low (< . %) prevalence respectively [ ] [ ] [ ] ] . there is a good probability that the required scale up to achieve massive scale testing might be greater in certain scenarios. we investigated if further improvement is available, especially in sparse prevalence occurrence where outbreaks are needed to be avoided by population scans. we have tested our proposed pooling schemes for standard -, -, and -well plate settings. the reason why testing schemes were restricted to standard plate settings is the practical concern that manual or robotic laboratory handling conventions generally follow standard well setups and integration/adoption in these circumstances is more feasible. our simulations indicate that the greatest efficiency gains promised by the proposed pooling schemes are achieved at very low prevalence rates for -and -well plate settings. this observation leads to the fact that such a high-efficiency gain approach should be limited to certain testing scenarios. the proposed group testing, along with the other approaches reviewed previously, would not be helpful in the diagnostic use for symptomatic cases around outbreak peaks, for instance when the prevalence in a tested population is greater than %. on the other hand, a few cases at the early phases of an outbreak are worth to detect, as they might be the seeds for exponential growth of epidemic curves. widespread testing for early detection of emerging clusters therefore might be a powerful preventive approach. our results claim that random pooling might be a preferable group testing strategy in similar scenarios. another use case might be scanning for asymptomatic cases, separate from diagnostic testing on symptomatic individuals. this might be either as extending contact tracing to be able to test greater number of case contacts or as a periodic scan of a population (e.g. healthcare workers and other risk groups). in case of community scans in which individual-level sensitivity can be sacrificed in return of spanning larger populations, single-pass group tests might also be useful. we have observed that for single-pass group testing, a small decrease in sensitivity could enable large efficiency gains at low prevalence groups. such a high-throughput group testing on relatively large populations could be devised as a tool for locating infection hot spots. assume that contact tracing in a relatively low prevalence cluster is being conducted using naive testing. it might be useful to extend tracing by testing several-fold more individuals but with the same number of tests, using group testing. the extended subpopulation may be very low prevalence, however, detecting any asymptomatic case in it could be very valuable. we ran simulations to investigate what should be the initial prevalence for such an expansion opportunity, and how many folds of an extension would be available in the proposed group testing scheme. we observed that up to x expansion is available around %- % prevalence band (fig. ). this result might be an implication that large scale contact tracing might be possible at early forming clusters. it should be kept in mind that our experiments are simulations designed on two major assumptions. first, we assumed that pooling will not attenuate the detection efficiency of molecular detection. lohse et al. [ ] and yelin et al. [ ] independently showed that pooling a single positive sars-cov- sample with tens of negative samples does not harm detectability of positives in case of rt-qpcr testing. the pooling size in our simulations does not exceed the experimented limits, so we believe the proposed pooling schemes should act similarly in practical settings. our second assumption is that the molecular tests are accurate enough to detect the samples without errors. therefore, all simulations are performed for a noiseless scenario. while the actual picture might not comply with this assumption, the experiments ran with p-best approach indicate that the imperfection of rt-qpcr tests does not have a negative effect on group testing. in fact, the encoding procedures of mixing matrices might even work as error-correcting codes for low prevalence. however, further studies and wetlaboratory experiments should be conducted to support this claim. another aspect of group testing is that the efficiency gains mentioned in this and previous studies do not translate as linear gains in sars-cov- testing economy. group testing only amplifies the number of tests, however previous steps of sampling, logistics, and any sample preparation steps remain unscaled. feasibility of prepooling operations is out of the scope where it might be another serious concern. moreover, group testing might be subject to greater use of consumables (e.g. more pipetting), imposing the risk of mixing errors or the need for robotics systems. expansion rates of single-pass and two-pass schemes at different prevalences. the expansion rates, showing how many folds the testing capacity can be expanded to include presumably negative dominant scan population (e.g. extending the tracing to not only symptomatic but also to asymptomatic contacts) conducting the same number of tests although the current popular approach of covid- testing is rt-qpcr based molecular tests, clearly group testing is not limited to pcr based molecular techniques. any testing scheme preserving positivity as well as lack of signals in the absence of positives while combining samples in pools can be trivially integrated to group testing approaches. igc/igm based serological tests or any prospective test strategies (e.g. crispr-cas based testing [ ] ) should be considered for large scale testing/scanning with group testing under appropriate circumstances. it should be noted that the current concept of group testing relies on recovering the actual sample profile from binary outcomes of pooled tests. testing schemes allowing quantitative outputs might be possible and further quantitative information might enable unprecedented efficiency gains. this opportunity can be hypothesized following the results of compressed sensing literature. for example, for the case of sudocodes [ ] , at a prevalence of . %, million subjects can be scanned by performing under . tests even with perfect recovery. of course, this requires very precise quantitative and unique measures for each test subject. it might be a promising research direction to investigate such testing options. for example, shallow shotgun sequencing allowing positive signals while pronouncing specific sequences belonging to each sample could be a candidate for ultra-high throughput group testing. proposed group testing algorithms assume and simulate under the circumstances that each sampled instance is independent. on the contrary, we know that covid- sampling is mainly conducted on populations with social contacts, violating the independence assumptions. sophisticated decoding algorithms informed by metadata might perform superior, allowing greater efficiency gains, while complicating the overall testing procedure in practice. nevertheless, we believe that even in primitive forms, group testing is a promising direction for efficient allocation of testing resources that should be considered for practical use. how will country-based mitigation measures influence the course of the covid- epidemic? covid- : extending or relaxing distancing control measures estimating the asymptomatic proportion of coronavirus disease (covid- ) cases on board the diamond princess cruise ship estimation of the asymptomatic ratio of novel coronavirus infections (covid- ) presumed asymptomatic carrier transmission of covid- asymptomatic transmission, the achilles' heel of current strategies to control covid- combinatorial group testing and its applications the detection of defective members of large populations group testing: an information theory perspective. found trends® commun inform theory evaluation of group testing for sars-cov- rna multi-stage group testing improves efficiency of large-scale covid- screening efficient high throughput sars-cov- testing to detect asymptomatic carriers the critical study of mutual coherence properties on compressive sensing framework for sparse reconstruction performance: compression vs measurement system equation of state calculations by fast computing machines group testing algorithms: bounds and simulations the use of a square array scheme in blood testing pooling of samples for testing for sars-cov- in asymptomatic people evaluation of covid- rt-qpcr test in multi-sample pools crispr-cas -based detection of sars-cov- sudocodes fast measurement and reconstruction of sparse signals publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the author thanks aycan gundogdu, ph.d., whose comments clearly helped in improving the overall quality of the manuscript. our simulations show that sparse random pooling can provide improved efficiency gains compared to conventional group testing or reed-solomon error-correcting codes. therefore, we propose that special designs for different scenarios could be available and it is possible to scale up testing capabilities significantly. not applicable. the codes, protocols, and datasets used during the current study are available from the corresponding author on reasonable request. no ethical approval was required for this study, since it used only simulated data. not applicable. the author(s) declare that they have no competing interests.received: may accepted: june key: cord- -q b ym authors: murakami, makoto title: lipoquality control by phospholipase a( ) enzymes date: - - journal: proc jpn acad ser b phys biol sci doi: . /pjab. . sha: doc_id: cord_uid: q b ym the phospholipase a( ) (pla( )) family comprises a group of lipolytic enzymes that typically hydrolyze the sn- position of glycerophospholipids to give rise to fatty acids and lysophospholipids. the mammalian genome encodes more than pla( )s or related enzymes, which are classified into several subfamilies on the basis of their structures and functions. from a general viewpoint, the pla( ) family has mainly been implicated in signal transduction, producing bioactive lipid mediators derived from fatty acids and lysophospholipids. recent evidence indicates that pla( )s also contribute to phospholipid remodeling for membrane homeostasis or energy production for fatty acid β-oxidation. accordingly, pla( ) enzymes can be regarded as one of the key regulators of the quality of lipids, which i herein refer to as lipoquality. disturbance of pla( )-regulated lipoquality hampers tissue and cellular homeostasis and can be linked to various diseases. here i overview the current state of understanding of the classification, enzymatic properties, and physiological functions of the pla( ) family. in terms of signal transduction, the phospholipase a (pla ) reaction, which hydrolyzes the sn- position of phospholipids to yield fatty acids and lysophospholipids, has been considered to be of particular importance, since arachidonic acid (aa, c : ), one of the polyunsaturated fatty acids (pufas) released from membrane phospholipids by pla , is metabolized by cyclooxygenases (coxs) and lipoxygenases (loxs) to lipid mediators including prostaglandins (pgs) and leukotrienes (lts), which are often referred to as eicosanoids (fig. ) . lysophospholipids or their metabolites, such as lysophosphatidic acid (lpa) and platelet-activating factor (paf), are categorized into another class of pla -driven lipid mediators ( fig. a, b) . more recently, a novel class of anti-inflammatory lipid mediators derived from b pufas, such as eicosapentaenoic acid (epa, c : ) and docosahexaenoic acid (dha, c : ), has also been attracting much attention (fig. c ). these lipid mediators exert numerous biological actions on target cells mainly by acting on their cognate g protein-coupled receptors. the pathophysiological roles of individual lipid mediators have been summarized in recent reviews. )- ) however, this principal concept appears to be insufficient to fully explain the biological aspects and physiological roles of the pla family. phospholipids comprise numerous molecular species that contain various combinations of fatty acids esterified at the sn- and sn- positions and several polar head groups at the sn- position. many, if not all, pla enzymes recognize such differences in the fatty acyl and/or head group moieties in their substrate phospholipids. moreover, several enzymes in the pla family also catalyze the phospholipase a (pla ), lysophospholipase, neutral lipid lipase, or even transacylase/ acyltransferase reaction rather than or in addition to the genuine pla reaction. therefore, the fatty acids and lysophospholipids released by different pla s are not always identical; rather, in many situations, specific fatty acids and lysophosholipids can be released by a particular pla in the presence of a given microenvironmental cue. in this context, pla enzymes act as one of the critical regulators of spatiotemporal lipid profiles, namely the quality of lipids (lipoquality). to comprehensively understand the lipoquality regulation by individual pla s in various pathophysiological contexts, their precise enzymatic, biochemical and cell biological properties, tissue and cellular distributions, and availability of phospholipid substrates in various pathophysiological settings should be taken into consideration. herein, i overview current understanding of the biological aspects of various pla enzymes in the context of lipoquality. obviously, the substrate specificity of individual pla s is the critical determinant of lipoquality. the in vitro enzymatic activity of pla s may be influenced by the assay conditions employed, such as the composition of the substrate phospholipids, concentrations of pla s and substrates, presence of detergents, and ph. hence, the enzymatic properties of individual pla s determined in different studies may not be entirely identical. since natural membranes contain numerous phospholipid molecular species, the results obtained using artificial phospho- lipid vesicles comprising only one or a few phospholipid species may not always reflect the true enzymatic properties of a given pla . addition of an excess amount of recombinant or purified pla to an enzyme assay often results in hydrolysis of bulk phospholipids, which makes precise evaluation of its substrate specificity difficult. the results obtained using a commercially available pla assay kit, in which a synthetic, chromophoric phospholipid is used as a substrate, should be interpreted carefully, since some pla s are unable to hydrolyze it efficiently. in this regard, mass spectrometric examination of the in vitro hydrolysis of natural membrane phospholipids extracted from the affected tissues or cells by pla , particularly at a low (physiologically relevant) concentration of the enzyme, could provide a valuable clue to the in vivo substrates and products of this enzyme. )- ) the overall tendency in this in vitro assay using natural membranes is recapitulated in several in vivo systems, often with even more selective patterns of hydrolysis that are relevant to the results of studies using pla knockout and/or transgenic mice (see below). importantly, the mobilization of distinct lipids by pla s in vivo relies not only on their intrinsic enzymatic properties, but also on tissue-or disease-specific contexts such as the lipid composition of target membranes, the spatiotemporal availability of downstream lipid-metabolizing enzymes, or the presence of cofactor(s) that can modulate the enzymatic function, which may account for why distinct pla enzymes even in the same subfamily exert specific functions with different lipid profiles in distinct settings. hereafter, i describe the current understanding of various pla s in the context of lipoquality. the classification, distributions, properties and functions of individual pla s, whose pathophysiological functions have currently been studied using their gene-manipulated mice, are summarized in table enzymes whose in vivo functions have been analyzed using knockout mice are summarized. the cpla family. the cytosolic pla (cpla ) family comprises isoforms (,- ), among which cpla o, /, c and map to the same chromosomal locus (fig. a) . ) cpla , (also known as group iva pla ) is undoubtedly the best known pla and its biological roles in association with lipoquality have been well documented. ) cpla , is the only pla that shows a striking substrate specificity for aa-containing phospholipids. strictly speaking, cpla , can also hydrolyze phospholipids containing epa, yet the low abundance of this b pufa relative to other fatty acids including b aa in cell membranes allows cpla , to release aa rather specifically in most situations. upon cell activation, cpla , translocates from the cytosol to the phosphatidylcholine (pc)-rich perinuclear, endoplasmic reticulum (er) and golgi membranes (particularly golgi) in response to an increase in the µm range of cytosolic ca d concentration, and is maximally activated by phosphorylation through mitogen-activated protein kinases (mapks) and other kinases. ), ) in addition, the phosphoinositide pip and ceramide- -phosphate modulate the subcellular localization and activation of cpla ,. ), ) the aa released by cpla , is converted by the sequential action of constitutive cox- or inducible cox- and terminal pg synthases to pgs or by the sequential action of -lox and terminal lt synthases to lts (fig. b ). mice deficient in cpla , display a number of phenotypes that can be explained by reductions of pgs and/or lts. under physiological conditions, cpla ,-deficient mice display a hemorrhagic tendency, impaired female reproduction, gastrointestinal ulcer, and renal malfunction, among others. )- ) under pathological conditions, cpla ,-deficient mice are protected against bronchial asthma, pulmonary fibrosis, cerebral infarction, alzheimer's disease, experimental autoimmune encephalomyelitis, collagen-induced arthritis, metabolic diseases, intestinal cancer and so on, whereas they suffer from more severe colitis and spinal cord injury. ), )- ) most of these phenotypes are recapitulated in mice lacking one or more of the biosynthetic enzymes or receptors for pgs and lts, lending strong support to the notion that cpla , lies upstream of eicosanoid biosynthesis in many situations. for instance, as is the case for cpla ,-deficient mice, mice lacking ltc synthase (ltc s), ltd receptor (cyslt ), ltb receptor (blt ), or pgd receptor (dp ) are protected from asthma, )- ) revealing the critical role of the cpla ,-ltb /ltc /pgd axis in this allergic disease. likewise, the decrease of pge in cpla ,-deficient mice can account largely, even if not solely, for the mitigation of arthritis, autoimmune encephalomyelitis, cancer and neurodegeneration as well as the exacerbation of colitis, since these phenotypes are mimicked by mice lacking pge synthase (mpges- ) or either of the four pge receptors (ep ). )- ) furthermore, cpla ,-triggered release of aa by platelets is coupled not only with biosynthesis of the pro-thrombotic eicosanoid thromboxane a (txa ), but also with o-oxidationmediated bioenergetics for blood clotting. ) importantly, inherited human cpla , mutations are associated with reduced eicosanoid biosynthesis, platelet dysfunction, and intestinal ulceration, ) , ) thus mimicking cpla , deletion in mice. on the other hand, the enzymatic activities and biological functions of cpla isoforms other than cpla , have remained largely unknown. reportedly, cpla o (group ivb pla ), which has a unique jimc domain in the n-terminal region, display pla , pla and lysophospholipase activities. ) cpla . (group ivc pla ), which uniquely lacks the c domain characteristic of the cpla family, is cterminally farnesylated and possesses lysophospholipase and transacylase activities in addition to pla activity. ) cpla / (group ivd pla ), whose expression is elevated in human psoriatic skin, ) shows pla activity in preference to pla activity. ) cpla c (group ive pla ) exhibits a unique transacylase activity that transfers sn- fatty acid of pc to an amino residue of phosphatidylethanolamine (pe) to form n-acyl-pe, a precursor of the endocannabinoid lipid mediator n-acylethanolamine. ) cpla (group ivf pla ) displays both pla and pla activities without fatty acid selectivity. ) however, these enzymatic properties of cpla o- vary according to the in vitro assays employed, implying that analyses using gene-manipulated mice for these enzymes will be necessary for clarifying their biological roles in the context of lipoquality. the ipla /pnpla family. the human genome encodes ca d -independent pla (ipla ) enzymes (fig. ) . these enzymes are now more generally referred to as patatin-like phospholipase domain-containing lipases (pnpla ), as all members in this family share a patatin domain, which was initially discovered in patatin (ipla ,), a potato protein. ), ) mammalian ipla /pnpla isoforms include lipid hydrolases or transacylases with specificities for diverse lipids such as phospholipids, neutral lipids, sphingolipids, and retinol esters. generally speaking, enzymes bearing a large and unique n-terminal region (pnpla ) act mainly on phospholipids (phospholipase type), whereas those lacking the n-terminal domain (pnpla ) act on neutral lipids (lipase type). analysis of mutant mouse models and clinical symptoms of patients with mutations for these enzymes have provided valuable insights into the physiological roles of the ipla / pnpla family in various forms of homeostatic lipid metabolism that are fundamental for life. among the ipla /pnpla family, pnpla (ipla o, also known as group via pla ) is the only isoform that acts primarily as a pla with poor fatty acid selectivity. ), ) although pnpla (ipla . or group vib pla ) displays pla activity, it acts as a pla toward phospholipids bearing sn- pufa. ), ) accordingly, hydrolysis of pufa-bearing phospholipids by pnpla /ipla . typically gives rise to -lysophospholipids (having a pufa at the sn- position) rather than -lysophospholipids (having a saturated or monounsaturated fatty acid at the sn- position). pnpla (ipla /) and its closest paralog pnpla (ipla ) have lysophospholipase activity that cleaves lysophosphatidylcholine to yield fatty acid and glycerophosphocholine. ), ) genetic mutations or deletions of these phospholipid-targeting pnplas cause various forms of metabolic dysfunction and neurodegeneration. )- ) in particular, pnpla /ipla o is also referred to as the parkinsonism-associated protein park , whose mutations impair ca d signaling in dopaminergic neurons. ) apart from the metabolic and neurodegenerative phenotypes, the lack of pnpla /ipla o leads to male infertility through an unknown mechanism. ) pnpla (ipla ), more generally known as adipose triglyceride lipase (atgl), is a major lipase that hydrolyzes triglycerides in lipid droplets to release fatty acids as a fuel for o-oxidation-coupled energy production, a process known as lipolysis. ) genetic deletion or mutation of pnpla leads to massive accumulation of triglycerides in multiple tissues leading to multi-organ failures, ) while protecting from cancer-associated cachexia by preventing fat loss. ) the activity of pnpla is regulated positively by abhd (see below) and negatively by perilipin and g s , which modulate the accessibility of pnpla to lipid droplets. ) the fatty acids released from lipid droplets by pnpla act as endogenous ligands for the nuclear receptor ppar, or ppar/, which accelerates energy consumption. ), ) the regulatory mechanisms and metabolic roles of pnpla have been detailed in other elegant reviews. ), ) mutations of pnpla (ipla c) are highly associated with non-alcoholic fatty liver disease. ) although the catalytic activity of pnpla is controversial, it may serve as a triglyceride lipase, since its loss-of function mutation increases cellular triglyceride levels. ) furthermore, recent evidence suggests that pnpla acts as a retinyl-palmitate lipase in hepatic stellate cells to fine-tune the plasma levels of retinoids. the expressions of pnpla and pnpla are nutritionally regulated in a reciprocal way; pnpla is upregulated, while pnpla is downregulated, upon starvation, and vice versa upon feeding. ) biochemical and cell biological studies have suggested that pnpla (ipla , which is absent in mice) might be involved in retinol ester metabolism ) and that pnpla might participate in triglyceride lipolysis coupled with autophagosome formation, ) although the in vivo relevance of these in vitro observations is unclear. unlike most pnpla isoforms that are ubiquitously expressed in many tissues, pnpla is localized predominantly in the upper layer of the epidermis. pnpla acts as a unique transacylase, catalyzing the transfer of linoleic acid (la; c : ) in triglyceride to the b-hydroxy residue of ultra-longchain fatty acid in ceramide to form b-o-acylceramide, a lipid component essential for skin barrier function. ), ) accordingly, genetic deletion or mutation of pnpla hampers epidermal b-o-acylceramide formation, thereby severely impairing skin barrier function and causing ichthyosis. the unique role of pnpla in the acylceramide-metabolic pathway in the epidermis is depicted in fig. . the pafah family. the paf-acetylhydrolase (pafah) family comprises one extracellular and three intracellular pla s that were originally found to have the capacity to deacetylate and thereby inactivate the lysophospholipid-derived lipid mediator paf. ), ) type-i pafah is a heterotrimer composed of two catalytic subunits, group xiiia and xiiib pla s, and a regulatory subunit lis- , the causative gene for a type of miller diecker syndrome. ) deficiency of type-i pafah leads to male infertility through an unknown mechanism. ) type-ii pafah (group viib pla ) preferentially hydrolyzes oxidized phospholipids (i.e., phospholipids having an oxygenated fatty acid at the sn- position) in cellular membranes, thereby protecting cells from oxidative damage. ) although plasma-type pafah (group viia pla ) is a secreted protein, it is described here as its structure is close to type-ii pafah. plasma-type pafah is now more generally called lipoprotein-associated pla (lp-pla ), existing as a low-density lipoprotein (ldl)-bound form in human plasma. ) a series of studies have revealed the correlation of lp-pla with atherosclerosis, likely because this enzyme liberates toxic oxidized fatty acids from modified ldl with pro-atherogenic potential. ), ) furthermore, deficiency of lp-pla decreases intestinal polyposis and colon tumorigenesis in apc min/d mice, ) suggesting an anti-tumorigenic role for paf in this setting. lysosomal pla . lysosomal pla (lpla ), also known as group xv pla , is homologous with lecithin cholesterol acyltransferase (lcat) and catalytically active under mildly acidic conditions. ) lpla hydrolyzes both sn- and sn- fatty acids in phospholipids and contributes to phospholipid degradation in lysosomes. genetic deletion of lpla results in unusual accumulation of non-degraded lung surfactant phospholipids in lysosomes of alveolar macrophages, leading to phospholipidosis, ) perturbed presentation of endogenous lysophospholipid antigens to cd d by invariant natural killer t (inkt) cells, ) and impairment of adaptive t cell immunity against mycobacterium. ) the plaat family. the pla-acyltransferase (plaat) family ( enzymes in humans and enzymes in mice) is structurally similar to lecithin retinol acyltransferase (lrat). members of this family, including group xvi pla (pla g ), display pla and pla activities, as well as acyltransferase activity that synthesizes n-acyl-pe, to various degrees. ) pla g is highly expressed in adipocytes, and pla g -deficient mice are resistant to diet-induced obesity. ) pla g and its paralogs in this family have also been implicated in tumor invasion and metastasis, ) vitamin a metabolism, ) peroxisome biogenesis, ) and cellular entry and clearance of picornaviruses. ) the abhd family. the ,/o hydrolase (abhd) family is a newly recognized group of lipolytic enzymes, comprising at least enzymes in humans. ) enzymes in this family typically possess both hydrolase and acyltransferase motifs. although the functions of many of the abhd isoforms still remain uncertain, some of them have been demonstrated to act on neutral lipids or phospholipids as lipid hydrolases. abhd selectively hydrolyzes phospholipids with medium-chain fatty acids. lipoquality control by phospholipase a enzymes no. ] abhd releases fatty acids from multiple classes of n-acyl-phospholipids to produce n-acyl-lysophospholipids. ) abhd acts as lysophospholipase or monoacylglycerol lipase, the latter being possibly related to the regulation of -arachidonoyl glycerol ( -ag) signaling. ), ) -ag is an endocannabinoid lipid mediator that plays a role in the retrograde neurotransmission and is considered to be produced mainly by diacylglycerol lipase ,. ) interestingly, in the brain, the aa released from -ag by monoacylglycerol lipase, rather than that released from phospholipids by cpla , (see above), is linked to the production of a pool of pge that promotes fever. ), ) abhd hydrolyzes lysophosphatidylserine (lysops), and is therefore referred to as lysops lipase. ) mutations in the human abhd gene result in accumulation of lysops in the brain and cause a disease called pharc, which is characterized by polyneuropathy, hearing loss, ataxia, retinitis pigmentosa, and cataract. ) abhd a acts as a phosphatidylserine (ps)-selective pla (referred to as ps lipase), being located upstream of abhd in the ps-catabolic pathway. ) although abhd (also called cgi- ) does not have a catalytic activity because of the absence of a serine residue in the catalytic center, it greatly enhances pnpla directed hydrolysis of triglycerides in lipid droplets by acting as an essential lipolytic cofactor. ) . lipoquality control by secreted pla s general aspects. the secreted pla (spla ) family contains catalytically active isoforms and one inactive isoform in mammals. ), ) based on the structural and evolutional relationships, these enzymes are categorized into classical (ib, iia, iic, iid, iie, iif, v and x) and atypical (iii and xii) classes (fig. ) . the spla family strictly hydrolyzes the sn- position of phospholipids, a feature that differs from intracellular pla s that often display pla , lysophospholipase, lipase, or transacylase/acyltransferase activity (see above). individual spla s exhibit unique tissue and cellular distributions, suggesting their distinct biological roles. as spla s are secreted and require ca d in the mm range for their catalytic action, their principal targets are phospholipids in the extracellular space, such as microparticles, surfactant, lipoproteins, and foreign phospholipids in microbe membranes or dietary components. the biochemical properties and pathophysiological functions of spla s have been detailed in several recent reviews. ), ) here, i describe several key features of lipoquality regulation by the spla family. in terms of the lipoquality, spla s have long been considered to display no apparent selectivity for sn- fatty acid species in the substrate phospholipids. this view was based on the fact that spla -ib and -iia, two prototypic spla s that were initially identified through classical protein purification from the pancreas and sites of inflammation, respectively, ), ) as well as a number of snake venom pla s that belong to group i and ii spla s, are capable of releasing fatty acids non-selectively. however, recent lipidomics-based evaluation of the substrate specificity of spla s toward natural membranes (see above) has revealed that several spla s can distinguish sn- fatty acyl moieties in phospholipids under physiologically relevant conditions. in general terms, spla -ib, -iia and -iie do not discriminate fatty acid species, spla -v tends to prefer those with a lower degree of unsaturation such as oleic acid (oa; c : ), and spla -iid, -iif, -iii and -x tend to prefer pufas including aa and dha. several spla s can also distinguish differences in the polar head groups of phospholipids. for instance, spla -x is very active on pc, while spla -iia has much higher affinity for pe than for pc, and this substrate selectivity has been partly ascribed to their crystal structures. ), ) therefore, in order to comprehensively understand the specific biological roles of this enzyme family, it is important to consider when and where different spla s are expressed, which isoforms are involved in what types of pathophysiology, why they are needed, and how they exhibit their unique functions by driving specific types of lipid metabolism. classical spla s. spla -ib, also known as "pancreatic spla ", is synthesized as an inactive zymogen in the pancreas, and its n-terminal propeptide is cleaved by trypsin to yield an active enzyme in the duodenum. ) the main role of spla -ib is to digest dietary and biliary phospholipids in the intestinal lumen. perturbation of this process by gene disruption or pharmacological inhibition of spla -ib leads to resistance to diet-induced obesity, insulin resistance, and atherosclerosis due to decreased phospholipid digestion and absorption in the gastrointestinal tract. )- ) the human pla g b gene maps to an obesity-susceptible locus. ) spla -iia is often referred to as "inflammatory spla ", since its expression is induced by proinflammatory cytokines such as tnf, and il- o or by bacterial products such as lipopolysaccharide. ) in mice, however, spla -iia in mice is distributed only in intestinal paneth cells (in balb/c, c h, nzb and dba, etc.) or not expressed at all due to a natural frameshift mutation (in c bl/ , a/j, c / j, p/j, /sv and b .riii, etc.). ), ) the bestknown physiological function of spla -iia is the degradation of bacterial membranes, thereby providing the first line of antimicrobial defense in the host. ), ) consistent with this, spla -iia preferentially hydrolyzes pe and phosphatidylglycerol, which are enriched in bacterial membranes. under sterile conditions, spla -iia attacks phospholipids in microparticles, particularly those in extracellular mitochondria (an organelle that evolutionally originated from bacteria), which are released from activated platelets or leukocytes at inflamed sites. ) hydrolysis of microparticular phospholipids by spla -iia results in production of pro-inflammatory eicosanoids and lysophospholipids as well as in release of mitochondrial dna as a danger-associated molecular pattern (damp). thus, spla -iia is primarily involved in host defense by killing bacteria and triggering innate immunity, while over-amplification of the response leads to exacerbation of inflammation. spla -iia, -iic, -iid, -iie and -iif are often classified into the group ii subfamily (spla -iic is a pseudogene in human), since they share structural characteristics and map to the same chromosome locus. spla -iid is constitutively expressed in dendritic cells (dcs) in lymphoid organs. spla -iid is an "immunosuppressive spla " that attenuates dc-mediated adaptive immunity by hydrolyzing pe probably in microparticles to mobilize antiinflammatory b pufas and their metabolites such as resolvin d (rvd ). ) as such, spla -iid-null mice exhibit more severe contact hypersensitivity and psoriasis, whereas they are protected against infection and cancer because of enhanced anti-viral and anti-tumor immunity. ), ), ) unlike spla -iia, which is stimulus-inducible (see above), spla -iid is downregulated by pro-inflammatory stimuli, consistent with its anti-inflammatory role. in mice, spla -iie instead of spla -iia is upregulated in several tissues under inflammatory or other conditions. spla -iie is expressed in hair follicles in association with the growth phase of the hair cycle ) and induced in adipose tissue in association with obesity in mice. ) spla -iie hydrolyzes pe without apparent fatty acid selectivity in hair follicles and lipoproteins, and accordingly, spla -iie-deficient mice display subtle abnormalities in hair follicles ) and are modestly protected from diet-induced obesity and hyperlipidemia. ) spla -iif has a long c-terminal extension containing a free cysteine, which might contribute to formation of a homodimer, and is more hydrophobic than other spla s. ) physiologically, spla -iif is an "epidermal spla " that is expressed predominantly in the upper epidermis and induced by il- , a th cytokine, in psoriatic skin. ) spla -iif preferentially hydrolyzes pufa-containing plasmalogen-type pe in keratinocyte-secreted phospholipids to produce plasmalogen-type lysophosphatidylethanolamine (p-lpe; lysoplasmalogen), which in turn promotes epidermal hyperplasia (fig. a-c) . accordingly, spla -iif-null mice are protected against epidermal-hyperplasic diseases such as psor- iasis and skin cancer, while spla -iif-transgenic mice spontaneously develop psoriasis-like skin. ) although spla -v was previously thought to be a regulator of aa metabolism, ), ) it is now becoming obvious that this spla has a preference for phospholipids having fatty acids with a lower degree of unsaturation. spla -v is markedly induced in adipocytes during obesity as a "metabolic spla " and hydrolyzes pc in hyperlipidemic ldl to release oa and to a lesser extent la, which counteract adipose tissue inflammation and thereby ameliorates obesity-associated metabolic disorders. ) transgenic overexpression of spla -v, but not other spla s, results in neonatal death due to a respiratory defect, which is attributable to the ability of spla -v to potently hydrolyze pc with palmitic acid (pa, c : ), a major component of lung surfactant. ) this unique substrate preference of spla -v has also been supported by a recent lipidomics analysis of the spleen (a tissue where spla -v is abundantly expressed), in which the levels of fatty acids with a lower degree of unsaturation (e.g. pa, oa and la), rather than pufas (aa, epa and dha), are significantly reduced in spla -v-deficient mice relative to wild-type mice (fig. ) . this is in contrast to the spleen of spla -iid-deficient mice, in which b pufas and their metabolites are selectively diminished, ) revealing distinct lipoquality regulation . e+ . e+ . e+ . e+ . e+ , were significantly reduced in spla -v-deficient mice relative to control mice. accordingly, la metabolites, including -and -hydroxyoctadecadienoic acids (hodes) among others, were substantially decreased in mutant mice relative to control mice, whereas none of the aa, epa and dha metabolites differed significantly between the genotypes. these results are consistent with the view that spla -v has a propensity to preferentially hydrolyze phospholipids having sn- fatty acids with a lower degree of unsaturation, as illustrated at right bottom. by different spla s. another intriguing feature of spla -v is that it is the only "th -prone spla " induced in m macrophages by the th cytokines il- and il- and promotes th -driven pathology such as asthma. gene ablation of spla -v perturbs proper polarization and function of m macrophages in association with decreased th immunity, ) although the underlying lipid metabolism responsible for this event remains obscure. probably because of this alteration in the macrophage phenotype, spla -v-null macrophages have a reduced ability to phagocytose extracellular materials. accordingly, spla -v-null mice are more susceptible to fungal infection and arthritis due to defective clearance of hazardous fungi and immune complexes, respectively. ), ) likewise, spla -v-null mice suffer from more severe lung inflammation caused by bacterial or viral infection, ) which could also be explained by poor clearance of these microbes by alveolar macrophages. among the mammalian spla s, spla -x has the highest affinity for pc leading to release of fatty acids, with an apparent tendency for pufa preference. spla -x is activated by cleavage of the nterminal propeptide by furin-type convertases. ) spla -x is expressed abundantly in colorectal epithelial and goblet cells and has a protective role in colitis by mobilizing anti-inflammatory b pufas. ) consistently, spla -x-transgenic mice exhibit global anti-inflammatory phenotypes in association with elevation of systemic b pufa levels. ) in the process of reproduction, spla -x secreted from the acrosomes of activated spermatozoa hydrolyzes sperm membrane phospholipids to release dha and docosapentaenioc acid (dpa, c : ), the latter facilitating fertilization. ), ) additionally, spla -x-null mice are protected from asthma, accompanied by decreased levels of pulmonary b aa-derived eicosanoids. ) unlike the situation in spla -v-null mice (see above), however, the th response per se is not affected in the asthma model ) and the lung damage is milder following influenza infection ) in spla -x-null mice, illustrating the distinct actions of different spla s in the same tissue. atypical spla s. spla -iii is unusual in that it consists of three domains, in which the central spla domain similar to bee venom group iii spla is flanked by large and unique n-and cterminal domains. ) the enzyme is processed to the spla domain-only form that retains full enzymatic activity. ) although spla -iii does not discriminate the polar head groups, it tends to prefer sn- pufas in the substrate phospholipids. spla -iii is expressed in the epididymal epithelium and acts on immature sperm cells passing through the epididymal duct in a paracrine manner to allow sperm membrane phospholipid remodeling, a process that is prerequisite for sperm motility. ) spla -iii is also secreted from mast cells and acts on microenvironmental fibroblasts to produce pgd , which in turn promotes proper maturation of mast cells. ) accordingly, mice lacking spla -iii exhibit male hypofertility and reduced anaphylactic responses. spla -xiia is evolutionally far distant from other spla s. ) spla -xiia is expressed in many tissues at relatively high levels, yet its enzymatic activity is weaker than that of other spla s. the properties and physiological roles of spla -xiia are currently unclear and await future studies using spla -xiia-deficient mice. apart from lipoquality regulation, spla -xiib is a catalytically inactive protein due to substitution of the catalytic center histidine by leucine. ) spla -xiib deficiency impairs hepatic lipoprotein secretion, ) although the mechanism is unclear. beyond the lipoquality control by spla s, several spla s binds to spla receptor (pla r , also known as the c-type lectin clec c) with different affinities. ) in mice, pla r binds to spla -ib, -iia, -iie, -iif and -x with high affinity, spla -v with moderate affinity, and spla -iid, -iii and -xiia with low or no affinity. ) pla r is homologous to spla -inhibitory proteins present in snake plasma and exists as an integral membrane protein or as a soluble protein resulting from shedding or alternative splicing. pla r may act as a clearance receptor or endogenous inhibitor that inactivates spla s, as a signaling receptor that transduces spla -dependent signals in a catalytic activity-independent manner, or as a pleiotropic receptor that binds to non-spla ligands. in support of its clearance role, pla r !/! mice show more severe asthma, likely due to defective clearance of pro-asthmatic spla -x. ) in support of its signaling role, pla r , probably through binding to myocardial spla s or other ways, promotes the migration and growth of myofibroblasts and thereby protects against cardiac rupture in a model of myocardial infarction. ) pla r has recently attracted attention as a major autoantigen in membranous nephropathy, a severe autoimmune disease leading to podocyte injury and proteinuria, ) although it is not clear whether this role of pla r is spla dependent or -independent. by applying lipidomics approaches to knockout or transgenic mice for various pla s, it has become evident that individual enzymes regulate specific forms of lipid metabolism, perturbation of which can be eventually linked to distinct pathophysiological outcomes. knowledge of lipoquality control by individual pla s acquired from studies using animal models should be translated to humans. current knowledges on the relationship between pla gene mutations and human diseases are summarized in table . nonetheless, future development of more comprehensive and highly sensitive lipidomics techniques will contribute to the discovery of novel pla driven lipid pathways that could be biomarkers or druggable targets for particular diseases. nakanishi, h., ikeda, k., taguchi, r., kabashima deletion of cytosolic phospholipase a promotes striated muscle growth lipid signaling in cytosolic phospholipase a ,-cyclooxygenase- cascade mediates cerebellar longterm depression and motor learning acute lung injury by sepsis and acid aspiration: a key role for cytosolic phospholipase a cytosolic phospholipase a ,-deficient mice are resistant to collagen-induced arthritis an essential role of cytosolic phospholipase a , in prostaglandin e -mediated bone resorption associated with inflammation cytosolic phospholipase a ,-deficient mice are resistant to experimental autoimmune encephalomyelitis phospholipase a reduction ameliorates cognitive deficits in a mouse model of alzheimer's disease group x secreted phospholipase a releases b polyunsaturated fatty acids, suppresses colitis, and promotes sperm fertility cysteinyl leukotrienes regulate th celldependent pulmonary inflammation leukotriene b receptor blt mediates early effector t cell recruitment prostaglandin d as a mediator of allergic asthma dual roles of pge -ep prostaglandin e -ep signaling promotes immune inflammation through th cell differentiation and th cell expansion acceleration of intestinal polyposis through prostaglandin receptor ep in apc " knockout mice involvement of prostaglandin e in production of amyloid-o peptides both in vitro and in vivo the prostaglandin receptor ep suppresses colitis, mucosal damage and cd cell activation in the gut mapping the human platelet lipidome reveals cytosolic phospholipase a as a regulator of mitochondrial bioenergetics during activation the enteropathy of prostaglandin deficiency inherited human cpla , deficiency is associated with impaired eicosanoid biosynthesis, small intestinal ulceration, and platelet dysfunction interfacial kinetic and binding properties of mammalian group ivb phospholipase a (cpla o) and comparison with the other cpla isoforms a novel calcium-independent phospholipase a , cpla ., that is prenylated and contains homology to cpla cloning of a gene for a novel epithelium-specific cytosolic phospholipase a , cpla /, induced in psoriatic skin a calcium-dependent acyltransferase that produces n-acyl phosphatidylethanolamines function, activity, and membrane targeting of cytosolic phospholipase a in mouse lung fibroblasts mammalian patatin domain containing proteins: a family with diverse lipolytic activities involved in multiple biological functions recent progress in phospholipase a research: from cells to animals to humans a novel cytosolic calcium-independent phospholipase a contains eight ankyrin motifs multiple splice variants of the human calcium-independent phospholipase a and their effect on enzyme activity cyclooxygenase- mediated oxidation of -arachidonoyl-lysophospholipids identifies unknown lipid signaling pathways activation of mitochondrial calcium-independent phospholipase a . (ipla .) by divalent cations mediating arachidonate release and production of downstream eicosanoids identification of an insulin-regulated lysophospholipase with homology to neuropathy target esterase evidence that mouse brain neuropathy target esterase is a lysophospholipase genetic ablation of calcium-independent phospholipase a . prevents obesity and insulin resistance during high fat feeding by mitochondrial uncoupling and increased adipocyte fatty acid oxidation loss of function variants in human pnpla encoding calcium-independent phospholipase a . recapitulate the mitochondriopathy of the homologous null mouse loss-offunction mutations in pnpla encoding neuropathy target esterase underlie pubertal failure and neurological deficits in gordon holmes syndrome mutations in pnpla are linked to photoreceptor degeneration and various forms of childhood blindness impairment of park -dependent ca d signalling is a novel determinant of parkinson's disease male mice that do not express group via phospholipase a produce spermatozoa with impaired motility and have greatly reduced fertility fat mobilization in adipose tissue is promoted by adipose triglyceride lipase defective lipolysis and altered energy metabolism in mice lacking adipose triglyceride lipase adipose triglyceride lipase contributes to cancer-associated cachexia the g /g switch gene regulates adipose lipolysis through association with adipose triglyceride lipase atgl-mediated fat catabolism regulates cardiac mitochondrial function via ppar-, and pgc- lipolysis -a highly regulated multienzyme complex mediates the catabolism of cellular fat stores biochemistry and pathophysiology of intravascular and intracellular lipolysis genetic variation in pnpla confers susceptibility to nonalcoholic fatty liver disease chronic overexpression of pnpla i m in mouse liver causes hepatic steatosis a feedforward loop amplifies nutritional regulation of pnpla identification of a novel keratinocyte retinyl ester hydrolase as a transacylase and lipase neutral lipid stores and lipase pnpla contribute to autophagosome biogenesis has a crucial role in skin barrier function by directing acylceramide biosynthesis pnpla is a transacylase essential for the generation of the skin barrier lipid b-o-acylceramide intracellular pafacetylhydrolase type i intracellular plateletactivating factor acetylhydrolase, type ii: a unique cellular phospholipase a that hydrolyzes oxidatively modified phospholipids brain acetylhydrolase that inactivates plateletactivating factor is a g-protein-like trimer targeted disruption of intracellular type i platelet activating factor-acetylhydrolase catalytic subunits causes severe impairment in spermatogenesis protection against oxidative stress-induced hepatic injury by intracellular type ii platelet-activating factor acetylhydrolase by metabolism of oxidized phospholipids in vivo antiinflammatory properties of a platelet-activating factor acetylhydrolase inhibition of lipoprotein-associated phospholipase a reduces complex coronary atherosclerotic plaque development phospholipase a inhibitors in atherosclerosis: the race is on deficiency of phospholipase a group decreases intestinal polyposis and colon tumorigenesis in apc min/d mice lysosomal phospholipase a is selectively expressed in alveolar macrophages lysosomal phospholipase a and phospholipidosis role for lysosomal phospholipase a in inkt cell-mediated cd d recognition lysosomal phospholipase a : a novel player in host immunity to mycobacterium tuberculosis generation of n-acylphosphatidylethanolamine by members of the phospholipase a/acyltransferase adpla ablation increases lipolysis and prevents obesity induced by high-fat feeding or leptin deficiency pla g phospholipase mediates gain-of-function activities of mutant p lrat-specific domain facilitates vitamin a metabolism by domain swapping in hrasls interaction of phospholipase a/ acyltransferase- with pex p: a possible involvement in the down-regulation of peroxisomes represents a switch between entry and clearance of picornaviridae in vivo metabolite profiling as a means to identify uncharacterized lipase function: recent success stories within the alpha beta hydrolase domain (abhd) enzyme family metabolomics annotates abhd as a physiologic regulator of mediumchain phospholipids abhd regulates multiple classes of n-acyl phospholipids in the mammalian central nervous system the serine hydrolase abhd controls the accumulation and efficacy of -ag at cannabinoid receptors the serine hydrolase abhd is a critical regulator of the metabolic syndrome the endocannabinoid -arachidonoylglycerol produced by diacylglycerol lipase , mediates retrograde suppression of synaptic transmission fever is mediated by conversion of endocannabinoid -arachidonoylglycerol to prostaglandin e immunomodulatory lysophosphatidylserines are regulated by abhd a and abhd interplay abhd controls brain lysophosphatidylserine pathways that are deregulated in a murine model of the neurodegenerative disease pharc adipose triglyceride lipase-mediated lipolysis of cellular fat stores is activated by cgi- and defective in chanarin-dorfman syndrome a new era of secreted phospholipase a the roles of the secreted phospholipase a gene family in immunology pancreatic phospholipase a : isolation of the human gene and cdnas from porcine pancreas and human lung cloning and recombinant expression of phospholipase a present in rheumatoid arthritic synovial fluid crystal structure of human group x secreted phospholipase a . electrostatically neutral interfacial surface targets zwitterionic membranes structures of free and inhibited human secretory phospholipase a from inflammatory exudate protection against diet-induced obesity and obesity-related insulin resistance in group b pla -deficient mice group b phospholipase a -mediated lysophospholipid absorption directly contributes to postprandial hyperglycemia the phospholipase a inhibitor methyl indoxam suppresses diet-induced obesity and glucose intolerance in mice group b phospholipase a inactivation suppresses atherosclerosis and metabolic diseases in ldl receptor-deficient mice linkage and potential association of obesity-related phenotypes with two genes on chromosome q in a female dizygous twin cohort phospholipase a -a mediator between proximal and distal effectors of inflammation a natural disruption of the secretory group ii phospholipase a gene in inbred mouse strains the secretory phospholipase a gene is a candidate for the mom locus, a major modifier of apc min -induced intestinal neoplasia mobilization of potent plasma bactericidal activity during systemic bacterial challenge. role of group iia phospholipase a staphylococcus aureus adenosine inhibits spla -iia-mediated host killing in the airways platelets release mitochondria serving as substrate for bactericidal group iia-secreted phospholipase a to promote inflammation dual roles of group iid phospholipase a in inflammation and cancer critical role of phospholipase a group iid in age-related susceptibility to severe acute respiratory syndrome-cov infection expression and function of group iie phospholipase a in mouse skin the adipocyte-inducible secreted phospholipases pla g and pla g e play distinct roles in obesity on the diversity of secreted phospholipases a . cloning, tissue distribution, and functional expression of two novel mouse group ii enzymes the functions of five distinct mammalian phospholipase a s in regulating arachidonic acid release. type iia and type v secretory phospholipase a s are functionally redundant and act in concert with cytosolic phospholipase a regulation of delayed prostaglandin production in activated p d macrophages by group iv cytosolic and group v secretory phospholipase a s transgenic expression of group v, but not group x, secreted phospholipase a in mice leads to neonatal lethality because of lung dysfunction group v secretory phospholipase a is involved in macrophage activation and is sufficient for macrophage effector functions in allergic pulmonary inflammation group v secretory phospholipase a modulates phagosome maturation and regulates the innate immune response against candida albicans a novel anti-inflammatory role for secretory phospholipase a in immune complexmediated arthritis group v phospholipase a in bone marrowderived myeloid cells and bronchial epithelial cells promotes bacterial clearance after escherichia coli pneumonia group x secreted phospholipase a proenzyme is matured by a furin-like proprotein convertase and releases arachidonic acid inside of human hek cells group x phospholipase a is released during sperm acrosome reaction and controls fertility outcome in mice importance of group x-secreted phospholipase a in allergen-induced airway inflammation and remodeling in a mouse asthma model key role of group v secreted phospholipase a in th cytokine and dendritic celldriven airway hyperresponsiveness and remodeling lack of group x secreted phospholipase a increases survival following pandemic h n influenza infection novel human secreted phospholipase a with homology to the group iii bee venom enzyme cellular arachidonate-releasing function of novel classes of secretory phospholipase a s (groups iii and xii) group iii secreted phospholipase a regulates epididymal sperm maturation and fertility in mice mast cell maturation is driven via a group cloning and recombinant expression of a structurally novel human secreted phospholipase a novel mammalian group xii secreted phospholipase a lacking enzymatic activity hepatocyte nuclear factor- , regulates liver triglyceride metabolism in part through secreted phospholipase a gxiib biochemistry and physiology of mammalian secreted phospholipases a deficiency of phospholipase a receptor exacerbates ovalbumin-induced lung inflammation circulating levels of secretory type ii phospholipase a predict coronary events in patients with coronary artery disease thrombospondin type- domain-containing a in idiopathic membranous nephropathy efficient phagocytosis requires triacylglycerol hydrolysis by adipose triglyceride lipase desnutrin/ atgl activates ppar/ to promote mitochondrial function for insulin secretion in islet o cells patatin-like phospholipase domain-containing protein is involved in hepatic fatty acid and triglyceride metabolism through x-box binding protein and modulation of endoplasmic reticulum stress in mice patatin-like phospholipase domain-containing / adiponutrin deficiency in mice is not associated with fatty liver disease brainspecific deletion of neuropathy target esterase/ swisscheese results in neurodegeneration group vib calcium-independent phospholipase a (ipla .) regulates platelet activation, hemostasis and thrombosis in mice mitochondrial dysfunction and reduced prostaglandin synthesis in skeletal muscle of group vib ca d -independent phospholipase a .-deficient mice mice deficient in group vib phospholipase a (ipla .) exhibit relative resistance to obesity and metabolic abnormalities induced by a western diet genetic ablation of calcium-independent phospholipase a . leads to alterations in hippocampal cardiolipin content and molecular species distribution, mitochondrial degeneration, autophagy, and cognitive dysfunction genetic ablation of calcium-independent phospholipase a . leads to alterations in mitochondrial lipid metabolism and function resulting in a deficient mitochondrial bioenergetic phenotype smooth muscle cell arachidonic acid release, migration, and proliferation are markedly attenuated in mice null for calcium-independent phospholipase a o age-related changes in bone morphology are accelerated in group via phospholipase a (ipla o)-null mice neuroaxonal dystrophy caused by group via phospholipase a deficiency in mice: a model of human neurodegenerative disease group via phospholipase a in both host and tumor cells is involved in ovarian cancer development platelet-activating factor and metastasis: calciumindependent phospholipase a o deficiency protects against breast cancer metastasis to the lung loss of pafah b reduces amyloid-o generation by promoting the degradation of amyloid precursor protein c-terminal fragments paf-ah catalytic subunits modulate the wnt pathway in developing gabaergic neurons increase of smooth muscle cell migration and of intimal hyperplasia in mice lacking the ,/o hydrolase domain containing gene age-related pulmonary emphysema in mice lacking ,/o hydrolase domain containing gene skin barrier development depends on cgi- protein expression during late-stage keratinocyte differentiation growth retardation, impaired triacylglycerol catabolism, hepatic steatosis, and lethal skin barrier defect in mice lacking comparative gene identification- (cgi- ) /o-hydrolase domain deletion induces adipose browning and prevents obesity and type diabetes platelet microparticles are internalized in neutrophils via the concerted activity of -lipoxygenase and secreted phospholipase a -iia secreted phospholipases a are intestinal stem cell niche factors with distinct roles in homeostasis, inflammation, and cancer secretory group v phospholipase a regulates acute lung injury and neutrophilic inflammation caused by lps in mice group v secretory phospholipase a promotes atherosclerosis: evidence from genetically altered mice group v secretory phospholipase a plays a pathogenic role in myocardial ischaemia-reperfusion injury group v secretory phospholipase a enhances the progression of angiotensin ii-induced abdominal aortic aneurysms but confers protection against angiotensin ii-induced cardiac fibrosis in apoe-deficient mice group x secretory phospholipase a regulates insulin secretion through a cyclooxygenase- -dependent mechanism group x secretory phospholipase a enhances tlr signaling in macrophages group x secreted phospholipase a limits the development of atherosclerosis in ldl receptor-null mice group x secretory phospholipase a augments angiotensin ii-induced inflammatory responses and abdominal aortic aneurysm formation in apoe-deficient mice group x secretory pla in neutrophils plays a pathogenic role in abdominal aortic aneurysms in mice mutations cause autosomal recessive congenital ichthyosis in golden retriever dogs and humans the gene encoding adipose triglyceride lipase (pnpla ) is mutated in neutral lipid storage disease with myopathy neuropathy target esterase gene mutations cause motor neuron disease genetic associations of nonsynonymous exonic variants with psychophysiological endophenotypes genome-wide association study identifies variants at p and q associated with development of cutaneous nevi lipoprotein-associated phospholipase a adds to risk prediction of incident coronary events by c-reactive protein in apparently healthy middle-aged men from the general population: results from the -year follow-up of a large cohort from southern germany tagging-snp haplotype analysis of the secretory pla iia gene pla g a shows strong association with serum levels of spla iia: results from the udacs study phospholipase a group iia expression in gastric adenocarcinoma is associated with prolonged survival and less frequent metastasis a novel polymorphism in secretory phospholipase a -iid is associated with body weight loss in chronic obstructive pulmonary disease phospholipase a group iii and group x have opposing associations with prognosis in colorectal cancer a gene involved in oxidative stress induced death, is associated with alzheimer's disease tagging snp haplotype analysis of the secretory pla -v gene, pla g , shows strong association with ldl and oxldl levels, suggesting functional distinction from spla -iia: results from the udacs study biallelic mutations in pla g , encoding group v phospholipase a , cause benign fleck retina key: cord- -wznzmssz authors: iannitti, t.; palmieri, b. title: therapeutical use of probiotic formulations in clinical practice date: - - journal: clin nutr doi: . /j.clnu. . . sha: doc_id: cord_uid: wznzmssz background & aims: the spreading of gastrointestinal diseases is growing all over the world. although for some of them an effective therapeutic approach has been found, palliation rather than cure is very frequent due to a partial knowledge of their aethiology and pathogenesis. this review, analyzing the main clinical studies, aims at being a state of the art update of the use of probiotic formulations in daily practice. methods: in this review we include all the most significant clinical trials involving the use of probiotic formulations for the treatment of several pathologies. results: dysbiosis has been observed in irritable bowel syndrome patients. probiotics may exert a beneficial effect on crohn’s disease affected patients who have shown gut microbiota antigens and altered wall permeability. moreover some probiotic formulations seem to enhance the therapy for helycobacter pylori reducing its pathogenic potential. intestinal ecology imbalance has been also linked to cancer induction, allergy, skin and urogenital diseases. in addition probiotics administration seems to be particularly useful to ease post-operative complications. conclusion: further future clinical trials, involving large numbers of patients, will be mandatory to achieve definite evidence of the preventive and curative role of probiotics in medical practice. the gastrointestinal (gi) tract starts from the mouth, involves the oesophagus, the stomach, the small and large intestine and ends at the anus (fig. ) . the gi tract has four main functions: ingestion, digestion, absorption, and defecation. in a normal human adult male, the gi tract is approximately . m long and can be divided into the upper tract which is made up of mouth, pharynx, oesophagus and stomach and the lower tract which is made up of the small intestine (duodenum, jejunum and ileum), the large intestine (cecum, colon and rectum) and anus. aerobic and anaerobic bacteria, yeast and fungi live into the gi tract which has more than m of surface area. all these organisms in a healthy intestinal tract live in a natural balance called symbiosis. there are more than species of commensal bacterial organisms within our bodies, the vast majority in the gut. in fact the mammalian gut is considered one of the most densely populated ecosystems on earth with a bacterial load in the region of organisms/g of fecal material in the large intestine. the several species of microorganisms in the adult human gut are known as the microbiota which may contain nearly times the number of genes contained within the human genome. the genome of these collective organisms is called the microbiome. the longitudinal distribution of intestinal microorganisms increases in density progressing from the small bowel to colon (fig. ) . anaerobic bacteria benefit the host by performing metabolic functions including fermentation, providing short-chain fatty acids (scfas), producing vitamins, adding to the trophic action of the epithelium and aiding in the development of the immune system. the stomach harbours only very few bacteria (mainly acidtolerant lactobacilli) because of the acidity due to the gastric juice. in the colon there are about a million times more bacteria than in the stomach due to a higher exposure to nutrients, slow transit, and low-redox potential. about % of feces are made up of bacteria. while new bacteria are produced, the old ones are flushed out of the intestine and they will be finally present in the feces. the different strains of bacteria living in the gi tract are summarized in table . the normal flora which colonizes the gi tract exert several functions: ) synthesizing and excreting vitamins in excess of their own needs, which can be absorbed as nutrients by their hosts (enteric bacteria secrete vitamin k and vitamin b , and lactic acid bacteria produce certain b-vitamins); ) preventing the pathogens colonization by competing for attachment sites or essential nutrients; ) being likely to produce substances which inhibit or kill non indigenous species; ) stimulating the development of certain tissues, i.e., the caecum and certain lymphatic tissues (peyer's patches) in the gi tract; ) stimulating the production of natural antibodies; ) producing a variety of substances ranging from relatively non-specific fatty acids and peroxides to highly specific bacteriocins which inhibit or kill other bacteria. , gut microbiota are also known to influence energy balance and in turn, emerging evidence demonstrates the importance of gut microbiota in the pathophysiology of obesity. the initial acquisition of intestinal microbiota plays a key role in the development of immune processes and protection against pathogens. the human fetus is sterile in utero and microbes colonize it during its passage through the birth canal. the host genotype is important in determining the populations of intestinal organisms which, after birth, are influenced by the baby exposure to numerous bacteria from the environment (e.g., skin, mouth, mother's milk). this initial microbiota is relatively unstable and changes during the initial period of life. reinhardt et al. report that infants are initially colonized by facultative anaerobes such as enterobacteria and gram-positive cocci, which are thought to create a reduced environment favorable for the establishment of obligate anaerobes, including bacteroides, bifidobacterium, and clostridium. tennison et al. report that the type of birth delivery has a significant impact on the development of the gut microbiota in fact vaginal delivery allows infant exposure to maternal bacteria, i.e. the longer the birth process is the greater exposure you have, while infants born by cesarean delivery acquire bacteria by exposure to the mother as well as isolates transferred by nursing staff, other infants, air and equipment. following birth, oral and cutaneous bacteria from the mother will be mechanically transferred to the infant by suckling, kissing and caressing. moreover the authors observed that breast feeding exposes the infant to bacteria, especially bifidobacteria, from milk ducts, nipple, and surrounding skin. breast milk contains antimicrobial components and growth factors that stimulate the development and maturation of the intestinal mucosa. the fig. . picture reported from "dibaise et al. gut microbiota and its possible relationship with obesity". key physiologic and microbiological features of the gut, relative concentrations of bacteria and the ph at various locations within the adult gut are shown (cfu ¼ colony-forming unit). table gi flora components. oral cavity (saliva) authors conclude that the development of infantile intestinal microbiota involves the initial vaginal exposure, transmission during neonatal care, subsequent breast feeding and finally, after the introduction of solid food, the bacterial profiles of breast and formula fed infants become similar to that of adults by the e years of life (conversion to adult microbiota). the gi tract bacteria are all essential for its normal physiology but they are also potentially pathogenic. dysbiosis occurs when the gi bacterial microflora ecology equilibrium is altered leading to an imbalance that can involve metabolic or immunologic feedback of the host. round et al. describe a healthy microbiota as a balanced composition of many classes of bacteria such as symbionts (organisms with known health promoting functions), commensals (permanent residents which provide no benefit or detriment to the host) and pathobionts (permanent residents of the microbiota with the potential to induce pathology). the authors underline that, in conditions of dysbiosis, there is an unnatural shift in the composition of the microbiota, which results in either a reduction in the numbers of symbionts and/or an increase in the numbers of pathobionts (fig. ). this condition can lead to mild subjective discomfort and even disease condition (e.g., dysbiosis can lead to non-specific inflammation which may predispose certain genetically susceptible people to inflammatory disease). the good balance of gi tract microflora is responsible for a lot of functions within the body such as vitamin production, hormonal activities, immunity and detoxification processes. in case of bacterial imbalance a release of toxic metabolic products is induced, followed by flatulence, bloating, intestinal pain and inflammation, cramping and constipation and/or diarrhea. it is important that a correct dysbiosis diagnosis is made because the only treatment of the symptoms will not lead to the solving of the real problem and will bring the patient to develop other diseases. in fact, intestinal dysbiosis should be considered as a possible cause, or a contributing factor in patients who have asthma, bronchitis, allergies, autoimmune disorders, breast and colon cancer, unexplained fatigue or neuropsychiatric symptoms. systemic effects such as halitosis, adrenal stress, diarrhea, candida, leaky gut syndrome, colon cancer and breast cancer can be considered a consequence of dysbiosis. possible factors which can contribute to dysbiosis are: host genetics, lifestyle, exposure to microorganisms and medical practices, diet and stress. birth in the sterile environment of hospitals can protect from exposure to dangerous pathogens, but can also prevent early exposure to health promoting bacteria. overuse of vaccination and antibiotics, which do not distinguish between pathogenic or symbiotic microorganisms, could adversely alter the microbiota. many chronic and degenerative diseases such as irritable bowel syndrome (ibs), inflammatory bowel disease (ibd), rheumatoid arthritis, and ankylosing spondylitis are considered today to be linked to abnormalities in the bacteria microflora ecology (fig. ). the term probiotic derives from the greek/latin word "pro" and the greek word "bios", meaning for life. the concept of probiotic was probably firstly introduced by the russian nobel laureate elie metchnikoff in ("the prolongation of life: optimistic studies") where he proposed the idea that ingesting microbes could have beneficial effects for human beings, especially to treat digestive diseases". the term "probiotic" was firstly used in , by lilly and stillwell, to describe substances secreted by one organism which stimulates the growth of another. the world health organization (who) and the food and agriculture organization of the united nations have defined probiotics as "live microorganisms, which, when administered in adequate amounts, confer a health benefit on the host." probiotics consist of bacteria or yeasts and can be considered functional foods that can re-colonize and restore the microflora symbiosis of the intestinal tract. most probiotics are bacteria similar to those naturally found in people's guts, especially in those of breastfed infants because they are known to have natural protection against many diseases. most often, the bacteria come from two groups, lactobacillus or bifidobacterium. each group involves different species (lactobacillus acidophilus, bifidobacterium bifidus etc.) which include different strains. some common probiotics, such as saccharomyces boulardii, are yeasts. some examples of bacteria used in probiotics formulations are lactobacillus acidophilus, lactobacillus rhamnosus, lactobacillus bulgaricus, lactobacillus salivarius, lactobacillus plantarum, lactobacillus casei, lactobacillus sporogenes, bifidobacterium bifidum, bifidobacteria longum, bifidobacteria infantis, streptococcus thermophilus and homeostatic soil organisms (hso's). a good probiotic must possess the following requirements: ) being able to adhere to cells; ) excluding or reducing pathogenic adherence; ) being able to persist, multiply and produce acids, hydrogen peroxide and bacteriocins antagonistic to pathogen growth; ) being able to be safe, noninvasive, noncarcinogenic and non-pathogenic; ) being able to coaggregate as to form a normal balanced flora. for an adequate amount of health benefits, a dose of billion colonyforming unit (cfu) has been recommended for at least days (  cfu/day). probiotics are available in food and dietary supplements (for example, capsules, tablets and powders) and in some other forms as well. in probiotic foods and supplements, the bacteria may have been present originally or added during preparation. probiotics must survive gastric and bile acids in order to reach the intestinal tract, colonize the host epithelium, and exhibit a beneficial effect. most conventional forms of lactobacilli-type probiotics are nonspore forming and, therefore, are inactivated by bile and low gastric ph. in addition, probiotics selected for commercial use must survive industrial manufacturing and storage to ensure long-term viability and activity. most cells of conventional lactobacilli die at c, while spore-bearing lactic acid-forming bacteria do not show a decrease in viable cells even after heating in saline at c for min. therefore the survival of the gut microbiota shapes intestinal immune responses during health and disease. probiotics through the gi tract is strongly affected by stomach acidity, the length of exposure to acid, the concentration of and length of exposure to bile salts and the level of bile salt hydrolase activity. probiotics must not be confused with prebiotics, nondigestible food ingredients that selectively stimulate the growth and/or activity of beneficial microorganisms already present in people's colons. the term prebiotic was first introduced by gibson and roberfroid in and is defined as "a nondigestible food ingredient that beneficially affects the host by selectively stimulating the growth and/or activity of one or a limited number of bacteria in the colon, and thus improves host health". when probiotics and prebiotics are mixed together, they form a synbiotic. a synbiotic is a supplement that contains both a prebiotic and a probiotic that work together to keep healthy the bacterial microflora of the human intestine. fermented milks (yogurt and kefir) are considered to be true synbiotic products, that is, functional foods, since they contribute to restore the normal bacterial microflora also supplying the food it needs to survive. however not all these products promote symbiosis. the best synbiotic combinations currently available include bifidobacteria and fructooligosaccharides (fos), lactobacillus gg and inulins, and bifidobacteria and lactobacilli with fos or inulins. fos are extracted from fruits and vegetables like bananas, onions, chicory root, garlic, asparagus, barley, wheat, jícama, tomatoes, onion rye, garlic and leeks. the jerusalem artichoke and its relative, yacón have been found to have the highest concentrations of fos. fos are a group of linear fructose oligomers (oligosaccharides), able to escape digestion in the human upper intestine and reach the colon where they are totally fermented mostly to lactate, scfas (acetate, propionate and butyrate), and gas, like dietary fibres. as a consequence of their fermentation, their caloric value is approximately kcal/g. a fecal bulking effect of fos has been observed in humans. an important property of sc-fos is the stimulation of bifidobacterial growth (fos chemical structure is made up of b- - -fructose-fructose which is recognized by the enzyme b-fructosidase which is typical of bifidobacteria that can easily metabolize it; the most of pathogens and putrefactive bacteria are not able to break fos chemical bond making very selective the utilization of these oligosaccharides) specifically while suppressing the growth of potentially harmful species such as clostridium perfringens in the colon. the prebiotic effect of sc-fos is dose dependent and chain length related and is associated with a decrease in fecal ph, an increase in fecal or colonic organic acids, a decrease in the production of nitrogenous end products in urine and stools, a decrease in fecal bacterial enzymatic activities and a modification in fecal neutral sterols. the sc-fos enhance magnesium absorption in humans and have been shown, in animal models, to reduce colon tumour development by enhancing both colon butyrate concentrations and local immune system effectors. buddington et al. studied the effects of dietary fos in healthy adult human subjects fed on a controlled diet for days ( g neosugar/d between days and ). fos caused b-glucoronidase and glycocholic acid hydrolase activities to decrease % and % respectively. the authors found that g neosugar/d alters the fecal flora in a beneficial way decreasing the activities of some reductive enzymes. williams et al. determined changes in the abundance of selected bacteria in anaerobic fecal samples from adult human volunteers who consumed g neosugar (mixture of sc-fos by nutrilite products inc.) daily for two weeks. the presence of fos in the diet acts on the increasing of the growth of the host's existing microbiota encouraging the proliferation of beneficial bacteria groups such as lactobacilli and bifidobacteria. bornet et al. report that in vitro and in vivo studies (in animals and humans) demonstrated that fos are good substrates for the bifidobacteria spp possessing b-fructoisidases and for bacteroides spp and that they are bad substrates for e. coli and c. perfrigens. fos feeding is also related to an increase of bifidobacteria and lactobacilli and to a decrease of c. perfrigens. bifidobacteria are responsible for acetic acid and lactic acid production which reduces the intestinal ph. this ph reduction restricts or prohibits the growth of many potential pathogens and putrefactive bacteria with a reduction of enzyme activities in stools (nitroreductase, decarboxylase etc.) with a deep impact on the metabolism of carcinogenic substances such as n-nitroso compounds, phenolic products of tyrosine and tryptophan and metabolites of biliary steroids. in conclusion fos are able to act on bifidobacteria and could be a protective factor against colon cancer. hidaka et al. performed several clinical studies based on the administration of fos and conclude that these compounds are responsible for cholesterol reduction (reduction in ldl cholesterol contents), suppression of putrefaction, normalization of colon microbial disorders and alleviation of constipation. the authors underline that their usefulness seems to be strictly related to the proliferation of bifidobacteria, to other saccahrolytic intestinal bacteria and scfas produced by these organisms as well. hidaka et al. performed some clinical studies using neosugar g (prepared from sucrose through the action of the enzyme b-fructofuranosidase produced by aspergillus niger), neosugar (a mixture of fos purified from neosugar g by removing the monosaccharides) and disaccharides through a resin treatment. applied foods containing neosugar such as jellies and drinks were also prepared for the clinical studies. the clinical studies showed that fos administration improved blood lipids in hyperlipidemia, suppressed the production of intestinal putrefactive substances and improved the intestinal flora with relief from constipation. aumenta et al. report that nondigestible oligosaccharides (ndos) have been found to stimulate absorption of several minerals and improve mineralization of bone. most of the scientific evidence for the functional effects of ndos is based on animal experiments in which ndos increase the availability of calcium, magnesium, zinc, and iron. this stimulatory effect of some ndos is assumed to be mainly due to their prebiotic character. prebiotics such as inulin, oligofructose, glucooligosaccharide, and galacto-oligosaccharide have been found to stimulate absorption and retention of several minerals, particularly magnesium, calcium, and iron. most of these findings were obtained in studies performed on rats. up to now the number of studies on the effect of ndos on mineral metabolism in humans is limited; positive effects on calcium absorption seem to occur under conditions of increased calcium requirements (adolescence and postmenopause) figs. e . the word probiotics refers to microorganisms that are able to confer health benefits on humans and that have been industrially prepared for nutritional and pharmaceutical use. the consumption of these products is growing very fast all over the world and probiotics are generally considered generally regarded as safe (gras). indu et al. suggest that probiotics are responsible for competitive exclusion of enteric pathogens from the gut lumen. the putative inhibitory mechanism should be the production of lactic acid and bacteriocins. moreover they restore the normal intestinal flora during an antibiotic therapy, trigger cytokines synthesis from enterocytes attaching to their surfaces, produce toxic metabolites like hydrogen peroxide and synthesize butyric acid which increases the turnover of enterocytes and neutralizes dietary carcinogens. probiotics exert several immunomodulatory functions acting on cellular and humoral responses. furthermore they can stimulate type helper t cells (l. casei), mononuclear cells leading to increased clearance of circulating pathogenic bacteria (l. acidophilus), macrophages to produce tnf-alpha, il- and no production, increase clearance of circulating pathogenic bacteria by kupffer cells and they can produce antirotaviral iga and antinfluenza igg antibodies (b. breve). snydman reports three theoretical concerns regarding the safety of probiotics: firstly the occurrence of disease, due to bacteremia, sepsis or endocarditis, secondly the toxic or metabolic effects on the gi tract and thirdly the transfer of antibiotic resistance in the gi flora. the author underlines that, although there are rare cases of bacteremia or fungemia related to the use of saprophytic probiotics, epidemiologic evidence through clinical trials and epidemiologic survey suggests that they can be safely used. wassenaar et al. highlight that bacteria used for probiotics formulation should be completely safe although there could be some flaws: ) sometimes virulence factors have been detected in probiotic bacterial strains; ) horizontal gene transfer can result in acquisition of virulence genes or antimicrobial resistance in probiotic bacteria; ) antimicrobial resistance in these bacteria can possibly aid the spread of unwanted resistance in endogenous bacterial populations. liong et al. observe that some bacteria strains, commonly used in probiotic formulations, such as lactobacillus, leuconostoc, pediococcus, enterococcus, and bifidobacterium have been isolated from infection sites, leading to the problem that these probiotics can translocate. the authors underlined that probiotics translocation hardly occurs in healthy humans (where it happens, detrimental effects are rare) but health-damaging effects of probiotics translocation can occur in immunocompromised patients. in these people probiotics might theoretically cause infections that need to be treated with antibiotics but, unfortunately, the antibiotic resistance of some strains has increased the complexity of their eradication. surely further investigations are required to analyze the mechanisms of probiotic translocation and infection. safety assessments should be focused on these mechanisms so that the negative effects of probiotics do not outweigh the benefits. lammers et al. studied mucosal gene expression of the pleiotropic proinflammatory cytokines (interleukin(il)- beta, il- ), th cytokines (interferon-gamma (ifn-gamma), tnf-alpha, il- ), regulatory cytokines (il- , transforming growth factor-beta), and the chemokine il- . in addition to assess the cytokines gene expression, the presence of polymorphonuclear cells in the mucosal tissue was evaluated. patients who were treated with probiotics had significant lower mucosal mrna expression levels of il- beta, il- , and ifn-gamma compared with placebo-treated patients. a lower number of polymorphonuclear cells was present in the tissue of patients within the probiotic group compared with the number of polymorphonuclear cells in the tissue of patients receiving placebo and patients having an episode of pouchitis. this study highlights that probiotic treatment is able to regulate the mucosal immune response reducing mucosal levels of neutrophilchemoattractant il- and tissue influx of polymorphonuclear cells, and may further act by inhibit t cells activation, reinforce the barrier function and keep a tight control of the potent proinflammatory cytokine il- beta. a randomized double-blind study was designed by marchan et al. probiotic bacteria or placebo were administered for month before delivery to mothers and for months to infants with a family history of allergy. plasma samples were analyzed for c-reactive protein (crp), total iga and ige, foodspecific iga, igg, and ige, il- , il- , il- , il- , tnf-alpha, and ifngamma. the association of crp with a decreased risk of eczema at years of age in allergy-prone children supports the idea that chronic, low-grade inflammation protects from eczema. low-grade inflammation induced by probiotics was characterized by elevation of ige, iga, and il- , a change typically observed in helminth infection associated induction of regulatory mechanisms. this study emphasizes the role of chronic microbial exposure as an immune modulator protecting from allergy. stadbauer et al. in an open-label study involving patients with alcoholic cirrhosis (lactobacillus casei shirota (lcs) ( .  ) times daily for weeks), healthy controls and cirrhotic patients who did not receive probiotics, report that probiotics restore neutrophil phagocytic capacity in cirrhosis, possibly by changing il- secretion and tlr expression, warranting larger randomized controlled and mechanistic studies. kekkonen et al. evaluated the effect of stimulation provided by several probiotic bacterial strains (streptococcus, lactobacillus, bifidobacterium, lactococcus, leuconostoc and propionibacterium) on cytokines production in human peripheral blood mononuclear cells (pbmc). the probiotic s. thermophilus and leuconostoc strains were shown to be more potent inducers of th type cytokines il- and ifn-gamma than the probiotic lactobacillus strains and the use of bacterial combinations did not result in enhanced cytokine production. the first study to investigate the effects of probiotics intervention on global lipidomic profiles in humans was designed by kekkonen et al. the study investigated the effect of three weeks' intervention with lactobacillus rhamnosus on global serum lipidomic profiles and evaluated whether the changes in inflammatory variables (crp, tnf-alpha and il- ) are reflected in the global lipidomic profiles of healthy adults. the authors observed that probiotic lactobacillus rhamnosus intervention may lead to changes in serum global lipid profiles, as reflected in decreased glycerophosphatidylcholines (gpcho), lysophosphatidylcholines (lysogpcho) and sphingomyelins (sm) and in the increasing of triacylglycerols (tags). among the inflammatory variables, il- was moderately associated with changes in global lipidomic profiles, with the top-ranked lipid associated with il- which is the proinflammatory lysogpcho ( : ). there was a weak association between the lipidomic profiles and the two other inflammatory markers, tnf-alpha and crp . takeda et al. in a placebo-controlled crossover trial, observed the effect of lcs on natural killer (nk) cell activity in humans. nk cell activity exhibited a declining trend during the period of placebo ingestion, but nk cell activity increased after intaking fermented milk containing  live lcs for weeks. when human pbmc were cultured in the presence of heat-killed lcs, nk cell activity was enhanced. the ability of lcs to enhance nk cell activity and induce il- production was correlated, and the addition of anti-il- monoclonal antibody reduced the enhancement of nk cell activity triggered by lcs. in addition, the separation of nk cells from lcsstimulated monocytes with membrane filter reduced nk cell activity to the intermediate level and almost deprived monocytes of the ability to produce il- . the authors demonstrated that lcs can enhance nk cell activity in vivo and in vitro in humans, and il- may be responsible for enhancement of nk cell activity triggered by lcs. changes in the composition of the gut microbiota have been implicated in the pathogenesis of allergic disorders suggesting beneficial interactions between the intestinal immune system and specific bacterial strains. ivory et al. designed a double-blinded, placebo-controlled study with seasonal allergic rhinitis (sar) sufferers in each group. the authors observed that volunteers, treated with lcs, showed a significant reduction in levels of antigen-induced il- , il- and ifn-gamma production compared with volunteers supplemented with placebo. meanwhile, levels of specific igg increased and the ige ones decreased in the probiotic group. so changes in antigen-induced production of cytokines were observed in patients treated with probiotics showing that probiotic supplementation modulates immune responses in sar and may have the potential to alleviate the severity of symptoms. twetman et al. randomly assigned forty-two healthy adults with moderate levels of gingival inflammation to one of three parallel arms: group a/p was given one active and one placebo gum daily, group a/a received two active chewing gums, and group p/p two placebo gums. the chewing gums contained two strains of lactobacillus reuteri: atcc and atcc pta (  cfu/ gum, respectively). the authors observed a reduction of proinflammatory cytokines (the levels of tnf-alpha and il- decreased significantly (p < . ) in group a/a compared with baseline after and weeks, respectively) in gingival crevicular fluid that points out that the probiotic approach can fight inflammation in the oral cavity. the skin is able to act as a physical barrier exerting several functions such as fluid homeostasis, thermoregulation, immunologic functions, neurosensory functions, metabolic functions and primary protection against infection. in case of thermal injury the burn can be colonized by several types of pathogens, i.e. primarily gram-positive bacteria such as methicillin-resistant staphylococcus aureus (mrsa), gram-negative bacteria such as acinetobacter baumanniiecalcoaceticus complex, pseudomonas aeruginosa, klebsiella species and fungal pathogens. the prevention of infection include early burn-eschar excision, topical and prophylactic antibiotics, and aggressive infection-control measures. the antimicrobial resistance of bacteria isolated from patients with burns has increased and bacterial colonization and infection remain the major causes of delayed healing and graft rejection following burns. topical treatment is necessary to reduce the incidence of burn wound infection. the ability of the probiotic organism lactobacillus plantarum to inhibit the pathogenic activity of pseudomonas aeruginosa, both in vitro and in vivo, was tested by valdéz et al. in vitro (lactobacillus plantarum whole cultures, culture filtrates acid filtrate and neutralised acid filtrate) and isolated, washed cells were tested for their effects on the production of the p. aeruginosa quorumsensing signal molecules, acyl-homoserine-lactones (ahls), and two virulence factors controlled by signal molecules such as elastase and biofilm. all were inhibited by l. plantarum cultures and filtrates, but not by isolated, washed cells. the acid l. plantarum growth medium itself had some inhibitory activity but the greatest activity was exerted by the whole culture. in vivo (a burned-mouse model was used) burns infected with p. aeruginosa were treated with l. plantarum at , , , and days post-infection. samples from skin, liver and spleen taken after , and days demonstrated that l. plantarum had inhibited p. aeruginosa colonization. there was also an improvement in tissue repair, enhanced phagocytosis of p. aeruginosa produced by tissue phagocytes and a decrease in apoptosis at days. the authors conclude that l. plantarum and/or its by-products are potential therapeutic agents for the local treatment of p. aeruginosa burn infections. peral et al. cultured l. plantarum in de man, rogosa and sharpe medium to provide an alternative method for burn treatment using silver sulphadiazine (sd-ag, a microbicidal agent) as a control. eighty burned patients from the plastic surgery and burns unit were grouped into infected (delayed) second-and third-degree and non infected (early) third-degree burns and treated with l. plantarum or sd-ag. the proportion of patients with delayed second-degree burns was . for l. plantarum and . for sd-ag (relative rate: À . %) in comparison with the decrease in bacterial load (< bacteria/g of tissue), promotion of granulating tissue wound bed and healing. in early third-degree burns, the values were . for l. plantarum and . for sd-ag (relative rate: À . %) in preventing wound infection and promotion of granulation tissue, . in graft taking for both treatments (relative rate: %) and . for l. plantarum and . for sd-ag (relative rate: À . %) in healing. in delayed third-degree burns, values were . for l. plantarum and . for sd-ag (relative rate: þ . %) compared to the decrease in the bacterial load (< bacteria/g of tissue) and providing a granulating tissue wound bed, . in graft taking for both treatments (relative rate: %) and . for l. plantarum and . for sd-ag (relative rate: þ . %) in healing. this study suggests that the l. plantarum treatment could be a valid therapy for the topical treatment of burns. probiotic formulations have been widely studied for the treatment of atopic dermatitis (ad; a type of eczema), a pathology defined as an inflammatory, chronically relapsing, non-contagious and pruritic skin disease which is associated with elevated ige levels and th responses. ad in animal models and human studies has been investigated using different probiotic different strains such as bifidobacterium, lactobacillus, and lactococcus. in several animal studies involving the use of probiotics it was observed suppression of specific or non-specific ige production, reduction of infiltrated eosinophils and degranulated mast cells, potentiation of regulatory t cell cytokines such as il- and tgf-beta relative to il- and il- and potentiation of th /th activity along with reduced symptoms of ad. several well-designed double-blind placebocontrolled human studies showed that some probiotic strains administered during perinatal period prevented the occurrence of ad but they cannot consistently show a reduction in specific or non-specific ige or a change in specific immunomodulatory cytokines. the administration of selected strains of probiotics during the perinatal period may be helpful in the prevention of ad. gueniche et al. designed a prospective, double-blind, placebocontrolled clinical study with a cream containing a % lysate of the non-pathogenic bacteria vitreoscilla filiformis. seventy-five volunteers with ad ( e years of age) were randomized to receive either v. filiformis cream % or vehicle cream daily for days. the therapy efficacy was evaluated by the following parameters: score of atopic dermatitis (scorad), transepidermal water loss (tewl), assessment of microflora and the patient's assessment of itch and loss of sleep. v. filiformis lysate significantly decreased scorad levels (p ¼ . ) and pruritus (p ¼ . ). active cream significantly decreased loss of sleep from day to day (p ¼ . ). v. filiformis lysate reduced staphylococcus aureus colonization of the skin. the skin barrier as determined by tewl also improved significantly with the cream alone. v. filiformis lysate significantly improved ad. this may be in part due to a reduction of s. aureus, but it seems to concern in most parts a direct immunomodulatory effect on skin-associated immune responses. zuccotti et al. analyzed the possible causes related to the increase of diagnosis of allergy related diseases in the last few years. they have noticed firstly a reduced microbial stimulation during infancy and early childhood which results in slower postnatal maturation of the immune system and development of an optimal balance between th and th -like immunity (the hygiene hypothesis) and secondly an altered microflora that promotes the persistence of those th cytokines (il- , il- , il- ) which are predominant at birth and prevent the shift toward a th response with il- and ifn-gamma production. now we are going to report some of the several studies involving the use of probiotic formulations to evaluate their efficacy for the treatment of allergic diseases basing on their ability to change either the composition and/or the metabolic activities of the microbiota or modulate immune system reactivity in a way that benefits health. wickens et al. designed a double-blind, randomized placebocontrolled study in which pregnant women were randomized to take lactobacillus rhamnosus hn (l. rhamnosus), bifidobacterium animalis subsp. lactis strain hn or placebo daily from weeks gestation until months if breast-feeding, and their infants were randomized to receive the same treatment from birth to years (n ¼ ). the infants' cumulative prevalence of eczema and point prevalence of atopy, using skin prick tests to common allergens, was assessed at years. infants receiving l. rhamnosus had a significantly (p ¼ . ) reduced risk of eczema (hazard ratio (hr), . ; % ci, . e . ) compared with placebo, but this was not the case for b animalis subsp lactis (hr, . ; % ci, . e . ). there was no significant effect of l. rhamnosus (hr, . ; % ci, . e . ) or b animalis subsp lactis (hr, . ; % ci, . e . ) on atopy. l. rhamnosus ( . %) was more likely than b animalis subsp lactis ( . %) to be present in the feces at months, although detection rates were similar by months. the authors conclude that supplementation with l. rhamnosus, but not b. animalis subsp lactis, substantially reduced the cumulative prevalence of eczema, but not atopy, by years. abrahamsson performed a double-blind, randomized, placebo-controlled trial involving families with allergic disease. the mothers received l. reuteri atcc (  cfu) daily from gestational week until delivery. their babies then continued with the same product from birth until months of age and were followed up for another year to assess if the oral administration of probiotic l. reuteri may alleviate and even prevent eczema in infants with a family history of allergic disease. the cumulative incidence of eczema was similar, % in the treated versus % in the placebo group. however the l. reuteri group had less ige-associated eczema during the second year, % versus % (p ¼ . ). skin prick test reactivity was also less common in the treated than in the placebo group, significantly so for infants with mothers with allergies, % versus % (p ¼ . ). wheeze and other potentially allergic diseases were not affected. the authors concluded that the treated infants had less igeassociated eczema at years of age and therefore possibly ran a reduced risk to develop later respiratory allergic disease. therefore probiotics may reduce the incidence of ige-associated eczema in infancy. kukkonen et al. studied the effect of a mixture of probiotic bacterial strains (lactobacillus rhamnosus gg (atcc ), l. rhamnosus lc (dsm ), bifidobacterium breve bb (dsm ) and propionibacterium freudenreichii ssp. shermanii js (dsm )) along with prebiotic galacto-oligosaccharides in preventing allergic diseases. one thousand two hundred and twenty three pregnant women carrying high-risk children were randomized to use a probiotic preparation or a placebo for e weeks before delivery. their infants received the same probiotics plus galactooligosaccharides (n ¼ ) or a placebo (n ¼ ) for months. probiotic treatment compared with placebo showed no effect on the cumulative incidence of allergic diseases but tended to reduce ige-associated (atopic) diseases (odds ratio (or), . ; % ci, . e . ; p ¼ . ). probiotic treatment reduced eczema (or, . ; % ci, . e . ; p ¼ . ) and atopic eczema (or, . ; % ci, . e . ; p ¼ . ). lactobacilli and bifidobacteria more frequently (p < . ) colonized the guts of supplemented infants. probiotic treatment showed no effect on the incidence of all allergic diseases for infants aged but significantly prevented eczema and especially atopic eczema. the authors observed an inverse association between atopic diseases and colonization of the gut through probiotics and concluded that the prevention of atopic eczema in high-risk infants is possible modulating the infants' gut microbiota with probiotics and prebiotics. postoperative complications in gi surgery could involve bacteremia and infectious complications. the main causes could be the translocation of the gi bacteria or its toxins as a consequence of bacterial overgrowth, the loss of intestinal epithelial integrity and the immunologic compromising of the host. probiotics could be good candidate to fight against these factors through the competition with potential pathogens for nutrients or enterocyte adhesion sites, degradation of toxins, production of antimicrobial factors, and local and systemic immunomodulation. the aim of this short paragraph is to report some important clinical trials which could help to evaluate the usefulness of probiotics action to ease the complication rate in patients undergoing surgery on the gi tract. some of the main important procedures which have been related to the use of probiotics are: first the ileal pouch-anal anastomosis (ipaa) which involves the removal of the entire colon and rectum, with preservation of the anus and sphincter muscles and is performed to avoid a permanent stoma (opening for collecting waste) in cases where the entire colon and rectum need to be removed usually in patients with chronic ulcerative colitis or pathologies associated with colon cancers; second the pancreaticoduodectomy to treat tumors of the pancreatic head, neck or uncinate process; third the surgical resection for patients with localized tumors affecting the pancreas. falk et al. analyzed the possible role of probiotics for the treatment of pouchitis which is the inflammation of the ileal reservoir and the major complication of ipaa following proctocolectomi for ulcerative colitis (uc). this review reported that patients with pouchitis have an increased number of anaerobes and aerobes, less bifidobacteria and anaerobic lactobacilli and more clostridia than patients not affected by that condition. the authors reported a double-blind study ( patients with chronic pouchitis treated with vsl# , a probiotic bacterial mix containing lactobacilli strains, three bifidobacteria strains and one streptococcus strain) showing that probiotics can prevent relapse of pouchitis. another study combining lactobacillus rhamnosus with fos confirmed the possible use of probiotic formulations to induce remission in this condition. pronio et al. reported that vsl# administration in patients with ipaa modulates the pouchitis disease activity score and expands the number of mucosal regulatory t cells (open-label study in which patients, without signs and symptoms of pouchitis, were randomized in different periods from surgery to sachets of vsl# once daily or no treatment for months). in particular the authors observed a significant reduction in pdai score and a significant increase in the percentage of mucosal cd þcd (high) and cd þlap-positive cells compared with baseline values. tissue samples at different points showed a significant reduction in il- beta mrna expression, and a significant increase in foxp mrna expression. rayes et al. designed a prospective randomized monocentric double-blind trial involving patients following pylorus-preserving pancreatoduodenectomy (pppd). group a received a composition of lactobacilli and fibers; group b received placebo, only fibers, starting the day before surgery and continuing for days. the study proved that early enteral nutrition, supplemented with a mixture of lactobacilli and fibers, reduces bacterial infection rates and antibiotic therapy following pppd. nomura et al. randomly allocated seventy patients with pancreaticobiliary diseases to two groups where the first group received probiotics and the second served as control before pancreaticoduodenectomy. the probiotics used in the study contained enterococcus faecalis t- , clostridium butyricum to-a, and bacillus mesentericus to-a and were first administered immediately after admission, e days before the operation, and then reintroduced on the second post-operative day. they were administered until hospital discharge. this study shows that the use of perioperative probiotics reduces post-operative infectious complications after pancreaticoduodenectomy, making it a promising potential adjunct therapy for patients undergoing high-risk hepato, biliary, and pancreatic surgery. reddy et al. designed a study where ninety-two patients were randomly assigned to one of four groups. group had mechanical bowel preparation (mbp) only, group had neomycin þ mbp, group had synbiotics þ neomycin þ mbp, and group had synbiotics þ neomycin but no mbp. changes in gut microflora were assessed by culturing nasogastric aspirates and polymerase chain reaction (pcr)-denaturing gradient gel electrophoresis of fecal samples. intestinal barrier function was determined by microbiological confirmation of bacterial translocation and measurement of intestinal permeability. the inflammatory response was monitored by measurement of serum crp and il- , and septic morbidity was recorded prospectively. they investigated whether it was possible to modulate gut microflora and preserve intestinal barrier function during elective colorectal surgery by using combinations of oral antibiotics, synbiotics and mbp. the authors did not observe a reduction in inflammatory response or septic morbidity. this study shows that a combination of mbp, neomycin and synbiotics reduces the prevalence of fecal enterobacteriaceae and bacterial translocation. van gossum et al. designed a multicenter clinical trial evaluating the efficacy of an oral administration of the probiotic lactobacillus johnsonii lal on early post-operative endoscopic recurrence of crohn's disease (cd). the study involved seventy patients with cd enrolled prior to elective ileo-caecal resection and randomly assigned after surgery to daily treatment with either (la , nestle, cfu) (group a, n ¼ ) or placebo (group b, n ¼ ) for weeks. the authors demonstrated that oral administration of the probiotic la in patients with cd failed to prevent early endoscopic recurrence at weeks after ileo-caecal resection. sugawara et al. investigated the effect of perioperative oral administration of synbiotics upon intestinal barrier function, immune responses, systemic inflammatory responses, microflora, and surgical outcome in patients undergoing high-risk hepatobiliary resection. patients with biliary cancer involving the hepatic hilus (n ¼ ) were randomized, before hepatectomy, into a group receiving post-operative enteral feeding with synbiotics (group a) or another receiving preoperative plus post-operative synbiotics (group b). lactulose-mannitol (l/m) ratio, serum diamine oxidase (dao) activity, nk cell activity, il- , fecal microflora, and fecal organic acid concentrations were determined before and after hepatectomy. the authors concluded that preoperative oral administration of synbiotics can enhance immune responses, attenuate systemic post-operative inflammatory responses, and improve intestinal microbial environment. these beneficial effects likely reduce post-operative infectious complications after hepatobiliary resection for biliary tract cancer. woodgard et al. focused on the issue of roux-en-y gastric bypass (rnygb) surgery, a treatment for morbid obesity, which is responsible for altering gi flora leading to bacterial overgrowth and dysmotility. the authors randomized forty-four patients undergoing rnygb to either a probiotic or control group; . billion colonies of lactobacillus were administered daily postoperatively to the probiotic group. probiotic administration was shown to improve bacterial overgrowth, vitamin b availability, and weight loss after rnygb supporting the hypothesis that altering the gi microbiota can influence weight loss. urogenital infections not caused by sexual transmission in women are still one of the most important medical issue. recurrent urinary tract infection (uti) is, in most cases caused by the uropathogens e. coli; recurrent bacterial vaginosis (bv) is usually caused by gardnerella vaginalis; recurrent yeast vaginosis is usually caused by candida albicans. the predominant bacteria in the urinary tract of healthy women are lactobacilli. infections are usually treated using antibiotics with the effect of decreasing the number of lactobacilli which cause gi symptoms, raise drug resistance and do not restore the urinary tract natural barrier to infections. zuccotti et al. reported some studies highlighting that probiotics could be a good alternative to antibiotic therapy due to their quality to adhere to uroepithelial cells and produce inhibitors of pathogenic growth and biosurfactant secretion. the same authors reported that oral lactobacilli-based therapy under viable conditions showed that these bacteria are able to colonize the urinary tract after enteral colonization. reid et al. reported that a daily intake of probiotic strains l. rhamnosus gr- and lactobacillus fermentum rc- , resulted in some asymptomatic bv patients reverting to a normal lactobacilli dominated vaginal microflora. the same authors reported other two studies regarding bv: firstly a twice daily use of hydrogen peroxide producing l. acidophilus in a product called vivag for six days led to a % improvement compared to none at all in the placebo group; secondly yogurt containing l. acidophilus, delivered in a tampon to pregnant women, showed to treat bv and prevented infection at months follow-up. reid et al. also reported a study which indicates that the recurrence of uti can be reduced using one or two capsules (l. rhamnosus gr- and l. fermentum b- , replaced more recently by rc- , freeze dried and placed in gelatine capsules, with dosage at per capsule) vaginally per week for one year, with no side effects or yeast infections. the authors also explored the use of probiotics for the treatment of yeast vaginitis reporting that l. rhamnosus gr- and l. fermentum rc- are able to kill and inhibit the adhesion of yeast to vaginal cells. moreover they reported a crossover study involving patients with recurrent vaginitis treated with eight ounces of l. acidophilus supplemented yogurt daily for six months and then switched to a yogurt free diet. the therapy resulted in . breakthrough infections compared with . per study term. czaja et al. performed a phase i trial to assess the safety and tolerance of a lactobacillus vaginal suppository for prevention of recurrent uti involving premenopausal women with a history of recurrent uti. they were randomized to use lactobacillus crispatus ctv- or placebo vaginal suppositories daily for five days. no severe adverse events occurred. mild to moderate vaginal discharge and genital irritation were reported by women in both study arms. seven women randomized to l. crispatus ctv- developed pyuria without associated symptoms. most women had high concentrations of vaginal h -producing lactobacilli before randomization. l. crispatus, lactobacillus jensenii, and lactobacillus gasseri were the most common lactobacillus species identified, with stable prevalence over time. according to this study l. crispatus ctv- can be given as a vaginal suppository with minimal side effects to healthy women with a history of recurrent uti although mild inflammation of the urinary tract was noted in some women. anukam et al. enrolled women diagnosed with bv (it is particularly common condition in black women and in nigeria it is often caused by mycoplasma, as well as atopobium, prevotella and gardnerella sp.) by discharge, fishy odor, sialidase positive test and nugent gram stain scoring. they were randomized to receive either two dried capsules containing l. rhamnosus gr- and l. reuteri rc- each night for days, or . % metronidazole gel, applied vaginally twice a day, in the morning and evening. the follow-up at day , and showed a significant cure for bv in probiotic lactobacilli treated subjects compared to metronidazole treatment. this is the first report of an effective ( %) cure for bv using probiotic lactobacilli. the authors conclude that, given the correlation between bv and hiv, and the high risk of the latter in nigeria, intravaginal use of lactobacilli can provide women with a self-use therapy, similar to over-the-counter anti-yeast medication, for treatment of urogenital infections. martinez et al. designed a study involving sixty-four brazilian women diagnosed with bv. they were randomly assigned to receive a single dose of tinidazole ( g) supplemented with either placebo capsules or capsules containing l. rhamnosus gr- and l. reuteri rc- every morning for weeks. at the end of treatment (day ), the probiotic group had a significantly higher cure rate for bv ( . %) than the placebo group ( . %) (p ¼ . ). in addition, according to the gram-stain nugent score, more women were assessed at "normal" vaginal microbiota in the probiotic group ( . % vs. . % in the placebo group; p ¼ . ). this study shows that probiotic lactobacilli can provide benefits to women being treated with antibiotics for an infectious condition. mastromarino et al. enrolled thirty-nine women with bv in a double-blind, placebo-controlled clinical trial to receive either one lactobacillus-containing tablet or placebo daily for days. after the completion of therapy, all of the patients in the lactobacillus-treated group (n ¼ ) were free of bv, showing a normal ( %) or intermediate ( %) vaginal flora, as compared with only two patients free of bv with intermediate flora ( %) from among the placebotreated women (p < . ). two weeks after the completion of therapy, treatment was successful (score < ) in % of lactobacillustreated patients as compared with % of those ones in the placebo group (p < . ). in the treatment group, the total number of symptomatic patients and the intensity of their symptoms, in particular vaginal malodour, were significantly reduced at both follow-up visits. the previously reported results brought the authors to conclude that intravaginal administration of exogenous selected strains of lactobacilli can restore a normal vaginal microbiota and could be a useful choice for the treatment of bv. larsson et al. investigated firstly if supplementary lactobacilli treatment could improve the initial cure rate after vaginal clindamycin therapy, and secondly, if lactobacilli as repeated adjunct treatment during menstrual cycles could lengthen the time to relapse after initial cure. a hundred bv diagnosed women were offered vaginal clindamycin therapy followed by vaginal gelatine capsules containing either freeze-dried lactobacilli or identical placebo capsules for days during menstrual cycles in a doubleblind, randomized, placebo-controlled trial. the authors concluded that supplementary treatment, combining two different strains of probiotic lactobacilli, does not improve the efficacy of bv therapy during the first month of treatment, but for women initially cured, adjunct treatment of lactobacilli during menstrual cycles lengthens the time to relapse significantly (more women remained bv free at the end of the -month follow up). renal failure can be faced removing waste products and excess fluid using a mechanical method called dialysis. the two forms of dialysis used in medical practice are hemodialysis (hd) and peritoneal dialysis (pd). hd cycles blood through a machine that filters the blood and returns it to the body cleaned of waste. pd cycles fluid into and out of the abdomen using the individual's own peritoneum as a filter. plasma uremic toxins levels such as phenol, p-cresol, and indican are produced in the intestine as bacterial putrefactive metabolites and accumulate to a great degree in the feces of hd patients and cannot be efficiently reduced by hd. intestinal microflora is deranged in hd patients as we can see an increase in aerobic bacteria such as escherichia coli and a decrease in anaerobic bacteria such as bifidobacterium. yangco et al. reported the successful utilization of nitazoxanide and probiotics to treat multirecurrent clostridium difficile infection (cdi) in a pd patient. a -year-old woman was admitted with hypotension, nausea and vomiting attributed to metronidazole therapy for cdi, her third cdi treatment regimen in months. during her admission, the patient developed cdi and was started on a -week regimen of nitazoxanide and probiotics to assist in reestablishing the colonic flora. the regimen was well tolerated and the patient remained disease free at follow up, four months later. hida et al. demonstrated that lebenin, a preparation consisting of antibiotic-resistant lactic acid bacteria, administred orally is able to reduce the levels of fecal putrefactive metabolites to levels comparable with those of healthy subjects. moreover the plasma level of indican also significantly decreased in these lebenintreated patients. an analysis of the fecal microflora revealed that a disturbed composition of the microflora characterized by an overgrowth of aerobic bacteria is restored to normal by oral administration of lebenin in hd patients. the authors demonstrated that oral administration of lactic acid bacteria in uremic patients is effective in reducing the levels of uremic toxins, especially that of indican, in the blood by inhibiting bacterial production by means of correcting the intestinal microflora. taki et al. demonstrated that the oral administration of b. longum in a gastroresistant seamless capsule to hd patients is effective in decreasing the pre-hd serum levels of homocysteine, indoxyl sulfate, and tags. the reduction in the serum level of homocysteine is mainly attributable to the supply of folate produced by b. longum in the human intestines. diverticular disease (dd) is an acquired weakening of the colon wall, and more rarely of the ileum and duodenum causing protrusions of the mucosa and submucosa through the muscular wall. these "pouches" occur in weak areas of the wall where blood vessels penetrate due to the high pressure inside the colon. often they involve primarily the sigmoid region of the colon. the term "diverticulosis" refers to the aymptomatic condition and the term "diverticular disease" refers to the condition associated with symptoms. the term diverticulitis is used to indicate inflammation of the bowel wall. here we report two interesting studies designed by tursi et al. evidencing the possible use of probiotics in the management of this condition. tursi et al. designed a study to investigate whether balsalazide (a novel orally administered prodrug of -asa in which an inert carrier molecule, -aminobenzoil-ß-alanine, has been bonded to a molecule of -asa. after administration, colonic bacteria split balsalazide into -asa and -aminobenzoil-ß-alanine, releasing the active -asa into the colon with minimal systemic absorption) and/or vsl# a probiotic mixture containing several billions of different bacterial strains, mainly lactobacillus and bifidobacteria, is effective in preventing diverticulitis recurrence. thirty consecutive patients ( males, females, mean age . years, range e years) affected by uncomplicated diverticulitis of the colon were monitored. after obtaining remission, the patients were randomly assigned to one of the following groups as follows: group a, balsalazide . g daily for days every month plus vsl# billions/day for days every month and group b, vsl# alone billions/day for days every month. primary endpoint was considered the maintaining of remission throughout a -month follow-up. secondary end-points considered were: firstly the assessment of the overall scores at the end of the follow-up and secondly the effects of the two different treatments with regards to every symptom assessed. the authors found that one group a patient ( . %) showed relapse of symptoms at the th month of follow-up; at the end of follow-up, patients were completely symptom-free ( . %) whilst patients complained of only mild, recurrent symptoms ( %); two group b patients ( . %) showed relapse of the disease at the th and th month of follow-up, respectively; at the end of follow-up, patients were completely symptom-free ( %), patients complained of mild, recurrent symptoms ( . %), patient ( . %) complained of mild but continuous symptoms; no side effects were recorded throughout the follow-up in both groups. this study showed that the combination probiotic/anti-inflammatory drug was found better than probiotic treatment in preventing relapse of uncomplicated diverticulitis of the colon, even if without statistical significance. tursi et al., after the pilot study, designed another study to assess if four different therapeutic schedules with mesalazine and/or probiotics are able to prevent the recurrence of symptomatic dd of the colon. this prospective, dose-finding study was conducted on patients, enrolled in an open fashion: mesalazine mg/ daily (group m ) or mesalazine . gr day/month (group m ); mesalazine mg/daily þ l. casei dg billion/day for day/ month (group lm ) or mesalazine . gr þ l. casei dg billion/day for day/month (group lm ); l. casei dg billion/day for day/ month (group l). seventy one patients completed the study ( . %). sixty six patients ( %) were symptom-free after the th month of treatment: of group m , of group m , of group lm , of group lm and in group l. four patients ( . %) suspended the treatment during the follow-up: all experienced recurrence of symptoms ( %), and two of them developed diverticulitis ( %). this study showed that mesalazine and/or l. casei seem to be effective in maintaining remission of dd for long-time. the authors found recurrence of the disease and complications in all the patients who suspended treatment. in europe and north america ibs is estimated to have an incidence of e %. in sweden, the most commonly cited figure is . %. the prevalence of ibs is increasing in countries in the asiaepacific region, particularly in countries with developing economies. ibs mainly occurs between the ages of and . the estimated prevalence of ibs in children is similar to that in adults. ibs is a common disorder of the intestines associated with cramping, stomach pain, gas, bloating, and changes in bowel habits. ibs can be characterized by constipation, diarrhea or both. diarrhea-predominant ibs (d-ibs) is characterized by an increased intestinal permeability accompanied by persistent low-grade immune activation in the gut presented as increased numbers of t lymphocytes, mast cells and enterochromaffin cells. in its normal condition, gut epithelial lining forms a relatively impermeable barrier between luminal contents and submucosa required for intestinal homeostasis. this barrier is determined by complexes of proteins composing the junctional complexes. tight junctions (tjs) are the most apical organelle of the epithelial junctional complexes and are crucial for the formation and function of epithelial barriers. tjs comprise numerous proteins, with the best characterized being zonula occludens (zo)- and occludin. the diarrhea form is the predominant form and brings the patient to experience abdominal pain, visible abdominal distension (bloating), bowel frequency particularly in association with pain, pain relieved by bowel action, rectal passage of mucous and sensation of incomplete evacuation. spastic colon syndrome is an ibs variant which is mainly characterized by constipation. the constipation ibs variant let the patient experience the same symptoms except for the bowel frequency which is replaced by the constipation which is responsible for the pain. ibs seems to be due to a dysfunction of the muscles of the organs of the gi tract or the nerves controlling the organs. nerves run for the entire length of the gi tract from the esophagus to the anus in the muscular walls of the organs reaching also the spinal cord and the brain. ibs is thought to result from an interplay of abnormal gi tract movements, increased awareness of normal bodily functions, and a change in of the nervous system communication between the brain and the gi tract. although the causes of ibs are not yet known some factors are usually associated to this condition: genetic influences, food intake, endocrine imbalances, malabsorption, post-operative changes, altered gi motility, heightened sensory function of the intestine, or malfermentation of food residues and psychosomatic factors such as a psychological morbidity, stress and an abnormal illness behaviour. ibs has a great negative impact on the patient's emotional health and quality of life especially for those who are facing this disease for their entire life. symptoms can be alleviated by the patient's education, reassurance, and dietary modification but they are not a definitive resolution. before considering the most recent clinical trials for the treatment of ibs it is worth to remember some important studies faced before. in vanderhoof et al. reported a study developed in poland using l. plantarum (lp v). this bacterium is able to synthetize nitric oxide, an important mediator of gut motility, it may displace the attachment of other organisms from the intestinal mucosa and it seems to be able to reduce any inflammatory component associated with ibs. the study results showed a reduction of symptoms of abdominal pain and constipation when compared with placebo. the same author reported another study to support the beneficial effect of lp v. this small double-blinded placebo-controlled crossover study in children with recalcitrant chronic, recurrent abdominal pain of childhood showed a significant reduction in the severity of abdominal pain in lp v-treated patients compared with results in control subjects. tsuchiya et al. realized a study to evaluate the efficacy of a symbiotic containing bifidobacteria ( .  / ml) for the treatment of ibs. the authors found that, after a weeks treatment on patients, the symbiotic was able to significantly reduce the intensity of the symptoms of ibs. o'mahony et al. realized a study to compare the response of symptoms and cytokine ratios in ibs with ingestion of probiotic preparations containing a lactobacillus or bifidobacterium strain. seventy-seven subjects with ibs were randomized to receive either lactobacillus salivarius ucc or bifidobacterium infantis , each in a dose of  live bacterial cells in a malted milk drink or the malted milk drink alone as placebo for weeks. b. infantis alleviates symptoms in ibs; this symptomatic response was associated with normalization of the ratio of an anti-inflammatory to a proinflammatory cytokine, suggesting an immune-modulating role for this organism in this disorder. furrie et al. designed a study based on the use of a symbiotic containing bifidobacteria to treat ibs. the symbiotic was successful in treating the pathology without evident adverse events and modulate the immunological parameters of the same. the treatment based on bifidobacteria and fos improves the intestinal habits and the quality of patients' life. table , adapted from guslandi et al. , summarizes some interesting studies involving the use of probiotics in the treatment of ibs. hun et al. designed a controlled study to evaluate the effects of the probiotic bacillus coagulans gbi- , on ibs symptoms. bacillus coagulans gbi- , (ganeden biotech, inc., mayfield heights, oh) is a patented strain of lactic acid producing bacteria that can sustain the low ph of stomach acid and become active in the intestine. strains of b coagulans produce coagulin, which is a heat-stable, protease-sensitive, bacteriocin-like inhibitory substance with activity against gram-positive bacteria. spores of bacillus are resistant to heat and hostile gi conditions and, therefore, are able to reach the intestine where they can germinate and proliferate within the host. b coagulans gbi- , maintains spore viability after years of storage without the need for refrigeration (unpublished communication, ganeden biotech, inc., mayfield heights, oh), making it particularly suitable for commercial use. this randomized, double-blind, parallel-group, placebo-controlled clinical trial involved subjects who received either placebo or b. coagulans gbi- , once a day for weeks. self-assessments of the severity of ibs symptoms (abdominal pain and bloating) were recorded every day for weeks. because baseline values were significantly different between the study groups, within-group analysis was conducted. all subjects met the rome ii criteria for ibs with diarrhea, i.e. they must have had, during the months prior to evaluation, and for a total of at least weeks (not necessarily consecutively), abdominal discomfort or pain that had of features: relief with defecation, onset associated with a change in frequency of stool and onset associated with a change in appearance of stool. individuals with any organic gi conditions or diseases, previous intestinal surgery, immunodeficiency, or lactose intolerance, or who were pregnant or lactating, were excluded from the study. patients who had taken commercially available probiotic medications within days of the study were also excluded. the authors obtained as results the improvements from baseline abdominal pain and bloating scores in the b coagulans gbi- , group which were statistically significant for all weekly comparisons (p < . ); in the placebo group, only changes in abdominal pain scores at and weeks achieved statistical significance (p < . ); no treatment-related adverse events or serious adverse events were reported during the -week study period. the authors, basing on the previous described results, suggest that the patented b coagulans gbi- , probiotic might be a safe and effective option for the relief of abdominal pain and bloating for patients with ibs. these results justify the design of larger scale, controlled clinical trials to verify these findings. henck et al. performed a clinical trial treating two hundred and ninety-eight patients with lower abdominal symptoms diagnosed as ibs for weeks by the compound symbioflor- (symbiopharm gmbh, herborn, germany), an e. coli product (n ¼ ), or placebo (n ¼ ) in a double-blinded, randomized fashion. patients were seen weekly by the physician, who assessed the presence of core ibs symptoms. both an abdominal pain score (aps) as well as a general symptom score (gss) were used as primary endpoints. responders had to have complete absence of ibs core symptoms at > or ¼ visit during treatment. the results showed that: the responder rate in gss to the drug was / ( . %) in comparison to placebo with / ( . %) (p ¼ . ); the improvement in aps was / ( . %) and / ( . %) for placebo (p ¼ . ); the response was reached from the third visit onwards with both medication and placebo; post-hoc analysis revealed no significant differences in efficacy of the drug between the gender and different age groups. the authors conclude that the probiotic symbioflor- is effective and superior to placebo in reducing the typical symptoms of ibs. barrett et al. aimed at determining whether l. casei strain shirota (yakult) can alter small intestinal bacterial overgrowth (sibo), as tested by the lactulose breath test, and whether it is associated with changes in symptoms in ibs. prior to the breath hydrogen test, dietary restriction (minimising intake of fibre and poorly absorbed short-chain carbohydrates) was advised for h and the subjects fasted overnight. the patients consumed g lactulose, made up to a ml solution with water. breath hydrogen samples were collected at baseline and every min for at least h. the authors recruited patients with ibs (rome ii criteria), who showed an early rise in breath hydrogen with lactulose (erbhal: defined as a rise of breath hydrogen of ppm or greater above the baseline breath hydrogen on two consecutive min samples, before min following the ingestion of lactulose. the time of the first rise in breath hydrogen of ppm or more was recorded). they consumed ml of yakult daily for wks. lactulose breath test was repeated at the end of the treatment period. symptoms were recorded daily using a cm visual analogue scale. fourteen patients completed the study, ( %) had reversal of erbhal, with the median time of first rise in breath hydrogen increasing from to min (p ¼ . ). there was no significant improvement in the symptoms score with probiotic therapy, except for wind (p ¼ . ). patients commencing with at least moderate symptoms and who no longer had erbhal at the end of treatment, showed improvement in the overall symptoms scores [median final score . (iqr . e . ), % reduction; n ¼ ] to a greater extent than those who had had persisting erbhal [final score . ( . e . ), % reduction; n ¼ ; p ¼ . ]. this study shows that yakult is effective in altering fermentation patterns in the small bowel, consistent in reducing sibo. the loss of erbhal was associated with reduced symptoms. this study findings need to be confirmed by a randomized controlled trial. adriulli et al. tested the efficacy of symbiotics in patients with d-ibs. patients were randomized to a prebiotic (n ¼ ), or a symbiotic formulation containing lactobacillus paracasei b (flortec, n ¼ ). primary efficacy was the responder rate for pain and global relief of symptoms in the overall population and in patients with predominant diarrhea (n ¼ ). post hoc time-trend analyses for changes within each treatment were carried out. the following results were obtained: patients with absent/mild pain amounted to . % in the symbiotic group and to . % in the prebiotic group at treatment week , and to . % and . % at the end of treatment; patients with amelioration of well-being were, respectively, . % versus . % at treatment week , and . % versus . % at the end of treatment; within each treatment group, patients with absent/mild pain increased in the flortec and the prebiotic group, but time trend analyses were significant only for flortec (p ¼ . ); in d-ibs, flortec significantly reduced bowel movements, pain, and ibs scores. the authors concluded that: flortec is encouraging in patients with d-ibs and is able to improve the pain and the patient's well-being even if in the future flortec has to be compared with an inert placebo to establish its efficacy for the majority of ibs patients. zeng et al. performed a study to determine the possible effect of lactic acid bacteria on the increased intestinal permeability in d-ibs. this treatment lasted weeks in a randomized single blind placebo-controlled study with d-ibs patients. patients were given either a probiotic fermented milk (streptococcus thermophilus, lactobacillus bulgaricus, lactobacillus acidophilus and bifidobacterium longum) or milk beverage containing no bacteria. the clinical symptoms were scored and intestinal permeability measured by a triple sugar test before and after treatment. small bowel permeability was measured as the ratio of l/m recovery and colonic permeability was measured as the total mass of sucralose excretion (mg). after probiotics treatment, small bowel permeability decreased significantly from . at baseline to . (p ¼ . ), the proportion of patients with increased small bowel permeability was lower than that one at baseline ( . % vs. . %, p ¼ . ). however, colonic permeability improved neither in the probiotics group nor in the placebo group at week . treatment with probiotics significantly decreased the mean global ibs scores compared with the baseline scores ( . ae . vs. . ae . , p < . ). therefore short-term active lactic acid bacteria treatment for d-ibs improves mucosal barrier function. enck et al. re-analyzed a study performed in and according to current ibs standards. two hundred ninety-seven patients with lower abdominal symptoms diagnosed as ibs were treated for weeks with the compound prosymbioflor(r) (symbiopharm gmbh, herborn, germany), an autolysate of cells and cell fragments of enterococcus faecalis and escherichia coli, or placebo in a double-blinded, randomized fashion. patients were seen weekly by the physician, who assessed the presence of core ibs symptoms. responders had at least a % gss and in aps reports at >/ ¼ visit during treatment. the responder rate in gss to the drug was / ( . %) in comparison to placebo with / ( . %) (p < . ), the improvement in aps was / ( . %) and / ( . %) respectively (p ¼ . ). the number needed to treat was . for gss and . for the aps report. kaplanemeier analysis revealed a mean response time of e weeks for active treatment and more than weeks for placebo (p < . ). this study leads the authors to conclude that treatment of ibs with the bacterial lysate prosymbioflor is effective and superior to placebo in reducing typical symptoms of ibs patients. drouault-holowacz et al. investigated the efficiency of a probiotic dietary supplement, containing four strains of lactic acid bacteria, on symptoms of ibs. one hundred and sixteen patients with ibs fulfilling the rome ii criteria were randomized in a parallel group, double-blind study to receive a placebo or a probiotic combination (  cfu) once daily for four weeks. the symptoms that were monitored weekly included discomfort, abdominal pain, and stool frequency and quality. quality of life was assessed before and at the end of the treatment using the sf and fdd-quality-of-life questionnaires. the study showed the following results: one hundred subjects completed the study ( in the probiotic combination group and in the placebo group); the probiotic combination was not superior to the placebo in relieving symptoms of ibs ( . % versus . % improvement); the decrease of abdominal pain between the first and the fourth week of treatment was significantly higher in probiotic treated patients (À . versus À . %, p ¼ . ). interesting findings were also observed from the ibs sub-groups such as a lower pain score at endpoint in patients with alternating bowel habits (p ¼ . ) and an increase of stool frequency in the constipated sub-group from the first week of probiotic treatment (p ¼ . ). the authors conclude that the probiotic combination was not significantly superior to the placebo in relieving symptoms of ibs. despite the apparent high placebo response, interesting findings were observed from ibs sub-groups in the field of abdominal pain and stool frequency. sinn et al. randomized ibs patients into a placebo (n ¼ ) and probiotics group (n ¼ ). lactobacillus acidophilus, sdc and . these two lactobacilli were obtained from infants' feces and examined for their biological and biochemical characteristics. they showed the ability to survive in high acidity and medium containing bile acids as potent probiotics (unpublished data). these two selected strains were freeze dried by a microbial company (culture systems, inc. usa). the freeze-dried bacteria were mixed with an excipient and packed into capsules under good manufacturing processing (gmp) conditions (natural f&p. korea). in this study, the excipient was added to the blend of bacteria to achieve the desired dosage concentrations,  cfu/ml. placebo capsules contained the excipient only. four week treatment with l. acidophilus-sdc , was associated with a reduced score for abdominal pain or discomfort compared to the baseline (p ¼ . ). the percent reduction in abdominal pain or discomfort exceeded the placebo scores by more than % ( . and . % for probiotics and placebo, respectively, p ¼ . ). there was a significant difference in the proportion of responders between the probiotics and placebo groups (p ¼ . ). there was no drop out or adverse events for either group during the study period. bittner et al. designed a study to extend a previous -week assessment of a probioticeprebiotic complex in patients with ibs. prescript-assistÔ (p-a) is a probioticeprebiotic complex reported to be associated with reduced signs and symptoms of several gi disorders, particularly ibs. the probiotic component is a complex of (anthrobacter agilis, a citreus, a globiformis, a luteus, and a simplex acinetobacter calcoaceticus azotobacter chroococcum and a paspali azospirillum brasiliense and a lipoferum bacillus brevis, b marcerans, b pumilus, b polymyxa, and b subtilis bacteroides lipolyticum and b succinogenes brevibacterium lipolyticum and b stationis kurtha zopfil myrothecium verrucaria pseudomonas calcis, p dentrificans, p flourescens, and p glathei phanerochaete chrysosporium streptomyces fradiae, s cellulosae, and s griseoflavus) soilbased microorganisms (sbos), all class i etiologic agents (they present "no or minimal hazard under ordinary conditions"). in this open-label, partially controlled, -year extension study, data were collected from ibs patients who continued treatment following a week study of the efficacy of the probioticeprebiotic complex. data were collected at and approximately weeks after the end of the original study. the authors observed that a total of patients entered the -week extension and completed the approximately -week follow-up study. the results in the control group weeks after crossover to treatment were similar to those from the original study, with reductions in ibs subsyndromes, i.e. general ill feelings/ nausea (p < . ), indigestion/flatulence (p < . ), and marginally colitis (p < . [ -tailed] ). treatment was associated with a continued reduction in general ill feelings/nausea at weeks (p < . ). at > or ¼ -week follow-up, the rate of remissions was . %e % (p < . ). based on these results, treatment with this probioticeprebiotic complex seems to be an option for short-term ( e weeks) and long-term (approximately weeks) reductions in ibs symptoms. guyonette et al. analyzed the effects of fermented milk containing bifidobacterium animalis dn- , and yogurt strains on the ibs in a multicenter, double-blind, controlled trial. the test product was a fermented milk (activia, danone), containing b. animalis dn- , ( .  cfu per pot) together with the two classical yogurt starters, s. thermophilus and l. bulgaricus ( . $ cfu ⁄ pot). the control product was heat-treated yogurt containing non-living bacteria (< cfu/pot). both the test and control products were without flavour, and had a similar appearance, colour, texture and taste. each serving, corresponding to one pot, contained g. both products were specifically prepared for the study and provided by danone research (palaiseau, france). a total of primary care adults with constipation-predominant ibs (rome ii) were randomized to consume for weeks either the test fermented milk or a heat-treated yogurt (control). hrqol and digestive symptoms were assessed after and weeks on an intention-to-treat population of subjects. the previously described results brought the authors to the following results: the hrqol discomfort score, the primary endpoint, was improved (p < . ) in both groups at weeks and ; the responder rate for the hrqol discomfort score was higher ( . vs. . %, p < . ), as it was higher the decrease in bloating score ( . ae (s.d.) . vs. . ae . , p ¼ . ), at week in the test vs. the control group. in those subjects with < stools/week, stool frequency increased (p < . ) over weeks in the test vs. control group. this study suggests a beneficial effect of a probiotic food on discomfort hrqol score and bloating in constipation-predominant ibs, and on stool frequency in subjects with < stools/week. in conclusion, the present large-scale study strongly suggests a beneficial effect of a probiotic food containing b. animalis dn- on hrqol discomfort score and bloating, and also on stool frequency in those subjects with < stools per week. further studies aiming at confirming the results obtained and to elucidate mechanisms of such effects should be of special interest for providing additional scientific evidence to support the use of such probiotic food to alleviate ibs symptoms and improve hrqol discomfort. gawro nska et al. evaluated the efficacy of l. rhamnosus gg for treating functional abdominal pain disorders (fapd) in children. a total of children who fulfilled the rome ii criteria for functional dyspepsia (fd), or ibs, or functional abdominal pain (fap) were enrolled in a double-blind, randomized controlled trial in which they received l. rhamnosus gg (n ¼ ), or placebo (n ¼ ) for weeks. the patients in the l. rhamnosus gg group were more likely to have treatment success (no pain) than those in the placebo group ( % vs. . %, relative benefit (rb) . , % ci: . e . , number needed to treat (nnt) , % ci: e ). for children with ibs (n ¼ ), those in the l. rhamnosus gg group were more likely to have treatment success than those in the placebo group ( % vs. %, rb . , % ci: . e , nnt , % ci: e ) and reduced frequency of pain (p ¼ . ), but not pain severity (p ¼ . ). for the fd group (n ¼ ) and fap group (n ¼ ), no differences were found. the authors conclude that the l. rhamnosus gg appears to moderately increase treatment success, particularly among children with ibs. fanigliulo et al. aimed at investigating the efficacy of rifaximine (a broad-spectrum, poorly absorbable antibiotic) on its own or in association with the probiotic strain of b. longum w in reducing symptoms in patients with ibs. they performed a monocentric, prospective, randomized open trial including patients randomized to two groups: group a ( patients) receiving rifaximin ( cp bid for ten days in a month) followed by a formulation of the probiotic strain of b. longum w (one granulated suspension for days on alternate weeks) and group b ( patients) receiving only rifaximin ( cp bid for ten days in a month). the clinical evaluation was performed at admission and after -months, taking into account the method of visual analogues. the authors observed that at the -month follow-up, group a patients reported a greater improvement of symptoms compared to patients in group b (p ¼ . ) even if the physician's opinion at t did not confirm these results (p ¼ . ). the previously reported results showed an increased colonization by means of b. longum w , after the cyclic administration of rifaximin, which eradicates the bacterial overgrowth of the small intestine and may reduce symptoms, especially those related to bowel habit and stool frequency in patients with ibs. the abnormalities observed in the colonic flora of ibs suggest, in fact, that a probiotic approach will ultimately be justified. colecchia et al. performed a study to evaluate the efficacy and safety of a symbiotic consisting of a probiotic, b. longum w , and the short chain oligosaccharide prebiotic fos actilight, in patients with constipation-variant ibs. six hundred and thirty six patients ( men, women) diagnosed with constipation-type ibs according to the rome ii criteria were enrolled in centers and received the symbiotic at a dose of g/die for at least days. a validated questionnaire investigating symptoms and stool frequency was administered before and after treatment. the results were based on patients' responses to visual scale items; frequency increased significantly after treatment in the "no symptom" class from % to . % for bloating and from . % to . % for abdominal pain (p < . ); in the severest symptoms classes (moderatesevere), symptom frequency dropped significantly from . % to . % and from . % to . % for bloating and abdominal pain, respectively. stool frequency significantly increased from . ae . times/week to . ae . times/week. the authors conclude that the study product can increase stool frequency in patients with constipation-variant ibs and reduce abdominal pain and bloating in those ones with moderate-severe symptoms. whorwell et al. assessed the efficacy of the probiotic bacteria b. infantis on a large-scale, multicenter, clinical trial of women with ibs determining the optimal dosage of probiotic for administration in an encapsulated formulation. after a weeks baseline, primary care ibs patients, with any bowel habit subtype, were randomized to either placebo or freeze-dried, encapsulated b. infantis at a dose of  ,  , or  , cfu/ml for wks. ibs symptoms were monitored daily and scored on to a -point likert scale with the primary outcome variable being abdominal pain or discomfort. a composite symptom score, the subject's global assessment of ibs symptom relief, and measures of quality of life (using the ibs-qol instrument) were also recorded. the authors report the following results: b. infantis at a dose of  cfu was significantly superior to placebo and all other bifidobacterium doses for the primary efficacy variable of abdominal pain as well as the composite score and scores for bloating, bowel dysfunction, incomplete evacuation, straining, and the passage of gas at the end of the week study; the improvement in global symptom assessment exceeded placebo for more than % (p < . ); two other doses of probiotic (  and  ) were not significantly different from placebo; of these, the  dose was associated with significant formulation problems. no significant adverse events were recorded. the authors conclude that b. infantis is a probiotic that specifically relieves many of the symptoms of ibs. at a dosage level of  cfu, it can be delivered by a capsule making it stable, convenient to administer, and amenable to widespread use. the lack of benefits observed with the other dosage levels of the probiotic highlights the need for clinical data in the final dosage form and dose of probiotic before these products are used in practice. ibd commonly refers to two chronic inflammatory diseases of the gi tract: uc and cd. the main difference between cd and uc is the location and nature of the inflammatory changes. cd can affect any part of the gi tract, from mouth to anus, although a majority of the cases start in the terminal ileum. uc affects the colon and the rectum. microscopically, uc is restricted to the mucosa while cd affects the whole bowel wall. the world gastroenterology organization reports that: uc incidence has been increasing in western countries since the second world war and in low-incidence areas in eastern europe, asia and developing countries; cd incidence is < per , in asia and south america, e per , in southern europe, south africa, per , in new zealand and australia, per , in canada, per , in the usa (based on data only from olmsted county, minnesota). the pathogenesis of ibd is not completely understood. genetic and environmental factors such as altered luminal bacteria and enhanced intestinal permeability play a role in the dysregulation of intestinal immunity, leading to gi injury. an abnormal activation of the mucosal immune system driven by the presence of the intestinal microbiota in a genetically predisposed patient seems to play a key role in this pathology. especially in cd the intestinal microbiota is strongly suspected to play a role in initiating and triggering the immune system, leading to a characteristic inflammation. furrie et al. used a synbiotc combining a probiotic, b. longum, isolated from healthy rectal epithelium, and a prebiotic (synergy ), a preferential inulin-oligofructose growth substrate for the probiotic strain to treat uc patients. treatment was employed in a double blinded randomized controlled trial using patients with active uc for a period of one month. clinical status was scored and rectal biopsies were collected before and after treatment, and transcription levels of epithelium related immune markers were measured. the authors conclude that short-term synbiotic treatment of active uc resulted in improvement of the full clinical appearance of chronic inflammation in patients receiving this therapy. sokol et al. determined the composition of the mucosa-associated microbiota of cd patients at the time of surgical resection and months later using fish analysis. they found that a reduction of a major member of firmicutes, faecalibacterium prausnitzii, is associated with a higher risk of post-operative recurrence of ileal cd. this study was conducted as part of a double-blind controlled trial that compared the efficiency of the probiotic l. johnsonii la strain and a placebo to decrease endoscopic recurrence after curative surgery for cd. although the whole human trial included patients, the present study, included only a subset of these patients. f. prausnitzii a e (dsm ), isolated from human fecal stool, was grown at c in lyhbhi medium (braineheart infusion medium supplemented with . % yeast extract (difco) and mg/l hemin) supplemented with cellobiose ( mg/ml; sigma-ealdrich), maltose ( mg/ml; sigma), and cysteine ( . mg/ml; sigma) in an anaerobic chamber. a lower proportion of f. prausnitzii on resected ileal crohn mucosa was also associated with endoscopic recurrence at months. the authors observed the antinflammatory effects in both in vitro (cellular models) and in vivo [ , , -trinitrobenzenesulphonic acid (tnbs)-induced] colitis in mice to evaluate the immunomodulatory properties of f. prausnitzii in caco- cells transfected with a reporter gene for nf-kb activity. the study showed the following results: ) f. prausnitzii had no effect on il- beta-induced nf-kb activity, whereas the supernatant abolished it; ) in vitro pbmc stimulation by f. prausnitzii led to significantly lower il- and ifn-gamma production levels and higher secretion of il- ; ) oral administration of either live f. prausnitzii or its supernatant markedly reduced the severity of tnbs colitis and tended to correct the dysbiosis associated with tnbs colitis, as demonstrated by real-time quantitative pcr (qpcr) analysis. in conclusion these results show that f. prausnitzii is an anti-inflammatory bacterial candidate. this bacterium exhibited anti-inflammatory effects, partly due to secreted metabolites blocking nf-kb activation and il- secretion. in vivo effects were associated with a decrease in proinflammatory colonic cytokine synthesis and with the induction of anti-inflammatory cytokine secretion. counter balancing dysbiosis, using the commensal bacterium f. prausnitzii as a candidate probiotic agent, appears to be a promising strategy in cd treatment. further clinical studies are required to establish the diagnostic tools to define the best population of patients for this probiotic species, and especially whether the clinical benefit is more pronounced in patients with low levels of endogenous firmicutes. vilela et al. evaluated the influence of saccharomyces boulardii on the intestinal permeability in cd. the authors randomized thirty-four patients according to the vienna classification for treatment with either placebo or saccharomyces boulardii. the first group, consisting of patients, received a placebo every h as an oral capsule containing mg cellulose, mg sucrose and . mg magnesium stearate. the second group, consisting of patients, received s. boulardii every h as an oral capsule formulation which contained mg lyophilized s. boulardii (about  cells), mg sucrose and . mg magnesium stearate (floratil Ò ). a third group, consisting of healthy volunteers, aged between and years, (mean age years), who agreed to take part in the study, within the ethical norms of human research, were submitted to intestinal permeability tests in order to establish control values. they were not assigned to any kind of treatment. baseline medications (mesalamine, azathioprine, prednisone, metronidazole and/or thalidomide) were maintained. intestinal permeability (l/m ratio) was evaluated immediately before the beginning of treatment and at the end of the first and third treatment month. the authors obtained the following results in volunteers, the l/m ratio was . ae . , whereas this value was . ae . in patients with cd (p ¼ . ). in the placebo group, there was an increase in l/m ratio by . ae . (p ¼ . ) at the end of the third month. in the s. boulardii group, there was an improvement in intestinal permeability, with a decrease in the l/m ratio by . ae . (p ¼ . ) in the same period. the previously described results bring the authors to the conclusion that patients with cd in remission present alterations in the integrity of the intestinal mucosal barrier according to l/m ratio. s. boulardii, added to baseline therapy, improves intestinal permeability but complete normalization was not achieved. fujimori et al. realized a study to assess the clinical usefulness of combined probiotic and prebiotic therapy in the treatment of active cd. ten active cd outpatients without history of operation for cd were enrolled (cd was diagnosed by established clinical, endoscopic, radiological and histological criteria.). their mean (ae) age was ae years and the main symptoms presented were diarrhea and abdominal pain. patients' initial therapeutic regimen of aminosalicylates and prednisolone failed to achieve remission. patients were thus initiated into a synbiotic therapy, consisting of both probiotics ( billion cfu daily) and prebiotics (psyllium . g daily). probiotics mainly comprised bifidobacterium and lactobacillus. patients were free to adjust their intake of probiotics or prebiotics throughout the trial. chron's disease activity index (cdai), international organization for the study of inflammatory bowel disease (ioibd) score and blood sample variables were evaluated and compared before and after the trial. the duration of the trial was . ae . months. by the end of therapy, each patient had taken a ae billion cfu daily probiotic dose, with six patients taking an additional . ae . g daily psyllium dose. seven patients had improved clinical symptoms following combined probiotic and prebiotic therapy. both cdai and ioibd scores were significantly reduced after therapy ( e , p ¼ . ; . e . , p ¼ . , respectively). six patients had a complete response, one had a partial response, and three were non responders. two patients were able to discontinue their prednisolone therapy, while four patients decreased their intake. there were no adverse events. high-dose probiotic and prebiotic cotherapy can be safely and effectively used for the treatment of active cd. in conclusion, our study shows that synbiotic therapy can safely reduce cd activity and achieve its remission. we found that synbiotic therapy is especially indicated for cd patients with frequent diarrhea. further studies, examining such areas as fecal flora and scfas that compare cd patients with probiotics to cd patients with synbiotics, are expected. larger scale studies and randomized controlled studies on the treatment of cd with probiotic therapy in combination with prebiotics are clearly necessary for a fuller appreciation of the therapeutic value of synbiotics. chermesh et al. designed a prospective multicenter, randomized study. patients were randomized to active treatment or placebo in a : ratio. active treatment consisted of synbiotic , which contains a mixture of prebiotics and probiotics, including lactic acid bacteria and fermentable fibers. the four lactic acid bacteria are pediacoccus pentoseceus, l. raffinolactis, l. paracasei susp paracasei , and l. plantarum ; the fermentable fibers are . g b-glucans, . g inulin, . g pectin, and . g resistant starch. the authors checked if treatment with synbiotic could prevent post-operative recurrence in patients with cd. follow-up consisted of endoscopic, clinical, and laboratory parameters. thirty patients were enrolled. no differences were found between the treatment groups regarding gender, age at diagnosis, age at surgery, weight, smoking status, type of disease, length of the resected segment, or medical treatment prior to surgery. no difference in either endoscopic or clinical relapse rate was found between patients treated with once daily dose of synbiotic or placebo. in our small study, synbiotic had no effect on post-operative recurrence of patients with cd. larger studies in patients with the inflammatory type of cd undergoing surgery, using higher doses of probiotics cocktail, may prove effective. this study highlights that synbiotic had no effect on post-operative recurrence of patients with cd. van gossum et al. designed a multicenter clinical trial evaluating the efficacy of an oral administration of the probiotic l. johnsonii, (la , nestec) on early post-operative endoscopic recurrence of cd. seventy patients with cd were enrolled prior to elective ileo-caecal resection and randomly assigned after surgery to daily treatment with either lactobacillus johnsonii, ( cfu) (group a, n ¼ ) or placebo (group b, n ¼ ) for weeks. the treatment consisted of the probiotic la in freeze-dried form and blended with maltodextrin at cfu/day. the placebo was maltodextrin only. the la powder was supplied in foil sachets (weight g) containing cfu of probiotics. the placebo was a powder of the same appearance and weight, also in individual foil packets. both probiotics and placebo were administered in combination with an enteral formula at ml/day (acd , nunspeet, holland, konolfingen, switzerland). the identity of the treatment sachet was blind to patients, support staff, and investigators (numerical codes). treatment codes were broken only by the statistician after completion of the trial. the primary objective was to assess the effect of la on the endoscopic recurrence rate at weeks. stratification was performed according to smoking status at randomization. seven and patients were excluded in the la and placebo groups, respectively. in intention-to-treat analysis, the mean endoscopic score was not significantly different between the two treatment groups at months (la versus placebo: . ae . versus . ae . , treatment effect: p ¼ . , smoke effect: p ¼ . ). the percentage of patients with severe recurrence (i þ i ) was % and % in the la and placebo groups, respectively (p ¼ . ). using a per-protocol (pp) analysis, the mean endoscopic score was not significantly different between the two treatment groups (la versus placebo groups: . ae . versus . ae . , p ¼ . ). the percentage of patients with severe recurrence (i ae i ) was % and % in the la and placebo groups, respectively (p ¼ . ). clinical relapse rate clinical relapse rate > , with an increase of clinical relapse rate > points or greater from baseline in the la and placebo groups was % ( / ) and . % ( / ), respectively (pp analysis: chi-square test, p ¼ . and log-rank test: p ¼ . ). oral administration of the probiotic la in patients with cd failed to prevent early endoscopic recurrence at weeks after ileo-caecal resection. vasquez et al. analyzed and compared the mucosa-associated bacteria (mab) in non-inflamed and inflamed ileal mucosa of cd patients (n ¼ ). tissue samples from the inflamed ileal mucosa and from the adjacent non-inflamed ileal mucosa were taken from surgical resection specimens. the mab were investigated using fluorescence in situ hybridization with group-specific probes and temporal temperature gradient gel electrophoresis (ttge). samples from both non-inflamed and inflamed mucosa were taken from patients biopsies. the distribution of the bacterial populations was not different between non-inflamed and inflamed mucosa. the bacteroidetes phylum was dominant and accounted for % of mab ( e %) in non-inflamed tissues and % ( e %) in inflamed areas. the proteobacteria represented % ( e %) of mab both in non-inflamed and inflamed areas. the clostridium coccoides group (firmicutes phylum) represented % of mab in non-inflamed tissues versus % in inflamed areas. for most of the patients the similarity index between ttge paired profiles was very high. the authors conclude that the dominant mab do not differ between non-inflamed and inflamed ileal mucosa in cd. this fact argues against a localized dysbiosis to explain the patchy distribution of mucosal lesions. helicobacter pylori (h. pylori) is a small curved to spiral rodshaped bacterium found in the epithelial mucus surface of most patients with active gastritis. h. pylori is strongly associated with duodenal peptic ulceration and it is the main etiologic agent of chronic gastritis and gastric cancer and other gastric malignancies. today the therapy to eradicate this bacterium is based on a combination of antibiotics and proton pump inhibitors (ppi). the ( )c-urea breath test is the commonly used test to diagnose the presence of h. pylori in the stomach. the test also finds application to understand if h. pylori has been eradicated through a treatment with antibiotics. the urea breath test is based on the ability of h. pylori to break down urea, a chemical made up of nitrogen and carbon, into carbon dioxide which then is absorbed from the stomach and eliminated in the breath. for the test, patients swallow a capsule containing urea made from an isotope of carbon. if h. pylori is present in the stomach, the urea is broken up and turned into carbon dioxide. the carbon dioxide is absorbed across the lining of the stomach and into the blood. it then travels in the blood to the lungs where it is excreted in the breath. samples of exhaled breath are collected, and the isotopic carbon in the exhaled carbon dioxide is measured. if the isotope is detected in the breath, it means that h. pylori is present in the stomach. if the isotope is not found, h. pylori is not present. probiotics seem to have a direct antimicrobial effect, as shown through in vitro studies, through competition with h. pylori, inhibition of adherence and production of metabolites and antimicrobial molecules. implementation of probiotics with standard anti-h. pylori regimens can also improve patients' compliance with therapy, reducing the incidence of side effects associated with antibiotic treatment. kim et al. performed a study to evaluate whether the addition of probiotics to ppi-based triple therapy increases the success in the eradication of h. pylori. three hundred and forty-seven h. pylori infected patients were randomized into a triple-plus-yogurt group (yogurt group, n ¼ ) or a triple-only group (control group, n ¼ ). triple therapy consisted of ppi b.i.d., clarithromycin mg b.i.d., and amoxicillin g b.i.d. for days. the yogurt group received triple therapy for week and one bottle of will yogurt per day for weeks, starting on the first day of the triple therapy. will yogurt (a korean brand) contains l. acidophilus hy , l. casei hy , b. longum hy , and streptococcus thermophilusb- . ( ) c-urea breath test was performed for at least weeks after completion of the triple therapy. eradication rates, compliances, and adverse events were compared. with the intention to treat analysis the h. pylori eradication rates in the yogurt group . % ( of ) was similar to that in the control group . % ( of ) (p ¼ . ). however, by means of pp analysis, the eradication rate in the yogurt group, . % ( of ) was higher than that in the control group, . % ( of ) (p ¼ . ). common adverse events were metallic taste ( . %) and diarrhea ( . %). the frequency of adverse effects in the yogurt group . % ( / ) were higher than in the control group, . % ( of ) (p ¼ . ). however, most adverse events were mild to moderate in intensity, and the severities of adverse effects were similar in both groups (p ¼ . ). the authors conclude that, the addition of a yogurt to triple therapy does not decrease the adverse effects of the triple therapy. however it increases h. pylori eradication rate in pp analysis, suggesting a possibility that the addition of will yogurt, commercialized as a kind of food, into triple therapy, might be an option to increase the h. pylori eradication rate. imase et al. examined intestinal microbiota changes during h. pylori eradication therapy and the preventive effect of cbm as a probiotic agent. nineteen patients with gastro-duodenal ulcer were randomly divided into three groups: group a (without probiotics), group b (with regular doses of cbm ) and group c (with double doses of cbm ). cbm is a probiotic agent containing approximately cfu per tablet. the incidence of diarrhea and soft stools during h. pylori eradication therapy was % in group a and % in group b, while none of the patients in group c reported diarrhea or soft stools. both bacterial counts and detection rates of bifidobacteria and/or obligate anaerobe were decreased by eradication therapy. however, bacterial counts of obligate anaerobes in group c were significantly higher than in group a (p < . ). additionally, during eradication therapy, c. difficile toxin a was detected in both group a and group b but not in group c. the authors conclude that side effects associated with h. pylori eradication therapy, including diarrhea and/or soft stools, are considered attributable to disturbances in the composition of intestinal microbiota caused by antibiotics, and to toxin a produced by c. difficile. the results of our study also suggest that these symptoms can be prevented by concomitant administration of a viable bacterial preparation containing cbm . francavilla et al. tested whether lactobacillus reuteri atcc reduces h. pylori intragastric load in vivo, decreases dyspeptic reuteri symptoms, and affects eradication rates after conventional treatment. in a double-blind placebo-controlled study, h. pylori positive subjects were given l. reuteri or placebo once a day for weeks. l. reuteri or placebo were both provided by nóos (biogaia ab, sweden) as chewable tablets and included either l. reuteri each tablet containing cfu of l. reuteri atcc or placebo which consisted of tablets identical in taste and appearance to the active study product except for the absence of freeze-dried l. reuteri (and cryoprotectants). everyone underwent upper endoscopy, ( )c-urea breath test, and h. pylori stool antigen determination at entry and ( )c-urea breath test and h. pylori stool antigen (used as both qualitative and semiquantitative markers) after weeks of treatment. sequential treatment was administered subsequently to everyone. in vivo, l. reuteri reduces h. pylori load as semiquantitatively assessed by both ( )c-urea breath test deltavalue and h. pylori stool antigen quantification after weeks of treatment (p < . ). no change was shown in patients receiving placebo. l. reuteri administration was followed by a significant decrease in the gastrointestinal symptom rating scale as compared to pretreatment value (p < . ) that was not present in those ones receiving placebo (p ¼ not significant). no difference in eradication rates was observed. l. reuteri effectively suppresses h. pylori infection in humans and decreases the occurrence of dyspeptic symptoms. nevertheless, it does not seem to affect antibiotic therapy outcome. the authors report that a -week supplementation with l. reuteri is effective in reducing h. pylori bacterial load in humans and theoretically may help to control gastric inflammation. cindoruk et al. investigated the efficacy and safety of s. boulardii in the prevention of side-effects related to h. pylori eradication. the secondary aim of the study was to define the effect of s. boulardii on the eradication success of anti-h. pylori therapy. one hundred and twenty-four patients with h. pylori infection (male/ female: / , mean age: ae . year) receiving days of triple therapy (clarithromycin mg b.i.d., amoxicillin mg b.i.d., and lansoprazole mg b.i.d.) were randomly assigned to s. boulardii or placebo. dyspeptic symptoms were recorded using modified glasgow dyspepsia questionnaire (gdq). side-effect profile and tolerability were assessed using a symptom-based questionnaire. h. pylori status was rechecked weeks after completion of eradication therapy. h. pylori eradication rate, although higher in the treatment group, was statistically similar in treatment and control groups: % ( / ) versus . % ( / ), respectively (p > . ). nine ( . %) patients in the treatment group and ( . %) patients in the placebo group experienced diarrhea (p < . ). epigastric discomfort was more frequent in the control group [ ( . %) versus ( . %), respectively (p < . )]. diffuse abdominal pain, abdominal gas, taste disturbance, urticaria and nausea symptoms were similar in both groups. gdq scores after treatment were significantly better for treatment group (mean ae sd, range: . ae . ( e ) vs. . ae . ( e ), respectively; p < . ). the authors conclude that s. boulardii improves anti-h. pylori antibiotherapy-associated diarrhea, epigastric discomfort, and treatment tolerability. in addition, saccharomyces boulardii supplement decreases post-treatment dyspepsia symptoms independent of h. pylori status. addition of s. boulardii does not affect the rate of h. pylori eradication. scaccianoce et al. enrolled consecutive dyspeptic patients with h. pylori infection. patients received one of the following therapies: a) standard -day triple therapy; b) standard -day triple therapy plus l. reuteri supplementation; c) the same -day triple therapy plus a probiotic mixture; d) a -day standard triple therapy plus a probiotic mixture. h pylori eradication was checked using a ( )c-urea breath test performed e weeks after treatment. the authors observed that the -day therapy plus probiotic mixture tended to achieve higher eradication rate ( %). the lowest incidence of side effects was observed following the -day therapy plus l. reuteri ( %) and the highest one the -day therapy plus probiotic mixture ( %). the authors underline that there is no significant statistically difference between the therapy regimens. this study shows that e days triple therapy with or without probiotic supplement fails to achieve acceptable h. pylori eradication rates. colon cancer is a multi-factorial and complex neoplasm involving both genetics and environmental factors. there seems to be a strong relationship between colon cancer, diet and intestinal microflora. the rupture of the intestinal microflora equilibrium due to a bad diet seems to be related to an increase in the risk of developing colon cancer. liong underlines the different properties attributed to probiotics and prebiotics in the past years such as anti-carcinogenic, antimutagenic properties, ability of modifying differentiation processes in tumor cells, production of scfas and alteration of tumor gene expressions but he also evidences that, despite all the positive findings, other researchers have also reported insignificant colon cancer protective effects. certain bacterial species in the colon produce harmful substances that seem to be correlated to cancer. that is why it has been thought that probiotics may modulate several major intestinal functions potentially associated with the development of colon cancer preventing the growth of deleterious organisms, producing anticarcinogenic substances and moving the balance of gut bacteria in favour of the ones beneficial for the organism. colon cancer has been correlated to high fat diets and it is thought to be due to colon raised levels of bile acids which help digest fat. these salts are released into the small intestine, and also re-absorbed there, but some may pass into the colon. the break down products of bile may have a cytotoxic effect on the cells lining the colon, increasing cell proliferation and possibly cancer. probiotic modulation of the intestinal microflora may affect the activity of one of the enzymes ( a-dehydroxylase) forming these toxic products but probiotics may also reduce the toxicity of bile salts binding to them. while growing in the colon, probiotics seem to exert different functions such as controlling the growth of potentially harmful bacteria, binding to mutagens, preventing harmful enzyme activity in the gut (b-glucoronidase, nitroreductase), interacting with the cells of the colon, forming conjugated linoleic acid, a compound with antiinflammatory properties that may inhibiting the development of cancer. it may also increase levels of butyric acid in the colon which is an important energy source and growth regulator for colon cells, stimulating the activity of beneficial enzymes that inactivate carcinogens (glutathione s transferase) and the immune system, and produce products that have a beneficial effect on the cells of the colon (lactobacillus and bifidobacterium produce lactic acid and similar scfas increasing the gut lumen acidity). moreover takeda et al. suggest that daily intake of lactobacillus casei strain shirota provides a positive effect on the activity of nk cells which seem to exert a key role in protecting the human organism against cancer. hatakka et al. examined fecal b-glucosidase, b-glucuronidase, and urease activities during administration of l. rhamnosus lc (lc ) together with propionibacterium freudenreichii ssp shermanii js (pjs). thirty-eight healthy men participated in this randomized, double-blind, placebo-controlled, two-period crossover study with treatment periods of weeks. subjects consumed daily bacterial or placebo capsules. bacterial capsules contained viable lc and pjs. lc (dsm ) and pjs (dsm ), which are commonly used in the manufacture of ripened, semi-hard cheeses. the freeze-dried bacteria were filled in gelatine capsules. the subjects consumed daily two capsules containing viable lc and pjs (  cfu of each strain daily) or two placebo capsules. the same amount of this particular bacterial combination had previously shown physiological effects in two human studies. the amount of bacteria in the capsules remained unchanged during the study. in addition to the bacteria, the capsules contained microcrystalline cellulose as a filler. the placebo capsules were of identical composition but without the bacteria. subjects were instructed to take the capsules daily with the first meal of the day. the activities of b-glucosidase, b-glucuronidase and urease, recovery of lc and pjs, and counts of total lactobacilli and propionibacteria were determined from feces. the mean fecal counts of total lactobacilli and propionibacteria as well as lc and pjs strains were significantly increased during the administration of bacteria ( . -, -, -and -fold, respectively). b-glucosidase activity decreased by % (p ¼ . ) and urease activity by % (p ¼ . ) during bacterial supplementation versus placebo. the change in b-glucosidase activity was negatively correlated with the change in propionibacteria counts (r ¼ À . , p ¼ . ), being À . versus . nmol/min/mg protein in subjects with increased and unchanged/decreased propionibacteria, respectively (p ¼ . ). in conclusion, the administration of lc and pjs was followed by an increase in the fecal counts of lactobacilli and propionibacteria and a decrease in the activity of b-glucosidase with increasing counts of propionibacteria. the authors conclude that the administration of lc together with pjs was associated with a decrease in b-glucosidase activity related to the increasing counts of propionibacteria, although we found no significant influence on the activity of three bacterial enzymes, b-glucosidase, urease and bglucuronidase, compared to placebo. to evaluate the effect of the carcinogenic potential of those enzymes and the safety of those strains further studies are warranted. roller et al. investigated whether daily intake of an syn modulates immune functions. in a randomized double-blind, placebo-controlled trial, thirty-four colon cancer patients who had undergone 'curative resection' and forty polypectomized patients participated. subjects of the syn group daily received encapsulated bacteria (  cfu of l. rhamnosus gg and  cfu of bifidobacterium lactis bb (bb )) and g of inulin enriched with oligofructose. controls received encapsulated maltodextrin and g of maltodextrin. prior to intervention (t ), and (t ) and weeks after the start of the intervention (t ), phagocytic and respiratory burst activity of neutrophils and monocytes, lytic activity of nk cells and production of il- , il- and il- , as well as tnf-alpha and ifn-gamma by activated pbmc were measured. in feces, the concentrations of transforming growth factor-b and prostaglandin e were measured. il- secretion by activated pbmc from the polypectomized group increased significantly between t or t and t (p < . ). in the cancer group, syn treatment resulted in an increased capacity of pbmc to produce ifn-gamma at t (p < . ). other immunity-related parameters were not affected by syn treatment, neither in the cancer nor in the polypectomized group. in conclusion, supplementation with this syn has minor stimulatory effects on the systemic immune system of the two study groups. the authors conclude thatno negative effects were observed in cancer and polypectomized patients with daily consumption of this syn for weeks, but more definitive testing is required to indicate conclusively that this product is safe. the syn supplement had only minor effects on the immune system of the subjects in both groups. it is possible that syn supplementation in humans preferentially affects the gut-associated lymphoid tissue rather than the systemic immune system. rafter et al. verified whether the prebiotic concept (selective interaction with colonic flora of nondigested carbohydrates), as induced by a synbiotic preparation oligofructose-enriched containing inulin (beneosynergy ; orafti, tienen, belgium; syn ), l. rhamnosus gg and bb , is able to reduce the risk of colon cancer in humans. the week randomized, double-blind, placebocontrolled trial of a synbiotic food composed of the prebiotic syn and probiotics l. rhamnosus gg and bb was conducted in colon cancer patients and polypectomized patients. treatment consisted of a synbiotic preparation that contained the prebiotic syn and the probiotic strains bb and lactobacillus delbreuckii subspecies rhamnosus strain gg. syn is an oligofructose-enriched inulin preparation. fecal and blood samples were obtained before, during, and after the intervention, and colorectal biopsy samples were obtained before and after the intervention. the effect of synbiotic consumption on a battery of intermediate biomarkers for colon cancer was examined. synbiotic intervention resulted in significant changes in fecal flora: bifidobacterium and lactobacillus increased and clostridium perfringens decreased. the intervention significantly reduced colorectal proliferation and the capacity of fecal water to induce necrosis in colonic cells and improve epithelial barrier function in polypectomized patients. genotoxicity assays of colonic biopsy samples indicated a decreased exposure to genotoxins in polypectomized patients at the end of the intervention period. synbiotic consumption prevented an increased secretion of il- by means of pbmc in the polypectomized patients and increased the production of interferon in the cancer patients. the authors conclude that the synbiotic intervention results in significant alterations in the composition of the colonic bacterial ecosystem, which presumably has consequences for the metabolic activity of the colon. these results also provide indirect evidence that some of the consequences of the synbiotic intervention might be a decreased exposure of the epithelium to cytotoxic and genotoxic agents, a decreased colonic cell proliferation and an improved mucosa structure. diarrhea is an increase in the water content, frequency, and volume of bowel movements. probiotics could be important for the treatment of diarrhea illnesses (viral diarrhea, antibiotic-associated diarrhea, clostridium difficile-related diarrhea, traveler's diarrhea (td)). viral gastroenteritis is characterized by watery diarrhea, vomiting, headache, fever, chills, and abdominal pain. the viruses that may be responsible for this condition are: rataviruses, caliciviruses, adenoviruses, astroviruses, toroviruses, coronaviruses and pestiviruses. citomegaloviruses are responsible for viral colitis. rotavirus is the most common cause of viral diarrhea and can injure the intestinal epithelium leading to malabsorption and can increase the secretion through the epithelium. the rotavirus has several ways of transmission: fecal-oral, through contaminated water supllies, poor hygiene, food and fomites. saavedra et al. reported that lactobacillus gg has been observed to decrease the rate of rotavirusassociated diarrhea and rotaviral shredding. moreover the author reported an interesting study which highlights that % of children treated with lactobacillus gg had an iga specific antibody-secreting cells (sasc) response to rotavirus versus % for placebo. another study performed on infants describes how infectious diarrhea was successfully treated adding a combination of bifidobacteria and streptococcus thermophilus to powdered formula. this study shows that the combination of b. bifidum and s. thermophilus also reduced the rate of rotavirus-associated diarrhea and decreased rotavirus shredding. td is a condition usually due to the ingestion of food and beverages contaminated by fecal matters. % of the cases are bacteria caused. the most common bacteria are enterotoxigenic e. coli and enteroaggregative e. coli, campylobacter jejuni, salmonella species and aeromonas species. some protozoa such as entamoeba histolytica and giardia lamblia or enteroviruses are generally minor causes of td. episodes of diarrhea are frequent side effects of antibiotic therapy. antibiotic therapy leads to an alteration of normal intestinal flora which may cause a loss of colonization resistance and an alteration of the metabolic functions of the normal flora. the first situation is followed by an abnormal growth of pathogenic organisms such as c. difficile, candida albicans, k.caytoca and salmonella spp which are responsible for toxigenic diarrhea. the second situation leads to a diminished digestion of non absorbable carbohydrates followed by osmotic water secretion and a diminished colic absorption of water and electrolytes caused by a diminished production of scfas resulting in diarrhea. dubey et al. conducted a double-blind randomized placebocontrolled study to evaluate efficacy and tolerability of vsl[sharp] (cd pharma india) in the treatment of acute rotavirus diarrhea in children. the patients were randomly assigned to receive days of oral treatment with vsl[sharp] probiotic mixture or placebo in addition to usual care for diarrhea. use of probiotic mixture vsl [sharp] in acute rotavirus diarrhea resulted in earlier recovery and reduced frequency of oral rehydration salt (ors) administration reflecting decreased stool volume losses during diarrhea without side effects. narayanappa et al. evaluated the efficacy and safety of bifilac in reducing the episodes (frequency) and duration of diarrhea induced by rotaviral infection and to evaluate the efficacy of bifilac to ameliorate the associated symptoms like dehydration and duration of rotaviral shedding in feces. the authors enrolled children aged between months and years and divided them into groups, one group received standard therapy þ placebo, the other group received standard therapy þ probiotic (bifilac) randomly. children were assessed for frequency and duration of diarrhea, a degree of dehydration, duration and volume of ors therapy, duration and volume of intra venous fluids and duration of rotaviral shedding. they conclude that synbiotic bifilac appears to be a safe and very effective adjuvant in the management of acute rotaviral diarrhea. henker et al. determined whether the stool frequency of infants and toddlers suffering from acute diarrhea could be normalized more quickly by administering the probiotic escherichia coli nissle (ecn) solution rather than by administering a placebo. the authors also assessed the safety of ecn. a total of children (aged e months) with acute diarrhea (>three watery or loose stools in h) were randomized to either a group receiving the probiotic ecn suspension (n ¼ ) or a group receiving the placebo suspension (n ¼ ) in a confirmative, double-blind clinical trial. depending on the age of patients, e ml per day of verum suspension ( viable ecn cells per millilitre) or placebo were administered orally. the causes of the diarrhea were viral rather than bacterial. ecn was found to be safe and well-tolerated, and it showed a significant superiority compared to the placebo in the treatment of acute diarrhea in infants and toddlers. basu et al. evaluated the role of l. rhamnosus gg as probiotic in acute watery diarrhea (awd). this randomized, controlled, blinded trial involved patients. the intervention group (n ¼ ) received ors with probiotic powder containing million cells of l. rhamnosus gg, while the control group (n ¼ ) received ors alone twice daily for a minimum period of days or till diarrhea ceased. during the study period all patients received ors and/or iv fluids for ongoing losses, and nutritional supplementation. none of them received any antibiotic or antidiarrhoeal medication. rotavirus was isolated in . %. there was no significant difference between treatment groups in the daily frequency or duration of diarrhea or vomiting or in the length of hospital stay. no complication was observed from the use of l. rhamnosus gg. l. rhamnosus gg supplementation did not decrease the frequency and duration of diarrhea and vomiting in children with awd, and does not reduce hospital stay in these patients. the efficacy of a combination of b. longum pl , l. rhamnosus kl a and l. plantarum pl for the prevention of antibioticassociated diarrhea in children was evaluated by szymanski et al. . seventy-eight children (age: months to years) with otitis media, and/or respiratory tract infections, and/or utis were enrolled in a double-blind randomized control trial in which they received standard antibiotic treatment plus a food supplement containing cfu of b. longum, l. rhamnosus and l. plantarum (n ¼ ) or a placebo (n ¼ ) orally twice daily for the duration of antibiotic treatment. patients receiving probiotics had a similar rate of diarrhea (>or ¼ loose or watery stools/day for > or ¼ h occurring during or up to weeks after the antibiotic therapy) as those receiving placebo (relative risk . , % ci . e . ). the mean number of stools per day was significantly lower in the experimental group (mean difference À . stool/day, % ci À . to À . ). no adverse events were reported. concluding the three probiotics do not significantly alter the rate of diarrhea, although they reduce the frequency of stools per day. the authors underline the overall frequency of diarrhea was surprisingly low even though these results should be interpreted with caution. ruszczynski et al. enrolled children with common infections (aged months to years) in a double-blind, randomized, placebocontrolled trial to assess the efficacy of administration of l. rhamnosus for the prevention of antibiotic-associated diarrhea in children. they received standard antibiotic treatment plus  cfu of a probiotic (l. rhamnosus strains e/n, oxy and pen) (n ¼ ) or a placebo (n ¼ ), administered orally twice daily throughout antibiotic treatment. any diarrhea (>or ¼ loose or watery stools/ day for > or ¼ h occurring during or up to weeks after the antibiotic therapy) occurred in nine ( . %) patients in the probiotic group and in ( %) patients in the placebo group (relative risk, rr . , % ci . e . ). three ( . %) children in the probiotic group developed diarrhea caused by clostridium difficile or otherwise unexplained diarrhea compared to nine ( . %) in the placebo group (rr . , % ci . e . ). no adverse events were observed. this study shows that administration of l. rhamnosus (strains e/n, oxy and pen) to children receiving antibiotics reduces the risk of any diarrhea. beausoleil et al. designed a study to assess the efficacy and safety of a fermented milk combining l. acidophilus and l. casei that is widely available in canada, in the prevention of antibiotic-associated diarrhea (aad). this double-blind, randomized study ivolved hospitalized patients which were randomly assigned to receive either a lactobacilli-fermented milk or a placebo on a daily basis. aad occurred in seven of patients ( . %) in the lactobacilli group and in of patients ( . %) in the placebo group (or . , % ci . to . ; p ¼ . ). the median hospitalization duration was eight days in the lactobacilli group, compared with days in the placebo group (p ¼ . ). the study shows that the daily administration of a lactobacilli-fermented milk was safe and effective in the prevention of antibiotic-associated diarrhea in hospitalized patients. hickson et al. designed a study involving hospital patients (mean age ) taking antibiotics. this randomized double-blind placebo-controlled study aimed at determining the efficacy of a probiotic drink containing lactobacillus for the prevention of any diarrhea associated with antibiotic use and caused by clostridium difficile. the patients received g ( ml) drink containing l. casei, l bulgaricus, and s. thermophilus twice a day during a course of antibiotics and for one week after the course finished. the placebo group received a longlife sterile milkshake. / ( %) of the probiotic group developed diarrhea associated with antibiotic use compared with / ( %) in the placebo group (p ¼ . ). logistic regression to control for other factors gave an or . ( % . to . ) for the use of the probiotic, with low albumin and sodium also increasing the risk of diarrhea. the absolute risk reduction was . % ( . %e . %), and the number needed to treat was ( e ). no one in the probiotic group and / ( %) in the placebo group had diarrhea caused by c. difficile (p ¼ . ). the absolute risk reduction was % ( %e %), and the number needed to treat was ( e ). they conclude that the consumption of a probiotic drink containing l casei, l bulgaricus, and s. thermophilus can reduce the incidence of aad and c. difficile associated diarrhea. wenus et al. , to study the preventive effect of a milk drink fermented with multistrain probiotics on aad, designed a doubleblind placebo-controlled study involving patients randomized to ingestion of a fermented milk drink containing l. rhamnosus gg, la- and bb- (n ¼ ) or placebo with heat-killed bacteria (n ¼ ), during a period of days. sixty-three patients completed the study according to the protocol; two patients ( . %) in the treatment group and eight ( . %) in the placebo group developed aad (p ¼ . ). the relative risk of developing aad was . ( % ci: . e . ) when they were given probiotic milk drink. this study proves that a fermented multistrain probiotic milk drink may prevent four of five cases of aad in adult hospitalized patients. koning et al. studied the effect of a multispecies probiotic on the composition and metabolic activity of the intestinal microbiota and bowel habits in forty-one healthy volunteers. they were given mg amoxycillin twice daily for days and were randomized to either g of a multispecies probiotic, ecologic aad ( cfu/g), or placebo, twice daily for days. after collection, feces was analyzed as to the composition of the intestinal microbiota, and betaeglucosidase activity, endotoxin concentration, c. difficile toxin a, scfas, and ph were determined. bowel movements were scored according to the bristol stool form scale. mean number of enterococci increased significantly from log . at day to log . (day ) and log . (day ) cfu/g feces (p < . ) during probiotic intake. although no other significant differences were observed between both intervention groups, within each group significant changes were found over time in both microbial composition and metabolic activity. moreover, bowel movements with a frequency > or ¼ per day for at least days and/or a consistency > or ¼ for at least days were reported less frequently in the probiotic compared to the placebo group ( % vs %, p < . ). this study shows that, apart from an increase in enterococci, no significant differences in microbial composition and metabolic activity are observed in the probiotic compared with the placebo group. however, changes over time were present in both groups, which differed significantly between the probiotic and the placebo arm, suggesting that the amoxycillin effect was modulated by probiotic intake. the intake of a multispecies probiotic significantly reduced diarrhea-like bowel movements in healthy volunteers receiving amoxicillin. sabia et al. focused on plasmid transfer by mating, a process that can occur in the gut microbiota. this process is particularly important when antibiotic-resistant genes are involved. the authors investigated the in vitro capability of two l. plantarum strains (one bacteriocin producer and one non producer) to interfere with the conjugation processes. different matings were performed adding to the donor and recipient cells l. plantarum d bac and l. plantarum / bac as agents of interference. conjugations added with a staphylococcus aureus strain or without any agent of interference were used as controls. both lactobacillus strains were able to decrease mating frequency. statistically significant differences in the viable transconjugants were obtained in the presence and in the absence of the lactobacilli. the effect was almost the same with the two l. plantarum independent of bacteriocin production. in the trial performed with streptococcus aureus, no decrease in mating frequency was observed, confirming that the capability to interfere with r-plasmid transfer ability can be a property of the tested l. plantarum strains. hoesl et al. focused on some interesting studies involving the admnistration of oxalobacter formigenes (discovered in ), a bacterium responsible for the degradation of oxalate in the human body. several studies showed a link between a lack of colonization by o. formigenes and a recurrence of oxalate stone formation. moreover, among the stone formers, a lack of o. formigenes is associated with hyperoxaluria. a higher urinary oxalate excretion in female calcium oxalate formers with recurrent uti may be associated with the application of antibiotics and a subsequent eradication of o. formigenes. a permanent decolonization was also found in cystic fibrosis patients. the authors analyzed some clinical trials involving humans who followed administration of mg of o. formigenes strain; hcl urinary oxalate excretion and oxalate/creatinine ratios were found to be reduced; o. formigenes was used in a first time cinical trial involving children, seven of whom still have functioning kidneys and two with end-stage kidney failure all affected by primary hyperoxaluria type i, an inherited, life threatening disease characterized by recurrent oxalate stone formation, nephrocalcinosis and eventual liver and kidney failure. administering daily teaspoonfuls of a frozen cell paste of live o. formigenes (ixoc- ) oxalate excretion in the urine of the children with functioning kidneys decreased between percent and percent followed by a gradual increase after the treatment was stopped. in the two children on renal dialysis a significant reduction in blood levels of oxalate was observed. in hoppe et al. designed a new study orally administering oxalobacter for weeks as frozen paste, ixoc- or as entericcoated capsules (ixoc- ). nine patients (five with normal renal function, one after liver-kidney transplantation, and three with renal failure) completed the ixoc- study. seven patients (six with normal renal function and one after liver-kidney transplantation) completed the ixoc- study. the preliminary obtained data indicate that oxalobacter formigenes is safe, leads to a significant reduction of either urinary or plasma oxalate, and is a potential new treatment option for primary hyperoxaluria. skovbjerg et al. designed a double-blind pilot/preliminary study involving children with long-standing secretory otitis media (som ¼ a pathology characterized by persistent fluid in the middle ear cavity) who were scheduled for insertion of tympanostomy tubes. they were randomized to nasal spray treatment with streptococcus sanguinis, l. rhamnosus or placebo for days before surgery. clinical evaluation was carried out after days of treatment. middle ear fluid (mef) was collected during surgery for quantification of cytokines and detection of bacteria by culture and pcr. nasopharyngeal swabs were obtained before treatment and at surgery. the authors observed that complete or significant clinical recovery occurred in / patients treated with s. sanguinis compared to / patients in the placebo group (p < . ). in the l. rhamnosus treatment group, / patients were cured or much better (p ¼ . compared with placebo). spray treatment did not alter the composition of the nasopharyngeal flora or the cytokine pattern observed in the nasopharynx or mef, except for a higher level of il- found in the nasopharynx of l. rhamnosus treated children. although the mechanisms for the effect remains to be investigated this study shows that spray treatment with s. sanguinis may be effective against som. probiotics seem to play an important role in the lumen of the gut elaborating antibacterial molecules such as bacteriocins. moreover they seem to be able to enhance the mucosal barrier increasing the production of innate immune molecules, including goblet cellederived mucins and trefoil factors and defensins produced by intestinal paneth cells. some strains promote adaptive immune responses (secretory immune globulin a, regulatory t cells, il- ). some probiotics have the capacity to activate receptors in the enteric nervous system, which could be used to promote pain relief in the setting of visceral hyperalgesia. moreover probiotics exert an important action improving the abnormalities of both the colonic flora and the intestinal microflora. they could be effective for treating various pathologies preventing the dysbiosis which characterizes or is associated with these conditions. further future clinical trials, involving large numbers of patients, will be mandatory to achieve definite evidence of the preventive and curative role of probiotics in medical practice. details about correct formulations in terms of amount of bacteria, viability and associated growth factors, will be required in order to standardize the administration schedule and achieve homogeneous, comparable results on selected cohorts of recruited patients. microbes in gastrointestinal health and disease the normal intestinal microbiota microecology, obesity, and probiotics. current opinion in endocrinology gut microbiota and its possible relationship with obesity a publication of the institute of food technologists' expert panel on food safety and nutrition probiotics e friendly bacteria with a host of benefits. dairy council of california effects of gut microbiota on the brain: implications for psychiatry intestinal microbiota during infancy and its implications for obesity prospettive terapeutiche dei batteri lattici. teoria e applicazioni nel dismicrobismo intestinale the gut microbiota shapes intestinal immune responses during health and disease targeting the human microbiome with antibiotics, probiotics, and prebiotics: gastroenterology enters the metagenomics era probiotics: potential pharmaceutical applications nutritional aspects of short-chain fructooligosaccharides: natural occurrence, chemistry, physiology and health implications witherly dietary supplement of neosugar alters the fecal flora and decreases activities of some reductive enzymes in human subjects influence of dietary neosugar on selected bacterial groups of the human faecal microbiota undigestible sugars in food products proliferation of bifidobacteria by oligasaccharides and their effetc on human health effetcts of fructooligosaccharides on intestinal flora and human health benefits of oral supplementation with symbiotic zir fos (bifidobacterium longum w þ fos actilight) sunbiotic containing bifidobacterium animalis and inulin increases stool frequency in elderly healthy people bifidobacterium longum with fructo-oligosaccharide (fos) treatment in minimal hepatic encephalopathy: a randomized, double-blind, placebocontrolled study effects of prebiotics on mineral metabolism monica di battista. i sinbiotici nella salute dell'apparato gastrointestinale probiotics that modify disease risk survival and therapeutic potential of probiotic organisms with reference to lactobacillus acidophilus and bifidobacterium spp dietary modulation of the human colonic microbiota: introducing the concept of prebiotics probiotics, prebiotics, and synbiotics: approaches for modulating the microbial ecology of the gut the safety of probiotics safety aspects and implications of regulation of probiotic bacteria in food and food supplements safety of probiotics: translocation and infection probiotic therapy in the prevention of pouchitis onset: decreased interleukin- beta, interleukin- , and interferon-gamma gene expression probiotics in infancy induce protective immune profiles that are characteristic for chronic low-grade inflammation effect of probiotic treatment on deranged neutrophil function and cytokine responses in patients with compensated alcoholic cirrhosis probiotic leuconostoc mesenteroides ssp. cremoris and streptococcus thermophilus induce il- and ifn-gamma production effect of probiotic lactobacillus rhamnosus gg intervention on global serum lipidomic profiles in healthy adults interleukin- is involved in the enhancement of human natural killer cell activity by lactobacillus casei shirota oral delivery of lactobacillus casei shirota modifies allergen-induced immune responses in allergic rhinitis short-term effect of chewing gums containing probiotic lactobacillus reuteri on the levels of inflammatory mediators in gingival crevicular fluid interference of lactobacillus plantarum with pseudomonas aeruginosa in vitro and in infected burns: the potential use of probiotics in wound treatment bacteriotherapy with lactobacillus plantarum in burns probiotics in primary prevention of atopic dermatitis effects of nonpathogenic gram-negative bacterium vitreoscilla filiformis lysate on atopic dermatitis: a prospective, randomized, double-blind, placebo-controlled clinical study probiotics in clinical practise: an overview probiotic study group. a differential effect of probiotics in the prevention of eczema and atopy: a double-blind, randomized, placebo-controlled trial probiotics in prevention of ige-associated eczema: a doubleblind, randomized, placebo-controlled trial probiotics and prebiotic galacto-oligosaccharides in the prevention of allergic diseases: a randomized, double-blind, placebo-controlled trial the treatment of pouchitis e is there a role for probiotics? probiotic administration in patients with ileal pouch-anal anastomosis for ulcerative colitis is associated with expansion of mucosal regulatory cells effect of enteral nutrition and synbiotics on bacterial infection rates after pylorus-preserving pancreatoduodenectomy: a randomized, double-blind trial probiotics reduce infectious complications after pancreaticoduodenectomy randomized clinical trial of effect of synbiotics, neomycin and mechanical bowel preparation on intestinal barrier function in patients undergoing colectomy multicenter randomized-controlled clinical trial of probiotics (lactobacillus johnsonii, la ) on early endoscopic recurrence of crohn's disease after lleocaecal resection perioperative synbiotic treatment to prevent postoperative infectious complications in biliary cancer surgery: a randomized controlled trial probiotics improve outcomes after roux-en-y gastric bypass surgery: a prospective randomized trial urogenital infections in women: can probiotics help? postgrad phase i trial of a lactobacillus crispatus vaginal suppository for prevention of recurrent urinary tract infection in women clinical study comparing probiotic lactobacillus gr- and rc- with metronidazole vaginal gel to treat symptomatic bacterial vaginosis improved cure of bacterial vaginosis with single dose of tinidazole ( g), lactobacillus rhamnosus gr- , and lactobacillus reuteri rc- : a randomized, double-blind, placebo-controlled trial effectiveness of lactobacillus-containing vaginal tablets in the treatment of symptomatic bacterial vaginosis human lactobacilli as supplementation of clindamycin to patients with bacterial vaginosis reduce the recurrence rate; a -month, double-blind, randomized, placebocontrolled study nitazoxanide and probiotics for the treatment of recurrent clostridium difficile infection in a peritoneal dialysis patient inhibition of the accumulation of uremic toxins in the blood and their precursors in the feces after oral administration of lebenin, a lactic acid bacteria preparation, to uremic patients undergoing hemodialysis beneficial effects of bifidobacteria in a gastroresistant seamless capsule on hyperhomocysteinemia in hemodialysis patients diverticular disease of the colon: new perspectives in symptom development and treatment balsalazide and/or high-potency probiotic mixture (vsl# ) in maintaining remission after attack of acute mesalazine and/or lactobacillus casei in maintaining long-term remission of symptomatic uncomplicated diverticular disease of the colon world gastroenterology organisation global guideline clinical trial: effect of active lactic acid bacteria on mucosal barrier function in patients with diarrhoeapredominant irritable bowel syndrome effect of a symbiotic preparation on the clinical manifestations of irritable bowel syndrome, constipation-variant. results of an open, uncontrolled multicenter study use of probiotics in childhood gastrointestinal disorders single blind follow-up study on the effectiveness of a symbiotic preparation in irritable bowel syndrome lactobacillus and bifidobacterium in irritable bowel syndrome: symptom responses and relationship to cytokine profiles is bifidobacterium a more effective probiotic therapy than lactobacillus for patients with irritable bowel syndrome? probiotic agents in the treatment of irritable bowel syndrome bacillus coagulans significantly improved abdominal pain and bloating in patients with ibs randomized controlled treatment trial of irritable bowel syndrome with a probiotic e.-coli preparation (dsm ) compared to placebo probiotic effects on intestinal fermentation patterns in patients with irritable bowel syndrome clinical trial on the efficacy of a new symbiotic formulation, flortec, in patients with irritable bowel syndrome: a multicenter, randomized study a mixture of escherichia coli (dsm ) and enterococcus faecalis (dsm ) for treatment of the irritable bowel syndromeea randomized controlled trial with primary care physicians a double blind randomized controlled trial of a probiotic combination in patients with irritable bowel syndrome therapeutic effect of lactobacillus acidophilus-sdc , in patients with irritable bowel syndrome prescript-assistÔ probiotic-prebiotic treatment for irritable bowel syndrome: an open-label, partially controlled, -year extension of a previously published controlled clinical trial effect of a fermented milk containing bifidobacterium animalis dn- on the health-related quality of life and symptoms in irritable bowel syndrome in adults in primary care: a multicentre, randomized, double-blind, controlled trial a randomized doubleblind placebo-controlled trial of lactobacillus gg for abdominal pain disorders in children role of gut microflora and probiotic effects in the irritable bowel syndrome efficacy of an encapsulated probiotic bifidobacterium infantis in women with irritable bowel syndrome world gastroenterology organisation global guidelines synbiotic therapy (bifidobacterium longum/synergy ) initiates resolution of inflammation in patients with active ulcerative colitis: a randomised controlled pilot trial seksik philippe, langella philippe. faecalibacterium prausnitzii is an anti-inflammatory commensal bacterium identified by gut microbiota analysis of crohn disease patients influence of saccharomyces boulardii on the intestinal permeability of patients with crohn's disease in remission high dose probiotic and prebiotic cotherapy for remission induction of active crohn's disease failure of synbiotic to prevent postoperative recurrence of crohn's disease multicenter randomized-controlled clinical trial of probiotics (lactobacillus johnsonii, la ) on early endoscopic recurrence of crohn's disease after ileo-caecal resection patchy distribution of mucosal lesions in ileal crohn's disease is not linked to differences in the dominant mucosa-associated bacteria: a study using fluorescence in situ hybridization and temporal temperature gradient gel electrophoresis chae jung sung song hyun. the effects of probiotics on ppi-triple therapy for helicobacter pylori eradication takahashi shin'ichi. efficacy of clostridium butyricum preparation concomitantly with helicobacter pylori eradication therapy in relation to changes in the intestinal microbiota vito leonardo miniello. inhibition of helicobacter pylori infection in humans by lactobacillus reuteri atcc and effect on eradication therapy: a pilot study unal selahattin. efficacy and safety of saccharomyces boulardii in the -day triple anti-helicobacter pylori therapy: a prospective randomized placebocontrolled double-blind study triple therapy plus different probiotics for helicobacter pylori eradication effects of a fermented milk drink containing lactobacillus casei strain shirota on the human nk-cell activity the influence of lactobacillus rhamnosus lc together with propionibacterium freudenreichii ssp. shermanii js on potentially carcinogenic bacterial activity in human colon consumption of prebiotic inulin enriched with oligofructose in combination with the probiotics lactobacillus rhamnosus and bifidobacterium lactis has minor effects on selected immune parameters in polypectomised and colon cancer patients dietary synbiotics reduce cancer risk factors in polypectomized and colon cancer patients probiotics and infectious diarrhea drug prophylaxis for traveleres' diarrhea. cid use of vsl[sharp] in the treatment of rotavirus diarrhea in children: preliminary results randomized double blinded controlled trial to evaluate the efficacy and safety of bifilac in patients with acute viral diarrhea the probiotic escherichia coli strain nissle (ecn) stops acute diarrhoea in infants and toddlers efficacy of lactobacillus rhamnosus gg in acute watery diarrhoea of indian children: a randomised controlled trial bifidobacterium longum pl , lactobacillus rhamnosus kl a, and lactobacillus plantarum pl in the prevention of antibiotic-associated diarrhea in children: a randomized controlled pilot trial clinical trial: effectiveness of lactobacillus rhamnosus (strains e/n, oxy and pen) in the prevention of antibiotic-associated diarrhoea in children effect of a fermented milk combining lactobacillus acidophilus cl and lactobacillus casei in the prevention of antibiotic-associated diarrhea: a randomized, double-blind, placebo-controlled trial use of probiotic lactobacillus preparation to prevent diarrhoea associated with antibiotics: randomised double blind placebo controlled trial prevention of antibiotic-associated diarrhoea by a fermented probiotic milk drink the effect of a multispecies probiotic on the intestinal microbiota and bowel movements in healthy volunteers taking the antibiotic amoxycillin interference of lactobacillus plantarum strains in the in vitro conjugative transfer of r-plasmids the probiotic approach: an alternative treatment option urology oxalobacter formigenes: a potential tool for the treatment of primary hyperoxaluria type spray bacteriotherapy decreases middle ear fluid in children with secretory otitis media unraveling mechanisms of action of probiotics the authors contributed equally to this work. this review was not supported by grants. the authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. the authors hereby certify that all work contained in this review is original work of tommaso iannitti and beniamino palmieri. all the information taken from other articles, including tables and pictures, have been referenced in the "bibliography" section. the authors claim full responsibility for the contents of the article. key: cord- - luhd s authors: järvelä, sanna; rosé, carolyn p. title: advocating for group interaction in the age of covid- date: - - journal: int j comput support collab learn doi: . /s - - - sha: doc_id: cord_uid: luhd s nan by now the refrain "we are living in unprecedented times" has become inexorably a mark of discourse, which will continue to evoke memories that as yet are too near and too raw to fully enumerate here. in a very short time, the whole world reached deep into its ingenuity and resourcefulness to rapidly transition to fully online education, work and life itself while living in various levels of isolation, sometimes under "shelter in place" orders. surrounded in some cases by innumerable loss and grief, weighed down by additional responsibilities, changing restrictions, and insecurity of basic resources, we as a global society reached out online for family, friends, and colleagues, and rediscovered that people are everything. at the same time we have entered into a worldwide process of mediated sensemaking and search for a path forward. in the midst of all this, we have taken the leap to a reality of online instruction shared by students, teachers, parents, administrators as well as researchers. most of the scientific communities have struggled to arrange their teaching online, continue their research work, and reschedule experiments, meetings and conferences. as co-editors-in-chief, we have observed the consequences of these happenings in our journal in terms of delays and challenges in the editorial process at all levels. nevertheless, thanks to the collective hard work of the journal team writ large, we are pleased to bring you this june issue of the international journal of computer-supported collaborative learning, which offers a scientific contribution to the global challenges continuing to mount. indeed, the need for effective virtual teamwork and computer-supported collaborative learning has never been as important as it is today, not only for the impact it has on learning, but also as it offers an amelioration for the isolation that has been felt by some more keenly in recent months than ever before. the four papers of this issue contribute to two topical themes: namely, studies of regulation strategies and new methods for scaling up design and evaluation, both of which are critical themes at this time in the history of our field. nadine melzner, martin greisel, markus dresel and ingo kollar argue in their study "regulating self-organized collaborative learning: the importance of homogeneous problem perception, immediacy and intensity of strategy use" that cscl research has not extensively addressed self-organized collaborative learning thus far. their study is quite timely, as during the current covid- situation, self-organized, technology-supported study groups might be even more frequent than in the past, and a better understanding of this phenomenon contributes insights to needs that must be addressed in future cscl research. more specifically, melzner and colleagues systematically explore and then report on regulation problems such self-organized study groups encounter during their learning process and how they try to cope with these problems, either effectively or ineffectively. in a longitudinal study students voluntarily studied for their exams in self-organized groups. they tested the hypotheses that members of self-organized study groups are more satisfied with their group learning experience (a) the more homogeneous their problem perceptions are within their group, (b) the more they apply immediate strategies to remedy their regulation problems, and (c) the more intensively they apply regulation strategies. questionnaire data was collected in which the students were asked to indicate the types of problems they experienced, the types of strategies they used to tackle those problems, and their satisfaction with their group learning experience after each of their self-organized study meetings. hierarchical linear modeling confirmed all their hypotheses. in addition, they selected two groups' self-reported situational data for qualitative analysis in order to offer additional insights into the mechanisms that may have contributed to the results. the melzner et al. study contributes insights to the cscl field that uncover what differentiates successful from less successful self-organized collaborative learning groups. in addition, their study brings a new concept to characterize regulation in collaborative learning, namely homogeneity of problem perception. in all, the results add to further research on how to design instructional support for computer-supported collaborative learning. deanna kuhn, noel capon and hueuyi lai discusse the fact that the complexity of collaborative cognition in naturalistic human settings makes it challenging to understand and study in their paper, entitled "talking about group (but not individual) process aids group performance". earlier research has shown that potential factors influencing group success in achieving an acceptable solution to a problem fall into two broad categories, namely attributes of the individual group members and attributes of the group as a whole (miyake and kirschner ) . individual factors point, e.g., to cognitive, social and personality factors while group factors deal with patterns of relationship among individual factors, such as similarity of group members or mixed cognitive abilities or personality. those studies have characterized a group's functioning and analyzed how patterns of collaboration emerge and develop (e.g., siqin et al. ) . in the kuhn et al. study, the discourse of small groups in a graduate business course was audio-recorded as they participated in a computer-supported simulation in which the group worked over a series of eight sessions in making decisions related to a business case. discourse transcripts were analyzed using a coding scheme distinguishing statements addressing the subject matter and meta-level statements that classified utterances expressed him/herself ("meta-self") and meta-talk referring to one or more members of the group or the group as a whole ("meta-group"). the questionnaire included questions pertaining to how well the group worked together and the relative contributions of individual members, which were distributed to each participant to complete individually at three points in time. the results of their study point to the importance of meta-level discourse about group process in a group's achieving coordinated action and a successful outcome. their analysis further suggests that discourse about the group's process, but not discourse about individuals' actions, was associated with superior group outcomes. the results show that meta-level talk about the group's activity stands to benefit the group's performance. talk referring only to individual performance, in contrast, did not show this effect. these findings support the earlier notions of an important role for metacognition in collaborative learning; emerging as the interplay between individual and group level social interactions, identified as meta-level talk in this study. the results support the value of detailed observational analysis, employing both qualitative and quantitative indicators of the way in which groups undertaking a joint task talk to one another during the process and how differences in such talk relate to differences in group success. this work contributes to the ongoing discourse housed within our recent issues that have similarly offered complementary methodological approaches for understanding shared and interactive temporal process of collaborative learning (schneider et al. ; järvelä et al. ) and have marked out a role for metacognition, supporting the idea that effective metacognition is associated with better group outcomes (hadwin et al. ). the body of knowledge accumulated within the cscl field holds as uncontroversial the truth that collaborative learning is not best conducted in a spontaneous fashion, but careful design of collaborative learning will contribute to effective computer-supported collaborative learning (tchounikine ) . various ways to script, prompt and structure the process of collaboration and support the roles and participation have been developed during the past decade (wang et al. ). what has not yet received attention is how to evaluate the complete designs and their instructional alignment for improving productive cscl. lanqin zeng, panpan cui and xuan zhang propose design-centered research (dcr) as an emerging methodology that focuses on how to design interventions and evaluate instructional alignment between the design and its engagement in order to extract insights for improvement in later design iterations. in their study, entitled "does collaborative learning design align with enactment? an innovative method for evaluating alignment in the cscl context", zeng et al. analyzed and evaluated the alignment between an online collaborative learning design and its enactment using groups. twenty online collaborative learning activities were designed and implemented. the collaborative learning design plans for the second round were optimized after reflecting on the misalignment in the first round, and then executed again by another groups. the results indicated that the alignment significantly improved after optimizing the collaborative learning design. the findings also revealed that optimizing a collaborative learning design can improve group performance. finally, a collaborative learning design framework is proposed, and implications for practitioners are discussed. the main contribution of this study is that it proposes an innovative method for evaluating the alignment between a collaborative learning design and its enactment to optimize the collaborative learning design. three indicators were developed and applied, including the range of activated knowledge, the degree of knowledge building, and an interactive approach, which can be adopted to evaluate the alignment between a collaborative learning design and its enactment. their results show promise for practitioners since they revealed that optimizing a collaborative learning design can improve group performance. as the lanqin article contributes a methodology for quantifying how small groups have or have not met objectives in terms of processes and outcomes, the mohamad saqr article "capturing the participation and social dimensions of computer-supported collaborative learning through social network analysis: which method matters?" offers a methodology for analysis of collaboration processes at the scale of a whole community using social network analysis (sna). sna is a goto methodology for analysis of community level data, but one must keep in mind that "the devil is in the details". many decisions regarding exactly how to operationalize the network, which measures to apply to the network, and how to interpret the results lead to instability in findings and difficulty in integrating knowledge across studies. saqr's research addresses these critical concerns in its aim to provide robust and valid methods for measuring and better understanding participation by connecting sna methods to problems in understanding the social dimensions of collaborative learning at a grand scale. data from university courses provided the foundation for the investigation. the paper provides practical guidance for application of sna in terms of selection of appropriate network representation as well as metrics for each dimension. in particular, the study focuses on subtleties that distinguish alternative network centrality measures and evaluates them in terms of how reliable they may be as indicators of students' participatory efforts, social relations, and performance when calculated appropriately. as we as a society begin our journey back to the face-to-face world, including our classrooms, we face the danger that concerns regarding safety will result in so much focus on distancing, that we will recreate the isolation we felt when sheltered in our homes. as we make critical changes to preserve our health, we will need methods like saqr's to maintain our awareness of how the safety measures we employ affect the inner workings of our communities, including learning communities, from a social perspective. closing remarks as we look to the future the emerging post-covid world demands dynamic and streamlined collaborative innovation and problem solving across sectors at local, national and global levels. currently, society, education and industry have proven largely unprepared and untrained for this massive global event, and have scrambled to rapidly prototype tools and technologies to meet these demands on the fly. we, the ijcscl journal community, have as our aim to accumulate and house knowledge illuminating how to design the technological settings for collaboration and how people learn in the context of collaborative activity. thus, as co-editors-in-chief, we feel that it is our responsibility to shepherd the journal towards contribution to the current discourse exploring what post-covid education will become, and ensuring that the knowledge to keep the world connected rather than isolated in learning, work, and life continues to increase. to this end, we call for strong empirical research with multidisciplinary methodological and theoretical perspectives to address these issues particularly in these times. challenges in online collaboration: effects of scripting shared task perceptions capturing the dynamic and cyclical nature of regulation: methodological progress in understanding socially shared regulation in learning cambridge handbooks in psychology. the cambridge handbook of the learning sciences unpacking the relationship between existing and new measures of physiological synchrony and collaborative learning: a mixed methods study fixed group and opportunistic collaboration in a cscl environment contribution to a theory of cscl scripts: taking into account the appropriation of scripts by learners adaptable scripting to foster regulation processes and skills in computer-supported collaborative learning key: cord- -z t plvh authors: poulton, kay; wright, paul; hughes, pamela; savic, sinisa; welberry smith, matthew; guiver, malcolm; morton, muir; van dellen, david; tholouli, eleni; wynn, robert; clark, brendan title: a role for human leucocyte antigens in the susceptibility to sars‐cov‐ infection observed in transplant patients date: - - journal: int j immunogenet doi: . /iji. sha: doc_id: cord_uid: z t plvh we analysed data from patients who tested positive for sars‐cov‐ rna who had previously been hla typed to support transplantation. data were combined from two adjacent centres in manchester and leeds to achieve a sufficient number for early analysis. hla frequencies observed were compared against two control populations: first, against published frequencies in a uk deceased donor population (n = , ) representing the target population of the virus, and second, using a cohort of individuals from the combined transplant waiting lists of both centres (n = ), representing a comparator group of unaffected individuals of the same demographic. we report a significant hla association with hla‐ dqb * ( % vs. %; p < . ; or . ; % ci . – . ) and infection. a bias towards an increased representation of hla‐a* , hla‐drb * , hla‐drb * and drb * was also noted but these were either only significant using the uk donor controls, or did not remain significant after correction for multiple tests. likewise, hla‐a* , hla‐b* and hla‐c* may exert a protective effect, but these associations did not remain significant after correction for multiple tests. this is relevant information for the clinical management of patients in the setting of the current sars‐cov‐ pandemic and potentially in risk‐assessing staff interactions with infected patients. factor in an infected individual's ability to produce an effective immune response (ishibashi et al., ) . a number of in silico studies have defined the potential for immune responsiveness based on differential viral peptide binding to hla alleles (fast, altman, & chen, ; nguyen et al., ) . these are useful in vaccine design but do not represent the situation in natural infection where the full hla type of the individual, comprising up to twelve alleles across six loci, informs the capacity for immune response. this study investigated hla profiles of patients admitted with pcr-confirmed sars-cov- infection to identify any potential hla bias which might indicate an impaired capacity to mount an effective immune response to the infection. the information is of value towards risk stratification and clinical management of patients and potentially in risk-assessing staff interactions with infected patients. the aim of this study was to analyse the hla types of individuals receiving hospital care for covid- symptoms, where the hla type was already known. the inclusion criteria for this study were (a) that the patient must have been previously hla typed at least at hla-a, b, c, drb and dqb and (b) must have a positive test for the presence of sars-cov- rna. a total of patients were included in the study, from manchester and from the leeds transplant centre. data were combined from both units to achieve a sufficient number for early analysis. all patients included in the study had previously been hla typed to support transplantation and required hospital treatment for covid- disease, indicating that their symptoms were severe, requiring clinical support or intervention. patients included in the study were either kidney transplant patients (n = ), individuals on the solid organ transplant waiting lists (n = ), or patients who had received haematopoietic stem cell transplantation (n = ). for the leeds patients, the male:female ratio was : , and the median age was . years (range - years). for the manchester patients, the male:female ratio was : , and the median age was . years (range - years). hla typing had been performed using either of two methods: (a) labtype ® sso hla class i (hla-a, b and c) and hla class ii (drb / / / and hla-dq) loci (onelambda inc), or (b) next-generation sequencing (holotype hla™; omixon or trusight hla, illumina). all tests were performed according to manufacturers' instructions. hla frequencies were analysed at first field resolution, and where second field typing data were available, types were converted into a serological equivalent specificity for analysis. we have performed analyses against two control populations group a: a uk (n = , ) deceased donor pool (https://nhsbtdbe.blob. core.windows.net/umbrarco-assets-corp/ /antigen.pdf)and group b: a local (n = ) wait-listed renal patient cohort comprising the active wait list from leeds (n = ) and a randomly selected cohort (n = ) from the manchester centre. the rationale behind the use of two separate control groups was an acknowledgement that problems exist in respect of both. control group a is representative of the uk population and the infection target of the virus, but it lacks proportionate representation of black, asian and minority ethnic (bame) groups. comparisons made with transplant patient groups may be confounded by this variance. the advantage of using the control group a in the context of this study is, however, that it represents a population assembled prior to the sars-cov- pandemic. conversely, the n = cohort (group b) is derived by combining unselected individuals on the renal transplant waiting list from each centre, but the sars-cov- infection/exposure history of the group is uncertain and incorrect inferences may then be drawn from its use. alternative control groups were considered but precluded on the basis of the problems in their confident construction at this time. statistical analysis was performed using medcalc v . (medcalc software) to compare frequencies of allele group carriage between the patient and control populations using fisher's exact test. odds ratios were calculated at % confidence intervals (ci) using medcalc software. each allele group was compared independently, and p ≤ . was considered to be significant. bonferroni correction was applied to accommodate multiple testing within each locus tested (gaetano, ) . the allelic frequencies were assessed in all populations. allele group carriage is defined as the number of individuals carrying the respective allele group. allelic frequencies are defined as the number of occurrences of the respective allele group divided by the total number of allele groups in the cohort. an allele group was considered to raise the risk of viral susceptibility when the or was above and considered protective against viral susceptibility when or was below . allele group carriage frequencies for all specificities where associations which were significant, or approaching significance are included in table . seventeen of the top twenty most frequent hla haplotypes in the uk population (allelefrequencies.net) were represented in this cohort revealing a broad susceptibility to infection. when comparing our patients with control group a, there were more significant associations observed than when compared against control group b. the strongest associations observed in risk of viral susceptibility observed were with hla class ii specificities. after bonferroni correction, hla-dqb * remains a significantly increased risk when compared with group b controls, but not group group b: . % vs. . %; p = . , p c = not significant; or = . ci . - . , p = . , p c = not significant). when the broad specificities were considered independently, hla-dqb * was not significant in its correlation with viral infection, suggesting that the primary association lies with dqb * , rather than dq . with such a small cohort, it is not possible to ascertain whether these observations are due to linkage disequilibrium between hla-dr and dq, or whether this is an independent observation. for hla class i, hla-a* was also significantly increased in the patients compared with group a controls ( . % vs. . %; p = . , p c = . ; or = . cd t-cell response (dipiazza, richards, knowlden, nayak, & sant, ) . cal manifestations of the disease described as covid- . while almost all patients develop covid pneumonia, approximately % cases progress to acute respiratory distress syndrome which occurs - days after the onset of symptoms . furthermore, individuals who develop respiratory distress have often been responding well during the first phase of the disease, but their symptoms return aggressively, requiring clinical support within a hospital environment. this phenomenon is suggestive of an immunological hiatus, in which these individuals have been unable to effectively mature their immune response to generate the production of potent neutralizing antibody. in this series of individuals requiring admission following in- in this regard, hla-a* has previously been identified as a predisposing type to infection with visceral leishmaniasis (kala-azar; singh, agrawal, & rastogi, ) and has been associated with the development of epstein-barr virus-driven post-transplant lymphoproliferative disorder in solid organ transplantation (reshef et al., ) . the occurrence of other specificities potentially within the hla-a* superset is also noteworthy and is the subject of further work in our laboratories. we also note the prediction, based on an in silico analysis, for poor ability of the closely related antigen hla-a* to present a repertoire of sars-cov- epitopes in the current paper from nguyen et al. ( ) . this paucity would be expected to impact on the quality of the linked immune response to the virus. utilizing the immune epitope database analysis resource, tepitool (tepitool iedb analysis resource), we therefore examined the top potential epitopes (fast et al., ) for key sars-cov- proteins in regard to their binding affinity to hla-a* : . based on ic < nm, only one epitope (ftisvtte) was identified that would be predicted to support a t-cell-based immune response. this link between a real-world observation and an in silico predication provides validation of both findings. in this study, the individuals who were positive for hla-a* were not also positive for hla-drb * , although these have been documented to be inherited on the same haplotype (allelefrequencies.net). a study of sars-cov- -positive individuals in a uk biobank population has also identified drb * : (or = . , ci . - . ) and dqb * : (or = . , ci . - . ) to be associated with an increased likelihood of testing positive for the virus (kachuri et al., ) . this is an in silico study in which hla types have been imputed, but these observations add support to our own observation in regard to hla-dr and dq in this early study of individuals with known hla types. the upregulation of hla-dr expression in lung tissue of patients affected with covid pneumonia suggests that this process is instrumental in the immunological control of the disease process and therefore must be considered to be biologically relevant. hla-dr and dr ( ) have previously been implicated in patients with impaired response to cytomegalovirus infection (ishibashi et al., ) , while hla-dr ( ) has also been documented to be associated with severe response to infection with mers-cov (hajeer, balkhy, johani, yousef, & arabi, ) . hla-dr has also been proposed to be the vector mechanism for viral entry of epstein-barr virus into b cells, reinforcing the concept that the molecule itself may be a mechanism for driving viral infection li and cohen ( ) . a primary inefficiency of the alleles hla-dqb * and * cannot be discounted in this very early uk study, due to linkage disequilibrium. this study has been deliberately independent of ethnicity as the uk population in this region of england is genetically heterogeneous with multiple populations of different heritages co-existing. it could be argued that the use of the uk deceased donors as a control population in this study has simply highlighted more frequent occurrence of antigens common to bame communities in our covid- population requiring hospital support for their disease. conversely, it may be legitimately argued that the bame link with susceptibility is explained through possession of these antigens. while either point remains valid, other specificities common to bame groups such as hla-a* and drb * were not impli- these are obviously tentative findings based on a limited number of cases in two centres. an unbiased surveillance of the transplant population to include those with mild symptoms or no symptoms would help to clarify this observation. we are now seeking to accrue additional data in substantiation of the association and to extend the scope of our study to in order to establish its basis. https://orcid.org/ - - - paul wright https://orcid.org/ - - - brendan clark https://orcid.org/ - - - allele frequency net database identification of major histocompatibility complex class ic molecule as an attachment factor that facilitates coronavirus hku spike-mediated infection the role of cd t cell memory in generating protective immunity to novel and potentially pandemic strains of influenza potential t-cell and b-cell epitopes of -ncov. biorxiv, - holm-bonferroni sequential correction: an excel calculator ( . ) association of human leukocyte antigen class ii alleles with severe middle east respiratory syndrome-coronavirus infection clinical features of patients infected with novel coronavirus in wuhan association between antibody response against cytomegalovirus strain-specific glycoprotein h epitopes and hla-dr the landscape of host genetic factors involved in infection to common viruses and sars-cov- epstein-barr virus and the human leukocyte antigen complex human leukocyte antigen susceptibility map for sars-cov- association of hla polymorphisms with post-transplant lymphoproliferative disorder in solid-organ transplant recipients common and well-documented hla alleles over all of europe and within european sub-regions: a catalogue from the european federation for immunogenetics infectious diseases and immunity: special reference to major histocompatibility complex the laboratory tests and host immunity of covid- patients with different severity of illness self-reported symptoms of covid- including symptoms most predictive of sars-cov- infection are heritable a role for human leucocyte antigens in the susceptibility to sars-cov- infection observed in transplant patients key: cord- -vjsurl authors: okino, cintia hiromi; mores, marcos antônio zanella; trevisol, iara maria; coldebella, arlei; montassier, hélio josé; brentano, liana title: early immune responses and development of pathogenesis of avian infectious bronchitis viruses with different virulence profiles date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: vjsurl avian infectious bronchitis virus (ibv) primarily replicates in epithelial cells of the upper respiratory tract of chickens, inducing both morphological and immune modulatory changes. however, the association between the local immune responses induced by ibv and the mechanisms of pathogenesis has not yet been completely elucidated. this study compared the expression profile of genes related to immune responses in tracheal samples after challenge with two brazilian field isolates (a and b) of ibv from the same genotype, associating these responses with viral replication and with pathological changes in trachea and kidney. we detected a suppressive effect on the early activation of tlr pathway, followed by lower expression levels of inflammatory related genes induced by challenge with the ibv b isolate when compared to the challenge with to the ibv a isolate. cell-mediated immune (cmi) related genes presented also lower levels of expression in tracheal samples from birds challenged with b isolate at dpi. increased viral load and a higher percentage of birds with relevant lesions were observed in both tracheal and renal samples from chickens exposed to challenge with ibv b isolate. this differential pattern of early immune responses developed after challenge with ibv b isolate, related to the downregulation of tlr , leading to insufficient pro-inflammatory response and lower cmi responses, seem to have an association with a most severe renal lesion and an enhanced capability of replication of this isolate in chicken. avian infectious bronchitis virus (ibv) is a highly infectious causative agent of avian infectious bronchitis (ib), a disease of high economic impact, which affects poultry worldwide. ibv replicates primarily in tracheal epithelial cells, inducing several mucosal pathological changes, including ciliary loss, degeneration and necrosis of epithelial cells, glandular degeneration, inflammatory cell infiltration and epithelial hyperplasia [ , ] . after replication at primary site in tracheal mucosa, viraemia and ibv secondary replication are also found in other respiratory a a a a a tissues (nose, lungs and air sacs) and in many non-respiratory epithelial tissues (kidneys, testes, oviduct, and gastrointestinal tract). nephritis is commonly observed, mainly in broilers, and depending on the pathotype of the ibv strain and on the bird age, it may cause high mortality, and microscopic lesions of degeneration and necrosis of the renal tubular cells and interstitial inflammatory cell infiltrate [ , , , ] . prevention of ibv infection is currently achieved through vaccination, especially by attenuated viral vaccines, suggesting that local mucosal immunity is essential for induction of effective protection against disease [ , , ] . in a previous study, we demonstrated that the dose of attenuated vaccine administered by local route is closely related to humoral and cellular immune responses at tracheal mucosal sites and their ability to confer effective protection against disease [ ] . the continuous emergence of new ibv variants in several countries [ , , , , ] are routinely pointed out as a cause of outbreaks in vaccinated flocks, leading to significant economic losses to the poultry industry [ ] . despite the great number of ibv strains and variants described over the last years [ ] , most of the studies have been limited to the classification and differentiation of ibv strains in genotypes, pathotypes, protectotypes, and/or serotypes, while, the specific immune mechanisms involved in pathogenesis of this virus remains poorly elucidated. a recent study has observed differential early immune response after infection with ibv when comparing ibv-susceptible and ibv-resistant chicken lines. even before infection, specific genes, including genes related to innate immune response, were found to be differentially expressed in each chicken line. despite these differences, viral loads were similar in tracheal samples of both chicken lines, indicating that ibv resistance might be associated with how the birds respond to the virus and not how they can prevent an initial infection [ ] . the innate immune response is the first line of host defense against infections, and several immune and non-immune cells on mucosal surfaces are involved on recognition of pathogen associated molecular patterns (pamp) of microorganisms. pamps are recognized through pattern recognition receptors (prr), among which toll-like receptors (tlr) are an important group. during a rna-virus infection, activation of innate immune responses depends on the interaction of endosome-associated (tlr and tlr ) and/or cytosol-located (rig-i like receptors) prrs. tlr and tlr interact with double-stranded (ds) rna or single-strand (ss) rna, respectively, and the subsequent activation pathways for tlr and tlr are mediated by trif (tir-domain-containing adapter-inducing interferon-β) and myd (myeloid differentiation primary response gene ), respectively, which lead to the production of anti-viral type i interferons (ifnα and ifnβ) and pro-inflammatory cytokines (il β and il ) [ ] . expression of genes related to the tlr pathway activation and type i ifn were already found to be upregulated in tracheal samples from birds challenged with reference strains of ibv [ , , ] . the inducible nitric oxide synthase (inos or nos ), responsible for the production of nitric oxide (no) by macrophages in response against microbial infections, is often associated with synergic effects combined with acute phase proteins and cytokines, as ifns and tnfs, leading to enhanced phagocytosis. alternatively, an excessive production of inos and consequently no may have negative effects by promoting excessive inflammation or apoptosis [ , ] . although a previous report did not identify a change in inos transcripts in both tracheal and lung samples during the early phase of ibv infection [ ] , increased levels of this enzyme was associated with high degree of disease severity in chickens infected with avian influenza h n [ ] , and virulent newcastle disease [ ] . the important role of pro-inflammatory cytokines on ibv pathogenicity was demonstrated in a previous evaluation of the kinetics of the inflammatory and cell-mediated immune responses in tracheal mucosa of birds infected with the m strain of ibv. tnfsf and tgfβ transcripts were found to peak at day post infection (dpi), followed by higher upregulation of il , il β and ifnγ. these increased levels of pro-inflammatory cytokines were associated to highest scores of lesions and viral load at dpi, whereas later, at dpi, highest increases in cd and granzyme homolog a mrna expression were detected and associated to a significant decrease in lesions and viral load [ ] . it has been recognized that il is associated with development of tissue damage in chickens challenged with ibv, including nephritis [ ] . levels times higher of il mrna after ibv challenge were observed in an ibv-susceptible chicken line compared to the disease-resistant chicken line [ ] . high level of il gene expression were detected in renal samples of chickens challenged with a nephropathogenic ibv strain and it has been well correlated with viral load and influx of inflammatory cells in this organ [ ] . during the development of adaptive immunity against ibv infection, the local cell-mediated immune (cmi) response was associated with cd +, cd + and cd + cells influx in the trachea from to dpi with ibv [ , ] . furthermore, cd and other cmi related genes were markedly increased during secondary response related to memory protection induced by the first antigen ibv exposition at dpi ( ) . conversely, the cmi genes were found most upregulated later, at dpi, in the primary adaptive immune response of non-vaccinated chickens and correlated with high virus load in trachea, indicating this response might be more involved in the ibv pathogenesis in this post-infection period of non-immune chickens [ ] . mechanisms underlying immune-pathogenesis caused by ibv and those relating to viral clearance have begun to be elucidated [ , , , , , , , ] . however, there are no studies regarding the existence of differential pathological and immunological profiles induced by ibv strains or isolates differing in virulence for chickens. the aim of this study was to investigate and compare the pathogenesis and the innate and adaptive immune responses induced by the infection with two brazilian field isolates of ibv classified in the br-i genotype. two brazilian field isolates bi/br/embrapa/ / (accession number: ku , identified as ibv a isolate) and bi/br/embrapa/ / (accession number: ku , identified as ibv b isolate), were isolated from clinical cases of avian infectious bronchitis in poultry flocks located in southern brazil. virus isolation and titration were carried out by inoculation of five -day-old specific pathogen-free (spf) embryonated chicken eggs/sample via the allantoic sac route [ ] and virus titers were expressed as % embryo infectious doses (eid ) according to the reed & muench method [ ] . ibv field strains were genotyped by automated dna sequencing (abi xl, applied biosystems) of a bp portion of the s gene amplified as described [ ] . the deduced amino acid sequences of s protein of ibv a and b isolates have . % of identity, and with regard h strain (massachusetts serotype) of ibv they have . % and . % identity, respectively. three groups of specific pathogen free (spf) chicks (white leghorn lineage) obtained from valo biomedia (uberlândia, sp, brazil) were housed in separate positive pressure isolators. at days of age, groups a and b were respectively challenged with . eid /bird of a strain of ibv and . eid /bird of b strain of ibv by intra-ocular and intra-nasal routes. one group remained mock infected (negative control group, referred as nc). during whole experimentation, chickens were monitored twice a day. if animals have presented severe depression and lethargy, they were separated to be euthanized, though, there were no animals in these conditions during experiment. the birds from groups a, b and nc were randomly euthanized by cervical dislocation, at , and day post-infection (dpi). tracheal and renal samples were collected from each group; a portion of the proximal third from each tracheal sample and a fragment of distal left kidney were immediately frozen in liquid nitrogen and kept at - ˚c until processing for rna extraction. another portion of tracheal and renal samples were subjected to histopathological analysis. throughout the experimental period, birds received water and feed "ad libitum", the room temperature was adapted according with the bird´s age, and the monitored ammonia concentration levels remained below parts per million (ppm). tracheal samples were divided into three fragments (proximal, medial and distal), and a portion of each fragment was prepared for histopathology. the severity of observed lesions scores were determined as previously described [ ] . absence of injury was classified as , while mild, moderate and severe were scored as grades to . morphological characteristics observed by histopathology included loss of cilia and epithelial cells, degeneration or necrosis of epithelial cells, degeneration of mucous glands, mucosal inflammatory infiltrate and epithelial hyperplasia. a sum of all scores of microscopic lesions from all evaluated fragments was amounted to final score per bird, ranging from to . birds presenting score values ! in two or more evaluated parameters or presenting marked heterophilic infiltration were considered as relevant lesions induced by ibv. the scores of microscopic lesions in the kidney samples were determined as previously described [ ] . the parameters evaluated included tubular degeneration and necrosis, and presence of inflammatory infiltrate, and the scores ranged from to according to the severity of lesions. rna extractions from the proximal third of tracheal and renal samples of experimentally infected chickens were performed using trizol reagent (invitrogen) followed by rna purification using rneasy mini kit (qiagen). the extracted rna purity and quantification were estimated by nm ultraviolet absorbance and readings at / nm, respectively. rna quality was verified with agilent rna nano kit (agilent technologies) in an agilent bioanalyzer instrument (agilent technologies) for determination of rin (rna integrity number) or by rna analysis in % gel electrophoresis. all tracheal and renal samples were tested for ibv viral load by rt-qpcr (hydrolysis probe system) using agpath-id one step rt-pcr kit (ambion), primers and lna-probe ( ´fam- bhq , idt) for amplification of the ´utr genome region of ibv, as described [ ] . cq (cycle quantification) results were used to calculate the log of rna copies (log ) using the linear equation from a standard curve. samples presenting cq were classified as positive for ibv. two-step rt-qpcr was used for the relative quantification of gene expression in the tracheal samples. cdnas were synthesised according to instructions provided with high capacity cdna reverse transcription kit (applied biosystems) and μl ( ng/μl) of oligo(dt) primers (idt). the pcr reactions contained ng of cdna, . μl of x quantifast sybr green master mix (qiagen), and μm of each primer (table ) in a final volume of μl. amplification included a pre-incubation step at ˚c for min, followed by cycles of ˚c for seconds and . ˚c for seconds. after amplification, a melting curve analysis was performed by raising the incubation temperature from ˚c to ˚c in . ˚c increments with a hold step of sec at each increment. all oligonucleotides used were designed using primer [http://frodo.wi.mit.edu] software, spanning exons according to gene sequences from ensembl [http://ensembl.org] and mrna sequences deposited in genbank. except for ifnα and ifnβ which are intron-less mrnas, then, residual genomic dna was digested with μl dnase i (promega) before cdna synthesis. efficiency of each specific real-time pcr was calculated table using two-fold serial dilutions of cdna pooled from all tested animals, and cq values plotted into the linear equation. the relative expression of all tested genes (table ) in tracheal samples of ibv-infected chickens was quantified as the fold change relative to the non-infected group (negative control), and the gene expression from each sample were standardised using the cq value of the top b/hprt constitutive reference genes for the same sample [ ] . the stability of the reference genes was tested using four candidates (top b, hprt , gapdh and histone h ) and the best genes were selected using bestkeeper and normfinder softwares. the comparisons of relative changes in gene expression, viral load and microscopic lesions between the experimental groups were performed using the kruskal-wallis test followed by wilcoxon test. all analyses were conducted using the sas . software ( ), and the probability level for significance was set as p . . the tracheal lesions observed in groups challenged with a or b ibv isolates at dpi were characterized by mild acute tracheitis, consisting of the presence of heterophils and mucus exudation in the tracheal lumen with congestion and heterophilic infiltration in the lamina propria and epithelial cell desquamation (fig a) . the most prominent lesions were observed at dpi, with lesion scores ranging from to , consisting of tracheitis. the microscopic pathological [ ] , congestion [ ] , heterophilic cell infiltrate [ ] . (b) proximal third of trachea from the group challenged with ibv a strain, at dpi, showing ciliary loss [ ] , degeneration and necrosis of some epithelial cells [ ] , lymphoid cell infiltrate [ ] and epithelial hyperplasia [ ] . (c) proximal third of trachea from nc group. changes consisted mainly of lymphoplasmacytic inflammatory infiltrate in the mucosa, ciliary loss and epithelial hyperplasia ( b). degeneration of the mucous glands and of epithelial cells was also observed at lower frequency and intensity. at dpi, lesions were mild, tending to tissue recovery. scores between and were found mainly in the challenged groups. the main histopathological changes were degeneration of the mucous glands, lymphocytic infiltration in the mucosa and epithelial hyperplasia. no relevant microscopic tracheal alterations were observed in the nc group at all post-infection intervals analyzed (fig c) . marked lymphoplasmacytic interstitial nephritis (lesion score ) was only observed in the challenged groups (a and b), at dpi (fig a) . tubular necrosis was not observed in any renal sample from all experimental groups. a higher percentage of birds challenged with ibv b isolate showed relevant tracheal (at dpi and dpi) and renal (at dpi) microscopic lesions ( table ) compared to the birds challenge with ibv a isolate. no positive samples were detected for the presence of ibv genome in tracheal and renal samples from the negative control (nc) group in any of the post-infection intervals analysed (fig and table ). high percentages ( . % and %) of tracheal samples were positive at dpi for the presence of ibv genome from chickens challenged with ibv a and b strains, and differed significantly from tracheal samples from nc group (fig a and table ). at dpi, all chickens from the challenged groups were ibv positive, with similar virus loads to those detected at dpi, differing also significantly different from nc group. the renal samples from chickens of a group showed . % of positivity for ibv genome in kidney samples while all the renal samples from chickens of b group were positive for ibv genome, (fig and table ). the presence and quantity of ibv genome in renal samples differed significantly from those of nc group. the viral load decreased at dpi in tracheal samples from all ibv challenged groups (a and b) (fig b) . despite of lower virus levels, all challenged groups maintained % of positive birds (table ) . additionally, all the chickens from group challenged with ibv b isolate were positive for the presence of ibv genome in renal samples and only . % were positive for the a challenged group, a significant higher viral load was found in b group when compared to other experimental groups (fig b and table ). significantly higher means of ibv genome load ( to times higher) were detected in group challenged with ibv b isolate compared to the group challenged with ibv a isolate, at dpi interval in tracheal samples (p = . ) and at dpi in renal samples (p = . ). (fig ) . the mrna expression data for tlr , tlr , myd , inos, ifnα and ifnβ in tracheal samples are illustrated in fig . tlr was significantly upregulated and peaked at dpi in ibv ibv positive birds at dpi ibv positive birds at dpi ibv positive birds at dpi trachea trachea kidney trachea kidney nc / ( %)* / ( %) / ( %) / ( %) / ( %) a / ( . %)* / ( %) / ( . %) / ( %) / ( . %) b / ( %) / ( %) / ( %) / ( %) / ( %) nc = negative control group; a = group challenged with ibv a isolate; b = group challenged with ibv b isolate. * one sample was lost during processing. challenged groups. at dpi, tlr transcripts also remained upregulated in challenged groups, although the levels were lower compared to values found at dpi. at dpi, tlr mrna dropped markedly in challenged groups, but still remained significantly upregulated (fig a) . no significant differences were detected in the expression of tlr gene between the tracheal samples of chickens infected with a and b ibv isolates, and significant differences were seen by comparing the birds from groups a and b with those from control mock-infected birds. tlr transcripts were downregulated ( times) at dpi only in the tracheal samples from b-challenged group, but their levels of expression rose at dpi and maintained at high levels at dpi in all challenged groups (a and b) (fig b) . myd mrna transcripts were upregulated in tracheal samples from all challenged groups (a and b) and at all post-infection intervals. at dpi, the samples from a group presented higher levels than those from b group (p = . ) (fig f) . ifnα was upregulated at dpi and dpi in tracheal samples from chickens of b group, and only at dpi in the samples from a group chickens. ifnβ transcripts were upregulated in chickens from b group at dpi and dpi, while in chickens from the a group, only at dpi (fig c and d) . the inos gene showed a significant increase in mrna expression at dpi in challenged groups. at dpi and dpi, these transcripts dropped to basal levels ( fig e) . il β transcripts were significantly upregulated in tracheal samples from all challenged groups at , and dpi and the highest levels of il β expression were reached at dpi. (fig a) . il mrna transcripts were significantly upregulated in tracheal samples from challenged groups at and dpi. at dpi, only the samples from group a showed upregulation in the expression of this cytokine gene (fig b) . the tnfsf mrna was only significantly upregulated at dpi, in the group challenged with ibv a isolate (fig c) . the cd and cd mrna transcripts were downregulated at dpi only in the tracheal samples from the b group. at dpi and dpi, all tracheal samples from challenged groups showed upregulation of cd and cd expression, and the highest levels of expression of these genes were observed at dpi (fig a and b) . at dpi and dpi, all challenged groups presented upregulation of cd β transcripts, and the highest levels of expression of this gene were detected at dpi (fig c) . the levels of ifnγ gene expression started to increase at dpi in group challenged with ibv a isolate. all challenged groups, presented upregulation of ifnγ transcripts, at dpi and dpi and the highest levels were found dpi (fig d) . the transcripts of granzyme homolog a mrna were upregulated in all challenged groups at the three post-infection intervals evaluated, except for the group challenged with ibv b isolate, at dpi (fig e) . the host-virus interactions that result in more severe pathogenesis induced by different pathotypes of ibv are not fully elucidate, but the ibv pathogenesis has been associated with high virus replication rates, induction of exacerbated inflammatory responses and delayed activation of anti-viral effector mechanism of innate and adaptive immune responses [ , , ] . in this study, we found a suppressive effect on expression of some early innate and adaptive cell-mediated immune genes in the primary site of virus replication (trachea) from chickens infected with one of the tested ibv isolates (b). this possibly contributed to an exacerbated pathogenicity of this ibv isolate, especially for kidney tissues, but not for a isolate. ibv b isolate demonstrated an enhanced ability for viral replication in chicken host, as we observed significantly higher ibv genome loads in tracheal samples (at dpi), and in kidneys (at dpi) of birds challenged with this isolate, compared to the group infected with ibv a isolate. furthermore, a higher percentage of positive birds for ibv genome and the presence of pathological alterations were observed in the ibv b infected group, especially in renal samples, that were ibv positive in birds infected with this isolate at dpi, while only % were positive in the group infected with ibv a isolate. this enhanced viral replication of ibv b isolate compared to a isolate, may have played a role as one of the determinants for the higher percentage of chickens with relevant microscopic tracheal and renal lesions in birds from the ibv b challenged group. this could result in increased pathology of the ibv b isolate. however, the reason for the differences observed in tissue tropism and pathogenicity of different ibv strains remains an open question and cannot be associated in the present study to differences in s protein sequences, as a and b ibv isolates have an identity of xx % for this protein. similarly, a recent study demonstrated that despite the same efficiency of s protein binding to the epithelial cells of oviduct, in a sialicacid dependent manner, observed for qx ibv strain (associated with nephropathogenicity and reproductive tract disorders) and b ibv strain (associated with nephropathogenicity), a high susceptibility to infection was observed for qx strain in contrast to the resistance to infection with b strain [ ] . the authors concluded that other cellular receptors and post-virus binding activation steps could be involved and play a role in the development of ib disease, although the attachment of ibv to host cells is considered as the first important step in virus infection and for determining the tissue tropism for this virus [ ] . in view of the differences observed here for these two brazilian ibv isolates (a and b) in terms of viral replication and pathological alterations induced, the current study investigated how innate and adaptive immune responses are developed after challenge with each one of these viruses, aiming to better understand the virus-host interactions and the putative immune-related mechanisms that might determine the course of pathogenicity induced by ibv isolates with different virulence profiles. several studies on innate immune responses elicited by viruses and mediated by prrs have demonstrated that the levels of expression of tlr genes are usually upregulated, in order to activate intra-cellular pathways involved in the production of type i anti-viral ifns and proinflammatory cytokines [ , , , ] . tlr was reported to be upregulated at dpi in trachea from chickens experimentally infected with a connecticut strain of ibv, but then the expression of this gene decayed to basal levels and remained unaltered at dpi and dpi [ ] . in contrast, in the current study an unexpected suppressive effect in the tlr gene expression was observed only during the early phase of ibv b isolate infection ( dpi), as the transcripts of this gene were found times downregulated. moreover, at dpi, other genes related to activation of tlr pathway were also affected, including the adapter myd and the pro-inflammatory cytokine gene (tnfsf ), which showed lower levels of expression in the birds from the group challenged with b isolate compared to the group challenged with isolate a. thus, these results demonstrate a differential profile of early type of innate immune responses induced by ibv b isolate compared to the ibv-induced innate immune responses of another study [ ] . in the later study, an upregulation in the transcription of tlr and myd genes was observed at dpi in tracheal samples from chickens infected with a connecticut strain of ibv, that has a typical respiratory and pathogenicity for chicken respiratory tract. although other genes related to innate immune responses were also found to be differentially expressed in response to infection with the brazilian ibv isolates, including tlr , type i ifns (ifnα and ifnβ) and inos, no significant differences were observed between the group infected with ibv b isolate and that infected with ibv a isolate. these results suggested that the identified differences between the two ibv isolates are not related to the biological activities associated with these innate response genes. however, tlr and inos genes were significantly upregulated and peaked at dpi, while type i ifns were significantly upregulated and peaked at dpi. these results contradict other findings for tlr , ifnα, ifnβ and inos gene expression in the respiratory tract of chickens challenged with a connecticut strain of ibv [ ] , since no significant differences were observed for inos and ifnα gene expression, and tlr was unaltered at dpi and ifnβ was upregulated at dpi. this indicates the likely existence of others factors and pathways in the innate immune responses that are triggered by the interaction of host and different pathotypes of ibv as well possible differences in structural and non-structural proteins of ibv strains involved in virus evasion from the immune responses [ ] . as memory immune responses induced by ibv vaccination could have some delay until reach effective anti-viral activities, the innate immune responses might be crucial to reduce the viral replication and pathological alterations induced by a virus pathogen as well exert a relevant role in the activation and shaping of the anti-viral adaptive immune responses. thus, we hypothesize that the suppressive effect on tlr pathway could be associated with an enhanced ability for viral replication and induction of lesions for both tracheal and renal tissues. however, further analyses of these assumptions are necessary. in addition, a reduction of expression of cmi-genes for adaptive immune responses was also observed only in the group challenged with ibv b isolate, as the transcript levels of cd and cd were significantly downregulated at dpi only in this group. granzyme homolog a and ifnγ transcripts were also differentially expressed between the challenged groups in this interval, as significant upregulation was observed only in a group. therefore the downregulation of cell-mediated immune related genes could be a consequence of a primary virus challenge effect and could have negative consequences for the chicken host. in a previous study, we were able to detect an increase in the expression of cell-mediated immune related genes at dpi in tracheal samples from birds vaccinated with massachusetts attenuated ibv strain and challenged with a virulent homologous strain. this early cmi response, was associated with the level of cellular memory immune responses conferred by immunization, and this effect was dependent on the vaccine dose administered and was negative correlated with the tracheal pathological changes induced by m strain of ibv [ ] . although we have not evaluated in this study the gene expression and/or the biological activity of mhc i and ii pathways, or other genes related to antigen presentation by dendritic cells, we can speculate that ibv b isolate might have some differentiated properties that confer to this virus a greater ability to decrease antigen presentation and to evade the host adaptive immune responses against this virus. this assumption is supported by the findings that all cellmediated immune related genes analyzed here have unaltered expression or were significantly downregulated in the group infected by b isolate of ibv at dpi, as shown the significantly downregulated levels of expression observed for cd and cd transcripts, and unaltered expression for ifnγ and granzyme homolog a genes in birds of this group. in contrast, at dpi, the ugroup challenged with ibv a isolate showed unaltered levels of cd and cd mrna, while ifnγ and granzyme homolog a transcripts were significantly upregulated. natural killer (nk) cells have important roles in the initial mechanisms of innate immunity against ibv, and were also important source of granzyme homolog a and ifnγ. although some authors have associated ifnγ production with the activity of nk cells after challenge with ibv [ ] , in our experiment, the profile of expression of ifnγ and granzyme homolog a may as well be associated with t cd + activation, since cd β and cd were also found to be upregulated in coincident time-points post-challenge in which ifnγ and granzyme homolog a genes were upregulated, especially when considering that nk cells are unable to express cd β and cd genes. in summary, this study has contributed to the better understanding part of host-ibv interactions, and to our knowledge, it is the first study that demonstrate that expression of distinct innate and cell-mediated adaptive immune genes are induced by two ibv isolates that were classified in the same genotype but differing in their virulence activities. overall, the results point out to the relevance of the involvement of the tlr pathway and the associate factors related to the suppression of early innate immune responses as well the early cell-mediated adaptive immune responses and the implications on the pathogenesis of infection by a more virulent ibv isolate. however, further studies are required to confirm this association, and to verify other cellular response pathways that may also be affected by this virus. it remains also to be further investigated the differences in the immune responses triggered by the ibv infection with more distinct genotypes of ibv strains that can differ in pathogenicity for the respiratory, urinary or other tissue targets for ibv infection in chickens. moreover, it is important for poultry industry and indirectly for human health to better understand how coronaviruses infect the chicken host and which genes and/or pathways are effectively involved in increasing the severity of this disease, especially considering the diseases caused by other coronaviruses such as severe acute respiratory syndrome-associated coronavirus and middle east respiratory syndrome coronaviruses. kinetics of lymphocytic subsets in chicken tracheal lesions infected with infectious bronchitis virus inflammatory and cellmediated immune responses in the respiratory tract of chickens to infection with avian infectious bronchitis virus nephritis associated with infectious bronchitis virus cal variant in game chickens transcriptome analysis of chicken kidney tissues following coronavirus avian infectious bronchitis infection characterization of nephropatogenic infectious bronchitis virus dmv/ / recovered from delmarva broiler chickens in increased expression of interleukin- related to nephritis in chickens challenged with an avian infectious bronchitis virus variant. pesq vet bras molecular mechanisms of primary and secondary mucosal immunity using avian infectious bronchitis virus as a model system humoral and cell-mediated immune response to different doses of attenuated vaccine against avian infectious bronchitis virus cellular, and humoral immune responses induced by different live infectious bronchitis virus vaccination regimes and protection conferred against infectious bronchitis virus q strain emergence of a new genotype of avian infectious bronchitis virus in brazil phylogenetic analysis of the s glycoprotein gene of infectious bronchitis viruses isolated in china during - cross-protective immune responses elicited by a korean variant of infectious bronchitis virus emergence of a novel genotype of avian infectious bronchitis virus in egypt infectious bronchitis virus variants: a review of the history current situation and control measures the early immune response to infection of chickens with infectious bronchitis virus (ibv) in susceptible and resistant birds induction of innate immune response following infectious bronchitis corona virus infection in the respiratory tract of chickens transcriptome of local innate and adaptive immunity during early phase of infectious bronchitis viral infection increased inducible nitric oxide synthase expression in organs is associated with a higher severity of h n influenza virus infection nitric oxide and macrophage function virulent newcastle disease virus elicits a strong innate immune response in chickens immune responses to virulent and vaccine strains of infectious bronchitis viruses in chickens interleukin- expression after infectious bronchitis virus infection in chickens effects of avian infectious bronchitis virus antigen on eggshell formation and immunoreaction in hen oviduct detection of viral antigen following exposure of oneday-old chickens to the holland- strain of ibv a simple method of estimating fifty per cent end points sequence analysis of nephropathogenic infectious bronchitis virus strains of the massachusetts genotype in beijing lna probe-based real-time rt-pcr for the detection of infectious bronchitis virus from the oviduct of unvaccinated and vaccinated laying hens analysis of relative gene expression data using real-time quantitative pcr and the (-delta delta c(t)) method differences in the tissue tropism to chicken oviduct epithelial cells between avian coronavirus ibv strains qx and b are not related to the sialic acid binding properties of their spike proteins pathogenicity and tissue tropism of infectious bronchitis virus is associated with elevated apoptosis and innate immune responses recent progress in studies of arterivirus-and coronavirus-host interactions rapid nk-cell activation in chicken after infection with infectious bronchitis virus m the authors thank tania alvina potter klein, dejalmo alexandre da silva, altair althaus and gláucio mata mattos (in memorian) for support provided during experimental infection in chickens. the authors also thank to francielle ianiski for processing of tissue samples for histology.validation: cho lb. writing -review & editing: cho hjm. key: cord- -zwp awk authors: sever, mustafa; mordeniz, cengiz; sever, fidan; dokur, mehmet title: accidental chlorine gas intoxication: evaluation of patients date: - - journal: j clin med res doi: . /jocmr . . sha: doc_id: cord_uid: zwp awk background: chlorine is a known pulmonary irritant gas that may cause acute damage in the respiratory system. in this paper, the socio-demographic and clinical characteristics of accidentally exposed patients to chlorine gas are reported and different emergency treatment modalities are also discussed. methods: two emergency departments applications were retrospectively analyzed for evaluation of accidental chlorine gas exposure for year . patients were classified into groups according to severity of clinical and laboratory findings based on the literature and duration of land of stay in the emergency department. the first group was slightly exposed (discharged within hours), second group moderately exposed (treated and observed for hours), and third group was severely exposed (hospitalized). most of the patients were initially treated with a combination of humidified oxygen, corticosteroids, and bronchodilators. results: the average age was . ± . years ( % ci). seven ( . %) of them were female and ( . %) were children. twenty-four patients ( . %) were included in the first, nine ( . %) were in second and six ( . %) were in the third group. the presenting symptoms were cough, nausea, and vomiting and conjunctiva hyperemia for the first group, first groups symptoms plus dyspnea for the second group. second groups symptoms plus palpitation, weakness and chest tightness were for the third group. cough and dyspnea were seen in . % and . % of the patients respectively. no patients died. conclusions: the authors recommend that non symptomatic or slightly exposed patients do not need any specific treatment or symptomatic treatment is sufficient. keywords: accidental; chlorine exposure; chlorine gas; chlorine intoxication; emergency department chlorine (cl ) is a yellow-green gas or boiling yellow liquid, slightly water soluble, and about two times heavier then air [ , ] . it has a pungent, irritating odor and is a strong oxidizing agent [ , ] . chlorine releasing agents are frequently used for industrial, household chemicals and water purification in swimming pools or city water sources [ ] [ ] [ ] . the risk of exposure to chlorine gas with large number of casualties is widespread, since chlorine is carried through densely populated areas in large quantities [ ] . inhalation exposure to chlorine can occur from inhalation of elemental cl or inspiration of vapors that contain chlorine releasing chemicals [ ] [ ] [ ] [ ] due to chemical transportation accidents [ , ] , accidental explosions, leaks, or malfunction of chlorinedisinfection systems [ ] , improper mixing of ammonia and hypochlorite bleach (forming chloramines gas) and school experiments [ , , ] . the respiratory system is the most adversely affected of all organ systems by chlorine gas exposure [ ] and complications are generally immediate with severe exposure, including acute respiratory distress syndrome (ards), respiratory failure, pneumomediastinum and death [ , , [ ] [ ] [ ] [ ] [ ] . in this paper, the social and demographic characteristics, clinical and laboratory findings of patients which have been accidentally exposed to chlorine gas due to chlorine tank explosion in southeast of turkey are reported. different treatment modalities in chlorine intoxication are also discussed. performed. three of them are ministry of health government hospitals (one is children's hospital) and other is university hospital. all hospitals' emergency departments (ed) medical records which explain above were retrospectively analyzed for evaluation of accidental chlorine exposure patients for year . the authors determined totally people who had been affected acutely by chlorine gas as a result of chlorine tank explosion that was used for city water source purification, and transferred to the hospitals in the city center. among these, authors could reach only patients' medical records (twenty three patients transferred to ministry of health children's, to university hospital eds). the rest of patients' medical records which transferred to other two hospitals' eds were not able to reach because the reasons of can't get permission and file record insufficiency. the authors determined patients' routine physical examinations were done at admission. depending on the patient's clinical picture by the discretion of the physician, the necessary diagnostic tests (e.g. chest x-ray (cxr)), complete blood counts, electrocardiograms (ecg), arterial blood gases (abg), and consultations were ordered. the authors classified the patients into groups according to clinical and laboratory findings based on the literature [ , , [ ] [ ] [ ] ] and duration of land of stay in the ed. first group was not affected at all or slightly exposed. these patients were principally mobile, they showed no vital or laboratory abnormalities. the main symptoms were mainly mild cough, nausea, weakness and burning in the eyes, and throat. they were completely treated and discharged from ed in less than hours. the second group was moderately exposed. the main predictors of this group were mild pulmonary symptoms (as mild dyspnea and/or mild to moderate cough, and palpitation) and/or tachycardia and/or tachypnea (> to ≤ breath/per minute). but they had no pathologic pulmonary examination findings. this group of patients were treated and observed in ed for to hours. the third group was severely exposed. they had severe dyspnea, chest tightness or pain, wheezing, tachypnea (≥ breath/minute), tachycardia and pathologic pulmonary physical examination findings such as crackles and/or ronki. all patients in the third group were hospitalized. some of the patients in the second and third groups showed abnormal laboratory results. most of the patients were initially treated with supplemental humidified oxygen (via nasal canulla or mask). various combinations of parenteral fluids, metyl-prednisolone, antiemetics and/or h blockers, antibiotics and inhalational bronchodilators were used appropriately. none of the patients received nebulized sodium bicarbonate therapy. all the data that we have presented are mean ± sd and in percentages. seven ( . %) patients were females and ( . %) were males. the ages of the patients ranged between and years and the average age was . ± . (ci %). twenty nine ( . %) were children (ranging between - years of age). thirty two patients ( . %) had no history of medical disease or smoking habit. however, patients ( . %) were smokers, one had history of hypertension, and one child ( years old) had asthma history. patient characteristics according to age groups are shown in table . the presenting symptoms were mostly associated with one another, including; cough (alone) (n = , . %), cough and nausea (n = , . %), cough and dyspnea (n = , . %), and different associations of these with chest tightness, burning in eyes and in throat, conjunctival hyperemia, weakness and vomiting symptoms were found in ( . %) patients respectively. cough and dyspnea were the most prevalent complaints among the patients and were seen in . % and . % of the patients respectively, in total. twelve patients ( . %) had no evident symptoms. in physical examination patients ( . %) were normal. tachypnea was the dominant sign with . % among the patients. regarding the laboratory findings, ( . %) patients were assessed by cxr, ( . %) were assessed by ecg and ( . %) were assessed by abg analyses. most patients did not have an ecg, abg or cxr performed. these tests were considered unnecessary for the patients who appeared well. only one patient ( . %) who used to be a smoker, showed pathologic findings in his chest radiograph (hyper-aeration, decrease in cardio-thoracic ratio, elevated diffuse reticular density). no ecg pathology was detected and ( . %) of abg analyzes were abnormal. eight ( . %) patients, whose abg analyzes were assessed as abnormal, had hypoxia. four of these patients were in the third group. of these patients, one ( . %) had respiratory alkalosis, while the rest three ( . %) had hypercarbia and respiratory acidosis. the authors did not need to perform decontamination to any patient because chlorine is a volatile gas and there were no severe eye or skin contaminations in our series. no patients received nebulized sodium bicarbonate therapy. among the patients who were evaluated in eds, ( . %) patients were in the first group and they were discharged after initial examination and symptomatic treatment except patients who refused any treatment except normal saline. seven ( . %) of the rest patients in the first group received only humidified oxygen and metyl-prednisolone. other ( %) patients in the first group who accepted treatment were initially treated with supplemental humidified oxygen (via nasal canulla or mask), various combinations and doses of parenteral fluids (e.g. normal saline, . % saline + % dextrose, and isolyte p ® ), and metyl-prednisolone ( mg/kg, intravenously). of these patients, received metoclopramide (alone, intravenously), received ranitidine (alone, intravenously) another received ranitidine and metoclopramide combination (intravenously), appropriately, in addition to the initial treatment. nine ( . %) patients were in the second group. in this group one patient received only humidified oxygen and metyl-prednisolone. three patients were initially treated in the same way with the first group. in this group, in addition to initial treatment, one patient received inhaler salbutamol, patients received ranitidine, and one patient received metoclopramide plus ranitidine and inhaler salbutamol combination. another patient received initial treatment plus metoclopramide plus ranitidine and inhaler salbutamol combination and wide spectrum antibiotic (intravenously). they were all observed and discharged in hours after application to ed. there were ( . %) patients in the third group who were severely exposed were hospitalized; patients were admitted to the adult intensive care unit, patients to the pediatric intensive care unite and patient to the pulmonary medicine department. no patient was diagnosed as bronchitis, ards and/or acute lung edema. invasive or non invasive airway support (as intubations, cpap or bipap) was not necessary. all the patients in this group were initially treated as in the first group. metoclopramide, ranitidine, inhaler salbutamol and antibiotic measure combination were also used appropriately. only one patient received teophyline measure in addition to this combination. no patients died. chlorine is a highly toxic gas well known for mortality and morbidity since its discovery in [ ] . the basic mechanism of toxicity is related to the solubility of chlorine in the water, because elemental cl maintains equilibrium with hydrochloric acid (hcl) and hypochlorous acid (hocl) in aqueous solution (cl + h o↔hcl + hocl) or (cl + h o↔ hcl + [o -] ) [ , ] . these chemical end-products cause damage to cellular proteins, resulting in direct tissue injury [ ] . the medical literature is replete, from household or swimming pool exposures to industrial or chemical transportation accident reports [ , , , , , [ ] [ ] [ ] [ ] . most unintentional exposures occur in the industrial field [ , , ] . transportation mishaps can release large quantities of cl gas into the air and trigger mass disaster incidents that can affect large number of adults and children together [ , ] . the wide availability of chlorinated compounds as household disinfectants and swimming pool chlorinators makes these agents potentially hazardous to a larger segment of the population, including children [ , [ ] [ ] [ ] [ ] . in most of the reports, patients' ages ranged similarly but pediatric population was not as crowded as in our series [ , , ] . in a review of patients who were exposed to chlorine gas, mrvos et al [ ] reported that they were between and years old. also guloglu et al [ ] reported that population age range in their study was between months and years of age and . % of the cases were children and adolescents. agabiti et al [ ] report was similar with mrvos et al and guloglu et al. they reported patients and ( . %) were children. in the present study, children's population ratio is high because our data include the children who were transferred to ministry of health children's hospital. the main accident involved more patients, mostly adults, transferred to other hospitals in the same city. children/adult ratio would be different if all the victims were included in this study. asthma, smoking habit, atopic persons and chronic exposure to chlorine gas were reported to be predisposing factors or conditions worsening the scene in many reports [ , , , , , ] . in the presented series, there were only six smokers and one asthmatic child. three of the smokers and the asthmatic child were admitted to intensive care unit but these patient numbers were not enough for evaluating these factors. the authors do not know how much chlorine gas was released into the atmosphere when the chlorine tank exploded. with considerable consistency around the world, chlorine has a time-weighted average exposure standard of . - parts per million (ppm) [ ] , but evans [ ] reported that doses below the . ppm can cause tickling of the nose and throat, itching of the nose and cough, burning of the eyes, and dryness of the throat. the fatal dose ranges from to , ppm. although, different chlorine gas exposure ratios can cause different complaints [ ] . evans [ ] also reported that even upper airway exposure from chlorine inhalation was predominant. however, exposures to concentration greater than ppm are typically associated with lower respiratory effects. the patients exposed to cl inhalation acutely, can appear in different range of clinical symptoms from fatal asphyxia or severe acute respiratory syndrome to slight injury such as simple irritation of the conjunctivae or nasal mucosa [ , , ] . however, the lungs can also be permanently affected and clinically manifested as a chronic suppurative cough, complicated by wheezes and breathlessness of variable intensity [ , ] . in many reports the most prevalent complaints of intoxication cases, as reported in sexton and pronchik's study [ ] , were skin, eye and throat irritations including pruritus, lacrimation, rhino rhea, conjunctiva irritation, oropharyngeal pruritus and irritation, cough, sore throat, laryngeal edema, dyspnea, and sometimes hoarseness and stridor, headache, chest pain, and anxiety [ , , , , , - , , ] . in our series most prevalent symptoms were cough (alone) and cough together with dyspnea. cough and dyspnea mostly accompanied one another. agabiti et al [ ] reported that eye irritation was observed in . %, nose and throat problems in . %, and respiratory symptoms in . % of the children in their study group. the corresponding values among adults were reported as . , . , and . % respectively. moulick et al [ ] noted that % of the patients had eye irritation, . % headache, . % abdominal pain, and . % vomiting. guloglu et al [ ] had found . % dyspnea and % cough and dyspnea in their series. the authors did not find any skin or severe eye irritation in the patients. but respiratory and gastrointestinal symptoms were similar with the literature. physical examination following exposure to high concentrations may reveal decreased breath sounds, tachypnea, tachycardia, hypoxia, wheezing, crackles (ards/noncardiogenic pulmonary edema) and crepitation (associated with pneumomediastinum) [ ] . in previous studies, guloglu et al [ ] reported that; . % of their patients had expiratory wheezing, and only one had expiratory wheezing, cyanosis, tachycardia, and extrasystoles, . % were normal. in our series, physical examination findings, normal patients' ratios, and results of abg analyses were similar. however, ecg's, cxr findings were normal contrary to the literature. a baseline cxr should be obtained if the patient is symptomatic and respiratory functions should be monitored, including abg and pulse oxymetry [ ] . chest radiographs can be normal, or they can sometimes show diffuse nodular opacities, patchy consolidation, pulmonary edema, and signs of vascular congestion. radiographic abnormalities may appear late as lung injury develops and progresses. persistent hyper reactivity and airflow obstruction may manifest radiographically as air trapping. the role of computerized tomography in evaluating lung injury is not established [ ] . the priority in acute exposures to high doses of cl should be removal of person from the hazardous environment [ , , ] . the goal of decontamination is to decrease further exposure to victims and to prevent secondary contamination of health care workers [ ] . immediate treatment of exposure, as with any toxic inhalation, should focus on the airway [ , ] . patient with significant ocular symptoms (e.g., pain, photo-phobia, and vision changes) should have their eyes irrigated with plenty of water or saline solution. the eyes should be examined for corneal abrasions [ , ] . also, for dermal injuries are caused by the caustic nature of the chlorine gas, contaminated clothing should be removed, followed by irrigation with plenty of water [ , , ] . guloglu et al [ ] reported that they preferred and recommended humidified o and ß agonist combination applications to be the supportive therapy in their study group because of trachea-bronchitis and broncho-constriction and/ or pulmonary edema and reactive airway dysfunction syndrome effects of chlorine gas. treatment implication was same in akdur et al [ ] case report of a years old woman who was diagnosed as pneumomediastinum due to chlorine intoxication. they also used methyl-prednisolone and death was not reported. in cases reported by agabiti et al [ ] , intravenous cortisone and humidified o were used in some cases, particularly in those admitted to hospital. no patient received nebulized sodium bicarbonate treatment. a few studies have used animal models, which involved systemic or inhaled corticosteroid administration treatment immediately following high-rate chlorine exposure. gunnarsson et al [ ] used a porcine model of cl inhalation and demonstrated that the immediate use of inhaled beclomethasone improved hypoxemia, pulmonary vascular resistance, and survival. in a similar study with ventilated pigs, wang et al [ ] reported that the timing of inhaled corticosteroids may be an important factor in the management of chlorine intoxication. the same authors [ , ] demonstrated that the combination of an inhaled ß agonist followed by a nebulized corticosteroid provided a greater improvement in cl induced lung injury than the administration of each agent alone. the above studies showed improved pulmonary and cardiovascular function but no effect on mortality [ , ] . nebulized sodium bicarbonate (nahco ) has also been suggested as a therapy for chlorine exposure. the proposed mechanism of the action is the neutralization of the formed acids in the respiratory tissues. cellular damage from oxy-gen free radical formation is not addressed by this therapy [ , , , ] . bosse gm [ ] reported in his retrospective case review of nebulized nahco treatment of chlorine intoxication that . % of patients clearly improved after using of bicarbonate. but there are not enough animal experiments about nebulized nahco therapy which will show the efficacy. against all, russell et al [ ] reported that there was no specific antidote for the treatment of casualties caused by exposure to chlorine, phosgene, or mustard; therefore, management is largely supportive. he also reported that, clinical data on corticosteroid treatment efficacy, which has been given in casualties because of accidental exposure to chlorine; were inconclusive because of the numbers of patient were inefficient and the indications for administration were unclear. similarly, fleta et al. [ ] reported that the criteria for administration of treatment are not clear and thus the efficacy of treatment can not be ascertained. supplemental humidified oxygen, intravenous corticosteroids, bronchodilator combination and symptomatic supportive therapy were the main treatment choices in our series, similarly to the most of the literature. applying too much steroids in our series can be a result of arbitrary decisions. also, there is no scientific evidence for empiric use of antibiotics. patients with acute lung injury and/or upper airway burns may require endotracheal intubation and mechanical ventilation. positive end expiratory pressure may be useful in enhancing oxygenation. since pulmonary edema may be delayed, patients with significant symptoms should be admitted for observation and further symptomatic care for hours. asymptomatic patients may be discharged home with close follow up [ ] . based on published reports, most patients who are exposed to an isolated cl inhalation, recovered completely [ , ] . however, noncardiogenic pulmonary edema, obstructive disease, restrictive disease, ards, pneumomediastinum has been reported in survivors [ , , [ ] [ ] [ ] [ ] [ ] . evans [ ] had reported in his review that the reasons of variable outcomes of individuals were high level exposure, minute ventilation, and host characteristics such as pre-existent asthma or ongoing smoking. in our series, in spite of different or arbitrary treatment modalities, there were no deaths and all patients' symptoms and physical examination findings were resolved. this result, in spite not being very explanatory, may be an effect of early systemic steroid treatment. this study revealed the first most crowded accidental chlorine gas exposure in turkey. therefore authors could not find enough similar national study to compare. the patients were classified into three groups, but couldn't compare in term of determine the significant differences such variables as exposure rate and age groups, and exposure rate and gender, because the reasons of groups' having small patient number and don't have heterogeneity and number similarity among groups. also, all patient treatments were not designed based on the literature, they were accepted completely arbitrary and authors could not classify the patients according to received treatments. the important part of patients didn't present for follow up because of socio-cultural reasons. this aspect affected our ability to gather information about long term prognosis. furthermore, authors were not able to reach the patients' medical data, who presented to other ministry of health government hospitals. we are not also aware of patients who were thought to be normal and had not been transferred from the scene of the accident by ems. all of these can be the important factors in statistical and outcome evaluation. all exposed individuals in authors' study have shown complete resolution of their symptoms. the authors recommend that non symptomatic or slightly exposed patients do not need any treatment or may be treated symptomatically. combined humidified oxygen and bronchodilators are still the best treatment option in addition to symptomatic supportive measures. animal experiments which research efficacy of different agents and their combinations on chlorine toxicity are necessary. simple asphyxiants and pulmonary irritants indoor swimming pools, water chlorination and respiratory health effects of inhalation of corticosteroids immediately after experimental chlorine gas lung injury explosion risk from swimming pool chlorinators and review of chlorine toxicity the toxicology of chlorine case report and literature review of chlorine gas toxicity chlorine inhalation toxicity from vapors generated by swimming pool chlorinator tablets gervais p. persistent asthma after inhalation of a mixture of sodium hypochlorite and hydrochloric acid acute accidental exposure to chlorine gas in the southeast of turkey: a study of cases reactive airways dysfunction syndrome (rads) due to chlorine gas exposure subjects with seasonal allergic rhinitis and nonrhinitic subjects react differentially to nasal provocation with chlorine gas acute accidental exposure to chlorine fumes--a study of cases intoxication of children by chlorine gas a rare complication of chlorine gas inhalation: pneumomediastinum short term respiratory effects of acute exposure to chlorine due to a swimming pool accident chlorine: state of the art management of chlorine gas exposure risk factors for acute chemical releases with public health consequences: hazardous substances emergency events surveillance in the home exposures to chlorine/chloramine gas: review of cases exaggerated responses to chlorine inhalation among persons with nonspecific airway hyperreactivity chlorine inhalation: the big picture chlorine poisoning at the swimming pool revisited: anatomy of two minidisasters chlorine gas exposure and the lung: a review trauma cases from harborview medical center chlorine-related inhalation injury from a swimming pool disinfectant in a -year-old girl toxicology of hazardous chemicals inhaled budesonide in experimental chlorine gas lung injury: influence of time interval between injury and treatment nebulized sodium bicarbonate in the treatment of chlorine gas inhalation the effect of nebulized nahco treatment on "rads" due to chlorine gas inhalation clinical management of casualties exposed to lung damaging agents: a critical review this study presented to be a poster presentation in turkish thorax society th annually congress (april rd - th, , antalya-turkey). key: cord- -ro y authors: sardu, celestino; marfella, raffaele; maggi, paolo; messina, vincenzo; cirillo, paolo; codella, vinicio; gambardella, jessica; sardu, antonio; gatta, gianluca; santulli, gaetano; paolisso, giuseppe title: implications of ab blood group in hypertensive patients with covid- date: - - journal: bmc cardiovasc disord doi: . /s - - -z sha: doc_id: cord_uid: ro y background: hypertension is the most frequent co-morbidity in patients with covid- infection, and we might speculate that a specific blood group could play a key role in the clinical outcome of hypertensive patients with covid- . methods: in this prospective study, we compared vs. non- blood group in hypertensive patients with covid- infection. in these patients, we evaluated inflammatory and thrombotic status, cardiac injury, and death events. results: patients in non- (n = ) vs. blood group (n = ) had significantly different values of activated pro-thrombin time, d-dimer, and thrombotic indexes as von willebrand factor and factor viii (p < . ). furthermore, patients in non- vs. blood group had higher rate of cardiac injury ( ( . %) vs. ( . %)) and death, ( ( . %) vs. ( . %)), (p < . ). at the multivariate analysis, interleukin- ( . , ci % . – . ) and non- blood group ( . , ci % . – . ) were independent predictors of cardiac injury in hypertensive patients with covid- . d-dimer ( . , ci % . – . ), interleukin- ( . , ci % . – . ) and non- blood group ( . , ci % . – . ) were independent predictors of deaths events in hypertensive patients with covid- . conclusions: taken together, our data indicate that non- covid- hypertensive patients have significantly higher values of pro-thrombotic indexes, as well as higher rate of cardiac injury and deaths compared to patients. moreover, ab blood type influences worse prognosis in hypertensive patients with covid- infection. hypertension is the most common co-morbidity and cause of death in patients with covid- infection [ ] . such a negative correlation between hypertension and clinical prognosis in covid- patients has been deeply investigated in recent trials [ , ] . angiotensin converting enzyme (ace ), known to be involved in the molecular pathways underlying hypertension, is a crucial co-factor mediating sars-cov- entry into host cells [ ] . indeed, the spike proteins of sars-cov- have a high binding affinity for ace , which are mainly expressed in endothelial cells of the lung and the upper airways [ ] . moreover, angiotensin converting enzyme inhibitors (acei) and angiotensin receptor blockers (arb) have been shown to up-regulate ace levels, which partially mediates their cardiovascular protective effects [ ] . nevertheless, according to the recent evidence, acei/arb therapy does not seem to increase the risk of covid- infection in hypertensive patients [ ] . secondly, acei/arb therapy discontinuation is not recommended, because it may lead to endothelial dysfunction [ ] . actually, endothelial dysfunction itself, mirrored by hyper-inflammation could cause alterations of the coagulation thereby aggravating the prognosis of the disease [ , ] . the ab blood group has been previously shown to play a functional role in viral infections [ , ] . intriguingly, patients with non- blood group have higher risk for covid- infection when compared to blood groups [ ] , and the ab blood group could influence the coagulation processes [ , ] . however, the pathogenic mechanisms underlying these events have not been fully investigated, and could be of great interest to the scientific community and for clinical applications. thus, we hypothesized that non- blood group could be a trigger of endothelial dysfunction, via overinflammation and promoting a pro-thrombotic status in hypertensive patients with covid- . actually, although hypertension is known to trigger endothelial dysfunction and a pro-thrombotic status [ ] , no data are currently available exploring the association of ab group with inflammatory/thrombotic status in hypertensive patients with diagnosis of covid- .therefore, in this study we investigated the inflammatory/thrombotic status and clinical outcomes as cardiac injury and death in hypertensive patients with covid- ,comparing vs. non- blood groups. in this prospective study, we analyzed covid- hypertensive patients consecutively admitted to the department of infectious disease at university of campania "luigi vanvitelli", naples, italy between february , and april , . covid- infection was categorized as follow: a) mild, patients with fever and no pneumonia evidence in imaging; b) moderate, patients with fever, respiratory tract symptoms, pneumonia confirmed at imaging without the need for invasive ventilation; c) critical, occurrence of respiratory failure requiring mechanical ventilation, presence of shock, other organ failure requiring monitoring and treatment in intensive care unit [ ] . patients with previous inflammatory disorders, malignancy, renal diseases; unavailability of a written informed consent; patients without cardiac biomarkers evaluation, including values of high-sensitivity troponin i (hs-tni) and creatinine kinase-myocardial band (ck-mb). the diagnosis of hypertension was made following the international guidelines [ ] , and/or by known history of hypertension and current anti-hypertensive therapy. all enrolled patients were treated with the same standard protocol: non-invasive oxygen therapy; hydroxychloroquine ( mg/daily) and lopinavir/ritonavir ( / mg daily). according to ab blood group, patients were then categorized as " and non- blood group", [ , ] . established cardiac biomarkers, including hs-tni, ck-mb, and myo-hemoglobin, were collected for every participant at hospital admission by investigators (v.m. and c.s.).the investigation conforms to the principles outlined in the declaration of helsinki for the study of human subjects or tissues. the institutional ethics committee of the university of campania "luigi vanvitelli" approved the study protocol. written informed consent was obtained from all participating patients. in this study, we investigated the inflammatory and coagulative status, and the cardiac injury and deaths in hypertensive patients with covid- , with the aim to compare vs. non- blood group. cardiac injury and death were reported in a previous study for patients with covid- [ ] . cardiac injury was defined as blood levels of cardiac biomarkers (hs-tni) above the thpercentile upper reference limit ( ) . data on cardiac injury and death were collected by two independent physicians (p.m; r.m) during clinical examination, laboratory and imaging tests in hospitalized patients, and by examination of hospital discharge schedules [ ] . laboratory and imaging evaluations -real-time reverse transcription (rt-pcr assay for sars-cov- respiratory specimens were collected from each patient and then shipped to specialized laboratories designated by the italian government for confirming covid- infection. the presence of sars-cov- in respiratory specimens was detected by established rt-pcr methods. laboratory analyses were obtained on admission before starting covid- medical therapy and during hospitalization. we tested respiratory specimens, including nasal and pharyngeal swabs or sputum, to exclude evidence of other viral infections, including influenza, respiratory syncytial virus, avian influenza, para-influenza, and adenovirus. we also performed routine bacterial and fungal examinations. laboratory assessments consisted of a complete blood count, blood chemical analysis, coagulation testing, evaluation of liver and renal function, and measures of electrolytes, c-reactive protein, procalcitonin, lactate dehydrogenase, and creatine kinase. venous blood for il- (human elisa kit, rd system) and d-dimer (human elisa kit, invitrogen) levels was collected in edta-coated tubes immediately after patients arrived at the department and weekly during hospitalization. the ab phenotypes were ascertained by genotyping for four single nucleotide polymorphisms of the ab gene: g del, a g, g a and c g, as described [ ] . briefly, we used single nucleotide polymorphisms of the c g to decipher the o allele, which, unlike other o alleles, does not have a deletion at nucleotide position [ ] . we determined genotyping by using the multiplexing capability of the massarray homogenous massextend assay of the sequenom system (san diego, ca, usa). therefore, the dna fragments surrounding the single nucleotide polymorphisms sites were amplified by pcr, treated with shrimp alkaline phosphatase to dephosphorylate unincorporated dntps, followed by the extension primers that form allelespecific extension products. however, each extension product had a unique mass, measured using maldi-tof. genotypes were automatically assigned to each sample using the mass array rt software. the presence or absence of fv leiden (a g, r q) and the prothrombin g a polymorphism was assessed by standard methods [ ] . all patients underwent ecg at hospital admission, and in case of elevation of cardiac biomarkers during hospitalization; findings compatible with myocardial ischemia included t-wave depression and inversion, st-segment depression, and q waves. two blinded physician (c.s, r.m) reviewed and analyzed ecg patterns. radiologic assessments included chest radiography and/or computed tomography (ct) at admission and weekly during hospitalization, and all laboratory testing was performed according to the clinical care needs of each patient. we determined the presence of radiologic abnormalities on the basis of the documentation or description in medical charts; if imaging scans were available, they were reviewed by attending physicians in respiratory medicine who extracted the data. two blinded physician experienced in lung imaging (g.g, v.c.) reviewed and analyzed chest radiography and ct patterns. major disagreement between two reviewers was resolved by consultation with a third reviewer. continuous variables were expressed as medians and interquartile ranges or simple ranges, as appropriate. categorical variables were summarized as counts and percentages. we performed only descriptive statistics, because the cohort of patients in our study was not derived from random selection. we performed a risk adjusted cox-regression analysis to assess survival from cardiac injury and deaths through days of hospitalization; cox models were adjusted for; age, gender, body mass index, heart rate, cholesterol, high density lipoproteincholesterol, low density lipoprotein-cholesterol, triglycerides levels, heart diseases, dyslipidemia, diabetes, current smoking, beta-blockers, ace-inhibitors, calcium inhibitors, thiazide diuretics, aspirin. only variables presenting a p value ≤ . at the univariate analysis were included in the model. we used a stepwise method with backward elimination, and we calculated odds ratios (or) with % confidence intervals. the model was evaluated with a hosmer and lemeshow test. kaplan-meier survival analysis was performed for cardiac injury events and deaths in patients divided in: vs. non- blood group. a p value < . was considered statistically significant. all calculations were performed using the software spss . we enrolled hypertensive covid- patients; the study population was then divided according to the ab blood group in (n = ) vs. non- (n = ). the main clinical characteristics of our population are shown in table . comparing vs. non- blood group, we found significantly different values of activated pro-thrombin time, d-dimer, and thrombotic indexes including activated pro-thrombin time, von willebrand factor (vwf) and factor viii (p < . ). patients in non- vs. blood group had higher rate of cardiac injury [ ( . %) vs. ( . %)] and deaths [ ( . %) vs. ( . %)], (p < . ) as shown in table . cardiac injury was diagnosed in ( %) of patients. then, we performed a multivariate analysis, which revealed that interleukin- (il- , . , ci % . - . ) and non- blood group ( . , ci % . - . ) were identified as independent predictors of cardiac injury in hypertensive patients with covid- (table ) . moreover, at multivariate analysis, d-dimer ( . , ci % . - . ), il- ( . , ci % . - . ) and non- group ( . , ci % . - . ) were identified as independent predictors of death in hypertensive patients with covid- (table ) . finally, we analyzed kaplan curves of survival ( fig. ) , observing a significant (p < . ) difference between o vs. non- hypertensive patients with covid- in terms of cardiac injury (upper panel) and death (lower panel). from the analysis of hypertensive patients with covid- infection, the main study results are: i) non- vs. patients have significant higher values of pro-thrombotic indexes; ii) non- vs. patients have higher rate of cardiac injury; iii) non- vs. patients have increased rate of deaths (p < . ); iv) il- level is an independent predictor of cardiac injury and death; v) d-dimer is an independent predictor of death; vi) non- group is an independent predictor of both cardiac injury and deaths in hypertensive patients with covid- . in our study, non- patients had higher values of prothrombotic indexes, and higher rate of cardiac injury and death. of interest, the ab blood type has been previously shown to influence the hemostasis by increasing vwf and fviii blood levels, as well as by genetic variations and over-inflammation, that can lead to thrombosis independently of factor viii [ ] . notably, non- blood group can influence the traditional risk factors for arterial or venous thrombotic events [ , ] ; besides, in patients with sepsis the non- blood group increases the risk for disseminated intravascular coagulopathy (dic) independently from disease severity [ ] . equally important, endothelial dysfunction in hypertensive patients can cause cardiac injury and stroke via thromboembolism [ ] . therefore, these events could underlie the worse prognosis in patients with hypertension and covid- . indeed, we have shown that covid- infection could affect endothelial cell function leading to thrombotic complications [ ] . according to the data presented here, the extent of endothelial dysfunction present in this class of patients could be further enhanced by a pro-thrombotic status in non- patients [ ] . hence, hypertension could confer a pro-thrombotic state and over inflammation in covid- patients, that could be , and myohemoglobin (μg/l), ast (mg/dl), alt (mg/dl), ck-mb (mg/dl) and ldh (mg/dl) as means ± standard deviations. the means for continuous variables were compared using independent group t tests when the data were normally distributed (normal distribution verified applying the kolmogrov-smirnov test), otherwise, the mann-whitney test was used. the pearson correlation coefficient and spearman rank correlation coefficient were used for liner correlation analysis. proportions for categorical variables were compared using the χ test, whereas the fisher exact test was used when data were limited. wilcoxon rank sum matched-pair tests were used to assess differences among the admission, hospitalization, and impending death. a -sided p < . was considered statistically significant. analysis began february , ami acute myocardial infarction, cabg coronary artery bypass grafting, ptca percutaneous coronary angioplasty, pt pro-thrombin time, aptt activated prothrombin time, ast aspartate amino transferase, alt alanine amino transferase, ck-mb creatinine kinase-myocardial band, ldh lactate dehydrogenase, bnp b type natriuretic peptide, hb ac glycated hemoglobin, pao /fio pressure of arterial oxygen to fractional inspired oxygen concentration, hs high specificity, lvtdd left ventricle end-diastolic diameter, lvtsd left ventricle end-systolic diameter, lvef left ventricle ejection fraction, * is for statistical significant (p < . ) then increased in non- blood [ ] [ ] [ ] [ ] [ ] . in line with this view, il- , a widely recognized marker of inflammation, is up regulated in non- vs. covid- patients, and independently predicts cardiac injury and death. indeed, il- plays a crucial role in the cytokine release syndrome [ ] . thus, the increased il- levels detected in covid- patients could result in worse prognosis and death [ ] . therefore, the therapeutic block of il- mediated signal transduction pathway by tocilizumab, has been proposed as an effective rescue treatment in severely ill covid- patients [ , ] . hence forth, il- serum levels could be used as marker of disease severity, such as predictor of worse prognosis for non- vs. blood group of hypertensive patients with covid- . in addition, assaying for the d-dimer could be used to add other predictive information on the risk of death in non- vs. hypertensive patients with covid- . consistent with our findings, a d-dimer greater than μg/ml has been proposed to help clinicians in identifying patients with poor prognosis at an early stage of covid- disease [ ] . indeed, augmented d-dimer level is a marker of enhanced thrombosis in patients with covid- , [ , ] . thus, the functional association linking d-dimer, thrombosis, fibrinolysis and poor prognosis could be extended to hypertensive patients with non- blood group, identifying these patients as individuals at high risk of a severe outcome following covid- infection. finally, in hypertensive patients all these adverse events could be seen as complications of an increased inflammation, thrombosis, and fibrinolysis [ ] , all phenomena that are particularly enhanced in patients with non- blood group [ ] . indeed, ab blood group could cause a higher susceptibility to severe acute respiratory syndrome [ ] , leading to the development of neutralizing antibodies against protein-linked n-glycans [ ] and acting on the stabilization of vwf [ ] . intriguingly, in a recent genomic study, authors identified a p . gene cluster as a genetic susceptibility locus in covid- patients with respiratory failure [ ] . moreover, the ab blood-group showed a potential involvement in covid- disease, with a protective effect for blood group as compared with the other blood groups [ ] . consequently, in the non- group all these adverse events could cause an increased rate of cardiac injury and death in hypertensive patients. in this regard, including elevations in serum biomarkers of cardiac damage, the standard ecg may represent a crucial test in the diagnosis of myocardial injury or heart rhythm disturbances in patients with covid- [ ] . indeed, ecg abnormalities, independently from the severity of pulmonary tract infection, could reflect a wide spectrum of cardiovascular complications and frequently occur after negative nasopharyngeal swabs [ ] . however, ecg abnormalities of covid- are still undefined, particularly during the acute phase of the disease [ ] . in this sense, it is critical to note that we found that the non- blood group results in . -fold and . -fold increased risk to develop cardiac injury and death in hypertensive patients with covid- . our study is not exempt from limitations. for instance, we did not report data on magnetic resonance imaging or echocardiography to determine the features of myocardial injury. however, we diagnosed cardiac injury by evaluation of hs-tni serum increase and ecg findings. thus, we cannot have definitive data and evidence about the mechanisms of covid- directly heart injury. thereby, this aspect requires further studies in order to be confirmed. again, we did not evaluate effects of vs. non- blood group in non-hypertensive covid- patients, that could be seen as control group and could limit the generalization of the present study results in overall population. taken together, our data indicate that covid- associated coagulopathy should be carefully managed in hypertensive patients with non- group as critically ill patient because such association could result in an increased risk of unfavorable outcomes as cardiac injury and death via inflammatory and hyper-coagulative mechanisms. therefore, we speculate that targeted anticoagulant therapies have to be introduced early in these high-risk covid- patients, namely hypertensive individuals with non- blood group, in order to reduce cardiac injury and death. further studies conducted on larger populations are needed to confirm these results. clinical characteristics of coronavirus disease in china hypertension, thrombosis, kidney failure, and diabetes: is covid- an endothelial disease? a comprehensive evaluation of clinical and basic evidence negative impact of hyperglycaemia on tocilizumab therapy in covid- patients could anti-hypertensive drug therapy affect the clinical prognosis of hypertensive patients with covid- infection? data from centers of southern italy human susceptibility and resistance to norwalk virus infection abo blood group and susceptibility to severe acute respiratory syndrome relationship between the abo blood group and the covid- susceptibility. medvis preprint abo blood group, other risk factors and incidence of venous thromboembolism: the longitudinal investigation of thromboembolism etiology (lite) the abo blood group system revisited: a review and update acc/aha/aapa/abc/acpm/ags/ apha/ash/ aspc/nma/pcna guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the american college of cardiology/american heart association task force on clinical practice guidelines association of cardiac injury with mortality in hospitalized patients with covid- in wuhan, china advance in the management of sepsis-induced coagulopathy and disseminated intravascular coagulation hypertension and the prothrombotic state the cytokine release syndrome (crs) of severe covid- and interleukin- receptor (il- r) antagonist tocilizumab may be the key to reduce the mortality negative impact of hyperglycaemia on tocilizumab therapy in covid- patients clinical course and risk factors for mortality of adult in patients with covid- in wuhan, china: a retrospective cohort study covid- and its implications for thrombosis and anticoagulation outcomes in patients with hyperglycemia affected by covid- : can we do more on glycemic control? diabetes care abo blood group and susceptibility to severe acute respiratory syndrome harnessing the natural anti-glycan immune response to limit the transmission of enveloped viruses such as sars-cov- abo blood group is a determinant of von willebrand factor protein levels in human pulmonary endothelial cells genomewide association study of severe covid- with respiratory failure electrocardiographic features of patients with covid- pneumonia publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements we thank all physicians those who have helped in carrying out this research.authors' contributions c.s: study design, data interpretation, major contributor in writing the manuscript and revision; r. m and g.p.: study editing and revision; p. m, v. m, p. c, v. c, j. g, a. s, g.g: data collection; g. s: study revision. all authors read and approved the final manuscript. the santulli's lab is supported in part by the nih (r -dk , r -hl ,r -dk , and r -dk to g.s.) and by the american heart association (aha- post to j.g.). the funding bodies played no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.availability of data and materials the datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.ethics approval and consent to participate the institutional ethics committee of the university of campania "luigi vanvitelli" approved the study protocol. written informed consent was obtained from all participating patients. competing interests none to declare. received: may accepted: august key: cord- -jiauk fq authors: risalde, maría a; molina, verónica; sánchez-cordón, pedro j; romero-palomo, fernando; pedrera, miriam; garfia, bartolomé; gómez-villamandos, josé c title: pathogenic mechanisms implicated in the intravascular coagulation in the lungs of bvdv-infected calves challenged with bhv- date: - - journal: vet res doi: . / - - - sha: doc_id: cord_uid: jiauk fq resistance to respiratory disease in cattle requires host defense mechanisms that protect against pathogens which have evolved sophisticated strategies to evade them, including an altered function of pulmonary macrophages (mΦs) or the induction of inflammatory responses that cause lung injury and sepsis. the aim of this study was to clarify the mechanisms responsible for vascular changes occurring in the lungs of calves infected with bovine viral diarrhea virus (bvdv) and challenged later with bovine herpesvirus type (bhv- ), evaluating the role of mΦs in the development of pathological lesions in this organ. for this purpose, pulmonary lesions were compared between co-infected calves and healthy animals inoculated only with bhv- through immunohistochemical (mac , tnfα, il- α, inos, cox- and factor-viii) and ultrastructural studies. both groups of calves presented important vascular alterations produced by fibrin microthrombi and platelet aggregations within the blood vessels. these findings were earlier and more severe in the co-infected group, indicating that the concomitance of bvdv and bhv- in the lungs disrupts the pulmonary homeostasis by facilitating the establishment of an inflammatory and procoagulant environment modulated by inflammatory mediators released by pulmonary mΦs. in this regard, the co-infected calves, in spite of presenting a greater number of imΦs than single-infected group, show a significant decrease in inos expression coinciding with the presence of more coagulation lesions. moreover, animals pre-inoculated with bvdv displayed an alteration in the response of pro-inflammatory cytokines (tnfα and il- ), which play a key role in activating the immune response, as well as in the local cell-mediated response. the bovine respiratory disease complex (brdc) is an important problem for the cattle industry, often resulting in severe economic losses [ , ] . this fatal bovine respiratory infection is a multi-factorial disease associated with a primary viral infection followed by a secondary bacterial infection. it is frequently characterized by concurrent infections of several pathogens. the etiologic agents related to feedlot pneumonias include bovine viral diarrhea virus and (bvdv- and bvdv- ), bovine herpesvirus type (bhv- ), bovine parainfluenza- virus, bovine respiratory syncytial virus, bovine adenovirus, bovine coronavirus, mannheimia haemolytica, pasteurella multocida, histophilus somni and mycoplasma spp. [ ] [ ] [ ] [ ] . resistance to respiratory disease in cattle requires host defense mechanisms that protect against viral and bacterial pathogens that have also evolved sophisticated strategies to evade the host immune responses, including among others an altered pulmonary macrophages (mΦs) function or the induction of profound inflammatory responses that cause lung injury and sepsis [ ] . the inflammatory process is a protective mechanism that occurs in response to trauma, infection or tissue injury [ , ] . increased blood supply, enhanced vascular permeability and migration of immune cells occur at damaged sites. in this process, mΦs play a central role in managing different immunopathological phenomena through the secretion of inflammatory mediators such as nitric oxide (no), prostaglandins, and the pro-inflammatory cytokines tumor necrosis factor-α (tnfα) and interleukin (il)- [ ] [ ] [ ] . no is a potent vasodilator, acting to maintain vascular tone and function within the vessel wall, generated from l-arginine by nitric oxide synthase (nos) enzymes. there are three main isoforms of nos with distinct functions and patterns of expression: endothelial nos, neuronal nos and inducible nos (inos) highly expressed in mΦs [ , ] . prostaglandins are other important inflammatory mediators implicated in the vascular homeostasis since its low levels can prevent or reverse aggregation of platelets and induce vasodilation [ , ] . these molecules are produced from arachidonic acid metabolites by the catalysis of cyclooxygenase- (cox- ) [ ] . pro-inflammatory cytokines induce integrin expression and redistribution of leukocytes, which contribute to their recruitment and activation at the site of inflammation [ , ] , as well as increasing vascular permeability and tissue injury [ , ] . there is evidence that inflammatory cytokines are the main orchestrators of the inflammatory cascade in brdc, detecting high levels of tnfα and il- in the airways of cattle infected with respiratory pathogens [ ] [ ] [ ] [ ] . bvdv is a pestivirus that although it is not a primary agent in the pathogenesis of brdc, it can suppress the host immune system and increase the risk of secondary infections, thus enhancing pulmonary colonization by other pathogens such as bhv- [ ] [ ] [ ] . the mechanisms of the immunosuppressive action of bvdv are object of debate, including changes related to decreased lymphocyte proliferation [ , ] , severe lymphoid depletion in lymphoid tissues [ ] [ ] [ ] , decreased chemotaxis and phagocytic activity [ ] , increased production of prostaglandin e [ , ] , increased no synthesis in response to lipopolysaccharide [ , ] and impaired production of pro-inflammatory cytokines [ , [ ] [ ] [ ] [ ] . therefore, the aim of this study was to clarify the mechanisms responsible for ultrastructural and histopathological changes occurring in the lungs of calves pre-infected with bvdv and challenged later with bhv- , as well as to analyze the role of mΦs in the appearance of the lesions. thus, this work will contribute to gaining a better understanding about how this virus predisposes to secondary airborne infections. the experimental design and collection of samples have been described by risalde et al. [ ] . briefly, twenty-four friesian calves ( - months old), bvdv and bhv- antigen and antibody (ab) free, were housed in the animal experimental center of cordoba university (spain). the animals had an adjustment period of one week before the study started and were separated into three groups based on the inoculation protocol: twelve calves were inoculated intranasally with ml of a suspension of non-cytopathic bvdv- strain with a titration of tissue culture infective dose % (tcid )/ml (courtesy of the institute für virologie, tiho, hannover, germany). twelve days later, when the calves showed neither clinical signs nor bvdv viraemia, they were challenged with ml of bhv- . strain iowa containing tcid /ml (courtesy of the hipra laboratories, girona, spain) (bvdv/bhv- group). two calves of this group, bhv- . -free, were used as bvdv infection controls. at the same time, ten calves were inoculated only with bhv- . (bhv- group). two un-infected (ui) animals were used as negative controls and received intranasally ml of tissue culture fluid free of viruses. the time point of bhv- . inoculation was defined as day . after virus inoculation, clinical examination was performed daily. in order to determine the number of platelets, edta blood obtained from coccygeal vein and nasal swab samples were collected at , , , , , , and hours post-inoculation, , , , , , , and days post-inoculation (dpi) with bhv- . . the infected calves were sedated with xylazine (rompun w % solution; bayer healthcare, kiel, germany) and euthanized by overdosing with thiopental-sodium (thiovet w ; vet limited, leyland, lancashire, uk) in batches of two at , , , and dpi. two animals of the bvdv/bhv- group were killed at dpi just before bhv- . inoculation (bhv- . -ui), being used as bvdv infection controls for this group. on the contrary, the two negative control animals were euthanized at the end of the study, being used as ui controls for the bhv- group. the experimental procedure was carried out in accordance with the code of practice for housing and care of animals used in scientific procedures, approved by the european economic community in ( / /eec amended by the directive / /ec). all euthanized calves were subjected to necropsy examination. the samples were collected from the lungs and immediately frozen at − °c for virological study; likewise, they were fixed in % buffered formalin solution for histopathological and immunohistochemical studies as well as in . % glutaraldehyde in . m pbs for ultrastructural analysis. lung tissue samples were analyzed to discard any infection with secondary bacterial pathogens, being subjected to microbiological routine cultures (xylose lysine deoxycholate agar, macconkey agar and blood agar) by using standard procedures. no bacteria were isolated from these samples. rneasy lipid tissue kit (qiagen) was used to extract bvdv ribonucleic acid (rna) from lung samples, according to the manufacturer's instructions. this rna was subjected to a one step real-time reverse transcription plus polymerase chain reaction (rt-pcr) using primers and taqman probes (at the same concentration) from conserved regions of the '-utr of bvdv- a [ ] . the reaction was performed using the real time ready rna virus master (roche, mannheim, germany) in a lightcycler . , according to the manufacturer's instructions. the samples with a cycle threshold value less than or equal to were considered as positive. the positive control was the ncp bvdv- strain at tcid /ml. a real-time pcr analysis of the bhv- deoxyribonucleic acid (dna), extracted from lung samples using genomic dna from a tissue kit (macherey-nagel, germany), was performed according to the oie terrestrial manual [ ] . after analyzing the results on an applied detector (applied biosystems, usa), any sample with a cycle threshold value less than or equal to was considered as positive. the positive control was the bhv- . strain iowa at . tcid /ml. glutaraldehyde-fixed samples were post-fixed in % osmium tetroxide, dehydrated in acetone and embedded in epon w (fluka chemie ag, buchs, switzerland). sections ( nm) were counterstained with uranyl acetate and lead citrate, and examined with a philips cm- transmission electron microscope. formalin-fixed samples were dehydrated through a graded series of alcohol to xylol and embedded in paraffin wax by routine techniques for light microscopy. samples were sectioned ( μm) and stained by different methods as haematoxylin-eosin and the fraser lendrum technique, or processed for their immunohistochemical study using the avidin-biotin-peroxidase complex (abc) method. the abc method for immunohistochemistry (ihc) was performed on serial sections of formalin-fixed samples, which were dewaxed and rehydrated as previously described by pedrera et al. [ , ] . briefly, endogenous peroxidase activity was exhausted by incubation with . % hydrogen peroxide in methanol for min at room temperature. the samples were subjected to different methods for antigen retrieval (table ) . after pretreatment, the sections were rinsed three times in pbs (ph . ) for min and then covered with % normal horse serum (pierce-endogen, woburn, usa) in . m tris buffered saline (tbs) (ph . ) or % normal goat serum in pbs for min at room temperature, for primary monoclonal ab(mab) and polyclonal ab(pab), respectively. after this blocking stage, sections were incubated with primary ab at °c overnight. after primary incubation, the slides were washed in pbs (three times for min each) and then incubated with the secondary antibodies for min at room temperature. biotinylated horse anti-mouse igg secondary ab (pierce-endogen) diluted : in tris buffer containing normal horse serum % was used for the primary mab. biotinylated goat anti-rabbit igg secondary ab (vector laboratories, burlingame, ca, usa) diluted : in pbs containing normal goat serum . % was used for the primary pab. after three further min washes in tbs, samples were incubated with the abc complex (vectastain w abc elite kit, vector laboratories, ca, usa) for h at room temperature. all tissue sections were finally rinsed in pbs and incubated with chromogen solution (novared w substrate kit, vector laboratories). slides were counterstained with mayer's haematoxylin. details of the primary mab and pab are summarized in table . tissue samples from cattle, in which reactivity for primary ab against cytokines and cellular markers used in this study had been demonstrated, were used as positive controls in ihc [ , ] . tissue sections for which the specific primary ab were replaced by rabbit or mouse non-immune sera (dakocytomation, glostrup, denmark) were used as negative controls. in order to evaluate the number of immunolabeled cells and to correlate the results obtained using different ab, two paraffin-wax blocks from the lungs of each animal were selected. cell counts were carried out on randomly chosen fields of . mm from tissue sections from these blocks. the results are given as the number of positive cells per . mm . identification of different types of immunolabeled cells was based on morphological features, location and size of the cells. the different pulmonary mΦs exhibited rounded or elongated morphology, an indented nucleus and abundant cytoplasm. interstitial mΦs (imΦs), pulmonary intravascular mΦs (pim) and pulmonary alveolar mΦs (pam) are localized in distinct anatomical compartments of the lung, including connective tissue, being adhered to the endothelium in the pulmonary capillaries and air spaces, respectively. pim and imΦs were grouped together and are described as "septal mΦs". a semiquantitative estimation of platelet aggregation factor-viii-positive was performed on randomly chosen . mm areas. the results are given as the presence of positive clusters of platelets per area as follows: absent (−), mild (+), moderate (++) and abundant (+++). for graphical representation and statistical analysis, they were scored from absent to severe ( to ). quantifications were performed by two experienced observers but with no previous knowledge of which group was being analyzed. data were assessed to calculate mean ± standard error values and were analyzed with the sas system for windows, version . (sas institute, cary, north carolina, usa). chi-square analysis was employed for the estimation of platelet aggregation factor-viii-positive for which a p < . was accepted as statistically significant, using a fisher's exact test in the instance of an expected value below . the duncan's multiple range test (p < . ) was used to analyze significant differences of the values in the same group at various time points (*) and non-paired student's t-test (p < . ) was used between both inoculated groups at the same time point (**). the main respiratory signs are given in risalde et al. [ ] . briefly, the calves pre-infected with bvdv show more intense respiratory signs such as cough, mucopurulent nasal discharge, dyspnoea and open-mouth breathing mainly between and dpi, while the calves of the bhv- group only presented a moderate serous nasal discharge. platelet numbers were within the clinically normal range in all calves throughout the study, except for animals from both inoculated groups, where an important decrease of platelet numbers to approximately % was observed at hpi. the presence of bvdv in the lungs of co-infected calves was detected by rt-pcr between and dpi ( - dpi bvdv), presenting the samples cycle threshold values between and ; whereas bhv- was detected by pcr from to dpi in these calves with cycle threshold values from to . on the contrary, bhv- was only detected between and dpi in the bhv- group, showing the samples higher cycle threshold values (between and ), while bvdv was not detected in these calves throughout the study. there were no remarkable lesions in the negative control animals. the pulmonary parenchyma of inoculated calves was affected by interstitial pneumonia with alveolar septal thickening produced by interstitial aggregates of mononuclear cells. the appearance of this alteration was earlier in the co-infected calves and was associated with occasional haemorrhages. the fraser lendrum technique revealed fibrin microthrombi in some pulmonary venules and capillaries of inoculated calves, being more severe in co-infected calves, mainly from dpi onwards ( figure a) . these changes were confirmed by the ultrastructural study together with the presence of fibrin in alveoli associated with pam in both inoculated groups at early stages ( figure b) . moreover, these animals displayed an intense hyperaemia as well as interstitial and alveolar oedema during this period. these findings were associated with a great quantity of platelets, whose detection was performed by ihc using anti-factor-viii ab. thus, in the negative control calves, this ab prompted positive granular immunostaining among sheathed capillary cells, free in the interstitium and occasionally in mΦs cytoplasm. however, in the inoculated groups, clusters of immunostained granular material were observed in blood vessels. moreover, numerous imΦs and periarterial mΦs, together with some pam, were swollen and displayed an intense positive granular and cytoplasmic reaction in both inoculated groups between and dpi (figure a, b) . in the bvdv/bhv- group, clusters of platelets were observed from dpi, being more evident throughout the study associated with mΦs engulfing platelets that peaked at dpi (score value of in all evaluated fields) ( figure ). subsequently, the positive reaction in mΦs and vascular lumina diminished considerably without recovering thereafter ( figure c ). there was a significant difference in the presence of platelet clusters in this group throughout the study (p = . ). in the bhv- group, these findings were observed from dpi with similar values to the co-infected group, decreasing the number of platelet clusters until the end of the study (figures d and ) . however, there was no significant difference in the incidence of these clusters in the lungs of animals infected only with bhv- . ultrastructural studies confirmed that there was an increase in the number of activated platelets forming multiple aggregations within the blood vessels, whose vascular lumina usually appeared completely occluded. the changes indicative of this activation were an enlarged and deformed shape of the cells, a partial or total decrease in granule numbers and a dilation of the open canalicular system. the most common form of platelet aggregation was the appearance of mosaic-like clusters comprising fully degranulated platelets with fusion of cytoplasmic membranes. occasionally, these membranes completely disappeared, giving rise to a finely granular structure with low electron density, containing vestiges of platelet organelles and surrounded by a membrane layer. in the bvdv/bhv- group, platelet aggregation occurred sooner and was more intense, increasing between and dpi ( figure a ) and not showing a total recovery at the end of the study ( figure c ). in the bhv- group this lesion was moderate, presenting retrieval signs from dpi ( figure b, d) . subcellular changes indicative of a slight secretory activation in imΦs such as enlargement, proliferation and dilation of rough endoplasmic reticulum and golgi complex cisternae were mainly observed in the bhv- group at dpi. moreover, from dpi, some pim and pam of both inoculated groups appeared enlarged and rounded, with loss of filopodia, increased number of lysosomes and varying amounts of cell debris in their cytoplasm, characteristic signs of phagocytic activation ( figure c) . immunolabeling of septal mΦs displayed similar kinetics in single and dual infections after bhv- . inoculation, although presenting differences in the magnitude of (see figure on previous page.) figure fibrin microthrombi in pulmonary venules of animals pre-infected with bvdv and challenged later with bhv- . . co-infected animals presented vascular alterations that facilitate the occlusion of the pulmonary venules as fibrin microthrombi observed with fraser lendrum technique (a) and tem (b) at dpi, as well as pim enlarged and rounded engulfing cell debris (arrowheads) observed with tem at dpi (c). their response. thus, the bvdv/bhv- group showed a higher number of these cells during the study, peaking at dpi (p < . ). the number of pam was also significantly higher in the co-infected calves at the start of the study, showing a decrease from dpi ( figure ). secretory activity of mΦs observed ultrastructurally was confirmed by ihc, which enabled the detection of mΦs-secreted inflammatory mediators. tnfα and il- α-producing cells, identified as septal mΦs and pam, were detected immunohistochemically in the lungs of control and infected animals. these proinflammatory cytokines presented differences in magnitude and kinetics between single and dual infections. tnfα-positive septal mΦs were associated with sites of inflammation in the bvdv/bhv- group (figure a ), showing only a slight peak at dpi (p < . ), whereas the bhv- group presented a longer response of this chemical mediator in peribronchial areas (from dpi; p < . ) ( figure b ). on the contrary, il- α-reactive septal mΦs were significantly different between both infected groups before bhv- inoculation ( dpi bhv- ). bvdv/bhv- group calves maintained lower numbers of il- α-positive septal mΦs throughout the study (figure c) , showing a delayed response to bhv- inoculation (from dpi onwards). by contrast, bhv- group calves displayed an early increase of this cytokine associated with peribronchial areas (at dpi; p < . ) ( figure d ). the number of pam positive for studied cytokines was low in both inoculated groups, presenting only a slight response at the end of the study, with the exception of an il- α peak in the single infected group between and dpi (figure ) . numerous groups of immunolabeled septal mΦs presenting inos-positive cytoplasmic granules, mainly imΦs, were observed in the pulmonary parenchyma of animals infected only with bvdv ( figure a dpi ( figure b ). in healthy calves, septal mΦs presented a similar response after bhv- inoculation; although in these animals the decrease of this mediator was observed later than in the bvdv/bhv- group. on the contrary, the number of inos-positive pam was higher in the bvdv/bhv- group and did not suffer changes throughout the study, while bhv- group calves showed a significant decrease from dpi (figure ). intracellular localization of cox- was perinuclear and cytoplasmic in the mΦs, being its expression scarce in the lungs during the study ( figure c ), except for septal mΦs of the bvdv/bhv- group at dpi (p < . ) (figure ). this intense expression occurred at sites of inflammation and injury, mainly oedemas, and was correlated with the degree of pulmonary inflammation ( figure d ). the objective of this study was to evaluate and characterize the vascular changes observed in the lungs of healthy calves and calves with subclinical bvd both experimentally inoculated with bhv- . , and to clarify the role of the pulmonary mΦs in the local response to the secondary pathogen. the results show that following bhv- inoculation, both groups of calves displayed a mononuclear cell infiltrate and prompted major vascular alterations in the lungs, marked by intense intravascular coagulation in small and medium-sized blood vessels from an early stage of the disease. three mechanisms, jointly known as virchow's triad, can induce thrombosis [ ] : ) endothelial wall injury; ) abnormalities of blood constituents (platelets, coagulation and fibrinolytic pathways); and ) abnormalities of blood flow. with regard to endothelial damage, infection by human herpes simplex virusbelonging to the same subfamily that bhv- [ ] has been shown to cause endothelial injury, favoring the exposure of subendothelial tissue and the release of procoagulant mediators [ , ] . here, however, neither histopathological nor ultrastructural examination disclosed any morphological evidence of endothelial damage in either of the inoculated groups. analysis of the cell components involved in coagulation pathways revealed fibrin deposits and intense platelet aggregation in the pulmonary microvasculature of both groups; these findings were particularly marked in the bvdv/bhv- group at dpi, coinciding with a significant increase of the rectal temperature and severe clinical respiratory symptoms [ ] . according to this, in the course of certain acute viral infections, platelets may be activated in vivo, leading to their degranulation, figure pro-inflammatory cytokines in the lungs of calves with and without pre-existing bvdv challenged with bhv- . . an immunohistochemical study revealed the presence of septal mΦs and pam positive for tnfα (a) and il- α (c) associated with sites of inflammation in the pulmonary parenchyma of the bvdv/bhv- group at dpi. however, the calves of the bhv- group presented a higher number of imΦs reactive to tnfα (b) and il- α (d) in the peribronchial areas of the lung at dpi. aggregation and withdrawal from circulation [ ] [ ] [ ] . the procoagulant activity of bvdv and bhv- has been reported in vitro [ ] . in our experimental study, it was increased in the co-infected calves due to the concomitance of both agents in the lungs between and dpi. despite the absence of bvdv in the blood of these calves at the moment of bhv- inoculation, it does not completely disappear, being detected by pcr in the lungs and by ihc in lymphoid tissues throughout the experience [ ] . however, there was no evidence in any stage of direct interaction between these viruses and platelets, which would suggest that platelet activation may be enhanced by indirect mechanisms including the expression of inflammatory mediators released by mΦs, which are known to play a major role in the maintenance of tissue homeostasis [ , ] . the study of pro-inflammatory cytokines revealed alterations in the kinetics and magnitude of tnfα and il- expression; both mediators can prompt changes in coagulation by increasing the number of endothelial adhesion molecules or increasing vascular permeability [ , ] . thus, the bvh- group calves display an increase in il- synthesis by septal mΦs coinciding with the onset of platelet aggregation in the lungs ( dpi). this, together with the subsequent action of tnfα, would favor the maintenance of the procoagulant setting. by contrast, bvdv/bhv- group calves, whilst exhibiting a higher number of imΦsthe main producers of these cytokinesdisplayed inhibited il- expression until dpi, along with a minimal tnfα response. this impaired cytokine production, also observed at the systemic level [ ] , indicates that the synergic action of both chemical mediators can be ruled out as a potential mechanism for inducing platelet aggregation in the co-infected group. calves inoculated only with ncp bvdv ( dpi for the bvdv/bhv- group) displayed greater expression of inos by septal mΦs than healthy calves [ , , ] . however, following bhv- inoculation, bvdv/bhv- group calves exhibited an early decline in inos ( dpi), an inflammatory mediator that limits the extent and duration of pathogen-induced platelet activation [ ] . this finding, together with the moderate response of tnfα, may have favored the appearance of platelet aggregates in the early stages of the disease, and intense aggregation coinciding with the greatest decrease in inos levels ( dpi). the intense platelet aggregation observed in the lung microvasculature of the bvdv/bhv- group at dpi, together with the increase in number and size of pim as a result of phagocytic and secretory activation would indirectly prompt a slowdown in blood flow and a subsequent response by the cox- enzyme aimed at reversing that process [ ] . however, in view of the damage observed at later stages, this action was presumably unable to counter the procoagulant events associated with the drop in inos expression, these being additionally enhanced by the delayed action of il- in co-infected animals. slowed blood flow, together with cytokine release, may lead to increased vascular permeability and extravasation of leukocytes into the pulmonary parenchyma [ , , , ] . therefore, the results of this study indicate that the concomitance of bvdv and bhv- in the lungs enhances a synergic action of their pathogenic mechanisms, disrupting the maintenance of pulmonary homeostasis by facilitating the establishment of an inflammatory and procoagulant environment, characteristic of the brdc, which appears to be modulated by inflammatory mediators released by pulmonary mΦs. in this respect, further research is required into the possible involvement of this concomitance, through the use of live bvdv and bhv- vaccines, in the triggering of an impaired pulmonary immune response. on the contrary, animals pre-inoculated with bvdvdespite suffering a transient infection -exhibit an alteration in the response of pro-inflammatory cytokines which play a key role in activating the immune response. ab: antibody; abc: avidin-biotin-peroxidase complex method; bhv- : bovine herpesvirus- bhv- group: calves inoculated only with bhv- ; brdc: bovine respiratory disease complex; bvdv: bovine viral diarrhea virus bvdv/bhv- group: calves inoculated with bvdv and bhv- dna: deoxyribonucleic acid; dpi: days post-inoculation ihc: immunohistochemistry; il: interleukin; imΦs: interstitial macrophages; inos: inducible nitric oxide synthase; mab: monoclonal ab mΦs: macrophages; no: nitric oxide; nos: nitric oxide synthase pcr: polymerase chain reaction; pim: pulmonary intravascular mΦs; rna: ribonucleic acid; rt-pcr: reverse transcription-polymerase chain reaction; tbs: tris buffered saline; tcid : tissue culture infective dose %; tem: transmission electron microscopy; tnfα: tumor necrosis factor-α bovine respiratory disease-a clinician's perspective pneumonia: identifying the causal agent economic impact associated with respiratory disease in beef cattle bovine viral diarrhea viral infections in feeder calves with respiratory disease: interactions with pasteurella spp., parainfluenza- virus, and bovine respiratory syncytial virus lung pathology and infectious agents in fatal feedlot pneumonias and relationship with mortality, disease onset, and treatments effect of stress on viral-bacterial synergy in bovine respiratory disease: novel mechanisms to regulate inflammation the impact of endogenous triggers on traumaassociated inflammation inflammasome adaptors and sensors: intracellular regulators of infection and inflammation pharmacological and biochemical demonstration of the role of cyclooxygenase in inflammation and pain the role of nitric oxide synthases in lung inflammation veterinary immunology: an introduction adenoviral-mediated gene transfer of nitric oxide synthase isoforms and vascular cell proliferation suppression of pro-inflammatory cytokines, inos, and cox- expression by brown algae sargassum micracanthum in raw . macrophages immunohistochemical demonstration of cyclooxygenase- (cox- ) and prostaglandin receptors ep and fp expression in the bovine intercaruncular uterine wall around term inflammatory cytokines enhance the interaction of mannheimia haemolytica leukotoxin with bovine peripheral blood neutrophils in vitro effect of experimental infection of cattle with bovine herpesvirus- (bhv- ) on the ex vivo interaction of bovine leukocytes with mannheimia (pasteurella) haemolytica leukotoxin secondary in vitro b lymphocyte (antibody) response to microbial antigens: use in appraisal of vaccine immunogenicity and cytokine immunoregulation tumor necrosis factor as a mediator of inflammation in influenza a viral pneumonia increased pulmonary secretion of tumor necrosis factoralpha in calves experimentally infected with bovine respiratory syncytial virus pulmonary expression of tumor necrosis factor alpha, interleukin- beta, and interleukin- in the acute phase of bovine pneumonic pasteurellosis bovine herpesvirus infection and infectious bovine rhinotracheitis bovine herpesvirus type infection of bovine bronchial epithelial cells increases neutrophil adhesion and activation effects in calves of mixed infections with bovine viral diarrhoea virus and several other bovine viruses the medicine and epidemiology of bovine respiratory disease in feedlots effect of passive immunity on the development of a protective immune response against bovine viral diarrhea virus in calves defective function of leukocytes from cattle persistently infected with bovine viral diarrhea virus and the influence of recombinant cytokines effect of concurrent experimentally induce bovine respiratory syncytial virus and bovine viral diarrhoea virus infection on respiratory tract and enteric diseases in calves distribution of viral antigen and tissue lesions in persistent and acute infection with homologous strain of noncytopathic bovine viral diarrhoea virus morphological changes and viral distribution in the ileum of colostrum-deprived calves inoculated with noncytopathic bovine viral diarrhea virus genotype- virus distribution and role of thymic macrophages during experimental infection with noncytopathogenic bovine viral diarrhea virus type depression of bovine monocyte chemotactic responses by bovine viral diarrhea virus effect of bvd virus infection on alveolar macrophage functions macrophages and respiratory viruses noncytopathic strains of bovine viral diarrhoea virus prime bovine bone marrow-derived macrophages for enhanced generation of nitric oxide cytokine regulation by virus infection: bovine viral diarrhoea virus, a flavivirus, downregulates production of tumor necrosis factor alpha in macrophages in vitro enhancement of apoptosis via an extrinsic factor, tnf-a, in cells infected with cytopathic bovine viral diarrhea virus bovine viral diarrhea viruses modulate toll-like receptors, cytokines and co-stimulatory molecules genes expression in bovine peripheral blood monocytes apoptosis in lymphoid tissues of calves inoculated with non-cytopathic bovine viral diarrhea virus genotype : activation of effector caspase- and role of macrophages hepatic immune response in calves during acute subclinical infection with bovine viral diarrhoea virus type response of proinflammatory and antiinflammatory cytokines in calves with subclinical bovine viral diarrhea challenged with bovine herpesvirus- real-time pcr for simultaneous detection and genotyping of bovine viral diarrhea virus oie: infectious bovine rhinotracheitis/infectious pustular vulvovaginitis virchow's triad revisited: blood constituents family-herpesviridae infection of vascular endothelial cells with herpes simplex virus enhances tissue factor activity and reduces thrombomodulin expression platelets from thrombocytopenic ponies acutely infected with equine infectious anemia virus are activated in vivo and hypofunctional enhanced platelet reactivity in cats experimentally infected with feline infectious peritonitis virus potentiation of platelet responses in vitro by feline infectious peritonitis virus early platelet aggregation as a cause of thrombocytopenia in classical swine fever induction of procoagulant activity in virus infected bovine alveolar macrophages and the effect of lipopolysaccharide comparison of pathologic changes and viral antigen distribution in tissues of calves with and without pre-existing bovine viral diarrhea virus infection following challenge with bovine herpesvirus- monocyte and macrophage heterogeneity arterial thrombosis associated with granulocyte-macrophage colony-stimulating factor (gm-csf) administration in breast cancer patients treated with dose-intensive chemotherapy: a report of two cases immunology of bovine viral diarrhea virus distinct role and location of the endothelial isoform of nitric oxide synthase in regulating platelet aggregation in males and females in vivo filovirus-induced endothelial leakage triggered by infected monocytes/ macrophages increased release of interleukin- beta, interleukin- , and tumor necrosis factoralpha by bronchoalveolar cells lavaged from involved sites in pulmonary tuberculosis submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution this work was supported by grants from the junta de andalucía-feder (p -agr- ). ma risalde and v molina were supported by a pre-doctoral grant from the spanish ministry of education and science. the authors thank the institute für virologie, tiho (hannover, germany) and laboratorios hipra sa (girona, spain) for providing the bvdv and bhv- . , respectively, and the farm "las rozuelas del valle" (torrecampo, spain) for providing the animals. we specially thank to a. muñoz for his technical assistance with the statistical analysis. the authors declare that they have no competing interests.authors' contributions mar participated in the design and coordination of the experiment, performed post-mortem and ihc examinations, analyzed the data and drafted the manuscript. vm participated in the design of the experiment, carried out tissue processing and participated in the ihc examinations and data analysis. pjsc participated in the design and coordination of the experiment, coordinated tissue sample collection at post-mortem and tissue sampling. fr carried out clinical monitoring and post-mortem examinations and helped with tissue sampling. mp carried out the clinical monitoring and tissue sampling at post-mortem. bg performed the molecular techniques. jcg conceived and coordinated the study, carried out the ultrastructural study and coordinated the drafting of the manuscript. all authors read, commented on manuscript drafts and approved its final version. key: cord- -vfnbs jn authors: rebmann, terri; wagner, william title: infection preventionists' experience during the first months of the novel h n influenza a pandemic date: - - journal: american journal of infection control doi: . /j.ajic. . . sha: doc_id: cord_uid: vfnbs jn background a novel strain of influenza a (h n ) was identified in april and developed into a pandemic by june . this rapid and unexpected event had enormous implications for infection preventionists (ip) internationally. lessons learned from this event should guide future pandemic planning efforts. methods focus groups were conducted at the association for professionals in infection control and epidemiology, inc, (apic) conference to evaluate ips' experience with the novel h n influenza pandemic and assess their perceived needs related to novel h n topics and products required for future education and reference materials. results forty ips ( from the united states and international) participated in the focus groups. needed reference materials identified by attendees included infection prevention guidance for nonacute care settings; occupational health polices; and brief, multilanguage patient/family educational materials. educational topics on which ips need to be trained include isolation precautions/personal protective equipment recommendations for novel h n patients, coordination between hospitals and community response agencies, and surge management. the rapidly changing and conflicting recommendations related to patient management made responding to this event challenging. ips require synthesized infection prevention guidelines developed in a concise, real-time format. conclusion ips must continue to partner with public health and other response agencies to address gaps in pandemic planning. infection preventionists' experience during the first months of the novel h n influenza a pandemic a novel strain of influenza a (h n ) was identified in late april . within a single week, the world health organization (who) raised the pandemic phase from to . the who pandemic phase indicates that there is sustained human-to-human transmission of a pathogen in at least countries and that a pandemic is likely imminent. the centers for disease control and prevention (cdc) reported the first case of laboratory-confirmed novel h n in the united states on april , ; a second case was reported days later. on april , the cdc activated its emergency operations center in response to the novel h n outbreak; days later, on april th, the cdc declared a public health emergency. early cases were identified in texas and california, but the outbreak soon spread widely across the united states. by may , , the cdc deployed % of the strategic national stockpile to aid states in responding to this event. on june , , the novel h n outbreak was officially declared a pandemic by the who. infection preventionists (ip) were on the frontlines during the early phase of the novel h n outbreak, helping health care agencies develop policies and procedures to respond to this rapidly evolving event. the surge of infected individuals and ''worried well'' taxed hospitals and health care agencies around the world. prior to being declared a pandemic, the novel h n outbreak grew exponentially in the weeks prior to the association for professionals in infection control and epidemiology, inc, (apic) annual educational conference and international meeting. this unexpected outbreak had enormous implications for ips internationally because infection prevention guidance related to novel h n patient management, such as recommendations on isolation and personal protective equipment (ppe) usage, came out sporadically from various organizations, including the who and cdc and health departments across the united states. the ips who responded to this event in the early months of the outbreak had unique experiences that may provide lessons learned for other ips and should guide future pandemic planning efforts. the purposes of this study were to evaluate ips' experience with the novel h n influenza pandemic and assess their perceived needs related to novel h n topics and products required for future education and reference materials. the aims are to understand better the novel h n pandemic and develop educational and planning/reference materials to aid in this and future infectious disease outbreaks. this project was conducted to support apic's goal of providing timely information relevant to novel h n and to complement the work of apic's emergency preparedness committee. the authors developed the questions for this study. all members of apic who were registered for the apic annual educational conference and international meeting were invited to participate in the focus groups, regardless of size or functionality of institution or work location (within or outside the united states). the only inclusion criteria was being involved in the direct response to the novel h n flu pandemic, defined as individuals who work in a hospital, health care, or public health agency that has handled/ managed at least confirmed positive case of novel influenza a h n in . the authors recruited potential participants via e-mail. one focus group met each day in a meeting room located in the conference center site on june and , . snacks were provided to the participants during the focus groups. the nominal group method was used to elicit information on the topics of interest. the focus group method (ie, opening-ended questions) was used to elicit details from participants' experience with the novel h n influenza pandemic. participants were informed that information collected would remain anonymous and that all responses were voluntary. focus group sessions were audiotaped, and the digital recordings were transcribed verbatim. content analysis included identifying, coding, and categorizing participants' response to the questions of interest. in addition, major themes that emerged were identified and categorized. subjects' demographic data were obtained for descriptive statistics. in addition, participants were asked to complete an -item survey containing items related to the novel h n flu pandemic, such as hospital or agency protocols for worker protection, isolation, and ppe usage during the event. the institutional review board of saint louis university approved this study. apic funded the costs of the food and meeting location for the focus groups; saint louis university covered the costs of data transcription. quotations that characterize the major themes are reported. the words enclosed in brackets of the quotations are used to explain the respondents' quotes and are not the participants' words. all individuals registered for the annual educational conference and international meeting were contacted. forty participants took part in the focus groups; the first focus group had participants, the second had , and the third had . most focus group participants ( %, n ) reported that they resided in the united states, spanning states; participants were from facilities outside the united states (australia, the united kingdom, and canada). most attendees worked in a hospital ( %, n ), public health agency ( %, n ), home health ( %, n ), or ambulatory care setting ( %, n ). the facility bed size ranged from (a small, rural facility) to , (a large, international multiagency health care system). approximately half of the attendees worked in an urban area ( %, n ); only % (n ) were from a rural area. the majority of attendees was female ( %, n ) and aged years or older ( %, n ). approximately half had a master's degree or more education ( %, n ). twentyseven participants ( %) were certified in infection control. a full description of the participants' demographic characteristics is reported in table . the participants identified many types of reference materials and education topics on which the participants believed ips need to be trained for future novel h n or other pandemics. the reference materials/ products that received the most votes during the nominal group method portion of the focus groups are outlined in table . the education topics that received the most votes during the nominal group method portion of the focus groups are outlined in table . in addition, a number of themes emerged from the focus groups related to infection prevention emergency management issues encountered during the novel h n influenza pandemic in spring . one of the most frequently cited topics of importance to focus group participants was the lack of infection prevention guidance for alternate care sites and nonacute care settings such as physician offices, ambulatory care clinics, long-term care, nursing homes, and others. as one participant noted, ''all the information that came out was basically for schools or acute care.'' other participants stated that it was difficult to know how to manage novel h n patients in this setting without guidance: one specific occupational health issue that focus group participants felt needs to be addressed is how to manage or prevent ill health care providers coming to work sick. as one participant stated, ''as much as you tell [health care workers] not to come to work sick, they still come.. we cannot allow employees to work sick, even with seasonal flu.'' money may be one potential reason that employees may work when sick. as one participant explained it, ''sometimes people will say, Ôi can't afford not to work.Õ '' another focus group participant agreed and added, ''it's hard to keep people off work when they are sick.'' focus group participants indicated that more administrative support and better human resource policies are needed related to furloughing staff and sick leave practices during pandemics. as one participant explained it,''we need [administrator's] support in saying that, when people are exhibiting symptoms, then they can't work in patient care.'' another participant agreed and added, ''of course the hospitals don't want to hear that you're not going to let the staff work.'' one focus group member stated that her human resource department was hesitant to furlough employees due to novel h n because it would cost the hospital money. she was told by human resources, ' compensation] would not cover occupational exposures to [novel h n ] because it's also out in the community.'' there was also some confusion about and hesitancy to enforce the cdc-recommended -day furlough period for staff infected with novel h n . as one participant stated,''we had more people who wanted to come back sooner than days.'' occupational health issues were present in the community, as well. companies were hesitant to allow employees to return to work without some reassurance from the medical community that the employee was no longer contagious. as one participant explained, ''we had employers calling up the emergency departments and saying, Ôi want this person tested, and they need to have a negative before we're going to allow them to come back to work.Õ '' this created a lot of extra and unnecessary work for hospitals and health care agencies. one issue that participants found particularly challenging was the difficulty in maintaining staff compliance and trust in the face of changing and conflicting practice recommendations/standards. the participants were asked which sources they used to obtain clinical information and infection prevention guidance about novel h n during the spring of . all the participants reported that they obtained information about novel h n from the cdc ( %, n ); other frequently cited sources of h n information included state health departments ( %, n ), the who ( %, n ), and apic ( %, n ). focus group participants indicated that novel h n clinical information and practice recommendations changed rapidly in the spring of . as one participant noted, ''the case definition changed like times during the course of the event for us.'' these rapid changes made it difficult for focus group participants to stay abreast of the latest recommendations. as one focus group member stated, ''the rules change so often, it's hard to keep up.'' another agreed and added, ''from o'clock in the morning until o'clock, [the recommendations were] totally different.'' not only were the recommendations changing rapidly, but many of the response agencies and professional organizations distributed conflicting guidelines. many focus group participants had a difficult time trying to interpret the inconsistent guidance from various agencies. as one participant explained: ''our biggest problem was that [these conflicting guidelines are] very difficult to interpret, especially when we go from cdc to state to local health departments. so we're trying to coordinate these efforts, and it's a constantly moving target.'' table . reference materials needed for current and future pandemics topics that require development into quick reference materials ranked by order of importance* infection prevention guidance for nonacute care settings (ambulatory care, home health, physician offices, and others) infection prevention guidance related to occupational health issues evidence-based information for physician education patient and family educational materials that are brief (eg, -page fact sheet) and available in multiple languages patient management materials that are brief (eg, patient placement/isolation, ppe use, and others) isolation precautions materials that are brief and simple: electronic format preferred communication procedures when supplies run out infection prevention guidance for pediatric facilities resource management tool for supply allocation during a variety of events screening tools and forms that are simple to use algorithm/check list outlining steps of an outbreak investigation *order of importance determined by the nominal group method. one focus group member stated that she found it works best if you let staff know up front that the information and recommendations will be changing rapidly. as she explained,''i say to everybody, Ôthis is fluid, this is going to change every day, so don't expect what i say today [to be] what i say tomorrow; expect this to be changing.Õ '' one focus group participant indicated that the rapid changes in recommended practice did not pose a problem at her facility. as she explained, ''our staff was great. they just said, Ôwhat is [the recommended practice] today? just tell me what it is.Õ '' however, this facility seemed to be the exception. the general consensus from focus group participants was that the rapidly changing and conflicting recommendations caused confusion among health care professionals. as one focus group participant noted, ''we [ips] understand why these [practice recommendations change], but i'm not always sure that our staff do.'' the focus group participants indicated that this confusion caused many health care providers to question the credibility of the ips. as one participant explained: ''it's very disconcerting for ips to have to constantly put out different messages. you are constantly sending out different messages to your staff, and, after awhile, they say, Ôoh, they don't know what they're talking about.Õ it's very difficult [to maintain] credibility for your department.'' another participant agreed and added: ''i think the difficulty was getting the staff to [trust you]. because, you know, here you started out with [one recommendation], and then you're telling them that now [it's changed], and i think that was really hard for staff. i think they're still having a hard time trusting that we're telling them the right thing.'' the focus groups participants stated that they felt the early response to novel h n was very positive in terms of staff's adherence to infection prevention. as one participant stated: ''i was amazed. i never saw more people wash their hands. i didn't have to tell one person to wear [a mask]; they were all putting them on. they handled the situation really very well. it was amazing to me how well [staff] pulled together. for the first time in a long time, everything i said [to do], they did.'' however, as the event wore on, the focus group members noted that staff compliance with infection prevention started to wane. as one participant stated, ''it's hard to keep staff vigilant in the midst of any outbreak.'' another agreed and added, ''we're already getting a little bit less vigilant. our protective measures are not there like they should be, and we had cases identified last week.'' the focus group participants stated that they believed health care workers' perceptions of the severity of novel h n led to poor compliance with ppe. as one participant stated, ''many of the staff decided not to wear ppe with the idea that they wanted to get the flu, but they wanted to get mild flu, so they wouldn't get [a more virulent form of disease] in the fall.'' however, this did not hold true for staff compliance with influenza vaccination. many focus group participants reported that they believe health care workers will be more eager to get vaccinated for influenza this year than in previous years. one participant stated, ''what i'm thinking of are those employees who refuse to ever get the flu shot.. when the h n vaccine comes out, i know they're going to be the first in line.'' this increased compliance with seasonal influenza vaccine is already occurring in areas outside the united states. as one participant explained, ''it's our flu season now in australia, and what we've found is that those people who usually don't want the flu vaccination are now standing at the door wanting flu vaccine.'' focus group participants indicated that communication was one of the biggest challenges and most timeconsuming aspects of responding to the novel h n pandemic. focus group participants indicated that the effectiveness of communication varied greatly from location to location. a few focus group participants stated that there was good communication between departments in the hospital and between the hospitals and health departments in the region. others, however, indicated that there were gaps in communication. one participant described the following: ''when i worked in jersey, we had a really good rapport with the department of health. we had meetings together, we planned together. so, there was communication. working in florida, i don't see that communication as much.'' another participant stated: ''what we found is that there's a huge gap in communication. i just felt that there was a disconnect, that we weren't as fluid as what i had seen in the past.. there wasn't that open communication. [information was released on] kind of a need to know basis.'' one gap in communication identified was between hospitals and physician offices. as one focus group member explained: ''there's no communication from the hospitals to the physicians in their offices. we had to end up sending things by snail mail because physicians-even though [they had an e-mail account] in the hospital-they didn't activate it, so.. how do you even get the information out?'' focus group participants reporting effective communication indicated that it involved frequent updates between departments and directors and between other hospitals in the region or their health care system. one participant described it this way: ''i think one of the things that i found extremely helpful-and i think was critical-was that, initially, we had huddles every day. everybody got together to [discuss the response].. and that huddle twice a day was so productive in disseminating the information.'' many focus group participants described very frequent communication between hospitals and health departments. one focus group member stated, ''[all the hospitals in the region] actually had daily phone calls with the health department at o'clock.'' another stated that,''i had meetings during the day for the department of health in the region.'' the frequent meetings required a lot of time, as evidenced by one participant's comment, ''i was on phone call conferences for at least hours a day, even on the weekend.'' devoting so much time to communication meant that focus group participants had to temporarily suspend routine duties. as one focus group member stated, ' communicating with patients and patients' families proved to be very difficult during the novel h n pandemic. focus group participants reported that information was released and was being changed very rapidly. this led to a lot of confusion and questions from patients and family members. the focus group participants indicated that it was essential to have patient educational materials available to address basic questions about novel h n . one of the most frequently cited gaps in this area was related to a lack of materials translated in multiple languages. the following quotes from participants explain the challenges focus group members faced: ''one of our biggest problems was getting information out in various languages. we have a lot of people asking us for information. obtaining sufficient numbers and the correct type of supplies is challenging during any large-scale event. the focus group participants indicated that there were a variety of issues related to obtaining supplies during the early part of the novel h n outbreak, even before the who declared the event a pandemic. as part of a survey distributed before the focus group started, participants were asked whether or not they requested supplies from a local, regional, or national agency; approximately half ( %, n ) reported that they had requested resources. approximately one third of the participants ( . %, n ) reported that they received supplies from the strategic national stockpile (sns). those who requested supplies versus those who received them were not congruent; of the participants whose facility/agency requested supplies, less than half ( . %, n ) actually received them. in addition, % (n ) of participants whose facility had not requested supplies received them. access to supplies was inconsistent among the focus group participants. one participant stated, ''we never had a problem with supplies,'' whereas others reported having trouble getting transport media for laboratory testing, masks, n respirators, disinfectant wipes, oseltamivir (tamiflu), and other products needed for infection prevention. focus group participants reported that supplies were back ordered and that companies could not provide hospitals with what they needed in a timely manner or limited the amounts that hospitals could order. outside the united states, focus group members had similar problems trying to obtain supplies. as one participant explained, ''we had the same problem here [in australia] with manufacturers.. they started to limit [the number of supplies you could order]. '' the lack of supplies or access to the wrong type of supplies had infection prevention implications in terms of making the response to novel h n even more challenging. as participants described it: ''[one] thing that was in really, really short supply was viral transport medium. our local public health department was getting us a day for awhile when we were in the scary part of it,. and so we were not able to test a lot of patients.'' ''we couldn't get our disinfectant wipes. they were back ordered. i said, Ôwait a minute. we have got to be able to clean this place and wipe things down and take care of our equipment and take care of our staff. what do you mean we don't have wipes?Õ but it gets back to our suppliers [who] don't keep it [in stock]. all of the sudden you have an outbreak situation, and i feel very vulnerable that whatever is the next pathogen or if this one comes back in the next wave this fall, what are we going to do?'' ''we had access to a municipal stockpile of tamiflu-which was like doses-which we blew through because everyone was freaking out, and there were so many contacts [who needed it]. after that we were told to go through our local distributors to get tamiflu. well, that was on allocation, and we were only able to get like doses per day, which was just enough to do our inpatients. and there was quite a gap before the strategic national stockpile was relocated and there was any release of [tamiflu]. so we couldn't get it, even if we wanted to pay however much for it. we couldn't get it.'' ''we had a lot of tamiflu, but we didn't have a lick of pediatric suspension tamiflu.'' ''i was really concerned about having enough tamiflu for my staff because, without my staff, i can't take care of a surge of patients.'' theft of supplies was also an issue reported by the focus group members. focus group participants reported that boxes of masks and respirators would disappear quickly in the hospital, presumably used or taken by visitors. some facilities even reported entire pallets of supplies being stolen from the hospital. one solution that focus group members identified during the response to severe acute respiratory syndrome (sars) and the novel h n pandemic was to keep supplies under lock and key. ''our [supplies are kept] off-site too, and, up until this situation, they would take these huge pallets and leave them on the loading dock. that's where ours were stolen from. we had several pallets of things stolen; not just masks, but gloves and so forth. we resecured and we rethought that out, and we have a new policy and procedure in place for that, and it's much more secure than it was prior.'' focus group participants expressed frustration with the way mutual aid agreements were managed during the early wave of the novel h n pandemic. many participants indicated that existing mutual aid agreements were not honored, which left the focus group members' facilities on their own in terms of obtaining resources and supplies. the infection prevention supplies with which the most focus group participants had difficulty during response to novel h n were masks and respirators. numerous issues arose in relation to masks and respirators, including running out of supplies, obtaining the incorrect supplies from regional or national stockpiles, not knowing which type of mask or respirator to use when caring for novel h n patients, and logistical issues in needing to fit test a large number of staff in a short period of time. participants were asked a series of questions related to mask and respirator usage during response to novel h n as part of the survey distributed at the start of the focus groups. one quarter of participants stated that their facility ran out of respiratory protection during their response to novel h n ( . %, n ). as one participant stated,''we didn't have enough n s. there was a problem with our regular n s to begin with. they were back ordered before this even started.'' in addition, many health care staff did not understand why their facility could not obtain more n respirators. as one participant described it, ''it was so frustrating because you were looked at like you could just turn on the key to get however many n s were needed. [the staff thought], Ôjust go order them.Õ. and it doesn't work that way.'' approximately one quarter of the participants ( . %, n ) reported that they implemented a policy to reuse respiratory protection during the novel h n outbreak to conserve supplies. most implemented the reuse policy before running out of supplies ( . %, n ); approximately one third reported that they depleted their stock of respirators before implementing a reuse policy ( . %, n ). focus group participants discussed the challenge of obtaining adequate supplies of respiratory protection during the initial wave of the novel h n pandemic. as one participant stated,''[we] ran out of [n respirators] pretty quickly. within that first couple of days, we reordered them, but they were on back order.'' some focus group members stated that respirators were available in their facility, but the sizes and/or styles did not address the staffs' needs. one participant described her experience: ''we had a lot of respirators available, but we ran out of m small size quickly and couldn't get anymore. we couldn't even evaluate whether the strategic national stockpile had that size and style. even if it had, it wasn't released to us, so we were stuck and had to scrounge trying to find that size.'' the lack of sufficient and appropriate supplies of respiratory protection led to unexpected challenges and suboptimal situations. one focus group participant stated that, '' [staff] were putting the wrong size [respirator] on because we didn't have the right size to fit them.'' another participant described the situation in her institution: ''one of the hospitals that i worked at had ppe issues in that they had decided to go with a regular conflicting guidelines related to isolation, mask, and/or respirator use focus group participants stated that it was very difficult to determine appropriate isolation and ppe use for novel h n patient management. most of the participants ( . %, n ) reported that they used a n respirator or equivalent as respiratory protection for staff, . % (n ) used an n respirator with a surgical mask on top of it, and . % (n ) had staff wear only a surgical mask. of the participants whose facilities had staff wear only a surgical mask when caring for novel h n patients for routine practice, % (n ) reported that staff were instructed to wear a n respirator or its equivalent during aerosolizing procedures. one third of all participants ( . %, n ) reported that their facilities changed ppe use guidelines for staff midway through the response to novel h n in spring of ; one third ( . %, n ) also reported changing their isolation precautions midway through the event. almost all of the facilities that changed ppe use also changed isolation precautions midway through the event ( . %, n ). most facilities used airborne and contact isolation ( . %, n ) or airborne isolation alone ( . %, n ) for novel h n patients. few facilities used droplet precautions alone ( . %, n ) or droplet and contact isolation ( . %, n ). of the facilities that chose to use droplet or droplet and contact isolation for novel h n patients (n ), almost one quarter of them ( . %, n ) used airborne precautions during aerosolizing procedures. the majority of participants ( . %, n ) reported that their facility recommended staff wear eye protection in addition to other ppe when caring for novel h n patients. focus group participants indicated that one of the hardest decisions they had to make during response to novel h n concerned whether to have health care staff wear a mask or respirator when caring for potentially infected patients. as one participant stated, ''[there were a lot of] questions about masking, whether to use a n or just the surgical mask.'' focus group members discussed the lack of scientific evidence available to guide decision making and the conflicting recommendations provided by the cdc and who. as one participant stated: ''our physician champion in our system was very distraught over the conflict between the cdc and who and when you use the respirator versus [a mask]. he felt that the science we were seeing supported what the who was recommending: the mask. and then we had individuals within our system [who didn't agree], and our system health care epidemiologist was very upset because we always follow the cdc recommendations.'' another participant indicated that the lack of scientific evidence led her hospital to take the most cost-effective approach: ''one of the reasons we stayed with the surgical mask during this outbreak was because i couldn't really justify for my chief financial officer the cost of the n over the surgical mask because i had no evidence to back anything up.'' switching recommendations/practice midway through the response created unique challenges for the focus group members. participants reported that health care staff were hesitant to switch from using a n respirator to a surgical mask because of concerns for personal safety. focus group participants reported that switching practice midway through the response also contributed to staff's confusion and question the credibility of the ips as was previously mentioned. many hospitals also shied away from using infection prevention practices that were different from the cdc recommendations. focus group participants explained their experiences as follows: ''[we had trouble] when we tried to switch from n s to regular surgical masks.. some institutions would not accept a recommendation that was different from the cdc's.'' ''[the staff think] Ôthe hospital down the street that has [n s] must love their employees more because they were able to provide them, so why should i go to work [where they won't provide n s]?Õ '' ''[one] thing that we looked at was the legislation from our occupational health and safety act. if we didn't offer [staff] the highest protection and then the staff got exposed, would we then be open to litigation because our health and safety office says, Ôdo this?Õ we're telling them to do that [ie, wear a surgical mask] when we could have offered them the n .'' fit testing is the process of verifying the adequacy and proper fit of a respirator for health care worker use. the occupational safety and health administration (osha) requires that all health care workers be fit tested prior to respirator use in health care settings. fit testing is a relatively time-consuming process that requires staff and supplies, including various sizes and styles of respirators. annual fit testing is part of most hospitals' respiratory protection program and is often spread out throughout the year. the novel h n pandemic posed unique challenges for hospitals because of the need to fit test a large number of staff in a short period of time and the desire to conserve respirators. this worked well in some facilities, but other hospitals had more difficulty. as focus group participants explained: ''our emergency operations plan includes just-intime fit testing for [events like pandemics], and it went very smoothly. we tested almost people in about days. and it worked beautifully for us.'' ''we had our staff fit tested prior to [the h n outbreak] ever occurring. but we ran out of certain models that we had a lot of our staff fit tested for. and so we did still have n s, but we had to do some pretty frantic fit testing to fit people for alternate models.'' ''we actually stopped fit testing respirators [during the event] mainly because we didn't want to waste [the respirators]. every time you fit test somebody, you can use up to respirators, and we just didn't want to waste them.'' to avoid the need or reduce the number of employees who needed to be fit tested, some hospitals decided to have health care workers use powered air purifying respirators (papr) instead of n s as respiratory protection when caring for novel h n patients. as one participant explained: ''we used paprs in our facility. we had made that choice about years ago to do that, and that was probably one of the best decisions we made, is to go with paprs. some of my colleagues have been doing just-in-time fit testing. some of them had to do like people in week.'' at the start of the novel h n outbreak, many clinicians used the rapid test for seasonal influenza a and b in an attempt to quickly identify potentially infected novel h n individuals. however, it was soon discovered that the sensitivity of these rapid tests was very low for novel h n , leading to numerous false negatives. confirmatory testing consists of reverse-transcription polymerase chain reaction (rt-pcr) or viral culture; this testing is usually obtained via state health department reference laboratories. the focus group participants stated that many patients with negative rapid tests were later found to be positive for novel h n on rt-pcr or viral culture. the focus group participants identified various infection prevention issues resulting from the lack of a reliable rapid test for novel h n . one issue identified by the focus group members was the lack of consistency regarding the use of the rapid test for surveillance or treatment purposes. as one participant noted, ''we don't clearly define what we want the testing to provide for us. it's either a surveillance and/or a treatment modality.'' many focus group participants emphasized that testing only lasted for a short period of time and had very specific rules regarding who could be tested. this caused a lot of confusion among the general public and made surveillance and control measures much more difficult for the focus group members. as one participant explained it, ''that's one of the reasons the decision was made to stop [testing] because we knew [novel h n ] was out there. so what's the point? we're not going to treat [the infected individuals]. we're not going to do anything unless they're admitted, critically ill, etc.'' another focus group member relayed her experience with the public's perception about rapid testing: ''we were pretty rigid about following the case definition.. that zeroed in on high-risk, hospitalized comorbidity patients. we had an year old who went to see a pediatrician, and the pediatrician wanted the child tested, but the child didn't fit into one of the groups in the algorithm. and so they sent the child's specimen to an outside lab.. and they were able to identify that the child did have h n swine origin influenza a. and then the media [said], Ôyou don't care about this year-old child!Õ because you refused to test the child.'' there were also challenges obtaining confirmatory testing that was coordinated through state public health reference laboratories. many focus group participants described long waits for test results that made implementing control measures more difficult. as one participant stated, ''[reference laboratories] back log initially was just horrid.'' focus group members stated that they often had to wait weeks for test results, making contact tracing, surveillance, and control strategies nearly impossible. two participants described their experience as follows: ' ' screening, triage, and visitor control focus group participants described varying degrees of success with their facility's attempts to screen and triage staff, patients, and visitors. some focus group participants stated that screening was successful. as one participant described: ''[everyone] had to be screened, and, if they didn't pass the first screening, then they were sent over to the next station to do a quick temperature check. if they were employees, they were sent to employee health and most of the time, sent home. so it really worked; it was really a cohesive effort on our part.'' other focus group participants described difficulties with the screening process, especially related to the large number of visitors and numerous entrances to facilities. as one participant stated, ''i'm envious of the people who were able to screen visitors. we're not that large-we only have beds-but the visitor traffic [was overwhelming]. we have about entrances to the hospital.'' another participant agreed and added, ''from our parking deck, [visitors] can get into the hospital at or different levels.'' solutions recommended by the focus group members to help control and screen visitors included locking the main entrances so people can exit but not enter without being screened and having security professionals or volunteers conduct visitor screening. phone triage was another strategy emphasized by numerous focus group participants as being an essential component of pandemic planning because it reduces unnecessary traffic in the hospital emergency department for patient screening. two participants described their experience with phone triage as follows: ''[phone triage is] a resource for people to call in and talk to a live person about whether or not they should come in to our emergency department. we had a resource line, but not / , and there were people that just needed to [hear from a medical professional] to say Ôno, your kid is not sick enough. stay home and watch his temper-atureÕ and to reassure them so they didn't end up in our emergency department.'' ''[phone triage is] something that pediatric facilities generally do pretty well because we don't want parents flooding in all the time every time there's something going around. i think we do that really well.. [we] have off-hours phone triage available for support, and i think that that's a lesson that perhaps everybody can learn, is how useful that is. and it will save you money, and parents and families would love the support.'' one focus group participant also described the need to have indoor or covered areas to triage individuals. the participant described her experience: ''we were going to triage outside, and we're in a very warm climate, and so mosquitoes [could have been a problem]. fortunately, rain hadn't started yet, but it could have been a really bad disaster. so, part of our next planning phase is to find ways to bring [triage] indoors, or at least to bring it under shelter, because had it been raining during those weeks, it could have been a disaster; and, as it was, we had to do a lot of mosquito prevention.'' focus group participants discussed many educational topics on which ips should be trained. the most important educational topics identified by the focus group participants according to their ranking using the nominal group method included the following: ( ) isolation precautions and ppe recommendations, ( ) coordination with community response agencies, ( ) surge management, and ( ) the ip's role in emergency management. a full list of educational topics identified by the focus group participants are outlined in table . the focus group participants emphasized that the written educational materials need to be much shorter than what was offered in spring . as one participant noted, ''the information sheets [created by cdc] were too long. the first one was pages.'' focus group participants stated that educational materials need to be evidence-based, short ( - pages at most), and written in ''bullet points,'' or else health care providers will stop reading. the focus group discussions provided several important findings. information provided by the focus group participants highlights a number of educational/reference materials that are needed for the current novel h n event and future pandemics and describes the best format for these items. whenever possible, reference materials need to be translated into multiple languages so that all health care clientele can access this information. pandemic planning educational and reference materials identified by the focus group participants need to be generated and made available as soon as possible, given the potential resurgence of novel h n or concomitant outbreaks of seasonal influenza and novel h n in fall/winter . the novel h n pandemic illustrates the need for ips to find new ways of controlling surge and preventing secondary health care-associated transmission during an infectious disease outbreak. historically, ips have been concerned primarily about hospitals and acute care settings. the novel h n pandemic demonstrates the need to implement infection prevention strategies in all health care settings, including ambulatory care centers, physician offices, home health, and long-term care. infection prevention emergency management guidance for these nonacute care settings has been lacking. it is essential that infection prevention recommendations be developed for these settings to help control disease spread and ultimately prevent and control surge in hospitals. one essential component of these recommendations is the identified need for a stronger focus on occupational health. staff surge capacity is necessary to maintain functionality of health care facilities during pandemics, and healthy staff contributes strongly to sustaining this capacity. occupational health issues that need to be addressed include having policies and procedures for screening/ triaging staff, furloughing employees, and better sick leave practices to prevent ill health care providers from coming to work sick during pandemics. changing standards and recommendations are to be expected during outbreaks of emerging infectious diseases and pandemics as more is learned about the causative agent and new anti-infective therapy and/or control measures are discovered. these changing practices must be communicated carefully to prevent mistrust among the staff. failure to do so can result in poor adherence to infection prevention practices because of confusion among health care professionals. this could lead to secondary transmission in health care facilities and occupational exposures. health care professionals should be told that outbreaks of emerging infectious diseases, such as novel h n , are expected to bring rapidly changing case definitions, surveillance methodologies, and control measures. these changes should be evidence based and communicated to staff as clearly and concisely as possible to prevent confusion and mistrust. researchers need to continue to examine disease transmission and appropriate isolation and ppe for novel h n . conflicting guidance on infection prevention for novel h n has led to a lot of confusion among health care professionals and frustration for ips. one third of the focus group participants reported that they changed isolation precautions and protective measures midway through response to the novel h n outbreak. focus group participants also reported that the potentially unnecessary use of n respirators caused much confusion for staff and resulted in a shortage of supplies in their facilities, according to those who participated in the focus groups. these focus groups occurred the week before the world health organization officially declared the novel h n outbreak a pandemic, yet hospitals were already running out of supplies-even after regional and national stockpiles were deployed. one quarter of all focus group participants' facilities ran out of respiratory protection supplies during the spring of , and almost one quarter needed to implement a reuse policy for respirators to conserve limited resources. hospitals need better plans for obtaining or reusing necessary equipment and supplies during patient surges. overall, the focus group method of inquiry served as a valuable tool in eliciting rich, detailed information about ips' opinions of lessons learned from the first part of the novel h n influenza a pandemic. structured surveys with closed-ended responses (opposed to the open-ended questions used in this study) may have revealed different opinions about references materials needed for future pandemics and educational priorities for ips. it is not known whether the ips who chose to participate differed from those who were eligible but chose not to participate. therefore, the information presented here may not be generalizable to all hospitals. this is especially true for the survey questions regarding hospital or agency protocols for worker protection, isolation, and ppe usage during the event; the small sample size needed for focus group methodologies may limit the generalizability of the survey results. ips involvement in preparedness and response to pandemics and other disasters involving a biologic agent is essential. this study identifies lessons learned from the first part of the novel h n influenza a pandemic and highlights gaps in emergency management most in need of being addressed: infection prevention in nonacute care settings, employee health during pandemics, communication, ppe availability and recommendations for use, and maintaining quality of care during times of rapidly changing and conflicting recommendations. ips must continue to address gaps in pandemic planning. one way to accomplish this is through the creation and distribution of ip-specific educational tools and reference materials for emergency management. the topics identified by ips who experienced the first wave of the novel h n influenza a pandemic should be used as the basis for these new educational initiatives. world health organization. current who phase of pandemic alert centers for disease control and prevention. novel h n flu situation update centers for disease control andprevention. novel h n flu situation update evaluation research team. centers for disease control and prevention. gaining consensus among stakeholders through the nominal group technique focus group fundamentals fit testing procedures (mandatory). . app a use of rapid influenza diagnostic tests for patients with influenza-like illness during the novel h n influenza virus (swine flu) outbreak key: cord- - q xkld authors: shengchen, d.; gu, x.; fan, g.; sun, r.; wang, y.; yu, d.; li, h.; zhou, f.; xiong, z.; lu, b.; zhu, g.; cao, b. title: evaluation of a molecular point-of-care testing for viral and atypical pathogens on intravenous antibiotic duration in hospitalized adults with lower respiratory tract infection: a randomized clinical trial date: - - journal: clin microbiol infect doi: . /j.cmi. . . sha: doc_id: cord_uid: q xkld objectives: the primary objective was to evaluate whether a molecular point-of-care test (poct) for viral and atypical pathogens added to routine real-time pcr could reduce duration of intravenous antibiotics in hospitalized patients with lower respiratory tract infection (lrti) compared with routine real-time pcr. methods: in this single-centre, open-label, randomized controlled study, we enrolled hospitalized adults diagnosed with lrti. patients were randomized to an intervention group (poct filmarray panel for viruses, atypical pathogens and bacteria plus routine real-time pcr) or a control group (routine real-time pcr for ten pathogens). the primary outcome was duration of intravenous antibiotics during hospitalization. the secondary outcomes included length of stay, cost of hospitalization and de-escalation within hours and between hours and days. intention-to-treat analysis was used. results: between october and july , we enrolled eligible patients ( in the intervention group and in the control group). duration of intravenous antibiotics in the intervention group was shorter than in the control ( . days (interquartile range (iqr) . – . ) versus . days (iqr . – . ); p < . ). length of hospital stay in the intervention group was significantly shorter ( . days (iqr . – . ) versus . days (iqr . – . ; p < . ) and the cost of hospitalization in the intervention group was significantly lower ($ . (iqr . – . ) versus $ . (iqr . – . ); p . ) than control group. more patients in the intervention group achieved de-escalation within hours ( . %, / versus . %, / ; p . ) and between hours and days ( . %, / versus . %, / ; p . ). conclusions: use of molecular poct testing for respiratory viruses and atypical pathogens might help to reduce intravenous antibiotic use in hospitalized lrti patients. clinical trial registration: clinicaltrials.gov identifier: nct . lower respiratory tract infection (lrti) is the leading infectious disease in the world [ ] . it is also the fourth commonest cause of death globally, accounting for about . million deaths worldwide in [ ] . viral infection is one of the most important causes of lrti [ ] . because of large overlap in symptoms and clinical presentation between bacterial and viral lrti, antibiotics are inappropriately prescribed to patients with viral infection. this may result in potential risks of antimicrobial resistance with a corresponding financial burden and environmental pollution [ ] . furthermore, inappropriate prescription of antibiotics is even more critical in china, which ranks as the world's most frequent user of antibiotics [ , ] . overuse of intravenous antibiotics in patients hospitalized with lrti constitutes an important part of the inappropriate prescription of antibiotics [ ] . in one retrospective study in a teaching hospital in beijing [ ] , the median duration of intravenous antibiotics was days (interquartile range e days) among hospitalized individuals with mild to moderate communityacquired pneumonia (cap). diagnostic uncertainty regarding the lack of microbiological evidence may be one of the most important reasons. laboratory-developed pcr testing is highly accurate for the diagnosis of microbial aetiology, with the turnaround time generally being e days [ e ]. however, experienced specialists are required for this test and the instruments have to be installed in a central laboratory. filmarray respiratory panel (biofire; salt lake city, ut, usa) is a new molecular point-of-care test (poct) platform, which can simultaneously detect viruses and atypical pathogens and provide results in about hour [ , ] . the sensitivity and specificity of this new molecular poct for detecting pathogens were high, with the sensitivity and specificity ranging from . % to . % and . % to . %, respectively [ , ] . a recently published randomized controlled trial showed that use of the filmarray respiratory panel was associated with reduction in proportion of antibiotic use among patients with acute exacerbation of chronic obstructive pulmonary disease (aecopd) and asthma [ ] . we speculated that molecular poct for the detection of viruses might reduce the duration of antibiotic use in adult lrti patients [ , ] . considering predominant overuse of intravenous antibiotics in china, the aim of this study was to evaluate whether combination of poct and routine real-time pcr for pathogen detection could reduce duration and improve deescalation of intravenous antibiotics in individuals with lrti compared with routine real-time pcr only. this was a single-centre, open-label, parallel randomized controlled study that took place between october and july in the chinaejapan friendship hospital (cjfh), beijing, china (clinicaltrials.gov identifier: nct ). cjfh is a large teaching hospital with beds. patients were recruited from the general ward of the department of pulmonary and critical care medicine, department of traditional chinese medicine lung disease and department of infectious disease in cjfh. hospitalized patients aged ! years who were preliminarily diagnosed as radiographically confirmed cap, aecopd or acute exacerbation of bronchiectasis were recruited on the day of hospitalization. patients were excluded if they were < years old, pregnant, had hospitalacquired pneumonia, or lung tuberculosis. we also excluded patients with human immunodeficiency virus infection, haematological cancer or solid tumour treated with chemotherapy or radiotherapy in the previous months, organ or bone marrow transplantation, splenectomy, or autoimmune diseases including systemic lupus erythematosus, rheumatoid arthritis, rheumatic polymyalgia and interstitial lung disease treated with immunosuppressive therapy for > weeks. in addition, patients with any other condition that may have increased serum procalcitonin levels, including severe burns, major surgical procedures, major trauma, long-term or severe cardiogenic shock, invasive fungal infection, or an acute attack of plasmodium falciparum, were also excluded. this study was conducted in accordance with the declaration of helsinki. the study was approved by the ethics committee of cjfh ( - ). written informed consent was obtained from each participant after meeting inclusion criteria and before randomization. random allocation sequence was generated using spss . software (statistical product and service solutions, ibm co. ltd, armonk, ny, usa) with a fixed random seed. simple randomization was conducted subsequently by sealing the group allocation cards into envelopes according to the sequence number. each envelope was opened only when patients met inclusion criteria and signed informed consent, with allocation of patients to intervention or control group accordingly. study participants, research staff and clinical care providers were not blinded to the group allocations. allocation of patients was blinded to data analysts. demographics and clinical characteristics were collected on enrolment. before the study commenced, research personnel were trained on how to take nasopharyngeal swabs and how to operate the filmarray respiratory panel instrument. routine diagnosis, treatment and microorganism detection of cap, aecopd and acute exacerbation of bronchiectasis followed chinese guidelines and consensus for these diseases [ e ]. in the intervention group, research staff took nasopharyngeal swabs from patients according to standard protocols within hours of admission. the samples were analysed immediately using the filmarray respiratory panel. the panel can detect viruses (influenza a (h and h ) virus, influenza b virus, respiratory syncytial virus, rhinovirus or enterovirus, human metapneumovirus, parainfluenza virus types , coronaviruses (oc , e, hku and nl ) and adenovirus), two atypical pathogens (chlamydia pneumoniae and mycoplasma pneumoniae) and one bacterium (bordetella pertussis). the results were reported and explained to physicians via telephone, sending text messages (with mandatory feedback) or face-to-face communication on the day of admission. in both the intervention and control groups, routine real-time pcr assays for the detection of viral pathogens (including influenza a (h n , h n ) virus, influenza b virus, respiratory syncytial virus, parainfluenza virus, adenovirus, epsteinebarr virus, herpes simplex virus and human cytomegalovirus) were performed in the cjfh microbiology laboratory with sputum or nasopharyngeal swab samples (see supplementary material, table s ). the results were reported and explained to physicians once obtained. other diagnostic tests such as blood gas analysis, c reactive protein, erythrocyte sedimentation rate, procalcitonin and routine microbiological testing were prescribed by physicians in both groups. the responsible attending physicians decided on antibiotic administration (including moxifloxacin, levofloxacin, types i/ii/iii/ iv generation cephalosporin, carbapenem, b-lactamase/b-lactamase-inhibitors, macrolide, penicillins, tetracycline), de-escalation or cessation of use in both groups without intervention of the research staff. management system and technical support framework for antimicrobial stewardship have been established in china. the medical department and pharmacy department regularly assess of the use of antibiotics in cjfh. all data were collected on a standard case report form and then input into an electronic medical database by an authorized assistant. the primary outcome was the duration of intravenous antibiotics during hospitalization. duration of intravenous antibiotics was defined as the total number of calendar days when one or more than one dose of intravenous antibiotics was used. the secondary outcomes included the proportion of patients who received intravenous antibiotics, the proportion of patients with antibiotics deescalation within the first hours and between hours and days, length of hospital stay, cost of intravenous antibiotics and cost of hospitalization. de-escalation of antibiotics was defined as reduction of antibiotic types, change from intravenous antibiotics to oral antibiotics, or from broad-spectrum antibiotics to narrowerspectrum antibiotics (see supplementary material, table s ). cost of hospitalization from the perspective of the hospital before deduction of benefits consist of six parts, including laboratory test (radiation, pathology and blood biochemistry test), medical care (oxygen therapy and doctor visit), surgery, blood storage or processing, drug and other (such as medical material) costs (see supplementary material, table s ). all outcomes were measured until discharge from hospital. participants were followed up in person at day by trained research staff if the length of hospitalization was < days, with six participants in the intervention group and eight participants in the control group lost to follow up. adverse outcomes included admission to intensive care unit (icu), death during hospitalization, readmission within days, and death within days. according to findings of branche et al. [ ] , we assumed that a day reduction of antibiotics use in the intervention group would be clinically significant. we estimated that patients would be required in each group to yield a statistical power of % to detect a -day reduction in antibiotic use in the intervention group at a significance level of p . . we further assumed that %e % of the study participants would be non-adherent or lost to follow up and set a total target recruitment number of patients in each group. data analyses were performed according to intention-to-treat analysis. per-protocol analysis by excluding participants whose diagnosis was ascertained not to be lrti after randomization or who were withdrawn for refusing nasopharyngeal swab was also performed. baseline characteristics were expressed as numbers (proportion), median (interquartile range) or mean ± standard deviation and comparisons were made using the c test, wilcoxon rank-sum test or student's t-test where appropriate. the median and interquartile range of the primary outcome (duration of intravenous antibiotics) and secondary outcomes, including length of hospital stay, cost of intravenous antibiotics and cost of hospitalization, were calculated and the difference between intervention and control group was compared using the wilcoxon rank-sum test. for other secondary outcomes (proportion of intravenous antibiotic use, de-escalation within the first hours and de-escalation between hours and days), any significant differences in the proportions calculated with the c test and unadjusted odds ratios calculated with a logistic regression model were used to look for differences between the intervention and control groups. differences and % cis involved in this study were absolute differences expressed as means or proportions. data analyses were performed using sas version . (sas institute inc.,). between october and july , we assessed patients for eligibility, and of them were eligible to participate in the study (fig. ) . a total of patients were randomly assigned ae, acute exacerbation; aecopd, acute exacerbation of chronic obstructive pulmonary disease; cap, community-acquired pneumonia; curb- , a pneumonia severity score calculator (measured by risk factors in total, with point for each criterion satisfied: confusion defined as an abbreviated mental test score ; blood urea nitrogen ! mmol/l; respiratory rate ! bpm; systolic blood pressure < mmhg or diastolic blood pressure mmhg; age ! years). data are presented as mean ± sd (standard deviation) or as median (interquartile range) for continuous variables and as percent for categorical variables. categorical variables were compared using c tests, and continuous variables were compared using wilcoxon rank-sum test or student's t-test. a the denominator is the number of community-acquired pneumonia. b the denominator is the number of study participants that received the procalcitonin test. to the intervention group and to the control group and included in the intention-to-treat analysis, with patients in the intervention group and patients in the control group who were ascertained not to have lrti after randomization or who were withdrawn for refusing nasopharyngeal swab. baseline characteristics of study participants in intervention and the control group included in intention-to-treat analysis and perprotocol are shown in table and the supplementary material (table s ) , respectively. all patients in the intervention group were tested using the filmarray respiratory panel and . % ( / ) of patients were also tested using routine real-time pcr, whereas . % ( / ) of patients in the control group were tested using routine real-time pcr for viral pathogens (see supplementary material, tables s and s ). the median duration of intravenous antibiotic treatment in the intervention group was significantly shorter than in the control group ( . days ( . e . days) versus . days ( . e . days); difference e . days, % ci e . to e . days; p < . ) ( table ). the proportion of participants who were given intravenous antibiotics was high in both the intervention and control groups, but with no significant differences observed between the two groups ( . %, / versus . %, / ; difference e . %, % ci e . % to . %; p . ). patients in the intervention group stopped having intravenous antibiotics earlier compared with the control group (p < . for log-rank test) (fig. ) . eight patients in the intervention group stopped intravenous antibiotic use on the same day as receiving the poct test result (data not shown). more patients in the intervention group achieved de-escalation within hours ( . %, / versus . %, / ; difference . %, % ci . %e . %; p . ) and between hours and days ( . %, / versus . %, / ; difference . %, % ci . % to . %; p . ) than in the control group. the per-protocol analysis also showed shorter intravenous antibiotic treatment and earlier de-escalation of intravenous antibiotics in the intervention group compared with the control group. the median length of hospital stay in the intervention group was significantly shorter than in the control group ( . days ( . e . days) versus . days ( . e . days)]; difference e . days, % ci e . to e . days; p < . ). the median cost of intravenous antibiotics and hospitalization were also significantly less in the intervention group ($ . ( . e . ) versus $ . ( . e . ); p < . and $ . ( . e . ) versus $ . ( . e . ); p . ). the per-protocol analysis also showed shorter length of hospital stay and lower cost of intravenous antibiotics and hospitalization in the intervention group compared with the control group. the proportions of adverse outcomes, including icu admission, death during hospitalization, readmission within days, and death within days were not found to be significantly different between intervention and control groups (all p ! . ) ( table ). in our study adding poct to routine real-time pcr testing shortened the duration of intravenous antibiotic treatment, reduced the length of stay and cost of hospitalization, and improved early de-escalation of intravenous antibiotics compared with routine real-time pcr assays in hospitalized lrti patients. admission to the icu and fatality rates were similar between groups. the efficacy of this new poct has been evaluated in retrospective studies [ , e ] , but most of them were conducted among paediatric patients [ e ] . a few randomized controlled trials have explored the impact of poct among adults, but with small samples [ , ] . one recent randomized controlled trial with a relatively large sample size evaluated the effect of the filmarray respiratory panel among adult patients with acute respiratory illness [ ] . however, only half of them were diagnosed with lrti, including pneumonia and aecopd. the heterogeneity of the study population, including asthma and upper respiratory infections, limited extrapolation to lrti. the advantage of our study is that only individuals with lrti were enrolled, excluding acute upper respiratory infection and non-infectious respiratory illness. another advantage of our study is that we enrolled patients throughout four consecutive seasons. in this study, we focused on duration of antibiotics, but not on withdrawal of antibiotics once the poct result was available. it is easy to understand that physicians can safely stop antibiotics as soon as they know the positive viral results for patients with upper respiratory infections or asthma, as demonstrated in the study by brendish et al. [ ] . however, for patients with pneumonia and other kinds of lrti, most chinese physicians refer to local clinical guidelines for duration of antibiotics, such as e days for cap [ ] , e days for cap with atypical pathogen [ ] , e days for aecopd [ ] and days for acute bronchiectasis [ ] . although it is difficult to exclude bacterial co-infection, the knowledge of viral aetiology will help physicians to decide whether to stop intravenous antibiotics earlier [ ] . considering that length of hospital stay for lrti patients was directly related to duration of intravenous antibiotics, we finally chose duration of intravenous antibiotics as the primary outcome. with the median cost around $ per hospital-day for patients with lrti, day less of intravenous antibiotics and day less of hospitalization could save billions of dollars in china. there are a number of limitations in our study. first, it was a single-centre study, the results of which need to be verified by future multicentre studies. second, the cost of the filmarray respiratory panel was not considered in the total costs of hospitalization since the filmarray respiratory panel is not commercially available in china. our post-hoc analysis indicated that the cost during hospitalization in the intervention group would be lower than, or at least equal to, that in the control group if the filmarray respiratory panel test cost less than $ . third, because the proportion of patients who received intravenous antibiotic therapy was high and duration of intravenous antibiotics was relatively long in both groups, extrapolation of our results should be carefully interpreted. fourth, the study was conducted in general wards, data are presented as per cent for categorical variables. difference between intervention and control group was compared using c tests and logistic regression model was used to calculate unadjusted odds ratios. a the denominator is the number of study participants that were followed up at day . without including patients from icus. the effect of poct needs further rigorous evaluation in patients who are more severely ill, including icu patients. in conclusion, this study found the addition of molecular poct testing to routine real-time pcr testing for respiratory viruses and atypical pathogens might help to reduce intravenous antibiotic use in lrti patients without resulting in adverse outcomes. more multicentre studies will be required to verify these findings. we declare that we have no competing interests. the content of the manuscript has not been published, or submitted for publication elsewhere. the abstract has been accepted for presentation at the ats international conference. this work was supported by the national science grant for distinguished young scholars (grant number /h ) and chinese academy of medical science innovation fund for medical sciences ( -i m- - ). biom erieux provided, free-ofcharge, filmarray panel punches and filmarray instruments. they did not participate in the design, conduction and analysis of the study. bc conceived and designed the trial, supervised the trial and allocated staff, had full access to all of the data in the study and takes responsibility for the content of the manuscript. sd and dy participated in the recruitment of patients and data acquisition. the randomization of participants into intervention or control group according to random sequence number was done by rs, and allocation of patients was finished by hl and yw. xg and gf performed the data analysis. sd, bc and xg drafted and revised the manuscript, and zx and bl ensured the quality control and running environment of the filmarray instrument. all authors reviewed the manuscript and contributed to the study report during the whole progress. all authors approved the final version of the manuscript. world health report: the ten most common infections fact sheet : the top causes of death available at: www.who.int/influenza/patient_care/clinical/brave/en impact of antibacterials on subsequent resistance and clinical outcomes in adult patients with viral pneumonia: an opportunity for stewardship bacterial resistance: challenge and strategies deadly sins of antibiotic abuse in china comprehensive evaluation of antibiotics emission and fate in the river basins of china: source analysis, multimedia modeling, and linkage to bacterial resistance potential for cost-savings in the care of hospitalized lowrisk community-acquired pneumonia patients in china routine molecular point-of-care testing for respiratory viruses in adults presenting to hospital with acute respiratory illness (respoc): a pragmatic, open-label, randomised controlled trial the clinical impact of the detection of potential etiologic pathogens of community-acquired pneumonia multiplex pcr point of care testing versus routine, laboratory-based testing in the treatment of adults with respiratory tract infections: a quasi-randomised study assessing impact on length of stay and antimicrobial use fil-marray, an automated nested multiplex pcr system for multi-pathogen detection: development and application to respiratory tract infection comparison of the biofire filmarray respiratory panel, seegene anyplexii rv , and argene for the detection of respiratory viruses serum procalcitonin measurement and viral testing to guide antibiotic use for respiratory infections in hospitalized adults: a randomized controlled trial impact of early detection of respiratory viruses by multiplex pcr assay on clinical outcomes in adult patients diagnosis and treatment of community-acquired pneumonia in adults: clinical practice guidelines by the chinese thoracic society, chinese medical association expert consensus on acute exacerbation of chronic obstructive pulmonary disease in the people's republic of china impact of multiplex polymerase chain reaction testing for respiratory pathogens on healthcare resource utilization for pediatric inpatients impact of a rapid respiratory panel test on patient outcomes the rapid diagnosis of viral respiratory tract infections and its impact on antimicrobial stewardship programs the potential of molecular diagnostics and serum procalcitonin levels to change the antibiotic management of community-acquired pneumonia we thank all the patients and clinical staff in the general wards of the respiratory critical medical department, traditional chinese medicine lung disease department, infectious disease department and laboratory of clinical microbiology and infectious diseases in the chinaejapan friendship hospital, including physicians, nurses and laboratory technicians. supplementary data to this article can be found online at https://doi.org/ . /j.cmi. . . . key: cord- - m mc authors: ahmad, shandar title: potential of age distribution profiles for the prediction of covid- infection origin in a patient group date: - - journal: inform med unlocked doi: . /j.imu. . sha: doc_id: cord_uid: m mc the covid- pandemic is a serious and global public health concern. it is now well known that covid- cases may result in mild symptoms leading to patient recovery. however, severity of infection, fatality rates, and treatment responses across different countries, age groups, and demographic groups suggest that the nature of infection is diverse, and a timely investigation of the same is needed for evolving sound treatment and preventive strategies. this paper reports an the analysis of age distribution patterns in six groups of indian covid- patient populations based on their likely geographical origin of infection viz. the united kingdom, north america, the european union, the middle east, and asian countries. it was observed that patient groups stratified in this way had a distinct age profile and that some of these groups e.g. patient groups from asia, the european union, and the united kingdom formed a different cluster than those from north america, the middle east, and other regions. patient age profiles of a population were found to be highly predictive of the group they belong to, and there are indications of their distinct recovery and fatality rates across gender. altogether this study provides a scalable framework to estimate the source of infection in a new population of covid- patients with unknown origin. it is also concluded that greater public availability of age and other demographic profile details of patients may be helpful in gaining robust insights into covid- infection origins. datasets and scripts used in this work are shared at http://covid.sciwhylab.org. the covid- pandemic is a major challenge and has already caused close to . million infections and more than , deaths worldwide [ ] . in order to understand and combat such a large-scale outbreak, the treatment and containment strategies must also consider the diversity of infection, and potential differences such as the manner in which a population responds to the many variants that might exist. a number of studies on the genetic diversity of these viruses have been performed [ ] [ ] [ ] . the biomedical community does not yet know much about the diversity of covid- variants and the likely impact on clinical outcomes, but the transmission dynamics and mutation rates of viral genomes are of critical significance [ , ] . for example at the time of writing this report the fatality rates in across the countries range widely from as low as < % to as high as > % [ ] . although the exact reasons of these dramatically different mortality rates and possible differences in affected age groups are not very well understood, it is widely recognized that the collection and presentation of accurate clinical data as well as elaborate epidemiological studies are needed in order to understand and control both current and future outbreaks such as covid- [ , ] . in many demographic studies, patient age has been recognized as one of the key factors predictive of clinical outcome, including fatality rate and severity of symptoms [ , , ] . however, the way in which a given viral variant might actually impact different patient age groups has not been well investigated. a detailed impact analysis of this kind requires sequencing of thousands of samples across various ethnicities and age groups, which is yet to be attempted. in this work, an alternative approach of labeling viral variants and their relationship to the age profile of patients is presented. using the travel history and potential origin of infection for indian covid- positive cases, six groups of patients have been identified from different geographical locations from where the infection was potentially carried. patient age profiles of these groups originating from north america, the united kingdom (uk), the european union (eu), asia, the middle east, and other regions reveal that patients from each region have clearly distinct age distributions and that these groups tend to cluster to form two super groups. there are also indications that the recovery and fatality ratios of patients may be related to the patient groups defined here. finally, an attempt was made to quantify how well a new population group can be assigned to one of these six categories based on a simple age statistic of these populations. results from randomly sampled populations from these data are highly promising in terms of these predictabilities. thus, this study establishes two clusters of three patient groups each from covid- infected cases, and proposes a framework to assign patient groups based on age distribution in a patient cohort. it is expected that further data on group wise clinical responses, coupled with automatic annotations of patient groups proposed here, can help in improving therapeutic strategies towards the covid- pandemic. this study is based on a crowd-sourced data on covid- patients in india compiled at www.covid india.org [ ] . json:api provided patient details including age, gender, recovery status, and possible source of infection. the resource is basically a compilation of daily updates provided by state (provincial) governments from throughout india, and it attempts to present crucial information in a unified format, most importantly: (a) patient identification number assigned by the data administrators (b) state-wise patient identification number (c) age of the patient (d) gender of the patient (e) travel history or any relevant detail of the patient that may reveal the source of infection (f) link to the potential patient(s) who could have been the source of this patient's infection and (g) current status of the patient e.g. recovered or deceased. several other aspects of data available in the sheet are not relevant for the current study. the first of these json:api files (raw_data .json) contains data about , patients, which is the primary source of data used in this study. this data is frozen on april , and is likely to remain unchanged. origin of infection is available only for the first few thousand cases, in the early stages of pandemic. therefore, the current study has utilized information from patients, of which many do not have age information, leaving behind fewer patients' data, as detailed in the results. for parsing json:api files, the r package called rjson, available from the cran repository, was installed and utilized. at least in stage of the pandemic, every patient can be traced back to the source of infection; for example travel history to a specific country with high infection rate. in the subsequent stages of pandemic, the number of cases with unknown source of infection grow, and the data becomes less useful for creating predictive models of infection origin. the current study will develop patterns from all the patient groups that could be traced with some confidence to their likely source of infection, so that the insights can be developed by the application of these findings to new patient groups for a better clinical response. in this study, the original travel history to a country has been taken as the source of infection. patients with no travel history but those whose likely contact with a person with a travel history, has been established and were labeled by the original source in order to expand the annotated data. in this way, all known sources of infection directly or traceable to travel history have been used for labeling the data. five specific groups of travel history have been defined by pooling travel history to similar locations. thus, all the patients with travel history to a member of european union have been labeled as the eu group. patients with travel history to the usa and canada, or those likely infected by them, were pooled into the north america (n_am) group and those from any asian country including china, singapore, and malaysia were likewise labeled as the asia group. similarly, middle eastern (mdlest) cases were those with travel history to iran or other middle eastern countries such as the united arab emirates (uae) and saudi arabia. such patients were excluded from the asian group. wherever the source of infection could not be ascertained or provided, the patients were placed in the "other" group. thus, five patient groups from a specific travel history or their infected cases along with a sixth group with untraceable source were identified in this study viz. "n_am", "uk", "eu", "asia", "mdlest" and "other" groups. the final number of patients in this study within each category with clear age annotation data is as shown in figure . in many but not all of the cases, age of the patient has been provided in the json:api source file of covid india.org in the attribute type "agebracket" and the same has been used for the purpose of this study. within each of the six patient groups, defined above, the patient age from this attribute has been used as a raw value for conducting statistical tests of significant difference using student's t-test in the r programing language [ ] . further, the raw age values were converted to their relative frequency histograms by computing the percentage of patients from within that group that fell within the -year class interval of eight age groups from to years range. these relative frequency histograms are used as group representative features for clustering these groups and making predictions of patient group label from a randomly sampled population (see below). in order to estimate the similarity between the six patient groups defined above, a hierarchical clustering using the "heatmap" function of r language was used. two clustering approaches were used to evaluate if they both produce similar outcomes. in the first approach the bin-wise population densities defined from their histograms were used to represent each patient group and an average linkage clustering was performed. next, the all-against-all pair-wise pearson correlations between patient groups were calculated from the bin-wise population density and then the clustering over rows of this pairwise matrix was carried out. some of the patient groups are expected to be more similar than others and such patient group clusters are explored from these two clustering patterns. recovery rate within each group of patients has been defined from within the closed number of cases and includes fewer instances than the overall number of patients because many cases were still not closed. thus, the fatality rate is defined as the number of deceased patients within the patient group relative to the total number of closed cases in that category. an additional parameter of recovery index was defined to estimate survival probability within each patient group as follows: where nr and nd are the numbers of patients recovered and deceased, respectively. this work aims to establish a framework in which a new group of patients such as a community or village can be assigned to one of the six patient groups defined above, so that treatment strategies may be optimized for that group. however, since we only have one population in each group; we cannot develop a model with pre-estimated confidence of its predictability. to overcome this problem, an approximate approach of creating multiple samples of populations were created wherein fifty instances of patients were created from the already labeled patient groups to create one population. subsequently, fifty training and fifty test sets of population from each of the six groups were created and represented by the histograms of the sampled populations. for each of the six patient groups, positive class data corresponded to fifty training and fifty test examples. an equal number of negative population instances were taken from remaining groups. a multiple linear regression model was trained over a set of corresponding fifty positive plus fifty negative training examples and tested on another set of one hundred (fifty plus fifty) example populations. performance levels of the training and the test data give us the approximate confidence levels at which the group levels can be estimated for new populations. for the six patient groups, separate prediction models were created to assess how well a given population from that patient group could be labeled in contrast to other populations. the predictive model in all cases for this work is a multiple linear regression (mlr) model, implemented using the lm function of the stat package in r [ ]. essentially, an mlr fits a linear equation with histogram bin frequencies as the independent variable, and the class label of origin of infection as the dependent variable, whereas the regression coefficients are determined during training so as to provide best classification of the training data based on known class labels of a population. these regression coefficients are preserved and the model's performance is tested on new sampled populations using these trained parameters. each trained model performance was estimated on independent data sets generated from the same populations using random sampling as described above. for each model, the positive class refers to sampled populations from one specific patient group and the negative class refers to all other sampled populations. binary class labels in this way are estimated using multiple linear regression using training/ testing protocols. the prediction performances are estimated first by taking the pearson correlation between binary class labels and regression values produced by trained mlr. in the same way, area under the curve (auc) of receiver operative characteristic (roc) was computed from the predicted analogue values for each pair of binary classes. note that auc of roc is a standard measure to assess performances of predictive models, where binary class labels are predicted with some variable confidence level, allowing choices of sensitivity and specificity levels based on the thresholds on predicted analog values. to assess the confidence in these models, the sampling, training and test steps were repeated times, and the prediction performance scores are presented as a box plot for each of these iterations. age distributions of patient groups: figure (a-c) provide the first assessment of patient age distributions within each group of patients. figure (a) shows a clear difference between the overall distribution of patients from eu and asia infections on the one hand and midest and n_am on the other. figure (b) shows a more detailed distribution, which suggests that even though the average age values place uk closer to midest and n_am, individual histogram bins suggest the case of uk to be more complex, and a rigorous clustering over histogram values suggest uk to be part of eu and asia. figure (c) reiterates, which relies on the difference of means between the data (t-test). in figure , we explore a detailed pattern of clustering between age groups in two different ways . figure (a) shows how the patients from different infection origins cluster in terms of age histograms. clearly, the uk group, which looked similar to n_am and mdlest in terms of average patient age, tended to cluster closer to the eu and asia group on account of a greater population density in the age range - , which suggests more younger people being infected in each of these three groups. a second test of clustering, shown in figure (b) was performed by first computing histogram-to-histogram correlations between all six against six groups of patients, and then clustering them based on correlation values. this method also produced clusters similar to those shown in figure (a), suggesting that the age group distribution patterns may be better clustered into uk/eu/asia on the one hand and mdlest/n_am/other on the other. patient recovery data and its gender-wise variation also confirms these two clusters (see below). in order to investigate if the patient groups are only characterized by their agewise population distribution or their recovery rates are also group specific; recovery and fatality rates were computed for each of the patient groups and then for the group clusters, as shown in figure . it is interesting to observe that the patient recovery rates also indicate clustering patterns similar to age histograms (sufficient recovery data was available and shown only for four patient groups for individual group comparison). for example figure (a) shows that overall/male/female recovery rate was higher in the case of asia/eu/uk groups. the n_am and asia groups do not have sufficient data to compute these values since an insufficient number of patients have recovered or died in these groups. merging the data from the patient group clusters, differences in the fatality rate become evident. we observe not only higher fatality rates in the mdlest/n_am/other group, but also subtle differences between male versus female fatality rates that are suggestive that fatality rate is lower for females. however, given the small number of patient data available in each of these cases, the confidence in this statistic cannot be ascertained with a proper test, and must wait for more data to emerge over time or may be confirmed by hospitals with more elaborate access to patient age values. next we assess whether the results can be used for group labels, whenever a new population age distribution becomes available from a community of patients. for example, can we predict if patients from a village carry covid- virus infection from asia, the uk, or any of the six groups studied here? random samples of populations were created to evaluate this, and the prediction models were created on random samples of populations. subsequently, these trained models were tested on new random sets as explained in the methods. figure shows the results from such prediction models in terms of correlation between predicted class and group labels for each patient group. it is observed that the population group prediction in each of these categories is as high as - % auc. the worst case is that of the middle east and other groups which also show a similar pearson correlation of . and above, with auc always reaching more than % on the average for the sample populations generated in each case (distribution for iterations shown as a box plot). even though the bootstrapping type of cross-validation is prone to overestimate performance levels because of redundancy between the training and test examples, such high levels of predictability from a small number of feature values ( probability density bins) is highly promising. there are many covid- related compilations of data in the public domain emerging from agencies as varied as who and state governments. infection origin studies like this could have been carried out on country-specific data, where all infections are more or less of the same origin. however, the age profile differences observed between different conditions would be further confounded by various factors such as: (i) the degree and target population being tested, (ii) ethnic variations from one place to the other, and (iii) general population age variations. taking the population data from similar national profiles takes care of differences between testing strategies, background population demographics, genetic variations, and time points of infection in a better way. some of the caveats still remain. the first of them pertains to the scarcity of data on age, gender, and recovery status. there are many patients in the database for which none or only some of this information are available. better recording of these data and making them available in a timely manner will help in furthering these studies. from the analytic perspective, the travelling population age profile from the uk, usa, and eu may in itself be different from those traveling from the middle east and asian countries, for which the data was not available for this study. these issues may need further investigation in the future. however, despite these caveats, this study provides a framework to utilize rudimentary patient population profiles such as patient age distribution to segregate them in terms of source of infection, and potentially develop combative strategies informed by these differences. one natural question that emerges from this study and for any data-driven study is that of causality. why should people with different travel history respond to a virus differently? if the population groups studied here are considered to be more or less uniform, because they are all taken from the same country, the differences are likely be due to the mutations in coronavirus in the country where patients were potentially infected. if this is indeed true, it would have huge implications for therapeutic and vaccination strategies, as treatments developed for one strain and target population may not be effective on other mutated variants. however, it would be a bit too early to draw an exact conclusion about all the variations attributed to mutations in the virus. as stated in the caveats above, the socio-economic backgrounds of people traveling to different countries may be one big confounding factor, among others. in view of these exciting possibilities and potential sources and implications of variations, further studies on the age profiles of covid- patients are required and continued. the study establishes that affected patient groups stratified by their travel and contact history have distinct patterns of patient profiles. out of the six categories of such patients, two clusters of patient groups were identified which also had differential patterns of male versus female fatality ratio across age groups, although only subtle differences could be recorded due to the available data size. a framework to assign a new patient population to one of these predefined categories in a predictive manner was also provided. overall, if the data can also be linked to detailed clinical history and genetic constructs of clinical variables, a powerful combative strategy against coronavirus may be developed which incorporates these findings. genetic diversity and evolution of sars-cov- origin and evolution of pathogenic coronaviruses the establishment of reference sequence for sars-cov- and variation analysis transmission dynamics and evolutionary history of -ncov clinical characteristics of imported cases of covid- in jiangsu province: a multicenter descriptive study covid- worldwide: we need precise data by age group and sex urgently defining the epidemiology of covid- -studies needed biomarkers of biological age as predictors of covid- disease severity covid- : death rate is . % and increases with age, study estimates team rc: r: a language and environment for statistical computing. r foundation for statistical computing acknowledgement: the authors confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome.the authors must make a clear statement that the laws which apply to them in their own country were followed. key: cord- -nwnt tde authors: wang, yi; yao, lin; zhang, jian-ping; tang, pei-jun; ye, zhi-jian; shen, xing-hua; xu, jun-chi; wu, mei-ying; yu, xin title: clinical characteristics and laboratory indicator analysis of covid- pneumonia patients in suzhou, china date: - - journal: bmc infect dis doi: . /s - - - sha: doc_id: cord_uid: nwnt tde background: sudden exacerbations and respiratory failure are major causes of death in patients with severe coronavirus disease (covid- ) pneumonia, but indicators for the prediction and treatment of severe patients are still lacking. methods: a retrospective analysis of collected cases was conducted and included approximately patients with covid- pneumonia who were admitted to the suzhou fifth people’s hospital from january , to february , . the epidemiological, clinical and imaging characteristics as well as laboratory data of the patients were analyzed. results: the study found that fibrinogen (fib) was increased in ( . %) patients, and when fib reached a critical value of . g/l, the sensitivity and specificity、da, helping to distinguish general and severe cases, were and %、 . %, respectively, which were significantly better than those for lymphocyte count and myoglobin. chest ct images indicated that the cumulative number of lung lobes with lesions in severe patients was significantly higher than that in general patients (p < . ), and the cumulative number of lung lobes with lesions was negatively correlated with lymphocyte count and positively correlated with myoglobin and fib. our study also found that there was no obvious effect of hormone therapy in patients with severe covid- . conclusions: based on the retrospective analysis, fib was found to be increased in severe patients and was better than lymphocyte count and myoglobin in distinguishing general and severe patients. the study also suggested that hormone treatment has no significant effect on covid- . novel coronavirus pneumonia is an acute infectious disease caused by severe acute respiratory syndrome coronavirus (sars-cov- ) infection and is mainly transmitted by respiratory particles [ ] . since the first novel coronavirus pneumonia case was reported in wuhan, china, the new coronavirus spread rapidly across the country, and it is also endemic in many countries around the world, including japan, singapore, thailand and the united states [ ] . thus far, thousands of cases have been confirmed. on february , , the world health organization (who) officially announced that the cause of the new coronavirus pneumonia is a new variant of coronaviruses and named the disease that it caused as coronavirus disease (covid- ). on february , , the national health commission of china temporarily named the pneumonia caused by the new coronavirus new coronavirus pneumonia (ncp). sars-cov- is a coronavirus that belongs to the genus betacoronavirus, with an envelope and particles that are round or oval and often polymorphic, with a diameter of - nm. its genetic characteristics are different from those of severe acute respiratory syndrome coronavirus (sarsr-cov) and respiratory syndrome coronavirus in the middle east (mersr-cov) [ ] . current research shows that it has more than % homology with bat sars-like coronavirus (bat-sl-covzc ) [ ] . when isolated and cultured in vitro, sars-cov- can be found in human respiratory epithelial cells in approximately h, while it takes approximately days to isolate and culture in veroe and huh- cell lines. thus far, we are not fully aware of the pathogenesis of covid- pneumonia, its development process in the body, or its route of transmission. the gold standard for the diagnosis is real-time fluorescence rt-pcr to test whether samples are positive for the nucleic acid of sars-cov- , but this method is time-consuming and has the possibility of false negatives. understanding the early epidemiological and clinical characteristics of covid- pneumonia patients is extremely important for diagnosis; therefore, we conducted a retrospective analysis of cases of covid- pneumonia. a total of cases were collected, including healthy donors, tuberculosis patients and patients with covid- pneumonia. the healthy donors were from the physical examination center and exclude tuberculosis, hepatitis b, hepatitis c, hiv infection and other pulmonary disease such as copd, bronchitis etc., the ages are to . tuberculosis patients are randomly selected inpatients with sputum culture positive about mycobacterium tuberculosis of our hospital and exclude hepatitis b, hepatitis c, hiv infection. covid- pneumonia patients were admitted to the pulmonary department building a of suzhou fifth people's hospital from january , to february , (the diagnosis conformed to the diagnostic criteria (nhc diagnostic criteria (v )) set out in the diagnosis and treatment of pneumonia infected by novel coronavirus ( th trial edition) issued by the general office of the national health commission on february , ). according to the nhc diagnostic criteria (v ), cases were classified as mild, cases as general, cases as severe, and cases as fatal. due to the limited sample size and to reduce sampling error, we combined the mild and general cases into group a, and we combined the severe and fatal cases into group b. we obtained informed consent from the subjects, and the study was approved by ethics committee of suzhou fifth people's hospital (clearance number: - ). covid- pneumonia patients present with chest ct imaging abnormalities, even asymptomatic patients, with rapid evolution from focal unilateral to diffuse bilateral ground-glass opacities that progress to or coexist with consolidations within - weeks. the assessment of both imaging features and clinical and laboratory findings could facilitate the early diagnosis of covid- pneumonia. the classification of the severity of covid- conforms to the nhc diagnostic criteria (v ) and is set out as follows: mild type: clinical symptoms are mild and no pneumonia is present in chest ct images; general type: fever, respiratory tract and other symptoms, chest ct images show pneumonia; severe type (meets any of the following): ① respiratory distress and rr ≥ breaths/min; ② oxygen saturation at rest≤ %; or ③ pao /fio ≤ mmhg; and fatal type (meets any of the following): ① respiratory failure and the need for mechanical ventilation; ②shock; or ③ the combined failure of other organs requires icu monitoring and treatment. blood samples of group a and group b were taken within - h of admission. blood tests were performed, and c-reactive protein, routine biochemical and coagulation parameters, and myoglobin levels were tested. in the control group, fasting venous blood samples were collected for examination on the day of the physical exam. the instrument used to analyze routine blood samples was a sysmex-xn blood analyzer from japan sysmex corporation, and the reagent used was a supporting product of the company. the instrument used to detect crp was a jet-istar immunoassay analyzer from zhonghan shengtai biotechnology co., ltd., and the reagent was a supporting product of the company. the instrument used to detect the coagulation index was a ca hemagglutination apparatus from japan sysmex corporation, and the reagent was a supporting product of the company. the instrument used to detect myoglobin was a roche , and the reagent was a supporting product of the company. statistical processing spss . statistical software was used for data processing. measurement data for normal distributions is expressed as ±s; comparisons between groups were performed by t test, the test level was α = . (both sides); the difference was statistically significant with p < . ; the measurement data of skewed distribution is expressed as "median (quartile) [m (q , q )]", and the differences between groups were compared by using the rank sum test. spearman's correlation was used for correlation analysis. the receiver operating characteristic (roc) curve were drawn, the area under the roc curve (auc) were calculated, and the absolute value of lymphocytes, fibrinogen, myoglobin and other indicators selected to alert the best cutoff value of the ncp and the corresponding sensitivity and specificity. comparison of the general patient information of group a and group b sixty-six patients with covid- pneumonia manifested chest ct imaging abnormalities, even asymptomatic patients, with rapid evolution from focal unilateral to diffuse bilateral ground-glass opacities that progressed to or coexisted with consolidations within - weeks. combining the assessment of imaging features with clinical and laboratory findings could facilitate the early diagnosis of covid- pneumonia. sixty-seven patients were collected in the study, the average age was years. there were patients in group a, with males, and patients in group b, with males. no significant difference in sex was observed between the two groups (p > . ). ninety percent of the patients in this study had a history of exposure to the hubei epidemic area, with an incubation period of - days and a median incubation period of . days ( . - . ). twenty-two percent of patients had chronic underlying diseases, of which hypertension and diabetes accounted for the highest proportion of chronic diseases, and there was no significant difference between the two groups (p > . ) ( table ) . of the patients, % had fever symptoms. there were more fever patients (> . °c) in group b; the duration of fever was longer in group b than in group a, and the difference was statistically significant (p < . ). in addition, cough ( . %), fatigue ( . %) and shortness of breath ( . %)were the most common symptoms, and a few patients had diarrhea ( %), which was more common in group a than in group b. according to the imaging findings, . % of the patients had lung lesions, among whom the cumulative number of lung lobes with lesions in group b was statistically significantly higher (p < . ) than that in group a (fig. ). the median time for the progression of lesions in covid- pneumonia patients was . days ( . , . ), and there was no significant difference between the two groups (p > . ) ( table ) . among the covid- pneumonia patients, patients had leukocyte abnormalities, of whom ( . %) had decreased white blood cells and ( . %) had increased white blood cells. a total of ( . %) patients had an increased neutrophil ratio, and the absolute value of lymphocyte counts was decreased in ( . %) patients ( ( . %) in group a and ( . %) in group b). the differences in the above indicators were statistically significant (p < . ). c-reactive protein increased in of patients, especially in group b, and the difference was statistically significant (p < . ). abnormal liver function was found in ( . %) patients (alanine aminotransferase (alt) and aspartate aminotransferase (ast) increased in and patients, respectively, with the maximum value of alt being u/l and that of ast being u/l). liver function indexes in group b were higher than those in group a, with statistically only patients had increased renal function. in addition, fibrinogen (fib), d-dimer, and myoglobin were significantly increased in patients in group b, which was significantly different from group a (p < . ) ( table ) . in a comparison of patients in group a with patients in group b, the lymphocyte count absolute value (l), myoglobin (mb) and fibrinogen of covid- pneumonia patients in group a were significantly higher than those in group b, with statistically significant differences (p ≤ . ) ( table ). in a comparison of group a with the healthy control group, the l was significantly higher in group a than in the healthy control group (p < . ). compared with group a, there was no significant difference in the absolute value of lymphocytes and fibrinogen in the tuberculosis group (p > . ) ( table ) . with the data of both group a and group b plotted in a receiver operating characteristic (roc) curve, the data of group a and group b were compared. the roc curve was used to evaluate the l, mb, fib and other indicators for the prediction of severe disease in patients with covid- pneumonia (fig. ) . the optimal truncation values (with maximum youden index) were selected, and the optimal truncation values of l, mb and fib were calculated as . * ^ /l, . ng/ml and . g/l, respectively. the area under the roc curve (auc) for l was . , for mb was . and for fib was . . when the optimal truncation value of the fib index was selected, the sensitivity, specificity and da for the prediction of severe disease in covid- pneumonia patients were %, . and . %, respectively, and the sensitivity, specificity and da of fib were significantly higher than those of l and mb (table ) . an analysis of the correlation of the cumulative number of lung lobes with lesions with l, mb, and fib in covid- pneumonia patients indicated that the cumulative number of lung lobes with lesions was positively correlated with mb and fib and negatively correlated with l ( table ) . sixty-one ( . %) patients were treated with oxygen therapy, among which nasal catheter oxygen was the main treatment in group a, while noninvasive ventilator-assisted ventilation or high-flow oxygen was needed for some patients in group b who were in respiratory failure, and the difference was statistically significant (p < . ). only ( . %) patients were treated with hormone therapy, of whom the proportion in group b was larger; the time of hormone use was longer in group b than in group a, and the difference was statistically significant (p < . ). the vast majority ( . %) of patients received antiviral treatment immediately after admission, with no statistically significant difference between the two groups (p > . ) ( table ) . at the same time, we also analyzed the effects of hormone therapy and nonhormonal therapy. compared with nonhormonal therapy, hormone therapy did not promote key indicators (fig. ). current research indicates that sars-cov- is more than % homologous to bat-sl-covzc [ ] . therefore, it is considered that sars-cov- was transmitted by bats [ ] , which needs further research confirmation. for describing the clinical and laboratory characteristics and analysis the oxygen therapy and hormone therapy, we conducted a retrospective analysis of cases of covid- pneumonia in suzhou, china. this study included patients with covid- diagnosed in the suzhou fifth people's hospital, which shows that, similar to chen's study [ ] , patients with sars-cov- infection were mainly middle-aged and elderly individuals, with a median age of years ( . . ), and ( . %) were males. ninety percent of the patients had a history of exposure to the hubei epidemic area, with an incubation period of - days and a median incubation period of . days ( . - . ), which is also similar to wang's study [ , ] . a total of . % of patients had underlying chronic diseases, of which hypertension and diabetes accounted for a higher proportion of chronic diseases, and there was no significant difference between the two groups (p > . ). fever is the most common clinical symptom of covid- pneumonia, with ( . %) cases in patients observed. fever occurred in the early stage of the disease, and ( . %) patients had a body temperature ≤ . °c, which was more common in group a. ten patients ( . %) had a body temperature ≥ . °c in group b, which was statistically significantly higher (p < . ) than that in group a. in addition, the duration of fever in group b was significantly longer than that in group a; the median fever duration in group b was . days ( . - . ), and the difference was statistically significant (p < . ). cough ( . %), fatigue ( . %) and shortness of breath ( . %) were also common, among which shortness of breath was more common in group b, while fatigue was more common in group a, and the differences were statistically significant (p < . ). these symptoms are considered to be related to lung lobe invasion in severe patients. diarrhea ( . %) and muscle soreness ( . %) were less common in patients; however, we still need to be alert to the patients who are diagnosed with mainly gastrointestinal symptoms, pay attention to strengthening protection, and conduct timely sars-cov- nucleic acid testing for patients with a history of epidemiology. the retrospective analysis of patients with covid- pneumonia indicated that ( . %) patients showed lung lesions on ct chest images, with multiple sites of distribution, and lesions were seen in both lungs and subpleural areas [ ] , mostly showing ground-glass note: comparing with group b, a p< . for indicators in group a, b p< . for indicator of l in healthy control group, comparing with healthy control group, p< . for indicator of l in comparing with tuberculosis group, comparing with group a, c p> . for indicators in tuberculosis group opacities, consolidation, interstitial changes, and interlobular septal thickening [ , ] (fig. ) . the median time from illness onset to lesion progression in covid- pneumonia patients was . days ( . , . ). the median number of cumulative lung lobes with lesions was . ( . , . ), and the cumulative number of lung lobes with lesions in group b was significantly higher than that in group a, with a statistically significant difference (p < . ). laboratory data showed that the wbc, n%, and crp in group b covid- pneumonia patients were significantly higher than those of group a patients, and the differences were statistically significant (p < . ). the increase in these levels is considered to be caused by systemic inflammation, which was relatively obvious in severe patients, but the possibility of bacterial infection or secondary fungal infection in some severe patients could not be ruled out. the absolute value of lymphocyte counts decreased significantly in . % of covid- pneumonia patients, especially in group b, compared with group a, with a statistically significant difference, suggesting that cellular immune function decreased in the early stage in covid- pneumonia patients, especially in severe patients. in addition, the l in the group a and tuberculosis group has no significantly different, but tuberculosis mainly causes the reduction of cd + t cells, while the covid- is cd + t cells. although the performance of them is similar, the types of lymphocytes which decrease are different. a total of ( . %) patients had abnormal liver function (alt maximum value of u/l, ast maximum value of u/ l). the liver function index of group b was statistically significantly higher (p < . ) than that of group a, suggesting that severe patients are more likely to have liver dysfunction. most patients had normal renal function, and only ( . %) had abnormal renal function indicators, both of whom were severe patients, suggesting that sars-cov- may not cause significant kidney damage. thirty-six ( . %) patients had hypoproteinemia, and serum albumin (alb) in group b was significantly lower than that in group a, suggesting that the function of synthetic alb was decreased by liver function damage in severe patients. in addition, the basal metabolic rate and resting energy consumption of severe patients were high, and alb catabolic metabolism was accelerated. therefore, attention should be paid to the treatment of decreased albumin levels in severe patients. fib is a coagulation factor mainly secreted into the blood by liver cells. it is involved in the blood coagulation process and is a key factor in thrombosis. in addition, fib is also a stress response protein fib [ ] . a total of ( . %) patients had elevated blood fib content, suggesting that sars-cov- infection could lead to a stress response in the body, promote the synthesis and release of fib by liver cells and macrophages, and thereby increase serum. in addition, fib in group b was significantly higher than that in group a (p < . ). the increase in fib in covid- patients is considered to be caused by systemic inflammation and is relatively obvious in severe patients. d-dimer is a product of fibrinolytic crosslinked fibrin clot formation. elevated d-dimer levels indicate high blood clotting and are a sensitive marker of acute thrombosis. this study shows that the value of ddimer in group b was significantly higher than that in group a (p < . ). it is considered that harmful substances such as viruses and endotoxins can activate coagulation factor xii after entering the blood, activate the endogenous coagulation system, and activate the fibrinolytic system, which leads to an increase in d-dimer. severe patients often have systemic inflammation, which could cause endothelial function to be impaired, resulting in platelet aggregation and the release of coagulation factors, thereby leading to the hyperfunction of the fibrinolytic system. the increase in fib and d-dimer indicates that preventive anticoagulation therapy should be given to covid- pneumonia patients, especially severe patients. treatment results indicated that ( . %) patients were treated with oxygen therapy, among which nasal catheter oxygen was the main treatment ( ( . %) patients in group a, ( . %) patients in group b). some patients in group b were associated with respiratory failure; thus, noninvasive ventilator-assisted ventilation or high-flow oxygen was needed, and the difference was statistically significant (p < . ). all patients received antiviral treatment immediately after admission, while only ( . %) patients were treated with hormone therapy, most of whom were from group b. additionally, the time of hormone use was statistically significantly longer (p < . ) in group b than in group a. in this study, l, mb and fib were selected as the meaningful laboratory indicators to help distinguish between general and severe covid- . the results showed that the values of l, mb, and fib in group b were statistically significantly different (p < . ) from those in group a. when fib reached a critical value of . g/l, the sensitivity and specificity were and . %, respectively, which were significantly better than those of l and mb. it can be seen from the roc curve that fib had the largest area under the roc curve ( . ), indicating that fib could be used as an effective laboratory indicator to help distinguish general and severe covid- , but the specificity of fib was low. therefore, a comprehensive diagnosis should be made based on clinical manifestations and meaningful data. for patients with chest tightness, l < . * ^ /l, and fib significantly higher than . g/l, we should be alert to the possibility that they may subsequently progress into severe covid- or have severe tendencies, which will help in the timely clinical assessment of the condition and the adjustment of treatment. our study has some limitations. this study did not cover all the covid- patients in our hospital, some patients were excluded but were not diagnosed, the number of selected patients was relatively small, and there might be biasing factors in the case selection. therefore, the findings of statistical tests and p values should be interpreted with caution, and it is important to note that nonsignificant p values do not necessarily rule out the difference between group a and group b patients. in addition, the patients' symptoms of discomfort are highly subjective; therefore, there might be errors in the reporting of clinical symptoms. some patients did not seek medical treatment in time; thus, the imaging performance may be lagging. therefore, further research is needed to obtain a full picture of covid- pneumonia. our study demonstrates the clinical features of patients with severe and mild disease. patients with severe disease higher peaks of fever, longer periods of fever and more lung lesions. we also found that fib would be a better marker for indicating the progression of this disease, and with better sensitivity and specificity than lymphocyte counts and myoglobin tests. this study further characterizes the clinical features of covid- pneumonia patients and shows that fib would be a potential clinical predictor for covid- patients. novel coronavirus outbreak in wuhan, china, : intense surveillance is vital for preventing sustained transmission in new locations the progress of novel coronavirus event in china sars-cov- , sars-cov, and mers-cov: a comparative overview potent binding of novel coronavirus spike protein by a sars coronavirus-specific human monoclonal antibody overlapping and discrete aspects of the pathology and pathogenesis of the emerging human pathogenic coronaviruses sars-cov, mers-cov, and sars-cov- _ncov: rapid classification of betacoronaviruses and identification of traditional chinese medicine as potential origin of zoonotic coronaviruses epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study incubation period and other epidemiological characteristics of novel coronavirus infections with right truncation: a statistical analysis of publicly available case data clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china imaging and clinical features of patients with radiological findings from patients with covid- pneumonia in wuhan, china: a descriptive study analysis of ct features of children with novel coronavirus infection aberrant coagulation causes a hyper-inflammatory response in severe influenza pneumonia publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we thank all patients, clinicians, and support staff who participated in this study.authors' contributions yw, xy, jcx and myw conceived and designed the study. yw, ly and jcx contributed to the literature search. yw, ly and xy contributed to data collection. yw jcx and xy contributed to data analysis. xy and myw contributed to data interpretation. yw and jcx contributed to the figures. jpz, xhs, pjt, zjy, and myw contributed to writing of the report. all authors read and approved the final manuscript. the datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the helsinki declaration and its later amendments or comparable ethical standards. all participants written informed consent for participation in the study was obtained, if the participants are children (under years old) informed consent will from their parent or guardian. the study was approved by ethics committee of suzhou fifth people's hospital and the clearance number was - . not applicable. the affiliated infectious hospital of soochow university, , guangqian road, suzhou, jiangsu, p. r. china . the fifth people's hospital of suzhou, suzhou, china.received: may accepted: october the authors declare that they have no competing interests. key: cord- - zx o p authors: rico, timóteo matthies; dos santos machado, karina; fernandes, vanessa pellegrini; madruga, samanta winck; santin, mateus madail; petrarca, cristiane rios; dumith, samuel carvalho title: use of text messaging (sms) for the management of side effects in cancer patients undergoing chemotherapy treatment: a randomized controlled trial date: - - journal: j med syst doi: . /s - - -x sha: doc_id: cord_uid: zx o p cancer patients are often not sufficiently oriented to manage side effects at home. sending text messages with self-care guidelines aimed managing side effects is the main objective of this randomized controlled trial. patients who started outpatient chemotherapy treatment between march and december at a hospital in southern brazil were invited to participate in this study and were allocated to the intervention or control group (ratio : ). each patient in the intervention group received a daily sms (short message service) with some guidance on management or prevention of side effects. all text messages were sent to the intervention group patients in an automated and tailored way by our app called chemotherapp. side effects experienced by patients were verified using the european organization for research and treatment of cancer quality of life questionnaire core- (eortc qlq-c ). results showed intervention group patients experienced fewer side effects compared to the control group in cycle (p < . ), in general. in addition, intervention group experienced less nausea in relation to the control group, in the cycle and cycle (p < . ). this study indicate text messaging may be a tool for supporting side effect management in patients receiving chemotherapy. this study was enrolled in clinicaltrials.gov with the identification number nct . this research was performed in accordance with the declaration of helsinki. electronic supplementary material: the online version of this article ( . /s - - -x) contains supplementary material, which is available to authorized users. chemotherapy is one of the main options in the treatment of cancer, and it is used to eradicate neoplastic cells through the administering of drugs, and can be applied in combination with radiotherapy or surgery [ , ] . available antineoplastic drugs do not specifically act on tumor cells, which often leads to the elimination of healthy cells [ ] . consequently, it can cause toxicity to organs, inducing side effects such as fever, nausea, vomiting, fatigue, diarrhea, mucositis, pain, among others [ , ] . these adverse effects can compromise quality of life, increase financial costs, diminish adherence to treatment and cause medical complications [ , ] . in addition, the financial costs of managing side effects of chemotherapy and the demand for better health care are increasing, potentially compromising cancer treatment [ ] . thus, there is an incentive for the development of cost-effective methods to prevent or ameliorate undesirable side effects [ ] . most people receive cancer treatment on an outpatient basis and manage side effects of the disease and treatment while at home [ ] . thus, developing patients' self-care skills is critically important to ensure safe and high quality care at home [ ] . the mobile phone is cited as the most widely adopted electronic supplementary material the online version of this article (https://doi.org/ . /s - - -x) contains supplementary material, which is available to authorized users. technology on the planet [ , ] . the ubiquity and capabilities of this type of mobile telecommunication technology has spawned a rapidly growing line of research and practice in the health care field, called mhealth (mobile health) [ ] . mhealth can be broadly defined as the usage of information technology and communication applied to the health field through mobile technology, assisting patients, populations and health professionals in improving health care. mhealth has the potential to transform the face of health service delivery across the globe [ ] , leading to the adequacy of health care and patients' quality of life, and ultimately the improvement of health care services. thus, mhealth can play an important role in health care procedures in the treatment of cancer, tackling the management of side effects, and empowering patients and care providers in regard to self-care [ ] . in this covid- era, mhealth interventions are an even more attractive strategy, to minimize patient's exposure [ , ] . one of the most used features in mhealth is text messaging (short message service -sms), since this technology is one of the most utilized functions in mobile phones, representing one of the most widely employed communication methods in the world, and an inexpensive intervention modality [ ] . review studies concluded that sms text messaging can serve as a tool to support patient self-management [ , ] . also, sms text message interventions are capable of producing positive change in the form of preventive health behaviors [ ] . the majority of patients desired to receive as much information as possible about chemotherapy-related side effects [ ] . the degree of satisfaction that cancer patients express about the information they receive has been associated with positive health outcomes, specifically regarding quality of life, performance status, side effects, and psychological well-being [ ] . however, cancer patients may not receive adequate support to manage side effects at home [ ] . some studies report that patients received little information from their health team about the management of treatment-related side effects [ , ] . several approaches based on text messaging (sms)method for communication have been used in cancer treatment, both in preventive measures [ ] [ ] [ ] [ ] [ ] [ ] and in clinical care situations [ ] [ ] [ ] [ ] . specifically in chemotherapy, there are different intervention methods that employ sms to monitor side effects as nausea, vomiting, and other symptoms, as well as in relation to patient adherence to their treatment. few published articles focus on the usage of sms messaging to manage the side effects of chemotherapy in combating cancer. we can highlight the following studies, conducted in singapore from november to january , and in united states from november and september , respectively [ , ] . both studies proved the feasibility of the usage of this technology to monitor side effects provoked by chemotherapy considering not randomized controlled trials. in addition, these studies found that text messaging does not interfere in the daily activities of patients. however, these studies did not focus on the prevention of side effects. in our previous study, we showed the acceptance and perception of cancer patients undergoing chemotherapy on an outpatient basis receiving daily text messages about prevention and managing side effects, as well as emotional support [ ] . some patients reported, through text messages, they felt more confident in treatment, felt supported and encouraged, therefore facilitating self-care. other patients reported they received new information about self-care, and that the messages helped them to take better care of themselves. thus, all patients participating in that study reported receiving text messages helped them better cope with treatment because they received useful self-care information about treatment through text messages. in addition, the adherent patients reported they would recommend these text messages to other patients initiating chemotherapy for cancer [ ] . from our previous results [ ] , we improved the present study expanding it to a considerable number of cancer patients, in order to verify other outcomes. to our knowledge, the present study is the first clinical trial employing text messaging (sms) with preventative advice and side effect management tips sent to cancer patients in outpatient chemotherapy. the primary objective of this study was to determine if the text messages received by the patients lead to a reduction in side effects brought on by chemotherapy. in addition, we verified clinical feasibility of sending sms text messages with self-care content to oncological patients. study design and management (ufpel). this he/ufpel has full capability to execute projects related to new actions and policies directed to sus (unified health system), since it is a reference in the area of oncology and it is supported % by sus, as well as characterized as a sentinel hospital. in addition, he/ufpel serves patients from municipalities. adult patients ( to years of age) diagnosed with cancer, who started the first outpatient chemotherapy treatment scheme between march and december of in he/ ufpel, were invited to participate in the study. participants needed to have their own cell phone, be literate and be able to speak and read in portuguese. all participants also needed to sign the free and informed consent form. participants were randomized to one of two trial arms (intervention and control) in a : ratio, one by one, as they started chemotherapy treatment. the participants assigned to the intervention group received a sms text message on their own cell phones on a daily basis, free of charge. in addition, patients in the intervention group were not required to respond to these text messages. all participants received standard care, which included instructions and information provided by oncologists, nurses, nutritionist, psychologist, pharmacists, among others. these text messages have content about the prevention of side effects as well as emotional support. the messages were sent automatically on a daily basis to each patient in the intervention group utilizing the application chemotherapp, developed by our group according to the methodology presented by rico et al. [ ] . the text messages containing advice were drafted in simple, clear, and objective language, in order to facilitate understanding with the patients. these messages were based on guidelines from the national cancer institute [ ] , as well as international cancer manuals [ ] and were prepared by a multidisciplinary team, with the support of the medical and nursing team of the oncology service of the he/ufpel. all of the messages were drafted and sent in brazilian portuguese. the messages are listed in the supplementary file . in order that each patient in the intervention group receive advice on dealing with the most common side effects, the messages were divided by themes. thus, the configuration of each message in chemotherapp, beyond registering the message itself, was also configured according to the theme covered. the messages were drafted and divided in nine themes: physical activity, hydration, emotional support, nausea/vomiting, constipation/diarrhea, hygiene, eating, immunity, and changes in the skin and sense of taste. for each of these themes, various pieces of advice were drafted and sent. in many cases the messages dealt with more than one side effect. the algorithm of chemotherapp for the automatic sending of text messages is timed with the treatment period of each patient [ ] , and does not send messages with the same theme for at least consecutive days. in addition, the algorithm does not repeat messages for a period of at least days. thus, the process of receiving the text messages is dynamic because each day every patient received a tailored message with a different topic. the patients in the control group received only standard care, and answered the questionnaires periodically. the first interview with each study patient was performed at the time of their first chemotherapy session. in this interview, the patients answered the socio-demographic questionnaire (age, sex, schooling, and marital status), as well as signed the free and informed consent term of the research. in addition, the ecog scale (eastern cooperative oncology group) was applied aiming to qualify the patients' well-being and capacity for self-care. the type of cancer of each patient was verified directly in the medical records of the he/ufpel oncology service. the european organization for research and treatment of cancer quality of life questionnaire core- (eortc qlq-c ) [ ] was employed as the base to verify the presence of side effects. in this questionnaire, patients from both groups responded if they experienced a side effect. the presence of side effects were verified: changes in the skin, changes in the sense of taste, fatigue, fever, diarrhea, pain, lack of appetite, shortness of breath, indigestion, mouth lesions, weakness, constipation, nausea, and vomiting. on the first day of the cycle , cycle , and cycle cycle, patients from both groups were interviewed using the questionnaire to measure the side effects experienced in the previous cycle. or rather, in the beginning of the cycle , the side effects experienced in the cycle were verified, in the beginning of the cycle the side effects experienced in the cycle , and finally, in the beginning of the cycle the side effects experienced in the cycle . in addition, in the beginning of the cycle the patients of the intervention group were asked if they read the received messages on a daily basis, and if the received text messages were considered helpful in their treatment. in addition, these patients were asked whether or not they had followed the guidelines received through text messages (followed all guidelines, followed almost all guidelines, followed half guidelines, followed a few guidelines). besides, these patients were asked about the level of satisfaction of the text messages received (very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, very dissatisfied). all interviews were conducted face-to-face with consenting patients while they were receiving the chemotherapy infusion. all the questionnaires were read to the patients, which has been shown to reveal more detailed and accurate information than written surveys, in order to reduce possible misclassification bias [ ] related to the low levels of education of some patients in brazil. all interviews were conducted by main researcher. we used the exact fisher test and the chi-square test to compare groups (intervention and control) regarding side effects. to compare the number of symptoms for each group along the cycles we used the wilcoxon paired test. the significance level was set as . for two-tailed tests. intentionto-treat analysis was applied to all cycles. data analysis were performed in march using stata software, version . . in total, patients participated in this study, in each group (fig. ) . the losses of participants ( patients in the intervention group, and patients in the control group) were due to death, abandonment of treatment, patient hospitalization, or treatment interruption. in addition, some patients ended their treatment in less than four cycles. almost % ( patients) of the patients were not included in the study for being illiterate, and thus, they were excluded from randomization. no patient refused to participate in the study. in the cycle , patients of the intervention group and patients of the control group were included in intention-totreat analysis. in the cycle , patients of the intervention group and patients of the control group were included in intention-to-treat analysis. in the cycle , patients of the intervention group and patients of the control group were included in intention-to-treat analysis. the most prevalent types of cancer in the participants were breast cancer, colon cancer and lung cancer. the majority of the participants were older than and were married. also, it was observed in patients of both groups that a large majority had never finished elementary school. most patients were between the scale of - on the ecog, which implies good capacity for self-care and completion of daily tasks. both groups were similar in the studied characteristics (table ) . each patient in the intervention group received, on average, sms text messages from the first day of treatment to the beginning of the cycle . all text messages were sent automatically via chemotherapp in the morning. all patients in the intervention group attested to have read daily the received text messages. besides, these patients have considered text messages received were helpful to cope with treatment. regarding the satisfaction in receiving the text messages, patients ( . %) reported being very satisfied, and patients ( . %) reported being satisfied. regarding the followed guidelines from text messages received, patients ( . %) reported to have followed all text messages, patients ( . %) reported to have followed almost all text messages, and ( . %) patient reported to have followed half of them. it can be observed on table intervention group experienced less multiple side effects in the cycle , compared to the control group. however, this result was in the limit of statistical significance (p = . ). in the cycle and cycle , both groups were equivalent with regard to multiple experienced side effects. more than % of the patients in the control group experienced multiple side effects in the first three cycles of treatment, on average. however, in the intervention group, the rate of multiple side effects throughout the first three cycles was closer to % on average (p = . ). in the cycle , cycle and cycle the patients from the intervention group had, on average, . , . , and . side effects, respectively. on the other hand, the patients from the control group in the cycle , cycle and cycle had, on average, . , . , and . side effects, respectively. the side effects most observed in the first three cycles of treatment in the control group were nausea ( %), fatigue ( %), and changes in the sense of taste ( %). in the intervention group, the most common side effects were fatigue ( %), weakness ( %) and nausea ( %) (fig. ) . table shows how many patients experienced (or not) each of the side effects analyzed, by group and cycle. two (nausea and indigestion) of the side effects measured showed statistical significance between both groups (table ). there was significantly higher reports of nausea in the control group in the cycle (p = . ) and in the cycle (p = . ), compared to the intervention group. whilst not reaching statistical significance, there is a trend for intervention group experience less nausea in the cycle compared to the control group (p = . ). besides, there was significantly higher reports of indigestion in the control group in the cycle (p = . ), compared to the intervention group. the intervention group showed far less average of side effects in the cycle , compared with the control group (p = . ). in the cycle , the intervention group also showed less average of side effects when compared with the control group, but in the limit of statistical significance (p = . ). in the cycle , there was no significant difference in side effects between both groups (p = . ). there was a change in the mean of the total sum of experienced side effects in intervention group. it was observed intervention group had an increase total sum of experienced side effects from cycle to cycle , from cycle to cycle , and from cycle to cycle . on the other hand, the total sum of the experienced side effects remained stable in the control group over the three cycles analyzed, from cycle to cycle , from cycle to cycle , and from cycle to cycle (table ). this intervention sent one text message a day from the st day of chemotherapy to the beginning of the fourth cycle for each patient of the intervention group, with general and accessible guidelines on self-care for cancer patients. in addition, this intervention did not focus on the prevention and management of a specific side effect, but informed the patients regarding the relief of the most experienced side effects. however, more self-care behaviors text messages were used for nausea than for the other side effects experienced by subjects. thus, the results of this clinical trial are directly related to the elaborate text messages, and to the algorithm of sending the sms by chemotherapp. the prevention and management of chemotherapy-induced nausea and vomiting (cinv) is a priority in the oncology setting [ ] . incidence of vomiting has been substantially reduced, but efforts to control nausea have been less successful, with nausea continuing to effect upward of % of patients [ ] . nausea was the symptom most frequently encountered in the patients of the control group in our study. seventy-three per cent of the patients in the control group, on average, reported some degree of nausea throughout the first three cycles, whereas % of the patients of the intervention group experienced some degree of nausea in the first three cycles on average. this clinical trial significantly reduced the symptoms of nausea in the patients that were subject to intervention, in the first and second cycle. the messages sent to the patients of this study focused on preventing nausea, taking into account that this was the side effect most feared by the patients. this intervention reduced side effects in cycle compared to the control group, on average. however, the mean of the experienced side effects remained stable in the control group over the three cycles analyzed, but in the intervention group it increased. the increase of total sum of experienced side effects in intervention group from cycle to cycle could be because the intervention group showed an immediate improvement, reducing the side effects in cycle in comparison to the control group. although the total sum of experienced side effects in intervention group from cycle to cycle has increased, on average the side effects of intervention group was lower in cycle and cycle compared to the control group, however, this average was statistical significance only in cycle . no strategy for managing the side effects used by control patients was effective, because there was no prevention of any side effects and no decrease in average of side effects in the three cycles analyzed. the intensity of side effects vary among patients receiving the same antineoplastic drugs [ ] . thus, the side effects may be more diverse and the reactions of patients more variable and individualistic [ ] . besides, many side effects increase and became more severe over time, including changes in taste, nausea, and vomiting [ , ] . spichiger et al. showed a significant increase in number of symptoms experienced from . at the start of chemotherapy to . by cycle [ ] . another study also found a gradual increase in experienced side effects from the first until fifth cycle [ ] . in addition, some side effects are difficult to prevent and to control through self-care behaviors, including taste changes, nausea, vomiting, weakness, and fatigue [ , ] . hence, management and prevention of side effects using self-care behaviors may not always be effective in all cycles of chemotherapy. we have decided to use the sms focusing one-way communication, which might restrict the potential of this technique. a review study identified two-way (sending text messages and receiving replies) text messaging is better than one- way text messaging (sending text messages only) to improve medication adherence [ ] . another study suggested interventions that provided and combined information, monitoring, feedback, and self-management could be more promising than interventions that only provided information to the patients [ ] . it is possible that the intervention patients did not feel as engaged with text messages in cycle and cycle as in cycle , since % of the intervention patients did not followed all guidelines received through the text messages, but, they followed almost all these guidelines. thus, the increase of total sum of experienced side effects in the intervention group, and the general improvement only in cycle , may be partly attributed to the one-way communication that may have affected patient engagement. side effects can frequently be prevented and/or managed with supportive medications when they are recognized early [ ] . however, in this research we have decided to elaborate the text messages only with non-pharmacological orientations. it is possible that because we did not use pharmacological orientation in this intervention, made it difficult to reduce the side effects in all cycles, which it were only reduced in the first cycle. still, study participants received pharmacological and non-pharmacological guidance from the treatment team. related works using mhealth applied to the management of side effects guided patients only after they indicated which symptom they were experiencing [ , ] . in addition, these studies instructed patients with pharmacological and non-pharmacological orientations. rather than wait for side effects to develop, intervention might be used to prepare patients for treatment and the expected challenges to quality of life [ ] . besides, the goal of symptoms management may not always be to prevent symptoms from occurring, but rather reduce impact on daily life [ ] . in our study, we instructed patients regarding prevention and management of side effects in antecipatory mode, sending daily guidelines on self-care even if patients were not experiencing a particular symptom. sending daily pieces of advice via text messaging helped patients to learn more about self-care, leading them to take better care of themselves. according to d'haese et al., providing information in a stepwise fashion may be more beneficial than provide information all at once [ ] . according to schofield and chambers [ ] , a new intervention must also be acceptable to both patients and clinicians. this present intervention found great acceptance with the participating patients, as well as all the health professionals involved (doctors, nurses, nutritionists, psychologists, social workers and other professionals). all of the participants in the intervention group were very grateful for all the text messages received, and they reported that the text messages helped to better confront their treatment. in addition, even though they were not requested to respond to the text messages, many patients expressed gratitude for the advice they received. all intervention patients who started cycle were satisfied or very satisfied about the received text messages. thus, this intervention showed clinical feasibility. the results of this study indicate the use of text messaging may be a tool for supporting side effect management in patients receiving chemotherapy. patients require preparation before beginning chemotherapy, which is commonly a very stressful time [ ] . incorporating text messages into prechemotherapy education may be useful. for example, changes in the taste could be more easily prevented if, since prechemotherapy, patients already received guidelines for prevention of this symptom based on behavior changes [ ] , since changes in the taste was the most increased experienced side effect from cycle to cycle in the intervention group. the side effect evaluation questionnaire was not carried out in the residence of each patient when they experienced side effects. side effects tend to be under-reported both qualitatively and quantitatively if they are reported after the fact [ ] . nevertheless, if this occurred, it occurred with both groups. possible additional factors could have influenced in the effect of the intervention. the type or quantity of additional information that the patients from both groups could have received from family members, friends, and the media (newspapers, television, and internet) could have interfered in this study. likewise, even in outpatient treatment, the information that patients could have received from the treatment team could have interfered in the intervention. we did not control or evaluate this kind of information. however, the demographic characteristics and patient illness of both groups were similar and, thus, the results should not contain significant estimation errors. text messaging technology in cell phones can lead to the so-called hawthorne effect [ ] , which provokes a change in behavior, in the case of the receipt of the messages, for the simple fact of the patient feeling cared for and appreciated. it is also believed that this effect is established by the patient's perception of their health care, which most certainly helps their self-care. another limitation is possible contamination between both groups. some side effects experienced by the patients showed themselves to be almost statistically significant in comparing both groups. nevertheless, other associations could not be found due to lack of statistical power. despite text message-based communication presenting numerous advantages, it is not also without its limitations. a potential limitation to the use of sms text-message-based interventions is the possible marginalization of certain populations, such as those that are illiterate. reduced visual acuity could be a potential limiting factor, making reading text messages difficult. in addition, unfamiliarity with sms text messaging technology is another limitation, particularly among senior citizens. in this study, patients with cognitive impairments and above years old were excluded. this mhealth intervention proved to be an acceptable and feasible means to educate and support cancer patients undergoing chemotherapy treatment. the results of this study demonstrate that text messaging based intervention has the potential to manage side effects. results of this clinical trial suggests that this intervention is associated with better chemotherapy-induced nausea related. further studies with larger sample sizes are required to confirm these results and to further explore other benefits from text messaging in oncology setting. this randomized controlled trial covered a broad spectrum of cancer patient characteristics. thus, this intervention can be easily adapted and applied in other hospitals and clinics that carry out chemotherapy in treating cancer, benefiting the general oncological population. in conclusion, the results of this clinical trial could be used to guide the development and testing of new interventions. in addition, the present intervention can be expanded and applied in other health areas, whether it be via text messages with advice on the management of certain diseases, or even text messages about prevention of health-risk factors. future studies may adapt this intervention to prevent a specific side effect, or even a symptom cluster. in addition, a possible adaptation of this intervention would be related to the algorithm of sending the text messages. increasing frequency of sending text message could show other results. besides, future studies could a d a p t t h i s i n t e r v e n t i o n e x p l o r i n g t w o -w a y communication. side effects of chemotherapy among cancer patients in a malaysian general hospital: experiences, perceptions and informational needs from clinical pharmacists doxorubicin: an update on anticancer molecular action, toxicity and novel drug delivery systems symptoms and treatment burden associated with cancer treatment: results from a cross-sectional national survey in the us the social construction of cancer chemotherapy toxicity: the case of taiwan the economic burden of toxicities associated with cancer treatment: review of the literature and analysis of nausea managing symptoms during cancer treatments: evaluating the implementation of evidence-informed remote support protocols the patient remote intervention and symptom management system (prisms)-a telehealth-mediated intervention enabling real-time monitoring of chemotherapy side-effects in patients with haematological malignancies: study protocol for a randomised controlled trial world in : ict facts and figures : ict facts and figures the performance of mhealth in cancer supportive care: a research agenda mhealth: new horizons for health through mobile technologies rapid scaling up of telehealth treatment for tobacco-dependent cancer patients during the covid- outbreak self-removing passive drain to facilitate postoperative care via telehealth during the covid- pandemic text messaging as a tool for behavior change in disease prevention and management mobile text messaging for health: a systematic review of reviews mobile phone messaging telemedicine for facilitating self management of long-term illnesses preventive health behavior change text message interventions: a meta-analysis information needs of early-stage prostate cancer patients: a comparison of nine countries effects of an interactive mhealth innovation for early detection of patient-reported symptom distress with focus on participatory care: protocol for a study based on prospective, randomised, controlled trials in patients with prostate and breast cancer understanding the concept of chemotherapy-related nausea: the patient experience the healthytexts study: a randomized controlled trial to improve skin cancer prevention behaviors among young people comparative effectiveness of a multifaceted intervention to improve adherence to annual colorectal cancer screening in community health centers: a randomized clinical trial effect of short message service as a reminder on breast self-examination in breast cancer patients: a randomized controlled trial can skin cancer prevention and early detection be improved via mobile phone text messaging? a randomised, attention control trial text-message reminders increase uptake of routine breast screening appointments: a randomised controlled trial in a hard-toreach population text-message reminders in colorectal cancer screening (triccs): a randomised controlled trial feasibility and acceptance of a pharmacist-run tele-oncology service for chemotherapy-induced nausea and vomiting in ambulatory cancer patients a health belief messaging framework and a randomized controlled trial of an sms-based intervention for cancer patient outcomes bidirectional text messaging to monitor endocrine therapy adherence and patient-reported outcomes in breast cancer text messaging (sms) helping cancer care in patients undergoing chemotherapy treatment: a pilot study instituto nacional do câncer reproducibility of the brazilian portuguese version of the european organization for research and treatment of cancer core quality of life questionnaire used in conjunction with its lung cancer-specific module the validity of self-reported smoking: a review and metaanalysis the effect of a standardized ginger extract on chemotherapy-induced nausea-related quality of life in patients undergoing moderately or highly emetogenic chemotherapy: a double blind, randomized, placebo controlled trial nausea, vomiting and quality of life of patients with cancer undergoing antineoplastic treatment: an evaluation by pharmacists update on anti-emetics for chemotherapy-induced emesis discordance between physicians' estimations and breast cancer patients' self-assessment of side-effects of chemotherapy: an issue for quality of care the effect of education in managing side effects in women receiving chemotherapy for treatment of breast cancer effects of web-based interventions on cancer patients' symptoms: review of randomized trials prevalence of symptoms, with a focus on fatigue, and changes of symptoms over three months in outpatients receiving cancer chemotherapy new insights into potential prevention and management options for chemotherapy-induced peripheral neuropathy one-way versus two-way text messaging on improving medication adherence: meta-analysis of randomized trials evaluation of a mobile phone-based, advanced symptom management system (asyms©) in the management of chemotherapy-related toxicity efficacy and costs of two forms of stress management training for cancer patients undergoing chemotherapy the effect of timing of the provision of information on anxiety and satisfaction of cancer patients receiving radiotherapy effective, clinically feasible and sustainable: key design features of psycho-educational and supportive care interventions to promote individualised selfmanagement in cancer care impact of a novel nurse-led prechemotherapy education intervention (chemoed) on patient distress, symptom burden, and treatment-related information and support needs: results from a randomised, controlled trial self-care strategies to cope with taste changes after chemotherapy immediate versus delayed self-reporting of symptoms and side effects during chemotherapy: does timing matter? the hawthorne effect: a randomised, controlled trial publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations this research was a two-arm, randomized controlled trial (rct), not blinded. the research is registered in plataforma brasil and received the approval of the research ethics committee of the faculty of medicine of the federal university of pelotas with the certificate of presentation for ethical appreciation (caae) , , . . . . also, this study was enrolled in clinicaltrials.gov with the identification number nct . this research was performed in accordance with the declaration of helsinki.acknowledgments the authors thank all the patients who participated in the study and all the professionals of the oncology service of the school hospital of the federal university of pelotas. also, this study was enrolled in clinicaltrials.gov with the identification number nct . this research was performed in accordance with the declaration of helsinki. this manuscript does not contain individual information. participants were referred to generically as "patients," "participants," etc. authors have no conflict of interest to declare. key: cord- -i r los authors: wu, huiyue; cai, tong; liu, yingxin; luo, dan; zhang, zhian title: design and development of an immersive virtual reality news application: a case study of the sars event date: - - journal: multimed tools appl doi: . /s - - -w sha: doc_id: cord_uid: i r los in recent years, virtual reality (vr) technologies have been applied to the field of journalism, where the concept of immersive vr news has been proposed. however, despite the fanfare, strong response, and sensational effect caused by its advent, immersive vr news remains a novel journalism paradigm that faces new challenges in its production process. currently, there is a lack of a unified design framework, and, since most studies in this area have focused on non-interactive vr news, the understanding of the effects of more interactive vr technologies on the news consumer remains inadequate. in this study, we propose a more practical design framework for immersive vr news products. following this framework, we designed a vr news application and conducted user evaluation in terms of media effects and user experience. based on the experimental findings, which demonstrated that non-interactive vr news products resulted in a distracting user experience and less immersion, while interactive vr news offered improved media effects and user experience, we then derived concrete design guidelines for immersive vr news design. finally, we highlight that this study provides a theoretical and practical reference framework for the further study of vr news. immersive journalism refers to news that aims to establish a connection between the audience and the news story by offering first-person experiences of events or situations [ ] . generally, the sense and illusion of embodiment is created through spatial perception as digital avatars, which is the basis of immersive journalism [ , , ] . "immersion" in journalism has evolved from the narrative strategies used by journalists to arouse audiences' empathy in the early practice into a multi-channel experience utilizing the technology changes of recent years [ , , ] . currently, immersive journalism is mainly presented in two forms [ , , ] . one is °v ideo, which can immerse audiences in real news scenes captured by photographic equipment. since this new product form is easy to develop, it has been widely used in the media industry; however, the lack of interaction and embodiment results in lower user engagement in traditional °video news. the other is known as vr news, which generates a digital experience that closely simulates the real world using virtual reality technologies. the interaction between users and virtual environments in vr news ensures a stronger sense of immersion [ ] . while immersive technologies are advancing, there is still insufficient clarity on the effects these technologies have for the news consumer. as a new form of news communication paradigm, there are still many open questions in the design and development of immersive vr news. for example, virtual reality technology has raised new requirements for the traditional news production process [ , , ] , and the change of perspective caused by the disappearance of the physical screen and the appearance of interactive elements brings a new challenge to the narrative frame of journalism [ ] . at the same time, academia is also exploring whether the application of vr in news may impair professionalism in journalism. for example, a deliberately misleading or fabricated perspective can impair the ability to convey accurate and true facts to the audience during an immersive experience [ ] . therefore, a set of production process standards and design specifications is required for the further application of immersive vr news. in this study, we explore the immersive vr news production process and propose concrete design guidelines through a practice case study. our work includes ) the production of immersive vr news investigated under different conditions (vr news with and without interaction); ) a deeper understanding of user experience and media effects in immersive vr news, and ) design guidelines for immersive vr news. we hope that our research findings will enable practitioners to design and develop more effective applications and consequently create a better interactive experience for immersive vr news products. our work primarily concerns research related to the evaluation of news production and systems; thus, our literature review focuses on work in these areas, including traditional news production and existing design practices in vr news products. currently, there is no general production process for traditional news. in general, the production process is flexible and variable to meet the needs of different news topics. paterson and domingo [ ] divided the online news production process into five stages based on ethnography, namely ) interview and observation; ) selection and filtering; ) processing and editing; ) distribution, and ) interpretation. in such a process, the stages of news selection, filtering, processing, and editing are guided by the gatekeeping theory proposed by white [ ] . gatekeeping refers to the system through which countless pieces of information are screened and processed into a limited number of messages and subsequently disseminated to the audience [ ] . white [ ] claimed that news stories must be strictly selected and filtered by gatekeepers in the news selection and filtering stage before they move on to processing. bass [ ] further emphasized that news information processing should also be guided by this gatekeeping theory. more recently, gatekeeping theory was suggested to be involved in the news distribution and interpretation stages as well [ ] , and even any decision-making process about the encoding of the information [ ] . many immersive vr news products have emerged in recent years. we collected previous applications and analyzed the component factors of news products, including the themes, narrative frame, and mode of user experience and media effects. as for news themes, current vr news products mainly focus on events that reflect social problems, e.g., hunger in la ; important historical events, e.g. aftermath vr: euromaidan, and some subjects with popular science value that are difficult for ordinary people to access or experience, e.g., home: a vr spacewalk. regarding narrative frame, the production of vr news is moving away from the linear and planned storytelling structure adopted by traditional news: in immersive vr news, the audience can not only understand the whole news event from an omniscient perspective (e.g., kiya) but also participate in the news story as bystanders (e.g., use of force) or even become the protagonist to experience the feelings of the parties involved (e.g., across the line). in terms of the mode of user experience and the effects of this media, the degree of user participation in the news varies in different cases. current mainstream immersive vr news mostly focuses on non-interactive products that only allow users to "visit" or experience news events from a bystander's perspective, although some recent products enable the users to interact with d objects in the virtual environment (e.g., remembering pearl harbor). existing evaluations of immersive vr news have primarily focused on ) immersion and empathy from the perspective of the user experience, and ) accuracy, credibility, and audiences' emotional attitude from the perspective of the media's effects. immersion although vr technologies have been recently used to convey news stories in immersive journalism, how the audience experiences these stories remains unclear. implementing an immersive experience is an important goal in a computer-mediated environment [ ] and immersion can be used to characterize the technical support of the vr environment [ ] . slater et al. [ ] claimed that walking in interactive space can enhance participants' experience in terms of presence and immersion. moreover, increased audience satisfaction, greater credibility, and a superior interactive experience can be achieved using vr interactive devices capable of triggering a high degree of immersion. this immersion largely depends on the user's characteristics, intent, and context rather than the definition by the media. it also affects the user's perception and view intention regarding the news story and can be defined both qualitatively and quantitatively. jennett et al. [ ] , for example, proposed a scale to measure the sense of immersion in immersive vr news. empathy the term "empathy" originated from the field of art and has been widely used in psychology. at first, it referred to the emotional connection between human beings and nature but was later used to describe a person's reaction to the feelings of others [ ] : wondra and ellsworth [ ] stated that empathy involves caring, identifying, and understanding others. rath et al. [ ] claimed that one of the important factors of the virtual reality technique is to provide a sense of empathy that is similar to a person's real life. more specifically, laws and luisa [ ] concluded that some immersive news is indeed approaching a form that can produce and enhance the user's sense of empathy. credibility credibility refers to the degree of trust that news audiences have in media, news organizations, or news sources [ ] . in addition to the sources and content of the news, credibility may also be affected by media technology, and there are concerns that immersive vr news may damage the credibility of news and weaken its ability to present facts to the audience [ , ] . in comparison, peña et al. [ ] suggested that the purpose of immersive journalism is not merely to present the facts but rather to offer an opportunity to experience them. their experimental results showed that immersive vr news with a high level of telepresence has higher credibility, and the experience feedback of the audience that used vr interaction devices capable of triggering a high level of immersion indicated a higher level of trust in the news content. similarly, nielsen and sheets [ ] claimed that virtual reality can add considerable value to traditional news products, potentially boosting engagement and trust. this credibility can be defined quantitatively; for example, meyer [ ] , proposed a credibility scale to measure this aspect of the immersive vr news product. accuracy regarding accuracy, tse et al. [ ] found that % of participants mentioned experiencing the fear of missing information in immersive vr environments, while % of participants noted that immersive media distract them from the content of the story itself. according to neisser [ ] and perry [ ] , the audiences' cognition should be identified as an important factor when considering the influence of media effects. based on the famous "stimulus-response" model, cognition reflects human psychological processes, such as attention, knowledge, memory, and perception. to measure the cognitive accuracy of immersive vr news, the six elements of news (i.e., w h: who/when/where/what/why/ how) has been popularly used in previous studies to measure users' perceptions of news information and its accuracy. emotional attitude audiences' attitude has always been an important dependent variable in news media effects research [ ] and has been extensively studied. attitude is typically divided into three independent aspects [ ] , that is, cognitive, affective, and conative. this "cognitive-affective-conative" (cac) framework has been widely used in communication studies [ , , , , , ] to measure audiences' attitudes; therefore, this study also measured the media effects of immersive vr news using this framework. in summary, while immersive technologies are advancing, the understanding of their effects on the news consumer remains inadequate. currently, there is a trend for audience identity diversification in the current vr news applications; however, our knowledge about whether user experience and media effects of vr news can be influenced by different audience identities is still limited. moreover, the current mainstream immersive vr news continues to focus on non-interactive products that only allow users to "visit" or experience news events from a bystander's perspective, and the user experience and media effects of interactive immersive vr news have rarely been investigated. we found that the narrative frameworks adopted in different studies differ markedly from those of traditional news coverage: the mode of viewing an event from the perspective of an omniscient narrator is not suitable for all news topics, and the viewing perspectives are beginning to diversify, such as making eye contact with the protagonist and even experiencing the feelings of other parties as the protagonist themselves. the degrees of participation and interaction of viewers in different cases vary. in interactive cases, specific interactions include those with the scene, object, and other characters through, for example, eye contact, and this degree of interaction is deepening. to address these issues, we proposed a design process for immersive vr news. by employing an iterative design method, this process provides a reference framework for designers to develop more practical and user-friendly vr news applications. based on this process, we designed and developed a vr news product, and, from the experimental results and findings, we derived concrete design guidelines for immersive vr news design. unlike the process of traditional news production, immersive vr news faces new production challenges. according to sirkkunen et al. [ ] , the technical production process of immersive vr news can generally be divided into three stages, that is, ) capturing new content with a camera and/ or voice recorder; ) post-production comprising image processing, motion graphics, and dmodeling techniques, and ) distribution with headset technologies and the associated content stores. this production process requires specialized knowledge in image processing, d modeling, and computer animation, which are difficult and beyond the reach of average journalists; therefore, traditional journalists must work with those who are proficient in hci or vr technologies to better understand the capabilities and limitations of vr technologies in immersive news storytelling [ , , ] . as a result, more studies are needed in journalism production to better understand how vr technologies work within the fields of news production and communication. one of the challenges of immersive vr news is the design of a reasonable storytelling framework, in which the time, space, and causality of the news story are more credible [ ] . another challenge is providing a vivid representation of the current news story rather than separating facts from opinions in the usual way adopted by traditional reporters or narrators. this kind of storytelling must be dealt with carefully otherwise it may degrade the capabilities of telling the truth to the public and, consequently, lead to ethical dilemmas [ , , , , , ] . designers, thus, inevitably face the challenge of balancing news reporting and conveying the facts accurately in immersive vr news. furthermore, the immersive vr news audience no longer comprises passive recipients of content but rather those with autonomy who can actively explore news content to a certain extent [ , ] . in such a situation, users' perception and intention can significantly impact their experience of immersive vr news [ ] ; for example, they may ignore the important information that the news reporter wants to convey while focusing on less relevant information in the vr scenario [ ] , which consequently leads to the suspension of the storytelling. therefore, the designers should pay attention to the user's behavior and experience when designing immersive vr news products. in summary, although the application of vr technology in the field of journalism provides a brand-new immersive experience as compared to traditional news, it also brings new challenges to the news production process, narrative framework, and journalistic professionalism. currently, there is a lack of unified framework and design guidelines that can be followed by the designers to create news products that can provide better user experience and media effects. to address the abovementioned issues, we proposed a practical method for developing more reliable immersive vr news products than the traditionally offered news products. we applied this method to an immersive vr news report-"beijing: preventative action for severe acute respiratory syndrome (sars)"-and investigated its user experience and media effects through user evaluation in two different storytelling frameworks: vr news without interaction (vr-i) in study and vr news with interaction (vr + i) in study . given that the current mainstream immersive vr news focuses on non-interactive products, we first explored the production process for vr-i in this study. figure shows the multi-stage design and development process we proposed for immersive vr-i products. unlike traditional media, such as text, images, and video, vr news production has both the attributes of journalistic professionalism and the characteristics of software product iteration; therefore, gatekeeping theory and the principles of journalistic professionalism were integrated into the production process to guide the news product design. in the first stage of our proposed process, specific news topics are selected, and related information is gathered according to the requirements of news production organizations. in the second stage, the news information obtained from multiple channels is sorted and processed based on the news topics determined in the previous stage. the third stage is the frame design, in which the structure of the content and the function modules are determined and designed. the fourth stage focuses on visual content design, the output of which will be fed into the fifth stage to develop the system. in the sixth stage, the whole system is evaluated to ensure that the product meets the requirements of both news products (e.g., media effects) and vr systems (e.g., user experience). throughout the design and production process, journalistic professionalism was considered as the core principle and guided the design practice. the principles of journalistic professionalism are widely used as the professional belief system and moral code by numerous news practitioners. throughout the design process of immersive vr news, we applied the five guidelines summarized by white [ ] and based on the global charter of ethics for journalists [ ] : & fairness and impartiality. this principle is mainly embodied in the first three stages of the production of immersive vr news, including newsgathering, news processing, and frame design. the designer should consider the content design based on multiple sources to balance reporting. more specifically, the balance between different sources and facts should be considered in terms of the immersive differences that virtual reality technology brings. & independence. this principle should be carefully considered in the frame design stage for vr news. given the fact that the user is involved in the vr news event as an actor may conflict with this principle, the designer should distinguish between opinions and facts during frame design to ensure that the user remains a participant or observer with a neutral attitude and is not arbitrarily involved in the news event. & truth and accuracy. this principle is applied throughout the whole production process, including scenes, characters, animations, and interactions. details in all these design stages are required to be consistent with the news facts, allowing users to access accurate information through multiple channels. & humanity. this principle reminds us that those news materials that are inclined to cause negative effects, such as excessive violence and bloody scenes, should be avoided in the newsgathering and processing stage. the user's physical experience should be carefully considered during the system development process to avoid adverse reactions. & accountability. this principle is consistent with the idea of user evaluation for virtual reality systems. all immersive vr news products should be carefully evaluated and refined iteratively to ensure the system is user-friendly and socially acceptable. immersive vr-i product process by collecting and analyzing the results of previous studies, we learned that immersive vr news has certain requirements for news subjects and is unsuitable for breaking or timesensitive news; it is more appropriate for social and disaster news, which have distinct characters and complete story timelines and are not commonly experienced by ordinary people. as such works can be used repeatedly for a relatively long period and are not prone to becoming outdated, they are focused on human nature and life experience in a more general sense, whereas in the case of ordinary news events, the application value of immersive vr news is insignificant. based on this analysis, we chose "beijing: preventative action for severe acute respiratory syndrome (sars)," an investigative news report broadcasted on the china central television (cctv) news channel on april , , as the news material for this study. we chose this news material because ) it has high social and humanistic values and represents the news type we have previously targeted; ) the video was released by a national chinese tv station whose news reports have been influential and authoritative, earning significant credibility and, thus, reflecting the typical news narrative and traditional mainstream media; ) the news event happened in the sars epidemic isolation ward of beijing you'an hospital, in which a reporter visits a patient, representing the kind of event that ordinary people do not often experience, and ) the epidemic is now fading into the distant past. most people today only hold vague ideas and limited knowledge about this event, which is conducive to a more accurate measurement of the media effects (e.g., accuracy of information reception) of immersive vr news. in this stage, we needed to process and screen the information collected in the newsgathering stage, based on gatekeeping theory. unlike traditional text and/or video news, the carrier of an immersive vr news report is a computer-generated virtual reality application. the development of this application involves a variety of different functional modules and design elements, including the scenarios, medical items, characters, and synopsis in the sars case. the outcome of this stage is a script design document (fig. ). newsgathering and processing were followed by frame design, in which the news content, structure, and system functionalities were considered and designed as a whole. in study , we adopted a linear, non-interactive narrative framework, which has been widely used by existing research on immersive vr news products (e.g., use of force, kiya, across the line). this news mainly takes the form of reporters' dialogues with doctors and patients while conducting interviews. the script of the entire news story encompasses three scenes (fig. ) , a clean area in the disinfection room, a doctor introduces and demonstrates the cleaning and preparation procedures before entering the partially contaminated area, including wearing protective clothing, headgear, protective glasses, and shoe covers, and explains the differences among the three areas. in the corridor, the doctor explains the functions of the protective shoe cover and disinfectant and then introduces the specific procedures for treating sars patients. in the ward, the reporter interviews a sars patient to understand her condition and treatment plan and talks with a doctor, asking why the doctor is risking his life to treat these patients. in this stage, we first made the d floor plan where the news story happened (fig. a) using autocad software and according to the video content we collected in the first stage. thereafter, the d scenes were modeled using unity d to match the d floor plan of the story (fig. b) . next, we used d modeling software (e.g., d max, maya) to create the characters (e.g., the reporter, doctors, and nurses) and adjust the details of the characters such as skin and the five sense organs to make them look more like the real people that were represented in the original news video. we then created character animation for the existing characters in a process that involved operation steps such as bone-binding, skin-covering, and controller building and based on the reporters' dialogues and movements in their interactions with doctors and patients in the hospital, following the truth and accuracy principles required by journalistic professionalism (fig. ) . in this stage, we used the oculus rift vr headset to enable the user to freely explore the virtual environment. the monocular resolution of the oculus rift vr headset is × while the binocular resolution is × . the refresh rate is hz. there are many development engines available in the vr field, such as unity d, unreal engine , cryengine , and cocos d. in this study, we chose unity d, which has been well integrated with the oculus sdk for the development of virtual reality applications. we used scripting languages to implement relevant interactive functions. in this stage, the proposed immersive vr application was evaluated in terms of user experience and media effects. participants and apparatus we recruited participants ( males and females) from a university via advertisements, webchat, and microblogs. they were aged between and (m = . , sd = . ) and were pursuing different majors, including economics, law, literature, science, engineering, and management. based on the information collected in the pretest questionnaire survey, individuals who had full knowledge of the content of the news material used in this experiment or who exhibited strong personal opinions and emotional attitudes were excluded during the recruitment process to avoid any influence of participants' biases on the accuracy and credibility of the experimental results. in addition to the oculus rift headset, we also used a web camera and a voice recorder to record the participants' behaviors and soliloquies for later data analysis. procedure during the experiment, participants were randomly divided into two groups: group a ( participants) and group b ( participants). participants in group a were required to view traditional d video news on a computer and those in group b were asked to wear the provided oculus vr headset to watch the vr news that was reproduced based on the traditional d video news segment. after the participants completed the experiment, they were asked to complete a questionnaire that contained items regarding media effects and user experience. to assess media effects, we generated six questions on the six elements of news (i.e., w h: who/when/ where/what/why/how) to measure the subjects' perception of the news information and its accuracy. six items were selected from the original -item panas adjective checklist [ ] to measure emotion, including "scared," "interested," "nervous," "inspired," "distressed," and "excited." we also used the five major credibility indicators [ ] to measure credibility. to evaluate user experience, we adopted jennett et al.'s [ ] immersion scale to measure immersion and the toronto empathy questionnaire of kourmousi et al. [ ] to measure empathy. after all participants had completed the questionnaire, our laboratory personnel conducted one-on-one semi-structured interviews with each participant to understand their views and suggestions on the entire system. the experiment lasted - min. results and user feedback media effects. as for accuracy, the average score of traditional video news and immersive vr-i was . (sd = . ) and . (sd = . ), respectively. the mann-whitney u test indicated that there was a significant difference between the two treatments (z = − . , p = . ). in terms of emotion, traditional video news and immersive vr-i averaged . (sd = . ) and . (sd = . ) for "scared," . (sd = . ) and . (sd = . ) for "nervous," and . (sd = . ) and . (sd = . ) for "distressed." the mann-whitney u test indicated that the traditional video news was superior to immersive vr-i news in terms of fear (p = . ), nervousness (p = . ), and distress (p = . ). as for credibility, the average score of traditional video news and immersive vr-i news was . (sd = . ) and . (sd = . ), respectively. the mann-whitney u test indicated that there was a significant difference between the two treatments (z = − . , p = . ). through experimental observations and interviews with the participants after the experiment, we found that they were easily distracted by irrelevant things in the vr-i report. traditional video news has a limited visual boundary, i.e., a frame, in which the reporter can precisely convey the content and the focus of the information they want to convey to the audience. in contrast, immersive vr news allows a -degree field of vision and all information is presented to the audience in parallel. moreover, compared with traditional third-person perspective video news, even though vr-i news provides a first-person perspective, it does not change the one-way dissemination mode of news information. in the news narrative, many participants were attracted by the new form of vr and looked around while wearing the hmd headset, thus distracting them from the main message that the news story aimed to convey. they stated: "the red hot water bottle on the bedside table attracted me" [p in group b] "my attention focused on the old cell phone by the patient's pillow, so i wasn't listening to the conversation between the reporter and the doctor and consequently missed a lot of important information." [p in group b] "if i had known in advance that i would be asked questions whose answers could be found in the conversation between the reporter and the doctor, i would not have paid attention to the scalpels during the experiment." [p in group b] user experience. as for immersion, the average score of traditional video news and immersive vr-i without interaction was . (sd = . ) and . (sd = . ), respectively. the mann-whitney u test indicated that there was no significant difference between the two treatments (z = − . , p = . ). regarding empathy, the average score of traditional video news and immersive vr-i was . (sd = . ) and . (sd = . ), respectively. the mann-whitney u test indicated that there was a significant difference between the two treatments (z = − . , p = . ). through the interviews, we learned that in watching the traditional video news, participants believed the characters and scenes were all real. as the news story unfolded and continued, the participants were unconsciously immersed in a depressing atmosphere and, thus, felt strong empathy. in contrast, the vr news application is an artificial virtual environment. although we tried to faithfully reproduce the story from the news video, we were unable to fully replicate material shot through a camera lens in various ways, such as the character model, scene model, scene tone, lighting, and shadows due to the limitations of the existing modeling capabilities. therefore, participants could not be fully immersed in the scene and, thus, could not feel such a strong sense of empathy. furthermore, participants also described the problem of "bystander identity" in the vr news report and described a reduced sense of immersion and empathy in this identity that they were assigned in the immersive vr environment: "i feel that it is boring to watch the conversation between the reporter and the doctor. i had nothing to do but watch the conversation foolishly in the virtual environment" [p in group b] "as a product experiencer, i prefer to be assigned to a specific identify (e.g., the reporter), so that i can have a deeper sense of telepresence" [p in group b] discussion of study overall, traditional video news was rated superior to immersive vr news without interaction in this study. the primary reason for this may lie in that the opportunity for participants to explore freely in the virtual environment facilitates the participants in focusing on different things according to their personal interests or habits. traditional immersive vr news without interaction, including the sars case in this study, did not precisely gatekeep the key information that needed to be conveyed to the audience, in particular, how the news information should be shaped, encoded, and highlighted in an immersive virtual environment with multiple degrees of freedom. this result was consistent with the findings reported by krugman [ ] that media effects in different modes are prone to be influenced by the motivation of watching and the degree of audience participation. the experimental results and findings in this study informed us of three important requirements that should be carefully considered in the design of immersive vr news products. the first is concentration, in other words, directing the audience's attention to the information that the news reporters want to convey. the second is information logic, which means information should be effectively inducted, summarized, and expressed in a more logical order to improve media effects. finally, engagement should be considered since emotions and a sense of empathy can be affected by the user's viewing perspective. participants should, therefore, be allowed to immerse into the news story in a more active approach to enhance the sense of engagement. compared to study , participants acted as protagonists (e.g., the reporter) rather than bystanders in this study and could actively interact with other characters (e.g., the doctors or the patients) rather than passively watching the conversation in the vr environment. thus, we extended the design method proposed in study : as shown in fig. , news content was rearranged and key information was refined in the news processing stage to lay the foundation for the selection of corresponding system functionalities and interaction techniques in the subsequent stages. in addition, in the frame design stage, a newly added interaction design module was integrated to determine the functional set according to specific requirements, design-appropriate interaction techniques according to the key information, and design the whole user experience process. similarly, a new user interface design module was integrated into the visual content design stage. in the system development stage, the news scripts and content logic structure were updated and modified to meet the requirements of corresponding system functions determined in the previous stages. finally, the interactive product was evaluated in terms of user experience and media effects. as mentioned above, information gatekeeping theory has generally been used in the realm of traditional media. in the new media era, it has been suggested that gatekeeping theory should be replaced by gatewatching theory [ ] , which emphasizes the shift from simply eliminating less important information to purposefully highlighting more important information [ ] . therefore, we applied gatewatching theory in this stage, emphasizing key information by redesigning the information structure and interactions to convey news more effectively rather than simply eliminating the less important content. according to the results of study , we identified three main design requirements, including concentration, information logic, and engagement (fig. ) . we embodied the three design requirements and proposed the commonly used function set for the immersive vr news. different functions were identified to match different types of information, for example, the point of information, "wearing the protective clothing," in the conversation between the reporter (the user in this study) and the doctor contains a piece of an important knowledge segment with a strong attribute of operability in the virtual environment, so we designed an interaction technique that enables the participant to practice wearing protective clothing in the news story. finally, four function types were identified throughout the three scenes, including event handling, dialogue, viewing item details, and scene transition ( table ) . the user experience process in this study was totally different from that of the previous study. in study , participants experienced the news event linearly as bystanders without clear roles or identities along a timeline predefined by the system. such an experience design was consistent with the concept of "public journalism" or "civic journalism" [ ] , in which the audience can obtain information without any restrictions. although this design idea represents the concept of "everyone as a gatekeeper," it is unrealistic to expect the average audience to play the role of a professional gatekeeper when obtaining news presented in a disorganized way. compared to the previous study, we proposed a new user experience mode based on gatekeeping theory, namely "two freedoms under two constraints." under this experience mode, the user is required to participate in the news events in a fixed flow of interactions and an organized way to obtain the necessary key information. once the users had completed the specified interaction tasks required by the system, they were allowed to explore the vr scenario freely within each scene (fig. ) . refined immersive vr news product process the "two constraints" refers to the constraints between different scenes, requiring that users could not redirect to the next scene unless they had completed all the given interactive tasks in the current scene. in addition, the constraints were also predefined between different interactive tasks, i.e., interactions could only be triggered in the proper stage of a specific scene. meanwhile, the "two freedoms" refers to ) the freedom to explore different things in the current scene, i.e., the user is free to explore the scene without the limit of time and space, and they can decide when to move on to the next scene according to their personal willingness, and ) the freedom to manipulate different objects involved in the same interactive task without an order constraint, for example, the user can pick up the medical record and then talk to the doctor, or they can pick up the medical record during the conversation with the doctor. we used the same apparatus as study . here, participants were required to use the two oculus touch controllers to perform the given interactive tasks, including grabbing an object in the three design guidelines for immersive vr news design ward and viewing details of this object, wearing disinfection gloves and goggles, and checking the medical records. forty-three college students ( males and females) participated in this study, aged between and (m = . , sd = . ). participants were pursuing different majors, including law, literature, computer science, medical engineering, management, and history. similar to study , none of the participants had ever watched the original video news before this study. participants in this study were assigned to group c. the experimental procedure was the same as study . during the experiment, participants were required to wear the provided oculus vr headset to view the vr news and interact with the system with the oculus rift handle controllers. after the experiment, all participants were asked to complete a questionnaire that has been used in study . we also conducted one-on-one semi-structured interviews with each participant to collect further user feedback from the participants. the experiment lasted approximately min. in this study, experimental results showed that the immersive vr news with interaction (vr + i) effectively improved media effects and user experience as compared to immersive vr news without interaction (vr-i). media effects the average accuracy scores for traditional video news, vr-i, and vr + i were . (sd = . ), . (sd = . ), and . (sd = . ), respectively. the kruskal-wallis test results showed statistically significant differences among traditional video news, immersive vr-i, and immersive vr + i (χ ( , n = ) = . , p = . ). post-hoc testing indicated that vr + i was perceived to be significantly more accurate than vr-i (p = . ), and traditional video news was also perceived to be significantly more accurate than vr-i (p = . ), while vr + i exhibited no significant difference from traditional video news (p = . ). participants mentioned in the interviews that the news information conveyed in the interactive experience existed as "memory points," which were more impressive than coherent yet non-interactive stories. such findings verified the importance of the interactivity as gatewatching [ ] in emphasizing information. for example, participants stated: fig. "two freedoms under two constraints" user experience mode "before i entered the ward, i was required to wear the protective equipment. this made me feel that the outbreak (sars) is very serious. i personally agree with this form of interaction technique because it enhances the sense of substitution and is quite impressive." [p in group c] "the interactive experiences, such as wearing protective clothing before entering the ward, were impressive. if you just sit on the sidelines and watch other people wear the protective clothing, you won't have a strong sense of substitution and you won't try to remember the detailed information conveyed by the news." [p in group c] for emotional attitude, the average scores for traditional video news, vr-i, and vr + i were . (sd = . ), . (sd = . ), and . (sd = . ), respectively in terms of interest, and . (sd = . ), . (sd = . ), and . (sd = . ), respectively in terms of nervousness. the kruskal-wallis test results showed statistically significant differences among traditional video news, immersive vr-i, and immersive vr + i regarding interest (χ ( , n = ) = . , p = . ) and nervousness (χ ( , n = ) = . , p = . ). participants explained that they experienced a higher degree of emotion due to the increased freedom and autonomy in vr + i. under the "two freedoms under two constraints" user experience procedure, participants can freely explore the news event without worrying about missing important information; therefore, they are more aware of the interest and nervousness conveyed by the news itself. one participant noted: "this is a relatively open-ended scenario, in which i can explore important news information in a free mode or make decisions to help the patient under the guidance of the doctor in a constrained norm way when necessary." [p in group c] in terms of credibility, the average scores for traditional video news, vr-i, vr + i were . (sd = . ), . (sd = . ), and . (sd = . ), respectively. the kruskal-wallis test results showed statistically significant differences among traditional video news, immersive vr-i, and immersive vr + i (χ ( , n = ) = . , p = . ). post-hoc testing indicated that vr + i was seen to be significantly more credible than vr-i (p = . ), and traditional video news was also significantly more credible than vr-i (p = . ), while vr + i exhibited no significant difference from traditional video news (p = . ). post-hoc interviews revealed that the higher news credibility may be attributed to both the enhanced subjective experience of "being there" and the objective fact that the vr + i conveys much more detailed information in a more effective way. participants observed: "the vr+i requirements for more real and richly detailed information prompt the news producers to review and present information in a more effective way, which consequently leads to an increase in authenticity and credibility." [p in group c] user experience the average scores for immersion for traditional video news, vr-i, and vr + i were . (sd = . ), . (sd = . ), and . (sd = . ), respectively. the kruskal-wallis test results showed statistically significant differences among traditional video news, immersive vr-i, and immersive vr + i (χ ( , n = ) = . , p = . ). as for empathy, the average scores for traditional video news, vr-i, and vr + i were . (sd = . ), . (sd = . ), and . (sd = . ), respectively. the kruskal-wallis test results showed that no statistically significant differences were found among traditional video news, immersive vr-i, and immersive vr + i (χ ( , n = ) = . , p = . ). participants showed a more positive attitude regarding immersion and empathy for vr + i as compared to traditional video news and vr-i, explaining that the scene transition and interaction design in vr + i made the news story clearer and conveyed key information more accurately to them: "the news is well organized. different from news or traditional vr news without interaction, i can learn what to do next and how to do it by touching the highlighted interactive widgets or the pop-out dialogue to obtain the necessary information or guidelines provided by the system when i was lost or confused." [p in group c] "the story proceeds in a good order and the interaction is impressive." [p in group c] based on the experimental results, we conclude that vr + i can effectively improve the media effects and user experience of virtual reality news. in the previous study, some participants walked around in the virtual space while others were attracted to some small widgets (e.g., the old-fashioned cell phone next to the patient's pillow). this kind of unrestricted user experience mode greatly affected the communication of key news information and, consequently, lead to the poor performance in media effects and user experience in study . in comparison, the advantages of immersive vr + i lie in ) capturing the user's attention exactly through different interactive techniques; ) enabling the user to explore key news information as an active seeker in the virtual environment; ) prompting the user's sense of social identity and duty, and ) embodying the application of gatekeeping theory [ ] effectively. for example, participants stated: "without interaction, vr news is just another form of video news. it's easy to get distracted if you just watch the news story on the sidelines." [p in group c] "the interaction and first-person substitution prompted me to pay attention to the doctor's advice. also, i felt that i must remember the important information, for example, how to wear the protective clothing correctly and wash my hands before and after meals in my daily life, because the outbreak (sars) was happening right next to me." [p in group c] despite the positive feedback, some participants raised concerns about the application of immersive vr news in practice: "the production techniques of immersive vr news are in an early stage of development, with high production difficulty and cost, making them difficult to design and develop." [p in group c] "for most people, particularly businessmen or white-collar workers, vr news is timeconsuming and troublesome to watch (e.g., the users must wear heavy head-mounted displays). in contrast, it is more efficient and convenient to watch traditional video news on personal mobile phones." [p in group c] "although vr news can provide a free navigation space, it usually requires expensive equipment (e.g., the head-mounted display and the handle controller) and a large space in the physical world to allow the user to move around." [p in group c] "it made me feel like i was really in a virtual world, with no way to embody myself in the virtual world." [p in group c] based on the results we obtained from these two user studies, we derived concrete guidelines for immersive vr news design. although immersive vr + i was rated superior to traditional video news and vr-i, many problems still exist, for example, the high cost of vr news production and consumption determines that vr news must be selectively applied to certain news types. currently, it seems unfeasible for media organizations to pursue vr news production on a large scale. however, scenes of disasters and major historical events and scenes that are difficult for ordinary people to access or experience are not prone to expiration, can be used repeatedly for quite a long time, and cover topics related to human nature and life experience, and, thus, are more conducive to vr production. it would not be meaningful to heavily invest in immersive vr news production for other common news events. the application of immersive vr news also brings new challenges for designers. for example, in an immersive vr environment, users rely on the vision channel to search for objects (e.g., the protective clothing). such eye-engaged interactive techniques may significantly degrade the interaction efficiency and user experience, particularly when users have to turn their head frequently to search for a target object in the limited field of view of a head-mounted display. such interactive techniques may increase the user's burden and even make them feel confused or frustrated. therefore, designers should provide suitable guidance in the vr environment, for example, indicators to guide the users' visual search path or interactive objects and eyecatching slogans to attract the user's attention and prompt them to continue the exploration and performance of the specified tasks that the system has pre-defined. designers should also consider the balance between freedom and constraint in immersive vr news. on the one hand, immersive vr news should allow the users to move around while navigating in a virtual environment, offering them greater freedom to explore news information. on the other hand, it is necessary for the information to be reasonably arranged under the framework of gatekeeping theory in vr news reporting. interaction design can balance the requirements of these two factors. through reasonably designed interaction technologies and guiding the user's attention in a reasonable way, the system can support free exploration under a certain degree of constraint (e.g., fig. ). while immersive vr technologies are advancing in the field of journalism, there is still insufficient clarity on the effects these technologies have for the news consumer. this study focused on the user perspective, which we hope can advance both academia and the industry. this study's contribution is fourfold. first, we propose a more practical design process for immersive vr news products that combines the process of news products from the perspective of news professionalism with the development of virtual reality applications from the perspective of iterative software development. second, we investigated the production of immersive vr news under different conditions (vr-i and vr + i). third, we provide a deeper understanding of media effects and user experience in immersive vr news, and fourth, we provide empirical evidence on the benefits of practices involving interactivity in immersive vr news. our results show that interactivity can significantly guide the users' attention on key information that a news reporter wants to convey, which has a significant positive impact on the media effects of vr news. meanwhile, interactivity plays a gatekeeper role, which is important to address issues such as information overload, parallel expression, and information interference that current mainstream vr-i faces. in addition, interactivity can enable the user to change from a passive bystander who watches news from an omniscient perspective to a protagonist who can experience the feelings of the parties involved in the news story. from the perspective of application, vr + i is similar to news games and is a valuable expansion of and supplement to traditional news. however, different from news games, vr + i cannot replace news and retains the basic connotations of news, so it must comply with the news reporting principles of truthfulness and fairness. our future work can be extended in various directions. for example, the proposed method was currently validated based on a single news case. in future, the application scenarios of immersive vr news can be expanded to further generalize the conclusions of this study. additionally, a larger-scale test regarding the effects of vr news should be conducted with more participants. network journalism": converging competencies of old and new media professionals refining the "gatekeeper" concept: a un radio case study the psychology of benevolence and its implications for philosophy gatewatching: collaborative online news production how peers mediate media influence on adolescents' sexual attitudes and sexual behavior exploring online news credibility: the relative influence of traditional and technological factors coordinated management of meaning: the consequentiality of communication and the recapturing of experience. in: sigman sj (ed) the consequentially of communication video journalism: experimental study on the effect of immersion on news experience and distant suffering gatekeeping: mass media systems and information control going beyond the classic news narrative convention: the background to and challenges of immersion in journalism influence of story structure on perceived story bias and new organization credibility global charter of ethics for journalists. the th ifj world congress in tunis. retrieved october st immersive journalism in vr: four theoretical domains for researching a narrative design framework fiji: a framework for the immersion-journalism intersection reformed gatekeeping measuring and defining the experience of immersion in games disrupting the narrative: immersive journalism in virtual reality the psychological appeal of personalized content in web portals: does customization affect attitudes and behavior understanding user resistance to participation in multihop communications immersive journalism and telepresence the toronto empathy questionnaire: reliability and validity in a nationwide sample of greek teachers. social sciences. mdpi the elements of journalism: what newspeople should know and the public should expect. penguin random house the impact of television advertising: learning without involvement can immersive journalism enhance empathy? digital journalism ethics guidelines for immersive journalism the effects of gratifications on intention to read citizen journalism news: the mediating effect of attitude importance placed on physical attractiveness and advertisement-inspired social comparison behavior among japanese female and male teenagers virtual reality, °video, and journalism studies: conceptual approaches to immersive technologies triple whammy! violent games and violent controllers defining and measuring credibility of newspapers: developing an index cognition and reality: principles and implications of cognitive psychology. san francisco . nielsen sl, sheets p ( ) virtual hype meets reality: users' perception of immersive journalism adoption and use of computer-based voice over internet protocol phone service: toward an integrated model making online news: the ethnography of new media production immersive journalism: immersive virtual reality for the first-person experience of news theory and research in mass communication: contexts and consequences virtual reality journalism. columbia journalism school the roots of a sociology of news: remembering mr. gates and social control in the newsroom media credibility: taking the measure of a measure empathy and embodied experience in virtual environment: to what extent can virtual reality simulate empathy and embodied experience? how does immersion work in augmented reality games? a user-centric view of immersion and engagement exploring immersive experience in journalism gatekeeping theory journalism in virtual reality: opportunities and future research challenges taking steps: the influence of a walking technique on presence in virtual reality was i there? impact of platform and headphones on video immersion development and validation of brief measures of positive and negative affect: the panas scales the "gate keeper": a case study in the selection of news the principles of ethical journalism an appraisal theory of empathy and other vicarious emotional experiences publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations he is currently an associate professor at sun yat-sen university her research interests include human-computer interaction, virtual reality, and usability engineering her research interests include human-computer interaction, virtual reality, and usability engineering multimedia tools and applications her research interests include human-computer interaction, virtual reality, and usability engineering he is currently the dean of the school of communication and design acknowledgments the authors would like to thank the anonymous reviewers for their insightful comments. conflict of interest the authors declare that they have no conflict of interest. key: cord- -aobdzwpx authors: pianta, l.; vinciguerra, a.; bertazzoni, g.; morello, r.; mangiatordi, f.; lund, v. j.; trimarchi, m. title: acetic acid disinfection as a potential adjunctive therapy for non-severe covid- date: - - journal: eur arch otorhinolaryngol doi: . /s - - - sha: doc_id: cord_uid: aobdzwpx purpose: sars-cov- is a new pandemic influenza caused by a coronavirus which main route of transmission is through exhaled droplets that primarily infect the nose and the nasopharynx. the aim of this paper is to evaluate the effect of acetic acid, the active component of vinegar, as a potential disinfectant agent for upper airways. methods: twenty-nine patients were enrolled and divided into two groups: group ( patients) was composed of patients treated with off-label hydroxychloroquine and lopinavir/ritonavir, whereas group ( patients) was composed of patients treated with hydroxychloroquine only, combined with the inhalation of acetic acid disinfectant at a . % concentration. a questionnaire-based evaluation of symptoms was performed after days in both groups. results: it appears that the number of patients treated with acetic acid (group ) that experienced improvement in individual symptoms was double that of the other group of patients (group ), although numbers are too small for robust statistical analysis. conclusions: considering its potential benefits and high availability, acetic acid disinfection appears to be a promising adjunctive therapy in cases of non-severe covid- and deserves further investigation. the main route of transmission of the new coronavirus called covid- (sars-cov- ) is through mucosal contact with infected exhaled droplets [ ] . considering the higher viral load detected in the nose, compared with the lower respiratory tract [ ] , this may be one of the first anatomical structures exposed to viral contagion as evidenced by the fact that acute anosmia is a relatively common presenting symptom [ , ] . with the rapid spread of covid- , global health-care systems have faced the challenge of treating an overwhelming number of patients for which there is no widespread immunity. as a result, many off-label therapies have been tried but so far with uncertain results. in addition, the mild symptoms in the majority of cases and the saturation of hospital beds may compel doctors to treat the majority of infected people at home. in this situation, experimental treatments are not readily available to those at home or be available in low-resource setting [ ] . acetic acid, the active component of vinegar, is a commonly available disinfecting agent. inhalation of a waterbased acetic acid solution to treat the symptoms of the common cold is a common folk remedy in italy. indeed, the anti-bacterial and anti-viral activities of acetic acid are documented in the literature [ ] [ ] [ ] [ ] . acetic acid causes inactivation and dis-aggregation of haemagglutinin glycoproteins (found on the surface of influenza viruses) by generating a low ph-dependent conformational change of those glycoproteins and it destroys the viral envelope and inhibits viral transmission [ ] . therefore, considering these antiviral properties and that the upper airways are the main site of sars-cov- entry and replication, we have explored the use of this historical therapy in early-stage cases of covid- by evaluating patients who were administered a disinfecting formulation of acetic acid as an intranasal aerosol. in this prospective study, we included patients attending the emergency department of cremona hospital with positive real-time polymerase chain reaction (rt-pcr) for sars-cov- performed on nasopharyngeal swabs. the study was conducted according to the ethical standards established in the declaration of helsinki (revised in ) and was approved by the local ethics committee (comitato etico val padana, protocol no. - -oss_altro-cr ). records of patients positive for covid- infection with mild symptoms who were discharged home after accessing the emergency room over march were evaluated and included in the study. exclusion criteria were asthma (due to the possible bronchoconstriction from the acetic fumes) and intolerance to sulphites. patients treated with off-label hydroxychloroquine and lopinavir/ritonavir, the standard treatment prescribed at that time, were included in group , whereas group was composed of patients treated with hydroxychloroquine only, combined with acetic acid nasal disinfectant at a . % concentration. while group was created prospectively, group was composed of patients that were recorded in the same period but retrospectively included in the study. the solution was prepared by patients at home, using . dessert spoons (approximately ml in total) of vinegar (with a % concentration of acetic acid) in ml of boiling water. patients were instructed to exclusively inhale the fumes of the solution through the nose using a commercially available device (fig. ) for min twice a day. inhalations could also be performed using a bowl with a towel over the head, with the only precaution of covering eyes to avoid possible local irritation. patients' symptoms at presentation, clinical course, symptoms after days and the presence of sars-cov- on nasopharyngeal swabs taken after days were recorded. symptoms were evaluated through a questionnaire based on general questions on comorbidities, general and ent symptoms associated with covid- infection. the questionnaire only offered a binary answer (yes/no) to the following questions: do you have/experienced any improvement/ resolution of cough? fever? shortness of breath? vomiting/ diarrhoea? fatigue during the day? headache? nasal sneezing? blockage/congestion of the nose? loss of smell/taste? twenty-nine patients were enrolled. there were patients in group (standard treatment) ( females and males, aged - years), and patients in group (acetic acid treatment) ( males and females, aged - years). treatment compliance was % in both groups; no adverse events related to acetic acid inhalation were reported. in group , all patients presented cough and fever, whereas in group , seven patients reported mild cold symptoms and eight patients cough and fever. all patients were followed for days. in group , one patient was hospitalized because of increasing severity of respiratory symptoms, while patients reported improvement of symptoms after days. seven patients out of had a negative rt-pcr for covid- at days. in group , after days, all patients reported symptom improvement, / patients tested negative for sars-cov- , whereas / patients were still positive. twice the number of patients experienced improvement in individual symptoms in group than group though numbers are too small for statistical analysis. (table ) . in all cases, the acetic acid inhalation was well tolerated as evidenced by compliance, although this was self-reported. the results of the study suggest a possible effect of acetic acid on the upper respiratory airway, which may lead to a faster clinical resolution of covid- . our study is one of the first attempts to identify a topical therapy that could influence the natural history of covid- . the efficacy of acetic acid could be attributed to the exposure of respiratory mucosa, a known hotspot of viral replication, to a highly effective disinfectant. acetic acid disinfection could not only improve the clinical course of covid- , but also reduce viral load in the airway and in the droplets exhaled by infected individuals. thus, a possible beneficial effect of this topical treatment in reducing the spread of the disease can also be hypothesized. the decision to avoid anti-viral therapies in group was based on the increasing concern about the real benefits of that treatment and in the updated italian guidelines (march ) [ ] , ritonavir/lopinavir is now not considered to be effective. therefore, taking into account the ineffectiveness of ritonavir/lopinavir, the pharmacological treatment regimens of the two groups can be considered equivalent. this study have (has) some limitations: first, it would have been important to have a visual analogue scale to evaluate symptoms referred by the patients; second, some factors like age and gender differences between studied group could be considered a bias in the outcome of the study; third, due to the emergent situation, no anosmia testing was performed in the emergency department so that it is only based on self-reported symptom. in conclusion, considering its potential benefits, high availability and absence of reported side effects, acetic acid disinfection appears to be a promising, cheap, easily administered and well-tolerated adjunctive therapy in cases of nonsevere covid- . this is a small study performed at the height of the covid crisis in a rapidly changing clinical environment. additional studies on larger samples with a control inhalation arm are needed to provide high-quality evidence to further support the employment of this ancient remedy. author contributions lp and mt made substantial contribution to the concept and design of the work; gb and rm contributed to the data acquisition and its analysis; av took his part in the interpretation of data and in drafting the article; vjl participated in revising the article critically and gave the final approval of the version to be submitted. funding this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. cough fever dyspnoea vomit/diarrhoea fatigue during the day headache blockage/congestion of the nose anosmia dysgeusia the transmission and diagnosis of novel coronavirus infection disease (covid- ): a chinese perspective sars-cov- viral load in upper respiratory specimens of infected patients sudden and complete olfactory loss function as a possible symptom of covid- presentation of new onset anosmia during the covid- pandemic effectiveness of common household cleaning agents in reducing the viability of human influenza a/h n inactivation of avian influenza virus using four common chemicals and one detergent moiemen n ( ) the antibacterial activity and stability of acetic acid the antibacterial activity of acetic acid against biofilm-producing pathogens of relevance to burns patients stability and inactivation of sars coronavirus ) vademecum per la cure delle persone con malattia da covid- conflict of interest none of the authors has any conflict of interest.ethical approval approval was obtained from the ethics committee of val padana (no. - -oss_altro-cr ). the procedures used in this study adhere to the tenets of the declaration of helsinki.informed consent informed consent was obtained from each patient for treatment and use of de-identified clinical data for study purposes. key: cord- -gl xzzdv authors: bhavani, sivasubramanium v.; huang, elbert s.; verhoef, philip a.; churpek, matthew m. title: novel temperature trajectory subphenotypes in covid- date: - - journal: chest doi: . /j.chest. . . sha: doc_id: cord_uid: gl xzzdv nan the novel severe acute respiratory syndrome coronavirus (sars-cov- ) and the resulting illness, coronavirus disease (covid- ), has affected over million people globally, with over , deaths. the highest number of cases and fatalities have occurred in the united states, with over , deaths as of the end of june . in contrast to other common viral infections, covid- presents unique challenges with high rates of hypoxemic respiratory failure, hyperinflammatory cytokine storm, coagulation abnormalities, and cardiac and renal dysfunction , . identification of covid- subphenotypes could lead to better understanding of the diverse host responses resulting in these heterogeneous presentations. fever is a common presenting symptom in covid- , and the thermoregulatory response to infection operates at the intersection of the immunological, neurological, cardiovascular, and other body systems , . thus, longitudinal temperature trajectories could provide unique insights into the multi-organ dysfunction seen with covid- . we have previously published a novel method of identifying subphenotypes in hospitalized patients with all-cause infection using longitudinal body temperature measurements . these temperature trajectory subphenotypes had distinct demographics, physiological and immune markers, and outcomes. we hypothesize that using a similar approach specific to covid- patients would identify subphenotypes with unique clinical characteristics and inflammatory and coagulation abnormalities. importantly we hypothesize that these temperature trajectory subphenotypes will have distinct outcomes, with the primary outcome of interest being -day inpatient mortality. we included all adult patients admitted to university of chicago medicine between march st and june th , who tested positive for sars-cov- . we excluded patients tested for sars-cov- more than three days after admission to exclude potential hospital-acquired cases. we also excluded patients who were discharged or died within hours of hospitalization, since these patients may not have adequate temperature data to be classified by the algorithm. we included temperature measurements taken in the first hours of hospitalization in the algorithm. the temperature data from hour to hour were split into onehour blocks of time. for patients with multiple temperature measurements in a one-hour block, the earliest measurement was used. we applied group based trajectory modeling (gbtm) to identify the temperature trajectory subphenotypes. gbtm is a finite mixture model used to identify clusters of patients following similar trajectories of a variable of interest (i.e., temperature) . we selected the four-group quadratic model based on our prior work . the gbtm algorithm computes a unique quadratic equation of temperature as a function of time for each of the four subphenotypes. patients are classified into the temperature trajectory subphenotype whose quadratic function most closely matches their temperature measurements. once patients were classified into subphenotypes, the differences in clinical characteristics between the subphenotypes were compared using analysis of rank (anova) or chi-squared tests, as appropriate. the primary outcome was -day inpatient mortality, which was modeled on subphenotype using cox regression analysis, controlling for demographics, comorbidities, and severity of illness. patients who were discharged from the hospital before days were assumed to be alive at days for the regression analysis. gbtm was performed using the traj package in stata. our final cohort consisted of hospitalized patients positive for sars-cov- . the median age was years (iqr - years), with % males, and a predominantly african american patient population ( %). the intensive care unit (icu) admission rate was %, and the -day inpatient mortality rate was . %. four subphenotypes were identified: group (n= , %) had normal presenting temperatures that increased over the subsequent hours; group (n= , %) had higher presenting temperatures but decreased over time; group (n= , %) had normal body temperatures throughout without significant changes; group (n= , %) had low body temperatures (figure ) . age was significantly different between the subphenotypes: group was the youngest, while group was the oldest ( vs years, p= . ). group had the highest prevalence of congestive heart failure (chf) ( %, p= . ) and chronic pulmonary disease ( %, p= . ). body mass index (bmi) was highest in group and lowest in group ( vs , p< . ). there were significant differences in laboratory results, with group having the highest d-dimer, troponin, lactic acid, creatinine, and total bilirubin ( table ) . although tylenol use was significantly different between the subphenotypes, the pattern of tylenol administration over time did not suggest antipyretic medications playing a role in the divergent temperature patterns of group and group . specifically, group consistently got more tylenol over time compared to group , suggesting that the increase in temperature over time was not due solely to inadequate antipyretic therapy. group had the highest -day inpatient mortality rate at . %, while group had the lowest mortality rate at . %. on cox regression controlling for demographics, comorbidities, and sequential organ failure assessment (sofa) score, patients' subphenotype was significantly associated with mortality (p< . ). group had almost five times higher hazard ratio of mortality than patients in group (hr . , % ci . - . ; p= . ). group and had higher hazard ratio of mortality compared to group but did not reach statistical significance (group -hr . ; p= . ; group -hr . ; p= . ). we report the use of longitudinal temperature measurements to identify novel subphenotypes in covid- illness. group were the youngest subphenotype with the highest bmi, while group were the oldest with high prevalence of pulmonary disease and chf. group had the highest mortality rate, while group had the most significant lab abnormalities with elevated creatinine, total bilirubin and lactic acid. the high mortality rate seen in group and the organ dysfunction seen in group suggest that both subphenotypes have a dysregulated response to covid- . conversely, group had the lowest mortality rate, suggesting a potentially favorable host response to infection. given the heterogeneity of covid- , and the diversity of potential therapeutics, identification of clinically relevant subphenotypes is necessary for a precision approach to treatment . for instance, it is unclear which patients benefit from therapies that block elements of the cytokine storm response , . fever is a hallmark of cytokine storm, and thus group with rising body temperatures and elevated crp levels may benefit from this type of therapy. similarly, prolonged time to normalization of body temperature correlates with sars- -cov shedding . therefore, group may have prolonged viral shedding and could require extended antiviral therapy. group were the oldest patients and had % prevalence of chf; given the age, high-risk comorbidity, and elevated d-dimer levels, group may be at higher risk for venous thromboembolism and may benefit from aggressive screening or treatment, hypotheses that should be tested in future work. the limitations of the study include that it is retrospective and single center. further research is needed using multicenter data to investigate the prognostic and phenotypic potential of temperature trajectory subphenotypes in covid- . in conclusion, we found four distinct subphenotypes of covid- patients with markedly different clinical characteristics and mortality rates. our results suggest that patients in these subphenotypes may have differing risks for developing cytokine storm, coagulopathy, cardiac and renal injury, and may require targeted management. group (n= , %) had low body temperatures. group had almost five times higher hazard ratio of death compared to group , when controlling for demographics, comorbidities, and severity of illness. novel coronavirus (covid- ) situation respiratory pathophysiology of mechanically ventilated patients with covid- : a cohort study presenting characteristics, comorbidities, and outcomes among patients hospitalized with covid- in the prediction models for diagnosis and prognosis of covid- infection: systematic review and critical appraisal central circuitries for body temperature regulation and fever. american journal of physiology regulatory, integrative and comparative physiology identifying novel sepsis subphenotypes using temperature trajectories group-based trajectory modeling in clinical research pharmacologic treatments for coronavirus disease (covid- ): a review covid- : immunopathology and its implications for therapy abbreviation list: . severe acute respiratory syndrome coronavirus (sars-cov- ) . coronavirus disease (covid- ) . group based trajectory modeling (gbtm) . analysis of rank (anova) body mass index (bmi) c-reactive protein (crp) . sequential organ failure assessment (sofa) score key: cord- - vkzci authors: li, hao; shi, yongmin title: study on the performance degradation of sandstone under acidification date: - - journal: acs omega doi: . /acsomega. c sha: doc_id: cord_uid: vkzci [image: see text] in most oilfields, acid fracturing is widely used for oil production. understanding the relationship between the individual factors (i.e., carbonate rock types, acid rock reaction kinetics, and deterioration of rock mechanical properties) can provide practical guidelines that can be used for the design and optimization of acid fracturing operation. this paper takes hydrochloric acid, acetic acid, and citric acid as the main research objects and carries out acidification experiments on sandstone in changqing oilfield, china. in addition, the effects of tribasic, dibasic, and monobasic acids on the mechanical properties of sandstone were studied. results show that in this study area, the most obvious effect was seen with the use of dibasic acids (hydrochloric acid + acetic acid), which effectively reduced the sample quality, uniaxial compressive strength, and elastic modulus. citric acid and mg promote the conversion of amorphous calcium carbonate to high-crystallinity calcite, forming a white precipitate. furthermore, it is found by scanning electron microscopy analysis that experimental group (hydrochloric acid + acetic acid) has the most ideal rock erosion effect. inductively coupled plasma emission spectrometry analysis shows that the acid rock is present in the solution. x-ray diffraction qualitative analysis of the composition and concentration of ions shows that the formation of white precipitates is citric acid and mg promotes the conversion of amorphous calcium carbonate to high-crystallinity calcite, forming a white precipitate. the findings of this study can help to better understand the erosion, failure state, and failure mechanism of different acid types on sandstone, which may provide certain references and guidelines for sandstone acid fracturing oil production. the focus of the development of low-permeability reservoirs is mainly to maximize the output of a single well while reducing development costs and improving the development benefits of using low-permeability reservoirs. acid fracturing is currently widely used in oilfield mining to significantly improve recovery. while acidification can be used in both carbonate reservoirs and sandstone reservoirs, the rock mineral structure and mineral chemical composition of sandstone reservoirs are more complicated than carbonate rocks. in and , labrind and lund et al. proposed that the dissolution rate of dolomite at °c will be limited by the surface reaction; − however, under the condition of °c, the dissolution rate of dolomite will reach the limit regardless of whether the experiment uses high speed or low speed. fogler et al. found that the dissolution of terranic acid and feldspar is caused by hcl, which has a catalytic effect on hydrogen fluoride (hf) and can improve the dissolution of minerals. fogler and hekim found that minerals in sandstone have different degrees of solubility in an acidic soil system. in addition, because hf has the dual nature of ionization and association, other forms such as h + , f − , hf, and hf − can be found in solution. thus, fogler et al. proposed that the first step in the melting of hf and siliceous minerals is f − chemistry adsorbed on the siliceous surface. , zhao et al. proposed the exact opposite of the study of fogler et al. this study reported that when hf reacts with siliceous minerals, it is not the fluoride ion that plays the leading role but the hf molecule. hartman et al. studied the reaction of various minerals with hcl system and hcl/hf system acid solutions. by detecting the concentration of aluminum, iron, magnesium, sodium, and other metal ions in solution after the reaction of various minerals with an acid solution, the corresponding results were obtained. the dissolution kinetic parameters of minerals and the experimental study of kaolinite were conducted under the same conditions. after comparing the experimental results, the obtained parameters are applied to the sandstone acidification simulation using the geochemical model. zhao et al. designed a variety of acid solutions to dissolve single minerals and found that % hcl + . % hf system acid solution has a higher corrosion rate of chlorite at °c, . %: polyhydrogen acid. the corrosion rates of the system to kaolinite, montmorillonite, and chlorite are relatively high, respectively, . , . , and . %. among them, the corrosion rate of montmorillonite increases obviously with the increase in polyhydrogen acid concentration, with an average that is greater than %. , li et al. concluded that high temperature, high pressure, and a strong acidic environment will accelerate sandstone destruction. the research period of this study ranged from h to days. due to the influence of the corona virus disease (covid- ), the research period was extended to days, and it was unexpectedly concluded that the citric acid action promoted the precipitation of regular carbonate in the sandstone, resulting in calcium crystals, and an experimental analysis of the reasons for precipitation. simple hydraulic fracturing has limited damage to the rock, resulting in a relatively single fracture initiation and a fixed direction. the use of acid for fracturing will destroy the internal structure of the rock through chemical reactions, thereby creating more cracks, and the cracks are complex and not fixed in direction so that more oil can be extracted ( figure ). for rock samples in different blocks, different acid types are needed. in this study, seven experimental groups and a control group were set up to analyze the chemical reaction between acid and rock. finally, it is concluded that the mixed use of hydrochloric acid and acetic acid is most suitable for this block. when compared to the previous work, this work, at first, studied the influence of monobasic acid, dibasic acid, and tribasic acid on the acidification of sandstone and concluded that dibasic acid (hydrochloric acid + acetic acid) has provided the best effect. further, icp-oes analysis of the ion composition and concentration in the solution after the reaction solidly revealed the trend of the acid rock reaction. however, this analysis method is not generally used. finally, it was found that the coexistence of citric acid and magnesium will promote the formation of amorphous calcium carbonate (acc). further, it is transformed into calcite with high crystallinity and forms a white precipitate, which is irreversible due to underground environmental pollution factors. thus, this method is not proposed for the acidification in oilfields. first, the sandstone used in this study is taken from a depth of m in china changqing oilfield, yuan block. the acid solution used in the experiment consists of hydrochloric acid, acetic acid, and citric acid. further, seven experimental groups and one control group are set (see table ). corrosion of a core with a diameter of mm and a length of mm at room temperature for days. change in the mass of sandstone samples subjected to acid treatment. the calculation equation based on the mass loss rate was used and is as follows where m is the mass loss rate, m is the mass before acid etching, and m is the mass after acid etching. the calculated mass loss for all samples is shown in figure a . acid etching can be clearly seen from the appearance of the cores before and after etching. there is no obvious change in groups − , , and , but the cores in groups and have been obviously damaged and white substances have been precipitated. from the appearance analysis, the greatest degree of damage to the core can be seen in the treatment of acetic acid + citric acid and in the presence of citric acid alone. as shown in figure b , the two groups with the most mass loss were and followed by , , , and . group resulted in a reddish brown color. this is because h + in the acid liquid reacted with illite and chlorite to form fe + , which further reacted with oxygen to form fe + , and finally reacted with acetic acid to form a colloid with fe + , resulting in a reddish brown color. the acid etching reaction was fully confirmed by the absence of a precipitate in the presence of strong acid, and only ca + will be consumed quickly. in the presence of citric acid, calcium carbonate crystals (aragonite) will be precipitated, causing the core to burst. analysis of mechanical properties, specific surface area, and porosity. the uniaxial compressive strength of the samples after acid etching was tested, and the stress−strain curves of sandstone samples exhibited three typical stages: compaction, elastic, and yielding ( figure a ). the strength and stiffness of the samples after acid etching are significantly smaller than those of the untreated samples. it can be found that the stress−strain curves of the samples decreased after different acid etching. compared with the untreated samples, the compaction phase becomes longer, the elastic phase becomes shorter, and the strain value at the peak load point is also not the same. sample was damaged by complete acid etching, and thus, the uniaxial compressive strength was not measured. in addition, the bottom of sample had been damaged by acid etching and the compressive strength was low. the results indicate that group (hydrochloric acid + acetic acid) showed the most obvious decrease in mechanical properties. as shown in figure b , the bet test results show that group has the highest specific surface area and porosity after (hydrochloric acid + acetic acid) treatment, which proves that the acid etching effect is the most pronounced. the second most pronounced effect was found in group , which proves that the erosion effect of acetic acid alone on the core is also ideal. groups and , which contained citric acid, show no obvious changes in the specific surface area and porosity. the results indicate that in acidic solutions, protons promote the displacement reaction of intergranular cations, thereby inducing the formation of larger pores in the mineral and loosening the structure. overall, the main process of water− rock chemical interactions is the gradual dissolution of clay minerals, which increases the porosity of the rock mass. it can be seen from figure that the physical adsorption and desorption curves of group are the most obvious, indicating that the porosity is the largest. sem analysis. an obvious imon mixed layer can be seen for the control group from the sem results ( figure a ). as shown in figure b , the surface is covered with more citric acid, which hinders the acid rock reaction to proceed further. calcium carbonate whiskers that have been generated can be clearly seen in figure e , and after figure h was analyzed, it the experiments of rodriguez-blanco et al. showed that ph and mg have an important influence on the pathway and mechanism of the conversion of amorphous calcium carbonate (acc) to crystalline caco . the neutral initial ph or the presence of mg in the solution will prompt the system to develop in the direction of acc directly crystallizing into calcite. , conversely, a higher initial ph value promotes the formation of metastable intermediate spherulites, which drives the system toward calcite through the second dissolution− recrystallization step. mg can improve the stability of acc and inhibit the crystallization of ball stone, which is beneficial to the direct conversion of acc to calcite. , analysis of icp-oes. the icp-oes elemental composition and content of the acid solution after the core erosion were measured. as shown in figure a , the newly added group was the white material precipitated from core samples and . concentrations of mg, al, fe, and k all show that group has the least content, the order is > > and > > , and the si element content is basically the same. the related reaction of feldspar mineral and acidic solution is as follows: calcite easily reacts with the acidic solutions as follows: the si element content was measured in all samples and showed that quartz exhibits a slight hydrolysis effect: a small amount of biotite and muscovite may react with acidic solution as follows: elemental analysis showed that feldspar, mica, and calcite in the sandstone reacted with h + in acidic solution, indicating that the sandstone mineral composition used in this article reacted with h + in acidic solution in chlorite than the chemical reaction in quartz and acidic solution more obvious. as shown in figure b , the ca + content of group is relatively low because the citric acid is limitedly attached to the rock surface, preventing further the reaction of h + . group shows a relatively high ion content, indicating that hydrochloric acid and acetic acid both react with minerals in the sandstone, although the cores used in groups and are the most damaged due to the formation of precipitated substances by weak acids. cracks and pipeline blockages are caused by the construction of a site, and thus, it is not recommended to use them separately in construction. the results show that the sandstone damage is causally related to the acidity of the infiltrating fluid, and similar results have been obtained under various acidic conditions. , solution acidification promotes chemical corrosion in water−rock interactions. in terms of sandstone composition, it contains a high proportion of clay minerals (montmorillonite, illite, chlorite, etc.), which expand and contract with hydration and water loss and are easy to develop in combination with structural and weathered cracks. in addition, the three dominant clay minerals in the sandstone are silicate minerals; the acidification of sandstone in this block is suitable for the joint use of hydrochloric acid and acetic acid. xrd analysis. xrd analysis resulted in groups − all showing a significant decrease in the peak intensity corresponding to the chlorite, which proved that the acid had effectively eroded the core (figure ) . group had the smallest decrease in sensitive minerals. it has also been verified that in the monobasic acid, group has the least remaining sensitive minerals, but at the same time, it also generates new white precipitated materials. the dibasic acid performs best in group followed by groups and . the same xrd analysis was performed on white precipitated materials (group in figure ) , and a more obvious aragonite crystal peak appeared at °, proving that the precipitated crystal was a calcium carbonate crystal. in this study, a series of uniaxial compression, bet, sem-eds, icp-oes, and xrd tests were performed on tight sandstone samples corroded by different types of acids. destruction characteristics including mass, porosity, specific surface area, uniaxial compressive strength, ionic components in acid solution, and acid rock reaction failure mechanisms were investigated. the microstructure and damage mechanism of sandstone after multiacid erosion were systematically studied. the damage to morphology and the mechanism depend on the type of acid and the rock mineral composition. according to the experimental results, the following three major conclusions can be drawn. ( ) the sandstone samples treated with different acid solutions showed a decrease in quality and mechanical properties. the hydrochloric acid and acetic acid test group having the highest porosity, specific surface area, and mechanical properties was significantly weaker than the untreated samples. ( ) as the strength of the acid solution changes from strong to weak, the leaching amount of alkaline cations in the sandstone increases. this is mainly because h + not only acts as a reactant but also provides energy for physical and chemical weathering. compared with monovalent cations, the leaching of divalent cations (ca + and mg + ) in sandstones is largely limited by the environmental ph. the calcium and magnesium contents in group are . and . times those of the control group, respectively, and the aluminum and iron contents are . and . times those of the control group, respectively. however, the k + in the sandstone does not change much, mainly because the potassium feldspar is difficult to be acidified and destroyed. − ( ) sem-eds results show that citric acid promotes the precipitation of regular aragonite crystals of calcium carbonate with a length of − micrometers. it is recommended not to add citric acid in acid pressure treatment. it is recommended to use hydrochloric acid and acetic acid in the acid pressure of this test block. the main advantage of this study is that the most commonly used acid is compounded and optimized, and the acid solution suitable for the acid fracturing system used in the yuan block of changqing oilfield is obtained. further, it is aimed at the ion exchange of different acid solutions and rock reactions. performed icp-oes, xrd, and sem-eds characterization and analyses revealed that the best option is the mixture of hydrochloric acid and acetic acid. moreover, the presence of citric acid will promote the formation of white precipitates, pollute the underground environment extensively, and block the crude oil pipelines. the limitations of this study are as follows: ( ) the obtained sandstone samples did not reflect the entire area as they are not taken from all the areas due to the difficulty of coring in the entire changqing oilfield. ( ) the developed (indoor) experimental pressure does not correspond (not able to attain) fully to the underground confining pressure. thus, the number of samples is increased and tests are carried out under high temperature and high pressure. the test is repeated. the acid rock reaction mainly produces precipitation materials such as iron precipitation, calcium precipitation, and na salt and k salt precipitation. when the reservoir contains minerals such as chlorite, the acid will chemically react with the minerals to form a precipitate. for example, in experimental group , calcareous precipitation is formed mainly from carbonate minerals such as dolomite and calcite, but it will be dissolved with the further addition of strong acid (hydrochloric acid), and because of this, precipitation will not affect the entire acid fracturing process. the white precipitates obtained in experimental groups and are amorphous calcium carbonate (acc) precipitates, which will seriously threaten the underground environment and block the wellbore. therefore, citric acid should not be used for acid fracturing during field application. when hydrochloric acid, acetic acid, and citric acid are compared, citric acid has the strongest calcium ion chelating ability. the reaction temperature in this study is room temperature, which is highly favorable for the chelation of calcium ions. it is found that the white precipitates generated in experimental groups and will cause great damage to the formation after acid pressure and will severely affect the future work. therefore, citric acid should not be used in field applications. acetic acid also has the same complexation effect on iron ions, so experimental group (hydrochloric acid + acetic acid) has the best effect without precipitation and will not cause any damage to the optimal group. ■ materials and methods materials used. rock samples. the core samples were taken from the yuan block of changqing oilfield, china. the lithology is mainly fine-fine feldspar sandstone. the detrital components are mainly feldspar (average, . %) and quartz (average, . %). the cement type was made mainly of clays, carbonates, and siliceous sensitive minerals: clay minerals are mainly illite (average . %) and chlorite ( . %); carbonates are mainly iron calcite (average . %) and iron dolomite ( . %); and siliceous materials are mainly quartz ( . %), occasionally pyrite ( . %) and ridge iron ore ( . %). the samples were prepared in a cylinder with a diameter of mm and a height of mm for convenient use in the experiment. the main parameters are shown in table . acidizing fluids. in this paper, the impact of polyacids on the performance of sandstone was studied. triacids (hydrochloric acid, acetic acid, and citric acid correspond to experimental group ), dibasic acids (hydrochloric acid + acetic acid, hydrochloric acid + citric acid, and acetic acid + citric acid correspond to groups − , respectively), and monobasic acids (hydrochloric acid, acetic acid, and citric acid correspond to the experimental groups − , respectively) and the control group for a total of eight experimental groups. the specific acid ratio and concentration are shown in table . table lists the main mineral content of the samples used in the main experiments. testing equipment and test procedures. acid erosion. the seven cores were dried in an oven at °c for h, and the mass was weighed and recorded. the samples were then added them to wide-mouth jars with the corresponding acid concentration, capped with stoppers, and placed in a dark place at room temperature. in the liquid erosion experiment, because of the corona virus disease (covid- ), the research period was extended to days. after days, the core was taken out and placed in an oven to dry at °c for h. the weight was weighed again and recorded. mechanical property tests. the mechanical properties of the carbonate rocks were measured by using the rtr- rock mechanics servo testing system manufactured by gcts company. uniaxial compression tests were run at room temperature, and the deterioration degree of the mechanical properties of carbonate rocks was determined under acidified conditions. to analyze the degradation mechanism of sandstone mechanical properties under acidizing conditions, scanning electron microscopy (sem-eds) images were used to identify the composition and type of sandstone microcrack fillers and cement. a surface scan analysis was conducted, as well as the composition of precipitated materials. after the core erosion was diluted with water, the acid solution had a solvent ratio of : , and the elemental composition and content determined by inductively coupled plasma emission spectrometry (icp-oes) were used to further analyze the impact of different acids on the composition of sandstone. a bet analysis of the change in the specific surface area and porosity after acid etching was conducted, and finally, an x-ray diffraction (xrd) analysis of the crystalline form of the core after acid etching was conducted to further corroborate the degradation mechanism. thermodynamic and kinetic aspects of argillaceous sandstone acidizing acidization-i. the dissolution of dolomite in hydrochloric acid acidization-ii. the dissolution of calcite in hydrochloric acid acidization the kinetics of the dissolution of sodium and potassium feldspar in hf/hcl acid mixture on the movement of multiple reaction zones in porous media dissolution kinetics: the nature of the particle attack of layered silicates in hf acid-sensitive aluminosilicates: dissolution kinetics and fluid selection for matrix-stimulation treatments research and performance evaluation on an ha integrated acid system for sandstone acidizing effect of acid-temperature-pressure on the damage characteristics of sandstone citrate effects on amorphous calcium carbonate (acc) structure, stability, and crystallization a non-classical view on calcium oxalate precipitation and the role of citrate the role of ph and mg on the stability and crystallization of amorphous calcium carbonate the kinetics and mechanisms of amorphous calcium carbonate (acc) crystallization to calcite, via vaterite the effect of additives on amorphous calcium carbonate (acc): janus behavior in solution and the solid state mechanistic insights into the crystallization of amorphous calcium carbonate (acc) enhancing the permeability of a carbonate rock core by dissolution/ precipitation treatment with organophosphorus additives evaluated by sem/eds and icp-oes physical and mechanical properties of sandstone containing a single fissure after exposure to high temperatures strength and post-peak response of colorado shale at high pressure and temperature mechanical properties of qinling biotite granite after high temperature treatment an experimental study of fractured sandstone permeability after hightemperature treatment under different confining pressures experimental investigation on triaxial mechanicaland permeability behavior of sandstone after exposure to different high temperature treatments temperature and pressure effect on permeability of chinese sandstone: a review both authors contributed equally to this work. the authors declare no competing financial interest. key: cord- - uxq xrs authors: alavi, maryam; moghanibashi-mansourieh, amir; radfar, seyed ramin; alizadeh, sepideh; bahramabadian, fatemeh; esmizade, sara; dore, gregory j.; sedeh, farid barati; deilamizade, abbas title: coordination, cooperation, and creativity within harm reduction networks in iran: covid- prevention and control among people who use drugs date: - - journal: int j drug policy doi: . /j.drugpo. . sha: doc_id: cord_uid: uxq xrs an unprecedented public health crisis confronts the world. iran is among the hardest-hit countries, where effects of the covid- pandemic are stretched across society and felt by the most marginalised people. among people who use drugs, a comprehensive response to the crisis calls for broad collaboration, coordination, and creativity involving multiple government and non-government organisations. this commentary provides early insights into an unfolding experience, demonstrating the operational and policy impact of an initiative, bringing together a diverse array of harm reduction stakeholders to address the pandemic. in the context of lived experiences of social and economic marginalization, this initiative intends to lead efforts in developing an equitable response to the covid- pandemic. in iran, the first two cases of infection with severe acute respiratory syndrome coronavirus (sars-cov- ) were confirmed on february , . by april , iran had the ninth and seventh-highest numbers of infections and deaths in the world, respectively (johns hopkins university, ). among people who use drugs (pwud), numbers of sars-cov- infections and deaths are unknown; however, the scale of the pandemic and vulnerability of pwud underscore the need for relevant and timely action, if the threat is to be controlled among this population. drug use is a significant public health issue in iran. in , an estimated . million people had used drugs in the previous year (nikfarjam et al., ) . since the revolution, iran has gradually shifted from zero-tolerance policies towards drug use to adopting harm reduction initiatives in the late s and drug law reforms in s (alam-mehrjerdi, abdollahi, higgs & dolan, ; ekhtiari et al., ) . by , opioid agonist therapy and needle exchange programs were available in more than clinics and nearly centres, respectively (national aids committee secretariat, ) . the non-government sector has played a significant role in this trajectory, in promoting a sharper focus on harm reduction vs punitive/criminal justice approaches, and in providing access to care among the most marginalised pwud (ghiabi, b) . in recent years, the harm reduction infrastructure has been utilised to scale-up therapeutic interventions among pwud mirzazadeh et al., ) , and is wellpositioned for provision of covid- control measures too, given appropriate public health leadership in policy development and allocation of resources. the government has a limited capacity for leading efforts in identifying and corresponding to the specific needs of pwud during a pandemic (farhoudian et al., ) . years of unilateral economic sanctions imposed by the united states, the rise of socially austere https://doi.org/ . /j.drugpo. . policies within a weakened economy, and ongoing restrictions on humanitarian trade transactions have contributed to significant shifts in priorities and reduced the potential for a comprehensive covid- public health strategy (ameli, ; kokabisaghi, ; murphy, abdi, harirchi, mckee & ahmadnezhad, ; takian, raoofi & kazempour-ardebili, ) . the necessity to act against the pandemic and gaps in covid- public health policy prompted a major non-government organization (ngo) to initiate administrative action and develop the covid- prevention and control working group, bringing together a diverse range of representatives from private and public sectors. this working group aims to enable greater collaboration between government and non-government sectors and develop an equitable covid- response among pwud. since early march, the government has implemented several physical distancing policies; these strategies are primarily in line with recommendations on continuity of care among pwud, including increases in take-home doses of opioid agonist therapy (farhoudian et al., ; united nations office on drugs & crime, b). decisions to close public parks and temporarily release more than , people from prisons, were made to reduce community and in-custody transmission (kinner et al., ) , although without significant oversight. many individuals from the lower socioeconomic background were not linked to adequate financial, harm reduction, and housing support postrelease from prison; and among many people without stable housing, closure of parks limited access to water and sanitation facilities. subsequently, on april , tehran municipality welfare, services & social participation organization published images of pwud and homeless people on twitter (@swsctehran), gathering in large groups in shoosh neighbourhood of south tehran (fig. ) . magnified on various media platforms, these photographs and similar video footage, instigated social panic and presumption of heightened transmission among this transient and marginalised community. these images and broader societal reaction reflected on the need for proactive and robust civil society response, enabling the development of public health policies within the context of underlying social and economic disadvantages of pwud. development of the working group was primarily a spontaneous response to an unprecedented challenge. this initiative was inspired by the principles of asset-based community development (mathie & cunningham, ; mcknight & russell, ) ; rebirth charity society (rebirth charity society, ), a well-known local organization, mobilised the existing networks among harm reduction stakeholders, to create a collective vision for equitable covid- response among pwud, garner broad support, and activate institutional resources. the working group was established using popular messaging applications. these platforms provided an accessible space to discuss critical issues, including covid- policy updates, scientific information and education, and service provision among peer-support workers and people attending community-based drop-in centres, homeless shelters, and mobile and outreach services. the leading group comprise members, including ngo representatives ( peer-support workers and management and coordination staff), three clinicians, three social workers, psychologist, sociologist, academic researcher, journalist, two members of an intergovernmental organization, and a representative from the state welfare organization. all members work in addiction care and pwud health, or associated fields; the majority ( %) have a history of drug use. several methods are used to mobilise members around the common goal. all members, particularly peersupport workers, are encouraged to collect and share stories of community success, including reports, video, and photographs of daily activities across the country. these stories are crucial in positioning and discussing supply shortages and priority actions. given the scarcity of resources, actions that solve existing issues within the community are ideal. disagreement about priority areas and solutions are not uncommon and are mostly resolved through open discussion (text, voice messages, or calls) on the working group messaging application. faceto-face meetings are rare, considering physical distancing guidelines. tasks are assigned to smaller groups, including fundraising, purchases, media releases, development of educational material, and publication of findings, reports, and recommendations. allocation of tasks is mainly volunteer-based. in all steps, from sharing of community stories to implementation of actions, inclusive participation of all members is profoundly meaningful. historically, peer-support workers are directly engaged in service delivery and play a limited role in the process of decision making. to address this issue, members who occupy leadership positions or those with perceived importance (e.g. highly educated individuals) ensure contributions of everyone, particularly peer-support workers, are valued. these efforts are reflected in highlighting community achievements, inviting peer-support workers to express their views and thoughts on specific needs of the community, and encouraging them to share their skills, passions, and social and associational networks with all members. where needed, knowledge, activities, resources, and investments from outside the group are sought. emerging as an immediate response to a health crisis, the working group has not developed a terms of reference for members; however, as the covid- pandemic unfolds in iran, members aspire to focus on experiences and successes of the past and continue to promote change that would improve health outcomes among pwud. direct care services for people who use drugs between march and april , the working group coordinated distribution of covid- prevention equipment and education booklets, personal items, food, and water among people attending community-based drop-in centres, homeless shelters, and eight mobile and outreach services (visiting street-based drug markets) in four provinces. on average, each person received face masks, two litres of hand sanitiser, five litres of surface disinfectant, five education booklets, meals and snacks, and three small bottles of water (excluding people in fars province) ( table ) . the working group collaborated with the united nations office on drugs and crime country office and state drug control headquarters to develop content for three covid- prevention education podcasts and a booklet. podcasts were prepared professionally, presented by a wellknown iranian producer (united nations office on drugs & crime, a). among people attending community-based drop-in centres, shelters, and mobile and outreach services, trained peer-support workers held face-to-face education sessions. they played the podcasts on speakers while displaying prevention measures, including hand washing. these sessions were held recurrently, and booklets were distributed among attending individuals. among people attending community-based drop-in centres, shelters, and mobile and outreach services, peer-support workers have carried out routine checks to identify people with common symptoms of sars-cov- infection, including fever, cough, and shortness of birth. thus far, five people were referred to hospitals, who did not test positive for infection. in addition to services directly to people in need, the working group actioned necessary support for peer-support workers. between march and april , the working group coordinated the distribution of covid- prevention equipment among peer-support workers in four provinces. on average, each person received facial masks, pairs of gloves, and litres of hand sanitiser (table ) . many pwud and homeless people access clean water through shelters and community-based drop-in centres (bastani, marshall, rahimi-movaghar & noroozi, ) . however, among those with limited engagement with these services, interrupted access to water deepens the experience of stigma and social marginalization. the recent closure of public parks, as a physical distancing measure, further stressed the need to resolve this issue. through a successful fundraising campaign, the working group has received water tanks, -liter capacity each, as well as commitment for ongoing free refills. peersupport workers and project coordinators were appointed to locate high-priority areas, organize logistics of transportation and installation of tanks, and educate people on the maintenance of their water source. working group policy advocacy violation of physical distancing by pwud and homeless people in tehran in early april marked the beginning of a campaign by several government organisations, led by factions within the state drug control headquarters, proposing swift capture and hold of these individuals in designated shelters for the duration of the pandemic. working group members noted several limitations within this proposal, including shortcomings in contextual relevance, and issues directly related to covid- , namely lack of separate quarantine facilities for people with and without covid- symptoms on arrival, suboptimal infrastructure for covid- prevention and treatment, and potential interruptions in access to opioid agonist therapy. the working group took several subsequent steps to ) initiate mainstream and social media debates on principles of equity, respect, and diversity in public health strategies; and ) participate in proposal revisions and development of covid- policies that are adjusted to the needs of marginalised people. the working group partnered with the state welfare organization, to develop a joint report of current covid- prevention activities and put forward a set of recommendations on an appropriate response to the pandemic among pwud and homeless people. as public discussion swirled on various media platforms (deilamizade, ; moghanibashi-mansourieh, ; mohammadi, ; nouri, ; radfar, ) , state welfare organization participated in several meetings with other government organisations, including the office of the presidency, to present the joint report and discuss concerns raised by the working group. in late april, the state drug control headquarters withdrew the initial proposal. they published the finalised protocol for the accommodation of pwud and homeless people, endorsing the recommendations of the working group on transportation, housing, medical, and harm reduction needs of these populations. several concerns remain about adequate implementation of this policy over the coming months, supporting the need for continued monitoring of health outcomes among people in government facilities and ongoing collaborations between the working group and government organisations, to inform future policies. in the past several months, many examples of civil society response to the covid- pandemic have been recorded in iran. the experience of the working group is among numerous grassroots initiatives that have enabled communities to organize, manage common problems, and develop a new understanding of government responsibilities and capacities (ghiabi, a) . among working group members, thus far the successful experience of covid- response provided much-needed space to develop an innovative model of cooperation within the harm reduction network and explore new ways of engagement with broader government organisations. grounded in values of equity and inclusion, members were able to share their expertise in identifying specific needs of vulnerable populations and participate in developing immediate and long-term solutions. the experience of collaboration within a nonjudgemental and inclusive environment was new to many members, given the common hierarchical culture of organisations in iran. use of messaging applications was an inexpensive method to increase the accessibility of information for all, enable faster communication about field and policy updates, reduce delays in decision making and implementation, and promote a platform for all members to contribute different types of knowledge and skills. inspired to share this experience with other members of the harm reduction community, working group is developing digital communication platforms to promote peoplecentred education and advocacy material for people in regional and rural areas. currently, the capacity of the working group in gathering member opinions and concerns and facilitating an active interaction with policymakers is built upon decades of working relationships among senior harm reduction stakeholders. key connections with government organisations are pivoted around influential individuals, particularly those within the state welfare organization who have longstanding ties within the community and non-profit sector. ongoing contribution to creating more effective governance systems would require the working group to maintain these connections while investing on developing a balanced organisational structure, involving components for a broader member base and policymakers who join the harm reduction network (albareda, ) . in the unprecedented times of a pandemic, iran finds itself in a difficult position to respond to a significant public health crisis and provide adequate care and support for its large population of vulnerable people. in most middle-income countries, including iran, control of the pandemic requires resolving significant financial and technical challenges (bedford et al., ; hopman, allegranzi & mehtar, ) ; however, the experience of this working group reflects on how greater collaboration among stakeholders and between government and nongovernment sectors could bring individual and population health benefits at the operational and policy levels. in support of equitable public health interventions among marginalised populations, particularly in settings with limited resources, the function of this working group highlights the need for empowerment of civil society, enhanced use of existing community assets, and meaningful collaboration in decision making. this manuscript is a commentary, reflecting on the experience of civil society responding to the covid- pandemic in iran. ethics approval was not necessary. authors have no commercial relationships that might pose a conflict of interest in connection with this manuscript. drug use treatment and harm reduction programs in iran: a unique model of health in the most populated persian gulf country an intervention to improve hcv testing, linkage to care, and treatment among people who use drugs in tehran, iran: the enhance study connecting society and policymakers? conceptualizing and measuring the capacity of civil society organizations to act as transmission belts sanctions and sickness the risk m iran: a qualitative study covid- : towards controlling of a pandemic the evolution of addiction treatment and harm reduction programs in iran: a chaotic response or a synergistic diversity proposed protocol for arrest and hold of people who use drugs contrasts realities on the ground (in farsi) covid- and substance use disorders: recommendations to a comprehensive healthcare response. an international society of addiction medicine (isam) practice and policy interest group position paper basic and clinical neuroscience mutual aid and solidarity in iran during the covid- pandemic. middle east research and information project: critical coverage of the middle east since under the bridge in tehran: addiction, poverty and capital managing covid- in low-and middleincome countries prisons and custodial settings are part of a comprehensive response to covid- assessment of the effects of economic sanctions on iranians' right to health by using human rights impact assessment tool: a systematic review from clients to citizens: asset-based community development as a strategy for community-driven development a one-stop community-based approach for hcv screening, diagnosis and treatment among people who inject drugs in iran: the rostam study the four essential elements of an asset-based community development process. what is distinctive about asset-based community process three key points about government proposal on arrest and hold of people who use drugs (in farsi). tasnim news, article code state welfare organization: there will be a massacre if people who use drugs are arrested and held. police: we are ready to proceed. elaheh mohammadi interviewes farid baratisedeh (in farsi) ministry of health and medical education. islamic republic of iran aids progress report on monitoring of the united nations general assembly special session on hiv national population size estimation of illicit drug users through the network scale-up method in in iran will covid- clear people who use drugs off streets? addiction experts disgaree with government proposal. marzieh nouri interviews abbas deilamizade and seyed ramin radfar (in farsi) dysfunctional government and role of non-government organisations in crisis management (in farsi) unodc iran developed assistance package on covid- for people who use drugs at hotspots in iran unodc suggestions about treatment, care and rehabilitation of people with drug use disorder in the context of the covid- pandemic we would like to acknowledge the united nations office on drugs and crime, country office in the islamic republic of iran, iranian drug control headquarters, as well as several ngo members of the covid- prevention and control working group, for playing a key role in all operational and strategic activities of the working group, including noore sepid hedayat (http://www.nooresepid.com/en/); siamaye sabz rahaye (http://simayesabz.org/?lang=en); payam avaran_e_hamyari (chatra) (https://www.chatrango.com/); toloo bineshanha society (https://toloo.org/); nasim mehr afarin; navid ham razi (https://nhi.org.ir/); khaneh khorshid (http://www. khanehkhorshid.ir/), and society for recovery support (http://srsorg. com/). key: cord- -k c jf authors: lundgren, a.-l.; johannisson, a.; zimmermann, w.; bode, l.; rozell, b.; muluneh, a.; lindberg, r.; ludwig, h. title: neurological disease and encephalitis in cats experimentally infected with borna disease virus date: journal: acta neuropathol doi: . /s sha: doc_id: cord_uid: k c jf barrier-bred cats were inoculated intracerebrally with either the rabbit-adapted borna disease virus (bdv) strain v or a newly isolated feline bdv, obtained from a cat with natural staggering disease (sd). three out of eight inoculated cats developed neurological signs and non-suppurative encephalitis; all three recovered from the acute stage of disease. sero-conversion and the development of neutralizing antibodies occurred in all of the virus-inoculated cats. in addition, cats inoculated with feline bdv showed an early peripheral t cell response not present in cats inoculated with bdv strain v, suggesting that the feline virus exerted a more vigorous effect on the immune system. using immunohistochemistry and a reverse transcriptase-polymerase chain reaction assay, bdv-specific antigen and nucleic acid could be demonstrated in brain samples from each cat with encephalitis, showing that incomplete viral clearance was probably responsible for the maintenance of inflammation. the successful induction of neurological signs and encephalitis in one cat infected with feline bdv, together with the detection of bdv-specific antigen and nucleic acid in the brain, provides strong evidence for the notion that bdv is the etiological agent behind feline sd. borna disease (bd) is a non-suppurative encephalomyelitis caused by a neurotropic enveloped, negative singlestranded rna virus of approximately . kb [ ] [ ] [ ] ] . natural bd is known in horses, sheep, cattle and ostriches [ , , , ] . experimentally, a broad range of animal species including rabbits, rats, monkeys and chicken are susceptible to infection [ , ] . the recent demonstration of borna disease virus (bdv) genomic transcripts as well as antigen in peripheral blood leukocytes of psychiatric patients [ , ] may point to some association of bdv with mood disorders in man. a feline neurological disorder, originally reported in sweden [ ] and referred to as staggering disease (sd), has recently been linked to bdv infection. this feline encephalomyelitis shows all the histopathological hallmarks of a viral infection in the central nervous system (cns): neuronophagia, microgliosis and heavy perivascular cuffing by mononuclear cells [ ] . however, no correlation has been found with traditional feline viruses such as feline leukemia, feline immunodeficiency and feline infectious peritonitis viruses [ , ] . initial studies showed that % of affected cats carry bdv-specific antibodies [ , ] . further investigations led to the demonstration of bdv-specific antigen and nucleic acid in cats with sd, and to the isolation and characterization of a feline strain of bdv from such animals [ ] . recent findings of bdv-specific antibodies in austrian cats with a neurological disorder similar to feline sd [ ] have provided additional evidence for the existence of natural bdv infection in cats. there has been only one report in the modern literature of experimental bdv infection in cats [ ] . in that study, out of cats inoculated intracerebrally with a rabbitadapted bdv strain developed clinical signs and died. however, the cats used for the experiment were undefined as to the presence of other pathogens, including feline viruses. the description of the clinical signs in the animals that died also appears to be more consistent with an acute viral infection such as feline panleukopenia than with bd. to investigate further the susceptibility of cats to bdv infection, we performed an experimental transmission study, using barrier-bred, specific pathogen-free (spf) cats. two different strains of virus were used: the laboratory reference strain v and the recently isolated feline bdv. following intracerebral inoculation, the animals were closely observed and immunologically monitored for months. we report on the appearance of neurological signs and encephalitis in some of the inoculated cats. all animals survived the infection, pointing to the importance of an early cellular as well as humoral immune response for viral clearance and recovery from disease. twelve barrier-bred -month-old health-monitored cats of the strain ico:fec eur, tif, obtained from iffa-credo (l'arbresle, france), were used for the study (six male, six female). all cats were vaccinated against feline panleukopenia, feline herpes and calici virus infection and rabies (leucorifelin and quadricat, rhone-merieux) at weeks of age, receiving booster injections at weeks of age. they were serologically negative for feline leukemia virus, feline immunodeficiency virus and feline coronavirus (virus laboratory, national veterinary institute, sweden). before the start of the experiment, the cats were conditioned for weeks, divided into three separate groups (i-iii) of two males and two females each. during this period, all males were neutered and blood samples were taken for flow cytometry analysis and white blood cell (wbc) counts. groups i and ii were kept freely roaming in rooms with controlled light cycle ( h light/ h dark) and temperature ( ± °c). each room was provided with a separate set of protection clothes, shoes and hair caps for the keeper. group iii was kept freely roaming in a room in a separate facility, with manual light supply, and attended by a different keeper. the cats were fed canned and dry cat food and water ad lib. the absorbent litter was changed daily. food as well as absorbent litter was handled separately for each group. two different virus suspensions were used for inoculations: . bdv strain v [ ] , a rabbit-adapted laboratory strain originally isolated from horses. infected rabbit brain suspension was diluted : in phosphate-buffered saline (pbs) and stored in aliquots of ml at - °c before use. the titer of the suspension was × focus forming units (ffu)/ml. . feline bdv, originally obtained from the brain of a cat with sd and thereafter passaged twice intracerebrally in newborn wistar rats [ ] . infected rat brain suspension was diluted : in pbs and stored in aliquots of ml at - °c before use. the titer of the suspension was × ffu/ml. on day , each cat was anesthetized using a mixture of medetomidine (domitor, lääkefarmos/farmos) at a dose of . mg/kg intramuscularly (i.m.) and ketamine (ketalar, parke-davis) at a dose of mg/kg i.m. serum was obtained and stored at - °c for bdv antibody determination. four cats (group i) were inoculated with bdv strain v and four cats (group ii) with the feline bdv isolate ( table ). all inoculations were given intracerebrally ( . ml/cat). a surgical site was prepared aseptically over the left parietal cortex, the skin was incised with a scalpel blade and a small hole drilled through the skull using a surgical dentist's drill. the virus suspensions were introduced into the left parietal cortex using a . x -mm needle. of the cats in group iii, two were given a normal rabbit brain suspension intracerebrally, while the remaining two were left as uninoculated controls. the cats were observed twice daily, for at least h each time, for signs of illness and/or changes in behavior. on days , , , , and all cats were anesthetized as described and serum, edta blood samples and heparinized blood samples were obtained for serology, blood chemistry, hematology and flow cytometry. cerebrospinal fluid (csf) was collected by cisternal puncture and analyzed immediately for cell content. on day post inoculation (p.i.), two cats from each group received an intravenous injection with cyclophosphamide (cyklofosfamide, orion), diluted in sterile water to a concentration of mg/ ml, at a dose of mg/kg body weight (table ) . cats which were not treated with cyclophosphamide were killed by pentobarbital overdose given intraperitoneally on day p.i. the cyclophosphamide-treated cats were killed in the same manner on day p.i. final blood samples and csf were taken from all cats, and postmortem examinations were performed within h of death. the brain and spinal cord were removed intact from all cats at necropsy. the brain was divided into two halves by a longitudinal cut through the midline of the corpus callosum and the brain stem. from the right half, small pieces (approximately x mm) were taken from different regions, snap frozen in liquid nitrogen and stored at - °c for later determination of viral rna by reverse transcriptase (rt)-polymerase chain reaction (pcr). the left half was fixed in buffered % formalin and cut in serial coronal slices including the olfactory bulb, frontal cortex, basal ganglia, parietal cortex, thalamus, hippocampus, temporal and occipital cortex, mesencephalon, caudal colliculus, pons, lateral cerebellar hemisphere and the medulla oblongata. after embedding in paraffin, -µm-thick sections were cut and stained with hematoxylin and eosin (h&e) for light microscopy. specimens from the cervical, thoracic and lumbar segments of the spinal cord, as well as from the cranial mesenteric ganglion and the sciatic nerve, were likewise processed. extraneural tissue specimens were sampled from the eyes, retropharyngeal lymph nodes, spleen, liver, kidneys, heart, lung, mandibular gland, pancreas, jejunum, adrenal gland, thymus, uterus, ovaries and the sartorial muscle. samples from all these tissues were formalin fixed and processed for histopathology; in adddition, some samples were snap frozen in liquid nitrogen and stored at - °c. for detection of bdv antigen, two different rabbit bdv-specific antisera (ll , bp ) and a monoclonal antibody (mab) kfu , recognizing the -kda protein of bdv [ ] were used on paraffin sections of the brain. the avidin-biotin immunoperoxidase complex (abc) method [ ] was used with -amino- -ethylcarbazole (aec) as the chromogen, as described previously [ ] . two cats from groups i and iii and three cats from group ii were examined immunohistochemically. the parietal cortex and hippocampus were selected for examination. for the three cats with encephalitis (see results), all brain regions with inflammatory changes were evaluated immunohistochemically. total rna was extracted from tissue samples using the trizol reagent (life technologies). the rna was dissolved in nucleasefree water and stored at - °c. rna concentration was determined by spectrophotometry at nm. rna was prepared from the following brain regions of all cats: basal ganglia, hippocampus, cerebral cortex and mesencephalon. from the three cats with encephalitis (see results), additional samples were prepared from the olfactory bulb, thalamus, cerebellum and obex. rna was also prepared from the kidneys and spleen of two cats from each group. the oligonucleotides were designed according to published sequences of the bdv genome encoding the / -kda protein [ ] , using the computer program oligo version . . the primer sequences have been described previously [ ] . for southern hybridization, the following p-labeled oligonucleotide located between the internal primers was used: ′-aaagcaggagccgagcagat- ′. the oligonucleotide probe was synthesized in a gene assembler plus (pharmacia lkb). the m-mlv rt and the corresponding buffer system were obtained from life technologies. all pcr reagents including nucleotides, × reaction buffer and taq polymerase (amplitaq) were obtained from perkin-elmer cetus. prior to pcr amplification, cdna was synthesized by the rt reaction as described previously [ ] . the external primers were used to prime selectively either the positive-strand viral mrna or the negative-strand viral genomic rna. pcr amplifications were carried out in -µl volumes containing µl of the rt reaction. reaction solutions comprised mm tris-hcl, ph . , mm kcl, . mm mgcl , µm each dntp, µm of each primer and . u taq polymerase. the samples were processed through cycles of min at °c, min at °c and . min at °c. following the first round of pcr, a second (nested) round was performed using µl of the first reaction with the internal primer pair for cycles of min at °c, min at °c and . min at °c. one fifth ( µl) of each reaction after the nested pcr was analyzed by electrophoresis in a % agarose gel in the presence of mg/ml ethidium bromide. the oligonucleotide probe was labeled with [γ- p]atp (sp. act. ci/mmol, amersham) using a t nucleotide kinase (pharmacia). southern blotting and hybridization were carried out using standard methods [ ] . to verify the integrity of the rna preparation, the amplification of a -bp βactin mrna served as an internal control [ ] . hemoglobin concentration, wbc counts, differential cell counts and csf cell counts were determined according to standard procedures at the department of clinical chemistry, faculty of veterinary medicine, swedish university of agricultural sciences. the absolute numbers of neutrophils and lymphocytes were calculated from the total leukocyte and differential counts. correction for contamination by peripheral blood in the csf was made by subtraction of wbc for every erythrocytes/µl [ ] . total protein concentration in serum was determined by the biuret method and serum protein electrophoresis was performed using a paragon system (beckman instruments). heparinized blood ( ml) was diluted : with rpmi (gibco) and layered upon ml ficoll-paque (pharmacia). tubes were centrifuged at g for min, peripheral blood mononuclear cells were isolated from the interface and the concentration of cells was determined by counting in a bürker chamber. the cells were transferred to polypropylene tubes, × cells/tube, and washed once in rpmi containing % fetal calf serum (fcs). for identification of lymphocyte subpopulations, mabs against feline cd (cat a, vmrd), cd (fcd , southern biotechnology), cd -like antigen/ pan t (cf a, vmrd) and cd -like antigen/b subset (f a, vmrd) were used. a mab against bromodeoxyuridine (m , dakopatts) served as isotype control. the cells were incubated with the primary antibodies (all diluted to a final concentration of µg/ml) for min on ice, thereafter washed once with rpmi-fcs and incubated with a fluorescein isothiocyanate (fitc)-conjugated f(ab′) rabbit anti-mouse igg (f , dakopatts) for min in the dark on ice. the cells were washed once with rpmi-fcs and resuspended in pbs containing µg/ml propidium iodide (pi, sigma). flow cytometry, computer analysis and statistical methods flow cytometry was performed using a facstar plus flow cytometer (becton dickinson immunocytometry systems) with standard optical equipment. cells were illuminated with an argon-ion laser (spectra-physics ) tuned to nm and operating at mw. data were acquired using the facstar plus software version . . off-line analysis was performed using the lysys version . . data from cells were acquired. the following parameters were collected: forward light scatter (fsc), orthogonal light scatter (ssc), fitc fluorescence (fl ) and pi fluorescence (fl ). dead cells were identified by their uptake of pi, and were excluded from further analysis. the lymphocytes were identified by their size (fsc) and granularity (ssc). the fitc fluorescence of the lymphocytes was further evaluated. the discrimination between positive and negative cells was set by placing the discrimination so that % positive cells were detected in the sample stained with isotype control for each cat. this number was then subtracted from the frequency of positive cells in the samples stained with antibodies to feline leukocyte surface antigens. statistical analysis of differences between the control group and the two exposed groups was performed with the mann-whitney u-test. the frequencies of cells positive for each of the markers cd , cd , cd -like/pan t and cd -like/b-subset in samples from the two infected groups were compared with frequencies of the control group at each sampling point. for the detection of bdv-specific antibodies in serum, an indirect immunofluorescence test (ift) was performed as described previously [ ] , using a double-stain technique. in brief, young rabbit brain cells infected with bdv and seeded on coverslips were incubated with equal volumes of cat serum and the bdv-specific mab kfu , recognizing the / -kda protein of bdv [ ] , followed by a second incubation with fitc-labeled goat anti-cat igg (dianova) and tetramethyl rhodamine isothiocyanate-labeled f(ab′) rat anti-mouse igg (dianova). cat sera were ranked as containing specific antibodies only if they induced a pattern of fluorescence identical to that induced by kfu . all positive samples were endpoint titrated. for evaluation of the neutralizing capacity, cat sera were decomplemented, diluted and subjected to a neutralization test based on the principle of plaque reduction, as described previously [ ] . sera from bdv-infected, as well as uninfected, rabbits were used as positive and negative controls. titers were expressed as the dilution at which the number of foci was reduced by %. in group i (inoculated with bdv strain v), one cat (no. ) showed bilateral protrusion of the third eyelid days p.i. the cat was also mewing more than usual. on day p.i., cat was shy and reserved. during the following days, a clear personality change was observed. the cat was extremely shy and cautious, ran away when approached and assumed a peculiar staring gaze. between days and p.i., clinical signs aggravated. the cat was moving in circles, especially when approached, and seemed unable to jump up and down normally. a slight to moderate hind leg ataxia was observed. after day , movements as well as behavior were normalized; however, for some days the cat seemed to be hypersensitive to sound and touch and had small tremors in the skin, most apparent in the eyelids and whiskers. an altered voice was also noted. between days and p.i., there were no changes in the clinical condition of this cat. the altered voice remained to the end, as did a certain mental dullness. another cat in group i (no. ) showed a slightly stiff gait and ataxia in the hind legs . months p.i. these signs remained constant until euthanasia. in group ii (inoculated with feline bdv), one cat (no. ) showed signs of rapid breathing and disturbed proprioception in the front legs on day p.i.. these symptoms disappeared completely on day and were interpreted as due to traumatic injury from the inoculation procedure. between days and , another cat in this group (no. ) showed bilateral protrusion of the third eyelid. at . months p.i., a third cat (no. ) was observed to hold its neck in a stiff position, sometimes turning the head with a twitchy movement, and also showing signs of slight hind leg ataxia. these clinical signs remained until the cat was killed on day p.i. hemoglobin concentration remained within normal limits ( - g/l) throughout the study. a transient decrease in wbc was observed in groups i and ii days p.i. true leukopenia ( . × - . × cells/l) occurred in three cats (group i: cats , ; group ii: cat ), due mainly to neu- in group i, a moderate increase in csf leukocytes was observed in two cats (nos. , ) days p.i. at the same time two cats in group ii (nos. , ) also showed a moderate increase in csf leukocytes. in both groups, mononuclear cells predominated. the highest csf cell count was detected in cat ( wbc/µl vs normal < wbc/µl). on day p.i., cats , and showed signs of pain and increased extensor tone of the front legs during cisternal puncture. because of this, csf sampling was interrupted and no csf analysis could be performed. throughout the remainder of the study, csf leukocyte counts were normal in both of the inoculated groups. table ). modified after luttrell and bang [ ] the control cats in group iii did not develop any clinical signs during an observation period of months. their hemoglobin concentrations, wbc counts, serum protein concentrations and csf cell contents remained within normal limits throughout the study. histopathological examination revealed encephalitis in the three cats with neurological signs. in group i, cat had a severe non-suppurative meningoencephalitis extending from the frontal cortex through the basal ganglia and the brain stem ( table ; figs. , a) . the lesions were characterized by broad adventitial cuffs consisting of mononuclear cells (lymphoid cells, cells resembling macrophages, and plasma cells), presence of inflammatory cell infiltrates in the neural parenchyma, occasional neuronophagia, microgliosis and scattered axonal degeneration. in the cerebral cortex and hippocampus, plasma cells were occasionally observed close to neurons. inflammatory changes were more pronounced in the white matter than in the gray matter, particularly in the internal capsule at the level of the basal ganglia and in the periventricular white matter of the rostral brain stem. in the spinal cord, ventrolateral axonal degeneration and loss of myelin were observed at all levels. another cat in group i, cat , showed histopathological evidence of a moderate non-suppurative encephalitis (table ) , with inflammatory lesions almost completely confined to the subcortical white matter. adventitial infiltrates were less extensive than in cat , and there were no signs of neuronophagia. occasional plasma cells appeared adjacent to hippocampal neurons. in the spinal cord, ventrolateral axonal degeneration and loss of myelin occurred at all levels (fig. b) . the only inflammatory change observed in the cns of the other cats in group i (nos. , ) was the presence of scattered plasma cells close to neurons and glial cells of the cerebral cortex and hippocampus (fig. c) . in addition, cat showed a slight mononuclear cell infiltration in the choroid plexus of the third ventricle and cat had a single, thin adventitial mononuclear cuff in the internal capsule at the level of the basal ganglia. cat of group ii had a mild non-suppurative encephalitis localized in the laterobasal temporal cortex ( table ). there were scattered adventitial cuffs consisting of lymphoid cells and a few plasma cells both in the gray matter and at the border between gray and white matter. occasional plasma cells were found in the vicinity of neurons in the frontal, parietal and temporal cortex. the other cats (nos. , , ) in group ii lacked encephalitic lesions. cat had a minimal adventitial infiltrate in the internal capsule at the level of the basal ganglia. cat had a slight mononuclear infiltrate in the choroid plexus of the third ventricle. scattered plasma cells in the vicinity of morphologically normal neurons were observed in the cerebral cortex of all three cats. with a few exceptions, extraneural tissues were histopathologically normal. cat in group i had markedly en-larged retropharyngeal lymph nodes with follicular hyperplasia. three cats in group i and two in group ii had larger and more active germinal centers in the spleen compared to group iii control cats. cat in group ii had a slight interstitial infiltrate consisting of lymphoid cells in the cortex of the kidney. the control cats in group iii showed no histopathological abnormalities of the cns or any of the examined extraneural tissues. in cat (inoculated with bdv strain v), bdv antigen was found within neurons and glial cells in all examined brain regions except the olfactory bulb and the hippocampus. positively stained cells were scattered in the cerebral cortex, often in regions adjacent to inflammation in the underlying white matter. usually, the antigen-containing cells appeared only in the cortex of the different regions, being notably absent from the basal and thalamic nuclei as well as from the immediate vicinity of adventitial cuffs. the staining of neurons was predominantly cytoplasmic and tended to be somewhat granular. the majority of the antigen-containing neurons had a shrunken appearance. in cat (inoculated with bdv strain v), a few antigen-contain- ing neurons and glial cells were found in the deep nuclei of the cerebellum, and in the cerebral cortex. the positively stained neurons did not show any cytopathic changes (fig. d) . of the cats in group ii (cats inoculated with feline bdv), cat had a few antigen-containing neurons and glial cells in the laterobasal temporal cortex, close to a region with several adventitial cuffs. bdv antigen could not be detected immunohistochemically in any of the other group ii cats. following selective priming for viral mrna or viral genomic rna in the rt reaction, no amplification products were detected by agarose gel electrophoresis after the first pcr. after a second (nested) round of pcr with the internal primer pair, the expected -bp bdv-specific band could be visualized in samples from at least one brain region in all cats with histopathological evidence of encephalitis. the specificity of the pcr products was verified by southern blotting and hybridization of a p-labeled oligonucleotide probe to the amplified dna (fig. ) . cat , which had the most severe inflammatory lesions, was positive for bdv mrna in the cerebral cortex and thalamus, while the hippocampus of this cat only contained viral genomic rna. in cat , bdv mrna could be demonstrated in the cerebral cortex and the cerebellum. cat was positive for bdv mrna in the hippo- campus. cat , which did not have detectable bdv rna in the brain, tested positive for bdv mrna in the spleen. all other cats were negative for bdv rna in the tissue samples examined. cats in group i showed an increase in the frequency of pan-t-positive lymphocytes days p.i. (fig. b) . this increase, however, was not significant. at days p.i., there was a significant increase of b cells and a decrease of t cells. after day , the population of t cells in the peripheral blood approached control values. a decrease in the frequency of cd -positive cells was consistent throughout the study, and was significant at , , and days p.i. (fig. e) . in group ii, there was a significant increase in the frequency of pan-t-positive lymphocytes days p.i. (fig. c) . the cd -and cd -positive subpopulations increased simultaneously, with a slight predominance of cd -positive t cells (fig. f) . the frequencies of t cells then declined, reaching a minimum days p.i. at the same time, a significant increase in the frequency of b cells was observed. this switch in t and b cell frequencies was more pronounced in group ii than in group i. during the remainder of the study, the frequencies of t cells increased and approached control values. however, a significant decrease in cd -positive cells was observed at and days p.i., and a significant decrease in cd -positive cells at days and p.i. (fig. f) . all cats in group i and ii sero-converted and developed neutralizing antibodies (fig. a-d) . antibodies detectable by ift appeared days p.i. in group ii and days p.i. in group i. from day and onwards, titers increased in both groups, reaching a maximum days p.i. in group ii and days p.i. in group i (fig. a, c) . titers ranged between : to : , the highest titer being recorded in cat . neutralizing activity was first detected in sera days p.i. in both of the infected groups. between days and p.i., the neutralizing antibody titers in group ii markedly increased (fig. b) . on average, the titers were higher in group ii than in group i, ranging from : to : . however, the cat with the highest ift titer (cat ) also had the highest neutralizing antibody titer (> : at day p.i). in some cats, neutralizing antibodies were detectable at one sampling point, undetectable at the next and then detectable again. this phenomenon occurred in both of the infected groups. the control cats in group iii did not develop any ift or neutralizing antibody titers. treatment with cyclophosphamide at days or p.i. did not result in any apparent reactivation of the infection. the clinical condition of the animals remained unchanged. as shown by flow cytometry, the effect on frequencies of cells in lymphocyte subsets was not significant (fig. a-f ). the aim of the present study was to investigate the susceptibility of cats to bdv, using two different strains of virus: the rabbit-adapted bdv strain v of horse origin [ ] and the newly isolated feline bdv [ ] . since the natural route of infection in cats is unknown, we chose to inoculate the animals intracerebrally to ensure viral access to the cns. of a total of eight inoculated cats, three developed definite neurological signs and encephalitis. two of these were infected with bdv strain v and one with feline bdv. the distribution pattern of inflammatory lesions in the present cats considerably differs from that in natural bd of horses, as well as that in feline sd, both of which show predilection for the limbic system and the brain stem [ , ] . one possible explanation for this may be the route of inoculation. as indicated by the periventricular localization of lesions in one of the cats inoculated with bdv strain v, spread of virus following intracerebral administration probably occurred via the csf and the ventricles. another explanation for the atypical distribution pattern in the present cats could be that histopathological examination was carried out only during the chronic stage (between and months p.i.), when the inflammatory reaction would be expected to be less prominent. in contrast, cats with natural sd usually are killed and examined post mortem at the peak of clinical disease and encephalitis. the presence of plasma cells close to neurons in all infected cats, including those without encephalitis, has previously been observed in natural cases of sd [ ] . it is possible that this phenomenon might be associated with antibody-mediated clearance of virus from infected cells, such as has been described in sindbis virus encephalitis of mice [ ] and experimental rabies virus infection [ ] . in this context, it is of interest that inflammatory brain infiltrates in experimental rabies of cats typically involve plasma cells in close association with neurons [ , ] . it should be noted that the genomes of bdv and rabies virus contain homologous sequences [ , ] and that bd and rabies also share several pathogenetic features [ ] . the clinical picture in one of the bdv strain v-infected cats, including an acute stage characterized by behavioral and motor disturbances, and a chronic stage predominated by mental dullness, is reminiscent of the biphasic neurological syndrome observed in rats and tree shrews experimentally infected with bdv [ , , ] . interestingly, recovery from the acute stage of disease in this cat coincided with a rise in neutralizing antibody titers, a phenomenon previously observed in experimentally infected rats [ ] . in the other two cats with neurological signs, a correlation between clinical recovery and the appearance of neutralizing antibodies was less clear. neutralizing antibodies in bd are thought to be directed against the -kda viral glycoprotein [ , ] , and have been shown to prevent bdv spread in infected cell cultures in vitro [ ] . however, the functional role of such antibodies in vivo awaits further elucidation. a comparison between the serological data and the flow cytometric results shows that the rise of serum antibodies detectable by ift coincided with an increase of peripheral b lymphocytes in both of the infected groups. the early peripheral t cell increase present in cats infected with feline bdv, but not with bdv strain v, and the fact that the former cats sero-converted somewhat earlier than the latter ones, suggest that the feline virus exerted a more vigorous effect on the immune system. this could be due either to the higher titer of the feline virus or to different antigenic properties of feline bdv and bdv strain v. none of the present cats developed the slowly progressive, paralytic syndrome typical of feline sd. they were all able to recover from the acute disease stage, and the inflammatory lesions in their brains at the time of death were less severe than the lesions usually observed in natural sd. it is possible that some of the differences between natural and experimental disease in cats may be dose related, as indicated by a recent study in rats inoculated intracerebrally with high-dose or low-dose attenuated bdv [ ] . the high-dose animals rapidly eliminated the virus by an early and efficient immune response, while in the low-dose rats the immune response was delayed and viral replication therefore proceeded, causing severe encephalitis. furthermore, it should be noted that no neutralizing activity has so far been found in sera from cats with sd ( [ ] and unpublished observations). in contrast, all of the experimentally infected cats developed a strong cellular as well as humoral immune response, including neutralizing antibodies. nevertheless, despite a seemingly adequate immune response, some of the present cats failed to clear virus completely from the cns, as evidenced by the presence of bdv-specific antigen and nucleic acid in certain brain regions. a limited viral replication apparently continued, providing the necessary antigenic stimulus for the maintenance of inflammation. it is of interest to note that bdv mrna was present in the spleen, but not in the brain, of one of the cats. this is in accordance with previous studies, showing that bdv during later stages of infection will spread centrifugally via peripheral nerve fibers to many different organs [ ] . the importance of this in terms of viral persistency, chronic carriers and shedding of virus calls for further investigations. in conclusion, we have shown that cats infected intracerebrally with either bdv strain v or feline bdv may develop neurological signs and encephalitis of a non-fatal character. an early cellular as well as humoral immune response seems to be instrumental for survival and recovery. clearly, further studies are necessary to understand the pathogenesis of bdv infection in cats. of special importance would be to investigate the clinical and immunological outcome of the infection when other, more natural, inoculation routes (for instance intranasally) are used. however, the successful induction of neurological signs and encephalitis in one cat intracerebrally inoculated with feline bdv, together with the detection of bdv antigen and nucleic acid in the brain of this cat, provides strong evidence for the notion that bdv is the etiological agent behind feline sd. human infections with borna disease virus: seroprevalence in patients with chronic diseases and healthy individuals borna virus infections in cattle associated with fatal neurological disease a novel marker for borna disease virus infection borna disease virus genome transcribed and expressed in psychiatric patients borna disease virus, a negative-strand rna virus, transcribes in the nucleus of infected cells genomic organization of borna disease virus sequence and genome organization of borna disease virus delineation of putative mechanisms involved in antibody-mediated clearance of rabies virus from the central nervous system borna disease of horses. an immunohistological and virological study of naturally infected animals borna disease -neuropathology and pathogenesis rabies and borna disease: a comparative pathogenetic study of two neurovirulent agents neutralizing antibodies in borna disease virus-infected rats persistent, tolerant or subacute infection in borna disease virus-infected rats the use of avidin-biotinperoxidase complex (abc) in immunoperoxidase techniques: a comparison between abc and unlabeled antibody (pap) procedures experimentelle prüfung der empfänglichkeit der katze für das virus der bornaschen krankheit feline ataxia due to nonsuppurative meningoencephalomyelitis of unknown aetiology antibody-mediated clearance of alphavirus infection from neurons borna disease: a persistent virus infection of the central nervous system biology and neurobiology of borna disease viruses (bdv) defined by antibodies, neutralizability and their pathogenic potential feline non-suppurative meningoencephalomyelitis. a clinical and pathological study clinically diseased cats with non-suppurative meningoencephalomyelitis have borna disease virus-specific antibodies natural borna disease in domestic animals others than horses and sheep immunoreactivity of the central nervous system in cats with a borna disease-like meningoencephalomyelitis (staggering disease) staggering disease in cats: isolation and characterization of the feline borna disease virus newcastle disease encephalomyelitis in cats borna disease in ostriches experimental chronic rabies in the cat behavioral disease in rats caused by immunopathological responses to persistent borna virus in the brain description of feline nonsuppurative meningoencephalomyelitis ("staggering disease") and studies of its etiology induction of protection against borna disease by inoculation with high-dose-attenuated borna disease virus chronic recrudescent rabies in a cat reference intervals for feline cerebrospinal fluid: cell counts and cytologic features molecular cloning: a laboratory manual behavior alterations in tree shrews (tupaia glis, diard ) induced by borna disease virus n-glycosylated protein(s) are important for the infectivity of borna disease virus (bdv) idiopathic non-suppurative meningoencephalomyelitis (staggering disease) in the swedish cat: a study of cases borna disease virus: immunoelectron microscopic characterization of cell-free virus and further information about the genome detection of borna disease virus rna in naturally infected animals by a nested polymerase chain reaction bornasche krankheit und enzephalomyelitis der tiere the authors wish to thank prof. georg gosztonyi for helpful discussions, miss christina nilsson and mrs. tine leiskau for excellent technical assistance, and miss pernilla mårtensson for excellent animal care. this study was supported by a grant from the agria insurance company, a dfg grant (lu / - , ) and an eu contract (bmh -ct - ; h.l. project leader). the flow cytometer used in this study was financed by the knut and alice wallenberg foundation. key: cord- -vl zhxyh authors: giallonardo, vincenzo; sampogna, gaia; del vecchio, valeria; luciano, mario; albert, umberto; carmassi, claudia; carrà, giuseppe; cirulli, francesca; dell’osso, bernardo; nanni, maria giulia; pompili, maurizio; sani, gabriele; tortorella, alfonso; volpe, umberto; fiorillo, andrea title: the impact of quarantine and physical distancing following covid- on mental health: study protocol of a multicentric italian population trial date: - - journal: front psychiatry doi: . /fpsyt. . sha: doc_id: cord_uid: vl zhxyh the covid- pandemic and its related containment measures—mainly physical distancing and isolation—are having detrimental consequences on the mental health of the general population worldwide. in particular, frustration, loneliness, and worries about the future are common reactions and represent well-known risk factors for several mental disorders, including anxiety, affective, and post-traumatic stress disorders. the vast majority of available studies have been conducted in china, where the pandemic started. italy has been severely hit by the pandemic, and the socio-cultural context is completely different from eastern countries. therefore, there is the need for methodologically rigorous studies aiming to evaluate the impact of covid- and quarantine measures on the mental health of the italian population. in fact, our results will help us to develop appropriate interventions for managing the psychosocial consequences of pandemic. the “covid-it-mental health trial” is a no-profit, not-funded, national, multicentric, cross-sectional population-based trial which has the following aims: a) to evaluate the impact of covid- pandemic and its containment measures on mental health of the italian population; b) to identify the main areas to be targeted by supportive long-term interventions for the different categories of people exposed to the pandemic. data will be collected through a web-platform using validated assessment tools. participants will be subdivided into four groups: a) group —covid- quarantine group. this group includes the general population which are quarantined but not isolated, i.e., those not directly exposed to contagion nor in contact with covid- + individuals; b) group —covid- + group, which includes isolated people directly/indirectly exposed to the virus; c) group —covid- healthcare staff group, which includes first- and second-line healthcare professionals; d) group —covid- mental health, which includes users of mental health services and all those who had already been diagnosed with a mental disorder. mental health services worldwide are not prepared yet to manage the short- and long-term consequences of the pandemic. it is necessary to have a clear picture of the impact that this new stressor will have on mental health and well-being in order to develop and disseminate appropriate interventions for the general population and for the other at-risk groups. the covid- pandemic and its related containment measures-mainly physical distancing and isolation-are having detrimental consequences on the mental health of the general population worldwide. in particular, frustration, loneliness, and worries about the future are common reactions and represent well-known risk factors for several mental disorders, including anxiety, affective, and post-traumatic stress disorders. the vast majority of available studies have been conducted in china, where the pandemic started. italy has been severely hit by the pandemic, and the socio-cultural context is completely different from eastern countries. therefore, there is the need for methodologically rigorous studies aiming to evaluate the impact of covid- and quarantine measures on the mental health of the italian population. in fact, our results will help us to develop appropriate interventions for managing the psychosocial consequences of pandemic. the "covid-it-mental health trial" is a no-profit, notfunded, national, multicentric, cross-sectional population-based trial which has the following aims: a) to evaluate the impact of covid- pandemic and its containment measures on mental health of the italian population; b) to identify the main areas to be targeted by supportive long-term interventions for the different categories of people exposed to the pandemic. data will be collected through a web-platform using validated assessment tools. participants will be subdivided into four groups: a) group -covid- quarantine group. this group includes the general population which are quarantined but not isolated, i.e., those not directly exposed to contagion nor in contact with covid- + individuals; b) group -covid- + group, which includes isolated people directly/indirectly exposed to the virus; c) group -covid- healthcare staff group, which includes firstand second-line healthcare professionals; d) group -covid- mental health, which includes users of mental health services and all those who had already been diagnosed with a mental disorder. mental health services worldwide are not prepared yet to manage the short-and long-term consequences of the pandemic. it is necessary to have a clear picture of the impact that this new stressor will have on mental health and well-being in order to develop and disseminate appropriate interventions for the general population and for the other at-risk groups. keywords: pandemic, global mental health, post-traumatic stress disorder, burn-out, anxiety, depression, resilience background the ongoing covid- pandemic represents an unprecedented event in terms of consequences for physical and mental health of individuals and for the society at large ( ) ( ) ( ) ( ) . in order to reduce the spread of the virus, national and international bodies and institutions have ordered quarantine, physical distancing, and isolation almost everywhere in the world. however, the psychological consequences of quarantine, such as frustration, loneliness, and worries about the future are well-known risk factors for several mental disorders, including anxiety, affective disorders, and psychoses ( ) ( ) ( ) . from a medical and sociological viewpoint, the pandemic caused by covid- represents a unique event, since it does not resemble any other previous traumatic event, such as earthquakes or tsunamis ( ) . in those cases, the traumatic factors are usually limited to a specific area and to a given time; affected people know that they can "escape" from the event. on the contrary, in the case of covid- pandemic, the "threat" can be everywhere and can be carried by every person next to us ( ) ( ) ( ) . therefore, people living in cities most severely impacted by the pandemic are experiencing extremely high levels of uncertainties, worries about the future and fear of being infected. the only comparable studies are those carried out during the sars outbreak ( ) ( ) ( ) ( ) ( ) . those studies showed that people experienced fear of falling sick or dying, feelings of helplessness, increased levels of self-blame, fear, and depression ( ) ( ) ( ) ( ) . during quarantine and physical distancing, internet and the social media can be useful in reducing isolation and increasing opportunities to keep in contact with family members, friends, and co-workers at any time ( , ) . however, internet may also represent a risk factor for mental disorders, in particular internet gaming disorder. moreover, internet can also have a negative impact on mental health of the most vulnerable people, such as those who live alone or the elderly, since it spreads an uncontrolled amount of information (a situation known as "infodemic"). in the current pandemic, the impact of quarantine and physical distancing on the mental health of the general population has been explored only in a few studies, mostly conducted in china, where the pandemic started ( ) ( ) ( ) . qiu et al. ( ) found that % of the population experienced psychological distress; in particular, those more vulnerable to stress and more likely to develop post-traumatic stress disorder were women and individuals aged between and years or older than years. moreover, people were more concerned about their own health and that of their family members, while less concerned about leisure activities and relationships with friends ( , ) . after china, italy has been the first country to face the contagion of covid- and one of the countries with the highest number of deaths due to this coronavirus (http://www. salute.gov.it/portale/nuovocoronavirus/). on march , the lockdown status has been declared by the italian government. this status included the definition of specific containment and quarantine measures, such as the interdiction of all public meetings and strict movement restrictions (i.e., possibility to go out only for working, serious health reasons, or other urgent needs). these containment measures have been prolonged until may . moreover, the expected psychosocial and emotional reactions to the pandemic observed in the general population may be significantly different in the chinese and italian populations due to their socio-cultural characteristics and historical contexts, which obviously impact on people's behaviors and attitudes. furthermore, the organization of public health system is different in italy compared to china and other eastern asian countries, also due to financial constraints. in fact, although in those countries the model of care has shifted in the last years to become more similar to a western model of care, it has to be acknowledged that years is a relatively short period of time, and differences may still persist. methodologically rigorous studies are needed in order to evaluate the impact of covid- and quarantine measures on the mental health of italian population. these data will help us to develop appropriate interventions for managing the psychosocial consequences of the pandemic ( ) ( ) ( ) . the present study has been developed with the aims to: a) evaluate the impact of covid- pandemic and its containment measures on mental health of the italian population; b) to identify the main areas to be targeted by supportive long-term interventions for the different categories of people exposed to the pandemic. the "covid-it-mental health trial" is a no-profit, not-funded, national, multicentric, cross-sectional population-based trial involving the following eleven sites: university of campania "luigi vanvitelli" (naples), università politecnica delle marche (ancona), università milano bicocca, università "statale" (milan), university of perugia, university of pisa, sapienza university of rome, "cattolica" university of rome, university of trieste, university of ferrara; the center for behavioral sciences and mental health of the istituto superiore di sanità (rome). the department of psychiatry of the university of campania "luigi vanvitelli" in naples is the coordinating center, which has originally conceived the study idea and design. an online survey has been set up through eusurvey, a web platform launched in by the european commission. the application, hosted at the department for digital services (dg digit) of the european commission, is available to all eu citizens at https://ec.europa.eu/eusurvey. the survey will be online from march to june , (https://ec.europa.eu/ eusurvey/runner/covidsurvey ). the survey takes approximately - min to be completed. participants can stop the survey at any time and save their answers as "draft" on the web-platform. furthermore, participants can interact with the principal investigator of the study and with all researchers through email messages at any time during and after study participation. participants will be subdivided into four groups: a) group -covid- quarantine group. this group includes the general population which are quarantined but not isolated, i.e., those not directly exposed to contagion nor in contact with covid- + individuals; b) group -covid- + group, which includes isolated people directly/indirectly exposed to the virus; c) group -covid- healthcare staff group, which includes firstand second-line healthcare professionals; d) group -covid- mental health, which includes users of mental health services and all those who had already been diagnosed with a mental disorder. the survey addresses the italian population aged over years through a multistep procedure: ) email invitation to health professionals and their patients; ) dissemination of the link through social media channels (facebook, twitter, instagram) and the mailing lists of national psychiatric associations; ) involvement of national associations of stakeholders (e.g., associations of users/carers); ) official communication channels (e.g., university websites; websites of the hospitals directly involved in the management of the pandemic). the invitation letter includes information on study purposes and confidentiality. the provision of the informed consent is mandatory in order to start the survey. the snowball sampling procedure-without the definition of strict inclusion/exclusion criteria (except that of age limit)-will give us the opportunity to recruit a large sample of the italian population and to evaluate the effect of the studied variables on the outcome measures. the survey includes the following self-reported questionnaires: the general health questionnaire - items (ghq- ) ( ); the depression, anxiety and stress scale - items (dass- ) ( ); the obsessive-compulsive inventory -revised (oci-r) ( ); the insomnia severity index ( ) ; the severity-of-acute-stress-symptoms-adult ( ); the suicidal ideation attributes scale (sidas) ( ); the impact of event scale - items ( ); the ucla loneliness scale -short version ( ) ; the brief cope ( ); the post traumatic growth inventory short form ( ) ; the connor-davidson resilience scaleshort form ( ) ; the multidimensional scale of perceived social support ( ); the pattern of care schedule (pcs)-modified version ( ); the maslach burnout inventory (only for health professionals) ( ) . respondents' main socio-demographic characteristics, as well as data on their internet use, will be collected through an ad hoc schedule. all assessment instruments used for the study are detailed in table . the primary outcome of the study is the global score at the dass- . this choice is due to the fact that this assessment measure has already been used in a large population study carried out in china, thus giving us the opportunity to compare the italian situation with the chinese one ( ) . our study hypothesis is that the pandemic and the related containment measures are associated with higher levels of depressive and anxiety symptoms in the surveyed population compared to a community italian sample not exposed to the pandemic ( ) . furthermore, a significant difference between groups will be identified (covid- quarantine group = covid- healthcare professional second-line < covid- + group = covid- healthcare professional first-line group < covid- mental health group). in the covid- quarantined group, the severity of obsessivecompulsive symptoms, evaluated through the oci-r, the perceived loneliness and suicidal ideation will be considered as secondary outcome measures. in the covid- + patient group, the severity of post-traumatic symptoms at the severity-of-acute-stress-symptoms-adult scale will be considered. the hypothesis is that post-traumatic symptoms are more severe in this group compared to the other ones. in the covid- health staff group, the presence of burn-out symptoms, in particular mental exhaustion, and suicidal ideation will be considered. we anticipate that first-line professionals will report higher levels of mental exhaustion and suicidal ideation compared to second-lines staff members. in the covid- mental health group, the secondary outcome measures will include the adoption of maladaptive coping strategies (e.g., drinking alcohol) and a poor resilience style. patients with pre-existing mental disorders are expected to adopt more maladaptive coping strategies and poorer resilience styles compared to the other three groups. the use of internet and social media will be tested as possible moderator of the impact of pandemic and quarantine ( figure ) . moreover, the exposure time to covid- and to the related containment measures will be tested as possible mediators of the severity of the clinical symptomatology. finally, the other exploratory outcomes will include the variety of coping strategies and resilience styles as well as the different levels of post-traumatic growth. statistical analyses will be conducted according to a multistep plan. missing data will be handled using the multiple imputation approach ( ) . descriptive statistics will be calculated for the dependent and confounding variables. a bilateral alpha of . is considered, and error and confidence intervals are calculated at %. the analytic plan will include: ) data cleaning of the online dataset and replacement of missing values; ) descriptive statistics of the general characteristics of the recruited sample, in terms of levels of depressive and anxiety symptoms, posttraumatic and stress-related symptoms, insomnia, satisfaction with life, suicidal ideation, hopelessness, post-traumatic growth, resilience, coping strategies, and social support; ) sub-groups analyses based on the level of exposure to the pandemic (i.e., covid- quarantine group vs. covid- + patients group vs. covid- healthcare staff group vs. covid- mental health group); ) calculation of a propensity score, in order to adjust our findings for the likelihood of being exposed to the pandemic and to the quarantine ( , ) . this method is adopted since it produces a better adjustment for differences at baseline, rather than simply including potential confounders in the multivariable models. the independent variables used for calculating the propensity score will include gender, age, socio-economic status, and geographical region. the obtained propensity score will be used to weight the observations in the multivariable analyses. in the final regression model, the inverse probability weights, based on the propensity score, will be applied in order to model for the independence between exposure to the pandemic/ quarantine and mental health outcomes and estimation of causal effects ( , ); ) development of a structural equation model (sem), in order to evaluate the possible role as mediators and moderators of coping strategies, post-traumatic growth and usage of social networks on the severity of depressive and anxiety symptoms, post-traumatic and stress-related symptoms, suicidal ideation, and hopelessness. in order to improve the external validity and generalizability of our findings, all analyses will be controlled for the impact of confounding variables, such as age, gender, and geographical region. data will be stored in an online dataset by the coordinating center. for safety reasons, the dataset will be protected by a twostep password. it will be possible to export data in compatible formats with common calculation software (e.g., microsoft access and excel) and in specific softwares (e.g., spss and stata) for the statistical analyses. this study is being conducted in accordance with globally accepted standards of good practice, in agreement with the declaration of helsinki and with local regulations. the study protocol has been approved by the ethical review board of the university of campania "l. vanvitelli" (protocol number: /i). our survey will give us the opportunity to describe the impact of the pandemic on the mental health of different subgroups of the italian population. in fact, the analyses will be run according to the four subgroups of respondents: the general population not directly affected by the virus (covid- quarantine group); people who have had a direct or indirect contact with the virus (covid- + patients group); those working in health care units as first or second-line staff (covid- healthcare staff group); people with mental health problems, independently from the contact with the virus (covid- mental health). this choice is due to the evidence that stress and traumas have a different impact on different target groups ( , ( ) ( ) ( ) . in the covid- -quarantine group, we anticipate that the pandemic and the related containment measures will increase the levels of stress, anxiety and depression, as well as other stress-related symptoms. in particular, physical distancing has obviously changed the patterns of daily routine in order to mitigate the spread of the disease, with serious consequences on mental health and well-being in both the short-and long-term ( ) . similar consequences would require immediate efforts for developing preventive strategies as well as direct interventions aiming to mitigate the impact of the outbreak on individual and population mental health. the longer the pandemic will last the most the ordinary life of the general population will be seriously affected. in particular, zhang et al. ( ) have highlighted the need to pay attention to the mental health of people who have not been directly infected by the virus though have been forced to stop all their activities during the outbreak. these people represent the most susceptible group to the detrimental impact of quarantine and physical distancing measures adopted during the lockdown. moreover, during the current pandemic, it is reasonable to expect that the incidence of severe mental disorders will increase, but also that of other mental health disturbances not reaching the threshold for a full-blown diagnosis ( ) . however, currently available data are based on studies carried out in china and the different socio-cultural context may limit the generalizability of findings to the italian and western contexts. therefore, we consider essential to collect italian data in order to develop data-driven guidelines for an adequate management of mental health problems during the emergency and the post-emergency phases. in fact, this survey will represent the starting point for developing, validating, and implementing psychosocial supportive interventions ( , ) , as discussed later in this paper. we hypothesized that internet and social media can play a buffering role in the development of psychiatric symptoms ( , ) . it may be that online contacts and interactions will limit the detrimental effects of social isolation ( ) . moreover, internet can represent the ideal setting for providing supportive interventions through tele-mental health applications ( - ). however, the positive effect of internet and social media has to be confirmed yet, since it is only speculative at this stage. in the covid- + patient group (i.e., those with a direct or indirect contagion), the impact on mental health has been mostly neglected during the acute emergency phase. of course, this has been due to the fact that the infection is a potentially lifethreatening condition, as confirmed by the need for hospitalization in intensive care units for many patients ( ) . in particular, the experience of being isolated in the hospital, the perceived danger, uncertainty about own physical conditions and the fear of dying alone can be considered risk factors for the development of post-traumatic, anxiety, and depressive symptoms ( , ) . the only study conducted in china so far has documented that over % of covid+ patients admitted to the hospital reported significant post-traumatic stress symptoms ( , , ) . furthermore, the authors found that providing patients with psychoeducational intervention is well received and perceived as helpful and useful by users. as regards the effects on mental health of those working in health care units as first-line or second-line staff (covid- healthcare staff group), we expect that many health professionals will experience symptoms of burn-out, including mental exhaustion, irritability, detachment from reality, and insomnia. in a survey involving medical and non-medical health workers, zhang et al. ( ) found a higher prevalence of insomnia, anxiety, depressive symptoms, somatization, and obsessive-compulsive symptoms in mental health staff. moreover, front-line medical staff working in close contact with infected patients (e.g., staff professionals working in the departments of respiratory, emergency, infectious disease, and intensive care unit) showed higher scores on depressive/anxiety symptoms and had a twofold increase in risk to develop a mental health problem ( ) ( ) ( ) ( ) . however, the effect on suicidal ideation of health professionals has not been investigated yet and will be the focus of one of our work-packages. finally, the pandemic will affect the mental health status of people who already suffer from mental health problems, independently from the contact with the virus (covid- mental health group). although the effects of the coronavirus on mental health have not been systematically studied, it is likely that the covid- will have detrimental effects on patients with pre-existing mental health problems. many patients with severe mental disorders have been overlooked during the pandemic, although they can have a higher risk of contracting the virus and of death considering the higher prevalence of somatic comorbidities compared to general population and the difficulties in accessing health services ( ) . however, if protracted, social isolation may increase the risk of recurrences of episodes of mental disorders, beyond triggering the onset of new mental disorders in most vulnerable people. moreover, objective social isolation and subjective feelings of loneliness are associated with a higher risk of suicidal ideation and suicide attempts ( ) . for many persons with mental disorders, being alone is a heavy burden, far beyond that experienced by many other persons ( ) . in patients with pre-existing anxiety disorders or obsessivecompulsive disorder, we expect an exacerbation or worsening of their clinical symptoms. moreover, the fact that there is not (yet) a definitive treatment for the covid infection represents another potential stressor, further increasing the levels of anticipatory anxiety and reducing personal functioning. in our study, both obsessive-compulsive and anxiety symptom clusters will be evaluated through reliable and validated questionnaires. we believe that our study has several strengths, which should be highlighted. first, this is the first national multicentric, noprofit study carried out in italy with a rigorous methodology for evaluating the impact of pandemic and quarantine on mental health. second, the development of a web-based platform for data collection will give us the opportunity to recruit a high number of participants. based on previous population surveys carried out in italy, an ideal target would have been , participants, but this target has been reached in only days. therefore, we expect to reach more than , people within the study period. a third relevant strength of our study is the selection of validated and reliable assessment instruments, which are available and validated in several languages. the next step of the project will be to adapt our survey to the european level, by involving several countries. fourth, several psychopathological dimensions will be evaluated, not only those usually assessed following natural disasters, such as the post-traumatic and depressive-anxious dimensions. in this study, we will also evaluate the obsessive-compulsive spectrum, the suicidal ideation, the maladaptive use of internet, among the others, which represent novel targets for psychiatrists ( , ) . our study has obviously also some limitations. in particular, the study sample includes the adult population only, due to existing restrictions related to the provision of informed consent of children and adolescents in italy. however, it is likely that the pandemic will have a detrimental impact on the mental health of adolescents as well ( , ) . moreover, being exposed to a traumatic event during early life is associated with alterations in the social, emotional, and cognitive development and could determine a variety of impairment in the adulthood. the effects of the pandemic on children and adolescents will be evaluated in an ad hoc study, in which we will explore the relationship between parents and their underage children during the pandemic. another limitation is related to the recruitment process, which might partially bias our findings, since only persons interested in the topic of the survey may have voluntarily participated. however, we expect that most people are interested in participating in the survey given the global magnitude of the current traumatic threat with collective psychological and social reactions. another possible limitation of our study is the choice to use a web-based online survey, which may have limited the participation of people not having access to the internet or not familiar with online tools, particularly the elderly. the cross-sectional design of the study does not allow an evaluation of changes over time as regards the levels of severity of symptoms. however, in order to overcome this possible bias, we will compare our findings with those already available from the italian population ( ) and will adopt a propensity score approach in order to understand the impact of the duration of exposure to the pandemic on the risk of developing psychiatric symptoms. with this methodology, we will be able to evaluate the levels of post-traumatic growth and the type of resilience styles in the study population in order to identify possible critical areas to be targeted in the post-acute phase. however, these psychological constructs are slow to change, and this is why we will promote a second wave of the survey, which will start six months after the end of the "lockdown phase" in italy. finally, the survey link can be used multiple times in order to allow sharing and re-posting it. this methodological choice could bias the findings, since the same person can potentially compile the survey several times. however, this methodological choice was due to the adoption of the "snowball" sampling, and it is rather unlikely that someone can compile the same long survey more than once. based on the findings of this study and on our previous work in the development of psychosocial interventions ( - ), we aim to develop a psychosocial intervention which will include elements of classic psychoeducation, cognitive-behavioral therapy, and motivational intervention ( ) ( ) ( ) ( ) ( ) . in particular, we are developing an experimental intervention which includes information on the mental health consequences of the pandemic and on strategies to prevent them; practical advices for promoting healthy lifestyle behaviors (e.g., healthy eating, regular sleeping patterns, physical activity, etc.); stress-management techniques; communication strategies; problem-solving skills. based on participants' needs, additional sessions on suicide prevention, burn-out, and internet dependence may be provided. the intervention will include face-to-face sessions and telemental health sessions ( , ) . information will be provided through instant messages (e.g., chatbot), email contacts, and the development of an ad hoc app. the modules of the intervention will be adapted according to the characteristics and the needs of the four above-mentioned target groups. in particular, in the covid- quarantine group, the main focus of the intervention will be the improvement of healthy lifestyle behaviors; for the covid- + patients group, the intervention will include a specific focus on post-traumatic symptoms and on the risk of being socially stigmatized; for the covid- healthcare staff group, specific sessions will be dedicated to the burn-out syndrome and the management of stressful situations; for the covid- mental health group, sessions on resilience, coping strategies, and the detection of early warning signs of relapses will be included. the proposed experimental intervention will be tested in a randomized controlled trial which will start when the acute phase of the pandemic will be over, and the control group will be represented by an informative group intervention on the effects of the pandemic on mental health. moreover, our survey is going to be translated into different languages in order to assess the impact of the pandemic in other european countries. the pandemic and the quarantine may have a detrimental impact on mental health. an increase of psychiatric symptoms and of mental health problems in the general population is expected. most health professionals working in isolation units and resuscitation departments very often do not receive any training or support for their mental health care. mental health services worldwide are not prepared to manage the short-and long-term consequences of pandemic. it is necessary to have a clear picture of the impact that these new stressors are having on mental health and well-being in order to develop and disseminate appropriate preventive interventions for the general population as well as for the different atrisk groups. this study is being conducted in accordance with globally accepted standards of good practice, in agreement with the declaration of helsinki and with local regulations. the study protocol has been approved by the ethical review board of the university of campania "l. vanvitelli" (protocol number: /i). vg, gais, ml, vv, and af designed the study and wrote the protocol. ua, gc, cc, fc, bdo, mn, mp, gabs, at, and uv revised the draft of the paper. all authors contributed to the article and approved the submitted version. we are very grateful to the healthcare professionals, patients, and general population who have dedicated their time to participate in our study. the consequences of the covid- pandemic on mental health and implications for clinical practice the psychological impact of quarantine and how to reduce it: rapid review of the evidence the emotional impact of coronavirus -ncov (new coronavirus d i s e as e) . p s y c h ia global mental health: how are we doing public responses to the novel coronavirus ( -ncov) in japan: mental health consequences and target populations mental health care measures in response to the novel coronavirus outbreak in korea the mental health of medical workers in wuhan, china dealing with the novel coronavirus ecological disasters and mental health: causes, consequences, and interventions. front psychiatry ( ) social support, interpersonal, and community dynamics following disasters caused by natural hazards development of a comprehensive, sustained community mental health system in post-earthquake haiti the psychological effects of quarantining a city prevalence of psychiatric morbidity and psychological adaptation of the nurses in a structured sars caring unit during outbreak: a prospective and periodic assessment study in taiwan the immediate psychological and occupational impact of the sars outbreak in a teaching hospital severe acute respiratory syndrome (sars) in hong kong in : stress and psychological impact amongfrontline healthcare workers quality of life and psychological status in survivors of severe acute respiratory syndrome at months postdischarge stress and psychological distress among sars survivors year after the outbreak posttraumatic stress, anxiety, anddepression in survivors of severe acute respiratory syndrome (sars) wen soon s. psychosocial and coping responses within the community health care setting towards a national outbreak of an infectious disease psychosocial impact among the public of the severe acute respiratory syndrome epidemic in taiwan mental health burden for the public affected by the covid- outbreak in china: who will be the high-risk group? loneliness and social internet use: pathways to reconnection in a digital world quality of life, and mental health outcomes in post-disaster urban environments: the l'aquila earthquake experience impact of the covid- pandemic on mental health and quality of life among local residents in liaoning province, china: a cross-sectional study vicarious traumatization in the general public, members, and non-members of medical teams aiding in covid- control mental health and the covid- pandemic a nationwide survey of psychological distress among chinese people in the covid- epidemic: implications and policy recommendations public mental health crisis during covid- pandemic measuring and improving the quality of mental health care: a global perspective improving the quality of global mental health care requires universal agreement on minimum national investment prevention of depression will only succeed when it is structurally embedded and targets big determinants a user's guide to the general health questionnaire manual for the depression anxiety & stress scales the obsessive-compulsive inventory: development and validation of a short version the insomnia severity index: psychometric indicators to detect insomnia cases and evaluate treatment response american psychiatric association. severity of acute stress symptoms-adult (national stressful events survey acute stress disorder short scale [nsesss]) the suicidal ideation attributes scale (sidas): community-based validation study of a new scale for the measurement of suicidal ideation brief measure of posttraumatic stress reactions: impact of event scale- a short-form measure of loneliness you want to measure coping but your protocol' too long: consider the brief cope a short form of the posttraumatic growth inventory development of a new resilience scale: the connor-davidson resilience scale (cd-risc) the multidimensional scale of perceived social support family burden in bipolar disorders: results from the italian mood disorder study (imds) maslach burnout inventory immediate psychological responses and associated factors during the initial stage of the covid- ) epidemic among the general population in china the italian version of the depression anxiety stress scales- : factor structure and psychometric properties on community and clinical samples multiple imputation for nonresponse in surveys the propensity score an evaluation of inverse probability weighting using the propensity score for baseline covariate adjustment in smaller population randomised controlled trials with a continuous outcome the outbreak of covid- coronavirus and its impact on global mental health post-traumatic growth in mental health recovery: qualitative study of narratives mental health and wellbeing among italian medical students: a descriptive study the mental health consequences of covid- and physical distancing: the need for prevention and early intervention social distancing in covid- : what are the mental health implications? digital phenotyping: a global tool for psychiatry digital interventions in severe mental health problems: lessons from the actissist development and trial the "online brain": how the internet may be changing our cognition towards a consensus around standards for smartphone apps and digital mental health the efficacy of app-supported smartphone interventions for mental health problems: a meta-analysis of randomized controlled trials baseline characteristics and outcomes of patients infected with sars-cov- admitted to icus of the lombardy region posttraumatic stress symptoms and attitude toward crisis mental health services among clinically stable patients with covid- in china timely mental health care for the novel coronavirus outbreak is urgently needed icd- ptsd and complex ptsd: structural validation using network analysis post-traumatic stress disorder: a state-of-the-art review of evidence and challenges psychological status of medical workforce during the covid- pandemic: a cross-sectional study factors associated with mental health outcomes among health care workers exposed to coronavirus disease exploring ptsd in emergency operators of a major university hospital in italy: a preliminary report on the role of gender, age, and education dsm- ptsd and posttraumatic stress spectrum in italian emergency personnel: correlations with work and social adjustment the role of mental health home hospitalization care during the covid- pandemic mental health during and after the covid- emergency in italy patients with smi in the age of covid- : what psychiatrists need to know the role of psychiatry in modern medicine unmet needs in modern psychiatry intergenerational transmission of trauma effects: putative role of epigenetic mechanisms resilience from a developmental systems perspective efficacy of psychoeducational family intervention for bipolar i disorder: a controlled, multicentric, real-world study lifestyle working group. a randomized controlled trial on the efficacy of a psychosocial behavioral intervention to improve the lifestyle of patients with severe mental disorders: study protocol psychoeducational intervention for perinatal depression: study protocol of a randomized controlled trial family management of schizophrenia: a controlled study of clinical, social, family and economic benefits a protection motivation theory of fear appeals and attitude change toward a theory of motivational interviewing scaling up psychological treatments for common mental disorders: a call to action hickie ib. the role of new technologies in monitoring the evolution of psychopathology and providing measurement-based care in young people the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. key: cord- -x l zgfd authors: patil, vijaykumar; ingle, d. r. title: an association between fingerprint patterns with blood group and lifestyle based diseases: a review date: - - journal: artif intell rev doi: . /s - - -w sha: doc_id: cord_uid: x l zgfd in the current era of the digital world, the hash of any digital means considered as a footprint or fingerprint of any digital term but from the ancient era, human fingerprint considered as the most trustworthy criteria for identification and it also cannot be changed with time even up to the death of an individual. in the court of law, fingerprint-proof is undeniably the most dependable and acceptable evidence to date. fingerprint designs are exclusive in each human and the chance of two individuals having identical fingerprints is an exceptional case about one in sixty-four thousand million also the fingerprint minutiae patterns of the undistinguishable twins are different, and the ridge pattern of each fingertip remain unchanged from birth to till death. fingerprints can be divided into basic four categories i.e. loop, whorl, arch, and composites, nevertheless, there are more than interleaved ridge and valleys physiognomies, called galton’s details, in a single rolled fingerprint. due to the immense potential of fingerprints as an effective method of identification, the present research paper tries to investigate the problem of blood group identification and analysis of diseases those arises with aging like hypertension, type -diabetes and arthritis from a fingerprint by analyzing their patterns correlation with blood group and age of an individual. the work has been driven by studies of anthropometry, biometric trademark, and pattern recognition proposing that it is possible to predict blood group using fingerprint map reading. dermatoglyphics as a diagnostic aid used from ancient eras and now it is well established in number of diseases which have strong hereditary basis and is employed as a method for screening for abnormal anomalies. apart from its use in predicting the diagnosis of disease; dermatoglyphics is also used in forensic medicine in individual identification, physical anthropology, human genetics and medicine. however, the machine and deep learning techniques, if used for fingerprint minutiae patterns to be trained by neural network for blood group prediction and classification of common clinical diseases arises with aging based on lifestyle would be an unusual research work. the study of fingerprint patterns was introduced by dr. harold cummins in but it is already in use before several hundred years ago. fingerprint patterns have been normally used for identification of an individual. now a days every organization or even may government institutes in india, use fingerprint verification to identify everyone uniquely and it also have been used as a biometric modality for gender and age identification. an individual is their own key; behind this catchy principle biometrics have become an attractive alternative to traditional identification methods such as tokens or passwords (fernandes et al. ) . current fingerprint matching methods were started in the sixteenth century. it was henry fauld in who first experimentally proposed the singularity and uniqueness of fingerprint. herschel (ravindran et al. ) added to the establishment of current fingerprinting identification. in the nineteenth century sir francis galton (mcbean et al. ) directed broad investigations and ordered the sorts of fingerprints relying on essential example as loops, whorls and arches. it was cummins (ferraz et al. ) who authored the expression "dermatoglyphics (derma ¼ skin, glyphic ¼ bends), to dermal edge arrangements on the digits, of palms and sole and furthermore demonstrated that edge design are resolved incompletely by heredity or natural impact which produce pressure and strain in their development during fetal life. the fingerprint design whorl might be winding, oval, roundabout or any assortment of a loop and record for around %. arches are the basic type up till now uncommon (about %). the fingerprint design has edges running from one side to the opposite side of the print without having any re-bend. the term composite is utilized for mix of type example that doesn't fit into any of the above characterization (azhagiri et al. ) . till date, analysts or researches have generally used fingerprint details as perspectives to build up any individuals uniqueness. the ridge patterns have been comprehensively classified into five different kinds called as arch, tented arch, whorl, ulnar and radial loop. an individual can have any of the above type in any of the its fingers. all things considered, dominant part of fingerprints found in populace review shows that percent of the prints are loops, - percent being whorls though just to percent consider arch or tented arch patterns or designs (singh and majumdar ) . some examinations done on twins have presumed that monozygotic or indistinguishable twins have comparable however not indistinguishable examples found. dermatoglyphics as a diagnostic aid used from ancient eras and now it is well established in number of diseases which have strong hereditary basis and is employed as a method for screening for abnormal anomalies. fingerprint minutiae patterns of ridges are determined as unique through the combination of genetic and environment factors. person identification using fingerprint algorithms are well sophisticated and are being established all over the world for security and authentication. the fingerprint also used to classify gender and age group but very few manual attempts have been made to explore relationship between fingerprint patterns with blood group and common clinical diseases like hypertension, type- diabetes and arthritis. it will be helpful for anthropologists to predict blood group and classify common clinical diseases than conventional pathological techniques from the fingerprints those are obtained from mined articles using deep learning techniques for early reminder to prevent such common clinical diseases those arises with aging and also crime investigators to minimize the range of the suspects it would be predicted using deep neural network. the dermatoglyphics and its important role in the diagnosis of different diseases like hypertension, type- diabetes and arthritis with genetic bases. apart from its use in predicting the diagnosis of disease; dermatoglyphics is also used in forensic medicine in individual identification, physical anthropology, human genetics and medicine. the research work is aimed in developing the deep neural network algorithms for accurate classification of the fingerprints obtained which include: • to enhancement fingerprint image during sampling or in data set preparation step fingers of an individual recorded using fingerprint scanner. to enhance the fingerprint images precisely, the research focuses to develop various pre-processing algorithms like-segmentation, normalization, orientation estimation, ridge frequency estimation, gabor filter and binarisation and thinning etc. • to extraction of features from fingerprints and finding similarity vector to build similarity vector using features of captured sample images of fingerprint required a feature extraction algorithm. the implementation of the biometric features extraction algorithms needs to extract features like-the ridge count, ridge thickness to valley thickness ratio (rtvtr), white lines count, ridge count asymmetry, minutiae map(mm) orientation collinearity maps(ocm), gabor feature maps(gfm), orientation map (om) for pattern type, d wavelet transform (dwt) • to predict blood group by using extracted feature of fingerprints the unsupervised machine learning technique will apply for classification of blood group which helps to identify relationship patterns of different features of fingerprints with abo blood type and then prediction will perform with the application of machine learning and convolutional neural network (cnn) technology with the help of rigid frequency count and distance formula to conclude blood group from feature vector. • to classify and analyse lifestyle diseases like hypertension, arthritis and diabetes normally common clinical diseases arise with the age but, now in current era these are no more only relevant to the age; due to busy schedule or lifestyle of an individual they arise at any stage of life. with the fingerprint images and blood group of an individual, the dataset include the external attributes like age, weight, height, skin color, eyes color, work nature, eating habits (vegetarian or non-vegetarian), region (rural or urban), addiction (if any like drink, smoke), etc. the rest of the paper is organized as follows. the conceptual background discussed in sect. . the literature review specificity discusses all the methods used in sect. and the evaluation and discussion included in sect. which illustrates the summary of different dataset/samples and methodologies used. finally, in sect. , we conclude the paper. the common types of fingerprint are as arch, tented arch, whorl, ulnar and radial loop, the fig. shows the different types of whorl patterns from fingerprint design. a whorl is portrayed by two deltas and one focal roundabout center. the center may have various examples. it might be winding, concentric circles, vertically compacted circles or even of the state of eye of a peacock quill. the edges start from one end, rise and hover towards the middle and go down towards the opposite end. recent advanced studies in genetics and developmental biology have guaranteed that the various projections of the human mind are physiologically associated with various fingers of both the hands. the practical coordination represented by the left half of the cerebral side of the equator is identified with the fingers of the right hand and the other way around. consequently, the focalized left half of mind is associated with the fingers of right hand, the thumb is facilitated by the unrivaled frontal projection, index is associated with the mediocre frontal flap, middle finger with parietal projection, ring finger with the fleeting projection and little finger with the rear piece of cerebrum, which is the occipital flap. correspondingly, the left half of the mind is associated with similar flaps of the cerebrum. each projection zone is liable for a portion of the other impression of the encompassing (singh and majumdar ) . tented arch is a pattern that is portrayed by a straight upstanding edge at the center of a straightforward arch pattern. loops are the most ordinarily up-to-the-minute highlights on a person's fingerprints just as in a subjective example space of a few fingerprints shown in figs. and . they are described by edges that start trickling out of a crosswise of the fingertip, circle from place to place the focal point of finger cushion, and back to a similar course where they began from. these loops can either flee from the thumb. because of an individual area of arm bones-radia and ulna, any loop opening endlessly from thumb is an ulnar loop, and the one which opening near the thumb is a radial loop. a spiral whorl is described round patterns that are fit as a fiddle at the core or center. this pattern has two deltas at the two corners. the concentric whorl pattern is showed by having concentric rings of edge patterns. lengthened whorl pattern is described by a long oval whorl flanked by two triradial on either side. every single other component of a whorl is likewise present right now a pattern. it is one of the uncommon fingerprint patterns. it appears to be a tai-chi pattern at the inside or the center, encompassed by different roundabout layers of edges. since the image has two symmetric yet oppositely situated arrangements, the subjects having imploding whorls grandstand doublemindedness. composite whorl or twofold circle is one of the uncommon fingerprint patterns. it is either present on thumb or at most, the index finger. it is once more, one of the uncommon whorl patterns that contain a peacock's eye-molded circle contained inside a whorl. the center comprises of more than one spiral which are lined by a straight line at one of the corners. it to some degree seems as though the pattern on a peacock's tail quills. this pattern ought to have one triradius on either the left or right side. at the point when a pattern can't unmistakably have the option to sort into any of the above pattern types, comprises a blend of at least two above talked about patterns like a combination of concentric whorl and transformed loop and so on., it is professed to be a variation pattern. they don't contain any plain arch or loop, be outspread or ulnar. they do exclude any regular pattern. although people have been utilizing fingerprints as a methods for recognizable proof for quite a while however right now, have put forth an attempt to make stride further to "study a connection between pattern of fingerprint and abo rh blood group", with the goal that one can get a thought regarding the normal blood group from the investigation of finger impression pattern and the other way around. natural attributes like fingerprints and blood groups can't be overlooked and imitated like keys, passwords, and so on subsequently are viewed as increasingly dependable, true and solid in scientific sciences. other than an investigation of "blood group" commonness in itself isn't just significant for transfusion medication yet additionally for organ transplantation and hereditary research, forecast of specific malignancies/infections for certain blood groups just as in advancement contemplates that help researchers to comprehend the spot person involve in development's stretching tree (fayrouz et al. ) . different types of fingerprint patterns are as follows: there are four unlike whorl patterns as: the plain whorl, the central pocket loop, the double loop, and the accidental whorl also it has different kinds of form shown in figs. , and . their normal highlights are that they have at any rate two deltas and at least one of the ridgelines bends around the center to shape a circle or winding or other adjusted, continually bending structure. the accidental whorl can be any pattern or blend of patterns that don't fit into any of the above characterizations. the expression "composite" is utilized to portray such patterns. positive distinguishing proof utilizing fingerprints can be set up just if to purposes of closeness exist in the minutiae (kanchan and chattopadhyay ; vij ; subrahmanyam ). arches are the most straightforward patterns and furthermore the rarest. there are two sorts: plain arches and tented arches. in these two types, the ridgelines stream into the print from one side, an ascent in the pattern, and stream out to the opposite side of the print. loops are shaped by ridgelines that stream in from one side of the print, clear up in the middle like a tented arch, and afterward bend back around and stream out or will in general stream out as an afterthought from where they entered. loops are assigned as being either spiral or ulnar, contingent upon which side of the finger the lines enter. the loop is the most well-known of the considerable number of patterns. target/concentric whorl spiral whorl concentric whorl elongated whorl imploding whorl imploding whorl accidental whorl or variant accidental whorl or variant most programmed frameworks for unique fingerprint examination depend on minutiae coordinating minutiae are neighborhood discontinuities in the finger impression pattern. an aggregate of distinctive minutiae types have been recognized some of the minutiae forms shown in fig. . the ridge closure and ridge bifurcation minutiae types are employed as unique mark of acknowledgment. now a day's biometric applications are designed for • authentication or identification of an individual applications like e-records security, cellular phones access, medical records management, library access and virtual learning etc. • e-governance: like, digital signature, aadhar cards, driver's licenses, border travel control, passport control, and welfare-disbursement etc. • digital forensic: such as, corpse identification, criminal investigation, terrorist identification, parenthood determination, and missing children (ramasubramanian and alexander ). blood group structures were discovered way back in by karl landsteiner. total foremost groups have been identified which vary in their occurrence of spreading various races of mankind. clinically, only 'abo' and 'rhesus' groups are of major importance. 'abo' system is additional discriminated as a, b, ab, o blood group types according to presence of corresponding antigen in plasma ). yet another biological record that remains unchanged throughout the lifetime of an individual is the blood group. determining the blood group of a person from the samples obtained at the site of crime, helps identify a person. landsteiner classified blood groups under the abo blood group system (imaq ) . dermatoglyphics as a diagnostic aid used from ancient eras and now it is well established in number of diseases which have strong hereditary basis and is employed as a method for screening for abnormal anomalies. the study of possible predilection of certain disease and malignancies from blood groups are some of the factors which encourages one to carry the study further. fingerprint minutiae patterns of ridges are determined as unique through the combination of genetic and environment factors. the identification of minutiae shown in fig. , it shows minutiae like ridge ending & bifurcation. dermatoglyphics and its important role in the diagnosis of different diseases like hypertension, type- diabetes and arthritis with genetic bases. machine learning is getting popular in all industries with the main purpose of improving revenue and decreasing costs; by using machine learning technique they automate and optimize their process to solve challenging tasks very efficiently. the proposed research work aims in creating a system that finds the relationship between blood group and minutes patterns of fingerprints which will be helpful to predict blood group and common clinical diseases of an individual by analyzing its fingerprints. the fingerprint having basic four categories which are loop, whorl, arch and composites but also there are more than interleaved ridge and valleys which explore unique characteristics of an individual which will help to design deep neural network or convolutional neural network (cnn) which predict blood group and common clinical diseases like hypertension, type -diabetes and arthritis. all ten fingerprints will be acquired in real time of both male and female from different age group and from various locations of country by using optical fingerprint scanner with external characteristics to from the large dataset as process. the fingerprint data will be acquiring using fingerprint scanner. all fingers of an individual are scanned to build dataset for training model with other necessary data collected by simple registration form where external attributes like age, weight, height, skin color, eyes color, work nature, eating habits (vegetarian or non-vegetarian), region (rural or urban), addiction (if any like drink, smoke), etc. will be recorded. the obtained fingerprint from database goes through various preprocessing stages for enhancement and removing the noise before feature extraction process which include segmentation, normalization, orientation estimation, ridge frequency estimation, gabor filter, binarisation and thinning from which the orientation estimation and ridge frequency estimation. after the preprocessing of fingerprints, it goes through four steps of feature extraction, one is frequency domain feature vector obtaining by undergoing image through different levels of processing to build feature vector from acquired finger dataset. the all combined vectors within the dataset will then be allowed to pass for unsupervised training model. it uses clustering technique which helps to find similarity measure or relationship between features of fingerprint and external attributes. the clusters formed by unsupervised learning attempts to build neural network model which is deep neural network technique including features extracted from fingers and external attributes of an individual, it will be used to generate predictive model to know the blood group of an individual as well as it used to analyses disease arises with aging. the deep neural network model uses similarity measures or minimum distance for the entire combined feature vectors database. the proposed study divided into four different cases as prediction of blood group, analysis and classification of hypertension disease, analysis of arthritis disease and analysis of diabetics disease. to work out the blood group of an individual, red cells of that individual are blended in with various neutralizer arrangements. if, for instance, the arrangement contains hostile to b antibodies and the individual has b antigens on cells, it will cluster together. on the off chance that the blood doesn't respond to any of the counter an or hostile to b antibodies, it is blood group o. a progression of tests with various kinds of antibodies can be utilized to distinguish blood group. on the off chance that the individual has a blood transfusion, the blood of the individual will be tried against an example of contributor cells that contains abo and rhd antigens. if there is no response, contributor blood with a similar abo and rhd type can be utilized. it shows that the blood has responded with certain antibody and is hence not perfect with blood containing that sort of counteracting agent if the blood doesn't agglutinate, it demonstrates that blood doesn't have antigens restricting the extraordinary immune response in the reagent. in the current framework, the blood group is resolved physically. right now, arrangements, for solutions such as anti-a, anti-b, anti-d to the three samples of blood occurred. after some time, agglutination might happen. contingent on the agglutination, the blood group can be controlled by the individual physically. the weaknesses of this framework are more odds of human blunders are conceivable. only specialists can tell the blood type by observing at the agglutination procedure. the traditional method of distinguishing the blood group is usually the plate test and the tube test . both of which are performed by under comprehensive analog procedures with human observation. in the current era of digitization, it is not an efficient way to handle such a basic yet indispensable medical technique in a full analog atmosphere. there are also a few techniques such as micro plate testing and gel centrifugation ramasubramanian and alexander ) . fernandes et al. ( ) presented result in his research paper allow concluding that abo, rh phenotype, reverse, and crossmatching individuals blood group is possible with the developed device and procedure. they proposed device that allows blood type identification near the patient, outdoor a conventional laboratory, without the need of to be a specialized assistant to interpret the test result of blood, and in a very short time ( min). the fast response time by device enables us it will be used in emergency situations, which is an advantage compared with the automatic commercial systems used in clinical laboratories (in average, response time of min). in addition, the methodology and test protocol applied to the sample's preparation is simple, without the need of sample dilutions or incubations. the prototype was implemented with noncomplex electronic components for a low-cost device. the implemented device distinguishes agglutinated from non-agglutinated samples using a classification algorithm (developed by the authors), based on the variation of od discrete values of samples, for each blood test. the device operation was validated for abo, rh phenotype, reverse, and crossmatching human blood typing based on donor's blood samples provided by the ipst and test results agreed with their typing using their gold standard commercial and automatic systems. the examination group is working in the advancement of programmed and scaled down gadgets for clinical applications. a case of this work is the advancement of a scaled down, minimal effort, versatile and programmed framework to blood typing in crisis circumstances, considering a spectrophotometric approach and within the sight of agglutination (cooperation between red blood cells' surface and explicit reagents). the use of a basic and quick exploratory convention permits deciding blood typing and empowers the structure of an electronic programmed framework. this framework will be helpful to decrease a few impediments of the current frameworks and techniques to blood typing. the outcomes can be influenced by a few variations that makes more enthusiastically the structure of a programmed framework, for example, the trial framework utilized for spectrophotometric estimations; the agglutination quality, which influence the contrasts among control and test samples; the time spent in test readiness since it is important blood and reagents weakening; and perform spectra estimation as quickly as time permits in light of the fact that the agglutinated cells continuously will in general settle in the base of the cuvette. proposed method by fernandes et al. ( ) depends on the examination of the rh phenotypes in human blood type dependent on the plate test and utilizing a spectrophotometric approach. this examination will be remembered for the versatile gadget recently created by the exploration group for deciding abo human blood type. in this way, this paper presents the rh phenotype assurance, including the d, c, c, e and e antigens, utilizing optical retention estimations, in the obvious range, to recognize an agglutinated test (cooperation among antigens and antibodies) from a non-agglutinated test (no association). to decide the nearness or nonappearance of every antigen five samples were set up by setting f. ll of the particular reagent and . f.ll of entire blood in the plate, as depicted in the reagents manual. every arrangement was blended for around one moment in a region of . cm . at that point, the plate was situated in the estimating set-up of the spectrophotometer. an o.d. range estimation of the f.ll reagents was likewise important to set the pattern and to additionally adjust the necessary gadgets. the authors presents the standards for the improvement of a scaled down, ease, compact and programmed framework, in view of a spectrophotometric approach, are introduced. the framework will have the option to decide abo and rh blood types in a brief timeframe and in situ, which is reasonable to crisis circumstances and permit the blood typing outside an ordinary clinical research facility. for that, the essential components of the framework ought to be: a light source, a light receptor and a microcontroller. . approval of the general test convention the convention applied in the framework use blood samples (from the portuguese blood institute) and business antibodies as reagents (monoclonal anti-an, anti-b, anti-ab and polyclonal anti-d from hos lab diagnostic). four test samples should be set up for each blood test. each test is acquired by blending blood in with a immune response. blending blood in with the reagents it tends to be acquired two kinds of samples: agglutinated, if there is antigen-counter acting agent connection; or non-agglutinated if there is no association. for instance, blending a positive blood type with anti-a, anti-ab or anti-d it is gotten an agglutinated test since this blood type has the a and d antigens. with the anti-b, it is gotten from a non-agglutinated test. . scaling down of the test framework after the approval of the spectrophotometry estimations to human blood typing, with the use of a quick and straightforward convention, the following stage was the execution of a particular light source framework by utilizing light emitting diodes (leds) and a photodiode estimating gadget (s - bq photodiode from hamamatsu), e.g., keeping away from the massive and costly framework dependent on a light source and monochromator. ramasubramanian and alexander ( ) a coordinated fiberoptic a microfluidic gadget for the location of agglutination for blood type crossmatching has been portrayed. the gadget comprises of a straight microfluidic channel through with a responded rbc suspension is siphoned with the assistance of a syringe siphon. the stream meets an optical way made by a producer got fiber optic pair incorporated into the microfluidic gadget. a nm laser diode is utilized as the light source and a silicon photodiode is utilized to recognize the light power. the separating between the tips of the two optic filaments can be balanced. at the point when fiber separating is enormous and the centralization of the suspension is high, the dispersing wonder turns into the prevailing system for agglutination identification while at low focuses and little dividing, opto-interruption turns into the predominant component. an agglutination quality factor (asf) is determined from the information. studies with an assortment of blood types demonstrate that the detecting technique effectively distinguishes the agglutination response in all cases. a dispensable coordinated gadget can be intended for future usage of the strategy for the close bedside pre-transfusion check. stomach muscle positive blood type will respond with against a, hostile to b, and against d antibodies and cause agglutination. henceforth, we just present outcomes for ab positive sort in detail right now. the information is illustrative of the outcomes acquired mouad. ali et al. ( ) proposed fingerprint recognition framework is separated into four phases. first is the acquisition stage to catch the fingerprint picture, the second is the preprocessing stage to enhancement, binarization, thinning fingerprint picture. the third stage is the feature extraction stage to remove the element from the thinning picture by use minutiae extractor strategies to separate ridge ending and ridge bifurcation from thinning. the fourth stage is coordinating (identification, verification) to coordinate two minutiae focuses by utilizing the minutiae matcher technique in which closeness and distance measurements is utilized. the calculation is tried precisely and dependably by utilizing fingerprint pictures from various databases. the fingerprint acknowledgment framework is separated into three phases that are fingerprint picture pre-processing, include extraction and coordinating. the coordinating stage is partitioning into two procedure id and confirmation. at the hour of catch the fingerprint picture, the pre-processing stage is applied to it. the yield of this stage will be passed to the component extraction organize which separates the minutiae point (ridge ending, bifurcation) from thinning fingerprint picture, at that point the bogus minutiae evacuation is applied to remove genuine minutiae. at long last, the genuine minutiae are put away in tangle lab record. at that point if the fingerprint is as of now selecting? at that point send it to the coordinating stage in any case do the enrolment stage and store it in the database as a format. in id case (one-to-many coordinating), the info include set, which is coordinating with n format from the database, n coordinating will be finished. the outcome will be considered as a coordinating score. if coordinating score more like , at that point the two fingers from a similar client. if coordinating score close to zero, at that point the two fingers from deferent clients. in confirmation case (coordinated coordinating), the info includes set, which is coordinating with one layout from the database, one coordinating will be done and chosen either the information fingerprint checked or unsubstantiated. siva sundhara raja and abinaya ( ) proposed work comprises of the accompanying stages as pre-processing, feature extraction and classification, as portrayed in fig. . the input pre-processing is the method to play out certain tasks for improving pictures preceding computational processing. it is a system that is utilized to conceal the data that isn't appropriate to the picture for additional processing. the pre-processing steps incorporate the accompanying: picture enhancement, picture resizing procedure, and thinning process. the picture enhancement process amends the lucidity of ridges and valley structure in the fingerprint picture. right now, the histogram evening out technique is utilized. they have taken two types of blood gatherings. mage resizing is utilized to extend or compress the all outnumber of pixels. with the goal that it has the predetermined number of lines and sections. the focal point bending is done when we zoom the focal point, it will transform into a bent shape rather than the keener shape. thinning is a morphological activity that is utilized to dispose of picking front picture components from double pictures. the feature extraction is a technique for catching the visual substance of pictures for ordering and recuperating. the methodologies depend on glcm, wavelet features, laws of surface features, minutiae extraction. the major features of the fingerprints like ridge endings, ridge bifurcations are called minutiae shown in fig. . minutiae states the distinction between one fingerprint from another fingerprint. a ridge ending is the place the ridge suddenly ends while ridge bifurcation is the place the ridge isolates into at least two branches. the extraction of minutiae turns out to be even more testing on account of the commotion present and lack of difference in the picture. ravindran et al. ( ) proposed work taken blood sample images and pre-processed it by using various techniques such as color plane extraction, color to gray image conversion. these blood image pre-processing terms can dramatically increase the uniformity of a visual investigation of collected samples. also, they are applied several filter processes which strengthen or reduce certain image details enable an easier or faster assessment. operators can augment a camera image with just a few clicks. filtering encompasses several image filters for image optimization mixed filter for edge detection improvement, noise suppression, character alteration, etc. image processing includes it includes several functions for image processing. contrast increase by static or dynamic binarization, lookup tables or image plane separation. resolution reduction via binning. the methodology proposed by rhiannon s. mcbean et al. ( ) having two different genetic technologies: single nucleotide variant (snv) mapping by dna microarray and second method was massively parallel sequencing (mps), concerning blood bunch genotyping. the steadiest transmissible change related with blood group bunch antigens are snvs. to perform prediction of the blood type antigen phenotypes, snv mapping which includes profoundly multiplexed genotyping can be performed on business microarray stages. microarrays recognize just known snvs, along these lines, to type uncommon or novel alleles not represented in the cluster, further sanger sequencing of the district is frequently required to determine genotype. a model talked about right now the recognizable proof of uncommon and novel rhd alleles in the australian populace. enormously equal sequencing, otherwise called cutting edge sequencing, has a high throughput limit and maps all purposes of variety from a reference grouping, taking into consideration recognizable proof of novel snvs. instances of the use of this innovation to determine the hereditary premise of vagrant blood bunch antigens are presented here. in general, the assurance of a full profile of blood bunch snvs, notwithstanding serological phenotyping, gives a premise to the arrangement of perfect blood in this manner offering improved transfusion security. ferraz et al. ( ) has developed technique that allows to analyses an image captured by a ccd camera detecting the occurrence of agglutination, through image processing techniques developed for determine the occurrence of agglutination. secondly allows determine the blood type of the patient through the classification algorithm developed. finally, allows store the information in a database built. the built database can store images captured and used in image processing techniques (each image contain four samples of blood and reagent), the standard deviation calculated in each four samples of the image, the result based by the value of standard deviation obtained for each of the samples (if agglutinated or not agglutinated in the sample of blood and reagent) and the result obtained by the classification algorithm (corresponding of blood type).the image will be processed by image processing techniques developed with the imaq vision software from national instruments (imaq ) . the descriptions of all the functions presented are presented in the references mentioned (imaq ; relf ) . the strategy proposed in tejaswini and mallikarjuna swamy ( ) caught pictures of slide tests were a camera comprises of a shading picture made from three examples of blood and reagent. the picture preparing technique is probed the few pictures gained. these pictures are prepared utilizing matlab programming. the picture preparing strategies, for example, shading plane extraction, thresholding, and morphological activities were performed on the pictures. the picture got in the wake of applying auto thresholding grouping capacity it very well may be seen that the item and foundation are isolated. in the following stage, neighborhood limit activity utilizing niblack work is applied it ascertains a pixel-wise edge and it very well may be seen just the outskirt portioned picture. the narkis banu and kalpana ( ) and relf ( ) present the blood group identification using blood cell images which takes from slide tests. picture acquired by the utilization of cutting-edge morphology; it very well may be seen that the portioned picture is filled utilizing shutting activity. progressed morphological activity opening is performed it tends to be seen that it smoothens the shapes of cells by evacuating little articles. at that point the pictures acquired by applying the shading plane extraction hsl luminance plane and measure work. at long last, the blood gathering can be resolved. the utilization of picture preparing procedures empowers programmed discovery of agglutination and decides the blood sort of the patient in a short interim of time. the strategy is appropriate and accommodating in crisis circumstances. keerthana and ranganathan ( ) build up an inserted framework that utilizes an image preparing calculation to perform blood tests dependent on blood composing frameworks. along these lines, the framework permits us to decide the blood sort of an individual killing customary transfusions dependent on the rule of the all-inclusive contributor, decreasing transfusion response dangers and capacity of result without human mistakes. this paper helps in lessening human intercession and perform total test independently from adding antigens to definite age of the outcome and gives the outcomes in most limited conceivable term with exactness and precision alongside capacity of result for additional references. actualizing a quality framework in the lab limits mistakes and guarantees that the correct test is performed on the correct example, the correct outcomes got, and the correct blood item gave to the correct patient at the ideal time. the proposed framework presents the plan and usage of a smart compact gadget that gives the best possible data that we require for the investigation with the decreased expense and the profoundly prepared administrators are not required. this framework utilizes an ai calculation like a neural system that underpins matlab programming for blood bunch recognizable proof and identification of blood check examination. this framework additionally discovers an answer utilizing various calculations and strategies which gives us the most extreme precision in blood bunch distinguishing proof and tallying. the work proposed by berlitz et al. ( ) utilized protein a covering of the gold surface of qcm biosensors for the immobilization of antibodies against blood bunch antigens an and b, which allows the recognizable proof of the four principle blood bunches a, b, ab and with two estimations. the rhesus framework was inspected with various examinations on and the fruitful recognition of rh-d, rh-c, rh-c, rh-e and rh-e antigens on human erythrocytes. the brisk, simple and dependable identification of blood bunch antigens an and b offers the chance of deciding the patient's association to the ab blood bunch framework by two estimations on hostile to an and against b sharpened quartz sensors. in satoh and itoh ( ) author also proposed a method which uses genetic analyzer for blood group prediction is recognized by the presence of three common representative alleles such as a, b, and o, in satoh et al. ( ) the author proposed the analysis of four snps at nucleotide positions , , and to reflect serologic specificity. sensor cells organized in equal and working on weakened entire blood without earlier planning of the blood tests will lessen the necessary time to approx. min. swapping the quartz sensors, encouraged by the card mounted sensors and the licensed module holder, broadens the blood bunch investigation into the rhesus, kell and further blood bunch frameworks. in any event, for blood bunch antigens with a low antigen number for every cell, techniques are accessible to get ready biosensor coatings with satisfactorily upgraded affectability. the proposed method utilized by dalvi and kumar pulipaka ( ) three samples of blood are blended in with three distinct reagents namely anti-an, anti-b and anti-d is taken on a slide. after some time, agglutination may or may not occur. after the occurrence of agglutination, the slide containing three samples of blood blended in with three distinct reagents is captured as an image and allowed to process in matlab image processing toolbox. this framework lessens the chances of false detection of a blood group. image processing techniques utilized for blood group detection are . pre-processing techniques, . thresholding, . morphological operations, . hsl plane . quantification. the color plane contains color information in image s. 'comparing' sections in an image is the concept utilized in image processing. comparison in grayscale involves straightforward scalar algebraic operators. in color plane extraction, they first convert the rgb image into a gray image and then channel the obtained outcome utilizing median separating. thresholding operation in image processing is utilized to create binary images. the grayscale samples are grouped into two parts as background and object. right now, thresholding is performed utilizing otsu's method. more than one threshold is resolved for a given image and segmentation is done creating certain regions. one background with many objects is the consequence of this staggered thresholding. it is a bunching based image thresholding. morphological is a tool for extraction image components that are valuable in the representation. in morphological operation, there are two fundamental operations, for example, dilation and erosion as far as the union of an image with a translated shape called an organizing component. here, closing operation is performed where dilation is followed by erosion. also, edge detection utilizing the canny edge detection strategy is performed. morphological operations are utilized to eliminate noise spikes and ragged edges. hsl plane stands for hue, saturation, and luminance. it is the representation of the rgb color model. shade is expressed in a degree around a color wheel, while saturation and brightness are set as a percentage. quantification is expressed as a number or measure of quantity. it measures power only in the region of the intrigued area. area (percentage of surface examined for full image), mean (average value of the pixel), standard deviation, least and maximum values of pixel power are resolved. also, region properties are extracted. utilizing the value of standard deviation, the occurrence of agglutination is recognized and accordingly the blood group is resolved. fayrouz et al. ( ) study reveals an association between the pattern of the unique mark and abo blood group. with ongoing advances in unique mark detecting technology and improvement in the accuracy and matching velocity of the finger impression matching algorithms, automatic personal identification is becoming an attractive/complement to the traditional methods of identification. as biometric technology matures, there will be an increased interaction among the biometric market and its identification application, since fingerprints will remain an integral part of the preferred biometric-based identification solutions in the years to come, a relationship of unique finger impression pattern to blood group presents scope for additional identification data which can be utilized for personal identification purpose, also investigation of possible predilection of certain disease and malignancies from blood groups are some of the factors which encourages one to carry the examination further. chosen randomly having distinctive abo blood groups, with the objective to a) study the distribution of unique finger impression pattern among the subjects having diverse abo and rh blood group b) correlate any relation between their characters and blood group. the data from the investigation showed that the male: female ratio was . : . most subjects ( . %) right now of blood group o followed by blood group a ( . %), b ( . %) and ab ( . %). rh-positive cases constitute about . % of all considered cases. the general distribution of the pattern of finger showed a high recurrence of loops enlisting . %; followed by whorls ( . %) and arches ( . %). in rhþve cases of blood group an and o loops occurrences were the most elevated ( % and . % individually) at that point whorls ( . % and . % separately), while in blood group b whorls were predominance in both rhþve and rh_ve cases. in all blood groups, there was the high recurrence of loops in thumb, record and little fingers. utilizes the slide test and image processing techniques utilizing the imaq vision from national instruments. the image captured after the slide test is processed and recognizes the occurrence of agglutination. next, the classification algorithm decides the blood type in the analysis. finally, all the information is stored in a database. in this way, the framework allows deciding the blood type in a crisis, eliminating transfusions based on the rule of universal donor and diminishing transfusion reaction dangers. this framework is based on a slide test for deciding blood types and the software developed utilizing image processing techniques. the slide test consists of the blend of one drop of blood and one drop of each reagent, anti-an, anti-b, anti-ab, and anti-d, being the outcome interpreted according to the occurrence or not of agglutination. the agglutination reaction means that occurred reaction between the antibody and the antigen, indicating the presence of the antigen appropriate. the combination of the occurrence of agglutination, or nonoccurrence, decides the blood kind of the patient (datasheet of diameddiaclon anti-a ; fingerprint identification -project ). accordingly, the software developed based in image processing techniques allows, through an image captured after the procedure of the slide test distinguish the occurrence of agglutination and consequently the blood sort of the patient. thakar and sharma ( ) process remarkable highlights which they found inside the fingerprint designs which make us equipped for offering input. in any case, different examinations have demonstrated that even the prepared and experienced specialists submit different sorts the fingerprint, these might be a result of the utilization of discretionary/nonstandard phrasing like clockwise/anticlockwise or bearings and so forth recorded as a hard copy a report. the traditional technique for fingerprint correlation with the focal point to find details in bearings, which is a tedious system should be changed. right now, a framework, optical sensor-based per users are utilized to peruse and gained fingerprint pictures in the accompanying three phases: firstly, picture handling calculations are utilized to get dark tone impressions of the fingerprint picture. also, the prepared picture is accordingly used to extricate the details (just bifurcations and ridge finishing). the third step is examining the position of various details (bifurcations and ridge finishing) on fingerprints, with the assistance of situation coordinated calculations. the separated pictures are contrasted, and the databases present in the framework and results are gotten. in any case, as opposed to the abovementioned, in the present examination, a semi-self-enough method has been utilized. in this way, in the present examination, a far-reaching endeavor has been made to extricate physically all the particulars present in the unique mark with the assistance of adobe photoshop (cs ) software and to build up an adjusted lattice which can be utilized to methodically discover the position of the details alongside estimating certain extra element like angle. azhagiri et al. ( ) study uncovers a huge relationship of blood groups o, a, b, ab to hypertension, peptic ulcer, anemia, rheumatoid arthritis, gastritis, diabetes, and bronchial asthma. the transcendence of the circle was most noteworthy among all blood groups. as indicated by this investigation, following outcomes were watched, loops were the most well-known unique finger impression example and arches were the least normal, whorls and blended were moderate, highest quantities of loops were found in blood groups o, b contrasted with an and ab, blood bunch o positive is the most well-known, o negative and ab negative is the rarest, loops, whorls, blended and arches were most elevated in females, group a was the most widely recognized blood bunch among guys, blood bunch o, b, were the most regularly observed blood groups in females, some basic clinical grumblings were found in all the blood groups. kanchan and chattopadhyay ( ) the result shows that each fingerprint is exceptional; loops are the most normally happening fingerprint design while arches are the least normal. guys have a higher occurrence of whorls and females have a higher frequency of loops. loops are transcendent in blood groups a, b, ab and o in both rh-positive and rhnegative people except for in o pessimistic where whorls are progressively normal. they can reason that there is a relationship between the conveyance of fingerprint designs, blood gathering, and sexual orientation and along these lines expectation of sex and blood gathering of an individual is conceivable dependent on his fingerprint design. rastogi and pillai ( ) present investigation shows that there is an association between the appropriation of fingerprint designs, blood gathering and sexual orientation. the discoveries of the examination can be finished up as follows: each fingerprint is one of a kind consequently it tends to be successfully utilized as a proof for distinguishing proof in the courtroom. loops are the most generally happening unique mark example and arches are the least normal. blood bunch o positive is the most widely recognized and a negative is the rarest. loops are overwhelming in blood bunch a, b, ab and o in both rh positive and rh-negative people except for in o adverse where whorls are progressively normal. whorls are progressively normal in blood bunch o negative. loops and arches are most extreme found in blood bunch some time whorls are increasingly regular in blood bunch o. blood groups an and b were the most widely recognized (similarly dominating) among guys, blood bunch o was the most generally observed blood bunch in females. guys have a higher frequency of whorls and females have a higher rate of loops. hence prediction of sexual orientation and blood gathering of a for every child is conceivable dependent on his fingerprint design. comparative examinations ought to be led to a bigger example in order to build the precision of prediction. joshi et al. ( ) present examination uncovers that there was an association between dissemination of fingerprint (dermatoglyphic) design, gender and blood groups. the general circulation example of the essential fingerprint was of a similar request in people with abo; rh blood groups for example high recurrence of loops, moderate of whorls and low of arches. the discoveries of the examination can be finished up as the loops are the most normally happening unique mark example and arches are the least normal, blood bunch o positive is the most well-known and a negative is the rares, loops are prevalent in blood bunch a, b, ab and o in both rh positive and rh negative people aside from in o antagonistic where whorls are increasingly normal and males have a higher occurrence of whorls and females have a higher frequency of loops. jha et al. ( ) study uncovered that blood bunch ab and o had a most noteworthy rate of loops ( . % and . % separately) trailed by whorls ( . % and . % individually), comparatively in blood bunch an and b the design of the loop was normal with . % in the two cases. the study inferred that there is a solid connection between blood groups and fingerprint design. from the examination, it was presumed that the recurrence appropriation loops design were most noteworthy in blood bunch ab ( . ), o ( . %) and b ( . %) individually. so also, the examination likewise inferred that the dispersion of whorls was most elevated in blood bunch a with . % circulation, then in blood bunch b with . % dissemination and for blood bunch ab it was discovered . % and arches were least in blood bunch b with . % appropriation. further investigation ought to be completed by expanding the example size to get the progressively exact portrayal of the populace and need increasingly comparative examinations in different districts as well with the goal that near examination should be possible. the study proposed by sudikshya et al. ( ) corresponds to the connection between different patterns of fingerprints and "abo" blood groups and "rh" blood types in nepalese guys and females. in spite of the fact that they realize that fingerprints are rarely indistinguishable and they never show signs of change from birth till death, this examination is an endeavor made to connect fingerprints with sex, diverse blood groups, and rh blood types which may thus improve the legitimacy of fingerprints in distinguishing proof and legal medication and can be utilized for conceivable prediction of specific illnesses. from the present investigation, the accompanying ends are drawn: ( ) loops are the most regularly discovered fingerprint pattern and arches are minimal normal in the two guys and females and furthermore in "abo" blood groups. ( ) the recurrence of loops is most noteworthy followed by whorls and arches in rh +ve blood types, while the frequency of whorls is most elevated followed by loops and arches in rh -ve blood types. ( ) our outcomes uncover the most elevated rate of loops in the center and little finger in all blood groups, while the whorls are usually found in ring fingers in all blood groups. the frequencies of whorls are likewise most elevated in forefinger and thumb in all blood groups aside from in blood bunch "o" where loops are as often as possible present. ( ) from this investigation, they can infer that circulation of essential pattern of the fingerprint isn't identified with sexual orientation and abo and rh blood gathering, yet its conveyance is identified with singular digits of two hands. narayana et al. ( ) they present the examination is an endeavor to relate fingerprint patterns with sexual orientation and blood gathering of a person. fingerprint patterns can be of help in anticipating the sexual orientation and blood gathering of a person. it might help in expanding the legitimacy of fingerprints in recognizable proof of people and tackling of wrongdoings. they got results areas: loops were the most generally discovered pattern and composite the least. in the loop pattern, the commonest pattern was an ulnar loop, which was measurably huge right now. blood bunch o positive was the most wellknown and ab negative was the rarest. rh-positive blood groups were more contrasted with rh-negative blood groups, which is demonstrated right now and critically dependent on the information too. blood bunch b was the most widely recognized among rh-positive blood groups followed by o, an and ab blood groups. among rh-negative b and a blood groups were similarly predominant followed by o and ab. loops were most elevated in guys, whorls and arches were most noteworthy in females. loops were prevalent in all the blood groups with the exception of a positive where whorls were prevailing. the most elevated number of the considerable number of patterns was found in blood bunch o and least in ab among rh-positive blood groups and factually demonstrated critical right now. composites were least generally found in all the blood groups. the study by sangam et al. ( ) they found the loops were connected more with o gathering, whorls with ab gathering and arches with b gathering. thumbs introduced a high recurrence of whorls in a + ves. record and ring fingers were related to the high recurrence of whorls in a-ves and ab + ves. so the prediction of blood gathering somewhat might be conceivable with the investigation of unique finger impression patterns which might be of extraordinary incentive in criminological medication, however, impact provincial varieties, sex and hereditary variables ought not to be disregarded. deopa et al. ( ) has an endeavor has been made in the present work to examine their connection with sexual orientation and blood gathering of a person. loops were the most widely recognized ( . %) fingerprint pattern while whorls were moderate ( . %) and arches were the least normal ( . %). guys had a higher rate of whorls and females had a higher frequency of loops. loops are overwhelming in blood bunch a, b, ab and o in both rh-positive and rh-negative people aside from in 'a' constructive blood bunch where whorls prevail marginally. whorls were most noteworthy in an and ab positive blood gathering, and loops were most elevated in o and b blood gathering. arches were least in all blood groups. there is an association between conveyance of fingerprint patterns, blood gathering, and sexual orientation and in this way prediction of sex and blood gathering of an individual is conceivable dependent on his fingerprint pattern. shivhare et al. ( ) does the investigation which uncovered the association between dermatoglyphic, blood gathering and sex: most subjects have a place with rh-positive and o blood gathering. loops are the regular and arches are extraordinary fingerprints. loops were most noteworthy in b blood gathering and least in ab blood gathering. whorls most elevated in an and least in b blood gathering. arches were most elevated in ab and least in b. loops higher in female and most reduced in male, whorls most noteworthy in male and least in female and arches most elevated in male and most reduced in the female. loops were most noteworthy in rh-positive and least in rh-negative. whorls most elevated in rh-negative and least in rh-positive. arches were most noteworthy in rh-positive and least in rh-negative. the investigation does by radhika ( ) uncovered that there is an association between the dissemination of fingerprint patterns, blood gathering, and sexual orientation. loop was most as often as possible seen fingerprint followed by whorl curve and composite. o positive is the most regular blood gathering and ab negative is missing. loops are dominating in blood bunch o followed by b and an in rh-positive subjects, trailed by whorls. curve and composite were basic among o and a positive subjects. morris et al. ( ) proposed method having outcomes that fingerprint asymmetry could be formed into a significant instrument for anticipating the danger of type diabetes mellitus and type diabetes mellitus and that wavelet examination is a technique that can be utilized to evaluate asymmetry in fingerprints. the benefit of fingerprints scored utilizing wavelet-based strategies over hereditary testing, is that it can demonstrate gestational condition and would be considerably less costly. the expense is significant, given late reports that both hazard mindful and chance unconscious people were keen on hereditary testing, however distinguished the requirement for minimal effort tests. they propose an increasingly far-reaching examination of fingerprint asymmetry as a predictor of both t dm and t dm chance, scoring asymmetry with wavelet investigation and contrasting with the prescient capacity of hereditary qualities alone, is justified. the propose work by used information digging veena vijayan and anjali ( ) which can be used for evaluating distinctive disease patterns, remedial data extraction, quiet support and organization and finding of clinical parameters. here a choice emotionally supportive network is recommended that predicts diabetes which utilizes choice stump as a base classifier in adaboost calculation. the framework utilizes a worldwide dataset taken from uci vault of ai for preparing which contains cases and characteristics and utilizations nearby dataset for approval which had been gathered from better places in kerala. the pc data framework with the adaboo-choice stump classifier gives a precision of . % for anticipating diabetes with an extremely low estimation of blunder rate. tafa and pervetica ( ) study the dataset which comprises of examples taken from three unique areas in kosovo. the characteristics of the database are bmi (weight file), glucose level before dinner and after the feast, the systolic and diastolic blood pressure, the genetic factor, the customary eating regimen, and day by day physical exercises. the last two qualities are assessed as follows. with respect to the issue of customary eating routine, while depending on contributions from the clinical clinicians, patients were inquired as to whether they took their dinners in roughly the same equidistant everyday interims, in any event, three times each day and furthermore if their suppers were not voluminous. the introduced approach depends on the joint usage of two calculations in matlab that have been executed on the recently gained dataset with the various credits when contrasted with the past work right now. the calculations are executed and assessed freely however the dynamic depends on the joint results from the two calculations. the point of this methodology is to settle on the choice progressively dependable. mehta and mehta ( ) study the one hundred type ii diabetes mellitus patients ( male and female) were chosen for study and contrasted and equivalent number of controls. fingerprints were acquired by a printing technique. parameters contemplated were arches, whorls, loops. circulation of fingertip patterns indicated a noteworthy contrast between diabetics and controls. the appropriation of fingertip patterns on both ways submit male diabetics and controls. the whorls were altogether expanded though loops and arches were essentially diminished in male diabetics when contrasted with controls. the whorls were fundamentally expanded while loops were essentially diminished in female diabetics when contrasted with female controls. nonetheless, arches were fundamentally diminished in the left hand of female diabetics. ameer et al. ( ) investigation right now spellbinding. an aggregate of one hundred patients partook right now was a completely known instance of diabetes mellitus. out of these one hundred patients, most of the patients were having a place with a whorl pattern of fingerprints i-e. fifty half while the number of patients having a place with the loop pattern was forty-five %, the composite was just , %, and no specific patient having a place with arch pattern. there is having to build up a definite and tremendous examination to investigate the association of fingerprint pattern with diabetic disease. this investigation offered reasonable weighting on the circulation of fingerprint pattern among diabetic disease patients. confinements of study where it was just restricted to clinical opd patients and limited uniquely to diabetes mellitus patients. the investigation by roshani et al. ( ) concluded whorls are the most regular pattern in both right and left hands of both male and female diabetic subjects and loops are the most normal pattern in both right and left hands, in the two guys and females in non-diabetic subjects. the arches were fundamentally diminished in both the right and left hand of males and females in diabetics and non-diabetic subjects. this examination shows a huge association between fingerprint patterns and diabetes in both genders. study might be helpful to distinguish the high-chance people in the populace, for type- diabetes mellitus; the most punctual prediction and finding of patients with type- diabetes mellitus will improve the aftereffect of treatment and further entanglements. notwithstanding; there are a few investigations that appeared inverse outcomes to our examination; subsequently, there is having to do additionally contemplates and bigger examples ought to be analyzed in detail to additionally approve the discoveries of this examination and arrive at a complete resolution. smail et al. ( ) examination demonstrated that the type of loop in typical guys is . %, even with the diabetes female gathering the type of loop is . %. this investigation demonstrated that the control male arches bunch is no worth which is zero, while in the patient female the arches bunch esteem is high to %. confinements of the examination gave us that the control male whorls run is . %, however for the female patients is %. which expanded worth. their investigation demonstrated that the type of loop in typical females is . %, yet in the diabetes male gathering, the type of loop is %. this investigation indicated that the control female arches bunch is . %, yet in the patient's male, the arches bunch esteem is high to %. another impediment of the examination gave us that the control female whorls run and the diabetes male or equivalent worth which is about . %. for the all-out typical and diabetes guys, the loop bunch in the ordinary male is higher than diabetes ( . % > . %). for the all-out ordinary and diabetes male the arches bunch in the typical male is lower than diabetes ( . % < %). for the allout typical and diabetes male, the entire gathering in the ordinary male is underestimating than diabetes ( % < . %). arches are found in five percent of fingerprint patterns. the ridges run starting with one side then onto the next of patterns, making no retrogressive turns. usually, there is no information in a curve pattern. igbigbi et al. ( ) have inspected the plantar and advanced prints of the sole of indigenous malawian patients matured - years going to the clinical outpatient center for diabetes mellitus, fundamental hypertension and a mix of the two conditions at lilongwe and queen elizabeth focal emergency clinics. the gathering comprised of diabetics ( guys, females), hypertensives ( guys, females) and diabetics with hypertension ( guys, females). all patients were analyzed as type diabetics after the age of years. their outcomes indicated that soles of all patients had a greater number of loops than arches and a greater number of arches than whorls, which were limited to the distal zones. in hypertension, whorls were found in zones i, ii and iii though, in patients with diabetes and hypertension, the whorls were found in zones i, iii and iv. in digits, the most prevalent ridge pattern was arches in all patients, trailed by loops and whorls were missing. in the principal digit, diabetic patients had no arches, yet ladies' hypertensives demonstrated arches. in patients with diabetes and hypertension, arches were available in both genders yet in men it was limited to the correct foot. loops were discovered distinctly in the first digit in quite a while. the recurrence of loops was most noteworthy in diabetic patients, high in diabetics with hypertension and least in patients with hypertension alone. tarca and tuluc ( ) have considered a complete number of patients with type diabetes mellitus, out of which ( guys and females) were youngsters and adolescents of ages somewhere in the range of and years. the disease showed in these cases between the age of and years. among the female patients, the loop was found in around equivalent extents in both the hands ( . % on the left hand and . % on the correct hand) while if there should arise an occurrence of typical subject the loops were found on the left side as it were. the loop dissemination on the five fingers indicated an expanded recurrence on the fingers from v and iii. whorls were increasingly visited in the male arrangement and on the correct hands. arches were increasingly visiting in the female arrangement. the presence of these markers, before the clinical sign of the disease, makes workable for their utilization in anticipation of insulin subordinate diabetes mellitus. udoaka and lawyer-egbe ( ) have considered an absolute number of ( guys and females) grown-up diabetic patients and the contrasted and the same number of ordinary subjects as controls. there was no huge contrast in the computerized patterns in the two groups. the atd point, dat edge, the absolute ridge include were fundamentally more noteworthy in the diabetic patients contrasted with the typical subjects. the pattern force record was higher in the diabetic guys however it was lower in the female diabetics. their perceptions can be utilized for distinguishing proof of diabetics. nezhad and shah ( ) have considered patients of diabetes type and typical subjects as control gathering. the mean period of patients and control bunch was ± and ± individually. among these % were guys and % were females. they have discovered that the state of loop and whorl are heterogeneous, and their number varies altogether contrast with a control gathering (p = . , p = . .). the a-b ridge includes demonstrated an expansion in the ridge considers as a real part of the diabetic men than control gathering. the atd point size in both the experimental group and control gathering of females was more than guys. these creators are of the sentiment that dermatoglyphics can be an appropriate strategy for hereditary examinations and diabetes type . sumathi and desai ( ) have considered a sum of patients of diabetes mellitus type and hypertension of either sex or age gathering of - years. they were coordinated with hundred controls. they discovered diminished a-b ridge include in female diabetics. the accompanying huge parameters have been found in their investigation in the palmar dermatoglyphics in type diabetes with hypertension. in both male and female patients, there is the nearness of diminished i pattern and nearness of expanded i pattern in the left hand. the nearness of diminished whorls saw in two hands of male patients. the nearness of expanded ulnar loops and whorls in two hands of female patients. padmini et al. ( ) their exploration concentrate on dermatoglyphics in diabetes mellitus underlined that however dermatoglyphics by and large don't assume any significant job in clinical analysis yet, it can fill in as a pointer to pick out subjects from a huge gathering of individuals for additional examinations to affirm or preclude diabetes mellitus have studied fingerprints and palmar prints from subjects, guys and females in the age gathering of years to years, of which % of cases were non-insulin subordinate diabetics and % of cases were insulin subordinate diabetics contrasted and controls. higher occurrence of variety in methods for ulnar loops ( . ), composite whorl ( . ), all-out finger ridge tally ( . ), total finger ridge check ( . ), dat points of the right hand ( . ) and left hand ( . ) in diabetics than in controls was seen by them. the rest of the parameters were low in diabetics than in controls. in male diabetics increment in methods for ulnar loops ( . ), outspread loops ( . ), complete finger ridge check ( . ), supreme finger ridge tally ( . ),atd edge of right hand ( . ) and left hand ( . ), dat edges of left hand ( . ) and adt of right hand ( . ) was seen than in controls. in female diabetics, huge increment in basic arches ( . ), all-out finger ridge tally ( . ), total finger ridge tally ( . ), dat points of two hands right ( . ) and left hand ( . ) was seen than in controls. sharma and sharma ( ) their investigation of diabetic cases and controls chose from the sms hospital, jaipur, india, found that the complete finger ridge check, total finger ridge tally, and the a-b ridge include were higher in all the patients. the atd points in the hands of the two sides in the patients were expanded in all the groups aside from left side in guys. in any case, they varied fundamentally on the correct side and on the left side in females, p < . . in the general groups right tda edge was huge. the smidgen and the tda edges on the two sides of the hands in all the groups were lower in the patients aside from left tda edge in guys. be that as it may, they varied just all together in the left bit, right tda in females. the aftereffects of their examination work demonstrated that dermatoglyphic variations from the norm might be utilized as an indicative instrument for anticipating the chance of the advancement of diabetes sometime in the future. taiwo and adebanjo ( ) have completed an examination to explain whether fingerprint pattern of dermatoglyphics is related to withtype diabetes or not. dermatoglyphic information was acquired from controls and type diabetic subjects going to the diabetic clinic of lagos university teaching hospital. they saw all-out finger ridge tally was fundamentally higher (p < . ) in diabetic subjects than in nondiabetics. considering the association between fingerprint pattern and type diabetes, dermatoglyphics might be utilized for the early id of hazard bunch people for reconnaissance purposes so as to forestall disease beginning. rakate and zambare ( ) have looked at the distinctions in the complete finger ridge tally, a-b ridge includes and atd point in patients with type diabetes mellitus with a control gathering. their examination was completed on type diabetic patients ( male and female) of to years and non-diabetic persons ( guys and females) of the equivalent age bunch as a benchmark group. in their examination, they found an expansion in the number of whorls, absolute finger ridge tally, a-b ridge tally alongside more extensive atd point in type diabetes mellitus patients. desai and hadimani ( ) have opined that dermatoglyphics is a developing order and its simple and prepared pertinence renders it as a valuable device to the clinician. the dermatoglyphics isn't to analyze and not for characterizing a current disease yet to forestall by anticipating a disease and to distinguish individuals with hereditary inclination to build up specific diseases. they have attempted to decide noteworthy palmar dermatoglyphic parameters if there should be an occurrence of sputum positive tuberculosis, diabetes mellitus type with basic hypertension, dermatitis, innate coronary illness, and down disorder and contrasted and the benchmark group. their investigation demonstrated that there were some hereditary components that were engaged with the causation of different diseases referenced previously. itis conceivable to anticipate from dermatoglyphics people's possibility of gaining disease. noteworthy discoveries they watched were: . the nearness of diminished whorls, . the nearness of expanded ulnar loops, . the nearness of expanded simian line in the left hand of considered patients. shivaleela et al. ( ) have done an investigation to discover the recurrence of different fingerprint patterns in type diabetes mellitus with and without ischemic coronary illness. their examination likewise planned to discover the recurrence of fingerprint patterns in type diabetes mellitus patients having the family ancestry of cardiovascular disease. twenty-five type diabetes mellitus male patients in the age gathering of - years were chosen, of which had an ischemic coronary illness and patients had the family ancestry of cardiovascular occasions. there was a higher recurrence of whorls in type diabetes mellitus patients than different patterns. less recurrence of arches, high recurrence of whorls and ulnar loops were seen in type diabetes mellitus patients contrasted and type diabetes mellitus patients without ischemic coronary illness. the thing that matters was not factually huge. dermatoglyphics in type diabetes mellitus and in patients with family ancestry of cardiovascular disease didn't show dominance of any of the fingerprints in ischemic coronary illness. therefore, they opined dermatoglyphics might be symptomatic apparatus in type diabetes mellitus however not in recognizing the hazard class for ischemic coronary illness. umana et al. ( ) completed an examination to decide the association between fingerprints patterns and diabetes mellitus utilizing subjects in zaria, nigeria. their consequences of type diabetic patients were contrasted and typical subjects. from their outcomes, there was an association between fingerprint patterns of guys with diabetes mellitus. from the above investigation, they reasoned that the male with a arch pattern of fingerprint in their correct hand is inclined to create diabetes mellitus at a later stage. mittal and lala ( ) have endeavored to discover an association of the dermatoglyphics patterns of the sound people and diabetes mellitus patients. an aggregate of subjects took part in their investigation of which were diabetic patients ( guys and females) and were solid people utilized as controls ( guys and females). they signify 'atd' point in both the hands of both the genders of diabetic patients was fundamentally more extensive when contrasted with that of the controls. contrasted with that of control, the mean tda edges in both the hands of both the genders of diabetics were restricted. they signify 'dat' edges were essentially thin just in the left hand of diabetic females when contrasted with left hands of female controls. burute et al. ( ) have meant to contemplate the different dermatoglyphic patterns in the patients of the development beginning diabetes mellitus (type diabetes mellitus) and contrasted and the dermatoglyphic patterns of controls. they did their investigation on ( male and female) clinically analyzed patients of development beginning diabetes mellitus. for correlation, solid controls (total = , guys and females) were considered. in female diabetics, essentially higher recurrence of arches and lower recurrence of whorls were seen than in controls. in diabetic female's outright finger ridge tally and complete finger ridge include were essentially lower than in controls. discoveries of their examination feature on the potential markers to foresee type diabetes mellitus on a bigger example size after a fastidious investigation of various fingertip dermatoglyphic factors. rakate and zambare ( ) have looked at the distinctions on the fingertip patterns to be specific, curve, loop, and whorl in patients with type diabetes mellitus with a control gathering. test for their investigation included palmar prints of type diabetic patients old enough gathering between and years out of them were guys and were female contrasted and same age gathering of non-diabetic people as control the gathering, out of the were guys and were females. in the example of type diabetes mellitus patients, they watched an expansion in the number of whorls in two hands of guys and females. the p-esteem was . . the ulnar loop and curve patterns were available in less incentive in diabetic patients which were measurably inconsequential. the plain whorl was available essentially higher in esteem in diabetic patients of guys and females. in diabetic guys in right hand whorls where present. yet, in charge just whorls were available; this distinction was critical at . levels. in the left hand of diabetic, whorl was altogether more than control , p-esteem was . . diabetic females additionally indicated higher recurrence of whorl pattern in two hands; on right hand contrasted and control and on left hand contrasted and . the p values were . on the right hand and . on the left hand. the central pocket loop whorl pattern watched more in diabetic patients. in the diabetic male they discovered on the right hand and on the left hand central pocket loop whorl pattern which was more contrasted and control right hand and left hand . the p-values were . and . separately. in diabetic females additionally central pocket loop whorl was watched all the righter hand , left hand than control bunch right hand and left hand ; p-values were . and . . the twofold loop whorl was watched more in diabetic patients. in diabetic guys on the right hand, twofold loop whorls were available which were more than control . likewise, on left hand in diabetic though in charge. the p-values were . and . separately. in diabetic females, likewise, more recurrence of twofold loop whorl was seen on right hand contrasted and control and left hand contrasted and in charge. the p-values were . and . . at the point when they thought about a wide range of whorls together among diabetic and control gathering, noteworthy contrasts were seen in the two guys and females. in diabetic guys on the right hand, whorls were available which were more than in ordinary. comparative discoveries were seen on left hand in diabetic while in charge. the p-values were . and . separately. in diabetic females, likewise, more recurrence of whorl was seen on right hand contrasted and control . the p values were . . karim et al. ( ) have looked at the distinctions in the fingerprint patterns and finger ridge include in patients with type diabetic mellitus with a control bunch in erbil city, kurdistan area, iraq. in their examination, non-insulin subordinate diabetes mellitus patients, guys, and females were contrasted and ( guys and females) sound controls. the appropriation of fingertip patterns of male patients indicated no noteworthy contrast in ulnar loops, spiral loops and rose arches while plane arches expanded altogether (p < . ) in diabetic type patients contrasted and controls, whorls diminished fundamentally (p < . ). higher frequency of ulnar loops, spiral loops and plane arches in female diabetics contrasted and control females. they saw that essentially expanded (p < . ) center finger ridge include in the left hand of male diabetic patients. fundamentally expanded (p < . ) file and little finger ridge check of the right hand was seen in female diabetic patients contrasted and control female groups. bala et al. ( ) have considered an all-out subjects out of which subjects having diabetes ( guys and females), subjects having diabetes with hypertension ( guys and females) and typical sound people ( guys and females) as control having a place with gangtok area of sikkim. all were clinically analyzed and affirmed by examinations as diabetic and diabetic with hypertensive patients. in their investigation, an examination of diabetic with control bunch indicated the mean estimations of atd and dat edges in two hands of diabetic patients lower than control, though mean estimations of adt edges were higher than control bunch on both right and left sides. the huge distinction was found in the correct hands of diabetes mellitus gathering. in both right and left hands of males and females, the mean estimations of atd point and dat edge of the diabetic gathering were lower than in charge. the mean estimations of adt edge were higher than control. no noteworthy contrast was found. the mean estimations of a-b ridge include in two hands were higher in diabetic male and female aside from in the left hands of male and profoundly noteworthy distinction was found in both hands of the female. mehta and mehta ( ) have analyzed fingertip patterns of type diabetic patients with controls. one hundred type diabetes mellitus patients ( male and female) were chosen for study and contrasted and equivalent number of controls. in two hands of guys and females' diabetic patients' frequency of whorls was essentially expanded. frequency of loops was fundamentally diminished in two hands of male and female diabetics contrasted with controls. arches were essentially diminished in both ways' hands of male diabetes mellitus patients. arches were fundamentally decreased in left hand of female diabetics. in their investigation, they expressed that dermatoglyphics can be utilized as a screening device for the conclusion of people who are progressively inclined to create diabetes mellitus and, in this way, forestalling the future diabetic intricacies. bala et al. ( ) have examined a sum of type diabetic patients ( guys and females) were contrasted and diabetics with hypertension patients of hilly district. the mean estimations of all-out finger ridge check and total finger ridge include were higher in male and lower in female diabetic gathering than diabetic with hypertension gathering. the mean estimations of a-b ridge include were lower in males and higher in females in diabetic gathering and a critical contrast was found. the mean estimations of atd edge were higher in diabetic gathering than diabetic with hypertension gathering. the mean estimations of dat edge were lower in the right hands and higher in the left hands of diabetic gathering. the mean estimations of adt point were higher in guys and lower in female diabetic gathering than diabetic with hypertension gathering. in the right hands, the mean estimations of fingertip ridge include were lower in all digits aside from in nd, fourth, and fifth digits in the male diabetic gathering. in left hands, the mean estimations of fingertip ridge include were lower in all digits of diabetic gathering apart from in nd, fourth and fifth digits and no critical contrast were found. in their examination, they watched an expansion in ulnar loops in the correct hand of male diabetic and diminished frequency in the left hand of male and in two hands of female diabetics. tafazoli et al. ( ) collected samples for this exploration was gotten from patients with acquired essential hypertension disease and ordinary subjects with no indications of essential hypertension disease until ages prior. print of their palm and fingers was acquired in two groups by printing ink. patterns of fingertips, atd edges, a-b ridge and the various types of details were found, recognized and measured outwardly within four divisions of fingerprints. the consequence of this investigation indicated two patterns of fingertips; whorl and curve in diseases are more than ordinary individuals. the most widely recognized tips in ordinary individuals is loop. in normal the quantity of the a-b ridge in female diseases and male-typical are individually more on normal than female ordinary and male sicknesses. the atd point is lower in patients than in typical. consequences of the overview on details demonstrated that frequency of the ridge ending (e) is between with the most elevated frequency. the frequency of bifurcation (b) is lower than the ridge finishing which it is between % in the left hands. additionally, in some part of the fingers noteworthy distinction was found. - . . - but in the right hand the second most patterns intermingling (c) which is between . and . %. the third most patterns in the left hand was seen in pattern unions (c) with a rate between . and . , however, in the right hand, the third most patterns are bifurcations (b), which is between . and . %. the method proposed by chakravathy et al. ( ) does observational examination included a correlation of palmar dermatoglyphic parameters among cases and controls. parameters were dissected quantitatively-atd edge; subjectively outspread loop, ulnar loop, curve, whorl and composite. as appeared in (graph i) out of all-out of cases, ( %) were guys and ( %) were females. of the absolute controls, ( . %) were guys and ( . ) were females. as indicated by (graph ii), they found that signify "atd" edge was higher in cases than controls and there was the factually critical association of signifying "atd" point in cases contrasted and controls. they likewise discovered both ways signify "atd" point was higher in cases than controls with solid factually huge association of right signify "atd" edge in cases than controls. by dissecting subjective parameters in study gathering, conveyance of dermatoglyphic patterns was measurably noteworthy in situations when contrasted and controls. the outspread loop was increasingly visiting in cases while ulnar loop was more ordinarily found in normotensive controls. the examination of subjective parameters in each hand of cases and controls demonstrated an appropriation of dermatoglyphic parameters that were factually huge. as appeared, looking at subjective parameters in each finger of the two cases and controls for the conveyance of dermatoglyphic patterns indicated factually noteworthy association. lahiri et al. ( ) used digital and palmar dermatoglyphic investigation of normotensive subjects and hypertensive subjects was performed. the parameters utilized were advanced ridge pattern, complete ridge tally, and atd edge. the outcome demonstrated that the twofold loop whorl patterns are available with higher frequency in hypertensives. if there should be an occurrence of the hypertensive people, frequency of twofold loop whorl pattern and curve are . % and . % individually yet those are simply . % and . % in normotensives. in spite of the fact that the distinctions of occurrences of whorl just as ulnar loop between two groups are not all that obvious, yet factually huge (p < . ). the occurrences of explicit patterns in the hypertensive and the normotensive populace have appeared. the all-out ridge tally unmistakably expressed that it is horribly raised if there should be an occurrence of the hypertensive populace contrasted with the normotensive populace. the various estimations of average total ridge count of hypertensive and normotensive people have appeared with their comparing frequency. subsequent to processing the remedied atd edge, a normal of the atd points of the two hands is made. the mean worth, most extreme and least qualities and model estimation of rectified atd edge (normal of both hands considered) in hypertensive gathering and normotensive gathering. the general pattern of this parameter is best comprehended by measurable examination (t trial) of all out arrangement of information which shows contrasts in estimations of atd edges of the hypertensive and normotensive gathering are of factual hugeness (p < . ). tafazoli et al. ( ) does the examination and conclude an observational, systematic and handy examination utilizing a case-control observational methodology with straightforward irregular testing and without substitution did on two groups of solid subjects and patients experiencing hypertension; individuals with no other explicit hereditary diseases which thus influence dermatoglyphic readings. that loops were the most widely recognized patterns on left digits in all patients (guys and females). from a factual perspective, there is an important distinction in frequency of various patterns on the left digit (p = . ) between genders yet other left digits indicated no measurably noteworthy contrast. on the correct digits, loops were higher in rate in the two sexual orientations however no huge factual distinction was seen between sexes for frequency of various patterns on right digits (p < . ). the higher occurrence of whorls on digit ii and of loops on different digits. their is no huge distinction in the frequency of the patterns between two hands (p < . ). as illustrated, frequency in the dissemination of loops were and . % for the left hand and . and . %, for the correct submit guys and females, separately. the distinction between frequencies of patterns was not measurably huge on any of the two h ands in both genders neither the right nor the left nor both frequency of loops on the left and the correct digits were - . % in guys and . - . % in females, separately. the contrast between frequencies of the patterns was not factually critical on two hands of both genders. the information shows that the frequency appropriations of whorls in the control and test (hypertensive) bunch were and % on the correct hand and and % on the left hand of guys, individually. no factually critical contrast was seen between the frequency appropriation of patterns on two hands of guys in the two groups (p = . , p = . ) level of whorl and arch is more in charge bunch than intolerant gathering while the level of loop is more in-understanding gathering than solid gathering in the two sexual orientations. the percent dispersion of whorls on digits of guys was as high as and . % in the control and the hypertensive gathering, individually. there has been no factually noteworthy contrast between two groups for frequency of patterns on digits in guys. level of whorl digit patterns in females was . and . % in the benchmark group and in the hypertensive gathering, individually. there has been no factually huge distinction between the two female groups in the frequency of patterns on digits. the dataset utilized and examination by wanga et al. ( ) was gathered from the behavior risk factor surveillance system (brfss) of centers for disease control and prevention (cdc) and is openly accessible and downloadable from the brfss site. brfss is the world's biggest and persistently led phone-based wellbeing study in regard to social hazard factors, incessant wellbeing conditions and utilization of preventive administrations. built-up in with states taking an interest in the study, it has a long history in conduct and incessant disease observation. the essential point of brfss is to track and measure singular wellbeing conditions and hazard practices that add to the main source of high grimness and death rates in the grown-up populace who are matured years and the older in united states. the review covers a wide scope of wellbeing hazard factors, preventive wellbeing practices and wellbeing conditions, including hypertension, diabetes and carcinoma related things. by gathering an assortment of data and sharing them with general society, brfss empowers scientists to examine the connections between interminable diseases and their hazard factors. we propose to anticipate hypertension just utilizing the surveys other than clinical test information, anthropometric information or hereditary information. its adequacy exhibits the practicability of building up a hypertension observation framework for an enormous size of the populace in a non-obtrusive and prudent way. what's more, the outcomes from this examination might be utilized to manage the advancement of projects outfitted towards forestalling and relieving explicit hypertension chance elements. ( ) they propose to coordinate calculated relapse examination and fake neural systems for synchronous hazard factor determination and hypertension prediction. in spite of the fact that theyt now, the proposed approach is basically a general system that can encourage specialists to break down other ceaseless diseases and different types of information. ( ) they detail the choice of fake neural system engineering and the setting of applicable parameters, which is a troublesome and testing task in model learning. this can conceivably assuage analysts of the mind-boggling model determination issue and empower them to concentrate on the issues under scrutiny. ( ) to manage the class irregularity issues, they propose a viable under-examining method. based on a bunch calculation and choosing the delegate tests from each group in the extent of the group size, the proposed strategy can choose the most discriminative examples from the greater part class while making us lose the minimal measure of data. ravindranath et al. ( ) proposed qualitative dermatoglyphics involving identical fingerprint pattern, interdigital pattern, hypothenar pattern and palmar wrinkle was concentrated on female and male rheumatoid joint pain patients. examination between understanding male and control male; and patient female and control female has been finished. 'chi' square test was performed. in male patients, with hands together, arches were expanded, loops/whorls were diminished. incomplete simian wrinkle was fundamentally expanded. in the correct hand, patterns were expanded in the third interdigital zone. then again, in female patients there was a noteworthy increment in whorls and diminishing in loops on the principal finger on both the hands, increment in arches on the third finger; the two arches and whorls on the fourth finger of left hand. the present examination has accentuated that dermatoglyphics could be applied as a symptomatic device to patients with rheumatoid joint pain. mazumdar et al. found there is an association between rheumatoid joint pain and dermatoglyphics. the conceivable relationship amongst ra and dermatoglyphics may empower dermatoglyphics as a marker device in the analysis of rheumatoid joint pain. the present examination has been attempted to discover the likelihood that the fingerprints and palmprints assume a significant job in the analysis of rheumatoid joint pain. the frequency of twofold loop whorl in the rheumatoid joint pain bunch was seen in pointing finger and center finger of right hand and left hand separately (mazumdar ) . the ulnar loops were altogether present in right and little finger of the left hand of rheumatoid joint pain patients contrasted and control. the complete fingerprint ridges were progressively various in right and left hand of rheumatoid joint inflammation gathering. narayanan et al. ( ) investigation was a case-control concentrate with cases with rheumatoid joint pain and controls. the result appears out of the all-out cases, ( %) were male and ( %) were females. of the complete controls, ( %) were guys and ( %) were females. the subjective parameters in female was a measurably critical increment in the number of whorls morally justified and left hands of female patients contrasted with the controls. there was a factually noteworthy reduction in the outspread loops in both the hands of female patients contrasted with the controls and the abatement is increasingly huge in the correct hand. there was no measurably huge distinction in the ulnar loop pattern circulation in either hand of female there was a factually critical increment in the finger ridge includes of right to deliver male patients contrasted with controls. there was a critical increment in the ridge check of patients. there was a factually noteworthy reduction in arches in the left hand of females with rheumatoid arthritis contrasted with the benchmark group. the left hand in male patients contrasted with the controls. absolute finger ridge check (included ridge tally of both ways hand) was fundamentally expanded in male rheumatoid joint pain patients contrasted with the controls. the ridge includes of the correct submit female patients was altogether higher than that of controls. the ridge includes left-hand fingers in female patients was fundamentally higher than that of controls. the complete finger ridge tally (right-hand ridge tally + left-hand ridge tally) was essentially expanded in female patients contrasted with controls. the expansion in all-out finger ridge include was increasingly huge in female patients contrasted with the male patients. there was no critical contrast in the pattern force in male patients contrasted with the controls. there was a measurably critical increment in the pattern power in the correct hand of females in examination with controls. rajangam et al. ( ) perform examination of male patients indicated a pattern towards criticalness for 'all-out finger ridge tally', centrality in left hand for 'total finger ridge check', and morally justified for 'a-b ridge tally'. then again, in the female patients, 'supreme finger ridge check' was seen as critical for the right hand and 'a-b ridge means' left hand. the watched contrasts between the male and female patients just as with that of the control might be a direct result of the expanded whorl pattern adding to two tallies and the width of the palm and fingers, along these lines a more noteworthy number of ridges might be available. obviously, the detail of spreading the fingers and the palm, likewise should be remembered. hwang et al. ( ) concluded that the outspread loop and whorl were progressively visit while the curve and ulnar loop were less continuous; these attributes of the spiral loop and whorl were unmistakable in the correct hand and fifth finger. the frequency of the spiral loop was turned around in their left hands and the third fingers. the complete fingerprint ridges were increasingly various in the ra gathering. contrasts of both palmprint ridges and palmprint point atd between the ra and the benchmark groups were not conspicuous, then again, palmprint ridges c-d was progressively various in the ra gathering. the shut wrinkle was progressively visit though open and meeting wrinkles were less incessant in the ra gathering. the typical wrinkle was less continuous though simian and sydney wrinkles were progressively visit in the ra gathering; the general attributes were unmistakable in their correct hands. the general attributes of sydney's wrinkles were turned around in the left hands of female ra gatherings. the all-out level of palm wrinkle transversely was lower in the ra gathering; the attributes of the sydney wrinkle were progressively conspicuous. swati and sujata ( ) used conventional radiograph which has been a standard path for distinguishing the jsw in ra since bones are obviously noticeable in x-beam. toward the beginning of the disease, % of the side effects of arthritis are found in hands. manual reviewing strategies are not ready to separate a little contrast in jsw figuring. electronic appraisal of joint space has an effect in dynamic and observing the treatment of joint pain patients. the info hand x-beam picture of the typical hand is of × pixels, this picture is resized in the preprocessing step, resized picture goals is × pixels. the division utilizes asm strategy, the quantity of emphases required is . the state of hand i followed flawlessly after the emphasis. the consequence of the asm division after emphasizes. to separate bone and non-bone districts binarization activity is performed. figure shows the aftereffect of binarization. binarization is finished by otsu's calculation. at that point, the skeletonization of the paired picture is completed. skeletonization brings about midline discovery it utilizes a diminishing procedure. at that point, the pinnacle and valley focuses are recognized along with the skeleton. the key focuses that is the specific joint area is followed by llm. ra tolerant joint area estimation process is appeared. at that point the different factual highlights are determined like mean, middle, change. joint area precision is determined by considering the number of exact joints recognized partitioned by the absolute number of joints that are . gobikrishnan et al. ( ) collected patient's data with rheumatoid joint pain in knee locale with disease span short of what one year and ordinary people with no knee disease utilized for this investigation. what's more, this examination was endorsed by the institutional moral council. absolutely patients and control subjects warm picture information was gathered. the mean period of patients utilized for the investigation was ± . what's more, the disease length was ± . the benchmark group mean age was ± . the patients with no clinical proof of knee inclusion was dismissed for this examination. the information was gathered by directing a camp at srm organization of clinical science. before the picture obtaining method composed endorsement from the patient to take part in the investigation was taken. the patients who had knee torment other than rheumatoid joint inflammation were dismissed for this investigation. the highlights like standard deviation, mean, skewness and kurtosis were extricated for patients and control subjects fragmented picture. the acquired outcome indicated essentialness. the standard deviation was beneath for control bunch above for patients experiencing rheumatoid joint pain. mean worth was underneath for control gathering or more for patients experiencing rheumatoid joint inflammation. kurtosis was beneath for control gathering or more for patients experiencing rheumatoid joint inflammation and skewness was underneath for patients experiencing rheumatoid joint pain or more for control gathering. the worth discovered higher for patients because of higher temperature variety. the table shows the different methods of blood group identification, which includes some of the traditional as well as unusual those are build using electrical or electronics components such as diode, sensors. the few researchers tried a software-based approach by processing image of blood sample, but only few used method called fingerprint pattern analysis to predict blood group with limited accuracy because thy apply this method with traditional paper and ink as sample collection mechanism, so it not provide high accuracy. in current era of digitization there are several image (fingerprint) computation techniques which explore a greater number of features from fingerprint image which extends the accuracy of prediction process. as per literature, there are many methods are available for determination of blood group from those some having pros and cons, but the popular and most traditional one is to take blood sample of an individual and test it against various antibodies to determine blood type to min but it not convenient to the small children's and individual having blood phobia. the fingerprint having lots of potential which explore different unique patterns those may leads to identify blood group very quickly and accurately. the table show various methods and dataset or samples which are used for analysis and prediction of lifestyle-based diseases such as diabetes, blood pressure/hypertension, rheumatoid arthritis. the diseases arise with age but not all humankind suffers from such agebased disease. the methods and dataset used to study age-based disease are limited only daily activity, x-ray samples and some are the techniques used after arrival of such diseases. the age, blood group, daily activity, lifestyle of individual and fingerprint patterns analysis helps researchers to generate indication or risk prediction in early age of an individual. as per literature, all authors attempt traditional method for sample collection as ink and paper, so they were only analyses the fingerprint patterns visible to human eyes those are like loops, arches and whorls. above literature shows relation between blood group and finger-print pattern summaries as follows: • loops were the determined common finger-print design and arches were the least common. • whorls and mixed were moderate. • more no of loops was originating in blood groups o, b related to a and ab. • blood group o +ve is the maximum found in samples, o −ve and ab −ve is the fewest. • loops, whorls, mixed and arches were uppermost in females. • group a was the utmost common group among sampled males. • blood group o, b, were the record usually seen in females. in type dm there is increased frequency in whorls, and decreased ulnar loop, increased frequency of sydney line, and increased incidences of arches in females (ravendranath and thomas ) . in maturity onset diabetes mellitus, there is decrease in mean value of tfrc, afrc, increase in arches and decrease in whorls (ravindranath et al. ) . the fingerprint of an individuals with t dm would be more irregular than an individual without t dm, regulatory for gender and age. diabetes regulate if wavelet analysis, a technique already used in forensics for fingerprint archival and matching, but not in previous studies of fingerprints as disease markers, would give results like the traditional ridge count or pattern analysis. the fingertips with whorls or double loops, applied a which rc formula that comprised half-unit values for those ridges situated between the core and delta point or between multiple cores. all ridge counting was as blinded to the diabetic and anthropometric status of the participants. the type diabetes, there is increased frequency in whorls, and decreased ulnar loop, increased frequency of sydney line, and increased incidences of arches in females (roshani et al. ). • surge in arches in diabetes in both sexes • growth in rate of recurrence of loops and arches and a lessened frequency of whorls especially in mid finger • reduced number of arches in the right hand of male and left hand of female having diabetics, it was more in diabetic males and females than in the controls • growth in radial loop, ulnar loop in both male and female diabetics. • increase in frequency of whorls in both types of gender in diabetics there is increase in tfrc, decreased frequency of axial triradius 't' in right palm of females and 't and t' in right palm of male, decreased atd angle and absence of axial of triradial in % cases (mandasescu et al. ) . above literature shows relation between patients having hypertension and not a hypertension finger-print pattern summary as follows: • higher prevalence of whorls and loops are associated with higher level of blood pressure • whorls and loops are prime ridge patterns in hypertensive patients • atd angle showed the mean of angle in patient surge rather than in control group • larger frequency of ridge endings in the thumbs and index fingers • amplified frequency in bifurcations and convergences in the middle, ring and little fingers there is increase in arches and decrease in loops and whorls in males, whereas in females there is increase in whorls and decrease in loops on the st finger of both hands (sengupta and boruah ) , with increase in arches on rd digit and whorls on th digit of left hand (bala et al. ) . above literature study shows change in fingerprint patterns of patients having summarized as follows: • ulnar loop was the most prominent digital pattern in both genders, • decrease in the radial loop in both male and female patients • loops were significantly decreased in the third finger of males and a first and fourth finger of females • decrease in the ulnar loops in both the hands of male and female patients. • increase in the whorl pattern in the right hand of male patients and in both the hands of female patients • decrease in the arches of the left hand of female patients. the strength of the present research work is that fingerprint itself having lots of unique and hidden patents and it also currently used as a traditional, effective, and unique identification method of an individual. the dermatoglyphics as a diagnostic aid used from ancient eras and now it is well established in number of diseases which have strong hereditary basis and is employed as a method for screening for abnormal anomalies. there are more than fingerprint minutiae patterns of ridges are determined as unique through the combination of genetic and environment factors. the weaknesses are in acquisition of fingerprint and finding different unique patterns from people of different age group due to the human digital fingerprint varies in texture as person ages, so it is very difficult to classify fingerprints because there are the fingerprints having the characteristics of two or more patterns changes with age of an individual. normally common clinical diseases like hypertension, arthritis and diabetes arises with aging, but due to busy schedule or lifestyle of an individual, it arises at any stage of life. so, it may lead to increase sample size and distribution of features required. the large datasets of fingerprint images acquired in real operational conditions are, rightly so, secured under data protection regulations that severely restrict the access to these data, even for research purposes. the fingerprints are having immense potential to have an effective method of identification. in this research, it investigates the problem of blood group identification and analysis of disease those arises with aging or disease called as lifestyle-based like hypertension, type -diabetes and arthritis from fingerprint by analyzing their patterns correlation with blood group and age of an individual. with the literature review study, it is observed that fingers of an individual are having multiple unique patterns those are need to be extracted with computerized method with fingerprints image captured using digital device which allow to find known association of fingerprints patterns which may enhance the authenticity of the fingerprints in blood group identification and early indication of lifestyle-based diseases of an individual. the fingerprint used as a traditional, effective, and unique identification method of an individual, in future it allows researchers to investigate with various diseases other than those are arised with age but also helps to explore different antibodies or reactive process of human body in several diseases. also, similar study helps to predict the risk of any kind of diseases in early age of an individual. the analysis and classification of community based on age, blood group, fingerprint patterns and lifestyle diseases help to tackle any pandemic in future like covid- in which mankind may suffer a lot having lifestylebased diseases like hypertension, type -diabetes. fingerprint recognition for person identification and verification based on minutiae matching finger prints pattern variation in diabetic patients analysis of left thumb print pattern among different human blood groups palmar dermatoglyphics patterns in diabetes mellitus and diabetic with hypertension patients in gangtok region comparative study of dermatoglyphic patterns of diabetes mellitus and diabetic with hypertension patients of hilly region rapid automated blood group analysis with qcm biosensors a role of dermatoglyphic fingertip patterns in the prediction of maturity onset diabetes mellitus (type ii) a handy tool for hypertension prediction: dermatoglyphics determination of blood group using image processing a study of fingerprint in relation to gender and blood group among medical students in uttarakhand region dermatoglyphics and health relation between fingerprints and different blood groups rh phenotypes analysis by spectrophotometry in human blood typing a complete blood typing device for automatic agglutination detection based on absorption spectrophotometry automatic system for determining of blood type using image processing technique automatic system for determination of blood types using image processing techniques development of a human blood type detection automatic system diagnosis of rheumatoid arthritis in knee using fuzzy c means segmentation technique. international conference on communication and signal processing ieee dermatoglyphic characteristics of patients with rheumatoid arthritis plantar and digital dermatoglyphic patterns in malawian patients with diabetes, hypertension and diabetes with hypertension an approach for minutia extraction in latent fingerprint matching fingerprint pattern examination of right hand thumb in relation to blood group efficacy of fingerprint to determine gender and blood group distribution of fingerprint patterns among medical students dermatoglyphics study of fingerprints pattern's variations of a group of type ii diabetic mellitus patients in erbil city design and development of blood sample analyzer using intelligent machine vision techniques a study on relationship between dermatoglyphics and hypertension detection of pre-diabetics by palmar prints: a computer study leading to a low-cost tool a case study on dermatoglyphics in rheumatoid arthritis approaches to determination of a full profile of blood group genotypes: single nucleotide variant mapping and massively parallel sequencing study of fingerprint patterns in type ii diabetes mellitus study of fingerprint patterns in type ii diabetes mellitus dermatoglyphics: an economical tool for prediction of diabetes mellitus a new method to assess asymmetry in fingerprints could be used as an early indicator of type diabetes mellitus study of fingerprint patterns in relation to gender and blood group use of palmar dermatoglyphics in rheumatoid arthritis: a case-control study an automatic system to detect human blood group of many individuals in a parellel manner using image processing application of dermatoglyphic traits for diagnosis of diabetic type patients spectrophotometric approach for automatic human blood typing development of an automatic electronic system to human blood typing the study of dermatoglyphics in diabetics of north coastal andhra pradesh population pattern of fingerprints and their relation with blood groups dermatoglyphics-quantitative analysis in rheumatoid arthritis fingertip patterns: a diagnostic tool to predict diabetes mellitus an integrated fiberoptic-microfluidic device for agglutination detection and blood typing a study of fingerprints in relation to gender and blood group finger ridge count and fingerprint pattern in maturity onset diabetes mellitus determination and classification of blood types using image processing techniques dermatoglyphics in rheumatoid arthritis dermatoglyphics in rheumatoid arthritis comparative study on the dermatoglyphic pattern among diabetic (type- ) and non-diabetic adults in north indian population dermatoglyphic patterns among type diabetic adults in north indian population finger print pattern in different blood groups forensic abo blood grouping by snps analyses using an abi prismr genetic analyser evaluation of abo subtyping by dna sequencing finger dermatoglyphic patterns in diabetes mellitus dermatoglyphics: a diagnostic tool to predict diabetes utility of dermatoglyphics in type ii diabetes mellitus (t dm) to assess the risk for ihd: apilot study a study of dermatoglyphic pattern in relation to abo, rh blood group and gender among the population of chhattisgarh dermatoglyphics: blueprints of human cognition on fingerprints a cost-effective method for blood group detection using fingerprints comparative study of the fingerprint pattern among diabetic (type ) & non-diabetic children in koya city modi"s medical jurisprudence and toxicology qualitative analysis of primary fingerprint pattern indifferent blood group and gender in nepalese study of dermatoglyphics in patients with type ii diabetes mellitus essential hypertension in the age group between - years international conference on automatic control and dynamic optimization techniques (icac-dot). international institute of information technology (i it), pune, ieee tafa z, pervetica n ( ) an intelligent system for diabetes prediction the study of dermatoglyphic patterns and distribution of the minutiae in inherited essential hypertension disease comparison of dermatoglyphic patterns between healthy and hypertensive people evaluation of association between digital dermatoglyphic traits and type- diabetes in lagos dermatoglyphics in insulin: dependent diabetes or diabetes mellitus type (t dm) determination and classification of blood types using image processing techniques digital grid method for fingerprint identification and objective report writing dermatoglyphic patterns of diabetic mellitus patients of ijaw origin in port harcourt dermatoglyphic and cheiloscopic patterns among diabetic patients: a study in ahmadu bello university teaching hospital zaria prediction and diagnosis of diabetes mellitus -a machine learning approach textbook of forensic medicine and toxicology predicting hypertension without measurement: a noninvasive, questionnaire-based approach key: cord- -arp mck authors: magiorkinis, g.; magiorkinis, e.; paraskevis, d.; vandamme, a.m.; van ranst, m.; moulton, v.; hatzakis, a. title: phylogenetic analysis of the full‐length sars‐cov sequences: evidence for phylogenetic discordance in three genomic regions date: - - journal: j med virol doi: . /jmv. sha: doc_id: cord_uid: arp mck the origin of the severe acute respiratory syndrome‐coronavirus (sars‐cov) remains unclear. evidence based on bayesian scanning plots and phylogenetic analysis using maximum likelihood (ml) and bayesian methods indicates that sars‐cov, for the largest part of the genome (∼ %), is more closely related to group ii coronaviruses sequences, whereas in three regions in the orf ab gene it shows no apparent similarity to any of the previously characterized groups of coronaviruses. there is discordant phylogenetic clustering of sars‐cov and coronaviruses sequences, throughout the genome, compatible with either ancient recombination events or altered evolutionary rates in different lineages, or a combination of both. j. med. virol. : – , . © wiley‐liss, inc. the recent epidemic outbreak of the severe acute respiratory syndrome, known as sars, was first reported in the guangdong province of china late in and since then several thousand cases have been reported worldwide, mainly in hong kong, vietnam, and canada ksiazek et al., ; poutanen et al., ] . analysis of the full-length genomic sequence of the causative agent of sars [marra et al., ; rota et al., ] established that this agent was a unique coronavirus (sars-cov) that displayed no obvious similarity to any other members of the coronavirus genus. coronaviruses (order nidovirales, family coronaviridae, genus coronavirus) have the longest genome ( , - , nucleotides) amongst all rna viruses. they comprise a highly divergent group of rna-viruses that cause a variety of respiratory and enteric diseases in humans and many animal hosts. previously available sequences of coronaviruses have been classified according to phylogenetic analysis into three main groups [marra et al., ; rota et al., ] . the newly identified sequence of the sars-cov was not found to cluster within any existing coronavirus group, thus suggesting the existence of an additional lineage, fourth group, within the coronavirus genus poutanen et al., ; rota et al., ] . the origin of the sars-cov still remains unclear, although data from hong kong researchers indicate that the sars-cov virus is almost identical to viruses infecting civet cats . genetic recombination has been detected between different murine coronaviruses [fu and baric, ] . thus, to determine whether recombination has occurred between sars-cov and any members of the three main coronaviruses groups, an in-depth analysis was undertaken of the evolutionary relationships between the sars-cov genome and representative sequences from all members of the coronaviruses genus available currently. amino acid sequence alignments were obtained using the clustal w program (v . ) [thompson et al., ] and subsequently edited manually for the major gene products orf ab, spike, m and n proteins to exclude ambiguous parts of the alignment. more specifically, x , x , x , x , x , and e genomic regions were excluded since a reliable alignment could not be obtained for these fragments. amino acid sequences derived from the full-length sequences of avian (nc_ ), bovine (nc_ ), human (nc_ ), murine (nc_ ), porcine (nc_ , nc_ ) coronaviruses, and the sars-cov (ay ) were used for all the genes. additional amino acid sequences were used for the spike, m, and n genes. for the spike gene, additional amino acid sequences were used for avian (np_ , aaa , aak , aac , aac , caa , p ), bovine (np_ , aal , aaa , baa , vgihqu), canine (caa ), feline (caa ), human (aak , p , caa ), murine (aaf , aaf , p , vgihmj, baa , jq , q ), and porcine (np_ , np_ , a , aab , aak , aam , aac ) coronaviruses. for the m gene, additional amino acid sequences were used foravian(aak ,p ,p ,mmih ),bovine (np_ , aaa , aaf , aal ), feline (aab , p , caa ), human (np_ ), murine (aaf ), porcine (np_ , aam , aab , aaa , p , d ), and rat (aad ) coronaviruses. for the n gene, additional amino acid sequences were used for avian (aao , aam , aac , aaf , cac , vhi-hai), bovine (np_ , aaa , aak , p ), human (np_ ), murine (a , p ), porcine (np_ , aak , p , cab , s , e ), rat (a , baa , q ), and turkey (jq ) coronaviruses. all the amino acid alignments are available upon request. after constructing the alignments, the separated genes containing only the common strains in all genes were joined in concatenates and a bayesian scanning plot was undertaken as described previously [paraskevis et al., ] using the wag model [whelan and goldman, ] as implemented in the mrbayes program [huelsenbeck and ronquist, ] . in particular, within a sliding window of a specified length, bayesian inference was carried out to determine the support of every clade within a given phylogenetic tree, and these support values were plotted along the alignment as described previously [paraskevis et al., ] . marginal posterior probabilities between sars-cov and sequences of coronaviruses groups i-iii were plotted throughout the concatenated alignment. posterior probabilities were estimated for a sliding window of amino acids moving in steps of amino acids. metropolis coupled markov chains monte carlo (mcmcmc) analysis was run for , generations, sampling every steps, and burn-in was set to , steps. mcmcmc had been checked previously so as to confirm that it had reached equilibrium up to this number of generations in different parts of the alignment, thus suggesting that , generations could be used as a fixed burnin throughout the alignment. phylogenetic trees were then constructed for every piece of the alignment with evidence of phylogenetic discordance, using the maximum likelihood (ml) and bayesian inference with wag [whelan and goldman, ] and mv [muller and vingron, ] substitution models, which have been constructed by distantly related amino acid sequences, and a g-distributed rates heterogeneity among sites as implemented in the tree-puzzle (parallel version . ) [schmidt et al., ] and mrbayes, respectively. a likelihood mapping analysis was also carried out, as implemented in the tree-puzzle program, to investigate the levels of phylogenetic signal in each separate region examined. exploratory phylogenetic analyses in the spike, m, and n genomic regions, including additional partially available coronavirus sequences, revealed that fulllength strains are representative and can be used for the exploration of phylogenetic analysis within the coronaviridae family along the full-genome. bayesian scanning and subsequent phylogenetic analysis revealed that the sars-cov sequence was related more closely to group ii than the other two groups in most of its genome (e.g., at the region spanning amino acid positions - in reference to the murine hepatitis virus orf ab gene) (fig. ) . this clustering was supported by high quartet puzzling support values and high posterior probabilities under various substitution models, thus suggesting that % of the sars-cov genomic sequence is related more closely to coronaviruses group ii than any other members of this family. likelihood mapping results revealed that all these regions contained enough phylogenetic information (data not shown). intriguingly, clustering of the sars-cov within group ii coronaviruses was not supported significantly in regions spanning amino acid positions: - ( - ), - ( - ), - ( - ) (positions in reference to the murine hepatitis virus orf ab are indicated with their respective positions in reference to the alignment in the parentheses) (fig. ) . in all cases, sars-cov was more closely related to group i, whereas group ii/group iii-sars-cov/group i nodes were separated by very small distances. likelihood mapping in the above regions revealed that they contain sufficient phylogenetic signal. thus, according to the results of phylogenetic analysis, it is suggested that sars-cov provides a separate lineage in these three genomic regions (fig. ) . moreover, in region spanning amino acid positions - ( - ), bayesian inference suggested a significant cluster between group iii and sars-cov, whereas this finding was not supported by the ml method. however, according to likelihood mapping analysis, the phylogenetic signal is very limited in this region; thus we cannot reliably infer the evolutionary relationships in this region. similarly, in a small fragment at the of m gene (amino acid positions - ( - ) with reference to the m protein of the murine hepatitis virus) showed a similar topology to the previous fragment, whereas given the discrepancy between bayesian and ml methods, it cannot be deduced that sars-cov is related more closely to group iii. according to the bayesian full-genomic scanning and phylogenetic analyses based on the ml and bayesian methods, evidence is provided that the sars-cov, for the largest part of the genome, is related more closely to group ii than to any other member of the coronaviruses sequences. the clustering between sars-cov and group ii is close to the root and probably reflects the evolutionary relationship between the ''parental'' sequences, from which sars-cov originated, and group ii. moreover, it was found that in three distinct genomic regions (aa positions - , - , - ), sars-cov shows no apparent similarity with any of the coronavirus groups characterized previously. these findings provide a new insight, in addition to previous studies, where sars-cov (using the neighbor joining method for phylogenetic tree reconstruction) was found not to be related significantly to any of the three coronavirus groups, or was separated by a short internal branch from group i and iii . moreover, three recent analyses indicated that sars cov was related more closely to group ii in partial genomic regions rest and mindell, ; snijder et al., ]. on the other hand, several analyses have noted that though sars cov is close to group ii, it has a recombinant origin [rest and mindell, ; stavrinides and guttman, ] , but these analyses were based only on partial genomic regions, and did not include an exploratory analysis using a sliding window approach [rest and mindell, ; stavrinides and guttman, ] . evidence is provided that, even though sars-cov in the majority of its genomic regions is closer related to coronavirus group ii, phylogenetic discordance in three partial genomic regions suggests a distinct clustering with respect to group ii. this could be a result of ancient recombination events, altered adaptive evolution in different lineages, or a combination of both. we do not want to speculate which of these explanations is correct, since, it is not easy to discriminate with certainty between these two factors. identification of a novel coronavirus in patients with severe acute respiratory syndrome evidence for variable rates of recombination in the mhv genome isolation and characterization of viruses related to the sars coronavirus from animals in southern china mrbayes: bayesian inference of phylogenetic trees a novel coronavirus associated with severe acute respiratory syndrome modeling amino acid replacement analysis of the evolutionary relationships of hiv- and sivcpz sequences using bayesian inference: implications for the origin of hiv- identification of severe acute respiratory syndrome in canada sars associated coronavirus has a recombinant polymerase and coronaviruses have a history of hostshifting characterization of a novel coronavirus associated with severe acute respiratory syndrome tree-puzzle: maximum likelihood phylogenetic analysis using quartets and parallel computing unique and conserved features of genome and proteome of sars-coronavirus, an early split-off from the coronavirus group lineage mosaic evolution of the severe acute respiratory syndrome coronavirus clustal w: improving the sensitivity of progressive multiple sequence alignment through sequence weighting, position-specific gap penalties and weight matrix choice a general empirical model of protein evolution derived from multiple protein families using a maximumlikelihood approach key: cord- -r vxz vu authors: mukherjee, pranab k.; esper, frank; buchheit, ken; arters, karen; adkins, ina; ghannoum, mahmoud a.; salata, robert a. title: randomized, double-blind, placebo-controlled clinical trial to assess the safety and effectiveness of a novel dual-action oral topical formulation against upper respiratory infections date: - - journal: bmc infect dis doi: . /s - - - sha: doc_id: cord_uid: r vxz vu background: current prevention options for upper respiratory infections (uris) are not optimal. we conducted a randomized, double-blinded, placebo-controlled pilot clinical trial to evaluate the safety and efficacy of arms-i™ (currently marketed as halo™) in the prevention of uris. methods: arms-i is patented novel formulation for the prevention and treatment of influenza, comprising a broad-spectrum antimicrobial agent (cetylpyridinium chloride, cpc) and components (glycerin and xanthan gum) that form a barrier on the host mucosa, thus preventing viral contact and invasion. healthy adults ( – years of age) were randomized into arms-i or placebo group ( subjects each). the drug was sprayed intra-orally ( × daily) for days. the primary objectives were to establish whether arms-i decreased the frequency, severity or duration of uris. secondary objectives were to evaluate safety, tolerability, rate of virus detection, acceptability and adherence; effect on uri-associated absenteeism and medical visits; and effect of prior influenza vaccination on study outcomes. results: of the individuals who completed the study (placebo: n = , arms-i: n = ), six presented with confirmed uri (placebo: , arms-i: ), representing a % relative reduction, albeit this was statistically not significant). influenza, coronavirus or rhinovirus were detected in three participants; all in the placebo group. moreover, frequency of post-treatment exit visits was reduced by % in arms-i compared to the placebo group (n = and , respectively). fever was reported only in the placebo group. arms-i significantly reduced the frequency and severity of cough and sore throat, and duration of cough (p ≤ . for all comparisons). arms-i was safe, well tolerated, had high acceptability and high adherence to medication use. medical visits occurred only in the placebo group while absenteeism did not differ between the two arms. prior influenza vaccination had no effect on study outcome. conclusions: this randomized proof-of-concept clinical trial demonstrated that arms-i tended to provide protection against uris in the enrolled study participants, while reducing severity and duration of cough and sore throat. a clinical trial with a larger number of study participants is warranted. trial registration: clinicaltrials.gov nct (retrospectively registered). electronic supplementary material: the online version of this article (doi: . /s - - - ) contains supplementary material, which is available to authorized users. upper respiratory infections (uris) are associated with significant morbidity and mortality, particularly in children, the elderly and those with underlying medical conditions (e.g. cancer, cardiopulmonary disease, diabetes and immunosuppression) [ ] [ ] [ ] [ ] [ ] . the centers for disease control (cdc) conducted a review of influenza cases over influenza seasons and reported that the annual rate of influenza-associated death in the us during this period ranged from . to . deaths per , persons [ ] . moreover, influenza is associated with million hospital visits and > , hospitalizations annually [ , , ] . infections associated with non-influenza viruses are known to cause million lost work and school days annually, and yearly economic burden due to viral uris ranges between $ and $ billion [ ] [ ] [ ] . uris are caused by respiratory viral pathogens including influenza, respiratory syncytial virus (rsv), human metapneumovirus, rhinovirus and adenovirus [ , , ] . the current prevention strategies for influenza involve the use of vaccines and antiviral medications. although vaccines are generally effective, their coverage and effectiveness vary ( - %) [ , [ ] [ ] [ ] [ ] . other limitations of vaccinations include vaccine/strain mismatch and "vaccine hesitancy" [ , ] . while neuraminidase inhibitors (nais, e.g. oseltamivir, zanamivir) are approved in the us to prevent and treat influenza [ , ] , these agents often induce only a modest decrease in symptom duration in people with uncomplicated illness [ ] [ ] [ ] . nais can also be associated with resistance development, side effects, high cost and limited effectiveness [ , [ ] [ ] [ ] [ ] [ ] [ ] [ ] . therefore, an unmet need exists for the development of an effective therapeutic approach to prevent uris. arms-i (currently marketed as halo™) was developed as a "first-in-class" novel dual-action formulation that can prevent viral uris by killing the virus (by disrupting the host-derived viral lipid membrane) while forming a protective barrier on the host mucosa. recently, our group demonstrated that the arms-i formulation exhibits novel potent activity against respiratory viruses in vitro [ ] , and reduced influenza-associated mortality and morbidity in an influenza infection murine model [ ] . in the current study, we report on the safety and effectiveness of arms-i in preventing uris in a randomized, double-blind, placebo-controlled pilot clinical trial. arms-i is a single-stream oral spray that targets the oral oropharynx mucosal surfaces, and comprises a broad-spectrum antimicrobial agent (cetylpyridinium chloride, cpc) that disrupts the viral lipid envelope through physicochemical interactions, and components (glycerin and xanthan gum) that form a barrier on the host mucosa, thus preventing viral contact and invasion. the current study was a randomized, double-blinded, placebo-controlled pilot clinical trial. the hypothesis of the study was that the use of the active product (arms-i) sprayed intra-orally × daily is associated with fewer episodes and a lower duration and symptom severity of acute uris. acute uris were defined as a combination of three of any of the following symptoms: fever (≥ . °c), non-productive cough, sore throat, rhinorrhea (runny nose), sinus congestion (stuffy nose) and malaise [ ] . the enrollment target was healthy men and women ( - years old, inclusive). health of study participants was assessed based on patient's recall of symptoms and clinical assessment (inclusion criteria: bmi of - kg/m , no tobacco/nicotine use for at least months, and nonpregnant or breast-feeding; for all inclusion/exclusion criteria and study design details, see protocol in additional file ). participants were enrolled into the study after informed consent following a clinical trial protocol approved by the university hospitals case medical center institutional review board for human investigation, cleveland, oh (protocol number - - , approval date: / / , for details regarding background information about the eligible participants and eligibility criteria, see full protocol in additional file ). all subjects provided written consent, obtained in accordance with federal regulations, and were compensated monetarily for their participation. the written document embodied the elements of informed consent as described in the declaration of helsinki and adhered to the ich harmonized guideline for good clinical practice. the clinical trial protocol went through a rigorous review at our institutional review board, and adhered to all components necessary for a pilot clinical study of this nature. moreover, the protocol was also carefully vetted by clinical-trials.gov during registration process (nct ), which did not indicate any deficiencies in trial design. there are no additional currently ongoing clinical trials with this product. study participants were randomized with equal proportion ( each) into two groups: (a) active product (arms-i) administered intra-orally by spray three times daily (dosing regimen selected based on a pilot clinical study evaluating the ability of arms-i to reduce oral microbial load [ , , ] ) or (b) placebo (purified sterile water containing the same flavor as the active but without neither the active antimicrobial agent (cpc) nor the barrier forming components) administered intra-orally by spray three times daily. randomization lists were generated using the website https://www.randomizer.org/, and all study personnel except the pharmacist were blinded. the active or placebo agents were selfadministered daily by participants for days. an exit visit occurred within weeks post-treatment. the study was conducted during the respiratory virus season in northeastern ohio (date range for patient recruitment was january , through march , ), completed on june , and unblinded on july , . the primary objectives were: ( ) to determine whether arms-i decreases the frequency of acute uris, and ( ) to assess whether arms-i decreases the duration and severity of uri-related symptoms. secondary objectives were: ( ) to assess the tolerability, acceptability and adherence to arms-i medications vs. placebo, ( ) to compare whether acute uris in those receiving arms-i compared to placebo are associated with differences in absenteeism (from work or school) and visits to physicians' offices, emergency departments and urgent care centers, ( ) to determine whether arms-i decreases the detection of respiratory viruses by polymerase chain reaction (pcr) [ ] [ ] [ ] [ ] , and ( ) to evaluate the effect of arms-i on those who did or did not receive the influenza vaccine. the endpoints were: ( ) frequency and duration of clinical respiratory disease at study visits and as assisted by electronic patient diaries, ( ) intraand extra-oral exams, ( ) solicited and unsolicited adverse events, ( ) respiratory virus multiplex pcr, and ( ) self-report for adherence to medication usage. subjectlevel characteristics were summarized per study group, age, gender, prior influenza vaccine status and medications taken for symptom relief. the study length and number of study surveys completed were used to summarize the information on the frequency, duration and severity of symptoms. severity of uri-related symptoms was scored on a -point scale ( = none, = minor, = mild, = moderate, = severe), based on diary entries from study participants with at least three symptoms using the validated wisconsin upper respiratory symptom survey (wurss- ) [ ] . determination of duration of uris-related symptoms was performed by assessment of self-reported diaries of study participants (with at least three symptoms) to identify instances where the symptoms were present for at least two consecutive days. frequency of symptoms occurring at least week apart were recorded as distinct occurrences (since multiple uri events can occur per individual in a season). participants with a diary-based uri event were asked to present at the clinic, where the study physicians examined them to confirm clinical uri. we used the research electronic data capture (red-cap) method to collect, store and disseminate trialspecific clinical data [ ] . electronic diaries were created using the redcap system, and participants recorded their symptoms and addressed the study-related questionnaire using these electronic diaries. data analysis was performed to address the primary and secondary objectives described in the study design. frequency of uri was assessed based on: ( ) visits to the clinic where the study participant had at least three uri-related symptoms ("sick visits", confirmed clinically by study staff ), ( ) interviews conducted by study nurses with the study participants within weeks of treatment completion and ( ) analysis of daily diaries electronically completed by study participants, describing the presence of at least three symptoms. sample size calculations were carried out assuming that the two groups would be of equal size and that the random assignment would be balanced. further, it was assumed that an average of two events would occur in the control group, compared to an average of . events in the treated group (mean ± sd = . ± . ), and that the average duration of illness would be days and days in the control and treated groups, respectively (mean ± sd = ± and ± , respectively). taking an alpha to be . , a sample size of per group would allow the detection of a % difference in primary outcomes between the two groups with % power. the sample size was increased to per group to account for potential losses to follow-up. each symptom of uris was investigated separately. for each endpoint, the total number of days for which there was an event was recorded. then, the number of days for which there was an event per days of person-time follow-up (related to the study duration per subject) was recorded in each group. since this is a prevention study conducted during the flu season of , we selected days so that we covered the entire season. next a logistic regression model was constructed. the data were taken at the day level, so the endpoint is yes/no for an event on that day. furthermore, the data included every day for which there was a completed survey. the endpoints were assessed for each treatment group (placebo vs. arms-i). because there were multiple daily observations for each individual in the study (nominally repeated measures per subject, but different for each subject) an ordinary logistic regression model was inappropriate because the observations within a subject from day-to-day would be expected to be correlated. therefore, generalized estimating equations were used to fit the regression model. medical visits (an indicator of whether a subject went to an emergency department, an urgent care center or a doctor's office due to uris symptoms on each day) and absenteeism (an indicator of whether a subject missed school or work or would have missed school or work if it were scheduled on each day) were analyzed the same way as the individual symptom analyses. the effect of vaccine status on the outcomes was assessed by fitting a multivariable logistic regression model with the treatment arms and vaccine status as the explanatory variables. a total of individuals were enrolled and randomly assigned to the two treatment arms, of which five did not begin the study. one subject (in placebo group) did not return for follow-up visit, and was excluded from the analyses. thus, analysis of results was performed for participants, of whom were in the placebo group and were in the arms-i group (see fig. and additional file for consort checklist). table summarizes the demographics of study participants. the age of study participants ranged between and years in both groups, with the mean age of . ± . years in the placebo group and . ± . years in the active group, with no significant difference observed between the two groups (p = . ). the gender distribution was also similar in the two study groups, with males and females in the placebo group ( . and . %, respectively) and males and females in the active group ( and %, respectively). the study duration (number of days from enrollment until the rd follow-up visit) was similar with . ± . for the placebo group and . ± . for the arms-i group. there were a total of surveys completed in the study ( in the placebo group and in the active group). moreover, percent surveys completed (number of surveys completed divided by study duration) were similar in both groups; . ± . % and . ± . % for the placebo and active group, respectively. among the enrolled individuals, there were six participants who presented to the clinic for clinical confirmation and collection of oral and nasal swabs related to the development of uris symptoms (confirmed uris episode). of the participants who presented with a confirmed uri episode, four ( %) belonged to the placebo and two ( %) belonged to the active group ( % ci . , . , p = . ), indicating a relative reduction of % in the latter. moreover, six (additional) subjects reported uri-related symptoms at their post-treatment visit (within weeks of study completion); among these individuals, four were in the placebo group and two were in the active group. analyses of diary entries showed that one additional subject in the active group and four additional subjects in the placebo group recorded symptom-based uris. these analyses showed that the cumulative frequency of uris tended to be lower in individuals using arms-i than those using the placebo. analyses of the symptoms reported by study participants in their daily diaries showed a total of occurrences of uris, observed in individuals. among these, occurred in the placebo group (in individuals) while occurred in the active group (in nine individuals). the frequency of uris tended to be higher in individuals in the placebo group than those in the active group ( % vs. %, respectively, or = . , % ci: . - . ), indicating a % lower relative frequency of uris in the active group. analysis of the data based on daily surveys (events) of symptoms also revealed a similar pattern with a % relative reduction in the frequency of uris in the active group, although this difference was not significant (or = . , % ci: . - . ). analysis of severity of uris showed that while fever was reported only in the placebo group ( . %), frequency of cough and sore throat were significantly reduced in the active group (table , p ≤ . ). moreover, severity of cough and sore throat were also significantly reduced in the active group compared to placebo group, while frequency of stuffy nose was significantly increased in the active group (p ≤ . , table ). chi-square analysis of symptoms in individuals with uris showed that the relative risk of cough in the placebo group was -times that of people in the active group, while the relative risk of sore throat was . -times that of people in the active group (table , p ≤ . ). furthermore, multivariable logistic regression analysis indicated that cough was the only symptom that associated significantly with uri, with less cough in the active group (placebo vs. active, p = . ; % ci: . - . ). we assessed the duration of symptoms in individuals who reported uris-related symptoms for at least two consecutive days. fever was reported only in the placebo group with duration of days. the median duration of cough, sore throat or runny nose was . days for each in the placebo group, while the median duration of these symptoms was , or days, respectively, in the arms-i group. the median duration of stuffy nose and malaise was days in both study groups. the maximum duration for all the non-fever symptoms was between and days in the placebo group, while this duration was lower ( - days) in the active group (p = . for cough, > . for all other comparisons). safety, tolerability, acceptability and adherence to use of arms-i the safety, tolerability, acceptability and adherence were evaluated by oral exams, solicited and unsolicited adverse events (aes), end-of-study acceptability surveys and self-reported use of sprays. as part of the study protocol, oral exams were conducted on all study participants. among the enrolled participants, abnormal oral exams were reported for four individuals, of which three belonged to the placebo group (cheek biting for two, and labial mucosal injury in one participant) and one was in the active group (enlarged tonsils at enrollment, not noted at subsequent visits or at end of study). none of these oral events were considered related to the study drug. a total of nine adverse events (aes) were reported in the study (with a -day duration), of which five occurred in the placebo group (headache, two; anxiety, labial mucosal injury and muscle strain, one each), while four occurred in the active group (headache, two; anxiety and extremity rash, one each). none of the aes were considered related to the study medication. participants were asked to complete an exit questionnaire with questions related to acceptability of the active product at the end of the study. we found that % of the respondents "strongly liked" or "liked" the taste of the active product, while . % were "neutral". moreover, % of the respondents had a favorable opinion about the smell ( % "strongly liked" or "liked", % were "neutral") of the product. in addition, . % of the participants stated that they would recommend the product to others, while a majority ( . %) expressed willingness to continue to use the product after the study ended. these results demonstrated that arms-i had high acceptability among the study participants. our analysis showed that the single-stream spray bottle was used as indicated in ≥ % of the days in the placebo and ≥ . % in the active group. these results indicate that study participants exhibited a high degree of compliance applying the study drug times a day. there were a total of surveys completed in the study ( in placebo and in active group). the medical care question was left blank on surveys, thus data is only available for surveys ( in placebo and in active group). among individuals with uris, there were two medical visits, both in the placebo arm, and nine absenteeism of which five ( . %) were in the placebo group, and four ( . %) in the active group. these results showed that medical visits occurred only in the placebo group while absenteeism did not differ between the two arms. pcr analysis performed on the oral and nasal swabs collected from individuals with uris showed the presence of influenza b, coronavirus or rhinovirus (oc ) in three participants (detected in february, march and april, respectively). all three infected participants belonged to the placebo arm. among the enrolled individuals, reported receiving influenza vaccine previously, of which ( . %) belonged to the placebo group while ( %) belonged to the active group. multivariable logistic regression analysis revealed the vaccine status had no significant effect on uris (p = . ). these results showed that vaccination status did not influence the uris between the two arms. in the current study, we evaluated the safety and effectiveness of arms-i, a novel intra-oral formulation in the prevention of uris in a randomized, double-blind, placebo-controlled proof-of-concept clinical trial in healthy adults. our data showed that the product is safe and well tolerated, and it reduces symptoms associated with influenza. use of arms-i was associated with a trend to reduced frequency of uris. our study demonstrated that arms-i was safe and had no drug-related adverse effects. this is to be expected, based on the known safety profile of the active ingredients and their long history of use in humans [ ] [ ] [ ] [ ] [ ] [ ] . the novel, patented arms-i formulation contains cetylpyridinium chloride (cpc) as an antimicrobial, and xanthan gum and glycerin as the barrier forming agents. these ingredients have been used since the s as components of various drug products including oral sprays, tablets, lozenges and capsules at concentrations similar to those present in arms-i [ ] . two randomized, double-blind clinical trials have reported the efficacy of orally administered agents in the prevention of uris. o'neil et al. [ ] compared the efficacy of commercially available echinacea capsules in preventing uris symptoms compared to placebo over a period of weeks during the winter months, and reported that echinacea capsules did not significantly alter the frequency of uris symptoms. bennett et al. [ ] determined the efficacy of low dose interferon alpha (ifnα) lozenges in the prevention of uris in healthy adults (n = , aged - years), based on weekly health data questionnaires. these investigators reported that lowdose oral ifn-α prophylaxis did not affect the incidence of uri, but did reduce the severity and duration of symptoms. our study showed that oral topical administration of the active agent was associated with a trend of frequency reduction, and significantly reduced severity and duration of cough and sore throat associated with uris. interestingly, severity of runny nose increased significantly in the active group, as did frequency and severity of stuffy nose, which could be linked to the fact that the product is applied orally and not intranasally. in this regard, lakdawala et al. [ ] identified soft palate of the oropharynx as an important site of isolation of transmissible virus and an initial site of infection. thus, drugs like arms-i, that target the oropharynx, could represent an novel approach for the prevention of viral respiratory infections. arms-i possesses a dual mechanism of action that: (a) targets the host by forming a barrier that prevents contact between the virus and the host mucosa, and (b) exerts direct virucidal activity that disrupts the outer viral membrane [ , ] . since cpc, the antiviral component of arms-i, targets host-derived lipid membrane through physicochemical interactions and does not target a viral protein, activity of arms-i is unlikely to be affected by mutations in the viral genome. thus, arms-i has the additional advantage of having a low potential for the development of resistance. limitations of the current study include being underpowered, and the low incidence of uris in the cohort, which may be due to the seasonal nature of uris, as well as participants who recorded uris in their diaries but did not present at the clinic. other potentially confounding variables include ethnicity, occupational status and co-morbidity of chronic respiratory diseases. in future planned investigations, we intend to power the clinical trial based on the low incidence of uris as well as conduct the study over multiple sites, and multiple seasons. arms-i is safe and well-tolerated, and it reduces influenza symptoms. this product has the potential to prevent viral upper respiratory tract infections. further clinical development of this novel product is warranted. seasonal influenza in adults and children-diagnosis, treatment, chemoprophylaxis, and institutional outbreak management: clinical practice guidelines of the infectious diseases society of america infections of the respiratory system characteristics and outcome of respiratory syncytial virus infection in patients with leukemia role of colonization of the upper intestinal tract in the pathogenesis of ventilator-associated pneumonia respiratory and allergic diseases: from upper respiratory tract infections to asthma estimates of deaths associated with seasonal influenza -united states acute upper airway infections upper respiratory tract infections the annual impact of seasonal influenza in the us: measuring disease burden and costs the economic burden of non-influenza-related viral respiratory tract infection in the united states illness severity and work productivity loss among working adults with medically attended acute respiratory illnesses: us influenza vaccine effectiveness network human rhinoviruses microbiology and laboratory diagnosis of upper respiratory tract infections surveillance of influenza vaccination coverage-united states, - through - influenza seasons interim estimates of - seasonal influenza vaccine effectiveness -united states vaccines for preventing influenza in healthy adults influenza activity -united states, - season and composition of the - influenza vaccine science and society: vaccines and public health vaccine hesitancy, vaccine refusal and the anti-vaccine movement: influence, impact and implications prevention and treatment of seasonal influenza antiviral agents for the treatment and chemoprophylaxis of influenza: recommendations of the advisory committee on immunization practices (acip) neuraminidase inhibitors for preventing and treating influenza in healthy adults and children review: oseltamivir relieves symptoms but does not reduce hospitalizations in influenza the value of neuraminidase inhibitors for the prevention and treatment of seasonal influenza: a systematic review of systematic reviews influenza virus resistance to neuraminidase inhibitors community transmission of oseltamivir-resistant a (h n ) pdm influenza association between adverse clinical outcome in human disease caused by novel influenza a h n virus and sustained viral shedding and emergence of antiviral resistance neuropsychiatric adverse effects of oseltamivir in the fda adverse event reporting system oseltamivir treatment for influenza in adults: a meta-analysis of randomised controlled trials influenza neuraminidase inhibitors: antiviral action and mechanisms of resistance. influenza other respir viruses barrier-forming formulation containing cetylpyridinium chloride (fcpc) possesses anti-infective activity against influenza virus novel antiviral prevents viral upper respiratory infections in vitro and in vivo validation of a short form wisconsin upper respiratory symptom survey (wurss- ) a barrier-forming oral formulation exhibits sustained post-antimicrobial effect barrier-forming oral formulation containing cetylpyridinium chloride (fcpc) exhibits potent activity against oral pathogens the frequency and seasonality of influenza and other respiratory viruses in tennessee: two influenza seasons of surveillance data influenza a virus isolation, culture and identification prospective evaluation of a novel multiplex real-time pcr assay for detection of fifteen respiratory pathogens-duration of symptoms significantly affects detection rate multiplex real-time pcr for detection of respiratory tract infections research electronic data capture (redcap)-a metadata-driven methodology and workflow process for providing translational research informatics support fda dailymed database accessed xanthan gum: safety evaluation by -year feeding studies in rats and dogs and a three-generation reproduction study in rats sprays and lozenges for sore throats scientific opinion on the evaluation of the safety and efficacy of cecure® for the removal of microbial surface contamination of raw poultry products british industrial biological research association (bibra) safety evaluation of cosmetics ingredients effects of echinacea on the frequency of upper respiratory tract symptoms: a randomized, double-blind, placebocontrolled trial low-dose oral interferon alpha as prophylaxis against viral respiratory illness: a double-blind, parallel controlled trial during an influenza pandemic year the soft palate is an important site of adaptation for transmissible influenza viruses the authors want to thank mr. raymond webber for assistance in conduct of the study. key: cord- - nfklun authors: eroglu‐ertugrul, nesibe gevher; yalcin, ebru; oguz, berna; ocal, turgay; kuskonmaz, baris; emiralioglu, nagehan; dogru‐ersoz, deniz; ozcelik, ugur; tezcan, ilhan; kiper, nural title: the value of flexible bronchoscopy in pulmonary infections of immunosuppressed children date: - - journal: clin respir j doi: . /crj. sha: doc_id: cord_uid: nfklun objectives: to demonstrate the value of flexible bronchoscopy (fb) and bronchoalveolar lavage (bal) when determining causes of lung infection in immunocompromised children; to investigate differences in causes and radiological features of lung infections following bone marrow transplantation (bmt) compared to other immunosuppressive conditions; to evaluate the reliability of radiological findings when predicting the pathogen. methods: we retrospectively evaluated immunosuppressed children who underwent fb and bal because pulmonary complications between january and may at the hacettepe university hospital pediatric pulmonology unit. two groups, group i (n = ) and group ii (n = ), consisted of patients who had primary or secondary immunodeficiency and those who were immunosuppressed because bmt, respectively. radiological findings before fb and macroscopic and microscopic findings of the procedure were evaluated. results: fb and bal were diagnostic in / patients ( . %) and the antimicrobial treatment changed for / patients ( . %). the most common pathogen was bacteria (streptococcus pneumoniae was the leading one). bacteria were more frequent in group i than group ii (p = . ). no significant difference in radiological findings between groups i and ii was found. considering all patients, a significant association was detected between viral pathogens and radiologically interstitial infiltration and a ground‐glass appearance (p = . ). however, no significant association was detected between bacterial and fungal pathogens and the radiological findings. conclusion: in immunosuppressed patients, fb and bal should be evaluated early for clarifying the causative agents. then, appropriate treatments can be utilised and the side effects and high cost of unnecessary treatment may be mitigated. eroglu-ertugrul et al. pulmonary problems constitute a major cause of mortality and morbidity among patients with immunosuppression. [ ] [ ] [ ] currently, flexible bronchoscopy (fb) is included as a routine diagnostic tool for immunosuppressed patients when respiratory findings (clinical or radiological) are present. , a special group of individuals with immunodeficiency consists of those who have received bone marrow transplantation (bmt) because diseases such as malignancies, hematological diseases, primary immune deficiencies and other hereditary disorders. pulmonary infiltration develops in % of patients who receive chemotherapy for malignancy and this significantly affects mortality. lack of early diagnosis and treatment for the aetiology causing the pulmonary problems in these patients adversely affects their prognosis. the interpretation of pulmonary radiological findings in immunosuppressed patients can also be quite difficult. the appearance of pulmonary infiltration also occurs because noninfectious causes such as the development of graft versus host disease (gvhd) following bmt, disease recurrence or secondary malignancy infiltration, toxicity from chemotherapy or radiotherapy. , in addition, an impaired inflammatory response as well as other predominant atypical and/or nonspecific aetiologies can cause an accurate aetiology determination to be difficult. empirical antibiotic treatment is usually initiated as soon as possible in these patients because of high morbidity and mortality rates, and any delay in treatment can adversely affect the immunocompromised patients' prognosis. , many empirical treatment studies have reported that fb and bronchoalveolar lavage (bal) yield diagnostically valuable results. , it has also been reported that microorganisms can be found or other diagnoses can be made through fb or bal in - % of children and adults with immunosuppression. in such patients, the use of fb and bal can provide a definite diagnosis and as a result, the appropriate treatment can be initiated. the purpose of the study was to demonstrate the value of fb and bal in determining the cause of lung infections that develop in immunocompromised children, to investigate differences between the causes and radiological features of lung infections following bmt in comparison to other immunosuppressive conditions and to evaluate the reliability of radiological findings for predicting the causative pathogen. our study retrospectively evaluated the charts of immunosuppressed children whose data were retrieved from patients who underwent fb and bal between january and may . the patients' demographic features, diagnoses, bronchoscopy indications and the entry route of the bronchoscope, complications because the procedure were all recorded. in addition, preoperative pulmonary radiological findings (direct radiography and/or hrct), the macroscopic findings of the procedure and the results of the microscopic studies of the bal were evaluated. the diagnostic yield of fb and its impact on the management were evaluated. because the patients experiencing severe respiratory distress and/or thrombocytopenia, we applied fb at the appropriate time, but during the procedure all patients were taking broad-spectrum antibiotics and/or antifungal therapy (all patients were taking multiple antibacterial agents, patients were taking antifungals, patients were taking antivirals). the procedure was conducted with an olympus® flexible bronchoscope that included . mm, . mm, . mm and . mm external diameter options. an intubation cannula was used for entry with patients who had already been connected to mechanical ventilators and for the remaining patients, either laryngeal masks (n = ) or the nasal cavity route were utilised. bal was performed from the focal area of the radiological pathology when present and the right lung middle lobe when widespread involvement was present. this study was approved by the institutional review board of the hacettepe university faculty of medicine. we evaluated the patients' radiological findings (chest x-ray and hrct) prior to the bronchoscopy, which were categorised as atelectasis, consolidation, ground-glass appearance, interstitial infiltration, nodular infiltration, bronchiectasis, increased aeration/air trapping, mosaic pattern, chronic changes, lymphadenopathy, mass and airway anomaly. a majority of the patients exhibited more than one finding and in these patients, the most significant/difference-making finding was determined for each patient. we performed cytological evaluations and microbiological studies of the bal fluid. microbiologically, the bal fluid was evaluated for aerobic bacteria, fungus and tuberculosis (tb). furthermore, we utilised pcr to evaluate the presence of respiratory viruses (bocavirus, coronavirus oc / hku , enterovirus, human rhinovirus, influenza a, influenza b, parainfluenza , parainfluenza , parainfluenza , parainfluenza , rsv a, rsv b, metapneumovirus and coronavirus /nl ). any observed pulmonary infection because cmv was defined as a viral load > copies in the bal fluid. immunofluorescence staining methods were utilised (indirect fluorescent antibody (ifa)) to detect pjp. we performed the statistical analyses with the ibm spss for the windows version . software package. the descriptive statistics were calculated using the data obtained from the analyses (percentage, frequency, mean ± standard deviation and minimum-maximum). in addition, we carried out chisquare tests to compare the quantitative variables (pearson's chi-square and fisher's exact chi-square tests) and a significance level of p < . was accepted. we reviewed the hospital records and charts of immunosuppressed patients ( female and male) who were evaluated with fb and bal. the age range was months to . years (mean, . ± . y; median . y). the patients were divided into two groups: group i (n = , %) included patients who had exhibited primary or secondary immunodeficiency and group ii (n = , %) included patients who were immunosuppressed after bmt. to provide more detail, the diagnoses and characteristics of the patients in groups i and ii are presented in table . • in radiological evaluations prior to fb, consolidation in / patients, atelectasis in / patients, diffuse/ local nodular infiltration in / patients, interstitial infiltration in / patients, a ground-glass appearance in / patients and bronchiectasis in / patients were detected. normal findings were present in the remaining / patients. some patients had more than one radiological finding; there were / patients with only one finding, / patients with any two of them and / patients with three of them (detailed radiological results are given in the supplementary table). • the macroscopic evaluation of fb provided findings consistent with infection in patients ( %), tracheomalacia was observed in patients, bronchomalacia in patients, airway anomaly in patients, mucosal hyperemia or hemorrhage in patients and normal findings were present in patients. • in the microscopic evaluations of bal, a microbiological agent was detected in patients ( . %) ( difference was determined for microbiological agents in this group, viral agents were the most common. the microbiological agents detected in the bal are provided in table . . comparisons of microbiological and radiological findings of patients in group i and group ii (table ) • bacterial pathogens were more prevalent in group i than in group ii (p = . ), but the results revealed no difference between two groups in regard to the presence of fungi, tb, viruses and pjp. • additionally, no difference was detected between the groups based on the radiological findings (atelectasis, consolidation, nodular infiltration, interstitial infiltration, ground glass and bronchiectasis). . one of our aims was to determine the role of radiological findings in predicting the causative pathogen group. when all of the patients were considered together, a significant association was determined between the presence of viral pathogens (including cmv) and the radiological findings of interstitial infiltration and/or a ground-glass appearance (p = . ). however, no significant association existed between the radiological findings and the presence of bacterial or fungal pathogens. in the bal sample, of patients ( . %) who were able to be tested for viral agents by a pcr method were found to be positive for viral agents. of these patients, ( . %) had interstitial infiltration and a ground-glass appearance. likewise, of patients ( . %) with a negative result on the viral pcr study did not have interstitial infiltration and/or a groundglass appearance. the predictive values of the aetiologic agent based on the radiological findings are provided in table . . an evaluation of all diagnostic methods related to fb (macroscopic pathologic findings and demonstration of a microbial agent in bal) revealed a diagnostic finding in of patients ( . %). the antimicrobial treatment changed for / patients ( . %); it was escalated based on the identified pathogenic agent in of these patients ( . %): • ganciclovir was given to patients because of pulmonary cmv infection, • anti-tb treatment was started in patients, • a new antibacterial was added for patients • a new antifungal was added for patients however, empirical antibacterial treatment was narrowed in patients because the pathogenic agent not being clearly identified and the competence of the other treatments already in use. treatment changes because the bal microbiology results are provided in table . . complications because the fb were procedure presented in of the patients ( . %), including mild and temporary hypoxia in patients, hemorrhage in patient and temporary bradycardia in other patient that resolved when the procedure was discontinued and did not reoccur during follow-up. no complications from the fb procedure resulted in permanent morbidity and/ or mortality. our results revealed that even though all of the patients received broad-spectrum antibiotics and/or antifungal therapy throughout the procedure, the fb and bal examinations provided significant data in / patients ( . %) that was haemophilus influenzae haemophilus haemolyticus - enterococcus faecium - pneumocystis jiroveci - aspergillus species cytomegalovirus and children with immunodeficiency. in these studies, treatment changes occurred in %, % and % of patients whose bal samples were positive for microbiological studies, respectively. likewise, treatment changes were also reported in . %, % and %, respectively, of the patients whose bal samples were negative for pathogenic agents. in our study, among all patients whose treatment was changed, / patients ( . %) had their treatment increased, whereas only / patients ( . %) had their treatment modified to narrow their current treatment (table ). in the overwhelming majority of the patients in group i, the rate of therapy escalation (n = , . %) was more prominent, especially the addition of antibiotics ( / vs / patients), because bacterial pathogens were more prevalent in group i than in group ii (p = . ). bacterial diversity was high in bal results and the antimicrobial agents at the time of fb did not cover most pathogens. other recent group i (n = ) group ii (n = ) p value reports investigating treatment changes also showed higher escalation as compared to de-escalation and continuation of treatment with nontargeted agents following negative bals ( . %) , although these differences were not as high as the rates we found. we explain this slight discrepancy because in our immunosuppressed population, after observable positive bal results, adding therapy seems reasonable, but the cessation of antimicrobial agents is more difficult in this critical population. in addition, we included patients who changed from prophylaxis to a treatment dose for some antibiotics (such as trimethoprim-sulfamethoxazole and ampicillin-sulbactam) and lengthening the duration of current treatment as a treatment change and this would count as an additive effect to our escalation rate. additionally, these findings point out the overuse of antibiotics and the tendency to continue their use, even in cases without any objective evidence supporting their use. our results also provided evidence that bal evaluation proved to be a very valuable approach for detecting a variety of aetiologic agents such as cmv, tb and resistant microorganisms. our research also investigated whether there were differences in aetiological agents and radiologic features according to which pulmonary infections had developed following bmt as well as in other immunodeficiency states. we determined that in the bmt group there were fewer bacterial agents than in the group with other immunodeficiencies, but no difference appeared for other aetiological agents. these results may be related to the protective effect of prophylactic antibiotics that had been administered since the beginning of the bmt process as well as the preparation regimens that cause t-cell depletion in order to prevent the occurrence of graft versus host disease, both of which may play a critical role in the increased frequency of the presence of viral and opportunistic agents in bmt patients. our results also revealed that bacterial agents, in particular, s. pneumoniae, which is recognised as the most common cause of community-acquired pneumonia in patients with immunodeficiency other than bmt, are also extremely important agents to be reviewed. another aim of our investigation was to evaluate the sensitivity of hrct for predicting causative pathogens before fb and bal had been conducted. in general, practice, bacterial, viral and fungal infections are suspected, respectively, as the causative agents in the presence of consolidation and atelectasis, infiltration and a ground-glass appearance and a nodular appearance. the empirical treatment is determined and initiated accordingly. our study demonstrated that only interstitial infiltration and a ground-glass appearance on ct were significantly related to cmv and other viral agents in bal, but their success in showing the bacteria and fungi detected in bal was low. importantly, the lack of an expected pathogen because immune dysregulation may have also been the reason for this finding. studies in recent years on the role of radiological findings in detecting infectious agents have only specified opacities, nodules and a ground-glass appearance as being associated with a pathogenic factor. in addition, rizik et al. evaluated children with immunodeficiency and determined that although bal results led to a treatment change in % of the cases, the type of radiological findings (focal or lobar vs diffuse, age > vs < ) was not ultimately associated with any treatment change. therefore, our study appears to be the first to evaluate the reliability of radiological findings in predicting the aetiologic agent in children with immunodeficiency as well as the association of viral aetiologies with radiological findings. according to the data from our study, it is recommended that viral investigations be initiated at an early period of treatment as well as to start early antiviral treatment in patients who present with a ground-glass appearance on the hrct. additionally, we recommend that these findings continue to be investigated in studies with larger patient group cohorts. limitations of our current study include its retrospective nature as well as the use of prophylactic antibiotics and antivirals by all patients prior to the study; however, previous research in the past and other recent similar investigations were also conducted under empirical treatment conditions. , , the fact that we could not evaluate the number of colony-forming units that grew in the bal is another major limitation of our study. contamination from the oropharyngeal flora cannot be ruled out, especially in patients with more than one isolated pathogen. however, we have considered these results when managing the therapy. no serious complications because bronchoscopy have been detected in the juvenile age group among immunocompromised patients as found in our study and reported in the previous literature; , however, this is not the case in adult patients with immune deficiency, who exhibited a higher incidence of serious complications. in conclusion, fb and bal should be done in these patients as soon as possible in order to clarify the causative anti-tb addition (n = ) -antifungal addition (n = ) anti-bacterial addition (n = ) narrowing the empirical treatment (n = , . %) n = ( . %) n = ( . %) applications of flexible fiberoptic bronchoscopes in infants and children use of bronchoalveolar lavage in immunocompromised children with pneumonia fiberoptic bronchoscopy and bronchoalveolar lavage for the evaluation of pulmonary disease in children with primary immunodeficiency and cancer. pediatr blood cancer the role of rigid and flexible bronchoscopy in children pediatric bronchoscopy guidelines pulmonary infiltrates in neutropenic patients with acute leukemia during chemotherapy: outcome and prognostic factors prognostic factors of non-hiv immunocompromised patients with pulmonary infiltrates the clinical importance of bronchoalveolar lavage in allogeneic sct patients with pneumonia diagnostic yield of bronchoscopy with bronchoalveolar lavage in febrile patients with hematologic malignancies and pulmonary infiltrates utility of bronchoalveolar lavage in immunocompromised children: diagnostic yield and complications a comparison of bronchoalveolar lavage versus lung biopsy in pediatric recipients after stem cell transplantation bronchoscopic evaluation of pulmonary infiltrates following bone marrow transplantation bronchoalveolar lavage (bal) in immunocompromised children: years single center experience cytomegalovirus load in bronchoalveolar lavage fluid: a clue to the diagnosis of cytomegalovirus pneumonia? diagnostic yield of bronchoalveolar lavage in immunocompromised children with malignant and non-malignant disorders the utility and safety of flexible bronchoscopy in critically ill acute leukemia patients: a retrospective cohort study bronchoscopy and bronchoalveolar lavage in the diagnosis and management of pulmonary infections in immunocompromised children key: cord- -lkgcxjya authors: huang, qiqi; gao, xiaona; liu, ping; lin, huayuan; liu, weilian; liu, guohui; zhang, jin; deng, guangfu; zhang, caiying; cao, huabin; guo, xiaoquan; hu, guoliang title: the relationship between liver-kidney impairment and viral load after nephropathogenic infectious bronchitis virus infection in embryonic chickens date: - - journal: poultry science doi: . /ps/pew sha: doc_id: cord_uid: lkgcxjya abstract to examine the relationship of impairments of the liver and kidney with viral load after nephropathogenic infectious bronchitis virus (nibv) infection in embryonic chickens, specific-pathogen-free leghorn embryonated chicken eggs were randomly divided into two groups (infected and control), with three replicates per group and eggs in each replicate. the eggs in the infected and control groups were challenged with . ml of . eld nibv and sterile saline solution, respectively. the embryonic chickens’ plasma and liver and kidney tissues were collected at , , and days post-inoculation (dpi), the liver and kidney functional parameters were quantified, and the tissue viral loads were determined with real-time pcr. the results showed that plasma potassium, sodium, chlorine, magnesium, calcium, and phosphorus levels were increased. the infected group exhibited significantly higher plasma uric acid, blood urea nitrogen, and creatinine levels than the control group at dpi. the plasma concentrations of aspartate aminotransferase and alanine aminotransferase were significantly increased in the infected group. the total protein, albumin, and globulin levels in the infected group were significantly lower than those in the control group. the liver-kidney viral load in the infected group peaked at dpi, at which time the kidney viral load was significantly higher than that of the liver. our results indicated that nibv infection caused liver and kidney damage in the embryonic chickens, and the results also demonstrated that the liver and kidney damage was strongly related to the tissue viral load following nibv infection in embryonic chickens. reported. a previous study identified nephropathogenic strains of ibv that cause infection. some strains of the virus can cause severe kidney damage, urolithiasis and high mortality (cook, et al., ; ziegler, et al., ) . infectious bronchitis (ib) has become a major health problem that affects the chicken industry in most countries of the world. in the poultry industry, many factors cause visceral gout in chickens, including high dietary calcium, vitamin a deficiency, mycotoxin toxicity, and renal insufficiency. however, nephropathogenic infectious bronchitis virus (nibv) has become an important factor of visceral gout (bayry, et al., ) . previous studies have reported that nibv can cause kidney damage and secondary gout (gaba et al., ; ziegler, et al. ) . early physiological studies documented the changes in water metabolism that are observed in the excreta of young male broiler chickens, and challenge with nibv causes significant increases in the fractional excretions of sodium (na), calcium (ca), potassium (p), and plasma uric acid (afanador and roberts, ) . abdel-moneim et al. reported severe congestion of the liver, spleen and lungs in birds that had died after experimental ibv infection (abdel-moneim, et al., ) . kinde et al. reported mature kidney pathology at days post-inoculation (dpi) (kinde, et al., ) , and mahmood et al. isolated the nephropathogenic strain of ibv from the kidneys of chickens at dpi (mahmood, et al., ) . most of the previous molecular tests for ibv have been applied to the detection of ibv in kidney, trachea, or cloacal swabs from chickens rather than embryonic chickens. in addition, embryonated chicken eggs were used to study several poultry pathogens such as viruses, bacteria, and fungi (jacobsen, et al., ; montgomery, et al., ) and were suggested as an alternative model for vaccine production (abdul hafeez, et al., ) . the pathogenesis and virulence of clostridium perfringens and eimeriatenella was also studied after experimental infection (alnassan, et al., ) . at present, there is no in embryonic chicken described for the investigation of nibv infection. the aim of the present study was to investigate the possible pathogenesis of nibv in the embryonic chicken. this study attempted to infect embryonic chickens with nibv and determine the plasma liver and kidney function indices and the tissue viral loads and to explore the relationships of the impairments in the liver and kidney with viral load. one hundred twenty leghorn embryonated chicken eggs were purchased from the shandong institute of poultry science and individually numbered. the eggs were set with the blunt end up in a forced-draft incubator and housed in a specific pathogen free (spf) environment at the clinical veterinary laboratory of the college of animal science and technology, jiangxi agricultural university. the eggs were incubated at . ± . • c and % to % relative humidity and were automatically turned every h. the eggs were removed from the incubator on embryonic day (ed) and marked to the upper junction chamber, and the allantoic membranes were located with a pencil. subsequently, the exposed shell was disinfected with % ethanol, a small hole was drilled in the shell with a whisk, and each embryo was injected with . ml of a virus solution via the allantoic cavity route. the hole was then closed with liquid paraffin, and the egg was placed back into the incubator until sampling (slawinska, et al., ) . for sampling (figure ), the eggs were removed from the incubator and candled to locate a distinct blood vessel of the chorioallantoic membrane (cam). after removing a piece of the shell using ophthalmic forceps, a drop of edible oil was smeared over the small area of the outer shell membrane to render this membrane transparent and make the blood capillaries clearly visible. next, blood (≥ μl) was taken from a capillary of the cam using a -ml syringe, collected in a heparinized tube and kept on ice. the blood was centrifuged ( , rpm, min, • c), and the plasma was collected and stored at − • c until analysis. preliminary experiments were performed to optimize the injection days, injection doses, and post-injection (pi) sampling time points. the experiments were approved by the ethical committee for experiment use of animals of the jiangxi agricultural university. a total of embryonated spf chicken eggs were used in this experiment. all embryonated chicken eggs were randomly divided into groups (infected and control), with replicates per group and embryonated chicken eggs in each replicate. based on the embryo median lethal dose (eld ), each egg ( -day-old) in the infected group was challenged with nibv at a dose . eld ( . ml) via the allantoic cavity route. simultaneously, the eggs in the control group were infected with sterile saline solution ( . ml per chicken egg) via the same route. after the injections on ed , blood and tissue sampling was performed at three sampling time points ( , , and dpi). the plasma was stored at − • c for biochemical measurements, and the liver and kidney tissues were stored at − • c for detection of the viral load via real-time pcr. the anatomical pathology symptoms were recorded. the individual egg weights were recorded at , , and dpi. a total of eggs was weighed and the embryos were euthanized with cooling at • c for hours, and their contents were removed from the shells to determine the embryo body, liver, and kidney weights. the values were calculated using the following formulae: ee ratio (%) = weight of embryo (g) /weight of the respective egg (g) hsi (%) = hepatosomatic index = weight of liver (g)/weight of the embryo (g) ksi (%) = kidney somatic index = weight of kidney (g)/weight of the embryo (g) the blood was centrifuged ( , rpm, min, • c), and the supernatant was collected. the plasma samples were analyzed at the clinical veterinary laboratory, college of animal science and technology, jiangxi agricultural university. the plasma electrolyte potassium (k), sodium (na), chlorine (cl), magnesium (mg), calcium (ca), phosphorus (p) concentrations, and blood urea nitrogen (bun), and creatinine (cr) contents were measured with an automatic biochemical analyzer (johnson & johnson, america). liver indicators, such as the total protein (tp), albumin (alb), globulin (glb), alanine aminotransferase (alt), aspartate aminotransferase (ast), alkaline phosphate (alp), and glutamyltranspeptidase (ggt) levels were measured according to the methods of the international federation of clinical chemistry (ifcc) (santos, et al., ) total rna was extracted from the individual embryonic organs of chickens (i.e., livers and kidneys) per group via homogenizing with a homogenizer in rna isolation reagent (takara, dalian, china) in low-temperature conditions according to the manufacturer's protocol. the rna was diluted in nuclease-free water, and the concentration was quantitated by uv spectrophotometry at nm. the integrity of the extracted rna was confirmed by . % agarose gel electrophoresis. before the reverse transcription reaction, all of the rna samples were individually treated with genomic dna elimination reagent according to the manufacturer's instructions to remove the genomic dna (takara, dalian, china). for reverse transcription, μl of total reaction mixture ( . μl of gdna eraser, . μl of × gdna eraser buffer, . μg of total rna, and μl of rnase-free dh o) was incubated at • c for min and stored at • c. the cdna was synthesized via a reverse transcription reaction that was performed in a reaction volume of μl that contained the following: the reaction solution formed from the genomic dna elimination reaction ( μl), rt primer mix ( . μl), × primescript buffer ( . μl), and primescript rt enzyme mix ( . μl), rnase-free dh o ( . μl). the reaction was performed on a pcr instrument f at • c for min and • c for sec and then stored at − • c. the nucleocapsid gene sequences from the sx strains of ibv were retrieved from genbank (accession number jx ). the sequences regarding the forward primer: -tgcacctgcacctaagtttg- , reverse primer: -aaactgcgggtcatctct- . the length of the constructed cdna standards was bp. the primers were synthesized by shanghai biological engineering co., ltd. the rt-qpcr assays were performed in triplicate (takara, dalian, china). total assay volume was μl, which consisted of the quantitative pcr assay reaction mixture g ( μl sybr premix ex tap ii ( ×), . μl ×rox reference dye ( ×), and rnase inhibitor, . mmol/l mgcl , rnase-free water), each primer (at final concentration of . μmol/l), μl cdna template. the thermal profile began with incubation at • c for min, followed by cycles of amplification alternating between • c for s (denaturation) and • c for s (annealing/extension). the sybr green i fluorescent signal was obtained once per cycle at the end of the extension step. each rt-qpcr experiment contained triplicate no-template controls, test samples, and dilution series. the detection and quantification limit of the sybr green real time rt-qpcr assay were determined using cycle-threshold (ct) values obtained for each reaction containing from to copies of the standard rna. then the obtained ct values were plotted against the amount of rna copy number to construct standard curve. results are expressed as viral load according to the established standard curve. the data were analyzed with the use of commercially available software. the viral load in each sample was quantified using the standard curve (data not shown) and the average viral genome copy number per group was calculated. among the treatment groups (control and infected) were performed with the student t tests multiple comparisons test to identify the significant differences. all data are presented as the mean ± the standard deviation (m ± sd), and values of p < . were considered significant, values of p < . were considered highly significant. no clinical signs or deaths were observed in the control groups, and some of the embryos in the infected group began to exhibit signs of death such as the presence of dwarf embryos ( figure ) . a tendency toward bleeding from the dead embryos appeared. after dpi (ed ), the embryos exhibited stunting lesions, curling, leg compression upon the head, and urate deposition in the liver and kidney. open egg shell examinations revealed that the dead embryos were atrophied, and embryonically enlarged kidneys were observed. in contrast, no visceral gout was observed in the embryos of the control groups. conversely, some of the embryos in the infected group developed typical visceral gout. the livers were enlarged with white urate deposits, and the kidneys were swollen and exhibited pale regions in a greater proportion of the divisions. there were noticeable chalky white masses surrounding the liver and kidneys. the liver and kidneys exhibited significant granophyric characteristics. the embryo: egg weight (ee) ratios, liver weights, kidney weights, liver somatic indices, and kidney so-matic indices (the liver and kidney parameters were normalized by the embryo weight) of the control and infected groups are given in tables and . the ee ratio was significantly lower in the infected group than in the control group at dpi (p < . ). however, the liver weight was significantly higher in the infected group than the control group at dpi (p < . ), and the kidney weight was significantly higher in the infected group than in the control group at dpi (p < . ). the hepatosomatic index (hsi) were significantly higher in the infected group than in the control group at and dpi (p < . ). the kidney somatic index (ksi) was significantly higher in the infected group than the control group at dpi (p < . ). the plasma electrolyte values are provided in table . the plasma concentrations of p and k were significantly higher in the infected group than in the control group at (p < . ) and dpi (p < . ). the plasma concentrations of na, mg, and cl in the infected group were significantly greater than those in the control group at dpi (p < . ). the plasma concentrations of ca in the infected group were significantly greater than those in the control group at (p < . ) and dpi (p < . ). in general, the plasma concentrations of p, k, na, mg, cl, and ca in the infected group exhibited significantly increased. the plasma ua, cr, and bun activity values in the embryonic chickens were compared between the control ee ratio (%) = weight of embryo (g)/weight of the respective egg (g). hsi = hepatosomatic index = weight of liver (g)/weight of the embryo (g). ksi = kidney somatic index = weight of kidney (g)/ weight of embryo (g). the ee ratio, his and ksi in embryonic chickens infected with nibv (n = ). the numbers in the table indicate: mean ± standard deviation. a,b the same letters indicate that the differences were not significant (p > . ). a,b the different letters indicate that the differences were significant (p < . ). . . . * , * p < . ; * * p < . ee ratio (%) = weight of embryo (g)/weight of the respective egg (g); hsi = hepatosomatic index = weight of liver (g)/weight of the embryo (g); ksi = kidney somatic index = weight of kidney (g)/ weight of embryo (g). and infected groups, and these values also exhibited significant differences (table ). the ua levels (p < . ) in the control group were much lower than those in the infected group at , , and dpi. the cr values (p < . ) in the control group were much lower than those in the infected group at and dpi. the bun levels at and dpi in the control group were significantly lower than those in the infected group (p < . ). the ua, cr, and bun values of the infected group compared with those of the control group and exhibited significantly increased. the function liver enzyme and blood parameters of the embryonic chickens that were challenged with nibv are illustrated in table . the embryonic chickens that were infected with nibv exhibited significantly increased plasma concentrations of ast and ggt at and dpi. the plasma concentrations of alt and alp were significantly increased in the infected group compared with the control group across the entire experimental duration, whereas the plasma tp and glb concentrations were significantly decreased at and dpi. compared with the control group, the infected group exhibited a significantly lower plasma alb concentration at dpi. the plasma alt, ast, alp, and ggt concentrations of the infected group were compared with those of the control group, which revealed significantly increased. the plasma tp, glb, and alb concentrations of the infected group were compared with those of the control group, which revealed significantly decreased. the detection and quantification limit of the sybr green real time rt-qpcr assay were determined using ct values obtained for each reaction containing from to copies of the standard rna. the values were plotted against the log of the number of template copies different superscript letters within the same row means between control and infected at the same day. (a, b, p < . ; a, b, p < . ). the assay standard curve was generated by plotting the ct values and log of -fold serial dilutions ( - ) of standard rna. an overall reaction efficiency of . % was estimated using the standard curve slope as indicated by the formula. . liver and kidney viral load in embryonic chickens at , , and dpi. the liver and kidney viral loads in the virus group peaked at dpi, and the viral load was significantly higher for kidney than for liver at dpi (p< . ). and a linear equation (y = − . x + . ) with an r value = . was generated (figure ) . the assay maintained linearity for at least seven orders of magnitude. using the slope from the linear equation, the overall efficiency of the assay was estimated to be . %. in the infected group, the virus was detected in the livers and kidneys of the sets of embryonic chickens that were killed at , , and dpi. results are expressed as viral load according to the established standard curve. the liver and kidney viral loads in the virus group peaked at dpi (figure ) , and the viral load was significantly higher for kidney than for liver at dpi (p < . ). the liver and kidney samples from the embryonic chickens in the control groups were negative throughout the experiment. the developing chicken embryo is indeed a valid and sensitive developmental research tool when used in a well-controlled experimental environment (vorster and lizamore, ) . a previous study indicated that the ee ratio is an objective method for the quantification of embryo dwarfism in ibv-inoculated embryonated chicken eggs and can be used to accurately determine the endpoints of virus titration and neutralization assays (dhinakar raj, et al., ) . in the studies of wideman and cowen (wideman and cowen, ) , graystrain ibv decreases the relative kidney weight ratio. in our study, the ee ratios were significantly lower in the infected group than in the control group, and the hsi and ksi were significantly higher in the infected group than the control group. these findings indicate that challenge with nibv decreased the body weight and induced liver and kidney swelling and hypertrophy. our results also supported those of a previous study that observed nephritis in non-vaccinated flocks that was characterized by enlarged and pale kidneys, frequent urate deposits in the kidneys, severe dehydration, and weight loss, and typical signs, including embryo dwarfing and death, in embryos that were observed in different passages after challenge (liu and kong, ; ziegler, et al., ) . in the present study, the changes in embryo body weight, hsi and ksi reflected impaired development and liver and kidney damage following nibv infection. there are several electrolytes in the chicken body, and each performs a vital role. balances of p, cl, k, na, ca, and mg are required for normal cellular metabolism and the maintenance of the physiological functions of the organs. however, neural-humoral regulation may affect the body fluids to ensure embryonic chicken health and prevent conditions that may result from fluid and electrolyte imbalances (levy, et al., ; mclafferty, et al., ) . in our study, the embryonic chickens infected with nibv exhibited significant increases in the concentrations of na and cl at dpi and significant increases in plasma k concentrations at and dpi. these results were likely due to nibv infection-induced kidney damage and chronic glomerulonephritis in the chicken embryos (afanador and roberts, ; cong, et al., ; wideman, et al., ) that led to the simultaneous retention of na, cl, and water and acute intravascular hemolysis that caused intracellular k influx in the blood and induced hyperkalemia due to kidney tissue damage (dote, et al., ; hahn and hahn, ) . however, crawford et al. reported that magnesium is the second most common intracellular cation after potassium and that approximately one-third of the magnesium in the extracellular fluid is bound to protein (albumin), while the remaining two-thirds are free (ionized). it is the ionized portion that is largely involved with the composition of bone and the metabolisms of several enzyme cofactors (crawford and harris, ) . our experiment suggests that the plasma mg concentration in the infected group was significantly higher than that in the control group at dpi. these results are likely due to the dysostosis caused by nibv, and nibv result in tissue cell injuries that lead to reductions in the syntheses of metabolic enzymes, which in turn leads to a decrease in the reabsorption of magnesium. the ca and p levels in the control group were uniformly and significantly lower than those in the infected group at and dpi. for this reason, approximately % of the ca and % of the p in the body exist in the skeleton (zelenka, ) . the dynamic distributions of the electrolytes ca and p in the blood exhibited significant increases in the virus group likely because the maintenance of ca and p is essential for forming the skeleton during the process of embryonic chicken growth. in the infected group, embryo development was blocked, and dysostosis resulted in the reduced absorption of ca and p in the plasma. in conclusion, the infection of embryonic chickens with nibv may result in the observed disturbances in plasma electrolytes. the kidney is the most important excretory organ in terms of the elimination of drugs and their metabolites. the most common of several parameters of kidney function that are examined include the plasma concentrations of ua, bun, and cr. increased plasma bun, cr, and ua levels have been reported to be markers of renal functional impairment in several previous studies (duru, et al., ; lumeij and remple, ) . plasma ua levels are related to nephrotoxicity and kidney injury in broiler chickens (kanbay, et al., ; kanda, et al., ) . we also found that plasma bun, cr, and ua levels were significantly higher following nibv administrations compared with the control group and resulted in kidney damage. the liver plays a central role in the metabolism and excretion of xenobiotics, and thus the liver is highly susceptible to the adverse and toxic effects of these agents. a noticeable indication of hepatic damage is the leakage of cellular enzymes into the plasma (giannini, et al., ) . the estimation of plasma marker enzymes is useful for quantitative evaluations of the extent and type of hepatocellular damage in chickens (giannini, testa and savarino, ; kemal., et al., ) . when the plasma membrane of a hepatocyte is injured, a variety of cytoplasmic enzymes are released into the circulation, and thus the enzyme levels in the plasma are increased. alt, ast, and alp in the plasma serve as indicators of liver function (jaensch, et al., ) . in our study, the plasma alt, ast, and alp levels in the infected group were significantly greater than those in the control group across the entire experimental period. we believe that nibv infection caused liver damage in the embryonic chickens. these findings are in agreement with the severe congestion of the liver, spleen and lungs of birds that have died following experimental ibv infection (abdel-moneim, zlotowski, veits, keil and teifke, ). ast exists mainly in the hepatocellular mitochondria, and when damage or severe necrosis of the liver occurs, only the plasma ast concentration is elevated. the plasma ggt levels of the infected group did not differ significantly from those of the control group at dpi but were significantly higher than the control group at and dpi. this pattern was observed because in the embryonic stages, ggt exists mainly in the intrahepatic bile duct epithelial cells and hepatic cytoplasm, and the development of the intrahepatic bile ducts in embryonic chickens is incomplete at days old (at dpi). existing research has demonstrated that the concentrations of tp, alb, and glb in the plasma serve as indicators of liver function (bernet, et al., ) . tp includes both alb and glb. changes in the levels of these parameters may explain the hypofunctioning of the hepatocytes after nibv infections. glb is related to immunity. alb is made in the liver, and when the liver is damaged, alb levels decrease (toro, et al., ) . additionally, in our study, the liver tp, alb, and glb activities in the infected group were significantly lower than those in the control group. this pattern was observed because embryonic chickens infected with nibv exhibit damage and functional lesions of the liver, and the synthesis of proteins is consequently reduced. in the present study, the changes in the plasma indicators reflected the liver damage that occurred after nibv infection. real-time pcr is widely used to quantify viral genes; sybr green i-based real-time rt-pcr assay is a good method for determination of viral load (acevedo, et al., ) and becomes a pivotal point for calculating the copy numbers of specific viral genes. in the infected group, nibv was detected in the liver and kidney, which indicated that the chicken embryos had been infected with nibv. these findings are in agreement with the ibv antigens were detected in the liver, kidney trachea, and lung of the birds tissues following experimental ibv infection. in our study, the highest detected levels occurred in the liver and kidney in the infected group. based on separate analyses of the liver and kidney tissues, the amount of viral rna in the liver peaked at dpi, which indicated that the liver function of the embryonic chickens was most strongly influenced by nibv infection at dpi. subsequently, the liver (along with many other vital organs) was exposed to danger. due to stress and the lack of proper and steady nutrients, the liver can become prone to infection, malfunction, and jaundice and even cease to function. these findings agree with the above results of liver function, which revealed that the changes in liver function indicators reflected the most serious liver damage at dpi. the amounts of rna detected in the kidney were highest in the virus group, and the levels of rna in the liver were lower than those in the kidney throughout the experiment. this pattern was observed because ibv strains vary greatly in terms of tissue tropism. nibv peaked in the kidney at dpi, and the viral load was significantly higher for kidney than for liver, which indicates that the kidney may be an important target of nibv infection. the amounts of viral rna in the kidney peaked at dpi, which indicated that the embryonic chickens infected with nibv exhibited the most severe kidney damage at dpi. these findings are consistent with the functional kidney results. in the present study, liver and kidney damage were strongly related to the viral rna levels in the tissues. we conclude that embryonic chickens infected with nibv exhibited decreased body weight, liver and kidney swelling and hypertrophy, and liver and kidney damage. our study demonstrated that liver and kidney damage were strongly related to the viral loads of the tissues following nephropathogenic infectious bronchitis virus infection in embryonic chickens. these results suggest that embryonated chicken eggs can be used to partially elucidate the pathogenesis of nibv in embryonic chickens. immunohistochemistry for detection of avian infectious bronchitis virus strain m in the proventriculus and nervous system of experimentally infected chicken embryos protective effect of egg-propagated eimeria tenella (local isolates) gametocytes as vaccine(s) against mixed species of coccidia in chickens a duplex sybr green i-based real-time rt-pcr assay for the simultaneous detection and differentiation of massachusetts and non-massachusetts serotypes of infectious bronchitis virus effect of nephropathogenic infectious bronchitis viruses on renal function in young male broiler chickens embryonated chicken eggs as an alternative model for mixed clostridium perfringens and eimeria tenella infection in chickens emergence of a nephropathogenic avian infectious bronchitis virus with a novel genotype in india effluent from a sewage treatment works causes changes in serum chemistry of brown trout (salmo trutta l.) severe acute respiratory syndrome vaccine development: experiences of vaccination against avian infectious bronchitis coronavirus coronavirus avian infectious bronchitis virus transcriptome analysis of chicken kidney tissues following coronavirus avian infectious bronchitis virus infection protection of chickens against renal damage caused by a nephropathogenic infectious bronchitis virus the long view: years of infectious bronchitis research balancing act: hypomagnesemia & hypermagnesemia egg:embryo weight ratio as an indicator of dwarfism induced by infectious bronchitis virus acute lethal toxicity, hyperkalemia associated with renal injury and hepatic damage after intravenous administration of cadmium nitrate in rats protective effects of n-acetylcysteine on cyclosporine-a-induced nephrotoxicity isolation, identification and molecular characterization of ibv variant from out break of visceral gout in commercial broile liver enzyme alteration: a guide for clinicians carvedilol-induced hyperkalemia in a patient with chronic kidney disease embryonated eggs as an alternative infection model to investigate aspergillus fumigatus virulence assessment of liver function in chickens using galactose and indocyanine green clearances uric acid in hypertension and renal disease: the chicken or the egg? uric acid level has a u-shaped association with loss of kidney function in healthy people: a prospective cohort study reduction of toxic effects of aflatoxin b by using bakeryeast (saccharomyces cerevisiae) in growing broiler chicks diets viral pathogenesis of a nephrotropic infectious bronchitis virus isolated from commercial pullets effect of water restriction on renal function in ostriches (struthio camelus) a new genotype of nephropathogenic infectious bronchitis virus circulating in vaccinated and nonvaccinated flocks in china plasma urea, creatinine and uric acid concentrations in relation to feeding in peregrine falcons (falco peregrinus) isolation and molecular characterization of sul/ / avian infectious bronchitis virus, indicates the emergence of a new genotype in the middle east fluid and electrolyte balance the embryo lethality of escherichia coli isolates and its relationship to various in vitro attributes hematologic and serum biochemical changes in salmonella ser typhimurium-infected calves effects of synbiotics injected in ovo on regulation of immune-related gene expression in adult chickens serum chemistry and antibody status to some avian pathogens of free-living and captive condors (vultur gryphus) of central chile the avian embryo a developmental research tool effect of dietary acidification on kidney damage induced in immature chickens by excess calcium and infectious bronchitis virus kidney function of pullets and laying hens during outbreaks of urolithiasis a reverse transcriptase-polymerase chain reaction survey of infectious bronchitis virus genotypes in western europe from allometric growth of calcium, phosphorus, magnesium, sodium, and potassium in slow-and fast-growing young chickens nephropathogenic infectious bronchitis in pennsylvania chickens this study was funded by national natural science foundation of china awarded to xiaoquan guo (no. , ), jiangxi young scientists target training program to xiaoquan guo (no. bcb ) and the technology r&d program of jiangxi province awarded to xiaoquan guo (no. bnb ). key: cord- -m lkrehi authors: nan title: proceedings of réanimation , the french intensive care society international congress date: - - journal: ann intensive care doi: . /s - - - sha: doc_id: cord_uid: m lkrehi nan introduction: veno-venous extracorporeal co removal (ecco r) is a promising new therapeutic option in the critical care setting. we conducted a prospective observational study of the use of ecco r in selected voluntary centers during years aiming to assess the prevalence of the ecco r use mainly among copd and ards patients. patients and methods: two medical devices: hemolung (alung technologies, pittsburgh, usa) and ila activve (xenios novalung, heilbronn, germany) were selected after literature and medico-economic evaluations. a specific medical and nurses training was provided in table characteristics of patients with known or de novo svv (small-vessel vasculitis) admitted to the intensive care unit for acute respiratory failure (arf) all arf (n = ) immune arf (n = ) non immune arf (n = ) p age , introduction: ineffective triggering is frequent during pressure support ventilation (psv). its occurrence is favored by dynamic hyperinflation that may arise when increasing the pressure support level (psl). decreasing the psl however fails to suppress ineffective triggering in a subgroup of patients that are therefore exposed to refractory ineffective triggering. proportional assist ventilation with load-adjustable gain factors (pav +) decreases the incidence of ineffective triggering in unselected patients but its effect on refractory asynchrony during psv is unknown. the main aim of our study was to assess the effect . the median gain during pav + was % [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the asynchrony index was significantly lower with pav + than psv ( % [ ] [ ] [ ] [ ] [ ] [ ] [ ] vs. % respectively, p = . ). moreover, the asynchrony index decreased in every patient with pav + (fig. ) . noticeably, the tidal volume was already protective in psv and decreased even more during pav + ( . ml kg [ . - . ] vs. . ml [ . - . ] respectively, p = . ); and the neural respiratory rate was high in both modes ( cycles min in psv vs. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in pav + , p = . ). total esophageal pressure-time product (ptpes) did not significantly differ between the two modes but the ptpes proportion that was wasted in ineffective efforts decreased with pav + ( % [ ] [ ] vs. % , p = . ). conclusion: our preliminary data suggest that: ( ) pav + reduces the incidence of refractory ineffective triggering; ( ) patients exposed to refractory ineffective triggering during psv seem characterized by rapid shallow breathing despite high ventilatory support, questioning the tolerance of both ventilatory modes. results with further inclusions will be presented. introduction: the use of alternatives to carbapenems to treat patients with extended-spectrum beta lactamase-producing gram negative bacilli (esbl-gnb) infections remains controversial. their use in patients with severe infections in the icu has been poorly studied. the aim of this study was to compare the outcome of icu patients having received carbapenems to those having received a carbapenem-sparing agent (csa). the charts of patients with esbl-gnb infection hospitalized in our icu between and were retrospectively reviewed. patients treated with betalactam betalactam inhibitor (bl bli), cefepime or quinolones were considered has having received an alternative to carbapenems (csa). patients having received such a csa were compared to those having received a carbapenems. primary outcome was treatment failure at day , defined as esbl-gnb infection recurrence (relapse with same pathogen) or death, whichever first occurred. results: patients with esbl-gnb infection were included. source of infection was the lung for most of them. characteristics of patients are displayed on table . their median saps ii and sofa scores were and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , respectively, and ( %) were on septic shock. patients received a carbapenem empirically, among whom were switched to a csa agent when antibiogram was available (csa-definite group), whereas carbapenems were pursued in the others (carbapenem-only group), mainly because pathogens were resistant to others antibiotics. among the patients having received a non-carbapenem agent as empirical treatment, pathogen was susceptible to this agent in and they pursued the same treatment (csa-only group), whereas were switched to a carbapenem (pathogens resistant to empirical treatment, carbapenem-definite group). treatment failure were not different among these groups (table ) . globally, patients received a csa as their definite treatment (csadefinite and csa-only groups), whereas received a carbapenems (carbapenems-only and carbapenems-definite groups). whereas duration of antimicrobial treatment was similar ( [ - ] days vs. [ - ] days, respectively, p = ns), treatment failure rate was not higher in the former, as compared to those having received a carbapenems ( vs. %, respectively, p = . ). conclusion: treatment of patients with esbl-gnb severe infection in the icu with a csa seems to be safe when the pathogen is susceptible to this csa. however, mic should be first determined before de-escalating to a csa. larger studies are needed. percentages of samplings which attained the pk pd targets for various crcl with potential suboptimal beta-lactam concentration in critically-ill patients with aki treated either with an early or a delayed rrt strategy. patients and methods: ancillary study in a subset of patients with severe aki (kdigo ), receiving a beta-lactam antibiotic, in a trial comparing two rrt initiation strategies. in this trial, patients from intensive care units were randomly assigned to either an early (immediate rrt) or a delayed (late or no rrt) rrt initiation strategy. beta-lactam residual concentrations were sampled at and h after inclusion. the appropriate concentration was defined as a trough of at least times the minimal inhibitory concentration (clinical breakpoint of eucast). the primary outcome was an adequate plasma concentration of the beta-lactam during the first days. results: among the patients included in the centers participating to this ancillary study, a beta-lactam trough concentration was evaluated in subjects, in the early and in the delayed groups. ninety patients ( . %) had an adequate beta-lactam dosage. rrt initiation strategy had no impact on beta-lactam concentration (p = . ). among the septic shock patients ( % of the sampled patients), ( %) had a correct antibiotic concentration. in contrast, only of the patients without definite sepsis ( . %) had a correct dosage. factors associated with an adequate beta-lactam trough concentration in univariate analysis were admission for a septic shock (p = . ), a higher plasma creatinine level (p = . ), a higher mean arterial pressure (p = . ) and a lower serum bicarbonate level (p = . ) at randomization. a higher sofa score was associated with an adequate beta-lactam concentration near to statistical significance (p = . ). multivariate analysis will be presented. in the context of severe aki, beta-lactam concentration reached a sufficient level in % of septic shock patients. interestingly, rrt initiation strategy was not associated with beta-lactam trough concentration. early rrt did not affect trough concentration of betalactam. we may hypothesize that physicians were highly vigilant and adapted antibiotic administration adequately in these patients. introduction: amikacin infusion requires to target a peak serum concentration (c max ) - times the minimal inhibitory concentration, corresponding to a c max at - mg l − for the least susceptible bacteria. recent study reported that % of critically ill patients do not attain this target with a mg kg dose ( ) . membrane sequestration, alteration of the volume of distribution and lack of data in this population make drugs pharmacokinetics (pk) on ecmo challenging. our study aimed to assess the prevalence of insufficient amikacin c max in critically ill patients on ecmo and to identify relative risk factors. patients and methods: prospective, observational, monocentric study of adult patients on venoarterial (va) or venovenous (vv) ecmo receiving a loading dose of amikacin for suspected gramnegative infections. intravenous amikacin was administered with a loading dose of mg kg of total body weight and c max was measured min after the end of the infusion. independent predicators of c max < mg l − after the first amikacin infusion were identified by mixed model multivariate analysis. results: from january to february , patients (median saps (interquartile range) ( - ); age ( - ) years) under va-ecmo ( %) or vv-ecmo ( %) were included. at inclusion, the sofa score was ( - ) and ( %) patients were on renal replacement therapy. overall icu mortality was %. c max was < mg l − in ( %) of the patients. independent risk factors of amikacin under-dosing were body mass index (bmi) < kg m − (odds ratio (or) . , % confidence interval %ci . - . , p = . ) and a positive h fluid balance (or per ml increment: . , %ci . - . , p = . ) (fig. ). our results were comparable to those observed in patients treated with amikacin without ecmo ( ) . conclusion: this large prospective study suggests that the prevalence and associated risk factors of amikacin under-dosing are similar in critically-ill patients with or without ecmo. the use of a mg kg dose in low bmi patients and in those with a positive -h fluid balance on ecmo is strongly encouraged to obtain adequate therapeutic targets and prevent therapeutic failure. results: fifty patients were included ( with delirium, controls), at day for controls and day for patients with confusion. delirium patients were more severely ill sofa [ ; ] versus [ ; ] (p = . ); with higher rass [ ; ] versus [ ; ] (p = . ). they presented with % bl overdosing versus % in controls (p = . ); with % of bl in therapeutic index: % in controls (p = . ). obesity and renal failure were not associated with bl overdosing but there was a trend with hypoalbuminemia (p = . ). discussion: trend in association of bl overdosing with delirium corresponds to previous studies, and would need a larger scale study to be confirmed. severity differences in groups would need changes in inclusion criteria to obtain homogeneous groups. a possible association of bl underdosing with poor evolution of infection and organ failures would need more precise evaluation. hypoalbuminemia could have an impact on bl overdosing. conclusion: delirium was not associated with bl overdosing but with therapeutic index. a high variability of bl concentrations warrants therapeutic drug monitoring. a larger scale study should include changes in design. feasibility and safety of low-flow extracorporeal co removal with a renal replacement platform to enhance lung protective ventilation in patients with mild to moderate ards schmidt matthieu , jaber samir , constantin introduction: extracorporeal carbon dioxide removal (ecco r) might allow ultraprotective mechanical ventilation with lower tidal volume (vt) (< ml kg ideal body weight), plateau pressure (pplat) (< cm h o), driving pressure, and respiratory rate (rr) to reduce ventilator induced lung injury (vili). the aim of this study was to assess the feasibility and safety of ecco r with a renal replacement platform (rrt) to permit ultra-protective ventilation in patients with mild to moderate acute respiratory distress syndrome (ards). patients and methods: twenty patients with mild (n = ) or moderate ards were included. vt was gradually reduced from to , . and ml kg − and peep adjusted to reach > pplat > cm h o. standalone ecco r (no hemofilter associated on the rrt platform) was initiated when arterial paco increased by more than %. ventilation parameters (vt, rr, peep), respiratory compliance, driving pressure, arterial blood gases, and ecco r system operational characteristics (blood flow, sweep gas flow, and co removal rate) were collected during a minimum of h of ultra-protective ventilation. complications, mortality at day , need for adjuvant therapies and data on weaning from both mechanical ventilation and ecco r were also collected. results: while vt was reduced from to ml kg − and pplat kept below cm h o, peep was significantly increased from . ± . at baseline to . ± . cm h o at vt = ml kg − . as a result, the driving pressure was significantly reduced to . ± . cm h o at vt = ml kg − (p < . ) (fig. ) . no significant differences in rr, pao fio ratio, respiratory system compliance were observed after vt reduction. mean extracorporeal blood, sweep gas flow and co removal were ± ml min − , ± . l min − and ml min − , respectively. mean treatment duration was ± h. main side effects related to ecco r were membrane clotting which occurred in patients after ± h. conclusion: a low-flow ecco r device driven by a rrt platform efficiently removed co while allowing ultra-protective mechanical ventilation settings in patients with mild to moderate ards (clinicaltrials. gov identifier: nct ). morimont philippe , habran simon , desaive thomas , janssen nathalie , amand theophile , blaffart francine , dauby pierre , kolh philippe , defraigne jean-olivier , lambermont bernard introduction: protective lung ventilation (plv) is recommended in patients with acute respiratory distress syndrome (ards) to minimize additional injuries to the lung. however, increased right ventricular (rv) afterload resulting from ards could be enhanced by hypercapnic acidosis resulting from ventilation at lower tidal volume. relative contribution of these factors (ards and plv) in rv afterload is not clearly established. the aim of this study was to compare rv afterload in ards combined with plv to rv afterload in plv alone. patients and methods: this study was performed in an experimental model of severe hypercapnic acidosis performed in series of pigs. in both groups, respiratory tidal volume was decreased by %. in the first group (ards group), an ards (obtained by repeated bronchoalveolar lavage) was performed before reducing ventilation, while in the second group (control group), hypercapnic acidosis was resulting from low tidal volume ventilation alone. results: in both groups, systolic pulmonary artery pressure (paps) significantly increased during plv. this increase was significantly higher in ards group than in control group (fig. ) . severe hypercapnic acidosis occurred in both groups: paco increased from . ± . to . ± . (p < . ) and arterial ph decreased from . ± . to . ± . (p < . ) in ards group while paco increased from . ± . to . ± . (p < . ) and arterial ph decreased from . ± . to . ± . (p < . ) in control group. pao significantly decreased in ards group ( ± to ± . mmhg, p < . ) but did not significantly changed in control group. conclusion: isolated hypercapnic acidosis resulting from plv was clearly responsible for increased rv afterload and this effect was significantly enhanced in ards. pulmonary vasoconstriction resulting from hypercapnic acidosis is strongly enhanced by factors like hypoxia, endothelial injuries or inflammatory mediators in ards. extracorporeal co removal could be the solution to limit afterload burden on the right ventricle when plv is achieved during ards. introduction: prone positioning has been shown to improve mortality in acute respiratory distress syndrome (ards) patients. the respiratory system driving-pressure (dprs) and the transpulmonary driving-pressure (dpl), measured with esophageal manometry, have been shown to be strongly correlated with mortality. the aim of this study was to investigate the evolution of the dpl during prone positioning and its relationship with evolution of oxygenation in ards patients. patients and methods: ten patients with ards equipped with esophageal manometry were enrolled. dprs, dpl and chest wall driving-pressure (dpcw) were measured before and h after prone positioning. respiratory system, pulmonary and chest wall elastance (ers, el, ecw) were calculated at the same time. finally, we studied the correlation between these respiratory variables and oxygenation indicators. patients were classified as responders to prone positioning if the change in the ratio of arterial oxygen partial pressure oxygen inspired fraction (delta.pao /fio ) induced by the manoeuvre was larger than the median value observed in the group. results: in the whole population, median value of delta.pao /fio was . mmhg, and patients were classified as responders and as non-responders. in responders, dpl significantly decreased from . ± . cm h o to . ± . cm h o (p = . ) and el decreased from . ± . cm h o l to . ± . cm h o l (p = . ) after prone positioning. other respiratory variables did not change. in non-responders, respiratory variables did not change. between responders and nonresponders, there was no significant difference between baseline respiratory variables. after prone positioning, delta.pao /fio was not related to baseline respiratory parameters. on the contrary delta. pao /fio induced by prone positioning was strongly correlated with changes in dpl (r = − . , p = . ) and changes in el (r = − . , p = . ). we did not find any correlation between delta.pao /fio and changes in dpcw or changes in ecw. the correlation between delta.pao /fio and changes in dprs (r = − . , p = . ) and changes in ers (r = − . , p = . ) did not reach significance. conclusion: in patients who respond to prone positioning by the highest improvement in oxygenation, dpl significantly decrease after prone positioning. the changes in dpl and the changes in el play a major role in the improvement in oxygenation induced by prone positioning whereas the changes in dpcw and ecw do not. introduction: whereas prone positioning (pp) has been shown to improve patient survival in moderate to severe ards patients, its rate of use was . % in lung safe study. however, lung safe study was not specifically focused on pp. therefore, present study aimed to determine prevalence of use of pp in ards patients (primary endpoint), physiologic effects of and reasons for not using pp (secondary end-points). the apronet study was a prospective international one-day prevalence study performed times in april, july, october and january . at each study day, investigators had to screen every patient staying in icu from to h and to fill electronic crf. for patients with ards (defined from the berlin definition criteria) at each study day oxygenation and ventilator settings were recorded. for those receiving pp these variables were recorded before and at the end of pp session. the reasons for not proning were also collected. values are presented as median ( st- rd quartiles). prevalence rates of pp were compared by using chi square for trend and groups were compared with nonparametric tests. introduction: although acute respiratory distress syndrome (ards) has been largely focused on, few data are available concerning hypoxemia independently of its cause in intensive care unit (icu) patients. a recent prevalence-point-day (ppd) evaluated the patterns and outcomes of hypoxemia in french speaking icus. here, we describe the main etiologies, management and outcomes of the patients of this cohort presenting with severe hypoxemia. patients and methods: a ppd was conducted among french speaking icus during spring . hypoxemia was defined by a pao fio ratio below . we analyzed the data from patients with severe hypoxemia (i.e. with a pao fio ratio < ) and compared their characteristics (causes of hypoxemia, ventilatory and non-ventilatory management) and outcomes to the patients with mild or moderate hypoxemia. results: among the hypoxemic patients the day of the study, ( %) had severe hypoxemia. the main cause of hypoxemia was pneumonia and this diagnosis was more frequent than in mild and moderate hypoxemia. whereas bilateral radiologic infiltrates were present in ( . %) patients, ards was diagnosed by physicians in only ( . %) of them. invasive mechanical ventilation (mv) was used in ( . %) patients. high flow oxygen was administered in ( . %) of them and ( . %) were under non-invasive ventilation (niv) the day of the study. median vt was . ( . - . ) ml kg of ibw. positive end-expiratory pressure (peep) was higher than in mild and moderate hypoxemic patients ( ( - ) vs. ( - ) and ( - ) cm h o respectively, p < . ). median plateau pressure was . ( - . ) and was higher than in mild and moderate groups. median driving pressure was ( - ) cm h o with no difference when compared to other groups. neuromuscular blocking agents were administered in ( . %) patients, inhaled nitric oxide (ino) in ( %) patients and only patients ( . %) were on prone positioning. fourteen ( . %) patients were under extracorporeal membrane oxygenation (ecmo). icu mortality was higher in severe hypoxemic patients as compared to mild and moderate ( . vs. . and . % respectively, p < . ). icu length of stay in icu survivors was not statistically different between groups. conclusion: severe hypoxemia, independently from ards, worsens the prognosis of icu patients. even though ards might be underdiagnosed, a protective ventilation was respected in severe hypoxemic patients. introduction: major changes in septic shock management raise the questions of the relevance of the classical risk factors of nosocomial infections in the current era and the link with the primary infectious insult. we herein investigated the risk factors and the outcomes of icuacquired infections in a recent cohort of septic shock patients. patients and methods: this was a -year ( - ) monocenter retrospective study. all adult patients diagnosed for septic shock within the first h were included. septic shock was defined as a microbiologically proven or clinically suspected infection, associated with acute circulatory failure requiring vasopressors. patients who survived the first three days were eligible for assessment of the risk of the first icu-acquired infections. the diagnosis of nosocomial infections were based on current international guidelines. patients were classified according to the development of pulmonary or non-pulmonary icu-acquired infections. the determinants of icu-acquired infections were addressed in a multivariate logistic regression analysis. results: patients were admitted for septic shock. patients remained alive in the icu after the first three days and could then be evaluated for the risk of icu-acquired infections. hence, patients remained free of secondary infections, patients first developed an episode of nosocomial pneumonia and patients first developed an episode of non-pulmonary infection. the mortality rates of patients with icu-acquired pneumonia, non-pulmonary icu-acquired infections and without secondary infections were , and %, respectively (p = . ). in multivariate analysis, the development of icu-acquired pneumonia was independently associated with male gender (or . , ci % [ . - . ], p = . ), renal replacement therapy (or . , ci % [ . - . ], p = . ), platelet transfusion (or . , ci % [ . - . ], p = . ) and a primary pulmonary infection (or . , ci % [ . - . ], p < . ). the development of non-pulmonary infections was independently associated with renal replacement therapy (or . , ci % [ . - . ], p < . ), fresh frozen plasma transfusion (or . , ci % [ . - . ] , p = . ), healthcare-associated septic shock (or . , ci % [ . - . ], p = . ). conclusion: icu-acquired pneumonia occurs preferentially in patients with septic shock of pulmonary origin. in addition, we identified the transfusion of blood products as a risk factor for pulmonary and nonpulmonary nosocomial infections. introduction: human serum albumin is used for the restoration of blood volume, emergency treatment of septic shock patients. several experimental studies suggested that albumin could have additional protective effects on the vascular wall and more specifically on endothelial functions. however, the in vivo effect of albumin in human endothelium remains unknown. the aim of this study is to assess the effect of albumin or saline infusion on skin endothelial function in septic shock patients requiring volume expansion. we performed a prospective randomized monocentric study in an -bed medical intensive care unit. all patients with septic shock who required fluid administration were included between h and h after vasopressor starting. patients were randomized to receive either ml of saline solution . % or ml of albumin %. norepinephrine dose was not modified h before and during the procedure. endothelium-dependant vasodilatation in the skin circulation was assessed by iontophoresis of acetylcholine before and after fluid administration. the improvement of skin blood flow in response to acetylcholine after fluid administration was compared between groups. for each patient, age, sex, saps ii, site of infection, global hemodynamic parameters and clinical microcirculatory parameters were recorded. results are expressed as mean ± sd. qualitative data were compared using chi- or fisher's exact test while quantitative data comparisons used student t test or mann-whitney as appropriate. results: twenty-two patients were included ( women, age: ± , saps ii: ± ). twelve patients received saline and received albumin. apart from age, no statistical difference was found between groups regarding demographic characteristics and baseline hemodynamic parameters. norepinephrine dose and mean volume of infused fluid before inclusion was not different between groups (table ) . before fluid replacement, endothelial response to acetylcholine iontophoresis was not different between groups (auc vs ; p = . ). volume expansion induced a slight increase of systolic arterial pressure, significantly higher in the albumin group ( vs %; p = . ) with no difference regarding cardiac output variations between groups. next, we compared the variations of endothelium response to iontophoresis before and after fluid infusion. the improvement of endothelial response after acetylcholine challenge was significantly higher in the albumin group ( vs %, p = . ). conclusion: in the early stage of septic shock resuscitation, we showed that albumin infusion had protective endothelial effects. this result has to be confirmed in a larger cohort. ] + all p < . ). we found no correlation between cognitive scores at hospital discharge and the severity of eeg-defined encephalopathy during the days of icu or during the first h after admission. however, sepsis survivors' scores were lower than controls' (p < . ) ( table ) . conclusion: in this study, eeg was more sensitive than clinical tools to detect sae but clinical scales correlated with the eeg grade. encephalopathy was not associated with short-term cognitive function. further study and a larger cohort are needed to determine which early eeg introduction: there is growing evidence that corticotherapy improves survival from septic shock. this observational study aimed at evaluating at bedside resistance to corticosteroids in adults with sepsis. patients and methods: participants-icu adults with septic shock or without sepsis admitted to the raymond poincaré university hospital. we also evaluated healthy controls. intervention-resistance to corticosteroids was assessed using a skin test. µl of dermocorticoid cream (class iii, betamethasone) was applied on a cm surface of the skin. at h, two independent physicians scored the blanching of the skin from to - -no blanching + -< % of surface + - to % of surface + - to % of surface, and -blanching beyond application area. cohen's kappa was used to measure concordance. a mean score of < indicated corticoresistance and a score of indicating normal sensitivity to corticosteroids. we also performed a µg acth test. results: we enrolled patients, patients with septic shock ( males, ) and patients without sepsis ( males, ). overall, ( %) with two measurements patients had concordant evaluation of score by the two physicians + while had a difference of -point in scores, resulting in a kappa of . ( % ci . - . ). in patients with septic shock, ( %) have corticoresistance, i.e. a mean score < , ( %) a score of or , and ( %) has normal sensitivity to corticosteroids. in non-septic critically ill, ( %) have corticoresistance, ( %) a mean score of - , and ( %) have normal sensitivity to corticosteroids. hence, as compared to non-septic patients, patients with septic shock were more likely to have corticoresistance (p = . ). discussion: topic application of corticosteroids on the skin results in activation of glucocorticoid receptors present within the vessels. subsequently, activation of lipocortin may inhibit the activity of phospholipase a , regulator of prostaglandins, leucotrienes and platelet activating factor. then, the coupling of alpha adrenoreceptors to their agonists is potentiated, increasing vessels smooth muscles sensitivity to catecholamines. the subsequent local vasocontriction is reflected by skin blanching. thus, the observed lack of skin blanching in septic patients may reflect altered coupling between gluocorticoids and glucocorticoids receptors. conclusion: roughly one out of two adults with septic shock may develop a resistance to corticosteroids as assessed by a skin blanching test in response to betamethasone. introduction: mild therapeutic hypothermia, currently recommended in the management of cardiac arrests with shockable rhythm could promote infectious complications and especially ventilator-associated pneumonia (vap) (mongardon et al. crit care med ). despite high incidence of vap and retrospective trials suggesting a benefit of shortterm ( h) antibiotics in this setting (davies et al. resuscitation ) , systematic use of antibiotic prophylaxis is not recommended in patients treated with mild therapeutic hypothermia after cardiac arrest. the primary objective was to demonstrate that systematic short-term antibiotic prophylaxis with amoxicillin-clavulanic acid can reduce incidence of early vap (< days) in patients treated with mild therapeutic hypothermia after out-of-hospital cardiac arrest. secondary objectives were its impact on incidence of late vap and on day mortality. patients and methods: multicenter two parallel-group doubleblinded randomized trial. adult patients hospitalized in icu, mechanically ventilated after out-of-hospital resuscitated cardiac arrest related to initial shockable rhythm and treated with mild therapeutic hypothermia were eligible. exclusion criteria were pregnancy, need for extracorporeal life support, ongoing antibiotic therapy or pneumonia, known chronic colonization with multiresistant bacteria, known allergy to beta-lactam antibiotics and moribund patients. patients received either intravenous injection of amoxicillin-clavulanic acid ( g mg) or placebo three times a day for days. the primary endpoint was the onset of early vap. all suspected pulmonary infections were adjudicated by a blinded independent committee. results: out of patients included, were finally analyzed, in treatment group and in placebo group (mean age . ± . years, sex ratio = , sofa score . ± . ). characteristics of cardiac arrest were similar in both groups (no flow = . ± . min vs . ± . min, low-flow = . ± . min vs . ± . min). early vap were confirmed, in treatment group vs in placebo group, with an incidence of . vs . %, respectively (hr = . + ic % = [ . + . ], p = . ) (fig. ). the procedure did not affect occurrence of late vap (> days), respectively vs . day mortality was similar in both arms ( . vs . %, p = . ) and no adverse event was related to study treatment. conclusion: short-term antibiotic prophylaxis with amoxicillin-clavulanic acid significantly decreases incidence of early vap in patients treated with mild therapeutic hypothermia after out-of-hospital cardiac arrest related to shockable rhythm. introduction: immunosuppressed (is) patients are prone to develop respiratory failure and to need ventilatory support. invasive ventilation shared a grim prognosis in the past and non-invasive ventilation had been recommended in these patients, however niv efficacy has been recently challenged and the advent of high flow oxygen therapy had brought even more complexity in the management of such patients. using the data from a recent point-prevalence-day of hypoxemia in icu, we compare the frequency, management and outcomes of hypoxemia in is and immuncompetent (ic) patients. patients and methods: the spectrum study was conducted in french-speaking icus in countries during spring . is was retained in case of malignant hemopathy, hiv positivity, immunosuppressive drugs, recent chemotherapy, neutrophil count < . g l. hypoxemia was defined as a pao fio ratio > and separate into severe (> ), moderate (> ) and mild (> ). we focused on the causes of hypoxemia, the ventilatory management and the outcome. results: among the patients included, ( %) were is out of whom ( %) were hypoxemic, proportion similar to the ic patients. mean age and igs- of hypoxemic patients were similar in is and ic patients. hypoxemia was mild in ( %), moderate in ( %) and severe in ( %) is patients with a similar distribution compared to hypoxemic ic patients. the causes of hypoxemia were also similar pneumonia being the leading cause. ( %) hypoxemic is patients fulfilled the berlin criteria for ards in a similar proportion to ic patients. respiratory support used in hypoxemic is patients was ambient air in , low flow oxygen in , high flow in , niv in and invasive ventilation in patients, with a different distribution from the ic patients (more patients on high flow therapy and less invasively ventilated). the day of the study, thoracic ct scan and echocardiography were performed in a similar proportion in is and ic patients whereas broncho-alveolar lavage was more frequently performed in is patients ( vs %, p < . ). finally, as expected, icu mortality was higher in hypoxemic is patients ( vs %, p < . ). conclusion: immunosuppression in the icu seems not to be associated with hypoxemia, severity of hypoxemia or ards. oxygenation management is slightly different from immunocompetent patients with more frequent use of high flow therapy. ( ) mmhg, ph . ( . ). were included in the l/kg/min group and in the l/kg/min group. no difference was observed between groups for baseline characteristics. failure rate was not different between groups- . vs . % + p = . . no center effect was observed for failure. discomfort was more frequent in the l kg min group- vs % + p = . . the length of stay was shorter in the l kg min group- . ( . ) vs . ( ) days + p = . . intubation occurred in patients in the l/kg/min group vs patients in the l kg min group (p = . ). conclusion: hfnc with a flow rate of l/kg/min did not reduce the risk of failure compared to l/kg/min at the initial respiratory management of avb in young infants. comparison of epinephrine and norepinephrine for the treatment of cardiogenic shock following acute myocardial infarction. optima cc study levy bruno introduction: despite the frequent use of vasopressors which are administered in % of patients in cardiogenic shock (cs), there is only limited evidence from randomized trials comparing vasopressor in cs. hence, the optima cc study was designed to compare epinephrine and norepinephrine in cardiogenic shock following myocardial infarction. patients and methods: multicenter, double-blind, randomized trial in french icu. cardiogenic shock patients due to myocardial infarction treated by pci were randomized to receive epinephrine or norepinephrine to maintain map at mmhg. dobutamine was introduced at the physician discretion according to a combination of parameters-echocardiographic parameters, cardiac index, lactate clearance, svo and swan-ganz derived parameters. results: / patients were ventilated ( %). there were no differences in the duration nor in the maximal dose or cumulated dose of epinephrine or norepinephrine. dobutamine was used in / ( %) in the epinephrine group and in / ( %) in the norepinephrine group. there were no differences in the duration, in the maximal or cumulated dose. arterial pressure evolution was similar. heart rate increased significantly in epinephrine group and did not change in norepinephrine group. cardiac index and cardiac power index increased significantly more in the epinephrine group than in the norepinephrine group. cardiac double product, a surrogate of myocardial oxygen consumption increased in epinephrine group and did not change in norepinephrine group. epinephrine use was associated with a lactic acidosis from h to h while arterial ph increased and lactate level decreased in norepinephrine groupepinephrine was significantly associated with an higher incidence of refractory shock- / ( %) versus / ( %) p = . ). the incidence of arrhythmia was identical (epinephrine- % versus norepinephrine- %, p = . ). ecmo was used in / ( %) in the epinephrine group and in / ( %) in the norepinephrine group (p = . ) mortality was / ( %) in the norepinephrine group and / ( %) in the epinephrine group (p = . ) epinephrine use was associated with a trend to an increased risk of death (p = . ) and an increased risk of death plus ecmo (p = . ) at days. there was a trend for an increased risk of death plus ecmo at j (p = . ). conclusion: in patients with cardiogenic shock following myocardial infarction, epinephrine use was associated with a lactic acidosis, an higher incidence of refractory shock and an increased risk of death plus ecmo at j . high dose immunoglobulins in toxic shock syndrome in children: a pilot randomized controlled study (ighn study) javouhey etienne , leteurtre stéphane , tissières pierre , joram nicolas , wroblewski isabelle , ginhoux tiphanie , dauger stéphane , kassai behrouz hôpital mère enfant, bron, france; hôpital jeanne de flandre, lille, france; hôpital du kremlin-bicêtre, le kremlin-bicêtre, france; chu nantes, nantes, france; chu grenoble, la tronche, france; hospices civils de lyon, bron, france; hôpital robert debré, paris, france; hospices civils de lyon, bron, france correspondence: javouhey etienne -etienne.javouhey@chu-lyon.fr annals of intensive care , (suppl ):co- introduction: superantigen toxins synthesized by s. aureus or by s. pyogenes are responsible for toxic shock syndromes (tss) which lethality can reach %. high dose intravenous immunoglobulins (ivig), able to neutralize these toxins, are frequently used even tough evidence of its efficacy is not supported by randomized controlled study (rct) . moreover, ivig are expensive and possibly harmful. before conducting a rct, a pilot study was first designed to assess the feasibility in the context of pediatric critical care. patients and methods: a double blinded rct was performed comparing g kg of ivig to isovolumic % albumin perfusion within the first h of tss in children aged between month to years. a priori criteria to determine the feasibility were defined as a rate of inclusion among eligible patients > %, a rate of protocol's deviations < % (treatment delivery, non-respect of blinding, premature stop), and by the practical and financial aspects of the protocol. secondary objectives were to assess the efficacy of ivig on organ dysfunction (using pelod- score), on mortality at day and their safety. the study was promoted by the hospices civils of lyon, approved by the cpp sud-est and registered at clinical trial (nct ). inform consent from both parents was required before randomization. this study was funded by csl-behring company. results: during the months study period, patients were included in centers. the inclusion rate was of % ( parent's refusals, parents were absent at admission). two patients were wrongly included (pneumococcal shocks), one patient didn't receive the treatment because he was transferred for ecmo in a non-investigator center, three patients were treated after h, and in two patients one bottle of treatment was missing. the blinding was well respected. missing data on the pelod score and mortality was lower than %, and no premature stop was reported. the ecrf completion was judged easy by investigators. the inclusion of children within the first h was judged challenging. the treatment delivery had to be improved, requiring the help of research assistants. seven serious and one severe adverse events were registered, all patients recovered and no death was reported. conclusion: this pilot study suggested that a rct is feasible. it provides crucial information to improve the recruitment, the respect of the protocol and the correct measure of organ failure. however, inclusion of international centers is necessary to attain the sample size required. indirect calorimetry-based method for the work of breathing assessment when compared to esophageal pressure (pes) measurement and electrical activity of the diaphragm (eadi) during a spontaneous breathing trial in continuous positive airway pressure. patients and methods: a prospective single center study. all intubated and mechanically ventilated children > months and < years old, hospitalized in the pediatric intensive care unit were eligible. patients considered as ready to extubate were included. simultaneous recordings of vo , pes and eadi were performed during steps: before, during and after the spontaneous breathing test in continuous positive airway pressure. results: twenty patients, median . months, were included. half of the patients were admitted for a respiratory reason. predicted resting energy expenditure was overestimated as compared to measured resting energy expenditure ( [ - ] vs [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] kcal kg day, p < . ). spontaneous breathing test was associated with an increase in esophageal pressure-time product from to cm h o s min. the same trend was observed in respiratory drive, assessed by eadi which increased from . [ . - . ] to . [ . - . ] . oxygen consumption obtained by ic was higher during spontaneous breathing test as compared to conventional ventilation ( . [ . - . ] vs . [ . - . ] ml kg min) but non significantly. changes in work of breathing as assessed by vo was poorly correlated with measurements from pes and eadi whereas we found a moderate correlation between pes and eadi values. spontaneous breathing test and extubation were successful in ( %) and ( %) patients, respectively. conclusion: during weaning from mechanical ventilation, spontaneous breathing test in continuous positive airway pressure induced an increase in work of breathing, both in respiratory drive, as measured by eadi and in respiratory mechanics, as measured by pes. oxygen consumption measured by indirect calorimetry does not seem to be a reliable tool to assess work of breathing in mechanically ventilated children. ben gheriba khalil , grimaud marion , heilbronner claire , roy emeline , hadchouel alice , renolleau sylvain , rigourd virginie hôpital necker enfants malades, paris, france correspondence: ben gheriba khalil -bg.khalil@gmail.com annals of intensive care , (suppl ): introduction: during the winter season - we had evaluated breastfeeding disruption after hospitalization for bronchiolitis in our hospital in infants under month (n = ). we observed % of mothers whose breastfeeding was stopped of modified. clinical severity had no impact on breastfeeding but % of mothers stated that lack of support and advice was the first cause of breastfeeding disturbance. we conducted this second phase to evaluate the potential impact of actions to promote breastfeeding on unwanted weaning during hospitalization for bronchiolitis. patients and methods: this is a cross sectional study during two epidemic seasons of bronchiolitis in a tertiary care hospital. all patients aged months or younger hospitalized with acute bronchiolitis and receiving at least partial breastfeeding were eligible for the study. patients discharged at home whose parents accepted to be contacted by phone were included. a bundle of actions to promote breastfeeding in patients with bronchiolitis was implemented (posters, flyers, staff training, equipment with breast pumps) between the two epidemic seasons. the data was extracted from the charts and from a phone survey two weeks after discharge to evaluate breastfeeding in eligible patients in our hospital. phase i (before action) had included patients hospitalized between december and march in all wards hosting patients with bronchiolitis. phase ii (after action) included patients hospitalized from october to december . the data from phase ii was compared with data from phase i. results: fifty patients could be included during the second step of the study, with a mean age of days. breastfeeding was exclusive for % of mothers (vs % in phase i). the median length of stay was days (vs days in phase i). twenty-one ( %) patients spent time in picu vs. % in phase i, needed intubation, received non invasive ventilation for a median length of days (vs. days in phase i). the number of patients needing nutritional support was ( %) during phase ii vs. ( %) during phase i. after implementation of our actions, ( %) mothers kept breastfeeding as before (vs. % in the previous epidemic season, p < . ), mothers ( %) stopped, ( %) switched to partial breastfeeding and ( %) reduced without stopping. conclusion: bronchiolitis is a high risk event for breastfeeding disruption but staff training and correct advices and support for mothers during hospitalization seems to diminish that risk. benefits of using a high temporal resolution database in the automatic real-time pediatric ards screening nardi nicolas introduction: pediatric acute respiratory distress syndrome (pards) is frequent in pediatric intensive care units (picu), potentially lethal and the diagnosis is often missed or delayed (palicc ) . in picu, data are usually recorded between to min which leads to only a minority of the arterial partial pressure of oxygen (pao ) that are usable to calculate a valid oxygenation index (oi). if not available, pao should be replaced by the spo if < % to calculate the oxygen saturation index (osi). using a high temporal resolution (htr) database that records data every - s, we aim to develop a relevant clinical algorithm of mass data aggregation to improve pards screening with the automatic oi and osi calculation. patients and methods: all the patients admitted to our pediatric icu between may and august were included. the htr and the electronic medical records (emr) were queried through structured query language (sql) following these steps-( ) data selection ( ) extraction to a linear format ( ) date and time synchronization ( ) data pivoting ( ) aggregation through a -min moving average ( ) hypoxemia calculation. statistical analysis included proportions, correlations and bland-altman analysis. results: between may and august , patients ( stays) were admitted to the picu. approximately million rows were retrieved from the databases including , pao values. the algorithm was able to calculate , ( % of the pao ) oi and osi. the comparison between oi and osi showed that . % of the results were between the limits of agreements (− . + . ), a bias of − . and a correlation r = . . the comparison between the ois from the htr and emr databases showed that . % of the results were between the limits of agreements (− . + . ), a bias of − . and r = . . conclusion: using a mass data aggregation algorithm on a htr database allows more pao to be used to calculate an oi than the usual emr. the oi results differ slightly between the htr and the emr. the accuracy is probably in favor of the htr because of the shorter timelapse between the oi parameters. the osi is possibly a biased oi surrogate and should be interpreted with caution. our next step will be to measure the impact of the algorithm on the pards real-time diagnosis and pards severity categories. introduction: early administration of appropriate antibiotic therapy with adequate concentration is the cornerstone of the severe sepsis and septic shock's treatment. adult studies showed alteration of distribution and elimination which can lead to insufficient drug concentration in septic patients. in children, studies are lacking and antibiotic dosing may be suboptimal. we aim to describe the plasma concentration of the most used beta-lactam in critically ill children, to describe the rate of patients with suboptimal exposure and associating clinical and biological factors. patients and methods: this was a prospective, single center, observational study designed in beds pediatric intensive care unit (picu) and high dependency care at the necker hospital (paris, france) from january to may . were included, children with severe sepsis or septic shock, aged less than years and weighing more than . kg, and receiving one or more of the following antibiotics-amoxicillin, cefotaxime, cefazolin, ceftazidime, piperacillin-tazobactam, meropenem and imipenem for suspected or proven infection. betalactam plasma concentrations were analysed using high performance liquid chromatography. results: we enrolled children (severe sepsis, n = ( . %) + septic shock, n = ( . %)) with a median age of months ( - . bacteria were identified in patients ( . %). a total of blood samples were analysed at a median of days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) following the onset of sepsis. twenty-four patients ( . %) had insufficient concentration (cefotaxime ( %) + piperacillin-tazobactam, ( %) + amoxicillin ( %) + meropenem ( %), cefazoline ( %), imipenem ( %) + ceftazidime ( %)). insufficient concentrations were associated with early measurements (< h from the sepsis' onset) (p = . ) and creatinine clearance increase (p = . ). adequate concentrations were associated with small age (p = . ). in conclusion, current standard beta-lactam dosing in children with severe sepsis or septic shock could be inadequate to reach the target concentrations. that could lead to the risk of clinical and bacteriological failures as well as the emergence of bacterial resistance. further pharmacokinetic studies are mandatory to improve antibiotic therapy in this vulnerable population. introduction: intermittent hemodialysis is a key support therapy in icu. despite protocol-based optimization, intradialytic hemodynamic instability (ihi) remains a common complication and could account for mortality and delayed renal recovery. the identification of patients at high risk for ihi is crucial but remains poorly explored. our objective was to test whether tissue perfusion parameters assessed at the bedside (mottling, index capillary refill time (icrt), and lactate) predict ihi and to develop and to validate a predictive score of ihi. patients and methods: prospective observational study in a -bed medical icu in a tertiary university hospital including hemodialysis sessions performed for acute kidney injury. exclusion criteria were patients with dark skin and dialysis performed in extreme emergency. mean arterial pressure (map), mottling score, icrt, and lactate were recorded just before starting hemodialysis. first episode of ihi requiring therapeutic intervention was recorded , , and min after hemodialysis starting. results: ninety-six hemodialysis sessions performed in patients were recorded. half of the patients received vasopressors (n = , %). ihi occurred in ( %) sessions and was more frequent among patients receiving vasopressors ( vs %, p < . ). mottling were more frequent ( vs %, p = . ), lactate levels higher ( . [ . - . ] vs . [ . - . ] mmol l, p < . ) and icrt longer ( . [ . - . ] vs . [ . - . ] s, p < . ) before sessions with ihi compared to sessions without, independently of map (p < . ). the incidence of ihi increased with the number of tissue perfusion alterations ( , , , and % for , , , and alterations, respectively, p < . ). a tissue hypoperfusion score, defined as icrt (seconds) + lactate level (mmol l) + if mottling presence was predictive of ihi independently of map (or . [ . - . introduction: epidemiological data suggest an increased risk of longterm chronic kidney disease after acute kidney injury (aki). in survivors of out-of-hospital cardiac arrest (ohca), aki is frequent and is associated with numerous factors of definitive renal injury. we made the hypothesis that aki after ohca was a strong risk factor of long-term chronic kidney disease (ckd). we aimed to evaluate renal outcome of ohca survivors according the occurrence of aki in icu. patients and methods: we used the cohort of consecutive ohca patients admitted between and in a tertiary medical icu previously described (geri et al. icm. ) . aki was defined by kidney disease improving global outcomes (kdigo) criteria. long-term creatinine level was the last blood creatinine assessment we were able to retrieve. the main outcome was the occurrence of ckd, defined by an estimated glomerular filtration rate (egfr) lower than ml min . m according to the mdrd equation. long-term mortality was evaluated as well. factors associated with ckd occurrence were evaluated by competing risk survival analysis (fine gray and cox cause specific models providing sub-hazard ratio (shr) and cox sub-hazard (csh)). results: among the ohca patients who were discharged alive, we were able to retrieve the outcome of patients (median age [iqr , ] , . % of male) who were included in the analysis. during a median follow-up time of . [ . - . ] years, ckd occurred in ( . %) patients and ( %) patients died. a previous history of arterial hypertension (shr = . [ . + . ], p = . + csh = . [ . + . ], p = . ), aki during icu stay (shr = . [ . + . ], p = . + csh = . [ . + . ] , p = . ) and an age higher than (shr = . [ . + . ] , p = . + csh = . [ . + . ], p = . ) were independently associated with ckd occurrence. aki was not associated with long-term mortality (shr = . [ . + . ], p = . + csh = . [ . + . ], p = . ). in ohca survivors resuscitated from an ohca, ckd was a frequent long-term complication. aki during icu stay was a strong determinant of long-term ckd occurrence. introduction: many critically ill patients have a moderate to high risk of bleeding but they also require prolonged intermittent dialysis to ensure a negative water balance without hemodynamic adverse events. thus, a heparin-free easy-to-use anticoagulation within the dialysis circuit is needed but, to date, usual protocols (iterative saline flushes, heparin grafted membranes) lead to - % of premature clotting and sessions that last greater than min are rarely achievable. we assessed the safety and efficiency of heparin-free regional citrate anticoagulation of the dialysis circuit using a calcium-free citrate-containing dialysate, with calcium reinjected according to ionic dialysance (an online measure of the instantaneous clearance of small molecules available in most of dialyzers). patients and methods: we prospectively reported the clotting events that occurred during all the heparin-free dialysis sessions that were performed with a regional anticoagulation based on calcium-zero citrate-containing dialysate (citrasate, hemotech, france) between january and august in a -beds icu. results: a total of dialysis sessions were performed in patients (mechanical ventilation n = + norepinephrine n = ). median duration of dialysis was min (iqr, - + maximum min), and median ultrafiltration volume was l (iqr . - . ). when assessed, urea and beta -microglobulin reduction rates were . % ± . % and % ± . %, respectively. postfilter ionized calcium was . ± . and . ± . mmol l at and h, respectively, within the extracorporeal circuit. a major clotting event that led to premature termination of the session occurred in only sessions ( . %) . in these five cases, major catheter dysfunction occurred before clotting within the circuit. prefilter ionized calcium remained within narrow ranges (before after change + . ± . mmol l), and total-to-ionized calcium ratio, a surrogate marker for citratemia, was unchanged and always below . . in sessions, no ionized calcium measurement was required. conclusion: dialysis anticoagulation with calcium-free citrate containing dialysate is an easy-to-use, efficient, and inexpensive form of heparin-free regional anticoagulation. calcium reinjection according to ionic dialysance allows prolonged hemodialysis sessions in critically ill patients without the need to systemically monitor ionized calcium. sessions can be safely extended according to the hemodynamic tolerance to ensure an adequate dose of dialysis and a negative water balance, a major point in patients with severe aki. introduction: brain injury is the first cause of death after cardiac arrest (ca) and multimodal neuroprognostication is a cornerstone of postresuscitation care. among the different usable information provide by electroencephalogram (eeg), the aim of this study was to evaluate the predictive value of eeg reactivity regarding neurological outcome at discharge. patients and methods: using our prospective registry of successfully resuscitated patients admitted to a cardiac arrest center between january and , we studied all consecutive comatose patients still alive at h and in whom at least one eeg was performed during coma. in addition to usual clinical findings, we collected eeg (patterns and reactivity, status epilepticus) and somatosensory evoked potentials characteristics. the eeg reactivity was evaluated by a blinded neurophysiologist and was defined as a reproducible change of the tracing (in amplitude or frequency) provoked by an auditory and a nociceptive standardized stimulation. we evaluated the predictive values of persistent lack eeg reactivity and other indicators regarding their respective ability to predict a favorable or unfavorable outcome. recovery of a level or on the cerebral performance category (cpc) scale at discharge was considered as a favorable outcome, as opposed to recovery of a cpc level - (unfavorable outcome). we included patients who were mostly male ( %), with median age of years. ca occurred in a public place in % of cases, and it was witnessed in % of cases. bystander cpr was initiated in % patients and the initial cardiac rhythm was shockable in % patients. median time to eeg was days ( - ) and % of patients were still sedated during the examination. a favorable neurologic outcome was observed in patients ( %). an eeg reactivity was present in patients ( %) with favorable outcome and in patients ( %) with unfavorable outcome. the positive predictive value (ppv) of a persistent eeg reactivity for prediction of favorable outcome was % . by contrast, the ppv of lost eeg reactivity for prediction of unfavorable outcome was % (ic % - ) with a false positive rate (frp) of . % ( . - . ). eeg electroencephalogram, ssep short-latency somatosensory evoked potentials, ppv positive predictive value, npv negative predictive value, fpr false positive rate in this population of post-cardiac arrest patients, the presence of eeg reactivity was poorly predictive of a favorable neurologic outcome. the absence of reactivity was highly predictive of unfavorable outcome. in combination with other indicators, searching for eeg reactivity may have important implications in the neuroprognostication process. conclusion: this subgroup analyses of a randomized controlled trial, found no survival benefit when comparing crystalloids to colloids in critically ill surgical patients. introduction: goal of a fluid challenge (fc) is in fine to increase the stroke volume (sv) or the cardiac index (ci) when an episode of hypovolemia or a preload dependence status are suspected. fc is one of the most common practices in icus, however, the way to assess the response to fc is not standardized. the present study aimed to evaluate whether the trans-thoracic echocardiographic (tte) assessment of the response to fc immediately at the end of the infusion or delayed min later could affect the results of the fc. patients and methods: prospective, observational, multicentre study including all icu patients in septic shock requiring a fc. were excluded patients with-arrhythmias, poor echogenicity and severe mitral or aortic regurgitation. fc was performed administering ml of crystalloids over min. fluid responsiveness was defined as a > % increase in stroke volume (sv). the following echocardiographic parameters were recorded-e wave, a wave, e a ratio, velocity-time integral (vti), ea wave and sa wave. map, hr and tte variables were collected at baseline (t ), at the end of fluid challenge (t ) and (t ) and min (t ) after the end of fluid challenge. quantitative data are expressed as mean and standard deviation (sd) or median and interquartile (iqr), according to their distribution. qualitative data are expressed as absolute number and frequency (%). results: from may th to january th , a total of patients were enrolled in french icus (mean age- ± years, median igs ii- , median sofa score- [ ] [ ] [ ] [ ] [ ] ). among the ( %) patients responders to fc at t , patients were transient responders (tr), i.e. became non-responders at t ( %, % ci = [ - ]) and ( %, % ci = [ - ])) patients were persistent responders (pr), i.e. remained responders at t . among the non-responders (nr) at t , became responders at t , ( %, % ci = [ . - . ] ). in the subgroup analysis, no statistical difference in haemodynamic and echocardiographic parameters was found between non-responders, transient responders and persistent responders (fig. ) . conclusion: the present study shows that, after a % vti increase at the end of the fc, vti returns to baseline at min in half of the responders. blood volume status (normo or hypovolemia) before initiating the fluid infusion could explain the transient or persistent response to fc observed in septic patients. mottling score is a strong predictor of day- mortality in sepsis patients independently of catecholamine dosing and other tissue hypoperfusion parameters dumas guillaume , joffre jérémie , hariri geoffroy , bigé naike , baudel introduction: sepsis is a frequent critical condition. mottling score, an hypoperfusion parameter, is well correlated with outcome. however, uncertainties persist regarding its value not only as a marker of patient severity but also as an independent predictor of mortality and treatment efficacy. we performed a post hoc analysis of four published prospective studies including sepsis patients with or without shock. we analyzed the relationship between the mottling score (from to ) and day- mortality according to other prognosis covariates such as catecholamine dosing, urine output and plasma lactate levels. first, factors associated with outcome were determined by multivariate analysis. second, mottling score-by-covariate interaction was studied to better understand its effect on mortality. finally, effect of mottling score variation at different time point (h -h -h -h ) was assessed. whereas ecmo was successfully weaned in ( %) patients. proportion of perfused vessel (ppv), perfused vessel density (pvd), micro flow index (mfi) and heterogeneity index (hi) were severely impaired before ecmo. re-establishing high and stable peripheral blood flow with va-ecmo led to a rapid decrease in heart rate and vasoactive inotropic support and significantly improved all microcirculation parameters within h. total vessel density and pvd, measured before and after ecmo initiation, were better in patients successfully weaned from ecmo (p < . ) (fig. ) . conclusion: cardiovascular support with ecmo-va rapidly improved macro and microcirculation in refractory cardiogenic shock patients. total vessel density and perfused vessel density were significantly better in survivors h after ecmo initiation and might therefore help to predict outcomes. further studies are now needed to better define the utility of this technology in larger groups of va-ecmo patients. introduction: thyroid storm is a rare but life-threatening disease related to thyrotoxicosis. it can lead to multiple organ failure including cardiovascular disorders or neurological impairment. to date, data on this disease in icu patients are scarce and limited to case reports. we therefore aimed to describe clinical presentation, outcomes and management of thyroid storm in icu patients. patients and methods: local diagnoses coding database (from january to july ) from french icu were interrogated for main and secondary diagnoses codes including thyrotoxicosis based on the international classification of disease th revision. thereafter two investigators reviewed all the medical records selected. inclusion criteria were thyroid storm based on the diagnostic criteria of the japan thyroid association (t. satoh, endocrine journal ). it combines thyrotoxicosis with elevated levels of free triiodothyronine (ft ) or free thyroxine (ft ) with at least two of the following symptoms-central nervous system manifestation, fever, tachycardia > bpm, congestive heart failure, or total bilirubin level more than micromol/l. clinical presentation, therapy used, and outcome were recorded. results: sixty-two patients (median age years (interquartile range - ) + saps ii ( - ) were included. thyroid storm was the first manifestation of thyrotoxicosis in ( %) patients. graves' disease ( %), amiodarone induced thyroiditis ( %), autoimmune thyroiditis ( %), and toxic multinodular goitre ( %) were the main causes of hyperthyroidism. amiodarone, thyroid hormone toxicity, antithyroid drugs withdrawal or infectious trigger were identified in ( %) patients. organ support including mechanical ventilation, catecholamine infusion, renal replacement therapy and veno-arterial ecmo were used in , , , and patients, respectively. main thyroid storm treatments included antithyroid drugs ( %), betablockers ( %), corticosteroids ( %), and plasmapheresis ( %). lastly, icumortality was %, with multiple organ failure responsible of death in all patients. although its incidence appears low, icu physicians should be aware of the multiple clinical features of thyroid storm. our preliminary data reported various specific therapeutic management of this potentially fatal disease. prompt initiation of targeted therapies is required for atypical hemolytic uremic syndrome (ahus) and thrombotic thrombocytopenic purpura (ttp), but no specific therapy is consensual for shiga toxinassociated hemolytic uremic syndrome (stec-hus). thus, rapid differentiation of stec-hus is mandatory to tailor the initial treatment. furthermore, apart from large outbreaks, characteristic features of this syndrome in adults have not been described. in this study, we retrospectively compared the characteristics of stec-hus, ahus and ttp patients at admission in two expert icus. patient were included if they presented with the triad of mechanical hemolytic anemia, thrombocytopenia and organ damage, and tmas were classified using international criteria. other causes than stec-hus, ahus and ttp were excluded. results: amongst tmas admitted between september and january , stec-hus, ahus and ttp were included. stec-hus patients were older ( ) than ahus ( , p = . ) and ttp patients ( , p < . ). they presented with more frequent digestive symptoms ( versus and % for ahus and ttp, p = . and < . ), but bloody diarrhea was rare ( %) and non-statistically different from other tmas. confusion was more frequent in stec-hus ( %) than ahus patients ( %, p = . ). biologically, stec-hus patients displayed elevated fibrinogen levels ( . vs . and . for a hus and ttp, both p < . ) and severe renal failure. forty-two percent required renal replacement therapy and % were treated with plasma exchange before the distinction from other tmas could be made. only ( %) stec-hus patient died in the icu (fig. ) . conclusion: characteristics supposed to identify stec-hus are largely shared with other tmas. in particular, the differential diagnosis between ahus and stec-hus appears to be more difficult than the stereotypical description derived from pediatric studies. severe hyperglycemia in icu patients: a higher mortality rate and a higher incidence of diabetes in a long-term follow-up study . ], p = . ) but not when admitted for coma, sepsis or cardiac arrest. mortality rate was significantly higher in patients with severe hyperglycemia compared to those without, regardless of preexisting diabetes (hnd hd vs. nhnd nhd groups + p < . ). patients with severe hyperglycemia had a higher incidence of type diabetes at ( vs. % + p = . ) and months ( vs. % + p = . ) compared to those who did not. conclusion: severe hyperglycemia occurring in the first days of icu admission was associated with higher mortality rate and an increased risk of diabetes in the following months regardless of preexisting diabetes. introduction: vitamin d deficiency is frequent in northwestern countries and could represent a modifiable risk factor for critically ill patients, in relation with its pleiotropic effects ( ) . some studies reported an association between oh vitamin d ( oh) deficiency, chronic health status and icu-and hospital-related outcomes. however, a large supplementation study have not been found to improve outcome of patients with moderate oh deficiency (< ng ml) ( ) . the aim of the study is to analyze the relationship between the severity of oh deficiency at icu admission, severity of illness and outcomes and ultimately to identify subgroups of patients in whom the likelihood of benefit of supplementation is larger. patients and methods: consecutive patients admitted over a -month period who stayed at least h in a medical surgical -bed icu were included. in these patients, demographic data, charlson comorbidity score, severity scores (saps and sofa) and -oh (chemiluminescence, diasorin) were collected at admission. icu and hospital length of stay (los) and mortality were recorded. correlations were searched between oh and the different scores, and vital outcomes ( - )). hypothyroidism was unknown before icu admission in % patients. median sofa score at icu admission was ( - ). myxedema coma, circulatory failure, respiratory failure, and severe hypothermia were respectively the main admission reason in , , , and % patients. a precipitating factor such as drugs thyroid toxicity, thyroid hormone withdrawal or infection was found out in only ( %) patients. main causes of hypothyroidism were thyroiditis and thyroidectomy. thirtytwo ( %) patients had alteration of consciousness with a median glasgow score at ( - ). in addition, median heart rate at icu admission was ( - ) bpm while hypothermia < °c was noted in ( %) patients. median tsh level at admission was ( - ) mui l, t and t levels respectively ( - . ) pmol l and ( - . ) pmol l. rhabdomyolysis was frequent with median cpk level ( - ) ui l. organ support including mechanical ventilation, catecholamine infusion and, renal replacement therapy were respectively used in , , and % patients. lastly, % patients received oral levothyroxine whereas the intravenous form was used in others. overall icumortality was %. our preliminary data showed that severe manifestations of hypothyroidism leading to icu admission represent de novo hypothyroidism in two-thirds of patients, leading to a high mortality. introduction: when it comes to infections of the central nervous system (cns), the greatest challenge in the emergency department (ed) is to identify patients that have a rare life-threatening diagnosis. alone or in combination, fever, headache, altered mental status encompass a broad differential diagnosis. antibiotics or antiviral therapy should be given as soon as possible, ideally after both blood and cerebrospinal fluid (csf) have been obtained. early treatment is associated with a lower mortality. patients and methods: we present here, a four-year ( - ) retrospective and monocentric study. during the period of the study, we included all adult patients with the diagnosis of cns infection (positive csf culture). we collected and analyzed all clinical, biological, imaging, treatments and evolution datas during the stay. a total of patients with cns infection have been included for statistical analysis. we analyzed a second group (n = ) with suspected cns infection (negative csf) as a control group. results: in the study population, mean age was ± . years old and the sex-ratio was . . there were no difference between the two groups in terms of clinical signs except for more altered mental status in the control group (p = . ). all patients of the study (n = ) benefited of lumbar puncture (lp) in the ed with an average time of ± min after admission. this delay was the same between the two groups (p = . ) but was significantly higher in the encephalitis subgroup (n = , p = . ). patients who had imaging (ct or mri) during the ed stay had more likely a delay in lp realization ( vs min, p = . ). patients where the cns infection diagnosis was firstly evoke by the triage nurse had lp more quickly (p = . ). the median door to-antibiotic-time was min with no difference between the two groups of the study (p = . ). % of all patients were hospitalized for an average length of stay of . ± . days and % of them were admitted in the icu. the inhospital mortality was % in the study population. introduction: there are numerous causes of acute exacerbations of copd (aecopd), the most common of which are bronchial and or pulmonary infections. viral etiologies may account for % of aecopd, but this rate is likely underestimated because of the limited performance of the conventional diagnostic tests. multiplex molecular diagnostic tests may identify several pathogens including viruses and bacteria, from a single respiratory tract sample, with high sensitivity. using these tests, respiratory viruses are identified in to % of cases, according to the series. the objective of this work was to describe the microbial epidemiology, the management and the outcome of patients admitted to the intensive care unit (icu) with moderate to severe aecopd, in the era of multiplex testing. a prospective non interventional multicenter study conducted in two university-teaching hospitals. in addition to the usual samplings, a nasopharyngeal swab was performed for multiplex polymerase chain reaction (pcr), using respiratory panels fil-marray biomérieux ( viruses and bacteria) or eplex automaton ( viruses and bacteria) depending on the center. the preliminary results involve the patients ( males + years ( - )) included in tenon hospital over a -month period. the mean fev was % ( - ) median % [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . drug therapies included anticholinergics (n = + %) and beta- -mimetics (n = + %), inhaled (n = + %) or oral (n = + %) steroids, and azithromycin (n = + %). a respiratory virus was identified in patients ( %), alone or in combination with a bacterium (n = ). a bacterial pathogen was identified alone times ( %). therapeutic interventions did not differ depending on whether a virus was detected or not-exposure to antibiotics ( ± . vs. . ± d + p = . ), administration of oseltamivir ( / vs. / + p = . ), steroids ( / vs. / + p = . ) and mechanical ventilation ( / vs. / + p = . ). the icu length of stay ( . ± . vs. . ± . d + p = . ) was similar. the icu and d-mortality rates were . and . %, respectively. conclusion: respiratory viruses are frequently involved in moderate to severe aecopd. the respiratory multiplex pcr should be performed in this setting and the results should be taken into account to more adequately use the anti-microbial treatments. introduction: prophylactic non-invasive ventilation (niv) is a well established method for prevention of post-extubation acute respiratory failure in hypercapnic patients. however, its role in the postextubation period, in traumatic brain injury patients, is uncertain. especially, because of effects of the brain injury, on respiration and airway control. we perform a study to assess the impact of prophylactic niv after extubation among patients with severe traumatic brain injury. patients and methods: over a period of year, adult patients with isolated severe traumatic brain injury, who were under invasive mechanical ventilation for more than h were eligible for inclusion in the study. they were randomized, after decision of extubation, to receive conventional therapy or conventional therapy associated with niv. conventional therapy consisted of oxygen delivery by facial mask, semi-recumbent position, mucus suctioning and nebulization therapy. the main objective of the study is to assess the impact on reintubation rate. extubation succes was defined by the absence of need for reintubation within the days. the secondary objective is to evaluate the effect on icu length of stay after extubation. the clinical benefit of non-invasive ventilation (niv) in patients with acute hypoxemic respiratory failure (arf) is being called into question. indeed, in a multicenter randomized trial recently conducted in hypoxemic arf patients (pa fi < ), intubation rate in the niv group was % and intensive care unit (icu) mortality rate was %, numbers higher than in the standard-oxygen group ( ) . an excessive tidal volume under niv is a hypothesis to explain these bad outcomes ( ) . our experience does not seem to support these data. therefore we wanted to-investigate the rate of niv success in hypoxemic arf and global in-icu mortality. estimate the average expired tidal volume and identify predictive factors of niv failure. conclusion: though limited by its design, our study seems to show a similar efficacy of niv following ue as compared to planned extubation, with a safety concern for rescue niv and a potential interest for "prophylactic" niv. further data is warranted. which is yet operator dependent and time-consuming, or by invasive methods including esophageal pressure or diaphragmatic electromyogram measurements. the main purpose of this study was to assess the relevance of curvex as a noninvasive diagnostic and classification tool for asynchronism management. this project is based on a prospective physiological tracing data-warehousing program (rea stoc, clinicaltrials.gov # nct ) that aims to record consecutive icu patients, over -years. all consecutive patients were recorded for a -hours period during -h following icu admission. all measurements were recorded with the patient laying supine, with a ° bed angulation. raw ventilatory pressure and flow curves were transferred to a centralized server using a dedicated network. the physician in charge of the study was informed of the online analysis on a routine basis. physiological recordings were associated with metadata collection. asynchronisms detection is based on a non-parametric hypothesis testing (random distortion testing), that requires no prior information on the signal distribution. beside asynchrony index monitoring (ai), five asynchronism's types were qualified-ineffective efforts (ie), short cycles (sc), multiple cycles (mc), prolonged inspiration (pi) and premature cycling (pc introduction: international guidelines recommend ultrasound (us) guidance for central venous catheter (cvc) insertion. however, evidence is lacking for several aspects of guidance such as probe shape or whether the needle has to be in plane (ip) or out-of-plane (oop). we assessed these issues in a randomized trial. success at first pass, number of attempts (needle passes), success, times between skin contact and needle skin penetration and between needle skin penetration and liquid back flow in the syringe were recorded. qualitative and quantitative values are expressed as number (percentage), and median (range), and were compared using the wilcoxon matched pairs test and the fisher exact test, respectively. results: for ijv puncture, first attempt success rate was more than % and was neither influenced by probe shape nor approach (table ) . conversely for rav puncture, using lp with ip approach was more frequently successful at first attempt ( vs %, p = . ). time elapsed between needle skin penetration and liquid back flow was shorter for rav puncture using ip approach ( s vs s, p = . ). time elapsed between probe appliance on skin and liquid back flow was significantly shorter with the linear probe for ijv whatever the approach and for rav using ip approach. rav puncture was more frequently impossible with mcp ( vs %, p = . ). arterial puncture occurred more frequently with mcp ( vs %, p = . ). lp use and ip approach were associated with more free event puncture ( ± ) . minimal ani, reflecting intense stress was . (± . ). objective and subjective stress of each team leader is shown in fig. . there was a significant negative linear correlation between minimal ani and maximal hr (rho = − . , p = . ). there was no significant correlation between self-reported stress vas (neither pre hfs or maximal stress) and minimal ani. conclusion: hrv monitoring is a feasible method to evaluate continuous physiological stress for team leaders in highly stressful simulationteaching. upgrading signal connection by bluetooth . or wi-fi could improve the method. focusing on specific stressful time points might improve stress assessment and its correlation with performance. introduction: simulation training has become available in health sciences faculties and proposed in many specialties. intensive care is one of the fields of development of simulation based training. the aim of the present study was to report the experience of the faculty of medicine of monastir simulation center in training medical students and residents in intensive care and to compare their respective perceptions. this was a descriptive study including students ( th year of the medical curriculum) and residents who received training during the last academic year ( ) ( ) , in the simulation center during their icu traineeship. simulation training was based on high-fidelity mannequins for students and seminars with high fidelity and procedural simulation training for residents. three sessions per group were organized for students and a total of five sessions for residents. we collected participant characteristics and used likert scale (from to ) to assess participant satisfaction, simulation fidelity, impact on clinical practice, stress level and instructor behaviors. chi test was used to compare students' and residents' perception of the simulation based-training. results: during the study period students (of the students' whole promotion) and residents actively participated at least in one of the simulation-based training sessions. median students' and residents' ages were respectively years ( - ) and years ( introduction: hospitals are encouraged to edit local antibiotic therapy guidelines. antibiogarde ® is an electronic antibiotic prescription referential developed by a multidisciplinary team of french physicians, regularly updated, and locally customizable, which has been purchased by more than french hospitals. we compared adequacy fig. team leader's objective (heart rate and ani) and subjective stress (declared vas stress) of initial antibiotic prescription by icu clinicians, antibiogarde ® proposal and national or international guidelines. patients and methods: between january and june , initial antibiotic prescriptions in an icu were retrospectively analyzed when microbiologically documented. antibiogarde ® and guidelines proposals were simulated, considering data available at the time of initial prescription. adequacy was defined when all bacteria responsible for infection were sensitive to at least one prescribed proposed antibiotic. national guidelines were used when published after . otherwise, most recent international guidelines were used. results: initial prescriptions were analyzed ( monotherapy) in patients (median age y, median saps ii , median sofa on prescription , icu mortality %, % immunocompromised). main sources of infection were lung (n = ) and intra-abdominal (n = ). leading isolated bacteria were enterobacteriaceae (n = , antibiotic resistance in ), streptococci (n = ), non-fermenting gram negative bacilli (n = , antibiotic resistance in ) and staphylococci (n = , resistance to methicillin in ). in the clinical settings analyzed, there was a proposal by antiogarde ® in ( %) and a guideline available in ( %) (p = . introduction: intubation is plagued with a high morbimortality, especially in emergency situations. it is now acknowledged that a seated position allows for optimized preoxygenation ( ) . however, there is no guideline concerning the patient's position for intubation. the patient is most often laid in a supine position, leading to a higher risk of aspiration ( ) . face-to-face intubation in sitting position (ftfi) would allow for an easier intubation and a lower morbidity. we focused on learning the ftfi technique using the macintosh laryngoscope and the airtraq videolaryngoscope in simulated difficult intubation situation and comparing the performance of the ftfi with the classic technique. the participants would intubate a high-fidelity manikin (simman g, leardal, norway) configured with a tongue edema (cormack b- ). for each trial, time to intubate (tti), success and complication rate, intubation difficulty and glottis exposure were noted. in classic position, three trials were performed with the airtraq followed by the laryngoscope in order to obtain baseline parameters. in ftfi, at least intubations were performed by each participant for each device. the utilization order was randomized. results: thirty physicians, with an experience of at least intubations each, were included. figure shows the learning curves of the ftfi based on the evolution of the tti measured for the airtraq and the laryngoscope. in classic position, the mean tti with the airtraq was . ± . s versus . ± . s with the laryngoscope (p = ns). in ftfi, once the technique mastered, the tti was ± . s with the airtraq versus . ± . s with the laryngoscope (p < . ). success rate, tti, complication rate, intubation difficulty and glottis exposure were better using ftfi versus classic intubation (p < . ). these parameters were even better with the airtraq than with the laryngoscope (p < . ). the learning profile of ftfi is different between the airtraq and the laryngoscope. it could be due to the participants' lesser familiarity with the airtraq. the better performances in ftfi could be due to better ergonomics allowing easier glottis exposure and learning ( ) . conclusion: face-to-face intubation in sitting position is easy to learn. it provides better performances and fewer complications than the classic intubation technique which might result in a lower morbidity. the airtraq provides even better results than macintosh laryngoscope. all participants recommend their colleagues to be trained in face-toface intubation. among non-invasive respiratory support, niv with bilevel pressure was the most frequent (n = , %) before cpap (n = , %) and high flow oxygen (n = , %). the proportion of patients on niv was up to % in the centres hosting more acs patients. conclusion: despite the absence of evidence from randomized controlled trials niv is nowadays commonly used in picu and hdu for scd patients with acs, especially in centres taking in charge a high number of scd patients. future physiological studies and randomized controlled trials might help to choose between the different ventilatory support options for acs. in transfused patients, the pre-transfusion hemoglobin was . ( . - . ) g dl in moderate pards and . ( . - . ) g dl in severe pards. the evolution of hemoglobin, osi, scvo and lactate after the transfusion is reported in the table . in our picu, a relatively restrictive policy of rbc transfusion was observed even in patients with severe pards. decision to transfuse seemed associated with the general severity status of the patient and with the hemoglobin level. further studies are needed to explore the generalizability of these findings, and to investigate the impact of transfusion on oxygen transport consumption balance in pediatric acute respiratory distress. introduction: pharmacokinetic parameters are altered in critically ill patients. for instance, in adult patients, it has been well demonstrated that augmented renal clearance results in subtherapeutic antibiotic concentrations. our objectives were to build a pediatric population pharmacokinetic model for piperacillin, in order to optimize individual dosing regimen. patients and methods: all children admitted in pediatric intensive care unit, aged less than years, weighing more than . kg, and receiving intermittent piperacillin infusions were included. piperacillin was quantified by high performance liquid chromatography. pharmacokinetics were described using the non-linear mixed effect modelling software monolix. monte carlo simulations were used to optimize dosing regimen, in order to maintain plasma concentration above the minimum inhibitory concentration ( mg l − for pseudomonas aeruginosa) throughout the dosing interval ( % ft > mic). results: we included children with a median (range) post natal age of . ( . - . ) months, median (range) body weight of . ( . - ) kg, median (range) pelod- score of ( - ) and median (range) estimated creatinine clearance of ( - ) ml.min - .m - . a one compartment model with first-order elimination adequately described the data. median (range) values for piperacillin clearance and volume of distribution were respectively ( . - ) l h − and . ( . - . ) l. body weight (allometric relationship), estimated creatinine clearance and pelod- severity score were the covariates explaining the estimated between subject variability. a third of the cohort attained the target, according to our dosing regimen and to the european guidelines. to reach the target and according to the simulated dosing regimens, children with acute kidney injury should receive intermittent infusion every h, administered on min. those with augmented renal clearance should receive a continuous infusion. to reach the target, standard intermittent piperacillin dosing regimen in critically ill children is not appropriate. in addition to body weight, dosing regimens should take into account the creatinine clearance. continuous infusion is adequate for children with augmented renal clearance. piperacillin individualized dosing regimens and therapeutic drug monitoring are mandatory in pediatric intensive care unit. introduction: all data support the need for early recognition, evaluation of pain in the nicu. multiparametric analysis including physiological parameters could be useful to have a more objective evaluation of pain in the nicu compared to scales built on external-evaluation. the newborn infant parasympathetic evaluation (nipe ® ) was developed to assess pain in newborns and infant, from preterm to the age of years. patients and methods: we conducted a monocentric, prospective study to compare the instantaneous nipe ® index value (nipei ® ) to the dan scale during acute procedural pain (picc line insertion) in preterm infants (under gw). the operators and the nurse were blinded to the continuous recording of nipei ® during the entire procedure. dan scale was assessed every min by a third person, trained to this scale and blinded to nipei ® . a direct correlation assessment between the dan scale and the nipei ® was performed by calculating the pearson's linear correlation coefficient. the differences between the nipei ® of non-painful (dan < ) and painful (dan ≥ ) infants were estimated by the wilcoxon-mann-whitney test. the usefulness of nipei ® as a new tool for pain assessment in neonates was estimated by the corresponding roc curve. our study was approved by our local ethic institutional review board. results: thirty-five preterm infants were included, nipei ® data were incomplete in infants. fifty percent of newborns were born before gw, and % had non-invasive respiratory support (continuous positive airway pressure cpap). at the time of the procedure, newborns had a median post-natal age of days and a median weight of grams. there was a moderate correlation between the nipei ® index and the dan scores (r = . + p < . ). the median nipei ® index was for non-painful events vs. for painful events, p < . . the area under the roc curve was . . for a threshold of nipei ® < , the sensitivity was . %, the specificity was %. positive likelihood ratio was . and the negative likelihood ratio was . ( fig. ) . we showed a correlation between the dan scale and the nipei ® index for pain assessment in preterm infants. the nipe ® monitor could be a useful and non-invasive tool for pain assessment in neonates. further studies are needed to confirm our results and to define more precisely the place of such monitors for pain evaluation in daily clinical practice in the nicu. introduction: the aim was to identify factors associated with the occurrence of acute pituitary hormone dysfunction in children with moderate to severe tbi and to describe the impact of this dysfunction on the stability of the children. patients and methods: prospective bicenter study including all children aged between month to years, admitted to picu for a moderate-severe tbi and with an expected stay > days. setting-pediatric intensive care units of grenoble and lyon, from to . endocrine explorations at the second morning following admission and h before discharge were performed-cortisol h cycle with free cortisol and acth dosages every h (or h if no central line) + free h urinary cortisol + tsh and t l, h urinary lh and fsh, blood level of testosterone or estradiol for children aged > years, and igf . patients were classified as having cortisol insufficiency if all the cortisol dosages were < nmol l and all acth were < pg l. tsh deficiency was defined as t l < . pmol l and tsh < . mui l. gonadotropin defciency was defined as urinary lh < . ui h and urinary fsh < . ui h for males + urinary lh < . ui h and urinary fsh < . ui h in female. patients with deficiency (acth and any deficiency) were compared to those without deficiency in terms of hemodynamic instability, respiratory instability, neurological and infectious complications for continuous variables means and % confidence interval were calculated and compared by t student test. chi- test was used to compare proportions. results: among the patients evaluated, had acth deficiency, and had at least one acute pituitary dysfunction. comparison of patients who presented acth deficiency with those who were not deficient found no differences in terms of patients characteristics, cause of tbi, level of severity and level of injury. paitents with acth deficiency required more frequently fluid bolus at day ( vs %, p = . ). all the markers of severity were higher and the need of vasoactive drugs were more frequent but the differences were not statistically significant. table shows comparison between patients with at least one pituitary hormone deficiency to those without deficiency. the same result was found. glycemia levels were lower in the group with deficiency. conclusion: we didn't find any predictive factors of pituitary hormone deficiency in children with moderate-severe tbi justifying a systematic screening of those patients. introduction: most intensive care unit (icu) patients cannot make decisions themselves. familiy members are actively involved in the care process as surrogate decision-makers and judges of care quality. however, family satisfaction with care is complex and is not clearly defined. the aim of this study is to evaluate the different procedures (reception book and staff education for aid and relationship) used in a new icu to improve the family care. patients and methods: we included in our study patients who had spent more than h in our department. a questionnairy, adapted to our population, was performed by our staff and validated by the hygiene and quality care departement. we proceded by phone calls, months after the inauguration of our icu. results: sixty-five questionnaires were included (fig. ). the average of age was ± with a sex ratio of . the average of the simplified acute physiology score (sapsii) was ± . the median stay was days [ - ] with a total mortality rate of %. mostly, we interrogated first-degree parents (n = ). only three families recieved reception book at admission. visit in patient room was autorised only for % (n = ) of family members. only four persons said they were disturbed in visit hours for architectural reasons (tight space). disponibility was found excellent in % (n = ) of cases for medical staff, % (n = ) for paramedicals. informations provided by physicians were clear in . % (n = ) of cases. fifteen of the family members ( %) asked psychology support. patients were followed up via phone calls during year after discharge. characteristics on admission and outcomes after discharge were analyzed stratified by ventilation modality niv vs imv. the overall survival was analyzed on the basis of the kaplan-meier curves. results: during the predetermined period of data collection, the follow-up involved patients. patients were treated by niv (group ) and patients needed imv (group ). there was no difference between the groups in age (p = . ), severity of copd (p = . ), physiological reserve at discharge (p = . ) and icu readmission (p = ). short term outcomes were not different between the groups- -month readmission ( . vs % respectively in niv and imv, p = . ) and -month mortality ( introduction: post-intensive care syndrome (pics) has been recently described as a combination of physical, cognitive and mental impairments appearing during a stay in an intensive care unit (icu). the prevention and detection of pics require the participation of each category of healthcare workers. however, the level of knowledge is unknown. we sought to assess the awareness among our icu staff in preparation for a follow-up consultation. the study used a short multiple-choice survey filled on a voluntary basis. all members of the staff were asked to fill the questionnaire over a one-week period. the assessment was composed by seven structured questions which aimed measure basic knowledge of post-intensive care syndrome and general strategies to diagnose that syndrome and the tests used. results: fifth five workers ( % of the staff ) of the department of intensive care answered the questionnaires ( % nurses, % physiotherapists, % physicians). the estimated ranges of prevalence of psychological problems were very low ( - %) for . %, low ( introduction: drafting a death certificate (dc) is a procedure considered as a part of doctor's daily practice, especially in emergency and intensive care departments. this certificate represents a civil, social, epidemiological and medico-legal act. it can engage the liability of the certifying doctor. the objectives of our study were to examine the content of dc drafted in emergency and intensive care departments, assess the quality of writing, and analyze drafting errors. patients and methods: a prospective study extended over a period of months from january to december , including all dc emanating from emergency and intensive care departments and received in the forensic department of habib bourguiba hospital in sfax. results: during the study period, dc meeting the inclusion criteria were collected. although confidential, the medical part of the dc was sealed by the doctor in onlyone third of cases. in the administrative section, nine socio-demographic parameters were studied. in % of the cases, less than four of the nine criteria were found. in the section concerning the certifying doctor data, parameters were screened. . % of the certifying doctors met at least six criteria. the most frequently missing parameter in this section was the identity of the person to whom the certificate was issued. the identity of the doctor was not mentioned in % of the cases. forensic data ( items) was complete in over three quarters of the certificates. nevertheless, in . % of cases, the medicolegal obstacle to burial box was left empty ( . %) or not ticked even if judicial investigation was required ( . %). the section on causes of death was the source of almost all of the drafting errors. we have classified these errors into six major ones, according the classifications reported in the literature. the percentage of certificate without faults was %. the most common major error was insufficient cause of death found in . % of cases followed by incorrect sequence of causes of death ( . %), medicolegal obstacle to burial not ticked although required ( . %), several causes of death mentioned simultaneously ( . %), unacceptable cause of death ( . %) and mechanism of death mentioned instead of the cause of death ( . %). our study showed that the quality of drafting of dc suffered from several insufficiencies, which encourages us to provide more effort in training doctors and to review the current official model of dc. introduction: septic shock is defined as a sepsis with hyperlactaemia greater than mm after correction of hypovolemia requiring vasopressors to maintain mbp > mmhg [ ] . it can be observed in pre-hospital emergency medicine (phem). the use of a reliable portable device for measuring lactate in phem would allow a better evaluation of septic patient facilitating their orientation towards intensive care unit (icu) or emergency department (ed). this portable delocalized biology device must be validated against the laboratory reference method (nfen iso ) [ ] . the aim of this study was to clarify the validity of a delocalized measure of lactatemia. we performed a prospective study including patients admitted into icu for septic shock (cpp number - - sc). lactate was measured in parallel on samples-one capillary with the portable device (lactate statstrip xpress, nova biomedical) and the other venous on a centrifuge tube for plasma analysis (architect c abbott diagnostics). we evaluated the analytical performance (coefficients of variation (cv) for repeatability and reproducibility evaluated at levels of quality control (qc)- . and . mm) and then the concordance between lactate levels measured by the devices and lactate levels measured by laboratory analyzer. results: at the qc concentrations tested, the cvs were in agreement with the limits set by the french society of clinical biology-cv < % for repeatability and < % for reproducibility. an excellent correlation was observed between the measurements-correlation coefficient r = . , slope = . and ordered at the origin = . . the latter suggested a low positive bias of the device not confirmed by bland-altmann graph analysis and graph of the differences. we verified the analytical performance of the device and showed an excellent correlation with the laboratory measurement. the delocalized measure can be used in phem in patients with suspected sepsis syndrome. this measure should allow a more accurate and early assessment of their severity in order to improve triage and hospital orientation between ed and icu. there is an association between mortality at d and hyperoxia in patients admitted in icu for refractory ohca requiring ecpr. these data underline the potential toxicity of high dose of oxygen and suggest that control of oxygen administration in such patients is an important part of the treatment. a value of pao between and mmhg after starting ecpr seems to be a target during treatment of ohca treated by ecpr. introduction: sepsis has been defined as a dysregulated host response to infection leading to life-threatening organ dysfunction (singer m et al., jama ) . a qsofa score relying on simple clinical criteria (respiratory rate, mental status and systolic blood pressure) has been proposed to better identify septic patients with associated higher mortality outside the intensive care unit (seymour cw et al., jama ) . the study aim was to evaluate the ability of qsofa to predict the development of organ failure and increased -day mortality in patients admitted for suspected sepsis in the emergency department (ed). patients and methods: prospective study conducted over a period of months comparing the prevalence of organ failure and -day mortality according to the value of qsofa at admission to the ed between group a (qsofa > = ) and group b (qsofa < ). as part of routine care, an electronic sepsis form was specifically created to identify prospectively and exhaustively all eligible patients on-line. for the purpose of the study, sepsis diagnosis was independently validated off-line by an adjudication committee which included three physicians who reviewed clinical, biological and microbiological data. for each patient, demographic data, source of infection, qsofa and sofa score, biological data and -day mortality were recorded. seventy-six patients of group a ( %) were hospitalized, of whom were admitted to the intensive care unit ( . %), and -day mortality reached . %. in group b, only patients developed an organ failure ( . %) and -day mortality was . % (table ) . the present study confirmed that the qsofa score is a reliable and practical tool to predict the development of organ failure and higher -day mortality in patients with suspected sepsis in the ed. limits of ct scan criteria and intravascular contrast extravasation to define pelvic angioembolization need: a specific assessment on the risk of false- introduction: opening of the mitochondrial permeability transition pore (ptp), triggered by cyclophilin-d (cypd) binding under stress conditions, plays a key role in ischemia-reperfusion injury. we sought to determine, using transgenic mice, whether cypd deletion (cypd −) would improve resuscitability and survival after experimental cardiac arrest (ca). additionally, we compared the protective effects of cypd deficiency with that of targeted temperature management (ttm). patients and methods: anesthetized mice underwent a min asphyxial ca followed by resuscitation (cardiac massage, resumption of ventilation, epinephrine). four groups of animals were studied-sham, control (ctrl), cypd-ca using mice lacking cypd (knockout mice), and ttm-ca with fast hypothermia induced by external cooling at reperfusion ( °c for h). two hours after ca, the following measurements were carried out (n = - group)-echocardiography, cellular damage markers (including s b protein and troponin ic) and mptp opening in mitochondria isolated from brain and heart. additional mice (n = - group) were included in the same groups for survival follow-up ( h and days). results: characteristics of ca were similar among groups. rate of restoration of spontaneous circulation (rosc) was significantly higher in cypd-and ttm groups compared to controls (p < . ). time to rosc was shorter in cypd-versus ttm and ctrl (p < . ). genetic loss of cypd and ttm prevented to a similar extent ca-induced myocardial dysfunction, increase in blood levels of both s b protein and troponin ic (p < . versus ctrl). ca resulted in a significant increase in ptp opening only in mitochondria isolated from brain (p < . versus sham). cypd deletion as well as ttm limited ca-induced ptp opening in brain (p < . versus ctrl). short-term survival ( h) was significantly improved in the cypd-and ttm groups when compared to controls (p < . ). however, only therapeutic hypothermia improved survival at day (p < . versus ctrl). in our murine ca model, genetic loss of cypd increased resuscitability and short-term survival but, unlike therapeutic hypothermia, failed to improve -day survival. introduction: early prediction of neurological outcome of post-anoxic comatose patients after cardiac arrest (ca) is challenging. prognosis of comatose patient relies on multimodal testing-clinical examination, electrophysiological testing and structural neuroimaging (mainly diffusion mri). this prognostication is accurate for predicting poor outcome (i.e. death) but not sensitive for identifying patients with good outcome (i.e. consciousness recovery). resting state functional mri (rs-fmri) is a powerful tool for mapping functional connectivity, especially in patients with low collaboration. several studies showed that rs-fmri can differentiate states of consciousness in chronically brain-damaged patients. a recent study also showed that functional neuroimaging can early detect signs of consciousness in patient with acute traumatic brain injury. however, rs-fmri has not been assessed for the early prognostication of post-anoxic comatose patient. we assessed whole-brain function connectivity (fc) of post-anoxic comatose patients early after ca using rs-fmri. nine patients ultimately recovered consciousness (good outcome) while eight died (poor outcome). we estimated fc for each patient following a procedure previously described. we statistically compared whole-brain fc between good and poor outcome group, to assess which brain connections differed between them. then, we trained a machine-learning classifier (a support vector machine, svm) to automatically predict coma outcome (good poor) based on wholebrain fc of comatose patients. finally, we compared this outcome prognostication based on functional mri to those using standard structural diffusion mri. results: good and poor coma outcome groups were similar in terms of demographics, except for time to rosc. good outcome group showed significant increase in whole-brain fc between most cortical brain regions + with the strongest changes occurring within and between occipital and parietal, temporal and frontal regions ( fig. ). using whole-brain fc and a svm classifier to predict coma outcome yielded to an overall prediction accuracy of . %(auc . ). interestingly, automatic outcome prognostication using functional neuroimaging achieved better results that structural neuroimaging methods like dwi (accuracy . %). conclusion: we used rs-fmri to predict coma outcome in a cohort of post-anoxic comatose patients early after ca. we deliberately chose to include only patients with indeterminate prognosis after standard multimodal testing, to assess the contribution of rs-fmri in the early prognostication of coma outcome. we found that automatic prediction based on functional neuroimaging yielded much better results than current dwi methods, notably for identifying patients who recovered consciousness. outcomes of post-anoxic comatose patients early after ca, using rs-fmri in rcts comparing treatment of severe pneumonia that may influence their ability to demonstrate differences between studied drugs. clinical cure was the most frequently used endpoint but its definition was highly variable. these results are not surprising as far as even guidance from regulatory agencies on how to evaluate hap vap treatments differ. the aim of this work was to reach a consensus on the most appropriate endpoint to consider in future clinical trials evaluating the efficacy of antimicrobial treatment for hap vap, using delphi method. patients and methods: twenty-six international experts from intensive care, infectious disease and from the industry were consulted using delphi method (four successive questionnaires) from january to january . more than % of similar answers to a question were necessary to reach a consensus. results: according to % the experts, clinical cure was the most desirable primary outcome among those found in the literature but two other endpoints were highly rated-all-cause mortality and mechanical ventilation (mv)-free days. consequently, % of the panelists agreed to use a composite endpoints and even a hierarchical composite endpoint to combine these items together in which clinical cure and mv-free days would be assessed at day and clinical cure at day after end of therapy. for vap, mortality was considered as the most clinically significant item by % of the experts, followed by mvfree days and finally clinical cure (fig. ) . for hap, a dual composite endpoint that only included all-cause mortality and clinical cure was chosen ( fig. ). among the various elements of clinical cure definition found in the literature, only three were retained by the experts-resolution at end of therapy of signs and symptoms present at enrolment, no further antimicrobial treatment needed and resolution or lack of progression of radiological signs of pneumonia. finally, we found a consensus on the signs and symptoms that should trigger the suspicion of pneumonia-worsening of gaz exchange, purulent tracheal secretions, hypotension and or vasopressor requirements and fever or hypothermia. we provide here two consensual endpoints (for vap and hap) that would help addressing the efficacy of antimicrobial molecules for hap vap treatment in future clinical trials. (table) . sm-vap were matched with control patients. in univariate analysis, risk factors for sm-vap weremale gender, chronic heart failure, respiratory, cardiovascular and coagulation sofa scores two days before vap, median number of antibiotics used, percentage of time with antibiotics before vap, parenteral nutrition, dialysis, catecholamine use and exposure to ureido-carboxypenicillin, ciprofloxacin, tazobactam or imipenem-meropenem during the week before vap (table) . patients with sm-vap were less likely to receive initial adequate therapy ( vs %, or . , p = . ). there was no statistical difference for icu or d mortality. d mortality was higher for sm-vap (table) . in multivariate analysis, exposure to imipenem-meropenem during the week before vap, respiratory and coagulation sofa scores two days before vap were independent risk factors for sm-vap. sapsii: simplified acute physiology score; sofa: sofa (sequential organ failure assessment); sofa resp: sofa respiratory score; sofa coag: sofa coagulation score; sofa cardio: sofa cardiovascular score conclusion: sm-vap represented . % of vap. we observed no differences in patients characteristics between the groups. imipenem-meropenem use during the week before vap was the most important risk factor for sm-vap. the higher risk of inadequate initial therapy with sm-vap had no impact on d mortality but d mortality was significantly higher. introduction: education of undergraduate students is key to improve hand hygiene (hh) behavioral changes amongst doctors [ . ] . our aim was to evaluate personal feedback using ultraviolet (uv) light inspection cabinets in a years program. our hypothesis was that its use for alcohol hand rub (ahr) application on first year would increase complete ahr application on nd year. patients and methods: this was a simple blind randomized trial comparing hh training with personal feedback using uv cabinet to a control group. on first year, students had access to a theoretical formation then were convened by groups for a demonstration of the correct execution of world health organization's (who) procedure [ ] . before hh training, each group underwent a cluster randomization. in the control group, the student hand rubbed under visual supervision and advises of a trainer. in the intervention group after the same visual assessment, completeness of ahr hand application was recorded under uv light and shown to the student. he was given free access to the uv cabinet to repeat the technique, until perfect application complete under uv light. an enhancement with a scenario-based learning was proposed to both groups. on second year, every student were asked to hand rub with the fluorescent ahr. a supervisor blinded to the group of randomization assessed the quality of the hh procedure visually, the completeness of hand application under uv light and compliance with the who's opportunities for hh during the simulation. results: after randomization students were included in the intervention group and in the control group. on second year, the rate of complete application of the ahr under uv was increased in the intervention group as compared with the control group ( % versus . % p < . ) ( fig. ) despite that visual assessment of hh procedures was similar between the two groups. in a logistic regression model including gender, intercurrent hh formation, intercurrent uv cabinet use, surgical unit traineeship and report of regular use of ahr, the hazard ratio for the intervention was . (ic . - . ). the rate of perfect compliance with the hh opportunities in the intervention group was increased ( . % versus . % p < . ) and the effect persisted in the logistic regression. conclusion: uv cabinets for undergraduate students' hh education improve the technique and the compliance with hh opportunities. included in a multifaceted education program, it must be considered a key tool for training. results: among the patients who underwent ecmo support for more than h, the bsi prevalence was . cases per ecmo days and microorganisms associated were most frequently gramnegative bacilli. as for positive ta cultures, microorganisms associated were oropharyngeal germs and gram-negative bacilli. two risk factors were associated with nosocomial bacteria occurrence in ta cultures-prior antibiotics and duration of mechanical ventilation more than days. we demonstrated a link between "positive ta culture" and "positive blood culture" and we showed a protective effect of using an antibioprophylaxis on "positive ta culture" and "global positive cultures" development. introduction: delirium in the icu is often under-diagnosed despite its related burden and impact on patients' morbidity, mortality and prolongation of hospital length of stay. the aim of this study was to assess the medical and paramedical community beliefs and practices regarding delirium in tunisian icus. patients and methods: between august st and / , healthcare professionals working at the icus of university hospitals of monastir and mahdia (tunisia) were asked to participate in the survey by completing a questionnaire anonymously (that specified participants' characteristics (age, gender, function, years of experience in icu) and their knowledge and perception of delirium in icu. the questionnaire consisted in questions of different types: likert style (: widespread scale in psychometric questionnaires in which the respondent expresses his or her degree of agreement or disagreement with an assertion), multiple choice, ranking and yes/no). results: during the study period, respondents out of ( % female, nurses: %), aged between - years in %, responded to the questionnaire. healthcare professionals experience in the icu was < year in . %; - years in . %, and > years in . %. participants asserted that the "most characteristic signs of delirium" were: insomnia ( %); confusion ( %); agitation ( %) and aggressiveness ( %). three-quarters of participants said they did not systematically search for signs of delirium in their patients. % thought that delirium was "an insignificant problem" or that "it was not a problem". only one and three participants respectively, said they attended a conference and read an article about delirium in icu the last year. half of the respondents felt that the most appropriate treatment for a patient with delirium was restraint. nearly one-third of participants thought that delirium was an under-diagnosed entity and only % felt that it was associated with long-term neuropsychological deficits. factors considered to be determinant in the occurrence of delirium were ards, shock, age, mechanical ventilation, postoperative status in , , , and %, respectively. conclusion: most tunisian healthcare professionals consider delirium as a common, underdiagnosed, and serious problem in the icu. yet, few participants actually monitor this condition. the influence of sedation choice on the delirium occurrence in critically ill poisoned patients: a randomized controlled trial khzouri takoua introduction: delirium is a common manifestation of acute brain dysfunction in critically ill patients. it is associated with a healthcare cost increase, and extension of the hospital stay length. the present study aimed to explore influence of patient characteristics and analgesicsedation on delirium incidence and to analyze its risk factors. patients and methods: it is a prospective single blind randomized controlled trial, started on the first july in a -bed toxicological intensive care unit, including all mechanically ventilated patients requiring sedation who were admitted for acute poisoning. they were randomly divided into two groups g et g receiving respectevily propofol-remifentanil and midazolam-remifentanil. delirium assessment scores were judged not adapted to our population and we retained the diagnosis of delirium on arguments inspired from diagnostic and statistical manual of mental disorders fourth edition (dsm-iv). results: until the th september , patients were included, with patients in g and in g . the two groups were comparable in terms of epidemiological characteristics. delirium was developed in patients ( %) (n = in g and n = in g ) with an average duration of ± h with no difference between the groups ( ± h for g - ± h for g , p = . ). compared to those without delirium, no differences were found in the patient characteristics among these two groups with regard to sex, age, psychiatric history and severity of illness (apache ii, igs ii score) and even with regard to hypnotic choice ( vs p = . ). delirium was associated to prolonged duration of mechanical ventilation ( ± h vs ± h, p = . ) and length of icu stay ( . h vs . h, p = . ) without significant differences. delirious patients had more hypotension (p = . ), and received more atropine ( . ). multiple logistic regression analysis identified atropine (or . , %cl . - . , p = . ) as an independent risk factor for delirium. the diagnosis and prevention of icu delirium are subjects of multiple ongoing investigations. we carried out this study to detect the risk factors of delirium in order to prevent it. it is important to note that our results are influenced by the studied population and are only preliminary. we rely on the study pursuit and the sample enlargement to better inform us as well on risk factors as protective. introduction: background: severe alcohol withdrawal syndrome is a common cause of hospital admission. delirium tremens is a potentially fatal complication of alcohol withdrawal. in severe delirium, very large dosages of benzodiazepines can be required despite well described side effects, such as coma and hypoxic cardiac arrest, although there is no recommendations for standardized treatments. objective -the aim of this study was to describe outcomes and risk factors for complications in patients with severe alcohol withdrawal syndrome treated in intensive care unit with continous infusion of benzodiazepine (bzd). we retrospectively reviewed the medical records of all patients hospitalized for alcohol withdrawal syndrome between and . only those who received continous-infusion of bzd, associated with close clinical monitoring and the evaluation of rass and cushman scores, without systematic recourse to mechanical ventilation, were included. results: we studied patients hospitalized in icu for severe alcohol withdrawal syndrome. the mean age (sd) was . ± . years, mean icu admission saps (simplified acute physiology score) ii score was ± . . all of them have received continous infusion of midazolam, with a median maximum perfusion velocity of mg h (interquartile range, ( , )). the median duration of treatement was days (interquartile range, ( , ) ). thirteen patients ( %) developed pneumonia, and or required intubation, and ( %) have had seizures. no cardiac arrest and death was observed. icu length of stay (los) was days ( , ) (median, interquartile range). patients who requiried intubation and or developed pneumonia, received substantially more bzd (median total dose, mg of midazolam vs. mg in the non-complicated group + p < . ), and their icu los was higher (median, days vs. days + p < . ). endotracheal intubation and or development of pneumonia were associated with a higher maximum perfusion velocity of midazolam (> mg h) (or . , ic % ( . - . ), p = . ). previous episodes of delirium tremens before icu admission were associated with higher complications such as mechanical ventilation and or pneumonia (or . , ic % ( . - . ), p = . ). in severe delirium, very large dosages of benzodiazepines can be used without systematic mechanical ventilation with a low incidence of complications. introduction: delirium is frequent in intensive care unit (icu) patients and is associated with increased mortality, increased hospital stay, increased cost and long term cognitive impairment in survivors. numerous pharmacological and non-pharmacological strategies have been investigated for delirium treatment without success. therefore delirium prevention strategies are recommended by current critical care practice guidelines. among the potentially modifiable risk factors for delirium, the impact of daylight exposure on delirium incidence and or duration has not been studied. the objective of this study was to investigate whether daylight exposition would reduce delirium burden in critically ill patients. we conducted a prospective study in a -bed medical intensive care unit (icu) over a -year period (january -january ). all consecutive adult patients receiving invasive mechanical ventilation (mv) for days or more were eligible for the study. patients were assigned to a room with windows allowing daylight exposure ("light" group) or without window ("dark" group), depending on bed availability. delirium was evaluated with the intensive care delirium screening checklist (icdsc) for a maximum period of days. delirium was defined by a icdsc score ≥ for two consecutive days. agitation was defined by a rass > or = + . the primary endpoint was cumulative incidence of delirium. data are presented as median (interquartile range) or number (percentage). results: a total of patients were included (age- [ + ] years, saps - [ + ], sofa score- [ + ], medical admission- %). of them, patients were admitted to a "light" group and to a "dark" group. incidence of known risk factors for delirium was similar in the two groups. delirium occurred in ( %) patients in the "light" group and in ( %) patients in the "dark" group (p = . ). the duration of delirium was [ + ] days. patients in the "light" group received significantly less neuroleptics to treat agitation than patients in the "dark" group ( vs. %, p = . ). this protective association persisted after adjustment for confounders in multivariate analysis (odds ratio = . + [ . + . ] + p = . ). daylight exposure does not impact on delirium burden in icu mechanically ventilated patients. however, daylight exposure is independently associated with a reduced prescription of neuroleptics to treat agitation. introduction: patients with convulsive status epilepticus (cse) frequently require mechanical ventilation (mv), either for general anesthesia in case of refractory generalized cse, or for airway protection. guidelines for the management of refractory generalized cse currently recommend general anesthesia for - h, followed by gradual withdrawal. our objective is to evaluate the incidence of refractory generalized cse among patients who required mv during pre-hospital management of status epilepticus, and to describe the management of general anesthesia in intensive care unit (icu). this ongoing multicenter retrospective observational study is conducted in french icus. all patients admitted in icu under mechanical ventilation between - - and - - with disease-code "status epilepticus" are included. exclusion criteria are-age < years, post anoxic se, acute traumatic brain injury, initiation of mv in icu, transfer from another icu, inclusion in a therapeutic trial on se, non-convulsive se. collected data include reason for mv, antiepileptic treatment, dosage and duration of general anesthesia, mode of eeg monitoring. outcomes are-relapse of se, mv duration, in-icu length of stay and mortality. results: among the medical files reviewed, met the inclusion criteria and were analyzed, and were excluded. a minority of patients ( . %) had a refractory generalized cse, most patients ( . %) had a non-refractory generalized cse + the others had mostly partial cse. the main reason for intubation was coma (n = , . %). the duration of general anesthesia was not significantly different in refractory cse patients compared to non-refractory cse patients (p = . ). data regarding main outcomes are summarized below-. these preliminary data suggest that the majority of the patients admitted in icu under mv for cse do not have a refractory status. indication of mv is mainly coma without persistent convulsions. the mean duration of general anesthesia before withdrawal is < h, and thus in discrepancy with guidelines, but does not seem associated with a frequent relapse of se. if this low rate of rse for patients admitted in icu and the safety of rapid withdrawal of ga are confirmed, the recommended - h duration of general anesthesia in icu could be challenged. introduction: induced coma in intensive care patients protect them against pain and neurologic disorders. however, a few of them may present a delayed wake-up when the sedation is interrupted. the aim of this work is to assess brain imaging findings in patients with this condition. patients and methods: retrospective review of imaging data of patients ( males and females), aged between and years, admitted in intensive care unit (icu) between june and september , who had sedation or general anesthesia and presented a delayed wake-up. they were explored either by mri (n = ) or computed tomography (ct) (n = ). patients with traumatic lesions were excluded. results: patients were admitted in the icu because of chronic obstructive pulmonary disease exacerbation (n = ), infectious pneumonia or pleural effusion (n = ), acute respiratory failure (n = ), heart disease (n = ). two patients underwent general anesthesia. septic shock and circulatory collapse occurred in and patients respectively. mri and ct showed lesions that may explain the wake-up delay in of and of patients, respectively. brain anomalies included anoxic lesions (n = ) with basal ganglia involvement (n = ), ischemic or hemorrhagic strokes (n = ), hepatic encephalopathy (n = ) and herpetic encephalitis (n = ). conclusion: brain imaging techniques help diagnosing causes of delayed wake-up after induced coma. anoxic lesions and strokes are mostly behind this condition. mri is more accurate than ct. introduction: gastric tubes are common in intensive care units used for enteral feeding, administration of drugs or aspiration of the digestive tract. these tubes offer an excellent tolerance but malposition may have serious consequences that can lead to patient's death. the actualy gold method to confirm their correct placement is chest x-ray. we report a study which evaluate the performance of gastric ultrasonography for the validation of the good positioning of the gastric tube. we carried out a prospective, monocentric study in a medical intensive care units. for each included patient, we compared the results of a gastric ultrasonography to the interpretation of a chest x-ray. results: one hundred and thirteen gastric ultrasonographies were performed from july to may . in cases, ultrasonography concluded that the gastric tube was correctly positioned, confirmed by chest x-ray. in cases, ultrasonography did not visualize the tube in gastric area. among these cases, only malpositions were detected by the chest x-ray. the sensitivity and specificity of gastric ultrasonography were . [ . + . ] and [ . + ]. positive and negative predictive values were and . , respectively. the ultrasonography was performed min [ . + . ] after the gastric tube placement while the chest x-ray was interpreted min [ . + . ] after this same placement (p < . ). our results suggest a good performance of gastric ultrasonography to check the positioning of the gastric tube. this result must be interpreted with caution because of a low power of the study. we planned a multi-center study to confirm our results. giabicani mikhael introduction: prognosis of cirrhotic patients hospitalized in intensive care unit (icu) remains poor. in many icus, cirrhotic patients are widely admitted and revalued after receiving optimal treatments. little is known about risk factors involved in the evaluation of the prognosis at day , except the persistence of organ failure. this susceptibility to organ failure would be related to an alteration of the regulation mechanisms of the systemic inflammatory response. the blood neutrophil-to-lymphocyte ratio (nlr) is an inflammation biomarker reported to predict clinical outcome in unselected critically ill patients and in patients with stable liver cirrhosis, but has never been studied in critically ill cirrhotic patients. the aim of this study was to evaluate the blood nlr as parameter to predict mortality of cirrhotic patients hospitalized > days in icu. retrospective monocentric study including consecutively cirrhotic patients hospitalized in a medical icu from to . for each patient, clinical and biological data at admission and day were collected. nlr at admission ("nlrd "), at day ("nlrd ") and its variation between admission and d ("delta nlr") were calculated. statistical analysis used appropriate non parametric tests and cox regression for survival analysis. the ability of the variables to discriminate survivors from non-survivors was determined using roc curves and a net reclassification index (nri). results: patients (median child-pugh score = [ - ], median meld score = [ - ]) were hospitalized more than days in icu. the major causes for icu admission were sepsis ( . %), gastrointestinal bleeding ( %) or respiratory failure ( . %). patients were followed up for . d . ( %) patients died- ( %) in icu, ( %) after icu discharge and ( %) after hospital discharge. in univariate analysis, factors significantly associated with mortality wereat d , nlr, meld and sofa scores + and between d and d -delta nlr, delta sofa and delta meld. predictors of death in multivariate analysis are shown in table . area under delta nlr roc curve was . (ci = . - . ). nri revealed that delta nlr was more efficient than delta sofa (nri = . %) to identify patients with a % mortality risk at least. conclusion: nlr is a novel inflammation index known to predict poor clinical outcomes. delta nlr is an independent predictor of mortality in critically ill cirrhotic patients and could be more effective than delta sofa in predicting hospital mortality in these patients. severe liver dysfunction acute liver failure related to exertional heatstroke: outcomes, histological features and role of liver introduction: severe acute liver injury and failure (sali alf) is a grave complication of exertional heatstroke (eh). liver transplantation (lt) may be a therapeutic option, but the criteria for, and timing of, transplantation have not been clearly established. the aim of this study was to define the profile of patients who require transplantation in this context. this was a multicentre, retrospective study of patients admitted with a diagnosis of exertional heatstroke-related sali alf with a prothrombin time (pt) lower than %, with or without hepatic encephalopathy. results: male patients (median age- . years) with ali alf related to exertional heatstroke were studied + nine of them ( . %) were listed for emergency lt. the latter differed from those who were not listed with respect to their more severe liver failure after d , a clear deterioration in their pt and alt values between d and d , and more marked organ dysfunction. four of these nine patients were subsequently transplanted. at the time of lt, all had pt levels lower than %, a marked rise in bilirubin levels and required support for at least one organ (or x organs were involved). histological findings on the explanted livers demonstrated massive or sub-massive necrosis and little potential for effective mitosis with a mitonecrotic appearance. the unlisted patients ( . %) were still alive months later and had not experienced any after-effects. conclusion: survival without liver transplantation in patients with heatstroke-related ali alf reaches . %. the indication for liver transplantation is based on an evolving dynamic. the lack of any signs of an improvement in liver function at or after d , in patients presenting with other organ dysfunctions or failure, means that liver transplantation should be envisaged. the peculiar histological features observed on all the explanted livers, and the aspect of abortive mitoses in hepatocytes could be attributed to the effects of heatstroke. . on admission, the mean pt was . % ( - ), the mean total bilirubin was umol l. paracetamol poisoning was the principal etiology with % of the patients- % in the prometheus group versus % in the standard group (p = . ). the hepatic encephalopathy grade was significantly higher in the prometheus group- versus . in the standard group (p = . ). there was no difference between the two groups concerning mortality on day (p = ) or day (p = . ). there was no difference concerning the length of stay in intensive care unit or in hospital between the two groups. patients ( . %) were transplanted. there was a statistical difference between the two groups concerning liver transplantation (p = . )- transplant ( %) in the prometheus group versus transplant ( %) in the standard medical care group. there was a significant improve of encephalopathy after the prometheus session (p = . ). therapy in our icu were included consecutively and prospectively in the cohort. mars ® therapy performed using a double lumen dialysis catheter in the femoral or jugular vein. we used the monitor mars ® tc (teraklin) coupled with the dialysis machine prismaflex ® (gambro). the albumin dialysate circuit consisted of ml of % human albumin and was regenerated by an anion-exchange column and an uncoated charcoal column (diamars ® ie , diamars ® ac ). results: ninety patients were included for sessions. the mean duration was h min (± h min). the population treated consisted of groups-acute-on-chronic liver failure (aoclf), acute liver failure (alf), post-surgery liver failure (post transplantation, post hepatectomy), refractory pruritus and drug intoxication ( fig. ). regarding biological efficacy-total bilirubin was lowered in aoclf and post-surgery groups (p < . ), also in the alf group although not significatively. meld score was lowered in the aoclf and alf group (p < . ). however clinical variables (glasgow score and encephalopathy) didn't improve significatively. in the refractory pruritus group, pruritus decreased in out of patients (p < . ). bile acid levels decreased to . % of its mean baseline level (p < . ). in the drug intoxication group improvement of the richmond agitation-sedation scale (rass) from deeply sedated (rass < = − ) to minimal sedation (rass > = − ) was obtained in out of patients. out of sessions, catheter-related adverse effects were low ( . %), thrombocytopenia was the main adverse effect ( . %). conclusion: we report our mars ® experience with the largest cohort of patients referred from a single hospital. we showed biological efficacy in all indications, although clinical efficacy was uneven. mars ® therapy in patients with refractory pruritus yielded promising results. tolerance was good and the main adverse effect was thrombocytopenia. global transplantation-free survival was low in patients with liver failure, reinforcing the need for a liver transplantation center when using mars ® . introduction: colonoscopy is crucial for the management of lower gastro-intestinal disorders, but its profitability is discussed in critically ill patients, mainly because of the complexity of colonic preparation. as the profitability of colonoscopy in intermediate or intensive care units (cicu) has been scarcely reported ( ), we investigated its indications and usefulness. patients and methods: retrospective bicenter observational study ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . main endpoint: diagnostic profitability of cicu in unselected critically ill patients. profitability was a priori defined as "high" if cicu led to adapt ongoing therapies; allowed an endoscopic intervention; or participated in the decision to limit therapeutic effort. secondary endpoints: describe the quality of cicu and its preparation; determine its position in diagnosis strategy; describe its morbidity. ) + investigation of a gram negative bacilli sepsis (n = , %) + sigmoid volvulus (n = , %) + and cancer diagnosis (n = + %). cicu profitability was deemed high in % (n = ), with an endoscopic intervention performed in % (n = ). the cicu lead to antimicrobial adaptation (n = ), emergent surgery (n = ), or to limit therapeutics effort (n = ). in cases ( %) the cicu was considered normal. patients' preparation was rated as good in % (n = ) + and the colonoscopy was complete in ( %). the cicu was mainly performed as a nd ( %) or rd ( %) investigation after an abdominal ct-scan or an upper digestive endoscopy (respectively performed in first instance in and %). three cicu were complicated by hemodynamic and respiratory failures, none were fatal. discussion: in our series of unselected critically ill patients, cicu were mainly performed to investigate lower gastro-intestinal bleeding. despite a low rate of good preparation, cicu is safe and its profitability is high in the majority of cases. conclusion: although performed in poor conditions, cicu seems useful in the diagnostic and the therapeutic management of critically ill patients, and not only in gastro-intestinal bleeding. ( ) church, surgical endoscopy . introduction: accurate pain assessment is associated with better outcomes in intensive care unit (icu) patients. specific scales for noncommunicative patients have been developed and validated but their routine use still remains inaccurate and subjective. analgesia nociception index (ani) is based on high-frequency heart rate variability. this study objective was to assess the correlation between the behavioral pain scale (bps) and ani during care procedures in deeply sedated patients. we conduced a french multicentric prospective observational study with blinded continuous recording of ani during h with spotting of care procedures in patients with rass less or equal to − . we compared pain assessment using bps and ani before (t ) and during (t ) each care procedure. the cares analyzed included prick glycaemia, turning, catheter insertion, dressing change and others. a behavioral pain reactivity (bpr) was defined by a bps elevation of at least point. we analyzed minimal ani values and its variations with calculation of deltaani (anit -anit ). because of the analysis of several cares per patient we used a bonferroni's correction in comparison of bpr and no bpr groups with a significant p value < . for this comparison. for others analyses the p value considered as significant was p < . . correlation between ani and bps was analyzed using a spearman correlation rank test. introduction: the pain associated with burn was one of the most painful injuries to treat. pain was induced by therapeutic acts such as wound debridement, dressing and other painful procedures. burn pain caused changes in neurophysiology and pharmacokinetics that may make standard pharmacologic analgesic therapy less effective than usual.virtual reality has been explored as an adjunct therapy for the management of acute pain for a number of conditions. in our study, we attempt to assess the impact of virtual reality on management of burn pain during dressing changes. patients and methods: before the therapeutic procedure (dressing changes), the concept of virtual reality therapy was explained to the patient (technology and equipment used). the video used was snow mountain. during the act, pain was assessed until the end of the procedure. the assessment of pain was based on visual analog scale (vas). for pain intensity, the scale was most commonly anchored by "no pain" (score of ) and "very intense pain" (score of ). results: during the study period, patients were included. the mean age was ± years. % of our patients were adults aged over years. they were men and women. the average burned surface area was ± %. pain was evaluated before the start of the therapeutic procedure. the mean initial pain severity score was . ± . (range to ). the pain assessment after virtual reality condition showed a significant decrease in the intensity of pain (p < . ). the mean pain decreased from . to . ± . with extremes ranging from to . conclusion: our study supports the use of virtual reality, simple noninvasive, as an adjunct therapy in the management of pain associated with dressing changes in burn patients. introduction: hypno-analgesia (ha) is used in the operating room and for complex pain. before implementation of ha in our intensive care unit (icu), most protocols for algogenic procedures included intravenous or epidural morphine and nitrous oxid. since , many caregivers have been trained, ha has been implemented and patient comfort is evaluated using ) a specific analogic scale of comfort ( to ) before and after the procedure + ) at the end of the procedure, a score of patient and caregiver comfort using a five item questionnaire ( to points). this pilot prospective study compares ha versus the standard protocol in the removal of abdominal drains after digestive surgery. the main objective was to evaluate the patient comfort before after the procedure using a scale of comfort + the secondary objectives were to test the patient and caregiver comfort scores and evaluate in the impact on consumption of analgesic. between may and september , two groups were obtained, according whether the procedure was performed by ha-trained or non-hatrained professionals (depending on caregivers availability in the unit). the number of subjects required to compare scales of comfort before vs. after drain removal was , using a nonparametric wilcoxon-mann-whitney test. results: eighty-eight patients were analyzed. the mean note in the comfort scale remained unchanged after vs. before drain removal in patients without ha (n = , + . points, ± . ), while it increased in patients with ha (n = , + . , ± . + p = . ). using our specific five item comfort score, patients and caregivers had a comparable level of satisfaction in ha and non-ha groups (patients . and . + caregivers- in both). a trend was observed in reduction of the consumption of morphine and nitrous oxid with ha, without altering their comfort. discussion: despite its limitations (mainly, its open non-randomized design), this study suggests that-ha may be used for algogenic procedures and is willingly adopted in icu by patients and professionals + specific scales scores, adapted for ha, may be useful to assess the effectiveness + finally, ha seems to be at least as efficient as classical procedures and could reduce the use of analgesic drugs. conclusion: ha adds value to patients and to all caregivers. prospective randomized studies are needed to valid the comfort scores we proposed, and to prove that ha reduces the consumption of analgesic drugs. introduction: pain has long been a focus of concern for doctors and caregivers. in intensive care unit, the inability to verbalize discomfort and pain are major stressors for patients. music therapy has demonstrated in many international studies its effect on the blood pressure and on the respiratory frequency. in this context, we conducted a study to evaluate the effects of standardized musical intervention on pain during painful cares in vigils patients hospitalized in critical care. patients and methods: design-we conduct a prospective, observational, randomised, single blind, mono center study. painful cares were studied and then distributed in two groups (n = with music, n = without music). the patients were equiped with a bose© helmet, and had or not music therapy during the care. our main criteria was the pain, it has been evaluated by a numeric scale before and after the painful care. we also estimated anxiety with the covi's heteroevaluation scale before and after the car. we also noticed if the care were stopped because of the pain, then we used a semi quantative numeric scale in order to estimate the feeling of the caregiver and the patient on the session. results: concerning pain, there is no significant difference between the two groups (p > . ). however, in the music group, pain decreased by % after the care (p < . ). anxiety was way lower in the music group than in the group without music (p < . ). we also noticed a decrease of % of the anxiety in the music group. the patients and the caregivers' feeling were the same in the two groups, with no significant difference (p > . ). on the other hand, caregivers tended to underestimate the difficulty of the session in comparison with the patients' (p < . ) in both groups. conclusion: music therapy did not improve the pain in a significant way, in the music group versus the group without but allowed a decrease of % of the pain after the care. nevertheless, music reduced by two patients'anxiety. introduction: sedation and analgesia is one of the basic themes in icu as complications associated with excessive sedation negatively impact the morbidity and mortality of patients. the objective of this study is to show that the nurse implementation of a sedation and analgesia algorithm is beneficial to the patient in terms of sedative drugs reduction and thus overall decrease in duration of mechanical ventilation (mv) and the morbidity and mortality which is associated with it, without altering patient comfort and tolerance of the environment. patients and methods: a before and after prospective, observational, non-interventional study was conducted in surgical icu in caen university hospital, between november and april . mechanically ventilated patients under sedation predicted to last h or more were included. during the "before" period, sedation and analgesia was managed by the physician, while during the "after" period, it was managed by the nurses according to the protocol. results: intubated and mechanically ventilated patients were admitted during the study period. among the eligible patients, were included during "before" period and during "after" period. the duration of mv after inclusion was significantly shorter in group "after" ( . [ + ] vs [ + . ] days, p = . ), as the duration of target rass (- à ) was significantly longer ( the patients experienced less of ventilator-acquired pneumonia (vap) and delirium during the "after" period ( vs . %, p = . , and vs . %, p = . , respectively). the nurse implementation of a sedation and analgesia algorithm was associated with a trend towards reduction in duration of mv, icu and hospital length of stay. moreover, prevalence of vap and delirium was reduced, in correlation to the significant decrease in sedative drugs. this type of algorithm is necessary to reduce morbidity and mortality associated with mv. introduction: central venous catheter insertion is a common practice for anesthetists and intensivsts. this invasive procedure generates pain and anxiety for patients. we aim to demonstrate that remifentanil improves the analgesia during scheduled central venous catheter insertion in mindful patients. patients and methods: a prospective, randomized, double-blind, controlled study in patients requiring central venous access. patients were randomly assigned to receive ng ml − remifentanil target controlled infusion (tci) and local anesthesia (la) with lidocaine or placebo and la. all patients were monitored in intensive care or postintervention care unit and systematically received oxygen. patients were asked to assess verbal numeric rating pain scale (vnrps) during the procedure. the primary outcome was the maximal vnrps. secondary outcomes were pain at each step, anxiety, patient satisfaction, operator ease and side effects. results: ninety patients were included ( in each group). all patients were analyzed. remifentanil significantly reduced maximal pain-vnrps ( % confidence interval [ci] - ) vs ( % ci - ) in the placebo group p = . (table ) . we did not observe any adverse event during this study, and there were no significant difference between the groups regarding side effects. conclusion: tci remifentanil is a safe procedure to reduce pain during central venous catheter insertion in awake patients. trial registration-clinicaltrials.gov identifier- , remidolcath. introduction: although guidelines on post-resuscitation care recommend the use of short-acting agents for sedation during targeted temperature management (ttm) after cardiac arrest (ca), the potential interests of this strategy have not been clinically demonstrated. patients and methods: before-after study. we compared two sedation regimens (propofol-remifentanil, period p vs midazolamfentanyl, period p ) among comatose ttm-treated ca survivors. management protocol, apart from sedation and neuromuscular blockers use, did not change between the two periods. baseline severity was assessed with cardiac-arrest-hospital-prognosis (cahp) score. time to awakening was measured starting from discontinuation of sedation at the end of rewarming. awakening was defined as delayed when it occurred after more than h. results: patients ( in p , in p ) were included. cahp score in p and p did not significantly differ (p = . ). sixty percent of patients awoke in both periods ( vs , p = . ). median time to awakening was . (iqr - ) hours in p vs. (iqr - ) hours in p . awakening was delayed in % in p vs. % of patients in p (p < . ). after adjustment, p was associated with significantly lower odds of delayed awakening (or . , % ci . - . + p < . ). patients in p had significantly more ventilator-free days, and lower catecholamine-free days between admission and day . survival and favorable neurologic outcome at discharge did not differ across periods. time course for awakening according to sedation period. these figures report the time course of patients included after discontinuation of sedation. at each time point, we report in the upper part, proportion of patients awoken after discontinuation of sedation, in the lower part, patients who died without awakening, and in the middle part (in white), patients still comatose. red dots indicate, for each period, the last patient awakening (after days in p and days in p ). black dots indicate the median time to awakening (too early to appear for period ). conclusion: during ttm following resuscitation from ca, sedation with propofol-remifentanil compared with midazolam-fentanyl was associated with an earlier awakening, and an increase in ventilator-free days. the new recommendations of the french society of anesthesia-intensive care (sfar) on perfusion and medication errors were revised in to promote proper use relating to drug administration with medical devices. to advance that of inquiry, practices of our intensive care unit (icu) were assessed in order to improve drug administration by central venous catheter (cvc). patients and methods: prospective evaluation by pharmacist resident and technical nurse during seven weeks, using a standard evaluation tool, in a bed icu. drug recommendations and sfar documents from were used as referential of conformity. the following parameters were evaluated- central venous lines mounting, drug administration and identification with a focus on narrow therapeutic index (nti) drugs. results: patients with cvc were analyzed between june and july . entered directly in the icu. were hospitalized for surgical reasons. had triple-lumen cvc. regarding the first parameter, no conformity was found due to lack of line identification ( %) or anti-return valve well positioned ( %). perfusion ramp position was above heart level in %, infusion tubing had contact with floor in %, and absence of plug on non-used lines is found in % of cases. regarding second parameter, non-conformities were due mostly to syringe label-absence of drug's concentration ( %), preparator identification ( %), patient identification ( . %), drug identification ( . %, all concerning propofol), date and time of medication preparation ( %), lack of color code of labels ( %). regarding nti, % were not administrated according to the recommendations-absence of dedicated line ( %), absence of administration on the nearest insertion site of the catheter ( %). conclusion: the evaluation highlight some improvement axis such as complete identification on syringes, sensitizing of icu healthcare team, or homogenization of cvc perfusion system. it calls for a second evaluation round after implementation of improvements. introduction: sedation is a corner stone of the care of patients receiving mechanical ventilation in the icu. sedation was associated with increased comfort and adherence to care, but also with increased morbidity, including delirium, increased duration of mechanical ventilation and length of icu stay. previous studies reported beneficial impact of reduced doses of sedative drugs and careful monitoring of patients comfort and consciousness. our goal was to assess the impact of the introduction of a nurses-dedicated sedation protocol in our icu. patients and methods: this monocentre retrospective before-after study included all the patients admitted in our icu, over two threemonth periods, from july and january , treated with invasive mechanical ventilation for more than h and older than yrs. after the first period, all physicians and nurses were trained to a new sedation management protocol. analysis was performed to assess the prescription and application of the protocol, its impact on the use of sedative drugs, icu length of stay, and duration of mechanical ventilation. major complications were also recorded. results: patients were included- before and after the protocol implementation. patients in both groups had similar baseline characteristics (men vs. %, p = . + mean age ± vs. ± years, p = . + weight . ± . vs. . ± . kg p = . + igs ± vs. ± , p = . + medical admission vs. %, p = . ). recordings of rass and bps did not differ between groups ( ± vs ± , p = + ± vs, ± , p = . ). the duration of sedation was significantly shorter after introduction of protocol ( . ± . vs . ± . , p < . ), as was the duration of mechanical ventilation ( . ± . vs . ± . , p = . ) and icu length of stay ( . ± . vs . ± . , p = . ). there was no difference in major icu complications, nor in mortality between groups ( and %). conclusion: although the implantation of a sedation protocol did not translate in increased recording of rass and bps scores, it was associated with improved outcomes. our data suggest that, more than the protocol by itself, beneficial effects reported after the implementation of a sedation protocol may be ascribed to increased awareness of the care givers and thus better management of sedation. introduction: workload affects the quality of care and the prognosis of critically ills patients. measuring workload in intensive care units (icu) has thus become essential for allowing a better matching between the activities required and the management of resources. in march , the medical icu of the university hospital of monastir (tunisia) moved into new buildings (more space and beds, computerbased prescriptions and monitoring, etc.). the aim of the present study is to compare the level of workload before and after the change of the icu buildings. patients and methods: during the two study periods (period -july-september and period -july-september ) adult patients consecutively admitted, for more than h, in the medical icu for arf and or sepsis were included in the analysis. data collected were the demographic characteristics (age, sex, body mass index (bmi), comorbidities, simplified acute physiology score (saps) iii), the nursing workload measured using the therapeutic intervention scoring system (tiss- ) and hospital survival. results: thirty-six patients ( male) were included in the study ( during period and during the second period). the medians of age, saps iii and bmi were respectively (iqr = ) years, (iqr = ) and . (iqr = . ). the main comorbidities were hypertension, copd and neurological disease respectively in , and %. the demographic characteristics were similar during the two periods. nurse workload was characterized by m tiss- = (iqr = ) and time of nurse's care of min (iqr = ). these two workload indicators were significantly higher during the second period (table ) . during the second period, "standard monitoring" and "frequent dressing changes" (> time day) were the activities with significant increase from, respectively to % (p < . ) and from to % (p < . ). the relocation of our icu in in new buildings was associated with a significant increase of the nurse workload with regard to patients with arf and or sepsis. . bland-altman analysis showed excellent accuracy and precision between recorded and collected data for all tested variables within clinically significant pre-defined limits of agreement. however, ( . %) data were missing and a delay was observed between videotaped and collected times. this delay was less than s and remained stable through all data for each patient. we identified that the missing data were due to a limit in the number of data being processed in the database at the same time and the delay between data presentation and data collection in the database was due to different server time settings. both technical issues were corrected. conclusion: our study identified two issues in the data collection process that slightly limited the accuracy of our high resolution electronic database. we recommend the performance of such validation study before using a high resolution database for clinical or research purposes. introduction: fluid overload, and also its variations, is known to jeopardize the outcome of icu patients. however, fluid balance remains difficult to assess accurately. in that context, our study aims to assess the prognostic value of body weight variations (bwv) from day to day on the -day mortality, length of stay (los) and the occurrence of ventilator-associated pneumonia (vap) and bedsore in critically ill patients with shock. patients and methods: adult patients admitted in icu with shock between and , and requiring mechanical ventilation during the first h, were extracted from a prospective multicenter cohort for a retrospective analysis. bwv was defined as the difference between the body weight of the day of interest and the body weight on admission. case mix, severity on admission, and outcomes were collected. fine and gray sub-distribution survival models were used, with icu discharge as competing event, adjusted on comorbidity and illness severity at admission at each landmark, from day to day . the impact of bwv on icu stay duration was estimated through a multivariate negative binomial regression model. the median age and saps score of the included patients were (iqr, - ) years and (iqr, - ), respectively. the bwv increased from . kg (iqr, - . ) on day to kg (iqr, − . to . ) on day . the day in-hospital mortality, the icu occurrence of bedsore and vap were , and . %, respectively. four categories of bwv were defined according to bwv interquartiles: weight loss, stable weight, moderate and severe weight gain. categories of bwv were independently associated with death on day and day (day : shr . ; % . - . p = . ; day : shr . ; % ci . - . , p = . ) (fig. ) . a weight loss tended to be associated with increased occurrence of bedsore, and weight gain with increased occurrence of vap. the extent of bwv increased the duration of icu stay independently of other severity factors. discussion: bwv may be another clinically relevant tool to assess the risk of death, mostly after day . the increased risk of bedsore in case of weight loss deserved to be confirmed. conclusion: body weight should be daily monitored for better prognostication. bwv-based restrictive strategies should be further evaluated. the clinical effectiveness of multi-layer silicone dressings in preventing icu acquired pressure ulcers: a randomised controlled trial introduction: the development of pressure ulcers (pu) in critically ill icu patients result in additional morbidity and may contribute to mortality in some cases. the minimisation of icu acquired pu remain an international challenge. this paper describes australian research that used multi-layer soft silicone sacral and heel dressings to prevent pu in critically ill patients. patients and methods: a total of critically ill patients were enrolled into an -month randomised controlled trial in one of melbourne's trauma centres. patients were randomised on admission to the emergency department and either had standard pu prevention or standard care plus the application of prophylactic sacral and heel dressings. patients were observed daily for pu development for the duration of their icu stay. results: patients in the dressing group has significantly reduced incidence rate of pu development compared to patients receiving standard pu prevention alone ( . vs . %, p < . ). patients in the dressings group had a relative risk reduction of % and a % absolute risk reduction for developing a pu regardless of their critical illness. results indicate the number needed to treat to prevent one pu was . additionally, we calculated the cost-benefit of this intervention and found the patients treated with prophylactic dressings cost . time less than the standard care group for wound care. discussion: the use of prophylactic dressings to prevent pu at our hospital have proved to be very effective in icu and subsequent studies have confirmed our results. it appears that the main mechanism of pu protection provided by these dressings is the reduction of pressure and shear forces leading to tissue distortion and cell death rather than the previously accepted ischaemic model of pu development. our current policy is now to use these dressings on all patients with a high risk of developing pu. the use of prophylactic multi-layer silicone dressings to prevent pu in critically ill patients is effective but it does not replace standard pu prevention methods. the use of these dressings sould be considered complimentary to best practice in pu prevention. iatrogenic events in intensive care unit: incidence, risk factors and impact on outcome ayed samia , merhebene takoua introduction: iatrogenic events (ies) are defined as harm resulting from medical intervention and health care, and not explained by underlying disease. mortality is reported to be as high as . % in cohorts of hospitalized patients experiencing ie. both length of stay and cost of hospitalization are increased by ies occurrence. we perform this study to determine the incidence, risk factors, and impact on outcome of ies in intensive care unit (icu). patients and methods: all patients admitted more than h to the -bed icu of a teaching hospital were prospectively screened. patients were monitored daily for adverse clinical occurrences. time and data about each ie were collected and they were considered as preventable or life-threatening events. for each patient, the followings were recorded-basic demographic data, indication for admission, severity scores on admission (sapsii and apacheii), need and duration of mechanical ventilation (mv), length of stay (los) in icu, intensive care work load score (omega), global mortality and ies related mortality. results: during the months period, patients were included and ( . %) were judged to have developed an ie while hospitalized. we recorded ies over days in icu so a density incidence of ie for patient-day. ies were considered preventable in % of cases and life-threatening in % of cases. ies occurred in a mean delay of ± days. global mortality rate was . % and ies related mortality rate was . %. patients with ies were significantly severe on admission, with a longer duration of mv and los in icu. omega score was significantly higher. multivariate analysis showed that omega score was the independent risk factor of ies occurrence (or . ic % [ . - . ], p < - ). dead patients were significantly severe on admission and experienced more ies than survivors. omega score, duration of mv and los were significantly higher. in multivariate analysis, ies and life-threatening ies were independent factors of mortality (or . ic % [ . - . ], p < - and or . ic % [ . - . ], p < - respectively). conclusion: ies in icu are common and frequent but one-third is preventable. work load icu score is the independent risk factor of their occurrence. ies impact largely the outcome especially the lifethreatening ones. efforts must be focused on preventing programs to reduce ies and improve the outcome. introduction: based on the recent sepsis- definitions, septic shock is defined by the combination of vasopressor requirement and serum lactate level > mmol/l. however hyperlactatemia and lactate kinetics may result from both increased production and impaired clearance in the critically ill, and may therefore not only rely on the severity of circulatory failure. we herein addressed the determinants of hyperlactatemia (> mmol/l) and the factors likely to impact on early lactate clearance in septic shock. patients and methods: this was a -year ( - ) monocentric retrospective study. all adult patients diagnosed for septic shock within the first h were included. septic shock was defined as a microbiologically proven or clinically suspected infection, associated with acute circulatory failure requiring vasopressors. the first lactate value (l ) was measured at the time of icu admission. hyperlactatemia was defined as a first lactate level > mmol/l. the second value (l ) was measured within h following the first measurement. lactate clearance was calculated as (l -l ) l time between l and l measurements) and expressed in mmol hour. parameters associated with initial hyperlactatemia and lactate clearance were investigated using multivariate logistic regression analysis. introduction: cardiac surgery with cardiopulmonary bypass (cpb) induces immunosuppression which has considerable implications for patients. cpb induces a significant increase in circulating neutrophils. neutrophil activation, associated with production of antibacterial peptides, reactive oxygen species (ros), cytokines, and other inflammatory mediators, as well as release of dna into the extracellular milieu (neutrophil extracellular traps (nets)), plays a central role in innate host defense and modulation of inflammation. however, it has been shown that, in septic shock or systemic inflammation as major surgery, immature circulating neutrophils can induce immunosuppression and increase the risk of secondary infections. staphylococcus aureus (sa) is one of the most commonly encountered bacterial pathogen responsible for poststernotomy mediastinitis, and neutrophils alterations may favor postoperative infections. the main objectives of this study were to evaluate the direct effects of cbp on neutrophils functions and to study the impact of different strains of sa on neutrophils bactericidal functions. patients and methods: blood samples were collected before and h after cardiac surgery with cpb and bone marrow samples were harvested directly after sternotomy, before initiation of cpb, and at the end of cpb, before sternal closure. septic patients were included as controls. circulating neutrophils analysis was performed using flow cytometry. we also studied netosis, ros production and bactericidal activity in isolated neutrophils before and after surgery using two strains of sa-one responsible of postoperative mediastinitis and one isolated from nasal carriage. results: blood cell count with differential demonstrated a significant increase in neutrophils h after surgery. flow cytometry analysis of blood samples indicated neutrophils were matures with a significant increase in degranulation marker (cd b). neutrophils life span was also increased after cbp. flow cytometry analysis of bone marrow samples showed no difference in cell composition and maturation before and after cbp. the neutrophil production of ros was significantly higher after cbp. however, cbp did not impact nets formation, phagocytosis and bactericidial function. moreover, there was no difference regarding the phagocytosis and the bactericidial activity when exposed to the two strain of sa. as expected, immature neutrophils count was significantly increased in septic patients compared to cardiac surgery patients. these results indicate that cbp promotes the recruitment of matures neutrophils via a demargination process. cbp does not induce neutrophil dysfunction. neutrophils should not be targeted to decrease postoperative infection after cpb. introduction: protein tyrosine phosphatase b (ptp b) is a negative regulator of both no production and insulin signaling and has been shown to be an aggravating factor in septic shock. stress hyperglycemia frequently occurs in critically ill patients and is associated with poor outcome. experimental studies on transgenic mice have shown that ptp b deletion resulted in a reduced insulin resistance and in a better survival during experimental model of sepsis. the main objective was to study the correlation between the ptp b gene expression and organ failure (through the delta sofa score between day and day ) or insulin resistance. patients and methods: twenty-seven healthy male volunteers have been included in this clinical trial. the product was administered by continuous intravenous infusion (civ). a single ascending dose design with dose levels was used. cohorts and received a -min single dose of motrem ( and mg and one and two volunteers respectively). then, cohorts to received either a -min loading dose (from . mg kg to mg kg) followed by . -hours maintenance dose (from . mg kg h to mg kg h) of motrem or a matching placebo ( - ratio). all volunteers were carefully monitored. before escalation to the next dose level, safety and pk data of the previous dose level were reviewed by a safety review committee. since immune system is at rest in normal individuals and thus trem- pathway is not activated, no pharmacodynamics parameters were analyzed. the main objectives of this trial was then to study the safety and pharmacokinetic profile of motrem. results: no product related changes in vital signs, clinical nor laboratory parameters were observed. no product-related adverse events were reported. the pk of motrem was linear; the main clearance was estimated at l/h/ kg which is higher than the hepatic blood flow in human (i.e., l/h/ kg) and is therefore indicative of an extensive enzymatic metabolism in blood + effective half-life was calculated to be about min. conclusion: motrem was found to be safe and well tolerated up to the highest dose tested ( mg/kg for a -min loading dose and mg kg h for a . -hours maintenance dose). safety and pharmacokinetics of motrem is currently being studied in septic shock patients in a phase iia randomised, double-blind, two-stage, placebo controlled, international, multicenter clinical trial (www.clinicaltrials.gov nct ). - ) is an immunoreceptor expressed on neutrophils and monocytes macrophages whose role is to amplify the inflammatory response driven by toll-like receptors engagement. the pharmacological inhibition of trem- confers protection in several pre-clinical models of acute inflammation. in this study, we aimed to decipher the role of trem- on the endothelium. we evaluated the expression of trem- in vessels and isolated endothelial cells by flow cytometry, qrt-pcr and confocal microscopy. we generated an endothelium-conditional trem- ko mice and submitted them to polymicrobial sepsis through clp. organs and blood were harvested at different time points and analyzed for cellular content, cytokine chemokine concentrations, and vasoreactivity. survival was monitored for week. results: trem- was expressed in aorta and pulmonary vessels from animals, and inducible after lps stimulation or during sepsis. these results were confirmed in human pulmonary microvascular endothelial cells. the pharmacological inhibition of trem- , using the synthetic inhibitory peptide lr , decreased the lps-induced trem- expression. sepsis induced a profound vascular hyporeactivity in wt animals, both in terms of contractility and endothelium-dependent relaxation. although contractility was still impaired in endotrem- -mice, vasorelaxation was completely restored. soluble trem- concentrations, a marker of trem- activation, were markedly increased in the plasma, the peritoneal lavage fluid and the lungs from wt septic mice compared to control. in endotrem- -mice, strem- level was reduced. plasma concentrations of soluble vcam- and il- were also reduced in endotrem- -animals. we observed an accumulation of neutrophils and inflammatory ly chigh monocytes in the lung of wt septic mice. this accumulation was dampened in endotrem- -mice. by contrast, endothelial trem- deletion favored the accumulation of reparative cells (ly clow monocytes). finally, survival was clearly improved in the endotrem- -group as compared to the wt group. conclusion: we reported that trem- is expressed and inducible in endothelial cells and plays a direct role in vascular inflammation and dysfunction. the targeted deletion of endothelial trem- conferred protection during septic shock in modulating inflammatory cells mobilization and activation, restoring vasoreactivity and improving survival. the effect of trem- on vascular tone, while impressive, deserves further investigations including the design of endothelium specific trem- inhibitors. - . ]. patients suffered from pneumonia, from intra-abdominal sepsis. we measured serum levels of total and free thiamine, thiamine mono di and triphosphate (tmp, tdp and ttp respectively), as well as the erythrocyte transketolase activity and arterial lactate at the time of admission. we also recorded the vital status at the end of the icu stay. results: % of our subjects exhibited particularly low levels of free thiamine (< nmol/l). there was no correlation between free (r = − . ; p = . ), or total (r = − . ; p = . ) thiamine concentration and lactate levels. there was no correlation between tmp (r = . ; p = . ), tdp (r = − . ; p = . ), ttp (r = − . ; p = . ) and lactate levels in the whole population. no correlation was found between the concentration of thiamine derivatives and arterial lactate levels in the subgroup of patients exhibiting the highest levels of lactate (> and > mmol/l). total thiamine and tdp concentration at the time of admission were significantly higher in icu survivors than in non-survivors (p = . and p = . ). during sepsis, we did not find any correlation between thiamine and lactate concentration. lower thiamine diphosphate concentration may be associated with icu-mortality. introduction: a positive fluid balance in sepsis is a determining factor for mortality. in previous experimental studies, sodium lactate has been shown to improve hemodynamic and avoid fluid overload ( ). to understand these beneficial effects, we investigated the impact of sodium lactate on capillary leakage, in comparaison to saline on capillary leak in a rat model. the sixteen sedated, mechanically ventilated rats were challenged with intravenous infusion of e.coli lipopolysaccharide ( mg/kg). two groups of eight animals were randomised to receive a continous perfusion ( ml/kg/h) of sodium lactate . % (treatment group) or . % nacl (control group). in order to inject the same caloric load in the two groups, a . ml/kg/h of either water of % dextrose solution were perfused. mean arterial pressure, heart rate, urine ouput were measured over a min period. an echocardiography was then performed and evans blue ( %, mg/kg) was intravenously injected min before sacrifice. organs were withdrawn and organs wet dry ratio and evans blue dye extravasation were measured. results: fluid balance, organs wet dry ratio and evans blue dye extravasation were not significantly improved in sodium lactate group. hemodynamics parameters were not significantly enhanced after sodium lactate infusion. discussion: previously, lactate administration has improves renal perfusion. in our study, the volume of urine output was decreased in the groups reflecting the severity of our model. and the vascular filling ( . ml/kg/h) higher than in the literature could impact our results. ( ) recently, the pressure electricy index-pmus eadi index (pei) has been described. ( ) the purpose of this study was to assess muscular pressure (pmus) using pei with our nava protocol. patients and methods: observational study, patients recovering from pneumonitis and acute respiratory failure. sbt was pressure support ventilation with cmh of assist and no pep. pei was calculated under nava and during sbt from airway pressure drop during end-expiratory occlusions, muscular pressure (pmus) was estimated from pei ( ) . another index, patient ventilator contribution index (pvbc) was also measured using the inspiratory peak of eadi and vt (inspiratory) during assisted and non-assisted breaths. we calculated pvbc-squared because it has been shown that it is more correlated to pmus ptot. results: results are summarized in the introduction: in icu, intubation is a high risk procedure associated with high morbidity. despite procedure's improvement with systematic application of fluid loading, early use of vasopressors and checklist use, morbidity remains high. first pass success is strongly correlated with adverse event occurrence. a recent study by semler et al. concluded than "sniffing" position is better than "ramped" position to increase first pass success even the primary outcome prespecifiedpulse pressure saturation was not different between the two groups. we conducted a post hoc analysis of the randomized clinical trial macgrath mac video laryngoscope or macintosh laryngoscope for intubation in the intensive care unit (macman) to determine the best position for intubation in the icu. patients and methods: macman was a multicentre, open-label, randomized controlled superiority trial. consecutive patients requiring intubation were randomly allocated to either the mcgrath mac videolaryngoscope or the macintosh laryngoscope, with stratification by centre and operator experience. an only inclusion criterion was-"patients must be admitted to an icu and require mechanical ventilation through an endotracheal tube". patients were excluded if-contraindication to orotracheal intubation (e.g., unstable spinal lesion); insufficient time to include and randomize the patient (e.g., because of cardiac arrest); age < years; pregnant or breastfeeding woman + correctional facility inmate; patient under guardianship + patient without health insurance; refusal of the patient or next of kin to participate in the study; previous enrolment in a clinical randomized trial with intubation as the primary end point (including previous inclusion in the present trial). post-hoc analysis was performed to assess association between patient position (sniffing or supine) and first pass success. between-groups baseline difference was adjusted for baseline covariates significantly associated with the group membership (p < . ). results: failure of first pass introduction: during acute exacerbation of copd oxygen should be titrated to avoid both hypoxemia and hyperoxia. the recommendations are not followed and automated oxygen titration may be useful in this population. the aim of this study was to evaluate a new device developed to automatically titrate oxygen based on spo target (freeo , oxynov, canada) and to compare oxygenation parameters with usual administration (manual flowmeter). the study is an observational monocentric study. we prospectively included patients hospitalized for acute exacerbation of copd receiving oxygen. written informed consent was obtained from all patient. in the first part of the study, we evaluated oxygen flowrate and spo during min at baseline based on management of the physicians in charge. the oxygenation parameters were compared with automated titration (freeo during h). in the second part of the study, oxygen was delivered with freeo until oxygen weaning or a maximum of h. we evaluated the oxygenation parameters during prolonged utilization, the duration of oxygen administration, a new bluetooth spo connection compared to wire spo connection (evaluated by visual analog scale - ). results: we present preliminary data of copd patients (sex ratio m f = ). mean age (± sd) was ± years, mean fev (± sd) was . ± . l. oxygenation data in both parts of the study are displayed in the table . time in the spo target was significantly increased with freeo in comparison with manual titration and oxygen flowrate was reduced by half. in the second part of the study, the % of time in the spo target with automated oxygen titration was above % and time with hypoxemia and with hyperoxia were low. in patients, we compared comfort with wire spo connection to bluetooth wireless spo connection. the comfort was significantly increased with wireless connection ( . ± . vs. . ± . , p < . ). duration of oxygen administration after inclusion ( . ± . days) and hospital length of stay after inclusion ( . ± . days). conclusion: automated oxygen titration maintains the patients within predetermined spo target more than % of the time and reduces oxygen flowrate in comparison with manual oxygen titration. the second part of the study demonstrates the feasibility to use automated oxygen titration during several days with similar outcomes as previously reported in similar population. there are several limitations of the study and additional evaluations of this device are required. introduction: hyperoxemia occurs up to % of mechanical ventilation days in the icu [ ] and is associated with increased mortality as compared to patients ventilated in normoxemia [ ] . intellivent-asv is a full closed loop ventilation mode adjusting automatically oxygenation's settings fio and peep according to spo for passive and spontaneously breathing mechanically ventilated patients. this post hoc analysis of a monocentric randomized controlled parallel group study compared frequency of hyperoxemia (pao > mmhg and or spo > %) and hypoxemia (pao < mmhg and or spo < %) and the percentage of ventilation time with spo > % and the percentage of ventilation time with spo < % between intellivent-asv and conventional ventilation mode in mechanically ventilated icu patients. the randomized controlled trial was performed in the general icu of hôpital sainte musse, toulon, france. eligible participants were adult aged or over, invasively ventilated for less than h at the time of inclusion with an expected duration of mechanical ventilation of more than h. exclusion criteria were broncho-pleural fistula, ventilation drive disorder and moribund patients. patients were allocated to intellivent-asv group or to conventional ventilation group (volume assist control and pressure support modes) using blocked randomization. the post hoc analysis was performed by the comparison of all arterial blood gases (abg) performed during the study period-the number of abg with hyperoxemia and hypoxemia, the median pao and spo for these arterial blood gases and fio associated were compared according to group. results: patients were included, patients in each group. the total number od abg was (mode conventional) vs (mode intel-livent-asv) (p = ns). the number of abg with pao > mmhg was respectively versus (p = . ) with sao > % was vs (p = . ) with pao < mmhg was vs (p = . ) + with sao < % was vs (p = . ). the percentage of time of ventilation spent with spo > % was % vs (p = . ), and with sao < % was . vs . (p = . ). the continuous control of oxygenation settings provided by intellivent-asv decreases significantly the number of blood gas with hyperoxemia as compared to manual oxygenation setting without increasing the risk of hypoxemia. introduction: in invasively mechanically ventilated patient, dyspnea is frequent and severe. relying on self-report, its measurement remains challenging in patients unable to communicate. a -item observation scale, namely the intensive care-respiratory distress observation scale (ic-rdos), has been proposed as a surrogate of dyspnea-visual analogic scale (d-vas) self-report in intensive care unit (icu) patients [ ] . however this scale has been validated among non-intubated patients and included one item "supplemental oxygen" not thoroughly adapted for intubated population. we sought to develop a dyspnea observation scale more suitable for intubated patients and to evaluate its performance to detect dyspnea. patients and methods: ancillary analysis of data prospectively collected from icu communicative patients enrolled for the validation of the ic-rdos. factorial principal component analysis was first performed to select variables that mostly contributed to the principal axes, among a set of observable variables with possible clinical relevance. to identify the best correlation between these variables and d-vas, were performed an iterative partial least square regression process (pls). iterative pls procedure identified five variables, of which the combination and weighting allowed optimal correlation with d-vas (r = . ; % ci . to . ; p value < . ), which constitute the ic-rdos [ ] . in a first step, we removed "supplemental oxygen", not relevant in intubated patients. we obtained a -items ic-rdos (r = . introduction: lung ultrasound (lus) has emerged in different clinical settings, such as in intensive care medicine (icm). early diagnosis of ventilator-associated pneumonia (vap) remains a challenge to the intensivist. however, scientific evidence is little available on whether lus reliably improves the diagnosis of vap. the aim of this prospective study was to assess whether lus could be an alternative to pulmonary computerized tomography (ct) for assessing diagnosis of vap in icm. patients and methods: twenty-one patients ventilated for duration more than days suspected of vap were included. lus was performed by a well-trained operator who was blinded of the vap diagnosis. the diagnostic gold standard of vap was on the basis of pulmonary ct and positive culture pulmonary. all clinical criteria for the diagnosis were collected the same day of lus and pulmonary ct. the ultrasound exam included anterior, lateral and posterior views from both sides of the chest with superior and inferior views. we classed patient in groups according diagnosis of vap with pulmonary ct (vap + or vap-) and lus (lus + or lus-). lus characteristics of vap diagnosis included profils-asymetric line b (profil a b), without sliding (profil b'), sub pleural consolidation (profil c), consolidation with punctiforme bronchogram (pb), linear air bronchograms (lb) or dynamic bronchograms (lbd), posteror lateral alveolar pleural suffusion (plaps), pleural effusion pathological (pep), shred sign (ss and complications according to insertion site. the advantage of this method is that it gives a pragmatic view of the real clinical situation. patients and methods: ancillary study of the akiki trial, an open pragmatic randomized controlled trial published in , in which patients with severe acute kidney injury were randomly assigned to either an early or a delayed rrt initiation strategy. the present study involved all patients who underwent at least one rrt session. number of rrt catheters, insertion sites, factors potentially associated with the choice of insertion site, duration of catheter use, reason for catheter replacement, and complications were prospectively collected. results: among the patients included in akiki, received rrt at least once and patients were finally included in the analysis ( missing data), leading to a total of rrt catheters. femoral site was chosen preferentially (n = , %), followed by jugular site (n = , %) and subclavian site (n = , %). investigating center was the sole factor significantly associated with the choice of insertion site in multivariate analysis (p = . ). higher weight did not affect choice of insertion site. mean duration of catheter use was . (+- . ) days without difference according to site. catheter dysfunction was the main reason for replacement (n = , %). suspicion of infection led to replacement of many catheters (n = , %) but was actually seldom proven (n = , % introduction: long standing dialysis (sled or crrt) allows a better hemodynamic tolerance as well as a greater performance to achieve a negative fluid balance in intensive care unit. dialysis alter hemodynamics mainly by short term variation of blood volume. in this study we took advantage of a continuous monitoring of blood volume during dialysis session to decipher the relationship between the variation of relative blood volume (rbv) with mean arterial pressure (map). this study is observational prospective, including all prolonged (> h) dialysis sessions in saint etienne nephrology intensive care unit between january and june . exclusion criteria were ongoing blood transfusion and blood volume controled ultrafiltration. medical records were compiled along with cardiac ultrasonography at the beginning when available. the statistical analysis was perfomed in two parts. the first part studied the performances of the first hour deltarbv (defined by rbv before minus rbv after h of dialysis) to predict a drop of map below mmhg (hypotension). this analysis excluded sessions with hypotension and intervention during the first hour. the second study was the modelization of the relationship between deltarbv and deltamap for every hour of dialysis without any intervention on blood pressure. both analyses were performed using mixed effects linear and generalized models. fig. vancomycin pk during sled results: a total of sessions on different patients were performed during the period. the characteristics of patients were as follows-sex ratio at , age (sd) . ( . ), weight . kg ( . ), sapsii score . ( . ) . patients on were taken in charge for fluid overload. in the first set of analyses (per sessions), sessions were excluded for intervention in the first hour. the adjusted deltarbv did not predict hypotension during the session (generalized mixed effect model, session and patients set as random effects, estimate . , p = . ). in the second set of analyses (per hour without any intervention), h were analyzed. adjusted deltarbv correlated strongly and inversly with deltamap (linear mixed effect model, random effects were sessions, patients and hour order in the session, estimate . , p < . ). conclusion: in our mostly fluid overloaded patients, the drop of rbv correlated with an increase of map. introduction: kidney transplant recipients (ktr) are at risk of icu admission because of prolonged immunosuppressive therapy and a higher risk of cardiovascular events, severe infections or drug-related toxicities. several retrospectives studies reported the short-term outcome of ktr admitted to the icu, but data concerning the risk of chronic kidney disease and anti-hla immunization are scarce. patients and methods: in this retrospective study, we addressed the in-hospital and long-term mortalities of the ktr admitted in a french icu ( beds) between january and june . predictive factors for death, long-term renal function and hla immunization were identified. results: the main causes for admission were acute respiratory failure ( . %), sepsis ( . %), post-operative period (peritonitis, hemorrhage + %). at the admission, mean age, saps and sofa score were ± years, ± and . ± . , respectively. renal replacement therapy, mechanical ventilation and vasopressors were required in ( . %), ( . %) and ( . %) patients. immunosuppressive regimen was modified in patients ( . % + steroids increase %, calcineurin inhibitors or antimetabolites withdrawal and %, respectively). in-hospital mortality was % ( . and . % at months and ). by multivariate analysis, ebv blood proliferation in the months preceding the admission in the icu, and the saps gravity score at admission independently predicted the in-hospital and long-term mortalities. among the patients alive at month after the admission in the icu and with available data, ( . %) and ( . %) progressed to a more severe ckd stage at months and , respectively. both, the severity of the aki and the preexisting ckd predicted the risk of progression of the ckd. last, de novo anti-hla immunization at month was identified in patients ( . %, donor specific antibodies ( . %)) and was significantly associated with the occurrence of acute transplant rejection (p = . ). in five patients who developed anti-hla antibodies, rbc transfusion during the icu stay was the only immunological trigger identified. discussion: outcome of ktr is closed to the general population admitted in icu and better than other immunocompromised patient, like patients from oncohematology. conclusion: worsening of the renal function and hla immunization are frequent and may impact mid to long-term prognosis because of the high risk of transplant rejection, end-stage renal disease and further transplantation contraindication. introduction: acute kidney injury (aki) is associated with a poor prognosis. although pulmonary embolism (pe) may promote aki through renal congestion or hemodynamic instability, its frequency as its impact on the prognosis of patients with acute pe have been poorly studied. patients and methods: using data from the registro informatizado de la enfermedad tromboembolica venosa (riete) registry, we assessed the frequency of aki at baseline, and its influence on the -day mortality rate of patients with objectively confirmed pe. aki was defined according to the "kidney disease-improving global outcomes" definition. we used multivariate analysis to assess whether or not the presence of aki independently influenced the risk for -day death. the study included , patients with acute pe, of whom ( . %) had aki at baseline. of these, patients ( %) were in stage , ( . %) in stage and ( %) in stage . the proportion of patients with high-risk pe in those with no aki, aki stage , aki stage and aki stage was- . , . , . and %, respectively (p < . ). after days, patients ( . %) had died. overall mortality was- % in patients with no aki, . % in aki stage , % in aki stage , % in aki stage , all p < . ). on multivariable analysis, aki was independently associated with an increased risk of death at days (odds ratio = . + % ci . - . ), after adjusting for the initial severity of pe, age > years, chronic heart failure or chronic lung disease, cancer, anemia and liver cirrhosis. conclusion: one in every - patients with acute pe had aki. moreover aki was an independent predictor of poor outcome in pe patients. this study suggests that pe (and its severity) should be considered as a risk factor for aki and aki may deserve to be evaluated as a prognostic factor in patients with acute pe. introduction: metabolic acidosis is frequently observed as a consequence of global ischemia-reperfusion after out-of-hospital cardiac arrest (ohca). we aimed to identify risk factors and assessing the impact of metabolic acidosis on outcome after ohca. patients and methods: we included all consecutive ohca patients admitted between and . using admission data, metabolic acidosis was defined by a positive base deficit and was categorized by quartiles. main outcome was survival at icu discharge. factors associated with acidosis severity and with main outcome were evaluated by linear and logistic regression, respectively. results: patients ( . % male, median age years) were included in the analysis. median base deficit was . [ . , . ] meq/l. male gender (p = . ), resuscitation duration (p < . ), initial shockable rhythm (p < . ) and post-resuscitation shock (p < . ) were associated with a deeper acidosis. icu mortality rate increased across base deficit quartiles ( . , . , . and . %, p for trend < . ) and base deficit was independently associated with icu mortality (p < . ). the proportion of cpc patients among icu survivors was similar across base deficit quartiles ( . , . , . and . %, p = . ) and . % of patients with a base deficit higher than . meq l survived to icu discharge with a good neurological recovery. severe metabolic acidosis is frequent in ohca patients and is associated with poorer outcome, in particular due to refractory shock. however, we observed that about % of patients with a very severe metabolic acidosis survived to icu discharge with a good neurological recovery. introduction: precarious socio-economic status can directly influence health, need for hospitalisation and mortality, according to a previous study performed in european countries. similar findings have been reported from anglo-saxon countries in the setting of intensive care. due to the different structure of the healthcare system in france, we aimed to investigate whether socio-economic status influences initial severity of disease and months mortality in patients admitted to intensive care in france. patients and methods: prospective, multicentre, cohort study including adult patients admitted to one of participating intensive care units (icus) between and , and presenting failure of one or more major organs. patients were considered to have a precarious socio-economic status if they presented at least one criterion of social vulnerability or a high epices deprivation score. results: data on social vulnerability were available for patients, of whom . % were considered to be socially vulnerable. compared to non-vulnerable patients, socially vulnerable patients were younger ( . vs . years, p = . ), more frequently had chronic disease ( . vs . %, p = . respectively for congestive heart failure and . %vs . %, p = . for chronic respiratory disease), had higher levels of physical dependency ( . vs . %, p = . ), and were more often classed as having long-term health conditions ( . vs . %, p < . ). conversely, non-vulnerable patients had greater severity of disease at admission to the icu than those classed as vulnerable, both in terms of saps ii and sofa scores (respectively . vs . (p = . ) and . vs . (p = . )). findings were similar after adjusting for major confounders (adjusted odds ratio (or) . , % confidence interval (ci) [ . - . ], p = . ). mortality at months was not significantly different between socially vulnerable patients and those not considered vulnerable, respectively . vs . % (p = . ), even after adjustment for initial severity. conclusion: despite less severe disease at admission to the icu among patients considered socially vulnerable, -month mortality did not differ significantly between those who were socially vulnerable and those who were not. these findings suggest that the french healthcare system provides good protection for the most disadvantaged members of society, particularly when they are admitted to the icu. introduction: an approach of the quality of care may involve assessing the patients' satisfaction. however, the extended caregiverpatient and family relationship, specific to the critically ill patients, may also require to assess the proxies' satisfaction. the opinionfamily tool was developed to assess the satisfaction of the critically ill patients' proxies, in an anonymous and continuous fashion. we conducted a study in the icu of tenon hospital (paris, france) between mars and august . the opinion-family questionnaire, built with categories ( items each), aimed to measure the proxies' satisfaction regarding their perception of the quality of care. all the proxies were invited to express voluntarily and anonymously his her degree of agreement as a response to a statement by the selection of the corresponding stars (strongly disagree- star, disagree- stars, neither agree nor disagree- stars, agree- stars, strongly agree- stars) using a secure touch screen disposed in the waiting room of the icu. results: altogether, patients were hospitalised during the study period, and proxies completed the questionnaire. all the responders spoke french. only responders ( %) answered more than one time. of the responders, ( %) were the referring person, ( %) were children and ( %) were spouses. during the study period, ( %), ( %), and ( %) responders had visited their relative to times, to times, and more than times, respectively. the different categories assessed by the opinionfamily tool were related to «the family and the patient» (fig. a) , «the family and the environment» (fig. b) , and «the family and the caregivers-availability, trust, support, and information» (fig. c) . the corresponding levels of satisfaction (responses of at least stars) were respectively , , , , , and %. some items were associated with a poor satisfaction (participation to the care, identification and availability of the caregivers). conclusion: the implementation of the opinionfamily tool allowed a continuous evaluation of the satisfaction of the critically ill patients' proxies. a systematic implementation of this tool in the icus may be useful to the caregivers for a better understanding of the needs of the proxies. in addition, this tool may allow rapid changes in icu organizations and behaviours to improve the proxies' satisfaction, which may ultimately, improve the care of patients. many factors influence end-of-life decisions (eol). we describe eol decisions in patients with acute respiratory failure and their impact on patients' prognosis. patients and methods: an international observational study included all patients with acute respiratory distress over a -month period. icu in countries were involved. demographic, clinical and biological data were compared between patients with and without decision of lst limitation. we also compared surviving patients after lst limitation decision to those who eventually died. results: among the patients, mortality was . %. a decision of lst limitation was reported in patients ( . %). in univariate analysis, patients with lst limitation decision were older and more frequently hospitalized for a medical condition, had a lower body weight, a higher sofa score, and presented active neoplasia immunosuppression or chronic liver failure more frequently (p < . for all). patients admitted after trauma, drug overdose or pulmonary contusion were less subject to have an lst limitation decision (p < . ). in contrast, patients with non-cardiogenic shock were more subject to these decisions (p = . ). eol decisions were less frequent in lower-middle income countries as compared to high and middle-high income countries (p < . ). multivariate analysis will be presented. among patients with an lst limitation decision, survived ( . %). mortality was higher in this group than in the whole study population (p = . ). in univariate analysis, death after decision of lst limitation was associated with admission for a medical condition (p = . ), severe ards, higher inspiratory pressure, non-cardiogenic shock, higher sofa score with or without respiratory component and chronic liver failure (p < = . for all). on the contrary, admission for trauma was associated with survival (p = . ). regarding the patients who died during their hospital stay, did not receive a decision of lst limitation ( . %). decision of lst limitation was more frequent in older patients (p < . ) and in high-income countries. conclusion: decisions of lst limitation are frequent in the icu, and are associated with increased age and medical severity. however, a significant percentage of these patients survived. interestingly, almost half of the patients who eventually died during their hospital stay had not been subject of a decision of lst limitation. evaluation of the decision-making process leading to a decision not to readmit a patient to the intensive care unit during a same hospital stay introduction: the risk-benefit ratio of (re-)admission to the intensive care unit (icu) has been widely discussed in the literature. however, the ethics of non-readmission during a single hospital stay have not been widely addressed. a decision not to re-admit a patient to the icu could be seen as a limitation of therapy, thus falling within the scope of the law dated april , by denying the patient access to potentially-available healthcare resources. in this context, we aimed to-( ) investigate whether decisions not to re-admit patients to the icu are taken in accordance with french legislation + and ( ) identify the characteristics of patients concerned by this type of decision. patients and methods: this study was based on data from the prospective, multicentre ivoire cohort (influence of socio-economic vulnerability on initial severity and prognosis of patients admitted to the icu + phrc-ir ). we identified patients included in two large regional university hospitals in the east of france for whom a decision not to re-admit was taken during a single hospital stay. the decisionmaking process was evaluated based on a questionnaire comprising items developed by a sociologist from semi-directive interviews with clinicians. results: among patients discharged from the icu alive, a decision not to re-admit to the icu during a same hospital stay was noted in the medical file of patients ( . %). this decision was primarily made on the day of discharge ( . %), and those involved in the decision included-the family, an outside consultant, and the patient themselves in , . and . % of cases respectively. the decision was justified in medical terms in . % of cases, and the main reasons cited were-( ) therapeutic impasse ( . %) + ( ) comorbidities ( . %) + ( ) degree of dependence of the patient ( . %). patients concerned by decisions of this type were generally older ( vs . years, p < . ), with more comorbidities (median vs , p = . ), greater loss of dependence according to katz's activities of daily living ( vs , p < . ), and longer duration of life-sustaining therapies ( . vs days, p = . ). conclusion: although the profile of the patients identified in this study likely justified the decision not to re-admit the patient to the icu, there is room for improvement in the decision-making process. introduction: most of organ donors are brain dead patients. in some cases, patients are identified as potential donors before brain death and will undergo intubation and mechanical ventilation for the sole purpose of awaiting brain death. the aim of this study is to evaluate the practices of professionals in charge of potential donors. (table ). in this case, the issue of organ donation was addressed to the relatives before intubation by % of icup and % of non icup (p = . ). % of participants never addressed organ donation before the brain death. for the % who have done so at least once, organ harvesting never happened in % of cases. legitimacy and difficulties ( table )- % of respondents felt that when a decision of treatment withdrawal or withholding is taken, the patient should not go to icu for any reason and % think that these patients should be allowed to die "quietly". the prospect of an extubation if brain death does not occur or in case of organ donation refusal is a problem for % of icup and % of non icup (p = . ). % of icup and % of non icup think they would need to receive training. conclusion: this study shows that pursuing mechanical ventilation for the sole purpose of awaiting brain death and organ harvesting is a common practice, and that intubating a patient for this purpose alone is done in most of cases but could still be more generalized. on the other hand, information to the relatives should be improved. - . ] . the effect of pp on the monitored parameters varies significantly between each patient but also between each session for the same patient. in positive responders, the effect continues statistically for to h depending on the parameter studied- . h for vd vt, . for phase slope, for petco and for cdyn. the maximum effect of prone positioning on selected parameters seems to be obtained after h of therapy. the acute respiratory distress syndrome (ards) is characterized by lung infiltration with activated neutrophils. neutrophil extracellular traps (nets) are antimicrobial structures released by neutrophils. nets have also been associated with tissue damage in experimental models of acute lung injury. whether nets are involved in the pathogenesis of human ards and could be a potential therapeutic target is unknown. we aimed to quantify alveolar nets production in patients with pneumonia and ards and assess its relationship with outcomes. patients and methods: prospective monocentric study. patients admitted in the icu in with pneumonia and moderate severe ards were included. immunosuppressed patients were excluded. nets (dnamyeloperoxidase) levels were measured by elisa in broncho-alveolar lavage (bal) fluid and serum samples of ards patients and in those of control patients (n = ). patients with higher and lower bal fluid nets levels were compared using the median as a cutoff value. results: thirty-five patients with bacterial (n = ), viral (n = ) or non-microbiologically documented (n = ) pneumonia and ards were included. nets levels were significantly higher in bal fluid than in blood of ards but not of control patients (fig. introduction: the ratio of arterial oxygen partial pressure to fractional inspired oxygen (pao fio or p f) is daily used to assess patients' evolution under ventilatory support. some studies reported the reliability of percutaneous oxygen saturation (spo ) to appreciate pao easy to get on bedside. thus two equations have been proposed-rice equation and ellis equation. however, no large prospective study assessed the reliability of such equations to estimate the p f at the bedside in real conditions. using the spectrum (severe hypoxemia-preva-lence, treatment and outcome) study, we aimed to evaluate the reliability of spo obtained by rice and ellis equation. this study is a planned companion of spec-trum study, a recent prevalence-point-day conducted by the srlf trial group in french-speaking icu aiming to report the patterns and outcomes of hypoxemic patients (defined by p f < mmhg). we included in the analysis all patients under mechanical ventilation with spo < % (according to limit of the rice study). spo and fio were measured simultaneously to arterial blood gas were drawn. results: among patients of the spectrum study, were on mechanical ventilation and had undergone arterial blood gas with simultaneously recorded spo and fio . of note, p f was < mmhg for + between and for + and between and for . pairwise correlations of truth p f with estimated p f was good (rice-spearman's rho = . , p < . -ellis-rho = . p < . ). bland-altmann test showed an important variability of results (p f vs rice (figure) - . ± . -p f vs ellis- . ± . ). the variability decreased with lower p f. caution may be used to interpret our results because we did not reported the quality of spo signal at the bedside. conclusion: regarding the variability of the results, whatever the used equation, caution may be used to predict the p f by the spo fio ratio in patients under mechanical ventilation. introduction: morbid obesity and ards both affect respiratory mechanics mainly through their respective impacts on chest wall and lung elastances. we present a unique series of patients combining very severe morbid obesity and moderate to severe acute respiratory distress syndrome (ards). we describe the use of trans-pulmonary pressures (tpp) measurements for optimization of external peep setting. patients and methods: the monocentric observational study was performed in morbidly obese patients admitted for moderate to severe ards. we performed an incremental peep trial ( cm h o steps) with tpp measurement (nutrivent probe, sidam, italy) in a semirecumbent position as previously described. a decremental peep trial after a recruitment maneuver was not performed since the safety of such a maneuver in this specific population is largely unknown. we defined two ways for determination of external peep setting-( ) peep necessary to obtain a positive expiratory tpp and ( ) peep necessary to obtain a plateau pressure between and cm h o (maximal alveolar recruitment express strategy). data are expressed as numbers (%) and medians (interquartile range). statistical analysis was made using the xlstat software. results: we enrolled during years morbidly obese patients (bmi (ir - )) admitted for a moderate to severe ards. clinical characteristics are displayed in table . the express strategy indicated a peep setting of cm h o (ir - ) whereas tpp-guided peep was cm h o (ir - ), p = . . driving pressure was higher in the express strategy peep setting ( . cm h (ir - )) than in the tpp-guided peep ( . cm h (ir . - )), p = . . tpp-guided peep setting was higher than indicated by the express strategy in all but one patient. one patient suffered from transient hypotension when external peep was set at cm h o, while no patient displayed an inspiratory tpp higher than cm h o. additional data will be provided during the meeting-pressure-volume curve at zeep ( patients), crf measurements ( patients) and abg and capnometry values at each peep level ( patients) . in our ards patients with extremely severe obesity, an incremental peep trial with tpp measurements appeared to be safe and indicated a peep setting significantly higher than for the commonly-used ards strategies. such an approach deserves further comparisons with other modalities of monitoring, such as crf measurements, eit studies, etc. severe poisoning by cardiotoxic drugs and circulatory assistance: -year experience at french university hospital tardif elsa , conil jean-marie , georges bernard , marcheix bertrand , crognier laure , bounes fanny , delmas clement chu rangueil, toulouse, france correspondence: tardif elsa -tardif.elsa@gmail.com annals of intensive care , (suppl ):f- introduction: toxicity from cardiac drugs is associated with a large number of fatalities, significant morbidity and healthcare consequences. severity of these poisonings can be explained by a refractory cardiogenic shock not responding to optimal conventional treatment. criteria of circulatory assistance indications remain unclear. the aim of the study was to describe and to compare patients intoxicated by cardiotoxic drug treated with or without veno-arterial extracorporeal membrane oxygenation (va ecmo). patients and methods: retrospective cohort study conducted at french university hospital. all patients intoxicated with cardiotoxic drugs between january and march were included. patients were divided into groups-with and without va ecmo. results: among the patients included in the study, patients were treated with va ecmo ( %) and patients with conventional therapies. ecmo was respectively employed for refractory shock and cardiac arrest in and cases, all patient required vasopressor support. in-hospital mortality was . % and was significantly higher in the ecmo group ( . %). beta-blockers with membrane stabilizing activity and non-dihydropyridine calcium channel blockers poisoning were the most commonly reported in the ecmo group. mean time from hospital admission to initiation of ecmo was h and the average ecmo duration was . days [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . no serious adverse reaction was reported during this period. results expressed in median value ± confidence interval conclusion: refractory cardiogenic shock following cardiotoxic drug poisoning requiring circulatory assistance is associated with significant mortality. even if its use seems justified by the literature, the implantation criteria must be specified and this after an optimal conventional treatment to prevent multiple organ failure. the cdv of patients in the edass group was significantly higher (p < . ) at all-time points after the introduction of catecholamines than among those without edass, as early as h from catecholamine initiation (fig. ) . a strategy in two steps (cdv > µg kg at h and or cdv > µg kg at h) was able to predict edass with sensitivity of %, specificity %, positive predictive value % and negative predictive value %. overall, this two-step strategy identified high-risk patients at h, of whom presented edass. conclusion: overall, our results confirm that early death directly attributable to septic shock could be effectively predicted by the cdv in the first hours of treatment. these results will help to select patients eligible for innovative therapies aimed at improving early mortality in septic shock. introduction: in patients with cardiac arrest, end-tidal co (etco ) has been proposed to monitor the efficacy of cardiopulmonary resuscitation (cpr) but uncertainty persists on its interpretation. we hypothesized that exhaled co may also by affected by occurrence of "lung airways" collapse previously noticed during cpr. because this closure may possibly also limit oxygenation + analysis of the entire exhaled co time waveform-may give information of high clinical value to manage cpr. we report preliminary results from a clinical and bench study aimed at describing the pattern of the capnogram during cpr. induces a systemic inflammatory response associated with an immune dysregulation and a significant pulmonary dysfunction which has been well characterized. surprisingly, there are only a few data available on immunological changes induced by ecls. we believe that ecls leads to immune dysfunction that could expose patients to nosocomial infections. patients and methods: a two-phase study was lead. first we analyzed blood cell count with differential (including lymphocyte, neutrophils and monocyte counts) in all patients who received ecls in our institution from to within the first week following ecls initiation. secondly, monocytes, granulocytes, dendritic cells and lymphocytes function were assessed at day , day and day using flow cytometry and functional tests in patients receiving ecls and compared to patients with cardiogenic shock without ecls. results: among patients with elcs we found an early and persistent lymphopenia and a late neutrophilia (found to be associated with poor outcome in critically ill patients). compared to control (n = ), we found in patients who received ecls (n = ) a significant increase in immature granulocytes ( . ± . on day one versus . ± ± , p = . ) and lymphocytes apoptosis. ecls induced changes in myeloid derived suppressors cells proportion ( . % ± . on day three versus . % ± . before ecls, p = . ), which has been recently associated with a higher incidence of nosocomial infections and seems to be major actors of sepsis-induced immune suppression. complement component a receptor (c ar) from the neutrophil cell surface, was also decreased after ecls initiation (ratio of mean fluorescence index . ± . on day one, p = . ) which is a sign of complement-induced neutrophil dysfunction in septic patients. conclusion: ecls induces quantitative and qualitative leukocytes dysfunctions that can lead to a greater susceptibility to nosocomial infections which contribute to the poor outcome observed in several studies. introduction: aspiration pneumonia is a common complication of cardiac arrest. although its real incidence remains undetermined, probabilist antibiotherapy is frequently or even systematically prescribed in these cases. we assessed the incidence of out-of-hospital cardiac arrest-related aspiration pneumonia and the impact of a microbiological documentation in regard to antibiotherapy course. patients and methods: all patients admitted for out-of-hospital cardiac arrest from to were studied. in our icu, aspiration pneumonia is suspected when a clinical syndrome (fever, per resuscitation constatation) and or chest radiography infiltrates were present. in case of suspected aspiration pneumonia, a microbiological documentation was performed before initiation of probabilist treatment with amoxicillin-clavulanate. we retrospectively defined if patients have aspiration pneumonia using the following criteria-per resuscitation constatation, chest radiography infiltrates, fever. the number of microbiological documentation leading to an antibiotherapy modification was recorded as well as pathogens types. data are expressed as numbers (%) and medians (interquartile range). statistical analysis was made as appropriate using the xlstat software. results: patients were studied. clinical characteristics are displayed in table . ( ) received a probabilist antibiotherapy and ( ) were retrospectively considered with aspiration pneumonitia. results of microbiological documentation were ( ) positive microbiological sample and ( ) with a positive threshold whose ( ) were considered colonized (i.e. no clinico-radiological sign). on the entire positive culture sample, ( ) were positive with oropharyngeal flora as unique pathogen, ( ) introduction: this study aimed to assess whether augmented renal clearance (arc) impacts negatively on piperacillin-tazobactam pharmacokinetic pharmacodynamics (pk pd) target attainment in critically ill patients receiving g day by continuous infusion. patients and methods: over an -month period, all critically ill patients treated by piperacillin-tazobactam for a suspected or documented sepsis without renal impairment were eligible. during the first three days of antimicrobial therapy, every patient underwent -hour creatinine clearance (crcl) measurements and therapeutic drug monitoring at steady state. the main pk pd outcome investigated in this study was the rate of empirical target non-attainment using a theoretical target mic of mg l − for piperacillin and mg l − for tazobactam. the secondary clinical outcome was the rate of therapeutic failure in microbiologically documented infections, defined as an impaired clinical response with a need for escalating antibiotics during treatment and or within days after end-of-treatment. over the study period, patients were included in the primary pharmacological analysis and in the secondary clinical analysis. using a mic of mg l − for piperacillin, the rate of empirical target non-attainment in the overall population was %, with a strong association with crcl ( fig. introduction: invasive fungal infections are a major burden in solid organ transplantation, especially in patients receiving liver graft. however, their incidence has decreased thanks to the development of an antifungal prophylaxis in the post-transplantation period. in patients at high risk of invasive fungal infection (ifi), this strategy is recommended, whereas its benefit remains controversial in low-risk patients. however, there is no clear definition of these two patients groups. our aim was to provide recent data on epidemiology, mortality and ifi risk factors in the early post-operative course in a population without any antifungal prophylaxis. results: the number of beta-lactam antibiotics was . of these requests, half were for piperacillin ( . %), and onethird were for amoxicillin ( . %). the other dosages were mainly for cloxacillin, cefepime, cefotaxime and ceftriaxone. the results confirmed that serum concentrations of piperacillin ( . ± . vs . ± . mg l − < . ) and amoxicillin ( . ± . vs ± mg l − < . ) significantly were higher in patients with neurological disorders or wakefulness delays. the roc curves allowed the predictive values associated with the presence of neurological disorders attributable to antibiotic treatment, corresponding to residual serum concentrations of piperacillin of mg l − and amoxicillin of mg l − . a predictive value for neurological disorders of these concentrations is proposed for residual serum concentrations greater than mg l − for both antibiotics ( % specificity and sensitivity). conclusion: our results suggest that there is an association between a residual concentration of piperacillin and amoxicillin greater than mg l − and the occurrence of neurological disorders. pharmacological therapeutic monitoring of beta-lactams in critically ill patients may be a useful intervention to optimize the antibiotic regimens and to avoid antibiotic-related toxicities. ( ) ( ) ( ) ( ) ( ) . patients with a gnb-bsi were included and were divided into two groups according to the resistance (r) profile (bsi due to a r isolate or not). the following resistances were considered-all gnb-bsi including pseudomonas spp., acinetobacter spp., stenotrophomonas spp. and enterobacteriacae (eb) for which the following antimicrobial resistances were considered-ticarcillin and ceftazidime (cefta) (pseudomonas (pa)), third generation cephalosporin ( gc) (eb) and imipenem (all gnb). after variable selection using random forest and univariable mixed logistic regression models, a multivariable analyses using a mixed model with a random effect (center). sub-group analyses were performed according to species (pa and eb) and resistance for eb. results: from , patients admitted in an annual median of french icus, experienced an icu-acquired (> h.) bsi, ( %) bsi due to gnb, including ( %) bsi due to r isolates. pa was identified in ( %) (mdr-pa bsis ( %)) and eb in ( %) (mdr-eb bsis ( ( %)). the raw mortality rate was % in the overall population and % in the patient with gnb bsi. it was significantly higher for r gnb bsi ( vs % for susceptible gnb bsi, p < . ). after adequate adjustment in a multivariate analysis, we showed that r-gnb bsi was significantly associated with mortality compared to susceptible strains (fig. ) . by considering species subgroup, the effect was not significant for resistant pseudomonas aeruginosa (p = . ) but remained significant when considering only eb. considering eb resistance, the impact of gc r showed a trend to an increased mortality risk whatever there was no effect of imi r (n = ( %)) on prognosis. limitation-the absence of information about antibiotic consumption may partly explain the remaining significant center random effect in the final models. conclusion: in a large french database, after adequate adjustment on prognostic factors, resistant bgn-bsi was associated with a higher icu mortality than susceptible one. the effect was mainly due to eb gc r. severely injured group versus . ± . days for the non-severely injured patients (p < . ). in multivariate analysis, heart rate (> min) and vittel score (≥ criterias) were related to the probability of belonging to the severely injured group (p = . ). the -hour mortality rate was . % in the ed and the -day mortality rate was . %. the development of a network in the ed hosting non vital polytraumas remains crucial. its primary goal will be to meet technical and time requirements and establish in-hospital triage algorithms based on clinical variables, in order to detect these patients at an early stage and offer them priority care in our overcrowded eds. introduction: the trauma of traffic accidents and particularly cranial trauma are, due to their frequency and severe consequences in both the short and long term, a real public health scourge on a global scale. studies of the epidemiology of cranial trauma by traffic accidents and their prognosis are rare at least in underdeveloped or developing countries. in addition, the impact of extracranial lesions on cranial trauma prognosis has long been discussed. the purposes of our study were to examine the epidemiological aspects and to determine the factors correlated to the immediate and distant prognosis of isolated cranial trauma. patients and methods: retrospective cohort spread over years (from to ) and including patients with isolated cranial trauma by traffic accidents (mean age . years, sex ratio- ). we proposed to study the factors correlated with a poor prognosis in terms of death in hospital and glasgow outcome scale (gos) at months unfavorable in dual analysis (univariate and then multivariate). for the gos study, patients were divided into groups-gos favorable for patients with good recovery (gos = ), recovery with a light handicap (gos = ), gos unfavorable for those having survived with a severe disability (gos = ), a vegetative or pauci-relational state (gos = ) and those who died (gos class ). results: hospital mortality was % and the gos at months was distributed as follows: death ( . %), vegetative state ( . %), severe disability ( . %), mild disability ( %) and good recovery ( . %). the -month gos was deemed unfavorable in . % of the cases. various after effects were observed in survivors: physical ( %) dominated by headache ( . %), sleep disorders ( . %) and epilepsy ( . %); memory disorders ( . %) or concentration ( . %) and finally emotional after effects ( . %) with irritability ( . %) and aggressiveness ( . %). in multivariate statistical analysis, independent predictors of mortality were arterial hypotension, hypoxia extradural hematoma (edh),, acute subdural hematomas (sdh), diffuse axonal injury and ventilator associated pneumonia. those correlated with an unfavorable gos were an age ≥ years, hypotension, cerebral edema, coma duration ≥ . days, edh and h glucose ≥ . mmol/l. conclusion: although the short-term prognosis of head trauma seems to be improved at present, the long-term consequences of cranial trauma remain fairly frequent, and often underestimated, which underlines the importance of their screening and their proper care. the average age of the survivors ( . ± . years) was lower than the mean age of the deceased ( . ± . ). ra was the cause of the trauma in % of the cases followed by the fall found cat % of the patients. prehospital care only concerned % of patients. the univariate analysis showed that the main factors of occurrence of death were age (p = . ), glasgow score (p = . ) anisocoria (p = . ), shock (p = . ) % of deaths were due to intracranial hypertension, haemorrhagic shock in % of patients and ards in % of polytrauma patients. conclusion: the management of polytrauma can not be improvised. the medical teams must be coordinated by an emergency physician in prehospital, a doctor anesthesiologist-resuscitator at the reception. some systematic gestures such as preparation of the reception allow to optimize the management of the time. introduction: benign cranial trauma is a major public health problem due to both its frequency and the health costs it creates. the aim of this study was to identify relevant clinical factors that could predict the achievement of brain ct and situations at risk for neurosurgical care and for which ct was a necessity. patients and methods: this is a month prospective study, including patients with benign traumatic brain injury (glasgow coma score gcs ≥ ), patients under years of age and patients with gcs < were excluded. epidemiological, clinical, paraclinical, therapeutic and evolutionary parameters were studied. a multivariate and univariate statistical study was carried out to reveal the predictive factors of a ct anomaly and the predictive factors for the neurosurgical care. data were entered and analyzed using spss . and excel software. results: the average age of patients was years with a predominance of male, and sex ratio of . . the cause of the btb was mainly represented by the accidents of the public road in . % of the cases. . % of the patients were asymptomatic, the most common symptomatology was dominated by the initial loss of consciousness ( . %), headache ( . %). the glasgow coma score was distributed as follows-gcs ( . %), gcs ( . %) and ( . %). . % of patients had clinical signs of trauma to the skulland or face. brain ct was performed in . % of patients, and . % had abnormal ct. the use of neurosurgical care was of the order of . %. in univariate analysis-the predictive factors for a ct abnormality were the intoxication during the brain trauma, the gcs < , signs of trauma in the skull face, the vomiting, the initial loss of consciousness, the comitial crisis and the predictive factors of neurosurgical care were the gcs < , the anisocoria, headache, the vomiting, the amnesia, the initial loss of consciousness, the comitial crisis, the anormal ct, the extradural hematoma or the subdural hematomat in multivariate analysis-the predictive factors for a ct abnormality were the gcs < , the initial loss of consciousness and the predictive factors for the use of neurosurgical care were the gcs < , signs of trauma in the skull face, the amnesia, the comitial crisis, the hsd. conclusion: an algorithm must be applied in collaboration between resuscitators and neurosurgeons to improve the quality of benign cranial trauma management. prognostic value of hyperchloremia in patients with traumatic brain injury: a prospective observational study taghouti introduction: background-traumatic brain injuries (tbi) are a major public health problem. they are the leading cause of death among those aged less than years. hyperchloremia is a common electrolyte disturbance in patients with tbi. hyperchloremia has been associated with increased morbidity and mortality in critically ill patients + however, its prognostic significance in tbi patients is poorly documented. the aim of this study is to describe the prevalence and outcomes of hyperchloremia in patients with tbi admitted to the intensive care unit. patients and methods: in a prospective design, we included consecutive patients with tbi ( males + median age- years) admitted to the icu in charles nicolle hospital of tunis from mars to september . adult patients (aged ≥ years) with isolated tbi or associated with minor extra-cranial injuries (defined as all non-head abbreviated injury scale < ) were included. hyperchloremia was defined as a chloride level > meg/l. clinical and laboratory variables were compared between survivors (n = ) and non-survivors (n = ). we assessed the association between hyperchloremia -h post-admission and -day mortality. p < . was taken to indicate statistical significance. results: the median sofa score at t was points and the median igs score was points. the median iss was points. there were cases of mild head injury, moderate head injury and severe head injury. the -day mortality was %. hyperchloremia occurred in patients ( %) and the incidence was significantly different between survivors and non-survivors ( vs. %, respectively, p < . ). in addition to hyperchloremia (p = . ), other laboratory variables were associated with -day mortality-hypernatremia (p = . ) and hypoalbuminemia (p = . ). conclusion: hyperchloremia -h post-admission was associated with -day mortality in patients with tbi. this index could be useful prognostic marker. efforts should focus on the prevention of hypernatremia and hyperchloremia in this vulnerable group of critically ill patients. child traumatic brain injury naili amine blida rp, algÉrie correspondence: naili amine -drnailiamine@yahoo.fr annals of intensive care , (suppl ):p- introduction: brain injury in children is common and mild in most cases, but it remains the leading cause of death and disability in children over year of age worldwide. the peculiarity of the child is that he possesses not mature brain and that the consequences of injuries acquired by traumatic brain injury can lead to the loss of capacities, as well as the non-acquisition of function, but above all the risk impact on learning abilities. the objective of the study is to define the incidence rate of cranial trauma in children as well as the mortality and morbidity of this scourge which presents a major public health problem. patients and methods: it is a descriptive retrospective study of a series of children hospitalized in neuro-resuscitation service during the period january to december , , including children admitted for cranial trauma. clinical, para-clinical, etiological and therapeutic data were collected from hospitalization records. results: in a series of children hospitalized during the defined period, children were admitted for cranial trauma, i.e. a frequency of %. the average age was years [ h of life- years], with a sex ration of among the children, had severe head trauma, a rate of % + whose causes are variable- road accidents, domestic accidents, traffic accidents, and obstetric accident, admitted with a pediatric glasgow score between and , and all required mechanical ventilation of the head trauma, were operated for different lesions- extra-dural hematomas, cranio-cerebral wounds, subdural hematomas, decompressive craniectomy, and embarrure. children had died following severe head trauma, i.e. a mortality rate of %, the morbidity rate of head trauma in the tipaza wilaya was . , children year, the average length of stay in intensive care units was days, with several complications of decubitus, and functional due to the primary and secondary lesions of the cranial trauma. the head trauma of the child is a public health problem, its functional prognosis can be dramatic when it is severe, its management must be early and multidisciplinary. introduction: the aim of the study was to identify factors predicting lung contusion in trauma children. patients and methods: retrospective study conducted for a period of years (january , -december , ) in a medical surgical intensive care unit. all trauma patients younger than years were included. two groups were compared-those with lung contusions (c + group) and those without lung contusions (c − group). results: we included patients. the mean (sd) age was . ( . ) years. chest injury was diagnosed in patients ( . %). all our patients needed mechanical ventilation. lung contusions were diagnosed in patients ( % of all patients and . % of patients with chest trauma). in multivariate analysis, independent factors predicting lung contusion were road traffic accident (odds ratio [or], . + % confidence interval [ci], . - . + p = . ), increased pediatric risk of mortality (prism) score (or, . + % ci . - . + p = . ), hepatic contusion (or . + % ci . - . + p = . ), and pelvic ring fracture (or, . + % ci . - . + p = . ). death occurred in patients ( . %). intensive care unit mortality was significantly higher in the c + group (or, . + % ci . - . + p = . ). however, mortality was not differentbetween the groups after adjusting for prism score (or, . + % ci . - . + p = . ) or after adjusting for injury severity score (or, . + % ci . - . + p = . ). conclusion: lung contusion is common in critically ill children with chest trauma. the diagnosis should be considered in patientswith road traffic accident, increased prism score, hepatic contusion, and pelvic ring fracture. introduction: chest trauma is often associated with pleural effusion (hemothorax and or pneumothorax). drainage of the pleural space by a chest tube is a common intervention in such situations. blunt dissection technique with a kelly clamp is preferred to classical trocar techniques to prevent severe complications, like perforation of thoracic or abdominal organs. despite these precautions, malposition remains the most common complication of tube thoracostomy. we investigated a new technique of bougie-assisted chest tube insertion to prevent chest tube malposition after chest drainage of post traumatic pleural effusion. patients and methods: we performed a controlled before-and-after study to assess the ability of a bougie-assisted chest tube insertion technique, compared to a standard blunt dissection technique, to prevent chest tube malposition. for the bougie-assisted group, we used a disposable eschmann-style bougie, commonly used to guide the endotracheal tube during difficult intubations. technique consisted in blunt dissection until the parietal pleura is opened. thoracostomy tube was preloaded onto the bougie and bougie was advanced alongside the finger, with apical or caudal direction after entering the chest cavity, depending on the type of pleural effusion. thoracostomy tube was then advanced forward utilizing a seldinger technique. the primary end point was optimal position of the chest tube. the tube position was blindly assessed on standard chest x-ray. in pneumothorax, optimal position was apical (above the aortic arch), and in hemothorax or mixed-effusion it was basal ( cm above the diaphragm or lower). results: a total of patients were enrolled (bougie-assistedn = + conventional-n = ). chest tubes were optimally position in ( %) in bougie-assisted group and ( %) in conventional group, or . , ic % = [ . - . ], p < . . efficacy of chest drainage (defined on chest x-ray as the absence of visible pleural line for pneumothorax and as a clear costophrenic angle for hemothorax) was assessed in ( %) in bougie-assisted group and in ( %) in conventional group, or . , ic % = [ . - . ], p < . . average procedure time was s ( % ci - s) for bougieassisted group and s ( % ci - s) for conventional group, p < . . no severe complication was observed in both groups. conclusion: bougie-assisted chest tube insertion technique prevents chest tube malposition, is safe, effective and shortens procedure time for the post traumatic pleural effusion drainage. introduction: infectious complications determine the prognosis of burned patients. however, the emergence of bacterial resistance to antibiotics threatens treatment efficacy, which is due to an inadequate antibiotic consumption inqualitative and quantitative terms. the objective of this study was to describe the profil of consumptionand susceptibility to antibiotics. and, to explore the predictive factors for theemergence of mrb in the service of burns and plastic surgery. patients and methods: it is a retrospective study including severe burnedpatients hospitalized for years in the plastic surgery department of theuniversity hospital ibn rochd from january to december . bacterialecology was described, and the distribution of the seeds by group, by species andby period of time was detailed. the ddd jh (daily defined dosage reportedin days of hospitalization) was used to assess the consumption of antibiotics. p correlation coefficients were calculated to explore the association betweenconsumption of antibiotics and the emergence of the bmr (multiresistantbacteria), and identified predictors of this emergence. results: on samples taken, bacterial and fungal strains were identified, with a predominance of p. aeruginosa ( . %), a. baumani i ( %) and s. aureu s ( %), the number of strains increased with the duration of the stay reaching itsmaximum from days in hospital. the ceftazidine ( . ddd dh), imipenem ( . ddd dh), and amikacin ( . ddd dh) were themost used antibiotics during our study, also + the profile of consumption increasedbetween and . bmr were isolated + the eblse were at the top ( . %) follow up of thecrpa ( . %), followed by the irpa ( . %) follow-up of the crab ( . %) then the irab ( . %) and finally the mrsa with a portion of . %. the profile of bacterial resistance has varied significantly for severalantibiotics bacteria pairs. conclusion: it remains difficult to show correlations between antibioticconsumption and bacterial resistance. however, these data are particularly usefulin the epidemiological surveillance of bacteria to better guide probabilisticantibiotic therapy. introduction: eclampsia is a rare but serious threat to maternal and fetal well-being. the aim of this study was to assess the incidence of eclampsia and its morbidity and mortality. patients and methods: we conducted a retrospective survey in a third level tunisian university teaching hospital from january to december . we included all patients with the diagnosis of eclampsia. results: in study period deliveries were registered. women with eclampsia were identified hence the incidence of eclampsia was . per deliveries. the median gestational age at the time of eclampsia was weeks. no maternal deaths due to eclampsia were recorded. the delivery mode was caesarean section in % of eclamptic patients. the recurrence of eclampsia despite magnesium sulfate prevention was observed in % of patients. severe complications of eclampsia were recorded in . % of patients- posterior reversible encephalopathy syndrome, acute pulmonary edema, and hellp syndrome. . % of new born were preterm. there were stillbirths and neonatal deaths. conclusion: the incidence of eclampsia was very high probably due to center effect. it's essential to raise awareness among mothers in the community regarding early signs and symptoms of preeclampsia eclampsia and to design a better tracking system for antenatal care program. introduction: to monitor maternal mortality which is an indicator of the quality of obstetrical care and anesthesia resuscitation, our country worked to set up several programs targeting maternal and child health. the aim of this work was-to evaluate the maternal mortality rate in our department and its evolution. to identify the cause of death and classify it depending on whether it is preventable or not. to spot the deficiencies either in the care management or the organization of the care system. to propose ways to improve our care and to fill the failures. patients and methods: it was a retrospective study about maternal death, performed at the department of gynecology and obstetrics, over a -year period (from to ) , that have reported cases of maternal death according to the world health organization definition. results: the maternal mortality rate (mmr) was . for every , live births. the average age of our patients was . years. the main risk factors for maternal mortality are unfavorable socioeconomic conditions, high-risk pregnancies, multiparity, primiparity and a poor follow-up of the pregnancy. the main causes of maternal death are represented by direct obstetric causes ( %) allocated as followspostpartum hemorrhage ( %), pregnancy toxemia ( %), acute fat hepatic steatosis ( %), infection ( %) and complications of anesthesia ( %). indirect obstetric causes were found in % of deaths. death was considered avoidable in . % of cases. conclusion: at the end of this work, we were able to pull several recommendations in order to reduce m.m.r. health education. facilitate access to care for the parturient, improve care and conditions of childbirth. continuous training of the medical and paramedical staff. introduction: mechanical ventilation can help improve the prognosis of sepsis. while adequate delivery of oxygen to tissue is crucial, hyperoxemia may be deleterious. invasive out-of-hospital ventilation is often promptly performed in life-threatening emergencies. we propose to determine whether the arterial oxygen pressure (pao ) at intensive care unit (icu) admission affects mortality at day (d ) in patients with septic shock subjected to mechanical out-of-hospital ventilation. patients and methods: we performed a monocentric retrospective observational study on patients with septic shock admitted to the icu. pao was measured at icu admission in patients subjected to invasive ventilation before any hospital admission. the primary outcome was mortality at day (d ). results: forty-nine ( %) patients with septic shock were mechanically ventilated before any hospital admission and transferred to the icu. the mean pao at icu admission was ± and ± mmhg for alive and deceased patients at d , respectively. pao was significantly associated with mortality at d (p = . ). using a roc curve, the corresponding auc was . [ . - . ]. for a pao > mmhg, the or for mortality at d was . [ . - . ] (p = . ), whereas for a pao < mmhg, the or was . [ . - . ] (p = . ). conclusion: in this study, we report a significant association between hyperoxemia at icu admission and mortality at d in patients with septic shock subjected to pre-hospital invasive mechanical ventilation. the adjustment of the pao is a crucial prognosis factor in patients with septic shock subjected to invasive out-of-hospital ventilation to avoid the toxic effects of hyperoxemia. however, blood gazometry is hard to get in a prehospital setting. consequently, alternative and feasible measures are needed, such as pulse oximetry, to improve the management of prehospital invasive ventilation. introduction: nowadays, benefit of enhanced ct-scan in positive diagnosis of acute pulmonary embolism (pe) is well established. it also allows evaluation of pe's burden on the right heart and shows several signs of acute cor pulmonale (acp). objectives -we aimed to assess benefits of control ct-scan h after thrombolysis in acute pe. patients and methods: we retrospectively enrolled patients with confirmed pe whom have been thrombolysed between january and august and controled with an enhanced ct-scan h after thrombolysis. assessement criteria were: qanadli obstruction index; signs of acp-right ventricle diameter left ventricle diameter (rvd lvd) and paradoxical interventricular septum (ivs). non inclusion criteria were: lack of initial or control ct-scan. results: during the study period ( years and months) we admitted patients from whom patients had acute pe ( . %). very severe patients that were thrombolysed as rescue therapy without initial ctscan and those who died before control ct-scan were not included. we enrolled patients-high risk mortality pe (n = , . %) and intermediate high risk pe (n = , . %). mean age was years and sex-ratio was . . at admission, mean severity scores were . ± . for saps ii and . ± . for apache ii. evolution criteria are listed in table . conclusion: control ct-scan is highly useful h after thrombolysis. it allows evaluation of response to pharmacological thrombolysis of acute pe and shows significative resolution of arterial obstruction degree and signs of acp. in december , after cancellation of the budget for a christmas tree, the nurses and caregivers of the night team spontaneously made and hung christmas decorations in our intensive care unit to make patients and their families feel better. the context was difficult with controversies around secularity. the town of paray le monial had been forced to remove a nativity scene and the city of melun had been criticized for setting one up. so we found it important to assess the perception of the approach by patients and relatives. patients and methods: decorations -hand-colored patterns about christmas theme printed on a paper decorations brought by the staff or already possessed by the unit-christmas balls, garlands, silver stardecorations made with service equipment-christmas tree consisting of inflated non-sterile gloves, cardboard, figurative nativity scene without a recognizable figure in a cardboard box with cotton, bed sheet to simulate snow. evaluation -all visitors and conscious patients received an anonymous single choice questionnaire with numerical scale and free fields from december th to december st, . results: answers were received, including-no negative opinion. neutral answer by a person who had not noticed the decorations. positive or extremely positive opinions. no answer without data. the comments pointed out the originality, the good idea, the warm comforting side. some asked for more decorations. others found them sober. the results show the good perception of the spontaneous action by the patients and their relatives. there was no negative response, particularly offend persons. however, it is possible that relatives or patients with negative opinions did not dare to express themselves. the initiative demonstrated a good cohesion of the night paramedical team, encouraging the interns and the day teams to take part in the coloring of the decorations. the initiative was initially aimed at the wellbeing of the patients and their relatives. however it has enabled an activity similar to preventing psychosocial risks among the healthcare team, allowing them to adopt a positive attitude in their approach to care. in addition, no significant costs were incurred thanks to the use of cheap materials, mainly recycled cardboard and standard quality white paper. the spontaneous decoration of our intensive care unit by the night care team was very well received by the patients, their families and their relatives. the initiative also made possible to enhance team cohesion and to value it. the associated costs were negligible. ventricular contractions. bp monitoring revealed a greater diastolic bp throughout h as well as during night-time. systolic bp higher than mmhg during sleep time was observed in % of participants. the frequency of arrhythmias and blood pressure variability are correlated with the increase in work stress and conflicts. conclusion: our results highlight the extent incidence of arrhythmia and blood pressure variability during intensive care unit night's shift probably due to the increased neuroendocrine stress response. ( %) and qrs enlargement ( %). ami was responsible for a significantly deeper coma (p < . ) but fewer seizures than clo (p = . ). three patients ( %) died. based on a univariate analysis, factors associated with death were cardiac arrest onset (p = . ), elevated plasma lactate concentration (p = . ), low arterial ph (p = . ), reduced pao fio ratio (p = . ) and prothrombine ratio (p = . ), increased aspartate aminotransferases (p = . ), alanine aminotransferases (p = . ) and serum creatinine concentration (p = . ) as well as marked catecholamine infusion rate (p = . ). the pharmacokinetic study showed significant increase in ami ( h vs. h) and clo ( h vs. h) elimination half-lives in overdose compared to pharmacological conditions, highlighting the contribution of organ failure to the delayed elimination of both toxicants. conclusion: ami and clo poisonings did not disappear and are still responsible for significant morbidities and mortality. ami was responsible for deeper coma with fewer seizures in comparison to clo. ami and clo elimination half-lives were significantly prolonged in overdose due to organ failure. introduction: severe poisonings and fatalities have been attributed to buprenorphine (bup) despite its ceiling respiratory effects, mainly if abused in co-ingestion with benzodiazepines. we previously showed that diazepam (dzp) bup combination induces severe respiratory depression in the rat, while each drug by itself does not. the objective of this study was to investigate the mechanisms involved in this drug-drug interaction using c-bup pet imaging and diaphragmatic electromyography in the sprague-dawley rat. patients and methods: c-bup was administered intravenously, mg kg unlabeled bup intraperitoneally and mg kg dzp subcutaneously. pet acquisition started with c-bup pet injection, min after dzp or its vehicle (veh + n = group) administration. suv normalized time activity curves (tacs) were generated and c-bup binding potential [bpnd, i.e. the ratio of the total receptor density (bmax) on the equilibrium dissociation constant (kd)] were modeled in different brain regions using a simplified reference tissue model with cerebellum as reference region. dem, implanted under anesthesia days before the experiment, was recorded during min in rats receiving veh veh, dzp veh, veh bup or dzp bup (n = group). after filtering and half-wave rectification, the first min auc of diaphragm contraction and workload were determined and compared between the groups. results: tacs and c-bup bpnd were not different between the dzp bup and the veh bup groups in all studied brain regions. diaphragm contraction was significantly increased in the veh bup group in comparison to the dzp bup group (p < . ). diaphragm workload was significantly increased in the veh bup group in comparison to the dzp veh and the dzp bup group (p < . and p < . respectively). discussion: dzp did not affect the c-bup brain distribution and brain binding suggesting that dzp does not affect bup transport across the blood brain barrier and bup receptors density affinity. bup administration induced an increase in diaphragm contraction and workload. this increase was inhibited in the presence of dzp suggesting that dzp bup combination-induced respiratory depression is mostly related to dzp. conclusion: respiratory depression related to dzp bup combination results from a pharmacodynamic drug-drug interaction. introduction: since the banning of dextropropoxyphene from the market, overdoses and fatalities attributed to tramadol, a who step- opioid analgesic, have increased markedly. tramadol overdose results not only in central nervous system (cns) depression attributed to its opioid properties but also in seizures, possibly related to nonopioidergic pathways, thus questioning the efficiency of naloxone to reverse tramadol-induced cns toxicity. our objective was to investigate the most efficient antidote to reverse tramadol-induced seizures and respiratory depression in overdose. patients and methods: sprague-dawley rats overdosed with mg kg intraperitoneal (ip) tramadol were randomized into four groups to receive solvent (control group), diazepam ( . mg kg ip), naloxone ( mg kg intravenous bolus followed by mg kg h infusion) and diazepam naloxone combination. sedation depth, temperature, number of seizures and intensity, whole-body plethysmography parameters and electroencephalography activity were measured. for each parameter, we compared the areas under the curves using mann-whitney tests for two-by-two comparisons between the four groups. regarding the effects of treatments on seizures, comparisons were performed using two-way analysis of variance followed by multiple comparison tests using bonferroni's correction. results: naloxone reversed tramadol-induced respiratory depression (p < . ) but significantly increased seizures (p < . ) and prolonged their occurrence time. diazepam abolished seizures but significantly deepened rat sedation (p < . ) without improving ventilation. diazepam naloxone combination completely abolished seizures, significantly improved rat ventilation by reducing inspiratory time (p < . ) but did not worsen sedation. based on the eeg study, tramadol-treated rats experienced electro-clinical seizures as soon as min after the injection, characterized by spike-waves and polyspikes with progressive decreased frequencies and inter-critical phases of slow delta waves until the next crisis. after diazepam naloxone injection, eeg waveforms consisted in hz-alpha rhythms and slow-down theta rhythms of drowsiness. none of these treatments significantly modified rat temperature. conclusion: diazepam naloxone combination is the most efficient antidote to reverse tramadol-induced cns toxicity. our experimental data greatly encourage administering this combination rather than naloxone alone as first-line antidote in tramadol-poisoned patients as an alternative to tracheal intubation. introduction: rubigine ® poisoning is a medical emergency that causes a major public health problem in underdeveloped countries, as it is frequently fatal. this poisoning is rare in france, but frequent in the french overseas departments (dom). the rubigine ® , made of fluoride and used as a rust remover, is the main source of poisoning in the caribbean. in martinique, the exact incidence of this intoxication is unknown, as there is no national and regional register. it could represent up to - % of severe acute poisoning. it was not until april that, following a prefectural order on the declaration, classification, packaging and labeling of substances, the composition of rubigine ® was modified to significantly reduce the mortality induced by its ingestion. the objective of our study was to describe the clinical features and complications that can occur after ingestion of rubigine ® as well as to determine the prognostic factors of death. we conducted a retrospective study over years, from to , including all patients admitted to emergency and intensive care units of the university hospital center (martinique) for acute rubigine ® poisoning. the usual demographic and clinical data were collected and comparisons between surviving and deceased patients were performed using a univariate analysis. results: fifty-five patients (mean age- years ( - ) + sex ratio male female- , ) were hospitalized at the university hospital of martinique. one-quarter of patients had no significant history. the average length of stay was . days ( - ). forty percent of patients experienced hypocalcaemia after initial intravenous calcium supplementation. complications included acute respiratory failure requiring invasive mechanical ventilation ( % of patients, duration of ventilation- . days, ( - )), renal failure ( %, of which % required extrarenal treatment, hemodynamic failure ( %), hepatic failure ( %), coagulation failure ( %), neurological failure ( %) and multi-visceral failure ( . %). three patients presented cardiogenic refractory shock requiring va ecmo ( . %) and another patient with digestive perforation ( . %). the mortality was . %, allowing the identification of prognostic factors of death. conclusion: rubigine ® poisoning is responsible for significant morbidity and mortality, despite optimal management. however, its incidence seems to have decreased sharply in recent years thanks to the strong mobilization and awareness of the population following the implementation of an information system by the university hospital 's clinical toxicology and toxico-vigilance unit, and different preventive measures introduced by the health authorities. introduction: since dextropropoxyphene withdrawal from the market, overdoses and fatalities attributed to tramadol, a who step- opioid analgesic drug, have increased markedly. besides central nervous system depression, tramadol overdose may result in seizures, usually included in the related serotonin syndrome. however, the serotoninergic mechanism of tramadol-induced seizures has been recently questioned. we investigated the effects of various specific pretreatments on tramadol-induced seizure onset and alterations in brain monoamines in the rat. patients and methods: sprague-dawley rats were randomized into five groups (n = group) to be pretreated with various agonists antagonists before receiving mg kg tramadol intraperitoneally- . mg kg ip diazepam + mg kg iv bolus followed by mg kg h infusion naloxone + mg kg ip cyproheptadine, and mg kg ip fexofenadine. seizure severity was graded according to the modified racine score ( ). we measured neurotransmitter concentrations in the frontal cortex using high performance liquid chromatography coupled to flurorimetry or radioenzymatic assay, as required. we used positron emission tomography-computed tomography to investigate interactions of tramadol with gaba-a receptors. the effects of treatments on seizures were compared using two-way analysis of variance followed by multiple comparison tests with bonferroni's correction. the areas under the curves of the effects on monoamine concentrations and the binding potentials in the pet-imaging study were compared two-by-two using mann-whitney u tests. results: diazepam abolished tramadol-induced seizures, by contrast to naloxone, cyproheptadine and fexofenadine pretreatments. interestingly, despite seizure abolishment, diazepam significantly enhanced tramadol-induced increase in the brain serotonin (p < . ), histamine (p < . ), dopamine (p < . ) and norepinephrine (p < . ) while no significant modifications were observed with the other tested pretreatments. based on positron emission tomography imaging using c-flumazenil fixation in the rat brain, we demonstrated molecular interaction between tramadol and γ-aminobutyric acid (gaba)-a receptors not related to a competitive mechanism between tramadol and flumazenil on the benzodiazepine binding site. our findings clearly ruled out the involvement of serotoninergic, opioidergic, histaminergic, dopaminergic and norepinephrinergic pathways in tramadol-induced seizures while strongly suggested tramadolinduced specific allosteric change in gabaa receptors that could contribute to seizures onset in overdose. conclusion: tramadol-induced seizures in overdose are mainly related to the gabaergic pathway. introduction: heparin-induced thrombocytopenia (hit) is a serious iatrogenic complication of heparinic treatments. the diagnosis of hit is difficult in the resuscitation environment because thrombocytopenia is a frequent and multifactorial phenomenon. the aim of this work was to study the clinical and biological presentation of patients with hit and the consequences attributable to hit on the evolution of patients in terms of morbidity and mortality and to develop a diagnostic strategy for hit for resuscitation patients. this was a retrospective, monocentric, descriptive and evaluative study conducted in our intensive care unit (icu) over a period of years months. an anti-pf antibody test was performed in patients who developed thrombocytopenia or a % drop in their initial platelet kinetics and the clinical picture. results: the incidence of hit was . % in patients hospitalized in icu. the clinicobiological severity scores, the reasons for admission to resuscitation were similar in both groups (hit+ and hit−) as well as the characteristics of the heparins used. the time of occurrence of thrombocytopenia was similar in the two groups. the diagnosis of hit was more often the only plausible diagnosis in the hit+ group. the t's score was significantly higher in the hit+ group. the evolution of the platelet count was similar in the two groups, in the decay phases as well as in the recuperation phase. hit+ patients showed significantly more thrombosis than hit− patients. there was no significant difference between the transfusion needs of hit+ and hit− patients. mortality was identical in both groups, as was the length of stay in icu. conclusion: hit is a rare disease. there was no evidence of a predisposing factor for the occurrence of the disease in a uniform resuscitation population. the diagnosis of hit is based on a cluster of arguments and not on an isolated event. biological tools are indispensable, in a complementary way to the clinical picture. pulmonary embolism in patients with sickle cell disease in intensive care unit: a challenging diagnosis jamoussi amira , zayet souheil , merhebene takoua results: during the study period, a total of patients with scd were admitted. among them, presented with respiratory distress and chest pain and then benefited first of trans-thoracic echocardiography that often showed right ventricle dilation and systolic pap > mmhg (n = ). all the patients underwent enhanced ct-scan and the diagnosis of pe was finally retained in cases ( . %) and hence colliged. the average age was . years ± . [ - years] with a sexratio = . the mean of apach ii score was . scd were diagnosed at the age of . years ± . [ - years] with a regular follow up in %. the reason for admission was acute respiratory failure in all cases. patients had clinical symptoms of pneumonia: pleuritic chest pain (n = ), dyspnea (n = ) and fever (n = ). all patients had a chest x-ray showing an alveolo-interstitial syndrome in cases ( . %) and an associated pneumonia in cases ( introduction: acute chest syndrome (acs) is the most severe complication of sickle cell disease and its evolution is unpredictable. acute pulmonary hypertension (ph) in acs is associated with an increased mortality, but its mechanism remains poorly known. our hypothesis is that acute ph is associated with a biological state of hypercoagulability in acs. in a prospective single center study, all consecutive scd patients with acs admitted to the intensive care unit (icu) of tenon hospital were included. specialized haemostasis dosages were performed on icu admission. a trans-thoracic echocardiogram was also performed on admission, and was repeated at steady state. results: among patients with acs, had a trans-thoracic echocardiogram and had a high echocardiographic probability of acute ph, including patient with bilateral pulmonary embolism and patient who developed multiple organ failure and died. there were no significant clinical, biological or radiological differences between patients with a low-intermediate probability of acute ph and those with a high probability of acute ph+ their evolution was similar. the exploration of haemostasis did not show between-group differences, regarding each parameter of haemostasis. however, when using a hierarchical cluster analysis, distinct profiles of coagulation were evidenced, defining biological classes. the subset of patients with a high echocardiographic probability of acute ph was more frequent in biological classes and which corresponded to hypercoagulability states. acute ph was transient in patients (n = ) with a repeated echocardiography at steady state. conclusion: acute ph may likely occur in patients with acs and a biological condition of hypercoagulability. further studies are needed to confirm these findings. gorham julie were the two independent predictors of survival after hospital discharge. in lung cancer patients admitted into the icu, the mgps is an independent predictor of survival after hospital discharge but not for mortality during icu stay. this inflammatory score could therefore be used as a long-term prognostic marker in this population of patients and would be more reflective of cancer, than reflecting the acute complication leading to icu admission. prospective and multicentric studies must be carried out to validate these results. introduction: recombinant active factor vii is a pro-hemostatic treatment used in obstetric haemorrhage, but no study has made it possible to specify its exact place in the decision algorithm. the objective of our work is to evaluate the efficacy and the benefit risk ratio of recombinant factor viia in the treatment of severe postpartum hemorrhage. we conducted a prospective study at the ibn jazzar university hospital in kairouan during the period from january , to december , . in total, we collected cases of recombinant factor viia in one postpartum haemorrhage. results: the mean age of our patients was + . years. the rate of childbirth was . %. the caesarean was the mode of delivery chosen for patients. the causes of postpartum haemorrhage in our series were-uterine atony in cases, uterine rupture and cervicouterine tear cases each, retroplacental hematoma and placenta accreta cases for each two and placenta praevia in cases. our patients were treated in an intensive care unit and the average hospital stay was . days. sulprostone was reported in cases ( . %), and all patients received a massive transfusion. the average time to administer rfviia was h min. the mean dose of factor vila recombinant was . ± . μg kg. five patients received a single dose, patients received a second injection and patients received doses. clinical efficacy-after a single injection, clinical efficacy with reduction in bleeding was observed in patients, i.e. %. the most frequent complication was insufficiencyrenal in cases including requiring hemodialysis, civd in cases, oap in cases, a multivisceral failure in cases, a septic shock in case and a mesenteric infarction in case. the progression was favorable in patients, while patients died ( . %). conclusion: it is important that new studies be carried out and shared experiences around the world on this drug appear to be effective and prevent invasive actions in the therapeutic arsenal of postpartum heamorrhage. introduction: post-partum haemorrhage (pph) is a life-threatening complication and remains a leading cause of maternal morbidity worldwide. the woman trial* estabished that early administration of tranexamic acid (ta) reduces mortality due to the bleeding in women with pph. our study purpose was to determine the effects of early administration of ta and fibrinogen concentrate on death, hysterectomy and transfusion in women with severe pph. patients and methods: this retrospective, monocentric study was performed in a third level tunisian hospital providing healthcare for more than pregnant women per year. were included in this study women with diagnosis of severe post partum haemorrhage after a vaginal or caesarean delivery from to . patients who received ta and fibrinogen concentrate were assessed in group (g ) and who not in group (g ). results: the incidence of severe pph was / deliveries. women were retained for data analysis g (n = ), g (n = ). anthropomorphic and obstetrics characteristics were not significantly different between the two groups. there was a significant difference between the two groups regarding to transfused units of red blood cells however, no difference in term of the use of frozen plasma and platelets concentrates was observed. perioperative hemoglobin nadir was significantly higher in g . the frequency of hysterectomy and pelvic packing were higher in g (table ) . no thromboembolic events and no haemorrhage related mortality were observed in the two groups. conclusion: in this retrospective study, early administration of tranexamic acid and fibrinogen reduces risk of hysterectomy transfusion. these encouraging results strongly support the need for a large, international, double-blind study to investigate the potential of the association "ta-fibrinogen concentrate" to reduce maternal haemorrhage related morbidity and mortality. introduction: immunodeficiency, acquired or congenital, is the first comorbidity associated with poor outcome in pediatric patients with acute respiratory distress syndrome (ards). the aim of this study was to describe outcome of pediatric patient with hematologic disease hospitalized in our intensive care unit for respiratory failure and to investigate the clinical variables associated with mortality. patients and methods: it was a retrospective monocentric descriptive study including all immunodeficient pediatric patient (malignant hemopathy, congenital immunodeficiency, bone marrow transplanta-tion…) from hematology hospitalized in our beds pediatric intensive care unit with the diagnosis of respiratory failure between january and february . results: fifty one patients were included corresponding to admissions. nighty percent of the patients met criteria for pediatric ards- % were severe, % moderate and % mild. extracorporeal circulation (ecc) was needed for patients. global mortality rate at picu discharge was %. twenty four patients ( %) received noninvasive ventilation (niv). height of them ( %) did not need invasive mechanical ventilation (imv). in patients who received imv, mortality rate was significantly higher if patients received before niv ( vs. %) p = . . all patients who needed imv after more than h of niv died (n = ). mortality was higher in children with griffon versus host disease ( vs. % p = . ). mortality of patients receiving ecc and renal replacement therapy (rtt) was respectively and %. conclusion: in our study, most of the patients hospitalized for respiratory failure met criteria for pediatric ards. if niv decrease imv requirement, it could be associated with higher mortality rate in case of failure. this result support recent recommendation that immunodeficiency is not a sufficient criteria to delayed imv. . flow and airway pressure were recorded at the asl inlet and mouth pressure into the manikin mouth. we defined "device driving pressure" as the peak mouth pressure minus the tele-expiratory mouth pressure. continuous data are reported as mean ± sd. results: as compared to the oxygen mask, vt increased significantly with m-niv and h-niv whatever the simulated respiratory effort ( ± and ± vs. ± ml respectively with the moderate simulated effort, p < . ; fig. ). hfnc and cpap were associated with a slight but non-significant decrease in vt as compared to the oxygen mask. overall, for a given respiratory effort, vt was influenced by the "device driving pressure", which tended to decrease when using hfnc and cpap and markedly increased with m-niv as compared to the oxygen mask. therefore, vt in m-niv with a simulated low effort was significantly higher than vt in cpap and hfnc with a simulated moderate effort ( ± ml, ± ml, and ± ml respectively, p = . for both comparisons). conclusion: in our bench model, the vt value was significantly influenced by the noninvasive ventilatory device. niv was invariably associated with significantly higher vt than with other devices, even when dividing by two the simulated inspiratory effort during niv. introduction: in icu, intubation is a high risk procedure associated with high morbidity. despite procedure's improvement with systematic application of fluid loading, early use of vasopressors and checklist use, morbidity remains high. several recent trials has been conducted with different metrics choose as primary outcome. however any evidence exists to choose one more than another: time to intubation, first pass success, difficult intubation. first pass success sine hypoxia and hypotension (dash- a) has been highlighted recently and choose by the game program without any scientific evaluation. we conducted a post hoc analysis of the randomized clinical trial macgrath mac video laryngoscope or macintosh laryngoscope for intubation in the intensive care unit (macman) to determine the best metric to choose for primary outcome for the next intubation studies in icu. patients and methods: macman was a multicentre, open-label, randomized controlled superiority trial. consecutive patients requiring intubation were randomly allocated to either the mcgrath mac videolaryngoscope or the macintosh laryngoscope, with stratification by centre and operator experience. an only inclusion criterion was-"patients must be admitted to an icu and require mechanical ventilation through an endotracheal tube". patients were excluded if-contraindication to orotracheal intubation (e.g., unstable spinal lesion) + insufficient time to include and randomize the patient (e.g., because of cardiac arrest) + age < years + pregnant or breastfeeding woman + correctional facility inmate + patient under guardianship + patient without health insurance + refusal of the patient or next of kin to participate in the study + previous enrolment in a clinical randomized trial with intubation as the primary end point (including previous inclusion in the present trial). post-hoc analysis was performed to assess association and prediction of life threatening complication (mild to moderate, severe, mild to severe) by different metric existing-time to intubation, first pass success, difficult intubation, first pass success sine hypoxia and hypotension. each metric was compared with another one. area under curve was built for every metric and all metrics were then compared. results: dash- a was superior to all others metrics included in the analysis for prediction of life threatning complications (all p < . ). failure of first pass conclusion: all metrics are not equal to predict severe life threatening complications during intubation in the icu. in this context, we recommend adoption of definitive airway sine hypoxia or hypotension at first attempt (dash- a) as primary outcome for intubation studies in the icu or as metric indicator tracked in quality improvement program. benbernou soumia introduction: introductionacute respiratory failure (arf) is a common cause of emergency use and one of the major reasons for admission to intensive care unit. it associates a vital risk imposing immediate symptomatic treatments and an etiological approach. [ ] among the etiologies of the arf, acute lung edema (ale), decompensation of chronic obstructive pulmonary disease (copd), chest trauma and pneumonia are the most frequent @it is a life-threatening pathology with a high incidence of mortality, since mortality is reported to be - % [ , ] for arf secondary to cardiogenic ale. the prevalence of arf in algeria remains unknown + the tahina study showed that respiratory diseases were the leading cause of consultation in the hospital [ ] . the the objective of this study is to estimate the frequency of use of the niv and to determine the associated factors of failure of the niv for the adult patients hospitalized for arf in the emergency department of oran hospital from january to november . prevalence of copd was found in the . % of tobacco subjects [ ] . the number of patients hospitalized for chest trauma continues to increase, resulting in an increase in the number of patients admitted for arf secondary to chest trauma. patients and methods: this is an observational and exhaustive study during the month of november, from the files of patients. the population-all subjects over years hospitalized for an arf at the reception and resuscitation units of the emergency department of oran hospital from january to november . results: ninety-seven patients were hospitalized for arf during this period. niv was used for patients. patients were acute lung edema. univariate analysis showed that spo was the only failure factor in this series. the failure rate of this technique was . %. niv is a technique that should be used more in the emergency rooms, which would make it possible to use less intubation specially in indications where the level of proof in the literature is important. demographic characteristics, etiology of exacerbation, comorbidities, the sapsii score, arterial blood gases at admission, respiratory, hemodynamic and neurological parameters, use of noninvasive or invasive ventilation, nosocomial infection, duration of niv, length of stay and mortality. results: during period study patients ( % women with a sapsii score ± ) were included. the etiology of exacerbation was bronchitis in % of cases and pneumonia in %. only patients have niv at home and patients have oxygen. pseudomonas aeruginosa was isolated in cases. twenty percent of the patients had developed a nosocomial infection, acinetobacter baumanii and pseudomonas aeruginosa were isolated in and % respectively. niv was used in patients at admission and the rate of niv failure was %. the duration of mechanical ventilation was ± days and the length of stay was ± days. the mortality was %. niv and oxygen at home were prescribed for patients. in univariate analysis survivors and non-survivors were comparable regarding baseline and clinical characteristics. nosocomial infections ( vs. %), and spassii score were significantly more elevated in non-survivors. in emergency department, the management of hypercapnic acute respiratory failure with hfo is limited. hypercapnia and acidosis remain moderate. patients are old with comorbidities. the mortality rate is high but expected given the number of limitation of active therapy. hfo appears to be effective for a majority of patients, but half of them required niv too. the niv hfo association seems an interesting option. but our methodology is perfectible and would require a randomized control tria. severe chronic obstructive pulmonary disease with chronic respiratory failure in intensive care unit: mortality and prognostic factors arnout chloé , faure morgane , novy emmanuel chu nancy, nancy, france correspondence: arnout chloé -arnout.chloe@gmail.com introduction: last decades, the number of patient with chronic respiratory failure due to chronic obstructive pulmonary disease (copd) admitted in intensive care unit (icu) increased. data about their real prognosis in the icu are lacking. the objective of this study was to evaluate mortality rate at months and to identify prognostic factors of copd patients with chronic respiratory failure, treated with long term oxygen therapy (ltot), admitted in icu. patients and methods: a retrospective cohort study was conducted in the french university hospital of nancy during years - on all copd patients treated with ltot admitted in icu. only the first admission was analysed. patients were included if they had spirometry, blood gas and oxygen flow in the year before admission in icu. other causes of chronic respiratory failure, and patients with tracheostomy before icu admission were excluded of the cohort. hospitalizations were selected using the international classification of diseases, th revision (icd- ). results: one hundred and thirteen patients were included, ( %) died in the first months after icu admission. mortality rate in icu was %. severity of copd was-mean bode score ± . , number of exacerbation per year requiring hospitalization ± . . ltot was used for . ± . years. acute respiratory failure was the main frequent cause- % pneumonia, % acute exacerbation of copd, % acute lung oedema. the sequential organ failure assessment score within the first h of icu admission was ± . need for mechanical ventilation was noted in % of cases and was associated to mortality with an odds ratio of . (ci % [ . - ] p = . ). in presence of other organ failure, mortality rate tends to increase. patients with median pao fio ratio > on first blood gas had a reduced risk of death (or . + ci % [ . - . ], p = . ). conclusion: this is the first study to assess mortality at month of patients with severe copd requiring ltot admitted in icu. severity of hypoxemia and use of mechanical ventilation are two prognosis factor of mortality. the addition of another organ failure seems to increase the mortality rate. severity of the chronic respiratory insufficiency less influenced short and long term outcome. this data have to be included in the global decision to admit a copd patient with ltot in icu. introduction: the remarkable progress in the outpatient care of the asthmatic patient (development and access to inhaled drugs) has made the admission of these patients exceptional in the icu. we have noticed a recent upsurge in asthmatic afmissions in the icu, and are investigating whether this fact was related to modifiable factors (access to adapted drugs) or an increase in the severity of the disease. patients and methods: retrospective, observational, three-center study conducted in three tunisian medical icu from january to july, . were included all consecutive patients admitted for severe acute asthma in three icus. were assessed-patient's demographic characteristics, asthma severity and its actual control based on global initiative for asthma classification (gina) , clinical characteristics of the acute episode, length of icu stay, ventilatory free days and mortality. results: out of the patients admitted within the study period, ( %) had severe acute asthma. the mean age was years (iqr - . ). sex ratio was . asthma was allergic in % with an average ancienty of . years. over all asthma was not very severe with no prior icu admission for acute severe asthma . % were mechanically ventilated at least one time. were classified severe and moderate persistant asthma respectively in . (%) and (%). . % were consideredpoorly controlled. low educational level and socio-economic status are the main determinants of poor control- % of analyzed patients didn't have a social care, and thus no accesse to prescribed anti-asthmatics + % didn't have a regular follow up and . % were jobless. when admitted to the icu- patients ( . %) needed invasive mechanical ventilation, one patient received niv. the mean length of stay was days (iqr . - . ). levels of auto peep and pic pressure at icu admission were respectively (iqr - ) and . (iqr , - . ) cm h o. mortality rate was %. this study suggests that low educational level and socioeconomic status (especially the lack of social care and joblessness) are the main determinants of poor control of asthma and may lead to the increase of rate of icu admission for severe acute asthma requiring mechanical ventilation. introduction: in emergency medicine, the boussignac system (bs) is sometimes used to administer oxygen and continuous positive airway pressure (cpap). in this case, fio value depends on the ratio between o flow and inspiratory flow (if). in some cases, the fio decreases due to the if increase. the aim of this study was to test a modified boussignac system in order to limit the fio decreases during inspiratory flow rate increases. the study was conducted on bench with bs connected to a two compartment adult lung model (dual test lung ® ) (dtl) controlled by a maquet servo i ® ventilator. three minute ventilation (mv- . . l min) with ti ttot = . were investigated. fio and mv measurements were made using an iworx ® ga gas analyzer. with a bs, two peep were analyzed- and cm h o. the bs was supplied by an o flow. in order to increase the fio , we have evaluated the addition of a t piece connected to a nebulizer at the air-room admission of a bs. the aerosol was supplied by an o flow of l min. the o flow was analyzed in continuous with a calibrated mass flow meter (red y vogtlyn ™ ). results: when mv increases, the fio decreases (p < . ). when peep increases, fio increases too (p < . ). the addition of an aerosol (o - l min) to a bs increases the fio (p < . ). however, in this last case, the gap between both fio decreases with increases mv (fig. ) . the addition of an aerosol connected to an o flow rate ( l min) at the entry of a bs limits the fio decreases during the mv increases. introduction: burned patients are at high risk of yeast colonization and thus of invasive fungal infections, particularly to candida (c.) spp., leading to an increase in morbidity and mortality. while pre-emptive antifungal therapy has improved survival, it may lead to an increase in antifungal resistance. the objectives of this work were to describe candida species distribution and to determine the antifungal susceptibility of candida isolates acquired in a burn unit. our study is a retrospective review of severely burned patients admitted to the burn unit of the ben arous traumatology and burns center with one or more positive culture sites for candida, during the -month period from may through august . a total of isolates were thus obtained. the susceptibility to antifungal drugs ( -fluorocytosine, fluconazole, ketoconazole, micronazole, itraconazole, amphotericin b) was determined using the fungitest ® broth dilution method for patients with infected normally sterile body sites or a candida colonization index superior or equal to . . since echinocandin and anidulafungine were recently introduced in tunisia, the susceptibility to these antifungal classes was tested for only one patient from our cohort. results: nasal and buccal sites were the most colonized body sites ( . % each), followed by axillary ( . %) and rectal sites ( . %) and urines ( . %). c. albicans was the predominant species ( . %), followed by c. glabrata ( . %), c. tropicalis ( . %) and c. parapsilosis ( . %). among the strains whose antifungal susceptibility was determined, majority of candida isolates were susceptible to fluconazole ( . %), which is the most frequently used molecule as a pre-emptive treatment in such cases in tunisia due to its availability and its efficiency. on the other hand, . % of the isolates were intermediate and . % were resistant to this antifungal drug, mainly c. glabrata for both groups. as for the other tested azoles, high rates of intermediate strains were noticed ( . % to itraconazole, . % to ketoconazole and . % to miconazole), mostly c. glabrata. only one strain was resistant to amphotericin b, which is not usually used in these cases due to its nephrotoxicity and the frequency of kidney failure in burned patients. our study demonstrates that c. albicans is the most frequent species in burn unit-acquired candidiasis. no major antifungal resistance was observed, apart from high rates of intermediate strains (mainly c. glabrata) to azole class antifungal drugs. introduction: infection, especially bacteremia, is a major cause of morbi-mortality in severely burned patients. mortalityrelated to bacteremia in burn patients was about % [ ] . we performed this study to determine the prevalence, the causative agents and outcomes of bacteremia in burned patients. introduction: carbapenems, the last line of therapy, are now frequently needed to treat nosocomial infections, and increasing resistance to this class of β-lactams limit antibiotic options in critically ill patients especially in burns. the objective of our study was to assess the impact of the detection of carbaménépases in optimizing treatments in burned. patients and methods: a prospective, monocentric study was carried out at the intensive care unit of burn in tunisia over months (march-august ). were included all patients who have had a carbapenemase research. the sample was carried out by rectal swab. all samples were analyzed by polymerase chain reaction (pcr) methods for presence of carbapenemase. during the study period, patients were included. the mean age was ± years. they were men and women. the average burned surface area was ± %. patients were transferred from another hospital structure in % of cases with a delay of h. % of patients had a septic complication with a delay of ± days. antibiotic treatment was empirical in cases. the therapeutic failure rate was %. results of carbame-nepases detected by pcr are detailed in table . in the group of patients pcr (+), the antibiotic treatment was changed in cases. the most association of antibiotics were-tigecycline in combination with colistin or in combination with fosfomycine and fosfomycin in combination with colistin. this leads to reduce therapeutic failure by %. conclusion: detection of carbapenemase in our study was higher ( %), allows us to identify regions with high risk of carbapenemase, improve therapeutic efficacy and strengthen infection control measures by isolation of all carbapenemase producing patient. introduction: icu-acquired bacteraemia is prevalent and poses a grave threat. providing information about the main causative bacterial agents and determination of their susceptibility to antibiotics may improve empiric therapy and early detection of emerging antimicrobial resistance. the aim of this study was to investigate the species distribution and antibiotic susceptibility of isolated strains from blood culture in burn intensive care unit during a five-year period. patients and methods: from january to december , a total of , non repetitive strains were isolated from blood cultures. incubation of blood culture vials and the detection of bacterial growth were performed by the bactec system. all isolated organisms were identified on the basis of standard microbiological techniques. antibiotic susceptibility testing was carried out by the agar disk diffusion method, and susceptibility results were interpreted using clinical breakpoints according to ca-sfm and guidelines. data were analyzed using the sir-system. minimum inhibitory concentrations of colistin, imipenem and vancomycin were determined using the etest ® method (biomérieux). results: of the , strains isolated, the most frequently identified species were staphylococcus aureus ( %), acinetobacter baumannii ( %), klebsiella pneumoniae ( %), and pseudomonas aeruginosa ( %). the rate of methicillin-resistant staphylococcus aureus (mrsa) was %. resistance to tigecycline and linezolid was and %, respectively. all strains were susceptible to glycopeptides. in addition, isolated acinetobacter baumanii strains showed high rates of resistant to all tested antibiotics except colistin. eighty per cent of these strains were resistant to ceftazidime and % to imipenem. resistance to rifampicin was % in , and has increased steadily to % by . similarly, high resistance rates were observed among klebsiella pneumoniae and pseudomonas aeruginosa to ceftazidime ( and % respectively), ciprofloxacin ( and %) and imipenem ( and %). conclusion: this study investigated on the local distribution patterns of causative organisms of bacteraemia in burn patients and the corresponding antimicrobial susceptibility profiles. multidrug-resistant pathogens, especially mrsa and acinetobacter baumanii, were the most frequently isolated organisms. hygiene measures and antimicrobial stewardship should be implemented to prevent the spreading of these resistant strains. introduction: pseudomonas aeruginosa is known opportunistic pathogen frequently causing serious infections in burned patients. multidrug resistance in this pathogen is increasing throughout the world and is a major problem in the management of these pathogens. analysis of serotype and resistance profile to antobiotics of p. aeruginosa help to establish a prompt control and prevention program. the aim of this study was to evaluate the frequency of antimicrobial resistance and the prevalence of pseudomonas aeruginosa serotypes isolated in the burn unit. patients and methods: during a period of years (from to ), strains of pseudomonas aeruginosa were isolated from burned patients. conventional methods were used for identification. antimicrobial susceptibility testing was performed with disk diffusion method and susceptibility data were interpreted according to breakpoints recommended by the french society of microbiology (fsm). serotypes were identified by slide agglutination test using p. aeruginosa o antisera (biorad). the imipenem-resistant strains have benefited from a research of carbapenemase production by the edta test. results: in our study period, bacterial isolates were found among which pseudomonas aeruginosa was the second most frequent bacterium isolated from burned patients ( %) after staphylococcus aureus ( %). the most frequent sites were-cutaneus infection ( %), blood culture ( %) and catheter ( %). the most prevalent serotypes were-o ( %), o ( %), o ( %), o ( %) and o ( %). the survey of antibiotic susceptibilily showed high pourcentage of resistance to the different antibiotics- % of strains were resistant to ceftazidim, % to ticarcillin, % to ciprofloxacin, % to amikacin and % to imipenem. among the imipenem resistant strains, % were metallo-beta-lactamase producers. the antibiotic to which p. aeruginosa was the most susceptible was colistin ( %). multidrugresistance was associated with o serotype in % of the cases. the global frequency of serotypes o , o and o was more than %. multidrug resistance and carbapenemase being associated with serotype o . serotyping of the strains isolated from burned patients will help to guide the first antibiotherapy. the dissemination of carbapenemases strains must be contained by implementation of timely identification, strict isolation methods and better hygienic procedures. and respiratory disorders ( . %)…). the therapeutic management was based on per operative resuscitation, organ failure treatment, probabilistic antibiotic therapy and median laparotomy surgery. the main etiologies of abdominal sepsis were-digestive perforations ( . %), purulent effusion ( %), intestinal necrosis ( %), cholecystitis ( . %). the bacteriological profile was -predominance of bgn ( . %) dominated by e. coli ( %) followed by klebsiella pneumoniae and acinetobacter baumanii ( . %), the mean duration of the hospitalization was . ± . days. the mortality rate was %. the main prognostic factors in our study in univariate analysis were-the advanced age, the diabetes, the organ failure, the increased gravity scores, the time to management, the use of catecholamines and the development of septic shock. the multivariate analysis showed a statistically significant association between the development of septic shock, the stercoral effusion, the peptic ulcer perforation, the operator and the therapeutic descalation. the abdominal sepsis is a serious affection, with great mortality. the improvement of its prognosis is based on a revision of the medical and surgical protocols, and an adapted antibiotic therapy depending on the direct examination of the samples, also of the bacterial ecology of the service. introduction: severe acute respiratory infections (sari) are common in critically ill patients. viruses can be found in immuno-competent patients. however, the main problem for viral infections is the diagnosis, isolation of the pathogen is often difficult and the symptoms not specific. the aims of this study were to describing the epidemiological characteristics of viral respiratory infections, to identify factors predictive of a poor outcome. introduction: in septic shock there are physiological changes with an increase in the volume of distribution, with implications for pharmacokinetics of antibiotics that make recommended doses potentially inadequate for target organisms with highest minimal inhibitory concentrations. to cover these bacteria, peak serum concentration (cmax) target is - pg ml. identification of predictive factors for insufficient cmax, in common practice, would make it possible to target the patients at risk in order to optimize dosage of antibiotic to be administered. objective of this study was to determine predictive factors of amikacin's cmax insufficient independently of the dosage. patients and methods: this was a retrospective study carried out between august and november in icu of our hospital. all adult patient receiving an initial injection of amikacin between and mg kg were included. clinical data collected were-amikacin dosage, body mass index (bmi), mechanical ventilation (mv), mean arterial pressure (map), use of noradrenaline and continuous hemofiltration (cvvh). biological elements were collected and for each, the last result in the h prior to admission and that at the patient's entry into icu were added to analysis. a comparison of this clinical and biological variables was made between two groups-the first one with an ineffective cmax of amikacin (< pg ml) and the second with an effective cmax of amikacin (> pg ml). results: patients were selected for statistical analysis. median dosage was . mg kg for a median cmax at . mg l. for patients, cmax was less than mg l and in patients, it was greater than mg l. there was a statistically significant relationship between a cmax greater than mg l and mv, bmi, pct measured before and after admission, albumin after admission, hemoglobinemia, hematocrit level after admission, the rate of urea after admission (table ) . a low bmi was associated with cmax < mg l. discussion: these results remain comparable to those found by taccone in , with dosages of mg kg having only % of the peaks above mg l + comparable also to montmollin's study in . conclusion: mv, bmi, pre-and post-admission pct, and albumin, hemoglobin after admission, hematocrit and urea after admission seems to be predictive criteria for insufficient amikacin's cmax independently of dosage. our study was limited to one icu, a heterogeneous recruitment, and that all samples have been taken at the right time. introduction: this study aimed to assess whether augmented renal clearance (arc) impacts negatively on ceftriaxone pharmacokinetic pharmacodynamics (pk/pd) target attainment in critically ill patients receiving g day by intermittent infusion. patients and methods: over an -month period, all critically ill patients treated by ceftriaxone for a first episode of sepsis without renal impairment were eligible. during the first days of antimicrobial therapy, every patient underwent -hour creatinine clearance (crcl) measurements and therapeutic drug monitoring at trough concentrations. the main outcome investigated in this study was the rate of empirical target non-attainment using a theoretical target mic of mg/l. results: over the study period, patients were included ( samples analyzed for therapeutic drug monitoring). the rate of pk/pd target non-attainment was %, with a strong association with crcl (p < . ) ( table ). there was no statistical association between pk/ pd target non-attainment and therapeutic failure. conclusion: when targeting %ft > mic of the less susceptible pathogens, patients with crcl > ml/min are at risk of subexposure in ceftriaxone ( g day). these data emphasize the need of therapeutic drug monitoring in patients with arc, especially when targeting less susceptible pathogens or surgical infections with limited penetration of antimicrobial agents. introduction: the septic shock is a major concern of the intensive care unit in the world because of its frequency and especially of its mortality which remains high in spite of the progress made in the optimizing care. the aim of our work is to analyze the prognosis factors related to death among patients with septic shock in the icu of the military hospital avicenna of marrakesh, and to focus on the physiopathological and therapeutic data of the septic shock in the light of last acquisitions in this field. patients and methods: we proceed to a prospective study including all patients with septic shock at admission to icu or secondary, over a -year period (january -december ). prognosis factors related to death in patients with septic shock were studied in univariate and multivariate analysis. results: eighty-six cases of septic shock were collected from icu admissions, the incidence is . %, the mean age was ± . . the sites of infection most often involved were the abdomen and lung ( %), there was a predominance of gram-negative bacilli, the number of organ failure is in average . ± . . the overall mortality was . %. prognosis factors related to mortality retained after logistic regression are cardiovascular organ failure followed by neurological. indeed, the number of patients with or more failures was ( %) in the group of patients who died. as the second factor influencing the high mortality found severity score . ± . , age is also considered a prognosis factor since of patients were over years. the average age of the deceased was ± years versus ± years in survivors (p < . ), yet the mortality according to the infectious agent was not found as factor influencing mortality (p = . ). conclusion: septic shock is a frequent reason for hospitalization in icu. the improvement of prognosis requires an early and adapted management of sepsis as well as increases efforts for control and prevention of nosocomial infection. introduction: vitamin d deficiency is common in critically-ill patients. in addition to its role in the regulation of phosphor-calcic metabolism, vitamin d is of paramount importance for the immune system. the aim of the current study is to assess the prognostic value of vitamin d deficiency in patients with septic shock. patients and methods: retrospective study conducted over months. all the adult patients with septic shock and vitamin d level screening performed within the first h of admission were included in the study. we excluded patients with chronic kidney disease and those receiving vitamin d supply. two groups were compared: those with a serum vitamin d level < ng/ml (g ) and those with higher level (g introduction: since immunity plays a central role in neoplasms surveillance, it is likely that sepsis induced immune dysfunctions may impact on the underlying malignancy. we developed a research project investigating the reciprocal relationships between bacterial sepsis and cancer. we reported that sepsis-induced immune suppression promoted tumor growth in post-septic mice inoculated with cancer. in a reverse cancer-then-sepsis model we observed that sepsis may conversely inhibit tumor growth. this study aimed at investigating the cellular and molecular mechanisms of sepsis-induced tumor inhibition, and most especially the role of monocytes macrophages and toll-like receptor (tlr) signaling. patients and methods: we used c bl j wild-type (wt), tlr -/-, tlr -/-and myd -/-mice. mice were first subjected to tumor inoculation by subcutaneous injection of mca fibrosarcoma cells. fourteen days after, mice were subjected to polymicrobial sepsis induced by cecal ligation and puncture (clp). controls were cancer mice subjected to sham surgery. alternatively, cancer mice were subjected to an i.p. challenge with tlr agonist (lps or heat-killed staphylococcus aureus (hksa)). the distribution of tumor-associated immune cells was assessed by facs at days and following surgery. the activation status of tumorinfiltrating monocytes macrophages was assessed by facs (mhcii, cd , cd , pdl , pd ). f / + cells were purified by facs and we assessed cytokines production (rt-qpcr) and bacteria phagocytosis. we confirmed polymicrobial sepsis dampens tumor growth in wt mice. a similar clp-induced tumor growth inhibition was observed in tlr -/-mice, but neither in tlr -/-nor myd -/-mice. a challenge with lps resulted in a marked anti-tumoral effect, whereas a challenge with hksa had no impact on tumor growth. tumor-infiltrating immune cells analysis retrieved monocytes/macrophages predominance with two different subsets based on f / expression (f / high and f / low). late-onset (day ) tumors from clp-operated mice displayed increased proportions of f / high. as compared to f / low cells, f / high cells displayed a more immature status with a lower expression of cd , mhcii and pdl , and a higher phagocytic activity. interestingly, f / high cells from clp-operated mice exhibited a higher phagocytic activity than those from sham-operated mice. conclusion: polymicrobial sepsis drives a potent antitumoral activity in cancer mice, which is associated with changes in the distribution and functions of tumor-associated monocytes macrophages subsets. our results converge on a critical role of tlr signaling, that should be further investigated. conclusion: post-agressive immunosuppression in icu is not specific to sepsis. in septic shock, the low counts in circulating ilc s could be explained by ilc plasticity (conversion of these cells into ilc s), by migration from the blood or by an exacerbated apoptosis. ilc s expansion, associated with a higher risk of secondary infection, could be promoted by il- , released by tissue injuries. ilc s could activate regulatory t cells via il- . these preliminary results must be confirmed on a larger cohort. they play a suppressive role in the immune system by the secretion of negative regulatory cytokines such as interleukin- or by immune cell contact inhibition. the objective of this pilot study was to develop and test a protocol to determine the breg level in septic patients. the level of breg were measured on whole blood sample by flow cytometry the first day of hospitalisation in septic patients. b cells were identified on the single-parameter expression cd combined with scatter. the breg were identified as subpopulation expressing cd /hicd hi or cd /hicd + (see fig. ). the results were expressed as percentage of the parental lineage gate and absolute value per microliter. this protocol has been optimised in order to be able to transfer technic into clinical practice. results: we include patients hospitalized in intensive care unit with severe sepsis or septic shock. the percentage of cd + cd hic-d hi was . ± . % with a mean of . ± . cells microliter. the percentage of cd + cd hicd + was . ± . % with a mean of . ± . cells microliter. we are able to measure and follow the evolution of breg during severe sepsis or septic shock. because breg could inhibit body immune function, we wish to conduct a prospective study to evaluate the correlation between breg level and the prognosis of patients with sepsis. the neutrophil/lymphocyte ratio (nlr) reflects an inflammatory state. the nlr has recently emerged as a prognostic marker in colorectal cancer patients, acute coronary syndrome and pulmonary embolism (kayrak m, heart lung circ ). the aim of this study was to assess the prognostic value of nlr in patients with septic shock. we performed a prospective observational study in septic shock icu patients within h of admission from january to july in charles nicolle hospital of tunis. exclusion criteria were age < years, pregnancy + oncohematological patients, recent blood transfusion, post-cardiac arrest and brain-death. nlr was measured soon after admission and h, h, and h after. demographic, clinical and biochemical parameters, severity scores, life-support therapies (vasopressors, ventilation), and length of icu stay were recorded. the primary endpoint was -day mortality. results: sixty-five patients ( males, median age, . years) with septic shock were included in the study. the -day mortality was %. the median sofa score at t was points and the median igs score was points. the sources of infection were as follows: the lungs (n = ), the urinary tract (n = ), the central nervous system (n = ), the abdomen (n = ), skin and soft tissue (n = ). the parameters that were identified through univariate analysis to be associated with -day mortality were igs score, lactate level, the nlr elevation at h , h and h . median nlr levels were significantly higher in non-survivors (n = ) than survivors ( introduction: the autonomic nervous system (ans) is highly adaptable and allows the organism to maintain its balance when experiencing stress. heart rate variability (hrv) is a mean to evaluate cardiac effects of ans activity and a relation between hrv and outcome has been proposed in various types of patients. we evaluated the feasibility of a automated hrv monitoring, based on standard electrocardiography monitoring, and investigated the different parameters that should be recorded. this project is based on a prospective physiological tracing data-warehousing program (rea stoc, clinicaltrials.gov # nct ) that aims to record more than icu patients over a -years period. patients and methods: physiological tracings were recorded from the standard monitoring system (intelliview mp philips), using a dedicated network and extraction software (synapse v , ltsi inserm u ) that enables simultaneous recording of different physiological curves, at their native resolution ( hz for ecg, hz for other). raw data were subsequently stored on a dedicated local server, before anonymization and analysis. all consecutive patients were recorded for a -hours period during the -hours following icu admission. all measurements were recorded with the patient laying supine, with a ° bed head angulation. physiological recordings were associated with metadata collection by a dedicated research assistant. hrv parameters were derived from electrocardiography monitoring using kubios hrv premium ( introduction: acute cor pulmonale (acp) is a frequent complication of acute respiratory distress syndrome (ards). it occurs in % of cases and might be associated with an increased mortality rate. it is defined by a ratio of telediastolic surfaces of right ventricular (rv) on left ventricular greater than . and a septal dyskinesia. however, systolic dysfunction defined by the guidelines of the american society of echocardiography has not been well studied in ards and in particular concerning the rv free wall longitudinal strain (rv-fw-ls). the aims of the present study were to identify the prevalence of rv systolic dysfunction and acp in ards, and to evaluate the effects of inhaled nitric oxide (noi) and prone positioning. we prospectively included patients to a mild to severe ards, and proceeded to standardization of ventilation and systematic echocardiography in semirecumbent position, with noi and in prone position. interpretation of examination was blinded to the investigator. we evaluated the presence of acp, systolic dysfunction identified by classical cardiologic criteria (rv fractional area change, rv tei index, tricuspid annular plane systolic excursion, velocity of the tricuspid annular systolic motion) and also by rv-fw-ls. results: sixteen patients were included. thirty-seven percent of patients were in severe ards. the prevalence of acp was % while right ventricular systolic dysfunction was identified in . % of patients with the classic cardiologic criteria and . % with the impairment of rv-fw-ls which represented the most sensitive test for right ventricular dysfunction detection (table ) introduction: the use of extra corporeal membrane oxygenation (ecmo) is increasing. brain complications may occur, resulting in an increased morbidity and mortality. the objective of our study was to analyze the incidence of neurological complications while receiving ecmo, the risk factors, and to describe morbidity and mortality in a large cohort of patients in intensive care unit. patients and methods: this was an observational, mono-centric, -year retrospective study in patients who received ecmo. primary outcome was the occurrence of neurological complication until d after ecmo. results: one hundred and eight patients were included in the analysis. twenty-seven patients ( %) presented a neurological complication. of these, died at d . there were ischemic sequelae ( . %), intracranial haemorrhages ( . %), cerebral edema ( . %) and one other lesion ( . %). the median time before occurence of a neurological complication was days after the implementation of ecmo. multivariate analysis revealed the presence of hyperlactatemia > . mmol l, neurological deficit at the beginning of the management, as well as the history of stroke before the ecmo implementation as predictive factors of neurological complication (or . , . the incidence of neurological complications under ecmo is about % and ischemic sequelae are the most frequent. history of stroke and low cerebral flow associated with ischemia-reperfusion seem to increase the occurrence of these complications and must lead to greater vigilance in these patients. - ] . eighteen patients ( %) survived at icu discharge with a good neurological outcome. by multivariate logistic regression analysis, female sex, initial shockable rhythm, and pre-ecmo arterial blood ph ≥ . were independent predictors of survival with good neurological outcome. all of the patients presenting with cpc score of or at icu discharge had a shockable rhythm and or ph ≥ . before ecls implantation. % of the patients presenting with these criteria had a good neurological outcome at icu discharge. all of the patients presenting with non-shockable rhythm and ph < . before ecls implantation died in the icu. conclusion: about one third of the patients presenting with shockable rhythm and or ph ≥ . before ecls implantation had a good neurological outcome at icu discharge. on the contrary, all of the patients presenting with both non-shockable rhythm and ph < . before ecls implantation died in the icu. these simple parameters might help to identify cardiac arrest patients which could benefit from ecls implantation. radjou aguila introduction: the decrease of lung volume is a keystone for the management of patients under mechanical ventilation in intensive care units. this procedure has not only led to a reduction of morbimortality in ards but also in all patients mechanicaly ventilated in intensive care units as well as in major surjery. nevertheless, the incidence of high volume (vt) on morbimortality is extremely variable (about to %). our main objective is to assess the incidence of high volume ventilation (> ml/kg predicted body weight, pbw) in our hospital intensive care units. moreover we were interested in determining the risk factors of high volume ventilation. we conducted a retrospective observational study from january to march in three intensive care units of a tertiary university hospital. all patients ventilated under sedation in vac mode during the h after admission were included in the study. of the patients admissions during the period, one of them ( %) have no height mentioned in their medical file and were exluded. among the patients considered, ( . %) were ventilated with high vt (fig. ). % of patients had a positive expiratory pressure ≥ cmh o. in multivariable analysis, height (smaller) and weight (lower) are the only associated factors with a high volume ventilation (p < . and p = . , respectively). discussion: the observed incidence on high vt patients is higher than that reported in most papers in literature (jaber et al. %, hess et al. %) . nevertheless, both studies were conducted in operating room with higher vt cut-off ( ml/kg). walkey and al showed that % of patients in ards were ventilated with vt › ml/kg of pbw. moreover, the same associated factors (smaller height and lower weight) have found in the study. older studies revealed higher bmi as factor to high volume ventilation. this difference could be explained by the use of predicted body weight. conclusion: although the growing literature and the recommandations aim to reduce the lung volume between to ml/kg of pbw, still one third of the patients in intensive care units are ventilated with too high lung volume. (fig. ). with either a nc overlap on one nostril or not. results: when the mv increases, the fio decreases. when the mouth opens, the fio decreases. when the prongs are overlapping one nostril the fio decreases slightly (mean ± % in absolute value). statistical differences were found between closed and open mouth and between overlap on one nostril and not (p < . ), except between tmo and cm at two mv ( and l/min) when nc overlap on one nostril (fig. ) . conclusion: when the prongs of nc are not correctly placed in the nostrils, the fio decreases, but this impact is limited in our bench study. the impact of mv increases and mouth opening on the fio values is also important. introduction: the weaning of mechanical ventilation is an essential and delicate phase in the management of a resuscitation patient. the neurosurgical patient presents a number of specific problems, such as impaired control ventilatory control, coughing or the pharyngo-laryngeal intersection. however, it often allows short-term ventilatory withdrawal in the neurosurgical patient, probably largely by the simple fact that it authorizes the definitive cessation of sedation. the objective of the study and demonstrate the place of tracheotomy in neuro-resuscitation patients, and prevent its complications. a retrospective descriptive study of patients hospitalized in the neuro-resuscitation unit during the period january to december , of which patients benefited from surgical tracheotomy, is a frequency of % of all inpatients during this period. clinical, para-clinical, etiological, and therapeutic data were collected from hospitalization records. in a series of hospitalized patients, during the defined period, patients had surgical tracheotomy, a frequency of %, in the literature two studies or the data were extremely variable, with % in the study namen versus . % in the coplin study. of the tracheotomies, were performed by neurosurgeons, and by resuscitators at a frequency of %. the tracheotomy was performed on average days after the intubation of the patients, after verification of the impossibility of the extubation of the latter either for central affection of the ventilatory controls, or reached the mixed nerves and disorders of the laryngo-pharyngeal intersection and according to expert recommendations in -tracheotomy should not be performed in the intensive care unit before the fourth day of mechanical ventilation. different pathologies that patients suffered and required tracheotomy were: post-operative complications of brain tumors (brain stem and mixed nerves) with patients, a rate of %, vascular pathologies (stroke and cvt)), with patients ( %), traumatic pathologies, with patients ( %). cases, %, cases of secondary bleeding of the orifice, cases of tracheal stenosis, and case of tracheomalacia. the decan made after pharyngolaryngeal neurological examination, and according to sfar recommendations experts suggest that a multidisciplinary decanulation protocol available in resuscitation departments. conclusion: tracheotomy in neuro-resuscitation has its place, especially in view of the different complications specific to this type of patient, but no study has demonstrated its improvement in vital prognosis. post-tracheotomy complications can be considerably reduced if the protocols and expert recommendations are applied. introduction: noninvasive ventilation (niv) in intensive care (icu) is associated with the occurrence of frequent asynchronies related to the leaks around the interface, mainly auto-triggering and delayed cycling. their detection requires a respiratory muscles activity monitoring. diaphragmatic ultrasonography is a simple imaging technique available at bedside to assess diaphragm motion. whether diaphragmatic ultrasonography would allow detecting asynchronies due to leaks during niv is unknown. the aim of this study was to assess two methods of diaphragmatic ultrasonography (excursion and thickening), coupled with the airway pressure signal to detect patient-ventilator asynchronies during niv. patients and methods: nine healthy subjects were placed under niv and subjected to intentional inspiratory and expiratory leakage on the ventilator circuit to generate delayed cycling and auto-triggering, respectively. the flow, airway pressure and diaphragmatic electromyogram were collected in order to identify the asynchronies generated by the leaks. in the meantime, an ultrasound recording of the excursion of the right diaphragm and of the thickening of the right diaphragmatic zone of apposition were performed and combined with the display of airway pressure on the ultrasound screen. these records were analyzed a posteriori to define the diagnostic performance [including sensitivity (se), specificity (spe), positive predictive value (ppv), and negative predictive value (npv)] of the excursion and the thickening to detect asynchronies. the experimental setup generated a median of asynchronies per subject (interquartile range - ). auto-triggering was correctly identified by continuous recording of both excursion (se = %, spe = %, ppv = %, and npv = %, fig. a ) and thickening (se = %, spe = %, ppv = %, npv = % + fig. c ). delayed cycling was detected with a slightly lower performance by diaphragm excursion (se = %, spe = %, ppv = %, npv = % + fig. b ) and thickening (se = %, spe = %, ppv = %, npv = % + fig d) . discussion: these encouraging results may be tempered by a variable effectiveness of the technique from one subject to another, in particular concerning the excursion. moreover, their generalization to critically ill patients may depend on several factors including echogenicity, stability and amplitude of the ultrasound signal in this population. conclusion: ultrasound is a simple clinical tool available at the bedside to detect delayed cycling and auto-triggering associated with niv leaks, provided that the airway pressure curve is displayed on the screen of the ultrasound machine. further studies are needed to assess its usefulness in detecting other types of asynchronies and its feasibility in critically-ill patients. introduction: although extra-corporeal co removal (ecco r) is not recommended, strong rational supports the concept. we aimed to describe our single-center experience of ecco r in the setting of mild to moderate acute respiratory distress syndrome (ards) and chronic obstructive pulmonary disease (copd). we performed a retrospective case note review of patients admitted to our tertiary regional intensive care unit (icu) and commenced on ecco r from november to august . demographic data, physiologic data (including ph and partial pressure of carbon dioxide in arterial blood [paco ]) before ecco r starting, and at day were recorded. results: twenty one patients received ecco r. thirteen were managed with hemolung ® device, seven with prismalung ® and one with ila ® . indication for ecco r were copd exacerbation (n = ), mild to moderate ards (n = ), uncontrolled hypercapnia due to pneumonia (n = ), and hypercapnia due to bronchial compression by mediastinal adenopathy (n = ). before starting ecco r, median minute ventilation, ph and paco were respectively . [ . , . conclusion: our observational cohort shows that ecco r therapy is effective to reduce paco and improve ph in the settings of mild ards and copd exacerbation. however, early weaning of sedation and pressure support ventilation might limit the decrease of respiratory rate and tidal volume. introduction: duchenne muscular dystrophy (dmd) is an x-linked recessive genetic disorder, caused by mutations in the dmd gene. respiratory failure is classical in the natural history of this disease. little is known about the diaphragm echographic pattern and the spectrum of patients with diaphragmatic paralysis in this disease. we aimed to assess the relationship between age and diaphragmatic motion and thickening fraction (tf) and to characterize the spectrum of patients with diaphragmatic paralysis. patients and methods: we included retrospectively dmd patients who experienced diaphragmatic echography and spirometry in our institution. diaphragmatic paralysis was defined as a diaphragm with tf < %. results: dmd patients were included in this study. all dmd patients were wheelchair bound. dmd patients had severe respiratory insufficiency with a median vc at % of predicted value [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . . % of patients were on home mechanical ventilation (hmv) and % were invasively ventilated. right diaphragmatic motion at deep inspiration was severely altered with a median of . mm [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . right tf of the diaphragm was severely altered with a median of . % [ . - . ] . . % of patients disclosed a paralyzed diaphragm pattern with a right tf < %. the age was inversely correlated with tf of the diaphragm (r = - . , p . ) and with the right diaphragm inspiration motion (r = − . p < . ). patients with diaphragm paralysis were older with median age at . years [ - . ], with severe respiratory impairment (median sitting cv = %) and median cumulated annual hmv duration at . years. conclusion: in dmd, age is inversely correlated with diaphragm function. diaphragm paralysis is frequent in older adult non-ambulant dmd. . the final probability model included the previous identified factors in addition to age and saps ii score, this model exhibited good calibration (hosmer-lemeshow x , p = . ) and good discrimination (roc-auc, . + % confidence interval, . - . ) (fig. ) . conclusion: our cohort study identified risk factors of icu death, mainly collected at admission among patients with aecopd. the proposed probability model has a good performance in predicting the short-term prognosis. further evaluation in other cohorts is needed. introduction: precarity is a complex notion including several components, and its definition is still debated. it is more subtle than financial poverty alone, and can increase population's health insecurity. we hypothesize that patients with precarity features may have different epidemiologic characteristics and icu outcomes than the general population. the aim of this study was to describe precarity features and outcomes of patients admitted to an icu located in a high poverty rate territory. patients and methods: we conducted a prospective single-center observational study of all patients admitted to icu of the saint-denis general hospital, from february to july . precarity features were classified in categories-absence of health insurance, lack of incomes or minimum allowances, homelessness or social home or hotel, and social isolation (no social link, or associations or neighbors). others social data were collected (speaking fluent french and education level) as well as usual clinical icu data. results: among patients included, precarity features were found in patients ( . %). income precarity was the most common, followed by accommodation precarity, health precarity and relation precarity (table ) . precarity was not associated with hospital mortality ( vs. . %, p = . ). all types of precarity were significantly associated with each other. precarious patients were younger ( vs. years-old, p < . ) and had less comorbidities. we found no differences concerning hospital or icu length of stay ( vs. days, p = . ) or concerning education level between precarious patients and the others. conclusion: our pilot study shows that precarity features are indeed very frequent and are often cumulated. with respect to the small patient sample, precarity does not seems to be associated with hospital mortality or length of stay. further investigations with larger patient samples and multicenter designs are warranted to investigate properly the impact of precarity on icu management and outcomes. introduction: population aging is a global and expanding phenomenon. elderly people are particularly vulnerable, and often need health care. this demographic evolution also affects intensive care units, and years old patient are now frequently admitted-it corresponds to % of admission in france. indeed we have analyzed the change in management of this very elderly people ( years old and more) over the past years in a french medical intensive care unit in a provincial university hospital. patients and methods: a retrospective cohort study was conducted using medical intensive care unit registry for demographic, physiological and diagnostic data from january to december . characteristics and treatment intensity during medical icu stay were specified, and short term and long term mortality were also recorded. results: a total of admissions, including octogenarians and older, were registered during the period. the proportion of very elderly people gradually increase from to %. intensity of treatment (organ support) increased from . from . per patient between the primary and the second part of the period, notably linked to mechanical ventilation ( vs. %, p < . ) and vasopressor infusion ( vs. %, p < . ). even if severity score increased (saps increase from . to . , p < . ), the icu mortality remains constant ( vs. . %). however, we were surprised to observe an increase in year mortality ( to %, p < . ). conclusion: between and , proportion of admission of very elderly people has increased two fold in our icu. although treatment intensity increases for more severe patients, icu mortality remains the same. nevertheless, absence of beneficial effect after year remains questioning. could icu to ward transfers and care course after hospital be optimized? lived alone at home, % in couple or with ther family, ( %) in retirement home and ( %) in nursing home. ( %) had a simplified ald score lower than indicating good functional independence. the more frequent diagnosis were acute pulmonary oedema and exacerbated copd. the mean simplified acute physiology score (saps ii) was ± . the treatment were were invasive mechanical ventilation ( %), only with noninvasive ventilation ( %), vasopressor agents ( %) and ( %) with renal replacement therapy. the average length of stay was . ± . days. after adjustment on sap-sii (without age), those invasive treatments were not associated with mortality no more than age. global mortality rate was %. ( %) were subject of a procedure for limiting therapeutics, among which ( %) died in the unit versus % for the other patients. the decision of therapeutic limitation was associated with severity of illness as measured by the sapsii (p = . ) but not with age. frequency of therapeutic limitation were similar in icu and intermediate care units. the mortality rate is lower than the older studies (s de rooij - %). unlike the study of p. biston ( ) which covers only the most serious cases, the mortality for any type of gravity remains reasonable. the procedure for limiting care were frequent especially for the most severe pathologies but all the patients who a decision of limiting care were stated were not dead. the patients over years old admit in french icu are very chosen. any major treatment appear to enhance mortality. introduction: due to advancements in medical technology and management of illnesses, an increasing proportion of critically ill patients are elderly. few information is available on the prognosis of these patients after icu discharge. the aim of this study was to analyze the clinical characteristics and long-term outcomes of elderly admitted to icu. patients and methods: monocentric, observational prospective study was performed. all elderly survivors (aged ≥ years) after an icu stay in a medical tunisian icu between january and december were included. data collected were: clinical features at admission, acute management procedures, functional characteristics and vital parameters (blood pressure, heart rate, abg's) at icu discharge. patients were followed during year via phone calls. a multivariate regression analysis was used to identify risk factors for one-year mortality. results: during the two-years study period, elderly patients were discharged alive. ( . %) were male. clinical features of elderly survivors were: mean age, . ± . years, median of charlson index, [ - ], chronic respiratory disease, ( . %), hypertension, ( . %) and diabetes ( . %). the most common reason for admission was acute respiratory failure in ( . %) patients and mean saps ii was . ± . . ( . %) patients required invasive ventilatory support, ( . %) vasoactive drugs and ( . %) received renal replacement therapy. the median of icu length of stay was days. the follow up was possible for ( . %) patients. mortality rate at year was . %. predictors of one-year fatal outcome in univariate analysis were as follows-saps ii (p = . ), heart rate at discharge (p = . ), decline in functional status (p = . ), world health organization (who) performance status at discharge (p = . ) and readmission within month (p = . ). multivariate regression showed that saps ii (or, . + % ci [ . - . ] + p = . ), who performance status at discharge (or, . + % ci [ . - . ] + p = . ) and heart rate (or, . + % ci [ . - . ] + p = . ) were independent risk factors of one-year mortality. conclusion: this study suggests that age and comorbidities should not be exclusion criteria for icu admission. in the long-term only saps ii, performance status and heart rate were significantly associated with one-year mortality in the elderly icu survivors. introduction: triage is an act performed at the entrance of emergency departments (ed's), it allows the classification of patients in different categories according to the seriousness and the priorities of treatment. vital emergencies are geared towards resuscitation room. in our ed, triage is not codified and is «done» in most cases by an unqualified staff. the aim of this work is to show the impact of absence of triage on the functionning of the resuscitation room. patients and methods: it's a prospective study, conducted in the ed of a university hospital, over months, including all patients over years old, admitted at the resuscitation room. epidemiological and clinical data of patients, their ccmu classification (classification clinique des malades aux urgences) have been specified, as well as their outcomes. we collected patients. the average age was . years old ( - years), for a sex ratio of . . forty patients ( . %) arrived «standing» at the ed. patients ccmu and represented . % of these admissions. the systolic blood pressure was under mmhg in % of cases, the glasgow coma scale < . in % of cases, and the spo < % in % of cases. mortality was . %. the other patients were admitted at the intensive care unit ( %), at the short stay hospitalization unit ( . %), at the operating room ( . %), or transferred to other departments ( . %). discussion: the patients ccmu and arrived by ambulance, «lying» , were considered as severe. the proximity of the resuscitation room of consultation rooms allows it to be used sometimes in flows' management and as a place of triage. the patients transferred straight to services didn't show signs of vital distress motiving their initial admission at resuscitation room or even at ed. those admitted at the short stay hospitalization unit were steady, but needed complementary examinations, specialized expert advice, or were waiting for a downstream bed. conclusion: a triage system must be introduced at the entrance of our emergency departments. the staff involved in that sorting must be identified, and disposing of a triage scale in order to figure out the degree of priority associated to patients conditions, and direct the ones needing urgent care towards the resuscitation room. results: one hundred patients were included, with average age of . years old ( - ) and sex ratio of . . these patients were brought to emergencies by their family in % of cases. reasons for admissions were varied, severe deterioration of their general condition ( %), alteration of consciousness ( %), respiratory distress ( %), convulsive seizures ( %). therapeutic interventions were cardio-pulmonary resuscitation ( %), fluid volume expansion ( %), mechanical ventilation ( %), administration of vasopressors ( %) and anticonvulsants ( %). mortality at the resuscitation room was %. thirty eight patients were admitted at the intensive care unit, equally at the short stay hospitalization unit (ssu) of ed. two patients returned home at the request of their family. discussion: these results show that ed's remain the last resort in front of oncology patient who is deteriorating, the occurrence of complications, and sometimes, the psychological exhaustion or family's obstinacy. emergencies departments continue admitting patients with terminal cancer, but are not organized for medium and long term care. the creation of a palliative care unit and the organization of home-based care will allow the prevention and treatment of complications as well as a psychological care, thus improving the living quality of these patients and their relatives. refusal of intensive care admission: assessment of a tunisian icu practices merhabene takoua introduction: need of intensive care exceeds its availability in several countries. as a consequence, rationing intensive care unit (icu) beds is common and often leads to admission refusal. purpose-to report refusal determinants and characteristics of patients associated with decisions to deny icu admission. this study was performed at the icu of abderrahman mami hospital, a -bed icu in ariana, tunisia. it was a prospective study enrolled between st january and th december . no predefined admission criteria were determined. decisions to admit are based on a combination of patient-related factors, severity of illness and bed availability. all consecutive patients referred for admission to icu during the study period were included. groups were defined gi-admitted patients and gii-refused patients. the reasons for refusal were categorized as follows: too well to benefit, too sick to benefit, patient or family refusal, necessity of other exploration not available in our institution and unit too busy. results: during the study period, icu admission was requested for patients of whom were admitted ( %). of the patients refused, only were admitted to icu later. refusal of icu admission came in % of cases from the emergency room and wards of our hospital, in % from other hospitals of whom % without icu. reasons of refusal were no beds availability ( . %), too sick to benefit from icu ( %), too well ( . %) and necessity of other exploration ( . %). no differences in demographic characteristic between the two groups were noted. among the refused patients, when compared with admitted patients, we found higher proportions of hematologic malignancies (p < . ) and cardiocirculatory arrest (p = . ). on the other hand, admitted patients were more likely to have cardio-respiratory comorbidities ( / vs. / , p = . ) and more need to mechanical ventilatory support ( vs. , p = . ). conclusion: our study confirms that icu refusal rate still high. it depends on both icu organization and patient characteristics. acute heart failure syndroms in intensive care: clinical features, management and outcome jamoussi amira , ajili achraf , merhebene takoua introduction: classification of acute heart failure (ahf) into clinical scenari (cs) was first proposed to facilitate early management ( ) . a decade after implementation of this approach, epidemiological and evolutive data based on this classification are interesting to investigate. that is why we aim to describe frequencies, management and mortality of each ahf syndrom in intensive care. a prospective study of patients > years with ahf admitted to the medical intensive care unit (icu) of abderrahmen mami hospital from january to august was conducted. patients were classified according to the clinical scenari ( ). clinical, therapeutic and outcome findings were recorded. results: during the study period ( months), we admitted patients in icu from whom ( . %) presented with ahf and then enrolled. the median age was of ± . years and sex-ratio . . a medical history of copd ( . %), hypertension ( . %), diabetes ( . %), ischemic cardiopathy ( %) and valvular cardiopathy ( . %) were noticed. at admission, severity assessement scores were: median apache ii . ± . and median saps ii ± . . clinical and evolutive characteristics according to clinical scenari are listed in table . conclusion: cs and cs are the most frequent ahf syndroms in icu and also have the best outcome. introduction: in cardiac arrest patients resuscitated from an ischemic ventricular fibrillation or tachycardia (vf/vt), both incidence and risk factors of recurrent severe arrhythmia are unclear. whether it is useful to give a prophylactic anti-arrhythmic (aa) treatment during the first hours and days is debated, particularly when a successful coronary reperfusion was provided. we aimed to evaluate the incidence of severe arrhythmia in patients resuscitated from an ischemic vf vt and to identify risk factors for developing arrhythmia during their icu stay. the procat registry captures all data from patients admitted in a tertiary hospital center after a resuscitated cardiac arrest (ca). we selected patients with an initial vf vt caused by an acute coronary syndrome (acs) and who were successfully treated with early percutaneous coronary intervention (pci) on admission. the primary endpoint was the recurrence of major arrhythmia between icu admission and icu discharge. all arrhythmias resulting in ca recurrence and or severe arterial hypotension requiring infusion of vasopressors were classified as major arrhythmias. multivariate logistic regression identified factors associated with the occurrence of major arrhythmias. results: between / and / , consecutive ca patients were included in the analysis. all patients underwent a successful pci of the infarct-related artery on hospital arrival. the only drug used as a prophylactic aa treatment was amiodarone, which was employed in / patients ( %). overall, / patients ( . %) had a major arrhythmia recurrence during their icu stay. a large majority of these major arrhythmia recurrences ( . %) occurred during the first h. characteristics of patients with and without major arrhythmia recurrence are described in the table . in multivariate analysis, public place location (or . [ . - . ], p = . ) and male gender (or . [ . - . ], p = . ) were both associated with a lower risk of major arrhythmia recurrence during the icu stay. prophylactic aa treatment was not associated with a lower risk of recurrences of major arrhythmias (or . [ . - . ], p = . ). conclusion: despite an early coronary reperfusion, more than % of our post-cardiac arrest patients experienced a recurrent severe arrhythmia during the post-resuscitation period, mostly during the first h in the icu. this proportion is much higher than what is reported in common acute coronary syndrome (without cardiac arrest) and further studies are needed to explore protective strategies. introduction: during symptomatic treatment of septic shock, markers of anaerobic metabolism may be used in a goal-oriented strategy. the recent international guidelines for management of sepsis and septic shock suggested guiding resuscitation to normalize lactate as a marker of tissue hypoperfusion. the purpose of this study was to evaluate the kinetics of lactate and other markers during the first three hours and to compare their levels between survivors and non survivors. we conducted a prospective, observational, single-center study of patients admitted to a general icu from the may to august . inclusion criteria were patients age ≥ , intubated and under mechanical ventilation with septic shock as defined by the third international consensus conference. simultaneous sampling of arterial and central venous blood gas were collected at h and h to obtain lactate (mmol/l), and scvo (%). delta pco (mmhg) and delta pco /cavo (mmhg/ml) were computed by our patient data management system and presented as a chart with additional hemodynamic data for clinical decision support. comparisons of values between groups were made by mann-whitney u test as appropriate. p < . was considered statistically significant. all reported p values are two-sided. statistical analysis was performed using systat ver. . . results: we studied intubated septic shock patients aged ± years, saps ii ± , sofa ± . . community pneumonia and peritonitis were the major sources of infection. icu mortality rate was %. all patients received norepinephrine ( . ± . µg/kg/ min), two patients received dobutamine ( . ± . µg/kg/min). the evolution of markers is summarized in table . at h and h , arterial lactate levels were higher in non-survivors than in survivors, but did not decrease at h in both groups. at h there was no statistical difference concerning scvo , delta pco and delta pco /cavo . after three hours of resuscitation, delta pco and delta pco /cavo ratio decreased and scvo increased in survivors. survivors had lower delta pco and delta pco /cavo ratio than non survivors. conclusion: although high lactate level is a key signal of anaerobic metabolism, it did not decrease during the first three hours in this group of severe septic shock patients. instead of using lactate, delta pco and delta pco /cavo kinetics could be integrated in a goaloriented strategy for septic shock resuscitation. introduction: to assess whether, in patients under mechanical ventilation, fluid responsiveness is predicted by the effects of short respiratory holds on cardiac index estimated by oesophageal doppler (cidoppler). patients and methods: in patients, before infusing ml of saline, we measured cidoppler before and during the last seconds of successive -second end-inspiratory occlusion (eio) and endexpiratory occlusion (eeo), separated by min. patients in whom volume expansion increased cardiac index (transpulmonary thermodilution) > % were defined as "fluid responders". results: eeo increased cidoppler more in responders than in nonresponders ( ± vs. ± %, respectively, p < . ) and eio decreased cidoppler more in responders than in non-responders (- ± vs. - ± %, respectively, p = . ). thus, when adding the absolute values of changes in ci observed during both occlusions, cidoppler changed by ± % in responders and ± % in nonresponders. fluid responsiveness was predicted by the eeo-induced change in cidoppler with an area under the receiver operating characteristic (roc) curve of . ( % confidence interval- . - . ) and a threshold value of % increase in cidoppler. it was predicted by the sum of absolute values of changes in cidoppler during both occlusions with a similar area under the roc curve ( . ( . - . )) and with a threshold of % change in cidoppler, which is more compatible with oesophageal doppler precision. in this case, the sensitivity was ( - )% and the specificity was ( - )%. conclusion: if consecutive eio and eeo change cidoppler > % in total, it is very likely that volume expansion will be efficient in terms of cardiac output. the measurement of cardiac output using a signal morphology-based form of impedance cardiography (physioflow ® ) in intensive care unit: comparison with the trans thoracic echocardiography. introduction: in the intensive care units, the cardiac output (co) is one of the main hemodynamic parameters required to manage patients in shock. the physioflow ® is a new non-invasive method using the waveform analysis of the thoracic impedance signal (ti) to assess co. in hemodynamicaly unstable patients, no studies have evaluated the level of agreement between the co estimated by transthoracic echocardiography (co-tte) and that measured using the waveform analysis of thoracic impedance physioflow ® (co-ti). the objective of this study was to evaluate the ability of co-ti relative to co-tte to estimate the absolute co value and detect the expected variation co (v-co) in critically ill patients. patients and methods: fourteen patients sedated and mechanically ventilated, in shock under catecholamines and monitorred with tte and ti physioflow ® were included. hemodynamic datas, stroke volume (sv) and co with two monitoring were performed at baseline min before passive leg raising (plr), s after plr and min after volume expansion (ve) of ml of saline solution. responders were defined by an increase > % of cardiac output (v-co) after plr. results: fourteen pairs of tte and ti measurements were compared. the median (iqr) age was years ( - ), igs was ( - ). only patients were responders after plr. there was a significant correlation between the co-tte and co-ti measurements (r = . , p < . ). the median bias was . l/min and the limits of agreement (loas) were − . and . l/min. there was a significant correlation between v-co-tte and v-co-ti (r = . , p = . ) (fig. ) . the median bias was- . % and the loas for v-co were respectively - . and + . %. conclusion: the co measured with physioflow ® , a signal morphology-based impedance cardiography, is correlated to the co measured with tte. however, the high loa observed in this preliminary study underline the necessity to remain careful and wait for further inclusions. - ] vs. . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] days, p = . ). despite imbalancedunderlying characteristics in terms of demographics and comorbidities, in-icu mortality rates were similar between patients ( . vs. %, p = . ). conclusion: prior bb treatment have limited impact on the severity of acute circulatory failure in septic shock and is not associated with increased mortality despite the underlying frailty of patients. introduction: cardiac output monitoring is a key component in the management of critically ill patients. cardiac output estimated by transthoracic echocardiography is documented in patient with atrial fibrillation, but a large part of transpulmonary thermodilution validation studies excluded this specific population. the objective of this study was to evaluate cardiac output mesurement and trend ability by transpulmonary thermodilution relative to transthoracic echocardiography in critically ill mechanically ventilated patients with atrial fibrillation. patients and methods: thirty mechanically ventilated patients requiring hemodynamic assessment were included in a prospective observational study. cardiac output was mesured simultaneously with transpulmonary thermodilution and transthoracic echocardiography. seventy-four pairs of cardiac output measurements were compared. the two measurements were significantly correlated (r = . et p < . ). the mean bias was - . l/min, the limits of agreement were - . and + . l/min, and the percentage error was . %. thirty-four pairs of cardiac output variation measurements were compared. there was no significant correlation between cardiac output variation measurements by transpulmonary thermodilution and transthoracic echocardiography. the mean bias was − . l/ min and the limits of agreement were − . and + . l/min. with a % exclusion zone, the four-quadrant plot had a concordance rate of . %. the polar plot had a mean polar angle of . ° with % confidence interval between − . ° and . °. conclusion: in critically ill mechanically ventilated patients with atrial fibrillation, cardiac output measurements with transpulmonary thermodilution and transthoracic echocardiography are not interchangeable. introduction: basic critical care echocardiography (cce) relies on transthoracic echocardiography (tte). we sought to assess the diagnostic capacity of a next-generation micro-digital broadband beamformer in patients with cardiopulmonary compromise. all patients with acute circulatory respiratory failure underwent two basic tte assessments using successively a next-generation micro-digital broadband beamformer ( elements, - mhz) incorporated in a sector phased array probe with twodimensional, m-mode and color doppler mapping capacities which was connected to a touchscreen interface (lumify, philips), and using a compact full-feature imaging system ( elements, - mhz + cx , philips). tte examinations were independently performed in random order by two intensivists with expertise in cce, within a -min time frame without therapeutic intervention. imaging quality was graded from (no image in the corresponding view) to (clear identification of % of endocardial boarders). the concordance of qualitative data was assessed using the kappa test and agreement of two-dimensional measurements (left ventricular end-diastolic diameter [lvedd], ratio of right ventricular (rv) and lv end-diastolic diameters [rvedd lvedd] + end-expiratory inferior vena cava diameter [dexpivc]) was evaluated using intraclass coefficient correlation (icc). results: thirty consecutive patients were studied, without any exclusion for absence of tte images (age, ± years, sap-sii, ± , % ventilated, % under catecholamines, lactate, . ± . mmol l). the proportion of echocardiographic views eligible for interpretation and mean duration of tte examinations were similar with the miniaturized and full-feature systems ( vs. %, . ± . vs. . ± . min, p = . ). two-dimensional imaging quality grade was lower with the miniaturized system ( system. concordance of two-dimensional measurements was also good-to-excellent (table ) . conclusion: for basic cce use, next-generation micro-digital broadband beamformer appears providing reliable information with good-to-excellent diagnostic capability, accurate two-dimensional measurements, and adapted therapeutic suggestions. these preliminary data require further confirmation. introduction: acute kidney injury (aki) in very old patients (over years) admitted in intensive care unit (icu) is a frequent issue and is known to be associated with a severe prognosis. we aimed at describing the clinical characteristics and prognosis of such a population. the objective of the study was dual: first to evaluate the short and long term mortality of these patients, second to determine the factors associated with a poor outcome. patients and methods: we conducted a descriptive, retrospective and monocentric study based on the hospital records of patients over years with aki admitted in our icu between january and december . the patients were selected according to the kdigo criteria ( ) . survivals at the discharge from hospital, at day and at year were assessed. the factors associated with mortality at year were scrutinized. results: after excluding patients for an initial therapeutic limitation, the data of remaining patients were reviewed. the patients were years old (interquartile range, iqr - ) and were predominantly male gender ( %). saps ii and sofa score at admission were (iqr - ) and (iqr - ) respectively. % of the patients needed for mechanical ventilation and % of them needed for catecholamine use. septic ( %), prerenal ( %), iatrogenic ( %) and cardiogenic injury ( %) were the leading cause of aki. dialysis was performed in % of patients. the overall mortality at the discharge from icu, at day and at year was , and % respectively (fig. ) . neither were the age, the comorbidities, the etiology of aki nor the need for dialysis associated to a significant increase in mortality. a stepwise cox regression analysis revealed saps ii and blood lactate level at icu admission as independent risk factors associated with year mortality. conclusion: aki at admission in icu is associated with a high mortality at year in an elderly population. main long term prognostic factors are linked to the initial severity at icu admission. introduction: the proportion of elderly around the world doesn't stop growing and increases the consumption in health care. however, lots of studies report the impact of the age on the decision to admit a patient to the icu despite no triage recommendation exists. the primary objective was to determine prognostic factors of death for the years and over at admission to the icu and secondly to evaluate their functional prognostic at short and medium term after their exit. patients and methods: prospective and observational study conducted in our icu beds unit from august to february . patients of years and over were listed. the dying patients arriving after a pre-hospital resuscitation for whom no therapeutic plan has been initiated and those admitted for an organ donation were excluded. the primary outcome was the duration between the admission and the potential death during the follow-up. the secondary outcomes were the necessity to entry an healthcare institution or the loss of one autonomy point on the adl french scale after the hospitalization. results: patients of the admissions were included. the igs ii and sofa average scores were respectively . ± . and . ± . . the most common diagnosis were a septic shock ( patients), a cardiopulmonary arrest ( patients), a cardiogenic shock ( patients) and a pulmonary oedema or a lung infection ( patients fig. survival of very old patients with aki in icu (%) each). patients ( . %) died during the follow up- at the icu, during ward and during re-education or after their home return. from a multivariate analysis (table ) , anisocoria, cardiopulmonary arrest and acute kidney injury (aki > ) seem to be independent risk factors of death. patients were alive at the end of the follow up. recovered their previous autonomy, needed a place in a specialized institution. all the other lost a part of autonomy months after their home return with the average loss of one point on the adl autonomy french scale. conclusion: anisocoria, aki and cardiopulmonary arrest seem to be independent risk factors of death for those patients. concerning the survivors, a stay at the icu lead to an increased dependency. other studies have to be led to evaluate which of our patients could have get the best benefit of their stay to prevent from a misuse of the structure. introduction: context-among the severe complications of preeclampsia, acute kidney injury (aki) poses a dilemma if features of thrombotic microangiopathy (tma) are present. although a hellp syndrome is considerably more frequent, ruling out a flare of atypical haemolytic and uremic syndrome (hus) is then of utmost importance. objective-to improve the differential diagnosis procedure in cases of post-partum aki. patients and methods: a hundred and five cases of post-partum aki, admitted in the last years ( ) ( ) ( ) ( ) ( ) in french icu from different regions, were analysed. initial and final diagnosis, renal features, haemostasis and tma parameters were all analysed, paying a special attention to their dynamics within the first days following the delivery. results: the main circumstances of aki were severe preeclampsia (n = ), post-partum haemorrhage (pph, n = ) and primitive tma (n = , including atypical hus and thrombotic thrombocytopenic purpura). among the thirteen cases of renal cortical necrosis, were associated with preeclampsia. congruence between the initial and the final diagnosis was low ( %). thus, none of the women referred to our centers for a suspicion of non-placental tma has received a final diagnosis of non-placental tma (and instead had a pe or a pph). conversely, all women with a final diagnosis of nonplacental tma were referred for a suspicion of pe-related tma, or with a pph which polluted the diagnosis. tranexamic acid was largely used in the context of pph ( %), at a dose up to grams total. taking into account the final diagnosis, we subjectively concluded that plasma exchanges and eculizumab were abusively indicated in and cases, respectively, of typical hellp syndrome. plasma exchanges were in itiated in all cases, a mean h following the admission. dynamics of hemoglobin, haptoglobin, and liver enzymes were poorly discriminant. the dynamic pattern of ldh and of platelets, in contrast, was statistically different between primitive tma-related aki and other groups-at day , platelets increased in preeclamptic women, and in other circumstances, but not in patients with primitive tma. a classification and regression tree (cart) independently confirmed the usefulness of platelets and ldh trajectory in the diagnostic algorithm (fig. ) . conclusion: the trajectory of ldh and platelet count is useful to identify the cause of post-partum aki, and the clinician may reasonably take therapeutic decisions at day post-delivery. introduction: continuous veno-venous hemofiltration (cvvhf) is a common practice in intensive care units (icu). because it is continuous, the choice of anticoagulation is essential-regional anticoagulation fig. analysis of post-partum aki cases with citrate or systemic with unfractionned heparin or low molecular weight heparin (lmwh). filter's lifespan is a major issue regarding filtration's effectiveness and cost. in this study, we compared the filter's lifespan between lmwh and citrate anticoagulation. patients and methods: a monocentric retrospective study was led from january to october . all the cvvhf sessions during this period were included. prismaflex© monitors (hospal) were used. practioners were free to choose between citrate or lmwh defining groups. we aimed a post filter ionized calcemia between . to . mmol/l in citrate group + and a post filter anti xa activity between . to . ui/ml in lmwh. results: cvvhf sessions were included- with lmwh anticoagulation, and with citrate. patients were years old on average, primarly males ( %), with an initial average saps ii score of . icu mortality was %. patients' hemostasis was measured before each cvvhf session, without any significant difference between the groups. global filter's lifespan was h + h in citrate group versus h in lmwh, without significant difference (p = . ) (fig. ) . no serious side effect, especially hemorrhage in the lmwh group, was reported. filtration efficiency, represented by the urea reduction ratio during the first cvvhf session, was similar, % ± % in lmwh group versus % ± % in citrate group (p = . ). conclusion: both anticoagulation-systemic with lmwh or regional with citrate can be used in icu. both methods enable long and comparable filter lifespan, with similar filtration efficiency and without serious adverse events. our results need to be confirmed by a randomized propective study. introduction: arf during the post-partum period is a rare complication. the main etiologies are post-partum haemorrhage (pph) and thrombotic microangiopathy (tma). rrt may be required. the aim of this study was to identify variables associated with rrt in this population admitted in icu. patients and methods: we conducted a study using retrospectively collected data in a cohort of patient with post-partum arf according to the kdigo criteria and requiring icu in the university hospital of lille from until . two groups were compared-rrt and non rrt patients. demographic and obstetrical data as well as data during icu stay and patients' outcome were collected. etiologies of arf, kdigo stage, anuria, hemolysis parameters and biological data at icu admission were studied. comparisons were made using a chi-two or fisher exact test or a mann-whitney u test. odds ratio (or) for the statistically different criteria were studied. results: twenty-two patients requiring rrt were compared to the patients without rrt. the two main etiologies of arf were tma ( . %) and pph ( . %). vaginal delivery was significantly more frequent in the rrt group compared with caesarian delivery (p = . ). use of rtt was significantly increased after pph compared the others etiology of arf (p = . ). in the rrt group, the icu length of stay was longer (p < . ) and igs ii score was higher (p < . ). higher kdigo score was observed in rrt patients (in the rrt group-kdigo = , = %, = %, and without rrt-kdigo = . %, = %, = %, p < . ). anuria h after icu admission was more frequent in cases of rtt ( . % versus . %, p < . ). hemolysis was greater in rrt patients with lower haptoglobin (p = . ) and increased lactate deshydrogenase (ldh) (p = . ). the association with rrt requirement was stronger with the duration of anuria, with an or at h at . [ . - . ] and at h at . [ . - ] . a lower haptoglobin was associated with a higher risk of rtt (or . [ . - . ]), as well as pph (or . [ . - . ] ) and vaginal delivery (or . [ . - . ]). conclusion: hemolysis parameters and anuria seemed useful criteria to identify patients at higher risk of rrt early during their icu admission. introduction: renal replacement therapy (rrt) has three aimsrestoring homeostasis, ensuring survival and preserving the potential for renal recovery. the main indication of rrt in icu is acute renal failure, correlated with a very important rate of mortality despite the progress made in its management. patients and methods: the objective of this work is to take stock of the indications and the objectives of the rrt in icu. through a prospective study, we report a serie of cases, collected at the multipurpose resuscitation unit of the avicenna military hospital in marrakech between september and september . results: the average age of our patients is , ± , years with extremes ranging from to years and a male predominance ( %). the main reasons for admission were hemodynamic distress in . % of cases, followed by septic shock in . % of cases, neurological and respiratory distress were noted in . and . % of cases, respectively. rrt indications were severe acidosis in % of patients, followed by % hyperkalaemia, acute pulmonary edema in %, hemodynamic instability in patients with chronic renal failure in %, acute renal failure in %, and hyperuriaemia in % of cases. the technique chosen is conventional intermittent hemodialysis with a synthetic membrane. the main duration of the sessions was h min ± mn. vascular access was a right internal jugular catheter in . % of patients and left in . %, right femoral catheter in . % of patients and left in . %, arteriovenous fistula (fav) and a tunneled catheter in . and . % of patients. mortality was , %, chronicity progressed in . % of cases and total or partial recovery of normal renal function in % of cases. conclusion: we have a high rate of mortality in our icu that's why we will focus on prevention of risk of renal failure in our patients. introduction: there is limited information on the outcome of acute kidney injury (aki) in patients with traumatic intracranial hemorrhage (tich). tich patient with aki was related high mortality rate. the aim of this study is to estimate the outcome using different renal replacement therapy on the survival rate and rate of long term renal-replacement therapy in adult tich patient. patients and methods: we retrospectively identified a total of tich patients with aki who required glycerol or mannitol therapy admitted to the intensive care unit during a -year period ending dec from the national health insurance research database. demographic data, severity of tich, medication, level of care, type of head surgery were collected. all patients subjects were older than > years. we also excluded patients diagnosed with tich before the cohort entry date, hemodialysis before tich, chronic kidney disease cancer coagulation defects purpura and other hemorrhagic conditions, mortality mechanical ventilation ischemic heart disease before tracking. the primary outcome was overall survival at day . the secondary outcome was the rate of long term hd therapy. results: a total of patients were enrolled. the kaplan-meier estimates of mortality at day did not differ significantly between the continuous veno-venous hemofiltration (cvvh) and hemodialysis (hd) strategies + deaths occurred among patients receiving cvvh-strategy group and deaths occurred among patients receiving hd-strategy group (adjusted hazard ratio: . , % ci . to . ; p = . ). the rate of long term hd was higher in the hd-strategy group than in the cvvh-strategy group ( . vs. . %, p = . ) especially in injury severity score ≥ group (table ) . discussion: in our study, tich patient with aki receving cvvh may have effect on renal blood flow protection or cytokine removal which lower the rate of long term hd. conclusion: these clinical data provides readers interventions to improve outcomes in this population and future study are needed to confirm the result. this study highlights the importance different renal replecement therapy in the tich with aki population (table ) . khaleq khalid , hattabi khalid , bensardi fatima zahra , bouhouri m. a , nciri a , hamoudi d , alharrar r introduction: the combined progress of abdominal surgery and anesthesia lead to more frequent surgical indications, including for fragile patients or serious pathologiespostoperative morbidity and mortality is an element that requires evaluation and analysis in surgical resuscitation. although pathological processes and new therapeutic approaches in surgery are currently well known, data on risk factors for morbidity and mortality are less available. the aim of our work is to evaluate the post-operative morbidity and mortality rate and to identify the main predictive factors. patients and methods: a retrospective-cohort, unicentric study that included all consecutive patients hospitalized in the surgical resuscitation department after abdominal surgery regardless of the operated organ, during years. the structured sheet of data collection included more than items on all perioperative data concerning the patient, the disease, and the operating surgeons. postoperative mortality and morbidity were defined as in-hospital death and complications. a first descriptive analysis of the various parameters collected was carried out a bivariate analysis was then performed to study the factors affecting morbidity and mortality in digestive surgery the comparison was made using the student's t test for quantitative variables and the chi square for the qualitative variables. a difference is considered significant when p < . ( %). results: among patients, the in-hospital death rate was . % and the overall morbidity rate was . %, the mean age was . ± , years with extreme ages of years and years with sex ratio of . . five factors were incriminated in post: operative mortality notably:renal failure p = . , duration of stay p = . , parenteral nutrition p = . , long duration of intubation p = . , perioperative blood transfusion p = . . three factors influencing morbidity were found: duration of stay p = . , parenteral nutrition p = . , long duration of intubation p = . . conclusion: knowledge of the true frequency of both mortality and morbidity is crucial in planning health care and research and identifying risk factors. introduction: tools to quantify and assess bowl management in critically ill are still very limited and often over-looked. with the primary fig. filter's lifespan concern of optimizing patients to preserve life, the problem of bowel care has been given less priority. the aim of this study was to use ultrasonographic measurements of gastric emptying in the critically ill as a tool of measurement of the impact of different specific factors of icu stay on bowl emptying. patients and methods: this is a prospective study conducted in an intensive care unit for months. it included patients. ultrasonic imaging of antral sections was undertaken every min for the first h and every min thereafter until total emptying. correlation analyses were calculated, applying an adjusted significance level (pb < . ) to correct for multiple testing. results: all our patients were above the age of . the median of age was years old . of our patients were male and were female. the total emptying median time was ± min. significant correlation was observed between length of stay and delay in bowl emptying. mechanical ventilation had also significant relation with slower bowl progression and gastric emptying. patients in septic shock had tendencies to earlier delayed bowl emptying compare to others patients included in our study. conclusion: the study we conducted is a pilot study. further studies should be conducted and unltrasonografic gastric assessment could be standardized in protocols to assess clinical decision making and improve nutrition and bowl management in icu patients. introduction: enteral nutrition, via a feeding tube, is often used in intensive care units (icu) to supply artificial nutrition to critically ill patients. the feeding tube is also commonly used to administrate drug therapy as well. however, there is a lack of knowledge of the nurses about this way of administration. this could be a potential source of medicine-related illness. the purpose of this study was first, to evaluate the nurse's knowledge on enteral drug administration, and second, to observe nurses and to evaluate the adequacy of their practices with guidelines, and to report medication-administration errors. patients and methods: this prospective study using the observation technique was conducted in icu (one medical and one surgical). first, a knowledge and practice questionnaire regarding drug administration trough enteral feeding tube was filled by each intensivist nurse. secondly, pharmacist performed observations of nurses during preparation and administration of medications. these practices were compared with the original medical prescription and with the data available in the literature. results: questionnaires were returned. nurses evaluated their knowledge as medium and as inadequate. there was a lack of knowledge on the type of drugs which can be used by feeding tube ( wrong responses). nurses and different drugs were observed during the drug administration phase. no administration totally complied with our institutional protocol, particularly the crush of tablets. when a tablet was crushed, in % an alternative formulation (in syrup for example) existed. the correct administration of drugs in feeding tubes is important and represents a challenge in icu. firstly, crushed tablets is the most frequent cause of obstruction of feeding tubes which have to be changed + secondly, crushed tablets destroys the controlled release of enteric coated dosage forms, resulting in a higher or a lower initial blood level. we have to train nurses for drug administration by feeding tube. on their daily ward, the pharmacist should improve the choice of medication's forms. introduction: acute variceal hemorrhage (avh) is a severe complication of portal hypertension. in addition, the variceal bleeding is still the most common lethal complication of cirrhosis. the most effective modality of treating is based on resuscitation combined with the endoscopic variceal band ligation. the purpose of this preliminary study was to find the factors associated with poor prognosis of avh in cirrhotic patients. patients and methods: this is a retrospective study, spread over months between january and december . are included all consecutive patients with liver cirrhosis hospitalized for variceal bleeding. we exploited the medical records to identify the clinical, biological and endoscopic parameters. results: a total of patients hospitalized for avh occurred during the study period. the mean age at admission was years, and are female. cirrhosis was post viral in % of cases. patients were classified as child-pugh c in % of cases. the median presenting model for end stage liver disease (meld) and clif sofa were respectively and . . twelve ( ) patients received beta-blockers and have required at least one endoscopic variceal band ligation at the time of the bleeding episode. in the acute phase, pharmacological treatment based on vasopressor (sandostatin)) was instituted in all cases and combining with antibiotic prophylaxis (c g or fluoroquinolone) in cases. in cases the endoscopy was made within h, active bleeding at endoscopy was observed in patients. esophageal avarices (ov) were grade i ( patients) grade ii ( patients) and grade iii ( patients). the eradication of varices was obtained in patients ( . % percentage of the cases). the variceal bleeding recurred in of patients ( %of cases) and patients died which within the first days. spontaneous bacterial peritonitis (p . ), hepatic encephalopathy (p . ) and the hemodynamic instability with schok (p . ) are correlated with early mortality at days. hepatic encephalopathy (p . ) and bacteremia (p . ) are corrolated with week motality. non selective betablocker (p . ) and primary use of band ligation when indicated (p . ) are protective factors and parameters of good outcome. conclusion: despite developing of endoscopic tools and respect of actual therapeutic guidelines in avh, the outcome is still poor. the prognosis appears to be dependent on the clinical condition at admission and primary prevention. introduction: the french intestinal stroke center based on a multimodal and multidisciplinary management has been developed to improve survival and intestinal viability. open surgical revascularization was decided for patients unsuitable for radiological revascularization and or suspected of intestinal necrosis. we aimed to study the prognosis of patients suffering from aoami in icu and who have benefited from open revascularization. single-center, observational and prospective study was carried out in a surgical icu of a tertiary center. patients with aoami managed in our intestinal stroke center from to and who underwent open revascularization were included. results: data of patients were collected. patients' characteristics are described in table . all patients had abdominal computed tomography angiography at the diagnosis, and patients ( %) presented signs of intestinal injury. thrombosis was the main mechanism of superior mesenteric artery (sma) occlusion ( patients, %). all patients received antiplatelet therapy, curative unfractionated heparin therapy and digestive decontamination. open revascularization was performed by sma endarterectomy ( patients, %), sma surgical bypass ( patients, %), retrograde open mesenteric stenting ( patients, %) and coeliac artery bypass ( patients, %). three patients ( %) underwent a radiologic endovascular revascularization attempt before open repair. small bowel resection ( cm ) was achieved in patients ( %). four patients ( %) had peritonitis. six patients ( %) had one or more relaparotomy ]), usually for hemodynamic instability ( %). only one patient died in icu ( %). icu lenght of stay was days ] and duration of mechanical ventilation was days [iqr - ]. overall, haemodynamic failure was present in patients ( %). median duration of vasoactive support was days [iqr - ]). severe acute respiratory distress syndrome was observed in patients ( %) and acute kidney injury in patients ( %, including patients who received renal-replacement therapy, %). enteral feeding was initiated in patients ( %) with a delay of . days [ . parenteral nutrition was administered in patients ( %), including patients ( %) without enteral feeding. five patients ( %) were discharged with small bowel syndrome. conclusion: icu patients who underwent open revascularization to treat aoami as part of a multimodal and multidisciplinary management in a dedicated intestinal stroke center have low mortality and intestinal resection rates. larger studies are needed to confirm these results. introduction: precise consequences of late transit in icu remain elusive. we have previously shown that defining late transit by the absence of stool within days after admission was not relevant because it did not identify a group of patients with specific outcome [ ] . to further improve this definition, we investigated the differences in outcome among patients according to their bowel movements frequency. patients and methods: preliminary results of a prospective, two centers, observational study. all patients admitted to icu, with a length of stay (los) of at least h were eligible and included with the following exceptions-abdominal surgery, bowel infection or any baseline condition known to alter transit time. patients were compared according to stool frequency-less than %, between and %, between and % or more than % of icu days. we also tested the former constipation definition of more than days after admission without stool passage. we registered demographic data, time spent under mechanical ventilation (mv), icu los, ventilation associated pneumoniae (vap) and vital status at discharge. results: over months, patients were screened and ( . %) were included, age . ± . years, mean saps ii ± , ( . %) mechanically ventilated. the most frequent exclusion criteria were los < h (n = ). % of the patients had stool less than % of icu days. patients with fewer bowel movements were more likely to be mechanically ventilated, without association with time spent under mv. there was a link between the time to first stool after admission and the stool frequency during icu (p < . vap n(%) ( . ) ( . ) ( . ) ( . ) death n(%) ( . ) ( . ) ( . ) ( . ) discussion: this study is limited by the number of patients leading to an imbalance between subgroups therefore limiting the comparison. conclusion: these preliminary results do not plead for an improvement of the late transit definition based on the frequency of stool. further data is warranted to better define this condition, and the management to provide. introduction: antibiotic therapy during acute exacerbation of copd (aecopd) still controversial and not well supported by clinical evidence. in fact half of these episodes are caused by viruses even during severe episodes with need to ventilator support. procalcitonin is effective to guide antibiotic therapy during acute exacerbation of copd without compromising patients' outcome, its efficacy in the intensive care setting still not well evaluated. we have conducted in a bed icu a before after study. during the first period (january -december ) patients with aecopd were included retrospectively and treated with antibiotics according to anthonisen criteria (control group). in the second period (january -may ) antibiotics were prescribed only if the procalcitonin level was greater than . ng ml (procalcitonin group). results: ninety-two patients were included, in the procalcitonin group and in the control group. antibiotics were administered at icu admission in patients ( %) in the procalcitonin group and in ( %) patients in the control group, p = . . only % of sputum cultures were positive at icu admission. time to recovery was similar between the two groups [ iqr ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , iqr ( - ), p = . ]. other patients' outcomes did not differ between the control group and the procalcitonin group with respectively: the mortality ( . vs. %, p = . ), the incidence of pavm ( vs. %, p = . ) and niv failure ( vs. %, p = . ). readmission to the hospital at day was significantly higher in the control group ( vs. %, p = . ). conclusion: using procalcitonin to guide antibiotic therapy during severe aecopd can reduce the use of antibiotics without compromising patients' outcomes. our study aimed to assess whether arc impacts negatively on cefazolin pharmacokinetic pharmacodynamics (pk/pd) target attainment and clinical outcome in critically ill patients. patients and methods: over an -month period, all critically ill patients treated by cefazolin for a documented respiratory infection without renal impairment were eligible. patients who underwent an empiric antimicrobial treatment > h before introduction of cefazolin were not included. during the first three days of antimicrobial therapy, every patient underwent -hour creatinine clearance (crcl) measurements and therapeutic drug monitoring at steady state. the main outcome investigated in this study was the rate of pk pd target non-attainment defined by an unbound concentration < µg ml (mic value for inoculum > ufc ml). the secondary outcome was the rate of therapeutic failure, defined as an impaired clinical response with a need for escalating antibiotics during treatment and or within days after end-of-treatment. results: over the study period, patients were included ( samples analyzed for therapeutic drug monitoring). in pharmacological analysis, the rate of pk pd target non-attainment was %, with a strong association with crcl (p = . ) ( table ). in clinical analysis, the rate of therapeutic failure was % ( ), with a strong association with inoculum effect (p = . ). there was a strong association between therapeutic failure, crcl > ml min and pk pd target non-attainment adjusted on the inoculum effect (p = . ). introduction: vancomycin has long been used as the standard therapy of infections due to methicillin-resistant staphylococcus aureus (mrsa). the side effects of this drug as well as the increasing resistance and its pharmacodynamics effects have fostered the development of newly active drugs. nevertheless it is still widely prescribed and it stands as the mostly used comparator in randomized study. an assessment of our medical practice regarding its use may enhance compliance to guidelines so as to promote a better use of vancomycin. patients and methods: in our bed hospital, the incidence rate of mrsa fell from . to . per patient days from to whereas the current proportion of mrsa isolates is about %. vancomycin is the most prescribed empirical or targeted antibiotic therapy covering mrsa in our medical intensive care unit of beds even if a shift towards the use of linezolid in nosocomial pneumoniae has been noticed during the last years. key points regarding the proper use of vancomycin have been implemented in our antibiotic stewardship program. moreover courses concerning this topic are provided to our junior doctors. a retrospective review of the quality of antibiotic use has been carried out in courses of vancomycin therapy and the following criteria have been assessed-indication, dosing schedules, serum levels of vancomycin, duration of antibiotic therapy and the overall degree of conformity of the prescription. results: regarding indication, conformity was observed in cases ( %). the dosing schedule was appropriate in cases ( %) only. of the remaining cases ( %), all of them were not adjusted to the serum concentration and in cases ( %) the general dosing recommendation was not respected. the loading dose was inappropriate in cases ( %) and the proper follow up of serum levels of vancomycin has not been carried out in cases ( %). the duration of antibiotic therapy was in compliance with the protocol in cases ( %) and a slight longer duration was observed in cases ( %). finally the overall degree of conformity of the prescription was observed in cases ( %) only. table . in the sfar srlf guideline, the limitation of the echinocandins use to the benefit of ampho deoxycholate explains most of the poor agreement or consensus rate between investigators. the idsa escmid guideline are more helpful to guide indications of empirical treatment which mainly explains their higher rate of both applicability and agreement rate. the rates of agreement do not reflect whether the choice between different class iii antifungal therapies is the best or not. conclusion: the idsa guideline seems to take a broader spectrum of clinical situations into account, particularly in guiding more precisely indications of empirical treatments. escmid or idsa reach more often consensus at the first reading. ( ), and was discovered during a chest x-ray examination for % ( ). diaphragmatic paralysis was confirmed for all cases with chest ultrasound. % of patients ( ) were receiving mechanical ventilation at the moment of the diagnosis. the paralysed hemidiaphragm was left sided in % ( ), and right sided in % ( ). there was no bilateral diaphragmatic paralysis. hemi-diaphragmatic plication was performed in % of the patients ( ), and median time from cardiac surgery to surgical plication was days (range - days). indications for plication were failure to wean from ventilator ( %, ), and respiratory distress ( %, ). plicatured patients were remarkably younger (median age at cardiac surgery- days, range - days) than non-plicatured patients ( . months, range days- years). the median ventilation time after plication was days (range - days). all patients were asymptomatic after diaphragmatic plication. two patients died ( %). cause of death was independant from surgical plication (cardiogenic shock, septic shock). conclusion: diaphragmatic paralysis is a rare but serious complication of cardiac surgery in children. it commonly occurs after open-heart surgery, and specifically after arterial switch operation. plicatured patients were younger than non-plicatured patients and needed more frequently a ventilatory support. a closer monitoring may be required for young patients and mechanically ventilated patients. indeed, both are more likely to be treated by a diaphragmatic plication, reducing mechanical ventilation and intensive care duration. a prospective study. consecutive children aged between days and -year-old admitted to the picu, intubated and mechanically ventilated were eligible and they reached inclusion if they had at least one chest tube. ppl was directly measured by a pressure transducer connected through a needle inserted into the existing chest tube. pes was measured by both a specific probe (gaeltec probe) and by the feeding tube after mobilization (pes-ft). results: patients (median age months (interquartile + - )) were included and exploitable signals were finally available in patients, who were included in the analysis. most of patients (n = ) were admitted after cardiac surgery and had a spontaneous breathing activity. median pes measured by gaeltec probe and by feeding tube was . (interquartile + . - . ) and . ( . - . ) cm h o, respectively. median ppl measured into the chest tube was . ( . - . ) cm h o. bland-altman plots are represented in the figure. conclusion: both ppl measured into the chest tube, pes measured by the gaeltec probe or by the feeding tube are reproducible methods. . respiratory syncytial virus was identified in infants ( %). an initial caffeine citrate loading dose of mg kg was usually administered, followed by a mg kg day maintenance dose, for a median treatment duration of days [ ] [ ] [ ] [ ] [ ] [ ] . therapeutic management (invasive and non-invasive ventilation, nutrition support) and clinical outcomes (death, length of stay) were similar between groups. there was no difference in potential caffeine adverse effects between groups or within the caffeine exposed group pre and post-caffeine administration. conclusion: caffeine treatment of bronchiolitis related apnea seems to be a standard practice in our picu. our study failed to show any influence of caffeine on clinical outcomes in this indication when compared with a small number of patients. further studies are needed to assess the efficacy and safety of caffeine treatment in this indication as well as the appropriate treatment regimen as pharmacokinetic data suggest that higher dose could be of great interest in this non-prematurely born population. introduction: during the last decade, many authors have raised awareness concerning the increasing rate of venous thromboembolism (vte) in critically ill children [ ] . the presence of central venous catheter (cvc) is one of the most important risk factor for venous thrombosis in children [ ] . the purpose of this study was to analyze incidence and risk factors for catheter-related thrombosis in children admitted in our pediatric intensive care unit (picu). patients and methods: all children aged less than years, admitted in the picu from january to june , and receiving at least one tunneled cvc, were included in our retrospective study. those with venous thrombosis unrelated to cvc placement were excluded. catheter-associated venous thrombosis (cavt) was confirmed using doppler ultrasonography. introduction: weaning from the ventilation is a crucial moment in the icu stay. because of the risks of mechanical ventilation (mv), such as ventilator-associated pneumoniae, it is recommended to begin the weaning process as soon as weaning criteria occurs [ ] . however, extubation is also a hazardous period, with to % of subsequent respiratory failure requiring reintubation, harboring a dismal prognosis [ ] . international guidelines display the criteria triggering the extubation. nevertheless, the physician in charge eventually takes the decision to extubate. in this regard, there could be variations from an individual to another. the main goal of our study was to identify the perceived impediments to mv weaning among physicians, from intubation to extubation. patients and methods: prospective single center study in a bed university icu. all patients admitted between february and may and undergoing mv were included. we daily registered the existence of the criteria recommending a spontaneous breathing trial (sbt), the occurrence of a sbt, the items recommending postponing extubation, and the occurrence of an extubation. the estimated reasons for all the aforementioned decisions were asked to the physician in charge. results: patients were included, gathering days of mv and sbt. the average duration of mv was . ± . days. there was one extubation failure requiring reintubation. there were sbt failures. in cases, sbt was a success but did not lead to extubation because of hypotonia, weak cough, subsequent respiratory failure, hemorrhagic bronchial secretions, hemodynamic instability, absence of weaning criteria, drowsiness (all the aforementioned n = ), post sbt hypercapnia (n = ). out of the sbt ( %) were done while one or several weaning criteria were absent. impediments to weaning trials were different according to the time lag since icu admission, with fluid overload, muscular weakness and persistent need for assist control ventilation settings being the most frequent reasons advocated after days (figure). no objective assessment of muscular or cough strength was performed at any time, neither was monitored the rr vt, vital capacity or inspiratory pressure. . % of patients had otolaryngologist follow-up. the overall mortality of the studied population was . % including mortality related to tracheostomy in patients. the tracheostomy for extended mechanical ventilation was significantly associated with an increase of mechanical ventilation duration before tracheostomy (p < . ), duration of mechanical ventilation (p < . ), length of stay in intensive care unit (p < . ) and mortality rate (p = . ). introduction: acute renal failure complicating surgery has a particularly harmful prognosis, with a mortality of % to %. this high mortality rate is attributed to patient-related factors, the severity of the disease and the type of surgery, but not to the acute renal failure itself. the aim of our study is to elucidate the prognostic factors of acute renal failure in the postoperative sepsis in a series of patients. it is a retrospective analytical descriptive study spread over a period of years (from january to december ), observations of postoperative peritonitis were collected in the service of resuscitation of surgical emergencies of chu ibn rochdof casablanca. the statistical analysis was carried out using the spss software. the results are expressed with or and % confidence intervals (ci at %). the results were considered significant when p is < . . the mean age of the patients was ± years with a sex ratio of . ( m ) . renal failure was the most frequent failure after hemodynamic failure, patients were oliguric, anuriques and patients had a preserved diuresis, patients were divided according to the rifle (r %, i %, f %) and akin (i %, ii %, iii %). the predictive factors of acute renal failure ari were studied in univariate and multivariate analysis, factors were retained including catecholamines-or . + ci at % between . and . + p = . + the surgical site-or . + ci at % between . and . + p = . . conclusion: acute renal failure is an independent factor of mortality in the post-operative sepsis, but remains that its presence is a pejorative prognostic factor. this was a retrospective study performed in a large university hospital. all patients receiving the molecule were included in the analysis. indication for sodium lactate, dose, and modality of administration were collected. we also collected clinical and biological variables before sodium lactate infusion, after h (h ), and after h (h ). an analysis of the evolution of these variables at h and h was performed. results: between january and may , patients, aged years, % males, sofa score [ - ], received an infusion of molar sodium lactate ( ml ). main indications for sodium lactate were hyperchloremic metabolic acidosis ( %), vascular filling ( %), mixed acidosis ( %), and intracranial hypertension ( %). % of the patients presented with a chloride sodium ratio > = . at basal time. sodium lactate was associated with a significant increase of mean arterial pressure at h (p = . ) and h (p = . ), a decrease of catecholamine dose (p = . ) and heart rate (p = . ) at h , and an increase of diuresis in the h period following initiation of the treatment (p = . ). we observed an increase of ph, bicarbonate, base excess, and sodium, at h and h (all p < . ). plasma lactate concentration was increased at h (p < . ), but was not different from basal value at h (p = . ). there were no significant variation of plasma chloride. chloride sodium ratio was significantly reduced. plasma sodium > = mmol l and ph > = . at h were observed in % of the patients. this retrospective study reports the largest number of critically ill patients having received sodium lactate. hemodynamic effects observed in this study are concordant with the data of the literature. the metabolic effects observed in this study, with rapid increase of ph, bicarbonate, and base excess, strongly suggest the potential interest of sodium lactate among critically ill patients presenting with acidosis and increased chloride sodium ratio. introduction: acute kidney injury (aki) is a frequent and severe condition in intensive care unit patients that may require renal replacement therapy, most frequently continuous renal replacement therapy (crrt). although hypoglycemia is a well-known complication of crrt using glucose free solutions, euglycemic ketoacidosis (eka) has never been described in this setting. patients and methods: all anuric patients with glucose free crrt solution induced eka (february -may ) were prospectively included and evaluated. ketoacidosis was deemed possible when nonlactic metabolic acidosis did not improve in patients on crrt. because all patients were anuric, we measured ketonemia and used urinary test strip in the effluent fluid. eka diagnosis was retained when arterial serum bicarbonate was < meg/l despite crrt, in the absence of lactic acidosis and in the presence of ketones in the serum or crrt effluent fluid. results: eighteen patients ( % of our patients under crrt in this period) developed eka during crrt using glucose free solution (phoxilium ® ). time between cvvhdf initiation and ketonemia detection was ( - ) days. patient characteristics are presented in the table . half of them had for a medical history of diabetes ( insulindependent). only patients were receiving insulin and most of them had low glucose or food intake. increasing glucose intake and insulin infusion resolved ketonemia in all cases. discussion: we describe for the first time the occurrence of euglycemic ketoacidosis in critically ill patients under crrt using glucose-free replacement solution. common features of the patients were multiple organ failure with anuria, normal glycemia without insulin infusion and low glucose infusion or food intake. critical illness-induced insulin resistance and starvation could altogether contribute to ketoacidosis even if acidosis is unusual in starvation ketosis. by removing substantial amounts of glucose from the blood, crrt with glucose free solution could worsen this condition, mask hyperglycemia and induce euglycemic ketoacidosis. in critically ill patients on crrt using glucose free solution, euglycemic ketoacidosis is common and should be detected, especially in patients with low glucose intake, no insulin infusion and unexplained metabolic acidosis. importantly, the diagnosis can be missed in anuric patients with normal blood glucose and in the absence of known diabetes. since, cvvhdf-induced ketoacidosis may contribute to persistent acidemia and its adverse effects, serum or crrt effluent fluid ketone level should be measured in this setting. . - ] years. main reasons for admission were hypercalcemia (n = ( . %)), followed by acute encephalopathy (n = ( . %)). median saps ii and sofa scores were [ . - . ] and [ ] [ ] [ ] [ ] [ ] respectively. main causes of hcm were hematological malignancies (n = ( %)), solid tumors (n = ( %)), iatrogenic events (n = ( %)) and endocrinopathies (n = ( %)). median calcium levels at admission, at day and at icu discharge were . [ . - . ], . [ . - . ] and . [ . - . ] mmol l respectively. more than half of the patients (n = ( %)) recovered from hcm days after icu admission. acute kidney injury occurred in ( %) patients and ( . %) patients required dialysis. neurological complications concerned ( . %) patients, mainly delirium (n = , . %). digestive events occurred in ( . %) patients. cardiovascular events concerned ( %) patients and consisted in de novo hypertension in ( %) patients, and ekg disturbances in ( %) patients. during icu stay, ( . %) patients required mechanical ventilation and ( . %) patients required vasopressors. volume resuscitation with crystalloids was the first treatment in ( . %) patients, ( . %) received bisphosphonates and ( . %) received corticosteroids. respective icu and hospital mortality were . and . %. there was no correlation between the degree of hcm and icu mortality (p = . ). icu and hospital mortality were associated with the underlying disease (hematological malignancies (p = . )). conclusion: hcm is associated with high mortality rates. the increased mortality is a consequence of the main mechanism, mainly underlying malignancy rather than hcm per se. the course of hcm may be complicated by organ failures that are most of the time reversible with early icu management. introduction: sepsis is one of the leading cause of death among patients with chronic kidney disease (ckd). the mechanisms of this higher mortality remain poorly understood. sepsis and chronic kidney disease are both conditions associated with a higher plasmatic concentration of bile acids. the farnesoid x receptor (fxr) is a key regulator of the bile acid metabolism and has recently been involved in the regulation of the inflammasome during sepsis. we explored the role of fxr in the prognostic of sepsis in an animal model of ckd. patients and methods: sepsis was provoked by the injection of . mg kg of lps weeks after the creation of ckd. the ckd was created by unilateral nephrectomy associated with contralateral thermocauterisation. the mice (c bl j) were randomly assigned to one of the following groups-sham placebo, ckd placebo, sham lps or ckd lps. a fifth group of ckd lps mice received a treatment with sevelamer (a bile acid sequestrant) during weeks. survival of the animals, serum biochemistry and molecular biology in the kidney were performed after sacrifice. results: whereas the sham lps animals survived, all ckd lps animals died during the h following the injection of lps. the plasmatic urea, il beta and tnfa concentrations increased with the creation of ckd (ckd placebo versus sham placebo animals) and with the creation of sepsis (ckd lps versus sham lps groups). whereas the expression of fxr rna did not changed with the injection of lps in the sham animals (sham lps versus sham placebo), the fxr rna decreased with the creation of sepsis in the ckd animals (ckd lps versus ckd placebo groups). the ckd animals treated with sevelamer weeks before the administration of lps (ckd sev lps group) had a lower plasmatic concentration of il b, tnfa and increased the rna expression of fxr in the kidney compared to the ckd lps group. also, the treatment with sevelamer improved the survival of the ckd lps animals. conclusion: our study demonstrates a relation between fxr and the prognostic of sepsis in ckd animals. the exact link and the potential therapeutic interest of targeting fxr and bile acids metabolism in ckd patients remain to be studied. introduction: dysnatraemia, dyskalaemia and hypomagnesemia are frequent metabolic disorders in intensive care, and their causes represent a major concern for the intensivist, especially in urgent conditions. in the diagnostic approach, we often use the urine analysis. although measurement of -hour urine electrolyte excretion ( -hu) is considered the most reliable method, the great burden and difficulty in collecting complete -hour urine has prompted the search for more practical methods, such as spot urine analysis. the aim of the present study was to compare electrolyte excretion in urine samples collected over different time periods, in comparison with a -hour urine sample collection considered as the gold standard method. patients and methods: this prospective and descriptive study included patients admitted in a tunisian medical icu, between september and december . baseline characteristics, medications and laboratory data including electrolytes and renal function parameters were obtained from all patients. multiple urine specimens for analyzing na + k + mg + urea + ca + phosphate + creatinine + proteins and uric acid were obtained from -hour, -hour and -hour urine samples during day and night time, and results were compared with those obtained from the gold standard method ( -hour urine collection). correlation analysis was performed using the spearman test. results: significant correlation was found for all biochemistry parameters between -hour urine results and those obtained from -hour and -hour samples regardless of day or night sampling. a comparative analysis for sodium and potassium is shown in fig. . conclusion: determination of electrolyte excretion from urine samples taken over different time periods, and h, provides a reliable estimation of -hour urine electrolyte excretion. it appears practical for early understanding of the mechanism of electrolyte imbalance. however, further studies are warranted to confirm the usefulness of this approach. use of the procalcitonin assay in an adult emergencies department: retrospective experience of a general hospital of the suburb of paris ( . - . ). other markers of infectious were poorly recorded (fibrinemia in ( . % + . g l [ . - . ] + immature forms on blood count- . %). only ( . %) had blood cultures in the ed ( patient [ ] [ ] ) and ( . %) other(s) microbiological sample(s), mainly urinary ( patients [ . % + among them % considered as positive]). % of blood cultures were positives, mainly for gram negatives ( %). final diagnosis in the ed was considered as infectious disease (id) in only patients ( . %, including sepsis and septic shocks). ( . %) was considered as non-infected (nid) and final diagnosis remains unprecise in ( . %). pct values was of . ( - . ) in the id vs. ( - . ) in the nid (p < . ), wbc was of . in the id vs. . in the nid (p < . ) and crp was of ( . - . ) in the id vs. ( - ) in the nid (p < . ). no correlation was observed between the pct value and admission to dechocage room admission. . identification of the involved drug was obtained in % of the cases, based on qualitative screening. management was mainly supportive and included sedation ( %), naloxone ( %) and flumazenil ( %). tracheal intubation was required in patients ( . %). one cardiac arrest but no death occurred in the ed. forty-three patients ( %) were transferred to the intensive care unit. conclusion: our dataset provides an interesting insight into the drugs involved in and clinical pattern of toxicity outcome of acute recreational drug toxicity presentations at the ed, despite possible under-declaration and coding. classical recreational drugs were more common ( %) followed by prescription drugs ( %) and nps ( %). and drug ( %) consumers + hiv-infected ( %) and depressive ( %) patients) were admitted to the icu. the main declared compounds were methylenedioxypyrovalerone (mdpv + n = ), -methylethcathinone ( -mec + n = ), -methyl methcathinone ( -mmc + n = ) and -methyl methcathinone ( -mmc + n = ), more frequently used in drug mixtures sold as bath salts or in poly-intoxication with conventional illegal drugs (mainly cocaine and gamma-hydroxybutyrate). nps was used in a recreational ( %), chemsex ( %) or solitary practice ( %). binge ( %) and intravenous ( %) self-administration was remarkable. patients presented acute encephalopathy with psychomotor agitation ( %), confusion ( % + glasgow coma score- [ ]), hallucinations ( %), anxiety ( %), seizures ( %), myoclonus ( %) and stereotypes ( %). ecg typically showed sinus tachycardia ( %), qrs qt abnormalities ( %) and atrio-ventricular block ( %). acute cardiac ischemia ( %) and dysfunction ( %), disseminated intravascular coagulation ( %) and multiorgan failure ( results: during the first and the second study periods and patients were respectively admitted in the icu. total micro-organisms density was and . for patients for the first and the second period, respectively (p < . ). acinetobacter spp and pseudomonas aeroginosa were the predominant isolated microorganisms with a respective density of . and . isolates for patients. figure summarizes the patterns of bacterial ecology and resistance in our icu before and after transfer to new buildings, showing a significant decrease in pseudomonas aeroginosa resistance for ticarcillin and ceftazidim, whereas acinetobacter resistant to carbapenems and enterobacteriacae esbl significantly increased. our study suggests that transfer of icu to the new buildings was associated with a decrease of pseudomonas aeroginosa resistance, whereas acinetobacter spp resistance and esbl enterobacteriacae incidence increased. introduction: infections caused by antimicrobial-resistant bacteria (amrb) are one of the main issues in the spectrum of critically ill patients as they are associated with higher mortality, morbidity, and length of stay. thus, an appropriate initial antimicrobial therapy is decisive for better patient outcomes. the aim of the study is to determine the adequacy of first-line antibiotic therapy guided by weekly amrb screenings. patients and methods: a months prospective study was conducted in -bed micu. were included all patients with more than h of icu stay. an amrb screening was conducted upon admission and on weekly basis for all the patients. the choice of antibiotherapy if indicated, was guided by the most recent colonization results. if the patient has received at least one active in vitro antibiotic against the isolated bacteria, the empiric antibiotherapy was considered appropriate. results: patients were included in the study. mean age and saps ii were respectively ± years and ± . the median length of stay was days. ( %) patients were colonized by amrb upon admission. the most frequent isolated microorganisms were-escherichia coli ( %) and klebsiella pneumonia ( %). were assessed hospital-acquired infections (hai)- ( %) in amrb colonized patients and ( %) in uncolonized ones. the antibiotherapy was considered appropriate in infections ( %). out of the colonized patients, ( %) developed hai. ( %) patients had a concordant colonization body site to the infection. of the nosocomial infections, ventilator-associated pneumonias and central venous catheter infections were the most frequent, both at % (n = and n = ) + followed by urinary tract infections % (n = ) and infective endocarditis % (n = ). ( ). overall, the isolates were-extended spectrum betalactamase productrice-enterobacteria ( %), imipenem resistant-acinetobacter baumanii ( %), and multi resistant-pseudomonas aeroguinosa ( %). ni were documented including caused by mdr bacteria and distributed as follows-ventilator acquired pneumonia-vap (n = ), bacteraemia (n = ), vap with bacteraemia (n = ), catheter related infection-cri (n = ), cri with vap (n = ) and catheter-related bacteraemia-crb (n = ). the performance of mdr bacteria-screening in predicting ni was poor with % of sensitivity, % of specificity, . % of negative predictive value (npv), and % of positive predictive value (ppv). nevertheless, the performance of the nasal swab in the prediction of vap was better with % of sensitivity and . % of npv. conclusion: mdr bacteria-screening is useful as it allows to identifying the mdr bacteria-carriers and helps for a rational use of antibiotics in severe ni. however, its diagnostic contribution in the occurrence of ni is poor except the interest of the nasal swab in the prediction of vap owing to its good npv. we aimed at determining the respective weight of these phenomenon and the physiological determinants of the respiratory variations of the ivc diameter. patients and methods: in mechanically ventilated patients (tidal volume- . ± . ml kg of predicted body weight) haemodynamic, respiratory and the intra-abdominal pressure (iap) signals were continuously computerised. cvp, iap and the ivc diameter (transthoracic echocardiography) were recorded during -second end-inspiratory and end-expiratory occlusions separated by s, before and after the infusion of -ml of saline. patients in whom fluid administration induced an increase in cardiac index (picco- ) > % were defined as "responders". the respiratory variations of the ivc diameter, cvp and iap were calculated as the (end-inspiratory-end-expiratory values) mean value. the compliance of the ivc was estimated by the ratio (end-expiratory-end-inspiratory ivc diameter) (end-expiratoryend-inspiratory cvp). results: fluid administration increased cardiac index by more than % ( . ± . to . ± . l min m , p = . ) in patients. the respiratory variations of the ivc diameter predicted fluid responsiveness (area under the roc curve- . ( % ci . - . ), p < . ). before fluid administration, the ratio of changes in ivc diameter over changes in cvp was not different between responders and non-responders ( . ± . vs. . ± . mm mmhg, p = . ). before fluid administration, the respiratory variations of the cvp tended to be higher in responders than in non-responders ( ± vs. ± %, p = . ). the respiratory variations of the ivc diameter were associated with the respiratory variations of cvp (r = . , p = . ) but not with the respiratory variations of iap (r = - . , p = . ). the respiratory variations of the ivc diameter were not explained by a higher ivc compliance but rather by higher respiratory variations of the cvp in responders than in non-responders. interestingly, it seems that iap, the ivc extramural pressure, was not involved in the respiratory variations of the ivc diameter. inclusions are ongoing. during the hospitalization in icu, there was no significant difference between the two groups regarding the proportion of patients with aki through icu discharge. in the intervention group, % of the patients had a glomerular filtration rate lower than ml min . m compared to . % in the control group (p = . ) at day- . we found no significant difference between the two groups neither on hematopoietic effects of epo or serious adverse events. in patients resuscitated from an ohca of presumed cardiac cause, early administration of erythropoietin compared to standard therapy did not confer any renal protective effect. salvetti marie , and the ratio of end-diastolic areas of both the right and left ventricle in the long axis view of the heart (rveda lveda) were measured. a lvef < % defined lv systolic dysfunction, a ci < l min m defined low cardiac output, and a rveda lveda ratio > . (± associated with a paradoxical septal motion in the short axis of the heart) defined rv dysfunction (± acute cor pulmonale). the preload-dependence was evaluated using deltasvc or deltavmaxao. front-line hemodynamic and metabolic parameters were recorded at the time of tee assessment. results: lvef and ci could be simultaneously measured in of patients ( %). patients ( %) had a low ci related to lv systolic dysfunction (lactate- . ± . mmol l), patients ( %) had a low ci and a preserved lvef related to a rv dysfunction or to a sustained preload-dependence (lactate- . ± . mmol l), patients ( %) had preserved ci and lvef (lactate- . ± . mmol l) including only patients ( %) with a hyperkinetic profile (high ci and lvef > %), and patients ( %) had preserved ci but altered lvef (lactate- . ± . mmol l) due to a marked tachycardia. none of the front-line hemodynamic parameters was discriminatory to identify the circulatory profile identified by tee assessment (table) . introduction: aortic end-systolic pressure (esp) is considered as a reliable index of left ventricular afterload. recently, the effective arterial elastance (ea), i.e., the ratio of esp over stroke volume (sv), has also been proposed as a reliable afterload index. our aim was to document peripheral estimates of ea (eapsap) at the bedside in critically ill patients, and to investigate the haemodynamic mechanisms responsible for ea changes after fluid administration (fa). in the validation study, carotid tonometry (complior) was prospectively performed on haemodynamically stable spontaneously breathing patients equipped with an arterial femoral (n = ) or radial (n = ) catheter. ea was defined as the ( . × csap) sv ratio, where csap was the central systolic arterial pressure directly measured from the calibrated carotid waveform. eapsap was calculated as the ( . x peripheral systolic arterial pressure) sv ratio. sv was obtained by transpulmonary thermodilution or transthoracic echocardiography. in the clinical study, we included patients with invasive haemodynamic monitoring (picco- ), in whom fa was planned. results: in the validation study, the complior allowed estimating ea in all patients (ea = . ± . mmhg ml). the (eapsap-ea) bias was smaller at the femoral than radial artery level ( . ± . vs. . ± . mmhg ml, p < . ) and was strongly related to the systolic pressure amplification between the carotid and peripheral artery (r = . , p < . ). ea was more strongly related to sv (r = − . ) than to esp (r = . ) (each p < . ). the four-quadrant plot analysis indicated that patients ( %) exhibited a concordant low ea high sv pattern or high ea low sv pattern, while only patients ( %) exhibited concordant high ea high esp pattern or low ea low esp pattern (p < . ). there was a negative relationship between changes in eapsap and changes in sv in the whole population, in fluid responders (cardiac index increases > % after fa), in pressure responders (mean arterial pressure increases > % after fa) and in non-responders, while no consistent relationship between eapsap and esp changes was documented. conclusion: ea may be reliably estimated at bedside by using the ( . x femoralsap) sv ratio. ea value and ea changes induced by fa were related to sv rather than to esp. thus, ea should be considered as an index reflecting sv rather than left ventricular afterload in critically ill patients. this study included a sham group (n = ), a cpb group (n = ), an ir group (n = ) and a cpb-ir group (n = ). rats were exposed to min of cec, min of left pulmonary ischemia and min of reperfusion. fonctional endothelial dysfunction was evaluated by measurement of the pulmonary artery reactivity. systemic inflammation was evaluated by the plasma assay of il- beta, il- and tnf-alpha. the endothelial glycocalyx was evaluated by plasma assay syndecan- and electron microscopy. the statistics were performed using an anova test, p < . . we showed that cpb associated with ir induce an endothelial vasorelaxation dysfunction mainly mediated by nitric oxyde (no introduction: during circulatory shock, the goal of increasing cardiac output is to correct tissue hypoxia, which can be manifested by an increase in oxygen consumption (vo ) associated with an increase in oxygen delivery. we hypothesized that, in patients in circulatory shock, veno-arterial co gradients (pv-aco ) could be a good predictor of an increase in vo in fluid responders. patients and methods: we included patients with circulatory shock who received a fluid challenge. circulatory shock was defined by the association of vasopressor requirements to maintain mean arterial pressure (map) and a blood lactate concentration ≥ mmol l. we measured cardiac index (ci) and arterial and central venous blood gases and arterial lactate before and after a volume expansion ( ml of plasmalyte ® ). cardiac index (ci) was measured using a pulse contour analysis method (picco + pulsion, munich, germany). ci responders were the patients in whom ci increased (Δci) by > %. in those patients, vo responders were those in whom vo increased (Δvo ) by > %. receiver operating characteristic (roc) curves were performed. the data was presented as median ( th percentile- th percentile). a p < . was considered as statistically significant. introduction: the autonomic nervous system (ans) is highly adaptable and allows the organism to maintain its balance when experiencing stress. heart rate variability (hrv) is a mean to evaluate cardiac effects of ans activity and a relation between hrv and outcome has been proposed in various types of patients. while electrocardiographic hrv assessment seems to be the gold standard, we evaluated the feasibility of an automated hrv monitoring based on standard photoplethysmographic monitoring. this project is based on a prospective physiological tracing data-warehousing program (rea stoc, clinicaltrials.gov # nct ) that aims to record more than icu patients over a -years period. introduction: diabetic ketoacidosis is an acute complication of diabetes, defined as metabolic acidosis with a high anionic gap, associating hyperglycemia > mmol l ( g l), positive ketonuria, or superior or equal ketonuria to ++, it is a medical emergency which can occur in a known diabetic patient, or not. objective-to describe the clinical therapeutic and prognostic aspects of diabetic ketoacidosis in the intensive pediatric care unit at the ehs canastel oran, algeria. patients and methods: retrospective study carried out over a period of years. from january , to january , , in the intensive pediatric care service. the data was entered and analyzed using excel . results: cases were retained on hospitalizations per year, % of cases had no history with diabetes, % occurred in known diabetics with insulin, but are not followed medically. our patients were aged from months to years, but the average age of these patients was years and months, with a slight female predominance, coma was preceeded by % of cases polydipsy polyuria syndrome and % weight loss, triggered by an infectious syndrome including % of ent cases, % of respiratory infections and % of cases with digestive infections characterized by fever, abdominal pain, vomiting. the delay between diagnosis and admission to ice was - days. at admission % of patients were scored at on the glasgow scale, with presence of the cough reflex, and % were scored at < requiring tracheal intubation and mechanical ventilation of h with signs of dehydration and ionic disorders, namely hypokalemia and hypernatremia, blood glucose at admission varies between . and g l with glycosuria at +++ and ketonesuria between ++ and ++++ in only % of the patients had metabolic acidosis, a cerebral computed tomography (ct) performed in % of cases found a slight cerebral edema. therapeutic management was the rehydration, correction of metabolic disorders and introduction of insulin into sap, with monitoring and subcutaneous relaying due to ketonuria negativity. the outcome was favorable for all patients. conclusion: diabetic ketoacidosis is a major complication of diabetes which can be avoided by a good prevention campaign and systematic screening of any child suspected of diabetes, recognition of risk situations such as infections and clinical manifestations in order not to delay the management. introduction: scorpion sting is a public health problem world wide with a global distribution of species. in algeria, scorpionic envenomation occupies a prominent place in declarations. in , cases were reported. the objective of our study is to describe the epidemiological, diagnostic, therapeutic and evolutionary characteristics of the scorpion sting in children. retrospective study of cases of scorpionic envenomation hospitalized in the pediatric resuscitation department of the ehs canastel oran conducted during the year the inclusion criteria were the presence of traces with at least one locoregional or general clinical signs. the parameters studied-age, sex, city of origin, time of bite, time of management, initial first aid, time limit for admission to pediatric intensive care, and severity criteria. results: % of these cases were boys and % girls. the mediane age . % of the punctures occurred during the day, the site of the injection was the lower limb in % of the cases and there were bites scorpion cases in the west of algeria and exactly in oran and tiaret. of the cases was the upper limb. the delay of the management was from to h for of the cases who were classified in the third classed according to the clinical signs of gravity. the type of the scorpion was not identified. we can classify all the patients that we received in our service into three classes − % in class i, with local signs such as pruritus, redness, abnormalities and local pain. eva - , calmed by the infusion of mg kg iv of paracetamol and application of xylocaine cream at the site of the sting. introduction: the residence of children in intensive care is most often due to the existence of one or more organ dysfunction which requires heavy treatment (intubation, ventilation, drainage, venous tract) and this in a hostile environment which amplifies the aggression organic. the main objective of our work is to study the consequences of hospitalization of children in pediatric resuscitation. patients and methods: this is a descriptive prospective study on the outpatient consultation file of canastel's ehs multipurpose resuscitation. we studied files and assessed memory, perception of contact and nuisance factors felt by sick children. results: out of children seen in post resuscitation. the sex ratio is . . the average age of children is years ( months- years). the average hospital stay is days. the average gos (glasgow out scale) is . ( ) ( ) ( ) ( ) . the average duration of ventilation is days. % of children had central vascular access. three children describe a total memory of the stay, some memory and none. three children have a good perception about the staff, one child dissatisfied and three others indifferent. the nuisance factors described by the children are pain ( ), cold ( ), noise ( ), hunger ( ) and light ( ) . conclusion: consequences of psychological trauma, insufficiently evaluated especially by the staff, which result in the appearance of psychological disorders (nightmares and anxiety) with sometimes even severe post-traumatic neurosis. hence the need to adapt the environment and mainly noise and respect for sleep. [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the median treatment duration time was at ( - ) minutes. femoral vein was used as vascular access ( %) and most of pe procedures ( %) were performed with citrate anticoagulation. median exchange volume was at [ - ] ml and renal replacement fluid was fresh frozen plasma (ffp) in %, % ffp and % human albumin % in % and human albumin only in % of procedures. adverse effects were observed in less than % of procedures and % were lifethreathening including cardiac arrest, heart rhythm disorders, cerebral oedema and hemolysis. other remaining complications were secondary infections %, hemorrhage %, and pulmonary oedema % in all patients. twenty patients deceaded (icu mortality %). icu and hospital lenght of stay was at ± and ± days respectively. of survived patients still underwent pe after their icu discharge + totally recovered whereas ( %) were on partial remission. conclusion: pe is a routine and feasible technique in icu. this study showed that tpp was the most commonly indication of its use and that outcome was fair. adverse effects frequently occured but most of them were not severe. further studies would benefit form larger cohort to improve indications, delay of initiation and practice of this treatment. renal replacement therapy was required in % of elderly versus % (p = . ). frequency of ttp, hus and ahus was similar beetween groups. tma was more frequently associated with ongoing cancer and drug use in elderly ( vs. %, p < . and vs. %, p < . , respectively). gastro-intestinal bleeding during icu occurred more often among elderly ( vs. % (p = . )). icu mortality rate was higher ( vs. %, p = . ). no difference was found concerning plasma-exchange therapy, steroids use, and rescue treatments for refractory-ttp. discussion: increased complication and mortality rates in the elderly group might be ascribed to more cardiovascular morbidity in this population. the association between tma and ongoing cancer suggests a routine oncological workup among elderly. introduction: neutropenia, defined by an absolute count of polymorphonuclear neutrophils less than < mm , exposes patients to infectious complications that can lead to sepsis or septic shock. the mortality risk is higher. the french guidelines published in were formulated to homogenize the clinical practices and improve survival. we performed a monocentric retrospective study including all consecutive patients admitted to the medical icu of a tertiary hospital to a neutropenia with sepsis or septic shock, between the th of december and the th of december . the study protocol was approved by the local ethics committee ( . ce ) and published on clinical trial (nct ). results: patients were admitted in icu during this period. patients ( %) presented a neutropenia with sepsis or septic shock. among these patients, % had hematologic malignancies and % had solid tumour. patients ( %) was treated empirically with antipseudomonal beta-lactam or carbapenem and aminoglycoside. ( %) skin or suspected catheter-related infections were treated with anti-mrsa (methicillin-resistant staphylococcus aureus), vancomycin or linezolid. adequate antibiotics as described in guidelines was performed to patients ( %). patients ( %) received aminoglycoside ( patients received initial dose in icu, patients complement dose) and ( %) received anti-mrsa with antipseudomonal betalactam or cabapenem. patients ( %) had microbiologically documented infections with, % of bacteria ( % of gram-posit cocci, % of gram-negative cocci, % of gram-negative bacillus), % of fungi and % of viral infection ( table ) . among of them, % ( ) of esbl, % ( ) of mrsa and % ( ) of emerging highly resistant bacteria (bhre). the icu-mortality rate was % ( ) with % of -day mortality ( ). the curves of the cumulative incidence of death risk between d and d were no different according to adequate empirical antibiotic treatment as like french guidelines (fig ) . by multivariate analysis, independent factors of adequate antibiotic treatment were septic shock (or, . + % ci . - . ) and febrile neutropenia > days (or, . + % ci . - . ) at icu admission. conclusion: according to the usual clinical practice, septic neutropenic patients was already treated empirically by bitherapy including antipseudomonal or anti-mrsa if there is a skin or suspected catheter-related infection. adjunction of aminoglycoside in of the symptomatology in case of overdose, make the diagnosis difficult, especially since the drug in question is often unspecified and the toxicological analysis is not exhaustive. introduction: carbon monoxide intoxication is a public health problem in tunisia and around the world. currently, it is unclear the impact of this type of poisoning in our country for lack of declarations. we propose in our work to study the epidemiological characteristics of fatal carbon monoxide intoxications collected in the forensic pathology department of the university hospital in sfax, tunisia, to describe the different steps used in forensic diagnosis of fatal carbon monoxide intoxication and to propose preventive measures to reduce the rate of these intoxications. patients and methods: it is a retrospective study of cases of fatal carbon monoxide intoxications collected in the forensic pathology department of the university hospital in sfax, tunisia during years ( january to december ). commemoratives were collected from medical and police records. a forensic autopsy and a toxicological analysis were carried out in all cases. results: fatal carbon monoxide intoxication is the leading cause of toxic death in sfax during the period of our study. we notice a decrease in the incidence of this type of intoxication. the average age of deaths was years and months with male predominance. the peak frequency of intoxication was in cold season. the most frequent form of intoxication was accidental. the source of carbon monoxide was mainly the defective water heater often placed in poorly ventilated areas. the classic carmine red-color of lividity was found in the majority of cases. myocardial distress, favored by hypoxia, has been reported in two subjects with a pathological coronary artery. the mean hbco level was . %. however, account must be taken of the survival time and the time elapsed between death and dosing of hbco. the incidence of fatal carbon monoxide intoxication has decreased since and the victim profile has not changed too much. the fatal carbon monoxide intoxication is still persists as a public health problem in tunisia. the reduction of its frequency requires the implementation of a well-structured prevention plan based on epidemiological data from a national registry. the identification of these data requires mandatory reporting of this type of intoxication in tunisia. introduction: olanzapine is an atypical antipsychotic drug frequently prescribed in the treatement of bipolar disorder and schizophrenia. acute poisoning with this molecule is rarely reported. through this study we aimed to evaluate the incidence and describe the different clinical features of acute olanzapine poisoning. patients and methods: retrospective analysis of all cases of olanzapine intoxication admitted in -bed teaching icu between january and decembre . inclusion criteria were patient age ≥ year, acute olanzapine intoxication, the intoxication severity was assessed by the poisoning severity score (pss) of the european association of poison centres and clinical toxicologists. the evaluation of electrocardiograms was performed in the first day of hospitalization. the durations of qrs and qtc was measured and arrhythmias and conduction disorders was identified. results: patients were included, the mean age was ± years. they were males and females. long term treatment with olanzapine was noted in patients ( %) who suffered from psychiatic desease. the supposed ingestion dose ranged from to mg. the mean consulting time was ± h after the ingestion. olanzapine was co-ingested with others drugs in patients ( %). co-ingested drugs were-benzodiazepine (n = ), levomepromazine (n = ), serotonin recapture inhibitor (n = ), amitriptilyne (n = ) and biperiden (n = ). the pss was moderate in cases ( . %), severe in cases ( %) and fatal in case. the main clinical signs were tachycardia and miosis in % of cases each of them (n = ), agitation in % of cases (n = ). ecg abnormalities has been detected such as prolonged qtc in cases with a mean duration of ± ms. in the group of monointoxication ( patients) the pss was moderate in cases ( . %), severe in cases ( %) and fatal in one case. the coma glosgow scale was < fig. kaplan-meier survival between admission and -day according to adequate empirical antibiotic therapy guidelines (log rank, p = . ) in cases. mechanical ventilation was required in % of cases (n = %) with a mean duration of ± heures. the mean duration of icu stay was of ± h. twenty three patients recovered during the hospitalisation, one patient died with severe poisoning. conclusion: as showed in this study, acute olazapine poisoning could be severe, and lead to death sometimes. introduction: voluntary drug intoxication (vdi) continues to be a major health problem in many developed and developing countries. in algeria, this has become a worrying concern. awareness-raising is launched to prevent the public from these dangers. vdi are intentional or rarely accidental and can be individual or collective and affect all age groups. the vdi represents the first reason for hospitalization in the emergency department university hospital of oran. in algeria there is no national or regional register of voluntary intoxication. knowledge of the causes of drug poisoning should therefore be extrapolated from foreign studies. to draw up an assessment of the imvs, a retrospective study was carried out over the years ( - ) . this survey consisted of collecting data on the nature of the drug, age, sex, major toxidromes, severe imvs requiring hospitalization in icu, mortality, e.t.c scores and glasgo scores. results: cases of acute poisoning were collected, with a predominance in patients aged between and , a percentage of . %. in addition, most patients were female with . %, a sex ratio of . with p < . . the main toxidromes were-opioid syndrome in % of cases and anticholinergic syndrome in % of cases. etc with a score of > % accounted for % of patients. severe vdi requiring resuscitation hospitalization were %. conclusion: acute poisoning remains high and steady in the oran region and the under- age group represents the most affected category. awareness campaigns must be launched throughout the year to better conserve and store medicines, phytosanitary products and other chemicals. improved socio-economic conditions would help to reduce voluntary intoxication. introduction: scorpionic envenomation is unevenly distributed throughout the world and is particularly frequent in some regions of the world, notably north africa. the purpose of this work is to describe the epidemiological profile of the scorpionic envenomations admitted to the resuscitation department of mahres. patients and methods: a prospective study conducted at the mahres intensive care unit over a period of months ( until ), including all patients admitted for scorpion envenomation. results: we collected cases of patients admitted to the resuscitation department of mahres from to , including cases of scorpionic envenomations, i.e. . %. the median age was years with extremes ranging from to years. the sex ratio was . scorpion stings occurred at night in % of patients, % in the first half of the night (between pm and - pm) and % in the second half of the night ( to h). venom inoculation points were in the lower limbs in % of cases, followed by upper limbs ( %). the color of the incriminated scorpion was yellow in %, black in % and unspecified in % of the cases. for admission classes, there were % class i, % class ii and % class iii. the traditional therapeutic gestures practiced by the patients or their entourage were the laying scarification ( %) and the suction ( %). all patients received anti-scorpion serum, an analgesic, serum and tetanus vaccine. the progression was favorable in all cases after an average hospital stay of ± days. conclusion: scorpionic envenomations are indeed a reality in mahres with a non-negligible frequency despite under-reporting of cases treated by traditional medicine or in other hospitals. they mostly affect young people and the associated clinical manifestations often remain benign. introduction: severe pediatric poisoning is defined by the need for intensive care monitoring due to the nature, quantity of the substance and or clinical manifestations. it is one of the frequent reasons for admission to emergency and resuscitation. the purpose of this work is to identify poisoning in children admitted to pediatric intensive care units in order to assess the frequency, identify the products involved, and the clinical and evolutionary aspects. patients and methods: this is a descriptive study over a -month period in the canastel oran multi-purpose pediatric intensive care unit from july to july . we included all children aged - years admitted for ingestion and inhalation of products toxic. results: children admitted to pediatric intensive care, mean age was years, % under years with extremes of months and years, a female predominance of % was observed with a slight predominance of accidental poisoning ( %) compared to voluntary poisoning ( %). in % the toxic is ingested orally. the most frequent toxicants were drugs with cases ( %), mostly antidepressants and antiepileptics, followed by organophosphates with cases ( %), co cases ( %), petroleum products and plants with cases ( %). the main clinical signs were neurological signs ( %) with predominance of coma and convulsions in cases ( %), respiratory distress was present in cases ( %) and digestive signs cases ( %). for therapeutic management gastric lavage, charcoal and antidotes were the most frequent treatments. the evolution was marked by a mortality of % or a death secondary to a poly-medicinal intoxication voluntary in a girl of years. mechanical ventilation in cases ( %) and an average hospital stay of days. conclusion: acute poisoning is a medical emergency that may require resuscitation. young children are most exposed with drugs are the most frequently incriminated. we propose, as a preventive measure, companions of information on the dangers of toxic products and especially of medicines by the surveillance of the child and the regulation of certain products. introduction: the place of neuron specific enolase (nse) dosing remains uncertain as an indicator of neurological prognosis after a cardiac arrest, the threshold value for predicting an unfavorable evolution being variable from one study to another. our objective was to determine a nse cut-off value predictive of poor neurological outcome after a cardiac arrest. patients and methods: we realized a monocentric prospective trial in a medical icu of a french university hospital from january st to december th . all patients over years old hospitalized for a cardiac arrest in medical icu were included. patients who died during the first h or admitted for cardiac arrest with a neurological cause were excluded. serum nse values (elecsys nse test, cobas ® analyzer) were assessed at h and h after cardiac arrest. somatosensory evoked potentials were recorded between h and h . the primary endpoint was neurological outcome at month using the cerebral performance category scale (cpcs). cpcs or was considered as favorable outcome and cpcs higher than as poor outcome. data were collected using cardiologic or neurologic consultations report, or by phone call to the patient. using a roc curve we determined the nse value at h with higher specificity and acceptable sensitivity. results: we included patients. average age was years old. noflow time and low-flow time were respectively . and min. hypothermia was performed in ( %) patients. patients ( %) died in the icu. the -day and -months survival rates were respectively and % with a favorable outcome of % at months. on the roc curve we found a cut-off value of ng ml with specificity of . ci % ( . - . ) and a sensibility of . ci %( . - . ). area under curve was . ci % ( . - . ). out of the patients with a rising nse between h and h had an unfavorable outcome. among patients with nse > ng ml, the cortical n responses were bilaterally present in of them. conclusion: in our study nse value over than ng ml at h was predictive of poor neurological outcome after cardiac arrest. nse may prove to be a useful marker in patients with present n responses, possibly limiting the duration of hospitalization by introducing therapeutic limitation or withdrawal of support. physicians assessment of prognosis in icu patients with brain introduction: outcome prediction in icu patients with severe brain damage is a difficult task with observed heterogeneity in physicians estimation. the aim of the survey was to evaluate the prognostic estimates and treatment recommendation of intensivists in real patients with various causes of severe brain damage. patients and methods: a web anonymous survey including a summarized clinical report of four patients who stayed in the icu was submitted to french intensivists. patient presented with prolonged hypoglycemic coma, patient with intracerebral hemorrhage, patient with central and extra pontine myelinolysis, patient with a brainstem hemorrhage. all these patients received full treatment in the icu and had a -month follow-up. physicians were provided with the four clinical vignettes including clinical history, brain imaging and other relevant exams (csf, eeg,…), evolution of symptoms within the first days of the icu stay. they had to estimate -month outcome using modified rankin scale (mrs) where a score from to was considered as a good outcome and to as a poor outcome. they had to provide a recommendation about care among the following-full treatment, care limitation, care withdrawal. results: physicians completed the survey. there were ( . %) female. ( %) respondents were residents and ( . %) had a > -year of experience. patients and had a good -month outcome with mrs and mrs respectively while patients and had a poor outcome, both with mrs . correct prognosis estimations were ( %), ( . %), ( %) and ( . %) in patients to respectively. care limitation or withdrawal was recommended by ( . %), ( . %), ( %) and ( %) respondents in patients to respectively. of interest, care withdrawal was recommended by ( . %), ( . %), ( . %) and ( . %) respondents in patients to respectively. univariate analysis did not display any factor related with a good prediction of prognosis. conclusion: in this study, overall predictions were pessimistic with important variations among respondents. although decisions to withdraw life sustaining care were relatively low with regard to estimated prognosis, both inappropriate care limitation leading to self-fulfilling prophecies and unreasonable prolonged life supportive care could result from these estimations. introduction: organ harvesting is a national priority because of the shortage of organs, responsible each year for the lengthening of transplant waiting lists. among the identified potential donors, the main cause of non-harvesting is the refusal of organ donation (od), which exceeds % in france and % in paris area. patients and methods: in a network of hopitals, each procedure on a potential donor by the donor co-ordinator is recorded in a report. after selection of the reports with interviews with relatives about od between and , the data in the reports were collected and a multivariate logistic regression was performed to identify the factors associated with the refusal. results: reports with interviews about od was found. the overall opposition rate is . %. among the children ( . % of cases) the opposition rate is . %. among adults, ( . %) expressed their will about od during their lifetime, with an opposition rate of . % and for the ( . %) of them who never expressed their will, the opposition rate is . %. the factors associated with opposition in multivariate analysis are presented in table . when the deceased had never expressed their will, the reasons given by the relatives to justify the refusal are specified in . % of the reports. these are religious grounds ( %), cultural grounds ( %), respect for physical integrity ( %). in % of the cases, relatives believe that the deceased would have been opposed, and in % of the cases, they choose to refuse because they do not know the deceased's opinion. discussion: french law is based on presumed consent. despite this, it is noted that when patients had never expressed their opinion about od (and therefore had not refused it), the opposition rate reached . % and was comparable to the patients who had expressed themselves. conclusion: in our study, factors related to refusal of od are mainly related to the characteristics of the deceased (religion, culture, history of ethylism) and those of relatives (disagreement, presence of a spouse), but little to the way of doing the interview. however, there is a trend for less opposition when the interview is conducted during the day (between - and - ). on the other hand, when relatives first address the issue of od, the opposition rate is lower. introduction: french intensive care society guidelines and the claes-leonnetti law recommend that intensive care teams organize collegiate and multidisciplinary discussions regarding limitation and withdrawal of care decisions. these moments, coined ethical staffs in our unit, require freedom and safety of speech, which can be difficult to obtain when people are caught in hierarchical and or power relations. we sought to assess the representations, perceptions and opinions of icu personnel regarding ethical staffs. patients and methods: a questionnaire, developed by the icu psychologist, was distributed to the entire unit (secretaries, nurses, nursing auxiliaries, doctors) over a period of months. this -question questionnaire covered session organization and power relations between participants. results: among the questionnaires distributed in the icu, were retrieved and analyzed. medical function was associated by respondents with roles linked with power (leading, knowledge, decision, explanation) whereas paramedical function was associated with roles linked with care (perception, account, spokesperson) (fig. ) . regarding representations of decision making, nurses were considered as decision makers in cases ( %) and doctors in cases ( %). discussion: although ethical staffs are presented as a place where each opinion counts, stereotypes representation appear in the different roles assigned-on one side doctors are in charge of explanation and decision, and on the other side, nurses are taking care of patient's feelings and assume a role of spokesperson. these stereotypes correspond to gender stereotypes assigning women to positions of care, empathy and relationship, and men to more intellectual and leading skills. these gender stereotypes attest a hierarchy internalized by each one, as highlighted by social sciences and gender studies. conclusion: our results highlight the existence of a global idea, shared by the majority-doctors are decision makers and therefore are in a power relation regarding paramedical staff. this hierarchical relationship persists in this moment wished egalitarian (each opinion would count equally). these is a linkage between professional power relations and gender power relations, which show an association between doctor and masculine "qualities" and caretakers and feminine "qualities". these power relations are rarely acknowledged but could have a significant impact on the decision process of these meetings, and should be further investigated. results. despite the diary, % had a qspt score > , indicating a higher post traumatic disorders. patients ( %) presented a anxiety score > and patients ( . %) had a depression score > . these results underline the need of psychological support after the stay. conclusion: many survivors of intensive care unit reported a high level of psychological distress. it seems important offer at this patient a psychological support after an intensive care unit stay. most patients needs return in intensive care unit to understand some elements of hospitalization. actually, this support lack to screening and treatment this psychological morbidity. prevalence and description of the complications following a percutaneous coronary intervention for a myocardial infarction in non-cardiac critically ill patients: a retrospective single-center introduction: type myocardial infarction (mi) is an emergency, which immediate invasive strategy by a percutaneous coronary intervention (pci) is based on guidelines for cardiologic patients. conversely, the invasive strategy remains uncertain for patients hospitalized in the intensive care unit (icu) for a primary non-cardiac disease with mi as a complication, given the ischemic and hemorrhagic risks. we aimed to assess the prevalence of-and describe the major adverse cardiac and hemorrhagic events occurring in the icu after an invasive strategy by pci in this context. we conducted a retrospective single-center -year ( - ) study. all the consecutive icu patients with a suspected mi undergoing a coronarography were screened. patients treated with an invasive strategy (pci performed within days of mi) were included. patients hospitalized in icu for cardiac disease were excluded. the major adverse cardiac events (mace) were defined as post-procedure events occurring in the icu, including death from cardiovascular causes, mi recurrence, need for emergent revascularization and stroke. the major adverse hemorrhagic events (mahe) were defined as post-procedure events occurring in the icu, according to the bleeding academic research consortium. results: icu patients suspected of mi underwent a coronarography. patients ( %) had significant coronary lesions. twelve patients were excluded-tri-truncular coronary involvement (n = ), delayed procedure (n = ), cardiogenic shock (n = ). patients were included ( men, years [iqr - - - ], patients mechanically ventilated, patients with sepsis septic shock, median sofa score at the time of mi [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ). a pci was performed during the first day after diagnosis of mi in patients ( %) (median time- day [iqr - - - ]). a mace occurred in patients ( %), including stroke (n = ) and mi recurrence without revascularization (n = ). no patients deceased from cardiovascular causes in the icu, neither at months post-procedure (table ) . a mahe occurred in patients ( %), of whom had a mace. altogether, the prevalence of major adverse cardiovascular events combining mace and mahe was . ( % ci . - . ). there was no difference between septic and non septic patients regarding the prevalence of mace or mahe. the prevalence of adverse cardiovascular events after an invasive strategy by pci is high in non-cardiac critically ill patients with mi. larger studies are needed to determine which patients may benefit from this procedure. introduction: resuscitated cardiac arrest (ca) lead to immune alteration including lymphopenia, decreased monocyte hla-dr (mhla-dr) expression and dysregulated production of cytokines. in a recent multicenter randomized clinical trial, we tested the hypothesis that cyclosprine a (csa) would limit organ failures following out-of-hospital cardiac arrest (ohca). in a substudy, we aimed to determine the influence of csa on ohca-induced immune dysfunction. this study is a predefined substudy of the randomized cyrus trial (cyclosporine in ca resuscitation). patients with non-shockable ohca randomly received either an intravenous bolus injection of csa ( . mg kg) at the onset of advanced cardiovascular life support (csa group) or no additional intervention (control group). patients from the coordinating center were sampled at admission (d ) and at h (d ). complete blood count, cd + lymphocytes count and mhla-dr were evaluated by flow cytometry. serum levels of il- , il- , il- , il- and tnf&# + were measured by elisa test on frozen samples. results: a total of patients were sampled- patients from the csa group and from the control group. the characteristics of the patients, including resuscitation data, were also similar between the two groups at admission. the severity of organ failure as assessed by the sofa score at admission was similar between groups. all patients introduction: critically ill patients experience major insults that lead to increased protein catabolism and a significant loss of lean body mass with an impact on weaning from the ventilator and muscle recovery. in critically ill patients, severe and persistent testosterone deficiency is very common after icu admission. administration of testosterone may induce skeletal muscle fiber hypertrophy and decreases protein breakdown. the aim of this work is to assess testosterone levels in critical ill patients and to evaluate the safety of testosterone gel administration. this is a single center study realized in a university icu of beds. total testosterone levels were measured in critical ill men with at least one organ dysfunction with sofa > . the study drug was androgel, a formulation of % testosterone in an alcohol-water gel, approved by the ansm for treatment of hypogonadism in men. androgel was applied to the abdomen, shoulders or upper arms once a day at the same time to dry and intact skin during icu stay. the daily dose was mg in men and mg in women daily. patients with history of prostate or breast cancer or psa > ng ml were excluded. results: total testosterone levels were measured in men. median length of stay at the time of measurement was days in icu and days in the hospital. plasma testosterone levels were low in all but patient. median testosterone level was ng dl (normal values - ng dl). testosterone levels were not correlated with score sofa or length of icu stay. we found a moderate positif correlation between testosterone levels and length of hospital stay (r = . =). testosterone gel was administered in men and in women. in these patients, the median score sofa was , icu death occurred in patients ( % icu mortality), median length of ventilation was days and median length of stay in icu days. all patients received mechanical ventilation and vasoactive treatment. patients needed renal replacement therapy. androgel was well tolerated. no ischemic cardiovascular events were described. there was no application site reaction or acne. median length of testosterone gel administration was days. conclusion: critical ill patients have low testosterone levels. testosterone gel may be safely administered during the acute phase in icu. randomized clinical trials are needed to evaluate the impact of testosterone gel on physical performance. introduction: stroke is the leading cause of physical disability and the second leading cause of death worldwide. two thirds of all strokes occur in developing countries and is increasingly a public health problem. the aim of this study was to evaluate the epidemiology of strokes in oran, algeria in order to create a stroke registry. patients and methods: a cross-sectional study was conducted on all patients admitted for stroke at the oran chu between january and september . sociodemographic data, modifiable and nomodifiable risk factors, type of stroke, degree of disability, severity scores (glasgow and nihss) were studied. the spss software, log rank test, was used for data analysis and statistical testing as well as kaplan-meier for survival studies. results: a total of stroke patients were enumerated, aged - years (mean ± sd = . ± . ), . % had an ischemic stroke and % had a haemorrhagic stroke. % of the patients were men and % of the women. high blood pressure, diabetes, emboligenous heart disease and smoking were the most common risk factors. intra-hospital mortality was . % and the overall survival rate at days was %. conclusion: this epidemiological study demonstrates that strokes at oran hospital may be similar to other locations. however, it seems necessary and useful to design a continuous patient registration system. introduction: the prevalence of hyperosmolar states and the relationship with mortality nevertheless remain unquantified and not objectively demonstrated. the aim of this work is to determine whether hyperosmolarity is a prognosis factor, and to assess the impact of hyperosmolarity on the evolution of patients. patients and methods: this is a retrospective descriptive and analytical study performed at the medical intensive care unit at the university teaching hospital ibn rushd in casablanca on the cases admitted during year. we noted epidemiological, clinical, biological and evolutionary parameters of all the patients and divided them into two groups according to their osmolar states, the first non-hyperosmolar group with plasma osmolarity of less than mosm l, called the control group and the second hyperosmolar group, plasma osmolarity greater than or equal to mosm l. results: patients were included. the first group comprised patients ( %) and the second comprised patients ( %). the two groups did not differ significantly about sex and age. hyperosmolar patients had more diabets . %. patients in the two groups did not show significant differences in clinical outcomes, including apache ii and saps ii scores. significant differences are reported between the two groups, in natremia, creatinemia, liver transaminases. the plasma osmolarity was significantly different between the two groups with a mean in the control group of . ± . mol l while in the hyperosmolar group it was . ± . mosmol l (p = . ). the prevalence of hyperosmolar states in the study was % with % mortality. in the control group % were intubated-ventilated + . % received vasoactive drugs and . % received antibiotic therapy. in the control group + %of the patients were complicated by nosocomial infection, . % by septic shock and % diseased by thromboembolic complications. the deceased subgroup used intubation artificial ventilation in . %, vasoactive drugs in %, and antibiotic therapy in . %. in the surviving subgroup, . % only contracted the nosocomial infection. in the subgroup died . % are of mixed hyperosmolar type + . % hyperglycemic hyperuremic + . % hyperglycemic hypernatremic type. conclusion: hyperosmolar states are an independent a prognosis factor. intubation and ventilation, vasoactive drugs and antibiotic therapy increases considerably in hyperosmolar states. furthermore, it induced serious complications as nosocomial infections and septic shocks that further aggravate the prognosis even within hyperosmolar states. introduction: hyperthermia represents a major life-threatening medical emergency, and is also one of the leading causes of death in young athletes worldwide. its incidence is rare and little understood, but its mortality is on the rise. the objective of this study was to describe the population of patients admitted for exertional hyperthermia in martinique and guadeloupe and to determine the prognostic factors. patients and methods: retrospective and prospective study, including all patients admitted for exertional hyperthermia in both emergency and resuscitation services in martinique and guadeloupe from january to june . results were expressed as mean ± sd or %. results: in years, patients were observed (age- ± , men and women), the main antecedents of which were- hypertension, chronic oh, psychoses, stress hyperthermia. ( %) of the patients had seizures initially. the pre-hospital management was < min. nevertheless, ( %) patients were admitted to icu due to organ failure (neurologic %, hemodynamic %, liver %). the progression was favorable, deaths, including fulminant hepatitis and multi-visceral failure. the average length of stay in intensive care units was days (± ). conclusion: despite considerable preventive measures, stress hyperthermia represents a major problem within the military, soldiers and other athletes, with a mortality rate about % in most published series. the most effective method is immersion in ice water. there is an urgent need to provide the region with a clear preventive policy, including a relief action plan, training for doctors, athletes and other health professionals at risk of hyperthermia. chapoutot anne-gaëlle , leteurtre stéphane , chamouine abdourahim ( ) . the university hospital of lille is a pediatric center including several itecus in its pediatric hematology or gastrology departments, and more recently in its pediatric surgical department. moreover, there are - itecu extra-beds within the - bed pediatric intensive care unit (ivecu). the hospital of mayotte has no pediatric ivecu but a polyvalent one for adults, which receives children when necessary, as well as a bed itecu. the aim of this study was to describe prospectively the pediatric population which was admitted in the itecus of lille and mayotte over a one-year period from june to may . patients and methods: in this twin-center, prospective and observational study, data were collected for each patient admitted during the test period in itecus of both lille and mayotte pediatric hospitalsgeneral information about the patient, characteristics of each stay, severity scores on admission, type of treatments implemented, the report of the stay and patient's evolution. a standard declaration was made with an authorization granted by the local commission on informatics and liberty (french commission informatique et liberté, cil). results: during the course of the study, about children were admitted in each center. the collected data allow to describe and compare both populations in terms of severity of each patient's condition. this study based on a very large cohort has permitted to compare the population of a regional hospital with that of a university hospital and to demonstrate that a health-care provision including a pediatric intensive care unit is needed on mayotte island. introduction: simulation in intensive care is an innovative method for teaching. respiratory settings are responsible for some morbi-mortality of our patients. for this reason we develop a simulator of artificial ventilation (simva) and virtual patients. mathematical model resolved differential equations of chest and lung movements in order to match with a clinical data base. the goal of this study was to evaluate and compare virtual patients respiratory mechanic with the results of different protocols of ventilation from large randomised controlled trial-arma ( ) and express ( ). patients and methods: virtual patients had ards, and were defined by different thoracic and pulmonar compliance, total resistance, lung volumes, pressure-volume relation, and pressure and volume recruitment coefficients. ventilatory protocols were high versus low vt (arma study) and max versus min distension according to pep (express study). each virtual patient was titrated on the simulator with the protocols. respiratory frequency was set around cycles minute and adapted to protocols. respiratory mechanic after titration was recorded and compared to results of the studies. results: results are summarised in the table-the difference between virtual and real patients were not significant. vm l/min . ( . ) . ( . ) . ( . ) . ( . ) . ctp: tharacopulmanar compliance (ml/cmh o) discussion: inspiratory plateau pressure and thoraco-pulmonary compliance were able to change according to pep or vt settings within the same range as the large rct studies. mathematical model of recruitment was adapted to create many different results while pep was titrated according to respiratory mechanics with the express protocol. conclusion: simulation of artificial ventilation with a software can be realistic and might be an interesting pedagogical tool to teach interactively and repetidly ventilatory settings and respiratory mechanics interactions in ards without any risk for the patient in our units. introduction: expiratory flow limitation (efl) has previously been investigated in ards patients on zero peep by using negative expiratory pressure (nep) technique on tidal breath. in ards patients with efl peep improved oxygenation from intrinsic peep homogenization rather than lung recruitment. the nep technique is no longer available. as efl should reflect airway closure it is important to assess it. we described a new technique to assess efl. patients and methods: thirty-nine ards patients ( mild, moderate, severe) were investigated at peep and . they were intubated, mechanically ventilated (evita xl) in volume controlled mode (tidal volume ± ml kg predicted body weight) in the semi-recumbent position. airway pressure and flow measured proximal the endotracheal tube were continuously recorded (biopac ). we measured respiratory mechanics by the occlusion technique at each peep and recruited lung volume between peep and by using low flow inflation method associated with measurement in change in end-expiratory lung volume. for the latter, patient was manually disconnected at the end of baseline tidal inflation downstream pneumotachograph to atmosphere til zero flow, then reconnected at previous settings. efl was assessed offline by superimposing flow-volume loops of disconnected and baseline breath. efl was defined if no change in flow occurred over all or part of the disconnected expiration as compared to the baseline breath and no efl (nfl) if any increase in flow during the expiration was present (fig. ) . the percentage of the tidal volume involved in efl was measured. results: efl was present in patients ( %) over % of the tidal expiration. patients with efl had significant higher body mass index ( ± vs. ± kg m , p < . ) and totalpeep at peep ( ± vs. ± cmh o, p < . ) than nfl patients and tended to be more hypoxemic. at peep efl patients had a significant better compliance ( ± vs. ± ml cm h o, p < . ) with no change in recruited lung volume ( ± vs. ± ml) and tended to be more hypoxemic than nfl patients. mortality at icu discharge was % in efl versus % in nfl (p = . ). conclusion: measurement of efl is feasible without the nep technique. at higher peep ards patients with efl markedly improved compliance of the respiratory system not related to lung recruitment. further studies are required to better understand efl in ards patients and to assess its impact on patient outcome. limiting factor being carbon dioxide accumulation and hypercapnic acidosis. extra corporeal carbon dioxide removal (ecco r) intervenes by maintaining ph and pco within physiological ranges. this combination is called ultra-protective ventilation. we report our experience with ecco r in ards and non ards patients with a focus on feasibility and safety. patients and methods: from june to july all patients who have undergone ecco r in our icu were included consecutively and prospectively. venovenous ecco r was used through a dual lumen venous catheter (femoral or jugular). results: nineteen patients underwent ecco r for a total of sessions. ecco r was implemented through a dual lumen venous catheter (femoral or jugular) with different devices-hemolung respiratory assist system ® (alung) (n = ), ila activve ® (novalung) (n = ) and prismalung ® (prismaflex system) (n = ). sessions were (iqr . - . ) days long. catheter diameters were fr (n = ), fr (n = ), fr (n = ) and fr (n = ). thirteen patients suffered from ards and had non ards indications for ecco r, including ultraprotective ventilation. tidal volume decreased during ecco r from . (iqr . - . ) to . (iqr . - . ) ml kg of predicted body weight (p < . ) while ecco r allowed maintaining of ph and pco within acceptable range (fig. ). driving pressure decreased from (iqr - ) to (iqr - ) cm h o (p < . ). the main adverse effect was thrombocytopenia ( patients). six selected patients had no anticoagulation during ecco r because of high bleeding risk. discussion: ultra-protective ventilation was achieved with a decrease of tidal volumes (vt < ml kg) and positive pressures. few data on ecco r are available in patients at high risk of hemorrhagic complications, we report here a subgroup of patients who underwent efficiently ecco r without anticoagulation. six patients underwent ecco r for non ards indications, of them had no structural damages to the lungs which has never been reported and eccor allowed implementing ultra-protective ventilation with no major adverse effect. we report our experience on ecco r for ards and non ards indications. ultra-protective ventilation (vt < ml kg) was safe and feasible. the impact of general practitioners consultation on ards complicating community acquired pneumonia donval ulysse , tadie introduction: community-acquired pneumonia (cap) is a potentially severe infection that results in numerous general practitioner (gp) visits and hospital admissions each year. cap is also the most frequent single cause of acute respiratory distress syndrome (ards). risk factors for development of ards in the course of cap are not clearly defined although prognostic factors associated with mortality have been extensively studied. gp visits, as an early diagnosis and earlier access to antibiotics prescription could significantly affect the course of cap. the aim of the present study was to evaluate the impact of general practitioners consultation on ards complicating cap admitted to our icu. patients and methods: we retrospectively reviewed the medical records of all patients aged over years admitted between october , and december , , for ards complicating community acquired pneumonia with a pao fio ratio < mmhg after at least h of lung protective mechanical ventilation (mv). ventilatory modalities for ards had been protocolized over the study period as our icu was recruiting patients for two consecutive multicenter trials (acurasys and proseva). consequently, the protective ventilatory strategy used in these two clinical trials was applied to every patient with ards. patients were divided into two groups according to whether or not they visited a gp before icu admission. : patients were admitted for ards complicating cap. patients ( %) had visited a gp before admission in icu (gp +) and did not (gp-). analysis of demographic data, respiratory microbiology patterns, ards severity at admission did not show any differences between the two groups. sofa score at admission was significantly higher in gp-compared to gp + patients ( . ( - ) vs. . ( - ) respectively + p = . ) although respiratory sofa scores were not different ( ( - ) vs. ( - ) respectively + p = . ). ( %) gp-( %) and ( %) gp + patients presented septic shock at icu admission (p = . ). multivariate analysis found that gp consultation ( . [ . - . ] + p = . ) with antibiotics prescription ( . [ . - . ] + p = . ) were associated with decreased mortality at day ( fig. ) . in patients admitted to our icu for ards complicating community acquired pneumonia, gp visits prior to icu admission was associated with a better outcome. the beneficial effect may be due to earlier antibiotic prescription which could significantly lowered severe infection and septic shock. introduction: optimal peep level during ards remains controversial because of its beneficial and adverse effects. the optimal level of recruitment and its effect on oxygenation are not well defined and no technique is currently validated. the aim of our study was to evaluate the correlation between the recruited pulmonary volume estimated by a new technique (crf inview ® ) and the evolution of pao as well as the respiratory and hemodynamic tolerance of the application of an increasing levels of peep . patients and methods: a prospective, monocentric study that will last years (january -january ), taking place in the intensive care unit at the military teaching hospital of tunis and including patients if they met standard criteria for ards (berlin criteria). the main criterion for judgment was the correlation between the recruited pulmonary volume estimated by a new technique (crf inview ® ) and the evolution of the pao after application of three increasing levels of peep ( - - ). the other secondary criteria were the respiratory and hemodynamic tolerance of the application of increasing levels of peep measured by the picco ® technique. aimed to investigate the concordance between the onset of three vae tiers and valrti, and their impact on outcomes. we performed a retrospective analysis of prospectively collected data from patients requiring mechanical ventilation for more than days in a -bed mixed icu of a tertiary university teaching hospital, between january and december , . vat and vap episodes were assessed by prospective surveillance of nosocomial infections, according to the american thoracic society criteria. vae were identified retrospectively, according to current cdc definitions. the agreement between vac, ivac, pvap and valrti was assessed by k statistic. the impact of vae and valrti on duration of mechanical ventilation, icu and hospital length of stay and mortality was also assessed for the first episode of vat and vap. results: we included patients ( ventilator days). vap ( . per ventilator-days), vat ( . per ventilator-days) and vae ( . per ventilator-days) were diagnosed. there was no agreement between vat and vae and the agreement was poor between vap and vac (k = . , % ci . - . ), vap and ivac (k = . , % ci . - . ) or vap and pvap (k = . , % ci . - . ). patients who developed vat, vap or vae had significantly longer duration of mechanical ventilation, icu and hospital length of stay, compared to patients who did not, with similar mortality rates. conclusion: vae are not relevant for vat diagnosis and have low agreement with vap, despite their negative impact on ventilation duration, icu and hospital length of stay ( fig. ) . the introduction: post-operative pneumonia (pop) is a frequent and severe complication of major lung resection surgery. in , we changed our surgical antibioprophylaxis protocol from cefamandole to amoxicillin-clavulanate and observed a significant decrease of pop incidence and mortality. in , we additionally implemented in the respiratory intensive care unit (ricu) an antimicrobial stewardship program based on a local antimicrobial guideline and a weekly multidisciplinary review of all antibiotic therapies by ricu physicians, infectious diseases specialists and microbiologists. our objectives were to describe our current epidemiology of severe pop and to assess the quality of antibiotic prescriptions. patients and methods: all patients with severe pop occurring within days after lung resection between january and december were included. we collected data on clinical presentation, results of microbiological investigations, antibiotic regimen and outcomes. the quality of antibiotic use was assessed using indicators previously validated in the literature. results: over patients who underwent major lung resection in our center, matched criteria for severe pop and were included. most were males (n = , %). the median age was years (minimum- + maximum- ). most patients had chronic obstructive pulmonary disease (n = , %) and ( %) a history of non-pulmonary cancer. the resection consisted in lobectomy in % (n = ). the median length of stay in ricu was days ( + ), and -day mortality was % (n = ). respiratory microbiological samples were obtained in all patients, in most cases invasively per bronchoscopy ( %). microorganisms were cultured at a significant level in ( %) patients. predominant species were enterobacteriacae ( %), haemophilus influenzae ( %), staphylococcus aureus ( %) and pseudomonas aeruginosa ( %). microorganisms were sensitive to third generation cephalosporins in ( %) and to piperacillin-tazobactam in ( %). in patients treated empirically, antibiotics were prescribed according to the guideline in % ( ). in documented pop, empiric antibiotics were active against documented micro-organisms in ( %), and were correctly changed to pathogen-directed therapy in ( %). the median duration of antibiotics was of days ( + ). conclusion: ten years after implementation of amoxicillin-clavulanate as surgical antibioprophylaxis, the proportion of enterobacteriacae increased. the -day postoperative mortality rate remained below %. we report high adherence to the guideline for the choice of empirical therapy and treatment duration. the rate of de-escalation to pathogen-directed therapy could however be improved considering the high rate of bacteriologically-documented pop. resistance of pa has reduced between both periods from % to % (p < . ) for ceftazidim, from % to % (p < . ) for cirpofloxacin and from % to % (p < . ) for imipenem. nevertheless, among the cases, the p period did not change the risk of developing an infection (rr = . , ci % . - . ), a vap (rr = . , ci % . - . ), a septicemia (rr = , ci % . - . ) or the mortality rates (rr = . , ci % . - . ). conclusion: colonization and infection with pa are risk factors of increased mortality rates and alos in icu. an antibiotic stewardship program allows to reduce the incidence of patients having a positive sample with pa, and the antibiotic resistance of pa strains, without reducing the infection rate of these patients. impact of a local care protocol on the duration of antibiotic therapy in community-acquired peritonitis: years of experience introduction: the use of antibiotics is a major public health, economic and ecological challenge. in , a french national warning plan was created to manage the use of antibiotics. it advocates monitoring of the prescription of antibiotics and the implementation of measures to assess professional practices. the great majority of guidelines concerning the duration of antibiotic therapy in community-acquired peritonitis are based on studies with low level of evidence. the objective of this study is to evaluate the implementation of a standardized operational report (sor) with a local antibiotic protocol in the management of community-acquired peritonitis at our institution. patients and methods: this is a monocentric, prospective cohort study-before and after the establishment of the sor. the primary endpoint is duration of antibiotic therapy. secondary endpoints are length of hospitalization, infectious complications, mortality, and changes in local bacterial ecology. we have also evaluated retrospectively these different criteria on cohort was constituted since . results: a total of patients were enrolled from january to june and patients from may to may . the duration of antibiotic therapy was decreased by to days in localized peritonitis (p < . ) and to days in generalized peritonitis (p < . ) (figure) . however, the compliance to the protocol was only %, which leads to an increase in the duration of antibiotic therapy and hospital stay when not used (p < . ). the hospital stay decreased from to days in the localized peritonitis (p < . ). amoxicillin clavulanic acid (amc) is the most used antibiotic with an efficiency of %. there was no impact on morbidity and mortality when amc was inadequate. the bacterial ecology was not modified, the rate of extended-spectrum beta-lactamase (esbl) producing enterobacteria (esble) was %. the use of a standardized antibiotic protocol reduced antibiotic therapy duration and hospital stay, particularly in localized peritonitis despite incomplete compliance to the protocol. to achieve full compliance, we need to continue the training of different physicians and continue the spread of the protocol. introduction: bacterial meningitis is an important public health problem because of its frequency and severity. they remain a major cause of mortality and morbidity in developing countries. the aim of our work is to establish the epidemiological characteristics and the prognostic factors . patients and methods: we did a retrospective descriptive and analytical study and we included all the patients admitted for severe meningitis for year in the medical intensive care unit of the university teaching hospital ibn rushd at casablanca-morocco. results: patients were included. the incidence of severe meningtis was . %, the mean age was years old and the sex ratio h f was , . , % were pneumococcal meningitis and % were tuberculosis in univariate analysis, factors influencing mortality significantly-the male sex patients with pulmonary tuberculosis as an antecedent.• a low glasgow score at admission. the presence of a neurological deficit arterial ph, mean (sd) arterial lactate, mean (sd) kidney disease-improving global outcomes chronic kidney disease guideline development work group members. evaluation and management of chronic kidney disease-synopsis of the kidney disease-improving global outcomes clinical practice guideline dramatic increase in venous thromboembolism in children's hospitals in the united states from antithrombotic therapy in neonates and children acute childhood arterial ischemic and hemorrhagic stroke in the emergency department childhood hemorrhagic stroke-an important but understudied problem emergency management of deeply comatose children with acute rupture of a cerebral arteriovenous malformation goulmane mourad -m.goulmane@hotmail.com annals of intensive care we recorded episodes of nosocomial infections-pneumonia (n = , . %), bacteremia (n = , . %), catheter related infections cri (n = , . %) and urinary infections (n = , . %). pathogens isolated were largely dominated by non-fermentent gram-negative bacilli (n = , . %)-acinetobacter baumanii (n = , . %) with % resistance to imipenem and tygecycline, pseudomonas aeruginosa (n = , . %) with . % resistance to ceftazidim and stenotrophomonas maltophila (n = ). other gram-negative bacilli were enterobacteries (n = ), which were wide-spectrum betalactamase secreting (n = ) and carbapenemase (n = ). gram-positive cocci were the second highest (n = , . %)-coagulase negative staphylococcus (n = ) which were resistant to methicilline ( %), enterococcus (n = ) which were resistant to vancomycin (n = , . %), staphylococcus aureus sensitive to methicilline (n = ) and streptococcus (n = ). candida was incriminated in cases of cri we report here that neonates had a reduction in hla-dr expression after cpb, and those with prolonged decreased hla-dr in the early postoperative period (day ) could represent a subpopulation at greatly increased risk of later ni. if confirmed in a larger cohort of patients, our findings could indicate that hla-dr may be a useful biomarker of immunosuppression after cpb in neonates. non-traumatic hemorrhagic stroke (nths) in comatose children: epidemiological features and clinical presentation conclusion: compared to normobaric ltot the fio is lower during niv with the same o flow. compensation for intentional and nonintentional leaks and so an increase of air flow despite a constant o input might explain this. in intermediate care the use of hv for niv may be interesting alternative in which case the clinician must keep in mind that the fio decreases compared to standard oxygen therapy. concerning home usage we hypothesize that this partial removal of o treatment could contribute to the poor results of niv in chronic copd. introduction: in february , we opened a beds-post icu rehabilitation center (service de rééducation post réanimation, «srpr»), dedicated to weaning from mechanical ventilation and global post icu rehabilitation. objectives-description of the characteristics and main outcomes of the patients admitted over the first year of activity. patients and methods: retrospective analysis of data extracted from the medical files. results: patients were admitted times in the unit over its st year, from different icus (median duration of stay in the icu . days (iqr - )). % were ventilated ( % with niv). % had a tracheostomy. % had icu acquired weakness + % were able to walk. an underlying chronic respiratory disease was present in % of cases. % were obese. difficult weaning was found to have one or several respiratory components in % of cases (including post surgery diaphragmatic paralysis), cardiac in %, neurologic in %. significant complications occured in % of cases. median duration of stay was . ( - . ) days. ten patients died in the unit, patients were re-transferred in the icu, where of them died. over half of the patients were discharged at home, in a rehabilitation unit (ssr) or in a hospital ward awaiting a rehabilitation bed. the remaining %, that still needed some form of medical or surgical care were discharged in the ward (fig ) . in intention to treat, successful weaning from invasive ventilation was obtained in % of patients. of the patients discharged alive from the unit after completing the rehabilitation program (n = ), % were completely weaned from mechanical ventilation, % were discharged with niv or cpap + patients ( %) were considered not weanable from invasive ventilation + decanulation of tracheostomy was obtained in % of cases + % of the patients could walk. conclusion: srprs offer a new concept of care for difficult to wean patients, with promising results. introduction: scarce data about patients with prolonged weaning from the mechanical ventilation are available in the literature. patients without successful weaning days after their first weaning attempt were classified in the group of the weaning according new definition (wind) classification ( ) . we here describe specific data concerning weaning and hospital evolution of group patients included in this prospective cohort. among the patients included in the wind study, were classified in the group . additional data concerning comorbidities, cause of weaning failure and hospital evolution were collected for ( %) of these patients. results: these patients had median [interquartile range] duration of invasive mechanical ventilation of [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] days and [ ] [ ] [ ] separation attempts. etiology of icu hospitalization was medical in ( %). they had a copd in ( %), hearth disease in ( %) and immusoppression in ( %). we noticed a mean saps ii of ± , a mean sofa d of ± and d of ± . tracheostomy for weaning was performing in ( %). at the end of their follow-up, ( %) were still alive- ( %) were still tracheostomized, still intubated and ventilated, ( %) treated with vni and ( %) were extubated (or decannulated) and breathed without assistance. among the patients still tracheostomized at the end of the follow-up, ( %) were still ventilated (permanently for of them, and partially for ) and ( %) had spontaneous breathing through their tracheostomy. these patients had a total icu length of stay of days. the destination at discharge from the icu is known for only of the survivors- ( %) in medical ward, ( %) in intermediate care units, ( %) in sub acute care, ( %) in icu and in surgical ward. conclusion: a third of the patients of the wind study classified in group and with available additional data died in hospital in months following intubation. at the end of the follow-up, % had spontaneous breathing without assistance, and % were still tracheostomized. among these tracheostomized patients, one third still required mechanical ventilation. ( )-béduneau, g., pham, t. and co ( ) . epidemiology of weaning outcome according to a new definition. the wind study. ajrccm, ( ) , - . introduction: copd patients have often polyglobulia because of associated hypoxemia especially in patients at the stage of chronic respiratory failure. we recently reported that anemia was present in % of patients with severe aecopd admitted to icu without impact on short-term prognosis. the aim of the present study was to assess the long-term impact of haemoglobin (hb) levels on outcomes of aecopd patients. patients and methods: in a prospectively collected database including consecutive patients admitted between and for aecopd in our icu. long-term status of patients following the first icu admission (surviving or deceased) has been verified by consulting the civil status registers. anemia was defined according to who criteria-hb < g dl in males + hb < g dl in females. long-term survival was assessed by kaplan-meier curve. results: the cohort included patients (median age , median ph . , . % males, niv as first ventilator mode in . %). anemia was observed in of the patients ( . %) with median haemoglobin levels at . and . g dl, in patients with and without anemia, respectively. anemia was associated with significantly lower years survival (log rank p = . ) (fig. ). the final model included age, saps ii score, comorbidities, home oxygen therapy, initial ventilatory mode, niv failure and haemoglobin levels. multivariate analysis identified age (or . per year + ic % . - . + p = . ), home oxygen therapy prior to exacerbation (or . + ic % . - . + p = . ), intubation at icu admission (or . + ic % . - . + p < . ), niv failure (or . + ic % . - . + p < . ), and haemoglobin (or . per decrease of g dl + ic % . - . + p = . ) as independently associated factors with years mortality . we conducted a prospective observational study including all patients who visited the sis during the last months. the collection of the usual anonymous demographic, medical and toxicological data was performed by the care-givers and social workers in charge of the drug users. data were declarative and no analytical confirmation was available except for the patients admitted in the icu. results discussion during months, drug users [f m sex ratio . + median age . years ( - ) + patients without resources ( %), without medical insurance ( %), unstable housing homelessness ( %)] visited the sis for drug injection or inhalation, representing , drug use including , inhalations and , injections by drug users day. drug users had no addictology ( %) or sociomedical ( %) follow-up. they were infected by hepatitis virus c ( %) and or hiv ( %). they declared to continue injecting in the public space ( %), sharing material ( %), and needles syringes ( %). the injected inhaled drugs in the sis were skenan ® (morphine, . %), crack ( % including injections), methadone ( . %), buprenorphine ( . %), heroine ( . %), and cocaine ( . %). these drugs were self-administered by polydrug users declaring concomitantly consuming crack ( . %), illicit morphine ( . %), cocaine ( . %), ethanol ( . %), cannabis ( . %), heroin ( . %), illicit methadone ( . %), benzodiazepines ( . %) and illicit buprenorphine ( . %). forty-five patients required a paramedical intervention in the sis resulting in calls to the emergency department and hospital admissions including transfers to the icu in relation to opioid overdose. no cardiac arrest and no death occurred. conclusion: sis visit for recreational drug self-administration rapidly becomes popular among drug users. illicit morphine (skenan ® ) glycemia (mmol/l) . ( - ) . ( - )ketones in the effluent liquid (g/l) . ( . - . ) ( - ) patients and methods: physiological tracings were recorded from the standard monitoring system (intelliview mp philips), using a dedicated network and extraction software (synapse v , ltsi inserm u ) that enables photoplethysmographic recordings from oximetry monitoring at a native resolution of hz. raw data were subsequently stored on a dedicated local server, before anonymization and analysis. all consecutive patients were recorded for a -hours period during the -hours following icu admission. all measurements were recorded with the patient laying supine, with a ° bed head angulation. physiological recordings were associated with metadata collection by a dedicated research assistant.hrv parameters defined in a previous study were derived using kubios hrv premium ( introduction: preventing post liver transplantation (lt) hepatic artery and portal vein thrombosis is challenging and includes enoxaparin administration. enoxaparin pharmacokinetics (pk) has not been investigated in children following lt. between-subject variability and critical illness may alter pk, leading to the risk of subtherapeutic exposure. patients and methods: clinical, biological and kinetic data were retrospectively collected in a single pediatric intensive care unit center from january to july . we described an enoxaparin pk model in children the first week following the lt. anti-xa activity timecourses were analyzed using a non linear mixed effects approach with monolix version r. results: anti-xa activity time-courses were well described by a one-compartment open model with first order absorption and elimination. body weight prior the surgery (bwpreop) and the related postoperative variation (bw(t)) were the main covariates explaining cl and v between subject variabilities. parameter estimates were cli = cltyp*(bwpreop ) + vi = vtyp*(bw(t) ) + where typical clearance (cltyp) and typical volume of distribution (vtyp) were . l h − and . l, respectively. standard dosing regimens of iu kg h were insufficient to reach the target range of anti-xa activity of . to . iu ml. specifically, children ( %) did never attain the target range during the whole period of treatment and all children were at least once under dosed. according to the final results, we simulated individualized dosing regimens within h following the first administration. more than iu kg h are suggested to reach the target range of anti-xa activity of . to . iu ml from the first day. standard enoxaparin dosing regimens is not appropriate to reach the target in pediatric liver transplantation patients. enoxaparin pk modeling should help the physician to achieve the target range from the initial dose and during the maintenance doses. higher dosing regimens, especially in youngest children are suggested to achieve the prophylactic target range. pharmacokinetic analysis of unfractionated heparin in critically ill children during extracorporeal membrane oxygenation: do we achieve the target? introduction: preventing thrombosis in children under extracorporeal membrane oxygenation (ecmo) requiring unfractionated heparin administration. unfractionated heparin pharmacokinetics (pk) has not been well investigated in children under ecmo. we described the unfractionated heparin dosing regimens and resulting anti-xa activities in children with ecmo. patients and methods: this is a single center retrospective study from march to september . were included children (< years old age) who were under ecmo for refractory hemodynamic failure related to (i) myocarditis or (ii) septic shock. anti-xa activity timecourses were analyzed using a non linear mixed effects approach with monolix version r. results: a total of children were included (septic shock, n = + myocarditis + n = with a median age of months ( - ), a median weight of . kg ( . - ) and median admission pelod- score of ( - ). bleeding occurred in children and thrombosis in . an initial bolus of unfractionated heparin ranging from to iu kg was infused and then continued by continuous perfusion with an initial dosing ranging from iu kg h to iu kg h. a total of anti-xa activity measurements were performed between h empirically antibiotics for these patients with severe infection may be recommended. introduction: prognosis of allogeneic hematopoietic stem cell transplant (hsct) recipients admitted to icu has improved with advances in hsct procedures and critical care management, but also with evolution in icu triage policy. our aim was to describe the outcome of hsct recipients admitted to icu according to a wide admission policy. patients and methods: retrospective multicenter study including all consecutive allogeneic hematopoietic stem cell transplant (hsct) recipients admitted to saint-antoine hospital medical icu, paris, france from to january to april . admissions were identified through a systematic review of icu database using icd- codes z and t . data were extracted from medical charts. qualitative and quantitative values are expressed as number and percentage, and median and interquartile range, respectively. comparisons between groups were performed using fisher's exact test and mann-whitney test for qualitative and quantitative variables, respectively. a p-value < . was considered to be significant. results: one hundred seventeen patients- men ( . %), median age [ - ] years-were included in the study. underlying hematological malignancies were: acute myeloid leukemia (n = , . %), myelodysplastic/myeloproliferative neoplasms (n = , . %), acute lymphoid leukemia (n = , . %), lymphoma (n = , . %), other ( . %). complete remission was achieved before hsct in ( %) patients. forty-nine ( . %) patients underwent myeloablative conditioning regimen and ( . %) received haploidentical grafts. twenty-eight ( . %) patients experienced disease relapse after hsct and ( %) graft versus host disease prior icu admission. median saps ii was and sofa score at day one [ - ]. the icu, hospital and -day mortality rates were respectively . , . and . %. in univariate analysis, factors associated with -day mortality were: saps ii (p = . ), invasive mechanical ventilation (p < . ), vasopressors (p = . ) and renal replacement therapy (p = . ). mechanical ventilation was the only independent factor of -day mortality (or . - . ], p < . ) with mortality rate reaching . % and even . % among patients with uncontrolled hematological disease. conclusion: prognosis of unselected hsct recipients admitted to icu remains poor, particurlaly among those receiving mechanical ventilation, and even more if hematological disease is not controlled. these results suggest that the implementation of an icu triage policy determined both by intensivits and hematologists would be helpful to identify good candidates for icu admission. introduction: acute respiratory failure (arf) is a common event in patients with primary malignant brain tumors (pmbt). even if many factors (corticosteroid therapy, swallowing disorders) suggest a specific etiologic spectrum, few data are available regarding its precipitating factors. our first aim was to compare the causes of arf between patients with pmbt and those with other type solid tumors. our second aim was to identify, among pmbt, the factors influencing survival in icu. patients and methods: bicentric case-control study from march to may . patients with pmbt (cases, primary central nervous system lymphoma included) admitted for arf were compared to patients with other kind of solid tumors (controls). the reason for admission "arf" as well as the causes of arf was determined by three experienced respiratory physicians and were required for inclusion: a respiratory rate > cycles/min and a pao /fio < for patients in spontaneous breathing and only a pao /fio < for patients under mechanical ventilation. in both groups were excluded patients with metastatic solid tumors, benign tumors or tumors with more than years of complete remission, recent post-operative patients, and patients with other immunodeficiency. results: a total of cases and controls were included. main patients' characteristics are reported in the table . acute infectious pneumonia was the leading cause of arf in both groups but was more frequent among cases ( vs. %, p < . ). cardiogenic pulmonary edema and exacerbation of chronic respiratory diseases were more frequents in controls ( vs. %, p < . ). pulmonary embolism was similar between the two groups ( vs. %, p = . ). among acute infectious pneumonia, pneumocystis pneumonia (pcp) and aspiration pneumonia were more frequent in cases ( vs. %, p < . and vs. %, p < . respectively). in multivariate analysis cancer progression (or- . %ic [ . - . ], p = . ), need for intubation (or- . %ic [ . - . ], p = . ) and respiratory rate (or- . % ci [ . - . ], p = . ) independently predicted icu mortality of pmbt patients. conclusion: in pmbt patients, the causes of arf differ significantly from other cancer patients. up to % of the admissions was related to preventable causes (pulmonary embolism, pcp) and a curable cause was identified in the majority of cases. our results suggest that pmbt alone is not a relevant criterion for icu recusal. introduction: drug intoxication is a common problem encountered in emergency departments. poisoning remains a major cause of hospitalization for young people, and that of the elderly is constantly increasing. objectives . determine the epidemiological characteristics of addicted patients . know the clinical manifestations of poisoning. patients and methods: a retrospective study of cases of acute poisoning recorded at the university hospital center chuoran between january and december was carried out. seizure on data processing by epi-info version . results: cases of acute poisoning, with an age ranging from to years. female patients predominated with %. people between the ages of and are the people most affected by poisoning. the nature of poisoning is varied. in this series, analgesics were found to be the leading cause of acute intoxication, with cases, % followed by psychotropic drugs ( %), benzodiazepines ( %), neuroleptics ( %), antiepileptics%) and antihistamines ( %). the majority of acute intoxications were managed within an average time of . ± . h with an interval between . and h. in % of cases the poisoning was asymptomatic, there were digestive manifestations in % of patients, % neurological, % cardiovascular and % respiratory. we deplore death in this series secondary to many drug poisoning. conclusion: acute drug poisoning is a common reason for admission to the emergency department of oran university hospital. the large number of drug families offered for sale, as well as the heterogeneity introduction: selective serotonin reuptake inhibitors (ssris) have been considered for their low toxicity comparatively to antidepressant agents. the present study aims to describe clinical features and prognosis of poisoning ssris. patients and methods: a retrospective study of patients admitted to our -bed teaching icu for acute ssris poisoning over a period of years from january to december . ssris poisoning was retained on a history of over dose ingestion, clinical signs and positive urine samples for ssris. results: thirty seven patients were collected, the middle age was ± years with a female predominance ( . %). a psychiatric history with depressive syndrome was noted in . % and a history of suicide in . %. paroxetine was the main invoked drug (n = ), followed by sertaline (n = ), then fluoxetine (n = ), venlafaxine (n = ) citalopram (n = ). the mean supposed ingestion dose was . mg. intoxication was pure in cases and associated with other drugs in cases-benzodiazepines (n = ), klippal (n = ), amisulpride (n = ), non-steroidal anti-inflammatory drug (n = ), prazin (n = ) and promethazine (n = ). neurological examination found drowsiness and mydriasis in % of cases (n = ), coma in . % (n = ), agitation (n = ), tremor (n = ), hyperreflexia (n = ), hypersudation (n = ), fever (n = ) and diarrhea in one patient. the qt was lengthened in five cases. treatment was symptomatic. five patients ( . %) required mechanical ventilation with average of ventilation duration of . h. all patients discharged alive the icu. conclusion: ssris poisoning is mainly manifested by serotonergic syndrome. evolution is favorable in the majority of cases. mechanical ventilation could be required. hemodynamic profile of shocks induced by dihydropyridine calcium channel blocker poisoning khzouri takoua introduction: acute calcium channel blockers (ccb) poisoning remains infrequent despite their increasing use. in our country, dihydropiridines are the most prescribed ones. very few works have studied the hemodynamic profile of acute dihydropyridines poisoning either by invasive means (right cardiac catheterization, transpulmonary thermodilution) or non-invasive (cardiac ultrasound). in this perspective, we carried out this study whose main objective was to illustrate the different hemodynamic profiles of shocks induced by dihydropyridine ccb poisoning. patients and methods: it was an observational retrospective study spread over months from st january to th december in a teaching toxicological icu, including all patients admitted for acute dihydropyridine ccb poisoning, who presented a shock and underwent right hemodynamic exploration.results: during the study period, ccb poisoning accounted for . % (n = ) of all the acute poisoinings requiring hospitalization in our intensive care unit. among them, had taken dihydropyridine which represents . %. four women aged of [ , ] were eligible. all the exposures were single-drug. the dihydropyridines involved were amlodipine in cases with a median value of supposed ingested dose (sid) of . mg and nicardipine in the other two ones, the median sid was mg. the delay of consultation was of . ± h after ingestion. gastrointestinal decontamination was performed in one patient with activated charcoal. the patients developed a shock within h, treated by initial vascular filling on average ml of crystalloids, noradrenaline alone in cases and with a combination of dobutamine in one patient. other adjuvant treatments (high dose insulin, calcium salts) have been used in all patients. their hemodynamic profile evaluation by right-handed catheterization swan-ganz was in favour of vasoplegia in cases with median values of systemic vascular resistances (svr) of dynes.s.cm- , of cardiac output (co) of (l min), and of the arteriovenous oxygen difference of . . the fourth patient's shock had mixed nature with svr of dynes.s.cm- and co of . (l min). all patients were discharged from the icu with a mean length of stay of days. conclusion: the dihydropyridine calcium channel blockers poisoning exposes to the shock risk due to several mechanisms. the clinician must be warned to look for signs of severity and understand its mechanisms by using the hemodynamic study in order to improve its management. goulmane mourad , alachaher djamel , djebli houria introduction: in daily practice, admission to the intensive care unit (icu) usually does not raise any major ethical problems. difficulties arise mainly in acute situations requiring intensive care that have not been anticipated and therefore, not adequately prepared and discussed. we hypothesized that non-admission of a patient to the icu must occur in the following circumstances-( ) with the patient's agreement, expressed either directly or through advance directives (ad), or as relayed by a surrogate or the family + ( ) according to a collegial decision-making process (if the patient is decisionally incapacitated) + and ( ) after seeking the opinion of an external consultant. the decision-making process must be documented in the patient's medical file. patients and methods: prospective, observational study in two hospitals (one large university hospital, one regional non-acamedic hospital) over a period of months. inclusion criteria were-patients aged ≥ years presenting with failure of at least organ that was directly life-threatening and requiring life-sustaining therapies. complete data collection was performed for each patient. results: a total of patients were included ( % from the emergency department and % from medical wards). the decision not to admit the patient to the icu was taken-( ) during night duty for patients ( %) + ( ) by a senior physician in %, and ( ) after clinical examination in ( %). the main reasons justifying the decision not to admit to the icu were-( ) metastatic cancer in patients ( %) + ( ) total loss of autonomy in ( %) + ( ) severe cognitive impairment in ( %) + ( ) premorbid state in ( %) + ( ) chronic organ failure for ( %) + and ( ) presence of ad (written or oral) specifying that the patient did not wish to be admitted to the icu in ( %). this study raises several points concerning the decision-making process for patients requiring intensive care. first, collegiality is observed in almost all situations of non-admission ( %). second, an outside consultant was contacted in around % of cases. third, % of patients had ad. fourth, the family or entourage were consulted in less than % of cases and finally, in around % of cases, the decision-making process was documented. conclusion: this study shows that in emergency situations, it is more difficult to take adequately structured decisions regarding icu admission than, for example, decisions regarding limitation or withdrawal of treatment in the icu. introduction: as known, tracheostomy is performed to improve quality of life (qol) in patients requiring prolonged mechanical ventilation. it is indicated to facilitate care of critically ill patients, in order to minimize risks of oro-tracheal intubation, and enhance recovery, allowing early discharge from icu with home ventilation. we aimed by this study to evaluate long-term survival and qol in tunisian patients discharged from the icu with tracheostomy, as well as related burden assumed by their relatives. patients and methods: patients who were admitted to the icu between and were eligible for inclusion in this retrospective cohort if they had a tracheostomy during their icu stay, and were discharged at home with a tracheostomy canula. for survivors, we used the short form health survey (sf ) to assess their qol at home. we estimated the degree of autonomy using the adl scale. to assess burden assumed by caregivers (family members most of the time) we used the short version of zarit burden interview. exclusion criteria were refusal of the interview or unavailability on the phone call. results: fourteen patients were discharged at home with a tracheostomy canula. only twelve responded to the phone call. four patients died month later. amoung the survivors, the removal of the tracheostomy canula was successful in patients after a mean duration of days. main findings are summarized in table . conclusion: tracheostomy shows good acceptance and acceptable qol. it allowed shorter length of stay in the icu and long-term survival after discharge from the icu, and should be encouraged for tunisian patients. in contrast, the qol of patients' relatives was more affected, with significant burden and work load. introduction: intensive care survivors present often some psychological disorders linked with experience memory loss or nightmares. the use of patient diaries has been developed and implemented by clinical staff to improve the quality of life after intensive care. patients received their diaries at icu discharge. this study was conducted in order to understand the potential benefits for patients the diary on prevalence anxiety, depression and post traumatic disorders during recovery. patients and methods: a structured interview study was administered to adult critical illness survivors who received ≥ h of mechanical ventilation in a medical and surgical intensive care unit. after months, this patients answered at two questionnaire-hospital anxiety and depression scale (had) and a screening instrument for ptsd (qspt). results: from the survivors at months, patients answered the questionnaires. we have two groups- patients had a diary and patients no diary. but these group are so low currently to compare introduction: in ards patients under ecmo common ventilator strategy aims at resting the lung by lowering tidal volume (vt) in the - ml kg predicted body weight range found in the literature analysis. we tested on the bench the not previously explored hypothesis that vt was not delivered in the % accuracy by most of icu ventilators in this low range. patients and methods: pneumatic test lung set at ml/cmh o compliance and cm h o/l/s resistance was attached to any of icu ventilators (v (drager), carescape r (ge healthcare), servo u (maquet), pb (covidien) and g (hamilton)) equipped with heated humidifier (fisher-paykel mr ) set off and adult ventilator circuit (rt evaqua fisher paykel). each icu ventilator was set in btps condition, at peep cm h o and fio . . airway pressure and airflow (hans-rudolph pneumotachograph) were measured (biopac m ) proximal to the lung model. for each ventilator a series of vt ranging from to ml was delivered for breaths each, at then at breaths/min respiratory rate (rr). the relationship of vt measured to vt set was assessed by linear regression over the icu ventilators for each circuit-rr combination. in each model, the change from the mean effect was assessed for each ventilator. for each model we obtained the mean effect of the ventilators then we compared the effect of each ventilator to the mean effect. results: for each combination of f and circuit, the mean slope was significantly lower than indicating that, on average, the set vt was under delivered (table) . there were differences in change in slope from the mean across the ventilators with interaction between ventilators and combinations. as an example, for the adult circuit f , carestation, pb and servo u performed better than g and v . across the combinations, v had consistent negative (greater underestimation than average) slopes and servo u consistent positive (lower underestimation than average) slopes whilst the slope sign in the three others changed direction. biomarkers. yet, hla-dr expression on alveolar monocytes was lower in ards than in controls, consistent with sepsis-induced immunosuppression at the alveolar level. functional differences observed between ards and controls suggested a tolerogenic profile of ards monocytes. introduction: despite their recommendation in the prevention of ventilator-associated pneumonia, oral care is not still clearly standardized. it generally includes a time for oropharyngeal and tracheal suctions which can induce a cough reflex in non-paralyzed patients leading to the mobilization of the endotracheal tube and a consecutively increased risk of tracheal microaspirations. during the oral care procedure, drainage of subglottic secretions at particular times before oro-tracheal suctions is expected to reduce microaspiration. the aim of this study is to assess whether this "optimized" oral care including subglottic drainage can reduce microaspirations. this is an open prospective study, including icu ventilated patients. two procedures have been compared in two randomized cross-over consecutive periods of one day each ( oral cares a day)-on day, they received routine oral care (oral care (o) then tracheal suction (t)) and on the other day they received optimized oral care (subglottic suction (sg ) then o then sg then t). the amylase enzymatic activity has been measured in o, t, sg and sg suctions as a surrogate for the oropharyngeal content. if present in t suctions, it defines microaspiration. since the amylase o content is not similar from a patient to another, the primary outcome was the median amylaset o ratio after routine versus optimized oral care. results: after informed consent, patients were included. were analyzed due to incomplete follow-up in patients. patients (sapsii ± ) were ventilated since . ± . days for a majority of respiratory indications. at day , and patients received routine oral or optimized oral car respectively without significant baseline difference. a trend in the reduction (− %) of amylase t o median ratio was observed after optimized versus routine oral care ( . % [ . - vs. . % [ . - ], p = . . conclusion: despite protection of trachea by the cuff of the endotracheal tube, amylase has been found in tracheal suctions (which represents the last step of oral care). in this pilot study with a limited sample of patients, a trend in the reduction of microaspirations was observed when subglottic suctions were interleaved between oral and tracheal suctions. an increased sample power could show more significant results, but we cannot eliminate that this weak effect could also be due to the inability of subglottic suctions to prevent microaspiration of the oral content. the study has been founded by teleflex. introduction: although necessary, mechanical ventilation can lead to ventilator-induced lung injury (vili) even when using protective ventilation strategies that combine low tidal volume (vt)( ml kg predicted body weight) and plateau pressure (pplat) <= cmh . lower positive pressures and tidal volumes could enhance lung protection + the hla-dr and pd-l expressions were higher on alveolar than on blood monocytes in both ards patients and controls (figure) . yet, hla-dr expression on alveolar monocytes was higher in controls compared to ards patients (p = . ). circulating monocytes had a higher phagocytic activity than alveolar monocytes (p < . ), but no significant difference was observed between ards patients and controls. an lps challenge increased the phagocytic activity of monocytes in controls (p = . ) but not in ards monocytes (p = . ). tnf-α intracellular synthesis was increased after lps exposure in circulating and alveolar monocytes of controls (p < . ) but only tended to do so in ards (p = . ). conclusion: differences in the phenotype of alveolar and circulating monocytes were observed in ards but also in controls, suggesting a physiological lung blood gradient in the expression of these results: until , ten patients were included and analyzed for the study. there was a significant difference between the volumes recruited at the three peep levels (p = . ). the recruitment evaluated was not correlated with pao . there is a significant decrease in cardiac index and pam caused by the increase in peep. conclusion: preliminary results from our study suggest that the estimated recruited lung volume estimated by crf inview ® technology appears to be poorly correlated with measured pao . the hemodynamic repercussions observed should also be considered in order to propose an optimal strategy for the optimal adjustment of peep. were compliant with the re-evaluation. ( %) patients received carbapenems according to the recommendations. a compliant prescription had no impact on hospital or icu length of stay and no impact on duration of mechanical ventilation but seemed associated with increase mortality (p = . ). discussion: the high rate of compliant prescriptions can be explained by the broad indications of carbapenems in the icu, especially in patients with septic shock. the increase mortality of patients with a compliant prescription is probably due to the severity of the infections. in order to achieve % compliance, we could suggested regularly updating the knowledge of carbapenems prescriptions, collaborating with bacteriology and infectiology teams, and establishing a computerized or paper prescription with feedback control. conclusion: the prescription of carbapenems appears most often in accordance with the recommendations in this icu. however, there is a need for improvement. introduction: bacterial infections are frequent triggers for diabetic ketoacidosis and a significant increase in morbimortality is observed in case of delayed antibiotic treatment. however the unnecessary administration of antimicrobial therapy can also lead to bacterial resistance. early sepsis markers are thus particularly useful for patients admitted in icu for diabetic ketoacidosis. patients and methods: we retrospectively studied cases of patients admitted in icu at avicenne french universitary hospital for ketoacidosis defined by ph < . and glycemia > . mmol l. clinical and biological data were analyzed at admission (d ) and on day (d ). results: between and , among patients admitted for diabetic ketoacidosis, were included. twelve out of were infected ( urosepsis, pneumonia, others). demographic data and comorbidities did not significantly differ between the infected and non infected group (ig and nig). antibiotics were administered to patients- ( %) in the infected group versus ( . %) in the non infected group. on d , there was no difference for-ph, temperature, leukocytes, neutrophils-to-lymphocytes count ratio and pct (table ) . on d , temperature, leukocytes, neutrophils-to-lymphocytes count ratio and pct were significantly higher in the ig. in the ig, the biological markers did not vary between d and d , whereas in the nig, leukocytes (p < . ), pnn (p < . ) and neutrophils-to-lymphocytes count ratio (p < . ) significantly decreased. surprisingly average pct levels seem to be particularly high in the nig on do as well as on d . conclusion: at admission, pct as well as other usual markers do not appear to be useful to differentiate infected from non infected patients admitted for ketoacidosis. however, on day , two different patterns can be drawn and help detecting non-infected patients and thus reduce exposure to antibiotics. these results should be confirmed by a prospective study, including a larger number of patients. ventilator-associated events (vae), reflecting worsening oxygenation, are defined as a persistent and significant increase in fio or peep level after a period of stability on the ventilator. vae definition includes ventilator-associated conditions (vac), infection-related ventilatorassociated complications (ivac) and probable ventilator-associated pneumonia (pvap). the relevance of vae for ventilator-associated pneumonia (vap) is low. however, the correlation between the three vac, ivac, and pvap, and the onset of ventilator-associated low respiratory tract infection (valrti), including ventilator-associated tracheobronchitis (vat) and pneumonia (vap), has never been studied yet. we on clinical examination. gravity scores-apache ii and saps ii. for lumbar puncture data, there is the proteinuria, glycorrhaphy resuscitation measures-drug intake and intubationin multivariate analysis, the factors of pejorative evolution-the male sex presence of meningeal syndrome. high proteinorachia. taking vasoactive drugs. the saps ii score. conclusion: according to this work, many factors influence the prognosis of acute meningitis in our population such as severity general scores, hemodynamic state and initial lumbar puncture data. we will need more investigations and prospective multicentric study to have more discrimination parameters. introduction: the emergence of atb-resistant bacteria has become an important public health problem, particularly in resuscitation environments, surveillance and monitoring of atb consumption is essential to combat this threat ecologically and economically. the aim of this work was to evaluate the consumption of atb in surgical resuscitation, to establish the cost, and to list the risk factors for bacterial resistance. patients and methods: it is a retrospective analytical study spread over year, studying patients who have received antibiotic therapy, the data on the consumption of atb were collected from the patient's medical records, the delivered doses were converted into ddd, according to the who standards and the end result is expressed in ddd days of hospitalization. the statistical analysis was carried out by the spss software. results: in our study, the mean age was . ± . , with male predominance + sex ratio . , traumatic pathology is the most common reason for admission, pneumopathy was the most frequent infection. overall atb consumption was . ddd dh, dominated by the class of betalactamins (cephalosporins . ddd dh, carbapenemes . ddd dh), the direct cost of atbs rises to . million dirhams, these are accounting for a large part of the pharmaceutical budget of the ibn rochd university hospital. bacteria found in order of frequency were acinetobacter baummanii, beta-lactamaseproducing enterobacteria, s. aureus and p. aeruginosa. acinetobacter baumannii showed the highest resistance rate. several risk factors for bacterial resistance were studied, notably the correlation between the use of atb and the emergence of resistant strains, only piperacillintazobactam was associated with the emergence of resistant strains of eblse, as well as other factors that were retained as significantly related to bacterial resistance by multivariate analysis-duration of hospitalization and perfusion of albumin. discussion: despite the limited number of studies done on atb consumption, it seemed that our results were similar to other national and foreign studies, the consumption of atbs is increased in hospital giving rise to the appearance of many multi-resistant bacteria. conclusion: in conclusion, resistance to antibiotics is a serious threat to public health both nationally and globally. it is therefore crucial to implement measures to counter this phenomenon + this is only possible through the proper use of atbs and gaits to prevent nosocomial infections. introduction: ventilaor-associated pneumonia (vap), the leading cause of infection in resuscitation, is also the main respiratory complication in cranial trauma. the aim of this study is to determine the specific risk factors for the occurrence of vap in this type of patient in an intensive care unit. patients and methods: we performed a retrospective study in our intensive care unit for an -month period (january , june ). all patients admitted for cranial trauma were included in the study and ventilated more than h in intensive care. vap is defined as late as of the th day of occurrence. the quantitative and qualitative variables studied were recorded at admission and during hospitalization. a univariate and multivariate analysis using the fischer and mann-whitney tests was performed. p is said to be significant if it is < . . results: our study included traumatic brain injury in older adults, of whom ( %) had one or more episodes of vap during their resuscitation. late vap accounted for almost of the cases ( patients). four independent variables were significantly related to the occurrence of vap-advanced age (p = . ), glasgow score (gcs) at admission < (p = . ), diabetes (p = , ), and the use of proton pump inhibitors for the prevention of stress ulcers (p = . ). the duration of intubation ( ± vs. ± days) and on intensive care ( ± vs. ± days) are significantly longer in the case of vap. mortality was significantly higher in vap- versus % (p = . ). the majority of early vap were due to both strepococcus ppneumoniae and haemophilus influenzae. the ecology of late vap was dominated by klebsiella pneumoniae, pseudomonas aeruginosa and acinetobacter baumanii. conclusion: of the four independent risk factors found in our study, glycemic balance and rapid airway safety by orotracheal intubation in the case of initial gcs < represent the relevant prevention axes of vap in traumatic brain injury in older adults. unfortunately, it is accompanied by a significant increase in bacterial resistance to antibiotics, leading to an increase in morbidity and mortality in intensive care units. patients and methods: this is a retrospective study carried out in our intensive care unit, covering all patients hospitalized between january and june and having contracted a nosocomial urinary infection. patients whose hospital stay was less than h and those fig. agreement between vae and lrti diagnostic with a nosocomial urinary tract infection acquired in another service were excluded. results: the study of resistance of the germs responsible for nosocomial urinary tract infection showed that-escherichia-coli was resistant to third generation cephalosporins in % of cases, at imipenem in % of cases, and without resistance to ertapenem and amikacin. pseudomonas was resistant to ceftazidime in % of cases, to imipenem in % of cases and to amikacin in % of cases. acinetobacter baumannii was resistant to imipenem in % of cases and to amikacin in % of cases. enterococcus faecalis had no resistance to vancomycin and ampicillin. staphylococcus aureus was resistant to methicillin in % of cases and without any resistance to vancomycin. mortality directly associated with nosocomial urinary tract infection was %. the comparison with previous studies has shown a significant increase in the bacterial resistance responsible for nosocomial urinary tract infection, which is of interest in monitoring the ecology of intensive care units and the resistance profile as well as the improvement of the management of antibiotics. introduction: nosocomial enterococcus infections are a constant concern in intensive care units due to their increasing frequency and the emergence of resistant strains to vancomycin. the aim of our study was to compare outcome findings of patients with nosocomial enterococcus infections according to their sensibility to vancomycin, and then to investigate predictive factors of mortality. patients and methods: it was a retrospective descriptive study, including all hospitalized patients in intensive care, between january st, and april st, , with nosocomial enterococcus infections. we recorded demographic and clinical findings, severity scores igs ii, apache ii, initial sofa and sofa at the time of infection, microbiological, therapeutic and outcome data. patients infected with vancomycin-susceptible enterococcus (vse) were compared to those having vancomycin-resistant enterococcus (vre) + then we searched for independent risk factors for vre. finally, a multivariate logistic regression was conducted to investigate independent predictive mortality factors. results: during the study period ( years and months), patients presented a nosocomial enterococcus infection with a median age of years [ - ] and a sex-ratio of . . at admission, patients ( . %) had respiratory distress. the median scores of igs ii, apache ii, initial sofa and sofa at the time of infection were respectively + + and . the infection sites were-urinary infection (n = , . %), bacteremia (n = , . %) and central line associated infection (n = , . %). patients had a vre nosocomial infections and vse. a septic shock complicated enterococcus infection in cases including cases of vre and cases of vse (p = . ). vre nosocomial infections were significantly related to arterial (p = . ) and venous (p = . ) femoral catheterization, to a duration of venous femoral catheterization > days (p = . ) and to e. faecium species (p < - ). no independent risk factor of vre was found. the median duration of hospitalization was days and the overall mortality rate was . %. multivariate analysis identified independent predictive factors of attributable mortality-patients in coma (or . + ic % = . - . + p = . ) and the occurrence of septic shock (or . + ic % = . - . + p = . ). conclusion: attributable mortality to nosocomial enterococcus infections was high and independent of the susceptibility of the strain to vancomycin. mortality was independently associated to septic schock occurrence and neurologic dysfonction. introduction: ventilator-associated pneumonia (vap) is defined by a lung infection contracted h after the putting under mechanically assisted breathing. risk factors predisposing to the development of vap among mechanically ventilated patients are many. some are related to the patient as age, history of copd, presence of an altered state of consciousness + others are related to care providing. patients and methods: a prospective nested case control study was conducted from marsh through april . all icu patients mechanically ventilated for more than h with endotracheal intubation or tracheostomy were included. cases of community-acquired pneumonia, non-mechanical ventilated hospital-acquired pneumonia, end-life patients and those aged less than years were excluded. the included patients with vap and those without vap were matched based on the age, the severity score and the comorbidities. for all patients included, preventive measures as assessed by the recent guidelines for preventing vap were applied after an education period of all medical and paramedical staff of the icu. the collected data are-age, comorbidities, admission severity scores, time to onset of vap, prior antibiotic therapy at the onset of vap, need for tracheostomy, duration of mechanical ventilation, length of stay in icu and become. results: during the study period, patients were mechanically ventilated. vap was observed in % of cases. vap was observed in cases with an incidence of % and incidence density of per patient-days of mechanical ventilation (mv). in univariate analysis, significant difference was found between the group with vap and the group without vap regarding admission for poly trauma, acute respiratory failure, the concept of prior antibiotic therapy, the need tracheostomy, the number of days alive without antibiotics and without mv, the duration of mechanical ventilation, length of stay and mortality. multivariate analysis showed that prior antibiotic therapy and the use of tracheotomy were independent factors for developing vap. prolonged duration of mechanical ventilation was an independent predictor of mortality in multivariate analysis with or . + % [ . to . ], p = . . the occurrence of vap was not an independent predictor to mortality. conclusion: the incidence of vap found in our study is similar to that found in the literature. an active strategy of rationalizing the prescription of antibiotics in intensive care units and a well-defined protocol of weaning from mechanical ventilation may reduce the incidence of vap and over-all morbidity and mortality. introduction: hyperoxemia is common in critically ill patients. hyperoxic acute lung injury (hali), reduced bacterial clearance, atelectasis and higher mortality rates were reported in mechanically ventilated patients with hyperoxemia. the aim of our study was to determine the relationship between hyperoxemia and mortality in patients with ventilator-associated pneumonia (vap). this retrospective observational single center study was performed in a -bed mixed intensive care unit (icu) during a -year period, from january to january . all patients with vap were included. vap was defined using clinical, radiological and quantitative microbiological criteria. hyperoxemia was defined as peripheral capillary oxygen saturation-spo ≥ %. spo was hourly collected in all study patients during the whole period of mechanical ventilation. the daily percentage of time spent with hyperoxemia was calculated as the number of hours with hyperoxemia divided by . results: among the patients receiving invasive mechanical ventilation (mv) > h during the study period, the incidence rate of vap was . vap per ventilator-days. patients developed vap and were all included in this study. ( %) vap patients died in the icu. the mean daily time spent with hyperoxemia was %. no significant difference was found in mean percentage of time spent with hyperoxemia between survivors and nonsurvivors at icu admission, before, after or at the vap diagnosis. age, and sequential organ dysfunction assessment (sofa) at the day of vap occurrence were independently associated with icu mortality (or . [ . - . ] per year, p = . + . [ . - . ] per point, p = . + respectively). no significant impact was found of time spent with hyperoxemia before vap occurrence, on mv free days, or icu length of stay (fig. ). discussion: several potential explanations could be provided for the absence of negative impact on mortality of hyperoxemia. first, the definition used for hyperoxemia could be debated, as no consensus exists. however, the definition used in our study was rather stringent and the mean daily time spent with hyperoxemia was in line with that reported by studies. second, the impact of hyperoxemia on mortality could have been confounded by a large number of patients included with pulmonary lesions at admission. third, the number of included patients was small. conclusion: our study found no significant impact of hyperoxemia at icu admission, or during icu stay, on icu mortality in vap patient. results: patients collected during this period. distal protected specimens were performed in patients suspected of vap. the diagnosis of this infection was made. in of them with other diagnostic criteria ( %) which represents an incidence density of . per , days. % of pavm are due to gram negative bacilli. the first germ involved in our series and pseudomonas ( %) followed by klebsielles ( %) followed by acintobacter baumanii ( %) enterobacteries representing the rest. % lung infection with gram-positive cocci (principally sensitive methicillin) pseudomonas was imipenem resistant in . %, baumanii was imipenem resistant in %. the resistance profile of the recovered germs (baumanii and pseudomonas) encourages the utmost rigor in the management of these patients, prevention is better attitude to adopt. introduction: the ventilator associated pneumonia (vap) appear in the second rank of the infections acquired in hospital after the urinary infections. the diagnosis is based on a beam of clinical, biological, radiological and bacteriological arguments. this work consisted of an epidemiologic analysis of the vap and aimed at evaluating of it the frequency, the risk factors, the antibioresistance of the isolated bacteria and the mortality factors. patients and methods: this retrospective study related to patients hospitalized in icu during a period of years from january to december . the study included all patients over years and ventilated more than h and developing vap. results: bgn predominant and represent . % of identified germs, the acinetobacter baumanni leads with . %, followed by klebsiella pneumonia ( . %), followed by pseudomonas aeruginosa ( . %), followed by e. coli ( . %), followed by enterobacter cloacae ( . %) and citrobacter frendi ( . %). the cocci gram positive (cgp) constitue . % of isolated germs of witch . % staphylococcus aureus, . % of non aureus staphylococci, . % streptococcus sp. the polymicrobism was found in % cases. the isolated germs were multiresistants. in this study, we find a very high mortality and a major additional morbidity of the np by prolongation of hospitalization, of mechanical ventilation and a major additional cost.conclusion: it appears in the light of this work that a strategy of prevention based on the strict application of hygiene measurements, the maintenance of the material of ventilation and the respect of care procedures prove to be urgent in our context. introduction: burns induce modification of distribution volume, increased clearance of drugs and decrease of protein binding. amikacin pharmacokinetics (pk) was altered with subthera-peutic serum concentrations. the aim of our study was to assess the pk of amikacin in burns after a loading dose given once a day according to this equation-dose(mg kg) = *pi( * , *dp ) + ( * , * dp ). threshold for therapeutic efficacy was a ratio of ≥ between the concentration achieved h after beginning the infusion (c peak) and the minimal inhibitory concentration (mic) of the isolated pathogen. patients and methods: this study was conducted in burn center in tunis. patients with documented and or suspected infections were included. were excluded pregnant women and patients with renal failure. enrolled patients received amikacin at a loading dose in h infusion. blood samples for pk analysis were assessed during days (total duration of amikacin)-immediately after the end of the first infusion (t ) and min after (t ) at day . for the nd, rd, th and th day, blood samples were taken before the infusion (t ), at the end (t ) and min after the end of it (t ). results: burned patients were included. the mean age was ± years with a body weight of ± kg. the mean dose of amikacin was mg kg day [ - mg kg day]. a peak between and μg/ml was reached in % of cases, corresponding to times the mic, break-points for enterobactericeae and pseudomonas aeuroginosa. total volume of distribution was . l kg ( . - . ) l kg, half-life time (t ) was . h [ . - h] and the amikacin clearance was . l h. a correlation was found between cpeak at day and cpeak at day (r = . ). conclusion: our study shows that an early achievement of an optimal cpeak mic ratio of amikacin was reached in half of cases with a correlation between cpeak in the beginning and at the end of treatment. so, initial cpeak was useful tu adjuste amk therapy in burns and predicts treatment efficacy. *pi-ideal weight + dp -admission weight-ideal weight + dp -actuel weight-admission weight. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord- -f amppy authors: kapicibaşi, hasan oğuz; kiraz, hasan ali; demir, emin tunç; adali, yasemen; elmas, sait title: pulmonary effects of ozone therapy at different doses combined with antibioticotherapy in experimental sepsis model date: - - journal: acta cirurgica brasileira doi: . /s - sha: doc_id: cord_uid: f amppy purpose: this experimental sepsis model created with escherichia coli aimed to investigate the histopathological effects of two different doses of ozone combined with antibiotherapy on lung tissue. methods: rats were divided into groups. then sepsis was induced intraperitoneally in the first groups. the (st) group was treated with cefepime, the (nd) and (rd) groups were treated with cefepime combined with ozone at a dose of . mg/kg and . mg/kg. lung tissue sections were stained with hematoxylin-eosin and assessed under light microscope and scored between - in terms of histopathological findings. results: in the comparisons between group and group in terms of cellular damage (p= . ), inflammation (p= . ) and overall score (p= . ), statistically significant positive effects were observed in favor of group . in the comparisons of groups and with group , only positive effects were observed in terms of inflammation (p= . , p= . , respectively). conclusion: although negative histopathological effects of ozone on tissue injury were detected, it was noteworthy that the increase in the ozone dose reduced the number of damaged parameters. (file registration number: / & decision number: / - ). our study included male sprague-dawley rats with mean weight - g in appropriate condition. during the study, rats were kept in ÇomÜ experimental research center in wire cages with -hour night- -hour day circadian rhythm, environmental temperature - °c and humidity - %. rats were fed with standard commercial feed and municipal drinking water. rat feed was stopped hours before the study; however, water was given freely during this time. all rat care was performed in accordance with the "regulation on the welfare and protection of animals used for experimental and other scientific purposes" ( . . - ) prepared by the ministry of food, agriculture and livestock. experimental animals were randomly divided into groups with equal numbers (n= ). sepsis was induced in rats in the first of these groups with . x cfu/ml escherichia coli atcc administered in ml saline via the intraperitoneal route in rats. rats in the th group only had ml intraperitoneal saline administered. twenty-four hours after escherichia coli administration, rats in the st , nd and rd groups were arranged in groups following skin cleaning for asepsis and the following treatments began. care was taken to administer treatments at the same time every day. additionally, an ozone generator (device name and model: turkozone blue s, device serial no: bg- ) was used to produce the ozone/ oxygen mixture for ozone therapy. sepsis is defined as life-threatening organ dysfunction caused by an unregulated host response to infection . the pathology of sepsis involves complex interactions between host organs and invading pathogens. ultimately tissue injury and organ failure are due to negative effects of systemic activation of host immunity , . sepsis forms a large problem in intensive care and is the main cause of death occurring there , . according to a report published by the global burden of disease, each year nearly million people die from infections and this is much greater than the number of people who die from cancer annually . lungs are the first organs affected by sepsis and sepsis causes severe injury to lung tissue . in spite of advanced antibiotherapy, supportive treatments and all technological opportunities, sepsis continues to be a situation progressing with morbidity and mortality . the earliest target-directed basic treatment principles for sepsis comprise determining high-risk patients, ensuring appropriate cultures and source control, and beginning appropriate antibiotherapy without delay . medical ozone therapy is an alternative treatment model linked to the administration of ozone and gas mixture with oxygen to body fluids or cavities. to date, clinical and experimental studies have shown that ozone therapy is beneficial for inflammation-mediated diseases like infected wounds, chronic skin ulcers, burns and advanced ischemic diseases . ozone/ oxygen mixtures are reported to display a variety of effects on the immune system like phagocytic activity modulation . additionally, ozone therapy is proposed to cause increased antioxidant enzyme expression . additionally, it is known that ozone is also an immune system modulator. though antiseptic properties of ozone are well known, it may harm not just the pathogen but also the patient linked to dose and exposure duration . ozone is one of the strongest oxidants and may show unwanted effects through a variety of mechanisms like free radical formation, lipid peroxidation, enzymatic activity loss, changes in membrane permeability, direct organ inflammation and injury . based on the known positive and negative effects of ozone, in our study we aimed to assess the effect of two different doses of ozone therapy added to antibiotic treatment in an experimental sepsis model induced with escherichia coli on the histopathologic findings observed in the inflammatory process in the lungs. pulmonary effects of ozone therapy at different doses combined with antibioticotherapy in experimental sepsis model kapicibaşi ho et al. acta cir bras. ; ( ):e th group: rats in this group were not given any treatment after administration of escherichia coli by the intraperitoneal route with the aim of inducing sepsis. rats in this group did not have a sepsis model induced, but were administered ml saline intraperitoneal at the start and were only administered subcutaneous saline at equivalent times to the treatments in the other groups. twenty-four hours after the final treatment in our study, rats were administered high-dose anesthetics (xylazine - mg/kg and ketamine - mg/kg) and lung tissue samples and blood samples were taken by accessing the thorax cavity with median sternotomy and rats were sacrificed. in the blood samples, the diagnosis of sepsis was confirmed by working with the rats escherichia coli protein (e.coli p) enzyme-linked immunosorbent assays (elisa) kits (shangai coon koon biotech co, china). in view of the data on the researched serums, the very low level of e.coli p in the rats of the control group was construed and reported as the absence of sepsis. the statistically significant differences concerning the presence of e.coli p in the first four groups in comparison with the control groups signify that sepsis was successfully induced in these groups (fig. ) . lung tissue samples were fixated for hours in % buffered formalin solution. later, tissue monitoring procedures were performed appropriate to groups and tissues were submerged in paraffin. sections with -micron thickness were taken from the prepared paraffin blocks and stained with hematoxylin & eosin (h&e) before being investigated with a light microscope (olympus bx , japan) at magnification above fields . the tissues were assessed by the parameters used by yamanel et al. with some modification and their scoring system was used. hemorrhage, cellular injury, alveoloseptal thickening and inflammation were scored from - and a general injury score (total score) was obtained by summing all scores per case. maximum care was taken to use the lowest number of animals necessary to gain scientific quality from the methods applied in the study and the obtained results. analysis of data used the statistical package for the social sciences for windows evaluation v. . (spss, chicago, il, usa) program. results are given as median and minimum-maximum values. comparisons of groups used the mann-whitney u test. tests were completed in the % confidence interval and values with p lower than . were accepted as statistically significant. as the histopathologic findings observed in the study are categoric data, the median and interval values are presented in table . when group is compared with the control group of group , group was identified to have more statistically significant injury in terms of cellular damage (p= . ), alveoloseptal thickening (p= . ), inflammation (p= . ) and total score (p= . ), with no significant difference between the groups in terms of hemorrhage (p= . ). when group is compared with group , there was no statistical significance for bleeding (p= . ) and alveoloseptal thickening (p= . ), while there were clear positive effects in group for cellular injury (p= . ), inflammation (p= . ) and total score (p= . ). when group is compared with group and group , positive effects were only observed in groups and for inflammation (p= . , p= . , respectively), with no statistical significance for the other parameters (p> . ). while there was no statistical significance for hemorrhage between group and group (p= . ), there were clear positive effects in group for cellular damage (p= . ), alveoloseptal thickening (p= . ), inflammation (p= . ) and total score (p= . ). when group is compared with group , there was no statistical significance for bleeding (p= . ), alveoloseptal thickening (p= . ) and inflammation (p= . ), but positive effects were pronounced in group for cellular injury (p= . ) and total score (p= . ). histopathologic findings of the groups are demonstrated in figure . comparison of groups and did not have any statistical significance (p> . ). bleeding / ( - ) / ( - ) ( - ) / ( - ) / ( - ) cellular damage / ( - ) b / ( - ) a,c ( - ) a,c / ( - ) a,c / ( - ) b alveoloseptal thickening / ( - ) / ( - ) a,c ( - ) a / ( - ) a / ( - ) b inflammation / ( - ) b / ( - ) a,b,c ( - ) b / ( - ) a, sepsis-linked acute lung injury is an important cause of morbidity and mortality in adults and children and significantly contributes to intensive care costs [ ] [ ] [ ] [ ] . many studies have created pioneering ideas for the use of ozone as a strong antimicrobial agent [ ] [ ] [ ] [ ] . ozone is a strong oxidizing agent and important disinfectant. according to literature data, exposure of bacteria, spores and viruses to ozone for only a few minutes causes inactivation [ ] [ ] . studies by ricevudi et al. proposed oxygen-ozone treatment as a new immunotherapeutic treatment method for the viral agent covid- causing this pandemic and that patients with covid- using this in combination with other treatment methods would benefit from the assisting and synergic effects of ozone therapy. again, as stated by ricevudi et al. the need for more studies is clear. the bactericidal effect of ozone is linked to attacking the biological material in microorganisms through the oxidation pathway. in fact, the antibacterial effect of ozone is said to be more effective than iodine and chlorine , . previous experimental studies have shown that ozone therapy has experimental benefits on pathologic processes , , . in many organs like pancreas, peritoneum, liver, mesenteric lymph nodes and cecum, ozone therapy has proven reducing effects on bacterial translocation . in an experimental necrotizing pancreatitis model, ozone therapy was seen to be more effective to reduce oxidative stress levels, tissue injury and bacterial translocation rates compared to hyperbaric oxygen treatment . schulz et al. observed a decrease in polymicrobial peritonitis after they administered intraperitoneal ozone. Çakır et al. reported the systemic inflammatory response markers of tnf-alpha and il- b levels reduced after ozone treatment. an experimental sepsis study by yamanel et al. compared hyperbaric oxygen treatment with ozone therapy and identified that both methods lowered oxidative stress indices, myeloperoxidase activity and serum proinflammatory cytokine levels. as a result, histopathologic injury reduced in the lung tissue of septic rats and ozone therapy showed to provide more benefits according to histopathologic injury scores and il- b levels. as a result of the experimental study, they proposed that ozone therapy may be a complementary medicine treatment method that could be applied together with antibiotherapy for sepsis. additionally, studies have shown that ozone causes clear air pollution, and irritation and injury when taken in with immune and inflammatory cells in the lungs. this event progresses with bronchial epithelium desquamation and alveolar septal injury results in emphysema and airway hyperresponsiveness , . ozone-linked injury and inflammation is linked to the dose and frequency of ozone exposure . in our study, positive effects were observed in terms of inflammation in group and group with added ozone therapy (p= . , p= . , respectively). however, it is considered that these effects are due more to antibiotic effects rather than to ozone therapy. the source point for this thought is that the cellular injury, inflammation, alveoloseptal thickening and general histopathologic scores in group , only administered antibiotics, were at statistically significantly low levels compared to group (p= . , p= . , p= . , p= . , respectively). similarly, the cellular injury and general histopathologic score were observed at statistically significantly low levels in group , administered only with antibiotic, compared to group , administered with high-dose ozone (p= . , p= . , respectively). when the results of our study are investigated, it was identified that ozone increased the negative histopathologic effects induced in the lung by inflammation. however, as the dose of ozone increased, the fall in the number of parameters with statistical significance confirms that positive effects may occur if the dose of ozone used was increased. additionally, a limitation of our study is that there was no group administered with ozone therapy alone after sepsis, so the histopathologic effects of ozone on lung tissue in sepsis could not be assessed. data obtained as a result of our study lead to the consideration that ozone therapy administered in addition to antibiotherapy may cause negative effects on lung tissue damaged due to sepsis. sepsis : definitions and guideline changes the pathophysiology and treatment of sepsis extravascular lung water and sepsis sepsis-induced long-term immune paralysis-results of a descriptive, explorative study epidemiology of severe sepsis in the united states: analysis of incidence, outcome, and associated costs of care allcause mortality, and cause-specific mortality for causes of death, - . a systematic analysis for the global burden of disease study does leflunomide attenuate the sepsis-induced acute lung injury? optimizing intensive care management in paediatric sepsis prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients scientific and medical aspects of ozone therapy. state of the art ozone as janus: this controversial gas can be either toxic or medically useful does ozone therapy normalize the cellular redox balance? implications for therapy of human immunodeficiency virus infection and several other diseases biological and clinical effects of ozone. has ozone therapy a future in medicine? biochemical basis of ozone toxicity a novel animal model of sepsis after acute lung injury in sheep ozone therapy and hyperbaric oxygen treatment in lung injury in septic rats has mortality from acute respiratory distress syndrome decreased over time? a systematic review recent trends in acute lung injury mortality management of acute lung injury and acute respiratory distress syndrome in children gruppo italiano per la valutazione degli interventi in terapia intensiva. variable costs of icu patients: a multicenter prospective study antibacterial activity of ozonized sunflower oil (oleozon) evaluation of ozonated oxygen in an experimental animal model of osteomyelitis as a further treatment option for skull-base osteomyelitis analysis of the bactericidal effect of ozone pneumoperitoneum ozone killing action against bacterial and fungal species; microbiological testing of a domestic ozone generator studies on the biological effects of ozone . induction of interferon gamma on human leucocytes ozone as a bioregulator. pharmacology and toxicology of ozonetherapy today oxygen-ozone immunoceutical therapy in covid- outbreak: facts and figures toxicity and biochemical mechanisms of ozone gaseous ozone treatment inactivates listeria innocua in vitro efficacy of hyperbaric oxygen therapy and medical ozone therapy in experimental acute necrotizing pancreatitis repetitive pneumoperitoneum with ozonized oxygen as a preventive in lethal polymicrobial sepsis in rats pulmonary effects of ozone therapy at different doses combined with antibioticotherapy in experimental sepsis model il- drives augmented responses to ozone in obese mice γδ t cells are required for m macrophage polarization and resolution of ozone-induced pulmonary inflammation in mice role of neutralizing anti-murine interleukin- a monoclonal antibody on chronic ozone-induced airway inflammation in mice key: cord- -ytdw d v authors: mok, chi chiu; ho, ling yin; chan, kar li; tse, sau mei; to, chi hung title: trend of survival of a cohort of chinese patients with systemic lupus erythematosus over years date: - - journal: front med (lausanne) doi: . /fmed. . sha: doc_id: cord_uid: ytdw d v objectives: to revisit the trend of survival of systemic lupus erythematosus in a cohort of chinese patients over years. methods: patients who fulfilled the acr criteria for sle and were followed in our hospital since were included. patients were stratified into two groups according to the year of diagnosis: ( ) – and ( ) – . survival of patients was studied by kaplan–meier analysis. organ damage as assessed by the systemic lupus international collaborating clinics (slicc) damage index (sdi) and causes of death in the first years of sle onset was compared between the two groups. cox regression was used to study factors associated with survival. results: a total of , sle patients were registered in our database. after excluding patients diagnosed outside the time period of – , patients were studied ( % women). all were ethnic chinese. the mean age of sle onset was . ± . years, and the mean duration of observation was . ± . years. seventy-seven ( . %) patients were lost to follow-up. groups and consisted of and patients, respectively. the mean sdi score at years of disease onset was significantly higher in group than group patients ( . ± . vs. . ± . ; p < . ), particularly in the neuropsychiatric, musculoskeletal, and gonadal domains. within years of sle onset, ( . %) patients in group and ( . %) patients in group died (p = . ). the - and -year cumulative survival rates were . and . % in group and . and . % in group patients, respectively (log-rank test p = . ). infection accounted for more than half of the deaths in both groups. more group than group patients died of vascular events, but the difference was not statistically significant. cox regression showed that the age of sle onset and damage score accrued at years, but not the time period in which sle was diagnosed, were significantly associated with mortality. conclusions: the improvement in survival of our sle patients is probably related to the accrual of less organ damage in the past years. systemic lupus erythematosus (sle) is a multisystem autoimmune disease that predominantly affects younger women. the disease course is characterized by periods of remission and exacerbation that are largely unpredictable ( ) . the consequence of this fluctuating disease course is organ damage, as a result of persistent disease activity or treatment-related complications. organ damage in sle is a major risk factor for further organ damage accrual, impaired quality of life (qol), and mortality ( , ) . with earlier referral and diagnosis, availability of renal replacement therapy, more potent antimicrobial drugs, less toxic immunosuppressive regimens, and improved supportive care for organ complications, the survival of sle has improved tremendously in the past few decades ( ). a recent meta-analysis ( ) of studies showed that survival of adult sle improved gradually from the s to the mid- s in both affluent and less affluent countries. however, the survival rate has plateaued since the mid- s despite a reduced proportion of patients deceased due to active sle. a substantial proportion of sle patients still succumbed of complications related to refractory disease or therapies ( ) . the mortality of sle is increased by at least three-to -fold when compared with the age-and gender-matched population ( ) . the commonest cause of death is infection, followed by vascular complications and cancer. thus, there are unmet needs to introduce more effective but less toxic therapies in sle and reduce long-term complications such as atherosclerosis, osteoporosis, and malignancies in order to improve the survival of the disease further. although there have been a number of survival studies of sle in the past decade, not too many were performed in the asian populations ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . analysis of the survival of hospitalized patients ( , ) , those admitted to the intensive care unit ( , ) or referred to tertiary centers ( ) , subsets of patients with nephritis ( ) , neuropsychiatric manifestations ( ), or pulmonary hypertension ( ) in some studies would create bias in the mortality rate. moreover, the follow-up of most of these asian studies was not long enough to look at the trend of survival over time. a large cohort of chinese sle patients in our hospital was followed by the same group of physicians since . we hereby report the secular trend of survival of these patients in the past years. tuen mun hospital is a large regional public hospital in hong kong providing medical services to a population of . million residing in the vicinity. all citizens are entitled to receive a full range of medical services from government hospitals by payment of a nominal fee. patients diagnosed to have sle after in our outpatient clinics or during hospital stay or referred from other hospitals are captured in a longitudinal database. adult patients under the care of all specialists such as rheumatologists, nephrologists, geriatricians, hematologists are included. all are ethnic chinese with their family origin in southern part of china. all patients fulfill four or more american college of rheumatology (acr) criteria for the classification of sle ( ) and are being followed by the same group of physicians at an usual interval of - weeks. more frequent clinic visits are arranged for those with active/unstable disease or complications. the demographic characteristics, cumulative manifestations of sle, and autoantibodies of the patients are captured. the clinical status of the sle patients in our registry is updated every months. organ damage of sle is assessed by the systemic lupus international collaborating clinics (slicc) damage index (sdi) ( ) , a validated instrument consisting of items that measure irreversible organ damage not caused by active inflammation in organ systems. each item should be present for at least consecutive months in order to be scored. the sdi score is updated annually. for patients who died during their disease course, we analyzed the causes of death according to the documentation of their attending specialists in the medical records based on investigation results or best clinical judgment. autopsy would be performed for uncertain cause of death, academic interest, or medico-legal purpose. for those who succumbed due to any causes, data were censored at the time of death. to study the trend of survival over time and the causes of death, we divided our patients arbitrarily into two groups: ( ) group : sle diagnosed between and ; and ( ) group : sle diagnosed between and . organ damage, mortality, and causes of death in the first years of sle diagnosis were also compared between the two groups. unless otherwise stated, values in this study were expressed as mean ± sd (standard deviation). comparison of continuous variables between two groups was performed using the independent sample students' t-test. categorical variables were compared by the chi-square test. when the frequency was < in any cell of the contingency table, the fisher exact test was used. correction for multiple comparisons was made by bonferroni's method. the cumulative probability of survival of the patients over time was studied by kaplan-meier analysis. for those who died or were lost to follow-up, data were censored at the time of death and last clinic visits or hospitalization, respectively. comparison of survival between two groups was made by the long-rank test. cox regression was used to analyze the hazard ratio (hr) and % confidence interval (ci) for survival. covariates included in the model were age of sle onset, sex, sdi score, renal involvement, ever use of hydroxychloroquine (hcq) within years of diagnosis, and time period in which patients were diagnosed. statistical significance was defined as a p-value of < . , -tailed. all statistical analyses were performed using the spss program (version . for windows ). up to march , a total of , sle patients were registered in our cohort database. one hundred and fifty-seven patients were excluded as the diagnosis of sle was made before or after . finally, patients were included ( women; %). all were ethnic chinese. the mean age of onset of sle was . ± . years, and the mean follow-up of these patients was . ± . years. seventy-seven ( . %) patients were lost to follow-up, and their data were censored at the last clinic visits. there were patients in group and patients in group . the cumulative manifestations of these patients are shown in table . the age of onset of sle was significantly higher in group patients. the prevalence of anti-ena antibodies was also significantly higher in this group. regarding clinical manifestations, arthritis and lymphopenia were significantly more frequent in group patients. the frequencies of other manifestations were similar between the two groups. regarding treatment of sle during the first years of diagnosis, more group patients had received hcq and mycophenolate mofetil (mmf) whereas more group patients were ever treated with cyclophosphamide (cyc). table shows the organ damage scores in the two groups of patients within years of disease onset. the mean total sdi score was significantly higher in group than group patients. among the organ systems, the sdi scores in the neuropsychiatric, musculoskeletal, and gonadal domains were significantly higher in group . the proportion of patients with organ damage in these three systems was also significantly higher in this group of patients. in those patients with organ damage, the mean time to first damage was . ± months in group and . ± . months in group (p < . ), suggesting that late damage was more common in group patients. within years of sle onset, ( . %) patients in group and ( . %) patients in group died (p = . ). table shows the causes of death in these patients. infection was the main cause of death in both groups, accounting for more than half of the deaths. vascular causes of death were more common in group than group patients, but the difference was not statistically significant. the cumulative survival rate of all the patients studied was . , . , . , and . % at , , , and years, respectively. figure shows the cumulative probability of survival of the two groups of patients. the -, -, and -year survival in group patients was . , . , and %, respectively. the corresponding figures for group were . , . , and . %, respectively. the difference in survival between group and group was statistically significant (log-rank test; p = . ). table shows the causes of death of all the patients studied according to the duration of sle. in addition to the patients who died within years of sle onset, other patients in the cohort died beyond years of sle onset (total deaths). patients who died beyond years of disease onset were less likely to be caused by infection but more likely to be contributed by pulmonary hypertension, chronic cardiopulmonary disease, and malignancies. table shows the cox regression analysis for factors associated with mortality. univariate analysis showed that age of onset, male sex, renal involvement, and sdi score at years were associated with mortality. the use of hcq was negatively associated with mortality. group patients showed a higher mortality rate than group , but statistical significance was borderline (hazard ratio . this is a survival study of an inception cohort of sle patients diagnosed since . our results showed that the overall year survival of our sle patients was . %, which is similar to those reported in asian studies after the s ( - , , , , ) . however, direct comparison is not feasible because the cumulative survival rate computed by the kaplan-meier method was not reported in most of these studies. in our cohort, there was an improvement in survival of patients diagnosed between and compared to those diagnosed between and . organ damage was also significantly less common in patients diagnosed in the more recent period. univariate cox regression analysis showed that survival of the group of patients diagnosed after (group ) was better than those who diagnosed earlier (group ) (p = . ; borderline significance). however, statistical significance was lost when damage score at years, sex, age of sle onset, renal involvement, and ever use of hcq were put into the multivariate model. as group patients had younger onset of sle (favorable factor for survival), the worse prognosis of this group was likely due to more organ damage accrued at years when compared to group patients. an interesting observation was noted when we compared the clinical manifestations of the two groups of patients. patients diagnosed after were significantly older at the time of sle diagnosis, and they were less likely to have arthritis and renal disease during the course of their illness. the mean age of sle diagnosis has increased from . years to . years in the period of - . this is consistent with our clinical impression that more sle patients in the recent decade were diagnosed in the middle age range with the presentation of hematological in the absence of musculoskeletal or dermatological symptoms. the reason for this observation is unclear, but it is unlikely to be the effect of increased referrals or awareness of sle by primary care physicians as our hospital has been the only specialty referral hospital for sle in the areas covered by public medical service in the past - decades. moreover, there has not been any change in the pattern of inter-specialty referral and our cohort of sle patients has included all the patients seen by different specialists in our department. one postulation is the increased use of hcq in our sle patients beyond dermatological and articular indications in the past decade, which might protect against the development of joint and renal manifestations. however, further clinical trials of hcq are needed to confirm this postulation. as shown in table , the prevalence of antibodies to the antiextractable nuclear antigens (anti-ena) has increased from the period - to - . this can be explained by the change in the methodology of anti-ena assay in our laboratory from counter immune-electrophoresis (ciep) to enzyme-linked another observation from the current study is that patients diagnosed after had accrued less organ damage at years, which is the most important factor for the improved survival. in particular, reduced damage in the neuropsychiatric, musculoskeletal, and gonadal domains has made the difference. in a cohort study from the us john hopkins university, glucocorticoid use was a major risk factor for organ damage accrual ( ) . the risk of organ damage was increased by more than -fold when the mean daily dosage of prednisone was > mg. the multicenter asia pacific lupus collaboration group also reported that the time-adjusted mean prednisolone dose was independently associated with damage accrual in sle patients ( ) . in a subset of patients with no disease activity over time, the mean prednisolone dose remained an independent risk factor for damage accrual. thus, every attempt should be made to limit the dosage and duration of glucocorticoid use in sle. the more judicious use of high-dose glucocorticoids in our cohort has led to the observed reduction in avascular necrosis of the bone and osteoporotic fractures. for instance, the standard dosage of prednisolone for severe lupus nephritis has reduced from mg/kg/day to around . - . mg/kg/day in recent years with the early use of glucocorticoid-sparing agents such as azathioprine and mycophenolate mofetil (mmf). moreover, the duration of high-dose prednisolone has been limited to < weeks. on the other hand, the substitution of cyclophosphamide (cyc) pulses to mmf as first-line induction therapy of major organ disease in most patients is linked to the lower incidence of premature ovarian failure in our patients. with the increased awareness of the cardiovascular complications, regular surveillance of traditional risk factors is being performed in recent years, which serves to explain the lower incidence of vascular complications such as ischemic stroke in our patients. as shown in our data, infection remains the main cause of death of our sle patients regardless of the time period of diagnosis. thus, more effort has to be done to minimize the risk of infection in sle patients. apart from the use of the minimally effective doses of immunosuppressive medications, measures to prevent common viral and bacterial infections are equally important. influenza and pneumococcal vaccines, which are safe and efficacious in sle ( ), are not routinely administered to our patients. these vaccinations should be more encouraged in the future by a standard protocol facilitated by our rheumatology nurses. personal hygiene and social distancing are crucial as reflected in the covid- global epidemic. antibiotic prophylaxis for certain opportunistic infections such as pneumocystis jirovecii pneumonia ( ) is not yet a routine practice in asian countries but should be considered for sle patients with multiple risk factors such as renal dysfunction, severe lymphopenia, and treatment with combination of multiple immunosuppressive agents, particularly high-dose glucocorticoid and cyc. there are several limitations in this study. first, we did not have data on the serial disease activity score over time and therefore it is uncertain if better disease control in recent years has contributed to the improved survival. second, data on the cumulative dosages of medications, particularly prednisolone and hcq, are unavailable for evaluation of their contribution to sle prognosis. finally, we did not have information of all the patients on the duration of symptoms before sle diagnosis and their drug compliance, which might also be factors affecting the long-term prognosis. we have presented the data of a large cohort of sle patients treated in a service hospital over years and confirmed the improved survival. the improvement in sle prognosis is mainly contributed by a significant reduction in organ damage accrual, which is linked to the more judicious use of glucocorticoids, early use of glucocorticoid-sparing agents, and the regular surveillance and treatment of traditional vascular risk factors. despite the decrease in the mortality figures, further reduction should be the target. as infection remains the main cause of death, protocolbased vaccination programs against common viral and bacterial infections, as well as antibiotic prophylaxis for opportunistic infections in high-risk patients, should be adopted in the future. it is hoped that sle patients can continue to live longer with less end organ damage accrual so that they can enjoy a better quality of life. the raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. the studies involving human participants were reviewed and approved by ethics committee, tuen mun hospital, hong kong. written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements. factors associated with damage accrual in patients with systemic lupus erythematosus: results from the systemic lupus international collaborating clinics (slicc) inception cohort long-term survival of southern chinese patients with systemic lupus erythematosus: a prospective study of all age-groups survival in adults and children with systemic lupus erythematosus: a systematic review and bayesian meta-analysis of studies from to life expectancy, standardized mortality ratios, and causes of death in six rheumatic diseases in hong kong effect of renal disease on the standardized mortality ratio and life expectancy of patients with systemic lupus erythematosus clinical characteristics and survival of patients with systemic lupus erythematosus in southeastern areas of south korea: a multicenter retrospective cohort study disease activity and damage in hospitalized lupus patients: a sabah perspective the clinical characteristics of systemic lupus erythematosus patients in indonesia: a cohort registry from an indonesia-based tertiary referral hospital one-decade study of distinct features, morbidity and mortality of systemic lupus erythematosus (an update on systemic lupus erythematosus in the fars province of iran) mortality of patients with systemic lupus erythematosus admitted to the intensive care unit-a retrospective single-center study effect of immunosuppressive therapies on survival of systemic lupus erythematosus: a propensity score analysis of a longitudinal cohort factors predictive of long-term mortality in lupus nephritis: a multicenter retrospective study of a japanese cohort long-term prognosis of patients with systemic lupus erythematosus-associated pulmonary arterial hypertension: cstar-pah cohort study mortality and prognostic factors in chinese patients with systemic lupus erythematosus prevalence, risk factors, and impact on mortality of neuropsychiatric lupus: a prospective, single-center study long-term mortality and morbidity of patients with systemic lupus erythematosus: a single-center cohort study in china prognostic factors of mortality in iranian patients with systemic lupus erythematosus admitted to intensive care unit differences in clinical features and mortality between childhood-onset and adult-onset systemic lupus erythematosus: a prospective single-center study the sarawak lupus cohort: clinical features and disease patterns of sle patients in a single tertiary centre from east malaysia the effect of comorbidity on hospital mortality in patients with sle from an asian tertiary hospital causes of mortality among inpatients with systemic lupus erythematosus in a tertiary care hospital in north india over a -year period survival rate among thai systemic lupus erythematosus patients in the era of aggressive treatment survival analysis and prognostic indicators of systemic lupus erythematosus in pakistani patients updating the american college of rheumatology revised criteria for the classification of systemic lupus erythematosus the development and initial validation of the systemic lupus predictors of organ damage in systemic lupus erythematosus: the hopkins lupus cohort factors associated with damage accrual in patients with systemic lupus erythematosus with no clinical or serological disease activity: a multicentre cohort study recommendations and barriers to vaccination in systemic lupus erythematosus prophylactic antibiotic usage for pneumocystis jirovecii pneumonia in patients with systemic lupus erythematosus on cyclophosphamide: a survey of us rheumatologists and the review of literature all authors have contributed to the interpretation of the data and approved the final manuscript. key: cord- - lxab u authors: qin, ling; yao, dong; zheng, lizhen; liu, wai-ching; liu, zhong; lei, ming; huang, le; xie, xinhui; wang, xinluan; chen, yang; yao, xinsheng; peng, jiang; gong, he; griffith, james f.; huang, yanping; zheng, yongping; feng, jian q.; liu, ying; chen, shihui; xiao, deming; wang, daping; xiong, jiangyi; pei, duanqing; zhang, peng; pan, xiaohua; wang, xiaohong; lee, kwong-man; cheng, chun-yiu title: phytomolecule icaritin incorporated plga/tcp scaffold for steroid-associated osteonecrosis: proof-of-concept for prevention of hip joint collapse in bipedal emus and mechanistic study in quadrupedal rabbits date: - - journal: biomaterials doi: . /j.biomaterials. . . sha: doc_id: cord_uid: lxab u steroid-associated osteonecrosis (saon) may lead to joint collapse and subsequent joint replacement. poly lactic-co-glycolic acid/tricalcium phosphate (p/t) scaffold providing sustained release of icaritin (a metabolite of epimedium-derived flavonoids) was investigated as a bone defect filler after surgical core-decompression (cd) to prevent femoral head collapse in a bipedal saon animal model using emu (a large flightless bird). the underlying mechanism on saon was evaluated using a well-established quadrupedal rabbit model. fifteen emus were established with saon, and cd was performed along the femoral neck for the efficacy study. in this cd bone defect, a p/t scaffold with icaritin (p/t/i group) or without icaritin (p/t group) was implanted while no scaffold implantation was used as a control. for the mechanistic study in rabbits, the effects of icaritin and composite scaffolds on bone mesenchymal stem cells (bmscs) recruitment, osteogenesis, and anti-adipogenesis were evaluated. our efficacy study showed that p/t/i group had the significantly lowest incidence of femoral head collapse, better preserved cartilage and mechanical properties supported by more new bone formation within the bone tunnel. for the mechanistic study, our in vitro tests suggested that icaritin enhanced the expression of osteogenesis related genes col α, osteocalcin, runx , and bmp- while inhibited adipogenesis related genes c/ebp-ß, ppar-γ, and ap of rabbit bmscs. both p/t and p/t/i scaffolds were demonstrated to recruit bmscs both in vitro and in vivo but a higher expression of migration related gene vcam was only found in p/t/i group in vitro. in conclusion, both efficacy and mechanistic studies show the potential of a bioactive composite porous p/t scaffold incorporating icaritin to enhance bone defect repair after surgical cd and prevent femoral head collapse in a bipedal saon emu model. steroid-associated osteonecrosis (saon) is a common orthopaedic problem following steroid treatment for many medical conditions such as rheumatoid arthritis, systemic lupus erythematosus, organ transplantation, asthma and severe acute respiratory syndrome [ e ] . osteonecrosis (on) mainly affects large joints, such as hip, that may subsequently progress to joint collapse requiring total joint replacement [ , ] . according to the centers of disease control and prevention of the united states, there were , total hip replacements performed in [ ] , in which on accounts for around % of all cases [ ] ; the total hospitalization cost of hip joint replacements in us was estimated to be around us$ billion in [ ] . the prognosis of joint replacement in saon patients is poor due most likely to impaired osteoblast, osteocyte and osteoclast functions with steroid use leading to impaired repair and osteogenesis as well as upregulation of adipogenic potential of bone mesenchymal stem cells (bmscs) [ , ] . our recent studies showed that phytochemical molecule icaritin, a metabolite derived from herbal fufang which was developed for treatment of postmenopausal osteoporosis [ , ] , could reduce saon incidence by inhibiting both thrombosis and lipid deposition in rabbits [ ] . we also showed icaritin was a unique phytomolecule capable of both promoting osteogenesis as well as inhibiting adipogenic differentiation of bmscs [ , ] . as icaritin is a chemically stable exogenous phytomolecule, we were able to incorporate it into poly lactic-co-glycolic acid (plga) and tricalcium phosphate (tcp) to form a plga/tcp/icaritin composite porous scaffold using low-temperature rapid prototyping (rp) technology [ e ] . rp technology is becoming popular in musculoskeletal tissue engineering due to its ease, flexibility and reproducibility for manufacturing scaffolds closely mimicking structural defects with complex structures [ , ] . the composite scaffold was tested for its efficacy as a bone defect filler for enhancing bone defect repair in both established saon and segmental ulnar defect rabbit models; the presence of icaritin significantly induced more new bone formation in the defects, attributed to the sustained release of the bioactive phytomolecule icaritin from the composite scaffold [ , , ] . however, unlike end-stage on in human beings, rabbit is a quadrupedal animal so that no hip joint collapse would occur after saon induction in our previous studies and also others. applying a recently established bipedal emu saon model with femoral head collapse similar to that typically observed in patients [ ] , this study was designed to test the ability of our unique plga/ tcp/icaritin scaffold to enhance bone defect repair within a bone tunnel after surgical cd and to prevent femoral head collapse. the underlying mechanisms associated with the potential enhancement of osteogenesis and anti-adipogenesis involving bmscs were also evaluated both in vitro and in vivo using our established costeffective quadrupedal rabbit saon model [ , , , ] , together with studying the signaling pathways involved. a flowchart describing the entire study is presented in fig. . this proof-ofconcept pre-clinical study is necessary before making a recommendation for conducting clinical trials and future clinical applications. plga/tcp composite scaffolds with or without incorporating icaritin were fabricated using a low-temperature rp machine (clrf- -ii; tsinghua university, beijing, china) based on our established protocol [ , , ] . briefly, plga ( : ) (shandong institute of medical instruments, jinan, china) was dissolved in , dioxane before tcp (beijing organic chemical plant, beijing, china) was added to form a uniform paste with a ratio of : (w/w of plga/ tcp) by vigorous stirring overnight. icaritin was added mg per g plga/tcp to form the plga/tcp/icaritin scaffold (p/t/i) based on our previous validation study [ ] . then the paste was spurted out layer-by-layer at a thickness of mm and distance of mm (default pore size) by a computer-driven nozzle to form a homogenous cubic porous scaffold. a demonstration scaffold measuring   mm is shown in fig. a . the exact size of the scaffold for each study was mentioned in the corresponding section below. the fabrication temperature in the production chamber was set at À c ensuring bioactivity of the phytomolecule icaritin. the scaffold was then lyophilized for h and sealed in a plastic bag before evaluation or implantation. for comparison, pure plga/tcp scaffold (p/t) was also produced in a similar fashion. all chemicals were purchased from sigmaealdrich (st. louis, mo, usa) unless specified. adult male emus of months old used for this study were provided and kept in shenzhen emu institute, where these emus received food and water ad libitum ( supplementary fig. s ). the animal experimental protocol was approved by the research ethics committee of shenzhen second peoples' hospital (licence no. e ). following the established protocol for inducing saon in emus [ ] , emus were treated with a combination of lipopolysaccharide (lps) (escherichia coli o :b ; sigmaealdrich) and methylprednisolone (mps) (pharmacia & upjohn, peapack, nj, usa). the animals were injected with lps ( mg/kg body weight) intravenously twice at day and day , and mps ( mg/kg body weight) intramuscularly injected at day , and . twelve weeks post-induction of saon, emus were anesthetized with xylazine ( mg/kg body weight) and ketamine ( mg/kg body weight) injection intramuscularly. a skin insertion was created to expose the greater trochanter. core decompression of mm diameter was performed from the greater trochanter along the axis of the femoral neck bilaterally. the tunnel direction was in the midaxis of the femoral neck. a pin, which was positioned mm away from the endosteal surface of the femoral head, was inserted to guide the drilling of the bone tunnel. using a mm diameter hollow bone drill, a bone tunnel was created from the greater trochanter towards the femoral head with reference to the pin and anatomical landmarks (depth of bone tunnel ¼ mm). this mm tunnel was expanded with a mm diameter drill bit. the hips of the saon emus were randomly assigned to one of following three groups: p/t/i group (n ¼ ), p/t group without icaritin used as vehicle control (n ¼ ) and empty control group without scaffold implantation (n ¼ ). the scaffolds were prepared into cylinders of mm diameter (fig. b) , and were press fitted into the bone tunnels (supplementary video s ). five additional emus were assigned to normal control group (n ¼ ) without saon induction and cd surgery, which the emus were euthanized one day after scaffold implantation as baseline for comparison. supplementary video related to this article can be found at http://dx.doi.org/ . /j.biomaterials. . . . magnetic resonance imaging (mri) (magnetom trio t mri system; siemens, germany) with a phased-array body coil was performed to determine successful establishment of saon weeks after saon induction, and also to confirm the correct position of the bone tunnel and placement of the cylindrical scaffold. for facilitating in vivo imaging examination, a specific posture device was used to obtain a highly reproducible emu position during mri scanning ( supplementary fig. s ). coronal turbo spin-echo t weighted fat-saturated images ( ms repetition time; ms echo time) were obtained with a slice thickness of mm, an interslice distance of . mm providing a field of view of mm  mm and a matrix of  pixels. twelve weeks post core-decompression and implantation, emus were euthanized and the femora were collected. the collapsed region at the femoral head was digitally imaged and evaluated visually for surface subsidence of the articular cartilage. ultrasound imaging and water-jet ultrasound indentation test were performed to measure the thickness and stiffness of emu femoral head cartilage using our established protocol (supplementary text) [ , ] . briefly, the thickness of the cartilage was calculated by averaging the distance of cartilage to the subchondral bone on three images obtained by b-mode ultrasound scanning ( supplementary fig. s ) . a water-jet ultrasound indentation probe ( supplementary fig. s a ) was used to measure the stiffness of the cartilage; the water-jet compressed the cartilage and the deformation was measured by an ultrasound probe installed at the tip ( supplementary fig. s b ). the experimental details of ultrasound imaging and indentation were provided in the supplementary text together with relevant references. after water-jet indentation test, the proximal femora were fixed in % ethyl alcohol for bone scanning using a high-resolution peripheral computed tomography (hr-pqct, scanco medical, brüttisellen, switzerland) with a source voltage of kev and current of ma. the entire scan length of mm with a spatial resolution of mm was used for animal experimental studies. for separating the signals of the mineralized tissue from the background signal, noise was removed using a low-pass gaussian filter (sigma ¼ . , support ¼ ), and mineralized tissue was then defined at a threshold of hounsfield units [ , ] . three-dimensional ( -d) images of the femoral heads were reconstructed. articular surface collapse was defined as a fracture and/or clear deformation of the femoral head matched the gross anatomical examination. the -d structure of the newly formed bone within the region of interest (roi) (the central tunnel of mm diameter) was reconstructed for histomorphometric analysis. bone mineral density (bmd), bone tissue volume fraction (bv/tv), connective density (conn. d.), trabecular number (tb. n), trabecular thickness (tb. th), trabecular separation (tb. sp) and structure model index (smi) in the rois were measured using the built-in software of hr-pqct system. prediction of femoral fracture load was carried out by micro-fea on the entire mm reconstructed micro-ct -d structure of each proximal femur. to downscale the fea calculation, eight voxels were downscaled into one voxel. a micro-fea model of the emu proximal femur was created by converting bone voxels to brick elements [ ] . then the finite element meshes were imported into abaqus software (dassault syst emes simulia inc., v elizy-villacoublay, france) to perform micro-fea. the number of brick elements in the micro-finite element model ranged from , to , . bone material properties were isotropic and linear-elastic. young's modulus was chosen as . gpa by assuming that the elastic properties of trabecular and cortical tissues were similar [ , ] . poisson's ratio was set to . [ , ] . the distal end of each model was constrained. load was applied vertically at the femoral head [ ] . the magnitude of load was initially chosen to be n for each node. supplementary fig. s showed one finite element model with boundary and loading conditions. the estimated failure load was computer based on a criterion developed by pistoia et al. [ ] , in which fracture was assumed to occur when % of the bone tissue was strained beyond a critical limit of microstrain. in these analyses, tissue-level effective strain was calculated from the strain energy density and the young's modulus of bone using the following equation: the estimated external load, which resulted in more than % of the bone tissue strained beyond microstrain, was taken as the predicted fracture load of the emu proximal femur. specimens without undergoing destructive evaluations were used for destructive compressive test. the proximal femur was sawed transversely at two locations, perpendicular to the long axis of the bone tunnel with a distance between the two cuts of mm, so that the proximal femoral was separated into three parts (head, neck and trochanter). an indentation test was performed using an h k-s material test machine (hounsfield test equipment ltd, redhill, uk) on the bony part of mm in thickness prepared from the mid-portion of the femoral neck. a custom-made indenter of mm in diameter was used to test the mechanical properties of the healing complex with new bone formed within the bone tunnel and its integration with the adjunct residual bone. the compressive test was performed at a rate of mm/min to record the maximum strength (n) and its displacement (mm) for subsequent calculation of energy (j) to failure. the femoral head and trochanteric region were used for histology. the femoral head was bisected along the coronal plane including the trochanteric region; half of each bisected region was decalcified and embedded in paraffin while the other half was embedded in methyl methacrylate (mma) without decalcification. histological evaluation was performed single blindly. . . . . decalcified sections. the specimens were decalcified with % formic acid solution and then embedded in paraffin. the trochanter regions were sectioned transverse to the bone tunnel for hematoxylin-eosin (h&e) staining and immunohistochemistry comprising vascular endothelial growth factor (vegf) and osteocalcin (oc). the femoral heads were sectioned along the coronal plane for fast green and safranin o staining based on published protocols [ , ] . a microscopic imaging system (leica q mc; leica microsystems, wetzlar, germany) was used to digitalize the histological sections for histological observation and histomorphometric assessment using image analysis software (image j . p, nih, usa). quantitation of the newly formed bone was performed by calculating the ratio of new bone within the bone channel and the entire initial bone tunnel cross sectional area using h&e stained sections. the degree of scaffold degradation in the bone tunnel was defined by evaluating the area ratio of the scaffold within entire bone tunnel at baseline (normal control group) and weeks after cd surgery. the area of the bone tunnel was defined as the area in the circle around the edge of the tunnel. formation of blood vessel and new bone within the bone tunnel was evaluated by defining the staining intensity and distribution of the vegf and oc stained regions [ ] . polarized microscopy was used to evaluate collagen fibers alignment of the new bone formed within the implanted porous scaffolds. for articular cartilage, the maximum thickness of safranin o staining of each slide was measured as an index of cartilage matrix proteoglycans content [ ] . . . . . undecalcified sections. mma embedded samples were prepared for scanning electron microscopy (sem) (jsm- , jeol, japan) with samples sectioned at mm thickness along the coronal plane using a diamond saw (isomet, buehler, germany) and then polished to mm using a soft cloth rotating wheel before acid-etching with % phosphoric acid for s, followed by % sodium hypochlorite for min [ ] . the sections were then sputter-coated with gold and palladium, as described previously for sem examination. for dynamic histology, samples were cut at mm in thickness using a heavy-duty microtome (polycut, leica, germany) for goldner's trichrome staining. rabbit bmscs were isolated using a standard protocol [ ] . briefly, new zealand white rabbits (male, -weeks of age) were anesthetized, then bone marrow was aspirated from the iliac crests and transferred into a centrifuge tube mixed with minimal essential medium -alpha (a-mem) (invitrogen, grand island, ny, usa). ficoll-hypaque density media ( . g/ml) was added, and the mixture was centrifuged at  g for min for collection of mononuclear bmscs. after washing with a-mem twice, the cells were seeded in cm tissue culture flasks at a density  cells/cm in a-mem with % fetal bovine serum (fbs), iu/ml penicillin and mg/ml streptomycin, and placed in an incubator at c containing % co . the first medium change was done three days after cell isolation and the suspended cells were discarded. thereafter, the medium was changed every three days. when confluence reached %, the cells were detached using . % trypsin and passaged at the ratio of : , with cells only of passage being used for subsequent experiments. primary bmscs from rabbits with or without saon induction (saon (þ) and saon (À)) (detailed protocol in section . ) were placed into -well plates. firstly, the osteogenic and adipogenic differentiation potentials of bmscs after saon induction were examined by culturing bmscs with a-mem containing osteogenic supplement (os) (  À m dexamethasone, mg/ml l-ascorbic acid -phosphate and mm glycerol -phosphate) or adipogenic supplement (as) (  À m dexamethasone, . mm -isobutyl- -methylxanthine, mg/ml insulin and . mm indomethacin). regarding the effects of icaritin, the osteogenic and adipogenic differentiation of bmscs from saon (þ) and saon (À) rabbits were studied with icaritin added, and . % dimethyl sulfoxide (dmso) served as a control. icaritin at a range of concentrations ( À , À , À and À m) were initially tested and À m was chosen for later studies based on the results of alp activity. at day , and (day , and for alp staining and assay), cells were collected for the following experiments: alkaline phosphatase (alp) staining (bcip/nbt kit, novex ® , life technologies, grand island, ny, usa); alp activity assay; mineralization assay (alizarin red s staining); oil red o staining; western blot for ccaat/enhancer-binding protein beta (c/ebp-b), peroxisome proliferator-activated receptors gamma (ppar-g), and adipocyte protein (ap ) for adipogenesis; and reserve transcription real-time polymerase chain reaction (rt-qpcr) for the expression of collagen, type i, alpha (col a), oc, runt-related transcription factor (runx ), and bone morphogenetic protein (bmp- ) for osteogenesis, and c/ebp-b, ppar-g, and ap for adipogenesis based on our published protocol [ ] . after optical imaging, the alizarin red s stained calcium precipitates were dissolved by % (w/v) cetylpyridinium chloride with the absorbance read at nm for quantification of the calcium formation. triplicate tests were conducted in each experiment. adipocyte like cell line t -l cells were cultured in dulbecco's modified eagle's medium (dmem) containing % fbs. for testing the inhibition potential of icaritin on adipocyte differentiation, cells ( /well) and composite scaffolds (   mm , piece/well) were placed simultaneously in -well plates overnight to reach confluence, and then the medium was changed to as medium for days before changing to adipogenic maintaining medium (dmem containing mg/ml insulin) on day . at day , the scaffolds were frozen and sectioned at a thickness of mm. these sections and the cells on the bottom of the well were stained with oil red o [ ] . a microscopic imaging system was used to digitalize the culture plates. thereafter, the intensity of oil red o stained adipocytes in the well grown alongside or within the holes of the scaffold was quantified. rabbit bmscs were cultured to confluence in -well tissue culture plates at a density of  cells/well in a-mem medium and then starved overnight. the confluent cell monolayer was then scraped with a tip [ ] and incubated for h with the serum free medium containing À m icaritin or . % dmso control. bmscs migration was quantified microscopically at time points of , , and h. the wound widths were measured using image-pro plus (media cybernetics, rockville, md, usa). the mrna expression of vascular cell adhesion molecule (vcam ), stromal cell-derived factor (sdf ) and chemokine receptor type (cxcr ) was examined by rt-qpcr. . . . bmscs recruitment p/t and p/t/i scaffolds of .  .  . cm were prepared for sterilization by % alcohol before uv treatment for min. six scaffolds were placed and fixed to the bottom of each well of a well plate (fig. a) . a total of  bmscs were placed into each well and cultured for h before counting the cell density, i.e. number of bmscs per unit area (cm /cells) around the scaffold within a defined area of .  mm away from the scaffold (fig. c) . the mrna expression of vcam in bmscs was evaluated by rt-qpcr. rna was isolated from the treated bmscs using rneasy ® mini kit and reverse transcribed into cdna by quantitect ® reverse transcription kit (qiagen, hilden, germany). cdna was used as template for rt-qpcr. primer sequences of rabbit genes of interest, col a, oc, runx , bmp- , c/ebp-b, ppar-g, ap , vcam , sdf , cxcr and glyceraldehyde -phosphate dehydrogenase (gapdh) as the housekeeping gene were listed in the supplementary table s . rt-qpcr was performed in -well plates using tf pack power sybr green pcr master mix and abi prism sequence detection system (applied biosystem, foster city, ca, usa). proteins from bmscs cultured in adipogenic induction medium with or without icaritin were extracted by ne-per nuclear and cytoplasmic extraction reagents kit (cat# , pierce, rockford, il, usa). the concentration of protein was measured by bca protein assay kit (cat# , pierce). fifty micrograms of protein was separated by % sds-page and transferred to pvdf membrane by buffer-tankeblotting apparatus (bio-rad, hercules, ca, usa). after blocking with % fat-free milk for h, the membrane was incubated with primary antibody ppar-g, ap and b-actin ( twelve -week-old male new zealand white rabbits with body weight of . e kg were used with experimental protocols approved by animal experiment ethics committee of the chinese university of hong kong ( / /grf). saon was induced with lps and mps in these rabbits based on our published protocol [ ] . two weeks post-induction, cd was performed under general anesthesia with xylazine ( mg/kg body weight) and ketamine ( mg/kg body weight). a bone tunnel of . mm in diameter was drilled by a trephine through the distal femur, from the attachment of the medial collateral ligament to the contralateral cortex, parallel to the coronal plane of the knee joint (fig. a) . the p/t (n ¼ ) and p/t/i (n ¼ ) scaffolds were randomly implanted into left or right distal femur (fig. b) . in order to find out whether p/t or p/t/i scaffold would attract mesenchymal stem cells (mscs), spio pre-labeled bmscs were injected into the bone marrow. a total of ml suspension of pre-labeled bmscs (  cells) was injected into the bone marrow mm proximal to the implantation site for histological analysis (fig. c ). one week after scaffold implantation, the rabbits were euthanized for sample harvesting. the tunnel region was selected for analysis. the femora were collected and fixed with buffered formalin and decalcified by % formic acid solution. after decalcification, the specimens were dehydrated and embedded in paraffin for sagittal sectioning at mm in thickness using a microtome, stained with prussian blue and then counterstained with nuclear fast red using standard protocols [ ] . all numeric data were expressed as mean ± sd. the incidence of collapse in emu model was defined as the number of collapsed hips divided by the total number of hips in each group, and analyzed with fisher's exact probability test. one-way analysis of variance (anova) followed by tukey's post-hoc test (multi-group comparison) and unpaired-sample t-test (two-group comparison) were used to assess statistical significance set p < . . statistical analysis was performed using spss . software (ibm, armonk, ny, usa). cripple gait pattern during loading and unloading gait cycle was not observed until week in some emus after saon induction. one week after cd surgery, emus with scaffold implantation recovered with a normal gait while an abnormal gait was still found in empty control group emus (supplementary video s and s ). supplementary video related to this article can be found at http://dx.doi.org/ . /j.biomaterials. . . . on t -weighed mr imaging, a subchondral osteonecrosis in the proximal femur was found at weeks following pulsed induction with lps and mps (fig. a ). one week after cd surgery, mr imaging confirmed a satisfactory tunneling procedure with the tunnel extending from the lateral femoral cortex to the subchondral bone (fig. b ). no emus died of surgery or over the entire follow-up period of weeks. the external appearance of the femoral head was imaged by digital photography while the cross sectional image of the bone tunnel at the endpoint was imaged by micro-ct (fig. ) . femoral head collapse incidence was % in empty control group, % in p/t group and only % in p/t/i group. fisher's exact probability test showed that the collapse incidence in the p/t/i group was significantly lower than the empty control group (p < . ). the articular cartilage thicknesses at both collapsed region and intact region were % and % higher in p/t/i group than in empty control group, respectively (p < . for both). although there was no statistically significant difference between p/t group and empty control group, or between p/t group and p/t/i group, the average cartilage thickness in p/t/i group was still larger ( % at the collapsed region and % at the intact region) than that of p/t group, and p/t group was also thicker ( % at the collapsed region and % at the intact region) than that of empty control group ( table ) . the cartilage stiffness at both tested regions of both p/t/i group and p/t group were significantly higher ( % at the collapsed region and % at the intact region for p/t/i group, % at collapsed region and % at intact region for p/t group) than those in empty control group, respectively (p < . ) ( table ). the average cartilage stiffness at both tested regions was higher in p/t/i group than those in p/t group, yet without reaching statistical significance. the representative safranin o and fast green stained images and thickness measurement were shown in fig. . the maximum thickness of safranin o stained tissue among groups were statistically different (p < . ) with a maximum of . mm in thickness found in p/t/i group (table ) . quantitative micro-ct analysis was performed for evaluating new bone formation and its microarchitecture within the bone tunnel in emu proximal femur (fig. ) . implantation with either p/t or p/t/i scaffold enhanced new bone formation in the bone tunnel while no bone was observed in empty control. bone tunnel with p/ t/i scaffold showed more bone formation when compared to p/t scaffold. significant higher bmd (mg/cm ) (p < . ), bv/tv (p < . ), conn.d (mm À ) (p < . ), tb.n (mm À ) (p < . ) and tb.th (mm) (p < . ) but lower tb.sp (mm) (p < . ) and smi (p < . ) were found in p/t/i group as compared with that of p/t group (table ) . the estimated fracture load of emu proximal femur was provided by micro-fea ( supplementary fig. s ). results showed that the failure loads were statistically significantly different among the three groups (p < . ), with the highest ( ± n) in p/t/i group, followed by p/t group ( ± n), and empty control group ( ± n) ( table ) . the indentation test showed that the maximum strength and energy to failure in p/t/i group and p/t group were both significantly higher than those in empty control group (p < . ). both parameters in p/t/i group were also significantly higher ( . % for maximum strength and . % for energy) than that of p/t group (p < . ) ( table ) . the histomorphological evaluation of bone healing in the tunnel is shown in fig. . there was almost no new bone formed in empty control group (fig. a &b ) . the bone tunnel was filled with more new trabecular bone in p/t/i group (fig. a &b ) while less new bone was observed in p/t group (fig. a &b ) . the area ratio of newly formed bone in p/t/i group was significantly larger than that in p/t group (p < . , table ). the difference in the degradation ratio of both types of scaffolds was not statistically significant with a slightly higher rate in p/t/i group (table ). under polarized microscope, there were more parallel collagen fibers in the newly formed bone in p/t/i group than that in p/t group (fig. c e ) . table cartilage thickness and stiffness measured by ultrasound indentation weeks after core-decompression surgery with or without scaffold implantation. empty control (n ¼ ) p/t (n ¼ ) p/t/i (n ¼ ) the immunohistochemical staining of oc and vegf are shown in fig. d&e . there were scattered oc signals shown in empty control group while more signals were observed in p/t group. most signals in p/t group were present around the edge of the bone tunnel. less oc signals were found in p/t/i group compared to p/t group; the signals in p/t/i group were mainly found at the edge of newly formed bone. scattered vegf signals were observed in empty control group. in p/t group, the signal spread mainly on or next to the edge of the bone tunnel with clusters of staining signals found near the edge of tunnel where some bone-like tissue was present. less vegf signal was observed in p/t/i group than that of p/t group. goldner's trichrome staining for osteoid of the new bone within the bone tunnel is shown in fig. . there was less new active bone formation found in p/t group while more new bone with osteoid and mineralized bone matrix were observed in p/t/i group. sem images showed that there was no osteocyte-like structure at the subchondral bone of the collapsed region in empty control (fig. a ) while there were some osteon-like structures in normal control group (fig. b) . the micro-structures of trabecular bone at the border of bone tunnel in p/t (fig. c) and p/t/i groups (fig. d) were similar to that of normal control group. two weeks after saon induction, bmscs were isolated from saon (þ) rabbits and saon (À) normal rabbits for comparison: ) compared with saon (À) group, the quantitative alp activity of bmscs decreased significantly by %, % and % in saon (þ) groups when osteogenic induction was performed and evaluated continuously at day , and , respectively (fig. a ). alp expression of bmscs also decreased in saon (þ) group at day , and (fig. b) . ) calcium deposition by saon (þ) group at all time points was observed to have significantly less calcium nodule formation as compared with saon (À) group (fig. c) . ) after adipogenic induction for days, both the number and size of the adipocytes increased in saon (þ) group as compared to that of saon (À) group (fig. d) . these findings demonstrated that bmscs of saon (þ) group had a significantly impaired differentiation potential in osteogenesis accompanied with elevation of adipogenic ability. icaritin was added to the culture medium to investigate its quantitative analysis of micro-ct for the newly formed bone within bone tunnel weeks after core-decompression surgery with or without scaffold implantation. empty control (n ¼ ) p/t (n ¼ ) p/t/i (n ¼ ) effects on the osteogenesis and adipogenesis of bmscs from saon (þ) and saon (À) rabbits for the following findings: ) alp activity assay showed that icaritin enhanced alp activity in a dosedependent manner in both saon (À) and saon (þ) groups, with an optimal icaritin concentration of À m. alp activity at day was enhanced by % and % in saon (À) and saon (þ) groups respectively (fig. a) . icaritin elevated alp expression both in saon (À) and saon (þ) groups with more obvious staining intensity change in saon (þ) group (fig. b) . ) icaritin increased calcium deposition in both saon (À) and saon (þ) groups (fig. c) . quantification of calcium nodules showed that the addition of icaritin increased the formation of calcium nodules by % and % in saon (À) and saon (þ) groups, respectively (fig. d) . ) rt-qpcr showed that col a, oc, runx and bmp- expression of saon (þ) group decreased about . -fold, -fold, fold and -fold compared to saon (À) group. icaritin significantly increased col a, oc, runx and bmp- expression . -fold, -fold, . -fold and . -fold in saon (À) group and -fold, -fold, fold and -fold in saon (þ) group (fig. e ). ) lipid droplets were significantly increased by % in saon (þ) group compared to saon (À) group (p < . ); with icaritin treatment, lipid deposition decreased by % and % in saon (À) and saon (þ) groups, respectively (fig. f&g ) (p < . for both). the expression of adipogenic differentiation regulatory genes c/ebp-b, ppar-g and ap in saon (þ) group was higher than saon (À) group by , and times (p < . ); while these two groups were treated with icaritin, the c/ebp, ppar-g and ap expression was reduced by %, %, and % in saon (À) group (p < . ) and %, % and % in table histomorphometric analysis of areal fraction of new bone and scaffold within the bone tunnel weeks after core-decompression surgery with or without scaffold implantation. empty control (n ¼ ) p/t (n ¼ ) p/t/i (n ¼ ) saon (þ) group (p < . ) (fig. h) . accordingly, the change in protein level expression of ppar-g and ap was also examined. western blot results showed that ppar-g and ap expression was upregulated in saon (þ) group, while the expression of ppar-g and ap proteins of saon (À) and saon (þ) groups was obviously lower after the addition of icaritin (fig. i ). the effect of p/t/i scaffold on adipogenesis of t -l was determined by oil red o staining. lipid droplet formation (fig. a) next to the scaffold in p/t group was slightly inhibited when compared to control group, where bmscs were seeded onto the standard tissue culture flask. for p/t/i scaffold, lipid droplet formation either next to the scaffold or within the hole of the scaffold was greatly inhibited when compared to that of p/t group. quantification of oil red o staining for the lipid droplet formation next to the scaffold showed a significant decrease (p < . ) in p/t/i group when compared to p/t or control group (fig. b) . comparing oil red o stained adipocytes within the drilled hole, it was found that the stained area of p/t/i scaffold was significantly less (p < . ) than that of p/t scaffold (fig. c ). scratch wound healing assay was carried out to determine the effect of icaritin on the migration of saon (À) normal bmscs. bmscs exposed to icaritin containing medium migrated into the denuded area and recovered the exposed surface within a shorter time period than bmscs exposed to dmso containing control medium (fig. a) . quantification of the cell migration rate showed that the migration rate of bmscs cultured in medium with icaritin was significantly increased by % than that of control group (p < . ) (fig. b) . the expression of migration factors by bmscs was detected using rt-qpcr after treatment with icaritin for h. cxcr /sdf genes expression did not have any obvious difference while migration regulatory gene vcam expression increased significantly (p < . ) with icaritin treatment (fig. ). as icaritin alone could promote migration of bmscs as confirmed above, we further tested the ability of p/t or p/t/i scaffold for potential recruitment of bmscs in vitro (fig. ) . bmscs grown away from (fig. b & ) and near to (fig. b & ) the scaffolds were imaged by optical microscope for quantification. there were % and % more cells around p/t and p/t/i scaffolds than other regions distant from the scaffolds of the corresponding wells (fig. d) . p/t/i group attracted % more bmscs than that of p/t group (p < . ). mrna expression of migration gene vcam was measured using rt-qpcr in order to detect at which stage that the scaffolds impacted migration of bmscs. the mrna expression of vcam increased by % in p/t/i group while there was no changes found in p/t group as compared to control group (fig. e ). saon rabbit model with spio labeled bmscs was chosen for studying the role of p/t and p/t/i scaffolds on the recruitment of stem cells for bone healing and preventing subsequent hip joint collapse caused by saon. presence of spio labeled bmscs in the histological section could be observed by prussian blue staining (fig. a) . it was found that without scaffold implantation, the tunnel was filled dominantly with fat cells, and there was no observable labeled bmsc in the tunnel. on the other hand, spio positive bmscs, which were injected mm away from the bone tunnel, were clearly observed to migrate and spread evenly into both p/t and p/t/i scaffolds implanted in the tunnels. there was no statistically significant difference in the number of spio labeled cells in the tunnel regions between p/t and p/t/i groups (fig. b ). this is the first study to demonstrate that p/t/i, a phytomolecule-based bioactive composite scaffold, can be an effective bone filler for prevention of hip joint collapse using our recently established bipedal saon emu model [ ] , while the underlying mechanism has been studied in vitro using rabbit bmscs [ ] and in vivo with a well-established cost-effective and easy- handling quadrupedal saon rabbit model [ , ] . large bipedal emu was chosen due to its suitability for orthopaedic and biomaterial research as a large bipedal animal model suitable for studying saon in a pre-clinical setting [ ] . mr imaging confirmed that saon occurred weeks post-induction in emus. at this stage, an abnormal gait similar to that seen in patients at stage i or stage ii on would be developed [ , ] . we undertook cd as a surgical intervention for studying the effect of p/t/i scaffold as bone defect filler after cd on prevention of femoral head collapse. the significantly lower incidence of femoral head collapse in p/t/i group suggests its potential for clinical trial studies and a wide range of clinical applications in the future. bone repair in emus with saon after cd surgery was rigorously investigated to uncover the different aspects of bone healing. more new bone formation in the bone tunnel, consistently demonstrated by micro-ct and histology, was found in p/t/i group reflecting the osteopromotive effect of the bioactive molecular icaritin. this agrees with our previous study on a saon rabbit model that showed both p/t and p/t/i scaffolds promoted bone repair, but with better treatment efficacy or promotive effect of p/t/i on bone repair than that of p/t [ , ] . the maximum strength and energy of roi in the bone tunnel of p/t/i group suggested that the addition of icaritin yielded the best new bone regeneration potential to partially restore the mechanical stability of the defect. the fracture load estimation by micro-fea revealed that the femoral head of p/ t/i group could resist the largest strength. the greatly improved mechanical properties seen in p/t/i group can be explained by the better quality of new bone as assessed by micro-ct and histology. degeneration of the articular cartilage was found to be associated with femoral head on and collapse of femoral head [ ] . articular cartilage degeneration might also be related to development of saon under similar mechanisms, where ischemia, edema and adipogenesis in the subchondral bone could cause pathological changes in microenvironment of the articular cartilage, leading to decreased collagen synthesis and increased apoptosis of chondrocytes [ , ] and therefore cartilage thinning that ultimately aggravating femoral head collapse. compared with the thickness of the articular cartilage in normal healthy emus reported in our earlier study [ ] , the cartilage of the saon emus in all three groups were all significantly thinner, especially at the collapsed region. however, p/t/i scaffold still performed the best in supporting the local mechanical and biological environment so as to maintain the thickness of articular cartilage of the involved joints. the ultrasound indentation test of the present study showed that p/t/i scaffold indeed helped maintained stiffness of the articular cartilage. in addition, the histomorphological results showed that p/t/i scaffold could help preserved structural composition of the articular cartilage through the osteopromotive effects of icaritin. as articular cartilage protected the subchondral bone from excessive stress, the relatively preserved cartilage in p/t/i group could prevent articular surface collapse in this group. mscs homeostasis is vital for bone development and repair. recently, it has been advocated that saon may be a disease of bone cells and/or mscs. the osteogenic ability of mscs is decreased during early saon development [ , ] . mscs are multipotent stromal cells which have the potential to differentiate into osteoblasts, adipocytes and other cell types. as corticosteroids promoted adipogenesis and inhibited osteogenesis, in vitro and in vivo, so that unbalanced differentiation of mscs might lead to osteonecrosis as reported by others [ ] . in this study, we found that icaritin could promote alp activity, alp expression and calcium nodules deposition of bmscs from saon (À) rabbits, suggesting that icaritin promoted osteogenic differentiation of bmscs for new bone formation or regeneration. furthermore, icaritin partially recovered the declined osteogenic potential of bmscs in saon (þ) group. our present work has clearly shown that icaritin can promote osteogenesis during bone repair in saon. lipid accumulation in saon was most likely due to the increased adipocytic differentiation of mscs. icaritin decreased lipid accumulation in both saon (À) and saon (þ) groups, demonstrating that it could inhibit adipogenesis during bone repair with saon. the enhancement of osteogenesis and inhibition of adipogenesis of mscs by icaritin with rabbit bmscs demonstrated its beneficial effect on bone defect repair in vitro and this can be translated to other saon animal models in vivo. in order to understand the mechanism of icaritin on osteogenesis of mscs, the expression of osteoblastic regulatory and marker genes bmp- , runx , col a and oc was determined. over the years, many research studies have shown that corticosteroids lead to down-regulation of bmp- , runx , col a and oc expression of bmscs in vitro and in vitro using various animal models [ , e ] . bmp- is an early osteogenic gene that modulates the promoter region of runx /cbfa . oc is a late osteogenic gene, and suppression of bmp- gene expression theoretically leads to a direct decrease of oc [ ] . therefore, bmp- serves as the main gene affected by steroids to suppress the osteogenesis in saon. in this study, the decrease of expression of these osteogenic markers of bmscs from saon (þ) rabbit compared to saon (À) rabbit reconfirmed our saon model in agreement with other studies. icaritin promoted the expression of genes of bmscs suggested that bmp- signaling pathway was involved in icaritin-mediated osteogenesis promotion [ ] . adipogenic markers ap and ppar-g were known to be upregulated in saon [ , , ] , together with c/ebp, the mrna expression of these three markers was of interest for us to confirm such an effect of icaritin. the increase in expression of these markers in saon (þ) showed that corticosteroid improved adipogenesis through c/ebp and ppar-g signaling pathways. c/ebps belong to the basic-leucine zipper class of transcription factors which have been implicated in the induction of adipocyte differentiation [ ] . c/ebps are expressed before the transcription of most adipocytespecific genes initiated and contribute to the subsequent induction of the major adipogenic transcription factors, including ppar-g . ** and ##: p < . ) for comparison between different regions (b vs. b or b vs. b ) and between groups (p/t vs. p/t/i), respectively. (e) rt-qpcr data on the migration related gene vcam of bmscs cultured with p/t or p/t/i scaffold with standard tissue culture treated surface as the control. **:p < . for comparison between p/t/i group and control group. [ ] . in particular, c/ebps and c/ebp-b stimulate ppar-g activity by controlling the production of ppar-g ligand, and phosphorylation of c/ebp-b is required for ppar-g-associated downstream proteins involved in adipogenesis [ ] . ap is expressed during adipocyte differentiation that has been regarded as a terminal differentiation marker [ ] . ppar-g is the key transcription factor in adipocyte differentiation and plays an anti-osteoblastogenic role as the master regulator of adipogenesis [ ] . after icaritin treatment, a significant inhibition of adipogenic differentiation appeared both in saon (À) and saon (þ) groups. western blot results further confirmed that icaritin inhibited ppar-g and ap expression at protein level. this suggested that icaritin inhibited adipogenesis of bmscs through ppar-g-mediated pathway. whether p/t and/or p/t/i scaffolds promoted bone defect repair in saon animal model via regulating stem cell homing, a fundamental mechanism on osteogenesis and potentially also angiogenesis/neovascularization, during bone defect repair in saon rabbit was further investigated in this study. the migration of mscs plays an important role in organogenesis during development and tissue repair. regulation of mscs homing from an endogenous niche or following systemic administration to the targeted region is critical for effective tissue regeneration. the homed mscs were reported not only to be able to offer themselves for tissue regeneration but also serve as vehicles for in vivo delivery of therapeutic genes or factors to promote repair [ ] . so a strategy for bone defect treatment shall not only facilitate osteogenesis and angiogenesis, but also trigger stem cell homing. in the saon rabbit model, both p/ t and p/t/i scaffolds were shown to promote spio labeled mscs homing to bone defect region after cd surgery for enhancing bone defect repair. as a void filler and drug carrier, p/t scaffold itself was demonstrated to be effective in recruiting bmscs migration. on the other hand, not only icaritin alone upregulated vcam gene of bmscs in vitro, but its bioactivity was also well preserved in p/t/i to upregulate vcam in vitro and promote spio labeled bmscs migration to bone defect region in saon rabbit model. vcam plays an important role in cellecell recognition, through interacting with the beta- integrin very late antigen- (vla ), by mediating both cell adhesion and signal transduction [ ] . vcam is involved in homing at the adhesion stage while vla- /vcam- expressed by mscs interacts with endothelial cells to promote firm adhesion of mscs on endothelial surface and transmigration across the endothelium [ , ] ; chemokines, e.g. sdf , may further chemoattract mscs from bone marrow to the injured tissue for repair enhancement [ ] . sdf is mainly expressed by stromal and endothelial cells, and cxcr is a specific receptor for sdf . the lack of effect of icaritin on cxcr /sdf demonstrated that probably other migration-stimulating factors, in addition to vcam- , other than sdf were involved in mediating the stimulatory response of icaritin on bmscs. since the prospect of icaritin as a novel osteogenic factor for stimulating bone regeneration was well demonstrated, we incorporated this anabolic phytomolecule icaritin into an osteoconductive biomaterial p/t to form p/t/i scaffold to explore its treatment efficacy for saon associated joint collapse using our recently established bipedal emu model. however, it was critical at the outset to ensure a sustained release of icaritin from the p/t/i scaffold. we previously reported the sustainable release of about % icaritin from a p/t/i scaffold over a period of weeks and our findings supported that the p/t scaffold was an appropriate carrier for local icaritin delivery [ ] . in addition, this scaffold also showed good biocompatibility and facilitated mscs adhesion and ingrowth, which are the essential underlying mechanism on promoting osteogenesis [ , ] . in our recent study using an saon rabbit model, both p/t and p/t/i scaffold showed bone healing enhancement yet with better osteopromotive effect in p/t/i scaffold [ ] . the results from the current study also confirmed that icaritin could be successfully incorporated into p/t and maintained its bioactivity for enhancing bone defect repair healing in such a large bipedal emu model that was explained at least in part by its effects on attracting migration of bmscs from remote region to the bone defect using a cost-effective rabbit model. one of the limitations of the current study design was that two different animal models were used for exploring treatment efficacy and its mechanism. for bipedal animal model, emu has a body size close to that of humans suitable for testing orthopaedic biomaterials, but emu is also a large and expensive animal model for pre-clinical research. we demonstrated saon-induced hip joint collapse in emu [ ] that was explained by higher body to lowerlimb weight ratio, i.e. higher mechanical loading imposed to the hip joint, which can only be induced in bipedal animal model such as emu [ , ] . on the contrary, rabbit saon model is a wellestablished, cost effective and easy-handling one yet never shows hip joint collapse due to its quadrupedal nature with body weight distribution on four limbs. however, rabbits have metabolic pathway and bone density and structure more similar to humans than aves [ , ] . taken together, we selected rabbits for studying the underlying mechanism of a -d bioactive scaffold containing an osteopromotive phytomolecule icaritin (p/t/i scaffold) at cellular and molecular level apart from limited availability of relevant antibodies and gene sequences for emu research. although p/t/i scaffold was shown to promote bmscs migration much better than p/t scaffold in vitro, the difference of these two scaffolds on the migration of spio labeled bmscs in vivo was not obvious. this finding might be explained by an insufficient cell number and sample size for quantitative analysis, more likely that the unlabeled yet significant host circulating and local mscs might have fundamentally contributed to the better treatment effects of p/t/i scaffold for bone defect repair in the current study. in conclusion, we tested porous composite scaffold p/t incorporating an osteopromotive phytomolecule icaritin (p/t/i scaffold) that showed as an effective bone filler for promoting bone defect repair and prevention of hip joint collapse in bipedal saon emu model. this effect was explained by its ability to promote msc migration to the bone defect region for enhancing osteogenesis and inhibiting adipogenesis, indicating p/t/i scaffold as a -d printed bioactive scaffold for potential orthopaedic applications involving large bone defect repair. all authors declare that there is no conflict of interest regarding the materials discussed in the manuscript. pathogenesis and natural history of osteonecrosis steroidinduced osteonecrosis in severe acute respiratory syndrome: a retrospective analysis of biochemical markers of bone metabolism and corticosteroid therapy nontraumatic osteonecrosis of the femoral head: ten years later steroid induced osteonecrosis: an analysis of steroid dosing risk epidemiology of nontraumatic osteonecrosis of the femoral head in japan risk factors for avascular bone necrosis in systemic lupus erythematosus with special feature on prescription drugs nontraumatic necrosis of bone (osteonecrosis) elevated adipogenesis of marrow mesenchymal stem cells during early steroidassociated osteonecrosis development impaired bone healing in rabbits with steroid-induced osteonecrosis epimedium-derived phytoestrogen flavonoids exert beneficial effect on preventing bone loss in late postmenopausal women: a -month randomized, double-blind and placebo-controlled trial the first multicenter and randomized clinical trial of herbal fufang for treatment of postmenopausal osteoporosis a novel semisynthesized small molecule icaritin reduces incidence of steroidassociated osteonecrosis with inhibition of both thrombosis and lipiddeposition in a dose-dependent manner icaritin, an exogenous phytomolecule, enhances osteogenesis but not angiogenesisean in vitro efficacy study printing and prototyping of tissues and scaffolds fabrication of a two-level tumor bone repair biomaterial based on a rapid prototyping technique comparative study of osteogenic potential of a composite scaffold incorporating either endogenous bone morphogenetic protein- or exogenous phytomolecule icaritin: an in vitro efficacy study comparative study of plga/tcp scaffolds incorporated or coated with osteogenic growth factors for enhancement of bone regeneration regeneration of the articular surface of the rabbit synovial joint by cell homing: a proof of concept study a review of materials, fabrication methods, and strategies used to enhance bone regeneration in engineered bone tissues plga/tcp composite scaffold incorporating bioactive phytomolecule icaritin for enhancement of bone defect repair in rabbits exogenous phytoestrogenic molecule icaritin incorporated into a porous scaffold for enhancing bone defect repair steroid-associated hip joint collapse in bipedal emus multiple bioimaging modalities in evaluation of an experimental osteonecrosis induced by a combination of lipopolysaccharide and methylprednisolone structural and degradation characteristics of an innovative porous plga/tcp scaffold incorporated with bioactive molecular icaritin evaluation of bone-tendon junction healing using water jet ultrasound indentation method noncontact evaluation of articular cartilage degeneration using a novel ultrasound water jet indentation system impaired bone healing in rabbits with steroid-induced osteonecrosis promotion of bone repair by implantation of cryopreserved bone marrow-derived mononuclear cells in a rabbit model of steroid-associated osteonecrosis a new method to determine trabecular bone elastic properties and loading using micromechanical finite-element models elastic modulus and strength of emu cortical bone the elastic properties of trabecular and cortical bone tissues are similar: results from two microscopic measurement techniques the elastic modulus for bone elastic properties of human cortical and trabecular lamellar bone measured by nanoindentation femoral bone strength and its relation to cortical and trabecular changes after treatment with pth, alendronate, and their combination as assessed by finite element analysis of quantitative ct scans estimation of distal radius failure load with micro-finite element analysis models based on three-dimensional peripheral quantitative computed tomography images microspectrophotometric quantitation of glycosaminoglycans in articular cartilage sections stained with safranin o partial patellectomy induces a decrease in the proteoglycan content in the remaining patellar articular cartilage. an experimental study in rabbits osteogenesis induced by extracorporeal shockwave in treatment of delayed osteotendinous junction healing changes in dentin appositional rates during pregnancy and lactation in rats endothelial progenitor cell and mesenchymal stem cell isolation, characterization, viral transduction icaritin, an exogenous phytomolecule, enhances osteogenesis but not angiogenesis-an in vitro efficacy study effects of basic fibroblast growth factor (bfgf) on early stages of tendon healing: a rat patellar tendon model durable mesenchymal stem cell labelling by using polyhedral superparamagnetic iron oxide nanoparticles lowintensity pulsed ultrasound increases cellular uptake of superparamagnetic iron oxide nanomaterial: results from human osteosarcoma cell line u os multiple bioimaging modalities in evaluation of an experimental osteonecrosis induced by a combination of lipopolysaccharide and methylprednisolone clinically translatable cell tracking and quantification by mri in cartilage repair using superparamagnetic iron oxides arco committee on terminology and staging.the arco perspective for reaching one uniform staging system of osteonecrosis the role of mr imaging in staging femoral head osteonecrosis exogenous phytoestrogenic molecule icaritin incorporated into a porous scaffold for enhancing bone defect repair articular cartilage changes in avascular necrosis: an arthroscopic evaluation corticosteroids alter the differentiated phenotype of articular chondrocytes increased chondrocyte death after steroid and local anesthetic combination elevated adipogenesis of marrow mesenchymal stem cells during early steroid-associated osteonecrosis development glucocorticoids induce osteocyte apoptosis by blocking focal adhesion kinase-mediated survival. evidence for inside-out signaling leading to anoikis current concepts on the pathogenesis and natural history of steroid-induced osteonecrosis steroid-induced adipogenesis in a pluripotential cell line from bone marrow osteogenic gene expression decreases in stromal cells of patients with osteonecrosis comprehensive characterization of four different populations of human mesenchymal stem cells as regards their immune properties, proliferation and differentiation bmp protein regulates osteocalcin expression via runx -mediated atf gene transcription icaritin, an exogenous phytomolecule, enhances osteogenesis but not angiogenesisean in vitro efficacy study the effect of core decompression on local expression of bmp- , ppar-g and bone regeneration in the steroid-induced femoral head osteonecrosis regulating adipogenesis transcriptional control of adipogenesis regulation of ppargamma activity during adipogenesis adipogenic differentiating agents regulate expression of fatty acid binding protein and cd in the j macrophage cell line ppargamma: a circadian transcription factor in adipogenesis and osteogenesis the stem cell movement mesenchymal stem cell adhesion to cardiac microvascular endothelium: activators and mechanisms mesenchymal stem cells display coordinated rolling and adhesion behavior on endothelial cells characterization of key mechanisms in transmigration and invasion of mesenchymal stem cells stromal cell-derived factor- enhances wound healing through recruiting bone marrow-derived mesenchymal stem cells to the wound area and promoting neovascularization emu model of full-range femoral head osteonecrosis induced focally by an alternating freezing and heating insult a new animal model of femoral head osteonecrosis: one that progresses to human-like mechanical failure the rational use of animal models in the evaluation of novel bone regenerative therapies use of animal models in musculoskeletal research the authors would like to thank vivian hung and yixin he for their assistance in hr-pqct scanning and sample preparation, and ge zhang, who currently works at school of chinese medicine of hong kong baptist university for their initial involvement in the joint development of emu saon model (in zheng lz et al. plos one ). supplementary data related to this article can be found at http:// dx.doi.org/ . /j.biomaterials. . . . key: cord- -oecpqf j authors: nan title: aspho abstracts date: - - journal: pediatr blood cancer doi: . /pbc. sha: doc_id: cord_uid: oecpqf j nan myelodysplastic syndrome (mds) and frequently arise in the context of inherited bone marrow failure (bmf) syndromes, such as shwachman diamond syndrome (sds). monosomy /del( q) is associated with high grade mds and propensity to progress to acute myelogenous leukemia, a major cause of morbidity and mortality for patients with inherited bmf. development of non-transplant strategies to treat bone marrow failure without simultaneously stimulating outgrowth of malignant clones remains a major challenge. objectives: the aim of this study is to investigate the molecular consequences of del( q) in the context of bmf with the goal of developing more effective treatments. design/method: to study the biological and molecular consequences of monosomy/del( q) in bmf, induced pluripotent stem cells were generated from sds patients (sds-ipsc) . a deletion of the mds-associated region of the long arm of chromosome was then introduced using a previously published modified cre-lox approach. results: the sds ipsc phenocopied bone marrow failure with slow proliferation and impaired hematopoietic differentiation. we next explored whether deletion of q conferred a relative fitness advantage within the context of bone marrow failure. proliferation of the sds-del( q) ipscs was reduced below that of both the isogenic sds ipscs and normal controls without an increase in cell death. sds-del( q) demonstrated reduced hematopoietic differentiation compared with isogenic sds cells. these data demonstrate that deletion of q fails to confer a relative growth advantage relative to isogenic sds ipscs and results in further impairment of hematopoiesis. to gain insight into the mechanisms of del q-associated clonal evolution in sds, we performed rna sequencing (rnaseq) of sds+/-del( q) ipsc. expression of tgf pathways and their downstream targets were reduced in sds-del( q) ipscs compared to isogenic sds ipsc. single cell rnaseq analysis of primary sds bone marrow cells confirmed that the tgf pathway is hyperactivated in sds. western blot analysis showed increased phospho-smad levels in sds ipscs compared to sds-del( q) and normal controls, while total levels of smad were unchanged. pharmacological targeting of tfg with small molecule inhibitors resulted in selective improvement of sds hematopoietic colony formation and myeloid differentiation without stimulating outgrowth of the isogenic sds-del( q) cells or normal controls. these results demonstrate that del( q) reverses the tgf pathway hyperactivation of sds. furthermore, inhibition of tgf selectively rescues hematopoiesis in sds but not in isogenic del q cells, suggesting a potential strategy to treat bone marrow failure without stimulating del q clonal outgrowth. background: standard therapy of medulloblastoma consists of treatment with alkylating agents and radiation after surgical resection. although a statistically significant increase in survival is reported with this regimen, / rd recur and become resistant this class of agents ultimately leading to mortality. large numbers of somatic mutations were observed in recurrent medulloblastoma (rm) after alkylating agent and radiation treatment. high mutation rates in tumors can have twofold effect; ) a large number of non-synonymous mutations that have no role as drivers can still cause functional tumor antigens increasing the neoantigen burden and immunogenicity. moreover, ) such tumors can gain mutations in canonical or non-canonical dna repair pathways leading to a gain in the number of mutations as seen in case of glioblastoma, this can lead to even higher accelerated mutational rate. evidences suggest that high mutational load can cause higher neoantigen burden thereby making the tumor more susceptible to immune checkpoint inhibition. we propose that post therapy recurrent medulloblastoma gain mutational signature and immunophenotype of malignancies demonstrating clinical response to immune checkpoint therapy. objectives: ) rm has molecular signatures identical to tumors with high immunogenicity and clinical response to immune check point inhibition. ) rm has the immune inflammatory phenotype; harboring high percentage of tumor infiltrating lymphocytes (tils), macrophages and monocytes. design/method: to test our hypothesis, we downloaded the raw bam files of previously published data from international cancer genome consortium (icgc) . this set of about matched primaries and recurrent medulloblastoma cases forms our discovery cohort. we have called somatic variants using the gatk pipeline by the broad institute. to validate our key findings, we have procured human medulloblastoma specimens and are conducting whole exome sequencing. the primary assays utilized to assess immunogenicity are immunohistochemical (ihc) staining of formalin fixed and embedded recurrent medulloblastoma tissue to identify tils, tumor associated macrophages and other markers. mg/m had dlts of dyspnea (grade )/hypoxia (grade ) but no dlts were observed in any other cohort. adverse events were generally mild to moderate, consistent with the safety profile observed in adults. across the desc cohorts, plasma concentrations were dose-proportional and steady state concentrations were lower on day vs. day . mean systemic exposure in the mg/m cohort was ∼ -fold greater compared with the adult rp d of mg bid. a pk:pd relationship between tazemetostat exposure and h k me levels in peripheral blood monocytes and granulocytes was observed in the desc phase. consistent and significant post-dose reductions in h k me occurred at doses ≥ mg/m . further analysis of twelve patients treated at the rp d confirmed that h k me inhibition was maximally inhibited. doses - mg/m showed confirmed objective responses (cr/pr) per recist/rano in patients with es (n = ), chordoma (n = ), and atrt (n = ). background: previous studies established that the platelet/ fibrin(ogen) axis promotes metastatic potential by impeding the clearance of newly formed micrometastases by natural killer (nk) cells. however, multiple important questions remain, including the potential of fibrin(ogen) to promote metastasis through interactions with cells other than platelets (e.g., inflammatory cells), and the fundamental question of whether fibrin polymerization is required for metastasis. objectives: determine the role of fibrin polymerization and fibrin(ogen) engagement of integrins iib and m in metastasis. design/method: we performed experimental and spontaneous metastasis assays in immunocompetent mice carrying specific fibrinogen structure/function alterations. results: expression of a mutant fibrinogen lacking the binding motif for the leukocyte integrin m (fib - a) significantly decreased metastatic potential relative to wildtype fibrinogen, suggesting a role for fibrin(ogen)inflammatory cell interactions mediated by m in metastasis. to directly determine the importance of thrombinmediated fibrin polymerization in metastasis, we analyzed metastatic potential in fibaek mice, which carry a form of fibrinogen essentially "locked" in the soluble state due to a mutation in the a chain thrombin cleavage site. metastatic potential in fibaek mice was diminished relative to control mice, speaking to the importance of thrombin-mediated fibrin polymerization in the metastatic process. however, the fibaek mice retained significant metastatic potential relative to complete fibrinogen deficiency, indicating that fibrinogen monomer retains significant prometastatic properties. in order to better define the role of fibrin(ogen)-platelet interactions in metastasis, we compared metastatic potential in control and fib Δ mice, carrying a form of fibrinogen lacking the chain binding motif for the platelet integrin iib . surprisingly, this mutation had no impact on metastatic potential. together, these studies suggest fibrinogen plays a multifaceted role in metastasis. fibrin(ogen)-leukocyte interactions mediated by m appear to have a role in metastasis. previous studies showed that macrophages promote the metastatic potential of circulating tumor cells, which may represent at least one important m expressing cell type whose prometastatic behavior is influenced by fibrin(ogen) interactions. these studies show that thrombin-mediated fibrin polymerization promotes metastasis, but soluble fibrinogen retains some significant prometastatic capacity. surprisingly, loss of the fibrinogen chain iib binding motif had no impact on metastasis. given the established importance of platelets in metastasis, these findings suggest that fibrin (ogen) is capable of platelet stabilization through mechanism(s) independent of this iib binding motif. platelets may bind polymerized fibrin at other sites, and/or fibrin interactions with other matrix proteins capable of binding iib are sufficient to support platelet functions required for metastasis. the role of platelets in hemostasis and thrombosis is well defined, but it is becoming increasingly evident that platelets also assist in host defense and inflammation. platelets participate in the innate immune system through direct antimicrobial activity and interactions with effector cells (chapman , garlanda , kapur ). in the adaptive immune system, platelets recruit and costimulate t-cells, and promote b-cell differentiation and antibody class switching (kapur , morrell ). the question remains: which mechanisms influence platelet immune function and are they developmentally regulated? preliminary studies in the palis lab have revealed significant dif-ferences in embryonic versus adult platelet gene expression, including regulators of immune and inflammatory responses such as beta -microglobulin (b m) and major histocompatibility complex class i (mhc ). mhc is expressed on all cell surfaces except red blood cells and its molecular chaperone b m is a marker of inflammation highly expressed in platelet alpha granules (zufferey ). preliminary data from the morrell lab reveals a mass release of b m during platelet activation, which drives monocyte differentiation to an inflammatory phenotype through tgfb receptor signaling. we therefore sought to determine whether developmental changes in platelet b m expression mediate differences in platelet-mediated monocyte activation. with trilineage hematopoiesis with a predominance of early myeloid precursors, with full maturation. microarray, elane and sbds sequencing and deletion/duplication analyses were negative. immunologic evaluation was significant for agammaglobulinemia and an absence of memory (cd +cd +) b cells. a gene primary immunodeficiency panel revealed two variants of unknown significance-c. g>a and c. g>t in dnmt b; one previously reported in association with icf . parental testing demonstrated parental heterozygosity. centromeric instability was confirmed in mitogen stimulated lymphocytes showing characteristic, multibranched chromosomes containing at least arms of chromosome and joined near the centromere. decondensation of the qh and qh regions and triradial configuration of chromosome was noted, and a diagnosis of icf syndrome was made. the patient was started on monthly intravenous immunoglobulin (ivig). prophylaxis for pneumocystis jiroveci pneumonia and respiratory syncytial virus was initiated. a / matched sibling hsct is being planned. demonstrated the diagnosis of high grade osteosarcoma. the patient was started on multi-agent chemotherapy with planned a whole femur prosthesis at time of local control. cases of osteosarcoma have been described in the literature in patients with nf (median age; years, range - years) with slightly male predominance ( cases). the femur was the most common site of involvement ( cases). four patients died of metastatic disease despite surgery and multi-agent chemotherapy. conclusion: nf represents a major risk factor for development of malignancy and uncommonly osteosarcoma in adolescents and adults. we report a rare case of an extensive involvement of osteosarcoma of the left femur in a child with known diagnosis nf . this presentation should alert the pediatric oncologists to monitor for bone tumors in patients with nf by physical exam and detailed medical history. hasbro children's hospital, providence, rhode island, united states background: dysautonomia is a paraneoplastic syndrome most commonly described in adult malignancies. despite current therapies aimed at symptoms management, it is often debilitating. we present a case of a -year-old girl who initially presented with autonomic dysfunction and was subsequently found to have hodgkin lymphoma. objectives: describe hodgkin lymphoma presenting with dysautonomia and discuss symptom management with rituximab design/method: case report a year-old-girl presented with severe symptoms of orthostatic hypotension necessitating prone positioning to prevent syncopal episodes. additionally, she reported anhidrosis, xerostomia, urinary retention, and constipation. she had unmanageable peripheral neuropathic pain despite multiple analgesia medications. initially, it was suspected that her symptoms were caused by an atypical presentation of guillain-barre syndrome. she was treated with intravenous immunoglobulin g, without response. due to a suspicion of a paraneoplastic syndrome a positron emission test/cat scan (pet/ct) was performed and revealed widespread fdg-avid nodal and splenic disease. pathology from a thoracoscopic biopsy of a mediastinal lymph node demonstrated classical hodgkin lymphoma. she was classified as stage ivb. a paraneoplastic panel obtained during the first cycle of chemotherapy revealed elevated anti-amphiphysin antibodies and glutamic acid decarboxylase (gad) antibodies. therapy was initiated with abe-pc (doxorubicin, bleomycin, etoposide, prednisone, cyclophosphamide) ; vincristine was held given her significant neuropathy. due to persistence of autonomic symptoms following her first cycle and presence of antiamphiphysin and gad antibodies, rituximab was incorporated into her treatment. following two cycles abe-pc, she had a rapid early response by fdg-pet/ct. she completed an additional three cycles of abd-pc. end of therapy imaging demonstrated complete response with a single persistent mildly fdg-pet avid lymph node (deauville ) and her antibodies were negative. she continues treatment of maintenance rituximab with significant improvement, but not resolution, of her orthostatic hypotension. at this time, the patient can ambulate with assistance. constipation and urinary retention have fully resolved and, her peripheral neuropathy, xerostomia, anhidrosis have improved. conclusion: this is rare case of a pediatric hodgkin lymphoma patient developing dysautonomia associated with antiamphiphysin and glutamic acid decarboxylase antibodies and subsequently managed with chemotherapy and rituximab. clinicians should be suspicious of a paraneoplastic syndrome when a neurologic disorder fails to improve with standard treatment. results: labs obtained at an outside hospital one month prior to presentation showed absolute neutrophil count (anc) and hemoglobin . g/dl. she presented to our institution with days of fever, hepatomegaly cm below costal margin, a white plaque on her tongue, and circumferential perianal ulceration. labs were significant for anc and hemoglobin . g/dl. anti-granulocyte antibody testing was positive. bone marrow biopsy showed arrest of neutrophil maturation. after initiation of filgrastim ( . mcg/kg/day), her anc increased to > and repeat bone marrow biopsy demonstrated left shifted myelopoiesis. biopsy of her oral lesion demonstrated invasive actinomyces prompting a prolonged course of antibiotics. biopsies of her oral and anal lesions were reported as myeloid sarcoma without mll rearrangement. chemotherapy was not initiated due to complete resolution of both lesions within weeks of initiating filgrastim and appropriate antibiotic coverage. she has not developed any further lesions concerning for malignancy. testing for common genes associated with severe congenital neutropenia and autoimmune lymphoproliferative syndrome was negative. her immunoglobulin levels and the measurement of age-appropriate vaccine responses were normal. after her lymphocyte subpopulation analysis indicated a selective deficiency in cd positive t-lymphocytes (absolute cd cell count ), the severe combined immunodeficiency panel from genedx showed compound heterozygous mutations in results: a male infant was born with a large thigh mass. the child was clinically well aside from restricted movement of affected leg. mri showed mass expanding into pelvis without other lesions. an interventional-radiology guided core biopsy of the mass was reported as high-grade spindle cell sarcoma without etv rearrangement. surgery was deferred because of concern that it would result in excessive morbidity. the mass was treated with vincristine and dactinomycin per infantile fibrosarcoma protocols. after months of therapy, no significant change in size of the mass was noted on physical exam or imaging. repeat biopsy was obtained to confirm diagnosis and allow for expanded tumor testing. this biopsy showed triphasic distribution of adipose, fibrous and mesenchymal tissue consistent with fhi with rare sarcomatous foci. additional chemotherapy was deferred and the child was followed clinically. his tumor has remained approximately the same size and still unresectable. next generation sequencing of tumor utilizing panel based technology revealed braf-erc fusion consistent with braf activating mutation. this mutation was confirmed by fluorescent in situ hybridization (fish) probe for braf. braf and mek inhibitors have been pursued as treatments to decrease size of tumor and allow for resection. conclusion: braf mutations have been characterized in a variety of malignancies. inhibition of braf and downstream signaling components has produced promising results in a variety of patients. this is the first case report of a braf mutation in a fhi. although management of fhi is typically surgical, this does suggest a potential therapeutic target and may allow for improved surgical outcomes especially in cases where up-front surgery would result in unacceptable morbidity. genetic sequencing of fhi and other rare tumors is an important tool and has the potential to identify mutations amenable to targeted therapies. background: icf is a rare autosomal recessive disorder characterized by hypo-or agammaglobulinemia and often opportunistic infections suggesting t-cell dysfunction. it is further categorized into subtypes - based on mutations in dna methylation. mutations in the helicase-lymphoid specific (hells) gene, which is required for t-cell proliferation and participates in de novo dna methylation, are characteristic of icf type (icf ). of approximately reported cases of icf, less than percent are characterized as icf . while malignancy has been reported in icf (angiosarcoma, acute lymphoblastic leukemia), and icf (hodgkin lymphoma), here we describe the diagnosis and management of an icf patient with neuroblastoma and neutropenia, which has not been previously described. objectives: describe a novel phenotype and mutation of icf and its management to further expand our understanding of this disease. results: a month ex- week premature male with bronchopulmonary disease and failure to thrive presented with acute respiratory failure in the setting of recent viral bronchiolitis with associated chronic diarrhea. he was subsequently diagnosed with multiple infections including pjp pneumonia, norovirus, parainfluenza, rhinovirus, and pseudemonal cellulitis. he presented with profound neutropenia and agammaglobulinemia with presence of b and t cells on lymphocyte phenotyping. ct revealed a paraspinal mass that was mibg-avid on further study, strongly suggesting neuroblastoma. bone marrow was normocellular and negative for malignancy, however revealed marked granulocytic hypoplasia and maturation arrest concerning for severe congenital or, less likely, immune-mediated neutropenia. metastatic workup was negative. whole exome sequencing revealed a homozygous variant of unknown significance (c. t>c) in the hells gene, portending a working diagnosis of icf syndrome. immunoglobulin supplementation, pentamidine prophylaxis, and g-csf were initiated. he was able discontinue g-csf after months of treatment. his neuroblastoma, initially categorized as l , met criteria for observation. however, followup mri revealed interval growth nearing the spinal canal. he underwent tumor resection, confirming mycn non-amplified, favorable histology neuroblastoma. after infectious prophylaxis and immunologic support were initiated, he incurred two other hospitalizations, the first for g-tube cellulitis and the second for parainfluenza respiratory illness. he now has stable neutrophil counts off g-csf and remains in remission from neuroblastoma. current plan is to proceed with bone marrow transplantation for immunodeficiency. conclusion: icf has not previously been described with neutropenia or neuroblastoma. this report not only describes a novel mutation and phenotype of icf and the management thereof, but also reveals the potential curative role of bone marrow transplantation in such disease. staten island university hospital -northwell health, staten island, new york, united states background: desmoid tumors are rare tumors that arise from highly differentiated fibroblasts. they occur in isolation or as part of the disease spectrum of familial adenomatous polyposis (fap) . fap mutations between codons - typically correlate with increased extraintestinal disease such as desmoid tumors and upper gastrointestinal polyps. we describe a patient with a large intra-abdominal desmoid tumor who is heterozygous for a c. c>t (p.arg cys) apc gene mutation. we are not aware of any other patients reported with this germline apc mutation presenting with a desmoid tumor. objectives: to discuss a novel apc mutation and the presentation of a rare case. design/method: review of clinical presentation, genetic analysis and management of a rare tumor. a -year-old female with no significant medical history presented with abdominal asymmetry and intermittent pain. she reported urinary urgency, shortness of breath, early satiety, decreased appetite and a -pound weight loss over the course of months. ct scan of the abdomen demonstrated a × cm abdominal tumor abutting the local organs but no presence of bowel obstruction. a biopsy revealed a spindle cell neoplasm favoring fibromatosis. there was no known family history of fap, colon cancer, or desmoid tumors. apc gene mutation analysis demonstrated a c. c>t (p.arg cys) heterozygous gene variant. due to size and location of the tumor, it was initially deemed unresectable. the patient was started on a course of monthly liposomal doxorubicin. she tolerated the initial cycles well and interval ct after cycles of chemotherapy revealed a % decrease in tumor volume. variability exists in phenotypic presentation with regards to the location of the afp mutation locus. while fap mutations associated with desmoid tumors typically have changes in the - codon region, our patient presented with a heterozygous mutation resulting in a missense mutation at codon . due to the change in polarity and size, the mutation is not considered to be of conservative nature. we are only aware of one other report of this mutation, which occurred in an individual with a personal and family history of colon cancer. we are not aware of any patients with desmoid tumors who also have this germline apc gene mutation. our case report highlights an apc gene mutation that is not well-described; we are not aware of any other cases of this mutation reported in patients with desmoid tumors. future evaluation and tracking of this mutation may lead to the determination of further clinical significance. background: over time, advanced care planning for location of death has been associated with increased deaths at home rather than in the hospital. in some cases, however, complex management and symptom control can prevent families from achieving their goal of keeping their child out of the hospital and at home at the end of life. ascites is a sequelae of many conditions including malignancy that might lead to significant morbidity. increasingly, interventional procedures are being utilized. peritoneovenous "denver" shunts are placed internally with one end in the peritoneal space and the other buried within a major vessel such as the svc. a one-way valve and pump buried under the skin allows the patient to pump fluid from the peritoneal to the vascular space. the shunt is used frequently in adults, but has not seen much use in pediatric oncology patients. objectives: to describe a case of a terminally ill patient with refractory wilms tumor with ivc involvement who received symptomatic relief with denver shunt placement. results: an -year-old female was diagnosed with relapsed, refractory, metastatic wilms tumor with pulmonary and hepatic involvement, with tumor extension to the hepatic veins and ivc. multiple chemotherapeutic regimens and palliative radiation to the ivc were administered, but her disease continued to progress, leading to pressure on the portal vein and portal hypertension. the resulting ascites was causing the patient significant pain and was difficult to manage. the patient's code status was changed to dnr/dni after discussion with her mother, who identified a desire to have the child die at home as comfortably as possible. a peritoneovenous shunt was placed in order to control the patient's pain and avoid frequent medical procedures and therapies. despite initial anxiety, the patient was able to utilize the pump and achieve significant improvement in her ascites and pain. she was able to spend the remaining six weeks of her life at home. ascites is a common phenomenon of end stage disease. peritoneovenous shunts are a treatment modality that may be considered to allow for pain control at the end of life for pediatric oncology patients with ascites. the procedure is relatively low risk, allows for self-control of the pump to maintain comfort, and is easy enough to use by the patient or family. background: extraneural metastases (enm) from pediatric glioblastoma multiforme (gbm) are rare, with an estimated frequency of . %. etiologic factors include multiple neurosurgical procedures and sarcomatous dedifferentiation. their occurrence can seriously affect the patient's quality of life and survival. while enms have been well documented in adults, pediatric cases have not been previously summarized. a year old male with a cerebral gbm developed extension of disease outside of the neuraxis approximately months post initial presentation and at the time of disease progression. metastases included exracranial temporal lesions, cervical and mediastinal lymph nodes and s of s bilateral lung nodules. a large pleural-based soft tissue metastatic focus was identified on imaging when the patient presented with respiratory distress secondary to a right tension pneumothorax, which was recognized and managed promptly. we summarize the main reported cases in literature to better define risk factors for and evaluate the proposed mechanisms underlying these systemic metastases. design/method: we performed a literature review on the pubmed database using the terms gbm and enm. patients under years of age who met the weiss criteria for the diagnosis of enm from primary cns tumors were included. results: our patient fulfilled two of the three weiss criteria with confirmed gbm at the primary site with all enm in the temporal soft tissue and cervical lymph nodes displaying histopathologic features similar to the primary cns tumor. the intrathoracic adenopathy and lung nodules detected upon chest imaging during workup for respiratory distress were assumed to represent additional metastatic foci. our literature review identified pediatric patients with enm from gbm with a median age of years (range . - years) and a slight female predominance ( % females vs. % males). the most common sites of metastases reported were pleura/lungs, bones, lymph nodes and liver. in of patients, metastases were associated with csf shunting. conclusion: pediatric oncologists should have an increased index of suspicion when caring for patients with gbm, particularly those who have undergone shunting procedures and present with systemic symptoms including bony pain, respiratory changes, transaminitis or cytopenias which should prompt timely investigation for enm. although enm of cns tumors carry very poor prognosis, their diagnosis has potential therapeutic importance because treatment of metastatic lesions may alleviate symptoms and improve the quality of life. additional studies may be warranted to evaluate the incidence of enm that can provide valuable insight into the pathogenesis and biology of high-grade gliomas. nicklaus children's hospital, miami, florida, united states background: sinusoidal obstruction syndrome (sos) has been reported in patients undergoing intensive chemotherapy and as a complication post-hematopoietic stem cell transplan-tation. sos may be complicated by portal hypertension, hepatorenal disease or multi-organ failure. however, despite treatment, there may be further potential complications that can be anticipated in patients with history sos. we report two patients with history of sos presented with post-procedural bleeding after gastric tube placement. we believe that their presentations may be associated to their previous diagnosis of sos. design/method: pubmed search was done with search for terminology including "sinusoidal obstruction syndrome" "defibrotide", and "bleeding". papers relevant to our cases were selected for literature review. results: case : a year-old female with history of desmosplastic medulloblastoma status-post resection and intensive chemotherapy was diagnosed with sos one month after her second part of planned tandem transplant. she was managed with paracentesis and defibrotide. due to malnourishment, patient had a gastric tube placement months after she completed therapy and had an episode of upper gastrointestinal bleeding postoperatively from the g tube site. case : similarly, a year-old male diagnosed with anaplastic medulloblastoma status post resection and adjuvant multiagent chemotherapy. his treatment course was complicated with sos after the second cycle of induction chemotherapy which responded to -day course of defibrotide. likewise, the patient had a major bleeding event from the g-tube site approximately two months after sos diagnosis. defibrotide was discontinued in both cases before g-tube placement. both patients had no previous history of bleeding disorders or relevant family history. in addition, comprehensive laboratory evaluations were within normal limits before both procedures. in sos, there is blockage of fluid out of the liver that leads to congestion, ascites, ischemia of the liver, and post-sinusoidal portal hypertension. two related causes of sos should be considered as an explanation for g-tube bleeding. similar patients should have close monitoring postoperatively or if possible surgical intervention should be delayed until the sos process has been evolved. nicklaus children's hospital, miami, florida, united states background: the development of treatment related acute myeloid leukemia (t-aml) and myelodysplastic syndromes (t-mds) is a potential complication after cytotoxic chemotherapy or radiation therapy. the incidence of development of t-aml/t-mds varies from - % depending on the treatment regimen used. cutaneous myeloid sarcoma (ms) is a common presentation of extramedullary leukemia and usually occurs in the setting of aml. we report a rare case of cutaneous ms in an adolescent female after successful treatment for ovarian yolk sac tumor (yst) stage i with bep (bleomycin, etoposide and cisplatin) therapy. the ms was managed only with biopsy and close observation. design/method: a pubmed search was conducted for queries including t-aml/t-mds, cytotoxic agents, cutaneous myeloid sarcoma, regression. relevant papers were selected for literature review. a year-old female was diagnosed with a left ovarian yolk sac tumor, for which she underwent left salpingooophorectomy and successfully completed cycles of bep over months. during routine follow-up months after initiation of treatment for ovarian yst, she was noted to have a small, non-tender, indurated nodule on the left side of her upper back approximately cm in diameter. punch biopsy of the skin nodule was performed and pathology was positive for cutaneous myeloid sarcoma. at the time of next follow-up less than one month later, the skin lesion had resolved. two subsequent bone marrow aspirates were performed one month apart and were negative for leukemic involvement or mds. examinations and work-up including whole body pet with ct scan were negative for evidence of disease. although cutaneous ms can be regarded as the herald of systemic myeloid disease rather than a localized process, our patient was monitored periodically with physical exam and laboratory evaluations. she remains free of disease more than four years after the presentation of cutaneous ms without any further treatment. spontaneous regression ms has been previously reported. the authors would like to stress that a conservative approach with close observation could be an option in cutaneous ms even with history of chemotherapy exposure. nesreen ali, iman sidhom, sonia soliman, sherine salem national cancer institute, cairouniversity, egypt children cancer hospital egypt, egypt background: acute leukemia is the commonest malignancy in childhood. the coincidental occurrence of leukemia with hemophilia is extremely rare. hemophilia is a congenital rare x linked bleeding disorder. the main complication of the two diseases is bleeding diathesis which may be lifethreatening due to many factors, deficiency of coagulation factors in hemophilic patients, thrombocytopenia from disease and chemotherapy in leukemic patients, certain cytotoxic drugs such as asparaginase which may result in coagulation disorders and infection which may lead to disseminated intravascular coagulation. objectives: reporting such a case is imperative to set up treatment guidelines for prevention of bleeding and to optimize the therapeutic approach for these patients. design/method: seventeen years old boy, presented to children cancer hospital egypt in june with pallor and multiple ecchymoses.he was diagnosed with precursor b acute lymphoblastic leukemia, cerebrospinal fluid (csf) was free, the chromosomal analysis revealed hypodiploidy , xy. he had moderate type of hemophilia a since birth, factor viii level was . % at time of diagnosis, coagulation profile revealed prolonged partial thromboplastin time (normal - ), factor viii was low %, prothrombin concentration and prothrombin time were normal % and seconds, virology screening for hepatitis b core igg/igm, hbs ag, hiv and hc igg /igm were negative.the patient started induction total xv sjcrh protocol, factor viii unit/kg was given at presentation before doing bone marrow aspiration(bma), csf and as a prophylactic before intramuscular asparaginase injection, intrathecal and bma. it was given immediately within hours before the procedures and platelets transfusion was given regularly to maintain platelets count about , . the minimal residual disease by flow cytometry was . % and . % at d and d induction. results: our patient received his induction and reintensification chemotherapy without any major bleeding event which reveals the success of our guidelines for the prevention of bleeding. he developed very early relapse at w maintenance by the same clone. he received salvage chemotherapy but didn't achieve remission and died out of disease and resistant clone. the development of leukemia on top of hemophilia is a major problem. bleeding complication during chemotherapy can be prevented by regular prophylactic factor viii and platelets concentrate transfusion with good supportive care. life threating bleeding complication may be correlated with the severity of hemophilia. we need to collect data about the biology of leukemic cells, complications, and cause of death to optimize care for these patients. background: mucoepidermoid carcinoma (mec) is a rare malignancy that arises from exocrine glands in the upper aerodigestive tract and tracheobronchial tree. conventionally, mec diagnosis is based on histology, with prognosis based on the extent of resection and detection of metastases. mec is characterized by a translocation of chromosomes q and p resulting in a fusion between the mect and maml genes, that occurs in - % of cases. this fusion transcript has been recognized to have a favorable impact on disease features and prognosis of mec. however, recent studies indicate that high grade mec can have mect -maml fusion positivity and multiple other genomic imbalances that have not been studied in much detail. owing to the rarity of mec tumors, more definitive data related to the clinical and prognostic significance of these molecular markers are limited. objectives: . identify the presence or absence of mect -maml fusion in the tissue of our patient. . analyze the incidence of the fusion in mec cases in children and young adults retrieved from the iowa cancer registry. . determine if fusion status correlates with clinical, pathological and outcome data in our cohort. design/method: we describe the case of a year-old caucasian male who presented with recurrent pneumonia, persistent cough and radiographic evidence of right lobar collapse. bronchoscopy revealed an endobronchial lesion and the patient underwent right upper lobe sleeve resection. pathology report was consistent with low grade muco-epidermoid carcinoma. we retrieved archived formalin-fixed paraffinembedded (ffpe) specimens of pediatric and young adult mec cases (ages - ) reported in iowa from - using the iowa cancer registry. testing for the mect -maml fusion in the index case and ffpe specimens will be done using a custom-designed laboratory validated next generation sequencing (ngs) assay with the ability to detect novel fusion partners. clinical, pathological and outcome data (age, sex, tumor site, tumor size, nodal metastases, clinical stage, histologic grade, treatment and follow up) will be analyzed to correlate with fusion status. the mect -maml fusion tested positive in our index patient. we will obtain irb approval to test for the fusion in the archived ffpe specimens and correlate clinical, pathological and outcome data. conclusion: mect -maml fusion is a frequent event in mec that has prognostic and potential therapeutic applications in adults. the results of this study may enlighten the clinical management of mec in children and young adults. children 's mercy hospital, kansas city, missouri, united states background: mutations in the samd gene are associated with a rare syndrome comprising of myelodysplasia, infection, restriction of growth, adrenal hypoplasia, genital phenotypes and enteropathy (mirage syndrome). diagnosis is made through exome sequencing. in the largest reported case series, of eleven patients diagnosed with mirage syndrome, two developed loss of chromosome . given the potent growth restricting activity of samd mutants, the loss of chromosome is considered the first documentation of adaptation by aneuploidy mechanisms in humans and led to myelodysplastic syndrome (mds), with deaths occurring from related complications at and years of age. objectives: to report a case of mirage syndrome with congenital thrombocytopenia progressing to bone marrow failure, managed uniquely with bone marrow transplantation. results: male born at weeks gestation with prenatal diagnosis of iugr, two vessel cord, oligohydramnios was found to have ambiguous genitalia, adrenal insufficiency, partial panhypopituitarism and congenital thrombocytopenia with bone marrow showing absence of megakaryocytic precursors. severe thrombocytopenia was present from birth. bone marrow evaluation demonstrated a hypocellular marrow with markedly reduced megakaryocytic and myeloid precursors and no evidence of myelodysplasia. he required gastric tube placement for failure to thrive, had a laryngeal cleft repaired and developed focal segmental glomerulosclerosis. mpl gene testing for congenital amegakaryocytic thrombocytopenia was negative. testing for fanconi anemia, shwachman-diamond syndrome and dyskeratosis congenita was also negative. approximately % of cells had loss of heterozygosity on chromosome q. exome sequencing showed that he is heterozygous for a de novo gain of function variant, c. g>a (p.arg gln), identified in the samd gene, confirmed by sanger sequencing and consistent with a diagnosis of mirage syndrome. at years of age, he developed pancytopenia requiring frequent transfusions with platelets and packed red blood cells. he underwent a successful bone marrow transplant at years of age without significant complications, and remains transfusion independent without cytopenias greater than months from bone marrow transplantation. conclusion: it is imperative to pursue work up for persistent congenital thrombocytopenia in a stepwise multidisciplinary manner. to the best of our knowledge, this is the first case of mirage syndrome associated bone marrow failure treated with bone marrow transplant. due to the individual rarity of mirage syndrome and pediatric myelodysplastic syndrome, it is important to maintain an index of suspicion given their association and explore bone marrow transplant as a therapeutic option. results: the patient demonstrated disease regression, initially, and continued without disease progression for months. the regimen has been well tolerated with only minimal side effects of dry skin (ctcae grade ) and a transient episode of brief erythrodysesthesia (ctacae grade ) that resolved spontaneously. the combination of sorafenib and capecitabine was effective and well tolerated in this adolescent patient with fl-hcc. our observations, although in a single patient, lend support for further testing of this novel oral chemotherapy regimen in patients with fl-hcc, a disease for which there is no effective standard chemotherapy approach. background: epstein-barr virus (ebv) is a ubiquitous virus associated with a broad range of malignancies due to its oncogenic potential. history of organ or bone marrow transplantation, immunosuppressive therapy, and primary or acquired immunodeficiency syndromes increases the risk of ebvassociated tumors. epstein-barr virus associated smooth muscle tumors (ebv-smt) are unique and rare neoplasms typically discovered in immunocompromised patients. most information related to pathogenesis and therapeutic options is limited to case reports and case series of adult patients. there are several gene expression pathways that ebv utilizes, the most notable of which is the mammalian target of rapamycin (mtor) pathway. the mtor pathway performs a key role through integrating various cell growth signals and factors to regulate protein synthesis and metabolism related to smooth muscle proliferation. sirolimus is an immune modulating therapy that targets the mtor pathway to block activation of lymphocytes. objectives: several case reports have demonstrated shortterm clinical remission of ebv-smt in adult patients with the use of sirolimus. we report the first case of long-term background: bilateral neuroblastoma is characterized as neuroblastoma arising in both adrenal glands, a rare presentation with little data on its genetic make-up. a two-monthold patient was diagnosed with bilateral neuroblastoma in our clinic. her risk assignment was based on biopsy of the left adrenal lesion, which showed mycn amplification, an unfavorable genetic marker. treatment regimen was intensified accordingly and after courses of chemotherapy tumors were excised. patient went on to receive a stem cell transplant and immunotherapy. with no knowledge of genetic similarity between the two tumors it is unclear whether biopsy of the right lesion would have yielded similar results or whether bilateral biopsies are needed for risk assessment of bilateral neuroblastoma. objectives: utilize whole exome sequencing (wes) to characterize the genomic signature of bilateral adrenal neuroblastomas excised following chemotherapy treatment. design/method: paraffin-embedded samples from left (l) and right (r) tumors underwent wes at the broad institute. we analyzed resulting data including somatic variant calls, indel mutations, and copy number variants (cnvs) using ingenuity software to evaluate and compare differences between the two tumor samples. preliminary analysis of the data shows important descriptive information on the two tumor samples. out of somatic mutations in the r tumor cells and mutations in the l tumor cells, only two common somatic mutations were present. out of cnv calls in the r tumor and in the l tumor, cnvs were common between the two tumors, or % of each tumor's cnv calls. there was a fold higher frequency in gains versus losses. the median size of the common cnvs was , (range to , , bp). cancerrelated genes with increased copy numbers included transcription factors, receptors for signal transduction pathways, and histone methylation proteins. conclusion: preliminary analysis of the wes results of the two adrenal tumors show some genomic divergence. because the tumor tissue was exposed to chemotherapy prior to excision it is difficult to determine whether genomic divergence is a result of independently originated tumors or subsequent adaptation to chemotherapy of a clonal cell population. the high number of common cnvs in the two tumors points to a common cell of origin, however the low number of common somatic mutations does not fit that picture. a future study to help elucidate the question will be wes of the original biopsy tissue to provide information on tumor mutations prior to the effects of chemotherapy. baylor college of medicine, houston, texas, united states background: although there has been significant improvement in the overall survival rates of children with cancer many children will still die from their illness or complications secondary to treatment. research surrounding the deaths of children who succumb to their disease is warranted to ensure we are providing the best care possible for these patients. objectives: this case series aims to explore pediatric cancer deaths by focusing on perhaps the most extreme cases of high intensity end of life care. we explore those patients whom we know are dying or our very likely to die as evidence by their do not resuscitate (dnr) orders. in all of these cases despite the patients very grim prognosis, their great likelihood of death and limitations placed of resuscitation methods all patients continued end of life care in the pediatric intensive care unit (picu). the primary medical records of all children with a cancer diagnosis who died between february , and january , in the picu with a dnr order seven days or earlier prior to death. each medical history included disease-directed treatment history and response with particular attention to the events surrounding the terminal admission. results: eight patients met criteria for this study representing . % of all cancer patients who died during this time period and . % of those who died in the icu. the average time between dnr and death is . days ( days - days). the average length of terminal admission was . days ( day - days). the average time between diagnosis and dnr is . months ( months - months). the average time between diagnosis and death is . months ( months - months). conclusion: these cases highlight the journey that patients, families and providers endure leading up to death. medical care is complex, there are very few absolutes that are encountered when caring for patients and decisions around limiting or withdrawing medical care are made in a context of the prior journey. . these cases help to understand the complexity of death and how two seemingly opposite ideals can be congruent in the event of an anticipated death. most of these cases show the need for improved anticipatory guidance surrounding death and greater consideration for de-escalation of care when death is expected. the hospital for sick children, toronto, ontario, canada background: rhabdomyosarcoma (rms) is the most common soft tissue sarcoma in children, with embryonal (erms) and alveolar (arms) representing the most common subtypes. arms tumors are associated with inferior outcome when compared to erms, and they are characterized in about % of the cases by a t ( ; ) or t( ; ) chromosomal translocation with creation of a pax -foxo or pax -foxo fusion gene, respectively. it is increasingly clear that the pax-foxo fusion status is an important poor prognostic factor, thus the histological classification tends to be replaced by the fusion status, particularly in terms of risk stratifica-tion in contrast to arms, there are no recurrent chromosome alterations in erms; however, there are multiple numerical chromosome changes that are frequent in these tumours: gain of chromosome , , and have been found in to % of emrs karyotypes. moreover, erms tumors show frequently allelic loss, the .p . chromosomal region being the most frequently involved. recently, novel gene fusions have been described also in erms tumours. these fusions involved mainly the ncoa and or the vggl genes. the rearrangement partners are variable, and include, i.e. pax ( q ), srf ( q ) and tead ( p ). objectives: to present a patient who died as a consequence of brain metastases while on therapy in the setting of an foxo negative rms and the identification of a new translocation t( ; )(q ;q ). design/method: case report and retrospective review of the literature. we report a case of pelvic embryonal rhabdomyosarcoma in a -month old boy. he was treated as per cog arst intermediate risk group, but unfortunately was found to have a large cerebellar tumour during the course of his chemotherapy treatment and he subsequently passed away. a novel translocation between chromosomes and was observed in of metaphase cells by g-band analysis in the autopsy sample of the brain lesion. breakpoints of the translocation were estimated to be at q and q . there were no additional clonal chromosome abnormalities in the tumour cells. conclusion: erms tumors with fusion genes involved have been exclusively described in patients less than months of age; they seem to be associated with spindle cell histology and, a favorable outcome. in our patient, a novel ( ; ) translocation was found and clinically, the patient had a dismal outcome. further studies are indicated to inquire whether this finding is of significance in term of prognosis for these patients. children 's national medical center, washington, district of columbia, united states background: iatrogenic immunodeficiency-associated lymphoproliferative disorders (lpds) are a group of lymphoid s of s proliferations or lymphomas that are well known to be associated with an immunosuppressed state. these disorders most commonly occur following hematopoietic or solid organ transplantation (called post-transplant lymphoproliferative disorders or ptld), but cases have also been described during the treatment of autoimmune and rheumatologic disorders by immunosuppressive and immunomodulatory medications. these disorders are strongly associated with infection by the epstein-barr virus (ebv) as a result of impaired immune function in the immunosuppressed state. while this phenomenon has been well documented in autoimmune conditions, cases affecting pediatric patients while on antileukemia chemotherapy are lacking. background: atypical teratoid/rhabdoid tumor (at/rt) of the central nervous system (cns) in children younger than years old has a prevalence of % to % and accounts for . % of all pediatric cns tumors. only - % of patients have leptomeningeal dissemination. rhabdomyosarcoma is the most common soft tissue tumor in childhood, but represent only - % of all pediatric cancers. rarely, it can metastasize or even directly extend into the cns, but typically, cases of cns involvement arise either from parameningeal areas or other primary sites. primary spinal or meningeal rhabdomyosarcoma is extremely rare. objectives: our objective is to describe two unique cns malignancies presenting as rare, primary leptomeningeal disease. design/method: case a -month-old female presented with vomiting, fatigue and listlessness, despite a normal head ct and brain mri. csf showed hypoglycorrhachia and mild pleocytosis. ceftriaxone was started, but she developed nuchal rigidity and cranial nerve vii palsy. repeat brain mri showed evolving leptomeningeal enhancement concerning for meningitis. she gradually developed worsening opisthotonus and ultimately a brain biopsy of the temporal lobe was consistent with at/rt. case a -year-old male presented with new generalized tonic-clonic seizure activity and intermittent headaches with photophobia, phonophobia, and vomiting. brain mri was significant for enhancement of interpenducular and suprasellar cisterns extending to the optic nerves and chiasm most consistent with meningitis. neurosurgery ultimately placed a lumbar drain for hydrocephalus, and a tissue biopsy demonstrated primary meningeal rhabdomyosacroma. results: in case , our patient's temporal lobe biopsy demonstrated grade iv malignant tumor cells consistent with atypical teratoid/rhabdoid tumor. fish demonstrated a homozygous deletion of smarcb ( q . ). she was started on chemotherapy per the dana farber at/rt protocol but ultimately was discharged home on hospice. in case , our patient's lumbar arachnoid biopsy demonstrated cellular tumor consistent with group iiia embryonal rhabdomyosarcoma. immunostaining was positive for cd , desmin, myogenin, and myo-d with neural markers ema and gfap highlighting the meninges but without a neural component to the tumor. he completed craniospinal radiation to gy total with lumbar boost to . gy total. he is currently receiving chemotherapy per arst protocol. conclusion: these two cases are particularly instructive because of their similar initial presentations and neuroimaging, but with very different and unique diagnoses. university of iowa, iowa city, iowa, united states background: ebf -pdgfrb fusion causes ph-like b-cell acute lymphoblastic leukemia (b-all), which has a philadelphia positive phenotype without the bcr-abl translocation. this is one of several mutations associated with ph-like b-all and leads to downstream overexpression of tyrosine kinase. ebf -pdgfrb fusion accounts for about % of children with ph-like b-all. patients with ph-like b-all previously had poorer outcomes with conventional chemotherapy. the addition of tyrosine kinase inhibitors (tki), like imatinib, has improved the outcome for many patients predicted to have tki sensitive mutations. objectives: to review clinical characteristics and outcomes of two cases of ph-like b-all at the university of iowa stead family children's hospital and to compare these outcomes to similar cases reported in the literature. design/method: a retrospective chart review was performed for two cases of ph-like b-all diagnosed and treated at the university of iowa stead family children's hospital. results: both patients were males diagnosed at years of age with high wbc count ( , and , ) and positive for ebf -pdgfrb gene fusion. patient (pt ) was cns b at presentation while patient (pt ) was cns negative; neither had testicular involvement. both started treatment according to cog protocol aall . peripheral blasts cleared by induction day for pt and induction day for pt . at end of induction, pt had m bone marrow and pt had m bone marrow but mrd %. dasatinib was started induction day for pt and induction day for pt . pt was still not in remission at end of consolidation; bone marrow cell culture for tki resistance showed best response to dasatinib. pt proceeded to anti-cd car t-cell therapy followed by tbi-based matched unrelated donor bone marrow transplant. pt had negative mrd at the end of consolidation and continues chemotherapy according to aall , dasatinib arm. both patients are currently clinically well. our patients had the same tyrosine kinase gene fusion and similar initial clinical courses. while both patients had persistent disease at end of induction, pt had almost % blasts while pt had significant reduction of disease burden before starting tki. pt showed good response with the addition of dasatinib while pt did not. these findings suggest that response to conventional chemotherapy may potentiate the effect of tki and may predict overall outcome. there are likely additional factors which must be taken into account when determining response to tki for patients with ph-like b-all which have not yet been identified. background: medulloblastoma is the most common malignant brain tumor of childhood. classically, medulloblastoma presents as a well-defined mass lesion in the cerebellum, with a high rate of metastatic dissemination. primary leptomeningeal medulloblastoma (plmb) is an exceedingly rare type of medulloblastoma presentation with a dismal prognosis in which patients present with isolated leptomeningeal disease without an associated mass. to our knowledge, only three pediatric and three adult cases of plmb (ages - years) have been reported, all of which died within months of diagnosis. this is the first case of plmb to report a molecular classification. objectives: to report the case of a pediatric patient with plmb in which histopathologic and molecular characterization was performed and to describe the patient's treatment and clinical course. design/method: retrospective review of the patient's electronic medical record and review of the literature. a -year-old boy presented with headache, vomiting, diplopia, and fatigue. physical examination revealed upward gaze palsy, left-sided extremity and facial weakness, and ataxia. magnetic resonance imaging (mri) of the brain revealed diffuse cerebellar leptomeningeal enhancement and edema without an identifiable mass and moderate hydrocephalus. mri of the spine and cerebral spinal fluid analysis were normal. a diagnosis of cerebellitis was rendered, and the patient underwent placement of a ventriculoperitoneal shunt. an extensive infectious, neurologic, rheumatologic, and oncologic workup did not identify an etiology. empiric antibiotics, high-dose steroids, and intravenous immunoglobulin therapy yielded minimal improvement. two months later, repeat mri of the brain performed for declining mental status demonstrated progressive thickening of cerebellar leptomeningeal disease. a suboccipital craniectomy with decompression and cerebellar biopsy were performed. pathologic examination revealed a diagnosis of plmb, classic histology, non-wnt/non-shh, without gain/amplification of myc/mycn, and p wild type pattern. craniospinal radiation to cgy with a cgy boost to the posterior fossa was delivered with concurrent carboplatin/vincristine over six weeks. two months following chemoradiation, mri of s of s the brain demonstrates significantly reduced pathological leptomeningeal enhancement of the cerebellum, and the patient is awaiting initiation of systemic chemotherapy while recovering from a surgical wound infection. conclusion: plmb is extremely rare but should be considered in patients with cerebellitis and diffuse leptomeningeal involvement who are refractory to medical management or in whom an etiology has not been identified. cerebellar biopsy is recommended early to enable timely treatment and improved outcomes. molecular classification should be performed in cases of plmb to further characterize this disease, inform treatment decisions, and improve clinical outcomes. background: primary intracerebral osteosarcoma is extremely rare and limited to case reports. ptpn gain of function is associated with noonan syndrome, which has increased risk of multiple cancer types including brain tumors, but osteosarcoma has never been described. ptpn mutations have been reported in many cancers as both oncogenes and tumor suppressors, however no ptpn mutations have been described in osteosarcoma. pdgfr-a is a growth factor receptor whose activation is implicated in several malignancies. pdgfr-a and ptpn concurrent mutations are described in glioblastoma. there is no known link between holoprosencephaly, noonan syndrome, and osteosarcoma. we report a case of multifocal intracerebral osteosarcoma in a child with lobar holoprosencephaly and chronic subdural hemorrhage and discuss the genetic changes found in the tumor. design/method: a seven-year-old caucasian female, with a known diagnosis of lobar holoprosencephaly, chronic subdural hemorrhage and well controlled seizure disorder presented with status epilepticus shortly after completing antibiotic therapy for infection of subdural hematoma. mri showed diffuse dural thickening with mass lesions in the frontal lobe, temporal lobe, and the parasagittal region, the largest of which was contiguous with the subdural space but none of the lesions were associated with bone on mri or by direct neurosurgical visualization. tissue obtained for concern for recurrent infec-tion resulted in a diagnosis of high grade osteosarcoma. dna analysis was performed to help guide treatment choice. results: standard metastatic work-up was negative for skeletal primary tumor or metastatic lesions outside of the brain. she was treated with high dose methotrexate for two cycles per modified aost . despite maximal supportive care, she quickly developed rapid tumor growth as well as intratumoral hemorrhage with resultant herniation and death from respiratory failure just three months after diagnosis. tumor gene sequencing discovered three mutations with described roles in cancer: pdgfra d >vr, kdm a loss of exons - , and ptpn a v. conclusion: to our knowledge, primary multifocal extraosseus intracerebral osteosarcoma has not been previously described. despite known cns penetration of high dose methotrexate, this tumor proved resistant and aggressive. holoprosencephaly is associated with a multitude of known genetic drivers, but none are found in this case. furthermore, the genetic changes in this tumor are not typical for osteosarcoma. pdgfr-a over-expression is described in osteosarcoma, but is not clearly correlated with worse overall survival. further research is required to determine the role of ptpn in osteosarcoma. background: anaplastic lymphoma kinase (alk) encodes a receptor tyrosine kinase whose activation induces pathways associated with cell proliferation, angiogenesis, and cell survival. alk rearrangements are rare in neuroblastoma, while alk mutations and gene amplification occur more frequently. alk mutations have been found to be associated with increased alk protein expression that is associated with a worse prognosis. alk is commonly mutated in neuroblastoma at three hotspots (f , r , and f ). the eml -alk rearrangement has mostly been associated with lung adenocarcinomas, with only a few cases of non-lung cancers found. it has never been reported in neuroblastoma. multimodal therapy and to report the successful management of treatment related iron overload. results: a -year old male presented with abdominal swelling and ct showed a right kidney mass and bilateral lung nodules. he underwent right radical nephrectomy with lymph node sampling. pathology was reviewed centrally and revealed wilms tumor with diffuse anaplasia with rhabdomyosarcoma arising within the stromal component and of nodes positive. he received adjuvant intensive chemotherapy and radiation to the hemiabdomen and whole lungs. the -week chemotherapy regimen was vincristine, doxorubicin, cyclophosphamide (per cog arst ) alternating with carboplatin and etoposide (per cog aren revised uh- ). treatment was complicated by multiple episodes of fever and neutropenia and anorexia requiring g-tube placement. post-therapy, he had persistent neutropenia and thrombocytopenia without related complications. every months for evaluations he underwent a bone marrow which revealed normocellular marrow with maturing trilineage hematopoiesis. evaluation for a bone marrow failure syndrome was unrevealing. starting at months into therapy and all posttherapy imaging showed splenomegaly. he received units of packed red blood cells through the duration of therapy. he was diagnosed with iron overload based on serum ferritin and imaging, including t *mri. he received therapeutic phlebotomy for years with normalization of serum iron studies, t * of the heart, and liver iron concentration. he is more than years from completing therapy with no evidence of recurrent disease. asymptomatic cytopenias persist and he has no evidence of iron overload. conclusion: though a rare development, clonal sarcomatous transformation can occur in wilms tumor. our patient's tumor was successfully treated with intensive multimodal therapy targeting the diffusely anaplastic wilms and the rhabdomyosarcomatous component. treatment-related iron overload in a pediatric patient with a solid tumor was successfully treated with phlebotomy. consideration should be given to screen patients with solid tumors who receive multiple packed red cell transfusions for iron overload at the completion of cancer therapy. primary children's hospital, university of utah, salt lake city, utah, united states background: malignant solid tumors are less frequently encountered in infants. primitive myxoid mesenchymal tumors of infancy (pmmti) are a myofibroblastic malignancy and cases are rarely reported in the literature. cure is achieved in the majority of cases with surgical resection, however treatment for unresectable cases remains an enigma. recently published literature postulates that the newly discovered bcor duplication found in pmmti is tumorigenic via an epigenetic pathway. this molecular signature resembles that of clear cell sarcoma of the kidney (ccsk) and the growing number of bcor mutated sarcomas. a similar chemotherapeutic backbone and local control used for ccsk, has been proposed for the unresectable subset of pmmti. utilizing this approach a month-old with relapsed disease has remained disease free for months. however, given the rarity of this disease and the lack of published literature, there is no known standard of care treatment for unresectable and/or recurrent ppmti. we report a case of unresectable recurrent pmmti, a rare infant tumor, with less than cases reported. design/method: medical record, radiological studies, pathology and literature was reviewed. results: our patient is a now month-old female who presented with constipation and lower extremity weakness in the first weeks of life. an mri demonstrated a large lumbar epidural mass with spinal cord impingement. given prolonged (> days) neurological symptoms and location, emergent chemotherapy was initiated. biopsy showed a bcor positive, primitive myxoid mesenchymal tumor of infancy (pmmti). she was treated with ifosfamide, carboplatin and etoposide, and demonstrated clinical and radiographic response. we gave two additional cycles of cyclophosphamide, carboplatin and etoposide until surgical resection was feasible followed by two post-surgical cycles of chemotherapy. unfortunately, four month post-therapy mri demonstrated two new lesions; an unresectable paraspinal soft tissue mass and a left iliopsoas groove mass. given bcor association and reported successful therapy with vincristine, doxorubicin, cyclophosphamide alternating with ifosfamide and etoposide, we elected to incorporate vinca-alkaloid and anthracycline into her regimen. she is being treated with vdc/ie with plan for radiation consolidation. conclusion: pmmti is a locally aggressive tumor, for which surgical resection is curative. for those not amendable to resection, best care practices are still being determined. we report a case of pmmti initially responsive to chemotherapy, but not curative. this is the second case to conclusively demonstrate chemo-responsiveness. bcor mutation seems to be a common feature of this cancer; its role in the pathogenesis and as a target is an area of investigation. medical college of wisconsin, milwaukee, wisconsin, united states background: atypical teratoid/rhabdoid tumors (atrt) are central nervous system (cns) tumors that most commonly occur in very young children. there is no widely accepted standard of care for atrt patients, and while survival rates are improving they are historically poor. patients with metastatic disease to the spine at diagnosis have a worse prognosis, and for patients > years old, the presence of metastatic disease often results in the use of craniospinal radiation. the importance of correctly identifying metastatic disease at diagnosis aids in decision making and can have both prognostic and therapeutic implications. mr imaging at diagnosis is used to identify metastatic disease; however, here we present a case of diffuse leptomeningeal enhancement that spontaneously resolved after resection of a primary supratentorial atrt. objectives: to describe the resolution of diffuse leptomeningeal enhancement after resection of a primary atrt tumor in a -month-old prior to any adjuvant therapy. results: a -month-old male presented with a month history of vomiting and weight loss, regression of gross motor developmental milestones, and left hemiparesis. a brain mri demonstrated a × . × . cm solid and cystic right atrial mass with diffusion restriction and post-contrast enhancement. smooth diffuse enhancement was noted along the surface of the brainstem and within the interpeduncular fossa. a spine mri demonstrated diffuse circumferential post-contrast enhancement along the surface of the entire spinal cord. the patient underwent a successful near total surgical resection of the primary mass. pathology confirmed the loss of ini- staining in tumor cells, consistent with a diagnosis of atrt. no immediate adjuvant radiation or chemotherapy was given. repeat imaging was completed days after resection. brain mr demonstrated expected post-operative changes within the surgical cavity without definitive residual mass or leptomeningeal enhancement. spine mr demonstrated complete resolution of the previously seen circumferential enhance-ment along the entire spinal cord. csf evaluation at that time was negative for tumor cells. after recovery from surgery, chemotherapy treatment was initiated. conclusion: leptomeningeal enhancement at the time of diagnosis of atrt has historically been considered clear evidence of metastatic disease. this case raises questions about the previously accepted etiology of these imaging changes and suggests that widespread leptomeningeal enhancement should be carefully interpreted in future patients with similar imaging findings. in this setting, clinicians should consider repeat imaging following primary surgical resection in order to provide appropriate prognostic information and inform therapeutic decisions. poster # primary ewings sarcoma of cervical cord mimicking cauda equina syndrome sucharita bhaumik, joshua chan nyu winthrop hospital, mineola, new york, united states background: ewing's sarcoma (es) is a malignant primary bone tumor usually involving long bones. primary es of spine is quite uncommon ( . %) and its location in the cervical spine is even more rare. cauda equina syndrome (ces) is symptoms due to damage to the bundle of nerves below the end of the spinal cord known as the cauda equina (low back pain, radiating shooting pain down the legs, paraplegia, and loss of bowel or bladder control). it often occurs with lesions of lumbosacral spine. treatment with high-dose steroids may provide pain relief and improved neurologic function (by reducing edema) while awaiting diagnostic studies objectives: to demonstrate an unusual clinical presentation and emergent management of cervical es presenting with ces like symptoms. : year old male presented with a left sided posterior neck mass. soon after, he developed weakness of left arm, urinary and stool retention and inability to walk or bear weight in both legs. on physical exam a left tempero-occipital × cm fixed, non-tender, non-fluctuant mass was noted as well as motor and sensory impairment of left upper extremity, bilateral spastic paraplegia and loss of sphincter control. mri cervical spine showed a left cervical tumor with moth eaten appearance involving the vertebral bodies of c -c , adjacent muscles, displacing vital structures of the neck and compressing the cervical spinal cord. the thoracic and lumbosacral spine had no disease involvement. due to rapidly worsening spinal cord compression he was emergently treated with high dose steroids. he gained back all function in his extremities and regained bowel and bladder control. this eliminated need for urgent neurosurgical intervention. results: biopsy of the neck mass showed small blue round cells consistent with es with ewsr gene rearrangement. staging work up revealed no additional metastatic involvement. he then initiated treatment for localized es with systemic chemotherapy and radiotherapy and has had excellent response to treatment so far. conclusion: this is the first known case of non metastatic primary cervical es mimicking ces where an acutely enlarging mass presented with rapidly progressive neurologic deficits due to compression of anterior spinothalamic tract. in these unusual presentations of ces without lumbodorsal involvement it is important to consider cervical lesions. early rapid steroid initiation should be considered while awaiting biopsy results to prevent worsening cord compression followed by es focused treatments. this increases the chance of a successful outcome. the initial improvement with steroids may confuse the tumor with being a lymphoma children 's mercy hospital, kansas city, missouri, united states background: von willebrand disease (vwd) is a relatively common bleeding disorder with a high degree of genotypic and phenotypic variation. bleeding is usually mucocutaneous but can be severe and include muscle and joint bleeds especially in type vwd patients. most common bleeding management consists of desmopressin, anti-fibrinolytics, and/or plasma-derived antihemophilic factor/von willebrand factor (ahf/vwf) complex. a recombinant vwf has become available in the last few years. anaphylaxis and inhibitor development in vwd are rare. objectives: to describe the rare clinical manifestation of anaphylaxis to factor concentrate in a patient with severe type vwd. results: a -year-old female with severe type vwd [baseline vwag %, activity < %, factor viii (fviii) %] originally presented with heavy menstrual bleeding (hmb) leading to anemia requiring blood transfusion. she underwent placement of a levonorgestrel-releasing intrauterine device (lngiud) and began norethindrone. her hmb continued despite the lngiud and an increase in norethindrone dosing. plasma derived ahf/vwf complex was administered, which she had previously received. following the infusion, the patient developed anaphylaxis with hives, wheezing, tachycardia, and itching requiring doses of diphenhydramine and dose of hydrocortisone with resolution of symptoms. subsequently, she received recombinant vwf without incident. however, due to her low fviii level, she also required treatment with a full length recombinant fviii product. she again developed hives and itching after this infusion. she has since received recombinant vwf with recombinant fviii/fc fusion protein without further allergic reaction. there was no evidence of an inhibitor with her most recent post-infusion vwf level was %, factor viii %. conclusion: anaphylaxis to plasma derived factor products has been documented far less frequently within the vwd population compared to those with hemophilia and is typically seen in those with large gene deletions, usually with type disease. therefore, similar type vwd patients with severe disease may benefit from gene sequencing. it is unclear in this patient's case to which aspect of her treatment she is allergic, as she reacted to plasma-derived ahf/vwf and full length recombinant fviii, but not recombinant vwf or recombinant fviii/fc fusion protein. we hypothesize that she may be allergic to an epitope in the fviii b domain, or that the presence of fc fusion may have had a protective effect. further investigation including genetic analysis is planned. nodules. biopsies were consistent with neuroendocrine carcinoma, large cell type (g ). next generation sequencing revealed a khdrbs -braf fusion. he received conventional cytotoxic chemotherapy regimens both with cisplatin/doxorubicin, capecitabine/temozolomide, and doxorubicin/etoposide, but achieved a minimal response followed by rapid disease progression, massive ascites, and renal failure secondary to bilateral ureteral obstruction. results: based on his prior genomic testing, therapy with single agent mek inhibitor (trametinib) was initiated. this produced a rapid, dramatic response with greatly reduced disease burden at all sites, resolution of ascites and return to completely normal activity within months. this response lasted for approximately months before the tumor again progressed. further therapy with an erk inhibitor was ineffective, and the patient expired from progressive disease. located on the chromosome q , the braf oncogene, as part of the ras/mapk pathway, is involved in cellular proliferation, differentiation, migration, and apoptosis. braf mutations are recognized in a wide range of adult malignancies: thyroid cancers, non-small cell lung cancer, cholangiocarcinoma, ovarian cancers, and multiple myeloma. braf mutations have also been described in adult neuroendocrine carcinoma of the colon. trametinib is a highly specific inhibitor of mek /mek , a downstream mediator in the braf pathway. it has demonstrated activity in a number of tumors including advanced melanoma and gliomas. trametinib was chosen for this patient based on his atypical braf fusion. we believe this is the first documented case of its successful use in neuroendocrine carcinoma in the pediatric population. conclusion: this case demonstrates the presence of braf fusion in a case of pediatric neuroendocrine carcinoma and significant response to single agent mek inhibition in this context. this cases raises the question as to whether the combination of a targeted inhibitor, in addition to either conventional chemotherapy or other braf inhibitors, might offer a better approach to therapy than current treatment options. albany medical center, albany, new york, united states background: warm autoimmune hemolytic anemia (waiha) is characterized by autoantibody, and occasional complement binding of protein antigens, on the surface of red blood cells at temperatures ≥ oc resulting in targeted destruction. we describe the case of a year old male with a history of evan's syndrome, poor immune response to vaccines and lymphoid hyperplasia, presenting with altered mental status and severe anemia, found to have a warm igg pan agglutinin with evidence of both intra and extravascular hemolysis. his course was complicated by respiratory failure requiring intubation, pulmonary emboli, enterococcus bacteremia and hypertension. he received multiple transfusions with only transient increases in hemoglobin. the aiha was refractory to multiple rounds of treatment with high dose steroids, ivig, rituximab, cyclophosphamide, bortezomib, plasma exchange and mycophenolate mofetil (mmf). objectives: given the refractory nature of our patient's aiha the decision was made to trial eculizumab, a monoclonal antibody targeting c complement, preventing its cleavage and activation, and shown to be effective in treatment of atypical hemolytic uremic syndrome and hemolysis due to an igm cold agglutinin. prior to eculizumab infusion, ch and sc b- assays were significantly elevated. design/method: the patient was given two doses of eculizimab days apart. results: his hemoglobin steadily rose independent of red cell transfusions with a corresponding decrease in reticulocyte count, ldh and ch levels. the patient has remained stable with a normal hemoglobin ( - g/dl) on maintenance steroids and mmf. although we cannot definitively conclude that eculizumab directly caused his recovery, the clinical course post-eculizumab suggests this may be an efficacious treatment for aiha. genetic testing showed monoallelic frameshift mutation of the nfkb gene and monoallelic missense mutation of the dock gene. given the role of nfkb in both immunodeficiency and autoimmunity, it is thought that the patient's phenotype is due to nfkb haploinsufficiency and he is currently considering hematopoietic stem cell transplant. st. joseph's regional medical center, paterson, new jersey, united states background: heterozygous -thalassemia typically manifests as thalassemia minor, characterized by mild microcytic hypochromic anemia with minimal clinical ramifications. coinheritance of -globin gene triplication has been reported to exacerbate the clinical and hematological phenotype ofthalassemia trait, due to increase in the alpha/non-alpha-chain imbalance. reported phenotypes range from asymptomatic thalassemia minor to moderate thalassemia intermedia, usually diagnosed in adulthood without transfusion dependence. this combination has been described in mediterranean, european and asian populations, but rarely reported in hispanics. objectives: to report two cases of unusually severethalassemia intermedia in hispanic patients with heterozygosity for triplicated -globin gene and a ( )-thalassemia allele. results: case : sixteen-month-old male of mexican descent presented with persistent microcytic anemia and jaundice. peripheral smear showed nucleated rbcs with basophilic stippling and target cells. hemoglobin electrophoresis revealed: hba- %, hbf- %, hba - . %. -globin gene testing revealed heterozygosity for ( ) mutation (ivsi-i, g→a). given the unusually severe anemia, -gene testing was performed which showed -globin gene(anti . ) triplication ( / ). at four years, he had splenomegaly and bilateral maxillary prominence. head ct showed irregular contour of the parieto-occipital region due to medullary expansion. due to significant persistent anemia ( - g/dl) and progressive bony deformities of the skull, patient began chronic transfusions at age eight after family declined splenectomy.case : fifteen-year-old female, of peruvian and honduran descent, presented for evaluation prior to cholecystectomy for gallstones and recurrent ruq pain. father had known thalassemia trait. her hb was . g/dl with hypochromia, microcytosis, and target cells. electrophoresis indicated -thalassemia trait (hba- %, hba - . %, hbf- . %), confirmed by gene testing (heterozygous for a ( ) mutation in codon c>t). given jaundice and gallstones, -globin gene analysis was ordered showing triplication ( / ). ruq pain resolved post-cholecystectomy, but she developed persistent painful splenomegaly. she began hydroxyurea to increase gamma-globin production and decrease excess alpha chains, but it was discontinued due to hematological toxicity. due to recurrent luq pain and progressive splenomegaly, she underwent laparoscopic splenectomy at age with resolution of symptoms and improved hemoglobin. conclusion: -globin gene testing should be considered in -thalassemia carriers with an atypical clinical presentation including hispanic patients. the wide variability in the phenotypic expression of (anti . ) mutation andthalassemia trait suggest interplay of other genetic factors which remain undefined. the clinically significant presentation amongst certain subjects, as in our two cases, makes it imperative to identify these factors to aid in phenotype prediction and genetic counseling. ashley bonheur, shivakumar subramaniyam, jogarao vedula, sucharita bhaumik nyu winthrop hospital, mineola, new york, united states background: wilms tumor (wt) is one of the most common solid malignant neoplasms in children. a diverse range of genes and mechanisms are implicated in wt pathogenesis. predisposing syndromes result from a disruption of wt gene, crucial for renal and gonadal embryogenesis. another gene is wt gene locus at p , an area of imprinting. the p tumor suppressor gene on chromosome p . is seen in patients with anaplastic histology. in addition to these genes, whole and partial chromosome gains of q, , q, , , & and losses of p, p, q, q, as well as loss of heterozygosity (loh) are commonly seen. some genetic markers appear to be predictive of outcome and are now incorporated into the assigning of risk-directed therapy. patients with loh at chromosome p and q are treated with more intensive chemotherapy, as they have been associated with increased risk of relapse and mortality. objectives: to describe a new complex translocation involving chromosome , , and in a case of pediatric wt. design/method: a four-year old female presented with abdominal pain and emesis. on exam, patient had a firm and large abdominal mass. radiologic studies revealed a complex lobulated right renal mass. right radical nephrectomy was performed. histopathologic studies showed wt with triphasic histologic features with blastema predominance, invasion of the lymphovascular and perinephric adipose tissues, perinephric lymph node involvement and no anaplasia. chest ct scan showed bilateral lung metastases. tumor cytogenetics showed an abnormal karyotype, a complex translocation of , , and . the rearrangement occurred due to translocation between chromosomal bands q and q , with an insertion of q - on the q region. pcr based genotyping using microsatellite markers additionally identified loh for chromosome p and q . the patient was treated for high risk stage iv wilms tumor with favorable histology and received intensive chemotherapy and radiation therapy to the flank and the lungs. she is now in remission months after, with no evidence of recurrence on surveillance scans. complex translocations associated with wt have not been rigorously studied. a question for further study is whether there is any relationship between recurrence potential with a complex translocation compared to common chromosomal abnormalities. further knowledge of the molecular pathology and genetic changes in wt will help the development of new targeted therapies, as well as new biomarkers to aid diagnosis, risk stratification, and monitoring of treatment and relapse. results: a week-old girl was referred for evaluation of an abnormal newborn screen. mother was a known carrier of hb khartoum trait while father was a known carrier of thalassemia trait. patient's hemoglobin quantification performed by capillary zone electrophoresis showed hbf %, hb variant %, and no detectable hba. the hb variant ran in the d zone, a pattern consistent with mother's hb. alkaline agarose gel electrophoresis banding pattern showed f/s. acid agarose gel electrophoresis pattern showed v/f. later testing revealed abnormal isopropanol stability with + precipitation at minutes. this electrophoresis pattern is consistent with the pattern previously reported of hb khartoum. clinically, the patient is a healthy, active child whom we have followed for two years. she has not had any significant anemia outside of her physiologic nadir. she has not had any hemolytic episodes, and her bilirubin levels have always been within the normal range conclusion: to the best of our knowledge, this is the only reported case of hb khartoum/ thalassemia. the proline to arginine substitution of hb khartoum introduces a charged group on the chain at the site of contact. the resulting unstable chains can dissociate into monomers and favor the formation of methemoglobin, leading to hemoglobin instability. we had wondered if this unstable hemoglobin might result in clinical hemolysis when challenged with oxidative stress, such as in periods of infection. however, in the two years we have followed this patient, she has never had a hemolytic episode. at two years of age, she has hbf . %, hb khartoum . %, and hba . %. whether hbf elevation is protective from oxidative stress remains to be determined as we continue to follow this child. university of puerto rico -medical science campus, san juan, puerto rico, united states background: gm gangliosidosis is a lysosomal disorder caused by -galactosidase deficiency due to mutations in the glb gene. it is a rare autosomal recessive neurodegenerative disorder with an incidence of about : , - : , live births worldwide. this neurological disorder has three clinical forms. gm type , or infantile form is characterized by psychomotor regression by the age of months, visceromegaly (hepatosplenomegaly), macular cherry red spot, facial and skeletal abnormalities, seizures, and profound intellectual disability. we present a -year-old female with gm type and acute lymphocytic leukemia (all). design/method: she was diagnosed with gm type at the st months of age and family history was remarkable for an older sister with gm type . diagnostic studies reveal homozygous exon of the glb gene for a sequence variant defined as c. c>t, predicted to an amino acid substitution p.aarg cs. results: patient presented to our hospital with petechiae in lower extremities, pallor and intermittent tracheal bleeding. physical examination shows a hemodynamically stable girl that is chronically ill dependent of mechanical ventilation, severe mental retardation and scatter petechiae at upper and lower extremities. laboratory workup revealed severe normocytic anemia (hgb: . g/dl) with immature peripheral cells and thrombocytopenia ( × /l). serum chemistry revealed increase ldh ( u/l), increase hepatic enzymes (ast: u/l), normal uric acid level. there was no evidence coagulopathy. chest x ray was unremarkable except for evidence of chronic pulmonary illness. abdominal sonogram hepatosplenomegaly. during hospitalization, bone marrow aspirate and biopsy was performed which was diagnostic of b cell acute lymphoblastic leukemia (all) with . % lymphoblast and orderly myeloid/erythroid maturation. flow cytometry: % b lymphoblast with aberrant phenotype c/w b-acute lymphoblastic leukemia. karyotype revealed hyperdiploid female of favorable prognosis. cytogenetic by fish: hyperdiploid all with extra copies of runx and igh (no bcr-abl translocation). family was oriented about the new diagnosis and the dismal prognosis in conjunction to her primary condition. parents agree on no chemotherapy treatment for all with only supportive treatment. to this date, there is no evidence in literature that has previously described association of gm and leukemia. life expectancy of patient's primary condition is null therefore, correlation with leukemia might not be a coincidental finding. this patient opens the possibility of malignancy as part of gm type thus, malignancy diagnosis should be considered as part of their medical lifetime course. university of south florida, tampa, florida, united states background: hematological manifestations related to hiv infection are not uncommon, with thrombocytopenia having an estimated prevalence of - %. the pathophysiology is likely multifactorial. studies suggest that the primary mechanism may be immunologic resulting in accelerated platelet destruction. additional theories suggest that infection of megakaryocytes may also play a role causing inadequate platelet production. treatment of hiv-related thrombocytopenia is challenging. first-line treatments include initiation and optimization of antiretroviral therapies, immunoglobulin (ivig), and glucocorticoids. however, this approach is not effective in all patients and second line treatment options are less well studied, particularly in the pediatric population. objectives: we aim to present and discuss the case of a year old patient with perinatally acquired hiv- infection and persistent thrombocytopenia who, after failing first line therapies, showed normalization of platelet count on the novel thrombopoietin receptor agonist, eltrombopag. design/method: a retrospective chart review of the case patient's medical record was conducted. additionally, a thorough literature review was performed on this topic including the pathophysiology of hiv related thrombocytopenia and its treatment modalities. the patient required monthly ivig infusions for about year, but did not show a sustained response, often with platelet count dropping to less than , in between infusions. after initiation of mg eltrombopag daily the patient showed a sustained increase in platelet count (range , - , ). during a brief week lapse in eltrombopag treatment his platelet count dropped to , . upon re-initiation of therapy his count increased to , . the patient has remained asymptomatic, off of ivig for over one year, with undetectable hiv viral load and greater than cd t cell counts. no side effects or grade laboratory abnormalities were reported. conclusion: treatment of hiv-related thrombocytopenia can be challenging. first line therapies, including ivig and glucocorticoids, are not effective in all patients. several other treatment modalities have been utilized, including anti-d immunoglobulin, dapsone, danazol, interferon alfa, vincristine, thrombopoetic growth factors including romiplostim and eltrombopag, or splenectomy, but these are less well studied. this represents the first reported case of a pediatric patient with hiv who showed a positive response to eltrombopag with a sustained improvement in platelet count and no adverse effects from treatment. eltrombopag may be a safe alternative to first line therapies in those patients with hiv and refractory thrombocytopenia, however additional studies are needed. university of illinois college of medicine at peoria, peoria, illinois, united states background: achromobacter xylosoxidans is a gram negative rod with peritrichous flagella which causes rare opportunistic infections most commonly encountered by immunocompromised patients. it is primarily associated with uncomplicated bacteremia, cather-associated infections, and pneumonia. most reports of bacteremia associated with a. xylosoxidans are nosocomial, associated with neoplasm, and occurring mainly in adults. most reported infections with a. xylosoxidans in children are associated with cystic fibrosis. there are very few reported cases of septic shock from a. xylosoxidans bacteremia and pneumonia in the pediatric oncology population. objectives: to describe a rare case of a. xylosoxidans septic shock in a pediatric patient with relapsed neuroblastoma results: a -year old boy with history of stage iv highrisk neuroblastoma underwent standard frontline therapy with chemotherapy, hematopoietic stem cell transplant, radiation therapy, and immunotherapy, followed by a dfmo trial for maintenance. his -month follow-up scans demonstrated relapse and he was subsequently treated with additional chemotherapy, surgical resection, and mibg therapy, crizotinib for an eml -alk fusion and finally ifosfamide, carboplatin and etoposide (ice). he developed neutropenic fevers and was started on cefepime, vancomycin and fluconazole. blood cultures were initially negative. on the th day of fever, his previously scheduled pet scan was performed during hospitalization and showed new pulmonary opacities. he did not have respiratory symptoms, but therapy was escalated to meropenem, vancomycin and amphotericin. emergent bronchoscopy was performed the same day, with all bacterial and fungal cultures remaining negative. overnight, he developed tachypnea and saturations in the upper s, requiring nasal cannula. ir-guided lung biopsy was performed the next day, a flexible bronchoscopy was done to remove blood clots in the airway, the patient was placed on a ventilator, femoral lines were placed, granulocytes ordered and pressors were started for deterioration to presumed septic shock. arterial and femoral lines were placed but patient continued to have hemodynamic instability on multiple pressors. the following day, blood and respiratory cultures returned positive for results: at days after the start of iti, the inhibitor was < . bu and continued undetectable months after initiation of iti therapy. in this patient, iti with high-dose plasma-derived factor viii and von willebrand factor (vwf) complex was well tolerated and effective. genetic analysis confirmed a large factor viii gene duplication of exons to . we believe our patient developed inhibitor so quickly ( exposure days) due to the possibility of this mutation causing a frameshift that introduces a premature termination codon. this might be functionally similar to a deletion in the factor viii gene which poses the highest risk for inhibitor development in patients with severe hemophilia a. this variant has only been identified previously in two unrelated patients diagnosed with severe hemophilia a. this duplication is not listed in dbsnp variant database, nor observed in the general population database. our case proves the effectiveness of this method for patients with severe hemophilia a and an inhibitor. it also shows that more research is needed to identify patients at risk for inhibitor development. background: mercaptopurine ( -mp) is a prodrug that is a core component of maintenance chemotherapy for patients with a diagnosis of acute lymphoblastic leukemia (all). suppression of the neutrophil count is used to demonstrate adequate dosing of -mp during this phase of therapy. bone marrow suppression is mediated by the active metabolite -thioguanine ( -tgn), whereas the metabolite -methylmercaptopurine nucleotides ( -mmpn) has been shown to cause hepatotoxicity. allopurinol has been used infrequently in all maintenance therapy in the setting of skewed metabolism when adequate myelosuppression is difficult to achieve due to excessive hepatic toxicity. when given in combination with allopurinol a reduced dose of -mp may result in both increased -tgn levels and decreased -mmpn levels. objectives: describe the characteristics and clinical course of patients treated with allopurinol and reduced dose -mp during maintenance chemotherapy for all. we performed a retrospective chart review of patients at aflac cancer and blood disorders center of children's healthcare of atlanta with new diagnoses of b or t-cell all who received allopurinol during maintenance chemotherapy. we identified eleven patients with b-cell or tcell all who received allopurinol adjunctive therapy during maintenance chemotherapy at a single institution between - . these patients received adjunctive allopurinol for - weeks (median weeks) with reduced -mp ( - % of full dose). all ten patients with genetic testing for thiopurine s-methyltransferase (tpmt) had wildtype genotype associated with normal enzyme levels. indications for allopurinol use were most commonly unfavorable -mp metabolite levels, transaminitis (n = ), pancreatitis (n = ) and hyperbilirubinemia (n = ). favorable metabolite shift was achieved in all patients. liver enzymes improved in of patients with transaminitis after initiation of allopurinol/reduced -mp. three patients who experienced pancreatitis during maintenance did not have recurrence after initiation of allopurinol ( of these patients previously reported). six patients developed pancytopenia while on allopurinol, and two of those patients developed pancytopenia severe enough to require allopurinol cessation. four patients developed isolated anemia (hgb < . g/dl) without thrombocytopenia or severe neutropenia. no patient has experienced a recurrence of leukemia. overall, treatment with allopurinol and reduced dose -mp was successful in producing a favorable -mp metabolite distribution and reducing toxicity. therapy was generally tolerated; however a major and notable side effect was pancytopenia, in two cases severe enough to stop allopurinol treatment. anemia may be more prominent with allopurinol usage. allopurinol effect is variable among individual patients despite normal tpmt genotypes. baylor college of medicine, houston, texas, united states background: congenital sideroblastic anemia, b-cell immunodeficiency, periodic fevers and developmental delay syndrome (sifd) is a rare inherited sideroblastic anemia syndrome, first described in with clinically similar cases. genetic variations of trnt were identified as causative. objectives: to present an unusual presentation of a patient with sifd complicated by diagnosis of concomitant alpha thalassemia trait. design/method: retrospective chart review. a five month old male infant was referred to our hematology center for evaluation of elevated hemoglobin barts identified on newborn screen. despite numerous attempts, blood work was unable to be collected. at seven months of age he had microcytic anemia (hemoglobin . g/dl, mean corpuscular volume fl) more severe than what would be expected with alpha thalassemia trait. no variant hemoglobin was identified with isoelectric focusing or high performance liquid chromatography. by nine months of age he developed growth failure, intermittent emesis with fevers, developmental delays (predominantly gross motor), hearing loss, a disproportionally large head and coarse, thinning hair. over the next ten months, he was seen by numerous specialists for seemingly unconnected problems including sensorineural hearing loss, elevated liver enzymes and growth hormone deficiency. alpha globin analysis revealed deletion of two alpha globin genes. at months of age, he was admitted with one week of fevers, jaundice, and emesis. peripheral blood smear showed microcytic hypochromic anemia with marked anisopoikilocytosis including target cells, elliptocytes, tear drops, spherocytes, poikilocytes, marked polychromasia, and coarse basophilic stippling. given the inconsistency of his laboratory findings with the diagnosis of alpha thalassemia trait and clinical syndromic findings, bone marrow biopsy was performed which revealed rare ringed sideroblasts. one month later whole exome sequencing revealed trnt splicing variant c. - c>g and novel missense variant c. a>t consistent with sifd. hemoglobin barts on newborn screen with moderate to severe microcytic anemia directed initial diagnostic work-up towards variant alpha thalassemia. as additional medical conditions developed the focus shifted to a unifying syndrome. compared to previously described cases, our patient was diagnosed at an older age, presented with anemia rather than episodes of febrile illnesses, and had rare sideroblasts on bone marrow examination. diagnosis in this case led to identification of the novel c. a>t variant in his sister who had similar, but milder, features. sifd is a rare disease with variable phenotypic severity making diagnosis challenging without high index of suspicion which is crucial for appropriate management. wiseman, blood, . chakraborty, blood, background: cholelithiasis is uncommon in childhood. cholelithiasis is known to occur more frequently in children with predispositions, including female sex, obesity, parenteral nutrition, previous abdominal surgery, use of oral contraceptives, family history of gallstones, chronic hemolytic anemias, hepatobiliary disease, or exposure to specific drugs. although there have been occasional case reports linking cholelithiasis to childhood leukemia or leukemia therapy, the prevalence and risk factors of cholelithiasis in patients with childhood leukemia remain unclear. objectives: to estimate the prevalence of cholelithiasis in patients diagnosed with childhood acute lymphoblastic leukemia (all), and to evaluate possible risk factors for the development of cholelithiasis in patients with childhood all. we performed a computer-assisted review of the electronic medical records of patients diagnosed for b or t-cell all at children's healthcare of atlanta in the period from to . patients with diagnoses of cholelithiasis, cholecystitis or who had a cholecystectomy were identified. possible risk factors of age, sex, bmi, history of abdominal surgery and parenteral nutrition use were abstracted. patients with underlying chronic hemolytic anemia or pre-existing gallbladder disease were excluded. results: seventeen cases of cholelithiasis and cases of cholecystitis without documented cholelithiasis were identified. among patients with cholelithiasis, were female. median age at diagnosis of cholelithiasis was . (range . - . ) years. seven patients had no symptoms referable to cholelithiasis at the time of diagnosis. the median age of leukemia diagnosis among these patients was . (range . - . ) years. the median interval from diagnosis of leukemia to gallbladder disease was . years. four patients had bmi over the th percentile for age. two patients had a prior history of intraabdominal surgery. no patient received oral contraceptive pills. six patients received parenteral nutrition for more than days. there was no documented family history of cholelithiasis. seven patients did not receive any cholelithiasis directed therapy. two patients were managed with medical management only, with endoscopic retrograde cholangiopancreatogram with stone extraction, and with cholecystectomy. our study estimates the prevalence of cholelithiasis in childhood lymphoblastic leukemia to be . %, higher than the reported prevalence in the general pediatric population of . - . %. although our cohort size is small, it appears that all therapy and supportive care modalities associated with all are likely to play a larger role in the development of cholelithiasis than known predisposing factors in the general population. further studies are warranted. background: an uncommon side effect of intravenous immunoglobulin (ivig) administration is clinically apparent, sometimes severe hemolysis. we describe a severe case of coombs-positive hemolytic anemia secondary to ivig administration. ivig is a blood derivative manufactured from pools of , to , individual plasma donations. ivig is not abo-type restricted, so anti-a, anti-b and anti-a,b isoagglutinins are detectable. objectives: to describe a rare but serious type of transfusion reaction leading to gross hemolysis after ivig administration. results: a -year-old male with a past medical history of obstructive sleep apnea and obesity was admitted to the pediatric intensive care unit for adenoviral pneumonia and subsequent respiratory failure requiring mechanical ventilation. he had a complex hospital course with many complications including acute respiratory distress syndrome (ards), septic-shock, and coombs-positive hemolytic anemia. the patient was treated with commercial ivig (baxter/baxalta) -mg/kg daily for five days. he had two isolated episodes of severe hemolysis in relation to ivig administration requiring multiple transfusions of packed red blood cells (prbc). examination of pre-transfusion peripheral blood smear showed spherocytosis with rouleaux formation and large clumped rbc aggregates. the patient's blood type was classified as blood group a, rh-negative and his initial prbc transfusions were of this type. subsequently, the patient's coombs test was found to be positive using polyspecific and anti-igg typing sera. the patient's antibody screen against reagent group o screening cells was negative ruling out autoimmune hemolytic anemia. however, type specific anti-a antibodies were detected in his plasma as well as the acid eludate prepared from the coombs-positive red blood cells. it was concluded that the patient's hemolysis was due to anti-a antibodies presumed to arise from ivig. the patient's rbc transfusions were changed to o-negative blood and the hemolytic process resolved. the patient ultimately died due to complications of ards. although hemolysis is a known side effect of ivig, it is rarely considered when deciding to administer ivig. in addition, it has rarely been described in the pediatric population. ivig is used in the treatment of a growing number of medical conditions. due to the critical nature of many of these patients, hemolysis secondary to ivig may not be considered and continued blood transfusions with the patient's specific blood type may be used. it is crucial to remember that severe hemolysis can occur from ivig, and the importance of transfusing with blood group o, rh-negative blood when applicable. university of maryland medical center, children's hospital, baltimore, maryland, united states background: coagulopathy is a well-described complication of acute promyelocytic leukemia (apml), and remains a leading cause in induction failure. with treatment, coagulopathy associated with apml has been shown to rapidly improve. multiple organ dysfunction syndrome (mods) in apml, including acute respiratory distress syndrome (ards), has been associated with infection, traumatic injury, malignant infiltration, and cytokine release syndrome. when mechanical ventilation is no longer sufficient, extracorporeal membrane oxygenation (ecmo) can be considered; however, coagulopathy, severe end-organ damage, and malignancy are all relative contraindications to initiation of treatment. we report the case of a -year-old female presenting in respiratory failure, disseminated intravascular coagulopathy (dic), with intracranial hemorrhage, and mods, diagnosed with apml, successfully treated with ecmo therapy. design/method: retrospective case analysis and literature review. our patient, a -year-old female was admitted in respiratory failure and altered mental status, following a fall shortly prior to presentation. initial laboratory values were notable for pancytopenia, dic, and acute renal failure. a non-contrast head ct showed left temporal lobe intraparenchymal hemorrhage. she was diagnosed with apml by peripheral smear, later confirmed by fish for t( : ), and was started immediately on high-risk induction chemotherapy as per cog protocol aaml , including all-trans retinoic acid, arsenic trioxide, idarubicin, and dexamethasone. cvvhd was required for acute renal failure. despite maximal respiratory support, she remained hypoxemic, with oxygenation index of , pao /fio ratio of . ecmo was initiated hours after start of induction, hours after admission. coagulopathy resolved on day of induction, ecmo was discontinued after days, mechanical ventilation and cvvhd were stopped after days and she continued to improve, eventually achieving remission with few neurologic side effects. despite relative contraindications to ecmo, this patient was successfully treated with ecmo without significant neurologic side effects. the correction of her coagulopathy was multifactorial: ) restoration of adequate oxygen delivery via ecmo improving endothelial function; ) successful organ support to allow sufficient response to induction chemotherapy with atra leading to the terminal differentiation of leukemic blasts; ) complement and contact system activation through contact with ecmo circuitry. this case illustrates that ecmo can still be considered in patients despite coagulopathy and end organ damage. sinai hospital of baltimore, baltimore, maryland, united states background: primary polycythemia vera is an extremely rare diagnosis in the pediatric patient and is defined by a marked elevation of red blood cells due to erythropoietin-independent mechanisms. presentations of this disorder range from the asymptomatic person to severe thrombotic events, such as budd-chiari syndrome or cerebrovascular stroke. mutations in the jak gene are found in adult and pediatric patients with polycythemia vera; however, the jak v f mutation is less commonly identified in pediatric patients. we describe an otherwise healthy -year-old female who presented with a significantly elevated total erythrocyte count, hemoglobin, and platelets, incidentally discovered upon routine annual blood work obtained by her pediatrician. design/method: this is a report and discussion of a rare case. demonstrated cellular marrow with trilineage hematopoiesis and no dysplasia. cytogenetics were not assessed. his hemoglobin and platelet count recovered but leukopenia and neutropenia persisted. follow-up evaluation at three months revealed fevers, ongoing cytopenias, a one-month of a nodular skin rash on the trunk and extremities resembling erythema nodosum, and hepatitis (peak alt and ast of , and , , respectively). following clinical evaluation, a skin biopsy was performed and was remarkable for atypical lymphocytes within the subcutis with t-cell markers, a high ki- , and positive tia- , perforin, and -f immunoperoxidase stains. negative stains for cd , cd , and ebv were noted. these results are consistent with sptcl. additional evaluation did not support a diagnosis of hlh. a staging evaluation was performed. pet-ct showed widespread hypermetabolic subcutaneous activity in the legs, trunk and skull and diffuse marrow hyperplasia. bone marrow demonstrated involvement with precursor b-cell acute lymphoblastic leukemia, with a mll gene rearranagement. his skin biopsy was retrospectively stained with tdt, cd , pax- , cd a, and cd with negative results, and a blood smear taken at the time of the skin biopsy did not demonstrate leukemic cells. conclusion: this is the first report of a patient with sptcl having a synchronous malignancy. the patient is doing well, currently in the maintenance phase of treatment for his all, and his skin disease has resolved on pet-ct. while it is possible that his presentation was a function of chance, the possibility of an underlying immune dysfunction or cancer predisposition warrants further investigation. cincinnati children's hospital medical center, cincinnati, ohio, united states background: hereditary xerocytosis (hx) is a rare red blood cell (rbc) dehydration disorder, characterized by variable hemolysis and propensity to iron overload. hx is often misdiagnosed as hereditary spherocytosis (hs). while splenectomy is curative for hs, it is relatively contraindicated in hx due to a substantial thromboembolism risk, signifying the importance of delineating these diseases. blood smear abnormalities are variable and often insufficient to make an accurate diagnosis. osmotic-gradient ektacytometry and genetic confirmation are critical in distinguishing these overlapping disorders. objectives: describe a family with hx, initially misdiagnosed as hs. discuss the importance of distinguishing these disorders and the utility of ektacytometry in making this distinction. design/method: a -year-old caucasian male was diagnosed with hs after presenting with prolonged neonatal jaundice starting on the first day of life. he described mild scleral icterus and history of intermittent jaundice and dark urine, without need for transfusions. his father, paternal uncle and paternal grandmother were all diagnosed with hs during childhood and underwent cholecystectomy. additionally, his father underwent splenectomy for abdominal pain. the child's blood counts revealed compensated anemia (hb . gm/dl) and reticulocytosis (arc × /mcl) with increased mcv ( . fl) and mchc ( . gm/dl). blood smear showed increased polychromasia and poikilocytosis with rare spherocytes and few stomatocytes. while the child had normal ferritin, his father had iron overload (ferritin ng/ml) despite no prior transfusions. osmotic-gradient ektacytometry profile of the child and father's rbcs showed a characteristic left-shifted, bell-shaped curve with decreased omin and ohyp, diagnostic of hx. the family is currently undergoing genetic studies. despite clinical similarities between hs and hx, distinguishing these diseases has significant management implications. hx is a disorder of rbc permeability, causing shortened rbc survival. stomatocytes on blood smear can raise suspicion for hx, but are insufficient to make an accurate diagnosis. identifying characteristic biomechanical membrane properties using osmotic-gradient ektacytometry is the gold standard for clinical diagnosis, which can then be confirmed by molecular studies. hs and hx can be easily and reliably distinguished using ektacytometry, as both disorders have very distinctive curves representing different rbc deformability patterns. after hx diagnosis was made, we counseled the family against splenectomy, as the risk of thromboembolism is significantly increased in hx compared to hs, and the father was diagnosed with iron overload. conclusion: hx is commonly misdiagnosed as hs. this case highlights the importance of making this distinction, and the utility of osmotic-gradient ektacytometry in reliably distinguishing these conditions. penn state health children's hospital, hershey, pennsylvania, united states background: relapsed acute myeloid leukemia (aml) presenting as an isolated central nervous system myeloid sarcoma (cns ms) is very rare and its treatment is not well-defined. thiotepa, vinorelbine, topotecan and clofarabine (tvtc) has been successful for re-induction therapy to induce remission prior to hematopoietic stem cell transplant (hsct). objectives: to describe our experience in utilizing tvtc therapy in two children with no extramedullary disease at initial diagnosis who presented with relapsed aml as intracranial myeloid sarcomas. results: case : month-old female was diagnosed with flt negative aml and completed treatment per the children's oncology group (cog) aaml study on the low risk arm without bortezomib. cerebral spinal fluid (csf) negative at diagnosis. fish testing positive for tcf gene deletion of unknown significance. mrd was undetectable after induction i and remained undetectable after each cycle. nine months off therapy, recurrent headaches prompted mri imaging which revealed two posterior fossa masses. csf and bone marrow testing were negative. stereotactic biopsy of the larger mass confirmed recurrence of aml. patient underwent two cycles of tvtc with a total of seven doses of intrathecal cytarabine with almost near resolution of the cns ms. completed cranial radiation and proceeded to allogeneic stem cell transplant with unrelated cord marrow donor and is disease free at approximately day + .case : year-old female diagnosed with flt and mll negative aml and completed treatment per cog aaml study on the low risk arm without bortezomib. csf negative at diagnosis. mrd was undetectable after induction i and completed therapy without complications. two months off therapy, a retrospective analysis of her diagnostic bone marrow by the cytogenetic laboratory to test a new panel identifying novel q partners revealed a cryptic insertional : (mllt /mll(kmt a) translocation. at four months off therapy, acute mental status changes prompted mri imaging which revealed two intracranial ms and lumbar spine involvement. resection of the larger lesion for symptomatic relief confirmed the mllt /mll(kmt a) fusion. csf positive for blasts and marrow negative for relapsed disease. patient completed two cycles of tvtc with a total of seven doses of it cytarabine with near resolution of cns disease (only mm contrast enhancement in the medulla). she received craniospinal radiation and is awaiting improvement in her cardiac function before proceeding to hsct. conclusion: tvtc is a successful reinduction regimen for relapsed aml with cns ms prior to hsct. background: acute severe anemia can be a life-threatening medical condition. the differential is quite broad for possible etiologies of acute severe anemia, including autoimmune hemolytic anemia (aiha) and atypical hemolytic uremic syndrome (ahus). autoimmune hemolytic anemia is an antibody-mediated process that targets the protein antigens located on the surface of red blood cells. treatment options for aiha include corticosteroids, with up to % of patients being responsive, with some requiring splenectomy. atypical hemolytic uremic syndrome is a medical urgency, defined as the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. the etiology is usually due to genetic causes, or less commonly, due to autoantibodies or idiopathic reasons. prognosis is very poor. objectives: differentiating between autoimmune hemolytic anemia and atypical hemolytic uremic syndrome can be a time-sensitive diagnostic dilemma while the patient is in critical condition, but this important delineation can vastly alter therapeutic options. design/method: here we discuss two cases highlighting the diagnostic workup involved in differentiating between atypical hemolytic uremic syndrome and autoimmune hemolytic anemia. patient a is a -year-old male who presented in extremis with severe anemia, uremic encephalopathy, and severe acute renal injury requiring hemodialysis and multiple blood transfusions. patient b is a -month-old male, who also presented in extremis with respiratory failure secondary to adenovirus/rhinovirus/enterovirus, with acute progressive renal failure and microangiopathic hemolytic anemia, requiring hemodialysis and cardiorespiratory support. : patient a underwent a full hematologic and infectious disease workup. subsequent laboratory studies confirmed enteropathogenic e.coli (epec) in the patient's stool; blood cultures remained negative. renal biopsy results were consistent pigment nephropathy. bloodwork indicated positive direct coombs. patient a was ultimately treated with steroids mg/kg/day, with significant improvement. patient b also included a full hematologic work-up, including adamts activity and ahus genetic panel, as well as full infectious disease work-up. subsequent laboratory test-ing revealed blood cultures growing streptococcus pneumoniae, with adamts activity at % (adult ref range: >/ = %), and normal complement levels. imaging findings also supported diagnosis of ahus. the management of a critically ill patient with acute severe anemia requires a thorough hematologic and infectious disease work-up. while molecular and genetic are helpful in definitive diagnosis of ahus, the utility of such results is limited by time. overlapping clinical presentation of a patient in extremis due to acute severe hemolytic anemia with progressive renal failure presents a rather broad differential, with time-sensitive treatment and prognostic implications. the favorable response to steroids delineates aiha from hus. background: d- -hydroxyglutaric aciduria (d- -hga) is a rare metabolic disorder characterized by developmental delay, hypotonia, and bi-allelic mutations in d- hydroxyglutarate dehydrogenase (d hgdh) or isocitrate dehydrogenase (idh ). metaphyseal chondromatosis with d- -hydroxyglutaric aciduria (mc-hga) is a type of d- -hga that has been previously reported in seven patients (omim ; pmid ), three of whom had somatic mosaicism for r variants in isocitrate dehydrogenase (idh ). we describe a -year-old boy with mc-hga who subsequently developed acute myeloid leukemia (aml) and was found to have a r variant in idh in a leukemic bone marrow sample. we report the first case of aml with this metabolic disorder. design/method: a -year-old hispanic boy presented with short stature, developmental delay, abnormal skin pigmentation, and unilateral congenital cataract. workup revealed multiple skeletal enchondromatosis and elevated urine d- -hydroxyglutaric acid levels. he was diagnosed with mc-hga. no pathogenic variants in d hgdh, idh and idh were identified in peripheral blood. germline testing with biopsies of skin lesions was declined by the family. two years later, he presented with streptococcal sepsis and pancytopenia. blasts were noted on peripheral smear. bone marrow morphology was consistent with acute myelomonocytic leukemia (∼ % blasts). chromosome analysis showed normal xy, and molecular testing by pyrosequencing idh and idh revealed a r c variant in idh ( % mosaicism). the patient is being treated as per the cog study aaml . end of induction i bone marrow aspirate was hemodiluted, but there was no obvious residual disease by flow cytometry ( . - . % sensitivity) or morphology. the previously identified idh variant was no longer detectable (limit of detection < %). although targeted therapy for aml with idh mutation is currently in phase i clinical trials in adults, there is no safety or efficacy data for using idh inhibitors in children. treatment with ivosidenib is therefore not currently an option for our patient. conclusion: this is the first case of aml reported with this rare metabolic disorder. somatic r variants in idh have been identified in three other mc-hga cases. this same mutation leads to the accumulation of d- -hydroxyglutarate in gliomas and aml. without any confirmed germline mutation or somatic mosaicism testing of multiple specimen sources, we can only speculate that the patient has an underlying somatic idh mutation associated with mc-hga which subsequently led to leukemogenesis. we present the first case of this association, to increase index of suspicion for development of aml in children with metabolic disorders associated with variants in idh . background: congenital combined deficiency of the vitamin k-dependent coagulating factors (vkcfd) is a rare heterogeneous autosomal recessive bleeding disorder. vkcfd is caused by mutations in the genes of either gamma-glutamyl carboxylase (ggcx) or vitamin k epoxide reductase complex (vkorc), which are responsible for the gammacarboxylation of vitamin k dependent proteins (vkdps) allowing for their activation. the clinical presentation ranges from no bleeding to intracranial hemorrhage. to date, vkcfd has been reported in few patients worldwide. objectives: we report a case of a girl with novel homozygous mutation of the ggcx gene, highlighting her clinical and biochemical characteristics with a review of the literature. a -month-old girl of consanguineous emirati parents, presented to our hospital with a history of bleeding from puncture site after receiving her second-month vaccine. that was associated with episodes of mild mucosal bleeding. review of systems was negative for jaundice, steatorrhea and failure to thrive and physical exam was unremarkable. investigations revealed markedly prolonged pt and aptt with high inr. fibrinogen, hemoglobin and platelets were always normal. activities of vitamin k-dependent factors including fii, fvii, fix, fx, protein c and s were all low. a measurement of proteins induced by vitamin k absence (pivka-ii) was done and came very high. this was associated with a mild elevation in liver enzymes but normal liver function test. the picture was supporting vitamin k deficiency, and as a result, she was started on oral vitamin k supplements of mg/day. she responded partially to vitamin k and required higher doses to stabilize her inr. after excluding acquired causes and due to her requirement of high doses of vitamin k, a mutation in either ggcx or vkorc genes was suspected. genetic analysis was conducted for her which revealed a novel missense homozygous mutation in the ggcx gene (c. a>t) confirming the diagnosis of combined deficiency of vitamin k-dependent clotting factors type . the asymptomatic parents were both heterozygous for the same mutation. results: she is currently stable on mg/day of vitamin k supplements. conclusion: vkcfd is a rare bleeding disorder with an overall good prognosis due to the availability of several effective therapeutic options. the function of the mutated gene is unknown. our patient demonstrated a partial response to vitamin k supplements suggesting presence of a residual carboxylation capacity and a possible role of this gene in the enzymesubstrate interactions. university of alabama at birmingham, birmingham, alabama, united states s of s background: gata is a zinc finger transcription factor that plays a critical role in the regulation of hematopoiesis and lymphatic angiogenesis. mutations leading to gata deficiency (gd) have been linked to a variety of clinical conditions. patients with gd have a striking predisposition to develop myelodysplastic syndrome (mds), acute myeloid leukemia (aml), or chronic myelomonocytic leukemia (cmml). acute lymphoblastic leukemia (all) has not been associated with gd, although the association of bcell all and gd has been previously reported. objectives: to describe a unique association of gata deficiency and t-cell all in a young child. results: an -year-old female presented with a one-week history of fever and malaise. she had a significant past medical history of verruca plantaris and self-resolving leukopenia associated with febrile illnesses. significant family history included sister with neutropenia and human papilloma virus (hpv) infection, and mother with neutropenia, monocytopenia, atypical mycobacterial infections, and hpv infection. peripheral blood revealed hemoglobin . g/dl, hematocrit . %, platelets , /ul, and white blood cell , /ul (neutrophils /ul, lymphocytes /ul, monocytes /ul). patient underwent a bone marrow biopsy demonstrating lymphoblast infiltration. flow cytometry analysis demonstrated monoclonal lymphoid blast population that co-expressed cd , cd , cd , nuclear tdt, cd , however, lacked expression of cd , cd , cd , cd , hla-dr, or myeloperoxidase. findings were consistent with tcell all with aberrant myeloid markers. cytogenetics analysis revealed ,xx,dic( ; )(p . ;p . ). patient began treatment as per children's oncology group aall and achieved remission at the end of induction. course of therapy was complicated by episodes of fever, reciprocating junctional tachycardia, asparaginase-associated thrombosis, viral meningitis, recurrent episodes of verruca plantaris, and resistant streptococcus pneumoniae or haemophilus parainfluenza infections causing chronic cough. later, she was also found to have low igm levels; after completion of therapy, she developed monocytopenia. lymphocyte subset panel revealed absent b cells, decreased number of natural killer (nk) cells, and cd /cd inversion. further work-up included gata sequence analysis that showed heterozygous nonsense mutation (c. c > t/c; reference nm_ ) likely resulting in gata haploinsufficiency. patient continues to be in remission, is receiving monthly immunoglobulin replacement and is on azithromycin for atypical mycobacterial prophylaxis. surveillance bone marrow biopsies have shown no evidence of mds or leukemia, however, have demonstrated persistent hypocellularity. the possibility of undergoing an allogeneic bone marrow transplant is actively being discussed given its curative potential. clinicians should be aware that t-cell all may be associated with gata deficiency. cincinnati children's hospital medical center, cincinnati, ohio, united states background: treatment for severe hemophilia a is centered on factor viii (fviii) replacement therapy. development of an alloantibody (inhibitor) against fviii is a significant treatment complication occurring in as many as - % of patients. high titer inhibitors render treatment with factor viii ineffective, necessitating the use of bypass agents that may not achieve hemostasis with the same efficacy. considering the substantial ramifications of inhibitor development on treatment, eradication of inhibitors is of great importance to achieve adequate hemostasis in this patient population. desensitization by immune tolerance induction (iti) is the primary method of inhibitor elimination. however, not all patients respond to iti. immunomodulation may be considered as the next line of therapy, although controversy remains in regards to agent selection and use. objectives: there is incomplete data on the use of immunomodulation therapy for inhibitor eradication in severe hemophilia a. we present a case of a pediatric patient with severe hemophilia a and high titer inhibitor who failed initial iti therapy to better illustrate potential treatment options for the future. design/method: a retrospective chart review was performed on a patient with severe hemophilia a at cincinnati children's hospital medical center. results: an -year-old caucasian male with severe hemophilia a secondary to intron inversion, was initially diagnosed following extensive bleeding after circumcision at birth. he was identified as having an inhibitor ( bethesda units (bu)) at months of age after exposure days of treatment. he failed multiple attempts of iti, with recombinant and plasma-derived (pd) fviii. he was advanced to immunomodulation therapy in combination with pdfviii, however demonstrated anaphylaxis to rituximab and ofatumumab. he underwent tolerization to rituximab, and received a six month course with a partial response (nadir of . bu). months following last dose of rituximab, a rising inhibitor titer ( . bu) was found. mycophenolate mofetil (mmf) was initiated with subsequent inhibitor stabilization and a decreasing titer ( . bu) over the course of the following year. mmf has been well tolerated without major side effects or infection throughout therapy. conclusion: development of an inhibitor against fviii is a considerable complication in patients with severe hemophilia a. use of immunomodulatory therapies following iti failure remains controversial. mmf has not been well studied in this patient population. we report a case of a patient who is being successfully treated with mmf with minimal side effects. further prospective studies should be considered to further define the role of mmf immunomodulation therapy. background: down syndrome (ds) children with aml (ds aml) have higher cure rates than their non-ds counterparts. outcomes for refractory/relapsed cases, however, remain dismal. somatic mutations of the gene encoding the transcription factor gata in ds aml patients are responsible for the observed hypersensitivity of ds aml blasts to cytosine arabinoside (ara-c). in view of excellent survival rates (approaching %) of ds aml patients, the ongoing children's oncology group (cog) aaml study seeks to determine the feasibility of treating standard risk (minimal residual disease/mrd negative) ds aml patients using a reduced dose ( -fold decrease) ara-c backbone. although results from japanese trials with this approach are promising, north american and european data are conflicting. although chromosome rearrangements in ds aml do not appear to carry the same adverse prognostic significance as in non-ds aml, monosomy in ds aml patients has been associated with a moderately worse outcome. isochromosome q, however, is rare and has only been reported in previous cases of ds aml. objectives: to report our institutional experience of very early relapse involving cases of ds aml patients treated per the reduced dose ara-c arm ( . g/m ) of the aaml study. design/method: we hereby report the disease course and cytogenetics of the above ds aml patients. : patient is a month old caucasian female who had gata mutation negative aml. patient is a -year old caucasian male whose chromosomal analysis revealed isochromosome q ( copies of the long arm of chromosome ). both patients achieved negative mrd (< . %) after induction i chemotherapy with thioguanine, low-dose ara-c and daunorubicin and proceeded per the reduced dose ara-c arm of aaml . patient relapsed immediately after completion of chemotherapy. salvage chemotherapy with mitoxantrone/high dose ara-c (hidac) failed to induce a second remission and the patient subsequently died of disease. patient relapsed within months from end of therapy. the patient underwent salvage chemotherapy utilizing a hidac backbone and remains in disease remission. the noted very early relapse following a reduced dose ara-c regimen in our above ds aml children suggests that testing for gata mutation and chromosome rearrangements may play a useful role in the development of future risk-stratified treatment strategies for ds aml. university of rochester, rochester, new york, united states background: in developed countries in the st century, severe nutritional deficiency is not an often considered differential diagnosis of unexplained childhood anemia. aside from iron deficiency anemia, vitamin deficiency severe enough to impact hematopoiesis is uncommon in the general pediatric population. here we present the unique case of a -monthold infant who presented with intermittent emesis, failure to thrive (ftt), developmental delay, macrocytic anemia, and neutropenia which was initially concerning for a congenital bone marrow failure syndrome. instead, she was discovered to have an underlying, potentially familial deficiency of b . objectives: . to describe the unique case of an infant with b deficiency. . to outline the importance of including b deficiency in the differential diagnosis of unexplained megaloblastic anemia in children. a -month-old exclusively breastfed infant presented for gastroenterology evaluation due to persistent emesis and poor weight gain over the course of months. her history was notable for delayed developmental s of s milestones and hypoactivity. marked pallor prompted hematologic evaluation, which revealed concern for macrocytic anemia (hemoglobin . g/dl, mcv ), reticulocytopenia ( . × ^ / l), and neutropenia (anc . × ^ /l). an otherwise reassuring physical examination and laboratory evaluation was notable only for the discovery of an undetectable b level and marked hyperhomocysteinemia ( mol/l). her hemoglobin (hgb) continued to decline (to . g/dl) over the first few days after presentation, and she required red blood cell (rbc) transfusion. within only a few days of initiation, daily cyanocobalamin injections resulted in a robust reticulocytosis response, improved hgb, immediate normalization in the neutrophil count, and resolution of hyperhomocysteinemia. additional history and laboratory evaluation from the patient's mother revealed a concurrent, asymptomatic maternal b deficiency as well as a history of a need for b supplementation in the maternal grandfather, raising concern for an inherited etiology. despite the rarity of vitamin-deficient hematologic abnormalities in the general pediatric population, b deficiency should be considered as a potential cause of an otherwise unexplained megaloblastic anemia, especially in the setting of concurrent ftt and neurodevelopmental delay. a detailed family history should be obtained in such cases and may have helped to prevent this patient's clinical sequelae had the deficiency been discovered sooner. our patient has experienced a favorable clinical response to b supplementation, attesting to the importance of vitamin b in early childhood growth and development. background: peg-asparaginase is universally utilized in the treatment of pediatric acute lymphoblastic leukemia (all). despite its high efficacy in this disease, it is associated with hypersensitivity and allergy in - % of patients. protracted anaphylaxis has been described in circumstances such as severe food allergy with ongoing allergen exposure; however, it has not yet been described in relation to peg-asparaginase. we describe the first reported case of protracted anaphylaxis after peg-asparaginase administration, provide guidance as to time course and management of protracted anaphylaxis, as well as evidence that erwinia asparaginase may be safely administered even in this high risk population. objectives: to provide guidance regarding the duration, course and management of protracted, severe anaphylaxis after peg-asparaginase therapy. a year old male with very high risk all presented for consolidation therapy with peg-asparaginase (intramuscular) and vincristine. one hour after administration, he developed generalized hives and angioedema, for which he was given diphenhydramine. he then quickly developed progressive hives, angioedema, subjective throat and chest tightness, and wheezing. he was treated with diphenhydramine, epinephrine, albuterol, and methylprednisolone with resolution of symptoms. one hour later, symptoms recurred and the patient became hypotensive; he was retreated with methylprednisolone and epinephrine, and was transferred to the pediatric intensive care unit (picu). in the picu, he was placed on an epinephrine drip, and continued on methylprednisolone, diphenhydramine, cetirizine, albuterol, and ranitidine. the epinephrine drip was successfully discontinued after hours, and his other medications were gradually weaned over the course of two weeks. of note, the patient did have st segment changes in his electrocardiogram during the first hours of anaphylaxis. these were associated with normal ventricular function as per echocardiogram, and resolved within one week. this patient has subsequently tolerated multiple doses of erwinia asparaginase (intramuscular) without premedication. this patient was acutely managed in the pediatric intensive care unit with steroids, anti-histamines, and continuous infusion epinephrine. symptoms consistent with severe anaphylaxis including hives, angioedema, throat and chest tightness, wheezing, and hypotension persisted for a total of four days before finally resolving. he has thus far tolerated multiple doses of erwinia asparaginase without any symptoms of allergy, hypersensitivity, or anaphylaxis. protracted severe anaphylaxis after peg-asparaginase therapy can be successfully managed with multi-agent therapy, including antihistamines, steroids, and continuous infusion epinephrine. re-challenge with an alternate form of asparaginase may be tolerated, even in a patient with protracted anaphylaxis to peg-asparaginase. ucsf benioff children's hospital oakland, oakland, california, united states background: vincristine (vcr) is widely used in pediatric cancers. unlike most cytotoxic agents, hematopoietic toxicity is uncommon. vcr-induced anemia has been observed but its mechanism has not been well studied. vinca alkaloid-induced membrane changes were seen in early studies of hereditary spherocytosis (hs) and anecdotal cases suggest vcr may increase hemolysis in such patients. here we describe a case involving severe vcr-induced anemia in a patient with hs and an explanation as to the mechanism. objectives: to describe the mechanism of vcr-induced anemia in hs. design/method: case report. a year-old female with hs was diagnosed with t-lymphoblastic lymphoma. she had required packed red blood cell (prbc) transfusions as a neonate and thereafter had done well without episodes of acute hemolysis or aplasia. complete blood counts (cbc's) demonstrated a compensated hemolysis, and she did not require further transfusions until she commenced chemotherapy. by the start of maintenance she had received many more prbc transfusions than the average patient. intermittent drops in hemoglobin (hb) did not correlate with any particular agent, and she had stable, mild splenomegaly. a clear pattern emerged during maintenance. her hb was - g/dl at monthly clinic visits, when she received vcr, intermittent intrathecal methotrexate, and corticosteroids. within - days, her hb dropped to . ± . g/dl, and reticulocyte count decreased from . to . ± . %. transfusion at day corrected hb, and the reticulocytes and hb returned to baseline. white blood cell and platelet counts did not change after vcr. blood samples from pre, immediately post, and days post vcr were analyzed and rbc characteristics and markers of hemolysis were not significantly different. ektacytometry showed identical curves, indicating no change in rbc deformability. in vitro incubation of patient blood samples with vcr also did not affect the osmotic deformability, confirming that a change in rbc rigidity was unlikely the reason for the drop in hb. these data indicate that a dysregulation of erythropoiesis was responsible for the anemia after vcr, rather than damage of peripheral rbc's. in most patients, maintenance therapy for lymphoblastic lymphoma does not cause severe anemia, likely because a temporary reduction in erythropoiesis in patients with a normal rbc survival and low reticulocyte count is not noticed. however, in a patient with decreased rbc survival and a brisk reticulocytosis, a disruption in rbc generation is more apparent. in conclusion, vcr administration to patients with an rbc disorder warrants close observation for potentially severe vcr-induced anemia. background: the addition of tyrosine kinase inhibitors (tki) to conventional chemotherapy has improved outcomes for pediatric patients with philadelphia chromosome-positive (ph+) acute lymphoblastic leukemia (all), however there remains an increased risk of relapse compared to other types of childhood all. typically, in relapsed disease the philadelphia chromosome persists and several mechanisms of resistance involving acquired mutations of the bcr-abl chimeric oncoprotein have been reported. objectives: describe a unique case of a pediatric patient with ph+ b-precursor all relapsing with b-precursor all without the philadelphia chromosome. results: an -year-old boy was diagnosed with ph+ bprecursor all with the presence of the t( ; )/bcr-abl translocation by cytogenetics and fluorescence in situ hybridization (fish), respectively. additional abnormalities included gains of runx and loss of one copy of etv . a remission bone marrow with negative minimal residual disease (mrd) was achieved at the end of induction with dasatinib and the esphall chemotherapy backbone. duration of tki therapy was two years post diagnosis. nearly one year after the completion of therapy, cytopenias prompted a bone marrow investigation. relapsed b-precursor all was established by immunophenotyping, however fish analysis did not identify the bcr-abl rearrangement. moreover, quantitative reverse transcriptase pcr was negative for the bcr-abl fusion transcript. again fish analysis of the bone marrow revealed multiple additional copies of runx and mono-allelic loss of etv , similar to the initial diagnostic sample. the patient was re-induced per aall anticipating a ph+ all relapse. however, with confirmation of the loss of the ph+ clone, tki therapy was not re-initiated. due to positive mrd of . % at the end of re-induction therapy, the patient was salvaged with blinatumomab therapy and subsequently underwent an allogenic stem cell transplant with a sibling donor. conclusion: this is the first known report of a pediatric patient with ph+ b-precursor all who developed recurrent b-precursor all without the philadelphia chromosome. the persistent findings of gain of runx and loss of etv makes it unlikely that a second unrelated b-precursor all developed following successful treatment of the original disease. this case highlights the possibility of a genetically distinct subclone present at the onset of disease that shared abnormalities of runx and etv but did not contain the philadelphia chromosome. nevertheless, the subclone harbored leukemogenic potential in the absence bcr-abl expression. it is plausible that the predominant clone present at diagnosis was effectively treated with dasatinib and extinguished, but the bcr-abl -negative clone persisted in the face of tki therapy. background: ligneous conjunctivitis is a rare form of pseudomembranous conjunctivitis that develops specifically in patients with type plasminogen deficiency. lack of plasmin activity in those patients result in defective fibrinolysis and formation of fibrin-rich membranous material/ masses that develops on the palpebral conjunctiva as well as other sites in the body.current management involve surgical excision of the masses that is usually complicated by multiple recurrences. recently, use of topical plasminogen concentrates helped delaying recurrence, but currently, those concentrates are not commercially available. we report on a -year-old omani girl, with hypoplasminogenemia who required optimization of plasminogen level at the time of surgery to delay/ prevent recurrence. objectives: case report on the peri-operative use of ffp versus cryopricipitate transfusion as an alternative replacement of plasminogen during surgical excision of ligneous conjunctivitis. design/method: pharmacokinetic study was performed to assess plasminogen recovery after ffp ( ml/kg) and precipitate ( bag/ kg) transfusion results: plasminogen levels remained subnormal after either ffp or cryoprecipitate administration. with ffp, the maximum concentration reached was almost % of normal. although half-life of plasminogen is known to be - . days, the patient seemed to have a high catabolic rate after receiv-ing cryoprecipitate, with plasminogen levels reaching basal levels within hours. because of the better recovery profile with ffp, we opted to give ffp before and after surgery. peri-operative management included ffp transfusion at ml/kg/ hours one day before and for days post operatively, followed by ml/kg once daily from day - , then ml/kg on th post-operative day. topical treatment was initiated using antibiotic and steroids ed on the day of surgery, followed by heparin ed on the second day. on follow up, she used topical heparin, cyclosporine, prednisolone, and topical lubricant eye drops for variable duration. clinical picture remained stable for almost year post operatively, when she started to develop recurrence of ligneous lesions again. background: ponatinib (inclusig®, ariad pharmaceutical) is a rd generation multi-targeted tyrosine kinase inhibitor (tki) approved for treatment of adults with chronic myeloid leukemia (cml) and philadelphia chromosomepositive acute lymphoblastic leukemia (ph+ all) resistant to or intolerant of other tkis. ponatinib has numerous drug-drug interactions and a black box warning for associated serious adverse vascular events and hepatotoxicity. for this reason, ponatinib use has been confined to specific high-risk populations. however, in patients who prove refractory to other therapies, the potential benefits of ponatinib may outweigh risks. to date, ponatinib has not been studied in the pediatric/adolescent and young adult (aya) population. furthermore, literature describing the use of ponatinib alone or in combination with other agents in pediatric oncology patients is scarce. objectives: to describe a single institutional experience using ponatinib in the pediatric patients with ph+ all. design/method: two cases of ponatinib use in pediatric ph+ patients resistant to other tkis were identified at our institution and are described. peripheral blood samples obtained from both patients identified bcr-abl p fusion transcripts and sanger sequencing was used to identify resistant mutations. results: our first case is a -year-old female who received upfront multi-agent chemotherapy plus dasatinib for ph+ all. relapse was confirmed on end-of-therapy bone marrow evaluation, thus bcr-abl mutation testing was performed and revealed a t i mutation. ponatinib was initiated then discontinued after one week due to clinically significant fluid retention with peripheral edema and bilateral pleural/pericardial effusions. the second case is a lateadolescent female with ph+ all who relapsed -years after stem cell transplant (sct). following relapse, tki therapy included both imatinib and dasatinib. due to persistence of bcr-abl fusion transcript despite tki therapy she was switched to ponatinib. shortly following initiation of ponatinib she developed a diffuse, maculopapular rash, which persisted despite dose reduction, resulting in ultimate discontinuation of the drug. bcr-abl mutation testing identified f l and f v resistance-conferring mutations. to date, there is scant existing literature detailing the use of ponatinib in pediatric patients. appropriate dosing is undefined and side effect profile not well described, particularly when used concurrently with other chemotherapeutic agents. thus, this case series reporting the response to and toxicity of ponatinib in pediatric ph+ all patients has important clinical implications. additionally, this is the first report of a pediatric ph+ all patient with documented t i mutation underscoring the importance of bcr-abl mutational testing, particularly at the time of relapse. cooper university hospital, camden, new jersey, united states background: myh -related disorder is a rare autosomal dominant disease, encompassing several subtypes: may hegglin anomaly, epstein syndrome, fechtner's syndrome, and sebastian syndrome. heterozygous mutations are seen in the gene encoding non-muscle myosin heavy chain iia (nmmhc-iia) which is involved in cell motility as well as functions to maintain cellular shape and integrity. the presentation of myh -rd is mainly characterized by macrothrombocytopenia, but various related expressions exist: nephritis often leading to renal failure, cataracts and sensorineural deafness ( ). a -year-old girl with history of extensive dental caries, hyperactivity, and speech delay due to suspected hearing loss was incidentally found to have thrombocytopenia at the time of genetic evaluation. she did not have any bruising or excessive bleeding. she did not respond to observation, immunoglobulins, or steroid therapy. her platelet count remained persistently low ( - k/ul). she underwent extensive evaluation to rule out platelet disorder vs. coagulation defect. her peripheral smear showed enlarged platelets by giemsa stain but no inclusion bodies were noted in granulocytes. her platelet aggregation and platelet surface glycoprotein by flow cytometry were negative. her coagulation profile was also normal. objectives: this case report summarizes the complexity in diagnosing myh -rd in a pediatric patient. design/method: since a unifying diagnosis for her clinical presentation was not apparent, whole exome sequencing (wes) was undertaken. results: wes revealed the r c heterozygous pathogenic variant, located in exon in the myh gene. myh gene alteration explained the patient's clinical features of macrothrombocytopenia and hearing loss. this mutation was paternally inherited, and her father demonstrates mosaicism. he was asymptomatic with normal platelet count but his morphology showed enlarged platelets with no inclusion bodies in granulocytes. when dealing with patients who have mild or no symptoms of bleeding diathesis but evidence of persistent macrothrombocytopenia, considering a platelet disorder belonging to myh -rd can help delineate certain predisposing syndromes and guide clinical management. patients are likely to benefit from early genetic testing while receiving supportive therapy. wes can highlight syndromes and provide information on recurrence risk for families. the renal and hearing abnormalities are indistinguishable between epstein and fechtner's syndromes, but the pathogenic variants differ ( ). the genotype-phenotype correlation implies that our patient may have either syndrome, although clinical features compatible with nephritis have yet to manifest. patients should be monitored closely for long-term progression of myh disease, and treatments should be initiated accordingly. we present an -year old female evaluated by genetics at birth due to prenatal microcephaly. chromosomes and microarray were normal. at age she developed standard risk pre-b-cell acute lymphoblastic leukemia (all). she completed treatment in and has been doing well in the interim, remaining in complete clinical remission. during and after treatment she exhibited developmental delay and neurocognitive deficits. at age her height and weight were at or below the th centile and head circumference was below the nd centile (approximately standard deviations below the mean and corresponding to the th centile for a -month-old girl). bone age was appropriate. she had a distinctive triangular face with micrognathia and a pointed nose resembling a seckel-like syndrome. the patient also had clinodactyly of the th toes, zygodactylous triradius involving the nd and rd left toes, tendency to sydney line in the right palm and a radial loop in the left middle finger. the patient's unique clinical presentation prompted a more thorough genetic evaluation, which led to a novel finding we feel is clinically significant with regard to the development of malignancy. design/method: whole exome sequencing (wes) was performed on the patient as well as her biological parents (trio). a de novo heterozygous mutation in the gene pcdh with potential relation to the phenotype was discovered. this c. dupa variant causes a frameshift starting with codon asparagine , changing this amino acid to a lysine residue and creating a premature stop codon at position of the new reading frame denoted p.asn lysfsx . this variant is predicted to cause loss of normal protein function via protein truncation or nonsense-mediated mrna decay. conclusion: pcdh is a member of the protocadherins family which is important in cell-to-cell adhesion and synaptic function in the central nervous system and is highly expressed in areas of the brain involved in higher cortical function and speech. aberrant expression of protocadherins has been associated with the development of malignancies in many organ systems. with regards to leukemia, the methylation status of this gene at diagnosis has been implicated in the prognosis of all and could be used as a biomarker to predict relapse. this patient's de novo mutation and clinical presentation are unique to what has been previously presented in the literature. we feel that this mutation is a clinically significant finding that may shed light on the role of this gene in the development of hematopoeitic malignancies. background: acquired hemophilia a (aha) is an uncommon and potentially life-threatening hemorrhagic disease characterized by sudden onset of bleeding in patients with neither personal nor family history of bleeding dyscrasia. it is usually seen in adults with autoimmune diseases, solid tumors, lymphoproliferative diseases, pregnancy or during the postpartum period; occurrence in the pediatric population has rarely been reported. we report a case of an otherwise healthy teenager who was found to have aha when he presented with acute onset of atraumatic soft tissue hematoma. results: a -year old male of middle eastern descent with history of congenital absence of the right external ear, but otherwise in good general health, presented to our emergency department with a three day history of progressive worsening of right lower leg pain, swelling, and paresthesia, without preceding history of trauma. evaluation by the pediatric orthopedics service documented significantly elevated compartment pressures, necessitating immediate four-compartment fasciotomy. pre-operative labs were significant for prolonged activated partial thromboplastin time (aptt) of . ( . - . ) seconds with normal prothrombin time (pt) and international normalized ratio (inr). ptt did not correct on mixing studies, suggesting the presence of a circulating anticoagulant. factors xii and xi were in the normal range; factor ix was elevated, ( - ). factor viii level was % and fviii inhibitor level was . bethesda units (< . ), confirming the diagnosis of aha. work up for autoimmune disease was negative. his bleeding and surgical hemostasis were managed with recombinant factor vii (novoseven) mcg/kg every hours for hours post operatively, with gradual interval prolongation. factor viii antibody eradication was managed with prednisone mg/kg/day. factor viii and inhibitor levels normalized by day of hospitalization. recombinant factor vii was discontinued; steroids were gradually tapered and discontinued at discharge (hospital day ). conclusion: acquired hemophilia is likely an underdiagnosed condition in pediatrics. while it is typically seen in adults with underlying autoimmune disease, solid tumors, lymphoproliferative disease, or during pregnancy or the postpartum period, pediatric cases may have no identifiable etiology. this case highlights the importance of considering this diagnosis in any patient with unexplained bleeding regardless of their age, so as to intervene early and prevent adverse consequences. university of oklahoma, oklahoma city, oklahoma, united states background: myeloid neoplasms associated with eosinophilia is a rare subtype of chronic leukemia characterized by clonal eosinophilia. the true incidence is unknown due to its rarity and possible classification as idiopathic hypereosinophilia syndrome. the most common chromosomal aberrations involve platelet-derived growth factor receptors (pdgfrs). we report one such rare case in a pediatric patient. most of the pediatric management of this entity is derived from adult case reports and case series. objectives: to describe a case of chronic leukemia presenting as eosinophilia results: a previously healthy year old caucasian male presented with a several week history of migrating joint pain, splenomegaly, and abnormal blood counts with leukocytosis, thrombocytopenia and absolute eosinophilia. white blood cell differential showed myeloid precursors suggestive of chronic myeloid leukemia. bone marrow evaluation showed % blasts and % eosinophils. bcr-abl testing was negative, ruling out cml. fish analysis for eosinophilic clonality revealed deletion of chic gene, resulting in fip l /pdgfra fusion gene, diagnostic for myeloid neoplasm with eosinophilia associated with pdgfr abnormalities. treatment was started with tyrosine kinase inhibitor (tki), imatinib mg daily. within months, fish analysis for fusion gene was negative. after approximately months of daily imatinib, he was switched to maintenance dose of mg weekly. he is approximately months since diagnosis and doing well on maintenance imatinib. in , the who revised its classification of some chronic eosinophilic leukemias to myeloid and lymphoid neoplasms associated with eosinophilia and rearrangement of pdgfra, pdgfrb, fgfr . the most common abnormality is the fip l /pdgfra fusion gene. other less common abnormalities include fusion genes kif b-pdgfra and etv -pdgfrb and point mutations in pdgfra . some features of chronic eosinophilic leukemia include absolute eosinophilia, splenomegaly, elevated vitamin b and tryptase levels, and organ damage from eosinophil infiltrates and cytokine release. patients with rearrangements or mutations involving pdgfra are usually very responsive to imatinib. starting doses have not been well studied or established. experts recommend co-administration of corticosteroids during the first few days of imatinib therapy in patients with a history of cardiac involvement and/or elevated serum troponin levels to prevent myocardial necrosis, a rare complication of imatinib therapy in eosinophilic patients. fortunately our patient did not have cardiac involvement and to date has not exhibited signs of chronic tki toxicity. conclusion: myeloid neoplasms with eosinophilia constitute a rare form of chronic leukemias. they are often associated with pdgfr abnormalities and are usually very responsive to tyrosine kinase inhibitor therapy. walter reed national military medical center, bethesda, maryland, united states background: germline samd l mutation is a rare cause of constitutional bone marrow failure with a unique propensity for clonal evolution to monosomy and mds. objectives: previous case series have demonstrated diverse clinical outcomes in patients with a germline samd l mutation. our case presents a novel samd l mutation (p.val leu). additionally, the case highlights the challenges in clinical decision making for a patient with a gene mutation that is known for clonal evolution towards monosomy with risk of progression to myeloid malignancy, but also known for self-correction through uniparental disomy or inactivating mutations which results in disease remission. design/method: a retrospective chart review and review of the literature was performed. dna was isolated from peripheral blood and used for whole exome sequencing. a peripheral blood sample from the patient's mother and father showed no samd l mutation. skin biopsies of the patient and parents were evaluated for uniparental disomy or new mutations. to determine the pathogenicity of this novel mutation, the specific samd l mutant dna was transfected into the human embryonic kidney cell line to assess its role in inhibiting cell proliferation. our patient presented at months of age with pancytopenia and hypocellular bone marrow in the setting of s of s sepsis. he had evidence of dysfunctional immune activation with hemophagocytosis and elevated soluble il with simultaneous severe hypogammaglobulinemia. analysis of the peripheral blood showed no increase in chromosomal breakage, normal telomere length, and normal flow cytometry. gene testing for primary hemophagocytic lymphohistiocytosis and inherited bone marrow failure were negative. after the patient recovered from his presenting illness, a repeat bone marrow biopsy demonstrated improved cellularity with myelodysplasia and cytogenetics significant for monsomy .whole exome testing demonstrated a novel samd l mutation. the patient continued to require intermittent ivig and failed to demonstrate appropriate leukocytosis with intermittent infections. on repeat bone marrow evaluation over the course of months, the patient demonstrated no evidence of evolution towards self-correction and had a persistent monosomy clone. the patient is scheduled to undergo a matched unrelated donor bone marrow transplant. our case highlights the unique clinical picture associated with constitutional marrow failure and clonal evolution secondary to a novel samd l mutation which is thought to cause pancytopenia by inhibiting cellular proliferation and often results in the development of monosomy which rescues hematopoiesis but with a risk for malignancy. background: notable labs developed a flow cytometricbased assay with a custom robotic platform to test fdaapproved drugs for anti-cancer activity against individual patient's tumor cells. this personalized assay is a potential method for identifying novel agents and drug combinations to treat aml patients who have failed standard therapies. objectives: to present the case of a teen who underwent successful treatment of relapsed aml post-sct with bortezomib, panobinostat, and dexamethasone-a regimen selected based upon results of notable lab testing. results: a -year-old male with m -aml had an isolated bone marrow relapse months after completion of scheduled therapy. at relapse, his aml was flt -itd positive. he achieved a second remission with negative mrd and underwent matched sibling donor bmt after busulfan/cyclophosphamide conditioning. bma performed on day + was mrd positive ( . %). repeat bma done on day + showed . % mrd. he started sorafenib on day + . he received donor lymphocyte infusion (dli) on day + , then received cycles of azacitadine (aza) followed by dli. marrow mrd by flow after sorafenib alone, sorafenib with dli, and sorafenib with aza/dli were %, . %, and . %, respectively. treatment was complicated by varicella meningitis, grade i skin agvhd, febrile neutropenia and c. difficile colitis, and metapneumovirus pneumonia. despite extremely low levels of leukemia (marrow mrd . %), notable lab testing performed on the patient's leukemia cells from marrow collected after aza/dli/sorafenib revealed sensitivity of his leukemic blasts to a combination of bortezomib, panobinostat, and dexamethasone. because of prolonged cytopenias, multiple infectious complications, and persistently positive mrd, he discontinued aza/dli/sorafenib and on day + started bortezomib . mg/m iv on days , , , and ; panobinostat mg po on days , , , , , ; and dexamethasone mg po on days , , , , , , , and . chemotherapy cycle started days later. he tolerated treatment without side effects and with resolution of rash and cytopenias. he achieved full donor chimerism, negative flt -itd, and complete remission by morphology and flow after two cycles. notable lab testing is a powerful tool for evaluating the sensitivity of small populations of leukemic blasts to novel drug therapy. results from notable lab testing may serve as a useful guide for treatment selection after failure of standard aml therapy. this patient achieved morphologic and mrd remission post-sct with bortezomib, panobinostat, and dexamethasone-a regimen predicted to be efficacious based upon notable lab results. maria ahmad-nabi, christine knoll, sanjay shah, esteban gomez, lori wagner phoenix children's hospital, phoenix, arizona, united states background: development of inhibitors in patients with factor ix deficiency (fixd) is a well-recognized complication occurring in - % of patients. within this subset a small percentage can develop anaphylaxis to factor. desensitization with cyclophosphamide, an alkylating agent used in the management of various oncologic malignancies, and reported for use in factor viii desensitization has been previously unreported for use in desensitization in patients with fixd. rituximab, an anti-cd antibody, however has been used. objectives: to induce immune tolerance (it) in patients with inhibitors to factor ix with either novel or under reported methods using cyclophosphamide and/or rituximab. we report a case series of patients at phoenix children's hospital with fixd who achieved it with cyclophosphamide and/or rituximab. results: patient one was a year old male with severe fixd, who at the time of desensitization had inhibitor levels of bu. he was desensitized with cyclophosphamide, then admitted for infusion of recombinant factor ix. he experienced a few minor symptoms of intolerance including an urticarial rash which was self-limited, and hemarthrosis of the right elbow on day which responded to novo . he tolerated the remainder of his infusion without issues. he continued recombinant factor ix daily, and returned to clinic for monthly cyclophosphamide for months. he did develop urticaria with hemarthrosis and spontaneous muscle bleeds which were tempered with zantac, zyrtec, solumedrol, and benadryl. he remained without a recurrence of inhibitors, however did have intermittent hemarthrosis of his ankles thereafter requiring prophylactic twice daily dosing recombinant factor ix. patient two was a year old male with severe fixd and a family history of anaphylaxis to factor causing early death in all male relatives with the disease. he had never received factor ix and did not have a detectable inhibitor prior to desensitization. he successfully underwent desensitization to recombinant factor ix with rituximab in the icu, and returned to clinic for weekly infusions x . he experienced no adverse reactions concerning for anaphylaxis. he continued to tolerate factor ix products without evidence of intolerance, development of inhibitors, and continues on as prophylactic dosing of recombinant factor ix every other day. our experience at a single institution proves cyclophosphamide as a novel agent for inducing it in those with fixd and anaphylaxis. it also provides further evidence that rituximab can desensitize patients with severe fixd. differences include longer duration for cyclophosphamide therapy ( months vs month). background: cartilage-hair hypoplasia (chh) is an autosomal recessive chondrodysplasia associated with defective cell-mediated immunity caused by mutations in the ribonuclease mitochondrial rna processing (rmrp) gene. cancer incidence is -fold higher in patients with chh than in the general population, especially non-hodgkin lymphoma. the use of rituximab, an anti cd antibody, results in decreased host b-cell number and impaired humoral function for - months. the safety of rituximab in pediatric patients with cancer and immunodeficiency is not well documented. a diagnosis of underlying immunodeficiency may discourage physicians from using rituximab due to the risk of severe bacterial infection or viral re-activation. objectives: to report a case of burkitt lymphoma in a young adult female with chh and defective cellular immunity successfully treated with rituximab. results: an -year old amish female with disproportionate short stature presented to our center for management of stage iv biopsy proven burkitt lymphoma with myc rearrangement. she had presented a week earlier with cervical, occipital, and submandibular lymphadenopathy, splenomegaly; fevers, night sweats, and weight loss for - weeks. on exam, her height was three feet associated with brachydactyly, mild bowing of the legs, normal size head without frontal bossing, fine and sparse hair. she had normal intelligence. her pattern of dysmorphisms was suggestive of chh (genetic testing not performed at time of diagnosis). pet-ct scan showed stage iv disease with involvement of cervical lymph nodes, spleen, iliac bone and bone marrow. treatment with standardintensity fab/lmb therapy (group c) with the addition of rituximab was initiated. she had an incomplete response to cop (∼ % reduction of tumoral masses) but achieved complete remission after copadam . her course was complicated with severe varicella zoster but she completed therapy and remains in complete disease remission for months after treatment completion. genetic testing subsequently performed proved homozygosity for chh with a n. a>g variant. she had no other opportunistic infections during or after therapy. conclusion: the use of rituximab was both safe and beneficial in our patient despite defective cell mediated immunity secondary to chh suggesting that rituximab may be safe to use in patients with cellular immune deficiencies. background: hemophilia a and b are bleeding disorders characterized by deficiency in factor viii or ix, respectively. spontaneous or provoked hemarthrosis is a known complication of hemophilia. repetitive episodes of hemarthrosis can lead to debilitating hemophilic arthropathy. lyme disease is a tick-born infection which is endemic to increasing parts of the united states. chronic lyme disease, the phase in which lyme arthritis typically develops, occurs months to years after initial infection and is characterized by swelling of one or more large joints generally in the absence of systemic symptoms. objectives: review cases of hemophilia a and b patients with episodes of provoked hemarthrosis refractory to intensive recombinant factor replacement therapy found to have concurrent lyme arthritis. design/method: we report two clinical cases and review relevant literature. results: first, we report a year-old male with moderate hemophilia a with a provoked knee hemarthrosis which failed to improve despite months of intense factor replacement therapy requiring multiple hospitalizations. factor replacement regimens included twice daily standard half-life recombinant factor viii products or daily to every other day extended half-life recombinant factor viii products with trough levels aimed as high as - %. factor viii pk studies were obtained for dosing, to confirm adherence, and to evaluate for subclinical inhibitors (inhibitor testing was negative). given protracted symptoms additional workup for hemarthrosis was pursed. lyme titers were positive for ( )igg, though negative for igm. he was treated with days of doxycycline during which time hemarthrosis greatly improved on examination and imaging, and he was able to recover function through physical therapy. second, we report a year-old male with moderate hemophilia b who required multiple hospital admissions for a provoked knee hemarthro-sis with no improvement in symptoms despite weeks of daily or twice daily factor replacement with standard halflife recombinant factor ix products aiming for % correction. we performed inhibitor testing (which was negative) and pk studies to assess for non-detectable inhibitors, dosing and adherence. lyme testing was positive for ( )igg, though negative for igm. he was treated with amoxicillin for days during which time hemarthrosis significantly improved on examination and imaging. diagnosis and follow-up imaging studies for both patients included mri and serial bedside ultrasounds performed as per uc san diego school of medicine mskus guidelines. background: relapse/refractory aml following allogeneic hematopoietic stem cell transplant (hsct) holds a high mortality rate. current relapse/refractory therapy modalities for younger patients may include re-induction with a clofarabinebased regimen followed by second allogeneic hsct. even for patients who undergo second hsct, the five-year survival rate is dismal. new therapies, including small molecule inhibitors, are being studied in the post-hsct relapse setting or those unfit for hsct with promising results. venetoclax is a small molecule inhibitor that has received breakthrough designation for aml treatment in elderly patients objectives: to report a young adult aml patient with relapse post hsct who was successfully re-induced with topotecan, vinorelbine, thiotepa, clofarabine (tvtc) and has sustained remission with venetoclax maintenance therapy. this approach appears to be unique in terms of reported literature. results: our patient is now a -year-old female noted to have mll rearranged aml at initial diagnosis when she was years old. she underwent chemotherapy consisting of cytarabine/daunorubicin according to standard + . due to persistent disease, she was re-induced with g-csf, clofarabine, and high-dose cytarabine (gclac) which put her in cr. her course was complicated by sepsis, colitis, gastrointestinal bleed, deep venous thrombosis, and transfusionassociated circulatory overload. given her co-morbidities, she received another cycle of clofarabine/cytarabine, and then proceeded to reduced intensity allogeneic hsct, according to bmt ctn . the patient tolerated hsct well and experienced no transplant-related complications, including no acute or chronic gvhd. unfortunately, she relapsed about month's post-hsct. initial salvage therapy consisted of another course of g-clac, but due to persistent disease the decision was made to re-induce her with topotecan, vinorelbine, thiotepa, and clofarabine (tvtc). during this time however, she was found to have extensive infection with a fusarium species requiring a course of anti-fungal therapy. bone marrow evaluation showed no residual disease with an mrd of < . %. once the absolute neutrophil count recovered, the patient was started on single-agent venetoclax for maintenance therapy, which has been well-tolerated. she remains in morphologic remission for over months. we describe herein a young adult with multiply relapsed aml wherein tvtc re-induction, followed by maintenance with venetoclax were safely used in the post-hsct setting. venetoclax therapy in the relapsed aml setting warrants further study. background: vitamin b deficiency is uncommon in children in developed countries, especially in the absence of risk factors like malabsorption or inadequate dietary intake. it often presents with non-specific symptoms and signs and can elude diagnosis. the recognition and treatment of vitamin b deficiency is critical as it can lead to bone marrow failure as well as severe neurological and developmental problems in children. to increase index of suspicion of vitamin b deficiency anemia in children. we report a rare case of vita-min b deficiency anemia in a child who presented with a severe macrocytic anemia, with signs of hemolysis and concern of malignancy. design/method: an almost three-year-old previously healthy girl presented with a few day history of fever, emesis, fatigue and pallor. she had no dysmorphic features, hepatosplenomegaly or lymphadenopathy on exam, growth and development were normal. laboratory findings showed severe macrocytic anemia (hemoglobin . grams/dl; mcv . fl) with reticulocytopenia. signs of intravascular hemolysis were present with elevated lactate dehydrogenase ( , units/l) and haptoglobin below assay limit. immune-mediated hemolysis was ruled out. initial picture of a hemolytic anemia was compounded by other findings of moderate neutropenia, mild thrombocytopenia and peripheral smear showing occasional blasts. further workup was done with a broad differential diagnosis that included leukemias, hemolytic anemias, bone marrow failure syndromes, and specific deficiencies. results: workup revealed abnormally low vitamin b levels along with significantly elevated homocysteine and methylmalonic acid levels indicating functional vitamin b deficiency. bone marrow evaluation showed megaloblastic anemia and dyserythropoiesis consistent with vitamin b deficiency, and ruled out leukemia. vitamin b deficiency can cause a hemolytic anemia like picture secondary to intramedullary hemolysis due to ineffective erythropoiesis. myeloid precursors are also affected which can lead to neutropenia, thrombocytopenia, and abnormal peripheral blood cells. in our patient, initial symptomatic anemia was treated with blood transfusion, followed by intramuscular vitamin b injections with normalizing lab values. so far, workup for an etiology for vitamin b deficiency is negative except for an equivocal range of anti-parietal cell antibodies raising concerns for pernicious anemia; however it is rare in this age group. another rare condition is an inborn error of the cobalamin transporter. she is currently on oral vitamin b supplementation and further workup will be planned based on response. conclusion: this case highlights the importance of early consideration and thorough evaluation of vitamin b deficiency in children with unclear etiology of anemia, so that prompt treatment can be initiated. memorial hospital/ university of miami, miami, florida, united states background: despite great success in the treatment of acute lymphoblastic leukemia (all), the outcomes for patients with relapsed all remain poor. prognostic indicators include timing and site of relapse. blinatumomab, is the first agent in its class that simultaneously binds cd -positive cytotoxic t cells to cd -positive b cells resulting in lysis of malignant cells. however, mechanisms of leukemia resistance to blinatumomab are unclear. objectives: to describe a case with multiple sites of extramedullary (em) relapse during blinatumomab therapy. results: a -year-old hispanic male with philadelphia positive, cd -positive b-precursor cell all refractory to chemotherapy, had failed a bone marrow (bm) and was placed on blinatumomab and imatinib. he achieved minimal residual disease (mrd)-negative systemic remission, but during his fifth cycle developed bilateral periorbital masses. biopsies confirmed cd -negative isolated em relapsed disease, which was treated with radiation therapy (rt). there was notable resolution of em disease and he continued systemic therapy. subsequently, he presented with a painful left scapular swelling. imaging showed muscle and lung parenchymal em relapse with cd -positivity confirmed on histology. he continued on blinatumomab with localized rt while awaiting car-t cell therapy. his bm mrd remained negative until he developed systemic mrd-positivity with cd -positive blasts following the sixth cycle. primary resistance to blinatumomab is poorly understood. it is proposed that expansion of cd -negative clones or downregulation of cd following blinatumomab may play a role. this was observed in our patient's periorbital relapse; but subsequent em and systemic relapses were cd -positive, consistent with the co-existence of multiple clones in relapsed all. it has also been postulated that em relapse could be linked to the failure of blinatumomab or t cells to migrate to em sites of disease or drug inactivation by the microenvironment. the second em relapse in our patient, with cd -positive disease suggests this as a possible mechanism of relapse. this was reported in patients with cd positive non-hodgkin lymphoma (nhl), and higher doses of blinatumomab however, have shown promising results in this population. despite blinatumomab's effectiveness in inducing remissions in patients with refractory/relapsed all, it appears to have limitations in patients with em disease. these may arise either from the multiclonality associated with relapsed all or due to the emergence of resistance to blinatumomab, including failure to migrate to em sites. background: cyclic neutropenia is a rare hereditary disorder, characterized by recurrent neutropenia, cycling at about week intervals, with variable associated symptoms including oral ulcers and fever. there are reported cases of cyclic neutropenia associated with chronic inflammation leading to development of reactive aa amyloidosis. one patient also presented with amyloid goiter. we report a new case of cyclic neutropenia with associated renal and thyroid amyloid. design/method: a -year-old female presented with a month history of thyromegaly, and recurrent aphthous ulcers associated with fevers. laboratory workup showed severe neutropenia, anemia, azotemia, and abnormal thyroid function, with an absolute neutrophil count - / l, hemoglobin - . g/dl, serum creatinine - . mg/dl, and uric acid - . mg/dl. thyroid stimulating hormone was elevated - . iu/ml, and normal free t . urinalysis showed + protein, + blood, and - urine red blood cells/hpf. chest radiograph showed mild narrowing of the trachea from thyroid compression. bone marrow biopsy showed a hypocellular marrow, with tri-lineage hematopoiesis, left shifted myeloid maturation with very rare mature neutrophils. both renal biopsy and thyroid fine needle aspiration revealed abundant amyloid. of note, her father had aa amyloidosis, resulting in end-stage renal disease (esrd) requiring hemodialysis, and recurrent aphthous ulcers. the family history suggested a familial predisposition. genetic testing revealed a pathogenic elane c. a>t gene mutation with autosomal dominant inheritance confirming the diagnosis of cyclic neutropenia. we treated our patient with daily granulocyte colony stimulating factor to reduce the burden of chronic inflammation induced by cyclic neutropenia, and to preserve renal and other end organ function affected by further amyloid deposition. results: proband with elane gene mutation positive cyclic neutropenia, amyloidosis of thyroid and kidney, with a positive paternal history of aa amyloidosis resulting in esrd. cyclic neutropenia may result in chronic inflammatory states leading to secondary amyloidosis. university of kentucky, lexington, kentucky, united states background: overall survival of burkitt lymphoma (bl), regardless of stage, is greater than % in the pediatric population when treated with multi-agent chemotherapy. adenovirus is a common, usually self-limited infection within the pediatric population; however, findings can vary within an immunocompromised host. hepatitis is a rare complication, with very few reports of radiologic findings in this patient population. we discuss a three year old male with history of bl who presented with clinical and radiographic evidence of relapse but was found to have adenovirus hepatitis. design/method: a case report of a patient with bl in complete remission after completion of standard of care chemotherapy, who presented with return of high fever, elevated ldh, transaminitis and hepatic lesions. we describe the hepatic imaging and pathology consistent with adenovirus hepatitis in this immunocompromised host. our patient presented at three years old with a six week history of worsening abdominal pain and fevers. he was found to have a right sided pleural effusion, multiple lesions of the liver, and diffuse abdominal lymphadenopathy; biopsy of lymph tissue was consistent with bl. he completed therapy per anhl arm b and was in a complete remission at the end of planned therapy. one month after completion of therapy, he returned with high fever, abdominal pain and transaminitis, similar to his initial presentation. ct scan showed multiple hypodense discrete lesions throughout the liver and re-accumulation of right sided pleural effusion. ldh peaked at u/l (uln u/l). uric acid remained within normal limits. bilirubin peaked at . mg/dl, conjugated . mg/dl. liver biopsy was performed, showing smudgy nuclei with immunohistochemical staining positive for adenovirus. there was no evidence of lymphomatous involvement. resolution of hepatic lesions and transaminitis, with normalization of ldh and fever, occurred with symptomatic treatment alone. adenovirus is known to cause systemic disease in immunocompromised patients and rarely hepatitis. no pediatric patients with discrete hepatic lesions secondary to adenovirus have been reported in the literature. three cases of discrete hepatic lesions have been reported in adult immunocompromised patients, two with fatal fulminant liver failure and one who required cidofovir. this case demonstrates that a common pediatric viral infection can present with lesions concerning for metastatic disease in a pediatric lymphoma patient. prompt diagnosis is vital in the management of these patients when recurrent lymphoma is in the differential. background: heparin induced thrombocytopenia (hit) is an immunologic process in which antibodies bind a heparin complex and cause a paradoxical hypercoagulable state. ramifications of this process may include a multitude of thrombotic events and bleeding complications secondary to platelet consumption. in our patient, hit manifested as increased bruising, an acute decrease in platelet count, and continual clotting of her crrt circuit. hit, although rare in pediatrics, should be included in the differential for children with thrombocytopenia who have received heparin products. to present a unique case report of a critically ill pediatric patient who developed hit in the presence of multiorgan system failure and to discuss the challenges encountered with identification of an alternative anti-coagulant. results: a yo obese, caucasian female child presented to our facility with bilateral pulmonary emboli (of unclear etiology). initially, she was started on a continuous heparin infusion, but was transitioned to enoxaparin within days without issue. five days after enoxaparin was initiated, the patient developed acute kidney injury (evidenced by increasing creatinine) attributable to her biventricular heart failure. due to her need for continuous renal replacement therapy (crrt), she was transitioned back to a continuous heparin infusion. whereas her initial platelet count on transition was normal, she developed severe thrombocytopenia ( , ul) within hours. due to intermediate risk but low suspicion for hit, pf antibodies were sent which were positive. after much discussion, she was transitioned to an argatroban infusion which was titrated according to ptt levels. within hours, her platelet count normalized. at discharge, she was prescribed apixaban for anti-coagulant management. conclusion: hit is an uncommon presentation in the pediatric population. given its rarity, there is often a delay in diagnosis which increases risk of complications such as bleeding, stroke, and limb ischemia. even if the diagnosis is suspected or proven, there may be challenges in initiating alternative agents as limited data exists on pediatric options. as argatroban remains the treatment of choice for patients with hit, experience in pediatric patients is limited, and dosing recommendations have been extrapolated from adult studies. anecdotal data exists for use of bivalirudin in children, although studies, primarily, focus on use in specific cardiac cases. in our patient's case, choice was further complicated by renal failure. this case study highlights the need for further research regarding the identification of a secondary anti-coagulant agent for use in pediatric patients with hit. background: subcutaneous panniculitis-like t-cell lymphoma (sptl) is a rare form of non-hodgkin's lymphoma characterized by infiltration of cytotoxic t-cells into subcutaneous tissue. sptl occurs in both adults and children and can present in both patient populations as either alpha/beta or gamma/delta subtypes. patients with the gamma-delta phenotype have an overall poorer survival, although the exact etiology is unclear. interestingly, both subtypes of sptl can present with secondary hemophagocytic lymphohistiocytosis (hlh), and this is associated with a worse prognosis. currently, there are no standardized treatment protocols for sptl, and clinical management includes watchful waiting, corticosteroids/immunosuppression, chemotherapy, and stem cell transplant. the primary objective was to compare how two patients with the same diagnosis responded acutely to therapy. we performed a retrospective chart review of two pediatric patients at our institution who were diagnosed with alpha/beta sptl and secondary hlh. we examined each presentation, treatment course, and outcome. we then completed a brief review of the current literature describing treatment of and outcomes for sptl with secondary hlh. results: these two patients presented in a similar manner with signs and symptoms of hlh. each was then subse-quently diagnosed with alpha/beta sptl after biopsy of cutaneous nodules and each had diffuse disease, as measured by pet. however, they demonstrated vastly different acute responses to therapy. one patient was pre-treated with systemic glucocorticoids before receiving definitive chemotherapy and tolerated therapy well as an outpatient. the other patient started systemic chemotherapy without steroid pretreatment and developed severe cytokine storm characterized by hypotension, cardiac dysfunction, multi-organ failure and cytokine elevation. both patients achieved complete remission (cr) after treatment with chop chemotherapy and remain disease-free - months off therapy. in patients presenting with sptl and secondary hlh, we propose that initial treatment with antiinflammatory or anti-cytokine therapy can decrease, or even prevent, the possibility of life threatening cytokine release as a result of cytotoxic chemotherapy. background: congenital dyserythropoietic anemia type ii (cda ii) is a rare autosomal recessive disorder, rarely presenting in the neonatal period. iron overload often occurs as a late sequela of ineffective erythropoiesis and intramedullary hemolysis. objectives: to report the novel use of iron chelation in an infant with cda ii associated with severe iron overload. the patient is a -month-old, former -week infant with prenatal non-immune hydrops and transfusion-dependent fetal anemia who presented with persistent anemia, reticulocytopenia, hyperbilirubinemia, liver dysfunction, and hyperferritinemia. his initial ferritin was . ng/ml, tibc ug/dl, and transferrin mg/dl. his bone marrow biopsy showed trilineage hematopoiesis and erythroid dyspoiesis characterized by binucleation of late-stage precursors. genetic testing revealed a compound heterozygous missense mutation and splice site mutation in the sec b gene, confirming the diagnosis of cda ii. initial liver biopsy revealed mild portal fibrous expansion, and abundant hepatic iron deposition. his ferritin continued to increase, peaking at , ng/ml, along with liver enzymes peaking at an alanine aminotransferase (alt) of u/l and aspartate aminotransferase (ast) of u/l. ferriscan showed an elevated estimated liver concentration of . mg/g dry tissue. repeat liver biopsy months later showed giant cell hepatitis with worsening mild portal fibrosis and hemosiderosis. additionally, tissue liver iron concentration was mcg/g dry weight. cardiac t * mri revealed mild cardiac iron deposition. given his significant degree of iron overload, deferoxamine was used to reduce hemosiderosis and liver morbidity in preparation for bone marrow transplantation. the patient received deferoxamine mg/kg/day iv x days/week for three months, without any clinically significant adverse events. blood counts and hepatic and renal function were monitored weekly without any abnormalities. growth parameters and liver enzymes significantly improved while receiving chelation therapy. as a noninvasive, cost-effective method, serum ferritin levels were monitored monthly to gauge response to treatment. despite receiving blood transfusions every - weeks, serum ferritin decreased to ng/ml and liver enzymes decreased to alt u/l and ast u/l prior to bone marrow transplantation. we report the use of deferoxamine in a patient with cda ii less than years of age, for treatment of iron overload. our patient tolerated deferoxamine well without significant adverse events or organ toxicity. deferoxamine may be a well-tolerated method of reducing iron burden in young patients with iron-loading pathologies. background: low grade gliomas with kiaa- -braf fusions typically have a favorable prognosis with infrequent rates of high grade transformation, low rates of metastasis and even lower rates of extra cns metastasis. while highgrade transformation has been reported for tumors with braf v e mutations and cdkn a deletions, it has not been pre-viously reported in gliomas with kiaa- -braf fusions. while there are case reports of high-grade cns malignancies metastasizing through a ventriculo-peritoneal (vp) shunt, low-grade gliomas metastasizing in this manner are extremely rare. objectives: to describe a unique case of peritoneal tumor dissemination of a braf fusion positive high grade neuroepithelial tumor in a child with a vp shunt placed for multifocal braf fusion positive low grade astrocytomas results: an eight-year-old male was initially diagnosed with multifocal low-grade astrocytomas of the hypothalamus and c -c spinal cord. initial testing revealed the kiaa- -braf fusion, but no cdkn a or braf v e mutation. initial surgical management included a vp shunt and resection of the cervical spinal lesion. he received vincristine and carboplatin, followed by transition to vinblastine given new thoracic metastatic lesions after months of therapy. at months after diagnosis, scans were concerning for diffuse leptomeningeal progressive disease and new intracranial lesions, necessitating craniospinal radiation. following a near cr, he presented months later with acute onset of abdominal pain. a ct scan revealed peri-renal and perirectal soft tissue masses, confirmed by exploratory laparotomy to be peritoneal tumor dissemination of high grade neuroepithelial tumor. a kiaa -braf fusion was noted and confirmed by rt-pcr, identical to that seen in the original cns tumors. additional findings included deletion of chromosome p (without q loss) and heterozygous and homozygous deletion of cdkn a found by fish. brisk mitotic activity justified a high-grade designation. salvage chemotherapy consisted of cycles of ice with subsequent resolution of pet-avid disease and only minimal peri-nephric tissue remaining. given the favorable response, surgical resection and multiple tissue biopsies were performed which documented no residual active disease. the shunt was revised and he started trametinib for maintenance. we present a unique case of peritoneal dissemination of high grade neuroepitheial tumors with the same kiaa- -braf fusion as multifocal low grade astrocytomas in a child with a vp shunt. this raises suspicion for tumor metastasis and transformation to a higher grade malignancy versus two distinct diseases, which may be indicative of an underlying cancer predisposition. texas children's hospital, houston, texas, united states background: polycythemia is a common referral to hematology. it is important to evaluate for a high oxygen affinity hemoglobinopathy, ensuring appropriate testing is performed for early diagnosis and avoidance of additional tests and procedures. a year old mexican female presented with an elevated hemoglobin and hematocrit, symptoms of plethora of her hands and feet, chest pain, palpitations, and fatigue. further confounding the picture, she also had significant menorrhagia and iron deficiency. she was diagnosed with the rare high oxygen affinity hemoglobin new mexico variant, only previously described once in the literature in a year old black boy. objectives: the patient initially presented at age with a hemoglobin of . g/dl and a hematocrit of . %. initial work up consisted of a hemoglobin electrophoresis which diagnosed sickle cell trait, a co-oximetry panel which was normal, and erythropoietin level of mu/ml, also normal. she was then lost to follow up and re-referred at age . she is a competitive basketball athlete, and at that time, she presented with a hemoglobin of . g/dl, and hematocrit of %. erythropoietin level continued to be normal at mu/ml. design/method: cardiology was consulted regarding chest pain and palpitations with a normal evaluation. chest x-ray was also normal. a bone marrow aspirate and biopsy was performed with results significant for mild erythroid hyperplasia and mild reticulin fibrosis. jak mutation, von hippel lindau, bpgm, and hereditary erythrocytosis mutations including phd , hif a, and epor mutation analysis were sent, all of which were normal. testing to mayo clinic for p rbc oxygen dissociation returned low at mmhg ( - mmhg normal range) and subsequently a hemoglobin electrophoresis identified a hemoglobin variant leading to beta globin gene sequencing. results: patient found to be heterozygous for hemoglobin new mexico, with . % hb new mexico and . % hba, and . % hba . there was no evidence of hbs. when evaluating patients with polycythemia, maintaining a high index of suspicion for high affinity hemoglobinopathies may eliminate further unnecessary and invasive testing for patients. caution should be used when using hemoglobin electrophoresis testing since hb new mexico is known to migrate similarly to hbs on hplc with minimal change that may not be detected in regular laboratories. most high affinity hemoglobinopathies are reported to not have significant symptoms. in this case, our patient complains of fatigue, occasional palpitations and plethora of hands and feet. we will need to further follow this patient for possible attributable symptomatology. divya keerthy, simone chang, warren alperstein, patricia delgado, claudia rojas, ofelia alvarez, matteo trucco university of miami jackson memorial hospital, miami, florida, united states background: improved technology is enabling detection of previously unidentified translocations and mutations in otherwise unclassified sarcomas. one such mutation is the bcl- co-repressor -internal tandem duplication (bcor-itd) allowing for the new classification of bcor positive undifferentiated round cell sarcomas (urcs). this sarcoma has a similar appearance to clear cell sarcoma of the kidney (ccsk), potentially representing an extra-renal manifestation of this tumor, but their clinical pathologic features are not identical. objectives: this case highlights how recombinant polymerase chain reaction (rt-pcr) and bcor immunohistochemical staining can ease the diagnosis of this rare sarcoma. results: a month-old female presented for right sided pre-septal cellulitis and a temporal subcutaneous mass. the detection of multiple other subcutaneous nodules on exam raised the concern for malignancy and she was admitted for evaluation. she had two subcutaneous masses on her abdomen, with more cutaneous masses on her legs, back, shoulder, cheek and submandibular areas. she lacked spontaneous lower limb movement and had bilateral clonus. imaging confirmed multiple masses throughout the body including paravertebral area from t to l , bilateral adrenal glands, left kidney and muscles of upper and lower extremities. initial differential included neuroblastoma, infantile myofibromatosis, rhabdomyosarcoma or atypical presentation of a renal tumor. however, synaptophysin and chromogranin stains were negative. with standard immunohistochemistry, the tumor could be only broadly classified as "undifferentiated sarcoma" maintaining the diagnostic challenge. using rt-pcr in the setting of a morphologically primitive round cell neoplasm with strong bcor expression, two external institutes simultaneously diagnosed the tumor as bcor-urcs. the primary lesion is unknown but potentially may have arose from the kidney. bcor-urcs has a heterogeneous histology with tumor cells appearing monomorphic in nests of - cells separated by septa with uniform nuclei. there is frequently an "orphan annie eye" appearance and sparse cytoplasm to the cells. diagnosis cannot be made solely on evaluation of this nonspecific histology. rt-pcr uses the genetic abnormality in undifferentiated sarcomas to narrow the differential and bcor immunohistochemical staining provides further context. bcor has significant diagnostic value given its sensitivity and specificity in urcs. another potential marker includes ywhae-nutm b fusions, which occur in smaller subset of cases, but requires further study. rt-pcr has helped further classify tumors leading to the diagnosis of a rare undifferentiated sarcoma with bcor overexpression. while this technology is beneficial, its availability is limited. if accessibility improves, earlier identification and treatment may be possible maximizing the chance for a positive outcome. background: hematohidrosis is a rare condition that mimics bleeding disorders. cases present with oozing blood tinged fluid from various sites like eyes, ears, nose, skin, etc. reported causes of this condition were stress or fear, physical activity, psychological disorders. the condition is self-limited and don't affect the general condition of the patients, but it may contributes to psychosocial problems and may increases their stress and anxiety. so this condition needs to be promptly treated. to test the response of this disease and the associated headache to propranolol treatment. design/method: our case female patient years old st offspring of non consanguineous marriage, was admitted with recurrent episodes of oozing blood tinged fluid from eyes, ears and nose months before admission, about . - ml from each orifice, lasted - minutes and subsided spontaneously. it could involve the sites simultaneously or - sites. the number of attacks was - times per day then gradually increased to - times per day. later on the patient developed a bleeding attack from umbilicus. these attacks were aggravated by stress and physical activity and decreased with rest and sleep. the condition was associated with severe headache involving the whole head, throbbing in nature of gradual onset, increased by physical activity and relieved by analgesics. the condition was not associated with vomiting, blurring or diminution of vision, ocular pain, eye discoloration. no earache, tinnitus or diminution of hearing. there was no other form of discharge from eyes, ears or nose. no history of ecchymotic patches, bleeding from other orifices or blood product transfusion. no history of trauma, drug intake, fever or rash. no symptoms of other system affection. past history of recurrent attacks of epistaxis and two operations were done that passed without remarkable bleeding. no similar condition in the family physical examination was free, no evidence of psychological problems. complete blood count, coagulation profile, platelets function, factor and c.t brain were normal. oozing fluid from the patient was analyzed showed the same components as blood. results: our case started oral propranolol . mg/kg/day based on its use in similar cases in literature. the frequency of attacks and headache reduced then stopped after months of treatment and didn't recur after stoppage of propranolol. propranolol can treat this condition successfully. further investigations are needed to determine the link between this condition and severe headache our case was suffering from. background: wilms tumor is the most common renal solid tumors of childhood and is derived from primitive metanephric cells located in the kidney. primary extra-renal wilms tumors (erwt) are extremely rare, estimated to comprise . - % of all wilms tumors. despite similar histologic appearance intrarenal and erwts differ in embryologic tissues of origin. erwts arise from the more primitive mesonephric or pronephric origin and, therefore, can develop anywhere along the craniocaudal migration pathway of these primitive tissues, most often retroperitoneal, inguinal/genital, lumbosacral/pelvic and mediastinal. these tumors are typically staged and treated per national wilms tumor study (nwts) guidelines, and, by definition, are stage ii or greater due to location beyond the kidney borders. based on the cases reported in the literature, outcomes for erwt are comparable to renal wilms tumors with an % local recurrence rate and an % two-year event-free survival. we report the first case of a stage iii testicular extrarenal wilms tumor in an -month-old male with an intrabdominal undescended testis who underwent complete surgical excision followed by chemotherapy and inguinal radiation. results: a full term -month old male underwent orchipexy for an undescended left testicle. the testicle was noted to be grossly abnormal with a pea-sized thickened tissue adherent to the upper pole and a separate mass outside of the scrotum on the superior epididymis. both masses were removed, and s of s pathology demonstrated wilms tumor with favorable histology and negative margins. ct imaging of the chest, abdomen and pelvis were negative for a primary renal tumor, local residual disease, pathologic lymph node enlargement or distant metastases. the tumor was classified per nwts as stage iii due to tumor removal in multiple pieces. the patient completed dd- a treatment with vincristine, doxorubicin and dactinomycin per aren with cgy left inguinal radiation. he is currently months off therapy without clinical or radiographic evidence of recurrent disease. primary erwt is an extremely rare malignant neoplasm associated with challenges in diagnosis, staging and treatment. based on the cases reported in the literature, outcomes are similar to that of intrarenal wilms tumor. there are four pediatric paratesticular wilms tumors reported in the literature and, to the best of our knowledge, this is the first case of stage iii testicular wilms tumor successfully treated with dd- a chemotherapy and radiation. in erwt, nwts guidelines for staging and treatment should be applied with evaluation of both kidneys to exclude an intrarenal primary tumor. background: patient is a yo f, with esrd secondary to atypical hus versus ttp, who presented with thrombotic microangiopathy, aki, thrombocytopenia and anemia after a living unrelated donor kidney transplant. patient initially had downtrending creatinine. on post-op day , hematology was consulted for an increasing ldh and drop in platelets. peripheral smear was notable for an absence of schistocytes. yet, biopsy of the kidney revealed microthrombi. the patient was diagnosed with a thrombotic microangiopathy. plasmapharesis was initiated on day # , at which time ms r was noted to have significantly elevated creatinine. plasmapharesis did not yield any correction in labs and significant bruising developed. patient was started on eculizimab; plasmapharesis was stopped. shortly after, creatinine, anemia and thrombocytopenia corrected to levels at which she was discharged. overall, patient was found to have progressive anemia, thrombocytopenia, an increasing creatinine and ldh ( s) concerning for atypical hus, despite absence of schistocytes on peripheral smear. she responded well to eculizimab, with correction of hematologic changes during induction. she was discharged on eculizimab and continued to respond with normalizing platelet counts and hemoglobin. the differential in light of patient's thrombotic microangiopathy and thrombocytope-nia also included ttp. yet, adamts remained normal. dic was unlikely given normal fibrinogen level and d-dimer. objectives: presentations of atypical hus vs ttp. discuss eculizumab as a treatment of atypical hus. highlight atypical presentations of illness in transplant patients. results: despite absence of schistocytes by smear, pt was diagnosed with atypical hus based on presentation and after failing plasmapharesis, she responded well to eculizumab. though her presentation was abnormal, her response to this antibody that blocks the complement cascade suggests that she was experiencing a complement-mediated process. there are rare documented cases in the literature of atypical hus without schistocytes. hemolytic uremic syndrome (hus) is characterized by hemolytic anemia, thrombocytopenia and acute kidney injury. atypical hus is a diagnosis of exclusion, not due common etiologies such as shiga toxin. among atypical causes are complement-mediated forms, caused by an antibody to complement factor. in addition to plasmapharesis, renal transplant and supportive care, the mainstay of treatment for atypical hus is eculizumab (an antibody that blocks the complement terminal cascade). this case describes a patient unique in that, she was diagnosed with atypical hus without any schistocytes by smear. secondly, she responded to eculizumab, with unremarkable gene studies. finally, this case highlights that transplant patients often have unique presentations. nicklaus children's hospital, miami, florida, united states background: synovial sarcoma is a spindle cell tumor categorized as a soft tissue sarcoma. the chromosomal translocation t(x; ) leading to the ss -ssx fusion protein is unique to this sarcoma. it is a slow growing tumor with common recurrences and often, at presentation, with evidence of metastatic disease. if resection is not feasible, then neoadjuvant with adjuvant chemotherapy is recommended. metastasis carries an unfavorable prognosis given synovial sarcoma historically does not respond well to chemotherapy. trabectedin is a well-tolerated alkylating agent currently indicated for the treatment of liposarcoma and leiomyosarcoma. we present a -year-old male with metastatic synovial sarcoma to the lungs that progressed and was refractory to chemotherapy. he was administered trabectedin as a form of palliative chemotherapy, with significant clinical and radiographic response. design/method: pubmed search was done with search for terminology including "synovial sarcoma" and "trabectedin". papers relevant to our case were selected for literature review. a -year-old male patient presented with a large right axillary mass. initial imaging showed a heterogeneous multiseptated mass invading the subscapularis and teres major muscles along with innumerable lung nodules. biopsy confirmed diagnosis of monophasic synovial sarcoma. the patient was started on protocol arst with ifosfomide, mesna, doxorubicin. he completed cycles followed by radical resection and sessions of radiation. due to progression of disease multiple chemotherapy regimens were tried including topotecan and cyclophosphamide, protocol advl with lorvotuzumab, and pazopanib. imaging of the chest continued to show significant progression of metastasis. the patient's clinical status deteriorated with worsening respiratory status, requiring l of oxygen therapy, and inability to ambulate. he was started on trabectedin . mg/m for palliative care. after cycles of treatment patient was no longer requiring oxygen and was ambulating without assistance. radiological imaging showed significant reduction in number and size of lung nodules. trabectedin is a recently approved alkylating agent for the management of sarcomas resistant to first line treatment. response in synovial sarcoma is scarcely documented in the pediatric population. epidemiology places the most common age group in the young adults and children. our case opens the doors to further consideration of the use of trabectedin in the pediatric patient with metastatic synovial sarcoma. background: gata is an x-linked gene that plays critical role in hematopoiesis. mutations of gata gene can be associated to various blood disorders including diamond blackfan anemia, cytopenia, congenital dyserythropoietc anemia and acute megakaryoblastic leukemia. we report a patient with macrocytic anemia and platelet dysfunction who carries a novel gata mutation that has not been reported. results: a now -month-old male with complex medical history including prematurity at weeks, dysmorphic features, global developmental delay, hyperinsulinism, hypogonadotropic hypogonadism, growth hormone deficiency, micropenis, failure to thrive, patent ductus arteriosus status post ligation, and severe hypotonia, was referred to hematology at months old for resolved, transient thrombocytopenia and macrocytic anemia since month of age. chromosomal microarray showed chromosome deletion of q . , which is the rps gene. he doesn't have a family history of diamond blackfan anemia (dba), despite mom having the same rps mutation. he was then diagnosed with dba. his lab workup showed mild macrocytic anemia (hgb . g/dl, mcv fl), normal to inappropriately low reticulocyte count, normal white blood cell and platelet counts, hgf %, erythroid ada . eu/gm hgb (elevated). he has abnormal pfa- , with prolonged closure time of both adp and epinephrine. he had low von willebrand antigen and ristocetin cofactor activity. he has severe pancreatic insufficiency. bone marrow biopsy showed normocellular marrow with trilineage hematopoietic maturation, without ringed sideroblasts. since mother has the same rps gene mutation, maternal labs were done and showed no evidence of macroytosis or anemia. the diagnosis of dba was questioned. whole exome sequencing did not identify any pathogenic sequence changes in the coding regions of rps gene, but detected a gata mutation r w, which was reported variant of uncertain significance. his mother shares the same mutation and is asymptomatic, but she may not be affected since gata iis xlinked. his father doesn't harbor the gata mutation. conclusion: gata gene encodes zinc finger dna binding hematopoietic transcription factor, which is important during erythroid differentiation. gata mutation r w has not been reported in literature and is a novel variant of gata mutation, which might be contributing to this patient's clinical picture. further studies are warranted to confirm gata mutation r w to be a pathogenic sequence change. alexander boucher, tomoyuki mizuno, alexander vinks, greg tiao, stuart goldstein, james geller cincinnati children's hospital medical center, cincinnati, ohio, united states background: hepatoblastoma (hb), the most common pediatric primary hepatic malignancy, can be associated with specific congenital syndromes. recently, chronic kidney disease and genitourinary anomalies have been linked to hb. cisplatin is a key chemotherapeutic agent in treating hb but its renal clearance and toxicity profile can limit its use for those with end-stage renal disease (esrd). objectives: using an institutional case series, we present data using cisplatin for hb in dialysis-dependent esrd and define recommended dosing for future use. design/method: a chart review of patients with concurrent hb and esrd on dialysis treated with cisplatin at our institution was undertaken. demographic data, diagnostic history, tumor pathology, alpha fetoprotein (afp), hearing assessments, dosing schema, treatment outcomes, and therapyrelated toxicities were reviewed. total cisplatin levels were collected at time points within days after each infusion. free cisplatin levels were also collected for infusions, as were dialysate cisplatin levels. pk parameters were generated using bayesian estimation with a published population pk model as a priori information. results: three patients meeting these criteria were identified. each had "low risk" (non-metastatic resectable) disease at presentation and underwent upfront resections. all had congenital renal anomalies with esrd prior to their hb diagnosis. all cisplatin infusions were given over hours, followed hours later by hemodialysis. patients and received cisplatin at % of children's oncology group's ahep weight-based dosing ( . mg/kg). patient received % of ahep body surface area-based dosing ( mg/m ) during cycle but required a second dose reduction ( mg/m ) for cycle due to prolonged cisplatin exposure (total area under the curve mg⋅h/l; average for all seven evaluable cycles mg⋅h/l) and early sensorineural hearing loss at - hz. no other hearing loss in any patient was identified; mild toxicities also included grade - emesis and grade neutropenia and thrombocytopenia. the median (range) of clearance, volume of distribution at steady-state, and elimination half-life at terminal phase for total platinum were . ( . - . ) l/hour/ kg, . ( . - . ) l/ kg and ( - ) hours, respectively. patients and received cycles with rapid afp normalization. patient required an additional cycles, for a likely second primary hb year after initial therapy. cisplatin can be used successfully in pediatric patients with esrd on hemodialysis to treat hb with minimal morbidity using % standard mg/kg-based dosing ( . mg/kg), achieving pharmacologically appropriate cisplatin exposures. background: treatment for immune thrombocytopenia (itp) has been grouped into rescue and maintenance therapy and often is reserved for patients with bleeding, severe thrombocytopenia, or for improvement in quality of life. splenectomy is considered one of the more invasive but definitive treatments with success rates of - %. treatment of itp can be more difficult in the setting of previous treatment with immune modulation or when the patient is immunocompromised and not a candidate for splenectomy. objectives: present an interesting case of a patient with an autoimmune disease that presented with severe thrombocytopenia, un-responsive to rescue therapy, and requiring emergent splenectomy in the setting of acute intracranial hemorrhage (ich). a year old female with a history of juvenile dermatomyositis presented with a fine purpuric rash on her extremities, wet purpura, and a platelet count of k/ l. bone marrow evaluation at that time was consistent with itp. she was on cyclosporine and plaquenil for dermatomyositis. platelets failed to increase after three doses of intravenous immunoglobulin and high dose steroids. following a two week course of oral prednisone and eltrombopag, she presented with persistent severe thrombocytopenia of k/ l, anemia of . g/dl, and a lower gi bleed. she was started on amicar, novo-seven, rituximab, and given platelet transfusions with no improvement in bleeding. subsequently, she developed a subdural hematoma with midline shift. surgery performed an emergent open splenectomy with concurrent continuous platelet transfusion. results: she was monitored closely post operatively and, due to ich, transfused to maintain platelets greater than k/ l. by week post-op she had normal platelet counts off transfusions. all medications were stopped within three days of discharge. she represented eight days later with abdominal pain and thrombocytosis and was found to have a portal vein, splenic vein and mesenteric vein thrombosis. she was started on lovenox therapy and admitted for monitoring due to her history of ich. it is unknown whether our patient's underlying immune dysregulation and history of treatment with immunosuppressive medications may have contributed to her unresponsiveness to multiple therapeutic agents. in addition, her significant bleeding did not allow us to fully evaluate her response to second tier therapy. this adds to the scarcity of literature of itp response in pediatric patients with autoimmune disease, and may support more aggressive therapy upfront in these patients. background: multivisceral organ transplantation involves concurrent transplantation of the stomach, pancreas, liver, and intestine with splenectomy, and has been classically used in the pediatric population for infants with intestinal failure from disorders affecting foregut integrity. while there is some data demonstrating its efficacy in adults with low-grade abdominal malignancies, it has not been traditionally used for hepatocellular carcinoma treatment. to describe a unique pediatric case of multivisceral organ transplantation as definitive therapy for refractory fibrolamellar hepatocellular carcinoma in an adolescent male. a year old male presents with a history of fibrolamellar hepatocellular carcinoma, tumor invasion of the portal vein, severe portal hypertension complicated by bleeding esophageal varices and hypersplenism. he had two treatments with yttrium- radioembolization, without significant response. he completed six cycles of traditional chemotherapy in combination with sorafenib with resolution of petavidity, but minimal decrease in tumor size and continued portal hypertension. since his disease remained relatively stable for over years, he was evaluated and listed for multivisceral organ transplantation. at approximately years and months after diagnosis, he underwent en bloc liver, pancreas, stomach, small bowel, and colon transplant with splenectomy. a single lymph node was positive for malignancy at the time of resection. in addition to expected post-transplant complications, he also developed skin only acute graft versus host disease at weeks after transplant, treated successfully with a thymoglobulin course. he clinically improved and was back to his baseline activity level, on full oral feedings within months post-transplantation. at three and six month post-transplantation, there is no concern for relapsed hepatocellular carcinoma on comprehensive imaging and evaluation. he is maintained on protocol immunosuppression and posttransplant support. we present the first known case of successful multivisceral organ transplantation in the treatment of refractory pediatric fibrolamellar hepatocellular carcinoma. background: hematohidrosis is a rare disorder that presents with spontaneous excretion of whole blood from intact skin or mucosa. diagnosis is based on clinical observation of the occurrence with the proven presence of erythrocytes and other blood components, without other abnormalities to account for the phenomenon. the existing literature is scarce and consists of primarily case studies. most reports describe bleeding from facial sites around the eyes, ears, and nose. the available literature suggests anxiety and physical or emotional stress reactions as the most common inciting events. little evidence exists regarding the ideal therapeutic approach, however propranolol has been used successfully to reduce bleeding frequency and severity in multiple case reports. a specific genetic etiology has not been elucidated, and no familial cases have previously been reported. we present a pair of half-siblings, both of whom presented with spontaneous cutaneous and mucosal bleeding before two years of age, and report on preliminary results of propranolol therapy. tanzania. at months of age, he became ill and developed spontaneous bleeding from his ears, nose, and scalp. he continued to have frequent bleeding episodes, usually related to illness or physical distress. a bleeding diathesis work-up was unremarkable, however some episodes were severe enough to require transfusions. the patient was subsequently diagnosed with hiv and hepatitis b, presumably acquired via unscreened blood product transfusions. patient b is an infant female born to the same mother as patient a, with a different father. she was healthy until two months of age when she developed spontaneous bleeding from the hairline, eyelids, ears and genital/rectal area. bleeding episodes were nearly always associated with irritability and crying. extensive coagulation workup was unremarkable. results: propranolol therapy was started in both patients, titrated to a goal of mg/kg/day. in both patients, the frequency and duration of bleeding episodes significantly improved. patient b continues to have milder occasional bleeding episodes from her eyes, ears and scalp but has significantly less discomfort and irritability during the episodes. conclusion: to our knowledge, there are no prior reports involving two related patients with hematohidrosis. this case series suggests that there may be a genetic predisposition which has yet to be identified. propranolol has shown effectiveness in reducing symptom frequency and severity. background: gliomas are the most common central nervous system tumors in children. they are classified into different grades based on genotype (idh, braf, tsc, etc.). lowgrade gliomas such as oligodendrogliomas, astrocytomas, and mixed oligoastrocytomas are classified as grades i and ii. of the molecular level alterations this case report focuses on the braf v e mutation. braf is a member of the raf family of serine/threonine protein kinases and it plays an important role in cell survival, proliferation and terminal differentiation. objectives: here we discuss two cases where dabrafenib, a braf kinase inhibitor, was utilized in the management of gliomas. the cases focus on the use of dabrafenib late versus early in disease course. design/method: patient jl is a year old female who was diagnosed with a low-grade glioneuronal tumor (c -t with a metastatic lesion to the brain) in . jl was treated with chemotherapy, radiation, and surgical resection. despite treatment, the patient's disease progressed. she developed lower extremity dysfunction, urinary incontinence, poor truncal control, and hydrocephalus. dabrafenib was started after the braf v e mutation was confirmed. patient lg is a year old female who presented in november with left facial and upper extremity weakness. ct and mri scans demonstrated a mixed solid and cystic lesion extending from the optic chiasm and hypothalamus to the right thalamus and posterior basal ganglia with additional involvement of the right cerebral peduncle. neurosurgical intervention was undertaken and dabrafenib was started after the braf v e mutation was confirmed. results: patient jl's mri scans have demonstrated improvement of the spine with diminished areas of enhancement along thecal margins, decreased volume and enhancement within the trigeminal plate cistern and resolution of ependymal enhancement within the right ventricle. the patient's most recent mri exhibits no disease progression in head or spine. jl has shown improvement clinically since starting dabrafenib. patient lg has shown improvement in strength and recent mri of the brain has shown resolution of enhancement along surgical resection margins, decreased hyperintensity along the inferomedial aspect of the right basal ganglia and no new enhancements. conclusion: low grade gliomas can alter a person's quality of life and even lead to life threatening complications. often the standard chemotherapy, radiation and surgery don't prevent these complications. genetic analysis can help clinicians target therapy towards certain mutations such as braf v e. dabrafenib has shown to decrease tumor burden, early utilization as therapy can help prevent morbidity and mortality. children's hospital of pittsburgh of upmc, pittsburgh, pennsylvania, united states background: copper is an essential cofactor in enzymatic reactions essential to proper hematologic, skeletal, neurologic and vascular function. copper requirements in children over the age of are mg/day, which is readily acquired in a typical diet. copper deficiency is known to occur in patients with the rare x-linked mutation and in older individuals with gastrointestinal bypass surgery; however, it is rarely reported in other conditions. objectives: to highlight individuals with autism spectrum disorders or developmental delay with a limited dietary repertoire are at risk for copper deficiency, thus a high index of suspicion must exist in order to diagnose the disorder. design/method: a y/o boy with a prior diagnosis of global developmental delay and oral aversion presented with slowly progressive fatigue, weakness, gait instability, and weight loss. his longstanding feeding difficulties were refractory to intensive feeding programs. his daily diet consisted of - oz of milk and - individual servings of butterscotch pudding ( - calories/day, . mg iron/day). initial complete blood count demonstrated white blood cell count of . , absolute neutrophil count of , hemoglobin of . , mean corpuscular volume of < , reticulocyte count of . , platelet count of . review of his peripheral blood smear revealed microcytic, hypochromic red cells without marked fragmentation, anisopoikilocytosis and ringed sideroblasts; there were no morphologic abnormalities of his leukocytes or platelets. iron studies demonstrated ferritin of , total iron binding capacity of , and % iron saturation. he had no evidence of b , folate deficiency or blood loss. additional evaluation revealed a serum copper level of (range - ), and cerulosplasmin of . (range - ). results: once a diagnosis of copper deficiency was made, the patient promptly began a course of parenteral copper repletion. he received iv copper mcg/kg/day x days then weekly intravenous infusions. given his malnutrition, a gtube was placed to begin oral copper repletion and enteral nutrition. within weeks his copper level improved as well as his blood counts. unfortunately, although his blood counts and copper levels normalized, his neurologic status remains below his old baseline although, he has made gains in his gross and fine motor abilities. conclusion: acquired copper deficiency in the pediatric population is a rare event but given the hematologic and neurologic consequences, prompt recognition and treatment is important. this patient's clinical course demonstrates the need to have a high index of suspicion of concomitant nutritional deficiencies other than those routinely evaluated such as iron, b and folate. background: lymphoepithelioma-like thymic carcinoma (lelc) is a rare, aggressive neoplasm with a high rate of invasion, metastasis and recurrence. there are no known curative therapies for metastatic lelc. we report the case of a -year-old male who presented with metastatic ebv positive lelc. sites of disease included a large primary anterior mediastinal mass and metastases to hilar lymph nodes, lungs and liver. he was initially treated with cisplatin and fluorouracil followed by mediastinal radiation. he had a partial response to therapy but his end of therapy scans showed disease progression in lungs, liver, and hilar, supraclavicular and axillary lymph nodes. objectives: molecularly targeted therapies tailored to the patient's genetic profile offer a novel approach to obtain improved survival outcomes. design/method: the patient enrolled on a precision medicine trial, nmtrc : molecular-guided therapy for the treatment of patients with relapsed and refractory childhood cancer (nct ). in this study, tumor/normal whole exome sequencing and tumor rna sequencing were performed and a molecular report detailing the results of genomic and gene expression analysis was generated. a treatment plan was designed within a molecular tumor board comprising oncologists, pharmacists, genomicists, and molecular biologists with domain expertise. results: exome sequencing revealed somatic coding point mutations and no structural mutations (focal copy number changes or translocations). candidate somatic driver mutations included tp s x and r w as well as kit n k. both genes have been previously implicated in thymic carcinoma. rna expression analysis demonstrated aberrant activation of biological pathways, including overexpression of kit, hdac , and , tyms, and dhfr. the molecular tumor board selected the combination of pemetrexed ( mg/m ) on day of a day cycle, imatinib ( mg daily), and vorinostat ( mg days - , - , and - ) . on day of cycle , he was admitted with a herpes zoster infection and imatinib was discontinued in order to reduce risk of herpes zoster recurrence. imaging after cycles showed a complete metabolic response on f- fdg pet and a partial response by ct size criteria. as of december , the patient had received cycles of pemetrexed and vorinostat. scans in december showed an increase in the size and metabolic activity of two right lower lobe pulmonary nodules. there were no new sites of disease and imatinib was re-started. background: systemic lupus erythematosus (sle) is a chronic autoimmune disease that affects multiple organ systems and is associated with many different autoantibodies. patients can present with vague constitutional symptoms including fever, rash, fatigue, and weight loss. some of the various hematologic manifestations of sle include anemia of chronic disease, leukopenia, autoimmune hemolytic anemia (aiha), and idiopathic thrombocytopenic purpura (itp). these can be the presenting signs of sle. evans syndrome (es), a disease characterized by itp and aiha, is a rare hematologic manifestation of sle. neurofibromatosis (nf ) is a relatively common neurocutaneous disorder. these patients are at risk of developing benign and malignant tumors. its association with autoimmune disorders, including sle, remains rare. objectives: there are few cases in the literature that have patients with the combination of sle and nf . this is the only case that has a patient with sle, nf , and es. results: a -year-old caucasian female presents with two months of vaginal bleeding, weight loss and petechiae. her exam is remarkable for petechiae and café au lait macules. laboratory findings show severe anemia and thrombocytopenia. she receives blood and platelet transfusions during stabilization, and a bone marrow aspirate is performed to rule out a malignancy which is negative. based on the presence of thrombocytopenia and a positive coombs test, an autoimmune process such as es is considered. screening tests for sle reveal positive antinuclear and anti-double stranded dna antibodies as well as low complement. she receives intravenous immunoglobulin and methylprednisolone and eventually her vaginal bleeding slows and her counts recover. she begins sle therapy with hydroxychloroquine and azathioprine. due to the presence of café au lait macules on her exam, a genetics evaluation is performed and the patient is also diagnosed with nf . to date, there are seven cases of sle with nf reported in the literature, only two of which are pediatric cases. there are no reports of the combination of sle, nf , and es. conclusion: es is a rare hematologic manifestation of sle but can be the initial presentation of this disease. one large study estimates % of childhood-onset sle cases are observed to have es. screening for sle should be considered in all es patients even in the absence of typical clinical findings. association of nf and sle has been rarely described. whether this association reflects a causal relationship or is coincidental needs more investigation. (lube, ped blood & cancer, ) . university of california san diego, la jolla, california, united states background: high grade glioma (hgg) has poor outcomes in adults and children. extraneural metastases are very rare in hgg, and poorly characterized with only a few small case series in adults and only isolated case reports in pediatrics. no genomic data has previously been published for any children with hgg who develop extraneural metastases. objectives: our objective is to describe the natural history of two children with hgg and bony extraneural metastases, comparing their clinical characteristics as well as whole exome sequencing data for both tumors. this information would suggest similar patients should be monitored closely for extraneural metastasis and may benefit from more systemic therapy. design/method: we present a case series of two patients who presented with hgg and had development of bony metastases less than six months after initial diagnosis. both patients had molecular profiling with whole exome sequencing (wes). the first patient was an -year-old male with a tumor found in the left lateral ventricle invading into the fornices, hypothalamus, and left midbrain, who had subtotal resection. bony metastasis were found at . months after diagnosis, and he died months after diagnosis. he initially received radiation, followed by nivolimuab. the second was a -year-old female with a tectal/pineal tumor and multiple spinal cord metastases, who had subtotal resection. she developed bony metastasis at . months after diagnosis and died months after diagnosis. her histologic diagnosis was pineoblastoma, revised to hgg after whole exome sequencing. she received craniospinal radiation followed by chemotherapy per acns (cisplatin, vincristine, and cyclophosphamide) for cycles. when she failed to respond satisfactorily to this therapy, wes of tumor was performed and the findings were consistent with hgg. treatment was transitioned to temodar and lomustine after hgg diagnosis was given. she had ongoing progressive disease despite this therapy as well as trials of nivolumab, everolimus, and vorinostat. neither patient had extraneural metastasis at presentation. in both tumors, whole exome sequencing identified the h f a k m mutation. both tumors also had additional known mutations associated with hgg but no other overlapping mutations. this case series represents the first description of the genetic alterations of pediatric hgg patients who developed extraneural metastases. while h f a k m is a common mutation in pediatric midline hgg, especially dipg, and is associated with more aggressive disease, there has not been an association with extraneural metastasis prior to this series. background: deferiprone-induced agranulocytosis is a well -known albeit rare side effect of the drug. incidence of agranulocytosis varies from . - . %, while milder neutropenia is reported in . % of patients treated with deferiprone. deferasirox is unknown to cause such a complication. clinical trials and post marketing side effect monitoring studied possible correlations between different risk factors and development of agranulocytosis. unfortunately, no studies directly addressed a special risk in a community with background of ethnic neutropenia, like oman. objectives: to report on the incidence of neutropenia among omani children with b thalassemia using different iron chelators design/method: a retrospective study conducted on patients < year-old with b thalassemia treated with different iron chelators. electronic patients records were reviewed to detect episodes of neutropenia either mild (anc . -< . /cmm), moderate (anc . -< ), severe < . , or agranulocytosis anc = ). data were collected including sex, age, personal or family history of ethnic neutropenia, iron chelating agent, infective complications, management and outcome. detailed clinical, laboratory ± radiological information were reported for patients who developed life-threatening agranulocytosis. among young patients with b thalassemia, treated between - in squh, neutropenia, was reported in patients ( . %).severe neutropenia was encountered on occasions in patients ( / : . %) ( on deferiprone including episodes of agranulocytosis, on defersirox, on combined chelation, and off chelation). moderate neutropenia was encountered in patients ( / : . %), on occasions: deferiprone ( ), deferasirox ( ), combined chelation ( ), and episodes off chelation. mild neutropenia was more prevalent, encountered in patients ( . %) on occasions ( on deferiprone, on defersirox, on combined chelation, and off chelation) of patients exposed to deferiprone, patients had neutropenia ( %), higher than previously reported. deferiproneinduced agranulocytosis was encountered in patients ( / = . %). three of them had life threatening complications. one patient developed pneumonia complicated by rupture of pulmonary artery aneurysm-massive hemoptysis, who recovered fully after catheter embolization. the second had facial cellulitis and treatment with gcsf was complicated by frequent ventricular extrasystoles. the third had sepsis, disseminated herpes simplex and required admission to icu for inotropic support. in a community with background ethnic neutropenia, neutropenia is more common to be encountered among thalassemic patients, both on and off chelation therapy. careful monitoring of anc and rational choice/modification of chelating agents is required for optimal management of iron overload and to avoid life threatening complications. objectives: this case control study aimed to evaluate the systolic and diastolic cardiac function in groups of children with ti: non transfused group and a group that received early regular blood transfusion comparing them to healthy controls. design/method: thirteen regularly transfused patients with ti with a mean age of . + . years were compared with eight patients who are non-transfused or minimally transfused (< rbcs transfusion/year); mean age . + . years and healthy controls with a mean age of . ± . years. clinical parameters and standard echocardiographic and tissue doppler imaging (tdi) were compared. results: young non-transfused ti patients had a statistically significant higher peak late diastolic velocity of the left ventricular inflow doppler, a mitral valve a wave duration over the pulmonary vein a wave duration ratio and the pulmonary s of s vein s/d velocities ratio compared to the transfused group with p values of . , . , . respectively. in addition, they have a lower e/a ratio of the mitral valve inflow and a larger left atrial to aortic diameter ratio compared to the control group with p values of . and . respectively. the diameters of the right and left outflow tract were significantly larger in the non transfused group with a trend to have a higher cardiac index compare to the transfused group. systolic function was similar in the studied groups and none of the patients had evidence of pulmonary hypertension. young patients with ti who are receiving early regular blood transfusion have normal systolic function. diastolic function assessment revealed indicators of an abnormal relaxation of the left ventricle in the non transfused group which indicate diastolic dysfunction. the abnormalities affected multiple diastolic function parameters which give an indication that the changes are clinically significant. a statistically significant increase in the diameters of the outflow tracts are likely attributed to high cardiac output status in nontransfused ti patients as they had a trend to have a higher cardiac index. these findings support the early commencing of regular blood transfusion therapy for ti patients to prevent serious cardiac complications in adult life. background: in the -week sustain study, crizanlizumab . mg/kg significantly reduced the frequency of scpcs versus placebo ( . vs . , p = . ) and increased the time to first on-treatment scpc ( . vs . months, p = . ) in patients with sickle cell disease (scd). to evaluate time to first scpc in sustain study subgroups and the likelihood of not experiencing scpc for the duration of the trial using post hoc analyses. design/method: sustain was a randomized, double-blind, placebo-controlled, phase study (nct ). inclusion criteria were: scd patients aged - years; - scpcs in previous months; concomitant hydroxyurea use permitted if ≥ months and stable dose for ≥ months. patients were randomized : : to receive intravenous crizanlizumab . mg/kg, . mg/kg, or placebo. study treatments were administered on days and , then every weeks to week , with the final assessment at week . median time to first scpc after first dose was summarized for crizanlizumab . mg/kg or placebo in these subgroups: - or - scpcs in previous months; scd genotype; and hydroxyurea use at baseline. hazard ratios (hrs) for crizanlizumab . mg/kg versus placebo were calculated based on cox regression analysis, with treatment as a covariate. descriptive statistics were used to summarize the frequency of patients who were scpc event-free for the duration of the study by prior scpc events, scd genotype, and hydroxyurea use at baseline. : patients received crizanlizumab . mg/kg and received placebo. there was a meaningful delay in time to first scpc with crizanlizumab . mg/kg versus placebo observed in the entire study population. the effect was present in both scpc subgroups, and the largest treatment difference was observed in hbss scd versus other genotypes ( . vs . months; hr: . ). in patients taking hydroxyurea who experienced - scpcs in the previous year, time to first onstudy scpc was longer with crizanlizumab . mg/kg versus placebo ( . vs . months; hr: . ). a greater proportion of patients treated with crizanlizumab . mg/kg were scpc event-free versus placebo in each of the analyzed subgroups. one third of patients who were taking hydroxyurea and treated with crizanlizumab . mg/kg were scpc event-free during the study versus . % with placebo, possibly suggesting an additive effect. with crizanlizumab . mg/kg, there was a clinically meaningful delay in time to first scpc and an increased likelihood of being scpc-free versus placebo in all subgroups investigated. cincinnati children's hospital medical center, cincinnati, ohio, united states background: shwachman-diamond syndrome (sds) is an inherited marrow failure syndrome associated with increased risk of myelodysplasia (mds) and acute myeloid leukemia (aml). objectives: this multi-institutional retrospective study investigated clinical features, treatment, and outcomes of sds patients who developed mds or aml by central pathology review. design/method: nine individuals presented with aml ( male, female), mds-eb / ( males, females, with mds ( male and female), and one male with isolated persistent somatic tp mutation. one mds-eb and mds patient progressed to aml. median age (years) at diagnosis of mds was (range . - ), mds-eb / was (range . - ) and aml was . (range . - ). complex cytogenetics were noted in / aml cases, with one having normal cytogenetics. complex clonal cytogenetic abnormalities were noted in of mds-eb /eb patients and clonal abnormalities in of mds patients. follow up was available for aml patients; are deceased. received chemotherapy with intent to proceed to hematopoietic stem cell transplant (hsct). four failed to achieve remission and died with disease without proceeding to transplant. one patient proceeded to hsct without prior chemotherapy. four of six transplanted subjects died with relapsed disease. treatment related mortality was largely infectious or gvhd. the sole surviving aml patient had normal cytogenetics, achieved remission with chemotherapy and underwent hscts with separate stem cell infusions due to two primary graft failures. he remains alive in remission more than years after diagnosis. of the mds-eb / patients, underwent ric hsct, three of whom are alive, one died of infection. the fifth patient has stable disease on continued decitabine monotherapy for . years. of mds patients with treatment data, had upfront hsct therapy, upfront chemotherapy and had no therapy. three patients required ≥ hscts all due to graft failure. follow up is available for , of whom are deceased, with relapsed disease. treatment related mortality was largely infectious or graft failure. one individual died of hepatic failure unrelated to mds. seven mds patients are alive in remission. in summary, prognosis is poor for patients with sds who develop aml due to resistant disease and treatment-related complications. better markers for risk stratification are needed to identify patients who would benefit from early transplant. novel therapeutic strategies are urgently needed to improve outcomes of sds patients with mds or aml. background: unlike primary myelofibrosis (pmf) in adults, which is associated with somatic mutations in jak , mpl, or calr, myelofibrosis in children is rare and the underlying genetic mechanisms remain elusive. here we describe families with autosomal recessive congenital macrothrombocytopenia with focal myelofibrosis (cmtfm) due to germline mutations in the megakaryocyte-specific immune receptor tyrosine-based inhibitory motif (itim) receptor g b-b. objectives: to characterize the clinical phenotype, histological features and identify the causative gene for cmtfm. we performed affymetrix snp . genotyping on the index family to identify shared regions of homozygosity by descent. whole exome sequencing (ws) was performed on all three pedigrees to identify potentially causative mutations. we studied affected children from families, with macrothrombocytopenia, anemia, mild leukocytosis and a distinctive pattern of bone marrow (bm) fibrosis centered around clusters of atypical megakaryocytes. affected children had mild to moderate bleeding symptoms and required platelet and red cell transfusions. none showed evidence of extramedullary hematopoiesis, and all were negative for mutations in jak , mpl, and calr. snp genotyping identified multiple statistically non-significant genomic loci, including the region of the major histocompatibility locus (mhc) on chromosome p (lod = . ). we focused on this region because affected individuals in two families shared a common homozygous human leukocyte antigen (hla) type and had congenital adrenal hyperplasia (cah) due to -hydroxylase (cyp a ) mutation; the cyp a and hla loci are located at p . and p . - p . . wes revealed homozygous frameshift mutations in the megakaryocyte and platelet inhibitory receptor g b-b, encoded within the candidate linkage region. we identified two distinct g b-b frameshift mutations (c. _ + dup; p. fs and c. inst; p. fs) in individuals within these three families. no other mutations that segregated with the phenotype were identified. to validate g b-b as a potential disease-causing gene, we evaluated g b-b expression in bm biopsy specimens from affected patient and control samples by immunohistochemical staining using a monoclonal antibody. g b-b was strongly s of s and selectively expressed in megakaryocytes of control samples, but completely absent in clinically affected individuals. a murine knockout that lacks g b-b has a strikingly similar phenotype with macrothrombocytopenia, myelofibrosis and aberrant platelet production and function, further affirming the causality of g b-b mutations. we showed that autosomal recessive loss-offunction mutations in g b-b cause cmtfm, uncovering the molecular basis of this rare disease. loss of g b-b-dependent inhibition of megakaryocyte activation likely underlies the distinctive focal myelofibrotic phenotype and might be important in other forms of marrow fibrosis. cardinal glennon, saint louis, missouri, united states background: intrauterine transfusion is the method of choice for management of fetal anemia due to red blood cell alloimmunization. despite the decrease in prevalence of anemia due to rhesus d alloimmunization with prophylactic administration of anti-rhd immunoglobulin in rh d negative patients, maternal red red blood cell alloimmunization with other type of red blood cell antigens remains an important cause of fetal anemia. newborn who received intrauterine transfusion for hemolytic disease may have prolonged postnatal transfusion requirement. objectives: -to evaluate clinical outcome of fetuses and newborns who received intrauterine transfusions. -to determine the need of packed red blood cell transfusions until months of age. we conducted a retrospective case series study of all intrauterine transfusions due to anemia secondary to red blood cell alloimmunization performed in our regional center ssm in st louis missouri, between april and january . we evaluated the indications, diagnosis, gestational age, and frequency of intrauterine transfusions, along with the infant's gestational age at birth, duration of admission, timing of blood transfusion and monitoring of hemoglobin. results: intrauterine transfusions were performed in patients. the most common causes of alloimmunization were due to d antibodies (n = , %) and kell antibodies (n = , . %). the median gestational age of the first intrauterine transfusion was . weeks, and the median pre-transfusion hemoglobin was . g/dl. the gestational age at the first intrauterine transfusions was found to be significantly correlated with the number of postnatal transfusions (r = . . p = . ). the median gestational age at birth was found to be weeks ( . - . weeks), with a hemoglobin of . ( . - . ). in our population, patients ( %) received postnatal transfusions, of which were during the first weeks of life, and close monitoring follow up with a hematologist was established in patients at their discharge from the nursery/nicu. one neonatal death occurred and severe morbidity due to severe anemia occurred in one infant. despite the continuing risk factor for persistent anemia, only patients had follow up hemoglobin monitored by their primary care provider. conclusion: infants with anemia due to red blood cell alloimmunization treated with intrauterine transfusion should be monitored closely via regular complete blood count for persistent anemia due to suppression of fetal erythropoiesis. sebastian hesse, piotr grabowski, juri rappsilber, christoph klein dr. von hauner childen's hospital, lmu university hospital, munich, munich, germany background: neutrophil granulocytes are the most abundant leukocytes in the peripheral blood. validated diagnostic options for these cells are limited, leaving many patients with functional neutrophil defects without a defined diagnosis. objectives: here we evaluate proteomics as a new diagnostic tool to investigate defects of neutrophil granulocytes. we analyzed neutrophil granulocytes from children with severe congenital neutropenia (scn) associated with elane mutations, children with chronic granulomatous disease (cgd) with cyba ( ) or cybb ( ) mutations and children with leukocyte adhesion deficiency (lad) due to itgb mutations. in addition we collected samples of children with genetically undetermined neutrophil defects. neutrophils from healthy individuals served as controls. cells were isolated from fresh venous blood using negative selection (purity > %). whole cell proteome analysis was done by data-independent acquisition. showed a correlation coefficient of ∼ . . principal component analysis demonstrated unequivocal separation of the proteome of healthy and diseased cells. differential expression analysis showed minimal proteome aberrations in lad with deficiency in cell surface receptors and upregulation of alpl (total downregulated proteins: / total upregulated proteins: ). analysis of neutrophils from cgd patients also showed limited proteome aberration. cyba and cybb were both diminished independent of genotype, whereas protein clusters around a stat / centered network were increased (total down: / up: ). neutrophils with elane mutations showed the gravest proteome disturbance (total down: / up: ) with an upregulated translational apparatus (srpdependent ribosomes and protein folding complexes) and increased mitochondrial proteins. proteins of each granule subset were dysregulated and metabolic pathways upregulated. a detailed analysis of the proteome from patients with genetically undefined diseases is currently ongoing. one patient with clinical phenotype of cgd was found to have no mutations of nadph oxidase members in whole exome sequencing but critically low levels of ncf on protein level. heterozygosity mapping showed autozytocity in the ncf region warranting current efforts to sequence promoters and intronic regions of the gene. mass spectrometry based proteomics promises exciting new insights into monogenic disease of neutrophil granulocytes and may offer new diagnostic options, in particular in synergy with genome sequencing. by virtue of our international care-for-rare alliance, open to new partners, we hope that our proteome focus may lead to better delineation of as yet unknown disease of neutrophil granulocytes. background: warm autoimmune hemolytic anemia (aiha) is an igg mediated disease. although it can be post-viral, it is often idiopathic and can also be a forme fruste for malignancy or an autoimmune disease. initial management includes steroids. it often relapses on steroid wean and can be refractory to the use of second line treatment such as rituximab. objectives: abatacept (ctla- -ig fusion protein, ctla- mimetic) has been used to ameliorate autoimmune manifestation associated with ctla- haploinsufficiency. we used abatacept as a novel therapeutic agent to manage patients with refractory aiha. design/method: a retrospective case series of two patients at phoenix children's hospital with severe refractory aiha. results: patient , a previously healthy year old female, presented with weeks of icterus, fatigue, and hemoglobinuria. spleen was enlarged cm below the costal margin. laboratory evaluation demonstrated: hemoglobin . g/dl, mild leukopenia /microliter, platelets , /microliter, reticulocytosis . %, positive direct coombs' test, mycoplasma igm and igg positive. bone marrow evaluation showed a hypercellular marrow. she continued to need packed red blood cell (prbc) transfusions despite receiving high dose steroids, ivig and rituximab from may-july . in august, she started sirolimus decreasing her transfusion requirement. after starting abatacept ( mg/kg/dose bi-monthly for three doses and then monthly) in october, she maintained hemoglobin of - g/dl without transfusion. patient , a previously healthy month old male, presented with one week of progressive fatigue, jaundice, and poor feeding. splenomegaly was absent. laboratory evaluation revealed hemoglobin . g/dl, leukocytosis , /microliter, platelets , /microliter, reticulocytosis . %, negative direct coombs' test, and non-specific reactivity on antibody screen. evaluation for inherited hemolytic anemia including a next generation sequencing panel was negative. further evaluation by blood bank showed + positive coombs' for c d due to a warm antibody. cold agglutinin disease was ruled out. bone marrow evaluation was normal. he received high dose ivig as a steroid sparing agent but continued to require prbc transfusions weekly. when prednisone did not seem to slow down hemolysis, treatment with abatacept was initiated and he has not required transfusions for two months. steroids are being weaned. we present successful treatment of two refractory aiha cases with abatacept. patient is steroid and transfusion free and continues on monthly abatacept and sirolimus. patient is also transfusion free and continues on a steroid taper. ctla- is crucial for suppressive function of treg cells. abatacept by binding to cd / seems to enhance treg activity ameliorating autoimmune hemolysis. children's minnesota, minneapolis, minnesota, united states s of s background: transfusional iron overload is common in patients receiving chronic red cell transfusions. as a result, iron chelation is required to minimize toxicity from iron overload. chelation with a single agent can be inadequate at controlling or reducing iron burden. when combination therapy is required deferoxamine may be added to oral chelation. deferoxamine is generally given subcutaneous over - hours for - days a week at - mg/kg/day. many patients struggle to remain compliant with this schedule which has prompted trials of intravenous high-dose (hd) deferoxamine. prior reports of short-term hd deferoxamine have shown minimal side effects however, prolonged use of hd deferoxamine has known toxicity. when compliance is a concern, our center has used hd deferoxamine infusions at mg/kg/hr x hours every to weeks. objectives: evaluate the safety and efficacy of hd deferoxamine at our institution to help guide future therapy. design/method: a retrospective review was completed of patients previously treated with hd deferoxamine between april and september at children's minnesota. final sample included patients ages to years with underlying diagnosis of thalassemia ( ) and diamond-blackfan anemia ( ). deferoxamine infusions were given for hours every - days with a mean length of treatment of days. results: all patients were on combination therapy with deferasirox, however deferasirox was held during deferoxamine infusion. mean pre-deferoxamine liver iron concentration (lic) was . mg/g and mean post lic was . mg/g (p = . ). ferritin mean pre-deferoxamine was ng/ml compared with mean post ng/ml (p = . ). two patients had possible allergy, leading to deferoxamine discontinuation. one patient developed hives, eye swelling and cough while the other had emesis and cough. another patient experienced facial nerve palsy of unclear etiology, which did not recur with resumption of deferoxamine. no respiratory complications were seen. results showed significant decrease in iron burden following combination therapy with high dose deferoxamine and deferasirox. no significant pulmonary, liver, renal, vision, or hearing toxicities were observed. three patients reported reactions to deferoxamine infusions. however, one of these was able to successfully continue deferoxamine without further incident. short-term, hd deferoxamine was effective at reducing lic in combination with oral chelation but requires further evaluation to assess for potential increased risk of toxicity. short-term hd deferoxamine may be considered in the setting of poor compliance of subcutaneous administration or inadequate chelation with single agent therapy. further studies are needed to clarify ideal dosing, timing and risk of toxicity. background: immune thrombocytopenia (itp) is the most common cause of symptomatic thrombocytopenia in childhood but remains a diagnosis of exclusion warranting further evaluation if atypical findings are present. two male children ( months and years old) with newly diagnosed immune thrombocytopenia (itp) were found on initial evaluation to have persistent elevations of lactate dehydrogenase (ldh), alanine aminotransferase (alt), and aspartate aminotransferase (ast). these serum enzyme abnormalities cannot be attributed to itp. in the setting of thrombocytopenia, elevated transaminases and ldh create diagnostic complexity for the hematology/oncology provider as their elevation raises concern for malignancy, hemolytic disease, and other systemic diseases. to raise awareness about an unexpected pattern of duchenne muscular dystrophy in patients undergoing evaluation for itp. to expand the differential of a hematologist/oncologist when abnormal labs support a nonhematologic diagnosis design/method: this case-series of two patients with their clinical and laboratory findings were discovered with retrospective chart review. results: after a thorough evaluation for hemolytic anemias, liver disease and infectious etiologies was negative, bone marrow and liver biopsies were considered. eventually, both children were found to have severely elevated serum creatine kinase (ck). skeletal muscle has the highest concentration of ck of any tissue. thus, significant ck elevation is almost exclusively attributable to muscle injury and is the most sensitive and specific enzyme for diagnosis of muscle disease. referral to a neuromuscular specialist and further genetic testing confirmed the diagnosis of duchenne muscular dystrophy in both children allowing initiation of appropriate interventions. to date, there is no clear genetic predisposition to itp in patients with muscular dystrophy although further investigation may be needed. hematology/oncology providers should consider obtaining a serum ck to rule out muscle disease in any male child with unexplained elevations of serum ldh and/or aminotransferases, as it provides an easy and inexpensive, non-invasive approach to screening. additionally, clinical history and physical examination can aid in the diagnosis of muscular dystrophy, with gross motor delay, abnormal muscle bulk, gower's sign, and proximal muscle weakness all possible findings. objectives: to identify the range of cbcs in patients with ds without infections, hematologic or immune disorders and to create more accurate reference ranges for total white blood count; hemoglobin; hematocrit; mcv; platelet count and absolute neutrophils (anc), lymphocytes, monocytes, eosinophils, and basophils. design/method: a retrospective investigation of healthy pediatric patients with ds who received a cbc between and as part of their medical care at a single, large, pediatric teaching hospital. the study group consisted of children with ds (male = , . %; mean age = . years, sd = . ) at time of blood draw. initially children were reviewed for possible participation in the study; however, patients were excluded due to not meeting the study's inclusion criteria. descriptive statistics were performed on demographic and clinical characteristics. kruskal-wallis h tests, anova, and t-tests were run to determine the significant associations between independent means. results: a significant difference in absolute neutrophils between racial groups, f( , . ) = . , p = . , was observed. there was an increase in anc from . +/- . with african americans to . +/- . in the other racial groups and to . +/- . with caucasians. differences were also found in anc in hispanics/latinos versus non-hispanic/latinos. the results were higher in non-hispanics and latinos, a significant difference of -. ( % ci, -. to -. ), t( ) = . , p = . . preliminary kruskal-wallis h tests run determined that there were significant differences between age groups for total white blood cell, hemoglobin, hematocrit, platelets, lymphocytes and anc. further studies are being run to evaluate in which age groups these differences lie and create reference ranges by age, race and sex. conclusion: among patients with ds, there are differences between racial groups and age groups. this data has been compared to previously established reference ranges for cbcs, but we are currently establishing healthy cbc controls which we will use to validate the reference ranges. these ranges will be published to help guide providers in workup and management of patients with ds. background: transfusion is a critical part of the care provided in the neonatal intensive care unit, but it is not without risks. low birth weight and premature infants can become anaemic from an immature haematopoietic system and frequent phlebotomy. these infants often receive multiple red blood cell transfusions. identifying infants more likely to require such intervention is important in ensuring the appropriate usage of this scarce resource. to determine whether birth weight, gestational age, gender, length of stay and mode of delivery can predict red cell concentrate (rcc) transfusion, units required, donor exposure and time to exposure. design/method: a retrospective chart review of all infants born below weeks gestation and/or birth weight less than , g who received a red blood cell transfusion between july and july in the cork university maternity hospital neonatal unit. results: infants met the inclusion criteria, ( . %) received a rcc transfusion. our study showed lower gestational age (p< . ) and lower birth weight (p< . ) infants are more likely to be transfused. donor exposure increases with a lower birth weight (p = . ). multivariate analysis showed infants with a lower gestational age (or - . per day; p< . ); lower birth weight (or - . per g; p< . ) and a longer length of stay (or . per day; p< . ) are more likely to receive a higher number of rcc transfusions. the time to first rcc transfusion is shorter in those with lower birth weight (or . per g; p< . ) and lower gestational age (or . per day; p< . ). gender and mode of delivery were not found to be predictors of red blood cell transfusion in this study. conclusion: low birth weight and premature infants are more likely to receive a rcc transfusion during admission to the neonatal unit. our study highlights predictors of rcc transfusion, donor exposure and time to transfusion. these can be used in identifying at risk infants, counselling parents and in anticipating transfusion requirements. emily southard, r. grant rowe, david williams, akiko shimamura, taizo nakano children's hospital colorado, aurora, colorado, united states background: the mecom locus encodes transcription factors that regulate hematopoietic stem cell self-renewal and maintenance. overexpression of mecom has been noted in - % of acute myeloid leukemia, several solid tumors, and denotes a poor prognosis. mutations that reduce mecom expression or that disrupt protein function, however, have been implicated in the development of bone marrow failure (bmf) through undefined pathways. an association between mecom mutations and radioulnar synostosis with amegakaryocytic thrombocytopenia (rusat) syndrome has been reported, however further characterization of this phenotype has yet to be explored. to characterize the phenotypic spectrum of a cohort of pediatric patients with novel mecom mutations. we performed a retrospective review of five patients with mecom mutations who were referred to hematology at children's hospital colorado or boston children's hospital. clinical, laboratory, and genetic data was collected on subjects and available family members. results: four of subjects were identified in infancy presenting with congenital cytopenias or physical dysmorphisms that prompted broad genetic screening. platforms for genetic detection included microarray, targeted genetic panels, and whole exome sequencing. three of subjects with cytopenias presented with congenital thrombocytopenia, of whom rapidly progressed to severe aplastic anemia. four of subjects presented with congenital anomalies, of whom demonstrated radioulnar synostosis. additional dysmorphic features identified include craniofacial (low set ears x ), cardiac (pda x , vsd x , aortic root dilation x ), pulmonary (pulmonary hypertension x , arteriovenous malformations x ), and developmental delay. one subject presented at age years with acute pancytopenia, hypocellular marrow, no dysmorphisms, and a mecom variant of unknown signif-icance. the identified mecom mutations include one . mb deletion involving several genes including mecom, one variant affecting a splice acceptor consensus sequence predicted to disrupt splicing, and three novel missense mutations, tyr cys, arg thr, and tyr cys, all of which were absent from public databases and were predicted in silico to be deleterious. we describe the phenotypic spectrum of patients with novel mecom variants. a subset of patients lacked radio-ulnar synostosis and had presence of additional systemic anomalies, demonstrating a varied clinical phenotype that is not isolated to rusat syndrome. a centralized publically accessible database to share clinically annotated mecom variants, together with analysis by experts in mecom function would advance our understanding of the clinical interpretation of mecom variants. mecom should be considered in the differential diagnosis of bone marrow failure and we advocate for the inclusion of mecom in targeted sequencing panels. cairo university, cairo, egypt background: beta thalassemia is regarded as a serious public health problem in the mediterranean region, southeast asia, and the middle east. however, very few studies have been conducted to assess the quality of life (qol) among thalassemia major patients. objectives: to assess the quality of life among b-thalassemia major patients using short form (sf)- questionnaire and to determine the factors associated with their quality of life. design/method: a cross-sectional study was conducted among thalassemia major patients who were attending the hematology outpatient clinic at cairo university hospital, during the study period. data were collected between october and march . the quality of life was assessed for patients aged ≥ years. the mean age of the studied group was . ± . years. the majority ( . %) had one monthly blood transfusion. the mean total score of sf- was . ± . . general health perception domain was the most affected domain with mean score, while vitality was the least affected one. there was no statistically significant difference between males and females regarding different quality domains except for vitality where the mean score was significantly higher in males than females (p = . ). age at onset of disease, and at first blood transfusion were the most documented factors positively correlated with the quality of life among the enrolled thalassemia patients. conclusion: the quality of life in thalassemia major patient was found to be compromised. all thalassemia patients should undergo assessment of the quality of life so that interventions focusing on the affected domains can be implemented. background: international adoption of children with special needs has become more prevalent in recent years leading to tremendous growth in the number of u.s. thalassemia patients adopted from foreign countries. currently % of the , thalassemia patients registered in the cooley's anemia foundation (caf) patient database have been adopted from foreign countries, primarily china. as this population continues to grow, further information is needed in order to provide these families with best supportive care. the primary goal of this study is to characterize the socio-demographics and health statuses of adopted children with thalassemia and their families. a secondary goal is to describe adoptive families' motivations, experiences, challenges, and support resources. design/method: a redcap survey was accessed by families of adopted children with thalassemia through the caf website and caf social media from january to august . following a four-question screen, eligible subjects were directed to complete an adoption questionnaire. families who had at least one adopted child with thalassemia receiving care at a participating thalassemia treatment center or hematology office in the u.s. were considered eligible. descriptive statistics were analyzed using sas . . respondents who were ineligible or who provided incomplete data were removed from the dataset prior to analysis. of survey respondents, qualified and completed the survey. these households had adopted a total of children with thalassemia ( . % male), most from china ( . %), where they had been living in orphanages ( . %). legal guardians identified primarily as christian ( . %). the majority had completed post-secondary education ( . %) with reported household incomes greater than $ , ( . %). most adoptive families were connected to an adoption group or community including online groups, local support groups, and adoption networks ( . %). commonly cited challenges were: ) volume of frequent medical appointments, ) insufficient support from their local care centers, and ) financial burdens. the reality of care for the population of adopted patients with thalassemia in the u.s does not seem to match the expectations set by their providers. we are hopeful this data will be used to assist adoptive families navigating the complexities of thalassemia care. the findings suggest that this population would benefit from additional outreach, education, guidance, and advocacy resources -especially in the early stages of adoption and during initiation of post-adoption medical care. background: in many higher-income countries, thalassemia major has become a chronic disorder; many outcomes are different in emerging countries with more limited resources. most analyzes of health-related quality of life (qofl) in thalassemia have been conducted in high-income settings. objectives: to assess the impact of health status on qofl in thalassemia patients in an emerging country. we assessed qofl in randomly-selected patients ( thalassemia major; with hemoglobin e thalassemia; five thalassemia intermedia) at the national thalassemia center in kurunegala, sri lanka where approximately patients are managed. treatment is free, but compared to north america/europe, access to tertiary staff and other resources are limited. overall, control of body iron as estimated by serum ferritin concentration (mean± sem, ± g/l) was not optimal in many patients. to understand the impact of health status on qofl, we used the sf v health survey, analyzing scores of physical function, pain, general health, social functioning, emotional and mental health, to generate overall physical and mental component scores. results: compared to reports from higher-income countries (american journal of hematology ; : - ), physical function scores (mean±sd, . ± . ) were similar in sri lankan patients; indeed, in three categories (physical role, social function, emotional role), sri lankan scores were slightly higher. by contrast, compared to scores from higherincome settings, those estimating bodily pain, general health, and mental health were significantly lower, resulting overall in a significantly lower physical component score in sri lankan patients. male sri lankan patients reported higher scores than females, and somewhat surprisingly, in four categories (physical function, physical role, social function and emotional role) reported higher scores than those obtained in higher-income settings. lower scores in physical functioning, leading to an overall lower physical component score, were recorded by females. patients with hemoglobin e thalassemia reported generally poorer qofl than those with thalassemia major. the lack of differences in qofl in patients with "high" and "low" hemoglobins was likely related to low pre-transfusion hbs (mean±sem, . ± . g/dl) in nearly all patients. these early data in a small cohort of thalassemia patients in an emerging setting suggest that in many patients bodily pain, reduced mental health, and poorer views of general health affect overall qofl. prospective studies in larger cohorts including evaluation of adequacy of transfusions and chelation therapy, complications, and overall accessibility of care may guide approaches to improve qofl in lower-income settings of thalassemia care. geetanjali bora, anand prakash dubey, tarun sekhri, mammen puliyel, aparna roy maulana azad medical college, new delhi, delhi, india background: in the last two decades, the presence of osteopenia has been described in optimally treated patients with transfusion dependent thalassemia, the pathogenesis of which seems to differ from osteopenia in non-transfused patients. the prevalence rate of low bone mineral density (bmd) in pediatric population is highly variable amongst studies done worldwide. furthermore, the role of metabolic and endocrine factors in determining bone mass in this population is not well understood. objectives: to assess bmd in subjects with transfusion dependent beta thalassemia by dual-energy-x rayabsorptiometry and find its co-relation with clinical, biochemical and hematological parameters. design/method: this is a comparative cross-sectional study and includes patients with transfusion dependent beta thalassemia between ages to years enrolled from a thalassemia day care center in the year - . at the time of enrollment age, sex, bmi z scores, pubertal staging, duration and type of chelation therapy were noted. enrolled subjects were scanned for bmd at lumbar spine l - and left femoral neck using dexa scan. the bmd was expressed in mean values and z scores. age, bmi, ethnicity and gender matched historic controls were used to generate z scores. ml of pre transfusion fasting venous blood samples were obtained to test for serum calcium, phosphate, alkaline phosphatase, pth, thyroid function panel, serum ferritin and serum igf- levels. mean values for pretransfusion hemoglobin and serum ferritin over last months were calculated. results: total no of subjects , median age . years, male ( %), female ( %), ethnicity % asian, bmi < rd centile ( %), pre pubertal %, all receiving transfusion and chelation therapy. prevalence of low (z score < - sd) and very low (< - . sd) bmd was %, % at l -l respectively and %, % at left femoral neck respectively. there was trend of lower bmd z scores with advancing age. statistically significant co-relation (p value < . ) was found between low bmd and low mean pretransfusion hemoglobin, serum phosphate, igf - and vitamin d levels conclusion: a sizable proportion of children and adolescents with transfusion dependent thalassemia have suboptimal bone mineral density and this decline may start as early as - years of age despite being on transfusion regimen highlighting the importance of yearly dexa screening and optimization of pre-transfusion hemoglobin, vitamin d and igf levels. vanderbilt university medical center, nashville, tennessee, united states background: it is well described that iron deficiency anemia (ida) can co-present with thrombocytosis or thrombocytopenia, though cases of thrombocytopenia are less frequent than thrombocytosis. prior reports of thrombocytopenia have included adult and pediatric patients with menorrhagia ( - ), menorrhagia due to uterine fibroids ( ), or other gynecologic abnormalities ( ). our cases highlight the pattern of ida, thrombocytopenia, and menorrhagia in the setting of significant menstrual clotting without observed gynecologic abnormalities in african-american adolescents. objectives: to describe the clinical course of three adolescent females with severe ida, menorrhagia, and thrombocytopenia. results: our cases included three female african-american patients ages - who presented with severe anemia and concurrent thrombocytopenia in the setting of menorrhagia. all three patients reported heavy and prolonged menstrual cycle bleeding with significant clots. two of the three were admitted for transfusions at presentation and noted to have significant menstrual bleeding with continued blood loss requiring additional transfusions until bleeding was controlled with estrogen therapy. these two patients were evaluated with pelvic ultrasounds revealing a prominent endometrium in both patients and hyperechoic material consistent with a clot in one patient. average hemoglobin on presentation was . gm/dl ( . - . ), average platelet count was , /mcl ( , - , ), and average mcv was ( - ). all had severe iron deficiency with an average ferritin of ng/ml ( - ) subsequently treated with oral iron. one patient had a prior history of ida that required transfusion and had subsequent normalization of her complete blood count. two patients had subsequent thrombocytosis before normalization of their platelet counts. two patients received platelet transfusions: one due to recent neurosurgical intervention with a higher goal platelet count and the other to help control menstrual bleeding after a nadir platelet count of , . a review of the clinical history and red cell indices pointed to ida and ongoing blood loss from menorrhagia as the reason for the bicytopenias. the thrombocytopenia in these cases may have been exacerbated by consumption of platelets in the significant clots all three patients reported. it is reasonable to treat with iron supplementation and supportive care which may include transfusions or management of menorrhagia with oral contraceptives or other hormonal methods. background: sickle cell disease is one of the most common inherited red blood cell disorders, yet many are not aware of their carrier status. the american college of obstetricians and gynecologists' guidelines recommend that pregnant women of african, mediterranean and southeast asian descent be screened for hemoglobinopathies with a cbc and hemoglobin electrophoresis . however, adherence to this practice and frequency of improper screening with sickledex is unknown. proper screening and counseling can impact families' knowledge, allowing for establishing relationships with pediatric hematology providers earlier. objectives: we sought to assess prenatal hemoglobinopathy screening practice patterns and methods of obstetrics & gynecology (obgyn) and family medicine providers in the nyc regional area. design/method: a cross-sectional electronic survey was administered to obgyn and family medicine practitioners from four nyc institutions. questions focused on prenatal hemoglobinopathy screening practices using case scenarios with variations on parental trait status and ethnicities. chisquare analyses were used to compare the two provider groups on categorical variables. there were total responses; surveys were complete, of which were obgyn and family medicine providers. respondents were mainly from academic medical centers, with the majority being faculty ( % of the obgyns and % of family medicine). no significant difference was found in frequencies of screening patients with a positive family history of a hemoglobinopathy. when asked about screening practices for patients without a personal/family history of a hemoglobinopathy, % of obgyns versus % of family medicine providers "always" screened for hemoglobinpathies (p = . ). when analyzed by ethnic background, there were significant differences by group in screening patients of white ( % vs %), black ( % vs %), mediterranean ( % vs %), and asian descent ( % vs %) (p≤ . for all). however, in cases where the hemoglobinopathy carrier status of both parents was known, there was no difference in screening with a hemoglobin electrophoresis. furthermore, > % of all respondents use sickledex for screening in the case scenarios. conclusion: this pilot survey highlights a difference in the methods and likelihood of prenatal hemoglobinopathy screening based on the type of prenatal care provider. screening differences can lead to variations in prenatal guidance, diagnostic procedures, informed decision-making and knowledge of families referred to pediatric hematology clinics. this is the first study analyzing prenatal screening for hemoglobinopathies in obgyn and family medicine. improving prenatal screening practices by collaborating with hematologists may decrease health care disparities and allow for earlier relationship building with pediatric hematology. . acog, opinion# , poster # hermansky-pudlak syndrome: spectrum in oman background: hermansky-pudlak syndrome (hps) is a rare autosomal recessive disorder, characterized by the triad of oculocutaneous albinism, a hemorrhagic diathesis resulting from storage pool-deficient platelets, and accumulation of ceroid/lipofuscin-like material in various tissues. before , nine different types of hermansky-pudlak syndrome were identified, which can be distinguished by their signs and symptoms and underlying genetic cause. in , a tenth type was defined based on mutations in the ap d gene. hps type is characterized in addition by severe neutropenia and recurrent sinopulmonary infection. the disease is more common in puerto rico, and this is the first report from oman. to describe the clinical, laboratory and genetic characteristics of hps sub-types in oman, including the first cases of hps type . design/method: this is a retrospective study, including cases with hps that had been suspected clinically and confirmed through genetic mutation analysis. clinical data included sex, age at presentation, initial clinical presentation (skin, eyes, development, neurological involvement, bleeding tendency, recurrent infections) and course of disease. laboratory data (complete blood counts, platelet and absolute neutrophil counts, coagulation screening, platelet function tests by platelet function analyzer, and platelet aggregation studies using different agonist had been recorded. pcr and next generation sequencing for genetic confirmation by testing mutations in hps , ap b , hps , hps , hps , hps , dtnbp ,, bloc s , bloc s genes had been done. results: seven omani cases with hps have been identified ( males and females). their age ranged between (at birth) to years. two patients had hps type , patient had type , while the other cases had hps type . no other sub-types were encountered in oman. all patients were products of consanguineous marriage. one patient had adrenal hge, while the others had mild hemorrhagic phenotype, characterized by recurrent bruising and mild epistaxis. laboratory testing confirmed variable platelet aggregation defects with different platelet agonists. all patients had characteristic hypopigmentation, iris transillumination, nystagmus, and foveal hypoplasia. both patients with hps type had the same homozygous mutation in the ap b gene (c. _ delta), and presented with severe neutropenia. early diagnosis and initiation of gcsf on one of them improved outcome and prevented the development of complications. late diagnosis in the other patient resulted in the development of bronchiectasis as a result of recurrent sinopulmonary infections. background: sickle cell disease (scd), a genetic disorder characterized by defective sickle hemoglobin (hbs), triggers red blood cell sickling, hemolysis, vaso-occlusion, and inflammation. ischemic injury from scd starts in infancy and accumulates over a lifetime, causing pain, fatigue, and progressive end-organ damage that culminates in early mortality. voxelotor (gbt ) is an oral, once-daily therapy that modulates hemoglobin's oxygen affinity, thereby inhibiting hemoglobin polymerization. objectives: to assess the safety, pharmacokinetics, and efficacy of voxelotor in pediatric patients with scd. design/method: this ongoing study is being conducted in parts: part a: a single dose of voxelotor mg in pediatric and adolescent patients; part b: multiple doses of voxelotor mg/d or mg/d for weeks in adolescents. part b's primary objective is to assess the effect of voxelotor on modifying anemia. secondary objectives include measuring other markers of disease modification, such as hemolysis; daily scd symptoms, using a patient-reported outcome (pro) measure; and safety. results: as of november , , patients ( females) had received voxelotor mg and patients ( females) had received voxelotor for ≥ weeks. the median age for the patients was years, % were receiving hydroxyurea (hu), and % had ≥ painful crises in the past year. data for hemolysis measures are available for patients who received voxelotor for weeks. six of the patients achieved a hemoglobin (hb) response of > g/dl increase. laboratory markers of hemolysis improved concordantly; the median reductions in reticulocytes and indirect bilirubin were % and %, respectively. ten of patients showed reduction in total symptom scores (tss) at week , with a % median reduction in tss from baseline. there were no treatmentrelated serious adverse events (aes) or drug discontinuations due to aes. voxelotor mg for weeks in adolescents with scd, the majority receiving hu, demonstrated consistent, sustained efficacy on hb levels and measures of hemolysis; > % of patients showed a > g/dl improvement in hb. improvement in tss in mildly symptomatic patients suggests that the pro is sensitive to treatment effect and supports use in the ongoing hope phase study. voxelotor's reassuring safety profile is consistent with results in adults. these interim results support ongoing clinical evaluation of voxelotor as a potential disease-modifying therapy for adults and children with scd. supported by global blood therapeutics. background: acute kidney injury (aki) is a common complication in sickle cell disease (scd), and a potential risk factor for sickle nephropathy. aki is associated with acute decline in hemoglobin (hb) during vaso-occlusive pain crisis and acute chest syndrome (acs). it is unclear which pathologic factor plays a stronger role in aki development during hb drop: increase in free heme during vaso-occlusive events secondary to hemolysis or hb decline itself. objectives: to investigate if hb decline alone is associated with aki, we tested if the renal function of patients with scd worsened during parvovirus b -induced transient aplastic crisis (tac), in the absence of accentuated hemolysis. design/method: with irb approval, a retrospective study of patients who had laboratory confirmed parvovirus-b was conducted. serum creatinine (scr), both during and within months from the tac event, was collected. comparisons of the clinical and laboratory characteristics were analyzed using the wilcoxon test for continuous variables. aki was defined as an increase in scr by ≥ . mg/dl or a % increase in scr from baseline. to evaluate differences in change in hb on aki risk, changes in scr during tac were compared to those during pain crisis or acs admissions by fitting a generalized linear mixed model for binary outcome. a comparative sample of acs events and vaso-occlusive pain crisis were used to estimate rates of aki according to hb levels. results: three ( %) of the patients with scd developed aki during tac. no association was identified between change in hb from baseline to tac event (p = . ). no cases of aki were identified until hb decreased < . g/dl or the change in hb was ≥ . g/dl from baseline. next, we developed a model to evaluate the impact of change in hb from baseline for patients admitted with tac, pain crisis or acs on aki. with a g/dl decrease in admission hb from baseline, patients with tac had a % probability of developing aki, while acute chest syndrome and pain crisis would have a % and % probability, respectively. our data suggest that aki is still prevalent during parvovirus b -induced tac. however, the risk of aki during a tac event is and times lower than that from severe anemia induced by acute chest syndrome and vasoocclusive pain events, respectively. hemolysis-induced anemia during scd crisis appears to have a more significant role in the development of aki as compared to agenerative anemia. background: the natural history of hemoglobin e beta thalassemia (hbethal), the commonest form of severe beta thalassemia worldwide, has been examined in very few longterm studies. previously, we reported findings in hbethal patients in sri lanka. objectives: to evaluate longterm requirements for transfusion and splenectomy, complications and death in hbethal patients. design/method: all available patients were reviewed - times annually over years. results: patients ( %) died, aged (mean ± sem) . ± . years; the (known) causes commonly included iron overload ( ) and infection ( ); patients surviving patients are aged . ± . years. of patients originally classified by severity (group the mildest, and group the most severe, phenotypes), ( %) were assessed as mild (groups and ), of whom transfusions had been discontinued in . ultimately, / ( %) resumed transfusions, often following shifts to increasingly severe phenotypes including increasing intolerance to anemia. age at resumption of transfusions (following a transfusion-free interval of . ± . years) was . ± . years; in the more severe groups and , regular transfusions were stopped in / patients and resumed in / ( %), at younger ages ( . ± . years) and after shorter transfusion-free periods ( . ± . years) than in "milder" patients. mid-parental height (mph) was ultimately achieved in %. patients ( %) were splenectomized; updated analysis of responses to splenectomy (originally "group " patients), showed that splenectomy (at . ± . years) was followed by an extended, but impermanent, transfusion-free interval ( . ± . years); % patients resumed transfusions, usually related to exercise intolerance or poor growth. in groups and , complications of anemia and ineffective erythropoiesis, including leg ulcers (in % and %) and gallstones ( % and %), were more frequent than in groups and ; fractures were observed ( - %) across all groups, except for regularly-transfused group patients ( %). pulmonary artery pressures > mm were recorded in % patients. evaluation of patients with hbethal requires observations over years, without which definition of patients as "mild" or "severe" may be misleading. while in many patients transfusions may be withheld or reduced in frequency, troublesome complications may surface with advancing age even in "milder" patients. although individual consideration of transfusion requirements is critical, the availability of effective chelation, where this can be provided without prohibitive cost, may alter the balance of risks and benefits of regular transfusions in hbethal. (premawardhena a. lancet ). background: social determinants of health (sdh) are environmental and socioeconomic factors, such as access to food and housing that affect health outcomes. pediatricians are increasingly screening for sdh as part of primary care visits, however less is known about screening for sdh in pediatric hematology. evidence suggests that sdh play a role in disease severity for children with scd, who face significant socio-economic and racial disparities. the goal of our quality improvement (qi) project was to increase the percentage of patients with scd who were connected to community resources for unmet social needs. design/method: we based our intervention on the successful implementation of wecare in our institution's pediatric primary care clinic. eligible patients were identified at the start of each clinic session. on arrival the parent was given a self-reported screening tool for six sdh (childcare, education, employment, food, utilities and housing). results were entered in the electronic health record by the physician or social worker who then printed a pre-existing resource list for patients with a positive screen. we used a series of plan-do-study-act (pdsa) cycles to study tests of change. we tracked process measures (percentage of patients screened, percentage of patients with an unmet social need who received a resource sheet), outcome measures (percentage of patients with an unmet social need who connected with a community resource) and balancing measures (staff, patient and provider satisfaction). run charts were reviewed weekly and then monthly to inform further tests of change. examples of pdsa cycles include who gave the paper survey to patients (social worker or physician versus medical assistant) and length of time between surveys ( to months). results: between august and december screening rates improved from % to %. of the patients screened, % report at least one unmet social need; of those % received a targeted list of community resources in the first month of the project, and % in the fifth month. finally, % of patients reached by phone had connected with a community resource within weeks of the clinic visit. we have successfully implemented universal screening for sdh for patients with scd in our urban pediatric hematology clinic without requiring extra staff. next steps include further pdsa cycles to connect more patients to appropriate resources, and tracking improvement in health care utilization outcomes from addressing sdh in this vulnerable patient population. background: the clinical manifestations of sickle cell disease (scd), chronic hemolytic anemia, and vaso-occlusion occur as a direct result of sickle hemoglobin (hbs) polymerization. voxelotor (gbt ) is a first-in-class, oral, oncedaily investigational agent designed to modulate hemoglobin's oxygen affinity in a targeted approach to inhibit hbs polymerization. objectives: to examine the pharmacokinetics (pk), safety, and dosing of voxelotor in children (aged - years) and adolescents (aged - years) with scd from part a of the gbt - study. design/method: gbt - is an ongoing, open-label, phase a study in patients aged - years with scd (sickle cell anemia or sickle beta zero thalassemia). part a of this study (the focus of this abstract) is examining pk of singledose ( mg) voxelotor. pk samples to measure whole blood and plasma voxelotor concentrations were collected up to days following single-dose administration. separate population pk (ppk) models were developed to describe the concentration versus time profiles of voxelotor in whole blood and plasma using nonlinear mixed effects modeling (non-mem, version . ). ppk modeling and physiologically based pk (pbpk) modeling were used to simulate voxelotor pk parameters and support dose selection for future evaluation in younger children. : part a included adolescents ( females; median age years [range - ]) and children ( females; median age . years [range - ]). mean weight was . kg (range - kg) and . kg (range - kg) in adolescents and children, respectively. voxelotor was well tolerated with no drugrelated grade ≥ adverse events (ae) or serious aes. a compartment model with first-order absorption best described the pk of voxelotor (and was the same model structure used for adults with scd). voxelotor pk exposures in adolescents were comparable to those observed in adults, but higher exposures were observed in children. ppk and pbpk modeling support the use of a weight-based dosing strategy in younger children (aged < years) in future trials. adult voxelotor doses can be used in adolescents. however, based on higher pk exposures, a lower weight-based dosing strategy is recommended in children. ppk and pbpk modeling provides an innovative approach to minimize experimental dosing in children and accelerate dose selection of voxelotor in ongoing and future clinical studies. this abstract is supported by global blood therapeutics. background: hydroxyurea (hu) reduces rates of acute complications, and improves long term outcomes in patients with sickle cell disease (scd) and is now fda approved for children. through previous work we have increased the number of eligible patients on hu in our clinic, however accessing a compounding pharmacy remained a significant barrier to hu adherence for infants and children who cannot swallow capsules. objectives: the objective of our quality improvement project was to improve adherence to hu among pediatric patients with scd at our urban safety net hospital by addressing barriers to obtaining liquid hu. design/method: to begin we met with the leadership of our outpatient pharmacy which offers mail order delivery. however, like most retail pharmacies, they do not have the necessary protective equipment to compound liquid hu. through a series of discussions, we began a unique partnership with our institution's inpatient chemotherapy pharmacy who compounds the liquid hu and delivers it to the outpatient s of s pharmacy, who then dispenses liquid hu to families. using a series of plan-do-study-act (pdsa) cycles we tracked adherence by calculating the medication possession ratio (mpr), defined as the percentage of days in a given period of time that each patient had their medication on hand. the mpr for liquid hu mpr among enrolled patients was tracked by pharmacy staff and reviewed monthly. additional pdsa cycles included adding automatic refills and reminder calls by pharmacy staff and improving communication about delivery. we also tracked patient satisfaction. results: between march and december , a total of thirty pediatric patients were enrolled in our program for on-site compounding and free mail order delivery of liquid hu. mpr for liquid hu is currently . % among enrolled patients, significantly higher than the mpr of % reported in the literature, and has risen steadily since the beginning of the project. families are highly satisfied with the program, specifically appreciating the convenience of mail order delivery, saving on delivery fees, and reminder calls when refills were due. by compounding and dispensing liquid hu directly from our institution's outpatient pharmacy we have significantly improved adherence to this hu therapy in our high-risk population. next steps include analysis of change in clinical outcomes for patients enrolled in this program. as adherence to hydroxyurea is associated with decreased acute care utilization and cost, programs such as ours could play a crucial role in reducing the excessive costs and ed utilization among this patient population. background: experience with the iron-chelator deferasirox is reported widely in higher-income settings. by contrast, real-life experiences in emerging countries are infrequently reported. objectives: to evaluate, in a non-trial setting, the real-life response to deferasirox in an emerging country. design/method: in sri lanka's national thalassemia center which manages patients without tertiary staff, quantitative evaluations of body iron or estimates of extra-hepatic iron, the records of patients who began deferasirox in / were retrospectively reviewed. results: baseline assessments (mean±sem) indicated substantial iron loading [serum ferritin (sf) , ± ug/l; serum alt ± . u/l (normal ≤ u/l)]. deferasirox was introduced at low doses ( . ± . mg/kg/day); many patients started at < mg/kg and, after months, doses remained ≤ mg/kg/day in % patients. after months, sf in % patients remained > , ug/l; only by months had (mean) sf declined to < , ug/l ( ± ; p< . ). similarly, mean alt normalized (to ± u/l) only by months. death and complications were not systematically recorded by staff who had been charged, without provision of additional resources, with the introduction of this new drug in hundreds of patients. these results contrast to those in sri lanka's tertiary thalassemia center where, in patients following the introduction of deferasirox ± . mg/kg/day, sf declined rapidly, even in relatively less ironloaded patients (from , ± to , ± g/l after months; p = . ). these findings underscore the importance, during the implementation of new drug regimens in lowerincome centers with marginal resources, for investments in methods to quantitate body iron burden, hands-on educational initiatives to guide day-to-day management by competent but non-expert staff, and data systems to record efficacy, effectiveness, toxicity and compliance. such investment is critical to optimising therapy and improving complications in thalassemia patients worldwide: even in sri lanka, where resources directed to thalassemia management are greater than in most of asia, results in the oldest living cohort (born - ) indicate under-treatment [elevated iron burdens (sf , ± ug/l) and high prevalences of diabetes ( %) and hypothyroidism ( %)]. even in a younger cohort (born - ) which has benefitted from improved treatments, the prevalence of many complications exceeds those reported from high-income settings. over the next decade, and two decades after the who declaration that the impact of thalassemia on global mortality and morbidity is underrecognized, increased investments by governmental and nongovernmental sources will be necessary to improve outcomes for asian patients with thalassemia. background: a major barrier to success in hydroxyurea (hu) treatment of patients with sickle cell disease (scd) is non-adherence. objectives: to optimize hu adherence in patients with scd. design/method: a care model was designed by the sickle cell (qi) team at children's hospital to improve hu adherence among scd patients. the original model included bimonthly family phone contact, monthly dispensing pharmacy phone contact and lab monitoring. adherence measures included obtaining hu from pharmacy monthly, completion of monthly labs, hb f percentage and mcv, and mtd achievement. from / - / , several pdsa cycles refined our care model. a one-year follow-up survey gathered feedback on the care model. the first-year data involved ∼ patients. the biggest improvements resulted from making pharmacy calls before patient/family calls, shipping liquid hu to outlying patients, and tracking call time/content. the qi goal was % hu adherence by / . the % baseline adherence rate increased to % by / , and has remained in that range. the completion rate of patient/parent phone calls increased from % the first month to % at six months. pharmacy prescription pick-up has increased from % to % per month. lack of liquid hu availability was overcome by shipping the medication to the patient's home. parental hesitance to share information by phone, especially with qi team members with whom they had no established relationship, was overcome by having the longtime sickle cell nurse do many of the early calls. however, survey feedback showed families became comfortable with several clinic personnel calling. the calls gave families the opportunity to ask questions about their child and/or get additional information about scd. the calls also provided an opportunity for seasonal flu shot or tcd testing reminders. the surveys gave information on the optimal time of day to reach each family, providing individualization and further increasing the percentage of completed calls. two families surveyed said they no longer needed two calls a month because they were now able to remember to pick up hu, administer it, and get labs on their own. this qi project has not only improved hu adherence, but also fostered health education/counseling, increased patient/parent satisfaction, and enhanced service utilization. medical team member and patient/family comments demonstrate that it has helped build relationships and trust between families and the medical care system. based on survey feedback, we will further individualize care to increase adherence rate and sustain improvements. cincinnati children's hospital medical center, cincinnati, ohio, united states background: the thalassemias are a heterogeneous group of genetic blood disorders caused by mutations that decrease or eliminate the synthesis of the -and/or -globin subunits of hemoglobin. the phenotype of thalassemia depends on the interaction of the -and -globin gene clusters, because both loci determine the -/ -chain balance. for example, a -thalassemia phenotype can be more severe than expected when coinherited with -globin gene triplication (copy number gain), which exacerbates the -/ -globin imbalance. objectives: describe four individuals with an incorrect diagnosis of -thalassemia trait who were later properly diagnosed by comprehensive genetic testing to have -thalassemia intermedia caused by heterozygous -thalassemia mutations coinherited with triplicated -globin loci. design/method: sequence analysis of the -globin (hba /hba ) and -globin (hbb) genes, and copy number variation analysis of the -and -globin gene clusters by multiplex ligand-dependent probe amplification. results: four unrelated individuals of northern european ancestry were evaluated for signs and symptoms not explained by a diagnosis of -thalassemia trait (previously made by a pediatric hematologist), including growth delay, splenomegaly, moderate anemia, marked elevation of hemoglobin f, thalassemic facies, reticulocytosis, and/or indirect hyperbilirubinemia. genetic testing revealed that all were heterozygous ( / ) for the same, single -globin mutation [hbb.c. c>t (p.q *)] and also heterozygous for an -globin triplication ( / anti- . ). their previous diagnoses of thalassemia trait had been made by complete blood counts, hemoglobin electrophoresis, and/or sequence analysis of the -globin genes only. these individuals' phenotypes ranged from moderate anemia only to multiple stigmata of thalassemia, demonstrating the phenotypic variation of a thalassemia genotype. correct diagnosis was made at an average age of . years. a trial of chronic transfusions was initiated for one patient for growth failure. all were educated about the potential for exacerbations of anemia, gallstones, osteoporosis, and iron overload (even without transfusions). parental genetic testing was recommended to assess reproductive risk, because inheritance of this complex genotype can be apparently autosomal dominant. conclusion: heterozygosity for a -thalassemia mutation does not necessarily indicate -thalassemia minor or "trait". when coinherited with -globin gene triplication, a symptomatic form of -thalassemia can occur. correct and timely diagnosis of thalassemia requires careful consideration of the degree of anemia and examination for organomegaly, bony changes, and jaundice. sequence analysis and copy number variation analysis of both the -and -globin gene clusters is key. hematologists need to be aware of this diagnostic possibility and how to test for it to prevent inaccurate or delayed diagnosis. background: the burden of healthcare costs for sickle cell disease (scd) is nationally estimated at over $ billion. the major components of these costs are inpatient and emergency center (ec) visits, many of which are potentially avoidable. in several chronic conditions, a subset of patients account for most of the avoidable encounters. identifying these patients is the first step in targeted care delivery. objectives: to measure and analyze scd patient utilization patterns in the ec and inpatient at texas children's hospital (tch). we identified all individuals under years old with any encounter at tch associated with an international classification of disease (icd)- or code for scd, including hgb ss, hgb sc, and hgb s/beta thalassemia. for each patient, we identified all inpatient and ec encounters in the days prior to their most recent encounter. finally, each encounter was classified as associated with pain, acute chest syndrome (acs), or "other" using an algorithm of discharge diagnosis codes and pharmaceutical delivery. the total number of scd-associated ec and inpatient encounters over the prior year was calculated for each patient. we stratified each patient according to their utilization patterns: low ( - encounters), intermediate ( - encounters), and high (≥ encounters). we identified unique patients with scd that had at least one encounter from july until june . there were , scd-related encounters in the days prior to their most recent encounter. most ( %, n = ) patients exhibited low-utilization patterns and % (n = ) were intermediate. finally, a small subset ( %, n = ) demonstrated high-utilization patterns and accounted for % of all encounters. high-utilization was associated with older age and public payment mechanisms. pain encounters were predominantly in pre-adolescents and teenagers with high-and intermediate-utilization patterns. acs was most frequent in pre-teens and younger teens in the intermediate-utilization group. finally, the youngest-aged high and intermediate users presented for other reasons such as febrile episodes and splenic sequestration. our findings reflect national trends in that a significant portion of encounters are attributed to a small subset of patients exhibiting a high-or "super-" utilization pattern. at our institution, scd super-utilization is associated with older age and pain. we also identified a group of infants and toddlers with frequent encounters for fever. to comprehensively address this burden, it will be important to design interventions targeted toward age and specific medical needs. background: background: the rarity of diamond blackfan anemia (dba) has hindered describing the spectrum of disease, identifying predictive correlations, and guiding datadriven recommendations. long-term toxicities from steroid or transfusion therapy that start in childhood remain the major clinical problems in patients with dba who do not receive stem cell transplant. objectives: objective: to define the dba patient population at st. jude children's research hospital including treatment responses and toxicities to help inform recommendations on treatment and monitoring. design/method: method: medical records were reviewed for all patients with dba treated at st. jude between and for diagnostic testing, treatment types and regimens, and outcomes. two-sample t-test or wilcoxon rank sum test was used to compare continuous variables in two groups depending on the normality of the data tested by shapiro-wilk test. results: a total of patients with dba were identified with a median age of . years (range months - years) at last follow up. a ribosomal protein gene mutation was identified in / patients ( %) with an rps mutation / ( %). thirteen different congenital malformations were described in / patients ( %). fourteen of twenty ( %) patients treated with corticosteroids had an initial response and of those achieved full remission. three patients became steroid-refractory and were unable to wean to an acceptable dose. five of twenty patients continue on lower-dose steroids. five patients currently require no therapy. univariate analysis revealed no statistically significant genetic predictors of response or remission, however, / rpl patients responded to steroids with / ( %) in long-term remission. ten patients are maintained on chronic transfusions and have undergone successful hematopoietic stem cell transplant. nineteen of treated patients ( %) had a treatment-related toxicity. patients on steroids were more likely to have short stature than patients on transfusions or in remission (p = . ). severe bone mineral density deficit occurred in / ( %) patients, in before age years. eight patients had hepatic iron overload, in one documented by age years. other severe toxicities included restrictive cardiomyopathy from iron overload, pathologic fracture, diabetes mellitus, and premature ovarian failure in one patient each. this genotypically and phenotypically heterogeneous dba cohort had a high rate of treatment-related toxicities, notably growth retardation, bone density loss, and hepatic iron overload even in very young children. these findings underscore the need for early standardized monitoring. background: patients with sickle cell disease (scd) face worsening morbidity and mortality between ages and , when they must transition from pediatric to adult healthcare.( ) an effective curriculum addressing disease knowledge, educational and vocational skills, self-efficacy, and social supports is critical to a successful transition. traditional didactic approaches have not led to durable knowledge retention. ( ) technology-based methods have been attempted, but the best educational approach remains unknown. objectives: . to understand how adolescent and young adult (aya) patients with scd view existing transition education. . to include patient preferences in improving our transition curriculum. we developed a qualitative survey to assess patient views of existing approaches for learning about scd and their opinions about preferred transition topics. thirty patients with scd aged to years old were recruited between january and december . responses were managed using redcap electronic data tools hosted at the university of rochester.( , ) qualitative and quantitative data analyses were performed, including independent t-testing to compare responses between age groups. results: approximately % of subjects were under years of age, while % were or older. seventy-one percent had a computer, and . % had a cell phone, with most reporting daily use. subjects reported greatest satisfaction with learning from their doctor during clinic visits ( . % agree or strongly agree) and websites on a cell phone ( . % agree or strongly agree); the least popular methods were online chat rooms and microsoft® powerpoint presentations. satisfaction was similar across age groups. recommended transition topics were viewed positively, with subjects ranking highest understanding their bloodwork ( . % agree or strongly agree) and understanding laws protecting students with chronic disease ( . % agree or strongly agree). older subjects ( - years old) agreed more strongly with learning about opioid addiction and understanding differences between adult and pediatric doctors than did younger subjects ( - years old) (p < . ). this pilot study was successful in helping us to understand the educational needs of aya patients with scd. preliminary data underscore the importance of education provided by the pediatric hematologist. our results also suggest that the optimal use of technology-based methods requires further investigation and that tailoring transition education by age group may be useful. background: similar to patients with transfusion-dependent beta-thalassemias (tdt-beta), survivors of hemoglobin barts hydrops fetalis (homozygous alpha- -thalassemia, tdtalpha) will require lifelong transfusions of erythrocytes. we have previously shown that a transfusion strategy that is based on the guidelines developed for tdt-beta (conventional transfusion) is suboptimal for these patients owing to the differences in the pathophysiology of anemia in the two conditions: in tdt-alpha, conventional transfusion strategy will lead to a gradual increase in non-functional hbh with subsequent tissue hypoxia and hemolysis. an aggressive transfusion strategy that was based on reduction of hbh and increase in "functional" hemoglobin level resulted in improvement of tissue oxygenation and reduction of hemolysis but was associated with significant increase in transfusional iron burden [amid et al, blood ] . objectives: to define the optimal chronic blood transfusion targets for hbh% and functional hemoglobin in patients with tdt-alpha. design/method: following research ethics board approval, longitudinal data of patients with tdt-alpha ( males, median age . ( . - . ) were retrospectively collected. variables of interest included total pre-transfusion hemoglobin, hbh%, and "functional" hemoglobin [measured as total hemoglobin x ( -hbh/ )]. outcome variables were lactate dehydrogenase (ldh, marker of hemolysis), and soluble transferrin receptor (str, marker of erythropoiesis). hemoglobin analysis was done using high-performance liquid chromatography and capillary zone electrophoresis. we examined the association of "functional" hemoglobin with str, and hbh% with ldh, using repeated-measures anova to adjust for the effect of multiple testing. we constructed receiver operating characteristic curve and calculated the area under the curve to define the best cut-off values for variables of interests. there was a strong association between functional hb and str, as well as hbh and ldh. the optimal cut-off for "functional" hemoglobin that was associated with str < . mg/l was g/l (auc = . , sensitivity and specificity of . % and % respectively). the optimal cut-off for hbh to supress ldh to < u/l was % (auc = . , sensitivity and specificity of . % and % respectively). the optimal pre-transfusion hbh% for reduction of hemolysis was % and the optimal "functional" hemoglobin to adequately supress erythropoiesis was g/l. to meet these hbh% and functional hb targets by simple blood transfusions, patients with tdt-alpha would require a hypertransfusion regimen with a minimum pre-transfusion total hb of g/l and consequently high transfusional iron burden. an alternative approach using exchange transfusion to reduce hbh% and improve functional hemoglobin would be associated with less volume of transfusion and potentially better long-term outcome. hospital sacre coeur, milot, haiti background: initial results of work developing a pediatric sickle cell disease (scd) clinic at the hôpital sacré coeur (hsc) in milot, northern haiti were presented at aspho . the purpose of this clinic is for a pediatrician with a special interest in scd to provide scd care, advising on trait and managing disease with penicillin prophylaxis (pcn) and hydroxyurea therapy (hu) for select patients. this clinic was started in collaboration with a us based hematologist and support from yale-new haven hospital. objectives: to describe the success and challenges of providing pcn and hu in the scd clinic at hsc through a review of patient records. design/method: since this clinic's inception, a database of patients, with basic clinical information has been kept and made accessible, through 'drop-box', to the us hematologist. the records of those that presented to the clinic were reviewed. the hemoglobin diagnosis was made either by clinical history and sickle cell prep or by hemoglobin electrophoresis through alpha laboratory, port-au-prince, haiti. results: ninety-nine individuals were seen in the first years of the program. fifty-six underwent a hemoglobin electrophoresis. of these , are ≤ years old. thirty-two were started on pcn vk, of which / ( %) were ≤ years old. eleven patients were started hu therapy. all patients on hu have shown progressive increases in hemoglobin. there have been no clinical complications of hu therapy. none of the patients taking hu have required hospitalization or transfusion in . three patients (not on hu) were hospitalized in for complications of scd (osteomyelitis, pain). in , with less than half the numbers in the program, there were admissions for severe anemia, pain, stroke and splenic sequestration. with ongoing external support and a local reputation for excellence in sickle cell care, the clinic at hsc has been able to expand services and improve the health of a growing number of patients with scd. early data suggests that pcn and hu therapies are helping to reduce complications and improve quality of life. challenges to date have included lack of funding for transportation to clinics, for hospitalizations and to cover the cost of electrophoreses. at the same time as continuing providing excellent care and gathering data, it is crucial to explore opportunities for collaboration and cooperation in ways that will assure that the clinic can become independently sustainable while continuing to improve the quality of life for the individuals it serves. background: ykl- is an inflammatory glycoprotein expressed by infiltrating macrophages in various inflammatory conditions. it has been found to be elevated in patients with different pathological conditions like acute and chronic inflammations, increased remodeling of the extracellular matrix (ecm), development of fibrosis and cancer. several studies have found elevated ykl- concentrations in sera of patients with liver diseases such as hepatic fibrosis by hepatitis c virus. it has been suggested that ykl- concentrations reflect the degree of liver fibrosis. to evaluate serum ykl- levels in patients with -thalassemia and its relation to viral hepatitis, liver stiffness as assessed by transient elastography (fibroscan, fs) and hepatic iron concentration. design/method: a prospective study included patients with -tm ( males and females) with mean age . ± . years (range: - years). serum ferritin level, liver enzymes (alt and ast), hbs ag, anti hcv ab and serum ykl- using elisa kit were evaluated. all patients were subjected to liver mri t * to detect liver iron content by the sequence and transient elastography (fibroscan, fs) to assess degree of liver stiffness. results: mean fibroscan value was ( . ± . ) kpa with a median . (range . to ) kpa. ( %) patients were categorized as f - and ( %) were stage f - , ( %) patients had severe fibrosis. their median serum ferritin was ng∖ml, with ( %) patients had values exceeding g/l. median cardiac t * was . with patients had values below ms, and the median lic was . mg/g dw with patients showed readings above mg/g dw. nyl- was evaluated as a marker of inflammation and liver fibrosis and showed mean value . (± . ) pg/ml, and range from to pg/ml. mean ykl- was significantly higher among males (p = . ), patients on chelation therapy (p = . ), patients on dfs (p≤ . ), in those with abnormal liver enzymes, splenectomised patients, patients with hbv sero-positivity, those with moderate elevation of t * and patients with high grades of liver fibrosis (p< . ). ykl- showed positive correlation with the rate of transfusion, lic, ferritin, alt and ast but negative correlation with weight, height and t *. roc curve analysis revealed that the cutoff value of ykl- at pg/ml could differentiate -tm patients with and without viral hepatitis with . % sensitivity and specificity of . %, area under the curve (auc) . , positive predictive value . and negative predictive value . (p< . ). roc curve analysis revealed that the cutoff value of ykl- at pg/ml could detect -tm patients with liver cirrhosis with . % sensitivity and specificity of . %, area under the curve (auc) . , positive predictive value . and negative predictive value . (p< . ). conclusion: serum ykl- levels are elevated in patients with -thalassemia and can detect patients with active viral hepatitis and liver stiffness. background: the most common splenic complication in pediatric patients with sickle cell disease (scd) is acute splenic sequestration (ass), which has often been managed with splenectomy. although splenectomy has been a treatment of choice for years, long-term vascular complications have not been thoroughly evaluated. pulmonary hypertension (phtn) is a severe complication of scd. in adults with scd, phtn has been associated with a -month mortality rate of approximately %. it has been reported that splenectomized patients with hemolytic disorders are at even greater risk of phtn. several medications exist to treat phtn, but with few studies of their efficacy or toxicities in patients with scd. additionally, these patients are often treated with either chronic prbc transfusions or hydroxyurea (hu) to raise hemoglobin, reduce hemolysis, and prevent vaso-occlusive events. objectives: to evaluate effect of chronic prbc or hu vs. no intervention, on tricuspid regurgitant jet velocities (trv) in pediatric patients with scd and history of splenectomy. design/method: retrospective chart review of splenectomized patients with hbss followed at marian anderson center at st. christopher's hospital for children, philadelphia, between and . we analyzed trvs ( hu, prbc, and from control group receiving neither treatment) from patients ( hu, prbc, neither). mean age at echo was . +/- . . data was analyzed with linear correlations and analysis of variance (anova), including the post hoc test of least significant difference (lsd) for all pairs of treatment groups. results: trv was not significantly correlated with age at time of assessment or with time between splenectomy and trv. univariate anova among groups yielded trv means of: . +/- . cm/s (hu), . +/- . (prbc), . +/- . (neither). we found a notable difference as the mean of the hu group was almost cm/s lower than the others, but no overall statistically significant association for any of the groups exists. however, when we performed post hoc tests to adjust for multiple comparisons and looked at all pairings within the anova, we found that the lsd between the hu and the prbc groups was statistically significant (p = . ), and that a trend exists between the hu group and the neither treatment group (p = . ). our data suggests that treatment with hu is correlated with a reduction in trv in pediatric patients with scd who underwent splenectomy. given these promising results, we believe our data warrants further study with larger treatment groups. nancy olivieri, gaurav sharma, susmita nath, rajib de, tuphan kanti dolai, prakas kumar mandal, abhijit phukan, amir sabouhanian, robert yamashita, angela allen, david weatherall, prantar chakrabarti background: hemoglobin e thalassemia (hbethal), which accounts for % of all severe beta thalassemia worldwide, has an estimated prevalence of . / , in west bengal, from which little information about clinical findings has been reported. objectives: to document clinical and laboratory findings in patients with hbethal, ultimately to improve resources for clinical management. design/method: we reviewed records from: a database recording patient names; clinic charts; "special" charts containing additional details; and, in transfused patients, transfusion day-care records. additionally, because in india's public hospitals original lab/imaging reports are commonly retained at home, % of families were interviewed to provide additional information. we excluded records of patients aged < years and patients aged < years who had not been reviewed since . results: while at least one visit had been recorded in , hbethal patients at nrs hospital, most patients are not regularly reviewed there. we examined charts [ ( %) aged ≥ years; ( %) aged - years; % male], representing approximately % of regularly-reviewed patients. most families ( . %) reported monthly incomes (< , indian rupees), below the monthly cost of living ( , rupees) in kolkata. mean (±sem) hemoglobin was . ± . g/dl. % patients were receiving eight or more transfusions per year; from , % had been treated with deferasirox, . ± . mg/kg/day. iron control estimated by serum ferritin concentration ( . ± g/l) was highly variable. a total of % patients were splenectomized. a substantial obstacle to documenting complications was the lack of recording, in any of the five sources, of many relevant parameters: for example, the status of sexual maturation (normal, delayed, or absent) was documented in less than %, and measurements of fasting blood glucose in less than %, of records. where recorded, complication rates were high: delayed/abnormal sexual maturation was recorded in % patients aged > years; in the patients aged > years and those aged - years, respectively, hypothyroidism was recorded in % and %, and elevated serum alt in % and %. in most evaluable patients > years, height was measured between the rd- th percentiles. cardiac findings, rarely documented, included pulmonary hypertension and reduced left ventricular ejection fractions in a few patients. despite dedicated attention to many aspects of thalassemia care, insufficient documentation limited a clear understanding of the current morbidity in hbethal patients. investment in personnel and technology will be critical to record relevant information, ultimately to improve clinical management, over the next decade. children's hospital of richmond at vcu health, richmond, virginia, united states background: sepsis is a common cause of death in children with sickle cell disease (scd). recommendations for care of fever in children with scd include immediate medical evaluation including blood culture and initiation of broad-spectrum antibiotic therapy. the increasing availability of pcr-based respiratory pathogen panels (rpp) provide the opportunity to rapidly identify viral causes of fever. the role for rpps in identifying the source of fever in children with scd and how it affects provider practice is not well studied. ( ) to determine the epidemiology of respiratory virus-associated fever in children with scd and ( ) to determine whether a positive rpp is associated with reduced risk of bacteremia in this population. this was a single-center, retrospective cohort study. we identified and reviewed the medical records of all children with scd seen in our emergency department (ed) with temperature ≥ . oc at home or in the ed from january , , through september , , as well as, all febrile children for whom rpps were sent since the introduction of rpps april . we reviewed the results of blood cultures, rpps, chest radiographs, and ed notes and discharge summaries to identify sources of infections. independent t test and chi-square analysis were used as appropriate to compare results using spss©. overall, the rate of bacteremia was %. there were no cases of bacteremia among children with positive rpps. % of children with negative rpps had true bacteremia. a positive rpp did not reduce the likelihood of bacteremia (p . ). patients with bacteremia had higher presenting temperatures than those without bacteremia ( . oc vs . oc, p . ). the most common rpp findings were rhinovirus/enterovirus ( %), human metapneumovirus ( %), and influenza a ( %). sending an rpp did not affect admission rate ( % and % respectively, p . ); however, likelihood of admission was lower in patients with positive rpps ( % vs %, or . [ . - . ], p . ). length of stay (los) was shorter in patients for whom an rpp was not sent ( . vs . days, p . ). as previously reported, bacteremia in febrile children with scd is very low, but remains a serious concern, particularly in the setting of high fever (> oc). a positive rpp did not reduce the odds of bacteremia, but did have a sta-tistically significant impact on both admission rate and los. more work is needed to understand how rpp results impact provider decision-making and care for children with scd. cincinnati children's hospital medical center, cincinnati, ohio, united states background: diffuse myocardial fibrosis is a common, if not defining, feature of the heart in sickle cell anemia (sca) that is strongly associated with diastolic dysfunction. we found diffuse myocardial fibrosis in every patient in a sca cohort (n = ) ranging in age from to years (niss ). the treatment and prevention of this complication of sca has not been studied before. objectives: because diffuse myocardial fibrosis must begin in early childhood, we hypothesized that early initiation and uninterrupted use of disease-modifying therapy for sca can prevent it. design/method: we use cardiac magnetic resonance imaging (cmr) to measure the myocardial extracellular volume fraction (ecv) to quantify diffuse myocardial fibrosis in individuals with sca who have been treated, uninterrupted, with hydroxyurea or chronic transfusion therapy since ≤ years of age. two comparison groups were used: individuals with sca who have not been treated with disease-modifying therapy since ≤ years of age (n = ) and controls without sca (n = ). results: we studied individuals ( m/ f) with a mean age of . years (range - ). mean age at the start of diseasemodifying therapy was . ± . years (range - ). only had evidence of mild diffuse myocardial fibrosis (ecv . ); the other had no detectable diffuse fibrosis (all had ecv < . , the upper limit of normal). mean ecv was . ± . , which was significantly lower than the ecv of individuals with sca who have not received early uninterrupted therapy ( . ± . ; p = . ) and not statistically different from normal controls ( . ± . ; p = . ). none had macroscopic fibrosis by late gadolinium enhancement or evidence of myocardial hemosiderosis by t * imaging. no patient had diastolic dysfunction by echocardiographic classification, right heart catheterization, or both. disease-modifying therapy for sca can prevent diffuse myocardial fibrosis, and possibly diastolic dysfunction, if started in early childhood. prospective trials of disease-modifying and anti-fibrotic therapy are planned to prevent diffuse myocardial fibrosis, which can be monitored noninvasively by cmr, and improve outcomes in sca. (niss, blood, ) . background: a statewide sickle cell surveillance system (sscss) was developed with the goal of determining the prevalence of sickle cell disease (scd) in indiana and the level of care that patients receive throughout the state. persons with scd are at high risk of infection, especially with encapsulated organisms, as well as at increased complications from influenza. utilizing sscss data, the relationship between vaccination status and mortality was explored. to determine if vaccination status is associated with mortality in persons with scd. the project was granted a waiver of consent by the st. vincent irb. death certificates were obtained to identify cause of death. deceased patients (cases) were matched by age, gender, and sickle genotype to living patients (controls). vaccination data were collected from the medical record and the children and hoosier immunization registry program (chirp) through the date of death for each case. cases and controls were assigned a point for completion of the pneumococcus, meningococcus and haemophilus influenza type b (hib) vaccine series and one point if the influenza vaccine was given within a year prior to death of the cases [max vaccine status score (vss): ]. total points were compared between the cases and controls. two tailed t-tests to compare means of continuous data and wilcoxon signed-rank test to compare ordinal data. one thousand forty-eight individuals were included in the sscss. six hundred and seven ( . %) were seen at one institution and included in this analysis (mean age = years). thirty-three of the ( . %) were deceased at the time of analysis. six point one ( . )% of controls and . % of cases received a vss of . the mean vss for cases was . ± . and . ± . for controls. thirty point three ( . ) % of controls had a vss of one or more, compared to % of cases (p = . ). patients who died of infection [streptococ-cus (n = ), pseudomonas (n = ) and unidentified organisms (n = )] were not up to date on vaccination against encapsulated organisms, but two had received the influenza vaccine in the year prior to death. in this sample, mortality occurred exclusively among adult patients, which is consistent with current patterns in developed countries. among these adults, vss and mortality rates were not related. limitations to the study include small sample size and potential incompleteness of vaccine records. vaccination rates and other standard of care indicators should be explored in a larger cohort of patients to determine associations with mortality. background: sickle cell disease (scd) is a genetic disorder resulting in acute and chronic complications, including delayed puberty. delayed puberty can have adverse physical and psychosocial effects on affected children and families. there are no published reports from ghana on pubertal timing in children with scd. the aim of this cross-sectional study was to describe pubertal changes in children with scd at korle bu teaching hospital (kbth), accra, and compare these findings to those in a control group without scd. design/method: children with scd and children with hb aa, ages - years, were consecutively recruited and matched for age, sex and socioeconomic status. investigator-administered questionnaires were used to obtain demographic data for all participants and information on menarche (girls only). pubertal status was assessed by physical examination using tanner staging. testicular volumes were determined in boys using a prader orchidometer. body mass index (bmi) and socioeconomic status (ses) of participants were analyzed to determine if there were any associations with tanner stage. of the with scd, ( . %) were hb ss and ( . %) hb sc. females comprised . % (cases and controls). mean age at onset of breast development was significantly delayed in girls with scd ( . ± . years) compared to controls ( . ± . years) but there was no significant age difference at onset of pubic hair development. mean age at menarche was significantly delayed in girls with hb ss ( . ± . years) and hb sc ( . ± . years), compared to those with hb aa ( . ± . years). in boys, the mean ages at onset of puberty were significantly delayed in those with scd ( . ± . years, for genital development and . ± . years, for pubic hair development), compared to those without scd ( . ± . years and . ± . years, respectively). mean testicular volumes were significantly lower in cases compared to controls, across all age ranges (p< . ). mean bmi in both cases and controls were similar at onset of breast development in girls. however, in boys with and without scd, mean bmi values were significantly different at pubertal onset. in univariate analysis, ses was not associated with tanner stage for both genital and breast development. mean ages at pubertal onset were significantly delayed in children with scd. longitudinal studies are needed to further characterize any associations with bmi and determine potentially modifiable risk factors affecting pubertal onset in scd. background: sickle-cell disease (scd) is a life-threatening genetic disorder associated with multiple chronic and acute complications. specific monitoring and treatment for children is a major part of the medical focus, but there remains a lack of real-world evidence of the disease burden and practice patterns among the pediatric scd population. objectives: to examine the clinical burden and management of scd among pediatric patients. design/method: a retrospective claims study was conducted using the medicaid analytic extracts database from jan - dec . pediatric patients (aged < years) with scd were identified using icd- -cm diagnosis codes ( . - . , . - . ). the first observed scd diagnosis during the identification period was designated as the index date. patients were required to have continuous medical and pharmacy benefits for at least months pre-and months post-index period. patient data were assessed until the earliest occurrence of the following events: disenrollment, death, or the end of the study period. patient demographic and baseline clinical characteristics, clinical outcomes (mortality, incidence of pain crisis, complications), scd management, and healthcare utilization were examined. all variables were analyzed descriptively. results: a total of , patients met the study inclusion criteria, with a mean age of . years. most patients were black ( . %) and had a charlson comorbidity index score of ( . %). mortality during follow-up was . in personyears, and the event rate of pain crisis in the inpatient setting was . in person-years. the three most common complications after pain crisis (highest rates in person-years) were fever ( . ), infectious and parasitic diseases ( . ), and asthma ( . ). rates of life-threatening complications were also examined in person-years, including acute chest syndrome ( . ), stroke ( . ), splenic sequestration ( . ), pulmonary hypertension ( . ), and pulmonary embolism ( . ). . % of patients were prescribed antibiotics during the one-year post-index period. other frequent medications utilized among children were folic acid ( . %), nonsteroidal anti-inflammatory drugs ( . %), opioids ( . %), and hydroxyurea ( . %). . % of patients had a blood transfusion within one year post-index date. patients had frequent health care utilizations in the inpatient ( visit), emergency room ( visits), office ( visits), and pharmacy ( visits) settings during the one-year follow-up period. pediatric scd patients are burdened with a high rate of complications including pain crisis. in addition, patients utilized a substantial amount of health care resources including outpatient office care and acute care visits. background: novel use of hydroxyurea in an african region with malaria (noharm, nct ) is a randomized controlled trial of hydroxyurea for very young children with sickle cell anemia living in uganda. during year , study participants received blinded study treatment of hydroxyurea or placebo; those receiving hydroxyurea had no increased risk of malaria, but had both laboratory and clinical benefits. during year , all study participants received openlabel hydroxyurea treatment. to assess the effects of open-label hydroxyurea treatment in a very young population of children with sickle s of s cell anemia living in uganda. study endpoints included the rates and severity of malaria infections, clinical sickle-related events, and laboratory effects. design/method: all children in the noharm trial were enrolled at mulago hospital sickle cell clinic in kampala uganda. during year , all children received open-label fixeddose hydroxyurea ( mg/kg/day) for months, after previously receiving either hydroxyurea or placebo for months. results: a total of children entered year of the noharm trial and received fixed-dose hydroxyurea, including males and females, at an average age of . ± . years. among children previously on placebo, there were malaria events in children, including with severity grade ≥ , and three deaths (two acute chest syndrome, one sepsis). clinical adverse event rates dropped from . to . per patient year, and hospitalizations were reduced from to . expected hematological benefits of increased hemoglobin, mcv, and fetal hemoglobin, along with decreased neutrophils and reticulocytes, were rapidly achieved. laboratory adverse events were infrequent at . events per patient-year, and only half of those were dose-limiting hematological toxicities. among children previously on hydroxyurea, there were malaria events in children, including with severity grade ≥ , and two deaths (one acute chest syndrome, one sepsis). clinical adverse event rates and hospitalizations were maintained at low rates, the hematological benefits of hydroxyurea continued throughout the extended treatment period, and dose-limiting toxicities remained infrequent. fixed-dose hydroxyurea treatment of young children with sickle cell anemia living in uganda is associated with no increased risk for malaria. clinical and laboratory benefits occur, including children previously on placebo who crossed-over to hydroxyurea treatment. future studies should focus on the optimal dosing and monitoring strategies, in an effort to determine the overall feasibility and safety of introducing hydroxyurea therapy across sub-saharan africa. background: acute chest syndrome (acs) is the second most common cause of hospitalization in patients with sickle cell disease and is a leading cause of morbidity and mortality. in mid- , an algorithm was implemented at cohen children's medical center to initiate transfusions within four hours of diagnosis of acs in order to improve patient outcomes. objectives: the aim of this project was to analyze the effect of early blood transfusion on the outcomes of patients with acs. we focused on the number of total transfusions, need for exchange transfusion, need for intensive care unit (icu) stay, and length of hospitalization. design/method: a retrospective chart review was completed on patients admitted to ccmc with a primary diagnosis of sickle cell disease and a secondary diagnosis of either acs or pneumonia during the years of - . data from the three years directly prior to implementation of the algorithm was compared to data from the three years directly after implementation of the algorithm. a total of patients were analyzed, of which belonged to the pre-algorithm group and to the postalgorithm group. patients from the post-algorithm group had a higher incidence of transfusions ( % with a mean transfusion number of . pre versus % with a mean of . post) as well as exchange transfusion ( % pre versus % post). the post-algorithm group had a shorter overall length of stay (mean of . days pre versus . days post). while the overall percentage of patients requiring an icu admission was similar in each group ( % pre versus % post), the post-protocol group had a lower likelihood of requiring an icu admission for reasons outside of line placement for exchange transfusion, most commonly for icu-level respiratory support ( % pre versus % post). despite a higher total number of transfusions, early recognition and transfusion for acs can lead to decreased lengths of hospitalization as well as decreased need for icu-level respiratory support. further studies comparing different center's clinical practice guidelines are necessary to improve the standard of care. background: novel use of hydroxyurea in an african region with malaria (noharm) was the first placebocontrolled randomized clinical trial of hydroxyurea in sub-saharan africa. in noharm, young children with sca received either hydroxyurea or placebo during year , followed by open-label hydroxyurea for all study participants during year . an ancillary noharm project was designed to determine if hydroxyurea treatment lowers transcranial doppler (tcd) velocities and possibly reduces stroke risk in this very young cohort. objectives: to perform tcd screening on the noharm cohort, measuring the time-averaged mean velocity (tamv) at the end of both year and year . we hypothesized that the maximum tamv would be lower for noharm study participants receiving hydroxyurea compared to those receiving placebo, and that key clinical and laboratory parameters would also influence tcd velocities. design/method: all children enrolled in noharm were eligible to undergo tcd examination at two study time points: month - when they were completing the blinded treatment phase, and again at month - at the end of the open-label treatment phase. tcd measurements included tamv readings from the main intracranial arteries: middle cerebral artery, distal internal carotid artery, and bifurcation on tcd. all tcd examinations were scored and classified as normal (less than cm/sec), conditional ( - cm/sec) or abnormal (greater than or equal to cm/sec), with higher scores correlating to greater risk of stroke. results: at the end of year , tcd exams were conducted of which were suitable for analysis ( hydroxyurea, placebo). based on the maximum tamv, the median velocity was cm/sec (iqr - ) for children on hydroxyurea and cm/sec (iqr - ) on placebo, p = . . maximum tamv values had negative correlations with hemoglobin concentration (- . ), fetal hemoglobin (- . ), and oxygen saturation (- . ); positive correlations were noted with age ( . ) and absolute neutrophil count ( . ). at the end of year , tcd exams were conducted and all were suitable for analysis; the median velocity was cm/sec on open-label hydroxyurea treatment, regardless of previous blinded treatment. all correlations with tamv were maintained except for age. conclusion: compared to placebo, hydroxyurea treatment for young children with sca living in uganda was associated with lower tcd velocities, which have been correlated in other studies with lower risk of primary stroke. tcd velocities were correlated with hematological and clinical parameters that can be improved by hydroxyurea therapy. children's hospital of richmond at virginia commonwealth university, richmond, virginia, united states background: acute chest syndrome (acs), defined by respiratory symptoms and a new pulmonary infiltrate, is a serious complication of sickle cell disease (scd). acs can occur during hospitalization for non-pulmonary conditions, such as a vaso-occlusive crisis or after surgery. nih clinical practice guidelines encourage incentive spirometry (is) which decreases the incidence of acs. it is additionally widely accepted that early, frequent ambulation in post-operative and pneumonia patients decreases the length of stay (los). to decrease acs events in children with scd at our children's hospital, we aimed for is use in % of ageappropriate pediatric sickle cell admissions. design/method: a multidisciplinary team examined inpatient acs prevention practices, including is, at children's hospital of richmond. key drivers were identified, including educational awareness of patients and healthcare staff, order placement, and documentation. we aimed for all scd patients ≥ months of age hospitalized with any admission diagnosis to participate in is with the use of a traditional incentive spirometer or similar age-and ability-appropriate devices (e.g. positive expiratory pressure devices, bubbles, and pinwheels). we secondarily aimed to increase activity events, specifically ambulation and out of bed time. educational and outreach tools included patient informational brochure and incentive program, and staff informational sessions and reference materials at workstations. a disease-specific order set was implemented including desired is and activity orders. data were collected prospectively may through november , during which pdsa cycles were conducted. admissions during the corresponding months of the previous year were reviewed for comparison. independent t-test analysis was performed using graftpad prism statistical analysis software. results: improvements reaching statistical significance included increase in is order placement from % to % of admissions (p < . ), and admissions with documented is use increased from % to % (p < . ). los decreased from a mean of . days to . days (p . ). post-admission development of acs also decreased from % to % of admissions, but did not reach statistical significance (p . ). there was an additional increase in appropriate activity order placement and documentation of activity events. conclusion: improving education and outreach to patients and staff, including implementation of a disease-specific order set, can improve is use and activity events. the decline seen in incidence of acs development during hospitalization, though not statistically significant, and the decreased los are encouraging, and efforts continue to improve on these trends. background: painful vaso-occlusive crises (voc) are a frequent and debilitating complication of sickle cell disease (scd) and are thought to occur due to progressive blockage of the microvasculature with rigid sickle shaped red blood cells. any trigger that decreases the microvascular blood flow (mbf) can promote entrapment of sickled cells in the microvasculature and progression to voc. exposure to cold wind and changes in weather are common triggers of voc and are associated with increased frequency of hospitalizations for pain in patients with scd. there is limited experimental data on the physiologic effects of these factors on peripheral perfusion in scd. to study the effect of graded thermal stimuli on the peripheral mbf in scd. design/method: scd and control (healthy or sickle trait) subjects aging to years were exposed to their individual threshold temperatures for heat and cold detection, heat and cold pain via tsa-ii thermode that was placed on the thenar eminence. mbf was measured on the contralateral thumb using photo-plethysmography (ppg). the vasoconstriction response within the complex ppg signal was detected using cross-correlation technique. mean mbf was derived from the ppg amplitude during each of these stimuli and compared to baseline mbf. cross correlation analysis showed that cold pain caused significant vasoconstriction response in % of the subjects, followed by heat pain ( %), cold detection ( %) and heat detection ( %).there was a significant drop in the mbf during cold pain (p < . ), heat pain (p < . ), heat detection (p = . ) and cold detection (p = . ) when compared to baseline mbf, with cold pain causing the greatest drop in mbf. thermal sensitivity and mbf responses were comparable between scd and controls. conclusion: exposure to graded thermal stimuli causes a progressive drop in mbf with exposure to cold pain eliciting the strongest vasoconstriction response. vasoconstriction occurred in the contralateral hand at an average of seconds after the stimuli, suggesting a neurally mediated mechanism. although there was no significant difference in vasoconstriction responses between scd and controls, the drop in mbf in patients with sickle cell disease can increase the likelihood of entrapment of the sickled red blood cells, leading to vaso-occlusion. these findings are consistent with extensive reports in literature that exposure to cold weather is associated with a higher frequency of voc. this suggests that neurally mediated vasoconstriction is likely an important factor in the pathophysiology behind cold exposure leading to voc in scd. background: vaso-occlusive crisis (voc) is a major cause of hospital admissions in children with sickle cell disease (scd). although the use of clinical biomarkers in voc has been studied, especially with regards to acute chest syndrome (acs), there is less data regarding overall voc severity prediction. in addition new biomarkers such as platelet to lymphocyte ratio (plr), neutrophil to lymphocyte ratio (nlr), and lymphocyte to monocyte ratio (lmr) have been little studied with regards to scd. objectives: to identify whether admission laboratory values, changes from well baseline laboratory values, and new biomarkers such as plr, nlr, and lmr could predict severity of vaso-occlusive crisis in children with sickle cell disease admitted with voc. design/method: this was a retrospective single center observational study of admissions of voc in children aged - years with hbss or hbs-b thal from september to november excluding those on hyper-transfusion protocol or having an admission diagnosis of acs. univariate analysis was done using student's t-test, mann-whitney non parametric test, or fischer's exact test as appropriate depending on the distribution between admission laboratory data of complete blood count (cbc), reticulocyte count, comprehensive metabolic panel, lactate dehydrogenase (ldh), change from well baseline cbc values within months previously, plr, nlr, lmr, and the development of complicated voc. complicated voc was defined as the development of secondary acute chest syndrome, prolonged admission duration > days ( hours), requirement of blood transfusion, and readmission within days. results: a total of admissions were studied. fifty-nine ( . %) were female. of the , ( . %) were complicated with no significant differences in sex (p . ) or age (p . ). univariate analysis revealed significant elevations in total bilirubin (p . ), ldh (p . ), and platelet count (p . ) in those with complicated voc. there is also significant difference in the percentage change of platelet count from baseline with greater decline in uncomplicated voc (p . ). there were no significant differences in plr (p . ), nlr (p . ), or lmr (p . ). conclusion: elevations in total bilirubin, ldh, and platelet count in admission laboratory values are associated with developing complicated voc. in addition, those with complicated voc present with significantly less decline in platelet count from baseline well cbc. plr, nlr, and lmr do not seem to be useful predictive biomarkers for severity of voc. background: sickle cell disease (scd) causes health problems of varying frequency and severity. the only validated biomarker for children with scd is transcranial doppler. if reliable predictors existed for scd severity, children with scd could be treated according to risk category. many patients with scd face psychosocial or economic hardships, but these factors have not been evaluated as risk markers for medical or functional severity of scd. objectives: the goal of this project was to develop and stratify a preliminary list of psychosocial risk factors for health outcomes that could be used as scd severity predictors. st. vincent institutional review board. a list of potential psychosocial risk factors for adverse health outcomes was compiled based on assessment materials utilized by the sickle safe program (indiana's hemoglobinopathy newborn screening follow-up program). this list of items was distributed to child abuse prevention ( ) and scd ( ) experts, who ranked each item on a likert scale of (least important) to (most important). mean scores were calculated using spss version ; assessments were retrospectively analyzed to determine psychosocial risk factor frequency. risk factors occurring in ≥ % of homes were considered high frequency events. overall, there was high agreement among experts on the risk factors that were considered the most important predictors of severe scd outcomes. the risk factor with the highest frequency ( %) was eligibility for public assistance programs. fifteen risk factors were rated ≥ by the experts. four ( . %) were high frequency events occurring in ≥ % of homes: a child with hbss or hbs thalassemia not taking hydroxyurea ( %); parent report that they had treated a fever (> ®f) at home in the past months ( %); tobacco use by someone in the household ( %); and the family reporting significant psychosocial stressors in the past year ( %). tobacco use in the home was significantly correlated with several other risk factors (smoking during pregnancy [r = . ], other health concerns in the child [r = . ], and child having health insurance [r = - . ]), suggesting that it is part of a constellation of health risk. in general, the risk factors that were rated as most important for health outcomes occurred less frequently in the sample. this study represents important progress toward identifying a group of psychosocial risk factors for scd severity, which is a necessary first step for future investigation of empirical relationships between candidate risk factors and scd outcomes. unitversity of cartagena, cartagena, bolivar, colombia s of s background: sickle cell disease is an autosomal recessive disorder characterized by a mutation in the -globin chain, which produces hbs. acute and chronic complications as aplastic crisis, acute chest syndrome, priapism, stroke, leg ulcers and primary/secondary prevention of stroke can be treated with simple transfusion or exchange transfusion. the latter offers advantages as lower iron overload, post-treatment hbs goal control, lower viscosity and improved microvascular circulation. but it is not a widely-used option because is associated with technical difficulties. objectives: standardization of a new partial exchange transfusion protocol in a group of patients with sickle cell disease, within the framework of a chronic transfusion program. design/method: this is a prospective descriptive study, which included patients under years with sickle cell disease ( hbss, hbs-tal), with indication of partial exchange transfusion in a chronic transfusion program, according to the institutional protocol; patients who fulfilled the inclusion criteria were enrolled in the study between february and december . a registry of the medical and technical complications was made in each of the procedures. a database was constructed in excel, and the graph-pad prism® version oc software was used for statistical analysis. the sequence is as follows: isovolemic phlebotomy and transfusion of packed red cells. depending of the recent hemoglobin level ( hrs), we do the phlebotomy there: hb: - . : cc/kg, hb: - . : cc/kg, hb> : cc/kg; isovolemic solution (ns , %) there: hb: - . : cc/kg, hb: - . : cc/kg, hb> : cc/kg and packed red cell transfusion there: hb: - . : cc/kg, hb: - . : cc/kg, hb> : cc/kg. the safety of this exchange transfusion protocol was analyzed in patients with sickle cell disease ( procedures). there were no differences in the sex distribution, and the median age was years. % of the population was homozygous. the indication of transfusion was . %( / ) primary stroke prevention, . %( / ) secondary stroke prevention and . %( / ) was other reason. a low percentage of complications was found ( . %); of which, those of medical origin (hypotension and nausea/vomiting) were only presented in . % of the total procedures. the standardization of this protocol was safe and its use could be extended to other low-income centers that treat patients with sickle cell disease that need chronic transfusion program including patient with hemoglobin level until gr/dl. we suggest do studies for measure the security and efficacy of this protocol in patients with acute complications. background: clinical trials that aim to achieve pain reduction have challenges achieving clinical endpoints as pain has no quantifiable biomarkers and may be unrelated to scd. furthermore, the threshold of seeking medical care differs between patients and vocs that occur at home are missed. we present a non-interventional, longitudinal study to identify vocs in patients with scd. objectives: to examine the longitudinal relationship between pros and biomarkers in subjects with scd before, during, and after a self-reported voc event, in order to build a model of in-home and clinical voc and to collect longitudinal pros and biomarker data from subjects that span voc events in the home, clinic and the hospital. design/method: longitudinal measures of pain, fatigue, function, activity, and biomarkers from scd patients in steady state and voc were studied over a six month period. patients self-reported pain, fatigue, function, and medication use using a novel epro tool. voc was reported in real-time, triggering a mobile phlebotomy team. blood was collected sequentially after self-reported voc (at home or hospital). blood samples were drawn two days after resolution of voc, as reported by the patient. during non-voc periods, blood was drawn every weeks to establish a baseline. biomarkers included leukocyte-platelet aggregates and circulating microparticles, cell and soluble adhesion molecules, cytokines, inflammatory mediators and coagulation factors. patients wore an actigraphy device to track sleep and activity and rest. results: twenty-seven of thirty-five patients experienced a total of days with voc > hr, of which only days resulted in healthcare utilization. voc days had significantly higher pain and fatigue scores. voc days were associated with significantly decreased functional scores, with significantly greater decreases during vocs requiring medical contact compared to at-home vocs. different activity profiles were identified for non-voc, at-home voc and medical contact voc days by actigraphy monitoring. at-home voc days exhibited increased daytime resting compared to non-voc days. medical contact vocs had decreased average and peak activity, and increased daytime resting compared to non-voc days. a sleep fragmentation index trended up for both at-home ( %) and medical contact voc days ( %). significant changes during voc days were observed in: c-reactive protein ( % increase), nucleated rbc ( % increase), monocyte-platelet aggregates ( % increase) and neutrophil-platelet aggregates ( % increase), interleukin- ( % increase), interleukin- ( % increase) and tnfalpha ( % increase). the identification and assessment of at-home vocs through use of epros, actigraphy and biomarkers is feasible as demonstrated by this innovative at-home study design. background: risk-stratifying sickle cell disease (scd) patients and demonstrating response to disease-modifying therapies is challenging due to the phenotypical heterogeneity of scd. a pathogenic role for procoagulant von willebrand factor (vwf) via excess vwf high molecular weight multimers (hmwm) has been proposed, with variable reports of increased vwf and hmwm in crisis vs. steady-state in adults, but less so for vwf in children with scd. moreover, vwf and multimers have not been studied in sickle trait. objectives: our pilot study evaluated the potential for vwf antigen (vwf:ag) and hmwm on densitometric tracings to serve as biomarkers for disease severity or treatment response in children and young adults with scd compared to sickle trait (hbas) siblings. design/method: we evaluated vwf:ag, vwf multimers and retrospective clinical data from hbss, hbsc and hbas subjects at steady state. one hbsc subject also had a crisis sample. median scd age was years ( . - . years). % were female. scd severity was judged by annual vasoocclusive and acute chest events, or stroke/elevated tcd. eight of ( hbss and hbsc) took hydroxyurea. four hbss subjects had severe scd, all of whom were chronically transfused. results: mean vwf:ag (normal - iu/dl) was higher for hbss ( +/- . ) and severe hbss ( +/- . ) compared to hbsc ( +/- . , p = . and . , respectively); however, lacked statistical significance when compared to hbas ( +/- . , p = . and . , respectively). vwf:ag was elevated in / ( %) steady-state, including / ( %) with "severe" disease on chronic transfusion and / ( %) taking hydroxyurea, in hbsc crisis but no hbsc / ( %) at baseline. vwf:ag was high in / ( %) hbas siblings. four ( %) had increased hmwm at baseline: hbss/severe disease/chronic transfusion, hbss/hydroxyurea and hbsc untreated. hmwm were increased only during vaso-occlusive crisis in hydroxyureatreated hbsc subject. no ultra-large hmwm were observed. in this preliminary study, in young scd subjects, vwf:ag trended higher in hbss vs. hbsc and in severe hbss participants at a single time-point, but serial evaluations at baseline, in crisis and with optimized diseasemodifying therapy are needed to determine the potential of vwf:ag and hmwm as biomarkers for severity or treatment response. surprisingly, vwf:ag was high in some sickle trait subjects. since hbas is associated with some health challenges such as increased thrombosis risk, further examination of vwf and endothelial dysfunction in sickle trait may provide novel insights into its role as a biomarker. background: the national heart lung & blood institute(nhlbi) guidelines for acute management of voe recommends rapid evaluation and treatment of pain, including administration of a parenteral opioid within -minutes of triage or -minutes from registration, pain reassessment & repeat opioid delivery within - -minutes. inf use has been increasing in peds due to its rapid onset and ease of administration. objectives: to evaluate ped utilization of inf & its effect on intravenous (iv) opioid administration and pain control for the treatment of voe. design/method: a retrospective review of emr was performed on children with scd± years presenting to a ped with voe (pain scores on a - scale) from jan-june . variables studied were median time (iqr, %ci) from ped arrival to first-parenteral-opioid-administration, time-to-first-iv-opioid, first & final pain score, disposition and readmission rate. time-to-first-iv-opioid was also compared to historical data (jan-dec ,n = ) prior to inf protocol initiation. . additionally, % patients received iv opioids within minutes of ed arrival in the inf+iv opioid vs. % in the iv opioids alone group (p< . ). no differences in -hour-returnrates were found in any of the groups, including inf alone group. conclusion: use of inf in the ped for voe is an excellent strategy to shorten time-to-first-parenteral-opioidadministration, improve pain scores & improve adherence to the nhlbi guidelines. however we had distinct unexpected findings: ( ) delays in iv opioid delivery after inf use & ( ) inf alone appeared to provide sufficient pain control without iv opioids for disposition home in % of voe patients. whether the latter reflects insufficient pain management or that there is a milder subgroup for whom inf alone is sufficient, requires further investigation. this study illustrates our experience with a ped-based inf protocol in terms of unanticipated delays in iv opioids and also discharges after inf alone. efforts are underway to further improve use of inf in voe management. st. christopher's hospital for children, philadelphia, pennsylvania, united states background: folate supplementation is commonly included as standard management in patients with sickle cell disease. however, clear evidence supporting the clinical benefits of this practice is lacking. a single study demonstrated improvement on the occurrence of repeat dactylitis at a higher dose of folic acid. to compare clinical outcomes in pediatric patients with sickle cell disease treated with folate supplementation versus those who were not. design/method: this study was a retrospective chart review that included patients to years old with sickle cell disease type ss and s followed at st. christopher's hospital for children. data collected included information about folate supplementation, red cell indices and the presence or absence of clinical outcomes including vaso-occlusive crisis requiring hospitalization in the last six months, acute chest syndrome, infections, asthma, sleep apnea, nephropathy, cerebral vascular disease, stroke and avascular necrosis. analysis of variance (anova) was used to evaluate mean differences between age, number of infections, number of voc events, hemoglobin, reticulocyte count, and mean corpuscular volumes. additionally, chi square analysis was implemented to evaluate differences in folate and non-folate groups for left ventricular remodeling (lvr), sickle cell nephropathy, asthma, obstructive sleep apnea (osa), nocturnal hypoxia, and avascular necrosis (avn). mean differences between the folate and non-folate groups were compared for patients on and off hydroxyurea therapy. one hundred and seven patients met inclusion criteria following review of clinical data. of the patients included in the study, patients were found to be taking folate ( %), while patients were not ( %). statistical analysis showed that there were no significant differences in the incidence of clinical outcomes between patients on folate versus those who were not on folate. of the patients who were not on hydroxyurea, hemoglobin levels were significantly higher in patients on folate versus those who were not (p = . ), but not significantly different for the patients on hydroxyurea. this study suggests that folate supplementation makes no significant impact on the red blood cell indices of anemia nor on the incidence of adverse clinical outcomes in children with sickle cell disease. however, a larger prospective study is needed to guide future considerations for folate supplementation in sickle cell patients in the clinical setting. background: tanzania ranks rd globally for the number of infants born annually with sickle cell disease (scd) but lacks a national newborn screening program. the prevalence of sickle cell trait (sct) and scd is highest in the northwestern regions around lake victoria served by bugando medical centre (bmc) a teaching and consultancy hospital in mwanza. bmc also houses the hiv early infant diagnosis (eid) laboratory that tests dried blood spots (dbs) from hivexposed infants. dbs can be tested for hiv and then retested for sickle cell trait and disease. to determine the prevalence of sickle trait and disease by region and district in northwestern tanzania using existing public health infrastructure. secondary objectives explored associations between sct, scd, malaria and hiv. design/method: the tanzania sickle surveillance study (ts ) is a prospective year-long cross-sectional study of hivexposed infants born in northwestern tanzania, whose dbs collected by the eid program are tested at bmc and available for further testing of sct and scd. samples from children ≤ months of age were tested by isoelectric focusing (ief) and scored independently by two tanzanian staff as normal, sct, scd, variant, or uninterpretable. dbs samples scored as disease or variant were repeated. over the course of months, ief gels have been run. a total of , dbs samples have been scored, including , from children less than -months old. the overall prevalence of sct is . % and the prevalence of scd is . %, along with . % hemoglobin variants. quality of the laboratory results is extremely high, with only . % dbs samples yielding an uninterpretable result. geospatial mapping of the first , samples revealed a regional scd prevalence ranging from . % up to . % among the regions served by bmc. the prevalence of sct and scd is very high in northwestern tanzania. geospatial mapping will identify high prevalence areas where targeted newborn screening can be started using existing public health infrastructure with minimal start-up cost and training. further data will enhance the accuracy of the map to the district level. background: pediatric patients with sickle cell disease (scd) could develop obstructive, restrictive or mixed abnormalities of pulmonary function (pf). several publications report progressive worsening of pf over time, which could lead to severe morbidity in adult patients with sickle cell disease. in adults with sickle cell anemia up to - % of mortality is related to lung disease. early intervention aimed at improvement of lung function could significantly decrease morbidity and possibly improve life expectancy. among disease modifying approaches commonly used in scd are hydroxyurea (hu) and chronic prbc transfusions. both interventions lead to increase of hemoglobin, decrease of hbs fraction, leading to decreased hemolysis. reports of effect of hu on pulmonary function are conflicting with some suggesting no effect and others proposing a slower decline of pulmonary function. the goal of our study is to evaluate effect of disease modifying therapies, like hu and chronic prbc on change of pulmonary function in pediatric patients with sickle cell disease. design/method: this study utilized a retrospective chart review of children with scd who had multiple pfts. we analyzed pfts from patients done during clinic visits. scd patients were divided into three treatment groups: hydroxyurea, chronic transfusions or neither. data was analyzed with linear correlations and analysis of variance (anova). comparison were made between the three groups specifically observing the changes in absolute numbers on pfts over time using the first and last pft the patient had. results: there were a total of patients with multiple pfts (ranging from - ); control ( ), hydroxyurea ( ) and chronic transfusion ( ). the mean changes of the control, and hydroxyurea for the pft parameters fev (- . the chronic transfusion group demonstrated a small improvement in pfts over time for fev ( . ), fvc ( . ), fef - ( . ), however there was a decline in fev /fvc (- . ). however, there was no statistically significant (p-value < . ) in the difference in any pfts parameters between any of the groups. in children with scd there is a decline of pf parameters over time. although no significant differences were seen between the three groups it appears chronic transfusion may improve or limit the decline in pfts. larger studies need to be done to evaluate difference in pf decline in patients with scd patients. background: the use of mobile technology in health care has been a growing trend. patients with chronic diseases such as sickle cell disease (scd) require close monitoring to provide appropriate treatment recommendations and avoid complications. we conducted a feasibility study for patients with scd hospitalized for pain using our self-developed mobile application (tru-pain: technology resources to better understand pain) and a wearable activity tracker. subjective symptoms such as pain and objective data such as heart rate (hr) were measured. we aimed to ) correlate nursing recordings with mobile technology recordings; ) get feedback from patients about usability. design/method: we enrolled patients with scd > years old and < hours from admission for uncomplicated vasoocclusive crisis, excluding patients admitted to icu. patients were given an ipad and a wearable device. they were instructed to record in the application at least once per day and to keep the wearable on, removing only to charge. prior to discharge, patients completed a feasibility questionnaire. we enrolled patients, % females, median age . (range to ) who were admitted for a median days (range to ) for uncomplicated pain crisis. patients used the application throughout hospitalization and made one entry/day (range to ). pain scores recorded via tru-pain correlated well (r = . , p< . ) with pain scores recorded in emr. there was an average of , data points recorded per day, by the wearable, with a maximum of , data points/day. the median amount of hours of wearable data per day was . (maximum of . ). the hr recorded via the wearable correlated significantly with the hr recorded in emr (r = . , p-value < . ). as for usability, % of patients indicated never having a problem with the technology, % found tru-pain 'very easy' or 'somewhat easy' to use, and % were 'very satisfied' with their participation in the study, indicating that it helped them track their pain. our pilot study during hospitalization shows strong potential for using tru-pain for patients with scd. pain data from application and hr from wearable correlated well to the emr data. according to the feedback received, our application was easy to use and helped patients track their pain. despite limitations of battery life, the use of wearable technology is feasible, providing additional data such as activity. we are optimistic that we can continue to improve our tru-pain system to help improve care in patients with scd. background: hydroxyurea, chronic blood transfusion, and bone marrow transplantation can reduce complications, and improve survival in sickle cell disease (scd), but are associated with a significant decisional dilemma because of the inherent risk-benefit tradeoffs, and the lack of comparative studies. these treatments are underutilized leading to avoidable morbidity and premature mortality. there is a need for tools to provide patients high-quality information about their treatment options, the associated risks, and benefits, help them clarify their values, and allow them to share in the process of informed medical decision making. objectives: to develop a health literacy sensitive, web-based, decision aid (ptda) to help patients with scd make informed choices about treatments, and to estimate in a randomized clinical trial the acceptability and effectiveness of the ptda in improving patient knowledge, involvement in decisionmaking and decision-making quality. design/method: we conducted qualitative interviews of scd patients, caregivers, stakeholders, and healthcare providers for a decisional needs assessment to identify decisional conflict, knowledge, expectations, values, support, resources, decision types, timing, stages, and learning, and personal clinical characteristics, and to guide the development of a ptda. transcripts were coded using qsr nvivo . stakeholders completed alpha and beta testing of ptda. we conducted a randomized clinical trial of adults, and of caregivers of pediatric patients to evaluate the comparative efficacy of the ptda, vs. standard of care. results: ptda (www.sickleoptions.org) was developed per decisional needs described by stakeholders and finalized following alpha testing, and beta testing by and stakeholders respectively. in a randomized trial of subjects considering various treatment options, qualitative interviews revealed a high level of usability, acceptability, and utility in education, values clarification, and preparedness for decision making of the ptda. a median % rated the acceptability of ptda as good or excellent and provided narrative comments endorsing the acceptability, ease of use, and utility in preparation for decision making. the ptda met international standards for content, development process, and efficacy with the exception of having a full range of positive and negative experiences in patient stories. compared to baseline ptda group had statistically significant improvement in preparedness for decision making (p = . ) and informed subscale of decisional conflict (p = . ) but not for decisional self-efficacy, knowledge, choice predisposition, or stages of decision-making. a ptda for patients with scd developed following extensive engagement of key stakeholders was found to be acceptable, useful, easy to use, to improve preparedness for decision making, and decrease decisional conflict. background: painful vaso-occlusive crisis (voc) accounts for the majority of emergency department (ed) visits and hos-pitalizations in sickle cell disease (scd). we are interested in studying mental stress and associated autonomic nervous system (ans) imbalance that cause vaso-constriction as possible triggers of scd pain. to this end, we developed a mobile phone application (app) to record daily pain frequency and intensity as clinical endpoints that might be predicted by ans parameters measured in the laboratory. in particular, we think that the aura may represent ans instability that precedes or even triggers change in blood flow and voc. objectives: to assess the feasibility of using an app to evaluate frequency and severity of voc and its potential association with mental stress and presence of aura. design/method: an app was developed for both ios and android systems to allow patients to track pain, stress, and aura. the idea was to create an app that was easy to use with the intent to only capture pain episodes, rather than detailed description of the pain. all scd patients were eligible and a parent version was available for younger children. de-identified data was automatically transferred to a hipaa compliant database via a cloud-based server interfaced to the main research project database. a feedback questionnaire was implemented after at least a month of utilization to assess usability. of the scd patients enrolled, participants utilized the app and of the participants that provided feedback indicated the app was easy to navigate. the mean pain scale was out of (standard deviation . ) for those that entered they had pain that day. although the mean stress level was out of , there was a statistically significant correlation between increasing stress levels and increasing pain scores (p < . ). aura was reported by patients, with patients reporting more than episodes. moreover, on days aura was present there was greater incidence that pain was present as well (p < . ). however, there was no statistically significant association between pain intensity and presence of an aura (p = . ). conclusion: consistent with prior research, reported pain intensity is significantly associated with reported stress intensity. although there was an association between presence of aura and pain, it did not seem to correlate with pain intensity. this uniquely designed app can monitor scd pain clinically and help understand the role of sickle dysautonomia in the genesis of scd pain. university of florida college of medicine, gainesville, florida, united states background: evidenced-based guidelines recommend the emergent evaluation of fever in children with sickle cell disease (scd). as the prevalence of bacteremia has decreased, outpatient management has become more common. however, fever can sometimes herald other complications of scd, such as acute chest syndrome, vaso-occlusive pain crisis, splenic sequestration, or aplastic crisis. institutional practices regarding fever management in scd remain variable, and little is known about the clinical outcomes of children hospitalized for uncomplicated fever. objectives: the primary objective was to determine the rate of bacteremia or scd-related complications per febrile episode in children with scd admitted to a single institution between january and june for uncomplicated fever. this was a retrospective cohort study of febrile patients up to years of age with scd, any genotype, admitted to the university of florida during the defined study period. eligible patients were identified by a database search using admitting diagnosis codes for scd and fever based on the international classification of diseases th and th revisions. encounters were manually reviewed to confirm eligibility. patients were excluded if they had other indications for hospitalization apparent at the time of admission, such as an acute vaso-occlusive episode requiring parental narcotics, asthma exacerbation, or additional complications of scd. the database search identified encounters, of which were excluded based on confounding indications for hospitalization. sixty-three eligible patients accounted for hospitalizations. the median age was years (range weeks- years); . % were male. mean duration of hospitalization was . days (range - days). eight positive blood cultures were identified; six of these were classified as contaminants. bacteremia or the development of a scd-related complication was identified in ( . %) admissions. these included acute chest syndrome (n = ), bacteremia (n = ), splenic sequestration (n = ), and red cell transfusion (n = ). exploratory analyses of potential predictors of bacteremia or scd-related complications showed no association with the presenting white blood cell count or degree of fever (p = . ). of the patients classified as having a scd-related complication, % had hemoglobin ss disease and % had at least one prior documented complication. % of the patients transfused had at least one prior transfusion. conclusion: while improvements in preventative care have substantially lowered rates of bacteremia in children with scd, fever warrants careful evaluation for other acute scdrelated complications. providers should consider inpatient observation in select cases. additional studies are warranted to define subsets of patients suitable for outpatient fever management. background: children with sickle cell disease (scd) exhibit lower neurocognitive functioning than healthy peers, even in the absence of stroke. among the domains commonly affected, working memory (wm) seems particularly affected by disease processes and wm deficits have significant implications for academic achievement and disease selfmanagement. few interventions to improve working memory in pediatric scd have been evaluated. to determine the effects of cogmed, a homebased computerized wm training intervention, in children with scd using a randomized controlled trial design. design/method: participants (ages - ) with scd completed a baseline neuropsychological assessment and those with wm deficits were randomized to either begin cogmed immediately or enter an -week waitlist. cogmed is a homebased intervention completed on an ipad that consists of increasingly challenging exercises targeting visual-spatial and verbal wm, practiced over sessions. at the end of training, participants completed a post-intervention neuropsychological assessment, including tests of visual-spatial and verbal wm from the wechsler intelligence scale for children-fifth edition (wisc-v). results: ninety-one participants (m age = . , sd = . ; % female; % hbss) enrolled in the study; % (n = ) exhibited wm deficits and were randomized to either begin cogmed immediately or wait - weeks before starting cogmed. among those that have received the intervention and reached the end of their training period (n = ), participants ( %) completed at least cogmed sessions, ( %) finished at least sessions, and finished at least sessions ( %). the mean number of completed cogmed sessions was . (sd = . ). paired samples t-tests revealed significant improvements on the working memory index (t[ ] = - . , p = . ) and on the digit span (t[ ] = - . , p = . ), and spatial span-backward (t[ ] = - . , p = . ) subtests. improvements were especially pronounced for participants completing at least sessions. partial correlations controlling for respective baseline scores indicated that the number of cogmed sessions completed was positively correlated with post-test scores on digit span (r = . , p = . ) and spatial span-backward (r = . , p = . ) subtests. among participants who completed at least cogmed sessions, % scored in the average range or higher on the working memory index at the post-intervention assessment, compared to % at baseline. results support the efficacy of cogmed in producing significant improvements in wm. a dose-effect was observed such that participants who completed more cogmed sessions had greater improvements in wm. home-based cognitive training programs may ameliorate scd-related wm deficits but methods for motivating and supporting patients as they complete home-based interventions are needed to enhance adherence and effectiveness. background: sickle cell disease is associated with myriad complications that lead to significant morbidity and early mortality. hydroxyurea has been used successfully to reduce the incidence of these complications and has led to significant improvements in quality and duration of life. at children's minnesota we recommend hydroxyurea in all patients with hb ss/s thalassemia as early as months of age with a goal of starting all patients before months of age. objectives: the purpose of this study was to evaluate the use of hydroxyurea therapy in young patients with sickle cell disease, with particular attention to those children less than one year of age. design/method: a retrospective chart review was conducted on patients less than years of age with sickle cell disease who began hydroxyurea therapy between january , and december , . the study population was divided into three cohorts based upon age at hydroxyurea initiation: cohort ( - year), cohort ( - years), and cohort ( - years). outcomes included laboratory data, clinical events (hospitalization, dactylitis, pain crisis, transfusion, splenic sequestration, acute chest syndrome), and toxicity occurring in the first years of life. results: a total of patients were included in cohorts (n = , mean age . months), (n = , mean age . months), and (n = , mean age . months). patients in cohort had higher hemoglobin (p = . ) and mcv (p = . ) and lower absolute reticulocyte count (p = . ) when compared to cohort . the wbc (p = . , < . ) and anc (p = . , . ) were significantly lower compared to both older cohorts. however, no patient had therapy held because of neutropenia. the mean baseline hemoglobin f in cohort was . % compared to . % and . % in cohorts and respectively (p = . , p< . ). the mean duration of therapy in cohort was . months, compared to . months in cohort (p = . ) and . months in cohort (p = . ). during this time, hb f levels remained higher in cohort (mean . %) compared to cohorts and (mean . %, p = . and mean . %, p = . ). patients in cohort experienced fewer hospitalizations (p = . ), pain crises (p = . ), and transfusions (p = . ). there was no difference in toxicity between groups. hydroxyurea was used safely in infants to months of age and resulted in more robust hematologic responses and a decrease in sickle-related complications when compared with patients starting hydroxyurea later in life. children's national health system, washington, district of columbia, united states background: children with sickle cell disease (scd) have a significantly greater risk of silent or overt cerebral infarction than the general population. infarcts are associated with declines in cognitive functioning and academic achievement. while infarcts are reliably identified using mri, scans are expensive and occasionally necessitate sedation. moreover, mri's are not recommended for routine monitoring of cerebral infarcts. additional tools are needed for discriminating the presence of a cerebral infarct that are brief, noninvasive, inexpensive, and repeatable. objectives: to evaluate differences in performance on cogstate, a computerized neurocognitive assessment, in patients with scd with and without history of cerebral infarct. design/method: participants included children with scd ages - (m = . , sd = . ; % female; % s of s hbss) enrolled in a cognitive intervention trial. participants completed the cogstate pediatric battery, which measures processing speed, sustained attention, verbal learning, working memory, and executive functioning. history of silent or overt infarct was determined via health record review. participants also completed measures of intelligence (iq) and math fluency. results: participants' standard scores across most neurocognitive measures were lower than expected compared to the standardization sample (mean iq = . , sd = . ). thirty percent of participants (n = ) had a documented history of cerebral infarct. participants with a history of cerebral infarct scored lower on cogstate tasks measuring sustained attention (t[ ] = . , p = . ) and executive functioning (t[ ] = . , p = . ), as well as on a measure of math fluency (t[ ] = . , p = . ). receiver operating characteristic (roc) analyses demonstrated that the cogstate task measuring sustained attention was a fair discriminant of patients with and without a history of infarct (auc = . , ci = . - . , p = . ), whereas iq score was not (auc = . , ci = . - . , p = . ). cogstate processing speed and sustained attention tasks fairly discriminated between patients with at least average or below average intelligence (auc = . , ci = . - . , p = . and auc = . , ci = . - . , p = . , respectively). finally, the cogstate processing speed task was good at discriminating between at least average or below average math fluency (auc = . , ci = . - . , p< . ). multiple tasks in the cogstate pediatric battery appear to adequately identify patients with a history of cerebral infarcts. in addition, cogstate tasks appear to be fair predictors of impairments in iq and academic achievement outcomes. cogstate is inexpensive and can be easily administered in a medical setting with minimal training in approximately minutes. results support the potential for cogstate to be used as a screening tool for medical and neuropsychological abnormalities in children with scd. st. christopher's hospital for children, philadelphia, pennsylvania, united states background: cardiovascular disease contributes to the morbidity and mortality of patients with sickle cell disease (scd). hydroxyurea therapy in scd has known clinical efficacy including improving anemia, decreasing episodes of vasoocclusive crisis and acute chest syndrome, and decreasing mortality. effect of hydroxyurea on cardiac function in children with scd is not well studied. an earlier study suggested the protective effect of hydroxyurea on left ventricular (lv) hypertrophy in scd. we hypothesized that hydroxyurea use would be associated with decreased lv remodeling and improved cardiac function. we aimed to evaluate the association between hydroxyurea use and lv remodeling and cardiac dysfunction in children with scd. design/method: we completed a retrospective study of patients with scd who were to years old, followed at st. christopher's hospital for children and had an echocardiogram completed in the past months. data collected included gender, bmi, scd genotype, hydroxyurea use, chronic transfusion use, and d and doppler echocardiographic parameters. cardiac structure, geometry, systolic function, and diastolic function echocardiogram parameters were included. analysis of variance (anova) tests were performed to assess for statistical significance of differences in cardiac parameters between patients with and without hydroxyurea use. analysis of covariance (ancova) tests were performed to control for age. results: demographic and echocardiogram data was collected on all patients who met inclusion criteria. of the patients included, ( %) were on hydroxyurea therapy. patients on hydroxyurea had significantly lower mean relative wall thickness (p = . ) and significantly higher mean peak early lv filling velocities (p = . ) and peak early lv filling/septal annuli early peak (e/ea) velocities (p = . ); however, only the e/ea velocities remained significant when controlling for age (p = . ). mean peak early lv filling velocities approached significance when controlling for age (p = . ). hydroxyurea therapy resulted in a significantly higher e/ea velocity, suggesting that these patients had worse diastolic function. it is possible that the patients initiated on hydroxyurea already had worse disease manifestations than those not on hydroxyurea, possibly accounting for the decreased diastolic function. when controlling for age, hydroxyurea use did not result in significant differences in cardiac structure parameters, systolic function parameters or cardiac geometry. prospective studies and larger sample size are needed to validate our findings, examine for additional statistically significant differences, and develop preventive strategies for cardiovascular disease in children with scd. background: acute chest syndrome (acs) is now the leading cause of death in children with sickle cell disease; mortality in the u.s. is reported to be - % and is mostly due to respiratory failure. early transfusion improves clinical outcomes. although patients with concurrent asthma are considered at increased risk for poor outcomes, risk factors for respiratory failure in pediatric acs have not been well-defined. to determine whether specific epidemiological and clinical features of children hospitalized with acs are predictive of the need for mechanical ventilation. design/method: data from the kids' inpatient database were reviewed to identify patients age < years with a discharge diagnosis of acs for the years , , , and . outcomes were defined by the international classification of diseases, ninth revision, clinical modification code. data were weighted to estimate total annual hospitalizations according to hospital characteristics in the united states. trends in healthcare costs, length of hospital stay, transfusion, and mechanical ventilation use were analyzed using multivariable linear regression. in addition, multivariable logistic regression was used to ascertain specific clinical or epidemiologic factors associated with mechanical ventilation use after adjusting for patient and hospital characteristics. the total hospitalizations for acs were , in ; , in ; , in ; and , in . reported use of mechanical ventilation ranged from . % to . % and was associated with non-black compared to black children (or, . ; %ci, . to . ) and the fall season (or, . ; %ci, . to . ), but not with age, preexisting asthma or hb-genotype. comorbidities of obesity (or, . ; %ci, . to . ), obstructive sleep apnea (or, . ; %ci, . to . ) and heart disease (or, . ; %ci, . to . ) were associated with mechanical ventilation use. the use of simple and exchange transfusion during all acs admissions ranged from . % to . % and . % to . %, respectively. among pediatric acs patients, those with obesity, obstructive sleep apnea or heart disease were at increased risk for respiratory failure and might benefit from early intervention (e.g., transfusion). surprisingly, asthma in children with acs does not appear to be a distinct risk factor for respiratory failure, and further studies are needed to clarify whether differences in treatment approach (e.g., addition of corticosteroids, bronchodilators) might impact on acs progression and/or severity even in high risk patients without asthma. objectives: to compare pulmonary functions between aa and k children with scd and to assess if a high hb f level contributes to better function. design/method: a cross sectional study was done on children with scd (hb ss disease) followed in comprehensive sickle cell programs. aa patients were followed at brookdale hospital, ny and k patients were followed in mubarak hospital, kuwait. children between the ages of and years who had pulmonary function tests (pft) done as a routine screening were enrolled. pft was done using spirometer and plethysmography. patients with congenital or anatomical lung abnormality, heart disease, pulmonary disease such as acute chest syndrome, acute asthma or pneumonia within weeks were excluded. results: there were children ( in each group) with scd,. restrictive pattern on pft was seen in / ( %) of aa vs. / ( %) of k (p> . ). obstructive pattern was seen in / ( %) of aa vs. / ( %) of the k group (p> . ). in both groups, children ( %) had normal pft. three/ ( %) in the aa group had a hb f> % as compared to / ( %) in the k group (p< . ). abnormal pft was noted in / children ( %) in each group. hbf was > % in / ( %) in the aa group vs. / ( %) in the s of s k group (p< . ). in patients with abnormal pft, mean hbf was . ± . in aa group, compared to . ± in k group (p< . ). conclusion: abnormal pft is highly prevalent among children with scd in both groups. aa children are more likely to have restrictive disease and k to have an obstructive pattern. level of hbf did not seem to protect k patients from abnormalities on pft. this finding should emphasize the importance of performing pft as part of the initial evaluation of all children with scd. background: sickle cell disease (scd) is a life-threatening disease with varied clinical spectrum and severity leading to premature death. there is a lack of validated prognostic marker in scd. recent evidence suggests that inflammation and platelet adhesion plays a critical role in the pathophysiology of vaso-occlusion in scd. elevated mean platelet volume(mpv) values are associated with a higher degree of inflammation in many disease states but it's effect on sickle cell disease or it's severity is unknown. objectives: to analyze the role of mpv in predicting disease severity/mortality in pediatric patients with scd. design/method: this is a single center retrospective study and included patients with sickle cell disease between months and years of age during a -year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . demographic information, lab data and clinical information including acute chest syndrome (acs), priapism, transfusions, sepsis, pain crisis, avascular necrosis were collected. all laboratory data were collected in steady state with no crisis in the recent past months. the disease severity score/probability of death was calculated using a validated model to predict risk of death in sickle cell disease (sebastiani et al. blood ) . pearson test was used to analyze correlation between mpv and probability of death. results: total no. of patients = ; male ( . %); female ( . %). median age is . years. all patients were of african-american origin. disease severity, hb ss - ( %); hb sc - ( . %) and sickle-beta thalassemia ( . %). patients on hydroxyurea has significantly lower mpv, p = . and this is independent of hb f levels. mpv has a significant positive correlation with the probability of death, p = . and correlation coefficient, r = . . on subgroup analysis, the correlation is even more significant in the age group between and years, p = . , r = . . using linear regression model, with probability of death as a dependent variable and hydroxyurea, mpv as independent variables, mpv maintains a significant association with probability of death (p = . ). conclusion: mpv is an independent biomarker predicting disease severity and probability of death in pediatric patients with sickle cell disease. hydroxyurea a known disease ameliorating agent is associated with lower mpv values. this effect is independent of the levels of fetal hemoglobin and may be due to anti-inflammatory effect of hydroxyurea or effect on the platelets. background: major success with initial qi projects by the sickle cell care team at children's hospital has precipitated ongoing inclusion of the qi approach to many other aspects of patient care. objectives: to optimize scd patient care utilizing qi processes. design/method: success of the scd qi team's initial project on transcranial doppler studies (tcds) and a second more complex project on hydroxyurea (hu) adherence, led to additional projects on completion of key immunizations, rbc phenotyping, and vitamin d level testing. using similar processes and principles from the hu adherence project, plan-do-study-act (pdsa) cycles were used to conduct smallscale tests of change. patient chart prep sheets, created for bi-monthly pre-appointment chart prep meetings, were significantly modified to include these focused care qi objectives. because of difficulty with emr database capability, data collected from the emr was tracked in excel spreadsheets or other unique tracking vehicles for the various parameters. for example, due to the clinic's diffuse, geographically scattered population, many separate non-shared primary care emrs, and lack of a mandatory state immunization registry; immunization records needed to be retrieved from pcps, outlying hospitals, public health departments, and fqhcs, and added to the emr and excel database. starting in / , all such data was collected and updated monthly. in one year's time ( - ) , the average immunization completion rate for seven key immunizations (pcv , pcv , hepatitis a, hepatitis b, meningococcal a, meningococcal b, and hpv) has increased by %. the biggest improvements were a % and % increase in completion for meningococcal a and meningococcal b, respectively. completion rate for rbc phenotyping rose from . % to . %. patients with at least one vitamin d lab test increased from . % to . %. since starting the tcd project in , the percent of patients who have completed their annual tcd has gone from a baseline of % to a sustained value of > %. conclusion: these qi projects have not only increased adherence to national recommendations for care of scd patients, they have helped establish a scd clinic methodology to create and implement sustainable processes. having the focused care initiatives prominently displayed on the patients' chart prep sheet serve as a reminder to medical team members to check the status of that item. this methodology is currently being used to formulate additional qi projects on annual renal function parameters and specialty visits, such as annual eye and dental exams. background: dominican republic has a high burden of sickle cell disease, and - % of children with homozygous hbss (sickle cell anemia, sca) will develop primary stroke. transcranial doppler (tcd) ultrasonography is an effective screening tool for primary stroke risk, but is not routinely available in dominican republic. hydroxyurea and blood transfusions are available, but no prospective screening and treatment program for stroke prevention has been implemented to date. ( ) to screen a large cohort of children with sca living in dominican republic, using tcd to identify elevated stroke risk; ( ) to determine the effects of treatments for stroke prevention (hydroxyurea for conditional velocities and transfusions for abnormal velocities). we hypothesized that both hydroxyurea and blood transfusions will decrease elevated tcd velocities and help prevent primary stroke. design/method: stroke avoidance for children with república dominicana (sacred, nct ) features a research partnership between cincinnati children's hospital and robert reid cabral children's hospital in dominican republic. the protocol, consent forms, and redcap database were prepared collaboratively and translated into spanish, and then irb approval was obtained at both institutions. in the initial prospective phase, children receive tcd screening over a -month period; those with conditional tcd velocities (maximum time-averaged velocity - cm/sec) receive fixed-dose hydroxyurea at mg/kg/day, followed by dose escalation to maximum tolerated dose, while those with abnormal tcd velocities (≥ cm/sec) receive monthly transfusions for stroke prevention. results: a total of children were enrolled in sacred, with an average age of . ± . years. initial tcd screening revealed ( . %) normal, ( . %) conditional, ( . %) abnormal, and ( . %) inadequate velocities. among children ( males, females, average age . ± . years) who initiated hydroxyurea at mg/kg/day for conditional tcd velocities, completed six months of treatment with expected hematological benefits including significant increases in hemoglobin concentration ( . to . g/dl) and fetal hemoglobin ( . to . %). no clinical strokes have occurred in the treatment group. repeat tcd examination after -months of hydroxyurea treatment revealed % ( / ) with previous conditional velocities had normal tcd velocities. the prevalence of conditional tcd velocities in the dominican republic is high, indicating an elevated stroke risk among children with sca. hydroxyurea treatment is associated with improved hematological parameters, lower tcd velocities, and probable decreased stroke risk. sacred is an important prospective and collaborative research trial providing epidemiological data regarding tcd screening, stroke risk, and hydroxyurea effects among children with sca. background: red blood cell aggregation is a rheologic property that explains the shear-thinning behavior of blood. at lower shear rate blood flow, red cells tend to aggregate, s of s whereas in higher shear rate blood flow, these aggregates are dispersed. this property is especially important in the venous system, where low shear rate blood flow predominates. there is inconsistent data in the literature concerning aggregation and aggregability in sickle cell disease (scd). objectives: because the lorrca and myrenne instruments have been shown to be similarly effective methodologies in red cell aggregation measurements, we aimed to determine whether the measurement of aggregation indices in scd, by myrenne and by lorrca, is consistent in our lab. design/method: we measured aggregation in blood samples corrected to % hematocrit. aggregability was measured using kda dextran in the myrenne but not the lor-rca. aggregation index using lorrca was measured in patients with scd and healthy subjects enrolled in a study of blood flow between and . aggregation and aggregability using the myrenne was measured in patients with scd and healthy subjects enrolled in a separate study of blood flow between and . results: using lorrca, we found that aggregation index in patients with scd was less than that of healthy subjects (p< . ). in the myrenne, aggregation at stasis was slightly higher in patients with scd compared to healthy subjects (p = . ) but aggregation at low shear rotation was not different. aggregability was higher in the patients with scd compared to healthy subjects at both stasis and low shear rotation (p< . ). red cell aggregation is an important determinant of low shear blood flow. deoxygenated venous blood is particularly important to low shear blood flow in patients with sickle cell disease. we found that two different aggregometers predict different aggregation results for scd. it is unclear why there is a systematic difference between the two methods, but there are some possibilities. first, the syllectogram in the lorrca is generated by the backscatter of light from the laser, while the myrenne measures transmitted light. second, the distance between the bob and cup in the lorrca is microns, while the gap between plates in the myrenne is microns, which might affect the disaggregation of red cells. further work is needed to understand the differences in red cell aggregation and aggregability when using these instruments, particularly when using aggregation as a predictor of blood flow and tissue perfusion. background: children with sickle cell disease (scd) are at risk of acute splenic sequestration crisis (assc). assc is a life-threatening complication characterized by splenomegaly, pain and severe anemia. assc most often occurs in young children with the most severe forms of scd and one-third of patients will have more than one episode. treatment is based primarily on expert opinion and includes blood transfusion and surgical splenectomy. objectives: we plan to assess the clinical practice patterns of physicians treating children with assc. design/method: a survey study was performed. the survey included six scenarios of severe scd with variation in age, hydroxyurea-use, and episode number of assc; questions focused on the acute and chronic management of assc. the survey was disseminated on three occasions over a six-month period, using an online survey tool, surveymonkey, to pediatric hematologist-oncologists participating in the american society of pediatric hematology-oncology hemoglobinopathy special interest group. the survey had a response rate of % ( / ). most respondents were recent graduates ( %; / ) practicing in academic urban centers with greater than sickle-cell patients. seventy-nine percent ( / ) recommended hydroxyurea initiation in - m/o with severe scd. prophylactic penicillin after surgical splenectomy was continued by % ( / ) after years. for the acute management of assc results did not vary despite patient age, hydroxyurea use, and the number of previous assc episodes. simple transfusion was preferred by % ( / ), with % ( / ) recommending slow transfusion and % ( / ) recommending routine simple transfusion. for the chronic management of assc, results varied based on patient age and the number of previous assc episodes. for a m/o after the first episode, % ( / ) recommended observation and % ( / ) hydroxyurea initiation. for a m/o with any prior episode of assc, % ( / ) recommended chronic transfusion therapy and % ( / ) surgical referral for splenectomy. for a y/o after the first episode, % ( / ) recommended surgical splenectomy and % ( / ) increasing hydroxyurea dose. for a y/o with any prior assc episode, % ( / ) recommended referral for surgical splenectomy. in this survey, we found most providers continue to recommend simple transfusions for assc and surgical splenectomy after two episodes. the majority of providers continue to delay referral for surgical splenectomy until age two, but earlier referral in children under two and use of chronic transfusion therapy were also reported. variability in chronic management highlights the need for further research of splenic sequestration. background: developing therapies for sickle cell disease (scd) is challenging in part because the accepted endpoint, vaso-occlusive crisis (voc), occurs infrequently, does not measure full disease burden, and is a measure of healthcare utilization. in phase / studies of patients with scd, voxelotor (gbt ) has demonstrated increased hemoglobin (hb) levels and reduced hemolysis and has been safe and welltolerated. voxelotor is being evaluated in the ongoing hope phase trial. objectives: to report the innovative phase / hope trial design with novel primary and secondary outcomes to accelerate drug development. design/method: hope (nct ) is a phase , randomized, placebo-controlled, multicenter study of oral voxelotor in patients with scd (aged - years) with baseline hb . - . g/dl and - episodes of voc in the prior year. to accelerate clinical trials to support drug development, the study combines a phase exploratory, dose-selection phase (group ) with a pivotal phase (groups / ). patients in group will be randomized : : to voxelotor or mg/day or placebo. analysis for dose selection will occur when the final patient has received weeks of treatment. group will continue enrollment with randomization : : until dose selection based on analysis of the group cohort. group will allow for a seamless transition into group , which will randomize patients : to the selected dose or placebo. the final data analysis set will include group patients who received placebo or the selected dose and all group patients. the primary endpoint is an objective laboratory measure and surrogate of clinical benefit, increase in hb > g/dl, from baseline to weeks based on voxelotor mechanism of action (inhibition of hb polymerization). this trial is the first to use a patient-reported outcome (pro), the -item sickle cell disease severity measure, as a secondary endpoint. this novel electronic pro, developed specifically for the hope study following fda guidance, will evaluate changes in scd symptom exacerbation and total symptom score from baseline to weeks. additional secondary endpoints include measures of hemolysis, rates of voc, transfusions, and opioid use. the study was designed to enable selection of pro-defined symptom exacerbations or traditionally defined voc as the key secondary endpoint after the group analysis. results: this study is ongoing. the hope trial, expected to complete enrollment by late , will evaluate the efficacy and safety of voxelotor compared with placebo in patients with scd. supported by global blood therapeutics. background: inflammation, coagulation activation, oxidative stress and blood cell adhesion are elements of sickle cell disease (scd) pathophysiology. patients with scd have low levels of the omega- fatty docosahexaenoic acid (dha) and eicosatetraenoic acid (epa) in plasma and blood cell membranes. dha is a bioactive fatty acid with anti-inflammatory, anti-blood cell adhesion and anti-oxidant properties. altemi-atm is a novel dha ethyl ester formulation with a proprietary delivery platform (advanced lipid technology® (alt®)) that enhances oral dha bioavailability. the scot trial investigated the effects of altemiatm in children with scd. objectives: to demonstrate the effects of altemiatm on blood cell membrane omega- index and selected biomarkers of inflammation, coagulation, adhesion and haemolysis associated with scd. s of s design/method: children with scd, aged - years (n = ), were enrolled. subjects were randomized to receive either placebo or one of three daily oral doses of altemiatm ( - , - or - mg/kg/day dha) for two months. the effects of altemiatm on red blood cell (rbc), white blood cell and platelet membrane omega- fatty acids index (total dha + epa levels) were assessed after four weeks of treatment. the effects of altemiatm on markers of inflammation, adhesion, coagulation, and hemolysis were assessed after eight weeks of treatment. cell membrane dha and epa concentration was determined by using lc-ms/ms method. the percent changes from baseline on blood cell membrane omega- index and select scd biomarkers were compared between the three dose groups and placebo using a mixed-model repeatedmeasures (mmrm) analysis with baseline blood cell membrane omega- index, hydroxyurea use, and treatment as fixed effects and patient as a random effect. after four weeks of treatment, blood cell membrane dha and epa levels were significantly increased in all altemiatm doses (p< . ). after eight weeks of treatment, significant reductions were observed in se-selectin (p = . ), and d-dimer (p = . ) in patients exposed to altemiatm dose level vs. placebo. hemoglobin was significantly increased at altemiatm dose level versus placebo. plasma high-sensitivity c-reactive protein, lactate dehydrogenase, soluble vascular cell adhesion molecule- and white blood cell count showed improvement after weeks of treatment in all three altemiatm doses levels but did not reach significance. conclusion: treatment with altemiatm enriches dha and epa in blood cell membranes of patients with scd and improves select sickle cell disease biomarkers of blood cell adhesion and thrombin generation. these findings provide insight into the mechanisms of action of altemiatm in sickle cell disease. brown university -hasbro children's hospital, providence, rhode island, united states background: despite clinical advances in the treatment of sickle cell disease (scd) in pediatric and young adult patients, pain remains a significant source of disease-related morbidity. physical therapy has been shown to be useful for the treatment of pain in children and young adults with various chronic illnesses of which pain is a significant component, however no data exists regarding potential benefits of physical therapy in pediatric and young adult patients with scd. objectives: to query healthcare providers and others involved in the care of pediatric and young adult scd patients regarding possible benefits of and barriers to physical therapy as a potential treatment modality. design/method: we conducted a web-based survey of healthcare providers within the new england pediatric sickle cell consortium (nepscc) in an attempt to identify potential benefits of and barriers to outpatient physical therapy in this patient population. results: nearly % of survey participants felt that physical therapy had the potential to be "somewhat beneficial" or "very beneficial" in pediatric and young adult patients with scd. a majority of physicians reported having referred patients with scd for physical therapy in the past. the most frequently identified perceived potential benefits included improved functional mobility, improvement of chronic pain symptoms, decreased use of opiates, improved mood symptoms, improved acute pain symptoms, and improved adherence with medications and clinic visits. significant perceived barriers identified included lack of transportation, time constraints, patient lack of understanding, and difficulty with insurance coverage. our study indicates that healthcare providers have an overwhelmingly positive view of the use of physical therapy in the management of pediatric and young adult patients with scd. significant barriers exist which need to be addressed. future research should focus on patient and parent perspectives regarding physical therapy, as well as a randomized controlled trial of a physical therapy intervention in this patient population. background: vitamin-d deficiency is fast becoming increasingly recognized in patients with sickle cell disease (scd). while it is estimated that these patients are five times more likely to develop vitamin-d deficiency, the exact clinical significance of this is largely unknown. given that this deficiency can be inexpensively and easily treated, our study sought to establish the prevalence of vitamin-d deficiency in our patient population and its relationship with disease severity. objectives: to estimate the prevalence of vitamin-d deficiency in patients with scd in our institution and to analyze their disease severity in relation to their vitamin-d level. design/method: through retrospective chart review we analyzed subjects that represent a cohort of patients followed at the adult and pediatric hematology services at university of miami with known diagnosis of scd that had a vitamin-d level drawn between january st, and august st, . we conducted a cross-sectional study and recorded the first vitamin-d level during this period. patient demographics, medical and social history information were collected along with laboratory data. the number of admissions for vaso-occlusive crisis (voc) and acute chest syndrome within one year preceding the collection the vitamin-d level was also recorded. results: a total of charts were reviewed, adult charts and pediatric charts. after exclusion, patients were enrolled. subclinical vitamin-d deficiency is only evident on laboratory blood testing of vitamin-d ( -hydroxy) and according to this laboratory result patients were classified as sufficient (≥ ng/ml), insufficient (< to ng/ml) and deficient (< ng/ml). out of the cases, . % ( / ) were deficient, . % ( / ) were insufficient and . % ( / ) were optimal. after statistical analysis two negative correlations were identified, increasing vitamin-d levels with decreasing white blood cell count (ci %- . (- . , - . )and decreasing incidence voc (ci %- . (- . , - . ). conclusion: this study confirms that there is a significant prevalence of vitamin-d deficiency in patients with scd. furthermore, the results of this investigation proved that vitamin-d deficiency is associated with acute pain and leukocytosis in patients with scd. given the multitude of confounding factors that affect vitamin-d absorption and intake, multivariate analyses are required to truly further investigate this relationship. texas children's hospital, houston, texas, united states background: hemophagocytic lymphohistiocytosis (hlh) is a rare but life-threatening condition of hyper-inflammation that is characterized by splenomegaly, cytopenias, hyperferritinemia, hypertriglyceridemia, hemophagocytosis and coagulopathy. although timely diagnosis is imperative, it is often challenging as these individual signs and symptoms may occur in a variety of clinical conditions. to report a case of undiagnosed sickle cell anemia presenting with severe ebv viremia and associated hemophagocytic lymphohistiocytosis results: a -month-old previously healthy male presented with respiratory distress, increased fatigue, and a focal seizure following a two-week history of cough and lowgrade fevers. physical exam was consistent with hypovolemic shock and revealed significant splenomegaly. laboratory testing revealed severe hypoglycemia, acidosis and electrolyte disturbances including hyperkalemia, hyperphosphatemia, and hyperuricemia. labs showed a leukocytosis (wbc , ), severely low hemoglobin ( . ), and platelets of , . coagulation testing revealed prolonged pt/inr and ptt, hypofibrinogenemia and a highly elevated d-dimer. additional workup was completed to determine etiology of acute presentation, given broad differential diagnosis. infectious studies were consistent with an acute ebv infection (plasma ebv pcr > , ). elevated levels of soluble il- and ferritin completed / criteria for the diagnosis of hlh. bone marrow evaluation showed trilineage hematopoiesis with no abnormal blast population or hemophagocytosis. results from hemoglobin electrophoresis sent from the initial cbc sample were notable for hbs . %, hbf . %, and hba of %, confirming the diagnosis of sickle cell disease. the patient was started on hydroxyurea and penicillin and splenomegaly resolved. with supportive care, he demonstrated gradual improvement in symptoms and laboratory abnormalities, including normalization of soluble il- , ferritin, cd , il- levels, immunoglobulins, and declining ebv titers. nk cell function has remained abnormally low, not eliminating the possibility of acquired hlh despite spontaneous improvement. conclusion: splenic sequestration associated with sickle cell disease in combination with acute infectious mononucleosis could have explained many of the presenting symptoms including anemia, thrombocytopenia, and splenomegaly. however, it does not explain the unusually high ebv titer and degree of inflammation meeting diagnostic criteria for hlh, which raises concern for an underlying immunologic abnormality such as x-linked lymphoproliferative disorder (xlp). although testing for xlp was negative, he will require s of s continued monitoring in the future for signs of relapse. this case illustrates the complexity of diagnosing lymphohistiocytic disorders and the significant overlap in presentation between these disorders and other medical conditions. background: vaso-occlusive crisis (voc) is one of the most distressing occurrences in patients with sickle cell disease (scd). patient controlled analgesia (pca) is recommended by nih and expert opinions favor its early use. we aim to review the use of pca in patients with voc and to evaluate if its early use is associated with faster pain control and reduced length of stay (los). design/method: this retrospective single center study included all pediatric patients admitted and treated with pca for a severe voc from to . "early" use was defined as start of pca within hours of arrival in the emergency department (ed) and "late" use after hours. time to reach adequate analgesia was defined as oucher, verbal scale or faces pain scale < / obtained twice consecutively in a -hours interval. time to reach adequate analgesia and los were compared between early-pca and late-pca groups. results: a total of patients presented episodes of voc treated with pca during the study. sixty-one episodes ( %) were treated with early-pca and ( %) with late-pca. both groups were comparable in terms of age ( . vs . years old), gender ( . % female vs . %), hemoglobin phenotype ( . % hbss vs . %), but median pain score at admission was higher in early-pca than in late-pca ( / vs / , median difference ( % ci , ). early-pca was associated with a median reduction in los of . days ( % ci . , . ) (median early-pca los . vs late-pca . days). time to reach analgesia could be evaluated only in a subset of patients ( in early-pca and in late-pca group). although time to reach adequate analgesia tended to be shorter in the early-pca group, it was not statistically different: median . hours vs . hours, difference of . ( % ci - . , . ). side effects were observed during ( . %) pca treatments ( / ( . %) episodes in early-pca, / ( . %) in late-pca group) among which ( . %) were significant adverse events. these were observed in patients who required interventions: desaturations requiring oxygen without intubation, neurologic abnormalities (hallucinations, visual abnormalities, no stroke), urinary retentions. conclusion: early use of pca for severe voc was associated with a reduced length of hospital stay despite that these patients had higher pain score on admission. prospective studies are needed to support these positive outcomes. background: acute chest syndrome is one of the leading causes of death in children with sickle cell disease - . while the cause of acute chest syndrome most commonly is not identified, fat embolism and infectious causes are believed to be most common. with an extremely high mortality rate, rapid identification and initiation of therapy is essential for survival. case presentation: we describe the case of an -year-old female with sickle cell sc disease who was admitted for vasoocclusive pain crisis and quickly progressed to multi-system organ failure due to fat embolism syndrome and parvovirus b infection objectives: the case highlights the presentation and diagnosis so other providers can optimize outcomes for those with this under-recognized syndrome design/method: her parvovirus studies returned after days which showed: parvovirus b dna pcr detected; parvo igg . (positive > . ); and igm . (positive > . ). the patient experienced an approximately . g/dl drop in hemoglobin( . to . g/dl/ hrs) with progressive thrombocytopenia (from , to , /ul) and a peripheral smear showed microcytic,normochromic red cells with nucleated rbcs and occasional nuclear budding, slight polychromasia, schistocytes, and polymorphic cells with toxic granules that suggested leukoerythroblastosis. she was emergently transferred to the regional quaternary care hospital for ongoing ecmo therapy where she experienced a change in her pupillary exam prompting a stat ct scan that showed severe, diffuse cerebral edema with transtentorial herniation. the decision was made to withdraw life-sustaining therapies and her family refused a post-mortem autopsy examination. fat embolism syndrome is a severe and uncommonly recognized complication of sickle cell disease, seen most commonly in those with a non-ss phenotype and previous mild disease course who present with severe, unrelenting vaso-occlusive pain episode and/or acute chest syndrome that progresses to respiratory distress with altered mental status and cutaneous changes. rapid identification and initiation of exchange transfusion therapy should be initiated with clinical suspicion because of the extremely high mortality rate. although previously considered rare, it needs to be considered in the differential diagnosis of more commonly encountered complications of sickle cell disease. background: patients with sickle cell disease (scd) experience vaso-occlusive crisis (voc), which results in extreme pain, often requiring opioids and admission. genetic and environmental factors affect the frequency and severity of these episodes. previous research has born conflicting evidence on whether environmental temperature is contributory. edmonton, alberta is the northern most city with a population over a million in north america. there is an increasing sickle cell population which is exposed to extreme winter conditions. this provides a suitable population and atmosphere to study the influence on cold external temperatures in scd. this study sought to identify if pediatric patients with scd, experience greater morbidity in cold external temperatures. board approved retrospective case control series. patients were identified through a clinical database, and emergency visit, phone call and admission data was collected over a fiveyear period. the average, minimum and change in temperature on day of presentation, and hours prior, was collected from the government of alberta, and was statistically analyzed using descriptive statistics, to determine the relation to vaso-occlusive events. results: one-hundred and eighteen patients were identified, and voc events reviewed. the mean patient age was . years of age with a range from . - years old. the female to male ratio was equivalent with female ( . %) and male ( . %) voc events. eight records ( %) had docu-mented cold exposures. the analysis between the temperature and the frequency of events did not yield significant correlation. average and minimum temperature on day of admission had the largest percentage of voc events occur at mild temperatures, from - . to • c and - . to respectively. change in temperature on day of admission, and hours had the largest percentage of voc events at a mild to moderate change in temperature of - degrees. data at & hours prior to admission showed similar results. secondary data analysis accounting for the lower proportion of extreme weather days in comparison to moderate temperate days showed no significant impact. there was no correlation of average, minimum or change in temperature on day of admission, or hours prior. multiple cofounding factors likely contribute to these results. as it was a retrospective study many confounding and precipitant factors may not be recorded or identified. a prospective study to better record specific cold exposure is warranted. children's national health system, washington, district of columbia, united states background: achieving optimal anticoagulation with unfractionated heparin (ufh) in pediatric patients receiving extracorporeal membrane oxygenation (ecmo) is often challenging due to antithrombin (at)-mediated heparin resistance (hr). intermittent at dosing during pediatric ecmo support does not maintain adequate at levels. continuous at infusion (cati) presents an alternative strategy to achieving consistent goal at levels and optimizing heparinization. however, cati during pediatric ecmo has not been adequately studied. objectives: to describe our center's experience with an ecmo cati protocol. design/method: in , we modified our ecmo anticoagulation protocols to include ufh titration according to anti-factor xa (anti-fxa) levels and cati in patients with at-mediated hr. the cati rate was calculated using baseline and goal at levels while accounting for the circuit volume. cati was administered with ufh into the circuit via a s of s y-infusion set. at and anti-fxa levels were monitored every hours. recombinant at (r-at) concentrate was used at our center until with subsequent transition to a plasmaderived at (pd-at) concentrate. due to the longer half-life of pd-at concentrate, the protocol was modified so cati is stopped once target at and anti-fxa levels are achieved. we conducted a retrospective study of all patients who received cati during ecmo support at our center. data are reported as median and interquartile range and compared using the mann-whitney u test. two-tailed p-value < . was considered statistically significant. since , patients [ males, age month ( . - )] on ecmo support received catis ( rat, pd-at) per our protocol ( patients received pd-at infusions during one ecmo run). the duration of cati was hours ( - ). cati administration led to significant increases in at and anti-fxa levels from baseline of % ( - ) and . units/ml ( . - . ) to the first level within goal of % ( - ) and . units/ml ( . - . ), respectively (p< . ). the respective times to achieve goal at and anti-fxa levels were hours ( - ) and hours ( - ). the respective peak at and anti-fxa levels were % ( - ) and . units/ml ( . - . ). during cati, no patient required circuit change, patient developed cannula thrombosis and patients experienced non-fatal major bleeding. conclusion: cati in pediatric patients receiving ecmo support with close monitoring of at and anti-fxa levels was associated with significant rapid increase in at, optimization of heparin effect, and reduction in thrombotic complications without increase in major bleeding compared to prior reports. a prospective study of this at dosing strategy is warranted. children's hospital of orange county, orange, california, united states background: inherited factor xiii (f ) deficiency is a rare bleeding disorder with wide heterogeneity in clinical manifestations ranging from mild bruising, and mucosal and umbilical stump bleeding to spontaneous, severe intracranial bleeding. the bleeding phenotype is influenced not just by zygosity of the fxiii mutation alone, but also by co-inheritance of variants in other clotting protein genes that also play a major role in clot formation and stability. we present a series of three siblings found with f a gene variant and platelet dysfunction linked to bleeding phenotype. design/method: retrospective chart review of the index case, coagulation studies and whole gene sequencing. the index patient presented at two years of age with a subdural hematoma after a fall, requiring emergent craniotomy. a week after initial evacuation, she re-bled, prompting an extensive work-up for potential bleeding disorders, including f activity, von willebrand profile, comprehensive fibrinolysis panel, pai- antigen level, platelet mapping thromboelastogram (plt-teg), and f genetic analysis. the patient's identical twin and older sibling, who had symptoms of bruising, underwent a similar evaluation. the index patient demonstrated consistently low f activity ( - %), and platelet function testing revealed decreased response to adp agonists. the twin and older sibling had normal f levels, and only slightly decreased response to adp in platelet studies. whole gene analysis of f and other genes on our next generation panel, revealed several intronic deletions in the index patient that were not shared by her siblings, which likely account for her decrease in circulating f levels. her symptoms have responded well to monthly treatment with factor concentrate. all three children shared the f variant, pro leu, previously described as a risk factor for intracranial hemorrhage. the f mutation, pro leu, has been associated with intracranial hemorrhage in young women, but the presence of the variant alone may not be enough to cause a severe bleeding phenotype. family studies identified novel deletions in the index patient which may account for her decreased f levels, which would have been overlooked with standard sequencing. future studies, including evaluation of 'platelet' f levels, should be performed when platelet dysfunction is detected. further laboratory and clinical evaluation is required to delineate the long term implications of the interaction of even mild f deficiency if present with additional clotting disorders such as the platelet function defect in these siblings. background: acquired hemolytic anemia can occur due to mechanical shearing of red blood cells and is classically seen in patients with prosthetic heart valves. there are reports of this same traumatic effect with other repairs, including annuloplasty. following valvular procedures flow disturbances can exist across the valve that lead to shear stress and hemolysis. although von willebrand disease (vwd) is typically seen due to an inherited disorder in the pediatric population, flow disturbances in the setting of valve abnormalities can lead to acquired von willebrand syndrome (avws). von willebrand factor multimers become unfolded and elongated in the setting of shear stress resulting in increased susceptibility to cleavage by adamsts- . specifically, loss of high molecular weight multimers (hmwms) can lead to a syndrome akin to type a vwd. objectives: to describe a case of mechanical hemolysis with acquired type a vwd design/method: a -month-old girl with history of hypoplastic left heart syndrome and severe tricuspid valve insufficiency underwent norwood procedure, blalok-taussig shunt placement and subsequently a bidirectional glenn and tricuspid valve annuloplasty. during the following month she requires weekly red blood cell (rbc) transfusions due to intermittent anemia. she also experienced bloody stools and dark urine. laboratory evaluation was notable for normocytic anemia, reticulocytosis, elevated lactate dehydrogenase, and low haptoglobin consistent with hemolytic process. immune-mediated hemolysis from transfusion reaction or presence of autoimmune or alloimmune antibodies testing was negative. to investigate gi bleeding, work up for vwd revealed normal vw activity and antigen but with loss of high molecular weight multimers consistent with acquired type a vwd. in consultation with cardiology, it was felt her tricuspid valve insufficiency jet could be leading to mechanical hemolysis and avws. a repeat echo showed persistent moderate tricuspid insufficiency but no other significant changes. due to the patient's continued need for weekly rbc transfusions she was subsequently trialed on pentoxifylline which is used in adult patients to decrease blood viscosity and increase erythrocyte flexibility in patients with mechanical hemolysis. her transfusion needs remained the same and the medication was discontinued after two weeks. she required one transfusion a week later but no transfusions since that time. although not commonly seen in pediatric patients, the diagnosis of mechanical hemolysis accompanied by avws should be pursued in a patient with congenital heart disease with significant anemia and/or bleeding. the work up in these patients is difficult as echocardiograms can be inconclusive thus an extensive hematologic evaluation is usually necessary. objectives: our aim was to assess incidence of and potential risk factors for central line-related dvt at our institution between - . additionally, our goal was to analyze if that incidence differed between the three central line types and identification of line-specific risks. design/method: a retrospective chart review of central line placements in pediatric patients at cleveland clinic between - was conducted. data included demographics, potential risk factors, line characteristics and any related thrombotic events. the study cohort consisted of lines in pediatric patients aged - years of age. there were . thrombi ( % ci . - . ) per , line days. statistically significant risk factors for thrombus include diagnosis group (liquid tumor highest rate of %, solid tumor lowest at %), type of line (picc %, broviac %, and mediport %), location of line, greater number of lines per patient, peg asparaginase ( % vs %), sepsis, and history of procoagulant state. line characteristics such as lumen size and number of lumens were not identified as a significant risk. there was a significantly higher rate of thrombus in than in the previous years when pooled ( % in vs . % from - , p = . ). the incidence of dvt in pediatric patients at our institution was highest with broviac lines, and significant risk factors in our patient population included liquid tumor, femoral vein location, peg asparaginase, sepsis, and history of a procoagulant state. the incidence of thrombi was highest in , and therefore highlights the urgent need for improvement in nationwide hospital practices to minimize risk of thrombi formation and early detection in the higher-risk s of s populations. there is still much to be learned regarding the characteristics specific to different central lines, which would influence thrombi formation. nyu winthrop hospital, mineola, new york, united states background: pediatric immune thrombocytopenic purpura (itp) is an autoimmune disorder with platelet counts < causing increased risk for significant hemorrhage. there is increased immunologic platelet destruction due to production of specific autoantibodies along with inhibition of platelet production. few randomized trials exist to guide management and ultimately each patient requires an individualized treatment plan. itp may be acute (diagnosis to m) or chronic (> months). one of the treatments of chronic itp is laparoscopic splenectomy (ls), which is very well tolerated. a rare complication of ls is splenosis, an autotransplantation or implantation of ectopic splenic tissue within the abdominal cavity or in any other unusual body compartment. splenosis is sometimes associated with relapsed itp due to preserved immune activity. the usual management of symptomatic splenosis is surgical resection. objectives: to describe medical management in a young patient with itp relapsed due to extensive unresectable splenosis following ls design/method: our patient was originally diagnosed at years with itp and was treated with ls at years of age for chronic severe thrombocytopenia and persistent bleeding not responding to first line therapies. she tolerated it well and had a complete response (cr) defined as a platelet count of > measured on occasions > days apart and absence of bleeding. she maintained a normal platelet count for twelve years after which she relapsed (loss of response after cr) with severe thrombocytopenia and hematuria necessitating high dose steroids. ct scans showed multiple wellcircumscribed soft tissue masses in the left lower quadrant adjacent to uterus and left ovary, involving left omentum and the anterior abdominal wall partly. findings were confirmed by damaged rbc nuclear scan to be splenosis. during laparoscopy the splenosis lesions were deemed too extensive and were not resected completely to avoid postoperative morbidity. she was started on sirolimus around the same time for treatment of her relapsed itp and steroids were weaned off. results: eight months since beginning sirolimus with therapeutic levels she remains in cr with no bleeding and has not required any steroids, immunoglobulins or anti d immunoglobulin. conclusion: sirolimus is a safe and effective steroid-sparing agent in treatment of chronic itp. this is the first instance of a patient with poorly resectable splenosis responding well to medications for itp. more data is needed regarding the longterm efficacy of such an intervention and whether it will eliminate the need for a second surgery in relapsed itp patients with extensive splenosis. background: storage pool disorders affecting platelets result in bleeding symptoms related to a deficiency or defect in alpha granules or delta granules. in delta-storage pool disorders (dspd,) there is a deficiency of the delta granules and their constituents, which results in the inability of platelets to properly activate as well as lack of proper constriction of blood vessels during bleeding episodes. amongst patients with dspd, females most commonly present with menorrhagia, while males tend to present with epistaxis and easy bruising. the international society on thrombosis and hemostasis (isth) developed a screening bleeding assessment tool (bat) for mild bleeding disorders, shown to be a validated tool in children. diagnosis of dspd is classically made with a platelet electron microscopy (pem) value < . delta granules per platelet (dg/pl), but recently lower diagnostic thresholds of dg/pl or even . dg/pl have been suggested. objectives: evaluate the correlation between pem and bleeding scores, and also examine various cut-off values used to diagnose and risk stratify patients with dspd. design/method: retrospective chart review of pediatric patients followed by hematology with a diagnosis of dspd was performed. clinicians obtained bleeding scores for each patient as standard of care in the hemostasis clinic. quartile ranges were established to appropriate three stages of severity based upon bleeding scores. statistical analysis was performed using software r and exploratory data analysis to evaluate for a correlation. results: amongst all patients, the average bat score was . and pem was . dg/pl. the average bleeding score for pem between . dg/pl and dg/pl was . , while the average bleeding score for pem below dg/pl was . . the correlation coefficient between pem and bleeding scores is . . using a threshold of dg/pl, % of patients would have met diagnostic criteria. quartile ranges for the bleeding scores are as follows: st quartile was - , nd quartile was - , and rd quartile was > . conclusion: patients with a more marked granule deficiency do not exhibit a more severe bleeding phenotype, suggesting proper platelet function is not solely determined by granule quantity in these patients. bleeding severity may be more appropriately assessed with bleeding scores rather than pem values, and using quartile ranges may aide in risk stratification and therapeutic interventions for dspd patients. further work remains to determine the optimal diagnostic threshold of pem dspd in pediatric populations. texas children's hospital, houston, texas, united states background: warfarin management has many challenging aspects including pharmacogenomics, food and drug interactions, lack of standardized dosing, patient compliance, tracking lab results from multiple lab locations, and the potential for significant bleeding or thrombotic complications. a literature review revealed limited data highlighting anticoagulation monitoring workflow and emr documentation and specifically, no data in the pediatric population. historically, the texas children's hospital cardiology and hematology centers were each documenting anticoagulation data within the epic tm system differently. epic's tm original design for anticoagulation documenting resulted in the necessity to duplicate documentation in order to see at-a-glance critical anticoagulation monitoring information. objectives: the objective of this project was to standardize inr documentation across departments to reduce the risk of patient safety events and improve workflow. design/method: a workgroup assembled consisting of nurses from the cardiology and hematology departments, along with staff members from the epic tm is support group. the workgroup identified current documentation practices, available epic tm tools, and brainstormed ideas to streamline and improve both documentation with the current epic tm tools. physician partners were identified in cardiology, hematology and coagulation laboratory to gain their input. a new anti-coag (ac) encounter was developed and first made available in an epic tm practice environment, then once approved, epic tm written education and training session were completed by both departments' staff. results: surveys were sent to health care providers in the cardiology and hematology centers prior to the new ac encounter, and also to health care providers six months after implementing the ac encounter. six responses were received for each survey. the pre-implementation survey showed the most problematic part of the documentation system for anticoagulation was no single place in the emr to find a complete anticoagulation picture. post ac encounter implementation survey results revealed more health care providers using the epic tm inr reminder pool, less time needed to compile a report of three months of anticoagulation information, less time needed to document individual encounters, less locations needed to document ac information and decreased amount of types of documentation used. standardized ac encounters improves workflow with less time needed to document and compile information, less types of documentation utilized and easier access to patients ac information. next steps include retrospective review of patients' inr time in therapeutic range to determine if there was an impact on patient compliance and continue to evaluate and modify the ac encounter to enhance user friendliness. caitlin tydings, jennifer meldau, christine guelcher, carole hennessey, eena kapoor, michael guerrera, yaser diab s of s children's national health system, washington, district of columbia, united states background: venous anatomic abnormalities (vaas) are considered a risk factor for developing deep vein thromboses (dvts) that occur as a result of significant alterations in venous blood flow. identification of predisposing vaas can be challenging. hence, diagnosis can be delayed or overlooked especially in pediatric patients. dvts in children or adolescents with predisposing vaas have been only described in sporadic case reports and small case series. objectives: to describe characteristics and outcomes of dvts in pediatric patients with underlying vaa treated at our center. design/method: we conducted a retrospective chart review of all pediatric patients with objectively confirmed extremity dvt treated at our institution over a -year period from to and identified all patients with underlying vaas. patients were managed according to standardized institutional protocols based on published guidelines. post-thrombotic syndrome (pts) was assessed at our center using the manco-johnson instrument. relevant data were collected and summarized using descriptive statistics. during the study period, of pediatric patients ( %) [ females, median age years (range - )] diagnosed with extremity dvt at our center were found to have an underlying vaa. vaas included may-thurner anomaly ( patients), venous thoracic outlet obstruction ( patients) and inferior vena cava (ivc) atresia ( patients). additional provoking factors were identified in patients at time of presentation. dvt locations included upper extremity veins ( patients), lower extremity veins ( patients) and lower extremity veins and ivc ( patients). the majority of dvts [ patients, ( %)] were completely occlusive. high risk thrombophilia (defined as inherited deficiency of antithrombin, protein c, or protein s, or antiphospholipid antibody syndrome) was present in patients ( %). all patients were treated with therapeutic anticoagulation with patients continuing indefinite anticoagulation. endovascular interventions were performed in patients and included percutaneous pharmacomechanical thrombectomy and/or catheter-directed thrombolysis ( patients), balloon angioplasty ( patients) and stent angioplasty ( patients). surgical interventions included thoracic decompressive surgery ( patients) and surgical thrombectomy ( patient vvas represent an important risk factor for developing extensive extremity dvt in adolescents. this special population is at risk for short-term and long-term com-plications. early identification and correction of vaas may improve outcomes. however, multicenter, prospective studies are needed for developing optimal evidence-based treatment approaches. alexander glaros, roland chu, sureyya savasan, meera chitlur, madhvi rajpurkar, yaddanapudi ravindranath children's hospital of michigan, detroit, michigan, united states background: acute budd-chiari syndrome (bcs) is a rare thrombotic emergency in children, and etiologies/treatment are less well-defined than in adults. in adults, a systematic approach including anticoagulation, relief of venous obstruction, and treatment of the underlying cause has proven successful. more recently treatment has tilted towards aggressive surgical interventions, which carry significant risk and are often not feasible. objectives: review our experience with three different patients with bcs and suggest a mechanistic based approach to treatment. the records of three patients with bcs were reviewed and their presentations, etiologies, treatment, and outcomes were reported. results: patient a was a -year-old female with paroxysmal nocturnal hemoglobinuria who presented with recurrent worsening abdominal pain over several months. narrowing of inferior vena cava (ivc) and hepatic veins was noted on imaging. liver transplant was not considered surgically feasible. she was treated with eculizumab, steroids, and anticoagulation with restoration of hepatic venous flow in weeks. patient b was a -year-old male with several weeks of right upper quadrant pain, fatigue, and pre-syncopal episodes, with a history of blunt abdominal trauma from football scrimmage weeks earlier. he was found to have near complete occlusion of the ivc and hepatic veins. liver transplant was not considered feasible. he was successfully treated with anticoagulation alone. patient c was a -yearold male with acute myeloid leukemia in induction cycle who developed severe pancytopenia; typhlitis was diagnosed and managed medically. days later he acutely decompensated, arrested, and was placed on extra corporeal membrane oxygenation, and imaging showed complete occlusion of the portal vein, hepatic veins, and ivc to the level of the atrium, with bilateral pulmonary emboli. emergency liver transplant or catheter based interventions was deemed not feasible. treatment with eculizumab was considered for presumed inflammation induced complement activation (c mg/dl [normal - ]; ch was u/ml [normal - ]) as a trigger for thrombosis, but the patient progressed quickly and died before it could be initiated. our experience with bcs shows that invasive interventional options and liver transplant may not be feasible in most patients for multiple reasons. rapid diagnosis and aggressive etiology-based medical management are paramount to successful treatment of this rare complication. eculizumab may be considered in treating bcs with complement activation not only due to innate disorders, but also secondary to acute inflammation when proper laboratory evidence is present. background: platelet aggregation studies are the gold standard for the diagnosis of platelet function defects during the evaluation of a patient with bleeding problems. the platelet aggregation test measures how well platelets clot in response to different concentrations of epinephrine, adenosine diphosphate (adp), collagen, arachidonic acid and ristocetin. because platelet function defects are often under-recognized and under-diagnosed in the pediatric patient, the true incidence is unknown. we report our experience in the diagnosis of platelet defects at our institution over a -year period in order to add some clarity to the limited pediatric data available. objectives: our primary objective is to document correlations/trends between less well-known platelet function abnormalities and clinically significant bleeding at our institution over a -year period. design/method: after appropriate irb approval obtained, we performed a retrospective chart review of all children who had platelet aggregation testing done from to . data collected included demographics (age, sex, race), personal and family history of bleeding, screening for coagulation defects and platelet aggregation test results. symptoms examined in our data were limited to epistaxis and heavy menstrual periods. for each of these symptoms, results were further analyzed to those with abnormal responses to adp and epinephrine. patients with existing bleeding diagnoses and those with incomplete medical records were excluded. we identified patients. of the patients with epistaxis, % had abnormal platelet aggregation testing while only % of those with heavy menstrual periods had abnormal results. within our population, abnormal platelet function assay (pfa- ) results or race did not appear to correlate with abnormal platelet aggregation testing. in the cases of epistaxis, sex was also noncontributory. our preliminary results suggest that platelet aggregation testing was more useful in predicting platelet defects in those with a clinical bleeding history of epistaxis as opposed to heavy menstrual periods. for other presenting symptoms, platelet aggregation testing did not offer diagnostic benefit. abnormal response to adp in the platelet aggregation test was the most common finding in our population; the clinical significance of which is not well understood. going forward, we plan to document whether abnormal results correlated significantly with the subsequent final diagnoses of our patients. background: decision making for severe hemophilia a in previously untreated patients (pups) has recently become a significant ethical debate. recombinant factor viii (rfviii) products previously were recommended to avoid transmission of blood borne pathogens associated with plasma-derived fviii (pdfviii) products. however, the increased incidence of fviii alloantibody inhibitors with rfviii products compared to pdfviii products has challenged this former standard of care. despite the support of the medical and scientific advisory council, recommendations considering pdfviii products for a pup remains controversial. design/method: we used a modified utilitarian approach involving clinical, public health, and research ethics. shared decision making permeates the framework to maximize understanding, minimize bias, respect informed consent or dissent, and provide care that aligns with patient and family values when medically and practically feasible. the framework has three tiers. first, it evaluates whether resources are scarce or abundant for equitable resource allocation. if fviii products are scarce, we s of s recommend developing a central supply for emergency use and then evaluating the needs of the severe hemophilia a patients. prioritization of who receives the factor products would be decided by a designated team based on the availability of the factor products and clinical scenarios, with no preference given to those on research trials. however, if resources are abundant, treatment for acute bleeding and standard of care prophylaxis measures, including primary prophylaxis, could continue. the second tier accounts for whether there is a new infectious epidemic or concern where a pathogen cannot be eliminated. if there is, healthcare and public health workers may limit the use of pdfviii products. if not, pdfviii and rfviii products are to be equally considered. the third tier evaluates whether the clinical scenario is emergent or not. if there is acute, emergent bleeding, the immediately available resource should be used, along with bypassing and/or adjuvant resources as needed until the bleeding has resolved or improved. to align with patient and family preferences, attempts to have both pdfviii and rfviii products available at similar costs in institutions would be ideal. this ethical framework endeavors to balance autonomy, beneficence, nonmaleficence and justice in helping guide discussions among providers, pups with severe hemophilia a, and their families. disclaimer: findings and conclusions are those of the author(s) and do not necessarily represent the official position of the centers for disease control and prevention, emory university, or children's healthcare of atlanta. background: von willebrand disease (vwd) is a common bleeding disorder which affects up to % of the population without gender predilection. bleeding associated with this condition results from a deficiency or abnormality in von willebrand factor interfering with formation of primary hemostasis. ehlers-danlos syndrome (eds) is a group of rare inherited connective tissue disorders which may have an associated bleeding manifestation without abnormalities in coagulation testing. bleeding symptoms reported in eds result from capillary and tissue fragility. joint hypermobility syndrome (jhs) is an inherited condition which is nearly indistinguishable from eds iii. reports of coinheritance of vwd and eds or jhs are infrequent. the objective of this retrospective study was to review patients with coexisting vwd and eds or jhs at the indiana hemophilia and thrombosis center in order to describe the type and severity of bleeding symptoms, physical examination findings, and pertinent laboratory data. design/method: the electronic medical record database of the indiana hemophilia and thrombosis center was queried for patients with a diagnosis of vwd and one of the following descriptors: hypermobility syndrome, hypermobility, hypermobile joints, or ehlers-danlos syndrome. the records of identified patients were reviewed for demographics, type and severity of bleeding symptoms, beighton scores (bs), vwd antigen, ristocetin cofactor, factor viii levels, vwd multimer pattern, vwd subtype, genetic testing for eds, and family history of eds. results: a total of patients with dual diagnoses of vwd and eds and patients with vwd and hypermobility were identified with this query. two patients had completed genetic testing for eds, and one had a col a gene mutation identified. significant bleeding symptoms in the vwd and eds group included hematuria and postoperative hemorrhage. two of these patients had delayed wound healing postoperatively. seven of the patients identified to have type i vwd and jhs had moderately severe and somewhat unusual bleeding episodes reported including hematuria, hematemesis, and hemoptysis; of these patients had significant perioperative bleeding. females composed % of the vwd and eds group and % of the vwd and jhs group. conclusion: coinheritance of vwd and eds is an uncommon phenomenon. patients with vwd and eds or jhs may have atypical and moderately severe bleeding, especially with procedural intervention. incorporation of bs into the assessment of patients with bleeding disorders is useful to identify potential inherited collagen disorders, as diagnosis of these conditions may impact clinical management. in the year-long phase ii study (ro fd ), / khe patients responded. patients were followed for years after study completion, collecting data on growth and development, complications of therapy, unexpected toxicities, and need for continuing sirolimus. objectives: after study therapy treatment of one year, objectives include: . assess long term toxicity over the - year period after study therapy completion . assess unexpected toxicity . assess overall condition of the patient . assess need for restart or continuation of sirolimus therapy design/method: prospective follow-up of patients with a diagnosis of khe from institutions. inclusion criteria: follow-up for - years post-study. results: follow-up included data at year (n = ) and - . year (n = ) time points. average age at the start of treatment was months. of patients were available for follow up. four patients are no longer on sirolimus: one patient completed study therapy and remains off treatment (ot) ( years), required years of treatment and is now . years ot and required an additional treatment course prior to successful discontinuation now and months ot. of the patients still on sirolimus, all restarted medication for symptoms of pain, swelling and/or edema interfering with quality of life and have made an average of . attempts to discontinue sirolimus. no patient had reoccurrence of kmp. all patients had improvement in clinical and radiologic appearance of khe but all have residual lesions noted on imaging and/or clinical exam. no unexpected toxicity, growth delay, developmental issues or other long term toxicity of sirolimus was noted. conclusion: this is the first prospective data on long-term follow up of khe patients treated with sirolimus. although numbers are small, sirolimus is well tolerated; however, over half the patients were still on medication at - year follow up. this stresses the need for continued long term follow up in these young patients and investigation of the mechanism of sirolimus effect. nationwide children's hospital, columbus, ohio, united states background: recent studies have identified that adult persons with hemophilia (pwh) have a higher prevalence of hypertension and renal disease than the general population. while hematuria is a known complication of hemophilia a and b (ha, hb), its long-term impact on pwh is not currently known. by annually screening our patients with urinalysis, our pediatric center identified that just under half of our patients demonstrated hematuria over a four-year period. motivated by a desire to identify early markers of hypertension and renal disease, we sought to determine if this finding is reflected in the pediatric hemophilia population as a whole. objectives: establish the population-wide prevalence of hematuria in pediatric pwh. design/method: we used the pediatric health information system (phis) database, which contains clinical and resource utilization data for inpatients from hospitals nationwide, to analyze the prevalence of hematuria, hypertension, renal disease and related diagnosis codes in pediatric pwh who were admitted from january to september . results: during the five-year period, , unique pediatric pwh accounted for , admissions. while the majority of admissions were for bleeding or infectious concerns, ( . %) patients had an affiliated admission code for hematuria. for admissions as a whole, the median age was years with % of those admitted being infants, % toddlers, % children, % adolescents, % older than . we identified % of admissions were for ha with the remaining % were for hb. there were ( %) admits in which a bypassing agent was administered. the median length of stay for persons with hematuria was days compared to days for nonhematuria/other bleeding. there were ( . %) admissions with hypertension reported; though, only patients received an antihypertensive medication during that admission. additionally, only ( . %) admissions reported a diagnosis code of renal disease. our study demonstrated that pediatric pwh are experiencing hematuria. in general, only patients with persistent hematuria require hospital admission so we suspect this data underrepresents the numbers of pwh experiencing hematuria that is managed in the outpatient setting. we also suspect that hypertension is grossly underreported and undertreated in pediatric pwh. additionally, there are a low number of patients experiencing renal disease requiring hospital admission among this cohort. given that there is little research into the long-term impact of hematuria in hemophilia, we feel these findings support the need for further vigilance of our pediatric pwh. background: gla and gsd can aggressively destroy bone, with significant impact on morbidity and mortality. the mtor inhibitor, sirolimus has been shown to be effective in the treatment of these diseases. based on the addition of mtor inhibition to bisphosphonate therapy in metastatic cancer therapy, regimens have been used for refractory or high risk gla and gsd but there is heterogeneity of diagnosis, and variability of drug regimens and assessment of effectiveness. objectives: . assess the variability of clinical features of gla and gsd . assess the heterogeneity of diagnosis . assess drug regimens and response assessment across multiple institutions design/method: we conducted a retrospective review from institutions of cases of gla and gsd treated with sirolimus and a bisphosphonate for at least months with assessment of clinical features, treatment protocols, response regimens and side effects. results: patients included gla (n = ) and gsd (n = ). the average age at diagnosis was years. clinical features included effusions: gla (n = ), soft tissue lymphatic malformations: gla (n = ), gsd (n = ), multiple splenic lesions: gla (n = ), and soft tissue swelling at the site of bony lesion: gsd (n = ). the presenting symptom in patients was pain with patients (gla) presenting with shortness of breath. fracture was noted in patients: gla ( ), gsd ( ). diagnostic and/or response imaging included mri, ct, bone scan, skeletal survey and dexa scan. treatment consisted of: initial sirolimus use with the addition of bisphosphonate secondary to worsening disease (n = ), initial therapy with other agents (interferon, chemotherapeutic agents, radiation) and change to sirolimus and bisphosphonate secondary to toxicity (n = ), sirolimus and bisphosphonates (n = ) and sirolimus, bisphosphonates and interferon (n = ). seventeen patients had stable disease and patients had improvement of disease. sirolimus protocol was standard; however, bisphosphonate protocol varied in dosing and frequency. side effects were tolerable and expected with no grade iii or iv toxicity. sirolimus and bisphosphonates are a safe and effective therapy for gsd and gla. a consistent medication regimen, redefined response and an improved radiologic classification will be important for the development of a prospective clinical trial. background: hemophilia a is a bleeding disorder from the deficiency of clotting factor viii. the most significant sequelae of hemophilia a is the tendency to develop hemarthrosis that incites joint destruction. the prevalence of overweight and obesity has been increasing in the general and hemophilia population and leads to several morbidities including arthropathy. this is a particular concern for hemophilia a as arthropathy is a consequence of joint bleeding. objectives: the purpose of this study was to detect the relation between body mass index (bmi) and joint health endpoints in a pediatric hemophilia population. design/method: participants in this study included patients from the hemostasis and thrombosis center at children's hospital los angeles. participants were pre-screened and approached for this study during routine follow-up appointments. patients aged - years old who have been diagnosed with hemophilia a, including mild, moderate, and severe, qualified for the study. informed consent was obtained from the patients or parents before enrollment. joint health was objectively measured by physical therapists from children's hospital los angeles using the hemophilia joint health score (hjhs). an hjhs total score is calculated by assessing: swelling, duration of swelling, muscle atrophy, crepitus on motion, flexion loss, extension loss, joint pain, and muscle strength in major joints. subjective data was also obtained by patients recording their annual bleed rate within the past year. of the patients, ( %) were normal weight, ( %) overweight, and ( %) obese. we used chi-square analysis to compare joint scores across bmi classifications (chi square = . , df = , p-value = . ). although, this did not approach statistical significance, the average hjhs score in patients who had a hjhs > shows an increasing trend among bmi classifications: . in normal bmi patients, . in overweight bmi patients, and . in obese bmi patients. the average number of annual bleeds in those with positive values show: in normal bmi patients, in overweight bmi patients, and in obese bmi patients. although a positive effect of adiposity was found in the joints of hemophilia a pediatric patients, the effect shows there was not enough evidence to conclude a difference. future studies are needed to address whether obesity has an effect on hemophilia and to determine whether overweight/obesity can lead to further complications in hemophilic joints. background: stagnant blood flow in slow-flow vascular malformations (vm), particularly in their venous components, can lead to localized intravascular coagulation (lic) that is characterized by elevated d-dimer levels, low fibrinogen and decreased platelet count this coagulation derangement can lead to localized thrombosis or bleeding which can result in pain, functional limitations, and possible progression to disseminated intravascular coagulopathy (dic). the treatment of vm and their associated coagulopathy has proven difficult. patients with complex vm are frequently managed with sirolimus, an mtor inhibitor, and have clinical benefits, including reduction of pain and improvement in functional impairment. it is possible that some of these improvements from sirolimus could be secondary to improvement in the coexisting lic. objectives: this study assessed the use of sirolimus to manage the coagulopathy seen in slow-flow vm. design/method: we reviewed charts of patients with vm who are followed in the vascular anomalies center at arkansas children's hospital and were started on sirolimus. efficacy was objectively assessed through improvement of ddimer, fibrinogen and platelet count. three sets of lab values (pre-sirolimus, - months post-sirolimus, and most recent) were obtained for each patient when available. we identified a total of patients who had been prescribed sirolimus. eighteen were excluded based on underlying condition other than slow-flow vascular malformation and for inadequate medical records. a total of patients ( combined vascular, venous) were included in the study. all had elevated d-dimer levels (mean . mcg/ml feu, median . mcg/ml feu, range ( . - . )) prior to treatment. two patients had an associated low fibrinogen (below mg/dl), indicating severe lic. with treatment, ( . %) patients showed an overall decrease in d-dimer levels with an average decrease of . mcg/ml feu between pre-and post-sirolimus labs, and an average decrease of . mcg/ml feu between pre-sirolimus and most recent values. the two patients with low fibrinogen prior to treatment showed a decrease in d-dimer levels (mean decrease of . mcg/ml feu) and an increase and normalization in fibrinogen (mean increase . mg/dl) after beginning sirolimus. no patient had thrombocytopenia. we report that treatment with sirolimus was effective in improving coagulopathy associated with slowflow vm as evidenced by decreased d-dimer levels and increased fibrinogen and/or platelets. long-term use of this medication in this population may decrease the bleeding and thrombotic complications that these patients experience, especially following invasive vascular procedures. background: safety and efficacy of bay - , a sitespecifically pegylated b-domain-deleted recombinant factor viii, in previously treated adolescents and adults aged - years with severe hemophilia a was demonstrated in the phase / protect viii study and ongoing extension. objectives: this subanalysis examines the efficacy and safety of bay - in adolescents in protect viii and the ongoing extension study (data cutoff, january ). design/method: in protect viii, patients (including adolescents) received bay - on demand or as prophylaxis for weeks. prophylaxis regimens for weeks - were twice-weekly ( - iu/kg), every- -days ( - iu/kg), or once-weekly ( iu/kg) infusions based on bleeding during a -week run-in period of iu/kg twice-weekly prophylaxis. patients continued their prophylaxis regimens in the extension or changed regimens at any time. results: twelve patients aged - years were included in the protect viii intent-to-treat population; s of s additional patient discontinued after dose (included in safety population). for patients receiving prophylaxis before study enrollment, median (range) number of total and joint bleeds in the months before study entry was . ( - ) and . ( - ), respectively. ten patients ( . %) had target joints at baseline (median [range], [ - ] per patient). during weeks - of protect viii for the entire time patients remained on their designated prophylaxis dosing frequency, the median (quartile [q] ; q ) annualized bleeding rate (abr) for patients receiving twice-weekly (n = ), every- -days (n = ), and once-weekly prophylaxis (n = ) was ( ; . ), . ( ; . ), and . ( ; . ), respectively (overall prophylaxis [n = ], . [ . ; . ]). two patients switched from once-weekly to twice-weekly (n = ) or every- -days prophylaxis (n = ), and number of bleeds decreased from to in one patient and to in the other. all patients from the main study continued in the extension; mean abr in the extension was . and varied by dosing regimen (twice weekly [n = ], . ; every days [n = ], . ; once weekly [n = ], . ). two patients changed from every- -days to once-weekly prophylaxis during extension (mean abr, . ). one patient had a nonneutralizing antibody to bay - at baseline; end-of-study titers were negative. no patient developed anti-peg antibodies or factor viii inhibitors or experienced a serious adverse event related to bay - during the main study or extension. in previously treated adolescents with severe hemophilia a, bay - prophylaxis was effective in prevention of bleeds, with less bleeding overall versus prestudy, and was generally well tolerated. funded by bayer. cincinnati children's hospital medical center, cincinnati, ohio, united states background: vascular malformations (vms) consist of a heterogeneous group of congenital disorders characterized by the abnormal development of blood and/or lymphatic vessels, which cause a broad spectrum of clinical manifestations. although considered benign, vms are frequently associated with cutaneous complications that can cause significant morbidity such as nodular overgrowth, skin thickening, pruritus, oozing or bleeding of lymphatic blebs and secondary infection. oral sirolimus has shown to be effective in the treatment of complicated vascular malformations but has known side effects and need for frequent laboratory monitoring. currently, there are limited studies on the use of topical sirolimus for the treatment of cutaneous manifestations of vascular malformations. objectives: to evaluate the efficacy and safety of topical sirolimus in vms with cutaneous complications and propose indications for use. design/method: this is a retrospective review of medical records of patients with vascular malformations treated with topical sirolimus from january to december . response was determined by subjective and objective improvement. results: twenty-four patients, ( %) females and ( %) males, with vascular malformations and cutaneous manifestations were treated with topical sirolimus. age ranged from - years. indications for treatment were: blebs ( %, n = ) causing either leaking, bleeding, pain, pruritus, swelling or recurrent infection; nodular overgrowth % (n = ); pyogenic granuloma % (n = ); bleeding % (n = ) and cosmetic % (n = ). treatment course ranged from - months. no major side effects were reported. one patient reported burning and itching sensation. regarding clinical response: % (n = ) patients had improvement in cutaneous lesions; % (n = ) had a stable lesions; and % (n = ) stopped treatment due to side effects. for prior/concomitant treatment: % (n = ) had prior surgery, laser or sclerotherapy; % (n = ) had concomitant oral sirolimus. of the patients not receiving concomitant systemic sirolimus, only % (n = / ) had been on oral sirolimus. of these patients, % (n = / ) had a very good response to topical treatment. : topical sirolimus appears to be beneficial and well-tolerated with a minimal side effect profile for the treatment of cutaneous manifestations of vascular malformations as a single agent or as adjuvant therapy with systemic sirolimus when symptoms are not adequately controlled. further studies are needed to prospectively analyze efficacy and safety of topical sirolimus in this patient population. objectives: to evaluate the safety and efficacy of long-term romiplostim in children with itp. design/method: all patients received weekly sc romiplostim from - g/kg to target platelet counts of - × ( )/l. median (min-max) treatment for the patients was ( - ) weeks for a total of patient-years, or . years per patient. at baseline, median (min-max) age was ( - ) years; % were female; . % had prior splenectomy. median (min-max) average weekly dose was . ( . - . ) g/kg, including escalation to a stable dose; patients started on g/kg. reasons for discontinuing romiplostim (n = , %) included consent withdrawn (n = ), required other therapy (n = ), and ae (n = ) (asthenia, headache, dehydration, and vomiting in one patient and anxiety in the other; none treatment related). fifty four serious aes occurred in patients but were treatment related in one (concurrent grade thrombocytopenia, grade epistaxis, and grade anemia). anti-romiplostim neutralizing antibodies were detected in one patient who discontinued to receive other therapy; antibodies were absent on retesting. from week on, median platelet counts remained > × ( )/l; median platelet counts were > × ( )/l from weeks - . nearly all ( %, / ) patients had ≥ platelet response (platelet counts ≥ × ( )/l, excluding ≤ weeks after rescue medication). most ( %, / ) patients had a platelet response ≥ % of the time and % ( / ) did ≥ % of the time. sixty ( %) patients (or caregivers) self-administered romiplostim. fifteen ( %) patients had treatment-free periods of platelet counts ≥ × ( )/l for ≥ weeks (ie, remission); these patients ( girls, boys) had had itp for a median (min-max) of . ( . - ) years, none had prior splenectomy, and had received romiplostim for . ( . - ) years. all had platelet counts > × ( )/l for ≥ months and / for ≥ months; the median (min-max) duration of being ≥ × ( )/l was ( - ) weeks. of baseline characteristics such as sex, platelet counts, itp duration, and number of past itp treatments ( , , , > ), only age < years was predictive of developing treatment-free periods ≥ weeks (p = . ). in this seven-year open-label extension, > % of children with itp achieved a platelet response and romiplostim was well tolerated. importantly, % of patients were able to discontinue all itp medications for ≥ months. funded by amgen inc. background: sirolimus is an immunosuppressive drug that is widely used in solid organ and bone marrow transplantation, and more recently for the treatment of vascular and lymphatic anomalies. sirolimus has been associated with decreased immunity in the transplant setting in patients that have received other immunosuppressive drugs or were immunosuppressed from previous chemotherapy. the effects of sirolimus on the immune system in chemotherapy naïve children who have not received other immunosuppressive agents are not well understood, and there is variability in the approach to fever and pcp prophylaxis. to understand the effects of sirolimus on the immune system of patients with non-complicated vascular or lymphatic anomalies by evaluating anc, alc prior to and after sirolimus therapy. design/method: multi-institutional retrospective review was done to include patients with non-complicated vascular or lymphatic anomalies. those with effusions/ascites, multiorgan involvement, or history of vascular-anomaly-related infections prior to treatment were excluded. results: twenty patients with kaposiform hemangioendothelioma (n = ), generalized lymphatic anomaly (n = ), cloves syndrome ( ), and simple vascular malformation (n = ) were included. age at initiation of sirolimus treatment ranged from . - years. male to female ratio was : . sirolimus was initiated due to extensive disease, lack of response to steroids or bisphosphonates, pain, dment, lymphatic drainage, and prevention of ongoing overgrowth. prior to the start of sirolimus (sir- ) the mean anc was and alc was . the target level of sirolimus varied by indication and patient, and ranged from to . after the st steady state level, month after sirolimus (sir- ) the mean anc decreased to and alc was . at months after sirolimus (sir- ) the mean anc was and alc was . the first sirolimus levels (sir- ) mean was . ; and sir- level was . . nine patients were placed on pcp prophylaxis at the start of sirolimus. none of these patients had an infectious complication while on sirolimus at a median f/u of months. one patient had mild neutropenia (anc > ) which normalized after discontinuation of pjp prophylaxis. conclusion: in this small cohort of patients we found that the anc and alc level in patients with non-complicated vascular or lymphatic anomalies at sir- was not different from the sir- or sir- . prospective studies that specifically track anc, alc, igg, and lymphocyte function should be conducted to better understand the effects of sirolimus in the immune system. this data will allow for uniform recommendations regarding prophylaxis and management of febrile episodes. background: acute infections and the associated systemic inflammation can increase the risk of venous thromboembolism (vte) and in certain well-defined clinical scenarios may be the primary trigger of vte in pediatric patients. pediatric data on vte in the setting of acute infection are sparse. objectives: to describe characteristics and outcomes of vte in pediatric patients with acute infections. we conducted a retrospective chart review of all pediatric patients with objectively confirmed vte treated at our institution since and identified all patients in whom an acute infection was identified as a vte trigger. patients were managed according to standardized institutional protocols based on published guidelines. relevant demographic, clinical and laboratory data were collected and summarized using descriptive statistics. since , acute infection was identified as a trigger in of vtes ( %) diagnosed at our center. the median age at time of vte diagnosis in this group was . years (interquartile range . - ). males were more commonly affected than females, representing % of cases. neonatal vte events accounted for % of cases. sepsis was the most common acute infection to be identified as a vte trigger [ / cases ( %)]. most vte events ( %) associated with acute infections were considered hospital-associated vtes. at time of vte diagnosis, % of patients were critically ill. extensive vte (defined as completely occlusive thrombosis involving > venous segment) occurred in % of patients. acute infection was deemed to be the primary trigger for vte in / patients ( %). infection-associated vtes in this cohort included cerebral sinus venous thrombosis due to sinus or cns infection ( patients, %), septic throm-bophlebitis ( patients, %), lemierre's or lemierre's-like syndrome ( patients, %) and osteomyelitis-associated deep vein thrombosis ( patients, %). systemic anticoagulation was prescribed in / patients ( %). anticoagulationrelated major bleeding occurred in / patients ( %). vte complications included vte recurrence ( patients, %), vte progression ( patient), acute pulmonary embolism ( patients) and arterial ischemic stroke ( patients). our study indicates that acute infection is a common risk factor for pediatric vte, especially in critically ill children, and can be the primary trigger in a significant proportion of vte cases associated with acute infections. anticoagulation appeared to be overall safe in this population and was associated with low rates of serious vte-related acute complications. however, our study also suggests that this population may be at increased risk for vte recurrence and anticoagulation-related major bleeding. background: epithelioid hemangiomas (eh) are rare benign vascular tumors that occur in soft tissues and bone and present between the third and sixth decades of life. a subset ( %) of eh harbor fos rearrangement. eh has been described in children, but little is known about the long-term outcomes of pediatric eh. the main objective is to obtain data to be used for improved understanding of this rare disease in order to provide standardization of care and development of future research studies. board-approved retrospective review of clinical, pathologic, and radiographic characteristics, and treatment outcomes in patients diagnosed with eh between and . results: eight patients were male; mean age at diagnosis was . years (range: - ). lesions involved the lower extremities (n = ), cranium (n = ), pelvis (n = ), and spine (n = ). multifocal disease was identified in five patients. the most common presentations involved significant localized pain and neurologic symptoms: headache, cranial nerve injury, loss of consciousness. radiographic studies identified variable features, such as multifocal lytic bony lesions with sclerotic margins, enhancing soft tissue component, and surrounding inflammatory edema. histologically, all specimens were composed of vascular channels lined by epithelioid endothelial cells without significant cytologic atypia; solid cellular areas (n = ). endothelial cells were positive for cd and egr, and negative for camta . fos rearrangement was assessed in only one specimen and detected. mean follow-up time was days (range: - ). patients were treated with surgical resection, intravascular embolization, bisphosphonates, propranolol, interferon, and sirolimus. one patient treated with interferon and one with sirolimus exhibited partial response for mean follow-up of . days. although eh is a benign neoplasm, it is difficult to manage without standard protocols and portends considerable morbidity. our findings suggest medical management, particularly sirolimus, may benefit these patients; however, long-term follow-up is needed in treated children. novel fos inhibitors are in development and may benefit patients with fos rearrangement. penn state health children's hospital, hershey, pennsylvania, united states background: central venous catheters (cvc) are often required in critical care settings in order to provide a secure point of access for life sustaining care. clinical studies identify cvc presence as the single most important risk factor for deep vein thrombosis (dvt) in children. venous thromboembolic event (vte) incidence rates in critically ill children with a cvc range from . - % and . - . per catheter days depending on the population studied. per institutional protocol, the penn state health children's hospital picu (hershey, pa) utilizes a low dose continuous infusion of unfractionated heparin (ldufh) at units/kg/hr as prophylaxis against cvc-related vte and to maintain line patency. the efficacy of this approach has never been evaluated. to determine if ldufh for prophylaxis results in lower incidence of cvc-related vte, catheter dysfunction and central line associated blood stream infection (clabsi) without increasing morbidities. to determine if the incidence of catheter related vte is lower than historical published data, a retrospective chart review was conducted utilizing the institutional electronic medical record for all patients in , aged - . years, who had a cvc during a picu admission. secondary objectives such as the incidence of catheter dysfunction, clabsi, and any associated bleeding complications are also being analyzed. results: interim data analysis revealed cvcs ( nontunneled cvc, totally implantable devices, tunneled lines, peripherally inserted central catheters [picc] ) in total patients with a median age of . years. overall vte incidence was . % ( / ) with vtes associated with non-tunneled cvc and with piccs. sixty one percent of non-tunneled cvcs received ldufh and % ( / ) of the patients with vtes associated with non-tunneled cvcs did receive ldufh prophylaxis. vte incidence rate of nontunneled cvcs with ldufh was . % ( / ) and . per picu catheter days. the only other vte events identified within our study cohort were in the picc group where two patients experienced vte, one of which was receiving ldufh. clabsi incidence was . % ( non-tunneled cvc, tunnel cvc, picc). no major bleeding complications were associated with ldufh. preliminary data demonstrates ldufh is efficacious in preventing cvc-related vte in comparison to published reports. further analysis will compare another similar sized and acuity level picu which does not practice the same method. background: fibroadipose vascular anomaly (fava) is a rare, challenging disorder associated with pik ca mutations. fava often causes painful replacement of muscle and soft tissues with fibrotic and adipose tissue and is associated with ectatic draining veins. treatments for focal lesions are surgical excision, cryoablation or sclerotherapy and the role of medical therapy is unclear. some fava lesions are too extensive or directly involve neurovascular structure, resulting in refractory pain. objectives: to retrospectively evaluate the efficacy of sirolimus in patient with residual symptoms after procedural therapies for fava design/method: retrospective review of individual cases from institutions of fava refractory to other therapies treated with sirolimus for at least months. cases were s of s identified by polling member of the aspho vascular anomalies special interest group. results: all seven patients report improvement on sirolimus therapy. all patients had received prior procedures, including sclerotherapy ( patients), cryoablation ( patients) and/or resection ( patients). mean age at sirolimus initiation was y (range - y). mean length of therapy is . months (range - months). six patients were treated with bid dosing and one adult received daily dosing. goals of sirolimus were improvement in pain or musculoskeletal dysfunction. pain and function improved in all patients, including discontinuation of narcotic use and resumption of participation in sports. time to symptom improvement ranged from - weeks. in four patients for whom dose was lowered, pain recurred in all four and responded to restarting or increasing sirolimus dose. while all patients do not have pre-and postsirolimus imaging, decrease in fava lesion size is seen in cases with available imaging. sirolimus side effects are similar to prior reports, most commonly mouth sores, elevated lipids and acne. we report the first known data supporting a role of sirolimus in refractory fava cases. sirolimus is welltolerated and initial improvement is rapid, within weeks of initiation. whether sirolimus has a role in upfront therapy to reduce lesion size prior to procedures deserves further study. objectives: to assess platelet responses in children with itp receiving romiplostim. design/method: eligible children had itp for ≥ months, ≥ prior therapy, and screening platelet counts ≤ × ( )/l or uncontrolled bleeding. weekly dosing was from - g/kg to target platelet counts of - × ( )/l. bone marrow biopsies were evaluated in europe at baseline and after or years (cohorts and ). as of mar , patients received ≥ dose. at baseline, median (min-max) age was ( - ) years, itp duration was . ( . - . ) years, and platelet count was ( - ) × ( )/l; patients ( %) had had prior splenectomy. the median (q , q ) % time with a platelet response (platelet count ≥ × ( )/l, no rescue medications past weeks) in months - was % ( %, %) (primary endpoint). over the course of the study, % ( / ) of patients had a platelet response. four patients maintained platelet counts ≥ × ( )/l with no itp medications for ≥ weeks. median (min-max) treatment duration was ( - ) weeks for patient-years in total. median (min-max) average weekly romiplostim dose over the course of the study was . ( . - . ) g/kg; the median dose was g/kg at year (n = ) and g/kg at years (n = ). most ( %) patients initiated self-administration. sixty-four patients ( %) discontinued treatment, most frequently for lack of efficacy (n = ), patient request (n = ), and adverse event (ae) (n = ). fortyone ( %) patients had serious aes (saes) including epistaxis ( %) and decreased platelet count ( %). five patients had treatment-related saes: headaches, abdominal pain, and each of presyncope and neutralizing antibodies (ab). there were cases of neutralizing ab to romiplostim (of patients tested), but none to tpo; / had continued elevated platelet counts and in / cases ab were not found on retesting. for cohort , of patients with baseline bone marrow biopsies, had evaluable on-study biopsies scheduled for year; patient had an increase from grade to . there were no findings of collagen or abnormalities. in this interim datacut of a romiplostim openlabel study in children with itp, % of children had a platelet response. overall, the median dose was . g/kg; the median romiplostim dose over time reached g/kg. no new safety signals were observed over patient-years. funded by amgen inc. background: hepatic hemangiomas are benign vascular tumors without a medical home, managed by multiple specialties. the diagnosis has been assigned historically to various vascular lesions affecting the liver with completely different clinical presentations, resulting in difficult standardized management. objectives: the consensus steering committee identified an acute need of clear definitions and evaluation guidelines using the updated international society for the study of vascular anomalies (issva) classification. the goal was to formulate recommendations that will be adopted by all specialties involved in the care of children with hepatic hemangiomas. design/method: we used a rigorous, transparent consensus protocol, with input from multiple pediatric experts in vascular anomalies from hematology-oncology, surgery, pathology, radiology and gastroenterology. in the first section, we precisely define the subtypes of hepatic hemangiomas seen in children (congenital and infantile) using clinical course, histology and radiologic characteristics. inclusion and exclusion limits to the diagnosis are noted. the following two sections describe these subtypes in further detail, including complications to be considered during monitoring and respectively recommended screening evaluations. conclusion: while institutional variations may exist for specific clinical details, a clear understanding of the diagnosis of hepatic hemangiomas affecting the pediatric population and the possible complications that require screening during the monitoring period should be standard. as patients with hepatic hemangiomas are managed by different medical and surgical specialties, a multidisciplinary consensus based on current literature, on the data extracted from the liver hemangioma registry and on expert opinion was required and was accomplished by this manuscript. objectives: to investigate the association between routine prophylaxis with bay - and bleeding outcomes after adjusting for key patient and pharmacokinetic (pk) characteristics. design/method: the leopold kids study evaluated safety and efficacy of bay - prophylaxis in previously treated boys aged ≤ years with severe hemophilia a. patients received bay - - iu/kg x/wk (n = ) or > x/wk (n = ) and were followed up for - months. prophylaxis dose and frequency were assigned by investigators. pk parameters, including area under the curve (auc), half-life, and clearance, were derived from a population pk model and reflect predicted pk values with a -iu/kg dose. patient characteristics were compared between the x/wk and > x/wk groups using wilcoxon rank sum or chi-square tests. negative binomial regression was used to model the association between prophylaxis frequency and annualized bleeding rate (abr) for total bleeds, first without adjustment and then adjusting for age, pk parameters, and bleed history. results: mean ± sd age for patients in this analysis was . ± . years. patients receiving prophylaxis x/wk had more bleeding episodes in the months before study entry (mean ± sd, . ± . [median, . ] for x/wk vs . ± . [ . ] for > x/wk; p = . ) and were more likely to have been treated on demand ( % vs %; p = . ). pk parameters were similar between the x/wk and > x/wk groups. without adjustments, abr during the study was % higher in the x/wk group compared with the > x/wk group (rate ratio [rr], . ; % ci, . - . ; p = . ). abr was % lower in the x/wk group (rr, . ; % ci, . - . ; p = . ) after adjusting for age, auc, and number of bleeds in the prior months. conclusion: abr was numerically lower but not significantly different between the x/wk and > x/wk groups after adjusting for age and pk parameters. these findings suggest that even among patient groups that are homogeneous with respect to age, pk, and bleed history, further individualization of bay - prophylaxis based on other characteristics may help reduce bleeding episodes even at a lower treatment frequency. larger real-world studies are needed to verify these findings. funded by bayer. stanford, palo alto, california, united states s of s background: vascular malformations may be of lymphatic, arterial, venous or capillary endothelial origin. they may be simple or complex, with complex malformations being a combination soft tissue and skeletal overgrowth. although likely present at birth, these malformations often become symptomatic with puberty or infection, and range from little or no clinical impact to life threatening symptoms. in malformations primarily of venous origin, pain may be significant and hypothesized to be caused by phlebolith development (intra-malformation thrombi), inflammation, consumptive coagulopathy, vascular engorgement, and endothelial proliferation. anti-angiogenic and anti-platelet therapies have been reported to relieve pain. however, the use of anticoagulation for pain is not well described. objectives: to report clinical features and outcomes of patients with vascular malformations of venous origin treated with anticoagulation for pain. we performed a retrospective review of patients with vascular malformations followed by the hematology service between january and december who were treated for pain with anticoagulation. pain relief was determined both by wong-baker pain scales and patient report. clinical data were extracted from electronic medical records. we identified five patients with venous malformations (vm) who had received anticoagulation for pain. four patients were female and median age was years old (range to years old) at time of initiation of anticoagulation. all five patients had vm of the extremity, two with vm of the lower extremity, and three patients had vm of the upper extremity. two patients had concomitant coagulopathy and demonstrated decreased d-dimer after initiation of anticoagulation. four patients received enoxaparin, and one adult patient received rivaroxaban. all patients reported improvement in pain after administration of anticoagulation. one patient exhibited mild epistaxis and bruising at the injection site. there was no significant bleeding or other complications. pain is a significant complication in patients with venous malformations. our case series suggests that anticoagulation is a safe and effective therapy for pain relief in this population. further investigation is indicated to compare the effect of anticoagulation to other therapeutic interventions such sclerotherapy, surgery, and sirolimus in the treatment of pain associated with venous malformation. maria ahmad-nabi, christine knoll, sanjay shah, lucia mirea phoenix children's hospital, phoenix, arizona, united states background: estimates of the incidence of dvt in patients with osteomyelitis range widely from %- %, however risk factors and outcomes of dvt in this cohort have not been thoroughly established. objectives: this study aims to estimate the incidence of dvt in patients with osteomyelitis, and to assess risk factors and outcomes of dvt in this cohort. design/method: after irb approval, a retrospective chart review was conducted for patients aged - years seen at phoenix children's hospital between - with icd / codes for osteomyelitis. exclusion criteria included chronic recurrent multifocal osteomyelitis, and chronic dvt. demographics, clinical factors and outcomes were compared between osteomyelitis patients with and without dvt using the fisher-exact and wilcoxon-rank sum tests, as appropriate for the data distribution. results: a total of study subjects with osteomyelitis had a mean (standard deviation) age of . ( . ) years. dvt was present in ( % of ) patients, and ( %), ( %) and ( %) patients received anticoagulation for < , - and ≥ weeks, respectively. patients with vs without dvt were more likely to be male ( % vs %; p-value = . ), and had significantly higher rates of bacteremia ( % vs %; p-value = . ). rates of central lines were comparable between dvt and non-dvt patients ( % vs %; p-value = . ); however patients with dvt vs without dvt had significantly longer mean length of stay ( vs days; p-value < . ) and higher rates of icu admission ( % vs %; p-value < . ). the incidence of dvt among osteomyelitis pediatric patients was estimated at %, with risk increased by male sex and bacteremia. patients with dvt had significantly higher rates of icu admission and longer length of hospital stay. many of these patients had standard practice management of their dvt with - weeks of anticoagulation. our data highlights the need for recognition of high risk patients, and the need for future efforts targeting dvt prophylaxis. baylor college of medicine, houston, texas, united states background: lymphatic malformations (lm) frequently occur in the head and neck and can often be disfiguring and even life-threatening. management options include observation, surgery, sclerotherapy, and sirolimus. the optimal sequence of therapeutic interventions has not been determined due to the lack of comparative clinical trials or established guidelines. thus, prenatal planning with a multidisciplinary team is beneficial. we present a case series of ten children with head and neck lms evaluated in at our multidisciplinary vascular anomalies center. a chart review was performed to assess treatment modalities and recent trends. results: seven of patients ( %) with head and neck lms were diagnosed prenatally. six patients required an ex utero intrapartum treatment procedure. all patients were started on sirolimus at a median age of . months (range days - years). four patients most recently started on sirolimus were less than months of age at the time of initiation. six patients underwent partial excision of lm during the first year of life; none of whom received sirolimus prior to surgery. sirolimus was discontinued in one patient given chronic clostridium difficile infections, and non-compliance in another patient. five patients received sclerotherapy. tracheostomy was necessary in six patients; one patient was de-cannulated after months on sirolimus. all patients have had radiographic and clinical improvement of lm with varying treatment modalities. current clinical observations show improved response with sirolimus and demonstrate tolerability of sirolimus at a young age. conclusion: treatment of pediatric head and neck lms is challenging and a multidisciplinary approach is necessary. as the majority of patients are diagnosed prenatally, prenatal planning and discussion of potential use of sirolimus is beneficial. availability of vascular anomalies experts in the prenatal/neonatal period offers the best management results, and early initiation of sirolimus should be considered for complex lesions. long-term follow up is warranted to investigate the efficacy and timing of treatment options. yale school of medicine, new haven, connecticut, united states background: to mitigate transfusion of pathogencontaminated platelets, amotosalen, a synthetic psoralen compound, is added to sdp components. exposure to uv-a light activates amotosalen and crosslinks dna/rna base pairs, preventing replication of a broad spectrum of viral, bacterial, and other pathogens that may contaminate platelets. pr-sdps were fda approved for clinical use with no age restrictions in . we initiated use of pr-sdps in november of for all patients. we retrospectively analyzed usage of pr-sdp vs conventional (non-pr) platelets (cp) in neonatal and pediatric patients with thrombocytopenia to compare hemostatic efficacy and the incidence of transfusion reactions (tr) for these products, after one year of a dual platelet inventory. design/method: since pr-sdp were fda-licensed, no irb approval was required; pr-sdp and cp were both considered standard of care. we evaluated transfusions for all pediatric patients age - years who received any platelet transfusion between november and november . we determined the volume (mean ml ± sd) of each type of platelet component transfused, the number of platelet transfusion episodes, and reported trs based on cdc hemovigilance guidelines. a subgroup analysis was performed for thrombocytopenic neonates ( - months). results: patients - years who received only cps (n = ) received a total of , ml of platelets ( ± ml/patient) over transfusions ( . ± . episodes/patient). for comparison, in patients who received only pr-sdp, a total of , ml of platelets ( ± ml/patient, p = . ) were infused over transfusions ( . ± . episodes/patient, p = . ). for neonates ( - months, n = ) who received only cps, , ml of cps ( ± ml/ patient) were transfused over episodes ( . ± . episodes/patient). for comparison, those who received only pr-sdp (n = ), received , ml of pr-sdp ( ± ml/patient, p = . ), transfused over episodes ( . ± . episodes/patient, p = . ). for all recipients - years (n = ), including additional patients who received both cp and pr-sdp, there were three reported allergic trs over transfusion episodes, while no allergic reactions were reported with pr-sdp transfusions. one febrile tr was reported to cp transfusion, while three were reported for pr-sdp. in conclusion, pr-sdps, in our pediatric population age - years, were comparable to cp products in regards to volume and episodes of platelet transfusions, and incidence/type of transfusion reactions. pr-sdp were safe and effective for use in this pediatric patient population. background: vascular anomalies are classified as either vascular tumors or vascular malformations. fibro-adipose vascular anomaly (fava) is a newly described entity which presents with distinct clinical, radiographic and histopathologic findings. we present a case in which the diagnosis of fava was complicated by a persistent low platelet count secondary to immune thrombocytopenia (itp). to describe a challenging diagnosis of a novel vascular anomaly (fava) complicated by severe thrombocytopenia. a year old male presented to hospital with bruising and left thigh pain related to a remote sports injury. blood work revealed a platelet count of × /l, but with an otherwise normal complete blood count. the following were also normal: aptt and fibrinogen; d dimer levels were slightly increased. he was treated with one dose of ivig ( . mg/kg) for presumed itp and responded well with his platelet count increasing to × /l. he returned to hospital weeks later with recurrent thrombocytopenia and worsening leg pain. an ultrasound of the left thigh revealed a . cm x . cm x . cm lesion within the vastus medialis. the diagnosis of an intramuscular hematoma secondary to persistent thrombocytopenia was made. the patient presented with multiple episodes of thrombocytopenia over the next several months. his itp did not respond to oral prednisone ( mg/day for days). he continued to have short-lived responses to ivig requiring infusions every other week as his platelet count would fall below × /l. his leg pain progressed, restricting him to a wheelchair. further imaging by mri brought into question the diagnosis of a hematoma and a biopsy of the thigh lesion was performed. the results were consistent with a diagnosis of fava; this was subsequently excised. conclusion: this is a unique case where a vascular anomaly was misdiagnosed as a hematoma due to a patient's persistent thrombocytopenia and history of an injury. fava is a newer entity which, unlike other vascular anomalies, has not been linked to thrombocytopenia or a localized consumptive coagulopathy. after excision of the fava, the patient's chronic pain, and mobility resolved, though his itp persisted. objectives: this preliminary, exploratory analysis of realworld administrative data was conducted to determine units dispensed and factor replacement product-related direct expenditures associated with a currently marketed shl or ehl rfix product. design/method: de-identified claims data from the commercially available truven health marketscan® research u.s. claims database were used to identify direct expenditures and number of international units (ius) dispensed for all patients aged - years with a diagnosis code of icd- . /icd- d who used nonacog alfa or eftrenonacog alfa during the study period (june , to july , ). reference weight measurements from the centers for disease control and prevention national center for health statistics' (cdc nchs) anthropometric data were used to estimate product dispensation on an iu per kg basis. the nonacog alfa and eftrenonacog groups comprised and patients, respectively. the median [iqr] age in the two groups was . [ . ] and . [ . ] years, respectively. while of the patients in the eftrenonacog alfa group had > calendar quarter of available data, only of the patients in the nonacog alfa group had > available quarter. the median rfix product dispensation per quarter was , ius (iqr, , ius) in the nonacog alfa group and , ius (iqr, , ius) in the eftrenonacog alfa group. incorporating attributed weight values, the median rfix product iu dispensation per kg per week was . iu/kg/wk (iqr, . iu/kg/wk- . iu/kg/wk) in the nonacog alfa group, and . iu/kg/wk (iqr, . - . iu/kg/wk) in the eftrenonacog alfa group. applying wac prices (eftrenonacog alfa = $ . /iu; nonacog alfa = $ . /iu), the calculated estimates of $/kg/week were $ and $ in the nonacog alfa and eftranonacog alfa groups, respectively. conclusion: preliminary real-world data derived from a large u.s. claims database revealed differences in product dispensation and factor product-related expenditures among pediatric patients with any severity of hemophilia b to whom an shl or ehl rfix product was prescribed. refinements of these data, potentially to exclude instances of sporadic usage, may shed light on real-world dispensation of rfix products among pediatric hemophilia b patients. background: vascular malformations can be classified as simple (including capillary, venous, lymphatic, arteriovenous), combined, malformations of major named vessels or associated with other anomalies. multiple modalities including laser treatments, sclerotherapy, embolization, surgery and pharmacological intervention (with mtor inhibitors like sirolimus) have been used for treatment of vascular malformations. these interventions have been used alone or in combination with varied outcomes. we present our institution's experience with a multimodal approach to simple and combined vascular malformations. design/method: we performed a retrospective chart review of patients with vascular malformations who were referred to our center for an interventional radiology evaluation from june -july . we included patients (age at presentation: months - years), referred initially for interventional radiology procedures (irp) for vascular malformations. all patients had symptoms of pain and/or swelling/deformity. diagnosis of was based on vascular imaging (doppler ultrasound, mri/a/v). nine patients had venous malformations (vm), five had macrocystic lymphatic malformations (lm), six had lymphatic-venous malformations (lvm), and two arteriovenous malformations (avm). patients initially underwent interventional radiology procedures. all the vm patients responded to sclerotherapy alone. three patients with lm responded to sclerotherapy alone, remainder required surgical intervention. one avm patient responded well to embolization, the other needed surgical resection after embolization. four lvm patients underwent irp with minimal improvement in symptoms ( - procedures attempted), surgical resection was attempted in patients with poor response and patients were started on sirolimus ( . mg/m /dose twice a day). all lvm patients started on sirolimus have responded well (decreased pain and swelling); time to initial symptom response ranged from weeks - month from starting medication. in this case series, patients with simple vm responded well to sclerotherapy alone, avm and lm patients needed irp and/or surgery for complete response. complex lvm did not respond well to surgery or irp; . % had improvement in clinical symptoms with addition of sirolimus to the treatment regimen. response to various modalities of treatment varied based on the type of vascular malformation. a multidisciplinary approach to management of vascular malformations is essential to provide multimodal therapeutic options for rapid symptom relief and improve the quality of life of these fragile patients, especially those with complex malformations. background: von willebrand disease (vwd) is the most common bleeding disorder in humans, affecting ∼ % of the united states' population. desmopressin (ddavp) is a longacting vasopressin analog that induces vasoconstriction and release of vwf. ddavp is used in patients with vwd and as a surgical prophylaxis, but carries anti-diuretic properties. to avoid electrolyte imbalance and hyponatremia, fluid restrictions are recommended in the hours post-ddavp administration. objectives: this study sought to examine perioperative practices and outcomes following ddavp administration and a fluid restriction protocol in a population of pediatric patients with von willebrand disease. design/method: a retrospective chart review was conducted for patients with von willebrand disease who underwent surgical procedures at children's hospital of pittsburgh of upmc between january , and december , . patient age, sex, weight, diagnosis, surgical procedure, total fluids administered, and post-operative sodium level were recorded. the primary outcomes noted were the proportion of patients exceeding % of the recommended fluid consumption for the -and -hour periods post-ddavp s of s administration, as defined by local guidelines. secondary outcomes were the presence of any bleeding requiring an er visit or readmission or hyponatremic seizures within hours of ddavp administration. results: data was compiled for patients ( females, males). the mean age was . years (sd . years), median age was years (range to years). procedures included dental ( ), otolaryngology ( ), orthopedics ( ), gastrointestinal ( ), plastics ( ), neurosurgery ( ), ophthalmology ( ), dermatology ( ), general surgery ( ) and gynecology ( ). % of patients exceeded % of the fluid volume recommended for the first -hour period post-ddavp administration while still in the surgical setting. no patients exceeded % of the fluid volume recommended for the total -hour period post-ddavp administration. post-operative sodium levels were obtained in only of patients. no patients returned to the er or were admitted for bleeding in the hours post-ddavp administration. no patients returned to the er or were admitted for hyponatremia or seizures in the hours post-ddavp administration. maintenance of a fluid restriction protocol effectively deterred negative outcomes in this cohort. however, a significant fluid volume was administered in nearly a third of patients despite the restrictions. given the risk of hyponatremia, and limited compliance with fluid restrictions, postoperative sodium levels should be recorded in following ddavp administration to assess the possibility of a hyponatremia and to reinforce the importance of fluid restrictions and their communication. results: a male fetus required in utero insertion of a pleuroamniotic shunt for bilateral pleural effusions diagnosed antenatally by ultrasound. shortly after delivery at term, he developed respiratory distress and was found to have reaccumulation of the pleural effusions. blood work on day of life showed a platelet count of , / l, which then decreased precipitously. he demonstrated schistocytes on blood-smear, signs of consumptive coagulopathy with hypofibrinogenemia and high d-dimers, and compensatory reticulocytosis. he required multiple transfusions and admissions to the intensive care unit for respiratory support. investigations ruled out congenital ttp, neonatal alloimmune thrombocytopenia, and noonan syndrome. given high clinical suspicion for an underlying vascular lesion causing kmp, a full body mri without contrast was undertaken. this showed a focal area of suspicious signal intensity in the upper paraspinal musculature. an ultrasound and mri with contrast demonstrated an extensive infiltrative vascular lesion involving the paraspinal musculature, prevertebral space, posterior extrapleural space, mediastinum, and neck. the child was commenced on prednisone ( mg/kg/day) and rapamycin ( . mg/m twice/day). there was no clinical or laboratory improvement after one month. a biopsy was performed which confirmed khe. in the second month of rapamycin therapy, the platelet count gradually normalized and the patient was discharged from hospital at . -months of life. prednisone was weaned off at . months of life. a repeat mri at months showed significant reduction in the khe. he is now almost years into therapy and doing well. conclusion: this is a unique case of khe with kmp that initially presented with extensive and recurrent pleural and pericardial effusions. this case demonstrates the importance of suspecting an underlying vascular malformation in the presence of kmp. our patient had a delayed but overall good response to rapamycin. further studies investigating duration of rapamycin therapy is key for the optimal management of these patients. rosa diaz, donald mahoney, lakshmi srivaths, donald yee texas children's hospital, houston, texas, united states background: since von willebrand disease (vwd) is the most common inherited bleeding disorder, it must co-exist with other less common bleeding disorders in some dually affected patients. however, reports of combined deficiencies in factor viii (fviii) and von willebrand factor (vwf) are rare. objectives: to study the prevalence and bleeding phenotype of combined deficiencies of fviii and vwf in males with hemophilia a in a hemophilia treatment center. design/method: we retrospectively reviewed the electronic medical records of males with hemophilia a followed at our institution during the past years. the primary and secondary outcomes for the study were ( ) the prevalence of combined fviii and vwf deficiencies and ( ) the bleeding phenotype of these patients. we identified vwf deficiencies in % (n = ) of the patients with hemophilia a. most (n = , %) patients were tested for vwf deficiency as part of the initial hemostatic evaluation, but one-third were tested due to clinical concern for inadequate response to fviii concentrate. the median duration of follow up was . years (range . to . ). patients were referred to our clinic at a median age of months (range to years) for evaluation of easy bruising (n = , %), mucosal (n = , %) and surgical bleeding (n = , %). primary diagnoses included with severe, moderate and mild discrepant hemophilia a. secondary diagnoses included with low vwf activity, type vwd and with type unclassified. patients experienced episodes of musculoskeletal (n = , %), mucocutaneous (n = , %) and cns bleeding (n = , %). a total of patients received factor prophylaxis. half of the patients were initially treated with fviii concentrates but subsequently changed to combined fviii/vwf products due to the frequency of breakthrough bleeding despite good compliance. all patients are on combined fviii/vwf products at the time of this review. a total of ( %) of this cohort developed chronic joint disease manifest as decreased range of motion and/or abnormal mri findings. combined deficiencies of fviii and vwf were present in % of our center's hemophilia patients. these patients exhibited a severe bleeding phenotype as evidenced by the high frequency of hemarthrosis, need for prophylaxis and high prevalence of chronic joint disease. while the optimal treatment strategy remains to be elucidated, early recognition of a combined deficiency may have important clinical implications, particularly in patients who demonstrate a suboptimal response to fviii concentrate alone. background: childhood neutropenia is heterogeneous and may be congenital or acquired. cerebral cavernous malformation (ccm ) is a neurovascular malformation disorder where lesions consist of low flow, dilated capillary endothelial channels with increased permeability, predisposing to hemorrhage and thrombosis. programmed cell death protein (pdcd ) activity has been implicated in glia and neuron migration, and recently linked to the dysregulation of the actin and microtubule cytoskeleton, thereby affecting cellular morphology and migration. variants of pdcd encoding pdcd have been associated with ccm . ccm causes a greater and earlier disease burden than other ccms, with % presenting younger than years. some patients have associated extra-neuronal manifestations, suggesting that pdcd plays a role in other tissues. we describe a patient with significant blood cytopenias associated with ccm . design/method: retrospective chart review to obtain patient data. results: an -month old female presented with seizure and was found to have multiple intracranial cystic lesions and abscesses due to s. pneumonia serotype f. during her treatment, she developed anemia (hemoglobin . - . g/dl), thrombocytopenia (platelets , - , cells/l), and profound neutropenia (absolute neutrophil counts of zero). initial bone marrow evaluation revealed a normocellular marrow but with marked granulocytic hypoplasia and % hematogones on flow cytometry. florescent in situ hybridization excluded cytogenetic changes characteristic of myelodysplastic syndrome. further evaluation included testing for neutrophil antibodies, chromosome breakage, and telomere length and results were normal. whole exome sequencing excluded mutations affecting congenital neutropenia genes, but detected a de novo pdcd variant (c. + g>a), thereby diagnosing ccm . the neutropenia has responded well to granulocyte colony stimulation factor (gcsf), which is still needed at months of age. moreover, the thrombocytopenia has progressed, requiring periodic platelet transfusions. over time, the bone marrow hematogone population has decreased to % at months of age, though the granulocytic hypoplasia persists. conclusion: our case describes the first patient with neutropenia and thrombocytopenia associated with ccm . we hypothesize the pdcd variant is the etiology of bone marrow dysfunction due to its role in actin and microtubule cytoskeleton formation, akin to the pathophysiology of xlinked neutropenia. supportive features of an underlying genetic cause of marrow dysfunction include the persistence of cytopenias beyond infection resolution as well as presence of hematogones. hematogones were previously reported to occur in patients with other congenital neutropenia disorders, indicating they could be a feature of congenital neutropenia and may be reactive to surrounding cell apoptosis. further testing of pdcd role in hematopoiesis should be explored. background: - % of adult women will suffer from heavy menstrual bleeding (hmb) during their lifetime. % of women with inherited bleeding disorders suffer from hmb. there is a paucity of data about hmb among adolescents and young adults (aya), a population in which hmb may have large social and educational effects. objectives: to study the social and academic implications of hmb in an aya population. design/method: this is a questionnaire based survey conducted in a medium-sized city in california. we recruited females - years of age from one high school and from local university. the questionnaire was set up in research electronic data capture (redcap) at our institute which allowed us to obtain objective data about the respondents' menstrual cycles. a link was sent to the high school students via their online portal schoolloop and to the university students via social media and word of mouth. data was collected over weeks from may to august . we received replies, some were not complete. using regression analysis, data was analyzed from respondents in the age group of - (with a mean age of ) years. we developed a composite score for hmb based on factors including saturation levels, number of pads, duration of bleeding, soaking of a pad within two hours, passage of clots, size and number of clots, and gushing sensation. we conducted statistical analysis of the drivers and implications of hmb based on the composite score. results indicate that having a relative with hmb, having other bleeding problems, and having anemia are drivers of higher hmb score. the results also indicate that hmb adversely affects quality of life as measured by participation in sports, social activities, after-school activities, tiredness, absenteeism, and gpa. hmb is also associated with increased rates of anemia and use of anti-depressants. hmb-driven anemia further adversely affects gpa. under-represented minorities are more likely to have a higher hmb score, as well as an increased adverse effect of hmb on gpa. the results suggest that the social costs of hmb are pervasive in the aya population, and especially pronounced among minorities. a relative with hmb is a significant driver of heavy menstrual bleeding. a hemostatic screen should be included when assessing the aya population with hmb. johns hopkins all children 's hospital, st. petersburg, florida, united states background: propranolol is a non-cardioselective beta blocker medication frequently prescribed for hemangiomas and hyperthyroidism. propranolol inhibits types i and ii iodothyronine deiodinases, enzymes that convert bioinactive thyroxine (t ) into bioactive triiodothyronine (t ). hypothyroidism is a well-recognized complication of diffuse hepatic hemangiomas that produce type iii deiodinase, an enzyme that converts t into bioinactive reverse t and t into diiodothyronine. thyroxine is typically selected for replacement in this population, even though doses up to % above physiologic may be necessary. we hypothesized that low dose, nearly physiologic t would be safer and equally effective because it bypasses propranolol's impact on the pituitarythyroid axis. we report an infant with diffuse hepatic hemangiomatosis and acquired hypothyroidism successfully treated with propranolol, prednisone, and triiodothyronine. design/method: a mo healthy female presented with abdominal distension, poor oral intake, and hepatomegaly. mri confirmed diffuse hepatic hemangiomatosis, the largest lesion measuring . cm by . cm. thyrotropin (tsh) was elevated at . (reference range* . - mcgiu/ml), total t # (rr - ng/dl), and total t ^ . (rr - mcg/dl). treatment was started with prednisone ( mg/kg/day) for three weeks, propranolol ( mg/kg/day) and t ( . mcg/kg/day). the t dose was slowly titrated to a maximum of . mcg/kg/day. thyroid hormone levels rapidly improved on t replacement. after two weeks, the tsh was . , tt , and tt . . after eight months, the tsh was . , tt , and tt . . at twelve months, the tsh dropped to . , tt , and tt . , suggesting decreased tumor production of type iii iodothyronine deiodinase. liver mri confirmed fewer hemangiomas, largest being . cm by . cm. the patient's t dose was reduced. both propranolol and t were discontinued after twenty-four months of treatment. one year off all therapy, this child has normal growth and development, only two < . cm hepatic hemangiomas and no evidence of hypothyroidism (tsh . ; tt ; tt . ). conclusion: t at near physiologic doses corrects the consumptive hypothyroidism associated with diffuse hepatic hemangiomas. t replacement is preferable to thyroxine due to its lower risk of rebound hyperthyroidism as the hemangiomas involute and type iii deiodinase production declines. there are two prior case reports describing t use without t , one employing propranolol and the other utilizing steroids for hemangioma management. this is the first case report with long term follow-up of a child treated with multimodal therapy including propranolol, prednisone, and triiodothyronine. *rr = reference range; #tt = total t ;^tt = total t background: multifocal lymphangioendotheliomatosis with thrombocytopenia (mlt) is a rare congenital disorder first described in that is characterized by multiple vascular abnormalities commonly involving the skin and gastrointestinal tract as well as consumptive coagulopathy often resulting in gi bleeding in infancy( ). to describe an unusual presentation and successful management of mlt in a neonate. design/method: baby h was born at full term after a pregnancy complicated by maternal sinus venous thrombosis requiring anticoagulation beginning at weeks. at birth, she was diagnosed with multiple hemangiomas based on clinical exam. at two weeks of age, she developed melena and hematemesis. cbc revealed platelet count of and she was referred to the ed. abdominal ultrasound was concerning for abnormal hepatic waveform; cxr showed multiple pulmonary nodules. workup revealed no other lesions and no further hematologic abnormalities. biopsy of presumed hemangioma ultimately revealed a smooth muscle-lined vascular proliferation without glut- immunoreactivity, consistent with mlt. her early course was complicated by an acute hemodynamically significant gi bleed; esophagogastroduodenoscopy identified six bleeding vascular malformations within the stomach that were injected with epinephrine and sclerosed with successful hemostasis. she received multiple prbc and platelet transfusions. central access was obtained and she was started on oral sirolimus based on previous reports of successful use in management of vascular malformations given its antiangiogenic and immunosuppressive effects ( ). she has tolerated it well with no evidence of toxicity and has achieved a partial response with stable of hemoglobin > and platelet count > . cutaneous lesions have diminished in intensity and she has had no further signs of gi bleeding. she receives pentamidine for pcp prophylaxis. she continues to have appropriate growth and development. we describe here an unusual presentation of an already rare disease. while cutaneous and gi lesions are typical of mlt, pulmonary involvement is not well-described in the literature. early identification of tissue-based diagnosis enabled timely stabilization and treatment of the patient. five months later, she continues to tolerate sirolimus and has shown significant response with diminished coloration of cutaneous lesions, stable blood counts, and no further bleeding. mlt is a relatively newly-recognized disorder with significant phenotypic variability. given that bleeding secondary to a kasabach-merritt-type consumptive thrombocytopenia is the major cause of morbidity and mortality in the first year of life in children with mlt, it is essential to recognize the diagnosis and initiate appropriate treatment as early as possible. north, arch background: patients with generalized joint hypermobility (jhm) may experience easy bruising or bleeding given the association between these symptoms and abnormalities in collagen, a required component of primary hemostasis. heavy menstrual bleeding (hmb) is a common initial presentation for females with underlying hemostatic defects and may be the sole manifestation of a bleeding disorder. however, limited reports describe jhm as a cause of hmb, leading to under recognition. objectives: to describe the clinical characteristics and management of young women presenting with hmb in the setting of jhm. design/method: this study utilized our hmb research registry. we included subjects - years, seen in the nationwide children's young women's hematology clinic between february and november with both hmb and jhm. medical records were retrospectively reviewed for history of presentation, menorrhagia impact questionnaire (miq): a validated quality-of-life tool for females with hmb, medication profiles and relevant laboratory studies. results: twenty-five patients met inclusion criteria (median age years, range - ) with an average beighton score of . (range to ). participants presented an average of . years (range months to years) after menarche despite % of patients reporting heavy to very heavy menses since menarche. according to the miq responses, most participants expressed hmb-associated limitations in physical activities ( %), social activities ( %), and work or school activities ( %). of the participants, % reported bleeding symptoms in addition to hmb, most commonly easy bruising ( %), epistaxis ( %) and cutaneous bleeding ( %). forty percent of young women presented with anemia due to chronic blood loss. results of hemostatic testing were unremarkable, with the exception of one patient who was also found to have type von willebrand disease. additionally, % of females reported arthralgia, with knees and ankles the most commonly affected joints. at time of presentation, % of participants reported failure of initial therapies and most patients ( %) were managed long-term with oral hormone therapy. in a small population of young women found to have jhm who initially presented with hmb, patients were likely to have prior bleeding symptoms as well as substantial delays from menarche to timing of presentation at our young women's hematology clinic despite limitations in activities of daily life. greater awareness of the associations between bleeding symptoms and jhm, despite typically normal hemostatic laboratory results, is necessary so that patients can more easily be identified and receive appropriate therapy. the objective is to determine the impact of cl care practices involving the home environment on ambulatory clabsi rates. design/method: information for the pi was collected through a comprehensive survey that was completed annually by the ccbdn member hospitals. responses to the questions about cl care practices involving the home environment were selected from the pi for . ambulatory clabsi rates and ambulatory total bloodstream infection (bsi) rates were obtained from another ccbdn database. the proportion of hospitals that did or did not employ a particular cl care practice was tallied. the mean ambulatory clabsi rate and mean ambulatory total bsi rate of the hospitals that did or did not employ a particular cl care practice were compared using generalized linear model techniques assuming an underlying negative binomial distribution. results: twenty-five hospitals submitted responses to the questions about cl care practices involving the home environment. one hospital was excluded for lack of bsi data. sixty-three percent of the hospitals programmatically educated parents about all aspects of the cl care bundle. the mean ambulatory clabsi rate for the hospitals that educated parents was significantly lower than that of the hospitals that did not ( . infections/ cl days vs. . infections/ cl days; p = . ). the mean ambulatory total bsi rate was also significantly lower ( . infections/ cl days vs. . infections/ cl days; p = . ). the mean ambulatory clabsi rates and mean ambulatory total bsi rates were not significantly different for the other cl care practices. conclusion: an analysis of cl care practices involving the home environment reveals that parental education of all aspects of the cl care bundle is associated with a lower ambulatory clabsi rate and lower ambulatory total bsi rate. this finding highlights the importance of systematically teaching family members the proper method of handling cl. background: children undergoing chemotherapy are at a high risk for developing nausea. dr. amy baxter in collaboration with pediatric oncology patients and nurses, developed and validated a pictorial nausea rating scale for children aged - years, called the baxter retching faces (barf) nausea scale. staff nurses at a large, academic, pediatric hospital located within washington, d.c., have identified variability in nursing assessment and documentation of chemotherapy induced nausea and vomiting (cinv) in pediatric oncology patients. the purpose of this quality improvement project was to utilize the barf scale to standardize assessment and documentation of nausea in pediatric oncology patients receiving chemotherapy. the primary aims of this project were to: assess feasibility of the barf scale in clinical practice; increase nursing knowledge about cinv through education sessions; increase documentation of nausea assessments through the use of the scale. the secondary aim of this project was to: increase the recognition of nausea through the use of a standardized assessment tool. design/method: the pdsa model was used to guide the design and implementation plan. in the first phase of the project data was collected to identify the prevalence of nausea in patients admitted for chemotherapy in the prior three months. education sessions discussing cinv and the utilization of the barf scale were conducted. pre and post assessment of nurses' knowledge of cinv and documentation were assessed. in the second phase the barf scale was implemented into practice. nurses were asked to utilize the barf scale to assess and document nausea scores in patients, aged to years, receiving chemotherapy. at the end of the implementation period nurses were surveyed about the feasibility of the scale. post data was collected to identify the prevalence of nausea documented in the electronic health record. this project was undertaken as a quality improvement initiative at children's national and it does not constitute as human subjects research. as such it was not under the oversight of the institutional review board. results: all data has been collected; however complete data analysis will be conducted in the upcoming weeks. background: sickle cell disease (scd) is the most common inherited blood disorder in the united states (us); however, there are few quality measurements to evaluate scd practice. in , the nhlbi published guidelines that include two key interventions for children with sickle cell anemia (sca): the use of transcranial doppler (tcd) screening for stroke prevention and hydroxyurea (hu) to prevent scd pain crisis. we conducted a national survey of scd management sent to providers in over institutions in the us to better assess knowledge of the guidelines and barriers to hu counseling and tcd screening guideline implementation. it was hypothesized that the barriers to tcd screening are different than barriers to hu counseling and prescribing. a -question anonymous survey was sent to providers by mail (follow-up by email). survey themes included nhlbi guidelines knowledge and comfort with understanding and implementing both tcd screening and hu use. the response rate was % ( / ) however one survey was incomplete. thus, were analyzed in the final data set. all of the respondents are in active practice, % s of s in academics and all care for children with scd. the majority of providers ( %) felt "very" or "extremely" confident in their knowledge of tcd screening and interpretation. similarly, % of providers felt "very" or "extremely" familiar with hu dosing and management. for tcd screening, % of providers estimated their screening rates were > % and % providers felt their annual screening rates were - %. the two biggest barriers to tcd screening noted by providers (of moderate to extreme significance) included: lack of support staff ( %) and lack of time during a patient visit ( %). regarding hu prescribing practices, % of providers offered hu to at least % of children with sca over nine months of age. the biggest barrier to hu prescribing noted by % of providers was concerns about patient adherence or access to the medication. only % providers felt that lack of support staff was a moderately significant barrier to hu prescribing. the pediatric scd providers surveyed all have access to the nhlbi guidelines. despite widespread guideline knowledge, there are different barriers for tcd screening versus hu prescribing, which prevent optimal implementation. as a result, although both recommendations are from the same nhlbi guideline, they likely will require different implementation strategies (systems-based interventions for tcd screening; interventions to improve patient adherence for hu counseling) to improve outcomes. background: invasive fungal disease (ifd) is a major cause of mortality and morbidity among pediatric immunocompromised patients such as those who receive chemotherapy or hematopoietic stem cell transplantation. the current diagnostic 'gold standard' of ifd remains culture of infected tissue obtained by biopsy. noninvasive biomarker testing for galactomannan or , -beta-d-glucan (bg) can have low sensitivity and does not provide species-level identification. nextgeneration sequencing (ngs) of cell-free plasma is a promis-ing noninvasive approach to providing species-level identification of ifd via a blood test and can further guide specific treatment. objectives: describe the incidence of positivity for fungal specific pathogens on ngs analysis in a high-risk immunocompromised pediatric population and correlate results with other 'standard' infectious studies if performed. design/method: immunocompromised pediatric patients with suspected ifd were enrolled and plasma was collected at time of enrollment. ngs was performed on extracted dna in cell-free plasma (karius, redwood city, ca). after removing human reads, remaining sequences were aligned to a curated database including pathogens. organisms present at a significance-level above a predefined threshold were reported. results: twenty-seven samples from enrolled patients have been processed thus far. of these subjects, were enrolled for prolonged febrile neutropenia (≥ hours) despite broad-spectrum antibiotics, for recrudescent febrile neutropenia, for abnormal imaging, and with other findings. after evaluation of routine studies performed, patients met criteria for proven ifd, for probable ifd, and for possible ifd using eortc/msg guidelines. the ngs plasma test identified the same pathogen as cultured from infected tissue or blood in % ( / ) of the proven cases. in the probable cases, pneumocystis jirovecii was identified in a patient with a positive bg ( pg/ml) and pneumonia. among the possible cases, toxoplasma gondii was detected in a patient with prolonged febrile neutropenia and lung imaging suggestive of ifd. additionally, candida glabrata was isolated in a patient with prolonged febrile neutropenia but no other criteria for ifd. numerous pathogens were also identified that could explain the above clinical parameters, including hsv , cmv, vzv, hhv , ebv, bk polyoma virus, and ureaplasma parvum. the cell-free plasma ngs test can detect invasive fungal infections from blood. the test identified fungi from proven ifd, detected pathogens in both probable and possible ifd cases, and is a useful diagnostic tool in the evaluation of ifd. supplies and sample shipment and processing supported by karius, inc. baylor college of medicine, texas children's hospital, houston, texas, united states background: practicing medicine is a lifelong learning process. as noted in the institute of medicine's seminal report, 'to err is human,' adverse outcomes do not typically result from individual recklessness; rather, they result from faulty systems, processes, or conditions that provide an environment conducive to making a mistake, or failing to prevent one. learning to systematically review errors and translate lessons learned into quality improvement (qi) initiatives is a critical component of practice-based learning and improvement for practitioners at all career levels. objectives: to develop a methodical, self-reflective and nonthreatening approach to incident analysis and translation of lessons learned into qi initiatives. design/method: we used a validated, structured case audit approach, modified from szostek et al: ) review all documentation relating to the case and identify all health care providers involved; ) interview stakeholders, including those who directly provided and supported care; ) use a qi tool to conduct a root-cause analysis; ) identify a systems issue that contributed to the outcome; and ) propose systems-level interventions and prioritize initiatives based on effort-yield projections. results: pdsa cycle : plan: establish a committee to ) identify potential cases, ) triage cases for conference presentation, ) determine timing and frequency of conferences, ) develop a training manual, ) record identified qi initiatives. do: we established a quarterly section-wide meeting to which all members of the pediatric hematology/oncology service are invited, including administrative and nursing leadership. we developed a training manual and structured presentation template. prioritized cases were discussed in advance during multidisciplinary case review sessions, and presented by senior fellows who were instructed to focus discussion on potential opportunities for qi. study: we identified cases, meeting criteria for mmi presentation. qi initiatives identified from this conference resulted in a number of systemic practice changes; however, we encountered challenges to sustaining these changes over time. act: objectives for the next pdsa cycle are to ) establish a method for tracking the adherence to recommended changes in practice, ) maximize sustainability by integrating qi initiatives into institutional qi leadership and practice standardization committees. we have successfully implemented an mmi conference that meets out of institute of medicine quality domains: safety, effectiveness, patient-centeredness, timeliness, and efficiency. a standardized, consistent approach to mmi presentations that includes identification of contributing factors and specific qi implications has the potential for improving both provider education and patient care/safety. johns hopkins university, baltimore, maryland, united states background: receiving a cancer diagnosis is a life-changing event for patients and caregivers, although little is known about the experience. while some oncologists receive dedicated training in delivering this bad news, the initial conversation is often with a primary pediatrician, and these providers often feel they do not receive adequate training in the communication of a cancer diagnosis. objectives: our objectives were two-fold: first, to better define the experiences of caregivers/patients when told of a cancer diagnosis, and to query how caregivers/patients believe providers can improve the disclosure of this bad news. secondly, to assess what, if any, training primary pediatricians received in this skill, and to assess how comfortable providers in various settings and stages of training are with communicating cancer diagnoses. design/method: from november - , semistructured, in-depth interviews were conducted with pediatric oncology patients and caregivers of patients (n = ) diagnosed in the past year regarding their experiences receiving the diagnosis at our institution. in addition, pediatric residents (n = ), outpatient pediatric primary care physicians and pediatric emergency medicine physicians (n = ) were interviewed regarding their experiences delivering cancer diagnoses. interviews were analyzed following principles of thematic analysis. interviewers with patients and caregivers had two common themes: ) all emphasized their wish for direct and thorough information; ) both patients and caregivers emphasized the gratitude they felt for physicians who gave them hope by emphasizing the good prognosis of their child's cancer. lack of training in this area, as well as lack of comfort delivering this news was common will all providers. additionally, providers report variable approaches to giving bad news, including ) whether to tell caregivers separately or tell the child and parents together, and ) whether to give favorable prognostic information. additionally, attending physicians also differed significantly in their approaches to teaching residents. while some believed residents should give the news to gain experience, others felt that this is not appropriate if residents are inexperienced. only one resident reported ever receiving feedback on his communication skills in this type of discussion. conclusion: we plan to build on these interviews to develop a national survey of patients, caregivers, and providers to better understand the issues surrounding this discussion. we will use the findings to develop a communication curriculum for pediatric residents, focusing on the discussions that occur in the outpatient setting by primary pediatricians. background: human papilloma virus (hpv), common in both females and males, is responsible for pathologies ranging from benign genital warts to cervical and penile cancer. hpv strains and are responsible for , malignancies each year in the united states, and one third of them arise in men. pharmaceutical companies have now developed a vaccine that will help prevent the virus-associated malignancies. the cdc initially recommended that females ages - years receive the vaccine series, then starting in they expanded the eligibility to males ages - years. despite being widely available and highly publicized, only % of eligible females receive the full vaccine series. objectives: this study aims to assess the knowledge of hpv, the attitudes towards the hpv vaccine, and identify barriers preventing its full utilization. once identified, we aim to overcome the barrier(s) in order to improve vaccination rates in eligible adolescents. we distributed a standardized questionnaire to the parents of eligible female and male patients in our pediatric hematology-oncology clinic. it assessed the parents' knowledge of hpv and the vaccine, their views of the vaccine, and reasons why they may oppose it. results: approximately % of parents claim they have been educated about hpv, mostly by their primary care physician. however, % did not know what disorders hpv caused; % felt the vaccine should not be added to the typical vaccine schedule; % of parents do not intend to vaccinate their child. of those that opposed the vaccine, one-third were concerned about potential side effects and nearly % feel they do not have enough information. additionally, % of parents are not aware that the vaccine is available at their child's doctor and only % of parents have discussed the hpv vaccine with their child's doctor. the largest barrier to the utilization of the hpv vaccine that we have identified appears to be lack of educa-tion. as a result, we have begun distributing the cdc's hpv and vaccine patient guide to our patients' families as an intervention. we are currently in the process of re-administering our survey to these families after implementing the intervention to assess its success in increasing both knowledge and utilization of the hpv vaccine. cancer institute, chennai, chennai, tamilnadu, india background: rasburicase is a recombinant urate oxidase enzyme approved for use in tumor lysis syndrome (tls) and it acts by reducing serum uric acid levels. using rasburicase at the recommended dose of . mg/kg/day for days is expensive and it is not known whether this extended schedule is clinically beneficial compared to a single fixed dose of . mg. the aim of the present study was to evaluate the efficacy of single dose rasburicase . mg in prevention and management of tls. design/method: rasburicase is available as single use . mg vial. at our institution a single dose of rasburicase . mg irrespective of bodyweight has been used in adults and in children a dose of . mg/kg (maximum . mg) has been used since for prevention and management of tls and subsequent doses are given based on biochemical response and clinical condition. we retrospectively analysed the case records of patients who had received rasburicase from january to january . the study included patients with hematological malignancies who received rasburicase. children accounted for . % (n = ) patients and males comprised % (n = ). rasburicase was used prophylactically in ( . %) patients, for laboratory tls in patients ( . %) and for clinical tls in ( . %) patients. single fixed dose rasburicase prevented laboratory/clinical tls in % of the prophylactic group and prevented clinical tls in % of the laboratory tls group. none of the patients in prophylactic and laboratory tls group developed clinical tls. however, majority of the patients with clinical tls required more than one dose rasburicase. single dose of . mg ( vial) rasburicase is efficient in preventing and managing laboratory tls and is economically viable in resource constrained settings. nicole wood, lauren amos, nicholas clark, chris klockau, karen lewing, alan gamis children's mercy kansas city, kansas city, missouri, united states background: medication reconciliation for newly diagnosed oncology patients is complicated and cumbersome. these patients are often admitted on no medications, and leave on multiple. chemotherapy and supportive medications are crucial. despite numerous individuals overseeing this process, prescribing errors or omissions still occur. when reviewing the literature, improvement occurs when there is an interprofessional and standardized process to medication reconciliation. objectives: this project's aim was to improve the accuracy of the discharge medication reconciliation process from % to % from february -august . the process measure was the percentage of patients discharged with an accurate checklist. additional time for staff spent in completing the checklist and avoiding an increased error rate by changing the prescribing process were followed as balancing measures. we created a discharge medication checklist which included a list of required home medications prescribed by the resident, ideally hours prior to discharge. it required fellow or attending review and pharmacy to review the list and educate the family. checklists were collected monthly and reviewed against the electronic medical record (emr) for accuracy. results: six pdsa cycles were completed. there were errors during the data collection time frame. in pdsa cycle , a patient received acetaminophen for pain control which is avoided at home. in addition, this patient received diphenhydramine instead of ondansetron, which is preferred as an antiemetic. in pdsa cycle , a patient with a pending diagnosis was sent home with acetaminophen. of note, this patient did not have a checklist completed upon discharge. this project provides a novel and important method to standardize the discharge medication reconciliation process in a complex patient population. it clarifies which types of medications these patients need, provides pharmacy teaching to families which was not done previously, and prescribes discharge medications to families sooner. after the first medication reconciliation error, the checklist was revised. no further errors were made following revision, with the exception of one patient without a completed checklist at dis-charge. our accuracy rate increased from % at baseline to % following implementation. we are in the process of making the checklist electronic and accessible in the emr. in the interim between the end of data collection and implementation into the emr, a leukemia patient was sent home without an epinephrine pen, further demonstrating the importance of this standardized discharge process. for this reason, we have re-instituted the checklist until the electronic version is available. background: survivors of pediatric cancer are at risk of losing pre-existing protective antibodies to vaccine preventable diseases. in a prior study, % of children < years lost humoral immunity to measles as a result of chemotherapy induced alterations in immune system. measles in recipients of immunosuppressive chemotherapy has mortality rates up to %. because of volitional vaccine refusal, there has been a dramatic increase in measles infection from cases in to in , including several statewide outbreaks. small pediatric oncology practices frequently share floor/clinic space with the general pediatric patients putting them at risk for measles since virulence starts hours prior to symptoms. there is no standard protocol for revaccinating post-chemotherapy patients. to assess measles risk based on serial humoral immune status in a cohort of pediatric oncology patients receiving intensive chemotherapy design/method: patients < years age with known vaccination status receiving intensive chemotherapy between july -june at our institution's pediatric oncology practice were included in this prospective study. serial measles igg antibodies were measured at diagnosis, months and months after initiation of chemotherapy using elisa. measles immunity was defined per lab standards. a comparison of pre-chemotherapy and serial post-chemotherapy immunization titers was made for all patients by diagnosis. the study population consisted of children ( male); patients had all, non-hodgkin lymphoma, sarcoma and other solid tumors. two patients ( . %), both unvaccinated had non-protective measles antibody levels at s of s baseline. of the remaining patients, . % patients ( leukemia, lymphoma and sarcoma) lost protective antibody titers at months after initiation of chemotherapy and . % ( leukemia, lymphoma and sarcoma) at months after initiation of therapy. % of the remaining patients who retained measles antibody titers within protective range at months also demonstrated a steady decline in antibody titers at and months from therapy initiation. the loss of protective measles humoral immunity occurred significantly more often in patients with leukemia compared to other malignancies. oncology patients in our practice undergoing intensive chemotherapy demonstrated progressive waning of protective measles igg titers. our data suggests that it should be standard practice to check all patients for measles humoral immunity prior to starting chemotherapy and at completion. larger studies need to be performed to establish guidelines for revaccinating post-chemotherapy pediatric patients, an intervention that is easily applicable and of low cost. background: the accurate determination of glomerular filtration rate (gfr) is important to screen for acute kidney injury, to dose chemo-therapy, and to identify risk for chronic kidney disease.being correlated with inulin clearance, measured gfr by iohexol plasma disappearance (igfr) is a new gold standard for measurement of gfr in pediatric cohort studies. igfr is based on the clearance of an exogenous marker and is unaffected by endogenous compounds or a patient's muscle mass. we compared igfr with -hour urine creatinine clearance ( crcl) and gfr estimating equations using serum creatinine (scr) and serum cystatin c (cystc) in pediatric patients with cancer. we recruited participants who were ages to yrs, continent of urine, and diagnosed with a malignancy in the past years. eligible subjects had stable kidney function for at least two weeks prior to the assessment of igfr. consented subjects had baseline assessments including height, weight and vital signs. blood samples were obtained for serum chemistry, and time zero iohexol. igfr determined by ml iohexol solution infused over - minutes followed by ml of sterile saline. blood was drawn at , , and minutes.at the same time of igfr, the crcl was collected. igfr was calculated using a two-compartment model and area under the curve. we compared igfr to published gfr equations (schwartz et al, kidney int ). results: ten subjects ( female/ male) agreed to participate. the distribution of diagnoses for the subjects: all = , lymphoma = , brain tumors = and hepatocellular carcinoma = . six patients were off therapy. the lower gfrs are noted in patients who had malignancies other than leukemia, likely due to the use of cisplatin based therapy. the average igfr was ml/min/ . m^ whereas crcl was . ml/min/ . m^ ; demonstrating the crcl overestimates gfr compared to igfr. comparing igfr to univariate equations using scr, cystc, and the multivariate equation with both, the univariate cystc equation correlated well with igfr; the others overestimated igfr. we found that crcl overestimated igfr. the univariate cystc equation better correlated to igfr than equations with scr. the poor performance of scr based methods to assess gfr might be due to decreased muscle mass and inadequate nutritional status. creatinine-based determinations of gfr alone, may not be accurate in this population. further study is needed to determine if igfr should be a standard of care to assess gfr in children with cancer particularly who are receiving nephrotoxic medications and incontinent of urine. background: pediatric oncology patients undergoing chemotherapy through indwelling venous catheters are at increased risk for severe sepsis especially when neutropenic due to chemotherapy. rapid triage and early recognition are essential because delayed initiation of antibiotics and fluids in these patients or delayed transfer to higher level of care after initial stabilization is associated with poor clinical outcome. our pediatric oncology out-patient clinic is designated as an article unit whereby the providers can initiate and give treatment such as intravenous fluid, antibiotics, chemotherapy and blood products. objectives: global aim-optimize management of early sepsis and decreased morbidity, mortality and hospital length of stay in the high risk pediatric oncology patients. smart aim-improve timely management with initiation of fluids and antibiotics and transfer of septic patients to higher levels of care by % in months in above patients design/method: multidisciplinary team with physicians and nurses was created. retropective chart review of sepsis patients treated at the clinic from april to october was done using an audit sheet to identify the barriers in the delivery of care. three patients were identified and data analyzed prior to intervention; two were analyzed post interventions. a key driver diagram was created by the group to drive intervention. a process map was designed to identify the different steps in the care of these patients to pinpoint areas needing improvement. different timed data points were used starting from time of arrival to clinic, time to antibiotics and fluids and time to transfer to higher level of care. rapid pdsa cycles were done to improve the processes and delivery of care. run charts were created. there was an improvement close to the goal of % for all data points used. pdsa cycles for improvement included conducting frequent mock codes with appropriate feedback real time coaching and process planning with nursing staff. we partnered with pharmacy for close loop communication with clinic staff and we improved communication between physicans at different levels. conclusion: sepsis in neutropenic pediatric oncology patients is deadly and can be reversed with timely management at different levels. given the promising results of the above project, we want re-inforcement of the processes to be a part of the daily practice of first line clinical staff. eventually we will extend the principles learnt in management and triage of sepsis to other outpatient emergencies chemotherapy related anaphylaxis background: chemotherapy-induced nausea and vomiting (cinv) is a common side effect in children receiving antineoplastic chemotherapy. recommended prophylactic antiemetic medications are based on the classification of chemotherapy emetogenicity. however, despite appropriate use of these antiemetic agents, some patients will still experience nausea and/or vomiting. children's oncology group clinical practice guidelines recommend the addition of olanzapine to prophylactic regimens for management of breakthrough cinv. objectives: our pediatric hematology oncology center implemented a quality improvement (qi) project aimed to increase the use of olanzapine in pediatric cancer patients years of age and older receiving moderately or highly emetogenic chemotherapy and experiencing breakthrough cinv over a month period. design/method: this qi project was conducted utilizing plan-do-study-act (pdsa) cycles. for the first pdsa cycle, baseline data was collected through chart review to determine the rate of olanzapine use for breakthrough cinv over a month period from july to december . breakthrough cinv was defined as use of or more doses of antiemetic agents other than those given for cinv prophylaxis. guidelines for treatment of breakthrough cinv were reviewed with pediatric hematology/oncology attending physicians and fellows. flyers were created that listed chemotherapy regimens considered moderately and highly emetogenic. if a patient experienced breakthrough cinv, a flyer was to be placed in the patient's roadmap binder to signal olanzapine should be added to the next chemotherapy block. data was collected over a month period in september following this first intervention. the second pdsa cycle consisted of didactic education and training of pediatric oncology nurses as well as pediatric residents regarding the addition of olanzapine for breakthrough cinv. rates of olanzapine use were then collected from october through november . results: olanzapine use increased from . % at baseline to . % after the first pdsa cycle ( = . , p = . ). after the second pdsa cycle, olanzapine use increased another . % to . % ( = . , p = . ). the administration of olanzapine was successfully increased by modifying patients' roadmaps after patients experienced breakthrough cinv as well as with education and training of pediatric oncology staff, fellows, residents, and nurses. background: venous thromboembolism (vte) is increasingly affecting children. according to an administrative database study, there was a % increase in the incidence of vte among children admitted to free-standing children's hospitals in the united states from to . risk factors for hospital-acquired vte are well-known and well-studied in adults, with evidence-based preventative measures available. similar guidelines are lacking for children. objectives: there is an ongoing national-initiative to develop and institute methods for screening and preventing hospitalacquired vte in children. in / , nationwide children's hospital instituted an electronic screening form required for all patients admitted ≥ hours. patients were scored and riskstratified based on eight risk-categories. a summated score was used to determine the vte risk level, and used to make prophylaxis recommendations for patients ≥ years; as well as patients ≥ years who were admitted to an intensive care (icu), surgical, or trauma unit. the purpose of this irb exempt, quality improvement initiative was to retrospectively review our experience with this risk-stratification tool. results: hospital-acquired vte events occurred in unique subjects. median age at vte diagnosis was years. only ( %) vte occurred in children ≥ years of age. ( %) vte were deep vein thrombosis (dvt), and ( . %) involved pulmonary embolism. vte was most common in subspecialty units including the pediatric and cardiac icus ( . %); neonatal icu, ( . %); and hematologyoncology, ( . %). ( %) vte were associated with central venous catheters (cvc) and events ( %) were associated with altered mobility. congenital heart disease/heart failure was the most common chronic medical condition associated with vte ( ( . %) events); whereas infection and trauma/surgery were the most common acute medical conditions associated with vte ( ( . %) and ( %) events, respectively). during ( %) events, subjects scored a summated score ≥ . in summary, in this single institution, prospectively maintained database, cvc remains the most common risk factor for vte, followed by cardiac disease, infection and trauma/surgery. most subjects who developed vte scored high (score ≥ ) on our screening tool. only a small proportion of vte occurred in patients older than years and thus eligible for thromboprophylaxis. our results indicate that future vte prevention endeavors should include these age groups in addition to exploring more aggressive prophylactic modalities including pharmacological prophylaxis. background: pediatric fellows are required to have active engagement in quality improvement (qi) activities, and yet a national acgme review found most trainees had "limited knowledge of qi methods" and "limited participation in interprofessional qi teams". the twenty fellows in our pediatric hematology/oncology training program identified blood culture utilization as their qi priority. our institution recently introduced a hospital-wide decision algorithm to guide providers regarding when to obtain blood cultures. there is often a low threshold to obtain blood cultures in immunocompromised pediatric oncology patients, but these are often low-yield or result in falsepositives. our fellows spearheaded a project to implement the algorithm in the inpatient pediatric oncology population and improve the proportion of appropriately drawn blood cultures. we investigated how appropriately the algorithm was being utilized on the inpatient pediatric oncology floor prior to and after several educational steps aimed at disseminating the algorithm to members of the care team. our primary endpoint was to quantify the proportion of culture episodes drawn "inappropriately", with a goal of reducing inappropriate episodes to ≤ %. the algorithm was initially introduced to the nursing staff and residents covering the twenty-bed inpatient unit in september . qi project planning took place with upper level fellows in january . fellows and faculty received intensive training on the algorithm in july-august . we then conducted a retrospective chart review of blood culture episodes drawn between august and november . upper level fellows scored ∼ culture episodes as to whether the decision to culture and number of cultures drawn were "appropriate" or "inappropriate", and catalogued the indications for culture episodes and if applicable, why the episode was found to be inappropriate. additionally, fellows discussed inappropriate culture episodes with the team onservice, to provide direct feedback on where the algorithm failed. results: between august -december on average cultures/ patient-days were drawn. forty-nine percent of culture episodes were inappropriate. from january -october , following targeted education on the algorithm, the rate of blood cultures drawn decreased to cultures/ patient-days. the average proportion of inappropriate culture episodes fell to . %, representing a % decrease in inappropriate culture utilization. correct application of a decision algorithm for blood culture utilization can reduce total cultures drawn on an inpatient pediatric oncology unit. fellow-led education of the multi-disciplinary team decreases the rate of inappropriate culture episodes as well as provides active engagement in qi. background: inadequate understanding of sickle cell disease (scd) is common and can affect patients' compliance and therefore their morbidity and mortality, especially after transition to adult care. optimal clinical care for scd includes disease education, which can be difficult given the breadth of possible topics and limited time in clinic. it is unclear how best to provide personalized, efficient education for adolescents with scd. this quality improvement (qi) study aimed to implement a questionnaire-based system to improve patients' knowledge of their scd and documentation of education by the nurse or physician. the study objective was to improve provider documentation and patient knowledge about their scd by identifying patients' gaps in comprehension. by january , the study aimed to increase education documentation from % to %. by april , the study aimed to increase use of a smart phrase for education documentation from % to %. by june , the study aimed to increase patients' knowledge about their disease by %. design/method: twenty-one scd patients enrolled on an irb approved qi study, with twenty active patients. our comprehensive team generated a questionnaire with knowledgebased questions for two age groups: - and - years old. at each comprehensive visit, a questionnaire was distributed, with at least -month intervals. the provider scored questionnaires and reviewed two educational topics, with wrong answers taking priority. plan-do-study-act (pdsa) cycles included pdsa# : patients completed questionnaire. pdsa# : a smart phrase addressing questionnaire topics was created and shared with providers. pdsa# : patients received education handouts during clinic education. documentation in clinic notes was the process measure and questionnaire scores was the outcome measure. results: pdsa# is complete, pdsa# has four patients remaining, and pdsa# is ongoing. due to variable visit frequency, there are multiple concurrent cycles. after pdsa# , free text documentation was completed an average of % over the course of months. after pdsa # documentation increased to % within months and questionnaire scores increased from an average of % to %. of the questions that patients got wrong on their first visit, they were significantly more likely to improve on retesting if the topic was taught to them than if it was not addressed ( % vs. %, p = . ). we are currently completing pdsa# and collection of post pdsa# data. questionnaire-based scd education coupled with standardized smart phrases improves patients' scd knowledge and documentation by providers. further improvement in knowledge is expected with the addition of handouts. background: exposure to suffering can have a profound impact on the wellness of caregivers, often referred to as the "cost of caring". this cost is especially high in pediatric hematology/oncology. repeated exposure to suffering has the potential to negatively impact resilience and increases the risk of burnout, thus impacting quality of care and patient satisfaction. we have developed a peer support team utilizing the critical incident stress management (cism) model. this model has been successfully used in other professions that frequently face traumatic events such as fire fighters, police and emergency medical technicians. the h.o.p.e.s. team (helping our peers endure stress) consists of volunteer multidisciplinary staff members who have received training to provide both group and peer support following any 'critical incident' that may impact one or more staff members. we hypothesize that implementation of the h.o.p.e.s. team will improve staff resilience, decrease overall rates of burnout and improve compassion satisfaction. s of s design/method: we are using both empiric metrics and anecdotal reports to assess the impact of the h.o.p.e.s. team. prior to the activation of the team, all pediatric hematology/oncology clinical staff members were surveyed using validated tools to assess their levels of resilience, burnout, secondary trauma and compassion satisfaction (proqolv and brief resilience scale). they were also asked to rate the number of times they had experienced critical incidents, as well as their perceived level of distress after dealing with traumatic events. after the h.o.p.e.s. team has been functional for months, we will send the same survey to staff members to measure changes, paying special attention to resilience and rates of burnout and compassion satisfaction. results: enthusiasm for development of the team has been high. of people approached to volunteer their time to participate in the multidisciplinary team agreed, including attending physicians, fellows, nurses, nurse practitioners, child life specialists, social workers, clergy and psychologists. all volunteers participated in a -day training conducted by an instructor from the international critical incident stress foundation. engagement in the first staff survey has been high, with of responding to date. data collection is ongoing. clinical staff in pediatric hematology/oncology may be particularly vulnerable to burnout and decreased resilience by repeatedly witnessing suffering and trauma. peer support interventions following critical incidents may lead to increased resilience and compassion satisfaction while decreasing rates of burnout. enthusiasm for the development of a peer support team has been high. background: monthly blood transfusions are an indicated therapy for pediatric patients with sickle cell disease with certain complications. maximizing transfusion efficiency in a busy infusion clinic requires: ensuring that appropriate blood units are available in the hospital blood bank; laboratory specimens are obtained from patients in advance; and coordination of clinic appointment and nursing availability. we sought to improve clinic efficiency through identifying ways to better communicate with patients/families regarding upcoming laboratory and transfusion appointments, and to assess the efficacy of implementing a web-based personalized text reminder (pinger.com). we measured the baseline frequency with which transfusion appointments were missed by families, moved to later within the week, or delayed due to late labs. a convenience sample of patients receiving monthly transfusions received a questionnaire about patient/parent preferences for appointment reminders and barriers to keeping appointments. those patients/parents who did not opt-out of an additional text reminder received personalized texts from their care team reminding them of lab and transfusion appointments. rates of missed/moved/delayed appointments were compared between the group receiving the additional text messages and the group only receiving standard, hospitalgenerated appointment reminders (telephone call). results: forty-one families ( patients) responded to the survey, capturing information on % of patients receiving chronic transfusion therapy. thirteen families ( %) declined the additional text reminders. families reported a preference for text reminders ( %), more often than email ( %) or telephone ( %), and % of families wanted to receive reminders for both transfusion and laboratory appointments. the majority ( %) of families reported competing work/life priorities as the reason for missed/late appointments. other families noted transportation/travel ( %), fear/illness/pain ( %), and lack of reminders ( %) as the reason for missed appointments. at baseline (twelve weeks), . % of appointments were missed on a weekly basis (range - of available per week), . % were moved, and % of appointments were delayed. during our intervention period (twelve weeks), % were missed, . % were moved, and . % were delayed (combined, both groups). there was no difference in missed ( . % texted vs . % standard), moved ( . % texted vs . % standard) or delayed ( . % text vs . % standard) appointments. though families at our center reported a preference for a text-based reminder, personalized text reminders for appointments did not improve clinic efficiency as measured by missed, moved or delayed transfusion appointments. there was no improvement in appointment adherence in the group receiving personalized texts in addition to standard hospital reminders. university of utah, salt lake city, utah, united states background: childhood cancer outcomes have improved significantly, in large part due to multi-institution collaborative clinical trials run by the children's oncology group (cog). approximately half of eligible children with cancer will enroll on a therapeutic trial, but little is known about the factors affecting caregiver decision-making regarding enrollment or how well the required elements of informed consent are conveyed during the consent process. objectives: . assess coverage of ten of the required elements of informed consent for cog therapeutic trials. . describe factors affecting caregiver decision-making regarding therapeutic trial enrollment. we surveyed families of children who were offered enrollment onto a phase cog therapeutic study for an initial cancer diagnosis in the previous months. fisher's exact or wilcoxon rank-sum tests were utilized to compare demographic and other motivating factors related to enrollment decision-making. results: seventy participants were surveyed. regarding of the basic required elements of informed consent, % knew the trial involved research, % knew consent was required, % knew the enrollment length for the trial, % knew they could continue care independent of enrollment, % knew who to contact with questions, % knew there were options besides enrollment, % knew they could withdraw at any time, % knew the information was confidential, % knew there were risks associated with the trial, and % knew there were benefits. of all participants, % (n = / ) enrolled onto a therapeutic study. among enrollees, % (n = / ) of the primary caregivers had completed college compared to % (n = / ) of those not enrolled (p = . ). when asked about factors impacting their decision, % (n = / ) of those enrolled said they felt there were no risks or did not know if there were risks associated with the study compared to % (n = / ) of those choosing not to enroll (p = . ). of those enrolled, % (n = / ) reported the physician recommendation "somewhat" or "strongly" affected their decision to enroll compared to % (n = / ) of those not enrolling (p = . ). of those who enrolled, % (n = / ) reported feeling pressured to enroll while % (n = / ) of those not enrolled reported pressure (p = . ). of enrollees, % (n = / ) reported they did not have enough time to decide compared to % (n = / ) of those not enrolled (p = . ). failure to convey all required elements of informed consent highlights possible deficiencies in the consent process for cog therapeutic trials. caregivers' perception of being pressured and lack of time to make an informed decision may impact clinical trial enrollment. background: abnormal uterine bleeding (aub) is a frequent adolescent gynecologic complaint. however, limited research exists to guide management, and acute care varies. we sought to improve emergency care for adolescents with aub by developing a clinical effectiveness guideline (ceg) and assessing its impact on quality of care. design/method: a stakeholder engagement group consisting of members from the departments of hematology/oncology, adolescent medicine, general pediatrics, and emergency medicine designed a ceg algorithm for emergency aub management. pediatric residents received ceg training and their knowledge and attitudes were assessed using pre and post intervention surveys. icd- and codes identified electronic health record data for patients presenting to the pediatric emergency department (ed) for aub months before and after ceg implementation. pre-pubertal patients and those with vaginal bleeding from trauma were excluded. a weighted, -point scoring system consisting of prioritized aspects of history, laboratory studies and management was developed to quantify the quality of care provided. t-test, chi square test, wilcoxon rank sum test, and a run chart were used for analysis. of the patients identified, met inclusion criteria. there were % of patients currently using some form of contraception, while . % had bleeding related to a current or recent pregnancy. median aub quality care scores were pre-and post-intervention (p = . ). run chart data showed no shifts or trends (overall median score, -points). both pre and post-implementation, points were deducted most frequently for not assessing personal/family clotting disorder history and inappropriate use/dosing of oral contraceptives. we successfully designed and implemented a ceg and educational intervention for aub management in a pediatric ed. these data suggest our ceg may be an effective tool to improve emergency aub care for adolescents, though additional cycles are needed. background: high-dose methotrexate (hd-mtx) is a common chemotherapy administered inpatient at most centers. its administration is particularly susceptible to error due to the need for frequent drug levels with resulting changes in supportive care. errors can prolong patient stay and cause patient harm. objectives: global aim-to reduce the length of stay (los) of hd-mtx admissions. smart aims-to increase the percentage of patients whose pre-hydration fluids are started by am from % to % by / / , and to increase the percentage of patients who receive hd-mtx by pm from % to % by / / . we used rapid process improvement methods to target earlier methotrexate administration. a key driver of prolonged los was hypothesized to be drug levels returning overnight rather than in the day time due to delayed hd-mtx start. changes implemented have included scheduling hd-mtx patients as the first patients of the day for their exam in clinic and scheduling labs to pass for hd-mtx on the day prior to admission. there are ongoing pdsa cycles to change the location of pre-hydration start from the inpatient room to the clinic exam room in order to meet hd-mtx administration time goals. we are piloting two different education materials to improve patient experience. one explains hd-mtx levels in a red/yellow/green stoplight format and the other reminds patients how to prepare for the admission. other interventions regarding how we test urine ph and safety checks in the ordering process for history of delayed clearance are in the planning stage. the project is ongoing, but as of / / , we start methotrexate by pm % of the time which is improved from a baseline of %. when the project was started, pre-hydration was never started before am. now, fluids are started by am % of the time. pdsa cycles are ongoing and we have yet to sustain reductions in los, but some months have shown decreased los by as much as hours from baseline measurements. rapid cycle improvement can be utilized to decrease los hd-mtx admissions. this has important financial implications as well as the potential to reduce secondary harm from unnecessary time in the hospital. pediatric cancer centers should schedule hd-mtx admissions first thing in the morning so that data regarding kidney injury and drug clearance can be interpreted by the day team and children are not cleared for discharge in the middle of the night. background: education and training for interdisciplinary pediatric oncology providers requires training in principles of palliative and end-of-life (eol) care. the experiences of bereaved parents can inform and enhance palliative care educational curricula in uniquely powerful and valuable ways. the objective of this study is to present an innovative palliative care educational program for oncology providers facilitated by trained bereaved parents who serve as volunteer educators in local and national palliative care educational forums and to describe how incorporation of bereaved parents in these educational forums affects participant comfort with communication and management of children at the eol. design/method: survey tools were adapted to determine how bereaved parent educators affected participant experiences in different educational forums: institutional seminars on pediatric palliative and eol care, role-play based communication training sessions, and an international symposium on pediatric palliative oncology. pre-and post-session surveys with incorporation of retrospective pre-program assessment item to control for response shift were used in the evaluation of institutional seminars and communication training sessions. results from feedback surveys sent to all attendees were used to appraise the participants experience in the international oncology symposium. results: involvement of trained parent educators across diverse, interdisciplinary educational forums improved attendee comfort in communicating with, and caring for, patients and families with serious illness. importantly, parent educators also derive benefit from educational with interdisciplinary clinicians. integration of bereaved parents into palliative and eol care education is an innovative and effective model that benefits both interdisciplinary clinicians and bereaved parents. background: poorly controlled chemotherapy-induced nausea and vomiting (cinv) significantly impairs patients' quality of life and contributes to ongoing medical costs through increased length of stay in the hospital or readmissions and outpatient visits for control of nausea, vomiting or dehydration. lack of adherence to national evidenced-based guidelines that dictate antiemetic prescribing for variably emetogenic chemotherapy leaves patients vulnerable to increased cinv and its ensuing complications. objectives: to review our institution's antiemetic prescribing practices and their consistency with the antiemesis guidelines from the national comprehensive cancer network (nccn) and children's oncology group (cog)-endorsed supportive care guidelines and to further develop tools to increase adherence to these national-based guidelines to improve control of cinv. we performed a retrospective chart review of inpatient chemotherapy encounters. we evaluated emetogenicty of chemotherapy (high, medium, low), initial antiemetic regimen ordered, number of as needed medications required and adherence to national evidenced based guidelines tailored to each level of emetogenicity in the prescription of antiemetics. results: fifty-five total inpatient chemotherapy encounters were reviewed over months. eighteen of these encounters were considered to have been highly emetogenic chemotherapy (hec) with the remaining of these considered to be moderately emetogenic. only out of hec encounters completely included all guideline-recommended agents. there was a demonstrable lack of consistency across providers with dosing of aprepitant and most as needed medications. there was significant variation in order of first, second and third line anti-emetics ordered -with lorazepam and promethazine being used most frequently. with an aim of improving antiemetic prescribing practices for our patients, we are currently rebuilding chemotherapy treatment plans in our electronic medical record to incorporate antiemetic drug order sets that follow evidenced-based guidelines for variably emetogenic chemotherapy. this will be used in conjunction with an education initiative about best practices in supportive care for all prescribers of antiemetics. review of our department's recent inpatient chemotherapy encounters show we are falling short in following nationally recommended standards for appropriate antiemetic coverage during chemotherapy. identification of these deficiencies allows for implementation of quality initiatives to improve prescriber adherence to evidenced-based guidelines for better control of cinv. background: there are currently no consensus guidelines for the management of pediatric oncology patients presenting with fever without neutropenia. historically, these patients had been treated similarly to neutropenic patients with empiric antibiotics. while there has been a shift towards reducing unnecessary empiric treatment, there has been limited research into the outcomes associated with withholding empiric iv antibiotics in this patient population. we assessed the safety and efficacy of our institution's current protocol of observing well-appearing patients who present with fever without neutropenia and compared the outcomes of the patients who did and did not receive empiric iv antibiotics. design/method: this was a prospective, single-institution cohort study. patients were included if they were currently undergoing chemotherapy for an oncologic diagnosis and presented initially as an outpatient with fever and nonneutropenia (defined as anc ≥ cells/mm ). for each episode we recorded lab and blood culture results, signs and symptoms of initial presentation, and clinical outcomes, including antibiotic administration and hospital admission. results: a total of episodes of well-appearing patients with fever without neutropenia were identified. compliance with the institutional protocol was high; . % of patients were observed without receiving empiric iv antibiotics. the majority of patients were discharged home and there were no serious complications or infectious deaths. the incidence of positive blood cultures was low ( . % including several likely contaminants), despite the presence of central venous catheters in the majority ( . %) of patients. there were no significant differences in age, oncologic diagnosis, central s of s line access, anc value, or incidence of bacteremia between patients who did and did not receive empiric iv antibiotics. patients who were admitted to the hospital were significantly more likely to have received iv antibiotics (p < . ) despite documentation of a reassuring exam. however, admitted patients who initially received iv antibiotics were just as likely to discharge within hours compared to patients who were observed. we propose that empiric iv antibiotic administration in febrile, non-neutropenic, otherwise well-appearing patients is unnecessary. our study demonstrated no adverse consequences of observation and no significant differences in clinical outcomes between patients who did and did not receive iv antibiotics aside from rate of hospitalization. this supports the practice of observation without empiric antibiotics for such patients. background: children with hepatoblastoma (hb) undergo repetitive computed tomography (ct) scans to determine response to treatment and assess for relapse. this imaging exposes children to radiation, anesthesia, and imposes financial and emotional burden. objectives: review our institutional experience to determine if afp measurements are sufficient to assess response to treatment and detect relapse. we conducted a retrospective chart review of all patients diagnosed with hb at our institution between - . data collected included serum afp, total number and type of imaging studies during and post treatment, and how relapse or progressive disease was detected. results: thirty-one patients were diagnosed with afp positive hb. during therapy, ct scans were performed: to assess for response to therapy or surgical planning (average scans/patient) and due to concern for progression with rising afp. off therapy, surveillance ct scans were performed (average of . scans/patient) and ( %) included the chest in patients with no lung metastasis at diagnosis. relapsed patients averaged . surveillance scans, . of which were done before relapse was noted on imaging. there were no cases of radiographic evidence of relapse without a prior increase in afp. during treatment, response to therapy based on imaging correlated with a decline in afp in all patients, arguing that repetitive scans are not needed in this setting unless required for surgical planning. only of scans performed during off therapy surveillance displayed evidence of relapse, all of which were preceded by rise in afp. our study represents the largest cohort of hb patients. prior studies suggest similar results, but included fewer patients, lower stage of disease and less than years of surveillance monitoring. at our institution, the cost of a ct c/a/p is $ , with reimbursement varying from - %. in comparison, the cost of an afp measurement is $ . . many scans also require anesthesia and result in emotional toil for families concerned about this procedure as well as the results. thus, afp demonstrates greater sensitivity, with significant cost savings and decreased emotional burden, and should be used for monitoring both during and off therapy, replacing routine serial imaging. background: we observed that our practice of drawing daily blood cultures in hospitalized patients with fever and neutropenia was wasteful; it resulted in excessive negative cultures that did not add to patient care. the smart aim of this quality improvement project was to reduce the number of negative blood cultures drawn on hospitalized patients with fever and neutropenia by % in months. design/method: after reviewing published evidence suggesting drawing daily blood cultures in febrile neutropenic patients was unnecessary, a new blood culture guideline was implemented: cultures were drawn at presentation for fever with neutropenia and, if negative at hours, repeat cultures were not drawn except for clinical change, new fever after being afebrile > hours, or antimicrobials were being changed/broadened. to impact key drivers, we educated staff and changed blood culture order sets to require providers to select a reason for ordering the culture and to eliminate a nursing order to draw daily cultures with fever. we compared the number of blood cultures drawn per central linedays (/ -cld) and the proportion of positive versus negative cultures pre-guideline (july -may ) and postguideline (june -december ). we calculated the cost savings from reducing cultures. to assess patient safety, potential septic events without a corresponding positive blood culture were reviewed. data were analyzed by service (oncology and stem cell transplant). a chi-square test was used to compare rates. in stem cell transplant patients, pre vs. postguideline, there were vs. total cultures drawn/ -cld; vs. positive ( % decrease, p = . ) and vs. negative cultures/ -cld ( % decrease, p< . ). in oncology patients, pre vs. post-guideline, there were vs. total cultures drawn/ -cld; vs. positive ( % decrease, p = . ) and vs. negative cultures/ -cld ( % decrease, p< . ). the decreased positive culture rate among oncology patients may be due to decreased culture contaminants and/or the effect of a concurrent initiative to decrease clabsi in that group. there were safety concerns; however, chart review concluded that the guideline did not lead to missed infections in these patients. for the first months of the guideline, the total cost savings in blood cultures was $ , . . the implementation of our new blood culture guideline successfully led to a substantial reduction in the collection of negative cultures and a cost savings without compromising the detection of bacteremia in hospitalized pediatric patients with fever and neutropenia. background: there are various evidence-based guidelines for treatment of adult cancers, such as the nccn guidelines. previously, care was standardized for most new diagnosis pediatric cancer patients through enrollment on a clinical trial. with decreasing clinical trial availability and enrollment and few, if any, evidence-based guidelines for pediatric cancer, care standardization is challenging for pediatric cancers. objectives: to assess consistency of care, as determined by plan of treatment by diagnosis, for pediatric patients receiving chemotherapy for newly diagnosed cancer at a single center. design/method: patients with a new cancer diagnosis at a large, tertiary care pediatric oncology center in calendar year were identified through reports from the chemotherapy order entry (coe) system. reports included diagnosis (recorded through standardized options) and the plan of treatment. chart review was used to exclude patients who started treatment elsewhere and patients being treated for relapse, to clarify diagnosis if the standardized options in coe were unclear, and to clarify treatment plan if needed. data was entered and analyzed in a redcap database. specific diagnoses were clustered into higher level disease groups and the distribution of treatment plans for patients within each was determined. this project was deemed exempt from irb approval for human subject research as a qualifying quality improvement project. of the patients with a first chemotherapy order in , were excluded due to one or more reasons: stem cell transplant ( ), transfer of care ( ), relapse ( ), and other ( ). an additional patients were excluded because < patients/year/diagnosis. there was no cns tumor disease group with > patients. thus, patients with hematologic malignancies or non-cns solid tumors are the focus of this analysis. for patients with intermediate risk rhabdomyosarcoma, the plan of treatment was the standard arm of a cog protocol, arst for patients and arst for subsequent patient after protocol activation. for all other diseases including lymphoblastic leukemia/lymphoma (excluding infants), classical hodgkin lymphoma, aml (excluding trisomy and apml), stage iii/iv burkitt lymphoma/diffuse large b-cell lymphoma, posttransplant lymphoproliferative disease, wilms tumor, rhabdomyosarcoma, ewings sarcoma, osteosarcoma, neuroblastoma, and retinoblastoma, only one treatment plan per risk category was used. conclusion: this analysis demonstrates highly consistent chemotherapy treatment at a single center for patients with hematologic malignancies and non-cns solid tumors. next steps include exploring strategies to group diagnoses for cns tumors and assessing the quality of evidence supporting the treatments given. background: rapid initiation of empiric antibiotics in patients with fever and neutropenia has been shown to reduce morbidity and mortality. current practice guidelines call for the initiation of antibiotics in these patients within sixty minutes and time-to-antibiotic (tta) has been suggested as a quality-of-care measure. many institutions, including our own, face barriers to meeting this time limit. objectives: utilizing a quality improvement model, determine barriers and implement an intervention to reduce the time-to-antibiotics for pediatric febrile patients with suspected neutropenia who present to the emergency department (ed) at our institution. we have identified and implemented an intervention utilizing the plan-do-study-act model for quality improvement. a twelve-month retrospective review was conducted to evaluate the efficacy of the current practice algorithm at our large, academic tertiary-care hospital. subjects identified were pediatric oncology patients undergoing active chemotherapy who presented to the ed with febrile neutropenia. we identified two specific barriers, triage level assignments and delay in ordering antibiotics. to address these barriers, we have created a wallet sized "fever card" that patients were instructed to show upon arrive to the ed. in collaboration with the ed staff, efforts were also made to educate all pediatric staff on the use of the fever card. post-intervention data collection is currently underway and pre-and post-intervention antibiotic delivery times will be compared. the pre-intervention cohort consisted of thirty-three encounters with a mean time-to-antibiotic delivery of minutes, or seventy-five minutes greater than the accepted standard of care. only one patient received antibiotics within sixty minutes of arrival. post-intervention data collection is currently underway. since identifying two barriers to meeting the standard of care at our institution, we have implemented a quality improvement measure that empowers patient families to direct appropriate triage in the ed as well as simplifying the treatment protocol for ed providers. we expect to identify an improvement in time-to-antibiotics from the pre-intervention to the post-intervention period. background: sickle cell disease (scd) is a genetic disorder in which sickle hemoglobin (hbs) triggers multiple downstream effects, including red cell sickling, hemolysis, vaso-occlusion, and inflammation. scd, a lifelong disease initiated at birth with injury that accumulates over time, causes significant end-organ damage and clinical complications that are undertreated and associated with early death. homozygous mutation (hbss) causes the severe form of scd. individuals with scd are at increased risk of infection, stroke, and retinopathy. clinical guidelines for pediatric patients with scd recommend prophylactic penicillin use (ages - ), annual screening for stroke with transcranial doppler (tcd) imaging (ages - ), and annual ophthalmology exams to assess for retinopathy (ages ≥ ). there are limited real-world data on implementation of these nhlbi-based recommendations. objectives: to describe utilization of penicillin, tcd screening, and ophthalmology care in children with hbss disease. medicaid administrative claims databases were used to identify us patients aged - years at first indication of hbss recorded in each calendar year from to . patients were required to have medical and pharmacy benefits for the calendar year in which they were identified and for months prior to their first recorded hbss indication. prior year utilization of penicillin, tcds, and ophthalmologist visits was measured for each annual cohort. annual cohorts included - commercial (mean age . years, % female) and - medicaid (mean age . years, % female) patients with hbss disease. fewer than half of all patients had received a tcd scan in the previous year, with similar rates seen across all age groups for both payers. ophthalmologist visits increased as patients aged, and while patients aged - years had the highest proportion with an ophthalmologist visit in both payer populations, the overall implementation remained low. in contrast to the low use of tcd and ophthalmology visits, penicillin use was highest in the - year age group: > % use in any given year for both payers. conclusion: although our data demonstrated high penicillin use in the - year age group, consistent with guidelines there is an opportunity to improve implementation of other guidelines-based recommended screening. for example, tcd screening can identify children at risk of scd-related stroke in order to initiate preventive therapies. further research to understand potential barriers to proper screening and to evaluate strategies to improve awareness, adherence, and implementation of recommended screenings in children with scd is warranted. supported by global blood therapeutics. background: childhood cancer therapy has improved where there are many long-term survivors. while psychosocial difficulties in pediatric cancer survivors are recognized, the prevalence of these problems at initial survivorship presentation is unclear. objectives: to examine the prevalence of overall internalizing symptoms (e.g., depression/anxiety) in pediatric cancer survivors presenting to a survivorship clinic and to examine how this is mitigated by receiving psychological services and by evidence of parental depression/anxiety. design/method: pediatric cancer survivors attending their first visit at the reach for survivorship clinic at vanderbilt (ages - ) were included. survivors' parents ( % female) completed the child behavior checklist (cbcl), beck depression inventory-ii, and beck anxiety inventory. survivors > years completed a self-report. the wilcoxon rank-sum and pearson's test were used for univariate analyses. the effect size and % confidence intervals (ci) estimated from the multivariable linear regressions were reported. results: childhood cancer survivors a median of years old and . years off therapy were included. thirty one survivors ( %) showed at least borderline clinical internalizing problems (t score > ) on the cbcl, but only of these patients ( %) reported receiving psychological services. nine other survivors with normal t score ≤ also reported receiving psychological services. parental depressive and anxiety symptoms were correlated to the parental report of survivor overall internalizing symptoms (spearman = . , p = < . and = . , p = < . respectively), however they were not correlated to survivor selfreports. furthermore, parents with mild to severe depressive symptoms or mild to severe anxiety symptoms were more likely to rate their child as having higher overall internalizing symptoms (p = . ; p = . , respectively). multivariable linear regression showed that when adjusted for age, gender, cancer diagnosis and time off treatment, reported utilization of psychological services ( = . , % ci [ . , . ],p = . ), and parent depressive symptoms ( = . , [. , . ],p< . ) were significantly associated with child overall internalizing symptoms. in an otherwise identical alternate model substituting parental anxiety for parental depression, parental anxiety was also a significant risk factor ( = . , [. , . ], p< . ). alternatively, parent anxiety/depressive symptoms were not significantly associated with child self-report of internalizing symptoms. childhood cancer survivors have an elevated prevalence of experiencing internalizing symptoms but seldom report receiving psychological services. childhood cancer survivors' parents with anxious/depressed symptoms are more likely to rate their children as having more internalizing problems, compared to patient self-reports. ongoing longitudinal analyses will help clarify the best timing for potential interventions. background: life expectancy for adults with sickle cell disease (scd) has remained unchanged over the past years despite improvements in pediatric scd survival. at greatest risk are the adolescents and young adults (ayas) transitioning from pediatric to adult care. allen county ranks rd in scd incidence among the counties in indiana, and has board certified pediatric hematologist-oncologists. when children "age out" of the pediatric system, there are few providers knowledgeable about managing adults with scd in the region. a novel partnership between hematologists and the family medicine residency program in allen county was initiated to educate family medicine residents (fps) about scd, hydroxyurea (hu), and management of scd-related complications with the goal to increase the number of knowledgeable providers to care for adults with scd. to determine the effectiveness of online learning modules in educating fps about hu, best practices for aya scd care and transition. three online learning modules about scd (comprehensive care of ayas with scd, hu, best practices in aya transition) were developed and cme-accredited. electronic pre-and post-tests were distributed to fps with five questions for each module covering: contraception; screening tests; hu indications, dosing and monitoring; developmental milestones and scd knowledge assessments. the st vincent irb reviewed the protocol and granted a waiver of consent. results: twenty-six fps ( %) completed the pre-and posttests. over two-thirds correctly identified the clinical benefits of hu on both assessments. knowledge about the rationale for hu therapy increased after the completion of the hu module ( % correct on pre-test vs. % on post-test, p = . ). the proportion of correct responses increased for all comprehensive aya scd care post-test questions, but only the leading cause of death and the priapism-related questions reached statistical significance ( % vs. %, p = . ; % vs. %, p = . , respectively). the proportion of correct responses for of the transition-focused questions was unchanged ( % for both), while the proportion of correct post-test responses on the self-care assessment question significantly increased ( % vs. %, p = . ). after module completion, fps were able to correctly identify common scd complications and why hu is an effective treatment for individuals with scd. the best practices of transition clinic module may need modification to improve physician understanding of the intricacies in establishing and maintaining a scd transition clinic. overall, online training is effective at educating fps and could be used to increase the number of providers knowledgeable about scd care. background: survival rates for pediatric hodgkin lymphoma (hl) exceed % with contemporary therapy. studies of pediatric hl survivors treated in the s- s have shown increased risk for treatment-related chronic health conditions. risk-adapted therapy, including tailored radiotherapy, has been developed to reduce long-term morbidity while maintaining excellent survival. little is known about chronic conditions associated with contemporary therapy presenting during the first years from therapy completion (early outcomes). objectives: to analyze survival and early outcomes of pediatric hl patients treated with contemporary therapy. we conducted a retrospective review of hl patients diagnosed < years of age at our institution from - . three-year overall (os) and event-free (efs) survival were calculated with kaplan meier statistics using sas . . results of standardized screening for targeted toxicities that developed between - years from therapy completion were identified and graded per ctcae criteria. censoring occurred at date of death, years from therapy completion, or december , . data from the last collection point were used for prevalence calculations in cases with multiple evaluations. we identified patients ( % male; % non-hispanic white; mean age at diagnosis . ± . years) with a median time since therapy completion of . years (range . - . ). initial treatment included: ( %) chemotherapy only and ( %) multimodality treatment. all patients received anthracyclines (median dose mg/m ) and % received alkylating agents (median cyclophosphamide equivalent dose [ced] mg/m ). the -year os was % with an efs of % ( % chemotherapy only, % multimodality treatment; p = . ). patients with relapsed/refractory disease received salvage treatment including chemotherapy only (n = ), multimodality therapy (n = ), or multimodality treatment including stem cell transplant (autologous n = ; autologous+allogeneic n = ). no patients developed thyroid dysfunction, cardiac dysfunction, subsequent neoplasm, or male gonadal dysfunction during the study period. pulmonary dysfunction was limited to ctcae grade . anti-mullerian hormone (amh) below the normal range was found in / pubertal females who received ced ≥ mg/m compared to / females who received ced < mg/m . two of the females with low amh also had follicle stimulating hormone > iu/ml. this study is the first to evaluate early outcomes in pediatric hl survivors. the results indicate contemporary chemotherapy and a lower rate of radiotherapy utilization lead to excellent -year survival rates with minimal early toxicities. females exposed to ced ≥ mg/m are at increased risk for gonadal dysfunction and should be prioritized for fertility preservation approaches prior to initiation of cancer therapy. background: cancer is one of the leading disease-related causes of death among individuals aged < years in the united states. recent evaluations of national trends of pediatric cancer used data from before , or covered ≤ % of the us population. objectives: this study describes pediatric cancer incidence rates and trends by using the most recent and comprehensive cancer registry data available in the us. design/method: data from us cancer statistics were used to evaluate cancer incidence rates and trends among individuals aged < years during - . data were from states and covered % of the us population. we assessed trends by calculating average annual percent change (aapc) in rates using joinpoint regression. rates and trends were stratified by sex, age, race/ethnicity, us census region, county-based economic status, and county-based rural/urban classification, and cancer type, as grouped by the international classification of childhood cancer (iccc). we identified , cases of pediatric cancer during - . the overall cancer incidence rate was . per million; incidence rates were highest for leukemia ( . ), brain tumors ( . ), and lymphoma ( . ). rates were highest among males, aged - years, non-hispanic whites, the northeast us census region, the top % of counties by economic status, and metropolitan counties. the overall pediatric cancer incidence rate increased (aapc = . , % ci, . - . ) during - and contained no joinpoints. rates increased in each stratum of sex, age, race/ethnicity (except non-hispanic american indian/alaska native), region, economic status, and rural/urban classification. rates were stable for most individual cancer types, but increased for non-hodgkin lymphomas except burkitt lymphoma (iccc group ii(b), aapc = . , % ci, . - . ), central nervous system neoplasms (group iii, aapc = . , % ci, . - . ), renal tumors (group vi, aapc = . , % ci, . - . ), hepatic tumors (group vii, aapc = . , % ci, . - . ), and thyroid carcinomas (group xi(b), aapc = . , % ci, . - . ). rates of malignant melanoma decreased (group xi(d), aapc = - . , % ci, - . -- . ). this study documents increased rates of pediatric cancer during - , in each of the demographic variables examined. increased overall rates of hepatic cancer and decreased rates of melanoma are novel findings using data since . next steps in addressing changing rates could include investigation of diagnostic and reporting standards, host biologic factors, environmental exposures, or potential interventions for reducing cancer risk. increasing pediatric cancer incidence rates may necessitate changes related to treatment and survivorship care capacity. background: while childhood cancer treatment modalities have improved, the delayed effects of cancer treatment continue to compromise the quality of life in survivors. metabolic syndrome (ms) is diagnosed based on the presence of three of the following findings -obesity, dyslipidemia, hypertension and insulin resistance per the world health organization (who) criteria. the increased risk of ms among childhood cancer survivors was first reported in the 's and is known to increase the incidence of cardiovascular disease in these individuals. objectives: assess the frequency of ms in childhood cancer survivors at our institution. . we conducted a retrospective chart review on pediatric cancer survivors, - years of age, who had been treated at sri ramachandra medical institute and research foundation between august and august . patients who received at least one year of treatment with s of s chemotherapy and/or radiation and surgery were included. medical history, family history of diabetes, cardiovascular diseases, and hypercholesterolemia, tanner staging, weight for height (< y per who criteria), bmi (> y per indian academy of pediatrics iap), blood pressure (nhlbi criteria), fasting blood sugar levels and lipid profile were obtained from the charts. statistical analysis of the data was done using ibm spss statistical software (version ). results: patients were studied, . % were male. . % were under years of age, . % between - years and . % above years. leukemia survivors comprised . % of the sample and non-leukemic's were . %. . % were treated with chemotherapy alone, . % with radiotherapy and chemotherapy, and . % underwent surgery with radiotherapy and chemotherapy. hypertension was found in . % of the study group, dyslipidemia in %, impaired fasting blood glucose in . % and . % were found to be obese. % of the study group was diagnosed with ms based on who criteria. conclusion: % of our study population was found to have ms per who criteria. individual metabolic complications were detected in % of the population. acute lymphoblastic leukemia (all) survivors appeared to be at high risk in our population. ms has been known to increase cardiovascular complications in cancer survivors. a multidisciplinary team approach to management of these patients is important to closely monitor and manage the long-term complications related to ms such as type diabetes and atherosclerosis. such an approach is essential to decrease long term morbidity and mortality from ms in this vulnerable population. background: the -year survival rate for childhood cancer exceeds %. however, up to % of these children require admission to the pediatric intensive care unit (picu) within three years of diagnosis. these children account for approximately % of all picu deaths, with mortality being higher for those post-hematopoietic stem cell transplant (hsct). national guidelines recommend that providers share informa-tion regarding prognosis and treatment options within the first hours of icu admission. these prognostic goals of care conversations (pgocc) are critical to the care of children with malignancies, a subpopulation at risk for increased mortality. to determine the frequency of pgocc as well as describe differences in patient characteristics and critical care therapies by pgocc status. design/method: a retrospective cohort study was conducted using the university of michigan virtual picu system database. picu admissions lasting longer than hours for patients ages to years between july , and june , with an oncologic diagnosis and/or hsct were identified. data on pgocc, patient demographics, diagnoses, picu interventions, and outcomes were recorded and compared between children with pgocc and those without using chi square test for categorical variables and kruskal-wallis test for continuous data. of picu admissions, % were male; the mean age was . years. the leading diagnoses were acute lymphoblastic leukemia ( %), acute myeloid leukemia ( %), lymphoma ( %), neuroblastoma ( %), and brain tumors ( %), and % of patients were post-hsct. pgocc was documented in ( %) patients. in comparison with patients who did not have a pgocc, children with a pgocc were more likely to be readmitted to the picu ( % vs. %, p < . ) and more likely to have had relapse of disease ( % vs. %, p< . ). patients with a pgocc had higher severity of illness scores (p = . ), higher use of non-invasive ( . % vs. . %, p = . ) and invasive conventional ventilation ( . % vs. . %, p< . ), and high frequency ventilation ( . % vs. . %, p < . ). also, patients with pgocc were more likely to receive continuous renal replacement therapy ( . % vs. . %, p< . ), arterial catheterization ( . % vs. . %, p< . ), and cardiopulmonary resuscitation ( . % vs. . %, p< . ). in only in critically ill children with hematologic-oncologic disease is pgocc held. children with pgocc were sicker and received more critical care interventions. future research is needed to evaluate the content of pgocc. background: central nervous system (cns) tumors and autism spectrum disorder (asd) represent significant disease cohorts in the pediatric population. asd diagnoses in children have a prevalence of %, in every children in the united states. additionally, more than , cns tumors are reported in children age to years in the united states with brain tumors being the most common solid tumor and the leading cause of death among all childhood cancers. the genetic etiology of autism and cns tumors is complex. specific gene alterations present in certain cancers have similarly been described and suspected to play a role in asd subtypes. targeted therapy panels, like foundation one (fo), have been beneficial in guiding treatment for some cancers based on distinct gene alterations. given the genetic overlap, the potential for therapeutic benefit and crossover from such actionable gene target panels merit further exploration in asd and cns tumors. we aim to identify and describe genetic alterations with known actionable targets in cancer therapy from fo as potential diagnostic, therapeutic and research targets for neurodevelopmental diseases. we plan to discuss the common genetic alterations between our cancers and neurodevelopmental diseases described in the literature. fo data was extracted and compared to the literature. each reported gene alteration from fo plus the keywords "autism", "psych" were used on pubmed to search for a suspected association if any with a neurodevelopmental disorder. results: twenty-one patients representing a cohort of six unique (astrocytoma-five, ependymoma-six, gbm-four, glioma-three, nerve sheath tumor-one, etmr-two) cns tumors were investigated. fo produced eighty total with sixty unique gene alterations. thirty-one ( %) of these yielded at least one published, suspected association to a neurodevelopmental disorder. the most common gene alterations were tp -four, cdkn a/b-five and braf-four. the main functional categories were cellular: proliferation, structure, differentiation and degradation; chromatin modeling; histone transcriptional modification; dna methylation and repair; strna; and neural signaling. sixty unique gene alterations were found in our cns tumor set using foundation one. thirty-one ( %) of these discrete alterations paired with at least one description in the literature as having been similarly altered in an asd subtype. many of these alterations have actionable targeted therapies presented through foundation one for our cns tumors and may be a relevant guide in the future of targeted therapy and research in asd subtypes. monoclonal antibody therapy usage is associated with significantly improved survival in b-cell nhl aya patients. although the usage has increased in the aya population from to , the magnitude of the increase is low. factors that affect the use of mab include race and insurance s of s type. further research is warranted to identify why privately insured patients are less likely to receive these drugs. background: prevention of chemotherapy-induced nausea and vomiting (cinv) remains a challenge despite advances in pharmacotherapy and the development of cinv clinical practice guidelines by the pediatric oncology group of ontario (pogo) that have been endorsed by the children's oncology group. achieving control of cinv in pediatrics further is complicated by the difficulty young children have vocalizing their symptoms. use of a validated nausea-assessment tool in conjunction with improved adherence to evidence-based guidelines may result in better quantification of symptoms and reduction of both nausea severity and vomiting frequency for pediatric patients undergoing chemotherapy. the pediatric nausea assessment tool (penat) has been validated for children ages - , and its integration into clinical practice may help optimize cinv control. objectives: this single-institution study sought to improve control of cinv in patients admitted for chemotherapy by standardizing the antiemetic regimens prescribed by all providers according to an institutional cinv algorithm developed from the pogo guidelines. we hypothesized that treatment using a standardized guideline would improve cinv control in patients admitted for chemotherapy. a baseline cohort of admissions for chemotherapy completed penat assessments and cinv diaries prior to receiving chemotherapy, four times daily during each admission, and daily for days following completion of chemotherapy from may , to january , . providers then were provided an institutional cinv treatment algorithm based on the pogo guidelines and received education at departmental meetings on appropriate implementation of this algorithm. a second cohort of admissions completed penat assessments and cinv diaries in a similar fashion from july , to december , . results: complete control of vomiting markedly improved following cinv guideline implementation ( % vs %, p <. ) with treatment failure also significantly reduced ( % vs %, p <. ). after controlling for the degree of emetogenicity of chemotherapy received, a patient was . times more likely to vomit prior to guideline implementation (or . , ci . - . ). there was no difference in nausea control, even after adjusting for the emetogenicity of chemotherapy. conclusion: control of chemotherapy-induced vomiting (civ) improved following widespread implementation of an institutional cinv treatment algorithm at a single institution. the severity of nausea reported remained unchanged which may reflect the difficulty of assessing nausea or an inadequate sample size. future research may focus on cinv treatment management through the use of guidelines specifically for breakthrough cinv and delayed cinv. background: aspho's professional development committee (pdc) recognized pediatric hematologists-oncologists (phos) serving in the united states (us) military have unique professional development needs that may not be addressed by aspho or a similar professional society. these individuals may also encounter challenges when transitioning to a civilian career. however, barriers to professional development have not been systematically characterized. the objectives were to characterize the number of phos with current or prior military service (mphos) and to identify any unmet professional development needs. design/method: a working group consisting of pdc members and both senior and early career mphos was formed. initial comments were solicited by email from known mphos regarding potential gaps in professional development and interest in working with aspho to improve support of mphos. a survey was developed and piloted with four members of the advisory group, questions were revised based on their feedback, and a final version was distributed via the aspho website and online community forum. targeted emails were sent to mphos identified through aspho and military databases. eligibility to complete the survey included ) completion of a fellowship in pediatric hematologyoncology, and ) current or prior service as an active duty military provider. quantitative and qualitative information were collected, including demographic data and perceived barriers to professional development. responses were summarized using descriptive statistics. results: sixty-five mphos were identified and surveys were completed for a % response rate. respondents were engaged in a variety of professional activities; % were male, % were serving active duty commitments, and % felt there were professional development gaps. areas of concern were categorized into nine themes with the most concerning being ) limited civilian knowledge of mpho practices ( % of participants), ) inability to attend professional society meetings ( %), and possibility of deployment ( %). participants expressed a desire for educational products to meet their specific needs and for networking opportunities with civilian colleagues. qualitative analyses identified concerns about low patient numbers and practice size. a subset of mphos perceive significant gaps in professional development. additional research is needed to better define areas for intervention, but many of the concerns align with those of similarly sized civilian programs and may be addressed through professional society networking opportunities, such as an aspho special interest group. background: infertility is an established cause of distress and has a negative impact on quality of life among childhood cancer survivors. the american society of clinical oncology has established guidelines on fertility counseling for individuals of reproductive age diagnosed with cancer, with the goal of improving reproductive and psychosocial outcomes. studies have shown that instituting a fertility team that can provide counseling and discuss fertility preservation (fp) options results in improved patient satisfaction in patients with cancer. objectives: the goal of this study was to examine predictors of referrals to the multidisciplinary fertility team, and documented fp interventions among these patients. design/method: an irb-approved retrospective medical record review was performed at a large pediatric academic center. all patients with new cancer diagnoses receiving chemotherapy were included from january (when the fertility team was established) to present. a standardized abstraction form was used to collect information about: age at diagnosis, gender, cancer type, whether a fertility consult was placed, and documented fp interventions. data were summarized descriptively and comparisons were made using nonparametric statistical methods. results: patients met inclusion criteria, of which ( %) were male. cancer types were as follows: leukemia/lymphoma, cns tumors, sarcomas, embryonal tumors, and langerhan's cell histiocytosis (lch). the mean age was . years, (range < - years). overall, % of all patients had a consultation with the fertility team. patients were significantly less likely to have a fertility consult if they were younger (p< . ). further, there were differences in the consultation rate between diagnoses, with % of sarcoma patients completing a consult, compared to % of those with cns tumors, % of those with embryonal tumor, % of those with leukemia/lymphoma and none of the patients with lch. our findings show that many children, adolescents, and young adults newly diagnosed with cancer are still not receiving fertility counseling despite: ) an expanding body of literature supporting the need to provide this counseling, ) guidelines published by several organizations recommending discussions about infertility risk and fp options, and ) presence of a multidisciplinary fertility team. specific strategies need to be developed to improve access for younger children, and for disease groups in whom fertility consults are underutilized, such as youth with cns tumors, embryonal tumors, and leukemia/lymphoma. background: socioeconomic status (ses) has on impact on overall survival in the pediatric oncology population. unfortunately, data are insufficiently detailed to explain the mechanism behind this phenomenon. how parents handle the health management demands placed on them at the time of a child's cancer diagnosis may represent a point of differentiation in health outcomes. objectives: determine the association between socioeconomic factors, cancer literacy, and parents' understanding of home emergency management and their responses to instances of pain, nausea, and fever. in a prospective observational study of parents whose children were newly diagnosed with cancer, we obtained demographic information and, using a validated instrument, (dumenci, ) we evaluated cancer literacy. we tested understanding of the education parents received about home emergency management with a -item multiple-choice vignette-based questionnaire focused on actions needed in home scenarios. we then followed parents' actual behavior through periodic phone calls assessing instances of nausea, pain, and fever and their responses to these episodes. results: preliminary analysis of participants showed an average score of on the -item parental understanding questionnaire (range - ). variables associated with increased score were college-level education by . points ( % ci [. to . ]), private insurance by . points [. to . ] and adequate cancer literacy by . points [. to . ]. actual behavior reported by families indicated that married parents and those with income above $ , were less likely to treat instances of pain by % ( % ci [ to ]) and % [ . to ], respectively. white parents, those with college-level education, and those with adequate cancer literacy were less likely to treat instances of nausea by % [ to ], % [ to ] and % [ to ], respectively. no associations were found between socioeconomic markers and parental responses to instances of fever. our findings suggest an association between demographic and socioeconomic markers and improved parental understanding of home emergency management. paradoxically, the same markers show a decrease in treatment response to pain and nausea. larger prospective studies are needed to link this behavior pattern to health outcomes, and help inform the extent of ses impact on home emergency management. emory university/children's heathcare of atlanta, atlanta, georgia, united states background: cardiovascular disease is a leading cause of morbidity and mortality in childhood cancer survivors (ccs). previous research showed wide practice variation in referral patterns to cardiology from the survivor clinic and in recommendations from cardiologists about the need for further testing or exercise restrictions. to develop a cardio-oncology algorithm in order to standardize referrals to cardiology and provide guidelines for cardiologists evaluating pediatric ccs. design/method: survivorship and cardiology experts developed a weighted scoring system for pediatric ccs who received cardiotoxic therapy based on time since treatment and risk factors identified by the children's oncology group (cog) and american heart association (aha). the cardiooncology algorithm assigned a score of - . the score range was categorized to guide cardiology referral: screening echo only ( - ), consider cardiology referral ( - ), recommend cardiology referral ( - ), and regular cardiology follow-up (≥ ). the algorithm also provides recommendations to cardiologists for screening and exercise modifications based on the score. after establishment of the algorithm, a convenience sample of institutional survivor clinic patient charts were retrospectively reviewed from the first month of each quarter from april -march to validate the algorithm, evaluate referral patterns to cardiology, and assess cardiology recommendations. the retrospective chart review evaluated patients ( % male; % non-hispanic white; % leukemia survivors; median age at diagnosis . years [range - . ]; median time off-therapy . years [range . - . ]). patients ( %) received anthracyclines (median dose mg/m , range - ) and ( %) received cardiac radiation. assigned cardio-oncology scores resulted in: % echo only, % consider cardiology referral, % recommend cardiology referral, and % regular cardiology followup. when evaluating detection rates of late effects by cardiooncology score, survivors ( %) had an abnormal echo: / echo only, / consider referral, / recommend referral, and / regular cardiology follow-up. assessing referral patterns prior to initiation of the algorithm revealed forty-two survivors ( %) referred to cardiology: / echo only, / consider referral, / recommend referral, and / regular cardiology follow-up. of the patients seen by a cardiologist at our institution, had further diagnostic testing ordered (i.e., stress test) and received exercise restrictions. a cardio-oncology algorithm and guidelines will standardize cardiac care for survivors by assigning a score to guide referral and cardiology practice after referral. prospective clinical use has begun and review will occur in one year to determine changes in detection rates of cardiac late effects, referrals, and recommendations from cardiologists. oregon health and science university, portland, oregon, united states background: delirium affects - % of patients (pts) in pediatric intensive care units (picu) and is associated with increased length of stay, decreased attention in school, and post-traumatic stress disorder. the diagnostic and statistical manual of mental disorders (dsm v) defines delirium as a "disturbance of consciousness […] with reduced ability to focus, sustain or shift attention" due to an underlying medical condition. despite the medical complexity of the hospitalized pho population, there are no published prospective studies looking at delirium in these pts. hypothesizing that delirium is under recognized in the pho population, we designed a year-long prospective study using a validated screening tool to determine the frequency of delirium in hospitalized pho pts and to identify associated clinical factors. design/method: baseline frequency of pts with symptoms suggestive of delirium was determined through retrospective chart review using a data mining program of electronic medical records (emr). for the prospective study, pho and picu nurses were trained to use the cornell assessment for pediatric delirium and to record scores within the emr on all pho pts once every -hour shift. predetermined demographic and clinical variables were entered daily into a red-cap database on all hospitalized pho pts. results: baseline frequency of delirium, without active screening, was determined to be . % of hospitalized pho pts. in the first months of the prospective study, consecutive admissions occurred among unique pho pts: oncology, hematology, and stem cell transplant pts. pts had at least positive delirium screen, for a prevalence per admission of . %. statistically significant variables associated with delirium, at p < . by univariate logistical regression, included prolonged length of stay, pt location (picu vs pho unit), and fever. adjusting for length of stay, administration of benzodiazepines and opiates were also significantly associated with delirium, p = . and . , respectively. on average, nurses completed delirium screening in % of each pts' -hour shifts. study accrual ends in jan and final data analyses will be reported in the abstract presentation. conclusion: delirium does occur in the pho hospitalized population and screening by trained nursing staff is feasible. pts at highest risk appear to be pts with prolonged hospital stays, picu admissions, or frequent use of benzodiazepines/opioids. routine screening should improve our recognition of delirium and allow us to promptly intervene, or prevent delirium in an effort to avoid potential acute and long term consequences. background: with high survival rates for children and adolescents with hodgkin lymphoma (hl), treatment regimens are now designed to maximize cure while decreasing risk of long-term health outcomes associated with chemotherapy and radiation therapy. within contemporary treatment regimens, the comparison of toxicities experienced by patients receiving chemotherapy plus radiotherapy (crt) versus only chemotherapy (co) has not been studied extensively. objectives: this study examines select self-reported adverse health outcomes in survivors of contemporarily-treated pediatric hl to better understand the balance between efficacy and toxicity associated with chemotherapy and radiation therapy. (cog) ahod that evaluated a response-based treatment paradigm in pediatric hl. patient who received initial chemotherapy were randomized based on early response to continued chemotherapy, chemotherapy plus radiotherapy or augmented chemotherapy plus radiotherapy. patients completed self-report questionnaires on health problems at , , , and years following therapy. we examined selected patient-reported pulmonary, gastrointestinal (gi), cardiac and endocrine outcomes. kaplan-meier survival curves were used to determine probability of survival without the selected adverse health outcome. log-rank tests were used to compare the co versus the crt group. results: a total of , enrolled patients, patients in the co group and patients in the crt group, completed , questionnaires at a median of . years after s of s completion of therapy (q , q : . , . ) which were analyzed. the cumulative -year incidence of endocrine dysfunction was significantly greater in the crt group versus those in the co group ( % versus %; p< . ), driven by the incidence of hypothyroidism ( % versus %; p< . ). there were no significant differences in cardiac ( % versus %; p = . ), pulmonary ( % versus % p = . ), and gastrointestinal dysfunction ( % versus %; p = . ) between the co and crt patients. conclusion: this study demonstrates low cumulative incidence overall of organ dysfunction early post completion of contemporary therapy for hl. the addition of radiation therapy significantly increased risk for hypothyroidism, but with no higher risk noted for cardiac, pulmonary or gi dysfunction. limitations include self-report status, potential selection bias, and relatively short latency period following end of therapy. longer follow-up is needed to determine more delayed risks for organ dysfunction in order to best define the balance between therapeutic efficacy and long-term adverse health outcomes related to chemotherapy and/or radiation therapy. background: identification of an organism via bronchoalveolar lavage (bal) or respiratory tract biopsy (rtb) has historically been considered the gold standard for diagnosis of invasive fungal infection (ifi); however, data previously published by our group showed that these procedures infrequently lead to a change in management in children with an oncological diagnosis or undergoing hematopoietic stem cell transplant (hsct). there is also a paucity of data on the cost of ifi in this population. to compare the costs of work-up and management of pulmonary ifi diagnosed based on ct scan alone versus ct scan or chest x-ray prompting a bal or rtb. design/method: we collected cost data on patients at ann & robert h. lurie children's hospital of chicago undergoing chemotherapy or within months of hsct who were suspected of having an ifi between and . in order to include sufficient time to account for post-procedure compli-cations but avoid including costs unrelated to ifi, data were included for days from the day of their diagnostic scan or procedure. cost data was available for of the patients previously studied. thirty-six of these patients were diagnosed with suspected ifi based on ct only and patients underwent bal or rtb. when evaluating specific costs, inpatient beds costs were higher in the bal and rtb group (median $ , versus $ , , p = . ), yet there was only a trend towards higher costs for antifungal agents (median $ , versus $ , , p = . ) and respiratory support (median $ versus $ , p = . ). many of the initial ct scans were not captured in the -day evaluation period for the bal or rtb group based on the study design; however, even when accounting for ct scans up to a week prior these procedures, the total cost of ct scans was higher in the ct only group (median $ versus $ , p = . ), as they had more scans. despite this, total costs were significantly higher for patients who underwent bal or rtb versus ct scan only (median $ , versus $ , , p < . ). combined with our previous data that bal and rtb infrequently leads to a change in management in children with an oncological diagnosis or undergoing hsct suspected to have an ifi, the significantly higher costs associated with these procedures makes these invasive diagnostic techniques even less desirable. batra, pediatr blood cancer, . background: while infants > months of age with acute lymphoblastic leukemia (all) have a poor prognosis, infants with acute myeloid leukemia (aml) fare better despite more intensive therapy. there are limited data on this difference, particularly differences in supportive care requirements during induction therapy for infants. objectives: to compare induction mortality and resource utilization in infants relative to non-infants aged < years, separately for all and aml. design/method: we used previously established cohorts of children treated for new onset all or aml at children's hospitals in the us contributing to the pediatric health information system. patients with down syndrome were excluded. follow-up started on the first day of induction chemotherapy and continued until the earliest of: days after commencement of chemotherapy, start of the subsequent course, or death. high acuity of presentation, defined as icu requirements involving or more organ systems within the first hours following initial admission were compared using log binomial regression. -day inpatient mortality was compared using cox regression. resource utilization rates (days of use per inpatient days) were compared using poisson regression. results: a total of all ( infants, non-infants) and aml ( infants, non-infants) were included in the analyses. infants were more likely to present with high acuity compared to non-infants for both all ( % and %, rr = . , % ci: . , . ; p< . ) and aml ( % vs %; rr = . , % ci: . , . ; p = . ). infants with all had higher inpatient mortality compared to non-infants even after accounting for differences in acuity of presentation ( . % vs . %, adjusted hr = . % ci: . , . ; p = . ). in contrast, inpatient mortality was more similar for infants and noninfants with aml ( . % vs . %, adjusted hr = . % ci: . , . ; p = . ) and comparable to rates among infants with all. infants with all and aml had higher rates of utilization of fresh frozen plasma, cryoprecipitate, diuretics, supplemental oxygen, and ventilation relative to non-infants. infants with all also had higher rates of total parenteral nutrition, ecmo, and patient controlled analgesics compared to noninfants. infants with all experienced significantly higher induction mortality compared to noninfants, a difference not entirely explained by acuity at presentation. differences in ru among infants may reflect higher presentation acuity and greater treatment related toxicity. further work is needed to elucidate the contribution of treatment related toxicity to early mortality in infants with all. background: fever in a child with cancer is a medical emergency due to the significant risk of a serious bacterial infection. many attempts have been made to risk stratify these patients. the respiratory pathogen panel (rpp) is a panel of polymerase chain reaction tests that identify seventeen common respiratory viruses and three bacterial infections. samples are taken via nasopharyngeal swab. rpps are frequently sent, but we do not have data to determine whether a positive result can lead to stratification to a lower risk of bacterial infection. ( ) to determine the epidemiology of respiratory virus-associated fever in pediatric oncology patients ( ) to determine whether a positive rpp is associated with reduced risk of bacteremia in this population. this was a single-center, retrospective cohort study. we identified and reviewed the medical records of all pediatric oncology patients seen in our emergency department (ed) with fever from the introduction of the rpp in april to september , . we reviewed the results of blood cultures, rpp, chest radiographs, and discharge summaries to identify sources of infection. we also identified the patients' cancer diagnosis, age, absolute neutrophil count (anc), and absolute lymphocyte count (alc). results: positive rpps were found among pediatric oncology patients who presented to the ed with fever. the most common positive rpp findings were rhinovirus/enterovirus (rev) ( %), parainfluenza ( %), influenza ( %), coronavirus ( %), and polyviral ( %). among patients with a positive rpp, % had bacteremia compared to % bacteremia among all pediatric oncology patients with fever (or . [ . - . ], p . ). all cases of bacteremia were associated with rev. there was no bacteremia identified in patients with rpps positive for other viruses (or . [ . - . ], p . ). rev positivity did not confer a lower risk of bacteremia than rpp negative patients ], p . ). anc (p = . ) and alc (p = . ) less than , and number of patients with severe neutropenia (p = . ) were not statistically different between the rev and non-rev positive rpp groups. rpps positive for viruses other than rev reduced the likelihood of bacteremia in febrile pediatric oncology patients in the ed setting. patients with bacteremia may have concurrent infection with rev. a larger study is warranted to determine if positive rpp results can inform clinical management of a child with febrile neutropenia. emily mueller, anneli cochrane, seethal jacob, aaron carroll s of s background: the usage of mobile health (mhealth), which refers to the application of mobile or wireless communication technologies to health and healthcare, has grown exponentially in recent years. mhealth tools have been used by caregivers of other vulnerable populations, but little has been focused on caregivers of children with cancer. objectives: to conduct a survey to understand the mobile technology usage, barriers, and desired mhealth tools by caregivers of children with cancer. we conducted a mailed cross-sectional paper survey of caregivers of all children who were diagnosed with cancer at riley hospital for children between june, and june, . the survey contained questions, both fixed and open-ended, in both english and spanish. up to three rounds of surveys were sent to those who did not respond. of the respondents, they were primarily parents ( . %), median age was . years (range - ), and most were white ( . %) and non-hispanic/latino ( . %). the top three annual household income brackets included $ , to $ , ( . %), $ , to $ , ( . %) and under $ , ( . %). the majority had an education: . % college graduates, % graduate degree, and . % high school education or ged. nearly all respondents owned a smart phone ( . %) and . % owned a tablet. the majority used an ios operating system ( . %), while . % reported use of a device with an android operating system. all caregivers reported use of at least one mobile website/app regularly for their personal use. while . % of respondents reported no barriers to mobile technology use, the top barrier selected was "data limitations" ( . %). overall, . % wanted at least one medical managementrelated website/app: medical knowledge ( . %), healthcare symptom tracking/management ( . %), and medication reminders ( %). healthcare system-related desires were high, as . % wanted access to their child's medical record and . % wanted a website/app to facilitate better communication with medical providers. there were no significant associations between socioeconomic status (income or education) with barriers or types of websites/apps desired by caregivers. since the vast majority of caregivers use mobile technology with minimal barriers, future research should focus on designing an mhealth tool to address the medical management needs by caregivers of children with cancer. by supporting caregivers through this type of mhealth tool, it could positively impact patient clinical outcomes through greater adherence to medications and treatment protocols. background: in children with fever and neutropenia, early initiation of targeted antibiotic therapy improves outcomes, yet there are no standards for choice of empiric antibiotics. in our institution implemented an early empiric ceftriaxone (eec) protocol to reduce time to antibiotic administration in febrile hematology-oncology patients who are potentially neutropenic when the absolute neutrophil count is not yet know. ceftriaxone is given immediately after obtaining blood for culture and lab studies. in patients found to be neutropenic, ceftriaxone is discontinued and cefepime is initiated. the purpose of this retrospective study was to evaluate our eec protocol in neutropenic patients by assessing ceftriaxone sensitivity of positive blood cultures and comparing rates of adverse outcomes with a cohort of patients treated prior to implementation of the protocol. we are now conducting a prospective study to more thoroughly investigate antibiotic sensitivities of organisms isolated from blood cultures of neutropenic patients. design/method: hematology-oncology patients with at least one positive blood culture between january and december were identified. patient demographics, neutrophil count, antibiotic treatment, isolated organisms and sensitivities, and adverse outcomes (increased respiratory support, hypotension requiring intervention, and icu admission) were obtained by retrospective chart review. fisher exact test was used to compare dichotomous variables between patient groups. we are now prospectively identifying febrile neutropenic patients with positive blood cultures and performing antibiotic sensitivity testing to several antibiotics commonly used as empiric therapy for febrile neutropenia. results: retrospectively, we identified neutropenic patients with a total of bacterial isolates from blood cultures. of organisms isolated, were tested for sensitivity to ceftriaxone and ( %) were not sensitive, / ( %) of gram-positive cultures and / ( %) of gram-negative cultures. ten of ( %) eec patients had an adverse outcome versus / ( %) of non-eec patients (p = . ). notably, % of eec patients required icu admission versus % of non-eec patients (p = . ). thus far our data obtained prospectively is revealing similar rates of ceftriaxone resistance with / cultures not sensitive to ceftriaxone ( %, ci . %- . %). in our retrospective study, no statistically significant difference was seen in overall adverse outcome rate between the two cohorts, though icu admission rates were significantly higher in eec patients. ceftriaxone resistance rates were high in tested isolates, which is further supported by preliminary data from our ongoing prospective study. given these data, eec may not be effective at improving outcomes in febrile neutropenic pediatric hematology-oncology patients. background: approximately in children diagnosed with cancer will die of their disease, despite advances in treatment. results: two focus groups of six parents each met in june . the parents were predominantly female ( female, male) and had lost their children an average of . years prior (range - . years). two parents were in the same family. nearly all patients were offered palliative care ( / ), all were offered hospice and most died at home ( at home, in the icu). parent discussion uncovered six broad themes: beneficial provider qualities, optimal communication, helpful systematic supports, struggles to feel like a good parent, struggles with a loss of control and unmet needs. parents appreciated providers who were consistent, reliable and honest. parents desired communication that was sensitive to the needs of the patient and family with a balance of hope and realism. parents appreciated the tangible supports pro-vided by social work and the emotional support of child life both for the patient and their siblings. some parents struggled to define and advocate for their child's quality of life, especially when it led to disagreeing with the medical team. several parents expressed frustration with unfamiliar caregivers in the hospital, especially trainees. they expressed a strong desire for more anticipatory guidance about the end of life including how to discuss it with their children. they also wished for a cancer-specific support group for bereaved parents. conclusion: bereaved parents of pediatric oncology patients in our focus groups appreciated consistent, reliable providers who communicated with a balance of realism and hope. they appreciated the tangible and emotional support they received and wanted more anticipatory guidance at the end of their child's life. these results can help guide clinical care, especially in communities without strong palliative care support. further research is needed to develop interventions to improve end of life care. background: clinical trials involving human subjects depend on informed consent (ic) to ensure ethical protections for participants. parents of children with cancer often lack full understanding of the basic elements of ic for clinical trials. additionally, the stress of their child's cancer diagnosis may affect their decision-making capabilities. this is especially problematic as these children rely on parents to fully comprehend clinical trials and weigh their benefits and risks. physician communication is critical for effective family-centered care. the acgme mandates that training programs teach and assess trainees' communication skills. however, there are currently no published curricula aimed at training pediatric hematology/oncology fellows to deliver ic effectively for cancer clinical trials. to develop and pilot-test a simulation-based curriculum to enhance communication skills of pediatric s of s hematology/oncology fellows in the delivery of ic for cancer clinical trials. we developed, tested, and implemented the curriculum from to in two phases. in phase- , we reviewed literature on simulation-based curricula and completed a needs assessment to create a clinical scenario and full curriculum using standardized patients. using miller's pyramid model, fellows' assessments included: immediate de-brief, surveys to assess pre/post confidence and knowledge of the basic ic elements ("knows" and "knows how"), and -degree summative assessments compiled from fellow self-assessments, faculty, and standardized patients ("shows how"). after initial testing and refinements done with fellow, in phase- , we implemented the curriculum with our fellows. likert scale ( strongly disagree- strongly agree) and basic p values are reported. results: fellows gave high mean ratings for training relevance ( . ) and standardized patients' preparedness ( ). almost all ( . ) reported they have used the knowledge gained in their clinical practice. increase in self-reported confidence (pre/post) was noted in all domains: general -describing possible benefits of the clinical trial . / vs. . / (p = . ), risks and potential side effects . / vs. . / (p = . ), and explaining alternatives . / vs. . / (p = . ); research -discussing purpose of the clinical trial . / vs. . / (p = . ), and randomization . / vs. . / (p = . ); and family-centered -addressing emotions during ic . / vs. . / (p = . ), and delivering bad news . / vs. . / (p = . ). summative evaluation mean ratings for all fellows were . (range . - . ). our novel simulated-based ic curriculum, significantly increased fellows' self-reported confidence and skills during ic delivery. importantly, our ic curriculum addressed not just research-related content but also management of parental emotional needs during the ic discussion. next phase includes kirkpatrick model program evaluation and dissemination across other training programs in our institution. national kaohsiung normal university, kaohsiung, taiwan, province of china background: taiwan's childhood cancer foundation reported in that the -year survival rate of childhood cancer was %. as a result, many childhood cancer survivors were back in school after treatment. however, childhood cancer survivors' educational outcomes suffered because of their long-term absence from school and late effects of cancer and cancer treatment. a few school reentry protocols have been developed by the nursing professionals in taiwan to facilitate students' return to school but remained experimental in nature and hardly accessible. parents, students, and teachers were left to their own devices to make individual school reentry plans. objectives: this study aimed to examine and uncover the commonalities among three middle school students' successful school reentry experiences from their teachers' perspectives and to analyze the factors contributing to their success. design/method: this is a qualitative interview study. indepth semi-structured interviews were conducted with three middle school teachers in december about their perceptions, observations, and experiences working with adolescent childhood cancer survivors. the students were two boys with leukemia and one girl with bone cancer. they were diagnosed in the first year of middle school when they were - years old and returned to school for the third and the final year. these students met the following criteria for successful school reentry: regular school attendance, average/above average academic performance, friendship maintenance, and high school diploma. the theme -bring the class to the hospital was found to be the key to the adolescents' successful return to school. without a prescribed school reentry protocol and in the face of limited bedside education services, the homeroom teachers, as links between school, home, and hospital, brought the class to their hospitalized students. they doubled as bedside teachers conducting lessons at the hospital or students' homes, became friends with the parents, witnessed firsthand the students' pain and triumph during treatment, brought the students back to school for visits and celebrations, delivered the classmates' wishes and news to the students, encouraged and welcomed classmates' visits to the hospital, and, together with parents and other teachers, developed flexible school reentry schedules for the students. this on-going study demonstrated the critical roles and functions of homeroom teachers in successfully bringing the students back to school during and/or after cancer treatment. further analysis will be focused on how and why these three homeroom teachers were able to carry out this unexpected task on top of their already full workload. jennifer kesselheim, shicheng weng, victoria allen, collaborative group fellowship program directors dana-farber/boston children's cancer and blood disorders center, boston, massachusetts, united states background: a novel, -module, case-based curriculum entitled "humanism and professionalism for pediatric hematology-oncology" (hp-pho) aims to foster pho fellows' reflection on grief and loss, competing demands of fellowship, difficult relationships with patients and families, and physician well-being and burnout. in small group facilitated sessions, fellows work to identify coping strategies and explore how the challenges of fellowship influence both their own doctoring and the patient experience. objectives: to administer the hp-pho curriculum in a prospective, cluster-randomized trial, measuring whether exposure to this educational intervention, compared to standard conditions, fosters humanism and professionalism and improves satisfaction with training. design/method: pho fellowship programs (n = ) were cluster-randomized to deliver usual training in humanism and professionalism (control) or the novel curriculum (intervention) during the - academic year. the primary outcome measure was the pediatric hematology-oncology self-assessment in humanism (phosah). secondary measures included a -point satisfaction scale, the maslach burnout inventory (mbi), the patient-provider orientation scale, and the empowerment at work scale. participating fellows were pre-tested in summer and post-tested in spring . a change score was calculated for each study instrument. we compared each outcome between arms using mixed effect models adjusted for pre-test score as a fixed effect and site as a random effect. results: randomization yielded intervention and control fellows. the two arms did not significantly differ in distribution of fellow age, gender, or post-graduate year. the intervention sites successfully administered of ( %) modules. change scores on the phosah were not significantly different between the control and intervention arms (adjusted mean difference = . ; % confidence interval [ci] - . , . ; p = . ). compared to the control arm, fellows' exposed to the curriculum gave significantly higher ratings on several items within the satisfaction scale including satisfaction with their training on "physician burnout" (adjusted mean difference = . ; % ci . , . ; p< . ), "physician depression" (adjusted mean difference = . ; % ci . , . ; p< . ), "balancing professional duties and personal life" (adjusted mean difference = . ; % ci . , . ; p = . ), and "humanism overall" (adjusted mean difference = . ; % ci . , . ; p = . ). change scores on other secondary measures were not significantly different between study arms. conclusion: exposure to the hp-pho curriculum did not alter fellows' self-assessed humanism and professionalism. however, the curriculum proved feasible to administer and intervention fellows expressed higher levels of satisfaction in their humanism training, indicating the curriculum's positive impact both for fellows and their learning environment. background: recent work has documented significant levels of unmet needs among adolescents and young adults with cancer, particularly psychosocial challenges during the transition to adulthood, (e.g., abrupt disruption to school and social life, and social isolation). given that adolescents and young adults drive mobile app use, a mobile-phone may be an ideal way to deliver a psychosocial intervention to adolescents and young adults with cancer. to use a patient-centered approach to inform a mobile-based mindfulness and social support intervention for adolescent and young adult patients with cancer. design/method: participants were ten aya with sarcoma ( % female; % adolescents); parents of the five adolescents, and six healthcare providers (n = ). formative research involved three steps: ( ) in-depth interviews were conducted with ten aya with sarcoma; parents of the five adolescents, and six healthcare providers (n = ). ( ) adaptations were made to an existing mindfulness app which offers a program for youth. modifications included creating a -week "mindfulness for resilience in illness" program, with relaxation exercises, and the addition of videos featuring two sarcoma survivors as program hosts. content was informed by the mindfulness curriculum for adolescents, learning to breathe. ( ) a private facebook usability group was organized to (i) elicit beliefs about the mindfulness app and potential future enhancements, and (ii) promote social support. results of the in-depth interviews revealed themes around adolescents' functioning and coping, including body image concerns; recurrence-related anxiety; anger over loss; and being overwhelmed by medical information. themes from the interviews were incorporated into a demonstration version of the mobile app. a patient-centered approach is widely recommended in the development of mobile-based health behavior change interventions and may be a useful way to inform development of a mobile-based mindfulness and social support intervention for adolescents and young adults with cancer. background: medical trainees consistently report suboptimal instruction and poor self-confidence in communication skills. despite these deficits, few training programs provide comprehensive pediatric-specific communication education, particularly in the provision of "bad news." an in-depth survey to examine the historical experience and communication needs of pediatric fellows was conducted at a large academic pediatric center as the first step towards the development of a comprehensive communication curriculum. to determine the previous educational and clinical experiences of pediatric subspecialty fellows, assess their levels of comfort in the context of various communication topics, and query potential modalities and topics for future communication training. design/method: the needs assessment survey was developed using previously developed and validated questions and review of the literature. the survey was reviewed by internal and external pediatric oncology and palliative experts and pre-tested with a subset of trainees to enhance content validity. results: thirty-two out of a total of fellows completed the survey ( % completion rate), of which % were pediatric hematology-oncology or subspecialty fellows. most fellows had participated in previous teaching sessions ( %), including those involving role play or simulation ( %). however, few fellows had received feedback from senior clinicians on their communication skills ( % of fellows had received feedback ≤ times). on a scale of -x, with indicating "not well prepared," the mean score for of communication items was < . fellows felt least prepared to lead discussions around informed consent for experimental therapies, end of life care, and autopsy. fellows indicated that didactic educational sessions and additional coursework were less useful strategies for improving their communication skills, whereas small group role play sessions with faculty and/or bereaved parent educators were most useful. fellows' overall communication preparedness score was not correlated with post-graduate year but was positively associated with the number of times they previously had delivered bad news to patients and families. fellows requested additional training on many topics, with greatest interest in learning skills to optimize communication with an angry patient or family. additional topic requests included placing limitations on resuscitation, withdrawing/withholding further therapy, and ageappropriate inclusion of patients in difficult discussions. despite self-report of prior communication skills training, pediatric subspecialty fellows felt underprepared to participate in difficult discussions with patients and families. learners identified role-playing and coaching with real-time feedback from other physicians and bereaved parents as more useful training strategies as compared to didactic sessions. background: when children die of cancer, parents must adjust to their child's absence amidst the lingering turmoil of what preceded their death: witnessing their child undergo painful treatments, making difficult decisions, and anticipating a devastating loss, all the while hoping for a recovery. adjustment to a child's death, as depicted by current bereavement literature, necessitates making meaning of one's loss. professional care staff can help parents make sense of their child's illness, and in turn, of their own parental experience during treatment. however, the extent to which relationships with professional care team members influence parents' ability to make sense of, and successfully cope with, their loss has not been examined. objectives: to examine how bereaved parents' interactions with their deceased child's pediatric oncology professional care team have impacted their grief symptoms design/method: to better understand how interactions with professional care staff relate to parents' grief outcomes, we conducted a mixed-methods study examining staff impact on parental grief. thirty participants whose children died of cancer one to three years ago completed an in-depth interview and psychometrically validated surveys measuring meaningmaking, depression, and grief symptoms. results: correlational analyses of the measures found that an increase in meaning making was associated with lower depressive and grief symptoms. a content analysis of the interviews found that many participants regarded staff "like family," had on-going relationships with staff after their child died, and described various ways staff interactions during treatment and after the child's death helped them make sense of their loss. in particular, participants described how interactions with staff have helped them find benefits in their loss and learn to create a new relationship with their child despite their physical absence. quantifying the interview data and statistically analyzing it along with the measures found that participants' increased frequency of describing staff's positive impact on their grief correlated with higher meaning-making scores and lower grief symptom scores. our study found that bereaved parents who lost their children to cancer were articulate in sharing their experiences of staff engagement and communication during treatment, offering numerous examples of how staff aided them in making meaning of their loss that were reliably associated with their subsequent grief. we hope the results of this mixed methods research encourage further study of the importance of staff interaction with families during the critical period of their children's care, and the lasting impact this can have regardless of the treatment outcome. memorial sloan kettering cancer center, new york, new york, united states background: although resiliency has been recognized as necessary for healthcare professionals, trainees feel unprepared for the emotional challenges inherent in caring for sick and dying patients. compounded by long hours, challenging work environments, and lack of formal training on handling emotionally difficult situations, many institutions are recognizing the need for interventions to reduce trainee distress. the goals of this fellow-led quality improvement initiative were: ) to determine whether there is a need for emotional support amongst pediatric hematology and oncology fellows, ) to provide formal resiliency and debriefing sessions, and ) to measure feasibility, acceptability and effectiveness of implemented curriculum. design/method: an anonymous survey to determine need for resiliency and debriefing sessions following a traumatic event was distributed to active pediatric hematology & oncology fellows at memorial sloan kettering cancer center in january . once need was established, an intervention consisting of a formal curriculum was developed and initiated in june , involving: ) scheduled and ad hoc debriefing sessions in response to traumatic events (including patient death, codes, interpersonal conflicts, end-of-life care); led by a psychiatrist and social worker with fellows and a pediatric oncologist mentor in attendance, and ) a resiliency didactic curriculum, led by a palliative medicine specialist, focused on skills such as contesting cognitive distortions and mindfulness. the effectiveness of these sessions will be measured using follow-up anonymous surveys at months (currently underway) and months post-initiation of intervention. the initial survey demonstrated most trainees ( / ) were present at or more deaths during their training, while less than half of respondents had attended a post-event debriefing session. % of respondents felt there was not sufficient emotional support from the institution for physicians caring for dying patients. a separate pre-intervention survey found all respondents ( / ) expressed a need for regular debriefings, and nearly all anticipated that they would benefit from such debriefings. concerns identified by trainees that would preclude participation in the curriculum included preference to deal with emotional situations privately and time constraints. trainees identified a need for formal debriefings and resiliency skill development. the program was easily implemented, and is both feasible and acceptable with good attendance. feedback received at the -month mark will determine deficits and possible improvements to the curriculum. the -month survey will measure effectiveness of the program and whether it should be continued. background: acute kidney injury (aki) is a common but under-recognized complication among patients with leukemia. it is associated with prolonged hospital stays, increased mortality, progression to chronic kidney disease, and delays or changes in cancer therapy which may affect a patient's prognosis. however, data on aki in pediatric patients with cancer is still lacking overall. we investigated the incidence of aki in patients who were newly diagnosed with all at our center from january to september . we performed a retrospective chart review of all patients who were newly diagnosed with all from neonate to years in our facility. we determined the incidence of aki in our population using the kidney disease: improving global outcomes (kdigo) diagnostic criteria. we also assessed for nephrotoxic exposures, nci all risk stratification and risk of aki, and tumor lysis syndrome (tls). we identified patients diagnosed during the study period who met inclusion criteria. median follow-up time was . months (range . - . ). the cohort was predominantly male ( . %) and hispanic ( . %). our analysis showed . % had aki by kdigo criteria ( % grade , . % grade , and % grade ), . % had aki on presentation, and % had multiple aki episodes during the study period. older age and longer length of hospitalization were associated with aki (p = . and p = . , respectively). there was no association between aki and nci all risk classification, contrast exposure, hyponatremia, elevated white blood cell count, uric acid levels, antimicrobial therapy, or diuretic use in this study. conclusion: aki was a common finding in our study population. the majority had grade aki by kdigo criteria. however, aki was associated with older age and a longer length of stay. further study is needed to determine the short-and long-term impact of aki on pediatric patients with all. st. jude children's research hospital, memphis, tennessee, united states background: in some regions, the availability of trained pediatric oncologists is a limiting barrier for the care of children with cancer. in , the unidad nacional de oncología pediátrica (unop) and the universidad francisco marroquín school of medicine in guatemala established a pediatric hematology/oncology fellowship program sponsored by st jude children's research hospital to provide central america and the caribbean with well-trained specialists. a systematic analysis of the impact of fellowship programs in pediatric oncology has never been done, especially in the context of a regional education program. objectives: this study sought to analyze the impact of the unop fellowship program based on the regional number of providers, pediatric cancer centers and patient volume. in addition, it sought to characterize the jobs and scientific output of the graduates. the impact will be evaluated in the context of a cost analysis. to define the volume of providers, pediatric cancer centers and patients, the directors of pediatric cancer centers in central america were sent an online survey to obtain these data. all the centers contacted maintain an updated hospital-based patient registry. in addition, the graduates of the fellowship program were also sent an online survey, asking about their job at graduation, current role and scientific productivity. the cost analysis will include assessment of direct costs including salaries and stipends for away rotations, as well as the indirect costs of faculty time spent teaching. since the establishment of the unop fellowship program, the region has more providers for pediatric cancer (p< . ) and centers treat a larger volume of patients (p< . ). two new centers have opened with graduates of the program. all but one graduate practice pediatric oncology ( / ) and the majority do it in their country of origin ( / ). no graduate practices outside of this region. almost half of the graduates ( %) hold a leadership role at their institution. the majority of their time is spent in the public sector (> %). the majority of graduates participate in clinical research ( %) and have participated in the creation or implementation of therapeutic protocols ( %). on average, the graduates have published peer-reviewed articles since completion of training. the unop fellowship program has had a favorable impact on pediatric cancer care in the region, contributing to the capacity to treat a larger volume of patients. graduates practice pediatric oncology in the region in the public sector, frequently hold leadership roles and are scientifically productive. background: abandonment of treatment is a major cause of treatment failure and poor survival in children with cancer in low-and middle-income countries. the incidence of abandonment in peru has not been reported. objectives: the aim of this study was to examine the prevalence and associated factors of treatment abandonment in pediatric patients with cancer of peru. we retrospectively reviewed the sociodemographic and clinical data of children referred between january and december to the two main tertiary centers for childhood cancer, located in lima, peru. definition of treatment abandonment was used from the siop (international society of paediatric oncology) podc (paediatric oncology in developing countries) abandonment of treatment working group recommendation. results: data of children diagnosed with malignant solid tumors and lymphomas were analyzed, of which ( . %) abandoned treatment. univariate logistic regression analysis showed significant higher abandonment rates in children living outside the capital city, lima (p< . ); prolonged travel time to a tertiary center (> hours; or . , p = . ); living in a rural setting (or . ; p< . ) and lack of parental formal job (or . ; p = . ). according to cancer diagnosis, children with retinoblastoma were more likely to abandon compared with other solid tumors. in multivariate regression analyses, rural origin and lack of formal parental employment were independently predictive of abandonment. conclusion: treatment abandonment prevalence in our country is high and closely related to socio-demographical factors. treatment outcomes could be substantially improved by strategies that help prevent abandonment of therapy based on these results. st. jude children's research hospital, memphis, tennessee, united states background: to improve the quality of a pediatric hematology/oncology fellowship program, a systematic assessment must be performed that can evaluate its current state and identify areas of opportunity, as well as modifications over time. unfortunately, widely agreed-upon metrics of quality for pediatric hematology/oncology fellowship programs currently do not exist. this is particularly important in this field due to the global shortage of specialists. for this reason, an assessment instrument that is applicable throughout the world must be created. objectives: the st. jude global education program assessment tool (epat) is a novel instrument that seeks to evaluate pediatric hematology/oncology fellowship programs around the world in systematic and objective way. epat will help determine key performance indexes that are relevant for quality education in pediatric hematology/oncology fellowship programs and establish the framework for improvement. design/method: firstly, key domains to be evaluated for program assessment were identified a priori based on the continuum of pediatric hematology/oncology fellowship programs in the context of geography and educational structure. subsequently, questions were formulated to evaluate these key domains, seeking to assess elements involved in ensuring competence in clinical practice, academic productivity and regional impact. due to the novelty of this tool and the lack of defined metrics of quality, epat relies on expert opinion in a two-step process: internally in the department of global pediatric medicine at st. jude children's research hospital and, subsequently, from a panel of experts in global pediatric oncology and medical education from around the world. ten key domains were identified to evaluate all aspects relevant to training programs around the world, regardless of educational and geographic context. questions have been created to assess these domains and, to make epat quantitative, these have assigned weights with a value reflective of their relative importance. this grading system allows for a score in each key domain, permitting monitoring of changes over time. epat is currently at the stage of external expert review, and subsequently will be piloted in five fellowship programs around the world to provide different geographical and patient care contexts for its validation. once epat is finalized, it will be distributed to pediatric hematology/oncology fellowship programs around the world to be applied. epat proposes a novel strategy to assess training programs in a systematic way that includes all aspects relevant for a training program in a global context. this tool will help guide improvements in pediatric hematology/oncology fellowship programs and assure a well-trained workforce. background: with the improvement in pediatric oncology patient survival and outcomes in the past several decades, monitoring for recurrence and long-term effects of therapy has become even more important. the utilization of personalized treatment summaries and survivorship care plans (scps) is one way to communicate this information with patients and families. the american college of surgeons commission on cancer (coc) created a standard regarding provision of scps to % of eligible patients by december , as a metric for accreditation of all cancer centers. the standard applies to all patients with stage i, ii, and iii cancer diagnoses and requires creation of the scp within one year of diagnosis or six months of completing treatment. during implementation at our pediatric cancer center, we identified barriers to use of the guidelines in the childhood cancer setting. objectives: define eligibility for an scp for pediatric oncology patients to include all patients with curative intent and to deliver scps within six months of finishing therapy. design/method: using chart review and a cancer center registry query, we identified childhood cancer patients potentially eligible for an scp by collecting stage, goal of therapy, and dates of treatment. all patients with curative intent were deemed eligible for an scp regardless of stage i-iv. patients being followed in the oncology clinic for posttreatment surveillance and care were included even if they had received an scp in the survivorship program or were greater than six months off therapy at time of implementation. as expected in the pediatric oncology population, acute lymphoblastic leukemia (all) was the most common diagnosis comprising . % of patients. all is stratified into risk groups instead of surgical staging categories, and treatment duration is greater than one year, unlike many adult-onset malignancies. these differences required interpretation of the guidelines to apply to our pediatric population for all and other pediatric diagnoses with non-surgically based staging. our pediatric oncology clinic has to date provided scps to of eligible patients by adapting the guidelines to focus on patients with curative intent to receive an scp by six months off therapy. cancer staging guidelines and goals for curative intent as well as lengths of treatment vary between the pediatric and adult populations. the coc guidelines require adaptation for optimal applicability to the pediatric oncology population. background: education in communication for fellows in fields that require difficult discussions with families are few in nature. adult learning pedagogies such as role play are under-utilized in medical education, and have been shown to be as effective as traditional teaching methods such as lecture. an -module course for fellows in hematology/oncology, hospice and palliative medicine, radiation oncology, and pediatric hematology/oncology was implemented in january/february . fellows participated in the program. topics covered including fundamentals of communication, coping and spirituality, delivery of bad news, communicating with families, sexual dysfunction during treatment, palliative care/death and dying, and burnout. objectives: overall goal of this course is to foster holistic physicians who views their patients as people with cancer, not cancer patients, and physicians that can communicate effectively with their patients throughout the disease continuum. by the end of the course, learners should be able to practice the fundamental principles of good communication. design/method: fellows initially participated in a pre-course osce to establish baseline skills. osce was facilitated by the center for learning and innovation at northwell, and included actors portraying a pediatric patient and family member to whom the fellow had to break bad news. two months later, the course was carried out over the span of eight weeks and included didactic sessions followed by minutes of role play scenarios. five of the eight modules included role play, with faculty members serving as simulated patients. after the course, a second breaking bad news osce was held. both osces were filmed, and feedback was given by the on-site actors. additionally, faculty members were given access to the videos in an on-line format and were given an evaluation tool to assess the fellows' performance pre-and post-intervention. fellows were given subjective surveys pre-and post-course as well. results: subjective data from participants showed a noticeable increase in comfort level in all areas on the pre-and post-course survey. data obtained from osce videos showed improvement in communication skills as assessed by sps and faculty members using a new evaluation tool developed by faculty. initial first-run data shows that this course is successful in improving communication skills as well as increasing fellows' comfort level across several domains of communication. future directions for our course include improving and validating our assessment tool, expanding our topic base to include more aya and pediatric scenarios, faculty development for improved role play, and investigating impact on practice after course completion. background: acute lymphoblastic leukemia (all) is the most common form of childhood cancer with approximately children diagnosed each year. survival rates have improved significantly over the past several years. children with all are at risk for developing musculoskeletal complications during and after completion of treatment, which can contribute to impaired activity, elevated body mass index (bmi), and risk for complications. interventions involving physical activity could improve musculoskeletal strength as well as overall health in these children. the aims of this study are to examine the feasibility of a directed physical activity program for children with newly diagnosed all during the initial intensive phase of therapy and to evaluate the overall health and quality of life of children participating in the directed physical activity program. design/method: all subjects will receive education materials about the importance and safety of physical activity and a nutrition handout. all subjects will also participate in the directed physical activity program under the supervision of a trained physical therapist for at least minutes every week for weeks. the program will entail four stations including a cardiovascular, balance/proprioception, strength and flexibility, and coordination and cardio. feasibility will be assessed by tracking the participation rate throughout the study period. other assessments will be made at study entry, at the end of weeks of physical activity initiative and months after completion of the intervention. assessments include overall strength and flexibility, weight, height, bmi, blood pressure and performance scores. descriptive statistics will be used for this study. results: a total of patients, male and female, enrolled in the study over a . month period. patient ages ranged from - years. half of the patients enrolled have completed the week program and all patients had stability or improvement of their physical functioning scores. further data collection and analysis is ongoing. patients in the early intensive phase of all therapy are at risk for complications that can affect their physical functioning. a directed physical activity protocol may improve their overall physical functioning. patients may not need specific physical therapy; however a directed physical activity program appears to be beneficial for these patients. the main roadblocks to successful completion of the program were difficulty with scheduling, strain on the parents and patient from treatment, unplanned admissions for fever, as well as nausea and fatigue at time of visit. albany medical center, albany, new york, united states background: communication skills are a core competency highlighted by the acgme. increasing resident confidence in delivering difficult news has been shown to lead to more s of s effective communication. currently, the majority of residency programs lack formal training in communication skills. our objective was to demonstrate feasibility and efficacy of integrating a standardized-patient based training program for communication skills into the curriculum of pediatric residents design/method: to date, pediatric and medicine/pediatric residents have participated in the program during the intern year. the program consists of three, two-hour long sessions, in which each resident is given several opportunities to act out case scenarios with a standardized patient. scenarios included informing a parent of their child's new cancer diagnosis and disclosure of a positive hiv test to a teenager. residents received post hoc peer to peer, and preceptor to learner feedback. pre and post-program surveys were completed by residents. results: following course completion residents reported an increase in confidence in multiple areas of communication including giving a difficult diagnosis (p< . ), discussing a poor prognosis (p< . ), responding to different patient/family member emotional responses i.e. crying or anger (p< . ), and organizing vital information to be relayed (p< . ). in conclusion, communication skills training of pediatric residents is feasible and provides a platform for developing valuable skills not taught elsewhere within the curriculum. background: for children with cancer, transitioning back to school during or after treatment can be challenging. literature supports the need for school re-entry programs to ease this transition. however, these programs vary widely among pediatric cancer institutions with little data addressing their program components. data from this study provides information on current school re-entry programs across these institutions. objectives: one objective of this study was to assess for correlation between the presence of a school re-entry program and other factors, such as geographic location and institution size. a second objective was to establish a list of differences between institutions' school re-entry program components. finally, we aimed to describe current school reentry practices, as well as program benefits and perceived areas for improvement. states with membership in the children's oncology group were offered enrollment in this study. a member of each institution was invited to participate in a survey established by the research team. this person was closely associated with the institution's school re-entry practices. each interview queried institution demographics, as well as program components (e.g., participants, target audience, resources). comment was also collected on program benefits and potential for improvements. analysis of transcripts was performed using pearson's correlation to assess for relationships between institution size, geographic location, and program presence. grounded theory was used for analysis of benefits and improvements. results: thirty-nine of forty-one pediatric institutions who were offered enrollment participated in this study. twentynine institutions ( %) indicated the presence of a school reentry program, and ten ( %) stated they had none. no correlation was found between institution size and the presence of a school re-entry program (p = . , ns). there was also no correlation found between institution location and the presence of a school re-entry program (p = . , ns). a major theme surrounding the benefits of having a program included education for the returning student's peers. for those with programs, perceived improvements included increasing staffing and the ability to offer more services. the results do not support the hypothesis that the presence of a school re-entry program is influenced by the size and geographic location of the treating institution. however, data seem to suggest that available staffing may influence the presence of a program. future studies are needed to address other potential influences, as well as to take an evidence-based approach to determine the effectiveness of the interventions present in these programs. cohen children's medical center/ zucker school of medicine at hofstra-northwell, new hyde park, new york, united states background: genetics/genomics is evolving at an extremely rapid pace. current advances lead to individual algorithms toward disease treatment for each disease with multiple branch points. fellows learn only a fraction of the knowledge and there is no formal approach to teaching critical analysis of information and application algorithms toward disease. additionally, as knowledge evolves extremely rapidly, any approach must teach self-acquisition and application of evolving discoveries. objectives: to create, implement and evaluate a novel curriculum for genetics/genomics targeted toward pediatric hematology/oncology fellows design/method: the curriculum includes four components: ) genetic and genomic medical knowledge, with one initial team-based learning session and weekly online multiple choice questions; ) essential pathways, which will teach molecular pathways common in oncogenesis and relevant to targeted therapy in microteaching sessions with using auditory, visual and tactile learning; ) knowledge acquisition and clinical judgment, to allow learners to gain experience into researching data available, then developing and prioritizing potential treatment plans using problem-based learning sessions in which they will stage a patient, research treatment options, prioritize and present findings; and ) synthesis to demonstrate independent ability to research and recommend therapy through an independent project in which the learner, given a case, will present the case and research findings, genetics/genomics, molecular pathways and make recommendations for therapy in molecular tumor board for faculty and fellows. to evaluate, we plan to recruit to institutions, match for size of programs and implement in half and evaluate nd and rd year fellows in both groups by mcq exam and satisfaction surveys. the creation of a multi-module, adult-learning based curriculum for genetics and genomics in pediatric oncology is feasible. implementation and evaluation are necessary to demonstrate efficacy. background: neuroblastoma is the most common extracranial solid tumor in children. chimeric anti-gd antibody ch . (dinutuximab) therapy has improved the survival of children with newly diagnosed high-risk, neuroblastoma patients as well at the time of first relapse/progression. acute neuropathic pain is a well-documented side effect of dinutuximab administration. however, additional adverse effects including sensorimotor neuropathy, ocular symptoms, and behavioral changes have been described. the incidence and severity of these effects are currently not well-documented in pediatric patients. with improved long term survival of patients receiving this modality, it is important to look for the potential late effects of dinutuximab. objectives: to determine the incidence and severity of neurologic, ophthalmologic, or behavioral changes after dinutuximab administration at our institution. we performed a retrospective chart review using our electronic medical record. we included all patients with high-risk neuroblastoma between the ages of and years at our institution diagnosed between and who received dinutuximab. patients with history of opsoclonus-myoclonus syndrome or gross sensorimotor neuropathy prior to receiving dinutuximab were excluded. we examined clinical documentation for subjective reports and objective exam findings of neurologic, ophthalmologic, or behavioral changes. we also looked for referrals made to neurology, ophthalmology, physical medicine & rehabilitation (pm&r), and psychology. : twenty-two patients met inclusion criteria. at the time of chart review, patients were alive and were deceased. eighteen patients received dinutuximab per anbl ; patients received dinutuximab per anbl . of these patients, patients reported symptoms of interest and reported multiple symptoms. six patients reported symptoms that began at least months after completing dinutuximab. nine patients had objective findings on exam, including decreased deep tendon reflexes, abnormal pupils, and nearsightedness. for patients, referrals were made to ophthalmology, pm&r for neuropsychologic testing, or neurology. two patients who reported symptoms of interest were not referred to a specialist. conclusion: neurologic, ophthalmologic, and behavioral symptoms were commonly reported and demonstrated on exam among pediatric patients with high-risk neuroblastoma who received dinutuximab. it is important to identify these effects so that appropriate specialist referrals can be placed for adequate management of these changes. we recognize that these symptoms may not be solely due to dinutuximab as these patients receive other agents including opioids, so a prospective trial is needed to further evaluate the long-term effects of dinutuximab and to determine how best to screen for these effects. akron children's hospital, akron, ohio, united states background: pediatric cancer is the leading cause of diseaserelated death in children in the united states (u.s.). in , over fifteen thousand children were diagnosed with cancer in the u.s. this population is at high risk for malnutrition due to the multimodal therapies they receive: surgery, chemotherapy, radiation therapy, antibody therapy, and/or bone marrow transplant. adverse effects of these therapies include taste changes, loss of appetite, diarrhea, vomiting, and/or mucositis, making it difficult for the children to be able to consume adequate amounts of nutrition during therapy. there is no "gold standard" measurement tool for identifying patients at risk for malnutrition. nutritional status is not frequently evaluated as a component of clinical trials. assessment of anthropometric measurements (weight, height, z-scores) at diagnosis, as well as over the duration of treatment, can assist in the early identification of malnutrition. the incidence and prevalence of malnutrition in this population is unknown at akron children's hospital. the purpose of this study is to describe the nutritional status and provision of nutritional support therapies in pediatric patients during their first year post new oncologic diagnosis. objectives: identify the incidence and prevalence of malnutrition across oncologic diagnostic categories over the first twelve months post diagnosis. we performed a retrospective records review of all patients newly diagnosed with cancer in at akron children's hospital. demographic and anthropometric data was collected at time of diagnosis and nutritional status categorized by z score. anthropometric and nutrition support data was then collected every two months for the first year after diagnosis along with incidence of unplanned inpatient admissions. results: a total of patients were included in the analysis, with . % malnourished at time of diagnosis; . % developed malnutrition the first year. patients with solid tumors represented % of patients with pre-existing or acquired malnutrition. overall, % of patients received at least one nutritional support modality. patients with pre-existing or acquired malnutrition had a non-significant increase in unplanned admissions (p = . ). our study demonstrated that patients with solid tumors were found to be at increased risk of pre-existing and acquired malnutrition, followed by leukemias, and experienced higher incidence of unplanned admissions in the time period observed. prospective, multi-center replication of this study, including detailed collection of nutrition therapies is recommended to guide development of diagnosis specific nutrition support guidelines. background: pediatric and young adult oncology patients treated with intense chemotherapy have a high incidence of transfusional iron overload. iron deposition can lead to heart failure/arrhythmias, liver abnormalities, endocrine dysfunction, ineffective erythropoiesis, and increased cancer and mortality risk. however, there is a paucity of data regarding recommendations for management of transfusional iron overload in these cancer survivors. consequently, long-term complications of transfusional iron overload specific to these patients have not been assessed. objectives: to assess screening and phlebotomy-based treatment algorithms for this population. design/method: a retrospective chart review of pediatric and young adults who completed oncology management, had iron overload, and initiated phlebotomy treatment was conducted. tiered screening occurred in patients that received at least packed red blood cell (prbc) transfusions. patients were recommended for evaluation and possible phlebotomy if: ( ) liver iron concentration (lic) > mg of iron/gram dry weight liver tissue by ferriscan and/or ( ) cardiac mri t * < ms. during phlebotomy, iron status was assessed quarterly and phlebotomy discontinued with lic < or normalization of ferritin/imaging lic verification. descriptive statistics were employed to report the characteristics of the study population. spearman correlations were utilized to describe associations between transfusions, lic, ferritin, iron saturation and number of phlebotomy sessions. results: twenty five survivors underwent phlebotomy. the mean age was . years (sd . ) and ( %) were female. oncologic diagnoses: all ( %), aml ( %), nhl ( %), ewing sarcoma ( %), osteosarcoma ( %), neuroblastoma ( %) and cns ( %). patients received a median of . (iqr - ) transfusions. median number of phlebotomy sessions was (iqr - ) over . years (iqr . - . ). prior to phlebotomy, median lic was . mg/g (iqr . - . ) and ferritin was . ng/ml (iqr - ) . no patients demonstrated abnormal cardiac t * mri (n = ). ( %) patients completed phlebotomy. one discontinued due to poor vascular access. no patients developed iron deficiency. lic was reduced by a median of . mg/g (iqr . - . ) and ferritin by ng/ml . correlation between number of transfusions and phlebotomy sessions was poor (r = . ). conclusion: management guidelines are lacking for transfusional iron overload in pediatric and young adult survivors of cancer. we demonstrate a phlebotomy algorithm that is effective and tolerated. correlation between number of transfusions received and phlebotomy treatments was poor, necessitating serial assessments. using this management algorithm, prospective studies can evaluate the effect of iron removal on iron overload complications in this patient population. penn state children's hospital, hershey, pennsylvania, united states background: cancer therapy leads to an impaired immune system that takes time to recover. it is important to ensure that these survivors have adequate immunity to prevent common yet potentially severe childhood illnesses. no validated guidelines currently exist for surveillance testing or re-immunization in this population. retrospective analysis involving a small cohort of pediatric cancer patients treated at penn state children's hospital showed % of patients screened for varicella immunity after therapy completion did not have adequate disease titers. to determine the proportion of pediatric cancer survivors who have lost humoral immunity to previously received vaccines; to determine the rate of response to single dose boosters or full vaccine series in seronegative subjects after one booster. design/method: pediatric cancer survivors treated at the children's hospital who are at least months from completion of cancer therapy are prospectively tested for antibody levels to hepatitis b, tetanus, varicella, measles, and strains of pneumococcus ( , b, v, c, f, and f). samples are analyzed by the cdc for measles and varicella avidity. seronegative subjects by commercial studies, are eligible to receive booster vaccines. titers are rechecked at least weeks after boosters to re-evaluate immunity; if still seronegative, subjects will receive the entire vaccine series. titers are finally tested at least weeks after the final dose of the vaccine series. immunity analyzed after therapy, after boosters, and after vaccine series. results: of pediatric cancers survivors who completed therapy, % were non-immune to hepatitis b, % nonimmune to > % of pneumococcal strains tested, % nonimmune to measles, % non-immune to varicella, and % non-immune to tetanus. of subjects who received mmr vaccine after therapy and prior to study enrollment did not have protective antibodies to measles. of the subjects who received varicella vaccine after end of therapy and prior to study enrollment, did not maintain protective antibody levels. cdc results for measles and varicella are pending, as well as repeat studies after vaccine boosters and series. conclusion: a significant percentage of pediatric cancer survivors do not retain immunity to hepatitis b, pneumococcus, measles, and varicella. after one booster, a high percentage of subjects did not develop protective immunity to varicella. only subject did not have immunity to tetanus, which is consistent with the high immunogenicity of tetanus toxoid. formal guidelines are needed to protect this population from vaccine-preventable illness post-therapy. children's hospital of richmond at virginia commonwealth university health system, richmond, virginia, united states background: childhood cancer survivors are at risk for being overweight. diet and physical exercise are important in maintaining a healthy lifestyle and weight; however, it has been reported that cancer survivors are less active than their peers. one reason for this may be that there are no clearly established risk-based exercise recommendations for cancer survivors. another reason may be that providers tend to focus s of s recommendations for exercise more towards patients who are overweight. objectives: to describe changes in physical fitness of childhood cancer survivors who exercise. design/method: 'moving forward' is a wellness and physical fitness program that the center for care beyond the cure at chor offers in partnership with the ask childhood cancer foundation and the ymca. the program is available for any childhood cancer survivor between y and y age, being seen at our center. survivors define their fitness or wellness goals and then work with a trainer once a week (at least) for min sessions throughout the year to achieve these goals. baseline and ongoing measurements for core strength, endurance, overall strength and balance were collected. the average of each of the parameters of all participants were compared from the beginning to the end of the program. over the year, there was a % increase in endurance as measured by the average of the miles walked in minutes, % increase in core strength as measured by the average number of sit-ups in secs, an % and % increase in overall strength as measured by the average weight lifted by leg press and the average weight lifted by chest press, and a % increase in balance as measured by the average number of seconds balancing on a single leg. in addition, each child had actually gained weight in the process with an approximately % increase in the average of the weights of all children. there are benefits to regular exercise beyond weight control, and improvements in physical fitness can be seen even without weight loss. regular physical exercise results in improved physical fitness and should be universally advocated to all patients. determining insulin resistance, measuring changes in fatigue and wellness perception following exercise are future directions that we intend to explore. dana-farber cancer institute, boston, massachusetts, united states background: improvements in adolescent and young adult cancer patient (aya) survival rates and quality of life outcomes have lagged behind those of children and older adults, highlighting a need for research targeting this unique population. current literature supports the value of strong ayaclinician communication, notably in facilitating therapeutic alliance, however little is known about aya communication priorities during cancer care and barriers to optimal ayaclinician communication. objectives: to explore aya and oncology clinician communication priorities and to identify barriers and facilitators to aya-oncology clinician communication. design/method: semi-structured interviews were held with aya cancer patients and survivors (ages - years) from a single large academic institution and oncology clinicians (physicians and nurse practitioners) from academic institutions in the northeastern united states. interviews were conducted in english by phone or in person. all interviews were audio-recorded and transcribed verbatim. analyses were aided by nvivo software. ayas identified a wide range of topics as important to discuss with clinicians. the most frequently identified topics were ) side effects of treatment (with an emphasis on physical appearance and function, n = ), ) social issues (including friendship, family, and school, n = ), ) looking ahead to the future (n = ), and ) sexual & reproductive health (including future fertility, contraception, and romantic relationships, n = ). clinicians prioritized ) cancer treatment and side effects (n = ), ) emotional and psychological health (n = ), and ) sexual and reproductive health with a focus on fertility risk and fertility preservation (n = ). aya reported facilitators to good communication including an open and long-established relationship with the clinician (n = ) and clinician engagement in age-appropriate and patient-directed conversations (n = ). barriers included parental presence during visits (n = ). clinicians reported barriers including ) clinician discomfort (not feeling wellequipped to discuss psychosocial topics such as sexual health, spirituality, and relationships with peers, n = ), ) presence of parents/family (n = ), and ) perceived patient discomfort discussing specific topics (such as sexual health, n = ). clinicians acknowledged the need for collaborative efforts with additional team members (i.e. nurses, psychosocial providers) to assist in meeting aya communication needs. conclusion: aya and clinician-reported communication priorities are largely aligned. however, ayas emphasize some topics, such as social function, appearance, and sexual health that are not highly prioritized by clinicians, which may result in gaps in care for ayas in treatment and in survivorship. these data identify opportunities for intervention, including clinician education, patient and family education, clinic-based intervention, and systems-based changes that can be developed and tested. background: primary care physicians (pcps) cite lack of knowledge and inadequate communication with the oncology team as major barriers to providing recommended surveillance for late effects of treatment to childhood cancer survivors. a standardized telephone handoff to pcps posttherapy is a potential strategy to increase survivorship care by pcps through interactive communication. to determine the feasibility of a structured telephone communication using the situation, background, assessment, and recommendation (sbar) communication tool delivered by a trained oncology nurse to increase pcp knowledge and willingness to provide survivorship care. design/method: from / / to / / , a registered nurse expert in childhood cancer survivorship attempted to contact by telephone the pcps of the most recent patients attending yale's childhood cancer survivorship clinic that were < years old, english-speaking, and ≥ years posttreatment. all pcps had been previously sent an individualized survivorship care plan (scp) that listed the patient's previous treatment history and recommended surveillance tests. upon successful contact and after confirming receipt of the scp, the nurse explained the definition of late effects, description of patient's diagnosis and treatment history, and associated potential late complications and schedule of recommended surveillance tests. the pcp was also asked about his/her ability and willingness to provide needed surveillance for late effects in the future. overall, of pcps were successfully contacted with a median of phone call (range: - ) that lasted a median of minutes (range: - ) after a median of business day (range: - ). no pcps ended the call mid-conversation. all pcps were receptive and expressed appreciation for the call. twenty-five of ( %) pcps expressed an understand-ing of the material discussed and endorsed belief in their ability and willingness to provide late effects surveillance for their patients. no pcps questioned discussing their patient's care with a nurse versus a physician. interactive, structured communications between nurses and pcps by telephone are feasible and are associated with high-levels of pcp confidence in providing survivorship care. background: childhood cancer (cc) admissions account for % of non-newborn pediatric hospitalizations. these hospitalizations are longer and more expensive than other hospitalizations. admission payer (medicaid or commercial) reflects both health policy and sociodemographic status. the objective of this study was to determine if length of stay (los) or cost of cc admissions differed by payer. we used the kids inpatient database, a sampling of all pediatric hospital discharges in the united states. analysis for this study was limited to admissions containing a cancer diagnosis in any discharge icd- codes. admissions were further subcategorized by discharge codes according to diagnosis (leukemia, lymphoma, solid tumor and brain tumor) and reason for admission (chemotherapy, procedure, infection, non-infectious toxicity or "other"). charges were converted to costs using cost-to-charge ratios. multivariable linear regression models were performed to control for age, gender, race, reason for admission, and diagnosis. results: there were , weighted admissions for children with a cancer diagnosis in . of these admissions, . % had medicaid, . % had commercial insurance, and less than % had other payers. the mean los for medicaid admissions was . days ( % ci . - . ), compared with . days ( % ci . - . ) for commercial insurance. surgical admissions accounted for the largest difference in length of stay with medicaid admissions being . days longer than those covered by commercial insurance ( . days vs . days), however, the difference was significantly different for all reasons for admission. in multivariable analysis admissions associated with commercial insurance were % shorter s of s (p< . ), accounting for approximately one hospital day, than admissions associated with medicaid after controlling for other variables including race. the mean overall cost for medicaid admissions was $ , ( % ci - ), compared with $ , ( % ci - ) for commercial insurance. in the multivariable model, cost was collinear with race. conclusion: los and cost of admissions associated with medicaid differed from those associate with commercial payers. medicaid admissions were % longer on average than commercial insurance, accounting for a difference in length of stay of approximately one day although the difference varied with the reason for hospitalization (chemotherapy, surgical procedure, infection, other toxicity, other). costs of admissions were not independent of race. further investigation into potential explanations for this difference including differential access to home care needs, outpatient reimbursement differences, social indications for prolonged hospitalization, and provider biases, is warranted. background: pediatric cancer is a major cause of morbidity and mortality among children surpassed only by accidents. despite improved outcomes in high income countries (hic) survival rates remain poor in the developing word. there are various diagnostic and therapeutic limitations contributing significantly for the survival gap. the main objective of the study is to to evaluate the outcomes of pediatric cancer in armenia and identify diagnostic and therapeutic limitations in the country. we conducted a retrospective study among (≤ years old) children with cancer (solid tumors and hematological malignancies), who were diagnosed and treated at the clinic of chemotherapy of muratsan hospital complex of yerevan state medical university between and . those patients, who didn't receive chemotherapy for any reason were not included in the study cohort. epidemiological, social, medical information was collected through the patient charts review. this included patient age at diagnosis, sex, place of residence (city vs village), the educational level and employment status of parents, type of cancer, stage, presentation of symptoms, first medical specialty consulted and the time consulted, initial work-up, the type of treatment received, information on the diagnosis/treatment received abroad. results: at our clinic during the mentioned period of time the majority of patients presented with hematologic malignancies- %. ( . %) patients had information on diagnosis delay. average delay in diagnosis was about days. in % of cases the first contact with "healthcare system" was through pediatrician, and in % with surgeon. out of relapsed patients received salvage treatment in armenia and abroad. from those who stayed for treatment in armenia patients survived. majority of relapsed patients had acute lymphoblastic leukemia. from leukemia patients immunophenotyping and cytogenetics were available for ( . %) patients; the majority of missing cases were between and , when these diagnostic modalities were not available or affordable in the country. ( %) patients received part of diagnosis and/or treatment abroad. the most frequent reason for going abroad was bone marrow transplantation, otherwise none available in armenia. out of patients were lost to follow-up, patients had a fatal outcome. patients were in remission at a median follow up of . years. conclusion: unavailability of cancer registry and several essential diagnostic/treatment modalities, luck of multidisciplinary care and palliative support, high rate of out-of-pocket expenses were among the main challenges of pediatric cancer care in armenia. background: adverse drug reactions (adrs) are increasingly recognized as important and sometimes irreversible complications of cancer treatment. anthracyclines and cisplatin are effective chemotherapeutic agents, but their use can be limited by cardiotoxicity (anthracyclines) and ototoxicity (cisplatin) in up to % of patients. genetic variants that can be used to predict who is most at risk of developing these adrs have been discovered and replicated. objectives: to create pharmacogenetic risk prediction models for anthracycline and cisplatin toxicities and discuss results with oncologists to facilitate incorporation into treatment decision-making when appropriate. design/method: risk prediction models were developed from the linear regression of strongly-predictive genomic variants (odds ratios ≥ ) discovered and replicated in at least three patient populations. these models were used to assess an individual patient's genomic risk of developing cardiotoxicity from anthracyclines or hearing loss from cisplatin. risk results were returned to oncologists showing where the specific patient's genetic risk of toxicity lies on a continuum between the lowest and highest risk groups across all studied patients using a multi-gene model. interviews were conducted with patients, families, and oncologists to determine how results were valued and utilized. results: patients have been genotyped and had their genetic risk results returned to their oncologists. the first patients have been characterized to determine the impact these test results have had on their clinical care. results were described as being useful in decision-making by patients and/or oncologists in % of cases. additionally, for patients in the most extreme risk groups (highest and lowest risk), a change in treatment plan was ordered % of the time for cisplatin patients and % of the time for anthracycline patients. this included increased cardiac and audiological monitoring, the addition of a protective agent, or choosing an alternative treatment protocol if the risk outweighed the benefits of remaining on the current treatment plan. in interviews, patients indicated that they felt more involved in decision making, and felt reassured by understanding their genetic risk of toxicities. genetic risk prediction models for anthracycline cardiotoxicity and cisplatin ototoxicity were highly utilized by patients and oncologists in decision-making. results were found to be an important tool for informing patients of the risk of adrs during cancer treatment, and resulted in patients and their families feeling more involved in decision-making. background: childhood cancer survivors are at increased risk of developing executive dysfunction, and low socioe-conomic status (ses) has been identified as one of the mediators of executive functioning. previous studies have used traditional measures of ses, such as parents' education level, family annual income and occupation. but more recently, area based socioeconomic measures like block group poverty status are deemed to be more useful in monitoring of social inequalities in health in the united states. block groups are statistical divisions of census tracts and generally contain between and , people. the current study aims to understand the association of block group poverty status (percentage of households in family's block group of residence living below the federal poverty level) with executive functioning among cancer survivor children. design/method: we used a retrospective cohort of childhood cancer survivors. relevant information was collected from the medical record, administrative data sets and parent-filled surveys. address information was geocoded using arcgis . to obtain data on the block group poverty status. a priori cut-points were set to represent block groups with families living below poverty level at %, . % to . %, and ≥ . %. executive functioning were assessed through a parent-rated instrument, the behavior rating inventory of executive functions (brief). multiple linear regressions were used to determine the relationship between block group poverty status and the brief scores. results: data was examined from families of childhood cancer survivors, ranging in age from to years. in this sample, . % families reported an annual income <$ , , . % reported income between $ , and $ , while . % reported annual income ≥$ , . primary care giver of . % of cancer survivors had more than more high school education, and . %, . % and . %, of families were living in a block groups with %, . - . % and ≥ % poor households respectively. block group poverty level was not significantly associated with annual income levels (spearman's rho = . , p = . ), or parental education level (spearman's rho = - . , p = . ). in a step-wise multiple linear regression, there was no statistically significant association seen between block group poverty status and executive functioning after adjusting for co-variables in the final model. future prospective study with a bigger sample size, longer follow up period and more robust measures of the executive functioning like a clinician administered test are needed to understand the effect of block group poverty status on executive functioning. to d completion was . days (range - ). all parents strongly agreed/agreed that d was helpful and would recommend d participation to another family. ten parents ( %) reported time spent on d was "just right." no parent felt more worried due to the intervention, though parent found d participation stressful. this interim analysis suggests that parents have a favorable d experience and recommend the intervention. to date, < % of enrolled parents fail to participate. d shows promise as an acceptable interdisciplinary communication intervention targeted to the early treatment period for childhood cancer. children 's hospital and research center oakland, oakland, california, united states background: screening echocardiograms are recommended by children's oncology group (cog) guidelines to assess for anthracycline-induced left ventricular (lv) systolic dysfunction. the yield of screening echocardiograms during chemotherapy and in the immediate post-therapy period is uncertain. objectives: to assess the incidence of lv dysfunction detected by screening echocardiograms during chemotherapy and in the immediate post-therapy period, defined as - months off-therapy. design/method: children diagnosed with cancer between january -march who received anthracycline chemotherapy were identified. echocardiograms were performed as per protocol, institutional and cog guidelines, and were reviewed retrospectively. lv dysfunction was defined as fractional shortening (fs) < % or ejection fraction (ef) < % ( ) results: in this cohort (n = , median age years), the most common diagnosis was all ( . %), followed by aml ( . %). of echocardiograms, ( . %) were performed during treatment and in the immediate posttreatment period. thirty-eight ( . %) patients had a > % decrease in fs compared to their pre-treatment echocardiograms. none of these patients required any treatment modification or cardiac medications. only patient ( . %) had echocardiogram-proven lv dysfunction discovered on a screening echocardiogram during her treatment course. she eventually died due to multi-organ failure following septic shock. this patient was receiving treatment for aml and had received mg/m of doxorubicin-equivalent anthracyclines at the time of the abnormal echocardiogram. one patient with metastatic ewing sarcoma had borderline lv dysfunction with a fs of % detected a month before completion of therapy. she had received mg/m of doxorubicin equivalent anthracyclines at the time of the abnormal echocardiogram. she did not require any therapy modification or additional cardiac medications. serial echocardiograms done on this patient have shown stable ventricular function. no off-therapy screening echocardiograms identified lv dysfunction. in our experience, the yield of echocardiograms to detect anthracycline-related cardiac dysfunction during treatment and in the immediate post-therapy period is very low. one patient developed lv dysfunction during treatment and one had borderline fs, while no lv dysfunction was identified within months of completing chemotherapy. though fs decreased in % of patients, none required intervention. further study is needed to optimize the use of echocardiography screening in children treated with anthracyclines. references: . landier w et al. jco . background: platinum-based chemotherapy increases the risk of sensorineural hearing loss in children with cancer. little is known about the impact of hearing loss on cognitive and emotional functioning in survivors. to determine the association of severe/profound hearing loss after platinum-based chemotherapy with ) cognitive impairment and ) emotional distress (i.e. anxiety and/or depression). cross-sectional study of all patients attending yale's childhood cancer survivorship clinic ≥ years off therapy for cancer diagnosed at < years and treated with cisplatin and/or carboplatin, but with no history of cns tumor, cranial radiation, congenital hearing loss, or developmental delay. hearing loss severity and hearing aid data were abstracted from audiograms and detailed clinical history. cognitive impairment was defined as behavior rating inventory of executive function t score ≥ , assessment by neuropsychologist, and/or history of special education. emotional distress was determined by brief symptom inventory t score ≥ (global or two subscales) or behavioral and emotional screening system t score ≥ , psychologist interview, and/or history of psychotropic medication/psychotherapy. the most recent available patient data were used. logistic regression with sas software, version . was performed. results: overall, patients ( % female, % white) met eligibility criteria with a median age of . years (iqr = . ) at diagnosis and . years at evaluation (iqr = . ) after a diagnosis of sarcoma ( %), neuroblastoma ( %), or other ( %) for which % received cisplatin and % received carboplatin. fifteen patients ( %) had severe/profound hearing loss in at least one ear. patients with severe/profound hearing loss had a significantly increased risk of cognitive impairment (or = . ; % ci = . - . ), but not emotional distress, compared to patients without severe/profound hearing loss. there was no significant association between age at diagnosis, current age, time since diagnosis, sex, race, ethnicity, or diagnosis with either cognitive impairment or emotional distress. similarly, there was no significant interaction between ) age at diagnosis and hearing loss or ) sex and hearing loss with either cognitive impairment or emotional distress. ten of the ( %) patients with severe/profound hearing loss in at least one ear were recommended hearing aids, of which ( %) reported compliance most of the time. we conclude that severe/profound hearing loss is significantly associated with cognitive impairment, but not emotional distress, in childhood cancer survivors. our data supports the need for interventions to improve hearing in these patients, including compliance with hearing aids. background: who grade anaplastic astrocytoma is a high grade glioma dependent on vascular endothelial s of s growth factor (vegf) mediated angiogenesis for its growth and infiltration. bevacizumab is a recombinant humanized monoclonal antibody which binds vegf-a and inhibits angiogenesis. common adverse effects of bevacizumab are hypertension, proteinuria, thrombosis and bleeding. while animal model based studies have shown that bevacizumab may impair ovarian function the effects of bevacizumab therapy on human fertility are not clear. since the physiology of pregnancy involves neovascularization/angiogenesis it is recommended that conception be avoided for at least months following exposure to bevacizumab. to describe the course of a young adult who became pregnant after receiving bevacizumab and radiation therapy for treatment of an anaplastic astrocytoma. a year old woman diagnosed with a localized hemispheric who anaplastic astrocytoma was treated with chemotherapy and radiation (temozolomide/ . gy) followed by cycles of bi-weekly bevacizumab/temozolomide. patient opted not to pursue fertility preservation prior to initiation treatment. she experienced bevacizumab-associated proteinuria and hypertension during treatment but received all protocol mandated doses (cumulative doses: bevacizumab = mg/kg; temozolomide = . gm/m ). she had a spontaneous unassisted pregnancy months after completing treatment. her pregnancy was uneventful and she was normotensive throughout. fetal ultrasonography at , , , weeks revealed no abnormality of the brain, heart, great vessels, kidney, extremities, placenta and umbilical cord. at weeks she delivered a female infant via cesarean section (birth weight: grams, apgars: and ) excessive post-partum hemorrhage was not reported. placenta was bi-lobed and weighed g. histological analysis revealed normal placental villous development and maturation and two small infarcts. conclusion: exposure to bevacizumab in our patient had no detrimental effect on fertility and on placental/fetal vascular development. we hope this report will add to the existing data on the effects of bevacizumab therapy on fertility. children's healthcare of atlanta, emory university school of medicine, atlanta, georgia, united states background: reports of malnutrition incidence and prevalence in young cancer patients are variable and not well established. previous research suggests children, especially less than years old, treated with intensive cancer-directed therapy are at higher risk for malnutrition. however, no standardized assessment has been used to evaluate risk in this population. objectives: we aim to assess the trends of weight-for-age for patients following cancer diagnosis. this study will be the first to use a standardized measure of treatment intensity (intensity treatment rating scale, itr- ) and will assist in targeting interventions for identification and treatment of malnutrition. design/method: this observational, retrospective study obtained data through the center's pediatric cancer registry and electronic medical record. patients were classified by tumor type (brain or non-brain tumor) and treatment intensity (itr- ). itr- incorporates diagnosis, chemotherapy, radiation, and surgery, beginning with lowest intensity ( ) to highest intensity ( ). inclusion criteria included new cancer diagnosis - at less than years old, with weight obtained and available within days of therapy start date. incomplete data, alternate growth charts, or treatment intensity of , were excluded. weight was obtained at start of therapy and through years after treatment initiation (approximately days) and converted to z-scores adjusted for age and sex. weight trajectories were modeled using generalized linear mixed models with subject-specific random intercepts and spline functions. separate functions were constructed for subgroups of interest (tumor type and itr). results: there were patients included: patients with brain tumors ( . %) and with non-brain tumors ( . %). of included patients, had treatment intensity of ( . %), of ( . %) and of ( . %). over the observation period, , valid weights were recorded. at initiation of treatment, no difference existed between z-score by tumor type (p = . ) or by intensity ( vs. , p = . ; vs. , p = . ; vs. , p = . ). tumor type did not affect z-score through the follow up period. z-scores were higher for intensity rating vs. and vs. (p = < . and p = . respectively) at days after the start of treatment and persisted through days (p = . and p< . respectively). higher treatment intensity is associated with decline in z-score and failure to return to baseline. future directions include further analysis on specific risk factors and timing of weight loss, longer-term follow-up of weight trends, and targeted interventions for identification, prevention, and treatment of malnutrition. objectives: asses the pt requirements for bleeding episodes in a prospective cohort of pcp using a < × e threshold compared to a < × e /l threshold in a historical cohort. we collected pt data in all pcps treated at our center between january/ through december/ . diagnosis, prescription for pt (prophylaxis vs bleeding disorder), plt count and transfused units were assessed for each pt. pcps treated from january/ through june received prophylactic pt with a < × e threshold (cohort a), and pts treated from july/ through december/ received prophylactic pt with a < × e threshold. pts done for procedures and pts with concomitant hemorrhagic pathology were excluded. we compared the number of pts prescribed as prophylaxis vs bleeding episode between cohorts. data analyzed: graphpad prims . ®. statistical analysis: percentages with confidence interval (ci); t-student test (parametric variables) and mann-whitney test (nonparametric variables). statistical significance: p< . . we reviewed pts ( in cohort a, cohort b) in patients. % had acute leukemia, % received and auto or allo hsct. diagnoses and the proportion of patients undergoing hsct was comparable in both cohorts. the average number of pts per patient was , in cohort a and , in cohort b (p = ns), but a significant difference was found when hsct patients were excluded from this comparison ( , pt per patient in cohort a vs , in cohort b, p = , ), which resulted in an estimated , % reduction in pts prescription. furthermore ( , %) pts were prescribed for bleeding episodes in cohort a versus ( , %) in cohort b (p = ns). patients receiving hsct in the entire group ver-sus those not receiving hsct had similar pt requirements for bleeding episodes ( % vs , % p = ns) conclusion: a < × e plt count threshold for prophylactic pts is safe in pcp in chemotherapy and hsct. it can result in a significant reduction in pt usage. key words: platelets, transfusions, prophylaxis, cancer, childhood. ucsf benioff children's hospital oakland, oakland, california, united states background: transition of care for adolescent and young adult (aya) survivors of childhood cancer from pediatric to adult-oriented long-term follow-up (ltfu) is complex. loss to follow-up is common, and little is known about the success rates among different models. the survivors of childhood cancer program (sccp) at ucsf benioff children's hospital oakland employs a community-based model for transitional care. our multidisciplinary team provides aya survivors a comprehensive treatment summary and recommendations, then facilitates transition to primary care or adult oncology ltfu programs. evaluate the success rate for transition of care among aya survivors of childhood cancer in our ltfu program, and identify barriers to successful transition. design/method: aya patients seen from november to august in the sccp with intent to transition were asked by email or telephone if they had followed up with their designated provider. the primary outcome was successful transition, defined as establishing care within months of their visit. patients were also asked about barriers to transition and to rate the new provider's familiarity with their cancer history and ltfu needs. results: transition was intended for patients. eightyseven were contacted and responded. of these, ( %) successfully transitioned, while ( %) were lost to followup. ages ranged from to years, at to years since completion of therapy. ten ( %) transitioned to a primary care provider, ( %) to an adult oncology ltfu program, and ( %) to a pediatrician. patients rated their new provider's knowledge above average ( . ) on a -point scale from poor ( ) to excellent ( ). survivors lost to follow up indicated the following barriers to transition: loss/change of insurance ( ), inability to find a provider ( ), too busy/forgot ( ), problems with transportation ( ), concerns about cost/copay ( ), and s of s other ( ). twelve patients requested further assistance with transition. conclusion: two-thirds of responding patients successfully transitioned. more work is needed to overcome various barriers to transition for one third of aya survivors. albany medical center, albany, new york, united states background: the transition from active treatment, to offtherapy follow-up, is a stressful event for parents of children with cancer. the psychosocial needs of parents after therapy have received limited attention in the united states with only published quantitative studies, the largest with parents. we have secured funding for and recruited a transition care coordinator (tcc) to investigate this further. objectives: our objective is to assess and screen parents at the end of their child's treatment, and to develop interventions to support parents during this time and thereafter. design/method: after informed consent, a standardized questionnaire, the psychosocial assessment tool (pat . ), was administered to parents at end of therapy (t ), months later (t ) and year later (t ). the tcc provided "universal" intervention to all families with an end of therapy binder containing a treatment summary, follow-up roadmaps, information on late effects, and survivor scholarships. based on their pat . scores, some parents were provided intervention specific to symptoms (targeted intervention for scores - . ) or referred to a behavioral health specialist through the clinic social worker for counseling (for scores > ). results: analysis of pat data showed that % of parents (n = ) scored in the targeted or clinical ranges; % of parents scored in those ranges at pat . significant gender differences were revealed with the mean score for men of . and for women of . . this was confirmed by showing statistical significance (p = . ) when analysis was conducted for only a subgroup of data composed of couples (n = ). analysis of pat data by couples (n = ) showed the mean score for men was . and for women was . (p = . ). gender differences were most apparent in caregiver stress reaction questions that focused on ptsd symptoms. when the subgroup of couples' scores (n = ) for caregiver stress reaction at pat was analyzed, there was a significant difference (p = . ) in caregiver stress reaction with a mean of . for men versus . for women. [note: subcategory scores range from to ]. this study was initiated in october using a tcc and the pat . screening tool. the results suggest greater stress on mothers after therapy, with a substantial proportion of parents having symptoms of ptsd after therapy. background: hodgkin lymphoma (hl) is a common childhood cancer characterized by an inflammatory microenvironment. chemotherapy and radiation may exacerbate this inflammation and contribute to the development of late effects (pneumonitis or pulmonary fibrosis). in a heterogeneous cohort of childhood cancer survivors exposed to pulmonarytoxic therapy, no association between pro-inflammatory cytokines and late pulmonary dysfunction was observed. our objective was to test this association in a relatively uniform cohort of survivors of hl, given the well-recognized proinflammatory background of this disease. objectives: to characterize off-therapy pulmonary function in survivors of hl treated with contemporary therapy, and to investigate its association with persistent systemic inflammation. design/method: blood samples, clinical data, and pulmonary function tests were obtained from survivors of hl ≥ months off therapy. lung function score (lfs), a validated method for assessing degree of pulmonary dysfunction on a scale of i to iv, was determined from diffusion capacity and forced expiratory volume in one second (fev ). for a control group, blood samples from patients with benign, noninflammatory hematologic conditions were used. plasma concentrations of inflammatory cytokines were measured on a luminex platform (emd millipore). associations between clinical features or cytokine levels and lfs i (normal) vs. ii-iv were evaluated using logistic regression or wilcoxon rank sum tests, respectively. results: of survivors (mean age at diagnosis: years, range: - ; mean time off therapy: . years, range: . - ), % were categorized as lfs ii (mild dysfunction), % as lfs iii (moderate dysfunction), and no survivors as lfs iv (severe dysfunction). higher lfs was associated with female sex (p = . ) but not other demographic, disease, or treatment factors. forty-eight survivors had blood samples collected at a mean age of . years (range: - ) with a mean time since treatment completion of . years (range: . - . ). of controls, the mean age at time of blood collection was years (range: - ). survivors did not have significantly elevated cytokine levels compared to controls. female survivors of hl ≥ months off therapy are at increased risk of pulmonary dysfunction. neither evidence for pulmonary dysfunction, as measured by lfs, nor duration of time off therapy were related to systemic inflammation in this study. pulmonary function deterioration and clinical pulmonary symptoms are rarely observed immediately following therapy but increase over time. future studies may consider exploring the contribution of systemic inflammation to pulmonary late effects in survivors farther off therapy, when risk for this late effect is greater. background: thyroid carcinoma is a very rare tumor in pediatrics, accounting for . - % of childhood carcinomas in the united states and europe. we aim to detect the risk of second malignancies among pediatric thyroid cancer survivors. the cohort analysis consisted of pediatric cancer patients aged less than years diagnosed with a primary thyroid cancer and identified by site code icd- - : c , reported to a seer database between and . they were followed up by death or the end of the study period (december , ) . out of patients diagnosed primarily with thyroid carcinoma, there were patients who had incidences of subsequent malignancies. the mean age of patients at initial diagnosis of thyroid cancer was years. females ( . %) had significantly higher incidence of second malignancies (sm) than males ( . %). the overall standardized incidence ratio (sir) of sm in thyroid pediatric patients was higher than expected (sir = . ). some specific sites showed significantly higher incidences: salivary gland (sir = . ), gum and other mouth (sir = . ) and kidney (sir = . ). the overall risk of sm in patients received radioactive iodine was higher than expected (sir = . ). the cumulative inci-dence of sms from the initial diagnosis of thyroid cancer was calculated with the survival methodology of competing risk, death treated as a competing event. cumulative incidence of sm was . % [ % ci ( . , . %)] at years and substantially expanded after years, reaching . % [ % ci ( . , . %)] at years. the cumulative incidence of each tumor type at years was . % [ % ci ( . , . %)] for breast cancer, . % [ % ci ( . , . %)] for salivary gland, . % [ % ci ( . , . %)] for each one of kidney and cervix uteri and . % [ % ci ( , . %)] for each one of ovary and melanoma of the skin. cumulative incidence of sm was stratified based on race, gender and radiotherapy exposure, but there was no statistical difference in each of them. conclusion: race, gender, histological subtypes, and radioactive iodine may play an important role as prognostic factors for developing sm among pediatric thyroid cancer survivors. identification of underlying mechanisms that raise the risk of sm is important for both treatment and follow-up strategy. background: the ethical practice of informed consent requires it be both voluntary and understood by the research participant. in pediatric oncology, parents must undergo informed consent to enroll their child with cancer into clinical trials, but often it can be difficult to understand especially for parents with low english proficiency. previous research has shown that parents of children with cancer have difficulty understanding voluntariness, and that parental satisfaction with informed consent does not always correlate with adequate comprehension. objectives: to examine socio-demographic and contextual correlates of comprehension of informed consent, voluntariness, and satisfaction in parents who consented to participation of their child in a cancer clinical trial. we focused on characterizing differences between non-hispanics and hispanics, the fastest growing ethnic group in the u.s. design/method: parents/guardians (n = ) of children aged - years with newly diagnosed cancer, who had consented to participation of their child in a clinical trial for cancer treatment at rady children's hospital-san diego were s of s prospectively recruited. parents completed questionnaires assessing comprehension, voluntariness, satisfaction, health literacy, socio-demographics, and acculturation level, if hispanic. comprehension was surveyed at baseline and longitudinally at months. comprehension, voluntariness and satisfaction outcomes were analyzed by socio-demographics, health literacy, and acculturation level using logistic regression. results: of the participants surveyed, ( . %) were hispanic and ( . %) were non-hispanic. we found that higher health literacy was associated with greater objective comprehension (p< . ), voluntariness (p< . ), socioeconomic status (p< . ), and acculturation (p< . ). hispanics reported lower objective comprehension (p = . ), voluntariness (p = . ), health literacy (p< . ) and ses (p = . ) compared to non-hispanics. spanish-speakers reported lower voluntariness (p = . ), health literacy (p< . ), and acculturation (p< . ) compared to englishspeakers. at the -month follow-up, comprehension in hispanics significantly improved (p = . ) compared to their baseline comprehension. satisfaction was moderately high across all subgroups and was not significantly impacted by socio-demographics, health literacy, or acculturation. in this study, with equivalent numbers of hispanic and non-hispanic participants, we found that hispanic and spanish-speaking parents of children with newly diagnosed cancer had inadequate informed consent comprehension, voluntariness and health literacy despite high satisfaction. our study suggests that hispanics and individuals with limited english proficiency are not making truly informed decisions for their child with cancer. to ensure the ethical practice of research in pediatric oncology, the informed consent and decision-making process must be improved with culturally and linguistically interventions for these underserved populations. memorial sloan kettering cancer center, new york, new york, united states background: pediatric oncology patients undergo repeated bone marrow aspirations and biopsies (bma/bx). these potentially painful procedures can exacerbate anxiety and distress. standard practice at memorial sloan kettering (msk) department of pediatrics is to use propofol, which has amnestic but no analgesic properties. we sought to evaluate whether the addition of local anesthetic would improve patient experience with bma/bx. the purpose of reppair: reducing procedural pain and improving recovery of quality of life (qol) (nct ) is to evaluate the efficacy of local anesthesia with ropivacaine in reducing procedural pain and improving post-procedure qol in pediatric neuroblastoma patients undergoing bma/bx with general anesthesia. reppair is a prospective, randomized, crossover clinical trial that opened for enrollment october . eligible patients were - years old with neuroblastoma. participants were observed on trial for two sequential bm procedures; one procedure with intervention a: propofol alone (pa), and the other with intervention b: propofol plus ropivacaine (p+r). participants were randomized to intervention sequence ab or ba and were blinded to the order of interventions. participants and recovery room (rr) nurses, who were also blinded, followed a standardized postprocedure pain management algorithm. the primary endpoint was percentage of participants requiring opioid analgesia in the hours post-procedure. secondary endpoints included total opioid in hours, non-opioid analgesia use, pain scores, time to first opioid, and short-term qol. qol was assessed by a parent-proxy metric that evaluated pain interference with sleep, physical, emotional, and social recovery. as of january , patients were assessed for eligibility and patients were randomized ( have completed both procedures). for the primary endpoint, a slightly higher proportion of participants required opioid for pa than p+r ( % versus %, p = . ). pain scores in the rr were significantly higher for pa than p+r (median [ th, th percentile]: [ , ] versus [ , ], p = . ). there were no statistically significant differences in total opioid or non-opioid analgesia, -and -hour pain scores, median time to first opioid, or pain interference scores. there were no adverse events. conclusion: preliminary findings of the reppair trial suggest that local anesthesia does not reduce the need for opioid analgesia or improve short-term qol in pediatric patients undergoing bma/bx with general anesthesia. local anesthesia did improve pain scores in the immediate recovery period. final results of this study will help establish evidence-based guidelines and optimize the experience of pediatric patients with bone marrow procedures at our center. background: children with advanced cancer experience a range of symptoms throughout treatment or at end of life, some of which are poorly controlled. minimizing suffering, including effective symptom management, in children with advanced cancer is a central value for pediatric oncology clinicians. patient-reported outcomes have been used in symptomrelated research in pediatric oncology patients; however the majority of literature specific to symptoms during palliative care and end of life for children and adolescents with advanced cancer is based primarily upon medical record reviews and to a lesser extent, patient self-report. the purpose of this study was to prospectively describe symptom frequency, severity, and level of distress in children/adolescents with advanced cancer using patient selfreport and parent proxy. design/method: a prospective cohort design was used for this study. five pediatric oncology institutions from across the united states participated. children and adolescents were eligible to participate if they were - years of age, englishspeaking, and had a diagnosis of advanced cancer, defined as a -week history of progressive, recurrent, or non-responsive disease or a decision not to pursue curative-focused therapy. a modified version of the memorial symptom assessment scale (msas) was used to measure symptom frequency, severity, and level of distress and was administered to child/parent dyads electronically via smartphones every two weeks. information regarding disease status and cancer treatment was collected concurrently. data was analyzed using descriptive statistics and univariate logistic regression analysis. results: a total of children and adolescents and parents participated in the study. the median age of child participants was years, with half being male. the median age of parents was years. the child participants had a variety of primary diagnosis, including: leukemia/lymphoma (n = , %), solid tumor (n = , %), and brain tumor (n = , %). the most frequently reported symptoms by children with advanced cancer and parents were pain (n = / , . %), lack of energy (n = / , . %), and nausea (n = / , . %). presence of disease (p = < . ), recent disease progression (p = . ), and receiving cancer therapy (p = . ) were significant factors on the presence of pain. high intensity cancer therapy was a significant factor on pain frequency (p = . ) and level of distress (p = . ). it is feasible to collect data prospectively in children with advanced cancer regarding symptom frequency, severity, and level distress. clinicians' increased understanding of the symptom experience may promote communication with children and adolescents and timely intervention. more research is needed to understand symptom clusters in children with advanced cancer. vanderbilt children's hospital, nashville, tennessee, united states background: febrile neutropenia (fn) is a frequent occurrence in children undergoing chemotherapy. though guidelines recommend adding a second antibiotic to broad-spectrum antipseudomonal coverage in specific scenarios, augmenting empiric therapy with a second antibiotic is common practice. additional empiric antibiotic (aea) use increases the risk of antibiotic toxicity and future antimicrobial resistance. data clarifying the indications for aea are limited in pediatric patients. objectives: to identify risk factors for gram-positive (gp) and gram-negative (gn) bacteremia in patients presenting with fn to determine situations in which aea use is warranted. design/method: a retrospective chart review was conducted of pediatric severe fn with absolute neutrophil count < / l occurring at a single institution between and . potential a priori risk factors based on clinical reasons for antibiotic expansion were chills, hypotension, mucositis, skin or soft tissue infections (sstis), recent administration of highdose cytarabine (hdac), and a diagnosis of acute myeloid leukemia (aml). potential factors for gn bacteremia were chills, hypotension, mucositis, and abdominal pain. the association between each potential risk factor and gp or gn s of s bacteremia was identified. logistic regression was used for multi-variable analysis. the review yielded episodes. gp bacteremia was isolated in cases ( . %) and gn bacteremia in episodes ( . %). in multivariable analysis, hypotension (or . ( % ci . , . ), p = . ) and sstis (or . ( . , . ) , p = . ) were independently associated with increased risk of gp bacteremia, while mucositis (p = . ), recent administration of hdac (p = . ) and chills (p = . ) were not. ten patients with aml didn't receive hdac, thus the association between aml and gp bacteremia could not be reliably estimated. hypotension (or . ( . , . ), p< . ) and chills (or . ( . , . ), p< . ) were independently associated with a higher risk of gn bacteremia, while mucositis (p = . ) and abdominal pain (p = . ) were not. of the gn infections, ( %) were resistant to cefepime, the empiric agent of choice at our institution. patients with fn with sstis, hypotension, or recent hdac had increased risk of gp bacteremia indicating potential benefit of empiric vancomycin in these settings, while mucositis and chills were not associated with gp bacteremia. hypotension and chills were associated with gn bacteremia, potentially warranting empiric antibiotic expansion, while mucositis and abdominal pain were not. identifying specific indications for aea use in pediatric severe fn use may improve antimicrobial utilization, decrease unnecessary antibiotic use, and improve patient outcomes. background: for children/young adults with incurable high grade gliomas (hggs), like diffuse intrinsic pontine glioma (dipg) or glioblastoma multiforme (gbm), oncologists endeavor to align therapy with patient/family goals of care, but may be influenced by providers' preferences or limited resources. ethical challenges can arise around the perceived purpose, risks and benefits of therapy options, provider conflicts of interest, access to care, deciding decisional priority between patients and families, and conflicts around end-oflife care. objectives: evaluate factors that play into longitudinal decision making for children and young adults with hggs, their families and oncologists using a qualitative approach with ethnographic elements. design/method: eligible patients were aged - with dipg, gbm, or secondary hgg. patient exclusions included: non-english speaking, in state custody, death prior to diagnosis, seen by oncology once, or an oncologist declined participation. key decision making visits (e.g. mri reviews) were serially audio-recorded, along with subsequent : semistructured interviews with patients and/or parents about the decision making process. field notes from clinician meetings, chart notes, and oncologist questionnaires were obtained. discussions and interviews were transcribed and independently coded by three investigators. inter-rater reliability was assessed during code book development. discrepancies were discussed until consensus met. constant comparison analysis with maxqda software continued until thematic saturation. results: twenty-two of eligible patients were approached; agreed to participate. one withdrew upon transferring care. mean age was . years (sd . ); % male, % caucasian, % african american, % hispanic, and % asian. four encounters, ( . hours), were recorded on average per patient. parent/patient interview themes included: ) hope (for a cure, prolonged life, and quality of life), ) importance of physician recommendations, ) importance of support systems (family, community, social media), ) food (as cancer etiology, intervention) ) finances (personal, research funding), ) communication (with medical providers, family, community), ) death, and ) god (beliefs, prayer, existential questions). oncologists desired prolonged quality of life, while patients/families transitioned to that hope from hope for a cure. decisions made in the setting of hggs are multi-factorial, ultimately reflecting the competing values of decision makers. optimism about treatment efficacy is held in tension with poor prognosis, allowing for functional hope. acknowledging patients' and families' shifting hopes allows for changes in goals of care and shared decision making. future work is needed to ) develop preference tools for pediatric patients and families to inform medical providers and ) provide training in communication and shared decision making with oncologists. emory university, atlanta, georgia, united states background: bone marrow transplantation (bmt) is a potentially curative but underutilized treatment for scd. our previous work has shown that there is variation in physician philosophy and practice in considering bmt as a treatment option for patients with scd, and physicians may not discuss this with patients and families as a potential treatment option. in a randomized clinical trial to test the effectiveness of a decision aid for disease modifying therapies for sickle cell disease, adult patients with scd as well as caregivers of adult/pediatric patients were interviewed about how they seek or have sought information related to scd, made decisions about treatments for scd, and identified a treatment option they were interested in learning more about using the decision aid tool. we performed a secondary analysis of these baseline data to understand patient information needs and attitudes regarding bmt as a treatment option for scd. the goals of this analyses was to understand patient and caregivers' attitudes and perceived information needs regarding bmt as a treatment option for scd. we performed an analysis of baseline interviews from caregivers of patients with scd or adult patients from a randomized control trial for a decision aid tool for scd. of the interviews belonged to caregivers of patients with scd. in addition to reviewing interviews for discussion of bmt, we interrogated for mention of terms such as 'bone marrow transplant' or 'cure' or 'stem cell transplant'. interviews were coded using nvivo and analyzed for emerging themes. results: of the baseline interviews, interviews met selection criteria. thirteen of the interviews were with caregivers of pediatric patients, and the remainder were with adult patients, including young adult patients with scd. the majority of participants want to learn about bmt or curative options. in many participants, this was expressed despite knowledge that they were not a likely candidate for transplant. desired information about bmt included eligibility, benefits, risks, long-term effects, quality of life and financial aspects related to bmt. of the patients who discussed how they learnt about bmt, approximately half mentioned that their healthcare provider had not previously mentioned this to them. we then examined knowledge of bmt and attitudes with demographic and clinical variables. patients and caregivers of pediatric patients with scd want to learn about bmt as a treatment option. healthcare providers should consider discussing bmt with their patients with scd. natasha frederick, anna revette, alexis michaud, jennifer mack, sharon bober dana-farber cancer institute, boston, massachusetts, united states background: adolescents and young adults (ayas) consistently identify the need for improved patient-clinician communication on sexual and reproductive health (srh) issues. however, oncology clinicians do not routinely integrate srh conversations with ayas through disease treatment and survivorship. little is known about why these conversations do not take place. objectives: explore aya perceptions of and receptiveness to srh communication with oncology clinicians and to identify barriers and facilitators to these conversations. design/method: semi-structured interviews were held with aya cancer patients and survivors (ages - years, men, women). twelve participants were on active treatment and were within years of treatment completion. interviews were conducted in english by phone or in person. the interview transcript underwent pre-testing with ayas. all interviews were audio-recorded and transcribed verbatim. transcripts were analyzed and summarized by two trained qualitative researchers according to standard comprehensive thematic qualitative analysis methods. analyses were aided by nvivo software. results: ayas perceived existing srh communication between ayas and oncology providers as inadequate. all ayas reported a need for improved srh communication with oncology providers, and three key areas of need emerged: ) general education; ) addressing specific srh issues experienced during treatment and survivorship; and ) understanding the long-term impact of cancer and treatment on srh. ayas felt that current srh discussions are limited and too narrow in scope and scale. ayas reported that most srh conversations focus exclusively on fertility (n = ), usually taking place at the start of treatment. other additional yet limited communication reported was about sexual activity (n = ), contraception (n = ), sexual function (n = ). no ayas reported conversations about potential treatment complications related to sexuality other than infertility. key barriers to srh conversations include patient discomfort initiating conversation (n = ) and presence of family members (n = ), with additional reported barriers including perceived provider discomfort (n = ), lack of rapport with provider (n = ), and age/gender differences (n = ). ayas felt that s of s communication tools such as handouts, brochures, and websites would be helpful facilitators to direct communication from the oncology clinician, and wanted conversations to start before treatment initiation and to continue through treatment and survivorship conclusion: ayas identify a key role for pediatric oncology providers in srh care from diagnosis through survivorship, however multiple barriers interfere with discussions about srh on a regular basis. identified barriers suggest that future efforts should focus on provider education and training in srh and srh-related communication in order to optimize care provided to this unique patient population. background: peripherally inserted central venous catheters (picc) provide secure vascular access in pediatric patients for the delivery of necessary therapies. the ease of placement in the inpatient and outpatient settings has expanded their utilization. however, recent data analyses show a significant increase in venous thromboembolism (vte) risk with the use of picc lines. with its rising use, modifiable risk factors need to be understood for preventative measures. objectives: in this study we aim to understand patient and catheter specific characteristics in relation to the development of vte. design/method: with irb approval, a retrospective interrogation of the electronic medical record and a picc database, at rainbow babies and children's hospital, was completed. the study cohort contained patients < years of age who had a picc line placed between january of and december of . data collected included indication for line placement, line dwell time, location of insertion including blood vessel and extremity, number of attempts at line placement, lumen size and indwelling line length. in addition, we collected number of days to vte formation, associated symptoms and location of vte. chi-squared analyses and fischer's exact test were used where appropriate for statistical analysis. we analyzed ( neonatal) newly placed picc lines. fifty line-associated vte events were found, for an incidence of . %. all vte occurred with the placement of the first picc line. intravenous therapies were the most common reason for line placement. no statistical significance was found between various indications for placement. the most common symptom of vte manifestation was extremity swelling, follow by extremity pain. right extremity picc was found to have a higher incidence of vte. larger catheter lumen sizes (> french) had a higher incidence of vte. we found a mean time of . days to vte detection. we were unable to find any clinical, patient or line specific factors leading to increased vte formation after statistical analysis. special consideration should be given to the duration of picc line use as this may reduce the incidence and comorbities associated with vte. there is still much to be understood about catheter associated vte formation as our analyses indicates the need for prospective data collection on a larger scale in hopes to create guidelines related to catheter use in pediatrics. background: the decision to transfuse a patient is a complex one and is never based solely on a number; however, certain hemoglobin or platelet count thresholds have been proposed in aiding physicians make transfusion decisions. in our hospital, the thresholds for packed red blood cell (prbc) and platelet transfusion in pediatric oncology patients are hemoglobin levels below . g/dl and platelet counts below , /mm (< , for brain tumors), respectively. recently, these thresholds have been questioned and we were asked whether we could safely lower the thresholds to < . g/dl of hemoglobin and < , /mm platelet count objectives: to investigate platelet and hemoglobin transfusion thresholds for oncology patients at children hospital of michigan design/method: retrospective chart review over a -month period, examining platelet and hemoglobin pretransfusion levels for each prbc and platelet transfusion given to oncology patients results: over the course of months, eligible oncology patients (median age years) received transfusions ( prbc transfusions and platelet transfusions). the mean pretransfusion hemoglobin level was . ± . g/dl (range . - . ) (n = ) for total prbc transfusions and this was not different among disease categories (p = . ). patients who had anemia symptoms and signs (n = ) had a slightly lower hemoglobin level compared to those who did not (n = ): . ± . vs . ± . g/dl (p = . ). the mean pretransfusion platelet count was , ± , /mm (range , - , ) for total platelet transfusions (n = ); , ± , /mm in patients with brain tumors (n = ); , ± , in patients with leukemia (n = ); and , ± , in patients with solid tumors (n = ). the mean pretransfusion platelet count was significantly higher in transfusions for brain tumors compared to that in the other disease groups (p< . for both). the mean pretransfusion platelet count was not different among those patients who had bleeding/bruising symptoms ( , ± , , n = ) versus those who did not ( , ± , , n = ) (p = . ). the bleeding/bruising rate was slightly but insignificantly higher in those who had platelet counts < , vs those who had ≥ , ( . % vs . %, p = . ). since most patients develop symptoms of anemia at hemoglobin above g/dl and about / of patients develop bleeding/bruising symptoms at platelet counts above , /mm , our current policy so far reflects a safe threshold for transfusion, and further lowering of the thresholds should be investigated in prospective studies. background: renal impairment is an important complication of childhood cancer and its treatment. serum creatinine level is frequently used as a screening test to monitor renal function; however, patients can have significantly decreased glomerular filtration rate (gfr) with normal serum creatinine. to determine the prevalence of chronic kidney disease (ckd) among children with cancer diagnosis, based on calculated gfr. to compare the difference between using serum creatinine value alone versus gfr in detecting ckd. design/method: retrospective review of medical records of patients, age - years, diagnosed between / - / with solid tumors were analyzed. serum creatinine and calculated gfr using schwartz formula were recorded. ckd as classified by the foundation of kidney disease and outcome quality initiative was used: ckd stage : gfr ( to ml/min per . m ) ckd stage : gfr ( to ml/min per . m ) statistical analysis using spss software v. . chi-squared test for proportions within group, and pearson chi-squared and fisher exact tests for statistical differences between groups. p-value < . was considered to indicate significance results: out of the records reviewed, ( %) were males and ( %) females, with mean age of . ± . years. ( . %) patients received one or more of nephrotoxic chemotherapy drugs; cisplatinum, carboplatinum, or ifosphamide mainly in the non-wilms solid tumors group ( . %) compared to ( . %) in the wilms tumor (wt) group. based on calculated gfr (by schwartz formula) ckd stage /or was diagnosed in ( %) patients with overwhelming majority ( %) were in the mild stage ckd, only ( . %) of those patients had abnormally high serum creatinine levels (p = . ). . % of patients who received nephrotoxic chemotherapy developed ckd, compared to . % in those who did not receive it, (p = . ). despite that only / ( %) of wt group patients received nephrotoxic chemotherapy, yet this group had higher percentage of ckd ( . %) compared to non-wt group ( . %) p = . . significantly lower mean gfr . ± was noticed in the wt group compared to . ± in non-wt group (p = . ) conclusion: high prevalence of mild ckd was found among solid tumor patients. using serum creatinine alone as measure of renal function significantly under estimates renal impairment in those patients. early identification of ckd is easily achieved by using calculated gfr, which can helps providers and care givers to avoid potential nephrotoxic antibiotics, contrast media, nsaids and dehydration that may further deteriorate renal function the university of texas southwestern medical center, dallas, texas, united states background: children with down syndrome (ds) have increased risk of developing leukemia. pediatric patients with ds-associated acute lymphoblastic leukemia (ds-all) are known to have significant toxicities with reinduction chemotherapy and historically poor outcomes with stem cell transplant (sct). anti-cd chimeric antigen receptor (car) t-cell therapy, tisagenlecleucel, demonstrated high rates of durable complete remission (cr) and a manageable safety profile in children with r/r b-cell acute lymphoblastic leukemia (b-all). objectives: characterize the efficacy and safety of tisagenlecleucel in pediatric/young adults with ds-all. design/method: pooled data from single-arm, multicenter, phase trials of tisagenlecleucel in pediatric/young-adult patients with r/r b-all (eliana, nct ; ensign, nct ) were analyzed. eight patients with ds-all were enrolled (data cutoff: eliana, november ; ensign, february ). seven were infused with tisagenlecleucel; patient died from all progression and intracranial hemorrhage before infusion. no manufacturing issues occurred during production. / infused patients were male, / had prior sct (age range, - years). / patients achieved cr or cr with incomplete blood count recovery (cri) by day (d) (cr+cri, %); died before d and was not evaluable. analysis of minimal residual disease was negative in bone marrow in responding patients. two patients had cd negative relapses at and months. ongoing remissions in patients without relapse ranged from to months. the safety profile (n = ) appears similar to that in patients without ds in the same trials (n = ). grade (g) / cytokine release syndrome occurred in % ( / ) of patients with ds and in % without ds. rates of other g / adverse events of special interest did not appear to favor a consistent trend between patients with/without ds (febrile neutropenia: % vs %; neurological events: % vs %; tumor lysis syndrome: % vs %). g / infections were not observed in patients with ds ( % vs %). one patient died after infusion due to intracranial parenchymal hemorrhage on d associated with ongoing coagulopathy. time and extent of tisagenlecleucel expansion and long-term persistence were similar between groups. conclusion: this is the first analysis of car t-cell therapy in pediatric patients with r/r b-all and ds. these data suggest that toxicities appear similar to those in patients with b-all without ds, remission rates in ds-all are high, and longterm outcomes with sustained persistence appear promising. further exploration of tisagenlecleucel as an alternative to sct in children with r/r ds-all is warranted. sponsored by novartis. background: hispanic adolescence and young adults are twice as likely to develop acute lymphoblastic leukemia (all) with high risk features as non-hispanic whites. they also have poor prognosis and % higher death rate. b-all with crlf overexpression caused by genetic alteration of the cytokine receptor, crlf is five times more common in this subgroup. approximately % of crlf b-all cases also have ikzf genetic alterations. ikaros is involved in transcriptional regulation of several important genes involved in leukemogenesis. overexpressed casein kinase ii (ck ) impairs functions of ikaros. objectives: understand the molecular mechanisms that regulate crlf expression in crlf b-all. here we present evidence that ikaros-mediated repression of crlf transcription in b-all in hispanic children is regulated by ck . design/method: primary b-all patient samples from hispanic children were used. ikaros retroviral transduction, ikaros shrna transfection, real time-pcr, luciferace assay, quantitative chromatin immunoprecipitation (qchip) coupled with the next-generation sequencing (chip-seq), cytotoxicity assay and western blot. results: ikaros binding to promoter of crlf was confirmed using quantitative chip. functional experiments such as overexpression of ikaros in b-all primary cells results in transcriptional repression of crlf whereas ikaros silencing using shrna resulted in increased transcription. these results suggest that ikaros negatively regulates crlf expression. molecular inhibition of ck with shrna targeting the ck catalytic subunit, as well as pharmacological targeting of ck with cx resulted in transcriptional repression of crlf . ck inhibition was associated with increased ikaros dnabinding to the promoter of crlf . however, the ability of cx to repress crlf is lost or severely reduced, in cells with shrna silencing of ikaros, as compared to cells with intact ikaros. moreover, similar results were noted following treatment with cx in leukemia cells obtained from high risk b-all patients with deletion of one ikzf allele. ikaros binds poorly to promoters of crlf gene in these cells. treatment with cx restores ikaros dnabinding to the promoters of crlf , which is associated with its strong repression. serial qchip analysis of the epigenetic signature at the crlf promoter showed that increased ikaros binding to the crlf promoter, following ck inhibition, is associated with enrichment for the h k me histone modification, which is a marker of repressive chromatin. results demonstrate that crlf expression is epigenetically regulated by the ck -ikaros axis .cx show antileukemic effect via restoration of ikaros tumor suppressor function, resulting in crlf repression suggesting advantage of using ck inhibitors as potential therapeutic approach in crlf altered b-all. results: hypodiploid all (modal chromosome number < and/or di < . ) was identified in patients ( . % of all patients; . % of nci standard risk (sr) and . % of nci high risk (hr)), who were removed from frontline protocol therapy post-induction. overall -year efs and os were . %± . % and . %± . %. transplant status was retrospectively available for / ( %), of whom underwent hsct in cr . five-year efs with hsct was . %± . % vs. . %± . % without (p = . ). -year os with and without hsct was . %± . % vs. . %± . % (p = . ). when corrected for the median time to hsct ( days), there were no significant differences in -year efs or os rates with and without hsct: . %± . % and . %± . % vs. . %± . % and . %± . %. no nci risk group or mrd subset benefitted significantly from cr hsct. sr patients (n = ) had -year efs and os of . ± . % and . %± . % with hsct (n = ) vs. . %± . % and . %± . % without. hr patients (n = ) had -year efs and os of . %± . % and . %± . % with hsct (n = ) vs. . %± . % and . %± . % without. for those with end-induction mrd < . % (n = ), -year efs and os were . %± . % and . %± . % with hsct (n = ) vs. . %± . % and . %± . % without. end-induction mrd-positive patients (n = ) fared poorly with both year efs and os of . %± . % with hsct (n = ) vs. . %± . % and . %± . % without. multivariate regression analysis including nci risk group, mrd, and cr hsct, showed only mrd negativity was significantly associated with efs (hr . , p< . ) and os (hr . , p< . ). patients with hypodiploid all fare poorly, particularly those with end-induction mrd ≥ . %. while cr hsct is a standard treatment approach, it does not confer significant benefit. we were unable to assess bridging therapy prior to hsct, and comparator groups are small. taken together, however, new strategies are urgently needed for these patients. background: ras-pathway mutations are known to play a pivotal role in a significant proportion of myeloid malignancies, including upwards of % of pediatric aml cases. ras-pathway mutations in myeloid malignancy commonly co-occur with mutations of epigenetic regulators, suggesting cooperative leukemogenesis. among the epigenetic modifiers most frequently mutated in myeloid malignancy are regulators of dna methylation. this indicates that the alteration of dna methylation contributes to leukemogenesis. the ten-eleven translocation (tet ) is an epigenetic regulator that plays an important role in regulation of dna methylation through its action of hydroxylation of -methylcytosine, which ultimately leads to passive de-methylation of dna cytosines. in myeloid malignancy, loss of function tet mutation is one of the most frequently co-occurring lesions in ras mutated malignancy. how specifically the altered methylation patterns in ras-pathway driven diseases promotes leukemogenesis is unclear. objectives: we hypothesize in mice with a ras-pathway mutation, that when an epigenetic modifier co-occurs, such as loss of function of tet , this primes stem cells and/or early differentiating progenitors for transformation by preventing the repression of stem cell self-renewal genes, inhibiting differentiation, enhancing ras signaling and leading to leukemogenesis. we have generated a novel murine model with constitutive deletion of tet (tet -/-) combined with an inducible activating krasg d mutation (krasg d/wt). mice have been tracked for evidence of hematologic malignancies and compared to mice with corresponding single genetic lesions. cooperative leukemogenesis will be demonstrated by decreased latency to disease onset, impact on malignancy lineage, in addition to investigating mechanistically through which pathways leukemogenesis may be promoted. results: krasg d/wt/ tet -/-mice demonstrate statistically significant differences in peripheral white blood cell count, hemoglobin, and platelet levels as early as -weeks post ras-pathway activation. peripheral cell lineage analysis demonstrates early skewing toward myeloid differentiation and marked splenomegaly in mice harboring both genetic lesions compared to wild type or mice with single genetic lesions. phospho-flow cytometric analysis reveals increased perk and ps activation in krasg d/wt/ tet -/-sca- enriched bone marrow cells compared to either genetic lesion alone. our study utilizing a murine model to examine how in ras-pathway mutations the addition of a co-occurring epigenetic lesion demonstrates that these lesions appear to cooperate to promote early myeloid differentiation with attendant changes in signaling pathways. this exploration to elucidate the mechanics of ras-pathway mediated disease lay the foundation for identification of patients who may benefit from existing therapies, such as dmtis, or identify new signaling targets for therapeutic exploration. background: the humoral immunogenicity of car , a chimeric antigen receptor (car) with a murine scfv domain developed for treatment with tisagenlecleucel in relapsed/refractory (r/r) pediatric/young-adult acute lymphoblastic leukemia (all), was evaluated in studies. little is known about the presence/impact of preexisting/treatmentinduced anti-murine car (mcar ) antibodies in patients treated with car therapy. objectives: patients from eliana (nct ; n = ) and ensign (nct ; n = ) were evaluated before and after tisagenlecleucel infusion to determine the impact of anti-mcar antibodies on cellular kinetics, efficacy, and safety. design/method: anti-mcar antibodies were determined by flow cytometry and reported as median fluorescence intensity. assay validation included evaluation of the interferences of intravenous immunoglobulin (ivig) treatment with the anti-mcar antibody assay. impact of preexisting and treatment-induced immunogenicity on cellular kinetics, efficacy, and safety was determined. treatment-induced immunogenicity was defined by a positive increase in anti-mcar antibody levels over baseline and was assessed by calculating the fold-change between preexisting (ie, baseline) and postinfusion levels. results: % of patients displayed preexisting anti-mcar antibodies; a similar incidence was detected in healthy volunteer samples during method validation. % of patients developed treatment-induced anti-mcar antibodies. no relationship was identified between tisagenlecleucel expansion (auc - d) and preexisting/treatment-induced anti-mcar antibodies (r < . and r = . , respectively); similar results were seen for cmax. presence of treatment-induced anti-mcar antibodies did not appear to impact transgene persistence or response. kaplan-meier estimates showed that preexisting/treatment-induced anti-mcar antibodies did not appear to impact duration of response or event-free survival. strip plots showed consistent levels of preexisting/treatment-induced anti-mcar antibodies across patients with safety events, including cytokine release syndrome, neutropenia, thrombocytopenia, and neurological events. there was no apparent relationship between treatment-induced anti-mcar antibodies and b-cell recovery categories (≤ months, > and ≤ months, > months, and ongoing sustained aplasia). no association existed between time of b-cell recovery and presence of treatment-induced anti-mcar antibodies. b-cell aplasia requiring ivig occurred following tisagenlecleucel in the majority of patients. the tisagenlecleucel concentration-time profiles in patients with treatment-induced anti-mcar antibodies were categorized by time following ivig administration. time of ivig administration had no impact on in vivo transgene expansion and persistence. we report the first comprehensive assessment of the impact of anti-mcar antibodies on clinical endpoints with car therapy. pediatric/young-adult patients with r/r all had a high frequency of baseline anti-mcar antibodies, and preexisting/treatment-induced anti-mcar antibodies did not impact the cellular kinetics, safety, and efficacy of tisagenlecleucel. cell-mediated immunity studies are ongoing. sponsored by novartis. background: adoptive immunotherapy, using cd engager (cd -eng) t-cells, has shown success in preclinical studies, recognizing and killing acute myeloid leukemia (aml) blasts in vitro and in vivo. cd -eng t-cells secrete bispecific molecules that recognize cd (t-cells) and cd (aml blasts), and are able to direct transduced t-cells and recruit bystander t-cells to kill cd -positive blasts. however, cd -engs do not provide costimulation and have not shown the capability for sequential killing of targets in vitro. we are seeking to improve the expansion, persistence and sequential killing capabilities of cd -engs by genetically modifying these cells with an inducible costimulatory molecule, which can be activated by a chemical inducer of dimerization (cid). we generated a retroviral vector encoding cd -eng and the inducible costimulatory molecule myd .cd linked by a a sequence (cd -eng. a.imc). cd -eng and cd -eng.imc t-cells were generated by retroviral transduction, and their effector function was compared with and without cid. we used flow cytometric analysis to assess transduction efficiency, chromium release assays to evaluate cytolytic activity, and elisa to determine cytokine production. we successfully generated cd -eng.imc tcells and achieved a mean initial transduction efficiency of % that was maintained above % throughout our study period. cd -eng.imc t-cells +/-cid and cd -eng t-cells readily killed cd -positive aml blasts (molm and kg a) in cytotoxicity assays when compared to the cd -negative control (k ). in co-culture assays, cd -eng.imc t-cells secreted increased il- and ifn-gamma in the presence of cid and cd -positive targets (kg a and molm ) when compared to co-culture with cd -positive targets in the absence of cid. in addition, cd -eng.imc t-cells displayed enhanced sequential killing capabilities and ifn-gamma secretion when stimulated weekly with cid and tumor cells at a : ratio when compared to cd -eng t-cells. conclusion: cd -eng.imc t-cells are able to recognize and kill cd -positive aml blasts in an antigen dependent manner. cd -eng.imc t-cells have improved effector function in the presence of cid as judged by cytokine production and their ability to sequentially kill cd -positive target cells. thus, inducible myd and cd costimulation is a promising strategy to improve the effector function of cd -eng t-cells, and warrants further active exploration in preclinical studies. background: eliana (nct ; n = ) is a pivotal multicenter study testing the efficacy of tisagenlecleucel, anti-cd car-t, in children/young adults with r/r b-all. tocilizumab (toci) has been used for management of moderate/severe (grade / ) crs in ≈ % of patients treated with tisagenlecleucel at equivalent doses used in approved nononcological pediatric indications (< kg received mg/kg; ≥ kg received mg/kg [ mg max dose]).( ) crs onset, as graded by the penn grading scale, generally occurred at a median of days (range, - ) after infusion, requiring administration of - toci doses in some patients via a protocol-specific treatment algorithm. toci is a humanized monoclonal antibody that inhibits il- receptor (il- r) signaling. the pharmacokinetics (pk) and pharmacodynamics (pd) of toci in pediatric patients with b-all with carassociated crs have not previously been described. objectives: characterize toci pk/pd for crs management following tisagenlecleucel infusion and describe its impact on cellular kinetics. design/method: toci pk and levels of soluble il- r (sil- r) were determined from serum and quantified using validated assays. maximum toci concentration (cmax) was derived using noncompartmental methods. sil- r, proinflammatory cytokines, and crs resolution time were characterized to describe toci pd. summary statistics and graphical analyses of tisagenlecleucel exposure by number of doses were performed to describe the impact of toci on tisagenlecleucel kinetics in patients responding to tisagenlecleucel infusion. : / patients with crs received the first toci dose at a median of days (range, - ) after crs onset. seventeen patients received dose (range, . - mg/kg); received doses ( - mg/kg); received doses ( - mg/kg), per the crs treatment algorithm. first-dose mean cmax (sd) was ≈ ( . ) g/ml; second dose, ≈ ( ) g/ml. individual patient pd concentration-time profiles showed increased sil- r levels after the first toci dose which remained elevated following the second dose. following toci administration, median time to crs resolution (including fever resolution) was days (range, - ). crs onset coincided with tisagenlecleucel expansion, followed by a peak in serum cytokines, including il- . the geometric mean auc - day and cmax of tisagenlecleucel transgene (by pcr) were % and % higher in tisagenlecleucel-responding toci-treated patients. conclusion: crs symptoms resolved within a median of days after toci administration. toci levels achieved in patients with b-all were similar to reported pediatric nononcological indications (tocilizumab label) and resulted in concentration/time-dependent sil- r increases. transgene continued to expand and persist following toci administration. these data support treatment with toci for crs management. ( ) buechner, eha, . sponsored by novartis. background: in acute myeloid leukemia (aml), mesenchymal stem and stromal cells (mscs) in the bone marrow microenvironment contribute to extrinsically mediated chemo-resistance and are therefore important potential therapeutic targets. the study of patient-derived mscs is at a competitive disadvantage, however, because traditional means of isolating mscs from a bone marrow aspirate interferes with isolating the more highly prioritized leukemic cells. many opportunities to study mscs are therefore missed. objectives: to develop a novel method of isolating mscs using the otherwise discarded portion of a bone marrow aspirate, thereby de-coupling the isolation of primary mscs from the isolation of leukemia cells. design/method: aml patient bone marrow aspirates were obtained prospectively from the children's oncology group. healthy patient marrow was purchased. experimental mscs were isolated from the bottom-most layer (rbc-layer) produced by density-gradient separation of a bone marrow aspirate, which is typically discarded. control mscs were isolated from the buffy coat (mnc layer). non-adherent cells were removed after hours, and adherent cells were cultured at % co with mem-alpha containing % fbs. growth curves were obtained by seeding -well plates with , cells per well. cells were stained using oil red o to observe adipocyte differentiation. results: rbc-layer mscs grow successfully following overnight shipment of the aspirate. identical to mnc-layer mscs, rbc-layer mscs exhibit a fibroblastic morphology and are adherent to plastic. rbc-layer mscs persist in culture up to passages before senescence. they exhibit a slower growth curve relative to mnc-layer mscs, but their overall doubling time is similar at approximately hours. surprisingly, mscs from the rbc-layer exhibit adipocyte differentiation on stimulation, revealing their stem-cell like qualities. we present a method of isolating mscs from the discarded portion of a bone marrow aspirate that does not interfere with the isolation of leukemia cells from the same patient. this portion of the aspirate can be shipped, or can sit for at least hours, without sacrificing its mscs. rbclayer mscs are nearly identical to mscs obtained conventionally. perhaps most importantly, rbc-layer mscs retain a stem-cell like capacity, showing them to be a highly valuable cell population in aml research. future plans include investigating potential selective enrichment of stem-cell mscs in the rbc-layer, which could explain the unexpected difference in growth kinetics. aml researchers now have the opportunity to study this exciting component of the bone marrow microenvironment without sacrificing valuable leukemic cells in the process. background: neutropenia is one of the most frequent side effect of chemotherapy associated with an increase in the risk of infection, especially in the cases when the depth and duration of neutropenia are extended. some genes, as variations of darc, gsdma and cxcl are known to influence white blood cell and neutrophil counts. our previous study conducted in children with acute lymphoblastic leukemia (all), showed that polymorphisms in these genes might play a role in the onset of chemotherapy complications during consolidation and maintenance treatment. objectives: in order to support our previous finding, we have expanded the study to the induction period in a cohort of all children treated at the sainte-justine university health center between july and july . design/method: previous associated single nucleotide polymorphisms (snps) in darc, gsdma and cxcl genes were analyzed for an association with the complications occurring during induction including the duration of low neutrophil count (pnn) and low absolute phagocyte count (apc), proven infections and delay between induction and consolidation phases. results: significant effect was found for all studied polymorphims. minor alleles of darc rs , cxcl rs and gsdma rs were all associated with higher risk of complications during induction treatment, whereas that of darc rs (particularly gg genotype) had a protective effect. the gg genotype of rs was associated with a lower risk of post-induction delay (p = . or = . , %ci . - . ), less frequent febrile episodes (p = . ) and lower number of days with apc/pnn count reduction (p = . for apc< . and p = . for pnn< . ). in contrast, the minor t allele of another darc polymorphism (rs ), was associated with longer apc/pnn count reduction (p = . for apc< . and p = . for pnn < . ), as it was the tt genotype of gsdma rs (p = . for apc< . and p = . for pnn< . ). the patients with the gsdma rs had also a higher risk of documented febrile episodes (p = . or = . %ci - . ). the aa genotype of rs cxcl was associated with a higher risk of post-induction delay due to infection (p = . , or = . , % ci . - . ). conclusion: this complementary study confirmed our previous results, showing overall that variations in darc, gsdma and cxcl genes influence the onset of chemotherapy complications in pediatric all, regardless of treatment phases. these polymorphisms might be useful pharmacogenetics markers possibly guiding an adjustment of chemotherapy intensity. background: pediatric acute myeloid leukemia (aml) has a poor survival rate of about % and there is an urgent need for newer targeted therapies. car t-cell based therapies are effective against all but similar therapies against aml are still under development. recent clinical trials have highlighted the concerns about toxicity and therapy related deaths from car t-cells. antigen selection is the key factor determining the specificity, efficacy and toxicity of car t-cells. while contemporary adoptive t-cell therapies use monoclonal antibodies against tumor associated antigens we employed the naturally occurring flt ligand (fl) to target aml cells expressing flt receptors. flt receptor is expressed on multipotent and myelomonocytic progenitors as well as myeloid leukemia cells. to generate fl containing chimeric tlymphocytes designated flcar t-cells and to evaluate their efficacy against aml cells. design/method: flcar was constructed by fusing the coding sequences of the human fl, cd costimulatory domain, and cd -zeta chain (intracellular region) in series. it was then cloned into the phiv-egfp lentiviral vector for expression in cell lines and primary t cells obtained from healthy donors. the empty phiv-egfp vector was used as a negative control. flcar was expressed on both cd + and cd + t-lymphocytes, confirmed by western blot. cell cytoxicity was evaluated by co-culturing flcar t-cells and aml cells followed by flow cytometric analyses. cytokine production was assessed by analyzing expression of interleukin- using quantitative rt-pcr. results: flcar t-cells were generated from cd + jurkat and cd + tk- cell lines with up to % lentiviral transduction efficiency. the efficiency for primary t cells was lower ( - %). flcar was expressed as a ∼ kda protein in cells and was partially phosphorylated on tyrosine. the expression of flcar on lymphocytes lead to increased basal il- expression in the cells. this was further augmented (by > folds) upon co-incubating flcar t-cells with flt expressing target cells. jurkat cells, tk- cells and primary human t cells expressing flcar suppressed the growth of flt -expressing aml cell lines and primary aml cells in vitro. notably, flcar t-cells generated from healthy donors caused strong inhibition of aml cells even at a lower transduction efficiency. in vivo experiments using nsg-sgm mice xenografted with human aml cells are underway. our data demonstrate that flcar can be effectively expressed on t-lymphocytes and mediate potent cytotoxicity against flt -expressing aml cells in vitro. being a completely human derived chimeric protein, it represents a promising candidate for further therapeutic development. holly pacenta, kelly sullivan, ahwan pandey, kelly maloney, joaquin espinosa children's hospital colorado, denver, colorado, united states background: individuals with down syndrome (ds) have a -fold higher risk of developing acute lymphoblastic leukemia (all) than the typical population. there are several important differences between all in individuals with ds (ds-all) and all in individuals without ds (nds-all): first, patients with ds-all have a lower percentage of favorable cytogenetic features compared to nds-all. second, patients with ds-all are more likely to have activating mutations in jak , crlf overexpression, and ikzf deletions. despite these clear genotypic differences, this knowledge has not yet been exploited for therapeutic purposes in ds-all. when outcomes for ds-all are compared to nds-all with similar cytogenetic features, the survival rates are similar. however, individuals with ds-all have an increased risk of treatment-related mortality (trm). current therapy for ds-all is similar to that for nds-all, with the exception of small changes to decrease toxicities that are more prevalent in ds-all. it was recently identified that interferon signaling is constitutively activated in healthy individuals with t . we hypothesize that aberrant interferon signaling could play a role in the unique leukemias observed in ds patients. objectives: to identify differences in gene expression and intracellular signaling cascades that are unique to individuals with ds-all, relative to both nds-all and healthy individuals with ds that can be exploited for therapeutic use. design/method: bone marrow samples were obtained from ds-all patients and matched nds-all patients based on clinical characteristics and genetic features. rna sequencing of these samples was performed and a total of samples were used for the transcriptome analysis ( ds-all vs. nds-all). the differential expression data was generated by deseq and analyzed using ingenuity pathway analysis. the analysis revealed that the chromosome genes that have been implicated in leukemogenesis are not differentially expressed in the ds-all samples, relative to nds-all. an inflammatory signature was identified, which included interferon gamma as an upstream regulator with predicted activation in ds-all. this finding is consistent with prior observations from healthy individuals with ds. other examples of results with potentially actionable targets include the upregulation of several genes in the ras pathway and genes involved in histone methylation. the increased interferon signaling seen in healthy individuals with ds was also identified in ds-all. this may contribute to the development of mutations in inflammatory pathways such as jak and crlf in ds-all. targeting these common pathways with small molecule inhibitors may have a therapeutic benefit in ds-all. cincinnati children's hospital medical center, cincinnati, ohio, united states background: next-generation sequencing (ngs) guides precision medicine approaches in oncology using therapies targeting molecular alterations found within an individual cancer. increased availability of ngs coupled with a proliferation of targeted drugs in development heightens the need for reliable pre-clinical animal models. here we report a patientderived xenograft (pdx) system with integrated molecular profiling for pre-clinical testing of conventional cytotoxic and novel targeted agents. objectives: to utilize ngs from patients with pediatric leukemia to guide rational pre-clinical trials in pdx leukemia avatars, and to determine pdx mice tolerance of and response to cytotoxic and targeted therapies. pediatric acute lymphoblastic leukemia (all) samples were obtained in adherence to an irb-approved protocol and xenografted into nod/rag/interleukin- (il- )rg (nrg) mice. ngs was performed clinically using the foundationone® heme panel. a de novo all sample bearing mutations involving jak , crlf , ntrk , cdkn a/b, ptpn and wt was used for pre-clinical testing. thirty-seven nrg mice were transplanted with million patient cells/mouse via iv injection. standard -drug induction chemotherapy was administered consisting of vincristine, dexamethasone, pegaspargase, and daunorubicin [vxpd, n = mice], in comparison to vehicle control [n = ]. parallel pdx cohorts were treated with single agent targeted therapies based on ngs findings, including ruxolitinib [n = ], crizotinib [n = ] and loxo- [n = ]. the four-week treatment period began on day + from transplant after confirmation of engraftment. following completion of therapy, residual disease burden was analyzed by flow cytometry (hcd +, mcd -cells) in the bone marrow [bm] . to date, pdx models have been established using over thirty ngs-profiled pediatric all samples, including six samples bearing philadelphia (ph) chromosome or phlike mutations. pre-clinical testing was performed in a repre- conclusion: ngs reveals concomitant mutations in ph-like all that may represent additional targets for therapy, or predict tyrosine kinase inhibitor (tki) resistance. we show that all xenograft nrg mice can tolerate a -week multi-agent cytotoxic chemotherapy induction regimen, as well as rational targeted agents, and serve as a robust pre-clinical model for precision medicine trials. background: osteonecrosis is a well-characterized all therapeutic toxicity attributed to glucocorticoids, asparaginase, and methotrexate that disproportionately affects adolescents. in ccg- , alternate-week dexamethasone during double delayed intensification (di) reduced osteonecrosis vs continuous dexamethasone with single di in rapid early responders (rer) ≥ y. to compare efs and os between hr-all patients with vs without osteonecrosis. design/method: hr-all patients - y on aall ( - ) received cog augmented therapy with a × randomization to: ( ) induction dexamethasone ( mg/m d - ) vs prednisone ( mg/m d - ), and ( ) interim maintenance (im) high-dose methotrexate (hdm) vs escalating-dose methotrexate/pegaspargase (ema). rer received single, and slow early responders (ser) double, im/di. initially, all received monthly dexamethasone maintenance pulses, patients ≥ y received di alternate-week dexamethasone, and patients ≤ y received di continuous s of s dexamethasone. there were osteonecrosis-related amendments: after / all patients ≥ y received di alternateweek dexamethasone; after / all patients ≥ y were assigned to induction prednisone, and all patients received di alternate-week dexamethasone and maintenance prednisone pulses. results: osteonecrosis was confirmed in / patients. the y cumulative incidence (ci) was . % overall and increased with age: - y . %, - y . % (alternateweek dexamethasone . % vs continuous dexamethasone . %; p< . ), ≥ y . % (p< . ). among randomized rer patients ≥ y, ci differed by glucocorticoid (dexamethasone . % vs prednisone . %; p = . ) but not methotrexate assignment (hdm . % vs ema . %; p = . ). among randomized ser patients ≥ y, ci was . % with no difference by regimen. results were similar for patients ≥ y. in the entire study population, patients with osteonecrosis had superior y efs ( . % vs . %; p< . ) and os ( . % vs . %; p< . ) than those without osteonecrosis. y efs was significantly higher among randomized patients ≥ y with vs without osteonecrosis ( . % vs . %; p< . ); this finding was present in different age ranges (≥ y, ≥ y, ≥ y) and rer/ser subsets within each, especially in the ≥ y rer ( . % vs . %; p = . ) and ser ( . % vs . %; p< . ) cohorts. across groups, asparaginase allergy was significantly associated with reduced osteonecrosis risk (≥ y: hr . ; p = . ). patients who develop osteonecrosis have significantly increased efs and os, suggesting host differences that increase sensitivity to develop osteonecrosis and render all cells more chemo-responsive. pennsylvania state university, hershey, pennsylvania, united states background: cdc (cell division cycle protein ) belongs to rho family of small gtpases in ras-oncogene superfamily. pro-oncogenic role of overexpressed cdc in ras driven solid tumors are well known. however, role of cdc in leukemia is yet to be established. ikzf encodes ikaros protein which has important role in regulation of lymphoid development and tumor suppression in leukemia. casein kinase ii (ck ) oncogene is overexpressed in leukemia. ck impairs ikaros function which can be restored by using ck inhibitors. objectives: to investigate role of cdc in leukemia and regulation of cdc by ikaros and ck in b-cell acute lymphoblastic leukemia (b-all). shrna transfection, real time-pcr, luciferace assay, quantitative chromatin immunoprecipitation (qchip) coupled with the next-generation sequencing (chip-seq), cytotoxicity assay and western blot. results: cdc is identified as one of the ikaros target genes by analysis of genome-wide dna binding of ikaros using chip-seq and qchip in b-all primary cells. expression of cdc was also noted to be higher in all patient samples compared to normal bone marrow. functional experiments showed that ikaros overexpression via retroviral transduction results in transcriptional repression of cdc . ikaros silencing using shrna resulted in increased expression of cdc . these data suggest that ikaros negatively regulates transcription and expression of cdc . ck directly phosphorylates ikaros and impairs its function as transcription factor. we noted that molecular inhibition of ck via sirna as well as treatment with specific ck inhibitor, cx also decreases expression of cdc . treatment with cx of primary b-all with ikaros haploinsufficiency restores ikaros binding to cdc promoter and represses cdc expression. however, this effect is evident only in presence of ikaros. treatment with cx in ikaros silenced (ikaros shrna) cells showed no change in expression of cdc . these results emphasizes the importance of ikaros in regulating cdc expression. furthermore, we analyzed the changes in epigenetic signature at the cdc promoter following treatment with cx . results show that loss of histone marker of open chromatin (h k ac) and increased histone marker for repressive chromatin (h k me ), at the cdc promoter. these data suggest that ikaros transcriptionally represses cdc via chromatin remodeling. a specific cdc inhibitor, ml showed cytotoxic effects on primary b-all cells. conclusion: cdc may have important role in hematologic malignancies. expression of cdc in b cell all is regulated by ikaros and ck . these results suggest that targeting cdc could be a potential therapeutic strategy in leukemia. caitlyn duffy, laura hall, justin godown, koyama tatsuki, scott borinstein monroe carell jr. children's hospital at vanderbilt, nashville, tennessee, united states background: systemic corticosteroids are widely used as treatment of acute lymphoblastic leukemia (all) and lymphoblastic lymphoma. there are anecdotal reports of bradycardia in pediatric patients receiving corticosteroids, but a more extensive analysis of this effect is needed. objectives: the aim of this study was to describe the incidence, severity, and timing of steroid-induced bradycardia and document any adverse events associated with bradycardia. design/method: we performed a retrospective review of all newly diagnosed patients at our center ( - ) with all/lymphoblastic lymphoma who received corticosteroids (dexamethasone - mg/m /dose or prednisone mg/m /dose) during induction chemotherapy. patients were excluded if they had a pre-existing cardiac abnormality or if they received prior corticosteroids. the average hour heart rate (hr) was assessed for the period prior to initiating steroid therapy and for the hour period surrounding the nadir following steroid administration. the degree and time of steroid induced bradycardia was assessed. adverse patient events and concomitant medication use was documented to identify other contributing factors to bradycardia. a total of children ( females, males, months- years) were included in the analysis with demonstrating a decrease in mean hr following steroid administration. median hr decrease was . beats per minute (quartiles . - ) from prior to initiating steroids to surrounding nadir. sixty one percent developed bradycardia less than or equal to the st percentile for their age range. nadir occurred doses (range - ) into treatment, which corresponded to hours ( - ) after initiation of therapy. of patients who experienced bradycardia, % were associated with dexamethasone rather than prednisone. hr nadir was not associated with other vital sign abnormalities. after completion of induction chemotherapy, % of patients had documented resolution of bradycardia with hr greater than the th percentile for age. it was observed that the children who continued to have relatively low hr were often younger ( months- years old). examination of nadir hr during subsequent hospitalizations in which steroids were not being administered (excluding hr during procedural sedation) did not demonstrate a significant incidence of bradycardia. concomitant opioid, beta-blocker, or other medication exposure did not contribute to the incidence of bradycardia. corticosteroid-induced bradycardia is extremely common in children, teenagers, and young adults with all receiving induction chemotherapy. bradycardia was not associated with clinical adverse events and resolved after completion of corticosteroid treatment. therefore, further cardiac assessment may not be warranted in the presence of bradycardia suspected to be secondary to steroid administration. baylor college of medicine, houston, texas, united states background: survival in newly diagnosed pediatric acute myeloid leukemia (aml) is approximately %; however survival falls dramatically if a patient relapses. currently, approximately one-third of patients with pediatric aml relapse on standard chemotherapy regimens. aml cells are exposed to proteotoxic stress at baseline due to their rapid and inefficient metabolism; proteotoxic stress increases after chemotherapy due to accumulation of reactive oxygen species resulting in misfolded proteins. this leads to activation of cell stress pathways, such as the unfolded protein response (upr) in the endoplasmic reticulum. because an activated upr can make cells more sensitive to proteotoxic stress, we hypothesize that upr activation correlates with response to chemotherapy. objectives: determine the status of upr in pediatric aml and its correlation with chemosensitivity; design/method: peripheral blood samples from pediatric patients with aml were collected at the start of induction chemotherapy, - hours (h) and h post initiation of systemic chemotherapy. tumor cells were sorted from peripheral blood mononuclear cells. expression of upr proteins was determined by chemiluminescence using an automated capillary electrophoresis system. clinical correlations were performed using an annotated database. we measured five upr proteins: grp (glucose regulated protein kda), phospho-eif , inositol-requiring enzyme (ire ) and activating transcription factor (atf ). patients with aml had - times higher expression of upr proteins (except atf ) at baseline than normal controls. grp -the key upr driver-had the highest level of protein expression in myeloid blasts. there was a wide variability in the level of baseline upr expression. eight out of samples expressed > fold increase in grp above those with the lowest grp levels. similarly, and patients respectively, had a > fold increase in peif and ire , compared to patients with low basal expression of these upr proteins. in our limited sample set, there was a trend towards lower overall survival (os) and event-free survival in patients with low baseline grp and ire . conclusion: upr has a variable expression at baseline in pediatric aml, with a trend towards lower os in patients with a low basal grp and low ire expression, suggesting less chemosensitivity in this subgroup. conversely, it is possible that blasts with an upregulated upr prior to chemotherapy manage proteotoxic stress less effectively, having faster apoptosis and hence a better response to chemotherapy in patients with a high basal upr. we are currently expanding our findings in a larger cohort of patients enrolled in the children's oncology group aaml protocol. background: children with newly diagnosed acute lymphoblastic leukemia (all) undergo chest x-ray (cxr) evaluation during initial diagnostic workup to ensure safe airway management. however, to our knowledge, no systematic assessment of cxr findings has been reported. objectives: to evaluate cxr findings at diagnosis of all and their associations with clinical characteristics. we reviewed the cxr findings at diagnosis of all in patients treated on the total xv and xvi protocols at st. jude children's research hospital. findings were evaluated for associations with clinical characteristics at presentation, and the clinical management of mediastinal masses was reviewed. mediastinal masses were seen in ( . %) of patients evaluated and were more common in older patients (mean age, . years) than in younger patients (mean age, . years) (p = . ), in males than in females (p = . ), and in patients with t-all than in those with b-all (p< . ). also associated with mediastinal masses were a higher white blood cell count (wbc) at diagnosis (mean, . × /l) (vs. a lower wbc; mean, . × /l) (p< . ), cns involvement (vs. no involvement) (p = . ), and standard/high-risk disease (vs. low-risk disease) (p< . ). other cxr findings included pulmonary opacity ( patients [ . %]), bronchial/perihilar thickening ( patients [ . %]), cardiomegaly ( patients [ . %]), and osteopenia/fracture/periosteal lesions ( patients [ . %]). pulmonary opacity was more common in younger patients (mean age, . years) than in older patients (mean age, . years) (p = . ) and in those with t-all (vs. b-all) (p = . ). bronchial/perihilar thickening, cardiomegaly, and osteopenia/fracture/periosteal lesions were also more common in younger patients than in older ones (p< . , p = . , and p< . , respectively) and in those with low-risk disease (versus standard/high-risk disease) (p< . , p = . , and p = . , respectively). of the patients with a mediastinal mass on cxr, underwent a confirmatory chest ct scan, and ( . %) were confirmed to have a mediastinal mass. notably, patients ( . %) had airway compression, and compression of venous structures was identified in of patients ( . %) who received iv contrast. the clinical course was evaluated for patients with mediastinal masses detected by cxr. fifty patients ( . %) required icu admission (mean stay, . days). general anesthesia was used for only patients ( . %), and patients ( . %) had a less invasive peripherally inserted central catheter. no deaths occurred in the acute phase. conclusion: cxr at the time of all diagnosis can detect various intrathoracic lesions and is helpful in planning initial diagnostic workup and management. background: mertk is a receptor tyrosine kinase that is aberrantly expressed in % of pediatric primary aml samples. mertk inhibition with the small molecule tyrosine kinase inhibitor (tki) mrx- decreases tumor burden and prolongs survival in aml xenografts. while treatment with mrx- reduces leukemia in the peripheral blood, it is less effective in the bone marrow, suggesting a role for the marrow microenvironment in therapeutic resistance. the jak/stat pathway has been implicated as a mediator of bone marrow derived resistance to tkis and inhibitors of this pathway are in clinical development for the treatment of aml. to determine the role of the bone marrow stromal niche in mediating resistance to mertk inhibition and to evaluate the efficacy of combined mertk and jak/stat inhibition. design/method: aml cell lines were cultured with or without the hs stromal cell line or hs conditioned medium, then treated with mrx- +/-the jak/stat inhibitor ruxolitinib, or control. induction of apoptosis and cell cycle arrest in aml cells was measured by flow cytometry. expression of h ax and total and phosphorylated stat were determined by immunoblot. results: co-culture with stromal cells significantly reduced aml cell death and g /m phase arrest in response to treatment with nm mrx- compared to no co-culture (cell death: . % versus . %, p< . ; g /m arrest: . % versus . %, p< . ). g /m arrest was accompanied by an increase in h ax expression which was similarly abrogated in co-culture. conditioned medium did not provide protection from mrx- induced apoptosis, g /m arrest, or h ax induction. mrx- inhibited stat phosphorylation but direct co-culture and conditioned medium potently increased basal stat phosphorylation which was not inhibited by mrx- . to determine whether the observed induction of stat phosphorylation was functionally relevant, cocultures were treated with both mrx- and ruxolitinib. while ruxolitinib potently inhibited the phosphorylation of stat in the presence of co-culture, combination treatment did not overcome stromal mediated protection from mrx- induced apoptosis. similarly, the addition of exogenous gm-csf induced stat phosphorylation but did not yield protection from mrx- functional effects in the absence of co-culture. together these data support a model whereby direct cell-cell contact with stromal cells in the bone marrow niche protects leukemia cells from mrx- induced apoptosis, cell cycle alterations, and dna damage. while co-culture potently induces phosphorylation of stat in leukemia cells, this is neither necessary nor sufficient for stromal-cell mediated protection from mertk inhibition and combined treatment with jak/stat inhibitors is unlikely to be therapeutically efficacious. background: mercaptopurine ( -mp) is an immunosuppressive thiopurine drug that is a key component of acute lymphoblastic leukemia (all) treatment. -mp is metabolized into -thioguanine ( -tgn), which is responsible for anti-leukemic effects, as well as -methylmercaptopurine nucleotides ( -mmpn/ -mmp), which are associated with hepatotoxicity. some patients preferentially metabolize -mp to -mmpn/ -mmp, increasing their risk for hepatotoxicity and potentially reducing anti-leukemic effects. hepatotoxicity can cause interruptions or delays in therapy that may jeopardize cure rates. allopurinol has been increasingly used in patients with inflammatory bowel disease (ibd) to shunt -mp metabolism toward -tgn and away from -mmpn to minimize hepatotoxicity and preserve therapeutic effects. objectives: this retrospective chart review expands upon our previously published case series of three patients with all in whom allopurinol was successfully used to redirect -mp metabolism. twelve additional patients have subsequently received allopurinol and -mp combination therapy at texas children's hospital. data from this larger patient sample, with longer follow up, is being analyzed to increase knowledge of the effectiveness and longitudinal effects of adding allopurinol to -mp to reduce risk of hepatotoxicity. design/method: data were abstracted from the electronic medical records of patients with all treated at texas children's hospital from to present, who had been found to have evidence of altered -mp metabolism and in whom allopurinol was added to -mp therapy due to concern for risk or recurrence of hepatotoxicity. metabolite levels, -mp dose, and alanine transaminase (alt) prior to initiation of allopurinol and approximately weeks later were compared. wilcoxon signed-rank test was applied for statistical analysis. : after the addition of allopurinol, patients experienced a significant decrease in mean levels of -mmpn (p = . ), correlating with a significant decrease in mean alt (p = . ). with the initiation of allopurinol, the mean -mp dose was decreased from to mg/m /day over an -week period. mean -tgn levels increased (p = . ). in follow up beyond weeks, no patients had further holds in -mp due to hepatotoxicity. addition of allopurinol appears to shift metabolism from -mmpn toward -tgn, with increases in mean -tgn levels despite a decrease in mean -mp dose. this may limit negative side effects, thus resulting in fewer gaps in therapy and possible improved outcomes. further analysis of -mp dose titration and effects on anc over time as well as effects on overall survival is ongoing. prospective background: alterations in epigenetic patterning are a fundamental feature in acute myeloid leukemia (aml). treatment with dna methyltransferase inhibitors (dnmti) yields responses in aml, but the molecular mechanisms underlying this effect are poorly understood. in prior work, we demonstrated induction of genes involved in the pirna rna (piwi) silencing pathway as a common gene feature of aml cell lines treated with decitabine. the piwi pathway is an rna silencing system, distinct from classical small rna transcriptional silencing, responsible for transposon-silencing in gametogenesis; emerging data suggest a role for this system in somatic cells. based on these data, we postulate that piwi induction plays a crucial role in aml recovery following demethylation and that disruption of this pathway would modulate response and/or recovery from decitabine treatment. to assess the effect contribution of the pirna pathway response following dnmti treatment in aml. design/method: to choose target genes in the pirna pathway for disruption, molm cells were first treated with escalating doses of decitabine. using quantitative rt-pcr, the dose-dependent expression of several pirna-associated genes were analyzed. two genes, mael and piwil , were selected for disruption experiments based on preliminary data suggesting decitabine dose-dependent responses. molm cells were transduced with shrna targeting these genes using a lentivirus delivery system with selection in puromycin. knockdown efficiency was assessed by rt-qpcr. to determine how gene disruption affected cell growth, knockdown cells were treated with decitabine nm. proliferation was assessed by celltiter glo assay following decitabine treatment. clonogenic potential was assessed by colony forming assays of transduced cells after treatment with decitabine at nm and nm. results: following decitabine exposure in molm , there was a markedly increased expression of mael and piwil compared to untreated cells ( : and : , respectively) . thus, these were the candidate genes chosen for disruption. of mael shrna constructs, two resulted in a % relative expression of mael compared to controls. of the piwil shrna constructs, the best knockdown showed % relative expression. there were no significant differences in proliferation or clonogenicity of stably selected mael or piwil knock-down molm cells following decitabine treatment. using gene knockdown procedures, mael and piwl do not appear to have a marked effect on growth and response to decitabine treatment in molm . however, these results may be limited by inefficient knockdown using shrna targeting methods. further work using a cas /crispr based inactivation of these genes is ongoing. children cancer hospital cairo, egypt background: hypodiploidy < chromosomes is very uncommon and have particularly poor outcomes in childhood acute lymphoblastic leukemia (all). it is subdivided into: near-haploid ( - chromosomes), lowhypodiploid ( - chromosomes) and high-hypodiploid ( - chromosomes). to determine if minimal residual disease (mrd) can identify a group of patients with better prognosis in the hypodploid population who can be treated with intensive chemotherapy alone. design/method: a retrospective study that included all patients under age of diagnosed as hypodiploid b-precursor all during the period between january -december and treated at children's cancer hospital egypt on sjcrh total study-xv for ir/hr all. sixteen patients had < chromosomes ( nearhaploid and low-hypodiploid), constituting % of all pediatric patients with b-precursor all during the study period. patients with near-haploid all had a median age of years (range - ), initial leukocyte count (wbc) median of . × /l (range . - . ), ( . %) were males and / ( . %) had hr-nci criteria. four patients ( . %) are alive in complete remission(cr) (range - months, median ), one died in induction and ( . %) had hematological relapse (range . - months, median ). patients with low-hypodiploid all had significantly older age (median years, range - ), median wbc . × /l (range . - . ), / ( . %) were males. one patient ( . %) is alive in cr, one died in induction, one failed to achieve cr post-induction and patients( %) had hematological relapse (range . - . months, median . ). mrd< . % by flow-cytometry on day- and end of induction was achieved in / ( . %) and / patients( %) with near-haploid, compared with / ( . %) and / patients( %) with low-hypodiploid; respectively (p = . , p = . ;respectively). allogeneic transplantation was performed during initial remission only in mrd negative patients (one relapsed and one is in cr) and in the patient with induction failure (relapsed post-transplant). five of the total six patients who had negative mrd on day- and end of induction are alive in cr ( / with chemotherapy alone). all patients with negative mrd at end of induction but with mrd levels≥ . % on day- (range . - . %) relapsed as well as all patients with detectable mrd at the end of induction. the difference in relapse was statistically significant in relation to negative-mrd on day- (p = . ), but not at end of induction(p = . ). conclusion: children with hypodiploid all and negative mrd on day- of induction are highly curable with intensive chemotherapy alone, while patients with negative mrd at the end of induction and detectable mrd on day- had dismal outcome. background: overall survival in pediatric acute myeloid leukemia (aml) has plateaued between - %, with death during induction chemotherapy seen in - % of patients. respiratory complications contribute to morbidity and mortality in pediatric aml induction, however the incidence, patterns, and predictors of respiratory adverse events (aes) during this period are unknown. to estimate the incidence of respiratory aes during induction therapy for de novo pediatric aml, to characterize and grade these respiratory aes, and to identify predictors of respiratory ae development. we conducted a retrospective longitudinal study from presentation to day in institutional de novo pediatric aml patients (≤ years) between march and december . outcomes included any nci ctcae grade - respiratory ae or death from another cause. demographic, disease, and treatment-related data were abstracted. the most specific, best-fitting ctcae category and grade for each ae was determined. descriptive statistics, survival analysis, multivariable logistic regression analysis, and time-toevent distributions were performed (sas v . , cary, nc) . among eligible patients, . % (n = ) experienced discrete respiratory aes. incidence of grade - aes was . % (n = ). a bimodal time-to-event distribution demonstrated peaks at treatment days and . induction death occurred in . % (n = ) including deaths from respiratory failure associated with disseminated fungal disease. in univariate analysis, those experiencing aes differed significantly in regards to older age at diagnosis (p< . ), higher initial wbc (p = . ), higher initial peripheral blast percentage (p = . ), coagulopathy at diagnosis (pt (p = . ), d-dimer (p = . )), fluid overload status (p< . ), occurrence of infection (p = . ), and occurrence of tumor lysis syndrome (tls) (p = . ). patients with hyperleukocytosis (p = . ), fluid overload (p< . ), and fab m morphology (p = . ) each had a significantly decreased probability of completing the follow up period without experiencing a respiratory ae. on multivariable analysis, fluid overload (aor . [ % ci: . - . ) and older age (aor . [ % ci: . - . ) were significantly associated with ae occurrence when gender, hyperleukocytosis, tls, and infection status were held constant. we describe a high incidence of respiratory aes during pediatric aml induction. fluid overload and older age at diagnosis are independently associated with ae development when controlling for other proposed risk factors. interventions focused on conservative fluid management and offset of fluid overload should be explored in newly diagnosed pediatric aml in an effort to reduce respiratory complications during induction. overall, all survival rates are outstanding and have continued to improve with risk-adapted therapy. the most striking improvement occurred in t-all where -year os rates now exceed % and parallel b-all. survival improvements, however, have not been observed uniformly across all subgroups. while the gap in outcome differences narrowed among blacks, outcomes for hispanics have remained static. further, no improvements in survival were observed in infants or ayas and new treatment approaches have been implemented for these populations. background: acute myeloid leukemia (aml) accounts for approximately % of new childhood leukemia cases. chest x-ray (cxr) is performed in all newly diagnosed aml cases to evaluate the safety of airway management for anesthesia during diagnostic procedures; however, cxr results in pediatric patients with aml have not been described. objectives: the primary objective was to evaluate cxr findings at diagnosis in patients with aml. the secondary objectives included assessing associations between cxr findings and clinical characteristics, with the overall goal of aiding in the evaluation of the use of cxrs as an initial diagnostic study in pediatric patients with aml. design/method: cxr findings and clinical characteristics were evaluated in patients with newly diagnosed aml who were enrolled in one of three protocols at st. jude children's research hospital (aml , aml , and aml ). the findings were categorized based on radiologic reports. further, the associations of these findings and clinical characteristics were evaluated. we evaluated cxr findings in a total of patients: from aml ; from aml ; and from aml . common cxr findings were pulmonary opacity (n = , . %), bronchial/perihilar thickening (n = , . %), splenomegaly (n = , . %), mediastinal mass and lymph nodes (n = , . %), pleural effusion/thickening (n = , . %), demineralization/fracture/periosteal lesions (n = , . %), scoliosis (n = , . %), and granulomatous disease (n = , . %). three cxr findings were associated with younger age at diagnosis: pulmonary opacity (median age, . years in patients with positive findings vs. . years in those with negative findings, p< . ), bronchial/perihilar thickening (median age, . years vs. . years, p< . ), and demineralization/fracture/periosteal lesions (median age; . years vs. . years, p = . ). two cxr findings were associated with older age at diagnosis: scoliosis (median age, . years vs. . years, p< . ) and granulomatous disease (median age, . years vs. . years, p = . ). higher white blood cell counts (wbcs) at diagnosis were associated with cxrs showing pulmonary opacity (median wbc; . × ^ /l vs. . × ^ /l, p = . ) or splenomegaly (median wbc; . × ^ /l vs. . × ^ /l, p = . ). french-american-british (fab) m /m subtypes were more frequently associated with pulmonary opacity compared with others (p< . ). we did not find significant differences between female and male patients. conclusion: cxr in patients with newly diagnosed aml showed a variety of thoracic, abdominal, and bony lesions that are important for the initial evaluation and management. pulmonary opacity was the most common finding and was frequently seen in patients who were younger or had higher wbcs at diagnosis or fab m /m . background: children diagnosed with acute lymphoblastic leukemia (all) require a central venous catheter (cvc) to administer chemotherapy safely. both external and internal cvcs carry risks of complications including thrombosis, infection, and possible replacement. internal catheters, such as a port, are generally used for the majority of patients for the duration of treatment since therapy lasts for several years. many institutions place a port at the time of diagnosis. other institutions prefer to start induction therapy via placement of a peripherally inserted central catheter (picc) and defer port placement until the completion of induction therapy due to concerns of increased risk of infectious complications with port placement. objectives: to compare rates of common cvc associated complications by type of cvc placed at start of induction therapy in children treated for newly diagnosed all at the jimmy everest center (jec) at the university of oklahoma health sciences center. design/method: a retrospective chart review analyzed data from newly diagnosed all patients treated at the jec between - . data was collected on complications including thrombosis, bacteremia, insertion site infection, cvc malfunction and need for removal. data collection began at the start of induction and was completed at the end of induction therapy. statistical analysis used a univariate and multivariate logistic regression model to compare complication rates between those who had a port versus those who had a picc placed at start of induction. results: data was collected on patients. fifty-six patients had a port placed at start of therapy while had a picc placed. fourteen percent of patients had a cvc associated complication. univariate analysis showed no statistically significant difference in rates of cvc associated complications between the groups (port %, picc . % p = . ). the rates of hospitalization for cvc associated complications were similar between both groups (port %, picc % p = . ). rates of cvc removal were also similar between both groups (port %, picc % p = . ). multivariate model that included baseline patient characteristics including type of all, patient body surface area, gender, ethnicity and age continued to demonstrate no significant difference in cvc associated complications between both groups. conclusion: this single institution study showed that there was no significant difference in cvc associated complications between port and picc line placement at the start of childhood all induction therapy. port placement can be considered as a safe option at the start of induction therapy. complete remission [cr] or cr with incomplete blood count recovery [cri]) within treatment cycles - . interim data are reported (nct ). results: seventeen patients were enrolled and received ≥ dose of lenalidomide; median age was years (range - ); patients were female. patients received median prior regimens (range - ). nine patients had previously undergone bone marrow transplantation (bmt). four patients had relapsed aml and were refractory to immediate prior treatment. median duration of study treatment was weeks (range - ); patients completed a median of treatment cycle (range - ). all patients were evaluable for primary outcome; achieved morphologic cri after cycles (no patients achieved cr). the responder was a -year-old male with history of r/r aml after first-and second-line treatment, bmt, and salvage chemotherapy. at baseline, he had a complex cytogenetic karyotype (monoallelic − q . , − q, − q . , − p ) with no identifiable molecular mutation; he was also positive for del( q) (− q , − q ). his post-treatment karyotype showed no abnormalities. sixteen patients experienced treatment failure; due to resistant disease, of indeterminate cause, and had treatment failure before a post-baseline assessment was performed. all patients experienced ≥ grade - treatment-emergent adverse event (teae). the most commonly reported were thrombocytopenia (n = ), anemia (n = ), febrile neutropenia (n = ), and hypokalemia (n = ). fifteen patients experienced ≥ teae related to lenalidomide. all patients discontinued treatment; remain in follow-up. the study is now closed to enrollment. ten patients died on study: during treatment, during follow-up. all deaths were attributed to aml or complications due to aml. conclusion: third-line lenalidomide monotherapy was associated with clinical response in of pediatric patients with r/r aml; however, treatment exposure was limited. safety data are consistent with the known profile of lenalidomide. lenalidomide was not an efficacious treatment for r/r pediatric aml. funding: celgene corporation, summit, nj, usa. cook children's medical center, fort worth, texas, united states background: it is well documented that pediatric patients with acute lymphoblastic leukemia (all) often experience significant weight gain during induction therapy and later struggle with obesity. however, some patients experience unintended weight loss during induction therapy; since this issue is not well reported, it often goes undertreated. although malnutrition is reported to be associated with decreased survival, increased risk of infection, and loss of lean body mass, there remains a scarcity of in-depth analysis of prevalence and risk factors that contribute to this problem. our study attempts to address this critical yet unmet need. objectives: our aim was to identify the clinical risk factors and outcomes associated with weight loss during induction therapy for pediatric all. design/method: this was a retrospective chart review of patients between and years of age diagnosed with all at cook children's medical center from / / to / / . for each patient, we collected height, weight, age, body mass index (bmi) z-scores at diagnosis and end of induction therapy, risk stratification, and whether consolidation was delayed. patients with a bmi > th percentile at diagnosis were categorized as being overweight or obese. using logistic regression analyses, we examined which variables predicted whether the patient had an increase or decrease in bmi z-score throughout induction. a critical alpha level of . indicated statistical significance. results: ninety-six patients met our inclusion criteria. of these, % experienced a decrease in bmi during induction therapy. compared to patients whose bmi increased during induction, patients with a decrease in bmi were more likely to be overweight or obese at diagnosis ( % vs. %; p< . ), to be ≥ years of age ( % vs. %; p< . ), to have a high-or very-high-risk stratification ( % vs. %; p< . ), and to experience a delay in the start of consolidation therapy ( % vs. %; p< . ). conclusion: this research highlights a risk not previously identified in the literature that may impact outcomes. patients treated on high-or very-high-risk protocols, who are overweight or obese at diagnosis, and who are ≥ years of age at diagnosis should be monitored closely for weight loss during induction therapy. patients who experience weight loss should receive prompt intervention. it is our hope that this information can be used for future prospective studies and to help develop evidence-based guidelines. background: p abnormalities have been observed in some patients with hematologic malignancies. loss of p function as a tumor suppressor gene in the chromosome plays an important role for development of leukemia. these patients usually have poor outcome due to the chemotherapy and are associated with poor prognosis. objectives: this study aimed to identify frequency of p abnormalities between iranian children and adult patients with aml (acute myeloid leukemia) malignancy. design/method: the p abnormalities were analyzed via bone marrow karyotyping and fish method in acute myeloid leukemia patients. in this study, p abnormalities were observed in ( %) patients out of diagnosed cases. a significant strong correlation between p abnormalities and other high risk factors (poor risk cytogenetic) were observed. from patients with aml malignancy ( p abnormalities), ( %) patients have complex karyotype, ( %) patients monosomal karyotype and ( %) patients have monosomal karyotype accompanied with a complex karyotype. overall, p abnormalities are independent risk factor in acute myeloid leukemia and evaluation of these abnormalities by fish or other complementary techniques prior to treatment, might help for better risk stratification of high risk aml patients. background: hepatotoxicity in treatment of acute lymphoblastic leukemia (all) is well studied and transiently affects most patients receiving antimetabolite therapy. rarely, patients develop liver injury severe or prolonged enough to undergo a liver biopsy. little is known about how these patients differ from patients that develop transient hepatotoxicity. we sought to describe disease and treatment characteristics for all patients that developed hepatotoxicity severe enough to undergo liver biopsy. we also looked for pre-dictive factors for liver biopsy, including signs of early hepatic injury from the initial treatment protocol. design/method: pathology reports of all patients from the liver biopsy database at children's healthcare of atlanta were collected. controls were matched : for age, all subtype, and treatment protocol. demographics, treatment protocols, and overall outcomes were collected through the electronic health record. hepatic lab results for transaminases, coagulation, and albumin were collected for induction, consolidation, interim maintenance, delayed intensification, and maintenance. results: sixteen patients diagnosed between - (median age at diagnosis years, range - ; % male; % pre-b all) were included in the case series. the median time from diagnosis to liver biopsy was . years (range - ). eight patients ( %) were in maintenance at the time of biopsy; none had active disease. eight ( %) were postbone marrow transplant. biopsy results included: steatosis ( ), acute inflammatory/infectious ( ), liver infiltration ( ), fibrosis ( ) and graft-vs-host disease (gvhd) ( ). six patients were deceased; -year all-cause mortality from diagnosis was %. thiopurine methyltransferase (tpmt) status was known in % cases and % controls. all cases had intermediate or wildtype status, which did not differ from controls (p > . ). patients requiring liver biopsy did not have evidence of acute hepatotoxicity (ast/alt > × normal values) during their initial treatment protocol. hepatotoxicity requiring liver biopsy is a rare outcome of all treatment. these patients had elevated rates of relapse, bmt, and -year all-cause mortality, suggestive of a more severe disease process. however, it is difficult to sort out the temporality of relapse, bmt, and hepatoxicity requiring biopsy in this limited sample. additionally, patients with bmt preceding liver biopsy have other confounding factors that makes them difficult to include in the analysis. finally, our limited descriptive data show no notable correlation between early hepatotoxicity and later indication for liver biopsy. future cohort or case-control studies with larger sample sizes are required to further explore early predictive factors for severe hepatotoxicity requiring liver biopsy. nathan gossai, joanna perkins, michael richards, yoav messinger, bruce bostrom background: the majority of chemotherapeutic agents used to treat hodgkin lymphoma are teratogenic. pregnancy screening prior to the start of chemotherapy is supported by clinical guidelines and baseline testing is a standard component in therapeutic trials. there is limited data available on the incidence of pregnancy screening prior to the start of hodgkin therapy but previous studies suggest that pregnancy screening, especially at pediatric institutions, is not consistently completed. objectives: the objective of this study is to evaluate the incidence of pregnancy screening and contraceptive counseling prior to the start of therapy in females diagnosed with hodgkin lymphoma. design/method: a retrospective chart review was performed for all female patients newly diagnosed with hodgkin lymphoma from to at the hospital for sick children in toronto, ontario. all patients who were intended to receive multi-agent chemotherapy were included, regardless of age. data collected included demographic and disease information, chemotherapy regimen and enrollment on clinical trial. all pregnancy testing within two weeks prior to the start of therapy was captured, as well as type of pregnancy test performed, documentation of menstrual status, contraceptive counseling and contraceptive provision. univariate and multivariate analyses were used to describe factors influencing the incidence of pregnancy testing. results: a total of female patients with newly diagnosed hodgkin lymphoma between the ages of and years were identified. sixty patients ( %) had pregnancy testing done prior to the start of therapy. testing modalities included serum and urine screens as well as quantitative beta-hcg measures. older age (p = . ), documentation of menstrual status at diagnosis (p = . ) and diagnosis between and (p = . ) were associated with higher incidence of screening. enrollment on a therapeutic trial was not associated with a higher incidence of screening (p = . ). contraceptive counseling was documented for patients ( %) and patients ( %) were prescribed contraceptive medications during therapy. pre-chemotherapy pregnancy testing was completed on % of females with newly diagnosed hodgkin lymphoma. improvement is required and interventions, including clarification of institutional standards, modification of chemotherapy order sets and staff education, are planned. (rao et al., cancer, ) . university of louisville, louisville, kentucky, united states background: granulocytic sarcomas (also known as chloromas or leukemia cutis) were first described by a. burns in . they are solid tumors comprised of immature granulocytic cells and represent extramedullary manifestations of underlying leukemia. chloromas are most commonly associated with acute myeloid leukemia. they may arise in other myeloproliferative disorders but are rarely seen in b or t cell acute lymphoblastic leukemia (all). objectives: although patients with all rarely have chloromas, it should remain on the differential for patients with unusual swelling or masses. design/method: we present a case series of two patients from our institution diagnosed with b cell all who had a chloroma as the presenting symptom. the first patient is a yo who presented to his primary provider with nasal congestion and a one-week history of bilateral eye swelling and was referred to an allergist when the symptoms did not resolve with anti-histamines. his review of systems was otherwise negative. he was referred urgently to ent two months later for a × cm mass palpated along the medial border of the left eye. an mri showed a left facial mass surrounding the zygoma and extending into the anterior inferior left orbit. biopsy revealed b cell acute lymphoblastic lymphoma, and bone marrow aspirate and biopsy confirmed the diagnosis as b cell all. the second patient is a yo who presented to his primary doctor for rapid growth of a scalp nodule that had been present for about months. he was referred to dermatology and treated for a supposed kerion from tinea capitis. the lesion continued to grow and became more irritated with this treatment. punch biopsy revealed a complicated phenotype of lymphoblastic lymphoma. however, after a lymph node biopsy and bone marrow aspirate and biopsy, the diagnosis was confirmed as b all. his only other positive point on review of systems was a questionably pathologic -pound weight loss and an area of matted cervical lymph nodes. for both of our patients, the chloromas completely disappeared during induction therapy. it is worth noting that both of these patients presented with the chloroma as the only symptom of the underlying leukemia. this led to initial misdiagnosis and delay in identifying their leukemia. therefore, while it is very rare for a patient with b all to present with a chloroma, our experience shows that all should be on the differential for patients presenting with unusual swelling or masses. background: hodgkin lymphoma (hl) is a lymphoproliferative neoplasm that commonly presents with history of adenopathy and a predictable pattern of disease involvement with or without systemic symptoms of fever and/or weight loss. in the hands of an experienced oncologist the diagnosis of hl is usually not a challenge. occasionally a diagnostic challenge is presented by a patient who has an atypical presentation which is suggestive of an alternative diagnosis. we describe a case series of patients diagnosed with hl whose initial clinical presentations lead to a diagnosis different form hl. honduras, nicaragua and the united states. results: six pediatric oncology centers from the american continent conducted a retrospective review of patients diagnosed with hl since . patients that had an initial presentation not suggestive of hl or who were initially diagnosed with a disease other that hl were included for a total of patients. argentina n = , guatemala n = , honduras n = , nicaragua n = , united states n = . five patients were female and male. patient's ages ranged from to years. most patients (n = ) were older than years. three patients ( %) presented with non-immune cytopenias without overt lymphadenopathy, of those one had active hemophagocytic syndrome. five patients ( %) were suspected to have localized solid tumors: ewing sarcoma n = , rhabdomyosarcoma n = , hepatocellular carcinoma n = , and soft tissue tumor of the cheek n = . two ( %) metastatic solid malignancy as they presented with disseminated pulmonary nodules. five ( %) with autoimmune disorders: hashimoto thyroiditis n = , autoimmune hemolytic anemia n = , nephrotic syndrome n = . ten ( %) with chronic infectious processes: brucella n = , tonsillar abscess n = , splenic abscess n = , and tuberculosis (tb) n = . patients with suspected tuberculosis were diagnosed outside of the united states. six of patients were ultimately diagnosed as having both tb and hl. seventeen patients had ann-arbor stage iii or iv, seven patient had stage ii with either b symptoms or bulky disease. patients were treated with various chemotherapy regimens according to the treating center: abvd, abve-pc oepa-copdac, avpc, beacopp. two patients had recurrent disease, one died of disease progression and one died from causes not related to hl conclusion: a small proportion of hl patients have atypical or unusual presentations. hl should be included in the differential diagnosis of solid tumors, autoimmune disorders, infections or cytopenias. the most common atypical presentation is an infectious process. background: acute lymphoblastic leukemia (all) represents the largest group of pediatric malignancies. the high cure rate of childhood all represents one of the most remarkable success stories in the war on cancer. in a lower middle income country (lmic) like the philippines, we reviewed the five year survival in a tertiary referral center. objectives: this retrospective cohort study aims to determine the survival of children - years old with all treated at a tertiary referral center for childhood cancer in the philippines from january to december . design/method: this is a retrospective cohort study that reviewed medical charts of newly diagnosed all ages to years old from january to december . a total of subjects were included in the study. the year overall survival (os) and event free survival (efs) were . % and . %, respectively. the year os for standard risk all was . % and for high risk patients was %. the year os for the patients on remission was . % and for those who relapsed was . %. univariate and multivariate by cox proportional hazards regression revealed wbc count at diagnosis, risk classification, immunophenotyping, and development of relapse showed significant prognostic impact for mortality. age and gender were reported with no prognostic significance. the -year os and efs were lower compared to developed countries but are comparable with other lmics. the prognostic factors for relapse and mortality were compatible with the literature. overall, the adopted treatment protocols for childhood all in this institution showed acceptable results. relapse has a significant prognostic impact for mortality. development of accessibility to care, increase awareness, early detection and resources at hand should be achieved. improvement in the follow up protocol to prevent delays in the treatment, patient education to prevent non-compliance and psychosocial support, to developed better supportive care, and expand facilities should be given emphasis to further improve survival and prevent relapse. objectives: here, we seek to further characterize this entity by describing the pathologic and clinical features of pediatric cases of burkitt-like lymphoma with q aberration. we collected pathologic and clinical data from the medical record on all pediatric high grade b-cell lymphoma (hgbcl) cases diagnosed at our institution over a -year period ( - ) . for those cases classified as neither burkitt lymphoma nor diffuse large b-cell lymphoma (dlbcl), fish for myc, bcl- and bcl- , as well as array comparative genomic hybridization (acgh), were performed. we identified cases of hgbcl, including cases of burkitt lymphoma presenting as purely leukemic phase. of the hgbcl cases, had burkitt lymphoma as defined by myc rearrangements, and had dlbcl. collectively, the majority of these patients had primary disease outside of the head/neck, and most patients presented with advanced stage (iii-iv) disease. of the remaining cases, q aberration was identified in cases using acgh. all cases histologically and immunophenotypically resembled burkitt lymphoma but lacked myc rearrangement, instead showing proximal gains in q -q and telomeric losses in q . qter. all cases involved primary disease in the cervical lymph node and/or tonsil. three of these cases were localized (stage ii), and the fourth case involved a few metabolically active but non-enlarged lymph nodes in the chest and abdomen (stage iii). all patients achieved complete remission with standard therapy for mature b-cell lymphoma, and were alive with no clinical evidence of disease at a median follow-up of months. although the number is small, our results suggest that the majority of non-burkitt, non-dlbcl cases of pediatric hgbcl carry q aberrations. in addition, patients with q aberrations appear to be more likely to present with lower stage disease, thus requiring less intensive therapy, and also tend to have primary disease in the head/neck. these findings further support the classification of burkitt-like lymphoma with q aberration as a distinct pathologic and clinical entity, and we propose that all pediatric non-burkitt, non-dlbcl cases of hgbcl regularly undergo further workup for possible q aberrations. marie claire milady auguste, joseph bernard st damien hospital, port-au-prince, port-au-prince, haiti background: hodgkin lymphoma (hl) and non-hodgkin lymphoma (nhl) account for % of cancers in the united states pediatric population ( , ). in central america and the caribbean, they are in second position among all types of pediatric cancers ( ). a previous study on pediatric cancers in haiti showed that the lymphomas were in fifth place after the leukemias, wilms tumor, retinoblastoma and the sarcomas ( ). the main objective of this study is to present the epidemiological profile of lymphomas managed at a haitian pediatric hospital. design/method: this is a retrospective study conducted on the cases of lymphoma diagnosed and managed at st damien hospital from january to december . key variables such as age, gender, stage at diagnosis, histopathological types and outcome were collected to present the characteristics of this retrospective cohort. of the cases of cancer diagnosed during the study period, ( . %) had the diagnosis of lymphoma. the sex ratio was . ( males for females) and the average age was . years [ - years]. there were cases of hl ( . %) and cases of nhl ( . %). . % of the patients were diagnosed at stages iii and iv. among the hl cases, ( . %) were nodular sclerosis lymphoma, ( . %) with mixed cellularity and ( . %) with lymphocytic predominance. for the nhl cases, ( . %) were burkitt's lymphoma and ( . %) lymphoblastic t-cell lymphoma. among the patients for who immunohistochemistry was found, the cases of hl were cd -positive and out of cases of nhl were cd -negative. only patient was hiv-positive, and patients had a confirmed exposure to epstein-barr virus. patients ( . %) were lost to follow-up, ( . %) were in remission, ( %) relapsed, ( . %) were still in treatment and ( %) were deceased. university of chicago, chicago, illinois, united states background: due to the adoption of risk-adapted therapy, pediatric and adolescent acute lymphoblastic leukemia (all) is associated with high cure rates. despite excellent outcomes in most children, patients with certain blast cytogenetic features do not fare as well. furthermore, african american, native american, and hispanic patients have worse outcomes than caucasian patients. while the outcome discrepancies are certainly multifactorial, and blast cytogenetics are related to age, it remains unclear whether ethnicity and blast cytogenetics correlate. the diverse patient population at the university of chicago provides an opportunity to evaluate for such a correlation. objectives: to describe cytogenetic findings in a racially and ethnically diverse population of patients of all age groups diagnosed with all at university of chicago from to and determine if there is a correlation between race/ethnicity and blast cytogenetics. results: a total of newly diagnosed patients with all between the ages of - from - were included in this study. of those, patients ( . %) had b-all, had t-all ( . %), one had early t-cell precursor all and one had mixed phenotype all (b/t). caucasians accounted for % of patients, african americans (aa) %, hispanics . %, asians . %, and % were of other races. age distribution had a bimodal pattern, with a peak in incidence at and another at years of age, consistent with published data. cytogenetic categories included: t( ; )(p ;q ), q rearrangements (kmt a), iamp , t( ; )(q ;p . ), t( ; ) (q ;q ), hypodiploidy, hyperdiploidy and double trisomy of chromosomes and . aa and hispanic patients with b-all presented more frequently between the ages of - years compared to caucasians (p = . and . , respectively). in aa patients, t( ; ) (q ;p . ) was overrepresented (p = . when compared to caucasians), and was mainly observed in patients between - years. caucasian patients were more likely than non-caucasians to have hyperdiploidy (p = . ), especially in patients aged - years. the rate of t( ; )(q ;p . ) was significantly higher in aa patients in our cohort, in particular in patients between the ages of - years. hyperdiploidy was more likely in caucasians aged - years. these findings may suggest that varying blast cytogenetics could contribute to outcome differences between races. ahmed elgammal, yasser elborai, mohamed fawzy, asmaa salama, eman d el-desouky, lobna shalaby national cancer institute, cairo, cairo, egypt background: hodgkin lymphoma (hl) in children is one of the malignancies that have a high chance of cure. stage iv hl remains a challenge for getting good clinical outcome as in other stages. many treatment protocols used to give combination chemotherapy while combined modality treatment is the mainstay in other treatment protocols. objectives: we aimed in to assess the outcome using consolidation radiotherapy to chemotherapy (combined modality treatment) versus combination chemotherapy alone in treatment of stage iv hl. design/method: we included patients with stage iv hl and whose data were retrieved from the medical records of the pediatric oncology department, national cancer institute, cairo university, egypt from till june and were followed till august . treatment was either to give cycles of abvd (adriamycin, bleomycin, vinblastine, dacarbazine) only or to give cycles of abvd followed by consolidation radiotherapy. the study included cases; were males and were females. mean age was . years ranging from to years. the histopathology subtype was nodular sclerosis in the majority of cases ( cases) followed by mixed cellularity ( cases) then only one case of lymphocyte rich. nine cases were initially bulky while cases were not. constitutional manifestations were present in cases while it was absent in cases. bone marrow was involved in only cases. radiotherapy was given after completion of chemotherapy to cases while cases received chemotherapy only. the -year overall survival for patients who received radiotherapy was superior to those who received chemotherapy alone; % versus . % respectively with statistical significance (p = . ). the -year progression free survival was also higher with radiotherapy than others; % versus . % (p = . ). patients with stage iv hl who received consolidation radiotherapy apparently had a better outcome than those who received chemotherapy only. this suggests that radiotherapy contributes significantly with chemotherapy to the cure rate for those patients. the feinstein institute for medical research, manhasset, new york, united states background: microrna (mirnas) are short non-coding rnas that play a decisive role in cancer biology, including leukemia. exosomes are microvesicles ( - nm) produced by most cells in biological fluids. exosomes represent the fingerprint of the parental tumor and are loaded with bioactive markers such as mirnas, which may regulate tumor growth. exosomal cargo can be transferred into target cells changing their biological properties. our study investigates a functional role for exosomal mir- a in pediatric acute lymphoid leukemia (p-all). objectives: / to demonstrate that p-all exosomes induce cell proliferation / to confirm that exosome-induced cell proliferation is disease-stage specific / to analyze exosomal mir- a expression profiles in p-all / to authenticate that inhibition of exosomal mir- a reduces leukemia proliferation design/method: exosomes were isolated by ultracentrifugation from healthy donors (hd) & p-all serum and conditioned medium (cm) of sup-b , jm , and cl- (control) human cell lines. cell lines were exposed to different sources of leukemia-derived exosomes in a paracrine or autocrine fashion for hrs in triplicates. proliferation was assessed by microscopic cell counting and confirmed by gene expression for proliferation, pro-survival and pro-apoptotic genes. mirna profiling was performed with the human cancer pathway finder microarray (qiagen). silencing of exosomal mir a was carried out by a mir- a inhibitor (qiagen), utilizing exo-fecttm exosome transfection reagent (sbi, system biosciences). further, exosomal mir- a silencing was confirmed by q-pcr. cellular uptake of texred-sirna (sbi, system biosciences) was confirmed by flow cytometry. transfer of exosomal mir a to the target cells was evaluated by q-pcr. we elucidated that cm-derived exosomes from sup-b and jm cell lines induce cell proliferation in sup-b , jm (autocrine and paracrine) and cl- cells (paracrine) (p< . ). serum p-all exosomes promote paracrine cell proliferation in all cell lines compared to hdderived exosomes (p< . ). heatmap analysis of mirna profiles of leukemia exosomes (all cell lines and p-all) identified mir- a significantly upregulated in leukemia exosomes compared to controls. mir- a was also upregulated in all cell lines after exposure to leukemia exosomes that induced proliferation. moreover, exosomal mir- a inhibition reduces leukemic proliferation in pediatric all. our data suggest that all exosomes induce cell proliferation of leukemic cell lines in both paracrine and autocrine fashion. exosomes regulate these phenomena in a highly orchestrated way, by transfer of functional exosomal mirnas such as mir- a. the results of this study suggest s of s that exosomal mir- a inhibition can act as a novel way for growth-suppression of pediatric leukemia. results: a total of disease sites were detected at pet/ct, while sites were detected at contrast-enhanced ct and bone marrow biopsy (bmb). pet/ct showed improved detection of nodal lesions (p < . ) (kappa value = . ), extranodal lesions (p < . ) (kappa value = . ) and bone marrow (p < . ) (kappa value = . ) compared to contrast enhanced ct and bmb. pet/ct had upstaged cases ( %) and down-staged cases ( . %) (p < . ) (kappa value = . ). among the upstaged cases, patients ( . %) were upstaged from stage ii to iii, based on residual in pet/ct not seen in contrast enhanced ct after abdominal mass excision. four patients ( . %) were upstaged from stage iii to iv based on bone marrow uptake in fdg-pet without positivity in bma or bmb.regarding response assessment, sensitivity was % for pet and % for contrastenhanced ct (p = . ). specificity was % for pet and % for ct (p< . ). positive predictive value for pet was %, while was % for ct scan (p< . ). negative predictive value for both pet and ct was % (p = . ). five patients had nd biopsy to confirm viability of the residual lesions, lesions were negative in pathological examination (all of them were metabolic negative in pet/ct; deauville score below ). one lesion was positive in pathological examination (was positive in pet/ct; deauville score of ). conclusion: pet/ct detected additional sites compared with contrast-enhanced ct and resulted in changing stage of disease. pet scan is significantly more specific than ct in the management of children with burkitt lymphoma. background: deep sequencing of the immunoglobulin heavy chain (igh) locus indicates that each b all is composed of innumerable subclones. in many cases, subclones exhibit differing phenotypic qualities. however, it remains unclear whether subclones demonstrate distinct tissue distribution within a patient. objectives: . to quantify the extent of clonal heterogeneity in diagnostic b all specimens; . to identify variability in clonal composition between bone marrow (bm) and peripheral blood (pb) disease sites. design/method: igh sequencing was performed on purified dna from pairs of matched bm and pb patient specimens. multiplex pcr was used to globally amplify the igh locus; next generation sequencing (ngs) was performed using illu-mina® miseq. index clones (defined as ≥ % of all sequence reads in a specimen) and their subclone progeny (defined by shared nucleotide bases immediately upstream of a common jh, or n_jx) were identified using igblast-determined vh and jh alignments (http://www.ncbi.nlm.nih.gov/igblast/) and an established in-house computational pipeline. results: up to index clones per specimen were discovered in of the samples. in the remaining ( bm/pb pairs), pair did not reveal a clonal igh and was eliminated from analysis; in the other, clone frequency did not reach the % index threshold, but predominant clonal precursors were inferred by the prevalence of their subclone progeny. subclone counts ranged from to , per index clone. a combined , subclones derived from pb index clones were observed; in contrast, bm index clones gave rise to only subclones. subclone heterogeneity was observed between all paired specimens. in bm/pb pairs, index clones existed in equivalent proportions between disease sites. in contrast, bm/pb pair demonstrated high-frequency index clones in the bm ( . % & . %) with limited representation of these clones in the pb ( . % & . %, respectively); in this case, the most prevalent clone in the pb ( . %) matched the least frequent index clone in the bm ( . %). similarly, another pair showed a predominant index clone in the pb ( . %) which was below index threshold ( . %) in the bm. in paired patient specimens, index clone predominance was discovered to be overtly distinct between bm and pb. among all pairs, the extent of subclone progeny derived from each index clone showed marked variability, with far higher subclone frequency in the pb than in the bm. our data indicate that b all clonal composition differs between disease sites. valley children's healthcare, madera, california, united states background: tuberculosis (tb) presenting with hodgkin lymphoma (hl) is rare. their coexistence could lead to delay in diagnosis of both tb and hodgkin lymphoma due to the similarities in signs and symptoms of presentation. most cases have been reported in the adult literature. we describe a case series of children that were suspected to have tb and were found to have coexisting tb and hl. results: a retrospective review of hl patients in guatemala and argentina over six years, uncovered patients with simultaneous diagnosis of tb and hl. eight patients were from guatemala (incidence of . %) and from argentina (incidence of . %). there were females and males. age ranged from - years (mean . years, media years). nine patients were suspected to have tb at presentation by the referring physician. two patients were found to have tb at the time of relapse through routine tissue culture. initial systemic symptoms included fever (n = ), weight loss (n = ), and night sweats (n = ). six patients had a second systemic symptom in addition to fever. time for referral to oncology center ranged from weeks to months. nine patients were diagnosed with tb and hl through a tissue cultures and with serum quantiferon. one patient was found to have hl without tb. two patients had no systemic symptoms and the diagnosis of tb came to light through routine tissue culture. five patients had stage iiib and ivb, two stage iia and one iib at diagnosis. hl treatment was given according to the insti-tutional standards depending on stage and risk with abvd, oepa/copdac +/-radiation therapy, and ice for relapse. five patients started anti tb treatment (isoniazid, rifampin, pyrazinamide +/-ethambutol for months followed by isoniazid and rifampin for - weeks) simultaneously with chemotherapy, and three others after completing cycles. the two relapsed patients started tb treatment after cycles of chemotherapy. seven patients are alive and have been followed for months - years. one patient died during therapy, another died for causes not related to tb or hl and one is currently receiving treatment. conclusion: tuberculosis can coexist with hl. in areas were the prevalence of tb is high, microbiology investigations of biopsy specimen should be strongly considered. therapy for tb can be given simultaneously with chemotherapy. coexistence of tb and hl does not appear to affect outcomes. the children's hospital affiliated to the capital institute of pediatrics, united states background: the pi k/akt signaling pathway plays a central role in cell growth, proliferation and survival in physiological conditions. this signal pathway is considered to be an innovative targeted therapy of cancer, and its abnormal activation has been proved to be related to t-cell acute lymphoblastic leukemia (t-all). despite improved treatment strategies, such as multi-drug combination, high-dose chemotherapy and all kinds of application and popularization of hematopoietic stem cell transplantation, children with drug resistance or relapse t-all are still rather worse and its overall outcome and prognosis are much poorer than the more common b-lineage all. objectives: to explore the relationship between the pi k/akt pathway and the pediatric t-all, so as to probe the exact molecular mechanisms of t-all and provide more directions for its treatment. design/method: cases of new or recurrent acute t lymphocyte leukemia children with clinical information were collected in the children's hospital affiliated to the capital institute of pediatrics from dec. to oct. , with age and gender matched healty children as control (all was informed consent). the expressions of key genes in pi k pathway were s of s analyzed by western blot rt-pcr analysis, the pi k enzyme activities were detected by elisa,and the ccrf -cem's proliferation and its apoptosis were tested by mtt and flow cytometry technology on t-all cell lines ccrf-cem in different treatment group. the results of t-all children in clinical showed that pi k protein and gene expression level were higher apparent than the control group (p< . ), and pi k enzyme activity increased as well (p< . ); pi k inhibitor ly made a significant inhibition of cell proliferation and promoted cell apoptosis. ly also enhanced the effectiveness of clinical commonly used chemotherapeutic drug dnr. in combination ly and dnr treatment group cell viability dramatically declined, apoptosis and the apoptosis relation protein casepase expression in t-all patients was obviously higher than the control and the single drug group; pi k/akt signaling pathway related proteins and gene expression level, pi k, akt, gsk transcription in ccrf-cem were significantly higher than the control (p< . ), while pten transcription was significantly lower than the control (p< . ). the abnormal activation of pi k/akt signaling pathway might play an important role in pediatric t-all patients, especially in the cell proliferation or apoptosis. the results might provide new train of thought and direction in targeted suppress this signal pathway or in combination with other chemotherapy drugs therapy in looking for the more effective and less cytotoxic treatment of pediatric t-all. cleveland clinic children's hospital, cleveland, ohio, united states background: non-hodgkin lymphomas (nhls) are a heterogeneous group of lymphoproliferative diseases which comprise % of all childhood malignancies. nhls can be divided in to b cell lymphomas and t cell/natural killer (nk) cell lymphomas depending on immunophenotype, molecular biology, and clinical response to treatment. although nk/t cell lymphomas occurring in childhood and adolescence comprise a small portion of all lymphomas, they present many diagnostic and therapeutic challenges. the role of angiogenesis in lymphoma pathogenesis is becoming more evident. high molecular weight kininogen (hk) is a central compo-nent of the kallikrein-kinin system. it has been previously reported that cleaved hk (hka) induces apoptosis of proliferating endothelial cells and inhibits angiogenesis in matrigel plug and corneal angiogenesis models. however, the role of endogenous kininogen in regulation of angiogenesis is in tumor microenvironment is unknown. objectives: to elaborate the role of hk in lymphoma angiogenesis, we used a murine t-cell lymphoma model and compared angiogenesis and tumor growth between wild-type and kininogen deficient (mkng -/-) mice. we also evaluated the effect of hka on lymphoma cell proliferation. design/method: el- murine t-cell lymphoma cells ( × ^ ) were implanted into wild-type and mkng -/-mice. tumor size was measured using calipers and tumor volume was calculated using the formula volume = length × width^ × . . seventeen days after cell implantation, tumors were harvested and processed by immunoblotting and immunofluorescent staining. cell proliferation assays (mts) were performed to investigate any possible inhibitory effect of hka on el- cell growth, with human umbilical vein endothelial cells (huvec) were used as a positive control. results: el- lymphomas grew more rapidly and to larger sizes in mkng -/-mice compared to wild-type mice, with significant differences apparent by day after tumor implantation (p< . ). by day , the volume of tumors in mkng -/-mice was approximately . -fold larger than in wild-type mice (mean volume ± standard deviation; ± vs. ± mm , respectively, p< . ). mts assays showed that hka does not directly inhibit the proliferation of el- cells in vitro, though it does significantly impair the viability of ecs studied simultaneously. conclusion: these findings suggest that hk is an important endogenous regulator of angiogenesis and tumor growth in this t-cell lymphoma model, and suggests that hka specifically modulates endothelial proliferation in tumor microenvironment. further work is needed to understand the mechanisms underlying these findings and provide future anti-angiogenic approaches to increase the therapeutic options for patients with nhl. bruce bostrom, jack knudson, nathan gossai, joanna perkins, michael richards, jawhar rawwas, susan sencer, julie chu, nancy mcallister, yoav messinger children's minnesota, minneapolis, minnesota, united states background: osteonecrosis causes significant pain and morbidity in older patients treated for acute lymphoblastic leukemia. besides altering the schedule of dexamethasone in delayed intensification there is no other intervention known to reduce the incidence of symptomatic osteonecrosis. pamidronate has been shown to reduce bone pain from osteonecrosis but not to prevent joint collapse when advanced. objectives: to compare the incidence of symptomatic osteonecrosis in patients who received prophylactic pamidronate compared with concurrent controls. to describe any increase in side effects from the use of pamidronate. design/method: patients age to years at time of all diagnosis were given intravenous pamidronate monthly for one year at the discretion of the primary oncologist starting in the first year of therapy. concurrent controls were patients age to who did not receive pamidronate. all patients were treated according to the concurrent cog protocols and received intermittent dexamethasone during delayed intensification. patients with bcr-abl all were excluded as the use of imatinib may increase the risk of osteonecrosis. imaging was only done if osteonecrosis was suspect based on clinical symptoms. patients were censored at the time of relapse. data were analyzed as of / / . this retrospective study was approved by the children's minnesota irb. of the patients evaluated % were male and % female, % had b-cell and % t-cell. the median followup is . years with a range of . to years. pamidronate was given to patients with developing symptomatic osteonecrosis. there were concurrent controls with developing osteonecrosis. there was no significant difference in the leukemia lineage, gender distribution or body mass index (bmi) at diagnosis between groups. for all patients the median bmi was with a range of to . the age at diagnosis was significantly higher in the pamidronate group with a median of . years vs. . in the controls (p = . ). by kaplan-meier analyses the incidence of symptomatic osteonecrosis was significantly lower in the pamidronate group at % vs. % in controls. the log-rank p-value was . and the breslow p-value, which is more sensitive to early events, was . . there were no untoward side-effects from pamidronate. pamidronate infusions significantly reduced the incidence of symptomatic osteonecrosis in patients over the age of compared to concurrent controls who did not receive pamidronate. arahana awasthi, dina edani, janet ayello, christian klein, mitchell cairo new york medical college, valhalla, new york, united states background: mature b-nhl, including bl and pmbl express cd +/cd b+ and have an excellent prognosis, however, subset of patients relapse secondary to chemoimmunotherapy resistant disease and have a dismal prognosis (≤ % yr. efs, cairo et al. blood. ; gerrard/cairo et al., blood, , goldman/cairo et al. leukemia, . pv has been demonstrated to possess significant preclinical activity against indolent cd b+nhl (polson et al. can. res. ). we previously observed that obinutuzumab (anti-cd mab) significantly enhanced cell death and increased overall survival against bl (awasthi/cairo et al., bjh ) in xenografted nsg mice. however, additive/synergistic effects of pv with obinutuzumab against mature pmbl/bl are unknown. to determine the efficacy of the pv or obinutuzumab/rtx alone or in combination against pmbl and rituximab (rtx) sensitive/resistant bl cell lines. design/method: raji rh (provided by m. barth, md, roswell park cancer institute) and raji/ karpas p (atcc, usa) were cultured in rpmi. tumor cells were incubated with pv, and/or anti-cd b, mmae (generously supplied by genentech inc.) with obinutuzumab /rituximab ( ug/ml) for hr with nk cells at : e: t ratio and cytotoxicity was determined by delfia cytotoxicity assay. six to week old female nsg (nod.cg-prkdcscid il rgtm wjl/szj), were divided into groups: pbs, isotype control, pv, anticd b mab and mmae ( mg/kg). mice were xenografted with intravenous injections of luc+ bl and pmbl cells and tumor burden was monitored by ivis spectrum system. results: os of mice receiving pv alone was significantly increased compared to anticd b ab or isotype control in raji ( . vs. vs. . our preliminary data indicates that pv significantly increased survival in bl and pmbl nsg xenografts compared to anti-cd b ab alone. furthermore, pv in combination with obinutuzumab significantly enhances in-vitro cytotoxicity in bl and pmbl compared to obinutuzumab or pv alone. results: maximal grades (g) / , , and crs occurred in , , and patients, respectively. median lowest fibrinogen levels were . , . , and . g/l in patients with maximal g - , , and crs, respectively. %, %, and % of patients with maximal g - , , and crs had lowest reported fibrinogen levels of ≥ to < . g/l. eight patients (all with g crs) had very low fibrinogen levels (< g/l), which occurred before (n = ) or during (n = ) maximal crs grade or at time of improvement (n = ). no patients with maximal g - crs had < g/l fibrinogen levels. at the onset of < g/l fibrinogen levels, patient had concurrent g , and had g - increased international normalized ratio and activated partial thromboplastin. cryoprecipitate was the primary treatment in the us, and fibrinogen concentrate (fc) guidelines for tisagenlecleucel-associated coagulopathy were developed for other countries because administration of fresh frozen plasma can be problematic. fc was available at / sites for infused patients: / (g crs) and / (g - crs). cryoprecipitate was available at / sites for infused patients: / (g crs), / (g crs), and / (g - crs). risk of bleeding increases in pediatric patients with comorbid thrombocytopenia and anticoagulant treatments. / patients had g / decreased platelets within day of < g/l fibrinogen levels. fatal case of intraparenchymal cranial hemorrhage occurred during resolving crs with g hypofibrinogenemia, ongoing thrombocytopenia, and continuous veno-venous hemofiltration with citrate. hypofibrinogenemia was observed more frequently in patients with higher crs grades during/when crs was improving or resolving. fc and cryoprecipitate treatment guidelines were developed. frequent monitoring and fibrinogen replacement are needed in patients with g / crs. sponsored by novartis. its prolonged cns half-life, may allow a reduction in the number of intrathecal injections. objectives: to safely reduce the burden of therapy by reducing the number of it injections and reducing the total dose of doxorubicin with the addition of liposomal cytarabine and rituximab. design/method: patients ( - years) with cd + b-nhl with fab group b good risk (=stage i/ii and stage iii with ldh < xuln), fab group b intermediate risk (=stage iii ldh ≥ xuln and stage iv {bm blasts < %}) and fab group c high risk were eligible. patients received fab backbone therapy with the addition of six rituximab ( mg/m ) doses; two doses prior to each of two induction courses and one dose prior to each of two consolidation courses. cumulative doxorubicin was reduced from to mg/m in gr patients. after systemic methotrexate clearance, patients received age based dosing of it liposomal cytarabine. it injections were reduced from nine to five. the primary outcome is safety and toxic deaths among evaluable patients with an estimated -year survival above %, monitored by an independent dsmb. results: to date, evaluable patients, fab group b and group c ( cns positive), median age years (range - ), males, burkitt/ dlbcl with gr, ir and hr have enrolled. there has been one grade anaphylactic reaction to rituximab and one grade facial nerve palsy. no other serious adverse events were attributable to protocol therapy. there has been death from progressive disease and relapse at a median follow up of months. efs and os are % and %, respectively. our initial results show excellent efs and os, consistent with published standard of care outcomes, with the addition of rituximab and intrathecal liposomal cytarabine despite the reductions in therapy. further enrollment is ongoing and continued long term outcomes are needed to confirm early results. future randomized studies are needed to examine both short term (mucositis, infections, hospitalization days) and long term (late cardiac toxicity) endpoints. . goldman etal, leukemia, . cairo etal, jco st. jude children's research hospital, memphis, tennessee, united states background: bereaved parents identify significant spiritual needs around time of death and throughout their bereavement journeys. spirituality has been identified as a primary means by which bereaved parents can find meaning in their losses, and this ability to find meaning is associated with lower maladaptive grief symptoms. the use of spiritual coping strategies has been associated with improved coping and mental health outcomes among bereaved parents. objectives: to better understand how bereaved parents' experiences with spirituality throughout bereavement effects objective measures of grief, depression, and meaning-making. design/method: thirty participants whose children died of progressive cancer or related complications one to three years prior to participation completed an in-depth semi-structured telephone interview about their experiences with grief. participants were prompted to describe the impact of their spirituality on their bereavement processes. additionally, participants completed surveys related to grief (prolonged grief disorder questionnaire, pg- ), depression (beck depression inventory, bdi), and meaning-making (integration of stressful life experiences scale, isles). results were analyzed using a mixed methods approach including semantic content analysis of qualitative content and kruskal-wallis h test and post-hoc analyses of quantitative data. results: correlation analyses demonstrated significant differences between participants with positive and negative spiritual experiences of bereavement. participants with negative experiences of bereavement had a statistically significant increase in scores on the pg- compared to those with positive spiritual experiences signifying greater symptoms of prolonged grief. participants with negative spiritual experiences with grief had significantly lower scores on the isles, suggesting a lesser degree of adaptive integration of their losses. there were no significant differences in depression scores between groups. conclusion: bereaved parents that have a negative spiritual experience of bereavement are at increased risk for prolonged grief symptoms and are less likely to find meaning in their children's deaths than bereaved parents that describe a positive spiritual experience of bereavement. providers should consider exploration of spiritual beliefs and provision of spiritual care for parents of children facing life-limiting illnesses during treatment and bereavement. background: langerhans cell histiocytosis (lch) is an inflammatory myeloid neoplasia characterized by frequent relapse, with treatment failure associated with higher risk of death and neurodegenerative disease (lch-nd). activating somatic mutations in mapk pathway genes have been identified in almost all cases, with braf-v e in approximately % of lesions. targeted therapies have been successful in treating other refractory cancers with braf v e mutations (such as melanoma). given the central role of mapk pathway activation in lch, mapk pathway inhibition may be an effective therapeutic strategy for children with lch. objectives: the purpose of this study was to report the efficacy and toxicity profile of a retrospective cohort of patients with lch treated with mapk pathway inhibitors. design/method: medical records from pediatric patients with lch (systemic and/or lch-associated neurodegeneration) who were treated with a mapk pathway inhibitor were retrospectively reviewed from five institutions. all patients had failed at least one prior systemic therapy and had a proven mapk pathway mutation. results: all patients in this series were less than years old (median = . years; range: - years) with a median of three prior treatments (range: - ). at the time of initial mapk inhibitor use, nine of the patients had lch-nd diagnosed clinically and/or by radiographic imaging; the remaining three patients had systemic disease. patients were treated for a median of months (range: - months) with various reasons for discontinuation. three patients received combination mapk inhibitor therapies and three patients received other concurrent lch-directed therapies. four of the twelve patients had a grade or toxicity reported and three of these patients required dose reduction in order to be able to successfully resume therapy. overall survival was % with median month follow-up (range: - months) with only one patient achieving transient complete response. the remaining ten patients had partial response or stable disease and four of these patients developed progressive disease while on therapy. conclusion: mapk pathway inhibitors may be a relatively safe salvage therapy for refractory systemic lch and lch-nd but the efficacy and durability of this strategy remains to be defined. combination with cytotoxic chemotherapies may be required in order to eradicate the disease-causing cell. future prospective trials of mapk pathway inhibitors for patients with refractory lch are needed in order to directly compare their efficacy and toxicity relative to other current salvage strategies. cincinnati children's hospital medical center, cincinnati, ohio, united states background: medication adherence during maintenance therapy has been shown to have a direct relationship with disease relapse in pediatric leukemia. previous research determined that patients who are ≤ % adherent to mercaptopurine ( mp) have a greater risk for relapse. the primary aim of the present study is to examine the relationship between metabolite profiles of mp with behavioral adherence rates obtained via electronic monitoring at , , and days. it is hypothesized that patients demonstrating low levels of thioguanine (tgn) and methylated mercaptopurine (mmp) will have lower behavioral adherence rates prior to the blood draw. design/method: in a multisite, prospective study of patients ages - years diagnosed with acute lymphoblastic leukemia (all) or lymphoblastic lymphoma (lbl), mp adherence was measured across months of maintenance therapy using behavioral adherence (electronic monitoring) and pharmacological (metabolites) measures of mp. mp is metabolized into mmp and tgn. cluster analysis was used to generate three mutually-exclusive profiles of mp adherence. behavioral adherence rates were calculated for , , and days prior to the blood draw. results: this study identified three metabolite profiles of mp across months. previous research indicated that low levels of both metabolites suggest nonadherence to medication. low levels of one metabolite with high levels of another metabolite indicate adherence to mp. in this study, . % of the low tgn-low mmp group had -day behavioral adherence rates ≥ % (mean = %); . % had adherence rates < % (mean = . %). in the high tgn-low mmp group, . % had a mean -day adherence of %; . % had adherence rates < % (mean = . %). the low tgn-high mmp group had % of patients with a mean -day adherence level of %; % had adherence rates < % (m = . %). at and -days, to % of patients in the low tgn-low mmp group had adherence rates < %. conclusion: these findings suggest that electronic monitoring and metabolite concentrations can be used to monitor mp medication adherence during maintenance therapy. it is notable that there is a sub-sample of pediatric patients who are identified as being nonadherent to mp based on electronic monitoring, however, metabolite levels indicate adherence to mp. similarly, a sub-sample of patients were identified as being adherent based on electronic monitoring, but metabolite profiles indicated sub-therapeutic levels of mp. our findings underscore the clinical significance of using both objective measures of medication adherence to inform clinical decision making. cincinnati children's hospital medical center, cincinnati, ohio, united states background: hemophagocytic lymphohistiocytosis (hlh) is a life-threatening hyperinflammatory syndrome characterized by non-remitting fevers, rash, hepatosplenomegaly, cytopenias, liver dysfunction and coagulopathy, and can include central nervous system involvement. several genetic diseases cause hlh by impairing normal lymphocyte or macrophage function. the hlh panel at the cincinnati children's genetics laboratories includes genes associated with hlh and other lymphoproliferative diseases, including the genes that cause primary hlh (prf , unc d, stxbp , stx , rab a), x-linked lymphoproliferative diseases (sh d a, xiap), itk deficiency (itk), hermansky-pudlak syndrome types and (ap b and bloc s ), chediak-higashi syndrome (lyst), cd deficiency (cd ), xmen syndrome (magt ) and lysinuric protein intolerance (slc a ). deletion/duplication analysis is available as a reflex test for all genes, as copy number variations (cnvs) are not directly assessed by sequencing. objectives: the prevalence of cnvs among large groups of patients with hlh in north america is unknown. we assessed the frequency of cnvs in the genes on the hlh panel through a retrospective review of orders for deletion/duplication analysis performed after next-generation or sanger sequencing: orders for all genes on the panel, and orders of - genes from the panel. deletion/duplication analysis was performed on a custom × k microarray annotated against ncbi build (ucsc hg , march ). deletion/duplication analysis resulted in a confirmatory diagnosis in of cases ( . %). pathogenic or likely pathogenic cnvs were most common in the three x-linked genes: sh d a ( deletions), xiap ( deletions, duplication), and magt ( deletions). hemizygous deletions in xlinked genes in male patients were typically suspected after amplification failure during previous sequencing. of the autosomal recessive genes, pathogenic cnvs were observed once in each of three genes: rab a (heterozygous), lyst (heterozygous), and stxbp (homozygous). in the two heterozygous cases, a second change was not identified by sequencing, so deletion/duplication analysis did not offer a confirmatory diagnosis. in patients, deletion/duplication analysis was performed after a pathogenic or likely pathogenic variant was identified in an autosomal recessive gene during sequencing; however, in no case was a second mutation uncovered by cnv analysis. we recommend that deletion/duplication analysis be routinely performed in all male patients with hlh who lack a genetic diagnosis after sequencing of hlh-associated genes, especially if any regions failed to amplify. deletion/duplication analysis may be performed in female patients after sequencing if a genetic form of hlh is highly suspected, but the yield is expected to be low. cleveland clinic children's hospital, cleveland, ohio, united states background: the development of post-transplant neoplasia, typically from lymphoproliferative disease (ptld), is a severe complication in transplant recipients and affects approximately % of pediatric solid organ recipients. rates of lymphoma in adult heart transplantation patients are comparatively low, at less two percent at ten years. there are few published reports of the long-term outcomes of neoplasia after pediatric heart transplantation. we aimed to identify the subsequent malignancies that occurred in pediatric heart transplantation patients in a large single institution, and describe their treatment and subsequent clinical course. we performed a retrospective chart review of all pediatric heart transplant recipients followed at the cleveland clinic children's hospital from january to october . we excluded patients who died within days of heart transplantation. we reviewed in depth the history and clinical course of subjects who developed neoplasms. results: between and , patients underwent heart transplantation and survived at least days post transplantation. nine patients ( . %) developed a subsequent malignancy. in this case series, the median age at heart transplant was years old and the median time to develop neoplasia was . months. primary neoplasia included monomorphic ptld ( ), polymorphic ptld ( ), burkitt lymphoma ( ), hodgkin's lymphoma ( ), plasmacytoma-like lymphoma ( ) and epstein-barr virus-associated smooth muscle tumor (ebv-smt) ( ). one patient with hodgkin lymphoma subsequently developed monomorphic ptld, one patient with polymorphic ptld subsequently developed ebv-smt and later, an undifferentiated gastric cancer. one patient with monomorphic ptld developed an ebv-smt. evidence of epstein-barr virus was present in six of nine patients at diagnosis of first malignancy. four of nine patients received reduction in immunosuppression as a primary intervention for the initial malignancy, with two complete responses (cr), one partial response, and one with progressive disease. five patients were treated with chemotherapy, with four cr and one with progressive disease. three patients died of malignancy (recurrent ebv-smt, undifferentiated gastric cancer, and monomorphic ptld post-hodgkin disease) and two patients died of other transplant related complications. conclusion: secondary malignancies represent a significant disease burden to survivors of cardiac transplantation. as expected, much of the malignancy burden is driven by ebv. despite aggressive histology, many malignancies can be successfully cured in this setting with a multidisciplinary approach. stanford university school of medicine, palo alto, california, united states background: current treatment of langerhans cell histiocytosis (lch) is based on extent of organ system involvement and if high risk systems are affected. gastrointestinal (gi) involvement is diagnosed in about % of lch patients, and classically presents in children under years of age with malabsorption, failure to thrive, bloody diarrhea and anemia. although the gi system is considered standard risk, a mortality rate over % occurring within years of diagnosis has been reported. this study was performed due to this discrepancy and the limited number of published cases. objectives: to review the clinical course and outcomes of patients diagnosed with gi lch. design/method: a retrospective chart review of patients with histologically confirmed gi lch diagnosed in the last years identified from the bass center histiocytosis clinical database was performed. two other pediatric hematology/oncology centers (ucsf benioff children's hospital oakland and san francisco) were queried for additional cases. results: four patients with biopsy proven gi lch [ subjects ( . %) from database records and l from center queries] were identified. failure to thrive, hypoalbuminemia, bloody diarrhea and rash were the most common presenting symptoms. lch of the skin was found in all patients. risk organ systems were involved in patients. of note, subjects were of african racial background. the median age at diagnosis was . months ( . months to years), mean albumin . g/dl ( . - . g/dl), mean esr of mm/hr ( - mm/hr). all patients initially received combination therapy per lchiii protocol (vinblastine, prednisone, and mercaptopurine). two patients had recurrent disease and received second line therapy (cytarabine, cda, and local radiation therapy). all patients are alive without active disease at last follow-up ( to months after completion of therapy). a systematic approach to evaluate gi involvement should be performed in children diagnosed with lch. from our experience, combination chemotherapy for patients with lch involving the gi tract is an effective intervention for active disease. cincinnati children's hospital medical center, cincinnati, ohio, united states background: bhatia indicated that rates of mp adherence ≥ % have better clinical outcomes. those with adherence rates ≤ % have an increased risk for disease relapse. the present study investigated patterns of mp medication adherence using group-based trajectory modeling in a large sample of pediatric patients. to describe patterns of behavioral adherence during the maintenance phase of therapy for a cohort of pediatric patients ages - years who were diagnosed with acute lymphoblastic leukemia or lymphoblastic lymphoma (n = ). previous research has documented the relationship between optimal levels of medication adherence with positive health outcomes. it was hypothesized that three groups would be identified: optimal adherence, deteriorating adherence, and chronic nonadherence. it was hypothesized that patients in the optimal adherence group would have adherence rates ≥ %. those with poor adherence would have adherence rates ≤ %. design/method: the present study was a longitudinal, multisite study investigating adherence to -mercaptopurine in a pediatric cohort of patients using electronic monitoring devices. daily adherence rates (electronic monitoring of mp) were examined across -months. health outcomes were measured at quarterly intervals through medical chart reviews. results: unconditional growth curve modeling indicated that the mean percentage of behavioral adherence was . % at baseline and declined to . % at -months. three trajectories of mp behavioral adherence were identified: ) optimal adherence ( % of patients): averaging % behavioral adherence across months; ) moderate adherence ( %): relatively stable nonadherence with rates of % across months; and, ) chronically nonadherent ( %): adherence decreased from % to %. with respect to patterns of medication adherence and relationship to clinically-relevant health outcomes, there were no significant differences in health outcomes between patients in the adherent versus nonadherent trajectories, including mean absolute neutrophil counts (anc), risk for infection as measured by anc, healthcare utilization, or risk for disease relapse. although longitudinal patterns of mp behavioral adherence were not related to health outcomes, it is notable that only % of the current sample had adherence rates ≥ %. in fact, % of the current sample demonstrated adherence rates ≤ %. our findings are important for development of future adherence promotion studies in pediatric cancer. our findings underscore the relative significance of tailoring adherence promotion interventions to subgroups of patients, including those with problematic patterns of adherence. patients who demonstrate adequate levels of adherence could still benefit from less intensive, preventative interventions to sustain and improve adherence. sophie gatineau-sailliant, pascale grimard, marie-claude miron, guy grimard, anne-sophie carret, jean-marie leclerc chu sainte-justine, montreal, quebec, canada background: vertebral involvement in langerhans cell histiocytosis (lch) is still a subject of interest, due to its low frequency and the absence of management's guidelines. objectives: to provide additional information on presentation, treatment and morbidity of pediatric lch vertebral lesions, we report cases of children with vertebral lesion of biopsy-proven lch, between january st and december st , at sainte-justine university health center (montreal, quebec, canada). we conducted a retrospective study by reviewing charts and imaging of vertebral lch in a population of children (median age of . years at lch diagnosis), followed for a median duration of months. symptoms at presentation, treatment modalities and morbidities were collected. results: vertebral lesions were present at lch diagnosis in of cases. they were usually diagnosed secondary to back pain in of cases and were asymptomatic in only one case. despite an epidural extension in of cases, no child developed neurological symptoms. lesions frequently involved vertebral body ( of cases) and were rarely unstable ( of cases). out of vertebral lesions, most of them had a dorsal localization ( of lesions) and of patients had lch in multiple vertebrae. at diagnosis, median vertebral height loss was . % compared to % at last imaging control. most used imaging modalities were pet-scan and plain x-rays. treatments were diverse and consisted in chemotherapy in all children but three and bisphosphonates in only cases. radiation therapy was not used in any patient. six out patients did benefit of an orthosis. a lch recurrence was observed in patients and involved vertebrae in cases. one patient with treatment-resistant lch disease had relapses, and required multiple lines of treatment. all children were alive and disease-free at their last follow-up, patients having radiological vertebral sequelae and only had clinical sequelae. our study is consistent with the epidemiological data described in larger cohorts of children with vertebral lesions of lch and the favorable prognosis associated with such lesions. nevertheless, aggressive treatment and long term follow-up seemed to be essential as recurrences are s of s not rare and spontaneous bone regeneration often incomplete. plain x-rays appears to be a good follow-up tool for vertebral lesions as it allows reliable measures, less exposure to radiation at lower cost. national cancer institue, giza, giza, egypt background: acute lymphoblastic leukemia (all) is the most common type of childhood cancer and also the most complicated in the treatment, so it requires many interventions for both treatment and to alleviate suffer form side effects. pancreatitis is one of the toxicities, which is more common in all as it appears in about % of the patients. it occurs in many drug combinations which induce pre-pancreatitis and even direct destruction of pancreatic tissues. pancreatitis can be induced by many drugs used in the treatment such as chemotherapeutic agents or supportive treatment. lasparaginase is the backbone drug of the treatment of all in which to doses are required to achieve complete remission status in the induction phase of treatment and to doses in the maintenance phase.it is an enzyme that destructs the l-asparagine amino acid into aspartic acid and ammonia thus deplete the asparagine from the extracellular matrix . many drugs are investigated for their effect on treatment of induced pancreatitis such as interleukin- , nsaid as antiinflammatory, glycerin tri nitrates as improvement of microcirculation, tnf-alpha antibody, paf inhibitor as specific anti-inflammatory and low molecular weight heparin .none of the drugs was investigated for their ability to prevent the occurrence of pancreatitis. objectives: this study was designed to evaluate the protective effect of enoxaparin and diclofenac against l-asparaginase induced pancreatitis design/method: acute pancreatitis was induced in rats by intra-muscular injection of l-asparaginase ( i.u/kg) given daily for five days. enoxaparin was given subcutaneous ( i.u/kg) and diclofenac was given intra-peritoneal ( mg/kg) daily for five days. then, markers of pancreatic injury, lipids, immune cell infiltration and oxidative stress were analyzed with histo-pathological examination of the pancreatic tissue results: during acute pancreatitis, oxidative stress markers were significantly changed as indicated by reduced tis-sue glutathione and increased malondialdehyde levels. this was accompanied with significant increase in immune cells infiltration as indicated by high levels of myeloperoxidase and pro-inflammatory cytokine tnf-alpha. triglyceride only showed increase level. treatment with enoxaparin and/or diclofenac restored levels of biochemical markers including serum alpha-amylase, reduced glutathione, malondialdehyde, pro-inflammatory cytokine tnf-alpha, myeloperoxidase and triglyceride. histological injuries of pancreatic tissues as vacuolation and necrosis of epithelial lining pancreatic acini, inflammatory cells infiltration and focal pancreatic hemorrhage were also reduced by treatment with enoxaparin and/or diclofenac. the present study emphasizes the potential protective effect of enoxaparin and diclofenac against l-asparaginase induced pancreatitis background: rosai dorfman disease (rdd), or sinus histiocytosis with massive lymphadenopathy (shml), is a rare condition of immune dysregulation of unknown etiology arising from the massive accumulation of non-langerhans type histiocytic cells inside lymph nodes. the disease classically presents as bulky, painless lymphadenopathy often associated with infection showing distension of lymph node sinuses by abundant histiocytic cells (cd a(-), s- (+)/cd (+)). in some cases, the disease can be self-limiting, but in cases with a prolonged chronic course of exacerbations and remissions, those with extranodal involvement, or disease that threatens vitals structures, treatment may be necessary. there is no treatment consensus. to describe a case of life-threatening, unresectable, recurrent rdd successfully treated with langerhans cell histiocytosis (lch) -inspired therapy. design/method: we compared this case to the current literature on chemotherapeutic treatments for rdd. we searched pubmed, ovid, and google scholar for similar cases. we believe this to be the first reported case of using lch therapy to successfully treat rdd. an -year-old male presented to an outside hospital with two years of massive neck swelling causing torticollis. biopsy confirmed rdd. he was intermittently treated with courses of antibiotics with partial response. surgical removal of the affected lymph nodes was unsuccessful due to proximity to the spinal cord. two years later, the patient presented to our institution. he was initially treated with prednisone with a fast tapering dose, but after a second relapse the decision was made to try chemotherapy following the lch- protocol of weekly vinblastine ( mg/m ), -mp ( mg/m ), and high dose steroid bursts. he experienced two additional relapses off therapy at ages and years old, including cmv(+) associated septic shock and cytokine storm requiring rapid response, picu admission, and ionotropic support. this last episode was treated with a more prolonged induction and maintenance therapy. an extended and slowly tapered maintenance therapy regimen of . years of daily -mp, monthly vinblastine and steroids with a slowly tapered dose during his fourth remission has resulted in -months of continuous complete remission-the longest stretch of his life. no similar cases were found. literature search demonstrated no consensus regarding the most effective treatment of rdd, with no previous cases being successfully treated following lch chemotherapy protocols. we hypothesize that the multi-agent relatively mild lch- therapy mitigates the immune dysregulation of rdd. this case suggests that lch- therapy can be used to treat cases of rdd that is not amendable to surgery or observation. nicklaus children's hospital, miami, florida, united states background: central venous catheters (cvc) are necessary in the management of patients with malignancies, especially children. patients with acute leukemia (al) have higher rates of central line associated complications such as bloodstream infections compared with other malignancies. objectives: to examine the choice of placement of cvc and the differences in outcome between peripherally inserted central catheters (picc) and ports in patients with leukemia during induction. design/method: retrospective chart review of patients with newly diagnosed leukemia at nicklaus children's hospital between and . results: ninety four patients with a new diagnosis of leukemia undergoing induction chemotherapy were identified. the average age was . years. overall, ( . %) patients had a port placed and ( . %) had a picc placed. the decision for picc or port was subjective and physician based. the main outcome measures were local inflammation/infection, bacteremia, thrombophlebitis, blocked catheter and premature removal. the most common complication was bacteremia ( . %). in a multiple logistic regression analysis for predicting whether patients had at least one complication, results showed that having at least one complication is . times the odds in patients with aml compared to patients with all (p = . ). when comparing picc vs. ports, patients with picc had more frequent episodes of blocked catheters ( . %) and premature removal ( . %) compared to the patients with ports ( . % and . %) (p = . and p = . respectively) during induction. local inflammation, bacteremia and thrombophlebitis were not statistically different (p = . , p = . and p = . respectively). the most common place for port placement was the right subclavian vein ( %). there was no significant association between port location and having at least one complication (p = . ). acute lymphocytic leukemia subgroup analysis: fourteen patients ( %) in the picc group had at least one complication and ( %) in the port group but that was not statistically significant (p = . ). our series showed a higher incidence of blocked catheters and premature removals with picc compared to ports in patients with leukemia during induction. the choice of placement of picc vs port was subjective and physician based. patients with all, despite receiving steroids and asparaginase during induction, did not show a statistically significant increase risk in thrombosis or infection but larger numbers may be needed in future studies. university of california, san francisco, san francisco, california, united states background: hemophagocytic lymphohistiocytosis (hlh) is classically a disorder of young children meeting systemic hyperinflammation criteria. presentation in late adolescence is uncommon. furthermore, though cns signs occur in - % of cases, initial isolated neurologic presentation is rare, frequently resembling encephalitis or demyelinating disorders. these cns signs can be isolated or precede systemic disease, delaying hlh diagnosis. hlh declaring in adolescence with predominant psychiatric features has not been well documented. objectives: to describe a case of cns hlh presenting with neuropsychiatric features in absence of classic hlh criteria. design/method: retrospective review of clinical, radiologic, histologic, immunophenotypic, and molecular features of a patient with cns hlh. a -year-old female presented with acute-onset headaches following nine months of progressive anxiety, short-term memory loss, emotional lability, perceptual disturbances, and hypomania. brain mri demonstrated numerous enhancing t hyperintense supratentorial and infratentorial white matter lesions in the left thalamus and caudate head. brain biopsy showed histiocyte-rich inflammation and associated demyelination. extensive evaluation including universal microbial pcr failed to reveal underlying infection or malignancy. past medical history was notable for presumptive pulmonary sarcoidosis diagnosed months prior with progressive respiratory failure with associated granulomatous pulmonary nodules which responded to systemic immunosuppression. at presentation of her neuropsychiatric symptoms, she had normal sil- r, ferritin, fibrinogen, and triglycerides. there was no pancytopenia, coagulopathy, bone marrow hemophagocytosis, fevers, or splenomegaly. given the possibility of partial immune suppression of systemic symptoms and the prominent neurologic symptoms, hlh screening labs were sent and notable for decreased natural killer and cytotoxic t lymphocyte function, normal granzyme expression and cd a mobilization, and absent perforin expression. genetic testing confirmed compound heterozygous mutations in prf (c. g>a, c. a>c) and familial hlh type . she was treated with low-dose dexamethasone and intrathecal chemotherapy per hlh- . due to lack of evidence of systemic inflammation, vp- and high-dose steroids were held. within one week of initiating therapy, she had decreased anxiety and improved cognition, with sustained, incremental neuropsychiatric improvement with additional intrathecal treatments. she tolerated dexamethasone tapering without symptom flare. mri also demonstrated parenchymal lesion improvement. for definitive treatment, she underwent unrelated allogeneic hematopoietic cell transplantation and remains at neurologic baseline as of eight months post-transplant with ongoing imaging improvement. conclusion: this case of familial hlh with compound heterozygous perforin mutations in an adolescent with isolated neuropsychiatric symptoms illustrates that cns hlh may be an underrecognized phenomenon in absence of systemic signs. standard hlh therapy may effectively reverse these symptoms with associated radiologic responses. rush university children's hospital, chicago, illinois, united states background: posterior reversible encephalopathy syndrome (pres), a recognized complication of pediatric leukemia treatment has been reported in up to % patients in various series. hypertension, chemotherapy and cortical spreading depression have been implicated in the pathophysiology. due to the combinations used, it is difficult to identify the offending drug, several have been implicated. since delay of chemotherapeutic treatment in children with high risk leukemia is unfavorable, it is important to recognize the characteristic radiologic findings, manage appropriately and reintroduce the treatment as soon as possible. pharmacoethnicity is now recognized as an important factor for variation in neurotoxicity in children with all. ethnic differences in reported pres events in pediatric patients with all has not been well described in literature. to describe the factors associated with pres in a cohort of high risk pediatric all patients at a single institution. design/method: a total of children with an average age of years ( - years) diagnosed with all between - were retrospectively reviewed for the occurrence of pres. various demographic factors, therapy received, clinical features, radiology related findings and management were reviewed. a search for all published articles on pres in leukemia was conducted using pubmed databases. results: five ( %) children (average age . years) developed pres during days - of induction. % of the patients that developed and % of those that did not develop pres were hispanic. all the patients that developed pres and % of those that did not were diagnosed with high risk all. all patients received vincristine, % received daunomycin and intrathecal methotrexate and % received asparaginase in the week prior to the event. mri findings confirmed pres in all patients with no evidence of methotrexate related leukoencephalopathy or leukemia. at the time of pres all patients were in remission based on mrd and spinal fluid cytology. two-thirds of the patients had seizures and hypertension at the time of the event with no prior history of either. all patients had complete recovery of normal mental status after resolution of pres. a higher incidence of pres than previously reported was noted in our series. hispanic ethnicity, high-risk all and exposure to vincristine, daunomycin and intrathecal methotrexate in induction were associated with pres in our cohort. a new association that emerged was that of hispanic ethnicity with pres .larger studies to understand the importance of pharmacoethnicity in pres may help in individualization of chemotherapy based on ethnic differences. children's hospital of illinois, peoria, illinois, united states background: hyper ige syndrome is a primary immunodeficiency characterized by susceptibility to skin and lung infections as well as increased propensity for malignancy. hemophagocytic lymphohistiocytosis (hlh) is a syndrome characterized by overwhelming activation of t lymphocytes and macrophages occurring as either primary hlh caused by genetic abnormalities or secondary hlh associated with infectious, malignant, metabolic, or immunodeficiency causes. we describe the first case to our knowledge of hlh in a patient with hyper ige syndrome. to describe a case of hlh in a pediatric patient with hyper ige syndrome. results: a -year old caucasian male with known autosomal dominant hyper ige syndrome (stat mutation) was transferred to the pediatric intensive care unit secondary to concern for septic shock. the patient had persistent slow bleeding from oral lesions and central catheter sites despite the addition of aminocaproic acid and recombinant factor viia. he also required numerous blood product transfusions sec-ondary to anemia and thrombocytopenia. clinical suspicion was high for hlh and the patient met criteria for diagnosis of hlh with the following: ferritin > , ng/ml, triglycerides mg/dl, decreased nk cell function with the sample only containing % nk cells, elevated soluble il- receptor at u/ml, splenomegaly, and fever. infectious workup was remarkable for a positive ebv qpcr with , copies/ml suggestive of ebv driven secondary hlh. familial hlh testing was unable to be completed. therapy was initiated based upon the hlh- study. the addition of ruxolitinib and anakinra were considered but the patient declined rapidly prior to treatment. ct of the head was concerning for a stroke with signs of edema and increased intracranial pressure likely leading to the development of symptoms consistent with brain stem herniation. the decision was then made to withdraw care. conclusion: to our knowledge, this is the first report of hlh in a patient with hyper ige syndrome. diagnosing hlh requires a high index of suspicion in critically ill patients, and prompt initiation of therapy is essential. this challenging case of hlh in a patient with hyper ige syndrome highlights the diagnostic challenge, variable presentation, and need for effective therapy in this vulnerable patient population. background: adolescents and young adults (ayas) with cancer are at risk for psycho-social as well as physical symptom burden during cancer therapy. the purpose of this study is to explore psychological and physical symptoms endorsed by aya while receiving therapy for cancer design/method: surveys were given in both inpatient and outpatient settings during cancer therapy. symptom screening in pediatrics tool (sspedi) and memorial symptom assessment scale (msas). symptoms severity was rated by teens on a point likert scale. spss , used for statistical analysis. results: : a total of aya on cancer therapy (age range - . years) % female, % male, . % acute leukemia, . % solid tumors, and . % diagnosis was not reported. % of aya on cancer therapy reported at least or more symptoms, % reported > symptoms cluster. of the physical symptoms that were reported as most distressing to the teens, mouth sores and headaches were the top causes. of the physical symptoms that were most frequently endorsed; fatigue was on the top ( %), followed by change in appetite %, vomiting %, and pain %., the least was bowel habit changes. aya rated sadness as the most frequent psychological symptom %, followed by feeling angry %, and scared %. statistically significant difference was noticed based on gender difference with more females reported symptoms (p = . ), while type of cancer (acute leukemia versus solid tumors) was not statistically different. conclusion: aya with cancer reported multiple physical and psychological symptoms with significant distress. females seem to report more symptoms compared to males. screening aya for cancer therapy related symptoms is feasible during routine visits and adds important information about the aya well-being. background: sinus histiocytosis with massive lymphadenopathy (shml), also known as rosai-dorfman disease, is a rare histiocytic proliferative disorder of unknown etiology. many treatment modalities have been employed; however, no uniform guidelines exist. objectives: literature review of treatment options for shml. design/method: chart review was performed on pediatric patients diagnosed with shml at the children's hospital at montefiore between and after irb approval. inclusion criteria included children between the ages of and years with shml. exclusion criteria included children with cutaneous shml. four cases of shml seen at montefiore are described. a comprehensive review of the literature identified additional cases published between and . manuscripts that did not include the treatment modality or outcome were excluded. results: many of the patients with shml responded to observation alone. of patients, patients were observed, with ( %) having resolution of disease, five having stable disease, and five being lost to follow-up. one patient received subsequent systemic therapy. surgical management was con-ducted upfront in patients. of those, ( %) had resolution of disease, one had stable disease, and one had recurrence with no further therapy noted. of the remaining nine patients, % were successfully treated with systemic therapy, consisting of either steroids ( ) or steroids and chemotherapy ( ). systemic therapy was used as first-line therapy in patients. steroids alone or in conjunction with chemotherapy resulted in resolution of disease in / and / patients ( / , %), respectively, with four patients having stable and three with progressive disease. chemotherapy without steroids resulted in resolution of or stable disease in / patients. radiation was ineffective. conclusion: shml is a rare disease with no published guidelines for treatment. from the results of the cases and a detailed review of the literature, it can be suggested that observation may be considered as first line management in patients providing there are no significant symptoms. for patients who are symptomatic or have significant progression, surgery may be considered. in patients with recurrence or refractory disease, steroids and/or chemotherapy may be used. the presence of nodal or extra-nodal disease did not seem to have a significant impact on the course of treatment. given the rarity of the disease, it is difficult to conduct a randomized control trial. further work, involving collaboration between centers and cooperation with the international rare histiocytic disorders registry would be helpful. boston children's hospital, boston, massechusettes, united states background: increasing census and intensified work compression on the inpatient oncology service at our institution was identified as leading to resident dissatisfaction, impaired resident learning and decreased perceived quality of patient care. objectives: to evaluate the impact of a redesign of a pediatric inpatient hematologic malignancy (ihm) service on resident perceptions of the educational value of the rotation and safety of patient care. design/method: during the - academic year, we initiated a bundled intervention on the ihm service. modifications included ) decreased patient volume: the ihm service was divided into two teams, utilizing an extra attending -a teaching service consisting of residents and fellows and a team comprised of nurse practitioners. ) intentional patient team assignment: patients were deliberately assigned to a care team based on educational opportunities and provider skill sets. ) intentional attending faculty selection: attending faculty with deeper clinical and teaching experience were selected to supervise on the teaching team. ) increased weekend staffing. after completing the service, junior residents completed an electronic survey to evaluate their perceptions of the educational value of the rotation, as well as their ability to deliver safe care while on the rotation. fisher's exact tests were used to compare responses from residents in who experienced the redesign to residents in , whose experience results: survey completion rates were % ( / ) in and % ( / ) in . intervention residents were significantly more likely than comparison group residents to choose the answers "very good" or "excellent" to describe both the overall quality of the rotation ( % intervention vs. % comparison, p< . ) and the educational experience on rounds ( % intervention vs. % comparison, p< . ). intervention residents also reported caring for fewer average primary patients daily on weekdays as compared to comparison residents ( . vs . patients, p< . , % ci - . to - . ). furthermore, intervention residents were more likely than comparison residents to "agree" or "strongly agree" that they could provide safe patient care on weekend days ( % intervention vs. % comparison, p< . ) and on nights ( % intervention vs. % comparison, p< . ) while on the oncology service. a redesign initiative of an oncology service with the development of a new teaching service led to improved resident perceptions of the educational value of the rotation and ability to provide safe care to patients. this approach could be useful to other services and institutions to promote similar outcomes in resident education and patient care. background: alk-positive histiocytosis is a rare histiocytic proliferative disorder that has been reported in three infants presenting primarily with hepatosplenomegaly, anemia, and thrombocytopenia. given the rarity of this disease, there are no standard treatment algorithms for this diagnosis and the disease course and outcomes remain largely unknown. the published series describes treatment ranging from monitoring alone to multi-drug chemotherapy regimens. there was ulti-mately resolution of presenting symptoms in all three cases despite varying treatment strategies. objectives: to report a newly diagnosed case of alkpositive histiocytosis that was treated with a novel approach using cytarabine monotherapy. results: a full term male infant presented at birth with difficulty feeding and hyperbilirubinemia. over the first few weeks of his life, he subsequently developed thrombocytopenia, transaminitis, and profound hypoalbuminemia. by six weeks of life, he was experiencing significant abdominal ascites requiring repeat paracenteses, massive hepatosplenomegaly, respiratory distress secondary to abdominal distension, anemia, and coagulopathy. he underwent numerous diagnostic tests, including a liver biopsy followed by a bone marrow biopsy that showed alk-positive histiocytic infiltrates in both sites. treatment was initiated with cytarabine mg/kg/day x days, repeating every weeks. throughout his course of five cycles of treatment, he experienced intermittent fevers and mild nausea with no other adverse events. by the end of five cycles, his hepatosplenomegaly resolved, his blood counts normalized, he demonstrated weight gain on oral feeds, and his liver enzymes normalized. he is currently months post completion of therapy and remains well with a normal physical exam and laboratory values. conclusion: treatment of alk-positive histiocytosis with lose dose cytarabine resulted in complete resolution of our patient's symptoms with minimal treatment related adverse effects, and few long-term treatment related risks. given the rarity of the diagnosis, the reporting of effective novel treatment options is important for future patient care. background: adult patients with melanoma or lung cancer harboring braf v e have benefitted from the development and subsequent approval of specific braf inhibitors. as such, delineating the subset of similarly targetable pediatric oncology patients may spur development and rational use of these inhibitors in children. importantly, other point mutations and fusions of braf may also be targetable in s of s children analogous to recent emerging data in adult cancer patients. objectives: to define the genomic landscape of known and novel braf alterations and raf fusions in pediatric malignancies and report index cases with clinical response to braf or mek inhibitors. design/method: dna was extracted from microns of ffpe sections of , tumors from pediatric (< years of age) oncology patients, and cgp was performed on hybridization-captured, adaptor ligation based libraries to a mean coverage depth of x for up to cancer-related genes plus introns from genes frequently rearranged in cancer. genomic alterations (ga) included base substitutions, indels, copy number alterations and fusions/rearrangements. a total of ( . %) braf-altered pediatric malignancies were identified. ( . %) harbored a single kinaseactivating braf short variant, indel, or fusion. an alteration resulting in reduced braf kinase activity was identified in ( . %) tumors while ( . %) tumors harbored multiple braf alterations, of which contained at least a single activating short variant. the remaining tumors ( . %) contained functionally uncharacterized variants. kinaseactivating braf alterations were identified in diverse tumor spectra comprised of brain tumors ( . %; subtypes), carcinomas ( . %; subtypes, with melanoma constituting % of cases), hematological malignancies ( . %; subtypes), sarcomas ( . %; subtypes), and extracranial embryonal tumors ( . %; subtypes). seventy-two ( . % of braf-altered cases) braf fusions were identified, ( . %) of which were kiaa -braf; involved the novel fusion partners: stard nl and khdrbs . seven ( . %) raf fusionpositive cases, predominantly brain tumors ( ), were identified; involved the novel fusion partners: tmf and sox . index cases of response to therapy of intracranial tumors will be presented. we describe a population of pediatric patients with targetable braf alterations predominantly enriched in primary intracranial tumors, but spanning diverse solid tumor types and hematologic malignancies. we additionally report a cohort of raf fusion-positive patients. an index case and multiple previous reports suggest raf or mek inhibitors may benefit pediatric patients with either intracranial or extracranial disease, and development of such drugs in pediatric indications is strongly warranted. background: diffuse midline gliomas (dmg) with h k m mutation, including diffuse intrinsic pontine glioma (dipg), are the leading cause of brain tumor-related deaths in children. there are no effective therapeutic strategies and the median survival remains dismal. genomic studies have identified a recurrent mutation in the majority of dmgs involving a lysine to methionine substitution (k m) in histones . and . , resulting in changes in the epigenetic landscape that dysregulate gene expression and promote gliomagenesis. panobinostat, a multiple histone deacetylase (hdac) inhibitor, was found to be one of the most effective agents against dipg patient-derived cell cultures and xenograft models in previous studies and is presently in clinical trial for dipg. hdac inhibition with panobinostat may also exhibit activity against h k m+ diffuse midline gliomas of the thalamus and spinal cord. to evaluate the effect of panobinostat as a single agent against patient-derived thalamic and spinal cord h k m+ diffuse midline glioma cell cultures and in an orthotopic xenograft murine model of h k m+ spinal cord glioma. design/method: patient-derived thalamic and spinal cord h k m+ diffuse midline glioma cell cultures were treated with single agent panobinostat at a range of concentrations. cell viability was evaluated using the celltiter-glo assay. panobinostat was systemically administered to orthotopic xenograft murine models of luciferase-expressing spinal cord h k m+ diffuse midline glioma. response to panobinostat was evaluated with ivis in vivo imaging. results: hdac inhibition with panobinostat significantly decreases cell proliferation with an ic of nm and nm in the spinal cord and thalamic glioma patient-derived cell cultures respectively. panobinostat slowed tumor growth in murine models of spinal cord glioma by . -fold in the brain (p = . , n = ) and -fold in the spinal cord (p = . , n = ) when compared to vehicle controls after week of administration. panobinostat is in clinical trials for dipg. this study suggests that hdac inhibition with panobinostat may also be beneficial for patients with thalamic and spinal cord diffuse midline glioma h k m mutants. background: brain tumors are the most common solid tumor of childhood and the leading cause of childhood cancer deaths. while medulloblastoma is the most common malignant brain tumor of childhood with a -year survival - %, children with high-grade gliomas (hggs) such as glioblastoma multiforme (gbm) fare much worse with a -year survival of - %. implicated in this poor outcome is the presence of treatment resistant brain tumor stem-like cells. gbm stem-like cells (gscs) have been implicated in tumor growth, treatment resistance and patient relapse, making them a key therapeutic priority. antipsychotic drugs (apds) have been used for decades in various psychiatric clinical settings and are associated with a lower incidence of cancer, including malignant brain tumors. currently, atypical apds are being evaluated for their potential to alleviate cancer and treatment induced side effects. furthermore these drugs may have direct anti-tumor effects, potentially via inhibition of dopamine d receptors (drd ). objectives: determine the anti-cancer effects of atypical apds on gbm stem-like cells design/method: the anti-cancer effects of apds (quetiapine and risperidone) were evaluated on gbm stem-like cell lines developed in our laboratory (glio and ) and the group medulloblastoma cell line hdmbo . cell proliferation/viability was determined using trypan blue exclusion and mts assays. the effect of apds on cancer stem cell self-renewal was determined by neurosphere assay. receptor expression and apds effect on cell cycle proteins were examined by western blot analysis. results: western blot analysis of gscs and hdmbo demonstrated robust drd expression indicating a viable therapeutic target. both apds induced dose dependent cell death of all cell lines tested. treatment with only um of either apd for days significantly reduced cell proliferation by % (hdmbo ) and - % (gscs). consistent with these findings, we observed an increase in cell cycle inhibitors p and p . furthermore at day both apds induced a robust increase in gsc death, approximately % compared to only % in non-treated controls. lastly, um apds significantly reduced gsc neurosphere formation compared to untreated controls by up to % suggesting inhibition of gbm stem cell self-renewal. our data indicates that clinically relevant concentrations (low micromolar) of these apds induce anticancer effects in both gscs, which are enriched with tumor initiation/propagation properties, and in the group (myc amplified) medulloblastoma cell line. these apds represent strong candidates as potential adjuvant therapies for the treatment of these brain tumors. background: while the poor prognosis for high risk neuroblastoma (hrnb) underscores the need for new treatment strategies, the elucidation of specific biologic subsets of neuroblastoma suggests a way to improve disease management. the identification of agents that target specific molecular pathways associated with the development or progression of diseases holds promise. dfmo, an inhibitor of odc, has been shown to decrease lin and mycn and target cancer stem cells in preclinical studies. currently % of patients undergoing immunotherapy relapse. dfmo is in studies to prevent relapse after immunotherapy and may be helpful during immunotherapy as well. the hypotheses for this study were that: ) the incorporation of a targeted therapy, selected based upon upfront tumor genomic interrogation, into standard induction chemotherapy for hrnb is safe, feasible and may increase the pr/cr/vgpr response rate at the end of induction therapy; and ) the addition of dfmo as maintenance during immunotherapy is safe and feasible and may decrease the relapse rate for hrnb. a multicenter feasibility pilot trial in subjects with newly diagnosed hrnb within the beat childhood cancer consortium. at diagnosis, patients' tumors underwent dna exome and rna sequencing which were analyzed within a molecular tumor board to identify the single best drug of targeted agents to be added to cycles - of induction chemotherapy. after consolidation with asct and radiation, the patients received dfmo along with standard dinutuximab and retinoic acid and dfmo for years after immunotherapy. patients were evaluated for additional toxicities with the addition of targeted agents and dfmo in addition to induction response. results: the pilot study of eligible patients has shown this process to be feasible. all patients have completed induction portions of the study. the combination of targeted agent with chemotherapy was shown to be safe without any unexpected toxicities. delays between induction cycles were < weeks and related to surgery, infection, or thrombocytopenia. the induction response demonstrated % cr/vgpr/pr rate, which suggests improvement over historical %. in addition, patients were eligible for the combination of dfmo with dinutuximab and retinoic acid was well tolerated and safe without additional toxicities due to dfmo. the pilot study of patients has shown the process of genomic sequencing and addition of a targeted agent to upfront chemotherapy and addition of dfmo to dinutuximab and retinoic acid maintenance therapy in newly diagnosed hrnb patients and is feasible and safe without any unexpected toxicities. background: identifying sub-populations of medulloblastoma tumors with stem cell-like properties holds promise for reducing disease recurrence, but there is no known unifying marker of medulloblastoma cancer stem cells. the granulocyte stimulating factor receptor (gcsf-r or cd ) is well understood in the context of hematopoiesis, but its role in solid tumor pathogenesis is less clear. neuroblastoma and melanoma subpopulations expressing gcsf-r have cancer stem cell properties of chemoresistance and increased tumorigenicity, and are enriched in tumors after chemotherapy. gcsf-r activation leads to signaling through the jak-stat pathway, suggesting a potential therapeutic target. we hypothesized that a subpopulation of medulloblastoma cells would express the gcsf-r and that this subpopulation would demonstrate chemoresistance and response to inhibitors of the jak/stat pathway. objectives: our objective was to identify a subpopulation of medulloblastoma cells expressing the gcsf-r and determine their relative growth rates, tumorigenicity, and responses to chemotherapy and jak/stat inhibition. design/method: medulloblastoma cell lines were sorted via flow cytometry for gcsf-r surface expression. subpopulations of gcsf-r-positive and -negative medulloblastoma cells were then monitored for growth by continuous live cell imaging. responses to chemotherapy were measured in subpopulations of gcsf-r-positive and -negative medulloblastoma cells using continuous live cell imaging to measure percent cell confluence and cell viability assays. ic values were calculated for each cell line and each agent. parental medulloblastoma cell lines and isolated gcsf-r-positive and -negative subpopulations were also treated with the jak / inhibitor ruxolitinib and growth rates, viability, and ic values were calculated. results: gcsf-r surface expression was identified on . - . % of medulloblastoma cell lines. isolated gcsf-r positive cells demonstrate a slower growth rate compared to gcsf-rnegative or parental unsorted medulloblastoma cells. gcsf-r positive cells are more resistant in vitro to vincristine, etoposide, and carboplatin, when compared to the gcsf-r negative population and an unsorted population of the same cell line. ruxolitinib is cytotoxic to medulloblastoma cells in vitro, with higher ic values noted in gcsf-r positive cells compared to unsorted and gcsf-r negative cells. we show that a subpopulation of gcsf-r positive cells are present in multiple medulloblastoma cell lines via flow cytometry, and that isolated gcsf-r-positive cells have a slower growth rate than gcsf-r-negative or unsorted populations. we also show that ruxolitinib has in vitro activity against medulloblastoma cell lines. we propose that jak inhibition may represent an adjunct therapy targeting overall tumor burden and specifically targeting the gcsf-r-positive subpopulation of medulloblastoma cells that may drive tumor recurrence. we investigated the efficacy of intensified adjuvant chemotherapy in osteosarcoma patients. design/method: we retrospectively analyzed the medical records of children with osteosarcoma treated at asan medical center between and . all patients received a -drug induction consisting of cycles of cisplatin and doxorubicin along with cycles of methotrexate (map), and proceeded to surgical resection. adjuvant ct was map or map with the additional ifosfamide and etoposide (mapie), and mapie was mainly considered for poor responders (tumor necrosis below %) or patients with metastases. results: among patients, patients had metastases at diagnosis. surgery was conducted in patients who responded to induction ct, and showed over % tumor necrosis. among patients who proceeded to adjuvant ct, and patients received to map and mapie protocols. with a median follow-up of months, the -year overall survival (os) and event-free survival (efs) rates of all patients were % and . %. of those patients, patients recurred, and of them died of disease progression. relapsed patients received salvage ct and/or surgery, and were rescued after autologous stem cell transplantation (sct). three patients developed treatment-related acute myeloid leukemia, and they are alive after allogeneic sct. according to the response to neoadjuvant ct, the os rates of good responders (n = ) and poor responders (n = ) were % and . % (p = . ), and efs rates were . % and . % (p = . ). of the poor responders, patients received map as adjuvant ct, and the other received mapie. the os rates of map and mapie group were . % and . % (p = . ), and efs rates were . % and . % (p = . ), respectively. when patients were classified into three groups: . localized disease & necrosis ≥ % (n = ), . localized disease & necrosis < % (n = ), . metastatic disease (n = ), survival rates were in the order of group > > (os = %: . %: . %, efs = . %: . %: %). in each group, intensified adjuvant ct by mapie did not improve survival outcomes. conclusion: initial metastatic disease and poor histological response to neoadjuvant ct were major risk factors for poor survival in osteosarcoma patients. we found that adding ifosfamide and etoposide to map did not improve survival outcomes of patients with adverse risk factors. more effective adjuvant therapy for these patients is needed. background: circulating cell-free dna (cfdna) that shed from tumors into circulation have been used for noninvasive molecular profiling in adult cancers but little is known about its utility in pediatric cancers. pediatric patients with metastatic and refractory solid tumors are known to have poor survival rates, and a key challenge in their management is obtaining biopsy samples especially at times when disease is widely spread or the patient is physically unfit for sampling. the development of a noninvasive profiling strategy is critical for optimizing molecularly guided therapy and assessing response to treatment. in this study, we want to determine the utility of cfdna to noninvasively analyze the molecular profiles of pediatric solid tumors such as neuroblastoma (nb), osteosarcoma (os), and wilms tumor (wt). design/method: tumor, plasma, and matched controls were collected from patients with nb, wt, and os, at diagnosis or time of disease progression. cfdna was extracted from the plasma and analyzed through multiple methodologies including a targeted next generation sequencing panels and shallow whole genome sequencing (swgs). results: fifteen nb patients, os patients, and wt patients had tumor molecular profiles known from different targeted next-generation sequencing platforms. in the cfdna of / nb patients, somatic mutations and copy number alterations previously reported in the tumors were detected, including recurrent nb drivers such as mycn amplification, alk, and atrx mutations. mutations not detected in the original tumor were also found in / nb patients including nras, mll , arid b, some of which are potentially actionable. in os, mutations known from the tumor were found in the cfdna of of patients, including atrx and notch mutations, as well as copy number alterations such as cdk amplification, which has targetable therapeutics available. of the two wt patients analyzed, cfdna revealed the same mutations as tumor in one patient, however in a cohort of patients where tumor was not available, cfdna revealed recurrent driver mutations such as amer , dicer . it is feasible to noninvasively identify somatic mutations and copy number alterations in cfdna of patients with pediatric solid tumors. establishing a platform using cfdna to identify molecular profiles of these tumors can serve as a powerful tool for guiding treatment and monitoring response to treatment. background: despite multi-modality therapy, the prognosis for patients with metastatic osteosarcoma remains poor necessitating development of novel targeted therapies. immunotherapy can be exploited to target osteosarcoma with exquisite specificity but remains limited by insufficient tumor specific targets. objectives: to overcome the dearth in tumor specific antigens, we have explored the use of tumor derived mrna (representing a tumor specific transcriptome) for development of personalized nanoparticle vaccines. design/method: rna-nanoparticles (rna-nps) can be amplified from limited amounts of biopsied tissue for induction of tumor specific t cells against osteosarcoma. since local vaccination strategies are mired by poor overall immunogenicity, we assessed the feasibility, immunogenicity and antitumor activity of intravenously administered rna-nps (tumor mrna complexed to dotap nanoliposomes) in pre-clinical murine and canine tumor models. we identified a clinically translatable np formulation for the delivery of rna to antigen presenting cells (apcs) that induces in vivo gene expression and preserves rna stability over time. tumor derived rna-nps induced antigen specific t cell immunity and mediated anti-tumor efficacy in several pre-clinical solid tumor models (i.e. b f , kr b). when administered intravenously, rna-nps increased expression of co-stimulatory molecules (i.e. cd , cd , cd , ccr ) and pd-l on cd c+ cells throughout reticuloendothelial organs (i.e. spleen, liver, bone marrow) and within the tumor microenvironment; this phenotype was strictly dependent on type i interferon. targeted inhibition of type i interferon signaling (via infar mabs) abrogated anti-tumor efficacy mediated by rna-nps. we enhanced the immunogenicity of this platform by simply combining mrnas encoding for immunomodulatory molecules (i.e. hcv-pamps, gm-csf) or by combining rna-nps with immune checkpoint inhibitors. addition of checkpoint inhibitors (pd-l mabs) to rna-nps increased tumor infiltrating lymphocytes, and intratumoral mhc class i/ii expression, and mediated synergistic anti-tumor activity in settings where pd- or pd-l inhibition alone did not confer therapeutic benefit. we then explored the feasibility of rna-nps in a large animal osteosarcoma model. in ongoing studies for canines with osteosarcomas, we have shown that sufficient amounts of rna can be extracted, amplified, and manufactured into personalized rna-np vaccines. conclusion: rna-nps reprogram systemic immunity and mediate anti-tumor activity providing near immediate immune induction without the complexity of cellular immunotherapy. the immune correlate of preclinical response to rna-nps is hallmarked by interferon dependent pd-l expression on activated apcs (cd c+ mhcii+ cd + cells). based on these findings, we are exploring the preclinical safety, efficacy and immunologic effects of rna-nps targeting canine osteosarcoma before first in-human evaluation. background: ewing sarcoma is an aggressive bone tumor affecting mainly adolescent and young adults. treatments are based on compressed schedule chemotherapy combined with local control (surgery and/or radiation). prognosis is poorer for patients with metastatic disease, older age and central primaries. survival when disease recurs within two years of diagnosis is < %. the ews-fli fusion gene t( ; ) (q ; q ) has been well characterized as a dominant ews driver-gene. the most common variation is ews exon with fli exon ( % of fusion positive patients). we designed a novel pbi-shrna tm ews/fli type lpx which has demonstrated, safety and efficacy in animal model (rao et all). the pbi-shrna strategy silences target gene expression by concurrently inducing translational repression and p-body sequestration as well as post-transcriptional mrna cleavage. to determine the safety and maximum tolerated dose of intravenous administration of pbi-shrna tm ews/fli type lipoplex in patients advanced ews. design/method: phase i study × escalation cohort. testing pbi-shrna tm ews/fli type lpx (starting iv dose of . mg/kg) on patients (≥ age ) with advanced ewing's sarcoma, all with a type translocation. intravenous infusion was given twice a week for weeks with the following escalation schema: % → % → % → % → %. required kps > % and adequate organ function. cytokines induction pre and post-infusion was analyzed (il- , il- , tnf-alpha, il ra). first cohort of patients has been enrolled (ages between - years). three relapsed patients had > lines of therapy and patient had refractory disease, patients received a complete cycle of pbi-shrna tm ews/fli type lpx with twice a week infusions. a total of doses were given. the most prominent related toxicity has been hematological, patient developed transient g neutropenia, another patient developed g anemia that required prbc transfusion, and of note this patient had significant bone and bone marrow involvement. one patient only received two lpx infusions; she developed a fatal rsv pneumonia. other reported grade toxicity includes fatigue and headache. evaluable patients (n ) had stable disease between and months before progression. one patient had sustained response for month before progression, two patients are still alive. our preliminary experience supports the safety and potential efficacy of pbi-shrna tm ews/fli type lpx as novel treatment for advanced ews with limited toxicity. il- increase correlates with higher bi-shrnai ews/fli lpx infusion rate and clinical symptoms. further clinical testing is indicated. background: as more children with cns malignancies (bt) are surviving, the late effects of the therapies they receive are better described. studies show that radiation therapy is particularly harmful to neurocognitive functioning, specifically processing speed, working memory, and attention span. these deficits have negative effects on quality of life, especially in academic and professional settings. a large proportion of s of s adult survivors of bt are unable to reach adult milestones such as living on their own, holding a steady job, and getting married. proton beam radiation therapy (pbrt), is touted for the potential to have fewer and less severe side effects than traditional photon radiation therapy (xrt). because of the properties of protons, the amount of damaging energy released in non-target healthy tissue is reduced when compared to xrt. although a study comparing iq testing between pbrt and xrt found no difference between the two therapies, no studies have compared the specific neurocognitive domains. it would be valuable to evaluate full neurocognitive testing scores (nct) since the specific domains, particularly processing speed (psi), appear to be most vulnerable to radiation therapy. objectives: our primary aim was to assess differences in psi for patients with bt who underwent pbrt versus xrt. a secondary aim was to assess differences in iq (fsiq) and working memory (wmi). we retrospectively evaluated all patients treated for bt at the jimmy everest cancer center within the past years who received rt and had nct post radiation. we examined the full nct results for both subsets of participants to evaluate differences in the specific domains of processing speed, working memory, and iq by measuring percentiles scored in these domains. objectives: we report our experience on imaging children with mm treated uniformly on an institutional melanoma trial. we retrospectively reviewed the clinical and imaging findings of patients with ajcc stage iic-iv cutaneous mm treated on our institutional mel protocol. brain mri/ct, pet/ct, ct chest, abdomen, and pelvis (ctcap) were performed at diagnosis in all patients. on treatment, stratum a patients (peg-interferon; ajcc iic, iiia, iiib) (n = ) had the same imaging repeated every months; stratum b (peg-interferon and temozolomide; unresectable measurable disease metastatic, or recurrent) (n = ) had pet scans every months and brain imaging every months; those in stratum b (peg-interferon and temozolomide; unresectable non-measurable, metastatic, or recurrent) (n = ) had the same imaging performed every months. off therapy all patients continued same imaging every months for years. results: there were patients ( female; median age years). eleven had spitzoid and conventional melanoma. primary sites included head/neck (n = ), trunk (n = ), and extremities (n = ). patients with spitzoid melanoma had imaging studies ( pet, ctcap, ct chest, ct brain, and mri brain) with a median of , , , and studies/patient respectively. median cost per patient was $ , . thirteen studies ( . %) showed suspicious lesions with additional scans and diagnostic biopsies of which one only was positive stratum a with tert promoter mutation and died from disease). for conventional mm, studies ( pet, ctcap, ct chest, ct brain, and mri brain) were performed with a median of , . , , , studies/patient respectively. median cost per patient was $ , . twenty ( %) showed suspicious lesions with additional scans and diagnostic biopsies; four were positive (two at diagnosis); both died of disease; the other two recurred locoregionally and were detected clinically; both are alive and disease free; one patient had diffuse metastases and died shortly after enrollment. after a median follow up of . years (range . - . ) patients are alive and disease free. children with spitzoid melanoma should have minimal imaging at diagnosis and follow-up given the low risk of recurrence and low yield and high cost of aggressive imaging protocols. patients with conventional mm should be imaged according to the adult guidelines. nationwide children's hospital, columbus, ohio, united states background: the role of infections in the long term outcome of patients with bone tumors is controversial. two retrospective studies have shown increased survival in osteosarcoma patients who had a post-operative wound infection, while another showed no changes in overall survival. to determine the relationship between wound infections and/or bloodstream infection (bsi) on survival in pediatric and young adult patients with osteosarcoma and ewing sarcoma treated at a tertiary children's hospital. design/method: a retrospective chart review was performed for patients with diagnosis of osteosarcoma or ewing sarcoma from - . patients received standard chemotherapy regimens for their disease type and stage. local control included surgical resection and/or radiation therapy. presence of infection was determined by bsi or wound cultures while receiving treatment for primary tumor. the median age of patients was (range - years) at diagnosis. % had a diagnosis of osteosarcoma and % had ewing sarcoma. of these, % of patients developed an infection during treatment; % had bsi, % had wound infections, and % had both. patients with bsi had a year os of . %, compared to % in those without bsi (p = . ). those with both bsi and wound infections had the poorest overall survival of %, compared to . % for patients without any infection. patients with wound infections alone had a year os of . %, compared to % of patients without a wound infection. our analysis revealed decreased os in patients with bsi; however, this could be due to other confounding factors in the presence of bsi. those with bsi or bsi and wound infections had the poorest survival. wound infections without bsi were associated with a slight increase in survival; however, this study was limited by the number of patients that had local wound infections. with the use of newer surgical techniques, availability of antimicrobials and routine use of prophylactic antibiotics, the incidence of infections while undergoing treatment is low. however, the importance of this clinical observation indicates a likely enhanced immune system associated with infection, supporting the role of immunotherapy for treatment of these aggressive tumors. background: hypoalbuminemia is a well-recognized effect of cancer and other chronic illnesses and is often regarded as a marker of malnutrition. in adults, hypoalbuminemia has been associated with adverse outcomes in patients with cancers of the lung, pelvis, head and neck, gastrointestinal tract, and bone marrow, as well as in some pediatric patients with ewing sarcoma and hodgkin lymphoma. hypoalbuminemia has not been well studied in children with cancer. to determine the incidence of hypoalbuminemia (using age-specific references) in children with cancer receiving chemotherapy at baseline (prior to starting chemotherapy) and to determine whether hypoalbuminemia is associated with inferior -year overall survival. design/method: we performed a single institution, irbapproved, retrospective review of pediatric oncology patients diagnosed between and . five-year survival was estimated using the kaplan-meier method; groups were compared using cox regression. we identified pediatric patients with a first diagnosis of cancer, brain tumor, or other condition possibly requiring chemotherapy. of these patients, were excluded for reasons including not receiving chemotherapy and missing data, leaving patients who had a serum albumin level within days prior to starting chemotherapy. the mean age was . years (sd . years); % were male; % were non-hispanic. the most common diagnosis was acute lymphoblastic leukemia ( of ; %). one hundred thirty nine of ( %) had hypoalbuminemia prior to starting chemotherapy. there was no statistically significant difference in -year overall survival between those with and without hypoalbuminemia ( % vs. %, respectively; hazard ratio . , % c.i. . - . ). conclusion: hypoalbuminemia at baseline in pediatric oncology patients requiring chemotherapy is common (one in five), and was not associated with inferior -year overall survival in this cohort. leptomeningeal metastases at diagnosis. standard treatment for completely resected, non-anaplastic supratentorial ependymomas is close observation. treatment for anaplastic or incompletely resected non-anaplastic ependymomas is maximal safe surgical resection followed by focal radiation. however, up to % of localized ependymomas recur. the role of chemotherapy in treating ependymomas is under investigation. extraneural metastases of anaplastic ependymomas have rarely been reported and the outcome is dismal. objectives: to report extraneural cervical node metastases of a non-anaplastic ependymoma and successful treatment with surgical resection, radiation, and systemic chemotherapy. design/method: retrospective review of patient medical records, including radiographic imaging and tumor tissue pathology, and comprehensive literature review. results: a previously healthy -year-old girl underwent gross total resection (gtr) of an isolated right parietal lobe ependymoma (who grade ii). at age years, magnetic resonance imaging (mri) revealed an isolated localized recurrence. she underwent gtr followed by observation. at age years, she again experienced isolated localized recurrence and underwent gtr followed by . gy focal conformal photon radiation. at each recurrence, pathology revealed a non-anaplastic ependymoma, and cerebral spinal fluid (csf) cytopathology and spine mri were negative. at age years, she developed an enlarged right posterior cervical chain lymph node. subsequent mri revealed a large rim-enhancing, t hyperintense lymph node and multiple abnormally enhancing regional nodes consistent with metastases. biopsy revealed a non-anaplastic ependymoma. mri of the brain and spine, computed tomography of the chest, abdomen, and pelvis, and csf and marrow evaluations were unremarkable. chemotherapy according to acns was initiated. mri after course demonstrated significant node size reduction. she underwent right neck node dissection. only one right level ii lymph node showed metastases. she was treated with . gy irradiation to the neck and additional courses of chemotherapy. she remains in remission months and months after diagnosis of metastatic disease and end of therapy, respectively. literature review reveals rare reports of extraneural metastatic disease of anaplastic ependymomas to bone, lung, or liver, and only involving lymph nodes, all associated with a poor outcome despite multimodal therapy. to our knowledge, this is the first report of extraneural metastases of a non-anaplastic ependymoma. extraneural metastases should be considered in children previously treated for non-anaplastic ependymomas who experience systemic symptoms, even in absence of cns relapse. multimodal treatment offers potential long-term disease control with acceptable toxicity. arun gurunathan, joel sorger, andrew trout, joseph pressey, rajaram nagarajan, brian turpin cincinnati children's hospital medical center, cincinnati, ohio, united states background: pigmented villonodular synovitis (pvns) is a benign neoplasm of the synovium. standard treatment is surgery, but post-operative recurrence rate is as high as %. radiation therapy can be used for local control, but is associated with late effects. while pvns is rarely fatal, aggressive disease and/or extensive surgery can result in substantial functional impairment. colony stimulating factor- (csf ) overexpression, often due to chromosomal translocation involving csf , drives pvns through recruitment of synovial-like mononuclear cells expressing the csf -receptor. tyrosine kinase inhibitors such as imatinib are active against the csf -receptor, and have shown benefit in the post-surgical relapse setting. however, questions remain regarding the broader application of imatinib and regarding optimal response assessment. to present three patients with pvns, each with different clinical scenarios, who demonstrate clinical response to imatinib monitored by changes in metabolic activity (maximum suv) on pet/ct. results: three patients with pvns demonstrate pet/ct response to imatinib, guiding management of their challenging clinical scenarios. patient is a year-old female with left hip pvns and high grade articular cartilage loss, with decrease in metabolic activity (suvmax . to . in months) on neoadjuvant imatinib, enabling total hip replacement surgery planning. patient is a year-old female with left knee pvns with recurrences after synovectomies, spared subsequent surgical control attempts after clinical improvement correlating with pet/ct response to imatinib (suvmax . to . in months). patient is a year-old male with right knee pvns that recurred after total knee replacement, now with clinical improvement correlating with pet/ct response to imatinib (suvmax . to . in months). all patients would have been characterized as stable disease by response evaluation criteria in solid tumors (recist). in each of these patients, imatinib has been tolerated well, with no therapy interruptions and absent or easily managed side effects (one patient takes dronabinol for decreased appetite, one patient takes prn immodium for diarrhea). all patients are currently still taking imatinib, with therapy length ranging from five to eleven months. in our series of three patients with pvns, imatinib shows promise for disease management in neoadjuvant and adjuvant settings with a tolerable side effect profile. imatinib should be considered in the treatment of pvns to spare surgical and radiotherapy related morbidity, and treatment effect can be monitored by pet/ct. background: metastatic rhabdomyosarcoma (rms) carries a poor prognosis with three-year event free survival rates ranging between %- % (depending on oberlin risk factors) due to the lack of significantly effective breakthroughs in the recent past. there is an urgent and unmet need for new treatment strategies against this disease. metastatic rms cell lines exhibit increased expression of the erm family membrane-cytoskeleton linker protein ezrin. knockdown of ezrin expression using sirnas decreases the metastatic potential of these cells, whereas forced expression of ezrin results in increased degree of metastasis. the activity of ezrin is controlled by its phosphorylation at the threonine (thr ) residue at the c-terminus of the protein, suggesting that alteration of ezrin phosphorylation may control rms growth and metastasis. our goal was to determine if pharmacological inhibition of thr phosphorylation in ezrin affects the growth, survival and metastasis in rms in vitro as well as in vivo. design/method: rms cell lines representative of the alveolar and embryonal histological subtypes were used. rms cells were treated with a small molecule inhibitor of ezrin, nsc , which specifically dephosphorylates ezrin at the thr residue. baseline expression of ezrin and perm levels as well as the effect of nsc on perm levels in the rms cell lines was determined by western blotting of cell lysates. viability of cells was assessed by trypan blue exclusion, and morphology visualized by bright field microscopy. the extent of apoptosis was detected by imaging caspase / activation using fluorescent microscopy. motility of rms cells was examined by performing a wound-healing assay. subcutaneous and orthotopic xenografts were established in nsg mice using rd cells (embryonal rms). mice harbor-ing xenografts were treated with intraperitoneal injections of nsc or dmso. results: ezrin is constitutively phosphorylated at the thr residue in a majority of the rms cell lines examined. nsc dephosphorylates ezrin at the thr residue in these cell lines. treatment with nsc inhibits growth, induces apoptosis and inhibits the migration of rms cell lines in vitro. further, treatment of nsg mice bearing subcutaneous or orthotopic embryonal rhabdomyosarcoma xenografts with nsc significantly impedes tumor progression without any obvious adverse effects. our findings suggest that dephosphorylation of ezrin at the threonine residue may have the potential to be a novel therapeutic strategy for rms patients. all india institute of medical sciences, new delhi, new delhi, delhi, india background: the role of laparoscopy in the management of pediatric intra-abdominal solid tumors is yet to be established. the safety of laparoscopic management of pediatric intra-abdominal tumors is still questionable. we study the results of the initial case series of pediatric intraabdominal tumors managed laparoscopically at our institute from july onwards. design/method: total children ( -males, females) who presented to us with pediatric intra-abdominal tumors were included. the tumors included wilms tumor (n = ), neuroblastoma(n = ), adrenal cortical tumor(n = ), ovarian teratoma(n = ).children were between months - years and received neo-adjuvant chemotherapy. a -port laparoscopic nephrectomy and lymph node sampling for wilms tumor and adrenalectomy for adrenal tumors was performed. the tumors were removed in-toto with no rupture (except in one). specimens were retrieved through a lumbar incision (n = ) or an inguinal incision(n = ). all the children are under regular follow up. two children with wilms tumor had recurrence. the neuroblastoma child underwent open surgery for recurrence later. conclusion: laparoscopy/laparoscopic assisted removal of pediatric intra abdominal tumor is a feasible and safe option. it has the advantage of less postoperative pain, shorter hospital stay and a better cosmetic result. proper patient selection, port placement and laparoscopic experience are contributory. background: targeting of proteins and cell surface antigens specific to cancer cells with monoclonal antibodies has proven to be an effective form of treatment in many forms of cancer. gd is a cell surface disialoganglioside that is expressed on the cell surface of some normal tissues including nerve cells, melanocytes, and mesenchymal stromal cells and is overexpressed in some pediatric cancers like neuroblastoma and osteosarcoma. dinutuiximab is a chimeric monoclonal antibody that is fda approved for the treatment of patients with high risk neuroblastoma and under investigation for the treatment of relapsed osteosarcoma. little is known about the patterns of gd expression in other pediatric malignancies. objectives: we sought to describe the patterns of gd expression in the following pediatric sarcomas: synovial sarcoma, rhabdomyosarcoma and ewing sarcoma. design/method: synovial sarcoma (n = ), rhabdomyosarcoma (n = ) and ewing's sarcomas (n = ) formalin fixed, paraffin embedded cores were obtained from the seattle children's research institute tissue microarray (tma) biorepository. tma blocks consisting of melanoma cores stained with and without gd antibody were used as positive and negative controls, respectively. slides were incubated with anti-ganglioside gd antibody clone q (ab from abcam) diluted : in % normal goat serum and % bsa in tbs overnight at ˚c. the negative control of human melanoma section was incubated in % normal goat serum and % bsa in tbs without primary antibody. the expression of gd was indicated by characteristic brown diaminobenzidine staining. the intensity and location of tissue staining were assessed and compared to positive and negative controls. staining was considered positive (+++) if the intensity of the staining was consistent with that of the positive control with - % of cells staining positive. classification of intermediate gd expression (++) was assigned to slides in which - % of cells stained positive. slides were classified as sporadic staining (+) if - % of cells stained positive. tissue was considered (-) if there was complete absence of staining, similar to the negative control. objectives: to evaluate the clinical presentation, management and treatment outcomes of children with malignant germ cell tumor at our institute design/method: a prospective study was conducted from june to dec in the department of pediatric surgery in a tertiary care institute in a developing country. all patients were evaluated for local disease and metastatic disease by imaging and tumor markers. risk stratified chemotherapy was used with low risk tumor receiving no chemotherapy, intermediate risk: courses of peb chemotherapy and high risk: courses of peb + courses of pe. upfront resection of the primary or the residual disease after neoadjuvant chemotherapy if feasible was performed. follow up was done with monthly tumor markers for months and imaging studies every - months for initial years. five year overall survival and disease free survival was calculated. results: during the study we treated children who formed the study group. of these ( %) were gonadal ( ; % testicular and ; % ovarian) and the remaining ( %) were extragonadal with sacrococcygeal (sct) being the most common site ( %). one hundred and thirteen children ( %) presented to us primarily while the remaining had received treatment elsewhere. stage or stage disease at presentation was present in ( %) children. recurrence was noted in ( %) patients. respectively. patients with testicular mgct and children with age - years and males had significantly poor rfs rates. conclusion: patients with mgct should be staged correctly and adjuvant chemotherapy is advisable to all patients except stage i endermal sinus tumor of testis. awareness regarding the same is still lacking in our country. meticulous follow up is needed as more than % of will recur. cure rates are dismal in children with recurrent mgct especially those who are not chemotherapy naïve. nemours children's specialty care, jacksonville, florida, united states background: radiotherapy for pediatric head and neck tumors often results in mucositis, limiting oral intake and compromising patients' nutritional status. this may be reduced through the improved conformality offered by proton therapy. despite widespread use of enteral tube feeding through a percutaneous gastrostomy (peg) or nasogastric tube (ngt), there is little data available regarding overall incidence of ngt/peg placement and perspectives of pediatric patients and caregivers. objectives: to (a) estimate the need for ngt/peg support and (b) characterize patient and caregiver perceptions surrounding enteral feeding in children with head and neck tumors undergoing proton therapy. design/method: dependent on development stage, patient (n = ) or parents (n = ) filled out a series of customized surveys according to a prospective irb approved study. seventythree percent of patients also received concurrent chemotherapy. questions addressed their current feeding route and perception, for example, "what aspect(s) of tube feedings are beneficial to you?" and "what aspect(s) of tube feeding worry or scare you?" fifty-five surveys were distributed before and after radiation, and with any change in feeding route. results: at the start of proton therapy, patient had a ngt and patients had peg. of these, patients ( %) had a ngt/peg in place exclusively for the administration of medication; only patient ( %) needed a ngt/peg for nutrition. in those patients without ngt/peg, % would "consider" enteral feeds. in patients without ngt/peg, the most commonly cited benefit was "maximizing my nutrition" ( %) and the most common negative aspect was "fear" of tube placement ( % of patients). all sub-populations ( % of patients) cited change in appearance as a negative aspect. in patients without ngt/peg at the start of proton therapy, % of patients/caregivers felt enteral feeding to be "unnecessary," and % of these patients would not "consider" ngt/peg even if their "physician advised it." over the course of proton therapy, the patients/caregivers who deemed enteral feeding "unnecessary" decreased from % to %. at completion of treatment, patients ( %) were using a ngt/peg tube for nutritional support but only one ( %) patient relied exclusively on their enteral feeds. two patients (without ngt/peg) ( %) required parenteral support. our data does not support prophylactic placement of ngt/peg in of children with head and neck tumors undergoing proton therapy. ongoing research is needed to identify which patients will need ngt or peg to supplement their diet. in this cohort, anticipatory counseling should focus on pain, cosmesis, and utility. children's national medical center, washington, district of columbia, united states background: ovarian sex cord-stromal tumors (osct) are rare neoplasms that typically present with signs/symptoms of an adnexal mass and signs of hormonal production approximately % of ovarian sex cord-stromal tumors in children are sertoli-leydig cell tumors (slct) with median age of presentation years overall. to our knowledge the youngest reported case in the literature describes a -month old female in china with a slct that was treated with oophorectomy alone. some studies have found an association in families between pleuopulmonary blastoma and osct with a germline mutation leading to dicer syndrome, which has been associated with a younger age at diagnosis. , objectives: to describe an unusual case presentation of slct in an infant results: -month old, twin female, ex- week premature infant presented to the emergency department on multiple occasions for abdominal distention and feeding intolerance initially thought to be related to previous omphalocele repair and umbilical hernia. an ultrasound demonstrated an × cm mass arising from the right ovary with large volume ascites. she required admission to the intensive care unit due to s of s respiratory distress from her significant ascites. serum tumor marker including hcg, afp and ldh were negative. patient underwent right oophorectomy with tumor capsule noted to be open at time of surgery. further imaging post operatively demonstrated no other sites of disease. the patient was classified as figo stage ic due to the presence of her significant abdominal ascites that was presumed to be malignant pre-operative tumor rupture. the pathological diagnosis was challenging and eventually resulted as a mixed germ cell sex cord stromal tumor with pattern of sertoli cell tumor with neuroendocrine differentiation. based on the staging of figo ic with pre-operative rupture, the decision was made to treat with a standard platinum based regimen as there is a higher incidence of relapse in stage ic patients when compared to ia treated with observation alone. our patient tolerated four cycles of chemotherapy well and end of therapy scans showed no evidence of disease. interestingly, her dicer mutation genetics performed by ion torrent tm next generation sequencing was negative in germline and tumor studies. to our knowledge, our patient is the youngest described with slct. she will continue to be followed with serial imaging alone as she had no evidence of elevated tumor markers at diagnosis. , due to young age and unusual diagnosis, she was referred to cancer genetics team. background: approximately % of patients with wilms tumor (wt) have metastatic disease at diagnosis and often have a grave prognosis. limited cell lines are available for the study of metastatic wt and long-term passaged cell lines do not always recapitulate the human condition. focal adhesion kinase (fak) is a non-receptor tyrosine kinase that controls cellular pathways involved in the tumorigenesis of pediatric renal tumors. using a novel patient-derived xenograft (pdx) model from a patient's primary wt (coa ) and matched isogenic metastatic wt (coa ), we previously demonstrated that fak is expressed and its inhibition led to decreased tumorigenicity of both the primary and metastatic pdxs. kinomic profiling is an innovative, high-throughput method used to investigate kinase signaling to identify potential therapeutic targets. to date, the kinomic profile of primary and metastatic wt has not been examined. objectives: investigate baseline kinomic differences between primary and metastatic wt and evaluate kinases upstream and downstream of fak as potential targetable therapies. design/method: cells from coa and coa were treated with pf- , (pf), a small molecule fak inhibitor. protein from cell lysates of treated and untreated coa and coa were combined with kinase buffer, atp, and fluorescently labeled antibodies and loaded into a phosphotyrosine kinase or serine-threonine kinase pam-chip® per the uab kinome core protocol. phosphopeptide substrate analysis with the pamstation® kinomics workstation (pamgene® international), pamchip® protocol using evolve software, and bionavigator v. . were used to analyze kinases upstream and downstream of fak. the primary wt had increased epha , ror sgk and decreased pdgfrb relative to the paired metastatic wt at baseline. treatment with pf increased ron, pdgfrb, p s kb, mak, camk g, vacamkl, camk d, ck a and pskh in the primary wt. treatment with pf decreased tnk , lmr , cck , epha , pdk , sgk , lkb and increased pskh in the paired metastatic wt. primary wt displayed a different kinomic profile compared to metastatic wt in a matched isogenic pdx model. these data reveal that alternative therapies to specifically target metastases are needed. furthermore, fak inhibition resulted in diverse kinomic alterations between primary and metastatic wt. inhibitors targeting many of these pathways, such as pdgfrb inhibitors, are currently available and potentially could be combined with fak inhibitors in the treatment of wt. the results of the current study indicate that kinases upstream and downstream of fak in primary and metastatic wt warrant further investigation. background: use of high-dose methotrexate (hd-mtx, g/m^ ) is a mainstay of standard therapy for pediatric osteosarcoma (os) in north america. in pediatric os, there is a narrow therapeutic window for hd-mtx, with decreased tumor response rate with mtx concentrations < m and decreased survival due to severe toxicity with concentrations > m. risk factors for hd-mtx toxicity have been defined in adults, including body mass index (bmi) and male gender, but such studies have not been conducted in children. we sought to examine the relationship between mtx levels and toxicities during hd-mtx infusion for pedi-atric os, thereby identifying risk factors for increased toxicity and providing a framework for therapeutic drug monitoring. design/method: this retrospective chart review included patients treated at texas children's hospital with hd-mtx as first-line therapy for os from - . data abstracted from electronic records included patient characteristics, bmi and body surface area (bsa), baseline and post-treatment laboratory values, mtx levels and hours after dose given ( h, h), hour mtx cleared (mtx < . um), grade / mucositis, myleosuppression, persistent lft elevation (ctace v . ), and % tumor necrosis. correlation between h mtx level and other covariates was summarized using descriptive statistics. we reviewed hd-mtx infusions corresponding to patients. bmi was found to significantly impact h mtx level (p< . ). female gender was also significantly associated with higher h mtx level (p< . ). percent necrosis (available in patients) was associated with h mtx levels at near-statistical significance (p = . ). h mtx level was not found to contribute to toxicities or associate significantly with mtx clearance. analysis in a larger cohort is ongoing. we have identified at least one patient factor (bmi) that significantly impacts h mtx levels and is of potential use for future modeling, as current models incorporate bsa only. our findings concord with studies in adult os in that bmi significantly impacts h mtx level but diverge in that female gender is associated with higher h levels. importantly, these data support targeting h mtx levels to ensure that minimum concentration for adequate tumor necrosis is reached. these results do not suggest that monitoring h levels would prevent toxicities, thus necessitating further characterization of any intrinsic patient factors that associate with toxicity. overall, our definition of the clinical factors that associate with h mtx levels contributes to a framework for therapeutic drug monitoring in pediatric os. children 's mercy hospital kansas city, kansas city, missouri, united states background: post consolidation immunotherapy with dinutuximab, aldesleukin (il- ), granulocyte macrophage colony stimulating factor (gmcsf) and isotretinoin is standard of care for children with high risk neuroblastoma. dinutuximab is combined in alternating cycles with s of s gmcsf or il , followed by a th cycle with isotretinoin alone. il- is administered as a hour continuous infusion on days - at miu/m /day followed by a higher infusion dose, . miu/m /day, in combination with dinutuximab on days - of cycles and . the miu/m /day dose may be administered inpatient or in the ambulatory setting. objectives: to retrospectively compare the incidence of inpatient and outpatient side effects and complications associated with low dose ( miu) il to provide the tolerability data necessary to evaluate these venues for future administration options. design/method: this study was a descriptive, singlecentered definitive study utilizing a retrospective convenience sample population of children with high risk neuroblastoma who received low dose il either as an inpatient or an outpatient without exclusion from may to june . subjects were identified by a tumor registry query post irb approval. electronic and paper medical records were reviewed for the dates and location of the infusions, the home health company used if applicable and all documentation regarding clinical status, side effects and toxicity. demographics was limited to age and gender. results: infusion venue was chosen by provider preference. twenty-six infusions, inpatient and outpatient via separate home health companies were all administered in entirety and without interruption. there were males and females ranging from - years of age. two children received a single outpatient infusion due to intolerance of il when combined with dinutuximab and received therapy in both settings. fever, inpatient and outpatient was the only common side effect. no source of infection was ever identified. there was one incidence of diarrhea and one patient with pruritus in both the outpatient and inpatient settings respectively. no planned outpatient infusions required subsequent admission however the outpatient fever did necessitate an er evaluation. conclusion: low dose il can successfully be administered outpatient. the medication has minimal side effects with fever occurring in %, none of which were associated with infection. no outpatient infusion required a subsequent admission. no patients who received cycle infusions outpatient opted to receive the next cycle inpatient. baylor college of medicine, houston, texas, united states background: metastatic ewing sarcoma (es) has an extremely poor overall survival, necessitating investigations into molecular mechanisms to identify novel targets and develop new therapies. we previously performed an in vivo study, using our mouse model, designed to provide insights into transcriptomic and proteomic signatures for metastatic es to identify potential therapeutic targets. comparing profiles of primary tumors to corresponding metastatic lesions, we identified aberrant expression of integrin ß (itgb ) and downstream activation of integrin-linked kinase (ilk) in metastatic lesions compared to primary tumors, implicating this pathway as a key regulator in the ability of es to establish and enhance metastasis. our hypothesis is that upregulation of itgb and its downstream signaling events play a key role in es metastasis and are viable therapeutic targets. objectives: to investigate the role of itgb and its downstream signaling pathways in driving the establishment and enhancement of metastasis in es and to investigate this pathway as a potential therapeutic target. to investigate the role of itgb and ilk in es metastasis, we used sirna to knock down itgb and ilk expression in established es cell lines and then performed functional assays in vitro, including cell proliferation and invasion/migration assays. we also tested inhibition of this itgb signaling pathway using available small molecule inhibitors targeting itgb , ilk and the downstream target ap- , using cilengitide, compound and sr , respectively. we are currently using these small molecule inhibitors as treatment in vivo and assessing rates of metastatic tumor formation. we generated stable itgb and ilk overexpression and knockdown cell lines, which we are using for similar in vitro and in vivo investigations. knockdown of itgb and ilk in our sirna cell lines resulted in decreased cell proliferation and decreased invasion and migration compared to controls. we also found significantly decreased cell proliferation using each of the small molecule inhibitors in vitro. our preliminary studies using compound in vivo established a safety profile and dose escalation is underway to assess the effectiveness of inhibiting es metastasis. these results support our hypothesis that itgb and its downstream signaling events play a key role in the ability of es to establish metastatic foci and may serve as a potential therapeutic target. we continue to investigate this pathway in vitro. we are also using our small molecule inhibitors and itgb and ilk overexpression and knockdown approaches to study these effects on metastatic tumor development in vivo using our mouse model. background: neuroblastoma (nbl) is characterized by phenotypic heterogeneity. outcome is excellent for patients with low-(lr) and intermediate-risk (ir) disease, whereas only % of high-risk (hr) patients will survive. -hydroxymethylcytosine ( hmc) is an epigenetic marker of active gene transcription, and hmc profiles are prognostic in many types of adult cancers. we hypothesized that hmc profiles will serve as robust biomarkers in children with nbl tumors, refining current risk stratification. objectives: analyze genome-wide hmc in nbl tumors and correlate hmc deposition with chromosomal copy number and gene expression. design/method: hmc was quantified by nano-hmc-seal-seq from the dna extracted from hr, ir and lr nbl tumors. read counts and clinical data were analyzed with deseq to identify genes with differential hmc patterns between risk groups. chromosomal copy number was assessed by chromosomal microarray analysis (cma) in a subset of samples ( lr and hr). expression of genes located on chromosome p was evaluated using publically available microarrays (e-mtab- ) of hr nbl tumors with known p loh status. results: globally, lr tumors had more hmc peaks ( , ) than ir ( , , p = . ) tumors, or hr tumors ( , , p = . ). , genes had different patterns of hmc deposition in hr versus lr tumors. ( %) of these genes mapped to chromosome p and had decreased hmc in hr versus lr tumors (padj < . ). in the cma analysis p deletion was detected in of the tumors tested. in the tumors with p loss, genes that map to p showed decreased hmc deposition compared to the hr tumors without p loss (p< . ). further, compared to the tumors without p loss, the expression of of the p genes was decreased (p< × - ), including chd , camta , and arid a, known and proposed tumor suppressor genes in nbl. conclusion: different patterns of hmc accumulation are associated with neuroblastoma risk classification. nano-hmc-seal-seq is sensitive to copy number variations and has the potential to identify these changes in patient tumors. our results suggest that hmc deposition contributes to the silencing of tumor suppressor genes in p and may also regulate the transcription of other genes that drive tumor phenotype. background: metastatic osteosarcoma has a -year survival rate of - %. pulmonary metastases remain a major treatment challenge in osteosarcoma. current treatment with conventional chemotherapy shows inadequate activity towards metastases and has toxic systemic side effects. chloroquine is a widely used anti-malarial drug and has been shown to have promising anti-cancer and anti-metastatic activity. polymeric drugs have been shown to have multiple advantages over their small molecular parent drugs, including enhancing the therapeutic efficacy, an improved pharmacokinetics profile and decreased systemic toxicity. we hypothesized that by developing chloroquine into a polymeric drug and combining it with conventional chemotherapy it will improve the treatment of metastatic osteosarcoma. objectives: to identify the optimal combination of polymeric chloroquine (pcq) with conventional chemotherapy active in osteosarcoma as a new means of treating metastatic disease in a murine osteosarcoma model. we synthesized and developed pcq and evaluated its anti-invasive activity using an osteosarcoma cell migration and invasion assay. we evaluated the efficacy of cell killing using combination drug therapies with pcq and a panel of conventional chemotherapy agents (doxorubicin, docetaxel, cisplatin and paclitaxel) using celltiter blue cell viability assay. to develop the murine osteosarcoma model, we intravenously injected luciferase-expressing human osteosarcoma cells b into nsg mice. we administered the drug combination that showed the strongest in vitro synergy to the mice and evaluated their anti-cancer and anti-metastatic effects in vivo. tumor growth and suppression were evaluated using whole body bioluminescence imaging. results: we successfully synthesized pcq that contains . % chloroquine with a molecular weight of . kd. pcq was also found to decrease the toxicity of the parent chloroquine. pcq showed strong inhibition of osteosarcoma cell migration with % inhibition compared to % by chloroquine. we screened the combination drug therapies and found the combination of pcq and doxorubicin to show the strongest synergism. the pcq/doxorubicin combination is currently being evaluated in the murine model. combination drug therapy using pcq and doxorubicin showed synergistic cell killing and inhibition of cell migration in vitro. the combination represents a promising treatment strategy for pulmonary metastatic osteosarcoma. emory university/children's healthcare of atlanta, atlanta, georgia, united states background: survival for relapsed high-risk neuroblastoma (rnb) is < %, underscoring the critical need for novel therapies. rnbs have increased ras/raf/mapk mutations and increased yes-associated protein (yap) transcriptional activity. yap is a transcriptional co-activator that binds with tea-domain (tead) transcription factors to regulate cellular proliferation, self-renewal, and survival. we found that shrna inhibition of yap decreases nb cell proliferation and sensitizes ras-mutated nbs to mek inhibitors, supporting yap as a tractable therapeutic target. verteporfin (vp), a photodynamic drug used for macular degeneration, is the only drug found to inhibit yap expression or yap:tead binding to kill tumor-derived cells. peptide is a mer yap peptidomimetic that also disrupts yap:tead interactions. we sought to determine whether these compounds are potent in nb via yap direct effects. design/method: yap expressing (nlf, sk-n-as) or yap null (ngp, lan , sk-n-as-shyap) human-derived nbs were incubated with vp, with and without direct light exposure, or with peptide . celltiter-glo and immunoblots were used to assess for cell death and yap-downstream protein expression, respectively. results: without direct light exposure, vp inhibits yap expression at nm dosing, yet no nb cell death was observed at equal or higher concentrations. egfr and erk / were inhibited along with yap, confirming yap/ras pathway coregulation. when vp was exposed to direct incandescent light for minutes, > % nb cell death occurred in all nbs tested, even those lacking yap. peptide caused no cell death or yap inhibition up to um. neuroblastomas are resistant to vp at doses sufficient to inhibit yap expression. in macular degeneration, light-activated vp produces reactive oxygen species, which we hypothesize is the off target mechanism killing nbs independent of yap. given the off target effects and the need for light activation, vp is not an ideal preclinical or clinical yap inhibitor. accordingly, peptide has poor cell permeability and low tead affinity, leading to its lack of efficacy. given the relevance of yap in rnb and other cancers, we are chemically optimizing a yap peptidomimetic with enhanced permeability, nuclear localization, and tead affinity to create a bonafide yap inhibitor for preclinical and clinical application. kayeleigh higgerson, aaron sugalski, rajiv rajani, josefine heim-hall, jaclyn hung, anne-marie langevin ut health san antonio, san antonio, texas, united states background: osteosarcoma is the most common bone malignancy in children, adolescents, and young adults. most study cohorts have to % hispanic patients that encompass many different hispanic backgrounds. the university of texas health science center at san antonio (uthscsa) sarcoma team serves a latino population that is predominantly mexican american, thus providing a unique opportunity for evaluation this population. this study expands on previous data collected from january to december from the same institution, providing increased insight into outcomes of mexican american children, adolescents, and young adults with osteosarcoma. objectives: to further understanding of osteosarcoma in latino children, adolescents and young adults. design/method: a retrospective analysis of demographics, tumor characteristics, response to treatment, and survival outcome of all localized osteosarcoma of the extremity patients below years of age diagnosed and treated by the uthscsa sarcoma team between january and june was performed. results: in our original cohort from january to december , we observed a significantly decreased -year eventfree survival (efs) in patients diagnosed before age (preadolescent) relative to patients diagnosed between ages and ( % vs. %, p< . ). patients had a -year overall survival (os) and event-free survival of % and % respectively. in our expanded cohort from january to june we evaluated sixty-six patients with a median age of (range, to y) with localized high-grade osteosarcoma of the extremity. the expanded cohort was % mexican american, with a median follow-up of months (range, to ). the analysis of our expanded cohort is ongoing and we postulate that the findings will hold true, as we increase the cohort size and length of follow-up. conclusion: analysis of our previous cohort, predominantly of mexican american ethnicity, showed that preadolescent patients had an increased rate of relapse when compared with previous large studies. we also showed a trend towards decreased efs for the entire cohort. we hypothesize that we will further validate these findings with this expanded cohort and this will support further investigation into potential causes of poor outcome in this vulnerable latino population. background: neuroblastoma in infants has the potential to regress or mature spontaneously. growing literature showed that some cases subjected to initial observation didn't show inferior outcome compared to actively treated similar categories. objectives: we investigated whether early active treatment can be safely avoided/deferred in selected favorable cases at the children's cancer hospital-egypt (cche). design/method: patients enrolled on the watch and see strategy (w&s) at cche had small primary tumor; inss stage - , uncomplicated stage s or stage infants (< days). tissue biopsy was not mandatory for infants below months of age with localized adrenal mass (stage - ). on progression, immediate intervention took place according to stage and risk of disease after biological characterization. results: thirty four nbl patients were enrolled on w&s strategy; m/f: . / . eighteen patients had stage s disease, patients had stage - and were stage . primary adrenal site was reported in patients ( . %), patients ( . %) had small mass measuring ≤ cm in its largest diameter. the -year os & efs were . ± . % and . ± %, respectively, with months median follow-up (range: - months). spontaneous total/near total resolution of mass occurred in / patients ( %). median time to eliciting regression was . months (range: . - . months), and . months (range: - months) till complete resolution. only / patients ( . %) witnessed progression ( local, distant and combined local and distant progression); median time to progression was months (range: - months) with / deaths after starting chemotherapy. watch and see strategy is a safe approach in localized and uncomplicated stage s neuroblastoma. progressive cases could be rescued. baylor college of medicine, houston, texas, united states background: ga- dotatate binds to somatostatin receptor expressed in neuroendocrine tumors (nets). it was approved by fda in for use with pet/ct scan for localization of somatostatin receptor positive nets in adult and pediatric patients. pediatric approval was based mainly on extrapolation of data from adults. objectives: to describe the use of ga- dotatate pet/ct scan in children with neuroendocrine tumors and compare with other imaging modalities. design/method: patients with nets enrolled in texas children's rare tumor registry between february and october were reviewed and those patients who underwent ga- scan were included. results: four patients with nets underwent ga- scans without any adverse reactions. first patient was a -yearold female with small bowel net with multiple liver metastases. mri abdomen and fdg pet at diagnosis showed s of s multiple liver metastases but could not identify the primary lesion. ga- scan was able to accurately identify the enlarged lymph nodes in the small bowel and was better than fdg pet in delineating the liver metastases. second patient was a -year-old female with recurrent small bowel net with liver, lung and paraspinal metastases. the lesions were initially detected by ct scan. octreotide scan failed to show any uptake in the identified lesions while ga- was taken up by the liver lesions, lung lesions > cm in size and the paraspinal lesion. third patient is an year-old male with pancreatic net with peripancreatic lymphadenopathy, multiple liver metastases and cardiophrenic lymph node involvement. the primary lesion in the pancreas could not be identified by ct scan, ct angiogram, mibg scan, or octreotide scan. in addition, there was uncertainty about involvement of the enlarged cardiophrenic lymph node. in addition to clearly identifying the primary lesion, ga- scan was able to detect multiple peripancreatic lymph nodes not detected by other scans and revealed uptake in the cardiophrenic lymph node confirming its involvement by the tumor. fourth patient is a -year-old female with malignant abdominal paraganglioma with solitary lung metastasis. both mibg scan and ga- scan were able to identify the primary lesion. ga- scan was performed after the lung metastasis was removed and thus its ability to detect it could not be confirmed. background: neuroblastoma is the most common extracranial solid tumor of childhood, with overall survival for high-risk patients (hrnbl) near %. the outcomes of hrnbl have improved with high dose chemotherapy followed by autologous stem cell rescue (abmt). data about factors influencing the rate of hematopoietic recovery following abmt in hrnbl is lacking in the literature. our objective was to identify factors influencing the rate of hematopoietic recovery following abmt in hrnbl. design/method: this was a retrospective chart review of patients with hrnbl treated at texas children's hospital from to . neutrophil engraftment was considered the first of three consecutive days with post-transplant neutrophil count greater than cells/ul. red blood cell and platelet engraftment were considered at a hemoglobin greater than g/dl and platelets greater than , /ul three days after the last transfusion. race and conditioning regimen were analyzed using one-way anova; amount of infused cells was analyzed using pearson correlation coefficients; chemotherapy delay and bone marrow (bm) involvement after cycle of induction chemotherapy were analyzed using independent sample t-tests. the study included males and females with a median age at diagnosis of . years. thirtyeight patients were caucasian, african-american, hispanic, asian, and did not have race documented. the mean dose of infused cd + cells was . × ^ cells/kg. forty-five patients received conditioning therapy with carboplatin/etoposide/melphalan (cem), received busulfan/melphalan (bu/mel), and received thiotepa/cyclophosphamide (thiotepa/cpm). the conditioning regimen administered was significant (p = . ) for time to engraftment of neutrophils, with bu/mel at . days, cem at . days, and thiotepa/cpm at days. a delay of chemotherapy during induction (n = ) was significant (p = . ) for time to platelet engraftment of greater than , /ul and trended towards significance (p = . ) for time to neutrophil engraftment. bm involvement at diagnosis and after cycle of induction was not significant for time to engraftment. dose of stem cells infused was the only variable significant for hemoglobin engraftment. background: osteosarcoma (os) is the most prevalent aggressive primary malignancy of the bone affecting children and young adults. approximately % to % of patients have metastatic disease at initial presentation, and % of those patients have isolated pulmonary metastases. although overall survival in patients with os has improved with advances in therapy, there have been no significant improvements in survival outcome in patients with metastatic disease. recent studies suggest that tumor-associated vascular cell adhesion molecule (tvcam- or cd ) plays a critical role in the metastatic progression of various tumors. indirect evidence from these studies suggest that vcam- / integrin signaling promotes tumor survival and metastatic progression by changing the tumor niche and associated immune response. to determine if interfering vcam- / signaling between pulmonary metastatic osteosarcoma (pos) and macrophages (macs) by down-regulating vcam- , depleting macs or blocking vcam- / signaling will reduce pos and improve overall disease-free survival. design/method: we used a pair of spontaneous, high-grade murine os cell lines from balb/c mouse (h- d), k and k m (derived from in vivo k metastasis). we used lentiviral shrnas to knockdown vcam- mrna and protein expression in k m (vcam- kd). we introduced luciferase into k , k m and various k m shrna cell lines to follow lung metastasis by bioluminescence (bli). we depleted macs by intranasal administration of liposomal clodronate formulation. we tested the ability of k and k m supernatants to polarize m macs into m or m phenotype in vitro. we also administered anti- monoclonal antibody (anti- mab) intranasally to assess the outcome of functional blockade of vcam- / signaling. results: k m over-expressed vcam- compared to k . mac depletion in k m -bearing animals exhibited reduced pos. weekly administration of anti- mab resulted in % tumor-free rescue among mice with established k m pos. interestingly, supernatant from k m but not k preferentially induced m -like macs, suggesting a novel integrin-mediated mechanism of m differentiation. validation data with additional os cell lines will be presented. despite aggressive multimodal therapy, overall outcome for patients with pos remains dismal at - %. for this reason, novel and directed therapy approaches are desperately needed. molecular targeted approaches for therapy are challenging, due to the complex genetic heterogeneity of os. immune-modifying therapy is a promising new alternative approach for pos. university of chicago, chicago, illinois, united states background: only half of all patients diagnosed with high-risk neuroblastoma achieve long-term survival. imetaiodobenzylguanidine (mibg) scans are routinely used to evaluate disease at diagnosis and following treatment, and the extent of disease is quantified using the curie scoring system. a previous study by yanik et al., has shown that for high-risk patients with mycn non-ampliified tumors, scores less than versus greater than following cycles chemotherapy are associated of superior survival, whereas scores less than versus greater than were prognostic in patients with mycn-amplified tumors. however, the prognostic significance of specific sites of metastatic disease at diagnosis is not known. to determine if site of metastatic disease determined by i-metaiodobenzylguanidine (mibg) imaging in high-risk patients at the time of diagnosis was associated with outcome design/method: we performed a retrospective chart review of high-risk neuroblastoma patients treated at comer children's hospital and lurie children's hospital in chicago between and with positive mibg scans at the time of diagnosis. we collected imaging data as well as other clinical data including bone marrow status. sites of disease were defined as curie regions with any positive value. kaplan-meier analysis was performed to evaluate the association with disease sites and survival. pearson correlation coefficients were calculated to compare bone marrow disease to sites of positivity on mibg scan. the cohort consisted of high-risk patients. had skull disease, and had pelvic disease. the presence of mibg positive disease in the skull and in the pelvis trended toward worse efs. efs at years for patients with disease in the skull at diagnosis was ± % and for patients without skull disease was ± % (p = . ). efs at years for patients with and without pelvic disease was ± % and ± % (p = . ). consistent with prior data, we found that the presence of bone marrow disease was associated with worse survival with year efs of ± % and ± % with and without marrow disease at diagnosis (p = . ). there is the highest correlation between pelvic disease on mibg scan and bone marrow disease with pearson coefficient . . pelvic disease noted on mibg scan likely reflects underlying bone marrow disease. in patients with high-risk neuroblastoma, skull disease and pelvic disease on mibg scan at diagnosis may predict worse event free survival. background: osteosarcoma is one of the deadliest cancers in the pediatric population with little progress in morbidity and recurrence rates since the 's. oncolytic herpes simplex- virus (ohsv) is an attenuated virus that has shown encouraging results against certain solid tumors. programmed cell death protein (pd)- -mediated t cell suppression via engagement of its ligand, pd-l , is also of particular interest due to recent successes in selected cancers, especially those with high genetic mutational loads. most pediatric cancers do not have a wide variety of mutations; however, osteosarcoma has a chaotic genome, prone to genetic mutations. it has been shown through numerous other studies that pd- inhibition alone is not sufficient to result in statistically significant tumor growth delays in osteosarcoma models and patients. we hypothesize the addition of ohsv therapy as an immunologic stimulus to pd- inhibition is efficacious for osteosarcoma. ( ) to determine whether ohsv therapy enhances response to pd- inhibition in immunocompetent murine models of osteosarcoma and ( ) to quantify and characterize the anti-tumor t-cells infiltration after treatment with ohsv and pd- inhibition individually and in combination. we utilized an immunocompetent transplantable murine model using a cell line derived from a spontaneous metastatic osteosarcoma (k m , balb/c background). we transplanted established tumor wedges subcutaneously and monitored tumor volume by caliper measurement. once tumors reached - mm , we administered intratumoral injections of hsv ( × plaque-forming units) every other day for a total of injections. we then gave intraperitoneal injections of ug anti-pd- or control antibody twice weekly, up to weeks, starting from the last dose of virus treatment. we monitored tumor growth via calipers twice weekly until tumors reached mm or cm diameter. we quantified and characterized innate and adaptive immune cell infiltrates in tumors using flow analysis. we found significantly prolonged survival with our combination therapy group compared to all other groups. we found that anti-pd- by itself had little impact on t cell recruitment while the combination group had higher influx of cd + cells with a reduced amount of t-regulatory cells (cd +foxp +cd +). we also found an increase in cd + effector memory cells. osteosarcoma is a deadly cancer with therapeutics remaining unchanged for the last years. here, we describe prolonged murine survival after treatment with combination of pd- inhibition and ohsv injection. the combination treatment changed the microenvironment to be more inflammatory. our data support further preclinical and clinical studies. background: neuroblastoma is the second most common cause of cancer related death in children. treatment for high-risk neuroblastoma has improved significantly over the past twenty years, however cure rates remain below %. immunotherapy has emerged as an effective therapy for neuroblastoma, however new modalities and targets are needed to improve outcomes. objectives: our lab has developed a chimeric antigen receptor (car) that targets b -h (cd ), an immune checkpoint molecule overexpressed on many cancers, including neuroblastoma. we hypothesized that b -h would be a good target for car based immunotherapy for neuroblastoma. design/method: neuroblastoma tissue microarrays of primary patient samples were screened for b -h expression by immunohistochemistry and cell lines were screened using flow cytometry. b -h car t cells were tested in vitro by measuring tumor cell killing and cytokine production after coculture with tumor cell lines and in vivo in an orthotopic model of neuroblastoma. results: b -h expression was detected by ihc on % of the screened neuroblastoma patient samples. b -h was expressed at high levels ( + or +) in more than half of these samples ( %). almost all cell lines screened were homogeneously positive for b -h by flow cytometry. retrovirally transduced b -h . - bb. car t cells were cocultured with three b -h positive neuroblastoma cell lines (sk-n-be , kcnr, and chla ) and robust tumor cell killing was demonstrated using an incucyte assay. supernatant from the co-cultures was harvested after hours and both interferon gamma and il- production were detected by elisa.in an orthotopic subrenal capsule xenograft model of neuroblastoma, mice treated with b -h car t cells show significant reductions in tumor growth and prolonged survival compared to those treated with untransduced control t cells. however, the treatment is not always curative.b -h car t cells express high levels of exhaustion markers (pd , tim , and lag ) when compared to cd car controls. in order to overcome inhibition from exhaustion, b -h car t cells were co-cultured with neuroblastoma cell lines and pd- blocking antibody. nivolumab significantly increased the production of il- and interferon-gamma by b -h car t cells. further studies are underway to determine if b -h car t cell activity is enhanced in vivo by treating animals with pd- blockade along with car t cells. conclusion: b -h is expressed on a majority of neuroblastoma samples and appears to be a promising candidate for car t cell therapy. b -h car t cells demonstrate activity against neuroblastoma xenografts that may be enhanced by the addition of pd inhibitors. helen devos children's hospital, michigan state university, grand rapids, michigan, united states background: osteosarcoma is the most common bone tumor in children. it is often metastatic at diagnosis and in this scenario less than % of children survive. polyamines, small molecules found in all cells, are involved in many cell processes including cell cycle regulation, immune modulation, cell signaling and apoptosis. they are also involved in tumor development, invasion and metastasis. in neuroblastoma, inhibition of the polyamine biosynthesis pathway with odc inhibitor alpha-difluoromethylornithine (dfmo) results in decreased cell proliferation and differentiation. these finding have led to multiple phase i and phase ii multicenter clinical trials in pediatric neuroblastoma patients. dfmo is an attractive drug as it is oral, well-tolerated, can be given for prolonged periods and is already used in pediatric patients. the polyamine pathway has not been evaluated in osteosarcoma. objectives: evaluate effect of inhibition of polyamine biosynthesis with dfmo on osteosarcoma proliferation and cell differentiation. design/method: up to three osteosarcoma cell lines were used: mg- , u- os and saos- . cells were exposed to mm dfmo for days with replacement of media and dfmo on day . intracellular polyamine levels were measured by high performance liquid chromatography (hplc). cell numbers were obtained with a hemocytometer using trypan blue. flow cytometry cell cycle distribution (facs) and propidium iodide were used to evaluate for cell cycle arrest. the protein expression of several osteosarcoma differentiation markers was measured by sds-page and western blot using differentiation specific antibodies. a bioluminescent cell viability assay was used to measure cell recovery over several days after dfmo was removed and replaced with standard media. results: dfmo exposure resulted in significantly decreased cell proliferation in all cell lines. after treatment, intracellular spermidine levels were nearly eliminated in all cells. cell cycle arrest at g was observed in u- os. cell differentiation was most pronounced in mg- and u- os cells as determined by increased osteopontin levels. remarkably, cell proliferation continued to be suppressed for several days after removal of dfmo. conclusion: based on our findings dfmo is a promising new adjunct to the current osteosarcoma therapy for high risk patients. it is a well-tolerated oral drug that is currently in phase ii clinical trials in pediatric neuroblastoma patients as a maintenance therapy. the same type of regimen may also improve outcomes in metastatic or recurrent osteosarcoma patients for whom there have been essentially no medical advances in the last years. background: recent studies demonstrate that lower levels of the ews-fli fusion oncoprotein are associated with enhanced metastatic capability in ewing sarcoma. the nf-kb transcription factor is a critical mediator of cxcr and cxcr -driven metastasis in multiple cancers, and increased cxcr and cxcr expression have each been associated with increased metastasis and poor prognosis in ewing sarcoma. we thus sought to investigate the impact of ews-fli on cxcr /cxcr -dependent nf-kb signaling in ewing sarcoma. objectives: the goals of this study are ) to determine the impact of cxcr /cxcr signaling on metastasis-associated nf-kb target gene expression in ewing sarcoma and then ) to investigate how the ews-fli fusion oncoprotein modulates this response . design/method: we utilized multiple ewing sarcoma cells lines including a , chla , chla , tc and tc . cxcr /cxcr cell surface expression was determined by flow cytometry. ews-fli level was modulated using sirna and expression levels were confirmed by western blot and rt-pcr. p dna binding was measured via elisa. nf-kb target gene expression was assessed via rt-pcr. results: consistent with ihc analysis of primary and metastatic patient tumor samples, the paired primary and metastatic ewing sarcoma cell lines chla and chla showed dramatic differences in cxcr and cxcr expression, with the metastatic chla line demonstrating much higher expression of both receptors. other cell lines (nonpaired) showed variable cxcr /cxcr expression. genetic knock-out of cxcr lead to significant decrease in expression of both cxcl /sdf- and il- , two nf-kb transcriptional targets known to play a key role in tumor metastasis. knock-out of cxcr did not alter endogenous ews-fli mrna levels. conversely, lowering the level of ews-fli using sirna lead to enhanced nf-kb signaling, indicated by an increase in p dna binding. consistent with this observation, treating ewing cell lines with ews-fli sirna also resulted in significantly increased nf-kb target gene expression compared to control cells and target gene expression was then further enhanced upon cxcr /cxcr receptor stimulation with the receptor ligand cxcl /sdf- . our findings indicate that the ews-fli oncoprotein negatively modulates cxcr /cxcr -dependent nf-kb signaling. this suggests that ews-fli low, cxcr /cxcr high cells, which are associated with enhanced metastasis and poor prognosis, would be anticipated to exhibit enhanced expression of key nf-kb target genes. importantly, the nf-kb pathway is a druggable target that could potentially serve as an "achilles heel" in this subset of high risk tumors. current work is evaluating nf-kb inhibition as an approach to treating metastatic and refractory ewing sarcoma. background: acute graft versus host disease (agvhd) is a major cause of morbidity and mortality following allogeneic bone marrow transplant (bmt) in pediatric patients. gastrointestinal (gi) agvhd is the most serious manifestation. recently, decreased paneth cell (pc) in a predominantly adult cohort was shown to correlate with agvhd clinical grading and response to treatment. we aim to demonstrate the relationship between pc counts and gi agvhd stage and response to therapy. design/method: charts of patients who underwent endoscopy following bmt between - were reviewed. for repeated biopsies during the course of agvhd, only the first was included for analysis. one pathologist retrospectively reviewed the biopsies and counted pcs in high powered fields; the average pc count was analyzed. twenty-six percent of biopsies were reviewed by a second blinded pathologist. statistical associations between pc counts and day (d ) response, agvhd stage, and other study covariates of interest were gauged using general linear regression. agreement in pathologist pc counts was quantified by intraclass correlation (icc). the research was approved by the children's healthcare of atlanta irb. results: seventy-eight biopsies were included in the analysis. mean age at transplant was . years ± . (range: months - years). most patients underwent transplant for hematologic malignancies ( , %). the majority of transplants used a matched unrelated donor graft -including cords ( , %) and myeloablative conditioning regimens ( , %) - % received total body irradiation. of these, % were diagnosed clinically with gi agvhd (stage , %; stage , %; stage , %; stage , %). icc showed good agreement ( . ) between the pathologists. mean pc was . for patients with no gut agvhd, . for stage , . for stage , . for stage and . for stage (p = . ). on multivariate analysis pc was strongly associated with gi agvhd stage (p< . ) after controlling for age, preparative regimen intensity, and diagnosis (malignant vs. non-malignant). mean pc counts were significantly lower in patients with no response to steroid therapy at d (complete response (mean . ) vs. persistent disease ( . ) vs. partial response ( . ) (p = . )). patients diagnosed with gi agvhd with pc counts less than had a higher risk of mortality (hr . , % ci: . , . ; p = . ). lower pc count correlated with stage gi agvhd, refractory disease at d , and mortality. incorporating pc count in pathology review during gi agvhd work-up may help in agvhd risk stratification. background: there have been increasing discussions pressuring health care teams and institutions for potentially bearing the cost of clostridium difficile infections (cdi) as a health care-associated infection in the recent years. the pediatric oncology patient population, though small, accounts for significant portion of all cdi with - -fold increased risk. hematopoietic stem cell transplant (hsct) recipients constitute a unique subset with distinct risk factors, such as severe immune deficiency state and graft versus host disease (gvhd). although there is ample data on cdi in adult hsct recipients, reports on pediatric experience are limited. objectives: to evaluate the incidence and patterns of cdi among pediatric hematology, oncology and hsct inpatients at our institution. a retrospective review of all clostridium difficile (cd) stool tests performed using toxin enzyme immunoassay and later, polymerase chain reaction targeting toxin genes between and in a large, urban academic children's hospital was performed. the data were analyzed for hematology, oncology, hsct inpatient population and all the other cases separately and statistical comparisons were performed. results: a total of samples were submitted to the microbiology laboratory for cd testing during the study period. while hematology patients constituted . %, oncology . %, hsct . % and others . % of the cases on whom cd testing was done; per patient average test number was . , . , . , and . , respectively. of all the cd tests per-formed, . % were positive. test positivity was higher in hsct ( . %) and oncology ( . %) cases tested compared with hematology ( . %) and other cases ( . %) with statistical significance (p< . ). overall recurrence rate was . %; hsct patients had the highest recurrence with a rate of % followed by oncology ( . %), hematology ( . %) and other ( . %) cases, again reaching statistical significance (p< . ). again, hsct patients had the highest average number of recurrences at . ( - ) followed by oncology . ( - ), general . ( - ) and hematology . ( - ) groups. there was no seasonal variability in the incidence of cdi among populations analyzed. prolonged hospital stay/antibiotic use and persistent diarrhea due to gvhd are the likely reasons for higher rate of cd testing in hsct as a result of increased monitoring and thus might have even caused underrepresentation of positive cd test frequency. higher incidence and frequencies of recurrence underscores the inevitable nature of cdi in hsct population as a consequence of the current therapies and may lead to future radical treatment approaches like fecal implantation. background: viral infections remain a challenge to treat post hct in children, and significantly contribute to morbidity and mortality. virus specific t cells (vsts) have shown tremendous clinical efficacy in treating viral infections post-hct, with minimal toxicity and long term efficacy. we have used donor-derived vsts in individual patients, however not all donors are agreeable to the process, and numerous patients may benefit from vsts who do not have an identified donor/have other disease indications objectives: we sought to actively build a third-party vst bank, for "off the shelf" use in eligible patients. design/method: vsts targeting cmv, adenovirus and ebv were manufactured using one of techniques. initially ebv transformed b cells were genetically modified with an ad f pp vector and used as antigen presenting cells (apc) to stimulate and expand ebv, ad and cmvpp specific t cells. more recently, vsts were expanded using s of s apc pulsed with commercially available peptide pools (pep-mixes) to expand ebv/cmv/ad specific t cells. products were entered into the "bank" via two mechanisms: a) left over products from our "donor-derived" protocol when patients no longer required vsts or were not at risk of developing viral infections, or b) by targeting regular blood donors based on their hla typing to ensure an appropriate mix of high frequency hla types for optimal patient matching and antigen presentation based on current knowledge of antigen presentation. results: a total of products are currently in the thirdparty vst bank ready for use. twenty seven of these are from our donor derived protocol, and three from targeted donors. all vst products met safety and in vitro efficacy testing. thirteen vst infusions have been given to patients. eleven infusions have been given for cmv and two for adenovirus. five out of seven patients responded to thirdparty vst infusions, with a median of vst infusions per patient (range - ). the median hla matching was out of per patient (range to ) no patients experienced adverse reactions, gvhd or other toxicity related to the vst infusion. a third-party vst bank is feasible and produces clinically appropriate vsts for use in patients with viral infections. hla typing and matching of vst products is essential to reduce toxicity and promote appropriate antigen presentation and expansion of vsts in vivo. further work is underway to further characterize the vsts using epitope mapping to better define the hla restriction and immunogenicity of each vst product. akron children's hospital, akron, ohio, united states background: acute graft-versus-host disease (agvhd) is a well-known complication of hematopoietic stem cell transplant (hsct) and a major cause of post-transplant related morbidity and mortality. first line therapy of agvhd involves corticosteroids and calcineurin inhibition. in patients with severe refractory gvhd, mortality can reach up to %. currently, there is no standard of care for the treatment of steroid refractory agvhd. many centers have looked at the use of antibody mediated control of agvhd to competitively inhibit the inflammatory cascade. basiliximab, a chimeric monoclonal antibody against the t-cell il- receptor, has been used in adults with steroid refractory agvhd. patients receiving this medication have demonstrated complete and partial responses to therapy with minimal toxicities. objectives: report the successful use of basiliximab in the treatment of agvhd in a -year-old following matched unrelated (mud) hsct. design/method: a -year-old male underwent mud transplant for high risk aml with monosomy . conditioning regimen included busulfan, fludarabine and equine atg. his clinical course was complicated by fever, mucositis and agvhd (stage skin; stage gi-biopsy proven). gvhd prophylaxis included tacrolimus and methotrexate, however with progressive skin rash, diarrhea, and early satiety, gvhd treatment with corticosteroids was initiated. as the patient continued to have worsening symptoms, basiliximab therapy was started. the patient received doses ( mg) iv basiliximab on two consecutive days and then received weekly therapy for a total of doses leading to initial improvement. the patient further developed acute on chronic gvhd on day + , and subsequently received a second course of basiliximab. after initial administration of basiliximab, the patient had near complete resolution of symptoms. however, with a small wean in his tacrolimus dose, the patient experienced another skin gvhd flare prompting the second basiliximab course. the patient was subsequently weaned off all immunosuppression by day + . the only acute complication the patient experienced while receiving basiliximab was right toe paronychia and asymptomatic low ebv titer. the patient is currently off all immunosuppression at the time of report without evidence of cgvhd. conclusion: this single case report, in a young pediatric patient, demonstrates the use of basiliximab may be a safe and efficacious treatment for pediatric patients with agvhd. university of california, san diego, la jolla, california, united states background: clinical outcomes after allogeneic hematopoietic stem cell transplantation (hsct) depend on restoration of t lymphocyte populations. association between recovery of cd +foxp + regulatory t cells (tregs) and protection from chronic graft versus host disease (cgvhd) has been described in adult hsct. in adults, t cell recovery is driven by expansion of donor t cells and treg reconstitution is hypothesized to result from peripheral conversion. restoration of t cells in pediatric patients has a larger contribution from thymopoiesis, however, the relationship between thymopoiesis and treg recovery is undefined. objectives: we hypothesized that effective thymopoiesis is important for restoration of treg populations and protection from cgvhd in pediatric hsct patients. design/method: we performed longitudinal flow cytometry of peripheral blood t cells from pediatric hsct patients and age-matched healthy donors. laboratory data were correlated with clinical outcomes to evaluate impact. recovery of tregs occurred in / ( . %) patients by post-transplant day . day treg frequency in patients that developed cgvhd ( . ± . % of cd + t cells) was reduced compared to cgvhd-free patients ( . ± . %). failure to restore tregs to > . % of cd + cells by day was associated with increased risk of cgvhd in the first year post-hsct (rr = . , p = . ). a majority ( . ± . %) of tregs from patients recovering the peripheral treg compartment expressed helios, a marker of thymic-derived tregs; only . ± . % of tregs expressed helios in patients failing to restore adequate tregs. this prompted examining the relationship between defects in thymopoiesis and inability to restore tregs. we evaluated thymic function by flow cytometry quantification of cd ra+cd +ptk + recent thymic emigrant (rte) cd + cells (confirmed by qpcr for trec content). most ( / , . %) hsct patients had detectable rtes by day post-hsct. thymic production of rtes was persistently absent in patients that developed cgvhd (< / ^ cd + cells in / patients), compared to cgvhd-free patients ( / patients > rte/ ^ cd + cells by day , average . ± . / ^ cd + cells). post-hsct thymic activity as measured by rte enumeration correlated with treg restoration; / ( %) rte+ patients restored tregs, compared to / ( %) of rte-patients. conclusion: failure to restore tregs after allogeneic hsct results in increased risk for cgvhd. in pediatric patients thymic generation of new t cells is an important contributor to restoration of the treg compartment. this data supports further investigation into mechanisms impairing post-hsct thymopoiesis and suggests peripheral blood tregs may be a prognostic biomarker for cgvhd. background: haploidentical stem cell transplantation (haplo sct) is riddled with unique challenges. objectives: we present our experience in the use of haplo sct with post-transplant cyclophosphamide (ptcy) and the adaptations required for each disorder for optimal outcome. design/method: we performed a retrospective study at the pediatric blood and marrow transplant unit, apollo cancer institutes, chennai, india. children up to years of age, diagnosed to have benign disorders and underwent haplo sct with ptcy from to july were included. results: ptcy was used in i.e. % haplo transplants for children with benign disorders. the underlying conditions included fanconi anemia , severe aplastic anemia , mds , jmml , hemoglobinopathy , prca , xld and primary immunedeficiency disorders (pid) . source of stem cells was peripheral blood in %, bone marrow in %. conditioning included fludarabine with treosulphan or cyclophosphamide for pids and aplastic anemia respectively. neutrophil engraftment by day+ - with a durable graft was noted in % transplants with graft versus host disease in %, cmv reactivation in %. mortality rate was % with infants less than months of age developing severe fatal cytokine release syndrome. the median follow up is year with years being the longest. no significant late effects have been noted with chronic skin gvhd in children. survival rate was superior among children with pids with survival of % in this group. haplo sct with ptcy is a feasible and costeffective option for cure in children with life-threatening benign disorders with no compatible family or matched unrelated donor. careful patient selection, reducing cyclophosphamide related free radical toxicity with the use of n acetylcysteine, limiting t cell numbers by capping cd at × /kg, post-transplant viral monitoring protocols are required to reduce morbidity and mortality. we have been working on universal access to care for children from s of s all socioeconomic background and incorporating innovations to reduce the cost of hsct without compromising outcomes. haploidentical hsct using tcr / depletion costs usd as compared to ptcy priced at usd. children with severe aplastic anemia and pids can be transplanted using reduced intensity conditioning and ptcy. in hemoglobinopathies, pretransplant immunosuppression is required to prevent graft rejection. graft versus host disease remains the main cause of mortality in children with fanconi anemia. mortality in infants less than months after ptcy has been high, tcr / depletion would be superior in this cohort. cincinnati children's hospital medical center, cincinnati, ohio, united states background: fanconi anemia (fa) is a congenital bone marrow failure syndrome with hsct the only curative option for associated bone marrow failure. patients with fa undergoing hsct may experience increased toxicity related to either their underlying disease, or the effects of medications, resulting in the inability to tolerate prophylactic medications or sideeffects from anti-microbial therapy. objectives: we postulated that increased cd cell dose would be associated with a rapid immune reconstitution and therefore early withdrawal of anti-infective prophylactic medications. design/method: patients with fa transplanted at cchmc from an unrelated donor had peripheral blood stem cell grafts collected and cd selection performed. where possible, patients had serial measurements of their immune system performed at varying intervals post hsct. we defined immune reconstitution as normalization of lymphocyte subsets-cd , cd , cd and cd cells, as well as a normal response to mitogen stimulation including phytohemagglutinin, concanavalin a and pokeweed. the first measurement of either normal cell number or mitogen response was recorded for each patient. results: a total of patients underwent hsct for fa at cchmc between and . patient demographics included a median age of years at hsct, the vast majority of patients having a fully matched or one anti-gen mismatched donor, and the majority of patients transplanted for bone marrow failure. there was a statistically significantly decreased time post-transplant to immune cell recovery in patients receiving > × /kg cd cells (median . ) compared to those receiving < × /kg cd cells (median . ). the median time to normalization of cd count was days (cd count > /kg) versus days (cd count < /kg), cd count days (cd count > /kg) versus days (cd count < /kg), cd count days (cd count > /kg) versus days (cd count < /kg) and cd count days (cd count > /kg) versus days (cd count < /kg). time to normalization of mitogen response was decreased posttransplant in those patients receiving increased cd cell dose at time of transplant, though this was not significant, reflecting low number of patients with evaluable responses. no patients in either group experienced gvhd or graft failure. patients with fa who are transplanted with higher cd cell doses have quicker immune reconstitution than those who receive lower cell doses. along with benefit to patients including less risk of infection and early termination of immune-prophylaxis medications, this supports the use of high dose cd selected grafts in this vulnerable population. background: parvovirus b (pvb ) infection after transplantation was first reported in . since then, numerous cases of pvb infections after hematopoietic stem cell transplantation (hsct) and solid organ transplantation (sot) have been reported. most report anemia as the predominant clinical manifestation. however, pvb has been associated with pancytopenia, hepatitis, myocarditis, and allograft rejection. we present a patient with acute lymphoblastic leukemia who developed bone pain and pancytopenia following hsct in the setting of pvb infection. to describe an unusual presentation of pvb in a patient with acute lymphoblastic leukemia following hsct. design/method: a search of the english-language medical literature was performed using pubmed and medline databases. a review of the patient's medical history was performed. a year old male with relapsed b-cell all and history of "fifth disease" in infancy presented four months after hsct with focal left arm pain and difficulties fully extending the arm. bone mri showed enhancement of the medullary space centered within incomplete transverse cortical fracture interpreted as pathologic fracture due to neoplastic involvement of the ulna with no history of inciting injury. subsequently, peripheral blood counts decreased from low normal values to wbc . k/microl, anc /microl, plt k/microl, and hemoglobin . g/dl. the patient's chimerism remained % donor. a bone marrow biopsy and aspirate were performed to assess for recurrent leukemia given persistence of bone pain and developing pancytopenia. marrow findings included morphologic cytopathic effects with erythroid precursors and strong parvovirus staining with no signs of red cell aplasia or recurrent b-cell disease by morphology or flow cytometry. pvb was detected in blood by pcr and immunoglobulins with resolution of cytopenia and bone pain. this case highlights an unusual constellation of symptoms following hsct in a child with all. unexplained bone pain and medullary infiltrates with pancytopenia suggestive of recurrent leukemia were likely triggered by pvb infection. the question remains if he had reactivation of pvb , a primary infection by a new strain, or the virus was aquired through stem cells. bone biopsy could not be justified in light of clinical improvement. so far, bone lesions have only been described with congenital pvb infection. pvb appears to be uncommon after hsct, with a review of literature yielding pediatric cases. however, it may be underestimated due to lack of routine screening. our patient's presentation supports that evaluating for pvb may be warranted in hsct patients presenting with symptoms suggestive of relapsed leukemia. background: cardiac injury may occur during hematopoietic stem cell transplant (hsct) in pediatric patients and can be asymptomatic for many years. recommendations for screening are available for patients who received anthracyclines or chest irradiation, but no guidelines exist for unexposed longterm survivors. we sought to define the prevalence of echocardiographic abnormalities in long-term survivors of pediatric hsct and determine the need for screening in asymptomatic patients. design/method: we analyzed echocardiograms performed on long-term survivors (≥ five years) who underwent hsct at cincinnati children's hospital between and . we analyzed echocardiograms for left ventricular ejection fraction (ef), end-diastolic dimension (lvedd), septal thickness, posterior wall thickness, and global longitudinal strain (gls). we normalized linear measurements for age and patient body surface area. we included for further analysis patients who had echocardiogram obtained for routine surveillance. results: a total of patients underwent hsct and were alive more than years after transplant in , with having an echocardiogram obtained ≥ five years postinfusion. those with an echocardiogram were transplanted more recently (median vs. ). however, no difference between screened and unscreened individuals was noted for age at transplant, sex, transplant indication, anthracycline exposure, chest irradiation, or cyclophosphamide based preparative regimen. indications for echocardiograms included: cardiac symptoms ( . %), congenital cardiac anomalies ( . %), hypertension ( . %), known cardiac or pulmonary disease ( . %), routine post-hsct surveillance ( . %), and unknown ( . %). the mean time post-hsct was . years. among routine surveillance echocardiograms, the mean ef z-score was - . . mean lvedd zscore was - . , mean septal thickness z-score - . , mean posterior wall thickness z-score - . , and mean gls - . %. for patients that had echocardiogram performed for routine surveillance, / patients ( . %) had ef measured, and / ( . %) had ef z-scores ≤ - . (abnormally low). patients exposed to anthracyclines had a mean z-score ef of - . vs. unexposed patients - . (p = . ). among individuals who received neither anthracyclines nor tbi only / ( . %) was found to have an abnormal ef, . % (z-score - . ) or gls (- . %). only one patient who had a normal ejection fraction (z-score - . , ef . %) had an abnormal gls, - . % (normal ≤ - . ). long-term survivors of pediatric hsct who are asymptomatic and did not receive radiation or anthracyclines likely do not require surveillance echocardiograms, unless indicated by clinical symptoms. patients exposed to anthracyclines or tbi require close echocardiographic s of s screening and clinical monitoring for the development of cardiac complications. duke children's hospital, durham, north carolina, united states background: children undergoing pediatric blood and marrow transplants (pbmt) experience significant symptom distress. mobile health (mhealth) technologies can be leveraged to collect and monitor patient generated health data, and subsequently enhance our understanding of pbmt symptom clusters, patterns, and trajectories. better understanding of symptom complexity can foster development of precision health strategies to improve patient outcomes. however, limited research exists in integrating mhealth technology into pbmt management. we aimed to explore the feasibility, acceptability, and usability of using a pbmt specific mobile application to collect and monitor symptoms and wearable technology (apple watch) to measure objective data such as heart rate (hr) and activity. design/method: an exploratory mixed method design began in october to monitor pbmt symptoms for patients using real-time data from: ) a self-developed mhealth application (app) to collect subjective symptom data; and ) apple watch to collect physiologic measures such as heart rate and number of daily steps. data is collected pre-transplant through days. acceptability will be assessed through satisfaction surveys at study completion. we have enrolled patients to date who are all currently using the app and watch. patients' average frequency of daily charting in the app %. the wearable average daily recorded measurements are for hr and for step count. most common symptoms recorded within the app include fatigue and pain. we have noted trends in data including a decrease in activity following transplant and gvhd and an increase following engraftment. patients have stated "the app is helpful to keep track of how my pain is doing day to day" and "i try to take more steps each day than the day before". patients often remove the watch for charging, then forget to put it back on, but consistently put it on upon reminder. finally, parents often were required to make app entries with patients too sick to record. we continue to enroll patients with enthusiasm from both patients and parents to use mhealth during pbmt. preliminary findings suggest feasibility of using the mhealth devices is strongly correlated to the patient's post-transplant stage and is facilitated by caregiver participation with device management (charging devices, reminders to wear watch and record in app). patients reported satisfaction and ease of use with devices, but found it difficult to keep up with charging and charting. these findings indicate using mobile devices may be useful methods to collect patient generated health data. cincinnati children's hospital medical center, cincinnati, ohio, united states background: bacterial bloodstream infections (bsi) are a common complication following hematopoietic stem cell transplantation (hsct) in both pediatric and adult populations, and are associated with poor outcomes. there is limited data describing the outcomes and characteristics of patients who develop three or more bsi after hsct. objectives: to describe the characteristics and outcomes of pediatric patients who develop three or more blood stream infections in the first-year post hsct. design/method: we performed a retrospective chart review of consecutive patients who underwent hsct at our institution from through to compile this case series. data were collected through the first year post-hsct including: patient demographics, underlying disease and therapy characteristics; and transplant complications such as thrombotic microangiopathy (tma), graft versus host disease (gvhd) and overall survival. bsis were classified according to current center of disease control guidelines. results: of patients, ( %) developed or more bsi in the first-year post transplant (total bsi cases = including all patients). of the cases, the majority underwent allogeneic hsct (n = / ; %). most cases were from unrelated donor (n = / , %). more than half of patients had grade - gvhd (n = / , %). sixteen ( %) had tma. of these cases, tma preceded the first bsi in n = / ( %). the majority of bsis were classified as central line-associated bloodstream infections (clabsis, n = / , %), followed by mucosal barrier injury laboratory-confirmed bloodstream infections (n = / , %) and secondary bsi (n = / , %). the majority of isolated organisms ( %) were associated with mucosal barrier injury pathogens. one-year overall survival in the cohort was % (n = / ). pediatric patients undergoing hsct who develop or more bsis in the first-year post transplant demonstrated an increased rate of tma compared to the overall institutional incidence of roughly %. tma diagnosis preceded the first bsi in over half of patients, suggesting that tma may predispose to recurrent bsi. improved strategies for early detection and treatment of tma as well as prevention of clabsis may help reduce the number of bsis ultimately leading to decreased morbidity and mortality in this patient population. background: in neutropenic pediatric patients, infection remains a significant cause of morbidity and mortality. while granulocyte transfusions have been utilized for decades to treat infections, including in the pediatric population, the efficacy of this intervention remains poorly described. previous guidelines have primarily utilized information from adult populations. furthermore, recruitment of donors typically involves friends or relatives of the patient with periodic involvement of community donors. the use of a readily available local donor population to improve availability has yet to be well described. as the immunocompromised population is particularly susceptible to worsening infection and clinical deterioration, the ability to rapidly harvest and deliver granulocytes warrants further investigation. to investigate the efficacy, safety, and outcomes of severely immunocompromised patients receiving granulocyte transfusions from a local altruistic granulocyte program in a pediatric tertiary care center. design/method: a retrospective review was performed to evaluate the context for receiving a transfusion as well as primary outcomes including infection clearance, survival to discharge, and overall mortality. the indiana blood bank assisted with timing the interval from initial order placement to onset of first granulocyte infusion. results: among the patient population reviewed, patients received separate granulocyte regimens. ages ranged from - years with a mean neutrophil count of at time of first transfusion. indications for transfusions included bacteremia (n = ), fungal pneumonia (n = ), and fungemia (n = ). primary outcomes included clearing infection ( %) and surviving to discharge ( %). the median time from initial order placement to infusion was hours, although there was no significant difference between responders who cleared the infection and non-responders who did not. however, additional investigation found that ward patients had a % chance of surviving to discharge while patients in the icu at time of initial transfusion had a % chance of survival to discharge. the readily available granulocyte transfusion program allows patients to quickly receive therapy in neutropenic settings. this is beneficial for patients as transfusion prior to clinical decompensation correlates with increased likelihood of infection clearance, and subsequently improved mortality. further investigation is needed, likely as a prospective study, to better explore circumstances that are beneficial for granulocyte transfusions. background: donor lymphocyte infusions (dli) are composed of immune cells to treat relapse after hematopoietic cell transplantation (hct). to date, data regarding its efficacy is limited in pediatric populations. furthermore, while outcomes related to cd content have been characterized, to our knowledge, the relationship between outcomes and other cellular content in dli has never been reported. objectives: determine whether the primary hematological malignancy, presence/absence of graft-versus-host disease s of s (gvhd), and unique phenotypic content of each dli impact overall survival (os) in pediatric patients with hematological malignancies. design/method: irb-approved, retrospective study investigating all consecutive dlis given to patients at the children's hospital of wisconsin. analyses were conducted using mann-whitney, fisher's exact, and chi-square. from from - patients ≤ years old with hematologic malignancies [myeloid (aml/ mds/cml/jmml),n = ; lymphoid (all),n = ] underwent dlis ( %% ≥ dlis). the median time between hct and dli was . (range, . - . ) years. there were significant differences between the lymphoid and myeloid groups, respectively, in regard to median age at hct ( . vs . yrs, p = . ) and at first dli ( vs years, p = . ). ultimately, there were no statistically significant differences in gvhd or os in products with either higher or lower cd , cd , cd , cd , or cd cellular content. however, the median cd /kg content was more than double in the patients who developed gvhd as compared to patients who exhibited no gvhd after dli ( . × vs . × , p = . ). patients receiving one dli had a -year os of ± % vs those receiving + dli of ± % (p = . ). with a median follow-up of . (range, . - . ) years, the year estimated os of patients in the lymphoid group was higher at ± % vs ± % in the myeloid group, although not significant (p = . ). our results indicate a survival benefit when using dli in a subset of patients who relapse after hct. unlike adult studies demonstrating little effect of dli in lymphoid diseases, many children with all achieved durable remission. while our analysis did not demonstrate that dli cellular content had a statistically significant effect on gvhd or os, it is possible that differences could be found if a larger population and more targeted cell doses were studied. more data will be needed to further define these relationships and identify patients who stand to benefit most. cincinnati children's hospital medical center, cincinnati, ohio, united states background: many arabic speaking muslim parents of children requiring bone marrow transplantation (bmt) receive medical care in the united states. providers may not understand the impact of islamic parents' religious beliefs and practices on their health care experience. objectives: to explore how islamic parents used religion in decision making and to understand the impact of their religious beliefs and practices on their overall health care experience. design/method: we used grounded theory, an inductive method gathering data from interviews and analyzing text, to identify core themes. ten caregivers of bmt children from middle eastern countries were interviewed by an arabicspeaking provider; interviews were coded by an interdisciplinary team. we identified key themes: . patience is a core belief in islam. patience results from the acceptance of allah's will. behaviors showing patience include praying rather than questioning and crying. . al qur'an provides comfort, healing, and protection. families listen to recitations of al qur'an in the patient's room because they feel that this practice not only comforts them but promotes healing as well. for some, certain portions of the qur'an were especially meaningful such as surat al-baqara, which explains that while we may think something is bad for us, allah will know it is good for us. . religious care in the medical center helped families feel respected. religious care in the medical center included interactions with chaplains, who were understood to be "religion experts," and provision of space for prayer and religious resources. . seeking religious consultation. religious consultation from imams or religious scholars (muftis or sheikhs) provides interpretations of the qur'an applied to the family's specific situation helps families make difficult decisions and follow allah's plan. . muslim beliefs guided decision making; muslim practices brought comfort, strength, and peace. drawn from the parents' understanding of islam. parents who addressed this topic said they would only do what islam allowed. they did indicate that most aspects of healthcare were understood to be allowed within islam. additionally, muslim practices of prayer, reading/listening to qur'an, and giving alms all provided comfort, strength and peace. we identified several recurring themes through our interviews that allowed us to understand how families use their muslim faith to deal with their children's illnesses and how it influences their decision making. we believe this better understanding will allow for more informed conversations about patients' health care and decision making, and shows respect for religious beliefs and practices. nemours/dupont hospital for children, wilmington, delaware, united states background: virtually all children will be infected with human herpesvirus (hhv- ) by the age of two. hhv- reactivation after stem cell transplantation causes multiorgan toxicities, including encephalitis, with inflammation and destruction of the temporal lobes and hippocampi, memory loss, and seizures. catatonia is characterized by posturing, immobility, mutism, and autonomic instability, and it's associated with various psychiatric and medical conditions. we describe a patient with hhv- encephalitis and unusual neurologic sequelae, including cognitive and neurobehavioral dysfunction and catatonia, which may impact our understanding of the pathophysiology of hhv- reactivation encephalitis. objectives: describe a case of hhv encephalitis with practice implications for stem cell transplantation. results: our patient was diagnosed with acute myeloid leukemia at age . within years, he relapsed and received two stem cell transplants. on the th day after his second transplant, he developed hyponatremia and refractory seizures. brain mri showed edema in the medial right temporal lobe with linear ischemic change. eeg showed diffuse encephalopathy. cerebrospinal fluid (csf) demonstrated white blood cells, red blood cells, and hhv- by pcr. his prophylactic antiviral was switched to foscarnet and ganciclovir. repeat mri showed abnormal signals in bilateral medial temporal lobes and the right insula. three months later he developed episodes of diaphoresis, hypothermia, agitation, mutism, and unusual posturing, recurring almost daily, recognized as catatonia. mri showed improvement of the abnormalities in the bilateral medial temporal lobes and hippocampi. eegs showed diffuse slowing. after months of antiviral therapy, csf was negative for hhv- . over the ensuing years, he had numerous episodes of diaphoresis, hypertension, hypothermia, pruritis, confusion, agitation, cogwheel rigidity, and bizarre posturing. dopamine blocking agents did not help. clonazepam helped reduce their frequency, and hot showers helped break acute episodes. further mris showed generalized cortical volume loss. he suffered from depression and severely impaired sleep and cognitive function. we describe a novel, debilitating outcome of hhv encephalitis which may provide diagnostic considerations as we continue to improve our understanding of the breadth of possible neurologic sequelae in transplant patients. hhv- is understood to infect and destroy the temporal lobes and hippocampi, but our patient's autonomic dysfunction indicate involvement of the hypothalamus and basal ganglia. antidopaminergic agents may worsen catatonia, and they were not effective for our patient. treatment of catatonia includes benzodiazepines; electroconvulsive therapy was not attempted in this case but may also be useful. background: epstein-barr virus (ebv)-related posttransplant lymphoproliferative disorder (ptld) is a lifethreatening complication in patients following hematopoietic stem cell transplantation, with a frequency estimated at . % and a cumulative incidence of mortality estimated as high as %. studies of ebv have hypothesized that the tonsils are critical for propagating this infection, as tonsillar epithelial cells have been shown to be the site of primary viral infection and continued viral shedding; however, to date no studies have been performed assessing the role of tonsillectomy in patients with ebv ptld. objectives: identify patients with localized ebv ptld treated with tonsillectomy to identify prognostic factors that may be able to help guide future treatment decisions. design/method: patients treated at memorial sloan kettering cancer center who had received hematopoietic stem cell transplantation and had billing codes for both ebv and tonsillectomy were eligible for inclusion in this study. a retrospective chart review was performed, assessing patient demographics, transplant characteristics, laboratory values, tonsillar pathology, and clinical course. any patient who did not have unilateral or bilateral tonsillectomy performed or who had non-localized disease (defined as disease involvement outside of the oropharynx and neck) was subsequently immunodeficiency; % (n = / ) fanconi anemia (fa); % (n = / ) hemoglobinopathy; % (n = / ) non-fa marrow failure and % (n = / ) a metabolic disorder. seventy one percent (n = / ) had normal amh for age pre-transplant, % (n = / ) had low amh for age pre-transplant; of these, % (n = / ) had an oncologic diagnosis; % (n = / ) had fa; % (n = / ) had previously treated hlh; % (n = / ) had non-fa marrow failure; one had a metabolic disorder and one a hemoglobinopathy. of the patients with post-transplant amh measurement % (n = / ) had low levels. of the patients with previously normal pre-transplant amh % (n = / ) underwent myeloablative conditioning (mac) regimen with a % (n = / ) having low amh levels post-transplant compared to %(n = / ) who underwent reduced intensity conditioning (ric) regimen with % (n = / ) having low amh levels post-transplant (p . ). fifteen percent (n = / ) had low levels pre-transplant and underwent mac regimen with % (n = / ) remaining low; % of these patients (n = / ) had fa. nine percent (n = / ) had low levels and underwent a ric regimen with % (n = / ) of amh levels remaining low; % (n = / ) of these patients had hlh treated prior to transplant. conclusion: amh levels can be used for detection of premature ovarian failure and fertility counseling. there is a higher risk of premature ovarian failure with mac regimens and prior chemotherapy vs ric regimens. follow up of this cohort will provide more information to understand the effects of hsct in ovarian function and the usefulness of amh as a predictor of fertility potential. background: there are no proven strategies to prevent blood stream infections (bsi) secondary to oral mucosal barrier injury after hematopoietic stem cell transplant (hsct). additionally, we recently reported progressive gingivitis and dental plaque accumulation in hsct recipients despite our current oral standard of care (three times daily oral rinse). xylitol is a non-fermentable sugar alcohol that reduces dental caries, plaque accumulation, and oral disease progression by inhibiting bacterial growth. we hypothesized that the addition of xylitol to standard oral care will decrease dental plaque accumulation, gingivitis and bacteremia from oral flora. objectives: identify a clinically effective strategy to improve oral health and prevent bsi secondary to bacterial translocation through the oral mucosa in patients undergoing hsct. we are conducting a prospective randomized control study to test our hypothesis. those in the intervention arm receive our current standard of care (three times daily oral rinse) in addition to daily xylitol wipes; controls receive oral standard of care alone. oral exams are performed at baseline and weekly for the first days post hsct. metagenomic shotgun sequencing (mss) of gingival samples is performed at all time points to evaluate microbiome diversity and pathogenic bacterial load. finally, we performed whole genome sequencing of pathogenic bacterial isolates causing bacteremia to assess for genetic relatedness to corresponding strains present within the patient's oral microbiome preceding the infection. : preliminary interim analysis of patients demonstrates improved oral health in patients receiving xylitol (n = ) over those receiving standard of care (n = ), measured by the oral hygiene index (p = . ) and gingivitis index (p = . ). in the nine patients having complete oral mss analysis, xylitol appeared to be associated with decreased streptococcus mitis/oralis domination in the oral microbiome. finally, patients receiving xylitol had no incidence of streptococcus mitis/oralis bacteremia through the first days compared to three patients ( %) in standard of care arm. interestingly, streptococcus mitis/oralis comprised % of the oral microbiome in one child who subsequently developed a streptococcus mitis/oralis bsi. we expect to complete this study in the next months (n = ). the addition of xylitol to oral standard care appears to decrease dental plaque and gingivitis in patients undergoing hsct. xylitol may also impede streptococcus mitis/oralis dominance in the oral microbiome with potential reduction in blood stream infections. (range: - days). twenty-one mdli ( %) were administered because of lymphopenia, fourteen of them ( %) in patients with concomitant viral/opportunistic infections. mixed chimerism/graft failure was the motive of % of the mdli (n = ) and six ( %) were administered to accelerate immune reconstitution. all infusions were well tolerated without appearance or worsening of gvhd. an increase in t-cell counts was observed following six mdli ( . %), although it was a transitory response ( - weeks) in five cases. viral/opportunistic infections were controlled in five cases ( . %), requiring a median of mdli to achieve this response. none of the mdli administered in cases of mixed chimerism/graft failure were effective in reverting this situation. our preliminary data suggests that mdli, is a safe adoptive immunotherapy strategy even with high dose of t-cells without infusion side effects or gvhd complications. some efficacy has been observed in patients with lymphopenia and opportunistic infections, with no positive results in patients with mixed chimerism/graft failure, up to date. however, to determine the real efficacy of this strategy, prospective studies are required. jun zhao, kristen beebe, lucia mirea, alexandra walsh, shane lipskind, alexander, ngwube phoenix children's hospital, phoenix, arizona, united states background: male adolescents undergoing myeloablative hematopoietic stem cell transplantation (hsct) develop infertility with impaired spermatogenesis with reported rates ranging from % to %. in nonmalignant diseases, myeloablative regimens have been replaced with reduced intensity conditioning (ric) with the hopes of better survival rate, less organ toxicity and improved quality of life. despite the increased use of ric regimens for hsct, the effects of ric on fertility remain unknown. objectives: to assess fertility following ric hsct in young adult males. we assessed gonadal function and semen characteristics in adolescent males (> years) who received a single ric hsct at phoenix children's hospital for nonmalignant diseases during - . male patients who were a minimum of year from ric hsct and had postpubertal development at tanner stage iii or above were eligible for this study. gonadal status was assessed by measuring fsh, lh, testosterone, and inhibin b levels, and semen anal-yses assessed fertility indicators (semen volume, sperm concentration, motility, viability, forward progression, morphology, and total count). results: hormone levels and semen analysis have been obtained for patients thus far. the median time between transplant and semen analysis was years. post hsct, ( %) patients showed abnormally elevated lh levels, but fsh, testosterone (total and free), and inhibin b levels were within normal range for all patients. sperm morphology and viability testing were not able to be performed due to low concentrations and volumes. as a result, the total motile sperm count, the most useful estimate for fertile potential, is essentially for all patients. conclusion: recruitment is ongoing, but so far our limited results suggest that ric hsct may have detrimental longterm effects on male fertility. a multi-institutional trial may be appropriate due to small patient numbers at each institution. we are currently exploring options to expand to other centers. further consideration is warranted regarding decisions made by providers, ways to improve anticipatory counseling provided to patients and their families prior to transplant, and how to augment the preventive care of these patients in longterm follow-up. currently all male patients being considered for ric transplant should be counseled to sperm bank prior to transplant. background: a previous systematic literature review identified all published studies of defibrotide treatment for patients of all ages with vod/sos. to assess day+ survival for defibrotidetreated pediatric patients (≤ or ≤ years, per study) all patients exhibited infectious complications with at least viral infection. four patients also had bacterial infections. of note, no patient developed evidence of fungal infections. conclusion: early institution of ecp in patients with high risk acute gvhd (grade - ) was very effective at treating agvhd, allowed for an aggressive steroid taper and contributed to excellent overall survival rates ( %). infectious complications were primarily viral and bacterial, with no fungal infections in this very high risk population. background: vod/sos is a life-threatening complication of hsct conditioning. vod/sos with multi-organ dysfunction (mod) may be associated with > % mortality. defibrotide is approved to treat hepatic vod/sos with renal/pulmonary dysfunction post-hsct in the us and severe hepatic vod/sos post-hsct patients aged > month in the eu. there are few published data on survival of neuroblastoma patients with vod/sos post-hsct. objectives: to report day+ survival and safety post hoc for patients with neuroblastoma and vod/sos post-hsct in the defibrotide t-ind trial. design/method: vod/sos was diagnosed by baltimore or modified seattle criteria or biopsy, with/without mod, after hsct or chemotherapy. defibrotide treatment ( mg/kg/day) was recommended for ≥ days. this post hoc analysis is based on adult and pediatric patients receiving ≥ dose of defibrotide, including with mod. results: among patients with neuroblastoma, developed vod/sos after hsct. for these post-hsct patients, . % were male and . % were female, median age was years (range - years): . % aged - months, . % - years, . % - years, and patient > years. day+ survival data were available for / of these neuroblastoma patients ( with mod and without mod); had autologous and had allogeneic transplants. kaplan-meier estimated day+ survival for the neuroblastoma group was . % ( % confidence interval [ci] , . %- . %). for the mod and no mod subgroups, kaplan-meier estimated day+ survival was . % ( % ci, . %- . %) and . % ( % ci, . %- . %), respectively. in the overall t-ind hsct population aged ≤ years (n = ) and pediatric autologous hsct subgroup (n = ), kaplan-meier estimated day+ survival was . % and . %, respectively. treatment emergent adverse events (teaes) occurred in . % (n = / ), with serious teaes in . % ( / ; most common: multi-organ failure, . % [ / ]). teaes lead to treatment discontinuation in . % (n = ; most common: pulmonary hemorrhage, n = ); death occurred in . % (n = ; > %: multi-organ failure, . %; vod/sos, . %). treatment-related adverse events, as assessed by investigators, occurred in . % (n = ; most common: pulmonary hemorrhage, . %). this post hoc analysis found kaplan-meier estimated day+ survival of . % in patients with neuroblastoma and vod/sos post-hsct, which was consistent with outcomes in pediatric patients after autologous hsct. the safety profile of defibrotide in neuroblastoma patients was consistent with the overall hsct population in this study and other defibrotide studies in pediatric patients. cincinnati children's hospital medical center, cincinnati, ohio, united states background: blood stream infections occur in nearly % of patients undergoing hematopoietic stem cell transplant (hsct) and fever is often the first symptom. timely administration of antibiotics is associated with improved outcomes, thus, early recognition of fever is paramount. current standard of care (soc) includes episodic monitoring of temperature in hospitalized patients, which may delay fever detection. therefore, continuous real-time body temperature measurement may detect fever prior to the current soc. temptraq is a food and drug administration cleared class ii medical device and consists of a soft, comfortable, disposable patch that results: of patients, were started on a pca in the days post hct. % were male with median age of y. % had all, and % aml. matched related donors were used in % and % received tbi. pca was initiated median d+ . oral mucositis alone was the most common indication ( %). a majority of patients were started on hydromorphone ( %); % started on morphine and % started on fentanyl. % started on continuous infusion. pca was used for a median of days (range - days). median pain score was highest d+ of pca use, however, there was inconsistency in charting of numerical pain scores. on d+ , patients had insufficient data to determine efficacy of pain control; of the remaining patients, % had good pain control while % had moderate and % had poor pain control using our devised scale. the most common toxicity observed was respiratory depression (∼ %), however, etiology was often multifactorial and not due to opiates alone. analysis is ongoing to assess variables predicting pca use as well as efficacy of pain control and correlation between current reporting scales and patient perception. conclusion: pca use is common in pediatric hct yet pain control remains inadequate. there's a need for better evaluation of pca management, especially uniform assessment of pain, thereby improving quality of life post hct. children's national health system, washington, district of columbia, united states background: actinomycosis is a rare invasive anaerobic gram-positive bacterial disease caused by actinomyces spp. that may colonize the oropathynx, gastrointestinal tract and urogenitial tract and can lead to abscesses. respiratory tract actinomycosis is characterized by pulmonary cavities, nodules, consolidations and pleural effusions. although actinomyces are nearly always sensitive to penicillin they are frequently resistant to cephalosporins and variable sensitives to fluoroquinolones. although rare in children, immunosuppressed patients are at increased risk for actinomycosis. to describe a case of next-generation sequencing identification of actinomycosis. a -year-old male with a history of very high risk b-cell acute lymphoblastic leukemia who was months status post a / matched unrelated donor bone marrow transplant complicated by prolonged fevers, persistent weight loss, and splenic lesions, treated with posaconazole and levofloxacin developed fever and cough in the setting of neutropenia. blood cultures demonstrated staphylococcus epidermidis. ct showed micronodules and effusion not consistent with s. epi, prompting bronchoscopy. all bacterial cultures were negative. patient was prescribed a three-week course of vancomycin with rapid improvement. design/method: s next generation sequencing (ngs) from bronchoalveolar levage sample was performed at the university of washington laboratory results: ngs assay from bronchoalveolar lavage showed major abundance of actinomyces most closely related to meyeri or oodontolyticus. demonstrated actinomyces. the patient was started on a six month course of amoxicillin with continued clinical improvement. in retrospect, the splenic nodules that were presumed fungal disease were likely actinomycosis, partially treated with levofloxacin. this case highlights the potential utility of ngs in the diagnosis of rare diseases in immunocompromised patients. actinomycosis was only demonstrated through ngs and led to a change in treatment regimen and durable clinical improvement. because actinomyces often mimics malignancy, tuberculosis or nocardiosis, the use of this novel test both targeted appropriate therapy and reduced the exposure to unnecessary medications to treat the differential diagnosis. finally, we highlight that actinomyces should be considered in patients who present with unexplained fevers, weight loss, and night sweats. haneen shalabi, cynthia delbrook, maryalice stetler-stevenson, constance yuan, bonnie yates, terry j. fry, nirali n. shah center for cancer research, national cancer institute, national institute of health, bethesda, maryland, united states background: car-t therapy, while effective, may not be durable for all, and antigen negative escape is a growing problem. hct, in relapsed/refractory all, can be curative, particularly for those in an mrd negative remission. we demonstrated that cd directed car-t therapy effectively rendered patients into mrd negative remissions (by flow cytometry) and the leukemia free survival post-hct was high . in pastorek, jesssica bruce, michael a. pulsipher, chloe anthias, peter bader, andre willasch, jennifer sees, jennifer hoag, wendy pelletier, brent logan, pintip chitphakdithai, lori wiener university of pittsburgh, pittsburgh, pennsylvania, united states background: more than , pediatric hscts are performed in north american and europe each year. the ethics of exposing a healthy child to donation procedures which have some risks and no direct medical benefits continue to be a topic of debate. pediatric donors may experience psychological distress and poorer quality-of-life during and after donation compared to healthy controls. although there are fact/jacie requirements related to the management of pediatric donors, it is unclear what standardized practices exist for psychosocial assessment/management of this group. objectives: to describe transplant center practices for psychosocial evaluation/ management of pediatric donors (< years) and to examine differences in practices by location (cibmtr/ebmt) and number of harvests (volume). design/method: data were collected via a single crosssectional survey distributed electronically to cibmtr and ebmt centers between / / and / / . : / ( %) of cibmtr and / ( %) of ebmt centers completed the survey. most centers had written eligibility guidelines for pediatric donors ( %). most also had a process for ensuring that donors were freely assenting to donate ( %), managed by a transplant physician ( %). a single physician often jointly managed donor/recipient care ( %). half of centers had a pediatric donor advocate ( %), who was most often a physician ( %) or social worker ( %). cost was the largest barrier to having a donor advocate ( %). most centers performed psychosocial screening of donors ( %) but rarely declined donors based on psychosocial concerns ( %). less than half of centers provided post-donation psychosocial follow-up ( %). comparisons by center location indicated that ebmt centers were more likely to have a physician doing joint donor/recipient care ( % vs. %; p = . ), less likely to have a psychosocial assessment policy ( % vs. %; p = . ), less likely to have a donor advocate ( % vs. %; p = . ), but marginally more likely to do post-donation psychosocial follow-up ( % vs. %; p = . ). large volume centers were more likely to have a psychosocial assessment policy than their medium/smaller counterparts ( % vs. %, %; p = . ) â€"there were no other differences on key psychosocial management variables by volume. although most centers have written guidelines for pediatric donor eligibility and mechanisms for ensuring assent, substantial numbers of donors do not undergo psychosocial assessment, are jointly managed with the recipient by a single physician without an assigned donor advocate, and do not receive psychosocial follow-up. the field would benefit from guideline development for the psychosocial management of pediatric donors. background: germline mutations in samd and samd l genes cause mirage (myelodysplasia, infection, restriction of growth, adrenal hypoplasia, genital phenotypes and enteropathy) and ataxia-pancytopenia syndromes, respectively, and are associated with chromosome deletions, mds and bone marrow failure (bmf). there are limited data on outcomes of hct in these patients. to describe outcomes of allogeneic hct in patients with hematologic disorders associated with samd /samd l mutations. results: seven patients underwent allogeneic hct for primary mds (n = ), congenital amegakaryocytic thrombocytopenia (camt)(n = ), and dyskeratosis congenita (n = ). retrospective exome sequencing revealed gain-of-function mutations in samd (n = ) or samd l (n = ) genes. constitutional mosaic monosomy was present in cases. two samd patients had features of mirage syndrome. unusual findings of panhypopituitarism, laryngeal cleft, and glomerulosclerosis were noted in one case. in another case with a samd mutation hypospadias & bifid scrotum were the only findings. the remaining patients had no phenotypic abnormalities. median age at hct was y (range: . - . ). patients received transplants from bone marrow (matched unrelated (n = ) & hla identical sibling (n = )), or unrelated cord blood (ucb) (n = ). five mds patients received myeloablative s of s conditioning (busulfan-based (n = ) or tbi-based (n = )); patients (mds (n = ); camt (n = )) received reducedintensity conditioning (ric) (fludarabine, cyclophosphamide, with ratg or alemtuzumab). syndrome-related comorbidities (diarrhea, infections, malnutrition, electrolyte imbalance, lung disease and hypoxia) were present in both patients with mirage syndrome. one patient with a familial samd l mutation, mds and morbid obesity failed to engraft following ric double ucbt. she died one year later from refractory aml. all other patients achieved neutrophil and platelet engraftment, at a median (range) of ( - ) and ( - ) days, respectively. posttransplant complications included severe hypertension (n = ), pericardial effusions (n = ), veno-occlusive disease of liver (n = ), and recurrent aspiration pneumonias (n = ). one patient developed grade iii agvhd which resolved with treatment. one patient developed mild skin cgvhd and suffers from chronic lung disease. all surviving patients had resolution of hematological disorder and sustained peripheral blood donor chimerism ( - %). overall survival was % with a median follow-up of years (range: . - . y). patients with hematological disorders associated with germline samd /samd l mutations tolerated transplant conditioning without unusual, or unexpectedly severe toxicities. allogeneic hct led to successful resolution of mds or bmf, with excellent overall survival. more data is needed to refine transplant approaches in samd /samd l patients with significant comorbidities, and develop guidelines for their long-term follow-up. shyamli singla, tiffany simms-waldrip, andrew y. koh, victor m. aquino background: steroid-refractory acute graft versus host disease (agvhd) is a potentially fatal complication of allogeneic hematopoietic stem cell transplantation (hsct). basiliximab (anti-il -r monoclonal antibody) as a single agent or in combination infliximab (anti-tnf-monoclonal antibody) has demonstrated efficacy in adult cohorts with steroid-refractory agvhd, but has not been well studied in the pediatric population. we adopted the use of basiliximab and infliximab as our institutional standard of care for steroid-refractory agvhd in pediatric hsct patients. to determine the response and survival of hsct children who received basiliximab and infliximab for the treatment of steroid-refractory agvhd. design/method: we retrospectively reviewed children who received basiliximab and infliximab for steroid-refractory agvhd refractory between september and december . complete response (cr) was defined as resolution of all clinical signs of agvhd. partial response (pr) was defined as at least one grade reduction in one target organ (e.g. skin, gut or liver) without increased grade in another target organ. no response was defined as either no improvement or progressive worsening of agvhd in at least one organ. baseline demographics, transplant details, laboratory findings, and treatment outcomes were also evaluated. results: of the evaluable hsct patients, children (median age yrs, range mo- yrs) with steroid-refractory agvhd received combination monoclonal antibody (mab) therapy. the median time from the start of steroid therapy to initiation of mab was days. the overall glucksberg grade of agvhd at the time of initiating mab therapy was grade i (n = , . %) ii (n = ; %), iii (n = ; %) or iv (n = ; %). the overall response rate was %, with ( %) patients achieving cr, ( . %) patients achieving pr, and ( . %) patients with no response at days following the start of mab therapy. the median overall survival was , , and days for patients who exhibited cr, pr, and no response, respectively. the overall survival at year following start of mab therapy was %. background: the role of high dose chemotherapy (hdc) and autologous stem cell rescue (ascr) in patients with high risk (advanced metastatic or relapsed) soft tissue sarcomas is controversial. despite multimodal chemotherapy, radiotherapy, and local control measure advancements, prognosis of patients with advanced metastatic or unresectable and relapsed sarcomas remains poor, with less than % years disease free survival. objectives: to determine if consolidation with myeloablative hdc and ascr improves relapse free (rfs) and overall survival (os) outcomes in a high risk patient subgroup. we performed retrospective review of all high risk soft tissue sarcoma patients who underwent hdc and ascr at the children's hospital at montefiore, bronx, ny between october and january . the protocol was approved by albert einstein college of medicine institutional review board. results: patients ( primary metastatic high risk disease, relapsed or recurrent disease) received hdc with ascr. primary diagnoses were rhabdomyosarcoma (rms) (n = , alveolar histology), primary site nasopharynx (n = ) and lower extremity (n = ). ewing's sarcoma (ews) (n = ), axial site (pelvic) in patients ( %). median age years (range - years), ( %) were male. all patients were in complete metabolic remission before transplant. median pre transplant comorbidity index was (range - ). patients ( rms and ews) received conditioning with carboplatin, etoposide and melphalan. remaining patients with ews received conditioning with busulfan, melphalan and topotecan. all patients received peripheral blood mobilized hematopoietic stem cell transplantation. stem cell mobilization achieved with high dose filgrastim in all patients except one who required addition of plerixafor. median cd +/kg s of s recipient body weight cell dose infused was . × ^ (range . - . × ^ ). median times to neutrophil and platelet (> , / l) engraftment were (range - ) and ( - ) days respectively. patients ( %) developed bk viuria (one with grade iii hemorrhagic cystitis); ( %) developed cmv viremia; and one patient ( %) had asymptomatic ebv viremia. there was no graft failure, sinusoidal obstruction syndrome or transplant related mortality. median follow up post-transplant was days (range - days). year probability of os and rfs were % and % respectively. hdc with ascr is a promising therapeutic strategy to consolidate remission and improve survival in select high risk soft tissue sarcoma patient subgroups. prospective clinical trials will inform the impact of disease status prior to hdc and ascr on outcome, optimal conditioning and long term relapse free and overall survival. background: absence of minimal residual disease is paramount for cure of pediatric acute lymphoblastic leukemia (all). the testis may harbor occult leukemia and this disease may result in treatment failure. objectives: the purpose of this study was to assess the longterm outcomes of boys with or without testicular leukemia pre-hematopoietic stem cell transplantation (hsct). design/method: retrospective analysis of boys with high-risk de novo ( with hypodiploidy all) or recurrent/refractory all was conducted. flow cytometry of bone marrow mononuclear cells was used to determine remission status. testicular evaluations were performed by physical examination and wedge biopsy pre-hsct. the median age at time of transplant was . years. all patients were in remission by flow cytometry of bone marrow mononuclear cells at the time of transplant and none had evidence of clinically apparent testicular disease. testicular leukemia was detected in patient and he underwent bilateral orchiectomy. he developed acute graft versus host disease (gvhd) of the duodenum and sigmoid colon which resolved, and the leukemia remains in second complete remission and he is free of hsct-related morbidity . months post-hsct. of the patients without testicular leukemia died a median of . months (range, . to . ) post-hsct ( with adenovirus infection and each with thrombotic microangiopathy and aspergillus pneumonia); experienced infection (staphylococcus species, corynebacterium, enterococcus, klebsiella, citrobacter, e. coli, epstein barr virus, adenovirus, bk virus, human herpesvirus- , candida albicans, fusarium, aspergillus, yeast, and other fungus); experienced gvhd ( of the gi tract, of the skin, of the liver, of the eyes, of the mouth, and of the lungs); and developed a second neoplasia (right lower leg leiomyosarcoma). one patient developed bone marrow minimal residual disease ( . % phenotypically abnormal cells detected months after / matched sibling hsct). reinduction therapy comprised weekly doses of rituxan, courses of blinatumomab and donor lymphocyte infusions with il- . two subsequent bone marrow evaluations were minimal residual disease negative. thirteen months post-hsct residual disease recurred ( . %) and he will receive inotumumab. overall median survival post-transplant of the boys is . months (range, . to . ) and of the surviving boys is . months (range, to . ). conclusion: testicular biopsy can detect occult leukemia pre-hsct. testicular leukemia pre-hsct does not appear to increase the risk of subsequent relapse or other hsct-related adverse events compared to those without it. yaya chu, nang kham su, sarah alter, emily k. jeng, peter r. rhode, mathew barth, dean a. lee, hing c. wong, mitchell s. cairo new york medical college, valhalla, new york, united states background: rituximab has been widely used in frontline treatment of b-nhl including burkitt lymphoma (bl), however, some patients retreated with rituximab relapse, which limit patient treatment options. novel therapies are desperately needed for relapsed/refractory b-nhl patients. several strategies for overcoming rituximab-resistance are currently being evaluated, including engineering immune cells with chimeric antigen receptors (car), as well as second-generation anti-cd antibodies. nature killer (nk) cells play important roles in the rejection of tumors. however, nk therapy is limited by small numbers of active nk cells in unmodified peripheral blood, lack of tumor targeting specificity, and multiple mechanisms of tumor escape of nk cell immunosurveillance. our group has successfully expanded functional and active peripheral blood nk cells (expbnk). b t m was generated by fusing alt- , an il- superagonist, to four single-chains of rituximab. b t m displayed tri-specific binding activity through its recognition of the cd molecule on tumor cells, activated nk cells to enhance adcc, and induced apoptosis of b-lymphoma cells. objectives: to examine if b t m significantly enhances the cytotoxicity of expbnk against rituximab-sensitive and -resistant bl cells. design/method: expbnks were expanded with lethally irradiated k -mbil - bbl and isolated using miltenyi nk cell isolation kit. alt- and b t m were generously provided by altor bioscience. nk receptors expression and cytotoxicity were examined as we previous described. ifng and granzyme b levels were examined by elisa assays. equal doses of rituximab, alt- , rituximab+alt- , obinutuzumab (obinu) were used for comparison. igg was used as controls. anti-cd car expbnk cells were generated as we previously described by mrna electroporation. rituximab-sensitive raji andresistant bl cells raji- r and raji- rh, were used as target cells. results: b t m significantly enhanced expbnk cytotoxicity against rituximab-sensitive raji cells, rituximab-resistant raji- r cells and resistant raji- rh cells compared to the controls igg, rituximab, alt- , rituximab+alt- , obinu (p< . , e:t = : ). furthermore, we confirmed the enhanced cytotoxicity by measuring ifn-g and granzyme b production. b t m significantly enhanced ifn-g and granzyme b production from expbnk against raji, raji- r and raji- rh compared to igg (p< . ), rituximab (p< . ), alt- (p< . ), rituximab+alt- (p< . ), and obinutuzumab (p< . ). when compared to anti-cd car expbnk cells, b t m + expbnk had the similar cytotoxicity against raji, raji- r and raji- rh as anti-cd car expbnk cells did (p> . ). conclusion: b t m significantly enhanced expbnk activating receptor expression and in vitro cytotoxicity against rituximab-sensitive and -resistant bl cells. the in vivo functions of b t m with expbnk against rituximab-sensitive and -resistant bl cells using humanized nsg models are under investigation. background: cardiac dysfunction, including left ventricular systolic dysfunction (lvsd), is a known complication in stem cell transplant (sct) survivors. while detection of lvsd by echocardiography is important in this population, there has been minimal research to determine if subclinical cardiac dysfunction exists in sct patients. cardiopulmonary exercise testing (cpet) is a valuable tool to assess cardiac function, and to determine how the heart responds to the stress of exercise. no studies have been performed to determine if sct patients with normal lvsd on standard echocardiography may have abnormal cpet. to determine the feasibility of cpet, as well as additional echocardiographic parameters, to detect dysfunction in sct patients with a normal ejection fraction on echocardiogram. design/method: we performed a cross-sectional analysis of sct survivors who were at least years post sct, years of age or older and with an ejection fraction > % (low end of normal range) on echocardiogram. we assessed the exercise capacity of all patients with cpet, and sub-clinical cardiac dysfunction through tissue doppler and strain analysis from the echocardiogram. results: seven patients ( male) have qualified and completed this study so far with an average age of . ± . years. the median time from transplant is . ± . years. all seven patients had a normal ejection fraction, however four patients had abnormalities on their cpet. these abnormalities included abnormal predicted peak oxygen consumption (vo ) ( %± . , normal > %) (the best predictor of functional capacity), predicted oxygen pulse ( %± . , normal > %) (measure of cardiac stroke volume) and ventilatory efficiency (ve/vco slope) ( ± . , normal < ). submaximal exercise data, used when patients are unable to complete a maximal effort test, demonstrated low-normal predicted vo at anaerobic threshold ( . %± . %, normal > % of was . days while patients who received autologous infusions had a mean number of days to engraftment of . . engraftment after hsct needs to be prompt to minimize duration of neutropenia and maximize survival rates . our data demonstrates that the infusion of hematopoietic stem cell products with a syringe or iv pump is an effective method of delivery for stem cell products and does not delay the time to engraftment. the median days to neutrophil engraftment was . days. this is comparable to data from the nmdp, which reports engraftment occurs within - days. the main limitation to this study was its small sample size due to the number of transplants done at our center. however, it does provide evidence to support that infusion of stem cell products via pump mechanism is a safe alternative to the infusion by gravity method in the process of the hematopoietic stem cell administration. johns hopkins all children 's hospital, st. petersburg, florida, united states background: leukemic relapse remains the most common cause of treatment failure after allogeneic hematopoietic cell transplant (allohct) for myeloid malignancies. most children who relapse post-allohct will die of their disease, making interventions to minimize this risk a high priority. objectives: to evaluate the safety and efficacy of posttransplant azacitidine for relapse prevention in children undergoing allohct for myeloid malignancy. design/method: we retrospectively reviewed the charts of children undergoing allohct for myeloid malignancies between february and november at johns hopkins all children's hospital. results: during the study period, children (ages to years, median ) underwent allohct for myeloid malignancies: de novo acute myeloid leukemia (aml), ; mixed phenotype acute leukemia, ; treatment-related aml, ; juvenile myelomonocytic leukemia with aml transformation, ; and myelodysplasia/aml, . thirteen were in first complete remission, were in cr or greater. most patients ( / ) received fludarabine/melphalan/thiotepa conditioning; received hla-identical related or unrelated donors, and received haploidentical bone marrow grafts with post-transplant cyclophosphamide. three patients never received planned azacitidine ( early relapse; early trm), leaving evaluable patients. azacitidine ( mg/m /dose for days, in -day cycles for up to cycles) was started at a median of days post-transplant (range - ). two-thirds ( / ) of patients received eight or more cycles. of five patients who stopped therapy early, only one was due to toxicity; other reasons included severe gvhd ( ), parental preference ( ), and relapse ( ). cycle delays occurred in patients, with a median cycles delayed per patient, mostly for mild myelosuppression with early cycles. no patient required blood product transfusion during therapy, but g-csf was used in three patients to maintain anc> / l. dose-modifications were made in patients (renal tubular acidosis, acute kidney injury, and myelosuppression). there were relapses ( %), two of which occurred in patients in cr , for a relapse incidence of % in patients in cr , with a median follow-up of months (range . to ). no patients who received azacitidine died of transplant-related mortality. conclusion: administration of azacitidine in children undergoing allohct for myeloid malignancies is safe and feasible, with most patients successfully receiving all planned cycles. toxicity was acceptable and there was no trm or secondary graft failure. despite the limitations of a small cohort, relapse incidence-particularly in patients transplanted in cr suggests a potential benefit in disease control that warrants investigation in follow-up studies. background: despite significant improvements in the success rate of hematopoietic cell transplantation (hct), graft failure remains an important complication in patients transplanted for severe aplastic anemia (saa). second allogeneic hct can salvage patients, but -year overall survival (os) rates have been reported as low as % . objectives: identify patients who developed dropping donor chimerism, graft rejection, and/or graft failure after first hct for saa, necessitating additional hcts or cellular boosts (defined as stem cell products infused without preceding chemotherapy), and evaluate treatment-related complications and os. with vod/sos with and without multi-organ dysfunction (mod) pubmed and embase databases were searched for "defibrotide and retrospective chart reviews; excluded publication types were: case reports (< cases); meta-analyses; reviews; animal, modeling, pharmacokinetic, chromatography, and adult-only studies; guidelines; articles; and letters. resulting reports were screened for exclusion criteria. full-text articles were then reviewed for eligibility. study characteristics of selected publications were summarized, and publications were categorized by patients' mod status. when necessary, additional data tables were requested. a random effects model was used for pooling data for efficacy. interstudy heterogeneity was assessed with cochran's q-test. percentage of total variation across studies due to heterogeneity (i ) was evaluated we quantified ∼ proteins in each sample. reproducibility for one donor at different time points children 's minnesota, minneapolis, minnesota, united states background: pediatric and young adult hodgkin lymphoma (hl) has five-year survival rates > %. chemotherapy required to achieve this rate is associated with a lifetime risk of cardiac deaths, second malignancies, pulmonary disease and infertility. as effective salvage therapy exists, outcomes may be improved by de-intensifying initial therapy to lessen toxicity.objectives: we piloted a regimen in low and intermediate risk hl patients using agents without known association to significant late effects. this retrospective chart review was approved by children's minnesota irb.design/method: the bvg(p) regimen incorporated bortezomib ( . mg/m day , , , ); vinorelbine ( mg/m day , ); gemcitabine ( mg/m day , ) every days and prednisone ( mg/m /dose bid x days). we treated newly diagnosed patients, ages - years, with non-bulk stage iia (n = ) or iib (n = ) hl. two patients received bvg and received bvgp with the addition of prednisone.results: newly diagnosed patients were all pet negative after the first or second cycle and remained pet negative at end of therapy, cycles. nausea was well controlled with -ht antagonists and scopolamine. pegfilgrastim was not necessary due to the high absolute neutrophil count nadir [median . and minimum . × /l]. there were no episodes of febrile neutropenia, infection or transfusion need. no patients experienced alopecia. one patient developed sensory neuropathy after the eighth dose of bortezomib that was controlled with gabapentin and a switch to subcutaneous bortezomib administration. of the five newly diagnosed patients, four remain in remission at , , , days; relapsed at previous disease sites at days and subsequently achieved remission with bvgp with the addition of brentuximab. this series provides early evidence to stimulate expansion of this pilot experience and subsequent multiinstitutional study leading to a randomized trial of bvgp and current chemotherapy for low and intermediate hl. st jude affiliate clinic at st francis hospital, tulsa, oklahoma, united states background: symptoms suggestive of morning hypoglycemia has been noticed in children receiving all chemotherapy. only few small studies looked at this therapy related complication. factors increase risk of hypoglycemia in all patients include accelerated starvation, steroid induced adrenal suppression, mercaptopurine therapy and prolonged fasting for procedures.objectives: to study the prevalence and risk factors for hypoglycemia during all therapy design/method: medical records of of children (up to years old) treated for all between - ( patients) were studied for evidence of morning hypoglycemia defined as blood sugar (bs) < mg/dl. statistical mean differences between the subgroups were analyzed with spss using a nonparametric mann-whitney u test.results: fifty two percent ( %) of patients developed hypoglycemia during all treatment, with an average of . episodes/patient. % were males and % females. almost / ( %) of patients with hypoglycemia were in maintenance phase of therapy. % of hypoglycemic episodes occurred in % of patients. majority of hypoglycemic episodes ( . %) occurred on the day of procedure when patients were fasting overnight. . % of hypoglycemic episodes occurred in children ≤ years, with . % in ≤ years. patients who developed hypoglycemia were significantly younger (mean age at time of diagnosis of all was . ± . at the hypoglycemia group versus the non-hypoglycemia ( . ± . ) p< . . no statistically significant difference was found regarding sex, or tpmt genotype. % of hypoglycemic children-all < years of age-presented with life threatening hypoglycemia symptoms including seizure and loss of consciousness. this study showed high prevalence of hypoglycemia during childhood all therapy. younger age, especially ≤ years, is associated with higher risk of hypoglycemia as well as life-threatening episodes. to decrease fasting hypoglycemia during therapy for childhood all, we recommend that children under the age of years receive bed time snack high in proteins and complex carbohydrates, and to get them up early the day of procedure to take clear sugary drink. hospital for sick children, toronto, ontario, canada ann & robert h. lurie children's hospital of chicago, chicago, illinois, united states background: childhood brain tumors are the most common solid malignancy and the leading cause of cancer-related mortality in children. the most aggressive type of pediatric central nervous system (cns) tumors is diffuse intrinsic pontine glioma (dipg). despite decades of clinical trials, there has been no substantial improvement with respect to therapeutic outcomes with most children eventually succumbing to the disease. research on adult high-grade gliomas has shown a targetable pathway through the inflammationinduced expression of indoleamine , dioxygenase (ido ) and its recognized ability to suppress the anti-tumor immune response. a limited understanding into the role of ido in pediatric central nervous system tumors serves as the foundation of this research project. furthermore, the integration of nanotechnology is a fundamental step for the investigation and targeting of ido . spherical nucleic acids (snas) composed of nanoparticles have been shown to transverse cellular membranes, exhibit stability in physiological environments, escape from degradation, and create precise targeting in brain tumors.objectives: the purpose of our project is to delineate the role of ido in pediatric dipg, and develop small inhibitory (si)rna oligonucleotides and snas aimed at therapeutically inhibiting the gene expression of immunosuppressive ido . our specific aims are to: ( ) confirm the gene expression ido in different human dipg cell lines; ( ) generate and characterize sirna oligonucleotides targeting human ido in vitro; and ( ) generate and characterize gold nanoparticles for targeted inhibition of ido .design/method: unique patient-derived dipg cell lines were grown in culture, stimulated with increasing concentrations of the proinflammatory cytokine, ifn , and analyzed for mrna levels. sirna specific to ido was transfected into cells. sna generation is in progress.results: ido is expressed in multiple human pediatric dipg cell lines. sirna targeting ido among exons and results in a significant decrease in overall ido expression by dipg cells. sna generation for targeting ido with improved penetration & stability is ongoing, with preliminary results demonstrating a robust ability to inhibit ido expression. the grim prognosis of children with dipg, the lack of effective therapies, and the expression of ido by human dipg cells emphasize the importance of developing the treatment capability to inhibit ido gene expression, as a excluded from this study. the remaining patients were analyzed using descriptive statistics.results: a total of patients meeting inclusion criteria were identified. of these, patients ( . %) received tonsillectomy alone, ( . %) underwent tonsillectomy and decreased immunosuppression, ( . %) received tonsillectomy and rituximab, and another ( . %) received tonsillectomy with additional therapy (including ebv-specific cytotoxic tlymphocytes, donor leukocyte infusion, and chemotherapy). of the patients who received tonsillectomy with or without a decrease in immunosuppression, all were diagnosed with high-grade lymphoma and achieved clinical remission following tonsillectomy with no evidence of relapse to date. on further analysis looking at ptld risk factors, all patients were under years of age, all received t-cell depleted grafts, and none had significant graft-versus-host disease (gvhd) at the time of ptld diagnosis. we have identified a population of patients with localized ebv ptld that achieved clinical remission with no evidence of recurrence following tonsillectomy, suggesting that tonsillectomy alone may be an adequate treatment for localized ebv ptld in a specific subgroup of patients. further analysis is needed to identify characteristics of this subgroup to determine which patients would be most likely to respond to this treatment. university of rochester, rochester, new york, united states background: malignant central nervous system (cns) tumors in young children have a poor prognosis and pose a significant therapeutic challenge. consolidation therapy with carboplatin and thiotepa was piloted in ccg- , cog acns , and cog acns with the goals of intensifying therapy and omitting or delaying radiation.objectives: to document outcomes for patients undergoing carboplatin/thiotepa consolidation with autologous stem cell rescue (ascr) and to demonstrate the feasibility and toxicity of this regimen.design/method: patients up to years old (median age: months) with malignant cns tumors treated at the university of rochester from - with at least one cycle of carboplatin ( mg/kg/day x days) and thiotepa ( mg/kg x days) followed by peripheral blood ascr were included in retrospective analysis. data were recorded on time to engraftment (defined by absolute neutrophil count (anc) recovery to > . × ^ /l), length of hospitalization, toxicity with each consolidation cycle, progression free survival (pfs) and overall survival (os). stem cell harvest data were also collected.results: eleven patients with malignant cns tumors ( atypical teratoid/rhabdoid tumor, primitive neuroectodermal tumor, glioblastoma multiforme, and pineoblastoma) received a total of cycles of carboplatin/thiotepa. of these, underwent stem cell harvest at our institution, with complications limited to procedure-related hypotension for patient with known autonomic instability, and catheter-associated deep vein thrombosis (dvt) for patient. four patients were in complete remission (cr) /status-post gross total resection, was in cr , and had residual tumor at the time of consolidation. nine patients received planned consolidation cycles, patient (of ) planned cycles, and patient of an anticipated cycles thus far. average time to engraftment for these cycles was . (+/- . ) days, with a mean hospital length of stay of (+/- . ) days. fever occurred in of cycles ( %); infectious toxicity included documented bacterial infection in cases (enterococcus faecalis bacteremia in , klebsiella pneumoniae in ). there were no regimenrelated deaths. with a mean follow-up of months, survivors have not yet completed all therapies, and patients have relapsed ( have died of disease). of the survivors, have been disease-free for > months. background: autologous hematopoietic stem cell transplantation (auto-hsct) has resulted in improved survival for patients with high-risk neuroblastoma. treatment intensification is however associated with greater complications. data on early infectious complications in low-and-middle income countries are limited.objectives: to review the early infectious complications following auto-hsct in patients with high-risk neuroblastoma.design/method: a retrospective chart review of pediatric patients with high-risk neuroblastoma who underwent auto-hsct at the american university of beirut medical center between and was conducted. infectious complications during the first days post-transplant were reviewed.results: forty-three patients ( males and females) with a median age at diagnosis of . years [range: . - . ] years underwent auto-hsct during the above-mentioned period. conditioning regimen consisted of melphalan, etoposide and carboplatin. all patients received antiviral and antifungal prophylaxis. median time for neutrophil engraftment was days [range: - ]. bacteremia and clostridium difficile infections occurred in ( %) and ( %) patients respectively. seven ( %) patients developed enterocolitis diagnosed by imaging, were adenovirus induced. cmv viremia was diagnosed in ( %) patients, of whom required treatment. varicella zoster reactivation, parvovirus viremia, toxoplasmosis encephalitis, bk virus cystitis ( patients) and central nervous system ebv related post-transplant lymphoproliferative disorder were diagnosed in different patients. there was no invasive fungal infection. sixteen ( %) patients have died, of whom died in the early post-transplant period, due to disease progression and ( . %) due to infectious complications. among the patients who died due to infection, developed toxoplasmosis encephalitis, developed severe enterocolitis, of which were adenovirus related. the mean igg level within one week post-transplant was lower in patients with clinically significant viral infection compared to others ( vs . mg/dl, p: . ). the mean igg level at the time of clinically significant bacterial infection was lower in infected patients compared to others ( . vs . mg/dl, p: . ). neither absolute lymphocyte count nor absolute neutrophil count at day post-transplant affected the incidence of clinically significant infections. our results show that the rate of infections during the early post auto-hsct period is higher than what has been described in developed countries and has a significant impact on mortality. prevention, early detection and improvement in the treatment is required to improve outcome. university of miami, miami, florida, united states background: allogeneic hematopoietic stem cell transplantation (allo-hsct) is a curative treatment for many malignant and non-malignant (bone marrow failure, immunodeficiency, or metabolic diseases) in pediatrics. despite advances in medicine, graft-versus-host-disease (gvhd) remains a significant cause of non-relapsed morbidity and mortality, specifically in those with malignant diseases.objectives: to highlight the complexity to acute gvhd management and seldom-described treatment approach. a year male with a history of high risk acute myeloid leukemia (aml) due to failed induction therapy. he received a matched ( / ) unrelated donor hsctmarrow product-conditioned with busulfan, fludarabine, and anti-thymoglobulin (atg). his post-transplant course was complicated by hhv- viremia, pres (prompting a change from prograf to cyclosporine), mucositis, and grade iii acute gvhd (skin s , gut s , liver s ) around post transplant day , which later morphed to ocular involvement by d+ . he was started on mg/kg steroids with good response but flared up with each attempt to taper steroid dose. a course of rituximab and later atg were tried without success in weaning off steroids. switching cyclosporine to sirolimus did not provide any additional benefit either. extracorporeal photopheresis (ecp) was started times a week. he initially responded well, yet was not able to wean off steroids. in addition, he developed a flare when ecp session was reduced to days per week. ecp was therefore increased to days per week, which appeared to stabilize skin lesions. a trial of weekly methotrexate was attempted to wean off steroids and photopheresis, which provided no response. finally, a trial of bortezomib on days , , , and of a day cycle as published in a case series of multiple myeloma patients who developed post hsct gvhd. skin lesions improved remarkably however dose had to be reduced due to related pancytopenia. given the response to therapy, he was continued on a weekly dose of bortezomib, receiving a total doses, which has permitted the slow taper of prednisone that has since been discontinued without a major flare. he however is currently maintained on ecp times per week, which is now been slowly withdrawn.conclusion: management of acute gvhd in pediatric patients after hsct can be challenging with no definite options for those who fail steroids or become steroid dependent after initial response. in these situations, bortezomib could be a valid therapeutic option. background: neuroblastoma (nbl) is the second most common solid tumor in children and despite recent treatment advances, overall survival for high risk nbl remains < %. the addition of immunotherapy has improved survival and includes anti-gd antibody therapy. the success of antibody therapy in neuroblastoma is primarily due to natural killer (nk) cell mediated antibody dependent cellular cytotoxicity. we previously demonstrated that nk cells from patients with high risk nbl can be successfully isolated and expanded to large numbers and exhibit potent anti-tumor effects against nbl ( ). thus, infusions of autologous expanded nk cells in high risk nbl in combination with anti-gd antibody are being studied in clinical trials. toll-like receptors (tlr) present on the surface of leukocytes are responsible for pathogen recognition, and activation of these receptors stimulate the production of cytokines that critically link innate and adaptive immune responses. the tlr agonist, poly(ic) is a synthetic analog of dsrna that has previously been shown to directly stimulate cytokine production and improve cytotoxicity in primary nk cells through activation of genes regulated by interferon-response elements (ire) ( ). we hypothesized that ex vivo activation of tlr pathways in nk cells during our normal -day expansion using k feeder cells expressing membrane bound il- would enhance their function.design/method: nk cells were isolated from peripheral blood mononuclear cells and expanded with our previously described expansion protocol in media containing il- and ug/ml poly(ic) ( ). at the end of the -day expansion, nk cells expanded with poly(ic) were compared to controls using a calcein cytotoxicity assay to measure cytotoxicity against high risk neuroblastoma and cytometric bead array to measure cytokine production. : surprisingly, the addition of poly(ic) during nk cell expansion did not improve proliferation, cytokine production or cytotoxicity compared to our standard expansion method. rnaseq demonstrated that our standard expansion method results in a modest decrease in tlr expression at the transcriptional level, but significant upregulation of several ireregulated genes. we conclude that either our standard approach interferes with tlr signaling or saturates the innate immune response pathway such that co-stimulation with poly ic does not produce an additive effect. we are performing expression analysis on nk cells receiving poly(ic) during expansion to further explore this hypothesis. background: gonadal dysfunction leading to infertility is a complication after hematopoietic stem cell transplant (hsct). anti-müllerian hormone (amh) is a marker of ovarian reserve; it is not controlled by gonadotropins and has minimal inter-cycle variations, therefore, it can be used as a marker of ovarian reserve and aid in fertility counseling.objectives: assess ovarian reserve in hsct patients utilizing amh levels. background: tgf beta is an immune suppressive cytokine frequently elevated in the tumor microenvironment causing tumor immune evasion. acute tgf beta treatment potently inhibits nk cell cytotoxicity, cytokine secretion, and proliferation. however, tumor infiltrating nk cells receive chronic inhibitory tgf beta signals in conjunction with activating signals from tumor cells. objectives: to this end, we hypothesized that long-term tgf beta-cultured nk cells would induce functional and phenotypical changes on nk cells that differ from short-term tgf beta treatment.design/method: to explore this, primary human nk cells were cultured with the leukemia cell line, k , alone or with exogenous tgf beta for weeks. : surprisingly, nk cells cultured in tgf beta proliferated faster, and upon challenge with a variety of cell line targets they secreted much greater quantities of ifnÎ ( -to -fold increase against / cell lines) and tnf ( -to -fold increase against / cell lines). further, the high cytokine secretion induced in these nk cells was no longer inhibited by adding additional tgf beta. degranulation was also increased ( / cell lines), however cytotoxicity was not enhanced in a -hour cytotoxicity assay. after resting in il- , the cytokine hypersecretion of tgf betacultured nk cells was maintained for several weeks suggesting this functional change might involve cellular reprogramming. we investigated the mechanism behind these functional changes and profiled genes involved in tgf beta signaling. we found significant reduction of smad transcription which corresponded to a striking decrease in smad chromatin accessibility. we also found significantly increased smad and decreased tgfbr expression. phenotypic analysis revealed that tgf beta also induced remodeling of the nk receptor repertoire with decreased nkp , cd , and klrg and upregulation of trail. the functional consequences of these tgf beta-induced changes on in vitro and in vivo nk cell function are currently under investigation. background: the use of t-cell depleted grafts in haploidentical stem cell transplantation (hsct) has been associated with a delay in early t-cell recovery which increases the risk of viral infections, relapse or graft rejection. conventional donor lymphocyte infusion (dli) after hsct transplantation is effective but conditioned because of a high prevalence of gvhd. the infusion of selected lymphocyte subpopulations with low aloreactivity is emerging as an effective strategy to rectify this issue. the depletion of cd ra+ naive lymphocytes, preserving cd ro+ memory t-cells, could provide a safe source of functional lymphocytes with anti-infection, antileukemic and anti-rejection properties, and lower rates of adverse effects. our objective is to present data of patients that have received cd ro+ memory t-cells dli (mdli) and assess its safety and outcome. we present data of mdli performed after hsct in cases of mixed chimerism, persistent lymphopenia, viral/opportunistic infections or as a strategy to accelerate immune reconstitution.results: fifteen patients with diagnosis of all (n = ), aml (n = ), mds (n = ), saa (n = ), sideroblastic anemia (n = ) and cgd (n = ), received mdli after hsct. a total of forty-three mdli were infused. the median dose of cd ro+ memory t-cells infused was . × /kg (range: . × - . × /kg), with a median dose of cd ra+ naive t-cells of . × /kg (range: - . × /kg). the mdli were infused at a median of seventy-seven days after hsct (range: - days), with a median interval between mdli of thirty-four days results: eight published studies reported survival outcomes for pediatric vod/sos patients (n = ), across all defibrotide doses. estimated day+ survival ( % confidence interval) was % ( %- %). for vod/sos with mod, studies were identified (n = ) with pooled estimated day+ survival of % ( %- %). only one openlabel expanded-access study, the treatment-ind, reported outcomes separately for pediatric vod/sos patients without mod (n = patients aged ≤ years). the day+ kaplan-meier estimated survival for those patients was % ( %- %). safety results were not pooled due to differences in reporting methodology; however, study results were consistent with the safety profile of the phase historicallycontrolled trial in vod/sos patients with mod ( % pediatric), in which / defibrotide-treated patients and all controls experienced ≥ ae. hypotension was the most frequent ae ( %, defibrotide; %, controls); common hemorrhagic aes (ie, pulmonary alveolar and gastrointestinal hemorrhage) occurred in % of defibrotide-treated patients and % of controls. in this pooled analysis of studies with defibrotide-treated pediatric patients with vod/sos, estimated day + survival was % (without mod, %; with mod, %). safety results in individual studies were generally consistent with the known safety profile of defibrotide. taken together, these results show a largely consistent defibrotide treatment effect in pediatric patients treated with defibrotide for vod/sos, with or without mod. results: six patients met inclusion/exclusion criteria. all patients were started on ecp while concurrently receiving . to mg/kg steroid therapy for agvhd plus a calcineurin inhibitor. patients had initiation of ecp within a maximum of weeks from initial diagnosis of agvhd (range - days). patients had grade - agvhd ( / patients with grade ) with skin, liver, and gi gvhd represented. patients received ei-ecp - times per week for the first weeks and then had ei-ecp frequency tapered based on initial response.after weeks of therapy patient had a decrease in overall gvhd grade by grade. all patients were able to have steroids tapered, with doses decreased by an average of % ( % - % decrease).at weeks of therapy, one patient with grade agvhd died of mof associated with infections. three patients had complete resolution of agvhd and patients decreased by grade. steroid doses were decreased by an average of % ( % - % decrease). continuously measures axillary temperature and wirelessly transmits real time-time data. the primary aim of the study was to evaluate the feasibility, safety and tolerability of continuous temperature monitoring in hsct patients using temptraq. we are performing a prospective observational study of pediatric patients ( - years of age) undergoing hsct at cincinnati children's hospital in cincinnati, ohio. enrolled patients wore a temptraq patch for days. a - rating scale survey was completed by the parent/guardian at the end of the study to determine tolerability, ease of use, satisfaction and desire for future use in the inpatient and outpatient setting. temperature data from the temptraq patch was compared to the standard episodic temperature monitoring to determine detection of febrile episodes. seven of ten patients have completed screening. we anticipate completion of the study in early february. the temptraq patch was well tolerated by study subjects (mean tolerability rating of . / ). one patient developed skin breakdown at the site of the temptraq patch attributed to recent thiotepa. the patch was easy to apply with an easy of application rating of . / . parents were overall satisfied (rating . / ) and would like to use the temptraq patches in future hospitalizations (rating . / ) and at home (rating . / ). temptraq patch identified fever (≥ . • f) in patients. the fever was never detected by episodic monitoring (soc) in patients and significantly delayed in the other patients (> hours). temptraq was well tolerated in pediatric hsct patients. timely fever detection was improved in temptraq over the current soc. background: serotherapy is commonly used in patients undergoing hematopoietic stem cell transplant (hsct) to reduce the incidences of engraftment failure and graft versus host disease. however, one well-known side effect is fever. as children undergoing hsct have compromised immune defenses, fever may also be an early indicator of bloodstream infection, which would warrant prompt use of broad-spectrum antibiotics. in a subset of patients with serotherapy-associated fever, antibiotics, which may induce antibiotic resistance and increase costs, may be unnecessary. we aimed to determine the incidence and characteristics of serotherapy-related fever, as well as the likelihood of concomitant bacteremia, in our institutional experience. a -year retrospective chart review was conducted of pediatric patients who received serotherapy as part of hsct conditioning at the university of minnesota. one-hundred sixty eight consecutive hsct patients who received serotherapy -either atg (n = ) or alentuzumab (n = ) -were identified. the median age at hsct was -years (range, . - years). a total of patients ( %) developed fever while on serotherapy (atg = , alentuzumab = ). one-hundred sixteen patients presented fever following the first infusion, and the median onset of fever was hours after commencing infusion (range, . - hours). fever resolved at a median hours (range, - hours). one hundred and fourteen patients ( %) underwent blood cultures. only seven patient were not started on ( %) empiric antibiotics, while % (n = ) were on antibiotic treatment prior to serotherapy for previously known or suspected infections. nine patients ( % of febrile patients, % of all patients) had positive blood cultures (atg = ; alentuzumab = ). no infection-associated deaths were observed.conclusion: while fever is common during serotherapy conditioning in children undergoing sct, episodes of concomitant bloodstream infection are rare. ongoing analysis identified potential risk factors for bacteremia as recent history of infection, first episode of fever following second or subsequent infusions, and previous central line placement. further analysis is being conducted to identify subgroups of patients for whom close monitoring alone may be safe. background: hsct is potentially curative for caya with high-risk leukemias; however, most lack an hla-matched aspho abstracts related donor. the risk of gvhd is increased with unrelated (urd) or partially matched related (pmrd) donors. selective t-cell depletion based on the elimination of t cells carrying and chains of the t-cell receptor may greatly reduce the gvhd risks, while allowing the maintenance of mature donor-derived alloreactive nk cells and / (+) t cells, which may augment the anti-leukemia effect.objectives: this is a prospective study of caya with acute leukemia who underwent hsct with mmrd or urds and tcr / /cd depletion. outcomes included engraftment, toxicities, viral reactivation, and relapse.design/method: this study included caya with acute leukemia transplanted between october and may . all received a myeloablative preparative regimen with targeted busulfan (n = ) or tbi ( cgy/ fractions) (n = ), with thiotepa ( mg/kg) and cyclophosphamide ( mg/kg). atg ( mg/kg x ) was given to those receiving haploidentical grafts and to the first who received urd grafts. immune suppression was not given post-hsct. the stem cell source was mobilized peripheral blood stem cells (pscs), which then underwent tcr / /cd depletion utilizing the clinimacs device under gmp conditions in the chop cellular immunotherapy lab.results: median age was (range . - . ). diagnoses included all ( -b-cell, -t-cell) and aml ( ; -secondary aml). urd were used for ; were / allele matched and were / matched. haploidentical donors were used for . median cd (+) dose - . × , / (+) cd (+) cells - . × , and b cells - . × . all patients achieved an anc at a median of d+ ( - ), and % had platelet engraftment at median d+ ( - ). nine patients ( %) developed acute gvhd (all skin, grades i-iv). five developed chronic gvhd (skin, gut, lung): limited in , extensive in . viral reactivations included: adenovirus ( , %), bk virus ( , %), cmv ( , %), and hhv ( , %). nine ( %) patients relapsed at a median of days (range - ) post-hsct, including aml patients ( . %) and all patients ( . %). transplant-related mortality was %; causes included sepsis ( ) and ards ( ). os was %; efs was % (gvhd-free efs %, lfs %). hsct with tcr / /cd depletion demonstrates excellent engraftment kinetics with limited gvhd without immune suppression. elimination of post-hsct immunosuppression may offer an excellent platform to augment anti-leukemic immune therapy or to enhance immune reconstitution. background: hematopoietic cell transplantation (hct) is the only curative treatment available for patients with sickle cell disease (scd). low bone mineral density (bmd) has been described in scd, but little is known about the impact of curative hct on this outcome. to determine the prevalence of low bmd and variables associated with low bmd in scd patients after hct. we conducted a retrospective chart review of scd patients who underwent hct at children's healthcare of atlanta (choa) between / and / and survived ≥ year post-hct. transplant characteristics, post-hct dual-energy x-ray absorptiometry (dexa) scan results, vitamin d levels, graft-versus-host-disease (gvhd) status, and fsh levels were reviewed. for patients - years of age, height corrected z-scores were calculated using a nihvalidated calculator, with t-scores used for older patients. bmd was categorized as low if between - and - sd below the mean and clinically significantly low if >- sd, in accordance with the children's oncology group long-term follow-up guidelines. vitamin d levels < ng/mol were considered deficient, and fsh levels > miu/ml suggestive of premature ovarian failure. fisher's exact test was used to compare variables in those with normal versus abnormal dexa scan results, with p< . considered significant.results: hct was performed on patients with scd, with surviving ≥ year post-hct. dexa scans were obtained in patients ( % female), with mean time from hct to dexa scan being years ( . - . years) and mean age at time of dexa . years ( . - . years). patients with and without dexa scans did not differ by sex, donor source, age at transplant, or vitamin d status. low bmd was noted in patients ( . %), with these patients more likely to be > years (pubertal; . versus . %, p = . ). acute gvhd was more common in patients with low bmd ( . versus . %), but not statistically significant (p = . ). clinically significant low bmd was noted in patients ( . % of those with dexa scans). these patients were older ( . years at testing), were more likely to be male ( . %), and all had acute and chronic gvhd, while none had evidence of gonadal failure.conclusion: clinically significant low bmd is uncommon after hsct for scd. patients at risk for low bmd include older patients and likely those with gvhd. this preliminary data suggests routine dexas may not be indicated for all patients who undergo hct for scd, but further data is needed. background: causes of renal dysfunction after hematopoietic cell transplantation (hct) include damage from radiation, nephrotoxic medications, graft vs. host disease (gvhd), hepatorenal syndrome, viral infections, or transplant associated microangiopathy. we sought to investigate the incidence of, and risk factors for, acute kidney injury in pediatric hct patients and associated risk with mortality.design/method: data from patients who underwent hct between and at a single institution were sequentially retrospectively captured on irb approved protocol. acute kidney injury (aki) was defined at multiple time points post-hct using the standardized criteria: kidney disease: improving global outcomes (kdigo). interval differences between values were analyzed using wilcoxon rank sum testing and categorical variables were analyzed using chi-square analysis.results: ninety-eight patients were included in the study: allogeneic (n = ) and autologous (n = ), mean age . years, of whom % were african american, % asian, % caucasian, % latino, and % mixed race. forty-seven percent of patients developed aki within the first years of hct. increased risk for aki was associated with a lower pre-transplant creatinine level (p = . ), abnormal pretransplant bun (p = . ) and an unrelated donor (p = . ) while preparative regimen intensity, race, or primary disease were not. twenty-six percent of patients developed aki within days of hct. of those with aki, % were exposed to either cidofovir, aminoglycosides, and/or ambisome for at least days versus % without aki and % were exposed to vancomycin compared to % without aki. evaluating outcomes at year after hct, of those with stage aki: % had reduced gfr and % died, while % had reduced gfr and % had died for patients with aki stage or . the absence of aki by day was associated with % reduced gfr and % death at -year after hct. overall, those with aki at any time in the first year post-hct had a . fold increased risk of death compared to those without. for patients who required renal replacement therapy (rrt, n = ), the risk of death was . fold greater compared to those who did not. in the % of patients who survived rrt, both recovered renal function within years.conclusion: acute kidney injury is common after pediatric hct, and may be associated with low creatinine, abnormal bun, unrelated donor pre-hct, and renal toxic medications. early-onset aki post hct is associated with an increased risk of mortality. these data should be validated in a larger prospective study but may offer opportunities to intervene and enhance outcomes. background: myeloablative hematopoietic stem cell transplant (hct) for pediatric malignant disease is associated with significant morbidity with % patients experiencing mucositis. patient controlled analgesia (pca) utilizing opioids is an effective strategy for pain management. we sought to describe and analyze pca use in d+ days post myeloablative hct for malignancies at lurie children's hospital of chicago from - .design/method: utilizing retrospective chart review, pca details were collected: indication, initiation day, pca duration, team managing pca (anesthesia or palliative), medication and dose in morphine equivalents, and pca toxicities. efficacy of pca was evaluated on pca day + , + , + , + using demands %, maximum pain score (rflacc, faces, vas) and subjective patient, parent and/or pain team perception of pain control. we devised a scale based on the above to designate pain control as good, moderate or poor. variables being analyzed include recipient age, sex, donor type, source, diagnosis, tbi use, gvhd/trm. this analysis, we analyze the depth of remission, car-t persistence, and post-transplant gvhd on our phase i anti-cd car-t protocol (nct ) to better understand the role of car-t in the peri-hct setting.design/method: children and young adults with relapsed/refractory cd + all treated on our phase i anti-cd car-t protocol were analyzed. mrd was assessed by flow cytometry (fc) in all, with pcr-based mrd analysis using igh or tcr testing assessed in select patients. hcts were performed at each patient's local institution based on standard of care and included varying conditioning regimens, donor types, stem cell source, and gvhd prophylaxis.results: on our cd car trial, patients were treated, the majority of patients (n = ) having relapsed following a prior hct. / patients ( %) attained a cr, of whom were mrd negative by fc. concurrent pcr based mrd analysis available in patients demonstrated that all patients achieved pcr based negativity. in , this was simultaneous with the month mrd negative fc, and in , pcr negativity was achieved over time (fc remained negative). patients proceeded to hct at a median time of days (range: - days) post-car-t, which was a first hct in . these two patients remain in an mrd negative cr, year post-car-t. no patients developed acute or chronic gvhd. car persistence was seen in patients who had detectable car-t cells on the pre-hct marrow suggesting the possibility of ongoing anti-leukemia surveillance prior to initiation of the conditioning regimen.conclusion: by inducing pcr negativity, car-t therapy may have a synergistic role with hct to improve leukemia free survival, prior to emergence of antigen negative leukemia, without an increased risk of gvhd. while the sample size is small, car-t therapy may offer an effective bridge to hct, particularly for those who are pcr negative, and those who have not had a previous transplant. given the underlying risk of hct related trm, pre-hct car may potentially allow for hct conditioning de-intensification as it may not be needed to eradicate residual disease. lee dw, ash abstract , background: post-transplant lymphoproliferative disease (ptld) is a complication after solid organ transplantation (sot) that is frequently due to epstein -barr virus (ebv) as a decrease in ebv-specific t cell immunity due to immune suppression allows for uncontrolled proliferation of ebv-infected b cells. outcomes for ptld are suboptimal with relapse rates approaching %. however, ebv-infected b cells in ptld express the ebv antigens lmp and lmp that can be targeted with immune therapy.objectives: we hypothesize that third party "off the shelf" lmp-specific t cell products may improve outcomes and decrease associated co-morbidities for patients with ptld by not only target the lymphoproliferating ebv-infected b cells but also restoring ebv-specific immunity.design/method: lmp-specific t cells (lmp-tcs) are manufactured from eligible donors with a broad range of hla types in our gmp facility to be used in a children's oncology group (cog) trial (anhl ) for patients with ptld after sot. lmp-tc products are manufactured from healthy donors using autologous monocytes and lymphoblastoid cell lines (lcl) transduced with an adenoviral vector expressing Δlmp and lmp as antigen presenting cells. lmp-tc products undergo comprehensive characterization by ifn-elispot assay to determine lmpspecific epitopes, class i and/or ii response, and hla restriction to guide selection of lmp-tc product for each patient.results: thus far, lmp-tc products have been manufactured. lmp-tcs were active against lmp (mean: sfu/ × ^ cells; range: - ), lmp ( ; - ), and lcl ( ; - ) as determined by ifn-elispot assay. at the time of cryopreservation, the lmp-tc products comprised a mean of % cd + t-cells, % cd + t-cells, and % nk cells. no b cells or monocytes were detected in the final products. thus far, we have identified novel lmp epitopes (lmp specific: n = ; lmp specific: n = ). approximately % of the lmp-tc products have lmp-specific activity through multiple hla alleles, and % have a mixed class i and class ii response. conclusion: thus, lmp-specific t cell products can be expanded from healthy donors to creat a third party bank, and identifying epitopes and hla alleles with lmp activity will facilitate selecting the most appropriate product for patients. while lmp-specific t cells have previously demonstrated safety and efficacy in phase i studies, anhl is the first trial using cellular therapy within a cooperative group setting. children's cancer hospital at the university of texas md anderson cancer center, houston, texas, united states background: in , the united states food and drug administration (fda) approved the first chimeric antigen receptor t cell (car-t) therapy; tisagenlecleucel. this cd -directed genetically modified autologous t cell immunotherapy has shown response rates of almost % among children and young adults with b-cell precursor acute lymphoblastic leukemia (all) that are refractory or in second or later relapse. cytokine release syndrome (crs) and car-t cell related encephalopathy syndrome (cres) are well described toxicities associated with car-t therapy. crs is a systemic inflammatory response and is typically characterized by fever, hypoxia, tachycardia, hypotension and multi-organ toxicity. cres may occur concurrently or following crs, or without any associated crs symptoms and is characterized by encephalopathy, delirium, seizures and rarely cerebral edema. almost half of patients who receive tisagenlecleucel may require pediatric intensive care unit (picu) support. crs and cres are generally reversible but may be associated with fatal outcomes. pediatric specific management guidelines, comprehensive training of multidisciplinary staff, effective communication and phased infrastructure ensure that adequate resources are available to facilitate early diagnosis and appropriate management of pediatric patients with crs and cres and allow for optimal patient outcomes and accreditation by the foundation for accreditation of cellular therapy (fact).objectives: develop a comprehensive program to ensure safe administration of immune effector cell (iec) therapy to pediatric patients.design/method: an inter-disciplinary pediatric cartox (car t cell therapy associated toxicity) committee consisting of cell therapy and picu physicians, neurologists, fellows, nursing leadership, advanced practice practitioners, pharmacists, registered nurses and social workers was created to monitor patient toxicity and establish specific clinical guidelines and diagnostic and treatments algorithms for pediatric patients receiving iec therapy. educational modules were developed as (i) live in-services and (ii) an online module with a competency based assessment. electronic medical record (emr) order sets and documentation and warning systems were also developed by the committee. the pediatric cartox committee developed a diagnostic and treatment algorithm for patients receiving iec therapy. emr orders and flowsheets were developed to support adherence to the algorithm. inter-disciplinary staff training and competency assessments were closely tracked. almost % of identified staff have completed training and achieved competency including, pediatric cell therapy staff, emergency center, picu, outpatient clinic/triage, neurology and sub-specialty staff and nocturnalists.conclusion: an inter-disciplinary approach can assist in institutional readiness for an iec program, promote quality assurance and perhaps fact iec accreditation. future directions include a program for ongoing staff competency assessments. predicted peak vo ) and abnormal oxygen uptake efficiency slope at the anaerobic threshold ( . ± . . , normal ± ). additionally, on echocardiogram three patients had evidence of diastolic dysfunction as evidenced by an elevated e/a ratio ( . ± . ) on tissue doppler. three patients demonstrated depressed longitudinal peak systolic strain (- . ± . ), indicating dysfunction not captured by ejection fraction. in this feasibility study, sct patients without evidence of lvsd on standard measures by resting echocardiogram can demonstrate abnormal exercise capacity. additionally, they can demonstrate systolic and diastolic dysfunction by measures not always included in standard echocardiography. these data suggest the need for a more thorough screening of survivors, and will be further validated as additional patients are recruited for this study. background: in hematopoietic transplantation, the t lymphocytes of the inoculum play a determining role in promoting hematopoiesis, transferring immunity to pathogens and acting as mediators of the graft-versus-leukemia effect (gvl). however, they are also responsible for graft-versus-host disease (gvhd), the main cause of post-transplant morbidity and mortality. the depletion of cd ra lymphocytes, by eliminating naive t lymphocytes from the inoculum, aims to conserve the gvl without producing gvhd.design/method: since april , patients ( boys and girls), with a median age of years, have undergone an allogeneic hematopoietic transplant from an hla donor identical with cd ra/cd depletion. the indication for transplant was: acute lymphoblastic leukemia ( ), acute myeloblastic leukemia ( ), myelodysplasia ( ) and medullary aplasia ( ). the donor was familiar in cases and unrelated in . the conditioning regimen was with fludarabine, busulfan and thiotepa. the median of cd + cells infused was . × / kg. on the day , + and + a programmed infusion of × / kg lymphocytes cd ra-was performed.results: all the patients grafted with a median leukocyte (> . × / l) and platelet (> × / l) engraftment time of and days, respectively. only one patient has developed acute gvhd grade i and no patient has developed chronic gvhd. immune reconstitution was early and rapid in all t cell subsets no patient has relapsed so far and only patient with myelodysplasia has developed an aml. she has received a nd transplant and has died of relapse. there was no case of toxic mortality. the event-free survival (sle) was ± % with a median follow-up of months. at present, patients are alive, out of immunosuppressive treatment and doing well. allogeneic transplantation with cd lymphocytes ra depletion resulted on very encouraging results, with a very low incidence of acute and chronic gvhd, but preserving the gvl effect by infusing cd ra-donor lymphocytes. miami children's health system, miami, florida, united states background: hematopoietic stem cell transplantation (hsct) using autologous or allogeneic progenitor cells is a potentially curative treatment for patients with high-risk malignancies and nonmalignant conditions. the american society for blood and marrow transplantation developed a task force to establish consensus guidelines for defining patient care in hsct and advocated for further studies to delineate safe procedural steps as an increasing amount of hsct are being offered to patients. there is limited evidence to support engraftment in recipients who receive their infusions via iv or syringe pump. we present novel data from patients who achieved neutrophil engraftment following hsct by a pump mechanism.objectives: to provide evidence supporting the use of pump (intravenous or syringe) infusion method in hematopoietic stem cell transplantations.design/method: a retrospective review was completed for patients who underwent hsct between and . inclusion criteria included patients who had received hematopoietic stem cell transplants between and and who were ages months to years old. the main outcome measure was days to neutrophil engraftment (defined as the first of three consecutive days with an anc > × /l).results: among patients who received infusion of hematopoietic stem cell products via pump mechanism, patients ( . %) received autologous products and ( . %) received stem cells from allogeneic donors. neutrophil engraftment (anc > × /l) occurred in a median of . days after stem cell infusion. the mean number of days to engraftment for patients who received allogeneic infusions s of s design/method: a retrospective chart review was performed at the children's hospital of wisconsin. statistical analyses included kaplan-meier estimate for os, mann-whitney test for comparing outcomes between subjects, and descriptive analyses.results: from - , patients with a median age of . ( . - . ) years at st hct were identified. patients were conditioned with cy/atg (n = ), cy/flu/atg (n = ), or cy/flu/atg/tbi (n = ) and received marrow (n = ) or cord blood (n = ) with median cd /kg dose of . ( . - . ) × . two patients developed grade i acute graftversus-host disease (gvhd); none developed chronic gvhd. due to dropping chimerism, graft rejection, or graft failure, nd hct (n = ) or boost (n = ) was offered. the median cd chimerism prior to hct/boost was ( - )%. median time between st hct and nd hct or boost was days ( days- . years). in patients receiving nd hct, used the same donor, of which used the same stem cell source (marrow) and switched to peripheral blood stem cells (pbsc). in patients who switched donors, used pbsc and used cord blood. most patients receiving nd hct underwent a uniform conditioning regimen of cy /flu /equine atg/ gy tli (n = ) or cy /flu /rabbit atg/ gy tbi (n = ); one received cy/atg. acute and chronic gvhd (limited seen in %) developed in % and % of patients, respectively. four patients required additional boosts and additional hct. after final intervention, cd and whole-blood chimerism at last follow-up was between - % (n = ) and - % (n = ), respectively. with a median follow-up of . ( . - . ) years, of patients are alive with an estimated -year os of . ± . %, having performance status ≥ % (n = ) or % (n = ). one patient developed chronic extensive gvhd and died of fungal infection . years after nd hct. our single-center experience demonstrates excellent ability to salvage patients who develop graft failure after initial hct. transplant-related complications such as gvhd and infections remain significant concerns. key: cord- -o hr mox authors: nan title: proceedings of réanimation , the french intensive care society international congress date: - - journal: ann intensive care doi: . /s - - - sha: doc_id: cord_uid: o hr mox nan rationale: expiratory muscles has recently been stated as the «neglected component» in mechanically ventilated patient. several authors stated these muscles importance in cough capacity, contractile efficiency of the diaphragm or reduction of hyperinflation. however, few studies reported potential factors leading to expiratory muscle weakness and its importance on weaning success or survival after mechanical ventilation. patients and methods: this study is a secondary analysis of our previously described cohort of patients ventilated for at least h assessed for respiratory muscles function. maximal expiratory pressure (mep) measurement was carried out during spontaneous breathing trial using a manometer with an unidirectional valve. mep diagnostic accuracy to predict icu-aw (icu acquired weakness), weaning success and sursvival within days were assessed using expiratory muscle strength as absolute values (cmh o), as %predicted values and as %lower limit of normal. results: due to the paucity of data reporting threshold value for expiratory muscle weakness, we considered our median value ( cmh o (iqr )) as the threshold value for expiratory muscle weakness group (mep ≤ cmh o) and normal expiratory muscle group (mep > cmh o). patients with low mep received more catecholamines (p = . ) and a higher duration of mechanical ventilation (p = . ). inversely, higher body mass index was associated with higher mep. patients with low mep presented more icu-aw compared to normal mep patients ( % vs. %; p = . ). no other outcomes were different between groups. mep was statistically able to predict icu-aw but area under (auc) receiving operating curves showed weak predictive ability (auc: . ( % ic . - . ; p < . ) for a threshold value ≤ cmh o. expiratory muscle weakness was unable to predict critical outcomes when adjusting mep to the %predicted or lower limit of normal. discussion: possible explanation is that contrary to inspiratory muscle weakness, cough inefficacy after weaning from mechanical ventilation could be managed with cough supplementation techniques (i.e. mechanical in-exsufflation). conclusion: in our cohort, mep was not associated with mechanical ventilation weaning or death. despite our results, different clinical techniques for quantifying expiratory muscle weakness may provide more beneficial results. compliance with ethics regulations: yes rationale: venoarterial extracorporeal membrane oxygenation (va-ecmo) is used to support tissue perfusion during extracorporeal cardiopulmonary resuscitation (e-cpr). shock, resuscitation and the extracorporeal circuit may trigger a capillary leakage and a vasoplegic shock. currently, in these situations, high doses of norepinephrine (ne) are required. because high ne doses may have significant cardiovascular side effects, alternative options to support arterial blood pressure are needed. in recent years, several approaches to decrease the administration of high ne doses have been tested, one of them is the administration of vasopressin (avp). randomized trials have shown that avp infusion increases arterial pressure and systemic vascular resistance, decreases catecholamine requirements in patients with or at high risk of vasoplegic syndrome and attenuates vascular dysfunction. currently, no data are available for the study of the effects of avp in shock state in post refractory cardiac arrest. patients and methods: pigs were randomized into two groups, in order to receive avp or ne. a refractory cardiac arrest of ischemic origin was surgically created and va-ecmo was started after a min period of cardio-pulmonary resuscitation. then, resuscitation lasted h in each randomization group. the evolution of the consequences of the shock was evaluated by lactatemia and microcirculation (sdf and nirs) at baseline hour, h (when ecmo starts), h and h . renal and hepatic functions were assessed. results: experimental conditions were met for animals (avp, n = ; ne, n = ). the groups were comparable on the shock impact and its severity. no significant differences were found between populations for ecmo flow and map. there was a significant difference on fluid volume resuscitation amount ( [ . - . ] ml in the ne group versus ml in the avp group, p < . ) (fig. ). no significant difference between the ne and avp groups for lactate clearance between h and h ( . [− . to . ]% vs . [ . - . ]%, p = . ). we did not find any significant for sublingual microcirculation indices and nirs values. renal and liver function evolution were similar in the two groups during the protocol. conclusion: avp administration in refractory cardiac arrest resuscitated by va-ecmo when compared to ne is associated with less fluid volume for similar global and regional hemodynamic effects. compliance with ethics regulations: yes. patients and methods: a single-center prospective study. patients younger than months with severe bronchiolitis and supported by niv or hfnc were included. niv/hfnc was discontinued according to the local practices and no protocol existed. exceptt the principal investigator, the attending team was blinded to the study. weaning failure was defined as the need to reinstate niv/hfnc in the h after discontinuation. ethical approval was not necessary for this study in accordance with the french data protection autority methodology reference number mr- . results: a total of patients (median age days, ( %) males) were included. respectively, ( %) and patients ( %) were supported by niv and hfnc at admission (fig. ) . regarding the mode of niv, a bilevel mode was used in patients ( %) (fig. ). in patients supported by hfnc, the ventilatory support was discontinued progressively by decreasing air flow in patients ( %) while it was stopped abruptly in ( %). in patients supported by niv, the respiratory support was stopped abruptly in ( %) of them while hfnc was used as a weaning method for ( %) patients. a total of ( %) patients experienced a weaning failure. patients supported by niv/ hfnc who experienced a prompt weaning had a lower pediatric intensive care unit (picu) length of stay as compared to patients in whom hfnc was used as a weaning method ( ± h versus ± h, p = . ). however, the hospital length of stay was similar according to the weaning method ( ± days versus ± days for prompt and progressive methods respectively, p = . ). the duration of the weaning process did not differ according to the bed-availability in picu. in patients with severe bronchiolitis, a prompt weaning from niv/hfnc was associated with a lower length of stay in picu. however, the hospital length of stay was similar according to the weaning method. we suggest that a prompt weaning should be preferred in order to reduce the risk of picu related complications. compliance with ethics regulations: yes. information and incitation to open a twitter account and to follow critical care journal feeds) or group (control group). ict were interrogated on their recent medical literature knowledge at and month on trials published in pre-selected journals. results: during the study period, on the french ict contacted, agree to participate: were already on twitter, were randomized to twitter incitation and to control group. at month, there were who answered electronic questionnaire. self-declaration of article knowledge was not different between groups (p = . ). knowledge of primary outcome of each trial was not significantly better in groups (p = . ). in per-protocol analysis of ict on twitter or not, knowledge of article and primary outcome were also not significantly different (respectively p = . and p = . ). short incitation to open a twitter account and follow major medical journals with specific focus on cardiac arrest did not improve knowledge of medical literature by intensive care trainees at month. further trials are needed to better imply intensive care trainees in scientific medical literature. compliance with ethics regulations: yes. - . ] ; p = . ) as independently associated with in-hospital mortality ( fig. ). discussion: triple therapy is the recommended first-line treatment of caps. however, herein, it was not significantly associated with better survival in critically ill, thrombotic aps patients. for the subgroup of "definite/probable caps" patients, double and triple regimens were associated with survival. but the bivariable analyses including the day- saps ii showed that survival was linked to in-icu anticoagulation and corticosteroids-not ivig or plasmapheresis. our findings indicate that corticosteroids should probably be added to in-icu anticoagulation to treat "definite/probable caps". frequent fever and elevated c-reactive protein in all thrombotic aps patients suggest a marked inflammatory state that could explain corticosteroid efficacy. neither plasmapheresis nor ivig impacted the prognosis of "definite/ probable caps", but that finding could be explained by a lack of power compared to caps registry data. conclusion: in-icu anticoagulation was the only aps-specific treatment independently associated with survival for all patients. doublebut not triple-therapy was independently associated with better survival of "definite/probable caps" patients. in these patients, double therapy should be used as first-line therapy while the role of triple therapy requires further evaluation. compliance with ethics regulations: yes. motor deficiency ( %) ( %) ( %) . cognitive impairment ( %) ( %) ( %) . intra-individual relationships between Δpdi and tfdi for mechanically ventilated (mv) patients (a) and healthy subjects (c). relationships between Δpdi and tfdi when breathing cycles were averaged for all participants during each condition for mv patients (b) and healthy subjects (d). − %: initial settings minus % inspiratory help, + %: initial settings plus % more inspiratory help, pep : zero positive end-expiratory pressure, sbt: spontaneous breathing trial. healthy subjects performed spontaneousbreathing (sb) and ventilation against inspiratory threshold at , , , and % of maximal inspiratorypressure (mip) groups. airway closure occurrence increased with bmi ( %, % and %, p = . ). when present, airway opening pressure was . cmh o ( . - . ) and similar between the groups. with increasing bmi, total peep increased from . to . cmh o between groups (p = . ). all values of esophageal pressure increased with bmi. endexpiratory esophageal pressure was strongly correlated with bmi (rho = . , p < . ), as illustrated in fig. . consequently end-expiratory transpulmonary pressure decreased from − . to − . cm h o with increasing bmi (p = . ). the ratio of eelv to predicted functional residual capacity was negatively correlated with end-expiratory pressure (rho = − . , p = . ), but not with bmi. driving pressure and elastance of the respiratory system, chest wall and lung were similar across all ranges of bmi. likewise, eelv was similar between groups. conclusion: in ards, increasing bmi is associated with increased occurrence of airway closure and increased values of esophageal pressure. conversely, chest wall elastance is not influenced by bmi, as well as lung elastance. including bmi in interpreting respiratory mechanics in ards patients can provide additional information for the clinical management. compliance with ethics regulations: yes. rationale: low tidal volume is the cornerstone of protective ventilation inthe initial phase of ards ( ) . whether such low tidal volume can still be achieved when the patient is allowed to breathe spontaneously under pressure support ventilation (psv) is unknown. in moderate-tosevere ards patients receiving neuromuscular blockade, we assessed the tidal volume and its potential association with the outcome during the "transition period" following neuromuscular blockade. patients and methods: retrospective observational study in two university intensive care units. patients fulfilling moderate-to-severe ards criteria less than h after intubation and receiving neuromuscular blockers were included upon entry in the "transition period". we defined the "transition period" as the h following neuromuscular blockers cessation. ventilatory and hemodynamic parameters were recorded every h during the "transition period". primary outcome was the association between mean tidal volume under pressure support ventilation (psv) during the "transition period" and the -day mortality after adjustment for confounding factors. data are reported as median [ st- rd quartile] or number (percentage). results: one hundred nine patients were included, with a pao /fio ratio of mmhg at intubation and mmhg at inclusion and a sofa score at [ . - ] . patients had been ventilated days [ - . ] before inclusion. during the "transition period", patients ( . %) were switched to psv. the median duration of psv was h . the mean tidal volume under psv was significantly lower in survivors than in non survivors at day ( . ml/kg [ . - . ] vs. . ml/kg [ . - . ] respectively, p = . ). by multivariate analysis (cox proportional hazards regression model), mean tidal volume during psv remained independently associated with the -day mortality after adjusting for sofa score and immunosuppression. patients with a mean tidal volume above ml/kg under psv during the "transition period" had a lower cumulative probability of survival at day as compared with others (log rank test, p = . ) (fig. ) . conclusion: in patients with moderate-to-severe ards, a higher tidal volume under psv within the h following neuromuscular blockers cessation is independently associated with the -day mortality.compliance with ethics regulations: yes. kaplan-meier estimate of the cumulative probability of survival according to the mean tidal volume (vt)-lower of higher than ml/ kg-under pressure support ventilation (psv) during the "transition period" transfusion is associated with adverse events, and equipoise remains on the optimal transfusion strategy in oncologic patients in surgical setting. patients and methods: this is a retrospective, single center study. all adults admitted to the intensive care unit (icu) after oncologic surgery from january to december were eligible. the following types of surgery for cancer or metastasis resection with a high risk of bleeding were eligible: thoracic, abdominal, neurosurgery, gynecologic, urologic, otorhinolaryngology or spinal surgery. the primary outcome was a composite outcome including post-operative complications (respiratory, cardiac, renal, thromboembolic, infectious and/or hemorrhagic) and/or hospital mortality. results: of the patients included, patients ( . %) had anemia (based on the who definition: hemoglobin level - . g/dl for female; hemoglobin level - . g/dl for male), patients ( %) had moderate anemia (hemoglobin level: - . g/dl) and patients ( . %) severe anemia (hemoglobin level < g/dl). fifty-six patients ( . %) received at least one rbc transfusion during their hospital stay. patients exposed to moderate and severe anemia required more often renal replacement therapy (rrt) for acute kidney injury (aki) ( . % vs. . %; p = . ), had more surgery-related infections ( . % vs. . %; p = . ). patients who received rbc had more often aki with rrt ( . % vs. . %; p < . ), thromboembolic events ( . % vs. . %; p = . ), sepsis ( . % vs. . %; p = . ), pneumonia ( . % vs. . %; p = . ), surgical site infections ( . % vs. . ; p < . ) and second surgery for infection ( % vs. . %; p = . ). the multivariate analysis found an association between moderate and severe anemia (moderate anemia: or . [ . - . ] ; severe anemia: or . [ . - . ]; p = . ) and severe post-operative complications (fig. a) . there was also an association between rbc transfusion and severe post-operative complications ]; p < . ) (fig. b) . conclusion: anemia was frequent in oncologic surgical patients. anemia, including moderate anemia, was independently associated to patient outcomes; however, rbc transfusion also negatively impacts on patients' prognosis. our study highlights the need for further research to identify the optimal hemoglobin threshold for rbc transfusion in surgical oncologic patients. compliance with ethics regulations: yes. rationale: right ventricular (rv) failure is a common complication in moderate to severe acute respiratory distress syndrome (ards). rv failure is exacerbated by hypercapnic acidosis and overdistension induced by mechanical ventilation. veno-venous extracorporeal co removal (ecco r) might allow ultraprotective mechanical ventilation strategy with a low tidal volume (vt) and plateau pressure (pplat). this study investigated if ecco r therapy could have beneficial effects on rv function. patients and methods: this prospective monocentric pilot study was conducted in a french icu from january to march . patients with moderate to severe ards with pao /fio ratio between to mmhg were enrolled. ventilation parameters, arterial blood gases, echocardiographic parameters performed by transthoracic echocardiography (tte), low-flow ecco r system operational characteristics, outcomes and adverse events were collected during the protocol. primary end point was evolution of rv echocardiographic parameters with ultraprotective ventilation strategy at ml/kg pbw during the -h following the start of ecco r. results: eighteen patients were included. efficacy of ecco r allowed an ultraprotective strategy in all patients. we observed a significant improvement of rv systolic function parameters assessed by tte (fig. ). tricuspid annular plane systolic excursion (tapse) increased significantly under ultraprotective ventilation compared to baseline (from . to . mm; p < . ). systolic excursion velocity (s') also increased after -day protocol (from . m/s to . m/s; p < . ). a significant improvement of aortic velocity time integral (vtiao) under ultraprotective ventilation settings was observed. there were no significant differences in the values of systolic pulmonary arterial pressure (spap). when patients were separated in two groups according to baseline paco level above or under mmhg, we showed the deleterious effect of hypercapnia on rv function, and observed in both groups a beneficial impact of an ultraprotective ventilation strategy on tapse. no severe adverse events directly related to ecco r were observed in our small cohort. conclusion: the low-flow ecco r allows ultraprotective ventilation strategy and improve rv function in moderate to severe ards patients. similarly to prone positioning, ecco r could become a strategy that enables to reconcile lung protective approach with rv protective approach in ards patients. large-scale clinical studies, including patients with severe rv dysfunction, will be required to confirm these results and to assess the overall benefits, in particular the best timing of beginning ecco r in ards patients. compliance with ethics regulations: yes. rationale: bronchoalveolar lavage (bal) is usually deemed to allow the diagnosis of a large array of pulmonary diseases and is usually considered as well tolerated in intensive care unit (icu) patients. however, recent data suggest that the diagnostic yield of bal could be rather low ( ) , and may question its innocuity ( ) . the present study aimed at assessing the benefit-to-risk balance of bal in icu patients. patients and methods: the study was approved by the appropriate ethics committee and registered with clinicaltrials.gov (nct ). in icus, from april to october , we prospectively collected adverse events (ae) during or within h after bal and assessed the bal input for decision-making in consecutive adult patients. aes were categorized in grades of increasing severity. the occurrence of a clinical ae at least of grade , i.e. sufficiently severe to need therapeutic action (s), including modification (s) in respiratory support, defined poor bal tolerance. the bal input for decision-making was declared satisfactory if it allowed to interrupt or initiate one or several treatments. results: we included bal in patients (age yrs ; female gender: [ . %]; simplified acute physiology score ii: ; immunosuppression [ . %], chronic pulmonary disease [ / ( . %)]). bal was performed either in non-intubated patients receiving standard o therapy (n = [ . %]), or noninvasive ventilation (n = [ . %]), or high-flow nasal cannula o therapy ( [ . %]), or in patients under invasive mechanical ventilation (n = [ . %]). a total of aes were observed in ( . %) patients. sixty-seven ( . %) patients reached the grade of ae or higher. the main predictor of poor bal tolerance identified by logistic regression was the association of a bal performed by a non-experienced physician (non-pulmonologist, or intensivist with less than years in the specialty or less than bal performed) in non-intubated patients (or: . [ % confidence interval . - . ] ; p < . ). ordinal regression also showed that when bal was performed by a non-experienced physician in a non-intubated patient, this was associated with an increased risk of ae of any grade (or: . [ . - . ]). a satisfactory bal input for decision-making was observed in ( . %) cases and was not predictable using logistic regression. conclusion: adverse events related to bal in icu patients are frequent, and sometimes serious. our findings call for an extreme caution when envisaging a bal in icu patients and for a mandatory accompaniment of the less experienced physicians. compliance with ethics regulations: yes. meningitis is a rare complication of critically ill patients with severe pneumococcal community-acquired pneumonia paul jaubert, julien charpentier, jean-daniel chiche, frédéric pene, alain cariou, guillaume savary, marine paul, jean-paul mira, mathieu jozwiak cochin, paris, france; mignot, versailles, france correspondence: paul jaubert (paul.jaubert@gmail.com) ann. intensive care , (suppl ): rationale: severe pneumococcal community-acquired pneumonia (pcap) is a frequent infection requiring intensive care unit (icu) admission. pneumococcal meningitis associated with pcap has been reported and could worsen the prognosis of patients. however, this complication is difficult to predict and lumbar puncture is not systematically performed, regardless the severity of pcap. thus, we investigated the characteristics of patients with pcap associated with pneumococcal meningitis. patients and methods: we retrospectively included all patients admitted for pcap in our icu between (inception of our electronic medical sheet) and the end of . community-acquired pneumonia was defined according to the criteria of the american thoracic society. we excluded all patients admitted in icu with initial suspicion of meningitis. variables regarding epidemiology, clinical and microbiological characteristics, management and prognosis of these patients were collected and analyzed. results: among the patients admitted for pcap ( ± years old, saps ii ± , % of men), % of the patients required mechanical ventilation and % vasopressors infusion. the icu mortality was %. s. pneumoniae was documented by a positive antigen test in % of the patient and/or by a positive sputum smear, tracheal aspirate or distal protected airway specimen in % of the patients, and/or by pleural aspirate in % of the patients and/or by positive blood culture in % (n = ) of the patients. a lumbar puncture was performed in % (n = ) of the patients with bacteriemia and in % (n = ) of the patients without bacteriemia, with a median delay of h [interquartile range: after the onset of antibiotherapy. alllumbar punctures (n = ) were performed for neurological signs: % of coma, % of confusion and % of seizures. when a lumbar puncture was performed, meningitis was diagnosed in % (n = ) of the patients with bacteriemia and in % (n = ) of the patients without bacteriemia (p < . ). the icu mortality ( % vs. %, respectively), age ( ± vs. ± years old, respectively), saps ii ( ± vs. ± , respectively) or icu length of stay ( ± vs. ± days, respectively) were not different between patients with and without meningitis (each p = ns). conclusion: meningitis is a rare complication of pcap and is more frequent in patients with bacteriemia. suprisingly, meningitis is not associated with higher icu mortality. further analyses are ongoing to identify independent risk factors of meningitis in patients with pcap. compliance with ethics regulations: yes. rationale: shock is the clinical expression of a circulatory failure that results in inadequate cellular oxygen utilization. whereas the host response to septic shock has been extensively described, knowledge of the pathogenesis of non-septic shocks remains limited. we aimed to characterize the systemic host response in shock related to non-septic conditions (nssh) as compared with septic shock (ssh). patients and methods: we performed a prospective study in two intensive care units (icus) in patients admitted for ssh (n = ) or nssh (n = ). immune responses were determined upon icu admission by measuring plasma biomarkers reflecting host response pathways implicated in the pathogenesis of critical illness (in ssh and nssh patients), and by applying genome-wide blood mrna expression profiling (in ssh and nssh patients). results: compared with nssh, patients with ssh had more chronic comorbidities, greater disease severity (apache iv score vs. , p < . ) and worse outcomes resulting in higher mortality rates up to one year after icu admission ( . % vs. . %, p < . ). plasma biomarker analysis revealed severely disturbed host responses in both ssh and nssh patients. however, ssh patients displayed more prominent inflammatory responses, endothelial cell activation, loss of vascular integrity and a more pro-coagulant state relative to nssh patients. blood leukocyte genomic responses were more than % common between ssh and nssh patients relative to health (fig. a) , comprising overexpression of innate pro-and anti-inflammatory pathways, and underexpression of lymphocyte and antigen-presentation gene sets. direct comparison of ssh to nssh patients matched for severity (fig. b) showed overexpression of genes involved in mitochondrial dysfunction and specific metabolic pathways, and underexpression of lymphocyte, nf-κb and cytokine pathways. conclusion: patients with ssh and nssh present with largely similar host response aberrations at icu admission; however, patients with septic shock show more dysregulated inflammatory and vascular host responses, as well as specific leukocyte transcriptome alterations consistent with greatermetabolic reprogrammingand more severe immune suppression. compliance with ethics regulations: yes. rationale: aki is associated with short and long term mortality and morbidity. although recovery has been demonstrated to be associated with outcome of critically ill patients, interpretation of available data is limited by time dependent nature of recovery and by competing risks. our objective was to describe renal recovery, pattern of recovery according to adqi definitions and risk factor of this later. monocenter retrospective cohort study. adult patients admitted in our icu from july to december were included. aki was defined according to kdigo criteria and recovery according to adqi definition. incidence of recovery at each time point was depicted using competing risk survival analysis. risk of transition between aki and no-aki was assessed by a semi-markov model. last, a trajectoire analysis was performed to depict most frequent recovery patterns. results are reported as n (%) or median (iqr). results: patients were included with a median age of ( - ). median sofa score at admission was [ ] [ ] [ ] [ ] [ ] [ ] . at icu admission, patients ( . %) had an aki stage , patients ( . %) an aki stage and patients ( . %) an aki stage . according to adqi criteria, aki was defined as rapidly reversed in patients ( . % of aki patients), persistent aki in patients ( . %) and as acute kidney disease (akd) in patients ( . %), remaining patients couldn't be classified (n = ). risk of recovery was of % per day until day then % per day (fig. a) . fine and gray model, taking into account death as competing risk, identified risk factors negatively associated with renal recovery, namely sofa score (shr = . per point; % ic = [ . - . ]), preexisting hypertension (shr = . ; % ic = [ . - . ]) and aki severity (stage vs. stage shr = . ; % ic = [ . - . ]). risk of de novo aki was maximal during the first days and ranged from to % per day. trajectoire model identified clusters of patients ( fig. b) , closely associated with patients' outcome: a) low patients' severity and no or mild aki (n = ; hospital mortality: %); b) moderate to severe aki but little associated organ dysfunction (n = , hospital mortality: . %); c) severe aki and multiple organ failure (n = ; hospital mortality: . %). conclusion: this study, assessing aki recovery patterns, is the first to our knowledge using adqi definition. despite the high rate of early recovery and of rapidly reversed aki, up to % of aki patients had not recovered at day and could therefore be classified has having akd. compliance with ethics regulations: yes. rationale: sepsis is the most frequent cause of acute kidney injury (aki). the "acute disease quality initiative workgroup" recently proposed new definitions for aki, classifying it as transient or persistent. we aimed to determine the incidence, attributable mortality and host response characteristics of transient and persistent aki in patients with sepsis. patients and methods: we performed a prospective observational study comprising consecutive admissions for sepsis in intensive care units (icus) in the netherlands, stratified according to the presence and evolution of aki. attributable mortality fraction (excess risk for dying with persistent aki relative to transient aki) was determined using a logistic regression model adjusting for confounding variables. in a subset of sepsis patients, plasma biomarkers indicative of major pathways involved in sepsis pathogenesis were measured. in a second subset of patients, whole-genome blood-leukocyte transcriptomes were analyzed. results: sepsis patients were included. aki occurred in . % (n = ), of which . % (n = ) was transient and . % (n = ) persistent. patients with persistent aki had higher disease severity scores on admission than patients with transient aki or without aki and more frequently had severe (injury of failure) rifle aki-stages on admission (n = , . %) than transient aki patients (n = , . %, p < . ). persistent aki, but not transient aki, was associated with increased mortality by day- (adjusted or . , % ci . - . ; p = . ) ( figure) and up to -year (adjusted or . , % ci . - . ;p = . ). the attributable mortality of persistent relative to transient aki by day- was . % ( % ci . - . %). persistent aki was associated with enhanced and sustained inflammatory and procoagulant responses during the first days, and a more severe loss of vascular integrity compared with transient aki. baseline blood gene expression showed minimal differences with respect to the presence or evolution of aki. conclusion: persistent aki is associated with higher sepsis severity, sustained inflammatory and procoagulant responses, and loss of vascular integrity as compared with transient aki, and independently contributes to sepsis mortality. compliance with ethics regulations: yes. rationale: to address the paucity of data on the epidemiology of patients admitted to intensive care units (icus) with in-hospital cardiac arrest (ihca), we examined key features, mortality and trends in mortality in a large cohort of patients admitted in french icus over the past years. patients and methods: from to database of the collège des utilisateurs de bases de données en réanimation (cub-réa), we determined temporal trends in the characteristics of ihca, patients' outcomes and predictors of icu mortality. results: of the icu admissions, ( . %) were cardiac arrests and were ihca ( . %). during the study period, the age of ihca patients increased by . years (p = . ) and patients presented more comorbidities (chronic heart disease, chronic kidney disease and cancer). patients were also more critically ill over the period as reflected by the increase of saps-ii by . % (p < . ). paradoxically, in-hospital management became lighter through the time with reduced respiratory support (p < . ), renal support (p < . ) and use of vasoactive drugs (p < . ). crude in-icu mortality decreased from % to . % over the past eighteen years (p < . ), fig. rationale: in surgery, prophylaxis antibiotic aims at preventing the occurrence of post-operative infections. for adults, it is currently recommended to only use prophylactic antibiotic therapy during the time of the intervention. but in pediatric cardiac surgery, there is no consensus around the optimal duration of use of antibiotic prophylaxis. the protocol was modified in in the icu and its time reduced to h. we aimed to determine whether h of post-sternotomy antibiotic prophylaxis was not less effective than h treatment to help prevent care-associated infections. patients and methods: after agreement of the ethics committee of our institution, we performed a retrospective non inferiority study, with an inferiority margin to %. the primary objective is to compare the incidence of care-related infections between a second-generation cephalosporin (c g) antibiotic prophylaxis during h and a -h protocols. the secondary objectives are to determine the infection's incidence, to identify the risk factors for nosocomial infections and to compare the incidence of multidrug-resistant infections. results: between january and july , children underwent cardiac surgeries with sternal opening. received h of c g antibiotic prophylaxis and received h of c g treatment. five previously infected children have been excluded. both groups were demographically and surgically similar. the median age was months (range a few hours of life to . years old) and the median weight was . kg. in the intent-to-treat analysis, incidence of care-related infections is at . % in the c g- h group and . % in the c g- h group. a multivariate analysis shows that the shorter -h time antibiotic prophylaxis is not inferior regarding infection prevention compared to h of antibiotic prophylaxis, p = . . as in the per protocole analysis, the c g- h group rate was . % and . % for the g g- h group. conclusion: it demonstrates that shortening the antibiotic prophylaxis treatment time to h does not affect or increase the rate of infections after a pediatric sternotomy surgery compared to -h protocole. prophylaxis in pediatric cardiac surgery should be short-lived. a multicenter prospective study would allow a consensus and confirm this decision. compliance with ethics regulations: yes. rationale: the use of "big data" is getting increasingly popular in the medical field, especially in intensive care where large amounts of data are continuously generated. however, big data can be misleading when essential clinical data are missing. the adequate adjustment for potential confounding factors (e.g., severity of respiratory distress) should be the key procedure in the big data analyses; however, it is challenging to capture the clinical severity within large electronic databases. bronchiolitis is one main reason for admission to pediatric intensive care unit (picu). the modified wood's clinical asthma score (mwcas) is widely used to assess the severity of bronchiolitis. the objective of the study is to build an automated mwcas (a-mwcas) to continuously assess the severity of respiratory distress in critically ill children. this retrospective study included all infants < years old with a clinical diagnosis of bronchiolitis, ventilated with non-invasive neurally adjusted ventilatory assist, in a canadian picu, between october and june . we developed an algorithm, using python . , which was directly connected to the electronic medical record. the components of the score were collected using structured query language (sql) queries and processed to derive the a-mwcas. for validation, the a-mwcas score was compared to the mwcas manually computed by a clinical expert (m-mwcas) . results: sixty-four infants were included in the study, for which of a-mwcas and m-mwcas were generated respectively. the cohen's kappa coefficient was applied to estimate the agreement between the two scores which was . ( % confidence interval) ( table ) which corresponds to . % of complete agreement. . % of the a-mwcas scores were within ± . of the m-mwcas. the kappa coefficient for the each score component were: . for the oxygen saturation, . for the expiratory wheezing, . for the inspiratory breath sounds, . for the use of accessories muscles and . for the mental status, respectively. discussion: the largest discrepancy was observed in the mental status, which clinical evaluation is relatively subjective and varies among care team members (doctor, nurse, respiratory therapist…). the automated score likely decreases this variability by consistently using the same source (respiratory therapist), but its validity should be confirmed in a prospective study. the a-mwcas provides a valid estimation of the mwcas that is fast and robust. after external prospective validation, it may help to add some clinical sense within large electronic databases, with improved assessment of the respiratory distress. compliance with ethics regulations: yes. rationale: in paediatric intensive care units (picu), survival rates have dramatically improved. this has been accompanied by increased morbidity, including psychological morbidity. these new impairments, that can affect the survivors and their families have been conceptualized under the frame of post-intensive care syndrome (pics) and picsfamily. the aim of this study was to explore the experience of critically ill children parent's during the stay in picu, and its impact on the family. patients and methods: we planned a prospective, single centre study for months. we collected qualitative written data from parents whose child had been admitted to the picu for the first time, for at least two nights. results: fifty-seven questionnaires were analysed from thirty-seven admissions. picu admissions were mostly unplanned. among parents % experienced very painful memories during admission and % have feared for their child's life. during the stay, noise has bothered % of parents, and many have described difficulties to rest at night. % had the sensation that their child was suffering, mostly from pain, tiredness, anxiety or fear. during picu stay, % of parents had to stop working, and siblings schooling was impacted in % of cases, % of parents considered themselves to be useful for their child and % have participated to nursing care. more than % were satisfied about information given and communication, % appreciated empathy and support from care givers. parents received support from family, friends, and also from other parents of hospitalized children. parents expressed relief ( %) and serenity ( %) to leave picu, % of them were in demand to meet picu staff again after discharge. conclusion: picu parent's experience is tough, and the impact on family is clear. these are known risks factors for pics. on a very positive note, parents seemed to be satisfied by family-centred care, and were able to preserve their parental role. however, there is still room for improvement of practices. compliance with ethics regulations: yes. the gut has been suspected to be involved in multiple organs dysfunction syndrome (mods) in the intensive care unit (icu). studies suggested a link between gastrointestinal dysfunction (gid) and outcomes. but these studies included very few patients and most of them were retrospective. patients and methods: this study is a secondary analysis of data from a previous study that included patients from french icus. gid is defined as the association of vomiting and constipation or diarrhea during the first week after icu admission. patients included were treated with vasopressors and mechanical ventilation. the first goal was to determine if gid is a risk factor of -day mortality in this population. secondary goals were to assess the impact of gid on nosocomial infections. results: among included patients, ( . %) had gid. by day- , ( %) of the patients with gid and ( %) of the patients without gid had died (odds ratio . [ . - . ]; p = . ). multivariable regression model did not show any association between gastrointestinal dysfunction and increased risk of -day mortality in patients (odds ratio . [ . - . ], p = . ). gastrointestinal dysfunction was strongly associated with other secondary outcomes ( table ). patients with gid had longer ventilation duration, icu length of stay and hospital length of stay. they also had more nosocomial infections, in particularly ventilator-associated pneumonia. this association still existed in a multivariable regression model for prediction of nosocomial infection including the same variables than the previous model (odds ratio . [ . - . ], p = . ). no association with day- mortality was observed. conclusion: gastrointestinal dysfunction was not a risk factor of day- mortality but was associated with an increased risk of nosocomial infection and an increased length of stay. this study is observational and no causality link can be done. however, our data suggest further studies on strategies aimed to limit gid. compliance with ethics regulations: yes. rationale: acute cholangitis (ac), a bacterial infection related to an obstruction of the biliary tree, may be responsible for life-threatening organ failure. however, little is known about the outcome and the predictive factors of mortality of critically ill patients admitted in icu for acute cholangitis. we aimed to describe characteristics of patients admitted in icu for ac and to analyze predictive factors of in-hospital mortality including the time to biliary drainage procedure. patients and methods: retrospective study of all cases of acute cholangitis admitted in french icus ( tertiary hospitals and non-ter- [ . ; . ] µg/l. % of patients (n = ) have positive blood culture, mostly gram negative bacilli ( %) and % producing extended spectrum beta lactamase enterobacteriaecae. at icu admission, persisting obstruction was frequent ( %) and therapeutic endoscopic retrograde cholangiopancreatography was performed in % of them. in a multivariable analysis, at icu admission, several factors were significantly associated with in-hospital mortality: sofa score (or = . [ % ic . ; . ] by point, p = . ), arterial lactate (or = . [ . ; . ] by mmol/l, p < . ), total serum bilirubin (or = . [ . ; . ] by umol/l, p < . ), obstruction nonrelated to gallstones (p < . ) and ac complications (liver abcess and/or pancreatitis) (or = . [ . ; . ] p = . ). in addition, time > h between icu admission and biliary drainage was associated to in-hospital mortality (adjusted or = . [ . ; . ] p = . ). conclusion: acute cholangitis is responsible for high mortality in icu. organ failure severity, causes and local complications of cholangitis are predictive factors of mortality as well as delayed biliary drainage. compliance with ethics regulations: yes. the united kingdom) were included (n = ). predictors of one-year mortality were retrospectively screened and tested on a single center training cohort. a predictive score was developed and tested on an independent multicenter cohort. results: four independent pre-transplantation risk factors were associated with one-year mortality after transplantation in the training cohort: age ≥ years (or = . , % ci = . - . , p = . ), pre-transplantation arterial lactate level ≥ mml/l (or = . , % ci = . - . , p = . ), mechanical ventilation with pao / fio ≤ mmhg (or = . , % ci = . - . , p = . ) and pretransplantation leukocyte count ≤ g/l (or = . , % ci = . - . , p = . ). a simplified version of the model was derived by assigning point to each risk factor: the transplantation for aclf- model (tam) score. a cut-off at points distinguished a high-risk group (score > ) from a low-risk group (score ≤ ) with one-year survival of . % vs. . % respectively (p < . ). the model and its simplified version were validated on the independent multicenter cohort. there was a significant difference between the high-risk and low-risk group with one-year survival of % vs. . % respectively (p < . ). conclusion: liver transplantation can be an effective treatment for critically ill cirrhotic patients with hepatic and extra hepatic organ failure provided patients are carefully selected and that they are transplanted at the optimal time in the intensive care. the tam score can help stratify post-transplantation survival and assist clinicians in the transplantation decision-making process at the bedside of aclf- patients. compliance with ethics regulations: yes. rationale: trans-thoracic echocardiography (tte) is commonly used in the initial management of patients with shock in icu. there is little published evidence for any mortality benefit. we compared the effect of echocardiography protocol versus standard care for survival and clinical outcomes. patients and methods: this randomized controlled trial included selected shocked patients (systolic blood pressure < mm hg and signs of organ hypoperfusion) randomized to early tte plus standard care versus standard care without tte. the primary outcome measure was survivalto days. secondary outcome measures included initial treatment and vasopressor weaning. results: consecutive subjects with circulatory shock (low systolic arterial blood pressure (sap) and signs of organ hypoperfusion) at the time of icu admission are included in the study. in the tte group: fluid prescription during the first h was significantly lower rationale: both the negative prognostic value and reversibility of left ventricular (lv) diastolic dysfunction in septic patients remain debated. the excess of mortality in septic shock patients with hyperdynamic profile has only been reported by small-size studies. accordingly, the primary objective of the prodiasys study was to assess the impact of lv diastolic dysfunction (and its severity) and of lv hyperkinesia echocardiographically identified during the initial phase of septic shock on -day survival. the secondary objective was to assess the potential link between lv diastolic dysfunction, cumulative water balance (on day ), and outcome. patients and methods: this was a multicenter, prospective, observational, cohort study. patients older than years hospitalized in icu for septic shock (sepsis- definition) were eligible. exclusion criteria were administration of inotropes, severe left valvular disease, constrictive pericarditis and moribund patients. in each patient, echocardiography was first performed within h after the diagnosis of septic shock and then daily until day , after vasopressor discontinuation, at icu discharge and on day or at hospital discharge, whichever occurred first. vital and biological parameters usually monitored for septic shock management were collected at each echocardiographic assessment. vital status was collected on day . associations between lv diastolic dysfunction or lv hyperkinesia and day- mortality were analyzed using a chi test. adjusted analyses were performed using logistic regression models, including variables known to be linked with the prognosis of septic shock (e.g., severity scores, delay of antibiotherapy). the relationship between the grade (i to iii) of lv diastolic dysfunction and -day survival were analyzed using a logistic regression model. the relationship between the presence of lv diastolic dysfunction and cumulated water balance on day were analyzed using a linear regression model adjusted on the body weight on admission. the relationship between the grade of lv diastolic dysfunction and cumulated water balance on day were analyzed using a linear regression model. diaphragm dysfunction and weaning induced pulmonary edema are two frequent causes of weaning failure but their coexistence and interaction have been poorly investigated. we hypothesized that diaphragm dysfunction may not induce a sufficient decrease in intra-thoracic pressure to increase venous return and generate a weaning induced pulmonary edema. we therefore investigated whether weaning induced pulmonary edema and diaphragm dysfunction are or not associated and evaluated the effect of diaphragm dysfunction on cardiac function and lung aeration during a spontaneous breathing trial (sbt). patients and methods: patients with readiness to wean criteria who had failed a first sbt were eligible. before and after a second sbt, diaphragm function was assessed by measuring the change in tracheal pressure induced by a bilateral phrenic nerve stimulation (ptr, stim), cardiac function (cardiac output, systolic pulmonary arterial pressure) was evaluated with echocardiography and lung aeration was estimated from the lung ultrasound score (lus). plasma protein concentration and hemoglobin were also sampled before and after the sbt. diaphragm dysfunction was defined by ptr, stim < − cmh o and weaning induced pulmonary edema was diagnosed in case of sbt failure associated with ) increase in plasma protein concentration or hemoglobin > % during the spontaneous breathing trial and/or ) early (e) over late peak diastolic velocity ratio > . or e over peak diastolic velocity ratio > . . results: fifty-three patients were included and / ( %) failed the sbt. diaphragm dysfunction was present in / ( %) of patients with weaning induced pulmonary edema, in / ( %) patients with sbt success and in / ( %) patients with other causes of sbt failure (p < . ). during the sbt, diaphragm dysfunction induced a significant increase in systolic pulmonary arterial pressure but no change in cardiac output. patients with diaphragm dysfunction had a higher lus as compared to their counterparts ( ± vs. ± , respectively, p < . ). conclusion: diaphragm dysfunction induces a loss of lung recruitment and a significant increase in systolic pulmonary arterial pressure during the sbt. coexistence of diaphragm dysfunction and weaning induced pulmonary edema is common in case of sbt failure but weaning induced pulmonary edema appears more likely to be involved than diaphragm dysfunction. compliance with ethics regulations: yes. rationale: diaphragmatic weakness in the intensive care unit (icu) is associated with poor outcome. prolonged mechanical ventilation is associated either with a decrease (atrophy) or an increase (supposed injury) in diaphragmatic thickness, both associated with prolonged weaning. shear wave elastography is a non-invasive technique that measures diaphragm shear modulus (sm), a surrogate of its mechanical properties. the aim of this study was to describe the diaphragm shear modulus during the icu stay and to describe its relation with diaphragm thickness. patients and methods: this prospective and monocentric study included all consecutive critically ill patients. ultrasound examination of the diaphragm (aixplorer; supersonic-imagine, aix-en-provence, france) was obtained by two investigatorsevery other day until icu discharge. demographics, diaphragm thickness, sm and outcomes were collected. a mixed model regression was used to study the relation between sm and diaphragm thickness. results: we enrolled patients from december st to june st, being invasively mechanically ventilated during the stay. diaphragm ultrasound evaluation was feasible in / ( %) patients. the duration of mechanical ventilation during the icu stay was [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] days with [ ] [ ] [ ] [ ] [ ] days spent on controlled mechanical ventilation. sm was . ± . kpa and diaphragm end-expiratory thickness was . ± . cm upon icu admission. increase and decrease ≥ % during icu stay occured in and percent of the patients respectively for diaphragmatic thickness, and in and percent of the patients respectively for diaphragmatic sm. diaphragm thickness over time was inversely correlated with diaphragm sm and with time spent under mechanical ventilation (table) . diaphragm sm over time was correlated with time spent under pressure support ventilation or under spontaneous breathing (compared to controlled ventilation) and with time spent under deep sedation. diaphragm sm was inversely correlated with age, sepsis, exposition to steroids (table) . no association was found between diaphragm sm and outcomes. discussion: our results are in line with the myotrauma concept, suggesting alteration in diaphragm mechanical properties associated with increased diaphragm thickness in critically ill patients. we hypothesize that this observation most likely reflects muscle injury and tissue infiltration with edema and inflammatory cells. conclusion: shear wave ultrasound elastography suggests that in critically ill patients, the increase in diaphragmatic mass is associated with an alteration in diaphragm mechanical properties as measured by sm. compliance with ethics regulations: yes. rationale: diaphragm dysfunction and intensive care unit (icu) acquired weakness (icu-aw) are associated with poor outcomes in the icu but their long term impact on prognosis and health-related quality of life (hrqol) is poorly established. this study sought to determine whether diaphragm dysfunction is associated with negative long-term outcomes and whether the coexistence of diaphragm dysfunction and icu-aw has a particular impact on two-year survival and hrqol. patients and methods: we used a previous cohort study conducted in our institution to follow up mechanically ventilated patients in whom diaphragm and limb muscle functions were investigated at the time of liberation from mechanical ventilation. diaphragm dysfunction was defined by tracheal pressure generated by phrenic nerve stimulation < cmh o and icu-acquired weakness was defined by medical research council (mrc) score < . hrqol was evaluated with the sf- questionnaire. results: sixty-nine of the patients enrolled in the original study were included in the survival analysis and were interviewed. overall two-year survival was % ( / ): % ( / ) in patients with diaphragm dysfunction, % ( / ) in patients without diaphragm dysfunction, % ( / ) in patients with icu-acquired weakness and % ( / ) in patients without icu-acquired weakness. patients with concomitant diaphragm dysfunction and icu-acquired weakness had a poorer outcome with a -year survival rate of % ( / ) compared to patients without diaphragm function and icu-acquired weakness ( % ( / ) (p < . )). hrqol was not influenced by the presence of icu-acquired weakness, diaphragm dysfunction or their coexistence. conclusion: icu-acquired weakness but not diaphragm dysfunction has a strong negative impact on two-year survival of critically ill patients. the presence of diaphragm dysfunction appears more likely to be a determinant of early prognosis and does not appear to have a significant impact on long-term survival. compliance with ethics regulations: yes. rationale: influenza can lead to severe condition with acute respiratory failure and acute respiratory distress syndrome due to a massive pulmonary inflammatory in response to the viral invasion. lung bacteriobiota has been described to be associated with pulmonary inflammation in chronic respiratory diseases such as chronic obstructive pulmonary disease or cystic fibrosis. lung mycobiota has been poorly investigated despite the well-known role for fungi in numerous respiratory diseases. the aim of our study was to assess the prognostic value of lung bacteriobiota and mycobiota among critically ill influenza patients. patients and methods: we prospectively included influenza patients admitted to icu. sputum were stored a - °c. bacterial and fungal dna were extracted thanks to qiaamp ® powerfecal ® pro dna kit. s rrna gene v -v regions and its regions were amplified by pcr and sequenced on illumina miseq ® . taxonomic assignation was obtained by dada pipeline and microbiota analysis were performed according to day- mortality by the mean of phyloseq package on r . . software. results: thirty-nine patients were admitted to icu for influenza with sputa available and finally dna samples available after extraction. bacteriobiota alpha diversity was significantly lower among non-survivors than survivors when expressed by the mean of shannon index, simpson index or evenness (respectively p = . , p = . , p = . ). area under the curve to predict day- mortality was . , ci [ . ; . ] for shannon index, . ci [ . ; . ] for simpson index and . ci [ . ; . ] for evenness. β-diversity analysis also demonstrated significant differences between survivors and non-survivors (adjusted permutational multivariate anova, p = . ). nonsurvivors had a higher abundance of staphylococcus, haemophilus, streptococcus and moraxella. none of the fungal alpha-diversity index nor beta-diversity were significantively different between survivors and non-survivors. non-survivors had a higher proportion of candida albicans and malassezia but not of aspergillus. conclusion: the lung bacteriobiota profile, but not the mycobiota one, of critically ill influenza patients is associated with day- mortality and may be used to identify subjects with a poor prognosis at the time of admission. compliance with ethics regulations: yes. that takes into account the interaction between multiple cellular pathways. the pathway profiles between moderate and severe influenza were then compared to delineate the biological mechanisms underpinning the progression from moderate to severe influenza. results: patients ( severe and moderate influenza patients) and healthy control subjects were included in the study. severe influenza was associated with upregulation in several neutrophilrelated pathways, including pathways involved in neutrophil differentiation, migration, degranulation and neutrophil extracellular trap (net) formation. the degree of upregulation in neutrophil-related pathways was significantly higher in severely infected patients compared to moderately infected patients. severe influenza was also associated with downregulation in immune response pathways, including pathways involved in antigen presentation, cd + t-cell co-stimulation, cd + t cell and natural killer (nk) cells effector functions. apoptosis pathways were also downregulated in severe influenza patients compared to moderate and healthy controls. conclusion: these findings showed that there are changes in gene expression profile that may highlight distinct pathogenic mechanisms associated with progression from moderate to severe influenza infection. compliance with ethics regulations: yes. rationale: herpesviridae reactivation among non-immunocompromised critically ill patients is associated with impaired prognosis, especially during acute respiratory distress syndrome (ards). however, few is known about herpes simplex virus (hsv) and cytomegalovirus (cmv) reactivation occurring in patients with severe ards under venovenous extracorporeal membrane oxygenation (ecmo). we tried to determine the frequency of herpesviridae reactivation and its impact on patients'prognosis during ecmo for severe ards. patients and methods: we conducted an observational, retrospective study in a medical icu (ards and ecmo referee center) between and . patients with a severe ards requiring a venovenous ecmo for days or more were included. hsv and/or cmv reactivation occurring after ecmo insertion was screened for these patients. patients with immunosuppression, antiviral therapy against hsv and/ or cmv prior to inclusion, or hsv/cmv reactivation known at the time of ecmo insertion were excluded. hsv reactivation was defined by a positive qualitative throat sample (virocult ® ) pcr or positive bronchoalveolar lavage (bal) pcr. cmv reactivation was defined by a positive quantitative blood or bal pcr. results: during a five-year period, non-immunocompromised patients with a severe ards necessitating a veno-venous ecmo were included. sixty-seven ( %) experienced hsv and/or cmv reactivation during ecmo course ( viral co-infection, hsv alone and cmv alone). hsv reactivation occurred earlier than cmv after the beginning of mv ( ( - ) vs. ( - ) days; p < . ) and after ecmo implementation ( ( - ) vs. ( - ) days; p < . ). in univariate analysis, hsv/cmv reactivation was associated with a longer duration of mechanical ventilation ( ( - . ) vs. . ( - ) days; p < . ), a longer duration of . ) vs. ( - ) days;p < . ), and a prolonged vs. ( - ) days; p < . ) and hospital stay ( ( - . ) vs. ( - ) days; p < . ). however, in multivariate analysis, viral reactivation remained associated with prolonged mv only. when comparing patients having cmv (alone or combined with hsv) vs. hsv reactivation alone, cmv positive patients had a longer mechanical ventilation duration and fewer ventilator-free days at day- and a longer icu and hospital length of stay. conclusion: herpesviridae reactivation is frequent among patients with sevre ards under veno-venous ecmo and is associated with a longer duration of mechanical ventilation. cmv seems to have a proper negative role on pulmonary fiunction as compared to hsv alone. hsv and cmv deserve to be researched in severe ards patients under ecmo. compliance with ethics regulations: yes. charlotte vandueren , benjamin zuber , eve garrigues , antoine gros , nicolas epaillard , guillaume voiriot , yacine tandjaoui rationale: respiratory syncytial virus (rsv) is a common cause of pediatric bronchiolitis and influenza-like illness in adults. its involvement in severe infections in adults remains unclear. the captif study aimed at comparing characteristics and prognosis of icu patients infected with rsv and influenza, assuming that, based on the limited evidence, the mortality of rsv infection would be lower than the influenza related one. patients and methods: multicenter franco-belgian retrospective study. adults admitted to icus between /nov/ and / apr/ with respiratory rsv infection were included and matched : to influenza patients on center and icu admission date. patients' characteristics, clinical presentation, and outcome were compared between groups using univariate and multivariable analyses. results: we report here the results for the first cases among included patients. mean age was . ( . ) years and saps- score was ( ), not different between groups. compared to influenza patients, rsv patients more frequently had chronic respiratory failure ( % vs %, p < . ) or immune suppression ( vs %, p = . ). frequencies of cardiac, renal and hepatic chronic diseases were similar. almost all patients had respiratory symptoms (> %), extrarespiratory symptoms were more frequent in influenza patients ( vs %, = . ). rsv patients more frequently had bronchospasm ( vs %, p = . ). clinical presentation such as ards ( %), shock ( %) and pulmonary coinfection ( %) were similar, however sofa score was higher in rsv patients ( . ( . ) vs . ( ), p = . ). the p/f ratio was around mmhg in both groups, paco was higher in rsv patients ( vs mmhg, < . ). respiratory assistance at diagnosis tended to differ (p = . ), rsv patients receiving more non invasive ventilation ( vs %) and less high flow oxygen therapy ( vs %) but invasive ventilation was required similarly ( vs %). during icu stay, ards was more frequent in rsv patients ( vs %, p = . ), accordingly prone position ( . vs . %) and ecmo ( . vs . %) were more frequently needed. length of mechanical ventilation ( days ( - ) ) and icu los ( days ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ) were not different. icu mortality was similar in rsv and influenza patients ( . % and . %), the multivariate analysis did not find an association between type of virus and mortality. conclusion: rsv infection is frequent in adult icu patients. it presents more frequently than influenza as an acute on chronic respiratory failure with bronchospasm. despite difference in case mix and clinical presentation, vrs severity and burden appear similar to influenza justifying effort to prevent and treat it. compliance with ethics regulations: yes. rationale: mortality in acute stroke patients requiring mechanical ventilation ranges from to % at year. studies evaluating indicators of outcome in these patients have limitations, including singlecenter, retrospective designs and no adjustment for withholding/ withdrawal of life-sustaining treatments (wlst). our objective was to identify factors associated with -year survival in acute stroke patients requiring mechanical ventilation. patients and methods: retrospective analysis of a prospective multicenter database between and . icu stroke patients entered in the database and requiring mechanical ventilation within h were included. were excluded patients with stroke of traumatic origin, subdural hematoma or venous cerebral thrombosis. factors associated with -year survival were identified using a cox model stratified on inclusion center, adjusted on wflst occurring during the first h. data are presented as median [q -q ] or percentages. cox model results are presented as hazard ratios (hr) and % confidence intervals (ci). results: we identified patients from icus, aged [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] years and % males. on admission, the glasgow coma score (gcs) was [ ] [ ] [ ] [ ] [ ] [ ] and the saps score was . types of strokes were ischemic ( %), hemorrhagic ( %) and subarachnoid hemorrhage (sah) ( %). ischemic stroke patients received thrombolysis or thromboaspiration in / ( %) cases, and hemorrhagic stroke/ sah patients received neurosurgery or embolization in / ( %) cases. reasons for endotracheal intubation were coma ( %), acute respiratory failure ( %), seizures ( %), cardiac arrest ( %) and elective procedure ( %). sixty-five ( %) patients received a decision of wflst in the first h. one-year survival year was %. variables independently associated with -year survival were stroke type (ischemic as reference, hemorrhagic hr . (fig. ) . inclusion period ( inclusion period ( - inclusion period ( / inclusion period ( - inclusion period ( / inclusion period ( - or having a stroke unit on site was not associated with -year survival. conclusion: in acute stroke patients requiring mechanical ventilation, the reason for intubation and the opportunity to receive a specific stroke therapy are independently associated with long-term survival. these variables should be integrated in the decision process regarding initiation of mv in acute stroke patients. compliance with ethics regulations: yes. rationale: international guidelines recommend targeted temperature management (ttm) between ° and °c for out-of-hospital cardiac arrest (ca) patients. however, it is unknown if this treatment is effective whatever the severity of the insult. we aimed to examine the association between ttm and long-term neurological outcome according to the risk evaluated at time of admission in intensive care unit (icu) using a dedicated and validated score. patients and methods: we used data prospectively collected in the sudden death expert center (sdec) registry (great paris area, france) between may and december and in the resuscitation outcome consortium-continuous chest compression (roc-ccc) between june and may . we used a modified version of the cardiac arrest hospital prognosis (mcahp) score to assess the risk of poor outcome at icu admission in each of datasets. we finally studied the association between ttm use and long-term neurological prognosis according to mcahp score at icu admission divided into tertiles of severity in each of the datasets. results: there were patients analyzed in the french dataset and in the north-american dataset. the mcahp identified categories: low risk (score < points, % of unfavourable outcome), medium risk ( ≤ score < , % of unfavourable outcome) and high-risk group (score > , % of unfavourable outcome). according to the mcahp score at icu admission, ttm was associated with a better long-term neurological prognosis in patients with low risk (aor = . [ . - . rationale: acute ischaemic stroke is associated with a high risk of mortality, morbidity and healthcare-related costs. over the last decades new treatments, such as thrombolysis and thrombectomy, have been introduced. because of their further improvement, complications have been decreasing. this also led to extending indications for treatment to patients who were previously not eligible. the impact of this evolution on long-term outcome and cost-effectiveness has mainly been assessed in clinical trials and simulation studies. patients and methods: this single-centre retrospective study included patients treated for stroke between january and february . functional outcome at days was assessed by the modified rankin scale (mrs). cost data were retrieved from individual invoices of patients. undiscounted total healthcare costs were calculated for the index hospital stay, capped at days. contribution of cost categories to total costs was analysed. mrs at days was used as a proxy for utilities to define quality-adjusted life years (qalys). multivariate analysis was done for gender, age, charlson comorbidity index, pre-stroke mrs, stroke severity (nihss) and treatment modality (thrombectomy, thrombolysis, thrombectomy + thrombolysis, no intervention). incremental cost-effectiveness ratios (icers), associated to each treatment modality, were calculated. results: no intervention was done in patients ( . %). patients ( . %) required thrombolysis, ( . %) thrombectomy and ( . %) the combination. total costs were mean , eur ) . hospitalisation costs (mean , eur, iqr - , ) represented % of total costs, compared with drug costs ( eur, iqr - ), procedural costs ( eur, iqr - ), honoraria ( eur, iqr - ), lab ( eur, iqr - ) and imaging ( eur, iqr - ). mean total costs differed between treatment modalities: , (iqr - , ) eur for no intervention, , ) eur for thrombolysis, , (iqr , ) eur for thrombectomy and , (iqr , ) eur for the combination (p < . ). drivers for total costs were treatment modality (p < . ) and nihss-stroke severity (p < . ). utility scores were . rationale: emergency endotracheal intubation (eti) in the intensive care unit (icu) often concerns hypoxemic patients with hemodynamic instability. a cardiovascular collapse (cvc) after eti is a life-threatening complication. french guidelines suggested systematic fluid loading prior to eti. our study aimed to predict cvc after eti, while using echocardiography, and to evaluate the impact of fluid loading. patients and methods: a prospective study of consecutive intubations was performed from june to november in three icus. patients were selected if mean blood pressure measurements ≥ mmhg before eti. cvc was defined as mean blood pressure < mmhg within min following eti. four echocardiographic examinations were performed: - min before and - min after eti (or when a cvc occurred); -after passive leg raising; - h following eti. patients were classified as fluid responders when the left ventricular outflow tract velocity-time integral increased by at least % compared with baseline. results: echocardiographic examinations were performed. cvc occurred in / procedures ( %). in cvc group, mean dose of diprivan, used for fast sequence induction, was higher ( . ± mg/kg vs . ± . mg/kg, p = . ). in the cvc group, fluid responsiveness was considered in % patients and left ventricular (lv) systolic dysfunction %. lv diastolic dysfunction did not concern any patient in the cvc group. systolic blood pressure (sbp) < mmhg was the sole independent risk factor for cvc occurrence in multivariate analysis: or . ci % . - . , p = . . fluid responsiveness independent risk factors for cvc patients was sbp < mmhg (or . , ci % . rationale: the autonomic nervous system is highly adaptable and allows the organism to maintain its balance when experiencing stress. heart rate variability (hrv) is a mean to evaluate cardiac effects of autonomic nervous system activity and a relation between hrv and outcome has been proposed in various types of patients. we attempted to evaluate the best determinants of such variation in survival prediction using a physiological data-warehousing program (reastoc clinicaltrials identifier nct ). patients and methods: physiological tracings were recorded at hz from the standard monitoring system (intelliview philips mp ) using the synapse software (ltsi inserm umr ), for a h period, during the h following icu admission. all measurements were recorded while patients were laying in bed, with the head at ° and without any medical intervention. physiological data were associated with metadata collection by a dedicated research assistant. hrv was derived using kubios hrv, in either temporal ( (sdnn), (rmssd) and triangular index (ti)), frequency ( (lf), (hf)), non-linear domains (poincaré plotting) and entropy. results: consecutive patients were recorded between may and april . a lower lf/hf (< . ) and sd /sd (< . ) ratios on admission were associated with a higher icu mortality. multivariate analysis enabled to develop a mortality predictive model (bicus) associating spo /fio and hrv parameters (lf/hf and shannon entropy) with an auc = . (p < . ) for a bicus value > (fig. ) . conclusion: hrv measured on admission enables to predict prognosis in the icu, independently of the admission diagnosis, treatment and mv requirements. bicus may help predict prognosis on a real time basis, using parameters derived from standard routine monitoring. compliance with ethics regulations: yes. rationale: stroke, in the context of type diabetes (t d) is associated with a worse outcome than in non-diabetic conditions, reflected by an increased ischemic volume and more intracerebral hemorrhage. an unbalanced diet is one of major risk for developing t d. we aimed at creating a reproducible mouse model of stroke in impaired glucose tolerance condition induced by high fat diet. patients and methods: adult c bl mice ( male and female) were fed for months with either high fat diet (hfd, % lipids, % proteins, % carbohydrates) or a normal diet (nd, . % lipids, . % proteins, . % carbohydrates) . we used a model of middle cerebral artery occlusion (mcao) by a monofilament for min. oral glucose tolerance test and insulin tolerance test were used for evaluating the pre-diabetic state. mice were euthanized h after reperfusion. systemic inflammation, cerebral infarct volume and hemorrhagic transformation were determined. results: hfd was associated with an increased glycaemia following the oral glucose tolerance test. plasma leptinlevels in stroke conditions were significantly higher in hfd vs nd group. the hfd group presented a significant increase of infarct volume (hfd: . ± . mm vs nd: . ± . mm p = . ) and hemorrhagic transformation (hfd: . ± . vs nd: . ± . p = . ) (fig. ) compared to nd group. discussion: in humans, one of the mechanisms leading to insulin resistance is low-grade inflammation. hfd increases gut permeability, which leads microbiota dysbiosis, thereby promoting metabolic endotoxaemia and a low-grade inflammation state. experimental mouse models available for diabetes studies use leptin receptor deficient mice which develop t d or destruction of pancreatic beta cells by streptozotocine injection (t d). studies using diet-induced insulin resistance models generally feed the mice for weeks or more. however, metabolic disorders could appear earlier such as increase inflammatory markers. in our model, a short exposition to hfd ( weeks) leads to an increase of the pro-inflammatory markers as plasma leptin and a more severe stroke status (infarct and hemorrhagic transformation). conclusion: two months of hfd in adult mice altered hyperglycemia control. this metabolic disorder was associated with significantly higher leptin production, increased infarct volume and hemorrhagic complications than in normal-fed mice. this new model is particularly relevant to study stroke under pre-diabetic conditions induced by hfd. compliance with ethics regulations: yes. eight weeks of hfd increase ischemic volume and hemorrhagic transformation. (a)-infarct volume (v) h after reperfusion, all value are mean ± sem, hfd: v = . ± . mm , n = , nd: v = . ± . mm , n = , *p = . (b)-hemorrhage transformation (ht) score h after mcao. all value are mean ± sem hfd: ht score = . ± . , n = , nd: ht score = . +/+ . , n = *p = . rationale: cardiac arrest (ca), as massive ischemia reperfusion (ir), is an universal health issue. medication taken at the time of the ca could have prognosis consequences. no medication has proven its benefit on ca prognosis. pharmacological pre-or postconditioning aims to reduce ir injury but with disappointing results. metformin (met) is a worldwide-prescribed antidiabetic drug, and several clinical reports plead for a potential protective effect in various settings of sterile and non sterile inflammation, including ir. our hypothesis is that met act as a preconditioning drug against ca-induced ir. patients and methods: retrospective single academic medical center survival study (french west indies) on resuscitated ca in icu (institutional ethical committee approval). data were extracted from medical charts, pmsi, and laboratory dbsynergy ™ software. anonymized data were entered on a excel ™ and transferred to ibm ® -spss ® software (v . . . ) for analysis. univariate study (chi- , fisher exact tests, student-t test, mann-whitney u-test if required) was followed by a multivariate model (odd ratio or and % ic: kaplan-meier estimator and non parametric logrank test-mantel cox model). assuming an overall in-hospital mortality for ca in icu of % with an expected mortality decrease of % by met, the number of patients to be included is . results: the inclusion period was to , with included patients ( diabetic patients among whom took met). the d mortality was % in met+ patients (n = ) versus % in nomet patients (n = ), p < . . comparing alive (n = ) versus deceased (n = ) at d in univariate then multivariate analysis, asystole on the first ekg, number of iterative cardiac arrest,sofa, no-flow, lactate, low-flow and sapsii appear as independent criteria associated with d mortality.conversely, met intake showed up as a protective criterion (or . , ci . - . ). the survival curve, including strata of low-flow duration at the cut-off min, is reported on the fig. . among diabetic patients (n = ), the mortality of patients in the met+ (n = ) was % versus % in the nomet (n = ), p = . . conclusion: in diabetic patients suffering of massive ir related to resuscitated ca, a current treatment by met is associated with a better survival. these results support a protective effect of met and are important to initiate prospective evaluations, because of millions diabetic people around the world and the potential benefit of met. the potential benefit in non diabetic patients and in sterile as well as non sterile inflammation should be addressed. compliance with ethics regulations: yes. rationale: during systemic inflammation, the accumulation of misfolded proteins in the endoplasmic reticulum (er) induces er stress (ers). in animal models, the inhibition of ers reduces inflammatory response and organ failure. cardiopulmonary bypass (cpb) induces a significant systemic inflammatory response but ers expression has never been described in cardiac surgery patients. our objective was to describe the variations of the glucose related protein of kda (grp ), the final effector of the ers, during cpb. patients and methods: we conducted a prospective monocenter study including patients undergoing cardiac surgery with cpb. two samples (paxgene ® tube + edta tube) were taken at three times: before cpb, h after the end of cpb (h -cpb) and h after (h -cpb). after rna isolation and reverse transcription, we performed a quantitative polymerase chain reaction to evaluate the expression of gene encoding for grp and determined the plasma level of grp using enzyme-linked immunosorbent assay. our main objective was to study the variation of grp between pre-cpb and h -cpb samples. our secondary objectives were to evaluate the association of ers with morbi-mortality: organ failure at h (catecholamines and/or invasive ventilation and/or acute renal failure), troponinemia and pao /fio ratio (lung damage control). fig. ). we found an inverse correlation between grp plasma level and troponinemia at h (r = − . ; % ci[− . ; − . ]; p = . ) and a correlation between the pao /fio ratio and grp plasma level at h (r = . ; % ci[ . ; . ]; p = . ). we showed a significant relationship between the variation in plasma concentration of grp and post-operative organ failure after cpb. further studies are needed to better understand the molecular mechanisms of ers in acute inflammatory organ failure in humans. compliance with ethics regulations: yes. patients and methods: in a retrospective monocentric study ( / - / ) conducted in cardio-vascular surgical intensive care unit (icu) in henri mondor teaching hospital, all consecutive adult patients who underwent peripheral va-ecmo were included, with exclusion of those dying in the first h. diagnosis of acute mesenteric ischemia was performed using digestive endoscopy, abdominal ct-scan or fist-line laparotomy. significative results in the univariate analysis were analyzed in a multivariate analysis using logistic regression. results: va-ecmo were implanted. median age was ( - ) years and median . va-ecmo was implanted after a cardiotomy in % of the cases and for a medical reason in % of the cases including % of refractory cardiac arrest. patients characteristics are reported in the table. acute mesenteric ischemia was suspected in patients, with a delay of ( - ) days after ecmo implantation. digestive endoscopy was performed in patients, ctscan in five patients and first-line laparotomy in three patients. acute mesenteric ischemia was confirmed in patients, i.e. an incidence of %. laparotomy was performed in six of the patients, two having a stage i colitis ischemitis with stable conditions and being considered too severe to undergo futile surgery. overall mortality was %. all the patients with acute mesenteric ischemia died in the icu. independent risk factors of developing acute mesenteric ischemia were renal replacement therapy , p = . )) and onset of a second shock state within the first days of icu stay (or . ( % ic . - . , p = . )). conversely, early enteral nutrition was negatively associated with acute mesenteric ischemia (or . ( % ic . - . ), p . ). conclusion: acute mesenteric ischemia is a relatively frequent condition among patients under va-ecmo for cardiogenic shock. its extremely poor prognosis requires low threshold of suspicion. compliance with ethics regulations: yes. ( ). it allows the computation of trans-pulmonary pressure ( ) and can be used to set positive end-expiratory pressure (peep) ( . ) . prone position(pp) can reduce mortality in patients with acute respiratory distress syndrome (ards), but peep selection in pp is controversial. in human ards end-expiratory pes at zero flow (peept,es) was not different between supine (sp) and pp at same peep ( ). as no study measured ppl in sp and pp in ards we aimed at comparing peept,es and end-expiratory ppl at zero flow (peept,ppl) in this condition. our hypothesis was that peept,es was close to dorsal peept,ppl (peept,ppldorsal) in sp and to ventral peept,ppl (peept,pplventral) in pp. in eight female pigs of kgs intubated, sedated, paralyzed and mechanically ventilated, ards was induced by repeated saline lavage until pao /fio < mmhg under fio and peep cmh o. pes was measured by nutrivent catheter. ppl was measured by custom-made pouch sensors inserted surgically into the right anterior and posterior sixth intercostal space. ppl sensors were filled with air. after ards induction animals were randomly assigned to sp or pp. in each position, a recruitment manoeuver was performed and peep decreased from to cmh o by steps of cmh o lasting min each, then the animals were crossed over into the alternate position where the same procedure was done. at the end of each step nonstressed volume and correct position (baydur maneuver) were determined for pes and ppl sensors, then a -s end-expiratory occlusion was performed and pes and ppl recorded. linear mixed model was used to compare the value of pes and ppl at each peep and position. results: box-and-whisker plots of pes and ppl in sp and pp are shown in fig. . there is marked dorsal-to-ventral gradient in ppl at each peep in sp, which is reverted in pp at peep and only. there was no interaction between pressures and peep or position. with increasing peep pes increased significantly from peep in sp and pp. peept,pplventral was significantly lower than peept,es in sp but not in pp. (medtronic) , carescape (ge)) were set in pressure support cmh o, peep cmh o, fio % and equipped with the same double limb ventilator circuit (intersurgical) without any humidification device. asl bench model was set with inspiratory/expiratory resistance (r) and compliance (c) combinations: r / -c , r / -c and r / -c mimicking normal, ards and copd conditions, respectively ( ) . inspiratory effort generated by asl consisted of consecutive breaths obtained from the esophageal pressure in a real patient at the time of a spontaneous breathing trial. for each icu ventilator and rc combination, two steps were performed: in the first, atc was not activated and ventilator attached to asl without ett (atc-ett-); in the second, atc was set on at % compensation for an ett mm id and such an ett (shiley hi contour, covidien) joined icu ventilator to asl (atc+ ett+). the null hypothesis is that vtatc+ ett+ minus vtatc-ett-is . primary end point was the breath by breath paired difference betwen atc+ ett+ and atc-ett-. it was tested to zero for each ventilator in each rc condition. results: median vt was ml. table displays mean (± sd) difference in vt (ml) between atc+ ett+ and atc-ett-: a negative value means that atc under delivers and a positive value that atc over delivers vt for a given patient's inspiratory effort and rc. in four ventilators (c , s , elisa and ) atc almost systematically under delivered vt. in several instances under compensation was greater than % median vt. by contrast atc performed better with the other three ventilators (evita xl, v and carescape ). conclusion: atc tended to under deliver vt. furthermore, there were marked differences between icu ventilators the clinician should be aware of when using the atc option. compliance with ethics regulations: na. rationale: during the last decades, identification of factors associated with ventilation-induced lung injury has led to improved survival in patients with ards. the mechanical power of ventilation is the total energy transmitted from the ventilator to the respiratory system per unit of time and comprises three different components: elastic related to peep, elastic related to tidal volume and resistive. this integrative variable has been recently proposed as an useful predictor of ventilationinduced lung injury and death among ventilated patients. our goal was to determine the respective impact of the total mechanical power and its three components on the outcome of patients with ards. patients and methods: we performed a post hoc analysis of a randomized, controlled study of patients with ards with a pao /fio ratio < . themechanical power at inclusion and averaged on the first days after inclusion (total and its three different components) was computed according to the following equation: powerrs (j/ min) = . respiratory rate tidal volume [peep ( ) + ½ driving pressure ( ) + (peak pressure-plateau pressure) ( )], where the ( ), ( ) and ( ) parts correspond respectively to the elastic related to peep, elastic related to tidal volume and resistive components. the association between each of these four types of mechanical power evaluated during the first days after inclusion and mortality at d was assessed one after the other through multiple logistic regression, allowing control for potential confounding variables at inclusion (age, igs score without age, group of randomization, pao /fio , arterial ph). results: data from patients were analyzed, among which ( . %) died before d . there was no difference concerning the mechanical power at inclusion between survivors and non survivors (either total or its three components). among the four different types of mechanical power tested during the first days after inclusion, the elastic component related to tidal volume was the only one that was independently associated with mortality at d (or . ; % ci . - . ; p = . ) (figure) . conclusion: our study shows that only the elastic component of the mechanical power related to tidal volume independently predicted mortality at d among patients with ards, whereas the total mechanical power, its elastic component related to peep and its resistive component did not. further studies are needed to better define how the mechanical power of ventilation could be useful to synthetize the risk of ventilation-induced lung injury. compliance with ethics regulations: yes. probability of death at d as a factor of mean value (on d -d ) of the elastic component related to tidal volume of the mechanical power. to examine the effect of early-stage mechanical ventilation (mv) on diaphragmatic contractility. in the nd step, if a diaphragmatic dysfunction was detected, we assessed its influence on the weaning from ventilator. patients and methods: we measured prospectively the ultrasounddiaphragmatic thickening fraction (dtf) between groups: a study group versus a control group (n = for each). the study group included all adult patients receiving mv, in whom, the dtf was measured within a minimum of h and a maximum of days of mv. for the control group, were enrolled after their approval for participation, adult volunteers in spontaneous ventilation (sv). patients with factors affecting the diaphragmatic contractility (neuromuscular disease, severe obesity, and neuromuscular blockers…) were excluded. the ultrasound measurements were obtained at the zone of apposition of the right hemithorax. teleinspiratory and telexpiratory diameters (tid/ ted) were taken on the medio-axillary lines: posterior, median and anterior. the dtf was calculated as following: dtf = (tid-ted/ted) x . at the st step, the dtfs were compared and at the nd step: the relationship between dtf and weaning was analysed. results: our groups were comparable in corpulence and co morbidities. the sv group was younger ( vs. years, p < . ) with a predominant female composition. the diaphragmatic exploration concluded that in the mv group, the mean tid tended to be higher but without significant difference ( . + versus . + mm, p = . ), the mean ted was significantly higher ( . + versus . + . mm, p = . ) and dtf was significantly lower ( . + . % versus + . %, p = . ). the ventilation mode had no effect on dtf ( . + % for control volume vs. . + % for psv mode, p = . ). fourteen among ventilated patients had a successful weaning with a mean duration of days. a negative correlation was found close to significance between dtf and weaning duration (rho = − . and p = . ). a dtf value > % wasassociated with weaning success (or = , % ci = [ . - . ] and p = . ) with sensitivity = . %, specificity = %, ppv = % and npv = %. conclusion: the diaphragmatic contractile function was altered from the first days of mv. weaning duration seemed to be negatively correlated with dtf, and a dtf at the first days of mv greater than % was predictive of weaning success. compliance with ethics regulations: yes. rationale: mechanical ventilation is a life-saving treatment that is however associated with lung injury and/or diaphragm dysfunction. the optimal ventilator settings to provide lung protective ventilation while maintaining safe diaphragm activity are difficult to determine. a noninvasive and bedside evaluation of the diaphragm activity could be helpful in this context. the present study investigated whether changes in diaphragm shear modulus (i.e. stiffness, Δsmdi) assessed by ultrasound shear wave elastography (swe) may be used as a surrogate of changes in transdiaphragmatic pressure (Δpdi) in mechanically ventilated patients. patients and methods: patients had to be ventilated for at least h without contraindications for the placement of an oeso-gastric catheter. pdi was monitored continuously and smdi was measured at the zone of apposition of the right hemi-diaphragm, at hz sampling rate. measurements were performed twice under initial ventilator settings and at the end of a weaning trial. pearson correlation coefficients (r) were computed to determine within-individual correlations between pdi and smdi and changes in pdi and in smdi occurring between initial ventilator settings and the end of the sbt were compared by a paired test. results: twenty-five patients were enrolled and displayed a significant correlation between Δsmdi and Δpdi (mean r = . , range = . - . , all p < . ) (fig. a ). compared to their counterparts, patients with significant within correlations had a lower respiratory rate ( . ± . vs . ± . breath/min. respectively; p < . ) and a significant increase in Δsmdi ( . ± . kpa vs . ± . kpa. p < . ) between initial ventilator settings and the sbt. patients without Δsmdi-Δpdi correlation only displayed an increase in Δpdi ( . ± . vs . ± . cmh o, p < . ) at the end of the sbt with no concomitant significant increase in Δsmdi ( . ± . kpa vs . ± . kpa, p > . ). (fig. b) . conclusion: smdi obtained by swe appears as a promising technique to assess diaphragm activity in mechanically ventilated patients but technological improvements are necessary to increase swe sampling rate before enabling its generalization in the icu. compliance with ethics regulations: yes. rationale: end-inspiratory (eip) and end-expiratory (eep) pauses are commonly used during volume assist control ventilation to assess plateau pressure and total positive end-expiratory pressure (peeptot). they can also be used during assisted ventilation (av) for muscle pressure assessment. it requires ventilators able to perform eip during av. plateau pressure (pplat) usually increases in av during eip due to "hidden" inspiratory effort. pressure muscular index (pmi) is equal to pplat minus the sum of peeptot (measured during an eep) and set pressure support (ps); it theoretically reflects patient's effort without esophageal pressure (pes) monitoring. pes is the gold standard method to assess inspiratory muscle pressure (pmus, difference of pes drop at neural end-inspiration and correction factor for chest wall elastance and tidal volume). we aimed to illustrate the feasibility of measuring pmi using a standard icu ventilator at the bedside and study the correlation between pmus and pmi. patients and methods: measurements were recorded in icu patients. pes was measured using an nasogastric probe (equipped with an esophageal balloon) inserted for advanced monitoring (severe acute respiratory distress syndrome-ards) or for a study protocol (difficult weaning after copd exacerbation). recorded eip, eep and pes were used for post hoc analyses. results reported as ranges and median [iqr] . correlation between pmus and pmi tested with spearman correlation test. results: out of eip and eep duos could be analyzed ( -esophageal spasm/ -calibration error). ventilator mode was pressure support ventilation (ps - cmh o). cmh o, pmus = . [ . - . ] cmh o, pmi = . [ . - . ]. for all recordings, spearman r coefficient between pmus and pmi was . (p = . ). conclusion: muscular effort can be assessed in av using eip and eep using icu ventilators. however, recordings can be influenced by expiratory muscles contraction. patient's ability to follow directions during the maneuvers is an important factor to obtain reliable values. there seem to be a correlation in our small sample between muscular pressure assessed without and with pes. compliance with ethics regulations: yes. rationale: severe pneumonia can culminate in acute respiratory distress syndrome (ards). an uncontrolled inflammatory response is a key feature favoring transition towards ards. however, the underlying mechanisms remain poorly understood. in this context, the contribution of "innate t cells" (itc) -a family of non-peptide reactive t cells comprising nkt cells, mucosal associated invariant t (mait) cells and γδt cells-has never been explored. itc have emerged as key players in orchestration of the host response during infections and inflammation processes. for these reasons, these cells are already seen as potential therapeutic targets in other medical fields (especially oncology). here, we hypothesized that a tight regulation of their functions could be paramount to control the inflammatory response and to prevent ards development. patients and methods: to explore this, we combined a murinemodel of influenza a virus (iav) infection mimicking ardssymptoms and a clinical study recruiting patients admitted in icu for severe pneumonia. using flow-cytometry approaches, we investigated ( ) the abundance and dynamics of itc in various compartments, ( ) their pattern of activation/regulation markers (respectively cd and pd- ) and ( ) their cytokine production. results: during experimental iav pneumonia, itc were transiently recruited into the airways. unlike γδt and nkt, mait cells phenotype was largely changed, displaying a progressive cd overexpression and increased il- a production. during the resolution phase, up to % of pulmonary maits expressed pd- (versus < % in controls), which can suggest emergence of regulatory functions. last, using gene-targeted mice, we suggested that mait cells confer a protective effect during pneumonia. in the ongoing clinical study, the proportion of circulating mait cells in patients was markedly decreased compared to controls ( . ± . % versus . ± . % of t cells), but not for nkt or γδt cells. notably, some patients with severe ards presented detectable levels of maits in their respiratory fluids. in addition, circulating mait cells in patients overexpressed cd and pd- ( . % and % respectively), but with a reduced proportion able to produce il- and ifnγ, compared to healthy controls. lastly, proportion of activated (cd +) mait cells significantly decreased with clinical improvement. conclusion: this translational approach combining in vivo animal experiments and clinical samples with ex vivo experiments indicates a preferential modulation in mait cells functions during severe pneumonia. these data justify an in-depth analysis of mait cells activation mechanisms and functions in this context, in order to further explore a potential use as a disease-progression marker and -in a long term perspective-as a potential therapeutic target. compliance with ethics regulations: yes. representative flow-cytometry dot-plots of mait cells labelling using fluorophore-conjugated mr tetramers loaded with -op-ru from lungs of an infected mouse (a) and blood sample of a patient with pneumonia (b). c: frequency of mait cells, proportion of cd and pd- + mait cells in bronchoalveolar lavage during experimental murine pneumonia. d: blood frequency of mait cells in patients with pneumonia compared with healthy controls (as % of total t cells) rationale: immune paralysis following hyperinflammatory states increases the risk of secondary infections and death. reversing t-cells exhaustion using recombinant il or immune checkpoints inhibitors may improve the prognosis of patients with sepsis admitted to the icu. however, there is an unmet need to better characterize the state of t-cells exhaustion in these patients, its reproducibility and its correlation with the outcomes before implementing immunotherapy in the therapeutic armamentarium against sepsis. patients and methods: prospective observational cohort study performed in two tertiary-care icus in a university hospital. peripheral blood mononuclear cells were collected at day in adult patients with sepsis admitted to the icu. the level of cd + and cd + t-cells exhaustion was quantified using multi-color flux cytometry targeting the following exhaustion markers: pd- , b and cd . cd + regulatory t-cells (cd + cd + cd hi cd lo cells) were also assessed. results: the patients included in the study could be split in five clusters according to their dominant pattern of exhaustion markers on cd + t-cell (i.e. no markers, pd- +, b +, b + cd + and b + pd- +) and independently of their underlying morbidities. no patients harbored a fully exhausted triple-positive pattern. by multivariate analysis, saps gravity score at day (p = . ), a dominant b and/or pd- cd + pattern (p = . ) and lung sepsis (p = . ) where associated with the risk of death at day , whereas hemoglobin level was associated with survival (p = . ). no cd + or cd + exhaustion pattern independently predicted the risk of secondary infections. neither the level of cd + regulatory t-cells nor the dominant cd + exhaustion pattern was associated with the outcomes. rationale: there is growing use of multiplex polymerase chain reaction (mpcr) for respiratory virus testing in patients with communityacquired pneumonia (cap). data on one-year outcomes in patients with severe cap of bacterial, viral and unidentified etiology are scarce. patients and methods: a single-center retrospective study was performed in intensive care unit (icu) patients with known one-year survival status who had undergone respiratory virus testing for cap by mpcr. one year after icu admission, mortality rates and functional status were compared in patients with cap of bacterial, viral or unidentified etiology. results: there were ( . %) patients in the bacterial group, ( . %) in the viral group and ( . %) with unidentified etiology. one-year mortality was . % (n = / ), % (n = / ) and . % (n = / ), respectively (p = . ). in multivariate analysis, one-year mortality was higher in the bacterial group than in the viral group (hr . , % ic . - . , p = . ), had a trend to be higher in the bacterial group compared to the unidentified etiology group (hr . , % ic . - . , p = . ) and was not different between the viral and unidentified etiology groups (hr . , % ic . - . , p = . ). severe dyspnea (mmrc score = or death), major adverse respiratory events (new homecare ventilatory support or death) and severe autonomy deficiencies (adl katz score ≤ ordeath) were observed in / ( . %), / ( . %) and / ( . %) patients, respectively, with no difference between groups. conclusion: cap of bacterial origin was associated with a poorer prognosis than viral or unidentified etiology. impaired functional status was observed in a substantial proportion at one-year, irrespective of the causative microorganisms involved. compliance with ethics regulations: yes. interest of unyvero multiplex pcr (curetis) for bal rapid microbiologic and antibiotic susceptibility documentations in immunocompromised patients under antibiotic therapy jean-luc baudel , jacques tankovic , redouane dahoumane , salah gallah , laurent benzerara , jean-remy lavillegrand , razach abdallah , geoffroy hariri , naike bige , hafid ait-oufella , nicolas veziris , eric maury , bertrand guidet rationale: our aim was to evaluate the interest of the unyvero rapid ( . h) multiplex pcr assay (performed on bronchoalveolar lavage [bal] samples) for the management of immunocompromised patients already treated with antibiotics and diagnosed with pneumonia (according to clinical and radiological findings). we thus performed an observational study that compared the results (and the length of time to obtain them) of routine microbiological evaluation and unyvero assay. patients and methods: from july to january and from april to august , we examined bal samples from immunocompromised patients (coming from hematology, oncology, hepatology, gastroenterology, internal medicine, and neurology units) diagnosed with pneumonia (based on clinical and radiological findings), and already receiving antibiotic treatment. the following data were collected: age, gender, saps score, lung ct scan ( %) or x-ray ( %) results, duration and content of prior antibiotic therapy, direct examination, culture, antibiogram and unyvero results, secondary confirmation of pneumonia or not, possible changes in antibiotic therapy that could have been made after obtention of unyvero results. informed consent was obtained from all patients. results: bal samples were analyzed in immunocompromised patients (m/f ratio . , saps . ± . ) mostly with hematologic ( %) or oncologic ( %) diseases. the patients received either corticosteroids ( %), or chemotherapy ( %), or immunotherapy ( %). % of the patients were under mechanical ventilation, % under optiflow. % presented a shock, % had aplasia or neutropenia, % were allografted, % were autografted. the duration of prior antibiotic therapy at the time of bal were . ± . days. direct examination was positive in . % of the cases, culture (both above and under the classical threshold of cfu/ml) in %, unyvero in . %. a retrospective analysis of all the cases confirmed the initial diagnosis of pneumonia in only % of the cases. compared to culture, the sensitivity of unyvero was %, its specificity %. unyvero could permit to rapidly deescalate antibiotic therapy in % of the cases and to rapidly stop it in %. the unyvero assay on bal samples is useful in this specific population for rapid obtention of microbiological results and also for confirmation of the negativity of cultures and thus permits a better management of antibiotic therapy, leading to a reduction of antibiotic resistance selection pressure in the icu. compliance with ethics regulations: yes. do not underestimate rsv pneumonia among critically ill patients erwan begot , suzanne champion , charline sazio , benjamin clouzeau , alexandre boyer , hoang-nam bui , marie-edith lafon , camille ciccone , julia dina , didier gruson , renaud prével chu bordeaux, medical intensive care unit, bordeaux, france; chu bordeaux, virology laboratory, bordeaux, france; national reference center for measles mumps and rubella, chu de caen, caen, france correspondence: erwan begot (erwan.begot@chu-bordeaux.fr) ann. intensive care , (suppl ):f- rationale: respiratory syncitial virus (rsv) is a well-known cause of respiratory failure among neonates but its pathogenicity in adults is now emerging as a potential cause of viral pneumonia. data are limited with conflicting results regarding rsv pneumonia severity in adults. data are lacking about critically ill rsv patients' characteristics and outcomes. the aim of this study is to compare rsv patients' characteristics, care and outcomes to influenza patients' ones. patients and methods: patients diagnosed with rsv and influenza pneumonia admitted to our medical icu were included. data were retrospectively recorded. quantitative data are expressed by median and interquartile range and compared by use of mann-whitney test. qualitative data are expressed by number and percentages and compared by use of fischer exact t-test. rsv strains were prospectively collected. results: eighteen critically ill patients with rsv pneumonia and with influenza pneumonia were included. rsv and influenza patients had the same characteristics at admission except for age (respectively yo [ ; ] and acute respiratory distress syndrome rates (respectively / ( %) vs / ( %), p = . ). they received similar treatment as suggested by oro-tracheal intubation rates (respectively / ( %) vs / ( %), p: . ) and antibiotics prescription (respectively / ( %) vs / ( %), p: . ). rsv and influenza patients also had the same rates of bacterial co-infections ( / ( %) vs ( %), p: . ). invasive aspergillosis remained a rare event but also occurred among rsv patients ( / ( %) vs / ( %), p: . ). acute coronary syndromes were as frequent in both groups (respectively / ( %) vs / ( %), p = . ). day- mortality was similar between rsv and influenza patients (respectively / ( %) rationale: respiratory distress from seawater drowning is commonly considered multifactorial. etiologies are debatable and include heart failure, infection and acute respiratory distress syndrome (ards). documented bacterial infections seems mostly related to the site of drowning. data in this regard are scarce with prospective studies lacking. the objective of our study was to describe prospectively the characteristics and determinants of respiratory distress from seawater drowning. patients and methods: all patients admitted for seawater drowning to seven intensive care units (icu) on the french riviera in the summers of and were prospectively included. recorded data included clinical features on examination, personal history, chest x-rays, echocardiography and biological results obtained within the first h. a paired student's t-test was used to study statistical differences between quantitative variables on admission and during early evaluation (i.e. first h). results: forty-eight patients were admitted to seven centers of which ( %) were diagnosed as having ards, ( %) early pneumonia and ( %) acute cardiogenic pulmonary edema. twenty-one ( %) respiratory samples were collected but bacterial culture was positive in only cases. multidrug-resistant bacteria were not observed, and amoxicillin-clavulanate as first-line treatment was effective in all cases. echocardiography performed in ( %) patients was normal and unable to identify specific patient profiles. the median clinical pulmonary infection score (cpis) on admission was (iqr, - ) and decreased rapidly and significantly (p < . ) within h to (iqr, - ) (fig. ) . conclusion: data from this multicenter cohort suggest that respiratory distress following seawater drowning can mimic bacterial pneumonia during the first h with subsequent rapid clinical improvement in patients admitted to the icu. probabilistic antibacterial therapy should therefore be limited to the most severe patients. isolate ards is often the only etiology found and is resolutive within h. this prospective cohort is the largest of its kind and gives a better insight into the limited impact of cardiogenic and infectious processes on sea drowning-related respiratory distress. compliance with ethics regulations: yes. rationale: patients treated with "extracorporeal membrane oxygenation" (ecmo) are at a higher risk of developing nosocomial infections and they are consequently often treated with beta-lactams. french guidelines recommend obtaining beta-lactam trough concentrations above four times the minimal inhibitory concentration (mic) of the causative bacteria. the ecmo device may alter the pharmacokinetics of these medications, which may result in underexposure to beta-lactam antibiotics. patients and methods: this observational, prospective, multicenter, case-control study was performed in the intensive care units of two tertiary care hospitals in france. ecmo patients with sepsis treated with piperacillin-tazobactam were enrolled. control patients were matched according to sofa score and creatinine clearance. the pharmacokinetics of piperacillin was described based on a population pharmacokinetic model, allowing to calculate the time spent above × the mic breakpoint for pseudomonas aeruginosa susceptibility after the first dose and at steady state between two piperacillin infusions. results: forty-two patients were included. the median age was years [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , the sofa score was [ ] [ ] [ ] [ ] [ ] [ ] , and median creatinine clearance was ml/min . there was no significant difference in the time above x mic in patients treated with ecmo and controls during the first administration (p = . ) and at steady state (p = . ). there was no significant difference between the trough at steady state (p = . ), with / patients ( %) exhibiting concentrations of piperacillin lower than x mic. ecmo support was not associated with a steady state trough concentration below x mic (or = . [ . - . ], p = . ). the only variable independently associated with this risk was a creatinine clearance ≥ ml/min, (or = . [ . - . ], p = . ). conclusion: ecmo support has no significant impact on piperacillin exposure. intensive care unit patients with sepsis are, however, frequently underexposed with piperacillin, which suggest that therapeutic drug monitoring should be strongly recommended for severe infections. impact of a visual support dedicated to prognosis of patients on symptoms of stress of family members rationale: family members commonly have inaccurate expectations of patient's prognosis. adding to classic oral information a visual support, depicting day by day the evolution of the condition of the patient, improves the concordance in prognosis estimate between physicians and family members. the objective of this study was to evaluate the impact of this support on symptoms of anxiety/depression of family members. patients and methods: we conducted a bi-center prospective beforeafter study. all consecutive patients admitted in the two icus were eligible. in the before period ( months), family members received classic oral information. in the after period ( months) , in addition to classic oral information, the visual support ( fig. ) was available for family members in the patient's room from the day of admission until discharge from the icu. at day and from admission, symptoms of anxiety/depression of referent family member were evaluated by hospital anxiety and depression scale (hads). results: patients and their referent family members were included ( in period before and after). characteristics of patients of the two groups were similar regarding age, reason for admission, saps ii at admission and sofa score at day . also characteristics of referent family members were comparable in terms of age, sex ratio, type of relationship with the patient and number of visits since admission. at day , total had score was [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in the group before without the support and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in the group after with the support (p = . ). the prevalence of symptoms of anxiety (had-a score > ) and depression (had-d score > ) was similar in the two groups (respectively . % and . % in the group before, and . % and . % in the group after (ns)). at day , total had score was in the group before [ - ] and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in the group after (p = . ). by multivariate analysis the following factors were significantly associated with total had score > at day : age of patient ]), number of visits of referent ) and previous or current treatment of referent for anxiety or depression . ]). conclusion: in this study, the use of a visual support dedicated to prognosis of patients did not modify the level of stress of family members. compliance with ethics regulations: yes. rationale: the use of sedation and opioids at the end of life is a topic of considerable ethical debate. incidence of discomfort during the end-of-life of icu patients and impact of sedation on discomfort are poorly known. patients and methods: post-hoc analysis of an observational prospective multicenter study comparing terminal weaning vs. immediate extubation for end-of-life in icu patients, aimed at assessing the incidence of discomfort events according to levels of sedation. discomforts including gasps, significant bronchial obstruction or high behavioral pain scale score, were prospectively assessed by nurses from mechanical ventilation withdrawal until death. level of sedation was assessed using the richmond agitation sedation scale (rass). results: among the patients included in the original study, ( %) experienced discomfort after mechanical ventilation withdrawal. patients with discomfort received lower doses of midazolam and equivalent morphine, and less frequently had deep sedation (rass - ) than patients without discomfort ( % vs %, p < . ). after multivariate logistic regression, immediate extubation was the only factor associated with discomfort whereas deep sedation and administrations of vasoactive drugs were two factors independently associated with no discomfort. death occurred less rapidly in patient with discomfort than in those without discomfort ( . h [ . - . ] vs . [ . - . ], p < . ) (figure) . long-term evaluation of psychological disorders in family members of dead patients did not differ between those with discomfort and the others. discussion: despite the theoretically expected anticipatory titrated doses of opioids and benzodiazepines to alleviate any discomfort after withdrawal of mechanical ventilation, half of the patients did not receive sedation or opiate when the decision to withdraw mechanical ventilation was taken. a major point that could interfere with the continuous deep sedation practice until death is the fear of potentially hastening death, and there is much controversy regarding its proper use in end-of-life care. conclusion: discomfort was frequent during end-of-life of icu patients and was mainly associated with terminal extubation and less profound sedation. compliance with ethics regulations: yes. rationale: bereavement in intensive care unit (icu) is associated with psychiatric disorders on relatives called post-intensive care syndrome family (pics-f). no isolated intervention (such as condolence letter) has shown a positive effect on these disorders, despite a well acceptance by relatives. we thought that a more integrated bereavement program should be considered. the goal of this study is to evaluate a combined psychologist-physician post-death meeting (pdm) in a bereavement program to evaluate needs and adhesion of relatives, and the effect on symptoms of anxiety and depression. patients and methods: monocentric, prospective study focused on relatives of patient admitted > h and deceased in icu. during patient's stay, relatives' presence was allowed on a h-basis and they could meet a clinician psychologist. formal meeting between relatives and the staff was realized at patient's admission and after important decision-making treatment. two weeks after patient's death, the psychologist called relatives to offer emotional support and to invite to a pdm. pdm occurs weeks after patient's death with the psychologist and the physician in charge of the patient. the objectives of the meeting were to provide emotional support, to answer medical question, and to detect symptoms of anxiety and/or depression with the hospital anxiety and depression scale (hads). we hypothesized that pmd would be able to alleviate pics-f at months. we aimed to enroll families to detect a % lowering of hads. results: the rate of pdm acceptance was lower than expected. after inclusions, only relatives accepted the pdm, whereas the phone call was well perceived ( %). main association with acceptance of pmd was a short duration of icu stay ( . days [ - . ] vs . days [ . - . ] p = . ) and icu admission for acute respiratory failure ( . % vs . %, p = . ) ( table ) . we found no relation between the number of in icu meeting (psychologist of medical staff) and pmd acceptance. for relatives who accept pmd we found a high proportion of symptoms of anxiety and depression ( % and %) with a hads at . [ - . ] (median, iqr). no evaluation was performed at months. conclusion: post death contact appears well perceived by relatives but pmd quite useless. this result may be explained by the inclusion of only late death (> h) where psychologist and medical staff had the opportunity to support relatives. further study should focus on early death (< h). compliance with ethics regulations: yes. rationale: pediatric intensivists frequently question themselves on the issue of limitation or termination of life-sustaining treatments (llst) carried out on children. such a decision comes under the claeys-leonetti law which forbids doctors from applying unreasonable treatment however, every so often, parents oppose themselves to a collegial llst decision that the medical and paramedical team had taken. such cases can even end up in court. in order to sort out this problem, this study focused on the factors that underlie the disagreement and the solution brought forward by pediatricians whenever parents demand to persue treatments although considered as unreasonable obstinacy. patients and methods: we carried out a qualitative study involving three multipurpose pediatric critical care unit. all pediatricians operating within these units were contacted. those who volonteered were met individually for a semi-directed interview. every interview was recorded and entitled to a complete hand-written retranscription. the interviews were analysed following the phenomenological interpretive analysis method and were subject to dual listing. results: pediatricians out of took part in the study. / claimed they would increase treatments or carry out cardiopulmonary resuscitation acts if asked to do so by parents, even if this went against the initial collegial decision. / claimed they would persue treatments although not beyond the current level. / said they would oppose themselves to parents concerning blood transfusion for comfort reasons. several key factors were identified as leading a doctor to the non-application of a llst decision: the certainty regarding the child's death on a short or mid-term basis ( / ), the litigiousness risk ( / ), the apprehension of mediatic pressure ( / ), the fear of a violent reaction from parents ( / ), other self-interest positions within the medical team ( / ), empathy towards parents ( / ), the uncertainty concerning the neurological prognosis ( / ), the lapse of time needed to fully accept the application in force of a decision ( / ). pediatricians out of admitted their own-suffering when confronted to the situation. conclusion: this study points out that pediatricians tend to follow parents' position when confronted to parental opposition. in such situations, pediatricians go against their own decision in order to safeguard the parental alliance even if it leads to unreasonable obstinacy, thus conflicting with medical deontological code obligations. compliance with ethics regulations: yes. rationale: end-of-life management strategies are clearly a worldwide issue of major importance that intensivists have to deal with on a daily basis. advance directives may be the solution sought to guide physicians to take such difficult decisions. yet, health care directives are not legislated in tunisia. the objective of this project was to draw a general descriptive overview to assess patients' wishes in tunisia. patients and methods: data were collected from a -item-questionnaire based on the french intensive care society's form for advance directives which was filled by people of general population in tunisia, including doctors and paramedics, from may to mid-september . all people included were or older and well informed of the form's utility. results: a total of participants were included. the mean age was . ± . years with extremes of and and a sex ratio of . . fourty-one ( . %) were either doctors or nurses and ( %) did suffer from a severe medical condition. among all the participants, ( . %) thought that end-of-life decisions were up to the doctor. for the rest, they willingly chose to be hospitalized in an icu, to undergo cardiopulmonary rescuscitation and to have ventilation support with orotracheal intubation or tracheostomy respectively in ( . %), ( . %) and ( . %) of the cases. only ( . %) refused temporary dialysis. when asked about sequelae they can live with, participants accepted hemiplegia in . % and paraplegia in . % of the cases. on the contrary, ( . %) refused to live in permanent coma and ( . %) disagreed to undergo tracheostomy and ventilation for life. moreover, ( . %) found that serious un aesthetic sequelae was a fatal consequence they could not survive. as well, only ( . %) consented to live with deep intellectual deficiency. regarding palliative care, ( . %) participants wished to be profoundly sedated until death, ( . %) prefered to die home over ( . %) in hospital. sixtytwo ( . %) desired to see a representative of their religion. furthermore, ( %) were for organ donnation. gender, being a health care professional and age under versus equal or over were not significant in dependent factors (p > . ). conclusion: it is our duty ashealth care professionals to spread advance directives awareness and education. nevertheless, the law should keep the pace with ethics evolution. compliance with ethics regulations: yes. rationale: adapted organ support techniques are needed to enhance reliability of preclinical animal experiments in the intensive care setting (guillon, annals of intensive care- ). a few renal replacement therapy (rrt) models have already been developed in rats, mostly hemodialysis in chronic kidney disease models or hemofiltration techniques in sepsis experiments. mounting evidence from clinical (gaudry, nejm- ) and histopathological studies suggest that rrt for acute kidney injury (aki) could impair renal recovery by acting as a 'second hit' leading to a maladaptive repair of tubular epithelium. we aimed to study this hypothesis in a hemodialysis model in rats with septic aki. patients and methods: on day , sprague-dawley rats were injected with lipopolysaccharide or placebo (nacl . %) intraperitoneally. on day , anesthetized rats underwent femoral artery catheterization for hemodynamic parameters monitoring. at the same time, one femoral vein and one carotid artery were catheterized for arterio-venous sterile extracorporeal circulation with or without passing through a miniature sterile polyester sulfone hemodialyzer ( cm surface, kda pores, microkros ® ) filled with dialyzate liquid in the outer compartment (table ) . vessels were ligated after the procedure and rats allowed to awaken. on day , rats were sacrificed. results: all rats injected with lipopolysaccharides o :b mg/kg survived at day . anesthesia was much challenging: ketamine + xylazine and tiletamine-zolazepam + xylazine required induction and maintenance intraperitoneal injections. these medications induced important hemodynamic parameters fluctuations and high mortality. isoflurane gas inhalation enabled better stability, less hypothermia and quick awakening. adequate temperature was controlled with a heating pad during the procedure and an incubator after. supine position was maintained. the whole circuit was anticoagulated with ml of heparinized saline ui/ml, since clots occurred in the absence of anticoagulation and bleeding when higher dosing was used. circuit (< . ml including dialyzer) was filled with saline solution before initiation, and total restitution of blood at the end of the experiment prevented any blood transfusion requirement. hematocrit was determined at beginning ( %) and end of experiment ( %). a peristaltic pump provided a blood flow rate of . ml/min, (higher rate was not tolerated) for h. of note, rats who underwent sham procedure (vessels ligature only) survived and did not display aki. circulation of a counterflow dialysate in the dialyzer is planned but has not been performed yet. conclusion: this hemodialysis system for rats is feasible at a reasonable price and might help research involving rrt in either ckd or aki. compliance with ethics regulations: yes. there were no significant relationship between rri and past medical history or severity score. we observed a significant negative correlation between rri and diastolic arterial pressure (p = . ) and heart rate (p = . ) as it could be expected by rri formula. an increased rri was associated with higher potassium (p = . ) and higher creatinine levels (p = . ). although not significant, we found a higher rate of subsequent rrt in the high rri group ( % vs %, p = . ). over the first days, fluid balance was significantly different between groups ( ml vs - ml respectively for low and high rri group, p = . ). since standard of care were similar, this suggests different fluid volume status between the two groups. in the low rri group, the cause of aki could predominantly be prerenal since positive fluid balance was not explained by more severe aki with refractory oliguria as shown by the low rrt rate. nevertheless, we did not observed any relationship between rri and the evolution of serum urea or creatinine levels, nor with the presumed aetiology of aki. conclusion: when focussing on the first rri measurement once stage aki was reached, rri ≤ . seems to be in favour of prerenal and transient renal dysfunction even if this is not supported by creatinine serum evolution. compliance with ethics regulations: yes. rationale: critically ill patients are at higher risk of bleeding but also dialysis filter clotting (inflammatory state). intermittent hemodialysis with calcium-free citrate-containing ( . mmol/l) dialysate (cafcit-ihd) recently emerged as a new safe and simple alternative to continuous renal replacement therapy allowing heparin-free extended dialysis sessions (> h). in this study, we aimed to answer to two issues still unresolved: (i) can citrate contained in the dialysate accumulate and lead to citrate intoxication in patients with liver disorders, and (ii) can citrate be avoided using citrate-and calcium-free dialysate (ccf-ihd)? patients and methods: monocentric retrospective study. among the sessions performed with cafcit-ihd, the ihd sessions ( critically ill patients) with citrate measurement available before and after the dialysis filter were reviewed. estimation of the liver clearance was performed using the picco lemon ® system (pulsion). in addition, sessions performed using ccf-ihd were reviewed. results: all the patients had liver disorders (post-liver transplantation period n = ; cirrhosis with child > a ). among the eighteen cafcit-ihd patients, fifteen ( %) and six ( %) received mechanical ventilation or vasopressive drugs, respectively. the median time of the dialysis session was h [ ] [ ] [ ] [ ] , with hourly ultrafiltration rate of ml (one premature termination not related to dysfunctional catheter). in all patients, ionized calcium (ica) decreased below . mmol/l after the filter, whereas post-filter calcium reinjection according to ionic dialysance led to a stable pre-filter (i.e. patient) ica. median citrate concentrations were all below . mmol/l after the filter (minimal concentration to obtain anticoagulation mmol/l) and all except one below the normal value (< µmol/l) before the filter. during all the sessions, ionized to total calcium ratio was below . and the strong ionized gap decreased. when available (n = ), no correlation could be identified between serum citrate concentration and liver clearance. last, in ccf-ihd sessions performed in critically ill patients, no premature termination occurred (median time of the sessions h) and post-filter ica also decreased below . mmol/l. no citrate accumulation could be identified in critically ill patients (even with liver disorders) and receiving extended dialysis sessions ( h or more) using calcium-free citrate containing-ihd. interestingly, we demonstrated that citrate is not required to obtain optimal regional anticoagulation (i.e. post-filter ica < . mmol/l), and a citrate-and calcium-free dialysate could be a safe alternative. compliance with ethics regulations: yes. rationale: ventilator induced diaphragmatic dysfunction is highly prevalent in adult critical care and associated with worse outcomes. specificities in pediatric respiratory physiology suggest that critically ill children may be at high risk of developing this complication, but no study has described the evolution of diaphragmatic function in critically ill children undergoing mechanical ventilation. this study aims to validate a method to quantify diaphragmatic function in mechanically ventilated children. in this prospective single-center observational study, children between week and years old intubated for elective ent surgery and without pre-existing neuromuscular disease or recent muscle paralysis were recruited. immediately after intubation, diaphragmatic function was evaluated using brief airway occlusion maneuvers during which airway pressure at the endotracheal tube (paw) and electrical activity of the diaphragm (eadi) were simultaneously measured for consecutive spontaneous breaths, while the endotracheal tube was occluded with a specific valve. occlusion maneuvers were repeated times. in order to account for central respiratory drive and sedation use, we recorded the neuromechanical efficiency ratio (nme, paw/eadi), in addition to the maximal inspiratory force (mif). in order to determine the optimal measure of nme during an occlusion, the variability over the three occlusion maneuvers of different variables (first breath, last breath, breath with maximal paw deflection, breath with maximal nme value, and median nme value) was assessed using coefficients of variation and repeatability coefficients. results: patients had a median age of . years (interquartile range . - . ), a median weight of kg ( - ), and were male ( %). the median evolution of paw, eadi, and nme ratio over the occluded breaths are represented on fig. . nme values corresponding to the last breath and the breath with maximal paw deflection were the least variable, with median coefficient of variation of % and % and repeatability coefficients of . and . , respectively. conclusion: brief airway occlusions can be used to assess diaphragmatic function in intubated children through both mif and nme ratio, and the latter should ideally be computed on the last breath or the breath with the largest pressure deflection to improve repeatability and decrease variation. compliance with ethics regulations: yes. epidemiology is poorly understood due to the rare use of validated diagnostic tools. the main objective of the study was to determine, by systematically calculating the wat- score, the incidence of ws in our surgical picu. the secondary objective was to analyze the risk factors, consequences and management modalities of ws. patients and methods: following institutional review board approval, we conducted a prospective monocentric study between july and january . all consecutive mechanically ventilated children admitted in our surgical picu with sedation/analgesia by continuous intra-venous (iv) benzodiazepines (bzd) and/or opioids for at least h were included. as soon as sedation was decreased and during h following their total discontinuation, wat- score was assessed twice a day. ws was defined by a wat- score > . the search for risk factors and consequences associated with ws was performed by univariate analysis (mann-whitney and chi test). ethical standards were satisfied and the lack of opposition from patients and their parents was systematically checked. results: the incidence of ws was % among the patients of our cohort including % of children admitted postoperatively and % after severe traumatic brain injury (tbi). significant results are reported in table . our results show that even for sedation time less than days, children could develop ws ( / patients). on the other hand, age, severity (pelod score), number of previous surgeries and severe tbi were not associated with ws. our study also demonstrated that cessation of sedation and prevention of ws was not uniform in our unit. the high incidence of withdrawal syndrome in our study, even in children sedated for less than days, and its consequences require thinking about prevention. we suggest a systematic monitoring of the occurrence of this adverse event using a validated score, from days of continuous iv sedation/analgesia. compliance with ethics regulations: yes. rationale: severe traumatic brain injury (tbi) is a major healthcare problem. amplitude and duration of intracranial hypertension is highly associated with patient outcome. the intracranial pressure (icp) is therefore one key parameter to monitor in the acute phase. when icp is monitored with an external ventricular drain, the pressure recorded by the monitor does not always correspond to the real icp, depending on the status (open/closed) of the -way tap. misleading values could therefore be sent to the patient medical record. our hypothesis is that a machine-learning algorithm will be able to identify automatically and in real time the reliable and non-reliable values of the icp signal. we retrospectively studied pediatric patients having an external ventricular drain between july and july , in a single pediatric intensive care unit. the icp signals were extracted from a high-frequency database ( hz) and pre-processed adequately. to train the algorithms, an annotated database was manually created with two classes: reliable icp vs. non-reliable icp (drain system opened to allow cerebrospinal fluid removal). eleven signal characteristics were compared between the two classes (mann-whitney test), and significantly differing variables were tested in the algorithms. we compared the performance of two machine-learning algorithms: the k-nearest neighbors (knn) and the support vector machine (svm). using -fold cross-validation method, % of the data was used to train the algorithms and % was used for testing. the best classifier was further validated by simulating a real-time icp analysis, using a s sliding-window approach with % overlap. the study was approved by the localresearch ethics committee. results: sixteen patients were included in the study. the training database created from patients, contained segments (of s duration) per class and per patient. eight signal variables were identified and kept to define the segments. the knn algorithm, with k = , led to the best performance, with a mean of % (mean ± sd: % ± . %). the knn was then visually validated on icp signals from the remaining two patients ( figure) . by simulating a real-time icp extraction, our algorithm was able to efficiently identify the reliable icp segments, and to display a mean value only for valid segments. university hospital picu (paris). all consecutive children ( month- years) admitted for acute encephalitis were included and diagnosis was confirmed using the consensus conference criteria's. data regarding clinical, biological and radiological presentations were collected as well as data on the therapeutics used and outcomes at discharge and at the last medical consultation. results: patients were included with a mean age of . years (range . to years old). infectious causes were identified in % (n = ), autoimmune causes in % (n = ) and acute demyelinating encephalomyelitis in % (n = ) of cases. etiology remained undetermined in % of cases (n = ). the most common pathogens were, in order of frequency, influenzae virus, mycoplasma pneumoniae and epstein-bar virus. the main clinical features were fever ( % n = ); epileptic seizures ( % n = ) and coma ( % n = ). regarding therapeutics, % of patients required mechanical ventilation and % of patients required hemodynamic support. % received corticosteroids, % intravenous immunoglobulins and % plasmatic exchanges. the use of these specific treatments was heterogeneous, especially in infectious and undetermined encephalitis, where respectively % and % received boluses of corticoids. the mean length of stay in picu was . days (range - days). the mortality rate was % and the overall rate of sequelae at discharge was % and % at distance, with % considered as severe (gose-ped score > ). the use of mechanical ventilation and young age at diagnosis were risk factors associated with poor prognosis at discharge. the etiology of acute encephalitis remains indeterminate in more than % cases with a clear predominance of infectious causes when an etiology is found. this is a severe pathology responsible for significant mortality and morbidity requiring long-term follow-up. compliance with ethics regulations: yes. rationale: preserving neurological outcome of children under extracorporeal membrane oxygenation (ecmo) remains challenging. acute brain injury (abi) is a frequent complication of ecmo that could be prevented by continuous neuromonitoring. cerebral near infrared spectroscopy (nirs) is routinely used for detecting cerebral complications of cardiac surgery. in adults and infants under prolonged ecmo, cerebral hypoxia is associated with poor neurological outcome. the aim of this study was to assess the value of an impaired cerebral oxygenation on mortality and occurrence of an abi in children under ecmo. patients and methods: children under years old were included in this observational retrospective monocentric study if they needed veno-venous (v-v) or veno-arterial (v-a) ecmo for respiratory and/ or circulatory failure and had concomittant nirs monitoring. cerebral desaturation was defined as a rsco value under % or under % from the baseline; cerebral hyperoxia was defined as a rsco value above %. proportion of time in cerebral desaturation and hyperoxia were recorded. neurological lesions were identified on imaging (mri or scan) by blinded radiologist and classified as major or minor. abi was defined as any hemorragic or ischemic lesion on cerebral imaging, including brain death. results: patients were included. ecmo duration was [ ; ] days. the mortality rate was ( . %), and the proportion of abi was ( %) including brain deaths, ( . %) major lesions, and ( . %) minor lesions. mean rsco was ± % in the right hemisphere, and ± % in the left hemisphere. there was no significant difference in cerebral hypoxia between survivors and non survivors, and between patients with and without an abi. cerebral hyperoxia was associated with a better survival (p = . in the right hemisphere, and p = . in the left hemisphere). in v-v ecmo and at the right conclusion: in our study, cerebral hypoxia was not associated with poor neurological outcome, but cerebral hyperoxia seems to be protective especially in v-v ecmo. this is the first study assessing the value of cerebral oxymetry in all age ranges pediatric ecmo. in this population, multimodal monitoring might be better than nirs alone to predict neurological impairment. further prospective studies are needed to assess first the feasibility, then the impact of such a monitoring. compliance with ethics regulations: yes. cerebral autoregulation impairment is associated with acute neurological events during pediatric extracorporeal membrane rationale: children supported by extracorporeal membrane oxygenation (ecmo) present a high risk of adverse neurological complications. as some animal studies have shown, cerebral autoregulation (ca) impairment after exposure to ecmo, may be a key factor. our main objective was to investigate the feasibility of ca continuous monitoring during ecmo treatment. the second objective was to analyze the relationship between ca impairment and neurological outcome. patients and methods: an observational prospective study including children treated by ecmo in centers was conducted. a correlation coefficient between the variations of regional cerebral oxygen saturation (rsco ) and the variations of mean arterial blood pressure(map) was calculated as an index of ca (cerebral oxygenation reactivity index, cox) during ecmo. a cox > . was considered as indicative for dysautoregulation. cox values were averaged inside mmhg-map bins, allowing determining optimal map (mapopt) and lower (lla) and upper (ula) limits of autoregulation in -h periods. neurological outcome was assessed by the onset of an acute neurologic event (ane) defined by occurrence of hemorrhagic or ischemic stroke and/ or clinical or electrical seizure and/or brain death during the ecmo treatment. rationale: myocardial ischemia reperfusion (ir) injury is the leading cause of perioperative morbi-mortality. protective effect of pharmacologic preconditioning such as anesthetic preconditioning (apc) with sevoflurane (sev) has been widely demonstrated in animal and human models. apc seems to protect myocardial cells from apoptosis, a programmed process of cell death tightly controlled by bcl- family proteins. however, the involved mechanisms in apc have yet to be characterized. we hypothesized that apc protects against myocardial apoptotic cell death by regulating bcl- anti-apoptotic members. to study the sev-induced apc mechanisms against myocardial ir, we used a validated in vitro model reproducing ir injury. rat cardiomyoblast cells h c were cultivated in . % o hypoxia in the presence of ischemia-mimicking medium. after min of ischemia, the reperfusion injuries are induced by replacing the culture medium with a krebs-henseleit normoxic medium for min. apc was performed by adding sev directly into the culture medium at an initial concentration of mm, prior to ischemia, for min. we then used another preconditioning agent, metformin (met), to explore the same signaling pathways. apoptotic cell death was measured by caspase activity assay and western blotting (expression of cleaved caspase ) under ir and apc conditions. results: our model faithfully reproduced the protective effect of apc which results in a significant decreased apoptosis under ir ( % reduction of the caspase enzymatic activity, correlated with a decrease of caspase cleavage). we showed that sev induces overexpression of the anti-apoptotic protein bcl-xl, which is responsible for the protective effect of apc. furthermore, these observations were confirmed in vivo in mouse heart lysates. we demonstrated that bcl-xl overexpression was due to the activation of the protein kinase akt. interestingly, we were able to show that preconditioning with met reproduces the protective effect of sev by inducing an akt-dependent bcl-xl overexpression. indeed, sev and met, which are both complex inhibitors of mitochondrial respiratory chain, seem to share a common reactive oxygenated species-dependent protective mechanism responsible for bcl-xl protein regulation. rationale: despite early endovascular treatment with successful recanalization, % of acute ischemic stroke (ais) patients experience a poor functional outcome after a large vessel occlusion. sepsis is frequent at the acute phase of stroke and is associated with poorer short and long term outcomes. we aimed to investigate the cerebral consequences of sepsis after recanalized ais and explore possible mechanisms involved. patients and methods: male c bl mice were randomly assigned to a x factorial plan to one of the following groups: ) a -minute middle cerebral artery (t-mcao) transient occlusion under inhaled general anesthesia, followed min after recanalization by intraperitoneal (i.p.) sepsis (lps, µg/g diluted in µl of nacl . %), (tmcao/ lps group); ) t-mcao followed by i.p. placebo ( µl of nacl . %) (tmcao/placebo group); ) sham operation (cervicotomy without carotid catheterization) followed by i.p. lps. (sham/lps group); ) sham operation followed by i.p. placebo, (sham/placebo group). in all groups, animals received subcutaneous fluid resuscitation ( µl nacl . %) immediately after the procedure and h later. twenty-four hours after recanalization, animals were scored for sepsis features and neurological deficit (on the modified neurological severity scale), (mnss) before sacrifice. the primary outcome measurement was a composite of death and hemorrhagic transformation at h. secondary outcome measurements included neurological deficit, sepsis features, neutrophil activation reflected by plasmatic myeloperoxydase (mpo) levels, stroke volume, and microglial activation in brain parenchyma (infarct core, perilesional area, controlateral hemisphere). results: t-mcao/lps animals had higher mnss ( . fold, p = . ) and sepsis ( fold, p = . ) scores at h with increased plasma mpo levels at h ( . fold, p < . ) and h ( . fold, p < . ), as well as, lower temperature ( . °c reduction, p = . ) and glycemia ( . g/l reduction, p = . ) as compared to tmcao/placebo animals. t-mcao/lps animals had a higher risk of unfavorable outcome at h ( -group comparison: p = . ; x analysis: t-mcao/lps, / − %vs. t-mcao/placebo / - %-, p < . ), whereas stroke volumes were not significantly different between groups. detailed results are presented in table . compared to t-mcao/placebo group, t-mcao/ lps animals had . fold increase (p = . ) in the mean number of microglial cells in the hemisphere controlateral to t-mcao, whereas no significant difference was observed in infarct core or peri-infarct parenchyma. conclusion: early sepsis after experimental ais worsens outcome and neurological deficit, without impacting stroke volume. early sepsisinduced systemic activation of neutrophils and increased microglial activation in the hemisphere contralateral to ischemia may have an important role on neurological outcomes observed in this setting. compliance with ethics regulations: yes. rationale: extracellular vesicles (evs) regulate diverse cellular and biological processes via facilitating intercellular cross-talk. several studies have suggested an association between lung injury and the generation of evs derived from platelets, neutrophils, monocytes, lymphocytes, red blood cells, endothelial cells, and epithelial cells. every year more than , patients require cardiac surgery with cardiopulmonary bypass (cpb). this cpb allows a substitution of the heart pump function and an oxygenation of the blood permitting a stop of the mechanical ventilation (mv). stopping mv during cpb is responsible for lung damage, leading to postoperative systemic inflammation while maintaining mv with positive expiratory pressure (peep) diminished the occurrence of atelectasis and the postoperative inflammatory response. in addition, this surgery is marked by immune dysfunction, leading to real immunosuppression of patients in postoperative care. a link between pulmonary injury and postoperative immunosuppression has been established, however, the mechanisms underlying this association are not fully known and evs may have a role in this post-operative immunosuppression. the purpose of this study is to investigate whether lung injury induced during cardiac surgery with cpb lead to the emergence of evs. the effect of mv during cpb on the production of these evs has also been studied. patients and methods: patients were prospectively divided into two groups: without mv during cpb and dead space mv with positive end-expiratory pressure during cpb. pao (arterial oxygen tension)/ fio (inspired oxygen fraction) ratio, biological markers of lung injury (cxcl , ccl , tnf-α, il- β, il- , rage, il- ) and blood cell count were collected before, h and days after surgery. the quantification of plasma evs was performed using turnable resistive pulse sensing and characterization of evs was performed using flow cytometry before, h and days after surgery. rationale: the benefit of prone positioning (pp) during moderate to severe acute respiratory distress syndrome (ards) may be related to its impact on the inflammatory response to ventilator-induced lung injuries. [ c]-pk is a positron emission tomography (pet) radiotracer that allows the non-invasive quantification of macrophages. we aimed to evaluate the effects of pp on [ c]-pk lung uptake in animals with experimental ards. patients and methods: experimental ards (by hydrochloric acid) was induced in pigs in supine position (sp), to obtain a pao / fio < mmhg. animals were under general anesthesia, neuromuscular blockade, and ventilated with a ml kg − tidal volume, and cmh o of positive end-expiratory pressure (peep). immediately after experimental ards, animals were randomized to be prone positioned, or to remain in sp. pet and computerized tomography (ct) were acquired h after randomization (h ). [ c]-pk uptake was measured on the whole lungs, and by dividing the lungs into regions or slices-of-interest (soi) along the ventro-dorsal axis, and was quantified by the standardized uptake value (suv), corrected for lung tissue density. results: pp was performed in animals, and sp in . after ards induction, pao /fio was [iqr, [ . - . ] in sp animals (p = . ). in pp animals, [ c]-pk suv was significantly lower in ventral soi, compared to sp, and significantly increased in dorsal soi ( fig. , *: p < . between groups in a given soi). in univariate analysis, [ c]-pk regional suv was positively associated with regional ct-measured peep-related increase in gas volume, and negatively with peep-related lung recruitment, but not with regional tidal volume. conclusion: during experimental ards, pp redistributed lung macrophage recruitment estimated by [ c]-pk uptake from ventral lung regions to dorsal regions, without affecting global macrophage influx. the intensity of macrophage recruitment was associated with peep-related lung inflation. compliance with ethics regulations: yes. rationale: acute respiratory distress syndrome (ards) is a pleiomorphic disease characterized by a severe respiratory failure associated with an increased mortality. nowadays, predicting clinical outcome of patients suffering from ards remains difficult. therefore, identifying new biomarkers to predict patient outcome, to evaluate response to therapy and to identify new potential pathways of interest are highly needed. exosomes are extracellular vesicles involved in cell-cell communication by transferring micrornas (mirnas) from donor to recipient cells. thus, exosomal mirnas can significantly affect biological pathways within recipient cells resulting in alterations of cellular function and the development of a pathological state. as biomarkers are highly needed in the particular field of ards, we realized a monocentric and prospective study to identify a new potential biomarker of interest. therefore, a prospective plasma sampling at the diagnosis of moderate to severe ards according to the definition of "berlin" has been performed. we analysed mirna content of exosomes from plasma ards patients compared to healthy subjects (hs) in order to identify new potential predictive biomarkers in ards. during one-year period, patients hospitalized in the icu of chu sart tilman suffering from infectious moderate-to-severe ards have been included. the ethical committee review boards of the hospital approved the research protocol (b , ref: / ), and informed consents were obtained. exosomes were isolated from plasma samples of ards patients and hs with standard ultracentrifugation protocol. exosomal mirna content was analyzed using small rna sequencing method, and diseases/biological processes associated to altered mirs were determined by bioinformatic analysis. results: for the first time, exosomal mirna expression modifications were studied in patients with moderate-to-severe infectious ards. we identified a new signature statistically significant composed of three up-regulated mirnas (mir- , mir- a and mir- ) and one downregulated (mir-let- b). conclusion: we identified potential biomarkers for ards from plasma exosomes. our findings may thus lead to predict ards outcome but also a better understanding about the roles of these mirs in the pathogenesis of ards and thus open new avenues for therapeutic approaches. in particular, exploit and develop the pro-fibrotic pathway induced by down-expression of mir-let- b. but also confirm in the future the current interest about mir- in its ability to restore pulmonary integrity after trauma. compliance with ethics regulations: yes. rationale: diabetic ketoacidosis (dka) is a life-threatening emergency. microvascular hyporeactivity was reported in these patients and was completely reversibly when ph was corrected with treatment: aggressive rehydration, electrolyte replacement and insulin therapy ( ) . red blood cell (rbc), a component of the microcirculation, showed alterations oftheir shape in diabetic patients ( ) but no data were available concerning the time course of the rbc deformability during treatment for dka. we aimed to assess the rbc deformability during dka treatment in icu patients. patients and methods: after approval by the ethics committee, rbcs deformability was assessed, in all icu patients admitted for dka and without infection, by ektacytometry technique (laser-assisted optical rotational red cell analyzer-lorrca): at icu admission, + h, + h and at the end of the icu stay ( - h). elongation index (ei) was defined as (l − w)/(l + w), where l is the length and w is the width. at °c, ei values were determined in the function of shear stress (ss) in a range of . - pa, based upon the laser diffraction pattern changes. a higher ei indicates greater rbc deformation. rbc deformability from patients with dka was compared at icu admission to healthy volunteers (v) and to diabetic patients followed in consultation (d). we also studied the evolution of deformability during treatment. results: icu dka patients compared to d and v were studied. as expected, glycemia and glycated hemoglobin were significantly higher in dka compared to d (respectively: glycemia: ( - ) vs ( - ) mg/dl and . % ( . - . ) vs . ( . - . ); all p < . ). dka patients received ( - ) ml of fluids and . ui/ kg bw ( . - . ) of insulin during their first h of icu stay. rbcs deformability from dka patients was significantly more altered at icu admission compared to others groups ( fig. ) and these alterations persists despite treatment. no correlations were observed between these alterations and quantity of fluids or insulin received, glycemia, glycated hemoglobin, ph, natremia, age or length of diabetes history. conclusion: in contrast of reversible microvascular hyporeactivity, rbc deformability from dka patients was already altered at icu admission and remains altered despite treatment. these alterations could contribute to the blood flow abnormalities observed in these patients. compliance with ethics regulations: yes. rationale: sepsis remains the first cause of acute circulatory failure in the emergency department (ed). standardized fluid resuscitation may not be adapted in certain patients, especially those with early sepsisinduced cardiac dysfunction in whom excessive fluid administration could be deleterious. information on early hemodynamic profile of septic patients in the ed are scarce. accordingly, we aimed at describing hemodynamic profiles encountered in septic patients assessed shortly after their ed admission using focused echocardiography. patients and methods: we prospectively enrolled adult patients with sepsis (qsofa score ≥ ) from january to july in the ed (nct ). focused echocardiography were performed by emergency physicians previously trained to ecmu level. each patient was evaluated according to a standardized protocol based on a limited number of simple binary clinical questions. investigators interpreted on-line the echocardiographic examination, determined the hemodynamic profile based on simple yet robust criteria (hypovolemia, left ventricular [lv] or right ventricular [rv] failure, vasoplegia with hyperdynamic state, tamponade, severe mitral or aortic regurgitation, or apparently normal profile), and recorded any substantial change in planned therapeutic management (surviving sepsis campaign ). data were digitally stored and validated off-line by an expert in critical care echocardiography. results: focused echocardiography were performed in patients (mean age: ± years; men: %; source of infection: pulmonary %, urinary %, abdominal %) after a median fluid loading of ml (iqr: - ml). according to sepsis- definition, patients had sepsis and sustained septic shock. mean sofa score was . ± . (hemodynamic failure %, respiratory failure %, renal failure %), mean lactate reached . ± . mmol/l, icu admission involved % of patients and overall -day mortality reached %. hemodynamic profile was hypovolemia in patients ( %), vasoplegia in patients ( %), cardiac failure in patients ( %) (lv failure: n = ; rv failure: n = ) and without relevant hemodynamic abnormality in patients ( %). ongoing therapy was altered based on early echocardiographic assessment in % of cases. mortality rate was not significantly different between groups (p = . ). conclusion: although hypovolemia was predominantly identified in patients presenting to the ed with sepsis during hemodynamic assessment, early ventricular dysfunction involved one-quarter of patients. these results suggest that early focused echocardiographic assessment promises to help the front-line physician tailoring the therapeutic management of septic patients in ed, especially regarding fluid resuscitation. compliance with ethics regulations: yes. right ventricular failure in septic shock characterization, incidence and impact on fluid-responsiveness guillaume geri , amélie prigent , xavier repessé , marine goudelin , gwenael prat , bruno evrard , cyril charron , philippe vignon , antoine vieillard-baron ambroise paré hospital, boulogne-billancourt, france; ambroise paré hospital, medical icu, aphp, boulogne-billancourt, france; chu limoges, limoges, france; chu brest, brest, france correspondence: guillaume geri (guillaume.geri@aphp.fr) ann. intensive care , (suppl ):f- rationale: right ventricular (rv) failure was defined by rv dilatation with systemic congestion. tricuspid annular plane systolic excursion (tapse) could be of limited value. we report the incidence of rv failure in patients with septic shock, its potential impact on the response to fluids, as well as tapse values. patients and methods: ancillary study of the hemopred prospective multicenter study including patients under mechanical ventilation with circulatory failure. with septic shock were analyzed. patients were classified in groups based on central venous pressure (cvp) and rv size (rv/lv end-diastolic area, eda). in group , patients had no rv dilatation (rv/lveda < . ). in group , patients had rv dilatation (rv/ lveda ≥ . ) with a cvp < mmhg (no venous congestion). rv failure was defined in group by rv dilatation and a cvp ≥ mmhg. passive leg raising (plr) was performed. results: % of patients were in group , % in group and % in group . in group and , rv/lv eda was higher than in group , . [ . ; . ] versus . [ . ; . ]. cvp was [ ; . ] mmhg in group . a correlation between rv size and cvp was only observed in group . higher rv size was associated with a lower response to plr (figure) . a large overlap of tapse values was observed between the groups. . % of patients with rv failure had an abnormal tapse. conclusion: rv failure is frequent in septic shock and alters fluid responsiveness. tapse was not accurate enough to diagnose rv failure. compliance with ethics regulations: yes. rationale: weaning-induced pulmonary oedema (wipo) is a leading cause of weaning failure in high-risk patients (heart failure, copd, obesity). we hypothesized that hypervolemia associated with positive fluid balance facilitates wipo in high-risk patients. patients and methods: in this prospective, observational, singlecenter study, patients with copd and/or heart failure with reduced ejection fraction (< %) were studied. exclusion criteria were nonsinus rhythm, severe mitral valve disease and inability to obtain adequate echocardiographic views. echocardiography was performed immediately before and during spontaneous breathing trial (sbt, -min t-tube). patients who failed sbt were treated according to echocardiographic results before undergoing a second sbt. fluid balance and body weight were collected at each sbt. shows interesting performance to predict fluid responsiveness in spontaneously breathing patients. nevertheless, measurement sites of inferior vena cava (ivc) diameters remain controversial for that purpose. the aim of the study was to test the accuracy of different measurement sites of civc to predict fluid responsiveness in spontaneously breathingpatients. this study is a post hoc analysis of two prospective cohorts. we included spontaneously breathing patients without mechanical ventilation presenting with sepsis-related acute circulatory failure and considered for volume expansion (ve). we assessed hemodynamic status at baseline and after a fluid challenge (fc) induced by a min-infusion of ml-gelatin %. the ivc diameters were measured off-line with ultrasonography using the bi-dimensional mode on a subcostal long-axis view. the civc was calculated as [ (expiratory-inspiratory)/expiratory] diameters during standardized (civc-st) and unstandardized breathing (civc-ns) conditions. breathing standardization consisted of a deep inspiration with concomitant control of buccal pressures and passive exhalation. patients were referred to be responders to fc (i.e. fluid responsive) when the stroke volume increased by ≥ %. results: among the patients included in the study, ( %) were responders to fc. the accuracy of civc-st and civc-ns before fc to predict fluid responsiveness differed significantly by measurement sites (interaction p value < . and < . , respectively). measuring ivc diameters cm from the junction of the ivc and the right atrium provided the best accuracy to predict fluid responsiveness ( fig. ). at cm caudal to the right atrium, civc-st was significantly better than civcns to predict fluid responsiveness: area under roc curve . ( % ci . - . ) versus . ( % ci . - . ), p < . . at cm, a civcst ≥ % and a civc-ns ≥ % predicted fluid responsiveness with sensitivity of % and %, and specificity of % and %, respectively. conclusion: accuracy of civc to predict fluid responsiveness in spontaneously breathing patients depends on both measurement sites of ivc diameters and breathing conditions. measuring ivc diameters during a standardized inspiration maneuver at cm caudal to the right atrium is the most relevant mean to optimize civc performance to guide ve. compliance with ethics regulations: yes. rationale: intermittent hemodialysis (ihd) is increasingly used in patients admitted to intensive care unit (icu) with acute kidney injury (aki) requiring renal replacement therapy (rrt). however, this technique is associated with nearly % of episodes of perdialytic hemodynamic instability (hi), a common cause of increased morbidity and mortality. at the same time, trans-thoracic echocardiography (tte) has become widely used in intensive care units and is now one of the hemodynamic monitoring methods used daily in the icu setting. patients and methods: search for one or more pre-dialysis tte criteria predictive of perdialytic hi, defined by a systolic blood pressure (sbp) lesser than mmhg or a suddain decrease in sbp of more than mmhg. prospective, observational study of standard care in a medical icu. collection of demographic, clinical and pre-dialysis echocardiographic data from included patients. results: twenty-five patients with a total of sessions of ihd between november and november were included in the study. tte was performed for each patient before each ihd session. hi occurred in hemodialysis sessions. in univariate analysis, the existence of prior heart disease ( % vs %, p = . ), a greater diameter of the left atrium ( . vs . cm, p = . ), a lower cardiac output ( . vs . l/min, p = . ), a right dysfunction assessed by lowered tapse and s-wave ( vs mm, p < . and . vs . cm/s, p = . , respectively) and an increase in paps ( vs mmhg, p = . ) were significantly associated with the occurrence of perdialytic hi (fig. rationale: several transthoracic echocardiography (tte) parameters of left (lv) and right ventricular (rv) systolic function are available. we compared the ability of these different parameters to track changes in lv or rv systolic function and to detect lv or rv systolic dysfunction in critically-ill patients. in patients ( mechanically ventilated and with atrial fibrillation), tte examinations were performed before and after i) infusion of -ml of saline (n = ), ii) changes in norepinephrine (n = ), iii) or in dobutamine (n = ) dosage. for the lv systolic function, we compared the mitral annular plane systolic excursion (mapse), the systolic (s') peak velocity of the lateral mitral annulus and the global longitudinal strain (glslv) to the lv ejection fraction (lvef), considered as the gold standard. for the rv systolic function, we compared the tricuspid annular plane systolic excursion (tapse), the systolic peak (s) velocity of the tricuspid annulus and the global longitudinal strain (glsrv) to the rv fractional area change (fac), considered as the gold standard. results: after pooling all values, lvef ( ± % at baseline) was better correlated to glslv (r = . ) than to mapse (r = . ) and s' wave (r = . ) (each p < . ). the concordance rate between changes (in %) in lvef and in the other parameters of lv systolic function was % for glslv, % for mapse and % for s' wave. both mapse and s' wave could not reliably detect moderate ( % ≤ lvef ≤ %) or severe (lvef < %) lv dysfunction. conversely, a glslv > − % predicted moderate lv dysfunction with a sensitivity of % ( % ic: - %) and a specificity of % ( % ic: - %) and a glslv > − . % predicted severe lv dysfunction with a sensitivity of % ( % ic: - %) and a specificity of % ( % ic: - %). after pooling all values, fac ( ± % at baseline) was better correlated to glsrv (r = . ) than to tapse (r = . ) and s wave (r = . ) (each p < . ). the concordance rate between changes (in %) in fac and in the other parameters of rv systolic function was % for glsrv, % for tapse and % for s wave.both tapse and s wave could detect rv dysfunction (fac ≤ %) with moderate reliability only. conversely, a glsrv > − % detected rv dysfunction with a sensitivity of % ( % ic: - %) and a specificity of % ( % ic: - %). in critically-ill patients, glslv and glsrv seem to be the best tte parameters of lv and rv systolic function. enrolments are still ongoing, which may allow further analysis. compliance with ethics regulations: yes. rationale: passive leg raising (plr), pulse pressure variation (ppv), and the -second end-expiratory occlusion test (eexpo) are frequently used to assess preload responsiveness. however, there are conditions in which they are not valid or feasible, which may preclude their applicability in the daily clinical practice. the aim of this study was to estimate the prevalence of such conditions in critically ill patients with acute circulatory failure. between january and april , all patients of a -bed medical icu were daily screened and those with acute circulatory failure, defined by norepinephrine infusion or fluid therapy > l during the previous h, were included. in each of them, we screened the criteria of validity/feasibility of ppv, plr and eexpo. results: eighty-four patients ( % with septic shock, % with cardiogenic shock, % with hypovolemic shock, % with non-septic vasoplegic shock) were enrolled in the study. among them, norepinephrine infusion was ongoing at the time of enrolment in % of the patients whilst % were under mechanical ventilation, and % with acute respiratory distress syndrome. plr was not applicable in % of cases. this was mainly due to venous compression stocking ( % of cases), intra-abdominal hypertension ( % of cases), and either an absence of cardiac output monitoring or impossibility to perform echocardiography ( % of cases). among the intubated patients, ppv was applicable in % of cases, including cases with high ppv under conditions generating false negatives (low tidal volume or lung compliance) or low ppv values under conditions generating false positives (spontaneous breathing, cardiac arrythmias). however, ppv was not interpretable in % of cases. this was mainly due to low tidal volume ventilation ( % of cases), spontaneous breathing activity ( % of cases), while the remaining non-interpretable cases ( %) had more than one reason. in the intubated patients, eexpo was not applicable in % of cases. this was due to impossibility for patients to sustain a -s hold of mechanical ventilation in % of cases, and either an absence of cardiac output monitoring or the impossibility to perform echocardiography in % of cases. plr and eexpo were both valid and feasible in % of the patients, and the three tests were all feasible in only % of patients. rationale: comorbid association between chronic respiratory diseases and sleep apnea syndrome (sas) revealed frequent with systematic search in icu following icu stay. this association carries prognosis impact depending whether specific treatment is implemented or not. nosas and stop bang scores are proposed for screening of sas in general population. the aim of the present study is to report the prevalence of sas in icu patients admitted for hypercapnic respiratory failure and compare association of nosas and stop bang score with sas severity. the study was conducted between january and september . patients consecutively admitted in the icu for hypercapnic respiratory failure had calculation of a no sas and stop bang scores at admission. in survivors nocturnal polygraphic records was performed to weeks following icu discharge. the association between the number of apnea-hypopnea episodes, bmi, and clinical variables suggestive of sas, was tested by poisson regression model. results: during the study-period, patients (mean age: ± years, ph . ± . , paco ± ) were admitted for hypercapnic respiratory failure. non invasive ventilation was used in % and death occurred in six patients. polygraphic records were performed in ( lost to follow-up) mean apnea-hypopnea index was ± with a minimum of and a maximum of . poisson logistic regression showed that no sas (p = . ) but not stop bang (p = . ) was associated with the level of apnea-hypopnea index. rationale: patients with severe acute exacerbations of chronic obstructive pulmonary disease (copd) may benefit from high-flow nasal oxygen regarding its physiological effects and good tolerance. bronchodilator vibrating mesh nebulization through high-flow nasal oxygen circuit has been described to induce similar effect to standard facial mask jet nebulization in stable copd patients. we aim to evaluate whether vibrating mesh nebulization of salbutamol through highflow nasal oxygen circuit is efficient in unstable patients with copd. patients and methods: we conducted a monocenter non-randomized physiological prospective cross-over study, between january and september , including icu patients with severe acute exacerbation of copd and respiratory acidosis treated by salbutamol nebulization. spirometry and airway resistances records were performed after a -h wash-out period without bronchodilator, before and after vibrating mesh nebulization of mg salbutamol through high-flow nasal oxygen circuit. the primary endpoint was forced expiratory volume in s after salbutamol nebulization. secondary endpoints included other spirometry parameters, clinical parameters, dyspnea assessed by a borg scale. results: fourteen consecutive patients were included, forced expiratory volume in s increased significantly after salbutamol nebulization through high-flow nasal oxygen ( ± ml, p = . ), as well as forced vital capacity ( ml ± , p = . ). airway resistances were not significantly changed after nebulization (− . ± . , p = . ) as well as peak expiratory flow (+ ml ± , p = . ). no difference was observed on borg scale (p = . ) and respiratory rate (p = . ) after salbutamol nebulization, while heart rate increased significantly (p = . ). discussion: salbutamol nebulization using vibrating mesh nebuliser placed on high-flow nasal oxygen circuit induces a significant but moderate bronchodilation in patients with severe acute exacerbation of copd. moreover, improvement of forced vital capacity after salbutamol nebulization suggests a reduction of dynamic hyperinflation. conclusion: salbutamol vibrating mesh nebulization through highflow nasal oxygen circuit increases significantly forced expiratory volume in s. compliance with ethics regulations: yes. t-piece versus sub-therapeutic pressure support for weaning from invasive mechanical ventilation in patients with chronic obstructive pulmonary disease: a comparative prospective study amira jamoussi, fatma jarraya, samia ayed, takoua merhabene, jalila ben khelil, mohamed besbes abderrahmen mami hospital, tunis, tunisia correspondence: amira jamoussi (dr.amira.jamoussi@gmail.com) ann. intensive care , (suppl ):f- rationale: the best weaning strategy for patients with chronic obstructive pulmonary disease (copd) remains unknown. the spontaneous breathing trial (sbt) represents a crucial step of weaning, but the choice between the t-piece (sv-tube) or the sub-therapeutic setting of the level of pressure support without positive expiratory pressure (psv) is still a matter of debate. we aimed to compare the success of extubation between two groups of copd patients according to the sbt type (vs-tube vs psv). patients and methods: it was a prospective and comparative study, from april to march , at the abderrahmen mami hospital's intensive care unit (icu). copd patients who underwent invasive mechanical ventilation (mv) for at least h and met the criteria for weaning were included and randomized to sv-tube or psv. a multivariate analysis was performed to determine the association between the sbt modality and the success of extubation (no re-intubation during the h following extubation). results: during the two years' study, patients were included. the mean age was ± years, the sex-ratio was . . weaning process was simple in patients ( %), difficult in patients ( %) and prolonged in patients ( %). fifteen and patients were respectively randomized to the sv-tube and psv groups. the mean duration of mv before randomization was comparable between the groups (sv-tube . ± . days vs psv . ± . days, p = . ). mean weaning time (days) was . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] for the sv-tube group and . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] for the psv group. the mean total mv duration (days) was higher in the sv-tube group than in the psv group ( . vs . , p = . ). the number of re-intubated patients within h following extubation was higher in the psv group ( / vs / , p = . ) as well as the overall reintubation rate ( . % vs %, p = . ). in multivariate analysis, the sbt's trial was independently associated to the success of extubation (or = . , ic [ . - . ], p = . ) in favor of sv-tube' modality. the median length of stay in intensive care was days [ ; ]. the mortality was higher in the psv group ( / vs / , p = . ). extubation failure was a factor associated with mortality (or = . , ci [ . , . ], p = . ). conclusion: ventilation weaning was easy in % of intubated copd patients. sv-tube as sbt modality was associated to success of extubation in patients with copd. mortality in intensive care was significantly higher in re-intubated patients. compliance with ethics regulations: yes. rationale: non-invasive ventilation has become the mainstay in hypercapnic respiratory failure. delaying intubation and invasive ventilation is associated with a worse outcome in these patients. although a predictive score of niv failure has been validated for hypoxemic respiratory failure no such score exists in hypercapnic respiratory failure. the aim of our study is to compare the performance of two scores in the predictive niv failure hypercapnic respiratory failure. patients and methods: consecutive patients admitted between january and july for hypercapnic respiratory failure, were included. hacor score and rox score were calculated in each patient at admission. in patients ventilated non-invasively, the outcome (niv success or failure) was noted. the area under curve (auc) and operative characteristics were computed for both scores. results: during the study-period, out of patients admitted for hypercapnic respiratory failure received niv as the primary ventilatory mode. these patients were mainly men ( / ), had a mean age of . ± years and had the following pulmonary disease: copd exacerbation . %, obesity-hypoventilation syndrome . %, bronchiectasis . %, and other diseases: . %. niv failure occurred in patients ( . %) and icu mortality in . %. mean hacor score and rox score were . ± . and . ± , respectively. the auc under roc was higher for hacor than rox ( . and . respectively) ( fig. ). the hacor score (cut-off ) had a sensitivity of . and specificity of . . conclusion: hacor score seems more accurate in predicting niv failure in hypercapnic respiratory failure. further prospective validation is needed. compliance with ethics regulations: na. rationale: published data on outcomes in respiratory weaning centers are limited and seem to depend on the organisation of healthcare systems and patient case-mix. the weaning center of our university hospital (post intensive care rehabilitation unit) admits for weaning and rehabilitation patients from medical and surgical intensive care units without severe neurological pathologies. the aim of this study was to describe patient's characteristics and outcome (weaning outcomes and survival) and to compare in subgroups according to the initial medical, surgical or cardiac surgical context. patients and methods: we conducted a monocentric retrospective observational study between / / and / / . «successful outcome» was defined by the association of survival and weaning from invasive ventilation. factors associated with evolution were investigated by uni-and multivariate analysis. survival after discharge was analysed according to the initial context and according to the type of ventilation at discharge. results: among patients included, ( . %) had a successful outcome with high use of non-invasive ventilation (niv) ( %). respiratory history (p = . ), female gender (p < . ), igs score at admission to the srpr (p = . ) and non-cardiac surgical setting (p < . ) were associated with an adverse course. the -month survival rate was % in discharged patients. the outcome was not different in the tree subgroups. niv rate at discharge was high in the subgroup of cardiac surgery patients. a multidisciplinary and personalised approach by a specialized weaning unit can provide a successful service model for patients who require liberation from prolonged invasive mechanical ventilation. compliance with ethics regulations: yes. rationale: high-dose insulin euglycemic therapy (hiet) is recommended as first line therapy for calcium channel blockers (ccbs) poisoning because of its inotropic effect. our first objective was to study its hemodynamic impact. we performed a retrospective cohort study of all consecutive patients admitted for ccbs poisoning treated with hiet, in one icu at the university hospital of lille between january and july . the hemodynamic impact was studied through mean arterial pressure (map), vasoactive-inotropic score (vis) and map/vis ratio during the h following hiet initiation. metabolic parameters were also collected. results: patients admitted for ccbs poisoning. patients treated with hiet in icu ( patients without circulatory shock, patients with shock after hiet and patients with shock at baseline before hiet). among shocked patients at baseline (n = ), no hemodynamic improvement was found except an increased map/vis ratio at h (p < . ). on the contrary, an initial worsening of vis ( [ rationale: ketamine is used in the induction and maintenance of general anesthesia. recently, there were concerns regarding its liver toxicity. we conducted a study to investigate the link between ketamine use and liver dysfunction (ld) in intensive care unit (icu) patients. patients and methods: data were extracted from the [anonymized] study, a randomized controlled trial designed to evaluate the effect of cisatracurium on -day mortality rate in moderate and severe acute respiratory distress syndrome (ards) patients. the main endpoint was the occurrence of a ld defined as a total serum bilirubin superior or equal to micromol/l. a matched case-control cohort was created: cases, receiving at least day of continuous ketamine infusion, were paired for with controls according to treatment with cisatracurium, hepatic and cardiovascular sofa sub-score, total serum bilirubin level at the time of inclusion, age, sex, ards from septic origin, shock anytime after inclusion. an analysis was also made on the whole cohort comparing the patients receiving at least day of continuous ketamine infusion to all patients who did not fulfill this criterion. results: cases were identified and matched to controls. in the ketamine group, the median ketamine duration was ( - ) days, and median total cumulative dose . ( . - . ) g. the occurrence of ld was higher in the ketamine group than in the matched control group ( . % versus . %, p = . , fig. ). the hazard ratio (hr) for ld in the ketamine group was . ( % ci . - . , p = . ). there was an increased risk of ld of . % per day of exposure to ketamine (hr . , % ci . - . p = . ) and of . % per gram of ketamine infused (hr . , % ci . - . , p = . ), with a risk starting to be statistically significant after days and gr. in multivariate analysis on the whole cohort, ketamine exposure (hr . , % ci . - . , p = . ), cumulative dose in gram (hr: . , % ic: . - . , p = . ) and ketamine exposure in days (hr: . , % ic: . - . , p < . ) remained independent risk factors for ld occurrence. conclusion: ketamine use in critically ill patients treated for ards is associated to a higher risk of liver dysfunction, assessed by total serum bilirubin. this risk is dose-dependent and increases with duration of treatment. the prescription of high doses or prolonged treatment with ketamine should probably be avoided in critically ill patients. compliance with ethics regulations: yes. rationale: ciguatera is one of the most common cases of marine poisoning associated with fish consumption in the world. the incidence of this intoxication is largely unreported. in martinique, the incidence of this intoxication seems constantly increasing. during the last years, numerous cases of large collective poisonings have been reported in martinique, especially during summer. the spectrum of clinical manifestations is large including gastrointestinal, neurological andcardiovascular symptoms. ciguatoxin, the toxin responsible for ciguatera fish poisoning is considered as a sodium channel agonist with cholinergic and adrenergic activity. it is rarely fatal and management of poisoned patients is essentially based on supportive care. the objective of this study was to describe the clinical characteristics and complications of ciguatera poisoning in martinique, focusing on the cardiovascular ones. observational, retrospective, single-center study covering six-year period from october to september , including all patients admitted to the emergency department of the university hospital of martinique (chu), and all patients who were declared to the regional health agency (ars) for ciguatera intoxication. results: one hundred and forty-nine patients ( ) who were ciguatera-affected were included. the incidence rate found was to be . cases per . patient-years in martinique over the period. about % of patients had gastrointestinal symptoms such as nausea, vomiting, diarrhea, or abdominal pain; % neurological disorders and % cardiovascular symptoms including, bradycardia, hypotension and interventricular block. ingestion of carangue fish was related to a major risk of chronic signs. conclusion: the incidence of ciguatera in martinique is increasing, with . cases/ . patient-years. the clinical presentation is defined mainly by digestive signs, followed by peripheral neurological disorders and cardiovascular symptoms. ciguatera fish poisoning in martinique presents similar clinical presentation to that of the other caribbean islands. there is no specific treatment. acute ciguatera poisoning is responsible for significant cardiovascular complications. physicians should be aware of the potential cardiovascular risk of ciguatera poisoning. compliance with ethics regulations: yes. rationale: pesticides have represented the most incriminated products in severe acute poisonings, in the developing countries, due to the availability of these products. organophosphate poisoning accounts for million poisonings/year worldwide. organophosphate (op) pesticides are used mainly as insecticides in agriculture. the moroccan anti-poison and pharmacovigilance centrer shows that op poisoning are responsible for % of all poisonings combined. the aim of our study: epidemiological, clinical, management and prognostic factors. patients and methods: a retrospective study was conducted on patients with op poisoning admitted to our nine-bed medical intensive care unit between january and december . inclusion criteria were: all patients over years of age and the exlusion criteria were: pesticide poisoning other than op, alcohol poisoning, drug poisoning, scorpionic poisoning and snake bites. statistical analysis was performed with spss software. results: forty patients were admitted for acute op poisoning. in morocco, organophosphores are available over-the-counter in several forms: rodentocides, malathion, cockroach trap, baygon insecticide ( fig. ). the average age was years with a female prévalence of . %. the intoxications were mostly intentional ( %). the symptomatology was determined by the three syndromes: central syndrome in %, muscarinic syndrome in %, nicotinic syndrome in %. rhythm disorders in %, and cardiovascular collapse in %. the symptomatic treatment was applied to all patients, antidotic treatment was administered in % of patients. the average length of hospitalization was days. conclusion: acute op poisoning is a real public health problem. its associated symptomatic treatment (respiratory and neurological resuscitation) and antidotic treatment. the mortality remains high in our context, therefore, we must attach great importance to the prevention. compliance with ethics regulations: yes. ( ). over an -month period, health officials in guadeloupe and martinique reported more than . such cases. assault of these brown algae represents not only an environmental and economic disaster, but also a threat for human health. after h on seashore, large amounts of toxic gas are produced by matter decomposition, including hydrogen sulfide (h s) and ammoniac (nh ). the acute effects on humans after exposure to high concentrations of h s are well described and of increasing severity with concentration, leading to potentially fatal hypoxic pulmonary, neurological and cardiovascular injuries (table ) ; however, the association of long-term exposure to sargassum and health events is unknown. although less documented, long term exposures may result in conjunctiva and upper airways irritation, headaches, vestibular syndrome, memory loss, and modification of learning abilities. in the absence of any available antidote, management of h s intoxication relies on supportive care and prevention using individual protection. the objective of this study was to evaluate the clinical characteristics and consequences of long-term exposure to sargassum among the local population. we conducted a prospective observational cohort study including all patients admitted to the emergency department at the university hospital of martinique from march to december due to exposure to sargassum. patients were managed according to the protocol established by the research group on sargassum in martinique. we assessed the patients exposure to sargassum and air pollutants using monitor located near of the patient's residence. demographics and clinical data (including cardiovascular, neurological and respiratory events) were collected. data are presented as mean ± sd or %.comparisons were performed using univariate analysis. results: in months, patients were included (age: ± years, m/ w, past history: hypertension (n = ), diabetes (n = ), asthma ( ). patients arrived with referral letter from their general practitioner ( %) and presented headaches ( %), developed gastrointestinal disturbances ( %), dizziness ( %), skin lesions ( %), cough ( %) and conjunctivitis ( %). not all patients were clinically symptomatic. in the patients presented in june ( %), symptoms more frequently occurred in the workplace or at home (p < . ). initial lung function tests were normal ( %). three patients were admitted in intensive care unit. conclusion: our study indicates that the magnitude of health effects following long-term exposure to sargassum may be larger than previously recognized. efforts to limit long-term exposure are mandatory. compliance with ethics regulations: yes. rationale: liver consequences of out-of-hospital cardiac arrest (ohca) have been poorly studied. the aim of this study was to describe the characteristics of ohca-induced acute liver dysfunction and its association with outcomes. we analyzed all consecutive ohca patients admitted to two academic centers between and . patients treated with vitamin k antagonist were not included. acute hepatocellular insufficiency (ahi), liver failure (lf) and hypoxic hepatitis (hh) were defined as a prothrombin (pt) ratio < %, a hepatic sofa sub-score > and an increase in transaminases > times the normal values, respectively. indocyanine green (icg) clearance was used as the reference measure of liver function in a subset of patients. multivariate logistic regression was used to identify potential risk factors for day mortality. rationale: neuron-specific-enolase (nse) is commonly used as a biomarker reflecting the extent of brain injury in different settings. in post-cardiac arrest patients, previous clinical studies reported that an increase in nse was predictive of a poor outcome but did not specifically focused on neurological outcome. in this prospective study, we aimed to determine the nse performance for prediction of severe brain damage in post-cardiac arrest patients. patients and methods: all consecutive patients admitted in our icu after cardiac arrest between january and february that were still comatose at h and had at least one measurement of serum nse were included. blood samples for nse measurement were serially collected at (h ) and h (h ) after cardiac arrest and serum nse levels were measured within h. we used the following criteria for the definition of severe brain damage (primary endpoint): cerebral performance categories (cpc) or level at discharge, brain death or withdrawal of life-sustaining treatments (wlst) based on neurological status. we also assessed the predictive value of serum nse using allcause mortality as a secondary endpoint. results: during the study period, patients were available for the analysis. they were mostly male ( . %), with an age of . years. among these patients, ( . %) had a good neurologic outcome (cpc - ) and patients were classified as having a severe brain damage ( wlst based on neurological status, brain deaths and survivors with . in univariate analysis, patients with severe brain damage less frequently received bystander cpr, had longer duration of no-flow, less initial shockable rhythm, more post-resuscitation shock and higher nse values: mean at h were . versus . ; and . versus . at h (p < . ). nse levels at h and h were strong predictors of severe brain damage (auc of . and . respectively, figure ) and also predicted all-cause mortality (auc of . and . respectively). to predict severe brain damage with % specificity, best nse cutoff values at h and h were . and . µg/l, with a sensitivity of . and . % respectively. conclusion: a high serum nse measured at h and h after cardiac arrest accurately predicted severe brain damage with a high specificity. our results support the use of nse for neuroprognostication after cardiac arrest, in combination with other predictors. compliance with ethics regulations: yes. rationale: the psychological care of patients, their relatives and of healthcare workers is a major issue in the intensive care unit (icu). psychologists may provide emotional support during trying times. the intervention of a psychologist may alleviate long term mental health issues such as post-traumatic stress disorder. the main objective of our study was to describe the availability of psychologists in french-speaking icus. patients and methods: internet survey conducted between march and may using surveymonkey (san mateo, usa). survey consisting of questions sent to subscribers of the srlf mailing list via mailchimp software (atlanta, usa). frequencies and percentages were determined for categorical variables and median and interquartile range for continuous variables. the icus with or without psychologist were compared using nonparametric fisher exact test. stata used (lakeway drive, te, usa). results: responses were obtained from unique icus in france (n = ), belgium (n = ), switzerland (n = ), algeria (n = ), morocco (n = ) and tunisia (n = ). ( %) icus were part of public hospitals, ( %) of private facilities. ( %) icus cared for adult patients, ( %) for children. the median number of beds was [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . ( %) icus were open to visitors / , ( %), to visitors > h/day and ( %) to visitors < h/day. psychological consults were established in ( %) wards ( icus did not answer). pediatric icus employed more psychologists than adult icus (p = . ). comparison of icus based on the presence or not of a psychologist appears in table . in icus where a consulting psychologist is available, their effective availability is . [ . - ] full time equivalent. consults are delivered to: patients ( %), families ( %) or healthcare workers ( %). out of the icus without a psychological consult, responders from ( . %) icus believe that a psychological consult is undesirable. out of the icus without psychological consult, ( %) responders cannot obtain a psychological consult, whatever the circumstances, ( %) can require an outside psychological consult when needed, while ( %) can require assistance from a psychologist working in another unit (several answers possible for each respondent). conclusion: psychologists consult in only half of adult icus but in almost all pediatric icus. % of icus are unable to provide a psychological consult. psychological consults are delivered in similar proportions to patients, their family and to a lesser extent to healthcare workers. responders from . % icus without an established psychological consult believe that the availability of a psychologist is undesirable. compliance with ethics regulations: na. rationale: comfort of patients in intensive care unit (icu) is now a real concern for the healthcare teams. perceived patient discomfort assessment is a daily practice for our staff. the primary objective of our study was to assess whether the overall discomfort score reported by patients hospitalized in a separate intermediate care unit differs from that reported by patients hospitalized in icu. a tailored multicomponent program consisting of assessment of icu-related self-perceived discomforts with a -item questionnaire, immediate and monthly feedback to healthcare teams and site-specific tailored interventions, was applied in our department, located in a general hospital, and comprising a -bed icu and a separate -bed intermediate care unit rationale: the transition period surrounding the discharge from icu to hospital ward is a critical period in the course of the patient. handoff of complex patients is at high risk for communication failures between providers, inaccurate cares and icu readmission. a transition program including a post icu follow-up has been proposed to improve handoff quality. post icu consults by icu team represent, also, an opportunity for improving feedback on the quality of icu cares. the goal of the present study is to assess the feasibility and the impact of a systematic early post-icu consult (epicuc) program on handoff quality in a bed mixed icu. patients and methods: before the development of the epicuc program, standardized handoffs were already applied including identified day and hour of discharge and both verbally communicate and written medical and nurse information for receiving team. from st march to th october , all patients who were discharged to the ward of our hospital were candidates for epicuc. epicuc were performed by icu staff (at least one icu physician) within the days following discharge. the epicuc consisted of a face-to-face discussion with the receiver team to assess the accuracy, completeness and understanding of passing information and of a patient visit. a standardized form was used for collecting data. the impact of epicuc on handoff quality was assessed by the number of communication failures and the number of patients in whom epicuc resulted in a management change. personal feeling of epicuc providers on its usefulness was assessed by a - rating scale. results: among the candidates for epicuc, were dead and already discharged alive from hospital at epicuc time. epicuc were performed in patients ( %) within ± days after icu discharge. epicuc ( %) were performed by both, nurse and icu physician. ( %) patients and receiver teams ( %) were available at epi-cuc time. epicuc duration was ± min. a communication failure was identified in epicuc ( %), either a rectification of passing information (n = ; %) and/or a change in patient management (n = ; %). the usefulness of the epicuc was rated at ± and ± by icu physicians and nurses, respectively. conclusion: the time spent for epicuc appears reasonable. epi-cuc identified a communication failure in one-third of handoffs and allowed care readjustment in one quarter of patients. factors associated with handoff failures will be presented during the congress. compliance with ethics regulations: yes. rationale: surviving a critical illness is a challenging condition for patients and relatives. the psychological aspects are directly affected by physical status and performance. patients can feel depressed or anxious facing difficulties during recovery time. the aim of this study was to correlate patients' perceptions of his health status and his clinical performance measured after icu discharge. patients and methods: this is a prospective pilot study of an icu follow-up clinic conducted in a single center from january to july . this clinic is multidisciplinary and includes two visits at and months after icu discharge. patients with more than days of icu los were eligible. all patients at and -m visit were evaluated with sf- , mwt, mrc and time-up-and-go test. we conducted an analysis comparing clinical performance data and qualitative data between and months after icu discharge. the investigation included patients who had at least days of icu length of stay. patients attended the consult at -m and patients attended the consult both times. the median age (iqr) was ( - ) and % were men. %, % and % of patients had medical, scheduled surgical and emergency surgical admission causes respectively, with median (iqr) saps iii score ( - ). %, % and % of patients had sepsis, delirium and mechanical ventilation as a support. the physical status was progressively increased overtime likewise the physical capacity assessed by sf- score with p-value . between and -m. however, no significant difference between the subjective dimension of sf- , which analyses the perception of the patient about his physical capacity, assessed at -m and at -m was demonstrated (p . ). in this pilot-phase of following a cohort of critically ill patients, the natural physical improvement does not seem to change the patient's perception of their performances. this paradigm rouses a different perspective that should take into account when setting up rehabilitation programs. compliance with ethics regulations: yes. post-traumatic stress disorder after discharge from an acute medical unit basma lahmer , naoufel madani , , jihane belayachi , , redouane abouqal rationale: post-traumatic stress disorder (ptsd) occurs after exposure to a traumatic event and comprises of symptoms of repeated re-experiencing of the said event, avoidance of reminders, emotional numbing and persistent hyperarousal. in individuals exposed to "medical stress", various studies found evidence of ptsd occurring after the onset, diagnosis, or treatment of physical illness. our study aims to determine ptsd's risk factors in patients of an acute medical unit (amu) after their discharge. patients and methods: it was a prospective, analytical study conducted over a period of months at an acute medical unit. we collected sociodemographic and clinical data, patients' medical history, and evaluated the symptoms of anxiety and depression during their stay using the hospital anxiety and depression scale (hads). the prevalence of severe ptsd symptoms was assessed with the impact of events scale-revised (ies-r) at weeks and months using a cutoff of . associations between ptsd as evaluated by ies-r at months and patients' characteristics, including hads scores at admission were investigated using unadjusted linear regression, for univariate and multivariate regression analysis. statistical analyses were carried out using spss for windows (spss, inc., chicago, il, usa). we included patients in our study with a mean age of . ± . . in our population, . % of patients scored higher than a ies-r cutoff at weeks compared to . % at months. the mean hads-anxiety score is . ± and that of the hads-depression score is . ± . . on one hand, higher hads-anxiety score during the stay in the amu was linked to higher ies-r scores at months β: rationale: objective of critical care includes restoration of functional capacities. prompt identification of muscle acquired weakness (icu-aw) is crucial to target efficient rehabilitation. in published literature, data of quadriceps strength (qs) cannot be compared because of insufficient standardization of measurement protocols. we recently validated a highly standardized protocol of qs measurement. in order to build basic and comparable knowledge and to identify the weakest patients, this study aimed to describe qs of critically ill (ci) patients during their short-term evolution, and to compare them to surgical (s) and healthy (h) subjects. patients and methods: this observational study included ci patients who spent at least days in icu, patients scheduled for elective colorectal surgery (s) and young healthy volunteers (h). maximal isometric qs was assessed using a handheld dynamometer (microfet ® ) and expressed in newton/kg (n/kg). dominant leg was tested in supine position using a highly standardized procedure. ci and s patients were tested at t (as soon as collaborative in icu) and month after discharge (m rationale: the post intensive care syndrome (pics) gathers various disabilities, associated with a substantial healthcare use. however, patients' comorbidities and active medical conditions prior to intensive care unit (icu) admission may partly drive healthcare use after icu discharge. to delineate the relative contribution of critical illness and pics per se to post-critical illness increased healthcare use, as opposed to pre-existing comorbidities, we conducted a population-based evaluation of patients' healthcare use trajectories. patients and methods: using discharge databases in a . -million-people region in france, we retrieved, over three years, all adult patients admitted in icu for septic shock or acute respiratory distress syndrome (ards), intubated at least days and discharged alive from hospital. healthcare use (days spent in healthcare facilities) was analyzed two years before and two years after icu admission. healthcare trajectories were next explored at individual level: patients were assembled according to their individual pre-icu healthcare use trajectory by clusterization with the k-means method. results: eight-hundred and eighty-two ( ) patients were included. median duration of mechanical ventilation was days (interquartile ranges [iqr] ; ), mean saps was , and median hospital length of stay was days (iqr ; ). prior to icu admission, we observed, at the scale of the whole study population, a progressive increase in healthcare use. however, clusterization of individual according to pre-icu healthcare trajectories identified patients with elevated and increasing healthcare use (n = ), and two main groups with low (n = ) or no (n = ) pre-icu healthcare use. patients with high healthcare use had significantly more comorbidities than those with low healthcare use. in icu, however, saps , duration of mechanical ventilation and length of stay were not different across the groups. interestingly, analysis of post-icu healthcare trajectories for each group revealed that patients with low or no pre-icu healthcare (which represented % of the population) switched to a persistent and elevated healthcare use during the two years post-icu. conclusion: for % of ards/septic shock survivors, critical illness appears to have a pivotal role in healthcare trajectories, with a switch from a low and stable healthcare use prior to icu, to a sustained higher healthcare recourse two-years after icu discharge. this underpins the hypothesis of long-term critical illness and pics-related quantifiable consequences in healthcare use, measurable at a population level. compliance with ethics regulations: yes. ( ) to describe the pre-hospital grading protocol developed by the northern french alps emergency network (trenau) for children, ( ) to evaluate its quality to detect the most severe trauma patients and ( ) to assess the accuracy of this procedure to perform an adequate triage. patients and methods: our regional trauma system included hospitals categorized as level i, ii or iii pediatric trauma centers. eachpatient was graded a, b or c by an emergency physician, according to the seriousness of their injuries at presentation on scene. the triage was performed according to this grading and the categorization of centers. this study is a registry analysis of an -year period ( to ). results: a total of children (mean age years, % were boys) with severe trauma were included in the cohort. fifty-seven, % and % of patients were admitted to a level i, ii and iii, respectively. road accident was the main mechanism of injury ( % of patients). thirtysix percent of patients had a severe trauma, defined as an injury severity score (iss) higher than . one quarter of patients had at least severe lesions and one-third of patients had a trauma brain injury. the pre-hospital gradation was closely related with injury severity score (iss) and intra-hospital mortality rate. the triage protocol had a sensitivity of % and a specificity of % to predict adequate admission of patients with iss more than . using a specific trauma score (including occurrence of death, an admission in intensive care unit and the need for urgent surgery), sensitivity and specificity reached and %, respectively. fourty-six percent of patients were not graded at the scene (non-graded group). undertriage rate was significantly reduced in the graded group compared with the non-graded group, ( % versus %), without significant modification of the overtriage rate ( % versus %). overall, mortality at discharge from hospital was %, but % in grade a patients. conclusion: implementation of a regional pediatric trauma system with a specific pre-hospital triage procedure was effective in detecting severe pediatric trauma patients and in lowering the rate of prehospital undertriage. compliance with ethics regulations: yes. rationale: critically ill children suffer from pathophysiological changes, leading to large between-subject variability in drug clearance. since piperacillin is eliminated mainly via the kidney, changes in renal function go along with a modified elimination, and possible subtherapeutic or toxic drug concentrations. we aimed to determine the most accurate glomerular filtration rate (gfr) estimation formula for assessing piperacillin clearance in critically-ill children. patients and methods: all children hospitalized in pediatric intensive care unit and receiving piperacillin were included. piperacillin was quantified by high performance liquid chromatography. pharmacokinetics were described using the non-linear mixed effect modeling software monolix. in the initial pharmacokinetics model, gfr was estimated according to the schwartz formula. in the study, gfr was estimated with additional formulas, developed with plasma creatinine and/or cystatin c. biases, precisions, spearman's rank correlation coefficient and normalized prediction distribution error (npde) were used to assess the models. results: we included children with a median (range) postnatal age of . ( . - ) years, body weight of . ( . - ) kg and estimated gfr according to the schwartz formula of . ( - ) ml min- . . m . piperacillin concentrations were best predicted with the model using the creatinine clearance. the correlations were most accurate: r = . between the population-predicted and the observed concentrations, r = . and r = . for the npde versus population-predicted concentrations and time, respectively. concerning the individual predicted concentrations, bias and precision were respectively − . mg l − and . mg l − . gfr estimations based on serum creatinine were higher than those based on cystatin c (p = . ). conclusion: in summary, the -h creatinine clearance is the best predictor of piperacillin clearance and this could be investigated for drugs with renal elimination. as a whole, literature and our findings strongly suggest using creatinine clearance to also estimate gfr in critically ill children. the gap between the gfr estimations is large depending on the formulas, with higher estimations with equations based on serum creatinine. compliance with ethics regulations: yes. rationale: acute pancreatitis (ap) incidence have increased dramatically over the past years. new guidelines in were recently published in order to standardize the definition and management of ap. the aim of this study is to describe the management of children that were diagnosed with ap from the pediatric intensive care unit (picu) in two french hospitals. patients and methods: this retrospective cohort study included children aged under years old, who were admitted to the picu of robert-debré hospital and trousseau from to with a discharge diagnosis of ap. data collected included management, severity and outcomes. we have also obtained data on clinical, biological and radiological presentation. results: sixty patients were included, the median age was years ( - ) and % had a co-morbidity mainly hematologic ( / ). most of the ap were moderate ( %) or severe ( %). hemodynamic failure was the main reason for picu admission requiring a median fluid resuscitation ml/kg complemented by a median intravenous fluid therapy of ml/kg/h ( - ) during the first h. twenty patients ( %) required mechanical ventilation. fasting has been instituted in patients ( %) for a median of days ( - ), whereas patients ( %) received parenteral nutrition, only patients ( %) received enteral nutrition. antibiotic therapy was given to patients ( %) including % for curative therapy. the median length of stay in picu was days ( ) ( ) ( ) ( ) ( ) . the mortality rate was %. conclusion: this is the first french study which precisely described the management of patients with ap in picu. it highlighted the differences withthe new international guidelines. this study could improve the management of pa in picu and open research perspectives. compliance with ethics regulations: yes. rationale: apheresis and therapeutic plasma exchange (tpe) for children diseases has been poorly investigated in mostly small-uncontrolled studies. the purpose of this study is to describe indications and safety of tpe in children. patients and methods: in this single center and retrospective study, we included patients who underwent tpe with an age < years old in the pediatric center of necker-enfants-malades hospital from january to december . data were retrospectively collected in an electronic case report form via a web-based data collection system. results: patients with a median age of . years [range . ; . ] were selected. they achieved a total number of procedures. indications were antibody-mediated rejection (n = ; %) or desensitization therapy (n = ; %) for solid organ or hematopoietic transplantations; microangiopathy (n = ; %); renal diseases (n = ; %) and pediatric inflammatory diseases (n = ; %); or hyperviscosity syndrome (n = ; %). each patient had an average of procedures for the first session [range ; ] with a median volume of ml [range ; ml] corresponding to a median (rang) total plasma volume (tpv) equivalent of . l/m [ . - . ]. within days since the beginning of sessions, patients ( %) present a total of adverse events (aes) potentially related to tpe. there was a median (range) of aes/patients [ - ]. there was no association between aes and diseases, severity of patients, venous access, plasma substitute and body weight. few of aes (n = for patients) were potentially life-threatening and concerned mostly critically ill children. allergic reactions represented only aes for patients (grade i n = ; grade ii n = ; grade iii n = ). at the months endpoint, ( %) patients died and ( %) patients had severe persistent disease. no death had been related to the tpe process. we describe one of the largest retrospective pediatric cohort updated to the last international recommendations. tpe in children is performed for specific and potentially refractory disease. it is feasible without a major risk of life threatening adverse events. compliance with ethics regulations: yes. yacine benhocine university hospital nedir mohamed, tizi-ouzou, algeria correspondence: yacine benhocine (yacine @yahoo.fr) ann. intensive care , (suppl ):f- rationale: although analysis of literature data shows that implantable chamber catheters (iccs) are less at risk of infectious complications than other central venous catheters, these complications can be serious, which may differ from ongoing treatments such as chemotherapy, and may lead to the removal of the implanted device. the literature on preventing these infections is quite disparate, as practices. purpose: to evaluate the incidence of infections, to identify responsible germs and to measure the impact of preventive measures. patients and methods: prospective, descriptive, mono-centric study, from january to january . all patients under the age of who have benefited from an implantable chamber catheter, whose insertion procedure is as follows: local anesthesia, surgical asepsis (polyvidone iodine) in an operating room, double disinfection, no antibiotic prophylaxis, routes used: subclavian ( %), internal jugular ( %) by anatomic registration. the main criteria of judgment are: the incidence of local and general infections, their time of onset, responsible microorganisms. statistical analysis used the statistical package for the social sciences software. results: patients were included, the average incidence density of early infection is . / day-catheters. the time of onset of infection is essentially between the nd and rd week post-exposure, of which % is general infection. ablation involved % of infected catheters. the causative organisms are mainly gram-positive cocci ( . %), gram-negative bacilli are less involved ( . %), with a significant number of candida infections ( %). discussion: higher incidence of data from the literature. to remedy this requires the implementation of additional hygiene measures: antiseptic showers preoperatively, chlorhexidine??, and practice changes: echo guidance, antibiotic prophylaxis or locks? second generation catheters? our practices are disparate especially since the recommendations specifically concerning the prevention of infectious risk associated with internationally published iccs are rare. conclusion: at the end of this work, our perspectives are to: update the procedure, highlight risk factors on which it is possible to act, the adhesion of the different staff to the protocols. compliance with ethics regulations: yes. rationale: the sepsis and septic shock pediatric guidelines advise to treat patients using care bundles. in the first hour, the «resuscitation bundle» contains an appropriate fluid resuscitation, a broad-spectrum antibiotics administration after blood cultures, and initiation of inotrope if needed. the objectives were to evaluate the resuscitation bundle compliance in a cohort of septic children with cardiovascular dysfunction, and to analyze the effect on severity and outcome in pediatric intensive care unit (picu). patients and methods: retrospective analysis of the diabact iii study. this study analyzed the care course of children with severe community-acquired bacterial infection, hospitalized in picus in france's west departments, between august and january . children with severe sepsis and cardiovascular dysfunction were retrospectively included. results: we included children of whom ( . %) had compliant bundled care. the severity scores at picu's admission were similar between groups (p = . for the prism score and . for the pelod ). there was the same proportion of fluid-refractory shock (p = . ), mechanical ventilation (p = . ), neurological dysfunction (p = . ) and cardiac arrest (p = . ). in the «resuscitation bundle compliant» group, . % died versus . % in the other group (p = . ). we highlighted a severity bias: the sickest patients were more likely to receive compliant bundled care. conclusion: in our cohort, the resuscitation bundle's compliance was low. we did not show some effect on morbidity nor mortality. however, this study helps understand the factors associated with resuscitation bundle's compliance. rationale: nosocomial infections with extended-spectrum β-lactamase (esbl) producing gram-negative bacilli (gnb) are an important cause of hospital morbidity and mortality. the objective of this study was to determine the incidence and risk factors of nosocomial esbl-producing gnb infections in a paediatric intensive care unit (picu). patients and methods: a prospective surveillance study was performed from january through march in a picu. all patients hospitalized for more than h were included. centers for disease control and prevention criteria were applied for the diagnosis of nosocomial infection. results: during the study period, patients (median age: ± days) were included. the average length of stay was ± days with a total of , days of hospitalization. newborns accounted for . % of patients. sixty-two per cent of patients were colonized with multi drug resistant gram-negative rods, on admission or during their stay in the picu. one hundred and nineteen bacterial infectious episodes were registered ( . / patient days). one hundred infectious episodes were caused by a gnb and ( . %) by esbls producing gnb with an incidence of . / patient days (bloodstream infections: episodes, ventilator acquired pneumonia: episodes). esbls producing gnb infection had a specific incidence of . per catheter-days, and . per mechanical ventilation-days. fifty-nine percent of patients infected with esbls producing gnb had a prior digestive colonization with a multidrug-resistant gnb. forty-one episodes ( %) occurred in patients with central venous catheters. klebsiella pneumoniae was the most frequently isolated bacteria ( . %). mortality in the esbls producing gnb group was high ( . %). associated factors of nosocomial esbls producing gnb infection were mechanical vrntilation (p < . ), central venous catheterization (p < . ) and colonization with multiple drug-resistant gram-negative bacteria (p < . ). conclusion: nosocomial esbl-producing gnb infection had an incidence of . per patient days in our unit and seems to increase the mortality rate. factors associated with this infection were identified. marie lemerle , aline schmidt , valérie thepot-seegers , achille kouatchet , valérie moal , mélina raimbault , corentin orvain , jean-francois augusto , julien demiselle chu angers, médecine intensive réanimation, angers, france; chu angers, maladie du sang, angers, france; chu angers-ico, angers, france; chu angers, pharmacie, angers, france; chu angers, labora-toire de biochimie, angers, france; chu angers, néphrologie dialyse transplantation, angers, france correspondence: marie lemerle (marielemerle@yahoo.fr) ann. intensive care , (suppl ):f- rationale: acute kidney injury (aki) is associated with high morbidity and mortality in the setting of tumor lysis syndrome (tls). thus, strategies aimed at preventing aki occurrence represent a major goal to improve prognosis of patients with tls. the role of hyperphosphatemia as a risk factor of tls has been poorly analyzed. the aim of this study was to study the association between hyperphosphatemia and aki, and to determine whether a cut-off value of phosphatemia or phosphatemia's variation was associated with aki development during tls. patients and methods: in this retrospective and monocentric study, we included all patients with tls and whithout aki at admission, admitted to hematology, nephrology and intensive care units of the university hospital of angers between / / and / / . results: one hundred and thirty tls episodes were identified in patients. aki developed during episodes of tls ( %). hospital mortality was much higher in aki patients ( . % versus . %, p = . ). phosphate maximal values ( . ± . versus . ± . ) and ldh maximal values ( . ± . versus . ± . ) were higher in tls with aki, before aki occurrence (p = . and p = . , respectively). we found no association between the other biological parameters of tls and aki (serum calcium, uric acid and potassium). after adjustment for cofounders, there was a strong association between a rise in phosphate level of . mmol/l (hr . ic % [ . - . ], p < . ), exposure to platinum salts (hr . ic % [ . - . ], p = . ) and increasing maximal ldh value (hr per ui/l increase . ic % [ . - . ], p = . ) with aki. conclusion: this study highlights the utmost importance of serum phosphate in the setting of tls: phosphate is an early relevant biomarker for the risk of aki development. further studies are needed to assess whether aggressive prophylactic treatment to control serum phosphate concentration, such as renal replacement therapy before aki onset, constitutes a valuable approach. compliance with ethics regulations: yes. retrospective cohort of patients admitted to the medical icu of university affiliated hospital after carts treatment between august and august . results: of the patients treated by carts in the haematology department, ( %) were subsequently admitted to icu. median age was [ . - . ] years, and ( . %) were female. carts were indicated for r/r lymphoma. the median time between carts injection and icu admission was [ . - . ] days. all patients had cytokine release syndrome (crs), and ( . %) developed car-related encephalopathy syndrome (cres). median sofa score and saps were [ - . ] and [ . - . ], respectively. four ( . %) patients had hypotension treated by fluid bolus (n = ) or vasopressors (n = ), and ( . %) had acuterespiratory failure requiring oxygen therapy (n = ) or mechanical ventilation (n = ). six ( . %) patients had neurological symptoms (impaired consciousness n = , confusion n = , transient aphasia n = ), of whom one developed refractory convulsive status epilepticus afterwards. all patients received broad spectrum antibiotics, of whom ( . %) had documented infections. six ( . %) patients received interleukin- inhibitor (single dose n = , multiple doses n = ), and ( . %) received intravenous dexamethasone. one patient died in the icu from septic shock. median icu and hospital length of stays were [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and [ . - . ] days, respectively. two ( . %) patients died from relapsing malignancy before hospital discharge. three months after icu admission, four ( . %) patients were alive in complete remission. conclusion: more than % of patients treated with carts required icu admission for the management of a crs or a cres. early icu admission, close collaboration between haematologists and intensivists, and prompt administration of appropriate therapy (il- inhibitor and/or dexamethasone) and supportive care resulted in a good prognosis. compliance with ethics regulations: yes. rationale: tisagenlecleucel (ctl ) is a chimeric antigen receptor t cell therapy that reprograms autologous t cells to target cd + leukemia cells, approved in the us since august and in the eu since august for children and young adult (< years old) with relapsed/refractory b-cell acute lymphoblastic leukemia (b-all). this study reports the experience of picu management of ctl toxicity in patients treated in robert-debré university hospitals. patients and methods: all patients (age < years old) treated by tisagenlecleucel infusions between march , and september , , included in sponsored-clinical trials or treated within the french compassionate program or with the commercial product, were retrospectively analyzed. results: twenty-four patients were infused and patients ( %) were managed in picu for stays. ( stays: n = and stays: n = ). median age at picu admission was . years old [ . ; . ] with a median delay after car-t cells infusions of days [ . ; ] . the median length of stay in picu was days [ . ; ] with a max at days. cytokine release syndrome (crs) was the main indication of picu hospitalization ( . %, n = ) with grade (n = ) and grade (n = ) according to american society for transplantation and cellular therapy (astct) consensus grading system and treated by corticosteroid (n = . ) and tocilizumab (n = , only one infusion). norepinephrine was the only vasopressor used. the median vaso-inotrope score (vis) for grade was [ . ; . ] with a maximum at . neurologic toxicity was observed in patients with a grade (status epilepticus) and grade (focal edema on neuroimaging with depressed level of consciousness) according to immune effector cell-associated neurotoxicity syndrome (icans) grading system from astct consensus. the status epilepticus was managed with anti-epileptic drugs without mechanical ventilation. the focal edema was related to hhv and toxoplasmosis encephalitis. evolution was positive with foscavir and ganciclovir and days of mechanical ventilation. one patient was hospitalized for septic shock secondary to gram-negative central line bloodstream infection in aplasia, with a vis score at . evolution was favorable with antibiotics and central line removal. no death in picu from severe tisagenlecleucel toxicity was observed since the beginning of the car-t cells program. conclusion: toxicity profile of tisagenlecleucel required frequent and early picu hospitalization after infusions for severe crs and icans management. compliance with ethics regulations: yes. rationale: car-t cell (chimeric antigen receptor t) therapy is a promising treatment in refractory acute lymphoid leukemia (all) and diffuse large b cell lymphoma (dlbcl). the main complication consists in a cytokine release syndrome (crs) leading to an inflammatory state that can be very severe with life-threatening organ failure. neurological toxicity is also reported. we aim to describe car-t cells-related complications in icu patients. patients and methods: this is a single-center prospective study conducted between july and august . all the patients who have received car-t cells and who required icu admission were included. crs grading was defined according to the most recent classification of the asbmt and neurological toxicity was assessed with the cartox scale. each admission is considered independent and therefore corresponds to one patient. results: admissions, representing patients ( men and women), were considered. the median age was years . twothirds of the patients have been diagnosed with dlbcl (n = , %) and one-third with all (n = , %), months [ - ] ago. they had received lines [ ] [ ] of chemotherapy and had a high tumor burden ( % of lymphomas classified stage iv). the majority of the patients was admitted because of hemodynamic failure (n = , %) or respiratory failure (n = , %), days [ ] [ ] [ ] [ ] [ ] after car-t cells infusion. sofa at admission was [ ] [ ] [ ] [ ] [ ] . all the patients presented at least one complication ( figure) , the most common being crs (n = , %) with a median grade of [ ] [ ] . neurological toxicity was reported in ( %) patients (worst grade at [ ] [ ] [ ] ). documented bacterial infection involved % of the patients and consisted in catheter-related infections for half of the cases. in the icu patients were managed with fluid resuscitation (n = , %) during the first day, vasopressors (n = , %) and broad spectrum antibiotics ( %). a single patient required mechanical ventilation and two patients underwent dialysis. tocilizumab (anti-il receptor) was given to patients ( % of crs) in a median time of . h [ . - . ] after icu admission. patients ( %) received corticosteroids. the median icu length of stay was . days [ ] [ ] [ ] [ ] . patients ( %) died in the icu and hospital mortality was %. the -fluorouracil ( -fu)-induced hyperammonemic encephalopathy is a rare but serious -fu adverse drug reaction, which could require the admission of patients in intensive care unit (icu). given the paucity of data regarding this -fu adverse drug reaction, we performed a retrospective national survey from the french pharmacovigilance database to better characterize -fu-induced hyperammonemic encephalopathy and its management. patients and methods: since the inception of the french pharmacovigilance database, we identified all patients that experienced -fu-induced encephalopathy. variables regarding epidemiology, characteristics, management and prognosis of these patients were collected and analyzed. results: from from to years-old, % of women) were included. overall mortality was % (n = ) and % (n = ) of patients were admitted in icu. the -fu-induced hyperammonemic encephalopathy started [ ] [ ] [ ] [ ] days after the onset of -fu infusion. the most common neurological disorders were consciousness impairment, confusion and seizures. abnormalities in ct scan, mri, electroencephalogram and lumbar puncture were found in %, %, % and % of the whole population respectively, similar in icu and non-icu patients. ammonemia was dosed in % of the whole population and in % of icu patients. hyperammonemia tended to be higher in icu than in non-icu patients ( [ - ] vs. [ - ] µmol/l, respectively, p = ns) and in patients with the lowest glasgow outcome scale, but was not different between survivors and non-survivors. among icu patients, % required mechanical ventilation and % anti-epileptic drugs administration. besides -fu discontinuation, lactulose intake, renal replacement therapy or ammonium chelators were used to decrease hyperammonemia in %, % and % of patients respectively. a complete neurological recovery was observed in up to % of icu and non-icu patients within a delay of [ - ] days. a dihydropyrimidine deshydrogenase (dpd) deficiency was found in % of tested patients. a -fu rechallenge was considered in % (n = ) of patients with complete neurological recovery, including a patient with a partial dpd deficiency, within a delay of [ - ] days after recovery. a -fu-induced hyperammonemic encephalopathy relapse was observed in % of patients with -fu rechallenge. no relapse was observed when -fu rechallenge was performed with a decreased -fu dosage. conclusion: we report the first national survey and the largest cohort of patients with -fu-induced hyperammonemic encephalopathy so far. this serious -fu adverse drug reaction must be known by intensivists, since more than half of patients are admitted in icu and specific treatments are available. compliance with ethics regulations: yes. immune related adverse events: a retrospective look into the future of oncology in the intensive care unit adrien joseph , annabelle stoclin , antoine vieillard-baron , guillaume geri , jean-marie michot rationale: immune checkpoint inhibitors (ici) represent a paradigmatic shift in oncology. with their new position as a mainstay in cancer treatment, new toxicities called immune related adverse events (iraes) have emerged. patients and methods: retrospective study including patients admitted in the icu within days after treatment with an ici in french hospitals. patients were classified into groups according to the reason for admission: irae, intercurrent adverse event (intae) or event related to tumor progression (tumprog). results: patients were admitted during the course of an ici treatment, including irae, intae and tumprog, with a significant increase between (n = ) and (n = patients, p for trend < . ). irae included pneumonitis, colitis, diabetes complications, hypophysitis, nephritis, myocarditis and cardiac disorders, hepatitis or allergic reaction and meningitis. the immune related nature of the complication was known before admission in only ( %) cases. mean age was (± ) years and % had a performance status of - . primary tumors were melanomas ( , %), non-small cell lung cancers ( , %) , urothelial carcinomas ( , %) and hodgkin lymphomas ( , %) . ici at the time of admission included anti-ctla ( , %), anti-pd /pdl ( , %) and anti-ctla /anti-pd combination in ( %) patients. mean duration of stay in the icu was . (± ) days. three patients required vasopressor therapy alone, with mechanical ventilation and one with extracorporeal membrane oxygenation. three patients required non-invasive ventilation and renal replacement therapy alone. six required only endocrine or electrolytic equilibration and others did not receive any form of organ support. icu mortality was %. compared with other admissions, anti-ctla or anti-ctla /anti-pd combination treatments were associated with irae diagnosis (or = . [ . - . ] , p = . for anti-ctla and . [ . - . ] for anti-ctla /anti-pd , p = . ) and so was the diagnosis of melanoma ( . [ . - . ] , p = . ). there was no difference in terms of icu and post-icu survival between irae (median post-icu survival months [ -na]), intae ( . [ . -na]) and ). six patients admitted for an irae were rechallenged with the same ici after icu discharge and achieved complete response. conclusion: we conducted the first study describing patients admitted in the icu for iraes. their specific and heterogeneous profile, along with the expected increase in the number of admissions, underlines the need for an in-depth knowledge for icu physicians in order to take part in the multidisciplinary care required by these patients. compliance with ethics regulations: yes. rationale: patients with advanced-stage non-small-cell lung cancer have high mortality rates in the intensive care unit (icu). in this context, acute respiratory failure due to cancer involvement is the worst situation. in the last two decades, targeted therapies have changed the prognostic of patients with lung cancer outside the icu. unlike cytotoxic chemotherapy, the fast efficacy of targeted therapies led some intensivists to use them as rescue therapy for icu patients. we sought to investigate the outcomes of patients with lung cancer involvement responsible for acute respiratory failure and who received tyrosine kinase inhibitor during icu stay. patients and methods: we performed a national multicentric retrospective study with the participation of the grrroh (groupe de recherche en réanimation respiratoire en onco-hématologie). all patients with non-small-cell lung cancer admitted to the icu for acute respiratory failure between and were included in the study if a tyrosine kinase inhibitor was initiated during icu stay. cases were identified using hospital-pharmacies records. we collected demographic and clinical data in icu charts. vital status was assessed at the time of study completion (august ). the primary outcome was overall survival days after icu admission. results: twenty-nine patients (age: ± years old) admitted to a total of icus throughout france were included. seventeen patients ( %) were nonsmoker. the most frequent histological type was adenocarcinoma (n = , %) and a majority had metastatic cancer (n = , %). epithelial growth factor receptor mutation was the most common oncologic driver identified (n = , %). during the icu stay, ( %) patients required invasive mechanical ventilation, ( %) catecholamine infusion, ( %) renal replacement therapy and one ( %) extracorporeal membrane oxygenation. in addition to tyrosine kinase inhibitor, ( %) patients received steroids (beyond . mg/kg/day) and ( %) cytotoxic chemotherapy during icu stay. seventeen patients ( %) were discharged alive from icu and ( %) were still alive after days (see kaplan-meier curve figure) . moreover, patients ( %) were alive one year after icu discharge. conclusion: despite a small sample size this study showed that, in the context of lung cancer involvement responsible for acute respiratory failure, the use of tyrosine kinase inhibitor should not be refrained in patients with severe condition in icu. compliance with ethics regulations: yes. rationale: acute respiratory failure is the leading reason for intensive care unit (icu) admission in immunocompromised patients and the need for invasive mechanical ventilation has become a major clinical end-point in randomized controlled trials (rct). however, data are lacking on whether intubation is an objective criteria that is used unbiasedly across centers. this study explores how this outcome varies across icus. patients and methods: hierarchical models and permutation procedures for testing multiple random effects were applied on both data from observational cohort (the trial-oh study: patients, icus) and randomized controlled trial (the high trial: patients, icus) to characterize icu variation in intubation risk across centers. results: the crude intubation rate varied across icus from % to % in the observational cohort and from to % in the rct. this center effect on the mean icu intubation rate was statistically significant, even after adjustment on individual patient characteristics (observational cohort: p-value = . , median or . [ . - . ]; rct: p-value: . , median or . [ . - . ]). two icu-level characteristics were associated with intubation risk (the annual rate of intubation procedure per center and the time from respiratory symptoms to icu admission) and could partly explain this center effect. in the rct that controlled for the use of high-flow oxygen therapy, we did not find significant variation in the effect of oxygenation strategy on intubation risk across centers, despite a significant variation in the need for invasive mechanical ventilation. conclusion: invasive mechanical ventilation has become an important endpoint in immunocompromised patients with acute respiratory failure. however, we found significant variation in intubation risk across icu in both an observational cohort and a randomized controlled trial. our results highlight the need to take into account center effect in analysis because it could be an important confounder. reasons for heterogeneity are various (case-mix differences, center practices). this gives opportunities to future improvement in care management and study design. compliance with ethics regulations: yes. rationale: influenza virus (iv) infection is a major cause of ards that has been the focus of attention since the pandemic h n (h n pdm ) iv. although iv-mediated damage of the airway has beenextensively studied emphasizing specificity compared to other causes of ards, the impact of iv infection on the prognosis of ards patients, compared to the other causes of ards, has been few assessed. patients and methods: systematic detection of iv in times of epidemic using rt-pcr in respiratory specimen is routine practice in our icu along with prospective data collection of patients admitted to our icu for ards with pao /fio ratio ≤ mmhg. all patients received lung-protective ventilation, the sequential organ failure assessment (sofa) score was calculated on the first days of mechanical ventilation. the primary endpoint compared the -day survival from the diagnosis of ards between patients with and without iv infection. results: from october, to may, , patients (pts) [median saps ii score = ( - ); age years ( - ); pao / fio ≤ mmhg, n = ( %)] were admitted to our icu for ards with pao /fio ratio ≤ mm/hg, including pts ( %) with iv infection (h n pdm iv a, n = ; h n a virus, n = ; b virus, n = ; associated bacteria, n = ). other main causes of ards were bacterial pneumonia without iv ( %), aspiration ( %), non-pulmonary sepsis ( %). ( %) received prone positioning, and ( %) extra-corporeal membrane oxygenation. the overall mortality rate at day- for the entire population was % ( pts ( %) with iv infection versus pts ( %) without iv infection, p = . ). kaplan-meier survival curves showed that survival was significantly higher in patients with iv infection than in those without iv infection. iv infection remained independently associated with a better prognosis at day- when entered as dichotomous variable (iv infection, yes/no) (adjusted hazard ratio (hr) = . , % ci . - . , p = . ) and when iv infection only was distinguished from other causes of ards including mixed infection iv plus bacteria (adjusted hr = . , % ci . - . , p = . ). of note, within the first days of mechanical ventilation, non-pulmonary sofa scores were significantly lower in iv patients although similar pulmonary sofa scores. conclusion: our results suggest that patients with iv related ards have less severe non-pulmonary organ dysfunctions than those with ards from other and a lower mortality at day- despite similar ards severity. compliance with ethics regulations: yes. rationale: acute respiratory distress syndrome (ards) remains frequent in intensive care unit (icu) with % to % mortality. according to joint theater trauma system, ards occurs among % of war casualties: direct lung trauma, blast lesions, burn, massive transfusion and systemic inflammatory response syndrome lead to ards development. however, there is no data reporting ards among french evacuated casualties from forward environment. our study's aim is to describe ards incidence and its severity concerning medical evacuations from war theater. patients and methods: this is an observational retrospective multicentric study analyzing all evacuated patient from war theater and admitted in icu. all patients developing ards according to berlin definition have been included. study has been approved by local ethic committee. primary study endpoint was ards developing. second study endpoints were ards severity, duration of invasive ventilation, ards treatments, icu length of stay and mortality. results: patients have been admitted in icu between and . have been excluded. a total of patients have been analyzed. % (n = ) were military aged ( - ) years. % (n = ) developed ards. we found % (n = ) war casualties, % (n = ) trauma not related to war and % (n = ) medical patients. among severe trauma, median iss was ( - ), ais thorax ( ) ( ) ( ) , and % benefited from surgery on forward environment and % (n = ) received massive transfusion. % (n = ) suffered from mild ards, % (n = ) moderate ards and % (n = ) severe ards. evacuation time was ( - ) h. at admission in icu, pao /fio ratio was ( - ) (fig. ). all patients were intubated. ards treatments used were curarization ( %, n = ), prone position ( %, n = ), inhaled nitric oxide (noi) ( %, n = ), almitrine ( %, n = ) and extracorporeal life support (ecls) ( %, n = ). invasive ventilation duration was ( - ) days, length of stay ( - ) days, and -month mortality % (n = ). conclusion: according to our study, ards among french evacuated patients from war theaters remains frequent: it occurs on % among icu admitted patients. % suffer from severe ards with % global mortality. those datas are consistent with us studies. also, we wonder if we must adapt our treatment capacities on forward environment for the most severe patients. in us army, a specialized team (acute lung rescue team) is trained to care the most hypoxemic war casualties with more treatment options as noi, ecls. compliance with ethics regulations: yes. rationale : we recently reported that septic shock patients with pneumonia exhibit a high risk of icu-acquired pneumonia, suggesting that a primary pulmonary insult may drive profound alterations in lung defence towards secondary infections ( ) . given their importance in lung immune surveillance, alveolar macrophages (am) are likely to play a pivotal role in this setting. the objective of this experimental study is to address the impact of primary pulmonary or non-pulmonary infectious insults on lung immunity. patients and methods: we established relevant double-hit experimental models that mimic common clinical situations. c bl/ j mice were first subjected either to polymicrobial peritonitis induced by caecal ligation and puncture (clp), or to bacterial pneumonia induced by intra-tracheal instillation of staphylococcus aureus or escherichia coli. respective control mice were subjected to sham laparotomy or intratracheal instillation of phosphate-buffered saline. seven days later, mice that survived the primary insult were subjected to intra-tracheal instillation of pseudomonas aeruginosa (pao strain). we assessed survival and pulmonary bacterial clearance of post-septic animals subjected to p. aeruginosa pneumonia, as well as the distribution and functional changes in alveolar macrophages. results: when compared to sham-operated mice, post-clp animals exhibited increased susceptibility to secondary p. aeruginosa pneumonia as demonstrated by defective lung bacterial clearance and increased mortality rate ( % vs. %, p < . ). in contrast, all postpneumonia mice survived and even exhibited improved bacterial clearance as compared to their control counterparts. when addressing whole-lung immune cell distribution at the time of second hit (day ), amounts of am were decreased in post-clp mice while preserved or even increased in post-pneumonia mice. antigen-presenting functions of am appeared similar in all conditions. percentages of apoptotic (annexinv + ) and necrotic ( -aad + ) am were comparable at day and day after the first hit. interestingly, both ly c high and ly c low monocytes were sustainably increased in the lungs of post-clp mice, while only transiently expanded following pneumonia, suggesting that differences in am counts could be related to modulated turnover from precursor monocytes. conclusion: using clinically relevant double-hit experimental models, a primary pulmonary infection conferred resistance to secondary bacterial pneumonia. ongoing investigations are aimed at addressing the antibacterial am functions, as well as the turnover-driving mechanisms.compliance with ethics regulations: yes. rationale: little is known on the role of exit-site signs in predicting intravascular catheter infections. the current study aimed to describe the association between local signs at the exit-site and catheter-related bloodstream infection (crbsi), which factors substantially influenced local signs and which clinical conditions may predict crb-sis if inflammation at insertion site is present. patients and methods: we used individual data from multicenter randomized-controlled trials in intensive care units (icus) that evaluated various prevention strategies regarding colonization and crbsi in central venous and arterial catheters. we used univariate and multivariate logistic regression stratifying by center in order to identify variables associated with redness, pain, non-purulent discharge, purulent discharge and ≥ local sign and subsequently evaluate the association between crbsi and local signs. moreover, weevaluated the role of thedifferent local signs for developing crbsi in subgroups of clinically relevant conditions. results: a total of patients, , catheters ( , catheterdays) and crbsi ( . %) from icus withdescribed local signs were included. redness, pain, non-purulent discharge, purulent discharge and ≥ local signs at removal were observed in ( . %), ( . %), ( . %), ( . %) and ( . %) episodes, respectively. the sensitivity of ≥ local sign for crbsi was by . %, whereas the highest specificities were observed for pain ( . %) and purulent discharge ( . %). positive predictive value (ppv) was low for redness ( %), pain ( %), non-purulent discharge ( %) and ≥ local sign ( %), but increased for purulent discharge ( . %). negative predictive values were high for all local signs. after adjusting on confounders, crbsi was associated with redness, non-purulent discharge, purulent discharge and ≥ local sign (fig. ). conditions independently associated with ≥ local sign were age ≤ years old (or . , % ci . - . , p < . ), sofa score (sofa < or . , % ci . - . , p < . ), non-immunosuppression (or . , % ci . - . , p < . ), catheter maintenance > days (or . , % ci . - . , p < . ) and insertion site (or for subclavian site . , % ci . - . , p < . ). however, the presence of ≥ local sign was more predictive for crbsi in the first days of catheter maintenance (or . , % ci . - . vs. > catheter-days or . , % ci . - . , p heterogeneity = . ). conclusion: this post hoc analysis showed that local signs were related to crbsis in the icu. local signs were independently associated with specific patient's and catheter's conditions. in the first days of catheter maintenance, local signs were predictive for crbsi. compliance with ethics regulations: yes. rationale: pneumococcal meningitis (pm) is the leading cause of bacterial meningitis in adult patients requiring icu admission and is associated with a high case fatality rate (cfr), ranging from to more than % ( ) ( ) ( ) . patients with pm may develop sepsis or septic shock that may impact management and outcomes. we aim to describe the epidemiology and outcomes of pm associated with sepsis in adult patients in france. we analysed the occurrence of pm with sepsis from to in adult patients, using the national french hospital database pmsi (programme de médicalisation des systèmes d'information). for all analyses, only the first hospital admission was considered. cases were identified using a combination of a diagnosis code for pm plus a diagnosis code for sepsis (either a code for organ failure or a procedure code for organ support). data recorded included comorbidities ( ), characteristics of the hospital stay, severity of the patients including major intracranial complications and characteristics of the infection. costs and endpoints were determined at the end of all the hospital stays related to the first admission for pm with sepsis. standardized incidence, hospital mortality, and cfr were estimated. temporal trends were assessed using cochran armitage tests of trends and linear trend analyses. results: a total of pm with sepsis aged ≥ years were hospitalized in france during - . the incidence of pm decreased from . to . per m inhabitants (p < . ) (fig. ) . most of them came from home ( %), were admitted in an academic institution ( %) and benefited from icu ( %). their median age was [ ; ] years. twothird of them had at least one comorbidity. the initial neurological presentations included coma ( %), focal signs ( %), seizures ( %) and brain stem involvements ( %). the saps ii score was [ ; ] points. the main neurological complications were cerebrovascular complications ( %), cerebral abscess ( %) and hydrocephaly ( %). pm was associated with pneumococcal septicaemia or pneumococcal pneumonia in % and % of cases respectively. the length of icu and hospital stays were [ ; ] and [ ; ] days respectively and only icu length of stay decreased over time (p < . ). the prognosis was poor since only . % of the patients were discharged to home. indeed, . % of them died and % were transferred to rehabilitation units. no temporal trends could be observed for these outcomes. the average hospital costs per case were , € [ . ; . ] . conclusion: pm with sepsis in adult in france remained a real burden associated with a high mortality rate, and disability. compliance with ethics regulations: na. rationale: mucormycosis is an emerging fungal infection, especially in patients with hematological malignancies. although this infection may lead to multi organ failure, no study has been dedicated to critically ill patients with hematological malignancy. the primary objective was to assess outcome in this setting. the secondary objective was to assess prognostic factors. patients and methods: this retrospective cohort study was performed in icus. critically ill adult patients with hematological malignancies and mucormycosis were included between and . mucormycosiswas classified as "probable"or "proven" regarding eortc criteria. variables are reported as median [iqr] or number (%). adjusted analysis was performed using cox model. results: twenty-six patients were included with a median age of years [iqr, . acute leukemia was the most frequent underlying disease (n = , %). nine patients ( %) were allogeneic stem cell transplantation (sct) recipients. nineteen patients ( %) had neutropenia and patients ( %) had received steroids. the main reason for admission was acute respiratory failure (n = , %) followed by shock (n = , %). the median sofa score at admission was [iqr, - ] points. only patients ( %) had received prior anti-fungal prophylaxis effective against mucorales. mucormycosis was "proven" in patients and "probable" in patients. diagnosis was made by histopathologic examination in patients, direct microscopy or culture in , and polymerase chain reaction in . rhizopus and mucor were the most frequent documented species. seven patients ( %) had concurrent aspergillus infection. mucormycosis was diagnosed day [− to + ] after icu admission. ten patients ( %) had pulmonary involvement whereas five patients ( %) had rhino-cerebral involvement. infection was disseminated in eight patients ( %). twenty-two patients ( %) were treated with liposomal amphotericin b. twelve patients ( %) received antifungal combination including posaconazole in . eight patients ( %) underwent curative surgery. multiple organ failure was frequent, patients ( %) requiring invasive mechanical ventilation (imv), ( %) vasopressors, and ( %) renal replacement therapy. icu and hospital mortality rates were % and %, respectively. only two patients were alive at day . three variables were associated with mortality in a cox model including allogeneic sct . ]; figure), sofa score (hr . [ % ic . - . ]) and dual therapy (hr . [ % ic . - . ]) (fig. ) . conclusion: mucormycosis is associated with a high mortality rate in patients with hematological malignancies, especially in allogeneic sct recipients. futility of icu management in these patients is to be considered and strategies aiming to improve these patients' outcome are urgently needed. compliance with ethics regulations: yes. rationale: sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. several mediators, alone or in combination, were proposed to characterize individual response, but none was proven to have good external validity. the aim of this work was to establish whether some combinations are linked to clinical phenotypes in patients with presumed sepsis, using the data collected in the captain multicenter cohort which methods and first results were previously published (parlato, icm ). patients and methods: patients were prospectively included at the time of sepsis criteria, ( %) of whom with a secondary confirmed infection. community acquired pneumonia was causal in % of infections. saps score = points [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , age = years , male sex = %. patients were followed for more than days, in whom usual icu clinical and biological parameters were collected, as well as plasma biomarkers and leucocyte associated rnas. patients were clinically classified according to their acute severity (sofa score, serum lactate), confirmed initial infection, outcome (secondary infection occurrence, icu survival). non-supervised principal component analysis of the maximal values of biomarkers assessed on first days of sepsis, and varimax rotation technique of the selected components using sas software. results: patients, med sofa day = pts, med serum lactates day = . meq/l, bacterial infection = ( %), enterobacteriaceae infection = ( %), vap and/or bacteremia after day = ( %), alive at icu d/c = ( %). five components explain % of the variance of the biomarkers. the first component ( % of the variance) was not linked to the clinical predetermined phenotypes. the second component ( % of the variance) was principally made of hla-dr rna, cd rna and cx cr rna, and linked to a lower initial severity (r = − . , p = . ), a less frequent confirmation of initial infection (p = . ), a lower occurrence of pneumonia or bacteremia (p = . ) or death (p = . ). conclusion: in our cohort, using non supervised analysis, we could separate a biomarker association linked to lower initial severity, lower rate of a bacterial cause to sepsis, and better outcome. the markers found are among those which are regularly considered as describers of the peripheral alteration of the immune system observed during sepsis (pachot, ccm ; friggeri, cc ; peronnet icm ) . compliance with ethics regulations: yes. ( ) compared a standard of care to a procalcitonin (pct) oriented use of antimicrobials for sepsis in icus. serial blood samples were biobanked in / icus ( / patients enrolled for pro-adrenomedullin (proadm) and pct concentrations). patients and methods: the aim of the study was to evaluate the respective impact of serial pct and proadm measurements in predicting relapse or superinfection and death on day *. relapse was defined as the growth of one or more of the initial causative bacterial strains (i.e., same genus, species) from a second sample taken from the same infection site at h or more after stopping of antibiotics, combined with clinical signs or symptoms of infection. superinfection was defined as the isolation from the same or another site of one or more pathogens different from that identified during the first infectious episode, together with clinical signs or symptoms of infection [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] points at amission, medical admission: ( %), immunocompromised: ( %), on mechanical ventilation ( %), pct and proadm at inclusion were [ . - . ] ng/ml and . [ . - . ] nm/l respectively. ( %) patients developed a first episode of recurrence or supereinfection after a median delay of days [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and ( %) died before d . the hr maximization process proposed an optimal cut point of ng/ml for pct and nm/l for pro adm to predict d death. in the multivariate cox model, both pct and proadm were associated with death but not with relapse or superinfection (table ) . conclusion: conclusion: both serial measurements of pct and proadm are independent predictors of death in patients treated for sepsis in icu. our study confirmed the use of nm/l as a good prognosis cut point for proadm. . compliance with ethics regulations: yes. rationale: the performance of serum ( - )-β-d-glucan (bdg) and its evolution to predict the occurrence of invasive fungal infection (ifi) in a high risk non immunocompromized population remains to be determined ( ). in a post hoc analysis of the empiricus randomized clinical trial ( ), we aimed to assess the prognostic value of repeated measures of bdg on the occurrence of invasive fungal infections. patients and methods: non-neutropenic, non-transplanted, critically ill patients with icu-acquired sepsis, multiple candida colonization, multiple organ failure, exposed to broad-spectrum antibacterial agents, and enrolled between july and february in french icus were included. bdg were collected in icu at day , , , and after inclusion. a value time of more than pg/ ml, pg/ml and an increase by more than % from the previous measurement (threshold of measurement error) were assessed at baseline and overtime. for that purpose, we conducted cause specific hazard models with death as a competing risk. we also planned subgroup analyses on the placebo and the micafungin groups. cumulative risk (cumrisk) of ifi at day were derived from models. [ . ; . ] ). neither a bdg > pg/ml, nor an increase by % of bdg over time were associated with the occurrence of ifi. similar results were found in the placebo subgroup. conclusion: among high risk patients, a first measurement of bdg over pg/ml was highly associated with the occurrence of ifi. neither a cut-off of pg/ml, nor repeated measurements of bdg over time seemed to be useful to predict the occurrence of ifi. the cumulative risk of ifi in the placebo group if bdg > pg/ml is . % questioning about the potential interest of empirical therapy in this subgroup. compliance with ethics regulations: yes. rationale: since the sepsis- conference, the distinction between sepsis and septic shock is based on blood lactate value. septic shock may be encountered in the pre-hospital setting. in order to reduce the mortality, the precocity of treatments implementation has been emphasized, particularly early antibiotic administration. prior antibiotic administration, and blood culture drawing must be performed. the aim of this survey was to clarify the capabilities of french prehospital emergency service (pems) to measure blood lactate and to draw blood culture prior to hospital admission for septic shock. patients and methods: we performed an electronic survey of auto-questions addressed to the deputy chair of the french pems in . results: sixty pems ( %) participated in the survey. twenty-five percent are able to measure blood lactate and % are able to draw blood culture in the prehospital setting. ninety-five percent declared lactate measurement is helpful in assessing severity. ninety percent claimed that the lactate value influences the hospital facility, emergency department vs. intensive care unit. twenty-eight percent believe that the impossibility to draw blood culture precludes prehospital antibiotic administration. sixty-three percent estimate that a protocol for septic shock management would be beneficial. conclusion: few french pems are able to measure lactate and draw blood culture in the prehospital setting. the impact of blood lactate measurement and blood culture drawing by pems on septic shock outcome requires further studies. compliance with ethics regulations: yes. rationale: head injury is a common cause of morbidity and mortality in the first four decades of life, accounting for approximately , annual hospital admissions in the united kingdom. the majority of patients recover without intervention, however some may develop a long-term disability or even die. the early detection of pathology is therefore absolutely critical in determining patients' prognosis, helping to provide appropriate timely management. the national institute for health and care excellence (nice) adult head injury guidelines, recommend that head injuries with specific risk factors should have a ct scan within h of risk factors being identified. furthermore the provisional report should be made available within h of the scan. this audit assessed the compliance of staff to the nice adult head injury guidelines. patients and methods: the previous adult ct head scans, requested due to head injury, from the emergency department (ed) at london north west healthcare nhs trust were analysed for compliance to the nice guidelines. the standards measured were: ( ) time from request of scan to completion of scan should be within h; ( ) time from completion of scan to publication of provisional report should be within h. the locally agreed target for both standards was %. results: on review of the ct scans, ( %) were completed within h of request. from the scans ( %) not completed within the hour, were due to porter unavailability, due to an uncooperative patient and the remaining reasons were not clear from documentation. following completion of the scan, scans ( %) were provisionally reported within h. conclusion: this study highlighted a good compliance by hospital staff in ensuring patients with head injuries are managed appropriately, following detection of risk factors indicating a ct head scan. having said that, the locally agreed targets were just short of being met. one factor resulting in delayed scans was porter availability. an intervention recently introduced is the use of the "e-portering" application, which will endeavour to save time for referrers requesting porters and allow patient tracking. it is also worth educating porters, via email bulletins, on the importance of priority scans, such as ct head following injury. furthermore, the findings of the audit were relayed to the radiology department to help improve reporting times and to the ed to re-emphasize prompt requesting of ct head scans when clinically indicated. compliance with ethics regulations: yes. rationale: continuous insufflation of oxygen (cio) performed with specific endotracheal tube during cardiopulmonary resuscitation (cpr) is as effective as intermittent ventilation on endotracheal tube. experimental data suggest that cio improves the efficacy of external cardiac massage and reduces gastric dilatation. as endotracheal intubation is a cause of cpr interruption and requires skilled staff, a specific device has been developed to perform cio without intubation. this device has been implemented progressively in our fire department since . we evaluated this practice. patients and methods: longitudinal study comparing the patients with out-of-hospital cardiac arrest managed by our fire department with cio or bag-valve ventilation between january and april . patients who received mechanical chest compression were excluded. the main outcome was hospital survival. secondary outcomes were the return of spontaneous circulation (rosc) and cpr quality. univariate and multivariate analysis was performed in the whole cohort and in the sub-groups of patient with shockable and non-shockable rhythms to take into account factors associated with survival (shockable rhythm, witness, age). results: among the patients included, have been ventilated with cio and with valve-bag. the mortality was similar in the two groups (cio: . % valve-bag: . % p . ). mortality and rosc were not associated with cio in the multivariate analysis (odds ratio or . %-confidence interval ci [ . - . ] and . [ . - . ], respectively). cpr quality was better with cio than with valve-bag regarding cpr fraction (ratio of duration of chest compressions on total duration of cpr, versus % p < . ) and adequacy to the guidelines of the rhythm and depth of chest compressions ( % vs % p < . and % vs % p < . , respectively). in both subgroups of patients, cpr quality was still better with cio than with valve-bag. in the subgroup of patients with shockable rhythm, univariate analysis showed a lower mortality among the patients with cio than among the patients with valve-bag ( . % vs . % p < . ) but this difference was not confirmed by the multivariate analysis (or . ci [ . - . ], p . ). conclusion: cio without intubation is associated with an improvement of cpr quality but neither with mortality nor return of spontaneous circulation in case of out-of-hospital cardiac arrest. compliance with ethics regulations: yes. rationale: cardiovascular accidents are a leading cause of death. a cardiopulmonary resuscitation (cpr) of quality has well shown that can reduce the mortality; despite this, survival rate has not changed significantly during last years. the aim of this study is to test a new wearable glove to provide lay people with instructions during out-ofhospital cpr. patients and methods: we performed a blinded, controlled trial on an electronic mannequin ambuman to test the performance of adult volunteers, non-healthcare professionals performing a simulated cpr both, without and with glove, following the glove instructions. the group without glove, also called "no-glove" is intended as control group. each compression performed on the electronic mannequin ambuman was recorded by a connected laptop computer, drawing a depth frequency curve over the time. primary outcome was to compare the accuracy of the two simulated cpr sessions in terms of depth and frequency of chest compressions performed by the same lay volunteers. secondary outcome was to compare the decay of performance and percentage of time in which the candidate performed accurate cpr. finally, the participants were asked if the glove was useful for cpr maneuvers. the difference between the two groups in regard to change in chest compression depth over time due to fatigue, defined as decay were also analyzed. results: chest compressions were included: in control group, in glove group (table ) . mean depth of compression in the control group was . mm versus . mm in the glove-group (p = . ). compressions with an appropriate depth were not statistically different ( . % vs . %, p = . ). mean frequency of compressions in the group with glove was . rpm vs . rpm in the control group (p < . ). the percentage of compression cycles with an appropriate rate (> rpm) was . % in the group with the glove versus % in the control group, with an observed difference of . % between the two groups, which was statistically significant (p < . ,ci = %). a mean reduction over time of compressions depth of . mm (sd . ) was observed in the control group versus a mean reduction of . mm in the group wearing the glove (sd . ), but this mean difference in the decay of compressions delivery was not statistically significant (f-ratio = . , ss = . , df = , ms = . , p = . ). conclusion: the visual and acoustic feedbacks provided by the device were useful in dictating the correct rhythm for non-healthcare professionals, translating in a significantly more accurate cpr. compliance with ethics regulations: yes. rationale: neuroprognostication after cardiac arrest (ca) is a crucial issue and current guidelines recommend delayed multimodal approach. we aimed to describe reasons for death in a prospective cohort of ca patients and evaluate the diagnostic accuracy of early combined neurological prognostication tools such as automated pupillometry (ap), continuous amplitude electroencephalography (aeeg) and cardiac arrest hospital prognosis (cahp) score performed h after return of spontaneous circulation (rosc). we set up a monocentric prospective cohort of adult ca patients admitted in icu after sustained rosc and collected data according to utstein style recommendations. reasons for death were described under recently proposed classification: withdrawal of life-sustaining therapies (wlst) for neurological reasons, wlst due to comorbidities, refractory shock or recurrence of sudden ca or respiratory failure. for patients who kept abnormal neurologic state after rosc with glasgow coma scale < , we analysed accuracy of early neuroprognostication tools (ap, aeeg and cahp score) to predict poor neurological outcome, i.e. cerebral performance category (cpc) > at hospital discharge. results: patients were admitted after sustained rosc from ca during the period ( . . to . . ). in-hospital mortality was %. neurological wlst was the first reason for death ( %). exhaustive early neuroprognostication with ap, aeeg and cahp score was available for patients. among them, poor neurological outcome at hospital discharge (cpc > ) was observed for patients ( % (fig. ) . this strategy would falsely misclassificate % of patients in a good neurologic outcome category. other survivors ( %) should then be investigated with further classical delayed neuroprognostication tools. compliance with ethics regulations: yes. rationale: management delay is one of the determining factors in the assessment of emergency department quality of care. asking for a specialized advice seems to increase the time of delay. our study aimed at measuring the delays in obtaining specialized advice and identify their major causes. patients and methods: we conducted a prospective study over the period of month. we included all adult patients presenting to the emergency department who required specialized advice. data of all patients was collected. waiting times and influencing factors were studied. results: a total of patients were included. the main reason for calling for a specialized advice was to ask for a department transfer in % of cases. the time of the day when specialized advice was solicited (n (%)): in the morning ( ); in the afternoon ( ); in the evening ( ). the main solicited specialties were (n (%)): visceral surgery ( ), trauma medicine ( ), cardiology ( ), urology ( ), and pulmonology ( ). the average waiting time between calling for and getting the specialized advice was ± min. seventy-five percent of the specialized advice was obtained within h. the causes of the delay were (n (%)): physician busy in the operating room ( ), unreachable physician ( ), physician in the outpatient clinics ( ). the impact of the waiting time was (n (%)): conflict ( ), worsening patient state ( ). the average time between calling for the specialized advice and reaching a management decision was ± min. conclusion: the increasing length of stay of patients in the ed is strongly correlated to the delay in obtaining specialized advice. the implementation of a strategy to reduce the waiting time is necessary to avoid overcrowding the emergency departments and provide optimal care. compliance with ethics regulations: yes. rationale: hypnoanalgesia has been used since few years to reduce icu-patients physical and psychological discomfort during invasive procedures. however, feasibility of overall well-being management of intubated patients with hypnosis has not been described. patients and methods: we report here the hypnotic accompaniment of a -year old patient without significant medical history hospitalized in our icu for a severe gbs during months. the gbs was diagnosed by electrophysiological study and immunologic markers. patient had nearly complete paralysis of all extremities, but no facial or bulbar muscles. he received mechanical ventilation during days, including weaning time. tracheotomy was performed at day . sedative drugs were stopped days after intubation. hypnosis sessions were startedvery early after intubation by one of our trained intensivist. eight hypnotic sessions of hypnoanalgesia or hypnotherapy were performed after approval of the patient and his parents. time distribution is reported in fig. . first and second sessions were performed in order to induce relaxation and reduce anxiety. following sessions were dedicated to: ) decrease pain intensity (initially neuropathic, then induced by physiotherapy), ) attenuate the negative perception of paralysis, ) reduce the discomfort of tracheotomy ) promote the belief in healing ) facilitate swallowing exercises. furthermore the patient was quickly trained to use self-hypnosis in order to dissociate him from pain, anxiety and icu pollutions. results: feasibility of hypnosis was judged satisfactory by the operating physician, despite mechanical ventilation. after extubation, final debriefing with the patient indicates that the most efficient sessions were those focused on anxiety disorders (using the suggestion of a safe place) and suggestions of mobility (using a mangas metaphor). the patient reported very positive perception of hypnosis use. he explained that self-hypnosis was effective to reduce many discomfort. he used it frequently (generally twice a day) for a puff of anxiety or before enoxaparin injection. our observation suggests that hypnosis seems feasible in icu-awake patients and may be an interesting way to improve their icu lived experience in combination with validated measures. further investigations are needed to evaluate its effects on post-traumaticstress disorder. compliance with ethics regulations: yes. rationale: there is little medical reference for hypnosis in the intensive care field. closed specialties such as anesthesia, emergency medicine can help and refer to hypnosis for certain technical procedures. objective: to propose landmarks for a successful implementation of hypnosis by intensivists within the intensive care unit. patients and methods: this monocentric prospective observational study was performed from february to june in the -bed medical icu of brest university hospital. collected data were: characteristics of patients and hypnosis sessions performed, demographic data, physiological parameters (heart and respiratory rates) and objective and subjective evaluation of hypnosis sessions quality. results: patients were included (mean age . ± years, saps ii . ± points). hypnosis sessions were performed, of which / under mechanical ventilation. patterns of hypnosis sessions were: anxiety/comfort ( %), during a technical procedure ( %): toe, cvc placement, thoracic drainage, upper digestive or bronchial endoscopy), initiation of noninvasive ventilation or before intubation. most of time, the hypnotic trance was permitted by formal hypnosis techniques with travel and nature themes suggestion. efficacy was qualitatively assessed and rated as "total effectiveness" for % of sessions. qualitative evaluation by hypnotherapist, technical operator and observers was respectively . ± . , . ± . and ± / . heart rate decreased from ± to ± bpm and respiratory rate/min decreased from ± to . ± rpm during sessions. discussion: after a meeting, the healthcare team carried out a brainstorming to propose hypnosis in our unit. several difficulties were observed to explain implementation failures such as: finding competent patient, respiratory assistance, difficult communication, noisy environment, many nursing care, unexpected emergencies, etc.…). this experience allowed writing a vademecum to perform hypnosis in intensive care. our aims are to get more trained caregivers and to integrate hypnosis during our postresuscitation consultation, especially for post-traumatic stress. conclusion: hypnotic tools can facilitate technical procedures and improve patients' and caregivers' quality of life within the icu. compliance with ethics regulations: yes. effect of a musical intervention during central venous catheterization in an intensive care unit: the music cat prospective randomized pilot study sophie jacquier, brice sauvage, gregoire muller, thierry boulain, mai-anh nay chr, orléans, france correspondence: sophie jacquier (sophie.jacquier@chr-orleans.fr) ann. intensive care , (suppl ):f- rationale: evaluate the effect of a musical intervention on patient anxiety during a central venous access or a dialysis catheter implantation in an intensive care unit. patients and methods: the music cat study was a prospective, single-centre, controlled, open-label, two-arm randomized trial, conducted from february to february . central venous catheterization with musical intervention was compared to standard care, i.e., the usual procedure of central venous catheterization without listening to music. eligible patients had to be able to hear, understand explanations and consent. randomisation was stratified according to ventilation type (mechanical ventilation or not) and catheter site (superior vena cava or femoral vein). the music care ® (paris, france) application was used to make the patients listen to music through headphones. each patient chose his/her musical topic on a digital tablet, just before the catheterization. the primary outcome was the change in anxiety visual analogic scale (vas) between the beginning and the end of the catheterization procedure (t -tf anxiety vas). secondary outcomes included the patient's pain vas at the end of the procedure (tf pain vas). results: patients were included in the standard care group versus in the musical intervention group. main reasons for admission were the need of central catheter for chemotherapy ( , %), and sepsis and/or shock in both groups ( , %). catheters were inserted in the internal jugular vein in most cases ( , %) and about one-third were tunnelled in both groups. there was no between-group difference regarding median t -tf anxiety vas: [iqr:− to ] in the standard care group versus − [− to ] in the music intervention group (p = . ) (fig. ) , with no significant interaction between the variables of stratification or the operator experience and the intervention. the median tf pain vas was not statistically different between groups: [ to . ] in standard care group and [ to ] in music intervention group (p = . ), with no significant interaction between the variables of stratification or the operator experience and the intervention. conclusion: in this first randomized pilot study of musical intervention for central venous catheterization in awake patients in the intensive care unit, the musical intervention did not reduce patients' anxiety as compared to usual care. as the study may have been underpowered, larger size trials are needed. compliance with ethics regulations: yes. rationale: sleep is markedly altered in icu-patients under mechanical ventilation and may be due to noise, light, patient-care activities, patient-ventilator asynchronies, or the result of acute brain dysfunction induced by sedative drugs. to our knowledge, sleep has never been studied at icu admission before any sedation. our study aimed at assessing sleep quality of non-intubated sedation-free patients admitted to icu for acute respiratory failure. patients and methods: observational study performed in a single centre of a teaching hospital. patients admitted to icu for acute respiratory failure (respiratory rate ≥ breaths/min and pao / fio < mm hg under high-flow nasal oxygen) could be enrolled. patients with hypercapnia, central nervous disease, intubated early after admission and those with a do-not-intubate order were excluded. sleep was evaluated by complete polysomnography (psg) that started in the afternoon following admission and was continuously performed until the next morning. results: over a -year period patients were screened and patients were included. among them, patients were excluded for the following reasons: patient was intubated shortly after psg initiation, psg was lost, and eeg recordings ( %) were stopped before midnight (electrodes turned off or loss of signal). therefore, patients in whom psg was complete during the nocturnal period were retained in the analysis ( rationale: convulsive status epilepticus (cse) is a common neurological emergency associated with high mortality and morbidity rates. there are strong experimental data suggesting a potential impact of secondary brain insults (sbi) on outcome after cse. however, there is no clinical proof to support this hypothesis. our objective was to evaluate the association between sbi (mean arterial blood pressure, arterial partial pressure of carbon dioxide, arterial partial pressure of oxygen, temperature, natremia, and glycemia) at day and neurological outcomes days after cse. patients and methods: this was a post hoc analysis of the hyber-natus multicenter open-label clinical trial randomized critically ill patients with cse requiring mechanical ventilation to either therapeutic hypothermia ( - °c for h) plus standard care or standard care alone. patients still alive at day after inclusion were enrolled from march to january in french medico-surgical icus. the primary outcome was favourable outcome days after cse defined as a glasgow outcome scale score of . results: median age was of years . a previous history of epilepsy was noted in ( %) patients. most episodes ( / , %) occurred out-of-hospital, and ( %) were witnessed from their onset. cse was refractory in ( %) patients and total seizure duration was min ( - ). a favorable -day outcome occurred in ( %) patients. maximal glycemia value and hyperglycemia > . mmol/l at day were the only sbi variables associated with outcome in univariate analysis. by multivariate analysis, age > years (or, . ; % ic, . - . ; p = . ), refractory cse (or, . ; % ic, . - . ; p = . ), and primary brain insult (or, . ; % ic, . - . ; p = . ) were associated with an increased risk of poor outcome, and a bystander-witnessed onset of cse (or, . ; % ic, . - . ; p = . ) was associated with a decreased risk of poor outcome. conclusion: in our population, secondary brain insults were not associated with outcome in critically ill patients with convulsive status epilepticus; whereas age, bystander-witnessed onset of status epilepticus, refractory status epilepticus and primary brain insult were identified as strong predictors of -day functional impairment. further studies are warranted to confirm our findings. compliance with ethics regulations: yes. rationale: acute stroke (as) is a leading cause of morbidity and mortality worldwide. however, data on the prognosis andfunctional outcome of patients with as requiring icu management is limited. our purpose was to identify factors associated with good outcome (defined by a modified rankin score (mrs) of - ) months after icu admission. patients and methods: retrospective cohort of patients admitted to the medical icu of a university-affiliated hospital between january and december and coded for acute stroke using the icd- criteria. patients with traumatic stroke and isolated subarachnoid hemorrhage were excluded. results: we identified patients. median age was [ . - ] years and ( . %) were males. main reasons for icu admission were coma ( %), hemodynamic instability ( . %), acute respiratory failure ( %), and cardiac arrest ( . %). glasgow coma score at icu admission was [ ] [ ] [ ] [ ] [ ] [ ] [ ] and points. types of stroke were hemorrhagic in ( . %) patients and ischemic in ( . %). mechanical ventilation was required in patients ( . %). seizures occurred in . % of the patients and convulsive status epilepticus in . %. pneumonia was diagnosed in ( . %) patients (aspiration pneumonia n = , ventilator associated pneumonia n = ). thrombolysis or thromboaspiration were performed in ( %) patients with ischemic stroke. surgical evacuation of expanding hematoma was performed in ( . %) patients, ( . %) had craniectomy, and ( . %) had external shunt for hydrocephalus. icu and hospital mortality were . % and %, respectively. six months after icu admission, ( . %) patients had a good outcome (mrs - ), ( . %) had significant disability (mrs - ), and ( . %) were deceased (lost follow-up n = , . %). on multivariable analysis, age (or . per year ( . - . ), p = . ), saps (or . per point ( . - . ), p = . ), and hemorrhagic stroke (or . ( . - . ), p = . ) reduced the likelihood of good outcome (mrs - ) months after icu admission. conclusion: in our study, prognosis of acute stroke requiring icu admission was poor and a good functional outcome occurred in less than % of the patients at months. age, severity at icu admission, and type of stroke predicted outcome. compliance with ethics regulations: yes. rationale: in intensive care units, severe spontaneous hemorrhagic brain injuries have a poor prognosis for mortality and functional outcomes. affected patients face particular ethical issues regarding the difficulty of anticipating their eventual recovery. in this context, prognostic scores can help clinicians in patients/relatives counseling and therapeutic decisions. the previous reviews pointed out many prognostic tools for intracranial hemorrhage and subarachnoid hemorrhage but did not focus on injuries explicitly severe nor assessed the methodological limitations of the models. our systematic review aimed to assess methodologically prognostic tools for functional outcomes in severe spontaneous haemorrhagic brain, with particular attention to their clinical utilities. patients and methods: following prisma recommendations, we queried medline, embase, web of science, and the cochrane by february , . we included multivariate prognostic models explicitly developed or validated on adults with severe intracranial or subarachnoid haemorrhage. we evaluated the articles following the charms recommendations (checklist for critical appraisal and data extraction for systematic reviews of prediction modelling studies) and the tri-pod statements (transparent reporting of a multivariable prediction model for individual prognosis. results: our review confirmed the multiple publications of prognostic scores, as we found articles aiming to develop or validate prognostic tools. relying on guidelines, we discarded articles due to the lack of prognostic capacities, validation, or predictor selection. articles developed and validated a prognostic tool and externally validated existing models (fig. ) . no score was of good methodological quality in intracranial hemorrhage. we highlighted two prognostic scores in subarachnoid hemorrhages: the sahit predicting unfavorable outcome or mortality at months and the fresh predicting unfavorable outcome at months. conclusion: although prognostic studies on haemorrhagic brain injuries abound in the literature, they generally lack of methodological robustness or show incomplete reporting. with the numerous published scores, we believe that it is time to stop developing new scores. ongoing validation, recalibration, and impact studies would keep improving existing good tools. the use of "patient-centered" approaches could also enhance them, and be more appropriate to inform patients and families about their long-term potential recovery. these considerations should drive future research in the modern era of neurocritical care prognosis. compliance with ethics regulations: na. rationale: respiratory pattern analysis by a visual examination is an important part of clinical assessment but is dependent on caregiver expertise and is subjective. furthermore, there is no easy medical device used in picu to measure tidal volume (vt) and minute ventilation (mv) in spontaneous breathing patients. the clinical research unit in critical care of chusj and ets have developed a non-invasive computerized d video analyzing system (retract system) to detect and perform a video analysis of respiratory status in children. the aim of this study is to test the reliability of the retract system to monitor respiratory distress in critically ill children. the retract system is detailed in reference . in summary, cameras reproduce in d the thorax and abdomen of a subject. the respiratory status (respiratory rate (rr), tidal volume (vt), minute ventilation (mv)) assessed by the retract system was compared on a bench test (high-fidelity mannequin) and in critically ill children, to the ventilator measurements and clinician expert evaluation (gold standard). bland-altman plots were used for comparison. results: we observed a significant agreement, on mannequin, between retract system and gold standard method in estimating vt, rr and mv, i.e. % of the paired differences were within the limits of agreement in bland-altman plots, as illustrated in fig. . in critically ill children (n = ), the correlation between the pairs of measures was also high (r > . , p < . ) and thecoefficient of determination with a high fit ( . < r < . , p < . ). for good correlation, the retract system needed to have a visual access to thorax and abdomen in a quiet subject. the retract system measurements of vt, rr and mv for respiratory distress monitoring in patients seems reliable. more testing are required to validate this method in usual practice and to develop the retractions signs video analysis. compliance with ethics regulations: yes. rationale: severe bronchiolitis requires hospitalization in paediatric intensive care unit (picu). non-invasive ventilation (niv) has been demonstrated to treat them since twenty years, its use is well defined but there is no consensus for the weaning. this study evaluated the application of a nurse-driven niv weaning protocol in hospitalized infants with severe bronchiolitis and verified its safety. this was a retrospective monocentric study in a picu of robert debré hospital-paris, france. in the epidemic period of bronchiolitis between and , all patients under one year old with severe bronchiolitis and requiring niv were included. two groups were compared: one group using the nurse-driven niv weaning protocol and one group without using this protocol. occurrences of complications, duration of ventilatory support and length of stay (los) in picu and total los were compared. results: patients were included in the study, in the no-protocol group, and in the protocol group. the nurse-driven protocol was using at the rate of % (n = / in the protocol group (p = . ). picu los were . days [ ] [ ] [ ] in the no-protocol group versus days [ - . ] in the protocol group (p = . ), hospital los was days [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in the no-protocol group versus days [ ] [ ] [ ] [ ] [ ] [ ] in the protocol group (p = . ) (fig. ) . the use of this first nurse-driven niv weaning protocol was feasible and simple with a very good application rate. its utilization was safe. the occurrence of complications did not increase by the use of this protocol. it would allow an optimal niv weaning without prolonging the ventilatory support duration nor picu los or hospital los. the professional practices appeared to be coordinated and the nurses appeared to be more autonomous. compliance with ethics regulations: yes. no-protocol and protocol groups comparison: cpap duration ( ), ventilatory support duration ( ), picu los ( ), hospital los ( ) rationale: first-line management of severe acute bronchiolitis in infants is mainly based on non-invasive ventilation (niv) and high-flow nasal cannula (hfnc) therapy. however, pediatric data regarding weaning from niv/hfnc are lacking. this study aims to identify the weaning practices from niv/hfnc in children with severe bronchiolitis. the weaniv-survey is a cross-sectional survey. a questionnaire was sent to french-speaking physicians with key roles in pediatric intensive care units. results: a total of % ( / ) of french university hospital were represented in the study. only % of pediatric centers used a protocol for weaning from niv/hfnc and nurses were considered as key-actors of the weaning process for half of participants. continuous positive airway pressure (cpap) was the mode of ventilation mainly used as the first-line therapy in clinical practice. the main criteriaconsidered toinitiate weaning process were: noor slight respiratory distress, a fio < %, a respiratory rate < /min and no significant apnea. three strategies to discontinue niv/hfnc were identified: /gradual decrease of ventilatory parameters (pressure or flow), /abrupt discontinuation and /gradual increase in off-ventilation time. abrupt weaning strategy was the most commonly used, no matter the mode of ventilation. a significant level of respiratory distress, the presence of apneas, an increase in oxygen requirement, and a respiratory rate > / min were identified as weaning failure criteria by most pediatric intensive care physicians. conclusion: in most centers, the weaning process does not follow any protocol. abrupt weaning seems to be commonly used as weaning strategy in children with severe bronchiolitis supported by niv/hfnc. based on the study findings, we suggest that criteria for weaning initiation and for weaning failure must be defined and weaning protocols generated. compliance with ethics regulations: yes. complications secondary to prone positioning occured for patients ( . %). conclusion: this first study, which evaluate prone positioning efficacy in severe p-ards shows evidence that prone positioning improves oxygenation parameters and survival rate. these results highlight the necessity to develop a multicentric prospective randomized study to confirm these conclusions. compliance with ethics regulations: yes. ( vs ) and vasoactive-inotropic score (vis) ( vs ) were significantly higher in the non-survivor group. cannulation was veno-venous ( %) or veno-arterial ( %) and patients ( %) were finally not initiated on ecmo. we observed an increase of patients cannulated in our picu over time (fig. ). there was no significant difference in mortality between patients transported on ecmo after cannulation in our picu and those who were transported to be cannulated in a referral ecmo center. the median time between the decision and the cannulation was . h and the median time taken in charge by picu transport team was approximately h. these periods were not significantly different between cannulation on site or in an ecmo center and between survivors and not-survivors. conclusion: in our study, multiple organ dysfunction, particularly hematologic and acuterenal failures, seems to be a risk factor of mortality. the delay between decision and management is similar whatever the cannulation site. specific ecmo mobile team and picu transport team seem to be essential, fast and trained to transfer these patients. it would be interesting to compare our cohort with children requiring ecmo already hospitalized in a referral ecmo center. compliance with ethics regulations: yes. rationale: life expectancy in patients with metastatic breast cancer (mbc) has substantially improved over the last decade. life threatening complications result from advanced diseases, infection and treatment-related toxicity. only few studies have assessed outcomes in this setting. we performed a hospital-wide study to investigate how icu resources are needed in patients with mbc. patients and methods: all patients with mbc managed at our hospital between and were retrospectively included. the primary outcome was overall survival (os). factors associated with icu mortality were identified using a multivariable cox proportional hazard model with sensitivity analysis. results are expressed as median [interquartile ranges] unless stated otherwise. results: among the patients managed at our hospital, ( %, including male) were admitted to the icu ( [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] patients per year). age was [ - ] years. patients were receiving their nd [ st- rd] line of treatment and had [ ] [ ] metastatic sites. sofa score at admission was [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . main reason for icu admission was sepsis (n = , %), acute respiratory failure (n = , %), coma (n = , %) and metabolic disorder (n = , %). invasive mechanical ventilation was required for patients ( %) and renal replacement therapy for ( %). sixteen ( %) patients died in icu. following icu discharge, median os was . months ( % ci [ . - . ]) and / ( . %) patients died within months. an antineoplastic treatment was resumed for / ( %) patients alive after icu discharge. factors independently associated with mortality were performance status ≥ (hr . , % ic [ . - . ] ) and sofa score at day (hr . per point, % ic [ . - . ] ). after sensitivity analysis, the number of treatment lines at icu admission was not associated with mortality. conclusion: icu admission is required in the course of the mbc disease for % of the patients. determinants of short term outcomes rely on performance status and disease severity but not on the characteristics of the underlying disease. ongoing analyses will assess whether icu survivors reach life expectancy of patients never admitted to the icu. compliance with ethics regulations: yes. hubert gheerbrant , jean-françois timsit , nicolas terzi , stephane ruckly , mathieu laramas , matteo giaj levra , emmanuelle jacquet , loic falque , denis moro-sibilot , anne-claire toffart chu grenoble alpes, grenoble, france; aphp, paris, france; outcom-erea, bobigny, france correspondence: hubert gheerbrant (hgheerbrant@chu-grenoble.fr) ann. intensive care , (suppl ):p- rationale: the prognosis of critically ill cancer patients admitted in intensive care unit (icu), remains an issue. our objective was to assess the factors associated with -and -month survival of icu cancer survivors. patients and methods: based on the french outcomerea ™ database, we included solid cancer patients discharged alive, between december and november , from the medical icu of the university hospital in grenoble, france. patient characteristics and outcome at and months following icu discharge were extracted from available database. results: of the cancer patients with unscheduled admissions, ( %) were discharged alive from icu. the main primary cancer sites were digestive ( %) and thoracic ( %). the -and -month mortality rates were % and %, respectively. factors independently associated with -month mortality included ecog performance status (ecog-ps) of [ ] [ ] . . - . ). interestingly, cancer chemotherapy prior to icu admission was independently associated with lower -month mortality (or, . ; % ic: . - . ). among patients with an ecog-ps - at admission, % (n = ) and % (n = ) displayed an ecog-ps - at and months, respectively. at months, ( %) patients received anticancer treatment, ( %) were given exclusive palliative care. discussion: factors associated with -month mortality are almost the same as those known to be associated with icu mortality. we highlighted that most patients recovered an ecog-ps of - at and months, in particular those with a good ecog-ps at icu admission, and could benefit from an anticancer treatment following icu discharge. conclusion: these results should be taken into account when deciding upon icu admission. it is of paramount importance to have an evaluation of both patient's general condition and anticancer treatment opportunities following icu discharge. compliance with ethics regulations: yes. rationale: the decision to urgently initiate medical anti-cancer treatment in cancer patients admitted to intensive care unit for cancerrelated organ failure is an issue. we currently lack criteria to select patients who may benefit from the treatment initiation. the purpose of our exploratory study was therefore to evaluate the characteristics of patients whose medical anti-cancer treatment is initiated in icu and to identify prognostic factors for in-hospital mortality. in these patients. patients and methods: we analyzed retrospectively, over a period of years ( / / to / / ), cancer patients over -year old admitted to our icu bordet and in whose anti-cancer medicaltreatment was initiated during in-icu stay. to identify prognostic factors for in-hospital mortality, we carried out a multivariate analysis of the factors influencing this mortality, considered as a binary. we also analyzed the long term survival of patients alive after their hospital stay (from the day of going out of hospital). results: overall, patients were included, men ( %) and women ( %), with a median age of years ( - ). of these, patients ( %) had a solid tumor and ( %) had a hematological tumor. in-icu mortality is % ( % ci - %) and in-hospital mortality % ( % ci - %). the prognostic factors for in-hospital mortality were age (mean vs in those who survived), the sofa score (median vs ), the saps ii score (mean vs ), the charlson score (mean vs. . ), the number of organ failure (mean . vs . ) and the presence of a therapeutic limitation (ntbr stated within h: % vs %). survival at year of patients who survived the hospital stay was % and median survival time was estimated to be . year ( % ci . - . ). in patients with a solid tumor, -year survival was % and % in those with a hematological tumor (p < . ). conclusion: we observed, in selected cancer patients admitted to the icu for a cancer-related complication, that the initiation of an anti-cancer medical treatment is feasible and can lead to interesting results, particularly in patients with a hematological tumor. compliance with ethics regulations: yes. rationale: considerable progress in the management of onco-hematology (oh) malignancies led to an increase in the number of patients proposed for intensive care unit (icu) admission. several guidelines offer decision models for icu transfer of these patients. we aimed to describe prognosis, adequacy of icu admission and denial in oncohematology patients. we included all oh patients proposed for icu admission in a tunisian medical icu, between january and july . from an admission proposal registry, were collected patient underlying condition, functional status, malignancy and predicted prognosis, acute critical illness and its reversibility, adequacy of icu rationale: cancer patients frequently need intensive care support for a life-threatening condition due to the underlying neoplasm or an adverse therapy-related event. however, there are poor data on their characteristics and outcomes in the intensive care setting. the aim of the present study was to describe clinical characteristics and to identify factors associated with in-icu mortality in critically ill cancer patients. patients and methods: it is a retrospective study conducted in the medical icu of farhat hached teaching hospital between january and december . all cancer patients with complete records were included. baseline characteristics, clinical parameters, severity of illness, primary tumor location and outcomes were collected. univariate and multivariate regression analyses were carried out to identify factors independently associated to poor prognosis. rationale: prognostic impact of underlying malignancy seems limited in most studies assessing outcome of critically ill cancer patients [ ] . however, only limited number of characteristics, namely disease progression status and preexisting stem cell transplantation, were usually assessed [ ] . primary objective of this study was to assess influence of hematological malignancy aggressiveness on hospital outcome. secondary objective was to assess influence hematological malignancy aggressiveness on type of infection. patients and methods: post-hoc analysis of prospective multicenter cohort performed in hospitals in france and belgium and including critically ill adults with underlying hematological malignancy admitted in icu from jan to may . a cox model was used to adjust for confounding variables then a propensity score matching on characteristics associated with underlying malignancy aggressiveness was performed. results: of the included patients, ( . %) had low grade malignancy (lg), the most frequent being myeloma (n = ), chronic lymphocytic leukemia (n = ), and myelodysplasia (n = ). patients with lg malignancy were older, underwent more frequently autologous stem cell transplantation (sct) and had less frequently altered performans status. they had more severe organ failure at icu admission (sofa score [ ] [ ] [ ] [ ] [ ] [ ] vs. [ ] [ ] [ ] [ ] [ ] [ ] , p = . ). before adjustment, mortality was % (n = ) and . % (n = ) respectively in patients with and without lg malignancy (p = . ). after adjustment for confounder using a cox model, a higher mortality was associated with nonlow grade malignancy (or . ; % ic . - . ). a propensity score then allowed a : matching upon variable associated with malignancy aggressiveness. after matching unadjusted mortality was % (n = ) in patients with lg malignancy and . % (n = ) in patients with high grade malignancy (p = . ) (figure) . in the matched cohort and after adjustment for confounder, high grade malignancies were associated with lower mortality (or . ; % ic . - . ). risk of fungal infection was unchanged by underlying malignancy before adjustment ( % vs. . % of patients with and without lg malignancy; p = . ) or after adjustment (hr . ; % ic . - . ). conclusion: despite anti-cancer advances, aggressiveness of hematological malignancies is associated with overall icu outcome. lowgrade malignancies displaying a better prognosis than non-low grade. aggressiveness of the underlying malignancy is not associated with risk of fungal infection. compliance with ethics regulations: yes. rationale: guillain-barré syndrome is the most common cause of acute flaccid paralysis and is associated with pulmonary embolism due to the mobility limitation. the aim of this study is to describe the incidence, the severity of pulmonory embolism in patients admitted to an intensive care unit (icu) for guillain-barre syndrome (gbs). patients and methods: twenty-eight adults patients with confirmed diagnosis of gbs were admitted to the icu in our university hospital center over a -year period and they were all included. prevalence, risk factors and course of vte were analyzed in icu patients with various forms and severity of gbs. results: during the study period, adult gbs patients were included. five ( . %) developped pulmonary embolism. the mean age was . ± . years and the sex ratio was . . the comparaison betewen the groups with and without pe showed that factors associated with the development of this complication were: respiratory failure requiring mecanical ventilation (p = . ), infectious complications (p < . ), blood pressure lability (p = . ), the delay of icu admission (p = . ), the delay to treatment initiation (p = . ), the sofa score (p = . ) and the presence of quadriplegia (p = . ). conclusion: pulmonary embolism is a frequent complication in patients with gbs. factors associated with this complication were: respiratory failure requiring mecanical ventilation, infectious complications, the delay of icu admission, the delay to treatment initiation, a high sofa score and the presence of quadriplegia. preventive measures in this category of patients have to be improved. rationale: acute respiratory distress syndrome (ards) is a life-threatening pathology associated with very high morbidity and mortality ( - %) in intensive care units (icu) and with even higher mortality among the severly burned patients worldwide ( à %). the aim of our study was to describe in tunisia burn patients with ards and to identify prognosis factors. patients and methods: we conducted a descriptive retrospective study between - - to - - , in burns icu, in ben arous, in tunisia. all burns who presented an ards, according to the berlin definition, during their stay in the icu, were included. when clinical or gasometric data was uncomplete, these patients were excluded. results: during the study period, patients were admitted to our burn unit including ventilated patients. fifty patients presented an ards: fifteen patients were excluded for lack of information, and patients were retained. the sex ratio was . . patients had a mean age of ± years, an average burned area of % ± %, an average unit of burn skin score (ubs score) of ± and an average sequential organ failure assessment score (sofa score) of . none of the patients had a history of cardiovascular or pulmonary diseases. the average time of onset of ards was ± days. ards was mild in case, moderate in and severe in . the etiology of ards was pulmonary in cases ( %) and extra-pulmonary in ( %). the pulmonary ards had as cause pneumonia isolated in patients, an isolated pulmonary burn in patients and a combination of pneumonia and lung burns in patients. extra-pulmonary ards were all due to sepsis and mainly to bacteremia. septic shock was associated with ards in patients ( %). the treatment was a conventional treatment based on protective ventilation, curarization and prone positioning in addition to the etiological treatment. the average length of stay in icu was days and mortality was % in these patients. conclusion: mortality from ards in burns in tunisia, is important especially in those with pulmonary burns as well as those with sepsis. the introduction of new treatments, such as extracorporeal membrane oxygenation, remains essential to improve the prognosis of burn patients. compliance with ethics regulations: yes. rationale: aspiration pneumonia (ap) is common in intensive care unit (icu). the incidence of ap among adults hospitalized with pneumonia ranges between and . %. usually one or more risk factors are identified to be involved in ap. the aim of this study was to determine the risk factors and predictors of mortality on patients with ap. patients and methods: we retrospectively included patients aged more than years and who were hospitalized in our icu for ap. patients were excluded if they had history of tuberculosis, if they have bronchiectasis or metastatic brain tumor. results: a total of patients were included. history of diabetes, hypertension, epilepsy and ischemic stroke were found respectively in . %, . %, . %, and . % of cases. the reason of icu admission were coma ( %), acute respiratory failure ( %), poisoning ( %) and cardiac arrest ( %). the incidence of acute respiratory distress syndrome (ards) was %. the most common organism isolated was staphylococcus aureus ( cases). risk factors for ap were epilepsy ( %), swallowing disorders ( %), ischemic stroke ( %), copd ( %) and degenerative neurological disease ( %). the mortality rate was . %. the median duration of mechanical ventilation was days [iqr - ]. in multivariate logistic regression analysis; saps ii score (or = . , % ic [ . - . ], p = . ) and ards (or = . , % ic [ . - . ], p = . ) were independently associated with mortality. conclusion: risk factors for aspiration pneumonia were epilepsy, swallowing disorders and ischemic stroke. ards and saps ii score were independent predictive factors of mortality. compliance with ethics regulations: yes. undetermined. the aim of this study was to evaluate the impact of hyperoxia on morbidity and mortality. patients and methods: this was a prospective study performed in the icu of abderrahmen mami hospital during a -month period. all patients admitted in icu during the study-period were included. those who didn't need oxygen therapy or in end of life stage were excluded. arterial blood gases were analyzed daily and each day with at least one value of oxygen arterial saturation (sao ) > % was considered as a day with hyperoxia. for each patient included, the number of times and days spent in hyperoxia was recorded as well as complications during the icu stay and the outcome. results: during the study-period, patients were included but only were eligible. mean age was ± years. acute on chronic respiratory failure was the most frequent reason of admission ( %). non-invasive ventilation was required for % of patients and invasive mechanical ventilation was necessary in % of cases. overall mortality was %. hyperoxia was observed in % of cases, with an average of ± times during the icu stay and ± days. a statistically significant association was observed between a long duration of hyperoxia and the occurrence of ventilator acquired pneumonia (p < - ), ventilator acquired bronchitis (p = . ), acute respiratory distress syndrome (p < - ), atelectasis (p < - ), septic shock (p < - ), rythm disorders (p = . ), reintubation (p < - ) and tracheostomy (p = . ). on multivariate analysis, independent factors of mortality were: simplified acute physiology score ii, cardiac failure, need for invasive mechanical ventilation and septic shock. hyperoxia was not independently associated with mortality. conclusion: hyperoxia is frequent in icu. it is significantly associated with icu complications but not independently associated with mortality. compliance with ethics regulations: yes. experience of the practice of prone position in patientswith acute respiratory distress syndrome in intensive care (chu oran) nabil ghomari, soumia benbernou, djebli houria faculté de medecine d'oran, oran, algeria correspondence: nabil ghomari (nabilghomari@hotmail.fr) ann. intensive care , (suppl ):p- rationale: mechanical ventilation (mv) in the prone position (pp) and low tidal volume have become recommendations with a high level of scientific evidence in recent years. the pp has been practiced for years in the chu oran emergency resuscitation service. we wanted to report the service experience in the practice of pp in patients with ards. patients and methods: retrospective study performed in patients with severe hypoxia ards with spo < % under fio > % or pao /fio < during the period march to december . results: patients received ventilation in pp. ards was secondary to thoracic trauma in % of patients, septic shock in % and aspiration pneumonitis in %. analysis of the success factors and improvement of oxygenation found that lobar ards, the delay < h and a duration of pp ≥ h were statistically significant. conclusion: the pp must be integrated into the arsenal of care of the patients in ards especially in our country where we do not have all the therapeutic options. compliance with ethics regulations: yes. julien goutay, nicolas cousin, thibault duburcq, erika parmentier-decrucq chu de lille, pôle de réanimation, hôpital salengro, lille, france correspondence: julien goutay (julien.goutay@gmail.com) ann. intensive care , (suppl ):p- rationale: in veno-venous extracorporeal membrane oxygenation (vv-ecmo) therapy, blood flow is the main determinant of arterial oxygenation and should be - ml/kg/min in adults. this flow rate is determined by several factors including the size of the inflow cannula. the impact on clinical outcomes of arterial cannula's size in veno-arterial ecmo (va-ecmo) has already been studied, and showed no difference for survival to discharge, weaning success rate and initial flow rate between a small cannula group and a larger one. our first objective was to describe the impact of inlet cannula size on the assistance flow rate in patients treated with vv-ecmo. secondary objectives were to analyze its impact on ecmo weaning, mechanical ventilation characteristics and mortality. patients and methods: we retrospectively reviewed all cases of respiratory failure treated with vv-ecmo admitted in the medical intensive care unit (icu) of lille's teaching hospital from january st, through march st, . inlet cannula size was collected and divided into two groups: the "small cannula" group had inlet cannula less than or equal to fr, while "large cannula" were larger than fr. primary endpoint was the initial flow rate according to the inlet cannula size, and its changes during the first h of assistance. secondary endpoints were the analysis of predictive factors associated with the choice of a larger inlet cannula, and the impact of its size on clinical outcomes such as successful ecmo weaning. results: patients treated with vv-ecmo were admitted in our hospital. eleven ( %) were cannulated with a large inlet device. mean initial ecmo flow rate was statistically higher in the "large cannula" group than in the "small cannula" one: . l/min (± . ) versus . (± . ) respectively, p < . . the difference was also significant during the first h of assistance. we found no difference between the two groups on clinical outcomes such as ecmo weaning time. in univariate analysis, weight was heavier in the "large cannula" group [ (± ) kg] than "small cannula" [ (± )], p < . . conclusion: ecmo initial flow rate was higher in a "large inlet cannula" group (internal diameter more than fr) compared with a "small cannula" group. we found no correlation with cannula-related haemorrhagic or thrombotic complications. inlet cannula size did not influence ecmo weaning, and duration time, but this may be a lack of statistical power. further prospective studies should confirm this results. compliance with ethics regulations: yes. rationale: burn patients are at risk of multidrug-resistant (mdr) bacterial infections with high mortality rate. therefore, monitoring the emergence of mdr pathogens in these vulnerable patients is important. this study aimed to assess digestive colonization with carbapenemase-producing gram-negative bacilli (cp-gnb) in patients admitted to the burn intensive care unit. patients and methods: our study was prospective and conducted over a one-year period (january to december ). every admitted patient was subjected to the screening. a double swab set was used to collect rectal swab specimens. one swab was used for mdr screening by disk diffusion method on selective media; the other for multiplex real-time pcr (cepheid's genexpert ® ) allowing detection of the most common carbapenemase-encoding genes (ceg) (blaoxa- , blakpc, blandm, blavim and blaimp). results: among the studied patients, ( . %) were detected positive at admission for cp-gnb by the genexpert ® carba-r assay. eleven patients, initially not colonized, acquired positive faecal carriage subsequently during their hospital stay. forty-two colonized patients ( . %) developed cp-gnb infection during their hospitalization. the ceg blandm quantitatively dominated by far with detections; either alone ( cases) or associated with other ceg ( cases). the second most frequent gene was blaoxa- . it was detected alone eight times and in association with other ceg times. forty-three patients carried blavim gene, usually in association with other ceg ( %). however, only one patient carried blakpc gene. the parallel screening by classical microbiology methods (disk diffusion on selective media) detected the presence of cp-gnb in all molecular positive samples. conclusion: our study describes the characterization of carbapenemase in burn patients and highlights their alarming spread. this emphasizes the importance of an active surveillance program by early detection of cp-gnb carriers and an isolation policy to limit the mdr infections expansion. compliance with ethics regulations: yes. rationale: invasive fungal infections are increasingly observed in the icus especially in burn units. inthe absence of simple and accessible techniques for early microbiological diagnosis, the use of antifungal treatment is increasing. little is known about the extent of the problem of antifungal prescription in burn icus. we aimed to evaluate the antifungal prescription in major burn patients. patients and methods: during the study period ( - ), all prescriptions of antifungals were analysed. analysis concerned demographics, clinical circumstances, as well as the basis of antifungal prescribing (targeted vs. empiric). among the patients admitted in this period, patients were treated with antifungals (sex ratio: . ; mean age: ± years, with low associated comorbidity). the tbsa was . % [ . - . ], ubs was [ . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . most of the patients ( . %) were transferred from another hospital structure within ± h. antifungal treatment was started at the average of the seventh day post wound injury, more often on an empiric basis. sofa score at the beginning of the treatment was ± . . lymphopenia was present in % and thrombopenia was present in %. index of colonisation was positif only in cases. the average candida score was . ± . . microbiological results were tardily collected, within weeks, in %. fungal urine infections were found in cases. candidemia and catheter-related infections were considered only in cases. the risk factors of fungal infection as described in literature were found in most of the patients including mechanical ventilation ( . %), length period of stay ( days [ . - . ]), central venous line ( %), severe sepsis or septic shock ( %), large-spectrum antibiotherapy for more than days ( %). conclusion: the management of antifungal infections in major burn patients is still challenging. antifungal prescription is based on clinical presumption. the empirical prescription reflects the lack of efficient laboratory support and late microbiological results prompting physicians to rely on clinical informations. the management of fungal infections is based on the improvement of mycological investigations. compliance with ethics regulations: na. rationale: invasive candidiasis is a widespread and alarming infection in intensive care units (icu) patients. its diagnosis is often difficult because of the lack of specificity of clinical signs and the low sensitivity of blood cultures. while the candida albicans species remain the most common cause of bloodstream infections, non-albicans are emerging. these infections are serious, associated with high mortality rate and requiring early diagnosis and appropriate treatment. in tunisia, few data are available. we aimed to determine the epidemiological profile of a series of candidemia in icu, the risk factors associated with the occurrence of candidemia and to describe the modalities of the mycological diagnosis of candidemia and their etiological profile. patients and methods: a retrospective longitudinal descriptive study conducted in the parasitology-mycology laboratory with the collaboration of the medical icu of la rabta hospital-tunis over a -year period from january , to december , . all hospitalized icu patients with at least one candida-positive blood culture were included. results: forty-three patients among hospitalized patients during the study period had at least one candidemia infection. the main risk factors for development of candidemia infection include invasive procedures, a prior use of antibiotics and parenteral nutrition. c. albicans was the most common species, detected in . % of patients. nonalbicans candida species were prominent ( . %), represented by c parapsilosis, followed by c. tropicalis and c. krusei then c. glabrata and finally c. lusitaniae. all the isolates tested were sensitive to the common antifungal agents. the mortality rate of our patients was high ( . %), and the detection of the albicans species in blood cultures was the only prognostic factor identified (or = . [ . - . ], p = . ). conclusion: candidemia in the medical icu patients is common and is associated with high mortality rate. despite the progress of biological tools, the diagnosis is difficult and needs to take into account the risk factors of the patients as well as scores based on clinical and microbiological parameters. a better identification of risk patients may help to early initiate empirical antifungal treatment. compliance with ethics regulations: yes. necrotizing soft-tissue infections in the intensive care unit: a retrospective hospital-based study kais regaieg, sabrine nakaa, arnaud mailloux, madjid boukari, johana cohen, dany goldgran-toledano groupe hospitalier intercommunal le raincy-montfermeil, montfermeil, france correspondence: kais regaieg (kais.regaieg@gmail.com) ann. intensive care , (suppl ):p- rationale: the objective of our study is to describe the epidemiological and clinical characteristics of necrotizing soft-tissue infections (nsti) and to improve therapeutic management. we conducted a retrospective observational study that included patients admitted in the intensive care unit (icu) of general hospital between september and aout with a primary or secondary diagnosis of nsti. we collected demographic and clinical data, cultured pathogens, lengths of stay, and in-icu mortality. results: during the study period, a total of patients admitted to the icu were diagnosed with nsti ( . % of the total number of patients). the mean of age was years. the sex ratio (m/w) was . . ten patients ( %) were directly admitted to the icu, others were transferred from medical or surgical wards. the mean of saps ii was . ( . ). the main indication to admission in icu was shock ( %). the most common comorbidity was diabetes ( %). the other co-morbidities associated with nsti were cardiovascular diseases ( %), obesity ( %) and carelessness ( %). the sites most commonly affected were extremities in patients ( %) and abdomen/ano-genital in patients ( %). in icu, a total of patients ( %) were mechanically ventilated [ (median duration: . days ( . )], patients ( %) were given vasopressors, and patients ( %) underwent renal-remplacement. all patients underwent one or more chirurgical intervention. patients ( %) underwent radical necrosectomy. in cases, an amputation was necessary. polymicrobian infection was seen in patients ( %). in patients ( %), we used vacuum assited closure therapy, which in patients was followed by definitive reconstruction by split skin grafts. the mortality in icu was %. the mean stay in icu was days . the mean duration of hospitalization of the patients who survived was days ( - ). on the basis of a univariate analysis, higher saps ii score and lactate levels were associated with increased mortality (p < . ). conclusion: ntsi is rare in icu but it's a life-threatening and disabling disease with a high mortality requiring a multidisciplinary management. early diagnosis and adequate treatment are necessary to improve clinical outcome and must be known by everyone. more studies are needed to estimate the interest and delay of new strategies such as negative pressure therapy. compliance with ethics regulations: yes. rationale: nosocomial infections remain a major cause of mortality and morbidity in burn patients. providing information about the main causative bacterial agents and determination of their susceptibility to antibiotics may improve empiric therapy and early detection of emerging antimicrobial resistance. the aim of our study was to investigate the species distribution and antibiotic susceptibility of isolated strains from a burn intensive care unit (icu). patients and methods: this study was performed retrospectively on all bacteriological samples taken from the burn icu at the trauma and burn center in tunisia during a seven year period (from january to december ). all isolated microorganisms were identified on the basis of standard microbiological techniques. antibiotic susceptibility testing was carried out by the agar disk diffusion method, and susceptibility results were interpreted using clinical breakpoints according to ca-sfm guidelines. minimum inhibitory concentration of colistin was determined using the e-test ® method (biomérieux), then using the eucast broth micro-dilution method (umic, biocentric ® ) since may . results: during the study period, the most frequent identified species were pseudomonas aeruginosa ( . %), staphylococcus aureus ( %), klebsiella pneumoniae ( . %) and acinetobacter baumannii ( %). these strains have been mainly isolated from blood cultures ( %) and skin samples ( . %). pseudomonas aeruginosa resistance to ceftazidime increased from . % in to . % in and resistance to imipenem and ciprofloxacin was . % and . %, respectively. four strains were resistant to colistin. rationale: community-acquired peritonitis is a heterogeneous condition characterized by peritoneum inflammation in response to a bacteria injury. the aim of our study is to describe the epidemiological, clinical, bacteriological, etiological, therapeutic characteristics of community peritonitis, and to evaluate the prognostic factors. patients and methods: this is a retrospective descriptive and analytical study spanning three years (between january and december ) involving cases of community peritonitis, hospitalized in the surgical emergency resuscitation department p ibn rochd casablanca university hospital. our study included adult patients with community-acquired peritonitis who underwent medical and surgical management. the studied parameters are the demographic data, the clinical and paraclinical signs, the care taken and the evolution of the patients. the study showed that the mean age was . ± . years, with a sex ratio of . . patients medical history included tobacco ( . %), extra-abdominal signs [hemodynamic failure ( %), renal failure (n = , %), hematological disorders (n = , %) and respiratory disorders (n = , %)]. therapeutic management was based on perioperative resuscitation, treatment of organ failure, probabilistic antibiotic therapy and median laparotomy surgery. the main etiologies of community peritonitis were: digestive perforation ( . %), purulent effusion ( %), intestinal necrosis ( . %), cholecystitis ( . %). intraoperative bacteriological specimens yielded the following bacteriological profile: predominance of ngb ( . %) dominated by e. coli ( . %) followed by klebsiella pneumoniae and enterobacter cloacae ( . %) the mean hospital stay was . ± . days. the mortality rate was . %. conclusion: improvement in the prognosis of community-acquired peritonitis can only be achieved by constant assessment of very early diagnosis and initiation of appropriate resuscitation and antibiotic therapy associated with a complete surgery carefully codified according to guidelines. compliance with ethics regulations: yes. rationale: klebsiella pneumoniae carbapenemase (kpc)-producing bacteria are a group of emerging highly drug-resistant gram-negative bacilli causing infections associated with significant morbidity and mortality. the aim of our study is to point out the incidence of bloodstream infections (bsi) caused by kpc in icu patients, its clinical presentation and course. patients and methods: we conducted a retrospective descriptive study. all patients hospitalized in the icu of our hospital who developed bsi caused by kpc from january , to december , were included. results: during the study period, patients were included. the mean age was . ± . years ranging from to years. sex ratio (m/f) was . trauma was the major cause of hospitalization in cases ( %). the most common past medical diseases were arterial hypertension in patients ( %). length of hospital stay prior to icu admission was ± . days. at infection onset, mean saps ii was ± . , mean sofa was . ± . and mean apache ii was . ± . . during icu hospitalization, all patients required invasive mechanical ventilation during . ± . days, had a central venous catheter (cvc) and an indwelling urinary catheter in place, patients ( . %) had tracheotomy, ( %) underwent surgery, ( %) presented acute kidney failure and ( %) needed hemodialysis. before the isolation of kpc, all patients presented infections. antibiotics prescript were: colistin in patients ( %), carbapenems in patients ( %), amoxicillin/clavulanic acid in patients ( %), cephalosporins in patients ( %), fluoroquinolones in patients ( %), tigecycline in patients ( %), aminosids in patients ( %), rifampicin in patients ( %), fosfomycin in patients ( %), glycopeptides in patients ( %). the delay for kpc-bsi onset was . ± . days. the most common infection sources responsible of kpc-bsi were: cvc in patients ( %) and pneumonia in patients ( %). kpc infection was responsible of septic shock in patients ( %). resistance rates were: gentamycin ( %), amikacin ( %), colistin ( %), fosfomycin ( %) and tigecycline ( %). antibiotics used to treat kpc bloodstream infection were resumed in table . the mean length of icu stay was . ± . days. out of the included patients, patients died (the mortality rate was %). death was related to kpc infection in patients. conclusion: the high prevalence of kpc-bsi in icu patients dictates the importance of implementation of infection control measures and strict antibiotic policies. compliance with ethics regulations: not applicable. we identified episodes of nosocomial infections in patients, representing a cumulative incidence rate of . per exposed patients. the incidence density was . infections per days of hospitalization. the prevalence of pneumonia was . %, followed by urinary tract infections . %, central venous catheterization infections . %, bacteriemia . %, meningitis . % and surgical site infections . %. the incidence rate of intubation-related pneumonia was . / day of exposure. the incidence rate of bladder-related urinary tract infection was . / day of exposure. the incidence rate of positive culture of the central venous catheter was . / day of exposure. the incidence rate of bacteremia related to stay was . / day of exposure. the mortality rate was . % with a significant difference between infected and uninfected patients (p = . ). microorganisms were gram negative bacteria in % of cases. conclusion: epidemiological surveillance of healthcare-associated infections is needed to establish prevention plans. compliance with ethics regulations: not applicable. in the prehospital setting, early identification of septic shock (ss) with high risk of mortality is essential to guide hospital orientation (emergency department (ed) or intensive care unit (icu)) prior to early treatment initiation. in this context, the severity assessment is most of the time restricted to clinical tools. in this study, we describe the association between prehospital shock index (si) and mortality at day of patients with ss initially cared for in the prehospital setting by a mobile intensive care unit (micu in this study, we reported an association between prehospital si and mortality of patients with prehospital ss. a si > . is a simple tool to assess severity and to optimize prehospital triage between ed and icu of patients with ss initially cared for in the prehospital setting by a micu. the association of si with biomarkers may be helpful to improve the screening for ss and decision making of ss in the prehospital setting. compliance with ethics regulations: yes. the failure rate and complications were comparable between the groups, but the ultrasound-guided internal jugular catheter appears to be faster to insert and requires fewer punctures, so it could be an alternative to the femoral one in emergency situations. rationale: neuromyelitis optica (nmo) is a rare but severe disease. the prognosis of treated nmo attacks remains unclear. we evaluated our practice, the early evolution and the prognosis of nmo patients. patients and methods: an observational study was performed on patients with nmo attacks presenting with visual or medullar symptoms admitted for plasma exchange (pe) therapy from january to august . treatment efficiency was defined as a negative shift of the visual or motor disability score (edss). nonparametric mann-whitney and fisher exact tests were used for statistical analysis as required. results: twenty-four patients had pe sessions. characteristics of the cohort are described in table . ( . %) died from complications of nmo attacks. treatment had an effect in ( . %) patients. the shift in the ambulatory and visual edss was respectively − . + . and − . + . . the non-survivor patients had all aqp antibodies (p < . ). residual edss was higher in the non-survivor group ( . + . vs . + . , p < . ). pulse steroids were administered in ( %) patient in the non-survivor group vs ( %) patients in the survivor group (p < . ). twelve ( %) patients previously given pulse steroid therapy responded to pe. discussion: we assessed the handling of nmo attacks and identified our flaws. we concluded that pulse steroid therapy should not be withheld or replaced by lower dosage. we also need to find a way to make attacks identified by physicians earlier to shorten the delay between its onset and patient's admission in a specialized care unit. we observed that the mean improvement is modest during the early phase of our treatment. but a modest improvement in the edss can have a great impact in the patient's quality of life and even survival. conclusion: nmo attacks remain a threatening disease despite aggressive treatment. shortening the delay of treatment and ensure adequate pulse steroid therapy coupled to pe could be a way to improve the prognosis. compliance with ethics regulations: yes. rationale: acute kidney injury in trauma patients is a problem that has been little studied in the intensive care unit (icu). its occurrence has been shown to be associated with high morbidity and mortality. we aim to determine the outcome of icu trauma patients with acute kidney injury (aki), including the incidence of death in the icu, of nonreversible renal impairment and icu complications. patients and methods: this is a prospective study, conducted in the department of emergencies and icu, including trauma patients with a minimum icu stay of days. renal failure was defined based on the new kdigo classification. predictors of mortality and poor outcome were identified using univariate and then multivariate analysis. results: one hundred and fifty patients were admitted during the study period for the management of post-traumatic injuries, among which patients were included. the incidence of aki in the studied population was % ( cases) with ( %) diagnosed with stage one, ten ( %) with stage two and ten ( %) with stage three. the overall mortality of patients with post-traumatic aki was . % ( patients) with a mean icu lengh of stay (los) at ± days and of days on ventilator at ± . eight patients ( . %) needed renal replacement therapy and thirty-four had non-reversible renal impairement ( %). during icu stay, eight patients ( %) were diagnosed with pulmonary embolism. on univariate analysis, the following variables were associated to mortality in patients with post-tramatic aki including; age, hemodynamic instability on the day of diagnosis and bilirubin levels on the day of aki diagnosis. besides, according to our analysis, the use of renal replacement therapy and the non-reversibility of renal impairment during icu stay were also associated to icu mortality. among these factors, the non-reversibility of renal impairment in the icu was a predictor of mortality on multivariate analysis (p = . , or = , . in this cohort, the following variables were predictive of non-reversible renal impairment during icu stay; including age (with a best cut-off of years old), medical history of hypertension, higher iss and diuretics' administration. on multivariate analysis, the age (p = . , or = . , ci . - . ) and use of diuretics (p = . , or = , ci . - ) were associated to non-reversible aki in the icu. conclusion: our study confirms that post-traumatic aki in the icu is associated to high morbidity and mortality. the identification of outcome predictors could be valuable to guide the management of aki. compliance with ethics regulations: yes. rationale: the occurrence of acute kidney injury (aki) in trauma patients is a problem that has been little studied to date. its presence has been shown to be associated with an increased risk of morbidity and mortality in affected individuals. to determine the incidence of post-traumatic aki and identify its predictive risk factors that could be eventually prevented. patients and methods: this is a -month long prospective cohortstudy, conducted in the department of emergencies and intensive care unit (icu) of a university hospital, including trauma patients with a minimum icu stay of days. renal failure was defined based on the new kdigo classification. predictors of aki were identified using univariate and then multivariate analysis. results: one hundred thirty patients were admitted during the study period for the management of post-traumatic injuries, among which patients were included. the incidence of aki in the studied population was % ( cases) with ( %) diagnosed with stage one, ten ( %) with stage two and ten ( %) with stage three. on univariate analysis, older age and medical history of diabetes or hypertension were predictors of aki. injury assessment found traumatic brain injury (ais > ), glasgow (gcs) on admission, and the diagnosis of fat embolism to be associated to post-traumatic aki. moreover, hemodynamic instability on admission and during icu stay, shock-index on admission, the amount of fluid administered the use of vasoactive drugs, sepsis, hyperbilirubinemia, p/f ratio and acute respiratory distress syndrome (ards) were also associated to post-traumatic aki. among these factors, ards (p = . , or = , ci - ), fat embolism (p = . , or = , ci . ) without preload-dependence, and were unclassified. multivariate analysis (using variables collected prior to hypotension) identified the following variables as risk factors for the occurrence of hypotension associated with preload-dependence: preload-dependence before hypotension (odds ratio = . , p < . ), fluid removal rate by crrt (or = . per increase in sd, p < . ), and lactate levels (or = . per increase in sd, p < . ). in this single center study, preload dependence-associated hypotension was slightly more frequent than hypotension without preload dependence in icu patients undergoing crrt. testing for preload dependence to adjust fluid removal could help prevent hypotension incidence during crrt. rationale: few studies report the relation between functionnal brain alterations during and after icu stay and abnormalities of cbf displayed on tcd. using vti as hemodynamic parameter is unusual for evaluation of cbf. the purpose of this preliminary study was to compare the values of vti of healthy controls (c) versus icu (p) with usual parameters (i.e. diastolic (vd) and mean velocities (vm), resistance (ir) and pulsatility index (ip)). rationale: accurate diagnosis of the level of consciousness is a challenge and different states such as coma, vegetative state (vs) or minimally conscious state (mcs) are often confused while they convey meaningful prognostic information. this distinction rely on the coma recovery scale-revised (crs-r) gold-standard. however, this clinical scale is imperfect since unresponsive patients can exhibit genuine signs of consciousness using advance neuroimaging techniques. expanding the range of behaviors indexing consciousness at bedside is thus of decisive importance. patients and methods: we designed and proposed a new clinical sign of mcs, the habituation to auditory startle reflex (asr), based on the blink response to repeated sounds: either inhibition of the automatic asr response (extinguishable) or nohabituation (inextinguishable response). we prospectively tested this new sing in patients suffering from disorders of consciousness after severe brain injury and first compared its diagnostic performances with the current gold-standard (crs-r) using standard discrimination metrics (auc, sensitivity, specificity, likelihood ratios) and their % confidence interval. we then investigated the correlates of this new sign on two validated neuroimaging diagnostic procedures (multivariate eeg-based classification of the state of consciousness and fdg-pet metabolic index of the best preserved hemisphere) using an anova with the state of consciousness and the asr response as independent variable. rationale: although continuous electroencephalography (ceeg) is commonly recommended in neurocritical care patients, implementation of this monitoring in routine is facing the need for a specific training of professionals. we evaluated the effectiveness of a training program for the basic interpretation of ceeg to critical care staffs in a prospective multicentre study. patients and methods: after completion of a pre-test, participants (physicians and nurses) recruited in french intensive care units (icu) received a face-to-face eeg learning course, followed by additional e-learning sessions at day- (post-course), day- , day- and day- , based on training tests followed by illustrated and commented answers. each test was designed in order to evaluate knowledge and skills through correct recognition of predefined eeg sequences covering the most common normal and abnormal patterns. the primary objective was to achieve a success rate of more than % of correct answers at day- in at least % of participants. results: among participants, ( . %) completed the full training program and of these ( . %) full-training participants achieved at least % of correct answers at day- . paired comparisons between scores obtained at each evaluation demonstrated a statistically significant increase over time. at day , rates of correct answers were greater than % for all predefined usual eeg sequences, excepted for the recognition of periodic and burst-suppression patterns and reactivity, which were identified in only . % ( % ci . - . ) and . % ( . - . ) and . ( . - . ) tests, respectively. discussion: this multicentric prospective study, which evaluated a training program for the basics of electroencephalography offered to critical care teams, provides interesting information about the training process and its impact on learners according to their different characteristics. we believe that participants reflect the heterogeneity of the various use of ceeg in the critical care setting. participants came from university and non-university icus, and whereas some of them used to monitor patients with ceeg, others were in an implementation process when the last monitored neurocritical care patients with intermittent eeg. in accordance with previous studies, we focused to the entire medical and nursing icu staffs. conclusion: a -months training program aiming to teach the basic interpretation of continuous eeg in the intensive care units was associated with a significant attrition in participation over time. however, participants who received the full training program were capable to accurately recognize the vast majority of eeg patterns that are encountered in critically ill patients. compliance with ethics regulations: yes. mourad goulmane oran hospital and university center, oran, algeria correspondence: mourad goulmane (goulmane.mourad@univ-oran . dz) ann. intensive care , (suppl ):p- rationale: cerebral venous thrombosis (cvt) is a rare but very serious disease with various clinical and etiological aspects. unlike ischemic arterial accidents, epidemiological studies are limited. the aim of our work was to study the clinical, etiological and evolutionary features of cvt in the algerian population from a sample of patients. patients and methods: this is a retrospective observational study conducted in the neurology department of the chu d'oran between january and december . in a clinical context suggestive of cvt, the diagnosis of certainty was provided by brain mri coupled with mra. all subjects benefited from a complete etiological assessment. the anticoagulant treatment was based on the low molecular weight heparin relayed by the anti-vitamin k. the duration of the follow-up was months. results: the mean age was . ± . years, the sex ratio was ( f/ h), the onset was subacute in % of cases. the main early signs were headache ( . %), visual disturbances ( %), epileptic seizures ( . %) and motor deficit ( . %). thrombosis predominated in the upper sagittal sinus and lateral sinuses; parenchymal lesions were associated in / of the cases. gynecologic obstetric causes were by far the most frequent. the evolution was favorable in . % of the cases. discussion: cvt is characterized by its clinical polymorphism, its predominance in young women, and its most often favorable evolution. the causes are multiple and often intricate requiring the realization of a systematic etiological assessment even if the cause seems obvious. the treatment of choice remains early anticoagulation, based on heparinotherapy even in case of hemorrhagic softening. the characteristics of cvt in the algerian population are distinguished by a high frequency of gynecological obstetric causes. awareness campaigns for women of childbearing age are useful. compliance with ethics regulations: not applicable. rationale: the ct-dragon score was developed to predict longterm functional outcome after acute stroke in the anterior circulation treated by thrombolysis. its implementation in clinical practice is hampered by the plethora of variables included. in addition, the score has not been validated in important subgroups such as stroke patients undergoing thrombectomy. given these limitations, the current study was designed to evaluate the use of a simplified score based on machine learning, as a possible alternative. this single-centre retrospective study included patients treated for stroke, in the anterior and posterior cerebral circulation, between - and - . at days, favourable (modified rankin scale (mrs): - ) and miserable outcome (mrs: - ) were predicted by ct-dragon. machine learning selected the aim was to describe the adherence rates to gold guidelines in critically ill copd patients and to identify predictors of low adherence. patients and methods: a prospective cohort study conducted from december to april in a -bed medical intensive care unit of farhat hached hospital. all adult patients admitted for aecopd during the period of the study were included. demographic and clinical data were recorded. adherence to gold was evaluated. univariate and multivariate regression analyses were carried out to identify factors independently associated to non-adherence to gold guidelines. results: seventy-seven patients were recruited. patients' characteristics were : mean age, . ± years; male ( . %); median duration of the disease, [ - ] years; mmrc scale ≥ , ( . %); health insurance coverage rate, ( %); pulmonologist follow up, ( , %); frequent exacerbator (≥ exacerbations in the last year), ( . %); median exacerbations episodes, [ ] [ ] [ ] . long-term oxygen use and home mechanical ventilation were respectively used in ( . %) and ( . %). eight ( . %), ( . %) and ( . %) belonged to copd groups b, c and d, respectively. pharmacological treatment included: saba-ics combination, ( . %), laba-ics, ( . %), laba-lama, ( . %) and lama-laba-ics, ( . %). overall adherence to gold guidelines treatment recommendations for the different stages of copd was ( . %). two patients ( . %) were over treated and ( . %) were undertreated. inappropriate treatment rate was ( %) in gold b, ( . %) in gold c and ( . %) in gold d. univariate analysis identified two factors associated with non-adherence to gold : the absence of pulmonologist follow-up ( % vs. . %; p = . ) and the low income ( . % vs. . %; p = . ). in multivariate analysis only the lack of pulmonologist follow-up was identified as an independent risk factor associated with gold guidelines discrepancies (or, ; % ci [ . - . ]; p = . ). there is a lack of adherence to gold guideline treatment recommendations in tunisian copd patients. this may lead to severe exacerbations. discrepancies were due to the poor access of severe copd patients to an appropriate pulmonologist follow-up. compliance with ethics regulations: yes. the operating theaters concerned were: the otolaryngology block, ophthalmology, vascular and thoracic surgery, and gynecological surgery. all patients over years of age were enrolled using the clinical parameters of difficult intubation (arne score > ), which will benefit from orotracheal intubation. the main judgment criteria were: first-pass success rate, intubation time, which is defined as the time between inserting the slide into the patient's mouth and obtaining the capnography curve, the cormack-lehane score and the pogo score (percentage of opening of the glottis). statistical analysis used spss software. results: a total of patients were included. no cases of failure with this device were observed, the duration of intubation was on average . s (only cases required more than min). the cormack-lehane score and involved patients ( . %), and the pogo score greater than % involved patients ( . %). one case required the features of the simplified score. discrimination, calibration and misclassification of both models were tested. results: % had proximal anterior stroke, % proximal posterior stroke and % lacunar infarcts in either circulation. in % no thrombus was objectivated. % of patients were treated with thrombectomy, % received thrombolysis and % underwent both thrombolysis and thrombectomy. % only received anti-platelet therapy. the area under the receiver-operating-characteristic curve (auc-roc) for ct-dragon was . ( % ci . - . ) for favourable and . ( % ci . - . ) for miserable outcome. r ofct-dragon was . and . for favourable (lack of fit, p = . ) and miserable (lack of fit, p = . ) outcome respectively. misclassification rate was % for favourable and % for miserable outcome with ct-dragon. selection of predictors from the ct-dragon was done by logistic regression, bootstrap forest and decision tree analysis. nih stroke scale, pre-stroke mrs and age were identified as the strongest contributors to favourable and miserable outcome, and included in the simplified score. auc-roc was . ( ci% . - . ) and . ( ci% . - . ) for the prediction of favourable and miserable outcome respectively. r was . and . for the prediction of favourable (lack of fit p = . ) and miserable (lack of fit p = . ) outcome respectively. misclassification rate was % for favourable and % for miserable outcome with the simplified score. the simplified score had better discriminative power than ct-dragon for both outcomes (both p < . ). the ct-dragon score revealed acceptable discrimination in our cohort of both anterior and posterior circulation strokes, receiving a variety of treatment modalities. the simplified score had a better discrimination, while maintaining comparable and good specificity and misclassification rate for miserable outcome. the simplified score needs further validation in a prospective, multi-centre study. compliance with ethics regulations: yes. rationale: the gold report represents a major revision to gold strategy guidelines. it brings new recommendations regarding diagnosis, severity assessment, and both pharmacologic and non-pharmacologic treatment of copd. however, adherence to evidence-based therapeutic guidelines is often poor in low-income developing countries and represents a significant barrier to optimal management. the setting up of an lma-fastrach (desaturation). a case of glottic edema has been noted. discussion: this study shows a very high success rate with this technique ( . % in the first trial and . % in the second trial), in the context of a predictable difficult intubation. the video-airtraq allows a very good visualization of laryngeal structures, a shortening of the duration of intubation, and is rarely responsible for immediate or secondary complications. all the data in the literature go in the same direction. conclusion: at the end of this work, our perspectives are to update the difficult intubation procedure, integrating the video-airtraq into our algorithm, as well as into our difficult intubation trolley. to take into consideration the cost of this device to eventually generalize it to all our structures. compliance with ethics regulations: yes. ) and beds of continuous monitoring. the activity of the cp is organized in a medical visit in the morning and in conducting projects in the afternoon. the activity is presented using a -years balance sheet results: the activity of pharmaceutical interventions (pi) or answers to requests from teams is shown in table . the solicitations doubled the second year. the cp is involved in the conduct of internal or polar projects (set up of cooperative sedation, nutrition…), the good use of health products (relay iv/po, infusion, crushed tablets and compatibility with gastric probe, drug incompatibilities, proton pump inhibitors…), the efficiency of the drug circuit (link with the pharmacy, reflection on the improvement of the circuit, regular meetings with nurses), medico-economic analysis of health products spending and the formalization of actions by protocolisation. he is also very involved in clinical research: patient screening, clinical study setup: blipic study (beta-lactam's dosing in pneumonia in icu in patients treated by continuous renal replacement therapy; clinicaltrials nct ) or in candiarea project (invasive infections to candida and preemptive treatment guided by biomarkers; in progress). a satisfaction survey submitted at months to nurses ( answers/ ) or to doctors/ residents ( / ) reported cp competence in the accompaniment of teams (> %) [in medico-economical, contribution of knowledge, vigilance reflex…], relevance of information transmitted (> %) [administration of drugs, dosage adjustments, …] and his relationship adapted to the units (> %) [communication, availability] . the development of clinical pharmacy in icu involves mastery of the specificities of icu by the cp, requiring a learning period and relationships adapted to clinical situations and teams. many health products projects specific to critical care are coordinated by the cp and made possible by medical and paramedical involvement. the cp appears as a vector of good use both in medical (reasoned prescription) and paramedical (good practices) with increasing solicitation of teams since his arrival. this reception has been facilitated by an innovative approach of clinical pharmacy deployment in our icu on an impulse of the clinical pole compliance with ethics regulations: yes. predicting models such as the news has been developed in the emergency department, but it has only been fewly evaluated in the icu. heart rate variability (hrv) reflects the autonomic nervous system response in various pathological situations and may vary according to patients' physiological status. the rox index, which reflects the acute respiratory failure severity, seems to be a good predictor of high-flow nasal canula failure. the aim of this study was to evaluate the potential value of news, hrv and irox (inversed rox) as poor outcome predictors, using artificial intelligence and machine learning. a retrospective analysis of a prospective datawarehousing project (reastoc clinicaltrials identifier nct ) on icu patients who did not require invasive ventilation. physiological parameters were collected on admission, within a -h delay. news, hrv (in time, frequency, and non-linear domains), and irox were computed and integrated into the prediction model. analysis was performed using medcalc and matlab machine-learning work-package. results: one hundred and twelve patients were included. patients who died in the icu (n = ) had highest news as compared with icu survivors ( . [ . - . ] vs. . [ . - . ] respectively; p = . ). the irox was higher ( . [ . - . ] vs. . [ . - . ], p = . ) and most hrv parameters also depicted higher values for icu survivors. considering a composite icu prognostic outcome parameter (mortality and/or need for any form of respiratory assistance and/or an icu los > median los), there was also a difference for news, hrv and irox (p < . ). the best value to predict icu mortality for news was (auc = . , p = . ), irox > . (auc = . , p = . ) and hrv (shannon entropy) > . (auc = . , p = . ). the best model to predict the need fo respiratory assistance combines irox and hrv (sd /sd ; auc = . , p = . ). adding shannon entropy on this model predicts either the need for respiratory assistance and icu survival (respectively auc . , p = . and auc . , p = . ). in icu spontaneously breathing patients, news, irox and hrv are different in between survivors and patients who died. the best model to predict the need for respiratory assistance combines irox and hrv (sd /sd ). compliance with ethics regulations: yes. rationale: sepsis is known for its important mortality in critically ill patients. the last guidelines defined sepsis as life threatening organ dysfunction. it rejected the concept of systemic inflammatory response syndrome (sirs) associated to suspected or confirmed infection, and considered the concept of dysregulated response to infection. actual guidelines recommend the quick sequential organ failure assessment score (qsofa) to identify patients with sepsis especially when outside intensive care unit. thus, outcomes have mainly to judge the value of sirs in the sepsis- era. the purpose of our study was to compare whereas qsofa score or the sirs criterion are superior to predict in-hospital mortality, shock and mechanical ventilation use in sepsis. our study includes patients in whom the sepsis- definition is met. therefore, this inclusion was retrospectively performed throughout emergency department (ed) admission cases for clinically suspected infection. we collected patients admitted to ed for sepsis. mean age was years ± with bornes of and . men were % of the patients. death occurs in . % of patients, sepstic shock in % and the use of mechanical ventilation in . %. qsofa ≥ has a significant association with in-hospital mortality (p < . ) but not sirs ≥ ( . ). neither qsofa ≥ nor sirs ≥ has association with the use of mechanical ventilation (p = . vs. p = ). whereas, both have a significant association for prediction of septic shock. the absolute sensitivity and negative predictive value in our study can be explained by the small size of our sample. this needs confirmation with literature data about the fact that sirs criterion are superior in term of sensitivity and npv than qsofa to predict septic shock. despite the weak odds ratio (or) of sirs before that of qsofa and the poor specificity and positive predictive value (ppv), we can conclude that sirs according to its sensitivity and npv, seems to persist useful in the sepsis- era as a reliable prognostic tool in the ed. this may need more large studies for confirmation. conclusion: despite sirs has no significant association with mortality in sepsis, it has largely higher sensitivity and superior npv to predict septic shock than qsofa in ed. compliance with ethics regulations: yes. our study aimed to determine the predictive factors of mortality in our patients. retrospective study over years in the intensive care unit of the hospital august. all patients with septic shock were included. a p value < . was considered significant. results: patients were collected. the age ranged from to years old. the average duration of hospitalization in pre-intensive care was days. the reasons for admission: (febrile respiratory distress: % of cases, polytrauma: % and % for sepsis), the most frequent infections: pulmonary ( %) and blood ( %). % received prior antibiotic therapy and % were immunocompromised. the overall mortality was %. the analytical study of the data shows that the age, the length of stay before admission in intensive care and that in intensive care, fever, hypothermia, slimming, hypotension, collapse, failures (respiratory, hematological, renal, hepatic and neurological) and the use of catecholamines are correlated with mortality, whereas sex, chest pain, tachycardia or bradycardia and mottling are not predictive of mortality. conclusion: despite improved techniques for the diagnosis and treatment of patients with septic shock, mortality remains high, especially in the presence of certain risk factors, hence the value of prevention in immunocompromised patients and the reduction in their length of stay in a hospital setting. compliance with ethics regulations: yes. conclusion: p. mirabilis is among the leading bacteria responsible for nosocomial infections in icu. they are emerging highly drug resistant pathogens whose incidence is rapidly increasing in icu. so that, it early identification with in vitro testing is of paramount importance to the success of infectioncontrol efforts. compliance with ethics regulations: not applicable. rationale: influenza is a potential lethal disease causing dozens of thousands excess deaths per year both in europe and in the united states. besides hygiene procedures, vaccination is a cornerstone of influenza prevention and guidelines recommend for vaccination among health workers (hw), especially if they are in close contact with frail people. despite these recommendations, the vaccination coverage is low among health workers both in europe and in the us. the relevance of a mandatory vaccination for health workers is currently a hot topic but data are scarce regarding intensive care unit health workers' opinion. patients and methods: health workers from medical, surgical and polyvalent icus received a link to the electronic record of the survey. results: among the icus, icu health workers (hw) (medical: and paramedical: ) were questioned. three hundred and forty-one icu ( %) answered, ( %) medical health workers (mhw) and ( %) paramedical health workers (phw) (p < . ). among mhw / ( %) were vaccinated vs only / ( %) phw (p < . ). discrepancies exist between medical and paramedical icu health workers' opinions and beliefs about vaccination for influenza and its acceptance. medical health workers were more prone to consider influenza as a potentially lethal disease occurring not only among frail people but also in healthy people, to consider the vaccine efficient and safe. to agree with "vaccination for influenza is mostly related with gain for pharmaceutical industry" (or: [ . - ] ) and to disagree with "the risk of guillain-barré syndrome is higher after an episode of influenza than after vaccination for influenza" (or: . [ . - ] ) were independently associated to the disagreement with a mandatory vaccination for icu hw. conclusion: vaccination for influenza should be strongly recommended as a tool of individual protection for icu health workers as for general population. as confidence in vaccine efficacy and concerns about vaccine side-effects impact the vaccination rate, objective information should be provided to icu health workers about the efficacy and the side effects of vaccination for influenza. compliance with ethics regulations: yes. rationale: intra-abdominal infections are a major cause of morbidity and mortality. sfar recommendations on this topic were published in february . the purpose of this work was to evaluate whether our antibiotic therapy was adequate for these recommendations and whether they were adapted to our unit. the secondary objectives were to look for different risk factors for mortality, to evaluate the impact of inappropriate antibiotic therapy, to evaluate the relevance of carbapenem prescription. this is a single-center retrospective observational study of secondary peritonitis in the tourcoing intensive care unit. for each peritonitis, the epidemiological data and the co-morbidities of the patients were collected. bacteriology and anti-infectious therapies were described to determine the rates of adaptation of our antibiotic therapy and that recommended by sfar. the adequacy of our treatments to the recommendations was also quantifiable. the description of the stay, the occurrence of a death was specified. results: peritonitis were included. the rate of adaptation of the sfar antibiotic therapy was %. the rate of adaptation of our antibiotic therapy was % and its adequacy rate of %. the main differences in prescriptions concerned over-prescription of antifungals, molecule against gram positive bacillus and a sub-prescription of aminoglycosides and beta-lactams, in particular carbapenems. the different mortality risk factors found were sofa score > (or . % ci . - . ), the charlson score > (or . % ci . - . ), the hollow organ perforation (or . % ci . - . ). a comparison of the appropriate or not antibiotic groups did not reveal a significant difference in mortality, number of surgical revision and length of stay. in % of nosocomial peritonitis, antibiotic therapy with carbapenem was recommended. after recovery of microbiological data, it was only necessary for . % of cases. conclusion: our work showed a low rate of compliance with sfar recommendations. these recommendations are applicable to our service by providing a particular reflection for fungal infections. our study does not show a correlation between mortality and inadequate antibiotic therapy, surgery remaining the major treatment. compliance with ethics regulations:yes. rationale: acinetobacter baumannii is a gram-negative opportunistic bacteria that has gained several drug resistance mechanisms over the last decades. analysis of a. baumanii's resistance profile helps to establish a prompt control and a prevention program. the aim of this study was to evaluate the epidemiology and antimicrobial resistance of a. baumannii isolates in a trauma and burn center in tunisia. patients and methods: retrospectively, we studied all strains of acinetobacter baumannii isolated over a -year period (from january to december ). conventional methods were used for identification. antimicrobial susceptibility testing was performed with the disk diffusion method, and susceptibility results were interpreted using clinical breakpoints according to ca-sfm guidelines. data were analyzed using the sir-system. minimum inhibitory concentration (mic) of colistin was determined using the e-test ® method (biomérieux), then using the eucast broth micro-dilution method (umic, biocentric ® ) since may . results: during the study period, non-repetitive strains of acinetobacter baumannii were isolated representing . % of all isolates, % of gram-negative bacilli (gnb) and . % of non-fermenting gnb. in our center, infections due to a. baumannii were endemic with epidemic peaks. a. baumannii was mainly isolated from burn intensive care unit ( %) and anesthesiology department ( . %). the most frequent sites of isolation were blood cultures ( . %), catheters ( %), respiratory specimens ( . %) and skin samples ( % sampling duration is also reduced, improving workflow. evaluators consider that bronchosampler rationalizes the cumbersome sampling process and that the closed system design reduces the risk of losing sample or sample contamination. the set-up, the suction capacity, the sampling quality and quantity have all been evaluated better or far better than that usually observed with usual sampling techniques and devices. finally, ( %) of users prefer bronchosampler to commonly used method. conclusion: this satisfaction survey shows that with its simple but revolutionary design, bronchosampler brings a real effective benefit in sampling procedure enabling the clinician to perform it alone, and ( %) of the survey evaluators consider that bronchosampler should replace their current practice. compliance with ethics regulations: yes. rationale: the possibility of having a sensitive, specific and prognostic biological marker for bacterial infections is a considerable challenge. a step was taken with the discovery of pracalcitonin. patients and methods: this is a prospective observational cohort study of patients in the medical resuscitation department of the university hospital of casablanca during the -month period, including patients in whom the pct was dosed. the data collected allowed us to form two groups according to the pct value: pct+ group with pct > ng/ml and pct− group with pct < ng/ml. the statistical analysis of these different data was carried out using epi info software version . . . results: % of our patients had a bacterial infection and % did not have one. we also distinguished community infections ( % of i+ patients) and nosocomial infections ( % of i+ patients). we found that the highest rates of pct were in nosocomial infections and the lowest pct rates were found in community-acquired infections. then, in each type of organ involvement we tried to vary the pct thresholds to . - and ng/ml in order to find the best threshold for which pct allowed to diagnose bacterial infection, justifying our choice of departure. we concluded that the best pct cut-off value in general was ng/ml, because it gave us the best sensitivity/specificity ratio ( % and % respectively) with a positive predictive value of % and a negative predictive value of %. the link between pct and bacterial infection was moderate (yule q-factor at . ). by analyzing the different therapeutic aspects, we showed that % of our patients had been treated with atb before the pct assay and that the broadest spectrum antibiotics available to our service were used in patients with pct levels the highest. finally, concerning the evolution, the higher the rate of pct, the higher the death rate, especially since % of patients with pct > ng/ml died. conclusion: procalcitonin is considered to be one of the best markers of systemic bacterial infection. indeed, its elevation is earlier than that of crp and its specificity is better compared to il- and il- . the rate of procalcitonin remains low in the presence of viral infection. procalcitonin is also a prognostic marker, its elevation is correlated with the severity of the infection, and its decrease is a good indicator of the effectiveness of antibiotic therapy. compliance with ethics regulations: not applicable. rationale: due to induction immunosuppression infection is the most common cause of mortality within the first year after lung transplantation (ltx). the management of perioperative antibiotic therapy is a major issue, but little is known about worldwide practices. we sent by email a survey to ltx centers around the world dealing with daily clinical vignettes concerning perioperative antibiotic therapy. we considered perioperative period as the period of the transplant surgery (per operative) and the postsurgery time before any infection occurrence (postoperative). after general questions on local practices, we asked each center for colonization definition and their diagnostic methods for microbial screening in recipients and donors. the clinical cases were related to specific issues concerning the management of antibiotic therapy in different clinical situations, including no prior colonization, prior colonization with sensitive or multi-drug resistant (mdr) microorganisms including prior colonization with mdr bacteria not sensitive to beta-lactams. the invitation and a weekly reminder were sent to lung transplant specialists for a single consensus answer per center between june and september . we received a total of responses from countries, mostly from western europe (n = ) and the usa (n = ), (fig. ) . systematic screening for bronchial colonization before ltx was mostly performed with sputum samples ( %), regardless of the underlying lung disease. definition of colonization was very heterogeneous and the delay between the last bacterial isolation in pre-transplant and the ltx to consider if the therapy should target these bacteria varied between week and more than year. in recipients without colonization, antibiotics with activity against gram-negative bacteria resistant strains (piperacillin/tazobactam, cefepime, ceftazidime, carbapenems) were reported in % of the centers, and antibiotics with activity against methicillin-resistant staphylococcus aureus (mainly vancomycin) were reported in % of the centers. for these recipients, the duration of antibiotics reported was days ( %) or less ( %) or stopped when cultures of donor and recipients were reported negatives ( %). in recipients with pre-transplant colonization, antibiotics were adapted to the susceptibility of the most resistant strain isolated in pre-transplant samples and given for at least days ( %). conclusion: practices vary widely around the world, but resistant bacterial strains are mostly targeted even if no colonization occurs. the antibiotic duration reported was longer for colonized recipients. compliance with ethics regulations: not applicable. the vancomycin was therefore considered as justified or not and appropriate or not. occurrence of nephrotoxicity and supratherapeutic exposure in this study group was compared to critically ill children control group. results: thirty one children receiving vancomycin lines of treatment whose ( %) observed a risk of acute kidney injury (aki) (n = ) and an aki (n = ) during the vancomycin treatment period were included. there was a trend to inversed relationship between plasmatic concentrations of vancomycin and estimated creatinine clearance (r = . ). seven patients observed a nephrotoxicity related to vancomycin, they had a higher plasmatic concentration of vancomycin (p = . ). seven patients ( %) had a supratherapeutic exposure to vancomycin. nephrotoxicity and supratherapeutic exposure were higher in children with or combined liver-kidney transplantation than in comparative critically ill children group. we found blood stream infection due to the central catheter and blood stream infections probably due to the central catheter. one hundred thirtyfive bacteria were identified of which ( %) were staphylococcus coagulase negative. nineteen ( %) lines of vancomycin were appropriate and ( %) were justified. conclusion: vancomycin could have been avoided in one third of children with liver or combined liver-kidney transplantation during the early phase of postoperative stage. vancomycin is associated with a risk of both nephrotoxicity and supratherapeuric exposure. vancomycin should be used with caution, appropriate indications and dosing in this vulnerable population. compliance with ethics regulations: yes. rationale: early bacterial infection is a major and severe complication occurring within the first month after pediatric liver transplantation (lt). the rise of antimicrobial resistance, especially extended-spectrum beta lactamase producing enterobacteriaceae (esbl-pe), is henceforth a concern for these patients. this study aimed to assess the epidemiology of early bacterial infections, including those caused by multidrugresistant (mdr) pathogens, and to identify the risk factors for infection. rationale: the number of cancer patients admitted to emergencies is clearly increasing and digestive oncology is the leading cause of consultation. the aim of this work is to identify the epidemiological factors, the therapeutic modalities as well as the predictive factors of mortality and to compare them with the data of the literature. patients and methods: patients admitted to visceral emergencies for an urgent syndrome revealing or complicating a primary or secondary digestive cancer, and who required immediatemedical and/or surgical intervention and who had stayed at the surgical resuscitation level in our hospital center for a duration of years. several data were entered on excel and analyzed using the spss version software.-epidemiological, concerning age and sex; -clinics including risk factors, history, general condition of the patient and clinical examination data; -para-clinical, interesting biological assessments, and morphological examinations-medical and surgical therapeutics; -postoperative follow-up-treatment results. the three most frequent sites were rated in order of increasing frequency: colo-rectum ( %), pancreas ( %), and stomach ( %). the age group most found was age over years with % of cases, % of patients had under years. this series includes men and women with a sex ratio of , . the installation method was mostly gradual with % of cases. our patients have consulted for urgent clinical presentations mainly occlusive syndrome noted in % of patients. abdominal ct was the first examination performed, followed by abdominal ultrasonography in % and %, respectively. the therapeutic management was medico-surgical. the surgery done in % of patients, % for palliative indication: % were operated for an ostomy discharge, % for a digestive bypass, % for a palliative resection and % for a stoma feeding. postoperative outcomes were % morbidity and % mortality. the main cause of death was septic shock in % of cases, thanks to multivariate statistical analysis three factors were deduced significantly related to mortality: the asa score: p = . ; or = . ; ic: [ . ; . icu and hospital mortality rates were % (n = ) and . % (n = ), respectively. ten patients were alive months after with a median rankin score at [ - ]. more than half of the patients without stupor had a favorable neurological outcome (fig. ) . in univariate analysis, mechanical ventilation and stupor were correlated with mortality, whereas dic and apl were not. by multivariate analysis stupor was the only factor significantly associated with a higher mortality (hr: . [ . - . ] ). conclusion: intracranial hemorrhage is associated with a high mortality rate in al patients, stupor at the onset of intracranial bleeding being independently associated with poor outcome. up to one third of patients will nevertheless survive and experience a favorable neurological outcome. compliance with ethics regulations: yes. neurological outcome assessing by modified rankin scale according to stupor or coma at intracranial hemorrhage diagnosis (blank reflect missing data) rationale: sinusoidal obstruction syndrome (sos, previously known as veno-occlusive disease) is a complication of high dose chemotherapy, frequently occurring during bone marrow transplantation (bmt). severe sos is associated with a high mortality rate, related to multi-organ failure (mof). defibrotide being the only available option for prevention and treatment. prognosis of patients with sos requiring intensive care unit (icu) admission remains unknown. the primary objective was to assess the outcome of these patients. secondary objective was to assess risk factors associated with hospital mortality. patients and methods: retrospective study conducted between january and july in french icus. critically ill adult patients with sos (according to ebmt classification) who received defibrotide were included. results are reported as median [iqr] or number (%). adjusted analysis was performed using cox model. results: seventy-one patients were included with a median age of years . underlying hematologic diseases were acute myeloid leukemia ( %), lymphoma ( %),myelodysplasia/myeloproliferative neoplasm ( %) or acute lymphoid leukemia ( %). sos occurred during myeloablative allogeneic bmt ( %), reduced conditioning allogeneic bmt ( %), autologous bmt ( %) or chemotherapy ( %, including gemtuzumab ozogamycin in patients). median sofa score at icu admission was ]. ebmt prognostic score was often "very severe" ( %). main reasons for icu admission were respiratory failure (n = ), acute renal injury (n = ), shock (n = ), liver failure (n = ), coma (n = ) and monitoring (n = ). median bilirubin level at icu admission was µmol/l [iqr - ] and platelets count g/l . mechanical ventilation (mv), vasopressors, and renal replacement therapy (rrt) were required in % (n = ), % (n = ) and % (n = ) of patients, respectively. sixteen patients receiving defibrotide experienced bleeding events. icu and hospital mortality rates were % and % respectively, mainly related to organ dysfunction. in univariate analysis, delayed defibrotide initiation, bilirubin level, organ supports, sofa, and ebmt scores were associated with hospital mortality. cox model identified older age (hr . , % ci . - . ), mv (hr . , % ci . - . ), rrt (hr . , % ci . - . ), as associated with mortality. prophylactic defibrotide was correlated with a better outcome (hr . , % ci . - . ). similar results were observed after adjustment for center effect. conclusion: when organ support is required, icu management is associated with high mortality. organ support (namely rrt and mv) and older age were associated with poor outcome. prophylactic defibrotide was associated with survival either due to selection process or to efficacy in this setting. additional studies are needed to confirm these results. compliance with ethics regulations: yes. rationale: prognosis of critically ill immunocompromised patients (ciip) has improved over time. neutropenia is common and is found in one third of these patients. prognostic impact of neutropenia remains controversial and little data focus on ciip admitted in a context of acute respiratory failure (arf). primary objective was to assess prognostic impact of neutropenia on outcome of these patients. secondary objective was to assess etiology of arf according to neutropenia. patients and methods: retrospective analysis of prospective multicenter multinational dataset. adults immunocompromized patients with arf were included. adjusted analyses included ( ) a hierarchical model with center as random effect; ( ) propensity score (ps) matched cohort; and ( ) adjusted analysis in the matched cohort. results: overall, patients were included in this study. median age was [iqr - ] and patients ( . %) were of female gender. median sofa score was [ ] [ ] [ ] [ ] [ ] [ ] [ ] and ps was [ ] [ ] [ ] [ ] . main immune defect were hematological malignancy in patients ( %), solid tumor in ( %), systemic disease in ( . %), and other immunosuppressive drugs in ( %). neutropenia at admission was observed in patients ( %). initial oxygenation strategy was oxygen in patients ( %), high flow nasal oxygen in ( %), non-invasive ventilation in ( %) and invasive mechanical ventilation in ( %). before adjustment, hospital mortality was significantly higher in neutropenic patients ( % vs. % in non-neutropenic patients; p = . ). after adjustment for confounder in a mixed model, neutropenia was no longer associated with outcome (or . , % ci . - . ). after ps matching, neutropenic and non-neutropenic patients were compared. hospital mortality was similar in both groups ( % vs. % respectively; p = . ). after adjustment for variables associated with mortality, neutropenia was not associated with hospital mortality (or . , % ci . - . ). arf etiologies were distributed similarly in both neutropenic and non-neutropenic patients (fig. ) , main etiologies being bacterial pneumonia ( % vs. %), invasive fungal infection ( % vs. %), pneumocystis jiroveci pneumonia ( % vs. . %), and undetermined etiology ( % vs. %) (p = . ). conclusion: neutropenia at icu admission is not associated with hospital mortality in this cohort of ciip admitted for arf. surprisingly, arf etiology did not differ despite the multiplicity of observed immune defects. compliance with ethics regulations: yes. rationale: hepatic dysfunction (hd) is commonly observed in patients with hematologic malignancies and associated with an increased mortality in allogeneic hematopoietic stem cell transplantation patients. we aimed to assess incidence, risk factors and prognostic impact of hd in a large multicenter cohort study of critically ill patients with hematologic malignancies. patients and methods: this research was a post hoc analysis of a franco-belgian multicenter prospective study assessing the prognosis of patients with hematologic malignancies admitted to intensive care unit (icu) between january and may . hd was defined as serum total bilirubin ≥ µmol/l at icu admission. for patients with hd, a review of medical hospital records was performed by an expert panel to assess management of hd by attending physicians. results: among the patients with hematologic malignancies admitted to icu, were included in the study, mainly patients with non-hodgkin lymphoma ( . %) or acute myeloid leukemia ( . %). hd at icu admission occurred in patients ( . %). factors independently associated with hd were the use of cyclosporine (or = . , % ci . - . , p < . ) and antimicrobial treatment (or = . , % ci . - . , p = . ) before icu admission, abdominal symptoms at icu admission (or = . , % ci . - . , p < . ), ascites (or = . , % ci . - . , p = . ), hepatic charlson comorbidity (or = . , % ci . - . , p = . ), increased creatinine at icu admission (or = . , % ci - . , p = . ), neutropenia (or = . , % ci . - . , p = . ) and myeloma (or = . , % ci . - . , p = . ). hospital mortality was . % and . % in patients with hd and patients with no hd respectively (p < . ). hd appeared as an independent factor of hospital mortality after adjustment with other organ failure (oradj = . , % ci . - . , p = . ). factors independently associated with hospital mortality among patients with hd at icu admission are reported in table . etiologic diagnoses for hd by physicians were undetermined for patients ( . %) including ( . %) for whom the existence of hd has not even been mentioned in the medical record. investigations were performed in % and only % of patients received a specific treatment for hd. conclusion: hd at icu admission is common, underestimated, poorly investigated, and impairs outcome in critically ill patients with hematologic malignancies. hd should be considered and managed as other organ dysfunctions. it raises the importance of an early severity assessment of hd and a development of diagnosis strategies to get therapeutic options, in close collaboration between hematologists and intensivists. compliance with ethics regulations: yes. rationale: acute respiratory failure (arf) is the main cause for admission to the icu for patients with hematological malignancies (hm). viral pneumonia is poorly described in this population. respiratory viruses pcr is a rapid and sensitive diagnostic tool. thoracic ct allows to guide the diagnosis but is also poorly described. the primary objective was to describe ct features suggesting viral pathogenicity. secondaryobjectives were to assess risk factors associated with the use of invasive mechanical ventilation (imv) and icu mortality. rationale: high-dose methotrexate (hd-mtx) is commonly used in the treatment of solid tumours and hematological malignancies. severe toxicities are frequent, leading to organ dysfunction, multiple organ failure and death. outcome of these patients when critical illness occurs is poorly studied. this study aims to describe mtx-induced toxicities and to assess outcome in critically ill patients. in this retrospective study conducted in the icu of one university hospital between january and december , all the patients who were given hd-mtx (single dose greater than mg/m ) in the icu were included. results are presented as median [interquartile range] and number (percent). results: patients ( men and women) aged years [ - ], were included. b-cell lymphoma had been diagnosed in patients (burkitt, n = ; diffuse large b cell lymphoma with cns (central nervous system) involvement, n = ; primary cns lymphoma, n = ) and t-cell lymphoma in two patients. patients were mainly admitted for coma (n = ; %) or acute kidney injury (n = ; %). mtx was administered at a median dose of . g [ - ] . fourteen patients had concomitant medication interacting with mtx. median mtx clearance was days [ ] [ ] . frequent mtx-related complication were mucositis (n = , %), diarrhea (n = , %) or hepatic failure (n = , %). during icu stay, patients experienced acute kidney injury (kdigo stage . [ ] [ ] ). two patients received carboxypeptidase and three underwent dialysis. overall, patients ( %) required mechanical ventilation, ( %) vasopressors. hospital mortality was % (n = ). cox model identified mtx concentration h after administration higher than . µmol/l as associated with hospital mortality (hr . , % ci . - . ) (fig. ) . conclusion: to our knowledge this is the first study assessing characteristics and outcome of critically ill patients receiving hd-mtx. mtx concentration at h was associated with hospital mortality. despite underlying malignancy, icu support of these patients was associated with a meaningful survival. compliance with ethics regulations: yes. rationale: high-dose methotrexate ( g/m ; hdmtx) is the cornerstone of chemotherapy in acute lymphoblastic leukemia (all) and several high-grade non-hodgkin lymphoma (hnhl). despite standardized prevention, acute kidney injury (aki) and other life-threatening complications still occur. given the cost of glucarpidase, an enzyme that metabolizes mtx in few minutes, and the complexity of hematological patients admitted to the icu, a better comprehensive view of the factors that predict hdmtx toxicity, as well as the role of glucarpidase as rescue therapy in patients with organ failure, is mandatory. patients and methods: retrospective monocenter study including all the adult patients referred for all or hnhl in a french university hospital, and who received hdmtx. aki was defined according to the kdigo classification. univariate analysis (fischer exact or mann-withney tests) followed by multivariate analysis (stepwise logistic regression) were used to identify before hdmtx the clinical and biological predictive factors of aki. outcomes following glucarpidase were also addressed. results: from dec- to sept- , patients received hdmtx (median dose g/m ; all n = , hnhl n = ), totalizing hdmtx pulses. sixty-nine patients ( . %) developed aki after a median time of days (stage n = , stage n = , stage n = including one requiring dialysis in the first week). by multivariate analysis, only age, body mass index and a diagnosis of all were significantly and independently associated with the risk to develop aki. mtx exposure (maximal serum concentration at h - ) was also associated with aki (auc . , p < . ). glucarpidase was used in patients ( %) that differed by a higher age and bmi, and a lower basal egfr. glucarpidase was followed by a rapid renal improvement but serum creatinine did not return to baseline ( vs. micromol/l). thirty patients with aki or delayed mtx elimination did not receive glucarpidase but none required renal replacement therapy and egfr was only slightly but not significantly reduced at the end of follow-up. extra-renal adverse-events (rbc and platelets transfusions, neutropenia, hepatitis, severe diarrhea, mucitis) were more frequent in patients that developed aki. eighteen patients were admitted to the icu, including and that required mechanical ventilation or vasopressor drugs, respectively. conclusion: few actionable factors predict the development of aki after hdmtx, suggesting additional genetic factors. aki was reversed by glucarpidase but progression toward ckd was the rule. further studies will have to identify patients that will actually beneficiate from glucarpidase. compliance with ethics regulations: yes. khaoula ben ismail, sana khedher, ameni khaled, nassereddine foudhaili, mohamed salem usi digestif-service de gastroenterologie-eps charles nicolles.tunis-tunisie., tunisia, tunisia correspondence: khaoula ben ismail (khaoula @hotmail.fr) ann. intensive care , (suppl ):p- rationale: infection is common and accounts for major morbidity and mortality in cirrhosis. patients with cirrhosis are immunocompromised and have increased susceptibility to develop spontaneous bacterial infections, hospital-acquired infections, and a variety of infections from uncommon pathogens. we aimed to evaluate the impact of infection on hepatic encephalopathy. patients and methods: this is a prospective study, conducted over a period of years from january to december . consecutive patients with approved decompensated cirrhosis admitted to our department are included. all clinical and biological data were collected from the medical records. univariate and multivariate analysis were used to identify the impact of infection on hepatic encephalopathy. results: a total of patients diagnosed with decompensated cirrhosis were enrolled in this study. mean of age was years ( - ). sex ratio was . . hcv ( %) was the main etiology of cirrhosis. the reasons of hospitalization were: oedema with ascitic syndrome ( % of cases), digestive bleeding ( % of cases), fever ( % of cases), and encephalopathy ( % of cases). patients with infection seemed to have a high incidence of hepatic encephalopathy with % versus % when the patients are none infections. the results also showed that in those with hepatic encephalopathy, an effective antibiotic treatment accelerates significantly wakefulness under h with a rate of % vs. % (p < . ) . in addition, the infection does not influence mortality or length of stay compared to other complications such as digestive bleeding. conclusion: we found that infection caused more episodic hepatic encephalopathy than other complication and an effective antibiotherapy accelerate wakefulness. compliance with ethics regulations: yes. rationale: hepatic encephalopathy (he) is a common cause of hospitalization in patients with cirrhosis. pharmacologic treatment for acute (overt) he has remained the same for decades. to compare polyethylene glycol electrolyte solution (peg) and lactulose treatments in patients with cirrhosis admitted to the hospital for he. we hypothesized that rapid catharsis of the gut using peg may resolve he more effectively than lactulose. patients and methods: this is a prospective study, conducted over a period of years. from janury to december , we have been interested in cirrhotic patients with hepatic encephalopathy. all clinical and biological data were collected from the medical records. univariate and multivariate analysis were used to identify the difference beteween peg and lactulose in the treatement of hepatic encephalopathy. results: a total of patients diagnosed with decompation of cirrhosis were enrolled in this study. mean of age was years ( - ). sex ratio was . . hcv ( %) was the main etiology of cirrhosis. the hospitalization reasons were: edematous-ascitic syndrome in %, gastro-intestinal bleeding %, fever in %, and encephalopathy was present in % of cases. a total of patients were randomized to each treatment arm. baseline clinical features at admission were similar in the groups. twelve of patients in the standard therapy arm ( %) had an improvement of or more in hesa score, thus meeting the primary outcome measure, compared with of evaluated patients receiving peg ( %) (p < . ). the mean ± sd hesa score at h for patients receiving standard therapy changed from . ± . to . ± . compared with a change from . ± . to . ± . for the peg-treated groups (p = . ). the median time for he resolution was days for standard therapy and day for peg (p = . ). adverse events were uncommon, and none wasdefinitely study related. conclusion: we found that peg led to more rapid he resolution than standard therapy, suggesting that peg may be superior to standard lactulose therapy in patients with cirrhosis hospitalized for acute he. compliance with ethics regulations: yes. acute pancreatitis and pregnancy janati adnane, lina berrada obstetric intensive care unit, casablanca, morocco correspondence: janati adnane (adnanejanati@gmail.com) ann. intensive care , (suppl ):p- rationale: the association of acute pancreatitis and pregnancy is rare but not negligible, it often cause a diagnostic problem given the gravidal context that can lead to serious repercussions. the objective of our study is to assess the particularities in the diagnosis, management and prognosis of acute pancreatitis during pregnancy patients and methods: this is a retrospective study about cases of acute pancreatitis occurred during pregnancy over a -year period ( - ) at the obstetric intensive care unit of the meriem maternity hospital in the chu ibn rochd casablanca. a retrospective analysis of the medical files of these patients was carried out, considering epidemiological and etiological criteria, the treatments administered and maternal/fetal fate. we found cases during this period, with an incidence of / . the average age of onset was years, % of cases occurred in the rd trimester. epigastric pain and vomiting were the common symptomatology. ultrasound showed biliary lithiasis in % of cases with increased pancreas size in % of cases. maternal mortality was zero. uncomplicated benign forms are the most common ( %). severe hypokalemia was found in % of patients. neonatal morbidity was marked by six premature deliveries. among them, a newborn died at day- of life discussion: the association of acute pancreatitis and pregnancy is rare, more frequent during the rd trimester, it mainly affects the young woman. lithiasic biliary pathology remains by far the most frequent etiology. the diagnosis is clinical most often represented by epigastralgia with vomiting and biological via lipasemia and amylasemia dosage. uncomplicated benign forms are the most common. hydroelectrolytic disorders are often found. abdominal ultrasound allows the etiological diagnosis. the treatment is above all symptomatic whose objective is the digestive rest, the correction of the hydroelectrolyte disorders but first of all relieve the pain. conclusion: acute pancreatitis is a rare event in pregnant women, but can have a maternal and fetal prognosis. it must be systematically evoked in front of the acute abdominal pains of the pregnant woman because the confirmation of the diagnosis is easy and the maternal results depend mainly on therapeutic management. prematurity remains the predominant factor in neonatal morbidity. compliance with ethics regulations: not applicable. rationale: aclf is a clinical concept defined in patients with chronic liver disease who presented organ failure(s) secondary to an acute decompensated event. liver transplantation in this indication showed good results in selected patients. the aim of this prospective study was to evaluate the outcome and the factors associated with a favorable selection to liver transplantation in this population. patients and methods: all consecutive patients admitted to the icu with cirrhosis and aclf, were recruited. patient with age < years or with fulminant hepatitis were excluded. results: between july and february , cirrhotic patients were admitted to icu. mean age was . ± . years ( . % male). cirrhosis was due to alcohol in . % of the patients. aclf grading at admission was: . % aclf (n = ), . % aclf (n = ), . % aclf (n = ), and . % aclf (n = ). of the patients, . % (n = ) were considered to be eligible for a transplant project and were assessed for liver transplantation. the main reasons were alcohol abuse ( . %, n = ), death within days after admission ( . %, n = ) and rapid improvement of the liver disease. of the eligible patients, % were transplanted with a mean time between admission to icu and liver transplantation of . ± . days. twelve patients died on the waiting list ( % of the listed patients), mainly of septic shock. among those who were assessed for liver transplantation but not listed (n = ), . % died before the listing (n = ) and . % were not listed because of severe comorbidities (n = ). the global mortality rate was . % (n = ). the and days rate mortality were respectively . % and . %. the overall -month patient survival was respectively % and % in the transplant and non-transplant group (p < . ) for the entire cohort. among eligible patients, factors associated with the absence of liver transplantation, in the multivariate analyses, were mechanical ventilation (hr . , % ci rationale: body composition is known to be a prognostic factor in cirrhotic patients. however, the link between this and the prognosis of patients in intensive care unit (icu) is unknown. the computed tomography offer accurate estimations of muscle mass by analysing a cross-section usually going through the third lumbar vertebrae. this retrospective study aimed to assess the feasibility of body composition (bc) analysis in cirrhotic patients with septic shock, using computed tomography (ct) and evaluate the impact of bc (muscle mass, subcutaneous and visceral fat) on outcome. patients and methods: this retrospective study included cirrhotic patients with septic shock hospitalized in icu who underwent an abdomino pelvic ct scan within h of admission. we collected the surface areas of muscle mass and adipose tissue on the ct scans. we compared bc data with mortality and with the number of organ failures. the average age was years . the average child and meld scores were respectively . [ - ] and . . the prevalence of sarcopenia was %. it was not associated with a higher mortality rate at day (p = . ) or with a higher number of organ failures at day (p = . ). we observed a higher subcutaneous adiposity index in patients who died at day (p = . ) and in patients with renal insufficiency at admission (p = . ). there was a trend (p = . ) towards more visceral fat in patients who died in icu. the assessment by ct of body composition reveal evaluation of bc using ct is feasible and reproducible and may constitute a promising tool to evaluate in cirrhosis critically ill patients. visceral fat mass seems associated with poor outcome in cirrhotic patients with septic shock compliance with ethics regulations: yes. rachid jabi, mohammed bouziane chu mohammed vi, oujda, morocco correspondence: rachid jabi (jabirachid@gmail.com) ann. intensive care , (suppl ):p- rationale: the infection of the necrosis constitutes a pejorative element in the management of the necrotico-haemorrhagic pancreatitis, in the absence of the drainage the mortality approaches %. the morbidity and mortality of surgery can be avoided with minimally invasive treatments. purpose: to compare the morbidity and mortality of the two groups of post-ercp pancreatitis and the other etiologies. patients and methods: a retrospective study over years between and and a comparison between pancreatitis secondary to post-ercp and other etiologies of pancreatitis. a p value of . is considered significant. the surgical treatment used in cases of superinfection post ercp against seven cases of other etiologies of pancreatitis. high mortality in post-ercp pancreatic arm % vs. % (p = . ). high morbidity in the operated group % vs. % (p = . ) represented mainly digestive haemorrhages. duration of stay was significantly longer in the operated group vs. days (p = . ). thrombocytopenia and beta-lactamase-producing enterobacteria have further complicated management in the post-ercp infected pancreatitis arm. the antibiotic resistance of infected pancreatitis in post-ercp patients is . % for ciprofloxacin, . % for imipenem and % for amikacin. conclusion: pancreatitis the most common adverse effect of ercp with significant morbidity and mortality. the collaboration between the intensive care unit gastroenterologist and the surgeon improves management since the risk factors are mainly related to the patient and can not be modified. compliance with ethics regulations: yes. gautier nitel, aghiles hamroun, anne bignon, gilles lebuffe chru lille, lille, france correspondence: gautier nitel (gautier.nitel@gmail.com) ann. intensive care , (suppl ):p- rationale: liver transplantation (lt) has been recently experiencing an expansion of its indications, allowing patients with potentially more co-morbidities to access to transplantation. in our era of graft shortage, we should focus on the identification of the best lt candidates. the aim of our work is to study the determinants of early morbidity and mortality after lt from three angles: occurrence of a major cardiovascular event (mace) or acute renal failure (kdigo stage - aki) in the first days postoperative, and death in the year following lt. retrospective study investigating the occurrence of mace or aki (kdigo - ) within days post-operative and mortality at year after lt, including patients who received a first lt between january and december in our center. analysis of risk factors by a multivariate step-by-step analysis. statistical significance for p < . . data presented in odds ratio (or) rationale: infectious complications are frequently reported in critically ill patients supported by veno-arterial extracorporeal membrane oxygenation (va-ecmo) for refractory cardiogenic shock, but their diagnosis is challenging. no study has specifically studied bloodstream infection (bsi) in this population and some recommendations suggest performing systematic blood culture (bc). in our unit, systematic bc are daily sampled. we investigated the interest of systematic bc to detect bsi under va-ecmo. patients and methods: in a retrospective analysis ( - ), and after exclusion of patients dying within h, all adult patients from cardio-vascular intensive care unit supported by va-ecmo were included. systematic daily and "on demand" bc (at the physician's discretion) performed from va-ecmo implantation to days after withdrawal were analyzed. bsi was defined as at least one bc positive to a pathogen (except for contaminants bsi which required at least two positive bc with the same bacteria in h). multivariable logistic regression was performed to identify risk factors for positivity of systematic bc. rationale: fungal infections are constantly increasing in hospitals. indeed, the increase in these infections and especially candida yeast infections is almost parallel to the increase in the widespread use of a wide range of implanted medical devices such as catheters. for this reason, we have been investigating, isolating and identifying candida yeast colonizing vascular catheters and studying the epidemiological and clinical characteristics of patients with colonized catheters. patients and methods: it is a prospective, transversal study conducted at the intensive care and neurosurgery services of the sétif university hospital, evaluating the fungal colonization of vascular catheters. these are collected from hospitalized patients for a period of months. a culture of the distal end of the catheter is performed directly after its ablation. the results obtained showed that among the samples taken, six are colonized by the yeasts, the incidence is %. six yeast of candida spp were isolated, % of them were candida albicans species, . % candida parapsilosis and . % were candida glabrata. conclusion: it appears that colonization of catheters occurs most frequently in patients with the following characteristics: extreme ages of life, male sex, antibiotic therapy and length of hospitalization or prolonged catheterization. compliance with ethics regulations: yes. rationale: the threat of emergent extensively drug-resistant bacteria (exdr) dissemination worldwide is real. it has become a global public health issue. in fact, glycopeptides-resistant enterococcus faecium (gre) and carbapenemase-producing enterobacteriaceae (cpe) are the lead microorganisms in the high resistant bacteria category. the aim of our study was to characterize the molecular mechanisms and to determinate the antimicrobial susceptibility profiles of gre and cpe isolated from burn patients. patients and methods: prospectively, we studied all cpe and gre strains isolated from burn patients between january and december . all isolated microorganisms were identified on the basis of conventional microbiological techniques. antibiotic susceptibility testing was carried out by the agar disc diffusion method, and susceptibility results were interpreted using clinical breakpoints according to ca-sfm guidelines. molecular characterization was performed by multiplex real-time pcr (cepheid, genexpert ® ) allowing detection of the most prevalent carbapenemase encoding genes (blavim, blandm, blaimp, (blaoxa- and blakpc) as well as the genes vana and vanb of gre. results: during the study period, exdr were isolated from burn patients. the most frequent sites of isolation were blood cultures ( %) and skin samples ( . %). cpe represented . % of isolated exdr ( strains). among them, the most frequently identified species was klebsiella pneumoniae ( . %) followed by enterobacter cloacae ( %). twenty-four cpe ( . %) expressed the blandm gene. the blaoxa- gene was found in strains ( . %) and ten strains ( . %) carried both genes. of the cpe, . % revealed ertapenem mic > mg/l whereas most strains were susceptible to imipinem and meropenem with . % and . % of susceptibility, respectively. the antibiotics showing the highest resistance rates were cefotaxime ( . %), piperacillin-tazobactam ( . %), ciprofloxacin ( . %) and amikacin ( . %). the most active agents were colistin and fosfomycin with . % of resistance for each. seven strains of gre were isolated ( . % of exdr). all of them expressed the vana gene, with vancomycin mic > mg/l. however, teicoplanin mics ranged from to mg/l. all gre strains were beta-lactam resistant and highly resistant to aminosides. linezolid and tigecycline were the only active antibiotics. the dissemination of these extensively drug-resistant bacteria must be contained by implementation of strict isolation methods and better hygienic procedures in order to limit their economical and health consequences. compliance with ethics regulations: yes. rationale: stenotrophomonas maltophilia has emerged as an important pathogen that induces nosocomial infections. it is a non-fermentative, gram-negative bacillus that causes severe infectious diseases, particularly bacteremia in the hospital setting. morbidity and mortality due to stenotrophomonas maltophilia seems to be high, particularly in critically ill patient. the aim of this study was to describe the clinical features, management and outcome of patients with stenotrophomonas maltophilia infections. patients and methods: this was a retrospective analysis of prospectively collected data of patients hospitalized in intensive care unit (icu) between january and december . collected data were: age, gender, comorbidities, severity scores on admission, prior infections, use of antibiotics, use of invasive devices (urinary tract catheter, or mechanical ventilation), microbiological data, and antimicrobial therapy and outcome. results: during the study period, patients with stenotrophomonas maltophilia infection were included, with a mean age of ± years. the simplified acute physiology score ii and acute physiology and chronic health evaluation ii on admission were respectively ± and ± . bacteremia caused by stenotrophomonas maltophilia was observed in patients ( %) and ventilator acquired pneumonia in two patients ( %). twenty four episodes were classified as primary bacteraemia and only one as secondary bacteraemia due to urinary infection. four patients ( %) developed septic shock. mean sofa on the day of stenotrophomonas maltophilia infection was ± . prior antibiotic use was observed in % including an antipseudomonal agent in % of cases. infection due to stenotrophomonas maltophilia was considered in cases. empiric antibiotic therapy was administered to patients ( %) and had included an appropriate agent in only five cases ( %). after adapting antibiotics, monotherapy was the choice for six ( %) patients while a combination of two antibiotics was indicated in the others ( %). the most used antibiotic was the colistin in episodes ( %). intensive care mortality was %. univariate comparison between dead and survivors showed a significant difference in prior nosocomial infection and respiratory comorbidities. no independent risk factor of mortality was found in multivariate analysis. rationale: thrombocytopenia is a frequent disorder in critically ill patients, and several studies have reported its correlation with poor prognosis. considering the major role of platelets in hemostasis, a significant drop in platelet count is an alarming sign in septic patients. the aim of this study was to show the relationship between thrombocytopenia and platelet level changes and mortality in septic patients. patients with criteria for septic shock (based on the third international consensus definitions for sepsis and septic shock) at admission or at any time during hospitalization were included in a prospective study conducted for a period of months (january -august , ) in a medical surgical intensive care unit. patients hospitalized for less than h were excluded. thrombocytopenia was defined as a platelet count less than . /mm , and recovery was defined as returning to levels more than . /mm after presenting thrombocytopenia. we assessed the platelet count during the hospitalization and its outcomes. we included patients. the mean ± sd age was . ± . years. sex ratio was . . thrombocytopenia during sepsis (group ) was found in patients ( %) with a mortality rate at %. the mortality rate among patients not showing thrombocytopenia (group ) was significantly lower % (p = . ). the receiver operating characteristic showed that in (group ), a drop in the platelet count (from admission to septic shock day) more than % was associated with poor outcome (sensibility = %, specificity = %, auc = . ). among the (group ), % showed recovered platelet counts. the mortality was significantly higher in the patients with uncovered thrombocytopenia ( % vs. %, p = . ). conclusion: thrombocytopenia was shown to be an indicatorof poor prognosis in our study. in addition, drops of > % and failure to recover the platelet counts were further determinants of unfavorable outcomes. compliance with ethics regulations: yes. mehdi gaddas , sarra dhraief , karim mechri , imen jami , amenallah messaadi , lamia thabet rationale: pseudomonas aeruginosa is known as an opportunistic pathogen frequently causing serious infections. multidrug resistance in this bacterium is increasing worldwide and poses a major problem in the treatment of infections due to this microorganism. analysis of resistance profile to antibiotics of p. aeruginosa helps to establish a prompt control and prevention program. the aim of this study was to evaluate epidemiological profile and antimicrobial resistance of p. aeruginosa isolates in a trauma and burn center. patients and methods: retrospectively, we studied all p. aeruginosa isolates over a -year period (from january to december ). conventional methods were used for identification. antimicrobial susceptibility testing was performed with disk diffusion method and susceptibility results were interpreted using clinical breakpoints according to ca-sfm guidelines. data were analyzed using the sirsystem. minimum inhibitory concentration of colistin was determined using the e-test ® method (biomérieux), then using the eucast broth micro-dilution method (umic, biocentric ® ) since may . results: during study period, non-repetitive strains of p. aeruginosa were isolated, representing % of all isolates. in our center, infections due to p. aeruginosa were endemic with epidemic peaks. p. aeruginosa was mainly isolated from burn intensive care unit ( . %) and anesthesiology department ( . %). the most frequent sites of isolation were skin samples ( . %), blood cultures ( . %), catheters ( . %) and urines ( . %). the survey of antibiotic susceptibility showed high percentage of resistance to the different antibiotics: . % of strains were resistant to ceftazidime, % to ticarcillin, . % to pipercaillin-tazobactam, % to imipenem, . % to ciprofloxacin and % to gentamicin. resistance to colistin was rare. it concerned only four strains, isolated from burn patients. the survey of antibiotic susceptibility evolution have shown a global increase of resistance to commonly prescribed antibiotics between and : from % to . % to imipenem, from . to . % to ticarcillin-clavulanate, from . % to % to ceftazidime and from . to % to gentamicin. whereas ciprofloxacin resistance rate have decreased from . to %. antibiotic resistant strains were mainly isolated from burn intensive care unit, with % of resistance to imipenem and . % to ceftazidime. the dissemination of multidrug-resistant strains of p. aeruginosa in our center must be contained by the implementation of strict isolation methods and better hygienic procedures. compliance with ethics regulations: yes. acinetobacter baumanii: therapeutic impasse sabah benhamza, mohamed lazraq, abdelhak bensaid, youssef miloudi, najib el harrar réanimation de l'hôpital du août, casablanca, morocco correspondence: sabah benhamza (benhamzasabah @gmail.com) ann. intensive care , (suppl ):p- rationale: acinetobacter baumanii (ab) is frequently responsible for nosocomial infection in the intensive care units, and its resistance to antibiotics continues to increase. the objective of our study is to determine the epidemiological profile and antibiotic sensitivity of isolated bacteria in the intensive care unit august , in order to optimize the probabilistic antibiotherapy of bacteremia in intensive care. patients and methods: this is a retrospective study performed in the intensive care unit of the hospital august , , spread over a period of years from january to january . results: the incidence of ab infection in our department was . % for all patients admitted to intensive care. the average age was years ± , male predominance (sex ratio . ). the average time to onset of infection was days. during the study period, ab strains were isolated, % of which were pulmonary, % blood, and % urinary. resistance to c g reached % in , % in and % in . for imipenem resistance was % in , % in , % in . for amikacin, resistance was % in , % in , and % in . for fluoroquinolones resistance was % in , % in and % in . cotrimoxazole resistance was around % in the last years conclusion: the resistance of ab to antibiotics has reached very alarming levels, especially for carbapenems. this requires resuscitators to change their antibiotic prescription behavior and to invest in the prevention of nosocomial infections. compliance with ethics regulations: yes. this is a prospective observational study conducted at the ed during the period of year. data of all patients admitted with suspected infection of any cause were collected. poor outcomes were defined as death and transfer to an icu within h. results: during the study period, a total of patients with a mean age of ± were included. % were male. within h of management in the ed, % of patients were transferred to the icu and % died. independent predictors of icu-transfer and death included low systolic blood pressure, fever and tachycardia. a prediction model containing these independent predictors had a good predictive accuracy with an area under the curve of . ( % ci . - . ). sensitivity was %, specificity %, positive predictive value % and negative predictive value %. conclusion: assessing readily available clinical variables at arrival to the ed can aid in predicting poor outcomes. [ ] [ ] [ ] [ ] [ ] [ ] . the most common co-morbidities were chronic respiratory failure (crf, n = ) and hypertension (n = ). respiratory distress (n = ) and coma (n = ) were the major indications for iv. us diaphragmatic exploration was performed at a median delay of iv at days [ ] [ ] [ ] [ ] [ ] [ ] . % of patients received sedation and . % received neuromuscular blockers. the ventilator mode was control volume in patients via endotracheal tube (n = ) and tracheostomy cannula (n = ). no major incident was detected during the turning of patients. both tid and ted decreased from the sp to the pp (fig. ) : tid (mm) ( in sp vs. . in pp, p = . ), ted (mm) ( . in sp vs. in pp, p = . ). the observed dtf was lower in the pp but without significance ( . vs. . %, p = . ). no difference was showed when the comparison between sp-dtf and pp-dtf was adjusted on the ventilator mode, obesity, neuromuscular blockers and crf. the positioning in pp in ventilated patients reduces both tele-inspiratory and tele-expiratory diameters of the diaphragm but not altered its contractile function. compliance with ethics regulations: yes. significance was considered at p < . . results: results are presented in the table below. discussion: nebuliser type influences the efficiency of aerosol delivery, with the vmn delivering a significantly higher % aerosol dose than the jn at the two circuit positions (p = . on inspiratory limb; p = . at the dry side of humidifier). in agreement with previous reports using bias flow, for both nebulisers, the location within the circuit has a significant effect, with the nebuliser on the dry side of the humidifier delivering more aerosol than on the inspiratory limb (p = . for vmn; p = . for jn). conclusion: for a mechanically ventilated adult tracheotomy patient, the type of nebuliser and the location of the nebuliser within the circuit influences aerosol delivery. rationale: automatic tube compensation (atc) is a mode available in most icu ventilators. it compensates for the resistive pressure into endotracheal tube/tracheostomy canula by continuously providing a pressure assistance based on internal diameter of a new endotracheal tube/tracheostomy tube. its use in icu is unclear. we designed a survey to further explore this. patients and methods: the survey was endorsed by the acute respiratory failure section and the clinicaltrials group of the european society of intensive care medicine (esicm). the pool was sent out via an email on june to the esicm members worldwide. the following closed questions were: country, years in icu, kind of icu, kind of hospitals, kind of respirators, atc use (never, always or in some patients), reasons to or not to use atc, ventilatory mode in which atc was used. the database was frozen on august st after two reminders. we used the gross national income per capita (usd) provided by the world bank to transform the respondent's country into a geographical-economical variable with levels: high-europe, high-noneurope and middle ( ) . atc use was coded as yes or no. the primary end-point was atc rate of use and the hypothesis was that less than % of the respondents do use it. variables were expressed as counts. groups were compared by chi square test. a logistic regression analysis was performed to explore the contributing factors to atc use. we received responses without any doublons, of which six were empty, from countries. four-hundred and nine respondents used atc always or in some patients ( % atc rate of use). this rate was not different between economical-geographical regions, icu, hospitals and years in icu. for those respondents who did not use atc the reasons were: atc mode not available in icu ventilators ( . %), atc not helpful mode ( . %), atc not known ( . %) and atc provides too much pressure assistance ( . %). for those respondents who used atc the reasons were: helpful in weaning ( . %), set by default ( . %) and physiological benefit ( . %). they used atc during spontaneous breathing trial ( . %), with any assisted mode ( . %) and with specific modes ( . %). we found no risk factor for atc use in the logistic regression model (fig. ) . the atc rate of use was unexpectedly high in this survey. this may result from respondents selection bias or from an a priori underestimation of its use. compliance with ethics regulations: yes. rationale: during pressure support ventilation (psv), adjusting the level of assistance mainly aims at maintaining the patient's respiratory effort within a normal range. however, respiratory effort measurement is impeded in clinical routine by the need of esophageal pressure recording. in this study, we evaluated the accuracy of assessing the respiratory effort from the flow and airway pressure signals using several machine learning algorithms based on the equation of motion of the respiratory system. patients and methods: using the asl simulator (ingmar medical) connected to a pb ventilator (medtronic) set in psv, we simulated a massive number of different respiratory cycles. each simulated cycle represented a unique combination of compliance and resistance of the respiratory system, duration and intensity of the muscle pressure (pmus), positive end-expiratory pressure (peep) and pressure support levels. using least squares regression methods, the flow waveform was fitted according to the equation of motion of the respiratory system to determine the compliance and resistance of the respiratory system, and the pmus. the hypothesis used (alone or in combination) to constrain the system were: linearity of pmus at the onset of the inspiratory effort, nullity of pmus at the end of insufflation, and nullity of pmus during expiration. thus, nine methods were built and tested. calculated and actual peak pmus values were compared using the bland-altman method. the nine methods of pmus assessment were evaluated using different simulated cycles. by limiting the analysis to selected cycles with a predefined applicability criterion (intrinsic peep less than cmh o), a limited inspiratory effort (peak pmus less than cmh o) and a high quality of fitting (r > . ), the method using the three hypothesis together to constrain the system was characterized by a bias of . cmh o and limits of agreement of - . and . cmh o. however, when widening the analysis to all the simulated conditions, no method allowed an accurate estimation of the peak pmus : the best one exhibited a bias of - . cmh o and limits of agreement of − . and . cmh o. conclusion: among the nine machine learning methods tested, some provided an accurate estimate of the respiratory effort in selected cycles but none allowed such accuracy across all simulated conditions. this incites to assess automated methods using a more complex physiological and physical model. compliance with ethics regulations: not applicable. rationale: there is a growing interest in esophageal pressure monitoring in mechanically ventilated patients. esophageal pressure can be measured with a specific nasogastric catheter equipped with esophageal balloon and connected to a pressure transducer. it is used as a surrogate for pleural pressure and may be considered as a corner stone in advanced care of ventilated patients to better assess lung and chest wall mechanics and easily detect patient-ventilator asynchronies. however, this promising technique is still seldom used in clinical practice. trained icu nurses may perform oesophageal pressure measurements which may help facilitate its implementation in the usual patient care. this study aimed at assessing whether a specific educational program to train nurses to perform esophageal pressure monitoring allowed reliable measurements. this was a prospective monocenter study performed in an academic icu. written informed consent was obtained from the nurses before inclusion in the study. the specific educational program consisted of a -min online theoretical course, a -h group theoretical teaching and a -min simulation training on a mannequin. then each participating nurse performed three esophageal pressure measurements (using nutrivent ® catheters and an icu monitor connected to arterial line pressure transducers system) on three different mechanically ventilated paralysed patients under supervision. a knowledge assessment was performed with a short written mcq test. the skill evaluation was by two trained experts. concretely the trained nurses performed an esophageal pressure measurement without assistance. their ability to control the esophageal balloon position by an occlusion test, to measure the inspiratory and expiratory airway and transpulmonary pressures and to calculate of respiratory system, lung and chest wall compliances was assessed at the bedside using a standardized evaluation form. we present here the preliminary results of the first nine included nurses. the written knowledge assessment was considered as rationale: several modalities of ventilatory support have been proposed to gradually withdraw patients from mechanical ventilation. we conducted this study to compare t-piece and pressure support ventilation (psv) ( cmh and peep ) in the process of weaning of mechanical ventilation in burns. patients and methods: it was a prospective randomized trial in burn icu in tunisia during months. mechanically ventilated patients who met standard weaning criteria were included [ ] . patients were randomized into two groups: group under t-piece and group under psv. duration of the test: - min. the tolerance of the vs test should be judged on clinical criteria. stopping the test if occurred: agitation, tachypnea > cycles/ min, tachycardia > / min, spo < %. successful withdrawal was defined as the ability to maintain spontaneous respiration for h after extubation. results: thirty patients were included, randomized into two groups. the mean age was ± years with a ratio sex of . the average tbsa was ± %. the cause of mechanical ventilation was essentially a face neck burned ( %). the following table shows the weaning outcome of both modalities. eighty percent of succeeded extubation for both groups (n = / ). the cause of failure of extubation was secretion retention and clutter in majority of cases followed by neurological and cardiac distress. the duration of mechanical ventilation does not influence the outcome of the weaning test (p < . ), with a mean of duration of ± days. conclusion: our study did not show any difference between the two weaning modalities in the matter of outcome of extubation. the choice of weaning test of mechanical ventilation is to be judged by the clinician according of the state of his patient. compliance with ethics regulations: not applicable. rationale: when expiratory tidal flow does not go up after increasing expiratory driving pressure expiratory flow limitation (efl) occurs. it is thought that efl heralds airway closure (ac). we investigated the role of chest wall elastance (ecw) in both efl and ac in acute respiratory distress syndrome (ards) patients. our hypothesis was that the lower the ecw to lung elastance (el) ratio the higher the likelihood of efl and ac. patients and methods: twenty-five moderate to severe ards patients were prospectively included in two centers. mechanical ventilation was delivered in volume-controlled mode with tidal volume ml/kg predicted body weight at positive end-expiratory pressure cmh o in semi-recumbent position. airway (paw) and esophageal (pes) pressures and flow were continuously recorded during min by a data logger (biopac ). then, end-expiratory and end-inspiratory occlusions were performed for s, then respiratory system was slowly inflated at constant flow. finally, patient was allowed to breathe out freely to atmosphere by using a three-way stop lock by-passing expiratory valve. ac and airway opening pressure (aop) were determined according to chen et al. ( ) . efl was assessed by the atmospheric method ( ) . dynamic elastance of chest wall (edyn,cw) and lung (edyn,l) were obtained from least square linear regression method over consecutive breaths. static elastance (est,cw and est,l) were determined by classic formulas and also by taking into account aop (est,cw_aop and est,l_aop, respectively). the performance of ecw/el ratio to predict efl and ac was assessed by the area under receiver operating characteristic (aucroc) curve. results: efl was observed in patients ( %) and ac in ( %). median aop was . cmh o ( % ci . - . ) . aucrocs for ecw/el ratios to detect efl and ac are shown in table . edyn,cw/edyn,l ratio was better to detect efl than est,cw/est,l ratio with edyn,cw/edyn,l ≤ . % sensitivity and % specificity. correction for aop made the performance of est,cw/est,l ratio as good as that of the edyn ratio. ac was poorly predicted by edyn and est ratios but its prediction greatly improved with aop correction. however, with the est,cw/ est,l_aop the critical ratio was . (sensitivity %, specificity %) and . (sensitivity and specificity %) for predicting efl and ac, respectively. conclusion: efl and ac are frequent in ards at peep cmh o. edyn,cw/edyn,l ratio lower than best predicted efl occurrence. once ac is taken into account est,cw/est,l ratio greater than accurately predicts ac. efl and ac are two distinct phenomena. compliance with ethics regulations: yes. rationale: anesthesia outside the operatingroom (aoor) in a pediatric environment was giving increasingly increasing indications and a lot of progress because of its interest in carrying out diagnostic and/or therapeutic explorations: % of the acts of anesthesia are performed outside the operating room. the objective of our study is: to clarify the importance and the frequency of the practice of the ahbo, to define its particularities, as well as an evaluation of the ratio: benefit/risk in order to reduce the morbidity and mortality. patients and methods: we report in this study the experience of the service of the resuscitation mother-child on the gestures of aoor. this is a prospective observational study, spread over a period of months: from / / to / / , dealing with acts performed for endoscopic digestive and bronchial procedures, cures in dermatology and radiotherapy, and medical imaging (ct and mri). results: of the procedures performed: were performed for ct, for mri, for arteriography and for endoscopic digestive procedures, for bronchoscopies, for radiotherapy treatments, for laser treatments in dermatology. anesthesia techniques use intravenous induction in % of cases using: hypnotics (propofol, midazolam, ketamine), morphine (remifentanyl, fentanyl), inhalation induction in % of cases (sevoflurane, halothane) and curare for cases of bronchoscopy (rocuronium). this anesthesia was marked by the occurrence of accidents in order of frequency: cardiac in % of cases (tachycardia, hypotension and rhythm disorders), and then respiratory in % of cases. the most serious accidents were admitted in reality and are represented by cases, of which required an intubation (bronchoscopy), a case of cardiorespiratory arrest recovered, cases of severe hypoxia associated with bradycardia and which required the ventilation with the mask (radiotherapy), and cases of bronchospasm requiring the deepening of the anesthesia (absence of tci). a good knowledge of the patient and the intervention, and difficulties specific to each specialty is necessary, as well as a preanesthetic consultation. the aoor must obey the same safety rules as in the operating theater and that in terms of: equipment, monitoring (integrate the capnograph to respiratory monitoring whenever deep sedation and when the continuous control of vas is difficult), anesthetic technique (tcbi) and post-procedure wakefulness management that must meet the same requirements as the sspi, especially for prolonged sedation. compliance with ethics regulations: yes. umbilical vein catheterization through wharton's jelly: a possibility for a fast and safe way to deliver treatments in the delivery room? suzanne borrhomée hôpital rené dubos, france correspondence: suzanne borrhomée (suzanne.borrhomee@gmail. com) ann. intensive care , (suppl ):p- rationale: a fast and safe venous access can be a critical issue in the delivery room during neonatal cardiopulmonary resuscitation, or before endotracheal intubation. here, we describe a new method to inject drugs using the umbilical vein, directly punctured through wharton's jelly. this method was performed in newborns between november and may . umbilical vein was identified and punctured easily and a reflux was obtained in all patients. the first step was antisepsis, and then the umbilical vein was punctured. the puncture was made approximately to cm above the navel. after checking for blood reflux, the nurse injected the treatment. the cannula was left in the vein during the injection and removed as soon as the intervention was over (intubation was performed, or the heart rate had increased). results: here, we report ten cases of emergency injection in the delivery room using this method: -four cases of cardiopulmonary resuscitation using this method to deliver epinephrine. cardiac massage was performed on all patients.-six cases of intubations in the delivery room using this method to administer the premedication. in all patients, the umbilical vein was identified easily. the equipment was the one usually used for venous injection in our unit and was manipulated and handled with ease. venous access was obtained in a matter of seconds, and blood reflux was observed in all patients. the treatments were efficient in all but two patients, which was imputable to the method in one patient. discussion: although this method has been known in our nicu for several years, there has been no publication regarding this method in neonates. inserting an umbilical vein catheter in the delivery room has been validated for resuscitation but this technique is lengthy and requires some sterility conditions that makes it even longer, and thus non-fitting for an emergency tracheal intubation. our method is fast and can be performed easily with no specific training. the whole manipulation procedure, from the beginning of the puncture to the end of the flush-out takes to s. we only identified few specific risks related to this method, mostly infectious, and the risk of drug diffusion. we describe a new route for administration of drugs in the delivery room that was successfully used in nine neonates. umbilical vein needle catheterization is not only safe and efficient, but is also fast and easy to perform without any special training. compliance with ethics regulations: yes. rationale: liver transplantation (lt) is the only option for children with end stage liver disease. recent advances in surgical procedure and immunosuppression have permitted a better patient and long term graft survival. however, acute cellular rejection remains a frequent complication occuring in to % of the cases according to different studies. it is more likely to occur during the first weeks post lt. many predictive factors of acute rejection have been described in litterature and results differ from one study to another. pediatric studies regarding this topic are few. the aim of this work is to study acute cellular rejection prevalence in the days following lt and to determine predictive factors. rationale: sedation practices for pediatric magnetic resonance imaging (mri) are highly heterogenous. the main challenge is to keep children immobile while being alone in a traumatizing environment for a long time. clinicians have to ensure hemodynamic and respiratory stability in this isolated environment while minimizing sedation neurologic adverse effects. in this series, we report the potential usefulness, feasibility, efficacy and safety of dexmedetomidine sedation for pediatric mri. patients and methods: a single center retrospective review of six children sedated with dexmedetomidine for mri in an emergency context. all children were hospitalized in the pediatric intensive care unit of a university hospital at the time of mri. results: data on six patients aged months to years is reported. five patients received dexmedetomidine by intravenous route (bolus of - µg/kg over min, followed by a continuous infusion of µg/ kg/h). one child received dexmedetomidine by intranasal route ( µg/ kg with atomization device). one child experienced bradycardia that did not require any intervention. very few movements were recorded during the mris for which images were rated as good quality. conclusion: dexmedetomidine seems a promisingly useful sedation agent for pediatric mri, thanks to its efficient sedative properties and good tolerability without respiratory compromise. compliance with ethics regulations: yes. rationale: computational models, or virtual patients, could be used to teach cardiorespiratory physiology and ventilation, determine optimal ventilation management as well as forecast the effect of various ventilatory support strategies. currently, there is no virtual patient specifically designed for modelling children cardiorespiratory system. thus, our research team has developed a cardiorespiratory simulator for children called "simulresp©". according to summers et al., the quality of a physiologic model is evaluated by three specific criteria: qualitatively, which relates to the model's ability to provide directionally appropriate predictions; quantitatively in steady states and in dynamics, which is the ability of the model to provide accurate predictions in steady state situations as well as dynamic transitions. the purpose of this study was to evaluate the quality ofsimulresp© according to these criteria. this study consisted in a prospective evaluation of the simulresp©'s predictions with simulated healthy subjects. the tests were performed with patients from to years old ( , , , , , years), with different characteristics; gender (m, f) and weight ( th, th and th percentile). blood gas values (ph, pco , po and spo ) were simulated for several virtual healthy patients with different characteristics. this study was conducted for both spontaneously breathing and mechanically ventilated patients. simulresp©'s quality and reliability were evaluated in terms of accuracy, robustness, repeatability and reproducibility. results: simulresp©'s validation procedures are ongoing. we intend simulresp© to be accurate when simulating healthy spontaneously breathing patients. but we hypothezised that simulresp© would not be able to simulate accurate blood gas values of mechanically ventilated patients conclusion: simulresp© is a promising computational model that will serve to perform calibration and validation procedures of clinical decision support systems and help clinican to determine optimal respiratory support strategies at bedside. further calibration procedures are yet required. compliance with ethics regulations: yes. the isthmic surgical tracheostomy, which was performed in the operating room by otolaryngologist under general anesthesia. the cutaneous incision was transversal in all cases.the choice of the cannula was adapted to the age, and the decanulation was carried out according to the evolution of the underlying disease. complications associated with tracheotomy are diverse, and common complications are such as careassociated pneumonia ( . %), tracheostomy tube obstruction ( . %), accidental decannulation ( . %), pneumothorax ( . %) and cases of tracheal stenosis ( . %). the mortality rate amounted to . %, where in most cases was due to the poor prognosis of the underlying diseases. the main factors of evolution are the patient's previous condition, cranial trauma, guillain-barré syndrome, tracheostomy time, prolonged tracheal intubation and the presence of complications. conclusion: regardless of the indication, the tracheotomy is an act of survival whose usefulness and effectiveness are certain. rationale: aspiration pneumonia (ap) is a frequently suspected complication of drug overdose requiring mechanical ventilation (mv) and admission to intensive care unit (icu). in the absence of reliable biomarkers for distinguishing between aspiration pneumonia and aspiration pneumonitis, antibiotic therapy is frequently prescribed. latest studies suggest that a care protocol could better select patients requiring antibiotic therapy. the objective was to determine the impact of a care protocol on the antibiotic prescription among patient admitted to icu for toxic coma with mv. we conducted a prospective observational cohort study in four icu. we included all patients admitted for toxic coma with mv. in the university-affiliated icu, a care protocol was applied. in the three others icu, physicians declared that they did not follow formalized conduct within the service and did as usual. results: we included patients in care protocol group and in control group. the mean saps ii was . (± . ) with a mean glasgow coma scale score at . (± . ) before intubation. within the total population, patients ( %) had a pulmonary bacteriologic sample (pbs), mostly because purulent tracheobronchial aspirate and new infiltrates on the chest x-ray (respectively . % and . % of the population with a bacteriological sample). among the patients with a bacteriological sample, ( %) were culture positive. the incidence of probabilistic antibiotherapy did not differ between the care protocol group (n = ) and the control group (n = ) . there was no difference for the incidence of pbs ( in each group). the others secondary outcomes did not differ either (table ) . conclusion: our study does not show that a care protocol allows a reduction of antibiotic prescription among patient admitted to icu for toxic coma with mv. our incidence of antibiotic prescription is lower than the previous studies. the absence of difference can be explain by two reasons: some of the physicians of the control group had been trained in the university-affiliated icu in the last years and may follow a management approach similar to that of the control group; despite our precautions, the existence of the study could have modify the practices in the control group. compliance with ethics regulations: yes. rationale: pancreatic surgery is associated with high morbidity, mostly due to infectious complications, so that many centers introduce post-operative antibiotics for all patients. such systematic prescriptions are not consensual and often rely on local practices. the aims of the study were to describe the occurrence of surgical site infection (ssi) and the antibiotic (atb) prescription after pancreatic surgery, and to determine the risk factors of post-operative surgical site infection, in order to better define the clinical indications for the prescription of antibiotics after major pancreatic surgery. patients and methods: all patients undergoing a scheduled major pancreatic surgery from january to november were included in the study. patients were classified in four groups according to the occurrence of a surgical site infection and to the post-operative antibiotic prescription as follows (ssi+/atb+; ssi-/atb+; ssi+/atb-, ssi-/ atb-). in addition, risk factors (fever and pre-operative biliary prosthesis) associated with the occurrence of a surgical site infection and with the antibiotic prescription, were analyzed using a logistic regression model. results: data from patients ( pancreaticoduodenectomies and splenopancreatectomies) were analyzed and classified as presented in the table. thirty patients ( . %) experienced a surgical site infection and ( . %) received post-operative antibiotics. we did not find any difference on post-operative antibiotic prescriptions ( . % versus . %, p = . ) between patients who developed a surgical site infection and those who did not. amongst the patients who were not prescribed antibiotics post-operatively, ( . %) did not develop a surgical site infection while ( . %) did. in-icu mortality did not differ between infected and non-infected patients ( versus %, p = . ). post-operative fever was different between ssi+ and ssi-( . versus . %, p < . ), while the prevalence of pre-operative biliary prosthesis was similar ( . versus . %, p = . ). amongst patients who did not develop a surgical site infection, antibiotic prescription was not associated with fever (p = ), but associated with a higher prevalence of preoperative biliary prosthesis ( . versus . %, p = . ). conclusion: non-systematic antibiotic prescription after major pancreatic surgery allowed to appropriately spare antibiotics in ( %) patients at the cost of under prescription in ( . %) patients. these results suggest that systematic post-operative antibiotic prescription could be excessive. fever appears to be a relevant clinical sign for individual-based prescription, whereas the presence of a biliary prosthesis does not. compliance with ethics regulations: yes. ( , ) . however, there is little evidence to support those recommendations ( ) . we aimed to describe care paths of pm with sepsis in french hospitals and to assess outcomes depending on their hospital trajectory. we conducted a retrospective analysis of the french medico administrative (pmsi) database of consecutive patients with pm and sepsis admitted to french hospitals, between and . only the first hospital admission was considered. cases were identified using a combination of a diagnosis code for pm plus a diagnosis code for organ failure or a procedure code for organ support. hospital trajectories were determined from the first admission to death or discharge, taking into account all potential transfers. costs and endpoints were determined at the end of patients' trajectories. five groups of patients were defined, according to care pathways: direct icu admission ( sticu); secondary icu admission, after initial admission to another unit including wards (ward ndicu) rationale: new-onset atrial fibrillation (af) is a common complication in patients with sepsis and is associated with increased mortality and morbidity rates. this condition results from a complex chain of events in response to infection, involving immunologic, humoral and cellular process and sympathetic overactivity. landiolol, the new injectable beta-blocker, with high beta selectivity and minimal impact on arterial blood pressure, may have beneficial effects in such a context. in this study, we aimed to investigate whether landiolol decrease the newonset of atrial fibrillation in a mice model of endotoxin-induced sepsis. patients and methods: thirty c bl/ male mice were randomly allocated to the following groups: sham (administration of µl of isotonic saline intraperitoneally-ip), septic (administration of µl of isotonic saline with mg/kg of lipopolysaccharide-lps-of e. coli o :b ip) and septic + landiolol (administration of isotonic saline with mg/kg of lps and, two hours later mg/kg of landiolol ip). four hours later, an attempt of af occurrence was triggered by a transesophageal electric pacing at fixed rate (as previously reported) in all mice previously anesthetized by isoflurane %. ekg was continuously recorded. results: ten mice per group (mean weight: ± g) have been included and analyzed. among the sham group the mean heart rate was at bpm versus bpm in the septic group. among the septic + landiolol group the mean heart rate was at bpm (p < , ). after transesophageal stimulation, none mice in the sham group had af, seven mice ( %) in the septic group had an af, and mice ( %) in the septic + landiolol group had an af. landiolol decreased the incidence of new-onset, sepsis-induced atrial fibrillation in mice (p = . ). conclusion: landiolol seems to have a protective effect against sepsis-induced af in mice. however, the mechanisms, including sympathetic activation and inflammasome pathways, should be investigated before drawn definitive conclusion regarding to efficiency of landiolol to prevent new-onset af during sepsis. compliance with ethics regulations: yes. - mg/l at or h, proportion of patients with a vancomycin serum concentration < mg/l, previously associated with resistance emergence and assessment of mortality and test of cure. results: a serum vancomycin concentration between - mg/l was reported in out of included patients ( %). a serum vancomycin concentration < ml/l and > mg/l were reported in patients ( %) and patients ( %), respectively. vancomycin serum concentrations during follow-up are shown in fig. . in multivariate regression analysis, a longer time between admission and initiation of vancomycin was the only parameter associated with a serum vancomycin out of this target, while acute kidney injury (aki) was associated with a lower incidence of subtherapeutic concentration. acute kidney injury rate was significantly higher in patients with a serum vancomycin concentration > mg/l. discussion: an adequate therapeutic target of serum vancomycin concentration was reached in % patients with nearly % < mg/l, which was similar to previous studies. aki and rrt requirement were higher in patients with serum vancomycin concentration > mg/l, whereas it is hardly to know whether it is a cause or a consequence. conclusion: these findings highlight the importance of a larger loading dose, vancomycin monitoring and measured creatinin clearance to improve vancomycin dosing protocol. compliance with ethics regulations: yes. rationale: suicide is a global phenomenon and one of the leading causes of death in the world. tunisia ranks second in the suicide rate in the maghreb, with . cases of suicide per , inhabitants. the aim of this study was to reconstruct the state of suicidal subjects before the act in order to identify their psychiatric profile. patients and methods: a -year prospective observational singlecenter ( -bed intensive care unit) study including all patients hospitalized for suicide attempt (sa). psychiatric evaluation of patients and contact with their families were done before intensive care unit discharge. results: seventy-one patients were enrolled with female predominance (sex ratio . ). mean age was ± years. familial or personal history of mental illness were found in ( %) and cases ( %) respectively. personal mental disorders were depression ( %), bipolar disorder ( %), schizophrenia ( %) and border line personality disorder ( %). twenty-five per cent had prior sa. sixty-three per cent were single, % married and % divorced. the common methods of suicide included drug ( %), chloralose ( %) and pesticide ( %) poisoning. mean igs ii and apache ii scores were ± and ± respectively. on admission, % of all patients were in coma, % had shock and % developed aspiration pneumonia. mechanically ventilation was done in % of all cases with mean duration of days. the mean length of stay in intensive care unit was days. mortality rate was %. psychiatric evaluation and contact with families deduced that the main precipitating factors for suicide were traumatic events. in fact: relationship problems (familial, marital or breakups), school failure and mourning were found in %, % and % of all cases respectively. reactional sa accounted for %. rationale: poisoning is a worldwide problem, associated with high morbidity and moratlity. in tunisia, the rate of fatal poisoning has been increasing in the last years, with emergence of new toxic substances. regardless of the toxic, fatal poisining is considered as a non natural death, that requires medico-legal investigation, to assess whether it is suicidial, crimnal or accidental death. this study aimes to determine the epidemiological characteristics of the cases of fatal poisoning in south, to identify the toxics used in oder to deduce the preventive measures. patients and methods: we conducted a retrospective study of all cases of fatal poisoning recorded in the forensic department of habib bourguiba university hospital in sfax, tunisia, over a -years period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . results: during the study period, cases of fatal poisoning were autopsied. the number of victims recorded per year varied between and cases with an average of cases per year. the average age was years with extrems ranging from months to years. nearly half ( . %) were younger than years. a male predominance was noted with a sex-ratio of . . the majority of victims were single, loweducated and from rural origin. personal antecedent of psychiatric pathology was found in . % of cases. psychotic disorders (schizophrenia) and depression were the most common pathologies. in our study we noticed that death occured every weekday without significant difference between days. however, the frequency of fatal poisoning was slightly higher in cold seassons ( . %). in . % of cases, victims were found dead at home. accidental fatal poisoning was the most common ( %). no criminal cases have been observed. we noted a male predominance in accidental forms and a female predominance in suicidal forms. carbon monoxide poisoning was the most common ( cases) followed by the organophosphorus poisoning which was noted in cases. conclusion: decreasing the mortality rate from poison ingestion requires increasing public awareness about poisons and improving emergency service equipment and health personnel training. compliance with ethics regulations: yes. severe acute poisoning by organophosphate pesticides: report of cases at the oran hospital and university center mourad goulmane hospital and university center of oran, oran, algeria correspondence: mourad goulmane (goulmane.mourad@univ-oran . dz) ann.intensive care , (suppl ):p- rationale: organophosphate pesticides are synthetic organic pesticides widely used in agriculture mainly as an insecticide, nemacid or acaricide. these are the agricultural products, the most incriminated in poisoning in our context. the objective of this work was to determine the clinical, paraclinical, and progressive characteristics of this poisoning in a resuscitation environment. patients and methods: retrospective study of cases admitted to intensive care (january -december ). inclusion criteria were clinical, para-clinical, therapeutic and progressive. results: cases were identified: women and men, mean age = . ± years. the suicide attempt was the main reason for the intoxication ( cases). the glasgow coma score averaged ± . the central syndrome was present in % of our patients, followed by muscarinic syndrome % and nicotinic syndrome in % of cases. therapeutic management consisted of mechanical ventilation in % of cases, the use of vasoactive drugs in % of cases and the administration of antidotal treatment in % of cases. the overall mortality was . %. conclusion: organophosphate pesticides intoxication is a real health problem in algeria. it is a serious condition dominated by the respiratory and neurological distress that causes most deaths. it concerns in our context especially young women who ingest the product for the purpose of autolysis. the diagnosis is based on the clinical and dosage of cholinesterase activity in the plasma. treatment combines symptomatic measures that rely primarily on respiratory and neurological resuscitation to antidotal treatment. the clinical course in this type of intoxication is generally favorable under treatment with regression of signs in a few days. mortality is high in our context, so it should be considered a diagnostic and therapeutic emergency. the commercial availability of these products is worrisome, justifying the use of a broad prevention program to inform the public and authorities of the danger of organophosphate pesticides compliance with ethics regulations: not applicable. . the clinical examination revealed that five patients met the criteria for serious intoxication with the following signs: coma in four patients requiring the use of mechanical ventilation, seizures (n = ), rhabdomyolysis (n = ), shock (n = ), toxic takotsubo (n = ) and hepatocellular failure (n = ) leading to patient's death. the use of mechanical ventilation was necessary in patients. the analysis of the severity factors did not show a statistically significant association between severity, age (p = . ), sex (p = ) and chronic consumption of psychoactive substances (p = . ). on the other hand, we did not find a statistically significant association between serious intoxication, the number of tablets ingested (p = . ), the apacheii score (p = . ) and the average length of stay (p = . ). conclusion: ecstasy acute poisoning is becoming more common in our country and can potentially be very serious regardless of age, sex, medical history or number of tablets ingested. on the other hand, the concentration of nmda could be the only factor to be taken into consideration upon admission. compliance with ethics regulations: yes. quarter of early trauma-related mortality, in some series. early identification of poor outcome predictors could be valuable to guide the most appropriate care. we aim to determine factors associated to mortality in patients with severe non-penetrating chest trauma admitted to the icu. patients and methods: this is a prospective cohort study, including all patients with isolated severe blunt chest trauma (abbreviated injury scale ais > ) admitted to the intensive care unit of a university hospital, over a one-year period. the primary objective was to analyse risk factors associated to death and poor outcome using univariate and multivariate analysis. results: one hundred-thirty patients were admitted to the icu for blunt chest trauma among them were diagnosed with severe isolated chest trauma and were included. the mean age was at ± , mean iss at ± and mean tts at ± . twenty-eight ( %) patients were diagnosed with acute respiratory distress syndrome, ( %) with post-traumatic acute kidney injury and fourteen ( %) with post-traumatic pulmonary embolism. the mean length of icu stay (los) was at ± days and mean number of days on ventilator was at ± days. thirty-two ( %) patients underwent elective tracheostomy for prolonged intubation. thirty-seven patients ( %) developed infections, among them thirty ( %) were diagnosed with pulmonary infection and seven ( %) with non-thoracic infections. overall mortality had an incidence of . % ( patients rationale: early hyperglycaemia in traumatic brain injury (tbi) is a part of the stress response. it is an important indicator of severity and a reliable predictor of prognosis. we aimed to describe the epidemiological, clinical and paraclinical characteristics and to assess the prognostic impact of this hyperglycaemia on the tbi. we conducted a retrospective study in the intensive care unit (icu) of our hospital between and . were included all patients with tbi and blood glucose > mmol/l at the first h post-trauma. results: during the study period, patients were hospitalized in our icu with tbi. early hyperglycemia (> mmol / l) was found in patients ( . %). in univariate analysis, glycaemia > . mmol/l (= mg/dl) at admission was significantly associated with mortality (p = . ). we observed that glycaemia > . mmol/l at h , > . mmol/l at h , > . mmol/l at h and > . mmol/l at h was significantly associated with mortality (p = . ; p < . ; p = . and p = . , respectively). the risk factors significantly associated with mortality were age > years (p < . ), saps ii > (p < . ), initial shock (p < . ), glasgow coma scale (gcs) < / (p < . ), coma period > days (p = . ). the ct scan lesions statistically associated with mortality were: subdural hematoma (p < . ), cerebral oedema (p < . ), intra cerebral haemorrhage (p = . ), cortical contusion (p = . ), contusion of cerebral trunk (p = . ), contusion of the corpus callosum (p = . ), thalamus contusion (p = . ). in multivariate analysis, independent risk factors statistically associated with mortality were age > years old (or = . ic [ . - . ]; (p = . )), glycaemia > . mmol/l at admission (or = . ic [ . - . ]; (p = . )),gcs < / (or = . ic [ . - . ]; p < . ), intracerebral hematoma (or = . ic [ . - . ]; p = . ). we recommend a mandatory control of the blood glucose levels during a tbi with a target between . and . mmol/l in the acute phase. compliance with ethics regulations: not applicable. the fat embolism syndrome (fes) is a set of clinical, biological and radiological signs resulting in the obstruction of microcirculation by micro-droplets of insoluble fats.the clinical signs of the fes are not very specific, the diagnosis is difficult and the risk of misunderstanding this syndrome is very real.the fes appears after a trauma, often few days later. however, it sometimes occurs without previous trauma; and it is particularly difficult to recognize in these cases. the aim of this work is to define the epidemiological profile, the clinical and para-clinical features of this syndrome and its therapeutic management. rationale: sedative and analgesic treatment administered to critically ill patients with mechanical ventilation need to beregularly assessed to ovoid complications of oversedation mainly in elderly patients. our objective is to evaluate our sedation practice in the elderlyin our unit patients and methods: it was a prospective observational study, including elderly patients over years of age without acute brain injury requiring sedation more than h of hospitalization in the intensive care unit of our university hospital between april and december . thirty patients were included. the aged was . years, the sex ratio was . . respiratory distress was the most common reason for hospitalization %. the most accepted diagnoses were the decompensation of copd in % of cases and septic shock in % of cases. the saps ii averaged ± points, sofa averaged ± . points. renal failure was found in patients ( %), hepatic impairment was noted in patients ( %), hypoproteinemia was marked in patients ( %). midazolam was used in % of patients. it was in combination with fentanyl in % of cases and remifentanyl in % of cases. the median ramsay score . ± . on the first day of sedation and . ± . on the second day of sedation. the median rass scale was − . ± . on the first day of sedation and − . ± . on the second day of sedation. the median bps scale . ± . on the first day of sedation and . ± . on the second day of sedation. the mean wake up time was ± , days. neuromyopathy of resuscitation was suspected in seven patients ( %), withdrawal syndrome was observed in two patients ( %) and acute cognitive dysfunction in two patients ( %). the median duration of sedation was . days ± . days, the median duration of mechanical ventilation was . ± . days, the median length of stay was . ± . days. ventilator-associated pneumonia was diagnosis among % of patients. the mortality in intensive care was %. conclusion: sedation analgesia in the elderly person should be adapted according to age, ideal weight and renal and hepatic function by decreasing the initial doses. it should be evaluated by the recommended scores by setting a sedation objective according to the pathology. compliance with ethics regulations: not applicable. rationale: more than original articles are newly indexed in pub-med every day. journal club (jc) is one way to cope with this abyssal amount of medical information. we aimed at ( ) describing journals and articles analyzed during our jc sessions ( ), reporting the proportion of published articles being analyzed during jc sessions and ( ) assessing the clinical impact on our daily practices for each journal. patients and methods: a retrospective analysis of prospectively collected data over a -year period from to in a universityaffiliated icu. jc sessions were scheduled weekly and participants were free to choose and expose orally an article recently published in any medical journal (general, icu or non-icu specialized). clinical impact of a journal was retrospectively and independently assessed by two attending intensivists (dc, hm) and was defined by the ratio of articles considered as having a direct impact on our daily practices over the number of articles of the same journal read during the same period. results: from august to august , jc sessions were held and articles-mostly original (n = / ; %)-from journals were analyzed, accounting for . % of the articles ( . % of the original articles) referenced in pubmed during the same period. median number of articles exposed per session was [ ] [ ] [ ] [ ] . median number of doctors attending each session was [ ] [ ] [ ] (attendings: [ ] [ ] , fellows: [ ] [ ] , residents: [ ] [ ] ). general, icu and non-icu specialized journals accounted for %, % and % of the exposed articles, respectively. most of the reported articles dealt with intensive care (n = , %) especially infectious diseases (n = / ; %), hemodynamics (n = / ; %) or icu-organization (n = / ; %). compared to general and non-icu specialized journals, the proportion of read-over-published articles was higher for icu-specialized journals ( . % vs. . % vs. . %, respectively; p < . ). among original articles, only ( . %) [interventional (n = / ; %); observational (n = / ; %) studies] were considered as having a clinical impact on our daily practices. compared to icu and non-icu specialized journals, general journals had a higher clinical impact ( . % vs. . % vs. . %, respectively; p = . ). data regarding the most read general, icu and non-icu specialized journals are detailed in table . in a french university-affiliated icu with regular jc sessions, the proportion of read-over-published articles and the clinical impact of medical journals appear minor. in the ocean of medical literature, general medical journals appear more worth reading by intensivists than icu-specialized journals. compliance with ethics regulations: yes. rationale: the world's population is aging and the and over's age group is growing fast (+ . % per year). this aging population is impacting intensive care units with exponential rates of elderly patients ( . % in , % in ) , associated with significant mortality (from % to %). the evolution and the prognostic factors of these elderly patients in intensive care are therefore a public health issue for optimal management. patients and methods: we included all patients aged and over who were operated and admitted to surgical resuscitation in our center, with a duration of stay greater than h, from april to july . the data collected were: general characteristics of this population, mortality in intensive care, at day and at months and the prognostic factors guiding their evolution in intensive care and at months. results: of the patients included in our study, mortality was . % in intensive care, . % at day and . % at months. the prognostic factors in the intensive care unit were the average dose of noradrenaline at day (threshold at . mg/h), the sofa score at day (threshold at points) and the igs score (threshold at points). the prognostic factors at months were ventilatory autonomy on day (spontaneous ventilation, non-invasive ventilation, invasive ventilation), the reason for admission to intensive care (acute respiratory distress or septic shock) and the fragility score (clinical failure scale with a threshold at ). conclusion: the mortality of patients aged and over is influenced by prognostic factors easily obtained daily at patient's bed. these prognostic factors could be an aid for the resuscitation teams to evaluate the relevance of the care undertaken in elderly or even very elderly patients admitted in an acute situation. compliance with ethics regulations: not applicable. assessing patient safety culture perception in the intensive care unit in tunisia oussama jaoued, chaoueh sabrina, sik ali habiba, wael chemli, gharbi rim, fekih hassen mohamed, elatrous souheil hôpital taher sfar, mahdia, tunisia correspondence: oussama jaoued (oussamajaoued@gmail.com) ann. intensive care , (suppl ):p- rationale: in tunisia health care system, patient safety has become a priority of quality assessment. the aim of our study was to describe the safety culture perception of the intensive care unit staff. patients and methods: the safety attitude questionnaire (saq-icu) was distributed to all intensive care unit staff by email. the questionnaire explores safety culture domains: "team work", "safety climate", "job satisfaction", "stress recognition", "perception of the hospital and intensive care unit management" and "work condition". results: eighty participants responded to the questionnaire, % of them were women. participants were doctors in . %. the coordination between physicians and nurses was very good only in %. thirtynine participants thought that the workload was high and % like their work. medical errors are handled appropriately in % of cases and it was difficult to discuss errors in % of cases. the hospital is a good place to work in % of participants, % of participants were less effective at work when there were tired. the hospital did a good effort of training new personal in % of cases. the number of medical staff was lower than expected in % of cases. half of participants would feel safe being treated as patients in their respective units. all domains explored by saq-icu could be improved according to attendants. conclusion: safety culture perception among intensive care unit staff had several deficiencies, mainly the working conditions, the ignorance of medical error reporting procedures and the lack of communication. rationale: the simplified acute physiology score ii (saps ii) is an icu scoring system used to predict the mortality risk in patients presenting at the icu. however the majority of critically ill patients present initially at the ed and their transfer to the icu may be delayed for hours. therefore, the ability to accurately assess mortality risk at ed may have a great impact. the purpose of this study was to evaluate the performance of saps ii in predicting early and late mortality in ed patients. patients and methods: this prospective study was conducted at the ed during a -month period. data for adult ed patients were evaluated. saps ii score was used to predict early and late mortality rates at -h and -day respectively. discrimination was evaluated by calculating the area under the receiver operating characteristic curve (auroc). results: during the study period patients were enrolled. the mean age was ± years, % of the patients were men. the mean saps ii was . the early mortality rate was % and late mortality rate was %. saps ii was efficient in predicting early mortality, with an auroc of . ( % ci . - . ). however, it demonstrated no value in predicting late mortality with an auroc of . ( % ci . - . ) conclusion: in this study, saps ii score was accurate in predicting early mortality, however this tool appears less suitable for predicting late mortality. compliance with ethics regulations: yes. oussama jaoued, chaoueh sabrina, sik ali habiba, yosri ben ali, fekih hassen mohamed, elatrous souheil hôpital taher sfar, mahdia, tunisia correspondence: oussama jaoued (oussamajaoued@gmail.com) ann. intensive care , (suppl ):p- rationale: the aging of the population increased the number of hospitalizations in icu. the aim of our study was to determine the impact of hospitalization of patients over the age of on morbi-mortality and consumption of care (omega score). patients and methods: this is a retrospective study carried out in the icu in the hospital of taher sfar in mahdia over a period of years. all patients hospitalized in the icu were included in this study. two groups of patients were individualized: g : patients over years old, g : patients under years old. results: during the study period, patients ( < years old and ≥ years old) with a mean age ± years and with a mean sapsii ± were included. the common reason for hospitalization was acute respiratory failure in % of cases. comparing the two groups, the severity score sapsii was higher among patients older than years ( ± vs ± , p < . ). the use of mechanical ventilation was more common in the first group ( % vs. %, p < . ). the incidence of nosocomial infections was similar in both groups ( % in the group g and % in group g , p = . ) and the use of renal replacement therapy was also similar in tow groups ( % in the g group and % in the g group, p = . ). the duration of mechanical ventilation and length of stay were similar between the two groups. workload evaluated by the omega score was higher in the first group ( rationale: icu outcome depends on quality of pre-icu care. we aimed to assess the chain of care of deteriorating ward patients (dwp), through evaluation of preadmission severity and delays before admission, and association with outcome. patients and methods: retrospective observational study in a single center ( beds general hospital) for year-may th of to . all adult patients admitted in the icu from the wards were included, except for scheduled surgery, or unexpected event in the operative theater. preadmission severity was assessed through levels of national early warning score (news ): group with news inferior to , group with news between and , and group with news superior to . these scores were established from vital signs during the h before icu admission. patterns of patients, including sofa and saps , knaus index, charlson comorbidity score, cause of admission and technics used in the icu, length of stay in the icu and in the hospital, limitations of life-supporting care, and mortality at and days after icu stay. satistical analysis was performed through chi and fisher tests on qualitative parameters, and with kruskal-wallis, student and mann-whitney tests for quantitave data. results: sixty-eight patients were studied: in group , in group and in group . most patients (all except ) had not respiratory rate monitoring before icu admission. icu mortality was associated with rising preadmission severity (group : . %; group : . %; group : . %). base patterns (charlson comorbidity score, knaus index) did not differ between the groups, and . % of patients presented with sepsis. main causes of admission were respiratory ( . %), hemodynamic ( %) or neurologic ( . %) failures. all patients admitted after cardiac arrest resuscitation ( patients) belonged to group . acute severity scores (sofa and saps ) followed preadmission severity. limitation or withdrawing of life support in the icu was higher in group ( . %) than in groups ( %) and ( . %) . median delay between first news equal or superior to and icu admission was h, and h between news equal or superior to . diffrences in delays were not associated with outcome. discussion: our study outlines weaknesses in the chain of care of dwp. emphasis should be put on respiratory rate monitoring and better assessment of severity. rationale: access to critical care is controversial in older patients for reasons: lack of available icu-beds and speculation on induced costs. in contrast, admission of young patients aged or under is infrequently questioned even though they develop catastrophic multiple-organ failure requiring full care. in addition, emotive reaction triggered in staff by these patients often represents a heavy psychological burden when icu-stay is < h. information on the epidemiology, clinical information and induced costs regarding such patients is lacking. patients and methods: this study retrospectively assessed the records of patients aged or under, and admitted from january to august . cost-related expenses charged to care-payers were obtained from our medical information department. data (number, percentages or medians) were reported and discussed by comparison with those of nonagenarians during the same period. results: of , icu-admissions, were aged or under ( %), of whom ( . %) died within the icu, with ( %) dying within h of admission despite full intensive care. the latter represent our study population ( . % of the screened population). the median age was . years , male gender was prevalent ( %). half the patients (n = , %) were referred from the emergency department, ( . %) from hematology, from oncology ( . %), from medical intermediate care units ( . %), and one from digestive surgery ( . %). the first diagnosis at admission was septic shock (n = , . %), followed by post-anoxic encephalopathy (n = , . %), coma (n = , . %), acute respiratory failure (n = , . %) and cardiogenic shock (n = , . %). sapsii was . all patients were ventilated and infused norepinephrine. two patients underwent ecmo, and others mars. mean (± sem) retribution per stay was , ± €, and mean retribution per "day of stay" €. discussion: full care of these icu-patients, with early mortality has a financial impact similar to that of nonagenarians at , ± , €; the cost per "day of stay" is therefore on average % higher than that of nonagerians (mean length of stay: . days), and, in our experience, % higher than that of average patients. conclusion: icu-patients aged or under represent a small percentage of admissions and display half our overall mortality: one third of them die within h of admission with a not insignificant financial impact for cost-payers. septic shock is the first cause of referral, followed by unexpected cardiac arrest. compliance with ethics regulations: yes. rationale: severity scores in patients with sepsis are useful for triaging and predicting mortality. mortality in emergency department sepsis (meds) score is validated in patients with sepsis in the emergency department. curb- is validated in patients with communityacquired pneumonia but not in sepsis. curb- is a simple bedside tool that has many common elements with new sepsis identification score-q sofa. the study aimed to assess the accuracy of curb- score in predicting icu admittance and mortality compared to meds score. patients and methods: this prospective study was conducted at the ed during a -month period. we enrolled all adult patients with sepsis admitted to the ed. meds and the curb- scores were calculated at admission. patients were studied using curb- score and their icu admission and in-hospital mortality were ascertained. results: a total of patients were enrolled. the mean age was ± years. % of the patients were men. % of patients had a curb- score ≥ points with a mean meds score of %. among these patients, % were admitted to icu and % died. the curb- score,was efficient in predicting both icu admittance and in-hospital mortality with an auroc of . ( % ci . - . ) and . ( % ci . - . ), respectively. conclusion: a higher curb- score was correlated with higher rates of icu admittance and mortality in patients with sepsis due to any cause. compliance with ethics regulations: yes. abderrahim achouri, hadil mhadhbi, khedija zaouche, hamida maghraoui, radhia boubaker, kamel majed university hospital center rabta of tunis, tunis, tunisia correspondence: abderrahim achouri (achouryabderrahim@gmail. com) ann. intensive care , (suppl ):p- rationale: sepsis is a major cause of mortality. in other hand, preexistent chronic diseases seem to worsen outcomes among critically ill patients. the acknowledgement of this fact may motivate studies in this type of situations in order to improve survival in sepsis. on that purpose, our study tried to check the impact of chronic pre-existent illnesses on outcomes in this type of emergency patients. patients and methods: we have included patients in whom the sepsis- definition was met throughout emergency department admission cases for infection. in this study, considered outcomes were in-hospital mortality, shock occurence and the use of mechanical ventilation. results: we collected patients admitted to ed for sepsis. mean age was years ± with bornes of and . men were % of the patients. cormorbidities were: insulin dependent diabetes mellitus in . % of patients, non insulin dependent diabetes mellitus in . %, chronic obstructive lung disease in . %, chronic renal failure in . % with % in chronic replacement therapy from total patients, coronary artery disease in . %, with stent in . % and . % with aortic coronary graft from total patients, arterial hypertension in %, chronic heart failure in . %, atrial fibrillation in . %,. death occurs in . % of total patients, septic shock in % and the use of mechanical ventilation in . %. we did not find any association between comorbidity and the use of mechanical ventilation, but association with in-hospital mortality was found in pre-existent coronary artery disease (p = . ) and in patients with coronary artery stent (p = . ). odds ratio (or) was respectively . ( % ic = [ . - . ]) and . ( % ic = [ . - . ] ). we found significant association between chronic heart failure and shock (p = . ) with or = . ( % ic = [ . - . ] ). discussion: the small size of our sample may enlimit the contibution of other comorbidities on outcomes in sepsis such chronic renal failure, especially with renal replacement therapy and diabetes mellitus. whereas, we can conclude that cardiac diseases have the most important impact on outcomes in sepsis. outcomes in sepsis can be affected by comorbidities, especially cardiac diseases. therefore, that needs large studies to check it. compliance with ethics regulations: yes. micafungin population pk analysis in critically ill patients receiving continuous veno-venous hemofiltration or continuous veno-venous hemodiafiltration nicolas garbez , litaty mbatchi , steven c. wallis , laurent muller , jeffrey lipman , jason a. roberts , jean-yves lefrant , claire roger chu nîmes, nîmes, france; university of queensland, brisbane, australia correspondence: nicolas garbez (nicolas.garbez@umontpellier.fr) ann. intensive care , (suppl ):p- rationale: to compare the population pharmacokinetics (pk) of micafungin in critically ill patients receiving continuous veno-venous hemofiltration (cvvh, ml/kg/h) to those receiving equidoses of hemodiafiltration (cvvhdf, ml/kg/h + ml/kg/h). critically ill patients in septic shock undergoing continuous renal replacement therapy (crrt) and receiving mg micafungin once daily were eligible for inclusion. total micafungin plasma concentrations were analyzed using pmetrics ® . probability of target attainment (pta) was calculated from monte carlo simulations using -hour area under curve/minimum inhibitory concentration (auc - /mic) cut-offs (c. parapsilosis), (all candida species) and (c. non parapsilosis). daily dosing regimens of , and mg were simulated for the first days of treatment. results: eight patients were included in the study. micafungin concentrations were best described by a two-compartmental pk model. no covariate, including crrt modality (cvvh and cvvhdf), was retained in the final model, confirmed by internal validation. the mean parameter estimates (standarddeviation) were . ( . ) l/h for clearance, . ( . ) l for the volume of the central compartment, . ( . ) /h and . ( . ) /h for rate constants. the standard mg daily dosing was unable to reach % of pta for all candida species except c. albicans on the second day of therapy (fig. ) . conclusion: there was no difference in micafungin pk between equidoses of cvvh and cvvhdf. a dose escalation to mg is suggested to achieve the pk/pd target of candida species with mics exceeding . mg/l in this population. these "off-label" dosing regimens should be further investigated in clinical trials knowing the favourable toxicity profile and the post-antifungal effect of micafungin in order to ensure efficacy and to prevent the emergence of resistance due to an inadequate initial antifungal dosing regimen. compliance with ethics regulations: yes. rationale: sepsis is an important cause of morbidity and mortality in hospitalized patients. recognizing and responding to patients who experience clinical deterioration remains challenging in daily practice. our purpose was to assess the ability of the quick sequential organ failure assessment (qsofa) score to identify, among patients reviewed by an intensivist, those at risk of adverse outcomes. patients and methods: retrospective cohort of patients with suspected infection reviewed by an intensivist in a university-affiliated hospital between january and june . outcomes of interest were hospital mortality and a combined criterion of hospital mortality or icu stay of days or more. results: during the study period, patients were reviewed by an intensivist, of whom ( . %) had suspected infection according to the sepsis- criteria. at the time of review, ( . %) patients with suspected infection were qsofa positive (≥ ) and ( . %) were qsofa negative ( - ). following the review, ( . %) patients were admitted to the icu, among whom ( . %) had a prolonged stay (≥ days). in-hospital mortality was . %, and . % of the patients met the combined criterion of in-hospital mortality or prolonged icu stay. qsofa positive patients required more frequently mechanical ventilation ( . % vs. . %, p = . ) and vasopressor support ( . % vs. . %, p < . ) than qsofa negative patients. moreover, qsofa positive patients had higher hospital mortality than qsofa negative patients ( . % vs. . %, p = . ). for the prediction of in-hospital mortality, a positive qsofa had a predictive positive value (ppv) of %, and a negative predictive value (npv) of %. for the prediction of in-hospital mortality or prolonged icu stay, a positive qsofa had a ppv of % and a npv of %. conclusion: hospitalized patients with suspected infection for whom a review by an intensivist was requested, are at high risk of hospital mortality. although the accuracy of qsofa for identifying patients at risk of adverse outcomes is limited, its integration in a multimodal risk assessment approach may help distinguish the subset of patients who will benefit from an escalation of care. compliance with ethicsregulations: yes. rationale: according to the sepsis- consensus, sepsis is identified as an increase of at least points in the sepsis-related organ failure assessment (sofa) score in patients who presented infection. the quick sofa or qsofa is considered as a predictive tool of sepsis and mortality when it is equal to points or more. systemic inflammatory response syndrome (sirs) criteria are of limited utility because of their low sensitivity. hyperlactatemia, as known is a determinant of tissue hypoperfusion. our objective was to evaluate the prognostic value of sofa > , sirs > , qsofa > and lactate level > mmol/l in infected patients. nine-month prospective cohort study. patients aged years or older who had a proven or suspected infection were included. sofa score, sris criteria, sofa q and lactate levels were determined within the first h of infection. the primary endpoint was hospital mortality at days. the predictive power of the studied parameters was determined using using the area under the receiver operating characteristic curve (auroc). results: a cohort of cases was studied with mean age at . years. bacterial pneumonia was the most common infection site ( %). in the first h of onset of infection the medians [iqr - ] of the sofa, sris, and sofa scores and lactate levels were respectively [ ] [ ] [ ] [ ] [ ] [ ] [ ] , [ ] [ ] , [ - ] and . [ . - . ] . the progression to severe septic status was observed in patients ( %) and norepinephrine was introduced in cases. median length of stay was days [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and mortality was %. overall, the accuracy in predicting mortality of the studied parameters was poor. an increase of sofa score by at least points had greater accuracy with auroc = . [ . - . ], sensitivity = % and specificity = %. conclusion: in infected patients, the sofa score had greater prognostic accuracy than the sirs criteria, the qsofa score or the lactate level. these results suggest that sirs, qsofa, and high lactate level may be useful in screening for sepsis, but this utility is limited in predicting mortality. compliance with ethics regulations: yes. rationale: quick sequential organ failure assessement (qsofa) has been validated for patients with presumed sepsis and others in general emergency department (ed) population. however, it has not been validated in specific subgroups of patients with a high mortality. the aim of this study is to evaluate the ability of qscore to predict prognosis in patients with decompensated liver cirrhosis. patients and methods: this is a retrospective study, conducted over a period of years from january to december . consecutive patients with decompensated cirrhosis, admitted in our department are included. data of all patients were collected and the qsofa score was calculated at admission. the main study endpoints were length of stay, complications and in-hospital mortality. results: a total of patients diagnosed with decompensated cirrhosis were enrolled. mean of age was years ( - ). sex ratio was . . hcv ( %) was the main etiology of cirrhosis. the reasons of hospitalization were: oedema with ascitic syndrome in % of cases, digestive haemorrhage ( % of cases), fevers ( % of cases), and hepatic encephalopathy was present in % of cases. the mean duration of stay was days ± . in-hospital mortality rate was % and mean score qsofa was . .the qsofa score was significantly correlated with length of stay (p = . ) and complications(p = . ) but not with in-hospital mortality (p = . ). conclusion: the qsofa score was not useful for predicting in hospital mortality in patients with decompensated liver cirrhosis but it was significantly correlated to the length of stay and complications. compliance with ethics regulations: yes. angioedema associated with thrombolysis for ischemic stroke: analysis of a case-control study clara vigneron , aldéric lécluse , thomas ronzière , sonia alamowitch , olivier fain , nicolas javaud médecine interne, centre de référence associé sur les angioedèmes à kinines (créak), hôpital saint-antoine, aphp, paris, france; neurologie, chu angers, angers, france; neurologie, chu pontchaillou, rennes, france; neurologie, hôpital saint-antoine, aphp, paris, france; urgences, centre de référence associé sur les angioedèmes à kinines (créak), hôpital louis mourier, aphp, colombes, france correspondence: clara vigneron (claravigneron@hotmail.fr) ann. intensive care , (suppl ):p- rationale: bradykinin-mediated angioedema is a complication associated with thrombolysis for acute ischemic stroke. risk factors are unknow and management is discussed. the aim of this study was to clarify risk factors associated with bradykinin-mediated angioedema after thrombolysis for acute ischemic stroke. patients and methods: in a case-control study conducted at a french reference center for bradykinin angioedema, patients with thrombolysis for acute ischemic stroke and a diagnosis of bradykinin-mediated angioedema, were compared to controls treated with thrombolysis treatment without angioedema. two matched control subjects were analyzed for each case. results: thrombolysis-related angioedema were matched to control subjects. the sites of attacks following thrombolysis for ischemic stroke mainly included tongue ( / , %) and lips ( / , %). the upper airways were involved in ( %) cases. three patients required mechanical ventilation. patients with bradykinin-mediated angioedema were more frequently women ( ( %) vs. ( %); p = . ), had higher frequency of prior ischemic stroke ( ( %) vs ( %); p = . ), hypertension ( ( %) vs. ( %); p = . ), were more frequently treated with angiotensinconverting enzyme inhibitor ( ( %) vs. ( %); p < . ) and were more frequently hospitalized in intensive care unit ( ( %) vs. ( %); p = . ). in multivariate analysis, factors associated with thrombolysisrelated angioedema were female sex (odds ratio [or], . ; % confident interval [ci], . - . ; p = . ) and treatment with angiotensin-converting enzyme inhibitors ([or], . ; % [ci], . - . ; p < . ). discussion: because of theretrospective case-control design and the lack of the total number of thrombolysis for ischemic stroke, the incidence of this complication could not be evaluated in our study. previous studies reported an incidence of . to . % of angioedema in patients treated with a thrombolytic therapy for acute ischemic stroke. our case-control study permits for the first time to analyse more cases to evaluate associated risk factors of this rare complication. conclusion: this case-control study points out angiotensin-converting enzyme inhibitors and female sex as risk factors of bradykininangioedema associated with thrombolysis for ischemic stroke. compliance with ethics regulations: yes. rationale: patients with inflammatory bowel disease (ibd), frequently treated by immunosuppressive drugs, are more susceptible to be admitted to the intensive care unit (icu). however, outcome and predictive factors of mortality are little known. therefore, we aimed to assess the outcome and prognostic factors for critically ill ibd patients. patients and methods: we retrospectively studied data of consecutive ibd (i.e. crohn's disease and ulcerative colitis) patients admitted in icus between and . in-icu and one-year mortalities were estimated and predictive factors of in-icu mortality were identified by univariate and multivariate analysis. results: seventy-six patients (male: %, median age: . [ . - . ] years, charlson index: [ . - . ]) entered the study. ibd type was largely represented by crohn's disease ( . %) and its localization was mostly extensive: l ( . % of crohn's disease) or e ( % of ulcerative colitis) according to the montreal classification. twenty-seven patients ( . %) were treated with corticosteroids and ( %) with immunosuppressive therapy (azathioprine: . % and anti-tnfα: %). reasons for admission were shock/sepsis ( . %) and acute respiratory failure ( . %). icu diagnoses were infection ( %), ibd flare-up ( . %) or both ( . %), and pulmonary embolism ( . %). at admission, sofa score was [ . - . ] and . fifty-three patients ( . %) required mechanical ventilation, ( . %) vasoactive drugs, and ( . %) renal replacement therapy. twenty-three patients underwent emergency surgery ( . %) and six urgent endoscopic treatment ( . %). in-icu and one-year mortality rate were . % and . %, respectively. prognostic factors of in-icu mortality were sofa score (hr . , % ci [ . - . ], p < . ) and azathioprine treatment before icu admission (hr . , % ci [ . - . ], p < . ) (fig. ) . previous immunosuppressive treatment with anti-tnf did not alter the prognosis and even the type of ibd. conclusion: our study showed that more than % of ibd critically ill patients were discharged alive from the icu and a majority of them survived after one-year ( . %). we also found that sofa score and previous azathioprine immunosuppressive treatment worsened icu outcome. higher severity of the acute event affected short-term prognosis and should be taken into account for best icu triage and management. intensivists should pay particular attention to patients treated by azathioprine. compliance with ethics regulations: yes. fig. outcome of ibd patients admitted to the icu according to precious treatment with azathioprine status all aps patients with any new thrombotic manifestation(s) admitted to icus. results: one hundred and thirty-four patients (male/female ratio: . ; mean age at admission: . ± . years), who experienced caps episodes, required icu admission. the numbers of definite, probable or no-caps episodes (fig. ) , respectively, were: ( . %), ( . %) and ( . %). no histopathological proof of microvascular thrombosis was the most frequent reason for not being classified as definite caps. overall, / ( . %) episodes were fatal, with comparable rates for definite/probable caps and no caps ( % vs. . % respectively, p = . ). the kaplan-meier curve of estimated probability of survival showed no between-group survival difference (log-rank test p = . ). discussion: our results suggest that the caps criteria do not sufficiently encompass all the parameters responsible for thrombotic aps patients' disease severity in the icu. the absence of items referring to organ dysfunction/failure in the caps criteria probably limited their ability to predict mortality. albeit useful for the retrospective classification and comparison of patients, the caps criteria may be too stringent and not yet ready-to-use for the management of icu patients. for physicians outside expert aps centres, the absence of caps criteria could be misleading and lead to rejection of the diagnosis for near-caps patients, thereby preventing them from receiving the appropriate aggressive treatment they indeed require. we think that, when confronted with a critically-ill thrombotic aps patient, caps criteria should be interpreted with caution and should not be the only elements taken into account to decide the intensity of the therapeutic management. rationale: % of resuscitation patients develop anemia during their stay, it can worsen the prognosis, prolong the length of stay and lead to transfusions that can be the cause of complications. the objective of our work is to specify the incidence of anemia in our unit, its etiologies and its therapeutic management. patients and methods: we conducted a descriptive and analytical retrospective study within the surgical emergency resuscitation department of ibn rochd university hospital of casablanca, over a period of years from to . we included all anemic patients. statistical analysis was performed with spss statistics . p < . was considered significant. results: we included patients with an estimated incidence of %, the average age was years, the sex ratio h / f was . . % of admissions were for traumatic pathology and % postoperative digestive surgery. % had hypotension at admission and the mean temperature was . % .the onset of anemia and its depth were related to length of stay with . % of patients who were anemic beyond the th day of hospitalization with a hemoglobin level that became < . g / dl beyond the th day. % of the patients had a normochromic normocytic anemia becoming microcytic with the lengthening of the duration of stay. ferritinemia dosed in % of patients and was normal. % of our patients had exclusive parenteral nutrition while % had an enteral / parenteral combination. % were transfused in red blood cells (rbc) and % of patients were transfused more than once. % received between and rbc units. in patients who received transfusion episodes costing euros, the transfusion was inappropriate. the total cost of the transfusion was estimated at around , euros. % were supplemented with oral iron with an increase in hemoglobin in % of them. % of the patients came out of the intensive care unit with a hemoglobin level < g/dl/l. the mortality rate of our patients was % with as predictive factors in multivariate analysis, hyperthermia, coagulopathy, the transfusion appears as a factor of good prognosis. the prevention of blood spoliation and the fight against inflammation and nosocomial infection remain the pillars of the management of anemia in intensive care but in view of our results and the protective role of transfusion it would be interesting to see again the transfusion thresholds in our context. compliance with ethics regulations: yes. (fig. ). discussion: we described a series of patients with severe acute viral myopericarditises associated with anti-rnapol autoantibodies, an association that has never been reported previously. the fortuitous association of these autoantibodies with acute myopericarditis is highly unlikely. acute myocarditis is a very rare disease with a reported incidence of / , inhabitants. anti-rnapol -antibody detection is also very rare: . % positive tests (including the patients in this series) out of samples during a -year period in our immunology laboratory. this % proportion of patients with proven influenza-virus infections suggest that such severe infections could trigger anti-rnapol autoantibody production. however, influenza is a common disease and anti-rnapol autoantibodies are very rare. furthermore, no anti-rnapol autoantibodies were detected in the patients with severe influenza-related ards. last, anti-rnapol autoantibodies remained detectable several months after the viral infection had been cured. conclusion: this previously unknown association between severe acute viral myopericarditis and anti-rnapol autoantibodies is probably not fortuitous. anti-rnapol antibody detection in acute myopericarditis patients could imply individual susceptibility to severe viral infection. further studies are needed to investigate the pathophysiological mechanisms involved in this entity and potential specific therapeutic strategies. fig. relative frequencies of digestive manifestations in critically ill tma patients rationale: arrhythmia-induced cardiomyopathy has been recognized for several decades, but most severe forms, i.e. cardiogenic shock and refractory cardiogenic shock requiring mechanical circulatory support, were rarely described in adults. in this retrospective study, we described patients admitted in our tertiary care center for non-ischemic acute cardiac dysfunction (or worsening of previously known cardiac dysfunction) and recent onset supraventricular arrhythmia who developed cardiogenic shock requiring veno-arterial ecmo (va-ecmo). results: in a years period, patients had va-ecmo for acute non ischemic cardiac dysfunction and recent onset supraventricular arrhythmia (table ). fourteen ( %) patients had known nonischemic cardiomyopathy and ( %) known paroxystic atrial fibrillation. cardiogenic shock was the first manifestation of the disease in patients. atrial fibrillation was the main cause of arrythmia ( % of cases). at ecmo implantation, sofa score was [ - ], inotropic score , lvef % [ - ] and lactate level was [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] mmol/l. twelve patients had sustained successful reduction after amiodarone and/or electric shock, all were weaned from ecmo and survived without transplantation nor long term assist device. among the patients with failure of reduction, underwent an atrio-ventricular ablation while on ecmo and had atrial tachycardia ablation; all were weaned from ecmo and survived. among the remaining patients without reduction and without ablation procedure, only the patients who were bridged to heart transplantation or left ventricular assist device survived. in univariate analysis, factors associated with unfavorable outcome were previously known heart disease, heart rate, renal replacement therapy, nt-probnp level, failure of rhythm reduction after amiodarone load and/or electric shock. among the patients who recovered and survived ( with successful reduction and with successful ablation), lvef increased from [ - ]% before ecmo implantation to [ - ]% at long term follow-up. discussion: this is the largest cohort of arrhythmia induced cardiomyopathies on va-ecmo and the first description of atrio-ventricular node ablation with favorable outcome in this setting. conclusion: arrhythmia induced cardiomyopathy is probably underrecognized and should be considered in any patient with nonischemic acute cardiac dysfunction and recent onset supraventricular arrhythmia. recovery is possible in the most severely ill patients on va-ecmo, even with severe left ventricular dilation. aggressive rate control by av-node ablation may be warranted in case of failure of reduction, and may allow recovery and favorable outcome. compliance with ethics regulations: yes. rationale: diagnosis of sepsis is a major challenge in intensive care units and is associated with a high morbidity and mortality. sepsis identification is even more difficult in patients with extracorporeal membrane oxygenation (ecmo) because of many confounding factors. the primary objective was to study the ability of c-reactive protein (crp) and procalcitonin (pct) values measured at ecmo support initiation (day ) to predict the occurrence of early sepsis in patients undergoing venoarterial ecmo (va-ecmo) or venovenous ecmo (vv-ecmo). the secondary objectives were to study the association between these biomarkers and mortality rate during ecmo support and in-hospital mortality rate. furthermore, we investigated the relationship between early sepsis and mortality. patients and methods: we performed a retrospective, monocentric study in the cardiovascular intensive care unit of the university hospitals of lille, france. between november , and december , , we included patients over years old, who underwent an ecmo support for a medical or surgical indication, and for whom biomarkers (crp and pct) levels were available for at least the first days of admission. biomarkers and blood cultures were daily assessed for the first ecmo support days. early sepsis was defined by sepsis diagnosis in the first days after circulatory assistance initiation. in-hospital mortality rate was censored at days. after univariate analysis, a cox multivariate regression model was used to assess if the association between biomarkers levels and early sepsis or mortality rate was independent. a kaplan-meier survival plot was used to describe the association between early sepsis and mortality. results: among patients included, underwent va-ecmo and underwent vv-ecmo. an early sepsis diagnosis was made in . % of va-ecmo patients and in % of vv-ecmo patients. pct and crp levels on day were significantly associated with early sepsis diagnosis (fig. rationale: fluids are one of the most prescribed drug in intensive care, particularly among patient with circulatory failure. yet, very little is known about their pharmacodynamic properties and this topic has been left largely unexplored. several factors may impact the haemodynamic efficacy of fluids among which the infusion rate. the aim of this study was to investigate the influence of the rate of fluid administration on the fluid pharmacodynamics, in particular by studying mean systemic pressure (pms). we conducted a prospective observational study in patients with septic shock to compare two volume expansion strategies. a fluid bolus, ml of normal saline were administered and several haemodynamic variables were recorded continuously: cardiac output (co), arterial pressure (ap), mean systemic pressure (pms, estimated from ci, pvc and map). infusion rate was left at the discretion of the attending physician. a "slow" and a "fast" groups were determined based on the median of the infusion duration. fluids effect was measured by the area under the curve (auc), maximal effect (emax) and time to maximal effect (tmax) for each haemodynamic variable. the effects of fluid on psm disappeared in one hour on average. compared to patients of the "slow" group, those of the "fast" group had a shorter tmax and a higher emax for pms (p = . and . respectively). the auc for pms was identical between group, while in case of similar effect of infusion rates, it should be larger in the "slow" group. regarding co, tmax was also shorter in the "fast" than in the "slow" group (p = . ). the decreasing slope from maximal effect was comparable between groups, for pms as for co. the effect of a ml fluid bolus with normal saline in septic shock patients vanished within one hour. a faster infusion rate increased the maximal and total effect of the fluid bolus and shortened the delay to reach the maximal effect. rationale: significant hypotension following spinal anesthesia is a common issue in everyday clinical practice. toavoid this potentially harming situation, an empirical fluid administration is usually performed before the procedure. inferior vena cava (ivc) ultrasound has been demonstrated effective in guiding fluid therapy in critical care patients. the purpose of this study was to evaluate the ivc ultrasound guided volemic status optimization in order to decrease post-spinal hypotension rate. patients and methods: in this prospective, controlled, randomised study, consecutive patients were recruited and patients were randomly assigned to a control group, consisting of pre-anesthesia empirical fluid administration (itt), an ivc ultrasound group in which fluid management was based on an ivc ultrasound evaluation, and a passive leg raising test (plrt) group in which volume optimization was performed following the above mentioned test. primary outcome was the hypotension rate reduction after spinal anaesthesia following fluid optimization therapy between the groups. secondary outcomes were the total fluid amount administered, the total vasoactive drug amount used and the time needed to realize the whole anaesthetic procedure in all three groups. results: % reduction in hypotension rate ( % ci - %, p = . ) was observed between the echocardiography group and the control group, and there was a reduction of hypotension rate by % (ci % - %, p = . ) between the echocardiography group and the plrt group. the total fluid amount administered was significantly greater in the ultrasound group than in the control group ( ml; sd ml, versus ml; sd ml, p = . ). the total amine consumption was % in control group, % in ivc group and % in plrt group. an increased of total study time was observed for the echocardiography group min (sd min) in comparison with the control group min (sd min) and ptlr group min (sd min), (p < . ). the study showed a faint but positive trend toward the use of ivc-ultrasound to identify patients in spontaneous breathing needing fluid optimization before spinal anesthesia compliance with ethics regulations: yes. rationale: we performed a systematic review and a meta-analysis of studies investigating the ability of the end-expiratory occlusion (eexpo) test to predict preload responsiveness, through the changes in cardiac output (co) or its surrogates, in adult patients. this meta-analysis was prospectively registered on prospero (crd- ). we screened pubmed, embase and cochrane database to identify all original articles published between and evaluating the ability of the eexpo test to predict a significant increase in co or surrogate, compared to the one induced by a subsequent volume expansion or by passive leg raising (plr). the meta-analysis determined the pooled area under the receiver operating characteristics curve (auroc) of eexpo testinduced changes in co to detect preload responsiveness, as well as pooled sensitivity and specificity and the best diagnostic threshold. subgroup analysis and sensitivity analysis were planned to investigate potential sources of heterogeneity. results: thirteen studies ( patients) were identified and included in the analysis. nine studies were performed in the intensive care unit and four in the operating room. preload responsiveness was defined according to co changes induced by fluid administration in studies (fluid-induced increase in co ≥ % or ≥ %) and according to co changes induced by plr in one study. the duration of the respiratory hold ranged between and s. for the eexpo test-induced changes in co, the pooled sensitivity and specificity were [ - ]% and [ - ]%, respectively, while the pooled auroc curve was . ± . (fig. ) . the corresponding best diagnostic threshold was . ± . %. when changes in co were monitored through pulse contour analysis compared to other methods the accuracy of the test was significantly higher ( ( ). continuing (decrease to % of peak level) or modification (decrease < %) of antibiotic therapy was guided by a serum pct assay from the third day of treatmentand every h until antibiotic was stopped. this last was stopped when pct levels had decreased of % from the initial value. results: a total of patients had been diagnosed as sepsis (n = , %) and septic shoc (n = , %). mean age was years ± . an average ubs and absi score of % and . the average length of stay in icu was days. patients were assigned into two groups: group a (favorable evolution, n = ); group b (unfavorable evolution, n = ). the therapeutic attitude according to the kinetics of the pct are presented in the table . we found a significant difference between patients with unfavorable evolution compared to those with a favorable evolution (in whom we stopped antibiotics) (p < . ), in terms of hemodynamic state, pct concentration and renal clearance. pctguided antibiotic treatment has been proven to significantly reduce length of antibiotic therapy in our patients. the average duration of antibiotic was . ± days. conclusion: pct measurement may help with the decision to initiate antibiotic therapy in low risk acuity of infection and allows more judicious antibiotic use by reducing antibiotic exposure. compliance with ethics regulations: not applicable. rationale: reducing the risk of severe hypoxemia during endotracheal-intubation (eti) is a major concern in intensive care unit but little attention was paid to co variations during this period. we conducted a prospective observational study to describe transcutaneous co (ptcco ) throughout intubation in patients who received preoxygenation with standardoxygen therapy (sot), non-invasive ventilation (niv), or high flow nasal cannula oxygen therapy (hfncot). patients and methods: patients over years undergoing eti in icu were continuously monitored for ptcco during intubation and the following h under mechanical ventilation (mv). haemodynamics and respiratory parameters were also recorded as well as arterial partial pressure of co (paco ) to evaluate reliability of the transcutaneous measure. results: two hundred and two patients were included in the study. we found a strong correlation between ptcco recorded at preoxygenation and the last paco available before intubation (r = . , p < . ). in % of patients ptcco values recorded at initiation of mv were out of - mmhg ranges. ptcco recorded at eti, at initiation of mv, min and h of mv were significantly higher than ptcco during preoxygenation (p < . by anova). variations of ptcco were significantly different according to the preoxygenation method (p < . for interaction in anova). lastly, a decrease in ptcco higher than mmhg within half an hour after the beginning of mv was independently associated with postintubation hypotension (pih) (odds ratio = . , % confident interval . - . , p = . ). conclusion: ptcco is a valuable tool to record paco variation in patients requiring invasive mechanical ventilation and could be useful to prevent pih. compliance with ethics regulations: yes. rationale: intubation in intensive care unit (icu) is a critical procedure which leads to serious adverse event in to % of cases. several recent trials were conducted to help physicians to choose medications, devices and modality of intubation. especially, videolaryngoscope (vl) led to several publications in the last few years, with increasing tools marketed and spread use (difficult airway management, routineintubation). we designed an online survey to take a picture of intubation process and devices availability in france. toolbox. it was positioned as a first line laryngoscope for every intubation in critically ill patients to reinforce the vl skill training. present study was performed using prospectively collected data from a continuous quality improvement database about airway management in a -beds french teaching hospital medical icu. all consecutive intubation procedure performed with vl from september to june were included. "first attempt success" group and "first attempt failure" group were compared by univariate and multivariate analysis in order to analyze the first attempt intubation success rate according to the level of operators' expertise, identify factors associated with first pass intubation failure and describe the intubation related complications. results: we enrolled consecutive endotracheal intubations. overall first attempt success rate was ( %). comorbidities, junior operator, the presence of cardiac arrest and coma were associated with a lower first attempt success rate. the first attempt success rate was less than % in novice operators ( - previous experiences with vl, independently of airway expertise with direct laryngoscopies) and % in expert operators (greater than previous experiences with vl) (fig. rationale: tracheostomy in intensive care unit (icu) has many advantages. but only patient comfort and shorter icu and hospital stay were demonstrated. the timing of this procedure is still debated. the aim of this study was to determine the impact of early tracheostomy on prognosis. we performed a retrospective study in a medical icu ( beds unit) from january to november . the technique of tracheostomy was exclusively surgical in the operating room made by the surgeon. the primary endpoint was mortality in icu. the secondary outcomes were post-tracheostomy incidence of ventilator acquired pneumonia, duration of mechanical ventilation and length of stay in icu. these criteria were assessed in relation to timing of the tracheostomy defined as early when performed before day of mechanical ventilation. results: forty-two patients were enrolled during the study period. mean age of patients was ± years. median length of stay in icu was of days. mortality rate was of %. comparing the two groups, early vs late tracheostomy, no difference was found with respect to mortality ( % vs. %, p = . ), vap occurrence ( % vs. %, p = . ), post-tracheostomy duration of mechanical ventilation ( ± d vs. ± d, p = . ), or length of stay in icu ( ± d vs. ± d, p = . ). in multivariate analysis, the only factor independently related to mortality was the sofa score patient on tracheostomy day with p = . and or = . (ci % [ . - . ] ). conclusion: tracheostomy in the intensive care unit remains a justified alternative despite the discordant data in the literature. in our study, the delay of the procedure didn't interfere with the evolution. however, the patient severity as attested by sofa score at the day of tracheostomy, was the only independent prognostic factor. those results should be confirmed by other large prospective studies. compliance with ethics regulations: not applicable. sabah benhamza, mohamed lazraq, youssef miloudi, abdelhak bensaid, najib el harrar réanimation de l'hôpital du août, casablanca, morocco correspondence: sabah benhamza (benhamzasabah @gmail.com) ann. intensive care , (suppl ):p- rationale: many unknowns remain as to the place of tracheostomy in intensive care. reluctance to perform a tracheotomy is numerous, especially when pre-exists chronic respiratory failure, but some data suggest benefits. we report in this work our experience in tracheotomy in the intensive care unit of the august hospital, casablanca. patients and methods: this is a retrospective descreptive study over years (january to january ) including all patients that have been tracheostomized in the intensive care unit of the august hospital . results: during the study period, patients were tracheostomized with a prevalence of . % in years, the predominance was male (sex ratio . ). the average age was ± years old. the indication for tracheostomy was prolonged ventilation in % of cases, extubation failure in % of cases, and intubation failure in % of cases. tracheostomy was performed on average on the th day of intubation. all patients were tracheostomized in the operating room by ent surgeons. the main complications attributable to tracheotomy were hemorrhage of the tracheostomy orifice in patients ( %) immediately resumed, cases of subcutaneous emphysema ( %), case of pneumothorax ( %), cases of orifice infection ( %). no patient died of a tracheostomy related cause. the tracheotomy in intensive care is still a subject of debate especially concerning the time of its realization. however it seems to reduce the duration of mechanical ventilation, facilitates the care and also the ventilatory weaning. compliance with ethics regulations: yes. rationale: hfnco is a frequently used device providing heated and humidified high flow oxygen with several advantages: decreased work of breathing, decreased dead space, increased end expiratory lung volume (eelv), more stable fio . the increase in eelv is relying of the positive expiratory effect generated by the device. the level of generated pep seems however to largely depend on whether the mouth is open or not. this study was aimed to assess the impact of mouth opening on eelv increase induced by hfnco using electric impedance tomography. patients and methods: the following hfnco trial was proposed to healthy subjects who used hfnco on a regular basis for patients care. oxygen flow was set successively during min periods at , and l/min (optiflowtm; fisher & paykel healthcare, auckland, nz). these three conditions were tested in semi recumbent and supine position chosen at random. measurement started in supine position with no flow (baseline) and each period was separated from the following by a wash out period on min during which the subject could breath normally with no supplemental oxygen. electric impedance tomography (pulmovista ® , dräger medical gmbh, lündbeck, germany) was performed applying a electrodes belt placed between the th and th intercostal space, including a reference electrode located on the abdomen. as no spirometer was used, the data of eelv computed on the eit device were expressed as percentage of variation of the value measured in supine or semi recumbent position with no flow. demographic data were expressed as median and extreme values. comparisons were performed using u mann whitney test. [ . - . ] accepted to participate to the study. when subjects received hfnco with open mouth (whatever position) no modification of eelv was observed (table ) . conversely, a significant increase in eelv was noted with closed mouth, whatever position. in the semi recumbent position the increase in eelv was even more important with l/min. conclusion: electrical impedance tomography illustrates the impact of mouth closure on eelv increase among healthy subjects receiving hfnco. compliance with ethics regulations: yes. rationale: in stable copd patients, nasal high flow oxygen (nhf) use can be associated with reduction in respiratory rate (rr) and minute ventilation (mv). in thesepatients, paco remains stable or decreases under nhf. this suggests a possible dead space reduction related to a washout effect of nhf. the aim of this study was to assess the physiological effects of nhf in hypercapnic patients with acute copd exacerbation. patients and methods: crossover study in hypercapnic patients suffering from acute copd exacerbation and treated with intermittent non-invasive ventilation (niv). nhf l/min or standard oxygenotherapy (stand o ) were randomly administered during h between niv treatments. rr, tidal volumes (vt), mv and corrected mv (cormv = mv x paco / ) variations were recorded during the last min of each study period using a respiratory inductive plethysmography vest. blood gas analysis was performed at the end of each oxygen administration period. visual analogic dyspnea score (vas) quoted from to was assessed by the patient after and min. results given as median [iqr] . wilcoxon tests were used to compare data between stand o and nhf. results: twelve patients were included and data could be recorded in ( (fig. ). dyspnea scores were not different between the modalities. conclusion: in case of acute copd exacerbation, using nhf between niv treatments was associated with paco and rr decrease. mv concomitantly decreased suggesting a deadspace volume reduction related to a washout effect of nhf. corrected mv decreased in all the patients except one. these results suggest that nhf could be used to deliver oxygen between niv treatments to copd patients suffering from acute exacerbation and could contribute reducing paco . compliance with ethics regulations: yes. rationale: the role of atypical micro-organisms in acute exacerbation of chronic obstructive pulmonary disease (copd) that require mechanical ventilation is poorly none. the aim of this study was to determine the role of atypical pathogens in severe acute exacerbation of copd. patients and methods: in this prospective study we included all patients admitted for acute exacerbation of copd requiring mechanical ventilation. atypical pathogens (chlamydophila pneumoniae and mycoplasma pneumoniae) were searched by serological diagnosis and by culture of sputum samples. in this study we included patients aged ± years. sixty-eight percent of sputum culture were considered significant. six cultures were positive with different microorganisms. neither chlamydophila pneumoniae nor mycoplasma pneumoniae were found. the prevalence of chlamydophila pneumoniae was . % (positive igg serum). the demographic characteristics was similar between patients with and without positive culture. the rate of noninvasive ventilation (niv) failure was % in positive serology group versus % in negative serology group (p = . ). the mortality was similar in both groups. in multivariate logistic regression analysis only positive serology (or = . ; % ic [ . - . ], p = . ) was an independent factor of niv failure. conclusion: a positive serology of chlamydophila pneumoniae was a predictive factor of niv failure without an impact on the morbidity and mortality of copd patient treated with mechanical ventilation. compliance with ethics regulations: yes. rationale: emergency departments (ed) receive a growing up number of patients with acute exacerbation of chronic obstructive pulmonary disease (copd) .non-invasive ventilation (niv) could be a good alternative to achieve a respiratory support, avoiding as much as possible the complications of invasive ventilation. the study aimed to assess the clinical outcomes of using niv in acute exacerbation of copd at ed and to identify whether clinical variables present at admission are predictive of niv failure. we conducted a prospective study conducted at the ed over a period of one year. data of all patients admitted for acute exacerbation of copd for all causes and requiring non-invasive ventilation were collected. niv failure was defined as need for endotracheal intubation or death. results: during the study period, a total of patients with a mean age of years (± ) were included. acute exacerbation of copd was due to bronchitis in %, to pneumonia in % of cases. % of patients had no apparent etiology of acute exacerbation of copd. bilevel positive airway pressure was performed on all patients, during a mean period of h (± ). clinical niv success was observed in patients ( %). the predictors of niv failure were advanced age, tachycardia, and hypercapnia. conclusion: the efficiency of niv in the management of acute exacerbations of copd at ed is well documented. this is further supported by our study which showed a clinical success in % of patients with acute exacerbation of copd. compliance with ethics regulations: yes. rationale: non invasive ventilation (niv) is often performed in elderly patients with acute respiratory failure (arf) at emergency department (ed). this technique may be subject to many difficulties, due to the presence of frequent co-morbidities. the aim of this study was to identify the predictive factors of niv failure in elderly patients with arf at ed. patients and methods: this was a retrospective study conducted at ed on year and months including patients aged more than years and who required the use of niv for an arf. all data were collected and analyzed using the spss software. patients were divided into two groups: niv failure and niv success. niv failure was defined by inhospital mortality, requirement of intubation or hospitalization at intensive care unit. results: during the study period, a total of elderly patients that required niv for arf were included. median age was years (min = , max = ) and sex ratio was . . the median charlson index was (min = , max = ). the etiological diagnoses of arf were acute decompensation of chronic obstructive pulmonary disease ( %), acute heart failure ( %), pneumonia ( %) and pulmonary embolism ( %). the arf was hypercapnic in % of cases and nonhypercapnic in %. niv failure concerned %. predictive factors of niv failure were clinical signs of right heart dysfunction (p < . ), c reactive protein (p = . ), initial ph (p = . ) and kidney dysfunction (p < . ). conclusion: in our study, niv failure in elderly patients with arf at ed was influenced by clinical signs of right heart dysfunction, c reactive protein, initial ph and kidney dysfunction. these clinical and biological factors could be useful to identify the most critical elderly patients and to better guide therapeutic decisions. compliance with ethics regulations: yes. rationale: the interest of ecco r in the management of very severe acute asthma exacerbations is still unclear. since it could help to control respiratory acidosis and /or to limit dynamic hyperinflation, its clinical benefits are uncertain, even in mechanically ventilated patients. the rexecor observatory is a prospective ecco r cohort in the great paris area. tencases of severe asthma treated by ecco r were retrospectively reviewed. mainly, arterial blood gases (abg), duration of ecco r and imv were collected and in-icu mortality were assessed. data are reported as median (iqr). results: ten patients ( men, age: (ic: - ) years, bmi: . (ic: . - . ) kg/m , fev- : . (ic: . - . ) l, ( (ic: - ) %), saps : . (ic: . - . ) points) were included. one patient suffered from cardiac arrest before admission and one had pneumothorax at icu admission. nine patients were under imv (started on the day of admission for ). before ecco r, patients received systemic corticosteroids, paralyzing agents, epinephrine and salbutamol. two patients suffered from pneumonia. ecco r was started (ic: - . ) days after intubation. venous vascular access was achieved via the right internal jugular route in patients and via the femoral route in . the hemolung device was used in patients, the ila activve in and the prismalung in . abg before and after day of ecco r are reported in table . duration of ecco r was (ic: . - ) days and patients were weaned from imv under ecco r. for the remaining patients, duration of imv after ecco r was (ic: - . ) days. icu stay was . (ic: - . ) days. the only one niv patient was not intubated. ecco r as stopped in patients because of complications (one hemolysis, one internal bleeding and one membrane clotting). one patient died in icu after limitation of life-sustaining therapy decision. we report a preferential use of ecco r in imv patients, contrasting with a marginal use in only one niv patient to prevent intubation. the mortality rate was low, in line with previous case series of severe acute asthma with ecmo or ecco r support. more studies are needed ( ) to better delineate the pathophysiological benefits of ecco r in asthma patients and ( ) to confirm strong clinical benefits. compliance with ethics regulations: not applicable. rationale: acute exacerbations of chronic obstructive pulmonary disease (aecopd) are the most important events characterizing respiratory illness progression. their management often needs noninvasive or invasive ventilation (iv). data of literature confirm that the mortality of aecopd requiring iv is high but are discordant about prognostic factors. the aim of our study was to describe the epidemiologic and clinical features of patients admitted for aecopd requiring iv, the treatment and the evolution in intensive care unit in order to deduce the independent factors of mortality. patients and methods: a -year retrospective analytic observational single-center study including patients hospitalized for aecopd requiring iv. results: fifty-eight patients were enrolled. mean age was ± years with sex-ratio of . . eighty one percent were smokers and % were classified gold stage . history of intensive care hospitalization and prior iv were found in % and % of all cases respectively. mean apache ii score was ± . the predominant precipitating factor for aecopd was respiratory tract infection ( % of all cases). twenty two percent of all patients presented septic shock. iv was initiated on admission in % of all cases and after noninvasive ventilation failure in % of all cases. forty-eight per cent of all patients developed septic shock as evolutionary complication. mortality rate was %. in univariate analysis: male gender (p = . ), duration of respiratory disease progression (p = . ), annual exacerbations frequency (p < − ), gold stage (p = . ), prior iv (p < − ), duration of symptoms before hospitalization (p = . ), apache ii score (p = . ), ph (p = . ), shock on admission (p = . ) and septic shock as evolutionary complication (p = . ) were predictors of mortality in our study. besides; shock on admission (p = . ) and as evolutionary complication (p = . ) were the two independent prognostic factors in multivariate analysis. conclusion: vital and functional prognosis of aecopd requiring iv depends on the severity of the underlying respiratory illness, the severity of the exacerbation and the quality of an early management. this emphasizes the importance of controlling modifiable risk factors including smoking cessation, basic treatment improvement and early appropriate treatment of these exacerbations. compliance with ethics regulations: yes. medical background, biological parameters, death-rate and outcome of patients have been compared. results: in total, patients have been included in the "hlh" population. death-rate in intensive care unit was % in the "hlh" group compared to % in the "not hlh" group (p = . ). we used more extrarenal cleansing in the "hlh" group ( % vs. %, p < . ), the duration of assisted ventilation was longer ( . days vs. . days, p < . ), as well as the duration of extrarenal cleansing ( . days vs. . days, p < . ) and those of amines ( . days vs. . days, p = . ). the average time of hospitalization was significantly longer in the "hlh" group ( . days vs. . days, p < . ). the secondary hlh to sepsis in intensive care unit, not well known and understudied, seems to have a different profile and a more serious outcome but no change in death-ratehas been found considering the pairing with the sofa. further studies are needed to plan a better therapeutic strategy within this population. compliance with ethics regulations: not applicable. serum and peritoneal exudate concentrations after high doses of ß-lactams in critically ill patients with severe intra-abdominal infections: an observational prospective study lisa leon, philippe guerci, elise pape, nathalie thilly, amandine luc, adeline germain, anne-lise butin-druoton, marie-reine losser, julien birckener, julien scala bertola, emmanuel novy chru nancy, vandoeuvre les nancy, france correspondence: lisa leon (lisaleon @gmail.com) ann. intensive care , (suppl ):p- rationale: critically ill patients with severe intra-abdominal infections (iais) requiring urgent surgery may undergo several pharmacokinetic alterations that can lead to ß-lactam under dosage. the aim of this study is to measure serum and peritoneal exudate concentrations of ß-lactams after high doses and optimal administration schemes. patients and methods: this observational prospective study included critically ill patients with suspicion of iai who required surgery and a ß-lactam antibiotic as empirical therapy. serum and peritoneal exudate concentrations were measured during surgery and after a h steady-state period. the pharmacokinetic/pharmacodynamic (pk/ pd) target was to obtain ß-lactam concentrations of % ƒt> x mic (minimum inhibitory concentration) based on a worst-case scenario (highest ecoff value) before bacterial documentation (a priori) and redefined on the mic of the isolated bacteria (a posteriori). results: forty-eight patients were included with a median [iqr] age of [ - ] and a saps ii score of . septic shock occurred in % of cases. the main diagnosis was secondary nosocomial peritonitis. piperacillin/tazobactam was the most administered ß-lactam antibiotic ( %). prior to bacterial documentation, patients ( . %) achieved the a priori pk/pd target. iai was documented in patients ( %). enterobacteriaceae were the most isolated bacteria. based on the mic (n = ) of isolated bacteria, % of the patients achieved the pk/pd target ( % ƒt> xmic). in the fig. we presented serum ß-lactams pk/pd target attainment and observed total concentrations of piperacillin-tazobactam at each timepoint in serum and peritoneal exudate. in critically ill patients with severe iais, high doses of ß-lactams ensured % ƒt> xmic in % of critically ill patients with severe iais within the first h. a personalized ß-lactam therapeutic scheme with a pk/pd target based on local ecology should be warranted. compliance with ethics regulations: yes. rationale: intensive care unit acquired bloodstream infections (icu-bsi) are frequent, and associated with high morbidity and mortality rates. the objective of our study was to describe the epidemiology and the prognosis of icu-bsi in our icu (cayenne general hospital). secondary objectives were to search for factors associated to icu-bsi caused by esbl-pe, and those associated with mortality at days. patients and methods: we retrospectively studied icu-bsi in the medical-surgical intensive care unit of the cayenne general hospital, during months (january to june ). we assessed survival at days from the diagnosis of icu-bsi. results: icu-bsi was diagnosed in . % of admissions giving a density incidence of . icu-bsi/ days. the median delay to the first rationale: necrotizing soft tissue infections (nsti) are a heterogenous group of severe infections. among them, group a streptococcal (gas) infection represent a subgroup that could benefit from specific therapies targeting the toxinic pathway, such as intravenous immunoglobulins or clindamycin. nevertheless, previous trials evaluating these treatments suffered from a low rate of gas infection among the study population. early identification of patients at high risk of gas infection would allow for assessing targeted treatment strategies. patients and methods: we conducted a secondary analysis of a previously published cohort of patients admitted to our tertiary center for surgically proven nsti between and . admission characteristics and microbiological documentation based on surgical samples, blood cultures or subcutaneous puncture were recorded. we compared patients with a documented gas infection to all other patients regarding admission characteristics. a generalized linear regression model was used to identify admission characteristics associated with a subsequent documentation of gas infection. results: among patients, ( %) had a gas infection, which was monomicrobial in ( %) cases. admission characteristics associated with gas infections by univariate analysis were nsaid treatment before admission ( ( . %) for gas infections vs ( . %) for others, p = . ) and leukocytosis as a continuous variable ( , /mm [ , - , ] vs. , [ - , ], p = . ). those inversely correlated with gas infections were immunodeficiency ( ( %) vs. ( . %), p = . ), and an abdominoperineal topography ( ( . %) vs. ( . %), p > . ). after multivariate analysis only immunodeficiency (or = . [ . - . ], p = . ) and an abdominoperineal infection (or = . [ . - . ], p = . ) remained associated with the absence of gas infection. using these criteria allowed for identifying subgroups of patients with increased likelihood of gas infections: from % overall (n = ) to % for non-abdominoperineal infections (n = ), % for patients without immunodeficiency (n = ) and % for both non abdominoperineal infections in patients without immunodeficiency (n = ). a sensitivity analysis for monomicrobial gas infections yielded similar results with the addition of younger age and non-nosocomial infections as predictors. conclusion: upon admission, the absence of immunodeficiency and of an abdominoperineal infection in nsti patients were covariables associated with gas infection. compliance with ethics regulations: yes. rationale: sickle-cell disease is the most common genetic disorder in the world. a complication of this disease is the acute chest syndrome (acs) which is associated with a high risk of death. respiratory tract infections are often mixed up and the introduction of betalactam antibiotics is recommended. glomerular hyperfiltration is common and responsible of a high risk of underdosing. this study compares cefotaxim continuous infusion to intermittent bolus in adult patients with acs. patients and methods: this observational retrospective monocentric study included acs admitted in intensive care unit and treated by cefotaxim with at least one plasmatic dosing between may and august . results: thirty patients received bolus administration while the others received continuous infusion. we observed patients ( %) and patients ( %) with a cefotaxim trough level ≥ mg/l in the bolus and continuous group, respectively (p < . ). the median residual concentration was mg/l [ - ] and . mg/l [ . - . ] in the bolus and continuous group, respectively (p < . ). there was no toxic effect induced by overdosing of cefotaxim. conclusion: compared to intermittent bolus infusion, continuous cefotaxim administration maximizes the pharmacokinetics parameters by obtaining a plasmatic concentration times above the minimal inhibitory concentration of usual germs associated with acs. continuous infusion of time-dependant antibiotics seems to decrease the risk of underdosing in patients with sickle cell disease. compliance with ethics regulations: not applicable. (n = , %), followed by esophageal varices rupture (n = , %), ulcer bleeding (n = , %) and diverticular hemorrhage (n = , %). infectious diseases were diagnosed in three patients ( %), including one clostridium colitis, one erosive gastritis with helicobacter pylori and one esophageal candidiasis. conclusion: gib is associated with a high mortality rate in immunocompromised patients, especially in patients with hematological malignancies. specific malignant lesions were the main etiology and may be difficult to treat. comparison with critically ill non-immunocompromised patients with gib will help physicians to provide specific therapeutic strategies in this population. compliance with ethics regulations: yes. risk factors for delayed defecation and impact on outcome in critically ill patients: a multicenter prospective non-interventional study benoît painvin ,* , arnaud gacouin , antoine roquilly , claire dahyot-fizelier , sigsimond lasocki , chloe rousseau , denis frasca , philippe seguin anesthésie-réanimation/chu rennes, rennes, france; réanimation médicale/chu rennes, rennes, france; réanimation chirurgicale/ chu nantes, nantes, france; réanimation chirurgicale/chu poitiers, poitiers, france; anesthésie-réanimation/chu angers, angers, france; centre investigation clinique/chu rennes, rennes, france; anesthésie-réanimation/chu poitiers, poitiers, france; réanimation chirurgicale/chu rennes, rennes, france correspondence: benoît painvin (painvinbe@gmail.com) ann. intensive care , (suppl ):p- rationale: delayed defecation is very common in intensive care units (icu) and it increases length of mechanical ventilation (mv), icu length of stay (los) and possibly mortality. the objective of this prospective multicenter study was to determine risks factors for constipation in icu and to evaluate their impact on mortality. patients and methods: it was a prospective multicenter non-interventional trial performed in university icus in france from january to october . all patients ≥ years old who had an expected los of days and mechanically ventilated for at least days were eligible. defecation was defined as the time of the first stool passage. results: patients were included in the analysis. a stool passage was observed in % of the patients during their icu stay with a mean delay of ± days. in multivariate analysis, risk factors for delayed passage of stool were non-invasive ventilation use and time spent under invasive ventilation whereas alcoholism, laxative treatment (before and after icu admission) and nutrition ≤ h favoured passage of stool (table ) . no relations between constipation and mortality were found. conclusion: we highlighted new and important independent factors for constipation in critically ill patients leading to a better prevention of this phenomenon.. compliance with ethics regulations: yes. rationale: community peritonitis is a frequent medical-surgical emergency of the adult, acquired by the patient in a non-hospital setting. careful multidisciplinary care is essential, involving surgeons, anesthetists, microbiologists and radiologists. the objective of our study is to determine the bacteriological aspects of intra-abdominal sepsis, to describe their sensitivity profiles and to propose treatment regimens for the management of community peritonitis. we conducted a descriptive retrospective study spanning a period of two years from january to january involving cases of community abdominal sepsis operated in the operating room of surgical emergencies of our hospital. we included in our study adult patients admitted for suspected or confirmed abdominal sepsis who had undergone bacteriological examinations on the abdominal collections. samples taken are sent directly to the bacteriology laboratory for bacteriological analysis of the results. the studies showed the mean age is . years old, with a sex ratio of . . we found positive results mainly of peritoneal origin with a percentage of . % peritonitis, dominate by intestinal peritonitis . % followed by the appendicular origin . % then peritonitis by perforation of ulcer. the most incriminated organism in intraabdominal sepsis is e. coli with a percentage of . % of the total germs found, followed by streptococcus spp . %, enterococci . %, non-fermenting bgn composed mainly of pseudomonas aeruginosa . %, staphylococci . % and acinetobacter baumanii . %. note also the presence of bacteroides fragilis is %. e. coli had a very low sensitivity profile for amoxicillin/clavulanic acid ( . %), unlike ceftriaxone, gentamicin, amikacin and ertapenem, which had a sensitivity of . %, respectively. . %, %, . %. conclusion: knowledge of the bacterial ecology of intraabdominal sepsis is important in the choice of probabilistic antibiotherapy, pending bacteriological findings. no data are yet available about nutritional management and risk of malnutrition in tunisian medical intensive care units (icu). the purpose of this study was to describe nutritional management in medical intensive care patients and to evaluate the risk of malnutrition. patients and methods: we conducted a prospective observational cross-sectional study in medical icus all around the tunisian country on the th september . all participant units received a questionary form about routine nutritional management and data of all patients hospitalized in icu on the study day. collected data were: demographic characteristics, reason for admission, severity scores and subjective evaluation of nutritional status on admission, type and volume of nutritional support on the study day and the day before, nutritional status, nutric score and biological data on the study day, reasons for nutritional interruption and other supports prescribed. results: thirteen icu all around tunisia participated to the study. no icu had a nutrition team and only one had a written nutrition protocol. four icus evaluated systematically the nutritional status on admission. all icus were aware and practiced early enteral nutrition in patients unable to maintain oral intake with a systematic supplementation of oligoelements and minerals. neither target energy nor protein intake were calculated. on the study day, patients were hospitalized with an occupation rate of %. mean age was ± years. mean body mass index was ± and % of patients were judged well nourished. enteral nutrition support was prescribed on admission in % of cases with a mean caloric intake of ± kcal/day. the mean caloric target on the study day was ± kcal/day with a mean caloric intake of ± kcal/day and a mean caloric gap of ± kcal/day. the mean nutric score and body mass index on the study day were ± and ± respectively. twenty patients were judged malnourished by the nutric score and twenty two by clinical evaluation. a good correlation was found between nutric score and clinical evaluation of nutritional status (k = . ). conclusion: tunisian icus don't have nutrition team or nutritional written protocol. early enteral feeding and supplementation is common. a good correlation exists between nutric score and clinical nutrition status evaluation. compliance with ethics regulations: yes. rationale: whether more intensive glycemic control (gc) is beneficial or harmful forcritically ill patient has been debated over the last decades. gc has been shown hard to achieve safely and effectively in intensive care. the associated increased hypoglycemia and glycemic variability is associated with worsened outcomes. however, modelbased risk-based dosing approach have recently shown potential benefits, improving significantly gc safety and performances. the stochastic targeted (star) gc framework is a model-based controller using a unique risk-based dosing approach. star identifies modelbased patient-specific insulin sensitivity and assesses its potential variability over the next hours. these predictions are used to assess hypoglycemic risks associated with a specific insulin and/or nutrition intervention to reach a specific target band. this study analyzes preliminary clinical trial results of star in a belgian icu compared to the local standard protocol (sp). the mean age in our series was . years with a male predominance (sex ratio = . ). the main revealing symptoms were epigastralgia, weight loss and vomiting. subtotal gastrectomy was performed in . % of cases and total gastrectomy in . % of cases. curative resection could only be performed in . % of cases. operative mortality was . % and morbidity was . %. the main factor influencing operative mortality was age greater than years. in univariate analysis the main prognostic factors; tumor size, degree of parietal invasion, presence of ganglionic invasion, presence of more than ganglia invaded, presence of metastases, locally advanced tumor, tumor stage and curative nature of resection. patient-related factors such as age associated blemishes and biological factors have a significant influence on the patient's prognosis. the prognosis of gastrectomies, although it has improved overall, remains mediocre. the only way to improve the prognosis remains the early diagnosis with an effective surgical management and the introduction of an adapted resuscitation. compliance with ethics regulations: yes. efficacy of multiple second line agents in refractory status epilepticus in a pediatric intensive care unit lea savary, claire le reun chu tours, tours, france correspondence: lea savary (lea.savary@hotmail.com) ann. intensive care , (suppl ):p- rationale: convulsive status epilepticus (cse) is the most common neurological emergency in children. refractory status epilepticus (rse) occurs whenseizures are not controlled with first-and secondline agents. in adults, rse requires pharmacological induced coma. in pediatric patients, association of second line treatment is often used to avoid general anesthesia although there is currently no data on the efficacy of this association. we performed a monocentric retrospective study to assess the efficacy of multiple second line agents in pediatric rse. all children admitted to clocheville hospital (tours) between january and december with a diagnosis of rse were included. our population was divided into two groups: need of general anesthesia (midazolam+) or not (midazolam-). results: children were included ( in group midazolam+, in group midazolam−) during the study period. among the patients with multiple second line agents, % did not need general anesthesia (n = ). in group midazolam+, cse was % longer in patients treated with multiple second line agents ( rationale: drowning is an acute respiratory failure resulting from immersion or submersion in a liquid. patients and methods: we report cases of drowning collated in the pediatric reanimation department during a period from to . the aim of our retrospective study was to analyze and compare the different epidemiological, clinical, parcalinical, therapeutic and evolutionary of drowning in our study. results: our study contains boys and girls, with a sex ratio (m/f) of , in an age between months and years. for cases studied, no one was classified stage i, . % classified stage ii, % stage iii, and . % stage iv. all cases collected by ou service were victim of accidental drowning, . % were secondary to the lack of parental supervision. among cases, had respiratory complications, cases of hydroelectrolytic disorders, case with infectious complications, cases of neurological and cases of cardiac or hypothermic complication. in our study, cases recovered well and cases died. the survival of the drowned person depends on the speed and efficiency of the intervention, which in thefirst place is prehospital, thus ensuring the first actions at the scene of the accident, which will have repercussions on the hospital care. this has an equal share in the improvement of the victim's prognosis. compliance with ethics regulations: not applicable. epidemiology of severe pediatric trauma following winter sport accidents in the northern french alps emilien maisonneuve , nadia roumeliotis , pierre bouzat , guillaume mortamet chu grenoble, grenoble, france; chu sainte-justine, montréal, canada correspondence: emilien maisonneuve (emilienmaisonneuve@orange. fr) ann. intensive care , (suppl ):p- rationale: this study describes the epidemiology of severe injuries related to winter sports (skiing, snowboarding and sledding) in children, and assesses potential preventive actions. we did a single-center retrospective study in our pediatric intensive care unit in the french alps. we include all patients less than years old, admitted to the intensive care unit following a skiing, snowboarding or sledding accident from to . results: we included patients (mean age . years and % were male); of which ( %), ( %) and ( %) had skiing, snowboarding and sledding accidents, respectively. the average iss (injury severity score) was . the major lesions were head (n = patients, %) and intra-abdominal (n = patients, %) injuries. compared to skiing and snowboarding, sledding accidents affected younger children ( vs. years, p < . ); most of whom did not wear a helmet ( % vs. %, p < . ). severity scores were similar amongst winter sports (iss = for skiing, for snowboarding and for sledding accident, p = . ). rationale: best strategies for the management of severe pediatric traumatic brain injury (tbi) are still not clearly established and wide variations among professional practices have been reported in the literature. unfortunately, these variations in practice have an impact on the patient's outcome. the objectives of this work were to assess the adequacy of professional practices to the guidelines for the management of severe head injury and to assess the level of agreement of respondents in the absence of guideline. patients and methods: a practice survey was conducted in frenchspeaking hospitals in canada, belgium, switzerland and france from april st to june th, . the survey was conducted as a progressive clinical case with questions based on guidelines and the literature from to . the questions related to the assessment and management of tbi during the acute and intensive care phase. results: seventy-eight questionnaires were included. the adherence to guidelines was good, with items out of obtaining an adherence rate of more than % regardless of the annual number of tbi managed by the centre. there was strong agreement among clinicians on the intracranial pressure (pic) (> %) and cerebral perfusion pressure (> %) thresholds used according to age. guidelines for indication of pic monitoring were almost perfectly followed in the case of glasgow score < and abnormal brain ct scan (n = , %). on the other hand, the natremia and glycemia thresholds and the role of transcranial doppler were not consistent. strong adherence to recent recommendations was achieved: seizure prophylaxis with levitracetam (n = / , %) and capnia threshold (n = , %). assessment of o pressure in brain tissue (n = , %) and autoregulation (n = ; %) was not a common practice. conclusion: overall, practices for the management of tbi appear to be standardised. variations persist in areas where there is a lack of literature and guidelines in paediatrics, so clinicians seem to refer to adult guidelines. compliance with ethics regulations: yes. choubeila guetteche chu constantine, constantine, algeria correspondence: choubeila guetteche (cguetteche@gmail.com) ann. intensive care , (suppl ):p- rationale: ingesting a coin cell is a common household accident in children, which can have serious consequences. the goal is to determine prognostic factors to improve management and reduce complications. patients and methods: we conducted a retrospective study including children under admitted in pediatric intensive care between january and may for ingestion of button cells, with epidemiological, clinical and paraclinical data collection. results: twenty-six children boys ( %), and girls ( %) were included, with an average age of months ( - ), increased incidence in recent years. clinical signs indicative were dysphasia with hyper-sialorrhea in cases, cervical pain in one case, respiratory distress in one case, the cell was located in the upper third of the esophagus in cases, third average in cases, third inferior in cases, the mean time before extraction was h. complications: cases of mediastinitis, cases of oesotracheal fistula, a case of perforation. conclusion: the young age of the child, the diameter of the battery, and especially the time of care are risk factors for the occurrence of complications, the prevention passes through the education of the general public and creation of channel of taking into account fast charge. compliance with ethics regulations: not applicable. yacine benhocine university hospital center nedir mohamed, tizi-ouzou, algeria correspondence: yacine benhocine (yacine @yahoo.fr) ann. intensive care , (suppl ):p- rationale: inhalation of foreign bodies is a common and serious accident in children, especially between and years old. at this age, children use their mouth to explore their environment. asphyxia is the immediate risk and respiratory sequelae may appear secondarily. the severity of this incident has been considerably reduced due to the progress of the instrumentation and anesthesia which condition the smooth running of the therapeutic act. aim: to evaluate the anesthetic modalities of the extraction of the foreign bodies of the airways in children, in order to optimize our care with a maximum of security. a prospective, mono-centric, descriptive study from january to november of patients treated for inhalation of foreign bodies in the airways. study population wasdefined by: age, sex, hospitalization context, physical and radiological examination data, anestheticmanagement. results: the average age of the patients was . months, the male predominated ( %), and the hospitalization context was polymorphic. general anesthesia was necessary in all cases, sevoflurane mainly for narcosis; the combination of an opioid in . % of cases and a curare in . %. spontaneous ventilation is desirable, but % was manually broken down intermittently between extraction attempts. cases of desaturation, bronchospasm, bradycardia, and pneumothorax have been reported. . % had a good evolution. discussion: the results of the epidemiological data are consistent with those of the literature. the penetration syndrome is very revealing. the chest x-ray is the key examination, the diagnosis is often based on indirect signs. in case of asphyxia by foreign body enclosed above or between the vocal cords, laryngoscopy and oxygenation is the first step to perform. in other cases, a rigid bronchoscopy is performed under general anesthesia; inhalation induction with sevoflurane is the technique of choice for many experienced authors. controlled ventilation is used in the majority of cases because spontaneous ventilation is not often not possible. the heterogeneity of anesthetic practices accounts for the multiplicity of clinical situations. conclusion: the inhalation of a foreign body is a diagnostic and therapeutic emergency. extraction of the foreign body takes place under general anesthesia, which is difficult and at risk. compliance with ethics regulations: yes. non-invasive neurally adjusted ventilatory assist (nava) in infants with bronchiolitis: a retrospective cohort study alex lepage-farrell, sally al omar, atsushi kawaguchi, sandrine essouri, philippe jouvet, guillaume emeriaud chu sainte justine, université de montréal, montréal, canada correspondence: alex lepage-farrell (alex.lepage-farrell@umontreal.ca) ann. intensive care , (suppl ):p- rationale: bronchiolitis is one main reason for admission to pediatric intensive care unit. most infants are successfully managed with nasal cpap or high-flow nasal cannula, but about a third of these patients are not sufficiently supported and require an alternative support. non-invasive neurally adjusted ventilatory assist (niv-nava) improves patient-ventilator interactions and could therefore improve the effectiveness of non-invasive support. our hypothesis is that niv-nava is feasible in infants with bronchiolitis and that it reduces the respiratory effort. patients and methods: we retrospectively studied all patients under years of age with a clinical diagnosis of bronchiolitis ventilated with niv-nava in our pediatric intensive care unit, between october and june . patients characteristics, respiratory and physiologic parameters, including diaphragmatic electrical activity (edi) were extracted from an electronic medical database (data collected every s). respiratory effort was estimated using the modified wood clinical score for asthma (mwcas) and the inspiratory peak edi, and -h periods before and after niv-nava initiation were compared (wilcoxon rank test). the study was approved by the local research ethics committee. results: during the study period, patients were admitted with bronchiolitis; infants ( boys) with a median ( th- th percentile) age of ( - ) days were treated with niv-nava after a failure of other non-invasive support methods, and all were included. twentyfive subjects ( %) had at least one comorbidity. the interfaces used were predominantly face masks ( %). the maximum ventilatory settings were nava level of . ( . - . ), peep of ( - ) cmh o, fio of % ( - ) and maximal pressure of ( - ) cmh o. total duration of non-invasive ventilation was ( - ) hours, including ( - ) hours in niv-nava. as detailed in the table , mwcas significantly decreased after niv-nava initiation, from . ( . - . ) to . ( . - . ), p < . . a decrease in inspiratory peak edi was also observed, which was particularly clinically relevant in infants with high baseline edi (> mcv). capillary blood ph and pco also significantly improved after niv-nava introduction. six patients ( %) needed escalation to endotracheal intubation. conclusion: this study confirms the feasibility of niv-nava in infants with bronchiolitis after failure of first line non-invasive support, with a low failure rate. niv-nava initiation was followed by a decrease in respiratory effort and an improvement in blood gases. this observational study supports the needs for prospective interventional trial. compliance with ethics regulations: yes. rationale: the use of blood transfusion is frequent in pediatric intensive care units and has increased significantly since . considered as therapeutic, it requires an assessment of the benefit / risk balance before making the transfusion decision. the aim of our study is to describe the transfusion practices in the pediatric resuscitation department of the ehs canastel, algeria. patients and methods: a retrospective observational study over a -month period from january of any blood transfusion performed in hospitalized patients, in the pediatric intensive care unit. we studied : the age, the sex, the history of blood transfusion, the indication of transfusion, the haemodynamic and respiratory parameters, the transfusional accidents, the length of stay in intensive care, the evolution after a blood transfusion. results: these included transfusion patients out of hospitalizations during the -month period, mean age was months.all patients had no transfusion history, % of patients had their anemia admission and % developed it during their stay. the reason for hospitalization was respiratory distress in %, convulsive condition in %, polytrauma in %, and head trauma in %. the indication of the transfusion was placed on a hb inferior or equal to g / dl in % of cases, in % on an hb superior to g / dl in addition to the clinical criteria of intolerance to anemia; in % of the cases no clinical or biological criteria found, the nature of the blood products was of the red cell in % of the cases and of the plasma concentrate in / of the cases and pfc in %. % received a+, % of a-, % of b+, % of o+ and % of o-. % of the patients had a transfusion-like reaction at min after the start of the transfusion; % of the patients were under artificial ventilation and % were under hemodynamic support, % under diuretic.the average length of stay was days; the favorable outcome was % of the patients after the transfusion with an increase in the hb level beginning, % of the patients had complications of their pathology and the death in % of the cases. conclusion: current transfusion practices in children often do not reflect the implementation of our current knowledge of the need for transfusion. hence the need to review the protocols and practice other transfusion alternatives to avoid complications and improve the quality of care. compliance with ethics regulations: not applicable. rationale: bacterial multi drug resistance is medical actuality nowadays, because of its morbidity and mortality especially in intensive care, it constitutes a real problem in our hospitals. we conducted a retrospective descriptive study, to identify bacterial drug resistance profile of patients with cross infections in the department of intensive care in august hospital. this study included patients hospitalized between st january and st december . the data was collected from medical records of this unit as from the register of the bacteriology service of ibn rochd university hospital. results: patients were hospitalized in the resuscitation service, of which had nosocomial infection, an incidence of . %. the mean age of the patients was years with male predominance (sex ratio . ), the average stay in intensive care was days. the site of infection was pulmonary in % of cases, blood in % of cases, urinary in % of cases, central catheter in %, neuro-meningeal in . % of cases. the germs isolated were: acinetobacter baumanii in . % of cases, pseudomonas aeroginosa in . % of cases, klebsiella pneumonia in . % of cases, enterococcus feacalis in . % of cases, e.coli in . % of cases and staphylococcus aureus in % of cases. acinteobacter baumanii showed resistance rates of up to % for the impenem and % for amikacin. regarding pseudomonas, it was resistant to impenem in % of cases and in % of cases to amikacin. compared to klebsiella, resistance to imipenem was % and % for amikacin. the mortality rate of infected patients was % conclusion: in the light of this work, we found that important emergence of multidrug resistance bacteria in intensive care unit is related to not only the immunocompomised state of patients but also to daily bad practices of health professionals such as the misuse of antibiotics. compliance with ethics regulations: yes. overnight culture of escherichia coli, klebsiella pneumoniae, staphylococcus aureus and pseudomonas aeruginosa, was also sequenced. results: twenty-four samples and the pc were analyzed. amplicon sequence analyses found similar results with the two primer pairs in % of cases. cultured pathogen was found in % ( / ) for human primer pair and in % ( / ) for earth primer pair. for each eta, ngs revealed bacteria unknown as pathogen globally identified as oropharyngeal flora in conventional microbiology (table ) . alpha diversity decreased for all vap patients overtime, average shannon . ( ; . ) versus ( . ; . ), and was higher in upper respiratory tract (os) versus lower respiratory tract (eta): average shannon . ( . ; . ) vs. . ( . ; . ) (ns). conclusion: this pilot study highlights the impact of s rdna amplification procedures (especially oligonucleotide sequences) used on the results in microbiome research. concordance between ngs and bacterial culture, as well as similar evolution of the alpha diversity than previously described ( ), enables us to validate our methodology using the "gut primers" pair f- r. these findings allow furthers major studies on the pulmonary microbiome of icu ventilated patients including comparison according to the occurrence of a vap or not. compliance with ethics regulations: yes. rationale: in the field of intensive care only few studies have explored bacterial microbiota whereas virome remained hardly considered. it appears essential to describe both evolution in mechanically-ventilated patients to improve the pathophysiological understanding of ventilator-associated pneumonia (vap) development. to date no study had been simultaneously conducted on lower respiratory tract with a single nucleic acid extraction before metagenomics analysis of bacterial microbiota and virome. we conducted a preliminary study to validate our methodology based on a common automated extraction of nucleic acids. patients and methods: twelve mechanically ventilated patients were selected: five who developped (vap) and seven controls (c) who did not. endotracheal aspirate (eta) were collected between intubation and day (or dvap for vap patients). conventional bacterial microbiology and multiplex respiratory viruses pcr were also performed. total nucleic acids were extracted using nuclisens easymag extractor. for the bacterial microbiota, region v of the s rrna genes was amplified. for the virome, the nextera dna xt kit (illumina) and rna seq trio kit (nugen) protocols were used to prepare viral dna and rna libraries. libraries underwent paired-end sequencing on the illumina miseq (bacteria) or nextseq- (virus) platform. after bioinformatics analysis we compared the performance of metagenomics analysis with conventional bacterial culture and other common viral detection methods. results: for culturable bacteria, concordance between conventional microbiology and sequencing was found in % ( / table . our preliminary results confirm the feasability of exploring both bacterial microbiota and virome on the same sample using a common extraction method. data from metagenomics were highly concordant with conventionnal detection methods for known pathogenic viruses and bacteria in lower tract respiratory sample and enables identification of other microorganisms. this is the first step for a large cohort study that aims to compare evolution of global lung microbiome in patients at risk of vap and assess how bacteria and virus interplay. compliance with ethics regulations: yes. references . clancy department of medical and toxicological critical care, lariboisière hospital one microorganism was isolated in . % and two in . % of cases. the main isolated microorganism were enterobacteriaceae in . % of patients. they were esbl-producers in . % of cases. initial antibiotic therapy was appropriate in . % of cases. factors independently associated with esbl-pe as the causative microorganism of icu-bsi were esbl-pe carriage prior to icu-bsi the sensitivity of esbl-pe carriage to predict esbl-pe as the causative microorganism of icu-bsi was . %, and specificity was . %. mortality at days was . % in the general population in multivariable analysis, there was no parameter which was independently associated to mortality at day from the occurrence of icu-bsi. conclusion: icu-bsi complicates . % of admission to icu and was associated with % in-hospital mortality assessing and applying individualized treatment for group a streptococcal necrotizing soft-tissue infection is possible service de réanimation médicale intensive care decompressive craniectomy in traumatic brain injury: about cases karama bouchaala sex ratio of . . the mean (sd) length of stay in icu was . ± . days. the mean glasgow coma score (gcs) (sd) was . ± . and gcs ≤ in . %. sofa score > was found in patients ( . %) and sapsii score ≥ in patients ( . %). the cerebral ctscan at admission showed acute subdural hematoma (asdh) in ( . %), cerebral oedema ( . %) and cerebral contusions ( %) teaching: fresenius medical care; patent or product inventor: gml czech republic banydeen rishika: no conflict of interest baptiste amandine: no conflict of interest baptiste olivier: no conflict of interest barbar saber davide: no disclosure barbier françois: no disclosure barbierlouise: trainings, teaching: ethicon, astellas; invitation to national or international congresses: sandoz, astellas barnerias christine: no disclosure baron aurore: no disclosure baron elodie: no conflict of interest barr att -due andreas: no disclosure barrau stephanie: no disclosure barraud damien: no disclosure barraud helene: no disclosure barrois brigitte: no conflict of interest baruchel andré: no disclosure bastide marie anaïs: no conflict of interest baudel jean-luc: no conflict of interest baudin florent: invitation to national or international congresses: dr baudin has received speaking fees from maquet critical care (epnv teaching: drager; invitation to national or international congresses: msd; hill rom beganton frankie: no conflict of interest begot erwan: no disclosure beinse guillaume: research support/scientific studies: association pour la recherche contre le cancer ion and fresenius kabi bensaid abdelhak: no disclosure bensardi fatimazahra: no disclosure benyamina mourad: no disclosure benzerara laurent: patent or product inventor: aphp benzerdjeb nazim: research support/scientific studies: amarape, icap; consultancy, expert: alphasights, msd; trainings, teaching: msd beqiri erta: no disclosure bÉranger agathe: no conflict of interest berard emilie: no conflict of interest berdai adnane: no disclosure berger patrick: no disclosure bernal william: no disclosure bernardin gilles: no disclosure berrada lina: no conflict of interest berthaud romain: no conflict of interest berthet guillaume: no conflict of interest berti enora: no conflict of interest bertoli sarah: no disclosure bertrand pierre-marie no conflict of interest besbes lamia: no disclosure besbes mohamed: no conflict of interest besch camille: invitation to national or international congresses: abbvie no conflict of interest boisseau chloé: no disclosure boissel nicolas: no disclosure boissier florence: no conflict of interest boivin alexandra: no conflict of interest bonacorsi stéphane: no conflict of interest bongiovanni filippo: no conflict of interest bonnardel eline: no conflict of interest bonnefoy-cudraz eric: no disclosure bonnet sixtine: no conflict of interest bonnevie tristan: research support/scientific studies invitation to national or international congresses: fresenius kabi and fresenius medi-calcare bucur petru: no disclosure buetti niccolo: research support/scientific studies: swiss national science foundation research grant and bangerter rhyner foundation supporting my postdoc bui hoang-nam: no disclosure burelli gabrielle: no conflict of interest burgel pierre-régis: no disclosure burghi g: no conflict of interest bustarret olivier: no conflict of interest butin-druoton anne-lise: invitation to national or international congresses expert: astra-zeneca; invitation to national or international congresses expert: hamilton medical; invitation to national or international congresses: hamilton medical chemli wael: no conflict of interest chenouard alexis: no conflict of interest cherkab rachid: no conflict of interest chevret sylvie: no disclosure chhun stephanie: no conflict of interest chiche jean-daniel: no disclosure chicoisneau maxence: no conflict of interest chlilek abdelaziz: no disclosure chocron richard: consultancy, expert: aspen chommeloux juliette: no conflict of interest chomton maryline: no conflict of interest chosidow olivier: no disclosure chouchana laurent expert: biotest; invitation to national or international congresses: sanofi research support/scientific studies: fresenius medical care; consultancy, expert: fresenius medical care; invitation to national or international congresses: xenios novalung, heilbronn, germany dachraoui fahmi: no disclosure dahoumane redouane: no conflict of interest dahyot-fizelier claire: no disclosure daix thomas: no conflict of interest daly foued: no conflict of interest damonti lauro: no conflict of interest dantan etienne: no conflict of interest darmon michaël: research support/scientific studies: msd no disclosure das vincent: no disclosure daubin cedric: no conflict of interest daubin delphine: no conflict of interest daudon michel: no disclosure daufresne pierre: no conflict of interest dauger stéphane: no conflict of interest daviet florence: invitation to national or international congresses: sandosz de courson hugues: no conflict of interest de jong audrey: trainings, teaching: baxter, medtronic; invitation to national or international congresses teaching: cardiosleep delhaes laurence: no disclosure delignette marie-charlotte: no conflict of interest dellamonica jean: trainings, teaching: medtronic; invitation to national or international congresses: msd, general electrics delpierre clément: no conflict of interest delville marianne: no conflict of interest demailly zoé: research support/scientific studies: srlf demarest elsa: no disclosure demaret pierre: no conflict of interest demiselle julien: no conflict of interest demondion pierre: no conflict of interest demoule alexandre: research support/scientific studies: drager, philips; consultancy, expert: baxter, respinor, lungpacer; trainings, teaching: fisher & paykel, hamilton, baxter; invitation to national or international congresses: fisher & paykel denis manon: no conflict ofinterest depeyre fanny: invitation to national or international congresses: pfizer deplante yvon: no conflict of interest dequin pierre-françois: research support/scientific studies: medimmune combioxin ferring pharmaceuticals a/s asahi kasei pharma america corporation derauglaudre lucie: no conflict of interest derbel karim: no disclosure derkaoui ali: no disclosure dervin krystel: no conflict of interest desaive thomas: no conflict of interest desguerre isabelle: research support/scientific studies: ptc inc, avexis; consultancy, expert: avexis, ptc inc, biogene; trainings, teaching: roche, ptc inc, avexis; invitation to national or international congresses: sarepta, biogen, avexis, biomarin desnos cyrielle: no conflict of interest desroys du roure françois: no conflict of interest detollenaere charles: no conflict of interest devaquet jérôme: invitation to national or international congresses expert: lungpacer; invitation to national or international congresses: lungpacer dreyfuss didier: research support/scientific studies: grant from french ministry of health drouot xavier: no disclosure du cheyron damien: no conflict of interest dubÉ bruno-pierre: consultancy, expert: novartis, gsk dubert marie: no conflict of interest dubost baptiste: no conflict of interest dubost jean-louis: no conflict of interest duburcq thibault: no conflict of interest duchemann boris: consultancy, expert: bms, msd, roche; invitation to national or international congresses no conflict of interest frÉrou aurélien: no conflict of interest fritz caroline: no disclosure fromentin mélanie: research support/scientific studies: msd; invitation to national or international congresses: msd frouin antoine: no conflict of interest frugier alexandre: no disclosure gaboriau louise: no conflict of interest gaci rostane: invitation to national or international congresses: bard gacouin arnaud: no disclosure gaddas mehdi: no conflict of interest gaillard arnaud: trainings, teaching: zoll medical gaimard sophie: no conflict of interest gainnier marc: no conflict of interest galbois arnaud: no conflict of interest galerneau louis-marie: invitation to national or international congresses: agir À domicile galicier lionel: consultancy, expert: novartis, eusapharma; trainings, teaching: baxalta, pfizer; invitation to national or international congresses no conflict of interest ichaÏ philippe: no conflict of interest imen sioud: no conflict of interest ioos vincent: no disclosure iserin franck: no disclosure issa nahema: no conflict of interest jaber samir: consultancy, expert: drager, fisher-paykel; medtronic; baxter xenios fresenius; invitation to national or international congresses: drager no conflict of interest jacq gwenaëlle: no conflict of interest jacquet emmanuelle: research support/scientific studies: unicancer (esme and storm studies invitation to national or international congresses: pfizer université laval-qc-ca labbe vincent: no disclosure labro laura: no disclosure lacaille florence: no conflict of interest lacampagne alain: no disclosure lacan claire: no conflict of interest lacherade jean-claude: no conflict of interest ladjemi maha-zohra: no conflict of interest lafon charles: no conflict of interest lafon marie-edith: no disclosure lafon thomas: no conflict of interest lagache laurie: invitation to national or international congresses advertising documents: philips; trainings, teaching: novartis, gsk, astra zeneca, boeringher; invitation to national or international congresses: chiesi, astra zeneca, sos oxygene, novartis, boeringher lamoth frédéric: consultancy, expert: gilead, msd, basilea; invitation to national or international congresses: msd expert: norgine; trainings, teaching: fujifilm, boston scientific lebreton guillaume: no disclosure lebrun-vignes benedicte: research support/ scientific studies: novartis; consultancy, expert: ansm lebuffe gilles: no disclosure leclerc maxime: no conflictof interest lÉcluse aldéric: research support/scientific studies: pgrx avc study; consultancy, expert: bms-pfizer, boerhinger ingelheim, bayer; invitation to national or international congresses: bms-pfizer, boerhinger ingelheim ledoux didier: no disclosure lefebvre francois: no conflict of interest macloughlin ronan: research support/scientific studies: aerogen ltd no conflict of interest mari arnaud: no conflict of interest marie damien: no conflict of interest marijon eloi: no disclosure mariotte eric: consultancy, expert: sanofi-aventis marjanovic nicolas: no disclosure marjanovic zora: no disclosure maroni arielle: no conflict of interest marot benoit: no conflict of interest marque sophie: no conflict of interest marti teaching: zambon, chiesi; invitation to national or international congresses no conflict of interest matusik elodie: no conflict of interest mauchien benedicte: no conflict of interest maury eric: research support/scientific studies: doran international, drager; trainings, teaching: vygon maxime virginie: no conflict of interest mayaux julien: invitation to national or international congresses stock shareholder: tanderev; patent or product inventor: tanderev mercat alain: research support/scientific studies: fisher-paykel, general electric; consultancy, expert: faron pharmaceuticals no disclosure merhabene takoua: no conflict of interest merle jean-claude: no disclosure mesotten dieter: no conflict of interest messaadi amenallah: no conflict of interest messika jonathan: invitation to national or international congresses: cslbehring; fisher&paykel metaxa victoria: no disclosure metogo mbengono junette arlette: no conflict of interest meunier anne: no conflict of interest meurice jean-claude: no disclosure meybeck agnes: consultancy, expert: janssen, gilead; invitation to national or international congresses teaching: msd no conflict of interest morimont philippe: no conflict of interest moro-sibilot denis: no disclosure mortamet guillaume: no conflict of interest mosbah nabil: no conflict of interest moschietto sebastien: no conflict of interest moucadel virginie: research support/scientific studies: biomérieux moulaire rigollet valérie: no disclosure mouliade charlotte: no conflict of interest moulin florence: no disclosure mounir yousfi: no conflict of interest mourabit karima: no disclosure mourvillier bruno: trainings, teaching: msd research support/scientific studies: aerogen; advertising documents: aerogen; patent or product inventor: aerogen musiari michele: no conflict of interest n'guyen quang-thang: no conflict of interest n'guyen tran: no disclosure nabil mosbah: no disclosure naccache lionel: no disclosure naimi skander: no conflict of interest nakaa sabrine: no disclosure nallet-amate megan: no conflict of interest natalis eloïse: no disclosure naudin jérôme: invitation to national or international congresses: novartis nay mai-anh: no conflict of interest nemlaghi safaa: no conflict of interest neofytos dionysios: research support/scientific studies: msd; consultancy, expert: msd, gilead, pfizer; invitation to national or international congresses: gilead, pfizer nesseler nicolas: no conflict of interest neviere remi: no disclosure nguyen alexandre: no disclosure nguyen khoa thao: no conflict of interest nicolau-travers marie-laure: no disclosure niÉrat marie cécile: no conflict of interest nieszkowska ania: no disclosure nigeon olivier: no conflict of interest nitel gautier: no conflict of interest nodea elena madalina: no conflict of interest noel marine: no conflict of interest nogier marie-béatrice: no disclosure noorah zaid: no disclosure nouira wiem: no conflict of interest noumeir rita: stock shareholder: softmedical noury norbert: no conflict of interest novy emmanuel: research support/scientific studies: msd; invitation to national or international congresses: pfizer expert: air liquide medical system ollivier veronique: no conflict of interest onimus thierry: no conflict of interest oppenheimer anne: invitation to national or international congresses: gedeon richter orkisz maciej: no conflict of interest orliaguet gilles: research support/scientific studies research support/scientific studies: oxynov; patent or product inventor: oxynov patrier juliette: no conflict of interest paugam catherine: no disclosure paul marine: no conflict of interest paul-bellon rachel: no disclosure paulo nicolas: no conflict of interest pavot arthur: invitation to national or international congresses: fresenius medical care france pehlivan jonathan: no conflict of interest peigne vincent: invitation to national or international congresses: air liquide pÉju edwige: no conflict of interest pene frédéric: consultancy, expert: alexion pÉpin-lehalleur adrien: invitation to national or international congresses: chiesi pere morgane: no conflict of interest pereira bruno: no disclosure perez didier: no disclosure perez pierre: no disclosure perez yonatan: no conflict of interest perier françois: no disclosure perin nicolas: no conflict of interest biomerieux robin emmanuel: no conflict of interest robin nicolas: no disclosure robineau olivier: no disclosure roch antoine: no disclosure roche anne: no conflict of interest roger claire: consultancy, expert: pfizer, fre-senius medical care; invitation to national or international congresses: msd,pfizer rolle amélie: no conflict of interest rondeau eric: no disclosure ronziÈre thomas: no disclosure roquilly antoine: no disclosure rosselli sylvène: no disclosure rouby jean-jacques: no disclosure rouis sana: no conflict of interest rouleau stéphane: no conflict of interest roulet sylvie: no disclosure roulland charlotte: no disclosure roumeliotis nadia: no conflict of interest rousse natacha: no disclosure rousseau anne-françoise: invitation to national or international congresses no disclosure sagnier anne: no disclosure saillard colombe: trainings,teaching: amgen, novartis; invitation to national or international congresses no conflict of interest schmidt aline: no disclosure schmidt matthieu: consultancy no disclosure schultz marcus: no conflict of interest schwebel carole: invitation to national or international congresses: pfizer scicluna brendon: no disclosure sculier jean-paul: no conflict of interest see perrine: no conflict of interest seghboyan jean-marie: no disclosure seguin amelie: no conflict of interest seguin philippe: consultancy, expert: lfb; invitation to national or international congresses: astellas sejourne caroline: no conflict of interest sellami walid: no conflict of interest sendid boualem: research support/scientific studies: allfun project, fp european commission; invitation to national or international congresses: pfizer senhadji lahcen: no conflict of interest serbouti rita: research support/scientific studies: fresenius medical care; consultancy, expert: fresenius medical care; trainings, teaching: fresenius medical care; invitation to national or international congresses: fresenius medical care serfaty lawrence: no disclosure sÉrie mathieu: no conflict of interest shaw geoffrey m.: no conflict of interest shi rui: no conflict of interest shimi abdelkrim: no disclosure shojaei maryam: no disclosure si-tahar mustapha: consultancy, expert: cynbiose respiratory; stock shareholder: cynbiose respiratory siami shidasp: no conflict of interest silva daniel: research support/scientific studies: fresenius medical care france; consultancy, expert: fresenius medical care france; invitation to national or international congresses: xenios novalung, heilbronn no conflict of interest sirault bruno: no disclosure sirodot michel: no disclosure slama michel: no disclosure slim amine: no disclosure smielewski peter: no disclosure soares marcio: stock shareholder: epimed solutions teaching: gilead; invitation to national or international congresses: pfizer spagnoletti marco: no conflict of interest steckelmacher claire: no disclosure stockx luc: research support/scientific studies: phenox, medtronic; consultancy no conflict of interest voiriot guillaume: research support/scientific studies: biomérieux, sos oxygène, janssen; consultancy, expert: biomérieux; invitation to national or international congresses: biomérieux von kietzell matthias: invitation to national or international congresses expert: aguettant; invitation to national or international congresses: vifor yacoubi wejden: no conflict of interest yager hélène: no conflict of interest yahya yosra: no conflict of interest yakini khalid: no disclosure yakouben karima: no disclosure yonis hodane: invitation to national or international congresses: lvl medical et pfizer younan romy: no conflict of interest youssoufa atika: no disclosure zacharia mahi: no disclosure zafrani lara: research support/scientific studies: jazz pharmaceuticals zambon olivier: no disclosure zaouak nadia: no conflict of interest zaouche khedija: no conflict of interest zarrougui wafa: no conflict of interest ze minkande jacqueline: no disclosure zeghdoud dalila: no disclosure zerbib yoann: no conflict of interest zerhouni amel: no conflict of interest zerhouni amine: no conflict of interest zerimech farid: no conflict of interest zerouali khalid: no disclosure zheng yi: no conflict of interest zimmerli stefan: research support/scientific studies: msd, pfizer, gilead; consultancy, expert: msd, pfizer; trainings, teaching: gilead; invitation to national or international congresses springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations farhat hached hospital, sousse, tunisia; yassminet regional hospital, ben arous, tunisia; habib bougatfa regional hospital, bizerte, tunisia; larabta hospital, tunis, tunisia; carthagene private hospital, tunis, tunisia; regional hospital of zaghouan, zaghouan, tunisia; regional hospital of tozeur, tozeur, tunisia; habib thameur hospital, tunis, tunisia correspondence: samia ayed (samia.ayed@yahoo.fr) ann. intensive care , (suppl ):p- geoffroy hariri, kyann hodjat-panah, laurene blum, jean-rémi lavillegrand, idriss razach, naike bige, jean-luc baudel, bertrand guidet, eric maury, hafid ait-oufella médecine intensive-réanimation, hôpital saint-antoine, paris, france correspondence: geoffroy hariri (geoffroyhariri@hotmail.com) ann. intensive care , (suppl ):p- rationale: hemolytic anemia (ha) is a common condition in intensive care unit but its diagnosis remains challenging. free hemoglobin (and heme) degradation leads to co release that can bind to hemoglobin to form carboxyhemoglobin (hbco). we hypothesized that hbco concentration could be used as a reliable diagnosis tool for ha. patients and methods: we performed a monocentric retrospective study in a -bed intensive care unit at st antoine hospital, paris, between and . all patients hospitalized for ha with arterial hbco dosage at admission were included. arterial hbco was measured in routine in our department with an il system ph/ blood gas analyzer. demographic and biological data were collected. a group control of patients with non-hemolytic anemia (hb < g/ dl) (nha) was also included. finally, we analyzed patients outcome according to hbco changes during icu stay. results: between and , patients with ha were included. nha patients were included in the control group. patients with ha were younger than patients with nha ( [ ; ] vs. [ ; ] years old, p = . ) but admission sofa was not different between groups ( [ ; ] , vs. [ ; ] , p = ns). among patients with ha, % had thrombotic microangiopathy, % had autoimmune hemolytic anemia and % had sickle cell disease. at icu admission, ha patients had higher hbco level than patients with nha ( . [ . ; . ] vs. . [ . ; . ] %; p < . ). hbco was a reliable biomarker of hemolysis (auc . ( . ; . ) p < . ). an hbco level threshold at . % identify hemolysis with a sensitivity ( - ) % and a specificity ( - ) %. in ha group, hbco was negatively correlated to hb level (r = . ; p < . ). in ha patients, changes of hbco level during icu management were associated with outcome, decreasing in survivors ( . [ ; . ] vs. . [ . ; . ] ; p = . ) but not in non-survivors ( . [ . ; . ] vs. . [ . ; . ] %; p = . ). conclusion: carboxyhemoglobin is a reliable diagnosis and prognosis biomarker for hemolytic anemia in icu compliance with ethics regulations: yes. rationale: thrombocytopenia is the most commonly hemostatic disorder encountered in intensive care, present in to % of patients. the mortality associated with this thrombocytopenia, the numerous pathological contexts associated with resuscitation and the lack of a recommended management strategy led to the establishment of these guidelines. the aim of our study was to determine the incidence, causes and risk factors associated with the occurrence of thrombocytopenia, as well as the impact of thrombocytopenia on the mortality and length of stay in the icu ibn medical resuscitation unit. rochd de casablanca, over a period of months. patients and methods: this was a prospective study, carried out in the medical resuscitation department of ibn rochd university hospital in casablanca over a period of months. there were two groups: ''sick'' group with thrombocytopenia with a platelets count < , / mm , and a ''control'' group without thrombocytopenia. patients with previous platelet disorders, hematologic malignancies, and patients undergoing chemotherapy were excluded. of the patients included, episodes of thrombocytopenia were identified, anoverall incidence of . %. sepsis was incriminated times ( . %), followed by ards in patients ( . %), massive filling in patients ( . %), disseminated intravascular coagulation in patients ( . %), and massive transfusion in patients ( . %). the drug origin was incriminated in patients ( . %). it was due to quinolones and imipenem. the mortality rate was deaths ( . %) which was inversely proportional to the lowest platelet count in the thrombocytopenia group, compared to deaths ( %) in the control group. the mean duration of stay in the thrombocytopenia group was ± days with extremes ranging from to days. conclusion: thrombocytopenia was a common abnormality in the intensive care system, it occured in many pathological situations and was a factor of morbidity and excess mortality. the most common etiology in this study was sepsis. the diagnostic and therapeutic approach depended on the particular clinical context in which thrombocytopenia occurs. its onset may constitute a hematological emergency, particularly when there is a major mucocutaneous and / or visceral hemorrhagic syndrome, which necessitates a rapid etiological diagnosis, and the establishment of an effective treatment, both symptomatic and specific. compliance with ethics regulations: not applicable. marc pineton de chambrun , romaric larcher , frédéric pene , laurent argaud , alexandre demoule , rémi coudroy , elie azoulay , yacine tandjaoui-lambiotte , stanislas faguer , alain combes , charles-edouard luyt , zahir amoura sorbonne université, aphp, hôpital la pitié-salpêtrière, institut de cardiométabolisme et nutrition (ican), service de médecine intensive-réanimation, paris, paris, france; rationale: catastrophic antiphospholipid syndrome (caps), the most severe manifestation of antiphospholipid syndrome (aps), is characterised by simultaneous thromboses in multiple organs. diagnosing caps can be challenging but its early recognition and management is crucial for a favourable outcome. this study was undertaken to evaluate the frequencies, distributions and ability to predict mortality of "definite/probable" or "no-caps" categories of thrombotic aps patients requiring admission to the intensive care unit (icu rationale: septic acute kidney injury (s-aki) is a frequent complication in critically ill patients and is associated with high morbidity and mortality. it is well known that chronic kidney disease increases the risk of pulmonary embolism (pe), but few studies have investigated the relationship between acute kidney injury (aki) and pe occurrence in septic patients. the aim of this study is to determine whether patients with aki are at increased risk of developing pe. patients and methods: were included, in a prospective study conducted over months (january -june , ) in a medical surgical intensive care unit, all the patients older than years with septic shock at admission or during hospitalization. two groups were compared: patients with kidney injury (aki+ group) and patients without kidney injury (aki− group). we studied the occurrence of pe in these two groups. results: we included patients. the mean (sd) age was . ( ± ) years. sex ratio was . . thirty one ( . %) patients developed pe. the occurrence of pe was significantly higher in (aki + group) [ patients ( %) vs. patients ( %); p = . ]. the incidence of pe according to kidney injury severity was patients ( %) kdigo i, patients ( %) kdigo ii, patients ( %) kdigo iii. in the aki+ group, pe was significantly associated with increased sofa score at admission ( points vs. points; p = . ), lower platelets count ( , vs. , ; p = . ), higher lacatatemia at septic shock day [ . vs. . mmol/l; p = . ] and higher c reactive protein level [ mg/l vs. mg/l; p = . ]. in a multivariate analysis the pe risk factors in (aki+ group) were thrombopenia (odds ratio = . ; ci [ . - . ], p = . ) and c-reactive protein value (odds ratio = . ; ci[ . - . ], p = . ). discussion: the increased risk for pe with aki may be due to endothelial involvement, vascular injury and the related changes found in procoagulant proteins (increased levels of fibrinogen, factor vii, factor viii, von willebrand factor, and plasminogen activator inhibitor- ). in our study, lower platelet and higher c reactive protein level were found in patients with pe, suggesting the participation of disseminated intravascular coagulation. these factors may contribute to increase pe risk. conclusion: the risk of pe is higher in septic patients with aki than in those with normal kidney function. therefore, because of paucity of evidence, larger studies are needed to understand pe pathway in septic aki and to establish efficient prophylaxis protocols. compliance with ethics regulations: yes. and of these patients ( . %) required intensive care. the lasted were males ( %) and a majority ( %) were younger than years of age. in intensive care patients, only ( . %) had nosocomial infection, majority were community acquired infections ( . %) with ( %) pneumoniae, ( . %) profound abscess, pyelonephritis ( . %), ( %) meningitidis. patients( %) required mechanical ventilation for days ( % ci - ), length of stay in icu was days ( % ci - ) and mortality rate was %. conclusion: hmkp infections lead young patients in intensive care unit in one third of case with a majority of pneumoniae requiring mechanical ventilation and with a high rate of mortality. furthers studies are needed to investigate the role of this particular strain in severity. compliance with ethics regulations: yes. rationale: infections secondary to snakebite occur in a number of patients, and are potentially life-threatening. bothrops lanceolatus bites in martinique average thirty cases per year and may result in severe thrombotic and infectious complications. we aimed to investigate the infectious complications related to bothrops lanceolatus bite. patients and methods: a retrospective single-center observational study over seven years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) was carried out, including all patients admitted to the hospital due to bothrops lanceolatus bite. clinical and biological data were reported using the dx care, x-plore et cyberlab softwares of the emergency medicine and analyzed. one hundred and seventy snake-bitten patients ( males and females) were included. thirty-nine patients ( %) presented grade or envenoming. twenty patients ( %) developed wound infections. the isolated bacteria were aeromonas hydrophila ( cases), morganella morganii ( cases), group a streptococuss, and group b streptococcus (one case each). patients were treated empirically with third-generation cephalosporin (or amoxicillin/clavulanate), aminoglycoside and metronidazole combinations. outcome was favorable. the main factor significantly associated with the occurrence of infection following snakebite was the severity of envenoming (p < . ). our findings clearly point towards the frequent onset of infectious complications in b. lanceolatusbitten patients presenting with grade and envenoming. conclusion: infectious bite-related complications of bothrops lanceolatus account for approximately % of the cases, with a strong predominance for grade iii and iv. thus, based on the bacteria identified in the wounds; we suggest that empiric antibiotic therapy including third-generation cephalosporin should be administered to those patients on hospital admission. compliance with ethics regulations: yes. rationale: endocrine abnormalities have been reported with varying frequencies, following traumatic brain injury (tbi). few studies have examined the clinical features and outcomes of isolated acute thyrotropic hormone deficiencies after tbi. theaim of the study was to evaluate the early changes in thyrotropic hormone levels after traumatic brain injury (tbi) and to evaluate whether hormone changes are related to outcome patients and methods: we conducted a months long prospective cohort, including all patients admitted to a university hospital icu with moderate to severe traumatic brain injury (tbi), defined as a glasgow coma scale below twelve (gcs < ). blood samples for basal hormone values of thyroid-stimulating hormone (tsh) and free thyroxine (ft ) were obtained on days , , and . tsh serum concentrations were considered normal at > . mu/l; ft at > pmol/l. a thyrotropic insufficiency was defined as low ft and low tsh plasma levels. all patients were screened with a brain mri. patients were also monitored for neurological deterioration, including cognitive decline, convulsive seizures, increase in cerebral edema and brain herniation that were simultaneous to the diagnosis. results: during our study period's, trauma patients were admitted to our icu and met the inclusion criteria. on admission, our patients had a mean age at . ± , a mean injury severity score (iss) at ± , a mean abbreviated injury severity (ais) of the head at . ± . and a mean gcs at ± . of the patients a thyrotropic insufficiency was diagnosed in patients ( %) during the first days. the median delay to thyrotropic insufficiency diagnosis was days. in three of ( %), the thyrotropic insufficiency was nonrecovering during the patient's icu stay and was transient for the rest. none of the patients with acute thyrotropic insufficiency had direct hypothalamic or pituitary lesions on the brain mri. factors associated to the occurrence of acute thyrotropic insufficiency were: the ais of the head ( . ± . vs. ± . , p = . ), cerebral contusions ( % vs. %, p = . ), subarachnoid haemorrhage ( % vs. %, p = . ) and subdural haematoma ( % vs. %, p = . ). thyrotropic insufficiency was associated to neurological deterioration (p = . ) on the day of diagnosis but did not affect icu mortality ( % vs. %, p = . ). in this study, low pituitary-thyrotropic axis hormone levels were found in the acute phase of tbi and were associated to neurological deterioration but with no perceived effect on icu mortality. compliance with ethics regulations: yes. rationale: acute diabetes insipidus following head injury and its effect on patients outcome have not been sufficiently evaluated in large prospective studies. the aim of this study was to determine the incidence of acute cdi, delay of onset predictive factors and its impact on tbi patients. we conducted a prospective cohort, including all patients admitted to icu with moderate to severe tbi, defined as a glasgow coma scale (gcs) below twelve. for each tbi patient plasma sodium was measured daily, and if abnormally high, urine specific gravity and osmolality were measured. cdi was diagnosed using the seckl and dunger criteria. acute cdi was defined as cdi diagnosed in the first week following injury. all patients were screened with a brain mri. results: during our study's period, trauma patients were admitted to our icu, presented with moderate to severe tbi and were included. on admission, our patients had a mean age at . ± , a mean injury severity score (iss) at ± , a mean abbreviated injury severity (ais) of the head at . ± . and a mean gcs at ± . twenty-three percents ( patients) of the patients developed hypernatremia and % ( patients) were diagnosed with acute cdi. in of ( %), the cdi was nonrecovering. the median delay to develop transient cdi was h and for non-recoviring cdi was h (p = . ). none of the patients with acute cdi had direct hypothalamic or pituitary lesions. factors associated to the occurrence of acute cdi were: younger age ( ± vs ± , p = . ), neuro-surgery ( % vs. %, p < . ), hemorrhagic shock ( % vs. %), p < . ), cerebral edema ( % vs. %), p < . ), and fractures to the base of the skull ( % vs. %, p = . ). patients who developed cdi had a significantly higher mortality than those who did not ( of ( %) vs. of ( %), p < . ). there were no difference in terms of mortality between non-recovering and transient cdi ( % vs. %, p = . ), similarly the onset of cdi did not affect mortality ( h vs. h, p = . ). patients with acute cdi had poor glasgow outcome scale ( ± . vs. . ± . , p < . ) and longer icu los ( ± vs. ± , p = . ). conclusion: acute cdi is associated with higher mortality and poor outcome. therefore it is essential to diagnose and treat it promptly and correctly. compliance with ethics regulations: yes. acute glucocorticoid deficiency following traumatic brain injury mariem dlela, rania ammar zayani, abir bouattour, najeh baccouche, mounir bouaziz habib bourguiba hospital, sfax, tunisia correspondence: mariem dlela (mariem @gmail.com) ann. intensive care , (suppl ):p- rationale: published data demonstrates that long-term hypopituitarism could be common after traumatic brain injury (tbi).however, few studies focused on radiological, clinical, and repetitive endocrine assessment in the acute phase. the aim of the study was to evaluate the early changes in the adrenal axis following (tbi) and to evaluate whether hormone changes affect patient's outcome. we conducted a prospective study, including all patients admitted to a university hospital icu with moderate to severe traumatic brain injury (tbi), defined as a glasgow coma scale below twelve (gcs < ). each patient underwent sequential measurement of plasma cortisol (pc) on days , , and after tbi. we defined adrenal insufficiency as pc less than ng/ml. patients who received glucocorticosteroid therapy were excluded. outcome was measured by incidence of death, and glasgow outcome scale (gos) on day thirty. souhila sadat, dalila zeghdoud, dalila bougdal, kamel guenane ehs salim zemirli, alger, algeria correspondence: souhila sadat (sadatsouhila@hotmail.fr) ann. intensive care , (suppl ):p- rationale: the renewed interest in the pathophysiology of severe traumatic brain injury (tcg), allowed the understanding of the pathophysiological mechanisms leading to neuronal death.the non-invasive, easy, patient-based technical dtc allows evaluation of cerebral blood flow. purpose of the study: to determine the contribution of transcranial doppler (dtp) in the prevention of post-traumatic ischemia. patients and methods: a monocentric, observational, prospective study over a period of years, including tcg in the monitoring of cerebral blood flow (dsc) was provided by the dtc. we collected the following data: age, gender, lesion mechanism, lesion association, glasgow score at admission, time to perform the initial scan, time to perform the initial doppler, various abnormalities found at the initial dtp, the analysis of the level of map according to each situation of cerebral blood flow, the proposed therapies, the time to obtain a correct dtc. ( %), the statistical analysis showed no difference between the delay in setting up a hypohemia and the presence of a correct cerebral blood flow (p = . ), the statistical analysis of the map in the dtc group hypohemia compared to the correct dtc group objectified the absence significant difference between the two groups. the realization of dtp allowed therapeutic prioritization, the introduction of norepinephrine was in % of cases, osmotherapy in % of cases, optimization of sedation in . % of cases, the introduction of penthotal in . % of cases and the completion of decompressive in . % of cases. statistical analysis of mortality showed a significant difference in mortality (p = . ) in the hypohemic dtc group compared with the correct doppler . conclusion: ttc is an essential monitoring tool of cerebral hemodynamics, which may in prove the neurologic outiome of tcg. compliance with ethics regulations: yes. rationale: hyponatremia is a frequent electrolyte disturbance in hospitalized patients. it is particularly common in brain-injured patients with significantly elevated morbidity and mortality. the aim was to study the prevalence of hyponatremia in the acute phase of post-traumatic cerebral aggression, its degree of severity, its predictive factors as well as its prognostic impact in the population of post-traumatic brain injury. patients and methods: this is a retrospective study, carried out over a period of years about all traumatized head patients who developed hyponatremia during the first h of their stay. the descriptive part treated all patients who developed hyponatremia by detailing its different stages of severity.the analytical part treated the patients who developed a hypo-osmolar hyponatremia with a threshold of mmol/l retained to define the severity. during the study period, the incidence of hyponatremia in head trauma patients was . %. the occurrence of hyponatremia was associated only with the occurrence of early seizures (p = . ).severe hyponatraemia was associated with paroxysmal occurrence (p = . ), mass effect (p = . ), and hemostasis disorders. the multivariate study revealed that severe hyponatremia was associated with the glasgow score (p < . ) and pupillary changes (p = . ). on the other hand, it is the initial variation in serum sodium that was associated with both the severity of the initial neurological examination; glasgow (p < . ), saps (p = . ), pts (p = . ) and prism scores (p = . ), haemodynamic instability (p = . ) and neurovegetative disorders (p = . ). lesional features have also been found.regarding the prognosis, the occurrence of initial hyponatremia had a protective effect: a more favorable gos score p = . and a lower mortality (p = . ). a poor neurologic prognosis as well as a high mortality were associated with the most severe hyponatraemia and particularly with the initial variation of the sodium level (p = . ;). the mortality was . %. it was also particularly related to the initial change in sodium levels (p < . , . ). we concluded that there is no association between post traumatic early hyponatremia and the severity of the initial clinical presentation. however, the depth of hyponatremia and especially the initial change in sodium levels have been associated with more severe clinical pictures and a more limited prognosis. compliance with ethics regulations: yes. rationale: post-traumatic epilepsy (pte) is one of the complications described in the aftermath of headtrauma. its incidence is variable in the literature because of its clinical polymorphism. objectives of the study was to analyze the epidemiological profile (clinico-biological, radiological, therapeutic and evolutionary) of the patients having presented pte and to determine the risk factors for this pathology by comparing them with the rest of the traumatized brain patients. patients and methods: our study was retrospective. it was conducted in the intensive care unit (icu) of our university hospital between and . were included in our study all patients admitted to the service with brain injury and a glycaemia above mmol/l during the first h post-trauma. results: the incidence of pte was . %. ( among ) the average age was . ± . years. the sex ratio was . . the average of gcs was . ± . . three ( . %) patients had initial motor impairment. seizures were observed in ( . %) patients during the first h of hospitalization. the mean delay of occurrence of pte was ± . months. pte was diagnosed before the end of the first post-traumatic year in patients ( % of cases). the most commonly observed brain lesions were cortical brain contusions ( rationale: electrolytic disorders are common in neuro-resuscitation, especially dysnatremias and dyskalemias. hyponatremias are the most frequent, including the main etiologies: the syndrome of inappropriate secretion of antidiuretic hormone (siadh) and the "cerebral salt wasting" syndrome (csw). diabetes insipude of central origin secondary to a lack of dha secretion is the second most common disorder. patients and methods: it is a prospective study, analysing all the brains injured admitted to the a intensive care unit of chu hassan in fez, morocco. study spread over a -month period from / / to / / . the objective of the study is to detect the most frequent hydro-electrolytic disorders and to evaluate the therapeutic effectiveness of the service protocols. results: all these brains injured have caused he disorders over a period of time varying between d and d : * cases of hyponatremia ( %)/ cases of hypernatremia ( %), * cases of hypokaliemia ( %)/ cases of hyperkaliemia ( %), * cases of hyperchloremia, or %/ cases of hypochloremia ( %). * cases of diabetes insipidus, or . %. * cases without he disorder ( . %). the treatment for these disorders was: *for hypona; it reached mmol/l, initially corrected by a -hour water restriction, followed by an increase in the basic ration and furosemide boluses according to the ecv, even sodium loads for a single case of salt loss syndrome, while the main etiology remains the siadh. *for hyperna, it has reached mmol/l, evaluated by the extracellular volume, corrected by enteral tap water after calculation of the hydric deficit. if hperna is associated with polyuria greater than cc/kg/h; we speak of: *insipude diabetes, with polyuria up to cc/kg/h, compensated with potassium-containing solutions and blood ionogram monitored every h. desmopressin was used in titration, by bolus of . µg, with a diuresis objective between and . ml/kg/h. *for hypokalemia, up to . g/dl, observed mainly in the acute phase of brain aggression, corrected by increase in br for a k between . and g/l, and by potassium loads if k below . g/l. the evolution: deaths or . % ( cases of uncorrected diabetes insipidus), the restriction of disorders were corrected. conclusion: a knowledge of the hydroelectrolytic disorders encountered in this context is essential, as well as the implementation of a diagnostic and therapeutic protocol, which will reduce the time required to correct these disorders. compliance with ethics regulations: yes. . ] u/h). however, workload was increased under star ( vs. measurements per day), as expected from measurement interval difference between star ( -hourly) and the sp ( -hourly). conclusion: this unique patient-specific risk-based dosing approach gc framework was successful in controlling all patients safely and effectively. these preliminary results are encouraging and show gc can be achieved safely and effectively at lower target bands. in turns, these improved gc outcomes could improve patient outcomes. compliance with ethics regulations: yes. rationale: although its incidence has declined in recent years, gastric cancer remains common worldwide and is the leading cause of gastrectomy. his treatment is mainly surgical, but his prognosis remains poor. many studies on survival and prognostic factors have been carried out in foreign series. patients and methods: this is a retrospective study covering a period of three years from january to december interesting patients who had a gastrectomy and hospitalized in emergency resuscitation department surgical uhc ibnou rochd from casablanca. the statistical analysis of the different clinical, paraclinical and therapeutic data was carried out thanks to an exploitation sheet. rationale: gram-negative bloodstream infections (gnbsi) require timely appropriate antimicrobial therapy in intensive care units (icu) patients. conventional techniques usually take - h for antimicrobial susceptibility testing (ast). innovative approaches (accelerate pheno ™ system) provide pathogen identification in ~ h and ast including minimal inhibitory concentrations (mics) in ~ h. we report, in icu patients with gnbsi, results of implementation of the accelerate pheno ™ in our laboratory. we prospectively screened all gnbsi episodes reported in adult icu patients between september and september . to allow integration into the laboratory workflow, the accelerate pheno ™ was run on blood bottles positive before am (day ), in parallel with routine procedures: maldi-tof identification after short incubation on solid media (day ), β lacta (bio-rad ® ) test (day ) and disk diffusion method for ast (day+ ). for each episode, antimicrobial regimen was reassessed by a multidisciplinary team of bacteriologists, infectious diseases and icu physicians by the end of day . we measured: (i) concordance of accelerate pheno ™ results with conventional techniques, (ii) number of antibiotic adaptations on day and (iii) number of patients within the therapeutic range (free fraction over x mic and below concentration at risk of adverse events), based on real-time measurement of beta-lactams concentrations. results: of patients reported with gnbsi over the study period, were included. mean age was of ± . years, / were males. main sources of gnbsi were pulmonary (n = ) and digestive (n = ). bacterial identification of the accelerate pheno ™ was concordant with standard techniques in ( %): enterobacteriacae (n = ), pseudomonas aeruginosa (n = ). overall categorical agreement for ast was of % ( errors including very major errors). by the end of day , the antibiotic regimen was de-escalated in ( %) patients, which was appropriate in ( %). in cases, de-escalation was possible, but not fulfilled by icu physicians. twenty patients had beta-lactams concentrations measurements: were in the therapeutic range, below and over. conclusion: accelerate pheno ™ provided rapid and accurate results for most microorganisms isolated in blood cultures of icu patients with gnbsi. however, in a laboratory with routine maldi-tof early identification and β lacta test performed on day , the impact on early adaptation of the antibiotic regimen was evident in around patient over . compliance with ethics regulations: not applicable. jean-luc baudel , jacques tankovic , redouane dahoumane , jean-remy lavillegrand , razach abdallah , geoffroy hariri , naike bige , hafid ait-oufella , nicolas veziris , eric maury , bertrand guidet service bactériologie, hôpital saint-antoine, paris, france; service réanimation médicale, hôpital saint-antoine, paris, france correspondence: jean-luc baudel (jean-luc.baudel@aphp.fr) ann. intensive care , (suppl ):p- rationale: evaluation of the accurateness of the accelerate phenotest bc kit for rapid analysis ( . h for microorganism identification and additional hours for antibiotic susceptibility testing) of positive blood cultures from icu and hematology patients. patients and methods: from february to august , we included patients from the icu and hematology units with positive blood cultures. the following informations were collected : gender, age, duration of prior antibiotherapy, source of the infection, results obtained by conventional microbiological methods and by phenotest (data obtained and time to obtention of results). informed consent was obtained from all patients. results: blood cultures were analyzed in patients (m/f ratio . , age . ±, from the icu and from hematology). % of the patients were receiving antibiotics at the time of blood culture collection (mean duration : . days). the source of infection was unknown in % of cases, urinary in %, catheter-related in %, ascites in %, pneumonia in %. in cases ( %), there was a perfect match between phenotest and conventional results (identification and antibiotic susceptibility testing). in cases ( %), the bacterium responsible was not present in the phenotest panel. in cases ( %), phenotest identification was correct, but some discrepancies were observed regarding antibiogram. in cases ( %) phenotest identification was again correct but no antibiogram was available. in cases ( %), where two bacteria were present, phenotest could not identify one of them. in cases, phenotest did not provide bacterial identification because too few bacteria were present in the blood culture bottle. conclusion: the phenotest panel covered % of the bacteria implicated in this study. when the bacterium responsible was present in the panel, the results given by the phenotest correlated in % of cases with those of conventional methods. some rare discrepancies were observed regarding antibiotic susceptibility testing that have to be analyzed further. in the remaining % of cases, where too few bacteria or two different bacteria were present in the blood culture bottle, technical limitations did not permit to correctly identify microorganism(s) present or to obtain an antibiogram. compliance with ethics regulations: yes. mélanie fromentin, antoine bridier-nahmias, constance vuillard, jean-damien ricard, damien roux inserm umr iame infection antimicrobials modelling evolution, paris, france correspondence: mélanie fromentin (mel.fromentin@wanadoo.fr) ann. intensive care , (suppl ):p- rationale: studying human lower respiratory tract microbiota by using ngs (new generation sequencing) method is complex because of many unexpected biases due to dna extraction and amplification procedures. lung microbiota evolution under mechanical ventilation evolution may be highly informative to evaluate the actual risk of vap (ventilator-associated pneumonia) development. before starting a large study on the lung microbiome of ventilated icu patients, a methodological study was mandatory. patients and methods: five control and three vap patients were selected. endotrachealaspirate (eta) and oropharyngeal swab (os) were collected at icu admission for control patients and, days before and on the day of vap diagnosis for vap patients. after automated extraction of total dna, hypervariable region v of the s rdna genes was amplified with two different pairs of primers f- r: oligonucleotides from the earth microbiome project (earth primer pair) and from the gut microbiome project (gut primer pair), followed by sequencing on illumina miseq plateform. after bioinformatics analysis with mothur ® software, we compared the performance of ngs alongsideconventional bacterial culture. differences in alpha diversity (microbial diversity in a sample), expressed as the shannon index, across respiratory tract site (upper or lower) and across time (before and at vap time) has been investigated. a positive control (pc), rationale: colistin is used as a last-line treatment to combat multidrug-resistant (mdr) gram-negative bacilli (gnb). worryingly, colistin resistance in klebsiella pneumoniae, pseudomonas aeruginosa and acinetobacter baumannii is increasingly reported worldwide. we hereby report the prevalence of colistin resistance among gnb isolated from burn patients in tunisia. the study was carried out on strains of gnb isolated from microbiological samples of burn patients hospitalized in the intensive care unit between october and december . identification was performed by conventional methods. antimicrobial susceptibility was tested by disk diffusion method and the results were interpreted according to ca-sfm guidelines. minimum inhibitory concentration (mic) of colistin was determined using the eucast broth micro-dilution method (umic, biocentric ® ) results: pseudomonas aeruginosa was the most frequently isolated bacteria ( strains), followed by acinetobacter baumannii ( strains) and klebsiella pneumoniae ( strains). the most common sites of isolation were blood cultures ( %), catheters ( %) and skin samples ( %). most of p. aeruginosa isolates were multidrug-resistant with high levels of resistance to imipenem ( . %), ceftazidime ( %) and ciprofloxacin ( . %). however, all of them were susceptible to colistin. in fact, mics of colistin against all p.aeruginosa isolates were less than or equal to . mg/l. a. baumannii strains had high resistance rates to beta-lactams : % to ceftazidime and % to imipenem. only one strain was resistant to colistin with a mic equal to mg/l. all k. pneumoniae isolates were resistant to extended-spectrum cephalosporins. one third of these strains were resistant to imipenem and more than half ( . %) were resistant to amikacin. two strains were resistant to colistin with high mics (> mg/l). both were carbapenemase-producers, carrying oxa- and ndm carbapenemase encoding genes. conclusion: these data suggest that colistin-resistant or pan-drug resistant gnb clinical isolates are still relatively rare. however, they have important global public health implications because of the therapeutic problems they present, especially for vulnerable populations such as severely burned patients. hence the need to test colistin regularly in the laboratory and to set up a monitoring program for mdr pathogens. compliance with ethics regulations: yes. rationale: descending necrotizing mediastinitis (dnm) are medicosurgical emergencies whose forecast is closely related to the precocity of the therapeutic assumption. the purpose of our work is to profile these patients as well as the therapeutic and evolutionary aspects. patients and methods: retrospective study over years in the intensive care unit of the hospital august. all patients with dnm on cervicofacial cellulitis were included. results: cases were collected, % of cellulitis, incidence of . patients / year. average age , sex ratio of . . smoking, chronic alcoholism and diabetes are the most common antecedents. the favoring factors were: (poor dental conditions: % of cases, non steroidien anti-inflammatory drugs: %, diabetes: %). in % of cases the front door was dental. average time taken to take care of days. c-reactive protein and procalcitonin were positive in all patients. in % the chest x-ray was normal. all patients received tri-antibiotic therapy. intubation were difficult in all patients, we used nasofibroscope in % of cases and a rescue tracheotomy in one patient. only one patient had a cervico-thoracic surgical approach; for all the others she was cervical alone. streptococcus was the most isolated germ. the complications were (septic shock: %, ards: %). the average hospital stay was days with a mortality rate of %. conclusion: dnms are poorly prognostic. the best treatment remains prevention by better management of dental abscesses and tonsillar phlegmons. rationale: the initial, empirical antibiotic therapy of ventilator-associated pneumonia (vap) is often based on timing of its occurrence in relation to the onset of mechanical ventilation. this is due to reported differences between causal pathogens associated with early-onset (e-vap < - days of mechanical ventilation) compared to late-onset vap (l-vap ≥ - days of mv). e-vap is most often reported to be due to antibiotic-sensitive pathogens while l-vap is frequently attributed to antibiotic-resistant pathogens. however, there is emerging evidence that the isolated microorganisms may be similar regardless of onset time. the aim of our study was to compare the clinical outcomes of critically ill patients developing e-vap and l-vap and to compare the causative pathogens of the two groups. patients and methods: all the patients with the diagnosis of vap admitted between january and december were retrospectively included. vap was suspected on the basis of clinical and chest x-ray findings. the identification of the causative organisms was performed with endotracheal aspirate (eta) cultures. results: ninety patients developed vap. e-vap was observed in patients ( , %), whereas patients ( , %) developed l-vap. among patients with early-onset vap, % received antibiotics prior to the development of pneumonia, compared to % with late-onset vap (p = . ). otherwise, no differences (sociodemographic factors, antecedents, severity score, length of stay, length of mv) between the two groups were observed. the most common pathogens associated with e-vap were enterobacter species ( . %), pseudomonas aeruginosa ( . %) and oxacillin-resistant staphylococcus aureus (orsa , %). enterobacter species ( . %), acinetobacter baumannii ( . %) and pseudomonas aeruginosa ( %) were the most common pathogens associated with l-vap. no difference was noted in the contribution of multidrug resistant bacteria mdr ( % vs. %). hospital mortality was significantly greater for patients with l-vap caused by mdr ( %) compared to patients with e-vap ( %) (p = . ). conclusion: this classification is no longer helpful for empirical antibiotic therapy, since both early-onset and late-onset vap were caused by mdr bacteria. this justifies the need of intensive care unit-specific knowledge of causal agents associated with vap to reduce the rate of administration of inadequate antimicrobial therapy. compliance with ethicsregulations: yes. key: cord- - rqnu bu authors: nan title: th international symposium on intensive care and emergency medicine: brussels, belgium. - march date: - - journal: crit care doi: . /s - - - sha: doc_id: cord_uid: rqnu bu nan the relationship between systemic glycocalyx degradation markers and regional glycocalyx thickness in non-septic critically ill patients is unclear. conjunctival sidestream dark fieldimaging for the purpose of glycocalyx thickness estimation has never been performed. we aimed to investigate whether changes in glycocalyx thickness in conjunctival and sublingual mucosa are associated with global glycocalyx shedding markers. methods: in this single-centre prospective observational study, using techniques for direct in-vivo observation of the microcirculation, we performed a single measurement of glycocalyx thickness in both ocular conjunctiva and sublingual mucosa in mixed cardio surgical (n= ) and neurocritical patients (n= ) and compared these data with age-matched healthy controls (n= ). in addition we measured systemic syndecan- levels results: in the sublingual and conjunctival region we observed a significant increase of the perfused boundary region (pbr) in both neuro critical and cardiac surgical icu patients, compared to controls ( . ], p< , ). we detected a weak correlation between syndecan- and sublingual pbr(r= . , p= . ) but no correlations between global glycocalyx damage markers and conjuctival glycocalyx thickness. conclusions: conjunctival glycocalyx thickness evaluation using sdf videomicroscopy is suitable and is impaired in non-septic icu patients but only measurements in sublingual mucosa are correlating with systemic glycocalyx shedding markers. global glycocalyx damage is more severe in cardiac comparing to neuro critical patients. introduction: endothelial dysfunction plays a major role in the sepsis related organ dysfunction, and is featured by vascular leakage. amp-activated protein kinase (ampk) is known to regulate actin cytoskeleton organization and interendothelial junctions (iejs), contributing to endothelial barrier integrity. we have already demonstrated its role in defence against sepsis induced hyperpermeability [ ] , but the underlying mechanisms remain unknown. this project aims to identify molecular targets involved in the beneficial action of ampk against endothelial barrier dysfunction. methods: experiments have been performed in human microvascular dermal endothelial cells. α ampk activity has been modulated via the use of a specific sirna or treatment by two pharmacological ampk activators (aicar, ). we have investigated the effect of this modulation on the expression/phosphorylation of connexin (cx ) and heat shock protein (hsp ), two proteins playing a key role in maintenance of iejs and actin dynamics respectively. results: we show that α ampk is required to sustain the level of cx expression as it was drastically reduced in cells transfected with a sirna targeting specifically α ampk. regarding hsp , its expression level was not affected by α ampk deletion. however, both ampk activators increased its phosphorylation on ser , in a α ampkdependent manner, while they had no effect on cx . our results also reveal that hsp phosphorylation concurred with the appearance of actin stress fibers at the periphery of cells, suggesting a beneficial role for phsp as well as f-actin stress fibers in vascular barrier function through reinforcing the endothelial tethering. conclusions: our work identifies the regulation of cx expression and hsp phosphorylation as potential protective responses underlying the beneficial action of ampk against endothelial barrier dysfunction. ampk could consequently represent a new therapeutic target during sepsis. introduction: sepsis induced cardiomyopathy (sic) is a serious condition during sepsis with a mortality rate up to % ( ) . sic is clinically manifested with left ventricle impaired contractility ( ) . melusin is a muscle-specific protein involved in sustaining cardiomyocyte survival thorough the activation of akt signaling pathways ( ) . pi k-akt signaling pathway plays a pivotal role in regulating calcium channel activity ( ) . we hypothesized that melusin overexpression could exert a protective effect on cardiac function during septic injury. methods: animals were treated with an intraperitoneal injection of lipopolysaccharide (lps) at mg/kg. sv strain knockout mice (ko) for melusin gene and fvb strain with cardiac-specific overexpression (ov) of melusin were compared. each group was studied together with a control group (wt). hemocardiac parameters were studied at hour and hours through echocardiography. another cohort of animals was sacrificed hours after mg/kg lps treatment and cardiac tissues and blood sample were harvested for wb analysis to quantify the expression of akt, p-akt and cacna c and elisa analysis for troponin levels. results: sv wt, ko melusin and fvb wt mice groups, fractional shortening (fs) was significantly impaired after lps challenge and was associated with compensatory tachycardia (fig. ) . fvb ov mice group didn't show decrease in fs. consistent with the increased akt phosphorylation observed in ov mice, the expression of cacna c was also significantly higher both at basal levels and after lps treatment in ov mice compared to wt mice (fig. ) . troponin levels didn't differ between mice groups after lps treatment conclusion: melusin has protective role in lps induced cardiomyopathy, likely through akt phosphorylation controlling the cacna c protein density. introduction: liver dysfunction is frequent in sepsis, but its pathophysiology remains incompletely understood. since altered liver function has also been described in icu patients without sepsis [ , ] , the influence of sepsis may be overestimated. we hypothesized that sedation and prolonged mechanical ventilation after abdominal surgery is associated with impaired liver function independent of sepsis. methods: sedated and mechanically ventilated pigs underwent abdominal surgery for regional hemodynamic monitoring and were subsequently randomized to fecal peritonitis and controls, respectively (n= , each), followed by h observation. indocyanine green (icg) retention rate minutes after injection of . mg/kg icg (icg r ) was determined at baseline, and , and h after sepsis induction (si), and at the same time points in controls. concurrent with icg r , plasma volume, total hepatic perfusion (ultrasound transit time), and bilirubin and liver enzymes were measured. anova for non-parametric repeated measurements was performed in both groups separately. results: icg r increased over time without significant differences between groups (table ). there was a parallel increase in bilirubin in septic but not control animals. the other measured parameters were similar in both groups at the end of the experiment. conclusion: liver function was impaired under sedation and prolonged mechanical ventilation after abdominal surgery, even in animals without sepsis. the underlying reasons should be further explored. introduction: previous work has shown the cytoprotective properties of antithrombin-affinity depleted heparin (aadh), by neutralization of cytotoxic extracellular histones [ ] , major mediators of death in sepsis [ , ] . aadh was produced from clinical grade heparin, resulting in preparations that have lost > , % of their anticoagulant activity. to gain insight into the mechanisms and the basic pharmacological aspects of aadh protective properties, we performed a systematic analysis of how aadh is tolerated in mice and ascertained its effects in three different in vivo models of inflammation and infection. methods: dose ranging studies, short term and medium term, were performed in c bl/ mice. the effects of i.v. administration of extracellular histones in the presence or absence of aadh were assessed in mice. we further analysed the effect of aadh in models of concanavalin a-and mrsa-mediated lethality. in all studies we assessed clinical signs, lab parameters and histology. results: aadh was well tolerated in both short term and intermediate term (till days) experiments in mice, in the absence of any signs of tissue bleeding. aadh was able to revert the cytotoxic properties of i.v. administered histones. in a concanavalin a mediated model of sterile inflammation, we confirmed that aadh has protective properties that counteract the cytotoxic effects of extracellular histones. in an in vivo lethal mrsa model, for the first time, aadh was shown to induce a survivalbenefit. conclusions: we conclude that aadh contributes to the overall increased survival by means of neutralization of extracellular histones and represents a promising product for further development into a drug for the treatment of inflammatory diseases and sepsis. introduction: urokinase (uk) and tissue plasminogen activator (tpa) mediate thrombolytic actions by activating endogenous plasminogen. thrombomodulin (tm) complexes with thrombin to activate protein c and thrombin activatable fibrinolysis inhibitor (tafi). activated protein c (apc) modulates coagulation by digesting factors v and viii and activates fibrinolysis by decreasing pai- functionality. methods: the purpose of this study is to compare the effects of rtm and apc on urokinase and tpa mediated thrombolysis utilizing thromboelastography. results: native whole blood was activated using a diluted intrinsic activator (aptt reagent, triniclot). the modulation of thrombolysis by tpa and uk (abbott, chicago, usa) was studied by supplementing these agents to whole blood and monitoring teg profiles. apc (haematologic technologies, vt, usa) and rtm (asahi kasai pharma, tokyo, japan) were supplemented to the activated blood at . - . ug/ml. the modulation of tpa and uk induced thrombolysis by apc and rtm was studied in terms of thromboelastograph patterns. the effect of both apc and rtm on plasma based systems supplemented with tpa was also investigated. patients treated with antibiotic therapy were eligible for inclusion. the plausibility of infection (definite, probable, possible, none) was determined based on the centers for diseases control (cdc) criteria. patients with sepsis (definite/probable/possible infection and a sofa score increase of >= ) were screened for death within days and secondary infections h to days after icu admission, using the cdc criteria. hla-dra and cd mrna expressions were determined by reverse transcription quantitative pcr. results: among icu admissions, a blood sample for rna analysis was collected in cases. two hundred fifty-seven patients met the inclusion criteria and provided written informed consent. sepsis was noted in patients. the sepsis patients experienced death in cases ( %), secondary infection in cases ( %), and death and/or secondary infection in cases ( %). table shows the results of hla-dra and cd expression related to death and secondary infections. conclusions: the mrna expression of hla-dra on icu admission was significantly decreased in patients with sepsis who died or contracted secondary infections within days. cd expression was not significantly decreased in patients with negative outcome. introduction: acid-base disturbances are common in patients with infection admitted to the intensive care unit (icu). more attention is given to hyperlactatemia in this patient population as a prognostic factor, although other acid-base disturbances may also have an impact on patient outcomes. our objective is to describe the acid-base profile of this patient population and determine the association between different acid-base abnormalities and icu mortality. methods: retrospective cohort of patients admitted with infection to an intensive care unit. patients were stratified according to ph (< . ; . - . ; > . ) and, then, according to the standard base excess (sbe) (< - ; - -+ ; > + ). in each of these strata and the whole population, the proportions of acid-base disturbances were quantified during the first hours of icu admission. to assess the association between acid-base disturbances and outcome, a logistic regression model was fit, adjusting for age, sex and saps score. results: patients were analysed. ( %) patients were acidemic and ( %) presented with a normal ph. metabolic acidosis (as assessed by sbe) was observed in all subgroups, regardless of ph levels (ph < ). lactic acidosis was observed in % of the whole population; sig (strong ion gap) acidosis, in %; sid (hyperchloremic) acidosis, in %; metabolic alkalosis, in %; and respiratory acidosis, in % of the patients. introduction: sepsis-induced brain dysfunction has been neglected until recently due to the absence of specific clinical or biological markers. there is increasing evidence that sepsis may pose substantial risks for long term cognitive impairment. methods: to find out clinical and inflammatory factors associated with acute sepsis-induced brain dysfunction (sibd) serum levels of cytokines, complement breakdown products and neurodegeneration markers were measured by elisa in sera of sibd patients and healthy controls. association between these biological markers and cognitive test results was investigated. results: sibd patients showed significantly increased il- , il- , il- and c d levels and decreased tnf-α, il- , c a and ic b levels than healthy controls. no significant alteration was observed in neuronal loss and neurodegeneration marker (neuron specific enolase (nse), amyloid β, tau) levels. increased il- β, il- , il- , il- , tnf-α and decreased c d, c a and ic b levels were associated with septic shock, coma and mortality. transient mild cognitive impairment was observed in of patients who underwent neuropsychological assessment. cognitive dysfunction and neuronal loss were associated with increased duration of septic shock and delirium but not baseline serum levels of inflammation and neurodegeneration markers. conclusions: increased cytokine levels, decreased complement activity and increased neuronal loss are indicators of poor prognosis and adverse events in sibd. cognitive dysfunction and neuronal destruction in sibd do not seem to be associated with systemic inflammation factors and alzheimer disease-type neurodegeneration but rather with increased duration of neuronal dysfunction and enhanced exposure of the brain to sepsisinducing pathogens. introduction: high levels of some aromatic microbial metabolites (amm) in serum are related to the severity and mortality of critically ill patients [ ] . several studies have discussed the imbalance and loss of the diversity of gut microbiota but there are practically no data on the gut microbial metabolites in critical conditions, only a little -in healthy people [ , ] . the aim of this work is to analyze the connection between serum and fecal levels of amm in icu patients. methods: simultaneously serum and fecal samples (sfs) from icu patients with nosocomial pneumonia (group i), sfs from icu neurorehabilitation patients (group ii) and sfs from healthy people were taken for gc/ms analyses. the following amm were measured: phenylpropionic (phpa), phenyllactic (phla), p-hydroxybenzoic (p-hba), p-hydroxyphenyllactic (p-hphla), p-hydroxyphenylacetic (hphaa), p-hydroxyphenylpropionic (p-hphpa) and homovanillic (hva) acids. data were presented as medians with interquartile range (ir, - %) using statistica . results: the sum of the level of most relevant metabolites ( amm) -phla, p-hphla, p-hphaa, and hva -in serum samples from group i and group ii were equal to . ( . - . ) μ m and . ( . - . ) μ m, respectively, and were higher than in healthy people - . ( . - . ) μ m (p< . ). we suppose the presence of the correlation of amm profile in blood and intestine. particularly, sfs of healthy people are characterized by the prevalence of phpa; amm are not detected in feces of non-survivors but only hva dominates in their serum in the absence of other (fig. ) . conclusions: the amm profiles in gut and serum are interrelated; amm in serum probably reflect the violation and loss of biodiversity of the gut microbiota in critically ill patients. introduction: since nitrogen oxide (no) is an essential component of the immune system, the dynamics of plasma no concentration was studied in order to predict the development of sepsis [ , ] . methods: with the permission of the ethics committee included the full-term newborns with respiratory diseases on a ventilator, retrospectively divided into two groups (i, n= -sepsis - days; ii, n= without sepsis), at , - , days was studied by elisa the plasma concentration of no, nos- , nos- , adma (multilabel coulter victor- , finland). to select points "cut-off" used the method of roc-lines. results: the statistical power of the study was . % (α< . ). at admission in patients of groups i and ii decrease the concentration of no and increased adma in plasma (p< . ) relative to healthy newborns. after - days, relatively in patients of groups introduction: sepsis-associated disseminated intravascular coagulation (sac) is associated with decreased platelet counts and formation. the widespread activation of platelets contribute to vascular occlusions, fibrin deposition, multi-organ dysfunction, contributing to a two-fold increase in mortality. the purpose was to measure markers of platelet function in the plasma of patients with clinically established sac and to determine association to disease severity and outcome. methods: plasma samples from adult intensive care unit (icu) patients with sepsis and suspected sac were collected at baseline and on days and . dic scores were calculated using platelet count, d-dimer, inr, and fibrinogen. patients were categorized as having no dic, non-overt dic, or overt dic. plasma levels of cd l, von willebrand factor (vwf), platelet factor- (pf- ), and microparticles (mp) were quantified using commercially available elisa methods. results: markers of platelet activation were significantly elevated in patients with sepsis alone and with suspected dic compared to normal healthy individuals on icu day (p< . ). levels of platelet-associated biomarkers were compared between survivors and non-survivors. pf- was significantly decreased in non-survivors compared to survivors (p = . ). patients were stratified based on platelet count and levels of markers were compared between groups. cd l, vwf, pf , and mp showed significant variation based on platelet count, with all markers exhibiting stepwise elevation with increasing platelet count. conclusions: markers of platelet activation were significantly elevated in patients with sac compared to healthy individuals. pf levels showed significant difference based on dic score or mortality, and differentiated the non-survivors compared to survivors. cd l, vwf, pf , and mp showed significant association with platelet count, increasing in a stepwise manner with increases in platelet count (table ) . prognostic value of mean platelet volume in septic patients: a prospective study a chaari king hamad university hospital, bussaiteen, bahrain critical care , (suppl ):p introduction: mean platelet volume (mpv) has been reported as a valuable marker of inflammatory diseases. the aim of the current study is to assess the prognostic value of mpv in septic patients. methods: prospective study including all patients admitted to the intensive care unit (icu) with sepsis or septic shock. demographic, clinical and laboratory data were collected. the mpv was checked on admission and on day . two groups were compared: survivors and non-survivors. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] days in survivors and . [ . - ] days in non-survivors (p= . ). conclusions: the decrease of the platelet count but not the increase of the mpv was associated with increased mortality in critically-ill septic patients. endotoxin activity assay levels measured within hours after icu admission affected patients' severity assessments a kodaira , t ikeda , s ono , s suda , t nagura tokyo medical university, tokyo, japan, introduction: sepsis profoundly alters immune homeostasis by inducing first a systemic pro-inflammatory, then an anti-inflammatory state. we evaluate the prognostic value of ex vivo lipopolysaccharide (lps) stimulation of whole blood in septic patients, at day and after intensive care unit (icu) admission. methods: this prospective cohort study included patients with severe sepsis or septic shock admitted to a surgical icu of a university hospital. blood was drawn on day and day , and stimulated ex vivo with lps for hours. tumor necrosis factor alpha (tnf), interleukin (il) , il and il were measured. twenty-three healthy adults served as controls. outcomes were ventilator and icu-free days, sofa score at day and , and need for dialysis during the course of sepsis. results: forty-nine patients were included (mean age ± years). the blood of septic patients was less responsive to ex vivo stimulation with lps than that of healthy controls, as demonstrated by lower tnf, il , il and il release ( fig. ). at day , patients above the th percentile of il release had significantly fewer ventilator and icu-free days than those in the lower th percentile (fig. ) . in contrast, patients in whom il release increased between day and day had significantly lower sofa scores at day and and need for dialysis, and more icu-free days than patients in whom il release decreased (table ) . conclusions: greater lps-stimulated il release in septic patients at day was associated with poorer clinical outcomes and may reflect the severity of the forthcoming immunoparalysis. however, an increase in il release between day and day was associated with favorable outcomes, perhaps signaling immune restoration. introduction: hyperthermic intraperitoneal chemotherapy with cytoreductive surgery (hipec-crs) is a curative treatment modality for peritoneal carcinomatosis. extensive debulking surgery, peritoneal stripping and multiple visceral resections followed by intraperitoneal installation of heated high-dose chemotherapeutic agents, a process leads to a 'high-inflammatory' syndrome. serum procalcitonin (pct), a biomarker for bacterial sepsis, in the heightened inflammatory state after hipec-crs might be of limited utility. our aim is to determine the trends of pct in the early postoperative phase of hipec-crs and to identify trends in patients with and without bacterial sepsis methods: in a case-control design, we reviewed all patients undergoing hipec-crs over a -month period ( ) ( ) ( ) . patients were divided into groups based on whether they developed bacterial sepsis in the first days after surgery (infected v/s non-infected). summary data are expressed as medians and ranges. two-tailed nonparametric tests were performed and considered significant at p values of less than . results: patients' data was analyzed. infections developed in % ( patients) with escherichia coli as the predominant pathogen isolated ( % isolates). pct levels (ngm/ml) were elevated postoperatively in both infected and non-infected patients; day infected . (iqr . introduction: early outcome in cardiac surgery has been an area of growing interest where the given risks raise several predictive models for assessment of postoperative outcome [ ] . procacitonin (pct) emerges as a possible predictive tool in cardiothoracic intensive care unit (cticu).we aim at testing the predictive power of pct for early morbidity, prolonged ventilation, icu and hospital stay, in patients developing early fever after cardiac surgery methods: a retrospective descriptive study done in tertiary cardiac center, enrolling patients who stayed for more than hours post-operatively in the cticu risk stratification included additive euro score and pct immunoluminometricaly prior to surgery and every hours in response to onset of fever. results: we screened consecutive patients who underwent open heart cardiac, of which patients were enrolled in the study. patients were divided into two groups based on the level of pct, those with value > ng/ml (group ) and those with level < ng/ml (group ). patients in group as compared to group , over the postoperative course was associated with prolonged icu stay (p= . ), length of mechanical ventilation (p= . ), length of hospitalization (p= . ), acute kidney injury (p= . ) and culture positivity (p= . ). multivariate analysis showed that pct > ng/ml was was significantly associated with positive cultures. (p= . ) conclusions: a rise of serum pct carries the signals of early icu morbidity and lengths of ventilation, icu stay and hospital stay methods: patients aged ( - ) days ( - days) underwent cardiac surgery with cardiopulmonary bypass for severe congenital heart disease. in the dynamics levels of pct, mr-proadm, ct-proavp and mr-proanp were measured before surgery and on the , , and days after the operation with the kryptor compact plus analyzer. data are presented as medians with interquartile range. the mann-whitney u-test was used to compare the data. values of p < . were statistically significant. results: patients ( %) required alv for more than hours. in this group statistically significant higher levels of pct, mr-proadm and mr-proanp were found throughout the period ( table ). the level of ct-proavp had increased to statistical significance since the day after the operation. patients were in the icu for more than hours. in this group statistically significant higher levels of pct, mr-proadm were found throughout the whole period ( table ). the higher level of mr-proanp was statistically significant on the st and th days after surgery, mr-proanp had a tendency of increasing values on nd and rd days. ct-proavp increased to statistical significance since the nd day after the operation and persisted throughout the studied period. conclusions: pct, mr-proadm and mr-proanp can be used as predictors of prolonged alv for children of the first year of life after cardiac surgery with cardiopulmonary bypass. the level of ct-proavp can be considered since the day after surgery. pct and mr-proadm may be used to predict the los in the icu. mr-proanp and ct-proavp can be considered since the and days after surgery respectively. introduction: early prediction of the risk of death among patients admitted at the emergency department (ed) remains an unmet need. the prognostic performance of hbp that is secreted by neutrophils was prospectively validated in a series of sequential ed admissions. methods: hbp and elements of qsofa were analyzed prospectively in serial ed admissions (main reasons for admission: acute abdominal pain . %; fever . %; vomiting/diarrhea . %; dyspnea . %; neurologic signs . %; non-specific complaints . %; most patients admitted for more than one reasons). upon ed admission patients were scored as low-risk, intermediate-risk and high-risk at the discretion of the physician. hbp was measured in blood samples upon admission by an enzyme immunosorbent assay. results: hbp was significantly greater among patients who died very early (fig. ). in five out of six of patients dying early hbp was greater than ng/ml. we combined hbp more than ng/ml and the presence of one sign of qsofa into a new score; this had . % sensitivity to predict -day mortality. the respective sensitivity of two signs of qsofa was . % (p: . ). the use of this new score allowed better stratification of patients originally considered at the triage as low-risk into high-risk (fig. ) . conclusions: we propose hbp more than ng/ml and one qsofa sign as an early score for -day mortality at the ed. introduction: despite of our growing knowledge in pathophysiology of septic shock still remain one of the most important factors of hospital mortality. it is thought that early diagnosis and treatment at early stage of septic shock would decrease its mortality. there have been on-going studies in recent years which research the usability of heparin binding protein (hbp) in early diagnosis of sepsis [ ] . to seek the usability of c-reactive protein (c-rp), procalcitonin (pct) and hbp biomarker combination in early diagnosis of septic shock. methods: patients, who have the diagnosis of septic shock, that are expected to stay in intensive care unit more than hours, and aged between - are included in the study. data are collected from the patients' blood samples that are drawn on admission, on the th hour, and on the day of discharge or death. results: it has been found in our study that, best "cut-off" value ng/ml, specificity . and sensitivity . for hbp. compared with other biomarkers, hbp was the best predictor of progression to organ dysfunction (area under the receiver operating characteristic curve (auc) = . ). conclusions: although there have been many biomarkers for early diagnose of septic shock, c-rp and pct are the most common used markers in nowadays' clinical practice. the usability of hbp in early diagnosis of sepsis is still being researched. we concluded that pct, c-rp and hbp biomarker combination is usable to diagnose septic shock at the end of our study. introduction: reduced adamts- and increased von willebrand factor (vwf)/adamts- ratio have been observed in sepsis and are associated with the severity of the disease [ , ] . however, their change during the septic episode and in the event of a change in the clinical status of the septic patients has not been investigated. the aim of the study was to assess the variation of these hemostatic parameters in critically ill patients during the course of a septic episode. methods: we monitored septic patients admitted in the intensive care unit (icu). improved (group a) while deteriorated (group b). we assessed vwf, adamts- and the vwf/adamts- ratio on admission in icu (time point ) and at the time of a change in patients' clinical condition (remission or deterioration, time point ). results: in group a, adamts- and the vwf/adamts- ratio did not significantly change ( . ± . vs . ± . conclusions: hemostatic disorders, as assessed by vwf and adamts- levels were detected in septic patients, while their changes differed according to the evolution of the septic episode. adamts- changes may be associated with outcome. methods: adult patients with at least one sign of qsofa and infection or acute pancreatitis or after operation were prospectively followed-up. blood was sampled the first hours; those with hiv infection, neutropenia and multiple injuries were excluded. sepsis was diagnosed using the sepsis- criteria. soluble urokinase plasminogen activator receptor (supar) was measured by an enzyme immunoassay. results: sixty patients were classified with sepsis using the sepsis- definitions. presence of at least two signs of qsofa had . % sensitivity, . % specificity, . % positive predictive value and . % negative predictive value for the diagnosis of sepsis. the integration of qsofa signs and supar improved the diagnostic performance ( fig. ) . conclusions: conclusions two signs of qsofa have significant positive prognostic value for sepsis but low sensitivity. this is improved after integration with supar. the intelligence- study is supported by the european commission through the seventh framework programme (fp ) hemospec. introduction: sepsis is a frequent reason for admission in the emergency department (ed) and its prognostic mainly relies on early diagnosis. in addition, no validated prognostic tool is currently available. therefore, identification of patients at high risk of worsening in the ed is key. the triage objective was to assess the prognostic value of a blood marker panel to predict early clinical worsening of patients admitted in the ed with suspected sepsis. methods: triage was a prospective, multicenter ( sites in france and belgium) study on biological samples conducted in partnership with biomerieux s.a. patients admitted in the ed with suspected or confirmed community-acquired infection for less than h were included. exclusion criteria were: admission in the ed for more than hours, septic shock at admission, immunodepression, sepsis syndrome days prior to admission. the protocol included clinical and biological time points (h , h , h , h , d ). patients were classified in groups at admission (infection, sepsis, severe sepsis) and divided into evolution/prognosis groups depending on worsening or not from their initial condition to severe sepsis or septic shock and sofa score's evolution. the evolution criteria were centrally evaluated by an independent adjudication committee of sepsis experts including emergency physicians and intensivists. patients were followed up to day for mortality. results: the study duration was years with patients included ( excluded). the centralized analysis is in progress to select the combination of biomarkers with the best prognostic performance comparing both evolution/prognosis groups. currently, patients have been classified as worsening and some results will be available in . conclusions: triage is the largest prospective multicenter study assessing the prognostic value of a panel of blood markers in eds which could help identification of septic patient at risk of worsening at time of admission in the ed and develop specific management. introduction: immune status characterization in intensive care unit (icu) patients presents a major challenge due to the heterogeneity of response. in this study, the filmarray® system was used with customized gene assays to assess the immune profile of critically-ill icu patients compared to healthy volunteers; from within the realism cohort. methods: a customized filmarray® pouch containing assays was designed; target and reference genes. detection and semiquantification of assays from whole blood collected in paxgene tubes occurs in the device within hour. a total of subjects from the realism cohort were tested in duplicates: trauma, septic shock and surgery patients, along with healthy volunteers. the patients' selection was based on hla-dr expression on monocytes, and pha-(phytohaemagglutinin) stimulated t-cell proliferation assay, to have various immune profiles. results: quantification cycle values of the target genes were normalized by the geometrical mean of reference genes to account for the different cell counts among specimens. the number of the cd + cells and hla-dr, determined by flow cytometry, showed good correlation to cd d and cd gene expression, respectively. seven genes showed significant differences in expression levels between the healthy volunteers and patient groups: cd d, cd , ctla & cx cr were down-regulated, while il- , il rn and s a were up-regulated in the patient populations. the use of relative quantitative difference of some markers was able to distinguish and introduction: early, rapid diagnosis is integral to the efficient effective treatment of sepsis; however, there is no gold standard for diagnosis, and biochemical surrogates are of limited and controversial utility. the cytovale system measures biophysical properties of cells by imaging thousands of single cells per second as they are hydrodynamically stretched in a microfluidic channel. this platform has been shown to measure dozens of mechanical, morphological, and cell surface biomarkers of wbc activation simultaneously [ , ] . in this study, we show the performance of the cytovale system in measuring biophysical markers for sepsis detection in the emergency department (ed). methods: we conducted an irb-approved prospective cohort study of emergency department (ed) patients with + sirs criteria and evidence of organ dysfunction. patients were included for analysis. blood samples for the cytovale assay were collected in the ed, and the diagnosis of sepsis was adjudicated by blinded clinician review of the medical record. captured imaging data were analyzed using computer vision to quantify mechanical parameters per cell, and a logistic model was trained to discriminate patients who had sepsis from those who did not. results: we found substantial biophysical differences between cells from septic and non-septic patients as observed at both the single cell level (fig. ) and when looking at the overall leukocyte populations (fig. ) . a multiparameter classification algorithm to discriminate septic from non-septic patients based on biophysical markers currently yields a sensitivity of % with a negative predictive value of %. conclusions: in patients presenting to the ed with of sirs criteria and evidence of organ dysfunction, the cytovale system provides a potentially viable means for the early diagnosis of sepsis via the quantification of biophysical properties of leukocytes. oxidative stress and other biomarkers to predict the presence of sepsis in icu patients v tsolaki, m karapetsa, g ganeli, e zakynthinos icu, larissa, greece critical care , (suppl ):p introduction: early identification of sepsis adds a survival benefit in icu patients. several biomarkers have been evaluated, yet an optimal marker is still lacking [ ] . methods: we prospectively determined oxidative status in patients admitted in a general intensive care unit of the university hospital of larisa. oxidative status was determined measuring the novel static (sorp) and capacity (corp) oxidation-reduction potential markers. other biomarkers (bnp, presepsin, crp) were measured, and the discriminative properties for the detection of sepsis were evaluated. results: oxidative status was evaluated in a hundred and fifty two consecutive patients. patients with severe sepsis and septic shock had significantly higher sorp values than patients without sepsis ( introduction: c-reactive protein (crp), is reported to be an effective marker for the assessment of vascular inflammation activity and acute coronary events prediction [ ] .we hypothesized that preoperative crp elevation is related to the occurrence of postoperative adverse cardiovascular outcomes. methods: we prospectively included patients scheduled to undergo different vascular surgeries from december to september . we assessed demographic data, comorbidities, revised cardiac risk index (rcri) and biomarkers (crp, cardiac troponin high sensitive ths, creatinine and urea) in the preoperative period. we also noted type and duration of surgery, intraoperative blood loss, icu stay and mortality. we evaluated crp as a predictive marker of major cardiovascular events defined as chest pain, ths elevation, electrocardiogram changes, arrhythmia, pulmonary embolism, stroke occuring within postoperative months. results: during our study, patients were scheduled to undergo vascular surgeries. from the patients, % developed adverse cardiac events (table ) . we showed the predictive value of crp in major cardiovascular event in a roc analysis (fig. ) . the cuttoff value of cpr was giving % of sensitivity and % of specificity. conclusions: our study pointed out that crp preoperative elevation could have a very strong predictive value of post-operative cardiovascular events in vascular surgery, this is in line with results showed by previous studies [ ] . introduction: elderly are particularly susceptible to bacterial infections and sepsis, and they comprise an increasing proportion of intensive care unit (icu) admissions. our aim was to evaluate the impact of age on critically ill infected patients. methods: we performed a post-hoc analysis of all infected patients admitted to icu enrolled in a -year prospective, observational, multicenter study involving icus. patients aged < , - and >= years were compared (group a, b, and c). multidrug-resistance (mdr) was defined as acquired non-susceptibility to at least one agent within three or more antimicrobial categories. results: of the patients analyzed, ( . %) were infected on icu admission. of these, ( %) belonged to group a, ( %) to group b and ( %) to group c. group c were more dependent, had higher saps ii and charlson scores (p< . ). icu and hospital length of stay did not differ between groups. microorganism isolation and bacteremia were higher in group b ( % and %, respectively) than groups a ( % and %, respectively) and c ( % and %, respectively; p< . ). septic shock was present in % of patients and was more frequent in groups b ( %) and c ( %) than group a ( %). the most common sources of infections were respiratory and intra-abdominal. isolation of gram-negative bacteria was significantly increased in group b and c (p= . ). the most common isolated bacteria were escherichia coli ( %), staphylococcus aureus ( %) and pseudomonas aeruginosa ( %) for all groups. in total, isolates ( %) corresponded to mdr bacteria, of which % were staphylococcus aureus. age was not a risk factor for infection by mdr. all-cause mortality in icu and hospital was: % and %; % and %; % and % -respectively for groups a, b, and c (p < . ). conclusions: old patients ( - years) were more prone to present with bacteremia, which could account for the increased severity of sepsis and higher all-cause mortality. age was not a risk factor for mdr infection. introduction: the rapid identification of pathogens using patient samples is crucial. delays in this can potentially have serious implications for patients and infection prevention/control [ ] . the aim of this project was to identify the number of microbiology samples sent, the number rejected and reasons for rejection, with the intention to reduce such instances. methods: data was collected retrospectively on icu admissions from january-june to a university hospital in the uk. patients were identified and data collected using the intensive care national audit and research centre (icnarc) database and from electronic patient records. data collected included: demographics, length of stay, microbiology samples sent and details on the rejected samples. results: patients were identified with a total of (median: samples/patient) samples sent to microbiology. were rejected ( %). ( %) patients had at least sample rejected. the median number of samples rejected per patient was (range: - ). the fig. (abstract p ). the area under the curve for crp elevation is . most common samples rejected were urine ( %), blood ( %), faeces ( %) and sputum ( %). ( %) of the samples were resent for testing (median day; range - ). reasons for sample rejection are shown in table . most rejections occurred within -hours of admission ( fig. ) . conclusions: this study confirms a high number of samples are sent to microbiology. although a few are rejected, overall this represents a large number, with most occurring during the first days of admission. reasons for sample rejection are remedial through improved training and vigilance. a bespoke guide to sample collection for microbiology coupled with a training program for healthcare professionals has been introduced with the aim to reduce sample rejections from % to . %. introduction: careful hand hygiene of health-care workers (hcws) is recommended to reduce transmission of pathogenic microorganisms to patients [ ] . mobile phones are commonly used during work shifts and may act as vehicles of pathogens [ , ] . the purpose of this study was to assess the colonization rate of icu hcws' mobile phones before and after work shifts. methods: prospective observational study conducted in an academic, tertiary-level icu. hcws (including medical and nursing staff) had their mobile phones sampled for microbiology before and after work shifts on different days. samples were taken with eswab in a standardized modality and seeded on columbia agar plus % sheep blood. a semiquantitative growth evaluation was performed at and hours after incubation at °c. results: fifty hcws participated in the study ( % of department staff). one hundred swabs were taken from mobile phones. fortythree hcws ( %) reported a habitual use of their phones during the work shift, and of them ( . %) usually kept their mobiles in the uniform pocket. all phones ( %) were positive for bacteria. the most frequently isolated bacteria were coagulase negative staphylococcus, bacillus sp. and mrsa ( %, %, %, respectively). no patient admitted to the icu during the study period was positive for bacteria found of hcws' mobile phones. no difference in bacteria types and burden was found between the beginning and the end of work shifts. conclusions: hcws' mobile phones are always colonized mainly by flora resident on hcw's hands, even before the work shift and irrespective of the microbiological patients' flora. further studies are warranted to investigate the role of mobile phones' bacterial colonization in the icu setting and to determine whether routine cleaning of hcws' mobile phones may reduce the rate of infection transmission in critical patients. methods: sixty samples were collected from aicu (n= ), picu (n= ) and or (n= ) during august to september . samples were randomly selected and taken at the end of the hcws duty with a sterile swab covering all mp surfaces. the inoculation was made into blood sheep and eosyn methilene blue agar for culture. isolated bacteria were identified according to standard microbiological techniques. antibiotic sensitivity testing was performed using disc diffusion method. results: overall mp bacterial colonization rate was %. main results are detailed in table . most common non pathogenic bacteria was staphylococcus epidermidis n= ( %). isolated pathogenic bacteria conclusions: we found high rates of mp colonization with pathogenic bacteria. an educational program is necessary to reduce the contamination and transmission of these high risk microorganisms. introduction: the objective of this study was to evaluate the variability in the dynamics and levels of airborne contamination within a hospital intensive care unit in order to establish an improved understanding of the extent to which airborne bioburden contributes to cross-infection of patients. microorganisms from the respiratory tract or skin can become airborne by coughing, sneezing and periods of increased activity such as bed changes and staff rounds. current knowledge of the clinical microflora is limited however it is estimated that - % of nosocomial infections are transmitted via air. methods: environmental air monitoring was conducted in glasgow royal infirmary icu, in the open ward and in patient isolation rooms. a sieve impactor air sampler was used to collect l air samples every minutes over hour ( : - : h) and hour ( : - : h) periods. samples were collected, room activity logged and the bacterial contamination levels were recorded as cfu/m of air. results: a high degree of variability in levels of airborne contamination was observed over the course of a hour day and a period in a hospital icu. counts ranged from - cfu/m over hours in an isolation room occupied for days by a patient with c. difficile infection. contamination levels were found to be lowest during the night and in unoccupied rooms, with an average value of cfu/m . peaks in airborne contamination showed a direct relation to increased room activity. conclusions: this study demonstrates the degree of airborne contamination that can occur in an icu over a hour period. numerous factors were found to contribute to microbial air contamination and consideration should be given to potential improved infection control strategies and decontamination technologies which could be deployed within the clinical environment to reduce the airborne contamination levels, with the ultimate aim of reducing healthcareassociated infections from environmental sources. new practice of fixing the venous catheter of the jugular on the thorax and its impact on the infection f goldstein, c carius, a coscia quintad'or, rio de janeiro, brazil critical care , (suppl ):p introduction: central line-associated bloodstream infection (clabsi) is an important concern in the icu, mainly in those with a high density of use of central venous catheter. any measures that may have an impact on the reduction of clabsi are important in reducing morbidity and mortality of hospitalized patients. therefore we present a retrospective study comparing the fixation site (neck vs. thorax) of the catheters implanted in the jugular vein, guided by ultrasonography and evaluating its impact on the incidence of clabsi. the purpose of our study was to identify if there is any positive impact on the reduction of clabsi when the catheter is fixated on the thorax. methods: a retrospective unicentric study comparing the infection rates between the year of , when the traditional technique of catheter fixation on the neck was used, and , when % of the catheters were fixated on the thoracic region. the criteria for clabsi were defined by the infection commission of quintad`or hospital and the data on clabsi were provided by the same commission. during this period there were no changes in the team of our unit and the patient's profile was the same. no deep vein catheter impregnated with antibiotics were used in the patients included in the study. the comparison used fisheŕs test as a tool. all the patients hospitalized in the intensive care unit with indication of the central venous catheter of short permanence in the internal jugular vein were included. patients with the central venous catheter of short permanence in other topographies, patients with hemodialysis catheter or with picc were excluded. results: during the year of , internal jugular vein catheters were installed in our unit using the traditional technique, fixing the catheter on the neck. in this period, cases of clabsi were detected. on the other hand, in the year of , internal jugular vein catheters were installed in the same unit, all of them, using the thorax as the point of fixation. although the number of catheters installed this year was higher, there was no case of clabsi. it appears that this position, provides a better fixation of the catheter, avoiding that the bandage gets uncovered. conclusions: during the year of , though there were more patients using deep vein catheters of short permanence, we had less clabsi events on our unity compared to the year of . fisher's exact test identified a p-value of this association of . . fixation of the internal jugular vein catheter in the thorax seems to contribute to the prevention of clabsi. further prospective and randomized studies are required to evaluate the contribution of fixation of the jugular vein catheter in the thorax in the clabsi prevention. introduction: the oral cavity of a patient who has been hospitalized presents a different flora from normal healthy people. after h hours of hospital stay, the flora presents a bigger number of microorganisms that can be responsible for secondary infections, like pneumonia, because of their growth and proliferation. the objective of our study was to assess the dental plaque index on patients on admission to an intensive care unit, and reassess days later, to evaluate the efficacy of oral hygiene. methods: prospective, descriptive and observational study in an intensive care unit of the chp. demographic, admission motive, hospital length of stay, feeding protocol, respiratory support need and oral hygiene protocol data was collected. the greene & vermillion simplified oral hygiene index (iho-s) was used as the assessment tool on the first h and on th day. results: patients were evaluated, of which were excluded for not meeting the minimal dentition. patients had a mean age of , ± , years, , % were males and most of medical and surgical scope ( , % each). mean hospital length of stay was , ± , days. the majority of patients were sedated ( %), under ventilator support ( , %) and with enteric nutritional support, under nasogastric tube feeding. initial iho-s score was , ± , , rising to , ± , (p< , ) days later. conclusions: various studies have proven the importance of a good oral hygiene to avoid bacterial growth and reduce the risk for nosocomial infections. in this study, we've observed a significant worsening of oral hygiene one week after admission. although this could be unimportant for a one week staying patient, it could indicate an increased risk for nosocomial infections for longer staying patients, which could benefit from a more efficient oral hygiene protocol. positive pocket cultures and infection risk after cardiac electronic device implantation-a retrospective observational single-center cohort study p pekić methods: we performed a retrospective observational single-center cohort study on patients who received de novo implantation of pacemaker, cardioverter-defibrillator or cardiac resynchronization therapy device in a two-year period. each patient was implanted using standard aseptic procedure according to local protocol and antibiotic (cefazolin) prophylaxis before the procedure. pocket aspirate was taken after irrigating the wound with normal saline just before device placement. results: we analyzed patients ( . % male, . % female). the most often implanted device was a ddd pacemaker followed by a vvi pacemaker. mean length of hospital stay was . ± . days. there were ( . %) positive cultures with overall ( . %) clinically apparent infections which required prolonged iv antibiotics, removal of device and reimplantation after infection resolution. in regard to microbiology, s. epidermidis ( . %) and coagulase negative staphylococcus ( . %) were the most often finding which is in contrast to the cultures described in the literature. the only statistically significant risk factor for positive pocket culture was male sex and presence of a urinary catheter. invasive vascular devices, previous intrahospital infection, and diabetes were not found to increase the likelihood of positive pocket culture. conclusions: positive pocket cultures after cied implant are a frequent finding mostly due to contamination and colonisation. the risk factors for such a finding differ from the usual and expected clinical circumstances. our results are consistent with those in the literature. it turns out that the most important preventive measure in cied implantation is strict aseptic procedure. introduction: intensive care patients are in constant risk of contamination due to suppression of their immune system, use of invasive procedures and medical equipment and health associated infections (hai). chlorhexidine gluconate (chg) is an antiseptic and disinfectant product. in medical research it has been found that daily chg bathing is affective in reducing levels of skin and central line related infections (climo, ) . it is also referred to in the recommendations of the ministry of health "prevention of septicemia due to central lines" ( ). methods: unit guide lines for patient dry bathing were written in may and thereafter began the implementation and instruction of nursing staff. quality control was inspected by observation. there was a phase questioner that included several categories such as: preparation of the chg solution, staff protection actions, infusions and surgical wound dressings, bathing performance and documentation. results: a gradual rise of %was observed in theperformance ofdry bathing according to the unit guidelines conclusions: % of observed dry baths where performed according to the guide lines. points for improvement: correct care of infusions and surgical wound dressing and verify use of separate wipes for each body part. next we will examine the correlation between the use of dry baths and theextent of infections in the unit. dry baths are nowconsidered an integralpart of the daily nursing routine. they have no substantial costs, help prevent complications from infection and add to the patient's safety. introduction: despite reductions in mortality reported with sdd, concerns about bacterial resistance and alteration of microbiome limit use. a retrospective observational study was conducted into the effect of local sdd protocols on vap rates and resistance patterns. over a -year period, regimens were used dependent on drug availability and hospital antibiotic stewardship concerns. the study was designed to review practice and identify any risks of partial implementation. methods: patients ventilated on a general intensive care were identified via clinical information systems. three periods were reviewed for adherence to sdd protocols, pre sdd (jan -feb ), full (july -sept ) and partial (july -sept ). high-risk patients during both sdd periods also received iv antibiotics for hours. patients admitted with pneumonia or tuberculosis were excluded from vap analysis. remaining patients' records were reviewed and the clinical pulmonary infection score (cpis) calculated for each ventilated day to identify vap rates. positive respiratory microbiological results for all patients admitted to the icu during each time period were reviewed to assess for wider changes in local resistance patterns. results: protocol adherence was assessed in patients during the full sdd period and during the partial ( table ). the number of patients included for analysis of vap rates during each period was pre sdd, during full sdd and during partial sdd. there were no significant changes in resistance patterns or clostridium difficule rates (table ) . conclusions: compliance with the available enteral antibiotics was reasonable but with iv antibiotics was poor. it is accepted that alterations and non-adherence to protocols risk development of resistant bacterial strains. within our unit no decrease in vap rates was seen but reassuringly no increased rates of extended bacterial resistance were identified during the treatment periods. introduction: arterial catheters are commonly used in intensive care units (icu) and are among the most frequently manipulated vascular access devices. our aim was to evaluate the rate of arterial catheterrelated bloodstream infection and colonization. methods: this was a -month, prospective and monocentric cohort study, performed in a multipurpose icu. all arterial catheters, inserted in or presented to the icu, were cultured and assessed for colonization or catheter-related bloodstream infection (crbi). results: we enrolled patients ( . % males, average age ± years, saps ± ) of whom a total of arterial catheters were analyzed for a total of catheter-days. radial arterial catheters were inserted in . % (n= ), femoral arterial catheters in . % (n= ) and other arterial catheters in . % (n= ). signs of dysfunction were found in . % and . %, respectively. radial arterial catheters colonization (n= ) and crbi (n= ) occurred at a rate of . and . / catheter-days. femoral arterial catheters colonization (n= ) and crbi (n= ) occurred at a rate of . and . / catheter-days, respectively. mean catheter time insertion was significantly higher in colonized catheters/crbi ( ± days; % ci: - ) when compared to arterial catheters with negative cultures ( ± days; % ci: - ); p = . ). colonized lines showed acinetobacter baumannii (n= ), staphylococcus epidermidis (n= ), enterococcus spp (n= ) and pseudomonas aeruginosa (n= ). crbi were caused by staphylococcus epidermidis (n= ) and staphylococcus haemolyticus (n= ). conclusions: the incidence of radial arterial catheters colonization and crbi were lower than reported rates in literature. colonization and crbi rates were higher in femoral catheters. femoral catheters showed dysfunction more frequently. prolonged catheterization was associated with colonization and crbi. a multimodality approach to decreasing icu infections by hydrogen peroxide, silver cations and compartmentalization and applying acinetobacter as infection marker introduction: nosocomial infections at the intensive care unit (icu) represent a substantial health threat [ , ] . icu infections are mainly attributed to the extended hospital delay which results in high morbidities and mortalities. methods: a cross sectional study was conducted at the intensive care unit, aseer central hospital, saudi arabia over months period ( ) ( ) . the intervention program included the application of mist of hydrogen peroxide and silver cations, physical separation and compartmentalization of the intensive care unit. the glosair™ system was used to deliver a mist of hydrogen peroxide and silver cations. hydrogen peroxide is an oxidizing agent, which kills microorganisms. results: a total of strains of acinetobacter species were identified from the patients over the months period (fig. ) . the mean infection rates decreased from . in the first three months of the program to in the last three month after continuous. conclusions: the program using the three procedures offered a significant decrease in infections at the icu as measured by acinetobacter count, which is one of the most hazardous nosocomial pathogens. introduction: the efficacy of ß lactam antibiotics is related to the time above mic. continuous or extended infusions can be used to increase the time above mic, especially in patients with normal or increased drug clearance. administering antibiotics by continuous infusion is not a new concept. a review in looks at the outcomes of continuous infusions [ ] . more recently an improvement in mortality has been demonstrated [ ] . our perception was that uptake of this low cost intervention was not common, so we undertook a survey to determine how commonly continuous infusions are used in england. methods: a telephone survey of all intensive care units in england was undertaken. questions included: -are you using continuous or extended antibiotic infusions? -which antibiotics are you using for continuous or extended infusions? -if not currently using has it been considered? data was collected over a week in june . results: there was an % response rate. ( . %) of the units continuously infuse some antibiotics, however . % of those only infuse vancomycin and not ß lactams. only of the total responders ( . %) infuse antibiotics other than vancomycin (i.e. ß lactams). conclusions: the theoretical advantage of continuous infusion of ß lactam antibiotics has been described for over years. there is now evidence that this may improve survival. despite this, uptake in england has been slow. introduction: infections contribute to a significant proportion of morbidity and mortality worldwide. while many infections are successfully managed with antimicrobial therapy, rates of antimicrobial resistance (amr) are increasing. certain patient populations such as those admitted to intensive care units (icu) are at high risk. methods: we conducted a retrospective, observational study of all icu patients at a tertiary referral hospital in rwanda from january through december we collected data on diagnosis, icu length of stay, mortality and hospital length of stay, as well as microorganism, site of culture, amr and antibiotics prescribe. results: overall, patients were admitted to the icu. most patients were admitted from the main operating theater (n= , %).the most common admitting diagnoses were sepsis (n= , %), head trauma (n= , %). a total of samples were collected from patients. the samples were from blood (n= , %), tracheal aspirate (n= , %),. the most common organisms isolated were klebsiella (n= , %), acinetobacter (n= , %), e.coli (n= , %), proteus (n= , %), citrobacter (n= , %), s aureus (n= , %), pseudomonas (n= , %), and other (n= , %). of klebsiella isolates, % and % were resistant to ceftriaxone and cefotaxime, respectively. of e.coli isolates, % and % were resistant to ceftriaxone and cefotaxime, respectively. all acinetobacter isolates were resistant to ceftriaxone and cefotaxime. conclusions: there is an alarming rate of antimicrobial resistance to commonly used antibiotics in the icu. expanding antibiotic options and strengthening antimicrobial stewardship are critical for patient care. the last three days g latten , p stassen zuyderland mc, sittard-geleen, netherlands, introduction: this study provides an overview of the prehospital course of patients with a (suspected) infection in the emergency department (ed). most research on serious infections and sepsis has focused on the hospital environment, while potentially most delay, and therefore possibly the best opportunity to improve treatment, lies in the prehospital setting. methods: patients were included in this prospective observational study during a week period in . all patients aged years or older with a suspected or proven infection were included. prehospital, ed and outcomes were registered. results: in total, patients visited the ed during the study period, of whom ( . %) patients had a (suspected) infection. (fig. ) median duration of symptoms before ed visit was days (iqr - days), with . % of patients using antibiotics before arrival in the ed. most patients ( %) had been referred by a general practicioner (gp), while . % of patients had visited their gp previously during the current disease episode. twenty-two patients ( . %) experienced an adverse outcome (icu admission and/or -day all-cause mortality): these patients were less often referred by a general practicioner (gp) ( . vs. . %, p= . ) and were considered more urgent both by ems and in the ed. conclusions: the prehospital phase of patients with an infection provides a window of opportunity for improvement of care. patients become ill days before the ed visit and . % already visited their gp previously during the current disease episode, while . % is currently using antibiotics. future research should focus on quality improvement programs in the prehospital setting, targeting patients and/or primary care professionals. introduction: worldwide, the prevalence of tetanus has decreased.-however, even if progress has been made in the combat to eradicate tetanus it may be a cause of admission to intensive care.the objectives of our study are to determine epidemiological,clinical and prognostic characteristics for severe tetanus in our unit. methods: we conducted a retrospective study in the medical intensive care unit of ibn rushd hospital in casablanca in morocco from to .we studied the epidemiological,clinical and prognostic characteristics of the patients who were admitted for severe tetanus. results: the incidence of severe tetanus was . % affecting male in %. . % were aged between and years old. in . % there were a integumentary portal of entry. contractures were present in %of the cases. at intensive care unit admission, . % of the patients were sedated. the anti-tetanus vaccination was never updated. according to the dakar score . % of the patients were listed dakar , . % dakar and . % dakar . for the mollaret score, the crude form was found in . %, the acute generalized form was found in . % and the severe form in . % of the cases.mechanical ventilation was necessary in . %. diazepam and baclofen were used in . %, phenobarbital in . % and propofol in . %. a serotherapy was used for all the patients and a preliminary vaccination dose for . %. all the patients received antibiotics, penicillin g . % and metronidazole . %. the mortality was . %. the length of intensive care stay was significantly higher. the need for an intubation,its duration and the occurrence of autonomic dysfunction have significantly influenced the mortality. conclusions: to improve the prognosis in these serious forms of tetanus,it is highly important to identify the warning signs and refer patients in intensive care for early and appropriate management in intensive care. introduction: bloodstream infections (bsis) are associated with increased mortality in the icu. the aim of the study was to evaluate the epidemiology and resistance patterns during the period to . methods: bacteria and fungi isolated from the blood of patients hospitalized in a mixed icu during the study period were retrospectively analyzed. sensitivity testing was performed with disk diffusion (kirby-bauer) and microscan walkaway plus for minimal inhibitory concentrations. results: during the study period patients were hospitalized in the icu. bsis were diagnosed in cases ( . %). the isolated microorganisms were acinetobacter baumannii ( %), klebsiella pneumoniae ( %), other enterobacteriaceae ( %), pseudomonas aeruginosa ( %), stenotrophomonas maltophilia ( %), enterococci ( %), staphylococci ( %) and candida spp. ( %). of the a. baumannii isolates, % were resistant to carbapenems, . % to colistin, and % to tigecycline. of the k. pneumoniae isolates % were resistant to carbapenems, % to colistin, and . % to tigecycline. of the p. aeruginosa species % were resistant to carbapenems and they were all susceptible to colistin. the rate of resistance to vancomycin was % for the e. faecium isolates, . % for the e. faecalis, while the resistance to methicillin of the coagulase negative staphylococci was %. the most commonly isolate species of candida was c. albicans. conclusions: multi-drug resistant isolates, especially a. baumannii and enterobacteriaceae, are a serious problem in our icu. gram positive bacteria are less common, but the resistance of enterococci to vancomycin is significant. antibiotic stewardship and infection control measures should be applied in a more strict way. nosocomial sinusitis in intensive care unit patients i titov introduction: nosocomial sinusitis (ns) is a complication of critically ill patients which develops - h after admission and is mostly linked but not limited to such invasive procedures as nasotracheal intubation and nasogastric tube placement. ns is often overlooked as a source of pyrexia of unknown origin, meningeal manifestations, sepsis and ventilator associated pneumonia in icu patients. ct scanning and sinus puncture are used to confirm the inflammatory process and identify the pathogen behind it. methods: a retrospective case study of . icu patients for a period of - was performed. we have analysed data from the ct scans of paranasal sinuses and bacteriological findings of samples obtained from sinus puncture. results: ( . %) patients were suspected of ns on the - th day of stay in the icu. the ct scan confirmed pathological changes in patients ( . %). hemisinusitis was detected in patients ( . %) and pansinusitis in patients ( . %). there was also an isolated case of maxillary sinusitis in patient ( . %). the pathogenic culture was identified only in ( %) samples, . % of which revealed isolated bacteria and . % a polymicrobial association. gram positive bacteria were detected in . % of cases and gram negative in . %. most cases revealed multiple antibiotic resistance. conclusions: . ns has proved to be largely caused by gram negative bacteria and polymicrobial associations. the use of broad spectrum antibiotics in icu may justify the presence of sterile cultures. .early identification of risk patients in icu as well as the use of screening ct scan may benefit timely diagnosis and adequate treatment of patients. .preventive considerations include: patient's bed head elevation, the use of oral gastric tube in sedated and coma patients on ventilation, nasotracheal intubation only if indicated, removal of nasogastric tube at night, proper hygiene. conclusions: only of , tb patients ( %) required critical care intervention (table ) . those admitted to icu were older and more likely to have pulmonary, cns, miliary or abdominal tb (table ) . mortality was high despite critical care input in a unit familiar with managing tb, and hour access to infectious diseases advice within the trust, likely due to overwhelming organ dysfunction, patient frailty and advanced tb infection. rates of drug resistant tb were low and comparable to uk-wide rates over that period ( % mono-drug resistant, % mdr) thus less likely a contributory factor to the majority of deaths. short term antibiotics prevent early vap in patients treated with mild therapeutic hypothermia after cardiac arrest t daix , a cariou , f meziani , pf dequin , c guitton , n deye , g plantefève , jp quenot , a desachy , t kamel , s bedon-carte , jl diehl , n chudeau , e karam , f renon-carron , a hernandez padilla , p vignon , a le gouge introduction: patients treated with mild therapeutic hypothermia after cardiac arrests with shockable rhythm are at high risk of ventilator-associated pneumonia (vap) [ ] . despite retrospective trials suggesting a benefit of short-term ( h) antibiotics in this setting [ ] , it is not recommended. the primary objective was to demonstrate that systematic antibiotic prophylaxis can reduce incidence of early vap (< days). the impact on incidence of late vap and on day mortality was also assessed. methods: multicenter, placebo-controlled, double-blinded, randomized trial. icu patients > years, mechanically ventilated after out-of-hospital resuscitated cardiac arrest related to initial shockable rhythm and treated with mild therapeutic hypothermia were included. moribund patients and those requiring extracorporeal life supports, with ongoing antibiotic therapy, known chronic colonization with multiresistant bacteria or known allergy to beta-lactam antibiotics were excluded. either iv injection of amoxicillin-clavulanic acid ( g/ mg) or placebo was administered times a day for days. all pulmonary infections were recorded and blindly confirmed by an adjudication committee. results: in intention to treat analysis, patients were analyzed, (treatment group n= ; mean age . ± . years, sex ratio= , sofa score . ± . ). global characteristics of cardiac arrest were similar (no flow= . min vs . min, low-flow= . min vs . min). vap were confirmed incl. early vap, in treatment group vs in placebo group (hr= . ; ic %=[ . ; . ]) (fig. ) . occurrence of late vap ( % vs . %) and day mortality ( . % vs . %) was not affected by the study procedure. conclusions: short-term antibiotic prophylaxis significantly decreases incidence of early vap in patients treated with mild therapeutic hypothermia after out-of-hospital cardiac arrest related to shockable rhythm and should be recommended. introduction: antibiotics are the most commonly prescribed drugs in icu.in the era of antibiotic resistance it is difficult to choose antibiotics during septic episode.the choice antibiotics mainly depends on clinical diagnosis,culture sensitivity and local flora. whether severity of illness really maters is not well known. to study antibiotic prescription pattern and whether the choice of antibiotic varies according to hemodynamic stability in patients admitted in icu.to study of microbiological isolates and their variability according to hamodynamic stability in icu patients. methods: all icu patients of more than years age who received antibiotics and where cultures had been sent were included in the study.patients discharged against medical advice and where treatment had been withdrawn were excluded in this study. this prospective observational study was conducted between july to march .patients were divided into stable and unstable group according to hemodynamic parameter and usage of antibiotics and microbiological isolated were correlated. icu mortality and length of stay were correlated between hemodynamically stable and unstable group. results: sepsis episode were analysed. mean age was years, male predominant, and average apache iv score was (sd ). we had patients in unstable group of which % patients got discharged and % of patients got discharged in stable group. antibiotic combination therapy was used more in hemodynamically unstsble patients(p . ). blbli was used more in stable group. drug resistance in microbiological isolates did not reveal any statistically significant difference among stable or unstable group. conclusions: there is a tendency to administer combination antibiotics in sicker group of patients with hemodynamic instability. prevalence of microbial flora did not show any statistical difference. outcome is worse in hemodynamically unstable patients. the clinical significance of candida score in critically ill patients with candida infection h al-dorzi , r khan , t aldabbagh , a toledo , s al johani , a almutairi , s khalil , f siddiqui , y arabi king abdulaziz medical city, riyadh, saudi arabia, msd, riyadh, saudi arabia, king saud bin abdulaziz university for health sciences, riyadh, saudi arabia critical care , (suppl ):p introduction: candida score (cs) is used to identify patients with invasive candidiasis in the icu, but its clinical use has not become widespread. our objective was to evaluate the clinical significance of cs in a mixed population of icu patients. methods: this was a prospective observational study of critically ill patients who had candida species growth during their stay in any of six different icus of a tertiary-care center. two intensivists classified patients as having candida colonization or invasive candidiasis according to predefined criteria. cs was calculated for each patient on the day of candida species growth as follows: . see text for description point for parenteral nutrition + point for surgery + point for multifocal candida colonization + points for severe sepsis. the receiver operating characteristic (roc) curve was plotted to assess cs ability to discriminate between invasive candidiasis and candida colonization. results: cs was . ± . in patients with candida colonization (n= ) and . ± . in those with invasive candidiasis (n= ) (p< . ). however, only . % of invasive candidiasis cases had cs >= (compared with . % of candida colonization cases; p< . ). the roc curve (fig. ) showed that cs had fair ability to discriminate between invasive candidiasis and candida colonization (area under the curve . , % confidence interval . to . ; p< . ). in patients with invasive candidiasis, cs was similar in hospital survivors and nonsurvivors ( . ± . and . ± . , respectively; p= . ). cs did not discriminate between survivors and nonsurvivors (area under the roc curve . , % confidence interval . to . ; p< . ). conclusions: cs was higher in patients with invasive candidiasis than those with candida colonization. however, its ability to discriminate between these patients was only fair. cs was not associated with hospital mortality. poor reliability of creatinine clearance estimates in predicting fluconazole exposure in liver transplant patients m lugano, p cojutti, f pea asuiud, udine, italy critical care , (suppl ):p introduction: invasive candidiasis (ic) is a frequent complication in liver transplant (lt) recipients, especially during the first - months after lt. fluconazole is a triazole antifungal used for prophylaxis and treatment of ic. due to its renal elimination, dose adjustments are usually based on estimated creatinine clearance (ecrcl). however, the reliability of ecrcl in predicting fluconazole clearance has never been investigated in this population. the aim of this study was to conduct a population pharmacokinetic (poppk) analysis in a cohort of lt patients who underwent therapeutic drug monitoring (tdm) in order to find out which covariates may influence fluconazole pharmacokinetics (pks). methods: this retrospective study included lt patients who were admitted to the intensive care unit of our university hospital between december and may , and who were treated with intravenous fluconazole in the first months after lt. tdm of fluconazole was performed with the intent of attaining the efficacy pharmacodynamic target (auc h/mic > . ). the tested covariates were: age, gender, ckd-epi ecrcl, time from lt, serum albumin and transaminases, saps ii score. poppk was carried out with pmetrics software. results: nineteen patients (mean±sd age, weight and serum creatinine of ± . years, ± . kg, . ± . mg/dl, respectively) with a total of fluconazole trough plasma concentrations were included in the poppk analysis. mean±sd fluconazole distribution volume (vd) and clearance (cl) were . ± . l and . ± . l/h. age and time from lt were the only clinical covariates significantly correlated with fluconazole vd and cl, respectively. conversely, ckd-epi eclcr was unable to predict fluconazole cl. conclusions: ckd-epi eclcr is unreliable in predicting fluconazole exposure in lt recipients. consistently, in this population adaptation of fluconazole dose should be based on measured crcl, and tdm may be helpful in optimizing drug exposure. outcomes of a candidiasis screening protocol in a medical icu m boujelbèn , i fathallah , h kallel , d sakis , m tobich , s habacha , n ben salah , m bouchekoua , s trabelsi , s khaled , n kouraichi introduction: the aim is to determine the incidence, characteristics and risk factors of invasive candidiasis (ic) in critically ill patients by using a weekly screening protocol. methods: a months' prospective study was conducted in a -bed micu. the candidiasis screening consisted of the culture of plastic swabs (from different body sites), urine and respiratory tract samples.it was conducted upon admission and on weekly basis for all the patients. decision to treat was based on clinical and microbiological features. results: patients were included. the colonization rate with candida spp was . %(n= ). screening samples were collected with a positivity rate at . %(n= ). table describes the isolated candida species by site. antifungal resistance was tested in ( %) species. the resistance rate to fluconazole was . %(n= ). the antifungal resistance of candida albicans is detailed in table . ( . %) patients presented an ic with a mean age and mean saps ii at . ± years and ± . respectively. ( %) presented acute renal failure upon admission. . % (n= ) of the patients needed mechanical ventilation. the median length of stay was days [ . - . ] and the mortality rate was . %(n= ). the mean sofa score upon infection was . ± . . the candida score was >= . and the colonization index was >= . in fig. (abstract p ). roc curve for candida score discrimintaing between invasive candidiasis and candida colonization . %(n= ) and . %(n= ) of the patients respectively. only one patient had a positive blood culture. mannan antigen and anti-mannan antibodies were screened only in five patients with a positivity rate at %(n= ). the most isolated species was: candida albicans . %(n= ). multivariate analysis showed that prior use of imipinem more than days was a risk factor for ic (or= . , ci [ . ; . ], p= . ). conclusions: this study showed the ecology and epidemiology of candida species in our micu with an increased ic rate and high mortality. prior imipinem use was a risk factor for ic. introduction: icu-acquired infection is as high as . episodes per patient-days in lower-middle income countries like india (who). almost three times higher than in high-income countries [ ] . candida infection is the rd most commonly acquired nosocomial infection in india burdening the debilitated patient with longer icu stay [ ] . there are no definite guidelines on whether & when to start antifungal treatment, specific to india where ifi risk is high and diagnostic facilities are limited. currently, the intensivists across india are using antifungals, according to their clinical experience and selective application of international guidelines leading to non-uniformity of patient outcomes. in an endeavour to synchronize anti-fungal therapy and educate intensivists from small cities of india, intensivists and infectious disease specialist of international repute were approached to design a module on 'invasive fungal infections -when to start anti-fungals in icu [ fig. ]. the ifi in india was summarised into a compact hour session for dissemination of knowledge using idsa as a reference guideline. intensivists from across india were trained on the module by our faculty. the module was rolled out to intensivists and pulmonologists focussing particularly on the tier- & tier - cities where avenues for learning are limited [ fig. introduction: trichosporon species are fungi found in nature and human normal flora but they can be an opportunistic pathogen, introduction: this study assessed whether empiric combination antibiotic therapy directed against gram-negative bacteria is associated with lower intensive care unit (icu) mortality compared to single antibiotic therapy. methods: retrospective cohort study on prospectively collected data conducted in the icu of a tertiary care hospital in india between july to march . all consecutive infection episodes treated with empiric antibiotic therapy and with subsequent positive culture for gram-negative bacteria were included. primary and secondary outcomes were all cause icu mortality and icu length of stay (los). outcomes were compared between infection episodes treated with single vs.combination antibiotic therapy. results: of total episodes of gram-negative infections . % received combination-antibiotic therapy. baseline demographic and clinical characteristics between single vs. combination therapy groups were similar (mean age: p= . ; sex: p= . ; mean apache iv score: p= . ). overall icu mortality did not significantly differ between single and combination antibiotic groups ( . % vs. %; p= . ). in single antibiotic group, icu mortality was significantly higher for antibiotic-resistant compared to antibiotic-sensitive bacteria ( . % vs. . %, p= . ). in combination group, significantly lower icu mortality was noted if bacteria was sensitive to even one antibiotic compared to pan-resistant bacteria ( . % vs. . %, p= . ). icu los was similar between antibiotic-sensitive bacteria and antibiotic-resistant bacteria, both in single and combination therapy groups (single, antibiotic-sensitive vs. antibiotic-resistant: mean los±sd . ± . vs. . ± days; p= . ; combination, antibioticsensitive vs. antibiotic-resistant: . ± . vs. . days; p= . ). conclusions: irrespective of the number of antibiotics prescribed as empiric therapy, outcome of patients solely depends on the sensitivity pattern of the bacteria isolated. pharmacokinetics of trimethoprim and sulfametrole in critically ill patients on continuous haemofiltration r welte , j hotter , t gasperetti , r beyer , r introduction: the combination of trimethoprim and sulfametrole (tmp-smt, rokiprim®) is active against multi-drug resistant bacteria and pneumocystis jirovecii. in critically ill patients undergoing continuous veno-venous haemofiltration (cvvh), however, its use is limited because of lacking pharmacokinetic data. methods: pharmacokinetics of both drugs were determined after standard doses in patients on cvvh and in critically ill patients with approximately normal renal function. quantification of tmp and smt was done by high pressure liquid chromatography (hplc) and uv detection after pre-purification by solid phase extraction. the total clearance (cltot) was estimated from arterial plasma levels and the haemofilter clearance (clhf) from plasma and ultrafiltrate concentrations. results: six patients on cvvh ( after the first dose, at steady state) and nine patients off cvvh have been enrolled ( after first dose, at steady state). after a single dose, cltot of smt was . ( . - . , median [range]) and . ( . - . ) l/h on and off cvvh, respectively. at steady state, we observed a cltot of . ( . - . ) and . ( . - . ) l/h, respectively, on and off cvvh. steady state trough levels (cmin) of smt amounted to - mg/l in patients on cvvh and - in patients off cvvh. cltot of tmp was . ( . - . ) l/h on cvvh and . ( . - . ) l/h off cvvh after the first dose. at steady state, its cltot amounted to . ( . - . ) and . ( . - . ) l/h on and off cvvh, respectively. cmin was - mg/l on cvvh and - mg/l in patients off cvvh. clhf accounted for - % of cltot of smt and - % of cltot tmp. conclusions: exposure to both antimicrobial agents is highly variable, but comparable in patients on and off cvvh. as considerable amounts of smt and tmp are eliminated by cvvh, no excessive accumulation appears to take place during treatment with standard doses. the positive impact of meropenem stewardship intervention at a brazilian intensive care unit w freitas introduction: loss of colistin as a clinical option has profound public health implications. widespread use of colistin in agriculture and humans has seen the emergence of mcr- mediated resistance amongst south african patients [ ] . we sought to describe the trends of colistin minimum inhibitory concentrations (mic) over two years using data collected by smart. methods: smart monitors the in vitro susceptibility of clinical aerobic and facultative gram-negative bacterial isolates to selected antimicrobials of importance, enabling longitudinal analyses to determine changes over time. the dataset comprised bacterial isolates from four different south african private pathology laboratories and one public sector pathology laboratory from - . the methods used in the study have been described elsewhere [ ] . isolate proportions between years were compared using the chisquared test with yates' continuity correction. ( ) ( ) ( ) ( ) days]; patients underwent renal replacement therapy. the median treatment duration (iqr) was ( - ) days. in . % of cases, antibiotic-therapy therapy combination (phosphomycin and colistin) was chosen. all the patients experienced a clinical response by / hours from the ceftazidime/avibactam commencing. in / bacteraemic patients negativization of blood culture occurred by hours as well as of the rectal swab in / patients. a (b) recurred and a second treatment was given. / ( . %) patients survived, whereas death was caused by multi-organ failure. the susceptibility test of strains showed sensitivity to ceftazidime/avibactam, whereas % of resistance to carbapenems, quinolones and iii/iv generation cephalosporin, tigecycline and piperacillin/tazobactam; . % of susceptibility to fosfomycin and colistin; (v) less than % of suceptibility to aminoglicosides. conclusions: the strains of kp-cp were susceptible to ceftazidimeavibactam despite the high carbapenem-resistance recorded in our icu, because od rare identification of kp-cp vim/ndl +. the preliminary data seems to confirm the efficacy and clinical utility of this antibiotic for the critically ill patients. introduction: multidrug resistant bacteria (mdr) are an increasing problem on intensive care units. lung infections caused by acinetobacter baumannii are frequently difficult to treat. phages have regained attention as treatment option for bacterial infections due to their specificity and effectivity in lysis. the aim of this preclinical study was to determine efficacy and safety of a novel phage preparation in mice. methods: mice were transnasally infected with a mdr a. baumannii strain [ ] and hours later treated intratracheally with a specific phage or solvent. phage acibel [ ] was produced as suspension including efficient depletion of endotoxins. at defined time points, clinical parameters, bacterial burden in lung and bronchoalveolar lavage fluid (balf) and cell influx were determined. further, lung permeability and cytokine release were quantified and histopathological examination was performed. results: mice treated with phages recovered faster from infectionassociated hypothermia. hours after infection, phage treatment led to a reduction in bacterial loads in lungs and balf. in addition, lung permeability and cytokine production were reduced in phagetreated mice. histopathological examination of the lungs showed less spreading of bacteria to the periphery in phage-treated mice, whereas cellular recruitment into the lung was unaffected. no adverse effects were observed. conclusions: for the first time a highly purified phage against a. baumannii was successfully used in vivo. the current preclinical data support the concept of a phage-based therapy against pulmonary a. baumannii infections. introduction: vap is common in critically ill patients and associated with high morbidity and mortality, especially when caused by antibiotic resistant bacteria. recently, phage therapy has emerged as a promising non-antibiotic based treatment of antibiotic resistant bacterial infections. however, proof-of-concept experimental and clinical studies are missing before its wider use in clinical medicine. the goal of this experimental study was to compare the efficacy of phage therapy versus antibiotics for the treatment of mrsa in a rat model of vap. methods: four hours after intubation and protective ventilation, rats were inoculated via the endotracheal tube with - x cfu (ld ) of the mrsa clinical isolate aw . the animals were subsequently extubated. two hours after bacterial challenge, rats were randomised to receive intravenously either teicoplanin (n= ), a cocktail of lytic anti-s. aureus bacteriophages (n= ) or combination of both (n= ). animals served as control (no treatment). survival by hours was the primary outcome. secondary outcomes were bacterial count in lungs, spleen and blood. kaplan-meier estimates of survival were done and multiple comparisons of survival rates performed using the holm-sidak method. results: treatment with either phages, antibiotics or combination of both significantly increased survival ( %, %, % respectively, compared to % survival for controls, p< . ). there were no statistical differences in survival rates between either forms of treatment ( fig. ) . treatments hinder the systemic extension of the infection into the blood and spleen without impacting bacterial counts within the lungs, but the numbers are too small to perform statistical tests (table ) introduction: the aim of the study was comparative evaluation of the clinical and microbiological efficacy of combination of amikacin thru nebuliser aeroneb pro and standard antimicrobal therapy (amtcomb) with standard antimicrobal therapy (amtst) in treatment of ventilator-associated pneumonia (vap) and ventilator-associated tracheobronchitis (vat) caused by multi-drug resistant gram-negative bacteria. methods: in prospective two-center study with retrospective control included patients with vap and vat. in amtst group (retrospective, n= ) we used combination of meropenem g every h iv as continuous infusion, cefoperazon/sulbactam g every h iv as continuous infusion and amikacin g iv every h. in amtcomb group (prospective, n= ) we used combination of amtst and amikacin inhalation mg every h thru nebuliser aeroneb pro. results: in amtcomb clinical cure rate was %, while in amtst . % (p< . ), clinical pulmonary infection score (cpis) on day was ( - ) points in amtst and ( - ) points in amtcomb (p< . ). recurrence of vap/vat was . % in amtst and . % in amtcomb (p= . ). on day infectious agent titer in tracheal aspirate was ( - ) cfu/ml in amtst group, while (no growth- ) cfu/ml in amtcomb (p= . ). microbiological eradication observed in patients in amtcomb vs in patient in amtst and microbiological persistance observed in patients in amtcomb vs patients in amtst (p= . ). in amtcomb on rd day sputum was less purulent (p= . ). amikacin nebulisation didn't led to deterioration of organ dysfunction: on day there was no difference in platelet count, creatinine and bilirubin levels as compared to day (p= . ; p= . , p= . , respectively). conclusions: addition of amikacin inhalation mg every h thru aeroneb pro nebuliser in patients with vap and vat was more efficacious than intravenous standard antimicrobal treatment with comparable safety profile. introduction: the aim of the study was to assess the effectiveness of inhaled colistin (ic) as an adjunct to systemic antibiotics in the treatment of ventilator-associated pneumonia (vap). methods: icu patients with vap were enrolled in this observational study. resolution of vap was assessed as primary endpoint; eradication of pathogens in sputum, weaning time, duration of icu stay and mortality were assessed as secondary outcomes. patients were split into groups: gr. (n = ) -addition of ic to systemic antibiotics without changing the basic regimen; gr. (n = ) -change in systemic antibiotics according to sensitivity. groups were comparable. ic was administered in a dose of million iu tid (xselia pharmaceuticals aps, denmark). statistical analysis was performed using statistica . (m, σ, newman-keuls test; p < . ). results: vap resolution rate was % in gr. (vs. % in gr. , p = . ); eradication of pathogens from sputum by the th day. treatment was achieved in % of gr. and % in the gr. (n = ) (p> . ); in gr. weaning from ventilation was possible earlier than in gr. - . ± . days. in gr. vs. . ± . days. in gr. (p = . ); in gr. duration of icu stay was shorter than in gr. - . ± . days vs. . ± . days. in gr. (p = . ). no mortality differences were detected. conclusions: administration of inhaled colistin million iu tid is effective as an adjunct to systemic antibiotics in the treatment of vap. this modified treatment promotes a more rapid resolution of vap, earlier weaning from ventilator, reduction of the duration of icu stay, with no impact on mortality. the addition of ic to systemic antibiotics should be considered as second-line regimen in vap patients. factors associated with no de-escalation of empirical antimicrobial therapy in icu settings with high rate of multi-drug resistant bacteria c routsi introduction: de-escalation is recommended in the management of antimicrobial therapy in icu patients [ ] . however, this strategy has not been adequately evaluated in the presence of increased prevalence of multidrug-resistant (mdr) bacteria. the aim of this study was to identify factors associated with no de-escalation in icus with high rate of mdr bacteria [ ] . methods: prospective, multicenter study conducted in greek icus over a -year period. patients with laboratory confirmed infections were included. sofa score on admission, on septic episode and thereafter every h over days, infection site(s), culture results, antimicrobial therapy, and mortality were recorded. only the first septic episode was analyzed. in order to assess the factors associated with no de-escalation, a multivariate analysis was performed. results: a total of patients (admission sofa score ± ) were analyzed. % of those had septic episode on icu admission; % patients had an icu-acquired. de-escalation was applied to ( %) patients whereas it was not feasible in patients ( %) due to the recovery of mdr pathogens or it was not applied, although the microbiology results allowed it, in patients ( %). septic shock on the day of septic episode was present in % and % of patients with and without de-escalation, respectively, p= . ). compared to no de-escalation, de-escalation strategy was associated with a shorter duration of shock ( ± vs. ± days, p< . ) and all-cause mortality ( . % vs. . %, p< . ). multivariate analysis showed that the variables associated with no de-escalation were: a deteriorating clinical course as indicated by an increasing sofa score (or . , p< . ) and a lack of de-escalation possibility due to recovery of mdr pathogens (or . , p= . ). conclusions: deteriorating clinical course and mdr pathogens are independently associated with no de-escalation strategy in critically ill patients. conclusions: the qsofa scale in the prognosis of sepsis does not differ significantly from the sirs criteria, but in the prognosis of mortality is significantly better than sirs. qsofa significantly worse in the prognosis of sepsis and death than the sofa scale. the international task force of sepsis- introduced the quick sequential failure assessment (qsofa) score to supersede the systemic inflammatory response syndrome (sirs) score as the screen tool for sepsis. the objective of this study is to prospectively access the diagnostic value of qsofa and sirs among patients with infection in general wards. methods: a prospective cohort study conducted in ten general wards of a tertiary teaching hospital. for a half-year period, consecutive patients who were admitted with infection or developed infection during hospital stay were included. demographic data and all variables for qsofa, sirs and sofa scores were collected. we recorded daily qsofa, sirs and sofa scores until hospital discharge, death, or day , whichever occurred earlier. the primary outcome was sepsis at days. discrimination was assessed using the area under the receiver operating characteristic curve (auroc) and sensitivities or specificities with a conventional cutoff value of . results: of patients (median age, years [iqr, - ]; male, [ %]; most common diagnosis pneumonia, [ %]) who were identified with infection in general wards, ( %) developed sepsis at a median of (iqr, - ) day, patients ( %) and patients ( %) met qsofa and sirs criteria at a median of (iqr, - ) and (iqr, - ) day, respectively. the qsofa performed better than sirs in diagnosing sepsis, with an auroc of . ( % ci, . - . ) vs . ( % ci, . - . ). with a conventional cutoff value of , qsofa had lower sensitivity ( % [ % ci, %- %] vs. % [ % ci, %- %], p < . ) and higher specificity ( % [ % ci, %- %] vs. % [ % ci, %- %], p < . ) than sirs (table ) . conclusions: among patients with infection in general wards, the use of qsofa resulted in greater diagnostic accuracy for sepsis than sirs during hospitalization. qsofa and sirs scores can predict the occurrence of sepsis with high specificity and high sensitivity, respectively. prognostic accuracy of quick sequential organ failure assessment (qsofa) score for mortality: systematic review and meta-analysis introduction: the purpose of this study was to summarize the evidence assessing the qsofa [ ] , calculated in admission of the patient in emergency department (ed) or intensive care unit (icu), as a predictor of mortality. the hypothesis was that this tool had a good prediction performance. methods: systematic review and meta-analysis of studies assessing qsofa as prediction tool for mortality found on pubmed, ovid, embase, scopus and ebsco database from inception until november . the primary outcomes were mortality (icu mortality, inhospital mortality, and -day mortality). studies reporting sensitivity and specificity of the qsofa making it possible to create a x table were included. the diagnostic odds ratio (lndor) was summarized following the approach of dersimonian and laird using the software r ('mada' package). the summary roc curve was created using the reistma model (bivariate model). the revman software was used to organize the data. results: the search strategy yielded citations. of unique citations, met the inclusion criteria ( , patients). the sensitivity and specificity from each study are shown in fig. . the meta-analysis of the dor was . ( % confidence interval (ci): . - . ) and of the lndor was . ( % ic: . - . ) (fig. ) . the pooled area under the summary receiver operating characteristic (sroc) curve was . . the summary estimative of the sensitivity was . and the false positive rate was . , by bivariate diagnostic random-effects metaanalysis. the chi-square goodness of fit test rejects the assumption of homogeneity, and the fit of the model for heterogeneity was better (p-value = . ). conclusions: the qsofa has a poor performance to predict mortality in patients admitted to the ed or icu. introduction: sepsis and septic shock patients are the most common cause of death in intensive care units. [ ] the aim of this study is to quantify the relationship between hours sequential organ failure assessment (sofa) scores change and in-hospital mortality as a treatment outcome in sepsis and septic shock patients. introduction: an outreach team, akin to a rapid response team, is made up of healthcare professionals assembled together for quick and effective reviews in managing of rapidly deteriorating or gravely deteriorated patients [ ] . this study aimed to look at the variety of patient referrals in terms of their severity, patient dynamics, reasons for referral and their subsequent dispositions. methods: patient records were randomly reviewed retrospectively from july to october . data were collated in an excel spreadsheet for comparison and then sorted in accordance with the clinical questions and percentages calculated. results: from the referrals, the severity criteria was done by calculating the national early warning score (news). it was found that % patients had a score of - , % had a score of - , and % scored more or equal to . % of patients were in the age range - years old. % referrals came from the emergency department (ed) where a consultant was involved in the decision of the referral; of this, % were referred during office hours of am to pm where there was greater manpower to aid management. % referrals came from inpatients on the general wards; % were done during office hours. % of referrals were transferred to ic/hd upon review; % were not, from whom died and were later admitted after procedures ( %) or because they deteriorated further ( %). for reasons for referrals and disposition decisions, see fig. . conclusions: despite having no set criteria for outreach team referrals, the accuracy rate was nearly % admissions to ic/hd based on clinician concerns. there was only % re-admission rate having been re-reviewed when the patients had not been deemed suitable for ic/hd admission initially. therefore referrals were done accurately and safely with the protocol of clinician referral openness directly to ic consultants. introduction: prompt recognition of patient deterioration allows early initiation of medical intervention with reduction in morbidity and mortality. this digital era provides an opportunity to harness the power of machine learning algorithms to process and analyze big data, automatically acquired from the electronic medical records. the results can be implemented in real-time. intensix (netanya, israel) has developed a novel predictive model that detects early signs of patient deterioration and alerts physicians. in this study we prospectively validated the ability of the model to detect patient deterioration in real time. methods: the model was developed and validated using a retrospective cohort of consecutive patients admitted to the intensive care unit in the tel-aviv sourasky medical centera tertiary care facility in israel, between january and december . in this study, we tested model performance in real time, on a cohort of patients admitted to the same icu between june and august . significant events that lead to major interventions (e.g. intubation, initiation of treatment for sepsis or shock, etc.) were tagged upon medical case review by a senior intensivist, blinded to model alerts. these tags were then compared with model alerts. [ ] [ ] [ ] [ ] . reviews occurred despite 'low news' (fig. ) . rrt review led to cc admission in ( . %) cases; median [iqr] news [ ] [ ] [ ] [ ] [ ] [ ] . probability of admission increased with higher news (fig. ), however admissions had 'low news'. of these were excluded due to high news trigger in the preceding hrs or post-operative status. the remaining ( . %) represented genuine low news cases; age [ - ], % male, admission apache ii [ - ] and day sofa [ ] [ ] [ ] [ ] [ ] . admission source was emergency department %, medical %, surgical %. diagnoses are shown in table . no low news patients with sepsis were qsofa positive. cc length of stay was [ ] [ ] [ ] [ ] days and icu mortality was . %. conclusions: a high proportion of rrt activity occurs at low levels of abnormal physiology. despite an association between news and cc admission, news fails to trigger for approximately one in ten admitted cases. clinical concern remains an important component of the escalation of acutely ill patients. meanwhile, novel markers of deterioration should be sought and validated. introduction: although rapid response systems are known to reduce in-hospital cardiac arrest rate, their effect on mortality remains debated. the rapid response call (rrc) is a system designed to escalate care to a specialised team in response to the detection of patient deterioration. there are diurnal variations in hospital staffing levels that can influence the performance of rapid response systems and patient outcomes. the objective of this study was to examine the relationship between the time of rrc activations and patient outcome. methods: review of retrospectively collected, linked clinical and administrative datasets, at a private hospital during a -month period. all patients with medical emergency team activation were included. rapid response calls occurring between : - : were defined as 'out of hours'. results: between january and october there were rrc. the trigger for rrcs activation was nurse concern ( ; . %), modified early warning score ( ; . %) and cardiac arrest ( ; . %). rrcs were "out of hours" being the main activation trigger a modified warning score > . "out of hours" patients had higher icu admissions ( . % versus %) and were more likely to have an inhospital cardiopulmonary arrest (or= . , p< . ). conclusions: the diurnal timing of rrcs appears to have significant implications for patient outcomes. out of hours calls are associated to a poorer outcome. this finding has implications for staffing and resource allocation. and septic shock) and severe sepsis (incl. septic shock) using icd- codes coded as primary and secondary discharge diagnoses and procedural ops codes. we assessed incidences and discharge disposition incl. mortality. results: incidences, mortalities and discharge disposition comparing and and the mean annual increase in incidence rates are reported in tables and . conclusions: the annual increase in standardized sepsis incidence rates is greater than in infections, but similar to the increase in infectious disease patients with organ dysfunction, which are less prone to coding incentives than sepsis codes. an increasing number of patients is discharged to nursing homes and hospice. given the alarming increase in sepsis cases and deaths, this analysis confirms sepsis as a key priority for health care systems. introduction: patients with urgent admissions to the hospital on weekends may be subjected to a higher risk of worse outcomes, which may be due to differences in compliance to established processes. because delays to antibiotic administration is an important measure of sepsis protocol efficiency and has been associated to worse outcomes, we aimed to assess the association of the weekend effect (admissions on weekend) with timing to antibiotic administration. methods: patients included in the sepsis protocol in the emergency department (ed) of hospital sao rafael, from january to july were retrospectively evaluated. sepsis protocol is supposed to be activated to every patient with a suspected sepsis diagnosis in the ed. we evaluated the association of weekend (saturday or sunday) admission with timing to antibiotic administration. introduction: current sepsis guidelines emphasize resuscitation of hypotension to a mean arterial pressure (map) of at least mmhg [ ] . a map less than mmhg appears to be associated with poor outcomes in postoperative patients in the intensive care unit (icu) [ ] . however, extent of hypotension in critically ill septic patients during icu stay and its relationship with adverse outcomes is poorly defined. we determined the magnitude of hypotension in icu patients with a diagnosis of sepsis and its association with major complications. conclusions: reduced mortality may be supposed to be correlated to a quicker recovery of organ damage sepsis related. pcrts should be warranted in the future to corroborate these preliminary data. introduction: the pd- /pd-l immune checkpoint pathway is involved in sepsis-associated immunopathy. we assessed the safety of anti-pd-l (bms- , bristol-myers squibb) and its effect on immune biomarkers and exploratory clinical outcomes in participants with sepsis-associated immunopathy. methods: participants with sepsis/septic shock and absolute lymphocyte count <= cells/μ l received bms- i.v. ( - mg; n= ) or placebo (pbo; n= ) + standard of care and were followed for d. primary endpoints were death and adverse events (aes); secondary endpoints were monocyte (m)hla-dr levels and clinical outcomes. methods: this observational study was performed using a prospective, multi-center registry of septic shock. we compared the -day mortality between patients who were excluded from the new definition (defined as < mmol/l after volume resuscitation) and those who were not (lactate level >= mmol/l after volume resuscitation), from among a cohort of patients with refractory hypotension, and requiring the use of vasopressors. results: of patients with refractory hypotension, requiring the use of vasopressors, had elevated lactate levels, while did not have elevated lactate levels (neither initially nor after volume resuscitation), and ( . %) had elevated lactate levels initially, which normalized after fluid resuscitation (fig. ). thus, these patients were excluded by the new definition of septic shock. significantly lower -day mortality was observed in these patients than in those who had not been excluded ( . % vs . %, p= . ). conclusions: it seems reasonable for septic shock to be defined by the lactate levels after volume resuscitation, however due to small sample size further large scale study is needed. results: significant downregulation (p< . ) of about pro-and anti-inflammatory cytokines, including il- , ip- , tnf-a, mip- a, mip- ß, il- , was documented. ifn-g effect on macrophages and dendritic cells was inhibited at the level of phosphorylated stat . ifn-ginduced expression of cxcl and cxcl in macrophages was reduced. patients treated in vivo with higher dosages of apoptotic cells had lower cytokine/chemokine levels compared to those treated with lower levels, and in inverse correlation to agvhd staging. in vitro binding of apoptotic cells to lps was documented. conclusions: the cytokine storm is significantly modified towards homeostasis following apoptotic cell treatment. the mechanism is multifactorial and was shown to include tam receptor triggering, nfkb inhibition, and lps binding. these results together with previous studies showing significantly higher murine survival in sepsis models of lps and cecal ligation puncture suggest that apoptotic cells may be used to treat patients with sepsis. a multicenter clinical trial in septic patients is planned in . moreover, the urine output significantly increased in survival group. conclusions: the present study suggests that cytokine-oriented critical care using pmma-chdf might be effective the treatment of sepsis and ards, particularly,in the treatment of ards associated with aspiration pneumonia in elderly patients. the polymyxin b immobilized fiber column direct hemoperfusion has an effect for septic shock but has no effect on sepsis: a cohort study and propensity-matched analysis k hoshino introduction: overwhelming cytokine release often referred to as "cytokine storm" is a common feature of septic shock, resulting in multiple organ dysfunction and early death. attenuating this cytokine storm early by eliminating cytokines may have some pathophysiological rationale. our aim was to investigate the effects of extracorporeal cytokine removal (cytosorb) therapy on organ dysfunction and inflammatory response within the first hours from the onset of septic shock. methods: patients with: sepsis of medical origin, on mechanical ventilation, noradrenaline > mg/min, procalcitonin > ng/ml and no need for renal replacement therapy, were randomized into cytosorb and control groups. cytosorb therapy lasted for hours. in addition to detailed clinical data collection, blood samples were taken to determine il- , il- ra, il- , il- , il- , tnf-α, pct, crp levels. introduction: blind pericardiocentesis leading to low success rate and high complication rates such as ventricular wall or oesophageal perforations, pneumothorax or upper abdominal organ injury.real time needle visualisation is allowing us to avoid this major complication [ ] . methods: we presented cases of acute traumatic cardiac tamponade secondary to severe chest injury. both patients presented with haemodynamic instability and echocardiographic features of pericardial tamponade. pericardiocentesis under ultrasound guidance at left parasternal area with needle directed from medial to lateral technique were performed (fig. ) . real time needle tip visualisation done throughout the procedure (fig. a) . needle placement in pericardial space was confirmed with agitated saline and guidewire visualisation (fig. b) . pigtail catheter was inserted and blood was aspirated until the patient were haemodynamically improved. repeated ultrasound was done to confirm the absence of ultrasonographic features of tamponade and complications. results: we demonstrated a successful real time needle visualisation ultrasound guided pericardiocentesis in cases acute traumatic pericardial tamponade. procedural time (time from needle piercing the skin to time needle entering the pericardium) in both cases were less than minute. post procedural ultrasound confirmed no major complications. conclusions: the real time needle visualisation using ultrasound was important to reduce major complications during pericardiocentesis. the safety of the highly invasive procedure can be improved with real time needle visualisation. osman a et al. eur j emerg med (in press), introduction: diagnosis of cardiac tamponade post continuous-flow left ventricle assist devices (cf-lvads) is challenging due to missing pulsatility. recent case study of sublingually microcirculation with incident dark-field imaging (idf) provide a new improved imaging for clinical assessment of cardiac tamponade in a patient with cf-lvad. we sought to examine the changes in microvascular flow index (mfi) as a sign of cardiac tamponade following lvad implantation. methods: off-site quantitative analysis of sublingual microcirculation clips with automated vascular analyses software (ava; microvision medical©), and the velocity distributions followed during admission till discharge in patients with end-stage heart failure treated with cf-lvad complicated by cardiac tamponade. results: eleven out of thirty lvad implantations, males, mean age ± years, april to january , (( heart mate (hm ) and heartmate ii (hm ii) (thoratec corp., ca)), were complicated by rethoracotomy due to early postoperative cardiac tamponade within week. there sublingual microcirculation was examined by a novel incident dark-field imaging (idf) before and daily post-lvad implantation. pre-lvad microcirculation was typical for heart failure, characterized by slowly, sludging movement of red blood cells (rbcs), (fig. a arrows) . directly after implantation, a normal microcirculatory flow was seen with a high rbcs velocity (fig. b) . on the day of tamponade the patients were stable except for severe failure of microcirculation as reflected by drop in mfi (fig. c ) and congestion in venules (* in fig. c ). in out of patients there was a significant drop in mfi before tamponade was clinically recognized (p< . ). shortly after rethoracotomy a quick restoration of microcirculatory flow has been found. conclusions: sublingual microcirculation imaging is a simple and sensitive non-invasive tool in early detection of cardiac tamponade. survey on the use of cardiovascular drugs in shock (ucards) - results: a total of physicians responded. as detailed in table , the respondents think that dobutamine is first-line inotrope to increase cardiac pump function (n= , %) and should be started when signs of hypoperfusion or hyperlactatemia despite adequate use of fluids and vasopressors in the context of low left ventricular ejection fraction are present (n= , %). the most accepted target was an adequate cardiac output (n= , %). the combination of noradrenaline and dobutamine was preferred to single treatment with adrenaline mainly due to possibility to titrate individually (n= , %). the main reason for adding another inotrope was to use synergistic effects of two different mechanisms of action (n= , %). according to respondents, phosphodiesterase-inhibitors should be used in the treatment of predominant right heart failure because of prominent vasodilatory effect on the pulmonary circulation (n= , %). they also believe levosimendan is the only inotrope that does not increase myocardial oxygen demand (n= , %). vasodilators are used in cardiogenic shock to decrease left ventricular afterload (n= , %). there is no experience or no opinion about the use of ß-blockers in shock states (n= , %). conclusions: this web-based survey provided latest trends on inotrope use in shock states which showed considerable diversity among respondents in opinions about its use. introduction: recent literature data clearly indicated that in patients with shock the resuscitation of macro-circulation often does not match with microcirculation and tissue perfusion improvement. unfortunately, the bed-side assessment of regional perfusion remains difficult, particulary in critically ill patients. in the last years thermography has been used in different medical fields but no studies have been performed on the use of this technique in critically ill patients. the aim of this study was to evaluate whether thermography is feasible and may provide useful data during resuscitation of patients with septic shock. methods: in patients with septic shock we collected central systemic temperature and infrared images (flir-t digital camera) of limbs at , , and hours after shock occurrence. thermal pattern distribution of the limbs was obtained by a specific analysis of the images (thermacam™researcher p). a systemic to peripheral temperature gradient called "Δ systemic-limb temperature" was calculated for each single temperature data collected. results: macrocirculatory and perfusion parameters improved in all the patients throughout the study period: mean values of noradrenaline dose decreased from . to . γ/kg/min, mean map increased from to mmhg and mean blood lactate decreased from . to . mmol/l. the "Δ systemic-limb temperature" pattern showed an heterogenous time course in the patients with a mean overall increase at and hours (fig. ) . conclusions: as expected, the regional data obtained by thermography did not match with macrocirculatory and systemic perfusion parameters. the significance and the relationship between treatments and data observed will be investigated by appropriate studies. regional differences in the treatment of refractory septic shockan analysis of the athos- data introduction: vasodilatory shock is a common syndrome with high mortality. despite established care protocols, regional differences in treatment remain. we sought to characterize these differences using data from the recently published athos- study [ ] . methods: individual patient data were analyzed at baseline and at h for regional differences in demographics, clinical characteristics, and treatment patterns, and grouped according to four geographical areas: the united states (us), canada (ca), europe (eu) and australasia (au). p-values were calculated by kruskal-wallis tests for continuous data and chi-square tests for categorical data. subsequent temporal analysis compared changes in the treatment of shock, indexed by changes in patient acuity level. results: regional differences existed with respect to bmi (p= . ), albumin (p< . ), cvp (p= . ), meld score (p= . ), apache ii score (p= . ) and sofa score (p= . ). baseline norepinephrine (ne) and ne equivalent doses were significantly higher in eu (p< . and p= . , respectively), and utilization of vasopressin was correspondingly lower (p< . ). at baseline, stress dose steroids were utilized to a greater extent in the us and ca (p= . ). temporal analysis revealed differences in the utilization of vasopressin and steroids with changes in patient acuity: in eu, increasing acuity was associated with a lower utilization of vasopressin, and in ca, increased acuity was associated with a lower utilization of steroids. steroid utilization was higher with increased level of acuity in au and the us. conclusions: significant differences in the treatment of vasodilitory shock exist globally, with important implications: (a) there are introduction: levosimendan is a calcium sensitizer and katp-channel opener exerting sustained hemodynamic and symptomatic effects. in the past fifteen years, levosimendan has been used in clinical practice also to stabilize at-risk patients undergoing cardiac surgery. recently, the three randomized, placebo-controlled, multicenter studies licorn [ ] , cheetah [ ] and levo-cts [ ] have been testing the peri-operative use of levosimendan in patients with compromised cardiac ventricular function. over smaller trials conducted in the past [ ] suggested beneficial outcomes with levosimendan in peri-operative settings. in contrast, the latest three studies were neutral or inconclusive. we aim to understand the reasons for such dissimilarity. methods: we re-analyzed the results of the latest trials in the light of the previous literature to find sub-settings in which levosimendan can be demonstrated harmful or beneficious. results: none of the three latest studies raised any safety concern, which is consistent with the findings of the previous smaller studies. in levo-cts, mortality was significantly lower in the levosimendan arm than in the placebo arm in the subgroup of isolated cabg patients ( fig. ) [ ] . the trend towards both hemodynamic and long term mortality benefits is maintained in recent meta-analyses [ , ] including the three larger recent studies. conclusions: despite the fact that the null hypothesis could not be ruled out in the recent trials, we conclude that levosimendan can still results: patients were included in levosimendan group and in control group. in the whole population, weaning failure incidence and mortality was comparable between the groups (respectively % vs %, pr , and % vs %, pr= , ). higher assistance duration, longer stay under mechanical ventilation and longer duration of stay in critical care unit were observed in levosimendan group. in the post-cardiotomy sub-group (table ) , weaning failure was lower in levosimendan group ( % vs %, pr , ) and levosimendan was an independent protective factor from weaning failure (or , , pr , ). positive impact of levosimendan may be explained in part by his calcium sensitizer effect and by facilitating recovery of myocardial calcium homeostasis in postcardiotomy cardiac stunning. conclusions: levosimendan failed to reduce the incidence of ecmo weaning failure, except for post-cardiotomy population. renal outcomes of vasopressin and its analogues in distributive shock: a systematic review and meta-analysis of randomized trials introduction: venous return (vr) is driven by the difference between mean systemic filling pressure (msfp) and right atrial pressure (rap) and determines the maximum ecmo flow. msfp depends on stressed volume and vascular compliance. it can be modified by absolute blood volume changes and shifts between stressed and unstressed volume. norepinephrine (ne) may increase stressed volume by constriction of venous capacitance and at the same time increase the resistance to systemic flow. we therefore studied the effects of ne on msfp, maximum ecmo flow and the ecmo pressure head (map-rap). methods: msfp was measured with blood volume at euvolemia and ne to ( . , . and . μg/kg/h) in a closed-chest porcine va-ecmo model (n= , central cannulation with left atrial vent and avshunt) in ventricular fibrillation. the responses of rap and vr (measured as ecmo flow, qecmo) were studied at variable pump speeds including maximum possible speed without clinically apparent vessel collapse at constant airway pressure. results: the ecmo pump speed and qecmo showed a strictly linear relationship (r . to . , range over all conditions) despite increased pressure head, indicating that the maximum qecmo was determined by vr alone. ne led to both increases in msfp and qecmo in a dose dependent way, indicating a rightward shift in the vr plot ( fig. ) via recruitment of stressed from unstressed volume ( table , fig. ). this resulted in an increased msfp during ne despite decreased absolute blood volume ( . ± . l vs. . ± . l, p= . ). the reduced blood volume was associated with hemoconcentration suggesting plasma leakage. conclusions: ne shifts the vr curve to the right, allowing a higher maximum ecmo flow. the ne induced increase in msfp results from recruitment of unstressed volume to stressed volume, which may be modified by changes in vascular compliance. the effects on pump afterload were not limiting. introduction: to locate vessels for percutaneous central venous catheterizations, it may be helpful to apply not only real-time ultrasound (us) guidance but also us-assistance vein prelocation. the aim of this study was to evaluate the superiority of two us methods compared to surface landmark methods by reviewing randomized control trials (rcts). methods: as updating an earlier systematic review [ ] , we searched pubmed and central in november . we included rcts which compared the failure rates of internal jugular or femoral venous cannulations among ) real-time us guidance, ) us-assistance vein prelocation and ) surface landmark methods. a frequentist network meta-analysis was conducted using the netmeta package on r. results: out of citations, rcts ( patients) were eligible. the number of studies comparing outcomes between real-time us guidance vs. surface landmark methods, us-assistance vein prelocation vs surface landmark methods and real-time us guidance vs us-assistance vein prelocation was , and . regarding cannulation failure rate, network meta-analysis in a fix-effect model showed that a p-score was lower in the real-time us guidance than us-assistance vein prelocation ( . vs. . ), by reference to surface landmark methods, and also regarding arterial punctures, a p-score was lower in the real-time us guidance than us-assistance vein prelocation ( . vs. . ). conclusions: based on the present network meta-analysis of rcts, pscores of cannulation failure and arterial puncture were lower in the real-time us guidance, suggesting that the us-assistance vein prelocation is superior than the real-time us guidance, both of which achieve lower rates of failure and arterial puncture compared to the landmark methods. we speculates that the inferiority of real-time guidance is associated with difficulties in manipulating the needle together with an echo probe in targeting relatively smaller veins in children. introduction: we present a case report of 'shoshin beriberi' in a young female who was 'fussy with food' that developed an acutely progressive metabolic acidosis and multi-organ failure requiring intensive care support. methods: our patient was a -year-old british woman who presented to the emergency department (ed) with a ten-day history of diarrhea, vomiting and increasing fatigue. she had a past medical history of gastroparesis, polycystic ovary syndrome (on metformin), laparoscopic cholecystectomy and hysteropexy. she lived with her husband and two children who had viral gastroenteritis two weeks previously. results: the patient had a metabolic acidosis (ph . ) with raised lactate (> ) on initial blood gas in the ed. a . % sodium bicarbonate infusion and hemofiltration were commenced overnight. the patient's ph and lactate remained static with an increasing work of breathing over this period. by morning she developed flash pulmonary oedema and hypotension, the first signs of acute cardiac failure. an echocardiogram displayed severely impaired left ventricular function with ejection fraction of %. the patient was intubated and inotropic support was commenced. it was thought that a micronutrient deficiency may have caused a rapid onset cardiac failure. pabrinex (containing ml of thiamine hydrochloride) was commenced and within hours the patient's metabolic acidosis markedly improved ( fig. ). complete reversal of the cardiac failure occurred over hours. conclusions: shoshin is a rare clinical manifestation of thiamine deficiency [ ] . it is an important differential diagnosis to bear in mind after excluding more common aetiologies of heart failure. especially in this case as our patient had no obvious risk factors at the time of presentation. we suggest empiric use of thiamine should be considered in treatment algorithms for young patients presenting with acute cardiac failure. the pateint had provided informed consent for publication. introduction: takotsubo syndrome (ts) is known to be an acute transient cardiac condition accompanied with acute heart failure. ts is often triggered by critical illness but that has been rarely studied in icu practice.therefore, it is known, that the use of catecholamines can directly induce ts, worsen lvot obstruction, and delay spontaneous recovery in ts patients, it is nearly impossible to avoid their administration in critically ill [ ] . methods: we have analyzed medical records from patients with ts, that were revealed during year in our hospital. ts was defined due to mayo criteria, including transient regional wall motion abnormalities, mildly elevated troponin level and no signs of obstructive cad on coronary angiography. results: out of patients who developed ts in icu or iccu, hemodynamic instability occurred in acute phase of ts in ( %) cases. ( %) of patients were admitted to icu in due to septic shock ( patients), major bleeding ( ), cerebral mass lesion ( ) and ards ( ) and required treatment with catecholamines. general mortality rate in ts patients was ( %), and ( %) in critically ill ts patients. mean duration of noradrenalin infusion was , days, dobutamine infusion , days. patients with ts needed more icu resources and longer icu-stay. mortality rate was higher in ts patients ( %) vs the icu-population ( %), p = . . conclusions: ts seems to be an often cause of lv dysfunction and acute heart failure in critically ill. it seems that ts could be a predictor of worse prognosis in critically ill patients. although catecholamine administration may worsen the patient prognosis and induce further ahf in critically ill patients it rearely can be avoided. introduction: previous studies on readmission following lvad implantation have focused on hospital readmission after dismissal from the index hospitalization. since there are very little data existing, the purpose of this study was to examine intensive care unit (icu) readmission in patients during their initial hospitalization for lvad implantation to determine reasons for, factors associated with, and mortality following icu readmission. methods: this was a retrospective, single center, cohort study in an academic tertiary referral center. all patients at our institution undergoing first time lvad implantation from february to march were included. patients dismissed from the icu who then required icu readmission prior to hospital dismissal were compared to those not requiring icu readmission prior to hospital dismissal. results: among lvad patients, ( . %) required icu readmission. the most common reasons for admission were bleeding and respiratory failure (fig. ) . factors found to be significantly associated with icu readmission were preoperative hemoglobin level of less than g/dl, preoperative estimated glomerular filtration rate < ml/min/ . m , preoperative atrial fibrillation, preoperative dialysis, longer cardiopulmonary bypass times, and higher intraoperative allogeneic blood transfusion requirements. mortality at year was . % in patients requiring icu readmission vs. . % in those not requiring icu readmission (age-adjusted or= . , % ci . to . , p= . ). conclusions: icu readmission following lvad implantation occurred relatively frequently and was associated with significant one-year mortality. these data can be used to identify lvad patients at risk for icu readmission and implement practice changes to mitigate icu readmission. future larger and prospective studies are warranted. atrial fibrillation and infection among acute patients in the emergency department: a multicentre cohort study of prevalence and prognosis t graversgaard odense university hospital, odense, denmark critical care , (suppl ):p introduction: patients with infection presenting with atrial fibrillation (af) are frequent in emergency departments (ed). this combination is probably related to a poor prognosis compared to lone af or infection, but existing data are scarce. aim: to describe the prevalence and prognosis for af and infection individually and concomitantly in an ed setting. introduction: its afterload reducing effects make peep the treatment of choice for cardiogenic pulmonary edema. studies indicate that peep may lower coronary blood flow. its effects on left ventricular contractility is unclear. most of the surrogate measures for cardiac contractility are dependent on afterload and contractility assessment under peep may therefore be biased. we have investigated cardiac contractility under peep with the endsystolic pressure volume relationship (espvr) as a load-independent measure of contractility. methods: patients scheduled for coronary angiography were ventilated with cpap and a full face mask at three levels of peep ( , and cmh o) in random order. structural cardiac pathologies were excluded with echocardiography. at every peep level, left ventricular pressure volume loops (millar conductance catheter with inca system, leycom, netherlands) were obtained. the endsystolic elastance was derived from a pv-loop family under preload reduction with an amplatzer sizing balloon in the inferior caval vein. all participants gave written informed consent. the study was approved by the bernese ethics committee. results: women and men with an age ± years were studied. ejection fraction was ± % at baseline. mean espvr at peep levels of , and were . ± . , . ± . and . ± . mmhg/ml (p = . , repeated measurements anova). dp/dt and ejection fraction did not differ between the peep levels (p= . and . ). conclusions: moderate levels of peep did not influence endsystolic elastance. higher peep and patients in cardiogenic shock should be investigated. introduction: we sought to assess the feasibility of d volumetric analysis with transthoracic echocardiography in critically ill patients. we choose a cohort typical of icu where accurate volumetric analysis is important: hypoxic, mechanically ventilated patients. d analysis is enticing in simplicity and wealth of data available. it is accurate in cardiology patients [ ] but has not been assessed in the icu. methods: patients were imaged within hours of admission. inclusion criteria: adult, hypoxic (p:f < ), mechanically ventilated, doppler stroke volume (sv) assessment possible. echocardiography: seimens sc real-time volumetric analysis with standard b-mode and doppler assessment. images unacceptable if > segments unable to be seen in volumetric planes. d left ventricle (lv) and right ventricle (rv) analysis with tomtec imaging and seimens acuson respectively and compared to doppler derived sv. % limit of agreement considered clinically acceptable [ ] . imaging was optimised for volumetric analysis ( - vols/sec). results: patients, in sinus, in af. no significant difference seen between doppler vs d simpson's biplane, d lv or d rv sv estimation. feasibility, sv values and bias are reported in table and fig. . limit of agreement for corrected doppler vs lv d sv = - % to %; rv d sv = - . % to . %. conclusions: d lv and rv volumetric analysis is feasible in majority of patients requiring mechanical ventilation, however lacks agreement with doppler derived stroke volume assessment. although images may appear sufficient, the semi-automated software appears to underestimate stroke volume. further larger studies using thermodilution are warranted. introduction: body position changes such as leg raising are used to determine fluid responsiveness. we hypothesized that the trendelenburg position increases resistance to venous return. together with abolishment of the hepatic vascular waterfall, this may limit the increase in regional blood flow. methods: inferior vena cava (ivc), portal vein (pv), hepatic, superior mesenteric (sma) and carotid artery blood flows and arterial, right atrial (ra) and hepatic (hv) and portal venous blood pressures were measured in anesthetized and mechanically ventilated pigs in supine and °trendelenburg positions. all hemodynamic parameters were measured during end-expiration at cmh o peep, and at inspiratory hold with increasing airway pressures (awp) of , , and cmh o, respectively. paired t test was used to compare pressures and flows in different positions during end-expiration. repeated measures anova was performed to evaluate the effects of awp on hemodynamic parameters. results: trendelenburg position significantly increased ra, hv and pv blood pressures at end-expiration, while qpv and qsma remained unchanged, qha increased and qivc showed a trend to decrease (table ). in both positions, all blood flows decreased with increasing awp, and the difference between ppv and qsma became smaller, indicating splanchnic blood pooling ( table ). in the trendelenburg position, splanchnic blood pooling was less severe compared to supine position. conclusions: trendelenburg position tended to decrease venous return from inferior vena cava. further increases in rap by augmenting awp led to a decrease in all flows and signs of abolished hepatic vascular waterfall. passive manoeuvers to assess fluid responsiveness evoke complex hemodynamic reactions which are not fully understood. introduction: despite of preventive measures, the incidence of deep venous thrombosis (dvt) in icu patients is estimated to range from - %. while clinical diagnostics is unreliable, ultrasound compression test (uct) has proven to be a highly sensitive and specific modality for the recognition of lower extremity dvt [ ] . delegating this competence to icu nurses can increase uct availability and enable preventive dvt screening. therefore, we decided to conduct a clinical study to evaluate the sensitivity and specificity of uct performed by general icu nurse in icu patients compared to an investigation by icu physician certified in ultrasound. methods: prior to the study, each nurse participating in the study completed one-hour training in uct and examined patients under supervision. then, icu patients without known dvt underwent uct in the femoral and popliteal region of both lower extremities performed by trained general icu nurse. on the same day, the examination was repeated by an icu physician. the results of the examinations of each patient were blinded to each other for both investigators until both tests were performed. in case of a positive test, the nurse immediately reported the result to the icu physician. the sensitivity and specificity of the test performed by general nurse was calculated in comparison with the examination by a specialist. results: a total of patients were examined. both lower extremities were examined in all patients. the prevalence of dvt of , % has been found. the overall sensitivity of the examination performed by general nurse was . %, the specificity % with negative predictive value of . %, positive predictive value of % and accuracy of . %. the results of our study have shown that general icu nurses are able to perform bedside screening of dvt by compression ultrasound test with a high degree of reliability after a brief training. methods: a cytosorb® (cytosorbents, new jersey, usa) ha device was inserted within the cpb circuit in ten patients undergoing elective cardiac surgery. one hour after cpb onset, the activity of coagulation factors (antithrombin (at), von willebrand factor (vwf), factors ii, v, viii, ix, xi, and xii) were measured before and after the device. pre and post device measurements were compared using student ttest, a p value < . was considered statistically significant. results: patients' mean age was . ± . years, % were female, the mean euroscore ii was . ± . . procedures were: coronary artery bypass graft (cabg) ( / ), aortic root replacement ( / ) and cabg combined with aortic valve replacement ( / ). mean cpb duration was . ± . min. pre and post ha measurements of coagulation factors activity are presented in fig. . post-device at and fii activity was significantly lower (respectively from . to . , p= . and from . to . , p= . ) compared to predevice measurement. there was no statistically significant difference between pre-and post-ha measurements for all other coagulation parameters conclusions: pre and post ha cytosorb® measurements for coagulation factor activity were not different except for a small decrease in at and fii activity. this might be related with intra-device consumption or adsorption. further analyses accounting for cpb fluid balance, the entire study population and timepoints are pending. introduction: the aim of this study is to evaluate changes in hemodynamics and microvascular perfusion during extracorporeal blood purification with cytosorb in patients with septic shock requiring renal replacement therapy. methods: eight adult patients with septic shock requiring continuous renal replacement therapy for acute renal failure were enrolled and underwent a -hour treatment with the emodasorption cartridge cytosorb. measurements were taken at baseline before starting cytosorb, after h (t ) and h (t ) and included: blood gases, macrohemodynamic parameters (picco ), vasopressor and inotropic dose, plasma levels of cytokines (interleukin [il]- , il , il , il , tumor necrosis factor alpha) and parameters of microvascular density and perfusion (sublingual sidestream dark field videomicroscopy). procalcitonin was measured at baseline and after h of treatment. results: a non-significant decrease in plasma levels of cytokines was observed over time. hemodynamic parameters and vasopressor requirement remained stable. the microvascular flow index increased significantly at t , total vessel density and perfused vessel density increased at t and t ( introduction: objective renal replacement therapy (rrt) with the oxiris filter is used in sepsis septic shock with aki, but few clinical studies compare the adsorbing effect of oxiris filter on the inflammatory mediators to rrt. the aim of this study is -to confirm whether oxiris decreases cytokines and procalcitonin in sepsis septic shock. -this effect is superior to rrt. -this translates in a better cardio renal response. methods: a coohort study and a propensity-matched analysis included patients admitted to three intensive care (aurelia hospital, european hospital, tor vergata -rome) with a diagnosis of septic shock. patients were submitted to rrt with oxiris filter and patients to rrt.il , procalcitonin, the cardiorenal indices and sofa score were compared before (t ) and at the end of the treatments (t ). all data are expressed as mean±sd. anova one way was used to compare the changes of the variables in the time. p< . was considered statistically significant. results: of patients submitted to rrt with the oxiris filter could be matched to septic patients who received rrt. il and procalcitonin decreased in the oxiris group (p< . ) but not in the rrt group.-map increased (p< . ) and noradrenaline dosage decreased in oxiris group (p< . ), but non in rrt group. also pao /fio ratio, diuresis, sofa improved only in the in the oxiris group (p< . ). conclusions: in sepsis/septic shock patients with aki, il and procalcitonin decrease more in the oxirs group then in the rrt group.this is associated with an improvement of the cardio -renal function and the clinical condition.the study confirms that rrt with oxiris filter may be useful in sepsis/septic shock when other convective/diffusive techinques fail. introduction: advos (hepa wash gmbh, munich, germany) is a recently developed ce-certified albumin-based hemodialysis procedure for the treatment of critically ill patients. in addition to the removal of water-soluble and albumin-bound substances, acid-base imbalances can be corrected thanks to an automatically regulated dialysate ph ranging . to . . methods: patients treated with the advos procedure between in the department of intensive care medicine of the university medical center hamburg-eppendorf were retrospectively analyzed. overall treatments in critically ill patients (mean sofa score ) were evaluated. additionally, subgroup analysis for hyperbilirubinemia, respiratory acidosis and non-respiratory acidosis were conducted. results: severe hyperbilirubinemia (> mg/dl) was present in treatments, while and treatments were performed to treat respiratory (paco > mmhg) and non-respiratory (paco < mmhg) acidosis (ph< . ), respectively. mean treatment duration was h. advos procedure was able to correct acidosis and reduce bilirubin, bun and creatinine levels significantly. the subgroup analysis shows an average bilirubin reduction of % per advos multi treatment in the hyperbilirubinemia group ( . mg/dl vs . mg/dl, p< . ). moreover, ph ( . vs. . , p< . ) and paco ( . vs. . mmhg, p< . ) were corrected in the respiratory acidosis group, while in the non-respiratory acidosis group, an improvement in ph ( . vs. . , p< . ), hco ( . vs. . , p= . ) and base excess (- . vs. - . , p= . ) could be observed. there were no treatment-related adverse events during therapy. conclusions: advos is a safe and effective hemodialysis procedure, which is able to remove water soluble and protein bound markers and correct severe acidosis in critically ill patients. score for timely prescribing (stop) renal replacement therapy in intensive care unit -preliminary study of a mneumonic approach introduction: the moment of initiation of renal replacement therapy (rrt) in critically ill patients and a reason for debate, without having objective criteria that indicate it. the objective of this study was to propose a score to help identify the ideal time for the initiation of rrt, and if there is correlation between this score and intensive care unit length of stay and mortality. methods: patients admitted to the intensive care unit, > -yearsold, to whom rrt were indicated by the intensivist. the study protocol was approved by the hospital das forças armadas ethical committe, and written informed consent was obtained from all patients. the stop was assigned according to the presence or not of each of the items (fig. ). they were classified into groups a and b according to fig. , and the group change was recorded. results: patients admitted to icu in the period, excluded for limitation of therapeutic efforts. were admitted to the study, with the mean age of . years; , % males (n= ). distribution among the groups: a (n= , . %), a ( , . %), a ( , . %), b ( , . %), b ( , . %) e b (no patients). there were statistically significant correlation between group change and mortality (p . ), and between the stop and nephrologist agreement (p . ). there was no correlation between stop value and icu los (p , ) or stop and mortality (p . ). conclusions: the stop value is correlated with hemodialysis indication agreement between intensivists and nephrologists, and not correlated with icu los or mortality. the group change was correlated to increased mortality, in the study population. the significance of stop as a tool in determining the moment of initiation of renal replacement therapy remains a work in progress. introduction: liver transplant (lt) in patients with renal dysfunction presents intraoperative challenges and portends postoperative morbidity. continuous renal replacement therapy (crrt) is increasingly used for intraoperative support; however, there is a paucity of data to support this practice. methods: pilot randomized open-label controlled trial in adults receiving cadaveric lt with a modification of end-stage liver disease (meld) score >= and preoperative acute kidney injury (kdigo stage ) and/or estimated glomerular filtration rate < ml/min/ . m . patients were randomized to intraoperative crrt (icrrt) or standard of care. primary endpoints were feasibility and adverse events. secondary endpoints were changes in intraoperative fluid balance, complications, and hospital mortality. analysis was intention-to-treat. results: sixty patients were enrolled, ( %) were randomized ( to icrrt; to control). mean (sd) was age ( ) years, meld was ( ), % (n= ) had cirrhosis; % (n= ) received preoperative rrt; and % (n= ) were transplanted from icu. one patient allocated to icrrt did not receive lt. seven ( %) allocated to control crossed over intraoperatively icrrt ( ( ) min, with only interruptions (all due to access). icrrt fluid removal was . l (range - . ). fluid balance was . l ( . ) for icrrt vs. . l ( . ) for control (p= . ). postoperative crrt was similar ( % vs. %, p= . ). there were no differences in reexploration (p= . ), mechanical ventilation time (p= . ), reintubation (p= . ), sepsis (p= . ), or mortality (p= . ). conclusions: in this pilot trial of high acuity lt patients, icrrt was feasible and safe. these data will inform the design of a large trial to define the role of icrrt during lt. clinicaltrials.gov: nct . the uptake of citrate anticoagulation for continuous renal replacement therapy in intensive care units across the introduction: the purpose of this descriptive study is to report the trend of citrate anticoagulation uptake, used for continuous renal replacement therapy (crrt), in intensive care units (icus) across the united kingdom (uk). citrate anticoagulation has been used in the uk since , but its uptake since then is unknown [ ] . methods: a survey questionnaire targeted pharmacists working in uk adult icus providing crrt. invitations to participate were distributed utilising the united kingdom clinical pharmacy association online forum as a platform for access. survey administration was by self-completion and submissions were accessible over a total of six weeks. basic demographic data, icu specifications, the citrate system in use and implementation details were sought. a descriptive statistical analysis ensued. results: responses were received of which were analysed after duplication removal. trusts, encompassing a total units, in the uk confirmed use of citrate anticoagulation for crrt. units reported a mean of days to implement a citrate system (range to days). prismaflex® (baxter) and multifiltrate (fresenius) were reported as the most commonly used citrate systems; ( . %) and ( . %) units respectively. conclusions: there are icus in the uk [ ] . we conclude that a minimum of units ( %) use citrate anticoagulation for crrt in uk critical care centres. citrate systems of anticoagulation are becoming an increasing popular choice for regional anticoagulation, falling in line with international guidance [ ] . these guidelines were introduced in which corresponds to increase national uptake. introduction: patients requiring renal replacement therapy (rrt) whilst on significant doses of vasoactive medications have often been deemed unsuitable to undergo ultrafiltration (uf). however with better understanding of the pathophysiology of renal injury [ ] in intensive care patients we hypothesise that vasopressor/inotrope requirement will not significantly increase with uf or with a more negative fluid balance (fb). methods: data was retrospectively collected in a general icu/hdu of adult patients requiring acute rrt for acute kidney injury. patients on chronic dialysis were excluded. percentage change in vasopressor index and mean arterial pressure were combined to form the combined percentage change (cpc) which we used as an index of patient stability. results: patients were assessed undergoing a total of rrt sessions. the mean age was with females and males. mean fb for the hours from start of rrt was + mls (range - to + mls). using a model to correct for significant covariates and plotting hour fb against cpc we found no significant effect of fb on stability p= . (fig. ). mean uf volume was mls (range - mls). there was a non linear relationship between uf and stability with moderate volumes improving but larger volumes worsening stability (fig. ). this did not reach statistical significance (p= . ) so may be due to chance but is likely due to a lack of power. conclusions: fluid balance has no effect on cardiovascular stability during rrt in our cohort but there may be a varying effect of uf depending on volume. introduction: exposure of blood to a foreign surface such as a continuous renal replacement therapy (crrt) filter could lead to activation of platelets (plt) and fibrinogen (fib) trapping. thrombocytopenia has been reported in adults on crrt but data in pediatrics are scarce. our institution uses regional citrate anticoagulation (rca) as standard of care with prefilter hemodilution and hf filters (polysulfone, surface area (sa) . m ) regardless of patients' (pts) age and size. as filter sa is relatively larger in younger pts, we aimed to investigate the impact of crrt filter change on hemostasis parameters in infants on crrt in up to first three filter changes. methods: retrospective chart review results: patients < kg were included, age . ( . - ) months, weight . + . kg, with filters. metabolic disease was the most common principal diagnosis ( / , %), liver failure (lf) was the most common comorbidity ( / , %). all patients received prefilter continuous venovenous hemodiafiltration with minimum dose of ml/ . m /h. thrombocytopenia was common at crrt start ( / , %). plts decreased in % filter changes ( / ) by + % (pre vs post plt ( - ) vs ( - ), p< . ). fibrinogen also decreased from ( - ) to ( - ), p< . ; there was no change in ptt, pt, or inr values before and after filter changes. bleeding events were seen in / ( %) of pts ( / of lf pts vs / others, p= . ), but were not more common in pts who had decrease in plts or fib with filter changes ( % with drop in plts vs % without, p= . ; % with drop in fib vs % without, p= . ). conclusions: thrombocytopenia is common in infants on crrt. further decreases in plt and fibrinogen can be seen in with crrt filter changes if the filters are relatively large compared to patient size. bleeding events seems more related to underlying comorbidity, and less to changes in hemostatis parameters observed with filter change but would need to be confirmed with further studies. intensive monitoring of post filter ionized calcium concentrations during cvvhd with regional citrate anticoagulation: is it still required? introduction: the aim of the present study was to evaluate the role of postfilter calcium concentrations (pfca) in terms of safety and efficacy in large retrospective cohort of patients treated with cvvhd and regional citrate anticoagulation. methods: retrospective, observational study at a university hospital with icus. all patients treated with rca-crrt were included in the study. results: among patients treated with rca-cvvh pfca at the start of the cvvhd was available in pts. the pfca concentrations were in target range ( . - . mmol/l) in the majority of patients ( %), whereas % and % of patients had the pfca below or above the target range, respectively. in the further h of cvvhd treatment the propotion of patients with targeted pfca increased to % and remained stable. at the start of the rca-cvvhd there was a significant but weak correlation between the pfca and ionized systemic ca (ica) with a spearman rank-order correlation coefficient (rho) of . (p < . ). the coefficient of variation of pfca concentraions was significantly higher if compared to the coefficient of variation of ica concentration. using per protocol adaptations the incidence of a severe hypocalcemia (< . mmol/l) was low and present only at first hours of therapy: % and % of patients with pfca below the target range and . % and . % of patients with pfca in target range, at h and h respectively (p< . ). there was no correlation between pfca concentrations and filter lifetime. the results of the present study support the previous reports about higher measurements variation of pfca compared to systemic ica ( ). nevertheless due to the weak correlation of ica and pfca as well as a low number of patients with a severe metabolic complication, the results of our study question the necessity of intensive pfca monitoring during rca-crrt. present results need to be validated in further trials. introduction: in critically ill patients, occurrence of pain is frequent and usually correlates with worse outcomes, such as prolonged icu length of stay (los) and mechanical ventilation. in this regard, pain leads to sympathetic activation, inflammatory mediators and therefore, potentially to organic dysfunction. the aim of this study is to evaluate the relationship between acute pain in critically ill patients and their association with acute kidney injury (aki). methods: retrospective cohort with adults patients admitted between june and june , from the icu of hospital sírio libanês hospital in sao paulo (brazil). main exclusion criteria were: length of stay < h, coma and previous aki. the predictor pain was obtained through daily electronic records according to numerical verbal scale ( - ). the outcome was defined as serum creatinine elevation equal to or greater than . mg/dl and/or greater than % increase at any time after the first hours in the icu. the multivariate analysis was performed by binary logistic regression through distinct groups of early or late predictive factors in relation to aki. results: after the exclusion of patients, the incidence of pain with numerical verbal scale equal to or greater than points was . %. the outcome occurred in . % of the cohort. in the binary regression, using the more early predictive factors, sex and pain presented independent relation with the outcome -adjusted or . ( . - . ) and . ( . - . ), respectively (p < . ). in the analysis conclusions: poor management of icu pain is associated to worse outcomes, including increased risk to aki. the search for a better pain management strategy in the icu scenario should therefore be reinforced. introduction: acute kidney injury (aki) is a common complication in hospitalised patients, strongly associated with adverse outcomes [ ] . a lack of baseline incidence and outcome data limits our ability to assess local strategies aimed at improving aki care. methods: in an audit in three linked inner london hospitals we interrogated our electronic patient data warehouse (cerner millennium power insight electronic data warehouse) with a specially written query to identify cases of aki, defined by kdigo creatinine criteria, in patients aged over y admitted for > h during january to june . we excluded palliative care and obstetric patients. in the absence of premorbid baseline (median - d pre-admission) the admission creatinine value was used. end stage renal disease (esrd) and primary sepsis diagnosis was obtained from icd coding. results: of admissions, we excluded with pre-existing esrd (hospital mortality . %) and with fewer than one creatinine result who could not be assigned aki status (mortality . %). of the remaining there were with aki ( . %), with mortality increasing from no aki group ( . %), to aki stage ( . %), and a further increase to aki stages - ( . %) (p< . ) ( table ) . patients with aki were older (p< . ), more likely to be medical than surgical (p< . ), more likely to have a primary sepsis diagnosis (p< . ) and had higher baseline creatinine (median vs p< . ). no known baseline was found in . % of patients with aki, but their mortality did not significantly differ to those with a baseline ( . % vs . %, p= . ). conclusions: an electronic query identified the local burden of aki and it's associated hospital-mortality; such baseline data is essential to assess the effect of quality improvement interventions in aki prevention and care. introduction: acute kidney injury (aki) is a common condition in critically ill patients [ , ] . loop diuretics are generally used as first line treatment. however, controlled trials show controversial results. we ought to search systematically and realize a metaanalysis on the matter. methods: an electronic search of randomized clinical trials in adult patient treated with diuretics for aki compared with standard treatment or a control group was conducted. the primary objective of the analysis was to assess recovery of renal function. secondary endpoints included time to recovery of renal function, need for renal replacement therapy (rrt), mortality in the intensive care unit (icu) and complications. introduction: increased venous pressure is one of the mechanism leading to acute kidney injury (aki) after cardiac surgery. portal flow pulsatility and discontinuous intra-renal venous flow are potential ultrasound markers of the impact of venous hypertension on organs. the main objective of this study was to describe these signs after cardiac surgery and to determine if they are associated with aki. methods: this single center prospective cohort study (nct ) recruited adult patients able to give consent. ultrasound studies were performed before cardiac surgery and repeated on post-operative day (pod) , , and . abnormal portal and renal venous flow patterns are defined in fig. . the association between the studied markers and the risk of new onset of aki in the following hours period following an assessment was tested using logistic regression with a % confidence interval. clinical variables associated with the detection of the signs were tested using generalized estimating equation models. this study was approved by the local ethics committee. results: during the study period, patients were included. the presence of the studied ultrasound signs is presented in fig. . during the week following cardiac surgery, patients ( . %) developed aki, most often on pod ( . %). the detection of portal flow pulsatility and severe alterations in renal venous flow (pattern ) at icu admission (pod ) were associated with aki in the subsequent hours period and was independently associated with aki in multivariable models including euroscore ii and baseline creatinine ( table ). the variables associated with the detection of abnormal portal and renal patterns were associated with lower perfusion pressure, higher nt-pro-bnp and inferior vena cava measurements (table ) . conclusions: abnormal portal and intra-renal venous patterns are associated with early aki after cardiac surgery. these doppler features must be further studied as potential treatment targets to personalize management. introduction: acute kidney injury (aki) is very prevalent after cardiac surgery in children, and associated with poor outcomes [ ] . the present study is a preplanned sub-analysis of a prospective blinded observational study on the clinical value of the foresight nearinfrared spectroscopy (nirs) monitor [ ] . the purpose of this subanalysis was to develop a clinical prediction model for severe aki (saki) in the first week of picu stay. methods: saki was defined as serum creatinine (scr) >/= times the baseline, or urine output < . ml/kg/h for >/= h. predictive models were built using multivariable logistic regression. data collected during surgery, upon picu admission, as well as monitoring and lab data until h before saki onset, were used as predictors. relevant predictors with a univariate association with saki, were included in the models. accuracy of the models was tested using bootstraps, by auroc and decision curves. results: children were enrolled, admitted to the picu of the leuven university hospitals after cardiac surgery, between october and november . patients were excluded. children ( . %) developed saki in the first week of picu stay. a multivariate model with admission parameters (maximum lactate during surgery, duration of cpb, baseline scr, rachs and pim scores), and postoperative measurements (average heart rate, average blood pressure, hemoglobin, lactate), was most predictive for saki ( fig. ) . conclusions: the risk of saki in children after congenital cardiac surgery could be predicted with high accuracy. future models will also include medication data. these models will be compared against and combined with nirs oximetry data to investigate the independent and added predictive value of the foresight monitor. introduction: acute kidney injury (aki) occurs in over % of the patients in the intensive care unit (icu). the predominantly ethiology of aki is septic shock, the most common diagnosis in the icu. aki significantly increases the risk of both morbidity and mortality [ ] . methods: icu patients with septic shock was studied within hrs from admission. patients after cardiac surgery served as control group. all patients were sedated and mechanically ventilated. renal blood flow (rbf) and glomerular filtration rate (gfr) were obtained by the infusion clearance of paraaminohippuric acid (pah) and by extraction of cr-ethylenediamine ( cr-edta). n-acetyl-β -d-glucosaminidase (nag), was measured. results: rbf was % lower, renal vascular resistance % higher and the relation of rbf to cardiac index was % lower in patients with septic shock compared to the control group. gfr ( %, p= . ) and renal oxygen delivery (rdo ) ( %) where both significantly lower in the study group (table ) . there was no difference between the groups in renal oxygen consumption (rvo ) but renal oxygen delivery was almost % lower in septic shock patients. renal oxygen extraction was significantly higher in the study group than in the control group. in the study group, nag was . ± . units/mikromol creatinine more, i.e times the value in patients undergoing cardiac surgery [ ] . conclusions: sepsis related aki is caused by a renal afferent vasoconstriction resulting in a reduced rbf and lowered rdo in combination with an anchanged rvo , this results in a renal oxygen supply/ demand mismatch. introduction: the primary aim was to determine if the addition of daily creatine kinase (ck) measurement was usefully guiding decision making in intensive care units within greater glasgow and clyde. methods: after a change to the daily blood ordering schedule to include ck, a retrospective audit was carried out covering a -month period within intensive care units. all patients with ck > units/ litre were included. basic demographics, apache score and admitting diagnosis were recorded. utility of ck was assessed by determining the associated diagnosis and whether the diagnosis was first considered (diagnostic trigger) due to ck level, clinical suspicion or haematuria. additionally, it was determined if and what actions had been taken based on the raised ck and associated diagnoses. results: data was collected from / / to / / . patients were captured with ck > units/litre from an average combined admission rate of patients/month [ ] . total male patients ( . %) and female ( . %). age range to years (mean . ). apache score range to (mean . ) with estimated mean mortality of . %. patients ( . %) had associated diagnoses with elevated ck including: burns ( . %), compartment syndrome ( . %), myocardial infarction ( . %), myositis/myocarditis ( . %), neuroleptic malignant syndrome ( . %), rhabdomyolysis ( . %), serotonin syndrome ( . %), surgical procedure ( . %). as outlined in fig. the diagnostic trigger was the routine ck measurement in patients ( . %), prior clinical suspicion ( . %), haematuria ( . %) and unclear in ( . %). action was the correlation analysis showed the egfrs from every formula could all to some extent reflect the glomerular function or gfr accurately. the gfr (scys) formula was a quickly and accurate method for estimating gfr and may apply clinically in critically ill patients. perioperative chloride levels and acute kidney injury after liver transplantation: a retrospective observational study s choi introduction: the risk of developing acute kidney injury (aki) after liver transplantation in the immediate postoperative period ranges between to %. most studies in critically ill and surgical patients evaluated the link between chloride-rich resuscitation fluids, not serum chloride levels, and the incidence of aki. the association between preoperative chloride level or difference in perioperative chloride levels and the incidence of postoperative aki after liver transplantation were evaluated. methods: adult patients (>= years old) who underwent liver transplantation at seoul national university hospital between and were included in the retrospective analysis. the difference between preoperative serum chloride level and the immediate postoperative serum chloride level was defined as intraoperative chloride loading. postoperative aki within days of liver transplantation was diagnosed according to the rifle criteria. patients were divided into normochloremia group ( - meq/l), hypochloremia group (< meq/l), or hyperchloremia group (> meq/l) according to their preoperative chloride level. intraoperative chloride loading was defined as the difference between preoperative serum chloride level and immediate postoperative serum chloride level. . ) compared to patients with preoperative normochloremia. meld scores > and age > years were also associated with increased risk of aki. intraoperative chloride loading was not a significant risk factor for aki after liver transplantation. conclusions: preoperative hyperchloremia and hypochloremia were both associated with an increased risk of developing aki in the immediate postoperative period after liver transplantation. introduction: perioperative acute kidney injury (aki) is associated with significant morbidity and mortality [ ] . certain urinary biochemical parameters seem to have a standardized behavior during aki development and may act as surrogates of decreased glomerular filtration rate (gfr) aiding in early aki diagnosis [ ] . aim of this prospective observational study was the evaluation of urinary biochemical parameters as early indicators of aki in a cohort of major surgery patients. methods: patients were studied. aki was defined according to akin criteria within hrs after surgery [ ] . at pre-defined time points (preoperatively, recovery room [rr] and on postoperative days [pod] to ) simultaneous serum and urine samples were analyzed additional studies must confirm these findings and reevaluate these simple parameters as potential aki monitoring tools. urinary liver-type fatty acid-binding protein is the novel biomarker for diagnosis of acute kidney injury secondary to sepsis t komuro, t ota shonan kamakura general hospital, kamakura, kanagawa, japan critical care , (suppl ):p introduction: acute kidney injury (aki) is the predictor of poor prognosis for the patient with sepsis and septic shock. several diagnostic criteria for aki is used on clinical settings, but useful biomarker is not known yet. urinary liver-type fatty acid-binding protein(l-fabp) is associated with kidney function and aki [ ] , but that is not still discussed about aki secondary to sepsis. thus, we conducted the study of the association between urine l-fabp and aki with secondary to sepsis. (fig. ) . the cut-off line of l-fabp was . μg/g cr. conclusions: l-fabp can be the novel biomarker for diagnosis of aki. further investigation need for diagnostic value of l-fabp and usefulness of early intervention for aki used by l-fabp. introduction: biotransformation of -hydroxyvitamin d to active , (oh) d occurs primarily in the kidney. our aim was to explore whether this process was altered in patients with acute kidney injury (aki). methods: consecutive patients admitted to critical care at a tertiary hospital were recruited. the aki group comprised patients with kdigo stage ii or stage iii aki; the non-aki group were patients requiring cardiovascular or respiratory support, but with no aki. vitamin d metabolite concentrations were measured on days , and . statistical analysis included comparison between groups at each time point, and longitudinal profiles of vitamin d metabolites. results: interim analysis of participants ( % of the recruitment target) showed that , (oh) d concentrations were significantly lower in patients with aki at day and day . considering longitudinal changes, -hydroxyvitamin d profiles were not different between the groups ( fig. ) but there was a trend towards a longitudinal increase in , (oh) d in patients without aki, which was not seen in aki patients (fig. ) . conclusions: interim analysis indicates significant differences in concentrations of , (oh) d, but not (oh)d, in critically ill patients with aki. recruitment is ongoing and further results are awaited. introduction: acute renal failure affects from % to % of patients in the intensive care units (icus) and it is associated with excess mortality. hydratation is a useful preventive measure but it is often controindicated in critically ill patients who, on the contrary, often benefit by a strictly conservative strategy of fluid management. fenoldopam, a selective dopamine -receptor agonist, increases renal blood flow and glomerular filtration rate by vasodilating selectively the afferent arteriole of renal glomerulus. the aim of our study is to compare renal effects of fenoldopam and placebo in critically ill patients undergoing a restrictive fluid management. methods: we enrolled patients admitted to our icu. patients were assigned by randomization to study groups: fenoldopam (n= ) and placebo (n= ). fenoldopam was infused continuously at , mcg/kg/ min and equivalent volume for placebo during a period of seven days. creatinine, cystatin c and creatinine clearance were daily measured as markers of renal function. the incidence of aki according to rifle criteria (risk, injury, failure, loss, end stage kidney disease) was also calculated. results: patients with a negative fluid balance at the end of the week (~- ml, p= , ) were included in the analysis, in the placebo group and in the fenoldopam group. there were not significant differences in the trend of creatinine, creatinine clearance, cystatin c and in the incidence of aki between the groups during the week of infusion. conclusions: a continuous infusion of fenoldopam at , mcg/kg/ min does not improve renal function and does not prevent aki in critically ill patients undergoing a strictly conservative strategy of fluid management. introduction: this study aims to evaluate the efficacy of a protocol implemented for dysphagia risk factors [ ] in hospitalized patients in a cicu (coronary intensive care unit). methods: patients hospitalized in the cicu of a medium-sized hospital in presidente prudente, sp, brazil, were subjected to a survey that screened for dysphagia during the period from january of to september of . patients with at least one risk factor for dysphagia were evaluated by a phonoaudiologist and are the subject of this study. the information was statistically analyzed using epi info, version . . . software. considering significant p < . two-tailed, for logistic regressions multivariate estimated in the sample. results: for this study patients were selected, of which . % were male and the mean age was . ± . years. a higher incidence of dysphagia was observed among patients who had at least one of the following risk factors: stroke (odds ratio . p< . ); brain tumor (or . p= . ); chronic obstructive pulmonary disease (copd) (or . p= . ); degenerative diseases (or . p< . ); lower level of consciousness (or . p< . ); ataxic respiration (or . p< . ); aspiration pneumonia (or . p< . ); orotracheal intubation > h (or . p< . ); tracheostomy (or . p< . ); airway secretion (or . p< . ); nasoenteral tube (or . p< . ); gastrostomy (or . p= . ). there was no statistical significance for age > , traumatic brain injury, oropharyngeal surgery and unfavorable dentition. four factors appeared less than times and could not be analyzed (chagas disease, human immunodeficiency virus (hiv), orofacial burn and excess saliva). conclusions: we concluded that the dysphagia triage protocol insertion was effective to identify dysphagic patients and can be used as an additional tool in the intensive care risk management. physiological bases of this age old concept, more recently applied to endotracheal intubation, have never been confirmed by current methods. we therefore decided to study the effects of an apnea oxygenation period under hfnc oxygen therapy by means of a novel modelization of the respiratory system. methods: firstly, an airway model was built with anatomical, physical and physiological attributes similar to that of a healthy subject (fig. ) . this system reproduces the physiological evolution of intrapulmonary gases during apnea by progressively increasing co levels after having cut off previous o supplies (fio %). secondly, the effects of a hfnc apnea oxygenation of l/min with an fio of % were analyzed by collecting intrapulmonary gas samples at regular intervals (fig. ) . results: after minute of apnea oxygenation, intrapulmonary oxygen levels remain stable at %. after minutes, oxygen fraction reaches %, and increases up to % in minutes. regarding co levels, no significant modifications were observed. conclusions: a novel experimental and physiological model of the respiratory system has been developed and confirms the existence of an alveolar oxygen supply as well as the lack of a co washout during hfnc apnea oxygenation. however, these effects are only observed after a delay of about . to minutes. therefore, the clinical interests of this technique to reduce apnea-induced desaturation during intubation of a hypoxemic patient in the icu seem limited without adequate preoxygenation. combination of both preoxygenation and apnea oxygenation by hfnc can most likely explain positive results observed in other clinical studies. effect of % nebulized lignocaine versus % nebulized lignocaine for awake fibreoptic nasotracheal intubation in maxillofacial injuries in emergency department h abbas, l kumar king george's medical university,lucknow,india, lucknow, india critical care , (suppl ):p introduction: topical lignocaine is most commonly used pharmacological agent for anaesthetizing upper airway during fibreoptic bronchoscopy. we compare the effectiveness of two different concentrations, % lignocaine and % lignocaine, in nebulised form for airway anaesthesia during awake fibreoptic nasotracheal intubation in terms of patient's comfort and optimal intubating conditions, intubation time. methods: institutional ethics committee approved the study and written informed consent obtained; patients of either sex, between - years age with anticipated difficult airway planned for intubation were included for this study. patients were randomly allocated into two groups (a and b) based on sealed envelope method; patients and observers were blinded by using prefilled syringes of lignocaine.one group was nebulized with ml of % lignocaine(group a) and other with ml of % lignocaine(group b) in coded syringes via ultrasonic nebuliser for minutes followed by inj midazolam . mg/kg iv and inj fentanyl microgram/kg iv just before the procedure. the fibreoptic broncoscope was introduced via nostril and the other nostril was used for oxygen insufflation ( - l/min). the fibroscope was introduced through the glottic opening and visualising tracheal rings and carina.the endotracheal tube railroaded over the fiberscope and cuff inflated. results: the primary outcome measure was patient's comfort during awake fibreoptic nasotracheal intubation. the mean patient comfort puchner scale score of group a was . ± . and of group b was . ± . . the mean value of puchner scale of group b was significantly higher.the mean procedural time of group b was significantly higher ( . %) as compared to group a (p< . ). the no of intubations attempts did not differ between the two groups. conclusions: % nebulised lidocaine provided adequate airway anaesthesia and optimal intubating conditions, patient comfort, stable hemodynamics. introduction: this systematic review and meta-analysis aims to investigate whether video laryngoscopy (vl) improves the success of orotracheal intubation, when compared with direct laryngoscopy (dl). methods: a systematic search of pubmed, embase, and central databases was performed to identify studies comparing vl and dl for emergency orotracheal intubations outside the operating room. the primary outcome was rate of first pass intubation. subgroup analyses by location, device used, clinician experience, and clinical scenario were performed. the secondary outcome was rate of complications. results: the search identified studies with , emergency intubations. there was no overall difference in first-pass intubation with vl compared to dl. subgroup analysis showed first-pass intubations were increased with vl in the intensive care unit (icu) ( . ( . - . ); p< . ), but not in the emergency department or pre-hospital setting. rate of first-pass intubations were similar with glidescope® and dl, but improved with the cmac® ( . ( . - . ); p= . ). there was greater first-pass intubation with vl than dl among novice/trainee clinicians (or= . ( . - . ); p< . ), but not among experienced clinicians or paramedics/nurses. there was no difference in first-pass intubation with vl and dl during cardiopulmonary resuscitation or trauma. vl was associated with fewer oesophageal intubations than dl (or= . ( . - . ); p= . ), but more arterial hypotension (or= . ( . - . ); p= . ). conclusions: in summary, compared to dl, vl is associated with greater first-pass emergency intubation in the icu and among less experienced clinicians. vl is associated with reduced oesophageal intubations but a greater incidence of arterial hypotension. compared success rate between direct laryngoscope and video laryngoscope for emergency intubation, in emergency department: randomized control trial p sanguanwit, n laowattana ramathibodi hospital, bangkok, thailand critical care , (suppl ):p introduction: video laryngoscope was used as an alternative to intubate in the emergency room, designed for tracheal intubation more success [ , ] . methods: we performed a prospective randomized controlled trial study of patients who had sign of respiratory failure or met indication for intubation from july to june . patients were randomly by snose technique; assigned to video laryngoscope first or direct laryngoscope first. we collect the demographics, difficult intubation predictor, rapid sequence intubation, attempt, cormack-lehane view and immediate complication. primary outcome was first attempt success rate of intubation. results: first attempt success rate of video laryngoscope was . % trend to better than direct laryngoscope was . %, (p= . ), good glottic view (cormack-lehane view - ) of video laryngoscope was . % better than direct laryngoscope . %, and statistically significant (p= . ), no statistical significant in immediate serious complication between direct laryngoscope or video laryngoscope. conclusions: compared to the success rate between using video laryngoscope or direct laryngoscope for intubation, video laryngoscope trend to better success rate, and better glottic view. -year cohort of prehospital intubations and rescue airway techniques by helicopter emergency medical service physicians: a retrospective database study p de jong, c slagt, n hoogerwerf radboudumc, nijmegen, netherlands critical care , (suppl ):p introduction: in the netherlands the pre-hospital helicopter emergency medical service (hems) is physician based and an adjunct to ambulance services. all four hems stations together cover / specialist medical care in the netherlands. in many dispatches the added value is airway related [ ] . as part of our quality control cycle, all airway related procedures were analysed. high quality airway management is characterized by high overall and first pass endotracheal intubation (eti) success [ ] . methods: the hems database was analysed for all patients in whom prehospital advanced airway management was performed in the period - . balloon/mask ventilation, supraglottic airway (sga) devices, total intubation attempts, cormack & lehane (c&l) intubation grades, successful eti, primary and rescue surgical airway procedures and professional background were reviewed. results: in the -year period, there were dispatch calls. in total patients were treated in the prehospital setting by our hems. of those, required a secured airway. eti was successful in of ( . %). in the remaining patients ( fig. ) an alternative airway was needed. rescue surgical airway was performed in . %, . % received a rescue sga, rescue balloon/mask ventilation was applied in . % of cases, was allowed to regain spontaneous ventilation and in . % of patients all airway management failed. hems physicians, ambulance paramedics, hems paramedics and others (e.g. german emergency physicians) had eti first pass success rates of . %, . %, . % and . % respectively (fig. ) . difficult laryngoscopy (no epiglottis visible) was reported in . % of patients (table ) . conclusions: our data show that airway management performed by a physician based hems operation is safe and has a high overall eti success rate of . %. the total success rate is accompanied by a high first pass eti success rate. introduction: incidences associated with endotracheal tubes are frequent during mechanical ventilation (mv) of intensive care unit (icu) patients and can be associated with poor outcomes for patients and detrimental effects on health care facilities. here, we aimed to identify factors associated with event occurrence due to unsafe management of endotracheal tubes (e-umet). methods: a retrospective observational study was conducted in three icus: one surgical icu, one stroke icu, and one emergency department, at a tertiary hospital in japan from april to march . patients requiring mv and oral intubation during their icu stay were included. the primary finding was the incidence rate of e-umet (biting, unplanned extubations, and/or displacement of the endotracheal tube). the patients were divided into two groups: with or without e-umet. to investigate e-umet, potential factors possibly related to its occurrence were obtained from electronic medical records. we conducted univariable and multivariable analyses to investigate e-umet factors. results: of patients, e-umet occurred in ( . %). the mean and standard deviation for age and acute physiology and chronic health evaluation (apache) ii score were ( ) and ( ), respectively. according to a multivariate logistic-regression analysis, significant risk factors associated with e-umet included patients of neurosurgery (odds ratio (or) . ; % ci, . - . ; p= . ), sedative administration (or . ; % ci, . - . ; p< . ), and higher richmond agitation-sedation scale (rass) scores (or . ; % ci, . - . ; p< . ). the use of a restraint (or . ; % ci, . - . ; p= . ) was an independent factor associated with a lower probability of e-umet. conclusions: this study suggests that risk factors associated with e-umet include neurosurgery, higher rass scores, and the administration of sedatives. patients with these factors and longer oral intubation periods might require extra care. introduction: the use of nasal high flow (nhf) as a respiratory support therapy post-extubation has become increasingly more common. nhf has been shown to be non-inferior to niv and reduces escalation needs compared to conventional oxygen therapy. clinical outcomes using nhf in patients with type ii respiratory failure (rf) is less well understood. our aim was to determine if nhf can be used successfully when extubating type ii rf patients compared to type i rf. methods: we conducted a retrospective observational study on the use of nhf as an extubation respiratory support in (n= ) consecutive patients in icu over a -month period. primary outcome was the need for escalation in therapy (niv, intubation and palliation) post extubation. patients were categorised as high risk if they scored >= from: age>= years, bmi>= and >= medical comorbidity. results: analysis was conducted on all fifty-six (n= ) patients. type i rf group was composed of (n= ) patients with a mean age of . (±sd) years. type ii rf group had (n= ) patients with a mean age of . (±sd) years. in type i rf patients ( %) were successfully extubated with nhf compared to patients ( . %) in type ii. in type ii rf the outcomes were more variable with a greater requirement for niv. of these patients % required niv, . % required intubation and . % received nhf therapy for palliation. a higher average bmi ( . vs . kg/m ) was found in unsuccessfully vs successfully extubated patients in type ii rf. in type i rf escalation of therapy was equally distributed with % in each category. conclusions: the use of nhf for respiratory support post-extubation may become standard practice for type i rf in critical care settings. our data suggests that nhf can be used but with caution in type ii rf and clinicians should risk stratify patients to identify those at risk of re-intubation and post-extubation respiratory failure. introduction: pathogenesis of ventilator-associated pneumonia (vap) relies on colonization and microaspiration. oral topical decontamination reduced the vap incidence from to % [ ] . the persistence of antiseptic effect in the oral cavity is questionable; we hypothesize that continuous oral antiseptic infusion may offer a better decontamination. aim of the work: we developed endotracheal tube that allows continuous oral infusion of chlorhexidine (chx), and we want to test the technique versus the conventional on bacterial colonization. (provisional patent: ) methods: a two identical bio models for the upper airways were manufactured by ( dx diagnostics, usa) to adapt the modified and the ordinary endotracheal tubes (ett). the two techniques tested were using six hourly disinfection with chx (group a) versus disinfection through the hours infusion technique (group b). five microorganisms plus mixed bacteria were used and each was tested for five times. normal saline was used constantly to irrigate the biomodels and ten ml aliquot was collected by the procedure end. culturing of the aliquots from decanted broth pre and post disinfection was performed. the time to apply chx by practitioner was also compared. results: there was a trend towards lower bacterial growth in group a in experiments which reach statistical significance only with pseudomonas aeruginosa (p= . ). in one experiment the growth was lower in group b (fig. ) . additionally there was time saving advantage in group b ( ± . versus ± . min, p= . ). conclusions: the novel technique got at least non inferior results, plus time saving advantage. these results may warrant future clinical trial. monitoring airways non invasive online analysing different particle flow from the airways is never done before. in the present study we use a new technology for airway monitoring using mass spectrometric analysis of particle flow and their size distribution (pexa particles in expired air). the exhaled particles are collected onto a substrate and possible for subsequent chemical analysis for biomarkers. our hypothesis was that by analysing the particle flow online, we could optimise the mechanical ventilation. our hypothesis was that a small particle flow would probably be more gentle for the lung than a large particle flow when the lung is squeezed out and the majority of all small airways are open. methods: in the present study we analyse the particle flow from the airways in vivo, post mortem and during ex vivo lung perfusion using different ventilation modes; volume controlled ventilation (vcv) and pressure controlled ventilation (pcv) comparing small tidal volumes( ) versus big tidal volumes( ) at different peep (positive end-expiratory pressure) and after distribution of different drugs in six domestic pigs. results: we found that vcv resulted in a significant lower particle flow than pcv in vivo but in ex vivo settings the opposite was found (fig. ). in both in vivo and ex vivo settings we found that big tidal volume resulted in a larger particle flow than small tidal volumes.air. the opening and the closure of the small airways reflect the particle flow from the airways. we found that different ventilation modes resulted in different particle flow from the airways. we believe this technology will be useful for monitoring mechanical ventilated patients to optimise ventilation and preserve the lung quality and has a high potential to detect new biomarkers in exhaled air. introduction: malaria is a common problem in underdeveloped countries, with an estimated mortality of more than one million people per year. pulmonary involvement is one of the most serious manifestations of plasmodium falciparum malaria. non-invasive ventilation (niv) decreases muscular works and improves gas exchange by recruitment of hypoventilated alveolus. in this context, we analyze the impact of the use of non-invasive ventilation in malaria with pulmonary dysfunction. methods: it's a retrospective cohort study. we analyzed electronic records of patients who were diagnosed with malaria, with acute respiratory failure, who underwent respiratory therapy with niv between - within the intensive care unit (icu). the study variables were: icu mortality, length of hospital stay, niv time and outcome groups. statistical analysis was performed with the pearson correlation coefficient, with significance level of p < . . the statistics were performed using the bioestat . program. results: thirty-one patients were included in the study. four results were analyzed according to table and fig. . % of the patients were discharged from the hospital. pearson's correlation coefficient analysis showed statistical significance in the group (niv/discharge) in the analysis of patients hospitalized versus niv ( % ci = . to . <(p) = . ). conclusions: the use of niv was positive in patients using this resource as first-line treatment of malaria in the fight against respiratory decompensation, with improvement of symptoms. introduction: cpap is used to improve oxygenation in patient with arf. we aimed to determine non-inferiority (ni) of helmet cpap to facemask in arf based on physiological (heart rate (hr) and respiratory rate (rr)) and blood gas parameters (pao and paco ). we also compared patients' perception in dyspnea improvement after cpap using dyspnea scale (visual analogue scale (vas)) and likert score. methods: we randomized patients to helmet (n= ) and facemask (n= ) with . % of arf was due to acute pulmonary edema. cpap was applied for minutes. patients' physiological and blood gas parameters were recorded before and after intervention. patients then marked on dyspnea scale and likert score. ni of helmet would be declared if confidence interval (ci) of mean difference between groups (helmet's mean minus facemask's mean) in improving physiological, blood gas parameters and dyspnea scale was no worse than predetermined non-inferiority margin (nim). secondary outcome was to compare incidence of discomfort and mucosal dryness between groups. methods: this is a single center retrospective study performed in the icu of tel aviv medical center, israel, a tertiary academic referral hospital. using the electronic medical record system and intensix predictive critical care system for analysis, all patients admitted to the icu between . and . were assessed. respiratory deterioration in mv patients was defined as acute adjustment of fio increase > % or peep increase > cmh o that persisted for at least hours. the primary outcome was icu mortality. secondary outcome was length of icu stay (los). a chi square test for trends was used for the significance of mortality data and a one way anova test for los. results: mv patients were admitted to the icu with an overall mortality of . %. mortality and los were tripled in patients who experienced at least one respiratory deterioration when compared to no events ( . % vs. . %, p< . and . vs. . days, p< . respectively) (fig. ) . increased events of respiratory deteriorations showed significant trend of increased mortality (p< . ). conclusions: in mv patients, a single respiratory deterioration event carries a times higher mortality rate and length of stay (los). any additional event further increases both parameters. association of lung ultrasound score with mortality in mechanically ventilated patients j taculod, jt sahagun, y tan, v ong, k see national university hospital singapore, singapore, singapore critical care , (suppl ):p introduction: lung ultrasound is an important part of the evaluation of critically ill patients. it has been shown to predict recruitability in acute respiratory distress syndrome. however, little is known about the application of lung ultrasound in predicting mortality in mechanically ventilated patients. methods: observational study of mechanically ventilated patients admitted to the medical intensive care unit (icu) of a tertiary hospital (national university hospital, singapore) in and . only the first icu admissions of these patients were studied. lung ultrasound was done at six points per hemithorax and scored according to soummer (crit care med ): normal aeration = ; multiple, well-defined b lines = ; multiple coalescent b lines = ; lung consolidation = . the lung ultrasound (lus) score was calculated as the sum of points (score range - ). we analysed the association of lus score with icu/hospital mortality, using logistic regression, adjusted for age and acute physiology and chronic health evaluation (apache) ii score. results: patients were included (age . ± . years; female [ . %]; apache ii . ± . ; sepsis diagnosis [ . %]). icu and hospital mortality were . % and . % respectively. lus score was associated with increased icu (or . , % ci . - . , p= . ) and hospital (or . , % ci . - . , p= . ) mortality, adjusted for age and apache ii score. conclusions: lus score was associated with increased icu/hospital mortality and may be useful for risk stratification of mechanically ventilated patients admitted to icu. introduction: ventilator asynchrony results in morbidities and mortality. the aim of this study was to explore whether and how physicians used patient-ventilator interactions(pvi) to set mechanical ventilators(mv) in thailand. methods: thai physicians treating mv patients were asked to respond to questionnaires distributed in conferences and to e-mails sent. types of asynchronies encountered and frequency of mv adjustment guided by pvi were evaluated. in addition, correlations between physician's knowledge and )confidence to manage asynchronies and )their experience were analyzed. results: two hundred and eleven physicians answered the questionnaires. most of them were medical residents and icu specialists. % of them set and adjusted mv by asynchrony guidance and the majority used waveform analysis to more than a half of their patients. the most and the least common asynchronies encountered were double triggering and reverse triggering, respectively, while the most difficult-to-manage and the most easily managed asynchronies were periodic/?a b show $ #?>unstable breathing and flow starvation, respectively. lack of confidence and knowledge of pvi were the major reasons of physicians who did not perform asynchrony assessment. for knowledge evaluation, more than % of physicians incorrectly managed asynchrony. chest and icu fellows had the greatest skills in waveform interpretation and asynchrony management with the mean score of . from the total , compared with specialist( . ), medical residents( . ), internists( . ) and general practitioner( . ). there were poor correlations between years' experience in mv management and the skill in waveform interpretation (r = . , p= . ) and between physician's confidence in pvi management and the clinical skill (r = . , p< . ) conclusions: the majority of thai physicians realized the importance of pvi, but the skill in asynchrony management was moderate. intensive programs should be provided to improve their clinical performance. methods: six deeply anesthetized swine underwent tracheostomy, thoracostomy and experimental plef with ml/kg of radiopaque saline randomly instilled into either pleural space. animals were ventilated at vt= ml/kg, frequency= bpm, i/e= : , peep= cmh o, and fio = . . quantitative lung computed tomographic (ct) analysis of regional aeration and global frc measurements by nitrogen wash-in/wash-out technique were performed in each of these randomly applied positions: semi-fowler's (inclined °from horizontal in the sagittal plane); prone, supine, and lateral positions with dependent plef and non-dependent plef (fig. ) . results: no significant differences in frc were observed among the horizontal positions, either at baseline (p= . ) or with plef (p= . ) ( fig. a) . however, component sector total gas volume in each phase of the tidal cycle were different within all studied positions with and without plef (p=<. ). compared to other positions, prone and lateral position with non-dependent plef had a more homogenous vt distribution among quadrants (p=. , fig. b ). supine was associated with most dependent collapse (fig. c ) and greatest tendency for tidal recruitment ( % vs~ %, p= . , fig. d ). conclusions: changes in body position in the setting of effusioncaused chest asymmetry markedly affected the internal distributions of gas volume, collapse, ventilation, and tidal recruitment, even when commonly used global frc measurements provided little indication of these important positional changes. of the respondents, % were affiliated with multidisciplinary icus, % with thoracic and/or cardiac icus and % with neuro-icus. most respondents ( %) had completed their specialist training. overall, arterial oxygen tension (pao ) was the preferred parameter for the evaluation of oxygenation (fig. ). the proportions of doctors' preferences for increasing, decreasing or not changing an fio of . in two (out of six) patient categories at different pao levels are presented in table and table . conclusions: this is the largest survey of the preferred oxygenation targets among icu doctors. pao seems to be the preferred parameter for evaluating oxygenation. the characterisation of pao target levels in various clinical scenarios provide valuable information for future clinical trials on oxygenation targets in critically ill icu patients. introduction: sonographic assessment of diaphragmatic excursion and muscle thickening fraction have been suggested to evaluate diaphragm function during weaning trial [ ] . the purpose of this study is to compare these two parameters to predict extubation success. methods: this prospective study was carried out during months from march to november . we enrolled patients who were mechanically ventilated for more than h and met all criteria for extubation. the non inclusion criteria were: age < years, history of neuromuscular disease or severe chronic respiratory failure. we excluded subjects who needed reintubation for upper airway obstruction, neurological or hemodynamic alteration. the scenario involves a patient expected to receive mechanical ventilation for at least hours in the icu. all proportions are percentages of respondents with % confidence intervals. *p < . for comparisons of proportions of "no change" versus adjacent lower pao level (mcnemar's test) introduction: ventilator induced diaphragmatic dysfunction is known to be a contributor to weaning failure. some data suggest that assisted ventilation might protect from diaphragmatic thinning. aims of this study are to evaluate, by ultrasound (us), the change in diaphragm thickness and thickening in patients undergoing controlled and assisted mechanical ventilation (mv) and clinical factors associated with this change. methods: we enrolled patients who underwent either controlled mv (cmv) for cumulative hours or hours of pressure support (psv) if ventilation was expected to last for at least days. patients < years old, with neuromuscular diseases, phrenic nerve injury, abdominal vacuum dressing system and poor acoustic window were excluded. diaphragm thickness and thickening were measured with us as described by goligher and clinical data were collected every hours until icu discharge. results: we enrolled patients, were excluded because they had less than measurements and for low quality images, leaving patients for analysis. as expected, during cmv diaphragm thickening was almost absent and significantly lower than during psv (p< , ). diaphragm thickness did not reduce significantly during cmv (p= . ), but during psv significantly increased (p< . ) (fig. , where "day " represents the first day of psv). during cmv, in / patients diaphragm thickness showed a >= % reduction. they had a significantly higher fraction of days spent in cmv (p= . ) and longer neuromuscular blocking drugs (nbds) infusion (p= . ). during psv, / patients showed an increase in diaphragm thickness >= %. duration of hospital stay was significantly lower for these patients (p . ). differences between the two groups are reported in table . conclusions: longer time spent in cmv and with nbds infusion seems associated with a decrease in diaphragm thickness. assisted ventilation promotes an increase in diaphragm thickness, associated with a reduction in the length of hospitalization. prediction of intrinsic positive end-expiratory pressure using diaphragmatic electrical activity in neutrally-triggered and pneumatically-triggered pressure support f xia nanjing zhongda hospital, southeast university, nanjing, china critical care , (suppl ):p introduction: intrinsic positive end-expiratory pressure (peepi) may substantially increase the inspiratory effort during assisted mechanical ventilation. our purpose of the study was to assess whether electrical activity of the diaphragm (eadi) can be reliably used to estimate peepi in patients undergoing conventional pneumaticallycontrolled pressure support (psp) ventilation and neutrally-controlled introduction: atelectasis develops in critically ill obese patients submitted to mechanical ventilation. the pressure exerted by the abdominal weight on the diaphragm causes maldistribution of ventilation with increased pleural pressure and diminished response to peep. our objective was to analyze the effects of peep in the distribution of ventilation in obese and non-obese patients according to bmi (obese >= kg/m , or non-obese: to . kg/m ), using electrical impedance tomography (eit). methods: we assessed the regional distribution of ventilation of surgical and clinical patients submitted to a decremental peep itration monitored by eit. we calculated the percent ventilation to the nondependent (anterior) lung regions at the highest and lowest peep applied. the highest compliance of respiratory system was consistently observed at intermediate values of peep (between those extreme values), indicating that the highest peep caused pulmonary overdistension, whereas the lowest peep likely caused dependent lung collapse results: were enrolled patients, with non-obese patients ( , ± kg/m ) and obese patients ( . ± . kg/m ). all patients presented progressively decreased ventilation to dependent (posterior) lung regions when peep was lowered (p< . ). obese patients consistently presented higher ventilation to the anterior lung zones (when compared no nonobese), fig. introduction: lung protective ventilation is the mainstay of mechanical ventilation in critically ill patients [ ] . extracorporeal co removal (ecco r) can enhance such strategies [ ] and has been shown to be effective in low flow circuits based on renal replacement platforms [ , , ] . we show the results of a pilot study using a membrane lung in combination with a hemofilter based on a conventional renal replacement platform (prismalung™) in mechanically ventilated hypercapnic patients requiring renal replacement therapy (nct ). methods: the system incorporates a membrane lung ( . m ) in a conventional renal replacement circuit downstream of the hemofilter. mechanically ventilated patients requiring renal replacement therapy were included in the study. patients had to be hypercapnic at inclusion under protective ventilation. changes in blood gases were recorded after implementation of the extracorporeal circuit. thereafter ventilation was intended to be decreased per protocol until baseline paco was reestablished and changes in vt and pplat were recorded. data from patients were included in the final analysis. results: the system achieved an average co removal rate of . ± . ml/min which corresponded to a paco decrease from . ± . to . ± . mmhg (p< . ) and a ph increase from . ± . to . ± . (p< . ) [ fig. ]. after adaption of ventilator settings we recorded a decrease in vt from . ± . to . ± . ml/kg (p< . ) and a reduction of pplat from . ± . to . ± . cmh o (p< . ). these effects were even more pronounced in the "per protocol" analysis [ fig. ]. conclusions: low flow ecco r in combination with renal replacement therapy provides partial co removal at a rate of over ml/min can significantly reduce invasiveness of mechanical ventilation in hypercapnic patients. introduction: in ecco r-crrt, efficiency of co removal is higher positioning the oxygenator (oxy) up-stream than down-stream the haemofilter due to higher blood flow (bf) [ ] . we tested whether this effect was due to lower pre-filter pressure (pfp). methods: ecco r-crrt circuit was tested in-vitro (n= ) with the following settings: l bovine blood; bf ml/min; oxy . m (euroset); cvvh post mode; substitution flow ml/h; uf rate function off; . m haemofilter (diapact®, b.braun avitum); sweep air flow . l/min. pfp was evaluated at baseline, , and hours. co extraction was measured at bf of , and ml/min. sweep air flow/blood ratio was : . co was add to obtain paco of mmhg. co removal rate calculation ( ): co removal rate = (co ecco r inlet-co ecco r outlet)* blood flow (eq. ) co molar volume at °c [l/mol] = ; solubility of co at °c = . mmol/(l*mmhg); hco i = inlet hco concentration [mmol/l]; hco o = outlet hco concentration [mmol/l]; pi co = inlet co partial pressure [mmhg]; poco = outlet co partial pressure [mmhg] equation becomes: co removal rate= x ((hco i + . x pico ) -(hco o + . x poco )) x blood flow (eq. ) results: bf of ml/min was always reached with the up-stream configuration. bf was reduced to ml/min with the down-stream configuration due to high pfp alarm (table ). co removal increased to . ± . to . ± . , and . ± . ml/min, at bf of , and ml/ min (p< . ). conclusions: bf of ml/min can be reached only with the upstream configuration due to lower circuit pfps. bf directly correlates to co removal efficiency. we may speculate that simultaneous use of crrt and lf-ecco r and activation of the uf rate function with the down-stream setting may further increase pfp thus forcing to more enhanced reduction of bf and less effective co -removal. introduction: we describe the use of a novel low-flow ecco r-crrt device (prismalung-prismaflex, baxter healtcare gambro lundia-ab-lund, sweden) for simultaneous lung-renal support. methods: a retrospective review of patients submitted to prismalung-prismaflex due to aki associated to hypercapnic acidosis during the period may -august at prato hospital icu was performed. data collected were: demographic, physiologic, complications, outcome. data were presented as mean ± ds; anova test was used to compare changes of parameters over time; significance was set at p< , . results: we identified patients (mean age ± yr, mean sofa ± ). causes of hypercapnia were moderate ards (n= ) and ae-copd (n= ). in all patients a fr double lumen cannula was positioned and ml/min blood-flow with lt oxygen sweep-gas-flow was maintained; iv-heparin aiming to double aptt was used. haemo-diafiltration (effluent flow ml/kg/hour) was delivered. in all cases prismalung-prismaflex improved respiratory and metabolic parameters (figs. and ) without any complications. all patients survived to the treatment, nevertheless patients ( ae-copd; ards) died during icu stay due to irreversible cardiac complications. in ards cases: patients were successfully weaned from imv, mean duration of the treatment was ± hours, mean duration of imv after ecco r-crrt was ± days. in ae-copd cases: intubation was avoided in patients at risk of niv failure, patients were successfully weaning from imv, mean duration of the treatment was ± hours, mean duration of imv after ecco r-crrt was , ± , days. fig. (abstract p ) . minutes after implementation of the combined renal replacement and ecco r circuit a moderate decrease in paco (- . mmhg) corresponding to a slightly higher ph ( . ) was observed conclusions: the use of prismalung-prismaflex has been safe and effective: it may be argued that it could be due to the low-blood-flow used. the positive results of this preliminary study may constitute the rational for the design of a larger randomized control trial. systemic il- production and spontaneous breathing trial (sbt) outcome: the effect of sepsis introduction: spontaneous breathing trial (sbt), a routine procedure during ventilator weaning, entails cardiopulmonary distress, which is higher in patients failing the trial. an intense inflammatory response, expressed by increased levels of pro-inflammatory cytokines, is activated during sbt. sepsis, a common condition in icu patients, has been associated with increased levels of the pro-inflammatory cytokine il- . il- produced among others by skeletal muscles, has been associated with severe muscle wasting and maybe by icu acquired weakness. we hypothesised that il- increases during sbt, more evidently in sbt failures. we anticipate this response to be more pronounced in formerly septic patients fulfilling the criteria for sbt. methods: sbts of -min duration were performed and classified as sbt failure or success. blood samples were drawn before, at the end of the sbt and hours later. serum il- levels and other inflammatory mediators, commonly associated with distress, were determined and correlated with sbt outcome. subgroup analysis between septic and non-septic patients was performed. )kg/m ) were monitored for . ± . hours. apneas were identified ranging from - s (fig. a) . apneas were observed in % of patients, suggesting low predictability of respiratory insufficiency. the average mv was ± . %mvpred, as patients were often sleeping or mildly sedated. we assessed the effects of each apnea on the temporally associated mv (fig. b) . while apneas ranging in length from - s decrease mv by as much as %, their effect over min is < %. on a min time scale, even s apneas led to lowmv just % of the time (fig. c) . conclusions: while apneas were ubiquitous, they seldom led to lowmv over clinically relevant time scales. large compensatory breaths following an apnea generally restored mv to near pre-apnea levels. nonetheless, some apneas can become dangerous when ignored, as when subsequent sedation decreases compensatory breath size. rvm data provide a better metric of respiratory competence, driving better assessment of patient risk and individualization of care. introduction: diffuse alveolar hemorrhage (dah) is an acute lifethreatening event and recurrent episodes of dah may result in irreversible interstitial fibrosis. identifying the underlying cause is often challenging but is needed for optimal treatment. lung biopsy is often performed in the diagnostic evaluation of patients with suspected dah. however, the role of lung biopsy in this clinical context is unclear. hence, we sought to identify the spectrum of histopathologic findings and underlying causes in patients with dah who underwent lung biopsy, surgical or transbronchial. methods: we identified patients who underwent surgical lung biopsy (n = ) or bronchoscopic biopsy (n = ) in the evaluation of dah over a -year period from to . we extracted relevant clinical pathologic and laboratory data. results: the median age in our cohort was years with % females. serologic evaluation was positive in % of patients (n= ). most common histopathologic findings on surgical lung biopsy included alveolar hemorrhage (ah) with capillaritis in patients of whom six had necrotizing capillaritis, followed by ah without capillaritis in patients. the most common histopathologic finding on bronchoscopic lung biopsy was ah without vasculitis/capillaritis in patients, followed by ah with capillaritis in patients. there were no procedure related complications or mortality observed with either method of lung biopsy. the clinico-pathologic diagnoses in these patients are shown in tables and . conclusions: in patients with dah undergoing lung biopsy alveolar hemorrhage without capillaritis was found to be the most common histopathologic finding followed by pulmonary capillaritis. these histopathologic findings contributed to the final clinico-pathologic diagnoses of granulomatous polyangiitis and microscopic polyangiitis in a substantial portion of cases. future studies are needed to ascertain the benefits vs. risks of lung biopsy in patients with suspected dah. note that, an apnea of -sec will (by definition) drive mv over a -sec window down to , but will only decrease mv over a -sec window down to~ % mvpred and to less than % over a -min window. (c) likelihood of an apnea of specific length to decrease mv below the low mv cutoff over various time windows. note that a single -sec apnea has just a % chance to decrease mv below % in a -sec window and less than % chance to decrease mv below the cutoff over a -min window. even -sec apneas have just % chance of decreasing sustained mv over a -min window below the % mvpred cutoff ( ) granulomatosis polyangitis ( ) ah without capillaritis ( ) antiphospholipid syndrome ( ) microscopic polyangitis ( ) ah with diffuse alveolar damage( ) microscopic polyangitis ( ) ah with pulmonary vascular changes( ) pulmonary hypertension( ) introduction: assessing the sensitivity of the peripheral chemoreflex (spcr), we can predict the likelihood of developing respiratory and cardiovascular disorders. spcr is one of the markers of disease progression and good prognostic marker [ ] . disturbed respiratory mechanics can make it difficult to evaluate. breath-holding test may be helpful in such situation, the results of this test are inversely correlated with peripheral receptor sensitivity to carbon dioxide in healthy people [ ] .the aim of the study was to compare the breath-holding test to single-breath carbon dioxide test in the evaluation of the sensitivity of the peripheral chemoreflex in subjects with copd. methods: the study involved patients with copd with fev /fvc < % of predicted, all participants were divided into two groups depending of disease severity (gold classification, ). in group (mild-to-moderate copd, n= ) all patients had fev >= % and in group (severe-to-very severe copd, n= ) all patients had fev < %. breath-holding test was performed in the morning before breakfast: voluntary breath-holding duration was assessed three times, with min intervals [ ] . a mean value of the duration of the three samples was calculated. the single-breath carbon dioxide test [ ] was performed the next day. the study was approved by the local ethics committee. all subjects provided signed informed consent to both tests. and january . the data was collected from the hospital electronic and paper notes, and data collected was mortality rate, apa-che ii score, icnarc score, type of respiratory support received and whether there was documentation of advanced decisions in case of acute deterioration. results: there were patients admitted to the icu with acute respiratory failure as a complication of pulmonary fibrosis. the median apache ii score was and icnarc standardised mortality ratio was . . nine patients died on icu ( %) and hospital mortality was ten ( %). eight patients ( %) received high flow nasal oxygen, six ( %) received non-invasive ventilation, and two ( %) received invasive ventilation. the median time to death was . days. of patients for whom paper notes were available, no patient had any documented ceiling of care or end of life decisions. conclusions: our study confirmed a very high mortality in this cohort of patients, supporting national guidance that invasive respiratory support has limited value. we advise that frank discussion with patients and their families should happen early after diagnosis, such that end of life plans are already in place in the event of acute deteriorations. introduction: arf is common in critically ill patients. we compared diaphragm contractile activity in medical and surgical patients admitted to icu with a diagnosis of arf. methods: adult medical and major abdominal laparotomic surgical patients admitted to a general icu with a diagnosis of arf were enrolled. arf was defined as a pao /fio ratio<= mmhg/% and need for mechanical ventilation (mv) for at least hours. diaphragmatic ultrasound was realized bedside when the patient was stable and able to perform a trial of spontaneous breathing. a convex probe was placed in right midaxillary line ( th- th intercostal space) to evaluate right hemidiaphragm. diaphragmatic respiratory excursion and thickening were evaluated in m-mode on consecutive breaths and thickening fraction (tf) was calculated. antropometric, respiratory and hemodynamic parameters, saps , sofa score, duration of mv, need for tracheotomy and timing, septic state and site of infection, superinfections, icu and inhospital length of stay (los) and outcome were recorded. patients with trauma and neuromuscular disorders were excluded. p< . was considered significant. results: we enrolled patients: % medical and % surgical, without differences for age, sex, bmi, saps , sofa score, sepsis and superinfections. moderate arf was prevalent in both groups. during diaphragmatic examination, no differences were recorder for respiratory rate, hemodynamic state and fluid balance. surgical patients showed a lower but not significant diaphragm excursion ( . vs . cm), instead tf was significantly reduced ( vs %,p< . ). no differences emerged on duration of mv, but tracheotomy were higher in medical ones ( vs %,p< . ). icu and inhospital los do not differ between medical and surgical patients and mortality rate was respectively % and %. conclusions: in arf, surgical patients showed a lower diaphragm contractility compared to medical ones, maybe due to the combination of anesthetic and surgical effects, but with no influence on outcome. (fig. ) . the slope of the regression line for pes/paw plots was consistently higher for slow compressions ( . ± . ), as compared to fast ones ( . ± . ). a good agreement between Δ pes and Δ paw (fig. ) was found during slow maneuvers, but not during the fast ones. conclusions: slow chest compressions must be used when checking position/inflation of esophageal balloon. the fast maneuver produces hysteresis and underestimation of Δ pes (but not in direct Δ ppl). pes monitoring at high respiratory rates may be problematic. methods: consecutive comatose post cardiac arrest patients were ventilated with volume assist ventilation ( ml/kg ibw, peep cm h o) using elisa eit (lowenstein medical, ge). orogastric tube (nutrivent, sidam, it) was inserted, and eit vest (swisstom ag, ch) was applied in all patients. measurements were performed min after admission and after hrs (fig. ) . optimal peep was defined as lower inflection point using pv curve (pv), positive ptpeep (ptp) and optimal regional stretch/silent spaces (eit) results: methods to determine peep using pv, ptp and eit were comparable in non obese patients (p=ns introduction: the driving pressure of respiratory system (dp) reflects the extent of lung stretch during tidal breathing, and has been associated with mortality in ards patients during controlled mechanical ventilation [ ] . aim of this study was to examine dp during assisted ventilation, and examine if and when high dp occurs in patients in assisted ventilation with pav+. methods: critically ill patients hospitalized in the icu of the university hospital of heraklion, on mechanical ventilation in pav+ mode were studied. continuous recordings of all ventilator parameters were obtained for up to three days using a dedicated software. dp was calculated from the pav+ computed compliance (c) [ ] , and the measured exhaled tidal volume (vt, dp=vt/c). periods of sustained dp above cmh o were identified, and ventilation and clinical variables were evaluated. results: sixty-two patients and hrs of ventilation were analyzed. in half of the patients, dp was lower than cmh o in % of the recording period, while high-dp (> cmh o) more than % of the total time was observed in % of patients. icu non-survivors had more time with high dp than survivors (p= . ). periods of sustained high-dp (> cmh o for > h) were observed in patients. level of assist, minute ventilation, and respiratory rate were not different between the periods of high dp and the complete recordings, while vt was higher and c was lower during the high-dp period compared to the complete recording. the median compliance was below ml/ cmh o during the high-dp period, and above ml/cmh o during the complete recording. conclusions: high dp is not common, but does occur during assisted ventilation, predominantly when compliance is below ml/cmh o, and may be associated with adverse outcome. table summarizes the percent of monitored time with reported data for the two devices. figure depicts mv decrease following propofol and cannula dislodgement fol- fig. (abstract p ) . bland-altman analysis demonstrated that cvp-derived Δppl and Δpes were correlated significantly lowing a jaw thrust. table ) . negative (a-et) pco was strongly associated with good outcome and were significantly associated with overall survival (fig. ) conclusions: in conclusion, the negative arterial to end-tidal co pressure gradient may predict patient survival in some subgroups. introduction: ards may result from various diseases and is characterized by diffuse alveolar injury, lung edema formation, neutrophil-derived inflammation and surfactant dysfunction. various biomarkers have been studied in diagnostics and prognostication of ards. the purpose of the study was to measure the expression of proinflammatory mediators like il- and tnf, a cellular receptor with a role in innate immunity(tlr- ),and a biomarker of fibrogenesis (mmp- ) in different phases of ards patients. methods: we studied patients admitted to our icu with diagnosis of ards during the month of january . six ml of blood were prospectively collected at two times: during the acute phase and in a sub-acute phase before icu discharge. blood samples were centrifuged to obtain the platelet-rich plasma and plasmatic rna (crna) was isolated from platelets.il- , tnf, tlr- and mmp- expression in crna was determined by the droplet digital™ pcr as copies/ml. results: all patient showed a decrease in il- , tnf, tlr and mmp- levels after the acute phase of ards (fig. ) . patient and were affected by influenza a virus (h n ), patient was admitted for pneumococcal pneumonia and patient was affected by legionella. adequate ethiologic treatment was promptly started in patients with bacterial infection. mean duration of mechanical ventilation was . days. all patient survived icu stay and were discharged from hospital. conclusions: il- , tnf, tlr- and mmp- expression detected by extracted platelets rna, may be a novel tool useful for clinicians indicating persistent inflammation with resulting progressive alveolar fibrosis and impaired lung function. more data are necessary to understand the real clinical significance of this biomarkers and their role in fibroproliferation and progression of ards. introduction: although mesenchymal stem cells (mscs) transplantation has been shown to promote lung respiration in acute lung injury (ali) in vivo, its overall restorative capacity appears to be restricted mainly because of low engraftment in the injured lung. ang ii are upregulated in the injured lung. our previous study showed that ang ii increased mscs migration in an angiotensin ii type receptor (at r)dependent manner [ ] . the objective of our study was to determine whether overexpression of at r in mscs augments their cell migration and engraftment after systemic injection in ali mice. methods: a human at r expressing lentiviral vector was constructed and introduced into human bone marrow mscs. we also downregulated at r mrna expression using a lentivirus vector carrying at r shrna to transduce mscs. the effect of at r regulation on migration of mscs was examined in vitro. a mouse model of lipopolysaccharide (lps) induce ali was used to investigate the engraftment of at r-regulated mscs and the therapeutic potential in vivo. results: overexpression of at r dramatically increased ang ii-enhanced human bone marrow msc migration in vitro. moreover, msc-at r accumulated in the damaged lung tissue at significantly higher levels than control mscs h and h after systematic msc transplantation in ali mice. furthermore, msc-at r-injected ali mice exhibited a significant reduction of pulmonary vascular permeability and improved the lung histopathology and had additional anti-inflammatory effects. in contrast, there were less lung engraftment in msc-shat r-injected ali mice compared with msc-shcontrol after transplantation. thus, msc-shat r-injected group exhibited a significant increase of pulmonary vascular permeability and resulted in a deteriorative lung inflammation. conclusions: our results demonstrate that overexpression of at r enhance the migration and lung engraftment of mscs in ali mice and may provide a new therapeutic strategy for the injured lung. introduction: reorganization of endothelial barrier complex is critical for increased endothelial permeability implicated in the pathogenesis of acute respiratory distress syndrome. we have previously shown hepatocyte growth factor (hgf) reduced lipopolysaccharide (lps)-induced endothelial barrier dysfunction. however, the mechanism of hgf in endothelial barrier regulation remains to be unclear. methods: recombinant murine hgf with or without mtor inhibitor rapamycin were introduced on mouse pulmonary microvascular endothelial cells (pmvecs) barrier dysfunction stimulated by lps. then, endothelial permeability, adherent junction protein (occludin), endothelial injury factors (endothelin- and von willebrand factor), cell proliferation and mtor signaling associated proteins were tested. results: our study demonstrated that hgf decreased lps-induced endothelial permeability and endothelial cell injury factors, and attenuated occludin expression, cell proliferation and mtor pathway activation. conclusions: our findings highlight activation akt/mtor/stat- pathway provides novel mechanistic insights into hgf protective regulation of lps-induced endothelial permeability dysfunction. introduction: mechanical ventilation (mv) is a life-saving intervention for critically ill patients, but may also exacerbate pre-existing lung injury, a process termed ventilator-induced lung injury (vili). interestingly, we fig. (abstract p ) . fluorescein isothiocyanate-dextran or fluorescein isothiocyanate-bsa analysis of the effect of hgf on pmvecs permeability fig. (abstract p ) . western blot analysis of hgf on mtor signaling pathway discovered that the severity of vili is modulated by the circadian rhythm (cr). in this study, we are exploring the role of the myeloid bmal , a core clock component, in vili. methods: we employed mice lacking bmal in myeloid cells (lyzmcre-bmal -/-) and lyzmcre mice as controls. at circadian time (ct) or ct , mice were subjected to high tidal volume mv to induce vili. lung compliance, pulmonary permeability, neutrophil recruitment, and markers of pulmonary inflammation were analyzed to quantify vili. to assess neutrophil inflammatory responses in vitro, myeloid cells from bone marrow of wt and bmal -deficient animals were isolated at dawn zt (zeitgeber time ) and dusk (zt ), incubated with dcfh-da and stimulated for min with pma or pbs. neutrophil activation (ly g/cd b expression) and ros production (dcfh-da/ly g+ cells) were quantified. results: injurious ventilation of control mice at ct led to a significant worsening of oxygenation, decrease of pulmonary compliance, and increased mortality compared to ct . lyzmcre-bmal -/-mice did not exhibit any significant differences when subjected to mv at ct or ct . mortality in lyzmcre-bmal -/-mice after vili was significantly reduced compared to lyzmcre controls (ct ). neutrophils isolated from control mice at zt showed a significantly higher level of activation and increased ros production after pma-stimulation compared to zt . ros production of lyzmcre-bmal -/-neutrophils did not differ from zt to zt . conclusions: the lack of the clock gene bmal in myeloid cells leads to increased survival after injurious ventilation and to loss of circadian variations in neutrophil ros production. this suggests that the internal clock in myeloid cells is an important modulator of vili severity. introduction: hemodynamic resuscitation by means of fluids and norepinephrine (ne) is currently considered as a cornerstone of the initial treatment of septic shock. however, there is growing concern about the side effects of this treatment. the aim of this study was to assess the relationship between the hemodynamic resuscitation and the development of the ards. methods: new zealand rabbits. animals received placebo (sham= ) or lipopolysaccharide (lps) with or without (edx-r, n= ; edx-nr, n= ) hemodynamic resuscitation (fluids: ml/kg of ringer's lactate; and later ne infusion titrated up to achieve theirs initial arterial pressure). animals were monitored with an indwelling arterial catheter and an esophageal doppler. respiratory mechanics were continuously monitored from a sidestream spirometry. pulmonary edema was analyzed by the ratio between lung wet and lung dry weight (w/d), and the histopathological findings. results: sham group did not show any hemodynamic or respiratory changes. the administration of the lps aimed at increasing cardiac output and arterial hypotension. in the lps-nr group, animals remained hypotensive until the end of experiment. infusion of fluids in lps-r group increased cardiac output without changing arterial blood pressure, while the norepinephrine reversed arterial hypotension. compared to the lps-nr group, the lps-r group had more alveolar neutrophils and pneumocytes with atypical nuclei, thicker alveolar wall, non-aerated pulmonary areas and less lymphocyte infiltrating the interstitial tissue. in addition, the airway pressure increased more in the group lps-r, and the w/d, although slightly higher in the lps-r, did not show significant differences. conclusions: in this model of experimental septic shock resuscitation with fluid bolus and norepinephrine increased cardiac output and normalized blood pressure but worsened lung damage. obese patients have been excluded from most of the clinical trials testing the effects of peep in ards. we hypothesized that in morbidly obese patients the massive load of the abdomen/chest further increases lung collapse thus aggravating the severity of respiratory failure due to ards. methods: we performed a clinical crossover study to investigate the contribution of lung collapse to the severity of respiratory failure in ards obese patients and to determine the specific contribution of titrated peep levels and lung recruitment to changes in lung morphology, mechanics and gas exchange. patients were studied at the peep (peepicu) levels selected at our institution and at peep levels establishing a positive end-expiratory transpulmonary pressure (peepinc) and at peep levels determining the lowest lung elastance during a decremental peep (peepdec) trial following rm. results: thirteen patients were studied. at peepicu end-expiratory transpulmonary pressure was negative, lung elastance was increased and hypoxemia was present (table ) . regardless the titration technique there was no difference in the peep level obtained. at peepinc level endexpiratory lung volume increased, lung elastance decreased thus improving oxygenation. setting peep according to a peepdec trial after a rm further improved lung elastance and oxygenation. at peedec level after a rm lung collapse and overdistension were minimized (fig. ) . all patients maintained titrated peep levels up to hours without complications. conclusions: in severely obese patients with ards, setting peep according to a peepinc trial or peepdec trial following a rm identifies the same level of optimal peep. the improvement of lung mechanics, lung morphology and oxygenation at peepdec after a rm suggests that lungs of obese ards patients are highly recruitable and benefit from a rm and high peep strategy. introduction: lung protective ventilation (lpv) strategies, principally focused around the use of tidal volumes < ml/kg predicted body weight (pbw) remains an enduring standard of care for ventilated patients. however, implementation of and compliance with lpv is highly variable. we used 'nudge'-based interventions to assess if these can improve lpv. methods: ventilation data analysis over years ( hours in patients) showed patients had been ventilated with a median tidal volume of . ml/kg pbw with a significant proportion receiving over ml/kg pbw (fig. ) , an effect more pronounced in female patients and those with higher bmi. interventions: ) creation of a software tool to easily identify and monitor patients receiving tidal volumes that were too high for their pbw ) attached laminated reference guides to each ventilator to calculate pbw ) presentation, opportunistic education and verbal prompts to relevant clinical care staff regarding importance of lpv and use of pbw rather than actual body weight ) incorporating checking of tidal volumes on a daily ward rounds from junior clinical members results: we collected hourly ventilation data of the patients over a -week period ( hours in patients) following our interventions. there was, overall a statistically significant reduction tidal volume (p< . ). there was improvement in the ventilation of male patients (p< . ) but female patients endured higher tidal volumes. there was a mixed picture in different bmi grades. conclusions: reducing tidal volumes in mechanically ventilated patients can be done through a mix of behavioural and educational interventions, as well as using technological shortcuts. this helps to reduce the effort on the part of clinical staff to adhere to best practices, and ultimately improve patient outcomes. introduction: lung protective ventilation (lpv) using a tidal volume (vt) of - ml/kg ideal body weight (ibw) is recommended in the intensive care unit and theatres to reduce the incidence of pulmonary complications. the aim of this audit was to assess the extent to which lpv is used in theatres in a busy district general hospital and to implement measures to promote adherence to the recommendations. methods: anaesthetists completed questionnaires for all patients undergoing general anaesthesia at northwick park hospital over week. demographics, actual body weight (abw), height, american society of anesthesiologists (asa) score, and procedural information were recorded. ventilatory parameters included the ventilation mode, vt, and positive end expiratory pressure (peep (fig. ) . significantly more females ( %) received vt >= ml/kg than males ( %) (p< . ) (fig. ) . vt was independent of age, asa, bmi, ventilation mode, speciality, and patient position. conclusions: over half of the patients received vt >= ml/kg ibw. females were more likely to be over ventilated. a likely contributing factor is the disparity between abw and ibw in this cohort. we organised staff teaching and constructed ibw charts with the appropriate corresponding tidal volumes to be displayed in all theatres to promote the use of lpv. results: there were significant differences in ards incidence between groups: ards developed in . % of protective mv groups vs. . % of standard mv group (p= . , fisher's exact test). vap patients ventilated in a protective mode presented with lower duration of mv ( . ± . days) and icu stay( . ± . days) than patients with standard mv ( . ± . and . ± . days). there were significant differences in mortality rates between patient groups: . % in protective mv and . % in standard mv (p= . , fisher's exact test). conclusions: protective mv prevents the development of ards in vap septic patients. introduction: reduction of tidal volumes (tv) below ml/kg associated with low driving pressure (dp) might improve lung protection in patients with acute respiratory distress syndrome (ards). the current study tests the combination of coaxial double lumen endotracheal tube (to reduce instrumental dead-space) and moderately respiratory rate (rr) (< bpm) to maintain co at clinically acceptable levels while using ultraprotective tv. the objective is to considerably reduce dp, which has been preconized as an index more strongly associated with survival than tv, per se, methods: juvenile pigs were anesthetized, intubated and mechanically ventilated. severe lung injury (p/f< ) was induced using a double-hit model: repeated surfactant wash-out followed by injurious mechanical ventilation using low positive end-expiratory pressure and high dp (~ cmh o) for hours. then vts of , , and ml/kg were used in random sequence for min each, both using a standard and coaxial endotracheal tube. at each vt level, rr was adjusted to achieve paco = mmhg but not exceeding bpm. lung functional parameters and blood gas analysis were measured at each vt level. statistical analysis was performed using mixed linear model. results: coaxial endotracheal tube, but not the conventional tube, allowed decreasing vt to and ml/kg, while keeping paco at approximately mmhg and rr< bpm, reducing dp of . cmh o and . cmh o, respectively, compared to the conventional vt of ml/kg (fig. ) . conclusions: in this ards model, coaxial tube ventilation associated with moderately high rr allowed ultraprotective ventilation (vt= ml/kg) and reduced dp levels, maintaining paco at acceptable levels. this strategy might have a significant impact on mortality of severe ards patients. the table shows oxygenation and respiratory mechanics. figure : echocardiographically measured right heart function. conclusions: in morbidly obese mechanically ventilated patients with ards an increase in peep by cmh o (from . ± . cmh o to . ± . cmh o) did not impair right heart function, but improved respiratory mechanics and oxygenation. introduction: mechanical ventilation can, while being lifesaving, also cause injury to the lungs. the lung injury is caused by high pressures and mechanical forces but also by inflammatory processes which are not fully understood [ ] . heparin binding protein (hbp) released by activated granulocytes has been indicated as a possible mediator of increased vascular permeability in the lung injury associated with trauma and sepsis [ , ] . we wanted to investigate if hbp levels were increased in bronco alveolar lavage (bal) fluid or plasma in a pig model of ventilator induced lung injury. methods: anaesthetized pigs were surfactant depleted by saline lavage and randomized to receive ventilation with either tidal volumes of ml/kg with a peep of cm h o (controls, n= ) or ml/kg with a peep of cm h o (ventilator induced lung injury (vili) group, n= ). plasma and bal samples of hbp were taken at , , , and hours (fig. ) . results: characteristics of pigs by study group are shown in table . plasma levels of hbp did not differ significantly between pigs in the control and vili group at any time of sampling. hbp levels in bal fluid were significantly higher in the vili group after (p= . ), (p= . ), (p< . ) and (p= . ) hours of ventilation (fig. ) . conclusions: in a model of ventilator induced lung injury in pigs, levels of heparin binding protein in bal fluid increased significantly over time compared to controls. plasma levels however did not differ significantly between groups. (fig. ) . conclusions: this meta-analysis concluded that corticosteroid treatment in ards provided no benefit in decreasing mortality. in addition, this treatment was not associated with increasing risk of nosocomial infection. (fig. ) . the change in the pao /fio ratio was significant [rr( %ci)= . ( . - . ), p= . ] (fig. ) . finally, trial sequential analysis and grade indicated lack of firm evidence for a beneficial effect. conclusions: surfactant administration may improve oxygenation but has not been shown to improve mortality for adult ards patients. large rigorous randomized trials are needed to explore the effect of surfactant to adult ards patients. moderate to severe acute respiratory distress syndrome in a population of primarily non-sedated patients, an observational cohort study l bentsen, t strøm, p introduction: extracorporeal carbon-dioxide removal (ecco r) might allow ultraprotective mechanical ventilation with lower tidal volume (vt) (< ml/kg predicted body weight), plateau (pplat) (< cmh o) and driving pressures to limit ventilator-induced lung injury. this study was undertaken to assess the feasibility and safety of ecco r managed with a renal replacement therapy (rrt) platform to enable ultraprotective ventilation of patients with mild-to-moderate ards. methods: patients with mild (n= ) or moderate (n= ) ards were included. vt was gradually lowered from to , . and ml/kg, and peep adjusted to reach <=pplat<= cm h o. stand-alone ecco r (prismalung, no hemofilter associated with the rrt platform) was initiated when arterial paco increased by > % from its initial value. ventilation parameters (vt, rr, peep), respiratory system compliance, pplat and driving pressure, arterial blood gases, and ecco r-system characteristics were collected during at least hours of ultraprotective ventilation. complications, day- mortality, need for adjuvant therapies, and data on weaning off ecco r and mechanical ventilation were also recorded. results: while vt was reduced from to ml/kg and pplat kept < cmh o, peep was significantly increased from . ± . at baseline to . ± . cm h o, and the driving pressure was significantly reduced from . ± . to . ± . cm h o (both p< . ). the pao / fio ratio and respiratory-system compliance were not modified after vt reduction. mild respiratory acidosis occurred, with mean ph decreasing from . ± . to . ± . from baseline to -ml/kg vt. mean extracorporeal blood flow, sweep-gas flow and co removal were ± ml/min, ± . l/min and ± ml/min, respectively. mean treatment duration was ± hours. day- mortality was %. introduction: there is no consensus on the management of anticoagulation during extracorporeal membrane oxygenation (ecmo). ecmo is currently burdened by a high rate of hemostatic complications, possibly associated with inadequate monitoring of heparin anticoagulation. this study aims to assess the safety and feasibility of an anticoagulation protocol for patients undergoing ecmo based on thromboelastography (teg) as opposed to an activated partial thromboplastin time (aptt)-based protocol. methods: we performed a multicenter, randomized, controlled trial in two academic tertiary care centers. adult patients with acute respiratory failure treated with veno-venous ecmo were randomized to manage heparin anticoagulation using a teg-based protocol (target - minutes of the r parameter, teg group), or a standard of care aptt-based protocol (target . - of aptt ratio, aptt group). primary outcomes were safety and feasibility of the study protocol. results: forty-two patients were enrolled, were randomized to the teg group and to the aptt group. duration of ecmo was similar in the two groups ( ( - ) days in the teg group and ( - ) days in the aptt group, p= . ). heparin dosing was lower in the teg group compared to the aptt group ( . ( . - . ) iu/kg/h versus . ( . - . ) iu/kg/h respectively, p= . ). safety parameters, assessed as number of hemorrhagic or thrombotic events and transfusions given, were not different between the two study groups. as for the feasibility, the teg-based protocol triggered heparin infusion rate adjustments more frequently (p< . ) and results were less frequently in the target range compared to the aptt-based protocol (p< . ). number of prescribed teg or aptt controls (according to study groups) and protocol violations were not different between the study groups. conclusions: teg can be safely used to guide anticoagulation management during ecmo. its use was associated with the administration of lower heparin doses compared to a standard of care apttbased protocol. methods: single-center retrospective study of patients (n= ; ± . years; % males) undergoing vv-ecmo for severe ards. the acp-score ( - ) was calculated immediately before ecmo initiation and at ecmo-day , -day and -day , as follows: pneumonia as cause of ards - point; driving pressure >= cmh o - point; pao /fio ratio < mmhg - point; paco >= mmhg - point. results: longer duration of mechanical ventilation before vv-ecmo was associated with higher acp-scores. patients with higher acp-scores before vv-ecmo also presented longer total duration of mechanical ventilation and hospital stay. after vv-ecmo initiation, acp-scores significantly decreased from . ± . to . ± . , . ± . and . ± . at ecmo-day , -day and -day , respectively. at ecmo-day , patients with higher acp-scores ( - ) presented increased hospital mortality when compared with patients with lower acp-scores ( - ): . vs. . %, respectively (p= . ). at ecmo-day , high driving pressures and low pao /fio ratios were the acp-score determinants that significantly associated with increased hospital mortality. conclusions: in severe ards, vv-ecmo support allowed a significant and sustained acp-score reduction in most patients. this was achieved by artificial lung correction of low pao /fio , hypercapnia and elevated driving pressures. after an initial period of vv-ecmo support, patients with higher acp-scores present higher mortality rates. our results suggest that on-going adjustment of ecmo and ventilation parameters is necessary to maximize outcome. introduction: we sought to use mechanical power to describe "lung rest" in patients with acute respiratory distress syndrome (ards) supported with extracorporeal membrane oxygenation (ecmo). mechanical power describes work done by the ventilator on the patient's respiratory system over time. this concept unifies tidal volume, rate, and total pressure delivered during the ventilatory cycle into a discrete value that may be useful to guide ventilatory support. we hypothesized that initiation of ecmo led to decreased mechanical power delivered to the patient. methods: we reviewed the charts of the three medical intensive care unit patients at our institution supported with ecmo for severe ards. we collected data on plateau pressure, driving pressure, and mechanical power before initiating ecmo, then at < hours, hours, and hours after. we calculated the mechanical power delivered by the ventilator to the patient in joules per minute as . x respiratory rate x tidal volume x (peak pressure -½ x driving pressure) [ ] . results: all patients were alive at discharge and at days. mean pao /fio at ecmo initiation was ± , mean plateau pressure was ± cm water. all patients received neuromuscular blockade at initiation of ecmo. following ecmo initiation, mechanical power decreased by an average of %± % initially, by %± % at hours, and by %± % at hours (fig. ) . by comparison, driving pressure changed by an average value of - . ± . , - . ± . , and - . ± . cm water over those same intervals. average plateau pressure changed by - . ± . , - . ± . , and - . ± . cm water during the same time period (fig. ) . conclusions: in our limited case series, mechanical power decreased significantly following initiation of ecmo in patients with severe ards. we suggest mechanical power may be more useful than changes in driving pressure or plateau pressure when pursuing "lung rest" during ecmo. introduction: it is not clear whether acute respiratory distress syndrome (ards) is independently associated with mortality after controlling for underlying risk factor and baseline severity of illness. we attempted to assess the attributable mortality of ards by performing a systematic review and meta-analysis. methods: we systematically searched pubmed, embase, scopus and reference lists to identify observational studies reporting mortality rates of critically ill patients with and without ards. all included studies were matched for underlying risk factor. primary outcomes were all-cause in hospital-mortality and short-term mortality (combined day-mortality and intensive care unit-mortality). we calculated pooled risk ratios (rr) and % confidence intervals (ci) with a random-effects model. our meta-analysis was registered with prospero. results: of the initially retrieved articles, studies ( cohorts) involving patients were included. the underlying risk factor was sepsis, trauma and other in , and cohorts, respectively. in-hospital mortality was higher in patients with versus without ards ( cohorts; patients; rr . , % ci . - . ; p< . ). we saw a numerically stronger association between ards and inhospital mortality in trauma (rr . , % ci . - . ; p< . ) than sepsis (rr . , % ci . - . ; p= . ). short-term mortality was higher in patients with versus without ards ( cohorts; patients; rr . , % ci . - . ; p= . ). ards was independently associated with mortality in approximately half of the cohorts which controlled for baseline severity of illness using a multivariable analysis. conclusions: the accumulated evidence suggests that ards is independently associated with mortality after controlling for underlying risk factor; the association is stronger for trauma than septic patients. evidence is mixed as to whether ards is independently associated with mortality after controlling for baseline severity of illness. introduction: evidence is mixed as to whether acute respiratory distress syndrome (ards) is independently associated with mortality after controlling for baseline severity of illness, particularly in patients with sepsis. methods: this was an observational study comparing mortality rates of septic patients with and without ards. subjects for the present study were enrolled in ongoing prospective cohorts of critically ill patients hospitalized in medical intensive care unit (icu) in the united states or south korea. ards was defined using the berlin definition for cases after and the american-european consensus conference definition for cases before . sepsis was defined using the sepsis- definition. baseline severity of illness was assessed using a modified sequential organ failure assessment (sofa) after exclusion of the respiratory component. the primary outcome was inhospital mortality. results: of the critically ill patients enrolled in the cohorts, ( . %) had sepsis and comprised the population of the present study. of the septic patients, ( . %) had ards. patients with versus without ards had higher sofa score; both total (median vs ; p< . ) and modified ( vs ; p< . ). the unadjusted mortality of septic patients with ards was higher than septic patients without ards ( . % vs . %; p< . ). after controlling for baseline modified sofa score, both moderate and severe ards remained significant predictors for in-hospital mortality [odds ratio (or) . ; % confidence intervals (ci) . - . ; p< . and or . ; % ci . - . ; p< . , respectively]. in contrast, after controlling for baseline modified sofa score, mild ards was not associated with in-hospital mortality (or . ; % ci . - . ; p= . ). conclusions: among critically ill patients with sepsis, moderate and severe, but not mild, ards are associated with mortality after controlling for baseline severity of illness. a multicenter study on the inter-rater reliability of heart score among emergency physicians from three italian emergency departments introduction: previous studies suggested that the heart (based on history, ecg, age, risk factors, troponin) score could be a valid tool to manage the patients with chest pain at the emergency department (fig. ). our hypothesis was that there could be heterogeneity in the assignment, because of the history and ecg parameters. for this reason, our objective was to test the heart reliability. there are no published studies on this topic. methods: this is a multicenter retrospective study conducted in italian eds between march and october using clinical scenarios. twenty emergency physicians were included, provided that they had undergone a course on heart score. we used scenarios from a medical database with each scenario including demographic and clinical characteristics. each participant assigned scores to the scenarios using the heart. we tested the measure of interrater agreement using the kappa-statistic, the confidence intervals are bias corrected. a p-value of < . was used to define statistical significance. results: the participants' assignment is shown in fig. . the overall inter-rater reliability was good: kappa = . (ci %; . - . ); with a good agreement between the low and high class of risk but a moderate reliability in the medium class: kappa= . , . and . . we have not found differences of inter-rater reliability among the senior (more than yrs in ed) and junior physicians: kappa= . (ci %; . - . ) and . (ci %; . - - ).the heart score showed the worse value of inter-rater reliability in the history and ecg parameters : k inter = . (ci %; . - . ) and . (ci %; . - . ). conclusions: the heart showed a good inter-rater reliability but a fair agreement in the history parameter. the clinical experience doesn't influence the agreement in the assignment. the main limit of this study lies in using scenarios rather than real patients. introduction: the aim of the experiment was to study the efficacy of preconditioning, based on changes in inspiratory oxygen fraction on endothelial function in a model of myocardial ischemia/reperfusion injury in conditions of cardiopulmonary bypass (cpb). methods: the prospective study included rabbits divided into four equal groups: hypoxic preconditioning; hyperoxic preconditioning (hyperp); hypoxic-hyperoxic preconditioning (hhp); control group. animals were anesthetized and mechanically ventilated. we provided preconditioning, then started cpb, and then induced acute myocardial infarction by ligation of left anterior descending artery. after minutes of ischemia we performed minutes of reperfusion. we investigated endothelial function markers (endothelin- (et- ), asimmetric dimethylarginine (adma), nitric oxide metabolites) at stages before ischemia (after preconditioning in study groups), after ischemia and after reperfusion. results: the level of et- after the stage of ischemia increased in all groups, a significant difference was between hhp and control group (p= . ), then et- increased even more after the stage of reperfusion (p= . hhp vs control group). the concentration of nitrite decreased after the stages of ischemia and reperfusion in comparison with the baseline in all groups. however, the level of nitrite after all types of preconditioning was higher than in the control group (p= . ; . ; . ). the total concentration of nitric oxide metabolites in the study groups was higher than in the control group: before ischemia (after preconditioning) p= . ; after ischemia p= . ; after reperfusion, p= . . concentration of adma was lower in the hhp comparing with the control group at the stages after ischemia (p= . ) and after reperfusion (p= . ). conclusions: hyperp and hhp maintain endothelial function: the balance of nitric oxide metabolites and the reduction of et- hyperproduction in a model of myocardial ischemia/reperfusion injury in conditions of cpb. upscaling hemodynamic and brain monitoring during major cancer surgery: a before-after comparison study introduction: hemodynamic and brain monitoring are used in many high-risk surgical patients without well-defined indications and objectives. in order to rationalize both hemodynamic and anesthesia management, we implemented monitoring guidelines for patients undergoing major cancer surgery. methods: early , and for all eligible patients, we started to recommend (standard operating procedure, sop) cardiac output, central venous oxygen saturation, and depth of anesthesia monitoring with specific targets (map > mmhg, svv < %, ci > . l/min/ m , scvo > %, < bis < ). eligibility criteria were pelvic or abdominal cancer surgery expected to last > hours in adult patients. pre-, intra-, and post-operative data were collected from our electronic medical record (emr) database and compared before (from march to august ) and after (from march to august ) the sop implementation. results: a total of patients were studied, before and after the sop implementation. the two groups were comparable in terms of age, asa score, duration and type of surgery, the surgical possum score was higher after than before ( vs , p= . ). the use of cardiac output, scvo and bis monitoring increased from to %, to %, and to %, respectively (all p values < . ). intraoperative fluid volumes decreased ( . vs . ml/kg/h, p= . ), whereas the use of inotropes increased ( vs %, p= . ). the rate of postoperative delirium ( vs %, p= . ) and urinary track infection ( vs %, p= . ) decreased, as well as the median hospital length of stay ( . vs . days, p= . ). conclusions: in patients undergoing major surgery for cancer, despite an increase in surgical risk, the implementation of guidelines with predefined targets for hemodynamic and brain monitoring was associated with a significant improvement in postoperative outcome. introduction: tissue perfusion and oxygen delivery is low in patients with severe preeclampsia, which would explain multiple organ failure and death in these patients. the aim of this study was to determine the relationship between the base deficit and the risk of adverse maternal and perinatal outcomes. methods: retrospective multicenter cohort study included pregnant patients with severe preeclampsia admitted to six intensive care units at tertiary referral centers during a ten years period in colombia. clinical information was gathered from hospital medical records. the correlation of base deficit with adverse maternal outcomes was evaluated using logistic regression analysis. outcomes were maternal death, acute kidney injury, hellp syndrome, transfusion, eclampsia and extreme neonatal morbidity. results: patients were included in the study, we found a total of ( , %) maternal deaths, the median calculated base deficit obtained was - . meq/l. patients with base deficit greater than - . meq/l had significantly higher mortality rates or . (ci . - . ) p , . this group of patients was also associated with a higher probability of developing a class hellp syndrome or . (ci . - . ) p , . a more mild alteration in the base deficit (greater than - . meq/l) was related to the appearance of kidney injury or . (ci . - . ) p . y complete hellp or . (ci . - . ) p . . conclusions: base deficit is related to worse outcomes in patients with severe preeclampsia. according to our results, a cut-off point greater than - meq/l, there is a higher risk of death and worse outcomes such as class hellp syndrome. comparison of two different laser speckle contrast imaging devices to assess skin microcirculatory blood flow g guven, y ince, oi soliman, s akin, c ince erasmus mc, university medical center rotterdam, rotterdam, netherlands critical care , (suppl ):p introduction: laser speckle contrast imaging (lsci) is a common, non-contact and practical method used to assess blood flow of tissue surfaces. we have lack of knowledge about comparability of different lsci devices due to the arbitrary units (au) used to define blood flux. we sought to examine the linearity between skin blood flux, recorded using two different lsci devices. methods: we performed post-occlusive reactive hyperemia test (porh) on the arm and measured blood flux on the hand using two different lsci devices (moor instruments, devon, uk and perimed ab, järfälla, sweden). all volunteers were measured at baseline, during occlusion and after release of occlusion during the hyperemia phase. the third finger and fourth finger nail were selected for recording blood flux and au were used to express values. results: fifteen healthy, non-smoker male volunteers participated in this study. an excellent correlation was found between the two lsci devices (finger: r : . , p< . & finger nail: r : . , p< . ). data were also assessed in terms of the variability at different stages of the porh test (fig. a-d) . correlation of devices was still high at baseline, first minute of occlusion and in the post-occlusion hyperemia phase. however, in the period between minute after start of the occlusion and the beginning of the hyperemia, correlation was lower for the whole finger (r : . , p= . ) and correlation was lost for fingernail (r : . , p= . ) between the two devices. conclusions: skin blood flux measured with two different lsci devices are linearly correlated with each other. however care should be taken when assessing patients with low blood flux such as occurs during shock and ischemic organs. introduction: the aim of this study was to evaluate the effects of hyperoxia and mild hypoxia on microcirculatory perfusion in a rat model. methods: spontaneously breathing anesthetized (isoflurane) male wistar rats (n= ) were equipped with arterial (left carotid) and venous (right jugular) cannulae and tracheotomy. rats were randomized in groups: normoxiainspired oxygen fraction (fio ) of . ; hyperoxia -fio ; mild hypoxia -fio . . the following measurements were taken hourly for hours: blood gases, mean arterial pressure (map), stroke volume index (svi) and heart rate (echocardiography), skeletal muscle microvascular density (sidestream dark field videomicroscopy). results: at hour, arterial o tension was ± mmhg in normoxia, ± mmhg in hyperoxia, ± mmhg in mild hypoxia (p< . ). hyperoxia induced an increase in map (from ± to ± mmhg at h, p< . ) and a decrease in svi (from . ± . to . ± . ml/kg at h, p< . ), while in mild hypoxia map tended to decrease and svi tended to increase (p> . ). microvascular density decreased in hyperoxia and increased in mild hypoxia (fig. ) . conclusions: in anesthetized rats, microvascular density decreased with hyperoxia and increased with mild hypoxia. introduction: the imbalance between oxygen (o ) delivery and o requirement in patients with sepsis can be assessed by central venous oxygen saturation (scvo ). the low or high scvo may indicate cellular hypoxia or inability to utilize the o . this study aims to determine the relationship between high scvo and mortality in patients with sepsis. methods: a retrospective observational cohort study was done by collecting data (i.e., baseline characteristics, severity of infection and vasopressors) from medical records of >= -year-old patients with sepsis and st scvo measurement within hours of sepsis, who were admitted in a university hospital between and . the patients were stratified by st scvo level (< %, - %, > %) and apache-ii score (<= , > ). the primary outcome was inhospital mortality. results: among patients, those with high scvo ( . %) and low scvo ( . %) were associated with adjusted hazard ratios for death of . ( . - . , p= . ) and . ( . - . , p= . ), respectively, while those with normal scvo ( . %) as control. when the patients were stratified by scvo level and apache-ii score, using patients with normal scvo and low apache-ii score as control, those with high scvo and low apache-ii score, and those with low scvo and low apache-ii score had adjusted hazard ratios of . ( . - . , p= . ) and . ( . - . , p= . ). for those with normal, high and low scvo , and high apache-ii score had adjusted hazard ratios of . ( . - . , p= . ), . ( . - . , p= . ), and . ( . - . , p= . ), respectively. conclusions: the scvo > % with apache-ii score > , but not only scvo > %, is independently related to increased mortality in patients with sepsis. introduction: serum lactic acid levels and scvo are useful predictive parameters for patients with sepsis. however, little is known the differences in the impact of lactate levels and scvo on the prognosis of septic patients. in this study, we investigated these differences by analysing septic patients' characteristics and prognosis. methods: this study is a post hoc analysis of data obtained from a multicentre, prospective, randomized controlled trial, which compared two fluid management strategies for septic patients requiring mechanical ventilation. we categorised patients into the following four groups: scvo >= % and lactic acid levels < mmol/l (hh group); scvo >= % and lactic acid levels < mmol/l (hl group); scvo < % and lactic acid levels >= mmol/l (lh group) and scvo < % and lactic acid levels < mmol/l (ll group). sofa score, saps ii score, lactic acid levels, scvo and bnp were evaluated. primary outcome was -day mortality, whereas secondary outcomes were the duration of mechanical ventilation, administration of crrt, duration of catecholamine therapy and length of icu stay. results: in total, patients were included: hh group (n = ), hl group (n = ), lh group (n = ) and ll group (n = ). no significant differences were observed in terms of patient characteristics. further, -day mortality was % in the lh group, . % in the hh group, % in the ll group and % in the hl group, and there was no significant difference in terms of mortality among the groups. furthermore, there were no significant differences in terms of secondary outcomes. on multivariate analysis using the hl group as reference, the odds ratios for -day mortality in the lh, hh and ll groups were . ( %ci, . - . ), . ( %ci, . - . ) and . ( %ci, . - . ), respectively. conclusions: because -day mortality was higher in the hh group than in the ll group, serum lactic acid levels may have bigger impact on the prognosis of septic patients. introduction: in septic shock endothelial damage can lead to failure of microcirculation and low microcirculatory oxygen saturation. in the skin this is seen as mottling and can be quantified using hyper fig. (abstract p ) . changes in microvascular density spectral imaging. there is insufficient data about associations between skin oxygenation, severity of illness, biomarkers of endothelial damage and mortality in patients with septic shock. methods: this single centre observational study was performed in consecutive intensive care patients with septic shock. within hours of admission hyper spectral imaging of knee area skin was performed and blood was sampled for assay of biomarkers of endothelial cell damage (plasminogen activator inhibitor - (pai- ), soluble intercellular adhesion molecule (sicam- ), soluble vascular cell adhesion molecule (svcam- ), thrombomodulin, angiopoetin- ). nonlinear fitting of optical density spectra was used to calculate relative skin oxy/deoxy hemoglobin concentration and obtain oxygen saturation. the association between skin oxygen saturation, biomarkers, sepsis severity (apache ii, sofa) and -day mortality was analyzed. results: the median (iqr) age of patients was years ( to ), and % were males. the median sofa and apache ii scores were ( to ) and ( to ) and -day mortality rate was %. patients ( %) had mottling. there was a relationship between skin oxygenation, plasma biomarkers (thrombomodulin and svcam- ) and sepsis severity assessed by sofa and apache ii scores, p < . . using logistic regression analysis, skin oxygenation and biomarker concentrations were not associated with -day mortality rate. conclusions: in our cohort of patients with septic shock, skin oxygenation and biomarkers of endothelial injury were strongly associated with initial severity of sepsis but poorly predictive of -day mortality. comparison between ultrasound guided technique and digital palpation technique for radial artery cannulation in adult patients: a meta-analysis of randomized controlled trials s maitra, s bhattacharjee, d baidya all india institute of medical sciences, new delhi, new delhi, india critical care , (suppl ):p introduction: possible advantages and risks associated with ultrasound guided radial artery cannulation in-comparison to digital palpation guided method in adult patients are not fully known. previous meta-analyses included both adult and pediatric patients and long axis in-plane technique and short axis out of plane technique in the same analysis, which may have incurred biases [ , ] . methods: pubmed and cochrane central register of controlled trials (central) were searched (from to th november ) to identify prospective randomized controlled trials in adult patients where dimensional ultrasound guided radial artery catheterization has been compared with digital palpation guided technique. for continuous variables, a mean difference was computed at the study level, and a weighted standardized mean difference (smd) was computed in order to pool the results across all studies. for binary outcomes, the pooled odds ratio (or) with % confidence interval ( % ci) was calculated using the inverse variance method. results: data of patients from studies have been included in this meta-analysis. overall cannulation success rate was similar between short axis out of plane technique and digital palpation [p= . ; fig. ] and long axis in-plane technique with digital palpation. ultrasound guided long axis in-plane approach and short axis out of plane approach provides better first attempt success rate of radial artery cannulation in comparison to digital palpation [p= . and p= . respectively; fig. ]. no difference was seen in time to cannulate between long axis and short axis technique with palpation technique. conclusions: usg guided radial artery cannulation may increase the first attempt success rate but not the over all cannulation success when compared to digital palpation technique. introduction: ultrasound guidance may improve the success rate of vascular cannulation. there is lack of data regarding the utility of usg guided arterial cannulation in critically ill patients in shock. we aim to compare the impact of using real time ultrasound guidance versus palpation method in achieving arterial catheterization in critically ill patients in hypotension. methods: a single center, prospective, randomized trial was performed among critically ill patients aged > years, with hypotension (or requiring vasopressor infusion) and on not previous cannulated radial arteries. patients were randomized in a ratio of : to the ultrasound group or palpation group. under aseptic precautions, arterial puncture was performed using appropriate sized leader cath (vygon, ecquen, france), under real time usg guidance using short-axis out-of-plane view with bevel down. data were recorded and compared between two groups. the unpaired student's t-test or mann-whitney u test were used for continuous variables, and the uncorrected chi-squared or fisher's exact test were used for proportions. results: a total of patients with hypotensive shock requiring radial artery catheterization were randomized into palpation (n = ) and ultrasound (n = ) groups. first pass success rate was significantly higher in ultrasound group as compared to palpation group ( % vs %, p< . ). cannulation time was significantly shorter in ultrasound group ( . vs . ,p< . ). early complications were significantly higher in palpation group compared to ultrasound group ( . % vs . %, p< . ). conclusions: in critically ill patients with hypotension (or requiring vasopressors), ultrasound guidance improved first pass success rate, shortened the cannulation time and reduced the rate of early complications in radial artery catheterizations. relationship between inferior vena cava diameter and variability with mean arterial pressure and respiratory effort b kalin, k inci, g gursel gazi university school of medicine, ankara, turkey critical care , (suppl ):p introduction: there is no consensus on the use of vena cava inferior (ivc) diameter and variability in the assessment of fluid response (fr) in spontaneously breathing icu patients. influence from respiratory effort, experience requirement and measurement problems are reasons for not being preferred. the aim of the study is to investigate the relationship between ivc diameter, variability and spontaneous breathing effort and hypotension measured by ultrasonography in spontaneously breathing intensive care patients methods: the maximum and minimum diameters of the ivc were measured and the collapsibility index (ci) was calculated. measurements were made in d mode on cineloop recordings. diaphragm thickening ratio was used as a measure of respiratory effort. correlations between respiratory effort criteria with ivc minimum diameter and ci were calculated by pearson's correlation coefficient. ivc measurement criterias, such as inspiratory diameter of < cm, %, %, % of the ci were compared with chi square test in hypotensive and non-hypotensive patients. we took two mean arterial pressure threshold for hypotension as and mmhg for this calculation. results: patients were included in the study. for both hypotensive threshold values, there was no significant difference in the rates of hypotensive and non-hypotensive patients with and without a minimum ivc diameter of cm below. even there was no significant relationship between the ci higher than %, % and % and hypotension (p> . ). in spontaneously breathing patients, a significant correlation was found between respiratory effort and ivc ci and ivc diameter < cm conclusions: at the end of the study, there was a correlation between spontaneous breathing effort ivc diameter and ci in the intubed patients. additionally the result that ivc ci is not different even between hypotensive and non-hypotensive patients suggests that this method should be used with caution in predicting fr. introduction: fluid responsiveness in icu patients can be assessed using changes in pulse rate and blood pressure following administration of a fluid bolus, assisted if necessary by cardiac output (co) monitors such as the lidcoplus. this uses pulse contour analysis to estimate stroke volume (sv), with > % change in sv following a fluid challenge (fc) signifying overall benefit. there is no evidence that the use of co monitoring improves patient outcomes and it is unclear if it improves clinical decision making. methods: a lidcoplus monitor was set up with the screen covered. a ml fc was administered over minutes. the heart rate, systolic and mean arterial pressures were recorded before and after the fc. the clinician administering the fc was asked to decide if the patient was fluid responsive. following this decision, the sv change was revealed and the clinician asked again to assess fluid responsiveness. results: forty-five fluid challenges were studied. use of the lidco changed the decision made on occasions (fig. ) . in three patients ( %), this change in decision was appropriate and either corrected a misinterpretation of the haemodynamic data or represented a patient whose only marker of fluid responsiveness was a sv change. in four patients ( %), the lidco changed the decision inappropriately from a correct interpretation of the haemodynamic data. in six patients ( %) the sv change was ignored when it should have changed the initial decision. in the remaining patients ( %) the decision made with the haemodynamic data was in agreement with the sv change and unchanged by revealing the lidco data. conclusions: the use of lidco monitoring only appropriately changed the decision made with information from basic haemodynamic monitoring in % of patients. this augmentation of decision making was only seen in patients whose basic haemodynamic parameters did not respond to fluid. it changed a correct decision inappropriately in %. overall, no improvement in the assessment of fluid responsiveness was seen. introduction: there are accumulating evidences suggesting that intraoperative blood pressure affects postoperative outcome including myocardial injury, acute kidney injury, stroke, and mortality. in a patient undergoing laryngeal microsurgery (lms), blood pressure usually rises sharply due to the stimulation on the larynx. since pulse transit time (ptt) has been reported to reflect arterial blood pressure fairly well, it has possibility to be a marker for blood pressure which reflects beat-to-beat changes in blood pressure and is less invasive than arterial catheterization. methods: intraoperative noninvasive blood pressure (nibp), electrocardiogram (ecg), and photoplethysmogram (ppg) of patients undergoing lms were recorded simultaneously. ptt was defined as a time interval between the r-wave peak on ecg and the point which the maximal rising slope appears on the ppg. the mean ptt values for one minute before and after the increase in blood pressure due to the stimulation on larynx were compared. parameters of ppg such as width, height, maximal slope, minimal slope, and area were also compared. then, correlation between blood pressure and each variable was calculated. results: as the larynx was stimulated by lms, nibps have surged (systolic blood pressure, . p< . ) significantly in most of the patients. systolic blood pressure and ptt were inversely correlated (r = - . , p < . ). minimum slope of ppg also showed good negative correlation with systolic blood pressure (r = - . , p < . ). conclusions: ppt showed good correlation with systolic blood pressure and may have potential to be used as noninvasive continuous blood pressure monitor during a surgery in which blood pressure changes abruptly. introduction: aim of this prospective randomized pilot study was to investigate influence of intra operative restrictive volume approach and post operative lung ultrasound (lus)on prevention and early detection of postoperative interstitial syndrome development methods: cardiac patients who underwent non cardiac surgical procedure were randomly assigned for: group a-liberal volume approach or for group b-combination of restrictive intra operative volume approach and small dose of norepinephrine. all patients post operatively received <= . ml/kg/h fluids, mostly crystalloids. lus was performed before surgical procedure and hours after their admission in icu together with arterial blood gases measurements. the ultrasound characteristic of interstitial syndrome was development of b profile results: before surgery all patients had a profile. twenty for hours later in a group significantly higher number of patients / ( . %) vs / ( . %) in b group,had b profile (p< . ).at the same time there were no significant difference between the groups in amount of patients with pao /fio ratio <= ( patients with positive b lines from a group vs patients from group b).(p> . ) conclusions: intra operative fluid restriction is efficient in prevention of post operative cardiogenic pulmonary edema development. lus is a simple non invasive method for early detection of interstitial syndrome even before development of signs of respiratory deterioration. introduction: the peak rate of left ventricular (lv) pressure (dp/dtmax) has been classically used as a marker of lv systolic function. since measuring lv dp/dtmax requires lv catheterization, other surrogates have been proposed using the peripheral arterial waveform. the aim of this study was to test the performance of lv and arterial (aortic and femoral) dp/dtmax for assessing lv systolic function against the gold-standard (the slope of the end-systolic pressure-volume relationship, emax) during different cardiac loading and contractile conditions. methods: experimental study in pigs. lv pressure-volume data was obtained with a conductance catheter and peripheral pressures were measured via a fluid-filled catheter into the aortic, femoral, and radial arteries. emax was calculated during a transient occlusion of the inferior vena cava. the experimental protocol consisted in three consecutive stages with two opposite interventions each: changes in afterload (phenylephrine and nitroprusside), preload (bleeding and fluid bolus), and contractility (esmolol and dobutamine) (fig. ) . measurements were obtained before and after each hemodynamic intervention. results: emax variations and lv, aortic, femoral and radial dp/dtmax changes throughout the study are shown in fig. . all peripheral artery-derived dp/dtmax underestimated lv dp/dtmax. percentage changes in lv and femoral ddp/dtmax were tightly correlated (r = . ; p< . ). both lv and femoral dp/dtmax were affected by preload changes during fluid infusion. all peripheral dp/dtmax estimations allow to detect lv systolic function changes according to emax during isolated variations in contractility. conclusions: femoral and lv dp/dtmax accurately reflected emax changes, although both were affected by preload changes during fluid administration. fig. (abstract p ) . emax, lv dp/dtmax and aortic, femoral and radial dp/dtmax changes. (table , fig. ). concordance was < % and radial loa was ±< °for all devices; mean polar bias was < °for ft only (table , fig. ) . conclusions: cs, ft and pa are not interchangeable with tptd, because of inaccuracy [ ] . when considering limitations they may be used for trending. introduction: about years ago, the german physiologist pflüger stated that the cardio-respiratory system fulfils its physiological task by guaranteeing cellular oxygen supply and removing waste products of cellular metabolism. methods: the study was performed in early postoperative period after major abdominal surgery in patients. the physical condition of patients corresponded to class of asa. the median age was . ( . - . ) years. duration of the surgery was , ( , - , ) hours. surgery was performed under combined epidural anesthesia with mechanical ventilation. the study was conducted in the following stages: -admission from operating room; -in - hours; - - hours; - - hours; -after - hours after the surgery. results: depend on rate of oxygen extraction index (ero ) groups were revealed: group (n= )low ero (< %) followed by recovery to normal levels to stage - (ero = - %), group (n= )normal level ero ( %) in all the stages, group (n= )high levels ero (> %) with recovery to normal levels to stage , group (n= )high ero (> %) in all the stages. oxygen extraction index at admission to icu after surgery can be normal ( . % of patients), reduced ( . % of patients) or high ( . % of patients). when oxygen extraction ratio is reduced metabolic recovery occurs classically after - hours; when ero is elevated -after hours. core temperature improvement is connected with the restoration of oxygen homeostasis. so, under normal and reduced ero even mild central hypothermia after surgery were not observed, and at an elevated ero moderate hypothermia after surgery was observed with only to - hours post-surgery restoration. conclusions: maintaining an adequate tissue oxygenation is the cornerstone of metabolic response and postoperative recovery in patient after major abdominal surgery. (fig. ) . patients with cso < %time above %h had an odds ratio of hospital survival of . ( %ci . - . , p= . ) (fig. ) . conclusions: cerebral oxygen desaturation below % was significantly associated with outcome in patients undergoing vaecmo. in patients with cso < %time above h%, prognosis was especially poor. prospective trials are needed to evaluate if cso is a viable target for therapeutic interventions. introduction: during the second consensus meeting on microcirculatory analysis the exploration of novel parameters related to physiological function of the microcirculation was proposed. capillary hematocrit (chct) is a direct measure of capillary hemodilution, a potential mechanism of microcirculatory dysfunction in states of shock. our hypothesis was that by application of advanced computer vision (i) chct can be reliably measured in given capillaries, and (ii) change in chct reflects capillary hemodilution induced by cardiopulmonary bypass (cpb). methods: in patients undergoing coronary artery bypass surgery sublingual capillary microscopy videos were recorded before and during cpb primed with hes / . . per-capillary chct was estimated as the product of the number of red blood cells (rbc) and an assumed volume of nl, divided by the capillary volume including plasma gaps. rbc number was assessed by manual counting in the first frame of a given video clip, as well as using a novel advanced computer vision algorithm employing blob detection to calculate the mean per-capillary rbc number in all frames of a given video clip (fig. ) . results: capillaries were analyzed, within a total of and frames using manual and algorithmic analysis. a good correlation was found between both methods for chct (r= . , p< . , fig. ). cpb initiation resulted in an decrease in chct from (mean±sem) . ± . to . ± . , p< . and . ± . to . ± . , p= . in manual and algorithm. conclusions: accurate measurement of chct is possible using advanced computer vision, and it reflects hemodilution induced by initiation of cpb. chct further is a determinant of capillary delivery of oxygen. combined with the assessment of functional capillary volume, blood flow velocity, and capillary hemoglobin saturation, chct may enable direct optical quantification of capillary delivery of oxygen as an integrated functional parameter of the microcirculation. fig. (abstract p ) . prognosis of patients with cso < %time above %h was poor fig. (abstract p ) . detection of single erythrocytes using a novel advanced computer vision algorithm in a representative capillary ribbon extracted from a video frame of the sublingual microcirculation fig. (abstract p ) . the area under cso < % was significantly lower in survivors introduction: cardiac function is known to be impacted by sepsis. passive leg raise (plr) is an effective method to predict fluid responsiveness (fr) or cardiac response to preload expansion. preload functional status and trending cardiac output may identify patient phenotypes with varying cardiac reserve, dysfunction and outcome. methods: patient data were analyzed from a currently enrolling prospective randomized controlled study, evaluating the incidence of fr in critically ill patients with sepsis or septic shock (fresh study, nct ). patients randomized to plr guided resuscitation were classified as plr+ (fluid responsive/preload dependent) if stroke volume (sv) increased >= % when measured with a non-invasive bioreactance device (starling sv, cheetah medical). patients were categorized into different phenotypic cohorts based on changing physiology exhibited on plr and trending cardiac output over the initial hours of therapy. results: a total of plr assessments were performed in patients. overall, % ( / ) of assessments indicated a patient was plr+ after receiving initial resuscitation fluid of~ l. most patients ( %) demonstrated a dynamic physiology with changing plr status occurring > time over hours. there were no differences among the groups with respect to age, gender, or qsofa score (fig. ) . patients in group exhibited a significantly decreased icu stay ( . hours) compared to group ( . hours, p= . ) (fig. ) . patients in group exhibited significantly increased echo evidence of lv/rv cardiac dysfunction ( %), compared to group ( %, p= . ) ( table ) . patients in group exhibited % evidence of echo based lv/rv cardiac dysfunction. conclusions: physiological based resuscitation phenotypes identify significantly different patient groups. patients who are initially not plr+, but then become plr+ with no improved co are significantly more likely to have confirmed lv/rv dysfunction and a significantly longer icu stay. introduction: accurate measurement of a patient's intravascular volume status remains an unsolved clinical problem in the icu setting. in particular, septic and cardio-renal patients often receive volume challenges or diuresis, respectively, with little appreciation of baseline bv or the resulting response. this can lead to volume overload and/or depletion and associated increases in morbidity, mortality and hospital length of stay. methods: we tested the performance of a novel, rapid, minimally invasive technique capable of measuring pv, bv and glomerular filtration rate (mgfr) in human subjects. the method consists of a single iv injection of a large ( kda) carboxymethyl dextran conjugated to a rhodamine-derived dye and a small ( kda) carboxymethyl dextran conjugated to fluorescein. plasma and blood volumes were quantified minutes following the injection of the dye based on the indicatordilution principle. results: this phase b study included normal subjects, chronic kidney disease (ckd) stage iii and ckd stage iv subjects. pv and bv varied according to weight and body surface area, with pv ranging from to mls, and both were stable for greater than six hours with repeated measurements. there was excellent agreement ( fig. ) with nadler's formula for pv in normal subjects. a hour repeat dose measurement in healthy subjects showed pv variability of less than +/- %. following an intravenous bolus of ml % albumin solution the mean +/-(sd) measured increase in pv was . ml +/- . ml post infusion (fig. ) . conclusions: this novel bedside approach allowed for rapid and accurate determination of pv, bv, mgfr (data not shown) and dynamic monitoring following clinical maneuvers such as fluid administration, with a high level of safety, accuracy and reproducibility. this approach should assist the intensivist especially with volume administration and removal in septic and cardiorenal patients. introduction: accumulating evidence shows that fluid overload is independently associated with adverse outcome in children and adults with acute lung injury. fluid restriction initiated early in the disease process may prove beneficial, potentially by diminishing the formation of interstitial edema. the main goal of this study was to determine the short-term biophysical effects of intravenous (iv) fluid restriction during acute lung injury in relation to age. methods: infant ( - weeks) and adult ( - months) wistar rats were mechanically ventilated (mv) hours after intratracheal inoculation with lipopolysaccharide to model acute lung injury. both age groups were randomized to either a normal or restrictive iv fluid regimen during hours of mv. thereafter the rats were sacrificed and studied for markers of interstitial edema formation (wet-dry weight ratios), lung permeability (total protein and alpha- macroglobulin (a m) in bronchoalveolar lavage; bal) and local inflammation (cell counts and cytokines in bal). results: restrictive fluid therapy was not associated with worsening of hemodynamic indices during the period of mv in either infant or adult rats. however, as compared to the normal fluid regimen, restrictive fluid therapy led to lower wet-dry weight ratios of the lungs and kidneys in adult rats (p < . ), but not in infants (figs. and ). no difference was found in total protein and a m in bal between the two fluid regimens in both age groups. also, neutrophil influx in the lungs did not differ between fluid regimens in both age categories, nor did the influx of inflammatory cytokines il- and mip- in bal fluid. conclusions: there is an age-dependent effect of early fluid restriction on the formation of interstitial edema in local and distant organs in the disease process of acute lung injury. further investigation of the effects of fluid therapies in experimental models may help steering towards better treatment in critically ill patients. . ) . in a multivariate analysis fb was independently associated with: group c (p< . ), a history of diabetes (p= . ), the acute physiology and chronic health evaluation iii score (< . ) and the duration of aortic-cross clamp (p< . ). the main findings of this study substantiated the hypothesis that the introduction of continuous fb-tracking throughout the entire care process, is associated with a significant reduction in the administration of fluids in post-cardiac surgery patients, independent of differences in their baseline characteristics. demonstrating that certain organizational changes can influence medical behavior beyond the scope of teaching and instruction, and therefore serves to provide awareness to the current issue known as 'knowledge-to-care gap'. using a protocol for fluid resuscitation: how well is it followed? introduction: positive fluid balance in icu patients has been correlated with worse outcomes [ ] . consequently, we developed a protocol to guide fluid resuscitation. the protocol was introduced in and mandates that fluid responsiveness is assessed when administering fluid boluses. once a patient becomes fluid unresponsive, no further resuscitation fluid should be administered. to assess responsiveness, the protocol advises the use of haemodynamic data such as heart rate and blood pressure as well as the change in stroke volume (sv) measured by a lidcoplus monitor. after years of use and a rolling education program this protocol was felt to be well ingrained in our unit culture. we then assessed how well it was being followed. methods: staff performing fluid challenges were asked to fill out a form recording the haemodynamic and sv data measured before and after a fluid challenge. they were also asked to record their interpretation of just the haemodynamic data and then this data combined with the sv data. results: forty five forms were completed. the protocol was not followed on occasions ( %). four patients who should have been assessed as responsive were deemed to be unresponsive. six patients who should have been assessed as unresponsive were assessed as being responsive. the remaining deviations from the protocol represent misinterpretation of the haemodynamic data but correct use of the sv data to reach a correct final assessment. conclusions: despite being a longstanding ingrained practice in our icu, this review suggests that the protocol for fluid resuscitation is being followed incorrectly approximately a third of the time. this could result in inappropriate under or over administration of iv fluid. we plan to review the educational programme and raise awareness of the protocol to try and improve future compliance. introduction: understanding the effects of therapeutics on the left ventricular (lv) loading conditions is of utmost importance in critically ill patients. the effective arterial elastance (ea=esp/sv, where esp is aortic end-systolic pressure and sv stroke volume) is a lumped parameter of arterial load that has been proposed as an index of lv afterload. we aimed at comparing the effects of fluid administration on esp (i.e., the lv afterload in the pressure-volume phase-plane according to the classic "cardiocentric" framework) and on ea. methods: in mechanically ventilated patients, we recorded ea from the femoral peripheral systolic arterial pressure sap (ea=( . ×femoral sap)/sv) before and after the infusion of -ml of saline. patients in whom fluid administration induced an increase in cardiac index (picco- ) >= % were defined as "responders". introduction: the respiratory variations of the inferior vena cava (ivc) diameter in mechanically ventilated patients with preload responsiveness could be explain by a higher compliance of the ivc and/or higher respiratory variations of the ivc backward pressure, i.e., the central venous pressure (cvp).we aimed at determining the respective weight of these two phenomena. methods: in mechanically ventilated patients, haemodynamic, respiratory and the intra-abdominal pressure (iap) signals were continuously computerised. cvp, iap and the ivc diameter (transthoracic echocardiography) were recorded during end-inspiratory and endexpiratory occlusions, before and after the infusion of -ml of saline. patients in whom fluid administration induced an increase in cardiac index (picco- ) >= % were defined as "responders". the respiratory variations of the ivc diameter, cvp and iap were calculated as (end-inspiratory -end-expiratory values)/mean value. the compliance of the ivc was estimated by the ratio between (end-expiratoryend-inspiratory) values of ivc diameter and cvp. results: fluid administration increased cardiac index by more than % in patients. the respiratory variations of the ivc diameter predicted fluid responsiveness (area under the roc curve: . ( %ci: . - . ), p< . ). before fluid administration, the compliance of the ivc was not different between responders and non-responders ( . ± . vs. . ± . mm/mmhg, p= . ), whereas the respiratory variations of the cvp were higher in responders than in nonresponders ( ± vs. ± %, p= . ). the respiratory variations of the ivc diameter were associated with the respiratory variations of cvp (r= . , p= . ) but not of iap (r=- . , p= . ). conclusions: the respiratory variations of the ivc diameter rather depend on the respiratory variations of the cvp than on the ivc compliance. the iap seems to not be involved in the respiratory variations of the ivc diameter. hours and gedi measured at the same time was examined. since the dataset used in this study consists of repeated measurement data, the analysis used the general linear mixed effect model (glmm). the multivariate analysis adjusted with age, cr, and cardiac index was also conducted. results: of the patients with the total bnp measurements conducted for times and gedi measurements for times, the median of age and saps were (iqr - ) and (iqr - ), and the hospital mortality rate was %. the univariable analysis and the multivariable analysis using glmm respectively found statistically significant differences, with regression coefficient at . %ci . - . (p= . ), and . %ci . - . (p< . ). conclusions: while a positive correlation between gedi and bnp was statistically identified, its effect may be minor in clinical terms, and its significant clinical difference remains unclear. introduction: fluids are a cornerstone of the management of critically ill patients who are at risk of multiple organ dysfunction syndrome. however positive fluid balance (fb) is associated with worse morbidity and mortality in this population, so fluid administration needs to be carefully titrated and the nutritional support products must be taken in consideration. objective: evaluate the impact of nutritional support in the fluid balance in a intensive care unit methods: observational prospective study, conducted in eleven portuguese icus of nine general hospitals. patients with years of age or older were eligible if they were ventilated and had a length of stay (los) in icu greater than days. demographic data, fluid balance along type of nutritional support used in the first days and were collected from the selected patients. results: patients were enrolled, . % were male, the median age - ± ( - ), icu los - . ± . days, mortality rate of . % ( ). % of patients were admitted for medical reasons, . % had normal weight, the remaining patients were either overweight or obese. the average daily fb in the eight days was ± ml, being the maximum at day with + ml, slowly trending down reaching a neutral balance at day and reaching - ml at day . in the first days the majority of the intake is due to resuscitation driven fluids, however the nutritional support contribution rises as the days passes, reaching % at day and % at day ( fig. ) . regarding the administration route, the enteral route was responsible to , % of fluids at day compared to , % of parenteral route. the nutritional support is an factor to take into account regarding fluid balance in intensive care units. in this study after the th day the nutritional support, it was responsible for more than % of the total volume that was delivered to the patient and with an higher impact with the increase in los results: we included patients with mean age years, % male, apache ± , saps ii ± , sofa in admission ± , mechanical ventilation %, continuous renal replacement techniques %. the mean total volume administered during the first days was ± l with a mean dcb of ± l and a mean fluid accumulation of % ± . regarding fluid accumulation: % have < %, % between - % and . % > %. th-day mortality and icu mortality were % i % respectively. during the first week, the percentage of fluid accumulation was significantly higher in non-survivors than in survivors ( . ± . l vs. . ± . l, p . ) (fig. ) . cumulative survival was significantly lower (logrank = . , p= . ) in patients with > % of volume gain since the th day (fig. ) . > % volume gain in the th day is a independently associated variable to mortality after adjusting by age, apache and haemodialysis (or = . ; ci % . - . ; p = . ) ( table ) . conclusions: in septic shock patients, fluid overload more than % since -day of evolution is associated with a higher th-day mortality. its early detection may influence the prognosis and survival. introduction: sepsis is defined as a life-threatening organ dysfunction due to a deregulated host response to infection [ ] . fluid infusion is one of the cornerstones of sepsis resuscitation therapies. one of the major adverse effects reported is fluid overload (fo). the objective of this study was to assess influence of fo on sofa score changes from day to day . methods: this study is a retrospective, multicenter, epidemiologic data analysis. it was performed in three french icus. all adult patients admitted for septic shock, caused by peritonitis or pneumonia and mechanically ventilated, were enrolled. delta sofa score was defined as the sofa score measured on admission minus sofa score measured on day . results: patients met the inclusion criteria of the study. fo occurs in about % of the patients. cumulative fluid balance at day was greater in the fo group ( . versus . ml, p < . ) ( table ) . delta sofa score was higher in the no fo group than in the fo group ( . versus . , p = . ) (fig. ). there was a stepwise decrease of delta sofa score when duration of fluid overload was greater (p = . ) (fig. ) . in linear modelling, association between fo status and delta sofa score was confirmed with an adjusted rr of . [ . - . ] (p = . ) ( table ) . conclusions: ) fo patients had more prolonged multi-organ failure during septic shock; ) the longer the fo is the longer the more multi-organ failure last. , (t ) and (t ) minutes later. cardiovascular parameters were also measured at above time points. biomarker change from baseline (fold-change), indexed to hemoglobin, was compared between groups using mixed effects models (bonferroni-holm corrected p< . ). results: minor differences in measures of shock between groups after fluid administration resolved by t . cryst showed increased fold-change in hyaluronan compared to other groups at t (fwb p= . , hes p< . , gelo p< . ), t (fwb p< . ) and t (fwb p< . ) (fig. ) . gelo had increased fold-change in hyaluronan compared to other groups at t (hes p= . ), t (fwb p< . ) and t (fwb p< . , cryst p= . ), as did fwb at t (hes p= . ). cryst showed increased fold-change in il compared to other groups at t (hes p< . , gelo p= . ), t (hes p= . , gelo p= . ,), t (hes and gelo p< . ) and t (hes and gelo p< . ) (fig. ) , of il at t (gelo p= . ), and of kc at shock (fwb p= . , gelo p= . ), t (fwb p= . , gelo p= . ), and t (gelo p= . ). conclusions: rapid large-volume crystalloid given for hemorrhagic shock was associated with increased hyaluronan, a biomarker of endothelial glycocalyx damage, and inflammation, including increased il , il and kc. introduction: a bi-center randomized controlled trial has recently been published that investigates the impact of the type of fluid (crystalloid versus colloid) on patient outcome following major surgery [ ] . the study used a closed-loop fluid delivery system to eliminate the clinician bias when determining when to deliver fluids. the goal of the current analysis is to compare the immediate hemodynamic response to ml fluid boluses of either a crystalloid or a colloid solution. methods: patient consent was obtained prior to transferring the data from [ ] to edwards lifesciences for further post-hoc analysis. the percent change in stroke volume (dsv) following each ml bolus was tabulated and cross-referenced to the type of fluid. the responder rate and the dsv cumulative distribution function (cdf) were determined for each type of fluid administered. a responder was defined as a dsv >= % for a ml fluid challenge. the mean dsv was compared between the two groups using a student t-test. results: from the datasets reported in [ ] , were used in the analysis. descriptive statistics are summarized in table and the cdfs are plotted in fig. . more crystalloid boluses were administered. in both groups, the responder rate was around %. mean dsv was not significantly different between groups (p = . ). we observed similar responder rates and cdfs with the two fluid types, suggesting that the immediate hemodynamic response to ml fluid boluses is independent from the fluid type. we therefore hypothesized that it is the longer intra-vascular persistence of the colloid that explain the lower number of boluses required to achieve the hemodynamic endpoints targeted in the clinical study [ ] . fig. (abstract p ) . cumulative distribution functions of delta stroke volume for crystalloid and colloid fluid boluses the reduction projected to an average annual saving of , usd ( introduction: colloids are widely used for volume resuscitation. among synthetic colloids, hydroxyethyl starch (hes) is commonly administered. in cardiac surgery, priming of the cardiopulmonary bypass (cpb) circuit with colloids minimizes resuscitation volume and results in less pulmonary fluid accumulation. however, the use of hes has been associated with a higher incidence of renal damage and a higher occurrence of coagulopathy. the aim of this study was to investigate the effect of low dose ( - ml/kg) hes % ( / , ) in cpb pump priming on fluid balance, blood loss, transfusion requirement and occurrence of acute kidney injury. methods: in a pre-post design, data from patients undergoing cardiac surgery with cpb were analyzed. in patients, priming solution consisted of ml balanced crystalloids, ml mannitol %, tranexamic acid g and i.e. heparin. for the other patients, ml of the crystalloids were replaced with hes % ( / . ), the other components were the same. patients were matched : with propensity score method. the primary endpoint was intraoperative fluid balance. secondary endpoints were perioperative blood loss, transfusion requirement and the occurrence of acute kidney injury. results: in total, patients were analyzed. the hes group showed less positive fluid balance than the crystalloid group (p< . ). there was no difference in intraoperative blood loss (p= . ) and transfusion requirement (p= . ). the occurrence of acute kidney injury was not significantly different between the two groups (p= , ). conclusions: low-dose administration of - ml/kg hes % ( / . ) to cpb pump priming decreased intraoperative fluid accumulation without increasing perioperative blood loss and transfusion requirement. there was no effect on the incidence of acute kidney injury. priming cpb pumps with a low-dose of hes % ( / . ) is an important component for a restrictive volume strategy and might safely be used in patients with preexisting renal dysfunction. introduction: most crystalloid solutions used in critically ill patients have a greater chloride (cl) concentration than plasma, which may be detrimental. replacing some cl with bicarbonate (hc ) reduces cl, but may increase partial pressure of carbon dioxide (pc ) in blood. such an increase in pc may be harmful [ ] . the main objective was to determine if a hco balanced fluid resulted in increased paco compared to a conventional balanced fluid. methods: single center randomized controlled trial in an adult icu, comparing balanced fluid (sodium,na= mmol/l, chloride,cl= mmol/l, hco = mmol/l) vs conventional fluid (na= mmol/l, cl= mmol/l, hc <= mmol/l). university ethics committee approval:m . we used the absolute difference between the pco and mmhg as a comparison for the fluid groups. betweengroup comparisons of pc from d -d was done by repeated measures anova. a p value < . was considered significant. results: patients were allocated to the conventional group and to the balanced group. at baseline the groups were well matched (p> . ) for age, weight, gender, severity of illness and organ support. there were no significant differences in pc between the two fluid groups, overall or at d , d or d . the balanced group showed a significant improvement in egfr (scr), between d and d (p= . ) while the conventional group exhibited a significant decline (p= . ). there were no significant differences between the groups with respect to fluid requirements, number of positive blood cultures, icu renal replacement utilization, icu length of stay, icu mortality and day mortality. conclusions: the use of a balanced fluid did not result in an increase in pco and appears to be safe. a beneficial effect on renal function was observed. introduction: the effects of crystalloids and colloids on macro-and microcirculation is controversial. our aim was to compare their effects on microcirculation during free flap surgery when management was guided by detailed hemodynamic assessment. methods: patients undergoing maxillo-facial tumour resection and free flap reconstruction were randomized into a crystalloid (ringerfundin, rf, n= ) and a colloid ( % hydroxyethyl starch, hes, n= ) groups. cardiac index (ci), stroke volume (svi) and pulse pressure variation (ppv) were continuously monitored by a non-calibrated device (pulsioflex -pulsion, maquet). central venous oxygen saturation (scvo ), venous-to-arterial pco -gap (dco ), lactate levels and hourly urine output was also measured, and a multimodal, individualized approach based algorhithm was applied [ ] . microcirculation was assessed by laser doppler flowmetry (periflux ldpm, perimed jarfalla, sweden). measurements were performed at baseline and from the start of reperfusion hourly for hours. for statistical analysis, two-way rm anova was used. results: there was no difference between the groups regarding age, sex, length of surgery (whole population: ± min). patients in the rf-group required significantly more fluid in total (rf: ± , hes: ± ml, p= . ). both groups remained hemodynamically stable (ci, svi, ppv, scvo , dco , lactate and urine output) throughout the study. there was no difference between the rf-, and hes-groups in the laser doppler measurements neither on the control site nor in the flap (fig. ) . conclusions: we found that when hemodynamic management is guided by a multimodal assessment and stability is maintained, there was no difference between crystalloids and colloids in macrocirculation and microcirculatory perfusion. introduction: our aim is to evaluate the impact of crystalloid fluids on immune cells. intensive care unit (icu) patients' inflammatory status can switch from an early pro-inflammatory to a late anti-inflammatory phase, which favors infections. they can receive different crystalloids, either normal saline (ns), ringer's lactate (rl) or plasma-lyte (pl). high chloride concentration present in ns has been associated with various complications [ ] , whereas high doses of nacl have inflammatory effects on immune cells [ ] . however, the immune consequences of crystalloids in humans are ill-defined. methods: using our comprehensive immunemonitoring platform, we assessed the immunological phenotype of peripheral blood mononuclear cells (pbmc) in humans. healthy subjects received a liter of ns, rl and pl. blood samples were taken before and h later. pbmc phenotypes were assessed by flow cytometry and cytokine concentrations were measured by a multiplex assay. off-pump cardiac surgery patients were also randomized to receive either ns, rl or pl during surgery and their stay in the icu. blood samples were drawn at various time-points. all leucocytes were analyzed in a similar fashion. we are still recruiting. results: study of healthy subject's pbmc suggested that rl reduced classical monocytes, whereas ns increased lymphocyte activation and il- and mip- b levels. in cardiac surgery patients, our preliminary results suggested that rl and pl reduced classical monocytes and increased non-classical monocytes compared to ns. neutrophils were also affected differently by crystalloids, where ns seemed to activate them more. conclusions: our results suggest that crystalloids have different immune consequences. a better understanding of their immune modulation will lead to personalization of their use according to the inflammatory status of patients to restore their immune homeostasis. this randomised controlled open-label pilot study included patients presenting to an emergency department with suspected infection requiring a fluid bolus. patients received either a single bolus of ml/kg of . % nacl (isotonic group) or ml/kg of % nacl (hypertonic group). blood biomarker concentrations of glycocalyx shedding (syndecan- , hyaluronan), endothelial activation (sicam- , svcam- ) and inflammation (interleukin- , - , - , ngal, resistin) were measured at t (before fluid) and hour (t ), hours (t ) and - hours (t ) later. changes in biomarker concentrations were compared between study groups using mixed regression models, with fold-change from t reported. differences in fluid volumes were compared using the wilcoxon rank sum test. significance was set at p< . . results: syndecan- concentration in the isotonic group decreased from t to t (fold-change . , % ci . - . ), which was significantly different to the hypertonic group (fold-change . , % ci . - . )(p= . )( table ) . interleukin- concentration decreased in the isotonic group from t to t (fold-change . , % ci . - . ), which was significantly different to the hypertonic group (fold-change . , % ci . - . )(p= . ). otherwise, there were no significant differences in change over time between groups for measured biomarkers. total fluid volume administered between t and t was significantly higher in the isotonic group (p< . ) ( fig. ) but not different for subsequent time periods. conclusions: biomarkers of glycocalyx shedding, endothelial activation and inflammation were not different between patients receiving either . % or % saline. also, % nacl did not reduce administration of additional fluids. introduction: acute changes in pco are buffered by non-carbonic weak acids (atot), i.e., albumin, phosphates and hemoglobin. aim of the study was to describe acid-base variations induced by in-vitro pco changes in critically ill patients' blood and isolated plasma, compare them with healthy controls and quantify the contribution of different buffers. methods: blood samples were collected from patients admitted to the icu and controls. blood and isolated plasma were tonometered at and % of co in air. electrolytes, ph, blood gases, albumin, hemoglobin and phosphates were measured. the strong ion difference (sid) was calculated [ ] and non-carbonic buffer power was defined as β=-Δhco -/Δph [ ] . t-tests and linear regression were used for analysis. results: seven patients and controls were studied. hemoglobin, hematocrit and albumin were lower in patients (p< . ), while sid and phosphates were similar. pco changed from ± to ± mmhg, causing different blood ph variations in patients and controls ( . ± . vs. . ± . , p= . ). patients had lower blood and plasma β ( ± vs. ± , p< . and ± vs. ± , p= . , respectively). figure shows changes in [hco -] and sid induced in blood by pco variations. in both populations, ± % of [hco -] change was due to sid variations, while only ± % to changes in atot dissociation. a significant correlation between hematocrit and Δsid was observed in the whole study population (fig. ) . conclusions: the β of icu patients was lower, likely due to reduced albumin and hemoglobin concentrations. similar pco increases caused therefore greater ph variations in this population. electrolyte shifts, likely deriving from red blood cells [ ] , were the major buffer system in our in-vitro model of acute respiratory acidosis. introduction: there is an increasing trend in the incidence of aneurysmal subarachnoid haemorrhage in hong kong and the disease carries high morbidity and mortality rate. electrolyte disturbance is one of the known complications of sah and the outcomes associated with this are not fully understood. the objective of this retrospective local study is to evaluate the pattern of electrolyte disturbances in patients with sah and their impact on the prognostic functional outcome. methods: patients with spontaneous aneurysmal sah who were admitted to icu at pamela youde nethersole eastern hospital, hong kong between st january and st december were included into this retrospective local study. collected data include demographic details, comorbidities, serum electrolyte levels (sodium and potassium) from day to of admission into icu, radiographic intensity of haemorrhage using fisher scale and the clinical grading of sah using wfns. prognosis of these patients was estimated using the glasgow outcome scale at months after initial insult (fig. ) . results: a total of patients were included in this study. the mean age was , with the majority of patients being female ( . %). the most common aneurysm location was in anterior communicating artery, though poor outcomes were shown significant in patients with posterior circulation aneurysms. whilst early-onset hyponatremia was not correlated with poor outcome, late-onset hyponatremia was associated with better outcome. logistic regression analysis identified independent predictors of poor outcome (table ) . patients who underwent interventional radiological procedure treatment was shown to have better outcome. conclusions: hypernatremia after sah is associated with poor outcome. there does not appear to be significant evidence that hyponatremia has an effect on short-term mortality or certain outcome measures such as gos, and its longer-term effects are not well characterized. fig. note logarithmic transformation of los data). we found a statistically significant difference between the two groups when comparing the length of stay (p < . ). conclusions: dean et al demonstrated no significant difference in the mean length of stay using the same definitions of hypo and eunatraemia as in this study [ ] . even though our data appears to contradict their findings, regarding the statistical significance seen, we feel that this is not significant clinically, given the very similar median times for los between the two groups; the unbalanced design may contribute to the statistical significance. fig. (abstract p ) . length of stay between the two groups (note logarithmic scale for los) fig. (abstract p ). gos at months group consisted of patients with mean age . (sd . ) years and mean sodium . (sd . ) mmol/l with a median los of . (iqr . - . ) days. we found no statistically significant difference (p = . ) between the two groups when comparing the length of stay (fig. ) . conclusions: darmon et al demonstrated prognostic consequences of an admission sodium greater than , eliciting hypernatraemia as a factor independently associated with -day mortality [ ] . in contrast, our study suggests that hypernatraemia (as defined) is not associated with the length of stay, however this result is limited by the unbalanced design of this small study. introduction: our aim is to determine whether auscultation for bowel sounds helps in clinical decision making in icu patients with ileus. ileus can be the consequence of an operation, a side effect of drugs or the result of an obstruction requiring direct operative correction. although auscultation for bowel sounds is routinely performed in the icu and a well-established part of the physical examination in patients with suspected ileus, its clinical value remains largely unstudied. methods: a literature search of pubmed, embase and cochrane was performed to study the diagnostic value of auscultation for bowel sounds. results: auditory characteristics (tinkling, high pitched and rushes) were highly variable in postoperative ileus, mechanical ileus and healthy volunteers. the inter-observer variability for the assessment of the quantity, volume and pitch of bowel sounds was high, with a moderate interobserver agreement for discerning postoperative ileus, bowel obstruction and normal bowel sounds (kappa value . ). the intra-observer reliability of duplicated recordings for distinguishing between patients with normal bowels, obstructed bowels or postoperative ileus was % [ ] . no clear relation between bowel sounds and intestinal transit was found (table ) . sensitivity and positive predictive value were low: respectively % and % in healthy volunteers, % and % in obstructive ileus, and % and % in postoperative ileus ( table ) . conclusions: auscultation with the aim to differentiate normal from pathological bowel sounds is not useful in clinical practice. the low sensitivity and low positive predictive value together with a poor inter-and intra-observer agreement demonstrate the inaccuracy of utilizing bowel sounds for clinical decision-making. given the lack of evidence and standardization of auscultation, the critically ill patient is more likely to benefit from abdominal imaging. introduction: stress ulcer prophylaxis has become a standard of care in intensive care unit (icu). however, it has been proposed that enteral nutrition (en) could play preventive role for gastrointestinal bleeding and some studies revealed no added benefit of acid suppressive drugs to patients on en. based on these backgrounds, we use proton pump inhibitor (ppi) as stress ulcer prophylaxis during starvation period, and discontinue it within hours after commencing meals or en. the aim of this study is to evaluate the applicability of our protocol by reviewing the incidence of upper gastrointestinal bleeding (ugib) in our icu. methods: we conducted a retrospective observational study. all consecutive patients admitted to our icu between april and march were reviewed. patients who had ugib within hours after admission, had previous total gastrectomy, or underwent upper gastrointestinal surgery were excluded. the primary outcome was the incidence of overt or clinically important ugib, and the secondary outcome was protocol adherence. we presented descriptive data as number (percentage) and median (interquartile range). results: a total of patients were included. of those, ( . %) were male, median age was ( - ), and median sofa score was ( ) ( ) ( ) ( ) ( ) ( ) ( ) . of all patients, ( . %) had overt bleeding, and ( . %) had clinically important bleeding. both patients who introduction: patients requiring operative procedures admitted under non-surgical specialties typically experience delays in treatment and fail to meet peri-operative standards with regards to the timing of operative intervention. patients admitted from medicine requiring an emergency laparotomy have an increased mortality when compared to those patients admitted from surgery ( . % v . %) [ ] . methods: we undertook a retrospective case note review of patients requiring a non-elective laparotomy at our hospital during a sixmonth period in . patients were identified using the emergency theatre booking system. data were gathered on admission details, peri-operative care and post-operative stay. results: two main investigators reviewed patients to standardise data extraction. six patients presenting with inflammatory bowel disease were excluded from analysis. most patients ( . %) were admitted through the emergency department; ( . %) of whom were initially admitted under medicine, with only . % of these reviewed by a senior clinician prior to admission (table ). there was no statistically significant difference in mortality between the medicine and surgery groups. there was a trend to increased length of stay in icu and in hospital in the medical group (table ) . conclusions: lack of senior decision making may have a direct impact on patient care due to the inappropriate streaming of patients to medicine. the increased mean length of stay in those patients admitted to medicine may reflect a delay in surgical intervention and therefore a prolonged recovery period. we are introducing an acute abdominal pain screening and immediate action tool to improve identification of these high-risk patients and early involvement of senior decision makers. introduction: biomarkers reflecting the extent of surgical tissue trauma should be investigated in an effort to predict and prevent postoperative complications. the aim of the present study was to investigate blood concentrations of selected alarmins in patients after colorectal surgery in comparison to healthy individuals. the secondary aim was to analyze the relationship between alarmins and inflammatory biomarkers during early postoperative period. methods: the prospective, single-center, observational study consisted of non-surgical (ns) group (n= ) and surgical (s) group (n= ) undergoing colorectal surgery. serum levels of selected alarmins (s a and s a ) and inflammatory biomarkers (leukocytes; c-reactive protein, crp; interleukin- , il- ) were analyzed. results: proteins s a an s a had significantly higher serum values in the s-group during all three days after the surgery. the multidimensional model taking into account age, sex, weight, group and days revealed significant differences between study groups for both proteins s a and s a (p< . , p= . , respectively). biomarkers (leukocytes, crp, and il- ) showed significant differences between study subgroups (p< . , p< . , and p< . , respectively). in s-group, moderate positive correlations were found between s a and all biomarkers: leukocytes (r= . ), crp (r= . ), and il- (r= . ). s a had moderate positive correlation with leukocytes (r= . ). levels of s a also positively correlated with intensive care unit and hospital length of stay (r= . , r= . , respectively) conclusions: protein s a might be considered as early biomarker of first wave of immune activation elicited by surgical injury after colorectal surgery. the increase of the alarmins is reflected by the elevation of routine inflammatory biomarkers. introduction: critical illness-induced liver test abnormalities are associated with complications and death in adult icu patients, but remain poorly characterized in the pediatric icu (picu). in the pepanic rct, delaying initiation of parenteral nutrition to beyond day (late pn) was clinically superior to providing pn within h (early pn), but resulted in a higher rise in bilirubin. we aimed to document prevalence and prognostic value of abnormal liver tests and the impact of withholding early pn in the picu. methods: we performed a preplanned secondary analysis of of the pepanic patients aged days to years, as neonatal jaundice was considered a confounder. plasma concentrations of total bilirubin, alt, ast, γ gt, alp were measured systematically during picu stay. analyses were adjusted for baseline characteristics including severity of illness. results: during the first picu days, the prevalence of cholestasis (> mg/dl bilirubin) ranged between . %- . % and of hypoxic hepatitis (>= -fold uln for alt and ast) between . %- . %, both unaffected by the use of pn. throughout the first week in picu plasma bilirubin concentrations were higher in late pn patients (p< . ), but became comparable to early pn patients as soon as pn was started on day . plasma concentrations of γ gt, alp, alt and ast were unaffected by pn. high day plasma concentrations of γ gt, alt and ast (p<= . ), but not alp, were independent risk factors for picu mortality. day plasma bilirubin concentrations displayed a ushaped association with picu mortality, with higher mortality associated with bilirubin concentrations < . mg/dl and > . mg/dl (p<= . ). conclusions: in conclusion, overt cholestasis and hypoxic hepatitis were rare and unrelated to nutritional strategy. however, accepting a large macronutrient deficit during week increased plasma bilirubin. a mild elevation of bilirubin on the first picu-day was associated with lower risk of death and may represent an adaptive stress response rather than true cholestasis. positive fluid balance is an independent risk factor for intensive care unit mortality in patients with acute-on-chronic liver failure introduction: muscle wasting is a common consequence of disuse and inflammation during admission to intensive care with critical illness. limb muscles are known to decrease in size during critical illness, but less is known about muscles of the trunk. in this study, we tracked how psoas muscle area changes at multiple levels, in a group of patients with acute severe pancreatitis. methods: paired computed tomography (ct) scans were obtained from patients admitted to the royal liverpool university hospital's icu with acute severe pancreatitis. the first scan was within days of admission, and the second took place between to days later. for each scan, three slices were identified: the top and bottom plates of l , and the mid-point of l vertebral body. on each slice, the cross sectional area (csa) of the left and right psoas muscle was calculated using imagej. the difference and percentage change in csa between both scans was calculated. white cell counts and c-reactive protein results were obtained, with peak levels correlated against change in muscle size. results: combined csa of the left and right psoas muscle increased from top to bottom plates and was positively correlated with height (r= . , p< . mid l level)) and weight (r= . , p= . , mid l level) at all three levels. at all three levels, there were significant losses of csa between the two scans (see table ). crp was moderately correlated with percentage change in csa (r= - . , p= . ). increasing weight on admission was associated with greater percentage losses in csa (r= - . , p< . ). wcc did not correlate with change in size. in critically ill patients with acute severe pancreatitis, there are significant losses in both psoas muscles throughout the l level. further prospective studies are required to determine if inflammatory markers and cytokines have a role in these losses, and to determine the functional effects of these losses. introduction: the evidence for penta-therapy for hyperlipidemic severe acute pancreatitis (hl-sap) is anecdotal. the purpose of our study is to evaluate the efficacy of penta-therapy for hl-sap in a retrospective study. methods: retrospective study between january and december in a hospital intensive care unit.hl-sap patients were assigned to conventional treatment alone (the control group) or conventional treatment with the experimental protocol (the penta-therapy group) consists of blood purification, antihyperlipidemic agents, lowmolecular-weight heparin, insulin, covering the whole abdomen with pixiao (a traditional chinese medicine).serum triglyceride, serum calcium, apache ii score, sofa score, ranson score, ct severity index, and other serum biomarkers were evaluated. the hospital length of stay, local complications, systematic complications, rate of recurrence, overall mortality, and operation rate were considered clinical outcomes. results: hl-sap patients received conventional treatment alone (the control group) and patients underwent penta-therapy combined with conventional treatment (the penta-therapy group). serum amylase, serum triglyceride, white blood cell count, c -reactive protein, and blood sugar were significantly reduced, while serum calcium was significantly increased with penta-therapy. the changes in serum amylase, serum calcium were significantly different between the penta-therapy and control group on th day after the initiation of treatment. the reduction in serum triglyceride in the pentatherapy group on the second day and th day were greater than the control group. patients in the penta-therapy group had a significantly shorter length of hospital stay. conclusions: this study suggests that the addition of penta-therapy to conventional treatment for hl-sap may be superior to conventional treatment alone for improvement of serum biomarkers and clinical outcomes. average energy expenditure (ee) for all patients was ± kcal/kg (mean ± sd). there was no difference in the average ee between the patients who survived and those who died: ± and ± kcal/ kg (mean ± sd) respectively (p > . ). however, there was a negative correlation between ee and saps score in the non-survivors groupcorrelation coefficient - . , p < . . the energy deficit (computed by subtracting caloric intake from ee measurement) was similar among survivors and non-survivors, . ± vs . ± kcal/kg, respectively (mean ± sd) (p > . ). the patients who survived had received ± kcal/kg while those who died - ± kcal/kg (mean ± sd) (p > . ). the provision of protein was also similar for both groups: . ± . g/kg for survivors and ± . g/kg for nonsurvivors (mean ± sd) (p > . ). there was no statistically significant correlation between provision of calories and protein and outcomes such as length of hospital and icu stay or duration of mechanical ventilation. conclusions: average energy expenditure in critically ill patients with acute severe pancreatitis roughly equals to aspen estimation of kcal/kg and does not differ among survivors and non-survivors. outcomes such as survival, length of hospital and icu stay and duration of mechanical ventilation were unaffected by caloric nor protein provision in this sample. introduction: disturbances in gastrointestinal motility are common in critically ill patients receiving enteral nutrition. slow gastric emptying (ge) is the leading cause of enteral feeding intolerance (efi), which compromises nutritional status and is associated with increased morbidity and mortality. this phase a study evaluated the efficacy, safety and tolerability of acute tak- (previously td- ), a selective agonist of the hydroxytryptamine receptor ( ht ), compared with metoclopramide in critically ill patients with efi. methods: this was a double-blinded, double-dummy study conducted in mechanically ventilated patients with efi (> ml gastric residual volume) randomized to receive either intervention (tak- . mg over hour and . % saline ml injection qid) or control ( . % saline over hour and metoclopramide mg injection qid). within hour of the first dose, patients received a test meal of ml ensure® and ge was measured using scintigraphy. primary objectives were to evaluate the safety and tolerability of tak- and its effect on ge (% retention at mins) vs control. results: a total of patients (intervention, n = ; control, n = ) were studied. the median ages were and years in these groups, respectively. post-treatment, a -fold greater number of patients had normal gastric retention (< % at mins) in the intervention group vs the control group ( vs ; fig. ). in the intervention and control groups, (table ) . no aes led to treatment discontinuation. conclusions: a greater proportion of patients receiving tak- had normal gastric retention after a single dose compared with those receiving metoclopramide. treatment with tak- was not associated with an increase in aes. these results support further evaluation of tak- in critically ill patients with efi. method to assess gastric emptying in the fed state in enterally tube fed patients: comparison of the paracetamol absorption test to scintigraphy j james introduction: the paracetamol absorption test (pat) is the most common and practical approach for assessing gastric emptying (ge) in critically ill patients. however, current methods require that paracetamol be administered to an empty stomach, removing gastric contents and depriving patients of feeding for several hours. the objective of this study was to develop methods to assess gastric emptying in these patients without interrupting feeding. methods: gastric emptying was assessed in the fed state using pat and scintigraphy in healthy volunteers. paracetamol g in ml was ingested immediately before consumption of a test meal of ml ensure plus containing kcal, . g protein, and . g fat plus mbq of mtc-dpta as a scintigraphic agent. comparisons were made between paracetamol absorption and the time to % and % gastric emptying by scintigraphy at baseline and after administration of ulimorelin μg/ kg, a prokinetic agent known to enhance gastric emptying. blood samples for paracetamol were collected for up to h post administration. values for normal gastric emptying were based on the % confidence intervals for pk parameters. sensitivity and specificity were assessed by receiver operating characteristic (roc) analysis before and after treatment. results: the pat correlated with scintigraphy and pk parameters for normal emptying were determined. cmax and auc were the most sensitive and specific parameters for assessing ge with lowest variability and areas under the roc curve of . and . , respectively. a h sampling period appeared sufficient to distinguish normal from abnormal emptying. conclusions: the pat can be used to distinguish normal versus abnormal ge in the fed state. under the conditions used, patients can receive up to ml enteral feeding over a h test period ( ml/hr). this method can be used to distinguish normal from abnormal gastric emptying in enterally tube fed patients without interrupting feedings. introduction: for mechanically ventillated critically ill patients, the effect of full feeding on mortality is stil controversial. we aimed to investigate the relationship of energy intakes with -day mortality, and nutritional risk status influenced this relationship. methods: this prospective observational study was conducted among adult patients admitted to icu and required invasive mechanical ventilation (imv) for more than h. data on baseline characteristics and the modified nutritional risk in critically ill [mnutric] score was collected on day . energy intake and nutritional adequacy was recorded daily until death, discarge or until twelfth evaluable days. patients were divided into groups: a)received < % of prescribed energy b) received >= % of prescribed energy. results: patients ( % male, mean age . ± . years, mean body mass index . ± . kg/m , mean mnutricscore . ± . ) were included. in the univariate analysis, mnutrİc score was associated with -day mortality. in the multivariable logistic regregression analysis, mnutric score(odds ratio, or . , ci . - . , p < o.oo ) was associated with -day mortality. nutritional adequacy was assessed, median nutritional adequacy was . ( . - . ). in patients with high mnutrİc score ( - ), received >= % of prescribed energy was associated with a lower predicted -day mortality; this was not observed in patients with low mnutrİc score ( - ). conclusions: nearly % of imv required patients admitted to icu were at nutritional risk, mnutrİc score is associated with -day mortality. energy adequacy of >= % of prescribed amounts were associated with decreased mortality in patients with a high mnutrİc score. results: patients included in the study were asa iv. four patients died in the first few days after surgery ( ÷ days). mean length of stay in icu was . ± . days. univariate analysis showed a correlation between hypoalbuminemia and the onset of mof (p = . ); reduction of the lymphocyte count and risk of mof (p = . ). sofa score showed a significant correlation with occurrence of pneumonia (p = . ) and mof (p = . ). including the -day mortality among confounders, albumin and lymphocyte count were the strongest predictors of mof. length of stay in icu and ventilation days did not have statistical significance. bmi showed no predictive value of any outcome. conclusions: our sample was poor but results of our study seem to indicate malnutrition as an independent risk factor for elderly patients undergoing emergency surgery. early multidisciplinairy screening of dysphagia at admission to the emergency departmenta pilot study d melgaard, l sørensen, d sandager, a christensen, a jørgensen, m ludwig, p leutscher north denmark regional hospital, hjørring, denmark critical care , (suppl ):p introduction: dysphagia increase the risk of aspiration pneumonia, malnutrition, dehydration and death. this combined with the fact that patients with dysphagia have a longer stay in the hospital makes early prognosis and appropriate treatment important. knowledge about effect of early dysphagia screening is limited. the aim of this study is to examine the prevalence of dysphagia in the emergency department (ed) population. methods: this study included consecutively hospitalized patients in days from pm- pm at the ed of north denmark regional hospital. the screening took place within hours of admission. inclusion criteria were any of the following: age ≥ years, neurological disorders, alcoholism, copd, pneumonia, dyspnoea, diabetes or unexplained weight loss. a nurse screened patients with a water test and with signs of dysphagia tested by an occupational therapist with the v-vst and the meof-ii. results: of eligible patients ( % male, median age years) ( %) were screened. it was impossible to screen patients ( %) to limited time and patients ( %) due to poor health condition and patients ( %) declined participation. the prevalence of dysphagia in the study population was % ( patients). results from the water test were confirmed with v-vst and meof-ii. in patients with lung related diseases or circulatory diseases was the prevalence respectively % and %. patients, not screened due to poor health condition, were tested during hospitalisation and the prevalence of dysphagia was % in this group of patients. conclusions: the prevalence in ed patients was %. patients transferred to other departments due to poor health condition had a prevalence of %. it is possible to screen patients in the ed. the water test is a useful screening tool in an acute setting. introduction: to improve protein and energy delivery in a nutrition delivery bundle was introduced to a level icu. greater protein and energy intake is associated with improved outcomes in the critically ill [ ] [ ] [ ] [ ] , but only % of prescribed protein and energy is delivered in icus worldwide [ , ] . methods: percentage of target protein and energy delivery was measured via participation in the international nutrition survey (ins) before and after a "nutrition delivery bundle" was introduced by the icu dietitian. the nutrition delivery bundle involved all stakeholders in icu nutrition care (fig. ) and included the following quality improvement measures: increased icu dietetic staffing, update of icu enteral feeding protocol with staff education, use of higher protein formulations, earlier patient nutrition assessment, daily calculation of percentage nutrition delivery, increased nutrition communication through more regular discussion of patient care with medical team, expansion of choice of nasojejunal tube available, monthly reporting of key nutrition performance indicators, improved resources for cover dietitian(s) when icu dietitian on leave (fig. ) . results: prior to a nutrition delivery bundle being introduced the mater misericordiae university hospital (mmuh) icu achieved % of protein and % of energy targets over the first admission days of consecutive mechanically ventilated patients in icu > hrs enrolled in the international nutrition survey. this increased to % of protein and % of energy targets in (table ) . conclusions: a % improvement in protein and energy delivery to critically ill patients was seen after the introduction of a dietitian-led nutrition delivery bundle. introduction: the critically ill polytrauma patient with sepsis presents with variable energetic necessities characterized by a proinflammatory, pro-oxidative and hypermetabolic status. one of the challenges the icu doctor faces is adapting the nutritional therapy based on the individual needs of each patient. through this paper we wish to highlight the trend of energy needs in the case of critically ill polytrauma patients with sepsis by using non-invasive monitoring of respiratory gases based on indirect calorimetry (ge healthcare, helsinki, finland). methods: this is a prospective observational study carried out in the anesthesia and intensive care unit "casa austria", emergency county hospital "pius brinzeu", timisoara, romania. we monitored vo , vco , energy demand (ed), and specific clinical and paraclinical data. we measured energy demand values monitored by direct calorimetry with values calculated based on standard formulas. results: values have been recorded in the study. the mean vo was . ± . ml/min/kg, the mean vco was . ± . ml/min/kg. in regard with energy demand, the mean ed obtained through direct calorimetry was . ± . kcal/day, and those obtained by using mathematic formulas were . ± kcal/day (p < . ). moreover, statistically significant differences have been observed regarding the mean difference between energy demand determined using indirect calorimetry and that determined mathematically, respectively between the enteral and parenteral administered ed. conclusions: continuous monitoring of the energy demand in critically ill patients with sepsis can bring important benefits in regard with the clinical prognosis of these patients through the individualization and adaption of intensive therapy for each patient. introduction: cachexia is defined as a complex metabolic syndrome associated with underlying illness, characterized by loss of muscle with or without loss of fat. in cancer cachexia, reduction in muscle size has been demonstrated to be an independent risk factor for mortality. loss of muscle in icu patients is rapid and extensive and is also associated with mortality risk, but methods to measure muscle mass in these patients are lacking. surrogate methods (dexa, ct, ultrasound, total body water) do not measure muscle mass directly methods: the d -creatine (d -cr) dilution method takes advantage of the fact that % of cr is found in muscle and that muscle mass can be assessed by cr pool size. cr is transported into muscle against a concentration gradient and irreversibly converted to creatinine (crn), which is excreted in urine. a single oral dose of d -cr is transported to skeletal muscle, and measurement of d -crn enrichment in a spot urine sample provides an accurate estimate of skeletal muscle mass. results: the method has been validated in preclinical and clinical studies; in a large longitudinal observation study in older men, d -cr muscle mass was strongly associated with habitual walking speed, risk of falls, and incident mobility limitation; dexa failed to show these relationships. the d -cr method is being used in a nicu study to measure changes in muscle mass in neonates (gates foundation grant). further, this method has been incorporated into a trial assessing the treatment effects of a ghrelin agonist in icu patients with enteral feeding intolerance (nct ). in this trial, the d -cr dose is delivered intravenously and a spot urine sample is collected at baseline and postdose. conclusions: the d -cr method provides a non-invasive, accurate way to assess therapeutic agents that may mitigate the loss of skeletal muscle mass; it is of particular utility in clinical settings where changes in muscle mass are consequential, such as muscle loss during an icu admission. introduction: vitamin c, an enzyme cofactor and antioxidant, could hasten the resolution of inflammation, which affects most intensive care unit (icu) patients. while many observational studies have demonstrated that critical illness is associated with low levels of vitamin c, randomized controlled trials (rcts) of high-dose vitamin c, alone or in combination with other antioxidants, yielded contradicting results. the purpose of this systematic review and meta-analysis is to evaluate the clinical effects of vitamin c when administered to various populations of icu patients. methods: eligible trials: rcts comparing vitamin c, by enteral or parenteral routes, to placebo in icu patients. data collection and analysis: we searched medline, embase, and the cochrane central register of controlled trials. after assessing eligibility, data was abstracted in duplicate by two independent reviewers. overall mortality was the primary outcome; secondary outcomes were infections, icu length of stay (los), hospital los, and ventilator days. pre-specified subgroup analyses were conducted to identify more beneficial treatment effects. results: pooling rcts (n= ) reporting mortality, vitamin c was not associated with a lower risk of mortality (risk ratio [rr]: . , % confidence interval [ci]: . - . , p= . , i = %). in a subgroup analysis, trials of lower quality (n= ) were associated with a reduction in mortality (rr . , % ci . , . , p= . ), whereas high quality trials (n= ) were not. no statistical difference existed between subgroups (p= . ). in addition, no effect was found on infections, icu or hospital length of stay, and ventilator days. conclusions: current evidence does not support the hypothesis that vitamin c supplementation improves clinical outcomes of icu patients. introduction: the protein intake for patients who met adequacy for energy was assessed within our cardiothoracic intensive care. nutritional support should aim to provide at least % of calorie requirements to achieve nutritional adequacy with suggested protein requirements of . - g/kg/day [ ] . guidelines highlight the difficulty achieving the correct protein:energy ratio from nutritional support to meet this target especially in the obese population. methods: the audit was registered with clinical governance. data was collected prospectively from patients requiring tube feeding for three or more days from january -october (table ). data included type and volume of feed and calories from other sources. patients who met adequacy for energy (fig. ) introduction: patients admitted to the intensive care unit (icu) are usually at high risk of malnutrition [ , ] . the purpose of our study was to compare the accuracy of nutric score, nrs and sga in predicting los-icu, los-hosp and in-hospital mortality. methods: a total of consecutive patients admitted between march to june in a mixed (medical/surgical) icu were assessed on day of admission using the three screening tools to classify them into high-risk and low-risk of malnutrition. day apache scores and demographic data were recorded. los-icu, los-hosp inhospital mortality and secondary outcomes studied were need for supplemental nutritional support, need for ventilation and need for dialysis in high-risk and low-risk patients by each nutrition assessment tool. results: of the patients studied, ( . %) were males and ( . %) were females. . % males and . % females were found to be at a high risk of malnutrition by at least one of the scores. the mean apache score for patients at high risk (using any one screening tool) was . (sd . ) and . for the low risk group (sd . ; p < . ). the nrs and sga demonstrated statistically significant correlation(p= . ) for length of icu stay for both the high risk and low risk group whereas only the nrs correlated significantly for the length of hospital stay(p= . ). mortality was significantly higher in high risk patients identified using all scores. conclusions: there was a wide difference in the percent of patients identified as high-risk using each of the scores. introduction: nitrogen balance (nb) may be an important tool in the nutritional management of critically ill patients. cancer patients present a special challenge regarding nutrition, due to its peculiar characteristics related to neoplasia and adjuvant treatments. objectives: to evaluate nb in patients with solid cancer in the postoperative period in the icu, analyzing the correlation between nb and the mortality outcome in the icu. methods: retrospective cohort study. we evaluated adult patients (> years) admitted to the icus of two different hospitals, with diagnosis of current cancer in postoperative period (elective or emergency surgeries). patients were excluded if the diagnosis of cancer was not confirmed. nb (measured through analysis of dietary protein intake subtracted from -hour urinary urea plus an estimate of nonurinary losses) was calculated on the st, rd and th icu day. nb was measured only while the patient was in the icu. results: during the study period, patients were included (mean age . , mean apache . , . % male). admission apache ii and abdominal-site surgery were predictors of mortality. the nb of all patients was negative on the st icu day. in the patients who survived, nb of the rd and th day remained stable (negative), whereas in patients who died nb was more positive (fig. ) . there was no difference in the amount of protein ingested on the st day between survivors and deceased patients. conclusions: among adult patients with solid cancer in the postoperative period in the icu, nb was persistently negative in the survivors between st and th icu day, but among the patients who died nb tended to be more positive on the rd day. nb monitoring could allow a more adequate individualization of nutritional management in this group of patients. fig. (abstract p ) . nitrogen balance in st, rd and th icu day introduction: nutritional therapy plays an important role in the treatment of critically ill patients. caloric and protein goals are defined, and artificial nutrition tailored to the targets which are related to outcome [ ] . questions rise about the mean caloric and protein needs of patients, once discharged from icu, and the evolution of body weight, and nutritional adequacy. the aim is to know the ratios between caloric needs and intake of patients with a minimum stay at icu of days. methods: after evaluation of critically ill patients, patients were prospectively followed during their entire hospitalization. data concerning nutritional needs, prescriptions and delivery were collected from the electronic medical file. nutritional calculations of oral intake were done by nubel. ratios were made during the entire stay and body weight was followed up. results: in female and male patients, median age . years (range - year), estimated body weight of . ± kg and actual body weight of . ± kg, a mean caloric need of ± kcal/ day and an effective delivery of ± kcal/day was observed. body weight increased in two patients and decreased in ( %). in ten out of twelve patients, underfeeding was present. one patient with a caloric need of kcal/day received a mean caloric load of kcal/day ( . %). conclusions: the overall observed evolution in body weight was negative in most of the patients. nutritional adequacy was low after icu discharge and never reached target. introduction: severe burn injury can create a rapid-onset, sustained proinflammatory condition that can severely impair all major organs. this massive systemic response has been documented clinically by associated biomarker measurements including dramatic elevations in cytokines such as il- . the severity of multi-organ injury and subsequent development of other systemic complications in burn patients have been well-correlated with il- levels, including the increased risk of sepsis/multi-organ failure and associated morbidity and mortality. considering that estrogen is a powerful and easy to use anti-inflammatory agent, an experimental burn model was created to test the potential value of parenteral β-estradiol (e ) as a feasible and inexpensive early intervention to mitigate the the profound pro-inflammatory response associated with severe thermal injury. methods: male rats (n = ) were assigned randomly into three groups: ) controls/no burn (n = ); ) burn/placebo (n = ); and ) burn/e (n = ). burned rats received a % °tbsa dorsal burn, fluid resuscitation and one dose of e or placebo ( . mg/kg intra-peritoneal) minutes post-burn. eight animals from each of the two burn groups (burn/placebo and burn/e ) were sacrificed at minutes (sham group at days only), with four each of the two burn groups sacrificed at days. tissue samples from major organs and serum were obtained and analyzed by elisa for il- at each of these intervals. results: in the burned rats, β-estradiol decreased the organ levels of il- significantly as measured at both early ( min.) and late ( day) phases post-burn (figs. & . also, sham animal levels were comparable to the estradiol group, conclusions: experimentally, a single, early post-burn dose of estrogen significantly mitigates the associated detrimental inflammatory response in all major organs up to days. in turn, this may present a promising potential therapy to decrease the widespread multipleorgan dysfunction seen in severe burn injury patients. early, single-dose estrogen increases levels of brain-derived neurotrophic factor (bdnf), a neurotrophin for neuronal survival and neurogenesis following indirect brain inflammation caused by severe torso burns introduction: prior studies have found that patients with severe burns may suffer significant neurocognitive changes. while frequently attributed to psycho-social issues, we have found a substantial, rapid and sustained ( min - day) increase in rat brain inflammatory markers (for example, il- ) following remote torso burns that is blunted by a single post-burn dose of estrogen. brain-derived neurotrophic factor (bdnf), one of the most active neurotrophins, protects existing neurons and encourages the growth and differentiation of new neurons and synapses. as estrogens not only blunt inflammation but also exert an influence on cns growth factors, we hypothesized that β-estradiol (e ) might affect levels of bdnf in the post-burn rat brain. methods: male rats (n = ) were assigned randomly into three groups: controls/no burn (n = ); burn/placebo (n = ); and burn/e (n = ). burned rats received a % °tbsa dorsal burn, fluid resuscitation and one dose of e or placebo ( . mg/ kg intraperitoneally) minutes post-burn. eight animals from each of the two burn groups (burn/placebo and burn/e ) were sacrificed at hours and at days, respectively (sham group at days only), with four each of the two burn groups sacrificed at days. brain tissue samples were analyzed by elisa for bdnf. results: mean levels of bdnf were significantly elevated within hours and continued to increase up to days post-injury in burned animals receiving the β-estradiol (> pcg/mg) as compared with the placebo-treated burned animals (< pg/mg) and controls (< . pcg/mg). see fig. . conclusions: early, single-dose estrogen administration following remote severe burn injury significantly elevated levels of bdnf in brain tissue. this finding may represent an extremely novel and important pathway to enhance both neuroprotection and neuroregeneration in burn patients. the value of cortisol in patients with the infection and multiple organ dysfunction. s tachyla, a marochkov mogilev regional hospital, mogilev, belarus critical care , (suppl ):p introduction: hormones changes in patients with infection and multiple organ dysfunction is a topic that hasn't been adequately studied. goal of study: to establish the value of cortisol in patients with infection and multiple organ dysfunction. methods: after approval the ethics committee of the mogilev regional hospital a prospective observational study was performed. the study included patients aged to years. all patients were hospitalized in the intensive care unit with the infection and multiple organ dysfunction. patients with endocrine diseases and receiving glucocorticoids were excluded. cortisol levels were measured on admission and during the course of treatment by radioimmunoassay. in group l (n = ) patients had a low levels of cortisol, in the m group (n = ) -normal cortisol, in group h (n = ) -high cortisol. results: cortisol level was in l-group . ( . , . ) nmol/l, in mgroup . ( . ; . ) nmol/l, in h-group . ( , ; . ) nmol/l. it is found that the mortality was higher in the groups l - . % (p = . ) and h - . % (p = . ), than in the m-group - . %. the mgroup odds ratio equals . at % confidence interval . - . when compared with the h-group. in the m-group in survivors patients (n = ) showed a decrease cortisol with ( . , . ) nmol/l to . ( . , . ) nmol/l (p = . ). while the no survivors patients (n = ) showed increase cortisol with ( . , . ) nmol/l to . ( ; ) nmol/l (p = . ). thus itself cortisol level is not a marker of mortality. receiver operating curve analysis for cortisol was performed: area under the curve equals . at % confidence interval of . - . (p = . ), sensitivity . %, specificity . %. conclusions: in patients with infection and multiple organ dysfunction may be observed disorders in cortisol levels. these disorders require correction to prevent the increased mortality. introduction: the hypothalamic-pituitary-adrenal (hpa) axis is a key regulator of critical illness. cortisol and adreno-corticotrophic hormone (acth) are pulsatile, which emerges from the feed forwardfeedback of the two hormones [ ] . different genes are activated by continuous or pulsatile activation of the glucocorticoid receptor, even when the total amount is the same [ ] . we aimed to characterise the acth and cortisol profiles of patients who were critically ill after cardiac surgery and assess the impact of inflammatory mediators on serum cortisol concentrations. methods: patients with > organ system failure, > days after cardiac surgery were recruited. total cortisol was assayed every min, acth every hour and il , il , il , il , il , tnf-α every hours. cortisol binding globulin (cbg) was assayed at and hrs. the relationship between cortisol and the inflammatory mediators was quantified in individual patients using a mixed regression model. results: all profiles showed pulsatility of both cortisol and acth and there was concordance between the two hormones (see fig. ). one patient died after hours (see fig. ). this patient lost pulsatility and concordance of cortisol and acth. mean cbg was . μ g/ml at the start of sampling and . μ g/ml at the end. there was an association between il (p= . ), il (p< . ), il (p= . ) and serum cortisol levels. there was no association between the other mediators and cortisol. conclusions: cortisol and acth are both pulsatile in critical illness. because pulsatility emerges from the interaction between the two hormones[ ]the premise of a 'disconnect' between the pituitary and adrenal gland is refuted. il , il and il may have roles in the control of cortisol during critical illness. introduction: elevation in plasma cortisol is a vital response to sepsis and partially brought about by reduced cortisol breakdown in which bile acids (bas) may play a role. vice versa, cortisol can also upregulate bas. we hypothesized a central role for the hepatic glucocorticoid receptor (hgr) in cortisol and ba homeostasis and in survival from sepsis. methods: in a mouse model of sepsis, we documented hgr expression and investigated the impact of hepatocyte-specific shrnaknockdown of gr on markers of corticosterone (cort), ba and glucose homeostasis, inflammation and survival. we also compared hgr expression in human septic icu and elective surgery patients. results: in mice, sepsis reduced hgr expression with % (p= . ), elevated plasma cort, bas and glucose and suppressed a-ringreductases. also in human patients, sepsis reduced hgr expression (p< . ), further suppressed by treatment with steroids (p= . ). in septic mice, further and sustained hgr-inhibition increased mortality from % to % (p< . ). at h, hgr-inhibition prevented the rise in total plasma cort, but did not affect a-ring-reductases expression. however, it further reduced cort binding proteins, resulting in elevated free cort equal to septic mice without modified hgr. after days of hgr-inhibition in sepsis, total and free cort were comparable to septic mice without modified hgr, now explained by further reduced a-ring-reductase expression, possibly driven by higher hepatic ba content. hgr-inhibition blunted the hyperglycemic sepsis response without causing hypoglycemia, markedly increased hepatic and circulating inflammation markers and caused liver destruction (p< . ), the severity of which explained increased mortality. conclusions: in conclusion, sepsis partially suppressed hgr expression, which appears to upregulate free cort availability via lowered cort binding proteins and a-ring-reductases. however, further sustained hgr suppression evoked lethal excessive liver and systemic inflammation, independent of cort availability. introduction: cortisol levels have been found to be increased in sepsis patients, and high cortisol levels have been correlated with increased mortality. the purpose of this project is to assess the association of plasma cortisol levels with severity of coagulopathy in a population of patients with sepsis and clinically confirmed dic. methods: citrated, de-identified plasma samples were collected from adults with sepsis and suspected dic at the time of icu admission. platelet count was determined as part of standard clinical practice. pt/inr and fibrinogen were measured using standard techniques on the acl-elite coagulation analyzer. cortisol, d-dimer, pai- , cd l, nlrp , and microparticles were measured using commercially available elisa kits and were performed. dic score was calculated using isth scoring algorithm. results: cortisol showed significant variation based on dic status (kruskal-wallis anova, p < . ). patients with non-overt dic and overt dic exhibited significantly elevated cortisol levels compared to healthy controls (p < . for both groups). cortisol levels showed dic based variations. patients with sepsis and overt dic had elevated cortisol compared to patients with sepsis and no dic (p = . ) (fig. ) . correlations were evaluated between cortisol and hemostatic markers platelets, fibrinogen, inr, d-dimer, and pai- as well as with the inflammatory marker, nlrp and the platelet markers cd l and microparticles. cortisol conclusions: cortisol showed a significant association with hemostatic status in a population of patients with sepsis and welldefined coagulopathy. cortisol levels were significantly elevated in patients with overt or non-overt dic compared to healthy individuals and in patients with overt dic compared to those with sepsis without dic. introduction: in most cases presenting with hypoglycemia in emergency departments (eds), the etiology of the hypoglycemia is almost identified. however, about % of cases, the etiology of hypoglycemia cannot be determined. methods: this is a -year prospective observational study. a total of patients were transported to our ed with hypoglycemia. after the investigation, a rapid acth loading test (synthetic - acth μg iv.) was performed on patients with unexplained hypoglycemia; i.e., μg acth was administered intravenously and blood specimens were collected before loading, at min and min after acth administration. we adopted a peak serum cortisol level < μg/dl or a delta cortisol of < μ g/dl for the diagnosis of adrenal insufficiency. results: among the patients, of ( . %) were using antidiabetic drugs, ( . %) were using hypoglycemia-relevant drugs, ( . %) suffered from digestive absorption failure including malnutrition, ( . %) had been consuming alcohol, ( . %) suffered from malignancy, and ( . %) suffered from insulin autoimmune syndrome. initially, an etiology was unknown in of ( . %) patients. rapid acth test revealed the adrenal insufficiency in ( . %) among them. administration of hydrocortisone in adrenal insufficiency patients promptly improved hypoglycemia. in those patients, serum sodium level was lower (na; vs. meq/l, p< . ) and serum potassium level was higher (k; . vs. . meq/l, p< . ) than in the other hypoglycemic patients, respectively. there was no significant difference in baseline plasma glucose level on ed between the groups of patients ( vs. mg/dl, p= . ). conclusions: the probability of adrenal insufficiency was much greater than that of the better-known insulinoma as a cause of hypoglycemia. when protracted hypoglycemia of unknown etiology is recognized, we recommend that the patient is checked for adrenal function using the rapid acth loading test. introduction: sepsis caused have showed serious alternations of thyroid hormones releasing, causing a nonthyroidal illness syndrome. the aim of the study was to measure thyroid hormone levels in septic patients and analyse its relation with clinical state and outcome. methods: prospective study in a cohort of consecutive septic patients. we studied thyrotropin (tsh), free triiodothyronine fraction (ft ) and free thyroxin fraction (ft ) serum levels, apache ii and sofa score. statistical analysis was performed using spss . . results: we analysed episodes of sepsis ( %) and septic shock (ssh) ( %), the median age of the patients was (inter-quartile range, . - ) years; the main sources of infection were: respiratory tract ( %) and intra-abdomen ( %); . % had medical diseases. apache ii score was [ - ], sofa score was [ . - ] and day mortality was . %. our data shown . % with low levels of tsh (< . uui/ml), . % had low levels of ft (< . ng/dl) and . % low levels of ft (< pg/ml). the tsh ( . vs. . uui/ml) and ft ( . vs . pg/ml) concentration of ssh group were significantly lower than those of sepsis group, whereas ft ( . vs . ng/dl) it was not statistically significantly. correlation of ft to apa-che ii (r = − . , p = . ) and sofa score (r = − . , p = . ). the profile of death patients were men ( . %, n = ), with significantly older ( vs. years; p= , ), as well as clinical severity scores, apache ii ( . vs. . ; p< . ) and sofa ( . vs . ; p< , ). non-survivors had significantly lower tsh . vs. . uui/ ml; p= . , and ft . vs. . pg/ml, p= . , however ft did not show statistical significance . vs. . ng/dl, p=ns. conclusions: conclusions: most of our septic patients present an altered thyroid function. our data suggest that tsh and specially ft may be used as a marker of disease severity and a mortality predictor. observational study to evaluate short and long-term bone metabolism alteration in critical patients. introduction: reduction of bone mineral density and/or muscle mass can be short and long-term complications in critical patients admitted in intensive care unit (icu). the study aims to evaluate, during a -month period, the following parameters: ) the alterations of bone metabolism and quantitative and qualitative parameters of bone tissue, ) the proportion of subjects with bone fragility, and ) the identification of specific risk factors. methods: an observational-longitudinal monocentric study is being conducted in adult patients hospitalized in icu. the evaluations performed at baseline, and month visits include analysis of biochemical and instrumental exams. results: a specific clinical-care pathway was created between bone metabolic diseases unit and icu, in order to perform specific anamnestic collection, biochemical analysis of bone metabolism, and instrumental exams. patients were enrolled and evaluated at the baseline visit. biochemical exams, performed within hours of hospitalization, showed that % (n: ) of subjects had a deficit of ohvitamind < ng/dl, associated with normal corrected serum calcium levels and of these % (n: ) had high pth levels. bone alkaline phosphatase was increased in % (n: ) of patients. conclusions: critical patients are "fragile" subjects, which should be monitored with a short and long-term follow-up. the creation of a clinical pathway that includes specialists of bone metabolism may be a virtuous way to identify patients who report bone mass loss and increased fracture risk. this study will allow to implement the knowledge regarding specific risk factors of bone fragility and the most appropriate therapeutic choices as prevention and treatment. a retrospective analysis of predictors for length of intensive care stay for patients admitted with diabetic ketoacidosis a fung, tl samuels, ae myers, pg morgan east surrey hospital, redhill, uk critical care , (suppl ):p introduction: diabetic ketoacidosis (dka) is one of the most common metabolic causes of admission to the intensive care unit (icu). the incidence of dka is quoted as between . - episodes per patients with diabetes mellitus (dm) [ ] . we aim to establish the factors that affect length of stay (los) on icu. methods: we undertook an analysis of patients admitted to icu over the last years with a primary diagnosis of dka. we assessed whether there was an association between the following factors and an increased length of icu stay: age, gender, body mass index (bmi), systolic blood pressure, heart rate, sodium, potassium, haemoglobin and ph. these factors were assessed using multiple linear backward stepwise regression. results: overall, admissions were identified over the time period from the ward watcher database. the median los was . days (iqr . - . ). our analysis demonstrated that length of icu stay (alpha level < . ) was significantly associated with bmi, low systolic blood pressure, and the presence of hyponatraemia or hypernatraemia. conclusions: we found the variables that affect the los for patients presenting to our unit with dka are bmi, elow systolic bp, low sodium and high sodium. we intend to extend this work to include survival analysis with the same subgroup of patients. maximal glycemic gap is the best glycemic variability index correlated to icu mortality in medical critically ill patients t issarawattna, r bhurayanontachai prince of songkla university, songkla, thailand critical care , (suppl ):p introduction: several evidences shown a correlation of glycemic variability (gv) and icu mortality. however, there have been no report of the correlation between various parameters of gv and mortality in medical icu patients. the aim was to determine the correlation between various parameters of gv and medical icu mortality, as well as, to identify the best gv index to predict icu mortality. methods: a retrospective chart review was then conducted in medical icu at songklanagarind hospital. the patient characteristics, causes of admission, apache ii, blood glucose within the first hours of icu admission and icu mortality were recorded. glycemic variability parameters including maximal glycemic gap, standard deviation, coefficient of variation and j-index of blood glucose were calculated. the correlation of those gv index to icu mortality was determined. the roc and auroc of each gv index were then compare to identify the best gv index to predict icu mortality. results: of patients, patients ( . %) were survived ( table ). all gv indexes were significantly higher in non-survival group (p < . ) ( table ). maximal glycemic gap was independently correlated to icu mortality and give a highest auroc compared to others gv. (maximal glycemic gap auroc . ( %ci . - . vs. coefficient of variation auroc . ( %ci . - . ) vs standard deviation auroc . ( %ci . - . ) vs j-index auroc . ( %ci . - . ), (p< . ) (fig. ) . conclusions: maximal glycemic gap independently correlated to icu mortality and was the best gv to predict icu mortality in medical critically ill patients. reliability of capillary blood glucose measurement for diabetic patients in emergency department h ben turkia, s souissi, a souayeh, i chermiti, f riahi, r jebri, b chatbri, m chkir regional hospital of ben arous, ben arous, tunisia critical care , (suppl ):p introduction: acute glycemic disorders should be early diagnosed and treated in emergency department (ed), especially hypoglycemia. can capillary blood glucose (cg) replace plasmatic glucose (pg). the objective of this study was to compare capillary blood glucose with venous blood glucose methods: patients with type diabetes were included. we realize a capillary blood glucose with a glucose meter (acu-check active-roche) and a concomitant determination of venous blood glucose with laboratory machine (synchrony cx delta system beckman coulter). a correlation study (pearson correlation) between the two measurements was evaluated and linear fitting equation was established. the concordance was checked with bland and altman method. results: during the months of the study, patients were included. the average age was +/- years old, with a sex ratio = . majority of patients ( %,n= ) had type diabetes and % was treated with insulin. we found an excellent correlation between the two techniques with a pearson correlation coefficient r= . .topredict the pg from cg, we can use this equation: pg(g/l)= . cg(g/l)+ . (r = . ; p= . ). we noticed a good concordance between the two techniques especially in case of hypoglycemia and moderate hyperglycemia (fig. ) . however, releases were noted with a pg higher than g/l. conclusions: in ed, the measurement of capillary glucose can exempt from venous blood glucose especially in case of hypoglycemia and moderate hyperglycemia. is frequently found in critically ill patients in icu, especially patients who are treated for a long time. this study aims to analyse the comparison between length of stay and dvt incidents in critically ill patients. methods: a cross-sectional study was employed. we include all patients who were years or older and were treated in icu of dr soetomo public hospital for at least days. data were collected from june until june . the patients were examined with sonosite usg to look for any thrombosis in iliac, femoral, popliteal, and tibial veins and well's criteria were also taken. results: thirty patients were included in this study. this study shows that length of stay is not the only risk factor for dvt in patients treated in icu. in our data, we found out that the length of treatment did not significantly cause dvt. other risk factors such as age and comorbidities in patients who are risk factors may support the incidence of dvt events. the diagnosis of dvt is enforced using an ultrasound performed by an expert in the use of ultrasound to locate thrombus in a vein. conclusions: length of treatment is not a significant risk factor for dvt. several other factors still need to be investigated in order for dvt events to be detected early and prevented. [ ] was used to retrospectively study trends and outcomes of cancer patients admitted to the icu between and . logistic regression analysis was performed to assess predictors of -day and -year mortality. results: out of , icu admissions, , hemato-oncological, , oncological and patients with both a hematologic and solid malignancy were analyzed. hematologic patients had higher critical illness scores, while oncological patients had similar apache-iii and sofa-scores. in the univariate analysis, cancer was strongly associated with mortality (or . , table ). over the -year study period, -day mortality of cancer patients decreased by % (fig. ) . this trend persisted after adjustment for covariates, with cancer patients having significantly higher mortality (or= . , %ci: . , . ). between and , the adjusted -day mortality decreased by % every year. over the decade, -year mortality decreased by %. having cancer was the strongest individual predictor of -year mortality in the multivariate model (or= . , %ci: . , . ) (fig. ) . conclusions: between and , the number of cancer patients admitted to the icu increased steadily and significantly, while longitudinal clinical severity scores remained overall unchanged. although hematological and oncological patients had higher mortality rates than patients without cancer, both -day and -year mortality decreased significantly over the study period. introduction: sepsis was redefined in with the introduction of an increase in sequential organ failure assessment Δsofa) score of >= and the quicksofa (qsofa) as screening tools for sepsisrelated mortality. however, the implementation of these criteria into clinical practice has been controversial and the applicability for hematological patients is unclear. methods: we therefore studied the diagnostic accuracy of different sepsis criteria for sepsis and mortality according to definition criteria in a retrospective analysis of hematological patients in an academic tertiary care hospital. patient characteristics and variables were collected in icuand non-icu patients to determine the systemic inflammatory response syndrome (sirs), Δsofa and qsofa. by applying the definition of sepsis as "life-threatening organ dysfunction caused by a dysregulated host response to infection" [ ] as reference, the scores were evaluated. in patients with sepsis who died, / were sirs-negative, / Δsofa-negative and / qsofa-negative ( fig. and table ). conclusions: in conclusion, these findings suggest that criteria proposed in the sepsis- definition might have limitations as screening fig. (abstract p ) . results of the logistic regression analysis for (a) -day and (b) -year mortality. all covariates were statistically significant except for white race in the -year mortality model. ***p-value< - , **p-value< . , *p-value< . fig. (abstract p ) . longitudinal change in -day mortality for cancer patients (yes) compared with controls (no) over the -year study period. mortality in the cancer group decreased from % to % (- %), while mortality in the control group decreased from to % (- %). enoxaparin pharmacokinetics in patients with augmented renal clearance, preliminary results of a single center study introduction: augmented renal clearance (arc) has being described in some groups of critically ill patients. the aim was to investigate the impact of arc on the pharmacokinetics of enoxaparin. methods: this is a prospective study in a surgical and medical intensive care unit (icu) carried out from august to november . patients < years old, under prophylactic treatment with enoxaparin and normal plasma creatinine, were included. anti-xa activity was measured at second day under treatment. creatinine clearance was calculated from urine sample collected during -hours. arc was defined by a creatinine clearance >= ml/min/ . m . results: thirteen patients aged years old (± . ) were included. six patients developed arc and of them were in therapeutic range. seven patients did not develop arc and of them were in therapeutic range. there was no differences between the two groups in achieving therapeutic range (fisher test, p= . ). we did not observe thromboembolic events. conclusions: we found no relationship between arc and therapeutic failure in patients under prophylactic treatment with enoxaparin. introduction: this study reviewed argatroban use in patients in a tertiary hospital critical care unit. argatroban is a direct thrombin inhibitor approved for use in proven or suspected heparin-induced thrombocytopenia (hit) in patients with renal dysfunction. methods: this was a retrospective cohort study in a medical and surgical icu in a tertiary teaching hospital. data was collected for adult patients treated with argatroban for proven or suspected hit april-august , excluding patients requiring ecmo. we scored patients using the t score and compared this to an elisa immunoassay optical density score which quantifies the pf /h antibody level. also noted was use of continuous haemodialysis and organ failure using the sequential organ failure assessment (sofa), scoring >= defines failure. results: patients were treated with argatroban for proven or suspected hit. / patients had a positive elisa. there was no relationship between t score and elisa optical density (fig. ) . infusions were commenced at either the manufacturer recommended dose of μg/kg/min or a reduced dose of . μg/kg/min. patients receiving the reduced dose had a median of organs failing compared to in the standard regimen. the time taken to the first aptr in range was longer with the reduced dose regimen, however, the time to a stable aptr was less (table ). in patients the dose of argatroban never stabilised. died and was very sensitive to argatroban and required cessation of the infusion for interventions. in the reduced regimen group, there were episodes of bleeding, minor pr bleed in a patient with organs failure and upper gi bleed. conclusions: in this population of icu patients the t score did not correlate with the elisa optical density score, as found previously. patients with multi-organ failure mostly received the reduced starting dose. however, the bleeding events were still confined to this group. this correlates with previous studies that organ dysfunction necessitates a dose reduction for argatroban. results: the mean age in our study group was ± years. the effects of tpe on standard coagulation were increased aptt ( ± to ± s, p= . ) and decreased fibrinogen levels ( ± to ± mg/dl, p= . ). a non-significant decrease in platelet count was observed ( ± to ± /mm , p= . ). on rotem parameters tpe was associated with increased ct in extem ( ± to ± s, p= . ) and intem ( ± to ± s, p= . ) and increased maxvt on extem ( ± to ± s, p= . ) and intem ( ± to ± s, p= . ). all other rotem parameters changed non-significantly. the decrease observed in fibrinogen levels was not associated with a decrease in fibtem mcf ( ± to ± mm, p= . ). conclusions: our results demonstrate that tpe is associated with minimum changes in clot kinetics initiation that do not result in either pro-or anti-coagulant changes. therefore, tpe with fresh frozen plasma can be safely used in normal subjects. introduction: acutely ill patients are prone to critical illness anaemia, a multifactorial condition with potential contribution of iatrogenic anaemia defined as lowered hb due to large/frequent venepunctions. decline in hb is most pronounced in the first days of icu stay. it correlates with the need for rbc transfusion, but the impact on patient outcome is uncertain. the aim of this study was to determine impact of phlebotomy on change in hb (Δhb), and correlation of Δhb with need for transfusion, presence of central venous catheter (cvc) and patient outcome. conclusions: critical illness anaemia is an unexplained phenomenon. impact of phlebotomy is hard to unequivocally determine since there are many confounders. the change in hb levels during icu stay correlates with the need for transfusion that could cause immunomodulation and potentially adverse outcome. every effort should be made to maintain adequate hb levels and lower the risk of iatrogenic anemia. introduction: anemia is prevalent in critically ill traumatic brain injury (tbi) patients and red blood cell (rbc) transfusions are often required. over the years, restrictive transfusion strategies have been advocated in the general critically ill population. however, considerable uncertainty exists regarding optimal transfusion thresholds in critically ill tbi patients due to the susceptibility of the injured brain to hypoxemic damages. methods: we conducted an electronic self-administered survey targeting all intensivists and neurosurgeons from canada, australia and the united kingdom working caring for tbi patients. the questionnaire was developed using a structured process of domains/items generation and reduction with a panel of experts. it was validated for clinical sensibility, reliability and content validity. results: the response rate was . % ( / ). when presented with a scenario of a young patient with severe tbi, a wide range of transfusion practices was noted among respondents, with % favoring rbc transfusion at a hemoglobin level of g/dl or less in the acute phase of care, while % would use this trigger in the plateau phase. multiple trauma, neuromonitoring data, hemorrhagic shock and planned surgeries were the most important factors thought to influence the need for transfusion. the level of evidence was the main reason mentioned to explain the uncertainty regarding rbc transfusion strategies. conclusions: in critically ill tbi patients, transfusion practices and hemoglobin thresholds for transfusion are said to be influenced by patients' characteristics and the use of neuromonitoring in critical care physicians and neurosurgeons from canada, australia and the uk. equipoise regarding optimal transfusion strategy is manifest, mainly attributed to lack of clear evidences and clinical guidelines ( -year) . no significant associations were found between ffp:rbc ratio and mortality rates. patients with higher apache ii score received more platelet transfusions and mortality rates were higher in those who received platelets:rbc ratio > . on multivariate analysis, higher apa-che ii score was an independent predictor of increased mortality. conclusions: the compliance with the recommended : : ratio of blood products was poor. there was no association between transfusion ratios and mortality after adjusting for apache ii score. introduction: the lack of evidence-based medicine supporting the transfusion decision is illustrated by the wide range of blood product use during first-time coronary artery bypass grafting (cabg). use of red blood cells (rbc) ranges from to percent, while the use of platelets range from to [ ] . approximately percent of cabg patients suffer abnormal bleeding, with platelet dysfunction thought to be the most common culprit [ ] . methods: the objective of this study was to evaluate the use of allogeneic blood and blood products among patients undergoing first-time cabg over the past years. the first patients who underwent cabg (on-pump and off-pump) from st of march each year were included for analysis. the percentage of patients receiving rbc, fresh frozen plasma (ffp), platelet and cryoprecipitate during the first hours intra-and postoperatively were analysed. linear regression analysis was performed in each group. results: our analysis shows that the use of rbc decreased over the last years, in contrast to the use of the other investigated products. (see fig. ) the increase of platelets was the most pronounced with a direction coefficient of . and had the least variability (r = . ). (see fig. ) the decrease in rbc was less obvious than the rise in platelet use (direction coefficient of . ) and had a higher variability (r = . ). the consumption of ffp and cryoprecipitate stayed constant (direction coefficient of . and . respectively). the higher incidence of semi-urgent cabg in recent years, which involves continuation of anti-platelet therapy until the day before surgery, can be an explanation for our observed increased use of platelets. the observed decrease in rbc transfusion over the past years might be due to rising awareness of complications associated with red cell transfusion. introduction: red blood cells (rbc) transfusion is frequently required in cardiac surgery and is associated with increased morbidity and mortality rates. the aim of this study is to identify predictors of rbc transfusion for patients undergoing cardiac surgery, emphasizing the use of bioelectrical impedance analysis (bia). methods: this was a retrospective study of patients who underwent elective cardiac surgery between years and in a tertiary reference center. patients' demographic and clinical variables, preoperative bia measurements and postoperative data were analyzed. the univariate and multivariate logistic regression analyses were used to identify the predictors of postoperative rbc transfusion. all of the calculations were performed with ibm spss v. . introduction: red blood cells (rbc) transfusion is a common intervention in cardiac surgery and is associated with higher mortality rates and predisposes serious adverse events. the aim of this study was to determine whether red blood cells (rbc) transfusion is linked to long-term results after cardiac surgery. methods: this observational retrospective study included all of the patients who underwent any of the sts defined elective cardiac surgery types from to . we evaluated - year all-cause mortality rates and secondary postoperative outcomes defined by the sts risk prediction model. patients were categorized according to whether they received rbc transfusions postoperatively; long-term results were compared using cox-regression analysis and kaplan-meier method. introduction: transfusion of packed red cells (prcs) is an important treatment option for patients requiring intensive care but, like all treatments, it is not without risk. these patients, although may be more sensitive to anaemia, are also at increased risk of transfusionrelated complications. we conducted an audit of blood prescribing and administering practices in our intensive care unit. methods: audit proformas were placed in blood prescribing forms for a -month period. all transfusions of prcs were logged over this time, and transfusion triggers, post-transfusion haemoglobin (hb) and whether hb was checked between units was recorded, in addition to other supplementary information. results: over a -month period, transfusion events were recorded, with an average age of the transfused patients of years old (range - years). % of transfusion events were for low hb, % for bleeding and in % of cases the indication was not documented. for patients transfused for a low hb, the mean transfusion trigger was g/l (range: g/l - g/l). only % had a transfusion trigger of g/l or less, and a further % who were transfused for a low hb had a hb of g/l or more. % of transfusion events involved transfusing or more units and, in only % of these cases the hb was checked between units. excluding the two bleeding patients, the mean increase in hb following a single unit transfusion was . g/l (range g/l - g/l), whilst in patients transfused two units, the average increase in hb was g/l per unit transfused (range g/l - . g/l), suggesting single unit transfusions may have greater hb yields. conclusions: our audit demonstrated variability in transfusion triggers and progress needed with administering practices when transfusing multiple units of blood in the non-bleeding patient. we have since implemented measures to meet guidelines in both prescribing prcs with restrictive triggers and in the administration and assessment of hb between units, and will be re-auditing. introduction: there is a perceived increased risk of bleeding in cirrhosis patients undergoing invasive procedures. this lead to a high rate of empirical prophylactic transfusion, which has been associated to increased complications and cost. the best strategy to guide transfusion in these patients remains unclear. our aim was to compare three strategies to guide blood component transfusion prior to central venous catheterization (cvc) in critically ill cirrhosis patients. methods: single center, randomized, double-blinded, controlled clinical trial conducted in brazil [ ] . all cirrhosis patients admitted to the icu with indication for a cvc were eligible. participants were randomized : : to three transfusion strategies based on: ( ) standard coagulation tests (sct), ( ) rotational thromboelastometry (rotem) and ( ) restrictive. the primary outcome was proportion of transfusion of any blood component prior to cvc. secondary outcomes were incidence of major and minor bleeding, icu length of stay (los), and -day mortality. analysis was intention-to-treat. results: participants ( in each group) were enrolled between september and december . most were male ( . %) and listed for liver transplantation. the study ended after reaching efficacy in first interim analysis. there was no significant difference in baseline characteristics among groups. regarding primary endpoint, there was ( . %), ( . %), and ( . %) events in sct, rotem and restrictive groups, respectively (p < . ). there was no difference between sct and rotem groups (p > . ). overall -day mortality was . % and was similar between groups. icu los did not differ between groups. there was no major bleeding. overall minor bleeding occurred in . % with no difference between groups. conclusions: a restrictive strategy is safe and effective in reducing the need of blood component transfusion prior to cvc in critically ill cirrhosis patients. a rotem-based strategy was no different from transfusion guided by sct. introduction: desmopressin (ddavp) is a vasopressin analogue which improves platelet function. its general use as a haemostatic agent is still controversial. the aim of study was to evaluate the effect of prophylactic desmopressin in blood coagulation in patients undergoing heart valve surgery. methods: prospective, randomized, double-blind clinical trial performed at the heart institute of the university of são paulo. a total of adult patients undergoing heart valve surgery were enrolled from february to november . immediately after cardiopulmonary bypass weaning and heparin reversal, patients were randomized in ratio : to intervention group: ddavp ( . μg/kg) or control group. blood samples were drawn at three different times, at baseline (t ), hours (t ) and hours (t ) after study medication. blood coagulation and perioperative bleeding were analysed using laboratorial tests and thromboelastometry, chest tube drainage and requirement of allogenic transfusion within hours. results: a total of patients were allocated to intervention and to control group. blood levels of factor viii at t ( . conclusions: prophylactic use of desmopressin in heart valve surgery does not influence coagulation and thromboelastometric parameters. identifying the impact of hemostatic resuscitation on development of multiple organ failure using factor analysis: results from a randomized trial using first-line coagulation factor concentrates or fresh-frozen plasma in major trauma (retic study) p innerhofer introduction: to clarify how hemostatic resuscitation affects occurrence of multiple organ failure. methods: analysis of secondary endpoints of the retic study [ ] (coagulation factors, activated protein c (apc), thrombin generation, rotem parameters, syndecan- , thrombomodulin (tm) and d-dimer) measured at randomization, and after patients had received ffp or coagulation factor concentrates (cfc) at admission to icu, and hours thereafter. we used factor analysis to reduce the highly interrelated variables to a few main underlying factors and analysed their relation to mof before and after hemostatic therapy. results: the factors concentration, clot and hypoperfusion representing trauma-induced coagulopathy (table ) were comparable between groups at baseline (fig. ) and only high hypoperfusionscore predicted mof, while after therapy a low clot-score also predicted mof. only the changes of the clot-score independently affected occurrence of mof (p= . , adjusted or . , ci . - . ), while changes of concentration (p= . , adjusted or . , ci . - . ) and hypoperfusion (p= . , adjusted or . , ci . - . ) did not. a lower clot-score occurred after ffp transfusion than use of cfc, mainly through persistent thrombocytopenia (platelet count r - ffp vs cfc p< . ) (fig. ) . the higher concentration-score after ffp did not affect mof and ffp had no beneficial effect on fibrinolysis, syndecan- , tm or apc. conclusions: hemostatic resuscitation should augment the factor clot, which is feasible with early fibrinogen administration but not with ffp. the found platelet-saving effect of early fibrinogen administration is important as platelets play a major role in inflammation and transfusion of platelets did not correct thrombocytopenia. introduction: the trauma induced coagulopathy clinical score (ticcs) was developed to be calculable on the site of injury with the objective to discriminate between trauma patients with or without the need for damage control resuscitation (dcr) and thus transfusion [ ] . this early alert could then be translated to in-hospital parameters at patient arrival. base excess (be) and ultrasound (fast) are known to be predictive parameters for emergent transfusion. we emphasize that adding this two parameters to the ticcs could improve its predictability. methods: a retrospective study was conducted in the university hospital of liège. based on the available data in the register (from january st to december st ), the ticcs was calculated for every patient. be and fast results were recorded and points were added to the ticcs according to the ticcs.be definition (+ points if be < - and + points in case of a positive fast). emergent transfusion was defined as the use of at least one blood product in the resuscitation room. the capacity of the ticcs, the ticcs.be and the trauma associated severe hemorrhage (tash) to predict emergent transfusion were assessed. results: a total of patients were included in the analysis. ( %) needed emergent transfusion. the probability for emergent transfusion grows with the ticcs.be value (fig. ) . positive predictive values (ppv) and negative predictive values (npv) of the three scores are displayed in table . conclusions: our results confirm that be and fast results are relevant parameters that can be added to the ticcs for better prediction of the need for emergent transfusion after trauma. fig. (abstract p ) . probability for emergent transfusion with ticcs.be values. fig. (abstract p ) . boxplots show available measurements of extrinsically activated clot firmness at min (exa ), fibrin polymerization at min (fiba ) and platelet count at baseline (r ) and after therapy at admission to icu, and hours thereafter (r to r ) for the cfc (blue, n= ) and the ffp (yellow, n= ) group as well as for patients without (white, n= ) and with (grey, n= ) multiple organ failure. table ) for the cfc (blue, n= ) and the ffp (yellow, n= ) group, as well as for patients without (white, n= ) and with (grey, n= ) multiple organ failure. each factor is given at the measurement time point baseline (r ) and following haemostatic resuscitation at admission to icu, and hours thereafter (r to r ). introduction: the management of the critically ill polytrauma patient is complex and is often a challenge for the intensive care team. the objectives of this study is to analyze the oxidative stress expression in polytrauma cases as well as to evaluate the impact of antioxidant therapy on outcomes. methods: this prospective study was carried out in the clinic for anaesthesia and intensive care "casa austria", form the "pius brînzeu" emergency county hospital, timisoara, romania, with the approval of the hospital's ethics committee. clinicaltrials.gov identifier nct . the patients' selection criteria included an injury severity score (iss) of or higher, and age of or higher. patients were eligible for the study. they were divided in two groups, group a (antioxidant free, control, n= ), and group b (antioxidant therapy, study group, n= ). the antioxidant therapy consisted in continuous iv administration of mg/ h of vitamin c until discharge from icu. the patients included in the study presented with similar characteristics, and no statistically significant differences were shown between group a and b regarding age (p > . ), sex (p > . ), iss upon admission (p > . ), percentage of patients admitted in the icu more than hour post-trauma (p > . ), and associated trauma (p > . ). among patients in group b statistically significant differences were identified regarding the incidence of sepsis (p < . ), multiple organ dysfunction syndrome (p < . ), mechanical ventilation time (p < . ), and mortality (p < . ). no statistically significant differences were shown regarding the time spent in the icu (p > . ). conclusions: following this study we can state that the administration of substances with a strong antioxidant character has positive influences on the outcome of critically ill patients, decreasing the incidence of secondary pathologies as well as mortality rates. icc increased by . %, icd increased by . %, slightly increased ma, and ircl was nearly in the normal range. conclusions: rapid and accurate diagnosis of the coagulation system by lpteg method at different stages of traumatic disease allows for more accurate selection and adjustment of the therapy, which allows improving the prognosis of the disease. introduction: evidence for tranexamic acid (txa) in the pharmacologic management of trauma is largely derived from data in adults [ ] . guidance on the use of txa in pediatric patients comes from studies evaluating its use in cardiac and orthopedic surgery. there is minimal data describing txa safety and efficacy in pediatric trauma. the purpose of this study is to describe the use of txa in the management of pediatric trauma and evaluate efficacy and safety endpoints. methods: this retrospective, observational analysis of pediatric trauma admissions at hennepin county medical center from august to november compares patients who did and did not receive txa. the primary endpoint is survival to hospital discharge. secondary endpoints include surgical intervention, transfusion requirements, length of stay, thrombosis, and txa dose administered. results: there were patients [<=] years old identified for inclusion using a massive transfusion protocol order. twenty patients ( %) received txa. baseline characteristics and results are presented as median (iqr) unless otherwise specified, with statistical significance defined as p < . . patients receiving txa were more likely to be older, but there was no difference in injury type or injury severity score (iss) at baseline (table ) . there was no difference in survival to discharge, need for surgical intervention, or thrombosis (table ) . patients who did not receive txa had numerically higher transfusion requirements and longer length of stay, but these did not reach significance. conclusions: txa was utilized in % of pediatric trauma admissions at a single level i trauma center, more commonly in older patients. though limited by observational design, we found patients receiving txa had no difference in mortality or thrombosis. introduction: the risk of venous thromboembolism (vte) in trauma is greatly increased and one of the leading causes of morbidity and mortality after an accident [ ] . prophylactic measures to prevent vte primarily consist of anticoagulants. in instances in which anticoagulation is contraindicated or inadequate, inferior vena cava (ivc) filters can be used [ ] . however, insertion of ivc filter as a prophylactic measure is controversial as filter-related complications are well documented and increase with treatment time [ ] . the objectives of our study were to evaluate ivc filter insertion indications and filter related complications in pelvic trauma patients. methods: patients with pelvic fractures were operated during the study period / / - / / . all patients who received ivc filter during the period were included into analysis. relevant data was collected from electronic patient journal. results: thirty four patients received retrievable filters during the study period ( males and females) ( table ) . median age of patients was years (range, - ). the predominant indication ( %) was prophylactic insertion. the median indwell time was days (range - days). despite ivc filter insertion one patient experienced lung embolism and another -dvt. in eleven cases ivc filters were tried to be removed at the treating hospital. in two cases filter extraction was unsuccessful and in another two cases filters were left in place due to ivc thrombosis. conclusions: majority of ivc filters were inserted outside guidelines [ ] and proportion of prophylactic indications is significantly higher ( % vs %) than seen in registry studies [ ] . filter related complications were observed in % of patients. more restrictive approach to prophylactic ivc insertion should be exercised. the impact of preinjury antiplatelet and anticoagulant pharmacotherapy on outcomes in patients with major trauma admitted to intensive care unit ( conclusions: patients on preinjury anticoagulants and antiplatelet agents showed an increased mortality; this may be the result of the greater incidence of bleeding, the older age and more comorbidities in this groups. is enzymatic debridement better in critically burned patients? introduction: early debridement of burned tissue reduces infection rate, icu stay and mortality. the use of proteolytic enzymes such as bromelain allows a faster, more effective and selective debridement of denatured tissue, preserving and exposing healthy tissues, reducing debridement times compared to standard of care. methods: retrospective observational study performed in the critical burn unit (march to september ) including patients > years old with a total body surface area (tbsa) burned > % and < %, or > years old with a tbsa burned > %, who underwent enzymatic debridement. mean and standard deviation were used for normal quantitative variables and median and interquartile range in the opposite case. qualitative variables were presented by absolute and relative frequencies. results: mean age was . ± . years old, % males, apache ii (ri - ), absi (ri - ). median tbsa burned was % (ri - %), % (ri - ) were deep dermal or full thickness. time until debridement was hours (ri - ). . % (n= ) had incomplete debridement after first application, % (n= ) received regional anesthesia, % (n= ) didn't need blood transfusion. % of patients who didn't have vasopressors prior debridement, needed the use of it with a mean dose of , mcg/kg/min. % of patients with vasopressors prior treatment, required an increase of dose by a mean of . mcg/kg/min. median icu stay was days. mortality was %. conclusions: topical bromelain allows a fast start of tissue debridement with a low rate of failure. the need for fasciotomy and blood transfusion was very low. topical treatment involved a fast and simultaneous debridement of the tbsa burned, generating an inflammatory response that in some cases required vasopressors. . . / ). the bche activity was measured by using point-ofcare-test system (securetec detektions-systeme ag, neubiberg, germany). levels of the routine inflammation biomarkers, i.e. c-reactive protein (crp) and the white blood cell count (wbcc), were measured during the initial treatment period. measurements were performed at the admission, followed by , and -hour time points. injury severity score (iss) was used to assess the trauma severity. results: the observed reduction in the bche activity was in accordance with the change in the crp concentration and the wbcc. the bche activity measured at the hospital admission negatively correlated with the length of the icu stay in patients with polytrauma (r = - . , spearman's rank correlation coefficient). conclusions: the bche activity might be used as an early indicator for the magnitude of the systemic inflammation following polytrauma. moreover, the bche activity, measured at the hospital admission, might predict the patient outcome and therefore prove useful in early identification of the high-risk patients. pharmacological interventions for agitation in traumatic brain injury: a systematic review introduction: among tbi complications, agitation is a frequent behavioural problem [ ] . agitation causes potential harm to patients and caregivers, interferes with treatments, leads to unnecessary chemical and physical restraints, increases hospital length of stay, delays rehabilitation, and impedes functional independence. pharmacological treatments are often considered for agitation management following tbi. however, the benefit and safety of these agents in tbi patients as well as their differential effects and interactions are uncertain. methods: the major databases and the grey literature were searched. we included all randomized controlled, quasi-experimental, and observational studies with control groups. the population of interest was all patients, including children and adults, who have suffered a tbi. studies in which agitation was the presenting symptom or one of the presenting symptoms, studies where agitation was not the presenting symptom but was measured as an outcome variable and studies assessing the safety of these pharmacological interventions in tbi patients were included. results: we identified references with our search strategy. two authors screened after removal of duplicates. after searching the grey literature and secondary databases, a total of potential articles were identified. eleven studies in which agitation or an associated behavior was the presenting symptom, studies where agitation was not the presenting symptom but was measured as an outcome variable, and studies assessing the safety of these pharmacological interventions were identified. overall, the quality of studies was weak. in studies directly addressing agitation, pindolol and propranolol may reduce assaults and agitation episodes. amantadine and olanzapine may reduce aggression, whereas valproic acid may reduce agitated behavior. conclusions: there is weak evidence to support the use of pharmacological agents for the management of agitation in tbi. impact of decompressive craniectomy on neurological functional outcome in critically ill adult patients with severe traumatic brain injury: a systematic review and meta-analysis p bonaventure, ja jamous, f lauzier, r zarychanski, c francoeur, a turgeon chu de québec -université laval, québec, canada critical care , (suppl ):p introduction: severe traumatic brain injury is associated with high mortality and functional disability. several interventions are commonly used to control the intracranial pressure to prevent secondary cerebral injuries. among them, decompressive craniectomy (dc) is widely performed; however, its impact on functional outcome is still under debate. our objective was to assess the efficacy and safety of this procedure in adult patients with severe traumatic brain injury. methods: we systematically searched in medline, embase, cen-tral, web of science, conference proceedings and databases of ongoing trials for eligible trials. we included randomized controlled trials of adult patients with severe traumatic brain injury, comparing dc to any other intervention. our primary outcome was the neurological function based on the glasgow outcome scale. secondary outcomes were mortality, intensive care unit (icu) and hospital length of stay, intracranial pressure control, and complications. two reviewers independently screened trials for inclusion and extracted data using a standardized form. we used random effect models to conduct our analyses and the i index to assess heterogeneity. results: we identified citations, from which we included trials for a total of patients. we observed no impact on the [ ] . univariate logistic regression analyses were performed to identify predictors associated with the decision for icp monitoring. results: a total of adult patients were included (tables and ). the risk of poor outcome estimated by the impact model was associated to the decision to monitor icp (fig. ) . icp was more often monitored in patients with severe tbi, with one dilated pupil at admission and positive ct findings (in particular, high marshall scores). conclusions: according to our results, the clinician follows a multifactorial reasoning: the main determinants for the decision to monitor icp are gcs, pupils' abnormalities and, above all, ct findings. future studies will be needed to clarify specific indications for the clinicians in the identification of patients who would benefit from invasive monitoring. trajectories of early secondary insults after traumatic brain injury: a new approach to evaluate impact on outcome. introduction: secondary insults (si) occur frequently after traumatic brain injury (tbi). their presence is associated with a worse outcome. we examined the early trajectories of hypotension (sbp< mmhg), hypoxia (spo < %) and pupillary abnormalities from the prehospital settings to the emergency department (ed), and their relationship with -months outcome. methods: in this retrospective, observational study we included all tbi patients admitted to our neuro intensive care unit (nicu) from january to december . we defined the trajectories of si: -"sustained" if present on the scene of accident and at hospital admission, -"resolved" if present on the scene but resolved in ed, -"new event" if absent on the scene and present in ed, -"none" if no insults were recorded. we investigated the association of si trajectories with -months dichotomized outcome (glasgow outcome scale (gos); favorable= - ; unfavorable= - ). results: patients were enrolled in the final analysis. hypoxia and hypotension were related with unfavourable outcome when introduction: guidelines for management of pediatric traumatic brain injury recommend maintaining intracranial pressure (icp) < mmhg [ ] . use of . % sodium chloride (nacl) is considered safe and effective for management of icp in adults, but evidence for concentrations > % in pediatrics is limited. this study will describe the safety and efficacy of . % nacl in reducing icp among pediatric patients. methods: this retrospective study evaluated patients <= years old who received . % nacl and had continuous icp monitoring. cerebral perfusion pressure (cpp), mean arterial pressure (map), icp, and brain tissue oxygenation (pbto ) were recorded hourly and were compared to baseline for hours after each dose. safety outcomes included peak serum sodium, peak serum chloride, and the incidence of stage acute kidney injury (aki) (serum creatinine elevation >= . mg/dl or >= %) [ ] . results: between august and july , eligible pediatric patients received doses of . % nacl; doses were included in the analysis of perfusion parameters. mean age was . +/- years ( months to years), and the median initial glasgow coma scale score was . subjects received a median of four . % nacl boluses, with a mean dose of . +/- . ml/kg. significantly lower icp and higher cpp (p< . ) were observed at all post-treatment time points (fig. ) ; pbto was also significantly increased during of the hours recorded (p< . ). there was no difference in map. peak post-treatment serum sodium and chloride were +/- meq/l and +/- meq/l, respectively (fig. ) . stage aki was observed in . % of patients, and in-hospital mortality was . %. conclusions: our data suggests that . % nacl is a safe and effective therapy for elevated icp in pediatric patients. methods: we performed a prospective study in adult patients with mild head trauma (gcs and ) qualified for acquisition of urgent head ct scan. the clinical symptoms potentially related to intracranial lesion including abnormal vitals, vomiting, headache, persistent dizziness were recorded. ons as well as head ct were then performed. all ons examinations were executed by an experienced sonographer to eliminating interrater bias. head ct findings were dichotomized as positive or negative finding for ich based on formal radiology reports. the patients' disposition including admission, surgery and safe discharge were followed. results: patients were enrolled for the survey. patients had at least one symptom related to potential intracranial lesion ( . %). the mean onsd was ± mm. patients were found to have ich and underwent neurosurgery thereafter. no significant difference of onsd was found between the groups with and without ich, as well as the group receiving surgery or conservative treatment. with introducing a conventional mm threshold of onsd, the sensitivity, specificity, ppv and npv was . , . , . and . , respectively. while incorporating occurrance of at least one positive clinical symptom with the onsd measurement greater than mm as a composite threshold, the sensitivity, specificity, ppv and npv was . , . , . and . , respectively. conclusions: the diagnostic value of ons in mild head trauma is defective. nevertheless, with the supplemental aid of recognition of clinical symptoms relevant to potential intracranial lesion, the overall accuracy would improve. a correlation between ykl- concentrations in cerebrospinal fluid and marshall classification in traumatic brain injurypreliminary results g pavlov , m kazakova , p timonov , k simitchiev , c stefanov , v sarafian medical university -plovdiv, plovdiv, bulgaria, university of plovdiv, plovdiv, bulgaria critical care , (suppl ):p introduction: establishment of prognostic models in traumatic brain injury (tbi) would improve the classification based on predictive risks and will better define treatment options [ ] . in recent years, one of the most intensively studied glycoprotein is ykl- . it is expressed as a consequence of broad spectrum of inflammatory and malignant diseases [ ] . this is study aimed to investigate the level of ykl- in tbi patients and its relationship with several clinical models. methods: we determined plasma and cerebrospinal fluid (csf) ykl- levels in six ( ) patientson the th and th hour after the tbi. each patient was examined by physical and instrumental methods for somatic and neurological status, clinical assessment and prognostic scales (gcs, marshall classification, apache iii). routine haematological and biochemical tests were also performed. as control served the csf of age-matched suddenly deceased healthy individuals (n = ), which was examined post mortem for ykl- levels. results: we found no significant difference between plasma ykl- levels till th and th in all patients (mean difference ± sd: ± ng/ml ) and calculated cerebral autoregulation (ar) as correlation coefficients (pearson) for each ih wave. z-ratios were divided according to binary ar outcome and correlation calculated with intracranial pressure before, during and after the ih waves. results: our preliminary analysis demonstrated a negative correlation between intracranial pressure and z-ratio in the grouped ih waves with preserved ar, but no correlation in the grouped ih waves with impaired ar (table and fig. ). this indicates a decrease in power in the eeg low frequencies ( - hz) and/or an increase in the eeg high frequencies ( - hz) for increased values of intracranial pressure when ar is preserved. conclusions: features of ih waves differ depending on the ability of the injured brain to autoregulate cerebral blood flow. these features might include different signature of eeg frequency changes. the causative links and clinical significance of the different eeg patterns remain unexplored and might represent a signature of neurovascular coupling. introduction: targeted temperature management of patients who have suffered a traumatic brain injury is often used in the hope of preventing further insult to the brain; however, there is no uniform approach to managing temperature either locally, nationally or internationally, and maintenance of goal temperature in this patient population is often challenging due to hypothalamic injury. we sought to evaluate the feasibility and safety of an esophageal heat transfer device (ensoetm, attune medical, chicago, il) to perform temperature management of patients suffering from traumatic brain injury. methods: this was an irb-approved prospective study of patients undergoing temperature management after traumatic brain injury. patients were treated with an esophageal heat transfer device connected to an external heater-cooler, and maintained at target temperature for at least hours. patient temperature obtained via foley catheter was recorded hourly, and the deviation from goal temperature during treatment reported. results: a total of patients were treated from august to may . temperature targets during treatment ranged from . to . degrees c. maintenance of target temperature was successful, with % of readings within +/- degrees c of target, and % of readings within +/- . degrees c of target. one patient developed a small hydrothorax, not attributed to device use. all patients survived to discharge from the icu, with median cpc of (range to ). conclusions: targeted temperature management of patients with traumatic brain injury using an esophageal heat transfer device was feasible and safe, providing a tight maintenance of goal temperature in this challenging patient population. introduction: traumatic brain injury (tbi) represents a serious problem in europe. it still is the principal cause of death in us and europe. every year in italy people on , suffers of tbi and on , dies. disability and incapacity from tbi provides "strong ethicals, medicals, social and health economy imperative to motivate a concerted effort to improve treatment and preventions" methods: our hospital is the hub for modena's county for tbi and we took part in the past year on european project creactive (collaborative researce on acute traumatic brain injury in intensive care medicine in europa) as branch of italian group giviti (gruppo italiano per la valutazione degli interventi in terapia intensiva). our study concerned about patients with tbi dismissed from icu that "personally" or by the family will accepted the consensus to be included in our follow up conducted after months from the dismissal. we collected clinical data from the admission to the dismissale and measured impact of tbi on all day life with gos-e and qolibri-os using telephonical interview. results: we collected data about patients, answered to the telephonical follow-up and only compilated the qolibri-os. we found out that patients admitted with lower gcs has worst outcome in terms of quality of life. it also appears that anisocoria during icu staying represents an odds ratio for death and is connected with worst quality of life after months from the dismissal (tables & ) . inability to re-start a normal work-activity appeared to be the most important factor on the perception that our patient have of their new lives. conclusions: anisocoria seems to be an indicator of severe brain damage. gcs, despite it's simplicity, still represent the best and easiest way to score tbi. work impairment appear to be the most important disability to determine subjective perception of quality of life after tbi, so efforts have to be made to improve work rehabilitation after the dismissal from hospital. introduction: hyperventilation (hv) reduces elevated intracranial pressure (icp) by changing autoregulatory functions connected to cerebrovascular co reactivity. criticism to hv is due to the possibility of developing cerebral ischemia and tissue hypoxia because of hypocapnia-induced vasoconstriction. we aimed to investigate the potential adverse effects of moderate hv of short duration in the acute phase in patients with severe traumatic brain injury (tbi), using concomitant monitoring of cerebral metabolism, continuous brain tissue oxygen tension (pbro ), and cerebral hemodynamic with transcranial color-coded duplex sonography (tccd). methods: a prospective trial was conducted between may and may at the university hospital of zurich. adults (> years), with non-penetrating tbi, first gcs < , icp-monitoring, pbro and/or microdialysis (md)-probes were included within hours after injury. data collection and tccd measurements took place at baseline (a), at the begin of moderate hv (paco - . kpa) (c), after minutes of moderate hv (paco - . kpa) (d), and after return to baseline (e) (fig. ) . repeated measures anova was used to compare variables at the different time points followed by post hoc analysis with bonferroni adjustment as appropriate. p-value < . was considered significant. results: eleven patients were included ( % males, mean age ± years). first gcs was ( - : median and interquartile range). data concerning paco , icp, pbro , mean flow velocity (mfv) in the middle cerebral artery, and md values are presented in table . during hv, icp and mfv decreased significantly. pbro presented a trend of reduction. glucose, lactate and pyruvate did not change significantly ( table ) . conclusions: short episodes of moderate hv have a potent effect on the cerebral blood flow, as assessed by tccd, reduce icp and pbro , and do not induce significant changes in cerebral metabolism. outcome of pediatric patients six months after moderate to severe tbi -results of creactkids study from three picu in israel paco arterial partial pressure of co , cpp cerebral perfusion pressure (mmhg), icp intracranial pressure (mmhg), pbro brain tissue oxygen tension (mmhg), mfv mean flow velocity in the middle cerebral artery introduction: delirium is a major cause of complications in postoperative patient in icu. risk factors for delirium include poor cerebral hemodynamics and peri-operative cerebral desaturations. intraoperative target cerebral oximetry monitoring may decrease the incidence of postoperative delirium in elective major abdominal surgery patients. methods: a single-blinded, randomised controlled trial in patients undergo elective major abdominal surgery who received postoperative care in surgical icu with age more than years were randomised into two groups. the intervention group was received intra-operative target cerebral oxygen monitoring using cerebral oximetry whereas the control group was not. delirium was assessed in both group at , , hour postoperatively. other risk factors for delirium, mechanical ventilator day, length of icu stay, length of hospital stay and post-operative complication were recorded. results: from august -march , patients who met the criteria were randomised to patients in intervention group and patients in control group. overall incidence of delirium was . % (intervention . % vs control . %, p= . ). baseline cerebral oxygen in intervention group was . ± . %. desaturation below % from baseline was found in from patients ( . %) and was the only significant risk factor associated with delirium (p=. , odd ratio . ). there was no significant different in mechanical ventilator day, icu length of stay, hospital length of stay and postoperative complication between both groups. there was no complication associated with application of the cerebral oximetry probe in the intervention group. conclusions: from this preliminary report can not demonstrated the significant different of intra-operative target cerebral oxygen monitoring by using cerebral oximetry in prevention of delirium. however the reduction of cerebral oxygen more than % from baseline in intervention group showed significantly associated with delirium postoperatively. the set score as a predictor of icu length of stay and the need for tracheotomy in stroke patients who need mechanical ventilation introduction: set score was initially developed as an in-house screening tool based on tracheotomy predictors identified in several retrospective studies. it combined the categories of neurological function, neurological lesions, and general organ function/ procedure, and weighed by allocation of certain point values [ ] . in our study it was very interesting to us to find a tool to judge application of early tracheotomy, and as we have a good culprit number from stroke cases so we decided to try to apply this score in our icu after discussion with the inventor of this score. methods: stroke patients were prospectively included in the study as they were ventilated or were very little potential for ventilation and assessed by the stroke-related early tracheotomy score (set score, table ) within the first h of admission (table ) . endpoints were length of stay and ventilation time (vt) after doing early tracheotomy. we examined the correlation of these variables with the set score using standard analytical methods. results: the set score with a value cutoff point of had a significant effect on decision of making tracheotomy and hence decreasing ventilation time and length of stay in icu, which affected outcome (figs. & ) . conclusions: all efforts must be exhausted in neuro intensie care to decrease the secondary changes of brain injury after stroke,early tracheotomy is a good tool to decrease length of stay in icu and ventilation time in these patients.inventing a tool to judge these decisions of doing tracheotomy was a challenge. set score proved to be valuable.further multi center trials are needed. fig. (abstract p ) . specificity for the cutoff point of set score. cut point of is the best to predict tracheostomy with sensitivity of . % and specificity of . %. cut point of is the best to predict early tracheostomy with sensitivity of . % and specificity of . %. since no patients had score so the previous analysis that consider cut-point of should remain the same but just change the number in the text to contraindication for pharmacological vte prophylaxis ( . %). overall, ncc patients were more likely to receive mechanical ( . % icu days) than pharmacological vte prophylaxis ( . % icu days), however pharmacologic was more likely among younger patients with lower apache ii scores. guideline concordant care varied by recommendation; lower for pharmacological and higher for mechanical vte prophylaxis. conclusions: ncc patients uncommonly receive guideline concordant pharmacological vte prophylaxis. collectively, our findings suggest that current vte prophylaxis prescribing practices may reflect uncertainty around risks associated with vte prophylaxis among ncc patients. methods: we retrospectively analysed prospectively collected data from consecutive ich patients that received dvt prophylaxis in a tertiary hospital. he was defined as an increase of > ml measured using the abc/ method or the semiautomatic software based volumetric approach. using multivariate analysis, we analysed risk factors including early dvt prophylaxis for he> h, hospital mortality and poor -month functional outcome ( m modified rankin score> ). results: patients presented with a median gcs of (iqr - ), hematoma volume of ml (iqr - ) and were y old (iqr - ). % received early dvt prophylaxis, % late dvt prophylaxis and % had unclear bleeding onset. hematoma volume was smaller in the early dvt prophylaxis group with . ml (iqr - . ) vs . ml (iqr - ) in the late prophylaxis group (p= . ) without any other significant differences in disease severity. delayed he (n= / , . %) was associated with higher initial hematoma volume (p= . ) and lower thrombocyte count (p= . ) but not with early dvt prophylaxis (p= . ) in a multivariate analysis adjusted for known risk factors. early dvt prophylaxis was not independently associated with m outcome. conclusions: although limited by the retrospective design, our data suggest that early dvt prophylaxis (< h) may be safe in patients presenting with primary ich, which supports the recommendations given by the neurocritical care society. introduction: there is a paucity of literature describing the relationship between clevidipine and its impact on intracranial pressure (icp). the safety of clevidipine in patients with intracranial hemorrhage is often extrapolated from studies using nicardipine, which has demonstrated a neutral effect on icp [ ] . the objective of this study was to determine if there was a relationship between clevidipine initiation and changes to cerebral hemodynamic parameters. methods: this study was a retrospective analysis of adults admitted to hennepin county medical center between july and july . individuals were included if they had intracranial bleeding and icp data recorded prior to initiation of a clevidipine infusion. baseline demographic data was collected, including age, gender, type of injury, and initial glasgow coma score (gcs introduction: aneurysmal subarachnoid hemorrhage (sah) is an acute cerebrovascular event with high mortality and is an important cause of neurologic disability among survivors. many complications in the course of sah, such as hydrocephalus, also play a role in the poor outcome. the aim of the study was to describe the characteristics of patients with sah admitted to the icu to evaluate the factors associated with outcome. methods: this study was conducted in two reference centersone in rio de janeiro and one in porto alegre. from july to september , every adult patient admitted to the icu with aneurysmal sah was enrolled in the study. data were collected prospectively during hospital stay. the primary endpoint was mortality and dichotomized functional outcome (poor outcome defined as glasgow outcome scale to ) at hospital discharge and months. dichotomous variables were analyzed using two-tailed fisher's exact test. results: a total of patients were included. demographic characteristics are presented in table . frequency of clinical and neurological complications are presented in table . in univariate analysis, factors most frequently seen in patients with unfavorable outcome were seizure ( % vs %, p= . ), hydrocephalus ( % vs %, p< . ), meningitis ( % vs %, p= . ), rebleeding ( % vs %, p= . ), vasospasm ( % vs %, p= . ), pneumonia ( % vs %, p< . ), sepsis/septic shock ( % vs %, p< . ), postsurgical neurological deterioration ( % vs %, p= . ) and delayed cerebral ischemia ( % vs %, p< . ). at months, out of patients with follow-up, % had poor outcome. conclusions: sah is associated with high morbidity. both neurological complications as clinical complications were associated with unfavorable outcomes. therapeutic interventions to prevent those may have an impact on clinical outcomes. introduction: brain tissue hypoxia (brain tissue oxygen tension, pbto < mmhg) is common after subarachnoid hemorrhage (sah) and associated with poor outcome. recent data suggest that brain oxygen optimization is feasible and may reduce the time with brain tissue hypoxia to % in patients with severe traumatic brain injury [ ] . little is known about the effectiveness of protocolized treatment approaches in poor-grade sah patients. methods: we present a retrospective analysis of prospectively collected data of poor-grade sah patients admitted to tertiary care centers where pbto < mmhg was treated using an institutional protocol. treatment options were left to the discretion of the treating neuro-intensivists including augmentation of cerebral perfusion pressure (cpp) using vasopressors if necessary, treatment of anemia and targeting normocapnia, euvolemia and normothermia. the dataset used for analysis was based on routine blood gas analysis for hemoglobin data matched to hourly averaged data of continuous cpp, pbto , temperature and cerebral microdialysis (cmd) samples over the first days of admission. results: patients were admitted with a gcs of (iqr - ) and were (iqr - ) years old. overall incidence of brain tissue hypoxia was %. during this time we identified associated episodes of cpp< mmhg ( %), hyperglycolysis (cmd-lacta-te> mmol/l, cmd-pyruvate> μmol/l; %), pco < mmhg ( %), metabolic distress (cmd-lactate-to-pyruvate-ratio> ; %), pao < mmhg ( %), hb< g/dl ( %), and temperature> . °c ( %) (fig. ). of these variables only hyperglycolysis was significantly more common ( %) during episodes of normal pbto ( % of episodes). conclusions: underutilization of ivt despite the overwhelming evidence that support the effectiveness of such therapy can be partly attributed to the fear of hemorrhagic complications. this fear is not justified by current data. the estrangement of the emergency medicine community regarding ivt and the domination of stroke experts in decision making is also a barrier. regional wall motion abnormalities and reduced global longitudinal strain is common in patients with subarachnoid hemorrhage and associated with markedly elevated troponin k dalla sahlgrenska university hospital, gothenburg, sweden critical care , (suppl ):p introduction: stress-induced cardiomyopathy after subarachnoid hemorrhage (sah) is a life-threating condition associated with poor outcome. regional wall motion abnormalities (rwma) is a frequent finding, however, assessment of rwma is known to be difficult. in the present study we hypothesized that global and regional longitudinal strain (gls and rls) assessed with speckle tracking echocardiography can detect myocardial dysfunction indicated by increased levels of the cardiac biomarker troponin (tnt). methods: this prospective study comprised patients with sah. the tnt was followed daily from the admission up to days postadmission and elevated tnt was defined as > ng/l. a transthoracic echocardiography examination was performed within hours after the hospitalization. the peak gls was determined using the three apical projections and presented as the mean of the segments. reduced gls was defined as > - % and reduced rls was considered present when segmental strain was > - % in > adjacent segments. introduction: deviations from strict eligibility criteria for intravenous thrombolysis (ivt) in ischemic strokes regarding either license contraindications to alteplase or relative contraindications to thrombolysis have been reported in international literature, with conflicting results on patients' outcome.the aim of our study was to evaluate safety and efficacy for patients receiving ivt outside standard inclusion criteria. methods: retrospective analysis of our department's thrombolysis database.we compared patients with strict protocol adherence (strict protocol group) [mean age years and national institutes of health stroke scale (nihss) at admission /range - ] and patients with protocol deviations (off-label group) [mean age years and nihss at admission /range - ],in particular patients > years old, patients with mild stroke-nihss< ,and with symptom-to-needle time - . hours ( patients had deviations). results: patients in the off-label group were older but had no difference in baseline severity scores (sapsii, nihss). they had no statistically significant difference on short-term (nihss at days, need for critical care support, primary adverse event) and long-term (mortality,functional outcome at months) outcome measures when compared to standard protocol patients. conclusions: in accordance with international literature,off-label thrombolysis is save and equally effective to standard protocol thrombolysis.thrombolysis strict protocol needs expansion of inclusion criteria. introduction: most scales (gcs,nihss) don't consider the pathway of secondary acute brain failure (sabf). neuron-specific-enolase (nse) could be usefull in diagnostic and treatment pts. with sabf [ , ] . methods: prospective study incl. pts. with abf. pts. were identical in condition, age and comorbidies. in main group, nse examed and choline alfoscerate was used, pts. was divided into subgroups ia (n= ) with acute ischemic stroke(ais) and ib (n= ) pts. with posthypoxic encephalopathy. the control group (n= ) pts. with ais treated by loc.protocol № . clinical, laboratory, and imaging variables were fully compared. pts. examed by abcde algorithm, gcs and nihss. brain ct, carotid doppler performed. considering criteria:nse(days , , ), neurological status, length of stay in icu (icu los). "ss- . "was used. results: the baseline nse was higher and correlated to nihss ( . ± . , ÷ = . ) in all pts. in ia, ib sbgroups nse decreased for - days vs. control group - days (÷ = . ) and correlated with regression neurological deficit. icu los in main group was . ± . days vs. control group . ± . days. sensitivity and specificity of nse as a marker of brain injury in pts. with ais were and % and in posthypoxic pts. were and %, respectively, which showed nse as eligible diagnostic criterion of posthypoxic cerebral edema. in ia (ais) pts. and ib (posthypoxic edema) were confirmed by increasing nse in fold and -fold respectively more vs. pts. who had only brain ct at first day. nse also correlated with regression neurological deficit and improving of the neurological status. although, two pts. in iib group died with nse - ìg/ml conclusions: . nse is an effective marker of the severity of damages even in the sabf, and shoved efficacy efficacy of treatment. . negative outcome can be in pts. with sabf and more -fold increasing nse and increasing up to - ìg/ml is a mortality predictor. . we included nse in local protocols p n-terminal pro-brain natriuretic peptide as a bio-marker of the acute brain injury introduction: the detection of biomarkers levels facilitates an early diagnosis of brain tissues damage, allows assessing the prognosis of the disease and its outcome, and performs the monitoring of the patient treatment. methods: we studied patients ( m, f.). st group comprised patients with severe brain trauma: asurvivors with good outcome (on glasgow outcome scale groups i-ii) (n= ), bdead or severely disabled (on glasgow outcome scale groups iii-v) (n= ). nd group comprises patients with intracranial and sub-arachnoid hemorrhages: assignment to groups a (n= ), b (n= ) was done using the same criteria as group . rd group comprises patients operated in conjunction with brain tumor. assignment to groups a (n= ) and b (n= ) was done using the same criteria as groups and . we tested the level of n-terminal pro-brain natriuretic peptide in blood ( - pg/ml) between st and rd days after severe brain injury and then every - days for the total duration of days. results: : statistical analysis failed to demonstrate noticeable difference in the level of ntprobnp between groups , , . we detected the differences between subgroups (p< . ). patients from groups a, a, a (n= ) ntprobnp level stayed below pg/ml in cases ( %), in the cases ( %) the level was above pg/ml, but by - th day decreased to the normal values. for patients in subgroups b, b, b (n= ) in cases ( %) ntprobnp level was above pg/ml at least once, in cases ( %) level stayed below pg/ ml but remain high for the entire duration of the study without significant decrease. conclusions: all the patients with acute brain injury show the increased level of ntprobnp above normal values, irrespective of ethiology of injury. in case when ntprobnp level increases above pg/ml and/or does not decrease to the normal values it is possible to predict a negative outcome. introduction: cerebrovascular and coronary artery diseases share many of the same risk factors [ ] . cardiac mortality accounts for % of deaths and is the second commonest cause of death in the acute stroke population, second only to neurologic deaths as a direct result of the incident stroke. methods: this is a prospective observational study from july to april done on adult patients (groupi: pts acute ischemic strokes & group ii: pts as control) in kafr-elsheikh general hospital icu. inclusion criteria: all patients with acute ischemic stroke while exclusion criteria: patients with heart or renal failure/sepsis&septic shock/ischemic heart disease or hemorrhagic stroke,full clinical examination&labs including admission quantitative serum cardiac troponin i elisa immunoassay,ecg, d echocardiography&ct brain on day & ,alberta stroke program (asp) early ct (aspect) to predict neurological outcomes and mortality in patient with acute ischemic stroke within days so survivors vs non-survivors in group were divided to g a & g b respectively. results: dyslipidemia, hypertension, diabetes mellitus were significant comorbidities in all ischemic stroke pts.tlc, urea, inr and troponin were significantly higher in case group vs control group.gcs was found to be lower in non-survivors at day &at rd day follow up while aspect was significantly lower only at rd day follow up.troponin level was significantly higher in non-survivors g b, it was also higher in patents who developed convulsion later during their icu stay& it was significantly inversely correlated to gcs and asp. troponin had sensitivity % and specificity % (roc curve analysis) conclusions: troponin level was predictor for mortality in patient with acute ischemic stroke.it is well correlated to gcs and asp on admission.it was a predictor for occurence of convulsions later in icu stay. introduction: based on examination and treatment of hyperkinetic disorder in patients with uws and mcs, we supposed that hyperkinesis manifesting the formation of the generator of pathologically enhanced excitation in cerebral cortex, basal ganglia, which subsequently causes the formation of hyperkinesis. halogencontaining anesthetic sevoflurane had a good clinical effect in patients with prolonged impairment of consciousness. methods: the study included patients with uws ( -hypoxia, -encephalitis) and patients with mcs ( -hypoxia, -encephalitis). hyperkinetic disorder presenting as permanent myoclonus of arms and legs, face. all patients were performed head mri and eeg (before, during and after anesthesia), crs-r assessment, patients -[ f]-fgd pet. initial anesthesia: propofol - mg/kg, rocuronium bromide (esmeron) , mg/kg, fentanyl - mg/kg and clonidine (clophelin) . - . mg/kg. maintenance of anesthesia is carried out due to the following scheme: inhalation anesthesia using sevoflurane ( . - . vol%, mac . - . ). additionally, during the nd - th hours of medical anesthesia was prescribed the intravenous injection using ketamine - mg/kg/hr. the anesthesia is used during hours. the patients were nurtured by balanced mixtures through nasogastric tube. after hours the patients were gradually transferred to the autonomous breathing. the control clinical and instrumental studies to evaluate the therapy effectiveness (eeg, crs-r) were performed. results: in patients ( mcs, uws) was observed the hyperkinetic disorder regression as decrease of hyperkinesis manifestation, patients didn't have a significant dynamics. conclusions: the artificially formed "pharmacological dominant" (using sevoflurane and ketamine) may decrease the activity of pathological system of the brain, which clinically presented as significant decrease of hyperkinesis manifestation in out patients. -year experience of using benzodiazepines in predicting outcomes and targeted treatment of patients in unresponsive wakefulness syndrome (uws). introduction: we accepted a hypothesis that in some patients uws is a consequence of a pathologic system (ps), that limits the brain functional activity. identification of a ps allow to predict consciousness recovery. eeg registration under benzodiazepines test (bt) has become the method of ps identifying in uws patients. methods: we examined uws patients ( -traumatic, -non traumatic). crs scales assessment, eeg with bt, mri of brain were performed for all patients. the midazolamum was administered iv . mg/kg,.in - min after bzd was recorded eeg for min. the test was considered to be positive if against the background of bzd eeg pattern restructuring was observed: the low-amplitude eeg activity was rebuilt with the advent of alpha-and beta-spectrum.in patients with slowwave activity of theta-and delta-spectrum appeared stable fast forms, and in patients with baseline polymorphic eeg pattern was recorded prevalence of alpha activity and (or) the alpha rhythm. in order to confirm the correlation between the bzd effect and eeg pattern restructuring, flumazenil was administrated at rate of . mg every to minutes until the original eeg pattern has been registered again. results: the bt was true positive (recovery consciousness in - month later) in traumatic and non traumatic patients. true negative (permanent uws month later) in traumatic and non traumatic patients. false positive - traumatic, non traumatic. false negative traumatic, non traumatic patients. sensitivity bt to vs/uws = . % sensitivity to mcs = . % conclusions: our data confirmed the correctness of hypothesis that a ps limits the activity of the brain in patients in a uws. we proposed diagnostic method of a ps activity and suppression. apparently, bzd are the drugs of first stage examination choice in the treatment of uws patients. early identification of sepsis-associated encephalopathy with eeg is not associated with short-term cognitive dysfunction introduction: septic-associated encephalopathy (sae) affects approximately % of septic patients. recent studies showed sae is associated with short-term mortality and long-term cognitive disability. however, diagnosis of sae is one of exclusion and its association with short-term cognitive deficit is uncertain. the aim of this study is to evaluate the sensitivity of clinical examination in detecting sae. the association between sae and short-term cognitive impairment is also assessed. methods: prospective observational study enrolling adult septic patients admitted to a mixed icu. exclusion criteria were: encephalopathy from another cause, history of psychiatric/neurologic disease, cardiac surgery. all patients received continuous eeg monitoring and were assessed for sae for up to days after inclusion. we performed a comprehensive consciousness assessment twice daily during the icu (gcs; full outline of unresponsiveness, four; coma recovery scale-revised, crs-r; reaction level scale , rls ; confusion assessment method for the icu, cam-icu). we defined altered brain function as gcs< , no correlation between cognitive function at hospital discharge and severity of eeg alteration was found. conclusions: eeg was more sensitive than clinical assessment in detecting sae. altered eeg was not associated with short-term cognitive function. analysis of the training needs in italian centers that use brain ultrasound in their daily practices: a descriptive, multicenter study r aspide introduction: as mission of siaarti neuroanesthesia and neuroicu group of study, we are mapping out the brain ultrasound training needs in our centers. although brain ultrasound is widely used to study the intracranial vessels and other issues, it is still not clear the homogeneity of the skills required in both neuro and general icu in italy. the aim of this study is to explore the use of us-tcd and validate a collection of criterea which would prove useful in any future national wide survey. methods: starting from sept. the seven center involved (bologna, catania, pisa, verona, bergamo, cesena, roma) collected clinical and sonographic data, basing on a crf of twenty criteria such as: kind of hospital and icu, number of beds and neuro-patients/year, the physicians specialization trained to perform us-tcd, the kind of us doppler device used and the kind of training course followed. as a second step, data were analyzed by coordination team, as third step, during annual siaarti conference, these centers had a deep discussion on these selected items, further modifying and adapting the content of the items. results: the result is a ready list of items, an available tool for all the participant centers, that are going to start with an internal test survey for a final validation. conclusions: there is more than one path to train a physician on brain us in italy and there are new possible applications, even outside of the neuro sub-speciality. from the preliminary discussion, it is clear that in italy we have a inhomogeneous frame of training and use. this group of study believes that among the anesthesiologists/intensivists, it is possible to find a useful number of physicians interested in training on this topic. the main aim is the production of a validated criterea collection, available for eventually future national survey, useful to help map out the real national training needs in italy on us brain. perinatal neurosurgical admissions to intensive care c nestor, r hollingsworth, k sweeney, r dwyer beaumont hospital, dublin, ireland critical care , (suppl ):p introduction: beaumont hospital is the neurosurgical centre for ireland serving a population of . million. we present data on all perinatal patients who required icu admission for neurosurgical conditions over an year period. our data presents an insight into the incidence and outcome of neurosurgical conditions during pregnancy methods: searching our database identified pregnant and recently pregnant patients admitted to icu with neurosurgical conditions. patient data was collected retrospectively by review of charts and of an electronic database. a further pregnant patients were admitted for neurosurgical intervention but did not require critical care. results: intracranial haemorrhage was the most common diagnosis ( subarachnoid haemorrhage and had intra-cerebral haemorrhage). patients presented with intracranial tumours and patient had a traumatic brain injury. patient was admitted post spinal tumour resection. patient was referred with an ischemic stroke after iatrogenic injury to the carotid and vertebral artery. the requirement for organ support in this cohort of patients was high; % required ventilation and % inotropes. patients underwent neurosurgical intervention & medical treatment. maternal deaths occurred at & weeks gestation. the modified rankin score (mrs) on discharge from hospital was <= for of the surviving patients (median= ). of the pregnancies (all singleton) there were foetal deaths. patient miscarried spontaneously at weeks, had a medical termination of pregnancy at weeks to facilitate chemotherapy and foetus died after maternal death at weeks. the remaining patients delivered normal babies. conclusions: neurosurgical disease requiring icu admission during pregnancy is rare; our data suggest an incidence of case per million population. maternal outcomes were mixed with more than half having a mrs> on discharge. foetal outcomes were good with only one miscarriage and good neurological outcome in all surviving infants. stepwise multivariable analyses that included interaction between time of day and arrest location were performed in a stepwise manner. results: prehospital als (adjusted or, . ; %ci, . - . ) but not good-quality of bystander-performed ccs ( . , . - . ) was associated with sustained return of circulation (rosc). neither provison of good-quality ccs nor prehospital als was a major factor associated with on-month survival. however, good-quality of bystanderperformed ccs ( . , . - . ) in addition to shockable rhythm ( . ; . - . ) and bystander-witnessed ohca ( . ; . - . ) were associated with higher chances of neurologically favourable one-year survival, whereas prehospital als ( . ; . - . ) and elderly ohca ( . ; . - . ) were associated with lower chances of the survival (fig. ) . the impact of good quality ccs on survival were preserved in bystander-witnessed ohcas with shockable initial rhythm. noncentral region (adjusted or for good-quality, . ; %ci, . - . ), lack of bls training experience ( . ; . - . ), elderly-only rescuers ( . ; . - . ), cc initiation following dispatcher-assisted cardiopulmonary resuscitation ( . ; . - . ), and female-only rescuer ( . ; . - . ) were associated with poor-quality ccs. cc quality in athome ohcas remained low throughout the day, whereas that in outof-home ohcas decreased during night-time. conclusions: provision of good-quality ccs before ems arrival but not prehospital als was essential for neurologically favourable survival. new protocol for start of chest compressions before definitive cardiac arrest improved survival from out-of-hospital cardiac arrest witnessed by emergency medical service introduction: healthcare providers including emergency medical service (ems) personnel usually confirm absence of carotid pulse before starting chest compressions. at the end of , ishikawa medical control council implemented new criteria for start of chest compressions encouraging ems to start chest compressions when carotid pulse was week and/or < /min in comatose adult patient with respiratory arrest or agonal breathing. methods: data were prospectively collected for out-of-hospital cardiac and respiratory arrests during the period of - . definitive cardiac arrest was recorded when loss of carotid pulse was confirmed by pulse checks performed every min after the early start of chest compressions. the effect of early chest compressions on the proportions of definitive cardiac arrest was analysed in cases with respiratory arrest and circulatory depression in initial patient evaluation. before/after comparison of neurologically favourable -y survival was performed in cases with ems-witnessed ohca. results: the early start of chest compressions did not significantly prevent definitive cardiac arrest that followed respiratory arrest with circulatory depression in the initial patient evaluation (fig. ) . time interval between start of chest compressions and definitive cardiac arrest confirmation (median; iqr) was ; . - min. the survival rate of all ems-witnessed ohcas after the implementation of new criteria was significantly higher than that before the implementation: adjusted or; % ci, . ; . - . (fig. ) . no complications related to early chest compressions were reported during the study period. conclusions: start of chest compressions before definitive cardiac arrest improved survival from out-of-hospital cardiac arrest witnessed by emergency medical service. healthcare providers including ems personnel should be encouraged to provide chest compressions on cases with respiratory arrest and severe cardiovascular depression. introduction: our study sought to determine if there is a difference in time to tracheal intubation between direct and video laryngoscopy during cardiac compressions. guidelines suggest no more than seconds should be taken to perform intubation to minimise any delay in compressions [ , ] . it is unclear if use of video laryngoscopes results in faster intubation times during cardiac arrest. methods: observational trial involving emergency, anaesthesia and intensive care doctors. participants' baseline data obtained by questionnaire. resusci-anne™ manikin with airway trainer™ head [laerdal] with grade airway was utilised. participants intubated the manikin times, once with each of: macintosh size blade, c-mac video laryngoscope (karl storz, germany) with size blade and portable mcgrath mac enhanced video laryngoscope (medtronic, usa) with size blade. order of laryngoscopes was randomised by computer generated sequence. continuous cardiac compressions were performed throughout attempts. results: total participants. there was a statistically significant difference in time to intubation between the devices using friedman test (p< . ). wilcox signed-rank test demonstrated time to intubation with videolaryngoscopy was longer, c-mac (p= . ) and mcgrath (p= . ) compared with direct laryngoscopy. there was no significant difference between the two videolaryngoscopes (p = . ). when controlled for participants level of seniority and previous experience with device, direct laryngoscopy was still significantly faster than c-mac (p = . ) and mcgrath (p = . ) conclusions: our study showed a disadvantage of video laryngoscopy during cardiac compressions. faster intubation times with direct laryngoscopy could result in less pause in compressions and decrease periods without perfusion. direct laryngoscopy is an appropriate first choice for tracheal intubation during cardiac arrest. introduction: the aim of this study was to describe the coronary angiographic findings in relation to specific ecg changes and comorbidity in survivors after cardiac arrest. methods: a retrospective cohort study of out-of-hospital cardiac arrest patients with data retrieved between - from national registries in sweden. unconscious patients with coronary angiography performed within days after return of spontaneous circulation and available ecg were included (fig. ) . results: after exclusion, patients were analyzed (fig. ) , (table ) . ( %) were women and mean age were years. patients without st-elevation were separated into groups with specified ecg changes and comorbidities. differences were observed in the incidence of any significant stenosis, total occlusion and pci performed, between the specified ecg changes, as well as between the comorbidity groups ( introduction: fewer women after return of spontaneous circulation from out-of-hospital cardiac arrest (ohca) are undergoing coronary angiography (cag) with possible percutaneous coronary intervention (pci). the aim was to investigate gender differences in comorbidity, cag findings and outcome after ohca in comatose patients with a shockable first ecg rhythm. methods: a retrospective cohort study of out-of-hospital cardiac arrest patients with data retrieved between - from national registries in sweden (fig. ) . results: there was no difference in age or comorbidity except for men having more ischemic heart disease, . vs . % (p= . ). rates of previous myocardial infarction did not differ, . vs . %. no difference was seen in rates of ecg indicating prompt cag according to guidelines. still, more men underwent cag but no difference in numbers of cag leading to pci was seen (table ) . furthermore, in patients with st elevation or lbbb, no gender difference in cag and subsequent pci was found. men had lower rates of normal cag findings but more triple vessel and left main coronary artery disease ( table ) . year survival did not differ, . vs . %. conclusions: our study suggests, that despite no gender differences in rate of ecg findings indicating a prompt cag, men seems to have a more severe coronary artery disease while women have more frequently normal angiograms. however, this did not influence year survival. introduction: the circadian clock influences a number of cardiovascular physiological processes. a time-of-day variation in infarct size has recently been shown in patients with st segment elevation myocardial infarction. however, there is no clinical evidence of circadian variation in patients with out-of-hospital cardiac arrest (ohca) of cardiac etiology. methods: we performed retrospective analysis using data from japan's nationwide ohca registry from january through december , which includes all ohca patients presented with ventricular fibrillation as first documented rhythm, and consequently confirmed cardiac etiology. in order to eliminate the night and weekend effects, we enrolled only patients suffered ohca in the morning we conduct a retrospective cohort study focusing on the association between ohca outcome and icu bed availability. the ohca data was acquired from a regional emergency operation center, and the icu bed information was obtained from a regional sur it exceeds physiological levels in order to avoid insufficient oxygenation [ ] . hyperoxia has been associated with increased in-hospital mortality, though uncertainty remains about this association. multiwave pulse co-oximetry has safely been studied intraoperatively as a guide to monitor hyper-and hypoxia by calculating an oxygen reserve index (ori) which could add information to pulse oximetry measures when spo is > % [ ] . methods: this is a monocentric prospective study including patients with successful resuscitation following ohca. the aim of our study is to evaluate the feasibility and assess the availability of novel non invasive oxygen and hemodynamic variables. collected data principally concern blood oxygen and circulation such as ori, spo , total hb, perfusion index and pulse rates. recording is ideally started at time of rosc. results: we monitored consecutive patients for a total time of . min during transport from ohca place to the er. spo signal was present for . % of transport time.oxygen reserve index signal was present for . % of the total transport time. pleth variability index (pvi) signal was present . % of the total transport time. sphb signal was present . % of total time from rosc to hospital. the confidence interval for each variable is given in fig. . conclusions: our pilot study shows that noninvasive measurements of hyperoxia, fluid responsiveness and hemoglobin are readily available from the prehospital phase of post-rosc care allowing for early tailored and goal directed interventions. increase in sofa score was associated with € ( % ci - €) increase in the cost per day alive in the first months after ca. the sofa score is a good indicator of disease severity but the overlap between outcome groups does not allow its use for early prognostication in ca patients. the association of sofa and its sub-scores with -month outcome and healthcare costs highlights that in addition to neurologic damage the full spectrum of multiple organ failure affects the survival and morbidity of ca patients. public opinion on cardiopulmonary resuscitation decision and outcome in out-of-hospital cardiac arrest patientsquestionnaire study ty li introduction: metabolomics is a novel approach that can characterize small molecules (metabolites) and has the potential to explore genotype-phenotype and genotype-environment interactions, delivering an accurate snapshot of the subject's metabolic status. in this context, the aim of metabolomics is to improve early diagnosis, classification, and prediction over the development of a pathological condition. to this end, metabolomics have not been used in the characterisation of cardiac arrest (ca), cardiopulmonary resuscitation (cpr) and return of spontaneous resuscitation (rosc). the aim of the present study was to explore whether metabolomics can characterize the ca versus rosc in a swine model of ventricular fibrillation (vf). methods: ten animals were intubated and instrumented and vf was induced with the use of a cadmium battery. vf was left untreated for min and the animals were then resuscitated according to the guidelines. defibrillation was attempted in all animals. venous blood was drown at baseline, min, min, min during untreated ca and finally at min, min, h, h after rosc in order to determine the metabolomic profile during ca and during the early post-resuscitation period. rosc was defined as the presence of an organized cardiac rhythm with a mean arterial pressure of at least mmhg for > min. blood was centrifuged and serum was analysed by high resolution h-nmr spectroscopy. nmr spectral data were submitted to multivariate discriminant analysis. results: eight animals survived the experiment and were included in the analysis. metabolites upregulated in the immediate rosc versus ca were succinate, hypoxanthine, choline and lactate. metabolites upregulated in the hour rosc versus ca were ornithine and alanine. the measured phases are shown in fig. introduction: early outcome prognostication in successfully resuscitated out-of-hospital cardiac arrest (ohca) patients remains challenging. prediction models supporting the early decision to continue with full supportive treatment could be of major interest following ohca. we constructed prognostic models able to predict good neurologic outcome within hours after icu admission. methods: upon icu admission, targeted temperature management at °c, hemodynamic and neuromonitoring (cerebral oxygen saturation measured with near-infrared spectroscopy and bispectral index (bis)) was initiated. prediction models for good neurologic outcome at days post-ca were constructed at hour , , and after admission using variables easily collectable and known to be predictive for outcome. after multiple imputation, variables were selected using the elastic-net method. each imputed dataset was divided into training and validation sets ( % and % of patients, respectively). cut-off probabilities yielding a sensitivity above % were determined and performance of all logistic regression models was assessed using misclassification rates. introduction: in many venues, ems crews limit on-scene care for pediatric out-hospital cardiac arrest (pohca), attempting treatment during transport. hypothesizing that neuro-intact survival can be improved by prioritizing on-site care, strategies were effected to expedite on-scene drug delivery and intubation (with controlled ventilation). methods: from / / to / / , data for pohca cases were collected. in , new training prioritized on-site resuscitation (phase i) using expedited drug delivery and intubation with controlled ventilation (~ breaths/min). training included psychological and skills-enhancing tools to boost confidence in providing on-scene care. in , drugs were prepared while responding (phase ii). american heart association guidelines were used throughout and no other modifications were made. neuro-intact survival in - was compared to phase i & ii outcomes. results: over the . -years, ems faced consecutive pohca cases. the great majority presented in asystole throughout. in those resuscitated, mean time from on-scene arrival to the st epinephrine infusion fell from . min ( - ) to . min (phase i) and . min (phase ii). by , it was min. for resuscitated patients and . min. for all patients. intubation and intraosseous insertion occurred more frequently in phase i/ii, but there were no significant differences in age, sex, etiology, response times, bystander cpr or drug sequencing. neuro-intact survival improved significantly from / in - to . % ( / ) in phase i and . % ( / ) in phase ii (p < . ; -tailed fisher's exact test) (fig. ) . conclusions: although historically-controlled, the sudden appearance of neuro-intact survivors following a renewed focus on rapid on-site care was profound, immediate and sustained. beyond skillsenhancing strategies, physiologically-driven techniques and supportive encouragement from leadership, pre-arrival psychological and clinical tools were also likely contributors to the observed outcomes. fig. (abstract p ) . effecting neurologically-intact survival for children with out-of-hospital cardiac arrest p improved outcomes with a bundled resuscitation technique to enhance venous return out of the brain and into the heart during cardiopulmonary resuscitation pe pepe , ka scheppke , pm antevy , d millstone , c coyle , c prusansky , s garay , jc moore introduction: lowering intracranial pressure to improve brain perfusion during cpr has become a focus for our team. combined with devices that enhance venous return out of the brain and into the thorax during cpr, outcomes have improved using head/chest elevation in the laboratory (fig. ) . this study's purpose was to confirm the safety/clinical feasibility of this new approach involving mechanical cpr at an angle. methods: , consecutive out-of-hospital cardiac arrest (oohca) cases (all rhythms) were studied for . years ( / / to / / ) in an expansive, socio-economically-diverse u.s. county (pop. . mill). in , ems crews used the lucas© and impedance threshold (itd) devices on such patients, but, after april , they also: ) applied o and deferred +-pressure ventilation several min; ) raised the backboard~ °; and ) solidified a pit-crew approach to expedite lucas© placement. neuro-intact survival was not recorded until , so resuscitation by ems to hospital admission was used for consistency. quarterly reports were run to identify any periodic variations or incremental effects during protocol transition (quarter , ). results: no problems were observed with head/torso-up positioning (n= , ), but rates of resuscitation rose steadily during the transition period with an ensuing sustained doubling (fig. ) over the ensuing years when compared to those studied (n= ) prior to the head-up approach (mean . %; range - % vs. . %, range - %; p < . ). outcomes improved across subgroups. response intervals, indications for attempting cpr and bystander cpr rates were unchanged. resuscitation rates in - remained proportional to neuro-intact survival. conclusions: the head/torso-up cpr bundle was not only feasible, but also associated with an immediate, steady rise in resuscitation rates during the transition phase with a sustained doubling of resuscitation rates, making a compelling case that this bundled technique may improve oohca outcomes in future clinical trials. introduction: cardiac arrest (ca) often requires intensive care unit (icu) treatment, which is costly. while there are plenty of data regarding post-ca outcomes, knowledge of cardiac arrest associated healthcare costs is virtually non-existent. methods: we performed a single-center registry-based study to determine expenditure data for icu-treated ca patients between and . healthcare cost evaluation included costs from the initial hospital treatment, rehabilitation costs and social security costs up to one year post-ca. we calculated mean healthcare costs for one year survivors and for hospital survivors who died within the first year after cardiac arrest. we calculated effective costs per independent survivor (ecpis) as an indicator of cost-effectiveness. we adjusted all costs according to consumer price index (cpi) in finland as of . all costs are presented as euros (€). results: we identified , ca patients eligible for the analyses. at one year after ca % of the patients were alive and % were alive and independent in daily activities. one year survival stratified by cardiac arrest location group was % for out-ofhospital ca patients, % for in-hospital ca patients and % for in-icu ca patients. for the whole study population, mean healthcare costs were , € per patient. healthcare costs for hospital survivors were , € per patient and for hospital non-survivors , € per patient. healthcare costs for those who survived to hospital discharge but died within the first year were , € per patient, while for one year survivors they were , € per patient. healthcare costs stratified by ca location are presented in fig. . mean ecpis were , €. conclusions: for icu-treated cardiac arrest patients, the mean ecpis were close to , €. the best prognosis and the lowest costs were observed for out-of-hospital ca patients. introduction: in lithuania the incidence of out-of-hospital cardiac arrest (ohca) is unknown, as there is no official coding for ohca as a cause of death in the national death registry. kaunas emergency medical service (ems) underwent major stepwise changes since , including implementation of medical priority dispatch system and dispatcher-assisted cpr instructions. we sought to describe the epidemiology and outcomes from ohca in kaunas, the second largest lithuanian city. methods: the incidence, demographics and outcomes of patients who were treated for an ohca between st january and st december in kaunas ems, serving a population of almost . million, were collected and are reported in accordance with utstein recommendations. results: in total, ohca cases of ems treated cardiac arrests were reported ( per . of resident population). the mean age was . (sd= . ) years and . % were male. % ohca cases occurred at home and . % were witnessed by either ems or a bystander. in non-ems witnessed cases, . % received bystander cpr, whilst public access defibrillation was not used. medical dispatcher identified ohca in . % of all cases and provided over-the-phone cpr instructions in . % of them. average ems response time ( % fractile) was min. cardiac aetiology was the leading cause of cardiac arrest ( . %). the initial rhythm was shockable (vf or pvt) in % and non-shockable (asystole or emd) in . % of all cases. return of spontaneous circulation (rosc) at hospital transfer was evident in . % and survival to hospital discharge was . %. conclusions: rosc and survival to hospital discharge in kaunas were similar to those reported in united kingdom in [ ] . routine ohca data collection and analysis will allow us to track the efficiency of service improvements and should become a standard practice in all lithuanian regions. outcomes of patients admitted to intensive care following cardiac arrest j mcloughlin, e landymore, p morgan east surrey hospital, surrey, uk critical care , (suppl ):p introduction: patients who have return of spontaneous circulation following a cardiac arrest are haemodynamically unstable and require critical care input. outcomes are often poor, with unadjusted survival to hospital discharge at . %, following an in hospital cardiac arrest [ ] . the aim of the study was to assess the survival of patients admitted to intensive care following a cardiac arrest, reviewing whether age and gender impacted on their outcome. methods: the inarc database for a general intensive care unit (icu) at a district general hospital was reviewed. since , patients were admitted following a cardiac arrest (both in and out of hospital). their age, gender and survival to icu discharge and overall hospital discharge were recorded. results: female patients and male patients of varying ages were admitted to our icu following a cardiac arrest. the mortality for both genders increased with increasing age. overall survival to the time of icu discharge following a cardiac arrest was similar for both females ( . %) and males ( . %). figures (female) and (male) below show the number of patients who survived or died on icu discharge, by age and gender. mortality rates increased when reviewing hospital outcome, as some patients died following discharge to the ward. conclusions: overall mortality in our icu following a cardiac arrest at any age is at least %, with the general trend appearing to rise with increasing age. more male patients were admitted to icu following a cardiac arrest than female, with similar survival rates for both male and female patients. more research could be undertaken to assess whether survival rates following a cardiac arrest have improved since and also to compare outcomes following either an in or out of hospital arrest. introduction: raw simplified eeg tracings obtained by a bispectral index (bis) device significantly correlate with standard eeg [ ] . this study aimed to investigate whether simplified bis eeg tracings can predict poor neurologic outcome after cardiac arrest (ca). methods: bilateral bis monitoring (bis vistatm, aspect medical systems, inc. norwood, usa) was started following icu admission. six, , , , and hrs after targeted temperature management (ttm) at °c was started, raw simplified bis eeg tracings were extracted and reviewed by two neurophysiologists for the presence of burst suppression, cerebral inactivity and epileptic activity. at days post-ca, neurologic outcome was determined using the cpc scale, where a cpc - and cpc - corresponded to good and poor neurologic outcome, respectively. results: of the enrolled ca-patients enrolled, had good and poor neurologic outcome. with a positive predictive value (ppv) of . and a negative predictive value (npv) of . , epileptic activity within - hrs predicted a cpc - with the highest accuracy. epileptic activity within time frames - hrs and - hrs showed a ppv for poor outcome of . and . , respectively. cerebral inactivity within - hrs had a poor predictive power (ppv= . , npv= . ). in contrast, cerebral inactivity between - hrs predicted a cpc - with a ppv of . and a npv of . . the pattern with the worst predictive power at any time point was burst suppression with a ppv of . , . and . at - hrs, at - hrs and at - hrs, respectively. conclusions: based on simplified eeg derived from a bis device, both the presence of epileptic activity at any time as well as cerebral inactivity after the end of ttm can be used to assist with poor outcome prognostication in successfully resuscitated ca patients. the helicopter as first response tool -rio de janeiro fire department experience. (interquartile range= ) min, followed by tih with flights ( %) and median time of (iqr= ) min, and ( %) were neo missions with median time of (iqr= ) min. total time of aircraft usage was higher for tih ( %), followed by neo ( %). evam was the most frequent mission, however it accounted for % of aircraft utilization time, where most victims had traumatic brain injury (tbi) followed by other traumatic injuries ( and cases respectively). tbi victims were predominantly males ( %) with a median age of (iqr= ) years. most commonly, tbi is a consequence of transportation accident ( %), where a motorcycle was involved in %, car collision in % and pedestrian run over % of the cases. conclusions: goa utilizes the air ambulance helicopter as a first response tool in % of total missions, where respect for the trauma golden hour is paramount. traumatic brain injury is the most prevalent diagnosis at the scene of event. therefore, goa training and equipment must be tailored to meet this demand, which translates in stabilization of critical patients outside hospital environment with limited resources. introduction: the intra-hospital transport of critical patients is associated with adverse events and worse outcomes. the objective of this study was to evaluate the safety profile of intrahospital transport after the creation of a specific group for this purpose. methods: evaluated all the transports of critical patients from october to september , in a large hospital, after the creation of a group consisting of intensive care physician, nurse and physiotherapist. clinical and non-clinical complications related to the transport and outcome of the patients were evaluated. results: a total of , transports were performed, . % of the male patients and . % of the patients being hospitalized. . % were under mechanical ventilation and . % under vasoactive drugs. at the time of transport, . % were clinically stable. during transport, . % presented clinical complications, being more frequent hemodynamic instability ( patients) and respiratory failure ( patients). non-clinical complications occurred in patients ( . %), and communication failures were responsible for . % of the occurrences. in cases ( . %) there was worsening of the clinical conditions during transportation, and in only one case this worsening resulted in an increase in the length of stay in the icu and in the hospital, with no correlation with deaths. conclusions: the implantation of a group specialized in critical patients to carry out in-hospital transport made the process safer with complications rates lower than literature and guarantee better quality of care. clinical profile of patients admitted to icu due to acute poisoning mp benitez moreno , e curiel balsera , mc martínez gonzález , s jimenez jimenez intensive care unit, hospital regional universitario carlos haya, malaga, spain; hospital regional universitario carlos haya, málaga, spain critical care , (suppl ):p introduction: patients suffering from acute intoxication, whether voluntarily for autolytic or accidental purposes, often require life support in intensive care units. methods: retrospective observational study of all patients admitted for acute intoxication who required admission to the icu of the regional hospital of malaga between january and august , older than years with admission to the icu for intoxication of any kind. we study patient characteristics in terms of age, sex and medical history, type of toxicity, severity and evolution in our unit. results: we found cases of patients who required admission to the icu due to acute intoxication, of which . % were women. the average age was . (standard deviation . ). the average stay in icu was . (standard deviation . ). . % of patients had a psychiatric history. as other background highlights, . % were addicted to illegal drugs and % were hypertensive. most patients took more than one toxic . % and intoxication was voluntary in . % versus accidental in . % of cases. the toxic was known in %. the most used benzodiazepines in . % of the total. the main cause of admission to the icu was due to neurological deterioration in of the cases registered and mechanical ventilation was necessary in patients. the maximum time in mechanical ventilation was days. the infection occurred in . %, with the majority being respiratory infection. the . % died in icu. the hospital stay presented an average of . days. conclusions: the profile of a patient admitted to the icu due to acute intoxication is that of a woman of middle age and psychiatric history, with voluntary intoxication of several toxic substances and requiring mechanical ventilation for a low level of consciousness for an average of days. the survival is very high and it would be necessary to analyze the possible relapses of these patients. mushroom that break hearts: a case report e karakoc, k demirtas, s ekemen, a ayyildiz, b yelken eskisehir osmangazi university, eskisehir, turkey critical care , (suppl ):p a introduction: because of the high mortality and morbidity mushroom poisoning is a significiant medical emergency [ ] . amanita phalloides (a. phalloides) is responsible for the % of the mortality in adults caused by mushroom poisoning. it causes damage in liver, kidneys and rarely pancreas, causing encephalopathic coma, disseminated intravascular coagulation, hemorrhage, hypovolemic shock and death but its effect on cardiac functions has not been established yet. there are three main groups of toxins;phallotoxins, virotoxins and amatoxins;amatoxin is the common responsible toxin from the fatality. we aimed to present a -year-old woman poisoned by mushroom complicated with hepatic,renal and cardiac toxicity methods: patient with nausea and vomiting started hours after mushroom eating,creatine kinase mb . ng/ml and cardiac troponin i . ng/ml her blood urea nitrogen, creatinine levels and liver enzymes were higher than upper limits in lab tests (table ) ; she was admitted to icu, treated for acute renal failure by hemodialysis.plasmapheresis was applied against potent mushroom toxins. at .day in icu, hypoxemia and severe swelling resistant to ultrafiltration was evaluated as a global left ventricular hypokinesia with ejection fraction(ef) %, end-diastolic diameter of . cm, and systolic pulmonary artery pressure (spap) of mmhg. oxygen was administrated to treatment.urine output improved at .day, three more plasmapheresis sessions were performed. hypoxemia was recovered,liver enzymes and creatinin levels decreased results: at control ef measured was %, end-diastolic diameter of . cm, spap of mmhg.than at the .day patient discharged from the icu.after a year follow up assessment she has no complaints conclusions: one of the major problems for amanita poisoning is diagnosis. patients who had mushroom poisoning should also be evaluated especially in terms of cardiac dysfunction with clinic signs, ecg, cardiac enzyme tests and eco introduction: the characterization of clinical and/or biological variables found in the emergency room predictive of a secondary admission in icu would help to improve the identification of patients at risk of aggravation in order to avoid the associated consequences, such as, an increased mortality and increased hospital stay. methods: this is a retrospective monocentric study of years with patients admitted secondarily to a medical icu within hours of admission to the general wards from the emergency department in the pitié-salpêtrière hospital in paris. each case was matched to controls. different variables were collected in the emergency room. results: patients, of whom were cases and controls were studied. pneumonia is the diagnosis the most frequent in cases followed by sepsis (in and %, respectively). conclusions: the risk of being admitted secondarily to intensive care is higher if patients consult for dyspnea or fever, if they are old smokers, if they have a high igs score, if an arterial blood gas is requested and if an icu medical advice is taken. the meds score under and being an active smoker seems to be protects for the unexpected transfer. introduction: managing the special needs of patients who present with agitation or psychosis can pose a greater challenge to an already busy emergency department as their symptoms can escalate rapidly. traditional antipsychotics used in the ed, such as haloperidol or ziprasidone often do not fully relieve patient's symptoms and may require administration of repeat doses or additional medications such as benzodiazepines to achieve effective results. this can induce excess sedation which can lead to longer length of stay in the ed and requires additional time at the bedside by the ed physicians and staff to manage these patients. adasuve® is an antipsychotic drug that works in a single-use device providing an aerosol form of loxapine that is rapidly absorbed by the lungs which may offer faster symptom relief, allowing subsequent earlier psychiatric evaluation and disposition. methods: to test this hypothesis, data including time of physician assignment and time physician documented discharge disposition and number of hours physician was assigned to the patients was retrospectively collected from patients who arrived to the emergency department presenting with agitation or psychosis that received adasuve or other types of antipsychotic medication such as ziprasidone, haloperidol and benzodiazepines or a combination of the three. results: we found that physicians who administered adasuve spent an average of . hours assigned to their patient compared to . hours when the physician administered any other type of antipsychotic medication. this resulted in a significant . -hour difference (p < . ) between the two groups. conclusions: in conclusion, less time spent assigned to a patient that received adasuve can be attributed to faster symptom relief which allowed the physicians to complete their psychological evaluations and develop dispositions more rapidly than with patients that received other antipsychotic agents. clinical work in language-discordant emergency department introduction: emergency residents are particularly vulnerable to sleep deprivation due to persistent conflicts between work schedule and the biological clock. recent approaches to address fatiguerelated risk mainly focused on reducing work hours and ensuring sufficient recuperation time. such approach has demonstrated its limits due to growing emergency rooms visits and emergency residents' shortage. dawson & mcculloch ( ) introduced the notion of proofing as a complementary approach to manage fatigue-related risk [ ] . fatigue proofing strategies (fps) aim to reduce the likelihood a fatigued operator will make an error, in contrast of reduction strategies (frs) aiming to reduce the likelihood a fatigued operator is working. most formal risk control systems do not encompass the notion of proofing and fps typically develop as informal practices. in this study, we aim to ) identify informal reduction and proofing strategies used by residents and ) to investigate how they relate to fatigue-related risk indicators. methods: first, we organized focus-group with a total of residents in order to identify informal strategies used to manage fatigue-related risk. second, we designed a questionnaire assessing the frequency of use of each reported strategy. introduction: this randomized controlled study assessed the impact of a -hour intravenous medication safety simulation-based learning (sbl) on self-efficacy, stress, knowledge and skills of nursing students. medication administration error is a worldwide concern [ ], that has been linked with a lack of knowledge and skills in safe medication administration among new graduate and student nurses [ ] [ ] [ ] . preventing medication errors could therefore involve training through simulation. methods: participants (n= ) were randomly assigned either to the control group (cg, n= ) or the experimental group (eg, n= ). while cg and eg both had a traditional clinical internship, eg beneficiated in addition the -hour sbl, using standardized patients in the context of an intensive care unit. the two groups were assessed twice: at t and t (four weeks later), through an objective structured clinical examination (osce) and questionnaires. two blinded experts rated the students osce with an evaluation grid. results: mean participants age was , . there were no statistically differences between groups at t . compared to the cg ( %), the eg increased its self-efficacy (+ . %) with a significantly difference (p< . ) at t . the sbl conducted to a greater increase of knowledge and skills in the eg (respectively + %, + %) than in the cg (respectively + % and + %), with a statistically significant difference (p< . ). conclusions: results reinforce the interest of a short sbl using standardized patients to improve medication administration. clinical impact of these observations requires further evaluation to determine potential transfer in clinical settings and retention over time. introduction: medication errors occur frequently in the intensive care unit (icu) and during care transitions. medication reconciliation by a pharmacist could be useful to prevent such errors. therefore, the aim of this study was to determine the effect of medication reconciliation at the icu. methods: a prospective -month intervention study with a pre-and post-phase was performed in haga teaching hospital ( ) and erasmus university medical center ( ). the intervention consisted of medication reconciliation by pharmacists at icu admission and discharge. the severity of potential harm of the medication transfer errors (mte) (pade= ; . ; . ; . ; . ) was scored. primary outcome measures were the proportions of patients with >= mte at icu admission and icu discharge. secondary outcome measures were the proportions of patients with a pade score >= . , the severity of the pades and a cost-benefit analysis. odds ratio and % confidence intervals were calculated. results: table shows patient characteristics. figure shows the primary outcome measures (oradj admission = . [ % ci . - . ] and oradj discharge = . [ % ci . - . ]). the proportion of patients with a pade >= . at icu admission reduced from . % to . % and after icu discharge from . % to . %. the pade reduction resulted in a potential net cost benefit of € per patient. conclusions: medication reconciliation by pharmacists at icu transfers is an effective safety intervention, leading to a significant decrease in the number of errors and a cost effective reduction of potential adverse drug events. introduction: in intensive care unit, administration of numerous drugs in icu patients via a central venous catheter provide a high risk of drugs incompatibilities. it has been reported in experimental studies [ ] that particles issued of drug incompatibilities could induce thrombogenesis, microcirculation impairment and inflammatory response which could aggravate the occurrence of organ dysfunctions [ ] . the objective of this study was to evaluate the occurrence of particles by reproducing in vitro the intravenous system and the drugs combination used in icu for patients suffering either septic shock or acute respiratory distress syndrome (ards). methods: first, we registered during a period of months the most common central venous catheter system used in patients admitted for septic shock or ards in three university hospital in lille. the second part of the study was to reproduce in vitro the previous infusion system in order to quantify the amount of particles generated during a simulated period of hours infusion. the egress of the iv line was connected to a dynamic particle counter qicpic analyser (sympatec inc ; clausthal zellerfeld, germany) (fig. ) . results: the most common intravenous system observed was a three lumen central catheter. the proximal lumen was dedicated for vasoactive agents, the medial lumen for sedation and the distal lumen for the other drugs infused continuously and discontinuously..among the drugs infused via the distal lumen of the central venous catheter, introduction: insufficient identification of possible organ donors in the icu is one of the main factors contributing to the loss of donors after brain death [ ] . up to % of potential donors might not be identified [ ] . the aim of this study was to evaluate how active search of possible brain dead donors affect the potential deceased donor pool. methods: the strategy implemented at university hospital with specialized icus from december to october and data compared to the matching period of the previous year. donor coordinator visited all icus every day and selected patients who met possible brain dead donor criteria: ) gcs <= ; ) severe brain injury. all data registered in original color coded follow-up system according to the patient status. results: a total of patients were identified as possible donors. there was no significant difference of potential donor numbers in study period comparing to previous year ( vs ). main causes of brain death remain intracranial hemorrhage and subarachnoid hemorrhage. the length of hospital stay of potential donors was significantly longer in study period comparing to previous year ( ± . vs . ± . , p= . ). there was no significant difference of donor's demographic data, conversion rates to actual donor or frequency of family refusals and medical contraindications. conclusions: active search of brain dead donors neither increased total number of potential donors nor increased conversion rates and did not change a donor profile in our donor center. longer observational period and more sophisticated follow-up system might be required. a fast hug bid a day keeps the patient ok! e sousa, t leonor, r pinho centro hospitalar de entre douro e vouga, santa maria da feira, portugal critical care , (suppl ):p introduction: regardless the underlying diagnose, providing meticulous supportive care is essential to critically ill patients management. in , vincent jl introduced the fast hug (feeding, analgesia, sedation, thromboembolic prophylaxis, head of bed elevation, ulcer prevention, glucose control) mnemonic for recalling what he considered the key issues to review in daily clinical practice. our intensive care unit (icu) decided to add bid (bowel regimen; indwelling catheter removal; de-escalation of antibiotics) indicators following some published data. since , the adequate use of this mnemonic became an instrument for quality of care evaluation. objectives for each variable were designed; regular annual audits done. the present study aims to audit the use of this mnemonic in a portuguese tertiary hospital icu, in . methods: a prospective observational study was performed. admissions in icu staying at least one h min and h min period, during the first six months of were included. all mnemonic variables were recovered from icu medical record database, as well as demographics, severity scores and clinical information. data was analyzed with microsoft office excel software. results: we included admissions. the predictable global fast hug bid assessment was entries [one per each full day ( h - h ) in the unit, per patient]. the mnemonic was used in about % of the opportunities. the target thresholds were considered as achieved in % of entries (concordance equal or superior to %). looking to individual variables, the best performance was achieved in h and u; worse performance was seen in s. the daily use of this mnemonic aims to revisit important intervention sectors in critical patient. applying the "plan-do-check-act" policy, this study allowed us to identify growth opportunities, reviewing or creating protocols, adopting more frequent training measures and seeking to take this model to other hospital areas. impact of incidents and adverse events in intensive care unit and its characteristics on outcomes e siqueira, l taniguchi, j vieira junior hospital sírio libanês, sao paulo, brazil critical care , (suppl ):p introduction: critically ill patients are usually exposed to adverse events (ae) due to acuity and complexity of care. ae might potentially result in disability or death, and increase in length of stay. our aim was to assess the incidents and ae in a general intensive care unit (icu). methods: this is a prospective cohort study conducted in a private tertiary hospital (hospital sírio-libanês) in são paulo, brazil. all consecutive patients who were admitted to the icu and all incidents and ae reported in the study period were evaluated. univariate and multivariate analysis were used to identify risk factors associated with hospital mortality. results: between may to november we studied patients and reported incidents and ae. overall, patients ( %) experienced some incident or ae during icu stay. we found higher severity of illness (saps of versus ; p< . ), mechanical ventilation (mv), use of vascular lines, drains and catheters, physical restraints, delirium and also an increased length of icu ( vs days; p< . ) and hospital stay ( vs days; p< . ) and hospital mortality ( % vs %; p< . ) among patients who experienced any incident or ae. independent risk factors for hospital mortality in our logistic model were: higher saps , mv and at least one adverse event during the icu stay. mortality was higher among patients who experienced late ae (> hours after icu admission) compared to patients who experienced early ae ( % vs %; p< . ). saps , sofa and mv were predictors of moderate and/or severe ae and a negative correlation between these events and icu occupancy rate was found. conclusions: patients who experienced incident or adverse event during icu stay had poorer outcome. ae, mainly moderate or severe, mv and severity of illness were independent risk factors to mortality. there was a negative correlation between moderate or severe adverse event and icu occupancy rate. monte carlo modelling of patient flow can aid complex intensive care bed and workforce capacity planning. introduction: models for icu populations based on the queuing model use arrival rate, length of stay, and bed number [ , ] . these models lack the complexity of specialised icus with different admission types, and patient subpopulations. results: > % of patients reported satisfaction on all areas except noise, patient facilities for hand hygiene and being informed about timing of operations. staff survey results revealed confusion regarding the interventions that are provided. baseline capacity for new patients was %, bed occupancy varied between and per day (overflow to recovery) with overall capacity at . % and mean length of stay (los) was . days (sd= . , n= , =range - ). following intervention, the los was reduced to . days (sd= . , n= , range - ). new patient capacity was increased to % with a bed occupancy range - . introduction: in clinical practice, when harm or potential harm occurs to patients, this can adversely impact upon the morale of staff involved and thereby affect clinical care delivered to subsequent patients. the personal narratives behind clinical incidents contain learning opportunities and individuals involved may reflect on the course of events and make changes to their practice to avoid recurrence. the aim of this study was to evaluate whether sessions enabling trainees to discuss their mistakes in a confidential environment improved trainee morale and safe clinical practice in an anaesthetic trainee cohort. methods: we conducted a survey amongst anaesthetic trainees in a london teaching hospital before and after a monthly, hour long, confidential, semi-structured, trainee lead "confession session" was introduced. results: initial results demonstrated that % of respondents (n= ) had made a mistake resulting in patient harm with % of these individuals describing negative feelings about themselves as a consequence. additionally, % of respondents had made a mistake causing a near miss, with % of these describing negative feelings as a result. of note, only % of respondents felt comfortable discussing errors with more senior colleagues, whilst % felt comfortable discussing errors with their peers. a follow-up survey identified that % of respondents (n= ) agreed that the session had the potential to improve clinical practice and trainee morale with % agreeing that their own clinical practice had improved from attending the sessions. conclusions: clinical mistakes leading to harm and "near misses" are common and provide opportunities to improve care. this trainee lead "confession session" appears to improve trainee morale and may improve patient care by encouraging trainees to engage in a process that seeks to understand error through sharing stories in a non-judgmental setting. funnel plots for quality control of the swiss icu -minimal data set introduction: a clinical database should be representative of the labelled population and guarantee completeness and accuracy of collected data. without explicit permission of the patients, swiss laws regarding data protection do not allow external audits based on periodic checks of random samples, supposed to give a general pattern of accuracy. to test alternative methods for quality control we introduced the principles of statistical process control to derive funnel plots from the swiss icu -minimal data set (mdsi). the mdsi from all certified adult swiss icus ( and ) was subjected to quality assessment (completeness and accuracy). for the analysis of accuracy, a list of logical rules and cross-checks was developed as e.g. range of saps ii according to age. errors were classified in coding errors (e.g. nems score > points) or implausible data (nems without basic monitoring). we also checked for icus producing significantly more errors -outliers -(> mean ± standard deviations [sd] or > . % confidence interval [ci] of an adapted version of the funnel plots, which allows the presence of trends depending of the icu's size. results: a total of ' patient mdsi ( items/patient; items for trauma patients) from the certified icus.were investigated. we detected ' patients ( . %) with an overall sum of coding errors and ' implausible situations. implausible situations related to supposedly inaccurate definitions (diagnostic and patient's provenance prior to icu admission) and discrepancies in the logical rules between diagnostics and treatments. figure is an example for imprecise coding of the diagnostic: icus declared having treated - % of their patients without a defined diagnosis. conclusions: accuracy of data in mdsi needs further improvement. funnel plots may be useful for meaningful interpretation of data quality and permit to identify icus disproportionately generating inaccurate and/or implausible data. introduction: lung cancer is the leading cause of intensive care unit (icu) admission in patients with the advanced solid tumors. this study was aimed to elucidate the clinical factors associated with icu mortality of advanced lung cancer patients and the effect of intensivist's contribution on their clinical outcomes. methods: we included patients with advanced lung cancer including non-small cell lung cancer (nsclc) with stage iiib or iv and small cell lung cancer (sclc) with extensive stage who admitted to icu from to . multivariate logistic regression analysis was performed to find the variables associated with icu mortality and in-hospital mortality. we applied autoregressive integrated moving average (arima) for time-series analysis of the intenvention of intensivists. results: among total patients with advanced lung cancer, patients ( . %) were admitted icu before introduction of organized intensive care at , and ( . %) were admitted after (fig. ) . the leading cause of admission was the respiratory failure ( . %) and cancer-related event ( . %) in terms of intensivist's and oncologist's perspective. before and after , the -day icu mortality rate was . % and . % (p = . ), and the hospital mortality rate changed from . % to . % (p = . ) (fig. ) introduction: decisions when to refer and to admit patients to the intensive care unit (icu) care are very challenging. demand typically exceeds supply in icu beds, which results in a constant need for evaluation of the processes involved in icu referral and admission with a view to optimising resource allocation and patient outcomes. the aim of this study was to evaluate the theoretical impact of a newly designed triage tool for icu referrals on a cohort of patients referred to icu (fig. ) . methods: we reviewed all patients consecutively referred to our icu, whether admitted or not, in february . demographics, referring speciality, role of the referrer, comorbidities, the presence of advanced disease or terminal illness, the presence of acute organ failure, dnr status, reason for not admitting, and icu mortality were recorded. a retrospective analysis of icu referrals using a pilot triage tool was carried out independently by three authors. results: forty-six patients were referred to our icu over the study period. of these, ( %) were admitted. patients were declined icu if their admission was deemed unnecessary ( %), futile ( %), or were transferred due to bed shortage ( %). of the patients referred, ( %) had an advanced disease or a terminal illness. of those, ( %) were admitted, dnr status was unclear in ( %), family was involved in ( %) and their icu mortality was %. by analysing retrospectively these referrals with the aid of a triage tool, we propose that the overall referrals could have decreased from to ( % percentage difference). dnr status and family involvement would have been clarified in all patients with advanced disease or terminal illness before icu referral. kappa score for inter-rater agreement was . . conclusions: adopting a triage tool for icu referrals could reduce the overall proportion of inappropriate referrals and admissions. end-of-life discussion would also be proactively clarified prior to icu admission. introduction: intensive care unit (icu) admission triage occurs frequently worldwide and often involves decisions with high subjectivity, possibly leading to potentially inappropriate icu admissions. in this study, we evaluated the effect of implementing a decision-aid tool for icu triage on icu admission decisions. methods: urgent icu referrals before (may, to november, , phase ) and after (november, to may, , phase ) the implementation of a decision-aid tool were prospectively evaluated. our primary outcome was the proportion of potentially inappropriate icu referrals (defined as priority b or patients, as described by the or society of critical care medicine [sccm] guidelines) that were admitted to the icu in hours following referral. we conducted multivariate analyses to adjust for potential confounders, and evaluated the interaction between phase and triage priorities to assess for differential effects in each priority strata. results: of urgent icu referrals, ( %), ( %), ( %), ( %) and ( %) were categorized as priorities b, a, , and (sccm ) or ( . %), ( . %), ( %), ( %) and ( %) were categorized as priorities , , , and (sccm ), respectively. overall, ( %) patients were admitted to the icu in hours following referral. the implementation of the decision-aid tool was associated with a reduction of admission of potentially inappropriate icu referrals [adjor ( % ci) = . ( . - . ), p = . ] (fig. ) . there was no difference on hospital mortality for the overall cohort between phase and phase . conclusions: the implementation of a decision-aid tool for icu triage was associated with a reduction of potentially inappropriate icu admissions. introduction: the aim was analyze the icu bed rotation pattern, the epidemiological characteristics of patients and to correlate them with prognostic score after software implementation methods: this is an epidemiological and retrospective study. data were collected between june and november , using epimed® monitor software, applied in an adult icu of a public hospital in bahia/brazil. authorization for collection and use of data was granted by the institution. all patients hospitalized in the period were included regardless of other exclusion criteria. results: during the period evaluated, there were . new hospitalizations, men ( . %) and women ( . %). . % ( ) were in the age group of to years, followed by . % of the patients ( ), who were between and . the mean duration of hospitalization in our unit was approximately , days. during the period covered, . exits occurred: patients ( . %) were introduction: early debriefing after stressful events holds great value in reflection on both an individual and team-based level. our objective was to implement routine structured debriefing sessions for doctors working in intensive care in order to optimise learning and develop strategies to improve practice. methods: % of junior doctors (n= , pre-implementation questionnaire) on the intensive care unit expressed a need for regular debriefing sessions to discuss challenging and complex cases. weekly sessions were implemented and structured using the sharp performance tool [ ] . key learning points were collected and added to a debrief list to track progress and assimilate learning. informal feedback was obtained on a weekly basis with formal feedback assessed following one month of implementation. results: min sessions occurred on a weekly basis supported by a consultant intensivist. desired outcomes included assessment of team performance, identification of key learning points and psychological support. following one month, % doctors involved felt that debriefing sessions were important and should continue. % felt that they left every session with a key learning point applicable to future clinical practice. common themes in perceived benefits included improved team communication and creation of an open environment to address concerns. conclusions: working in intensive care exposes doctors to challenging and stressful situations. implementation of a regular structured debrief session provides an opportunity for clinicians to address concerns, consolidate learning and develop strategies to improve clinical practice. nurse staffing patterns, outcomes and efficiency in resource use in the context of icus with a "low-intensity" nurse staffing: a multicenter study in brazilian icus m soares introduction: studies investigating nurse staffing and outcomes were often conducted in high-income countries with low bed/nurse ratios. our objective was to investigate the association between nurse staffing patterns, outcomes and resource use in brazilian icus. methods: retrospective cohort study in , ( % medical) patients admitted to medical-surgical icus during - . we retrieved patients' data from an icu registry (epimed monitor system) and surveyed participating icus about characteristics related to icu organization. we used multilevel logistic regression analysis to identify factors associated with hospital mortality. we evaluated efficiency in resource use using standardized mortality rates (smr) and resource use (sru) based on saps . results: saps score was ( - ) points and hospital mortality was . %. intensivists were present / in % icus. median bed/ nurse ratio was . ( . - . ) and at least the chief nurse was boardcertified in critical care (bccc) in % icus. bed/nurse technicians ratio was . ( . - . ). adjusting for relevant characteristics at patientlevel (age, admission type, sofa, performance status, comorbidities, hospital days before icu) and icu-level (hospital type, checklist use, / intensivist, protocols), bed/nurse ratio was not associated with mortality [or= . ( % ci, . - . )]. however, mortality was lower in icus with at least the chief nurse bccc [or= . ( . - . )]. in multivariate analysis, bed/nurse ratios <= [or= . ( . - . )] and having the chief nurse bccc [or= . ( . - . )] were associated with higher efficiency. conclusions: in a "low intensity" nurse staffing scenario, bed/nurse ratios were not associated with mortality. however, having at least the nurse chief bccc was associated with higher survival. moreover, bed/nurse ratios <= and presence of chief nurse bccc were associated with higher efficiency in resource use. methods: a systematic search on the value of acute non-physician provider on the icu was conducted. the methodological quality of the included studies was rated using the newcastle ottawa scale (nos). the agreement between the reviewers was assessed with cohen's kappa. results: in total studies were identified. twenty comparative cohort studies were identified which compared non-physicians with either residents or fellows. all studies comprised adult intensive care. most of the included studies were moderate to good quality. a random effects meta-analysis from all studies regarding length of stay and mortality showed no differences between non-physicians and physicians, although there was a trend to better survival when implementing acute non-physician providers in the icu (figs. & ) . mean difference for length of stay on the icu was . ( % ci - . - . ; i = %) and for in hospital - . ( % ci = - . - . ; i = %); while the odds ratio for icu mortality was . ( % ci = . - . ; i = %) and for hospital mortality . ( % ci . - . ; i = ). conclusions: the acute care non-physician provider in the icu seems a promising clinician on the icu with regard to quality and continuity of care. whether they also can reduce mortality remains to be determined by designing studies, which adequately measure the contribution of the non-physician providers in icu care overall and per task. their role in europe remains to be elucidated. burnout and depression in icu staff members n bahgat menoufia university hospital, shibin elkom, egypt critical care , (suppl ):p introduction: family and success in work are the most important sources of person satisfaction in life, chronic prolonged exposure to stressful high workload in intensive care units (icu), create a bad psychological state named burnout syndrome in which person is depressed, exhausted and thinks to leave job. in this study we made a survey on icus staff members in egypt menoufia university hospital to explore and find risk factors increase depression and burnout among nurses and doctor. methods: questionnaires were given to all intensive care staff for estimating the prevalence and associated risk factors of burnout using maslach burnout inventory (mbi) with its three subscales emotional exhaustion (ee), lack of accomplishment (la), and depersonalization (dp). depressive symptoms using the beck depression inventory scale. blood sample was taken for assessing depression biomarkers including il- , tumor necrosis factor (tnf)-alpha, and coenzyme q (coq ), which appears to be one of the most reliable peripheral biomarkers. results: participants were respond in our survey from icu members the response rate was . %, the depression symptoms found increased in nurses more than physicians in icu with more desire to leave the job. there was strong correlation between the degree of depression symptoms and decrease percent of personal accomplishment. impaired personal relationships at work and increased night shifts were major risk factors of burnout syndrome. levels of the proinflammatory cytokine (il and tnf alpha) were elevated in members who recorded sever degree of depression score with decrease in concentration of co-enzyme q . conclusions: the health workers in icu had high liability for depression and burnout syndrome. the risk factors differ between nurses and doctors. il , co-enzyme q and tnf alpha concentrations had god correlation with degree of severity of symptoms. impact of a tailored multicomponent program to reduce discomfort in the icu on post-traumatic stress disorder: a casecontrol study p kalfon , m alessandrini , m boucekine , m geantot , s renoult , s deparis-dusautois , o mimoz , j amour , e azoulay , c martin , t sharshar , m garrouste-orgeas , k baumstarck , p auquier introduction: reducing discomfort during the icu stay should be beneficial on long-term outcomes. the aim of this study was to assess the impact of the implementation of a tailored multicomponent program to reduce discomfort in the icu [ ] on the occurrence of posttraumatic stress disorder (ptsd) months after discharge from the icu. methods: design: case-control study; the cases were patients hospitalized in the icus which implemented the tailored multicomponent program; the controls were patients hospitalized in the icus which did not implement the program. exposition: the tailored multicomponent program consisted of assessment of icu-related self-perceived discomforts by using the iprea questionnaire, immediate and monthly feedback to healthcare teams, and tailored site-targeted measures under control of a duo of local champions. general procedure: eligible patients were recalled months after the icu stay. data collection: sociodemographics, clinical data related to the icu stay, discomfort's levels assessed the day of discharge from the icu, life situation (home/care center), pstd (ies-r) and anxiety-depression symptoms (hads) months after the icu discharge. results: from the eligible cases and eligible controls, cases and controls were included (reason for exclusion: deaths after discharge from the icu, lost to follow-up, patient refusal, cognitive incapacity). a total of . % of the cases and . % of the controls presented certain symptoms of ptsd at months (p= . ). after adjustment for age, gender, iprea score, mccabe score, presence of invasive devices during the icu stay and considering anxietydepression symptoms at months, cases are less likely to have ptsd symptoms than controls. conclusions: our tailored multicomponent program for discomfort reduction in the icu can reduce long-term outcomes as ptsd. diffusion of such a program should be enhanced in the icus paving the way for a new strategy in care management. introduction: cognitive dysfunction is a major factor leading to disability and poor quality of life in icu survivors. in order to identify patients at risk for developing cognitive dysfunction due to critical illness or icu treatment, one has to discriminate between patients with pre-existing cognitive dysfunction and those developing new cognitive dysfunction or worsening of cognitive function during icu treatment. we investigated the incidence of pre-existing cognitive dysfunction in icu patients using the informant questionnaire on cognitive decline in the elderly (iqcode) and its relation with delirium during icu treatment. methods: patients relatives were asked to fill in the iqcode on admission. an overall score on cognitive dysfunction was calculated by the average of the score on each item of the questionnaire. the incidence of delirium was based on the cam-icu score. statistical analysis was performed using the fisher's exact test. p-values of less then . were deemed significant. results: in total consecutive patients admitted to our icu were analyzed, of whom . % (n= ) showed decline in cognitive function prior to icu admission. cognitive function was divided in four groups; no change . % (n= ), slight decline . % (n= ), moderate decline . % (n= ) and severe decline . % (n= ) (fig. ). incidence of delirium is shown in fig. . patients with moderate to severe cognitive dysfunction showed significant more delirium during icu treatment than patients with no change in cognition ( . % and . % respectively, (p= . )). conclusions: almost half of the patients admitted to the icu have cognitive dysfunction prior to icu admission. to assess ones cognitive function after icu treatment one has to take in to account the patients pre-existing cognitive functioning. patients with a moderate to severe pre-existing cognitive dysfunction develop significantly more delirium during icu treatment. introduction: our aim was to identify and analyse patients treated for pocd admitted to a thoracics/urology intensive care unit at university college london, uk. pocd is rising in the ageing high-risk surgical patient. early identification of those at risk and timely intervention could help reduce associated morbidity and mortality [ ] . methods: we identified patients treated with haloperidol, midazolam, lorazepam, olanzapine, clonidine or chlordiazepoxide from our electronic data system. these pharmacological interventions were used as surrogate markers of primarily hyperactive pocd, acknowledging other forms of delirium may be unaccounted for. of admissions ( . %) were shortlisted from august to july . patients were excluded if the drugs had been used for other indications. prevalence of known pocd risk factors were then detailed. on these data we performed a cluster analysis using r. results: of the patients ( . %) suitable for analysis, the mean age was . patients underwent elective procedures. were male and were female. % patients had thoracic surgery. the mean pain score in the first hours post-op was . (sd= . ), (with = no pain, = very severe pain). % had evidence of poor sleep and % evidence of anxiety. in the hours prior to evidence of pocd, the mean pain score remained . (sd= . ), % had evidence of poor sleep and % had evidence of anxiety. % of our population was septic during their itu admission. conclusions: our analysis demonstrates pocd is highly prevalent in male patients over undergoing thoracic procedures. we will now develop a pocd pathway targeting improved postoperative management of pain, sleep, anxiety and infection in this patient population. introduction: our objective was to determine the feasibility of employing family-administered tools to detect delirium in the critically ill. the use of family-administered delirium detection tools has not been assessed in the icu where patients are critically ill and frequently intubated. family members may be able to detect changes in patient cognition and behavior from pre-illness levels earlier than unfamiliar providers. these tools may be a valuable diagnostic adjunct in the icu. methods: consecutive patients and family members (dyads) in the largest adult icu in calgary, canada were recruited (aug. -sept. , ). inclusion criteria were: patients with a richmond agitation sedation scale (rass) >=- ; no primary brain injury and glasgow coma scale score of < ; ability to provide informed consent (patient/ surrogate); and remain in icu for hours. data were collected for up to days. family-administered delirium assessments were completed once daily (family confusion assessment method & sour seven). to assess feasibility, we assessed proportion of eligible patients and percent family member enrollment. barriers to enrollment were categorized. results: of admitted patients with family, ( %) met inclusion criteria and ( %) dyads consented. % of admitted patients did not have family and were thus ineligible. % of enrolled dyads assessed delirium at least once, with a median of (of total) assessments. the most common reason for non-enrollment was refusal by the family, who commonly reported feeling overwhelmed by the icu environment. barriers with nursing staff were encountered, including not providing access to patients and patient exclusion. conclusions: these data suggest that employing family-administered delirium detection tools in the icu is feasible for a subset of the population. future studies will validate the use of these tools in the icu, decrease modifiable barriers to enrollment, and test strategies to overcome attitudinal barriers towards employing these tools. introduction: psychological impact of critical illness and icu stay on patients can be severe and frequently results in acute distress as well as psychological morbidity after discharge [ ] . however, the stressful experience in icu and its influence on patient recovery, remain relatively understudied. we assessed patients in icu for acute distress and psychological symptoms with validated tools. methods: we conducted an observational study in a group of awake icu adult patients admitted in a tertiary centre for at least hours, from january until october , with mixed diagnosis on admission. we collected demographic factors, saps ii at admission, mechanical ventilation, day of sedation, history of psychopathological disorder. un-sedated and alert, critical care patients were assessed with tools such as intensive care delirium screening checklist (icdsc), hospital anxiety and depression scale (hads) and intensive care psychological assessment tool (ipat). results: patients were recruited, (mean age . ± . years, . % males). saps ii at admission was . ± . , . % was mechanically ventilated (mean duration . ± ), mean duration of sedation was . ± . days and a rate of . % had an history of psychopatological disorder. . % of the sample had clinical delirium (icsdc> ) and was not assessed with others tools, . % had subclinical delirium (icsdc <= ). regarding psychological outcomes, . % (mean score . ± . ) reported a score (>= ) on hads that indicates a possible diagnosis of anxiety and . % (mean score . ± . ) of depression. a rate of . % reported a score >= on ipat suggesting an acute distress. conclusions: the study's key finding was that acute psychological distress was high in awake icu patients. further work is needed to determine the efficacy of early psychological interventions to reduce the incidence of acute distress and psychological outcomes after icu stay. introduction: a high percentage of polytrauma patients require surgery within the first hours to stabilize primary traumatic injuries. one of the main intraoperative complications in this type of patients is due to hemodynamic instability [ ] . thus, it is necessary to implement multimodal monitoring involving both hemodynamic monitoring and monitoring of general anesthesia. the objectives of this study were to identify the possible implications of entropy monitoring on hemodynamic stability in critically ill polytrauma patients. methods: prospective observational study, deployed in the clinic of anesthesia and intensive care, emergency county hospital "pius brinzeu" timisoara, romania. clinicaltrials.gov identifier. there were two groups, group a (n = ), in which the depth of hypnosis was monitored through entropy (ge healthcare, helsinki, finland) and group b (n = ). results: the incidence of hypotension and tachycardia episodes was statistically significantly lower in group a, unlike the control group (p < . ). moreover, a statistically significant (p < . ) consumption of inhaled anesthetic agent was recorded in group a compared with group b. consumption of vasopressor was also lower in group a (p < . , difference between means . ± . , % confidence interval . - . ) conclusions: deploying monitoring for the depth of hypnosis in general anesthesia using entropy can significantly increase the hemodynamic stability of critically ill polytrauma patients. introduction: the use of methadone as a potent analgesic has been gaining ground in the intensive care setting, such as where it is possible to properly select the group of patients who will benefit from the drug, as well as monitoring of possible complications. the objective of this study is to evaluate the safety of the use of methadone in critically ill patients in a large hospital. methods: a retrospective analysis of all patients who used methadone in a neurological intensive care unit for a period of four months and the results were evaluated. results: in the four-month period, patients used methadone during intensive care. % of the patients were male, with a medical age of . ± . years. the main indication for the use of the medication was for analgesia in patients who were weaned from mechanical ventilation. the mean time of use was . days. in all cases evaluated, analgesia was effective, with methadone being used alone or in combination with other drugs, according to an institutional protocol. among the complications found, patients presented hypotension ( %); presented bradycardia ( %); presented constipation ( %); had excessive sedation ( %) and had other complications. all complications were reversible. patients of the studied population died, however, without correlation with the use of methadone. conclusions: the use of methadone, in the studied group, was effective in the control of analgesia, with no impact on patient safety when used in a monitored way. introduction: renal colic is a common disorder which presents with dramatic acute pain. providing rapid relief, using effective pain control medications is the clinical priority to treat the patients. this study aims to compare the effect of iv ketorolac versus morphine in releasing renal colic pain by measuring pain severity and duration and also the need for additional doses. methods: we performed a clinical pilot cohort study from during on patients with the clinical diagnosis of renal colic who recruited from the emergency department (ed) of rasool-e-akram hospital and firoozgar hospital. participants who were candidate to receive either morphine or ketorolac were divided into two groups who received either mg ketorolac iv or mg morphine. the pain was evaluated using the visual analog scale (vas) at four time points: before drug injection (vas- ), minutes (vas- ), minutes (vas- ), and minutes (vas- ) after injection. in cases when the pain was not controlled with the first injection of drug beyond minutes; additional doses (rescue) were injected. statistical analyses were performed using spss . results: one-hundred-fifty patients treated with morphine and ones with ketorolac were studiedthe group treated with morphine scored on average . before the injection, which was roughly . points higher than ketorolac. morphine reduced patients' vas scores more intensely (median: , iqr: versus median: , iqr: ; p value< . ). in general, patients treated with morphine were more likely to need a second (rescue) dose, when compared to ketorolac group ( . % vs %, p value= . ). conclusions: morphine is a better option for pain release in cases of renal colic. ketorolac released the pain to an acceptable level; but, because of its slower action time, we recommend it in cases with moderate than severe pains. effect of analgesics on cardiovascular and hormonal response to operative trauma d loncar stojiljkovic, mp stojiljkovic sgh, , serbia critical care , (suppl ):p introduction: objective of this study was to compare the effects of two analgesic regimens, one opioid and one non-opioid, on cardiovascular and hormonal reaction of patients undergoing elective surgery under general endotracheal anaesthesia. methods: a total of elderly patients, asa , scheduled for elective abdominal surgery were assigned to receive on induction a single dose of either fentanyl ( . mg, + . mg) or a fix combination of etodolac and carbamazepine (novocomb, dose mg+ mg iv bolus). haemodynamic parameters and concentrations of prolactin cortisol and growth hormone (gh) [ ] were determined at critical points and h after operation. results: both fentanyl and novocomb blocked the hypertensivetachycardic response to surgical trauma. cortisol was a more appropriate endocrine marker of stress than prolactin or gh since fentanyl as an opioid analgesic increased secretion of prolactin [ ] , while carbamazepine from novocomb did the same with gh [ ] (figs. & ) . conclusions: cortisol plasma concentration correlates positively with cardiovascular parameters in patients undergoing elective abdominal surgery who received fentanyl or novocomb as intraoperative analgesic. its suppression is better marker of analgesia than prolactin and gh. volatile anaesthetic consumption and recovery times after long term inhalative sedation using the mirus system -an automated delivery system for isoflurane, sevoflurane and desflurane introduction: the new mirus system as well as the anaconda uses a reflector to conserve volatile anaesthetics (va) [ , ] . both systems can be paired with icu ventilators, but mirus features an automated control of end-tidal va concentrations (etva). we compare feasibility and recovery times for inhalational long term sedation with isoflurane (iso), sevoflurane (sevo) or desflurane (des). methods: asa ii-iv patients undergoing elective or emergency surgery under general anaesthesia were included. patients were randomized into three equal groups iso, sevo and des. the mirus system was started with a targeted etva of . mac. we used the puritan bennett icu ventilator and performed a spontaneous breathing trial. if successful, the target concentration was set to mac and recovery times measured. results: patients were comparable in demographics, tidal volume, respiratory rate and sedation time (total h: iso ± h; sevo ± h; des ± h; p= . ). in all patients, a mac of . was reached. conclusions: mirus could automatically control end-tidal va concentrations in ventilated and spontaneously breathing patients. the recovery times are only prolonged in the iso group and could be shortened by removing the reflector. the higher etva required for a . mac using des and sevo were associated with an increased va consumption. introduction: intranasal analgesia is increasingly used in order to relieve pain in the emergency department. this non-invasive approach avoids discomfort, stress and risks related to the parenteral route of administration. the objective is to compare intranasal (in) fentanyl versus any parenteral opioid (intravenous, subcutaneous, intramuscular) for the effectiveness of acute pain relief in an adult population. methods: the systematic review was registered in prospero (crd ). the research of articles was conducted through embase, central, and medline databases. randomized clinical trials comparing the effectiveness of in fentanyl to any parenteral opioid for acute pain relief (<= days) in an adult population (>= years old) were considered for inclusion. studies on breakthrough cancer pain were excluded. two different reviewers extracted data and analyzed the quality of the selected articles. the main outcome was the difference between pain levels before and after analgesia. the effect size was approximated using the inverse of variance of standardized mean differences, based on a random-effect model. heterogeneity was quantified using a test of i . results are presented with % confidence interval. results: eight randomized clinical trials with cohorts and a total of patients were selected ( in fentanyl vs control group). selected articles contained a low risk of bias. there is no significant difference between the average levels of pain before and after analgesia comparing the two groups (smd . [ic % - . à . ], p= . ; i = %) (fig. ) . conclusions: in fentanyl is as effective as other parenteral opioid to relieve pain during the first hour of treatment. introduction: the aim of this study is to underline the importance of sedation protocol when performing the pegj procedure in advanced parkinson's disease (pd) patients. research about the use of sedation in endoscopy is getting more and more widespread as to answer to the increasing grade of complexity and duration of endoscopic procedures as to offer comfort to the patient in terms of analgesia, tolerability, and amnesia. sedation is also a way to assure quality and safety examination and to improve its outcome [ ] . methods: this observational retrospective study includes pd patients scheduled for pegj procedure (fig. ) in order to start therapy with duodopa gel. we propose an anesthetic technique (table ) to support pegj with both local anesthesia and moderate sedation so as to provide analgesia and patient's comfort. this technique ensures mean duration of pegj procedure was '± '. mean stay time in recovery room '± '. compared to our old experience, we collected lack of patient's discomfort, anxiety, and memory, high procedure compliance and improvement of the quality of procedure without use of opioids. conclusions: based on our experience, we consider this sedation protocol effective for different reasons: to relieve or abolish patient's discomfort, anxiety, and memory, to ensure compliance with the procedure, to ensure patient's analgesia and patient's safety and, finally to assure procedure's quality and rapid discharge. anyways, a multicentric study should be done to test our protocol. introduction: studies have shown that icu survivors exhibit longterm neurocognitive impairment and perceived reduction in quality of life after icu discharge, but studies examining sleep architecture and sleep disordered breathing (sdb) in icu survivors after icu discharge are scanty. the aim of our study was to assess sleep architecture and sbd in icu survivors. methods: icu survivors were screened for eligibility. inclusion criteria were: age - yrs, mechanical ventilation >= hours, gcs of at the time of hospital discharge. patients with a history of sbd, chronic neuromuscular disorders, chronic restrictive lung disease, congestive heart failure and respiratory failure at hospital discharge were excluded. patients were evaluated within one week after hospital discharge and months later. at both visits patients completed health related quality of life questionnaires (sf and epworth sleepiness scale), underwent a physical examination, lung function tests including maximum inspiratory and expiratory mouth pressures, and an overnight full polysomnography (psg). results: sleep quality at days of hospital discharge is poor, characterized by severe disruption of sleep architecture and excessive sdb, mainly of obstructive type which in % of patients was classified as moderate or severe. although at six months after hospital discharge sleep quality remained relatively poor, significant improvement in n stage and ahi was observed, with more patients to be classified as normal or mild sdb. both at hospital discharge and months later quality of life was reduced but there was no relationship between the health related quality of life and sleep disturbances. conclusions: icu survivors experience significant deterioration in their quality of life status with minor improvement months later and a variety of sleep disturbances that seems to start getting better months later. introduction: disrupted sleep in critically ill patients may be associated with delirium, prolonged stay in icu and increased mortality. polysomnography (psg), the criterion standard method of sleep monitoring, is challenging in icu due to interpretation difficulties, as the patterns defined by the standard classification for scoring sleep are absent in many critically ill patients. the aim of this study was to investigate if the presence of atypical patterns in critically ill patients' psg is associated with poor outcome measured by -days mortality in conscious critically ill patients on mechanical ventilation. methods: psgs (median duration hours) recorded in conscious critically ill mechanically ventilated patients were scored by an expert in sleep medicine blinded to patient characteristics. standard sleep scoring classification was used if possible. otherwise, modified classification for scoring sleep in critically ill patients proposed by watson et al. was applied [ ] . the association of sleep patterns (normal or atypical) and micro-sleep phenomena (sleep spindles and kcomplexes) with days mortality was assessed using weibull model by calculation of hazard ratios (hr). results: hr analysis showed twice as high mortality risk in case of atypical sleep compared to normal sleep; this was however not significant (hr . ; % ci . - . ; p= . ). the presence of sleep spindles in psg significantly reduced mortality risk to / (hr . ; % ci . - . ; p= . ). the presence of k-complexes in psg reduced mortality risk to ½, though not significantly (hr . ; % ci . - . ; p= . ). conclusions: the absence of normal sleep characteristics in psg in conscious critically ill patients on mechanical ventilation is associated with poor short-term outcome. antipsychotics (aps) prescribing in critically ill delirious patients, the reported versus the perceived practice e almehairi , g davies , d taylor introduction: aps are the most commonly prescribed drugs in hyperactive/mixed delirium and agitation in critical care (cc) [ ] . yet evidence in cc is scant, there are known adverse effects (ade) and prescription is out with the european license. meticulous observation of ap selection, prescribing and safety, alongside delirium assessment/plan is essential to gain new knowledge and patients. when accompanied by prescribing clinicians perspective of delirium ap treatment results are more interpretable. we conducted a two-part single centre cohort study that aimed to describe/compare real to perceived delirium assessment/plan, aps prescribing and safety in cc adult patients at gstt. methods: part : a prospective survey, of cc prescribing clinician's beliefs and attitudes to delirium assessment/plan, aps prescribing and safety over previous months. part : a meticulous audit of aps prescribing and safety and delirium/agitation assessment and plan, over period of months. results: part survey. of prescribers ( . %) completed survey. % of reported using aps to treat delirium, with % selecting atypical aps as first option. part audit. there were admissions to cc. aps were prescribed in . % ( prescription), . % ( prescription) were in delirium/agitation patients (table ) . survey (vs.) audit: in the survey % reported daily delirium screening whereas only . % undertook daily screening in audit (fig. ) . higher quetiapine and lower iv haloperidol maximum daily dose were prescribed in audit in comparison with survey reported doses ( table ) . lead ecg was used to monitor ap ade. in survey % reported assessing ecg once or more daily. audit revealed only % actually did so (fig. ) . conclusions: authors believe perceived vs actual can identify key areas for quality improvement (qi). major differences were in delirium assessment/plan and safety monitoring sedation practices in turkish icus, the aim was to provide knowledge on this matter. methods: an electronic survey form was generated with google forms. first part of the form included questions about demographics, and choices and routines of sedation administration. this part mostly contained multiple choice questions, which more than one choice could be indicated. second part was comprised of some statements to investigate the attitudes of physicians, which were indicated on a five-point likert scale. the link for the survey was posted to all email addresses registered in the turkish society of intensive care member database. results: of members, ( %) completed the survey form. demographics are given in table . sedation was generally applied by the physicians ( %). the indications were mechanical ventilation ( %), agitation ( %), seizures ( %), anxiety ( %), delirium ( %). drug choices of the respondents are shown in fig. . sedation level was evaluated daily by % of respondents, mostly using ramsay scale ( %). daily established sedation level was indicated in . %, and daily interruption of sedation was indicated in . % answers. sedation protocol was not used in . % of the answers. analgesics applied commonly, while % routinely evaluated pain and visual analogue scale (vas) was the preferred method in % of the answers. . % of physicians indicated routine use of neuromuscular blockers. in . % answers routine evaluation for delirium was indicated, mostly using cam-icu.when the knowledge of sccm guideline pain, agitation and delirium management, % indicated a positive answer.the respondents indicated their opinion for some comments on sedation, the answers are shown in the table . conclusions: it may be concluded sedation practices may need to be improved by increasing awareness on novel concepts in this area. fig. (abstract p ) . the prediction-corrected vpc plots for dexmedetomidine pk. the vpc plots show the simulation-based % confidence intervals around the th, th, and th percentiles of the pk data in the form of blue ( th) and gray ( th and th) areas. the corresponding percentiles from the prediction corrected observed data are plotted in black color methods: a prospective multinational cohort study was performed in icus in sweden, denmark and the netherlands. all adult patients with an icu stay >= hours were screened for inclusion. primary outcome was psychological problems three months after discharge from the icu, assessed with the questionnaires hospital anxiety and depression scale (hads) and post-traumatic stress symptoms checklist- (ptss- ). a subscale score > in the hads and a score > in the ptss- part b indicate clinically significant symptoms of depression, anxiety and pts and was considered an adverse outcome. we collected data on known risk factors for psychological problems post-icu. univariable and multivariable logistic regression modelling of risk factors was performed in order to create an instrument to be used bedside, predicting individual risk for adverse psychological outcome. results: patients were included and ( %) returned follow-up questionnaires. % of patients scored above the predefined cut-offs having symptoms of depression, anxiety or pts. age, lack of social support, depressive symptoms and traumatic memories at discharge remained significant after multivariable modelling and constituted the screening instrument ( table ) . the predictive value of the instrument was fairly good with an area under the receiver operating characteristics curve (auroc) of % (fig. ) . we developed an instrument to be used at icu discharge, predicting individual patients' risk for psychological problems three months post-icu. the instrument can be used as a screening tool for icu follow-up and enable early rehabilitation. improving the patients hospitalization experience in an intensive care unit by contact with nature w yacov , y polishuk , a geal-dor , g yosef-hay kaplan medical center, rehovot, israel; kaplan medical center, rehovot, israel critical care , (suppl ):p introduction: the intensive care unit is characterized by a noisy and threatening work environment using multi tecnologic equipment.the staff works very intensively caring for very complicated and unstable patients.whilst caring for the patients physical needs one must not forget the patients mentally needs.the improvement of the patients hospitalization experience by changing the environment improves the mood and responsiveness to treatment gives hope for healing to the patient and family. methods: a quality questionare with open questions relating to the subjective sensory experience of the patients and their families. the patients were transferred to the "sun balcony" for a period of - minutes having their families alongside. music was transmitted and the patients were offered food and drinks if their condition allowed. results: the patients reported a significant improvement of hospilizaton experience following their exposure to the "nature environment". patients described the sensory experience as a positive, pleasant, quiet and relaxing experience. the contact with the sun, wind, sky and grass and being outside on the "sun balcony" allows a disconnection from the threatening icu environment. conclusions: the "sun balcony" gave the patients a sense of hope and wish for healing. mobilizing complicated patients to the "sun balcony" is a big challenge which requires planning and preparation by the staff. yet by the proactive and creative thinking of the staff the patients are tranferred to the "sun balcony" to give them encouragement, a feeling of well being and hope for recovering. this intervention is costless and a routine procedure in the intensive care unit. introduction: long-term psychological outcomes of patients(pts) discharged from icu represent an emergent relevant matter of concern.systematic reviews refer prevalence of %- % for anxiety, %- % for depression and %- % for posttraumatic symptoms in ards patients.the onset of psychiatric symptoms after discharge, might be associated with patient's competence to process memories related with hospitalization and with memories. methods: we selected ards pts in icu of a tertiary centre (jan -dec ) at least hour, for months follow-up and pts for months follow-up after discharge. the psychopathological assessment was performed using scale as: impact event scale-revised (ies-r), hospital anxiety and depression scale (hads), icu memory tool (icu-mt). results: mean age was . ± . at months follow-up and , ± , at months. ptsd symptoms was fund respectively in % and . % pts at and months; anxiety symptoms % and . % of pts;depression symptoms in % and . %. significant correlations were fund between psychopathology at months and memories of icu: hads anxiety with delusion memories (r . ,p< . ); hads depression with factual (r . ,p< . ), feeling (r . ,p< . ) and delusion memories (r= . ,p< . ); feeling (r . ,p< . ). at months significant correlations was fund between hads anxiety and feeling memories (r . ,p< . ); ies-r and factual (r . ,p< . ), feeling (r . ,p< . ) and delusion memories (r . ,p< . ). the results of the study confirmed the importance of assessing psychopathology after discharge from icu. the onset of these symptoms appeared to be mediated by specific traumatic memories related with icu hospitalization. the main clinical recommendation emerging from this study is to investigate psychiatric history and develop psychological strategies to manage frightening or delusional experiences during icu stay. introduction: the aging of the population is a fact. the subgroup of very old (>= years (ys)) is the one that increases the most rapidly. intensive care unit (icu) admission of these patients is an ongoing discussion worldwide. our icu has designed the voolcano aiming its characterization and reviewing outcomes, to find some predictive indicators. the purpose of this first analysis is to evaluate specifically the group of very old patients (volds) admitted to a tertiary portuguese hospital icu. methods: retrospective observational study was preformed, included all volds admitted in icu during years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . demographic data, admission diagnosis, severity scores, charlson comorbidity index, length of stay and outcomes were considered. data analysis used spss software. results: we found a total of admissions. the median age was . ys with iqr ; mostly male with medical admission diagnosis (sepsis and respiratory failure due to infection). there was a median acute physiology and chronic health evaluation ii of (iqr ) and simplified acute physiology score ii of (iqr ). median charlson comorbidity index was . (iqr ). median length of stay was . days (iqr . ). concerning outcomes, we found intra-icu mortality of %; intra-hospital after icu discharge mortality of % and mortality after hospital discharge of %. identified as predictors of intra-hospital mortality the use of mechanical ventilation (p < . ), urgent surgical admission or medical admission versus schedule surgical admission (p < . ) and the absence of oncologic disease (p = . ). on multivariate analysis, only mechanical ventilation (p = . , hr . , % c.i. . - . ) and urgent surgical admission versus schedule surgical admission (p = . , hr . , % c.i. . - . ) remain significant. conclusions: recognizing the need to understand what is the biologic|funcional age (opposed to chronologic age) would be beneficial in the selection of volds to icu admission. organ failure and return to work after intensive care s riddersholm , s christensen , k kragholm , cf christiansen , bs rasmussen aalborg university hospital, aalborg, denmark; aarhus univeristy hsopital, aarhus, denmark critical care , (suppl ):p introduction: organ failure is associated with an unfavorable prognosis. nevertheless, the association with capability to return to work remains unclear. therefore, we investigated the association between organ support therapy as a proxy for organ failure and return to work in a nationwide cohort of icu survivors. methods: we linked danish registry-data on icu-and hospitalsurvivors working prior to hospital admission during - , - years of age, with an icu length of stay > hours and not previously treated with dialysis, to data on return to work. we reported cumulative incidences (chance) of return to work with death as competing risk, and compared rate of return to work in adjusted cox regression-models by number of organ support therapies including renal replacement therapy, cardiovascular support and mechanical ventilation and stratified on primary hospital-admission diagnosis. results: of , patients - years of age, % ( , ) survived to hospital discharge (tables and ). among these, the chance of return to work was . % ( % ci [ . - . ]) within two years (fig. (fig. ) . when stratified an increasing number of organ support was associated with a decreased chance of return to work among patients with infection, respiratory failure or trauma but not among patients with neoplasms or endocrine, gastrointestinal and cardiovascular diagnoses. introduction: mortality rates among people with moderate to severe learning disabilities (ld) are times higher than in the general population [ ] [ ] [ ] . this study was designed to examine critical care admissions with learning disabilities in terms of mortality, demographics and reason for admission. methods: data was retrieved for adult patients (> years old) between sept and . the ward watcher database for icus within surrey and sussex healthcare nhs trust was interrogated using search words including, learning disability, cerebral palsy, down's syndrome and autism. results: there were episodes ( . % of all admissions) of patients admitted with ld. % of the ld patients had more than admission. respiratory is the most common system affected ( %). logistic regression suggests survival is highest in those with a neurological reason for admission (p= . ). proportionally ld patients were young compared to the total population (fig. ) . we found that mortality appears to increase rapidly in those over years of age and overall mortality is greater in those with ld (fig. ) . conclusions: from april all uk trusts will be required to complete a detailed review for patients with ld who die whilst in hospital care. this follows mencap's report 'death by indifference' which exposed deficiencies in the care of people with lds who died whilst in nhs care and the subsequent confidential inquiry into premature deaths of people with learning disabilities. in our population, ld patients have an earlier death than the general population and the overall mortality from critical illness is greater. a multidisciplinary approach at the emergency department to admit potential organ donors for introduction: the aim of the present study is to improve the recognition of potential organ donors by implementing a multidisciplinary approach for organ donation at the emergency department (ed) [ ] . methods: in a prospective intervention study, we implemented this approach in six hospitals in the netherlands. when the decision to withdraw life sustaining treatment was made at the ed in patients with a devastating brain injury without contra indications for organ donation, an intensive care unit (icu) admission for end-of-life care was considered. every icu admission for end-of-life care was evaluated. interviews were conducted with emergency physicians, neurologists and icu physicians according to a standardized questionnaire. this interview focused on medical decisions that were made and difficulties arising during hospitalization. results: from january to november data were collected on the number of patients admitted to the ed with acute brain injury. in total, potential organ donors were admitted to the icu for end-of-life care. donation was either requested in the ed ( %), icu ( %), neurology department ( %), or donation was not requested ( %). out of donation requests, families ( %) consented to donation. this led to successful organ transplantations. in four of these patients family consent was obtained to intubate them solely for the purpose of organ donation. the most important points raised during the interviews were: explaining the non-therapeutic icu admission to the family, the location where donation should be requested (ed/icu) and utility of icu resources. conclusions: a close collaboration between the ed, neurology department and icu is necessary and achievable in order not to miss potential organ donors in patients with acute brain injury with a futile prognosis in the ed. introduction: there is a relationships between intensive care patients losing the ability to speak and negative emotions [ ] . nursing care is challenging when patients are unable to verbalise and factors like pain and comfort are misjudged.. our intensive care unit has introduced a communication tool intelligaze grid which enables patients with primary motoric disorders to communicate their needs. a quality improvement study reviewed the methods of communication and interactions that our nurses use for patients who are ventilated. the objective of the study was to promote areas of improvement with communication in the icu. methods: we used a mixed-methods qualitative and quantitative study to evaluate the communication tools used by our nursing staff to interact with ventilated patients. a convenient data sample for all nurses working on particular dates was collected which is % of the nursing workforce. the study has been approved as a quality assurance project by the human research ethics committee of nepean hospital. results: sixty registered nurses ( %) participated in the study. the most common communication tool used with patients was closed yes/no questions( %), followed by hand gestures( %), magnetic writing board( . %), lip reading( . %) and alphabet board( . %). the descriptive analysis identified challenges were levels of sedation, weakness, non-english speaking patients and delirium. a significant finding was that only % of nurses identified the patients message being understood and % acknowledged listening as effective communication. conclusions: communication is a vital aspect of icu nursing and is achieved through dialogue and specialised skills. the study concluded that icu nurses find it difficult to communicate effectively with ventilated patients. the introduction of intelligaze grid has improved patient communication and promotes holistic nursing care. p withdrawn introduction: substantial variability in eolp occurs around the world [ ] . differences in eolp were previously reported in europe in the ethicus i study [ ] . methods: icus worldwide were invited to participate through their country societies. consecutive admitted icu patients who died or had treatments limitations during a month period from . . to . . were prospectively studied. regions included north, central and southern europe (ne, ce, se), north and latin america (na, la), asia (as), australia (au) and africa (af). previous eolp definitions were used [ ] . results: icus in countries participated enrolling , patients. figure shows differences in eolp by region and figure in patient competency by region. conclusions: worldwide differences included more cpr in af, la, and se and less cpr in ne, au and na. there was more withdrawing (wd) in ne and au and less wd in la and af. more patients were competent in au and ne and less were competent in af, se and la. introduction: the decision of end-of-life care in the icu is very tough issue because the law, ethics, traditions and futility should be concerned involving family's will. especially, stop or withdraw therapy is a quite difficult operation in japan because of our traditions. recently there are few legal issues due to some guidelines. our hypothesis is some difference over time exists in thoughts about end-of-life care in the icu. the purpose of this study is to know changing methods: a questionnaire survey, which consists of questions with optional answers related to the thoughts of participants about end-of-life care of hopeless or brain death patients, was performed to nurses and doctors in our icu. the questions were; whether accept to withdraw therapy or not and with family's will, whether positive or not to donate of organs from brain death patient, necessary of icu care for brain death patient, feel guilty and stress for doing stop or withdraw therapy. the optional answer has gradations from 'yes' to 'no' for all questions. it was guaranteed to be anonymous for them in the data analysis. we conducted entirely same survey in . the answers between in and in were fig. (abstract p ) . patient mental compentency by region kidney disease: improving global outcomes acute kidney injury working group references nice clinical guidelines: idiopathic pulmonary fibrosis in adults: diagnosis and management references . zambon et al annual update in inten care references references references damage control management in the polytrauma patient crash- trial collaborators guidelines for the management of severe traumatic brain injury references references references . soar et al; european guidelines for resuscitation we acquired the confirmed date of death from the finnish population register centre database and gross -month healthcare costs from the hospital billing records and the database of the finnish social insurance institution. results: a total of patients were included in the study and were alive at months. median (interquartile range, iqr) -hour sofa score was ( - ) in -month survivors and ( - ) in non-survivors. the sofa score had an area under receiver operating characteristic curve of . ( % ci . - . ) for predicting -month mortality. in multivariate regression model with age and gender, sofa score had an odds ratio, or ( % confidence interval, ci) of . ( . - . ) for predicting -month mortality. all except cardiovascular sub-score also had p predictive factors for secondary icu admission within hours after hospitalization in a medical wards from the emergency room m cancella de abreu hôpital saint antoine p acquired neuromuscular weakness in eldery patients with femoral bone fracture, could we decrease the incidence? d pavelescu, i grintescu, l mirea emergency hospital floreasca p adasuve enables quicker dispositions of acute psychiatric patients in the emergency department k hesse , e kulstad , k netti , d rochford isi web of science and clinicaltrials.gov. data extraction: eligible studies were case reports and randomised controlled trials (rcts) that evaluated the effects of drug incompatibilities in critically-ill patients on morbidity or mortality as primary or secondary outcomes, or adverse events. two investigators independently reviewed the eligibility of the study from abstracts or manuscript data. data synthesis: twelve articles met the selection criteria (fig. ). the six articles reporting rcts concern only four rcts. rcts were single-centre studies comparing infusion with or without filter. two of them included adult patients. the others included pediatric and neonatal intensive care unit patients. primary endpoints were systemic inflammatory response syndrome (sirs), organ failure, overall complication rate, bacteremia, sepsis, phlebitis and length of stay. results: the results are mixed with one rct reporting a reduction in sirs, organ failure and overall complication rate, two studies in disagreement over the occurrence of sepsis and one study reporting no impact on length of stay. the six articles on case reports show different drug incompatibility situations european directorate for the quality of medicines & healthcare of the council of europe. guide to the quality and safety of organs for transplantation p current status and problems of organ transplantation before and after the enactment of the revised organ transplant law in p morale: introducing the anaesthetic trainee confession session results: of total patients admitted during study period, were eligible for study; . % were males and ( %) patients were transferred during after-hour. mean age of two groups (daytime vs. after-hour . ± . vs. . ± . years) was similar(p= . ) methods: retrospective analysis of prospectively collected data between october to february of a tertiary care icu in india. patient data collected on all consecutive icu admissions. primary and secondary outcomes were icu los and hospital mortality respectively. icu patients payer status were categorized as self-paid, corporate (paid-fully or partially-by-employer), and insurance (paid-fully or partially-by-third-party-payer). all analyses were adjusted for illness severity and icu support (vasopressor use, mechanical or noninvasive ventilation, blood transfusion). results: of patients admitted during study period significantly higher number of patients received icu support in self-paid and corporate groups compared to insured group ( . %and . % vs. . %; p= . ) braden scale is predictive of mortality in critically ill patients, independent of its efficiency as a predictive tool of pressure ulcer risk d becker , tc tozo discharged and died ( . %). the turnover rate of the icu was . . the occupancy rate calculated during the period was . %. there were only readmissions ( . %) within hours of admission. regarding the hospital evolution of these patients we had exits in this period, ( . %) were discharge and ( . %) were deaths, of these, ( . %) were after discharge from the icu. the mean saps score was . (ranging from to ). the probability of death, according to the standard equation was . % and the adjusted for latin america of . %. conclusions: the icu has a high occupancy rate and rotation turnover, as well as a higher mortality than predicted by the score. these indicators show the great population demand that we have and alert to the impact on the sustainability of the unit and patient safety methods: research/ethics approvals were obtained. surveys, interviews, round tables, targeted delphi exercises and non-participant observation were conducted across four adult critical care units, involving professionals. these methods were used to describe the baseline 'paper-based' workflow/inter-professional communication systems; and semi-quantitative quality improvement measures. secondly, critical care services worldwide were visited to generate a database of experience, lessons and models of optimised informatics delivery. results: key challenges at baseline in relation to workflow/communication information transfer between different healthcare professionals site visits revealed the importance of human resources; lead time technology advances; the prioritisation of nursing workflow and pharmacy medicines/prescribing database creation/testing and the importance of the hardware interface and ergonomics. improvements included patient safety/experience p work-related stress amongst doctors and nurses in intensive care, a&e, acute medicine, anaesthetics and surgery i lever *, h nawimana introduction: work-related stress is associated with anxiety, depression, days off-work, errors and 'near misses' [ ]. our objective was to references . kerr et al p pre-existing cognitive dysfunction in critically ill patients and the incidence of delirium during icu treatment p validation of the sos-pd scale for assessment of pediatric delirium: a multicenter study e ista , b van beusekom children's hospital, rotterdam, netherlands; umc groningen -beatrix children's hospital p introduction: delirium in critically ill children has gained attention in the last few years and the incidence seems higher than anticipated before. the sophia observation withdrawal symptoms-pediatric delirium (sos-pd) was developed to combine assessment of delirium with iatrogenic withdrawal syndrome, two conditions with overlapping symptoms. the current study evaluates the measurement properties of the pd component (pd-scale) of the sos-pd scale. methods: in a multicenter prospective observational study in four dutch picus, patients aged months to years and admitted for more than hours were included. these patients were assessed with the pd-scale three times a day. criterion validity was established: if the pd total score was or higher the child psychiatrist was consulted to confirm the diagnosis of pd using the diagnostic and statistical manual-iv criteria as the "gold standard". the child psychiatrist was blinded to outcomes of the pd-scale. in addition, the child psychiatrist assessed a randomly selected group of patients to establish false-negatives the pediatric delirium scale had an overall sensitivity of . % and a specificity of . % for a cut off score of points. the positive predictive and the negative predictive value were respectively, . % and . %. the icc of paired nurse-researcher observations was . ( % ci . - . ). in total patients were diagnosed with delirium during the picu stay. conclusions: the pd scale shows a good validity for early screening of pd. so, the pd scale is a valid and reliable tool for nurses to assess delirium in critically ill children p frequency, risk factors and symptomatology of iatrogenic withdrawal from opioids and benzodiazepines in critically ill neonates, children and adults: a systematic review of clinical trials ma duceppe , m perreault we also examined the grey literature. we included studies reporting frequency, risk factors or symptomatology of iatrogenic withdrawal of opioids, benzodiazepines (or both) in critically ill patients. we considered all study designs except case reports and case series. pairs of reviewers independently abstracted data and evaluated methodological quality using the cochrane collaboration tool, newcastle-ottawa or quadas- . pros-pero (registration number: crd ). results: we identified unique citations through database search and full-texts were assessed for eligibility. thirty-three studies were included; the majority were observational and only a few included adults proportion of perfused small vessels at to p use of methadone in critically ill patients p the use of intranasal fentanyl versus parenteral opioid for acute pain relief in adults: systematic review and meta-analysis p sleep disorders in icu survivors c alexopoulou, a proklou p impact of dexmedetomidine on the duration of invasive mechanical ventilation in pediatric intensive care patients -dexped trial m genest peri-operative dexmedetomidine in high risk cardiac surgerymulticentre randomized double blind placebo controlled pilot trial y shehabi we compared vasopressors, inotropes, pacing and cardiac complications for safety and severe acute kidney injury (aki), dialysis and death (major adverse kidney events make) for efficacy. methods: adults patients undergoing cardiac surgery [combined (valve + coronary bypass) or complex] or with preoperative glomerular filtration rate (egfr) < mls/min/ . m were included. salvage or transplant surgery, dialysis, egfr < mls/min/ . m and those on extracorporeal support were excluded. dex ( . ug/kg/hr) was started at induction of anaesthesia and continued up to hours after surgery. equivalent volume of saline was given to control group. standard intra and post-operative care was provided. results: we randomized patients in the dex group and in the placebo (pgp). the mean(sd) age . ( . ) and egfr . ( . ) in all patients. no significant differences at baseline. in the dex, . % underwent complex surgery vs . % pts in the pgp. the mean(sd) bypass time and aortic clamp was comparable ( ) and ( ) min. the vasopressor requirements methods: nine tracheostomized copd patients ready to be weaned from ventilation were enrolled.for each patient, the sleep architecture was studied by polisomnography (sleep profiler-advanced brain monitoring) performing recordings:basal registration, continuos infusion of propofol or dexmetomidine from pm to am. rass target was - /- . results: the mean dose was . mg/kg/h for propofol and . mcg/ kg/h for dexmedetomidine.quantitative analysis showed, a statistically significant longer total sleep time (tst) and less sleep fragmentation (awakenings/hour) using dexmedetomidine. qualitative analysis showed non statistical differences between the two regimens: longer n and n stage with propofol and a longer n and rem phase with dexmetedomidine. furthermore, a reduced number of dosage adjustment was needed during dexmedetomidine sedation methods: a -year prospective observational cohort analysis was performed. all patients consecutively admitted to the medical or surgical icu or burn unit of a university hospital with an icu-los of >= days were included. qol was assessed at baseline (bl) and at months (m), year (y) and lt (median . years (iqr . - . )) after icu discharge with eq- d and sf- surveys. at lt, questions about daily life were added. in subanalysis, we compared groups (g and g ) based on median icu-los. results: patients ( % men) with a median age of , an apa-che ii score of and a sofa score of at icu admission were included. patients ( . %) were lost to follow-up. median icu-los in the cohort, g and g was (iqr - ), (iqr - ) and days (iqr - ) respectively. during icu stay, g had significantly more and longer need for any type of organ supportive therapy (p< . ) and had higher maximum sofa scores (p< . ). icu, hospital, m, y and lt-mortality rates in the cohort were , , , and % respectively. these rates were similar in g and g and the outcomes were assessed by telephone interviews at month after discharge. factors associated with readmission and post icu mortality are presented as odds ratios. results: during the study period, elderly patients were discharged alive. the follow up was possible for ( . %) patients. predictors of one-month readmission in univariate analysis were coronary disease (p= . ), sapsii (p= . ) and decline in functional status (p= . ). in multivariate analysis ) were the independent predictors of early readmission. mortality rate at month was . %. risk factors of onemonth mortality in univariate analysis were sapsii (p= . ), heart rate at discharge (p= . ), world health organization(who) performance status at discharge (p= . ) and decline in functional status (p= . ). in multivariate analysis p= . ), decline in functional status (or, . ; %ci comorbidities don't have an important impact on short term outcome after critical illness, which is most strongly predicted by severity of illness and physiological reserve at discharge. p characteristics and outcome of elderly patients in intensive care unit i coelho health inequalities & people with learning disabilities in the uk: emerson & baines cipold p comparison of home and clinic follow-up visits after hospital discharge for post-icu patients: a cross-sectional study r rosa , c robinson , p berto , p cardoso , l biason in a post-icu follow-up service which is reference for tertiary hospitals in southern brazil. post-icu patients with a icu stay > h (for medical and emergency surgical icu admissions) or > h (for elective surgical icu admissions) who were discharged alive from the hospital were invited by telephone to participate in a clinic-based multidisciplinary appointment months after icu discharge. home visits were offered to patients who claimed impossibility to attend the clinic appointment due to the severity of their disabilities graph of total mortality in ld vs all patients fig. (abstract p ). graph of admission age in ld vs all patients references p evaluation of family satisfaction instrument in multicultural middle eastern critical care units a p breaking bad news in the emergency department: a randomized controlled study of a training using role-play simulation i bragard , jc servotte , i van cauwenberghe p introduction: this is a randomized controlled study aiming to assess the impact of an e-learning and a -hour role-play training in breaking bad news (bbn) each assessment included a video-recorded role-play with two actors playing the role of relatives, and questionnaires. two blinded experts rated the videos. results: out of participants, % were trainees and % were anaesthesia residents. eg (n= ) and cg (n= ) were not different at baseline on the several variables. there were significant group and time interaction effects. only eg increased their selfefficacy p deficits of end-of-life care (eolc) perceptions among physicians in intensive care units managed by anesthesiologists in germany m weiss , a michalsen , a toenjes p ethicus end-of-life practices (eolp) in worldwide intensive care units (icus)-the ethicus ii study a avidan p multidisciplinary team perceptions about terminal extubation in a teaching hospital in brazil s p changing thoughts about end-of life care in the icu; results of a survey the feel guilty for withdraw therapy in nurses was also significantly decreased in years ( % vs. %, p< . ). conclusions: some of end-of-life thoughts in the icu were shown differences in nurses compared with years ago introduction: workload resulting from in-flight emergencies has not been quantitatively analysed in the literature. for hospitals local to major airports, this may have significant financial implications. methods: review was carried out of all cases admitted to east surrey hospital from gatwick airport over a year period beginning in . data were collected by interrogating the icnarc database. demographics, presenting pathology and length of stay for each patient were recorded. in addition, the cost of care for patients admitted during was calculated using recent median figures for intensive care admission (local ccg rates). results: since , patients were admitted from gatwick airport. this was approximately % of our critical care admissions. the mean (sd) age was . ( . ) years, and the median [iqr] length of stay [ . - . ] days. around % of these patients were non-uk or eu nationals and therefore not entitled to nhs care. reasons for admission included cardiac ( . %), respiratory ( . %), central nervous system ( . %), and gastrointestinal issues ( %). during , patients were admitted resulting in a total of . patient days in critical care. the total cost attributable to this group of patients was calculated to be £ , . conclusions: there is a substantial additional financial burden on hospitals that regularly receive admissions from major airports simply due to their geographical location. there is no additional funding available for providing this service. the pattern of presenting conditions in our population is similar to that seen in previous reports describing inflight emergencies [ ]. given the increasing accessibility of air travel and the economic pressures on healthcare providers, further analysis of the financial impact of this patient group on certain hospitals would be welcome. methods: we developed a monte-carlo simulation [ ] with separate referral rates for emergency, elective, and ventilated patients. bed occupancy is classified according to admission type with a conversion to prolonged ventilated stays at a rate of % [ ]. we used data from our neurointensive care unit to complete the parameters required for the model e.g. beds and , referrals/day. outcome measures were bed occupancy, and failed admissions. we tested two scenarios: increased referral rate ( . /day), and increasing to beds. results: the model simulated our intensive care where we have a high occupancy rate. increasing referral rate led to a consumed icu and an increase in failed admissions (fig. ) . lastly, increasing bed numbers eased pressures with fewer failed admissions. conclusions: we recommend a personalised icu monte-carlo population model for specialist units for a more accurate representation of icu bed occupancy. these icu specific models should be more useful for predicting staff, bed and financial requirements in specialist units where healthcare resources are changing e.g. increasing geographical referral radius. conclusions: better patient flow increased occupancy and standards. staff education and clear protocols are needed to improve patient booking and efficiency. assess stress levels and causes of stress among doctors and nurses at university hospital lewisham and queen elizabeth hospital woolwich. we surveyed staff using uk health and safety executive's management standards (hsems), a -question validated tool which identifies stressful work conditions requiring intervention. methods: we conducted an anonymous survey of doctors and nurses working in intensive care, accident and emergency (a&e), acute medicine, anaesthetics and surgery over six weeks. results were analysed using the hsems analysis tool and broken down into seven areas: job demands, managers' support, peer support, relationships, role, level of control and possibility of change. each area was scored from - ( represents lowest stress). we compared the trust's results against national standards. results: healthcare professionals completed the survey. intensive care had the lowest stress levels and scored above average in all areas (n= , mean . , s.d. . ). this was followed by a&e (n= , mean . , s.d. . ), anaesthetics (n= , mean . , s.d. . ), surgery (n= , mean . , s.d. . ) and acute medicine (n= , mean . , s.d. . ) which had the highest stress levels. when compared to hsems targets peer support exceeded national standards. however, there is a clear need for improvement in staff's ability to control and change their working environment. conclusions: stress levels on intensive care were reassuringly low when compared to other departments as well as national standards. we identified areas that need improvement and with the support of hospital management we will initiate hsems-validated measures to reduce stress. p tools for sepsis-associated mortality in hematological patients and should be studied in larger cohorts.conclusions: our results present clinical data of protocolized pbto -targeted therapy and show that there is room for further optimization. a larger cohort with predefined interventions is needed to proof the effect on longterm outcome after sah. impact of phone cpr on rosc outcome a giugni , s gherardi , l giuntoli introduction: early cardiopulmonary resuscitation (cpr) improves survival in out-of-hospital cardiac arrest, and phone-cpr instructions can increase the number of victims receiving cpr before emergency medical service (ems) arrival. little is known about the impact of cpr phone instructions on the outcome of patients (pts) with return of spontaneous circulation (rosc). the target of this study is to investigate the impact of phone instructions on mortality, and on neurological outcomes of patients who survived an out-of-hospital cardiac arrest. methods: we enrolled pts admitted to icu after rosc following out-of-hospital-cardiac-arrest, from / / to / / ; pts younger than , in-hospital cardiac-arrest-victims, pts who underwent cardiac arrest in health facilities, and missing data records were excluded. written informed consensus was obtained for all pts during follow up. data about comorbility, mortality, neurologic outcome, cpr timing according to utstein style, complications in icu, metabolic state on er admission, were collected. study population was divided into two groups for statistical analysis: pts with immediate cpr guided by phone instructions (phone-cpr group) and those who did not underwent immediate cpr by laic bystanders. data were extracted from icu, ems databases and registered ems phone calls. results: pts met study criteria. phone cpr were given in cases, % of the whole study population. results are summarized in tables and conclusions: phone-cpr significantly reduced cpr-free interval. it correlates with a significative increase in shockable rhythms on ems arrival. there is no significative reduction in mortality and in disability, even if a decrease trend can be observed. phone-cpr seem to be a promising, effective and easy to use tool to improve survival and disability in rosc, and should be widely applied. early hemodynamic complications in cardiac arrest patients-a substudy of the tth- study j hästbacka introduction: our aim was to determine the incidence and severity of hemodynamic complications during therapeutic hypothermia and analyze whether these complications can be predicted from data available on admission. methods: this is a substudy of the tth- study, where cardiac arrest (ca) patients were randomized to receive therapeutic hypothermia treatment for either or h [ ] . hypotension within four days from admission was recorded and defined as mild, moderate, severe or circulatory failure. arrhythmias were recorded and classified as mild, moderate or severe. we calculated the incidence and distribution of severity of the events. we used multivariate logistic regression analysis to test association of admission data with any hypotension or any arrhythmia. results: of all patients, . % had hypotension which was mild in . %, moderate in . %, severe in . % cases. . % had circulatory failure. an arrhythmia was present in % of patients. of these, . % were mild, % moderate and . % severe. bradycardia (n= ), new ca (n= ) and circulatory shock (n= ) were hemodynamic reasons for preterm rewarming. in multivariate analysis age (p= . , or . ) and admission map (p= . , or . ) were significantly associated with hypotensive complications. only use of mechanical compressions was significantly associated with risk for arrhythmia (p= . , or . ). conclusions: hypotension and arrhythmias were frequent in cardiac arrest patients during days - from admission, but mostly mild or moderate in severity. age and admission map were associated with hypotension. only the use of mechanical compressions was independently (negatively) associated with arrhythmias. introduction: in a retrospective study from the pittsburgh clinic, which analyzed survival data from patients admitted to a hospital with a cardiac arrest outside the hospital, it was found that patients with opioid overdose showed significant improvements in neurological status when discharged from the hospital compared with patients who did not receive opioids [elmer j. et al., ] . methods: after local ethic committee approval case-records of patients with cardiac arrest and subsequent resuscitation for the period - in the clinic of traumatology and orthopedics in astana were analyzed. criteria for inclusion in the study were hospital cardiac arrest, trauma to the musculoskeletal system. results: out of case-records, ( . %) patients with out-ofhospital cardiac arrest were excluded. among all hospital stops of blood circulation, we found only successful cpr ( . %). among the patients who were successfully resuscitated, groups were identified: i - patients ( %) who received ketamine or/and opioids before the blood circulation stopped ( - minutes); ii - patients ( %) who did not receive these medicines. the mean age in group i of patients was . ± . years, in group ii - . ± . years (p> . ). patients of the second group had an average life expectancy of . ± . days, with a maximum postresuscitation life of days. patients of the first group were in the hospital for . ± . days (p < . ), with a maximum period of days. in the first group, the final neurologic evaluation according to the glasgow scale was . ± . points, while in the second group it was . ± . points (p < . ). conclusions: a retrospective analysis revealed a better survival and neurological outcome in patients who received ketamine or/and opioids before circulatory arrest.introduction: the revised organ transplant law was enacted in japan in . under the revised law, it is now possible to donate organs with the consent of the family even if the intention of the potential donor is unknown. organs from brain-dead children under the age of can also be donated. methods: the aim of this study was to assess how to provide prompt transplant medical care and improve the donor's condition. this was achieved by clarifying the problems encountered in the process leading to brain-dead organ transplantation at our institute before and after the enactment of the revised organ transplant law. there were cases of organ donation at our institute from january to june . among them, the background factors of cases leading to organ donation were examined. results: the causes of the brain-dead condition were cerebrovascular disease (n = ; subarachnoid hemorrhage, intracerebral hemorrhage), trauma (n = ), suffocation (n = ), cardiopulmonary arrest on arrival (n = ), suicide by hanging (n = ), cardiomyopathy (n = ), and lethal arrhythmia (n = ). the organs donated for transplantation were kidneys, eyes, lungs, livers, hearts, and tissues (i.e., heart valve, bone, and skin). the time lapses were as follows. the number of days from informed consent to family acceptance was . days before the enactment of the revised organ transplant law and . days after the revision. the number of days from informed consent to organ removal was . days before the revision and . days after the revision. even after the enactment of the revised organ transplant law in japan, it still takes about days from informed consent to organ removal, with no current initiatives to shorten the time to organ removal. conclusions: although years have passed since the enactment of the revised organ transplant law in japan, there are still administrative and management problems that need to be addressed to achieve optimal organ transplantation. the financial impact of proximity to a major airport on one critical care unit introduction: in septic patients, increased plasma levels of cell-free hemoglobin (free-hb) are associated with a reduction of perfused vessel density (pvd) of sublingual microcirculation and to adverse outcomes caused by hemoprotein-mediated lipid peroxidation. recent studies show that acetaminophen protects from damage due to lipid peroxidation in sepsis [ ] . the aim of this study is to detect changes in sublingual microcirculation after the infusion of a standard dose of acetaminophen in febrile septic patients. methods: prospective observational study on adult septic patients admitted to our intensive care unit. pre-infusion (t ), minutes (t ) and hours (t ) after the end of the infusion of acetaminophen, sublingual microcirculation was assessed with incident dark field illumination imaging; vital signs, plasma levels of acetaminophen and free-hb were assessed. results: preliminary descriptive analysis on the first patients shows a median sequential organ failure assessment (sofa) score of (interquartile range iqr - ) and baseline temperature of , c°( iqr . - °c). an increase of the proportion of perfused vessels (ppv) was evident both at t and t ( introduction: in common sedation is required during mri for adult uncommunicative patients or those with different psychiatric disorders [ ] . although it can be challenging to obtain the deep sedation level required to prevent the patient's movement while maintaining respiratory and hemodynamic stability. limited access to the patient may pose a safety risk during mri. objectives: to compare efficacy and safety of dexmedetomidine sedation versus propofol during mri in adults.methods: this prospective randomized study was conducted at department of anesthesiology and intensive care at postgraduate institute of bogomolets national medical university (kyiv, ukraine) during - . uncommunicative conscious patients with acute ischemic stroke were included in the study and randomly allocated to groupsdexmedetomidine (d) and propofol (p). the sedation goal was the same in the both group (rass to - ). patients in group d receive dexmedetomidine infusion in dose . conclusions: in this prospective randomized study dexmedetomidine comparing to propofol was associated with higher sedation quality and lower incidence of complication during acute ischemic stroke patients sedation for mri. the usefulness of dexmedetomidine after lung transplantation in intensive care unit. introduction: dexmedetomidine (dex) showed some advantages in the sedation of patients in intensive care unit (icu) [ ] . other studies described efficacity of dex in icu delirium [ ] . the aim of this study was to evaluate the efficacity and safety of dex after lung transplantation in icu. methods: we conducted a prospective monocentric study in our surgical icu between november at november . in the first part of the study (november at november ), lung recipients did not received dex; in the second part of the study dex was used for the sedation in mechanically ventilated patients after lung transplantation. we compared the duration of mechanical ventilation in the two groups and the occurence of adverse effects. results: in total lung recipients were enrolled. there was no difference between the two groups in demographic data, one or double-lung transplants, the cause of lung transplantation and the use of epidural infusion. in the dex group, mechanical ventilation support was hours versus . hours in the other group (p= . ). there was no difference between delirium in the two groups ( / , p= . ). the occurence of adverse events like hypotension and bradycardia was significantly higher in the dex group ( / for hypotension, p= . ; / for bradycardia, p= . ). conclusions: the use of dex after lung transplantation in icu was not more efficience for the mechanical ventilator weaning. lung recipients delirium was significantly the same in the two groups. the most notable effect was the occurence of bradycardia and hypotension in the dex group.introduction: dexped evaluated the impact of a prolonged exposure (>= hours) to dexmedetomidine on the duration of invasive mechanical ventilation (imv), length of picu and hospital stay and use of other sedative agents. methods: dexped is a retrospective cohort study that included patients aged to years, admitted to the picu of the montreal children's hospital between november st and april th , requiring imv and sedative agents for >= hours. patients exposed to dexmedetomidine during imv (n= ) were compared to non exposed patients (n= ) using a propensity score analysis ( : ratio). , and received more opioids and benzodiazepines. however, a secondary analysis redefining exposure as initiation of dexmedetomidine within the first hours from intubation suggested that exposure was associated with a greater short-term probability of extubation, although this study was not powered to perform this analysis. conclusions: dexmedetomidine was associated with a longer duration of imv. however, the association was inversed when patients received dexmedetomidine as a primary sedative agent. it is uncertain whether this difference of associations is due to immortal time bias or clinical features. timing of initiation of dexmedetomidine in relationship to other sedatives may impact patient outcomes and should be considered in the planning of future trials. is an α -agonist which has been increasingly used for analgosedation. despite of many papers published, there are still only a few concerning the pk of the drug given as long-term infusion in icu patients. the aim of this study was to characterize the population pharmacokinetics of dex and to investigate the potential benefits of individualization of drug dosing based on patient characteristics in the heterogeneous group of medical and surgical patients staying in icu. methods: all the subjects were sedated according to modified ramsay sedation score of - . blood samples for dex assay were collected on every day of the infusion and at the selected time points after its termination. the dex concentrations in the plasma were measured using lc-ms/ms method. the following covariates were examined to influence dex pk: age, sex, body weight, patients' organ function (sofa score), catecholamines and infusion duration. non-linear mixed-effects modelling in nonmem (version . . , icon development solutions, ellicott city, md, usa) was used to analyse the observed data. results: concentration-time profiles of dex were obtained from adult patients ( table ). the dex pk was best described by a twocompartment model (fig. ) . the typical values of pk parameters were estimated as l for the volume of the central compartment, . l for the volume of the peripheral compartment, . l/h ( . ml/min/kg for a kg patient) for systemic clearance and . l/h for the distribution clearance. those values are consistent with literature findings. we were unable to show any significant relationship between collected covariates and dex pk. conclusions: this study does not provide sufficient evidence to support the individualization of dex dosing based on age, sex, body weight, sofa, and infusion duration. seems to reduce the wakefulness time and the sleep fragmentation but, while we haven't found differences in sleep architecture using dexmedetomidine or propofol. introduction: the early mobilization program during intensive care hospitalization presents numerous benefits related to the outcome of the patient. the objective of this study is to evaluate the safety of the implementation of an early mobilization protocol within the first hours of admission and its impact on high functional status of the icu. methods: retrospective study, from march to may , evaluating patients admitted to the neurological icu, assessing the hemodynamic, respiratory and neurological variables in patients submitted to the early mobilization program, consisting of progressive therapeutic activities, including sedestation and orthostatism assisted on the board and evaluated the impact on the functional status/degree of high muscle strength of the icu. results: from march to may , , patients were admitted to a neurological intensive care unit, of whom , were included in the early mobilization program. the mean age of the patients was . years, with saps of . points (estimated mortality risk of . %) and real mortality of . %. during the program, % presented clinical instability, which was promptly reversed in all situations. ninety-one percent of the patients presented maintenance or gain of muscle strength/functional status. conclusions: the application of an early mobilization program within hours of patient admission was shown to be safe, positively influencing the rehabilitation of neurological patients. introduction: given the worldwide rapidly aging of the population, the demand of critical care for elderly is increasing. data on short -term outcomes of elderly patients after icu discharge are sparse. the objective of our study was to assess short term outcomes of elderly after icu discharge and their potential risk factors.introduction: patients aged years or older presently account for approximately - % [ ] of all intensive care unit (icu) admissions in europe. the major challenge nowadays is to admit those elderly patients who will benefit from icu treatment. the objective of this study is to describe the characteristics and outcomes of patients >= years old admitted to the icu. methods: retrospective observational study of all patients aged >= years admitted for > h in . demographic data, admission diagnosis, apache ii and saps ii scores, use of icu resources and mortality were collected. results: patients ( %) were included, with a mean age of , . female gender was more prevalent ( . %). mean length of stay was , days with mean saps ii and apache ii scores of , and , respectively. the most prevalent type of admission was medical, , % (n= ) and from these the main reasons for admission were respiratory disease (n= ; , %) and sepsis (n= ; %). icu mortality rate was , % (n= ), whereas -month mortality was , % (n= ).survival rate was often related with cardiovascular ( [ , %], p<. ) and respiratory diseases ( [ %], p=. ), whereas nonsurvivors were admitted due to sepsis and neurologic causes. mortality rate was independent from the mean length of stay, noninvasive ventilation and renal replacement therapy, but dependent for previously comorbidities. mechanical ventilation was an independent predictive factor of icu mortality (p<. ) and -month mortality (p=. ). conclusions: nearly % of patients aged >= years were discharged alive from icu, and less than % survived months after icu admission.our study revealed a better prognosis for admissions due cardiovascular and respiratory diseases. efforts should be done to identify earlier septic and neurological patients that benefit icu treatment, and reevaluate the critical patient pathway, in this special population.conclusions: more than % of icu-survivors returned to work. overall, the chance of return to work within two years was independent of the number of organ support therapies in patients with at least one organ support therapy. however, in subgroups, the chance of return to work decreased with increasing number of organ-support therapies. factors associated with non-return to work among general icu survivors: a multicenter prospective cohort study r rosa introduction: critical care patients may develop long-term health problems associated to their illness or icu treatments, which may affect their work capacity. unfortunately, studies evaluating the impact of critical illness on work-related outcomes are scarce.therefore, we aimed to investigate factors associated with non-return to work among icu survivors. methods: a prospective cohort study involving icu survivors of brazilian tertiary hospitals was conducted from may to august . patients with a icu stay > h (for medical and emergency surgical icu admissions) or > h (for elective surgical icu admissions) who were discharged alive from the hospital were evaluated through a structured telephone interview months after discharge from the icu. a stepwise multivariate poisson regression analysis adjusted by age, gender and years of education was used to evaluate the association of sociodemographic-and icu-related variables with nonreturn to work. results: in total icu survivors completed the -month follow-up. of these, ( %) were working before icu admission. only of patients ( %) returned to work within the first months after discharge from the icu. percentage of risk of death at icu admission (relative risk [rr], . ; % confidence interval [ci], . - . ), decrease in physical functional status in relation to the pre-icu period measured by barthel index (rr, . ; % ci, . - . ), not having a introduction: the aim of this study was to assess the accuracy of physician's prediction of hospital mortality in critically ill patients in an intensive care unit (icu) scarcity setting. methods: prospective cohort of acutely ill patients referred for icu admission in an academic, tertiary hospital in brazil. physicians' prognosis and other variables were recorded at the moment of icu referral. results: there were analyzed referrals. physician's prognosis was associated to hospital mortality. there were ( . %), ( . %) and ( . %) deaths in the groups ascribed a prognosis of survival without disabilities, survival with severe disabilities or no survival, respectively (p< . ) (fig. ) . sensitivity was %, specificity was % and the area under the roc curve was . for prediction of mortality. after multivariable analysis, severity of illness, performance status and icu admission were associated to an increased likelihood of incorrect classification, while worse predicted prognosis was associated to a lower chance of incorrect classification. physician's level of expertise had no effect on predictive ability. conclusions: physician's prediction was associated to hospital mortality, but overall accuracy was poor, mainly due to low sensitivity to detect mortality risk. icu admission was associated to increased incorrect classification, but there was no effect of physician's expertise on predictive ability. what are physicians in doubt about? an interview study in a neuro-intensive care unit. introduction: inescapable prognostic uncertainty, lack of decisionmaking capacity, risk of death or disability and long recovery trajectories complicate decision-making after traumatic brain injury. methods: to elicit experienced physicians' perspective we interviewed neurosurgeons, intensive care-and rehabilitation physicians from oslo university hospital about being in doubt about whether to offer, continue, limit or withdraw life-sustaining treatment and on how such cases were approached. interviews were audiotaped and transcribed verbatim, coded and analysed using systematic text condensation by a clinician (ar) and a medical ethicist (rf). results: the difficulty of decision-making when there is prognostic uncertainty was acknowledged, leading to adaptive approaches; willingness to change and adjust plans along the way. to have access to different opinions within the physician group was seen as constructive. time-critical decisions were based on team discussions and physician's discretion. none-time critical decisions were reached through a process of creating common ground between the medical team and family. themes physicians where in doubt about or expressed different opinions towards: ) appropriate aggressiveness of treatment in a given situation. ) if and when to initiate discussions on appropriateness of treatment. some believed that even addressing the issue in young patients or if small improvements were seen was inappropriate due to the possibility of late recovery. physicians questioned the value of previously expressed patient's wishes in this context. ) optimal timing and type of decisions. the need for nuanced individualized plans was recognized. to have a plan as opposed to just "wait and see" was seen as especially important in medical unstable patients. conclusions: physicians expressed different views on appropriateness and optimal timing of level of care discussions and decisions in traumatic brain injury. a need for a more structured approach was exposed. fig. (abstract p ) . association of physician's prognosis with hospital mortality (p< . ).introduction: this cross sectional study was designed to investigate the level of family satisfaction in intensive care units in a tertiary hospital in the united arab emirates (uae), which is a multicultural society methods: family members of patients who were admitted to intensive care unit for more than hours or over were included in the study. families were approached with a validated fs -icu family satisfaction survey questionnaire [ ] . one hundred questionnaires were collected over a period of months from january to march in our pediatric medical surgical and cardiac, adult cardiac and adult medical/surgical intensive care units. results: the overall level of satisfaction rate was comparable to other high-income and developed countries with total satisfaction score, medical care score and decision making score of . ± . , . ± . , and . ± . respectively (table ) . conclusions: this is the very first study from the uae demonstrating a high level of patient family satisfaction in both adult and pediatric intensive care units. this study also highlighted areas where further improvement needed to occur.introduction: in order to apprehend the structural aspects and current practice of end-of-life care (eolc) in german intensive care units (icus) managed by anesthesiologists, a survey was conducted to explore implementation and relevance of these items. methods: in november , all members of the german society of anesthesiology and intensive care medicine (dgai) and the association of german anesthesiologists (bda) were asked to participate in an online survey to rate items. answers were grouped into three categories: category reflecting high implementation rate and high relevance, category low implementation and minor relevance, and category low implementation and high relevance. results: five-hundred and forty-one anesthesiologists responded, representing just over / of anesthesiology departments running icu's. the survey revealed new insights into current practice, barriers, perceived importance, relevance, and deficits of eolc decisions. only four items reached >= % agreement as being frequently performed, and items were rated "very" or "more important". items attributed to category , to category , and to category , representing a profound discrepancy between current practice and attributed importance. items characterizing the most urgent need for improvement (category ) referred to desirable quality of life, patient outcome data, preparation of health care directives and interdisciplinary discussion, advanced care planning, distinct aspects of changing goals of care, standard operating procedures, implementation of practical instructions, continuing eolc education, and inclusion of nursing staff and families in the process. conclusions: the survey generated awareness about deficits in eolc matters in critical care. consequently, already available eolc tools have been made available through the website of the german society of anesthesiology and intensive care medicine (dgai): http:// www.ak-intensivmedizin.de/arbeitsforen.html.introduction: this study evaluated differences in eolp after years in european icus that also participated in the ethicus i study [ ] . methods: all previous ethicus i centers were invited to participate in the ethicus ii study. consecutive admitted icu patients who died or had treatment limitations during a month period from . . to . . were prospectively studied. previous eolp and region definitions were used [ ] . eolp in the different regions of the ethicus i study [ ] were compared to the same icus in the ethicus ii study. results: of the original icus participated again in this study. figure shows the differences in eolp by region. figure notes differences in patient mental competency at the time of decision, information about patient's wishes and patient discussions in both ethicus studies. conclusions: changes included less cpr (especially in the south) with more withholding and withdrawing therapies. there was a greater number of competent patients with discussions and knowledge of their wishes.introduction: palliative extubation is performed in patients with terminal ilnesses in which mechanical ventilation might prolong suffering. even though the procedure involves nurses, respiratory therapists and doctors, some professionals feel unconfortable performing a palliative extubation. the concept of withdrawing life support can be easily confounded with euthanasia, specially in low income countries, where there is usually less education on palliative care. methods: a questionary containing open ended questions concerning a hypotetical case of intracerebral hemorrhage and prolonged coma, with potential indication for palliative extubation was applied to members of an emergency department intensive care unit staff ( doctors, nurses, respiratory therapists (rt). results: more than half of the professionals ( %) had never participated in a palliative extubation. four professionals ( %) believed palliative extubation is euthanasia. when asked about their own preferences in such a situation, only two ( %) would like to be tracheostomized. symptoms anticipated by most professionals were dyspnea and respiratory secretions. four ( %) would feel very uncomfortable performing palliative extubation because they either felt to be killing the patient or unable to manage symptoms conclusions: most professionals in this tertiary emergency intensive care unit never witnessed a palliative extubation. however, most of believe this procedure is beneficial. some still cannot understand the difference between palliative extubation and euthanasia. education in palliative care and withdrawal of life support can be helpful to clear concepts and relieve moral distress in the team. key: cord- -yknwveyz authors: nan title: abstracts_poster presentations date: - - journal: eur j nucl med mol imaging doi: . /s - - - sha: doc_id: cord_uid: yknwveyz nan t am and t / rv increasing. and vice versa in patients with t vm and t / rv decreasing residual pulmonary hypertension was diagnosed. it may be explained on the one hand by residual imbalance in vascular tonus regulation, on the other hand by morphological changing in vascular wall. in inoperable patients (because of high risk of postoperative acute right ventricle failure) t am and t / rv decreasing predominated. in inoperable patients and in children with residual pulmonary hypertension we discovered mottled lung perfusion pattern that pointed either to local or diffuse circulatory disturbances. the expression of these symptoms was directly proportional to pulmonary artery pressure. conclusion. the performing of perfusion lung scintigraphy and first pass radionuclide angiography with vasodilatators allows estimating right ventricle function and pulmonary microcirculation. it may be used for predicting of postoperative right ventricle function and pulmonary artery pressure normalization. one of the main goals of whole body scintigraphy with radioactive iodine, performed after total thyroidectomy for differentiated thyroid carcinoma of follicular origin (dtcfo), is to quantify the residual tissue left, thus identifying the patients who need to be reoperated. to avoid the stunning effect, one may administer a low activity of i (e.g., , mbq) or use other radiopharmaceuticals, in particular the i. aim to compare scintigraphic imaging and cervical uptake of i and mtc in patients submitted to total thyroidectomy for dtcfo, in order to evaluate the suitability of mtc for the identification of patients whose volume of residual thyroid tissue constitutes an indication for a second surgical intervention. materials and methods prospective study from / / to / / in patients submitted to total thyroidectomy for dtcfo: female and male, aged - years (mean , ± , years). after withdrawal of levothyroxine, we obtained scintigraphic images and determined the cervical uptake of i hours after oral administration of mbq ( μci) of the radionuclide. then, we proceeded to the i.v. administration of mbq ( mci) of mtc, and, minutes later, acquired scintigraphic images and calculated the cervical uptake of the radionuclide. we used a siemens e-cam dcr dual head gamma camera, with medium-energy and low-energy high-resolution collimators for i and mtc respectively. images of the activities to be administered as well as of the patient`s cervical region in anterior projection were acquired at cm from the detector. results all of the patients presented cervical uptake of i ranging from , to , %, mean , ± , . in patients, who presented a very low or absent cervical uptake of mtc , a median i uptake of , % ( , - , %) was found. in patients the cervical uptake of both radionuclides had a median value of , ± , for i and , ± , for mtc, with an high correlation (r = , ). all the patients with a cervical uptake of i exceeding % presented a mtc cervical uptake above %. conclusions a high correlation was found between the cervical uptake of mtc and i in patients submitted to total thyroidectomy for dtcfo. cervical scintigraphy with mtc was shown to be useful in the identification of patients requiring repeat surgery for voluminous residual thyroid tissue. imaging a breast cancer with tc m mdp scintigraphy s. i. mihajlovska, , n. kosturski, ; clinical hospital, bitola, the former yugoslav republic of macedonia. the aim of the study was to assess the value of tc m mdp scintimammography in the detection of breast carcinoma. fifty six patients ( - years, mean ) were included into the study. there were patients with diagnosed malignant lesions, patients with mastectomy and normal patients. all women were injected with - mbq of tc m mdp and double phase ( min. and h.) breast imaging was made. whole body scans and lateral views of both breast were obtained in prone position with elevated arms. focal accumulation of mdp uptake in tumor localization was considered positive. results: a clear uptake of tc m mdp was evident in of malignant lesions individuated (sensitivity . , specificity %). no false positive results were observed. out patients presenting lymph node metastases (sensitivity . %). radioactivity accumulations were detected on contralateral nonoperated gland in two of patients who had masteclomy . for detection malignancy mammography, ultrasonography and biopsy were performed but they were negative. definitive diagnosis were made base on the histopathologic results and showed malignant lesions. our study suggests that scintimammography with tc m mdp seems to be a highly sensitive and specific method in the differentiation of breast lesions. this method can be added to routine presurgical bone scintigraphy as a diagnostic tool. the aim of this study was to evaluate the results of early and late lymphoscintigraphy scan using medium sized particles of labeled human serum albumin (hsa) and to compare the results of preoperative imaging and intraoperative probe detector technique in localization and detection of slns in melanoma patients. material and methods: study enrolled patients ( male and female, mean age ± yr) with malignant skin melanoma. the localizations of the skin lesion were as follows: trunk , upper extremities , limbs and head . the patients were given a total of . ml ( - mbq) mtc-hsa with the particle size of - nm (sentiscint-mediradopharma, hungary) in four to six small portions, intradermally, around the melanoma or on both sides of the scar after the making diagnostic excision. dynamic lymphoscintigraphy was performed immediately after the tracer was injected, followed by early and late ( - h) static scintigraphy. at the time of the surgery, blue dye was injected around the tumor at two to four sites, minutes before surgery. during the surgery, a gamma probe (europrobe, france) was used to localize sentinel lymph nodes. results: a total of slns were detected in lymphatic basins in patients on dynamic, early static and late lymphoscintigraphy. ten patients were found to have sln, in patients slns were detected, while in one patient slns were detected in one lyphatic basin. no additional sln was detected on late static scintigraphy h after labelinig, and all slns localized preoperatively were found during the operation by collimated gamma probe detector, even h after labeling. vital blue dye failed to color sln in patients, and slns in patient in whom slns were found by lymphoscintigraphy. seven out of patients had metastatic spreading in the lyphatic basins. the slns were positive in all patients with metastatic disease and were the only site of metastases in out of patients. conclusion: the results of our study suggest that the use of medium sized colloidal particles should be preferred in a melanoma patient because slns could be detected early after radiopharmaceutical application but with prolonged selective concentration in the sln, giving the surgeon enough time to make a surgery plan either for the same day or for the day after lymphoscintigraphy. the results demonstrated lymphatic mapping using lymphoscintigraphy as highly accurate method for staging melanoma patients. conclusion: in our study, there was a significant correlation between the pattern of brain glucose metabolism and regional myocardial mibg uptake. in particular, decreased cardiac mibg uptake in inferior wall tends to correlate with hypometabolism in subcortical nucleus. key words: mibg, heart, spect, fdg, brain, pet the treatment options for patients with follicular lymphoma have substantially improved recently, due to the development of radioinmunotherapy, which combines radiation and antibodies. the most important example is y-ibritumomab tiuxetan (zevalin®), which is specially indicated in relapsed and/or refractory follicular b-cell non-hodgkin lymphoma (nhl). aim: show our experience in the use of zevalin® in those patients with follicular lymphoma, whose previous treatments have failed. material and methods: since april until february we have treated patients ( women and men) with ages between and years old. all patients had to follow these criteria: follicular lymphoma, previous treatment with rituximab, platelet counts x /l and bone marrow involvement %. the administered dose was . mbq/kg if platelet counts x /l, and of . mbq/kg if x /l. days post-treatment, the weekly clinical and analitical survey was done, until haematological recovery was confirmed. the evaluation of the therapeutic response was done after three months. results: from the patients studied, died ( . %), because of the progression of the disease, the other due to heart failure. had not yet been evaluated ( . %) and from the remaining , had a complete response ( . %), had a partial response ( . %) and had a stabilized status ( . %). toxicities were primarily haematologic and reversible, with non extrahaematologic toxicity observed. conclusions: based on our experience, the treatment of nhl with zevalin® is useful and secure, due to the minimal secondary effects. the use in early stages of the follicular lymphoma could improve the therapeutical results. aim: to evaluate the usefulness of mtc-ciprofloxacin scintigraphy (cp) in patients with hip or knee arthroplasty and suspect of infection. material and methods: fifteen patients ( women, men) with a mean age of ± years and clinical symptoms, haematological and/or mtc-hmpao leukocyte scan suggestive of prosthetic infection were included. cp was performed at h, h and h alter intravenous injection of mbq of mtc-ciprofloxacin. anterior and posterior views centred in the affected joint were performed in all patients. a conventional bone scan, mtc-hmpao leukocyte scan and mtc-colloid scan were performed in all cases. the final diagnostic of arthroplasty infection was established by positive microbiologic analysis, macroscopic evidence of purulent material, or after visualization of more than neutrophils in the periprosthetic tissue. results: diagnosis of arthroplasty infection was established in / cases (coagulase-negative staphylococcus ( ), aureus staphylococcus ( ), e. coli ( ) and polymicrobial agents in the remaining cases). cp was able to correctly diagnose all cases of infection. cp images at ' postinjection showed false positive cases, and at h false negative case was found. in one patient with knee prosthetic loosening without infection and intense inflammatory changes, cp was positive and then considered as a false positive case. on the other hand, mtc-hmpao leukocyte scan was non-diagnostic in / cases of infection.conclusions: cp is useful in the diagnosis of arthroplasty infection of the hip and knee. cp images obtained at h alter injection are recommended. presence of synovitis may cause false positive images with cp in knee prostheses. surgical removal of pgs is a difficult procedure especially when their localization is deeper than expected. the aim of the study was to evaluate the number of deeply situated pgs in relation to their right or left positioning. materials and methods. in this retrospective study consecutive patients who had a positive scan ( with primary and with secondary hyperparathyroidism) were included. a double phase sestamibi technique followed by a pertechnetate scan was used. early right and left degree oblique images were routinely obtained in order to evaluate the depth of the pgs. findings were classified in to two groups based on the degree of change of the relative position of pgs and the thyroid gland (tg) in the oblique compared with the anterior image. group i included pgs where the relative position of the pg and tg in the anterior an oblique images remained the same or changed only slightly. those pgs were characterized as not deeply located. group ii included pgs that in oblique images the pg to tg distance was significantly increased and were characterized as deeply situated. the localization of the pgs was confirmed by the available surgical data. results a total of pgs were identified ( upper right, upper left, lower right and lower left). group i included / upper right, / upper left, / lower right and / lower left ( of the total pgs). group ii included / upper right, / upper left, / lower right and / lower left ( of the total pgs). upper left and lower right pgs were significantly more frequently located at a significant depth compared with the upper right and lower left sites (p< . and p< . respectively). conclusion these results indicate that upper left and especially lower right pgs are more frequently deeply located; information which is useful for the procedure of surgical removal, mainly when preoperative imaging has not been performed. in recent years, picture archiving and communication systems (pacs) and electronic transfer of radiological images using the dicom file standard has become more widely employed in diagnostic radiology. it seems to be likely that nuclear medicine will be integrated within such systems. on the other hand, many departments possess older equipment without digital output facilities. there is an increasing tendency to display and archive evaluated images ('save-screens', printouts) on non-dedicated, inexpensive systems using file formats capable of data compression. this was the reason for examining the value of the jpeg format in this pilot study. fifty scanned planar bitmap images of the most frequent scintigraphic examinations (thyroid, bone, myocardium, lungs, and kidneys) were compared with jpeg format at different data compressions by two blinded observers. the visualization of details, e.g. pathologic findings, is described for all these images as the visual appearance of the images and the storage capacity required. relevant loss of clinical information did not occur up to compression factors of . . a major decrease of subjective image quality was seen at compression factors > . . compared to bitmap files, the use of these factors reduced the storage capacity required by % at a (jpeg-related) compression factor of . , and % at a compression factor of . . compared to the gif format, a reduction by . - . could be achieved. use of the jpeg format can therefore be recommended to save costs of image transfer or archiving of standard planar scans for nuclear medical evaluation. the evaluation of genotoxic effect of gamma radiation in nuclear medicine workers to be used [ ] . material and methods: in a previous work we recorded the personal whole-body dose values received by the workers over a period covering the starting of a pet unit (october, ) and the subsequent years until march, [ ] . then, we reported a substantial increase ( %) of the whole-body dose received by the technologists which was then related to the initial increasing number of pet exams. following a clear evidence of this initial increase of whole-body dose to be related with the technologists contact with the patient during preparation to exam, a wholebody lead shielding, with a thickness higher than the tenth-value-layer (tvl) for kev photons, was implemented for protection during patient handling and exam preparation. all the dosimetric measurements considered in this work were executed by the same personal dosimeter provider (nrpb, uk) . results: after shielding started to be used by the technologists during pet patient handling, we observed a clear reduction of whole-body doses back to levels close to the ones observed before the pet implementation. conclusion: the increased dose received by the technologists before shielding implementation can now be even more clearly related with the time needed to handle the pet patient at the exam and with the higher exposition rate constant of f- when compared with other isotopes used in nuclear medicine (namely tc- m). in conclusion, we can say that whole-body shielding is an affective way to reduce doses to the technologists during this stage of pet procedures. besides shielding during patient preparation image acquisition, a remote control similar to the ones existing in a common gamma-camera could be also useful in the reduction of the doses. [ ] j.a.m. santos et al. impact of fdg-pet in the occupational whole-body dose received by several professional groups in a nuclear medicine department, annual congress of the eanm, athens, (oral presentation, ) aim: the dose administered to the hands of nuclear technologists working with petnuclides is a problem of concern ever since the introduction of pet as a routine examination in nuclear medicine. the dose to the hands can be monitored using ring tld's. the aim of this study is to determine the accuracy and detection limits of extremity dosimetry using ring tld's. material and methods: two types of tld's with different thicknesses, , and , inch respectively, were used. the tld's were exposed to ionising radiation using a cs source. the tld's were exposed to various doses under several angles. the use of sets of tld's, each consisting of thick and thin tld, averaged out the effects of single tld's. to improve statistics each exposure was repeated times. a perspex rod with a diameter of mm was used to simulate a human finger. after each exposure the tld's were read out using a harshaw . uncertainty analysis was used to determine detection limits and uncertainty intervals for both types of tld's. results: analysis of the measured data shows that within the uncertainty intervals the measured dose matches the exposed dose. no significant angle dependence is found. the relative error in the measured dose is larger at smaller doses. this effect occurres in both types of tld's. the effect was more pronounced in the thin tld, yielding a higher detection limit for the thin tld then for the thick tld. the detection limits for the thin and thick tld are μ sv and μ sv respectively. the main contribution to the uncertainty at low doses is the effect that manipulating a tld induces an artificial dose during tld read out. this effect probably scales with the volume/surface ratio of the tld and the amount of manipulation, needed to get the tld out of the ring, into the tld reader. conclusion: due to its high detection limit, is the thin tld, in contrast with the thick tld, not suitable to be used for extremity dose monitoring in nuclear medicine. the detection limit of both tld's can be improved by reducing the amount of manipulation, needed to put the tld in the tld reader, and to improve the protection against mechanical impacts. both can be achieved by improving the construction of the ring. new experiments are conducted using an improved design of the ring. aim: despite international recommendations about the use of the si units system [ ] determined in by the cipm (comité international des poids et mesures), non-si units in radiation physics and other fields of science are still in use today and included in scientific publications. some of these, such as the roentgen (r), rad, rem and curie (ci) are called traditional units and still temporarily acceptable by the si system although its use has been discouraged and a cessation has already been proposed for the year by the cirrpc. in nuclear medicine, these units have also been thoroughly used through the years. nevertheless, si units are slowly taking their place in the current clinical nuclear medicine practice and there is a general tendency for homogeneity towards its universal acceptance. however special care should be taken in this process. discussion: although the rad, rem and roentgen have already been almost universally replaced by their si units, the curie is still widely used in parallel with the bequerel (bq). the consequences, although minimal, can not be disregarded. activity values tend still to be written as integer multiples of the milicurie (ex. mci, mci) in most of the nuclear medicine literature, even if a conversion is provided, resulting in awkward values of activity expressed in si units, altering the number of precision digits, as seen in the above example, and leading to erroneous appreciation of measurement errors. for example when writing " mci", it is implicit an error of . mci ( %) while writing " . mci", an error of . mci ( . %) is assumed. on the other hand, when writing " mbq" instead of " mci", we assume an error of . mbq, i.e. . % (which is much less than the actual precision of a clinical purpose activimeter). conclusion: supplementary effort, besides simple conversion of traditional units into si should be pursued. significant digits number and the errors associated with them should be considered. the calculation of other important nuclear medicine physical quantities, such as the suv in pet or activity per body mass, should also be written and thinked primarily in si and optionally converted to traditional units and not vice-versa (ex. . gbq/kg - mci/kg; mbq/kg - . mci/kg). [ ecnc, in guidelines for radionuclide imaging of cardiac function will be published by the same institutions. methods and results: authors from several different european countries are collaborating and have written a draft of the new guidelines including the following sections: ) radiopharmaceuticals and dosimetry, ) acquisition of radionuclide ventriculography (first pass and planar and tomographic equilibrium ventriculography) as well as gated perfusion imaging, ) right ventricular ef, ) left ventricular (lv) ef, ) lv volumes, ) lv diastolic function, ) lv regional function, ) physics and software, ) reference values, and ) clinical indications. discussion and conclusion: the paramount principle is to write evidencebased guidelines, referring to original, peer-reviewed papers from international journals. however, such evidence is not always available. in lack of evidence for the best choice of performance of a procedure or indication, we emphasize the lack of evidence by expressions like "there is general consensus" or "most centres use" etc. the guidelines will be published in the ejnm with direct links from eanm, ecnc, and esc, and they will be regularly updated. influence of radiation source geometry on determination of in and y activity of radiofarmaceuticals p. kolenc peitl, p. tomše, a. so an, m. krošelj, t. gmeiner stopar; university medical centre ljubljana, ljubljana, slovenia. aim: measuring of the radioactivity of radiopharmaceuticals before injection to patient is essential in nuclear medicine. measurements are performed by use of a dosecalibrator. to assure accurate readings quality control checks are performed and proper calibration factors used. calibration factors are not only dependent on the type of the radionuclide but also on a number of other factors, including nature of the container and volume of the solution in it. the aim of our study was therefore estimation of the impact of these factors on radioactivity readings for y and in in four different dose-calibrators before implementing radiotherapy with y based radiopharmaceutical into routine use. material and methods: ycl and incl solutions were gravimetrically dispensed in seven different containers ( , and ml vials and , , and ml syringes). in each container several dilutions of the parent solutions were performed. mass, activity and time for each source geometry were recorded for all dose-calibrators (two vdc- , capintec and ptw). measurements were background, time and mass corrected. aliquotes of both parent solutions were calibrated in national metrology laboratory, vienna, austria (bev). from our measurements and results from bev correction factors (cf) and volume correction curves were determined. results: in: accurate results with ± % precision for all source geometries in all vials were obtained using manufacturersupplied cf in both vdc- and capintec calibrators. for ptw the uniform cf ( , ) was determined for all geometries in all types of vials. the uniform cf for each type of syringe was determined in each dose-calibrator: readings have to be reduced for up to % for vdc- and up to % for capintec and ptw, depending on syringe. y: the uniform cf for each type of syringe was determined in each dosecalibrator: readings have to be reduced for up to % for vdc- , % for ptw and % for capintec. in the vials the volume correction curves have to be used to increase readings for up to % in % in capintec and to reduce readings to % in ptw. conclusion: our results show that manufacturer-supplied cf without ckecking the influence of radiation source geometry cannot be blindly trusted. ignoring this fact measurements can lead to errors reaching % in preparation and dispensing of in and y radiopharmaceuticals. aim: bone grafting is essential modality for reconstruction of congenital and acquired bone defects. our aim was to determine the viability of bone grafts by three phase bone scintigraphy with histopathological confirmation. method: two different grafting methods in new zealand rabbits were evaluated; autogenous bone grafting and demineralisation bone matrix (dbm) method, which has been developed to improve incorporation and formation of new bones. one centimeter square sized bone defects were made on the parietal bones of rabbits. the acquired bone defects on the left side were replaced by grafting the healthy parietal region from the right and the bone defects on the right side were replaced by using dbm grafts. at the second week; as early stage and in the sixth and twelfth weeks as late stages of the graft operation, dynamic three phase bone scans were performed. the rabbits had intravenous bolus injection of mci ( mbq) tc- m hdp under anesthesia and the images were acquired with a pinhole collimator. early and late stages of bilateral parietal regions were visually and quantitatively assessed with equal pixel region of interests (roi). visual assessments were scored from to (zero as no uptake, as mild, as moderate and as highest uptake). results: osteoblastic radioactivity uptake ratios were evaluated from to in all grafts and histopathologically those grafts were viable. perfusion and blood pool images were similar in both bone grafts in all rabbits at all stages. in the quantitative assessment right parietal to occipital roi and left parietal to occipital ratios were as follows; at the second week dbm . ± , , autogenous bone graft , ± , (p= , ); at the sixth week dbm . ± , , autogenous bone graft , ± , (p= , ) and at the twelfth week dbm . ± , , autogenous bone graft , ± , ( p= , ) . in all phases of bone scintigraphy there was no visual or quantitative difference in statistically by between grafting methods statistically (p< . ). conclusion: the determination of graft viability by three phase bone scintigraphy in both dbm and autogenous bone graft method is an in-vivo, sufficient, useful and cost-effective imaging modality. p -monday, oct. , , : aim: it is widely accepted that myocardial perfusion spect should be acquired with ecg-gating. with this technique additional information about the pump function of the left ventricle is gained. the purpose of this study was to evaluate the relationship between left ventricular stress and rest ejection fraction (ef) in myocardial perfusion spect and to analyse possible influencing factors. material and methods: in this study consecutive patients from our outpatient clinic with a -day stress/rest protocol were enclosed. the patients consisted of women and men, with a mean age ± s.d. of . ± . years. in patients a coronary heart illness was known. the stress was induced ergometric by bicycling in all patients. the spect acquisition was carried out min after i.v-injection of tc- m-mibi (stress-study) or after min (rest-study) with a double headed gamma camera e.cam (siemens). the reconstructed slices of the short heart axis were used for fully automatic determination of the left ventricular ejection fraction and assessment of semiquantitative segmental pathology scores through the software dm-spect (university of michigan). results: the matched ef-values of the stress and rest study showed a small, but significant difference in the paired t-test (p = . ). the average value for the stress ef ( . %) lay about . percent points below the value of the rest ef ( . %). in a regression analysis the decrease of the ef ( ef) between the stress and the rest study showed no dependency with age (p = . ), the summed stress pathology score (sss) (p = . ) or the summed rest pathology score (srs) (p = . ). however a significant increasing of the ef was found with the summed pathology difference scores (sds) (p = . ) and a growing rest ef (p = . ). conclusion: the stress ef was found to be significant lower then the rest ef. this indicates a stress induced injury of the heart still influencing the ef at the post stress acquisition time of the spect. higher ef values correlated positively with stress-induced ischemia, according to the sds score. in contrast a perfusion abnormality alone in rest (high srs score) or stress (high sss value) had no significant influence to the ef. the additional information gained with gated myocardial perfusion spect can contribute to the assessment of stress-induced stunning of the myocardial pump function. aim: in many institutions, the first line imaging modality for suspected pulmonary embolism is lung scintigraphy. the value of adding ventilation imaging and single photon emission computed tomography (spect) to the perfusion study is controversial. the prospective acute pulmonary embolism (ape ) trial is planned to include patients suspected of pulmonary embolism. the aim is to determine if ventilation imaging and spect, as an adjunct to planar perfusion imaging, improves the interpretation of lung scintigraphy. this is a report from an initial pilot study. consecutive patients clinically suspected of pulmonary embolism entered the study. within four hours we performed scintigraphic examinations and, if abnormal, pulmonary angiography which was considered the gold standard. readings were done by expert physicians blinded to clinical data and other imaging modalities except the chest x-ray. results: of the patients who entered the pilot study, two had normal scintigrams and in one case logistics failed. the results presented are from the remaining patients, of whom six had pulmonary embolism and eight did not. planar perfusion images correctly identified five patients with pulmonary embolism and five patients without, but failed to identify one patient with and three patients without pulmonary embolism. perfusion spect and combined perfusion and ventilation imaging (both planar and spect) correctly identified all patients with pulmonary embolism and four patients without, but failed to identify four patients without pulmonary embolism. in the table below, the corresponding sensitivities and specificities are presented. conclusion: the ape pilot study showed no clear benefit from either ventilation imaging or spect, suggesting that planar perfusion imaging alone may be sufficient in suspected pulmonary embolism. however, the number of patients in the pilot study was small and definitive conclusions cannot be drawn until the results from the ape trial become available. the aim of the study was to compare myocardial blood flow (mbf) and coronary flow reserve (cfr) measured by positron emission tomography (pet) and the severity of coronary artery stenosis on coronary angiography. methods: we studied patients with angiographically proven coronary heart disease (chd) with dynamic [ n]ammonia pet imaging at rest and after dipyridamole. mbf was calculated by firstpass extraction method. the coronary flow reserve (cfr) was defined as the ratio between the stress and the rest mbf. results: mbf at rest did not differ between the patients with coronary atherosclerosis and the controls ( , ± , ml/min/ g vs , ± , ml/min/ g ns) with the exception of infarct-related regions where mbf at rest was significantly low ( , ± , ml/min/ g, p< , ). during hyperemia mbf significantly decreased in the regions supplied by diseased coronary vessels in the patients ( , ± , ml/min/ g. vs , ± , ml/min/ g., p< , ). it was revealed a significant correlation between mbf during hyperemia and coronary artery stenosis degree (r= - , ; p % stenosis showed an attenuated response to dipyridamole (cfr = , ± , ) . cfr was significantly low in regions supplied by arteries without significant stenoses in the patients vs the controls ( , ± , vs , ± , ; p< , ) due to an influence of coronary heart disease risk factors: myocardial hypertrophy, smoking, diabetes mellitus. conclusion: [ n]-ammonia pet imaging provides the valuable information about functional severity of coronary atherosclerosis. cfr impairment in regions without significant stenosis can be explained by an influence of coronary heart disease risk factors. silent ischemia elicited on resting post-nitrate gated-spect by a coronary steal mechanism is associated with short term outcomes in prior myocardial infarction g. carboni, t. castiello; univ. campus bio-medico, roma, italy. the value of post-nitrate cardiac gated spect (g-spect) in patients (pts) with prior myocardial (m) infarction (i) is still uncertain .thirty-six such pts ,mean age +- years , % males , were thus studied by g-spect , at rest , after sublingual administration of mg isosorbide dinitrate (n) and at controlled conditions ( baseline ) . methods: in all pts , g-spect , ( % with thallium , with % mibi ) , was carried out on a dual-head gamma camera and ejection fraction (ef), extent and reversibility (r) of abnormal defects (ads) were analyzed with cedars-qgs-cequal softwares. extent of ads after n administration was calculated as a percentage (%) of total lv pixels ( p ) and r as a % of the ads . the ads were considered significant when > than % p and concordant with regional hypokinesia on echocardiograpy . all pts were followed-up for cardiovascular events (ce) . results: overall pts , only showed partial r of ads . on a cox regression model (chi-square = , p < . ) , only r ( b = . , p < . ) was associated with the hazard of ce ( in pts cardiac death , in pts major ce ) but not with age, ef, cad , prior cabg or ptca , ( p = ns for all ) . results did not change when data were adjusted for risk factors. on kaplan-meier curves , pts with r showed also lower event-free survival probability versus those without r ( % versus % at a months follow-up ) , log-rank test: p < . , hazard ratio = . , % ci = . to . ) . conclusions: in % ( / ) of pts under study , resting post-n g-spect elicited partial r of ads ( residual m ischemia in prior mi ) in absence of any increase in m demand. a n-induced " coronary steal " from low flow coronary territories (infarct-related coronary artery) to non ischemic territories cannot be thus excluded . such a paradoxical effect occurs silently and may identify m instability , predict short-term outcomes and imply concern for n chronic therapy in prior mi . the aim of this study was to compare the results of ejection fraction (ef) values and volumetric data derived from gated myocardial perfusion spect( g-spect) using both qgs (siemens icon) and d-mspect( d) algorithms and to determine normal limits in patients with normal cardiac perfusion and function. methods: one hundred and sixty-six consecutive patients ( men, m, female, fm, ± years old) referred for the evaluation of suspected coronary heart disease ( chd) using g-spect were included in the study. inclusion criteria: having normal cardiac perfusion and function; exclusion criteria: previous chd, left bundle branch block, ischemia finding, q or qs pattern in ecg and severe arrhythmia at rest .modified bruce protocol was performed in stress test. ef%, end-diastolic (edv;ml) and end-systolic volumes (esv; ml) and stress/ rest left ventricular cavity dilatation index (cdi) were calculated. results: the mean values of overall ef, edv and esv in s and r were as follows. qgs: r-ef%= . . in volume comparison, although there was high correlation (r= . - ) between the methods , the mean differences were significantly different (p< . ). conclusion: ejection fraction limits in normal patients obtained in this study were in concordance with those of previously reported in the literature. ef values derived from d were significantly higher than those of qgs both in s and r g-spect and the methods do not prove to be interchangeable for ef calculation in normal patients. key words: left ventricular ejection fraction, gated perfusion spect, normal limits aim: generator-produced rubidium- ( rb) is of interest for centers lacking access to a cylotron. quantitation of myocardial blood flow (mbf) has been performed with rb using compartment-based models. however, reproducibility of such mbf quantitation with rb is not known precisely. material and methods: fourteen individuals (mean age ± y range - y; w, m; including volunteers and patients with angiographically proved cad) underwent dynamic pet imaging studies ( frames) at rest and during adenosine stress ( . mg/kg/min for min) after injection of mbq of rb (discovery ls, gems). after waiting period of min, the rest-adenosine stress sequence was repeated. mbf was determined using a -compartment model including a correction for flow-dependent extraction fraction of rb (pmod . analysis software, www.pmod.ch). myocardial flow reserve (mfr) was defined by the ratio of stress/rest mbf. for comparison, paired t-test and bland-altman plots were used. results: there was no difference in hemodynamic parameters between baseline and repeat measurements (rate-pressure product: . e ± . e vs. . e ± . e mmhg/min, p= . ). one volunteer refused to undergo adenosine stress because of side effects. there was no significant difference between baseline and repeat studies regarding mbf at rest ( . ± . vs. . ± . ml/min/ml, p= . ), during adenosine stress ( . ± . vs. . ± . ml/min/ml, p= . ) or in mfr ( . ± . vs. . ± . , p= . ). the correlations between baseline and repeat studies were also excellent (rest: r = . y= . ·x; adenosine: r = . y= . ·x; mfr: r = . y= . ·x) . finally, overall agreement was very good on bland-altman plots with out of measurement pairs ( %) being within reference range for difference, without any systematic difference (p= . ). conclusion: these results demonstrate an excellent reproducibility of myocardial blood flow measurements with rb at rest and under adenosine challenge. aim: diabetic patients develop coronary artery disease (cad) more frequently and have a higher incidence myocardial infarction (mi) .cad is also an important cause of mortality in patients with diabetes. its early detection is fundamental to improve medical treatment. the aim of this work is to describe single-photon emission computed tomography myocardial perfusion imaging (spect mpi) findings in patients with diabetes mellitus type (dmii) with atypical chest pain and analyze whether the presence of others risk factors are reliable predictors of positive scyntigraphy. materials & methods: authors interviewed all patients with dmii that underwent spect myocardial-perfusion with mtcmibi from december to march that had read and accepted informed consent. method of inducing stress was infusion of dipyridamole in . % cases and exercise loading in the others ( . %). ejection fraction (ef) was assessed by ecg-gated technique. patients that had reported previous heart infarction with or without revascularization intervention were excluded. results: authors interviewed diabetic patients who underwent spect mpi during this period. . % were women, ages ranging from to years old (mean value= . ). it was found perfusion abnormalities in patients ( . %); exams showed reversible defects and of them had irreversible lesion. % of the abnormal exams showed only one lesion; % showed two compromised walls and % showed walls affected. ejection fraction ranged from to % (median= ). concerning to risk factors, patients ( . %) affirmed being sedentary, patients ( %) were overweight, patients ( . %) were smokers, patients ( , %) had hyperlipidemia and patients ( , %) reported positive family history of cvd. authors also assessed whether the presence of risk factors would be correlated to a positive exam. no statistical correlation was individually significant: smoking (p= , ) and sedentatariness (p= , ) both analized with exact fisher' test; and overweight (p= , ), hyperlipidemia (p= , ), and positive family history (p= , ) , assessed with qui-square test. conclusion: frequency of perfusion abnormalities in diabetic patients with atypical chest pain was high ( . %).this data suggests that occult cad is common among asymptomatic and poorly symptomatic patients with diabetes. perfusions abnormalities in these patients by means of spect mpi could provide incremental information about silent cad. individualy, risk factors for cad had not statiscaly significant correlation with a positive spect mpi in this study, probably due to the small population surveyed. early primary percutaneous coronary intervention (pci) is a very effective technique in the treatment of the acute myocardial infarction (ami), since it allows the recanalization of the affected coronary vessel. objective: the aim of the study was to evaluate the extension of saved myocardium defined as the difference of perfusion score pre and post pci. patients and methods: patients with ami and st segment elevation were studied prospectively ( women, mean-age: . ± . years) . two gated-spect detections were acquired after mtc-mibi injection in all cases. the first injection before pci and the other after it ( . ± . days), following the habitual methodology. the initial acquisition was carried out at the exit of the catheterization lab in patients ( . ± . minutes) and after seven hours of stay in the coronary unit in patient. the quantitative automatic valuation of the segments was performed by the software qps (cedars). pre and post pci (sss, srs) score, the difference of the score (sds) and the percentage of extension (ss%, sr% and sd%) was evaluated. according to the coronary angiography the dilated arteries were left anterior descending arteries (lad) and right coronary arteries (rc). in patients the revascularization was angiographycally effective. results: in patients there was not significant difference between pre and post spect quantification ( not effective revascularization and with large ami). in the rest of patients salvaged myocardium is showed. sss shows the pre-dilatation deffect, srs shows the residual deffect (ami) and sds shows the saved myocardium. conclusions: the myocardial perfusion quantification by gated-spect allows a precise valuation of the saved myocardium by primary pci in the ami. side effects in patients undergoing myocardial perfusion imaging in one centre. medicine, aarhus university hospital, skejby, aarhus, denmark. aim: to analyse the frequency of side effects in stress myocardial perfusion imaging (mpi) related to gender, age, referral diagnosis and type of stress. material and methods: we included consecutive patients referred for mpi in the period june -december ( ½ years). bicycle stress was first choice ( %). patients who could not perform the test or were treated with betablockade were stressed with adenosine in combination with a minor work load when possible ( %) otherwiseand in case of left bundle branch block -adenosine was injected at rest ( %). dobutamine was used in patients with severe chronic obstructive lung disease or atrioventricular block ( %). results: the investigation included men and women aged to years (mean of years). the women were on average . years older. the patients suffered from ischemic heart disease (ihd) ( %) or were suspect to ihd ( %). side effects: only patients ( . %) had side effects. the most frequent side effects were: atrioventricular blockade ( . %), bronchospasme ( . %) and "other unspecified side effects" ( %). rare side effects were arrhythmias ( . %), ami/unstable angina ( . %) and syncope ( . %). no patients died. uncomplicated angina and well-known subjective symptoms to pharmacological stress and work load were not registered. patients stressed with bicycle had seldom side effects ( . %), whereas frequency was about % after adenosine and dobutamine stress but with differences in type of side effects. there was a higher prevalence of side effects in women ( vs. %), especially for ami /unstable angina ( %) and other unspecified side effects ( %). only syncope was more frequent among men ( %). the frequency of side effects increased with age from . % in the thirties to . % in the eighties. patients referred with known or suspected ihd had the same frequency of side effects. conclusion: during a ½ year period patients were examined with stress mpi. no one died and only . % had side effects apart from angina and wellknown subjective symptoms to pharmacological stress and work load. less than % had arrhythmias, ami /unstable angina or syncope. the prevalence was higher during pharmacologic stress than work load. the prevalence was more frequent in women and increased with age. cardiovascular disease is the leading cause of death among patients with type diabetes, myocardial ischemia being frequently silent. coronary artery disease detection is challenging in women due to a variety of factors. aim our purpose is twofold: to investigate the association of silent ischemia and diabetes in women; and determine the sensitivity of myocardial perfusion gated spect in these patients. material and methods poststress and resting gated spect was performed in women ( with type diabetes and nondiabetic) with suspected coronary artery disease. of the diabetic patients underwent coronary angiography within . months. mean age was . years. a -day stress/rest protocol was used with mtctetrofosmin and pharmacologic stress (adenosine: , dobutamine: ). perfusion analysis was semiquantitative based on a segment model determining the summed stress store (sss) and the summed difference score (sds). the sss< was defined as a normal scan, sss: to as moderate and sss> as severe ischemia, respectively. the sds < was considered no ischemia, sds: to moderate and sds> severe ischemia, respectively. poststress lvef was considered normal if > %. results p< . sds detected ischemia more frequently is diabetic versus nondiabetic patients. results of coronary angiography were positive with good vessel-territory correspondence in patients. two patients had false negative myocardial gated spect yielding a sensitivity of . %. clinical presentation, age ( vs . ), stress agent and risk factores (arterial hypertension, dyslipemia and smoking) were not different between nondiabetic and diabetic patients. there is no statistically significant difference between both groups in age variable. conclusion female patients with type diabetes present more severe ischemia than nondiabetic patients of similar conditions and clearly benefit from early coronary angiography. diabetes is considered a coronary artery disease (cad) risk equivalent with the evidence of an increased mortality rate in diabetic patients. cad is often silent and when it becomes clinically manifest it is in an advanced state. however, there is a wide variation in prevalence of cad in diabetes, possibly related to the presence of additional risk factors. aim of the study was to prospectively assess the usefulness of myocardial perfusion spect (mps) in asymptomatic diabetic patients and occult cad in comparison with traditional risk factors. methodology: among patients, pts with diabetes mellitus ( type i; type ii) and high likelihood of cad underwent rest-stress mps with mtc-tetrofosmin and a -segments scoring model was used for spect analysis. a summed stress score (sss) > indicated abnormal mps, sss - a mild, sss > - a moderate and sss > a severe perfusion defect. multiple risk factors and clinical predictors like duration of diabetes, presence of peripheral vascular disease, dyslipidemia, hypertension, active smoke, family history of cad or diabetes and body mass index, were analysed. results: according to the spect results, patients were classified in: group a ( pts with normal mps), and group b ( pts with reversible, pts with mixed, with fixed perfusion defects). moderate or large stress defects occurred in and pts, respectively. the analysis of the presence of cad risk factors or the association of two of these was not statistically significant (table ) . conclusion: mps is effecting in detect occult cad and silent myocardial infarction in asymptomatic patients with diabetes mellitus while the usual risk factor analysis or the association of or more of these, are inadequate to predict the presence of cad in this population. effects of cardiac resynchronization therapy: evaluation by first-pass radionuclide angiography and multiple gated equilibrium blood pool scintigraphy s. minin, v. chernov, e. makarova, g. savenkova, y. lishmanov; institute of cardiology, tomsk, russian federation. background: cardiac resynchronization therapy (crt) reduces symptoms and improves left ventricular function in many patients with heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony. but changes of pulmonary and central haemodynamics after crt are not clear. aim: to evaluate of chronic crt effect on pulmonary and central haemodynamics as well as on left ventricular ejection fraction (lvef) in patients with severe heart failure. material and methods: the study involved patients (m/f: / , mean age: + . years). we studied scheduled for implantation of a crt device based on conventional criteria (nyha class iii or iv, lvef < %, left bundle-branch block and qrs duration > ms). two patients had ischemic and patients had idiopathic dilated cardiomyopathy. first-pass radionuclide angiography (fpra) and multiple gated equilibrium blood pool scintigraphy (muga) were performed before and month after crt. results: our data show a significant clinical benefit of crt (nyha class change from . + . to . + . ; p= . ). we found significant increase in cardiac output from . ± . to . ± . ml/min (p= . ), stroke volume from . ± . to . ± . ml (p= . ), cardiac index from . ± . to . ± . ml/min/m (p= . ) and stroke index from . ± . to . ± . ml/m (p= . ). also increase in lvef from . ± . to . ± . % (p= . ) was shown. all patients after crt had improvement in pulmonary haemodynamics: the time of radionuclide bolus transit thought arterial section of lung (tam) and time of radionuclide bolus transit from right to left ventricles (tlung) decrease from . ± . to . ± . sec (p= . ) and from . ± . to . ± . sec (p= . ), respectively. conclusion: our results suggest that crt improved of pulmonary and central haemodynamics as well as of left ventricular contractility in patients with severe heart failure. fpra and muga are useful methods fore monitoring of crt effect. aim the aim of this study was to investigate whether early myocardial tetrofosmin imaging (t , min after injection) provided additional information in detecting coronary artery disease with respect to standard delayed scan (t , - min). one-hundred and twenty patients ( male, female, mean age +/- yrs, range - ) with anginal symptoms underwent single or two-day stress-rest tetrofosmin gated spect. in all conditions, t an t were obtained after stress and at rest with the same gamma cameras and using the same acquisition parameters. combines myocardial perfusion/function analysis was performed on a segment model using qps/qgs software (cedar sinai). coronary angiography was obtained within one month in all patients and stenosis > % at quantitative analysis was considered significant. results among clinical and nuclear variables, univariate predictors of coronary artery disease included: gender; previous myocardial infarction; previous ptca/cabg; t and t summed stress, rest and difference scores, t and t post-stress and rest wall motion scores; t and t post-stress and rest ef, t and t ef. multivariate logistic analysis of the most predictive and not correlated variables revealed previous myocardial infarction, t summed difference score and t ef as the most important predictors of significant coronary artery disease (p< . ). according to roc curves analysis, the optimal cut-off to identify coronary artery disease was for t summed difference score providing a global diagnostic accuracy of . (sensitivity: . ; specificity: . ). moreover, roc analysis showed that a reduction in t ef after stress > % was the optimal cut-off to identify patients with coronary artery disease (sensitivity: . ; specificity: . ; accuracy: . ). the combination of t summed difference score and t ef resulted in a significant increase in the global chi-square for prediction of significant coronary artery disease ( . vs . ; p< . ). conclusions our data suggested that early minutes tetrofosmin gated spect is superior to standard delayed - minutes imaging providing indexes of both perfusion and function highly predictive of coronary artery disease. serum levels of crp, creatine kinase (ck), creatine kinase mb fraction (ck-mb) and troponin i of patients with acs of high-risk, were measured on admission and every hours for hours. patients were evaluated with stress/rest mtc-tetrofosmin gspect before discharge or up to one month after acs. patients have been divided in group . acute st elevation myocardial infarction (stemi) without history of prior myocardial infarction (pmi) ( , %), . stemi and pmi ( , %), . non-st-elevation acute myocardial infarction (nstemi) without pmi ( , %), . nstemi and pmi ( , %), . unstable angina (ua) without pmi ( , %) . ua and pmi ( , %) . infarct size was measured by myocardial perfusion defects in spect ("bull eye"); lvefr by gated spect and the left ventricular dysfunction in stress was evaluated by the ratio of ventricular volume stress/rest > , or when the stress lvef was significantly lower than the lvef at rest (more than percent). results: the serum levels of crp on admission were similar in all groups. the pcpr, ck, ck-mb and troponin i levels were significantly related to infarct size determined by spect in all the groups, except in the patients with ua without pmi. the pcrp levels were significantly related to mn size (p = , ), with a tendency to more infarct zone in the patients with pmi. higher pcrp (> mg/l) were related to infarct zone > % of left ventricular myocardium (p= , ). pcrp levels were not related to myocardial ischemia in either groups (p= , ). the maximum cpr levels were found in patients with lower lvefr (p= , ). left ventricular dysfunction was not related to pcrp levels (p= , ). conclusion: the high levels of c reactive protein are related to extension of myocardial necrosis and low left ventricular ejection fraction at rest, determined by gated spect irrespective of clinical form of acute coronary syndrome, but they are not related with stress-induced systolic left ventricular dysfunction of ischemic origin. the aim of the study was to assess ( ) diagnostic accuracy of myocardial perfusion spect (mps) with low-dose ct attenuation correction (ac), and ( ) the risk of concomitant correction artifacts (ca). methods: ac has been clinically validated in patients with coronary artery disease (cad) verified by coronarography (group a). ca were studied in patients with normal mps finding (group b). in both groups, gated stress mps has been performed with mtc-tetrofosmin using hybrid dual-head gamma camera with low-dose ct (ge infinia-hawkeye). rest mps was performed only in the group a. for data processing, d-mspect programme was used. ac was applied using ct attenuation maps. in both groups of patients, perfusion defects were compared in emission scans with and without ac. quality of spect/ct registration was assessed visually. results: in the group a without ac, perfusion defects on inferior wall were found in of patients. with ac, / ( %) of these defects completely disappeared. in comparison with coronarography, specificity of findings in the territory of the right coronary artery (acd) increased by % from to %. in the group b without ac, no perfusion defect was found in any of patients. with ac, perfusion defects appeared in the anterior wall and in the apex in / ( %) patients. in these patients, apparent spect/ct misregistration was found. in / patients without perfusion defects on ac scans, spect/ct registration was good. conclusions: considering perfusion defects in the teritory of acd, ac improved specificity of mps. in this area, no correction artifacts were found in any patient. in the anterior wall and in the apex, high frequency of correction artifacts reduced the value of ac unless the reality of the perfusion defect was supported by registration of emission and transmission scans. in order to optimise the diagnostic accuracy of ac mps, simultaneous assessment of emission scans with and without ac and inspection of the fused spect/ct images remains necessary. background: wbr is an iterative method for resolution recovery. it is designed to simultaneously suppress noise and improve image resolution and is optimised for short gated cardiac perfusion acquisitions. we have demonstrated in previous studies that the wbr technology applied to cardiac perfusion scans doesn't influence functional and perfusion parameters. considering that transient ischaemic dilation (tid) is believed to be also an important parameter for cad severity, the aim of this study is to compare the tid indexes obtained from the two reconstruction spect methods (fbp/wbr). methods: patients (pts) were studied: women and men. mean age: ± years old. with past ami. after pharmacological stress test, pts went through a double stress spect acquisition. the first acquisition used views, s/view with detectors at º and images were reconstructed by fbp. the second acquisition used views, s/view, and images were treated by wbr. the studies were analysed and processed with cedars-sinai software. perfusion scores (sss and sds) and functional parameters (lvef, edv, esv, sms, sts) were obtained. tid index resulted from the ungated lv stress and rest volumes ratio (usv and urv). we considered abnormal values of tid index >= . .for statistical analysis, we used paired student t-test to compare fbp and wbr tid indexes. we also determined the correlation coefficient (cc) between tid and lvef, edv, esv, scores and ungated volumes) results: global paired t test for wbr and fbp tid indexes showed p< . . there were only / high tid for wbr and / for fbp. from these high tid, only one had a normal perfusion scan. the others had necrotic and ischaemic lesions. although pts had perfusion scans showing cad lesions, only ( %) showed a high tid index on fbp and ( %) on wbr. conclusions: this study showed that tid index determination isn't influenced by the reconstruction method (fbp/wbr). in neither techniques (fbp or wbr), did tid index show a good correlation to lvef, edv, esv, to the ungated volumes or to any score (sss, sds, sms, sts).the low incidence of significant tid in patients with known cad is also of concern. p scintigraphic and hemodynamic pattern of diabetic patients with and without cardiac autonomic neuropathy undergoing adenosine stress myocardial perfusion scintigraphy p. keinrath , f. gürel , r. weitgasser , c. pirich ; nuklearmedizin und endokrinologie, salzburg, austria, innere medizin i, salzburg, austria. myocardial perfusion scintigraphy (mps) is recommend for cardiac risk assessment in diabetic patients. in many countries, however, there is no agreement on diabetic patient selection for mps. recent studies have demonstrated an attenuated heart rate response in diabetics during dypirdamole mps (lee et al. j nucl. cardiol. ) representing a subgroup with presumably increased cardiac risk. methods: we aimed to investigate whether this effect could be also found in adenosine stress mps in diabetics with or without cardiac autonomic neuropathy (can). can was diagnosed by the vagus programme ( beat to beat variation, valsalva test, : ratio and orthostasis test). patients with a mean age of ± years with diabetes underwent adenosine stress mps ( pts without and pts with can). patients were asymptomatic or had episodes of atypical chest pain, but a negative physical exercise test. results: mean ejection fraction was ± % in can positive and % ± in group can negative subjects. mps was classified as abnormal in % ( patients) without can and in % ( patients) with np, respectively (n.s.) mean stress defect scores were ± in patients with can and ± in patients without can (n.s.) . baseline heart rate (can negative pts: ± , can positive pts ± ) and maximum heart rate (can negative pts: ± , can positive pts ± ) as well as absolute or relative heart rate increase were not different in can negative or positive diabetics, either. conclusion: in this study in diabetics hemodynamic to response adenosine was not different between patients with and without can. there was not difference in scintigraphic outcome between subjects with or without can, either. our data suggest that the presence or absence of can does not yield information on cardiac risk stratification comparable to the well validated information given by scintigraphic parameters, alone. purpose of study: a reverse redistribution (rr) pattern is described with technetium (tc- m) myocardial perfusion stress (mps) imaging. the aim of this study was to determine if there was an angiographic correlation of the finding of a rr pattern on tc- -m mps imaging. method: we reviewed consecutive tc- m tetrofosmin spect stress studies over a year period. patients ( . %) were found to have a rr pattern, of which patients had undergone coronary angiography within months. correlation was sought between rr pattern and location of angiographic stenoses, the effect of reversible perfusion defect (rd) or a fixed defect (fd) in addition to rr pattern on angiographic findings was also determined. results: of patients, rr pattern occurred anterior in , lateral in , inferior in with having rr in more than territory. of the patients who had angiography / ( %) had normal coronary angiograms, / had vessel disease (vd), / had vd and / had vd. of the studies patients had rr pattern involving more than one coronary territory. stenosis location correlated poorly with rr pattern (lad/anterior / , cx/lateral / , and rca/inferior / ). in cases, there was a rr pattern without rd or fd, of which cases had normal angiographic findings, had angiographic disease not correlating with the rr pattern and had angiographic disease correlating with the rr pattern. in cases, there was a rr pattern together with rd or fd but normal angiography. in the remaining cases ( %), there was angiographic disease with evidence of rr pattern with rd and/ or a fd as well but correlation with coronary territory was poor (as given above). conclusion: ( ) rr pattern alone should not be used to make a decision to proceed to angiography. ( ) rr pattern does not reliably correlate with the location of significant coronary artery stenosis ( ) rr pattern in addition to rd or fd does not influence angiographic findings. correlation of myocardial perfusion single photon emission computed tomography with coronary artery calcium score in coronary artery disease -an indian perspective. s. simon, i. muthukrishnan, p. nagwani, h. r. kulkarni; apollo hospitals, chennai, india. objectives: the consequences of atherosclerosis can be detected by coronary artery calcium score (cacs) and stress induced myocardial ischemia on myocardial perfusion single photon emission computed tomography (mps). we assessed the relationship between stress induced myocardial ischemia on mps and magnitude by slice computed tomography (ct) in patients undergoing both tests. methods: our study included patients with no earlier history of coronary artery disease (cad) of both sexes ( males , females ) in age group of - years. our patients were referred by cardiologists after they underwent cacs. of these patients ( %) presented with symptoms which included chest pain (non anginal, anginal, atypical) presence or absence of shortness of breath, and rest ( %) were asymptomatic. for each patient coronary risk factors were noted. all these patients underwent cacs and rest and stress mps one day protocol with tc m sestamibi within days. according to the cacs patients were divided into groups a ( - cacs ), group b ( and above cacs ), group c ( group a with symptoms), group d (group b with symptoms). results: myocardial perfusion study was positive for inducible ischemia in % in group a ( n= ), % in group b (n= ), % in group c ( n= ), % in group d (n= ). from these we observe that the incidence of ischemic mps is more with increasing cacs (p= . ), in patients with symptoms (p= . ) which are statistically significant. and also it is noted that more frequency of inducible ischemia in patients who presented with symptoms irrespective of cacs who are at short term risk. in negative mps cacs may be useful in long term risk stratification in finding out subclinical atherosclerosis. conclusion: the general perception is that the cacs is a good tool for long term risk stratification but it may be applicable to those patients with no significant risk factors. when there are risk factors mps is a better indicator for risk stratification for cad irrespective of cacs. further studies incorporating prognostic follow up is required. objective: peripheral arterial disease (pad) is frequently associated with significant coronary artery disease (cad) and cardiovascular morbidity/mortality. however, there is a paucity of studies disclosing the prevalence of cad by stress tc m sestamibi myocardial perfusion imaging tomography (spect) and the effects of atherogenic risk factors (arf) on abnormal myocardial perfusion. we thus investigated the prevalence of silent cad and the impact of other arf in hypertensive (ht) patients (pts) with pad vs those without pad and no known cad. material and methods: we investigated treated ht pts without known cad; men, women aged . ± . years. all pts underwent stress and rest dipyridamole stress spect imaging that were analysed blindly by experienced observers. other arf were also evaluated. it is important to note that, of these pts, or . % had type diabetes mellitus. results: we found that pad was present in pts or . % of our studied population. moreover, overall silent myocardial ischemia was observed by spect in ( . %) of the ht pts. of note, the frequency of silent cad increased from . % to . % in pts with pad (p= . ;rr: . ). analysis of arf indicated that pts with pad were more closely associated with male gender (p< . ), hypercholesterolemia (p= . ) and smoking (p< . ) as compared with pts without pad. most importantly, silent cad was further increased in ht pts with pad affected by type diabetes mellitus (dm) (p< . ;rr: . ). indeed, the prevalence of silent cad increased from . % in ht pts to . % in ht pts with dm plus pad. conclusion: in this large scale population of high risk treated ht pts, the prevalence of silent myocardial ischemia is significantly greater in ht pts with pad. furthermore, the prevalence of silent cad increased significantly in dm pts. these findings should be clinically relevant in order to select ht pts who are the most suitable candidates for silent cad who require intensive medical or surgical intervention. objectives: coronary artery disease (cad) is a major complication of type diabetes mellitus. because cad is often asymptomatic and the disease can be controlled through screening programs, myocardial perfusion scintigraphy may be the best practical way to accomplish this on a larger scale. the aim of our study was to screen the silent coronary artery disease in type diabetic patients by perfusion myocardial scintigraphy. we also analyzed the risk factors that might be related to cad in type diabetes mellitus (t dm) patients with no classical cardiac ischemic symptoms. methods: gated single-photon emission computed tomography was performed using a same day stress/rest protocol with tc- m sestamibi. we screened a total of patients: diabetic patients without evidence of cad and diabetic patients with evidence of cad . gender, patients' age, known diabetes duration, smoking status, hba c, the presence of who-metabolic syndrome defined hypertension and level of cholesterol and triglycerides were examined in order to access relationship to cad in diabetic patients. results: a semi-quantitative visual interpretation was made using short axis, horizontal, and vertical long axis myocardial tomograms and a five grade ( - ) scoring system in -segmental model. a study was judged abnormal if the sum of stress scores (sss) was . two groups of patients were compared: group a ( patients) without clinical evidence of cardiac disease and group b ( patients) with clinical evidence of cardiac disease. compared with group b patients (we excluded patients with combination of reversible and fixed defects), group a patients tended to have fewer perfusion reversible changes by visual analysis (t- , , p< , ), as well as by sss test (p= . ). correlation coefficient has been sign among visual analysis and sum stress scores (c = . ) . thirty-eight asymptomatic patients with normal resting ecg (group a) were examined by stress/rest myocardial perfusion scinigraphy with tc- m sestamibi. fifteen patients ( %) considered to have positive test or significant myocardial ischemia. twenty-three showed no significant ischemic lesion (p < . ). diabetes duration of . years was associated with silent cad (ci: . ; . ), tryglicerides and hba c were significantly associated with asymptomatic cad as well. (p< . and p< . ). conclusions: a considerable proportion of t dm patients have silent cad ( %). the patients with diabetes duration seven years and more should be screened routinely for the presence of cad as well as the patients with high level of hba c. m. l. de rimini , m. catalano , s. comenale pinto , r. ancona , p. caso , r. merenda , a. scalzone , p. muto ; nuclear medicine aorn monaldi, naples, italy, non invasive cardiology, aorn monaldi, naples, italy. diastolic function (df) abnormalities can be an early sign of cardiomyopathy in diabetic (dm) patients (pts) with no coronary artery disease (cad) or systolic (sy) left ventricular (lv) dysfunction. echocardiography (echo) with doppler measurements of transmitral and transtricuspidal flow and myocardial (m) tissue doppler (dti), strain (s) and strain rate (sr) can evaluate df. aim: to evaluate early d dysfunction in dm pts without documented cad. methods: we studied male pts: non-dm and dm, mean age: ± . selection criteria were: no history of cad or hypertension and normal perfusion at stress/rest (str/r) m-gspect (sss/sds ). qgs quantified lv sy (ef; rwm; rwt) and d (pfr/edvs; ttpf) f. echo system seven ge, equipped with tvi function, calculated lv/rv sy and df, pulmonary artery wedge pressure (pcwp), by e/ea and left and right atrial (la/ra) peak sy tissue s and sr in and chambers view, at the level of the apical segment of the septal, lateral, anterior and inferior la walls, and ra free wall. pulsed doppler and dti studied early (e) and late (a) d wave velocity, ratio e/a, deceleration time (dect); l-r isovolumic relaxation time (ivrt) and pulsed doppler of pulmonary vein flow. results: at echo: significantly higher prevalence of abnormal d mitral (ratio e/a= , vs , ) and tricuspidal (ratio e/a= , vs , ) flow patterns and a longer mitral valve dect ( versus msec) was observed in dm vs non-dm pts. although no differences were found in la/ra diameters and volumes, the m atrial s and sr were found to be significantly (p= , ) lower for atrial septum, ra free wall and la anterior wall in dm pts in respect of controls. no differences were found in dm and non-dm pts for sy function: ef= % vs %, ivrt ( vs msec), propagation velocity of transmitral flow during early ventricular filling (vp= , vs , cm/sec) and pcwp ( , vs , mmhg) . similarly at gspect: str/r pfr/edvs mean value = . / . in dm and . / . in non-dm pts (p= , ); rest tpfr was longer in dm pts ( ± ms) than in non-dm pts ( ± ms), with preserved sy function (lvef= ± % / ± %) in all pts. conclusions: gspect can assess str/r df; impaired pfr/edvs, tpfr, la/ra s and sr in dm pts with no hypertension or cad and preserved lv-sy function can suggest an earlier functional effect of a specific dm cardiomyopathy independently of cad. würzburg, würzburg, germany, st. antonius ziekenhuis, nieuwegein, the netherlands, objectives: for quantitative comparison of myocardial perfusion spect scans (mps), the -segment model conventionally used for clinical analysis has an undesirably low resolution, resulting in numerical obfuscation of extreme differences in small areas. the objective of this study was to establish a segment model that allows for detailed quantitative comparisons of mps and compare this to the segment model. methods: a -segment model was defined by quartering each segment of the -segment model. both models were applied to tl- and tc- m repeated phantom mps, repeated tl- and repeated tc- m-sestamibi patient mps from an ethical board-approved study. mean segmental counts-per-pixel values for the -and -segment model were calculated based on data-points extracted from mps using the munichheart software. for each segment the difference between repeated scans was calculated. spiral profiles for the difference per segment between scans were then generated. results: tl- : the overall variation between repeated phantom mps was . % ( % ci: - . to . %) for the segment model. for the -segment model this was . % ( % ci: . to . %). for patient scans overall variation was - . % ( % ci: - . to - . %) for the -segment model and - . % ( % ci: - . to - . %) for the -segment model. tc- m: the overall variation between repeated phantom mps was . % ( % ci: - . to . %) for the segment model. for the -segment model this was . % ( % ci: - . to . %). for patient scans overall variation was - . % ( % ci: - . to . %) for the segment model and - . % ( % ci: - . to - . %). spiral profiles: comparing the spiral profiles for the -and -segment model showed that the -segment model showed higher extreme deviations than the -segment model. regions of variability could be identified in more detail than in the segment model. conclusion: the -segment model allows for more detailed analysis of differences than the -segment model when comparing mps quantitatively. research support: supported financially by tyco healthcare. würzburg, würzburg, germany, st. antonius ziekenhuis, nieuwegein, the netherlands, utrecht university, utrecht, the netherlands, tyco healthcare b.v., petten, the netherlands, umc utrecht, utrecht, the netherlands. objectives: simultaneous acquisition of a tl- rest myocardial perfusion spect (mps) and a tc- m-sestamibi labelled stress mps is a much sought-after procedure in nuclear cardiology. before this procedure can be applied clinically, tl- rest-mps before and after an exercise test need to be compared for equality. for interpretation of this comparison, the normal variation between two repeated mps needs to be known. the objective of this study was establishing a normal range for the variation between repeated rest tl- and repeated stress tc- m-sestamibi mps. methods: ethical board approval was obtained. in patients repeated tl- rest-mps and in patients repeated post-stress tc- m-sestamibi mps was performed. also repeated anthropomorphic thorax phantom mps were obtained for both isotopes. quantitative analysis of mean counts-per-pixel for each segment in a segment model was done using the munichheart program. subsequently, statistical methods were used to calculate a normal range of variation. visual analysis was performed by independent observers scoring each of the repeated segments for each patient on a scale of - . results: tl- : the overall variation between repeated phantom mps was . % ( % confidence interval (ci): - . to . %). for patient scans this was - . % ( % ci: - . to - . ). observer scored . % of segments differently between repeated scans; observer did so in . % of segments. the observers disagreed in . % of segments. the differences were not clinically significant. tc- m: the overall variation between repeated phantom mps was . % ( % ci: - . to . %). for patient scans this was - . % ( % ci: - . to . %). observer scored . % of segments differently between repeated scans; observer did so in . % of segments. the observers disagreed in . % of segments. the differences were not clinically significant. overall: the mean difference per segment for repeated phantom spect scans did not differ significantly between the tl- and tc- m tests (paired t-test, p= . ) , and were significantly correlated (pearsons' r = . , p = . ). the mean difference per segment for repeated patient spect scans differed significantly between the tl- and tc- m patients (paired t-test, p= . ) conclusion: on average, tl- and tc- m-sestamibi mps show only minor variation when repeated; a normal range of variation between scans was calculated. the difference between tl- phantom-and patient-mps indicates a biological source of variation in patients. research support: supported financially by tyco healthcare aim: to study the prevalence of ischemic heart disease (ihd) in patients with diabetes mellitus who are asymptomatic for ihd with myocardial perfusion study (mps) . materials and methods: this retrospective study included patients known for diabetes mellitus of more than years duration of both sexes with or without additional risk factors for ihd but without any clinical evidence of ihd. patients were selected from the group referred by the cardiologists for myocardial perfusion single photon emission computed tomography (spect). patients with known ihd were not included in this study. age matched asymptomatic non-diabetics [n = ] without risk factors for ihd were evaluated with myocardial perfusion spect as controls. these patients were subjected to a rest and stress technitium- m sestamibi myocardial perfusion spect. the images were interpreted as fixed perfusion defects, inducible ischemia or both. twenty-two patients with inducible ischemia underwent coronary angiography. these results were correlated with glycosylated hemoglobin {hba c}; duration of diabetes; and presence of additional risk factors for ihd -hypertension [bp> / ], hyperlipidemia [total cholesterol > mg/dl, ldl > mg/dl, hdl < mg/dl], obesity [body mass index > kg/ sq. m], smoking, and a family history of premature ihd. results: significant perfusion abnormalities were found in out of the patients [ %] and out of the [ %] controls. hence cad was [relative ratio] times more prevalent in diabetics than in controls. in patients, the extent of myocardial ischemia or perfusion defects increased with duration of diabetes and with poor glycemic control [elevated hba c] statistically significant with [p = . ]. nine out of patients [ %] who underwent angiography had significant perfusion abnormalities in mps but without significant coronary stenoses [< %]. the correlation of mps with coronary angiogram showed a sensitivity and specificity of % and % respectively. conclusion: due to autonomic dysfunction in diabetes mellitus, chest pain is uncommon in spite of the underlying "silent" myocardial ischemia, warranting a thorough cardiac evaluation. mps is a sensitive modality for screening of subclinical ihd in diabetics. . perfusion of . %, . % and . % in the segments with severe, moderate and mild perfusion defects respectively. pre-operative rest mps showed / hypo-perfused segments with ( . %) segments with severely decreased perfusion, ( . %) segments with moderately and ( . %) with mildly decreased perfusion. after revascularization, perfusion in these segments was improved in . %, . % and . % respectively. there was no change in . % of segments with severely decreased perfusion. conclusion: the positive effect of cabg surgery in the area of severely hypoperfused segments on rest mps was not observed in more than in % of segments. segments with severely decreased perfusion showed fixed defects normally associated with myocardial infarction. however the significant improvement in myocardial perfusion after cabg was demonstrated in segments of moderate and mild perfusion defects. myocardial perfusion scintigraphy with tc m sestamibi provides useful information for assessment of coronary artery bypass surgery and prognosis of revascularization in patients with ischemic heart disease. the role of captopril renal scintigraphy for the qualification to the pta of the stenosed renal artery. m. kostkiewicz , t. przewlocki , d. rzeznik , w. szot , a. kablak-ziembicka , w. jarosz , w. tracz ; john pauil ii hospital, dept of nuclear medicine, krakow, poland, john pauil ii hospital, dept of nulcear medicine, krakow, poland. stenosis of renal artery is the most common cause of secondary hypertension and renal insufficiency. renal perfusion imaging (rpi) with ace inhibitors is well acknowledged study in diagnosis of these diseases. percutaneous transluminal angioplasty (pta) of stenosed arteries is currently one of methods of treatment in this group of patients, however, there are no effective methods of noninvasive control in those subjects and indications for pta still remain unclear. methods the group of patient studied comprised of people ( males and females, mean age . _+ , ) with ischemic heart disease, referred for pta, in whom angiography revealed stenosis of one or both renal arteries. all the patients had rpi with ace inhibitors performed with -days protocol with minimum hours between the first and second study -initially and months after pta. the values of gfr, time to peak of renographic curve (tmax), renal perfusion images, value of renal inflow and shape of renographic curves were analyzed. two independent observers were evaluating data in aim to refer the patient for pta. -grade scale was used: -stenosis not significant or normal images, -borderline stenosis, -significant stenosis. the data obtained were compared with ultrasonographic studies. rpi was repeated after months to evaluate late outcome of treatment and probability of recurrent stenosis. results. in studied group of patients left renal artery stenosis was found in pts, right in pts and bilateral in pts. pta proved to be successfully performed in all those pts. in pts recurrent stenosis was found and subsequent pta was performed. in pts, despite successful pta, no improvement in renal function was found in control study. those pts had low gfr values (below ml/min.) together with nephrectomic type of renographic curve. scintigraphic image was consistent with angiographic localization of renal artery stenosis. in pts, despite the presence of significant stenosis the scintigraphic images were normal. conclusions rpi with ace inhibitor is substantially efficient study in referring pts for pta and evaluation of late results. in case of severely impaired renal function the rpi should be the reason for postponing the pta. kbn po bo aim: coronary revascularisation is effective in many patients with stable angina pectoris. however, in some patients symptoms may persist or even progress, probably because of persisting regional hypoperfusion. we examined the rates of unchanged or worsened perfusion two years after coronary revascularisation. material and methods: a prospective series of patients ( females) with a mean age of . ± . years underwent coronary revascularisation for stable angina pectoris. myocardial perfusion scintigraphy (mps) was performed before angiography and two years later. the decision of invasive management was based exclusively upon patient history and angiographic findings since the result of mps was kept secret. the mps studies were reviewed to determine if a change, e.g., from a reversible to a mixed defect or from a mixed to a fixed defect was due to improvement (i.e., smaller defect) or deterioration (i.e., larger defect or decreased reversibility at unchanged defect size). results: before revascularisation, the rates of normal perfusion or of reversible, mixed, or fixed defects were % ( / ), % ( / ), % ( / ), and % ( / ), respectively. two years following revascularisation, improvement in perfusion was noted in % ( / ), % ( / ), % ( / ), and % ( / ) of these groups, respectively, summing up to improvement in % of the entire study population ( / ). perfusion remained unchanged in % ( / ) corresponding to % ( / ), % ( / ), % ( / ), and % ( / ) of patients with initially normal perfusion, or reversible, mixed, or fixed defects, respectively. in the remaining % ( / ) of patients there was a worsening of perfusion. worsening of perfusion was deemed serious in only of the patients with a worsened perfusion. conclusion: two years following revascularisation, the relationship between improvement, no change, or a deterioration in myocardial perfusion was in stable angina pectoris patients approximately : : . serious deterioration was a seldom event. improvement was noted exclusively in the patients with reversible or fixed perfusion defects suggesting that preoperative mps might potentially improve the overall result of coronary revascularisation by straining off patients with normal perfusion or fixed perfusion defects. f. marranzano , m. caruso , c. privitera , g. privitera , g. rapisarda , a. la rosa , s. gusmano ; dip. immagini az.osp.un. ove, catania, italy, uoc cardiologia az.osp.un. ove, catania, italy. aim to determine the clinical features of myocardial perfusion imaging in a novel heart syndrome with transient left ventricular apical ballooning( ab) , but without coronary artery stenosis, that mimics acute myocardial infarction. several case studies of ab, so called takotsubo cardiomyopathy ( tm), have been reported. tm is characterized by angina-like precordial pain and st-segment elevation and limited release of cardiac enzymes. sometimes appears with dyspnea or syncope. the catheterization procedure shows normal coronary arteries, and apical dyskinesia is observed on contrast ventriculography. the incidence of this syndrome is not clear but it develops predominantly in elderly women. case report we present the case of a year-old woman arrived to the emergency department of our institution hour after emotional stress ; symptoms began with angina and dyspnea at rest . the electrocardiogram on admission showed small progression of the first vector and stsegment elevation in leads v to v , with a moderate increase in levels of cardiac serum markers (ck , ck-mb, and troponin i ). on physical examination, she had a pulse of beats/min and her blood pressure was / mm hg. two-dimensional echocardiography showed left ventricular dilatation with preserved systolic function in the basal segments; the midventricular segments and the apical segments were dyskinetic. the diagnosis of acute anterior myocardial infarction was established, and thrombolysis was performed by use of recombinant tissue plasminogen activator. partial signs of reperfusion were observed , with reduction of st-segment elevation. four hours after the initial symptoms appeared acute rest-sestamibi myocardial perfusion g -spect was perfomed. results acute rest-g-spect showed perfusion defects on the septal, anterior, and apical walls . by use of gated spect, it was possible to assess myocardial dyskinesia of the anterior wall and apex. coronary artery study revelead no significant stenosis of main epicardial vessels . one month later a stress-rest g-spect study ( two days maximal exercise protocols) showed no perfusion defects, and the wall motion abnormalities had disappeared, with completely normal heart function. conclusion we report a case of severe, reversible myocardial perfusion defects and left ventricular wall motion dysfunction , seen on gated spect , compatible with tm , in patient with normal coronary angiograms and dyskinesia on contrast ventriculography.g-spect is therefore a useful method for the diagnosis and follow-up of tm because it is a noninvasive imaging technique that shows the complete reversibility of this entity. clinical utility of myocardial stress-rest perfusion scintigraphy with adenosine in elderly patients with diabetes mellitus. g. p. gerasimou, t. aggelopoulou, a. revela, e. dedousi, g. liaros, e. papanastasiou, a. siountas, k. psarrakos, s. chatzimiltiadis, s. gavriilidis, a. psarrakou; ahepa university hospital, thessaloniki, greece. coronary artery disease (cad) in elderly patients with diabetes mellitus (dm) is often characterized by occult or absent symptoms. these patients are not able to achieve an acceptable level of ergometric exercise. this study has as purpose to assess the diagnostic value of stress/rest radionuclide myocardial perfusion scintigraphy (rms) with adenosine (adn) in patients with dm, older than years, with a low clinical prevalence of cad. materials and methods: fifty-six patients ( females) with dm (mean age . + . ), with equivocal symptoms of cad are enrolled in the study. all patients underwent pharmacological intervention with adn at a dose of μg/kg/min in min under ecg inspection and mbq of tc m-tetrofosmin (tf) were injected at the rd min of adn infusion and stress study was taking place min post tf injection. four hours after pharmacological test, rest study was performed min post iv injection of mbq of tf. coronary angiography (ca) has been performed to all patients. results: the left ventricle of the patients was divided into segments (apex and apical plus basal segment of the anterior, lateral, inferior wall and interventricular septum). a segment was considered as abnormal, if the counts revealed were less than % compared to the data of normal population. in ca, a stenosis was considered significant when it exceeded % of a vessel's lumen or accordingly to the fraction flow reserve. in of the patients stress/rest radionuclide tf test has been considered within normal limits. in these patients ca revealed a stenosis of the coronary vessels in one of the patients, in one of the coronary vessels. in the remaining patients, reversible myocardial ischemia has been mentioned to out of a total of segments, whilst findings compatible with myocardial infarction have been reported to of these patients, numbering additional segments of the left ventricle. ca has been considered as abnormal in of these patients, with total occlusion of the coronary arteries in both patients with myocardial infarction as mentioned to rms. according to these results, the sensitivity of rms has been considered as high as . %, whilst specificity was at the level of . %. conclusions: in elderly patients with dm, presenting silent myocardial ischemia, rms with adn challenge, is a sensitive tool in the diagnosis of cad. purpose: some authors reported that a reduced i- bmipp uptake in the myocardium in patients with hcm, and the reduction of i- bmipp related to the myocardial abnormalities. we hypothesized that the abnormality of fatty acid uptake and metabolism may occur before it can be visually recognized on spect images in patients with hcm. a distribution volume (vd) of i- bmipp could be useful for detecting such abnormality of myocardial fatty acid metabolism. the purpose of this study was to investigate vd of i- bmipp in myocardium through a compartment model analysis in patients with hcm. methods: twenty-eight normal controls and patients with hcm were studied. i- bmipp and tc- m tetrofosmin spect were performed. according to the literaturere, the uptake of tc- m tetrofosmin and i- bmipp are preserved in very early phase of hcm. in moderately advanced phase of hcm, the uptake of i- bmipp is reduced, but the uptake of tc- m tetrofosmin is preserved. in severely advanced phase, the uptake of tc- m tetrofosmin is also reduced. based on these results, we defined early hcm as normal uptake of tc- m tetrofosmin and i- bmipp, moderately advanced hcm as normal uptake of tc- m tetrofosmin and decreased uptake of i- bmipp, and severely advanced hcm as decreased tc- m tetrofosmin and i- bmipp. moreover, all the myocardium was divided into segments. finally, these segments of hcm were categorized into early, moderately and severely advanced hcm segments. by using the timeactivity curves, we analyzed bmipp pharmacokinetics through a -compartment model. we defined k and k as influx and outflux rate constant between blood and reversible component, k as specific uptake rate constant between reversible and irreversible compartments. additionally, we calculated k /k as vd. results: the results were summarized in the table. the vd of i- bmipp was gradually decreased with progression of hcm, and there was statistically significant difference between normal and each hcm group (p < . in each group). conclusion: vd of i- bmipp might be useful index to evaluate the progression of hcm. however, uptake of i- bmipp was not reduced in early hcm group at least with visual qualitative approach. these results indicated that a mathematical compartment model analysis might be useful to detect subtle change of fatty acid metabolism in patients with hcm, and not only for identification of hcm in very early stage, but also for evaluation of the progression of hcm. aim: mtc-sestamibi (mibi) shows good retention in normal myocardium after the initial uptake. but, the washout is sometimes observed in ischemic hearts. these suggest the possibility that the washout rate of mibi would be a useful indicator of myocardial damages or dysfunction. this experimental study evaluated the mibi washout by hypoxic myocardial damage using electrically paced isolated rat hearts. methods: isolated rat hearts were electrically paced at beat/min and were perfused with oxygen-saturated krebs-henseleit solution of constant flow of ml/min. heart rate and left ventricular pressure (lvp) were measured. after mibi ( to mbq) was infused for minutes, mibi washout was observed in the following two groups: the control group that was continuously perfused with oxygen saturated solution for minutes and the hypoxic group that was perfused with oxygensaturated solution for min followed by nitrogen-saturated solution including glucose. cases of irreversibly damaged hearts were excluded. radioactivity in the heart was continuously measured using a gamma camera equipped with pin-hole collimator. mibi washout rate was evaluated by the slope of time-activity curve (tac) for roi of whole heart. results: the mean mibi uptake in the isolated heart was . ± . %/added dose. in the control group, mibi showed good retention with a very gentle slope of tac (- . ± . %/min). in the hypoxic group, the slope of tac was significantly increased (- . ± . %/min). under hypoxic condition, lvp was reduced first, and then the diastolic pressure (dp) was elevated. the change of tac slope simultaneously occurred with the rise of dp, not at the initiation of the hypoxic condition. carbonyl cyanide-m-chloro phenylhydrazone (cccp), a mitochondrial uncoupler, induced similar increase of the slope of tac under the same condition, suggesting that the mibi washout induced by the reversible hypoxic damage observed here was implicated in mitochondrial function. conclusion: the myocardial washout rate of mibi can be a useful marker of myocardial viability. aim: initial clinical studies have shown that bone marrow progenitor cells had beneficial effect on the healing process after myocardial infarction. the aim of the present study was to evaluate the effects of intracoronary infused bone marrow derived progenitor cells (cd +) on regional myocardial viability and perfusion by [ f]fdg pet and [ mtc]mibi spect in patients with first episode of acute myocardial infarction. materials and methods: patients were treated by percutaneous revascularisation and stenting of the occluded artery; left anterior descending (lad), right coronary artery (rca). all patients received intracoronary infusion of autologous cd + bone marrow stem cells ± days after the revascularisation. all patients underwent fdg-pet and mibi-spect before transplantation and months afterwards during follow-up. for quantitative evaluation of myocardial [ f]fdg and [ mtc]mibi uptake a ventricular segmentation scheme ( segments) was applied. mean signal intensities (msi) of the segments assigned to the lad/rca distribution were callculated for each patient. results: pet studies showed a highly significant increase of the msi in the infarct area from . ± . % to . ± % (p= . ). no statistically significant differences were found in myocardial [ mtc]mibi uptake before ( . ± . %) and after ( . ± . %) stem cell translpantation(p= . ) conclusion: our results indicate that local intracoronary cd + progenitor cell therapy results in a significant increase in myocardial viability of the infarct zone. aim in patients with previous myocardial infarction, the relationship among viability, ischemia, volume overload and systolic dysfunction is still unclear. methods we studied patients (age ± yrs, male) with previous myocardial infarction ( anterior, inferior, lateral). all patients underwent a single day rest postnitrate/stress tetrofosmin g-spect study. g-spect analysis was performed using qgs/qps protocols. viability was scored according to a summed rest score (srs) < (mostly viable), - (partially viable), and > (mostly necrotic). in each category, summed difference score (sds) provided the presence (sds> , group ) or the absence (group ) of myocardial ischemia. results according to srs, patients showed mostly viable, partially viable and mostly necrotic myocardium. in patients with mostly viable myocardium, mean resting lvef resulted lower in g than in g patients ( ± % vs ± %, p< . ) and significantly changed following exercise only in g (from ± % to ± %, p= . ). mean resting edv was higher in g than in g (p< . ) and did not change following exercise in both groups (p=ns). delta sms (resting sms -exercise sms) resulted significantly lower in g than in g patients (- . ± . vs - . ± . , p< . ) , suggesting the presence of exercise induced regional stunning. in patients with partially viable myocardium, mean resting lvef was lower in g than in g patients ( ± % vs ± %, p< . ) and significantly changed following exercise only in the presence of myocardial ischemia (g , from ± % to ± %, p= . ). mean resting edv was higher in g than in g patients (p< . ) and did not change following exercise in both groups (p=ns). again, delta sms resulted significantly lower in g than in g patients (- . ± . vs . ± . , p< . ). in patients with mostly necrotic myocardium, mean resting lvef resulted similar between g and g ( ± % vs ± %, p=ns) and did not change following exercise (p=ns). similarly, mean resting edvs were ± ml and ± ml (p=ns) in g and g patients and did not change following exercise (p=ns). delta sms resulted similar between g and g patients (- . ± . vs - . ± . , p=ns) . conclusions in patients with previous mi, ef decreases and edv increases proportionally to the amount of scarred myocardium. at any level of tissue viability, transient ischemia has an additional role in determining the degree of resting systolic dysfunction and volume overload. repetitive episodes of ischemia during daily activity could modulate the extension of scar and the time course of lv dysfunction. several studies have indicated that contrast-enhanced magnetic resonance imaging (cmr) enables the visualization of infarction and reperfusion.so far there are only a few reports comparing cmr with spect early after ami.the aim was to compare tl- rest(r)-redistribution(rd) perfusion spect results with cmr in patients early after ami. methods:twenty-nine patients ( males, females; ± yrs) with recent ami were studied.within days after ami, the patients were performed tl- r-rd perfusion spect using mci activity.cmr was carried out - minutes after , mmol/kg of iv.gadobutrol injection.myocardial perfusion and contrast enhancement was analyzed using a segment model.myocardial perfusion was scored in tl- spect as follows: =normal ( %- % maximal myocardial activity(mma), = - % mma, = - % mma , = - % mma and =< % mma ;myocardial contrast enhancement on cmr images was graded as: =no contrast enhancement, =hyperenhancement of - % of the wall thickness(wt) =hyperenhancement of - % of the wt, =hyperenhancement of - % of wt and =hyperenhancement of - % of wt.in cmr the existence of microvascular obstruction(mo) was also evaluated.total segment scores(tss) in r,rd and cmr for each patient were calculated by summing of segment score values. results:the mean tts values were calculated as: r-tss= ± . ,rd-tss= . ± . and cmr-tss= . ± . .the mean differences between r-rd tl- and cmr were significant(p= . ); cmr-tss values > r and rd-tts in / patients. in / patients, mo was observed.in / patients with mo, perfusion was normal in r-rd tl- (r and rd-tts= , cmr-tss= ).in / patients without mo,r-rd tl- perfusion findings were normal (r and rd-tts= ; cmr-tts= and ), / patients had r-tts =o, rd-tts= and cmr-tts= .in the analysis of a total of segments, poor agreement was found between cmr versus r and rd results (kappa= . ve . ).according to coronary artery territories the agreement between the segments were: lad: cmr -r, rd (kappa= . and . ), rca:cmr-r,rd (kappa= . and . ), lcx: cmr-r, rd (kappa= . and . ). conclusion:a poor segmental agreement was observed between cmr and tl- r-rd study. the segments in rca territory showed the worst agreement comparing to lad and lcx. cmr detected infarcted areas larger in % of patients. this was compatible with related literature including histopathology. possible explanations for overestimation in cmr, early after ami include an altered washout characteristics of the contrast medium in the ischemically injured but viable myocardium. follow up studies after revascularization are needed to obtain reliable results in identifying accurate viable and necrotic tissues. in patients with previous myocardial infarction evaluation of myocardial viability and global left ventricular ejection fraction (ef) may provide clinically useful diagnostic and prognostic information. gated spect imaging allows simultaneous assessment of myocardial viability (according to extent of perfusion defect and preserved wall thickening) and function (left ventricular ef). the aim of the study was to compare myocardial perfusion and global ef in patients with previous myocardial infarction (mi) before and after angioplasty. materials and methods: study group consisted of patients (mean age ± year, male) with previous myocardial infarction (before . ± months) and single vessel coronary artery disease ( lad, lcx and rca). all patients underwent coronary angioplasty and stenting of infarct related coronary artery. to evaluate myocardial perfusion and function we performed rest ecg gated mibi acquisition after nitroglycerin administration. left ventricular ef was calculated from gated spect data by commercially available software d-mspect. myocardial perfusion abnormalities were expressed as defect extent in per cent of entire left ventricle. myocardial region was considered as viable when systolic wall thickening was present and mibi uptake was % of peak myocardial activity. perfusion and function were evaluated before and - months after stenting. results: according to myocardial perfusion and preserved systolic wall thickening the patients were divided in two groups: group i consisted of patients with viable segments after mi and group ii of patients with non-viable segments. the mean left ventricular ef in group i was higher than in group ii ( ± % vs. ± %, p< . ) and perfusion abnormalities were grater in group ii than in group i ( ± % vs. ± %, p< . ). after successful angioplasty and stent implantation in group i global lvef slightly increased ( ± vs ± %, p> . ) and perfusion abnormalities significantly decreased ( ± % vs. ± %, p< . ). on the contrary, in group ii there was no significant improvement of lvef ( ± % vs. ± %, p> . ). perfusion abnormalities were larger after angioplasty, although without statistically significance ( l± % vs. ± %, p> . age . ± years submitted for evaluation of viability with mtc-sestamibi using rest-nitrate protocol with gspect and rnv. eighteen pts. had repeated studies at six months for assessment of therapy, so a total of pairs of studies were obtained. gated spect was performed between and min after administration of mtcsestamibi ( mbq/k) at rest, using frames per cardiac cycle, x zoom factor and no beat rejection. rnv was performed hours later with labeled rbcs in left anterior oblique projection, frames per cardiac cycle, x zoom factor, and % window beat rejection. patients with complete arrhythmia or with ectopic beats > % of total beats were not included for analysis. edv, esv and lvef were determined using the qgs (cedars-sinai) software package for gspect aim coronary artery disease (cad) shows higher incidence in diabetics than in nondiabetic population and is more advanced at diagnosis. the prognosis of cad is less favorable in patients with diabetes than in nondiabetics. postinfarction mortality is higher in diabetics. the available data suggest that occult cad is a comon finding among asymptomatic diabetics. stress/rest myocardial perfusion imaging (mpi) could be a useful, noninvasive procedure with diagnostic and prognostic roles. methods study population of patients, of them presented diabetes mellitus. clinical follow-up of - months, for confirmed cardiac deaths, non-fatal myocardial infarction and others adverse cardiac events (ace) mpi was performed after administration of mbq tc m-tetrofosmine in stress and mbq in rest ( day protocol). some patients also underwent radionuclide ventriculography and coronary angiography. the obtained images were categorized as normal or abnormal: reversible, fixed or mixed myocardial perfusion defects, severity and anatomic location (right, descending and circumflex coronary artery). results aim: due to the aging of population and high frequency of obesity, the prevalence of type ii diabetes mellitus (dm) is increasing rapidly in western nations and the associated coronary artery disease (cad) is nowadays the leading cause of death in diabetic subjects. the purpose of this study was to evaluate the long-term prognostic value of gated-spect myocardial perfusion imaging (gmpi) for the occurrence of cardiovascular events in patients with dm. materials and methods: a cohort of consecutive patients ( women and men, mean age ± years), with at least a five-year history of dm were enrolled in this study. the population was clinically classified according to history of cad and chest pain into high-(n= ) and low-risk (n= ) groups. all subjects underwent clinically indicated rest/stress tc- m sestamibi gmpi with physical exercise (n= ) or dipyridamole (n= ). to determine the prognostic value of gmpi the first endpoint was major acute cardiac events (cardiac death or non-fatal myocardial infarction) and the second endpoint was the revascularization rate. patients data were analysed using both kaplan-meier event-free survival curves and cox multivariate analyses. results: follow-up was completed in all patients with a median period of . years ( . - . ). the prevalence of abnormal gmpi was % (n= ) with reversible defects occurring in % (n= ), fixed defects in % (n= ) and mixed defects in % (n= ). patients with a normal gmpi had neither cardiac death, nor myocardial infarction, independently of a history of cad or chest pain. among the independent predictors of cardiac death and myocardial infarction, the strongest was abnormal gmpi (p< . ), followed by history of cad (hazard ratio (hr)= . ; p= . ) and inability to exercise (hr= . ; p= . ). patients with normal gmpi had a revascularisation rate of . % during the follow-up period, significantly lower than subjects with abnormal gmpi ( . %). compared to normal gmpi, cardiovascular events increased . fold for reversible defects, . fold for fixed defects and . fold for the association of both defects. conclusion: dm patients with normal gmpi seem to have an excellent prognosis independently of history of cad. on the opposite, an abnormal gmpi led to a more than -fold increase in cardiovascular events. this study outlines the additional value of gmpi in predicting cardiovascular events and risk-stratifying dm patients even if larger prospective trials are mandatory to confirm these findings and to assess their potential impact in clinical settings. the detection of myocardial ischemia in patients with preexisting left bundle branch block (lbbb) remains problematic. myocardial perfusion scintigraphy (mps) with dipyridamole is the preferred non-invasive diagnostic modality for this group of patients. materials and methods: seventy six patients with preexisting lbbb underwent sestamibi perfusion imaging with dipyridamole infusion protocol ( . mg/kg). stress and rest spect studies were acquired using single head ecam (siemens) and double head toshiba gca- a gamma cameras. images were interpreted by consensus of two experienced observers and classified as, low risk group (normal mps, small reversible/small fixed defect) and high-risk group (a large severe fixed or reversible defect and dilated lv cavity). patients with mean age of ± years (range= - years) were included in the study. these patients were followed up for months ± months and occurrences of hard cardiac events (mi or cardiac death) were asked by telephones. results: out of patients had low-risk scans ( %) and had high-risk scans ( %). in low risk group cardiac deaths were observed in / ( . %) and non-fatal mis were seen in / ( . %). in high-risk scans, suffered cardiac death ( . %) and non-fatal mis in ( . %). over all survival rate was . % in the low-risk group compared with . % in the high-risk group with a significant difference (p= . ). conversely, the negative predictive value of a normal myocardial perfusion scintigraphy for the occurrence of death was %. conclusion: myocardial perfusion imaging with dipyridamole stress provides important prognostic information in patients with left bundle-branch block, which is incremental to clinical assessment. aim; revascularisation of occluded coronary arteries and bypass grafts with insertion of drug coated and non drug coated [bare metal] stents has become the preferred choice of treatment in recent years for patients with multivessel coronary artery disease [cad] .our aim was to evaluate the role of gated spect [gspect] in patients who underwent multivessel ptca /stents. materials and methods: we evaluated patients[ males, females, mean age yrs] referred with chest pain - months after ptca/stent procedure in multiple coronary vessels including bypass grafts.all patients underwent two day stress/rest technetium- m-tetrofosmin myocardial perfusion gated spect [gspect] [ ] [ ] [ ] [ ] [ ] .coronary angiography showed instent restenosis in patients and progressive cad in patients with patent stents. patients were treated with redo ptca/stent and had cabg .no myocardial event was seen at - months follow-up. [ %] patients were considered normal [sds - ] .coronary angiography showed partial instent restenosis in of these patients. no adverse myocardial events were seen in these patients at - months followup. [ %] patients had fixed defects and event free follow-up .conclusion:our study shows that technetium- m-tetrofosmin myocardial perfusion gspect can be used as a powerful prognostic tool in patients who were treated with multivessel ptca/ stents aim: extension and severity of myocardial scar may condition short and long term efficacy of autologous stem cell treatment. methods: five male patients (mean age ± yrs) with previous myocardial infarction, multivessel coronary artery disease underwent to intramyocardial , ml injections of autologous stem cell in scarred myocardium concomitant with off-pump coronary artery bypass grafting. after open heart surgery, stem area was mapped on a d heart model by a cardiologist and a cardiac surgeon and transferred to the -segment model used for scintigraphic analysis. delivery area was chosen according to: ) dominance of scar; ) akinesis; ) ungraftability of the tributary coronary artery. mtc tetrofosmin gated spect ( mbq, views in a degrees orbit, double head gamma camera) was performed at rest before, weeks and four years after treatment with the same camera and acquisition parameters. severity of scar was quantified as number of standard deviations below matched normals according to qps protocol (ge health care) in segments. in the same segments regional wall thickening was quantified by qgs protocol (ge health care). results: ten weeks after the implantation, gated spect showed an improved regional perfusion in stem area in patients in whom the reduction of scar was % and %, respectively. one patient showed a further reduction of % after four years. patients who did not improve regional perfusion both at short and long term follow-up showed a more extensive scar area and an impairment in regional wall motion before surgery. conclusion: in patients with previous myocardial infarction and multivessel coronary artery disease undergoing stem cell treatment in ungraftable areas, reperfusion was higher in those segments with more viability and less akinesis. results observed at weeks were confirmed by gated spect at long term follow-up. gated spect appears to be an optimal tool to assess short-and long term effect of stem cell treatment on regional blood flow and function. background: there is a lack of validation and standardization of acquisition parameters for myocardial i-metaiodobenzylguanidine (mibg). this lack of standardization hampers large scale implementation of i-mibg parameters in chronic heart failure (chf). methods and results: in a retrospective multi-center study i-mibg planar scintigrams obtained on chf patients ( % male; % dilated cardiomyopathy; nyha>i) were reanalyzed to determine the late heart-tomediastinum ratio (h/m). there was a large variation in acquisition parameters. multivariate forward stepwise regression showed that a significant proportion ( %, p< . ) of the variation in late h/m could be explained by a model containing patient related variables and acquisition parameters. left ventricular ejection fraction (p< . ), type of collimation (p< . ), acquisition duration (p= . ), nyha class (p= . ) and age (p= . ) were independent predictors of late h/m. conclusions: acquisitions parameters are independent contributors to semi-quantitative measurements of cardiac i-mibg uptake. improved standardization of cardiac i-mibg imaging parameters would contribute to increased clinical applicability for this procedure. objectives: for investigating the effects of suppression of myocardial sympathetic innervation on the myocardial adrenergic activity and norepinephrine transporter (net) density, the study undertaken i -metaiodobenzyl guanidine (mibg) myocardial imaging and and myocardial net immunohistochemistry in sprague-dawley (sd) rats following surgical sympathectomy (sx) at superior cervical ganglia. methods: twelve -wk-old male sd rats were included in this study, rats were subjected to right-sided surgical sx (rsx group), rats were subjected to left-sided surgical sx (lsx), and another rats were subjects to sham operation for control (c group) . all rats were undertaken myocardial imaging within hours following operation. i-mibg myocardial images were performed for the early and delayed imaging using a gamma camera (picker prism xp) equipped with a -mm pinhole collimator. the heart-to-mediastinum count ratios (h/m) of the -min initial imaging and the -h delayed imaging were determined, then the myocardial washout rate (mwo) was determined for being a marker of uptake- activity. following i-mibg myocardial imaging, the rats were sacrificed and the isolated hearts were collected for net immunohistochemistry. results: the results demonstrated the early mibg h/m of rsx rats were lower than that of control rats (h/m: . + . in rsx; . + . in control rats, p < . ), whereas h/m in lsx rats were similar to control rats (h/m: . + . in lsx; p= ns vs. control rats). the mwo of control rats were higher than that of sx rats; whereas the lsx rats were higher than that of rsx rats (control rats: . + . , vs. rsx: . + . ; p < . ; lsx . + . ,p < . vs. control rats). the myocardial net immunohistochemistry revealed the density in rsx rats were higher than in lsx rats, whereas the net density in lsx were higher than that of control rats. conclusion: based on the above findings, we suggest myocardial sympathetic dennervation will develop following right-sided sympathectomy, which will accompanied by compensated uptake- system on presynaptic nerve endings of postganglionic neuron, demonstrated by lowered mwo and increased net density. role of i -mibg cardiac scintigraphy in differential diagnosis between alzheimer's and lewy bodies dementia e. m. covelli, p. sullo, g. mazzarella, m. salzillo, g. vitale, g. belfiore; s. anna e s. sebastiano hospital, caserta, italy. purpose: lewy bodies are abnormal structures in the mid-brain: microscopic protein deposits found in nerve cells that disrupt the brain's normal functioning. lewy body disease (lbd) is the second cause of dementia in older adults caused by abnormal structures in the brain. lbd diagnosis can be difficult because many of the symptoms are similar to alzheimer's disease (ad), and cerebral perfusive tomography is always non conclusive. i -metaiodobenzylguanidine (i -mibg) is a radioiodinated analogue of noradrenaline. i -mibg scintigraphy is a non-invasive and safe diagnostic tool to assess and evaluate cardiac sympathetic innervation. the aim of this study is to evaluate the cardiac sympathetic innervation by i -mibg scintigraphy in patients with clinically demential symptoms and inconclusive tc m-ecd perfusive tomography in order to help the differential diagnosis between lbd and ad. methods: fourteen patients ( f, m; mean age ± years) with suggestive dementia symptoms underwent cerebral tc m-ecd tomography and cardiac i -mibg scintigraphy. cerebral perfusive tomography was performed one hour after tc m-ecd ( mbq) injection and qualitative analysis was used for diagnosis. cardiac i -mibg scintigraphy was carried out in all patients within one week and planar scintigraphic images were acquired hours after i -mibg ( mbq e.v.) administration. semiquantitative analysis was also performed calculating delayed ( hours) heart to mediastinum count-ratio (h/m) by drawing regions of interest (rois) over the upper mediastinum and whole heart to confirm diagnosis. results: all patients submitted to cerebral tc m-ecd tomography presented severely reduced tracer uptake suggestive to dementia but we observed a different cardiac innervation pattern between ad and lbd patients. in fact, cardiac i -mibg scintigraphy showed normal uptake (delayed h/m: . ± . ) in eight patients diagnosed as having ad and abnormal reduced cardiac tracer accumulation (delayed h/m: . ± . , p< . ) in remaining six lbd patients. conclusions: a significant decrease of cardiac mibg accumulation indicating a relevant degeneration of myocardial sympathetic neurons in lbd patients was detected. therefore, these preliminary data suggest that cardiac i -mibg scintigraphy may be useful in the differential diagnosis between ad and lbd especially when cerebral tc m-ecd tomography is not conclusive and it can be considered a suitable and helpful tool in the management of patients with dementia syndromes. a new iterative reconstruction algorithm (wbr™) has been recently proposed for cardiac spect. the wbr™ technology, based on accurate modelling of the emission-detection process, was designed to reduce noise improving lesion detectability without affecting the image resolution. few data exist on the comparison between filtered back-projection (fbp) and this new algorithm in a clinical setting. aim. the aim of this study was to compare the performance of fbp and wbr™ in the clinical arena. methods. a group of pts, with different cardiac pathology, scheduled for a stress-rest spect were studied. a two-day mtc-sestamibi protocol was used. all pts performed standard ecg-gated spect acquisitions with a dual-head@ ° camera, with a time/frame of sec. immediately after the conclusion of the acquisition, a second ecg-gated acquisition was performed at half-time/frame ( sec). standard-time spect was reconstructed with a conventional fbp (butterworth, . , ); half-time spect was reconstructed with wbr™. tracer uptake was blinded evaluated by two experienced observers in segments with a point scoring system (from =normal to =absent). discrepancies were resolved by consensus. summed stress scores (sss) and summed rest scores (srs) were calculated. lv ef were automatically calculated with qgs. results. no significant differences were observed in sss and srs between half-time wbr™ spect ( . and . , respectively) and standard-time fbp spect ( . , and . , respectively, ns) . lv ef on rest acquisitions was also comparable ( . % on half-time spect vs . % on standard-time spect, ns). lv ef on post-stress studies in half-time spect ( . %) was lower than standard-time spect ( . %), although not statistically significant. conclusions. visual analysis of half-time/frame spect reconstructed with the new algorithm wbr™, was comparable to that of a standard time/frame spect acquisition reconstructed with conventional fbp. differences in the time elapsed from the end of the stress test and the spect acquisition could be involved to explain the differences of lvef between the two post-stress studies. results from the present study do not necessarily apply to spect studies employing an reduced activity of injected tracer, and further studies are needed. aim: present devices used for gated spect mpi may be incapable to identify the r wave as a proper triggering signal in patients with a pacemaker, mainly with dualchamber stimulation. the aim of our study was to assess in how many such patients the use of r wave fail and to test the usefulness of pulse wave as an alternative. material and methods: we evaluated a group of pts with pacemaker referred to our department for stress mpi. there were m and f, mean age y ( - ). two data sets were acquired at rest, the first set synchronized with r wave and the second set with pulse wave. cequaltm and qgstm software were used for processing. we compared ejection fraction (ef), end-diastolic and end-systolic volumes (edv, esv). paired t-test and correlation were used for comparison. results: we were unable to get good data in / ( . %) pts using synchronization with the r wave. in all of them the data synchronized with the pulse wave were acceptable for processing. in the whole group, the mean ef, edv and esv calculated using the r wave for triggering were . ( . - . ), ( - ) and ( - ) respectively, using the pulse wave . ( . - . ), ( - ) and ( - ) respectively, p= . for ef, p= . for edv and p= . for esv. correlation for ef was . (p= . ), for edv . and for esv . (p = . for both correlations). conclusion: there is a significant number of pts with pacemaker in whom the use of the r wave does not allow to evaluate parameters of the heart function ( . % in our group). we believe that the use of the pulse wave is the only alternative in such pts. quantitative data correlate highly with the data calculated with ecg trigger. the relation between helicobacter pylori infection and cardiac syndrome x;a novel study objectives: cardiac syndrome x (csx) is characterized by an angina pectoris and/or presence of positive none-invasive test (exercise tolerance test or myocardial perfusion scan) accompanied with normal coronary angiogram. several mechanisms such as ischemia, inflammation and endothelial dysfunction have been suggested. this study was carried out to assess the possible role of helicobacter pylori (hp) in this syndrome. methods: hp infection was distinguished by urea breath test (ubt) in patients with csx, and compared with two sex-and age-matched control groups. ubt classified as; negative, intermediate, positive for h. pylori. statistical analysis was carried out using anova and t tests. a p-values of . or less were considered to be significant. results: each group consisted of patients with a mean age of . ± . [sd] years, . ± . years, and . ± . years in csx, cad and healthy control respectively. fifty percent ( ) of csx patients had positive result, while none of two control groups had the same results (p-value= . ). the negative and intermediate results were not statistically significant in three groups. conclusion: with respect to the high occurrence of hp infection and likely contributory effect of inflammation in subjects with csx, potential role of hp infection in the pathogenesis of csx is proposed. however well planned clinical trials are required to validate this initial result. the interpretation of medical images by inexperienced physicians would theoretically be improved with a second opinion of a more experienced colleague or by a decision support system. in the present study we evaluate the performance and interobserver variability between inexperienced as well as experienced physicians and a decision support system regarding classification of myocardial infarction and ischemia. method: seven physicians, all specialists in nuclear medicine but with varying experience, participated and were compared with the care decision support system. each of the physicians interpreted patients with gated myocardial perfusion scintigraphy (mps) first a preliminary interpretation was made without the advice from the decision support system. the image was then processed by the computer and within seconds the physician received the advice from the decision support system and the interpretation and report was finalized. result: the sensitivity regarding interpretation of ischemia increased with % (p< . ) for the whole group with the help of a decision support system, both for inexperienced, % (p< . ) and experienced physicians, % (p= . ). the increase in sensitivity was larger in the anterior and inferior areas of the heart. conclusion: in the present study a second opinion from a decision support system increased the precision of physicians interpreting nuclear images, both for inexperienced as well as experienced physicians. a decision support system based on artificial intelligence is always available and can give advice regarding presence of infarction or reversible ischemia with the same precision as an experienced physician. a new iterative reconstruction algorithm (wbr™) has been recently proposed for cardiac spect. the wbr™ technology, based on accurate modelling of the emission-detection process, was designed to reduce noise improving lesion detectability without affecting the image resolution. few data exist on the comparison between filtered back-projection (fbp) and this new algorithm. aim. the aim of this study was to compare the performance of fbp and wbr™. methods. an antropomorphic phantom was acquired with a dual head@ ° camera, equipped with a lehr collimator. a solution of mtco -was used to fill the different regions of the phantom: mbq for both right ventricles and heart cavity. two different activities were used to fill the heart wall: . mbq (comparable to the activity usually obtained in clinical setting; standard dose) and . mbq (half-dose). a cold lesion was simulated in anterior, septal, posterior, and lateral region with a cubic cm cold disk inserted in the cardiac wall. for each wall activity and the different lesions, two sets of acquisitions were recorded: one at sec/frames (standard time) and one at sec/frame (half time). each spect was reconstructed with conventional fbp (butterworth, . , ) and with wbr™; a circular roi was drawn on the short-axis slice better displaying the lesion. an activity-vs-angular position histogram (circumferential profile) was obtained and the fwhm was calculated for each lesion. results. the average fwhm in half-time/standard dose ( . degrees) and halfdose/standard time ( . degrees) wbr™ spect were comparable to that of standard time/standard dose fbp spect ( . degrees). however, the fwhm in half time/half dose wbr™ spect ( . degrees) was worst than standard time/standard dose fbp spect. conclusions. the new iterative reconstruction algorithm wbr™ compared well in respect to conventional fbp spect, allowing half-time or halfactivity studies. however, further studies are needed to verify the potential clinical application of this method. fanbeam reconstruction using an iterative algorithm including d-collimator modell s o. s. grosser , t. prautzsch , g. ebel , m. seemann , j. ricke ; radiology und nuclear medicine, universitaetsklinikum magdeburg, magdeburg, germany, scivis, goettingen, germany. aim: fanbeam geometry improves resolution and sensitivity imaging small volumes and small field-of-views. reconstruction of volume data from fanbeam projections is usually performed using filtered back-projection algorithm (fbp). this procedure considers the imaging geometry, but attenuation and collimator characteristics are ignored. to improve imaging quality we performed reconstruction using an d-itertiv reconstruction algorithm for fanbeam geometry. the algorithm incorporates the distance and location dependent point spread function of the collimator and attenuation of the object. material and methods: examinations were performed using an e.cam variable (siemens medical solutions) gamma camera with fanbeam collimators. for this system the location dependent point spread function for different distances to the collimator front and for different positions orthogonal to the focus line were estimated. a d-system model is derived. it is used for iterative reconstruction with gma (geometric mean algorithm). we performed spect with a jaszcsak-phantom with different count rates (high/low) and different numbers of projection angles (n= , and ). data were reconstructed using a clinical established fbp including chang's attenuation correction and with an iterative algorithm using a contour based attenuation correction. furthermore the reconstructed data were examined for image quality and artifacts. spect homogeneity and resolution of solid spheres with different diameters were estimated. additionally line profiles, resolution and contrast were examined. results: the visual image quality of gma reconstructed data is significant improved compared to images reconstructed by fbp. in addition iterative reconstructed images show an better signal-noise-ratio snr (gma: . ; fbp: . ; p= . ) and a significant higher contrast in small solid spheres. fbp shows typical extra corporal artefacts. these artefacts are not to notice in images reconstructed with gma. conclusion: utilization of iterative fanbeam reconstruction including a d-collimator model results compared to standard fbp to an improved image quality, significant higher snr and an increased contrast. using the iterative algorithm is connected with an acceptable time involved. the main obstacle of fbp is the noise otherwise it is the best technique of tomographic reconstruction. determining the best filter and the proper degree of smoothing can help to ensure the most accurate diagnosis. unfortunately there have been significant discrepancies in selection of proper filter and adjustment of the filter parameters to individual cases. the purpose of this study was to define an optimal parameter for the tomographic reconstruction procedure in routine single photon emission tomography (spect) studies. in this study hoffman brain phantom is modified in such a way that only software capability is evaluated. the phantom is composed of several independent slice that can be imaged individually (planar) or in -d composition (spect). method and materials: the designed phantom was filled with water containing mtc. dual head mediso gamma camera spect system, equipped lehr and legp parallel hole collimators was used. energy window was set at ± % of photo peak. planar image of the slices were acquired separately at - cm from the collimator face collecting counts. tomographic image was performed using the phantom in d position. a total of projection images with × matrix were acquired over °. the time per view was and sec. planar images were used as reference ideal image for each corresponding reconstructed slice images. all the spect images were reconstructed using different filtering conditions. the quality of reconstructed images was evaluated by comparing the reconstructed images with the reference image using the universal image quality index (uiqi). results: at all count density no significant difference observed between metz and wiener (), however the difference between these two and other filters was quite significant (p< . ). the optimum filtering condition was significantly related to the count density (signal to noise ration) of the data. the results of this study are summarized the tabel- . finally, all of the acquisition studies regardless of counts or collimator, that the mean of uiqi was the most for wiener filter in comparison with the other filters. discussion: the data from this study suggests that the hanning and hamming are the weakest of the seven filter types tested. this is due to response of hanning and hamming filters at the low frequencies. based on the results of this study, wiener filter provided best image quality. aim: gated myocardial perfusion scintigraphy is an efficient tool to simultaneously assess myocardial perfusion, wall motion, left ventricular volumes and ejection fraction (lvef). filtered back projection (fbp) is often used for tomographic reconstruction, as this method can efficiently determine the transaxial slices. in a previous study we have investigated the effects of the applied smoothing filters on the measured volumes and ejection fractions. it turned out that the smaller volumes were underestimated, also resulting in an overestimation of the lvef for small hearts. iterative reconstruction techniques like osem perform better in low signal-to-noise ratio studies. so, we can apply filters with a higher cut-off frequency, which in turn may result in better estimates of the smaller volumes. in this study we have investigated the differences in measured volumes after fbp and osem reconstruction. methods: studies (ex/re) from patients were selected. all studies were reconstructed with fbp using an order butterworth filter with fixed cut-off frequency equal to . . the first studies were also reconstructed using osem. by increasing the cut-off frequency of the filter from . to . , a single frequency for all studies was selected above which the lvef was not changing anymore. in a former study this method was also applied to select the optimum cut-off frequency for fbp reconstructed studies. next all studies were reconstructed using both, fbp and osem, each method with their optimum cut-off frequency. a standard software package (germano) was used to determine the left ventricular volumes. fbp and osem results were compared on a study by study basis. results: the optimum cutoff frequency for osem turned out to be equal to . ( . for fbp). the comparisons of the volume measurements as well as the lvef are shown in the table. a good correlation was found between the two reconstruction methods. both, esv and edv volumes determined after osem turned out to be somewhat larger than those calculated from the fbp reconstructed studies, especially for the smaller lv volumes. lvef in turn, was found to be lower for osem compared to fbp with differences ranging from - % to + %. aim: erdheim-chester disease (ecd) is a rare multisystem, non-langerhans form of histiocytosis of unknown origin. it involves multiple organs and typically causes symmetrical osteosclerosis of the long bones. we describe patients with histologically proven ecd whose pet/ct showed vascular lesions. materiel and methods: case is a -year-old man operated for aortic regurgitation with a bicuspid aortic valve. spumous histiocytes were found in samples collected during surgery. a thoraco-abdominal ct showed an infiltration of main thoracic and abdominal arteries, and a perisplenic and perirenal fibrosis. bone scintigraphy showed symmetrical increased uptake of the long bones. case is a -year-old woman who had a history of weight loss and a severe biologic inflammation. a thoraco-abdominal ct scan revealed infiltration of the mediastinum, subrenal abdominal aorta and the superior mesenteric artery. bone scintigraphy did not reveal any abnormalities. the patients underwent a f-fdg pet/ct for evaluation of the extent of the disease. results: case : fdg pet imaging showed a marked hypermetabolism within the vascular lesions seen on the ct scan, with a more important fdg activity on the thoracic vascular lesions. there was no abnormal fdg uptake on the long bones. on the other hand, increased fdg uptake was observed on two dorsal vertebrae which was proved to be an extra-medullary meningioma. pet imaging failed to depict perirenal and perisplenic fibrosis. case : fdg pet showed only hypermetabolic foci: one on the level of the left pulmonary artery and the others of the superior mesenteric artery and the subrenal abdominal aorta. there was no abnormal fdg uptake on the skeleton. conclusion: fdg pet can detect extra skeletal lesions such as vascular involvement. in our cases, skeletal lesions were not depicted. this could be explained by effective treatment, since fdg pet was performed under chemotherapy. in ecd, fdg pet may be used for evaluation of the extent of the disease and the assessment of the response to therapy, but more further studies are needed. the prevalence of coronary steal in dipyridamoleinduced myocardial perfusion scintigraphy: the philippine heart center experience r. b. matias; philippine heart center, quezon city, philippines. to determine the prevalence of coronary steal in patients undergoing dipyridamoleinduced myocardial perfusion scan (mps) in the nuclear medicine division of phc to identify the subsequent mps abnormality in patients who developed coronary steal during dipyridamole induction. to determine if there is an association between mps abnormality and coronary steal. coronary steal is caused by redistribution of flow away from collateral-dependent myocardium following coronary vasodilatation. although coronary steal has been well described in canine studies, there are more limited observations of the absolute magnitude of coronary steal in humans and its relationship to clinical signs of myocardial ischemia. there is controversy whether chest pain and ecg changes with coronary vasodilation represent true myocardial ischemia because of coronary steal. dipyridamole (dipy) is often used as an alternative to exercise in the detection of coronary artery disease by radionuclide techniques that produce selective vasodilatation of normal coronary arteries, predominantly in the small, resistance vessels of the coronary bed. method: patients from january , to december , who developed chest pain with respective ecg changes after induction of dipy during mps procedure were included in the study. ecg changes include st segment depression or elevation of > mv in or more leads. perfusion abnormalities include evidence of inducible ischemia (mild, moderate or severe), fibrosis or scar and infarcts. normal perfusion scan pertains to those with no definite evidence of ischemia and defects which are due to soft tissue attenuation. a. hughes; royal preston hospital, preston, united kingdom. aim gated spect is a well established technique that allows simultaneous assessment of the perfusion and function of the left ventricle (lv). both global and regional lv function can be assessed using this technique and analysis of regional wall motion and thickening can help to identify viable myocardium and eliminate attenuation artefacts. most centres use an acquisition protocol that divides the cardiac cycle into frames. temporal resolution can be improved by using frames per cycle, but there will be a loss in the signal-to-noise ratio if the duration of the study is not increased. the aim of this study was to compare regional wall motion and thickening scores derived from gated spect using and frames per cycle. thirty-four female patients with normal perfusion and function were imaged on a philips forte jetstream gamma camera. gated datasets with and frames per cycle were acquired simultaneously one hour after treadmill exercise. all data were filtered using a -dimensional butterworth filter and reconstructed using filtered backprojection. regional wall motion and thickening scores were computed for a -segment model of the lv using the cedars-sinai qgs software. results wall thickening scores for the -frame datasets were consistently higher by - % throughout the myocardium. additionally, there was a significant increase in circumferential variation in thickening in the mid and distal portions of the lv, with the anterior and antero-lateral segments exhibiting the largest differences. wall motion scores were ~ % higher for the -frame data except in the septal wall, where the scores were comparable. comparing motion and thickening scores of patients with known functional defects with data from the normal patient group did not reveal an increased sensitivity of one technique over the other. conclusion the acquisition and processing of gated spect studies using frames per cycle is feasible on modern imaging systems. although there is an increase in temporal resolution over data acquired using frames per cycle, resulting in differences to the normal ranges, there does not appear to be an improvement in the detection of functional abnormalities. aim: brain natriuretic peptide (bnp) is a neuro-hormone representing a marker of heart impairment. female patients undergoing radiotherapy for left breast cancer may develop cardiac impairment. to evaluate this potential heart damage, bnp was measured in women treated by left breast radiotherapy. methods: twenty-four women with left breast carcinoma undergoing breast conservative surgery and radiotherapy (single dose gy; total dose gy followed by boost of gy on tumour bed) underwent bnp measurement, echocardiography and electrocardiogram at baseline ( week before treatment) and ( nd evaluation), ( rd evaluation) and ( th evaluation) months after radiotherapy. four patients were also evaluated months after radiotherapy, because the study is still in progress. aim: the aim of the study was to compare lv dyssynchrony assessment by gated myocardial perfusion spect (gmps) and tissue doppler imaging (tdi). background: recently, it has been demonstrated that left ventricular (lv) dyssynchrony is an important predictor of response to cardiac resynchronization therapy (crt); dyssynchrony is predominantly assessed by tdi with echocardiography. information on lv dyssynchrony can also be provided by gmps with phase analysis of regional lv maximal count changes throughout the cardiac cycle which tracks the onset of lv thickening. methods: in patients with heart failure, depressed lv function and wide qrs complex, gmps and d echocardiography, including tdi, were performed as part of clinical screening for eligibility for crt. clinical status was evaluated using nyha classification, -minute walk distance and quality-of-life score. different parameters (histogram bandwidth, phase standard deviation (sd), histogram skewness and histogram kurtosis) of lv dyssynchrony were assessed from gmps and compared with lv dyssynchrony on tdi using pearson's correlation analyses. results: histogram bandwidth and phase sd correlated well with lv dyssynchrony assessed with tdi (r= . , p< . and r= . , p< . respectively). histogram skewness and kurtosis correlated less well with lv dyssynchrony on tdi (r=- . , p< . and r=- . , p< . respectively). conclusion: lv dyssynchrony assessed from gmps correlated well with dyssynchrony assessed by tdi; histogram bandwidth and phase sd showed the best correlation with lv dyssynchrony on tdi. these parameters appear most optimal for assessment of lv dyssynchrony with gmps. outcome studies after crt are needed to further validate the use of gmps for assessment of lv dyssynchrony. aim. using radionuclide methods to study the correlation between the disturbances of central hemodynamics and the renal functional activity in patients with heart failure. material and methods. thirty seven patients (median age was , ± , years) with coronary artery disease (cad) and heart failure (hf) of nyha class ii or iii were examined using radionuclide renoscintigraphy and radiocardiopulmonography. parameters of cardio-pulmonary hemodynamics and renal function were estimated. results. we observed the damage of most of cardio-pulmonary hemodynamics parameters in all patients. that indicated the reduction of contractive activity of the left and right heart ventricles with pulmonary hypertension development. the disturbances of renal function were note in % of pts with hf and included the decrease of glomerular filtration rate and/or the increase of parenchymal clearance of mtc-dtpa. using multiple linear regression analysis significant positive correlations were detected of the damages of renal filtration and evacuatory parameters with the decrease of cardiac minute volume, cardiac index and efficiency factor of circulation. therefore the decrease of cardiac output is one of the basic factors of renal dysfunction pathogenesis in patients with hf. furthermore were detected significant negative correlations between the disturbance of pulmonary circulation and the decrease of glomerular filtration rate. conclusion. the radionuclide methods are available for the evaluation of influence of hemodynamics disturbances on renal function in pts with hf. aim to explain our experience with gbps, the obtained measurements of right and left ventricular ejection fraction (rvef and lvef) from gbps and corresponding values determined by equilibrium imaging, due to erv is the standard technique used to evaluate ejection fraction. to assess the reproducibility and reliability, the advantages and limitations of both thechniques. materials and methods patients underwent gbps and erv. there were females and males, with a range age between to years, who had risk of cardiotoxicity induced by chemotherapy (this is the most frequent indication to evaluate fvef), except the younger patient, who presented congenital cardiopathy, and the two older men, who presented cardiac failure. imaging was performed min after administration of mbq m tclabelled blood cells, acquiring spect with ecg gating. next a planar image was acquired, about min after injection. the data were processed using qube algorithm on a segami workstation by a physician specialist in nuclear medicine and processed again to assess intraobserver reproducibility. a second operator reconstructed and processed the same studies, to assess interobserver reproducibility. bland-altman analysis was applied. results the mean of lvef's values obtained with gbps was . , versus . from erv. for rvef was . with gbps and . with erv. the intraobserver reproducibility of lvef and rvef was higher for erv than gbps in both observers (in the best of cases, the limits of agreement ± sd calculated using bland-altman analysis were - . ± . for gbps vs. . ± . for erv from lvef, and . ± . for gbps vs. . ± . for erv from rvef). the interobserver reproducibility presented less differences between both techniques. lvef and rvef obtained from gbps were compared with those from erv using bland-altman analysis. the mean difference was . with ds . from lvef and - . with ds . from rvef. processing of data obtained with erv for rvef was unsuccessful in patients, in this cases gbps was very useful to estimate rvef. conclusions gbps presented a intra-inter-observer reproducibility slightly lower than erv. this technique provides values of lvef higher than erv (approximately %), but rvef's values were very similar to obtained with erv. in cases that rvef is especially difficult to estimate with erv, gbps is very usefull. aim: the aim of the study was to identify myocardial viability by mtc-tetrofosmine (rest and nitrate) in patients with ischemic left ventricular aneurysm. material and methods: the study involved patients (men) aged - with stable angina of the ii-iv nyha classes, chronic left ventricular aneurysm, all of them had a history of - previous transmural myocardial infarction. all patients before operation were underwent mtc-tetrofosmine myocardial spect according to protocol "nitrate-test ( mg of sublingual isosorbide dinitrate) -rest". all patients underwent coronary artery bypass surgery (abs) and aneurysmectomy by dore. after operation patients in weeks were underwent mtc-tetrofosmine myocardial spect only rest. analyse was performed by dividing the left ventricle into segments for spect. result: segments of left ventricle were analyzed on mtc-tetrofosmine spect. after mtc-tetrofosmine nitrate-test the amount of aperfusion sectors decreased in % in comparison with rest. after the surgery, we found that the amount of aperfusion segments was %; the amount of normal perfusion segments was %. we analyzed perfusion scans and myocardium segments for assessment size of the perfusion defect. average the perfusion defect before operation in mtc-tetrofosmine spect rest was . ± . %. after mtc-tetrofosmine nitrate-test it decreased to , ± , % (p< . ). after the surgery it was . ± . %. we found significant difference in intensity of accumulation mtc-tetrofosmine in the perfusion defect on rest and nitrate-test (p< . ). conclusions: mtc-tetrofosmine spect by protocol rest -nitrate -rest is useful techniques for the identification of viable myocardium and to predict functional recovery after revascularisation in patients with ischemic left ventricular aneurysm. diagnostic value of gated spect myocardial perfusion imaging using thallium- in patients with latent coronary artery disease h. shi, y. gu, w. liu, w. zhu; zhongshan hospital, fudan university, shanghai, china. aims: to investigate the diagnostic value of spect myocardial perfusion imaging using thallium- for the patient likelihood of latent coronary artery disease. materials and methods: fifty-two asymptomatic aircrews with positive results of exercise treadmill test underwent dipyridamole pharmaceutical stress and rest spect myocardial perfusion imaging using thallium- . patients with myocardial perfusion imaging positive findings accepted coronary artery angiography. patients with myocardial perfusion imaging negative findings were followed up till five years. results: twenty-four patients showed positive results in myocardial perfusion imaging and twenty two of them detected coronary artery stenoses with more than % luminal narrowing by coronary artery angiography and two of them were negative results in coronary artery angiography. twenty eight patients showed normal in myocardial perfusion imaging and no cardiac events happened in the following five years after myocardial perfusion imaging performed. conclusion: spect myocardial perfusion imaging using thallium- is very useful method for detecting latent coronary artery disease, especially for negative predictive value. and its diagnostic accuracy is much higher than exercise treadmill test. association of left ventricular functional parameters measured by gated single photon emission tomography and by two-dimensional echocardiography c. groselj, , b. simonic, , b. groselj, ; university medical center, ljubljana, slovenia, medical faculty, ljubljana, slovenia. introduction lvef, edv and esv are good clinical indicators of left ventricular function and volumes, routinely measured by echocardiography (echoc). in former decade the emory cardiac tool box (ectb) was developed, a toll for assessing left ventricular function and volumes from gated spect myocardial perfusion scintigraphy (gspect). gspect myocardial function assessment provides an important incremental information. aim of the study the aim of the present study was to validate the accuracy of the ectb in assessing lvef, edv and esv from gspect using echoc as a reference values. patients and methods consecutive patients, males and females; mean age +/- y, range - y, with suspected or known coronary artery disease were examined using mtc-mibi gspect ( gates/cardiac cycle) min after tracer injection at stress. the gspet data were reconstructed using an automatic algorithm employing filtered back projection (fbp) and further analyzed by emory cardiac (ec) toolbox. all patients underwent two-dimensional ( d) m-mode echoc in the same diagnostic evaluation. the results of both methods were compared. aim to determine if an average residual activity could be assumed for stress and rest myoview administrations. method an audit of residual activity in the syringe following myoview administrations for myocardial perfusion imaging was conducted at guy's and st thomas' (gstt) and the royal free hospital (rfh). residual activities for both stress and rest administrations were measured. myoview was administered using ml terumo syringes and ml braun injekt syringes at gstt, and ml bd luer-lok syringes and a y-tap extension set at rfh. stress activities were administered via a -way tap (gstt) and y-tap extension set (rfh). rest activities were directly injected into a vein. results at gstt residuals for rest studies and residuals for stress studies were collected using terumo syringes. residuals for stress studies were collected during a trial of braun injekt syringes. at the rfh residuals for stress studies and residuals for rest studies were collected. the residual activities from gstt, using the terumo and injekt syringes follow a normal distribution for both stress and rest administrations, and there was no dependence of residual activity on time of injection. there was a statistically significant difference in residuals between technologists for stress injections but not rest injections. the mean stress residual using terumo syringes ( . mbq), is significantly higher (p = < . ) than the mean rest residual of . mbq. the mean stress residual for braun injekt syringes of . mbq was significantly lower than the mean for terumo syringes of . mbq (p=< . ). the mean stress residual using the y-tap extension of . mbq was significantly lower than the stress administration with terumo syringes (p= . ). there was no significant difference between the rest and stress residual activities at the rfh (p= . ). conclusion: the significant difference between stress and rest residual activities was attributed to increased difficulty flushing the syringe during the stressing procedure, compared to direct injection. the significant difference between the stress residuals using the terumo and y-tap extension set but not between the rest residuals demonstrates that the stressing method using a y-tap extension reduces the residual activity and is not due to technologist working practices. due to the overall large variation of residuals assuming a single average residual activity may not be good practice. however, residual activities were significantly reduced using the injekt syringes and the y-tap extension set. using injekt syringes would reduce the residual of rest injections as well as stress injections. the value of radionuclide methods in patients with suspicious chronic myocarditis. , -complained about chest pain and dyspnea, had myocardial conduction disorders. echocardiography showed abnormalities at patients: hypokinesia (total or local) at al cases, mitral valve prolapse -in cases. abnormalities of laboratory indexes were found at patients (increasing of erythrocyte sedimentation rate, levels of ast and kfk). all patients underwent spect with mtc-hmpao-leucocytes at hours post injection, following by gated-spect with mtc-mibi at the rest condition. both scintigrams were then combined, using fusion display application, to define more exactly the localization of mtc-hmpao-leucocytes uptake in the heart. the presence, character and magnitude of perfusion defects, ejection fraction (ef) of left ventricle (lv), motion and thickening extent were also estimated. results: perfusion defects were detected at cases, with average size - , ± , % (max - %), which localized in ventricular septum, anterior or inferior wall of the lv. ( ). the viability of labelled stem cells was tested by flow cytometry with propidium iodure (facscan® becton dickinson™). the proliferation capacity was tested by cell culture on specific media (rpmi-based cell media). after determination of optimal dose, we made an intramyocardial injection of labelled stem cells on a healthy rabbit. a spect scintigraphy was then performed with static acquisitions at and h after injection. results: the labelling efficiency was good for all samples with an average rate of % ( - %). the viability was . % of living cells (no significant difference with control groups). the labelling with . mbq did not interfere on the proliferation whereas the higher activities, . or . mbq, stopped proliferation. the lowest dose does not disturb the viability and proliferation of stem cells and allows spect scintigraphy until at least h after intramyocardial injection of labelled stem cells on animal. conclusion: the labelling of rabbit bone marrow stem cells was successfully performed with indium- oxine. thus, we can follow stem cell therapy by spect scintigraphy without affecting cell viability or proliferation. the usefulness of an f-fdg pet/ct image obtained at hours after intravenous f-fdg injection in detecting aortic f-fdg uptake compared to that obtained at hour after injection aim: atherosclerosis is an immune inflammatory disease. increased macrophage metabolism is seen in active atherosclerotic plaque inflammation. f-fdg concentrates in those lesions and many studies have reported clinically and experimentally regarding the f-fdg images of atherosclerotic plaque inflammation. most of the studies used pet or pet/ct images obtained at about hour after intravenous f-fdg injection (as an early image), but to our knowledge there have been no reports using pet or pet/ct images obtained at hours after injection (as a delayed image). therefore we investigated the usefulness of the delayed pet/ct images in detecting aortic f-fdg uptake comparing with the early images. forty-one patients were participated in this study who were referred for tumor staging or seeking recurrence or metastatic lesions using fdg-pet/ct. we reviewed the early and delayed images visually for the presence of aortic f-fdg uptake. aortic f-fdg uptake was evaluated visually by dividing into the following sections: ( ) ascending aorta, ( ) aortic arch, ( ) thoracic descending aorta, ( ) upper abdominal aorta and ( ) lower abdominal aorta. we also examined the degree of aortic blood-pool f-fdg activity. results: the delayed image showed decreased blood-pool f-fdg activity in all lesions of the aorta. the number of aortic f-fdg uptake seen in the early image, the number of uptakes seen in the delayed image and the number of obtained clear visualizations in the delayed image of each section were as follows: ( ); , and , ( ) ; , and , ( ); , and , ( ); , and , ( ); , and , respectively. conclusion: this presentation illustrates the change in the aortic f-fdg uptake over time and the usefulness of delayed pet/ct images. about half of the aortic f-fdg uptake lesions in the delayed image showed clear visualization compared to the early image. the reasons were thought to be not only decreasing the blood-pool f-fdg activity but also increasing the aortic f-fdg uptake itself in the delayed image. aim: to measure the equivalent doses of radiation to medical staff performing nh myocardial perfusion pet scan. methods: the study was conducted in during pet examinations. nine examinations were performed on patients with severe ischaemic heart disease and consisted of two pet scans (one rest and one dipyridamole pharmacological stress scan), and eight examinations were performed on asymptomatic hiv patients and consisted of three pet scans (one rest, one cold pressor stress and one dipyridamole pharmacological stress scan). an electronic dosimeter was placed on the chest, and highly sensitive thermoluminescent dosimeters (tld) were placed on the right index finger and the right wrist of the two technologists and the physician, performing the examinations. when examinations consisted of two scans ( s), the primary technologist (t ) withdrew nh from the production facility and performed injection of the tracer into the patient. the second technologist (t ) nursed and observed the patient during the whole scan, and the physician (p) monitored and observed the patient during the pharmacologic stress. when examinations consisted of three scans ( s), the roles were the same, but the physician additionally held the left leg of the patient in ºc water and coached the patient through the cold pressor testing. results: when performing two scans, the mean equivalent doses to the index finger were μsv, μsv and μsv, and the mean equivalent doses to the wrist were μsv, μsv and μsv for t , t and p respectively. when performing three scans, the mean equivalent doses to the index finger were μsv, μsv and μsv, and the mean equivalent doses to the wrist were μsv, μsv and μsv for t , t and p respectively. the mean equivalent doses to the chest when performing two scans measured by electronic dosimeter were ± . μsv for t (p= . vs. s and p< . vs. b and p), ± . μsv for t (p= . vs. p) and ± . μsv for p and when performing three scans, ± . μsv, ± . μsv and ± . μsv for t , t and p respectively. conclusion: mean equivalent dose is less than ‰ of the current one year dose limit for the most exposed member of the medical staff when performing a myocardial perfusion examination with three nh pet scans. equivalent dose is dependant on work function and scan regimen as well as patient morbidity. the role of f -fdg pet in the diagnosis of large vessel vasculitis purpose: physiological accumulation of fdg into salivary glands often causes false positive findings in diagnosing head and neck lesions. it has been reported that some amount of radioactivity were excreted into saliva, therefore gargling before pet scanning has been investigated for improving the image quality in this region, however the actual efficacy of it is still unknown. in this study, we assessed the efficacy of lemon stimulation for encourage secretion of radioactivity in saliva to obtain images with higher quality. methods and materials: thirty normal subjects were examined fdg pet before and after lemon stimulus. region of interests of salivary glands, oral cavity and soft tissue were determined according to anatomical margins of them using fusion image with ct, and suvs were measured. radioactivities in saliva before and after lemon stimulation were also measured by a curiemeter. results: the suvs of salivary glands were shown in table ( pg: parotid gland, smg: submandibular gland, slg: sublingual gland ). there were no significant differences between before and after lemon stimulation. in addition, radioactivity in saliva after lemon stimulation was . +/- . microci in ml of gargling water which was as low level of radioactivity as that of background ( . +/- . microci/ml). conclusions: although low level of radioactivity was present in saliva after injection of fdg, excretion of it was not influenced by lemon stimulation in normal subjects. therefore, alternative imaging methods need to be developed for reduction of physiological accumulation of fdg into salivary glands and for improving image quality in the area of oral cavity. aim. diffusion weighted mr imaging is a technique allowing to grade non-invasively the tumour cellularity, basing on the principle that molecules in living tissues routinely undergo random (brownian) motion. adc (apparent diffusion coefficient) is a value describing microscopic water diffusibility in presence of factors restricting diffusion within tissue (cell membranes, viscosity). our aim was to investigate the existence of a relationship between metabolic activity as measured by fdg pet and water diffusivity as evaluated by apparent diffusion coefficients (adc) in brain tumours. methods. gadolinium-enhanced fast spoiled gradient echo (gd-fspgr), diffusion weighted magnetic resonance imaging (dwi) with adc maps and fdg pet were performed in patients ( glioblastoma multiforme, astrocytoma, brain metastases) with tumour lesions. adc and fdg pet images were coregistered with enhanced fspgr images to identify tumour sites. spherical d tumour and contralateral control region of interest (rois) of the same geometric parameters were drawn on fspgr, adc and pet images, using gd-fspgr as target for statistical parametric mapping with fused localization of adc and pet (by using mricro). pet and adc ratios of the tumour and control roi were obtained and linear regression analysis was carried out. results. a significant correlation was not shown between pet and adc ratios in all lesions studied; plotting ratios, if pet values were greater than . , adc data were below , while if adc indices were greater than , pet ratios were below . . a significant correlation (r = . , p = . ) was found between pet and adc findings in lesions, having pet and adc ratios lower than . conclusions. our data, although preliminary, show that a relationship might exist if pet and adc present low ratios. this could be due to the fact that in high cellularity areas, structures and cell membranes could increase impedence to water diffusion, causing decreased adc values and increased fdg uptake, while areas with low cellularity, i.e. necrotic areas, present increased adc and reduced fdg uptake. aim: according to literature, f-fluoroethyl-l-tyrosine (fet) was found to be a new valuable pet tracer to image brain tumors. particularly, fet uptake was higher in recurrent gliomas than in radiation injuries, whereas ct and mri showed a limited specificity in differentiating between post-therapeutic unspecific changes and neoplastic lesions. in this study we evaluated the contribution of fet pet/ct in the diagnosis of tumor recurrence in patients with gliomas undergoing multimodal treatment or radiosurgery. methods: the study included patients with glioma (primary grading: =who grade iv, = grade iii, = grade ii) who showed neuroradiological findings suspected for tumor relapse after multimodal treatment ( patients) and gliasite radiation therapy using radioactive iodine -i-iotrex ( patients). brain pet/ct scans (discovery ls pet/ct scanner, ge healthcare, milwaukee, wi, usa) were performed min after injection of - mbq of ffluoroethyl-l-tyrosine (iason labormedizin gesmbh & co. kg graz-seisberg, austria) using d mode acquisitions in / cases and d acquisitions in / the fet uptake in the most active part of the lesion was quantified by the standardized uptake value (suvmax) and lesion-to-brain ratio (suvmax/bg). brain lesions with a suvmax/bg of at least . were interpreted as probable recurrent disease. previously undergone breast cancer surgery and sentinel node biopsy and, when indicated, axilla lymphadenectomy, were enrolled. a sct scan was already performed in these patients when they came to our institution for pet/ct scanning. we compared sites and number of sct-diagnosed relapses with pet/ct results. results. in / patients (pts) ( %) sct scanning showed relapses not observed by pet/ct; in of these pts metastases observed in sct scans were located in liver or lungs. in other pts metastases sites were axillary or mediastinal lymph node chains. in / pts ( %) pet/ct results were coparable to sct ones. / pts ( %) had negative sct scanning, while pet/ct revealed widespread bone or lymph nodes metastases. finally in / pts ( %) pet scans showed unclear meaning high metabolic activity bone and lymph nodes areas; while in the same pts sct imaging revealed different sites of relapses as in lungs. conclusion. pet/ct seems to have higher sensitivity and positive predictive value than sct in detecting lymph node and bone relapses; sct appears more reliable than pet/ct to reveal lung or liver metastases. comparison of m aim. breast carcinoma express the na+/i-symporter and may -albeit not a routine procedure -be imaged with iodide ( i) and mtechnetium-pertechnetate ( mtco -) scintigraphy. objective of our prospective study was the comparison of mtco --and i-spect with fdg-pet in patients suspicious for breast cancer. methods and patients. twenty-nine untreated patients suspicious for breast carcinoma were prospectively examined with thorax spect with mtco -(n= ) or i (n= ), respectively, and fdg-pet (n= ) prior to biopsy. tumor-to-background ratios (tbr) were calculated for spect findings. mean and maximum suv were calculated for pet findings. findings were compared in an intra-individual lesion-tolesion analysis. results. in / patients, malignancy was verified with histopathology. in imaging the primary tumor, sensitivities of mtco --spect, i-spect and fdg-pet were %, % and %, respectively. tbr mean was . ± . in mtco --spect and . ± . in i-spect. in fdg-pet, mean tumor suv was . ± and maximum tumor suv was . ± . . in contrast to fdg-pet, mtco --spect was not sufficient in imaging nodal and distant metastases in the thorax, and i-spect failed in imaging lymph node infiltrations. distant metastases were not present in patients of the i group, and the value of i-spect was not evaluated. conclusion. in contrast to fdg-pet, mtco --and i-spect are not sufficient in imaging breast carcinoma in clinical practice. showed an overall accuracy of %, with sensitivity and specificity of % and % respectively. conversely, dual-time point pet-ct showed an overall accuracy of %, for lesions with an suvmax . and/or with a positive suvmax, with sensitivity and specificity of % and %, respectively vs %, % (both, p< . ) and % (p=n.s.) of single-time point pet-ct. in addition, on pet-ct, malignant lesions showed an increase in fdg uptake between time point and , with a %suv of ± . conversely, benign lesions showed either no change or a decrease in suvmax between time point and , with a % suv max of ± (p < . ). discussion. mri shows higher sensitivity compared to pet-ct in disclosing breast malignancy. dual-time point improves pet-ct accuracy in patients with suspicious breast malignancy over single point pet-ct. on pet-ct examination there is increasing uptake of fdg over time in breast tumor, conversely, benign lesions show a decrease in fdg uptake over time. these changes in suvs over time might be considered a reliable parameter that can be used to differentiate benign from malignant lesions of the breast, on pet-ct examination. aim : to evaluate the significance of early and late delayed image in the lesion that suv is over . . material and methods : cases suspected malignancy obtained three-phase ( ± min, ± , ± after fdg injection) pet/ct scan. the maximum suv value in three phase were recorded as suv ,suv ,suv . retention index of each lesion in two delayed phase were calculated according to the following formula: ri =(suv -suv )/suv * %.ri =(suv -suv )/suv * %. the diagnostic value of two delayed images was compared through roc curve. the most proper cut-off value of ri in two different delayed phases was established. results : / lesions were malignancy, / lesions were benign, that were proven by pathology, clinical, laboratory and radiological examination. suv in each lesion was over . . ri ,ri in malignancy were . %± . %, . %± . %, the correlation coefficient was . (p= . ). ri ,ri in benign lesion were . %± . %, . %± . %, the correlation coefficient was . (p= . ). through analysis of roc curve, the area under roc curve in early delayed image was . ± . (null hypothesis: true area = . , p< . ), when ri = %, the maximum youden's index was . , the diagnostic sensitivity, specificity and accuracy was . %, . %, . %. the area under roc curve in late delayed image was . ± . (null hypothesis: true area = . ,p> . ), that suggest late delayed image has no diagnostic value. conclusions : the retention index of two delayed phase in benign and malignant lesion have good relativity. the diagnostic value of early delayed image is higher than late delayed image. when ri was % in early delayed image, it has maximum diagnostic efficiency. the aim of the study is to evaluate the use of pet-ct for detection of mediastinal lymph node (mln) metastases from preoperatory staging of non small cell lung cancer in order to avoid mediastinoscopy before surgery. material and method we studied patients (p), out of them were women, between - years old (medium of years). we used a ge discovery ls equipment to realize the pet-ct studies after the administration of mbq of f-fdg and multislide ct without iv contrast. we analized histologically the primary tumour and mediastinal lymph nodes in all patients by means of mediastinoscopy or thoracotomy. we determined tumour staging and the standard uptake value (suv) of the tumour and mediastinal lymph nodes with activity above vascular pool. results primary tumour location: hilium p, right lower lobe p, left lower lobe , lingula p, medium lobe p, right upper lobe and left upper lobe . hystological analyse of primary tumour: adenoesquamous carcinoma p, adenocarcinoma p, large cell carcinoma p , bronchioloalveolar p and others p. differentiation grades: indiferentiated , %, low , %, moderate %, high , % and non valuable %. suv t = , ( - , ) ; suv t = , ( - ); suv t = , ( - ); suv t = , ( - ). staging: ia p; ib p; iia p; s iib p; iiia p, iiib p and iv p. detection of mediastinal metastases: sensitivity: . , specificity: . , ppv: . ; npv: . and diagnostic accuracy: . . the false-positive pet-ct scan were carcinoma abcessed, fibrohistiocitosis and inespecific adenitis . false negative scan in p with subcarinal mediastinal station afectation milimetric nodal size. the hight npv of pet-ct can avoid mediastinoscopy. but it must be considered that a positive or negative pet-ct does not assess or exclude malignancy in mediastinal nodes. aim: pet is a useful technique in the staging of non small-cell lung cancer (nsclc). although there is a wide experience with fdg-pet and ct, the introduction of pet/ct deserves to investigate its role in the context of diagnostic ct as a routine technique for nsclc staging. the aim of this study was to compare the contribution of fdg-pet/ct and diagnostic ct in the staging of nsclc. material and methods: sixty-six patients with nsclc, male and female were studied, (average age of years). all patients underwent a fdg-pet/ct and a ct, in -month interval. the findings of both techniques were compared, and the final diagnosis was made by histological findings, clinical follow up, and response to therapy. results: fdg-pet/ct and ct findings were concordant in of the patients ( %). in of them, the same lesions were identified. in of the patients ( %), the results disagreed. thus, in of the discordant patients ( %), the fdg-pet/ct showed a greater involvement than ct, related to the extension of lymph node involvement in patients ( false positives) and to the number of metastasis in ( false positives). in of the discordant patients, the fdg-pet/ct showed a smaller involvement than ct: less lymph nodes in ( %) and less metastasis in ( %). therefore, in / patients fdg-pet/ct and ct showed differences in location of the involved lymph node region. staging was modified by fdg-pet/ct in / ( %): it was increased in ( %) ( false positives) and diminished in ( %). in patients ( %), fdg-pet/ct modified the therapeutic setting, avoiding surgery in ( %), discarding adrenal metastasis in ( . %), and diminishing the lymph node extension in ( , %) patients. objective: diffusion-weighted mri is known to provide images seemingly similar to those of fdg-pet. in the present study, we examined and compared lung cancer cases using fdg-pet/ct and dwibs (diffusion-weighted mri) on the same day. [subjects] we examined lesions that were confirmed to be lung cancer with lymph node metastasis based on biopsies in addition to one pulmonary hamartoma lesion in patients who underwent follow-ups longer than months. the mean lesion size was . ± . mm (range: - mm). materials and methods: after -hour fasting, fdg was intravenously injected at a dose of . mbq/kg and then its distribution was analyzed using discovery st elite system (ge) one hour later. dwibs was performed to the consented patients, immediately prior to pet analysis, by taking images (slice thickness = mm, b-factor = ) with a single shot epi method using a -ch body array coil with signa excite . t (ge). both images were visually evaluated. the tracer accumulation in the liver and the signals in the spinal cord were considered to be positive for pet, dwibs, respectively. results: twenty ( . %) of the malignant lesions were positive on fdg-pet/ct, whereas lesions ( . %) were positive on dwibs. there were no significant differences between the two modalities (p = . ). the benign pulmonary hamartoma was negative on pet, but positive on dwibs. pulmonary adenocarcinoma ( . mm) in the right upper lobe showed false-negative findings on pet, but ct scanning of this node indicated suspicious pulmonary adenocarcinoma. in addition, left pulmonary hilar lymph node metastasis ( mm) associated with left upper lobe cancer and pulmonary adenocarcinoma ( mm) in the right upper lobe showed false-negative findings on dwibs. conclusion: both pet and dwibs detected malignant lesions almost the same level. however, dwibs is less efficient in differentiating malignant lesions from benign lesions because dwibs showed benign lesions such as pulmonary hamartoma as positive. by-lesion analysis. the vertebrae were the most frequently involved bones ( / = . %), followed by ribs ( / = . %), and pelvic bones ( / = . %). suv values of the metastatic foci range from . to . (mean . ; median . ). the ct patterns were classified into four groups: osteolytic ( / = . %); osteoblastic ( / = . %), mixed ( / = . %) and invisible type ( / = . %). osteolytic and invisible skeletal metastases showed higher value of fdg uptake than osteoblastic (the difference were statistically significant, p < . ) and mixed lesions (the difference were statistically borderline, p = . ). conclusion: our preliminary data shows that [ f]fdg-pet/ct provides a powerful combination of functional and morphologic information allowing an accurate characterization of bone metastases in lung cancer in terms of both metabolism and structural changes. , suvmax, and suvmean were calculated for each adrenal lesion. moreover, fdg adrenal uptake was compared with radioactivity of aorta, liver, and spleen by calculating the adrenal lesion-to-aorta, the adrenal lesion-toliver, and the adrenal lesion-to-spleen suv ratio. standard of reference for confirming the definitive nature of the adrenal lesions was either histophatology or clinical/imaging follow-up data. the value of [ f]fdg-pet/ct imaging was assessed by using independent t tests and receiving operating characteristic analysis (roc). results: of the lesions, turned out to be malignant based on subsequent growth (n = ) or histophatology (n = ), while were benign based on stability for months (n = ) or histopathologic analysis (n = ). there was a statistically significant difference in hu and suv between benign and malignant masses (p < . ), while the difference in size was not statistically significant (p = . ). the cutoff values derived from roc analysis for best discriminating malignant from benign lesions were as follows: suvmax of . (auc = . , sensitivity = %, specificity = %, ppv = %, and npv of %), hu of (auc = . , sensitivity = %, specificity = . %, ppv = . %,and npv of %), and a adrenal lesion-liver suv ratio of . (auc = . , sensitivity = %, specificity = %, ppv = %,and npv of % purpose: positron emission tomography (pet) is a radioisotope imaging method for obtaining information of organs and metabolisms within the human body. one of the most important criteria for quality-pet images is a high contrast value. injection doses and scan durations have important effects on the contrast of pet images, especially for the overweight patients. in this study, we have investigated the impact of injection doses and scan durations on the spatial resolution of the pet images within the lung lesions with diameters . , . , . and . cm consecutively. material and method: for the study, a whole body phantom was designed considering a standard adult human body of average weight of kg. the lung-lesions were filled with different an activity-concentration as , and times more than that of lung-tissue background. seventy-two transaxial pet images were acquired with combinations of , , , , , mbq/kg injected doses and , , , min/bed scan durations using a siemens biograph hi-res pet/ct. results: it was found that the visibility and contrast value of lung lesions increased with the increasing of injection doses and scan duration. two minutes scan duration for a bed position is not sufficient to localize a lesion with . cm diameter with all injection doses. apart from this, all scan durations and injection doses used in this study are sufficient to detect the lesion of . cm diameter. conclusion: we concluded that minimum contrast value for the visibility of a lung tumor pet image is and min/bed scan duration and mbq/kg injection dose are sufficient to detect the lung lesion used in this study. objective: pulmonary nodules associated with low or absent flourodeoxyglucose (fdg) tracer activity on fdg pet can generally be managed conservatively after consideration of multiple clinical parameters and risk factors. in some instances, patients with such pulmonary nodules have hilar and mediastinal lymph nodes with definite abnormal fdg uptake, confounding study interpretation and patient management. we hypothesized that a high level of fdg uptake in hilar or mediastinal lymph nodes, in the setting of a pulmonary nodule with low or absent fdg uptake, is due to benign inflammatory processes. methods: a total of pet-ct reports were reviewed and twenty-seven studies with discordant pulmonary nodule and hilar or mediastinal lymph node metabolism were identified. discordance was defined by an suv ratio of lymph nodes to nodule of greater than . . the suv (standardized uptake) values (average values, not corrected for lean body mass, and measured at - minutes post fdg administration) were calculated from filtered back projection images, and ratios were then calculated based on those suv values. a retrospective chart review was performed on the cases that met the study criteria and the follow-up (biopsy or follow up imaging) was documented. patients with a known diagnosis of malignancy or sarcoidosis were not included in the study. results: the suv values for the nodules ranged from . - . , with a mean of . . the suv values for the lymph nodes ranged from . - . , with a mean of . . in of twenty-seven patients biopsy found histologic findings of necrotizing granulomas or histoplasmosis. in of the twenty-seven patients, follow-up imaging revealed the hilar or mediastinal lymph nodes had decreased in size or remained stable. the remaining nine patients have yet to be followed up. conclusion: in patients undergoing fdg pet for evaluation of a pulmonary nodule, a nodule with low or absent glucose metabolism can likely be managed conservatively, even when there is definite associated abnormal glucose metabolism in hilar or mediastinal lymph nodes. f-fdg uptake of n lymph nodes and primary tumor on pet: clinical significance in stage iiia n non-small-cell lung cancer purpose: this study evaluated the potential role of f-fluoro- -deoxy-glucose (fdg) uptake by primary tumors and n nodes on positron emission tomography (pet) in patients with stage iiia n non-small-cell lung cancer (nsclc). experimental design: we analyzed pet scans of nsclc patients who received surgical resection and proved pathologically to have stage iiia n disease between january and april . on each patient's pet scan, fdg uptake by the primary tumor and n nodes were evaluated using the maximum standardized uptake value (suv). the highest suv of the n nodes in each patient was used for analysis. the suv of the node was affected by histology (p = . ). whereas a different survival outcome was not observed according to the suv of the primary tumor (p = . ), the suv of the node ( median vs. > median) was associated with survival (p = . ). patients with a low ratio of the node suv to the primary tumor suv ( median) showed better survival than those with a high suv ratio (> median) (p = . ). in the multivariate analysis, the t stage (p = . ) and ratio of the node suv to the primary tumor suv (p = . ), adjusted for the size of the n node ( cm vs. > cm), remained significant prognostic factors. conclusion: these results suggest that fdg uptake by the n node, especially relative to the uptake by the primary tumor, may predict survival of patients with stage iiia n nsclc. accuracy of dual-phase fdg pet for diagnosis of pulmonary nodule with initial suv less than . c. chen, b. lee, w. yao, p. wu, c. chu, n. chiu; national cheng kung university medical center, tainan, taiwan. aim: f-fdg pet is a very useful tool for the evaluation of pulmonary lesions with high sensitivity and specificity when using cutoff standard uptake value (suv) of . . however, false results may occur, such as in bronchioalveolar carcinoma or inflammatory foci. studies indicated the usefulness of delayed pet images to improve accuracy. our study aimed to clarify the efficiency of delayed pet in pulmonary nodules with initial suv less than . . material and methods: we collected dualphase fdg pet studies, imaging at hr and hr post-injection, that showed pulmonary lesions with initial suv less than . . those with final pathological reports were recruited for further analysis. we analyzed the difference in suvs, retention index (ri) (%) (ie. subtracting the hr suv from the hr suv and dividing by the hr suv), and rate of further increase of suv between benign and malignant pulmonary lesions. results: totally lesions, in patients, were recruited. ten, including nine of granulomatous inflammation, were benign and were malignant. for the benign lesions, the average suv on hr and hr images were . (range: . to . ) and . (range: . to . ), respectively. for the malignant lesions, the average suv on hr and hr images were . (range: . to . ) and . (range: . to . ), respectively. further increases of suv on delayed hr images were observed in of the benign ( . %) and of the malignant lesions ( . %). no significant differences in suv, ri, rate of further increase of suv were found between the benign and malignant pulmonary lesions. conclusion: further increases of fdg uptake on delayed pet images occur not only in malignant lesions but also in benign lesions, such as granulomatous inflammation. therefore, delayed fdg pet is not useful for differentiating benign and malignant pulmonary nodules with initial suv less than . , especially in the epidemic area of granulomatous diseases. irmet spa, torino, italy, università di torino, dipartimento di scienze cliniche e biologiche, aso s. luigi, orbassano, torino, italy. introduction. the role of fdg pet/ct in the management of patients with non small cell lung cancer has been widely investigated in the recent years and its usefulness has been proved in the initial diagnosis, staging, restaging in case of suspected recurrence and radiotherapy planning. our aim was to evaluate the accuracy of pet/ct with fdg in the preoperative mediastinal nodal staging of nsclc with histological results as gold standard. materials and methods. patients ( men, women, mean age ) with early clinical stage nsclc were included. all of them were preoperatively studied with clinical evaluation, whole body c.e. ct, whole body fdg-pet/ct, fibrobronchoscopy. all patients underwent surgery. pet mediastinal nodal findings were compared with histo-pathological ones; these latter were used as the reference standard. statistical evaluation was performed on per-nodal-station. sensitivity, specificity, positive and negative predictive value and accuracy of pet were calculated. results. pet correctly classified out of the lymph nodes histologically evaluated, with an accuracy of . %. in particular, pet correctly evidenced malignant nodes out of , and non malignant nodes out of . so, sensitivity and specificity resulted . % and . %, respectively. in the remaining nodes, we had false positive (all reactive hyperplasia) and false negative nodes (in all cases, the node diameter was inferior to x mm), with positive and negative predictive value of . % and . %, respectively. conclusions. our study, in concordance with the literature data, demonstrate that fdg-pet/ct has high specificity, but low sensitivity in mediastinal nodal staging. in patients with non small cell lung cancer (nsclc), pre-operative assessment with fdg pet/ct provides accurate tnm staging resulting in improved management plans. assessment of the visceral pleura is important since visceral pleural disease changes tumour staging from t to t , hence from stage ia to ib, which reduces post operative year survival from to %. although orthogonal planes are available, attention is often focused on the axial and coronal planes when pet/ct data is analysed. the aim of the study was to assess the impact of additionally reviewing images in the sagittal plane to assess visceral pleural involvement. method consecutive patients who had pet/ct for nsclc staging were reviewed. we assessed the effect of analysis of the sagittal plane in determining extension of the tumour onto interlobar fissures, and so by implication involvement of visceral pleura. results pet/ct identified patients with t disease. in , t disease was diagnosed by size criteria, or extension onto the fissure on axial pet /ct. / patients ( . %) were upstaged from t to t by diagnosis of extension onto the fissure not diagnosed prior to sagittal plane review. in patient multiple lumbar vertebral collapses due to osteoporosis was diagnosed on sagittal plane images. conclusion review of the sagittal plane on pet/ct images especially when the primary tumour is in the vicinity of an interlobar fissure can improve accuracy of t staging, and thus provide important prognostic information. background: accurate staging of small-cell lung cancer (sclc) is critical for patient treatment and prognosis. the most common staging system adopted from the veterans affairs research service lung group includes two stages, limited-stage disease is defined as tumor confined to one hemithorax and the regional lymph nodes, whereas extensive-stage disease is defined as disease beyond these bounds. patients with limited-stage disease are offered combination chemotherapy and concurrent thoracic radiation therapy. patients with extensive-stage disease are offered combination chemotherapy without thoracic irradiation. [ f]fluoro- -deoxy-d-glucose (fdg) positron emission tomography (pet) scan is widely used for the staging evaluation of non small cell lung cancer, however, its use in small cell lung cancer (sclc) remains investigational. the aim of this study was to evaluate fdg pet for sclc staging and to determine the impact of pet on treatment planning. patients and methods: from february to march , we prospectively performed pretreatment fdg-pet on patients, with sclc who also underwent a conventional staging. tumor-nodemetastasis system staging was assigned for each patient, with and without pet information and modification of treatment planning was assessed. results: fdg-pet demonstrated findings consistent with extensive-stage sclc in fifteen of patients. fdg-pet correctly upstaged nine ( %) of patients to extensive-stage disease. pet correctly identified tumor in each sclc mass (primary or nodal) that was suspected on computed tomography (ct) imaging, thus giving a lesion-based sensitivity relative to ct of %. pet identified unsuspected bone metastasis for eleven patients, hepatic lesions for patients and in others sites. fdg-pet correctly downstaged one ( %) of patients to limited-stage disease who had a adrenal mass in ct and negative in pet confirmed by histology. treatment was modified for ten patients ( %), patients underwent only chemotherapy and one had both chemo and radiotherapy.conclusion: fdg-pet has high sensitivity for sclc and appears to be of value for initial staging and treatment planning. aim: non small cell lung cancer (nsclc) is the leading cause of cancer mortality in both females and males. some studies have linked tumor glucose metabolism as evidenced by f- fdg pet to survival but these study populations were heterogeneous. we aimed to assess whether tumor glucose metabolism is related to tumor size, disease stage and tumor histology in patients treated with radiation therapy and curative intent. material and methods: patients ( males and females, mean age: years) underwent d conformal radiation therapy. all patients underwent pre-treatment staging with f- fdg pet (pet-ct) and were evaluated by the assessment of tumor size in two dimensions, maximum suv (suvmax), and tumor histology. eighty-one patients were clinically staged by tnm (t n = , t n = , t n = and t n = ). in out of patients the tumor was histologically analysed (squamous cell carcinomas = , adenocarcinomas = , large cell carcinomas = , non-small-cell-lung-cancer = ). results: in non-parametric analysis tumor metabolism as measured by suvmax was associated with tumor stage( r = . , p < . ). suvmax was related to -d tumor size in patients with nsclc (r = . , p < . ). this relation was stronger in patients with adenocarcinoma (r = . , p < . ) than in patients with squamous cell cancer (r = . , p < . ). multivariate analysis indicated that up to % of suv variability could be explained by tumor size. conclusion: in nsclc some relation exists between disease stage, primary tumor size and suvmax as an indicator of glucose metabolism. however, it is notable that tumor histology has substantial impact on these relations. correlation between staging fdg-pet, some cell cycle markers and survival in lung cancer. a. sanchez-salmon , i. aim: a great part of the patients with lung cancer have spread disease at the diagnosis. fdg positron emission tomography ( fdg-pet) is recommended for staging these patients in order to avoid unnecessary surgery in advanced disease. we report the evaluation of the relation between the suvmax (" standardized uptake value ") of the pet, cell cycle markers and the patients' survival in lung cancer patients. material and methods: there were patients ( men and women) studied, with an average of years old and a range of - years old. in the histological evaluation cases were squamous, adenocarcinoma (including bronquioloalveolar), undifferentiated, oat cell, and neuroendocrine tumours. five patients were in stage ia, in ib, in iia, in iib, in iia, in iiib and in iv. the follow-up ranged between and months. the inmunohistochemical study was realized by blocks of tissue microarrays using the envision (dako) system. results: an association between the suv and the negativity for the d cyclin (p= . and p (p= . ) was found. there is also a positive correlation between the suv and the index of proliferation (mib- ) as well as between the suv and the a inducible factor inducible by hypoxia (hif- a) expression but both of them did not reach significance. the of the suv maximum values associated with the age and with the squamous histology. there was found no correlation of the suv neither with the tnm nor with the survival. conclusions: . fdg-pet is very useful method for staging lung cancer. . fdg-pet is associated with different biological characteristics of the tumours . in our experience, it does not seem to be a good survival marker . background: the diagnostic and therapeutic management of different lung nodules in a single patient is challenging. the nature can be benign, as hamartoma, or malignant, as primary cancer or metastases. despite a high number of researchers and proposal for diagnostic work-up have been published accurate differentiation of benign from malignant lesions remains unsolved. aim of our study is to assess whatever integration of morphologic and metabolic imaging can help in the differential diagnosis between malignant and benign lung nodules in patients bearing multiple lung nodules. aim: f-fdg pet is widely accepted for evaluating patients with lymphoma; the role of pet in paediatric patients is still debated. aim of our study was to assess the usefulness of f-fdg pet imaging in paediatric hodgkin (hd) and non-hodgkin (nhl) lymphoma. materials and methods: paediatric subjects ( males, females; mean age years, range - years) with malignant lymphoma ( hd, nhl) were enrolled in the study. f-fdg pet was performed following standard procedures ( , mbq/kg of fdg were injected iv in the hours fastened patient, image acquisition was performed after one hour uptake). overall pet scans were carried out, at lymphoma presentation and during follow-up. pet results were compared with conventional imaging (ci) information (mr and/or ct) and with clinical followup; in all cases at least one contemporary imaging method was available, as well as months follow-up. results: out of scans, pet findings were consistent with clinical follow-up and other ci data in cases ( true positive, true negative results) with an overall sensibility and sensitivity of % and % respectively. the remaining two cases resulted falsely positive, and in one subject this was due to prominent thymic uptake. considering all scans, pet was more accurate then conventional imaging in the assessment of children with lymphoma, identifying active disease in ci negative scans and in ci inconclusive cases and excluding the presence of lymphoma in ci inconclusive and ci positive scans. conclusions: our data show the usefulness of f-fdg pet to accurately evaluate children with lymphoma. the presence of hyperplastic thymus in one case may have accounted for inaccurate pet reading, although in other cases prominent thymic uptake did not affect pet reporting. a recent report has emphasized the number of false positive pet findings in children: our data do not support this observation. nonetheless particular care has to be paid when reporting pet scans carried out in paediatric patients. purpose: in this retrospective study we aimed to assess the clinical impact of pet/ct imaging on staging and management of both hodgkin disease (hd) and nonhodgkin lymphoma (nhl). the results are also compared with the ct imaging findings. materials and methods: a total of patients with newly diagnosed lymphoma were included in the study. there were hds and nhls. the age range was - with a mean age . years. each patient was undergone whole body pet/ct examination with low dose ct acquisition by administrating only oral contrast in addition to establish full diagnostic ct examinations of cervical, chest and abdominopelvic regions. pet/ct scanning from the skull base to the upper thigh was performed using a dedicated pet/ct scanner (siemens biograph hi-rez lso), only when the patient's blood glucose level did not exceed mg/dl. the interval of pet/ct and ct was weeks at maximum. the findings suggesting for disease involvement obtained from the both modalities were recorded on a data sheet according to their topographic localization. the diagnostic certainty of two modalities was made according to clinician's final decision mainly based on clinical follow-up status of the patients. results: a total of disease sites in patients were recorded according to final clinical decision. of these, sites were revealed by pet/ct, but only were shown by ct. two modalities were agreed in sites. thirtythree sites were demonstrated only by pet/ct, which caused upstaging in ( %) patients. whereas ct found sites despite of negative pet/ct, which did not caused upstaging of the disease in any patient. in of the patients in whom pet/ct upstaged disease, treatment strategy was changed to the more aggressive protocols. conclusion: fdg pet/ct has a very important contribution in the initial staging of lymphomas, by changing the treatment strategy in a considerable percentage of the patients. according to our opinion ct appears to have a minimal role in initial staging beyond of pet/ct scanning and can be omitted in routine clinical settings. high negative predictive value of midtreatment fdg-pet/ct in response assessment of malignant lymphoma. aim f-fdg-positron emission tomography/computed tomography (pet/ct) is currently used in staging/restaging and in the definitive evaluation of response to therapy of hodgkin disease (hd) and aggressive non-hodgkin lymphoma (nhl). in fact, this functional imaging modality allows an accurate evaluation of disease extension as well as a metabolic characterisation of residual masses after chemo and/or radiotherapy. the use of f-fdg pet/ct for response assessment during treatment is still under debate: midtreatment scan seems to be predictive of final response to therapy, however its role and prognostic value remains to be proved. in our study we evaluated the predictive value of interim pet/ct scan in patients with hd and aggressive nhl, compared to the final therapy response. materials and methods consecutive patients ( male, female; mean age±sd: ± ys) were staged by f-fdg-pet/ct (pet- ), whole body ct and bone marrow biopsy for hd (n= ) and aggressive nhl (n= ). all of them underwent interim pet/ct (pet- ) after - cycles of chemotherapy, and final restaging with whole body ct and pet scan (pet- ) at the end of the treatment. results hd: out of patients had a negative pet- scan. at the end of the treatment, of them ( %) presented complete response, while , partial response. the remaining patients were positive at pet- . at the end of the treatment, ( %) of them were in complete response, while ( %) had partial response. nhl: out of patients had a negative pet- scan. at the end of the treatment, all of them had complete response. the remaining patients presented a positive pet- scan. at the end of the treatment, ( %) of them were in complete response, while ( %) had partial response. conclusions our data confirm that interim pet/ct scan has a very high negative predictive value, both in hd and aggressive nhl ( % and %, respectively). further studies are needed to demonstrate how this information can affect patient management and patient outcome. aim we performed a systematic review of the literature to analyze positron emission tomography with f-fluorodeoxiglucose (fdg-pet) as a diagnostic tool in the evaluation of lymphomas response to chemotherapy or immunotherapy in terms of diagnostic accuracy and clinical usefulness. methods and material bibliographic search was performed between july-august , with a date limit consensus established in . we used medline, embase and cancergov, as bibliographic primary fonts adopting in each case the most convenient searching strategy, adopting free vocabulary to specific thesaurus. cochrane library and other health technology agencies data bases were also reviewed. the methodology quality assessment of every article was determined by the quadas questionnaire. the software tools use to manage all extracted data were reference manager . , spss . and epidat . . results the number of primary article localized was . two independent reviewers performed screening of all references, and the final number of articles selected to be analyzed was . despite of the differences among equipment, no difference in patient's preparation and studies acquisition were found. all studies consider visual qualitative analysis as part of the evaluation, and only four did semiquantitative analysis using standard uptake value (suv). six of ten studies performed fdg-pet scans in hodgkin lymphoma at the end of the treatment. global results of sensitivity, specificity, positive predictive value, negative predictive value and accuracy correspond . % [ %ci, , . - . ] . work in progress to evaluate the possibility of develops meta-analyses of diagnostic test. conclusion despite of the small number of studies and the heterogeneity of the different population, it is important to emphasized the global results of negative predictive value of the fdg-pet in both hodgkin and non-hodgkin lymphomas and also at the different early and late response evaluation. study supported by the quality plan of the spanish national health service. months after fdg-pet) despite of additional therapy. two patients were noted as false-positive. in four patients only slightly increased fdg uptake was observed (equivocal findings). conclusions: fdg pet enables reliable prognosis in short and long-term follow-up of patients with hd and nhl , especially in patients without pathological uptake of fdg. false positive fdg uptake seems to be a problem. no one of our fdg negative patients relapsed. our results show that fdg negative patients usually have good prognosis and stay in complete remission for a long time. therefore, results of pet are predictive of immediate success of therapy as well as of disease-free survival. negative pet scan is an important contribution in the management of these patients due to its prognostic value and may reassure patients and their doctors that disease is not active. the bone lesions (bl) in hodgkin's disease (hd) are rare ( to %) in the initial staging but have to be detected for a more aggressive treatment. bl are explored mainly by the invasive unilateral bone marrow biopsy (bmb), insufficient compared with the bilateral one. the aim of this study is to evaluate the agreement between bone positive fdg-pet, bone ct and mri for rachis bl detection in hd, before and during chemotherapy. material and methods: patients (mean age ± years, men) with hd histologically proven and with fdg-avid lesions in the bone were analysed. only one suffered from lumbar pain. all underwent unilateral bmb, bone ct, and then mri of axial skeleton at the time of first staging. all those imaging exams were repeated for early interim evaluation (after cycles of chemotherapy) and month after the end of treatment (after cycles). each lesion was defined by its localization, the intensity of its signal: t , t on mri, bone destruction with ct by a neuroradiologist, fdg uptake with maximum standardized uptake value by a nuclear physician. results: the bmb was positive only in cases. a total of lesions were visualized on initial staging fdg-pet (average suvmax , ± , ) and on mri. on bone ct, only of lesions were detected. for of lesions, fdg-pet presented a vertebra hypofixation corresponding to a massive infiltration on mri. the localization of bl on fdg-pet and mri was well correlated except for patient (kappa= , ; , ; , ; , respectively for patients to ). indeed for this patient, a mismatch was noted between a homogeneous intense uptake of the thoracic rachis without pathological signal on mri at the same level. we concluded to a falsepositive fdg-pet by bone marrow hyperplasia. at mid and end of treatment, the fdg-pet became relatively normal whereas mri showed healing pattern on several vertebrae. on the follow-up, one patient recurred on mediastinal lymph node without bl. conclusion: fdg-pet and mri were the most accurate imaging modalities for bl in this context, complementary, especially in the whole spine assessment. fdg-pet allowed a better wholebody analysis and was enough sensitive to detect bl, including vertebra hypofixation. during treatment, bone fdg-pet became negative earlier than mri. the mri remained more precise for the small bl individualization. objective: because of anatomic changes after operation, detecting recurrent tumor is difficult in post-operative stomach cancer patients, especially in patients with paucity of intra-abdominal fat tissues. this study aimed to compare fdg pet/ct and enhanced ct in the detection of recurrent tumor according to body mass index (bmi) and anatomic regions. materials and methods: total of patients who had pet/ct and enhanced ct within month of each other, and diagnosed with recurrence were included. cases were pathologically confirmed and diagnosed clinically. we classified the patients into groups according to the bmi (kg/m ): group i < . ; group ii . ~ . ; group iii . ~ . ; and group iv > . . we compared pet/ct and enhanced ct findings by the anatomical sites: anastomosis site or stump; lymph node (ln); seeding nodules; bowel wall; and solid organ. result: five patients had only extraperitoneal lesions, and one had diffuse ascites without a focal lesion. cases were false negative in both pet/ct and enhanced ct. excluding these cases, we compared the findings of pet/ct and enhanced ct. in group i (n= ), pet/ct found ln lesions, seeding nodules and foci of bowel wall thickening, while ct found ln lesions, seeding nodules, foci of bowel wall thickening. in group ii (n= ), ln lesions, and seeding nodules were discovered on pet/ct. and ln lesions, seeding nodules, and foci of bowel wall thickening were detected. conclusions: fdg pet/ct may be more useful than enhanced ct in detection of metastatic lymph nodes and seeding nodules in patients with low bmi (groups i and ii). however in cases with seeding metastasis presenting as bowel wall thickening, enhanced ct could be more useful. aim: gastrointestinal tumors can be detected incidentally by fdg-pet. even though measurement of standard uptake value (suv) has been proposed to determine the nature of these tumors, the method has been criticized. because dual-time point fdg imaging was reported to increase accuracy of fdg pet, we conducted this study to analyze the use of suv and delayed fdg imaging in the evaluation of gastrointestinal tumors. material and methods: gastrointestinal tumors with dual-time point fdg imaging were collected. images were acquired at hr and hr post-injection. those with final pathological results were enrolled. we recorded the hr and hr suv of the lesions for further analysis. results: there were ten benign and fourteen malignant gastrointestinal lesions enrolled in this study. average hr and hr suv of the benign lesions were . (sd: . ) and . (sd: . ), respectively. average hr and hr suv of the malignant lesions were . (sd: . ) and . (sd: . ), respectively. for differentiation of benign and malignant lesions, best accuracy (accuracy: . , sensitivity: . , specificity: . ) could be obtained by using criteria of initial suv higher than and further increase of delayed suv higher than %. conclusion: delayed imaging can improve the accuracy of fdg-pet in differentiating benign and malignant gastrointestinal lesions. however, the accuracy is not high. evaluation of liver metastases from colo-rectal cancer after chemotherapy: fdg pet seems not to improve ct sensitivity m. rodari, c. carnaghi, c. tronconi, l. rimassa, f. r. lutman, g. ciocia, a. chiti; istituto clinico humanitas, rozzano -milano, italy. aim: neoadjuvant chemotherapy has been successfully used to treat patients with colorectal liver metastases. selection of those patients who can benefit from surgical resection after chemotherapy still poses a significant clinical problem. fdg pet is a useful tool in the assessment of liver metastases from colo-rectal cancer, but few data are available on its sensitivity after chemotherapy. we aimed to assess fdg pet and ct in the pre surgical evaluation of patients bearing liver metastases. materials and methods: data from patients with liver metastases from colo-rectal cancer treated with chemotherapy, evaluated with fdg pet and contrast enhanced ct scan at the end of treatment were retrospectively reviewed. nineteen patients ( males, females; median age years; range - ) were evaluated. chemotherapy regimens were: folfox ( patients), folfiri ( patients), other ( patients). median time between end of chemotherapy and ct was . weeks, between end of chemotherapy and pet . weeks and between end of chemotherapy and surgery . weeks. all patients underwent surgery and had pathological confirmation of liver lesions. nine patients underwent segmentectomy, wedge resection, right hepatectomy and explorative laparotomy with liver biopsies. results: data from patients were evaluated and liver lesions were confirmed by pathology. results on a perlesion basis shown a sensitivity of % for pet and % for ct. a complete agreement between pet or ct and histology was documented in and patients, respectively. pet sensitivity increases for lesions larger than cm ( % vs %). conclusions: our results suggest that pet and ct scan have sub-optimal sensitivity in the evaluation of colo-rectal liver lesions after neo-adjuvant chemotherapy, particularly for lesions < cm. the combined use of the two imaging techniques seems not to significantly increase the sensitivity of ct alone. introduction: the basic of pet/ct by use of f-fluorodeoxyglucose (fdg) is significantly increased glucose metabolism in the malignant neoplasm cells. the fdg metabolism depends on many factors such as: histopathology and presence of other factors which increase fdg metabolism. knowledge about the fdg metabolism in the stomach cancer cells' is not clear and some types of cancer are not avid in this type of diagnostics. aim: the evaluation of the fdg metabolism of pathological lesions in gastric cancer patients according to its histopatological type. material & methods: retrospective analysis of the pet/ct results of patients ( women, men, mean age , ) suffered from stomach cancer. the study population consists of patients with the primary stomach cancer and patients with confirmed recurrence. there were tubular adenocarcinoma, mucinous adenocarcinoma and low differentiated stomach cancers. pet/ct studies were performed on the biograph lso min after iv. of mbq/kg fdg. standard uptake value -suv was calculated. pet/ct results and mean values of suv were calculated for the each histopathological type of stomach cancer. results: lesions with pathological increase of fdg metabolism were fund in patients ( , %) with tubular adenocarcinoma, (mean suv , ± , ), ( %) patients with mucinous adenocarcinoma (mean suv , ± , ) and ( , %) patients with low differenciated stomach cancer (mean suv , ± , ) false negative results were found in patients with mucionous adenocarcinoma, with tubular adenocarcinoma ( low differenciated -g ) and with low differentiated cancer. conclusions: . higher differentiated tubular adenocarcinomas and low differentiated stomach cancers are characterized by the highest fdg metabolism. . mucinous adenocarcinomas is characterized by the low level of fdg metabolism. . histopatological type of stomach cancer must be taken into consideration during setting of indication to the pet/ct study. polyps: a feasibility study p. mainenti , b. salvatore , c. sirignano , t. de falco , a. speranza , g. fiumara , f. ricci , l. evangelista , l. pace , m. salvatore ; ibb-cnr, naples, italy, aou "federico ii", naples, italy, department of diagnostic imaging, university "federico ii", naples, italy. aim: to evaluate: ) the feasibility of pet/ct colonography (pet/ctc) in patients with colo-rectal polyps; ) the impact of metabolic information on ctc findings and the added value of morphologic to functional information in the characterization of focal colorectal uptakes. materials and methods: ten patients with colo-rectal polyps underwent pet/ctc previous colo-rectal air insufflation and just after therapeutic conventional colonoscopy (cc). a radiologist and a nuclear medicine physician analysed the pet/ctc images. the grade of overlapping of morphologic and metabolic information in the colon-rectum was evaluated. sensitivity and specificity for colo-rectal polyps of pet, ct and pet/ct were calculated. results: polypoid lesions were identified at cc: < mm, between and mm, > mm ( hyperplastic polyps, tubular adenomas, adenocarcinoma and submucosal lipoma). the overlapping of morphologic and metabolic information was excellent in scans, good in and moderate in . pet/ctc showed a sensitivity of % for lesions > mm and a specificity of %. the metabolic information did not allow to disclose any further polyp missed on ctc. the morphologic information permitted to classify correctly all focal radiotracer uptakes. conclusions: pet/ctc is a feasible study. adding a colonographic protocol to pet/ct images seems to allow characterizing correctly all colo-rectal focal radiotracer uptakes. the metabolic information does not seems to increase the accuracy of ctc. aim. metastases of colon cancer are often diagnosed in an advanced stage. in patients with this kind of neoplasm, pet with [f- ] fluorodeoxyglucose (fdg) is more sensitive and specific than the ct for detection of metastases. the cea level is used for monitoring the cancer but without anatomical localization of the lesions. the aim of this study was the retrospective assessment of the value of the pet/ct and ct in the diagnostics of the group of patients with an increased cea level. material & methods in the time between march and april , studies were made to diagnose colon cancer . we selected patients referred to the pet-ct study with an increased cea marker level who were being diagnosed for colon cancer with complete information about ct with contrast media. pet studies were made by using the siemens biograf lso scanner according to typical pet protocol. we compared the results of the particular methods of diagnostics, performing patient to patient analysis. results: in cases ( , %)pet/ct and ct gave consistent results. there was patients ( , %)with negative results of pet/ct and ct . there were negative pet/ct results ( , %) and ct negative results( , %). in patients pet/ct positive results( , %) corresponded with the negative ct results. in patients ( , %)ct positive results corresponded with the negative pet/ct results. mean cea level in this group of patients was , ng/ml. conclusion: pet/ct was found to be the more valuable than ct tool for detecting colon cancer metastases in the group of patients with increased level of cea, additionally giving exact information about their localization. there is a need to conduct a prospective study to assess the value of the pet/ct in the diagnostics of colon cancer in connection with histopathology. introduction. although the fdg-pet is indispensable in the follow-up of colo-rectal carcinoma (crc) when recurrence suspicion exists (elevation of markers and/or findings in structural image), is not defined the role that can suppose its inclusion in the systematic follow-up of these patients. the aim of this work is to analyze the impact that can suppose the incorporation of the fdg-pet in the systematic management of crc patients without suspicion of tumour recurrence. population and methods. from a cohort of patients with crc, a total of (mean age , +/- , years; rectum, sigma, colon) were followed-up during two years by simultaneous use of fdg-pet and structural image (mainly us and ct) evaluated in blinded conditions. results. fdg-pet was considered negative in / patients, without findings in the structural image. in / ( , %) cases fdg-pet showed not suspected tumour recurrence, without findings in the structural images in of them ( / / ; %/ , %). dissemination of was determined as hepatic metastases ( ), pulmonary metastases ( ), retroperitoneal lymph node ( ) and mesenteric implants ( ) . that is, fdg-pet showed unsuspected tumour disease in , % of patients, % of them free of significant structural changes. conclusions. even though the little number of patients, our series suggests that the inclusion of the fdg-pet in the systematic follow-up of the treated crc patients can improve their clinical management. aim. primary carcinoma of the gallbladder is a rare malignancy which is very difficult to diagnose and characterizes an extremely poor prognosis,. using fdg pet/ct we can obtain functional and morphological images of the entire body the aim of the study is a retrospective evaluation of pet/ct in patients with gallbladder carcinoma incidentally detected during cholecystectomy. material and methods. between march and december pet/ct was performed on patients ( women, men; age , yrs ) with gallbladder carcinoma detected incidentally after cholecystectomy. the pet/ct was performed with a biograph lso minutes after an intravenous administration of mbq/kg fdg. results. pet/ct scanning presented lesions of increased fdg metabolisms in patients. in patients liver metastases, hilus of the liver , site of the gallbladder removal, postoperative scar metastases, metastases in lymph nodes of the abdominal cavity, lymph nodes of the retroperitoneal space metastases, omentum metastases were found. all were true positive. there were true negative results in the remaining patients. conclusions. . pet/ct by fdg is a useful method in gallbladder cancer patient diagnostics. . pet/ct enables the diagnostics of the residual tumors, recurrence and distant metastases of the gallbladder carcinoma.. background it is known that f- fdg pet has a low sensitivity in the detection of hepatocellular carcinoma (hcc). we prospectively compared c- acetate pet results to those of f- fdg pet in patients with hccs. methods we prospectively analysed four patients (m:f= : , age range: - ) with histopathologically or clinically confirmed hccs underwent c- acetate pet and f- fdg pet. whole body c- acetate pet was performed min after injection of mbq of c- acetate. f- fdg pet was done within day before or after c- acetate pet. results a total of hcc lesions were confirmed histopathologically or clinically. f- fdg pet detected only lesions of them whereas c- acetate pet detected lesions. two false positive lesions were found on both pets, respectively. conclusion although the number of patients was very small, c- acetate pet may be complementary to f- fdg pet and useful in imaging of hcc. further studies including more patients are needed. comparison of hepatic fdg uptake between japanese people with and without metabolic syndrome objectives: liver demonstrates heterogeneous fdg uptake pattern and sometimes shows abnormally increased uptake even though there is no malignant tissue. recently, fdg uptake in liver was correlated with fasting plasma glucose, reported. over the past decades, there has been a dramatic increase in the number of subjects with the metabolic syndrome in japan as well as in western countries. the international diabetes federation defines metabolic syndrome as the presence of central obesity plus any two of the following three factors (fasting plasma glucose, lipid deviation and blood pressure). therefore, we evaluated the significance of hepatic fdg uptake associated with metabolic syndrome and hepatic enzymes. methods: sixty one patients ( men and women; age range, - years; mean age, . years) underwent whole-body fdg-pet imaging for cancer screening. patients with sever hepatic disease had been excluded. all patients were instructed to fast for at least h before the intravenous injection of fdg. pet image was obtained hour after injection of . mbq/kg of f- fdg with pet camera. the fdg uptake in liver was analyzed semiquantitativly using roi on transaxial image at umbilical level and we compared mean standardized uptake value (suv) between normal and metabolic syndrome group, based on waist circumference, raised triglyceride level, reduced hdl cholesterol, raised blood pressure, and raised fasting plasma glucose. we also evaluated effects of fasting plasma glucose and hepatic enzymes, i.e., aspirate aminotransferase (ast), alanine aminotransferase (alt) and -glutamyl trasopeptidase ( -gt) on hepatic fdg uptake. results: the average of hepatic suv in abnormal groups of blood glucose level, lipid deviation and blood pressure was significantly higher than that of normal group, respectively (blood glucose level; . ± . vs . ± . (p< . ), lipid deviation; . ± . vs . ± . (p< . ), and blood pressure; . ± . vs . ± . (p< . ). there was much more significantly high hepatic fdg uptake in metabolic syndrome group than normal group ( . ± . vs . ± . , p< . ). on the other, hepatic fdg uptake of abnormal ast, alt and -gt groups showed no significant difference from normal groups. conclusions: there was significantly high hepatic fdg uptake in metabolic syndrome group than normal group. this result suggests that we need careful interpretation of the liver in a case of metabolic syndrome. aim: contrast materials with high iodine concentration have been found to improve parenchymal enhancement on ct imaging. however, intravenous contrast materials (cm) may cause artifacts on pet/ct when using the ct data for pet attenuation correction. the aim of this retrospective clinical study was to assess the feasibility to use a highly concentrated contrast material (hccm) containing mg iodine/ml in pet/ct imaging. intravascular and parenchymal enhancement, potential ct and pet artifacts, and the accuracy of pet tracer quantification were assessed and compared to a lower concentrated cm containing mg iodine/ml (lccm). material and methods: whole-body fdg-pet/ct-scans of oncologic patients were investigated: patients each with hypervascularized and non-hypervascularized tumors underwent fdg-pet/ct with either an application of hccm or lccm. ct enhancement (hounsfield units) and tracer uptake (maximal standardized uptake value, suvmax) were measured at defined positions in different vessels and parenchyma. the quality of ct enhancement, the extent of potential ct and pet artifacts as well as the quality of tumor delineation were defined on a -point-scale. the influence of pet artifacts on clinical interpretation was defined. mann-whitney-wilcoxon-test was performed to evaluate statistically significant differences (p< . ). results: in patients with hypervascularized tumors, hccm led to significantly higher ct enhancement in / positions compared with lccm. in patients with nonhypervascularized tumors, hccm provided significantly higher ct enhancement in / positions. no significant differences using hccm and lccm were found both for hypervascularized as for non hypervascularized tumors with regard to the quality of ct artifacts, to the suvmax, to the quality of pet artifacts, the quality of tumor delineation on ct, and the quality of tumor delineation on pet. no statistically significant difference was detected between hccm or lccm concerning the influence of pet artifacts on clinical image interpretation. conclusion: hccm leads to a stronger contrast enhancement on ct images than lccm without causing more artifacts on ct or pet. the application of hccm is feasible in hybrid pet/ct and should be considered in patients with hypervascularized tumors. aim: is to determine the clinical utility of -fdg pet/ct in follow-up of patients with malignant melanoma. materials and methods: we studied patients in followup after surgery, having ajcc stage iii melanoma and contrast-enhanced computed tomography (ct) total body negative. in all patients a whole body (legs included) pet/ct scan was performed after an intravenous injection of - mbq of f-fdg in normoglucemia conditions. images were evaluated by nuclear physicians. results: of the pet/ct scans showed sites of active disease: limph nodes ( axillary, parasternal, supraclavicular, external iliac, bronchopulmonary, paratracheal), suprarenal gland, bone, subcutaneous and skin. all pet/ct findings were confirmed by histology or clinical evolution; pet/ct caused changes of treatments. conclusion: in our study pet/ct is superior to ct scan in detecting lymph nodes, skin and subcutaneous metastases. as everybody knows: the early detection of resecable melanoma metastases with early treatment decreases the risk of recurrence and increases survival. aim. to value pet/ct scanning sensibility and specificity compared with those of standard ct (sct) in staging lymph nodes, liver, bone and other organs metastases in patients (pts) with malignant melanoma (mm). patients and methods. between september and march , pts, age - years, mean , were enrolled. all pts were previously submitted to surgery to remove mm, sentinel node and, when indicated, other regional lymph nodes. a sct scan was already performed in these pts when they came to our institution for pet/ct scanning. we compared sites and number of sct-diagnosed relapses with pet/ct results. results. in / ( %) pts sct scanning showed a cerebellar relapse not observed by pet/ct. in / ( %) pts pet/ct results were comparable to sct ones; of these pts had a lung relapse, hadn't metastases, had an ovarian mass which was described as an ovarian cyst by sct, while pet/ct wasn't able to define it as malignant or benignant lesion. / ( %) pts had negative sct scanning, while pet/ct revealed bone or lymph nodes metastases; in of these pts there were widespread metastases. finally in / ( %) pts pet scans showed high metabolic activity lymph nodes, while in the same pts sct imaging revealed different sites of relapses, above all liver. conclusion. pet/ct and sct seem to have, in staging or restaging of mm, the same sensibility in discovering lung metastases, while pet/ct sensibility is higher than sct one relative to bone or lymph nodes relapses. pet/ct sensibility appears lower in detecting liver involvement. sct shows more specificity than pet/ct in describing cerebellar and ovarian lesions. aim: ovarian cancer is the leading cause of death as concerns gynecological cancer in the western countries. the difficulty in the detection of recurrence and the bad prognosis of the disease is well known. this study was designed to determine the value of fdg pet/ct compared to mri and ct, in the evaluation of recurrence disease. material-methods: patients went through fdg pet/ct examinations (siemens biograph lso) from june -march . the injected radioactivity dose for all scans was between - mbq ( - mci). all of them had ovarian cancer and underwent the pet/ct for restaging. mean age was . ± . years. in women with ovarian cancer, were subjected to ct scans (group a) and to mri (group b) for disease reevaluation just before pet/ct evaluation. results: / patients had positive pet/ct scan (suv . ± . ), / patients had positive ct while / had positive mri. group a: / patients ( , %) had match findings in pet/ct and ct scans ( cases negative results and case positive result) pet/ct scan outbalanced ct in / patient cases ( . %) -(mainly in extra pelvic disease). in cases with negative ct, pet/ct was positive ( . %). in / patients with negative pet/ct, ct was positive and of them had non diagnostic ct. group b: in / patients ( %) we had match findings in pet/ct and mri as well. in / patients ( . %) we had mri (+) and pet/ct (-) while another one had mri (-) and pet/ct (+). the critical point is that in / patients with mri (+) and pet/ct (+), pet/ct outbalanced mri (mainly in extra pelvic disease).in patients with tumor markers, of them had elevated serum ca and had normal ca levels. in / women with elevated serum ca pet/ct was observed (+) and in / pet/ct was (-). in the cases with normal ca level we found pet/ct (+). conclusion: according to the results of this study pet/ct scan presents a plain superiority in effectiveness over the ct scan. -fdg pet/ct may detect recurrent ovarian cancer more accurate than mri. also -fdg pet/ct is a very promising technique compared to raising levels of tumor markers. introduction: only sporadic data support the use of labelled-choline as oncological probe to monitor the pca response to treatment in patients. aim: to evaluate early modifications of f-methyl-choline ( f-ch) uptake in an animal model of prostate cancer (lncap xenograft on balb-c nude mice). material and methods: hormonosensitive prostate cancer xenografts were obtained in the back legs of athymic nude mice by subcutaneous injection of - lncap cells suspended in a solution of rpmi medium and matrigel®. animals were kept in appropriate facilities until tumour size reached . - ml. mice were then treated twice a week by intra-peritoneal administration of docetaxel ( mg/kg). sequential f-ch animal pet acquisitions ( _to_ min after ip injection) were performed basically and in the course of treatment of eight mice, to observe tumour metabolic changes after - cures and cures of docetaxel. because some animals died after the fifth cure of docetaxel, not enough data were available to perform further statistical analysis. results: tumor xenograft volumes continued to rise during the first cures of chemotherapy but tumour growth significantly slowed down afterwards. before tumour growth stabilization, f-choline pet revealed a decrease in tumour metabolism characterized by a significant fall (p= . ) of both suvmean (- %) and suvmax (- %) in comparison with initial values. a transitory stabilization of tracer amount in tumours (%id/ml) was also noted. nevertheless, this observation was restricted to the induction phase, while later pet studies (after or more cures) demonstrated a slight increase of semi-quantitative parameters in parallel to a tumor size regrowth, suggesting a docetaxel failure in the tumour proliferation control. conclusion: these preliminary data show that docetaxel treatment inducted a rapid decrease of semiquantitative index of f-choline uptake in lncap xenograft tumours. nevertheless, these observations are limited in time due to the suboptimal control of tumour growth by chemotherapy in these small animal series. purpose: we studied dynamic pelvic imaging followed by whole body ffluorocholine pet/ct imaging for the assessment of salvage radiotherapy in prostate cancer patients presenting either biochemical recurrence or suspicion of residual disease. methods: we evaluated patients with a persistent > , ng/ml or elevating psa (median . ; range . - . ), after radical prostatectomy combined or not with radiotherapy and after radiotherapy commonly with additional hormonotherapy. systematically all patients underwent early dynamic pelvic imaging within the first minutes after intravenous injection of mbq f-fluorocholine, followed by total body pet/ct scan (siemens sensation or ). late pelvic imaging after minutes was performed in patients. fused pet/ct images were interpreted visually by observers. correlation was made with other imaging modalities including endorectal mri ( patients) and bone scintigraphy ( patients). first results: overall, of the patients showed positive pet/ct for local or distant recurrence, were equivocal and negative. when classified according to site, were positive for local recurrence, equivocal and negative. loco-regional lymph nodes were positive or equivocal in patients. of the patients with positive pet/ct findings for distant sites, were positive for lymph node, for bone and for adrenal metastases. when classified according to psa levels, patients were equivocal and negative in range ng/ml, positive and negatives in range > to ng/ml, and positive and ambiguous in range > ng/ml. subsequently patients underwent salvage radiotherapy with the radiation field centred according to pet/ct findings as well as other imaging modalities. conclusion: dynamic and late ffluorocholine pet/ct imaging was advantageous in assessing loco-regional recurrence of prostate cancer. / patients with psa > ng/ml had positive pet/ct findings. consequently, salvage radiotherapy field could be better defined. further evaluation of the accuracy of this technique in the detection of recurrence using quantitative criteria as well as long term follow-up is underway. aim: pet/ct using f-choline (fch) was found to be valuable in the detection of prostate cancer recurrence even at lower psa levels. we evaluated the possible use of fch pet/ct in early re-staging of prostate cancer relapse with regard to the degree of glandular differentiation of the primary prostate tumor [gleason score(gs)]. methods: patients who had well/moderately differentiated primary prostate tumors (gs </= ) and were at low-risk for recurrence, and more patients who had poorly differentiated primary prostate cancer (gs> ) and were at high-risk for recurrence underwent a whole body pet/ct scan at > min after injection of . mbq/kg of fch (iason labormedizin gesmbh & co. kg graz-seisberg, austria) because of rising psa (> . ng/ml) after initial therapy (prostatectomy n= , radiotherapy n= , hormone therapy alone n= ). ( %) patients with gs> and ( %) patients with gs </= were under adjuvant hormonal therapy at the time of examination. focal high uptake of fch was rated (visual interpretation) as probable recurrent disease. corresponding images of ct from pet/ct (discovery ls pet/ct scanner, ge healthcare, milwaukee, wi, usa) were also used to achieve the diagnosis. results: prostate cancer recurrence was confirmed in all but one fch positive case in the clinical course. no fch negative patient had prostate cancer relapse from the clinically available data during a month follow-up . fch pet/ct detected recurrent disease in / ( %) high-risk patients (local recurrences n= , distant recurrences n= ) and in / ( %) low-risk patients (local recurrences n= , distant recurrences n= ). among them, high-risk patients and low-risk patients were under hormonal therapy. median psa in fch positive cases was . and . ng/ml for high-risk and low-risk patients respectively; median psa in fch negative cases was . and . ng/ml for high-risk and low-risk, respectively. fch pet/ct obtained true positive findings even at lower psa levels (< . ng/ml) in many ( / ) cases with gs> (median psa . ng/ml, range . - . ) but in only few ( / ) cases with gs</= (median psa . ng/ml, range . - . ). ( %) high-risk patients as well as ( %) low-risk patients developed recurrence in the first years after therapy. all recurrences (local n= , distant n= ) were identified by fch pet/ct, and for patients pet/ct was the only test showing recurrent disease. conclusion: fch pet/ct is proven as feasible in early detection of prostate cancer relapse, especially in those with poorly differentiated primary prostate cancer. introduction: retroperitoneal (rp) lymph nodes represent the regional lymphatic drainage in germinative testicular tumors. these lymph nodes often remain enlarged even following chemotherapy (cht), while the histopathological findings in resected lymph nodes consist of fibrotic tissue ( %), teratoma ( %), or other viable tumor cells ( %). aim: evaluation of the benefit of f-fdg pet in prediction of the viability of the rp masses via comparison of pet positive or pet negative findings in patients following curative cht plus rp residue resection. patients and methods: from september through june ( months) a total of pet scans were performed in patients with germinative testicular tumors. the presented study group includes patients after cht, in which the rp masses were resected within an average of days following the pet scan. the patient age ranged from to years (average . years, median . ). the tumors included seminomas and non-seminomas. results: the pet scan results subdivided the rp masses into pet positive (n = , activity of the lesion higher than the referential activity of the liver), and pet negative (n = ). in the pet positive subgroup the resection confirmed persisting tumor tissue in cases, while false pet positive results were recorded in patients with inflammatory changes within fibrosis (in both seminoma and nonseminoma). fibrotic changes were correctly detected via pet in patients with seminomas. the negative pet scans in patients with non-seminoma proved problematic due to eventual histopathological findings of teratocarcinoma micrometastases ( x), mature teratoma ( x) as well as fibrotic changes ( x). conclusion: in case of seminomas the fibrotic residual masses were detected correctly. we have recorded false pet positivity due to inflammatory changes in fibrotic tissue in various histological tumor types. our data suggest limited capability of pet to differentiate residual fibrotic masses from mature teratoma in case of nonseminomas (both findings can appear as pet negative). support: iga mzcr grant nr - / . aim: the incidence of testicular cancer has increased three-fold over the last decades, with the highest incidence being in european countries. a relatively new method fdg pet/ct, might be useful to overcome the diagnostic problems in re-staging testicular carcinoma. this study was designed to determine the value of fdg pet/ct compared to mri and ct, in the evaluation of recurrence disease and postchemotherapy residual mass in testicular carcinoma. material -methods: we examined patients who underwent whole-body pet/ct (siemens biograph lso) scans with -deoxy - -[f f]fluoro-d-glucose (fdg). the injected radioactivity dose for all scans was between - mbq ( - mci). all of the patients had history of testicular carcinoma and underwent the pet/ct for re-staging. mean age , ± , years. in men with testicular carcinoma, were subjected to ct scans (group a) and to mri (group b) for disease reevaluation just before pet/ct reevaluation. results: / patients had positive pet/ct scan (suv , ± , ), / patients had positive ct while / had positive mri. group a: / patients ( , %) had match findings in pet/ct and ct scans ( cases negative results and cases positive results). in cases with positive ct, pet was negative ( , %) while in cases with negative ct, pet was positive ( , %). in / patients we had mismatch findings between pet/ct and ct (in patients, pet/ct scan outbalanced ct, while in cases we had the opposite result). group b: in / patients ( %) match findings observed between mri and pet/ct scan ( cases negative results and case positive result). / patients ( %) had mri (+) and pet/ct (-) while / patients ( %) had mri (-) and pet/ct (+). in / patients ( %) with mri (+) and pet/ct (+), pet/ct outbalanced mri. in men with tumor markers, of them had elevated blood levels. / patients with abnormal tumor markers had positive pet/ct scan, while / patients had negative pet/ct (all cases with elevated afp levels). on the other hand in patients with normal tumor markers of them had negative pet/ct and positive pet/ct scan. conclusion: these preliminary results demonstrate that fdg pet/ct was superior to conventional techniques in restaging patients with testicular carcinoma. fdg pet/ct was a sensitive and reliable modality for detection of residual viable tumor in these patients. aim: primary extragonadal germ cell tumors (exgcts) account for nearly % of all gcts and are characterized by a poor prognosis. radical post-chemotherapy surgery of residual masses represents the standard of care. in case of residual viable tumor or teratoma, complete resection may be curative. however, when only necrosis is found, patients will be exposed to surgery-related morbidity and mortality without any survival benefit. no reliable factors predictive of the presence of viable tumor or teratoma in residual masses are available yet. fdg-pet has been successfully used for staging primary gonadal gct, but its role in the management of residual masses form gcts has not yet defined. we aimed to assess fdg-pet as a tool to detect residual tumor after chemotherapy. materials and methods: we evaluated consecutive patients with exgcts (mean age years, range - ), who underwent residual surgery following standard platinum and etoposide based chemotherapy. four patients had primary mediastinal location, peritoneal. four patients had a non seminomatous tumor, had seminoma. three patients were metastatic at the time of first diagnosis. four out of patients were classified as poor prognosis (pp) according to the igcccg. the patients with good prognosis (gp) had cycles of chemotherapy, the others had cycles.. all patients had fdg-pet, following standard procedures, at the end of chemotherapy and before undergoing residual surgery. fdg-pet results were compared with pathological findings. results: after chemo the four pp patients were classified as in partial response, the gp as complete response. the mean tumor shrinkage on ct was %. a correlation between fdg-pet and pathological finding was found in all cases: two patients with positive pet had viable tumor in postsurgical specimen, while patients with negative pet had necrosis or fibrosis. conclusion: following chemotherapy for exgcts, complete surgery of residual masses remains the recommended standard of care since it may be curative in an approximately half of patients with residual viable tumor or teratoma. among other clinical factors a positive fdg-pet might help to identify patients at higher risk for residual disease. in these patients, complete surgery may be suggested even in centimetric residual disease. fdg-pet may also help to address surgery to active lesions in patients with thoracic and abdominal disease. introduction and aim: multiple myeloma (mm), malignant b cell and plasma cell disorder, involves the skeleton in more than % at diagnosis. conventional and radionuclide methods are routinely used to evaluate these lesions. recently, fdg pet/ct has been introduced to the field. in this study, our aim was evaluate the accuracy of fdg pet in detecting myeloma lesions and its influence on patient's management comparing with clinical, radiological and bone scintigraphic findings. materials and methods: pts ( f, m) were evaluated; group i had patients ( f, m; aged - years) with mm, group ii had pts ( f, m; aged - years) with solitary plasmocytoma and group iii had patients ( f, m; aged - years) with monoclonal gammopathy. mean follow up period was , ± , months. in group i, pts were referred for evaluation of extent of disease before bone marrow transplantation (bmt) and pt referred for assesment of bmt response, pts had pain and referred for assesment of the extent of disease, and other pts with no complaints referred for follow up. in group and , pet/ct was performed to evaluate the extention of disease. the results of whole body bone scintigraphy (wbs), radiographs, and mri or ct imaging modalities as well as the clinical course at the same period were used to compare with fdg pet/ct results. results: the results are summarized in this table. conclusion: pet/ct scan is helpful to evaluate mm pts. it appears to be more sensitive than other radiologic and scintigraphic examination for the detection of lytic bone lesions. however, it may not be sufficient for detection and differentiation of small lesions and diffuse marrow involvement. in this study, / pts had negative pet/ct and positive bone lesions. it was thought that the combination of pet/ct and other radiological and scintigraphical examination might be more succesfull than pet alone. since pet investigation was performed mostly during active disease evaluation of its impact on survival, response was not avalaible. it is also important to emphasize the disadvantages of pet/ct in myeloma treatment, steroid related hyperglycemia, early vertebrate operations the frequently performed cause false positivity. however, we took precautions to delay imaging untill months following surgery and avoding imaging during glucose intolerance. pet/ct has the applicability to whole body imaging which is hard to apply to mri and results with better resolution compared to whole body mri. , lymphoma (n= ),hepatoma(n= ), prostatic carcinoma(n= ), gastric cancer(n= ),esophageal carcinoma(n= ), multiple myeloma (n= ), thyroid cancer (n= ), osteosarcoma (n= ), renal carcinoma (n= ),unknown primary origin (n= ); nonmalignant cases ingcluding:osteoporosis(n= ),bone tuberculosis(n= ), inflammation (n= ), hyperparathyroidism (n= ).in of malignant cases f-fdg pet/ct showed tracer accumulations corresponding to etiologic diagnosis .the sensitivity of f-fdg pet/ct was / ( . %).the false negative rate of f-fdg pet/ct was / ( . %).in f nonmalignant cases f-fdg pet/ct showed abnormal tracer accumulations . the specificity was / ( . %).the false positive rate of f-fdg pet/ct was / ( . %). conclusion: whole body f-fdg pet/ct is a valuable tool in etiologic diagnosis of suspected bd,the diagnostic accuracy could be more improved combinding with ct ,mri appearance and clinical informations. aim: the aim of this retrospective study was to evaluate the potential additional diagnostic role of f-fdg pet/ct imaging for the detection of unknown primary origing cancer (cup). materials and methods: the study population consisted of consecutive patients ( men, mean age: ± . years old) with suspected cup, tumoral markers abnormalities and/or paraneoplasic syndromes. an f-fdg pet/ct was performed in all patients population. all acquired images were assesed by a nuclear medicine with experience in pet and pet/ct and a radiologist physician. results: the initial evaluation of patients showed two differents findings: . patients with macroscopic lesions: presence of masses and lymphoadenophatiesmostly supraclavicular -in patients ( %) and liver and bone metastases in patients ( %). . patients without macroscopic lesions: high serum levels of tumour markers in patients ( %) and paraneoplasic syndromes in cases ( %). pet-ct results were: normal test in patients, non-specific features in patients and hypermetabolic lesions sugestive of malignancy (suv > ) in patients. primary tumor was sugested in patients and re-stage of neoplasm was performed in %. pet/ct was abnormal in all patients of the group with macroscopic lesions, except in one case. in the second group, pet/ct was suggested of malignancy in only of % of patients. conclusion: pet/ct identified primary tumour in % of patients with suspected cup, showing a better accuracy than other imaging techniques. in our study the diagnostic accuracy of pet/ct was higher than previously described in literature ( - %). however, the main limitation of this technique is the low ability to detect metastatic occult primary tumors in patients without macroscopic lesions. objectives: to provide accurate preoperative localization of parathyroid adenomas (pa) and to facilitate minimally invasive surgical approach to pa, as opposed to open cervicotomy and bilateral neck exploration. methods: for the same patients spect and mri scans were acquired with fiducial skin markers (fsms) placed on patient's thorax and neck. spect scans were obtained using: (i) mci of tc- m pertechnetate; (ii) min. and (iii) min. after administration of mci of tc- m sestamibi. mri was acquired with a t magnet using t -weighted spin-echo sequences. a deformable finite element model (fem) has been implemented for accurate nonrigid registration and fusion of spect and mri images. in this model fsms are used to sample d image deformation between spect and mri. in this method the intermodality displacements of the corresponding fsms observed in spect and mri are determined, then fem is used to distribute the fsms displacements linearly over the entire volume, followed by creation of a warped mr image registered with the spect image and by mri and spect volume fusion. a commercial ansys fem software was used for fem calculations along with our own programs for d image warping and fusion. results: we verified correct anatomical intermodal registration of the fused spect/mri images using organs with known high uptake of radiopharmaceuticals. the target registration error not exceeded mm. conclusions: our nonrigid registration and fusion method allowed creation of a detailed anatomic map of the neck and thorax from mri accurately combined with a functional d map from spect for improved preoperative localization of the parathyroid adenomas. aim: we describe our experience with ga-dotatoc pet imaging in neuroendocrine and neuroectodermal tumours as compared to in-octreotide, i-mibg and cross sectional imaging over a two year period. material and method: thirty-three patients ( f, m) with a variety of neuroendocrine and neuroectodermal tumours underwent ga-dotatoc pet imaging. the mean administered activity was mbq. the number of lesions, intensity of uptake and overall quality of the images were compared with octreotide or mibg (performed within months in % of cases) and radiological investigations such as ct, mri and angiography (performed within months in % of cases). results: five patients ( %) had additional lesions on the ga-dotatoc scan compared with other nuclear medicine imaging. in two of these patients the ga-dotatoc scan showed the lesions more clearly than the in-octreotide scan due to better resolution. in / ( %) patients, in-octreotide or i-mibg demonstrated more lesions than the ga-dotatoc scan. of these cases, / were in patients with benign phaeochromocytomas. in / ( %) patients all scintigraphic tests were negative when radiological investigations including angiography demonstrated lesions. conclusion: ga-dotatoc pet has an emerging role in detecting a wide range of neuroendocrine and neuroectodermal tumours. it shows better resolution and demonstrates extra lesions compared to in-octreotide and i-mibg. in has lower sensitivity than i-mibg for benign phaeochromocytoma but higher sensitivity in malignant neuroectodermal tumours. the multi-modality approach remains essential as % of these tumours were only detected with anatomical imaging. the increasing use of pet-ct should improve the sensitivity of this technique. breast cancer is the most frequent tumour in women. it would be very useful to identify patients responders to neo-adjuvant treatment from not responders. aim: the aim of this study was to systematically review the literature regarding the value of fdg-pet and pet-ct in the assesment of treatement respond after neo-adjuvant theraphy. materials and methods: systematic review of the literature, searching relevant studies in medline and cancerlit. for the selection of the studies we applied inclusion and exclusion criteria that had been previously set. two independent reviewers assessed the methodological quality of each selected study (flynn criteria) and the eficacy diagnostic level (fryback). most relevant data and statistic results were obtained from each study. results: studies were found in the primary search. after aplying inclusion and exclusion criteria, four studies were selected. in three of these four studies the metodological quality was modarately low (c group) ; all the studies were in level ii of diagnostic eficacy. with a statistical analysis , . sensitivity, . specificity and . accuracy were obtained. most of the authors agree in the necessity of perform some pet studies during neoadjuvant treatment. most authors also agree that it would be suitable to use a semicuantitative analysis using "standardized uptake value" (suv) from assessment the response. the threshold value for differentiation responders and no-responders is different depending on the study. conclusions: recent studies suggest that fdg-pet may identify patients responders to neo-adjuvant therapy earlier then other conventional imaging modalities. it is still not clear when to perform pet studies or which is the appropriate threshold value for differentiation responders and not-responders. finally, further prospective investigations on a larger number of patients need to be performed. objectives: paragangliomas are usually slowly growing, somatostatin receptor (sstr)-expressing, benign tumours of the head and neck region. however, they can also be locally invasive and cause bone destruction and dysfunction of cranial nerves. up to % of paragangliomas are malignant and may metastasize, leading to distant lesions. therefore, accurate whole body tumour screening is important. the aim of this study was to assess the accuracy in detection of sstr-positive lesions derived from paragangliomas by ga-dota-tyr -octreotide (dota-toc) pet/ct or ga-dota-toc pet/mri fusion. methods/patients: in this study, the clinical value of sstr imaging with ga-dota-toc pet was assessed in patients ( male and female, age ranged from to ). seven patients underwent whole body imaging with ga-dota-toc pet, and in patients cerebral ga-dota-toc pet imaging was done. each patient received mbq ga-dota-toc, images were obtained - minutes post i.v.-injection. combination of morphologic and functional imaging was done by pet/ct or pet/mri, providing more accurate information in staging and restaging. the interpretation of ct and pet scans was done independently. results: of the investigated patients with paragangliomas patients showed true-negative and true-positive results. all known lesions were also shown by pet. additionally unknown bone lesions were detected in a patient with metastatic disease. because of the high sstr-expression in one patient with local recurrence of invasive paraganglioma, treatment with the sstr-analog lu-dota-tate was initiated, since no other therapeutic options were available. over one year six therapeutic cycles with an overall dose of , gbq were performed, without severe side effects. in the follow up one year after first treatment by ga-dota-toc pet/ct, minor response was observed. conclusion: ga-dota-toc pet provides accurate information concerning extension and localisation of paraganglioma lesions for initial diagnosis, for selection and for follow up after radionuclide-peptidetherapy. furthermore, our data indicate that whole body imaging with ga-dota-toc pet might be useful to delineate distant and small metastases of paragangliomas. . fourteen patients had more than one fdopa-pet examination (between to ). forty examinations were performed without combined ct and (since july ) with combined ct. the impact of fdopa pet was evaluated, on a per-patient basis, thanks to a questionnaire filled in by the referring physician and the pertinence of the induced decisions was assessed thanks to the follow-up data. results: -carcinoid tumour of the small bowel: of patients were evaluable. an impact of fdopa-pet was reported in of them (rate: %), corresponding to an adequate decision in all patients (major therapeutic changes in patients, minor therapeutic changes in patients and orientation of biopsies or complementary imaging in patients). among the examinations performed in these patients, examinations were true-negative (tn), were true-positive (tp) and only one was false-negative (fn) (residual tumour measuring mm, responsible for clinical symptoms). -non-carcinoid digestive tumours: of patients were evaluable. an impact of fdopa-pet was reported in of them (rate %), corresponding to an adequate decision in patients (decision of surgery and decision of medical therapy) and a non-pertinent decision in patients (inappropriate cancellation of surgery and futile complementary exploration of a questionable focus of fdopa uptake). the examinations performed in these patients corresponded to tp, tn, fp and fn results. conclusion: the overall rate of change in patient management was %, with a significant difference between the rate in carcinoid and in non-carcinoid tumours ( % vs. %, p < . ). fdopa-pet appeared to be a major tool for the management of carcinoid digestive tumours with excellent diagnostic performances and induced pertinent changes in the management of patients at a rate similar to that of fdg-pet in other malignancies. background: fdg pet has a role to evaluate the response to molecular targeting therapy with imatinib mesyilate against gastrointestinal stromal tumor. metabolic response assessed by fdg pet is earlier than morphological changes determined by ct or mri. the assessment of early response to the molecular targeting therapy has a clinical significance in terms of evaluating effectiveness and determining alternative therapy based on the possibility of ineffectiveness in the early stage of the expensive therapy. purpose: we have conducted preliminary study of fdg pet to assess early response to the chemotherapy with gefitinib to non-small cell lung cancer (nsclc). materials and methods: four patients with advanced nsclc who have measurable lesion and epidermal growth factor receptor mutation, and were scheduled for gefitinib therapy were evaluated. the study was approved by the institutional review board and all the patients gave informed consent. fdg pet was done prior to, days and - weeks after the commencement of the therapy. pet was performed after injection of - mbq/kg fdg by d acquisition using a dedicated whole-body pet scanner (set w, shimadzu, japan). transmission data was acquired simultaneously with emission data using the external source. uptake of fdg in the tumor was evaluated by the semiquantitative evaluation using standardized uptake value (suv). outcome of patients was correlated with the changes in the size of the tumor and the suv. results: conventional response evaluation with ct revealed that two of four patients showed partial response (pr) and the others showed stable disease (sd) with minor response. progression free survival (pfs) of the two pr patients was . and . months. pfs of two patients with sd was . and . months. fdg pet showed decrease in fdg uptake ( . % and . % of initial study) in sd patients as well as in pr patients. conclusion: fdg pet could represent early response to gefitinib and have a role to estimate prognosis even in patients with sd which is evaluated by conventional ct. aim: dynamic pet studies with f-fdg were performed in patients with advanced non-small cell lung cancer (nsclc) who received palliative chemotherapy to evaluate the impact of full kinetic analysis and assess its value with regard to short ot long survival. methods: the evaluation includes metastatic lesions in patients with nsclc. all patients received a combined chemotherapeutic protocol consisting of vinorelbin and oxaliplatin. the survival data served as reference for the pet data. all patients were examined prior to onset of chemotherapy and on day - after onset of the first cycle. the following parameters were retrieved from the dynamic pet studies: suv, fractal dimension (fd), two compartment model with computation of k , k , k , k (unit: /min), the fractional blood volume (vb) and the fdg-influx according to patlak was calculated using the formula (k x k ) / (k + k ). we used a two group classification, namely a short and long term survival group based on the median survival time ( days) as a cutoff. a support vector machines (svm) analysis was used for classification of the two a priori defined groups. results: the observed survival times varied from to days with a median survival time of days. most kinetic parameters demonstrated only small changes, mostly declining after one cycle. the change in all kinetic parameters did not correlate to the survival based classification.the change in suv was significant between the first and second study (p= . ) but without an impact on the prediction of short ot long survival. svm based analysis revealed the highest correct classification rate (ccr) between short and long survival for the combination of suv and influx of the first study and suv, influx, k , k of the second study with a ccr of . %. conclusion: the results demonstrate, that a full kinetic analysis of the f-fdg kinetics in nsclc is helpful for the classification into short or long survival and may be used to identify those patients who may benefit from this palliative chemotherapeutic protocol. aim: (a) to evaluate the efficacy of fdg pet in the early prediction of chemotherapy effect on human testicular cancer xenografts; (b) to determine the optimal delay between chemotherapy administration and fdg imaging. material and methods: animal model eight week-old male nude rats bearing subcutaneous human embryonal carcinoma xenografts (n= per animal) were treated with a single dose of cisplatin. a control animal received saline serum. pet imaging sa-pet imaging (phillips mosaic system) was performed . hours after injection of - mbq of fdg in the tail vein. fdg uptake was evaluated with tumour/background ratio (t/b ratio). animals were imaged at day (baseline examination), day , day and day . immunochemistry at each point, rats were sacrificed for immunochemistry studies which comprised cell proliferation (cyclin a), apoptosis (cleaved caspase ), and macrophagic infiltrate (anti-cd ). whole slice quantification (pixit® software) was used for comparison with sa-pet data. results: sa-pet imaging fdg uptake in rats who received cisplatin showed a biphasic evolution: initially, a peak was observed at day , with t/b ratios ( . +/- . ) higher than those observed at day ( . +/- . ), p< . . secondly, a decrease was seen from day to day , although t/b ratios at day were still higher than those at day . the decrease of fdg uptake became statistically significant at day (p< . ). in the untreated rat images, tumours demonstrated an increase of fdg uptake at day (far lower than that observed in treated animals) then remained stable. immunochemistry a significant increase of apoptosis was observed at day ( . +/- . ; p= . ) and day ( . +/- . ; p= . ) in comparison with day ( . +/- . ). a transient increase in cell proliferation was observed at day ( . +/- . ; p= . ) in comparison with day ( . +/- . ), and was followed by a decrease at day ( +/- . ; p= . ). macrophage infiltrate, a well known cause of false positive findings, remained low when fdg uptake was increased after chemotherapy. conclusion: fdg pet may be useful in the early evaluation of treatment in patients with testicular cancer. a very early increased fdg uptake precedes a transient increase in cell proliferation but does not reveal refractory disease. additional studies investigating the effect of chemotherapy type, dose and schedule are currently underway in our laboratory. purpose. the purpose of this study was to analyze the diagnostic accuracy of pet and pet/ct in the evaluation of treatment response, both analyzing early response to treatment (ert) after a few cycles of chemotherapy, and after having completed the treatment (ahct), in patients with hodgkin disease (hd) and non-hodgkin lymphomas (nhl). methods. we performed a systematic review of the literature, searching medline and embase databases for studies published until december . we included articles that evaluated pet and pet/ct in patients with lymphoma after treatment (ert and ahct). the eligibility was based in articles with sufficient data for calculate parameters of diagnostic accuracy, with separated analysis in hd and nhl. we calculated values of sensitivity (se), specificity (sp), positive probability rate (ppr) and diagnostic odds ratio (dor). results. we selected studies for analysis. the diagnostic parameters for ert in pet and pet/ct in patients with hd were: se of . ( recent studies have demonstrated the effective use of imatinib mesylate for the unresectable, metastatic or recurrent gist. the aim of this study was to evaluate the role of f fdg pet/ct in gist patients treated with imatinib mesylate. material and methods: eight consecutive patients with gist proven by surgery ( stomach, small bowel, small bowel and peritoneum, and rectum) underwent thirteen f fdg pet/ct imaging after the start of imatinib mesylate therapy ( mg/day or greater if disease progression). patients were overnight fasting and had normal blood glucose levels. pet/ct was acquired - minutes after the intravenous injection of - mbq of f fdg. iterative reconstruction algorithms were applied and pet images were corrected for attenuation on the basis of ct data. a visual analysis of images was performed. standardized uptake value (suv) was calculated for each lesion. in the patients who underwent serial fdg pet/ct imaging, the therapy response was assessed according to the recist criteria for ct and eortc recommendations for pet. results were confirmed by clinical follow-up, radiographic findings or histological analysis. results: five patients were therapy-responders. the response was complete in , of them had abdominal lymph nodes and the other, peritoneal implants. the remaining patients had a partial response showing persistent fdg uptake in lung ( ) and in liver metastases and lymph nodes ( ). this latter patient showed a complete response increasing the imatinib mesylate dosage to mg/day. one patient had a disease progression showing new hepatic lesions on fdg pet/ct; a partial response was documented (a decrease of suv in two liver lesions) after a left hepatectomy and an increase of dosage to mg/day. two patients were no-responders. one patient had an unresectable pelvic gist and the other multiple peritoneal implants. both patients died in a - months period after fdg pet/ct. conclusion: tumor response to imatinib mesylate should be assessed by fdg pet/ct. fdg pet/ct imaging identified the degree of therapy response with a clinical impact on the management of patients with gist. of doses that mimics maximum tolerated dose (mtd) used clinically. the body weight of each mouse and the size of tumor implants were monitored throughout the experiment. the mice were scanned with f-fdg on days , , , and post tumor inoculation using high-sensitivity projection imaging (ppis- , hamamatsu) with f-fdg for monitoring the anti-tumor effect of ctx. the results of ppis imaging was compared to those of micropet imaging (r , concorde). result: ctx treatment resulted in growth inhibition of the ct- tumor and a decreased of the body weight of the mice as compared to the untreated controls. both the highsensitivity projection and micropet f-fdg imaging modality are equally effective in monitoring the ctx-induced tumor growth changes. conclusion: our results demonstrated that ppis imaging modality is as effective as micropet in the monitoring of the tumor response to ctx chemotherapy. these results suggest that the high-throughout screening imaging system may be employed for evaluating new anticancer drug using murine tumor models. aim: aim of the study was to evaluate the usefulness of ffdg-pet/ct in patients (pts) with lower rectal cancer treated with neoadjuvant chemo-radiotherapy (crt). fifty-five pts were enrolled in the study. all patients had known rectal cancer located within cm from the anal verge. the pts characteristics were: men, women, mean age ( - ). stage: pts (ut n-m ), pts (ut n-m ), pts (ut n+m ), pts (ut nxm ), pts (ut n m ), pts (ut nxm ). chemotherapy consisted of a weekly schedule of oxaliplatin (oxa) and -fluorouracil ( fu) or fu alone. radiotherapy started the same day as cht and was delivered up to a dose of . gy in daily fractions of . gy. rectal surgery was performed - weeks after the end of neoadjuvant treatment. fdg-pet/ct was performed at staging and - weeks after the end of crt. pathological examination of surgical specimens included the tumor regression grade (trg) evaluation according to mandard. pts were followed up for - months. suvmax pre and post crt was measured in the site of the primary lesion. results: twenty-nine pts were considered as complete pathological responders (group : trg - trg ). twenty-six pts were classified as pathological non responders (group : trg - trg ). the mean suvmax decrease compared to the baseline was % (range - % to - %) in group and % in group (range - % to - %). the mean value of suvmax post crt in group and was respectively and . . in group pre therapy suvmax mean value was . , while in group was . . interestingly, pts with trg showed a pre therapy suvmax mean value of while pts with trg showed a pre therapy suvmax mean value of (p < . ). conclusion: in our series of patients no correlation was found between metabolic response (suvmax decrement) and pathological response (trg). however a correlation was found between pre-therapy suvmax value and pathological response (trg vs trg ). aim: to evaluate the fdg metabolism in patients (pts.) with high risk soft-tissue sarcomas receiving an induction or neoadjuvant chemotherapy. the treatment effect was assessed with regard to the prediction of therapy outcome. methods: the ongoing evaluation includes patients with high grade soft-tissue sarcoma with different histologies. pts. received an induction chemotherapy consisting of adriamycin mg/m /day and ifosfamide mg/m /day - (ai-g regimen, six cycles) prior to peripheral blood stem cell transplantation, and pts. were treated with pre-operative chemotherapy consisting of etoposide mg/m /day + , ifosfamide mg/m /day - and doxorubicin mg/m /day (eia regimen, cycles). pts. were examined prior to onset of therapy and after completion of the first cycle of ai-g and after two cycles of eia chemotherapy, respectively. the restaging data of patients ( pts with ai-g and patients with eia treatment) served for reference. restaging was performed using ct and/or mri after six cycles of ai-g or four cycles of eia chemotherapy. results: restaging data are available in pts. according to recist criteria, clinical outcome was as follows: pt. showed no evidence of disease (ned), partial remissions (pr), stable diseases (sd), and pts. progressive disease (pd). due to the small number of pts., we dichotomized the data in pts. with ned/pr (n = ) and pts. with sd/pd (n = ). median suv prior therapy was . suv in comparison to . suv after chemotherapy. median influx was . prior to chemotherapy in comparison to . following therapy. most kinetic parameters showed only small changes, only vb declined after one cycle. we used discriminant analysisto classify the patients into responders and non-responders. da revealed a correct classification rate of % using all kinetic data of the baseline study and % using all kinetic data of the second study. conclusions: on the basis of these results, kinetic fdg data are helpful for the prediction of chemo-sensitivity in patients with high risk sarcomas. f-fdg pet/ct monitoring of tumor response to chemotherapy: does f-fdg imaging can be used as a chemosensitivity testing method? s. song, g. huang; renji hospital, shanghai jiaotong university, shanghai, china. aim: the aim of this study was to determine if fdg-pet/ct can be used as an in vivo individual chemosensitivity testing method, especially in those who underwent chemotherapy at the begining. material and methods: fourteen vx xenografts bearing new zealand rabbits with total of tumors in axillary fossa close to anterior wall were randomly divided into control group(n= ) and cisplatin chemotherapy group(n= ). the tumors were - mm in size. in treatment group fdg-pet/ct images were obtained before administration cddp(pett ),during treatment ( min after administration cddp pett ), d(pett ), d(pett ) and d(pett ) after chemotherapy. in control group fdg-pet/ct were obtained every days from the first imaging to days of total pet/ct imaging since the rabbit were inoculation vx tumor. results: mean suvmax ( - min after injection )of the control group were increased steadily, which were . ± . (petc ), . ± . (petc ), . ± . (petc ), . ± . (petc ), . ± . (petc ) and . ± . (petc ) respectively. in cddp treatment group, according to the degree of suvmax decrease on pett and pett , we divided the xenografts into a responder group (partial response + stable disease, n = ) and a nonresponder group (progressive disease, n = ). we use the (pett -pett )/ pett degree> % as the criteria of response. the retention index and t/m ratios showed marked changes at the time point of pett in the responder group, although the tumors did not show any significant change in volume at that time. paraffin section stained with haematoxylin and eosin of sections showed that the number of viable tumor cells in the responder group decreased at days, and peaked at days. necrotic cells and fibrotic tissue were observed after cddp treatment of and days. the decrease of fdg uptake in responder group on pett was an early marker that the individual was sensitive to cddp, and correlated well to days pathology results. in non-responder group there were no significant changes in pathology results compared with control group. conclusions: early evaluation by fdg-pet/ct, especially during cddp administration is useful. the decrease of fdg uptake was an in vivo biomarker to predict later pathology result. the study included patients diagnosed and treated of nmlc. fdg-pet/ct was done and weeks after chemoteraphy and/or radioteraphy respectively. pre-treatment staging was done with the addition of fdg-pet/ct in patients, and only by ct in . the images were evaluated by visual and semiquantitative analysis and the results were compared with ct findings. final diagnosis was based on the information obtained from clinical records. a good therapeutic response (gr) was achieved in patients, no changes (nc) in , and progression of the disease (pr) in . results: fdg-pet/ct and ct findings agreed in of the patients ( %) and disagreed in ( %), with gr, with nc and with pr. in of the , fdg-pet/ct revealed more lesions than ct ( in gr, in nc and in pr), showing a more extensive nodal disease in , extra-nodal metastatic disease in and local growth in one. in of the patients with discordant findings ( %), all with gr, fdg-pet/ct rule out tumoral disease suspected by ct findings. in patients ct studies were non-diagnostic ( with gr and with pr), and in of them fdg-pet/ct rule out disease, in confirm it. overall, fdg-pet/ct was definitive to establish the final diagnosis in of the with gr ( %), in one of the with nc, and in of the with pr ( %). interestingly, regarding the employment of pet/ct at staging, of the in whom it was applied, showed gr; however of the in whom staging was based only in ct, only showed gr unlike who showed pr. conclusion: the results demonstrate the value of fdg-pet/ct and confirm that it must be included in the assessment of the response of treatment of nmlc. in addition to clarify non-diagnostic ct scans, revealed a considerable number of unsuspected tumoral lesions. moreover, when fdg-pet/ct is employed for the initial staging a better therapeutic response is obtained. . males and females. they were of post solid organ transplantation namely heart (n= ), lung (n= ), liver (n= ), and kidney(n= ) that were performed from september until october . they were for staging purposes (n= ), and as follow up assessment( n= ), post therapy. the biopsy procedure and tissue samples were obtained prior to the pet ct scan. the results of a total pet ct were compared with conventional imaging (us, ct, mr), both of which imaging were done about the same time. results: cases were confirmed ptld by histopathological diagnosis. patients developed ptld early(less than months)and patients developed late ( months and later) after transplant. the mean time to onset is . months. ptld histological subtypes revealed malignant lymphoma,(ml) in cases, polymorphic lymphoproliferative disorder (pld) in cases, multiple myeloma (mm) in cases. in patient, diagnostic histology type was not available. cases involved only the lymph nodes and cases involved extranodal. in / examination, pet ct and conventional imaging were concordant. in comparison to conventional imaging, the pet ct study results showed lower sensitivity ( . % vs %) but similar specificity( % vs %). the overall accuracy of pet in diagnosis and follow-up is almost similar to conventional imaging ( . % vs %). conclusion: this study suggest pet ct is an accurate diagnostic tool in staging and follow-up of ptld patients. however, reconfirmation with histology of all positive findings remains mandatory. it is also a useful modality in patients with impaired renal function as a result of chronic immunosuppressive treatment. as no contrast medium is necessary, contrast related nephrotoxicity in ptld patients is avoided. further study is recommended before implementing pet ct as a routine diagnostic tool in suspected cases of ptld following solid organ transplantation. keywords: aim: f-fdg pet is increasingly used in radiotherapy planning. the aim of this study was to evaluate from a retrospective study the feasibility of using f-fdg pet/ct to detect and delineate the target volumes in advanced nsclc. this implementation into radiation treatment planning has required strong collaboration between radiation oncologists and nuclear physicians. patients and methods: from april and october , were enrolled for radical radiation therapy staging patients with unresectable nsclc ( males and females; mean age . years), performance status > % (karnofsky), squamous cell carcinoma, adenocarcinoma and large cell carcinoma, stage iii (n= ), stage iv (n= ). whole body pet/ct (biograph sensation siemens) was performed after min from the injection i.v. of mbq f-fdg, followed by pet/tc scan of the roi on bed for radiotherapy. gtvs were determinated and based on the pet data. results: after fdg pet/tc, out of pts were judged to be potentially eligible for curative treatment; out of pts underwent concurrent chemotherapy, out of pts performed successive surgery (in one of these a focal thyroid uptake of fdg were investigated and malignant lesion were demonstrated by cytological analysis -papillary cancer-). out of pts fdg pet/tc detected distant metastases (controlateral lung, adrenal and bone); in this pts was given palliative therapy. mean rate of radiation was gy ( - ). gtv was changed in all pts (decreased in pts and increased in pts). out of pts had mild toxic effects ( oesophagitis, cough, dyspnoea); out of pts moderate toxic effects ( oesophagitis, dyspnoea). all pts were followed for at least months; pts presented relapse ( with local and with distant recurrences), pts were in stable disease and pts were in complete remission (median time of months: range - ). one patient died post-treatment. conclusion: our data, even if obtained in a short number of pts, seems to confirm that fdg pet/tc could add information to precisely identify the gtv in advanced nsclc so as to obtain a better local control of disease. the technique of tumor contour definition by fdg pet/ct lead to substantially different volumes, especially in pts with necrotic or colliquative areas in the tumor mass. as we know from literature pet significantly altered the gtv or ctv in %, therefore all patients underwent a whole-body pet scan after a ct scan. the ct images provided morphological volumetric information, and in a second step, the corresponding pet images were overlaid to define the effective target volume. the images were exported off-line via an internal network to an rt simulator. we consider definitive follow-up after two years from treatment or in case of patient death's. the dose range is ÷ gy, with a mean of , gy. five patients have a negative pet, so the rt field was the whole mediastinal area to prevent prospective micro metastases. in all the others cases we have considered the pet area as the gtv for rt. results: nine patient were excluded from the study owing to change in the disease stage subsequent to the pet/ct study, sclc and nsclc. among the remaining patients, we have definitive follow-up for pz ( %) and temporary follow-up for the others . we verified ( %) not evident disease, ( %) sistemic progression or diffused metastases, ( %) stationary disease and ( %) with relapses in the rt field or in the neighboring. conclusion: fdg-pet is a highly sensitive imaging modality that offers better visualisation of local and locoregional tumour extension. this study lead to the conclusion that the use of pet/ct in radiotherapy planning allows a better patient management and gives comforting results about relapses in field. the assessment of the radioimmunotheraphy with it is important to assess the therapeutic response in refractory or relapsing lymphoma patients before progression of disease. therefore, we intended to find out the optimal timing for assessing the treatment response of the i-rituximab in patients with refractory nhl using f-fdg-pet/ct (pet). methods: twenty-eight patients with nhl (dlbl in , mcl in , mzbcl in , fl in , malt in ) refractory to previous chemotherapy ( to cycle, median: cycle) were enrolled. pet was performed at pretreatment, and days, days, and - days after i-rituximab. we compared pre and post-treatment pet with parameters; mean suv, maximum suv (suvmax), volume of interest (voi) of lesions, total metabolic volume volsum) and adjusted metabolic volume (suv*volsum). we correlated the decrement (%) of individual pet parameters calculated by roc curves with the clinical assessment of the treatment of months after i-rituximab. results: clinical assessments for the i-rituximab were cr in , pr in , sd in and pd in . area under the curve of the calculated decrements of each pet at , , and - days after i-rituximab were . , . and . for suvmax, and . , . and . for suv*volsum. there were statistically significant differences in the pet parameter decrements on days after i-rituximab (p< . ). moreover, there was tendency of disease progression in the ~ days pet parameters. conclusion: the assessment for the treatment of i-rituximab in patients with refractory nhl using pet was recommended at days after treatment. second dose of irituximab was recommend within ~ days before progression of disease. aim: ct images provides additional anatomical information for pet/ct study. however, the role of contrast medium in pet/ct is still controversy. in this study, we demonstrate the results and our experience by using ct contrast medium enhancement in fdg pet/ct examination. material and methods: between dec. and apr. , fdg pet/ct studies were performed on patients. patients whose images had either insufficient anatomic information or equivocal findings in fdg pet/ct were included in the study. subsequently we performed delayed imaging without and with intravenous contrast medium. the impact of contrast medium was assigned a value on a -point probability scale. results: during this period, fdg pet/ct delayed studies with contrast medium enhancement in patients were recruited for the study. among these scans with contrast medium enhancement, malignancy of the digestive system ( / , %) is the most frequently required for this procedure, especially in colorectal cancer ( / , %). in fact, contrast medium technique was useful for delineating the boundary of tumor and its surround tissues, evaluating vascular invasion of the tumor, and determining the vascularity of suspected lesions. there was mild adverse effect occurred in patients with skin rash and patients with extravasating contrast medium. conclusion: an additional imaging with contrast medium enhancement in fdg pet/ct study may provide useful information in cases with insufficient anatomic information or equivocal findings. the relatively side effect for contrast medium is acceptable in this study. introduction: the accumulation in the stomach and colon often pesters nuclear medicine physicians with the interpretation as to whether " normal or not " because f-fdg frequently accumulates not only in the abnormal lesion like malignant tumor but also in the normal stomach and intestines. the purpose of this study is to assess the ability of scopolamine butylbromide that inhibits the periatalsis to reduce the physiologic uptakes in the stomach and colon. methods: we studied people who had a checkup for cancer using pet/ct. all people are less than fifty years old and mean age was . ± . ( to ). fifty-four people were female and ninety-four people were male. we administered an intravenous drip injection of isotonic sodium chloride solution including scopolamine butylbromide of mg to people in this study for minutes. the drip was started at five minutes before the injection of f-fdg. we categorized the degree of f-fdg uptake in the stomach and along the colon into four grades according to the following scale: grade : no visible uptake; grade : lower than in the liver; grade : similar to the liver; grade : higher than in the liver. also, we measured suv in the stomach (circle roi, mm in diameter) and counted the number of nodular uptakes in the colon that is higher than in the liver per man. results: the mean grade of stomach in the injection group ( . ± . sd) was significantly lower than that in the non-injection group ( . ± . sd) (p< . ). also, the mean grade of colon in the injection group ( . ± . sd) was significantly lower than that in the non-injection group ( . ± . sd) (p= . ). the suv in the stomach averaged . ± . sd in the injection group, and . ± . in the non drip injection group. the averaged suv in the drip injection group was significantly lower than that in the non drip injection group (p< . ).the number of nodular uptakes in the colon ( . ± . sd) in the injection group was lower than that in the noninjection group ( . ± . sd), but the significant difference was not found (p= . ). conclusion: our results indicate that the intravenous drip injection of scopolamine butylbromide can reduce the physiologic uptake in the gastrointestinal tract, especially in the stomach. aim: to detect malignant tumors pet images are usually obtained about hour after intravenous administration of fdg, but fdg uptake by malignancies is often greater in delayed scans than in early scans. we investigated malignancies that were only detected on delayed scans and showed no fdg uptake on early scans. materials: two pet specialists judged the fdg-pet images of lesions in patients ( men and women with a mean age of . ± . years), which showed no uptake on early scans and abnormal uptake on delayed scans. these lesions were shown to be malignant by histology in cases, by follow up in cases, and by other methods in cases. methods: pet images were obtained from to minutes (early scans) and from to minutes (delayed scans) after administration of fdg following hours of fasting. the roi was set on the sites of abnormal fdg uptake on delayed scans and the corresponding area on early scans, after which the suv max of each roi and the rate of increase were calculated. results: the lesions included metastatic liver tumors, metastatic lung tumors, metastatic mediastinal lymph nodes, abdominal lymph nodes, prostate cancers, cases of peritoneal dissemination, primary lung cancers, bladder cancers, esophageal cancer, mesothelioma, hepatoma, and cholangioma. the suv max values for the early scans and delayed scans were . ± . and . ± . , respectively, while the rate of increase was . ± . . discussion: among the lesions, the most common was metastatic liver tumors, presumably because fdg uptake by these lesions increased over time and normal liver uptake decreased. the second most frequent diagnosis was metastatic mediastinal lymph nodes, also presumably because fdg uptake by these lesions increased over time and mediastinal background uptake decreased. four prostate cancers and bladder cancers were detected on delayed scans because bladder uptake was markedly decreased on these scans. the other lesions were too small for abnormal uptake to be detected on early scans. conclusion: examination of a delayed scan is extremely useful for detecting malignant tumors that do not show fdg uptake on the early scan, especially lesions surrounded by high background activity, such as those in the liver, mediastinum and bladder. fdg uptake in cold and heat treated mcf- cells, comparison with cell viability, apoptosis, and tumor marker changes c. zhang, x. sun, j. liu, p. liu, g. huang; renji hospital, shanghai jiaotong university, shanghai, china. aim: to investigate the fdg uptake changes in cold and hyperthermia therapy and its correlation with cell viability, apoptosis and tumor marker changes. material and methods : an in vitro cultured breast adenocarcinoma cell line, mcf- , was divided into groups. hyperthermia group: cell was treated in degree centigrade min. hypothermia group: cell was treated in degree centigrade min. hypo-and hyperthermia group: cell was treated in degree centigrade min and degree centigrade min. chemotherapy group: cell was treated with microgram cisplatin for hours. and control group: cell was untreated. the levels f-labelled fdg uptake, a -( , -dimethylthiazol- -yl)- , -diphenyltetrazoliumbromide viability assay, flow cytometry assay and tumor markers (ca ,ca ) were detected at hour and hour. results : the change of f-fdg uptake is early than tumor marker (which came out at the h) under our study conditions. in treated mcf- cells, the levels of f-labelled fdg uptake were significantly lower than control group. the levels of f-fdg uptake depression were well correlated with cell viability and apoptosis data. conclusions : fdg uptake is sensitive and well correlated with cell viability and apoptosis assay, and can be used for early response monitoring in hypoand hyperthermia therapy. purpose: to prospectively analyse the relevance of pet/ct in the clinical management (benign disease/malignancy, initial staging, re-staging) of the primary pleural malignancy (ppm). methods: consecutive patients ( - y.o., median y.o.; m, f) with pleural disease were included. all of them underwent a wholebody pet/ct investigation (discovery ls, ge healthcare) with standard dose ( . mbq fdg/kg). studies were reviewed. pet/ct findings were assessed according to the tnm international mesothelioma interest group clasification. the clinical indications were: suspected ppm (group a: n= ); initial staging of primary malignant mesothelioma (pmm) (group b: n= ); re-staging following therapy (group c: n= ) and assessment of recurrence (group d: n= ). for clinical management and to establish prognosis the following subgroups were compared: t -t vs t , n -n vs n -n y m vs m . imaging findings were correlated with surgical and histopathologic staging in all patients. results: in group a (n= ) malignancy was excluded in / patients and confirmed in / cases, thus avoiding multiple invasive procedures and speeding up diagnosis. in group b (n= ) pmm was staged as: epithelioid (n= ), sarcomatoid (n= ) y (n= ) was unknown. it was located on the right-sided (n= ) and left-sided (n= ) pleura. eight studies diagnosed irresectable disease: t (toracic wall/mediastinum infiltration) in / ; n (mediastinal adenopathy) in / and m in / . globally pet/ct diagnosed / patients ( %) with extensive disease significantly modifying their clinical management. in group c studies were performed to assess response to therapy: chemotherapy (n= ): / with stable disease and / with disease progression, / with partial response and / had no previous study for comparison; surgery (n= ): to assess incomplete surgery (decortication) showed residual disease and without evidence of recurrence; surgery and chemotherapy (n= ) without evidence of recurrence. pet/ct showed unknown metastasis in two patients and a synchronic unknown malignancy (synchronic squamous cell carcinoma in the contralateral lung) which was confirmed by pathology. conclusions: pet/ct is a non-invasive multimodality imaging technique with significant relevance in the clinical management of the primary pleural malignancy. estimation of optimal kinetic model and prediction of pathological diagnosis of anterior mediastinal tumor using c-acetate dynamic pet study aim: recent studies indicated that c-acetate (ac) may be a complementary tracer in pet imaging of thymomas. but, kinetics of ac in tumor tissue is not completely elucidated, and it is unknown which kinetic model (km) is most optimal. the aim of this study is to evaluate which km is most optimal for analyzing ac dynamics in thymoma tissue, and whether dynamic ac-pet study can predict pathological diagnosis of mediastinal tumors using this "most optimal" km. methods: dynamic ac-pet studies were performed for suspected thymic tumor with anterior mediastinal mass on chest ct scan. (in addition, static ac-pet scans and fdg-pet studies were also performed just after dynamic ac-pet studies.) we assumed candidates of four kms as follows: we analyzed datasets of cases diagnosed pathologically ( thymomas of type a/ab, thymomas of type b /c, and thymic cysts) from august until december , applying to these (a)-(d) kms, and calculated akaike informational criterion (aic) of each km, and determined which km is most optimal, based on values of aic. furthermore, we analyzed datasets again using this "most optimal" km, and estimated parameters, and compared with pathological diagnoses. results: aics of (a) c- p km became smallest in all datasets, and it seemed to be "most optimal" among kms. using c- p km, we estimated rate constants (k , k ) and blood volume and calculated metabolic rate (mr) defined as k /k in thymomas of who type a/ab, mrs were more than . (k >k ), and in the remaining tumors, mrs were less than . (k < k ). cases with thymomas (type a/ab/b /c) were successfully detected by static ac-pet scan, but cases among thymomas were false negative by fdg-pet. cases with thymic cysts demonstrated neither ac nor fdg uptake. conclusion: this study indicated that c- p km may be "most optimal" for pharmacokinetic analysis of ac in anterior mediastinal tumors, and mr obtained by dynamic ac-pet studymay be useful for discriminating between type a/ab thymomas and thymic cysts, or type a/ab thymomas and more aggressive histology, as well as static ac-pet scan. objective: a potential false-positive fdg pet interpretation in oncologic imaging is fdg-uptake in brown adipose tissue. the purpose of this exhibit is to demonstrate the characteristic as well as the atypical locations and appearance of hypermetabolic brown adipose tissue in the neck, thorax, and abdomen. methods: twenty-one patients ( female, male; age range, - year-old) with brown adipose tissue on pet/ct studies were documented out of approximately scans. lesions were defined as brown adipose tissue by increased fdg metabolism corresponding to fat density tissue on ct scan. results: there were two cases of hibernoma, two cases of lipomatous hypertrophy of the interatrial septum and the reminder seventeen cases of brown fat were identified in neck, supraclavicular, superior mediastinal, perinephric and retroperitoneal regions. hibernoma is a benign neoplasm presenting as a focal lipomatous mass indistinguishable by conventional imaging from a lipoma with increased fdg metabolic activity of brown adipose tissue. lipomatous hypertrophy of the interatrial septum is characterized by excessive deposition of fatty tissue in the interatrial septum. the typical appearance of brown fat in the neck appeared as bilateral curvilinear areas of fdg activity with extension into the supraclavicular regions. mediastinal fat demonstrated focal activity in the mediastinum and mapped to the adipose tissue surrounding the large vessels. perinephric fat illustrated curvilinear or focal activity corresponding to the perinephric adipose tissue surrounding the upper pole of the kidneys. retroperitoneal fat demonstrated focal activity mapped to adipose tissue. conclusion: hypermetabolic brown adipose tissue can be misinterpreted as adenopathy or malignant mass in the setting of known primary malignancy. knowledge of this potential pitfall and precise localization with ct are important in preventing misinterpretation as malignancy. male), consecutive fdg whole-body scans were obtained with a pet/ct scanner. scanning was performed using the discovery ls pet/ct scanner (general electric medical systems). patients were fasted at least h before the pet acquisition. intravenous injection of . mbq/kg of f-fdg was followed by a tracer uptake phase of about min, during which the patients sat in a quiet room without talking. imaging parameters were as follows for an acquisition at - bed positions: kv, mas, . s per ct rotation, a pitch of , a table speed of . mm/s, . mm coverage, and a . s acquisition time. all pet/ct scans were examined retrospectively by observer on an interactive display using fusion software (xeleris; general electric medical systems). results: twenty-five patients ( male and female) of the scans ( . %) demonstrated brown fat uptake. the incidence rate was . % in scans of female patients and . % in scans of male patients. patients with brown fat uptake were younger than patients without ( . ± y vs. . ± y, p< . ). although there was no significant difference in bmi between patients with brown fat uptake, they tended to be thinner (bmi, . ± vs. . ± , p> . ). bmi was . ± for male patients and . ± for female patients with brown fat uptake (p> . ). when comparing the monthly incidence rate from april to october, the incidence was highest from november to march in the whole group of patients ( . % vs. . %, p< . ). conclusions: fdg uptake in brown fat occurs particularly in female, younger patients and those with lower bmi values. the incidence of brown fat is clearly increased during the cooler period of the year. aim:the aim of the study was to evaluate the feasibility as well as the agreement between tl- and tc- m mibi in brain spect for the differentiation of brain lymphoma and toxoplasma encephalitis -a distinction which is not always possible by routine ct or mri. methods:we studied female patients with acquired immunodeficiency syndrome during a -month period who had intracranial lesions on ct or mri. dual isotope tl- and tc- m mibi brain spect was performed in order to obtain simultaneous acquisition. we calculated uptake ratios by drawing roi around each lesion as well as in the opposite side. we compared our findings with pathologic data and clinical follow up. results:of the patients studied, had intense focal uptake in the lesion(s). / had either biopsy -or autopsy-proven lymphoma ( true positive). one patient with purulent infection had focal uptake ( false positive). patients with negative scans had toxoplasma encephalitis on clinical follow up ( true negative). tl- and tc- m mibi spect tally with each otherwith mibi slightly prevailing -as far as it concerns the lesion-to-normal tissue uptake ratios which were higher for sestamibi compared with those of tl- . conclusions: . patients with aids having intracranial mass on ct or mri may benefit from tl- or tc- m mibi spect in order to distinguish lymphoma and toxoplasmosis. . tl- and tc- m mibi may give similar results. meningiomas account for about % of all intracranial tumors. although grade i meningiomas have a benign clinical course, malignant ones are associated with - % recurrence rate and less than years median survival. evaluation of their proliferation rate is useful for assessing their biological behavior, with implications in patient prognosis. spect by various radiotracers can metabolically characterize intracranial tumors. we evaluated whether mtc-tetrofosmin (tf) uptake in meningiomas correlates with cellular proliferative activity and with tumor grade. materials & methods: consecutive cases with diagnosed meningioma ( males, females; mean age . years) were enrolled. brain spect by tf had been performed within a week prior to surgical excision. in the excised tumor specimens we assessed the ki- index by the mib- immunostaining method, reflecting cellular proliferation and aggressiveness. tf uptake was assessed visually and semiquantitatively, by calculating the lesion-to-normal (l/n) uptake ratio. pearson bivariate correlation analysis was performed between the level of tracer uptake (as expressed by the l/n ratio) and ki- expression and tumor grade. statistical significance was set at p < . . results: / patients were diagnosed with typical benign meningiomas and / had malignant meningiomas. intensity of tf uptake in the region corresponding to the ct/mri findings ranged from faint to profound. a significant correlation was found between both tf uptake and tumor grade (r = . , p < . ) and between tf uptake and ki- expression (r = . , p = . ). conclusion: this pilot study implies that tf brain spect could prove useful in differentiating benign from malignant meningiomas and is a potential indicator of their proliferative activity. comparison of brain spect with tc m-mibi and ctscan in discriminating of radiation necrosis and brain tumor recurrence s. dabiri oskouie , m. amiri ; tabriz university of medical scienses, tabriz, iran (islamic republic of), babol university of medical scienses, babol, iran (islamic republic of). aim: tc m-mibi has been proposed for use as an imaging agent for various tumors, including brain neoplastic lesions. in spite of many advances in diagnosis and therapy, brain tumors still represent a serious challenge for clinicians. after radiotherapy, deterioreting clinical status can be due to either radiation necrosis or recurrent tumor. computed tomography and magnetic resonance imaging offer imperfect discrimination of radiation necrosis and tumor recurrence. the aim of this study is to compare tc m-mibi scan and ct-scan results in this group of patients. material and methods: twenty six patients ( male, female, mean age of years) with primary brain tumors and deterioration of clinical status after radiotherapy were enrolled in this study. tc m-mibi brain spect was performed minutes and hours after iv injection of mbq ( mci) tc m-mibi. images were obtained with adac dual head camera. transverse, coronal, and sagital views were reconstructed. images were visually assessed. results: focal tc m-mibi was observed in patients. eight of these patients expired within months. biopsy of patients in this group confirmed tumor recurrence. ct-scan was positive in patients and the rest had equivocal or negative results. of patients with negative tc m-mibi scan, only patients died during months follow-up. six of these patients had positive, five had equivocal and one had negative ct-scan. ct-scan results didn't correlate with survival rate. conclusion: patients with negative mibi scan showed higher months survival rate ( . % ) compared to patients with positive mibi scan ( . % ). focal uptake on tc m-mibi scan is probably due to recurrent tumor. it can be concluded that brain spect with tc m-mibi is a useful method for discriminating radiation necrosis from tumor recurrence in patients following brain radiotherapy. aim: the differentiation between tumor recurrence and radiation necrosis remains a challenge. these entities have discrete treatment options and prognosis. radiation necrosis can occur between months to few years after irradiation, i.e. the same period during which recurrence is most frequent. in many cases morphologic brain imaging by ct/mri is unable to distinguish between these two pathological entities. although glioma cell line studies substantiated a plausible imaging superiority of mtc-tetrofosmin (tf) over other tumor-seeking radiopharmaceuticals, little has been reported on its in vivo imaging properties.we sought to evaluate the usefulness of tf brain tomography in distinguishing glioma recurrence from radiation necrosis. materials & methods: brain tumor patients ( males, females; mean age . years) were prospectivelly enrolled in the study. the initial diagnosis had been glioblastoma multiforme ( cases), anaplastic astrocytoma ( ), anaplastic oligodendroglioma ( ), grade ii astrocytoma ( ), and low-grade oligodendroglioma ( ) . all patients had been operated upon and then received adjuvant external-beam radiotherapy (total dose gy; no residual tumor on ct/mri), while of them also received temozolomide-based adjuvant chemotherapy. in all cases neurologic symptomatology relapsed in a mean period of months, arousing suspicion of tumor recurrence. ct/mri could not differentiate between recurrence and post-irradiation necrosis, so tf spect was performed. the level of tracer uptake (as expressed by the lesion-to-normal brain [l/n] uptake ratio) was compared between radionecrosis and recurrence by the two-sided mann whitney u non-parametric test. statistical significance was set at p < . . results: in / cases an abnormally increased tracer uptake appeared in the region that ct and/or mri indicated as suspicious; in half recurrence was confirmed histologically after surgery, while in the other by growth of the lesion over a -month follow-up period and clinical deterioration. the remaining / patients had faint uptake in the suspicious region, compatible with radiation injury; these lesions remained morphologically unaltered over a mean month follow-up period, with no clinical deterioration in patient's condition, a course most likely favoring the diagnosis of radiation injury. statistical analysis verified that tumor recurrence had significantly higher tf uptake, as compared to radionecrosis (p = . ). conclusion: metabolic brain imaging by tf could offer useful information in the workup of treated brain tumors, where radiomorphologic (ct/mri) findings are inconclusive between recurrence and radionecrosis. aim: distinquishing neoplastic from nonneoplastic intracerebral hemorrhage (ich) constitutes a common challenging problem since on standard neuroradiologic imaging neoplasms can be hidden behind an intracerebral hematoma, while some hemorrhagic nonneoplastic lesions may mimic neoplasms. ct and mri cannot always distinguish between neoplastic and nonneoplastic hemorrhage due to considerable overlap of findings. in contrast to neoplastic ichs, nonneoplastic ones display faint radiotracer uptake and only several days (> ) after the onset of the episode. accurate diagnosis is therefore critical in providing optimal patient care. we evaluated the usefulness of brain spect by the tumor-seeking tracer mtc-tetrofosmin (tf) in diagnosing hemorrhagic brain tumors among patients with nontraumatic intracerebral hematomas. materials & methods: ten patients ( males, females; mean age . years) diagnosed with spontaneous intracerebral hematoma on ct/mri were prospectively enrolled in the study. all underwent tf brain spect within a mean period of days after onset of symptoms. imaging was performed early ( min) post-injection. surgery was performed in / within a week; in the remaining / the diagnosis was based on a 'wait-and-see' policy of clinical and morphologic (ct/mri) follow-up. results: faint or absent tf uptake in the region corresponding to the ct/mri findings was found in cases, while only displayed significant tracer accumulation. the latter patient and of those with negative spect underwent surgery, which revealed an underlying tumor (glioblastoma) solely in the patient with positive spect. the hemorrhage cases lacking tf uptake that were not operated upon demonstrated a diminution in the lesion size on ct/mri follow-up and clinical improvement, thus considered as representing non-neoplastic intracerebral hematomas. conclusion: tf could prove useful in the early noninvasive assessment of nontraumatic brain hematomas, allowing differentiation between neoplastic and nonneoplastic intraparenchymal cerebral hemorrhage. # investigation of pediatric brain tumours using combined indium-octreotide / mtechnetium-dtpa brain scintigraphy g. dabasi , i. szilvási , p. hauser , m. garami , d. schuler , a. doros , j. járay ; semmelweis university transplantational and surgical clinic, budapest, hungary, semmelweis university department of nuclear medicine, budapest, hungary, semmelweis univ. .dept. of pediatrics, budapest, hungary. brain tumours are the most frequent pediatric solid tumours.some of them (especially medulloblastomas) express somatostatin receptors (ssr). in- -octreotide scintigraphy (os) can visualize ssr expression of various types of tumours. increased octreotide uptake might be non-specific due to impaired blood-brain-barrier (bbb). conventional brain scintigraphy (bs) with mtc-dtpa assess integrity of the bbb. aim of our study was to evaluate os for differential diagnosis of pediatric brain tumours using a double-tracer technique. patients and methods: children with brain tumours were studied. patients had medulloblastoma, patients had different types of brain tumours: glioblastoma, ependymoma, astrocytoma, primitive neuroectodermal tumour (pnet) and cerebral metastasis of ewing sarcoma. diagnosis was based on histopathology and conventional radiological investigations. all patients underwent cs using tc- m-dtpa and os with in- -octreotide on the next day.tumour to background ratios (t/bg) were measured at minutes of the dtpa and at hr of the octreotide scans. t/bg on os was compared to t/bg on bs. only tumours with t/bg on os higher than on bs were defined as ssr positive. results. cases ( , %) were ssr positive: medulloblastomas, ependymomas, astrocytomas, glioblastomas. patients had lower t/bg on os than on bs. in this group ( , %) patients had no uptake of octreotide in the tumour region defined by dtpa scan. diagnoses of these tumours were: astrocytoma, ependymomas and medulloblastomas and in pnet . in ( , %) patients moderate uptake of octreotide was seen, but t/bg on os was lower than t/bg on bs. diagnoses were: glioblastoma, astrocytoma, ependymomas, metastasis of ewing sarcoma, medulloblatomas and pnet. conclusions: os has not proved to be useful for differental diagnosis of pediatric brain tumours. ssr expression defined by higher t/bg ratio on os than on bs is not specific for medulloblastoma. in our opinion somatostatin analogue and/or targeted radiation therapy is indicated only in patients with specific octreotide uptake, i.e. with higher t/bg on os than on bs. this combined scintigraphic approach can be used to evaluate therapy of pediatric brain tumours with ssr expression. although magnetic resonance imaging (mri) is an excellent tool to diagnose brain tumors, the functional information is limited. on the other hand mtc-mibi brain spect is considered a useful tool in the management of brain tumors. aim: mtc-mibi tumor uptake is related to histological grading, cellular proliferation index and prognosis. our aim was to evaluate mtc-mibi brain spect and mri studies efficacy in the differential diagnosis between recurrence of malignant gliomas and glioblastomas and the local modification after radiotherapy. material and methods: eight patients with suspected recurrence after surgical removal of a glioma ( low grade and high grade), - months before study and treated with radiotherapy were investigated. for brain spect - mbq of mtc-mibi were i.v. injected to each patient minutes before image acquisition by a dual-head gamma camera. gd-dtpa enhanced t and t weighted mri studies were carried out in every patient within days before mtc-mibi spect. the ratio between the tumor roi on a slice with maximum uptake and a mirrored control roi was calculated and if > it was considered pathological. results: spect and mri studies well correlated being both positive for recurrence in patients as confirmed by biopsy, while both negative in patients, considered as having radiation effects (evaluate by clinical follow up). one patient with negative spect was operated being severely symptomatic and the biopsy was positive for low grade tumor. combined sensitivity was , %, specifity %, npv % and ppv % conclusion: mtc-mibi brain spect and mri studies provide high specifity of detection of relapses of gliomas and glioblastomas and also the most adequate anatomic depiction of extent of tumor process. clinical follow up of these patients is underway to assess correlation of metabolic response to clinical response. aim: the aim of this study was to assess the incremental diagnostic value of i spect/ct fusion imaging compared with conventional i planar scintigraphy in patients with thyroid carcinoma. materials and methods: seventy-nine patients with thyroid carcinoma underwent i spect/ct and i planar imaging - days after administration of either a therapeutic dose (n= ) or a diagnostic dose of i (n= ). reconstruction of fusion images were performed by using external markers placed at locations on each patient's skin to mark the same geometric plane and combining spect and ct images on a workstation. without knowing the clinical information of the patients, nuclear medicine physicians interpreted first i planar images and then i spect/ct fusion images. i spect/ct fusion imaging was considered to have an incremental diagnostic value when it demonstrated different but precise localisation from the i planar scintigraphy. results: as compared with the conventional i planar scintigraphy, i spect/ct fusion imaging had an overall incremental diagnostic value in . % ( / ) of patients, with more lesions detected in . % ( / ) of patients. the undetected activity at the thyroid bed was demonstrated in . % ( / ) of patients, of whom had markedly elevated serum thyroglobulin level. the percentage of the detection of unsuspected lung metastases, bone metastases, and lymph node metastases were . % ( / ), . % ( / ), and . % ( / ) of patients. the previously considered lymph node metastases were excluded in . % ( / ) of patients. conclusion: i spect/ct fusion imaging had an incremental diagnostic value over conventional i planar scintigraphy in patients with thyroid carcinoma for precise localisation of lesions and improved interpretation, which led to more appropriate patient management. optimal time for i post-treatment whole body scan: comparison between -day scan and -day scan after treatment c. somboonporn, k. roysri; nuclear medicine division, department of radiology, faculty of medicine, khon kaen university, khon kaen, thailand. objective: i post-treatment whole body scan (wbs) is a widely accepted test in identifying the presence of thyroid remnant and the extent of functioning metastases in well-differentiated thyroid carcinoma (wdtc) patients. sensitivity in detecting lesions depends on image quality and the amount of i taken up by the lesions. although the scan is conventionally performed - days after i administration, optimal scanning time, however, that gives the best detection rate has not been well established. therefore, we compare the sensitivity of lesion detection between the scan performed on the day of discharge from the hospital (day- scan) and that performed days after treatment (day- scan) on the same patient basis. material and method: i post-treatment wbs was prospectively studied in patients ( female and male, mean age . + . years) treated with high-dose i therapy from november until january in our nuclear medicine division. both day- scan and day- scan were performed in every patient and the scans were interpreted by two nuclear medicine physicians with consensus. the number, location and grading of uptake ( = no abnormal uptake, = minimally increased but abnormal uptake, = clearly seen abnormal uptake) by each lesion were compared between the two types of scan. results: three patients were negative by both scan types, whereas patients had at least one lesion seen in either day- or day- scan. the two scans were concordant in terms of the number of lesion detection in from the overall detected lesions ( %). day- scan found lesions ( in the neck, in the lung, in the mediastinum) not visualized in day- scan. day- scan revealed lesions not seen in day- scan of patients; both of them were in the mediastinum. eleven lesions in patients having abnormal uptake had increase in uptake grade in day- scan compared with day- scan. two patients with elevated serum thyroglobulin disclosed a cervical lesion that had not been seen in both pre-treatment scan and day- scan. two patients showed more metastatic lesions in bone and mediastinum in day- scan which were not seen in day- scan. conclusion: i post-treatment wbs performed days after treatment is better than the scan performed days after treatment because it yields higher lesion detection rate. hence, it provides more accurate staging, risk stratification and better management plan in wdtc patients. value of post-treatment i spect/low dose ct on the management of patients with thyroid cancer k. taborska, k. michalova, p. racek, p. vlcek; clinic of nuclear medicine and endocrinology, the ndmedical school of charles university and faculty hospital motol, prague, czech republic. accurate assessment of inconclusive foci on whole body i scan after radioiodine therapy is important for treatment planning. due to lack of anatomic landmarks it is not always to evaluate correct site involvement or sometimes distinguish metastatic spread from physiologic uptake without further examination such as ultrasound, ct or mri. aim of our work was to analyse usefulness of i spect/low dose ct after radioiodine therapy when unexpected or new unknown areas with accumulation of i were found on post-treatment whole body scans. material and methods: patients ( females, males, age - years) with thyroid cancer at various stage of their disease were examined between august and march . planar scintigrams were performed with sophy dstxi (ge ) within four to six days after administration of , - , gbq i, spect/low dose ct examination was acquired with symbia t (siemens) at the same or next day. results: precise localization was obtained in all evaluated regions. spect/low dose ct images improved characterization of equivocal foci of i uptake as definitely benign in patients. additional morphologic imaging was recommended in patients, patients were admitted to surgery due to solitary neck lymph nodes involvement and patients to ovarectomy due to i uptake (teratom was histologically proven). in patients subsequent radioiodine therapy was scheduled with tailoring of the administered dosage according to skeletal, lung or nodes involvement. conclusion: results of the post-treatment spect/low dose ct scans were finally implemented into the management of all patients, patients were spared further examination and findings in patients helped to direct additional follow-up. spect/low dose ct examination was found to be a valuable tool in management patients with thyroid cancer. v. valotasiou, s. gerali, c. zerva; "alexandra" university hospital, athens, greece. introduction: diffuse liver uptake (dlu) seen on i wbs of patients with operated thyroid cancer, represents liver metabolism of iodoproteins and may indicate either functional thyroid remnants, recurrence of the tumor or functioning metastases. aim: the aim of our study was to evaluate the frequency and clinical significance of dlu on i wbs in patients with thyroid cancer in the presence and absence of thyroid visualization (tv). materials-methods: we studied patients ( men, women) with operated thyroid cancer ( papillary, follicular, mixed papillaryfollicular, hürthle), mean age . years (age range: - years). two hundred thirty-three out of patients (group a) underwent post therapy wbs - days (mean . days) after the administration of - mci of i (mean . mci), while / patients (group b) had diagnostic wbs. dlu was graded by two nuclear medicine physicians from - ( =no uptake, =faint uptake, =moderate uptake and =intense uptake). results: group a: / patients had tv (group a ) and / patients (group a ) had no tv. in group a , / patients had dlu ( / had visible metastases on wbs) and / patients had no dlu ( / patient had visible metastases). in group a , / patients (group a a) had dlu and / patients (group a b) had no dlu. group a a: / patients had visible metastases on wbs ( / had dlu grade= ) and thyroxin-free thyroglobulin (tg) levels - ng/ml. the other / patients had thyroxin-free thyroglobulin (tg) levels . - ng/ml, findings which raised the suspicion of hidden metastases in these patients. group a b: thyroxin-free tg was - . ng/ml. group b: / patients had tv (group b ) and / (group b ) had no tv. in group b , / patients had dlu ( / had visible metastases on wbs with dlu grade= ) and / had no dlu ( / had visible metastases on wbs). in group b , / patient had dlu and / had no dlu. conclusion: dlu in the presence of tv may be due to functioning thyroid remnant although the possibility of recurrence or functioning metastases can not be excluded. nevertheless, dlu in the absence of tv on delayed post therapy wbs, may indicate hidden metastases and therefore could offer additional information in the management of patients with thyroid cancer. aim: to evaluate the role of the parathyroid hormone (pth) assay in patients with primary hyperparathyroidism (phpt). material and methods: we studied patients, mean age years, clinical and biochemical diagnosis of phpt, surgical complete exploration after the sestamibi scanning and anatomopathological confirmation of the removed glands. the pth values were obtained before surgery, by range of normality and pg/ml. results: the patients presented a mean average of pth pg/ml. . pth/histology: pth/hyperplasia: n= , mean= , , tip deviation= , , tip error= , pth/adenoma: n= , mean= , , tip deviation= , , tip error= , . pth/ mtc-sestamibi scintigraphy: pth/negative: n= , mean= , , tip deviation= , , tip error= , pth/positive: n= , mean= , , tip deviation= , , tip error= , . pth means: n= , minimum= , , maximum= , , mean= , , tip deviation= , . glandular weight means: n= , minimum= , maximum= , mean= , , tip deviation= , conclusion: we didn't observe significant relation between the scintigraphy and the pth. there was obtained a statistically significant difference (p= , ) between the averages of the weight of adenomas ( , mg) and hyperplasias ( , mg). the comparison of the pth values of both groups hadn't got statistical significance. the results of the sestamibi scanning didn't show statistical relation with the pth values. aim: several authors have reported false positive i- accumulations due to various clinical conditions in the absence of residual thyroid tissue or metastasis of differentiated thyroid carcinoma (dtc). in this report, we present a case with dtc having false positive i- accumulation due to a large hydatid cyst in the liver is presented. case report: a years old woman underwent bilateral near total thyroidectomy for . cm papillary thyroid carcinoma located right lobe. sonographic examination of the patient demonstrated an ovoid, complex cystic mass with dimensions of x cm in the right lobe of liver. the mass was well delineated, and contained septated cystic parts as well as solid appearing components. the appearance of the some solid parts was in favour of detached membranes. color doppler ultrasonographic evaluation yielded no vascular signal in the mass. these sonographic findings were found to be concordant with a type ce- hydatid cyst according to the world health organization classification. the immunoblot test was confirmed hydatid disease. surgical extirpation of the cyst suggested by interdisciplinary consultations was planned to be performed after the radioiodine therapy. two month later the thyroid surgery mci ( mbq) radioiodine therapy was performed for ablation of the thyroid remnant. the post-ablative whole body i- scan displayed minor uptake in the thyroid bed concordant with residual thyroid tissue and a focal, intense and homogeneous uptake of radioiodine in right lobe of the liver which was reported to be a hydatid-cyst lesion by usg. conclusion: while some cystic lesions of kidney and liver have been previously reported as causes of false positive radioiodine accumulation, this is the first reported case of uptake i- by a hepatic hydatid-cyst up to our knowledge. we therefore suggest that hydatid cystic lesions should be considered as false positive i- accumulating pathologies while interpreting wholebody i- scans. a. mestre, m. negre, g. obiols, j. mesa, f. porta, j. castell-conesa; hospital universitari vall hebron, barcelona, spain. purpose: to assess the role of i scintigraphy in the initial staging of differentiated thyroid cancer in comparison with i post-treatment imaging. methods: this prospective study included patients, male and female, age range - years. all of them were diagnosed of differentiated thyroid cancer ( papillary, follicular) and treated with total thyroidectomy. we compared i scans ( of them with spet) with their corresponding post-treatment i whole-body images with a maximum interval of months between them, evaluating the number of foci and localization in each exam. patients received a dose of mci of i. images were obtained to hours after administration. therapeutic dose of i ( - mci) after was used as the gold standard diagnostic scanning. patients were studied with rhtsh administration and one with thyroid hormone withdrawal. results: in out of patients i scan findings were completely concordant with those of corresponding post-treatment i images with a concordance rate of %. patients showed the same number of foci in cervical region (concordance %) while three patient showed an increased number of lesions in i image. three patients showed more intense uptake in i images than in the i ones. two out of patients presented metastatic disease in i and i scans. nevertheless, at least two additional foci were observed on post-treatment i images. conclusion i pretherapeutic scan is comparable to i post-therapeutic imaging in differentiated thyroid carcinoma patients with an acceptable concordance in cervical region and at distant site. although some lesions were missed on i images, no changes in therapeutic management of patients were observed. i versus mtc-sestamibi to detect thyroid cancer recurrence in cervical lymph nodes in cases with increased serum thyroglobulin s. gerali , p. valsamaki , j. koutsikos , s. tsiouris , e. pantazi , e. karga , s. luccetti , c. zerva ; "alexandra" university hospital, athens, greece, university general hospital of ioannina, ioannina, greece. aim: the detection of cervical node metastases from differentiated thyroid cancer (dtc), in the setting of increased serum thyroglobulin (tg), may be accomplished by the post-therapeutic i whole-body scan ( i-wbs). the method's effectiveness is directly dependent on the iodine-trapping ability of the cancer cells, under thyrotropin (tsh) stimulation (tsh> μiu/l). in this clinical setting, we used the non-specific tumor-seeking radiotracer mtc-sestamibi as an alternative diagnostic approach. scintigraphic findings were correlated with neck ultrasonography (us) and evaluated against the results of lymph node biopsy. materials & methods: we retrospectively studied dtc patients [ men, women, aged - years (mean ± sd = . ± . years). the histologic types were: papillary cell, follicular cell, and hürthle cell carcinomas. patients had undergone total thyroidectomy and i ablation therapy and eventually presented with elevated serum tg levels. we performed neck us and mtc-sestamibi wbs, min after iv injection of mbq tracer activity. repeat ablative dose of ( - mbq) was then administered and posttherapeutic i-wbs was performed - days later. the findings of the three imaging diagnostic modalities were correlated and compared with the lymph node biopsy histology that provided the definite diagnosis. results: mtc-sestamibi identified / cases of cervical lymph node metastases ( papillary, follicular, and all hürthle carcinomas). positive post-therapeutic -wbs was observed in / cases. detection of dtc recurrence in cervical lymph nodes by mtc-sestamibi scintigraphy and post-therapeutic i-wbs was accomplished with a sensitivity of % versus %, respectively. conclusion: the application of mtc-sestamibi in detecting dtc metastases in cervical lymph nodes seems rewarding, since it demonstrates higher sensitivity than i-wbs, probably due to additional recognition of dedifferentiated non-iodophilic lesions. also, no discontinuation of the thyroxine replacement / suppression therapy is required and the method offers high-quality imaging, with results available on the same day. we present our experience in the follow-up of these patients with serum calcitonin assays and dmsa (v) scans. a retrospective review of the hospital's medical records was performed. sixteen patients ( males, females, age; - yrs) with histologically proven medullary thyroid carcinoma, and who had basal serum calcitonin assays and dmsa (v) scans as part of their post-operative follow-up assessment, were included in the study. dmsa (v) scans were performed on these between - . all patients had prior total thyroidectomy. two patients had synchronous papillary carcinoma of the contralateral thyroid lobe and patient had men a syndrome. patients had serum calcitonin assays performed pre-operatively or within weeks of surgery. all patients had calcitonin levels greater than pg/ml. the lowest level was pg/ml. four out of patients showed normalisation of the serum calcitonin levels within months of surgery. of the patients with elevated serum calcitonin levels, patients showed an initial decline in calcitonin levels up to months post-surgery (but still above pg/ml) and a subsequent increase. both patients were found on subsequent dmsa (v) scans to have residual or recurrent foci of disease. the rd patient was lost to follow up. tc- m dmsa (v) scans and serum calcitonin levels performed within a month apart were analysed. findings were concordant in of instances ( . %) and discordant in of instances ( . %). sensitivity of dmsa (v) scans for detecting recurrence was . %, using calcitonin levels as the reference. there were no false positive scans. clinical follow-up periods ranged from - months. two patients had only one follow-up scan performed within months of surgery and were considered lost to follow-up. at the end of their follow-up periods, of patients ( . %) were disease -free, patients ( . %) had residual or recurrent disease; the other patients' ( . %) status had biochemical recurrence without detectable disease. in conclusion, calcitonin levels are a sensitive and specific indicator of disease recurrence in postoperative follow-up of patients with medullary thyroid carcinoma. calcitonin normalisation (< pg/ml) within months of curative surgery may be a strong predictor of disease-free status whereas a less than complete normalisation of calcitonin may predict eventual disease recurrence. in cases of elevated calcitonin, tc- m dmsa (v) is an affordable, readily available and sensitive imaging agent. objective: the objective of the study was to evaluate the usefulness and accuracy of intra-operative hand held gamma probes in minimally invasive radio-guided surgery (mirs) of parathyroid adenomas. material and methods: patients who were suspected as having parathyroid adenoma by virtue of a high serum pth and were subsequently diagnosed as having a solitary parathyroid adenoma on the basis of localization study with tc- m-sestamibi were included in the study. all these patients then further underwent minimally invasive parathyroid surgery by being injected with tc- m-sestamibi to hours before their planned surgeries. a hand held gamma probe was used intra-operatively to precisely localize the adenoma followed by the surgery. results: tc- m-sestamibi correctly identified and precisely localized the parathyroid adenoma in all cases. intra-operative gamma probe also was able to localize the parathyroid adenoma and hence facilitated in the mirs. all patients have been disease and symptom free on a month follow up. conclusion: gamma probe guided mirs is a very attractive surgical approach to treat patients with primary hyperparathyroidism due to a solitary parathyroid adenoma. the procedure is technically easy, safe, with a low morbidity rate and has better cosmetic results and lower overall costs than convention bilateral neck exploration. introduction: in primary hyperparathyroidism, the main diagnostic procedures for presurgical localization of parathyroid adenomas are ultrasound of the neck and radionuclide imaging. the sensitivity of the nuclear imaging has proven to be far superior to ultrasound as later is operator dependant. difficulties in radionuclide imaging arise when primary hyperparathyroidism presents with a multinodular goiter with an incidence ranging from % to % in endemic regions. case report: presented here is a case of a year old female who presented with bony aches and pains. on examination she was found to have a mng. her labs showed the hormonal assays of the thyroid to be in normal range, however, she was found to have a high serum pth. she was advised a parathyroid scan for the localization of adenoma which showed an area of increased tracer uptake at the lower pole of the left lobe of the thyroid. this area however corresponded with a palpable left sided thyroid nodule on clinical examination. to remove any controversy as to the true origin of this nodule she was advised a tc- m-pertechnetate scan. the pertechnetate scan showed an area of photon deficiency in the same area. the patient was then underwent an ultrasound which on doppler studied confirmed a parathyroid adenoma at the lower pole of the left lobe of the thyroid. the patient was then planned for a minimally invasive parathyroid surgery by injecting mibi hrs before the planned surgery. a successful surgical outcome was reported and a parathyroid adenoma confirmed on histopatholgy. at months follow up, her pth and calcium levels became normal and she had also shown remarkable recovery symptomatically. unusual metastatic localizations of differentiated thyroid carcinoma n. ben rais; ibn sina hospital, rabat, morocco. introduction: the majority of thyroid cancers have a slow evolution, a more often loco-regional extension, and a good forecast. remote metastases, when they exist, generally touch the osseous skeleton and/or pulmonary tissu. however, unusual metastatic localizations much more exceptional are possible. the authors report through this work two cases of atypical metastasis of differentiated thyroid carcinoma followed in nuclear medicine department of ibn sina hospital in rabat. material and methods: our two patients had initially underwent a total thyroidectomy for differentiated thyroid carcinoma histologically confirmed. they had profited weeks after the surgical gesture from a reference isotopic exploration ( iodine whole body scan and thyroglobulin dosage). the paraclinic assessment was supplemented by a computed tomography (ct). results: revealing symptomatology in the first years old patient was dominated by a blindness associated with an elective up-take of radioactive -iodine on the level of hypophyseal gland extending to the sphenoid bone. the second years old patient reported right basithoracic pains resisting to the usual antalgic treatment with a bulky mass driving back the kidney right to the bottom at ct with and important up-take -iodine at whole body scan; a surrenalectomy was thus carried out with conservation of the kidney. in the cases the rate of thyroglobulin was considerably high. an activity of , gbq -iodine was managed with the patients. the evolution was marked, in the short run, at the first patient by a recovery partial of the sight, the disappearance of pain in the second patient and a remarkable reduction of thyroglobulin rate at both. discussion: unusual metastasis of differentiated thyroid carcinoma constitute an exceptional entities in the evolution of the disease. their treatment and following up does not seem to be significantly different from that of the traditional metastatic forms, insofar as the -iodine therapy keeps all its value to improve or at least stabilize the evolution of this pathology. the diagnostic process and further therapeutic decisions in a case of the solitary pulmonary nodule (spn) pose a challenge in everyday medical practice. differentiation whether the spn is benign or malignant based on traditional methods, may be inconclusive and does not ensure prompt diagnosis and optimal medical management. in this context, evaluation of the usefulness of the receptor scintigraphy with somatostatin analogue mtc-depreotide in diagnosis of a spn seems to be essential and determines the aim of this study. material. examined group consisted of patients with the spn diagnosed radigraphicaly. computed tomography (ct), somatostatin receptor scintigraphy (srs), and fine needle aspiration biopsy (fna) or surgery with histopathological verification were performed in all the patients. in each case the surgery type was selected based on pathological result: in some cases an operation was more radical with excision of the local lymph nodes. method. ap and pa projections of the planar images and spect examination were carried out between the nd and th h after iv injection of mtc-depreotide. radiopharmaceutical activity was mbq. srs was performed using a dual-head gamma camera varicam (elscint, haifa, israel) equipped with high-resolution collimators. tomographic projections were acquired every ° in ° geometry, each of s duration. a matrix of × pixels was applied ( . mm/pixel). reconstruction of the images was performed by means of the iterative method. semiquantitative analysis of mtc-depreotide uptake in the pulmonary nodules and lymph nodes was based on the calculation of the tumor/ background ratio (tumor activity/ activity in a region located in the contralateral lung). results. in patients with radiotracer uptake visible in an area corresponding to the tumor location on ct, the diagnosis of pulmonary cancer was confirmed. false negative result was obtained in one case (no depreotide accumulation in a nodule which turned out to be a cancer). in cases uptake of somatostatin receptor analogue was seen in the non-cancerous lesions (carcinoid in patients and tuberculoma in person). there was no tracer accumulation in benign lesions. conclusion. obtained results suggest that srs performed with mtc-depreotide is clinically useful and may be recommended as a part of the diagnostic algorithm for the management of the spn. thallium- -scintigraphy in differential diagnostics of inflammatory and neoplastic processes of lungs and mediastinum purpose: to estimate the efficiency of tl-scintigraphy in differentiating the inflammation and tumor of the lungs and mediastinum. materials and methods: the tl-scintigraphy has been applied in the investigation of patients ( male and female of mean age of . ± . years) with affection localizations. the scintigraphy was carried out at early and at deferred phases (in and minutes after the intravenous introduction of mbq tl, respectively). the accumulation focus has been estimated visually, and the coefficients er, dr, and ri=dr/er have been evaluated. the tl-scintigraphy results have been compared with the data of clinical examinations and the results of treatment (n= ), radiography (n= ), and ct (n= ). the affection of the lungs and mediastinum have been confirmed in / cases ( / -inflammations, / -tumors), and rejected in / cases. results: the affections have been visualized in / ( . %) cases ( / -tumors, / inflammations). the absence of an tl-scintigraphy uptake has been found in / cases ( false-negative results). the found absence can be referred to a tumor type and/or tumor smallness (d < cm). the correlation between coefficients ri and er at inflammations (r=- . , p< . ) and tumors (r=- . , p< . ) is due to the delivery and removing tl from an accumulation focus by the blood-groove. we found that ri=- , er+ . at inflammations, and ri=- , er+ . at tumors. on this basis, we offer the formula ricrit.=- . er+ . to differentiate inflammations and tumors. thus, the quantitative criterium of an inflammation is ri<- . er+ . , while at a tumor -ri>- . ·er+ . . conclusion: the differential diagnostics of inflammations and tumors in lungs and mediastinum has been found to be correct in / cases. the sensitivity, specificity, and accuracy of the tumor diagnostics by tl-scintigraphy have been estimated as . %, % and . %, respectively, and as % for all three parameters (estimated on a sample of small amount) of the inflammation diagnostics. s p -monday, oct. , , : pm - : pm, poster area diagnostic oncology: planar scintigraphy and spect -breast cancer scintigraphy a. spanu , f. chessa , g. b. meloni , d. sanna , p. cottu , a. manca , s. nuvoli , g. madeddu ; dept. of nuclear medicine university of sassari, sassari, italy, dept. of radiology university of sassari, sassari, italy, dept. of surgery university of sassari, sassari, italy, dept. of pathology university of sassari, sassari, italy. aim: planar scintimammography (sm) acquired with a conventional gamma camera has proved a useful complementary tool to mammography (mx) in the diagnosis of bc, but with unsatisfactory sensitivity in small size carcinomas. in this study we assessed the role of planar sm with a high resolution dbc in the diagnosis of bc, comparing the results with those of mx. methods: a consecutive series of patients scheduled for biopsy for suspect bc at conventional procedures (clinical examination, mx, us) was studied. mtc-tetrofosmin planar sm was acquired in all patients using a new developed small field of view high spatial resolution ( . mm) dbc (lumagem s/ k) mounted on a modified mammography unit allowing the similar projections as mx as well as breast compression during acquisition. scintigraphic data were compared to mx findings and correlated to histological findings. results: patients had bc (unifocal in cases and multifocal in cases) and patients had benign disease; in total carcinomas ( mm and > mm) and benign lesions were ascertained. dbc planar sm was true positive in / ( . %) bc patients, detecting / carcinomas (overall sensitivity: . %), and was true negative in / ( . %) patients with benign disease, excluding malignancy in / lesions (overall specificity: . %). sm sensitivity was % in carcinomas > mm and . % in those mm. globally, sm was more accurate than mx in / ( . %) cases, detecting cancer in patients with mx indeterminate for dense breast ( / tumors were < mm), assessing additional tumor foci (all < mm) in pts with multifocal disease and correctly classifying patients as affected by cancer ( cases) or by benign disease ( cases), all of these with inconclusive mammographic findings. however, mx was more sensitive than sm in patients, in each of these detecting one bc < mm, false negative at sm. conclusion: dbc planar sm appears a highly sensitive diagnostic tool in the detection of primary bc, also when small in size at a very early stage and in the assessment of multifocal disease. a wider employment of this procedure is thus suggested, especially in indeterminate or inconclusive mammographic findings to improve sensitivity and specificity of mx. aim: preliminary studies have demonstrated the usefulness of planar scintimammography (sm) with dedicated breast camera (dbc) in the detection of unifocal primary bcs. in this study we evaluated the usefulness of this radioisotopic procedure in the diagnosis of multifocal/multicentric bc, comparing the results with those of mammography (mx). methods: a series of consecutive patients with suspected bc, imaged preoperatively from november to february with dbc planar sm in adjunct to standard procedures, including mx, was reviewed. following the i.v. injection of mtc-tetrofosmin, sm was acquired in all cases using a new developed small field of view high spatial resolution ( . mm) dbc (lumagem s/ k) mounted on a modified mammographic unit allowing the similar projections as mx as well as breast compression during acquisition. scintigraphic data were related to final surgical histopathological findings and compared to those obtained with mx. results: at surgery, / ( . %) patients had multifocal ( cases)/multicentric ( cases) bc, bilateral in one case, including patients with palpable multiple ipsilateral invasive bc and with non palpable multiple microscopic foci of carcinoma in situ. dbc planar sm was true positive for cancer in all cases, while mx was true positive in / cases and false negative in one who had distinct foci ( and mm in size) of invasive carcinoma. sm assessed multifocal/multicentric condition in / patients with multiple invasive bc, showing additional tumor foci than mx in cases, while in one patient missed a subcentimetric focus, also negative at mx. moreover, sm correctly defined tumor extension ascertained at surgery in all patients with carcinomas in situ, including with only microcalcifications without masses at mx. in no case mx was more accurate than sm. conclusion: high resolution dbc planar sm proved a very useful diagnostic tool in multifocal/multicentric bc detection correctly assessing local disease extension and demonstrating a better performance than conventional mx. a wider employment of this radiosotopic procedure is thus suggested as a complementary tool to conventional methods in planning the surgical treatment of multifocal/multicentric bc patients. correlation of mammographic density with the mode of scintimammographic mtc-(v)dmsa uptake in various breast pathologies v. papantoniou , e. sotiropoulou , s. tsiouris , n. ptohis , m. sotiropoulou , a. tsigris , a. stipsanelli , k. sirgiannnis , k. dimitrakakis , p. valsamaki , e. kounadi , n. makris , c. zerva , a. antsaklis ; "alexandra" university hospital, athens, greece, university general hospital of ioannina, ioannina, greece. aim: to investigate the mode of mmtc-(v)dmsa distribution in correlation with mammographic density, in women with dense breasts and various breast lesions. materials & methods: women (aged . ± . years) scheduled for breast surgery due to suspicious palpation and/or mammography, were submitted to doublephase (v)dmsa scintimammography ( and min after intravenous tracer administration), - days before surgery. dense breast (%) area on mammography ([dense breast area / whole breast area] × %) and tracer uptake (%) area on scintimammography ([tracer uptake area / whole breast area] × %) were calculated by computer-assisted means and were correlated with the histological findings. calculation of the lesion-to-background (l/b) ratios at and min was performed at the sites of maximal breast activity. retention ratio (rr = l/b min minus l/b min) and retention index (ri = [l/b min minus l/b min] / l/b min] × %) were calculated and compared (mann-whitney u test) between the various breast pathologies. continuous data are expressed as mean ± sd; significance level was set at p< . . results: histology revealed benign non-proliferating lesions (bnpl), benign proliferating lesions (bpl), carcinomas in situ (cis), and infiltrating carcinomas (ic). bpl were associated with the highest breast density values, followed by cis. breast density was . ± . in bnpl, . ± . in bpl, . ± . in cis, and . ± . in ic. significant density differences were found between bnpl-bpl (p= . ), bpl-ic (p= . ), and cis-ic (p= . ). likewise, bpl were found to have significantly higher (%) tracer uptake compared to the other histologies. scintimammographic (%) uptake was . ± . in bnpl, . ± . in bpl, . ± . in cis, and . ± . in ic. (v)dmsa retention over time was profound in bpl and cis. rr was . ± . for bnpl, . ± . for bpl, . ± . for cis, and . ± . for ic, while the ri was . ± . , . ± . , . ± . , and . ± . , respectively. significant differences in (v)dmsa rr were found between bnpl-bpl (p= . ), bnpl-cis (p= . ), bpl-cis (p= . ) and bpl-ic (p= . ), whereas significant ri differences were found between bnpl-bpl (p= . ), bnpl-cis (p= . ), and bpl-ic (p= . ). conclusion: (v)dmsa's kinetic behaviour is possibly related to the early onset of cell proliferation in the process of carcinogenesis, in women with dense breasts. furthermore, increased breast density is associated with benign proliferating lesions with potential of evolving into malignancy and also with cis. the combination of mammography and scintimammography may be helpful in selecting those women at risk, who could benefit from prophylactic treatment. a. spanu , a. farris , f. chessa , d. sanna , m. pittalis , s. nuvoli , g. madeddu ; dept. of nuclear medicine university of sassari, sassari, italy, dept. of oncology university of sassari, sassari, italy. aim: conventional imaging procedures proved of limited value in assessing tumor response to neoadjuvant chemotherapy in patients with lapbc. in the present study we evaluated and compared the usefulness of mtc-tetrofosmin planar scintimammography (sm) and spect in monitoring the response to neoadjuvant hormone or chemotherapy in patients with lapbc. methods: patients affected by lapbc were studied before and after completing hormone ( cases) or chemo ( cases) neoadjuvant therapy prior to surgery. in all cases, following mbq mtctetrofosmin i.v. injection, both conventional planar sm and spect were acquired using a dual-head gamma camera equipped with hr parallel hole collimators. in cases planar sm with a new developed small field of view high spatial resolution ( . mm) dbc (lumagem s/ k) mounted on a modified mammography unit allowing similar projections of mammography and breast compression during acquisition was also acquired. planar and spect findings were evaluated visually, mutually compared and correlated with definitive histopathological findings in all cases. results: four patients had a complete pathologic positive response, while residual tumor was ascertained at histology in patients. no uptake areas were detected at both conventional planar sm and spect, excluding residual tumor after therapy, in / ( %) cases, in accordance with histology. dbc planar sm was performed in of these cases resulting true negative. conventional planar sm detected residual tumor in / ( %) cases, resulting false negative in patients with a pt c tumor, including one mucinous bc, and in patients with multiple and scattered subcentimetric tumor foci. spect was true positive in / ( . %) cases, but missed the mucinous bc and the subcentimetric tumors which were also false negative at conventional planar sm. however, these latter carcinomas were identified only at dbc planar sm which was true positive also in the other patients with macroscopic residual tumor in whom the procedure was performed. conclusion: both conventional planar sm and spect proved useful diagnostic tools in monitoring the response to neoadjuvant hormone or chemotherapy in lapbc. spect appears more sensitive than conventional planar sm in detecting residual tumor; however, our preliminary data seem to suggest that sensitivity can further increase by high resolution dbc planar sm, especially in subcentimetric tumor foci. these data need to be confirmed in larger series of patients. the role of mtc-mibi gated spect for assessment of anthracycline cardiac effects in breast cancer patients a. tzonevska, k. timcheva, m. dimitrova; national oncology hospital, sofia, bulgaria. aim: evaluation of adverse cardiac effects from anthracycline breast cancer therapy may enable identification of patients of risk for cardiotoxicity. the aim of the study is to assess the possibilities of mtc-mibi gated spect for early evaluation of patients of risk after anthracycline therapy. material and method: the study included s patients with breast cancer (mean age years ) after anthracycline therapy ( total dose mg farmarubicine ), - months after treatment. all of the patients had clinically normal cardiac status and performed echocardiography (echocg). gated spect myocardial scintigraphy was performed at rest after i.v. injection of mbq of mtc-mibi. a spect gamma camera siemens diacam was used. data were acquired for s for each projection using x matrix over °. images were gated at frame per cardiac cycle with an r-wave trigger. myocardial perfusion in each segment was estimated and regional systolic wall thickening and ejection fraction (ef) were measured and compared to echocg. results: the results demonstrated normal myocardial perfusion, regional systolic wall thickening and ef in patients. in patients there was mean to moderate hypoperfusion affecting myocardial segments ( anterior segments in patients, inferior segments in patients ). among these patients, patients established normal ef ( %- %) and patients had slightly reduced ef ( %- %) and regional systolic wall thickening in the hypoprfused regions as these results matched the echocg findings. it is concluded that mtc-mibi can be of use for early detection of adverse effects of anthracycline cancer treatment, before positive echcg results. the role of mtc-mibi scintimammography in recurrent breast cancer z. rajkovaca , j. mijatovic , g. vuleta , a. matavulj , p. kovacevic , n. ponorac ; clinical centre, banja luka, bosnia and herzegovina, medical faculty, banja luka, bosnia and herzegovina. breast conservative surgery has now become commonplace as it is less mutilating than radical surgery. the probability of recurrent tumour in this form of surgery increases. post-surgery and radiotherapy changes as fibrosis, inflammation have reduced the accuracy of convectional method of breast imaging as x-ray mammography. the aim of this study is to asses the accuracy of mtc-mibi scintimammography in patients with suspected recurrent breast cancer in the breast or loco regional tissues. methods: nineteen ( ) women (median age years, range - years) with suspected recurrent breast cancer in the breast or loco regional tissues were investigated. after routine analyses (clinical examination, ultrasound, x-ray mammography and fine needle aspiration biopsy) they were examined by scintimammography ( minutes after iv injection of mbq of mtc-mibi). all patients with suspected recurrent cancer in the breast or loco regional tissues ( ) undergone surgery and the final diagnosis was determined by histopathological examination. another patients were followed - months. the scintigraphic studies were correlated with radiological findings and/or with histopathology. results: there were patients with recurrent cancer ( with loco-regional recurrent and in another breast). x-ray mammography identified seven of these cancers. mtc-mibi scintimammography identified ten of eleven recurrent breast cancers. the one cancer not seen on scintimammography was positive on x-ray mammography. in the five out of seven patients without cancer, scintimammography were reported as having no changes consistent with cancer. x-ray mammography showed suspected cancer lesions in three out of seven patients without cancer. there were two false-positive scintimammograms and one false negative. axillary lymph node recurrence occurred in two patients. bought of them were positive on scintimammography. mtc-mibi showed higher sensitivity, specificity and accuracy per patient than did x-ray mammography ( . % vs. . %, . % vs. . % and . % vs. . %, respectively). conclusions: mtc-mibi scintimammography has high sensitivity, specificity and accuracy in patients with suspected recurrence of cancer in the breast or loco-regional tissues. to identifying recurrent breast cancer disease is better to use scintimammorapfy than x-ray mammografphy. aim: to evaluate breast scintigraphy in the diagnosis of breast cancer by quantitative analysis and image enhancement to emerge suspected lesions. breast scintigraphy demonstrates better specificity of mammography in cases where mammography is proven to be non-diagnostic (dense breast, scar tissue).. method: patients with a suspicious breast lesion and an abnormal mammography completed a scintigraphic study of the breasts. - mbq of tc m-tetrofosmin is injected intravenously in the arm vein contralateral to the breast with the suspected abnormality. the patient was laid prone with a single breast dependent from the imaging table of a spect gcamera. the contra lateral breast was compressed against the table to prevent cross talk of activity. the images obtained, as an interfile , were transferred via procyon starlab program to a pc and processed by image pro plus, software for data analysis, visualization and application development that combines the tools necessary for interactive analysis and display. results: the visualization of the image improved significantly, by applying image-processing techniques. in the histograms of the image pixels, brightness/contrast deficiencies are illustrated. the image contrast is adjusted appropriately by applying spatial filters and gamma correction technique. highactivity chest and abdominal organs such as the myocardium and liver are masked out, in regions of interests rois, by count subtraction. a logarithmic scale is chosen so that low-count areas are enhanced. semi-quantitative parameters were determined to characterize and improve the sensitivity and specificity. the tumor to background ratio (t/b) was calculated by using regions of interest (roi) of standardized shape and size over the site of the greatest activity and the surrounding normal tissue and creating the corresponding profiles. focal, increased uptake relative to surrounding tissue is classified as a positive study through the profile index. in every case scintigraphic results are compared with histological findings. conclusion: breast scintigraphy seems to be a very promising alternative imaging technique, especially, where mammography proves to be non-diagnostic. image processing techniques improve both the specificity and the sensitivity of the technique. one of our near future goals is to classify the grade of malignancy through the technique of image processing in breast scintigraphy. tc m-depreotide scintigraphy: priliminary study l. iordanidou, a. georgakopoulos, n. bolanos, e. trivizaki, s. saranti, k. rethimniotakis, n. stefanakos, p. koutsiouba; metaxa cancer hospital, piraeus, greece. aim:. accurate staging of disease recurrence is critical on treatment decisions. findings from conventional imaging can often be inconclusive, especially in areas previously treated with surgery or radiation. the aim of this study was to determine the potential role of m tc depreotide scintigraphy in the evaluation of breast cancer recurrence , particularly to intrathoracic tumor sites after primary treatment. patients and methods m tc depreotide scintigraphy (whole body and thoracic spect) was performed in female patients (mean age , age range - years) who had previously treated for invasive breast cancer. the impact of m tc depreotide on defining the disease recurrence was determined by comparing tc m depreotide results at the time of the examination with findings from conventional imaging (ci) performed before(mean time interval of days, range, - days) the final diagnosis of recurrent or metastatic breast cancer was confirmed by histopathological findings or clinical and radiological follow up . results overall of the patients under study, patients had confirmed recurrent or metastatic breast cancer, and were free of disease recurrence. eight of female patients had equivocal findings on ci of the thorax, and had findings indicative for metastatic disease. . m tc depreotide spect correctly identified the nature of equivocal findings as detected by ci imaging in out of patients: patients were truth positive ( malignant) , patient was truth negative ( benigh) and patient false positive (infection). m tc depreotide scintigraphy detected in all patients the metastatic lesions that had already been shown by ci imaging and in comparison with ci findings showed extent of disease increased in (new metastatic lesions ) and no change in patients. conclusions these preliminary results suggests that m tc depreotide scintigraphy is useful for detecting recurrent breast cancer and it seems to provide a better understanding of the extent of disease as compared with conventional imaging modalities. objectives: it is important for clinical physician to stage, to evaluate effectiveness, to diagnose recurrent and survived tumor in routine clinical practice. the purpose of this study was to validate the clinical application value of f-fluorodeoxyglucose ( f-fdg) using single photon emission computed tomography with coincidence detecting imaging in staging of lymphoma and evaluating the therapeutic effective. methods: eighteen patients with nhl were performed with f-fdg metabolic imaging preand post-therapy using a vertex plus epic mcd/ac from adac company. the imaging was performed min postinjection of f-fdg . - . mbq using adac vertex plus mcd/ac (spect with coincidence detection). qualitative and semi-quantitative analyses were made during interpretation of f-fdg imaging. qualitative analysis is that malignant neoplastic lesions were identified if there were f-fdg concentrated area beyond normal tissues (brain, heart, gastricintestinal tract, kidney and bladder et al). semi-quantitative analysis, such as t/b (ratio of radioactive counts of tumor and normal tissue) was performed. when t/b > . the lesion are regarded as malignant lesions. f-fdg images were compared with synchronous routine images such as ultrasonography and ct. results: thirty studies were performed in patients with nhl in this study. there were true positives, true negatives, false positives and false negative. the accuracy, sensitivity, specificity, positive predictive value(ppv) and negative predictive value(npv) were %, . %, %, . %, . %, respectively. f-fdg imaging led to a change of . % in the clinical staging, and . % in the management. the ppv and npv of recurrence detected by f-fdg spect/pet were % and %, while ct's were % and % after therapy. four of five patients with negative entered clinical complete remission (cr), whereas all the patients with abnormal f-fdg uptake relapsed or reprogressed. progression-free survival (pfs) with negative f-fdg was - months (median: . months) and pfs with positive was - months (median: . months). conclusion: f-fdg metabolic imaging using spect with coincidence detection plays an important role on clinical application of the diagnosis and management of patients with nhl. key words: f-fdg; spect; coincidence imaging; lymphoma rituximab and . ml of an medronate kit, reconstituted in ml of . m pb was irradiated for min at nm. irradiated solution was aliquoted into nitrogen-filled vials and stored at - oc. each aliquot was labelled with mbq of mtcpertechnetate. radiolabelled antibody was sterilised by filtration under aseptic conditions using a . um filter. the effectiveness of the labelling method was evaluated by determination of the number of free thiol groups per photoreduced antibody using -iodoacetamidofluorscein reaction method, radiochemical purity determination of mtc-rituximab by tlc and size-exclusion hplc and testing of in-vitro stability of the preparation. immunoreactivity of mtc labelled rituximab was further explored on ramos cells using a direct binding assay. until now six patients (age - y) with cd + lymphoblastic b-cell nhl and one with cd -nhl as diagnosed by lymph node biopsy and planned for mabthera® or y-zevalin treatment, were injected with mbq of mtc-rituximab. whole body and spect images were taken h, h, h and h post injection. scintigrafic results were compared with ct findings. results in all cases high radiochemical purity over % was observed with preserved affinity of mtc radiolabelled rituximab for cd antigen, irf being above %. on average . fee thiol groups per photoreduced rituximab were determined. in all patients expected activity was seen in the blood pool, liver, spleen and kidneys. accumulation of mtc-rituximab in involved sites was clearly seen on the whole body and spect images performed as early as h p.i. in some patients and and h p.i images in all patients. pathological, moderately to markedly increased mtc-rituximab activity was seen in all ct confirmed nhl involved sites h and h p.i.. conclusion mtc-rituximab is a promising imaging agent suitable for assessing expression of cd in patients with nhl prior to (radio) immunotherapy. bone involvement in lymphoma:comparison of mtcmibi and mtcmdp scintigraphy d. vassileva , a. tzonevska , m. dimitrova ; national centre of haematology and transfusiology, sofia, bulgaria, national centre of oncology, sofia, bulgaria. bone lymphoma is uncommon and presents diagnostic and therapeutic difficulties. aim:the purpose of the study was to compare mtcmibi and mtcmdp scintigraphy in bone lymphoma, with an attemt to define the relevance of each modality with respect to disease detection and possibly the interrelationships of scan pattens with disease activity. material and methods: patients with malignant lymphoma (hodgkin's disease, non-hodgkin's lymphoma and myeloma) and suspected bone involvement were investigated. the bone scans were obtained at hours after intravenous injection of mbq mtc mdp and min and hours after i.v. injection of mbq mtcmibi. the scintigraphic results were compared with the data of conventional imiging methods and hystological results. results: the results from the both scintigraphies were devided in groups: i group-in patients with osteolytic lesions both mtc mibi and mtc mdp scintigraphy were true positive for the presence of active disease. the mdp scans depend on the osteoblastic activities around the lesions. the scans detected lesions, especially in the femur, humerus, ribs,sternum, thoracic and lumbar spine, pelvis. ii group-the m tc mibi scans were positive ( lesions) and mtc mdp negative in patients. mtcmibi accumulation attributed to bone marrow metastases may occur at an early stage, before the bone remodeling process can be detected on conventional bone scans. iii group-in patients, positive m tc mdp scans and negative mtc mibi scintigraphy were found. pathological fractures and persistent reactive bone formation after therapy ( lesions) were detected in patients by positive bone scintigraphy only. the m tc mibi image may become positive before the m tc mdp and may subsequently revert to normal in the presence of an abnormal mtc mdp scan. in one patient with positive mmdp scintigraphy demonstrated lesion in humerus, the bone biopsy showed osteomyelitis. iv group-no abnormal images on the both scintigraphy were found in patients, defined as a desease remission. conclusion: mtc mibi scintigraphy is helpful in early diagnosis , in detecting the extraosseous lesions and in early remission after therapy in lymphoma. mtc mdp scintigraphy is of limited value for the initial diagnosis of sceletal involvement but is a sensitive method for the detection of pathological fractures and osteblastic activity after chemotherapy.the combination of mtcmibi and mtcmdp scintigraphy gives an accurate diagnosis and helps to asses the extent of the disease in lymphoma with bone involvement. the purpose of this ongoing clinical study is to optimize the follow up as well as the primary diagnosis of patients with neuroendocrine tumors. different methods, like f-dopa-pet/ct and in- octreotid spect/ct, conventional imaging modalities and biochemical markers are performed individually in a comprehensive concept. methods: up to now patients with suspicion of recurrence of a neuroendocrine tumor or in a preoperative assessment have been examined in our department. in addition to conventional imaging studies (ct/mri or ultrasonography) f-dopa pet/ct, if demanded in -octreotid spect/ct, a complete patient history, physical examination and biochemical markers (including cga, a h urine collection for determination of -hiaa and the predominant pancreatic peptide) were performed. results: patients demonstrated pathological findings in the f-dopa pet/ct and/or in the in- octreotid spect/ct. the results from the two imaging modalities were helpful in deciding the primary treatment options, meaning adequate resection with curative or palliative intent for primary and regional lesions. the somatostatinreceptorscintigraphy allows additional information about the treatment option with somatostatin analoga. in one patient with recurrence of a carcinoid tumor (clinical symptoms, hies + cga elevated) f-dopa pet-ct demonstrated clearly the extent of the metastatic disease (multiple peritoneal and iliacal metastases). in- octreotid spect/ct, however, demonstrated only tracer uptake in the iliacal lymphnodes, the multiple peritoneal metastases showed no somatostatin receptor expression -showing the different tumor biology of the metastases in one single patient. conclusion: each of the performed modalities (mri,ct, ultrasonography, f-dopa pet/ct, in- octreotid spect/ct, patient history, physical examination and biochemical markers) are of great value and can contribute in the whole concept of treatment options, follow up and therapy monitoring in patients with neuroendocrine tumors. in-octreotide scintigraphy is a very important procedure for the staging and followup of somatostatine receptors expressing cancers. however, a major drawback of the technique is the lack of anatomical landmarks. the best solution to this problem is the fusion with radiological images obtained using spect/ct devices. since this kind of machines is not still widely available, we propose a simple way to improve the anatomic localisation of in-octreotide foci. patients and methods: inoctreotide images (after injection of mbq activity) have been recorded at , and, if necessary, hours. according to the findings on the images acquired at hours, planar and tomographic images at hours have been obtained with a simultaneous double isotope acquisition, after administration of a bone tracer ( mtc-hmdp, mbq) three different energetic windows have been centered respectively on the two in peaks ( and kev) and on the mtc peak ( kev) we validated this technique in consecutive patients. results: we show several images where the association between in-octreotide and bone scan provided useful information on the anatomical localization of the lesions visualized by the somatostaine scintigraphy. conclusion: double isotope tomography is a simple technique and it's easily feasible in every nuclear medicine department. this modality of image acquisition allows to improve the anatomical localization of in-octreotide scintigraphy. aim: pentetreotide is a dtpa conjugate of octreotide, a long-acting analog of the human hormone, somatostatin. in pentetreotide (octreoscan) binds to somatostatin receptors on cell surfaces, and can be used for scintigraphic localization of neuroendocrine tumors bearing corresponding receptors. the aim of the study is detection of primary and metastatic neuroendocrine tumors. patients and methods: the total of patients ( males and females, age ± years) patients were investigated. scintigraphy of the whole body, (and tomography o/ o if necessary) were performed h, h and h after i.v. administration of mbq -in pentetreotide. if needed, the study was supplemented with liver/spleen radiocolloid and/or bone diphosphonate scintigraphy. the study was performed with orbiter gamma camera and microdelta computer, using medium energy collimator and two photopeak activities ( . kev± % and . kev± %). results: in the group with seven neuroendocrine carcinomas of unknown origin, there were six true positive (tp) findings (two with liver metastases, two with liver, lung, and bone metastases, one with liver and mediastinal lymph node metastases and one with liver and retroperitoneal lymph node metastases), while one was false negative (fn) (poorly differentiated carcinoma with retroperitoneal metastases). in four patients scintigraphy influenced further patient management. from the group of nine pancreatic neuroendocrine tumors, in five neuroendocrine pancreatic carcinomas there were three tp (two with liver metastases) and one fn (poorly differentiated). in two patients with pancreatic gastrinomas both findings were tp, while in one patient with insulinoma it was tp and in the other tn. in four patients scintigraphy influenced further patient management while in two contributed. from the group of four neuroendocrine lung tumors there were two tp (two patients with bronchial carcinoid, one with liver metastases and the other with liver, lung and bone metastases), in one patients with atypical lung carcinoid after surgery, finding was tn, while in one with neuroendocrine lung tumor (acth secreting) it was fn (small mediastinal tumor. in one patient scintigraphy influenced further patient management while in one contributed. because of the the high uptake of radiopharmaceutical, and widespread metastases, six patients were indicated for radionuclide therapy with y-dota tate, and three of them received it. conclusion: preliminary results show that scintigraphy of neuroendocrine tumors is a useful method in diagnosis, staging and follow up of the patients suspected to have neuroendocrine tumors in the lungs. it is also helpful in the appropriate choice of therapy, including the radionuclide one. centre, we noticed an increasing number of referrals for octreotide studies in patients with mild symptoms or signs suspicious for a net and raised gi peptides but no history of a net and no suggestion of a net on other imaging. therefore, an audit was undertaken to assess the use of octreotide studies in this patient group. method a retrospective review was performed of all octreotide studies performed in to firstly detect what percentage of referrals were performed for this group of patients. secondly, within this group, the number of normal and abnormal studies was examined. results studies were performed in total in with of these falling the category of interest. of these were normal with the remaining raising the possibility of an abnormality, but further imaging appeared normal. discussion & conclusions we concluded that octreotide studies did not appear to be useful in investigating this subgroup of patients. aim. the aim of this study based upon a large series of consecutive patients evaluated by spect in-pentetreotide for a neuroendocrine tumor, was to evaluate the variability of reconstructing parameters used during spect study, in relation to the patient body weight and body district, looking for the possibility to standardize such parameters. materials and methods. patients underwent in-pentatreotide scintigraphy by -and -hr whole-body and planar scans, and -hr spect examination. all patients were injected with - mbq of in-pentetreotide at least week after somatostatin analogs discontinuation. spect was sitematically acquired at the level of the head, chest, and abdomen. spect parameters were selected as follows: acquisition, gamma-camera dual-head, medium energy collimators, step and shoot method, no circular orbit, matrix x , sec. per view for a total of views; reconstruction, two procedures were compared, iteractive method using iterations vs. filtered back projection using butterworth filter with different cut-off and order values. results. the results we obtained are summarized on table (see below) , where reconstructing parameters of in-pentetreotide spect were correlated to patient's boby weight (b.w.) and body discrict. patients with b.w. patients with b.w. part lower than kg greater than kg head cut-off order - cut-off order - , - , , - , thorax cut-off order - cut-off order - , - , , - , order - abdomen cut-off order - , - , order - , - , order - , - , order - conclusions. in our experience, the optimal spect images were obained by applying the butterworth filter. moreover, it was possible to standardize the reconstructing parameters for the body districts of the head and chest, while in the abdomen the choice of these parameters was more variable; this is probably due to the fact that in-pentatreotide is physiologically trapped in various abdominal areas, and in different manner as a function of time, especially the liver, the spleen, the bowel, and the urinary tract. aim: as spect/ct evolves, its applications, including ct parameters, need to be evaluated in order to improve diagnostic accuracy and to assure that radiation exposure is minimal. here, we evaluate the added value of an additional "diagnostic" ct-scan (centred on a solitary focus) in cancer patients referred for bone staging and, for whom, a conventional low-dose spect/ct acquisition was planned. material and methods: patients with a solitary focus observed on whole-body bone scintigraphy (wbs) and classified as indeterminate or suspicious, underwent a low dose spect/ct acquisition ( kv, mas, mm slice thickness); the ct-scanning area being similar to that obtained during the spect acquisition. in addition, a "diagnostic" ct-scan ( kv, mas, . mm slice thickness) centred on the focus obtained from the ct-topogram, was performed. nuclear physicians considered prospectively wbs, low-dose spect/ct and finally the centred spect/ct. radiation dose exposure was evaluated by means of a computed tomography dose index (ctdi). results: thirty-one consecutive patients (mean age: yrs +/- ) were included in the study. whole-body bone scintigraphy depicted solitary indeterminate or suspicious foci in and patients, respectively. after low-dose spect/ct, these foci turned out to be malignant, or benign, in and patients, respectively, and remained indeterminate in patients. low-dose spect/ct altered the interpretation of the wbs results in pts of the "indeterminate focus" group and pts of the "suspicious focus" group. an additional diagnostic ct-scan was accurately centred in all but one patient and altered low-dose spect/ct results in only patient, in whom a solitary indeterminate focus on wbs was classified as indeterminate on low-dose spect/ct and subsequently benign on diagnostic spect/ct. additional foci (not found by wbs) located outside the scanning area of the centred diagnostic ct-scan were found in patients. ctdi measurements were . +/- . mgy and . +/- . mgy in low-dose and "diagnostic" ct, respectively. conclusion: these preliminary results show that, ( ) a conventional low-dose spect/ct is adequate for patients presenting with a solitary focus on wbs, provides an acceptable radiation dose exposure and identifies / ( %) of foci; ( ) a ct volume session should not be limited to the area of the solitary focus since additional foci overlooked by wbs and located outside the centred ct-scan occurred in pts ( %) and thus required ct data acquired over the entire spect region of interest for thorough elucidation. tl-scintigraphy in differential diagnostics of inflammatory and malignant tumoral processes of the musculoskeletal system purpose: to estimate the efficiency of tl-scintigraphy in differentiating the inflammation and tumor. materials and methods: the tl-scintigraphy has been applied in investigation of patients suffering the inflammatory and neoplastic diseases of the musculoskeletal system. the scintigraphy was carried out at early and at deferred phases (in and minutes after the intravenous introduction of mbq -thallium, respectively). the intensity and contour's sharpness of the radiotracer accumulation focus have been estimated visually, and the coefficients er, dr, and ri=dr/er have been evaluated. the thallium- -scintigraphy results have been verified morphologically (n= ) and compared with the data of ultrasonic (n= ), -phase scintigraphy (n= ), mrt (n= ), wbc-scintigraphy (n= ), radiography, (n= ), ct (n= ), clinical examinations, and results of treatment (n= ). results: the affections have been visualized in / ( . %) cases ( / inflammations, / -tumors). the correlation between coefficients ri and er at inflammations (r=- . , p< . ) and tumors (r=- . , p< . ) is due to the delivery and removing -thallium from an accumulation focus because of blood-groove. we have found that ri=- . ·er+ . at inflammations, and ri=- . ·er+ . at tumors. on this basis, we offer the formula ricrit.=- . ·er+ . to differentiate inflammations and tumors. thus, the quantitative and qualitative criteria of an inflammation are: ( ) ri<- . ·er+ . ; ( ) at an early phase, the contour's sharpness of the radiotracer accumulation focus is better than at a deferred phase; ( ) a homogeneous accumulation of radiotracer at a deferred phase. at a tumor they are: ( ) ri>- . ·er+ . ; ) at an early phase, the contour's sharpness of the radiotracer accumulation focus is worse than at a deferred phase; ) a heterogeneity accumulation of radiotracer at a deferred phase. conclusion: the use of the above formulated criteria results in / ( . %) success in the differential diagnostics of inflammations and tumors. the sensitivity, specificity, and accuracy of the tlscintigraphy are estimated as . %, . % and . %, respectively in the diagnostics of inflammations, and as . %, . % and . % -in that of tumors. patients with lung cancer. furthermore,to quantify the octreotide uptake for the positive sr metastases in order to assess the potential benefit of somatostatin derivatives therapy. patients and methods: twelve patients ( males and females, aged from to years old) with histologically confirmed lung cancer were evaluated ( with sclc and with nsclc).final diagnosis of bone metastases was based on the combination of clinical findings, the results of imaging methods including x-ray, computed tomography(ct) and bone scintigraphy(bs).the octreotide scanning included anterior and posterior views at and hours tomographic images when it was necessary and quantification of sr regional uptake for detected bone metastases graded with score to ( ,no uptake; ,low uptake; ,moderate uptake; ,intense uptake;).the images of each patient were evaluated independently by at least two nuclear medicine physicians. considering the small patient population no statistical analysis was performed. results: sr scintigraphy visualized the primary tumour in all cases. sr scintigraphy showed skeletal involvement in patients ( with sclc and with nsclc). the detected bone lesions were fewer than in the bs (sensitivity on a lesion basis , %), although two patients demonstrated more widespread bone metastases than the bs . in the remaining patients sr scintigraphy showed no skeletal involvement (sensitivity on a patient basis , % ). in our series, % of skeletal metastases showed strong uptake, % showed moderate uptake ,while low uptake was demonstrated in %.thirty percent of skeletal metastases showed no uptake. conclusion: indium octreotide scintigraphy provides great potential for the visualization of receptor-positive metastases mainly in sclc patients. the patients with high sr uptake (grade and ) could benefit from the treatment with radiolabeled somatostatin analogues. aim: this study looked at the incidence of positive bone scans in patients with low prostate specific antigens levels and compared this with the published recommendations for bone scanning in prostate cancer. material & method: we looked at bone scans in patients with known prostate cancer undertaken at our institution in . these were all reported as clearly "negative" or "positive". scans which were in any way ambiguous were excluded from the study. we then looked at the prostate specific antigen (psa) levels in these patients and compared this to the published recommendations which state that bone scans can be confidently be excluded in cases where the psa< , should be omitted where psa< and can cautiously be omitted at psa< . results: we had no positive bone scans at psa< in agreement with the published data, however, there were positive scans at psa < ; positive scans at psa< and positive scans at psa < . this is an incidence of %, which is much higher than the published data would suggest. for those patients with high psa values > , / ( %) patients had a positive scan in agreement with published data. conclusion: patients with prostate cancer and psa< should not routinely have bone scan imaging but those with psa - have a % incidence of a positive scan and should be considered for bone scintigraphy. purpose: breast cancer is the most common form of malignant disease among women associated with metastases in bones. ca . and cea are two of the most widely used tests for monitoring breast cancer. mtc mdp bone scintigraphy is the most widely using imaging test for early detection of bone metastases. carbon anhydrite antigen (ca) . is a high molecular weight glycoprotein defined by two monoclonal antibodies (df and d ), of clinical relevance in the monitoring of treatment and detection of recurrence in breast cancer. this is a prospective study evaluating the efficacy of ca . and cea in monitoring breast cancer and early detection of metastases in bones. methods: |sixty two females with high-risk breast cancer were included in the study. response evaluation was based upon clinical examination, -rays or histology and elaborated marker criteria. results : elevated ca . were found in patients with breast cancer associated with bone metastases ( . %) and patients without bone metastases( %). the sensitivity of ca . tests was %, whereas specificity was %. elevated cea levels were found only in patients with breast cancer associated with bone metastases ( . %). cea sensitivity was only . % whereas specificity was %. the specificity of bone scintigraphy for early detection of bone metastases were % whereas specificity were %. the combination of cea and ca . increased the overall sensitivity by only . %. ca . was a significantly more powerful marker than cea for early detection of bone metastases, but clearly less favorable than bone scintigraphy. conclusions: ca . monitoring should be considered an expensive and inefficient method for early detection of bone metastases from breast cancer, and it provides no additional value when used in combination with cea. bone scintigraphy still continuous to be most efficient test for early detection of bone metastases. ( ) other malign disease (bladder ca, renal cell ca, colon ca, multiple myeloma, uterine ca, leukemia, lymphoma, malignant mesothelioma, thyroid ca, thymic ca, pancreatic ca, larynx ca, etc.). the most metastatic cancers for bone are prostate ca ( %), breast ca ( %), lung ca ( %), gastric ca ( %), respectively. for the other malignancy types, bone metastasis ratio is %. bone metastasis determined in % of the patients with malignancy. suspicious lesions were not evaluated as metastasis. we frequently find the metastatic locations at extremities, pelvic bones and vertebrates for prostate ca; vertebrates, ribs and pelvic bones for breast ca; ribs, vertebrates and pelvic bones for lung ca; vertebrates and pelvic bones for gastric ca; extremities and ribs for others. conclusion: visualisation of metastatic bony lesions in / of cancer patients indicated the importance of whole body bone scintigraphy for these patients. if we assume some of the suspicious lesions as metastasis, the ratio of metastasis is increase ( - %). the excess amount of the bone metastasis and the frequency of the metastatic extremity lesions are unexpected. comparison of bone scintigraphy and x-ray imaging in the patients after revisal endoprotesis operation of hip joint. p. korol, a. kosiakov, n. shincarenko, d. levinskiy; clinical city hospital # of kyiv, kyiv, ukraine. aim: the aim of the study to evaluate the level of disease after revisal endoprotesis operation of hip joint using of bone scintigraphy and x-ray imaging. material and method. patients after revisal endoprotesis operation of hip joint were imaged by a standard method of whole body bone scan. intestinal uptake was observed visually hours after the intravenous administration of mbq m tc mdp. a whole body bone scan; anterior, posterior, oblique spot views of the hip joint region were obtained. the data of bone scan were compared with x-ray imaging. results. total number of patients with bone scans and x-ray imaging was statistically evaluated. / pts ( %) with bone scans had in the field of hip joint inflammatory process that is indicative of instability of the hip joint endoprotesis. however, on x-ray imaging, inflammation in hip joint was identified in / pts ( %) events only. in total there were matching scans and statistical data showed overall good correlation r= , . within the group of different matching regions correlation varied: r= , for head of hip; r= , for broach of hip; r= , for cervical of hip. conclusion. bone scintigraphy is more sensitive and specific method of the determination to stabilities of the hip joint than x-ray imaging in the patients after revisal endoprotesis operation of hip joint. complex regional pain syndrome i (crps) previously known as reflex sympathetic dystrophy (rsd) is a disabling condition with annual incidence estimated at . / , general population. symptoms include intense, prolonged pain and burning of the extremity, change in limb temperature, sweating and swelling. proposed mechanism is an abnormal response to noxious stimuli resulting in dysfunctional interaction between sensory, motor, immune and autonomic nervous systems. crps could be related to prior fracture or sprain, significant physical stress (surgery, myocardial infarction) or thought to be idiopathic in up to % of cases. important associations of crps with other clinical conditions include hepatitis c, cirrhosis, aids, pancoast and pancreatic tumors. crps is believed to represent a paraneoplastic syndrome in these conditions. our exhibit focuses on the radiographic/scintigraphic features of crps; reviews the current literature regarding association of crps with malignancy and presents an illustrative case of a patient who developed crps affecting the hand in association with metastatic bone lesion in proximal forearm. crps was the first presenting symptom of osseous metastasis in this patient. the main goal of this exhibit is to increase interpreters' awareness of crps, its potential association with malignancy, and the need for imaging investigations to establish the diagnosis and associated pathology. imaging features: plain radiography is normal in the early stages; patchy subchondral and peri-articular osteopenia can develop later, occasionally in combination with soft tissue swelling. three phase m-technetium- to evaluate the relapse frequency of malignant melanoma (mm) in patients (p) diagnosed of mm, who underwent surgery and sentinel lymph node detection and biopsy (slnb) materials and methods: p (aged - ; mean , ) who underwent surgery and slnb during - were included. parameters studied were: absence/presence of disease, tumor relapse (local or spread to other organs) and number of deaths. these items were evaluated depending on: mm's localization ( head-neck -hn, chest -ch-, arms -a-or limbs -l-) and breslow index (bi). the survival was estimated by kaplan-meier method results: the slnb was positive in p and negative in p. % of p studied with slnb negative were free of disease during our evaluation ( years). depending on mm's localization: in p it was located in ch ( %). relapsed p of them ( %); (bi> mm in p and , >bi mm p and , >ib< mm p). in p it was located in l ( %). relapsed p of them ( %; ib> mm; slnb positive). local relapse in / p and metastasis in / p. none of the patients with mm located in a ( p; %) showed local relapse or metastasis. in the group of patient analysed the most frequent localization was ch, and the worst prognostic factors were: mm's localization (l and ch), ib> mm and slnb positive. these results lean upon de value of slnb as a good method to foresay de long term tumor's relapse. aim multiple radioactive lymph nodes are often detected by lymphoscintigraphy to identify sentinel lymph node(s) (sln) in breast cancer patients. it is not clear whether these additional lymph nodes are "true" sentinel nodes, or second-echelon lymph nodes that have received radiocolloid particles passing through the sln. various criteria based on the degree of radioactivity regarding the "hottest" node have been proposed to define which radioactive lymph nodes should be removed in order to minimize the false negative rate of the procedure. aims of this study were: to determine the frequency with which the most radioactive node "fails" to be pn+ when the less radioactive lymph nodes contain metastatic disease; to establish which lymphoscintigraphic criteria best define the radioactive lymph nodes to be removed. a total of patients referred to pisa university hospital with operable breast cancer underwent radiocolloid lymphatic mapping and radioguided sln biopsy. to determine how often a less radioactive sentinel node is positive for tumor when the most radioactive lymph node is not, we considered as slns both those with the highest counts and any additional radioactive lymph nodes counting % or more of the hottest node. we identified two groups of pn+ patients, the former in which the most radioactive node was positive for tumor and the latter in which the less radioactive lymph nodes contained metastatic disease when the "hottest" did not. results: a total of out of patients ( . %) were found to have sentinel node metastases detected by histology or immunohistochemistry. we identified positive axillary nodal basins from patients in whom at least one positive sentinel node was found and more than one sentinel node was harvested. in out of these nodal basins, a less radioactive lymph node was positive for tumor when the most radioactive sentinel node was negative. if only the most radioactive sentinel node in each basin had been removed, % of the nodal basins with positive sentinel nodes would have been missed. the "parallel" lymphoscintigraphic pattern (multiple lymphatic channels originating in the region of the primary tumor and running to different lymph nodes) was associated with increased likelihood of finding the "hottest" lymph node negative for tumor while another, less radioactive, sentinel node contained metastatic disease ( of out patients; %). conclusion: we suggest the intraoperative threshold of % for optimal detection of nodal metastases in breast cancer patients. aim: due to its ability to depict sentinel nodes (sn) in expected and unexpected sites of lymphatic drainage lymphoscintigraphy is an important part of the sentinel node procedure. however, in prostate cancer lymphoscintigraphy has limitations in indicating the anatomical localization of deep located sentinel nodes inside and outside the pelvis. for this purpose spect-ct was evaluated in addition to lymphoscintigraphy in patients scheduled for laparoscopic pelvic lymphadenectomy. methods: in patients (mean age . y, range - y) with prostate cancer of the intermediate prognostic group (inclusion criteria: t or psa> μg/l or gleason score > ) mtc-nanocolloid was injected peri/intratumorally in depots of . ml per lobe guided by transrectal ultrasound. images were performed at min and - h. delayed planar images were followed by spect-ct (spect: matrix x , x -sec frames, ct: kv, mas, b s kernel) with -min acquisition using a hybrid camera. after correction for attenuation and scatter spect images were fused with ct and analysed using d orthogonal reslicing. sn were anatomically identified according to the lymph node groups inside/outside the pelvis and evaluated in relation to laparoscopic extended pelvic lymphadenectomy (epl) which was performed in all patients in combination with laparoscopic gamma probe guided sn dissection. results: mean injected dose was mbq (range - mbq). sn were visualized in patients ( %). in all these patients drainage was bilateral. drainage to the lymphatic groups included in the epl area was seen in all patients and spect-ct enabled anatomical sn localization in all of them. in patients ( %) additional sn, appearing in early images of lymhoscintigraphy, were visualized outside the area of epl (para-aortic, aortic-iliac junction, pre-vesical, inguinal). all sn outside the epl area were found at laparoscopy. sn metastases were found in patients ( %). in two of these patients metastases were found in sn located outside the epl area. conclusion. in addition to the anatomical localization of pelvic sn in prostate cancer, spect-ct may lead to an accurate identification of sn outside the pelvis. the anatomical spect-ct information concerning the location of these sn may subsequently guide its resection using a laparoscopic gamma probe. aim: determine if the size of the metastases in the sentinel node (sn) of patients (p) affected of breast cancer smaller than cm has any relationship with the finding of metastases in other axillary lymph nodes (am conclusion: the detection of the sentinel node with the combination of the gamma probe and the blue dye is also possible in t> cm. in % of these patients axillary lymph node dissection can be avoided, and in % the sln is the only one affected. therefore we consider that these patients should be included as a general indication in breast cancer sentinel node detection. the usefulness of sentinel lymph node mapping in colon cancer staging: preliminary experience. aim the presence of regional nodal metastatic disease in colon cancer is an important prognostic factor. improving identification of lymph node disease would significantly better select patients who may benefit from adjuvant chemotherapy. our study aimed to determine the usefulness of sentinel lymph node (sln) mapping in detecting regional lymph node metastatic disease in patients with potentially curable colon cancer. materials and methods we prospectively studied patients ( men, mean age: +/- ) with left colon cancer with no evidence of metastatic disease or lymphnode involvement at abdominal ct. patients underwent surgical resection with standard colectomy confined to the affected segment. mtc-nanocoll® ( mci/ml x ) was injected submucosally at sites around the tumour by colonoscopy hours prior to surgery. lymphoscintigraphy was performed hours after injection to verify radio colloid migration to the sln. slns were harvested ex-vivo from the mesentery of the resected specimen using a gamma probe. all nodes were examined by haematoxylin & eosin (he) staining. in addition sln were multisectioned and examined by immunohistochemical (ihc) staining with cytokeratin. results at least one sln was identified in % of patients ( / ), with a mean of sln/patient (range= - ). the mean number of lymph nodes from the standard lymphadenectomy was (range= - ). sln examination with he adequately predicted the regional nodal status in of ( %) cases ( negative and positive). in patients ( % of all patients studied), ihc of sln was the only indicator of metastatic disease. sln failed to predict nodal metastatic disease in patients (false-negative rate %). conclusions lymph node mapping using radio colloid is feasible in colon cancer, yielding a high rate of sln identification. although the false-negative rate is high ( %), sln technique improves staging in colon cancer patients, upstaging % of patients, who may benefit from adjuvant chemotherapy. follow-up in primary breast cancer after sentinel lymph node biopsy. during the follow-up (fu) period, we analysed the appearance of axillary and/or locoregional metastases in both groups by performing an echography of the axilla twice a year and annually a mammography. we also considered the presence of systemic metastases in both groups. results: in group a, pts ( %) were followed-up for two to four years. one pt ( . %) experienced axillary metastases after two years from surgery (pt c, g , idc with a single negative sln removed); four pts had locoregional recurrences; one pt developed bone metastases and four pts showed systemic involvement (total recurrences: cases). in group b, pts had only one positive sln ( %), two positive sln were found in pts ( %), three positive sln were removed in pts ( %) and more or equal to six sln were carried away in cases ( %). among the pts in this group who had a complete fu ( %), there were two cases of systemic metastases.conclusion: the accuracy of sln method was %. the risk of developing axillary metastases in pts with t breast cancer seems to be very low in our follow-up. objective: indication of sentinel node biopsy (snb) has not been fully established for patients with dcis. our aim was to relate the conversion rate to invasive carcinoma with sn positivity in high risk dcis, and also to refine the clinical presentation analysis in order to achieve a better patient selection for snb. relation between conversion rate and invasive carcinoma with sn positivity in high risk dcis did not reach statistical significance, thus a subset of selected high risk patients could not be redefined. however , the relevance of snb positivity cannot be overlooked in high risk dcis patients, and more studies are still needed to refine its final indication. radioisotopic identification of sentinel lymph node in early stages of cervical cancer with tc- m nanocolloid (preliminary results) v. g. moschogiannis; "metaxa 's" cancer hospital, piraeus, greece. the aim of this study is to investigate the feasibility and the utility of the detection of sentinel lymph node in early stages of cervical cancer with radionuclide method. method: women (median age , years) with cervical carcinoma, stage ia (no ), stage ib (no ), stage ib (no ), underwent sln detection during primary operation. exclution criteria was stage iib or more advanced disease. one day before the surgery, patients were injected intracervical with a total dose of mbq tc- m nanocolloid, devided in four injections, and one hour after the injection a lymphoscintigraphy was performed. on the day of surgery, ml of patent blue dye was injected in the cervix, at the same sites as the radioactive isotope injections. using a laparoscopic gamma probe and visual detection of blue nodes, the sln were identified and removed for pathological assesment. results: lymphoscintigraphy identified one or more sentinel nodes in out of patients ( , %), while blue dye identified sln in pts ( , %). the combination of blue dye and radioactive tracer detected lymph nodes in pts ( . %). in one woman, where the lymph nodes were not identified with tc- m nanocolloid, the stage of the disease was ib . in pts, we had a bilateral visualisation of lymph nodes. the average number of sln per patient was , . metastatic disease to the lymph nodes was found in pts. in total, in pts. the sentinel nodes were located in the distal parametrium, in pt they were located paraaortic and in pts, in the area of the external and internal iliac artery. conclusion: our findings confirm that sentinel lymph node detection with radiocolloid, in combination with blue dye, is feasible and improves detection rate in patients with cervical carcinoma and also allows the identification of lymph nodes in areas that are not frequently sampled. this technique must be evaluated in larger studies, that may lead to better treatment selection of patients with early cervical cancer. the sentinel lymph node (sln) is the first node in a nodal basin that receives the direct lymphatic flow from malignant melanoma (mm). however, in some patients, their lymphoscintigraphic study reveals the presence of lymphatic nodes in the area between the primary mm and the regional basin. these nodes are called "in transit nodes" or "aberrant nodes" and, by definition, they are also slns. aim: to determine the percentage and location of "in transit" slns in our group of mm patients and assess if it is really necessary to harvest them. method: in this study a total of patients were included. the day before surgery a lymphoscintigraphy was performed by injecting - mbq of mtc-nanocolloid in four doses around the primary mm or the biopsy scar. blue dye was injected in the majority of patients a few minutes before surgical procedure. a hand-held gammaprobe was used to better localize the slns. results: lymphoscintigraphy showed "in transit" slns in / patients ( . %). during surgical procedure of them were harvested ( . %). sln identification and excision proved most difficult to achieve in the popliteal and epithroclear regions. metastatic cells deposits were subsequently identified in ( . %) of these "in transit" slns. conclusions: lymphoscintigraphy has a pivotal role in the identification of "in transit" slns. the incidence of these nodes is relatively low in mm patients. however, these slns present metastatic deposits in a significant percentage of cases and it warrants a surgical search for them. role of spect-ct in sentinel node identification and intraoperative lymphatic mapping. first results of a pilot study in patients with breast cancer in thailand. c. chotipanich, y. kongdan, k. sumboonnanonda, r. suvikapakornkul, p. lertsithichai, k. cheuamsamakkee, s. promma, k. poonak, p. chouplywech, c. sritara; ramathibodi hospital,faculty of medicine, mahidol university, bangkok, thailand. purpose: to retrospectively evaluate the clinical usefulness of the role of spec-ct in sentinel lymph node identification in patients with breast cancer which has not yet been established in thailand. material and methods: a retrospective study of women ranging from in the age of to years(median age year) who underwent spect-ct lymphoscintigraphy from january to december was analyzed. all of the patients underwent lymphoscintigraphy with subareolar injection of tc- m dextran with planar and spect-ct fusion imaging. planar and spect-ct fusion images were assessed separated by a nuclear medicine physician. sentinel lymph node biopsy guided by intraoperative injection of vital dye (blue patent) and hand held gamma probe was performed. results: the sentinel node was detected using two methods in all cases ( %) and positively metastatic in . %. there were concordance between lymphoscintigraphy findings and blue dye in %. of the total lymph nodes, planar imaging detected nodes ( %), while spect-ct fusion detected nodes ( %). spect-ct fusion detected nodes, which were missed by planar imaging ( were obscured by the scattered radiation from the injection site and were misinterpreted as a single node on planar). one of the patients ( %) had a non-nodal false positive on planar imaging, when further assessed in spect-ct data. in additional, spect-ct fusion imaging gave information on localization of sentinel lymph nodes ( at level i, at level ii, at level iii, more than one level), which could not be evaluated by planar imaging. conclusion: it can be concluded that spect-ct fusion is more feasible and useful for identification of sentinel lymph nodes in breast cancer and provides information on the anatomical localization. background: it is considered that previous excisional biopsy might affect the performance of the sentinel node localization in breast cancer, and it is the aim of this study to present our experience in the therapeutic approach of the sln biopsy in patients with previous excisional biopsy because of non-palpable breast cancer. methods: retrospective study of cases of breast cancer in the period - divided in group a ( patients) with prior diagnostic excisional biopsy and group b ( patients) with non-previous surgery. lymphoscintigraphy was performed after peritumoral injection of mtc-colloidal rhenium sulphide (nanocis); the sentinel node was located with a gamma ray detection probe (europrobe) and periareolar isosulfan blue dye (lymphazurin). axillary lymph node dissection (lnd) was completed only when the sln was positive for metastasis or not located. results: table . sentinel lymph node detection rates in previous excisional biopsy. number positive lympho-positive of patients scintigraphy gamma probe/blue dye a (previous ( %) ( %) excisional biopsy) in cases the sln was not detected and axillary lymph node dissection was performed ( positive and negative for metastasis). because non-palpable lessions are smaller (most of them are microcalcifications) the rate of metastasis in the sln is clearly smaller than in the conventional group of palpable breast cancer. conclusion: lymphatic mapping and the combination of the gamma probe with the blue dye in the detection of the sentinel node is also feasible in patients with previous excisional biopsy. aim our work was aimed to a retrospective evaluation of our series of sentinel lymph node scintigraphy in order to evaluate the relationships between breast tumour dimensions and frequency of positive results. patients and methods in the last years patients, in tnm stage or , all females, underwent sentinel lymph node scintigraphy for a breast cancer. the test was performed according to usual procedures (subcutaneous injection of mbq of mtc-nanocolloid followed by repeated breast scans until the first lymph node was scintigraphically evident allowing the record of its position with a marker on the skin. at surgery, (a quadrantectomy was usually performed), the sentinel lymph node was histologically extemporaneously examined in order to detect the possible tumoral involvement. according to tnm system the patients were grouped as t a ( cases), t b ( cases), t c ( cases) and t ( ) cases. due to the small number of subjects in class t a in our study these patients were grouped together with t b patients. statistical analysis of the differences of the positive case frequency between the groups was performed by chi square test. as expected, bigger tumour dimensions were associated with higher frequencies of positive cases. in fact, the frequency of positive extemporaneous studies resulted of cases in the t a-t b group ( / = . ); of cases in the t c group ( / = . ) and of cases in the t group ( / = . ). the frequency differences between group (t a+t b) and group t c (p< . ) and between group (t a+ t b) and group t (p< . ) resulted highly statistically significant. the frequency difference between group t c and t group did not reach statistical significance (p< . , ns) . conclusions the relationships between breast cancer dimensions and lymph node metastatic involvement are well known, thus our data could not appear to offer a new and original contribution to address this issue. however, our study discloses some additional quantitative insights in order to evaluate the specific phenomenon of sentinel lymph node metastatic involvement and can, consequently, be of interest in breast cancer care. larger series of patents (the work is in progress) will allow us to study the frequency of positive sentinel lymph node scintigraphy according also with the different histotypes of breast cancer. sentinel lymph node scintigraphy (snc) in the preand perioperative diagnosis of breast cancer e. schmidt, z. szabo, g. szalai, e. kalman, g. tizedes, g. pavlovics, k. zambo; university of pecs, pecs, hungary. the importance of snc in the perioperative diagnosis of breast cancer is well-known. using the method with further completitions, results useful additional informations. the aim of our study was to establish, how these informations influence the treatment and management of the patients. patients and methodes: women were observed whose breast cancer was proved by fine needle biopsy (fnb). snc was performed a day before the planned operation. the radiopharmaceutical ( mbq mtc-senti-scint) was injected peritumoral, in - portions, using us guide. anterior and lateral planar scans were performed and hours after the injections from the chest and axilla. the projections of the sn were marked on the skin. with help of this markers us guided fnb and cytology of sn was performed in cases. the operation was carried out the next day with removing of sn and low axillary blockdissection, or -in cases of metastatic laesions -total axillary blockdissection. in both group, dynamic lymphoscintigraphic images were recorded for minutes immediately after the injection. then, static images were taken until the sln was visualised. two-four hours after the radiopharmaceutical injection, patients were taken to the operating room. before the incision, blue dye solution was injected peritumorally to all cases. aided by blue dye and gamma probe, sln detection was carried out during the operation. then, histopathological confirmation was performed. results: there was not a significant statistical differance between group i and group ii in terms of patients characteristics. in group i, identification rate of sln was % ( / ) in both lymphoscintigraphy and intraoperative gamma probe application. in / cases of this group, only one sln was observed in the axillary region; however, in / patients, slns were found in both axillary and internal mammary regions. there was a positive correlation among lymphoscintigraphy, intraoperative gamma probe application, blue dye and histopathological examination in % of this group. in group ii, detection rate of sln was . % ( / ) in lymphoscintigraphy; however, this rate was . % ( / ) in the intraoperative gamma probe application. all slns, which were detected with nuclear medicine techniques, were in the axillary region in this group. there was a positive correlation among lymphoscintigraphy, intraoperative gamma probe application, blue dye and histopathological assesment in . % of group ii patients. however, this rate increased to . % when the results of lymphoscintigraphy were excluded. conclusion: tc- m hig, which appears to be more effective and successful than tc- m nanocolloid, may be a preferable agent on sln identification in both lymphoscintigraphy and intraoperative gamma probe application in patients with early-stage breast cancer. usefulness of lymphoscintigraphic imaging prior to surgical detection of sln in breast cancer aim: the sentinel lymph node (sln) radioisotopic detection is a well established method in the surgical management of invasive breast cancer. however the interest of lymphoscintigraphy (ls) before surgery remains questionable. methods: in a prospective study including patients with breast cancer, mbq of radiocolloid (nanocoll* health amersham) were subcutaneously injected in the peri-areolar breast bearing a less than cm tumor day before surgery. all patients had a planar anterior ls with a large field of view camera (helix elscint general electric*) of the thorax, axillary and basicervical region. the body contour was imaged with a transmission view of a co planar source in the back of the patient. women were operated by validated surgeons and divided into groups: in group i (n= ) the more radioactive node was marked on the skin and the ls and report were known by the surgeon; in group ii (n= ), no marker was drawn and the surgeon does not know ls results. intraoperative identification of the sns was based both on blue dye mapping and probe detection (gammed iib eurorad system) scar length, surgical duration time and number of removed sln were compared within both groups using mann-whitney test. results: ls showed axillary sln in %, mammary internal sln in . % and supra clavicular sln in %. the median scar length was not significantly different in both groups (p = . ): . mm [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in group i and . mm [ ] [ ] [ ] [ ] [ ] [ ] in group ii. the median duration time for surgery was not significantly different (p = . ) in group i ( mn [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ) and in group ii ( mn [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ). the number of removed sln was not significantly different (p = . ) in both groups (group i: [ ] [ ] [ ] , group ii: [ ] [ ] objectives -to calculate the rate of detection of the sn in patients with bc subjected to n-c. -to establish the predictive value of the sn with respect to the axillary state. material and methods. we studied patients with locally advanced bc subjected to n-c; age - years (average years). the initial size oscillated between - cm (average ' ) , showing good answer ' %, partial ' % and bad %. they were administered between - mbq of mtc-nanocoloides in peritumoral intraparenchymatous location ( ) or combined (intradermal and intraparenchymatous) ( ). in nonpalpable cases the injection was guided by ultrasound or stereotaxy ( cases). static images were taken between minutes and hours postinjection, being made external cutaneous mark of the sn. the sn was extirpated separately, being followed by a complete axillary ganglionary dissection. the histological study of the sn included staining with haematoxylin-eosin and inmunohistochemical in negative cases. results in the linfoscintigraphy at least one sn was visualized in out of patients ( ' %), with drainage to internal mammary in cases ( ' %). the rate of intraoperating detection was ' % ( / ). two visible cases could not be localized in the operating room and nonvisible cases could be extirpated. out of cases ( %) not located had axillary ganglionary affectation. the histological study of the sn with haematosylin-eosin was negative in out of cases ( ' %) showing tumoral invasion of the rest of the chain in a single case (rate fn ' %). out of the negative cases were positive with inmunohistochemical ( %), being in the three cases the only positive node. this was the only positive case in ( ' %), of the cases with affectation of the gc. without axillary affectation a sensitivity for ganglionary affectation of ' % with a npv of ' % was obtained. conclusions. the technique of the sn is feasible in bc subjected to n-c with a rate of detection above %. the failure in the location of the sn seems to indicate bad prognosis due to the high incidence of ganglionary affectation. a negative gc or with micrometástasis can avoid the complete axillary node dissection due to the high npv for the rest of the chain. phytate lymphoscintigraphy (spect) and ct from december of to march of . lymphoscintigraphy was performed hours after subcutaneous injection under the nipple of tc- m phytate using a gamma camera (symbia; siemens, forchheim, germany, and hoffman estates, ill.). contrast-enhanced ct was performed using acuillion (toshiba medical systems, tokyo, japan). image fusion between spect data and ct volume data was performed using fusion soft (fused vision d) on siemens e.soft workstation. twenty-six patients were divided into groups. the first group patients ( patients) were examined without markers. the second group patients( patients) were examined by spect and ct with markers on the upper and lower ends of sternum ( markers). the third group patients ( patients) were examined with markers on the upper and lower ends of sternum and outside of the nipple of opposote side ( markers) . a small vessel containing tc- m was used as marker for spect and that containing beads of mm-diameter for ct. results: in the first group patients examined without markers, preparation of the fusion images of spect and d-ct were difficult. in the second group patients examined with markers (the upper and lower ends of sternum), preparation of the fusion images were sometime difficult. in the third group patients examined with markers (the upper and lower ends of sternum and outside the nipple of opposote side), the fusion images were easily prepared and the anatomical identification of sentinel lymph node of breast carcinoma could be easily performed. conclusion: the fusion images of spect and d-ct were easily prepared by placing markers at the upper lower ends of sternum and outside the nipple of opposote side. as a result, anatomical location of sentinel lymph nodes of breast carcinoma could be easily identified. resection of non-palpable breast lesions without needle-guide needs an intraoperative pathological examination to confirm lesion inclusion and healthy margins. in those hospitals without an intraoperative pathological resource, a second surgery may be needed. roll technique to guide surgeon is more extensive. the use of tracer inside the tumour allows the lesion resection with free margins and decreases the number of second procedures. moreover, an intraoperative image can be acquire intraoperatively with a portable gammacamera, which can predict if margins are involved. aim: to value the usefulness of an intraoperative gammacamera to assess non-palpable breast lesions resection. material and methods: patients: women with non-palpable breast lesions were included, mean age ± . years. injection: the day previous to surgery, an intratumoural injection of mtc-nanocolloid was performed guided by ultrasonography. lymphoscintigraphy: it was performed to know the lymphatic drainage and spread of radiotracer in the breast. surgery: the lesion was removed guided by a gamma-probe. an image of the surgical piece was acquired by the intraoperative gammacamera (sentinella s , gem imaging, valencia, spain) and a second image was performed using a technetium pointer to draw the outline. an image over surgical bed was done to confirm the absence of activity after resection. ap: lesion inclusion and healthy margins were evaluated intraoperatively. results: all lesions were removed. centred lesion was found by portable gammacamera in / , out of place in / and in contact in cases. a pathological exam detected free margins in / with centred lesion ( %), affected margins in of with lesion not centred. that means a concordance of % ( / ). conclusion: bearing in mind these issues, the use of an intraoperative gammacamera can avoid an extra surgery in those centres without pathological exam during sugery, without delay in the surgical act. some aspects can raise the rate of concordance: to increase the number of projections or to improve the way of injection. objectives: the purpose of this study is to evaluate the efficacy of sln biopsy using imaging and gamma probe in oral cancers. material and methods: patients (mean age = . yrs) with operable oral cancers with clinically negative lymph adenopathy were studied. standard neck dissection was performed in all. scintigraphy was performed a day before surgery by injecting tc- m labeled nannocolloid submucosally in the peri-tumoral area. first lymph node to appear on the scan was labeled sentinel lymph node and marked on the skin. this hot node was explored intraoperatively using gamma probe followed by block neck dissection. results: the sentinel lymph node (sometimes associated with additional nodes) was identified in patients ( . % success rate). in patient ( %) sln was not visualized on the scan (failed study). the gamma probe guided localization was successful in while in cases it failed. in out of ( %) cases sentinel lymph node stood in agreement with the result of histopathology of remaining lymph nodes ( benign and malignant). the remaining lymph nodes, however, showed a discordance with the final histopathological result. sln was negative in all cases with disease spread to other nodes (? skip lesion / varied drainage patterns). conclusions: early results of lymphoscintigraphy with gamma probe guided sln biopsy have been encouraging; however, a variable lymphatic drainage pattern may result in skip metastasis. therefore, we recommend that every hot lymph node should be biopsied to minimize the possibility of this discordance. further, studies should be undertaken to establish the operator learning curve in this technique. introduction: sentinel node biopsy quickly became standard of care in breast cancer, before consensus on the technique was reached and without randomised studies having shown a similar or decreased axillary recurrence rate. a review of twenty-six learningphase studies on sentinel node biopsy followed by routine axillary node dissection demonstrated a median false-negative rate of % (range of - %), which is more than the % that is generally considered acceptable. axillary clearance is no longer done in patients with a tumour-free sentinel node. long-term follow-up results of such patients have now been published and these prompted this literature review to determine the axillary recurrence rate of the sentinel node procedure in breast cancer patients. methods: we searched the current literature for studies concerning patients with breast cancer, a clinically node-negative axilla, no subsequent axillary node dissection in case of a sentinel lymph node without disease, and a median follow up duration of at least three years. the axillary recurrence rate was calculated in the patients with a tumour-negative sentinel node biopsy. results: fourteen studies were published between and describing a total patients with a median follow-up time of months. all papers describe the injection of a radiopharmaceutical and the use of lymphoscintigraphy. mtc-nanocolloid was the most common radiopharmaceutical, used in nine studies. ten investigators additionally injected blue dye intraoperatively and all surgeons used a gamma ray detection probe. twenty-four of the sentinel node-negative patients recurred in their axilla with a median time to recurrence of months (range of - months). the median recurrence rate was . % and calculated when corrected and weighed for the number of patients per study. conclusion. the sentinel node procedure was introduced to limit morbidity without exceeding the - . % axillary recurrence rate seen in the past after routine axillary clearance. it is gratifying that this review of studies with a long-term follow-up finds the recurrence rate in sentinel node-negative patients well within the desired range. ( %); mean age y ( - y). lymphoscintigrapy was performed h post peritumoral radiocolloid injection. a subdermal reinjected dosis was performed in cases of no lymphoscintigraphy sentinel node detection post peritumoral injection. a handled gammaprobe was used to radioguide sentinel node surgery. axillary lymph node dissection (alnd) was performed on p ( %), ( p from group a and p from group b). the following parameters were analysed in both groups: sentinel node lymphoscintigraphy detection rate (snld) and the subdermal reinjection requierements (sr), sentinel node surgical detection rate (snsd), number of sentinel node metastases as well as the presence of metastases in other axillary lymph nodes. in the non sentinel node surgical detection group the rate of positive nodes was also analysed. results: data of pelvic sln scintigraphy helped to determine the direction of lymph outflow from tumor-affected testis or the stump of spermatic cord and prostate to sentinel lymph nodes by normal or changed lymph collectors. thus, sln scintigraphy led to exact determination of local lymph node dissection or delineation of fields' size and configuration for local radiation therapy. conclusions: finding of the lymph outflow routs with mtc-colloid increases the validity of early lymphatic cancer spread detection, including or excluding cases of lymph nodes enlargement. determination of the lymph outflow routs gave an opportunity to configure the radiation fields within sites of mtc-colloid accumulation. the aim of this study was preoperative scintigraphic imaging and subsequent intraoperative detection with small hand-held gamma probe and blue dye in some malignant tumours to identify the sentinel node (sln) of breast cancer group i and colorectal cancer group ii. method: group i - female with histologically proven breast cancer in early stage t -t by palpable and non-palpable lesions. scans were performed in anterior, oblique and lateral view - hours after administration of mtc-colloid / mbq in total volume . ml / peritumourally. by patients with non-palpable lesions ( patients) injections were under sono-graphic guidance. the site of sentinel nodes was marked on the skin. the same method was used for patients with colorectal cancer group ii, with more scans and without skin markers. results: group i -sentinel node was found in / patients except nodes in the internal mammary chain and nodes located very close to tumour. the sensitivity in this group was %. all nodes were examined routinely and by immunohistochemical staining. histologically / sentinel nodes were positive (micrometastases in eleven). group ii involved patients with colorectal cancer. lymph-nodes were found in / cases. the sensitivity of the method in this group of patients was %. according to pathologist / had tumour positive lymph-node. the method of detection of the sentinel node in total mesorectal excision is not therapeutic but diagnostic method, and it has quite a high level of sensitivity. conclusion: this study has demonstrated feasibility of the proposed procedure. sentinel node biopsy requires a multidisciplinary approach (surgery, pathology and nuclear medicine) for reliable results. the association of blue dye (in breast cancer only) and intra-operative gamma probe has made the procedure more effective, less time-consuming and less invasive. lymphoscintigraphy and radioguided surgery can be very useful as a prognostic sign, whether it detects sentinel lymph-node (some with micrometastases that would otherwise be missed). this method is easy and safe. the histological examination of sln improves staging of the disease and can help in planning of the follow up treatment. initial experience of preoperative lymphocintigraphy and sentinel lymph node biopsy in thyroid cancer patient. c. chotipanich, y. kongdan, k. cheuamsamakee, s. amnuaywattakorn, c. sritara; ramathibodi hospital,faculty of medicine, mahidol university, bangkok, thailand. purpose: to evaluate the clinical usefulness of the lymphoscintigraphy and of hand held gamma probe procedure for slnb in well differentiated thyroid cancer which have not yet been established in thailand. material and methods: three female patients with thyroid nodule highly suspected for thyroid carcinoma by fine needle aspiration cytology ranges from the age of to years underwent preoperative lymphoscintigraphy. all of the patients underwent lymphoscintigraphy with intratumoral injection of tc- m dextran . mci under ultrasonography guidance. sentinel lymph nodes were identified using gamma probe. results: three patients had papillary carcinoma.the sentinel lymph node was detected in all cases ( %). one patient showed a lymph node metastasis in the sentinel lymph node in the jugular compartment. there were no intra or operative complications. conclusion: this is the first report of slnd in thyroid carcinoma in thailand. our preliminary findings indicate that the identification of sentinel lymph nodes in thyroid cancer is a practical and safe method. in order to improve this technique as a standard procedure for staging of thyroid cancer further studies with a larger number of patients in thailand have to be done. key words: sentinel lymph node, thyroid cancer, lymphoscintigraphy radioisotopic identification of sentinel lymph node in early stages of cervical cancer with tc- m nanocolloid (preliminary results) e. trivizaki , v. moschogiannis , s. saranti , l. iordanidou , p. zarganis , k. rethimniotakis , a. georgakopoulos , p. koutsiouba ; department of nuclear medicine, "metaxa' s" cancer hospital, piraeus, greece, department of gynecology, "metaxa' s" cancer hospital, piraeus, greece, piraeus, greece. the aim of this study is to investigate the feasibility and the utility of the detection of sentinel lymph node in early stages of cervical cancer with radionuclide method. method: women (median age , years) with cervical carcinoma, stage ia (no ), stage ib (no ), stage ib (no ), underwent sln detection during primary operation. exclution criteria was stage iib or more advanced disease. one day before the surgery, patients were injected intracervical with a total dose of mbq tc- m nanocolloid, devided in four injections, and one hour after the injection a lymphoscintigraphy was performed. on the day of surgery, ml of patent blue dye was injected in the cervix, at the same sites as the radioactive isotope injections. using a laparoscopic gamma probe and visual detection of blue nodes, the sln were identified and removed for pathological assesment. results: lymphoscintigraphy identified one or more sentinel nodes in out of patients ( , %), while blue dye identified sln in pts ( , %). the combination of blue dye and radioactive tracer detected lymph nodes in pts ( . %). in one woman, where the lymph nodes were not identified with tc- m nanocolloid, the stage of the disease was ib . in pts, we had a bilateral visualisation of lymph nodes. the average number of sln per patient was , . metastatic disease to the lymph nodes was found in pts. in total, in pts. the sentinel nodes were located in the distal parametrium, in pt they were located paraaortic and in pts, in the area of the external and internal iliac artery. conclusion: our findings confirm that sentinel lymph node detection with radiocolloid, in combination with blue dye, is feasible and improves detection rate in patients with cervical carcinoma and also allows the identification of lymph nodes in areas that are not frequently sampled. this technique must be evaluated in larger studies, that may lead to better treatment selection of patients with early cervical cancer. radionuclide study of sentinal lymph nodes in breast cancer patients n. voit; institute of oncology of amsu, kyiv, ukraine. background. dissemination of breast cancer (bc) to lymph nodes plays is essential not only for survival but also for choice of tactic of the treatment. in accordance with a concept of sentinel lymph nodes (sln) a study of them is aimed to the identification of first draining nodes respectively to nodes of primary tumor. specific feature of sln is enlargement of first lymph node and visualization of afferent lymph vessel from tumor to it. aim was to study status of sentinel lymph nodes during their intraoperation detection using manual gamma europrobe. materials and methods. bc patients were examined using lymphscintigraphy in combination with intraoperation detection of sln. a technique was performed using mtc-nanocole infused peritumoraly and intracutaneously ( mbk/kg body weight) and . - . ml of water. next step of study was performed using ofect "e cam" (siemens). early ( min) and late ( h after administration of rpp) images were obtained. a day after intraoperation detection of sln was performed by manual gamma-probe. results. in accordance with the obtained data it was revealed that in of patients lymph nodes of axillar pool on side of the lesion were visualized. in patients lymph nodes on contralateral side were detected. in patients with visualized lymph nodes histological examination revealed sln. in patients they appeared to be affected by metastases, in the remains -no malignancies. conclusion. examination of sln using manual gamma-probe can be used for estimation of pathways of metastatic spread and rate of malignant injury of lymph nodes in bc patients. using of lymphoscintigraphy in combination with gamma-detection and following biopsy of sln is a perspective direction in the development of organ-saving surgical interventions in breast cancer. aim of study: while investigating different kinds of tumours, the conception of sentinel node has been used in our hospital for many years. in our work we are trying to find out the usage of mapping of lymph node and its biopsy on those patients who suffer with carcinoma of colorectum. method: we examined a group of patients with carcinoma of colorectum. with the help of applied colloid mtc and patent blau we performed lymphatic mapping in a submucosly or subserosly circulatory way around tumor. the searched nodes were presrved and marked. marked nodes were later investigated in a histological and imunohistological way. conclusion: we are persuaded that in the foreseeable future with this method we will be able to specify staging and decide on an operation and actinotherapy extent, wich should be proved by an ongoing study with oncological and oncosurgical departments cooperation. in the future we can also see lymphatic mapping utilization on laparoscopic operationsin oncosurgery of colon and rectum. lymphatic mapping also brings a possibility to detect aberant lymph vessel and lymph nodes in tumour surroundings. aim: multi-drug resistance (mdr) is a major challenge in treatment of multiple myeloma (mm). mtc-mibi is washed out from malignant cells in the presence of p-glycoprotein (pgp) mdr . this phenomenon results in non-visualization of the lesions and low sensitivity of whole body scan (wbs) in detection of active mm. the objective of the present study was to assess the value of sestamibi wbs in prediction of response to treatment and mdr. materials and methods: thirty four patients with mm ( male, female, . ± . years) entered the study. thirteen patients had no previous history of treatment and had history of previous chemoradiotherapy. the diagnosis and staging of the disease were based upon the standard criteria. for each patient routine laboratory tests, pgp measurement and wbs with mtc-mibi were performed in the beginning of the study and the response to treatment was assessed during one year follow up. the baseline wbs was considered positive for detection of active lesion when at least one area of non-physiologic increased activity was noted while the result of wbs was positive for mdr when the patient had active disease but no abnormal activity was seen. the value of the baseline pgp tests and wbs for prediction of patient's outcome and response to therapy were assessed. results: the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of wbs for determining the active disease were . %, %, . %, . % and . %, respectively. in cases who were in active state, these values for diagnosis of mdr with wbs were . %, . %, %, . % and . %, respectively. also the above values for detection of mdr with pgp were %, %, . %, . % and %, respectively. the percentage of patients who were resistant to multiple course treatment during one-year follow up was . % in cases with active disease and positive baseline wbs ( / ) and % in those with active disease and negative baseline wbs ( / ), with no statistical difference. conclusion: neither the baseline scan nor pgp findings are of great value in detection of mdr. furthermore, no difference was noted between the sensitivity of baseline wbs for detection of active lesion in the group of the patients who showed drug resistance later in the course of treatment and in the group with complete response to therapy. so, the low sensitivity of wbs for detection of active mm lesions is not definitely related to drug resistance. purpose: the aim of this study was to evaluate mtc-dtpa-deoxyglucose ( mtc-dtpa-dg) for the assessment of chemotherapy effect and biodistrbution in breastbearing nude mice. mehtods: each animal was xenografted subcutaneously in the right fore-leg with × cells per . ml of the mcf- breast carcinoma cell line. on day postinoculation, mammary tumor-bearing mice ( - g, n= per each group) were administration a single i. v. injection of taxol ( . mg/kg) and doxorubicin ( . mg/kg) in group , taxol ( . mg/kg) and doxorubicin ( . mg/kg) in group respectively. mammary tumor-bearing mice were treated with cisplatin ( . mg/kg) in group and cisplatin ( . mg/kg) in group . . ml of saline was injected intravenously in control group. on day , , , , , post-therapy, tumor-bearing mice were imaged with mtc-dtpa-dg ( . mci/mice, i.v. ) at . - hours after administration. the radio of tumors to non-tumors (t/nt) was counted by roi technology. tumor volume and inhibition rate of each group were calculated. radioactivity in each sample tissue was calculated as the percentage of the injected dose per gram of tissue wet weight (%id/g). results: scintigraphy in tumor animal models demonstrated that tumor tissue could be clearly visualized with mtc-dtpa-dg. there was significance difference in the t/nt among group , group and control group (f= . , p= . ) on day post-therapy. there was significance difference in tumor volume between group and control group (p< . ) on day , , post-therapy. biodistrbution of mtc-dtpa-dg demonstrated tumor uptake was observed, at the same time less brain and heart uptake was observed. conclusions: mtc-dtpa-dg could assess the chemotherapeutic tumor response. the technique developed allows for mechanism-specific targeted assessment of cell nuclei activity using mtc-dtpa-dg. aim neuroendocrine gastroenteropancreatic tumors (negep) are relatively rare tumors arising from neuroendocrine cells. they are characterized by slow growth and by specific symptoms and syndromes. the location (foregut, midgut or hindgut) of the primary tumor affects the functionality, the clinical course, and the treatment of the disease. for inoperable, well-differentiated tumors, biotherapy with somatostain analogs (sa) or interferon alfa represents the treatment of choice with two purposes: to control symptoms and tumor proliferation. somatostatin receptor scintigraphy (octreoscan -o) has been proven to play an important role to plane the clinical management of patients (pts) with negep. aim of this work was to compare accuracy of o alone or in association with ct and chromogranin a (cga) serum level and to evaluate impact on quality of life of sa treatment. material and methods: we submitted pts with primary negep tumors originated from foregut in / ( % stomach, % pancreas), from midgut in / ( % ileum, % coecum) and from hindgut in / ( % rectum) to o, ct and serum cga levels assessment. then, six of them received long acting sa treatment for a mean of months and performance status was assessed by ecog criteria before and after therapy. / pts submitted to sa, followed by ct and serum cga, repeated o after at least year. all pts were intravenously injected with mbq of in-pentetreotide. , and hours whole body and abdomen o spect scan were obtained. results o diagnosed primary tumors or metastatic lesion in and was truly negative in pts. both the results were in agreement with ct and cga. o resulted false negative in pts when compared with ct and cga serum levels. similarly ct and cga were, in two other pts, false positive and false negative, respectively. pts treated with sa, especially whose with no metastases, showed performance status improvement, except one, who suspended biotherapy after month, because of side effects. its worth of note that in pts who after biotherapy had normal o and ct scan, also cga lowered within normal limits. conclusions in our limited series we showed a significant improvement of accuracy to detect negep by combining o, ct and serum cga and their association allows to select people to administrate somatostatin analogs, able to improve quality of life through a control of symptoms and tumor growth stabilization. aim: the aim of this study was to compare the efficacy of low dose tc- m methoxyisobutylisonitrile (mibi) administration to high dose tc- m mibi administration on intraoperative localization of parathyroid adenomas with gamma probe in patients with primary hyperparathyroidism (phpt). material and methods: twenty-seven patients with phpt were included in this study. these patients were divided into groups. group i consisted of cases ( women, men; mean age: . ± . years) to whom mbq of tc- m mibi was injected intravenously in the operating room minutes before the start of the surgery. group ii was composed of patients ( women, men; mean age: . ± . years) to whom mbq of tc- m mibi was administered hours before the operation.the minimally invasive parathyroidectomy was performed in all cases. intraoperative localization of the pathological gland was carried out by the use of gamma probe in all subjects. surgical resection of the parathyroid adenomas was carried out. then, the excised tissues were evaluated histopathologically. parathyroid hormone (pth) level was registrated prior to and after the surgery in all cases. results: significant statistical difference was not found between group i and group ii in terms of patients characteristics. the parathyroid adenomas were identified (total parathyroid adenomas) and excised in all group i ( %) and group ii ( %) patients. when the results of gamma probe application to the results of histopathological examination were compared, a positive correlation was found between them. in group i, the mean preoperative level of pth was ± pg/ml (reference range: - pg/ml); however, the mean value of pth after the operation was ± pg/ml. in group ii, these values were ± pg/ml, ± pg/ml, respectively. the mean operation time was ± minutes in group i and ± minutes in group ii. there was not a statistical difference in the operation time between two groups. conclusion: low dose tc- m mibi application may be prefered in the intraoperative identification of parathyroid adenomas with gamma probe in patients with phpt since this procedure appears to be as effective as high dose tc- m mibi application. moreover, unlike high dose administration, low dose tc- m mibi application does not require a long waiting period after the radiopharmaceutical injection and in this method the radiation exposure of the patient and operation team is much lower. aim: the aim of this study was to compare the effectiveness of low dose to high dose tc- m methoxyisobutylisonitrile (mibi) applications on intraoperative identification of parathyroid glands in chronic renal failure patients with secondary hyperparathyroidism. material and methods: nineteen patients with secondary hyperparathyroidism were included in the study. patients were divided into two groups. group i included patients ( men, women; mean age: . ± . years) to whom mbq of tc- m mibi was injected intravenously in the operating room minutes before the surgery. group ii consisted of patients ( men, women; mean age: . ± . years) to whom mbq of tc- m mibi was administered intravenously hours before the operation. aided by gamma probe, parathyroid gland localization was carried out during the operation in both group i and ii. all patients underwent surgical resection of the parathyroid glands which were then evaluated histopathologically. parathyroid hormone (pth) level was registrated prior to and after the parathyroidectomy in all subjects. results: regarding the patients characteristics, significant statistical difference was not observed between group i and group ii. the hyperplastic parathyroid glands were identified and excised (total parathyroid glands) in all group i ( %) and group ii ( %) patients. when the results of gamma probe application to the results of histopathological examination were compared, it was observed that they were correlated. in group i, the mean preoperative level of pth was ± pg/ml (reference range: - pg/ml); however, the mean value of pth after the operation was ± pg/ml. in group ii these values were ± pg/ml, ± pg/ml, respectively. the mean operation time was ± minutes in group i and ± minutes in group ii. a statistical difference was not found between two groups in the operation time. conclusion: the low dose tc- m mibi application may be prefered in the intraoperative identification of parathyroid glands with gamma probe in patients with secondary hyperparathyroidism because it appears to be as effective as high dose tc- m mibi application. additionally, in contrast to high dose, low dose tc- m mibi application does not require a long waiting period after the radiopharmaceutical injection and with this method radiation exposure of the patient and operation team is much lower. radioguided sentinel node biopsy after breast surgery p. santoro , c. mazzone , g. d'eredità , f. lauriero , a. niccoli asabella , g. rubini ; nuclear medicine, bari, italy, general surgery, bari, italy. aim. previous breast surgery is often considered a controindication for subsequent lymphoscintigraphy and radioguided sentinel node biopsy (rsnb) because of surgery deep lymphatic drainage changes. this study wants to measure rsnb feasibility and accuracy after breast nodulectomy. patients and methods. between march and february , women, who were previously submitted to breast nodulectomy were enrolled. in all these women sentinel node wasn't dissected because of false negative extemporary histopathological examination on breast surgery piece. all women were submitted to lymphoscintigraphy on the day before surgery with subdermic tracer injection. nanocoll was injected in four points around scar in pts undergone higher-external quadrantectomy. in pts undergone a different quadrantectomy tracer was injected in points around scar + in points in higherexternal quadrant or in retroareolar site only. on the day after lymphoscintigraphy lymph node identified as sentinel lymph node (slns) was dissected during surgery. the radioactivity of lymph node was detected in vivo and ex vivo by intraoperative of gamma-probe (scintiprobe mr- pol. hi tech.). all lymph nodes were examined histopathologically with hematoxilin and eosin staining. lymph nodes metastasisnegative were immunostained with anticytokeratin antibodies. results. in women, preoperative lymphoscintigraphy showed a sentinel lymph node; in one patient there wasn't tracer drainage (she was years hold and with voluminous breast). preoperative identification rate: %. lymphatic metastases were detected only in sentinel nodes of women; these patients were submitted to total axillary dissection. both node metastases were located in sentinel nodes and axillary non sentinel nodes were all negative at histopathological and anticytokeratin antibodies stainings. at a median follow-up of months, no axillary relapses were observed in patients who were not submitted to axillary lymphadenectomy (positive predictive value= %). ct and pet/ ct, performed at our institution, were main imaging follow-up surveys. conclusions. rslnb after previous limited breast surgery appear feasible and reliable for its high positive predictive value. it is necessary to analize a larger number of women and to follow them for a longer period. aims: liver regeneration after loss of hepatic tissue is a fundamental parameter of liver response to injury. recognized as a phenomenon from mythological times, it is now defined as an orchestrated response induced by specific external stimuli and involving sequential changes in gene expression, growth factors production, and morphologic structure. much of the investigation on the mechanisms and kinetic of hepatic growth has been done only in partially hepatectomized animals and in hepatocytes primary cultures. the study of the hepatic extraction fraction (hef) by radioisotopic methods gives information about physiological mechanism of uptake, transport and allows also the excretion quantification of the hepatobiliary system by using mtc-ida derivates. this prospective study aimed to estimate the interest of hef in the evaluation of human liver regeneration / function of patients with hepatic tumoral disease underwent partial hepatectomy. methods: patients with colorectal metastases (n= ), hepatocellular carcinoma (n= ) and others (n= ) were included. liver function was assessed after intravenous bolus injection of mtc-n-( -bromo- , , -trimethylphenylcarbamoilmethyl -iminodiacetic acid (mebrofenin) that was uptaked by the hepatocytes and eventually excreted via billiary pathway without any change to its chemical structure. the hef is calculated using deconvolution analysis of first pass curve coming from scintigraphic data. we evaluated the pre-operative hef and in the th day and one month after the hepatic resection. we considered the hef values of . ± . % (med ± sd) as normal. for statistical analysis, t-student test was used. results: the pre-operative, th day or one month after the partial hepatectomy hef (med±sd) was . ± . %, . ± . % and . ± . %, respectively. there was not statistically difference between the three evaluations of hef (ns). conclusion: these results allow us to say that the human liver regeneration is early enough to normalize the hef at day after partial hepatectomy, being this evaluation of undoubtedly interest to know the function kinetics and indirectly knowledge about human liver regeneration. additionally, this fast functional liver recovery has high clinical importance, once more aggressive adjuvant chemotherapy can start much early after surgical treatment. objectives: some studies have demonstrated that a newly developed body diffusionweighted (dw) mri is useful for differentiating benign or malignant lesions in patients with bone and soft tissue tumors. thallium- (tl) spect has been widely used for clinically same purpose. we compared dw-mri with tl-spect to clarify the characteristics of these two methods. methods: both mri and tl-spect were performed on bone and soft tissue tumors ( malignant lesions and benign lesions), whose final diagnosis was based on histology. dw-mri was performed with an echo planar imaging sequence. the apparent diffusion coefficient (adc) value (× <sup>- </sup> mm<sup> </sup>/sec) was calculated on the lesions. the early and delayed tl-spect were performed, and the uptake ratio of the lesion to the contralateral normal tissue was obtained on the early images (early ratio; er) as well as on the delayed images (delayed ratio; dr). the diagnostic accuracy of malignant lesions was evaluated by visual interpretation. the adc values as well as er and dr in the lesions were evaluated and compared for quantitative evaluation of dw imaging and tl-spect, respectively. results: high sensitivity was observed in both dw-mri and tl-spect in visual interpretation. low specificity was observed on dw-mri ( . %), suitable specificity was observed on tl-spect ( %). in quantitative assessment, the sensitivity, specificity were calculated when the cut-off value of adc was less than . on dw-mri, and the cut-off value of er was over . on tl-spect. specificity on adc was only . %, although high sensitivity % was observed. there were significant differences between the uptake ratio of the benign and that of the malignant lesions (er: . ± . vs . ± . , p < . ; dr: . ± . vs . ± . , p < . ). however, there was no significant difference between the adc values of the benign and that of the malignant lesions ( . ± . vs . ± . ), suggesting that the adc values might not be conclusive in distinguishing between the benign and malignant lesions. conclusions: the adc values of bone and soft tissue tumors overlapped and could not be used to differentiate between benign and malignant tumors. whereas the er values and delayed visual assessment of tl-spect has high diagnostic ability for bone and soft tissue tumors. therefore, tl-spect has a better diagnostic ability than dw-mri for evaluation of bone and soft tissue tumors. clinical usefulness of thallium- scintigraphy in diagnosis of desmoid-type fibromatoses: comparison of planar and spect images t. shinya , s. akaki , s. sato , s. kanazawa ; okayama kyokuto hospital, okayama-city, japan, okayama university medical school, okayama-city, japan. aim: it has been reported that delayed thallium- (tl- ) scintigraphy is useful for differentiating malignant soft-tissue tumor from benign lesions. physiological muscle accumulations increase on delayed images in most cases, which often make it difficult to evaluate tl- accumulation on planar images in patients with soft-tissue tumors. desmoid-type fibromatoses are relatively rare soft-tissue tumors of fibroblastic origin and are locally aggressive. they are classified within the intermediate spectrum of fibroblastic/myofibroblastic tumors in the who classification. there are several case reports that describe tl- accumulation in desmoid-type fibromatoses. currently, however, no detailed documentation exists which describes tl- accumulation in desmoid-type fibromatoses. the purpose of this study was to evaluate the usefulness of tl- accumulation on planar and spect images, and the pattern of change in patients with desmoid-type fibromatoses. material and methods: sixteen patients with desmoid-type fibromatoses underwent whole-body tl- scans preoperatively, and we studied desmoid-type fibromatoses retrospectively ( primary tumors, recurrent tumors). in all tumors, early and delayed images were acquired at - minutes and hours after injection. tl- images were visually interpreted for degree of tl- accumulation and pattern of change. we employed a three-grade system to evaluate degree of tl- accumulation: = no appreciable accumulation, = accumulation higher than that of normal muscle but lower than cardiac accumulation, = accumulation higher than cardiac accumulation. we employed a three-pattern system in evaluating pattern of change on planar and spect images: pattern of decrease= more accumulation on early images, constant pattern= equal accumulation on both early and delayed images, pattern of increase= more accumulation on delayed images. surgical resection with histopathological analysis confirmed the diagnosis. purpose: cardiac sympathetic dennervation is a common event in synucleinopathies and the basis for to use scintigraphy imaging using iodine-labelled metaiodobenzylguanidine ( i-mibg) with diagnoses purposes in these diseases. our purpose is to explore diagnostic accuracy of this technique in order to differentiate patients with lewy bodies disease (lbd) from others with cognitive and movement disorders not associated to synucleinopathies. material and methods: series of cases constituted by patients with lbd (mckeith revised criteria) and control patients [essential temblor ( ), parkinson's disease and dementia without sinucleinopaties ( )]. all the patients underwent scintigraphy imaging using i-mibg and early and late cordis/ mediastinum (c/m) rate was measured. c/m rates between groups were compared (mann-whitney u-test) and area under roc curve (aroc), sensitivity, specificity and proportion of correct classifications were calculated. results: there were not differences between groups in age and sex. early and late c/m rate were significant smaller in the group with synucleinopathies (u= ; p< . in both cases). late c/m rate had a greater discriminatory ability (aroc= . ) than early rate (aroc= . ). for the late c/m rate, value . shows a sensitivity . and a specificity . , with correct classification of % of the patients. conclusions: in this small series, scintigraphy imaging using i-mibg shows a good discriminatory ability to correct identification of lbd patients. we used the established criteria for the diagnosis of every disorder and the dsm-iv criteria for the diagnosis of dementia. the majority of the patients had an mri and the rest a brain ct scan. all the patients had a brain spet with m-tc hmpao (adult dose mbq, single-headed camera, uhr parallel-hole collimator, sec/image, images on a x matrix. we applied the neurogam software on the reconstracted data for the evaluation of rcbf alterations in specific brodmann(br) areas in the left(l) and right(r) brain hemispheres. results: from logistic regession analysis we found statistically sigificant correlation of a number of neuropsychiatric symptoms with alteration of rcbf in the following brodmann areas: ) delusions related to hypoperfusion in l bra )agitation related to hypoperfusion in r bra )depression related to hypoperfusion in l and l bra )anxiety related to hyperperfusion in l bra )apathy related to hypoperfusion in l bra )irritability related to hypoperfusion in l bra )disinhibition is associated to dysfunction in several regions, related to hypoperfusion in r, l, r bra. conclusion: the data support the involvement of multiple cortical regions in both hemispheres in mediating social and emotional behaviour and the subsequent neuropsychiatric symptoms resulting from rcbf alterations in degenerative dementias. the contribution of dopamine transporter imaging to the distinction between dementia with lewy bodies and alzheimer's disease (besides tc- m hmpao findings) x. geronikola-trapali , i. armeniakos , t. doskas , g. stampoulis , a. prentakis , a. stefanoyannis ; university general hospital "attikon", nuclear medicine department, athens, greece, university general hospital "attikon", neurological department, athens, greece. aim: distinguishing between dementia with lewy bodies (dlb) and alzheimer's disease (ad) is often very difficult because of the significant overlap between them. the pathological features of dlb include cerebral cortex loss, lewy body inclusions and loss of nigrostriatal dopaminergic neurons. on the other hand in ad there is no significant dopaminergic degeneration. the aim of this study was to evaluate the role of dopamine transporter imaging with i- ioflupane (datscan) in order to distinguish these two types of dementia in case of inconclusive tc- m hmpao brain perfusion findings. materials & methods: patients over the age of who fulfilled the dsm-iv criteria were studied. cognitive function was assessed using mmse, clock and verbal fluency test. neuroimaging data were obtained from mri scans and all diagnoses were made before and independent of the spect scans. applying these criteria patients with ad (possible) and patients dlb (possible) participated. ten controls, group matched for age and the same clinical assessments as dementia patients were recruited. our study included two different steps: st: we performed cerebral perfusion spect imaging min after i.v. injection of mbq tc- m hmpao (ceretec -amersham). interpretation of the data followed. nd: one group of the above patients (i.e. without the predominant cbf pattern) were further evaluated with i- ioflupane (datscan). spect imaging was performed - hours after i.v. injection of mbq i- ioflupane. results:the interpretation of tc- m hmpao images revealed significant perfusion deficits in temporoparietal regions in the / ad patients. parietoocciptal deficits were identified in / dlb patients. we found evidence of datscan results: seven patients with neuropathology consistent with ad had a normal striatal uptake. three patients fulfilling the criteria of dlb showed a marked reduction of the tracer uptake in the putamen bilaterally. one patient with clinical diagnosis of dlb revealed a generalized bilateral decrease of uptake with preservation of the striatal shape. conclusion:i- ioflupane (datscan) improves significantly the distinction between dlb and ad patients (in life) and it could be a useful tool towards this direction. objectives: long-term chronic alcohol consumption is associated with regional structural brain damage and cognitive deficit including memory impairment. neuroimaging research has commonly linked chronic alcohol abuse with generalized frontal hypoperfusion. the aim of our study was to evaluate rcbf in alcohol induced cognitive decline and effect of memantine on rcbf. methods: twenty-eight patients (m: , mean age: . ± . , age range: ~ ) who fulfilled dsm-iv criteria for alcoholic dementia were enrolled in the study. on resting state, we were studied with technetium- m ethyl cysteinate dimer single-photon emission computed tomography (tc- m ecd spect) before and after memantine treatment. these results were analyzed with spm (statistical parametric mapping version ). results: brain areas with increased rcbf after memantine treatment in alcohol dementia; uncus (ba ) of both limbic lobes, parahippocampal gyrus (ba ) of left limbic lobe, both superior frontal gyrus (ba ), right inferior parietal lobule (ba ), cuneus of left occipital lobe (ba ), and left superior temporal gyrus. brain areas with decrease rcbf after memantin treatment in alcohol dementia; left medial frontal gyrus (ba ), cingulate gyrus (ba ) of left limbic lobe, left claustrum, right brainstem, left superior temporal gyrus (ba ), fusiform gyrus (ba ) of right temporal lobe, culmen of left cerebellum, and fusiform gyrus (ba ) of right occipital lobe. conclusion: we demonstrated increased rcbf of cognitive-related areas (ba , ba ) of brain after memantine treatment in alchoholic dementia. in conclusion, we suggest that use of memantine will be a new possible treatment of alcohol induced cognitive decline. patients ( initially mci and normal at nt) clinical symptoms worsened; demtect became suggestive for d in the mci cases and in / patients initially normal and for mci in the remaining negative patient. mmse became positive for d in the former patients who were enrolled for therapy and persisted negative in the latter one, in all of whom spect worsened. the remaining / patients ( initially mci and demtect negative) did not show clinical/nt change, while spect further worsened in one mci patient persisting negative in depression case.conclusions: mtc hmpao spect may be a useful complementary tool to nt, in particular demtect, to identify and monitor mci and to early ascertain its progression to d. moreover, in our study, spect proved more sensitive than nt also preceding mci diagnosis in some cases. the purpose of the study is to demonstrate imaging features of pet brain in dementia and to determine whether the mri anatomic changes correlate with dementia. method: from january to december , patients with suspicion for dementia clinically performed fdg pet/ct ( women, men, age range from - y). pet/ct results were compared and correlated with most recent mri ( day to month). results: ten patients with alzheimer's disease diagnosed clinically were consistent with hypometabolism of the temporo-parietal cortices on pet-ct frequently in an asymmetric pattern, with increasing degrees of frontal cortex hypometabolism in relation to advanced disease. there was sparing of the occipital and cerebellar cortices and motor sensory strips. on pet-ct imaging, cases showed temporo-parietal defects similar to alzheimer's disease, but there also was additional hypometabolism of the occipital cortices. these imaging findings were congruent with the clinical findings of visual hallucinations, leading to a diagnosis of diffuse lewy body disease. in this study, both alzheimer's disease and lewy body dementia correlated with age-appropriate global atrophy in of total dementia patients; of medial temporal lobe atrophy on mri. two patients presented clinically with alzheimer's type dementia. pet-ct with mr correlation showed vascular dementia in one patient, with wedge shaped hypometabolism in right fronto-temporal distribution and left cerebellar diaschisis. the other patient had bilateral mesial temporal hypermetabolism on pet-ct and increased signal intensity in the bilateral temporal lobes on t wi of mri, representing limbic encephalitis. one patient had both normal pet/ct and mri. conclusion: pet is useful modality of illustrating metabolic distribution of dementia. medial temporal lobe atrophy and age-related brain atrophy are associated with dementia. mri can detect structural alteration and differentiate underlying non-dementia disease such as mesial temporal encephalitis. aim: dementia is the progressive decline in cognitive function due to damage or disease in the brain beyond what might be expected from normal ageing. particularly affected areas may be memory, attention, language, and problem solving. it`s a disease strongly associated with age; % of those aged - , % of those aged - , and % of those aged or older suffer from the disease. the most common cause is alzheimer's disease. positron emission tomography (pet/ct f-fdg) is a valuable tool for understanding functional changes in brain's patients (pts) with several causes of dementia. as such, it can provide valuable physiological alterations for diagnosis, management and research of dementia disorders. pet helps to identify dementia causes and makes a differential diagnostic with other illnesses. the aim of the present study was to evaluate the value of the pet/ct f-fdg metabolic patterns for the differential diagnosis and the cause of dementias. material and methods: between january and march , pts ( women, men; age: - years; mean: . years), with isolated cognitive deficit or dementia (using standard clinical criteria) underwent pet/ct f-fdg brain studies, after a reversible illness had been excluded. pet/ct was performed in fasting pts minutes after a mbq f-fdg intravenous administration. some days before pet/ct, single photon emission computed tomography (spect/ct) was done in of the patients. fdg-pet brain scans results were evaluated and compared to spect/ct. results: f-fdg pet/ct scans confirmed the presence of a bilateral temporo-parietal hypometabolism pattern associated with alzheimer`s disease in / pts ( %); / presented a frontal involvement and / a occipital involvement. in ( %) pts we can see fronto-temporal hypometabolism pattern suggesting a frontal lobe dementia and in ( %) pts a bilateral temporal hypometabolism is present that could imply a premature stage alzheimer's disease. only patient had a f-fdg-pet/ct pattern compatible with vascular dementia ( %). pet/ct and spect/ct are congruent positive results in all studies. conclusion: f-fdg pet/ct brain scan may provide clinician with additional information helpful to establish the cause of dementia after reversible illness has been ruled out. the purpose: is to demonstrate the imaging features of dementias on brain fdg pet and to determine whether visible anatomic changes on mri correlate with these findings. methods and material: fifteen patients ( women and men, age range - years) with clinically suspected dementia underwent fdg pet/ct from january to december . the results of pet/ct were retrospectively correlated with the findings from the most recent available brain mri ( to days from the date of the pet/ct). results: ten patients with clinically diagnosed alzheimer's exhibited temporo-parietal cortical hypometabolism on pet, frequently in an asymmetric pattern, with increasing degrees of frontal cortical hypometabolism seen in relation to severity of disease. there was sparing of the occipital and cerebellar cortices and motor sensory strips. on pet imaging, patients showed temporo-parietal defects similar to alzheimer's disease, but with additional occipital cortical hypometabolism. this additional abnormality was congruent with clinical findings of visual hallucinations, leading to a diagnosis of diffuse lewy body disease. of patients with alzheimer's disease and lewy body dementia, showed age-appropriate global atrophy, and showed medial temporal lobe atrophy on mri. two other patients presented with alzheimer's type dementia, however pet-ct with mr correlation showed multi-infarct dementia in one, with wedge shaped hypometabolism in a right fronto-temporal distribution and left cerebellar diaschisis, while the other patient showed bilateral mesial temporal hypermetabolism on pet and increased signal intensity in the bilateral mesial temporal lobes on t wi mri, consistent with limbic encephalitis. one patient had normal pet/ct and mri, despite clinical dementia. conclusions: pet is a useful modality for aiding in confirmation and differential diagnosis in dementias. medial temporal lobe atrophy and diffuse brain atrophy are seen with dementia but lack of specificity by mri. mri is a powerful tool for differentiating dementias from other underlying disease, such as mesial temporal encephalitis. cerebral spect with hypercapnia in the examination of cerebrovascular reserve capacity p. sirucek , o. kraft , t. hrbac ; clinic of nuclear medicine university hospital, ostrava-poruba, czech republic, clinic of neurosurgery university hospital, ostrava-poruba, czech republic. aim aim of this diagnostic examination is choice of suitable patients with neurological deficit the most often after cerebrovascular accident with demonstrated carotid artery or intracranial artery occlusion. these patients would have benefit from bypass surgery (anastomosis between arteria cerebri media and arteria temporalis superficialis). methods from to we examined patients ( women, men, average age . yrs. the oldest patient was yrs old, the youngest yrs old). scintigraphy was done by means of double-headed camera e.cam by siemens with convergent collimators fan beam (matrix size x , zoom . , degrees of rotation , number of views , time per view sec.). processing was done by means of software e.soft. we have used filtered back projection reconstruction, filter butterworth (cutoff . , order ). in all patients we have done brain spect in native conditions and then after stress -by inhalation of air enriched by co . after increase kpa of partial pressure of co in expired air we injected i.v. mbq radiopharmaceutical mtc bicisate (neurolite) and then we did brain spect. native (rest) and stress examinations were compared. visual evaluation divided findings in three-grade scale: cerebrovascular reserve capacity (cvrc) was normal in unchanged finding in stress and rest, cvrc was reduced or strongly lowered in worsening of finding in stress. results pts had normal cvrc, pts had cvrc decreased and pts strongly reduced. pts were operated: in pts ec-ic anastomosis, endarterectomy in pts. in ec-ic anastomosis a blood flow was controlled by means of ultrasonography. in pts anastomosis was functional and in pts non-functional. pts indicated improvement of neurological finding. pts had unchanged finding, but from these pts patients had normal finding in time of surgery. pts had pathological finding without change, but after surgery they were without another stroke. in these patients we expect risk decrease of another cerebrovascular ischemic accident. conclusion examination of cvrc by means of brain spect and hypercapnia is an easy method which is able to help with choice of patients with cerebrovascular occlusion for bypass neurosurgery and to determine patients in whom surgery will improve neurological finding. introduction: interictal f- fdg pet is frequently used in the identification of epileptogenic foci in patients with intractable partial seizure. we have observed increased metabolic activity in the posterior ocular bulb (pob) in some patients with intractable partial seizure undergoing pet scanning in our facility. the purpose of the current study was to further investigate this observation by evaluating and comparing increased fdg uptake in (pob) in patients with seizure and in normal volunteers. methods: brain fdg pet/ct images for fifteen normal volunteers and patients with intractable partial seizure referred for interictal cerebral were retrospectively evaluated. all studies were acquired on a dedicated pet/ct scanner (gemini, phillips) with low-dose, non-contrast ct. two nuclear medicine physicians, blinded to clinical data, indepedently analyzed the pob tracer activity. chi-square test and interrater reliability with kappa were used. brain mri was available in of the seizure patients. a radiologist reviewed brain mri studies for any possible pob pathology. results: of the normal volunteers, ( %) showed no significant fdg uptake in the pob. in the one volunteer with increased pob uptake, significant falx calcification of unknown significance was noted on the ct portion of the pet/ct exam. of the seizure patients, ( %) had increased fdg uptake in the pob: unilaterally in and bilaterally in cases. on a patient bases, statistical significance was present between the two studied groups (p = . ). on an individual eye basis ( x for normal volunteers + x for seizure patients = pob areas), a high interrater agreement (kappa . ) was present for most cases ( / ) demonstrating feasible delineation of normal from abnormal pob uptake. available brain mri of patients showed no abnormalities at the pob or orbits. conclusion: when present, visually increased fdg uptake along the pob is abnormal and may be associated with seizure. however, further studies are needed to investigate underlying pathophysiologic mechanism(s) for this phenomenon. a prospective study including ophthalmological and neurological examination is pending in our institution. aim: there is a continuous scale of preoperative fdg-pet findings (from normal to abnormal) in temporal lobe epilepsy (tle) patients. the discrimination between normal variability and pathology seems to be a clinical challenge in some cases. the aim of this work was to define the cut-off point for different methods of fdg-pet evaluation and to define their accuracy. materials & methods: patients with refractory tle were indicated to preoperative fdg-pet from three departments. all consecutive patients, in whom histopathology proved hippocampal sclerosis (hs), were included into this study. the control group consisted of oncologic patients without any clinical signs of brain involvement. roc analysis was utilized for the assessment of accuracy of semi-quantitative parameters of manual evaluation by two operators as well as automated brain analysis using two software applications: scenium (siemens; alpha v. . ) and brass (hermes medical solutions; v. . ) . results: the areas under the roc curves were calculated for the extent of asymmetry in hippocampus , (brass), , (scenium); for side difference of z-value in mesial temporal lobe , (scenium); for manual assessment of asymmetry , (operator ) and , (operator ) and didn't differ significantly between respective methods. a similar analysis in all other regions of interest gave worse results. the correlation coefficient of subjective evaluation between both operators was r= , (ci %: , - , ). the cut-off points for the best discrimination between hs and control groups were for asymmetry of hippocampus: , % (brass) and , % (scenium); for manual assessment of asymmetry: , % (operator ) and , % (operator ); for side difference of z-value in mesial temporal lobe: - , (scenium). the extent of asymmetry assessed by all methods was able to correctly predict the side of operation in % of patients with tle (ci %: , - , ). conclusion: fdg-pet is a reliable diagnostic tool for discrimination between patients with hs and control group. sensitivity and specificity is at the level of % approximately, regardless of the method of evaluation used. furthermore fdg-pet is capable to correctly predict the side of operation in % of patients with hs. completely automated analysis is less laborious and operator independent. it gives the same results as careful manual assessment. manual assessment requires meticulous compliance with standardized evaluation methods. objectives: to evaluate the diagnostic performance of our new d ordered subsets expectation maximization (osem) algorithm vs. conventional fbp (filtered back projection) reconstruction algorithm in the functional brain perfusion spect imaging with tc- m hmpao and ecd in investigation of cerebrovascular decease, dementia, seizure disorders, tumors and arteriovenous malformation. methods: the tc- m hmpao or ecd brain spect data for patients (n= ) acquired for clinical purpose as a standard-of-care for the deceases listed above were retrospectively reconstructed. the subjects with independently confirmed (e.g. by mri studies) presence of perfusion abnormalities were selected for this study. the patients were administered mci of tc- m hmpao or ecd minutes prior to imaging. prior to radiopharmaceutical administration, standard pre-injection protocol was applied including placing the patient in a dark, quiet room with minimal visual and auditory stimulation. the spect scans were acquired with a triple-head gamma camera (triad , trionix) equipped with low energy high-resolution fan-beam collimators ( x , degree, -degree stops for s). the reconstructed images for the same patients were obtained using the standard-of-care clinical fbp algorithm with hanning filter ( . ny) and our new d osem algorithms. the same radiologists in blinded studies independently read them. our d osem algorithm is a fully d reconstruction method with fan-volume system model and with total variation optimization. the clinical findings from images reconstructed by the two algorithms were compared with ground truth information provided by corresponding complementary studies including ct, mri, pet, clinical examination and follow-up studies. results: we established an increase in the specificity and sensitivity in locating the site and spatial extent of brain perfusion abnormalities while using our d osem, as compared to fbp algorithm. conclusions: our new d osem algorithm applied to hmpao and ecd spect brain studies instead of conventional fbp algorithm resulted in improved diagnostic performance. to obtain a good quality ictal spect, the determining factor is the time delay from ictal eeg onset to tracer injection. aim: the aim was to study which phase of the eeg is the determining factor for reporting the lateralization of the ictal spect using siscom. the key phases in eeg chosen for study are brain activity lateralization (bal) at the onset (bal_o), bal at the moment of tracer injection (bal_ti) and then again seconds postinjection (bal_ ) methods: the study consisted of patients ( males and females) of an average age of years, with drug resistant complex partial seizures. there were temporal and extratemporal seizures. the spects were ictal in cases and postictal in the remaining , with an average tracer injection time of seconds from seizure onset. brain spects were carried out after the injection oh hmpao-tc m using an ecam gammacamera (siemens) and following siscom methodology for an accurate identification of the maximum brain activity during ictal spect. analysis was used to establish which of these eeg phases showed most agreement with the bal seen in the siscom. results: siscom identified bal on one side in / patients while eeg in . all cases without bal using eeg, were lateralized using siscom. bal_o occurred in patients, bal_ti in and bal_ in only . in the agreement study between bal_o and siscom, of the cases with bal, were lateralized on the same side and in the contralateral side (p = . ). in the case of bal_ti, of the patients that were lateralized, of these patients were on the same side of the brain and only one in the contralateral side (p = . ). finally, in the case of bal_ , patients were lateralized, of these were on the same side and two on the contralateral brain hemisphere (p = . ). conclusions: the highest degree of agreement was between siscom and bal_ti. this suggests that the tracer injection time is the determinant in correct interpretation of ictal spect. purpose: i- iomazenil(imz) is a one of the benzodiazepine partial-inverse agonist and has been widely used to evaluate a distribution of central benzodiazepine receptors. some authors reported that d-ssp could be useful to detect subtle change of tracer distribution in brain. however, a result of d-ssp depends on the normal database. we hypothesized that a distribution of central benzodiazepine receptors may change with age. the purpose of this study was to evaluate an age-specific normal distribution of i- iomazenil(imz) spect imaging. method and materials: twenty-nine subjects who were hospitalized in our hospital were studied. imz brain spect and brain mri were performed within weeks period. they were suspected of having epilepsy on the basis of clinical findings, but no significant abnormality was seen in their imz spect and no major abnormality in their mri. these findings visually interpreted by radiologists. these subjects were classified into groups by their age; - years ( males, females), - years ( males, females), - years ( males, females), and years and older ( males, females). three hours after the intravenous injection of mbq of imz, spect data acquisition was performed using a triple head digital gamma camera system. unpaired student t tests were performed to compare the imz accumulation in each group using d-ssp, and z score maps were obtained. two radiologists visually and independently evaluated these z score maps, and compared the imz accumulation between each group. results: the imz accumulation of the - years group in the cerebellar hemisphere was higher than the other groups. it of the - and - years groups in the central sulcus were also higher than the other groups. on the other hands, it of these younger groups in the frontal lobe were lower than the other groups. furthermore, it in the posterior cingulate gyrus and the occipitotemporal lobe increased with age. coclusions: according to our result, the distribution of imz could be change with age, and to assemble an age-specific normal database might be important. aim: to assess the role of brain perfusion spect in the management of patients with spontaneous intracerebral hemorrhage (sich). method: sich pts were studied. all pts underwent same day ct and brain spect with mtchmpao, h- d from onset of stroke. results: / pts ( . %) showed a larger perfusion defect than expected after ct. in pts hematoma diameter was comparable on ct and spect; pt had quasinormal aspect of spect study. in pts with larger defects, spect revealed a large cold spot with similar size compared with ct, and a surrounding hypoperfused area. / pts revealed cortical hyperperfusion, adjacent to hypoperfused area and corresponding to a normal-appearing brain tissue on ct. in pts we found crossed cerebellar diaskisis. in pts we found cortical hypoperfused area in the contralateral cortex, with normal appearing brain tissue on ct. discution: many mechanisms and scenarios were proposed in order to identify the pathologic factors involved in the pathology of sich: edema, ischemia, inflammation, microglial activation, hemotoxicity, apoptosis... all of these factors are affecting brain tissue surrounding hematoma and are responsible of the progressive neurological deterioration; most of these damages are not revealed by anatomical imaging techniques. despite the latest advances in medical treatment and neurocritical care, patients suffering sich still have a very poor prognosis, with a greater mortality and larger neurological deficits at the survivors than for ischemic stroke. in a significant number of our patients ( . %!) brain perfusion spect revealed different types of perfusion changes in the brain tissue surrounding hematoma, corresponding to normal appearing brain tissue on the ct scans. further studies are definitely required to demonstrate prognostic significance of these changes, but we can assume that all these areas contain viable tissue that can be a target for neuroprotective strategies. conclusions: brain perfusion spect can play an important role in sich, by early demonstrating functional changes responsible of clinical deterioration, thus allowing prompt dedicated therapeutic intervention. aim: to evaluate influence of hypotensive treatment on cerebral perfusion and cognitive function in patients (pts) with arterial hypertension (ah). material and methods: the study involved patients ( males and females, mean age ± ) with moderate essential hypertension. perfusion brain spect with mtc-hmpao and comprehensive neuropsychological testing were performed before and after months of antaginist ca treatment. brain spect slices were divided into symmetrical (right and left) regions of interest per patients: inferior and superior frontal lobes, temporal, anterior and posterior parietal, occipital lobes and cerebellar hemispheres. regional cerebral blood flow (rcbf)(ml/ g/min) in these regions was calculated. results: hypoperfused regions were revealed in pts. all pts had no focal neurological symptoms. antihypertensive therapy within month led to the brain perfusion improvement and positive effect on cognitive function in pts with ah. medical treatment followed by the increase in rcbf relative to baseline in right and left anterior parietal regions ( . ± . vs . ± . , p= . ; . ± . vs . ± . , p= . , correspondingly), in left temporal cortex ( . ± . vs . ± . , p= . ), in left inferior frontal region ( . ± . vs . ± . , p= . ). also growth in cerebral perfusion in right and left superior frontal regions, in right inferior frontal cortex and right and left occipital regions was observed. measures of immediate verbal memory, delayed verbal memory and learning showed a significant increase theirs after treatment an average on % (p= . ), % (p= . ) and % (p= . ), correspondingly, as well as improvement in immediate and delayed visual memory, attention on % (p= . ), % (p= . ), and , % (p= . ), correspondingly. relationship between the changes of cerebral perfusion and dynamics of cognitive status was found. improvement of immediate verbal memory correlated well with increase in rcbf in left temporal region (r = . ; p= . ). betterment of delayed verbal memory related to growth in cerebral perfusion in left anterior parietal region (r = . ; p= . ) and left inferior frontal region (r = . ; p= . ). positive correlation was shown between dynamics of attention and changes rcbf in right and left anterior parietal regions (r = . ; p= . , r = . ; p= . , correspondingly). conclusion: our results suggest that brain spect is useful technique for evaluation of medical treatment dynamic and understanding of cognitive disorders mechanisms in patients with arterial hypertension. improvement of cognitive functions after treatment in patients with ah was connected with the increase in brain perfusion. efficacy assessment of encephalo-duro-arteriosynangiosis for childhood moyamoya disease using dimensional stereotactic roi template analysis of brain perfusion spect s. hyun, k. lee, s. lee, y. cho, e. lee, j. choi, y. choi, y. choe, b. kim; samsung medical center, seoul, republic of korea. objectives: we evaluated the efficacy of encephalo-duro-arterio-synangiosis (edas) for childhood moyamoya disease using -dimensional stereotactic roi template ( dsrt) analysis of brain perfusion spect. methods: eighteen patients (f: m = : , mean . ± . yr) with childhood moyamoya disease who underwent bilateral simple edas were included. resting and acetazolamide (acz) challenged cerebral perfusions were measured with mtc-ecd spect . ± . days before the one side operation and . ± . months after the other side operation. the spect images were anatomically standardized using spm followed by normalization of counts using proportional scaling with the mean value of cerebellum at . we calculated the cerebral vascular reserve index (cvri) image as follows: cvri (%) = [(acz image -resting image) / resting image] x . fully automated roi analysis with dsrt was performed on resting, acz, and cvri images. dsrt calculated the area-weighted mean value of segments by quantification of constant rois in each hemisphere. we compared the mean value of each segment between pre-and postoperative groups. wilcoxon matched-pairs signed-ranks test was used for statistical analysis. results: comparison between pre-and postoperative brain spect revealed no significant improvement in resting perfusion. after edas, there was significant acz challenged perfusion improvement in the central (pre . ± . vs. post . ± . , p= . ) and parietal region (pre . ± . vs. post . ± . , p= . ). cvri improved in the central region with a mean difference of . (pre - . ± . vs. post - . ± . , p= . ) and the parietal region with a mean difference of . (pre - . ± . vs. post - . ± . , p= . ). cvri in the lenticular nucleus region was significantly reduced (pre - . ± . vs. post - . ± . , p= . ). conclusions: pre-and postoperative cerebral perfusion and vascular reserve in childhood moyamoya disease can be effectively assessed by dsrt. our results provide objective evidence that simple edas improves cerebral perfusion in the middle cerebral artery territory without direct benefit in the anterior and posterior cerebral artery territories. segments: callosomarginal, precentral, central, parietal, angular, temporal, posterior cerebral, pericallosal, lenticular nucleus, thalamus, hippocampus, and cerebellum aim of the study: to evaluate metabolic activity using f-fdg ct-pet in order to establish both carotid vulnerability to rupture and asymptomatic progression linked to plaque inflammatory cells. methods: patients with symptomatic or asymptomatic unilateral carotid arteries were studied. all of them were scheduled for carotid endarterectomy (ce). f-fdg head and neck ct-pet was performed using a discovery st scanner (ge healthcare) prior to ce and days following surgery. two speciality-trained persons blinded to the vascular examinations results reviewed and quantified the scans. two-centimeter circular regions of interest were drawn on ct images around the area including carotids in each slice, and then transferred onto the corresponding coregistered pet image to enable f-fdg uptake values based on maximum standardized uptake value. the analysis included vascular region mm over and below the level of the carotid bifurcation, and slice-activity curves were calculated in order to visualize plaque and basal metabolism. results: carotid plaques with inflammatory infiltrates had a major f-fdg uptake (p< . ). no significant correlation was found between degree of f-fdg uptake and time from symptoms to ct-pet imaging, symptomatic or asymptomatic patients, degree if carotid stenosis and vascular risk factors. we found significant correlation between the degree of f-fdg accumulation in carotids scheduled for ce and contralateral carotids (p< . ). the f-fdg ratios in the contralateral arteries remained increased on the follow-up imaging at days. statines treatment was correlated with more pronounced decreased in f-fdg-uptake at days (p< . ). conclusions: this is the first in vivo study using f-fdg ct-pet imaging demonstrating that carotid atherosclerosis is a bilateral disease. identification of inflammatory regions in the contralateral carotids has the potential to offer early aggressive pharmacotherapy in these patients. aim. we report our clinical experience with m tc-hmpao spect imaging in patients with giant intracranial aneurysm in order to identify patients without a sufficient collateral perfusion during internal carotid artery (ica) temporary occlusion test (tot). material and methods. consecutive patients ( man, women; mean age years; range - years) affected by a giant intracranial aneurysm, who could potentially benefit from permanent ica occlusion, underwent a tot to evaluate the efficiency of cerebral collateral perfusion. one patient with sudden onset of intese headache during tot (absolute contraindication for permanent ica occlusion) was excluded from this series whereas patients were injected with twenty mci of m tc hmpao after a endovascular balloon had been blown up for ten minutes. images were obtained by a dual headed gamma camera using a circular orbit and a ° step and shoot technique. data were processed after a backprojection and an attenuation correction, by using a low pass filter. both a qualitative and a semiquantitative analysis of images were performed. results. in patients, no perfusion impairments were found and a permanent ica occlusion was made. the procedure resulted in aneurysm thrombosis and no signs of ischemic injures occurred in the follow-up period. four patients showed a reduced perfusion during tot. one of these patients underwent surgical revascularization by ec/ic bypass. a new tot, after surgical revascularization, revealed no perfusion alterations and the patient underwent permanent ica occlusion without any subsequent ischemic injury. conclusion. m tc hmpao is an effective tool in identifying patients who cannot undergo permanent ica occlusion. intracranial arteriovenous malformation (avm) is an abnormal collection of immature blood vessels within the brain. treatment of the brain avms includes three modalities: endovascular embolization, which reduces the size and vascularity of the lesion, standard microsurgery or radiosurgery. very little relevant literature concerning the role of spect in the evaluation of avm treatment through endovascular embolization encouraged us to study this problem. material. examined group included patients ( women and men) at the age of - years. all the patients had been previously diagnosed with intracranial avm and subsequently qualified for the endovascular embolization procedure. the patients were in good clinical condition and had no symptoms of recent intracranial haemorrhage. methods. brain scintigraphy was performed on the same day, prior to embolization and - days after treatment. administrated activity of mtc-ecd (polatom, poland) was to mbq. spect examination was carried through minutes after iv radiotracer injection with two-head gamma-camera varicam. acquisition was performed using high-resolution collimators, with one projection for each ° in a ° orbit. a matrix of × pixels was applied. filtered back projection with metz filter was used for reconstruction. regional cerebral blood flow (rcbf) was evaluated visually and semiquantitatively using voxel-based analysis with brain spect quantification software (compart, warsaw, poland). embolization procedure was performed under general anaesthesia. angiography was carried out using siemens equipment (multistar). partial or complete obliteration of avm was followed by postembolization angiography. results. no serious side effects were observed after embolization. in each patient, spect showed the nidus of avm as a region of decreased radiotracer accumulation. after embolization significant changes of perfusion (cut off cluster size- , ml, cut-off percentage- % in semiquantitative analysis) in an area adjacent to the avm nidus were found in pts: deterioration of perfusion in pts ( , ml- , ml mean , ± , ml, %- % mean , ± , %) and improvement in patient ( , ml, , %). significant perfusion changes in the areas remote to the nidus were seen in pts: areas of perfusion deterioration and regions of rcbf improvement after embolization. these areas were located in cerebral and cerebellar hemispheres both ipsilateral and contralateral to avm. conclusions. perfusion changes in patients with avm treated through endovascular embolization can be detected by means of m tc-ecd spect with voxel-based analysis. deterioration of perfusion after embolization seems to prevail over improvement. mean cerebral blood flow,response to paco and rcbf distribution in the patients with diabetic mellitus a. komatani; yamagata univ., yamagata, japan. aim: the diabetes mellitus (dm) is widely known as a risk factor of many diseases e.g. retinopathy, nephropathy, neuropathy and angiopathy, etc. to confirm the possibility of dm as a risk factor for the cerebral infarction and/or vascular dementia, we inspected mean cerebral blood flow (cbf), its distribution, and flow reserve in patients with dm. materials: fifty-one males aged . ± and forty seven female aged . ± with dm. ten males aged . ± and twelve females aged . ± . for healthy control. methods: mean cbf was measured using xe-spect with kanno-lassen's method, and the flow reserve was estimated as a response to paco by sodium bicarbonate (hco -) injection. the distribution of regional cerebral blood flow (rcbf) was estimated using statistical parametric mapping (spm) with m tc-ecd. results: the mean cbf was . ± . ml/ g/min in the group of dm patients, and . ± . ml/ g/min in the group of healthy control. no significant difference was seen between the both groups (p= . ). regional flow reduction in the white matter especially at the sub cortical region was observed in most of the dm patients. no significant difference in the mean cbf was seen between with and without complications of hypertension and/or hyperlipemia. the correlation between the mean cbf and the dilation of the disease tend to have negative correlation (p= . ). the percent increase with the sodium bicarbonate injection was . ± . % in dm patients and . ± . % in healthy controls. the flow reserve in dm patients was significantly poor compared with control group (p< . ). conclusion: the most obvious findings of dm patients were flow reserve reduction, and the reduced regional flow in the white matter especially at the sub cortical area. the reduction in mean cerebral blood flow was not so major characteristic of dm patients. dm should be a certain risk factor for the cerebral infarction and/or vascular dementia due to micro angiopathy with dm. brain metabolism in patients with unilateral carotid stenosis. regional changes evaluation after endarterectomy using ct-pet with f-fdg a. fernandez leon , j. krupinsky , m. font , r. de juan , p. pifarre , a. carvajal , f. rubio , a. domenech , c. gamez , j. gispert ; idibell. hospital de bellvitge. unitat pet., barcelona, spain, idibell. hospital de bellvitge, barcelona, sudan. aim of the work: atheroesclerosis is a chronic inflammatory disorder but it is still unclear whether patients with unilateral carotid disease are at higher risk of contralateral carotid artery progression. both carotid vulnerability to rupture and metabolic brain changes related to vascular disease may be linked to plaque inflammatory cells. imaging with f-fdg pet has been shown to be unique in detection of plaque inflammatory activity and secondary brain changes. methods: we studied patients with symptomatic or asymptomatic unilateral carotid arteries. all of them were scheduled for carotid endarterectomy (ce). all patients received an integrated fdg-pet/ct using a discovery st scanner (general electric healthcare) prior to ce and days following surgery. pet was performed with , mm slice thickness with no overlapping slices in d mode including brain and neck structures. a stiff cervical collar was worn to minimize patient movement. approximately mbq of fdg was administered intravenously as a bolus and static emission images were obtained min later. attenuation correction -slice ct helical scans (ctac) were obtained at , mm slice thickness, kv tube voltage and ma tube current. all images were pre-processed using the algorithms provided with the spm software package. images were normalized to the pet template and smoothed with a gaussian kernel of mm fwhm. then, images were masked so that all remaining voxels had an activity higher than % of the brain global value in all cases. relative intra-subject changes in brain metabolism were determined in a voxel-by-voxel manner by subtracting the post and pre images and expressing this difference in percentage units relative to the first image [ x(post-pre/pre)]. finally, these images were thresholded and the number of voxels showing changes over/under % were recorded, as well as the average relative metabolic change in them. results: in / patients significant increased metabolism in unilateral or bilateral carotidean territories were observed after endarterectomy. in half cases there was concordance between brain changes and affected carotid. in / we observed decreased bilateral metabolism after ca. no changes were observed in / patients, all of them with left arterial disease. no significant correlation was found between brain changes and time from symptoms to pet imaging, symptomatic or asymptomatic patients, degree of carotid stenosis and vascular risk factors. conclusions: f-fdg ct-pet imaging can demonstrate bilateral changes in brain metabolism after endarterectomy, mainly in carotidean territories. objective to evaluate the efficacy and the diagnostic value of cerebral perfusion quantification in patients (p) with carotide artery stenosis (cas) who underwent surgical endarterectomy. materials and methods p were studied. showed right and left carotide stenosis. most of them had bilateral cas and underwent surgery of the main affected artery. eco-doppler, basal and months after endarterectomy mtc-spect with mci of mtc-ecd scan (vg gems gamma camera, fan beam collimator) were performed in all p. the perfusion was analysed by spm comparing each patient's study (pre and post surgery) with a healthy control group. the changes in both the extension and intensity of the cerebral hypoperfusion before and after surgery were also evaluated. results a significant carotide artery flow improvement was found in all p by eco-doppler. in p the basal cerebral perfusion analysis by spm was normal. in p an increase of the intensity (mean , %) and extension (mean %) of the hypoperfused areas seen in the basal study was detected. in p a decrease of the intensity (mean , %) and extension (mean , %) was seen. conclusion spm is a useful method to analyse the post surgery cerebral perfusion changes in p with carotide stenosis, detecting a significative hypoperfusion decrease (intensity and area) in of p. a post surgery worsening was found in p. these results are uncertain and further long term studies would be needed to clarify these findings. aim: study of brain perfusion in patients with arterial hypertension (ah) and type ii diabetes mellitus (dm). material and methods: fifty seven patients with moderate essential hypertension (mean age , + , years) were investigated by brain spect scanning with m tc-hexamethylpropylene amine oxime ( m tc-hmpao). thirty three patients were found to have ah without carbohydrate metabolism disturbance (gr.i) and patients -ah with type ii dm (gr.ii) in stage of compensation and subcompensation. all patients had no focal neurological symptoms. spect was performed at baseline and during adenosine test. results: hypoperfused regions were revealed in all patients. the dercrease in radiopharmaceutical accumulation was found in of brain regions in patients of gr.i. the most significant cerebral blood decrease was marked in parietal brain region ( %). hypoperfused regions were observed less frequently in temporal ( %), occipital ( %) and frontal ( %) brain lobes. cerebral perfusion disorders in patients with ah and dm were more pronounced in comparison with patients of gr.i (p= , ). thus, of brain regions ( %) were hypoperfused in pts of gr.ii. microcirculation disorders of greater degree were found in occipital brain lobes, where hypoperfusion was revealed in of ( %) brain regions. the less pronounced decrease in accumulation of m tc-hmpao was observed in parietal ( %), temporal ( %) and frontal ( %) brain lobes. use of adenosine test in both patients groups did not affect cerebral perfusion in hemispheres (p= , and p= , , respectively). however, in some cases brain perfusion decrease in individual regions was observed. at the same time in frontal lobe almost double increase in hypoperfused regions quantity as compared with baseline was found. this fact may testify to cerebrovascular reserve decrease in frontal region in these patients. conclusion: our results suggest that the signs of brain hypoperfusion and the decrease in cerebrovascular reserve take place in patients with essential hypertension and diabetes mellitus as well as in ah patients without it even if they have no focal neurological symptoms. the most pronounced cerebral perfusion disorders are revealed in patients with ah and diabetes mellitus in comparison with ah patients without carbohydrate metabolism disturbance. [ i]fp-cit is suitable for the quantification of dopamine (da) transporters localized on the membrane of presynaptic dopaminergic neurons. the practical use of [ i]fp-cit spect has become a routine diagnostic tool to investigate the integrity of the nigrostriatal pathway in vivo and also to directly assess the progression of parkinsonism. previous studies applying roi methods for data analysis have evaluated the effect of medications on the striatal da transporter imaging, that is however still debated. aim of the study was to evaluate the effect of treatment with dopamine agonist drugs on da transporters in patients with parkinson's disease (pd) by means of a voxel-based analysis of [ i]fp-cit spect data. spect [ i]fp-cit binding to the da transporters was evaluated in patients both without any medication and during treatment with dopamine agonist drugs (ergot-derivatives and non-ergotderivatives) after reaching the maximal optimazed dose (mean days). a -head gamma camera equipped with lehr collimators was used for data acquisition ( x matrix, pixel size mm, projections, ° circular orbit) after the i.v. injection of mbq of [ i]fp-cit. filtered back projection with a butterworth prefilter ( . cycles/cm, order ) was used for reconstruction, applying uniform attenuation correction ( . cm- ). reconstructed data were realigned, spatially normalized to a [ i]fp-cit spect template and smoothed. individual voxels values were expressed as % of occipital mean counts. spm was then used for data analysis. both caudate and putamen [ i]fp-cit binding values were bilaterally not significantly different on baseline and during treatment (p< . ). no statistically differences were also observed when comparing patients treated with ergot-derivatives versus non-ergot-derivatives. in conclusion, the results of the voxel-based analysis, a less operator-dependent approach than roi methods, confirm that dopamine agonist medications do not affect the spect imaging with [ i]fp-cit and support the needless of withdrawing both ergot-derivative and non-ergot-derivative drugs to measure da transporter levels. the absence of effect of this treatment on spect measurements is particularly important when the neuroprotective effect of dopamine agonist drugs is going to be assessed by [ i]fp-cit imaging. the diagnosis of alzheimer's disease (ad) versus lewy-body dementia (lbd) and parkinson's disease (pd) with dementia is often problematic, especially in patients with both dementia and parkinsonism. aim of the study was to assess the usefulness of spect with [ i]fp-cit, a dopaminergic presynaptic ligand evaluating integrity of nigrostriatal pathways, combined with rcbf spect for differentiating in-vivo lbd, pd with dementia and ad, by means of a voxel-based approach. most previous spect studies have applied roi methods for analysis, which are subjective and operator-dependent. fifteen patients with probable lbd, with probable ad (nincds/adrda criteria) and patients with dementing pd underwent rcbf spect with mtc-ecd and a brain spect with [ i]fp-cit. patients were matched for age, sex and severity of cognitive impairment (mmse). spect was performed with a dual-head gamma-camera - hr after the i.v. injection of [ i]fp-cit ( mbq) and about hr after mtc-ecd ( mbq). comparison of the[ i]fp-cit striatal binding ratios and rcbf spect patterns among ad, lbd and pd was performed by means of the voxel-based spm analysis (spm , unpaired ttest for statistical analysis). the spm analysis showed a significant (p< . ) bilaterally reduced binding in caudate and putamen in lbd and pd patients compared to ad. striatal uptake was indistinguishable between patients with lbd and pd. ad patients had significantly (p< . ) reduced rcbf in the temporo-parietal and frontal areas versus both the lbd and pd groups. lbd and pd patients showed significantly reduced (p< . ) rcbf in the occipital regions versus the ad patients. whereas, no statistical differences in the rcbf patterns were found between lbd and pd patients. in conclusion, the spm voxel-based approach is a viable alternative to the method of roi analysis, and could be included in the routine clinical analysis. nigrostriatal impairment as evaluated by means of [ i]fp-cit spect allows to differentiate lbd or dementing pd from ad patients. the rcbf study adds further informations about the existence of a common or different neurobiological substrate underlying the clinical spectrum of parkinsonism-dementia. on the other hand, it appears that [ i]fp-cit and rcbf imaging cannot differentiate lbd from pd with dementia. background a differential diagnosis between idiopathic parkinson's disease (ipd) and multiple system atrophy (msa) is clinically difficult. we analyzed the difference in glucose metabolism between ipd and msa using spm (statistical parametric mapping). methods this study included ipd patients (age range: - yr), msa patients (age range: - yr) and healthy controls (age range: - yr) who underwent f- fdg pet. using spm (statistical parametric mapping , wellcome department of cognitive neurology, london, uk) software, all the images were spatially normalized into the standard template, smoothed with mm fwhm isotropic gaussian kernel. the count of each voxel was normalized versus the total count for the brain (proportional scaling in spm) to remove global cerebral blood flow differences between the individuals. images of ipd were compared with those of healthy controls and msa patients in a voxel wise manner using spm (uncorrected p < . ). the ipd patients were found to have a significant glucose hypermetabolism in comparison with the healthy controls in both basal ganglia, thalami, cerebellar areas and decreased metabolism in motor cortical areas. the msa patients demonstrated diffusely decreased cerebral glucose metabolism in both both cerebellar areas compared to the ipd patients. conclusion although the number of patients studied is small, spm analysis may be useful in differential diagnosis of patients with idiopathic parkinson's disease and multi-system atrophy. further studies including more patients may be warranted . normal or aspecific findings at ct/mr. brain spect was performed - hrs after mbq i fp-cit (datscan, amersham health) i.v. injection by a dual head gamma camera with fan beam collimators. spect images were analyzed qualitatively and quantitatively calculating conventional putamen/occipital (p/o) and caudate/occipital (c/o) ratios normalized with phantom and compared to age matched normal controls (c) provided by the data processing software (normal values: p/o= . ± . ; c/o= . ± . ). when the two analysis data were controversial the binding potentials were determined by another software (neurotrans d, mirage) that corrects the partial volume effect applying the talairach atlas as anatomical d reference. results: i-fp-cit spect was normal at qualitative analysis in / ( . %) patients without difference in both p/o and c/o ratio in respect of c, thus classifying these cases as affected by et. spect was pathological in / ( . %) cases; in of these, monolateral putamen uptake defects were ascertained in concordance with clinically evidenced site and p/o ratios ( . ± . ) in all involved putamen were significantly lower than in controlateral ones ( . ± . ; p< . ) and c (p< . ). bilateral defects were detected in the remaining / pathological cases, clinically classified as monolateral; however, p/o ratio was bilaterally low only in / cases with mean values significantly lower (p< . ) than c in both putamen (left: . ± . ; right: . ± . ) while, it was low monolaterally in the remaining / . however, in these latter, at d analysis, binding potentials were low bilaterally. all patients classified as pd underwent l-dopa therapy. conclusions: i-fp-cit brain spect may be useful in patients with clinically suspected resting tremor of recent appearance to clarify uncertain differential diagnosis between pd and et, thus permitting the most appropriate treatment. moreover, spect also gave more information on disease extension in respect of clinical data utilizing both qualitative and semiquantitative analyses, with d binding potentials evaluation obtaining higher performance in our cases. ) the placement of rois in basal ganglia not uniquely defined. these issues are most prominent in patients with low tracer uptake in the basal ganglia (advanced pd, candidates for surgery etc.), but also of importance in longitudinal studies. we propose an automated method relying on histogram analysis that does not involve operator interaction. materials and methods the algorithm exploits the pharmacokinetic feature of high target-to-background ratios of the ligands. simple histogram analysis of the image slices containing the basal ganglia and occipital cortex can reveal estimates for specific and unspecific uptake. the histogram analysis consists of parts: ) thresholding for extraction of brain pixels, ) calculation of the median pixel value in the brain as an estimate of unspecific uptake, ) calculation of the median of the pixels with the highest tracer uptake corresponding to the size of the basal ganglia. the algorithm was tested on fp-cit images from patients and compared to the manual "crescent roi" analysis. the parameter of interest was the ratio of uptake in the basal ganglia compared to the background. results in / datasets the agreement of the ratios was within . , in / datasets within . . datasets with "patchy" tracer uptake with areas of low uptake in the background region exhibited the largest differences. in one dataset, the algorithm failed to identify the slice with the basal ganglia. this dataset was excluded. conclusion despite its simplicity, the algorithm reproduces clinically reported results in most cases with good correspondence. deviations are prominent in cases with patchy unspecific uptake. in longitudinal studies the algorithm may provide valuable information as both inter-and intra-operator variance are removed. white matter normalization -a novel analysis method with improved sensitivity in pet perfusion studies of neurodegenerative diseases. p. borghammer , k. y. jonsdottir , a. gjedde ; pet center, aarhus university hospital, aarhus, denmark, center for integrative functional neuroscience, aarhus university, aarhus, denmark. aim: in pet studies of cerebral blood flow (cbf) and glucose consumption, the data analysis is complicated by the very large inter-subject variability. to overcome this problem, data normalization is often carried out by dividing each voxel in a subject scan with the global mean (gm). it is an often overlooked fact, that even subtle differences in global mean between the groups introduce bias into the analysis. we suggest, that normalization to white matter mean (wm) might improve analysis sensitivity and diminish the risk of creating artifacts. materials & methods: earlystage parkinson’s disease (pd) patients and healthy age-matched controls underwent cbf pet scans while resting. we employed both region-of-interest (roi) and voxel-based statistics. the analysis was carried out on non-normalized data and after normalization to gm and wm mean, respectively. the findings of these three analyses were compared. results: roi: no significant differences were found in absolute values of cbf in whole brain or any of the major lobes. after normalization to gm, pd patients had decreased cbf in parieto-occipital lobes, and in whole grey matter (all p< . ). after wm normalization, we found significant differences in the same areas and additionally in the frontal lobe (all p< . ). voxel-based: gm normalization yielded a single small voxel-cluster of significant decrease in the medial occipital lobe and a cluster of significant increase in left primary motor area (mostly white matter). wm normalized data disclosed much larger significant clusters of decreases cbf in occipital lobe and lateral parietal lobe bilaterally (p< . for all clusters), but no increases. conclusion: following wm normalization, significantly larger areas of cortical cbf decreases were detected than after gm normalization. conversely, only in gm normalized data, we detected increased cbf in pd. wm hyperactivity has been reported numerous times before in studies of pd patients. there is no basis or prior evidence for wm hyperactivity in animal models of pd. we propose, that the wm hyperactivity, reported in numerous pet studies of human pd, is an artifact created by wrongful normalization to gm, since gm is most likely decreased in pd, although this is rarely detected in the absolute data due to insufficient subject sample sizes. the wm normalization method seems to be more sensitive to detect expected (true) decreases and less prone to create artifacts such as wm hyperactivity. aim. i-fp-cit is a neuroreceptor tracer successfully used in diagnosing dopaminergic deficit in parkinsons' disease (pd) at an early stage due to the loss of dopamine transporter (dat). this study evaluates the possibility of making a more extensive and larger early diagnosis of the dopaminergic damage using semiquantitative analysis of i-fp-cit spect in patients with suspected parkinson's disease compared to only qualitative tests. methods. the study was carried out on patients with suspected pd. another people were involved as a control group, they were similar age-wise to the pd group and at follow-up months later essential tremor was evidenced and not pd. spect was carried out hours after the dat tracer had been administered. both qualitative and semi-quantitative analyses were performed in the region of the striatum in the patients studied. the semiquantitative analysis was made out and the patients with results superior to the standard deviation of the established range were selected. result. in patients out of ( %) a reduction of dat activity in at least one region of striatum was evident. visual analysis of the images diagnosed dopaminergic damage to the putamen controlaterally to the side where the symptoms were present in . %; to adjacent caudate nucleus in . % and damage to the base nuclei isolaterally to the symptoms in . %. while the semi-quantitative analysis gave the following results: . %, . % and . % respectively.conclusions. the results indicate that i-fp-cit spect allows a more accurate characterisation of the dopaminergic damage in patients with suspected parkinson's disease. g. p. sechi , s. nuvoli , v. agnetti , k. paulus , f. chessa , g. cocco , a. spanu , g. madeddu ; neurology dpt, university of sassari, sassari, italy, nuclear medicine dpt, university of sassari, sassari, italy. aim: in parkinson's disease (pd) patients we used i-fp-cit spect to investigate whether the tripeptide gsh may have an effect on dat, gsh ability to cross the blood-brain barrier (bbb) being still debated. material and methods: twenty consecutive pd patients (h-y stage - ) were studied, never been treated (group ) and on chronic carbidopa/levodopa and/or dopamine agonist therapy (group ). in all pd patients and in healthy subjects were performed: updrs motor battery and webster step-second test, and spect - hrs after mbq i-fp-cit (datscan, amersham ge) i.v. injection. spect images were evaluated both qualitatively and semiquantitatively calculating putamen/occipital (p/o) and caudate/occipital (c/o) ratios, normalized with phantom and compared to age matched normal controls (c) provided by processing software data. both group and group patients were treated for weeks with i.m. gsh therapy, μg twice daily, group maintaining basal treatment. after gsh, pd patients repeated spect and neurological tests comparing data to basal values. results: at the first observation, in involved putamen of group patients and in of group , p/o was low (< . ), with mean values, in the putamen, significantly (< . ) lower ( . ± . ) than the not involved putamen ( . ± . ), and those of healthy subjects ( . ± . ) and c ( . ± . ) ; no difference was ascertained between the latter groups. in all cases c/o was normal. after gsh therapy, there was p/o increase in / involved putamen with an increment percentage > in % of cases, mean values ( . ± . ) being significantly (p< . ) higher than basal values ( . ± . ); in / putamen p/o had no change and in the remaining / further decreased, but not significantly. in particular, an increment percentage > % there was in % of group putamen and in % of group . the not involved putamen had no significant change. updrs slightly improved in patients. conclusions: i-fp-cit spect proved useful to evidence that gsh therapy may increase putamen dat binding, particularly in never treated pd patients in our series, thus indicating bbb penetration of this tripeptide. a potential therapeutic role of parenteral gsh might be suggested in pd patients. objectives: many studies show changes of serotonin transporter (sert) in various neuropsychiatric diseases. sert is also the primary target for selective serotonin reuptake inhibitors (ssris), widely prescribed for the treatment of major depressive disorder and other mood and anxiety disorders. so, in vivo measurement of sert function is useful tool for studying pathophysiology of neuropsychiatric diseases. recently, as most valuable candidate for measurement of sert function, c- amino- -( -dimethylaminomethylphenylsulfanyl)benzonitrile ( c-dasb) was developed and showed its potential for evaluation of sert. use of c-dasb thought to be able to investigate various neuropsychiatric diseases, but age-related change of sert density is reported in normal cases. in this study, we tried to measure the density of sert with c-dasb in healthy volunteers, and evaluate the age-related change of sert density. methods: we studied sert activity in male subjects ( - y old) using c-dasb and pet brain imaging. pet examination was performed min after intravenous injection of c-dasb. regions of interest (rois) were drawn on mr images and pasted to corresponding pet slices. all subjects had also spect perfusion studies with m tc-ecd. three analytical methods without arterial blood sampling (the transient equilibrium, the linear graphical analysis, and the ratio of target to reference region) were used to estimate binding potentials (bps). cerebellum was used as the reference region in each method. results: bps obtained from each method had almost same values. test-retest reproducibility showed the verification of this study. a significant negative correlation was observed between c-dasb sert binding and age (thalamus: r = - . ; p = . , striatum: r = - . ; p = . ). decrease of c-dasb binding was approximately % per decade in thalamus. conclusion: in this study, we showed the age-related decline of sert in thalamus and striatum with c-dasb in normal subjects. these results indicate that c-dasb can apply for clinical studies on treatment of neuropsychiatric diseases using age-matched controls. background: the prevalence of depression in parkinson's disease (pd) is about % and the rate of depression is twice that seen in other disabling diseases. however, the pathophysiology of depression in pd remains obscure. regional brain changes have been demonstrated in non-pd patients with depression with the core perfusion deficit in bilateral parietal regions. objective: to determine whether pd patients with major depression exhibit differential brain perfusion compared to non-depressed pd patients. methods: we studied right-handed pd patients who fulfilled dsm-iv criteria for depression (dpd: females, mean age ± years, mean disease duration ± years) and right-handed non-depressed pd patients (ndpd: females, mean age ± years, mean disease duration ± years). diagnosis of pd was made according to the uk parkinson's disease brain bank criteria. all dpd and ndpd patients were in hoehn and yahr stage or and matched for age, disease duration and severity (updrs-iii). we excluded patients with dementia, cognitive and/or executive function deficits assessed by the mini mental state examination, the frontal assessment battery and the wisconsin card sorting test. the beck depression inventory (bdi) was used to quantify the severity of depressive symptoms. all subjects underwent resting state m tc-ethylcysteine dimer brain perfusion spect. statistical parametric mapping (spm ) was used for data analysis (p< . uncorrected). results: we observed hypoperfused regions in the left and right inferior frontal gyrus and in the left middle frontal gyrus; furthermore we found two areas of hyperfusion: the first one in the right thalamus and right hyppocampus and the other in the posterior cingulum, cerebellar tonsil and posterior lobe of left cerebellum. bdi mean score was ± for dpd and ± for ndpd (p< . , mann-whitney test); updrs-iii mean score did not differ between pd subgroups (dpd: ± , ndpd: ± ). conclusion: our analysis outlined that major depression in pd is associated with hypoperfusion of inferior and middle frontal gyri. the findings suggest that loss of dopaminergic innervation in pd might cause impairment of fronto-striatal circuits and which plays a key role in the manifestation of depression in pd. introduction obsessive-compulsive disorder (ocd) has been suggested to be a neurobiological disorder arising from abnormalities in the serotonergic system. despite the therapeutic efficacy of serotonin uptake inhibitors, evidence from neurobiological studies does not provide consistent evidence for serotonergic abnormality. converging lines of evidence suggest a role for dopamine in ocd. objectives to investigate the binding potential change of [ c]-sch to dopamine d receptors in patients with ocd. methods seven patients fulfilling the dsmiv criteria for ocd and seven age and gender matched ( +/- years) volunteers underwent a single minute dynamic positron emission tomography (pet) scan with [ c]sch ( +/- mbq) with a specific activity of +/- ci/mm. pet scans were co-registered to individual mri and regions of interest compared. from the individuals mri, a cerebellar grey-tissue was defined as the reference region. logan graphical analyses was performed and distribution volume ratios (dvr's) defined for caudate, putamen, anterior cingulate, orbito-frontal-cortex and thalamus. results significant reductions (p = . ) in d binding potential were found in the caudate nuclei of patients in comparison to controls. conclusion this study is the first demonstration of a dopamine d abnormality in ocd. the findings implicate dopamine in the neurobiology of ocd and may help explain neuropsychological and neuroimaging findings associated with the disorder. background: cerebral activity patterns are distinctly modified by clozapine and typical neuroleptics. however, no study has directly compared to date the brain activity patterns while treatment with clozapine and other atypical antipsychotics. this comparison could contribute to a better comprehension of its respective mechanisms of action. the aims of this study were to compare the regional cerebral blood flow (rcbf) patterns of a group of schizophrenic patients who were switched from risperidone to clozapine due to lack of efficiency and to assess the corrrelation between the improvement in symptoms and the perfusion changes. material and methods: we have studied patients ( males; paranoid and undifferentiated patients, according to dsm-iv criteria) with m tc-hmpao-spect imaging at baseline (after a chronic treatment with risperidone) and after a month of treatment with clozapine. patients were performing a stroop test paradigm minutes before and minutes after a bolus intravenous inyection of mbq of m tc-hmpao. spect images were analyzed with the spm (from the welcome dept. of cognitive neurology, london, uk) software package comparing baseline and after clozapine conditions. one-tailed significant threshold was set to p= . with a minimum extent of voxels. the correlation between the clinical improvement and the changes in rcbf was assessed with a spm general linear model using rank-transformed symptom scores and checking separately for direct and inverse associations. results: in comparison to the risperidone condition, brain perfusion with clozapina was significantly lower on the posterior orbital gyrus in the right side and on the ipsilateral parahippocampal gyrus. in addition, patients showed a higher perfusion as compared to risperidone on the inferior prefrontal cortex as well as on parieto-occipital region. positive symptom improved was directly correlated with the increase of activity in two frontal areas, left prefrontal and left premotor and the improvement in negative symptoms was directly related to the increase of perfusion on cerebellum and on visual association areas. however, no association was found between decreases in perfusion and clinical changes. conclusion: these data suggest that the effects of clozapine and risperidone on rcbf patterns during the perfomance of a cognitive test were quite distinct. the clinical changes correlated with the higher perfusion areas produced by clozapine. this may be consistent with the effectiveness of clozapine in patients that failed to respond to risperidone. hungary, department of nuclear medicine university of szeged, szeged, hungary. several data suggest the role of the dopaminergic system in depression, but the results with functional imaging are contradictory. the selective serotonin reuptake inhibitor (ssri) antidepressants are believed to mainly act by selectively binding to the serotonin, but some of the ssris also exhibit other neuropharmacologic effects. the aim of this study was to evaluate the dat activity of untreated patients with unipolar depression and compared to healthy volunteers. we also studied the effect of sertraline on dopamin transporter activity in depression. materials and methods: we performed overall i-fp-beta-cit-spect examinations in healthy controls (mini) and in depressed patients (dsm-iv), the inclusion criteria was a score of at least on the hamilton depression scale (ham-d, items). in age-matched healthy subjects and in patients baseline i-fp-beta-cit-spect investigations were done, in the depressed patient group the dat spect was repeated after weeks sertraline treatment. on the transversal reconstructed spect slices at the level of the basal ganglia, regions of interest were fixed by self-developed semiautomatic technique. the binding potential was estimated by the ratio of the specific to non-specific activity ({mean striatal activity-mean occipital activity}/mean occipital activity.) results: in the patients group, the median baseline binding potential was . (range: . - . ), in the control group, this value was . (range: . - . ). a mann-whitney u-test revealed that this difference was not statistically significant (z=- . , p= . ). in the patient group, the median binding potential after sertraline administration was . (range: . - . ), which indicates a decrease of % of fp-cit binding. ham-d scores showed % decrease after sertraline treatment. spearman's correlation indicated no significant relationship among binding potentials, ham-d scores, age, and education (p> . ). conclusion: we didn't find any significant difference in the baseline values of dat activity between control and untreated depressed subjects. the ham-d score showed decrease after treatment, which prove effectiveness of therapy. sertraline treatment decreased the dat occupancy ( %) but further investigations are needed to support this finding. aim: dopamine d receptor (d r) availability appears to be important in addictive behavior. for example, low striatal d r binding predicts high rates of intravenous cocaine self-administration in animals. the study of striatal d r availability in mouse models of cocaine addiction may therefore be important to unravel the role of the d r in addiction. additionally, endogenous dopamine release, induced by psychostimulants, may differ in drug-addiction. we recently developed a highresolution single-pinhole spect system to perform studies in small laboratory animals. in this study, we evaluated the feasibility to image d r and to assess dopamine release in mice using the d r antagonist [ i]ibzm and our pinhole spect system. materials and methods: male c bl/ j mice were scanned on our single-pinhole spect system [habraken et al. jnm ] . in this system, the mouse is tightly fitted in a cylinder which is positioned directly and horizontally above the pinhole aperture, and rotates during data acquisition. the pinhole collimator is connected to an adac arc © scintillation camera. a -mm pinhole aperture was used. all experiments were acquired, step and shoot, with a % energy window around kev in a x matrix, ror of mm, field of view . mm. reconstruction was performed using the feldkamp algoritm. images were analyzed with fixed rois for the striatum and cerebellum. in a first study, mice were injected intravenously with up to mbq [ i]ibzm and scanned continuously up to h p.i. ( frames of min.) to study the pharmacokinetics of the radiotracer ( studies in mice). in a second experiment, the feasibility to assess dopamine release was evaluated. nine mice were injected min. before ibzm injection ( mbq) with saline i.p., and acquisition was started min. ( timeframe of min.) after bolus injection of ibzm. approximately week later, the same group of mice was rescanned, but now the mice received . mg per kg body weight amphetamine i.p. min. prior to the injection of ibzm. results: injection of [ i]ibzm resulted in clear specific binding in the striatum, with highest specific to non-specific binding ratios min. after injection. in the second experiment, amphetamine induced a significant decrease in striatal ibzm binding ratios. conclusion: this study shows the unique possibility to image striatal d r and to assess endogenous dopamine release in the mouse brain. aim: quantitative assessment of functional pet data is attractive since it can lower variability across institutions and may enhance the consistency of image interpretation independent of reader experience. various quantitative indices have been suggested for functional brain imaging of the dopaminergic system including advanced kinetic models and simplified semi-quantitative measures such as the specific binding index (sbi) computed as the ratio of uptake in a region with specific receptor binding to a reference region. a common problem with these indices is their dependence on the reference region of interest (roi) and the spatial resolution of the imaging system. therefore, partial volume effect results in underestimates of this index compared to the true value. materials and method: a new index named the specific uptake size index (susi), which considers total uptake in the object not just activity concentration, was recently proposed and claimed to be independent of roi size and system resolution. the validity of this index is assessed in this work using pet images acquired from an anthropomorphic striatal phantom study and f-dopa studies of patients potentially suffering from parkinson's disease. for the latter, the external brain contour was drawn manually using the patient's coregistered mri to exclude the bony skull and cerebral border thus avoiding partial volume effect. the influence of roi size was assessed by drawing non-overlapping rois of different size around the striatum not necessarily covering the whole striatum. results: phantom studies showed that sbi measures based on maximum counts were . and . for right and left striatum, respectively, and proved to deviate considerably from the true value ( . ). the susi estimate is nearly constant in the striatum for rois greater than cm . below this volume, the susi estimates are not reliable. the clinical studies seem to report that the sbi derived from susi is always greater than the sbi derived from maximum counts in the rois. the sbi derived from susi that uses total uptake instead of maximum uptake is likely to be more accurate for small objects. conclusion: we have demonstrated using phantom and clinical data that the susi is approximately independent of the roi size allowing to guarantee good reproducibility of quantitative parameters estimates. significant increases and decreases of regional uptake were obtained using t-statistics at every voxel from patients and normal control groups. clusters consisting of a minimum of contiguous voxels with an uncorrected p< . were considered to be significantly different. results: the gmfcs scales of the spastic diplegia type cp patients were level in patients, level in two and level in one patient.the pyramidal tracts in the patients were grossly normal in terms of connectivity and white matter volume. [ f]-ffmz binding was increased in the motor and premotor areas and bilateral visual cortices. conclusion; altered gaba a receptor binding in the motor cortices might play a important role in the pathogenesis of motor dysfunction in spastic type cp as the gabaergic signaling in the motor and visual cortices plays an important role in the development of peri-lesional or use-dependent plasticity after brain damage. msa is a neurodegenerative disease that manifests itself with clinical symptoms of parkinsonism combined with cerebellar ataxia, autonomic failure and pyramidal signs. the form with predominant parkinsonism (msa-p) accounts for % cases and its differentiation from parkinson's disease (pd) is often difficult. the aim was to examine potential role of scintigraphy in differerential diagnosis of msa-p and pd using binding potential of the striatum for i-fp-cit (datscan) and i-ibzm to reveal complex dysregulations in dopaminergic transporter/receptor system. methods: the study has been performed in patients suspected for diagnosis of msa-p based on clinical criteria including mri and poor response to dopaminergic therapy (n = ), patients with verified pd (n = ), and age-matched healthy controls in order to obtain normal values of diagnostic indices with fp-cit (n = ) and ibzm (n = ). inclusion of individuals and their informed consent has been approved by ethical committee of the hospital. in patients, both fp-cit and ibzm examinations have been performed with the same administered activity ( mbq). control subjects underwent only one study, either fp-cit or ibzm. spect data have been recorded by triple-head gamma camera picker prism and dual-head gamma camera ge infinia-hawkeye. striatal binding capacity has been assessed visually and semiquantitatively as binding ratios striatal/occipital (sor) for fp-cit and striatal/frontal (sfr) for ibzm. results: in comparison with healthy controls, significantly reduced sor has been found in both msa-p and pd patients (p= . ) in nucleus caudatus and in putamen. however, no difference has been found between the two groups of patients. in patients with msa-p, there was no difference in density of presynaptic dtransporters between nucleus caudatus and putamen. in contrast, sfr has been significantly reduced in nucleus caudatus and in putamen in patients with msa-p with respect to healthy controls (p= . ) while no such difference was found in patients with pd. in of patients suspected for msa-p, diagnosis has been changed to pd due to normal density of d receptors in the striatum. in patients with msa-p, binding capacity for postsynaptic d receptors was reduced more in putamen than in nucleus caudatus (p= . ). conclusion: assessment of dopaminergic transporter density in striatum using only fp-cit is not sufficient to differentiate msa-p from pd. instead, complex information is required on the dysfunction of dopaminergic transporter/receptor system in the striatum that can be obtained by comparison of fp-cit and ibzm scans. aim: to evaluate the usefulness of calculating an specific uptake index (sui) and the i-ioflupane spect (datsp) cut-off points as a supporting tool to diagnosis. material and methods: we included patients ( men and women with an average age of ) who had a diagnosis of suspected essential tremor (et) vs parkinsonian syndrome (ps). all patients received datsp four hours after a dose of mbq loflupane -i . using a visual appraisal method, we clasified the patients into normal ( ), minor( ), moderate ( ) and severe ( ) . the quantification was made on two consecutive central transaxial views, drawing irregular and/or geometric regions of interest (rois) in striatum (str), caudate nuclei (c), anterior putamen (ap), posterior putamen (pp) and occipital. we calculated the sui using the following formula: counts in roi-counts in occipital/counts in occipital. we drew cor curves to determine discrimination cut-off points of pathological trouble. all data was captured and recorded in microsoft excel format, with analysis carried out using the statistical package, spss. results: the results from the visual appraisal method were normal, minor, moderate and severe patients. we calculated two discrimination cut-off points for the sui str of pathologic ( + + ) and severe ( ) with values < , (s %, e %) and < , (s %, e %) respectively. we also calculated two discrimination cut-off points for the sui pp of moderatesevere ( + ) and severe ( ) with values of < (s %, e %) and < (s %, e %) respectively. we related the sui in str, c, ap and pp and the differents pathological groups. we obtained statistically significant difference between the suiof the group and the rest. conclusion: quantification of the sui is statistically significant to differenciate the severe group from the rest. the calculation of the sui pp is more useful given its highest sensitivity and especificity. regarding to gender and age , there were no significant statistical differences found. the visual appraisal method continues to be, in our case, the best tool for diagnosis to differenciate between these type of patients than obtaining quantitative values. aim it has been demonstrated that [ i]fp-cit single photon emission computed tomography (spect) might be useful to characterize dopamine transporters (dat) loss in basal ganglia in parkinson's disease (pd), progressive sopranuclear palsy (psp) and lewy body disease (lbd) patients, but it is not capable to distinguish between these diseases. the aim of our study was to quantify serotonin transporters (sert) availability in the mesencephalic region of pd, psp and lbd patients by [ i]fp-cit spect. materials and methods patients ( age-matched pd, age-matched psp, age-matched lbd and age-matched healthy controls) were enrolled in this study. spect was performed in all cases after i.v. injection of mbq of [ i]fp-cit, using a double head gamma camera (infinia-ge). software coregistration of functional and morphological (mr) imaging data were then used to define regions of interest (roi) including mesencephal and the occipital lobe. the ratio of specific (mesencephal -occipital lobe) to non specific (occipital lobe) binding was calculated. results by semiquantitative analysis, the ratio of mesencephaloccipital lobe (specific) to occipital lobe (non specific) were different between pd (mean= . , range= . - . ), psp (mean= . , range= . - . ), lbd (mean= . , range= . - . ). when compared to controls (mean= . , range . - . ), were not different for pd. as compared with control values, the psp and lbd patients had a significant reduction of specific [ i]fp-cit binding in the mesencephalic region. conclusions our results suggest that sert in mesencephalic region can be used in diagnostic differentiation between pd, psp and lbd. our findings need to be confirmed in larger number of patients. objective: it is necessary to obtain an arterial blood sample to calibrate and individualize the standard arterial input function for regional cerebral blood flow mapping with iodine- -imp (imp) autoradiographic (arg) method (j nucl med ; : ) . the objective of this study was to propose an alternative method without blood sampling to estimate individual calibration coefficients for arg method. methods: if the individual difference in the brain distribution volume (vd) of imp is small enough, the calibration coefficients for the standard input function (cf: (kbq/ml) / (cps/g blood)) can be estimated from a product of cf and vd that can be obtained by -compartment model analysis of brain time-activity data using the uncalibrated standard arterial input function. to validate this method, consecutive patients with various cerebral diseases ( ± years old, m/f= / ) were studied with imp dynamic spect. imp ( mbq) was infused intravenously over min. immediately after starting the infusion, dynamic spect data acquisition ( rotations/ min) was performed. seven to ten minutes after starting the infusion, onepoint arterial blood sampling was performed to measure cf. by threshold percentages ( , , , %) to the maximum, the mean+ . sd and the mean+ sd of voxel count in the brain, twelve whole brain time-activity curves (tacs) normalized by the volume of interest given in kbq/ml were generated. each tac was fitted to compartment model using the uncalibrated standard arterial input function to obtain a product of influx rate constant (k : ml/min) and cf (cfk ), and efflux rate constant (k : /min). dividing cfk by k , the quotient (cfk /k ) gave a product of cf and vd (cfvd). the correlation between estimated cfvd from -compartment model analysis and measured cf from arterial blood sampling was investigated in a set of brain tacs. results: measured cf ranged from . to . ( . ± . ). in every compartment model fitting, cfk , k , and cfvd could be determined with small error of estimate. among the eight conditions for determining the brain border, the best correlation between estimated cfvd and measured cf was noted in the set of tacs determined by the threshold of % to the mean+ . sd of voxel count (cf= . cfvd + . , r = . , n= , rmse= . , p < . ). conclusion: in arg method, the calibration coefficients for the standard arterial input function could be estimated without arterial blood sampling, using proposed linear regression equation. brain death is present when all functions of brain stem have irreversibly ceased. before discontinuation of artificial ventilation and organ harvesting the instrumental confirmation is necessary in addition to neurological findings. authors present own experiences with brain perfusion scintigraphy in the diagnosis of brain death. patients and method: brain scintigraphies for confirmation of clinical diagnosis of brain death in patients ( male, female, in age - years) were performed in the years [ ] [ ] [ ] [ ] . patients were examined as potential donors of organs, seven from other reasons. about mbq of mtc-hmpao was injected as bolus to central vein. dual-head spect gamma cameras with lehr collimators for acquisition of the date were used. flow images ( s per frame) were acquired from the time of tracer injection to one minute. planar images in four projections or spect of the head were obtained subsequently. in brain death flow images show completely absent of the blood flow superior to the circle of willis circulation and planar images or spect demonstrate no radiopharmaceutical uptake in the whole brain. results: in patients the brain death was unambiguously confirmed. in two patients (a female after cerebellar hemorrhage and a male after suicide of hanging with repeated scintigraphy after h) had brain perfusion partly preserved and brain death was not confirmed. we did not find mismatch between dynamic and static images. no side effects were observed. conclusions: cerebral perfusion scintigraphy is simple, reliable, safe and cost-effectives method for confirmation of irreversibility of clinical signs of brain death. the great advantage against x-ray angiography is exactness of findings also in cases of head injury and after craniotomy. other advantage of perfusion scintigraphy is non-invasivity and there is no fear of damage of organs for transplantation due to injected x-ray contrast substances. aim: to determine whether age-matched normal database (ndb) is necessary for the detection of alzheimer's disease (ad) using brian fdg pet and automatic image analysis. material and methods: we generated age-specific ndb sets ranging in age from yr to yr; each consisted of males and females. in order to assess the diagnostic performance using these ndbs to distinguish ad patients from normals, patients ( males, females; mean age, . ± . yr) with probable ad and normal subjects ( males, females; mean age, . ± . yr) were recruited. the image analysis was performed using neurostat. the changes of relative fdg activity with age were measured for the posterior cingulate gyri and precunei (pcgp). a receiver-operating characteristic (roc) analysis was performed for comparison of the diagnostic accuracy using these ndbs. results: there was no significant difference in area under the roc curves (az) for the discrimination of ad patients from normals (table) . furthermore, there was no significant correlation between the relative fdg activity in pcgp and age. conclusions: our results indicate that age-specific normal database for fdg pet may not be necessary for the detection of ad. this could be explained by the lack of significant correlation between relative fdg activity in pcgp and age. aims: anatomical imaging methods, especially computerized tomography (ct) and magnetic resonance imaging (mri) are helpful in diagnosis of acute traumatic brain injuries (atbi) however, they are not as efficient as single photon emission computed tomography (spect) for the diagnosis of traumatic brain injury with chronic symptoms (tbics). our aim was to compare brain perfusion spect and ct or mri findings in patients with a history of thics being followed for more than one year. material and methods: ninety two patients fulfilled the criteria to enter our study. sixty-two of these patients had a history of a mild brain disease (group a) while the remaining cases had a history of moderate to severe brain disease (group b) .the age of our patients ranged between - y, with mean age . ± . y. the mean post-traumatic period was . ± . y. these patients presented with various neurological signs and symptoms especially due to hypofrontality and hypotemporalism. brain perfusion spect with m tc-ecd and ct or mri were obtained in all patients with a maximum interval of one month between each procedure. in our study, the brain was divided into ten areas five regions in each hemisphere. the spect, ct and mri images were interpreted separately by two nuclear medicine physicians and two radiologists who were blinded to all study results. results: out of a total of brain regions, brain perfusion spect revealed lesions ( %) while, anatomic modalities ct or mri detected significantly less lesions ( . %) (p< . ). conclusion: brain perfusion spect may be more useful than anatomic imaging procedures in identifying tbics, especially in patients presenting with symptoms of hypofrontality or hypotemporalism. brain perfusion spect can be effectively used to identify the chronic complications of remote traumatic brain injuries. effect of aerobic training on tc m-sestamibi uptake by rat brain: evidence for exercise augmentation of the blood-brain barrier (bbb) function ? introduction-aim: bbb effectively contributes to brain homeostasis maintenance. tc m-sestamibi does not enter normal brain and its uptake is very low. cerebral capillary endothelium, a major bbb component, is characterized by a five-fold mitochondrial content compared to capillaries of systematic circulation. high mitochondrial density is potentially related to increased pumping energy demands of the bbb. mitochondria are also a known subcellular target of tc m-sestamibi. moreover, p-glycoprotein, a membrane efflux pump, using tc m-sestamibi as substrate is abundant on bbb. this study investigates the impact of the aerobic trainning on brain uptake of tc m-sestamibi and a possible explanation is discussed animals and methods: twenty-four adult male wistar rats were allocated to a trained (n= ) and an untrained (n= ) group. endurance exercise on a motor-driven treadmill had the following characteristics: speed m/min for min, days/wk for weeks. on completion of the training program, tc -sestamibi ( . mbq/kg body weight) was administered i.v. to all animals. two hours after injection, heart, brain, blood and various skeletal muscles of the hindlimbs were removed. tc m-sestamibi uptake was calculated, after activity measurement in a well-type counter, as % of injected dose (id) per tissue gram. differences between trained and untrained rats were assessed for significance at p< . level by the independent student's t test. results: tc sestamibi uptake in both myocardium and skeletal muscles of trained animals was significantly higher than that of untrained, thus evidencing the effectiveness of the exercise scheme.tc -sestamibi uptake was very low in brain, comparable to blood levels. however, uptake in trained rats was about double than in untrained: . vs . %id/g, p< . . conclusion: despite being low, tc -sestamibi uptake in rat brain is increased after a period of aerobic training. both accelerated fuel transportation and increased prohibitive activity against various exercise-related metabolic products by the bbb during repeated exercise bursts, may induce mitochondriogenesis in bbb endothelium, thus explaining increased tc -sestamibi uptake in trained animals. the purpose of this study was to investigate the neurological variables associated with chronic traumatic brain injury in amateur boxers. material and methods: cerebral perfusion changes were evaluated using technetium- m hexamethylpropyleneaamineoxime single photon emission computed tomography (tc- m hmpao spect). spect were performed in boxers and healthy volunteers. images were acquired using a dual-headed gamma camera equipped with high resolution parallel-hole collimators. quantitative analyses were done using brain spect assessment tool in general electric xeleris work station (neurogam). results: analysis of tc- m hmpao spect images showed that the boxers had more cerebral perfusion changes than healthy volunteers. all cortical areas showed decreased blood flow especially in frontal and temporal areas in boxers. conclusion: in conclusion, the results showed that tc- m hmpao spect could be helpful to investigate cerebral blood flow abnormalities in amateur boxers and differences from healthy volunteers. cerebral perfusion changes should be taken into consideration in evaluating boxers having any neurological symptoms. the difference of brain fdg uptake pattern between health adults and cancer patients m. si, j. liu, g. huang, x. sun; renji hospital, shanghai jiaotong university, shanghai, china. aim: to determine the difference of brain fdg uptake pattern between health adults and cancer patients. material and method: the brain fdg uptake patterns of patients who performed pet/ct scan in our center from aug. to dec. .were retrospectively studied. the inclusion criteria is: ( ) absence of clear focal brain lesions (epilepsy, cerebrovascular diseases etc). ( ) absence of metabolic diseases, such as hyperthyroidism, hypothyroidism and diabetes. ( ) absence of psychiatric disorders and abuse of drugs and alcohol. ( )cancer patients were diagnosed definitely of variable cancers except brain cancer or brain metastasis. the normal group consists of subjects for tumor screen and got negative results. the age is ranging from to yr. the cancer group consists of various cancer patients. the age is ranging from to yr. both groups were sub grouped into six starting from years old with the interval of years old, and the gender, educational background and serum glucose were matched. all subgroups were compared to the subgroup of normal - years old called control subgroup ( subjects). the t-statistic analysis was applied to all brain images using the spm software. results: with the increasing of age, similar hypometabolic brain areas are detected in both normal group and cancer group ,they are mainly in the cortical structures such as bilateral prefrontal cortex, superior temporal gyrus(ba ),parietal cortex (inferior parietal lobule and precuneus(ba ),insula(ba )),parahippocampal gyrus and amygdala(p< . )and are especially apparent in the prefrontal cortex(ba )and sensory-motor cortex(ba , )(p< . ). but characteristic hypometabolism in cingulate gyrus and bilateral cerebellum are only seen in cancer group.compared to the same age interval of normal subgroup, each cancer subgroup shows significant hypo-metabolism in cingulate gyrus (p< . ),as well as bilateral cerebellum and basal ganglia(lentiform nucleus and thalamus)(p< . ). conclusions: relative hypometabolism in limbic system such as cingulate gyrus and basal. fahr's disaese is a rare of unknown aetiology disorder characterised by massive symmetrical calcifications of the basal ganglia, dentate nuclei and subcortical white matter. although the clinical pattern of fahr's disease is variable; neurobehavioural, cognitive, extrapyramidal-cerebellar symptoms, dementia, seizures and speech disorders are most common clinical features. clinical and ct scan examination is enough for diagnosis. in the literature there is no study performed to evaluate the value of hmpao brain perfusion spect in fahr's disease to the best of our knowledge. the clinical, ct scan and hmpao brain spect findings of a years-old woman with fahr's disease is reported. the patient presented to a neurologist with difficulty to use the upper limbs bilaterally (more prominent of the left side) and reduced movement ability six years ago. on neuropsychiatric examination; a mild deterioration of frontal functions was mentioned and computed tomography showed no abnormality. when symptoms progressed she was reevaluated and a non-enhanced ct scan revealed extensive, symmetrical intracranial calcifications involving the dentate nuclei and white matter of cerebellum, globus pallidus, putamen, caudate nucleus, internal capsule, thalami and centrum semiovale. serum levels of ionised calcium, phosphorus and parathyroid hormones were within normal range. she had no family history and was diagnosed as idiopathic sporadic fahr's diasease. spect images did not demonstrate perfusion abnormalities in all calcification foci visualised bilaterally on ct scan. hmpao brain perfusion spect images showed hypoperfusion in the left visual centre compared to that of right side and perfusion defect in the right basal ganglion. spect images did not demostrate perfusion abnormalities in all calcification foci visualised bilaterally on ct images. spect findings were not only congruent with the coresponding ct scan abnormalities but also correlated more specifically with the clinical findings. this case suggests that hmpao brain perfusion spect is useful in the clinical approach of fahr's disease providing more specific and clinically relevant information as compared to anatomical imaging. chronic fatigue syndrome (cfs) is an heterogeneous disease: disabling fatigue lasting at least months and accompanied by numerous rheumatological, infectious and neuropsychiatric symptoms. nowadays there is not a test with enough sensitivity or specificity to constitute a reliable diagnostic tool. aim: to describe the usefulness of brain perfusion spect in the evaluation of patients with chronic fatigue syndrome (cfs), comparing the basal brain perfusion pattern with the cortical changes after physical exercise and a mental test. material and methods: thirty-five patients ( female, mean age years) with clinical criteria of cfs (holmes and fukuda) were included. all of them underwent a m tc-ecd brain perfusion spect ( mbq, double-headed gammacamera) in basal condition and after a stress test. the study consisted in physical exercise in the morning and injecting the tracer at the middle of a neurocognitive test (wais modified) in the afternoon. all the brain spect were blindly evaluated by experts, using a semiquantitative score: normal uptake (score ), slight hypoperfusion (score ), mild hypoperfusion (score ) or severe hypoperfusion (score ). cortical areas: frontal, temporal, parietal and occipital. results: patients showed a normal brain spect in basal and stress condition and patients ( . %) showed decreased perfusion in both studies, without changes in the intensity and localization of perfusion deficits. in patients ( . %) changes in perfusion were appraised: eighteen ( . %) showed decreased perfusion after psychological test with regard to basal condition (p= . ). frontal and temporal lobes were predominantly involved. eight patients ( . %) showed improvement in brain perfusion after the neurocognitive test (p= . ). conclusion: our results showed a high percentage of blood flow impairment in cfs patients, which worsened after a combination of physical and stress-mental test. brain perfusion spect might be a useful tool to improve diagnostic approach to an elusive illness such as cfs. the use of an objective neuroimaging method may help in the characterization and monitoring of brain perfusion abnormalities in cfs. the intoxication has adverse effects on health: digestive, endocrinologic and neurologic symptoms. these symptoms are unspecific (dizziness, asthenia, itchy sensation..) and often difficult to distinguish from a functional disorder. the aim of this work was to evaluate the brain perfusion changes in patients exposed to organophosphorate compounds. material and methods: nine patients (p) ( women; aged - years; mean age: ) with chronic exposure to organophosphorates were included. brain perfusion spect ( mci m tc-ecd) was performed in all p using gems vg, hawkeye gamma camera and fan beam collimator. brain perfusion was analysed in all patients using spm program and comparing each patient with a healthy control group. in all cases neuropsychological test, electroencephalogram, ct scan were also obtained. results: in p the brain perfusion was normal. the remaining showed hypoperfusion in different brain areas: p (parietal lobe - right; left-); p (posterior frontal); p (right mesial temporal); p (posterior temporal, anterior and temporo-parietal). conclusions: in of the patients exposed to organophosphorates spm detected significant brain hypoperfusion. the cerebral lobe involved was variable. further studies are necessary to confirm these results. recently, the physikalisch-technische bundesanstalt (ptb) and the company aea technology (now: qsa global) organized a joint national comparison of m tc solutions in order to obtain information on the quality of routine activity measurements in nuclear medicine in germany. the participants were asked to measure the activity in p -type glass ampoules and in syringes. the results and supplementary information on the instrument characteristics, uncertainties, radionuclidic impurities and steps for quality control had to be stated in a questionnaire prepared by the organizers. in this contribution, the m tc comparison results for two different geometries are presented and compared with results of previous comparisons. in particular the distribution of the deviations (a i -a i, ref )/a i, ref with the activity a i stated by the participants and the ptb reference activity a i, ref were analyzed. about % of the results fulfil the limitations prescribed by the european pharmacopoeia [ ] , i.e. the deviation to the reference value is less than ± %. the data clearly indicate a considerable reduction of the deviations compared to results obtained in previous comparisons [ , ] . in spite of this improvement there is still a considerable number of results which do not comply with the ± % criteria. these data were carefully analysed to detect potential causes for discrepancies and to find steps for further improvements of the quality in nuclear medicine. after a period in which the results of all participants were collected, all of them obtained a calibration certificate stating the reference activity value from the ptb. this document can be used as an important tool for quality control in the respective institute. [ (t) time from the elution to the labeling. test anova (p = . < . ) indicates significant differences and test of bonferroni specifies that these occur between group with respect to and , and do not occur between groups and . conclusions the increase of the rcp in groups and indicates that can be used eluents with a time over to hours, unlike at the specified in the technical leaflet of the ceretec®. this radiochemical can be used in the leukocytes labeling without decrease in its efficiency. aim the development of m tc-labeled infection imaging agents will contribute in the differential diagnosis of infection versus aseptic inflammation. currently, there are several formulations for the labeling of fluoroquinolones with tc- m that show contradictory data. our aim was the development of tc- m analogs of fluoroquinolones (norfloxacin and ciprofloxacin) of well-defined structure as well as their biological evaluation in vitro and in vivo. materials and methods fluoroquinolones, fq (norfloxacin and ciprofloxacin) have been functionalized at the n atom of the piperazine ring, by conjugation on suitable bifuctional chelators, n, n-( -picolyl)amino-diacetic acid (pada) and l-cysteine to form o-c h n-ch n(ch cooh)ch co-fq (fq-pada) and hoocch(nh )ch sch ch ch -fq (fq-cys) respectively. fq-pada and fq-cys reacted with [ m tc(co) (h o) ] + ( . ml, - mci) and produced two types of neutral m tc complexes, fac-[ m tc(co) (fq-pada)] and fac-[ m tc(co) (fq-cys)]. in vitro studies were performed, by incubating these m tc complexes with x cfus of s. aureus and e. coli. in vivo studies were performed by injecting μci of the m tc complexes via the tail vain in mice. results and conclusions the m tc complexes synthesized were analyzed by hplc and showed, in all cases, the formation of one radioactive species. in vitro studies of the m tc complexes resulted in - % binding in s. aureus, while the binding to e. coli was found to be lower for all the compounds tested ( - %). in vivo biodistribution studies in mice ( and min p.i.) showed that all the compounds present fast blood and soft tissue clearance. preliminary studies showed that only small percentage of activity accumulates in muscles with induced aseptic inflammation (turpentine oil, negative control) resulting in an inflammation to normal tissue ratio . . further in vitro and in vivo evaluation is in progress, in order to prove the potential radiopharmaceutical use of these novel technetium- m compounds as specific infection imaging agents. aim: the application of the heart-lung machine in human medicine implies the sideeffect of activated granulocytes which may cause inflammatory processes in the human organs. for this reason tc- m hmpao labeled granulocytes were used to localize the inflammatory process in pigs. imaging was performed to determine the distribution of tc- m hmpao labeled granulocytes in the organs and thereby the state of inflammation. material and methods: domestic pigs aged about month weighing - kg were examined. after gradient centrifugation of ml venous blood from the animal to isolate the granulocytes for labelling with - mbq tc-hmpao, the labeled granulocytes were then reinjected into the pig following thoracotomy. imaging was performed after at least hours of incubation time with a dst-xli gamma camera (ge). in each case a whole body scan (ap; scan speed cm/min) was carried out and in some cases spect imaging ( projections; acquisition time s/step). for quantification the geometric mean of the corresponding roi's over the liver, spleen, lung and brain of the anterior and posterior view of the whole body scan were obtained. the count rate was correlated to the administered activity and the weight of the animal. as reference organ the liver was selected. e.coli lps induced inflammations were generated as a positive control. results: the main part of the activity is located in the liver ( %). the activity in the spleen is decreased by a factor , and the activity in the brain is reduced by a factor in comparison to the liver. partly found unexpected high count rates in the lung were related to pneumonia of the animals. artificially generated inflammations were well displayed. conclusion: this method is basically suitable for inflammatory process imaging in pigs. the presented model is herewith suitable to answer questions concerning inflammatory process imaging in human medicine. the animals should be pre-treated with antibiotics in individual cases to preclude unspecific activity enhancement if applicable. introduction: the recommended method (meth ) to determine the radiochemical purity (rcp) of tc- m tetrofosmin (tfos) involves developing an itlc-sg strip in dichloromethane:acetone ( : ). in this system, colloids and hydrophilic impurities remain at near origin, free pertechnetate (tco ) runs near the front, and tfos migrates with an rf of ~ . . the disadvantages of this method include the need to prepare a fresh mixture of volatile solvents daily, sensitivity to spot size, and slight variations in the rf of tfos which result in falsely low rcp values using the cut and count technique. an alternative method (meth ) developed for rcp testing of tc- m sestamibi (proulx et al, appl radiat isot ; : - ) has now been validated for tfos. methods: meth uses two strips of itlc-sg developed in -butanone and saline, respectively. in -butanone, insoluble impurities and tc- m gluconate intermediate (gluc) remain at the origin while tfos and tco migrate near the front, whereas in saline the impurities tco and gluc migrate with the front and the remainder stays at the origin. rcp is calculated as % minus the two impurity measurements (note that gluc is double counted, however it is a very minor component). meth was compared with meth on samples of tfos and impure mixtures with free tco , colloid, and/or gluc added. a preparation at high radioactivity concentration without oxygen venting was used to produce an additional impurity. results: with clinical preparations of tfos there was no significant difference in rcp measurements: meth . ± . %, meth . ± . % bound, n= ; paired t-test p=ns. with impure mixtures ( . - . %) the regression line had the equation: rcp(meth ) = . rcp(meth ) + . , n= , r = . . most importantly, in the critical region around the % cutoff, the meth produced results ~ % lower than meth . in the period during which meth has been in routine use, it has detected one product failure and the result was confirmed by meth . during this period the mean rcp was . ± . % (n= ). conclusions: this report presents validation of a new method for rcp testing of tfos which is rapid, uses standard solvents and media, does not require daily preparation of a mixture of volatile solvents, provides clear and reproducible separation between impurities, and can also be used with sestamibi. aim: quality controls on renal scintigraphic agent m tc-mag prepared following procedures recommended by manufacturer, in our experimental conditions, gave poorly reproducible radiochemical purity results and often below the minimum acceptable. for this reason we investigated if modification of physical and chemical variables involved in preparation and storage could enhance m tc-mag radiochemical purity. material and methods: parameters involved in this study were the following: time elapsed between elution and labelling, age of the technetium generator column, opposite sequence of dilution and heating steps, activity/volume ratio for labelling, duration of heating and storage temperature of labelled drug. moreover, we aimed to study m tc-mag stability beyond four hours from labelling. quality controls were performed immediately after labelling, at minutes, at , , , , hours and in some experiments till to hours. as analytical technique a double paper chromatography (whatman n. ) was choosen, eluted with acetone to separate free pertechnetate and with acetonitrile: water ( : ) mixture to separate reduced hydrolyzed technetium. results: dilution after labelling is not recommended. storage at °c did not prolong stability, so it is also not recommended. the following parameters did not influence labelling yield and stability of m tc-mag : time elapsed between elution and labelling, age of technetium generator column, prolonged heating. labelling with innovative activity/volume ratio ( . gbq in . ml) constantly gave higher radiochemical purity results compared to recommended ratio ( gbq in ml). beyond, it was demonstrated for both labelling procedures a prolonged stability of m tc-mag till to hours after labelling. conclusion: m tc-mag chelation complex demonstrated an high physical chemical stability significatively influenced only by activity and volume used in labelling procedure. labelling with . gbq in . ml allows preparation of an higher number of doses from the same kit and the execution of diagnostic procedures requiring higher activities than conventional. finally, if evidences emerged from this study about m tc-mag prolonged stability will be confirmed by other experiments, it would be possible to administrate it till to hours after labelling, a double time compared to hours time interval recommended by manufacturer. aim: sodium iodide- is well known as a radioisotope that is used for studies of the thyroid and its metastases. i labelled compounds are used for kidney, heart and brain studies.since demand for i- is increasing a serious effort for production of i- has performed. material and methods: for production of i, a home made target was designed. the main part of the target contained; conical target vessel that was mounted in an aluminium cylinder of length cm and diameter . cm for water cooling during bombardment. front and rear target windows made by titanium foil and cooling system. in addition, some other part such as a cold finger, decay vessel, vacuum pump and four fingers also designed and installed on the system. i was produced from the reaction of mev protons with . % enriched xe with cyclon- . bombarded xenon was transferred to the vessel and stored there up to about hours to allow cs decay to i with the maximum efficiency. the remaining xenon gas was then transferred into the reservoir capsule using a cryogenic technique. the produced, i which is deposited on the wall of the decay vessel, was rinsed out by dissolution in . μs water at ºc. nitrogen gas pressure was used for the transfer the i solution to the chemical hot lab. the ph, and adjusted with sodium hydroxide. results and discussion: a sample of production was send to quality control. quality control results were in good accordance with the united states pharmacopoeia conclusion: using this system with the above specification, the production yield could be increased by increasing the current. the results shows no chmical or radionuclide impurity, and enable to produce i- withouht any more purification step. aims: in order to overcome the limitations of the reported methods, a short and simple method for the preparation of radioiodinated n-succinimidyl- -iodobenzoate that is widely used for radioiodination of antibodies is described. material and methods: the method involves the reaction of in situe generated trimethylsilyl radioiodide from trimethylsilyl chloride with n-succinimidyl- -[ , ( , -butanediyl)-triazene]benzoate available from the condensation of n-hydroxysuccinimide and -( -carboxyphenyl)- , -( , -butanediyl)triazene in the presence of dicyclohehyl carbodiimide. the recent triazene was prepared by precipitating the diazonium ion of -aminobenzoic acid with pyrrolidine. a microwave-mediated rate acceleration was observed during the radioiodination step. results: activation of radioiodination reaction by exposure to microwave irradiation (in a domestic oven at mhz for minutes) afforded the radioiodinated product in % radiochemical yield. conclusion: when compared with alternative methods, the present approach, which reduced the reaction sequence until steps was faster and the method required less expensive reagents and purification was easier. aim: transarterial chemoembolisation (tace) is a promising approach in the therapy of malignant, hypervascularized liver tumors. developing and optimizing radioiodination reactions and adding the labelled product to an original drug-deliveryembolisation-system was the main goal of this present investigation. this may help to determine an individual, pharmakokinetical parameter and possibly will increase therapeutical effects in prospective animal and human studies. material and methods: in a first step iodogen ® as radioiodination agent was used for labelling anthracycline analogs (doxo-, epi-. dauno-, iododoxorubicin). the labelled products were characterized and separated by hplc (radio-and diodenarray-detektor) and tlc. in a next step another direct electrophilic radiolabelling [iodine monochloride (icl) methode] with c.a. i- -nai and i- -nai ( °, min) has been performed. the subsequent hplc-isolating was changed by spe (sep-pak c -cartrigde). after removing the solvent the product was solubilised in . % saline solution. results: the radiochemical yield (rcy) with iodogen-method was ± %. in comparison to that the iodine monochloride method achieved higher rcy's for doxo-( ± %), epi-( ± %), dauno-( ± %) and iododoxorubicin ( ± %). in vitro stability of all products was controlled after h. specific activity lay around mbq/μmol. conclusions: the direct iodination method with icl was proved to be a viable labelling possibility of anthracycline analogs. specific activities are very low, but these results are sufficiently working in case of use in combination with unlabelled therapeuticals in a chemoembolisation system. higher rcy's of iododoxorubicin can be explained by isotopic exchange. after validation of radiolabelling conditions and results the chemoemolisation system with radiolabelled anthracycline and the sterilisation of the used materials needs further investigation. this could lead to a proved method for nuclear medical imaging of a radio-chemoembolisat for locoregional application. the development of new pet radiopharmaceuticals demands strategies for the identification of dedicated targets. following the identification of a target, the "in silico" search for substrates is a promising approach to achieve specific drugs. methods: the search for targets for new radiopharmaceuticals demands the use of large scale gene expression data, usually obtained by gene array techniques. we used gene array data, obtained from tissue specimen ( human tumors, reference tissue samples) to search for differencially enhanced genes, in order to identify possible targets for new radiopharmaceuticals. furthermore, ten samples from a human colorectal cell culture line were evaluated. gene expression data were obtained using the u a and u plus . gene chip (affymetrix inc., santa clara, ca, usa). gene expression values were converted to relative expression values (rev): rev = * (gene expression value -minimum expression value) / (reference gene expression -minimum expression value). the genepet module of the pmod software (pmod technologies ltd., adliswil, switzerland) was used for data evaluation. the fast rigid exhaustive docking (fred) software (openeye scientific software, santa fe, nm, usa) was used to assess receptor/ligand properties. results: the gene expression data comprised (u a) or (u plus . ) probe values for each tissue sample. following normalization, matrices were calculated for the ratios tumor/reference tissue as well as for the mann-whitney test variable of each gene. search strings were applied to select those genes related to receptors and cell membrane proteins. furthermore, discriminant analysis based on the support vector machines method (svm) was used to select those genes from the subgroup which provide the best discrimination between tumor and normal tissue. the final svm analysis provided genes related to cell receptors, mainly belonging to the group of g protein-coupled receptors. following the identification of targets, the fred software was used to assess possible substrates for these receptors. conclusions: molecular biological data, obtained by gene array analysis, provide a promising approach for the development of new pet radiopharmaceuticals. the combination with computational drug software helps to select a subgroup of substrates for receptors and membrane structures, which are then further evaluated using conventional lab procedures. aim several radiolabelled amino acids have proven to be useful as a radiopharmaceutical substance for pet imaging of tumors. o-( -[ f]fluoroethyl)-ltyrosine (fet) seems to be one of these promising compounds. this f-labelled amino acid can be synthesized with high radiochemical yield. large production and distribution is allowed by using f. fet provides excellent quality for pet imaging of solid gliomas in brain. from these points of view fet is the right choice for our interest. the synthesis of fet is known, however, modification of the method for our facilities was necessary. the aim of this study was to adapt synthesis method in order to start production of fet as a commercial pet imaging tracer. materials and methods the synthesis was performed with tracerlab mx system (coincidence), which is originally designated for production of [ f]fdg. therefore, some modifications in method had to be done. synthesis is based on phase transfer mediated nucleophilic f-fluorination of o-( -tosyloxyethyl)-n-trityl-l-tyrosine tert.butylester with subsequent hydrolysis by mixture trifluoroacetic acid / , -dichloroethane. subsequently, purification of reaction mixture was completed by reversed phased hplc. quality control was done with hplc for radiochemical and enantiomeric purity. results because the production automat did not resist the mixture trifluoroacetic acid / , -dichloroethane, we changed the deprotection step and applied m hcl. the fluorination yield ranged from to % and overall yield was - % (uncorrected for decay). radiochemical purity was over % and enantiomeric purity was %. conclusion we successfully developed and tested the synthesis of [ f]fet in our production conditions. nowadays we are providing biodistribution and preclinical studies with animals. finally, we are intended to distribute fet to medical facilities. acknowledgement this work is supported by the project no aim: evaluation of a ge/ ga generator to produce carrier free ga radionuclide and optimization of a synthesis method to obtain ga-dotatoc for clinical purpose. materials and methods: imaging of sstr expressing tumours, such as neuroendocrine, lymphomas, meningiomas and breast cancers, has been greatly improved by utilization of ga-dotatoc radiopharmaceutical and positron emission tomography. in this study ga-dotatoc was synthesized from a mci ge/ ga generator (cyclotronco., obninsk, russia) carrying out the following steps: i) ga in cationic form ga + was eluted from the generator by a . m hcl solution and trapped in a cation exchange cartridge. ii) metallic and radionuclidic impurities, such as fe (iii) and zn (ii) were washed to waste by rinsing the cartridge with a % acetone / . m hcl solution. iii) ga + was eluted to the reactor with a % acetone / . m hcl solution and reacted with nmol of dotatoc in a no buffered water solution. ge (iv) breakthrough and ti (iv) impurities remained in the cartridge and were subsequently eluted to waste by m hcl and water iv) after labelling, in order to eliminate not reacted ga + , the crude solution was passed in a apolar c cartridge where ga-dotatoc was trapped. v) final product was eluted by ethanol and diluted with an appropriate amount of saline solution for the final formulation. during the validation of the method a complete set of quality controls including radiochemical purity by radio-tlc and radionuclidic purity by -spectrometry was performed; sterility of the preparations was also assessed. results: about syntheses were carried out during six months of activity and an amount ranging between to mbq (depending on the ge/ ga generator life) of ga-dotatoc was obtained. mean synthesis yield was computed to be ± % (not corrected for decay) in a synthesis time of about minutes. radiochemical purity was about % and highest radiochemical impurity resulted in free ga + not reacted ( ga-dotatoc: r f = . free ga + rf = . ). radionuclidic purity was observed to be greater than . % and final solution resulted sterile. conclusion: after elution in cationic form and the purification steps described, ge/ ga generator can be considered a safe source of pure ga for high yielding labelling of peptide or other molecules. ga-dotatoc produced with this method can be efficiently utilized in nuclear medicine department for clinical evaluations. synthesis and biological evaluation of c-labeled acyclic-and furo[ , -d]pyrimidine derivative of bicyclic nucleoside analogs (bcnas) for structure-brain uptake relationship study of bcna tracers s. k. chitneni, j. balzarini, a. verbruggen, g. bormans; katholieke universiteit, leuven, belgium. we recently synthesized and evaluated several bcnas labeled with c- , f- or i- as potential pet or spect tracers for non-invasive imaging of varicella-zoster virus thymidine kinase (vzv-tk) gene. these studies resulted in a new reporter gene/probe system but none of these tracers were taken up in the brain in biodistribution studies despite fulfilling the theoretical requirements for passive diffusion of such molecules through bbb. we have now synthesized and evaluated a c-labeled bcna ([ c]-( )) with a hydroxyethoxymethyl side chain instead of a deoxy ribose sugar for bcnas, and a bcna without sugar moiety ([ c]-( )). methods: the precursor compounds ( ) and ( ) were synthesized by sonogashira coupling of -iodo- -[( -hydroxyethoxy)methyl]uracil and -iodouracil, respectively, with -hydroxyphenyl acetylene, followed by cyclization in situ. they were converted to non-radioactive ( ) and ( ) by methylation of the phenol for ( ) and at the n- of the pyrimidine ring for ( ) using ch i in the presence of k co in dmf. the radiolabeling was achieved using [ c]methyl triflate. the methylation products were purified using c- semi-prep hplc. the affinity (ic ) of the non-radioactive compounds for vzv-tk was determined in vitro in competition with [[ h]-ch ]dthd. the logp of [ c]-( ) and [ c]-( ) was determined and their biodistribution was evaluated in normal mice at and min pi. results: synthesis yields were % for ( ), % for ( ), % for ( ) and % for ( ). the rcy for [ c]-( ) and [ c]-( ) was % and %, respectively, and the rcp was > % for both tracers. the identity of the tracers was confirmed by co-injection with the authentic ( ) or ( ). logp . value of both tracers was . . ic values of ( ), ( ), ( ) and ( ) for vzv-tk were , , and μm, respectively. similar to the previously synthesized bcna tracers, negligible brain uptake was seen at min and min pi for both [ c]-( ) and [ c]-( ), which were cleared mainly by the hepatobiliary system and to a lesser extent to the urine at min pi. blood clearance was rapid for both tracers (< . % id in blood at min pi). conclusions: lack of uptake in brain for [ c]-( ) and [ c]-( ) confirms that bcna tracers do not cross bbb despite their lipophilic character. in general, this observation can be extended to other uridine-or uracil-based nucleoside analogues also. this study was funded by the ec- aim: fluoromisonidazole [ f]fmiso, has been used with pet in humans for the identification of hypoxic tissue in stroke. however, [ f]fmiso suffers from low cellular uptake into hypoxic tissue and slow clearance from normal cells, requiring long periods between iv-injection and imaging. in we have reported the radiolabelling of another class of compounds (sulfoxide containing nitrogen mustards) that have great affinity for hypoxic tissue. in this study, we have performed in vivo analysis to evaluate these compounds ([ f]so and [ f]so ) as potential imaging agents. method and materials: to determine the uptake of the tracers in the ischemic penumbra, mcao stroke-induced rats were injected with the desired tracer immediately after stroke. uptake times of . , and h post injection were assessed and autoradiography performed. a delayed injection study (injection hrs post stroke, sacrificed hrs post injection) was also performed to determine if the tracer is binding to the infarct tissue. autoradiography and histology was used to correlate infarct regions with uptake of the tracer. a pet/ct scan of so was also investigated. all data was compared to the current gold standard [ f]fmiso. results: at h post injection, the density ratios and the hemispheric area of uptake of the three tracers ([ ( , ) carried out by distillation of the intermediate f-fluorobromomethane (fbrme) and subsequent alkylation of dimethylaminoethanol (dmae) or by gas phase conversation of fbrme to f-fluoromethyltriflate followed by dmae alkylation. the aim of this study was the investigation of a one pot synthesis without distillation on an automatic synthesis module for production of high radioactivity amounts of fmc. materials and methods: trapping the target water on an anion exchanger, elution with kryptofix® . . /potassium carbonate and azeotropic drying was performed according to a standard procedure. the nucleophilic substitution with dibromomethane as precursor was optimized with respect to time and temperature. the second reaction step was carried out by addition of dmae in acetone to the intermediate fbrme and also optimized with respect to time and temperature. subsequently the solvents were evaporated and a sodium hydroxide solution was added to the residue and heated for additional min. by transferring the product solution over a cation exchange the fmc was trapped on the cartridge. after washing with ethanol and water, fmc was eluted with saline. the qc was performed by hplc and tlc. results: the strategy for the synthesis of fmc (according to ( ) ) was transferred to an automatic, remote controlled synthesis unit. the optimization of the nucleophilic substitution results in a radiochemical yield of - % in min at °c. the alkylation reaction in the same reaction vessel proceeded with radiochemical yields of - % in min at °c. this result in an overall radiochemical yield of ± %, which only slightly differs from the non automatic synthesis ( - % ( )). destroying the byproduct bromomethylcholine by basic hydrolysis was nearly quantitatively. total synthesis time was approximately min. the radiochemical purity was > %. conclusions: the two step one pot synthesis of fmc was successfully adapted to an automatic, remote controlled synthesis unit. this process allows the efficient and reliable production of fmc with high radioactivity amounts in less than one hour. references: ( ) introduction: there is an increasing need for pet radiotracers to be produced at high specific radioactivity (sa) to delineate low population binding sites in man or for imaging studies on small animals. these studies often require radioligands with very high binding affinities, which also imposes the need for producing the radioligand at high sa. an example of these tracers is the high affinity dopamine d / radioligand [ f]fallypride which we are using for human and micropet studies. to perform these studies successfully and in particular to enable us to perform two pet studies consecutively from one radiochemical preparation we have investigated means to improve the sa of the final product. method and results: based on analysis of the various components of the radioligand synthesis, including the precursor's chemical purity, the key determinate of the sa of [ f]fallypride was identified to be the cyclotron-generated [ f]fluoride, prepared by the o(p,n) f method. using our standard [ f]fluoride production protocol based on μa for min which produced - gbq, we obtained - gbq of [ f]fallypride at end-of-synthesis (eos). the sa was determined, using a calibrated radio-hplc-uv system, to average gbq/μmol (range - gbq/μmol, n= ). we then modified our [ f]-fluoride production method to perform an irradiation consisting of μa for min in which the target product was then emptied unused. this was followed by a second [ f]fluoride production ( μa for min) to be used for the radiosynthesis process. the amount of [ f]fluoride ( - gbq) and the radiochemical product of [ f]fallypride ( - gbq) did no change significantly. however the sa of [ f]fallypride at eos was found to increase significantly to average gbq/μmol ( - gbq/μmol, n = ). with these sa we are able to perform two consecutive human studies within hrs from eos while keeping to our imaging protocol criteria of mbq dose and a maximum limit of nmol of co-injected mass of fallypride. conclusion: using a two stage irradiation protocol we have been able to double the sa of our [ f]fallypride product. as well as being at the required level for performing micropet studies these sa allows us to perform multiply pet studies from one preparation enabling more efficient use of our regular productions of this tracer. using this protocol has also enabled us to reduce the required activity of [ f]fallypride to be produced while still obtaining the required sa's for our studies, therefore reducing radiation dose to the production staff. u. choudhry , r. paul , p. blower , s. biagini ; university of kent, canterbury, united kingdom, king's college london, london, united kingdom. background: current methods for f labelling of peptides for pet imaging are timeconsuming and complex. more efficient (preferably single step) methods, analogous to m tc kits, are required because of the short half-life ( min). we have previously shown that the reaction of fluoride with alkoxytrialkylsilanes is fast and that the product is stable to hydrolysis up to ph . when bulky alkyl groups are used. we therefore selected the tert-butyldiphenylalkoxysilane group for evaluation with nocarrier-added f. aims: to demonstrate radiolabelling of a tertbutyldiphenylalkoxysilane with f and establish appropriate conditions. material & methods: f in k. . . /ch cn/k co was prepared by a conventional procedure: ml of aqueous f- ( mbq) was passed through the qma cartridge (conditioned with ml of m sodium bicarbonate and ml water) and eluted in ml k. . . /ch cn/k co solution. no azeotropic drying was performed. to this solution was added . ml tert-butyldiphenylmethoxysilane ( mg/ml in ch cn) and μl trifluoroacetic acid (tfa). rp-hplc (water/acetonitrile/ . % tfa) and tlc (silica/hexane) were performed after min incubation at room temperature. results: both hplc and tlc showed the presence of a single radioactive, hydrophobic species corresponding to a bona fide cold sample of the tert-butyldiphenylfluorosilane (rt min, rf . ) and no significant residual free f (rf ). conclusion: the alkoxytrialkylsilane prosthetic group reacts very efficiently at room temperature with f in the presence of kryptofix without the need for drying by azeoptropic distillation, offering the basis of a very convenient route to radiolabelling biomolecules for f pet. objectives: intra-arterial administration of particles containing beta-emitting radionuclides appears to be a useful alternative of liver tumour therapy. particles of a well-defined size are trapped in the vascular bed of the tumour and remain there while delivering a high dose of radiation in order to destroy both primary and metastatic liver tumours. methods: ho-pla-ms were prepared using the solvent evaporation technique. ho-acetylacetone complex and polylactic acid (pla) was dissolved in chloroform and consequently added to % polyvinyl alcohol. this mixture was stirred s for at least hours until chloroform was evaporated. the precipitated microspheres were centrifuged, washed with distilled water and . m hcl and finally collected on a cellulose nitrate filter. microspheres were placed in the screwed titanium ampoules and irradiated in the channel providing lower neutron flux in order to avoid radiation degradation of prepared microspheres. results: generally, mg of microspheres were irradiated at the neutron flux cm - s - and the radioactivity reached after minutes neutron irradiation ranged from - mbq. the particle size distribution highly depended on the speed of the stirrer and on pla molecular weight. microspheres of the ideal size - mm and the mean diameter of mm were obtained after stirring at rpm and microsieving using mm and mm pore size sieves. holmium as a paramagnetic lanthanide was visualized using mri. study was performed using the polyacrilic glass phantom. non-radioactive microspheres containing holmium in % agar was used. the amount of microspheres used for visualisation ranged from to mg and and this amount corresponds with the amount intended for the future aplication. discussion: microspheres of the size of - mm is considered to be an ideal size for immobilisation inside the tumour tissue. granulometric analysis proved minimally % prepared particles conform to this dimension. mri study on holmium loaded microspheres provided image of sufficient signal strength within the all studied concentration range and seems to be promissing for possible imaging of microspheres after decreasing radioactivity owing to decay. . interest of ytracis ® radiochromatographic control prior to zevalin ® radiolabelling. aim: the zevalin ® (ibritumomab tiuxétan) radiolabelling with ytracis ® ( yttrium) fails in about per cent of cases despite following a rigorous and well tried procedure. the origin of the failures remains unclear in most cases. after experiencing a labelling failure in our department we performed a chromatic control of the ytracis ® marker solution. materials & methods: one patient who presented a recurrence from a refractory follicular lymphoma was referred to our department for a y-zevalin therapy. the radiochromatographic purity (rcp) of the labelled zevalin ® was controlled by thin layer chromatography (tlc) using strips of itlc-sg paper and . % nacl solvent. in the present case the strip scanning performed with a radiochromatograph showed a rcp value of . ± . % (m ± sd) (normal > %), and an impurity peak with a migration front (rf) of . ± . . for this reason, the treatment was cancelled. the analysis of the critical procedure steps (registration, storage, labelling, rcp control) and the manufacturer inquiry did not permit to identify the non conformity source. therefore the present ytracis ® lot has been controlled by tlc as well as successfully used lots with the same procedure as performed for the zevalin ® rcp test. results: the tlc strip readings of the control ytracis ® lots gave a single migration peak (rf: . ± . ). the tlc strip readings of the tested ytracis ® lot showed a first migration peak (rf: . ) corresponding to . ± . % of the deposited activity. a second migration peak with a rf: . ± . not present on the control lots was detected corresponding to . ± . % of the deposited activity. the impurity nature could not be identified due to the lack of product. conclusion: considering the possible failures of zevalin ® radiolabelling with ytracis ® we suggest to include a simplified and systematic rcp control of the ytracis ® solution during the source registration procedure. the rcp control is a main step before the zevalin ® labelling and the patient convocation. at present, no useful data is available concerning the efficiency and the safety of sm-edtmp (quadramet®) therapy in patients with renal function impairment, especially in chronic renal failure treated with dialysis. we report the case of a years-old woman who suffered from painful bone metastases. her medical history consisted of untreated asthma, hypertension, left breast adenocarcinoma and chronic renal failure for which she benefited from haemodialysis times a week. the patient was referred by the geriatric department to perform bone scintigraphy for the initial evaluation of skeletal metastases because of her hypercalcemia and bone symptoms. the bone scan revealed multiple secondary lesions. pain evaluation by visual analogic scale (vas) was expressed as and the recorded motor score was / . these findings were diagnosed as extensive metastases of her breast cancer. this patient was given the opportunity to benefit from internal radiotherapy with quadramet®. considering her renal failure and urinary excretion of sm-edtmp after intravenous administration, nuclear physician decided that careful and cost-effective treatment could only be achieved by performing % of the conventional activity, i.e. . mbq/kg ( . mci/kg) instead of mbq/kg ( mci/kg), hours before haemodialysis. her haematological status recorded hours before, made feasible the radionuclide therapy. the administration was performed in the nuclear medicine department without any problem. the clinical follow up included adequate monitoring of bone pain response, haematological status and supportive medication. treatment efficacy was assessed according to vas, motor score, analgesics consumption and performance status. painful osteoblastic lesions were significantly alleviated after internal irradiation (vas, ; motor score, / ). onset of pain improvement took place weeks after internal radiotherapy. there was an obvious decrease in opioid analgesics use in the active phase of the treatment.. no relevant haematological toxicity occurred. however, a temporally recoverable mild anaemia was observed. this finding was likely related to arterio-venous fistula inflammation. conclusion: in this case, management of painful bone metastases with sm- edtmp in a dialysis patient was successfully performed. our observation demonstrates that such therapy is feasible in patients under chronic haemodialysis. radionuclide production for biomedical applications has been studied in recent years at infn-lasa laboratory, in co-operation with the cyclotron laboratory of the joint research centre (jrc ispra, italy), taking advantage of extensive experience in the experimental nuclear physics and nuclear chemistry fields. several research aspects concerning radiation detection and the relevant instruments, the measurements of excitation functions of the involved nuclear reactions and the required radiochemistry methods have been investigated. the latest studies on high specific activity, accelerator-produced radionuclides in no-carrier-added (nca) form, for use in therapeutic applications and in related spet/pet diagnoses investigated, are: . nca cu, produced by nat zn(d, xn), nat zn(d, pxn) and zn(d, p) reactions for simultaneous + /metabolic radiotherapy, with intrinsic pet imaging, including the short-lived radionuclide cu; . g re, produced by w(p,n) and w(d, n) reactions, for bone metastases pain palliation by beta ( . mev) metabolic radiotherapy, including spect imaging; . nca at/ g po, produced by the bi( , n) reaction, with internal spike of the emitter at from the bi( , n) reaction (leading to very small amount of po as radiotoxic long-lived impurity), for high-let metabolic radio-and immuno-radiotherapy; targets are irradiated at the scanditronix mc- cyclotron (k= ) of the jrc with proton or alpha beams up to mev, he + particle beam up to mev or deuteron beams up to . mev. activity measurements are performed either at jrc ispra or at lasa laboratory: , x spectra are measured with hpge detectors, spectra with pips detectors with a resolution of kev (fwhm), and spectra with a conventional liquid scintillation counting lsc and spectrometry system with horrocks number capability for quenching correction, and a higher-resolution liquid scintillation portable spectrometer with / pulse shape analysis (psa) discriminator. in order to produce nca radionuclides suitable radiochemical separation processes for the radionuclides of interest, together with quality control checks must be developed. the radiochemical separations adopted are presented for each radionuclide produced. in order to evaluate production feasibility or to confirm the cross sections experimentally obtained, calculations for the involved nuclear reactions are carried out with the empire-ii code, taking into accounting the major nuclear reaction channels. objectives: due to the more favourable physical characteristics of re, re-lipiodol is an interesting alternative for i-lipiodol in the treatment of hepatocellular carcinoma (hcc). a water-in-oil emulsion (w/o) was prepared as carrier system using lipiodol as oil phase, containing m tco -/ reo in the inner aqueous phase. the aim of present study was to optimize the formulation of the w/o emulsion based on a plackett-burman -run statistical design. methods: types of emulsions were prepared according to the orthogonal plackett-burman design. to optimize the formulation, the influence of causal factors such as rpm, rotation time, aqueous phase, oily phase, volume ratio, type and concentration of emulsifier was evaluated. for each run the cumulative percentage of administered activity released from each formulation (cpa), was calculated in vitro. the latter quantity will be an important indicator for the whole body irradiation of the patient. in vitro release rate characteristics were measured using a dialysis system. results: plackett-burman analysis showed a significant influence (p< , ) on cpa for volume ratio (p = , ), rotation time (p = , ), emulsifier concentration (p = , ) and oil phase (p = , ) with volume ratio as most important factor. no significant influence was found for the aqueous phase (p = , ), type of emulsifier (p = , ) and rotation rate(p = , ). conclusion: stable lipiodolized w/o emulsions could be prepared according to the plackett-burman experimental design. based on our statistical screening design, volume ratio, rotation time, emulsifier concentration and oil phase could be identified as factors affecting the release characteristics of the formulation significantly (p< , ). in further optimization steps, these factors should be taken into account. such conjugates were achieved when the ratios of rhil :hynic reactions were set from : to : (ca. % efficiency of the substitution), and the purification step was performed on pd- column. the next most essential parameter of radiolabelling reaction was the ph of the reaction medium, which should be kept in the range of - . . gf-hplc analysis indicated that two radioactive species of m tc-hynic-il (monomer and dimmer) are formed during radiolabelling, although dimmer could be selectively removed by purification on tc column. the optimized conditions of the wet-radiolabelling ( μg of rhil :hynic, - mg of tricine, - μg of sncl , ph - . , min in rt) enabled to achieve m tc-hynic-il monomer (radiochemical purity > %, specific activity ca. mbq/μg il- ) with overall yield of ca. %. the two vial freeze-dried kit was prepared: first vial with μg hynic-il , second vial with mg tricine and μg sncl . unfortunately, radiochemical purities of the m tc-hynic-il preparations obtained using the dry kit were unsatisfied and did not allow giving the purification step up. conclusions: our study showed that rhil- can be efficiently radiolabelled with tc- m via bifunctional chelator -hynic, and tricine as coligand. however, investigation are still ongoing to receive one-step preparation of ready to use m tc-hynic-il radiopharmaceutical. aim: the purpose of this study was to compare biodistribution profiles and elimination pathways of dota-tyr( )-octreotate (dota-tate) and dota-l-nal( )-octreotide (dota-noc) labelled with in- in rats. whereas clinically used radiolabelled dota-tate shows high affinity to somatostatin receptor subtype sstr and low or absent affinity towards the other somatostatin receptor subtypes, dota-noc exhibits high affinity to somatostatin receptor subtypes sstr , and . materials and methods: for the cell experiments, rat pancreatic carcinoma ar j cells expressing sstr receptors were employed. for biological experiments, male wistar rats ( - g) were used. the peptides were administered to rats intravenously in the dose of . μg per animal. the kinetics of the peptide uptake in the kidney was also studied on the proximal tubule-derived opossum kidney (ok) cell line. results: in-dota-tate and in-dota-noc showed high and comparable rates of internalization into ar j rat pancreatic carcinoma cells in agreement with their similar affinity to somatostatin receptor subtype sstr . both peptides under study exhibited similar distribution profiles in rats. radioactivity was rapidly eliminated from the blood and most organs and tissues. high radioactivity uptake in somatostatin receptor-rich organs and in the main elimination organ (the kidney) was determined. due to higher lipophilicity of in-dota-noc its plasma protein binding was higher, the blood radioactivity decrease was slightly slower and liver accumulation was significantly higher in comparison with in-dota-tate. the physiological internalization of radioactivity into somatostatin receptor-rich organs (the pancreas and adrenals) was for in-dota-noc about twice of that for in-dota-tate. no significant differences in the renal radioactivity uptake were found. these results were confirmed also in the study of the peptide uptake by the ok cells. elimination pathways were comparable for both peptides under study. conclusion: radiolabelled dota-noc represents promising somatostatin receptor-specific peptide for diagnosis and radiotherapy of some neuroendocrine tumours due to its very high uptake in tissues with high density of somatostatin receptors. the study was supported by the grant agency of the czech republic -grant no. / / . whereas the peptides labelled with radiometals were eliminated into urine mostly in the parent form and only traces of metabolites were detected, a significant portion of metabolites of iodinated compounds (especially in the longer time intervals after dosing) in rat urine were found. in time intervals up to hour after dosing, the distribution profiles of all peptides under study were similar. high radioactivity uptake in organs with high density of somatostatin receptors (the pancreas and adrenals) and also in the kidney was determined. whereas high radioactivity accumulation in the above-mentioned organs continued for a long time for the peptides labelled with radiometals, this uptake significantly decreased with time for iodinated derivatives. the physiological internalization of radioactivity in somatostatin receptor-rich organs is mediated by their somatostatin receptors. renal uptake and retention of the peptides involves glomerular filtration and subsequent partial reabsorption in the proximal tubular cells by endocytosis. the peptides could be consequently transferred to lysosomes and digested by proteolytic enzymes. resulting breakdown products remained in the lysosomes for a long post-injection period for the agents labelled with radiometals. on the other hand radioiodinated break-down products could cross biological membranes from the sites of metabolism to the central distribution compartment and finally be eliminated by urine. conclusion: the reason of different metabolites proportion of the peptides under study in rat urine was in different rates of externalization of brake-down products from the sites of biotransformation. k. durkan, f. yurt lambrecht, p. Ünak; institute of nuclear science, izmir, turkey. aim: bombesin-like peptides are neurotransmitters and cancer growth factors. bombesin-like peptides express several human cancer, including small cell lung, prostate, breast, colon and pancreatic cancer receptors. litorin is a peptide derivative as amphibian bombesin. in this study, a new m tc labeled bn-like peptide (litorin) was prepared and biodistribution studies in normal rats were investigated. materials & methods: litorin was labeled with tc- m by using μg stannous chloride at ph . . after the labeling procedure, the radiochemical analysis of radiolabeled peptide was determined by radio thin layer chromatography (rtlc) and radio high performance chromatography (rhplc). in vivo biodistribution studies were performed in normal male albino wistar rats with blocked and non-blocked receptors. the stability was investigated in human serum. results: labeling yield was . ± . %. serum stability results showed that in vitro stability of the radiolabeled peptide was quite high. the radiolabeling efficiency was . ± . at h during incubation. significant uptake in bombesin/gastrin releasing peptide (bn/grp) receptor rich tissues such as the pancreas ( . ± . %id/g, min post injection) was observed. the uptake in the pancreas could be blocked by cold litorin ( . ± . %id/g at min). m tc-litorin exhibited very hydrophilic and eliminated via renal filtration and urinary excretion. conclusion: m tc-litorin showed high uptake in the gastrin-releasing peptide receptor-rich pancreas and might be useful radiopharmaceutical in the detection of bombesine receptor-expressing cancers in vivo. introduction: in the process of sm production, the eu (t / , years, kev, kev, kev) is generated like main radionucleidic impurity. however, the low proportion of this radionucleid in the final product, inferior to . %, assures its harmless. objective: to quantify the amount of eu present in the waste generated by sm-edtmp use and to evaluate its incidence in the waste management. material and methods: the remaining liquids of quadramet ® vials of different lots and patients' urine collected during h p.i were analysed. the emission espectrum's analysis of each sample and the estimation of the eu specific activity were performed with a nai(tl) detector. results: the average eu ratio in vials versus the sm nominal activity was . %, which agreed with manufacturer indication. the mean eu ratio in vials and in urine were of · bq/l y · bq/l respectively. in both cases exceeded the valid limit for drinking water ( bq/l). eu / sm-edtmp ratio in urine, was approximately of . %. conclusions: the waste management program of sm must consider current eu ratio, establishing the suitable dilutions, in agreement with the characteristics of each center, as the final concentration must not exceed the valid limit for drinking water. biodistribution of the chemical species containing eu and sm seems to be differents. the potential of the - kda fraction of the water-soluble polymer polyethyleneimine, functionalised with methylene phosphonate groups (pei-mp) and labelled with mtc ( hr half-life and kev gamma), msn ( . d half-life, conversion electrons) and re ( . d half-life, . mev beta-) has been described elsewhere. distinct differences in the biodistribution in animal models were found for the different radionuclides. mtc-pei-mp had high bladder and kidney uptake. msn-pei-mp had moderate reticuloendothelial uptake, reasonable bone-uptake and considerable uptake in the bladder wall. re-pei-mp showed rapid clearance of all organs as well as considerable and early excretion in the urine and little bone uptake. it is postulated that the size of the polymer complex changes with the different metal ions which is the reason for this difference in biodistribution. methods: nonradioactive sn(ii)-pei-mp and re-pei-mp were prepared according to the labelling procedures. parallel radiolabelled equivalents were used to prove the labelling was successful. as mtc is no-carrier-included, the mass of this metal ion is negligible and will not influence the result. therefore the kit formulation (a mixture of pei-mp, sn(ii), sn(iv) and buffer) was used to simulate mtc-pei-mp. all solutions were kept under ar and were analysed for size by conventional gpc using an agilent isocratic pump. results: the average gpc size results showed that the size of the polymer fraction is . kda, and . kda for the tc- m kit formulation ( mtc-pei-mp), . kda for sn(ii)-pei-mp and . kda for re-pei-mp. conclusions: it seems that the polymer contracts upon complexation with sn(iv) due to ml complexes but expands with sn(ii) which prefers m l complexes. as low specific activity re was used in earlier experiments, it was expected that the size of re-pei-mp would be considerably higher. y is a widely used radionuclide in therapeutical nuclear medicine applications. to be safely administered to patients, y solution must fulfill specific quality requirements; it must be at correct ph, endotoxin free, metal free, and it should have only minute amounts of long-lived parent nuclide sr. the aim of this work is to develop a fast, efficient and reliable method to determine sr content in y solution. the separation of y and sr is performed by using highly selective extractive chromatographic sr resin. y sample is loaded to the column in diluted nitric acid. yttrium under this condition does not retain on the column so it is first washed out and collected. yttrium fraction is measured with a dose calibrator. strontium is eluted from the column with water. the strontium fraction is evaporated to near dryness and dissolved in scintillation cocktail. finally the sample is measured with liquid scintillation counting (lsc). the problem in using lsc in sr determination lies with the ingrowth of y in the sample. high energetic y spectrum (max. kev) overlaps sr spectrum (max. kev), hence obtaining a 'pure' sr spectrum is impossible. an indirect mathematical model that utilizes counts of the beta spectra originating from each nuclide is a convenient method for subtracting y from the sr y spectrum. a pure y spectrum is measured and a window in the high energy area of the spectrum is selected. the window area is normalized with the yttrium- counts in the sr y spectrum. the two spectra are subtracted from each other resulting in a pure sr spectrum. the developed method allows a rapid sr content determination with sr/ y ratio as low as - . the time needed for the entire quality control procedure is in the range of one hour. same mathematical method can be used to determine tungsten- content in rhenium- solution from w/ re -generator. ( ). only the patients with normal globular volume (vg) and vp (vg exp< % vg theoretical; vp exp< % vp theoretical) have been studied. calculation formulas were: vg(hts/( -hts)) for vp calc, , * age + x body surface (bs) for female vg th, * bs - for male vg th, * bs for female vp th, * bs for male vp th. data were analyzed for means. a student test and regression analysis were performed using the excel program of microsoft, inc. results: the student test has shown that it existed a significant difference between vp exp and vp calc for males (p< . ) and females (p< . ). however, the regression analysis has shown a correlation of vp exp versus vp calc for males (r= . for minutes blood sample) and females (r= . for minutes blood sample). when the equations of correlation lines have been used to find vp exp from vp calc on a patient's sample, a significant difference was remained between the two vp. discussion and conclusion: according to these results, the use of i-has seems to be indispensable to obtain a good estimation of vp. as it has been shown by morin, et al. in (ouest-médical, è année n° , mai ), the use of hts to calculate the vp calc. explains this result. hts is obtained from the formula: venous ht * x where x estimation is . . in reality, x depends on the person. so to limit the viral risk linking to the use of i-has, only red cell mass measurement by cr will be done in research of myeloproliferative syndrome (vaquez disease, ) and cr and i-has will be used in other cases. to optimize the choice of the technique (single or double isotopes), we are developing a prescription medium in order to obtain all necessary informations to choose the best technique. aim activity measurement of i radiopharmaceuticals, may be affected by several factors such as recipient shape and its nature (kind of glass, plastic, etc); as well as, the own attenuation produced by liquid volume in which radiopharmaceutical is dissolved. the aim of this study is the assessment of variation between measured activity and reference activity, using two different dose calibrators. as well as, the calculation of corresponding correction factors necessary to obtain the most exactly dose with each dose calibrator. material and methods we have used two dose calibrator for activity measurement: capintec crc ® - r (dc ) and capintec crc ® - (dc ). activity measurement of i was performed using the corresponding channel of each dose calibrator. measurements of i activity were performed to the radiopharmaceuticals into manufacturer vial, and others after withdraw the whole radiopharmaceutical activity into a ml syringe. those measurements were performed in both dose calibrators. the measured activity in each case was compared with reference activity. also, we have calculated the medium variation percentage (mvp) of measurements performed versus reference activity, as well as, the medium correction factor (mcf) for each measurement. results the mvp of measurements performed versus reference activity in case of dc was . ± . in syringe and in manufacturer vial - . ± . . in case of dc mvp in syringe was . ± . and in manufacturer vial - . ± . . mcf were calculated in each case. for dc : syringe, . ± . ; manufacturer vial, . ± . ; and for dc : syringe, . ± . and manufacturer vial, - . ± . . conclusions our results showed than measured activity for i using manufacturer vial was significantly lower than reference activity, in both dose calibrators; while, on the contrary, when the radiopharmaceuticals was measured in syringe, the activity resulted higher than reference activity, and moreover, higher in case of dc . in consequence, to get the most exact activity measurement of i radiopharmaceuticals, it is necessary the calculation and use of the correction factor corresponding to the dose calibrate used to the measurement, both for manufacturer vial activity and syringe activity. introduction: dextrans are glucose polymers, whose versatility has led to their application in numerous fields. m tc-labelled dextrans have been proposed as possible substitutes for human albumin and labelled red blood cells in angiography and cardiac pool studies. objective: to assess the pharmacokinetics of a m tc-labelled dextran- preparation in rats. material and methods: eight wistar male rats with an average weight of g were administered with mbq of m tc-dextran- in a volume of μl via cannula in jugular vein. blood samples of ml were taken at , , , , and min post-injection and kept in a flask with anti-coagulant; . ml of each sample was centrifuged to obtain plasma. aliquots of . ml of total blood and plasma were measured in a well counter for minutes. the activity of each sample was determined as a function of time and the following pharmacokinetic parameters were determined: plasma concentration, apparent distribution volume and plasma clearance of the radiopharmaceutical. results: tc-labelled dextran- shows the characteristic kinetics of a vascular tracer. in every case le was tested: in vivo/in vitro method: . - . ml m tc-rbc aliquots were added to ml of nacl . % solution into sterile vacuum blood collection tubes. the tubes were centrifugated at xg for minutes and supernatant (cell-free plasma) was transferred into plastic test tubes. le was calculated by measurement, both cell-free plasma and rbcs packed, activities using a dose calibrator (capintec crc ® - r). in vivo method: ml whole-blood was withdrawn from a peripheral vein using a ml heparinnized syringe. it was centrifuged at xg for min and supernatant was transferred into plastic test tubes. le was calculated by measurement, both cell-free plasma and rbcs packed, activities using a well counter. le was expressed as percentage and the mean value and the standard deviation were calculated for each method. the gammacamera used was a double headed variable tangential philips axis. results average le of m tc-rcbs by in vivo/in vitro method was . ± . % (low le . % and high le= %), on the other hand, the m tc-rcbs by in vivo method yielded an average le of . ± . %, in a range of . to . percent. in each case, gammagraphics images were tested by two different independent testers, neither of them detected any undesirable uptake because of low quality of m tc-rcbs, or by any in vivo unlabelling. conclusions according to our results, the le using in vivo methods was slightly lower than le by in vivo/in vitro method. perhaps, both of them were into an acceptable range to be used for lvef studies. moreover, lvef studies performed have not shown any significant difference, so both methods are useful to get m tc-rbcs in fact, we think that the use of m tc-rbcs by in vivo method is preferable, because it is a simple system, easy to perform, safe and efficient to assess lvef getting good results and image quality. introduction: insulin-like growth factor (igf- ) and its binding proteins, mainly igfbp , have a very important role in the regulation of fetal growth. the synthesis of igf- and igfbp is regulated to diverse hormonal factors, such thyroid hormones. the purpose of this study is to determine the possible association between the hypothyroidism status of pregnant women and the levels of igf- and igfbp respectively. objective: assessment the relationship between thyroid hormone levels and igf- and igfbp serum levels in pregnant women. aim: the polyazaligands such as dtpa or dota are suitable for transitionmetal and lanthanide ions, and their complexes have found important use in the radioimmunotherapy and radioimmunodiagnosis. a key parameter for these applications is a fast and efficient complexation of a convenient radioisotope. acyclic dtpa forms complexes immediately; complexation with macrocyclic dota is much slower. however, the macrocycles are better from all other aspects (e.g. kinetic and thermodynamic stability). in general, the most suitable central ions for dota-like ligands are trivalent lanthanides and indium. the in isotope was chosen for this study, because it has convenient radio-properties. we present here an investigation of two new bifunctional monophosphinic acid h dota derivatives having distant paminobenzyl (do a-p abn ) or carboxylic groups (h do ap pra ) suitable for a further conjugation. material and methods: do a-p abn and h do ap pra were prepared according to the published procedures. incl was purchased from amersham plc.. the reactions were followed with radio-tlc on silikagel plates or rp-hplc on lichrocart c column (merck). biodistribution and elimination studies were carried out using male wistar rats. results: the studied ligands exhibit a fast complex formation at optimized conditions (ligand:metal ratio : , ph . , °c, min). as expected, higher ph and temperature accelerate the complex formation reactions. however, ph where precipitation of colloid metal hydroxides can occur (>~ ) is not suitable. biodistribution studies showed a rapid clearance from most organs including blood and muscle. the main elimination pathway was urine excretion mostly by the mechanism of glomerular filtration. conclusion: the resultes indicate that do a-p abn and h do ap pra are promising for radiolabelling of target-specific biomolecules. initial the relationship between proinflammatory cytokines, il- and tnf-, and hyperthyroisdim is not well known. serum levels of cytokines may indicate activity levels of immune functions. on the other hand some hyperthyroisdim variant have a immune component. objective: to measure and compare serum concentrations of proinflammatory cytokines, interleukin- and tnf-, in patients with different hyperthyroid diseases. material and methods: analyses were conducted in sera samples drawn from patients with graves-basedow disease, patients with multinodular goitre, patients with thyroiditis and euthyroid controls. serum tsh, ft , ft , il- and tnf-concentrations were measured by irma or ria assays. statistical analysis: a one-factor anova and subsequent bonferroni test were performed. results: in-dota-tate in μl is required. under these conditions the radiolabelled peptide is vulnerable to radiolysis and oxidation, which results in loss of biological activity. labelling conditions were investigated to obtain a chemically stable product with intact high and specific receptor-binding. moreover, high sa can only be achieved when the ingrowth of non-radioactive competing cd is low. cd is the decay product of in. incl is produced and delivered every week, thus the radiolabelled peptide should preferably be stable for week. in-dota-tate was therefore tested chemically and biologically. materials and methods: labelling conditions like time of labelling, temperature during the labelling, specific activity and the addition of several quenchers (ethanol, ascorbic acid and gentisic acid) in different combinations and concentrations were tested. radiochemical purity (rcp) was determined by using a hplc c column at t= up to week after labelling biological stability of in-dota-tate was tested (at - m) by performing uptake and internalisation experiments using the somatostatin receptor expressing rat pancreatic cell line ca . parallel in vitro autoradiography was performed on rat brain sections, both with * - m and - m of in-dota-tate. results: mbq/nmol in-dota-tate was prepared. use of quenchers was inevitable to maintain rcp and prevent loss of receptor affinity. conditions were optimal in the presence of ethanol, ascorbic acid and gentisic acid. at t= rcp was ± %, whereas after week the rcp was ± %. uptake of in-dota-tate ( - m) to ca cells was % [dose/mg protein] of which % was internalised. similar results were found in experiments throughout the week. receptor-binding of in-dota-tate was confirmed on brain sections, and could be blocked in the presence of an excess ( - m) of octreotide analogue. corrected for decay and exposure time the specific receptor-binding of in-dota-tate to brain also remained constant. conclusion: optimised labelling conditions of in-dota-tate and the presence of a combination of quenchers enables the production of this radiopharmaceutical with a high and intact rcp for a week. since the chemical status, and the intact high and specific receptor affinity are maintained, centralised production and shipment of "hot liquids" are now possible. aim in order to satisfy the good preparation norms in nuclear medicine all radiopharmaceuticals employed for diagnostic and therapy have to be tested by quality control (qc) by determining radiochemical purity (rp) the purpose of this study was to validate a simplified qc method for gamma and beta radiopharmaceuticals using storage phosphor screen technology and adapting the complexity of the optiquant software of cyclone perkin elmer to common usage. material and methods: gamma and beta radiopharmaceuticals habitually used in our laboratory (diluted : in normal saline) were tested by instant thin-layer chromatography (itlc). all the chromatographic strips were tested exposing phosphor screen (multi-sensitive medium ms) at progressively increasing times (from to seconds) to establish the better time of exposure (for the average of our strips: seconds). then we have performed itlc for each radiopharmaceutical to calculate the average of distribution areas of radiopharmaceutical and its impurities in order to find the background area. since cyclone can simultaneously measure different chromatographic strips, we have estimated a minimal distance ( . cm) between the various strips avoiding images superimpositions. we have compared itlc results measured by cyclone and by gamma-counter and the agreement was excellent (correlation coefficient . ). then by the optiquant software we have saved in a scheme of lanes -templates-the exact dimensions of the chromatographic strips well as the distribution areas from the origin (o) to the solvent front line (f) and the background area of each radiopharmaceutical. results this simplified method is easy for user at all levels of computer expertise, moreover consent to scan a screen, display and analyze the image, report the data of various chromatographic strips at the same time with high sensibility and resolution, clearly visualizing the distribution of the radiopharmaceutical and its impurities. the scheme of lanes (templates) saved in the software optiquant allows a rapid, automatic and exact measure of rp (less than minutes for different strips at the same time) providing a profile for a graphical representation of data. conclusion this simplified method for the measurement of radiochemical purity is easy, rapid, optimized and standardized no matter who the users are. introduction: hidroxyethyl starch is the most used agent in the sedimentation of the erythrocytes during the radiolabelling procedure for leukocytes. colloid dextran- , a plasma expander, have been proposed as possible alternative to hidroxyethyl starch in this process. objective: to assess the usefulness of the plasma volume expander colloid dextran- as an alternative to hydroxyethyl starch in the sedimentation of the erythrocytes in leukocytes radiolabelling by m tc-hmpao. material and methods: two identical samples of ml of blood in ml of acd were obtained from patients referred to our department for labelled leukocytes scintigraphy. leukocyte concentrations were obtained by using a hes solution, following the established protocol. simultaneously, another leukocyte concentration was obtained using a % dextran- solution in saline solution of . %. concentrations of leukocytes, platelets and red blood cells were determined in the plasma obtained. the efficiency of the labelling was estimated, the cell viability was calculated by means of the trypan blue method, and the in vitro leukocyte recovery and erythrocyte:leukocyte ratio in final suspension of labelled cells were determined. results are expressed as arithmetic means ± standard deviation. the student's t test for related samples was used to compare means, considering p < . as significant. results: aim: to assess the effect of scatter coincidences, partial volume, positron range and non-colinearity on the ratio of the specific striatal uptake to non specific uptake (sur) in fdopa pet studies. materials and methods: the simset monte carlo code was employed to simulate acquisitions of the pet/ct siemens biograph scanner. the study was performed by using a numerical model obtained from a ct-image of a striatal phantom. theoretical sur values of . , , . , , . and were simulated. neither axial nor angular compression were considered. as a consequence, sinograms with transaxial bins (bin size of . mm) and angular positions were obtained. simulations were carried out with/without positron range and noncolinearity effects. true and scatter coincidences were stored separately so that an ideal scatter correction (isc) could be performed. a d iterative algorithm kept in the stir library (http://stir.sourceforge.net) was used to reconstruct the d pet data. the reconstruction parameters were: iterations, subsets and a reconstruction grid of x x (x-y pixel size of . mm and z pixel size of . mm). different reconstruction strategies were employed in order to evaluate the effect of degradations: a) osem d, reconstruction of the sinograms with total coincidences, b) osem d+isc, reconstruction of the sinograms with only true coincidences, equivalent to an ideal scatter correction, c) osem d+isc+pvc, reconstruction of the sinograms using the isc and including a partial volume effect correction and d) osem d+isc+pvc+prc+ncc, reconstruction of the sinograms using isc, including a pvc and without positron range and non-collinearity effects. a linear regression analysis was carried out between calculated and theoretical surs. the slope of the linear fit was considered to be the recovered sur (rsur). in all cases, the correlation coefficients were also calculated. results: for all reconstruction strategies, the correlation coefficients were higher than . . the slope of the linear fit was: a) osem d: . , b) osem d+isc: . , c) osem d+isc+pvc: . and d aim recent developments in pet d scanners have enabled the spatial resolution to achieve - mm fwhm range. with such an optimization, even small patient movements during data acquisition can lead to severe image quality degradation. frequently, patients who undergo pet brain scans suffer from movement disorders. if a head cushion is used, the probability of involuntary movements is still high. monte carlo simulator codes may assume a relevant role in understanding the image implication of these occurrences. the aim of this work is to show the potentiality of the geant application for tomographic emission (gate) to simulate the results of head movements during a realistic static pet study in image quality. materials and methods we used gate platform to model the ecat exact hr+ scanner. an attractive feature of gate is its capacity to simulate the behaviour of the scanner's detectors and the signal processing chain. to achieve this, we have defined a resolution of % and energy blurring between %- % at kev, a global sensitivity for each crystal of %, and an energy window of - kev. we have applied a paralyzable dead-time model. a coincidence time window and a delayed window were simulated. the hoffman brain phantom was used as an emission map to map f-fdg activity in ventricles, white and grey matter. a mbq f-fdg administered activity d pet minutes static hoffman simulation was performed. fiducial markers were simulated to allow the identification of movement occurrence directly in the brain sinograms. results we obtained d sinograms with radial bins and azimuthal bins for seconds time frames. a total of . e+ f decays were acquired for each static aquisition. a c language programme was conceived in order to obtain a sinogram representing the whole of simulated data. through an exploratory analysis we verify that a : relation between fiducial markers' activity and f-fdg brain activity allows clear visual identification of these markers on the sinogram containing the whole data. conclusions the preliminary results suggest that is possible to obtain realistic brain pet sinograms under realistic simulation conditions. we are currently simulating translation movements with different ranges of magnitude and to couple this information with marker activity v.s. marker dimension. rotation movements of different magnitudes will also be simulated. simulated sinograms will be used to develop a correction method suitable for correcting intra-frame movements. wall motion and thickening estimation in myocardial gated spect: a comparison between two commercially available programs l. s. maffioli, a. vignati, f. cammelli, c. songini; ospedale civile di legnano, legnano, italy. routinary interpretation of gated spect is based on a visual evaluation of the rest/stress perfusion images of the left ventricle, an analysis of global function expressed as ejection fraction (ef) and left ventricular volumes and an assessment of the regional wall motion and thickening in the gated spect images. in order to calculate left ventricular ejection fraction (lvef), end-diastolic volume (edv), wall motion (wm) and thickening (wt), various types of programs are commercially available. aim of the study: we evaluated the reproducibility of ef, edv, wm and wt results obtained from two commercially available software packages in a clinical model. methodology: fifty consecutive male patients with suspected or known cad were evaluated with rest myocardial gated-spect. each study was reconstructed using a standard filtered back-projection on the same processing workstation (odyssey philips). in order to avoid influences, pixel size and reconstruction parameters were maintained constant in all patients. two programs were compared to evaluate functional parameters: cedars-sinai quantitative gspect (qgs) and d-mspect (michigan university). so, on the same reconstructed slices, lvef, edv, wm (in mm) and wt (%) were computed in a segment model (apex, anterior, septal, inferior and lateral wall), representing the whole left ventricle. statistical analysis was performed. results: a good correlation between the programs was found only for the estimation of lvef and edv (r = . and . respectively), while a poor correlation was found for wt and wm. the r values for wt and wm are summarized in table . qgs provided bad bull's eye images in patients, and d-mspect, in patients. conclusions: cedars-sinai quantitative gspect (qgs) and the d-mspect programs provide reproducible results for the estimation of lvef and edv. in spite of these favourable results, we noted that the estimation of wt and wm only moderately correlate between qgs and d-mspect. for these parameters, the poor correlation suggests caution for the clinical use of polar maps and values of wt and wm. aim various computer algorithms are available to segment the myocardium in gated myocardial perfusion scintigraphy, to calculate functional parameters such as left ventricular ejection fraction (lvef). the ability of these algorithms to reproducibly detect the myocardium will depend on how well defined the wall is in the images of the heart, and hence on the size of any myocardial defects and the count in the heart. this study was carried out to measure the inter-operator variability of lvef calculated with the cedars-sinai and stanford methods, and to determine how this varied with count and defect size. materials and methods consecutive gated myocardial perfusion studies carried out at the bristol royal infirmary were included. a circular region of interest was drawn over the lao image of the heart and the count in the region was recorded; patients were grouped into upper quartile, lower quartile, and intermediate counts. the defect size was determined using the perfusion quantification package myoquant, and patients were grouped into no defect ( / ), defect size - % ( / ) and defect size > % ( / ). data was processed to determine lvef using multidim (stanford) and qgs (cedars-sinai). results lvef was on average . % (sd . %) lower with multidim than qgs. inter-operator variability for lvef was . % for multidim and . % for qgs. lvef decreased with increasing defect size for both multidim and qgs. the difference in lvef between qgs and multidim decreased significantly, from . % to . %, as defect size increased from zero to > % of myocardium. inter-operator variability of lvef increased with perfusion defect size for multidim, but not for qgs. lvef, and the difference between qgs and multidim, did not change with count. the inter-operator variability was greater for lvef with lower count, for both multidim and qgs, but this was only significant for multidim. conclusion the inter-operator variability of lvef measurements in gated mps may be affected by algorithm, count and defect size. overall, qgs and multidim had very similar average inter-operator variability for lvef, but multidim was more affected by count -worse with low count -and defect size -worse with large defects -than was qgs. aim: imaging from the source that striking the whole crystal area with a uniform flux of photon, is the main method for calculation of non-uniformity in gamma camera systems. in such condition a perfect system produces images of uniform count density. however noise is a major problem in evaluation of non-uniformity in low count test images. noise causes random fluctuation in count density that is hard to distinguish from real non-uniformity in the image. in this study we used statistical methods in fourier domain for calculation of non-uniformity in simulation nuclear medicine images. methods and materials: using the monte carol method, uniform and nonuniform flood images of different matrix sizes and counts density were generated. the uniformity of the images was calculated using the conventional method (integral and differential uniformity) and proposed (fourier transformation) method. results: the value of integral and differential uniformity shows that these parameters are suitable for calculation non-uniformity only in small matrix size image (high count density). however fourier transformation could perfectly reflect the non-uniformity even at very low counts almost in all matrix size. discussion: in daily uniformity test (low count density image) it is not possible to quantify the non-uniformity of test image accurately. however if data is transformed into the frequency domain, non-uniformity may be better be distinguished from random noise in data. aim:simulation is the first step for improving the imaging tests and developing the imaging systems. simset is a routine powerful simulation software for simulating nuclear medicine systems specially pet and spect. it is necessary that the parameters of these simulation software be accuracy and according to standards in real systems. in this study we considered the simset software with intrinsic quality control tests.material and methods: we perform four routine intrinsic quality control tests(uniformity , spatial resolution , spatial linearity , energy resolution) in a virtual spect system that was simulated by simset. we also used the ncat softwares to produce the phantoms of quality control. these tests were performed according to the nema methods. the calculations were done in mathlab and for more accuracy all the procedures were repeated times.result: we acquired integral and differential uniformity less than % for counts per pixel , spatial resolution less than cm , spatial linearity less than . % and energy resolution was exactly the same as the default value that be set. conclusion:all the parameters that we calculated were according nema standards. but the calculated values were ideally less than the parameters in real spect systems. it shows that it needs more study to extend the result of simulating to real condition. background: the discovery that the use of herceptin® (trastuzumab) in breast cancer may cause cardiotoxicity in some patients has led to calls for rigorous cardiac monitoring of patients, both to ensure that they are eligible for the drug and at regular intervals once therapy has begun. one of the techniques indicated for this cardiac monitoring is the gated blood pool study (muga scan). patients can only be accepted for therapy if their ejection fraction (ef) is within the normal range of the centre performing the study. it is therefore important that centres have a robust and reproducible method for measuring ef. the aim of this study was to assess the reliability of muga processing carried out at our centre. method: gated blood pool studies are performed following the administration of mbq tc m in vivo labelled red blood cells. the studies were performed on a siemens ecam gamma camera with a high resolution collimator. the data was processed using nud hermes fuga software. we selected the most recently reported muga studies which had been routinely processed by different operators. these scans were retrospectively reprocessed by two experienced operators independently. the ef results initially reported were compared with those obtained by these investigators. results: for the studies assessed, the mean (± sd) reported ef was . ± . %. the mean ef obtained by investigator was . ± . % and the mean ef obtained by investigator was . ± . %. using the paired t-test, there was found to be a significant difference between the reported efs and those obtained by both investigators (p< . ). however, there was no significant difference found between the efs obtained by the two investigators (p> . ). review of the original data processing, showed that the selection of the background region was not consistent, with regions of high activity (e.g. gut) included in a number cases. conclusion: in this preliminary review of our working practices, significant differences were found in the ef results reported when compared with subsequent re-processing by single operators carefully selecting the background region. further work is intended to ascertain other possible reasons for these differences and assess whether further training and regular review of practice is needed to ensure reliable results are reported. objectives: to enhance signal-to-noise ratio in a selected volume-of-interest (voi) centered on the heart and to improve diagnostic performance of nuclear spect studies. methods: the new method of simultaneous spect acquisition and reconstruction using a cone-beam and a parallel beam collimator has been introduced and evaluated. we simulated nuclear spect scans with tc- m sestamibi using monte carlo method (simset). we also acquired spect data using physical phantoms on a two-head gamma camera (e.cam, siemens). the normal hearts, as well as hearts with various size defects were imaged. for tomographic reconstruction we used our new fully d ordered subsets expectation maximization (osem) algorithm with cone-volume system model combined with parallel-volume system model. total variation optimization regularization was also implemented in this approach. we evaluated signal-to-noise ratio improvement in the selected voi and accuracy of determination of the extent and location of the defects in the heart using our combined cone-beam/parallel-beam acquisition and reconstruction method, as compared to conventional parallel-beam only approach. results: we established an increase in the accuracy in locating the site and the spatial extent of heart abnormalities while using our combined cone-beam/parallel-beam acquisition and reconstruction method, as compared to parallel-beam only approach. conclusions: application of our new combined cone/parallel-beam method might results in improved accuracy in nuclear cardiology spect studies. i- mibg is a radiopharmaceutical used for evaluation of cardiac symphahetic function based on the heart to mediastinum count ratio (h/m ratio) in myocardial scintigraphy. images are acquired by detecting the photons within ± % energy window centered on the kev photopeak. the radioactivity contains a considerable scatter fraction due to high energy gamma-rays with kev ( . %) and others emitted from i- . scattering and penetration of these high energy photons thrausk the lead the collimator are the prime cause of deteriorating image quality. the aim of this study is to evaluate validity of a monte carlo code for estimating the fraction of scattered photons for various types of collimators on i- mibg myocardial study. materials and methods: calculations were carried out using a monte carlo simulator which consists of the hexagon code modelled the collimator and the nai code modelled the nai detector system including the back-compartment. the code provides the energy spectrum for every pixel identifying the unscattered, the scattered and the penetrated photons. the simulated image was formed using these energy spectra. the phantom used in the measurement was made from the breast-shaped sheets of paper soaked with the i- solution. the organs such as chest wall, left-and right-lungs and heart, were simulated by the overlapped sheets having the different activity densities, respectively. the mix-dp plastic was used as the scattering medium. experimental data were acquired using the prism irix (philips) gamma-camera attached with various collimators such as the legap, the lehr and the megap. comparisons of the energy spectrum, the count profile and the planar image between the measurement and the simulation were made under the conditions with and without the scattering medium. results: the simulated count profiles along a line agreed well with the measurements. the simulated and the experimental planar images were compared with each other using the method of power spectrum analysis. the characteristics of the images obtained on the frequency domain and the subtracted images agreed between the simulation and the measurement. conclusion: monte carlo simulation of the scintillation camera system using i- enabled to reproduce the experimental images with a high accuracy. the present study is useful for the improvement of the quantitative evaluation on i- myocardial imaging. effect of administered dose level on image quality of brain perfusion imaging with m tc-hmpao: a quantitative analysis a. p. stefanoyiannis, x. geronikola-trapali, i. armeniakos, s. n. chatziioannou, a. prentakis, e. efstathopoulos, a. gouliamos; second department of radiology, nuclear medicine division, school of medicine, university of athens, athens, greece. aim: brain perfusion imaging by means of m tc-labeled hexamethyl propylene amine oxime (hmpao) is a well-established diagnostic procedure. the administered dose range recommended by the supplying company and reported in bibliography is rather wide (approximately . - mci). in this study, a quantitative evaluation of the radiopharmaceutical performance for different values of administered dose ( , , mci) was carried out, based on computer-generated indicators of image quality. subsequently, a generic image quality index was correlated with the administered dose, to produce an overall performance indicator. by means of this analysis, the necessity of higher dose administration was examined, taking into consideration patient absorbed dose. materials & methods: a sample of patients ( administered with mci, with mci and with mci) was utilised. some patients were classified as normal, while others presented various forms of pathology. evaluation of image quality was based on contrast, noise and contrast-to-noise ratio indicators, denoted ci, ni and cnr respectively. calculation of all indicators was based on wavelet transform. an overall performance indicator (denoted pi), produced by the ratio of cnr by administered dose, was also calculated. results: the results of quantitative evaluation are presented in table , where the % differences of estimated indicators for mci and mci subsamples versus the control subsample of mci are reported. calculation of skewness parameter revealed the normality of ci, ni and non-normality of cnr, pi populations. application of appropriate statistical tests (analysis of variance for normal and kruskal-wallis test for non-normal populations) showed that there is a statistically significant difference in ci (p< . ), ni (p< . ) and cnr (p< . ), but not for pi (p> . ) values. application of tukey test for normal populations ci, ni led to the conclusion that ci( mci) = ci( mci)<ci( (mci) and ni( mci)>ni( mci), while ni( mci) can not be characterised. finally, application of non-parametric multiple comparisons showed that cnr( mci)>cnr( mci), while cnr( mci) can not be characterised. the discovery ste is a dedicated brain and whole body pet scanner, with design features that enable high image spatial resolution combined with high sensitivity. the scanner combines eight multislice helical ct scanner with a pet tomography which consists of bgo crystals arranged in rings. the crystal sizes are . × . × mm in the axial, transaxial, and radial dimensions, respectively. the pet detector ring diameter is . cm with axial and transaxial fields of view (fovs) of . and cm, respectively. the ct scanner is a -slice lightspeed. this study evaluated the nema performance of the scanner. performance measurements of spatial resolution, sensitivity, image quality, scatter fraction and counting rate performance for d and d were made using the nema procedures. the low energy thresholds of -dimensional and -dimensional are set to and kev, respectively, and the both high energy is kev. the coincidence time window of d and d are set to . ns and . ns, respectively. in addition, images from the d hoffman brain phantom acquired in d modes is shown to demonstrate the image quality obtained from the scanner. the average transaxial (axial) fwhm resolution measured . ( . ) at r = cm and . ( . ) at r= . the system sensitivity in the center for d and d was measured as . kcps/mbq and . kcps/mbq, respectively. the scatter fraction was . % and . % in d and d. the peak noise equivalent count rate (necr) was . kcps at kbq/ml in d and . kcps at kbq/ml in d for a noise-free estimation of randoms. the contrast of the , , and mm hot spheres in the image quality phantom in d ( d) were . % ( . %), . %( . %), . % ( . %) and . % ( . %), respectively. the results show good system resolution and sensitivity in both d and d, making this scanner highly suitable for brain and whole body studies. the choice of two-dimensional ( d) compared with three-dimensional ( d) imaging and the effect of reducing the scan time duration in bgo based positron emission tomography computed tomography (pet ct) scanners remains a matter of discussion. in our study of patients with known or suspected head and neck cancer ( lesions total) we used a d and d acquisition protocol utilising min, min and min scan time durations on an axial single-field-of-view (sfov). the scan sequence was d min, d min, d min, d min, d min and d min to minimise redistribution and decay bias in results. semi-quantitative analysis was achieved by drawing regions-of-interest (roi) around each tumour maximum fdg uptake (suvmax) and associated uniform background mean uptake (b) in all scans to calculate suvmax, lesion signal / background ratio (i.e. suvmax/b) and image noise as the % coefficient of variation in the background (i.e. %cv in b). for suvmax in all paired scans d > d at min, min and min; differences were highly statistically significant (p< . ) with mean % differences of approximately , , and respectively favouring d. lesion signal / background ratio differences between paired d and d scans were highly statistically significant at min, min and min (p< . ) with mean % differences of approximately , , and respectively favouring d. noise differences between paired d and d scans were statistically significant at min, min and min (p< . ; p< . , p< . respectively) with mean % differences of approximately , and respectively favouring d. all lesions were seen irrespective of acquisition mode or scan time duration. we conclude that scan time durations of min may be implemented in d without significant loss of semi-quantitative information when applying our acquisition protocols and reconstruction algorithms in head and neck cancer patients on a bgo based pet ct scanner. aims: modern petct systems have detector configurations and reconstruction algorithms optimised for maximising patient throughput for whole-body fdg oncology studies. the aim of this observer study is to determine the optimum scanning time for such studies and to assess how bmi can affect this time. to understand more about perceived image quality, the relationship between image quality and image noise is also assessed. material and methods: twenty-five randomly selected patient studies were acquired in d mode on a ge dst petct scanner using list mode acquisitions, to allow the reframing of studies into imaging times of two, three, and four minutes per bed position. data was then randomised and presented to three observers in three sessions. in each session three datasets of variable quality were presented as a training set before the observer was asked to rate image quality of the study patients using a five-point scale. image noise was also characterised at several locations throughout each dataset. results: reduced imaging time led to lower image quality scores, with paired comparisons showing the largest difference in scores (mean: . %ci: . - . ) between and minutes per bed position. using our imaging protocol, minutes per bed position is necessary for an adequate (score > ) scan in the majority of studies ( / ). the relationship between score and bmi for each scanning time is shown in table . for bmi's less than , minutes per bed position were adequate in ( / ) studies. for ( / ) studies with bmi > a scan time greater than minutes was required. image noise also decreased with imaging time in similar manner to image quality, and there was also a significant association between image noise and image quality (p < . ). however, no significant difference in noise was seen between adequate and inadequate scans, and no significant association was found between noise and bmi. conclusions: using our modern petct system and protocol, minutes per bed position is adequate for most patients, although scanning time should be extended for obese patients, and could be reduced for those not overweight. furthermore our data shows a strong relationship between image quality and image noise. and mm) and by a torso background (fillable compartments), whose volume is equal to ml, was used. the tank and the spheres were filled with a set of known f-fdg concentrations in multiple experiments. in every setup, the six spheres were filled with equal concentrations of f-fdg in a fixed standard background concentration of . μci/ml, simulating clinical situation. background activity concentration was calculated from the analysis of fdg-pet studies. the experiments was repeated times; in each measurement the contrast of the spheres was % inferior in comparison to the previous one; we obtained contrast value ranging from about % to %. the emission scans were performed in d mode, acquiring a single bed centred upon the spheres. the transmission scans were performed in spiral mode, kv, ma, slice thickness . mm, pitch . . a d iterative algorithm (osem, subsets, iterations) was used for image reconstructions. a ge xeleris workstation and an advantage windows workstation were employed for image analysis. for each measurement, contrast was estimated as a function of the diameter of the spheres. a contrast-detail curve was obtained, and contrast-detail threshold was estimated. to estimate volume of small lesions, we used a threshold at % of the maximum voxel intensity value of the lesion. results lesion nominal contrast is well correlated with lesion measured contrast (r = . ). the tcdd (threshold contrast detail detectability) for the mm diameter sphere is about %, for mm diameter sphere is about %, for the mm diameter sphere is about %, for the mm diameter sphere is about %, for the mm diameter sphere is about %. conclusionswe investigated the performances of our pet/ct scanner used in d modality for lesion detectability. next step will be the investigation of the effect of acquisition and reconstruction on lesion detectability. pet has a reputation in the quantification of brain perfusion and metabolism. recent advance of pet/ct brought a new era in oncology pet. most of newly shipped pet instruments are pet/ct scanners, all of which are designed to use mainly in d mode and ct based attenuation correction. although d acquisition and ct attenuation correction have many advantages, there are remaining problems in terms of quantitative accuracy. in this paper, we focus on the effect of direct photons from radioactivity outside the fov, and the accuracy of ct based attenuation correction. the lack of interplane septa of d scanner results in an increase of random events of direct photons from outside the fov. it may badly affect the accuracy of image. in particular, oxygen- gas inhalation study for brain, high radioactivity outside the fov exists throughout the scan. we performed an o- co gas inhalation pet scan in a healthy subject using d-lso pet/ct, under the steady state condition. thanks to the lso detector, better quality images were obtained than expected prior to the scan. however, random events were % of true events. a high fraction of random must be derived from activity outside fov, especially from lung. in an experiment with external activities placing cm apart from a phantom, image deterioration was observed with increase of the external radioactivity. to estimate the accuracy of ct based attenuation correction, we performed an experiment with high attenuation objects. a phantom with multiple rod inserts was used. six inserts were filled with same amount of radioactivity, and of the were also filled with contrast material of different density. with the increase of density, measured events tend to increase, even the same activities exists. it might affect the quantitative accuracy in the region with high attenuation. our goal is to establish a method to obtain highly quantitative brain pet images, using d pet/ct designed mainly for whole body scan. aim: contrast-to noise ratio (cnr), was studied as a function of emission scan duration (esd) and activity at the start of acquisition (a acq ) for different target sizes and target-to-background (t/b) ratios using a multivariate approach in a wide range of conditions approaching the ones that can be encountered in the clinical practice, using a d-lso based pet/ct scanner. material and methods: an annular ring of water bags of cm thickness was fitted over an iec phantom in order to obtain counting rates similar to those found in average patients. a supplemental set of micro-hollow spheres was positioned inside the phantom. the phantom was filled with a solution of water and f ( kbq/ml) and the spheres with various t/b ratios of . , . and . . sequential imaging was performed to acquire pet images with varying background concentrations of about , , . , . and . kbq/ml. the esd was set to , , , and min/bed. lesion detectability was visually and quantitatively assessed. results: with t/b ratios of . , . and . the . , . and . mm spheres were detectable for the whole ranges of background activity concentration and esd, respectively. the regression equation that best summarizes the results obtained in a multiple regression model with cnr as predicted variable and t/b ratio, activity at the start of acquisition (a acq ), sphere area and esd as predictor variables may be written as: cnr=- . + . x( - /t/b)+ . x(aacq) / + . x sphere a + . x (esd) / the multiple r of model fitting equals . . all of the variables were statistically significant predictors of cnr, whose variance can be accounted for, in order of increasing weight, by esd ( = . ), t/b ratio ( = . ), sphere a ( = . ) and a acq ( = . ). conclusion: cnr depends only slightly on a acq : the weight of a acq in explaining cnr is more than halved with respect to the contribution of esd. cnr values exhibited an essentially flat response for a acq in the wide range explored . (from . to . mbq). as cnr is closely related to lesion detection, this finding suggests that also lesion detectability might not strongly depend on the injected activity, in this range. if confirmed by further studies on lesion detectability on anthropomorphic phantoms, these findings would suggest using lower fdg activities, which could be a gain both from a radiation protection and economical point of view. aim: the respiratory gating system varian rpm (real-time position management) was implemented on a ge discovery ste pet-ct scanner to reduce artifacts and drawbacks due to breathing. analyses of a moving phantom and patient acquisitions were performed to estimate the potential benefit of such a system in clinical practice. material and methods: a phantom containing spheres of different size (volume ranging from . to ml, filled with f, lesion-to-background ratio of about : ) was acquired with a ge discovery ste pet-ct coupled to a varian rpm system. breathing motion was simulated with the standard imaging gating respiratory platform (period s, amplitude mm). two series of pet-ct acquisitions were performed: i) without taking into account the motion tracking (non-gated mode) ii) by dividing the breathing period in bins and reconstructing pet-ct images for each bin (gated mode). then patients showing uptaking lesions in lungs or liver were acquired. the maximum of the weight body standard uptake value (suv bw max ) was compared for gated and non-gated acquisitions for lesions. the motion amplitude of each lesion was evaluated. results: in the phantom trial the images acquired in gated mode showed better recovery coefficients: for the smallest spheres the enhancement ranges from % to %. for the largest one the relative increase is %. in patient acquistions in gated mode lesions showed an increase less than % in suv bw max or a small decrease, an increase from % to %. lesions had motion amplitude less than mm, showing an average enhancement of suv bw max in gated mode of %. lesions with motion amplitude higher than mm (up to mm) showed an average increase in suv bw max of %. conclusions: when a periodic movement due to breathing is present in pet-ct exams, the varian rpm system provides a general improvement in the image quality, reduced motion artifacts in ct, higher suv in pet, more precise match of ct and pet, more accurate volume delineation for radiotherapeutic purposes. a high variability in the advantages of a gated acquisition was observed, depending on lesion features such as the motion amplitude. aim: f- -dopa pet is a well-established method to image dopamine transporter system in human brain. in pet/ct scanners, ac is performed with a ct-based method (ct-ac) as compared to ge- /ga- source transmission scan (s-ac) of pet only scanners. the influence of ct-ac on the determination of the influx constant (ki) to measure dopamine transporter expression is unknown. methods: ten volunteers and parkinson disease patients ( ± y) underwent a -frame -min or -frame -min acquisition after the injection of mbq of f- -fdopa, performed after ac acquisitions (ct-ac: kev, ma; s-ac: -min transmission scan; discovery ls, ge). striatal and occipital rois were drawn and time-activity curves (tac) were generated summing the central slices encompassing the striatum. ki was computed using the occipital cortex tac as input function. differences in striatal and occipital tac were characterized, and differences in ki derived using voxel-based kinetic analysis (pmod software). comparisons were performed with pearson's correlation and bland-altman plots. results: absolute differences in striatal and occipital tac between ct-ac and s-ac were < . kbq/ml ( %) in all studies (mean - . ± . kbq/ml [- ± %]). absolute difference in ki was < . e- /min ( . %) in any striatal voxel (mean - . e- ± . e- /min [ . ± . %]). correlation of ki between both ac methods was excellent (y= . x+ . , r= . , p< . ) without systematic error (p> . ). all measurement pairs were within bland-altman's reference range (- e- to + e- /min). the largest variations were observed around the skull's outline and at the interface between air and bone, in relation to differences in ac maps resolution or minor patient motion (n= ). conclusion: ct-based ac introduces a difference < % in tac and < % in voxel-based striatal ki estimates as compared to source ac. average differences of ± %, an excellent correlation between ac methods and absence of systematic differences allows using both ac method or norms interchangeably when comparing patient groups. however, in follow-up studies aiming at assessing individual disease progression or response to treatment, the same ac method should be used to avoid introducing additional variability. v. schulz , j. zeintl , a. szikszai , j. hornegger , t. kuwert ; clinic of nuclear medicine, university of erlangen/nürnberg, erlangen, germany, chair of pattern recognition, university of erlangen/nürnberg, erlangen, germany. aim: this study investigates the influence of ct-based attenuation correction on the quantification of uptake of i- . methods: data sets acquired using a hybrid spect/ spiral-ct system (symbia t , siemens, hoffman estates, il) in patients with thyroid cancer were retrospectively analyzed. the whole group of patients was divided into a subgroup exhibiting i- uptake in the thyroid bed (n = ; tg) and another one with foci located elsewhere (n = ; ntg). using regions of interest (rois), ratios were determined between the counts in the focus and those determined in the whole transversal slice. roi measurements were performed in uncorrected tomograms (nac) as well as in images corrected for attenuation using the registered ct images (ac). the minimal distance of the focus to the surface of the body (dist) was correlated to the ratio between the values determined for ac and nac (ac/nac ratio). furthermore, the roi measurements were also performed in ac scans in which spect and ct images had been misaligned by cm in one dimension beforehand (acx, acy, acz). results: the mean differences of i- uptake ratios between ac and nac were . % in tg and . % in ntg. both differences were, however, not significant due to their large standard deviations (p > . ). no significant correlation could be found between dist and the ac/nac ratio. ac using misaligned pairs of patient data sets led to a significant change of whole-slice uptake ratios for acx and acy in tg and for acz in ntg, the differences ranging between . to . % (p < . ). conclusions: ac did not affect i- uptake ratios significantly in our study, probably due to the fairly high energy of i- or also heterogeneities of the investigated group of patients with regard to the location of the foci of i- uptake. in i- -spect scans, ct-based attenuation correction should be performed with particular attention to artefacts caused by misalignment between spect and ct. objective: in nuclear oncology, ga- spect studies can still play a useful clinical role. recently, hybrid spect/ct system provided nonuniform attenuation correction with the spatial distribution of attenuation coefficients using a ct data. the purpose of this study was to verify the effects of nonuniform attenuation correction on the hot spot lesion detectability in thoracic spect images with ga- . methods: we evaluated hot spot lesions from patients with ga- thoracic spect. using our combined spect/ct system (millennium vg, ge), all patients underwent ga- spect and ct examinations. spect images were reconstructed with and without nonuniform attenuation correction. to assess the impact of attenuation correction, we compared the values of legion to normal tissue contrast. furthermore, we performed simulation study with numeric digital phantom consisted of lung and soft tissue attenuation coefficients. the phantom imitated a human thorax, in which several lung hot lesions were located in the lung field with homogeneous activity. after generating projection data from the phantom with taking attenuation into account, reconstruction was performed with and without attenuation correction. as with patients study, we compared the values of legion to normal tissue contrast. this simulation study was calculated using the software "prominence processor" developed by maeda. results: in the patients study, the average values of contrast increased from . to . with nonuniform attenuation correction. the contrast of hot spot lesions was also improved by nonuniform attenuation correction in the simulation study. on the other hand, without attenuation correction, legion to lung contrast was decreased significantly depending on the background activity in the lung. conclusion: nonuniform attenuation correction using spect/ct improves the lesion contrast in ga- thoracic spect imaging. ( ), control study in men ii ( ) and primary pheochromocytoma ( ). the scintigraphic result was correlated with those obtained in morphologic imaging techniques and follow up during a mean time of months. results: in patients the scintigraphy was negative: in of them the planar study was doubtful and spect-ct was negative and in cases both of them were negative, showing the absence of uptake in the radiological lesions visualized in of them (size of lesion < mm). the scintigraphy was positive in cases: were positive in the planar imaging (in one of them, spect-ct localized higher number of metastases) and were doubtful, contributing the spect-ct to the confirmation of pathological functionality and its location. the positivity of the i-mibg scintigraphy confirmed the clinical diagnosis of pheochromocytoma and the consequent indication of surgical treatment in all cases ( ), except in one with diseminated disease. the diagnosis in the negative cases was essential hypertension or non-hipersecretory lesions. the performance of the spect-ct represented an increase of the specificity ( % vs % for planar imaging). conclusion: in % ( / ) of cases the spect-ct helped to establish the final scintigraphic diagnosis contributing to a better diagnostic and therapeutic management accuracy. aim audit new low dose ct protocols used for localisation imaging on the philips precedence spect/ct system. method low dose protocols for localisation ct (l-ct) have been created. all are helical with identical pitch and use the doseright-dom auto ma feature: • l-ct abdo: a body protocol for viewing conventional axial ct images ( mas, kv, collimation x . , slice width mm, rotation time . s, ctdi v . mgy). • l-ct abdo mpr: a modified version of l-ct abdo with thinner reconstructed slices (collimation x . , slice . mm) making it more suitable for multi planar reconstruction (mpr). the mas was doubled ( mas, ctdi v . mgy) to maintain the same noise level. • l-ct neck: a protocol for scanning the neck using the head filter ( mas, kv, collimation x . , slice width mm, rotation time . s, ctdi v . mgy). over months, a range of spect/ct scans were performed of the body, neck or feet. an audit questionnaire was designed and completed by the reporting consultant radiologist to find out how l-cts were viewed, the amount of detail required in the image, an acceptable level of noise and if the overall image quality was acceptable. results spect/ct scans were included in the audit, using l-ct abdo (mean dlp mgy.cm), using l-ct abdo mpr (mean dlp mgy.cm) and using l-ct neck (mean dlp mgy.cm). scans were viewed in mpr mode, including of the l-ct abdo scans. image detail of < mm, - mm and - mm were required in ( %), ( %) and scans ( %) respectively. ( %) l-cts were considered to have poor image quality, of which were due to patient related artefacts. the other unacceptable scans were of feet. feet l-cts were audited, were considered acceptable but comments were made on of these indicating that a higher resolution ct would have been preferred. conclusion despite the subjective nature of these results, we now have an insight into some of the imaging requirements of l-ct. the majority of viewing and reporting was done in mpr mode requiring the thinner slices of the l-ct abdo mpr protocol. the low dose l-ct protocols are acceptable for most of our scans, except feet, where high resolution is critical (and more important than low noise). a new anthropomorphic phantom will be used to further develop these protocols and create new ones tailored to specific exam types. the audit will then be repeated. morphological image processing for automatic arm removal in spect-ct images. objectives: image fusion of longitudinal spect-ct and ct to ct studies is frequently required to detect significant changes with time. but accurate image registration is hampered by the presence of the patients arms in the field of view which may take radically different positions or even not be present in some imaging sessions. the objective of this study is to investigate the feasibility of automatic arm detection and removal even in the difficult case when the arms are touching the body. methods: the process of arm detection and removal consists of a: an automatic thresholding step is applied to each ct section to segment the data into foreground with value representing the thorax , abdomen and arms if distinct from the body and background with value zero. b:holes frequently occur within the thorax and abdomen from air , gas etc, to remove these areas the morphological image operation of opening using structured elements is applied to smooth out the resulting sections. c:connected components are identified within each section and from the number and respective sizes of the detected regions the arms may be automatically detected and removed when distinct from the abdomen. d: should the number of regions detected not reflect the presence of the arms then the morphological operation of watershed segmentation is applied . this operation automatically separates or cuts apart objects that touch. it starts with our segmented binary image and calculates a distance map to find the fattest parts of the object, the peaks or local maxima of the distance map. purpose: the aim of this study was to control the inflammatory process and evaluate the volume of the inflamed synovium of the knee during the radiation synovectomy (rs) treatment of chronic synovitis. gadolinium-dtpa contrast-enhanced t weighted images are useful in identification of pannus tissue, which can be seen as areas of increased signal intensity adjacent to low signal intensity of joint fluid. the fusion of ho-fhma (holmium ferric hydroxide macroaggregates) spet images and mri images is often inaccurate. to avoid this problem, we aimed this volume procedure to facilitate fusion of mri and spet images. methods and material: the patients with rheumatoid arthritis were treated with ho-fhma. the spet images were taken after hours of rs. the mri images were taken three times. the first mri imaged before rs and study was used as a reference to the later imaged mri studies. the second mri was taken after one week and third mri after three months after rs. all mri control images are taken in the same manner. the images are processed with region growing method to separate inflamed synovium of the knee. the region of interests (rois) masked in every slices of the study. all rois were checked by two independent radiologists. the volume calculation was confirmed by the ml filled syringe in the same manner like patient studies. volume evaluation was possible and accurate with this procedure. result: this volume evaluation procedure shows clearly the effect of the therapy. comparing these volumes of the same patient we can see how inflamed synovium volume decreases. also the changes of the joint fluid volume can be evaluated. decreasing of the relative synovium volume after one week of rs and after three months of rs was average , % / , %. conclusion: mri is an accurate procedure to estimate the volume of acute synovitis. the volume quantification of the inflamed pannus and synovial fluid was made possible by this procedure and the effect of the therapy is accurately determined. the volume evaluation of the treated knee with rois make possible to increase accuracy of spet and mri image fusion. objectives: reconstruction of pet images from projections is a problem which from a clinical perspective seems like a chapter completed in the mid eighties; in particularly replacing already established algorithms like fbp and osem are not easily accepted. this is well justified by lack of stability of the new algorithms, the often edgy looks of the resulting images, and in general by too complex ways of obtaining the results. methods: for obtaining quantitatively correct results for use in s multi-subject region-of-interest(roi) studies, it is also well known how crucial correct delineation of the roi's for the individual subjects are, making it possible to compare binding potentials for specific roi's between subjects. when delineating the roi's, it is essential not to include tissue outside the respective region while at the same time, it is beneficial to include as much tissue as possible to lower the noise in data. this leads to the well known trade-off between bias and variance, where the size of the region is the parameter that can be optimized. results: for a number of simulated tracer distributions, we demonstrate the effect that resizing the regions have on the mean activity within a region. segmented mr images are used for simulating the tracer a possible tracer distribution in the brain and the mean activity in the insula and putamen are set to known values. knowing the true mean activity, we visualize how a scaling of the regions minimizes the error on the mean activity. it is further shown how this scaling depends on the algorithm used for reconstruction and any filtering applied to the reconstructed images. among the reconstruction algorithms, we show how an edge-preserving algorithm allows us to defining larger regions in the sense that the size that minimizes bias+variance is closer to the size of the anatomical region. conclusion: for our simulations, we conclude that for obtaining quantitatively correct measures for the mean activities in the regions, we should define our regions smaller than the regions derived from the anatomical information and for a typical case, we can reduce our bias by half by choosing either penalized least squares or an edgepreserving algorithm instead of fbp. the pet-fdg dynamic acquisitions are usually used with compartmental methods which suppose a modeling stage. these techniques are not widely used in clinical routines because of their complexity. we propose a simple and direct non invasive approach without modeling stage. the aim of this work is the definition of the cerebral physiological kinetic curves activity of fdg since its injection. material and methods: control subjects without cerebral diseases are evaluated for this study. all acquisitions are made on a biograph tm pet/ct (siemens medical solutions) with minutes total acquisition duration; an intravenous bolus of f-fdg is done during acquisition. to determine the beginning of the volume reconstructions, the arrival time of the tracer in the brain is evaluated using list-mode files. the number and duration of the reconstructed volumes (aw-osem) are respectively: x seconds; x seconds; x seconds; x seconds; x seconds; x seconds. in-house idl software (itt industries inc.) was developed to construct and analyze the fdg time activity curves of grey and white matter, arteries and veins. regions of interest (rois) for cerebral regions ( rois for each matter and rois for each vascular region) are drawn on the ct volume and then reported on pet volumes. normalization of the curves of each subject is done either by using the accumulated true events during each interval of reconstruction or by using the accumulated activity of fdg in the venous region. the standard deviations (std) are calculated at each temporal sample of the "characteristic cerebral curves" (ccc) that we define as the mean subjects' curves. results: vascular fdg curves are constructed with good temporal sampling of the few seconds after the injection showing the fdg bolus arrival at early stage. the dispersion of the ccc is evaluated for normalized and unnormalized subjects' curves at late stage (between seconds and minutes). the maximum std to mean ratio of the grey matter is . for unnormalized curves, . for the true events based normalization and . for venous based normalization; for white matter the values are respectively . , . and . . conclusion: we have defined a direct approach describing the physiological normalized curves of fdg kinetics in the cerebral regions with good temporal sampling and low dispersion. this allows the definition of key parameters of the curves. the comparison of ccc with pathological cerebral curves could be done in diseases as alzheimer. the use of normal brain spect databases that are not age-matched to the subject(s) under investigation: a feasibility study l. barnden; the queen elizabeth hospital, adelaide, australia. voxel-based statistical analysis of brain spect with the spm package offers adjustment for nuisance effects that may produce false positive results or introduce regional nuisance variance that degrades the sensitivity for detecting effects of interest. for each voxel, the software essentially performs a linear regression of the nuisance parameter versus counts and removes (adjusts out) any effect before reporting results for the effect of interest. this 'analysis of covariance' can be used to adjust for age effects provided the ages of each subject are input to spm and, in principle, should permit use of non age-matched normal databases. this approach was assessed by dividing a subject normal database into four age groups - ( subjects), - ( ) , - ( ) and - ( ) and running spm to detect significant regional differences between the - age group and each of the three other age groups with and without adjustment for age. without adjustment for age, significant regional differences were detected for all three age groups with spatial distributions that resembled the ageing effects for the whole database. after adjustment for age, there was no significant difference between the elderly and any of the other three subgroups except for one location for the - to - comparison. the coefficient of variation in gray matter suggested that using the youngest group of normals may confer a slight statistical advantage. this work demonstrates that, provided extreme age differences are avoided, it is acceptable to use a normal database that is not agematched to the patient(s) under investigation. introduction during the last years, siscom (substracted ictal spect coregistred to mri) analysis of multimodality images realised in the assessment of medically refractory partial epilepsy has been widely used. however, other methods can be explored like fractal analysis. indeed, this mathematical tool is known for its ability to characterize heterogeneities into a structure. the aim of this work was to present the preliminary results of an application based of this tool for the characterization of observable anomalies in ictal and inter ictal spect. methods we have developed an algorithm to evaluate the d fractal dimension (fd) of d images of spect. the fd is estimated by a differential box-counting approach which consists in iteratively subdividing the image on boxes with increasing size and to evaluate the df as the slope of the regression line binding sizes of the boxes and the mean of maximum deviations of gray levels in each box. as a first assessment of the algorithm, we used simulated data with a well defined fd. then we tested the algorithm on a database containing patients with ictal and interictal exams and a control group of volunteers distributed by age: between and years, between to and more than . finally, as application we used the method on an imagebase of patients with partial epilepsy. tc- m hmpao brain perfusion ictal and interictal images were acquired on a brain dedidated system: the tomomatic (medimatic). the procedure was to subdivide the images into subimages and to compare the fd of the paired subimages of ictal and interictal. results for the comparison of healthy groups and pathologic group, we found a significant difference (mann-whitney test, p< . ) whereas no difference was observed between the different healthy groups. as for the final application, we found a significant difference between the subimage where hyper-fixation focus were detected. conclusion in consideration with these promising preliminary results, we are working on a method to perform a multidimensional fractal analysis (multifractal) of the images. this method will lead us to fine characterization of local heterogeneities and thus a better localisation of epileptic focus. nevertheless, routine application of ml techniques to large scale biomedical data set is still a relatively new occurrence. otherwise, complex configuration and datapreprocess is an obstacle for physicians. this study proposes an innovative and userfriendly machine learning software for large-scale molecular and clinical data. we choose the excel file with customized header as the data standard. we use support vector machine (svm) as our machine learning algorithm in the platform. svms are a set of related supervised learning methods used for classification and regression. for handling large-scaled molecular data, some feature selections methods like recursive feature elimination are introduced in the system. the platform is a module of the pmod software (pmod technologies ltd., adlisvil, switzerland). results: on the machine learning platform, we developed some applications and did some researches related to molecular and clinical data. some examples are illustrated as follows: ( ) we developed a machine learning based tool for parameter imaging and kinetic modeling of dynamic pet study. we collected studies of kinetic modeling as training samples and built different regression models for different pet parameters. using the models, we can predict the quantitative pet parameters of vois or pixels according to the tac. ( ) classification study for gene expression data. the study addresses the problem to find a small subset of genes which provides the best discrimination for a specified classification, for instance to discriminate between normal and tumor tissues. this subset can then potentially be used for genetic diagnosis, or for drug discovery. ( ) we did a prediction study of short-term survival in patients with advanced non-small cell lung cancer following chemotherapy based on fdg-pet. the study demonstrates that a full kinetic analysis of the f-fdg kinetics is helpful for the classification into short or long survival and may helpful to identify those patients who may benefit from this palliative chemotherapeutic protocol. conclusion: the new machine learning platform provided a very unique tool for the classification and regression analysis of molecular and clinical data. the studies on the platform show that it can be widely used in the medical and biological fields. coronary artery disease (cad) is one of the world's most premier causes of early mortality, so any improvement of diagnostic process is highly appreciated. in the clinical setting, cad diagnostic is performed in a sequential manner. the four diagnostic levels consist of evaluation of ( ) signs and symptoms and ecg at rest, ( ) ecg testing during the controlled exercise, ( ) stress myocardial perfusion scintigraphy, and ( ) coronary angiography, which is considered as the reference method. in our study we focus on improving diagnostic performance of stress myocardial perfusion scintigraphy. this method bases on series of medical images. in clinical practice, these images are manually described (parameterized) and subsequently evaluated by expert physicians. we present an innovative alternative to manual image evaluation -an automatic image parametrization of multiple resolutions, based on texture description with specialized association rules, and image evaluation with machine learning methods. our results show that multi-resolution image parameterizations equals the physicians in terms of quality of image parameters. however, by using both manual and automatic image description parameters at the same time, diagnostic performance can be significantly improved with respect to the results of clinical practice. our experiments with artex image parameterization algorithm in conjunction with bayesian machine learning (naive bayesian classifier) produced highly significant results, improving diagnostic accuracy, specificity and sensitvity by more . - . %. while these values contribute to more accurate clinical diagnostics, the improvement of sepecificity by almost % also suggests that % of negative patients (no cad present) may be reliably diagnosed without resorting to coronary angiography. background: recently, it has been recommended that nhs clinical biochemistry laboratories routinely provide a measure of renal function, egfr (estimated glomerular filtration rate), based on the modification of diet in renal disease (mdrd) formula which uses serum creatinine concentration, age, ethnic origin and gender. in our centre, a further modification is applied to the formula to account for the method of serum creatinine analysis. the aim of this study was to evaluate the accuracy of egfr in our centre by comparing with the "gold standard" cr-edta gfr method. method: we measure cr-edta gfr using a sample technique following the recommendations in the british nuclear medicine society guidelines. patients were included in this retrospective study of which were male and were female, with mean age years (range - years). only patients who had cr-edta gfr measurements within two weeks of a reported egfr were included. where egfr exceeds ml/min/ . m², it is reported as "> " rather than an exact figure due to the decrease in accuracy with increasing gfr. results: for the patients, mean (± sd) measured gfr was . ± . ml/min/ . m² and mean egfr was . ± . ml/min/ . m². the mean difference between measured gfr and egfr was found to be . ml/min/ . m². the correlation coefficient was . and a paired t-test showed there was a significant difference between the two methods (p< . ). limiting the analysis to patient's with egfr< ml/min/ . m² led to a similar correlation ( . ) and again significant differences were found using the paired t-test (p< . ). for these patients, mean measured gfr was . ± . ml/min/ . m² and mean egfr was . ± . ml/min/ . m². the mean difference between measured gfr and egfr was found to be . ml/min/ . m². conclusion: in this preliminary study, absolute values of gfr and egfr were found to be significantly different. in general, egfr was found to overestimate compared with measured gfr. our findings agree with previous work suggesting that egfr becomes less accurate as gfr increases. however, egfr may be a useful indicator of the intrapatient changes in gfr as qgs and ectb behave differently and produce variable results from one another, they should not be used interchangeably. introduction estimation of reliable cardiac ejection fraction for oncology patients is of great importance in the therapy follow-up procedure. aim the development of automatic processing algorithm for the determination of left ventricle and background regions. methods multiparametric method was applied for the lv roi determination in every sequential image of the representative cycle. from amplitude, phase and temporary dc images of fourier time analysis segmentation of both ventricle and atrium structures was performed in the phase histogram, the lv spatial structure was separated from the other heart components by the size condition and the local minimum counts in the dc component between lv and rv and la. backround region was computed from the definite number of pixels with minimum counts in the lv close vicinity. for quality control of segmentation the visual inspection during the analysis is provided for every frame and the manual lv delineation with manual or automatic background selection is used as an alternative method. results completely automatic computational algorithm is fast enough (less than minute for frames' study and x matrix) and gives highly comparable ejection fraction value to the standard roi method (r > . ; n= ) for well separated lv from rv and lv from la studies. visual inspection of the computation procedure is provided for the lv edge delineation by the cine display mode and the time sequence of parametric images for ejection and filling rates. conclusions the new multiparametric pattern recognition method with the controlling visual tools was developed for the completely automatic processing of muga studies. for patient studies with careful positioning it can safely replaces the standard "manual" methods. aim: to investigate the effect of crystal thickness on the spatial resolution of pet detectors which use artificial neural network (ann) based positioning algorithms. finding this relationship is important in determining the best trade-off between spatial resolution and sensitivity for the optimal design of a pet detector. studies have been made to investigate this trade-off for the anger based positioning algorithms but not for the ann based algorithms. materials and methods: we took the approach of conducting monte carlo simulation studies due to the complex nature of this relationship. we chose parameter values for a continuous lso based positron emission mammography (pem) system. we used the builder, grit and detect software programs for the simulations. the detector consisted of a continuous lso scintillation crystal with an area of x mm and varying thickness levels of - mm. the hamamatsu h multi-anode ( x ) flat-panel pspmt is assumed to be mounted on the crystal. monoenergetic kev photons have been sent perpendicular to the crystal surface. training sets were constructed from simulated data on a x uniform grid with mm for each interval with photon incidences at each point for the first quadrant of the crystal. an energy threshold of kev was set in order to reduce the influence of weak events, namely compton scatters. tests were performed on sets of simulated data on a x uniform grid with mm for each interval taking photons at each point with the same energy discrimination. the inputs of the neural network, namely pspmt-anode outputs were reduced to four as x+, x-, y+ and y-, one from each corner of the resistor network. results and discussion: initial results show that nonlinearity is considerably reduced and spatial resolution improved by the ann method at different thickness values, thus rising also the question of whether the more expensive and less light efficient but more sensitive lso should be prefered to nai. a look-up- aim: the continuous crystal concept for pet offers a number of advantages such as low cost but suffers from edge effects, distortions and low spatial resolution when used with anger logic. in particular, resolution degrades rapidly with increasing crystal thickness. in this study, we aimed to develop and evaluate a new positioning and depth of interaction algorithm to be used with a continuous crystal small organ pet system in order to overcome these deficiencies. materials and methods: the algorithm we present uses a lookup table, which is constructed by using the pmt outputs of scintillation events, simulated at each sample point of a three dimensional grid covering the entire crystal volume using the detect monte carlo simulation package. scintillation point estimation is done by matching the pmt outputs of an event with the data inside the lookup table. the nearest neighbor algorithm is used during matching. during the process, we apply a first threshold for each pmt output to eliminate low energy events and then a second threshold to the nn algorithm in order to remove probable compton scatterings inside the crystal which reduce resolution. the performance of anger logic and the new algorithms are compared over a limited region for a detector configuration consisting of x x mm continuous nai crystal coupled to square pmts with dimensions x mm each. the grid consists of . mm spaced points over the entire crystal volume. kev rays are sent along a line perpendicular to the crystal face midway between the center and the edge of the crystal. results: the anger logic results in resolution loss due to uncertain depth of interaction along any line perpendicular to the crystal face. we obtained an average resolution of . mm with the new algorithm as opposed to nearly mm with the anger logic. this reflects the reduction of the positional uncertainty caused by crystal thickness as well as the elimination of most compton scattered rays. furthermore, edge effects and nonlinearities are totally eliminated. simulation results show that the new algorithm implemented for a small organ pet can provide with acceptable performance in terms of resolution and distortion while offering a low cost alternative. this algorithm can also be used in the doi determination. availability of a shielding system for brain studies in d thorax scan aim to examine the potential availability of a shielding system for brain studies in d thorax scan using fdg. material and methods a pet scanner (ge advance nxi), a shielding system for brain studies (ipl neuroshield), a cylinder phantom ( cm × cm), iec body and nema scatter phantoms were used in this study. the cylinder phantom was filled with mbq of f to simulate the brain. the background region of the body phantom was filled with an activity of . kbq/ml. the four hot spheres were filled with an activity concentration of times that of the background. the largest two spheres were filled with water only. the lung insert filled with foam pellets and water was placed in the center of the phantom. the line source of the scatter phantom was filled with mbq. emission and transmission scans were performed in three conditions. in condition , the body and scatter phantoms were used according to the nema nu - image quality measurement protocol. in condition , the cylinder phantom was used in addition to two phantoms used in condition and placed on opposite side of the scatter phantom. in condition , the shielding system was used in addition to all phantoms and located between the cylinder and body phantoms. in every condition, emission data was acquired in d mode and for min, which was performed three times. transmission scan time was min. after compensated by randoms correction, model-based scatter correction and segmented attenuation correction, the acquired data were reconstructed using fore- d iterative reconstruction with ~ iterations and subsets. according to the nema protocol, the pixel values on each image were examined. results with the % contrast and the accuracy of attenuation and scatter correction, there was not much difference among the results in three conditions. however, the % background variability for , , , , and mm spheres in condition were about . , . , . , . , . and . times those of condition , respectively. those of condition were about . , . , . , . , . and . times those of condition , respectively. these results show that the random events from the cylinder phantom were reduced by the shielding system. conclusion in d thorax study with fdg, our preliminary results show that the shielding system is potentially useful to reduce the random events from brain. aim. to describe and quantitatively assess the influence of a malfunctioning block detector on reconstructed pet images for a full ring block designed scanner. methods. by using raw data acquired with fully calibrated and perfectly functioning ecat hr+ pet scanner (cti-siemens) in d (span ) and in d (span ) mode, one block detector with % loss of efficiency was simulated. the effect of defective block was studied with: -the cm diameter ge uniform phantom scanned at high counting statistics and reconstructed with fbp ramp filter and awosem i/ s ( iterations, subsets); -the anthropomorphic alderson phantom filled with f and acquired at clinical counting statistics and reconstructed with awosem i/ s, as routinely used in wb-pet fdg studies, and i/ s. defective block was simulated also on d transmission and blank scan data to separately study the effect on μ-maps. taking as reference the original images, defective images were evaluated qualitatively and quantitatively by assessing % difference of suv ( suv % .). results. defective block severely affects measured μ-map: overestimated coefficients can be generated along the correspondent fan angle. a considerable reduction of such artefacts can be obtained by segmenting transmissive data. visually and quantitatively, defective block slightly influences reconstructed images of d or d emission data when segmented attenuation coefficients are used. as shown by reconstructed high counting statistics uniform images defective block generates different artefact shapes on d and d data: -in d mode with ramp fbp or i/ s awosem they appear as cold stripes along the fan angle covered by the defective detector; -in dmode a very slight distortion on the edge tangential to the fan is visible only with awosem. on the uniform and alderson phantom images, in regions where artefacts were visible suv% was less than %. conclusions.this study showed that for hr+ scanner, even a % loss of efficiency of a block, in spite of the evident defect on sinograms, does not substantially affect qualitatively and quantitatively d/ d mode reconstructed images ( suv% variations less than %) when segmented or non altered attenuation coefficients are used. simulations on patient studies are under evaluation to confirm results obtained with phantoms. it is worth noting that the clinical use of a scanner with a defective block is to help temporary patient management and not to change maintenance scheduler or lower the quality standards. contrast and sensitivity performances of elscint, general electric, siemens and smv multi-heads cameras. mbq tc- m. a cm-diameter cylindrical phantom with home made hot ( - mm) and cold ( - mm) rods inserts was filled with about mbq tc- m. a tomography of or steps over ° was recorded in h-mode with a circular trajectory. using a * matrix and a hardware zoom, projection pixel size was adjusted to . mm for the vg, to . mm for the dst and to . - . mm for the other cameras. reconstructed slices were obtained by ramp filtered backprojection and chang attenuation correction using a ge vision . powerstation. hot and cold contrasts were determined using in-house developed software. from the known shape of the phantom and the pixel size, this software automatically proposed a template of regions of interest (roi) of predefined sizes. for each rod, two circular rois were used: one having the rod diameter and a smaller one. for each roi, the software computed the contrast using the roi mean pixel value and the roi minimum (cold) or maximum (hot) pixel value. the user was allowed to shift and rotate the template in order to coregister the rois with the rods and the background areas. results. the cold contrasts were very similar although the multispect- , the dst and, to a lesser extend, the magicam delivered somewhat lower contrasts. the smv cameras, the multispect- and the magicam, but again to a lower extend, generated lower hot contrasts than the other cameras. among the cameras that presented the highest contrasts, the sensitivity of the e-cam was to % higher. conclusions. recent multi-heads cameras from ge and siemens perform equally well from the point of view of contrast in tomography but with differences in sensitivity amounting to - %. monte carlo simulation for in- imaging using a scintillation camera with a low-energy general purpose collimator indium- (in- ) emits gamma rays with two different energies, kev ( %) and kev ( %). for in- imaging, the use of a medium-energy (me) collimator is preferable to a low energy (le) collimator. the me collimator, however, has poorer spatial resolution than the le collimator. we reported the improvement in spatial resolution of in- imaging with the combination of the low-energy general purpose (legp) collimator and the collimator-penetration correction (cpc) by a blurring filter in eanm' athens. the aim of this study is to validate a monte carle simulator developed for investigating the cpc method on in- imaging using the legp collimator. material and methods: in order to simulate a commercially available scintillation camera, we modified the in-house monte carlo program (mcep code) that our coauthor has previously developed for the transport of photons and electrons in matter. in this modified mcep code, interactions of photons in the scattering medium, the camera collimator, the nai crystal, and the back-compartment (including the light guide, photomultipliers, and electronics located behind the nai crystal) were accounted for. furtermore, special attention was paid to collimator penetration. simulations were carried out for some in- sources in air and in water, and energy spectra in the energy range - kev and images with two % energy windows set at the kev and kev photopeaks were calculated. images were separately obtained for unscattered, scattered and penetrated photons. in order to validate the modified mcep program, data acquisitions were performed using the gamma camera (gca a/di, toshiba, japan) equipped with the legp or megp collimators under the same condition as the calculations. results: the energy spectra calculated for both the legp and megp collimators were in good agreement with the measured ones. the simulated planar images for the in- source also agreed well with the experimental measurements in spatial resolution and the count profiles. the images simulated for the legp collimator's septal penetration of the kev gamma rays were very similar to the acquired images. conclusion: the modified mcep program for the in- source was validated through comparison with experimental data measured on the real scintillation camera. since this program allows for an accurate septal penetration of the kev gamma rays on the legp collimator, it is very useful for studying and optimizing the cpc method. as nuclear medicine imaging has been widely used in diagnostic and treatment, improving the image quality is so important which is not performed by conventional collimators. slit-slat collimator has been proposed for this purpose although the optimization of such collimators has not been performed yet. in order to compare the system with slit-slat and hexagonal collimator this work is performed, in which the gamma camera system with both slit-slat collimator and hexagonal collimator was simulated by monte carlo method. the simulation of hexagonal system was compared with practical results and a good correlation was found between them so in this way the validity of our simulation code was confirmed. the nai(tl) crystal thickness for simulated gamma camera systems with both slit slat and hexagonal collimator for detection of kev photons was set to be / in .since in our case we compare slit slat and hexagonal system ,collimator parameters were chosen the same as legp collimator. the simulated ss collimators consisted of lead plates and the imaging was performed by rotating the ss collimator from to in steps of . each. spatial resolution, detection efficiency, geometric efficiency and modulation transfer function (mtf) of this system for both hexagonal and ss systems were evaluated and compared. moreover the mtf of ss system was confirmed by the fourier transform of point spread function. based on the mtf value, our result showed that the spatial resolution of mentioned systems are the same whereas the relative detection efficiency of the ss system was about . times more than efficiency of hexagonal system as well as the geometric efficiency of slit slat system, which is . times more than hexagonal. the results of this study show that the ss collimators have great advantages over than hexagonal collimators by providing much higher detection efficiency, besides higher geometric efficiency while maintaining a comparable spatial resolution. as a result using this collimator makes it possible to have a better image quality in nuclear medicine imaging systems. a. kamali asl , s. sarkar , s. star artifact is one of the conventional artifacts in nuclear medicine imaging which is produced by gamma penetration in collimator septa. this effect is more profound for high energy photons. thick collimator septa reduce septal penetration but lead to formation of hole pattern in detection area and consequently degrading the quality of images, (dark area under collimator surface). one of the most important issues in collimator design is to how to reduce contribution of photon penetration and hole pattern artifact in acquired images. a gamma camera system with both hexagonal parallel hole (hex) and slit-slat (ss) collimators was simulated by monte-carlo method. the validity of simulation was done with practical data for kev photons and a good correlation was found between them. point spread function (psf), modulation transfer function (mtf), spatial resolution, efficiency, star artifact, hole pattern artifact and optimum geometry for ss collimator were evaluated for high energy photons ( up to kev ) and were compared with those of a conventional hex collimator. the efficiency of the system with ss collimator after background subtraction was measured to be times higher than hexagonal collimator and spatial resolution was . mm and . mm with % statistical error for ss and hex collimators respectively. based on our ss collimator optimum geometry, septal penetration was reduced while star artifact was remained unchanged.. by increasing the number of step rotation of ss collimator, a free star artifact imaging is achievable. the contribution of septal penetration of an optimum ss collimator was reduced more than % in comparison with hex collimator. consequently our simulation data showed that with ideal collimator material, contrast has been improved about - % . our results showed that using ss collimator has a profound effect on increasing efficiency while the spatial resolution was comparable with the system using the conventional hex collimator. in addition to increasing efficiency, star artifact was removed and contrast was improved using high attenuation material such as depleted uranium or high density material. modelling of system response with depth-dependent resolution as part of iterative reconstruction has been proposed as a resolution recovery technique in spect. recently, such schemes have become commercially available by manufacturers within routine reconstruction software implemented at clinically practical processing times. as well as improving on reconstructed spatial resolution such schemes may offer improvements in terms of signal-to-noise by supporting a more accurate detection model. we have assessed the performance of one such scheme, the philips astonish, available as part of osem reconstruction for clinical spect data. on the basis of point spread function measurements in a thorax and neck phantom the algorithm demonstrated substantial improvements in fwhm and fwtm for the parameters tested both with m tc and i spect data without affecting conservation of counts. an additional feature of precise modelling of the acquisition process appears to be an improvement in the statistical properties of the images with lower dependency on acquisition times. as convergence of statistical schemes is generally dependent on activity distribution the performance of the algorithm was assessed with more complex objects and with patient data. patient data were acquired with 'concurrent imaging' allowing multiples of seconds i.e. , , and sec per projection recorded from the same scan in order to assess the effect of counting statistics. on the basis of test objects, depth-dependent resolution modelling shows encouraging results for recovering resolution in data acquired with wider collimation and higher sensitivity. preliminary results with m tc-mdp and post-therapy i spect studies demonstrate improvements in signal-to-noise levels and reconstructed resolution. introduction: the cyclone storage phosphor imager is a digital film-less autoradiography system for qualitative and quantitative imaging of radioactivity. reusable storage phosphor screens capture and store the activity and are then scanned to create a high resolution digitized image. the phosphor-imager is a versatile tool in nuclear medicine for a broad range of applications. aim: to demonstrate the versatility of the phosphor-imager in common nuclear medicine techniques including in-vivo imaging, histology, quality control of protein radio-labeling and radionuclide uptake in cultured cells. methods: tissue from mice treated with i pr a was exposed to storage phosphor screens. histological tissue sections of rat with in and tc labeled octreotide were exposed to storage phosphor screens. thin layer chromatography (tlc) plates spotted with lu octreotate and developed with solvent were exposed to storage phosphor screens. in cultured cells in multi-well plates and collimators were exposed to storage phosphor screens. conclusion: the storage phosphor-imager is a versatile tool in nuclear medicine. it offers high resolution and quantitative analyses with a linear dynamic range of orders of magnitude. it detects activity with a better efficiency than film and can significantly reduce exposure times compared to film. the storage phosphor-imager is a useful and relatively inexpensive autoradiography device for gels, chromatograms, tissues and multi-well plates. determination of internal contamination is one of the important task in radiation accident management program. cs is one of the important radioisotopes in radiological and nuclear accident. possibility for using routine gamma camera system for this situation could be of great value. an adult bottle mannequin absorption (bomab) phantom has been used for calculations. a gamma camera with low energy general purpose (legp) and high energy general purpose (hegp) collimators has been simulated with monte-carlo method and evaluated with practical data. the simulated bomab phantom has standard dimensions. minimum detectable activity (mda) and counting efficiencies for cs and i were simulated individually. also the members of bomab phantom with different contamination of cs and i have been studied. the result of benchmarking showed a good correlation between simulation results and practical data. for the first time our new data regarding mixed cs- i source reveals strategies will exist for evaluation. the mda for cs with gamma camera is several times higher than mda's whole body counter but availability and logistically using the gamma camera in large accidents will be appreciated for primary triage and response. in other way our results showed that using a thicker or higher density of crystal can to improve the quality of results. also background contribution has important rule in accuracy of mda. determination of the weights of downscatter windows in i- spect studies r. de nijs, c. svarer; copenhagen university hospital, copenhagen, denmark. aim iodine- emits photons of kev which are detected in an imaging window. downscatter of high energy photons contributes significantly to this window, primarily by penetration of the collimator and backscattering into the crystal. for determining the weights in the triple energy window (tew) approach it is assumed that the count energy density varies linearly inside the imaging window. since the peak value of the backscattering is positioned at kev close to the energy of the imaging photons this is not the case, and the correct weight might be significantly different. for low count (e.g. dynamic) studies broader energy windows are preferred and a method of determining the weights is needed, since the ratio of the downscattered photons in the imaging window and the downscatter correction window is not known. methods if it is assumed that there are no primary and scattered photons detected in the background of the projection data, the weight for a downscatter correction window can be determined by minimizing the background outside the object. as an illustration the dual energy window (dew) scatter correction was extended with a broad downscatter correction window d ( - kev). in the dew approach a scatter window s ( - kev) is subtracted from the imaging window i ( - kev). both the scatter and the imaging window were corrected for downscatter by subtracting the weighted downscatter window. final images were reconstructed from i-k *d-k *c=i-(k -k *k )*d-k *s, where c denotes compton scattering, k and k are downscatter weights for i and s, and the weight k is the empirical dew scatter multiplier which was assumed to be . . measurements were performed on a -headed irix camera (philips medical) with legp collimators. reconstruction was performed with and without (down)scatter corrections in x matrices ( . mm pixel size) using fbp, a low pass th order butterworth filter at . nyquist and uniform attenuation correction. results human studies of both the serotonin (i- -adam) and dopamine (pe i- ) transport system were analyzed. the downscatter weights k and k were measured to be . - . and . - . for both studies. for a flat energy spectrum these values would be . (same window width) and . (= / ), respectively. conclusions the weight of a downscatter window can be determined by minimizing the background in the projection data. this makes an extension of the dew approach with a broad downscatter window possible. objectives: we devised a new correction method that combined attenuation correction using a difference of intrinsic dual-energy between lower energy emissions ( kev) and higher energy emissions ( or kev) without transmission scan and compton scatter correction using triple-energy window (tew) method for kev because of enhancing a difference of intrinsic dual-energy in ga citrate ( ga), and applied to jis phantom and tumor phantom spect studies. methods: attenuation coefficients ratio and counts ratio for kev/ kev or kev/ kev were calculated from spect data acquired by energy window of kev, kev and kev, respectively. the jis phantom for concentration linearity and resolution measurements was used. in phantom study, size of tumor simulated sphere types with . , . , . , . and . cm in diameter, and tumor types were created with tumor to non-tumor (t/nt) activity ratios of . : , . : and . : . the images reconstructed by non-attenuation-scatter (a(-)s(-)) as a conventional method, only scatter (a(-)s(+)) and attenuation-scatter (a(+)s(+)) correction were compared by visual and quantitative analysis, respectively. results: the adequate attenuation coefficients ratio and counts ratio for kev/ kev were . and , respectively. for jis phantom, concentration linearity was kept, and then fwhm was shown improvement. in the tumor phantom, the t/nt ratio was improved by attenuationscatter (a(+)s(+)) correction, and approached the real value. the quality of image for attenuation-scatter (a(+)s(+)) was higher than that for non-attenuation-scatter (a(-)s(-)). conclusions: it is suggested that a new correction method that combined attenuation correction using a difference of intrinsic dual-energy and compton scatter correction using triple-energy window (tew) method for kev is useful in ga tumor spect studies. background and aim: in vivo neuroimaging techniques in correlation with mri imaging, offers a potential which can reliably assess early clinical and pre-clinical diagnosis in parkinson's disease. the aim of this study was to compare striatal's volume from mri volumetric measurements with the specific binding index (sbi) from regional datscans results method: in thirty five patients both dopaminergic imaging using i -fp-cit spect and mri scanning were performed. specific binding index (sbi) has been calculated from regional datscan both for left and right striatum respectively, by applying the formulas: sbi left=( cv left/ cb-vv)/vs and sbi right=( cv right/ cb-vv)/vs where: cv left: total counts in left striatum roi, cv right: total counts in right striatum roi cb: total counts in background region divided by volume of the background region. vv: volume of roi, vs: volume of standard striatum (set to . ml) mri imaging has been evaluated by employing high spatial resolution t -weighted sequence such as t -weighted/ gradient-spinecho followed by a contiguous echo planar imaging sequence at the mid-brain striatal level in sagital projection. multi-planar reconstruction images have been analysed and volumetric measuerements created in order to compare volume in relation to the sbi results. statistical significance of these results was assessed using the mann-whitney test. results: the overall results show a significant relation between the two imaging modalities for discriminating normal, parkinsonian syndromes ( ps) and essential tremor (et) patients . aim: patients with carcinoma of the breast undergoing sentinel lymph node (sln) imaging in nuclear medicine may also undergo ultrasound guided wire localisation when the primary tumour is non-palpable. the wire localisation is performed by radiologists shortly after sentinel node imaging using m tc colloid. due to operational restrictions the wire localisations can only be undertaken after sentinel lymph node imaging. therefore, it was felt necessary to carry out a study to assess radiation dose to staff performing the wire localisation procedure. method: in our centre there are two regimes for patients undergoing sentinel lymph node localisation; patients injected with mbq of m tc colloid are sent for surgery on the same day whilst patients injected with mbq undergo surgery the following day. a number of dose measurements were performed including extremity, whole body and instantaneous dose rate readings during the procedures. chest and ring monitor badges were worn by the two radiologists whilst performing the wire localisations. in this study patients were included of which were injected with mbq and injected with mbq. results: for the patients the mean delay between injection and the wire localisation procedure was . hours ( mbq) and . hours ( mbq). the mean duration of all procedures was minutes.. all doses measured using the body and ring monitor badges were below the minimum detectable limits of μsv (whole body badge) and μsv (ring). a mean instantaneous dose rate of μsv hr - was measured at the minimum observed source-radiologist separation ( cm) for patients injected with mbq. based on this, body and finger dose estimates per procedure were calculated as . μsv and . μsv for the mbq patients and . μsv and . μsv for the mbq patients. conclusions: the measured dose estimates from our study show that doses received by radiologists performing ultrasound guided wire localisation procedures following patients injected with m tc colloid are insignificant. for comparison, in order to receive the annual public dose limit of msv any one radiologist would need to perform approximately procedures per year. aim: radioguided surgery and sentinel lymph-node biopsy has become standard of care in patients with breast cancer. these procedures are usually done in operating room working in close proximity to an electrosurgical unit (esu) that is known to produce high levels of electromagnetic (em) fields. this study analyses the risks deriving from the interference of esu with the operation of a gamma-probe (gp) and suggests some practical recommendations intended to minimize them. methods: we investigated the function of hand-held gps of different manufacturers (csi(tl) scintillator) evaluating their change in operations and malfunctions in the presence of strong em fields. while the tests were under way both esu and gamma probe have been set as for routine clinical use simulating a typical operating-room environment (esu's output power ranging from to w -full, ± % and ± % photopeak energy window). results: all devices tested were affected by electromagnetic interferences (emi) especially when the hand held gp was used in close proximity (< cm) of the electrosurgical return-plate and the surgeon was coagulating tissues. the interferences recorded range from a simple buzzing noise to an erroneous data displayed. in the worst case the device emitted a continuous audio signal also there were no radioactive isotopes nearby. conclusions: our study demonstrates that gamma probes are particularly sensitive to electromagnetic disturbances that can be radiated during electrosurgery activities. based on the previous results the overall suggestions and recommendations intended to avoid these unwanted effects can be summarized as follows: • do not allow electrosurgery cables to lay over or contact the cables of gp; • do not place the esu's return-plate near the lymph-node excision region; • whenever possible, use the narrower energy windows setting for the intended purpose; • all sources of rf energy should be kept at a sufficient distance from gp. considering that electromagnetic radiation it's governed by the inverse square law we suggest to place the esu and all other accessories at least . meter away from gp. aim: we aimed to analyze the different steps involved in the maintenance procedures required to run a medical cyclotron. we are operating an iba cyclone / , which is dedicated to clinical pet radionuclides production. cyclone / is a fixed energy cyclotron that accelerates hions until mev and dions until mev; our machine has eight exit ports equipped with five targets: one titanium liquid target "large volume" for f production, one niobium liquid target "large volume" for f production, one silver liquid target "small volume" for f production, one aluminum gas target for c production and one aluminum liquid target for n production. materials and methods: eight scheduled maintenance interventions are required every year, operated by iba field engineers and by the hospital staff; the complexity of the maintenance interventions changes depending on which cyclotron part has to be checked. target maintenance: no need to open the cyclotron (no vacuum shut-down); targets must be disconnected from the cooling lines; mean execution time: min/target source maintenance: cyclotron must be opened (vacuum shut-down); ion source must be disconnected from the cooling lines; mean execution time: hour stripper-foils maintenance: cyclotron must be opened (vacuum shut-down); mean execution time: min after every interventions a short beam is made on each target to verify the cyclotron yield. results: since the cyclotron started to produce radionuclides, in may , we made twenty-eight maintenance interventions, operated in part by iba field engineers and in part by the hospital staff; intervention time varied from few hours to a maximum of two days. from the radiation protection point of view, the operator total body absorbed dose is mainly dependent on the time between the last radionuclide production and the intervention. for this reason maintenance intervention are scheduled on monday, after days of cyclotron stop. up to now, from the collected data we measured a mean total body absorbed dose of μsv (range - μsv) for hospital workers, with a mean time of stay inside the bunker of min (range - min). conclusion: after three years of experience we can state maintenance interventions (i.e. routine target, ion source and stripper foils maintenance) can be performed by hospital staff without particular problems. on the other hand, for more technical demanding problems, field engineers has to be called on-site to perform the required procedures. background: phantoms using printed radioactive paper sheets from an ink-jet printer may be used to provide test objects with a close approximation to the d activity distribution in organs. however, these phantoms do not necessarily accurately represent the attenuation properties of soft tissue since they are made of a composite of paper and perspex. we propose that a stack phantom constructed of paper and sheets of spacing material can be produced with a close approximation to the attenuation properties of soft tissue, provided the correct ratio of paper to spacing material is used. aims: to measure the effective linear attenuation coefficient of paper, and to use this information to calculate the composition of a paper and spacing material stack phantom to have soft tissue (water) attenuation characteristics. the effective linear attenuation coefficients of paper and water were measured for m tc using a gamma camera (siemens e.cam) with an leap collimator in broad beam geometry. the paper was a standard office printer paper, g/m . the measured values were used to select a spacing material from published attenuation values. perspex was selected since it has a higher attenuation coefficient than water, to balance the lower attenuation coefficient of paper in the composite phantom, and because of its availability, low cost and ease of machining. the effective linear attenuation coefficient of perspex was measured, and the correct proportions of paper and perspex for use in the phantom were calculated. a stack phantom with these proportions was constructed and the linear attenuation coefficient of the paper-perspex composite was measured. results: the measured effective linear attenuation coefficients were . cm - for water, . cm - for paper and . cm - for perspex. this gives a required paper to perspex ratio of . : for water equivalence. the linear attenuation coefficient of this composition was found to be . cm - (difference to water: . cm - ). in a cm thick phantom this difference in attenuation represents a small ( . %) increase in gamma ray penetration between soft tissue and the phantom. conclusions: paper-perspex composite stack phantoms can be constructed to have attenuation properties very similar to soft tissue, enabling pseudo-anatomical soft tissue equivalent phantoms to be produced. production of radioactive quality assurance phantoms using a standard inkjet printer. j. a. van staden, h. du raan, m. g. lötter, a. van aswegen, c. p. herbst; univ. of the free state, bloemfontein, south africa. aim: the use of a standard inkjet printer is proposed to produce radioactive phantoms that can be used for the routine quality control of gamma cameras. the purpose of this study was to evaluate the printed radioactive phantoms and demonstrate their use by the determination of the camera resolution. material and methods: the ink used to print the phantoms was obtained by adding a well mixed solution of black ink and m tc pertechnetate to the cartridge of a hewlett-packard inkjet printer. ms powerpoint software was used to create an image that is representative of the radioactive distribution required. the distribution was then printed on paper using the radioactive ink. imaging was performed with a ge at starcam camera fitted with a low energy all purpose collimator and alfanuclear acquisition software. the amount of activity to be deposited on paper per unit area was predicted and compared to the measured activity. the uniformity of the printouts was compared to the uniformity obtained with a standard co flood source. joining two a size printed phantoms to create larger sources was evaluated. the spatial resolution obtained with printed sources was compared to that obtained using standard line source techniques. a resolution image was also obtained from a m tc printed bar quadrant phantom and compared to an image obtained with the lead bar pattern using a co flood source. results: the results indicated that the uniformity of the printed phantoms compared well with those obtained with the co flood source [integral uniformity . % (printed source) and . % ( co flood source)], and the accuracy of the activity predicted to be deposited was better than %. there was no difference in the resolution measurements obtained with the printed sources and those obtained with the standard methods. conclusion: this study demonstrates that affordable phantoms can easily be created to evaluate system uniformity and resolution in any department where a standard pc and inkjet printer are available. aim: a lot of sophisticated models are available for the quantitative interpretation of dynamic pet data. parameters in these models are used to define quantities, such as metabolic rate, blood volume and flow, etc., characterizing the functional physiological and/or biochemical status of tissue in vivo. normally, these models are so sophisticated that the physicians cannot easily handle them without much experience. this study proposes an innovative machine learning method for parameter imaging and kinetic modeling of pet data, which can automatically predict the values of quantitative pet parameters using learned regression models from accumulated training studies of kinetic modeling. materials and methods: the support vector machine (svm) approach was used as machine learning algorithm in the tool. svms are a set of related supervised learning methods used for classification and regression. we used the cross-validation and grid-search for automatically choosing the kernels parameters. we choose the spreadsheet file with customized header as the data standard. based on the java implementation, the software is currently offered for different operating systems. by now, we collected studies of quantitative pet parameters as training samples from -tissue compartments modeling. each training sample comprises the value of pet parameter as y value and input data as well as model data as x values. then different regression models are built for different pet parameters. using the models, we can predict the values of quantitative pet parameters of vois or pixels according to the tac of them. the tool is integrated to the pmod software (pmod technologies ltd., adlisvil, switzerland). results: squared correlation coefficient was calculated from cross-validation. the highest correlation coefficient was obtained for k for . . two correlation coefficients were also very high: vb = . , inf= . . other three correlation coefficients were below . : k = . , k = . , k = . . parametric images were also calculated for these parameters using the trained models. conclusion: the initial results show that machine learning based calculation of quantitative pet parameters is helpful for parameter imaging and kinetic modeling of pet data. it can be applied to any kinetic model based on the training studies of specific model from modeling expert. specially, the machine learning based method can be integrated with other kinetic models and be used as initialization technique for the models to decrease the number of iteration of the iterative-based kinetic methods. densitometry by dual-energy x-ray absorptiometry (dxa)is the gold standard for osteoporosis diagnosis and pharmacological treatment monitoring. the hologic qdr-discoverya densitometer offers a positioning scan mode and three different measurement scan modes: "fast-array", "array" and "high-definition", which differ in image definition, scan time and patient radiation dose. aim of this study was to assess a possible significant differences, between in-vivo bone mineral density (bmd) result measured by different scan mode and if this differences are clinically significant. patients enrolment started just after annually routine maintenance and calibration procedures by hologic inc. all acquisitions were performed by the same skilled operator. repeated acquisitions were performed for each skeletal site through the three different scan modes without repositioning of the patient between scans. analysis on whole patients and on a obese subgroup (body mass index > ) was carry out. bmd was expressed as g/cm and as t-score (sds from normal reference population database) for instrumental diagnosis (t-score > - sd for normal; t-score ranging between - and - . sd for osteopenia and t-score < - . sd for osteoporosis). patients ( man) for lumbar spine and ( men) for femoral neck were enrolled. we found a significant differences between bmd measurement in fast array/array mode and high definition mode ( , g/cm p< , anova, bonferroni's multiple comparison test). moreover, bmd differences were correlated with bone mineral content (bmc) values for fast array vs high definition (r= , ; p< , ) and for array vs high definition (r= , ; p= , ). the difference between different scan modes were statistically significant, but seem too small to be relevant in order to achieve a correct clinical diagnosis; . % of lumbar spine instrumental diagnosis based on array mode measure was different from those calculated on high definition and . % of total hip on fast array from high definition. our data suggest that for correct clinical diagnosis a physician evaluation of dxa results is needed. aim: renal volume measurement is an essential part of split renal function assessment in mr urography. the aim of this study was to assess the accuracy and repeatability of a three-dimensional segmentation algorithm based on the belief functions theory in calculating renal volumes from mr images. materials and methods: the true volume of various sized animal kidneys was obtained by fluid displacement. each kidney was examined using two different mr units. d proton-density weightedacquisitions with incremental slice thickness were obtained. the mr volume was then measured with a segmentation algorithm based on the belief functions theory. two independent observers performed all segmentations twice. accuracy, intra-and interobserver variability were evaluated by the bland-altman method. the number and type of manual corrections were recorded, as well as the whole processing time. the mean renal volume estimated by fluid displacement was ml (range, - ml). the maximal standard deviations of the difference were: . ml (accuracy), . ml and . ml (respectively intra-and inter-observer variability). segmentation of axial slices provided better accuracy and reproducibility as compared with coronal ones. overlapped coronal slices yielded poor results due to the partial volume effect. the mean processing time, including optional manual modifications, was shorter than seconds. conclusion: the belief functions theory is an accurate and reproducible mathematic method to assess renal volume from mr adjacent images. in the s the discovery of expression of somatostatin receptors on net cells made the use of somatostatin analogues in diagnosis and therapy possible. the aim of the study was to assess response of targeted radio-nuclide therapy with radio-labeled somatostatin analogue y [dota , d-phe , tyr ] octreotate (dotatate) and mixed y/ lu-dotatate in treatment of disseminated nets. materials and methods: patients with diffuse nets were enrolled, divided into two randomization group by pts. one group was treated by y dotatate: men, women, aged , +/- , . second group was treated by y/ lu dotatate: men, women, aged , +/- , . before therapy blood tests for hematology, kidney and liver function, cga were done. all patients underwent ct and scintigraphy with m tc-hynic-tate. treatments of y -or mixed y/ dotatate were repeated - weeks apart up to total calculated doses - mci /m ; per one course we usually used mci. mixed amino acids infusion was used for kidney protection. results: y dotatate: . regression of disease (pr -decrease of size and number of metastases, decrease of cga level, good clinical response) was observed in pts . stable disease (sd-stable size and number of metastases, decrease of cga) was observed in pts . patients died no nephrotoxity was observed. wbc and plt levels were stable during therapy in pts. in pts leucopenia was observed (wbc level < x / mm ); serious neutropenia < x / mm , was observed in pts. plt level decreased in pts, but thrombopenia was observed only in patient . y/ lu dotatate . pr was observed in pts, . sd in pts. . patients had progression of disease during the therapy, of them died. in pts increase of ceratinine level was observed (abnormal creatinine level from the beginning of therapy). liver tests were stable.wbc level was decreasing during therapy in all patients; we observed no serious neutropenia. plt decreased in / pts. conclusions: . it seems that y dotatate or mixed y/ lu dotatate come to the same results in treatment of patients with diffuse neuroendocrine tumors in month observation. . higher decrease of plt was observed in group treated by y dotatate than y/ lu dotatate. . lower decrease of wbc was observed in group treated by y dotatate than y/ lu dotatate, however in that group serious neutropenia < x / mm was observed p results y-dota tate therapy in patients with neuroendocrine tumors -own experience of years therapy j. kunikowska , l. krolicki , a. hubalewska-dydejczyk , a. sowa-staszczak , r. mikolajczak , d. pawlak , m. kobylecka , j. maczewska ; med.univ. of warsaw, nm dept., warsaw, poland, collegium medicum cracow, cracow, poland, obri polatom, swierk, poland. the aim of the study was to assess response of targeted radio-nuclide therapy with radio-labelled somatostatin analogue y-[dota , d-phe , tyr ]-octreotate (dotatate) in the treatment of disseminated nets. material and methods: patients (aged , +/- , ): carcinoid- pts, insulinoma- pt, gastrinoma- pts, pancreatic net- pts, neuroendocrine cancer without primary tumor- , stomach net- pt were enrolled in the study. before the therapy, blood tests for hematology, kidney and liver function and cga were performed. all patients underwent ct scans and m tc-hynic/edda-octreotate srs. . scintigraphy examinations were made with two-head elscint gammacamera, using m tc labelled somatostatine analogueoctreotate, with - mbq activity; using planar and single photon emission computed tomography (spect) techniques. and hours after injection the data was acquired in x s mode, matrix x . ct scans were performed on ge light speed . images were acquired before iv injection of contrast media mm slices thickness and in the arterial - , mm, and portal venous phase- , mm.pmod software was used for fusion imaging. treatment with y-dotatate was repeated every - weeks up to the total of mci/m . mixed amino acids infusion was used for kidney protection. results: one year observation: regression of disease (prdecrease of size and number of metastases, decrease of cga level, good clinical response) was observed in pts, stable disease (sd-stable size and number of metastases, decrease of cga) in pts. patients died. no nephrotoxicity was observed. wbc and plt levels were stable during therapy in pts (without chemotherapy). in pt with previous chemotherapy (last course a month before radiotherapy), plt level decreased ( x /mm to x /mm after the first course); the patient died two months after the beginning of the therapy. in pts leucopoenia was observed (< x /mm ) but serious neutropenia (< x /mm ) was found in pts with previous chemotherapy. thrombocytopenia (plt < x /mm ) was observed in patients with previous chemotherapy. two years observation: prolonged pr - pts; sd- pts, progression of disease in pts: with gastrinoma and stomach net without hormonal activity ( and months after radiotherapy). blood tests stable. conclusion: pr and sd were observed in / patients with disseminated net. severe haematologic toxicity was mainly observed in patients after prior chemotherapy -the question of optimizing the time between chemotherapy and radiotherapy is still open. this study was supported in part by a research grant for scientific research ( /p. - / ) from the ministry of health and ministry of education. o. solodyannikova, g. sukach, v. tratsevsky; institute of oncology of amsu, kyiv, ukraine. background. limitations of possibilities of radio-and chemotherapeutical methods for medullary thyroid cancer (mtc) resulted in use of radionuclide pharmaceuticals (rp) for its treatment. the most frequently used is i-meta-iodinebenzilguanidin ( i-mbg). problematic is monitoring of mtc patients and estimation of treatment efficacy. aim was the analysis of treatment results of mtc patients using i-mbg and m tc-carbomec for the follow-up and estimation of the treatment effectiveness. materials and methods. patients received intravenous i-mbg ( mbk). there were no complications or side effects during day stay at a clinic. three patients received repeated therapy with an interval of one year. the follow-up included scintigraphy (sg) of thyroid gland with m tc-carbomec, estimation of blood calcitonin level, ultrasonic examination and in some cases computed tomography. the repeatedly treated patients were under the follow-up during two years. during this period the whole-body scanning on residual dose of i-mbg and three times with m tc-carbomec was performed. in seven patients, who received single i-mbg treatment, diagnostic scanning was performed three times (follow-up - . years). in eight patients, treated with i-mgb, term of the follow-up -a year, diagnostic examinations with i-mgb and m tc-carbomec were performed twice. in patients diagnostic scanning with m tc-carbomec was performed after surgery, in of them -once, in -twice (follow-up - . - . years). results. during observation various reactions for i-mgb treatment have been detected. in of patients ultrasonography, sg and calcitonin level , , months after the treatment didn't detect prolongation of the pathologic process. after first course of therapy in one patient increase of calcitonin level months after resulted in appearance of hyperfixed lymph nodes on sg with m tc-carbomec. in one patient with metastatic foci in liver i-mgb therapy and control with m tc-carbomec months after didn't detect negative dynamics. in two patients with men syndrome and mtc sg with i-mgb, performed on residual therapeutic dose, revealed rp decrease but sg with m tccarbomec performed months after treatment and calcitonin level didn't reveal signs of disease progression. in patients, who didn't receive i-mgb, basing on diagnostic scanning with m tc-carbomec dissection of neck lymph nodes was carried out and sg with m tc-carbomec half a year after didn't detect prolongation of the process. conclusion. use of radionuclide therapy and diagnostics significantly increase outcomes of mtc patients' complex treatment and monitoring. p -monday, oct. , , : pm - : pm, poster area radionuclide therapy/dosimetry -clinical thyroid, bone pain palliation and miscellaneous a. k. sinha, male; national university hospital, singapore, singapore. paper describing therapeutic uses of radium was published; in , {sup } na was administered as a therapy to a leukemia patient. three years later, uptake of {sup } sr was noted in bone metastases. during the s, there was increasing use of iodine therapy for thyroid diseases, including thyroid cancer. radiolabeled antibodies targeting human tumors in animals were reported in ; antibody tumor imaging in humans was reported in . since then development of new radioisotopes and new radiopharmaceuticals, coupled with improvements in technology, make therapeutic nuclear oncology an area of growth for nuclear medicine. our aim is to project the role of therapeutic nuclear medicine in different cancer and its related complication in poster presentation. these radionuclide therapy done at national university hospital, and singapore general hospital, singapore with i- ,receptor based antibodies, peptides and bone-seeking radionuclides. methods: it involved a retrospective review on the treatment of different type of the cancer and its related complications (thyroid cancer, non-hodgkin's b-cell lymphoma, neuroendocrine tumor, liver tumor and bone pain from metastatic disease) with radionuclides, performed at national university hospital and singapore general hospital, from to in the dept of nuclear medicine. results: results are encouraging and it will be presented in the poster. conclusions: globally increasing numbers of the cancer patients, including those with thyroid cancer, lymphoma, different form of neuroendocrine tumors, liver cancer, metastatic bone involvement with prostate and breast cancer, radionuclide therapy has already become an important component of modern medical practice. new drugs application (nda) is promising form of therapy on the new horizon in the field of targeted peptides and antibodies therapy. mapping of human genome is the greatest scientific achievement of this era. molecular methodologies that were developed during human genome project, led directly to the discovery of improved molecular targets for targeted therapy. the current era moving toward increasing sophistication of radiopharmaceutical formulation, including antibodies, peptides, nano particles, fusion proteins and small organic molecules which will lead to better agents and better patterns of practice for established practice. aim: the most widely accepted protocol for the treatment of painful bone metastases suggests to administer a weight-based activity of sm-edtmp (sm) ( mbq/kg). this procedure is obviously inadequate for over weighted patients, with the risk to deliver more than gy to bone-marrow. in order to easily approach to a pre-therapy dosimetric evaluation, we tried to estimate the sm uptake by a dual mdp bone scan semiquantitative study. patients and methods: the bone uptake of ( f/ m) pts with painful skeletal metastases was studied. the week before the treatment each pt underwent mdp bone scan with a double acquisition ( min and - hrs p.i.) under the same conditions, in order to evaluate the skeletal uptake and personalize the radioactive amount of sm for the treatment. prior to inject mdp the patients were invited to void. mins after i.v. injection the patients underwent total body scan (wb) with a double-head gamma camera, with particular attention to include the whole body in the field of view. a post-micturition acquisition was repeated - hrs later, under the same conditions. identical acquisitions were performed mins and hrs after sm injection. methods: rois were drawn in order to calculate the counts for each wb. the counts were decay corrected and the geometric means for opposite views were calculated. the uptake was estimated as: u= xcnts(delayed)/cnts(early). statistical analysis was performed. results: mdp skeletal retention ranged from % to % (mean= , sd= ). sm retention ranged from % and % (mean= , sd= ). a good correlation was found between sm and mdp retention (linear regression coefficient r = . ; y= . x+ . ). if two cases (who received zolendronate the day before the study) are excluded from the study (due to a markedly interference of bisphosphonate uptake), the correlation improves (linear regression coefficient r = . ; y= . x+ . ). conclusions: the dual mdp bone scan methodology is useful to predict the retention of sm in patients with painful bone metastases. this approach can lead to a personalized dosimetry in planning radiometabolic treatment to administer the highest activity of sm, respecting the constraint of gy to the bone marrow. recent zolendronate infusion could impair bisphosphonate uptake. aim: to investigate haematological safety after multiple doses of rhenium -hedp, a betta-emmiting factor used in the palliative therapy of painful bone metastases. patients and methods: aiming to that, we evaluated patients with painful osseous metastases ( men with prostate cancer, women with breast cancer), mean age= . +/- years, who received fixed doses ( mbq) of rhenium -hedp, far off other therapeutic manipulations. of these, patients (group a, mean age= +/- years, men) underwent multiple ( - ) radioanalgetic therapies (mean= . +/- . ) and the rest patients (group b, mean age= . +/- . years, men) underwent only one therapy. haematological status (hgb, wbc and plt count) and karnofsky pain scale (ks, estimated by an established numeric rating scale, values - ) of all patients were followed up every days for months after last therapy. results: respective pretherapeutic blood count absolute values (+/-sd) of groups a and b: hgb= . +/- . and . +/- . , wbc= +/- and +/- , plt= +/- and +/- thousand. maximum percentile decrease of blood counts during the three month follow up period in groups a and b: hgb= % and %, wbc= % and %, plt= % and . %. paired t-test analysis did not show statistical difference in hgb values between pre-and post any radioisotopic therapy in both groups, while significant decrease in wbc count was seen only in group a (p= . ). the plt count was clearly decreased after therapy in both groups (p= . and . respectively), but significant myelosupression was evolved only in three patients of group a (one with grade and two with grade myelotoxicity). finally, patients with good pretherapeutic clinical status (ks>/= , mean= +/- , n= ) had less decrease in plt count after therapy compared to those with ks< (mean= +/- , n= ) (respective decrease= . +/- . % versus . +/- . %, p= . ), irrespectively of patients' age, pre-therapeutic plt count or the number of radioisotopic therapies received. conclusion: rhenium -hedp is safe enough to be readministered several times if an acceptable haematological baseline status exists, especially in those patients who present with a more favourable pretherapeutic karnofsky pain index. a. tsaroucha, g. meristoudis, t. liotsou, v. giannakopoulos, c. batsakis, a. balomenos, j. christacopoulou; dept of nuclear medicine,''sotiria'' hospital, athens, greece. introduction:the role of radionuclide bone palliation therapy in patients with prostate cancer as well as breast cancer is well established. aim: the aim of the study was to evaluate the efficacy and toxicity of radionuclide palliative treatment in patients with lung cancer. method: fourteen patients with lung cancer were included in this study. they were randomized in two groups. the first group a n = patients received mbq/kgr sm-edtmp and the other group b n= received mbq re-hedp. all of them had a positive bone scan demonstrating a multifocal spread of osseous disease. blood cell counts and renal function tests were in all patients within safe limits. two of the patients were on non steroid anti-inflammatory drugs, two on weak opioids and ten on strong opioids analgesic therapy. pain was scored by an eight-point-rating-scale. pain response as well as possible myelotoxicity were checked , , and weeks after radionuclide administration. the treatment was deemed effective if the pain retreated by at least two points. results: four of the patients of group a and three of group b experienced obvious reduction of pain. however no patient demonstrated complete pain relief. the overall pain response was %. the onset of the palliative effect was between to weeks in both groups, and its duration ranged from to weeks. two of the responded patients reduced the strong opioids consumption and these two were retreated after weeks . however retreatments were less effective than initial ones. flare phenomenon occurred in two patients, one of each group. one of them eventually responded to the therapy. mild transient myelotoxicity, concerning white blood cells and platelets, occurred in three patients, two of group a and one of group b. conclusions: patients with lung cancer and metastatic bone pain can benefit from radionuclide palliative therapy. although our sample was small, radionuclide analgesic therapy in patients with lung cancer seems to be less effective than in patients with prostate or breast cancer. the two radiopharmaceuticals did not show any difference in palliative efficacy or toxicity. radionuclide treatment for painful bone metastases in patients with hormone-refractory prostate cancer j. dolezal; teaching hospital, hradec kralové, czech republic. aim: to assess the efficacy of the sm-edtmp treatment in patients with disseminated prostate cancer with bone metastases and pain. materials and methods: thirty-eight men (aged - , mean years) with bone disseminated hormonerefractory prostate cancer and bone pain received samarium-edtmp. mean applied dosage was mbq per kg of patient's body weight. karnofsky performance status, pain score (numerical rating scale), analgesic score (who) and blood count were evaluated before and and months after the treatment. results: significant pain relief was observed in % and % of patients, mild relief in % and % and no effect in % and % of patients one and three months after administration, respectively. the pain palliation was accompanied by an improvement in mobility and a decrease in necessary dosage of analgetics. mild and transient bone marrow suppression was observed as a side effect of sm-edtmp treatment. none of the patients showed haematological toxicity grade , and only patients showed grade (nci ctc). the majority of patients had haematological toxicity grade or . conclusion: after administration of sm-edtmp bone pain palliation was observed in % of patients for three months. the haematological toxicity after sm-edtmp treatment was mild and transient. values for group ii: +/- , +/- , . +/- . % and . +/- . %. with the exception of only one patient of group i who deteriorated scintigraphically, the ssi of the rest patients was unchanged. paired t-test analysis did not show statistical difference in bsi pre-and post any radioisotopic therapy in both groups, while only in group i was seen a significant improvement in ks after the completion of therapies (p= . ). furthermore, patients of group a (pretherapeutic bsi= . +/- . ) had insignificant ks change (from +/- to +/- ), while those of group b, who set out with mean bsi= +/- , resulted in an interestingly better clinical outcome (ks from +/- to +/- , p= . ), although no difference in age, number of therapies or blood counts were observed. conclusion: in spite of a minimum scintigraphic deterioration in most patients throughout the follow up period, the post-therapeutical karnofsky scores might suggest an unexpectedly favourable clinical outcome, at least in a short-term follow up period, specifically in patients who present with a more adverse pretherapeutic bone scan and who would receive multiple rather single doses of rhenium -hedp. introduction and aims: samarium-edtmp has proved to be effective as palliative treatment in patients with difosfonate fixing bone metastases (as breast, lung, prostate cancer). its utility has also been demonstrated in patients with osteosarcoma bone metastases, when administered at high doses (from to mci/kg). prognosis of patients with osteosarcoma presenting bone metastases at diagnosis or with disease relapse or progression is generally very poor. aim of this study was to evaluate the feasibility of treatment with samarium-edtmp at the doses of mci/kg in cases of osteosarcoma with multiple bone metastases, followed by re-infusion of peripheral blood progenitor cells (pbpg) gathered after administration of cycles of ciclofosfamide and etoposide (ce). patients and methods: six patients with osteosarcoma were enrolled in the study: were affected by osteoblastic forms and grading iv, had condroblastic form -grade iii and with a round cells form. two patients had metastases at onset (vertebral, pelvic, femoral and pulmonary) and went immediately treated with samarium-edtmp, patient was treated following the second disease recurrence (at femoral and pelvic levels), patient underwent treatment after the the first recurrence (at femoral and pulmonary levels). samarium-edtmp was administered via slow e.v. injection in a single dose of mci/kg, followed days later by re-infusion of pbpc ( . x /kg cellule cd +, range . - ). all patients underwent pet-ct. results: treatment was well tolerated by all patients and no cases of severe extra-haematological toxicity occurred. white blood cell and platelet nadir took place respectively at days (range - ) and ( - ) from administration of samarium-edtmp. thirty days after the administration of samarium-edtmp one of the patients at second recurrence showed bone and pulmonary progression, the patient at first recurrence showed stable disease, on the other hand, the two patient treated at onset showed partial response (with meaningful improvement of pet scan and bone scintigraphy). approximately five months after the radiometabolic treatment three patients are died and one of patients affected by osteosarcoma with bone metastases at onset is well (partial response) conclusions: although results are still preliminary, high dose radio-metabolic treatment with samarium-edtmp appears to be well tolerated and pbpc infusion allows to control haematological toxicity. aim: to assess the outcome results at months follow up of patients with painful knee oa treated with single y- rs and factors that influence the results. methods: the rs treatment response was assessed retrospectively for painful at exercise knees of patients. the duration of oa symptoms was ± months with / knee joints presented also pain during the night and / knees abnormal knee flexibility. knee joints were assigned according the steinbrocker radiological grading system ( grade_ , grade_i, grade_ii, grade_iii and grade_iv). rs was performed with intra-articular knee injection of mbq y- silicate according eanm guidelines. rs response was assessed at months in terms of a -point visual-analog-scale (vas) pain improvement from baseline values, of the improvement of knee flexibility and pain remission during the night. rs success rate results were classified as poor (vas < ), fair (vas >= - ), good (vas >= - ) and excellent (vas > ), with excellent and good results considered as success, while fair and poor results as failure. results: the percentage of vas knee joint pain improvement from baseline values was . ± . %. there was a significant difference of the vas pain improvement in patients with the duration of disease symptoms less or more than years (p= . ), with the patient's age of less or more than years (p= . ) and with radiographic changes (p< . ). with radiographic changes adjustment it was found that knees with no or mineral oa radiographic changes (steinbrocker-grade -i) respond better than those with more advanced changes (steinbrocker-grade iii-iv) in terms of vas improvement ( . % versus . %). the overall success rate for rs (vas ), was . %. failure response was . %, with no response at all found on / knees. complete response as a complete remission and a % vas improvement was found on / knees. success rate was % for knees with no or mineral oa radiographic changes and % with steinbrocker-grade ii, while the success rate of knees with more advanced changes was . %. after rs treatment, pain during the night was improved on . % and knee flexibility was totally improved on . %. these response values were significant different from the baseline values before rs treatment (p< . ). conclusions: rs in patients with oa seems to be safe, without significant side effects and short time effective. our findings implicate rs might be more beneficial in the early stages of oa. study objectives: examination of anti-inflammatory effect of -holmium-phytate injection. methods: phases i-ii, randomized, simple-blind, placebo-controlled comparative study using increasing dosage. patients suffering from chronic synovitis, rheumatoid arthritis and seronegative spondylarthritis were examined. the protocol commenced with screening. patients were randomly distributed into four treatment arms: group i. holmium phytate injectable suspension marked by mbq ho + mg of ml triamcinolone acetonide/ta/ + ml of % lidocaine injection./lid.inj./ group ii. mbq ho. + mg of ml ta + ml lid.inj. group iii. mbq ho + mg ml ta + ml of % lid.inj. group iv. solely mg of ml ta + ml of % lid.inj. inflammatory activity of the affected knee-joint was tested prior to treatment, and the th and th days, and , , , , , , and months after treatment. testing was done based on the following parameters: measurement of swelling of knee-joint [cm]; flexion -heal buttocks distance [cm]; degree of knee-joint pain. visual analogue scale /vas- - /; patient's opinion on inflammation of knee-joint /vas- - /; doctor's opinion on given inflammation of knee-joint /vas- - / results: even after year period . % of the findings were rated as excellent or good. . % of the patients do not need another punction even after a years period. we found no deviations in either haematological or chemical parameters during the study period. administration of holmium- phytate is a safe procedure. we did not detect symptoms of radiation sickness. during the study period, inflammation decreased in the group receiving and mbq. conclusion: ho- isotope is an effective radiopharmacy treating synovitis. due its adventageous features it produces less radioactive damage on the organism than the traditionally used isotopes ( -y, -er, -re). due to its physical parameters it is optimal to treat large joints, and medium size joints. -holmium-phytate has a: radiation type beta energy maximum: . mev; and radiation type gamma, energy maximum: . mev; soft tissue penetration: maximum . mm; /average: . mm /; half-life: . hours; particle size: . - μm study objectives: measur the synovial thickness after -holmium radiosynoviorthesis by sonography. methods: phase i-iia, randomized, simple-blind, placebo-controlled comparative study using increasing dosage. patients suffering from chronic synovitis, rheumatoid arthritis, or seronegative spondylarthritis were examined. patients: gender (male/female): - ; diagnosis (ra / snsa): / ; stage of knee joint x-ray (i / ii): / ; duration of synovitis (years): . ; duration of disease (years): . ; number of punctures before the ho- treatment: . ; number of steroid injections before the treatment: . . the protocol commenced with screening. the patients were selected according to inclusion and exclusion criteria. patients were randomly distributed into four treatment arms: group i. mbq holmium phytate / -ho/ injectable suspension and mg of ml triamcinolone acetonide /ta/, and ml of lidocaine injection % group ii. mbq ho injectable suspension, and mg of ml ta and ml of lidocaine % group iii. mbq ho injectable suspension and mg of ml ta and ml of lidocaine %. group iv. solely mg of ml ta and ml of lidocaine injection %. there were month follow-up period after the administration of the isotope. we measured the quantity of the synovial fluid and the thickness of the synovia before the treatment, and the th , th days and , , , , , , and months after the treatment. we measured the synovial thickness the following locations: in the midline, lateral and medial, by the condylus of femur medial and lateral. results: the thickness of the synovia decreased significantly in the group ii. ( mbq) and iii. ( mbq). after a transient improve (the steroid effect) the thickness of the synovia began to rise in the group i. ( mbq) and in the control group. we find a significant correlation between the synovial thickness and the clinical improvenes. conclusions: the -holmium-phytate is an effective new radiopharmacon in the treatment of synovitis. we detect the clinical improvement by sonography. the effective dose is - mbq. ultrasound monitoring of the synovial thickness after -homium-phytate radiosynoviorthesis. two years results phase iii prospectiv study m. szentesi , z. farbaky , i. buday ; semmelweis univ., chair of introduction there is no consensus whether a fixed or a calculated activity of i should be used for treatment of graves' hyperthyroidism. there is no evidence that precise dosimetry leads to an improved clinical outcome. a fixed activity designed to treat the majority of patients without attempting to ablate the thyroid gland, is a simple compromise strategy. aim the aim was to examine the quality of a method developed at our institution decades ago, based on estimating the i activity one should use for treatment of graves´ disease. this method was compared with administation of a fixed activity of mbq i. material and methods our estimation method is based on the thyroid uptake of m tc-pertechnetate and the size of the thyroid gland, estimated by palpation. sixty consecutive patients with graves´ disease were randomised to receive either an individually estimated activity or a fixed activity of mbq. in average, mbq (range - mbq) was administered to patients, and patients received mbq. three patients did not, after all, want radioiodine treatment. the patients were followed until they had started thyroxin substitution or, if still euthyroid, typically for one year. each time tsh, free t and free t were measured, and side effects were noted. results among the patients who received an estimated activity, ( %) were still hyperthyroid and needed further treatment. thyroxin substitution was started in patients ( %) after an average period of . months (range . - ) . five patients were euthyroid after the treatment. of the patients given a fixed activity of mbq, ( %) were still hyperthyroid. thyroxin substitution was started in patients ( %) after an average of . months (range . - ). one year after treatment ( %) patients were still euthyroid. in summarize, the success rate of the treatment was % and % in the estimated and mbq group, respectively. this difference is not significant (p= , ), but our findings are in accordance with other published studies. conclusion the study indicates that a fixed dose of mbq as well as an estimated activity in the range of - mbq give a reasonable outcome and at the same time are in compliance with the alara principle. however, % of the patients given an estimated activity needed more than one treatment of radioiodine compared to % in the fixed activity group. this is a case of v.c., a years old, female, from las pinas city, philippines, diagnosed as a case of graves' disease. during the course of therapy, the patient had allergy to antithyroid drugs (atds) and beta blocker (propanolol). she developed rashes all over the body sparing the face the day after taking her atds as well as propanolol, thus all medications were discontinued. other options, such as rai therapy and surgery, with their respective advantages and disadvantages were fully explained to the patient who then opted to undergo rai therapy. in our institution, we usually compute the dose based on the size of the gland and radioactive iodine- uptake measurements (raiu) rather than using fixed doses. thyroid scintigraphy and raiu were done which revealed poorly visualized thyroid gland and markedly diminished -hour uptake but normal -hour uptake [raiu - hour uptake: % (nv= - %); hour uptake: % (nv= - %)]. * note: variations in normal uptake values compared to us are due to iodine deficiency still existing in some regions. because of the very low -hour uptake, we reviewed the probable causes, which can result in low uptake values. all causes were ruled out and the patient was advised to undergo two weeks of strict low-iodine diet prior to repeat thyroid scintigraphy and raiu. thereafter the result of repeat study showed diffuse thyromegaly with elevated uptake values indicating rapid trapping and organification processes [raiu - hour uptake: % (nv= - %); hour uptake: % (nv= - %)]. the day after the study, the patient was given mci i- based on the estimated weight of the gland, rapid thyroid iodine turnover ("small pool") and hour uptake. this was considered to be the highest allowable dose of rai to decrease the probability of relapse and the need for re-treatment. currently, approximately weeks after the therapy, the patient is noted to have responded satisfactorily to therapy with resolution of symptoms. aim: the aim of the study was to analyze the outcome i- therapy for autonomous thyroid adenomas in patients observed during years. materials and method: we investigated patients with plummer's disease (m/f ratio : , ; mean age , ± , years). , % of these patients had an unifocal nodule, while , % had multifocal toxic autonomous nodules. the patients always stopped for weeks before administration of radioiodine therapy. we administered i- activity of ± , mci. the mean duration of follow up was , years results: in patients ( %) a single dose was administered and the other ( patients - %) needed - doses. after four years , % of the patients who received a single dose were euthyroid with scenografic normalization. the percentage of euthyroidism was the same after ten years. the recurrent hyperthyroidism was , % - . in these patients the mean nodular weight was , gr, the mean administered dose per gram was , ± , μci. the incidence of hypothyroidism was , % within , - , years. in these patients the mean administered dose per gram nodular tissue was , ± , μci and the mean nodular weight was , ± , gr. the nodular weight was statisticaly higher in patients who had recurrent hyperthyroidism vs hypothyroidism (p= , ) and vs euthyroidism (p= , ). no differences were observed in the outcome between unifocal and multifocal nodules. conclusion: i- therapy is a simple, safe, effective and economical treatment of plummer's disease. euthyroidism can be achieved by determination of individual dose related to nodular weight and radioiodine uptake, also by preventing extranodular uptake and by evaluating more accurately the nodular weight the use of radioiodine for treatment of hyperthyroidism is based upon the radiationinduced cell changes resulting from the highly energetic beta-rays emitted by i. the magnitude of such effect appears directly proportional to the radiation dose. aim: monitoring the effect of radioiodine treatment in patients with nodular toxic goiter. material and methods: definitive radioiodine treatment is performed in patients with nodular toxic goiter, female, mean age , and male mean age , .the disease duration is , months in female and , months in male. before treatment all of the patients passed sonography, if necessary fine needle biopsy, hormonal status, radioiodine uptake test and scintigrsphy. antithyroid drug treatment was withdrawn days before radionuclide examinations. the radioiodine uptake is measured at , and hour, administered activity is , mbq. the scintigraphy was performed at hour. the patients monitoring was performed at rd month after treatment with clinical examination and hormonal measurements, at th , th and th month with clinical examination, hormonal status, radioiodine uptake and scintigraphy. radioiodine treatment was performed with dose of - mbq. results: from treated patients are female with conservative treatment duration , months and this represents twice longer duration in comparison to the male.in definitively cured patients the radioiodine uptake decreased to values , %, months after treatment and the trend retained in the follow up controls and reaches to , % compared to the initial values. in no effectively cured patients there is no significant variety in the test. the thyroid weight in the follow up period decreased with - % in comparison to the initial values. definitive treatment is determined in , % at month, in , % at month and in , % at month after treatment and this trend is observed in follow up tests. all of the patients received antithyroid drug therapy for to months followed by hormonal control and clinical examination. conclusions:for the assessment of the treatment effectiveness and due establishment of disease relapse, the follow up period for months after treatment is required.hypothyroid status after radioiodine treatment is an indicator for definitive treatment.the variety of the radioiodine uptake and the thyroid weigh are indicators for assessment of therapy effectiveness.the absorbed radioiodine dose in the thyroid gland is - gy . key words: hyperthyroidism, nodular toxic goiter, i diagnostics, i therapy, absorbed dose. the effect of radioiodine therapy on some parameters of oxidant/antioxidant balance in patients with subclinical hyperthyroidism s. s. abdelrazek, f. rogowski, a. zonenberg, m. szelachowska, a. niko ajuk, a. parfie czyk, p. szumowski, b. telejko, k. siewko; medical university of bialystok, bialystok, poland. oxidative stress plays an important role in hyperthyroidism-induced tissue damage. increased oxidative stress, with elevated levels of free radicals, together with diminished antioxidant have been described previously in patients with hyperthyroidism. aim: we aimed to determine whether patients with subclinical hyperthyroidism are subject to oxidative stress and whether radioiodine therapy has benefit effect on the oxidant and antioxidant status in subclinical hyperthyroidism. material and methods: we studied patients with untreated subclinical hyperthyroidism, ( female, male), aged - years; patients with multinodular goitre (mng), and patients with solitary autonomous nodule (atn). normal adult volunteers (age-and sex-matched) were studied as control group. qualification of these patients was based on clinical features and characteristic appearance on thyroid scintigraphy and ultrasongraphy. all the patients had normal levels of serum ft and ft , serum tsh levels was less than . mu/l and effective half-life measured by the use of t and t was more than days at the time of treatment. malignant changes were excluded in all nodules by fine needle aspiration biopsy. in the investigated groups, we evaluate malondialdehyde (mda) as a marker of oxidative stress, glutathione (gsh) and glutathione peroxidase (gpx) activity as a parameters of antioxidant system before and months after treatment with radioiodine. the serum ft ft and tsh were evaluated before and monthly up to months after rit, thyroid ultrasound, and thyroid scan were done again after months of i therapy to assess the volume of thyroid gland and thyroid nodules. the activity dose was calculated by the use of marinelli's formula and ranged between and mbq. the absorbed dose ranged between - gy, and was proportional to thyroid volume. follow up control was done every weeks. results: subclinical hyperthyroidism caused a significant increase in mda level (p < . ) as well as a significant decrease in gpx activities (p < . ) and gsh level (p < . ) compared to euthyroidism controls subject. achievement of euthyroidism after months of radioiodine administration resulted in a significant decrease of mda level, significant increase of gsh level and non significant increase in gpx activities. thyroid volume reduced to about % (average), repeated rit given to one patient. conclusions: our results confirm the imbalance of the antioxidant/oxidant status in subclinical hyperthyroid patients. radioiodine therapy was more effective to improve these balances. aim: the aim of this study is to evaluate the effectiveness of the fixed dose ( mbq) of radioiodine treatment on the function and the size of toxic adenoma (ta) and multinodular toxic goiter (mntg). patients' population: thirty patients ( m, f, age range - , mean age . ) with ta and mntg were included in the study. twenty six patients had ta and patients had mntg. fifteen patients had subclinical hyperthyroidism and patients had overt hyperthyroidism. eight patients were previously treated with antithyroid drugs. method: thyroid scan were performed, volumes of nodules were measured sonographically, thyroid hormones, tsh level and h iodine uptake were determined in all patients. all of them received fixed dose of radioiodine ( mbq). every three months (min. and max. months) thyroid hormones, tsh and the volume of the nodules were measured. results: the initial mean volume of nodules was . ml ( . - . ml). after (n= ), (n= ) and (n= ) months the volume decreased to mean . ml ( . - . ml) (p< . ), mean . ml ( . - . ml) (p< . ) and . ml ( . - . ml) (p< . ) respectively. subclinic hypothyroidism was developed in five patients during the follow-up period of nine months. only two patients were received the second dose of radioiodine after six months because of the persistent hyperthyroidism. overt hypothyroidism was not developed in any patient. the rest of the patients found to be euthyroid during the follow up after the initial treatment. conclusion: our data indicate that fixed dose ( mbq) of radioiodine was effective in both functions and volumes of ta and mntg in a short time of period. aim: rai therapy has been used for over half-a-century for the treatment of hyperthyroidism. it is extremely effective option but there are no definite methods or tests to assess the final outcome of treatment as the response varies according to a number of factors. this study was carried out to assess pulse rate at six weeks post rai therapy as an initial clinical predictor of final outcome as documented at six months on follow up. materials & methods: fifty consecutive patients referred to the department of nuclear medicine, diagnosed as having hyperthyroidism from july to december were included in the study. ( %) males and ( %) females with an age range of - years (mean age . ) were given single dose ranging from mci( mbq)- mci( mbq); mean dose . mci( . mbq). the baseline pulse rate for every patient was recorded twice; taken by the staff nurse and nuclear medicine physician and average of the two documented. the patients were followed for at least six months post rai therapy on an out-patient basis and assessed both clinically and biochemically (t , t and tsh). at six weeks the follow up pulse rate was again assessed and correlated with the tsh levels at six months. results: the baseline pulse rate per minute ranged from - with the mean pulse rate of . pre-therapy. the follow up pulse rate ranged from - per minute with the mean pulse rate . post rai therapy. it was observed that if the pulse rate was > per minute at six months post therapy, this was related with an adverse outcome at six months post treatment. when correlated with the tsh levels this was statistically significant applying fisher exact test and chi-square test with p-value of . and . respectively. conclusion: assessment of pulse rate at six weeks post rai therapy can be used as an initial clinical predictor of final outcome at six months, however, more studies with a larger cohort of patients would help confirm this in due course. purpose: in view of the euratom / regulations, a study was performed in two greek centers, in order to evaluate radiation dose to family members of patients treated with radioiodine ( i) for ablation (group i), follow-up treatment (group ii) and hyperthyroidism (group iii), provided that they followed hospital guidelines for days. the annual dose limit for the public is msv/year. however, relatives helping in the support and comfort of patients are considered volunteers and dose constraints are established for them. this constraint for adult relatives (< y) is msv during the patient's treatment. method: the radiation doses received by adult family members ( adults) of patients treated with i were measured using thermoluminescent dosimeters (tld) mounted on wrist bands, for days. the administered activity was . gbq ( mci), . gbq ( mci) and - . mbq ( - , mci) for groups i, ii and iii respectively patient's exposure rates were also measured by a survey meter for distances , and meters during the same period of days. radiation safety instructions were the same for all groups. results: radiation doses to all family members were below the recommended dose constraints, for the measurement period of days. the estimated doses to infinity were also calculated and found to be below the recommended dose constraints. the patient's exposure rates at m, at the time of their release from the hospital ranged between - μsv/h, . - μsv/h and , - μsv/h for groups i, ii and iii respectively. conclusion: the radiation dose to family members of all groups is well below recommended dose constraints, provided that they comply with hospital guidelines. according to our results, days of hospitalization is sufficient for groups i and ii. papillary carcinoma of the thyroid is usually an indolent tumor with a good survival prognosis especially when small and limited to the thyroid gland. the annual incidence of thyroid cancer per million individuals in the czech republic is approximately - new cases, thyroid cancer is rare in children below years of age -we have in our group % of children cancers and about % of microcarcinomas. thyroid cancer is five times more frequent in females than in males, the incidence increases with age. the median age at diagnosis is between - years. the authors followed since to a cohort of the patients suffering from differentiated thyroid carcinoma and detect microcarciomas since to (n= total patients). we studied this phenomenon and discovered that this change was limited to females and to the less advanced cancers t . the number of papillary cancers in women with more advanced stages did not change as well as any differentiated cancers in men. this unexpected finding cannot be explained by differences in radioactive fallout, and other factors should be looked for, as age, better evaluation of thyroid morphology in women. the increase of t cancers is remarkable, as during the years to a total of new t cancers were diagnosed in females compared to new t cancers between and , than more than six fold increase. in patients with a thyroid carcinoma of less than . cm in diameter, which represent % (n= ) of all of our patients (n= ) form - , the prognosis is excellent and routine rj ablation is not indicated. however, we still prefer total thyroidectomy in these patients. recurrent disease was detected in % of these patients, usually in the form of lung metastases or recurrent disease, typically during the first five years at the diagnosis. we found lung metastases after years after diagnosis in one patient! the fifths version of tnm classification classified tumours into the categories t ( - mm), t ( - mm). the new sixth version of tnm classification changes that clasiffication by shifting the categories into t ( - mm) and t ( - mm). this new version thus does not allow to distinguish the patients with significantly different probability of the metastasis occurrence in the - mm category. this research was supported by av cr et and by msmt cr m . v. voliotopoulos , i. valais , m. margaritaki , v. gianakopoulos ; iatropolis magnitiki tomografia, athens, greece, sotiria general hospital, athens, greece. the association between thyroid cancer and hypothyroidism is considered a rare event. in the international bibliography the incidence of coexistence of thyroid cancer and hyperthyroidism is between , % and , %. materials and methods: in our clinic since now, we treated patients with thyroid cancer and of them was operated at firs time for thyrotoxocosis and the malignancy was detected incidentally. %of them were men and %women.among them had moltinodular goiter and the rest % had graves'disease.the histological examination revealed papillary, follicular and hurthle cells carcinoma. results: all patients received radioiodine therapy and in one patient because a high radioiodine uptake ( , %) and after days of withdraw of t and a tsh level of , ngr/ml we used the recombinant tsh (thyrogen).in the wbs days after therapy in this patient the uptake was very intense in the thyroid bed. conclusion: the rate of incidence thyroid carcinoma in these subjects with thyrotoxocosis was similar to previous studies reported from other european countries. the ablation therapy year after therapy was very successful and with no need for a new therapeutic session. despite many years of experience in thyroid cancer treatment the optimal dose of iodine- necessary for successful ablation is not established. the aim of the study was to compare the rate of ablation with different doses of radioiodine. the rate of ablation was compared in four groups of patients. statistical differences were evaluated with mann-whitney u-test, kruskal-wallis test or pearson's chi-square exact test and a p value less than . was considered to indicate statistical significance. consecutive patients with papillary thyroid cancer ( women, median age years; range - years), who have undergone total thyroidectomy were retrospectively studied. ablative doses of i- were applied - weeks after the surgery. patients were hypothyroid, with tsh more than miu/l. patients were randomized into four groups according to i administered activity, starting at mci ( patients), then mci ( patients), mci ( patients), until mci ( patients). the outcome of thyroid ablation was assessed by conventional mci whole body-scan, performed in hypothyroid state - months after ablation (first control study), and finally months after (second control study). successful ablation has been defined as the absence of residual thyroid uptake in thyroid bed. the rate of successful ablation was similar in the group of patients received and mci ( % and . % respectively). the higher rate of ablation ( . % and . %) was achieved in the groups treated with and mci of radioiodine. in conclusion, our study indicates that a mci dose of radioiodine is a sufficient for a satisfactory thyroid ablation rate. use of low effectively and mci dose for initial ablation is justified by the convenience of administration, the lower expence and the lower whole-body radiation dose, and in our opinion this modality is convenient for group of patients with low risk of recurrent disease. introduction: although the differentiation thyroid cancer (dtc) has proven to be a good prognosis with significant decrease in mortality rates, many countries recently witnessed an increase incidence of this pathology. in this respect,this study aims at assessing years of dtc management in national cancer centre, through a population survey. materials &methods: patients were referred to the department of endocrinology and nuclear medicine, for dtc management between and .all patients have undergone a surgery with total thyroidectomy even for papillary microcarcinoma followed by an iodine ablation. results: this study confirms that the dtc incidence increased through the years essentially from (between to times).the female sex is times more frequent than in male ( %vs %) with a median age at diagnosis stage between to years in % of patients. in % of the cases ( % for solitary nodule), the multinodular goiter is the principal reason for the first consultation. even though the fine needle aspiration biopsy (fna) was performed only in % of patients, % were malignant. the papillary histology type is times more frequent than follicular type ( % vs %). % of patients have received an activity of . gbq of i- , while % have received . gbq , % more than . gbq as cumulative activity. after a minimum follow up of one year % of patients have had an undetectabletg. conclusion: although the increase incidence of dtc has been observed since , the reasons according to our understanding are due to the early stage diagnosis using fna, the frequent availability of neck ultrasonography and the multidisciplinary approach, rather than the fallout atmosphere of radioactive iodine or the population's exposure to thyroid radiation. as for the rest of the results, it is noticed that a patient is generally a female sex in % of the cases, aged between to years in %.they present a multinodular goiter in % with papillary histology type in % aim: well differentiated thyroid carcinoma of the ectopic thyroid tissue is a very rare entity. our aim in this study is to determine the frequency of this clinical condition and to present the clinical experience obtained in the management of our patients with thyroid carcinoma of the ectopic thyroid tissue. material and method: the clinical records of well differentiated thyroid carcinoma patients treated and followed in our institution between the years and were retrospectively evaluated. the carcinoma focus was found in an ectopic thyroid tissue in cases. the localization of the ectopic thyroid tissue was thyroglossal duct in patients, parapharengeal region in one patient, submandibular region in one patient and submental region in one patient. results: mean age of the patients ( f; m) is , years. histopathological examination of ectopic tissue specimen revealed that of the patients had papillary carcinoma and one of them had follicular carcinoma. near total thyroidectomy was performed in all of the patients. seven of patients had a focus of well differentiated carcinoma in thyroid tissue also. the size of the thyroid tumor was between - mm in cases and below mm. (papillary microcarcinoma) in cases, of them being multifocal. two patients had regional lymph node metastasis; there was hyoid bone and regional muscle tissue invasion in another patient. only sub-total/near-total thyroidectomy was performed for two patients of the patients whose thyroid gland was normal. for the other patients with advanced disease and patients who had carcinoma of the thyroid gland also; radioiodine ablation therapy was performed after thyroidectomy. two patients were lost to follow-up. mean remission time was . ( - ) months for the other patients who are currently under follow-up (for - months) by sonographic examination and thyroglobulin level measurement at intervals. conclusion: the occurrence of ectopic thyroid tissue carcinoma is uncommon in regard to all thyroid carcinomas. the evaluation of thyroid gland for concomitant carcinoma in the thyroid tissue leads to the incidental detection of papillary microcarcinoma in majority of these patients. however, the clinical course of the disease is favorable with a management protocol similar to well differentiated thyroid carcinoma. if we hypothesize that stunning effect arose from either the ablative action of the diagnostic i- dose or the early effects of the therapeutic i- dose , this like stunning phenomenon should concern any thyroid remnants independently to the time interval between the above iodine doses. aim: the goal of this study was to investigate the presence of like stunning phenomenon in patients who received both diagnostic and ablative i- dose with a delayed time interval (> months) between them. material and methods: the study included patients ( men, women, mean age years) with a histology of differentiated thyroid carcinoma , disease limited into the thyroid bed and uptake . ± . . a therapeutic i- dose of - mci was given - months after the mci i- diagnostic whole body scanning. all patients had a whole-body scan on the th posttherapy day while of them had it also on the rd day. a quantitative estimation of the thyroid remnants was considered on the rd day (dx) for the diagnostic wbs, on the rd (rx ) and th (rx ) day for the posttherapy wbs. the ratio therapeutic/diagnostic (rx /dx) concentration of i- in residual thyroid remnants was calculated for all patients and stunning was considered when rx /dx was lesser than . the ratio rx /rx and rx /dx were also calculated for the / patients. results: of the patients, ( %) exhibited rx /dx < (likestunning effect). the like-stunning population included / ( %) patients with uptake > %, / ( %) patients with uptake between % and % and / ( %) patients with uptake < %. among the patients with posttherapy evaluation on the rd and th day, patients had rx /rx > and rx /dx> , indicating a clear early curative action of the therapeutic i- dose and patients had ratio rx /dx< and rx /dx< indicating a clear curative action of the diagnostic i- dose. conclusion: our results support the hypothesis that thyroid like-stunning phenomenon can be observed in patients with a diagnostic and a delayed consecutively therapeutic i- dose. this like-stunning effect could be the consequence of destructive effects from either the diagnostic or the therapeutic i- dose, mostly when the thyroid remnants are major. objective: studies have suggested that i- whole body scans (wbss) can underestimate the extent of well differentiated thyroid cancer. we wanted to find out if i- wbs images provide an accurate foundation for deciding the therapeutic dose of i- . method: three hundred and thirty three i- wbss of consecutive patients from january to march were retrospectively reviewed. all patients received total thyroidectomy for well differentiated thyroid cancer, and were on low iodine diet for at least weeks, and reached tsh greater than miu/l prior to the i- wbs. i- wbss were obtained after the patients were given high dose of i- (> mci) for remnant thyroid tissue, local recurrence, or metastasis. the i- wbs and post-therapeutic i- wbs were performed less than weeks apart, the images were reviewed for abnormal radioiodine uptakes. results: in cases, i- wbs and post-therapeutic i- wbs agreed on the extent of the thyroid cancer. however, in cases, post-therapeutic i- wbss detected additional lesions such as further metastatic lymphadenopathy of the mediastinum or distant metastasis to the lungs. in of these i- wbs and i- wbs discrepant cases, the therapeutic dose of i- may have been increased had the physician known about the presence of additional lesions. conclusion: i- wbs performed prior to high dose radioiodine therapy underestimated the extent of well differentiated thyroid cancer in . % of the cases, and may have lead to suboptimal therapeutic dose in . % of the cases. therefore, i- wbs images alone may not be accurate basis for determining the dose of radioiodine therapy. aim of the study: to determine the recurrences and disease related deaths in patients (pts) with differentiated thyroid carcinoma (dtc) treated by surgery and by radioactive iodine ( i) as initial therapy. patients and methods: two hundred eighty dtc pts were operated and after that treated by i once or several times. all pts received life-long hormonal therapy. duration of follow-up: mean . + . years, median . years, range months- . years. probabilities of the recurrences and disease related deaths were calculated by kaplan-meier's method and the significance of differences was determined by log-rank test. results: two hundred fifty eight pts were in the remission after initial therapy; the recurrences appeared in ( . %) of them during follow-up period. the probabilities of recurrences after , and years were %, % and %, respectively. the significant influence on the appearance of recurrences had: the absence of i accumulation in tumor, incomplete remission, initial tnm stage iii and iv, pts' age > years and nodal metastases. the disease related deaths occurred in pts ( . % of all treated pts) during follow-up period; deaths occurred after recurrences in pts ( . % of pts with recurrences). the probabilities of disease related deaths after , and years were %, % and %, respectively. the significant influence on the deaths had: the initial tnm stage iii and iv, pts' age > years, distant metastases, absence of i accumulation in tumor, masculine gender and nodal metastases. conclusion: all followed pts were initially treated surgically and by radioiodine. the appearance of recurrences progressively increased with years after initial therapy, so it is necessarily to follow-up pts till the end of their life. it is very important to treat pts until complete remission of disease is reached, to decrease the frequency of recurrences. disease related deaths occurred more frequently after onset of recurrences; it is indispensably to treat relapses to achieve the stable complete remission, if this is possible. the retrospective evaluation of metastatic bone disease in differentiated thyroid carcinoma Ö. küçük, e. Özkan, e. tokmak, p. tarı, g. aras; ankara university medical faculty, ankara, turkey. aim: bone metastases(bm) are seen clinically in %- % of patients (pts) with differentiated thyroid carcinoma(dtc).due to difficult treatment, the prognosis is poor. we evaluated metastatic bone disease in our dtc group, retrospectively. material-method: bm were detected in pts out of with dtc who were treated and follow-up in our clinic between - (age range - years; f, m). papillary carcinoma was diagnosed in / pts and follicular carcinoma in / . a total of . - . gbq ( - mci) i- was given to each patient. the duration of follow-up ranged from to months. i- whole-body scan(wbs), tc- m mdp whole-body bone scan, the determination of tg and antitg levels and/or a ct scan were carried out in the assessment of a diagnosis and follow-up of pts with bm. results: the frequency of bm were found . % in our analysis. classification was performed according to detection time of bm. group ; pts diagnosed with primary bm, group ; pts with bm detected in post-ablative wbs, group ; bm diagnosed in the follow-up period in pts. in group , / pts had only bm, / pt had bone and brain metastases, / pts had lymph node and/or lung metastases also. in group ; pt had only bm, pt had bone and lung metastases. in group ; pts had bone, lymph node and/or lung metastases, pt had bone, lymph node, lung and brain metastases. in the follow-up period, pts from group and pt from group were died. the bm were seen in - months after the diagnosis for group . bm were persistent after the therapy on the other hand, additional new lesions were observed. tg level was high in all pts remarkably except pts (tg-max: ng/ml). one of these pts with normal tg level had high anti-tg level ( iu/ml), the other one had normal anti-tg level (< iu/ml). pts had anti-tg levels higher than tg levels. bm were persistent after the therapy on the other hand, additional new lesions were observed, especially in group . discussion: the frequency of bm has been reported %- %. this ratio were found . % in our analysis. we observed higher ratio of diagnosed dtc with primary bm ( %) (grup ). its prognosis was worst than other groups. conclusion: tg is more important parameter than anti-tg and the prevalence of the other organ metastases is high in dtc pts with bm. aims: based on the icrp recommendations, the policy for releasing patients with differentiated thyroid carcinoma (dtc) who underwent thyroidectomy and received ablation doses of i- , from the nuclear medicine departments should be based both on general national rules and specific regional conditions. the aim of this research was to study the kinetic, urinary excretion pattern and dosimetric characteristics i- to estimate the radiation doses to the public, and to check the policy for the release of these patients. materials and methods: twenty-nine patients with dtc who referred to our department were selected for this study. the mean radioactivity doses administrated was ± . gbq (range . - . ). the instantaneous dose rates were measured immediately after the administration of therapeutic radioiodine with patients in the upright position at distance of meters and just before they left the department at distances of . , and meters using a survey meter. also, urine samples from each patient were collected every - hours for up to days after radioiodine administration. results: the maximum dose received by the nursing staff was . msv/week, less than the dose recommended by the icrp. the dose rate and remaining activity values of out of patients were higher than those of the others and this contributed to a high standard deviation. only one of these six patients had metastases. it was noteworthy that other patients with metastases showed a moderate dose rate exposure or moderate remaining radioiodine activity in the body. on average sixty hours post administration of radioiodine, % of the administrated dose was excreted through the urine, % remained in the body and % decayed or excreted through other routes. conclusion: these results indicate that family members should take into consideration the duration and the distance of being in close contact with the above patients. the time-rate curve of urinary excretion of radioactivity in all patients showed multiple peaks due to the retention and redistribution of radioiodine within the body and the enterohepatic cycle of radioiodinated thyroid hormones. based on the study results, at least in countries as ours we strongly recommend changing the policy for release of all patients receiving radioiodine therapy except those who are capable to keep instructions properly. patients should be discharged when radioiodine body retention and instantaneous dose rate are less than mbq and msv/h at a distance of m, respectively. aim: radioiodine therapy (rit) after a total thyroidectomy is the standard treatment of differentiated thyroid cancer (dtc). since more than % of the incorporated iodine in healthy patients is cleared by the kidneys, the rit of renal failure patients (rfp) affords high requirements concerning dosimetry. aim of this study was to determine the progression of activity in rfp and to compare the results to renal healthy patients with dtc ( patients). material and methods: in the recent years we treated rfp with dtc. one of them was treated times ( x rit + diagnostic scan (ds)), twice and one patient once. consequently the activity progresses of collectively rits were documented and assessed dosimetrically. applicated activities were between and mbq ( mbq for ds). the remaining activity was measured twice a day and immediately before respectively after the haemodialysis with an individual calibrated gamma probe. hence the mean halflife was determined with an exponential fit on the one hand, and the integrals between the single measured values on the other hand for calculating the mean whole body dose (wbd). haemodialysis was done on the first and third day after application. results: the calculated halflife averages . days ( . - . ). the wbd per patient averages mgy ( - ) corresponding to a mean wbd of . mgy/mbq. in comparison, the effective halflife for non-rfp averages . days ( . - . ) and the wbd averages mgy ( - ) corresponding to a mean wbd of . mgy/mbq. the mean elimination of radioiodine per haemodialysis averages % (+/- %). conclusion: about % of the remaining activity is eliminated per haemodialysis. the effective halflife during the time interval between two haemodialysis in one patient varies depending on the grade of renal failure and should therefore be observed. the mean effective halflife for the total rit of rfp is increased times compared to healthy patients. the dose per applicated mbq is enhanced correspondingly . times. therefore, we suggest to decrease the activity for rfp with dtc to an amount of % of the activity, administered in non-rfp. retrospective analysis of patients with differentiated thyroid carcinoma (dtc) e. urbanova, j. vizda; nuclear medicine university hospital, hradec kralove, czech republic. nuclear medicine has had a major impact on the management of dtc, especially in post-operative ablation, detection and therapy of recurrence or metastases. aim of this study was long term follow-up patients ranged from to yrs after radioiodine therapy. method: during the period lasting from february till december radioiodine therapy was performed for pts after thyroidectomy due to dtc. papillary carcinoma was diagnosed in / pts and follicular in / an in one pts histologically mixed type was found. thyroid hormones treatment was done to compensate the lack of endogenous hormones and to stop tsh secretion. follow up for all pts consisted from the wbs (whole body scintigraphy) performed after thyroid remnant ablation with i. further clinical, plain x-ray of the chest, vocal cord and us (ultrasound) of thyroid gland and neck examination and periodic serum tg (thyreoglobulin) measurements and later wbs with m tc-mibi and rarely ct were performed. results: despite early detection and adequate initial treatment we observed after mean follow-up of ten yrs, three neck lymph-nodes recurrences and two pulmonary, one bone and one vocal manifestation of disease. so seven pts were retreat with radioiodine therapy. after yrs seven pts showed recurrence due to pulmonary and bone metastases and five pts were follow-up for second carcinoma. two pts died due to cardiovascular disease and one after generalisation of the disease. completely free of disease after years were pts but lot of other complications were present (e.g. haematuria, hypertension, nephrolithiasis). two patients showed one side decrease in salivary function. maximum total administered activity of i for one patient with repeated therapy for pulmonary, bone and brain metastatic process during years was about mci. conclusion: the demonstration of distant metastases can be present after long period after beginning of the disease. for the evaluation of lung metastases in dtc, determination of tg levels and the i wbs were the most important procedures. computed tomography is a useful addition, because m tc-mibi imaging alone may not be enough to detect lung metastases from dtc. short and long complications of i treatment should be taken into the careful consideration with the benefit for the patient with long survival. our first experience with low dose radioiodine ablation therapy in low risk patients with differentiated thyroid carcinoma z. rajkovaca , j. mijatovic , m. skrobic , g. mikac , g. vuleta , a. matavulj , p. kovacevic , n. ponorac ; clinical centre, banja luka, bosnia and herzegovina, medical faculty, banja luka, bosnia and herzegovina. the optimal dose of iodine- for ablation of functioning residual thyroid tissue after (near)total thyreidectomy is controversial. the aim of this study is to present our experience with low ( . gbq) dose i- in ablation of differentiated thyroid cancer remnants in low risk patients. material and methods: a total of patients (mean ages of . years, range - years) with papillary and follicular carcinoma were treated first time in our department with i- for ablation of a postoperative thyroid remnant after (near)total thyreidectomy. patients with stage pt or pt n m were including in the study. patients were divided into two groups according to size of postoperative residual thyroid tissue, level of thyroglobulin and age. group a, patients received . gbq i- , group b, patients received . gbq i- . six months after treatment, all patients were reassessed after withdrawing l-thyroxin for to weeks with i- whole body scan and serum thyreoglobulin measurement. a successful ablation was defined as the absence of thyroid bed activity in mbq i- neck scan, the neck uptake of < . % of the administered activity and the thyroglobulin value of < ng/ml. results: in group a successful ablative therapy was seen in ( . %) of patients. of these . % had papillary carcinoma on histopathology and . % had follicular carcinoma. in group b successful ablative therapy was seen in . % of patients. of these . % had follicular carcinoma on histopathology and . % had papillary carcinoma. there were no statistically significant differences between these two groups in relation to thyroid ablation. also, there were no statistically significant differences in thyroglobulin serum level months after i- treatment. the remaining ones, . % and . % respectively, received the second course of i- for remnant ablation. / patients required therapy in group a and / in group b. response to low dose i- was same in patients with papillary and follicular type of carcinoma. conclusion: our evaluation of early efficacy of adjuvant radioiodine treatment in low risk patients with differentiated thyroid carcinoma shows no differences between two radioiodine activities - . gbq and . gbq in relation to thyroid ablation. we recommend the activity of . gmbq in low risk patients. thyroid stunning phenomenon is the impairment of therapeutic i uptake by normal or metastatic thyroid tissue, as a result of previous administration of a diagnostic activity of the same radionuclide. it has been demonstrated after the administration of diagnostic activities of - mbq ( - mci) of i. we can avoid it using i in the whole-body scintigraphy. however, even the ablative therapeutic activity itself may cause stunning, because of the high radiation dose absorbed by the thyroid remnant in the first hours of the iodine accumulation (self-stunning). aim to evaluate the occurrence of self-stunning in residual thyroid tissue after total thyroidectomy for differentiated thyroid cancer followed by i therapeutic ablation. materials and methods a prospective study was conducted from / / to / / in patients submitted to total thyroidectomy for differentiated thyroid carcinoma of follicular origin ( female and male, aged from to , mean , ± , years). withdrawal of levothyroxine intake, low iodine diet throughout the foregoing week and analytical studies including iodinuria were required before undertaking both diagnostic and therapeutic procedures. cervical uptake was determinated hours after oral administration of mbq ( μci) of i. ablative therapeutic was performed days later, with i activities ranging from to mbq ( to mci), mean mbq ( mci). cervical uptake of the radionuclide was determined hours later. we used a siemens e-cam dcr dual head gamma camera, equipped with medium and high-energy collimators for i and i respectively, to obtain segmentary images of the patient`s cervical anterior region, as well as the i capsule to be administered and a known activity of i, cm from the detector. results in the diagnostic study, the cervical i uptake varied between , % and , % (mean , %). the post therapeutic uptake of i oscillated between , % and , % (mean , %). in all of the patients, a reduction in the cervical uptake of iodine ranging from - , % to - % (mean - , %) was observed in the post therapeutic study, as compared with the diagnostic one. this reduction was found to be statistically significant (t = , ; p < , ). conclusions we verified the occurrence of selfstunning in all of the patients subjected to ablative therapeutic with i. a. georgakopoulos, s. saranti, l. iordanidou, e. trivizaki, k. rethymniotakis, e. matselas, p. koutsiouba; metaxa's cancer hospital piraeus greece, piraeus, greece. if we accept the hypothesis that stunning phenomenon could be related to the curative radiation dose of iodine - , either the diagnostic or the early therapeutic iodine- (i- ) action could contribute to a stunning effect production. aim: the aim of this study was to investigate whether the diagnostic or the early therapeutic i- radiation dose provoke a partial ablation, giving thus the stunned appearance of the thyroid remnants. material and methods: patients with total/near total thyroidectomy (uptake . ± . ) for differentiated thyroid carcinoma received the first ablative iodine dose ( - mci) within months from the diagnostic mci i- dose. the patients were evaluated with diagnostic wbs hours after the administration of mci i- and with posttherapy wbs days after the ablative i- dose. furthermore of the above patients were evaluated with onemore posttherapy wbs on the rd day of the ablation. serum tsh, tg and anti-tg were considered in hypothyroid state. the patients were divided into groups according to the uptake value. group a(uptake > %) consisted of patients, group b (uptake %- %) of and group c (uptake < %) of patients. a quantitative estimation of the thyroid bed activity was performed for the diagnostic, the rd day posttherapy and the th day posttherapy wbs. the ratio therapeutic/diagnostic (rx /dx) concentration of i- in thyroid remnants was calculated and stunning was considered when the ratio rx /dx< . the ratios rx /rx and rx /dx were calculated for the patients with the additional rd posttherapy day wbs. results: of the patients ( %) demonstrated stunning phenomenon (rx /dx < ). between them / ( %) had a days interval between the diagnostic and the therapeutic dose, / ( %) had a - days interval and the rest ( %) patients had a - days interval. the stunned population consisted of / ( %) patients of group a, / ( %) of group b and / ( %) of group c. among the patients with the rd and th day posttherapy wbs, had rx /rx > and rx /dx> indicating a clear early curative action of the therapeutic i- dose and other patients had ratio rx /dx< and rx /dx< indicating a clear curative action of the diagnostic i- dose. conclusion: a partial ablation could be generated by either the diagnostic or the early curative therapeutical i- . the density of this phenomenon seems to be directly proportional to the extent of the residual thyroid tissue. radioiodine treatment is contraindicated in pregnancy. still, inadvertent therapy does occur. radioiodine was given to two pregnant women with graves' disease and thyroid cancer respectively, both in their th gestational week. routine pregnancy tests based on urinary -hcg had failed to indicate pregnancy in both cases. methods: estimation of doses to the foetuses and foetal thyroids. scrutiny of pregnancy testing. results: doses to foetal thyroids were ablative ( - gy). total foetal dose in the graves' patient was mgy and compatible with survival, whereas a foetal dose of approximately mgy together with induced hypothyroidism was fatal for the foetus of the cancer patient. conclusions: routine pregnancy tests (urine -hcg) may not only fail early and but also later in pregnancy.the -hcg level can be low from mid term, especially in case of a male foetus. the possibility of pregnancy should be considered in all fertile women before therapy with radionuclides or cytostatic regimens, and a clinical investigation undertaken on wide indications with determination of serum -hcg, preferably together with an ultrasound examination. more than two decades ago, the radiation absorbed dose thresholds for successful radioiodine- (i- ) treatment of residual thyroid tissue and lymph node metastases ( gy, n= , p< . and gy, n= , p< . , respectively) were established by maxon hr et al. n engl j med . [ ] . until today, these thresholds have been frequently cited in dosimetric context related to postsurgical thyroid cancer patients. the aim of this study was to review some quantitative dosimetric works published so far, in order to explore if the initially proposed thresholds [ ] ). the data were adopted from available works exactly in the form in which they had been published or presented and were statistically analyzed using x tables. three-hundred gy has been not statistically proven absorbed dose threshold for successful ablation of remnant thyroid with i- [ , , , , ] . suggested absorbed dose-rate threshold of gy/h for successful thyroid remnant ablation [ ] was not proven too. the lowest study-specific thresholds for successful thyroid remnant ablation were derived as follows: gy (n= , p< . ) [ ], gy (n= , p< . ) [ ] , gy (n= , p< . ) [ ], . gy/h .and. gy (n= , p< . ) [ ] . further support of the latter values is the mean absorbed doses of therapeutic i- delivered for successful ( ± gy) and unsuccessful ( ± gy) thyroid remnant ablation (n= , p< . ), as presented in abstract by haq m et al. eur j nucl med mol imaging . quantitative in-vivo data published to date does not support a widely-accepted dosimetric approach to thyroid remnant ablation based on the threshold absorbed dose of gy. in contrast, intrathyroidal doses of i- in the range of - gy appear to be evidence based cut-off values required for significantly higher success-rate of thyroid remnant ablation in postsurgical thyroid cancer patients. aim: this study evaluates the incidence of radiation thyroiditis and its relationship with i- thyroid remnant uptake following i- adminstration for post surgical completion ablation therapy for thyroid cancer. methods: patients having an initial post surgical administration of either mbq or mbq i- between jan -dec were retrospectively reviewed. the activity of thyroid remnant i- on the hour post administration scan was measured and correlated with neck symptoms experienced. following review of medical records, patients were classified as having insignificant, mild or severe thyroiditis based on no treatment, nsaids, or steroids respectively. statistical analysis was performed using ordinal and regular logistic regression for thyroiditis (yes/no). results: patients were included ( f, m; - years). patients received mbq and patients received mbq.the mean i- thyroid uptake was . mbq (range - mbq). / ( %) patients developed symptomatic radiation thyroiditis. incidence and severity of thyroiditis increased with increasing i- thyroid remnant activity (p=< . ). the risk of developing any degree of thyroiditis increased by % for every mbq increase in activity (or= . ( % ci , - . ). severe thyroiditis was not seen with remnant uptake < mbq while / ( %) of patients with remnant uptake > mbq experienced severe thyroiditis. for patients treated with mbq and mbq, thyroid remnant ablation success rate was % and % (p=ns), incidence of any thyroiditis was % and % and incidence of severe thyroiditis was % and % (p=< . ) respectively. conclusions: initial post surgical i- thyroid remnant uptake of > mbq often produces significant thyroiditis. lower initial administered i- activities may be desirable for low risk disease, particularly when a larger thyroid remnant is suspected. this lower initial administered dose does not appear to significantly compromise success rate of thyroid remnant ablation. ) . after oral administration of -i the external whole-body dose rates were measured at a distance of meter in each hospitalization day until the dose rates fall bellow the release dose rate level of μsv/hr. results: the dose rate decay was biexponential for all four groups. by considering the dose rate limit of μsv/h at m for releasing patients, % . of patients satisfied this limit after days , % . after days and % . after days. there was total of three cases with hospitalization times more than days because of functional thyroid reminants and widespread metastasis. the cumulated dose received by the nursing staff was μsv/week, less than the dose recommended by the international committee for radiation protection (icrp). discussion: our data clearly showed that suitable guidelines can be derived to limit the annual dose to less than msv for children, members of the public and staff who may come into contact with cancer patient treated with radioiodine . aims: negative diagnostic i whole body scan with elevated serum tg levels are found in % of patients with differentiated thyroid cancer (dtc). empirical radioiodine treatment has also been advocated by some researchers with controversial outcomes. we performed an anterospective study to aim the answer to abovementioned dilemma and also determine the capability of tl- scintigraphy in these patients. materials and methods: we studied patients with a mean age of ± . years who had a history of follicular cell derived thyroid cancer (fcdtc) and elevated serum tg levels with a negative i diagnostic wbs and also were treated with radioiodine. in patients also whole body scan with tl- was carried out. paired t test and correlation tests were carried out. a p-values of . or less were considered to be significant. results: the mean pretreatment and posttreatment tg were . ± . ng/ml and . ± . ng/ml respectively. there was statistically significant difference between pre and posttreatment tg (p value< . ). eleven cases showed at least % decreased in tg value (remission group), patients revealed less than % decreased in tg value (stable group) while subjects demonstrated tg increment in posttreatment tg relative to pretreatment tg value (progression group).there was no significant correlation between cumulative and also last i- doses in three groups (remission, stable and progression groups) [p value> . ]. in the posttreatment wbs, patients showed abnormal findings in their images. in follow up scan with tl- , out of cases had positive scan. in our study at least % of subjects demonstrated the reduction or normalization of serum tg occurred in the first post-treatment follow up. thus, our study support benefits of empiric rai therapy of diagnostic rai scan-negative and tg-positive fcdtc patients .in addition, for the management of fcdtc patients who do not have rai accumulation and have elevated tg, other imaging modalities such as tl- scan are helpful. conclusion: we recommend rai therapy in dtc patients with elevated tg and negative wbs .in addition, at hospitals without access to pet, we can expect improvements in the detection of recurrence and metastasis to make a logical management after total thyroidectomy using i- and t - as complements to each other. objectives: for radioimmunotherapy (rit) with y- -labelled monoclonal antibodies, a surrogate nuclide for assessing biokinetics is necessary as y- is not appropriate for imaging. due to similar half-life, coordination chemistry and metabolic handling in- is used. however, differences in biodistribution of these nuclides have been reported. here we present a method for an intraindividual comparison of blood biokinetics of in- -and y- -labelled anti-cd antibody for rit. methods: for five patients ( male and female, age: median years, range - years) with aml or all blood serum activity data were collected during dosimetry (in- ) and therapy (y- ). the median and range of the applied activities for in- and y- were mbq ( - mbq) and mbq ( - mbq), respectively. a set of models (sums of to exponentials, with various combinations of shared or non-shared parameters) was chosen and fitted to the data of each patient. non-shared parameters means fitting the in- and y- data with extra parameters, while shared means using a common parameter for both nuclides. all parameters, which describe later parts of the serum time activity curve were fitted non-shared, as the treatment could affect serum time activity curve. the fit parameters were calculated using a minimum sum of squares algorithm. the model which supported the data best was selected using the corrected akaike information criterion. the models were ranked according to the akaike weights. results: the model when sharing the parameters of the first exponential between the in- -and y- -labelled time activity curves is ranked best in four out of five patients. one patient's data were best described sharing only the half-life, but not the prefactor of the exponential. all best models were substantially supported (wi = . - . ) by the data and r as a measure of goodness of fit was higher than . . the areas under the curves from to h p.i. of the best fit model of in- and y- had a ratio of . ± . . conclusions: the introduced method is a powerful and straightforward approach for intraindividually quantifying similarities or equality of blood serum biokinetics. this is a pivotal step in the surrogate nuclide selection process, since equality or high similarity is a necessary, although not sufficient, condition for extrapolating from a pretherapeutical dosimetry on the therapeutic radiation absorbed dose. introduction a dosimetric study involves many different specialists and many different steps. it starts with the labelled of the radiopharmaceutical (in cl -dotatoc) and proceeds with the administration, the collection of biological samples, the scintigraphic exams and the physic and mathematical analysis of all data collected. aim we want to evaluate the contribution of different specialists involved in the collection data for dosimetric study before y cl -dotatoc therapy, the mantime and instrumentation-time for all steps. materials and methods the biologist of nuclear medicine department label the in cl -dotatoc with the help of a medical physicist for radioprotection. meanwhile a nurse make the infusion of the aminoacid to the patient. then a physician administer the radiopharmaceutical to the patient. immediately the collection of blood samples starts (nurse). the patient makes the complete urinary collection using dedicated containers that the biologist (who directs all steps) provides to change at established time intervals. the biologist divides all samples in test-tubes containing the same volume of liquid and then the physicist measures them by a spectrometric system. the tecnologist of nuclear medicine units performs five whole-body scans at the patient at difference times and days. the physicist performs the spect and ct applying appropriate reperies to the patients to carry out images fusion. using compartimental models and dosimetric software the physicist calculates residence-times and dosimetric data for critical organs and lesions. the result of all these work is delivered to the physicians who compiles therapeutic plane. results the patient is busy for four days. the biologist, as director of the entire procedure, is busy for all first day and for two hours in next days. the physicist is busy for four hours in first day, two hours in second day (for spect/ct) and for about three hours when all samples are collected for the data analyse. the nurse in busy in the first and second days (when he can work in routine too). the phisicians is busy for a few minutes the first day for administration and then for about two hours for the compiling of the therapeutic plane basing on the dosimetric data. conclusions all the procedure is time-expensive, but the dosimetric study is an important step of the therapy with y cl -dotatoc. to optimise the work is very important that all specialists involved are in harmony and organized. we already have performed dosimetric study and we now have a consolidated organization. aim: peptide receptor radionuclide therapy (prrt) with lu- dota-tate is used for the treatment of patients with neuroendocrine tumors. the aim of our study was to determine the organ and tumor kinetics for dosimetric calculations. material and methods: patients (aged +/- years; m, f) with metastasized neuroendocrine tumors (somatostatin expression verified before by ga- dota-noc pet/ct) were treated with activities of . - . gbq lu- dota-tate ( - cycles). on the basis of conjugated planar whole-body scintigraphies . h, h, h, h and h p.i. the time-dependent whole-body, organ and tumor activities were determined and dosimetric calculations were performed according to the mird scheme using olinda software. blood samples were drawn from patients to estimate the absorbed dose to the red marrow. to describe the kinetics we used the withdrawn s following parameters: mean half-life and uptake (fraction of injected activity/dose, id) which were calculated using the fit of the time-dependent activity curve to a mono-or bi-exponential function. results: the renal uptake decreased for the first - hours p.i. with a mean half-life of . +/- . h, followed by a second phase with a longer half-life of +/- h. the maximum kidney uptake was +/- %. the uptake in the spleen was with +/- . % id stable until hours p.i. and then showed a decline with a half-life of +/- h. the tumor uptake showed an increase until h p.i. to a maximum of . +/- . % id per unit mass and then slowly decreased with a half-life of +/- h. liver metastases showed a higher maximal uptake ( . +/- . %) as compared to lymph node metastases ( . +/- . %). the blood kinetics were fitted to a tri-exponential function with large variation: half-life : . +/- . h; half-life : +/- . h and half-life : +/- h. the following organ absorbed doses were calculated: kidneys: +/- sv; spleen: +/- sv; metastases: +/- sv ( +/- sv for lymph node, and +/- sv for liver metastases). the resulting dose to the red marrow was . +/- . sv. conclusions: the relatively low organ doses compared to y- labelled peptides for prrt correlate with the low clinical toxicity of the radiopharmaceutical. the effective treatment of patients with neuroendocrine tumors using lu- dota-tate is confirmed by the mean absorbed tumor doses. individual patient dosimetry should be performed due to the large interindividual variations concerning the organ and tumor doses. aim: an individualized quantitative method to calculate activity distribution and kinetics is needed for accurate, patient-specific dosimetry for optimized internal radiotherapy treatment. our objective is to design a clinically viable, simple procedure that will provide patient specific, quantitative and -dimensional ( d + time) estimate of the dose-rate absorbed from an internally delivered radiopharmaceutical. methods: the elements of the procedure are as follows: • quantitative reconstruction of spect data using patient-specific transmission or ct-based attenuation maps. our qspect method includes attenuation and scatter corrections, and accounts for system resolution, and cross-talk and septal penetration when needed. • quantitative data reconstructed from a spect scan are being combined with the information obtained from a series of - whole body scans (wb) in order to determine quantitative biokinetics of the tracer in tumours and critical organs. • estimation of dose delivered to organs of interest using three complementary elements: (a) voxelized d quantitative activity concentrations, (b) temporal information about biodistribution of this activity, and (c) analytical calculation of the delivered dose. this calculation will be based on the known physics of photon and particle interactions and will use our analytical photon distribution (apd) method. • for repeated radiotherapy treatments, d dose-rate maps may prove to be particularly useful, as the final goal of this project is the determination of the reliable dose-response relationship. materials: simulations and phantom experiments were performed in order to evaluate the accuracy of quantitation for different isotopes relevant for oncology and to design new acquisition protocols that would provide quantitative biodistribution information in clinical setting. investigated isotopes included tc- m, in- , i- , and i- . experiments used siemens e-cam + profile transmission system and ge infinia + hawkeye ct. activity in "tumour"-like containers placed in air and active background was measured using planar, wb, tomographic and a combination of two spect and five wb acquisitions. results: the results of our studies show that in planar and wb studies the quantitation errors vary from about - % to - % depending on the activity distribution and the method of data processing. our qspect technique results in activity estimation with errors in the order of - %. similar accuracy levels were achieved in quantitatition of activity kinetics from a combination of spect+wb studies. conclusions: improved accuracy of biodistribution quantitation obtained from a combined protocol of spect+wb offers new promise for patient specific dosimetry. incorporated into our apd calculation these data will provide -d voxelized dose maps. dose assessment of salivary glands in radioiodine therapy d. shahbazi-gahrouei, z. shahi, k. ziaei; dept. of medical physics, isfahan uni. of medical sciences, isfahan, iran (islamic republic of). the use of radioactive iodine ( i) has become an important adjunct to the treatment of thyroid cancer and hyperthyroidism. salivary gland has the ability to concentrate radioactive iodine under normal circumstances. salivary gland dysfunction and dry mouth are the common side effects of high-dose radioiodine therapy. the purpose of this study was to determine the absorbed dose of salivary glands. materials and methods: twenty patients who were divided into two groups of were studied (a group without pilocarpine and the b group received pilocarpine during treatment). the absorbed dose of parotid glands and the submandibular glands of patients was measured using thermoluminescent dosimeter (tld) at three different times ( hours, days and months after treatment). the attenuation coefficient of patients and the effects of pilocarpine were also determined. results: in group a total attenuation coefficient was . , . , and . for parotid glands and the right and left submandibular glands, respectively. in group b total attenuation coefficient was . , . , and . for parotid glands and the right and left submandibular glands, respectively. the results also showed the dose decreases to cgy after and half life for a and b group, respectively. conclusions: the findings showed that the dose decreases to cgy after half life of iodine therapy. the exponential coefficient attenuation of salivary glands varied between % to %. pilocarpine should be effective to increase excretion of radioactive iodine and increases . to times coefficient attenuation. aim: commercially available radiopharmaceuticals for radiosynovectomy (rso) are expensive and not always accessible for developing countries. cost effective and safe agents are therefore needed. herein we present the biokinetic data of rhenium- -tin colloid (re-col) and phosphorus- colloid (p-col) in patients undergoing rso of the knee. methods: in patients (pts) treated with ± mbq re- ( ) in knee serial blood samples at , , , , , , , , h and urine up to h were collected. additional, in pts treated with ± mbq p- blood measurement at , , , h and urine sampling up to h were studied. median particle size range for re-col μm (range: - ) and for p- . μm ( . - . ), respectively. results: in rabbit animal model, retention of radioactivity in the synovium for re-col at and h were . ± . % and . ± . % of id respectively. in patients undergoing rso of the knee with re-col, average %id in blood at , , and h were . ± . %, . ± . %, . ± . % and . ± . % respectively. total excreted activity in urine at h was . ± . %id (range: - . ). for p-col %id in blood at , , and h p.i. were . ± . ; . ± . , . ± . , . ± . respectively, and . ± . %id in h-collected urine. percent id in blood at h and the area under the curve up to hs were significantly lower for re-col compared to p-col, p< . and p< . respectively. discussion and conclusion: p-col showed a longer retention in blood and a higher urine excretion than re- tin colloid indicating a lower in-vivo stability for p-col formulation. data suggest that blood radiation exposure is lower for re-col than for p-col. both radiopharmaceuticals are however, suitable for radiosynovectomy. as a generator product, re- provide excellent availability and can be cost effective which is however dependent on the frequency of use. p- as a cheep reactor product provide a good and cost effective alternative. reference: . jeong jm et al. appl radiat isot , : - results of an iaea led crp e . . objectives : the objective of this work was to determine normal organ mean absorbed dose and effective dose equivalent and effective dose for c-pib dosimetry in humans. methods : patients ( female, male, mean age . y) were administered with a bolus infusion of c-pib (dose range . - . mbq) and immediately scanned on a gemini pet/ct camera. sequential wholebody pet images, which extended from head to upper thigh, were acquired, representing time points over a period of minutes. resultant images were reconstructed using an iterative single scatter simulation algorithm. using in-house developed software, voi analysis for each time point was performed to obtain activity concentration in normal tissue. organs considered as source organs were brain, lung, liver, kidney, spleen, gallbladder contents and bladder contents. using reference man (icrp ) values for organ volumes, the total activity was calculated per organ for each time point and the cumulated activity was determined from the area under curve of a bi-exponential fit to the resultant time activity curves. the cumulated activities were used as input to olinda. results : large accumulation of c-pib was visualised in gallbladder, liver and urinary bladder. accordingly, the organs with the greatest mean absorbed dose (mean ± sd) were gallbladder wall ( . ± . μgy/mbq), urinary bladder wall ( . ± . μgy/mbq), liver ( . ± . μgy/mbq) and kidneys ( . ± . μgy/mbq). effective dose equivalent (ede) was . ± . μsv/mbq and effective dose (ed) was . ± . μsv/mbq. of note, due to its high absorbed dose, gallbladder wall has a large contribution towards ede, whilst not being considered in the calculation of ed. conclusions : organ dose estimates for c-pib are comparable to other reported c ligands. analyzed and used to determinate the red-marrow-dose. the residence-time in lesions, with s-factors (mird), are used to calculate lesions-dose. data are elaborated by compartimental-models to write the therapeutic plan. patients treated with y cl dotatoc have been followed for appraising the course of disease. results we collected these average and range dose-data (mgy/mbq): red-marrow ( . , . to . ); kidneys ( . , . to . ); spleen ( . , . to . ); liver ( . , . to . ); urinary-bladder ( . , . to . ); total-body ( . , . to . ) . the dose to principal lesion has been calculated for patients (average . , . to . ) . patients had kidneys-dose less than lesion-dose and patients had liver-dose less than lesion-dose. / patients had lesion-dose greater then red-marrow-dose, liverdose and kidney-dose. we followed patients ( patients not treated, patients in progress of treatment). patients had a positive results to the treatment (complete or partial result or disease stabilization) and patients a negative one (progression of disease). among patients with positive results, had lesion-dose greater than critical organs-dose (reached gy to lesion), for patients the lesion-dose has not been calculated. only patient who reached gy in lesion had a negative responce. conclusions the variability of the dosimetric results shows the importance to perform a personalized dosimetric-study. follow-up showed that the patients treated till gy to the lesion had a positive result to the therapy (only one exception). among the patients treated till the reaching of the dose-limit to the critical organs (lesion-dose less then gy), had a positive result. in conclusion, the therapeutic plan wrote on the base of dosimetric-study has a real utility. aim: the pharmacokinetics and dosimetric profile of y-dotatoc is well known, being the kidney the critical organ. however, in end-stage renal failure, biodistribution could be altered and organs such as red marrow (rm) could be critical. the aim of this study was to evaluate the biodistribution and dosimetry of y-dotatoc in a patient with end-stage renal failure undergoing dialysis. methods: a female patient affected by abdominal lymphnode metastases from endocrine carcinoma, asked to eradicate her disease with y-dotatoc in order to be enclosed in the waiting list for renal transplant. the patient suffered from renal failure since the age of . at years old she was operated for lymphnode metastases from gastrin secreting endocrine carcinoma of unknown origin. a subsequent octreoscan showed persistence of abdominal lymphnodes ( mm). gastrin: pg/ml. mbq in-dotatoc were administered for dosimetry. blood samples and planar images were obtained up to h p.i. patient-specific dosimetry was evaluated by imaging analysis and actual organ masses (ct). the blood-derived method was used for rm dosimetry, considering the rm specific activity equal to that in blood. the number of disintegrations (nd) was obtained for all source organs; for rm, the rm specific activity equal to that in blood. the olinda/exm code was used to calculate absorbed doses. results: nds (h) in source organs were: . (rm); . (spleen); . (liver); . (remainder of body-rb). absorbed doses (gy/gbq) were significantly higher than published results (mean±sd): . (vs. . ± . ), spleen; . ( . ± . ), liver; . (vs. . ± . ), rm, . (vs. . ± . ), total body. this confirmed a redistribution of the activity usually eliminated through kidneys, with fast and higher uptake in liver and spleen. tumour dose was gy/gbq. the treatment was considered feasible, with rm critical organ, liver second limiting organ, spleen irradiation of some concern. the patient conservatively received . gbq. therapy was well tolerated. only reversible grade toxicity on wbc and plt, and grade on hb, occurred. six months after octreoscan and mri showed disappearance of the lesions. gastrin: pg/ml. conclusions: in patients undergoing dialysis, rm is the critical organ. these results showed the feasibility of y-dotatoc therapy even in patients who would be logically excluded. in such cases, a deep analysis of the tumour dose and risk-benefit balance should guide, addressing y-dotatoc to cases without other options. assessment of absorbed dose and therapeutic response of tumor in repeated high-dose i- anti-cd monoclonal antibody (rituximab) radioimmunotherapy for non-hodgkin's lymphoma nearby tumor. the shape of d-roi of tumor was determined from the mip pet image. the volume of tumor was measured from the ct image, the % change of tumor volume before and after rit was used to evaluate the therapeutic response. the value of ct-based tumor volume was compared with that measured by pet image at the cut-off suv of . . in tumor dose estimation, the time-activity curve (tac) of tumor region was used, and the both absorbed fractions of beta-and gamma-ray were considered together. results: bi-exponential decrease was observed in fitting of tac of tumor. the values of ct-and pet-based tumor volume were . ± . cc and . ± . cc, respectively, and showed the linear relationship(r= . ). the values of absorbed dose for tumor and the %changes of tumor volume before and after rit were . ± . rad, were . ± . %, respectively, and did not show the linear relationship(r=- . ). the values of absorbed dose for tumor and the % changes of tumor volume did not show the linear relationship with the number of repeated administration(r= . and - . , respectively). conclusion: aligning pet and planar images could estimate the quantitative values of absorbed dose to tumor. the data suggest that potentially equal absorbed dose and therapeutic response of tumor could be expected in repeated rit with i- rituximab for nhl. purpose: gastric cancer is one of the most common cancers, and is the second most common cause of cancer related mortality in the world. the a antigen is a glycoprotein which is homogenously expressed by more than % of colorectal cancers and % of gastric cancer and in the normal intestinal mucosa, but not in other epithelial tissues including gastric epithelium. in order to determine the in vivo characteristics of hua , a cdr grafted humanized monoclonal antibody against the a antigen, a clinical trial was conducted in patients with gastric carcinoma. patients and methods: thirteen patients were entered into the study. they were assigned serially onto one of four dose levels ( . , . , . , . mg/m ) of hua . patients with early gastric carcinoma received a single infusion of i-hua one week prior to surgery. biodistribution of i-hua was evaluated by the imaging at least occasions including on the day of administration and on upto days. adverse events were assessed. ex vivo imaging and immunohistochemical analysis were performed on the samples of biopsy and surgical specimens. results: no dose-limiting toxicity was observed and the maximum tolerated dose was not reached. although cancer tissues with low expression of a by immunostaining in biopsied frozen sections did not show positive imaging with i-hua , cancers with high expression of a by frozen and paraffin sections in the biopsied specimen showed positive ex-vivo imaging and positive antigen expression in resected gastric cancer specimen, and the biodistribution analysis also showed tumor uptake of i-hua . conclusions: humanized monoclonal antibody hua demonstrated selective localization to gastric cancer that strongly expresses a antigen. these targeting characteristics of the hua indicate potential for the targeted therapy of advanced gastric cancer that is refractory to cytotoxic chemotherapy or recurrence after surgery, and could also be exploitable for the adjuvant therapy after curative resection of early gastric cancer. metabolic radiation therapy is mediated by emitter labelled radiopharmaceuticals allowing lethal target radiation. unfortunately, such medical practices using emitter radioisotopes is associated with an increase of medical staff radiation exposure in nuclear medicine department. this gives us reasons to quantify medical staff radiation in our department during -i lipiodol, -y-colloid and -sm edtm treatments of hepatocellular carcinoma, arthritis (radiosynovectomy) and bone metastases respectively. methods: injections of i-lipiodol, -y-colloid radiosynovectomy sessions and -sm-edtm treatments were studied. whole body doses (wbd) and right and left finger doses (rfd, lfd) for radiopharmacists (rp), nurses (n), radiologists (rd) and rheumatologists (rm) were evaluated by cylindric lif-thermoluminescent dosimeters (tld) placed on the waist or on the inward second finger. results: wbd for medical staff during . ± . gbq -i lipiodol injections were . ± . , . ± . and . ± . μsv for respectively rp, n and rd. rfd and lfd were respectively . ± and . ± μsv for rp, . ± . and . ± . μsv for rd. the use of angioseal ® hemostatic puncture closure device deployed for haemostasis after -i lipiodol injections afforded a two fold decrease in rds' exposure compared to manual compression. during the -y colloid syringe filling sessions (mean activity per session: . ± . mbq, n= ), the wbd for rp was . ± . μsv, rfd was . ± and lfd was ± μsv. wbd for rm and n performing intra-articular infusions were respectively . ± . and . ± . μsv per mbq injected. fd, normalized to mbq injected, were . ± μsv (rfd) and . ± μsv (lfd) for rm and . ± . (rfd) and . ± . μsv (lfd) for n. during -sm edtm syringe filling ( . ± . gbq) rp wbd was . ± . μsv rfd was . ± . and lfd was . ± μsv. n exposure during -sm-edtm administration was . ± . (wbd) and . ± . μsv (rfd) conclusion: fortunately, annual extrapolated wbd and fd doses remain under legal limits but observed values are not negligible and have to be added to those relative to -iodine treatment of thyroid disorders for example. such considerations may confirm the interest of protocol optimization, personal information and studies focusing on radioprotection. evaluation of factors affecting the accuracy and precision of a technique for quantification of volume and acticity with in spect. m. s. kotzassarlidou, c. tziaka, t. kalathas, a. raptou, n. salem, a. makridou; theagenion cancer hospital, thessaloniki, greece. aim: accurate in vivo volume and activity determination is essential in clinical research, especially for estimating organ absorbed dose during radionuclide therapy. in this study volume and activity concentration were estimated using single photon emission computed tomography (spect) for volume and activity concentrations of -in sources between . - . ml and - mbq/ml. all sources were of regular geometry. the influence of voxel size, source size and shape was studied. materials and methods: spect acquisitions have been carried out by sopha dst xli -head gamma camera over o, elliptical orbit and step and shoot mode, according to the following protocols: - x , frames, sec/frame, - x , frames, sec/frame. pixel size [cm] and system sensitivity, [cps/mbq] of both matrix sizes for -in spect have been determined in advance. processing was performed on vision workstation using a butterworth reconstruction filter (order , nyquist . ). attenuation correction was applied and transaxial images of one pixel thickness were obtained. the segmentation algorithm used for volume quantification was the autothresholding method. pixel value with the maximum counts in all slices was selected and percentage ( - %) of it was determined. pixels of all slices with a value equal or greater than the predetermined value belonged to the source. volume estimation was obtained by summing the number of voxels within the source contour in each slice and multiplying their total by voxel volume. activity estimation was obtained by summing the counts of the above regions and dividing their total by acquisition time and the system sensitivity. results: the best correlation between nominal and measured volumes by -in spect images was obtained with threshold percentage of % and % for x and x matrix size respectively. error increases as nominal volume decreases (r=- . , p= . ) for x whereas for x it increases proportionally to the threshold (r= , , p< . ). activity estimation was best obtained for threshold percentage of % for x . conclusions: autothreshold technique is effective for in vivo volume and activity quantitation of lesions with volumes greater than the system spatial resolution (i.e. volmeas> . ml). in case of smaller lesions ct is preferable for volume quantitation. where d k is the mean absorbed dose to region k (gy); a is the administered activity (bq); s (r k r j ) is the mean absorbed dose in target region k irradiated by source region j; j is the residence time in source region j (s), which is j = t t a j (t)dt / a = t t a j (t) / a dt = t t %id dt. where a j is the activity of source region j at the time of t. we calculated the mean absorbed dose of critic organ by mirdose . software (internal dose information center at oak ridge institute for science and education, oak ridge, tn), using the dynamic bladder model ( h void) . we summed up the resident time of lungs and tumor as the "lungs" resident time. corrections were made for lungs masses. for the mass of tumor tissue ( m t ) we assumed unit density and employed the ct volume ( v t ) : m t = × v t . tumor background subtraction was attempted using ct scans to estimate true background thickness. absorbed doses to tumor tissues (d t ) were estimated using the same approach taken for normal organs. s-factors for tumors were estimated by comparison with lungs. according to equation d t =m lungs ×(d " lungs" -d lungs )/ m t and d t =m lungs ×(d " lungs" -d lungs )/ m t , where d " lungs" , the mean absorbed dose of mixed lungs and tumor. by equation, we can easy to calculate the d t and d lungs . results: the absorbed dose of red marrow ranged from . to . gy; thyroid, from . to . gy; ovaries, from . to . gy; testes, from . to . gy; kidneys, from . ~ . gy; liver, from . to . gy; lungs, from . to . gy; and effective dose equivalent from . to . gy. the results shows tumors with highest uptake of ( . ± . )%id of i-chtnt at h. the mean absorbed dose of tumors (within a) was [( . ± . ), from . to . ]gy, d reached ( ± )%, d reached ( ± )%, and the tumor-to-nontumor ratio (t/nt) was . ± . (from . to . ). conclusion: repeated intravenous i-chtnt is needed because single intravenous dose of i-chtnt could hardly depress the growth of tumor masses. objective: to study tgf- and bfgf expression in normal prostate and bph and inhibitory effects of specially designed sr /y applicator radiation on the expression in hyperplasic prostatic diseases. method: bph patients were divided into two groups, the intracavitary exposure group and the hyperplasia group. all patients in exposure group were treated with sr /y applicator. patients were practiced operation days after the exposure, another patients were practiced operation days after the exposure, and the rest patients were practiced operation days after the exposure. patients in hyperplasia group were not treated with intracavitary exposure. expression of tgf- and bfgf were detected through immunohistochemical staining technique. results: tgf- positive expression rates of np and bph epithelial cells were higher than those in correspondent stromal cells (p< . ). no statistically significant association was found between tgf- positive expression of epithelium and stroma in bph tissues and the correspondent expression in np (p> . ). compared with the hyperplasia group, tgf- positive cell rates in bph epithelial and stromal cells were significantly increased , and days after sr /y applicator exposure (p< . ). expression of bfgf existed not only in epithelial and stromal cells of bph, but also in normal prostatic tissues. the bfgf positive expression rates in bph epithelial and stromal cells were higher than those in np epithelial and stromal cells (p< . ). bfgf positive expression rates in bph and np stromal cells were higher than those in corresponding bph and np epithelial cells (p< . ). bfgf levels in bph epithelial and stromal cells descent sharply , and days after sr /y applicator exposure (p< . ).conclusion: exposure of -rays from sr /y applicator had noticeable effects to enhance tgf- expression and inhibit bfgf expression in bph tissues. objective: to investigate expressions of bcl- and bax in benign prostatic hyperplasia (bph) tissues and influence of radiation from specially designed sr /y applicator on bcl- and bax expressions. method: bph patients were divided into two groups, the intracavitary exposure group and the hyperplasia group. all patients in exposure group were treated with sr /y applicator. patients were practiced operation days after the exposure, another patients were practiced operation days after the exposure, and the rest patients were practiced operation days after the exposure. patients in hyperplasia group were not treated with intracavitary exposure. expression of bcl- and bax were detected through immunohistochemical staining technique. results: the bcl- positive expressions in both normal prostate(np) and bph epithelial cells were higher than those in corresponsive stromal cells(p< . ),while the bcl- positive expressions in epithelial and stromal in bph tissues were higher than those in np(p< . ).meanwhile, the bax expression in np epithelial cells was higher than that in bph(p< . ),and the bcl- expressions of epithelia and stroma in bph were higher than the corresponsive bax expressions(p< . ). no statistically significant association was found between the bcl- expressions of epithelia and stroma in np and the correspondent bax expressions(p> . ).compared with the hyperplasia group, bcl- in bph epithelial and stromal cells reduced sharply, and bax positive cell rates increased distinctly , or days after the intracavitary exposure by sr /y applicator radiation(p< . ). conclusion: bcl- and bax play an important role in regulation of prostatic apoptosis and the treatment of radiation with sr /y applicator before surgery can accelerate apoptosis in prostatic tissues. the purpose of this study was the quantitative analysis of the internal contamination with four uranium isotopes in the population living near the uranium conversion facility in port hope, ontario, canada; the oldest operating uranium processing plant in the world. the urine samples of symptomatic patients presenting with symptoms of musculo-skeletal, cns, immune system, and neoplastic disease were obtained from among a large population. control samples were also analyzed. the urine samples were analyzed in a specialized radiochemistry laboratory by mass spectrometry, including pre-concentration of urine by co-precipitation, oxidation of organic matter, uranium purification by ion-exchange chromatography, and icp-ms double-focusing thermo finnigan neptune multi-collector. natural uranium has a u/ u ratio of . and does not contain u. background total uranium concentration in the urine of humans is ng/l (usa nceh). our results show of samples containing uranium of non-natural origin. one sample was highly positive for depleted uranium (du) with a u/ u of . ± . and a relatively normal abundance of total uranium. this sample contained a concentration of u with a u/ u ratio of . x - ± . x - indicating its reactor origin. three samples contained detectable amounts of u, one being paradoxically high with a u/ u ratio of . x - ± . x - . one of these three samples contained a higher than normal concentration of total uranium ( . ng/l). the u in these samples indicates its origin as contamination with non-natural uranium. the remaining five samples were negative for both depleted uranium and uranium- . the history of uranium contamination of the vicinity of port hope has been verified in objective scientific literature . our results suggest long-term contamination and possible adverse effects on the body burden of the current population of port hope. these preliminary results warrant additional multidisciplinary studies. aim: standard treatment of differentiated thyroid carcinoma (dtc) is total thyreoidectomy followed by radioiodine therapy (rit) and diagnostical i- -whole body scan (d-wbs). radioiodine (ri) is eliminated via kidneys. in patients with dtc and end stage renal failure (esrf) doses between and mbq were administered orally. the aim of this study was to evaluate the therapeutical effectiveness of rit using reduced amounts of ri. material and methods: during the last seven years esrf patients suffering from dtc were treated with rit. one patient received four ri treatments . one patient got two rits and d-wbs and one patient received two rits. the activity doses administered ranged between and mbq for rit and between and mbq for d-wbs, respectively. hemodialysis was done on the st and rd day after ri administration. serum thyroglobulin (tg) was measured prior to and after ri applications using tg-sria( brahms, sensitivity , ng/ml) during tsh stimulation indium oxinate is a radiopharmaceutical that decays by electron capture with a half life of hours, emitting gamma radiation with energies of kev and kev as well as low energy auger electrons. indium oxinate is used in nuclear medicine for the in-vitro labelling of separated blood cells, which are then administered to patients to investigate inflammation at the sites of infection and abscesses. because of the potential toxicity of its auger emissions indium has also been evaluated recently as a potential tumour therapy, where indium has been conjugated to somatostatin receptor analogues or to tumour-specific antibodies. aims: the aim of this investigation was to study the dna-damaging effects and cytotoxicity associated with cellular exposure to indium and to evaluate the intracellular and intranuclear doses of indium required to elicit cytotoxic effects. methods: we have investigated cellular toxicity of indium oxinate in ht fibrosarcoma cells and mcf- breast epithelial cells using the colorimetric mtt assay and the clonogenic survival assay. the results were compared with data obtained from similar experiments in which cells were treated with equimolar amounts of indium oxinate that had been subjected to several weeks of decay, in order to determine the degree of cytotoxicity attributable to radioactive emissions. the single cell gel electrophoresis (comet) assay was also used to determine dna damage associated with exposure to indium oxinate. cellular and nuclear uptake were measured using a phophorimager or a gamma counter. results: ht cells that were subjected to mbq/ml indium oxinate exhibited . % cellular survival in the clonogenic survival assay compared to untreated control, while treatment with a molar equivalent of the decayed indium oxinate exhibited % survival compared with the same control. mcf- cells exhibited zero cellular survival when subjected to treatment with mbq/ml compared to untreated control, while treatment with decayed indium oxinate exhibited % survival compared with the same control. the comet assay showed dna damage only at doses where cell toxicity was observed. cellular and nuclear uptake showed that % of indium taken up by the cell was contained in the nucleus. the results demonstrate that radioactive emissions associated with mbq/ml indium oxinate elicit significant dna damage and cytotoxicity in ht and mcf- cells. these data will allow correlation of intracellular dosage and nuclear proximity with cytotoxicity and dna damage. auger electrons and it effect on cell viability. in vitro preliminary results m. laranjo , a. m. abrantes , i. carreira , m. f. botelho ; biophysics/biomathematics institute, ibili-faculty of medicine, coimbra, portugal, biology institute, faculty of medicine, coimbra, portugal. aim: because auger electrons cause a high energy deposition limited to the area of the decay site the ensuing biological effects may represent an alternative in cancer radiation therapy. mtc is the most used radionuclide in nuclear medicine. besides its energetic gamma emission, its hours half-life makes it the preferred radioisotope for patient administration. as mtc is also an auger emitter, the possibility to use it not only in diagnosis but also in treatment should be investigated. in order to examine the effects of mtc auger electrons in cancer cells, we investigated the survival and proliferation after exposure to mtc-pertechnetate. material and methods: adenocarcinoma colon cells (atcc -widr) developed in dulbelcco's medium with % of fetal bovine serum and incubated in ºc, % co atmosphere were used. mtc-perchnetate ( mbq) was added to the medium during different exposure times ( , , and minutes) which resulted in absorbed doses of . , . , . , gy, respectively. after the incubations, mtc-perchnetate uptake was calculated. the cell viability and proliferation were evaluated , and hours after exposure. cell viability was evaluated by trypan blue exclusion test. this vital stain does not pass trough the membrane of living cells however, traverses the membrane at a death cell. with this method it is possible to estimate the ratio between living cells and death cells. to access cell proliferation we used mtt ( -[ , -dimethylthiazol- - yl]- , -diphenyltetrazolium bromide), an yellow tetrazolium salt that is reduced in metabolically active cells to form insoluble purple formazan crystals. these are solubilized by the addiction of a detergent and then quantified by spectrophotometric means. results: regarding uptake of mtc-pertechnetate it increases proportionately to the incubation time ( % for . gy; % for . gy; % for . gy and % for gy). the viability indicates an increase of proliferation on the first hours after irradiation, but after this time it decrease progressively with the time. h after treatment the proliferation values were % for . gy; % for . gy; % for . gy and % for gy. h after treatment the proliferation values were % for . gy; % for . gy; % for . gy and % for gy. conclusions: these preliminary results indicate that there are time dependent effects on proliferation and cell death. y. lin , w. chang , w. lin ; chunghsing university, taichung, taiwan, taichung veteran general hospital, taichung, taiwan. the aim of this study was to investigate of various basic amino acid solutions and other compounds in order to assess their safety and their capacity to inhibit the renal uptake of in- -dotatoc. materials and methods: male spraque-dawley rats ( - g) , in the presence of reuptake blocker, were injected with in- -dotatoc. at hours after injection, rats were sacrificed and organs were isolated and counted for radioactivity. results: lysine ( mg/kg) were resulted in more than % inhibition of kidney uptake, but it may induce hyperkalacmia and metabolic changes. combination of arginine and histidine were also resulted more than % inhibition, nevertheless it have less side effect than lysine. maleate ( mg/kg) were more effective to reduce renal uptake about over %. further, coinjection of colchicines ( mg/kg), vincristine ( . mg/kg), noscapine ( mg/kg), nocodazole ( mg/kg) hours before injection of in- -dotatoc were significantly reduced kidney uptake (respective inhibitions of %, %, % and %). conclusions: administration of these compounds effectively reduce kidney radioactivity in order to allow the administration of higher doses of radiolabelled somatostatin analogues for scintigraphy and peptide receptor radionuclide therapy. introduction hyperthyroidism is a common disease in old cats and is preferably treated with radioactive iodine. treatment results are good, with - % of the cats becoming euthyroid. concurrent subclinical kidney disease is not uncommon in this patient group and close monitoring of kidney function is mandatory. a recent research protocol at our institution necessitated the use of iohexol as a gfr marker to investigate kidney disease immediately prior to treatment with radioactive iodine. since it is generally known that iohexol reduces (radio)iodine uptake in the thyroid, this study was set up to evaluate its effect on absorbed dose in the thyroid and to investigate whether this procedure influenced long term outcome of treatment. materials and methods hyperthyroid cats, presented for i -treament, participated in this study. gfr measurement using iohexol was performed in patients one day before injection of i . cats received only i and functioned as control-group. the iohexol-group received an average activity of mbq i (sd ± mbq); the control-group received on average mbq i (sd ± mbq). scintigraphic scans were performed , and h post-therapy. a syringe with known reference activity was scanned using the same parameters. roi's were drawn over the thyroid region, background and reference activity for all time points. cumulative activity was calculated. a factor was obtained using mirdose . software converting the cumulative activity into absorbed dose, taking into account the thyroid volume. results the mean estimated absorbed thyroid dose in the iohexol-group was gy (sd ± gy), which was significantly different from the control group: gy (sd = gy) (p< . ). of the cats that received iohexol, a higher percentage remained hyperthyroid ( %) months after treatment compared to the control group ( %). these results however did not reach significance. (p> . , -test) . conclusion the administration of iohexol to evaluate kidney function reduces absorbed thyroid dose of i in this small group of cats but does not seem to influence long-term outcome of feline hyperthyroidism. p -monday, oct. , , : pm - : tc-mibi were . μsv.h - ± . and . μsv.h - ± . respectively, at cm from the patients. for tl, the average dose rates at the distances of , and cm from patients hours after administration were . , . and . μsv.h - respectively. these values were in close agreement to the mean corresponding value of . , . and . μsv.h - obtained by munford et al . the maximum departure dose rates at these distances were . , . and . μsv.h - .mbq - respectively. external doses rate of tl fell gradually, until three days after administration. after injection of m tc-mibi a rising of the external dose within - hours was seen. the maximum departure rate per unit activity at the distances of , , and cm were . μsv - .mbq - , . μsv - .mbq - , . μsv - .mbq - and . μsv - .mbq - respectively. significant exposure from patients after injection of m tc-mibi was limited on the few hours after administration. maximum and average absorbed dose of nuclear medicine staff from tl were . and . μsv.h - , and for m tc-mibi were . and . μsv.h - in each scan. conclusion: significant exposure from m tc-mibi for cardiac investigations has limited to a few hours after administration. in case of administration tl the dose rates from the patients continues to decrease until three days after injection. these data could be considered as a base for calculative exposure dose in close contact during working hours of nuclear medicine staff. . one of the most effective treatments for thyroid carcinoma is the use of iodine- . in recent months a number of patients with end stage renal failure have been referred to our hospital for thyroid ablation therapy. this has presented a number of challenges from a radiation protection perspective, for both the patient and the staff involved. in establishing this procedure we aim to provide an effective combination of treatments for these patients. in addition the radiation dose to all staff involved in this therapy must be considered. to date two patients in end stage renal failure, both requiring regular haemodialysis sessions, have been treated at our hospital. a multidisciplinary team was involved in establishing this procedure and helped to identify the risks involved. a dialysis facility was provided in one of our dedicated treatment rooms to enable the best possible arrangement for radiation protection purposes. all staff involved were given radiation safety training before the therapy was conducted. a member of the radiation safety team was also on hand for the duration of each dialysis session. each patient received mbq of i- in capsule form with dialysis sessions conducted immediately prior to the therapy and and hours after administration of the capsule. each patient was successfully dialysed on all three occasions, with no unexpected complications being noted. dose rate measurements were performed on a daily basis, which is a routine occurrence for all our patients. dose rates were also measured immediately prior to and after the completion of each dialysis session. all staff involved were provided with radiation monitoring in the form of whole body tld monitors, extremity monitors and electronic personal dose meters. our dose rate measurements show slower clearance rates, by approximately %, in these two patients when compared to 'standard' cases. however, this is to be expected as the main excretion route for i- is via the kidney. by implementing appropriate radiation safety training and methods staff doses were also able to be kept to a minimum. maintaining the regular dialysis schedule for both these patients also allowed us to deliver an effective therapy without compromising the patient's welfare. skin cancer is the most common cancer in humans. many different treatments are currently used in the management of this kind of tumours, and include surgical techniques, topical therapy and radiotherapy. the healing percentage usually range from to % by using the best therapeutic treatments. in the present paper a new therapeutic option for the treatment of squamous cell carcinoma (scc) and of basal cell carcinoma (bcc) proposed. it consists in a superficial radiotherapy with beta emitters isotopes, characterized by the use of a synthetic resin incorporating radioactive re, that is able to perform a selective irradiation treatment of the cancer lesion. patients with histologically confirmed diagnosis of bcc and of scc were enrolled for the treatment, by choosing the cases in which a relapse of the tumour was present, or in which a surgical operation would have been impossible or aesthetically unacceptable. all treatments were performed in the nuclear medicine dept. of s.eugenio hospital, rome. in all treated cases, an apparent clinical remission occurred in approximately months; a complete healing was obtained in % of the treated cases, in % of the cases after a single application. neither unaesthetic scars, nor side effects, were observed. after a follow up of - months, no signs of clinical relapses were present in any of the treated patients; when a histological examination was performed, a complete tumour regression was observed. treatment of verruca plantaris with microwave and p application therapy y. ma, y. liu, p. lu, g. huang; renji hospital, shanghai jiaotong university, shanghai, china. aim: to study the clinical curative effect of verruca plantaris with microwave and p application and its application value. material and methods: patients with extremity verruca plantaris were chosen by random from outpatient, out of them, the patients is male and is female, their average age is . ± . s ( ±sd) years old, randomly divided them into two groups: ( ) microwave treatment group have ,the wart bodies were eliminated by microwave under local anaesthetize. ( ) individuals were treated with p application therapy ,the liquid of radionuclide p were dropped in gauze, drying them and then fixing them in corresponding focus surface for application therapy, randomly divided patients into three groups with hours, hours, hours application each time, a group has patients average. about - times. and once a week until the lesion recovered. the clinical reaction and curative effect were observed. results: the clinical cure rate, recurrence rate, side effective occurrence rate and complication occurrence rate are . %, . %, . % and . % respectively in microwave treatment group and they are . %, . %, . % and . % respectively in the group of p application therapy. conclusions: the characteristics of treatment of verruca plantaris, with p application therapy are simple method , convenient, safety , little pain, notable curative effect, it is a kind of successful effective treatment method. using ligandtracer® to quantify protein-cell interactions in real-time l. vennstrom , h. bjorke , k. andersson ; ridgeview instruments ab, uppsala, sweden, uppsala university, uppsala, sweden. aim: validate a novel biosensor (ligandtracer®) designed to detect how radiolabelled proteins bind to cell surface receptors in real-time and explore new possibilities with the biosensor. material and methods: different cell lines (e.g. a and skov- ) and radiolabelled proteins (e.g. egf and trastuzumab) known to bind to the receptors egfr or her were used in this study. cells and reagents were placed in ligandtracer grey and binding traces of the protein-cell interactions were recorded in real-time without user intervention. the results were compared to data obtained from classical protocols. results: the results obtained with ligandtracer grey agreed with classical protocols and was highly repeatable. the time resolution in ligandtracer data was superior to the classical protocols used. furthermore, the novel biosensor required less disposables and manual workload. conclusion: the automated, real-time binding traces obtained with ligandtracer relieve researchers from manual workload and provides data with higher time-resolution. apart from replacing manual protocols in protein-cell interaction measurements, this novel method opens up many new possibilities in the field of cell-based assays. p -monday, oct. , , : pm - despite of progress in pediatric oncology, metastatic neuroblastoma in children over year of age still remains great challenge. nearly % of children in this group present bone marrow involevement. in staging of neuroblastoma , the assessment of tumoral infiltration of bone marrow is an important indicator of prognosis. for detection of bone marrow metastasis traditional staging includes bone marrow aspiration biopsy. another method, scintigraphy with radiolabeled metaiodobenzylguanidine (mibg), specifically taken up for cells of sympathetic origin, is now considered as the first line method for the staging and follow-up of neuroblastoma. the aim of this study was to assess the respective values of these two methods: mibg scintygraphy and bone marrow aspiration biopsy in determination of the extent of neuroblastoma. materials and methods: i-mibg scans and bone marrow aspiration biopsy were performed at a time of diagnosis and were repeated at interval of mean months (from months to months) during at least two years. retrospectively there were evaluated i-mibg scans of children ( stage iv, stage iii and stage ii) and were compared with the results of bone marrow aspiration biopsy. mibg scan was divided into three groups: -no tracer uptake in the skeleton, -diffuse uptake in the skeleton with or without focal lesion, -focal lesion in one or more bones. results: there was no tracer uptake in mibg scans, all of them had negative bone marrow aspiration biopsy. focally increased uptake was seen in mibg scans but only in of those scans bone marrow biopsy was positive. diffuse uptake in the skeleton with or without focal lesion was detected in mibg scans and bone marrow aspiration biopsy was positive in . conclusion: mibg scintigraphy has very high sensitivity and specificity for detection of bone marrow metastasis. to assess bone marrow involvement mibg scintigraphy is more sensitive than bone marrow aspiration biopsy. mibg scan seems to be very good method for staging of neuroblastoma even when bone marrow aspiration biopsy is negative. the study aimed to determine if the fetal anteroposterior renal pelvic diameter (rpd) is predictive of obstruction as determined by scintigraphy. methods: neonatal lasix augmented(f+ ) mag studies conducted over months for the clinical indication of sonographically detected antenatal hydronephrosis (rpd> mm in mid trimester, mt, and > mm in the third trimester, tt) were retrospectively analysed. the sonographic mt, tt and postnatal (pn) rpd were noted. pnrpd> mm on the postnatal ultrasound was defined as postnatal hydronephrosis. this was based on scott and renwick's findings of % of the postnatal population falling in the - mm range (br j urol : - ). two blinded nuclear physicians classified the scintigraphic studies as 'obstruction' or 'no obstruction' based on the half time drainage (t / ) and frusemide washout curves. results: a total of patients ( hydronephrotic kidneys) were identified with measurements at mt in n= , at tt in n= and at pn in n= . antenatal hydronephrosis detected in / tt kidneys had resolved on the postnatal ultrasound. a series of one-way anova's were performed separately for the right and left kidneys to compare the means of the trimester measurements for those that were obstructed on scintigraphy. though the probability of obstruction was greater at higher rpd, in all groups, there was no statistically significant difference for the mt and tt mean rpd measurements in the obstructed versus non-obstructed group (p>. ). the mean pnrpd was found the most reliable predictor of obstruction on scintigraphy (p=. rt and p=. lt). the ppv for prediction of obstruction with rpd> mm is % and the npv for prediction of nonobstruction at rpd < mm is %. the findings were also correlated with results of the micturarting cystourethrogram(mcu) when it was available. mcu was available in / patients and / kidneys. vesico-ureteric reflux(vur) was identified in / ( . %) patients and / ( %) kidneys. there was no statistically significant relationship between the rpd and presence of vur. conclusion: antenatal hydronephrosis is more prevalent in the male fetus. the pn-rpd has a higher predictive value for diagnosis of obstruction compared to the mt and tt measurements, with higher likelihood of obstruction at higher diameters. the negative predictive value is % to s exclude obstruction if pn-rpd< mm.this group of patients can hence be observed with follow-up sonography rather than subjecting them to have renogram studies. objective: clinical presentation of myocarditis (myo) varies from asymptomatic cases to acute heart failure. endomyocardial biopsy (emb) is an invasive method, therefore another procedure would be advisable, especially in children. the aim of study was to investigate of the scintigraphy with m tc-anty-granulocyte antibody ( m tcaga) usefulness in pediatric cases with suspected myo. methods: between between to aged , - , yrs) with the symptoms of myo were evaluated at initial presentation and month later. all pts underwent heart scintigraphy with m tcaga; - mci the tracer activity was administered iv and acquisition in ap projection was performed and hours later. the estimation of m tcaga uptake was evaluated by calculation of the heart-to-lung ratio (hlr), value of , or more was considered as a positive result. m tcaga scintigraphy was performed in control group of children with suspected enterocolitis (hlr , ) . emb was performed with immunohistchemical method in pts (no consent in one case). the results of heart scintigraphy were compared with emb. results: the mean time from onset of symptoms of myo which included fatigue, heart failure (n= ), ventricular arrhythmias (n= ), chest pain (n= ) to diagnosis of myo was , ± mo. positive m tcaga uptake was observed in pts (mean hlr , ± , ), in cases intense (hlr> ), in moderate (hlr< ) and in pt borderline (hlr , ) . higher hlr (mean , ± , ) was found in the pts who presented within mo of the onset of symptoms than in those who presented in later phase (mean hlr , ± , ). emb results showed evidence of myo in pts, no evidence in one case. all pts with hlr> showed evidence of active myocarditis in emb. follow up m tcaga scintigraphy was performed in pts (mean hrl , ± , ); follow up emb in pts showed evidence of persistent inflammatory process in myocardium. conclusion: . , % of the pts with positive heart scintigraphy showed evidence of myocarditis in emb. . intense myocardial uptake of antigranulocyte antibodies with hlr> strongly indicates active myocarditis. . although further studies are necessary to establish its sensitivity and specificity, scintigraphy with m tcaga seems to be an advisable diagnostic method in pediatric cases with myocarditis. dynamic renal scintigraphy in patients with hydronephrosis e. urbanova , i. novak , j. vizda ; university hospital, nuclear medicine, hradec kralove, czech republic, university hospital, pediatric urology, hradec kralove, czech republic. the aim of this study is to evaluate the kidney function before and after operation for hydronephrosis. stenosis of proximal ureter is the most common anomaly, causing dilatation of the renal pelvis and thus hydronephrosis. in all children in our study ureteropelvic obstruction was suspected and hydronephrosis with dilatation of renal pelvis was detected by ultrasound. for functional relevance of urinary tract obstruction dynamic renal scintigraphy (drs) was used. material and methods: during the past months children in age - years without clinical sign of infection were included in our study. preoperative data, early and late complications and outcome were recorded. imaging studies included urinary tract sonography and drs, which were compared pre and postoperatively. patients were hydrated before scintigraphy and were advised to empty urinary bladder before investigation. for drs as radiopharmaceutical technetium m labeled mag was used. frusemide was administered intravenously minutes after the start of examination at dosage of . mg/kg body weight to achieve forced diuresis. scintigrams were recorded in posterior view. the zoom factor was chosen . - , matrix x . total time of examination was minutes. the definition of the region of interest (roi) for each kidney was either semiautomatic, using a roi drown around the kidney, or fully automated. it was routine to obtain post-void images for gravity-assisted drainage. quantitative functional parameters were interpreted in conjunction with image review and perfusion, parenchymal and excretory phases were described. an attempt was made to define the approximate limits of reversibility of stasis in affected kidney after operation, so drs was repeated in children from our study - months after the operation. results: drs in comparison pre and post-operation in the children showed marked improvement of washout (wo). in addition the six children with wo = about % also showed months later small improvement at scintigraphy. conclusion: sonography is suited to documenting the anatomical situation and can be repeated without radiation burden, but drs can be used to assess the functional relevance of urinary tract obstruction before and after the operation. the careful attention to the technique of the examination is necessary, because there are still many controversies surrounding the physiology and interpretation of the renogram. early diagnosis and suitable therapy of functionally relevant urinary tract obstruction are very important to avoid chronic renal damage. aim: glomerular filtration rate (gfr) is generally considered the best functional measure among several important functions of kidney. cystatin c is a nonglycosylated basic protein produced at a constant rate by all nucleated cells and eliminated by glomerular filtration. serum cystatin c reflects renal function in children independent of age, gender, height, and body composition. recently, cystatin c has been studied as an alternative marker of gfr and more accuracy than serum creatinine.the aim of this study was to compare measured gfr by two-plasma sample method (tpsm) with serum cystatin c level in paediatric population. materials and methods: the study population comprised consecutive patients ( boys, girls, mean age . ± . ), included thalassemia (n= ), acute lymphoblastic leukemia (all) (n= ) and fanconi anemia (n= ). blood samples were taken at and min post-injection of - mbq of tc- m dtpa from the contralateral arm. slope-intercept method was used for tpsm gfr measurements. serum cystatin c level was also measured on all patients. results: tpsm gfr values varied between - ml/min/ . m (mean: , ± ml/min/ . m ). serum cystatin c levels ranged from . to . mg/l with a mean of , ± . mg/l. there were found statistically significant negative correlation between tpsm gfr and serum cystatin c level (r = - . , p< . ) . regression analysis showed the curve equation formula as follow:gfr (ml/min/ . m ) = -( x serum cystatin c )ninetyfive % confidence interval is: . -( . x cystatin c) to . -( x cystatin c); p< . . conclusion: this study showed that there was statistically significant negative correlation between gfr value in tpsm and serum cystatin c level. cystatin c may reflect the quantitative renal function in the paediatric population. further studies are needed to validate this conclusion in paediatric population. there is increasing evidence that botulinum a toxin (boa) might have a powerful role in the management of children with functional voiding problems. the aim of this study was to analyze radionuclide uroflowmetry evidence of effectiveness of boa injection in treatment of dysfunctional voiding in children. patients and methods: study enrolled female children, - year old, with dysfunctional voiding and recurrent urinary tract infection, in whom pharmacological and biofeedback treatment failed. a dose of units of botulinum-a toxin (dysport) was injected intrasphincterically at sites in all children. urodynamic and radionuclide uroflowmetry was performed in all children before, and months after the treatment. radionuclide uroflowmetry was performed using mtc-dtpa or mtc-mag and the following parameters were analyzed: functional bladder capacity measured as voided volume plus residual urine volume, presented as a percent of predicted bladder capacity (fbc, %), residual urine volume presented as a percent of fbc (ru,%), voided time (vt,s), average flow rate expressed as voided volume divided by voiding time(afr, ml/s), peak flow rate expressed as afr multiplied by peak bladder emptying rate (pfr, ml/) and ejection fraction calculated as ratio of counts between peak bladder emptying rate minus minimal bladder emptying rate, and mean bladder emptying rate (ef,%). all children have been tested before and six month after the treatment using empirically designed international reflux study modified questionnaire, regarding daytime and nighttime symptoms, voiding and bowel habits and quality of life. results: the relative changes-each in comparison with the value before dysport injection therapy were as follows: fbc increased by % versus % (ns), ru decreased by % versus % (p< . ), afr increased by ml/s versus ml/s (p< . ), pfr increased by ml/s versus ml/s (p< . ), ef increased by % versus % (p< . ) and vt decreased by s versus s (p< . ). significant symptom score improvement was detected six months after the treatment, being decreased by versus . no major side effects occurred. conclusions: although we surveyed only a few patients, the efficacy after boa injections in difficult-to-treat children with bladder dysfunction seems promising. only slight improvement of bladder function parameters detected by means of radionuclide uroflowmetry with the significant improvement of urinary tract symptoms six month after the treatment could be addressed to improvement in voiding dynamics and significant reduction of postvoid residual urine volume. these results raise hope of keeping high-risk children with bladder dysfunction under conservative control longer. before and after the furosemid provocation was , /min and , /min respectively. in cases the number of waves actually increased, and there was no change in the remaining cases. in cases we compared the change in ureteral function before and after reconstructive surgery. the mean peristaltic wave number before the operation was , /min, and decreased to , /min afterwards. conclusion: according to previous studies, the ureter adapts to increased urine flow by increasing the transported bolus volume. in our study, megaureters adapted to the same challange by increasing the frequency, which is an indication of impaired renal drainage. the decrease in frequency following surgery may be the result of a succesful operation. b. ajdinovic , l. jaukovic , z. jankovic , a. peco-antic ; military medical academy, belgrade, serbia, university pediatric clinic, belgrade, serbia. objective: urinary tract infection (uti) is a common condition in children with vesicoureteral reflux (vur), and may lead to renal damage. the aim of this study was to determine the incidence and the pattern of abnormal dmsa findings in children with hystory of bacteriologically proven uti. materials and methods: standard m tc-dmsa renal scintigraphy was performed in children ( boys and girls, aged from seven months to seven years ), six months after the initial infection. findings were classified according to the image appearance and relative kidney uptake (rku) and related to the grade of vur, sex and child's age. results: micturating cystourethrography (mcu) revealed vur ( uni and bilateral) of grades i, ii, iii, iv and v in , , , and patients respectively. dmsa images were normal with rku within normal limits in patients and equivocal in pts findings were interpreted as abnormal in cases due to scarring, and in pts with decreased rku. bilateral scarring was shown exclusively in children with bilateral vur. scarring rate was significantly associated with vur of higher degree (p< . ) and male gender ( p< . ). no significant difference was found between renal scarring and child's age in same gender group. poor kidney function (rku less than %) was shown in / patients. conclusion: renal damage on dmsa scintigraphy highly correlated with grade of vur. a strategy to perform mcu in only patients with abnormal dmsa finding is proposed. disordered gastric emptying is frequent and clinically important complication of diabetes mellitus (dm). the aim of this study was to determine gastric emptying rate(ger) in children and adolescents with type dm, and to investigate relationship between ger and microalbuminuria in these patients. subjects and methods: ger with solid meals was assessed by a radionuclide method using solid meal in diabetic children and adolescents and age matched healthy controls. the patients were divided into two groups according to duration of diabetes as less than years (group a) and longer than years (group b). the patients ingested scrambled egg bound to mci of tc- m sulphur colloid bound to a scrambled egg. images were obtained from anterior and posterior projection in a x matrix with . zoom factor. the period of data collection began as soon as the subjects finished the meal. the data were acquired for s per frame, for a total of min. a region of interest corresponding to the stomach was outlined to the determine the gastric counts for each image. a power exponential fit was used to analyse the time-activity curve over the stomach and to calculate the half-time of gastric emptying. delay was recognized if ger was longer than minutes. three consecutive timed overnight urine collections were used to calculate microalbuminuria. increased microalbuminuria was defined as a median value is greater than or equal to . μg/min. data were evaluated using mann whitney u analysis, kruskall wallis analysis and pearson's correlation tests. results: the mean values of ger were . ± . minutes for diabetic patients and . ± . minutes for control group; and the difference was not statistically significant (p= . ). ger didn't differ significantly between group a and group b and control group (p> . ). there was no significant difference of ger among in patients who have higher and lower microalbuminuria level (p> . ). there was no correlation between ger and duration of diabetes and microalbuminuria (p> . ). conclusion: we did not detect any significant changes of ger in children and adolescents with type dm. no relationship could be found between microalbuminuria and ger. aim: scintigraphy with tc- m dmsa is considered a reference method for assessment of renal parenchymal lesions and estimation of differential renal function (drf). however, comparisons with tc- m mag indicated certain disadvantages of dmsa such as relatively higher radiation exposure to kidney and time consumption. tc- m mag with high tubular secretion suggests that it may be useful in infants. the aim of this study was to evaluate the performance of tc- m mag dynamic renal scintigraphy in the detection of renal parenchymal defects and in the estimation of drf comparing to tc- m dmsa scintigraphy. materials & methods: a retrospective review of the records between april -january indicated that a total of infants ( boys and girls) aged under years, underwent both tc- m dmsa and tc- m mag scintigraphies within weeks of each other. parenchymal phase of mag scintigraphy were compared to dmsa images for right and left kidneys, separately. the renal cortical analysis of mag scintigraphy was performed on the summed image obtained from dynamic images. and also, differential function was calculated in mag and dmsa studies and then compared. results: findings corresponded completely in % of patients. there was no statistically significant difference between calculated drf on dmsa and mag images. however, in the left kidney, mean mag value ( . %) tend to be higher than that of dmsa ( . %). there is a high correlation between the drf (r= . and r= . ; for the left and right kidney, respectively; p< . ). accepting dmsa is a gold standard method to assess renal cortical lesions, the sensitivity and specificity of the mag cortical scintigraphy were calculated as % and %, respectively. compared with dmsa, mag was as sensitive as dmsa however lower specific than dmsa. the results showed that most of renal parenchymal lesions detected on dmsa scans can be identified on mag parenchymal scans. both studies can be equally used for the calculation of drf. tc- m mag may be acquired for evaluating of renal parenchyma especially in infants because it is a feasible, useful, rapid ( min) functional imaging method and lower radiation dose. because of low specificity of tc- m mag cortical analysis, tc- m dmsa scintigraphy have to be acquired in the definite diagnosis and management of renal cortical lesion therapy. aim: congenital diaphragmatic hernia (cdh) is often combined with primary hypoplasia of the pulmonary vascular bed, which is one of the most significant prognostic factors in patients with cdh. in this study, the values of lung perfusion and ventilation scintigraphies were investigated to assess the lung regarding pulmonary vascular hypoplasia in the pediatric patients with cdh. material and methods: patients ( boys, girls) were included in the study. all patients had respiratory distress within the first hours of life due to cdh. six patients had left-sided and patients had right-sided cdh. all cases underwent a surgical repair of cdh in the newborn period (mean age: . days). the mean ± days after the operation, lung perfusion scintigraphy was carried out with . mbq/kg of tc- m maa. the perfusion images were evaluated quantitatively. for quantitative analysis, the regional distribution of each lung was expressed in a percentage of total lung perfusion. next day, lung ventilation scintigraphy was performed with . mbq/kg of tc- m dtpa by placing a see-through mask over the child's mouth and nose allowing them to be able to breathe as if via a nubulizer. ventilaton images were evaluated quantitatively in a similar manner as to the perfusion study. results: in one patient, the perfusion rate of the side of cdh was % and the ventilation rate of the same lung was %. because of the combination of the good ventilation and restricted perfusion, it was thought that primary pulmonary vascular hypoplasia might exist in this patient. in other / cases, the mean perfusion rate was . ± . % and the mean ventilation rate was . ± . % in the side of the cdh. in these patients, a statistical difference was not observed between perfusion and ventilation results (p> . ). having been considered that ventilation disorder with secondary perfusion disorder might develop, the pulmonary vascular hypoplasia could not be eliminated in these cases. conclusion: this study reveals that the combination of lung perfusion and ventilation scintigraphies, which are objective, quantitative, non-invasive, and easily performed methods, may helpful in determining the pulmonary vascular hypoplasia in pediatric patients with cdh. additionally, it can be suggested that these methods may be useful to evaluate the growth and development of lung affected by cdh especially during the first year of life when respratory function studies are difficult to obtain. using the same site for tracer injections and blood sampling makes edta clearances more acceptable to patients and ensures that blood samples will be successfully obtained. but there are predicted problems from tracer contaminating the samples or saline diluting the samples. in practical terms the two important questions are (a) whether same site sampling (sss) produces an increased rate of recognisable poor test results, and (b) whether it produces undetected bias or errors in the results. since february -sample edta clearance studies have been performed, of which had separate sites for injection and sampling, and the remainder used the same venous access for injection and blood sampling. in addition, studies from another hospital (w) that used different sites were included. a review of the results produced the following:-recognised problems: were noted as follows:-venous access not obtained ( ) ward lost samples ( ) patient fainted ( ) vein "blew" during tracer injection ( ) tracer contamination of first sample ( ) . unrecognised problems: were looked for by using the following quality assurance factors:-( ) the r value of the log-plot fit to the data points. ( ) the ratio v d / weight. ( ) the first point position relative to a line drawn only through the second and third points. the different groups studied were group n= hospital w and group n= hospital a . both of these first two groups used separate sites for the tracer injection and sampling. groups to used the same site for injection and sampling, as follows:-group n= sss (antecubital fossa luer) group n= sss (pic line) group n= sss (luer in hand vein) group n= any method but gfr< ml/min. results: with one exception, none of the qa factors showed any difference between the groups studied. the exception was group (low gfrs), and this group showed a lower r value than the others. conclusion: the one case of sample contamination was detected by looking at the data and the routine qa values. assessment of the qa values in the remaining data did not suggest any undetected bias in the group results. objective: ureteropelvic junction stenosis and vesicoureteral reflux are the most frequent entities identified by antenatal hydronephrosis. aim: to determine the incidence and pattern of abnormal renal scintigraphy findings in postnatal investigation of children with antenatal hydronephrosis. patients and methods: twenty four infants ( boys and five girls) who presented with antenatal hydronephrosis and mild to moderate hydronephrosis on ultrasound in newborn period were referred for renal scintigraphy. ten patients with vesicoureteral reflux documented on micturating cystoureterography received dmsa renal scintigraphy and patients received dtpa scintigraphy. results: antero posterior pelvic diameter on ultrasound ranged from to mm. dmsa renal scans identified congenital scars in two boys with bilateral reflux of grade v and unilateral reflux of grade iii. global hypoplasia (relative kidney uptake (rku) less than %) was found in three, and poor kidney function (rku less than %) in two patients. significant obstruction was shown on dtpa diuretic renal scintigraphy in near the half of patients ( / ). some slowing in drainage (t / greater than minutes) with no reduction in differential renal function was identified in three patients. differential renal function less than % was obtained in one case. conclusion: high proportion of abnormal renal scintigraphy findings was obtained ( %). renal scintigraphy was useful in determination of underlying cause of antenatally detected hydronephrosis. pediatric urolithiasis is very important because of its effects on the growing kidney, the significant recurrence rate, the association with urinary tract infections (uti) and the long term outcome. in this study we aimed to determine the renal cortical state by dmsa in children with urolithiasis who had experienced uti during follow up. patients with urinary tract abnormalities were not included to the study. a series of patients ( boys, girls) with a mean age of . ± . months and a mean follow up period of . ± . months were studied by dmsa. dmsa scar grading was performed for each subject according to imperiale et al. number of utis, the localization of the stones were noted. uti was treated with proper antimicrobial therapy. stone patients were treated medically according to their stone analysis or urinary metabolic analysis. uti attacks were recognized during follow up. only patients ( %) showed scars on dmsa. scar grading was in two patients and in two patients. of these four patients children with single uti showed score on dmsa and children with or more uti showed score on dmsa. the localization and the side of the stones were the same in all subjects. we conclude that urolithiasis often coexists with uti and the risk of renal injury is not low . dmsa scan evaluation is important during the follow up of these patients. introduction -aim: gfr is the best measure of kidney function and is accurately measured by cr-edta, which follows bi-exponential kinetics. as the widely applied multiple sample technique assumes a monoexponential pattern of tracer elimination, gfr is overestimated and corrections for the missing, initial, fast component of tracer clearance have been incorporated in current european guidelines. these are the linear chantler's (ch) and the quadratic brochner-mortensen's (bm) corrections, diverging, however, at different gfr levels. the aim of the present study was to analyse the agreement between gfr measurements after applying the two correction methods at various gfr levels in a mixed adult population. patients and methods: four hundred ninety six pts ( women), aged . ± . yrs were enrolled in the study. pts were referred for gfr measurement for chronic kidney disease or as kidney donor candidates, renal transplant recipients and renal transplant donors. gfr was measured with the slope-intercept, two-sample technique after i.v. administration of cr-edta . values were normalized for body surface area calculated according to haycock's formula and were expressed as ml/min/ . m . bland-altman analysis was applied for assessment of agreement. results: patients were allocated in low (< , pts), intermediate ( - , pts) and high (> ml/min/ . m , pts) uncorrected gfr groups. mean (sd) uncorrected gfr values were . ( . ), . ( . ) and . ( . ) ml/min/ . m for the three groups, respectively. after ch / bm corrections, gfr values were . ( . ) / . ( . ), . ( . ) / . ( . ) and . ( . ) / . ( . ) ml/min/ . m for the three groups, respectively. mean gfr differences (ch -bm) were - . ( . ), . ( . ) and . ( . ) with % confidence limits - . - . , - . - . and . - . ml/min/ . m for the three groups, respectively. - ) and gamma camera equipped with a low energy high resolution collimator interfaced with a computer. regions of interest (roi) were drawn over the whole kidneys. radioactivity-time curves were generated from the roi. time to peak activity (t max ), time from peak to % activity (t ½ ) and the uptake slope of each kidney were calculated from the renograms. the same protocol was repeated for the same animal times at days intervals at , and °c higher temperature. blood pressure was measured using a catheter inserted into the femoral artery connected to a recorder and renal blood flow was also measured through renal artery using an electromagnetic blood flow sensor connected to a flowmeter. creatinine and urea in blood were measured in control and hyperthermic rabbits. results: during hyperthermia the experimental curves shifted to the right of the control curves indicating that there was a delayed renal uptake of mtc-mag- and clearance of radioactivity. this delay was proportional to body temperature. from body weight and height. linear regression analysis was applied to assess association between variables. results: all patients were overweight or obese, with bmi . ± . (range . - . ) kg/m . gfr was . ± . ml/min. gfr was moderately correlated to bsa ( . , p< . ), lbm (r= . , p< . ) and tbw (r= . , p< . ) . prediction equations were: gfr = - . + . x bsa, gfr = . + . x lbm and gfr = . + . x tbw. no statistically significant difference was detected between the slope coefficients ( . vs . ) conclusion: despite the common beliefe, tbw is equally good to bsa or lbm as a gfr predictor in overweight or obese patients with normal renal function, thus questioning the importance of bsa normalization. as we see at these results, no significant difference was found between group i and group ii, regarding the number of patients with skeletal metastases. conclusion: low levels (< ng/ml) of serum prostaticspecific antigen can not eliminate the possibility of existance of skeletal metastases, as was expected. even more, as the difference of the pathological bone scans between group i and group ii was not significant, values of psa ng/ml cannot be considered as a safe threshold for the exclusion of the indication of bone scan. background: the rutland-patlak plot is used in renography for determining relative kidney function and for separating blood background in the measured renogram. in the uptake phase the plot is a straight line, but the duration of this phase may differ from patient to patient. a good method for drawing the line in the patlak-rutland plot should be accurate and precise, while taking into account that data may show unusual behaviour or be noisy. aim: this work compares three methods for drawing the line with the aim of finding a method that gives reliable results on all groups of data. materials and methods: data were collected from consecutive m tc-dtpa renographies routinely made in the department ( kidneys). independent of this collection, renographies were selected where at least one of the kidneys has a renogram with irregular behaviour early in the renogram, such as decrease in the renogram about minute p.i., or unusually noisy data ( kidneys with "problematic" renograms). from each renogram points for the rutland-patlak plot was calculated and three methods were used independently to draw the line: .) manual drawing on hardcopies by three independent observers. slope and intercept were determined afterwards. .) linear regression on the first points measured after minute p.i. (from to about minutes p.i.). .) points for linear regression were selected by an algorithm developed for the purpose, based on possible exclusion of early points and possible inclusion of points later than minutes p.i., to reduce weighted residual variance. results: in the group of consecutive patients ( kidneys) friedmann test showed significant differences among methods (p < . ). pairwise comparison showed no significant difference between method and , whereas method yielded slightly lower values of slope and slightly higher values of intercept than the other two methods. estimates on uncertainty gave similar results: no significant difference between method and , significantly higher uncertainty estimates in method than the other two methods. for the group of selected "problematic" renograms ( kidneys) method was used as reference method. method failed in a number of cases compared to the reference method, whereas method showed good results. see table. conclusion: method gives results that are accurate and precise on normal and "problematic" renograms. the method is operator-independent. method fails in a number of cases. results: among patients that underwent each of the three studies, no statistically differences were observed regarding age, sex, disease duration and type of lesion. / renograms ( %) were interpreted as abnormal ( ou, on). / dmsa renal scintigraphies ( %) were abnormal and / gfr measurements ( %) were also abnormal. conclusions: in patients with spinal cord lesion and neuropathic bladder, "functional" obstructions and parenchymal scars seem to be the most common nephrourological complications, while nephropathy detected by renogram and/or gfr measurement is found in a smaller number of patients. it is suggested that diuretic renogram and dmsa renal scintigraphy should be performed as part of the diagnostic and therapeutic management of all these patients. patients who were booked for dtpa renograms and edta clearances on the same day had those injections given at the same time, and the plasma samples were counted on a collimated gamma camera at the end of the day. an excel program was used to calculate the m tc-dtpa results (using times that had been recorded to correct for tc-decay during the day). after hours to allow the technetium to decay, the cr-edta was counted in a sample counter, and the results compared. it is sometimes difficult to differentiate peripelvical cysts / ppc / and hydronephrosis / hn /, based only on the symptoms of the patients / pts / and the data from the ultrasonography. the aim of the study was, using dynamic renal scintigraphy, to differentiate these two entities.we have investigated pts, using - mbq mtc-ec. in all of them, the ultrasonographic data showed hypoechogenic area in the region of the kidneys' pelvis and it was difficult to differentiate ppc from hn. after performing renography, in of the pts, there was an "accumulation" type of the curve, in -a "retention" type, in -the curve was with a delayed excretion and in normal. in all of the pts with an "accumulation" or "retention" type of the curves, additionally a diuretic renography was performed / using . mg/kg furosemid , injected on min. p.i. of mtc-ec /, to differentiate obstructive from nonobstructive hydronephrosis. in the latter pts there was a quick outflow of the radioactivity from the pelvicaliceal system after the injection of the diuretic / t ½ min./. using additional imaging methods and follow up of the pts, of them with a normal or delayed excretion, finally were diagnosed as having only ppc, and from those with an "accumulation" or "retention' type - were with a non-obstructive hydronephrosis and -with an obstructive hydronephrosis, due to different reasons. only patient with ppc had non-obstructive hydronephrosis. divided renal function of the kidneys with hn was lower - . % than that of the kidneys with ppc- . % / p< . /. we consider, that using dynamic renal scintigraphy without or with diuretic, further elucidating of the diagnosis could be made and the appropriate therapy of the patient could be planed. conclusion: the renography is a reliable tool for differentiation of the ppc from hn. using additionally diuretic renography, not only differentiation of the obstructive and non-obstructive hydronephrosis could be made, but according to the obtained results, the following therapy could be chosen. excretory function. aim of the study was investigation whether clearance parametric images of kidneys widen the diagnostic capacity of traditional procedures. materials and methods: individuals were studied in whom diabetes type i (insulin dependent) was diagnosed. a second group of healthy volunteers served as controls. individual kidneys were studied and their images and renoscintigraphic curves evaluated. in all individuals a dynamic kidney study was performed after administration of the m tc-ethylenodicysteine (ec) and erpf determined. after processing of aquired data conventional images were created by summation of scintigrams received in the phase of secretion of rf. from the same images the clearance images were created. both types of obtained images served for the evaluation of defects of kidney parenchyma. for both types of images a level score scale was used to provide semiquantitative measure of observed pathology. renographic curves were evaluated by analyzing their shape, taking into account relative contribution of each kidney to total uptake (or erpf). elimination of urine from the pelvic and ureteral space was evaluated on basis of phase iii of the renogram. mean renal transit time (mtt) and mean parenchymal transit time (ptt) of the tracer were also calculated. results: analysis of clearance parametric images revealed that regional defects in function of renal parenchyma were more frequent in kidneys of patients with diabetes than in the controls ( , % vs , %). in conventional summation images there were no significant differences in defect frequency noted between the groups ( , % vs. , %) . there were no differences between ptt and erpf between the groups (p= , and , resp). relative uptake of ec in both groups did not differ and was within the normal range of values. there were a larger mean value of mtt and more frequent flattening of the curve in phase iii in patients with diabetes than in control group (p= , and p= , , resp.) , what could be due to the functional uropathy, seen in diabetic patients. conclusions: . clearance parametric images reveal additional information on regional function of kidneys even if other values characterizing global function of kidneys are still within the normal range. . parametric clearance images should be included as a component of dynamic kidney studies. s. inanir, g. ege aktas, t. erdil, h. turoglu; marmara university, istanbul, turkey. aim: tc- m dmsa renal cortical scan is a reference method in determining relative renal function (rrf). tc- m mag- is also recommended for the estimation of rrf, particularly in young children. the aim of this study was to compare mag- and dmsa rrf estimations, and, to assess reproducibility of these estimations in children with unilateral hydronephrosis. methods: we reviewed mag- and dmsa scans in children with unilateral hydronephrosis and a normal contralateral unit. all were imaged with agents within months. mag- rrf was calculated using different time intervals ( - minutes and - minutes) and perirenal c-type region of background activity. no background correction method was used in the calculation of dmsa rrf. all data were processed twice by two independent operators. results: in the repeated estimates of mag- rrf, the maximum mean differences were . % (sd: . %) within observer and . % (sd: . %) between the observers. intra-method analysis showed statistically significant agreement between repeated measures of rrf for agents as well as for operators (intraclass correlation coefficients of early and later phase of mag- and dmsa rrf values were . , . , . for operator and . , , . for operator , respectively, p< . ). there were significant correlations between the mag- and dmsa rrf estimations (r= . / . at - min, . / . at - min for the repeated measures of rrf for operator i, and . / . , . / . for operator , respectively, p< . , pearson). when each scan was classified as normal or abnormal according to rrf values, inter-method analysis showed statistically significant agreement between mag- and dmsa rrf estimations (kappa statistic). however, a disagreement was revealed between the methods when borderline and supranormal estimates of rrf were taken into consideration. conclusion: in children with unilateral hydronephrosis, our results indicated a close correlation between dmsa and mag- rrf estimations with a good reproducibility. renal perfusion scintigraphy using technitium- m is commonly performed after renal transplant to assess vascular flow to the transplanted kidney. this allows cases of vascular compromise to be detected early to minimize damage to the transplanted kidney. this retrospective study evaluates the outcomes of a series of renal perfusion scans performed in a tertiary care hospital in the post-operative management of renal transplantation. in addition, we define a renal transplant perfusion index (rtpi) as the ratio of the cumulative counts in the renal transplant to the cumulative counts in the aorta from start of the renal perfusion scan to time of peak aortic curve, and attempted to correlate the values in each patient with the eventual outcome. over a month period, all recipients of a kidney transplant and who subsequently underwent renal perfusion scan within the same admission were recruited into the study. the medical notes were analyzed for scan results and patient outcome. a scan was deemed normal if no evidence of major vascular compromise was detected, abnormal if there is a perfusion defect seen and/or there is delay in perfusion to the transplanted kidney. a patient's outcome was deemed uneventful if there were no transplant-related complications prior to discharge (i.e. vascular compromise, biopsy-proven transplant rejection or acute tubular necrosis), and eventful if complications arose. a total of patients were included. scans were normal, of which patient had an eventful outcome (transplant rejection). another scans were abnormal, of which patients had eventful outcomes ( with vascular obstruction, with transplant rejection or acute tubular necrosis). the sensitivity of this study in detecting a transplant-related complication was %, and the specificity was . % (thus giving the likelihood ratio for a positive test as . ). the positive predictive value was . % and the negative predictive value was . %. the mean rtpi in patients with uneventful outcomes was . ± . , compared to . ± . in patients with eventful outcomes. a tc- m renal perfusion study has become a mainstay of management after renal transplant. this study quantifies its utility in predicting outcome after renal transplantation when done in the post-operative period. it also suggests that an elevated rtpi is associated with patients who develop acute post-transplant complications. the ectopic kidneys belong to the inherited abnormalities of the kidneys. the aim of the present study was to evaluate the function of the ectopic kidney with renal dynamic scintigraphy with mtc -dtpa. materials and methods: a retrospective study of the renal dynamic scintigraphies done between to year was done. out of renal scintigraphic examinations patients with an ectopic kidney were found- men and women with age from to years. in all of them diagnosis an ectopic kidney was put for the first time due to the scintigraphic examination. the scintigraphy was done on a gamma -camera siemens according to a predefined protocol with quantitative measurements in two phases: perfusion and secretionexcretion. mbq/ kg / mtc -dtpa was injected as bolus at the very beginning a quality assessment and quantitative determinations of t max, t ½, relative function of each kidney and glomerular filtration rate /gfr/ were done. results: in all patients the ectopic kidney was found in the pelvis above the urinary bladder. in patients the right kidney was ectopic and in the rest the left one has an ectopic position. in patients the ectopic kidney was hypoplastic. preserved kidney function with spastic drainage were found in patients. reduced secretion, excretion and drainage were found in patients. afunction of the ectopic kidney was seen in patients. conclusion: we consider that renal dynamic scintigraphy with mtc -dtpa can be helpful either for diagnosis or for evaluation of the function of the ectopic kidneys aim: to evaluate if renal pelvic dilatation is associated with dysregulation of the rennin-angiotensin system (ras) in foetuses in the second trimester of pregnancy that could represent an early predictor of arterial hypertension development after birth. the study consisted of non-diabetic heterozygousthalassemia pregnant women aged between and years, on their second trimester of pregnancy ( st to rd week of gestation). the foetuses had normal development and no obvious congenital abnormalities on ultrasound. maternal and foetal blood was collected and total rennin and active rennin were measured by an immuno-radiological (irma) method; inactive rennin (prorennin) concentration was calculated by subtraction of the active rennin from the total rennin concentration. foetal renal pelvis was evaluated by ultrasound. the mann-whitney u test was used to compare active rennin, prorennin, and the prorennin-to-active rennin ratio between maternal and foetal blood. the same comparison was performed between foetuses with and without pelvic dilatation, as well as between their mothers. continuous data are expressed as mean ± sd; significance was set at p< . . results: a significant difference as regards prorennin, active rennin, and their ratio was observed between pregnant women and their foetuses (p< . ). furthermore, a significant difference was found in the prorennin-to-active rennin ratios between foetuses bearing renal pelvic dilatation and those without (p= . ), while no significant ratio difference was found between their mothers (p= . ). conclusion: dilatation of renal pelvis in the nd trimester of pregnancy seems to upregulate the ras system, with all the possible consequences of renal dysfunction and arterial hypertension after delivery; thus ultrasonographic evaluation of the foetal renal pelvis and measurements of foetal rennin should be considered. foetuses prorennin (μu/ml) . ± . . ± . active renin (μu/ml) . ± . . correlation with urodynamics and classification by american spinal injury association (asia) impairment scale refluxes (vur) and recurrent urinary tract infection. these situations can lead to scar formation in the renal parenchyma and renal failure that have serious impact on the quality of life and long term survival in this group of patients. the aim of this study was the detection by diuretic renogram of urological and/or nephrological complications in the special group of patients with spinal cord injury and neuropathic bladder. materials and methods: forty-six diuretic renograms were performed in patients with normal renal function (males/females= / , mean age , ± , years, mean disease duration , ± , years) that were referred by the neuropathic bladder unit of the national rehabilitation center. all patients were classified according to asia impairment scale and underwent urodynamics. the different types of neuropathic bladder were defined according to international continence society (ics) terminology. one week after the urodynamics, the diuretic renogram was performed (i.v. injections of mbq tc- m mag- and mgr furosemide at zero timeprotocol f ). our studies were classified as normal (n), ou and obstructive nephropathy (on). results: according to the asia impairment scale, patients were distributed as: a= patients, b= patients, c= patients, d= patients and e= patient and according to ics, detrusor and sphincteric mechanism overactivity was revealed in patients, detrusor overactivity and sphincteric mechanism underactivity in patient and detrusor and sphincteric mechanism underactivity in patients. twenty-eight/ renograms ( %) were interpreted as abnormal ( ou, on). on was detected in males with disease duration of and years. no correlation was found between renogram results and asia impairment scale and type of neuropathic bladder dysfunction. conclusions: diuretic renogram revealed a great number of "functional" obstructions in patients with spinal cord injury and neuropathic bladder. the obstruction is independent of the type of neuropathic bladder. nephropathy is the future threat. the aim of this study was to established the alleles distributions of vdr fok i polymorphism and how one influence on intact parathyroid hormone /pth/ level and some biochemical markers of bone turnover -serum osteocalcin /oc/ and bone alkaline phosphatase /bap/ in predialysis patients with chronic renal failure /crf/. material and methods. forty patients - men and women with crf were investigated. vdr polymorphism was detected about polymerase chain reaction. the serum oc was analyzed using an original kit elsa-osteo and an automatic minigamma counter /abbott, usa/. the bap was measured with special kit "alkphase-b" of metra biosystems. the level of pth was determined with an immunoenzymetric assay. the serum and urine creatinine, total calcium, phosphorus, total alkaline phosphatase were measured according to standard methods, recommended by ifcc. the results. the distribution of allelic variation of vdr fok i in predialysis patients were follow: / . %/ with "ff" alleles, / . %/ with "ff" and / . %/ with "ff" alleles. the level of creatinine clearance were similar in three groups. no significant difference in serum calcium, phosphorus, alkaline phosphatase existed among groups. the intact pth was highest in patients with "ff" alleles - . ± . pg/ml versus . ± . pg/ml in patient with "ff" alleles and . ± . pg/ml in "ff" group /p < . /. the bap in patients with "ff" alleles was higher then bap in patient with "ff" - . ± . u/l versus . ± . u/l but the difference was not significantly. significantly higher serum oc levels were registered in predialysis patients compared to the healthy controls - . ± . ng/ml versus . ± . ng/ml / p < . /. the serum oc was highest in predialysis patients with "ff" alleles - . ± . ng/ml but the difference was not significantly compare to patients with "ff' and "ff" alleles. conclusions: / we detected the follow distribution of fok i allelic variation in our patients: / . %/ with "ff" alleles, / . %/ with "ff" and / . %/ with "ff". / the intact pth was highest in patients with "ff" alleles and this is not due to difference of serum calcium and phosphorus. / the serum oc and bap in patients with "ff" alleles were highest but compare to patients with "ff' and "ff" alleles the difference was not significantly continuous ambulatory peritoneal dialysis (capd) is an effective mode of management for end-stage renal disease. dialysate leakage represents a major noninfectious complication of this procedure. this technique may caused increased intraabdominal pressure resulting in hydrothorax and hernia with reported incidence of % to % and % to %, respectively. a -year-old male who was undergoing continuous ambulatory peritoneal dialysis (capd) for diabetes mellitus nephropathy had scrotal swelling on the first day of initiation of the procedure. peritoneoscrotal scintigraphy was requested in which tc- m sulfur colloid ( mbq; mci) was mixed into a -liter dialysate bag under aseptic technique and instilled into the peritoneal cavity thru an indwelling catheter. sequential scintigraphy revealed gradual advancement of radiotracer via the right inguinal canal and reaching the right scrotum by hour post-instillation. patient underwent right herniorapphy. one month postsurgery, peritoneal dialysis was resumed and scrotal swelling did not recur. p -monday, oct. , , : introduction: dysphagia is a common and disabling symptom, often associated with tracheo-aspiration phenomenon, characterising different neurological and neuromuscular disorders. amyotrophic lateral sclerosis (als) is the most common degenerative motor neuron disease in adults and dysphagia is the most frequent symptom. aim: to evaluate the role of oro-pharyngo-oesophageal scintigraphy (opes) in the diagnostic approach to patients with als. materials and methods: patients divided into two groups underwent opes: group a (control group) included healthy volunteers (female/male / ; mean age ± yrs); group b patients (female/male / ; mean age ± yrs) with als. opes is based on the rapid sequential acquisition of images ( frames/sec. for a total " examination); ml of water containing mbq of m tc-sulfur-colloid are administered by a straw to patients standing in an ° right anterior oblique position in front of a gamma-camera with a large field-high-resolution-low energy collimator. the evaluation of sequential scintigraphic images and a/t curves allows a qualitative (bolus fragmentation with multiple swallowing, naso-pharyngeal or pharyngo-oral refluxes, premature ingestion of the bolus, laryngo-tracheal aspiration) and a quantitative analysis of swallowing disorders [oral, pharyngeal and oesophageal transit times (ott, ptt, ett) as well as retention indexes (ori, pri, eri), and tracheal aspiration percentage ( conclusions: opes appears to be a sensitive test in characterising different swallowing disorders that affect patients with als: propulsion defect (documented by increased oral and pharyngeal transit times, and retention indexes) and incoordinate swallowing (with tracheo-aspiration). opes is a simple, non-invasive and welltolerated test which can provide qualitative and quantitative information of the swallowing phases, useful for rehabilitative and therapeutic purposes. juice as sialogogue j. hsieh; chi mei medical center, yungkang city, taiwan. purpose: to assess the feasibility of using the locally popular and widely available dried sour plum as a substitute for the frequently used lemon juice in stimulated salivary gland scintigraphy (ssgs) and to evaluate the utility of parotid gland stimulated salivary excretion fraction (ssef) as a semi-quantitative functional parameter in pre-radiotherapy and post-radiotherapy head and neck cancer (hnc) patients. methods eighty patients with hnc underwent ssgs and ssef of parotid glands were determined. patients were classified into two groups: twenty in preradiotherapy group (pr) and in post-radiotherapy group (po). each half of the group pr and group po were further subdivided into two groups using different gustatory stimulus: lemon group (l) and dried sour plum group (d). in group pr, those with subjective or objective xerostomia were excluded. in group po, patients underwent ssgs at least three months post-radiotherapy and includes only those who had completed the course of curative radiotherapy and had not received adjuvant or neo-adjuvant treatment. results the ssef of parotid glands greater than % was able to distinguish normal from abnormal salivary function in hnc patients. there is no difference between two different kinds of sialogogues l and d in both group pr and group po using % as a cut-off reference for a normal ssef. conclusions the use of dried sour plum as substitute for lemon juice is feasible in ssgs and the finding of using % as a cut-off reference for a normal ssef was able to distinguish normal from abnormal salivary function in hnc patients. the relationship between helicobacter pylori infection and obesity enteroclysis and xray angiography were negative too. results: twenty-three patients had positive scintigraphy with in vivo tagged rbcs and patients had negative scintigraphy. gi bleeding stopped spontaneously in these patients with negative scintigraphy and these patients did not undergo push-enteroscopy, intra-operative enteroscopy or surgery. final diagnosis of our patients with positive scintigraphy was determined in patients (push-enteroscopy - patients, intra-operative enteroscopy - patients or by surgery - patients). these patients had following final diagnoses: bleeding small bowel arteriovenous malformation ( patients), uraemic enteritis with bleeding erosions in ileum and jejunum ( patients aim: the vanishing bile duct syndrome (vbds), is an acquired and pathologic process that occurs in the biliary tree and is recognizable as an absence of bile duct in an individual portal tract. the underlying processes responsible for bile duct loss include immunological, infectious, ischemic, metabolic, and toxic processes. the purpose of this study was to investigate the potential role of dynamic mtc-hida hepatobiliary scintigraphy (dhbs) in the evaluation of patients affected by chronic liver disease with histological liver involvement characterized by small bile duct injury. material and methods: the study comprised consecutive patients ( males, female), aged between - years. at diagnosis, showed chronic hepatitis c virus (hcv) infection, wilson's disease. all patients underwent standard biochemical liver function tests including parameters of cholestasis gammagt (ggt) and alkaline phosphatase (af) and liver biopsy. dhbs was performed after i.v. injection of mbq m tc-iminodiacetic acid. acquisition of images started at the moment of injection and time/frame acquisition was sec for min. time-activity curves were recorded from regions of interest placed over hepatic parenchyma and main intra-hepatic biliary ducts. quantitative analysis of the curves was performed using deconvolutional analysis and non-linear regression, measuring parenchimal and ductal time point at maximum peak counts (t max ) and t ½ of excretion. results: a liver biopsy revealed in all patients marked ductopenia consistent with vbds. laboratory parameters showed ggt elevation in hcv patiens with concomitant increase of af in one of these. the analysis of quantitative data obtained by dhbs showed in all patients a slow blood clearance and excretion of hida documented by delayed time of parenchimal and biliary t max and abnormal parenchimal and ductal excretion t ½ . no correlation was found between hida t ½ ductal excretion and parameters of cholestasis. however, positive correlation between liver parenchimal/ductal t ½ and histologic scores was observed. conclusion: the dhbs is able to assess the different aspects of hepatic function in vbds. although the present study includes a small number of patients, we believe that this method may be of clinical value in revealing the real hepatic and biliary function showed by correlation with histologic data. its clinical use may be crucial in follow-up and in prognostic evaluation of vbds patients. aim meckel's diverticulum is the most frequent congenital anomaly of the gastrointestinal tract, with an incidence of about % of the population. it is a sacculation attached to the ileum due to the failure of the vitelline duct to disappear. the mucosal lining of meckel's diverticulum containes island of heterotopic mucosa, which may give cause to serious complications such as peptic ulcer, hemorrhage and perforation. the aim of our study was to compare scintigraphy with ultrasonography (us) in the detection of meckel's diverticulum. materials and methods we recruited children, younger than years of age, with painless rectal bleeding. all the patients underwent first scintigraphy and then ultrasound. for the scintigraphic evaluation mbq ( mci) of mtc-pertechnetate (tco -) were administered intravenously. the initial scan was made min to hr after the radiopharmaceutical administration. anterior abdominal images were obtained at a frame rate of one images every - sec over the course of to minutes. acquisition parameters were: single head gamma camera, parallel hr collimator, matrix x , frames. activity in the ectopic gastric mucosa should appear simultaneously than that of normal gastric mucosa. activity in the urinary tract, most often confused with for a meckel's diverticulum, usually first appears after activity is seen in the normal gastric mucosa. for the abdominal sonography a mhz convex-array probe was used. sonographic demonstration of noncompressible, tubular, aperistaltic structure with a double-layered wall, located far from the cecum suggested for meckel's diverticulum. all us scans were reviewed by one of the authors blinded to the scintigraphic results. results out of patients showed abnormal scintigraphic findings with suggestive for meckel's diverticulum. ultrasound confirmed these results in patients of the seen by scintigraphy and was negative in cases. conclusion ultrasound imaging is one of the most widely utilized medical imaging modality that will continue to improve the quality of healthcare in diagnostic application. however scintigraphy is easier to perform, is less operator dependent and has a better sensitivity compared to ultrasound. also scintigraphy is noninvasive, painless, relatively inexpensive. it can be concluded that scintigraphy is still of value in the diagnosis of patients affected by meckel's diverticulum. making of patient with hcv related hepatopathy. our results confirm that both, painless thyroiditis and graves disease, may occur during the treatment with ifn . in this connection, non immunogenic hyperthyroidism may be related to the acute release of hormones circulation (painless thyroiditis). a simple imaging method as pertechnetate thyroid scintigraphy allows to make a differential diagnosis between graves disease and painless thyroiditis and is essential to address the patients towards an appropriate treatment of hyperthyroidism. uptake ( . - %) ft ( - pmol/l) ft ( - year old (mean . ± . ) ( f, m) multinodular goiter patients were included to the study. after taking blood and urine samples, tcpu tests and thyroid scintigraphies were done and the patients were evaluated with thyroid ultrasound. by performing i- uptake measurements . and . hour uptake levels were calculated. results: in this study, of patients (% ) had urinary iodine level above μg/gr cre that indicates sufficient iodine intake. there was a significant negative correlation between tcpu levels and urine iodine levels as indicated in the literature. according to tsh levels, while patients were euthyroid, were hyperthyroid ( subclinical, overt clinic). tcpu levels were found to be higher in hyperthyroid patients than euthyroid ones, but this difference was not statistically significant. in euthyroid patients there were hyperactive nodules. there was a significant positive correlation between patients' tcpu and i- . and . hour uptake values. conclusion: in conclusion, our patients' median urinary iodine level was μg/gr cre which was sufficient. after iodinisation, high percentage (% ) of patients were hyperthyroid. we found that half of euthyroid patients had hyperactive nodules which showed the importance of thyroid scintigraphy in the evaluation of multinodular goiter patients. correlation of tcpu and i- uptake levels suggest that tcpu can be used instead of i- uptake levels. our preliminary results suggest that it would be important to evaluate the relationship between urinary iodine and tcpu levels in larger series of mng patients after mandatory iodinization. abnormal thyroid function and/or with thyroid antibodies an important problem in nuclear endocrinology is the "blocking" of thyroid gland, which necessitates to postpone investigation, to experience adverse clinical effects of stopping medications and a delay of making diagnosis. the aim of the study was to introduce and to determine the clinical value of the scintigraphy with mtc-mibi in patients / pts / with a "blocked" thyroid. in pts / aged - years /, indicated for a thyroid scintigraphy after proper preparation, an investigation was performed with mbq mtc-pertechnetate, min. p.i. in of them ( . %), the thyroid was "blocked" and additional scintigraphy was done with - mbq mtc-mibi, and min.p.i. it was estimated that in all pts there was a visualization of thyroid. in of them, a large "hot" nodule was visualized in the early and late image. later on a differentiated thyroid carcinoma was proved histologically. in another patients "cold" nodules on the early and late scans were detected and benign cysts were proved. therefore according to the type of the nodule, visualized with mtc-mibi and its kynetics, we could help in differentiation of the diseases, to chose the treatment option and to deretmine the prognosis of the patient. as a conclusion we consider, that a scintigraphy with mtc-mibi is a useful tool in pts with "blocked" thyroid. in addition -in patients with nodules, the investigation could help in their differentiation and therefore-a recommendation for therapy. purpose: the aim of this study was to determine an optimal radioiodine treatment by comparing the clinical and biochemical outcome of patients with graves disease treated with estimate doses of radioiodine to those treated with fixed doses. material and methods: a total of consecutive patients of thyrotoxicosis treated with j- were divided into two groups according to the amount of j- administered:i group- patients who received estimated dose of - mbq(mean mbq), ii group- patients who received fixed dose of mbq.all patients were pretreated with antithyroid drugs and were stopped one week before using radioiodine therapy.in , %( / ) patients with recurrent disease were given an additional dose(total dose mbq).the outcome were followed from months to years(median , years). results: at six months after single dose of radioiodine therapy, euthyroid state was achieved in % patients in the fixed dose group and % patients in estimated dose group. there was significant difference in the rate of development of euthyroid state in respect to the given dose of j- (p< , ). % patients in the fixed dose group became hypothyroid,compared to % patients in estimated dose group.the median time to hypothyroidism was weeks. % patients in fixed dose group remained hyperthyroidism six months after radioiodine therapy,compared with % patients in the estimated group.in that group significantly more patients who received low( - mbq) doses remained hyperthyroid,compared to those who received high(< mbq) doses.the thyroid volume reduction was significantly (p < , ) higher in successfully tred patients( %) than in those that remained hyperthyroid( %). conclusion: there was significant difference in outcome between the two treatment regimes.better control of thyroid states can be achieved by estimated j- dose,while fixed radioiodine offers an affective treatment option where is required rapid control of thyrotoxicosis and long term hypothyroidism is a recognized outcome. evaluated by visual examination (grading "high", "moderate" uptake and "no uptake") and by calculation of background radiouptake ratio (rur) was evaluated. results: patients had a intense mibi retention and underwent surgery: (histology revealed papillary carcinoma and folliculary folliculary carcinoma in one pat. folliculary adenoma, pts. had a moderate uptake and underwent surgery too- pat. have benign nodule in another two thyroiditis). using the / -minute thyroid lesion to background radiouptake ratio (rur), malignant and benign thyroid nodules could be separated with a sensitivity, specificity, and negative predictive value of . %, . %, and . %, respectively. the mean rur for malignant thyroid lesions was . +/- . , whereas for benign lesions, the ratio was significantly lower, . +/- . (p= . ). conclusions: in patients, in whom a needle aspiration cytology is not possible (hampered by antigoagulation therapy), the tc- m mibi scintigraphy appears to be a useful additional diagnostic tool in the preoperative assessment of suspected thyroid nodules differential diagnosis of the main types of hyperthyroidism is performed with the help of thyroid scan m tc- m, which brings out the size, the shape, the nodularity and the functional state of the gland. a second scintigraphy, this one with i, is necessary to estimate the therapeutic activity of i in hyperthyroidic patients. both radionuclides are trapped by thyroid gland in a similar manner, however, m tc is not organified. hence, the results of both types of scans are not expected to be identical in all the circumstances. aim the aim of this study is to evaluate and compare the correlation between the uptake of m tc and i in graves disease, toxic multinodular goiter and toxic autonomous nodule, in order to ponder, in these three situations, the performance of the m tc scan only, which exposes the patient to a lower radiation dose. materials and methods this is a retrospective study, based on a population of patients, divided into groups: a) patients with graves disease; b) with toxic multinodular goiter; c) and with toxic autonomous nodule. all of them underwent a thyroid scintigraphy h after administration of , mbq ( μci ) of i and a thyroid scan minutes after the administration of mbq ( mci) of m tc pertechnetate. we used a siemens ecam dcr dual head gamma camera, with the same acquisition conditions ( x matrix), and the uptake of each radionuclide was calculated. the results in each of the groups were correlationed and compared. results in plotting the m tc uptake against the uptake of i, the best fit was a linear regression model for the three studied groups. the calculated coefficient of determination (r ) was , for patients with graves disease; , for patients with toxic multinodular goiter; and , for patients with toxic autonomous nodule. conclusions our results demonstrated a poor relationship between the uptake of m tc and i in graves disease, toxic multinodular goiter and toxic autonomous nodule, especially in the former. thus, it will not be feasible to rely solely on the m tc thyroid scan and exclude the i thyroid scintigraphy as part of the protocol in none of these situations. purpose: higher levels of urokinase-type plasminogen activator (upa) and its inhibitor (pai- ) are linked to the poor prognosis in a variety of malignances. upa and pai- were expressed in most thyroid carcinomas, as had been measured immunohistochemically. however, no relationship between their expression and clinicopathological parameters were described. aim of the present study was to investigate the expression and clinical relevance of upa and pai- in thyroid cancer. patients and methods: upa and pai- in paired cytosol samples of thyroid tumor and normal tissue were determined in patients using enzyme-linked immunosorbent assay and correlated to the known prognostic features. results: both upa and pai- concentrations were significantly higher in malignant thyroid tumors (upa= . ± . and pai- = . ± . ng/mg protein) than in normal tissue (upa= . ± . , p= , and pai- = . ± . ng/mg protein, p= , ) with positive correlation of the two proteins in the tumors. upa and pai- were significantly higher in anaplastic vs. well-differentiated cancers (upa p= . and pai- p= . ), if extrathyroidal invasion (upa p= . and pai- p= . ) or distant metastases (upa p= . and pai- p= . ) had been present, and in tumors whose size exceeded cm in diameter (upa p= . and pai- p= . ). only pai- , but not upa was significantly higher in multicentric vs. solitary tumors (p= . ) and lymph node positive compared to lymph node negative patients (p= . ). the differences of upa and pai- did not reach the significant level when patients with well-differentiated tumors below and above years of age had been compared. survival analysis revealed the significant impact of both upa and pai- on the progression-free survival (pfs) ( . vs. . months for patients with low and high upa, respectively, p< . ; . vs. months for patients with low and high pai- , respectively, p= . ). conclusions: the correlation of high upa and pai- with the known prognostic factors of poorer outcome and with lower pfs rate in patients with thyroid cancers proved that these proteins could be an additional prognostic parameter. aim: to evaluate the changes of myocardial parameters in patients with confirmed primary hyperparathyroidism, asymptomatic for coronary artery disease (cad). a total of patients (mean age . ± , years) with suspected primary hyperparathyroidism and no-cardiac related major symptoms (myocardial infarction, pectoris angina) were examined using cervical planar, spect and dynamic, and gated rest-cardiac spect acquisitions. we analyzed the myocardial-rest parameters including myocardial perfusion, left regional ventricular ejection fraction (lvef), regional motility and thickening. acquisition was performed by obtaining early dynamic study, planar cervical images at min, min and - h after iv administration of mbq of m-tc-tetrofosmin (myoview); cardiac gated spect acquisition at min post-injection. results: patients ( , %) were positive for parathyroid adenoma ( m-tc-tetrofosmin scintigraphy), and confirmed through ct/mri and surgical exeresis with histological exam. / patients ( , %) had myocardial parameters changes including perfusion defects, decreased leftventricular regional ejection fraction, systolic thickening and motility disorders. patients ( , %) had normal myocardial perfusion scintigraphy result. out of patients with unconfirmed parathyroid adenoma had normal mps result. patient have moderate perfusion defects. all the results were correlated with parathyroid hormone, calcium and phosphorus plasma and urinary levels. conclusion: among patients with primary hyperparathyroidism, a high percent was affected by important changes of myocardial perfusion and systolic function ( , %). we have to underline that all these patients were asymptomatic for cad. we can therefore conclude that gated-spect is definitely a useful tool for management of patients with primary hyperparathyroidism. negative predictive value of undetectable tg level in tsh suppression during the early follow-up of low-risk differentiated thyroid carcinoma a. piccardo, s. morbelli, p. bianchi, f. barbera, g. villavecchia, m. cabria; ospedali galliera, genoa, italy. aim: is noted that tsh stimulated thyroglobulin(tsh-tg) alone is sufficient for early follow-up of low-risk differentiated thyroid cancer(dtc) patients with no clinical evidence of disease after thyroidectomy and thyroid i ablation. recent data indicate that serum thyroglobulin at the time of remnant ablation( ablation-tg) can be correlated with tsh-tg measured months later and can predict persistent or recurrent disease in postoperative period. there is also consensus that, during long term follow-up, tg measurement during thyroid hormone suppression(thst-tg) are sufficiently sensitive to forgo further testing in a low-risk patient who is clinically free of disease and has had undetectable tg after recombinant human tsh(rhtsh) or thyroid hormone withdrawal(thw). however only a small fraction of relapsing dtc patients, at month follow-up, show undetectable tg under t treatment(< . ng/ml). the aim of this study is to evaluate, in low risk dtc patients early follow-up, the negative predictive value(npv) of undetectable thst-tg measurement and undetectable thst measurement + ablationtg compared with rhtsh-tg. materials and methods: we enrolled patients with histologically proven dtc treated by total thyroidectomy and radioidine. in all patients we measured ablation-tg levels. inclusion criteria were: tumor grater than cm, smaller than cm, limited to the thyroid, not of virulent subtype, which were completely resected with or without nodal metastases but without distant metastases, negative anti-tg antibodies. all patients present undetectable thst-tg at month follow-up. at year after radioiodine treatment, all patient underwent on rhtsh stimulated tg assay. results: based on rhtsh-tg assay(> ng/ml), histology, clinical data and long term follow-up persistent/ relapsing disease was proven in patients. tg positive( . - . ng/ml) after rhtsh, with no evidence of disease was observed in patients. patients showed undetectable rhtsh-tg. the negative predictive value of undetectable thst-tg and rhtsh-tg were respectively . % and %. the ablation-tg levels were < ng/ml in patients. in this group the npv of undetectable thst-tg was %. conclusion: these data seem to indicate that undetectable thst-tg assay, evaluated by high sensitive methods combined with low ablation-tg levels may avoid a significant number of high cost rhtsh-tg. further confirmation on a larger group of patients are needed. the results sensitivity and specificity of % and % respectively, however with fna combination, the specificity of the combined procedure increased to %. serum tg measurement was detectable ( ng/ml) in tumor patients with a sensitivity of % but gave no localization information, which was important for surgical intervention. as a non-invasive imaging modality, fdg pet had a sensitivity, specificity, positive predictive value and accuracy of %, % and % and %. conclusion: ultrasonography of the neck is a practical modality that can be employed as first line investigation in papillary thyroid carcinoma patients with a clinical suspicion of loco-regional recurrent disease. it can be combined with radioiodine and pet findings and lead the patients to surgical intervention for a promising complete cure. retrobulbar mtc-diethylenetriamine-pentaacetic-acid uptake predicts the effectiveness of immunosuppressive therapy in graves' ophthalmopathy l. galuska , b. Újhelyi , j. varga , l. szabados , a. erdei , i. garai , e. v. nagy ; university of debrecen, debrecen, hungary, university of debrecen, pet-ct medical diagnostic ltd., debrecen, hungary. aim of study: in graves' ophthalmopathy, only patients with immunologically active disease respond to immunosuppressive therapy, while those in the fibrotic stage do not. in the present series we aimed to show if m tc-ethylenetriamine-pentaacetic-acid (dtpa) spet is able to predict the success of imunosuppressive treatment. patients and methods: orbits of patients with graves' ophthalmopathy ( women and men) were studied. patients with graves' disease and eye signs suggestive of activity of the orbital autoimmune process (cas ) were entered in the study. all received corticosteroid treatment and were additionally treated with orbital irradiation. dtpa spet was performed before, and to months after the initiation of immunosuppressive treatment. orbital dtpa uptakes were numerically quantified and compared before and after treatment. the calculations were performed for the entire orbit voi as well as the anterior and posterior segments separately. the control group consisted of orbits of patients who had no thyroid disease. results: in the control group, the dtpa uptake of the orbit as a whole, the anterior, and posterior segments were . ± . , . ± . and . ± . bq/cm (mean±sd) respectively. the upper normal reference limit of posterior segment dtpa uptake was set to the % percentile of the control group, . bq/cm . the mean dtpa uptake of the orbits of go patients was higher before immunosuppressive treatment than after therapy ( . ± . bq/cm and . ± . bq/cm , respectively, p= . ). the anterior and posterior segment values correlated with those of the entire orbit. of the orbits with an initial dtpa uptake . bq/cm in the posterior segment, % has improved, while of those orbits with an initial dtpa uptake above . bq/cm , % has improved. conclusions: for a favourable treatment outcome, the positive predictive value of an initial dtpa uptake > . was . %, while a negative predictive value of a dtpa uptake . was . %. patients with dtpa uptake above . may be predicted as responders, while those with a dtpa uptake below this value have only low chance of benefit from immunosuppressive treatment. aim: marine-lenhart syndome (mls) was defined as graves`disease with autonomously functioning nodules. currently there exist no data about the actual incidence of this desease and the results of radioiodine therapy. methods: in a prospective trial patients with initial diagnosed hyperthyreoidism were evaluated. physical examination, interview, ultrasound, scintigraphy and determination of t , t , tsh and antibodies were carried out in all patients. all patients were followed up at least one year after radioiodine treatment. results: mls was diagnosed in patients (incience . %). following treatment with radioioidine patients had normal serum tsh levels. hypothyreoidism was present in patients and hyperthyreoidism persisted in patients. a newly diagnosed orbitopathy was not observed after radioiodine treatment. conclusion: the actual incidence of mls was . % in patients with newly diagnosed hyperthyreoidism. treatment with radioiodine offers the chance for euthyreodism but includes a significant probability for a second therapy. the optimal method to determine iodine- treatment doses is to obtain time-activity curves from serial measures, after administration of a trace dose. a simplified method is based on a -hours i- uptake. it's still unclear the potential usefulness of tc- m scan (routinary performed during the diagnostic work-up) to estimate the iodine uptake. aim of the study. we evaluated the possibility to use the -minute tc uptake computed during standard tc scintigraphy to reliably estimate the maximum thyroid radioiodine uptake. methodology. we consecutively evaluated patients: with uni-or multinodular goiter (ng) and with graves' disease (gd). each patient underwent both tc scintigraphy and i- uptake. tc scan was acquired with a gamma camera equipped with a lehr-p collimator, ± minutes after the i.v. injection of mbq of the tracer. tc uptake was computed by measuring the syringe before and after injection under the same geometrical conditions. i- time/activity curve was obtained acquiring planar images with a gamma camera equipped with a hegp collimator at several times ( hrs, hrs, > hrs) after oral administration of . ± . mbq. thyroid uptake at any time was calculated according to standard methods. statistical analysis was performed. results. our data demonstrate different kinetics between ng and gd. mean iodine maximum uptake per mass of thyroid tissue (umax) resulted similar between groups: . ± . (ng) and . ± . (gd) . mean time to reach max iodine uptake (tmax) resulted statistically different: . ± . (ng) and . ± . (gd) (p< . ). tc uptake mean values and standard deviation (s.d.) were . ( . )% for ng and . ( . )% for gd. the best fitting demonstrated a natural logarithmic correlation between tc uptake and umax for both ng and gd. a strong correlation was found between umax vs. the natural log of tc uptake. regression coefficients r were: introduction: interferons (ifn) are a family of naturally occurring proteins with antiviral and immunomodulatory activities. there is a wide range of thyroid abnormalities related to ifn administration. thyroid autoimmunity has been widely reported as a side effect of ifn treatment as well as hypothyroidism and thyrotoxicosis. methods: a retrospective analysis of radionuclide thyroid studies of patients who had thyroid scans and were on interferons was done. all patients had thyroid scans obtained after iv injection of mci of tc m pertechnetate as well as thyroid uptake after oral administration of uci of i- . results: there were six thyroid studies of five patients , four on alpha ifn for hepatitis c viremia and one patient on beta ifn for multiple sclerosis were identified. patients included females and males ranging in age from to . patients had no history of thyroid disease prior to interferon therapy. scintigraphic diagnoses included one patient with simple goiter, one with subacute thyroiditis, one with diffuse toxic goiter and two with nodular toxic goiter. one patient developed first the nodularity then the hyperactivity in the intervening tissue later as seen on the follow up scan.conclusion: thyroid scintigraphy shows different interferon induced scintigraphic patterns and is valuable to differentiate hyperthyroidism due to graves' like pattern from ifn -induced thyroidits. adrenal or retroperitoneal masses preoperatively was beneficial. the number of positive cases continued to grow, indicating a more judicious referral in the recent years. conclusion: the experience of with in-house preparation of mibg was rewarding. the impact on clinical endocrine practice was so significant that mibg scintigraphy had become a routine investigation for all neuroendocrine tumours in our institution. the aim. data on the thyroid blood flow in healthy subjects without thyroid disease are scarce. the aim of our work was to evaluate the influence of thyrotropin (tsh) concentration on the peak systolic velocity (psv) in a group of healthy persons. patients and methods. we included euthyroid subjects, females, males, aged to (mean, . ± . years). all subjects were negative for thyroid peroxidase antibodies (tpoab) and thyroglobulin antibodies (tgab). colour flow doppler sonography (cfds) was performed using a . mhz linear transducer. psv was measured at the level of intrathyroid arteries with a sampling volume of mm. in each subject psv was expressed as a mean of five measurements. results. mean tsh concentration in all subjects was . ± . mu/l, (min. . , max. . mu/l, reference value: . - . mu/l). according to their tsh concentration, subjects were divided into groups: first group with tsh between . and mu/l (n = ) had mean psv . ± . cm/s, second group with tsh between . and . mu/l (n = ) had mean psv . ± . cm/s, third group with tsh between . and . mu/l (n = ) had mean psv . ± . cm/s, and fourth group with tsh between . and . mu/l (n = ) had mean psv . ± . cm/s. when compared with group one, psv was significantly higher in group four (p = . ). additionally, in all subjects a significant correlation between tsh concentration and psv (r = . , p = . ) was found. conclusion. we established a significant positive correlation between tsh concentration and psv in euthyroid subjects without autoimmune thyroid disease. the results are in accordance with the data on the stimulative influence of tsh on angiogenesis. radioiodine and m tc-peretechnetate uptakes are currently used for the assessment of thyroid function. i has the disadvantages of high radiation dose due to itsemission, high energy rays and longer half life. i is cyclotron produced agent and is costly. m tco has the advantages of quick assessments, low radiation dose and better image quality. however, both studies need preparation of patient with low iodine diet and cessation of anti-thyroid /thyroid replacement therapy. m tc-sestamibi has been recently evaluated by various investigators for the assessment of thyroid function with an advantage that there is no need of such preparation. the current study was done to assess the m tc-sestamibi thyroid uptake and t max . for this purpose, nine euthyroid volunteers (group i), patients with grave's disease (group ii), patients with hypertrophic hashimoto's thyroiditis (group iii) and patients with atrophic hashimoto's thyroiditis (group iv) underwent m tc-sestamibi thyroid scintigraphy. dynamic images of thyroid were acquired for minutes along with static syringe images (pre & post injection) for two seconds. maximum uptake of m tc-sestamibi was seen at minutes post injection in volunteers as well as in patients in various groups. images at , , , , minutes revealed gradual tracer clearance from thyroid. in ev, minutes m tc-sestamibi uptake was (mean±sd; . ± . %). in gd and hht patients minutes m tc-sestamibi uptake (mean ±sd; . ± . % and . ± . % respectively) was greater than in ev (p< . and p= . respectively). aht patients revealed minutes m tc-sestamibi uptake (mean±sd; . ± . %) lower than in ev and hht (p= . and p= . respectively). mean minutes m tc-sestamibi uptake showed strong correlation with mean minutes m tc-pertechnetate uptake in gd patients (r= . ) and with tsh levels in hht patients (r= . ). it is concluded that minutes is optimal time interval between m tc-sestamibi injection and calculation of thyroid uptake. minutes m tc-sestamibi uptake can differentiate euthyroid individuals from gd patients. no preparation with low iodine diet and cessation of anti-thyroid drugs before m tc-sestamibi uptake is a great advantages which possess its role as possible alternative radiopharmaceutical for thyroid uptake calculation. possible use of thyroid us and thyroid abexaminations in follow up in detecting high risk patients or early and subclinical hashimoto thyroiditis k. zaplatnikov , w. wiedemann , m. plotkin , f. grünwald ; nuclear medicine clinic nürnberg, nürnberg, germany, nuclear medicine department university hospital charite berlin, berlin, germany, nuclear medicine department university, frankfurt, germany. aim patients with hashimoto thyroiditis (hit) show typically decreased echogenicity of the thyroid ultrasonography (us). in this study, we investigated the association between the us pattern, tsh values and level of thyroid antibodies (anti-tpo,tg-ab) in order to evaluate the usefulness of us for hit screening. method included were consecutive pts with suspected hit ( f, m, mean age ± yrs) and control group with pts ( f, m, mean age ± yrs). blood samples were analysed for thyroid-ab, tsh and periphere thyroid hormones. us or scintigraphy of the thyroid was performed in follow up ( and mo). results pat. with decreased echogenicity and high level of thyroid autoantibodes (n= , gr.i) had a higher mean tsh ( . miu/l) compared with pts. with normal echogenicity and thyroid autoantibodes (n= , gr. ii) ( . mu/l, p< . ). pts. with normal echogenicity had thyroid autoantibodies too (n= , gr. iii) with mean tpo-ab ( ± ng/ml) and tg-ab ( ± ng/ml). pts. with decreased echogenicity (gr. i) had a higher level of thyroid autoantibodies (anti-tpo,tg-ab) than subjects from gr. iii (p< . ). conclusion we found a strong association between hypoechogenicity at thyroid us and higher levels of serum tsh/thyroid abs in pts suffering on hit. our results suggest that a decreased echogenicity represents a reliable sign of hit. however, a normal echo pattern cannot exclude a hit. this indicates a possible use of thyroid us and thyroid ab-examinations in follow up in detecting high risk pts or early and subclinical hit. application of somatostatin receptor scintigraphy in patients with thyroid associated ophthalmopathy j. deng; xijing hospital, fourth military med. univ., xi'an, china. the study aims at investigating the effectiveness of the orbital somatostatin receptor scintigraphy (srs) with m tc-oct in curing patients with active graves' ophthalmopathy disease and their response to the corticosteroid therapy. method: a somatostatin analog, oct, was labeled with m tc by a direct method. the compound's labeling efficiency was confirmed by paper chromatography. the subjects of the experiment were patients with graves' ophthalmopathy (go) and four volunteers without eye disease or graves' disease (gd) as the control group (cg). during the study, single photon emission computed tomography (spect), computed tomography (ct) and the left and right lateral position planar imaging of the heads of the subjects were obtained four hours after the iv injection of mbq m tc-oct. corticosteroid therapy (methylprednisolone, mg po tid for month) was then given to all patients in the next day and lasted for one month, after that the srs was repeated to all patients. radioligand uptake within each orbit (o) and occipital (oc) was measured using the region of interest (roi) method and the o-to-oc ratio was determined before and after corticosteroid treatment. clinical activity of graves' ophthalmopathy was evaluated before and after the treatment by calculating the ophthalmopathy index (oi). key results: comparing to the o/oc ratio of the control group at the scintigraphy ( . ± . , p< . ), a significant change in the o/oc ratio was observed in patients with active go between pretreatment and post-treatment ( . ± . vs. . ± . , p< . ). no significant change in the o/oc ratio was found between the cg and the go patients after post-treatment ( . ± . vs. . ± . ,p> . ). there was no significant change in the o/oc ratio in patients with inactive go (p> . ) in both pre-treatment and post-treatment periods and in the cg (p> . ). conclusions: in those patients with active graves' ophthalmopathy, somatostatin receptor scintigraphy showed markedly increased orbital uptake of m tc-oct. the study demonstrates that m tc-oct scitigraphy is a good indicator and able to predict the clinical response to the corticosteroid therapy in patients with go. this method should be considered as an objective and safe method to select proper treatment therapy. the use of real-time quantitative polymerase chain reaction (quantitative real time pcr) amplification of the human epidermal growth factor receptor (egfr) in lung cancer patients and cases of benign pulmonary disease and healthy controls. results median concentration of free circulating dna in serum of lung cancer patients, benign pulmonary disease and healthy controls was . ng/ml, . ng/ml and . ng/ml, respectively. the diagnostic sensitivity, specificity and accuracy of free circulating dna for lung cancer was . %, % and . %, same as the diagnostic value of combinations for detecting lung cancer was . %, % and %, respectively. conclusion the free circulating dna in the serum at diagnosis in lung cancer patients may be a new better tumor marker. sialoscintigraphy with m tc-pertechnetate in evaluation of salivary gland function in patients after radiotherapy with head and neck carcinoma j. niewiadomska, g. lapinska, d. kolataj, m. benke, i. kozlowicz-gudzinska, d. kiprian, a. sackiewicz; institute of oncology, warsaw, poland. radiotherapy in patients with head and neck carcinoma can result in temporary or permanent damage of the salivary glands. xerostomia can exert negative effects on the patients quality of life. aim: the aim of study was to evaluate salivary glands function in patients receiving radiotherapy due to head and neck cancer. materials and methods: patients ( men, women, aged - years) with larynx and pharynx carcinoma were enrolled in this study and underwent scintigraphy prior to radiation therapy as well as in the th and in the th month of follow-up. the patients were divided in two groups. first group consisted of patients with the area of parotid glands irradiated in %- %. second group included patients with the area of parotid glands irradiated in %- %. in both groups % mass of submandibular glands was irradiated. each patient received total irradiation dose of - cgy. dynamic salivary scintigraphy was performed with single-head gamma camera spx after injection of mbq tc m-petrechnetate. gland function was stimulated with lemon juice at min of the study. up (uptake ratio), t max (time at the max count), ms (maximum secretion) and ma (maximum accumulation) were calculated and analyzed. results: in both groups complete dysfunction of submandibular glands was observed in the majority of patients during months after rt. in comparison with the first group, in the second the parotid glands damage was less and reversible. among patients with retained salivary glands function, higher values of ma, ms, up parameters were observed in cases with parotid glands irradiated in - %. conclusions: sialoscinigraphy is a valuable non-invasive method for assessing salivary glands function in total and for each gland separately. in patients with head and neck carcinoma, radiotherapy leads to salivary glands damage which may last up to months after irradiation. degree of dysfunction is correlated with the area of irradiation. peritoneal dialysis and hydrothorax e. urbanova; nuclear medicine university hospital, hradec kralove, czech republic. continuous ambulatory chronic peritoneal dialysis (capd) is an affective renal replacement therapy for patients with end stage of renal disease. development of hydrothorax is serious but relatively less common complication. plain radiograph shows presence of hydrothorax but cannot establish its association with peritoneal dialysis and assessing the outcome of pleurodesis procedure. aim of this study was to show two patients (pts). with hydrothorax and capd. method both pts were undergoing caps for five monts. they were admitted to the hospital for breathlessness and right side chest pain. plain radiographs showed presence of hydrothorax. cytological examination of pleural fluid was negative for malignant cells. in view of transudative nature of pleural aspirate, a peritoneo-pleural communication was suspected. patients were subjected to peritoneal scintigraphy to establish the communication between peritoneal and pleural cavity. radiopharmaceutical m tc-colloid (administered activity mci) was injected into dialysate bag and infused through catheter into peritoneal cavity. to reach homogenous mixing of activity within peritoneal cavity the patient was asked to roll into bed. static scans incorporating thoraco-abdominal region were acquired at frequent time intervals with dual head gamma camera equipped with leap collimators. results by one hour some radioactivity was noted in right pleural space, but after two hours scintigrams were much better with ascent of activity up to apex of pleural space on the right side. hydrothorax was present in both pts on right side due to transit of dialysate fluid through peritoneo-pleural communication. conclusion peritoneal scintigraphy is simple, non invasive procedure with diagnostic value in evaluating connection between capd and hydrothorax. introduction. recently, a somatic point mutation of the b-raf gene (v e) has been identified like the most common genetic event in papillary thyroid carcinoma (ptc), with a variable prevalence between the different series ( - %). its detection can be made on thyroid biopsys as well as in cytological samples obtained by fine needle aspiration biopsy (fnab). for these reasons, it has proposed like a molecular marker in the early diagnosis of the ptc. objectives. to know the frequency of b-raft a in operated patients of thyroid cancer. to value the utility of the detection of this mutation in the ptc diagnosis. material and methods. the detection of mutation b-raft a was made in patients with thyroid cancer diagnosis. for the test were used fixed paraffin-embedded thyroid tissue sections coming from the surgery. patients had a thyroid fnab previous to the surgery in which also the presence of the mutation was analyzed. the techniques used for the detection of b-raft a were: dna extraction, pcr/rflp and mutation confirmation by sequentiation. results. of the analyzed biopsies ( ptc, follicular carcinomas, hurthle carcinomas, anaplastic carcinomas and high degree sarcoma), b-raft a mutation was positive in , % of tumors ( / ). according to the histologycal type, the mutation was detected in , % of ptcs ( / ): , % of classic variant, , % of micropapillaries ( / ), , % of follicular or mixed variants ( / ) and % of the variant of high cells ( / ). the mutation was not detected in any of the histologycal types different from ptc. of the patients who in the last had a previous paaf year, the mutation was positive in % of the patients ( / ) with a fnab previous to the surgery in the last year. conclusions. the presence of braft a mutation is specific of ptc and displays an elevated frequency in this group of patients. in of the patients with a previous fnab in last year, a precocious and definitive diagnosis of cpt could have been given by detecting braft a mutation in the cytology. waist circumference predicts silent myocardial ischemia in patients with diabetes mellitus: a myocardial perfusion study g. p. carboni, s. manfrini; università campus bio-medico, roma, italy. silent myocardial ischemia (smi) is a frequent condition in patients (pts) with diabetes mellitus but its mechanism and clinical relevance are still uncertain. aim:we screened for smi consecutive such pts , mean age +- years , % males , by rest/stress gated single photon emission computed tomography ( g-spect). methods: imaging was carried out on a dual-head gamma camera with thallium or sestamibi .extent of abnormal defects ads was considered significant when > than % of total lv pixels ( p ) and reversibility (myocardial ischemia) as a % of the ads p . visual images were analyzed with a score from to . relationship between imaging results and clinical parameters such first-degree family history of diabetes ( % of pts) , waist circumference ( +- cm ) , mass body index ( +- ), duration of diabetes ( +- years ) , type of diabetes ( % of pts with type , % with type ) ,total cholesterol ( +- mg/dl ) , ldl-cholesterol ( +- mg/dl) hdl-cholesterol ( +- mg/dl ) ,triglycerides ( +- mg/dl ) , hypertension ( % of pts ) , glycosylated haemoglobin ( +- % ) , c-reactive protein ( . +- . mg/l ) , current therapy ( insulin:in % of pts ; ace-inhibitors: in % of pts ; calciumantagonists: in % ; of pts ; statins: in % of pts ) were then analyzed for study . all pts were also followed-up for cardiac events ( ce ) for an average time of +- months. results: overall pts , % ( / ) revealed clear-cut smi on g-spect but only subject of these had a major ce after month follow-up. on a logistic regression model ( chi-square = , p < . ) , smi was significantly associated only with waist circumference but not with the rest of clinical parameters. when data were adjusted for established risk factors and current therapy, results did not change ( p = ns for all). conclusions: this study suggest that pts with diabetes mellitus , abnormal waist circumference indicates predisposition to an accelerate development of smi . stress myocardial perfusion imaging may thus indicate early appropriate prevention and treatment. the aim of this study was to evaluate the possible application of bone mineral density measurement using dual energy x-ray absorbtometry (dexa) in the diagnosis of transient osteoporosis of the femur. methods: fourteen patients were included this study ( males and females), with age range - years. all patients presented with hip pain, diagnosed by bone isotope scan and confirmed by mri as transient osteoporosis of the proximal femur. all patients underwent dexa scan for bilateral proximal femurs. bone mineral density values and t-score values were recorded. bone density was considered normal if t-score >- , consistent with osteopenia if tscore was (- ) -(- . ) and consistent with osteoporosis if t-score was < - . . t test was used in statistical analysis and p< . was considered significant. results: tscores in the affected femurs were ranging from (- . ) and (- . ) with a mean value of (- . ). t-scores were consistent with osteoporosis in patients, osteopenia in and normal bone density in one. t-scores in the controlateral femurs were ranging between ( . ) and (- . ) with a mean value of (- . ), with significant difference compared to affected side (p< . ). t-scores were consistent with normal bone density in , osteopenia in and osteoporosis in patients. t-score difference between the affected and the normal side was ranging between - . , and twelve patients ( %) had a tscore deficit in the affected side with more than sd compared to the controlateral side. conclusion: dexa scan can detect significant drop in bone density in patients with transient osteoporosis of the femur. although most cases didn't show t-score values of osteoporosis, still using the t-score difference compared to the controlateral femur as cutoff value may have application in establishing the diagnosis. aim: spondylodiscitis still remains a diagnostical problem. the aim of the study was to assess the sensitivity and diagnostic value of bone scintigraphy and leukocyte scintigraphy in spondylodiscitis detection. material and methods: the documentation of patients with clinically confirmed spondylodiscitis, who were treated at the department of infectious diseases between and , was reviewed. according to algorithms valid in our hospital bone scintigraphy has to be done in patients with suspected spondylodiscitis if spine on plain x-ray is inconclusive. leukocyte scintigraphy is mainly used for detection of infective foci and in patients with fever of unknown origin. m tc dpd, activity mbq, was used for bone scintigraphy. whole body scintigrams in ap and pa projections were done between two and four hours after radiopharmaceutical injection. if scintigrams were inconclusive, spect of suspected part of body was done. m tc hmpao labelled leukocytes, activity to mbq, were used for leukocyte scintigraphy. scintigrams of the whole body were performed minutes and two hours after radiopharmaceutical injection. results: bone scintigraphy was done just before or during hospitalization in ( %) patients. at the time of bone scintigraphy patients had working diagnosis of spondylodiscitis or were suspected of having spondylodiscitis. patients had different working diagnosis. radiopharmaceutical accumulation in the region with spondylodiscitis was: -increased in ( %) out of cases, -normal in ( %) out of cases. leukocyte scintigraphy was performed just before or during hospitalization in ( %) patients. of them had working diagnosis of spondylodiscitis or were suspected of having spondylodiscitis. radiopharmaceutical accumulation in the region with spondylodiscitis was:increased in ( %) out of cases, -normal in ( %) out of cases, -decreased in ( %) out of cases (absent activity in vertebral body), -irregular in ( %) out of cases (increased and decreased). the activity in the region with spondylodiscitis was normal in out of patients with working diagnosis of spondylodiscitis and decreased (absent) in of them. conclusions: -bone scintigraphy is important investigation in diagnostic process in patients suffering for spondylodiscitis due to its very high sensitivity. -leukocyte scintigraphy is without diagnostic value in patients with spondylodiscitis. the spect technique was confirmed to be more sensitive than the conventional planar bone scanning for the detection of reactive bony lesions in patients with back pain ( ) . the newly developed hybrid spect/ct device can provide enhanced anatomical localization of the lesions detected on spect. the aim of this study was to investigate the value of spect/ct bone scanning in the evaluation of patients with back pain, which has not been clearly examined yet. methods: we retrospectively evaluated bone scans of patients with back pain (age ± years, men) that had both planar and spect/ct images performed. planar, spect & spect/ct scans were separately reviewed by observers for bony lesion presence, location, & specific diagnosis based on each scan. the confidence in each of these assessments was categorized as uncertain, probable or certain. the final diagnosis was confirmed by surgical/pathological, radiological correlation, or follow-up for up to months. results: there were lesions detected in patients with final diagnosis of arthritis, degenerative disease, fracture, and normal scans. spect/ct findings were more accurate in predicting the final diagnosis (lambda value . , uncertainty coefficient error reduction %) than spect alone (lambda value . , uncertainty coefficient error reduction %). the localization certainty was significantly higher in spect/ct than spect alone (p < . ). as to lesion presence, spect significantly improved lesion certainty, without additional significant improvement by spect/ct. the diagnostic confidence in the determination of the underlying bony abnormality by spect/ct was significantly higher than spect alone (p < . ). conclusions: while the detection of bone scan lesion is significantly enhanced by spect, the hybrid spect/ct can additionally clarify the exact location of these lesions and visualize the associated ct changes. the improved certainty of these factors is the likely reason behind the superior confidence in spect/ct specific diagnosis of the bone abnormality in patient with back pain. aim of the study: stress fractures (sf) have been considered a hazard of strenuous physical activities, such as the military training of army recruits. the aim of our study was to demonstrate the association between the findings of bone scanning and some clinical parameters of physical strain that result in bone injury in this specific group of young people. patients and methods: ninety four male recruits, - years old (mean= ± years), under a similar training program and with suspected sf of the lower extremities underwent three-phase bone scanning after injection of mbq mtc-mdp. they were divided into various groups according to: a) body mass index (bmi): (< =normal, - =overweight and > =obese), b) duration of military service ( - months = recruits, and > months = post-trained soldiers), c) location of the primary symptoms (knees-tibiae, or feet), d) duration of pain symptoms (</= days or > days), e) pain intensity, in a - scale, where = pain free and = very intense pain, f) results of plain radiography (positive/negative) and g) results of bone scintigraphy (grade = negative in all phases, grade = positive only in the rd phase, and grade = positive in all phases). paired chi-square statistical tests were applied for all parameters. results: seventy two patients ( % of the sum) had scintigraphically positive bone pathology ( on the leg and on the feet), while the rest / ( %) had negative bone scans. sf were found at patients ( %), more commonly in the feet rather than the legs (x = . , p= . ) and in recruits rather than post-trained soldiers (x = . , p= . ). positive scintigraphic results also correlated to pain intensity (x = . , p= . ), although the former were not correlated to bmi, duration of pain, or the results of plain radiography. plain radiography had sensitivity= %, specificity= %, ppv= %, npv= % and accuracy= % in the detection of sf, taken bone scintigraphy as "gold standard", with no correlation to any of the aforementioned clinical parameters of bone injury. conclusions: army recruits under the basic training program seem to suffer more severe bone lessions, located mainly in the feet, regardless of overweight or the duration of pain symptoms. regarding bone scanning as the "gold standard" diagnostic method, pain intensity is a strong predictor of an adverse clinical condition (bone fracture rather than a milder lession) bone scintigraphy and xray in detection of active osteoarthritis.their relation to type of knee pain. a roc analysis. aim: bone scintigraphy is a valuable method for detecting synovitis in knee joints with severe osteoarthritis. both clinical symptoms and proven hyperperfusion set the indication for radionuclide synovectomy (rs). the aim of our study was to evaluate the clinical usefulness of blood pool (bp) and static scan (ss) in respect with joint pain, clinical and x-ray findings. materials and methods: knee joints of patients ( ± . years old) referred for setting indication for rs were clinically evaluated and classified by x-ray steinboecker system and type of pain (only under stress/ both under stress and rest). two-phase bone scintigraphy was performed according to the procedure guidelines of our department and intensity of tracer accumulation in joints was scored. to check scintigraphy or simple xrays' ability to evaluate dolorous active synovitis complete statistical receiver operating characteristic (roc) curves were analyzed. results: of all knee joints studied . % were painful at exercise while % were continuously dolorous. in general bp was positive in . % and ss in . %. osteoarthritic joints were x-ray graded . % as , . % as i, . % as ii, . % as iii and . % as grade iv. bp had a sensitivity of . , specificity of . , ppv of . and npv of . at exercise pain and . , . , . and . at continuous pain respectively. all values were critically better than these of ss and xray. area under roc curve for bp was larger than this for ss and for xray (the smallest) in painful joints ( . , . and . respectively) with statistically significant differences. conclusion: bb scintigraphy is a useful technique for detecting active synovitis in knee joints with oa better than ss or simple xray. tracer accumulation is strongly related to the type of pain. introduction condylar hyperplasia is a common cause of crossbite malocclusion and facial asymmetry. treatment often includes surgery and it's necessary to know the growth activity of the hyperplastic condyles for treatment assessment. nuclear methods are beginning very useful in this pathology. objetives the aim of our study is evaluate the correlation between histopathologic findings and uptake intensity in spect in patients with condylar hyperplasia. patients and methods prospective study in patients with clinical suspect of condylar hyperplasia and positive m tc mdp spect. the patients with increased uptake of m tc mdp in any tmj were considered positives and were classificated in three grades of uptake. all patients were referred to surgery (condylectomy or condylar shave). an hystologic study classified the samples in three activity grades. a stadystical analysis of spect and hystopatological finding was done. results condylar hyperplasia was confirmed by hystological findings in all cases. a strong correlationship was confirmed between the uptake intensity and anatomopatologycal findings. conclusions condilar spect with m tc mdp is an easy diagnostic method with high sensitivity for the diagnosis of condylar hyperplasia and is very useful to evaluate the grade of hyperplasia. progressive condition and early surgical intervention may prevent further deformity of the hip join. although the prognosis and treatment of these conditions differ greatly, in the early stages the radiographic appearance of toh my be confused with avn. we will attempt to define radiologic characteristics that distinguish toh from avn. patients and method: in years , patients ( f, m) were referred with acute hip pain; male with bilateral hip pain in the third trimester of pregnancy ( hips). in all patients radiographs, bone scan and mri was performed. the diagnosis of toh was confirmed by complete clinical recovery and normal mri in the follow up with conservatively treatment.. results: no patients had radiographic changes. bone scanning showed uniformly increased uptake at the affected femoral head extending down into the femoral head in all patients. the changes on mri were a pattern of diffuse edema without focal defects, and intact articular surface, but patient with focal defect which diagnosis was avn. conclusion: diffuse edema pattern on mri without focal defects and bone scanning with homogeneously increased uptake in the femoral head and neck is highly suggestive of toh. introduction: reflex sympathetic dystrophy (rsd) or complex regional pain syndrome is a condition of burning pain, stiffness, swelling and discoloration of the affected limb (commonly hands and feet). females are affected more commonly than male ( : ) . only one in five affected patients is able to return to a normal level of functioning. bone scan is highly sensitive ( %) and specific ( %). it is also a useful guide to prognosis. about % of patients with positive bone scan experienced a favorable response to steroid as oppose to % of those with negative scintigrams. case report: this is a years old male presented with weeks h/o severe burning sensation and pain in the left hand. he has had a laminectomy over c -c about weeks back. follow up mri revealed no nerve compression. x-rays of left hand was unremarkable. a three phase bone scan was performed with mbq of tc- m mdp. results: dynamic and blood pool images revealed abnormally increased blood flow over left forearm, wrist and hand. delayed images revealed diffusely increased tracer uptake over the left wrist, carpal, metacarpo-phalangeal and inter-phalangeal joints. a diagnosis of reflex sympathetic dystrophy was made. he was started on oral steroid therapy with analgesic for months and responded well to the treatment. conclusion: it is concluded that three phase bone scan is a safe, non-invasive, cost effective, highly sensitive and specific modality for the diagnosis of reflex sympathetic dystrophy and also a good predictor of response to treatment. aim: fdg pet can assess the activity of several inflammatory diseases. idiopathic retroperitoneal fibrosis (irf) is a rare disease characterised by a fibro-inflammatory mass which surrounds the abdominal aorta and the iliac arteries and often causes obstructive uropathy. we explored the ability of fdg-pet to predict response to therapy and post-treatment relapse in irf patients (pts). methods: twenty-four consecutive irf pts (m/f: / ; median age yrs, range - ). the treatment was oral prednisone for month and then prednisone+methotrexate or tamoxifen for months. ct or mri were performed at diagnosis, after months of treatment and at the end of treatment. pet was performed in all pts before treatment, and in / pts also after the end of therapy. the treatment-induced reduction in size of irf, as assessed by ct/mri, was defined as absent if < %, mild if - %, and marked if > %. fdg uptake was graded from to +. the pts were compared with controls. results: at diagnosis, ( %) pts showed a pathologic fgd uptake with main patterns: diffuse ( / pts, %), and focal ( / pts, %). diffuse pattern: had grade +, had + and had + uptake; the reduction in size of irf was marked in / ( %) pts with grade + and of pts with grade + and absent in with +, with + and with +. focal pattern: had grade +, had + and had + uptake. a marked response was observed in only / pts with grade +; mild responses in / pts with grade +; no response in / patients with grade +, / with grade + and / with grade +. both pts without pathologic uptake showed no reduction. after the end of treatment, / pts had a residual pathological uptake whereas had no uptake. posttreatment relapses were observed in / pts with a residual uptake, and in only / pts without. conclusions: the distribution and intensity of vascular fdg uptake may predict response to treatment in irf patients; a post-treatment residual uptake heralds disease relapse. spect/ct may provide an incremental value to routine indium- labeled wbc scintigraphy, as suggested by a recent report with a limited number of patients ( ) . in this study, we verify this finding in a larger group of patients and also evaluate the different possible contributory factors to the diagnostic confidence of spect and spect/ct scans. methods: we retrospectively evaluated indium- wbc planar scans of patients (age ± years, men) with known or suspected infection that also had spect/ct performed. planar, spect and spect/ct scans were separately reviewed by observers in respect to infection presence, location, and the specific diagnosis based on each scan. the confidence in each of these assessments was categorized as uncertain, probable and certain. the final diagnosis was confirmed by surgical/pathological correlation; follow up scan/radiological examination or up to months clinical follow-up. results: in planar images with uncertain infection location, spect improved locations to probable sites that were further improved to definite and probable sites by spect/ct. correspondingly, in probable location sites on planar images, spect improved locations to definite sites compared with definite sites improvement by spect/ct. conversely, spect significantly improved infection presence certainty in uncertain and probable planar subcategories, without significant additional improvement by spect/ct. in spect/ct, the specific diagnosis confidence was significantly higher when both infection presence and location site were certain, which was more frequently attained than with spect scans alone ( vs , p < . ). final diagnosis was categorized as non-specific/abscess, specific soft tissue infection, osteomyelitis, combined osteomyelitis/soft tissue infection, and normal/physiological uptake. spect/ct findings were more accurate in predicting the final diagnosis (lambda value . , uncertainty coefficient error reduction %) than spect alone (lambda value . , uncertainty coefficient error reduction %). conclusions: in indium- wbc scintigraphy, the infection presence recognition is improved by both spect and spect/ct, while the use of spect/ct leads to considerable enhancement in infection localization as well. the significant improvement in both these factors is the likely reason for the high confidence in the spect/ct specific diagnosis of infection. . bar-shalom r, et al. j nucl med ; : - objectives: in aortic aneurysm (an) tissues, chronic aortic wall inflammation is mediated by macrophage infiltration, which is playing important role for tissue degeneration. some studies have shown that weakening of the mechanical properties of the degenerated tissues may progress the expansion of the aneurysm. especially, saccular ans often expand rapidly and are suspicious for an infected aneurysm. in the present study, we hypothesized that fdg accumulated in saccular an walls because these lesions had strong inflammatory reaction with macrophage infiltration and investigated whether fdg accumulated in saccular ans. methods: a retrospective survey was conducted on patients with an who underwent fdg-pet. after at least h fasting, the study subjects received an intravenous administration of fdg. one hour after fdg injection, pet imaging was carried out. fdg images were visually evaluated for the presence of increased fdg uptake in the carotid arteries. we divided the ans in patients into two groups (saccular-type or fusiform-type) according to the morphologic characteristics. we assessed inflammatory marker (crp) and pathologic characteristics (atherosclerotic or inflamated) in two groups. results: of ans were divided into saccular-type and fusiform-type ans. of saccular-type ans were pet-positive, whereas only one of fusiform-type ans was pet-positive. there was no significant difference in the values of crp and aneurysmal size in two groups. ans proven pathologically were divided into saccular-type ( infected, atherosclerotic ans) and fusiform-type (all atherosclerotic ans). fdg accumulated in all of saccular-type ans. conclusion: fdg frequently accumulated in saccular-type ans. ans in which fdg accumulates may have a high risk of rapid expansion and rapture because these lesions are suspected to have inflammatory reaction with macrophage infiltration. aim aim of this study was that of confirming additional clinical effectiveness using spect/ct with mtc hmpao-labelled leucocyte in infection and inflammation . materials and methods we studied ninety-seven patients (pts) ( females and males; mean age . ± . years); all patients underwent labelled leucocyte scintigraphy for known or suspected infectious or inflammation processes: pts with orthopedic implants, pts with suspected osteomyelitis , pts with spondylodiscitis, pts with fever of unknown origin (fuo), pts with inflammatory bowel disease (ibd), pts with suspected septic arthritis and pt with suspected vascular graft. in addition with planar and whole body protocol images spect /ct was performed using dual head gamma camera equipped with a low-power x ray system (infinia hawkeye -g.e.healthcare ). after injection of - mbq of mtc hmpao-labelled leucocyte spect/ct images of the interesting area were obtained in all cases at h or h according with the clinical query. final diagnosis of infection and inflammation was made on the base of bacteriologic, surgical data or clinical followup. results spect/ct results proved on the whole cases true-negative and true -positive, false -negative and false-positive results. in orthopedic implants and osteomyelitis cases spect /ct permitted to distinguish between soft -tissue infection and bone involvement and allowed to change clinical and surgical management in % cases; spect/ct detected precise localization in ileal and ileocolonic tract in positive ibd cases. additional value of spect/ct was in fuo cases since it permitted a diagnosis of renal abscess in pt with polycystic kidney who previously underwent renal transplant, in another pt, abnormal focal uptake in catheter for haemodialysis and in cases with liver , lung and sub-diaphragmatic abscess respectively. the overall sensitivity and specificity of spect/ct mtc-hmpao labelled-leucocyte was % and % respectively. conclusion spect/ct with mtc hmpao-labelled leucocyte is a useful tool for infection and inflammation detection that provides a precise anatomy localization, expansion and tissues differentiation mainly between soft tissue infections and osteomyelitis. furhermore, it underlines the role of mtc hmpao-labelled leucocyte in cases of suspected abdominal-pelvic or thoracic sites of infections increasing the diagnostic accuracy of positive findings. objective: hemodialysis (hd) activates neutrophils and causes increased lung retention. m tc fanolesomab is a monoclonal antibody that radiolabels white blood cells and myeloid precursors in vivo. it reacts with cd , expressed on the surface of polymorphonuclear neutrophils, eosinophils and monocytes. serious complications occurring < min. after injection was reported in patients (pts) with compromised cardiopulmonary reserves. lung retention of this agent has not been addressed yet. we hypothesized that there might be an excess transient retention of these invivo labeled and probably activated wbcs in the lung capillaries post hd, which may contribute to pulmonary compromise. methods: we retrospectively and semi-quantitatively determined the degree of invivo labeled m tc wbc activity on anterior (a) and posterior (p) whole body images of the consecutive pts. a and p rois were drawn in the upper (u), middle (m) and lower (l) lung zones and over the chest wall soft tissue background and used to calculate the geometric means of conjugate rois (lung uptake ratio). pts without esrd and not on hd were used as controls. elapsed times from the last hd to imaging times were determined. result: mean± sd injection to imaging time: ± min ( - ). of the pts with esrd on hd, had hd < hr before the imaging (group i), pts had hd - before the imaging (group ii). geometric mean lung uptake ratios for right (r) u, rm, rl, left (l) u, lm, ll in group i were . ± . , . ± . , . ± . , . ± . , . ± . and . ± . , respectively. those values for group ii were . ± . , . ± . , . ± . , . ± . , . ± . and . ± . , respectively. control ratios were . ± . , . ± . , . ± . , . ± . , . ± . and . ± . , respectively. a trend of subtle increase in lung uptake ratios was noted for group i, especially in left lung. however, differences weren't statistically significant. conclusion: a recent hd done < hrs might play a role in the activation of the invivo labeled m tcwbcs causing prolonged lung retention in esrd pts, which is not present > hrs. despite the strong trend, lack of statistical significance in group i pts might be due to relatively long ( - min) injection to imaging time and small pt population. purpose:in this study, we aimed to investigate the role of tc- m hmpao white blood cell (tc- m wbc) spect in the evaluation of bone infections in addition to tc- m mdp -phase bone (tc- m -p) scans and planar tc- m wbc scans. materials and methods: the patients who had tc- m -p and tc- m wbc scans between january and march for the investigation of suspected bone infections were evaluated retrospectively. from these, patients whose pathological, bacteriological, surgical data, and clinical onset showed infection were included to our study. for every patient, tc- m -p, planar and spect tc- m wbc scans were performed within one week. our patient group consisted ( %) males and ( %) females whose ages were - (mean age was . ) and who had bone infections in various localizations: patients ( %) had infections of foot, patients ( %) had infections of knee ( of them had knee prosthesis), patients ( %) had infections of hand, and patient ( %) had infection of leg. results: the images of tc- m -p and planar tc- m wbc scans were evaluated together and tc- m wbc spect images alone. the results were as followings: were enrolled the study. the patients were suspected of bacterial infection due to travmatic injury ( pts), diabetic foot ( pts) and prosthetic surgery ( pts). whole-body images at , and hours after iv slow injection of mci ciprofloxacin labelled with technetium- m in-house were obtained. threephase bone scintigraphy was also performed in patients in a period of to days. final diagnosis was obtained by microbiological and patological examinations and clinical follow-up for a period of to years. results there were positive findings on tc- m ciprofloxacin images and of them were proved to be true-positive. staphilococci was the most common agent isolated by microbiological analysis. in one of the patients with false-positive finding, intensive bone repair was noted on bone scan images. ciprofloxacin imaging was true-negative in patients and failed to show bacterial infection in patients (chronic osteomyelitis in , hip and knee posthesis in and diabetic foot in patients). the overall sensitivity, spesificity, negative/ positive predictive value and accuracy of tc- m ciprofloxacin imaging were % % %/ % and % respectively. conclusion tc- m ciprofloxacin is a sensitive and practical procedure that can be used in detecting musculoskeletal infection. it also contrubutes to discriminate aseptic loosening and prosthetic infection and avoids unnecessary orthopaedic surgery. along with three-phase bone scanning false-positive results can be reduced where excessive new bone formation might be the potential cause of false-positive results. objectives: infection of hd vascular access site is a frequent cause of mortality morbidity in hd patients. the incidence is lowest in patients with avf. although the prosthetic hd access (avg and/or catheters) has been acceptable alternative to the native avf, the patients are often plagued by more complications (i.e., infection, thrombosis). aim of the study was to determine the accuracy of infection detection using invivo labeled tc- m wbc imaging in patients with avf as hd access as compared to those with prosthetic hd vascular access (avg, catheter). methods: consecutive patients with end stage renal disease being treated with hd and who had suspected infections were retrospectively analyzed. two nuclear medicine physicians evaluated the tc- m wbc images in a blinded fashion. vascular access infection was diagnosed if radiotracer uptake at the site was focal fashion and more prominent than the surrounding blood vessels. the scan results were correlated with clinical/laboratory information, cultures and outcome. results: in patients a total of vascular access sites were evaluated. there were avg, avf, and hd catheters. none of the avf was infected but % showed collateral formation. invivo labeled tc- m wbc scan showed evidence of infection in / avg (% ) of the avgs, compare to / ( %) of the hd catheters (p: . ). when compared, avf versus prosthetic hd access (avg + catheters), the incidence of detected infection was % versus % (p: . ). the sensitivity, specificity, positive predictive value, negative predictive value and accuracy for the detection of infection with the tc- m-wbc scan in avgs were: %, %, %, %, and %. the values for the hd catheter were %, %, %, % and, %, respectively. conclusions: a properly formed arteriovenous fistula is less likely than other types of vascular access to become infected. hemodialysis catheters and arterio venous grafts had similar rates of infection. the tc- m wbc scan has an accuracy rate of - % in detecting infection in arterio venous grafts and hemodialysis catheters i.e., prosthetic hemodialysis access. objectives: this was an intraindividual analysis of the utility of currently available radionuclide imaging techniques: phase bone ( pbo), bone (bo), gallium (ga), bone/gallium (boga), labeled leukocyte (wbc), leukocyte/bone (wbc/bo), and leukocyte/marrow (wbc/ma), to determine the most accurate radionuclide technique for diagnosing the infected hip prosthesis. methods: patients, females, males, - years old, with failed hip replacements, total arthroplasty, hemiarthroplasty, weeks- years old, who completed all radionuclide imaging tests and who subsequently underwent surgery formed the basis of this retrospective study. one experienced nuclear physician reviewed all images. diagnostic criteria for infection were as follows: pbo= triad of periprosthetic hyperperfusion, hyperemia, & increased periprosthetic activity on delayed, bone, images; bo= increased activity around the shaft of the femoral component, ga= any increased periprosthetic activity except focal activity at the tip or trochanters, bo/ga= spatially incongruent distribution of activity or, if congruent, ga activity >bo activity, wbc= increased periprosthetic activity relative to contralateral limb or surrounding normal activity, wbc/bo= spatially incongruent distribution of activity or, if congruent, wbc activity >bo activity, wbc/ma= spatially incongruent distribution of activity. imaging results were compared with surgical, histopathological and microbiological results for all prostheses. results: there were infected prostheses. final diagnoses in the remaining cases include aseptic loosening ( ), failed acetabular liner ( ) , and component malposition ( ) . imaging results are summarized in the for all prostheses the pbo scan demonstrated only moderate sensitivity and low specificity. for reasons that are as yet unknown, the test was not sensitive, but moderately specific, for diagnosing prosthetic hip infection, while in contrast, it was very sensitive, but not at all specific, for diagnosing prosthetic knee infection. conclusions: the phase bone scan is of limited utility for diagnosing infection of lower extremity joint prostheses. the test is not sensitive for prosthetic hip infection and too nonspecific to serve as a screening test for knee prostheses. malignant otitis externa is a rare infectious disease of the external auditory canal commonly caused by pseudomonas aeruginosa. the disease may have a protracted course with extension to other bony and soft tissues structures of the skull base. evaluation of disease extent is crucial for initial management with further evaluation required to document resolution during treatment. ct will delineate bone and gross soft tissue involvement but may be normal in early disease. mri is useful to assess soft tissue extent of disease but assessment of resolution is difficult with both modalities. bone scintigraphy will detect early bone involvement but remains abnormal for some time therefore is unreliable for assessment of resolution or detecting early recurrence. gallium- citrate can be used to assess disease extent but like bone scintigraphy is non-specific and partly reflects bone activity. there is less published data on the use of in- white cell imaging which has been said to become negative before complete resolution. it is possible that this drawback relates to the imaging properties of in- and the difficulty of localising small low intensity foci of white cell accumulation on planar views. in three recent cases of suspected skull base osteomyelitis low intensity foci of white cell accumulation were identified on planar imaging with in- labelled white cells. use of spect combined with 'hawkeye' (low power ct: ge-millenium vg) allowed accurate localisation of these foci. dual isotope acquisition with combined in- and tc- m mdp assisted in this process as the more intense and extensive uptake by the bone agent helps to identify the initial extent of disease and which transverse slices to examine in detail on the lower count data acquired with the in- spect. in each case imaging was repeated during the clinical course of the disease to document resolution with scintigraphic findings mirroring the clinical course. conclusion use of in- combined with tc- m mdp spect and 'hawkeye' can be useful to assess extent of disease in suspected skull base osteomyelitis on initial presentation, to monitor response to treatment and to assist in determining when to discontinue antibiotics. it is possible that this may be more specific and may present a viable alternative to ga- citrate in such cases. careful attention to imaging parameters is required to avoid acquisition of meaningless data in view of the low counts obtained with in- spect particularly as disease resolution occurs. the utility of m- ; conclusion: many common diseases manifest themselves with no specific sign or symptoms, but with fuo associated to an increase of no specific marker of inflammation. our data show that, even if, most of patients with fuo had negative scintigraphy with leukoscan, it can help clinician to identify the cause of fuo and to decide the best therapeutic treatment. the main etiologies of fever of unknown origin (fuo) are infections, cancers, and noninfectious inflammatory preocesses. in this prospective study, we aimed to evaluate the diagnostic role of f-fluorodeoxyglucose (fdg)-pet in fuo, since this substance has an increased uptake by neoplastic and inflammatory cells. methods: the study included patients ( male, female, mean age . ± . years, range - years) referred to our unit for fdg-pet study between march and december . siemens lso hirez pet-ct camera was used for the record of the imaging. one hour after injecting - mci fdg, a whole body pet-ct from vertex to toe was obtained. results: among patients studied by pet-ct, ( . %) had foci with increased fdg uptake. the remaining had normal findings. among those patients with increased fdg; malignant neoplastic process, inflammatory process, and infection were diagnosed in , , and patients respectively. modern combination chemo-and radiotherapy have raised long-term survival of hodgkin lymphoma (hl) to more than %. however, the longer follow-up has shown serious long-term adverse effects related to the treatment, including heart and lung diseases, and secondary malignancies. in order to reduce these long-term side effects, alternative therapeuties are becoming more tailored to the individual patient's prognosis. in this regard, an important predictor of outcome is the early establishment of treatment response. conventional methods as ct scan have proven to be poorly accurate to this purpose. recently, early interim fdg pet/ct has been reported as a strong and independent predictor of progression-free survival in hl. in particular, a positive early interim fdg pet/ct is highly predictive of progression in patients with advanced stage or extranodal disease. in the present prospective study, we collected consecutive patients with newly diagnosed hl since . all patients underwent initial staging with fdg pet/ct (it was positive in all patients) along with standard staging procedures, including ct. fdg pet/ct was repeated after (fdg pet ) and cycles of chemotherapy, and after completion of chemotherapy (abvd schedule). evaluation of this last fdg pet/ct was discriminant to decide for radiotherapy in bulky disease. the follow-up range was of - months. all the fdg pet negative patients are in complete disease remission, except for one case (patient /see table) who experienced early relapse, resistant to autologous bone marrow transplantation. she is now in disease progression and a shift in lymphocyte depletion histo-type has been documented. results are shown in the subtotal splenectomy is effective in decreasing both the hematologic complications of hs and infectious complications of total splenectomy. the objective of this retrospective study on patients was to identify clinical and/or biological factors which could predict the rate of regrowth of the splenic remnant and influence the beneficial effect of subtotal splenectomy on red cell life span. material and methods : sixty one patients (m= ; f= ) with hs who underwent subtotal splenectomy between february and march were included in this analysis. for each patient, preoperative and postoperative clinical and biological data were collected: date of first symptoms, the clinical and biological indications for subtotal splenectomy (propensity for fatigue , number of transfusions, associated cholelithiasis, mean values of haemoglobin and reticulocyte counts), patient's age at the date of surgery. postoperative growth and functional value of the splenic remnant were assessed by abdominal single photon emission computed tomography (spect). acquisitions were performed after injection of autologous heat damaged red blood cells labelled with technetium m. splenic volume was calculated on reconstructed axial slices by means of a threshold algorithm previously validated on a phantom study. results & conclusion: statistical analysis was done with r software. mean values of haemoglobin, reticulocyte counts and clinical scores were compared between preoperative and postoperative follow-up periods. median delay between subtotal splenectomy and splenic scintigraphy was days (range - ). three patients developed splenic necrosis postoperatively and were dropped from the statistical analysis of predictive factors. the mean splenic volume measured by spect was ml (range ml - ml ; median= ml). the mean haemoglobin values increased from . g/dl before surgery to . g/dl after surgery. univariate and multivariate analyses were performed to identify the predictive variables of splenic regrowth. we describe a case of hairy cell leukemia (hcl) coexistent with non-hodgkin's lymphoma (nhd). this combination is reported to be extremely rare with no clear demonstration of the clonal relationship between the two condition. after a previous failure of purine analogs therapy, our patient was successfully treated with rituximab resulting in normalisation of blood cell count cessation of blood transfusion and negative iliac crest biopsy. unfortunately, the patient developed intense and persistent bone pain during the st line treatment for hcl. skeletal x-rays, whole-body ct scan and bone mri were unremarkable and bone scintigraphy showed non-specific changes. laboratory examinations were normal. to better evaluate these non-specific findings, a fdg-pet/ct was performed, followed by a guided bone marrow biopsy of the left femoral diaphysis. this demonstrated an aggressive high grade lymphoma, characterized by immunoblasts and polymorphous centroblasts in a diffuse pattern, expressing cd , cd a, cd , ig k for a %, nuclear and cytoplasmic bcl- antigen, a high proliferative index (mib- > %), and alk negative. these parameters, along with the absence of a low-grade component, were consistent with the diagnosis of primary bone marrow diffuse large b-cell lymphoma (lbcl). shortly afterwards, ldh rapidly increased to u/l and hb levels decreased to g/dl; esr was mm, ferritin was ng/ml, fibrinogen mg/dl, -m mg/l. an attempt was made to assess and compare b cell clonality of both disorders using a seminested pcr approach, as previously described ( ); unfortunately no major ig h gene rearrangements could be detected in both disorders with the primer pairs used for the assay. in may the patient was started on weekly chemotherapy scheme (vacop-b). diffuse bone pain rapidly resolved and hb concentration, esr, -m and ldh normalized. unfortunately in july, six weeks after chemotherapy, she became sleepy and developed loss of memory, and central nervous system involvement with lbcl was confirmed with csf cytology and immunophenotyping. brain mri showed diffuse subependimal disease. therefore, the patient was given both intrathecal and systemic rd line chemotherapy with progressive neurological improvement. however, her clinical condition showed rapid deterioration culmibnating in cessation of chemotherapy. the patient eventually died of progression of her disease in august . it can be recommended the early performance of fdg-pet/ct in poorly understood bone pain to identify bone and bone marrow localization of nhd. objective: the aim of our retrospective study is to compare the recurrence (local, regional node or distant metastasis) after sentinel lymph node biopsy (slnb) with and without axillary lymph node dissection (alnd) in patients with breast cancer. patients and methods : between may and september , patients with early-stage invasive breast cancer (<ct , cn , cm ), underwent slnb in our institution. patients were treated with alnd after slnb and patients without. all patients were classified pn+ or pn based upon presence or absence of metastatic lymph node by pathologic analysis. a total of patients ( . %) were pn+. the median follow-up period is months (range - ). the site of first recurrence was classified as local, regional node or distant metastasis. results : recurrence occurred in / patients ( . %). the median interval to recurrence was months. local, regional node and distant metastasis recurrence occurred respectively in . %, % and . % of pn patients treated with slnb alone (n= ), and in . %, . % and . % of pn patients treated by slnb with alnd (n= ). in patients with positive nodes (n= ), regional node recurrence and distant metastasis are sensibly more frequent (respectively . % and . %), while local recurrence is comparable ( . %). conclusions : as reported by several others teams, our study demonstrates that local, regional node and distant recurrence rate in patients treated by slnb without alnd, providing sln is negative, is not greater than after alnd. this remains true after a long time follow-up (over years). our results support that slnb alone in sln-negative patients is a safe method to assess axillary lymph node status in early-stage breast cancer. ( ) ( ) ( ) ( ) - ( ) ( ) ( ) ( . ) - ( ) ( ) ( ) ( . ) > ( ) ( ) ( ) ( . ) median follow-up months months months months median interval to months months months recurrence recurrence ( . ) ( . ) ( ) ( . ) local ( . ) ( . ) ( ) ( . ) regional node ( ) ( . ) ( ) ( . ) distant metastasis ( . ) ( . ) ( ) ( . ) alnd, axillary lymph node dissection; sln, sentinel lymph node; aln, axillary lymph node aim: although it is well documented that previous excisional biopsy is not a contraindication in sentinel lymph node biopsy (slnb), there are studies reporting problems caused by previous surgical applications. in this study we aimed to review retrospectively if there is a relation between problems encountered and presence of previous excisional biopsy during snlb. material and method: a total of female patients were included in the study. seventy two of them were patients having previous excisional biopsies. mci of tin colloid was injected at quadrant around areola intra/subdermally hr before surgery. patients were imaged at anterior and lateral projections and during operation slns were excised with the guidance of gamma probe. results: application difficulties were analysed in main topics and were seen in patients. dilated lymphatic channels showing activity stasis caused problem in patients. leakage of the activity in a localization other than injection site was the case in patients (into the biopsy cavity in and in an intradermal pouche in patients). non-vizualization of sln at first injection was the problem in patients. when occurence of this problems and presence and localization of previous biopsies were compared no correlation was detected between dilated lymphatics and biopsies. presence of dilated lymphatic channels were more often in non-biopsied patients ( / ) than biopsied patients ( / ) . although dilated lymphatics increased operation time did not prevent detection of slns. all patients showing activity leakage have had biopsies within weeks with periareolar insicions. leakages formed focal activity accumulation areas mimicking sln appearences. the real sln could not be visualized in patient having leakage into the biopsy cavity. in other patients having leakage into dermal pouch slns are succesfully identified. all patients with nonvisualized slns at first injection were patients having previous biopsies. in of them with a second intraparenchimal injection done just before the operation slns could be detected. in the rd patient who had additionally morbid obesity sln could not be identified. conclusion: although previous excisional biopsies do not compromise the effectiveness of the technique, especially when done with periareolar insicions it may cause problems in periareolar injection technique. detection of sentinel lymph nodes in breast cancer: every day practice and pitfalls g. moulin-romsee , e. d'hondt , f. persyn , b. van calster , s. ceyssens , p. neven , s. stroobants ; ku leuven, leuven, belgium, uza, antwerp, belgium. the sln technique has radically changed the management of breast cancer by reducing the need for axillary lymph node dissection. controversy and variety in every day practice however exists. we investigated the effect of different methodologies as part of an internal iso audit. methods: initially, mbq tc-nannocolloid was injected peritumoral and images were acquired after - min and hours (group i, april-september ). because a decreased visualisation on scintigraphy was noted (group ii, january-april ), the procedure was adapted (group iii, may-september ). the tracer was injected subdermal and for the -day protocol, the dose was increased to mbq. if lymphoscintigraphy was negative after hours another mbq was injected periareolar. differences in patients characteristics, visualisation and identification rate between the patients groups were statistically analysed. results: scintigraphic visualisation and surgical identification rate was % and % for group i, % and % for group ii and % and % for group iii. except for age, patients' characteristics were similar (bmi, hooked wire). the odds of finding a preoperative sln is significantly higher in group iii compared to both other groups (or= . ) which is explained by the higher count rate of the resected sln (p= . ). other factors that are associated with a decreased detection rate are hooked wire (or= . ), bmi (or= . ) and age (or= . ) discussion: we advocate the use of a single subdermal deposit since it drains more rapidly and is easier to perform. failure to detect a sln is more frequently in association with hooked wire, higher age and patient overweight. when a -day protocol is used, sufficient dosage should be used to ensure strong signal perioperatively. aim axillary treatment for breast cancer can increase resistance to lymph outflow from the arm. lymphatic collector vessels may have to pump against a chronically raised afterload, leading to lymphatic collector pump (lcp) failure and breast cancerrelated lymphoedema (bcrl). a new lymphoscintigraphic technique was used to measure lcp function in normal and bcrl arms. materials and methods in an ethics committee approved study we first measured hand to axillary lymph node transit time (t transit ) using intradermal injection of m tc-human igg ( m tc-hig, mbq) using -camera imaging. lcp force was assessed by placing a sphygmomanometer cuff at mmhg around the upper arm before injection and retention of m tc-hig distal to the cuff and absence of axillary counts at >t transit indicated inhibition of lcp function. after t transit max cuff pressure was lowered by mmhg steps until m tc-hig passed under the cuff and reached the axilla, indicating the pressure (p pump ) lymphatics could overcome. results t transit was ± [sd]min ( min for t transit max) in healthy subjects ( ± years). lcp force (p pump ) was assessed in healthy controls ( ± years) and women with bcrl ( ± years, - % forearm swelling). p pump was ± mmhg in controls, and lower at ± mmhg, in bcrl subjects with swollen forearms (p= . , unpaired t-test). background and aim based on our previous experience with radioguided occult lesion localisation (roll) in the breast, we have recently introduced similar roll method for the detection of clinically non-palpable lesions in the neck with mtclabelled macroagregates ( mtc-maa). patients and methods radioguided biopsy was performed in patients ( males and females, age - years) who had ultrasonographically proven non-palpable lesions in the neck. in these were clinically suspected to be lymphoma, in / patients with papillary thyroid carcinoma (ptc) who already had total thyroidectomy and radioiodine ablation or therapy these were suspected to be ptc lymph node metastases and in / a relaps in the thyroid bed. in patient repeated supraclavicular lymph-node biopsies were inconclusive, in another a primary ptc was cytologically suspected to be located in a thyroglossal duct cyst. the radiotracer ( mtc-maa . mbq in . ml volume) was injected intratumorally under the us guidance. all the patients underwent planar scintigraphy of the neck imediately after radiotracer application - - hours before surgery. the location of the injected radiopharmaceutical in the neck was marked on the patient's skin with a point -co source and indellible ink. injected activity, taken up by the neck lesions, was intraoperativelly detected and located with a gamma probe. in all patients scintigraphy revealed intense focal uptake in the neck. all the marked lesions were intraoperativelly easily detected with gamma probe. histopathological findings confirmed lymphoma in (follicular b-cell in , anaplastic large cell in and hodgkin's lymphoma in patient) and ptc metastases in patients. in a patient with thyroglossal cyst histopathology excluded any neoplastic infiltration. in a patient in whom repeated supraclavicular lymph node biopsies were inconclusive, a radioguided biopsy revealed a metastasis of a poorly-differentiated pancreatic adenocarcinoma. in one patient with ptc and elevated tg levels after total thyroidectomy and repeated radioiodine therapies, suspected to have a relaps in the thyroid bed, histology of a scintigraphically and intraoperativelly »hot« paratracheal lesion was negative, probably due to the fibrosis as a consequence of surgical and radioiodine therapy. conclusion our work suggests that intraoperative radioguided detection of nonpalpable lesions in the neck after mtc-maa under the us guidance is simple and accurate method. the aim of the study was to determine the reliability of the diagnostic procedure of radioguided occult lesion localization (roll) and to detect sentinel lymph nodes in occult lesion localization (snoll) using two kinds of radiopharmaceuticals. a total of female patients (mean age ), in whom mammography, breast ultrasound, and fine needle aspiration cytology detected high risk occult lesions, were enrolled in the study. material and methods: the day before surgery ( hrs) under ultrasound guidance mbq mtc-maa (from . mbq to . mbq) in a volume of . ml was injected into the center of the lesion. usually about ten minutes after radiotracer was injected, anterior and oblique scintigrafic images were acquired. the breast contour was outlined with flexible marker co and the nipples marked with point source ( am). on the day of surgery mbq of m tc-nanocolloid in a volume of . ml was subdermally injected above the marked localized breast lesion. images made twenty minutes later in anterior and anterior-oblique projection revealed a sentinel lymph node. results: in all patients scintigraphy uncovered activity in the lesions and sentinel lymph nodes. the average lesion size of . mm was detected mammographically, and of . mm with ultrasound. cytological findings confirmed invasive ductal malignant tumors in ( . %) and suspect in ( . %) patients. puncture of the suspect lesion was not performed in ( . %) patients and only one patient ( . %) had normal findings. tumerectomy was performed in all patients. patohistological findings confirmed malignant breast cancer in ( . %) patients, of which metastases in sln were detected in five ( . %). conclusion: the obtained results show that a method of choice for a safe and quick localization of the occult breast lesion and sln is the combination of simultaneous detection of the occult localized breast lesion with m tc-maa under ultrasound guidance and the detection of sln with a lymphoscintigraphic subdermal injection of mtc-nanocolloid. introduction: chyluria may present as chylous clot, chylous clot retention, hematuria, flank pain, dysuria, weakness, fever and weight loss. it is a late manifestation of filariasis, a parasitic infestation endemic in south east asia. other associated conditions include repeated retroperitoneal infection, especially tuberculosis, trauma, genitourinary or gastrointestinal tumors, malignancy of the thoracic duct and thyroid, ureteric stone, hydrocele, inguinal hernia and pregnancy. lymphangiography has been the main imaging modality in investigating chyluria, chyloperitoneum and chylothorax. however, it requires tedious cannulation of lymphatics, is invasive and is not readily reproducible. lymphoscintigraphy using m tc labeled colloid delineates the pattern of lymphatic drainage, is fast, non-traumatic and has no known side effects. we are reporting a case of chyluria developed after a spinal surgery in which lymhoscintigraphy was used to localize the lymphorenal fistula. case history: years old male who had a history of laminectomy over l -l level and after months he presented with complaint of chyluria and repeated urinary retention. on examination his vitals were normal and his cbc, lfts and serum creatinine were within normal limits. his urine reported milky in color with enormous fat and cellular component. his ultrasound abdomen revealed right renal cyst and mild prostatic enlargement. lymphoscintigram was performed with mbq ( . cc volume) of m tc labeled nannocolloid injected subcutaneously as . cc aliquot in nd and rd interdigital spaces of both feet. hr delayed whole body images revealed reduced traveling and relatively less outlined left inguinal lymph nodes, a normal flow and well outlined inguinal lymph nodes were seen in the right lower limb. there was evidence of visualization of tracer in the left kidney with appearance of para-aortic lymph nodes consistent with left sided lymphorenal fistula. a follow up cystography confirmed the appearance of chylous urine from the left ureter. patient refused surgery. discussion: chyluria is a relatively common condition is south east asia. lymphangiography has been the main imaging modality but it is invasive and requires expertise for canulation and significant radiation exposure. lymphoscintigraphy using tc- m labeled colloid is safe, non-invasive and reproducible technique and gives less radiation exposure. it is invaluable in detection of site of lymphorenal fistula and cystoscopy during active chyluria helps to determine relative severity of the involved site of urinary tract. thus these two investigations together help determine the site of operation. granulocyte-colony stimulating factor (g-csf), a hematopoietic growth factor, is widely used to accelerate recovery from neutropenia after severe chemotherapy, both decreasing the risk of infection and mobilizing peripheral blood stem cells. g-csf is commonly administrated to healthy donors to mobilize peripheral blood stem cells for allogeneic hematopoietic stem cell transplantation. adverse events from g-csf use in healthy donors been described in approximately % of cases, and are comprised predominantly of bone pain, headache, and general fatigue. pulmonary complications caused by g-csf include cough, dyspnea, and interstitial or alveolar pulmonary edema with mild-to-severe deterioration of blood oxygen level. few cases of acute respiratory distress syndrome (ards) following g-csf administration have been reported. the present study was designed to determine the pulmonary clearance rate of tc- m diethylenetriaminepentaacetic acid (tc- m dtpa) in healthy donors for allogeneic hematopoietic stem cell transplantation and the role of tc- m dtpa aerosol scintigraphy in the early detection of lung involvement. material and methods: five healthy donors ( female, male; aged ± years) were studied. tc- m dtpa aerosol inhalation scintigraphy and pulmonary function tests (pft) were performed before and after days g-csf administrations. on the basis of the scintigrams the percentage decline in activity per minute (kep) was evaluated, which represented an accurate parameter of lung membrane permeability. results: increased lung epithelial permeability was observed in all of the donors after days g-csf administrations. there was statistically significant difference between two studies ( . ± . and . ± . for left lung; . ± . and . ± . for right lung, p< . , paired t test). but no significant change was observed in pft (p> . ). conclusion: our preliminary results show that subclinical alveolitis may be present in healthy donors after g-csf administrations since it is known that an increase in the epithelial permeability of the lung is an early manifestation of interstitial disease. assessment of mean transit time in the engrafted lung with xe- lung ventilation scintigraphy improves diagnosis of bronchiolitis obliterans syndrome in living-donor lobar lung transplant recipients t. shinya , s. sato , k. kato , s. akaki , h. date , s. kanazawa ; okayama kyokuto hospital, okayama-city, japan, okayama university medical school, okayama-city, japan. aim: staging of bronchiolitis obliterans syndrome (bos) after lung transplantation is based on declines in forced expiratory volume in s (fev ). use of computed tomography (ct) has been described for early detection of bos. the aim of this study was to evaluate the usefulness of xe ventilation scintigraphy in early detection of bos after living-donor lobar lung transplantation (ldllt) and to compare xe wahout imaging with ct finging for early detection of bos after ldllt. material and methods: subjects comprised double-lung recipients and single-lung recipient, who had undergone ldllt at our institution and survived > year. clinically diagnosed bos developed in recipients. declines in graft function were evaluated using a combination of methods: dynamic spirometry; computed tomography; and xe ventilation scintigraphy. findings for all transplanted lungs were compared between ct and xe washout imaging. assessment of xe washout was assessed using mean transit time (mtt) of bi-and unilateral lungs. correlations between mtt of bilateral lungs and fev % were evaluated. differences between mtt of bos and non-bos lungs and between mtt of non-bos and donor lungs were also evaluated on bi-and unilateral lungs, respectively. an appropriate cut-off value for mtt of bi-and unilateral lungs was set for the diagnosis of bos. results: in all bos cases, prolonged-washout images of engrafted lungs revealed early-phase bos with declines from baseline fev , while only bos case could be detected using ct. a significant correlation was identified between mtt and fev % (r=- . , p< . ). mtt of bi-and unilateral lungs was significantly longer in bos lungs than in non-bos lungs (p< . ). the cut-off mtt for bi-and unilateral lungs for diagnosis of bos were set at . s and . s.conclusion: our data show that xe washout imaging offers excellent potential for early detection of bos compared to early ct findings. using xe washout imaging and mtt with radioactive tracer offers a non-invasive indication of selective ventilatory function in grafted lungs after ldllt. mtt appears useful for identifying bos after ldllt and allows evaluation of graft function in bi-and unilateral lungs. pet and ct evaluate of pulmonary nodules in an integrated pet/ct system w. s. huang , c. y. cheng , c. y. chang , c. s. liu , c. h. ku , j. k. lee ; department of nuclear medicine, tri-service general hospital, taipei, taiwan;, taipei, taiwan, department of radiology, tri-service general hospital, taipei, taiwan;, taipei, taiwan, school of public health, national defense medical center, taipei, taiwan., taipei, taiwan, dept. of nm, chung shan med. univ. hosp., taichung, taiwan., taichung, taiwan. aim: the fdg pet and ct have proved useful in evaluating pulmonary lesions. this study was performed to compare the respectively diagnostic power of pet and ct in the evaluation of single pulmonary nodules (spn). material and methods: a total of patients with spn and without previous history of malignancy were analyzed. of them, with known spn, the other were accidentally found from a physical check-up. both pet and ct images were independently interpreted and were graded by the -point scales as described (radiology ; : ) . equivocal pet and ct image (grade ) were dealt with conditions: ) dropped, ) regrouped in to positive results or ) regrouped into negative results. malignant diagnosis was based on histological findings or a clinical/ radiological follow-up at least m. four comparisons were applied to assess the performance including ) ct; ) pet; ) test in parallel (ct or pet positive); and ) test in series (ct and pet positive). we used student's t test for univariate continuous variables and the test for categorical variables and fisher's exact test whenever the expected value for at least one cell was < (sas version . , cary, nc). receiver operating characteristic curves were applied to calculate the areas under the curves of interest and for comparisons (medcalc version , mariakerke, belgium). results: pet yields equivocal results, of them had negative ct that turned out to be benign lesions. the other patients had both equivocal pet and ct and two of them proved to be malignant. ct revealed equivocal results, were confirmed by pet as malignancy, the other were benign. out of the ct equivocal lesions turned out to be malignant. conclusion: pet and ct play synergic role in the combined pet/ct scanner. fdg pet produced less equivocal lesions. combining interpretation of both pet and ct information helps resolve more than half of equivocal lesions. key words: f-fdg; pet/ct; single pulmonary nodules running title: pet/ct in pulmonary nodules aim: to evaluate the situation of the work-up of patients with suspected pulmonary embolism at the national level especially in relation to the use of new diagnostic methods. method: we used a questionnaire send to all nuclear medicine departments in the czech republic. questions were selected to evaluate the methodology of the lung scintigraphy from the aspect of performance, results description, use of criteria and several time and quantitative parameters. we also asked about some concomitant and concurrent examinations. results: / ( %) departments filled in and returned the questionnaire. as to methodology, the planar images ( or to views) are mostly used; only departments perform only spect. lung perfusion scintigraphy is available only during working hours on working days; only in department also on weekends. ventilation scintigraphy is performed only selectively. in the assessment of images, mostly standardized criteria in combination with any own are used (predominantly modified pioped). radionuclide venography is performed on all but departments, thrombi imaging is not available at all. the number of perfusion scans declined yearly about %, ventilation scans increased about % and venography declined about % between years and . ct scanners with less than slices are mostly available for ct angiography. conclusion: the main drawback of lung scintigraphy is its time unavailability and predominance of planar imaging. the increase of ventilation scintigraphy could be done by the effort to increase specificity. the decline of perfusion scans is not significant, although it could be done by the low quality of ct scanners. long lasting exposure to toluene that is commonly used in automobile and spray paints, may cause in occupational asthma. in this study, we aimed to investigate the effect of toluene on tc- m clearance rate of alveolar epithelium and on spirometric lung function tests in auto painters who exposed to toluene at least for ten years. twenty-eight autopainters with a mean age of . ± . years and a healthy group with a mean age . ± . were included in the study. tc- m dtpa aerosol inhalation scintigraphy, and spirometric lung function test was administered to all subjects. clearance half time (t½) and penetration index (pi) on the first minute image after tc- m dtpa scintigraphy were calculated. t½ and pi values were ( . ± . and . ± . ) for painters, and ( . ± . and . ± . ) for healthy group, respectively (p= . , p= . ). there was a negative correlation between mean t½ and %fvc, %fev values (p= . , p= . , respectively). whereas, a positive correlation was observed between mean pi and fev /fvc, %fef - (p= . , p= . ). comparison of pef values between painters ( . ± . ) and healthy subjects ( . ± . ) yielded significantly different results (p= . ). however, t / and pi did not correlate with pef. in painters group, t½ and pi significantly differed when painters with obstruction ( . ± . , . ± . ; respectively) compared with painters who did not have obstruction ( . ± . , and . ± . ; respectively) (p= . , p= . , respectively). toluene exposure duration did not show a relationship with t½, pi and sft. our results indicate that toluene exposure affects bronco alveolar permeability and may cause obstructive changes that might be demonstrated by sft. however, we could not detect any relationship of toluene exposure duration with any parameter. to show if toluene exposure duration has any affect on occupational asthma development further studies are needed. technetium labeled human polyclonal immunoglobulin g ( mtc-hig) scintigraphy in the early detection of pulmonary involvement in connective tissue diseases (ctd) considering analgesics as the first option. if these fail, other therapeutic options can be considered, including metabolic radiotherapy with sm as the greatest exponent. aim: evaluate sm treatment response in patients with painful bone metastases. material and methods: we studied patients ( men; women) with ages between and years old (with a mean age of . years) with painful bone metastases resistant to analgesic therapy. mbq/kg of sm were administrated intravenously. each patient remained hospitalized for hours in our nuclear medicine unit in a room, conditioned for metabolic radiotherapy treatments. pain was evaluated following a visual scale before and after treatment (considering: total response: improvement > points; partial response: improvement - points; no response: improvement points). results: in out of patients ( %) an effective therapeutical response was observed. of these effective responses ( %) showed a total pain disappearance, while in the remaining ( %) the pain was partially soothed. the therapy was repeated in patients, obtaining an efficient response, similar to the previous one. treatment was effective for to weeks (average: . weeks). no response was observed in out of patients ( %), including patients who suffered sudden-deaths in where the response could not be evaluated. conclusions: treatment using sm may result effective in painful bone metastases resistant to analgesic therapy. if the symptoms reappear, a new dose would achieve equally satisfying results. accurate interpretation of fdg-pet images requires optimal knowledge of the normal distribution of the tracer in various anatomical structures. this distribution may change due to age, gender, and physiologic conditions. our aim was to assess cervical spinal cord fdg-pet uptake as a function of age and gender. methods: head and neck fdg-pet images of subjects were retrospectively assessed ( male, female; age: - years). the subjects had undergone head and neck fdg-pet imaging for a variety of reasons. the subjects did not have any evidence of fdg uptake which could interfere with measurement of spinal cord uptake. the subjects had no previous history of chemotherapy and radiation therapy. fdg uptake in the cervical spinal cord was visually evaluated. mean and maximum standardized uptake values (suvs) of cervical spinal cord were calculated for all subjects with visible spinal cord uptake. subjects were separated into three age groups, each consisting of two decades, and into two groups based on gender. one way anova and t tests were used for statistical analysis to calculate the differences of mean and maximum values for age groups and for gender. results: amongst subjects, had visible cervical spinal cord fdg uptake. three did not have visible cervical spinal cord uptake. the mean suv ranged from . - . , the maximum suv ranged from . - . . averages and standard deviations (sd) of the mean and maximum suvs for age groups from the youngest to the oldest were . ± . , . ± . , . ± . , and . ± . , . ± . , and . ± . , respectively . averages and sd of the mean and maximum suvs for men were . ± . and . ± . , respectively, and . ± . and . ± . , respectively, for women. there were no statistically significant differences between the mean and maximum suvs amongst age groups or between genders. conclusion: these preliminary data show that fdg uptake within the normal cervical spinal cord is not affected due to aging or gender. further studies are required to confirm our results and to determine the significance of this observation in normal and pathological states. fusion of near-isotropic spiral ct to d nuclear medicine data to improve the accuracy of roi delineation in hepatobiliary and renal imaging b. corcoran, m. carroll, m. buxton-thomas; king's college hospital, london, united kingdom. objective in dynamic planar hepatobiliary imaging of auxiliary liver transplants and both dynamic and static renal imaging, regions of interest (roi) are used to generate time activity curves (tac) and to calculate the relative function of two organs. on the hepatobiliary image it is often difficult to differentiate the native and transplant livers. in both static and dynamic renal imaging, the edges of poorly functioning kidneys are often difficult to identify. the advent of high resolution spiral ct, available through pacs connectivity, now allows near-isotropic quality orthogonal images to be reconstructed. we use the coronal anatomical data to improve the delineation of the organs. fusing the coronal data to nuclear medicine imaging allows the more accurate rois to be applied in generating the tac and the calculation of physiological divided function. method for calculation of divided function from the dynamic data a composite image of the uptake phase is created. on a hermes workstation, orthogonal coronal sections are generated from high resolution spiral ct (transverse slice width = . mm, slice separation = . mm). a coronal section through the liver is chosen which clearly shows the division between the native and transplant. the summed ct image is fused, using mutual information rigid transformations, to the composite nm image. accurate rois drawn on the ct image are then applied to the nm image and divided function is calculated from the relative regional counts. result the method was applied to several patients undergoing sequential post-transplant hepatobiliary imaging ( mtc-ida) where spiral ct of the liver was available. the ct data provided greater confidence in differentiating the two functional regions of native and transplant liver. the method has also been applied to the deconvolution analysis of renograms ( mtc-mag ) and static renal scans ( mtc-dmsa). conclusion in hepatobiliary investigations for monitoring liver transplants, coronal images generated from spiral ct can be used to improve roi delineation in the calculation of relative function between native and auxiliary liver regions. the method has also been shown to have a useful application in the renal imaging of poorly functioning kidneys. with promising results from ongoing clinical trials, alpharadin™ (ra- ) looks destined to become commonplace in nuclear medicine. this paper aims to introduce the radiation protection requirements with ra- to those less familiar in working with short-lived alpha emitters and dispel some common misconceptions. traditional teaching of radiation protection has focussed on beta-and gamma-emitting radiation due to their more common application, ease of detection and less stringent regulations for handling open radioactive sources in the laboratory. as such, alpha-emitting radionuclides have traditionally been confined to research or use in sealed sources. in some countries, alpha emitters have developed an unwarranted reputation as a dangerous form of radiation. it is important to emphasise that alpha radiation only poses a radiation risk when long-lived alpha-emitting radionuclides become incorporated into the body and irradiate a small area of tissue for a long period. outside of the body, there is a much lower risk when working with alpha radiation compared to beta radiation and working procedures are often simpler. alpharadin™ is an alpha-emitting radiopharmaceutical in clinical development for tumour therapy and pain palliation in patients with skeletal bone metastasis. the alpha emitter ra- does not have inherent properties that make it a dangerous radionuclide. on the contrary, radiation protection parameters for alpharadin™ offer some significant advantages when compared to traditional beta emitters (table ). comparison of radiation protection parameters for ra- , sm- and sr- aim the purpose of this study was to analyse the radiation emergency triage, treatment and hospital protection procedures in london after the contamination of alexander v. litvinenko with the polonium in london . identifying strengths and weaknesses allowed us to draw conclusions for improved future radiation emergency management (rem) strategies particularily for hospitals. materials we researched numerous public documents and conducted interviews with medical professionals at various hospitals involved in the case. methods we reconstructed the sequence of emergency management procedures such as triage and the treatment of the patient as well as radiation protection measurements taken. we then identified key characteristics and compared them with typical hospital rem procedures for radiation victims. furthermore, we then analysed the results in the light of radiation mass casualties to detect the weaknesses of current disaster management concepts. results the medical effects of internal contamination with the radioactive isotope polonium was not immediately diagnosed. a treatment plan was applied rather late. the single case allowed an intensive care with technical resources and a number of medical professionals to diagnose the patient which would have been impossible if the number of casualties was higher. the psychological effects of the radiological contamination remained rather unclear. the patient died a few weeks later. the received dose and exact cause of his death (radiation vs. toxicity in particular) are still disputed. conclusion our research shows that the contamination with radioactive isotopes in general still remains a very unusual challenge for medical professionals. even specialist hospitals confronted with cases of radiation poisoning are quickly taken to the limits of their diagnostic and treatment capacity. only the concentration of medical specialists and the intense usage of resources could eventually help to diagnose the illness. we can conclude that other non-specialist hospitals would perform rather inadequately if confronted with the same case and much worse if there were more casualties of that kind. future improved emergency management strategies will strongly rely on adequate, continuous and specialised training of hospital staff, appropriate equipment as well as communication and triage among hospitals. aim: the aim of this study is to evaluate the efficiency of the radiation protection program of a department of nuclear medicine equipped with a pet and therapy units. material and method: the department has a workplace monitoring system. we calculate the mean dose of the radiation exposure levels that the workers were submitted in each part of the department and compare with the whole body dosimetry, during one year. the workplace monitoring system is a tam radiation meter system from tema sinergy, italy and consists on eight geiger-muller detectors with a dose rate range between , μsv/h and , sv/h and an energy sensitivity from kev to mev. the whole-body dosimeters are tld. the eight detectors are installed in: radiopharmacy, waiting room for accompanying persons, waiting room for injected patients (at two points), room for injected patients, pet radiopharmacy, pet command room, and waiting room for pts injected with f-fdg. the monitoring data of each main area is compiled in a hour database. results: the monitoring results, in each area per year were: conclusions: when compared with each other, we conclude that the results match: the mean dose in the main areas where the workers usually are and the whole body values. the mean dose for the area monitoring system was , msv/year and the mean dose for the whole body dosimetry was , msv/year. these results are in the scope of the national legislation and the european regulation of radiation protection and are demonstrative that we are working in good conditions of radiation protection. since several years, our department of nuclear medicine works with the department of haematology in the field of radioimmunotherapy of non hodgkin lymphomas using antibodies (anti cd zevalin® schering-bayer, anti cd immunomedics) labelled with high activities of yttrium (y ) (cis bio international and nordion). the manipulation of such activities of a ß-emitter can induce a great exposure of the hands of the personnel when appropriate radioprotection procedures are not applied. at the beginning, we used the radioprotection material present in our laboratory, but with increasing experience we added some improvements in our practice: -use of a shielded suit -use of an electric infusion pump for zevalin® administration -use of radiation attenuating gloves for ß-emitters -use of a radioprotection kit in polymethyl-methacrylate (pmma) supplying by schering-bayer -local production of a pmma protection box for the perfusion of the anti cd . material and methods: *in , an electronic dosimeter was placed under the gloves at the palm of one hand of the radiopharmacist during these steps. *in , more precise studies were made with tld chips placed at the palm and at the extremities of the thumb and the index. day, and is a minimally necessary criterion of agencies that accredit nuclear medicine laboratories. tracking trends in daily qc on a monthly basis is helpful in detecting developing camera problems, which if addressed in a timely manner, will avoid unnecessary unscheduled camera downtime and maintain image quality. increasingly, the environment in which hospitals and clinics operate is through consortiums, which, by virtue of their design, necessitate the development of standardized, uniform means of detecting and documenting problems and methods of solving these problems. we have implemented algorithms written in a version of visual basic on commercial nuclear medicine computers to analyze intrinsic and extrinsic flood uniformity values for a wide range of gamma camera models from various manufacturers. these algorithms use data transmitted via ethernet among sites using the dicom standard. computed parameters include integral and differential uniformity values for full field of view and central field of view regions of interest, which are generated automatically and are tailored to each detector type. output values are stored automatically in ascii files, which are updated each time the analysis programs are run. the display format of flood fields is adjusted automatically for as few as up to as many as simultaneously displayed individually normalized flood fields for flexibility of recording floods on film. algorithms written in mathcad (mathsoft, inc.) further analyze the resultant ascii files, segregating uniformity values for each detector of each camera in groups of monthly values, deleting duplicate records, plotting uniformity versus date curves, identifying values that exceed predetermined action levels and tabulating the number of times a detector does not meet standard criteria, prompting required attention for uniformity problems. a microsoft word file is generated automatically as a permanent record. these sets of algorithms have been instrumental in providing an ongoing method of guaranteeing standardized high quality imaging at different sites and facilitating certification by accreditation organizations. aim: to fully implement alternative services that internet offers to the easy transfer of complete patients' examinations. prosperity of easy interchange in every day practice of nuclear medicine found its application through the internet media. we use a simple and safe way to interchange images and diagnostic information between the scintigraphic acquisition and processing location and the clinical department in order to improve patient's health care and young doctors' education. we present our experience in transferring patient data, spect slices, d spect images in video (movies) form and animation display to medical specialists. materials and method: images and patient reports are transferred and saved through dedicated software to a workstation that transform gamma-camera scintigraphic images in a pc readable format. the data are transferred to the local server pc via a local area network -in which the medical system computer is also included-and are modified by procyon starlab ge software to bmp type image files. spect slices and/or d processed spect images as well as dynamic or gated studies can be send to the connected pc. medical record data are combined with the images and movies in a hypertext file that can be sent as an attachment via an e-mailer functioning under windows environment. the receiver side should be equipped with a similar e-mailer and can view or print patient's set of images and data through a suitable browser. the mailed series of images are characterised by diagnostic quality analogous to that of the original sets that someone can see as simple series or in a cine form of tomographic slices, dynamic studies and d images in a gamma camera. results:transfer via e-mail has been used in our center for the exchange of complete studies including data, images and movies to and from our colleagues when particular patients are concerned. furthermore, both patients' files and educational files can be downloaded, from our department ftp location, by a unique password. conclusion: a full patient template transfer enables the archiving of particular files from the authors' institute database ensuring the security desired and it has been proven to be a quick and safe mean of exchange of dynamic set of nuclear medicine information between physicians and scientific centers. usual www connection gives the possibility of patients' data transfer as well as interchange of relative comments towards both directions. cost effective solution has been achieved using standard hard-and software. picture archiving and communications system: a convenient connecting point between nuclear medicine and radiology for higher specifity k. f. wurm, m. zobel, b. clewing; department of radiology and nuclear medicine, göppingen, germany. aim: picture archiving and communication system (pacs) has become an important component of many radiological departments. the major benefit of pacs based on its ability to communicate images and reports to different physicians in a short and common modality. the aim of our study was to create the benefit for nuclear medicine results using pacs as the connecting point to additional radiological images. material and methods: in a period of months we investigated patients with different bone lesions, metastases and inflammatory deseases. all patients underwent bone scintigraphy with mtc-hdp. all images were evaluated and adjudged. in a second view the additional informations of radiological issues using pacs were documented. results: / patients presented an area with increased focal activity in bone scintigraphy. using the early pictures after min. additional pathological results could be detected. in correlation with radiological images using pacs cases are documented as an unambiguous benign lesion, previously adjudged as a suspected area. / cases were adjudged as a benign lesion, however using pacs pathological lesion were documented. conclusion: the progressive spread of picture archiving and communication system (pacs) in medical imaging constitutes some of the most common changes in the radiological and hospital activities during the last decade. using pacs as the connection point between radiological and nuclear medicine images both department have a benefit and the numbers of false positive/false negative results are reduced. pacs creates a synergy that will be otherwise only realized using spect/spiral-ct hyprid imaging. uptake of technetium- mdimercaptosuccinic acid in cats e. vandermeulen , a. dobbeleir , h. ham , a. piepsz , t. waelbers , s. vermeire , k. peremans ; department of medical imaging of domestic animals, faculty of veterinary medicine, ghent university, ghent, belgium, department of nuclear medicine, university hospital, ghent, belgium, saint-pierre hospital, brussels, belgium, department of medicine and clinical biology of small animals, faculty of veterinary medicine, ghent university, ghent, belgium. aim: the purpose of this study was to calculate the fractional uptake (fu) of technetium- m dimercaptosuccinic acid (tc m -dmsa) in cats at , and hours and to test the influence of prone compared to supine positioning on the fu due to flexible kidney position in cats. material and methods: a total of cats were injected with a mean dose of , mbq tc m-dmsa. the cats were anesthetized (induction with propofol, maintenance with isoflurane on oxygen) and anterior and posterior images were acquired in prone position at , and hours after injection. rois were placed over the kidneys and the geometric mean kidney activities calculated. additionally, a second anterior and posterior view was acquired with a calibrated source positioned between the kidneys. the calibrated source activity was obtained by substraction of the activities in a large roi on both anterior views. this was repeated for the posterior views, and the geometric mean of the calibrated source was calculated. from the posterior and geometric mean activity, the attenuation correction value can be calculated. the kidney uptake was calculated from the geometric mean of kidney counts and the attenuation value. after decay correction the uptake was expressed as a fraction of the injected dose (fu). in cats these tests were repeated in the supine position. results: the mean values of fu in cats scanned in prone position were . ± . for the left kidney and . ± . for the right kidney at hours. fu values at and hours were respectively . ± . , . ± . for the left kidney, . ± . and . ± . for the right. in supine compared to prone position, a small but systematic lower fu was observed: the difference being . at hours, . at hours and . at hours. conclusion: fractional uptake of mtc-dmsa can be calculated up to hours. a small uptake increase is observed over time. using the method of geometric mean minor differences were obtained in prone and supine position. this difference decreases at h, which might indicate a higher background contribution in prone position. organotypic slice cultures (osc) of human brain specimens represent an intriguing experi-mental model for translational studies addressing, e.g., stem cell transplantation in neurodegenerative diseases or targeting invasion by malignant glioma ex vivo. however, long-term viability and phenomena of structural reorganization of human osc remain to be further characterized. here, we report the use of the positron emission tomographic radiopharmaceutical f- -deoxyglucose (fdg) for evaluating the viability of brain slice preparations obtained either from postnatal rats or human hippocampal specimens. anatomically well preserved human hippocampi obtained from epilepsy surgery (n = ) and rat hippocampus slice cultures obtained from six day old wistar rats (n = ) were dissected into μm horizontal slices using a vibratome. all slices where placed onto interphase nylon culture plate inserts, subsequently transferred into six-well culture dishes containing . ml of culture medium and kept in a humidified atmosphere at °c and % co for at least days. the slices were incubated with - mbq fdg in phosphate buffered saline up to h, either with or without supplementation of glucose at a concentration of . mg/ml. radioactivity within the medium or slice cultures was measured using a gamma-counter. in addition, distribution of radioactivity was autoradiographically visualized and quantified as counts per mm tissue per mbq fdg (cd) for the whole slice. all experiments were carried out at least in triplicate. in rat hip-pocampal slices, fdg accumulated over minutes with a doubling time of approximately minutes and reached , , ± , counts/mm , whereas the incorporation of the radioactive label in human slices was in the order of , , ± , counts/ mm . the elevation of glucose concentration within the medium led to a significant three-fold decrease of fdg accumulation in rat slices and to a . -fold decrease in human specimens. in conclusion, fdg specifically accumulated in organotypic brain cultures of human or rodent origin. fdg is thus suited to investigate the viability of osc. furthermore, these preparations open new avenues to study the factors governing cerebral fdg uptake in normal and diseased brain tissue ex vivo. changes in metabolism and gene expression in hepatomas expressing antiangiogenic genes u. haberkorn , j. hoffend , a. altmann , k. schmidt , a. dimitrakopoulou-strauss , l. strauss , m. eisenhut , r. kinscherf ; purpose: human troponin i (trop), the soluble receptor for vascular endothelial growth factor (sflt) and angiostatin (astat) are potent inhibitors of endothelial cell proliferation, angiogenesis and tumor growth in vivo. transfer of these genes into tumors may induce changes not only in perfusion, but also more general ones such as changes in metabolism. experimental design: after generation of morris hepatoma (mh a) cell lines expressing trop, sflt or astat we quantified ffluorodeoxyglucose ( fdg) uptake by dynamic positron emission tomography (pet) after tumor inoculation in aci rats. furthermore, expression of glucose transporter- and (glut- ; glut- ) as well as hexokinase- and - were investigated by rt-pcr and immunohistomorphometry. in addition, changes in gene expression were measured using gene arrays. results: fdg uptake, vascular fraction and distribution volume were significantly higher in all genetically modified tumors. immunohistomorphometry showed an increased percentage of hexokinase- and - as well as glut- and - immunoreactive (ir) cells. using gene arrays and comparing all three groups of genetically modified tumors, we found changes in expression of genes related to apoptosis, signal transduction, stress or metabolism. conclusions: trop, sflt or astat expressing mh a tumors show enhanced influx of fdg, which is caused to several factors: enhanced exchange of nutrients between blood and tumor, increased amounts of glucose transporters and hexokinases and increased expression of genes related to apoptosis, matrix and stress which induce an increased demand for glucose. a. altmann , k. schmidt , j. hoffend , a. dimitrakopoulou-strauss , l. strauss , m. eisenhut , r. kinscherf , u. haberkorn ; university hospital, heidelberg, germany, dkfz, heidelberg, germany. purpose: growth of malignant tumors is dependent on sufficient blood supply. thus, inhibition of tumor angiogenesis is emerging as promising target in treatment of malignancies. human calreticulin (hcret) is a potent inhibitor of basic fibroblast growth factor (bfgf)-induced endothelial cell proliferation in vitro and bfgf-induced angiogenesis and tumor growth in vivo. experimental design: to obtain more information about functional changes in the angiogenic process we established morris hepatoma (mh a) cell lines expressing hcret (hcret-mh a). the effects of hcret expression on proliferation and apoptosis of human umbilical vein endothelial cells (huvecs) were measured in co-culture experiments in vitro. to evaluate changes in tumor perfusion h o was used for positron emission tomography studies in vivo. additionally, immunohistological quantification of vascularization, apoptosis and proliferation as well as gene array analyses were performed. results: the in vitro experiments demonstrate reduced proliferation and increased apoptosis in huvecs when being co-cultured with mhhcret cells. in support, tumor growth of mhhcret is diminished in vivo together with a reduction in pcna staining and an increase in apoptosis as determined by immunohistology. however, tumor perfusion and blood volume are increased in hcret-mh a corresponding to an increased microvessel density. furthermore, hcret-transfected tumors show changes in expression of genes related to angiogenesis, apoptosis, stress, signal-transduction and metabolism. conclusions: hcret expression leads to inhibition of tumor growth, increased apoptosis and changes in the expression of multiple genes involved in angiogenesis, stress reactions, signal transduction and apoptosis which indicates a multifactorial reaction of tumors. an enhanced microvessel density is seen as part of these reactions and is associated with increased perfusion as measured by pet. aims progressive improvement in the noninvasive imaging of different tumor associated antigens has lead to study a series of pancarcinoma radioligands. among them, monoclonal (radio) antibodies for cell adhesion molecule integrin v occurring on both the tumor and endothelial cells that line tumor infiltrating blood vessels has recently gained widespread support from preclinical trials in our laboratories. in this study, this effort continues by applying iodine ( i)-labeled monoclonal antibody to visualize and quantify the subunit of integrin v in three histologically different types of murine tumors. material and methods monoclonal antibody anti-cd ( c .g ) against the subunit of the integrin v was directly labeled with i using a standard iodogen method. the radiochemical purity of the resulting mab- i of % was achieved in a reaction time just after the iodination, and . and . %, respectively after and hr post-labeling. the diagnostic value of the mab- i radiotracer was elucidated by planar scintigraphic imaging followed by quantification of the tumor integrin subunit level in male c bl/ , c h and balb/c mice wk after s.c. inoculation of the syngeneic lewis lung (llc), breast or sarcoma (l ) murine cancers, respectively. the imaging and biodistribution studies of the mab- i radiotracer were done hr after a single intravenous injection of to μg mab- i in tumor-bearing mice. results the transplanted tumors expressing the subunit of the integrin v were visualized on the scintigraphic images of all the examined murine tumor experimental models. on the images the liver and kidneys and the bladder were also the organs with the highest activity levels, illuminating the renal excretion pattern of the radiolabeled tracer. muscle, brain and skin tissues had relatively low activity uptake. biodistribution analysis, studied hr after μg mab- i injection, revealed a quite similar profile of the tumor-to-muscle count ratio (t/m) of . ; . and . for llc, breast and l tumors, respectively. the tumor-to-non tumor ratio (t/nt) for selected organs was increased with increasing the radiotracer dose up to μg. the binding potential extrapolated from the graphical analysis of scintigraphic data correlated well with the biodistribution studies. conclusion the present study showed that the radiolabeled monoclonal antibody, mab- i that binds to the subunit of the v integrin, is able to target and image murine tumor tissues independently of their histological origin. phage display for the identification of a hepatoma binding peptide t. prenzel , a. altmann , w. mier , s. krämer , m. eisenhut , u. haberkorn ; university hospital, heidelberg, germany, dkfz, heidelberg, germany. hepatocellular carcinoma (hcc) is usually diagnosed at a late stage and has a high recurrence rate after resection. increasing the concentration of chemotherapeutics in a carcinoma and thus lowering the side effects for the organism is a problem in the diagnosis and therapy of hcc. a prerequisite for a specific accumulation in the tumour are molecules with a high binding affinity for tumour cells. due to their small size peptides are very useful tracers showing easy penetration into tumor tissues. the aim of this work was the identification of peptides with high affinity for hepatoma cells using different selection conditions. methods: we used a amino acid phage display library to identify hepatoma specific peptides. this libraray was exposed to hepg cells. six peptides with the selected amino acid sequences were synthesized by solid phase peptide synthesis and radiolabelled with radioactive iodine. the properties of these peptides were evaluated by in vitro binding experiments. furthermore, a biodistribution study was performed in tumor bearing mice. results: five of the six peptides showed low binding to hcc cells. the linear peptide e with positive binding was investigated by further studies. in in vitro binding experiments these cells showed the highest peptide binding rate after ten minutes with no evidence of internalization. competition experiments demonstrated that binding of i- -e was reduced by the addition of unlabeled peptide. e binds weakly to huh cells and primary human hepatocytes. the half life determined in human serum was more than one hour. peptide degradation products were isolated and characterized by mass spectrometry. we assume a a rapid deiodation and breakage of ammonium early after incubation start. biodistribution studies of e in balb/c nu/nu mice carrying hepg tumours revealed a two-fold higher e accumulation in the tumour as compared to the liver. conclusions: the peptide e showed some properties that make it a possible carrier for liver cancer imaging or the delivery of isotopes or drugs to hepatocellular carcinomas. further investigations will be necessary in order to characterise the value of e and its derivatives. purpose: histone deacetylase (hdac) inhibitors trigger differentiation, decrease cell proliferation and induce apoptosis in tumor cells. furthermore, they seem to act selectively to alter transcription of fewer than % of expressed genes. suberoylanilide hydroxamic acid (saha) is a new hdac inhibitor used in phase i/ii clinical trials. in order to determine whether there is preferential tumor accumulation of saha we studied the uptake of the drug in sensitive tumor cell lines. experimental design: after labelling of saha with iodide a mtt assay was done to assess the effects of iodination on therapeutic efficacy in different tumor cell lines (thyroid carcinoma, hepatoma, colon carcinoma). therefafter, uptake, competition and efflux studies were done using i- labeled saha. finally, a biodistribution study was performed in tumor bearing mice. results: iodinated saha analogs showed equal toxicity as compared to unmodified saha. the uptake of i- -saha was time dependent with a plateau at h and was inhibited by the presence of unlabeled saha with ic values around nm. furthermore, a rapid efflux was observed with a % decrease of intracellular activity after minutes. the biodistribution study showed high accumulation in liver and kidney and a moderate accumulation in the tumor. also a rapid washout was seen with . %id/g and . %id/g in the tumor at h and h after tracer administration, respectively. the tumor to organ ratios were highest for brain and for for h and h) and muscle ( . and . for h and h). conclusions: iodinated saha showed rapid efflux and no preferential tumor accumulation. for therapeutic activity tumor selective uptake may be not a necessary condition. rather low amounts of the drug seem to be sufficient to change the balance between acetylated and non-acetylated histones in a manner that leads to differentiation, inhibition of proliferation and apoptosis. radiolabeling and biodistribution of pkf - , an inhibitor of the wnt signalling pathway u. haberkorn , w. mier , m. eisenhut , b. beijer , a. altmann ; univ.hosp., heidelberg, germany, dkfz, heidelberg, germany. the wnt signalling pathway plays key roles in cell fate specification, cns patterning and control of asymmetric cell division. constitutive wnt signalling is observed in many tumors including colorectal carcinoma where > % have an activating mutation of the wnt canonical pathway leading to an accumulation of beta-catenin. the binding of beta-catenin to tcf represents a promising target for therapy and could be used for imaging of the wnt signalling pathway. methods: after labeling of pkf - , a small molecule interfering with the beta-catenin/tcf interaction, with i- we performed uptake studies in vitro using two human anaplastic thyroid carcinoma (c and sw ) and two human colon carcinoma (hct and caco ) cell lines. efflux experiments were done with sw and hct cells. finally a biodistribution study with i- -pkf - was performed in tumor bearing mice. results: we observed a time dependent uptake with a plateau after h incubation with a higher uptake in the thyroid carcinoma cell lines as compared to the colorectal carcinoma cells. no significant efflux was seen during the first minutes after incubation of the tumor cells. the biodistribution study revealed different values with %id/g for sw tumors and . %id/g for hct tumors at h after tracer administration. this uptake was followed by a decrease in activity with %id/g and . %id/g at h and h for sw and . %id/g and . %id/g at h and h for hct . tumor-to blood ratios at h were for brain, . for muscle and . for liver at h for sw tumors. these remained stable until h. similar data were obtained for hct tumors. conclusions: iodinated pkf - may be used as a tracer for the visualization of wnt signalling. however, at present its exact binding site -beta-catenin, tcf or the complex of both -remains to be elucidated. preparation and in vitro evaluation of mtc-hyniclactadherin as a potential radioligand for apoptosis detection studied. they were divided into three groups randomly: ason, son and asonblocked group. pcna ason and son were both radiolabeled with m tc after being coupled with hynic and were injected to the former groups respectively, and the latter were given unlabeled ason before the injection of m tc -hynic-pcna ason as control. then scintigraphy experiments were performed on all the objects. after the last imaging session, the animals in the first group were sacrificed and their aortic arteries were removed for ex-vivo scan. moreover, the arteries were dissected into segments for well counting, pathological examinations and pcna staining. results: abdominal aortas of all the rabbits could be seen soon after the injection. however, accumulated radioactivity was observed only in the rabbits in the first group hours later, and the count ratios of the lesion to the background of the abdomen were . ± . while . ± . for vessels of the son group (p < . ) and . ± . for the blocked group (p < . ). the ex-vivo scan of the arteries revealed good correlation of tracer accumulation. the atherosclerotic lesions were predominantly of american heart association class ii. the percentages of injected dose for the plaque and non-plaque vessels were . ± . and . ± . , respectively (p < . ). the pcna index was ( . ± . ) % and ( . ± . ) %, respectively (p < . ). there is a significant correlation between these two sets of data by regression analysis(r= . , p< . ). conclusion: m tc-pcna ason scintigraphy can reveal the abnormally increased radioactivity of the lesions of the atherosclerotic arteries in rabbit model and it has potential to be used to diagnose the atherosclerosis noninvasively. objective: the aim of the study was to determine the location and range of fdg uptake in knee joint and to detect the influence of aging on fdg uptake. methods: thirty seven patients (age range - years, m and f) who had fdg pet which included lower extremities and who had no known disease of the knee joints were included. maximum standardized uptake value (suv max) was measured by placing regions of interest (roi) around the medial, lateral synovia, joint space, entire knee and patello-femoral joint in all the subjects. several roi's were placed on adjacent axial slices in the above mentioned regions of interest and average suvmax for each region of interest for both knees was calculated for all subjects. analysis of suvmax was carried out for the effects of age. the correlation of knee fdg uptake with aging was also determined. results: there is positive correlation between suvmax measurements in all knee compartments and age where the r (pearson correlation) measured . for all regions of the knee (p< . ). the most affected part of the knee by age was the medial synovium where the p value was less than . . the average suvmax ± standard deviation (sd) for medial, lateral synovia, joint space, entire knee and patello-femoral joint was . ± . , . ± . , . ± . , . ± . and . ± . respectively. conclusion: there is significant correlation between age and metabolic activity in different regions in the knee and effects of aging was noted most in the medial synovium. the increased fdg uptake in the knees with aging may be secondary to cumulative effect of weight bearing on knee joints with increasing age. the increased metabolic activity can also be secondary to inflammation associated with degenerative joint disease, the incidence of which also increases with normal aging. further studies to investigate the role of fdg-pet in aging and related disorders such as degenerative joint disease would be of further value in clarifying the nature of our finding. to increased metabolic activity. brown fat occurs often in the supra-clavicular region and the increased fdg uptake can complicate the interpretation of the pet-studies. materials and methods: a thin, -year-old girl with the diagnosis of malignant melanoma was pet/ct scanned with mbq f-fdg (intravenous injection while supine). after injection, she continued resting supine for min and was scanned min post injection. the scan showed an extremely high uptake in the brown fat. the scan was performed during the winter months where the patient was exposed to cold temperatures and a new scan was requested. three months later, a new scan was performed where a more envolved pre-scan preparation was prescribed for the day of the examination. the patient was instructed to keep warm from the time she woke up and during transportation to our pet centre. after arrival, she was kept warm, mg oral diazepam was given, and she rested supine min prior to injection of mbq f-fdg and min after. the last min she was allowed to sit, but still kept warm and the scan was performed min post injection. results: the first pet scan demonstrated a very high uptake of fdg in brown fat in the chest and neck area and the scanning could not be optimally reported. the second scan was without brown fat uptake and was clinically relevant in following the patient's illness. conclusion: planning and simple preparatory procedures like keeping warm prior and throughout the whole injection/uptake process and a comfortable room temperature are important to avoid increased fdg uptake in the brown fat. muscle relaxing medication like diazepam can be useful if the patient is nervous or agitated. fused pet/ct images aids in image interpretation and it is often possible on axial slices to differentiate between brown fat, muscle and lymph nodes. however, it is important to prevent uptake in brown fat as much as possible to avoid confusion between pathologic and physiologic activity. the -iodine whole body scintigraphy has high sensitivity for the detention of bone, lymph nodes, and pulmonary metastasis of differentiated thyroid carcinoma, in particular when acquired after the administration of therapeutical activities. but if this scintigraphic images supplies functional information, sensible and precocious, possesses, on the other hand, slight anatomic detail, not allowing to locate the source of the pathological alteration. to get an anatomic reliable reference of areas of hyperfixation of i detected in the whole body scintigraphy after therapy, it might be an advantage to have a simultaneous acquisition of bone scan with mtc-mdp and i. aim we intend to describe the technical procedure and to present some images resultant from the application of this protocol to patients with thyroidectomy, for differentiated thyroid carcinoma, for localization of focal hyperfixations detected in the i whole body scintigraphy after ablation therapy. materials and methods in the whole body scintigraphys acquired days after the administration of the therapeutical activities of i, were detected focal hyperfixations of i in the thorax that, for its localizations, could involve pulmonary or bone structures. after hours of the administration of mtc-mdp, were acquired, simultaneously in the peak of energy of the two radioisotopes, whole body scan, segmentary images of the thorax and, in some cases, thorax spect. it was used a gamma camera siemens e-cam dcr dual-head, equipped with high energy collimators. before the reconstruction of the tomographic studies, we added the corresponding plans of each isotopes. the visual analysis of the segmentary images was facilitated by the use of a software that allows to overlap the images of the two isotopes and to individually vary the brightness and contrast scales of each one of them. results the analysis of the acquired images allowed to verify that the i focal hyperfixations found in the studied patients were secondary lesions in the bone. conclusion the simultaneous acquisition of bone scintigraphy with mtc-mdp and i whole body scintigraphy, in double window of energy, with the help of a processing commercial software, allowed the anatomic localization of areas of focal hyperfixation of i, contributing for the orientation of the patients later imagiologic studies. in- labelled octreotride and spect/ct image fusion from two seoarated equipments -clinical case i. paula, t. coutinho, a. fonseca, l. pereira, l. bastos; instituto portugues oncologia, porto, portugal. aim: in- labelled octreotride (octeroscan tm ) is used for imaging somatostatin receptor expression in tumours and their metastases. precise location of the lesions is quite difficult and the spect/ct image fusion can improve accuracy and provide additional information on the anatomic location of increased uptake of octeroscan tm . this clinical case illustrates that the registration and fusion of images from independent acquisitions by spect and ct can be useful in the location of increased uptake of octeroscan tm , and shows the benefit of the resultant images when compared with the conventional whole-body spect. material and methods: we show the case of a years old female patient with suspected neuroendocrine tumour. a whole-body scan with mibg i- plus a whole body spect octeroscan tm scan (e-cam siemens) and ct images (biograph pet/ct by siemens) were acquired. the spect and ct scan were performed sequentially with perforated pmma markers with approximately mm with to mbq of tc- m, which can be seen both in transmission and emission tomographic images, attached to the skin over the bilateral iliac crests and the sternal furcula. the reconstruction of the spect and ct raw data as well as the manual registration and fusion of both sets of images was made with the syngo siemens software based in invariability of the position of the tc m markers relative to the patient body. results: whole-body scans with mibg i- were negative. first octeroscan tm whole-body scan showed only two small lesions in the upper abdomen and in the bowel. the second octeroscan tm whole-body scan and spect images showed abnormal uptake sites but only spect/ct fusion images showed the exact location of the metastases in the upper abdomen, bowel, liver, upper mediastine and a small lesion on the right breast (suspicious of breast cancer). conclusion: this case illustrates the benefit of spect/ct octeroscan tm and the usefulness of combining spect and ct images from two separated devices without a dedicated spect/ct device. we show that spect/ct fusion images has a clear advantage over conventional whole-body scan and can lead to a more precise lesion location in the case of octeroscan tm somatostatin receptor expression. the effect of activity outside the field of view in estimation of human neuroreceptor binding with pet. t. shiraishi, m. shidahara, k. tanimoto, a. ando, t. miyamoto, r. koganezawa, h. fukuda, k. watanabe; national institute of radiological sciences, chiba, japan. objectives: to estimate the binding of radioligands for neuroreceptors, quantitative analysis using dynamic pet scan data of target regions with a reference region in the brain is the traditional strategy to estimate the binding of radio-ligands for neuroreceptors. in the study estimating the binding potential (bp) of dopamine d receptor, high activities were sometimes observed in lung, liver, gallbladder, intestine and urinary bladder, as well as in the brain. those activities accumulated in the tissues outside of field of view (fov) have effect on quantification of pet scanner as noise, especially on the reference region owing to non-existence of dopamine d receptor. in this study, we analyze the effect of the activities outside of fov on bp value using d and d acquisitions. methods: pet scanning was carried out using cti-simens ecat exact hr+. we prepared the high activity ( kbq/ml) phantom used as the activity of target region and the low activity ( kbq/ml) phantom used as the activity of reference region. both of them were filled with ge- ga source, and another phantom filled with f solution ( mbq) was fixed outside of fov as the noise. after min pre-injection transmission scan, pet scans were performed with d and d modes under decaying the radio-activity outside of fov. the pet scan at decaying radio-activity outside of fov to a background was used as ideal scan. rois were placed on target and reference region, bp values were calculated with the roi values. results: the radio-activity of reference region was + . % higher compared to that of ideal scan in d mode. in d mode, by the contrast, the increase of radioactivity of reference region were + . %. as for the bp value, the decrease of bp value compared to that of ideal scan was - . % in d mode, while that of d was - . %. the coefficient of variation (cv) of bp values in d mode was obviously higher than that of d due to the radio-activity outside of fov. conclusion: based on our analysis, it is clear that the bp values were underestimated due to increase of the radio-activity outside of fov, especially in d mode. furthermore, because of radioactivity outside of fov, the bp values of d mode were varied widely, while bp value of d was stable. these results indicate that human neuroreceptor pet studies estimating bp values should use d acquisition mode to suppress the effect of radioactivity outside of fov. abstract datscan is a diagnostic tool used routinely to differentiate patients with parkinson's disease from those with essential tremor. by using iodine labelled dopamine active transporter proteins to image the pre-synaptic striatal uptake in the basal ganglia region of the brain. data suggests datscan has . % sensitivity in differentiating between parkinson's disease and essential tremor aim to investigate whether the clinical diagnosis of patients whom present with parkinson's syndromes would be affected depending on if the images were analysed using a qualitative or quantitative method. to assess the difference in the image interpretation of separate health care professionals. methods a blinded anonymous retrospective analysis of patient studies was interpreted by; . consultant radiologist . experienced clinical technologist . trainee clinical technologist the results were compared with the original clinical report by a different radiologist. each study was interpreted twice at different times, using; a) qualitative analyses of image b) quantitative analyses using proprietary software. results table n/a software references to a normal range so there is no equivocal range. a mismatch was when operators report disagreed with the original report. the qualitative data shows that of the operators are fairly comparable with the original clinical report. the radiologist had mismatched the report with original report in ( %), technologist ( %) and trainee ( %). the quantitative and qualitative results for the technologist show a large difference and are possibly due to the operators rois. the radiologist and trainee appear to have good agreement between qualitative and quantitative results. further analysis comparing the studies original report with an abnormal quantification result hence mismatch with the original report indicated radiologist ( %), technologist ( %) and trainee ( %). conclusion qualitative assessment results indicate less variability between each grade of operator and the current gold standard original report. there is a wide variability in quantification between operators and original report that is likely to represent the difference in patient roi's. this may be due to the complexity of the software but could be improved by further training. the clinical data, we studied the current situation on the exposure to fingers and efficacious measures to decrease and monitor the exposure. methods: with ned (nuclear educated dosimeter: unfors, sweden) as a semiconductor dosimeter, first, we measured energy response and direction response as sensor characteristics and then the each medical staff in the five different clinical workplaces put the dosimeter on the index finger of their dominant hands to measure the dose. the staff's details are as follows: physician who injects ri drugs into the patients, radiological technologists who extract technetium from the mo-tc generator and handle ri drugs, physician who injects f-fdg-pet drugs, pharmacists who test the fdg and radiological technologist who position the patients. results: as the energy becomes higher, the response tends to be lower. it is because the energy response is a semiconductor element. based on the result, we set a calibration constant. the direction response ended in good result except sensor-cable junction part. the finger dose of the physician who injected ri drugs was . μsv, radiological technologists handling m tc . μsv per day (consultation period days), physician who injected f-fdg-pet drugs . μsv ( cases, right finger . μsv, left finger . μsv), pharmacists who tested the fdg . μsv, and radiological technologist who positioned the patients . μsv. this dosimeter can measure a real-time finger dose easily and its high sensitivity helped us to know the exposure situation effectively. (table and ). conclusion: this dosimeter provides a simple and effective solution to radiation protection procedures and follow-up. we measured the finger doses of nuclear medicine staff in our institute this time and found that the value ended in less than the annual limit ( msv per year). but, workers who use f-fdg pet showed high exposure compared with no-pet case, and it should be considerd reduction of radiation exposure methods. introduction: the dynamic renal scintigraphy used dtpa-tc m and captopril test constitutes a process of noninvasive functional exploration for the diagnosis of rénovascular hypertension. it permits to distinguish the hypertension induced by renal arterial stenosis from the stenosis of meeting associated with a primitive arterial hypertension. case report: a years old girl, without notable pathological antecedent, developed two months before the first consultation, a severe arterial hypertension with cephalgias and buzzing in the ears. the clinical examination objectified a breath in the left lumbar pit to the auscultation. the renal angiography objectified a stenosis of infrarenal aorta due to circumferential parietal thickening associated to renal arteries stenosis more marked in the left side. the dynamic renal scintigraphy after administration of captopril highlighted a marked collapse of the rate of tracer collecting exceeding % on the left side with an increase in the time of collecting on the right side testifying to a frankly positive test prevailing on the left. a transluminal angioplasty of the left renal artery and a revascularisation surgery on the right side were carried out. the evolution was marked by an improvement of blood pressure figures, which contributed to a considerable reduction of posology of the antihypertensive treatments. discussion: the dynamic renal scintigraphy using dtpa-tc m with captopril test constitutes a noninvasive process, little irradiant for patients. its principal goal is to affirm the incrimination of the renovascular stenosis in the arterial hypertension genesis and to determine which hypertensive patients, with a renal arterial stenosis, could be treated successfully by the surgical or endoscopic revascularisation of the kidney. usefulness of oro-pharyngo-esophageal scintigraphy in the evaluation of inhalation into the tracheobronchial branch: a case report acquired image by count setting( kcnt), that scan time of mm pin hole collimator was longer than mm pin hole collimator about . times(mean time- mm: . sec, mm: . sec). thyroid images by the mm pin hole collimator was acquired within about minute except in the case of low level thyroid uptake like hypothyroidsm. we confirmed that the region of nodule was discriminated by mm hole better than mm hole through image of patient who has nodule. even if detected count value in the mm pin hole collimator was % of mm pin hole collimator in the image of patient who has nodule, nodule portion of thyroid was certainly discriminated in the mm pin hole collimator's image. we confirmed that scan time of each diseases were needed better in mm hole.(hyperthyroidism - . times, hypothyroidism - . times, goiter - . times, thyroidal nodule - . times) . conclusion although scan time is longer by using mm pin hole collimator if we adjust time and count, mm pin hole collimator image is more useful than mm pin hole collimator image. especially, it provide useful diagnostic information in pantient who has nodule. racial variations in bone scintigraphy: an original investigation r. allie, q. siraj; royal hospital haslar, portsmouth nhs trust, gosport, united kingdom. by merit of its high sensitivity for early detection of bone pathology, bone scintigraphy remains the modality of choice for investigating sports injuries. this department regularly performs bone scans on military patients referred for musculoskeletal problems for the early detection of stress fractures and other musculoskeletal pathologies. for some time we have noticed that there appears to be a difference in the bone-to-soft-tissue uptake between caucasians (whites) to afro-caribbeans (blacks). bone scans of military recruits ( males, % blacks and females, % blacks) were analysed. all subjects were injected and imaged according to departmental protocol using the same gamma camera. regions of interest were plotted over the bone and soft tissue to obtain bone-to-soft-tissue ratios. these were compared for each ethnic group. the results showed a significant statistical difference (p = . ) between the two groups. these findings were independent of gender, dose and waiting times. there was also a significant difference in respect to acquisition times (p = . ) for k counts. though many options were explored, no obvious cause could be determined for this phenomenon. more research is required to shed further light on the matter; however, the various plausible hypotheses will be discussed. aim: to learn about acute osteomyelitis as a complication in varicella and about imaging findings at different points in the course of the disease. background: acute osteomyelitis is a rare complication in varicella. to our knowledge only cases have been reported in the litterature. materials and methods: the clinical symptoms, findings and course of the disease are illustrated by patients, a boy ( months) and a girl ( years) admitted to our hospital. bone scintigraphy ( m tcmethylenediphosphonate) and radiography were performed on the first or second day after admission in both patients. mr imaging was performed in the girl the . day. radiograms and scintigrams were performed later in both patients. results: the first scintigrams showed increased activity in the distal part and slightly reduced activity in the proximal part of the right humerus in the boy, and increased activity in the left tibia metaphysis in the girl. scintigrams after days in the boy showed further increased activity in the right humerus, now affecting the whole diaphysis.scintigrams after weeks were normal in the girl. the first radiograms were negative in both patients. radiograms after days showed irregular osteolytic lesions and periostal reactions in the proximal humerus diaphysis in the boy. later radiograms showed slowly normalizing conditions. radiograms in the girl after month were normal. the mr images in the girl showed bone marrow edema in the left lateral tibia metaphysis and medial femur condyle. both patients recovered completely after adequate treatment with antibiotics. discussion: the scintigraphic findings in the boy could represent reactive hyperemia in the distal part of the humerus diaphysis and a transient reduced perfusion, before activity accumulation in the proximal diaphysis, where the infection was localized. bone scintigraphy, preferably a multiphase study, is positive in osteomyelitis within - hours after onset of symptoms, with - % sensitivity. radiographs do not show significant changes the first days, even weeks, but are necessary in the follow-up. . mr imaging allows early detection of osteomyelitis, bone marrow edema appears during the first days of infection. the sensitivity is ~ %. conclusion: acute osteomyelitis is a serious complication in varicella and should be considered in any child with pain in a limb or joint after an episode of varicella. successful treatment depends on early detection. bone scintigraphy and mr imaging are sensitive methods showing pathological changes within the first days of osteomyelitis. background/aims. circulatory and pulmonary complications are common in patients with cirrhosis and portal hypertension and some patients have gas exchange abnormalities that may progress to the hepatopulmonary syndrome (hps). the prevalence of hps is, however, variably reported from to %, but its precise relation to the liver function is poorly understood. the aims of the present study were by means of lung perfusion scintigraphy (lps) to assess the prevalence of hps in consecutive portal hypertensive cirrhotic patients in relation to patient characteristics and during a % oxygen test. methods.forty-one patients ( . ± . yrs, women and men) with alcoholic cirrhosis (child class a/b/c: / / ) entered the study. all underwent a haemodynamic investigation with the determination of splanchnic and systemic haemodynamics. all had a contrast-enhanced echocardiography (cee) and a lps performed to diagnose extrapulmonary shunt fraction (epsf) and hps. in addition, measurement of pa,o , alveolar-arterial oxygen gradient (pa-a,o ), lung diffusing capacity (dl,co) and a % oxygen test were performed. results. all patients had portal hypertension (hvpg: . ± . mmhg). five patients had a positive cee and epsf above %. three of these patients had a pa,o below . kpa giving a frequency of hps of %. the dl,co was reduced in % of the patients and correlated significantly with metabolic liver function (gec: r= . , p= . ), splanchnic haemodynamics (post-sinusoidal resistance: r=- . ,p= . ; hepatic blood flow: r= . ,p= . ), and systemic haemodynamics (central blood volume: . ,p= . ; plasma volume: . ,p= . ; blood volume: r= . ,p= . ). pa,o was reduced below . kpa in % and pa-a,o was above . kpa in % patients. pa-a,o was significantly higher in patients with positive cee, . ± . vs . ± . kpa than in those with a negative cee (p< . ). the change in pa-a,o after % oxygen inhalation was significantly reduced in child class c patients,- . ± . kpa, compared with child class a and b patients( p< . ). moreover, the change in paa,o correlated with the epsf fraction in the total patient population (r=- . , p< . ). conclusions. whereas pulmonary dysfunction in cirrhosis is frequent and relates complexly to metabolic, splanchnic and central systemic haemodynamic complications, the prevalence of patients fulfilling the criteria of hps is below % even in patients with advanced disease. lps is considered a useful contribution in the evaluation of pulmonary dysfunction in cirrhosis. aim: emboli cause ventilation/perfusion (v/p) mismatches, usually with typical triangular character. however, in the area of middle lobe and lingula they might differ in form on sagittal tomographic images. mismatches are sometimes observed only in these areas and they may cause dilemma in interpretation. we wanted to validate if these type of changes are caused by emboli or movement of lung position during first minutes, known otherwise in cardiology as "upward creep" of the heart. materials and method: before perfusion spect, consecutive patient performed two ventilation (v) spect. first and second ventilation studies were then compared with each other and v /v quotient was calculated in order to estimate changes in lung position during the first minutes. images were validated visually and quantitatively. change index was expressed as the fraction of the lung volume that had a quotient (v /v ) below . or above . . results: visual and quantitative analysis did not show significant changes in lung position due to "upward creep" that can influence false interpretation of mismatches caused by pulmonary embolism. conclusion: v/p mismatches identified in middle lobe and lingula by spect are reliable for interpretation for pulmonary embolism. correlation between ctpa and v/q scintigraphy in the diagnosis of pulmonary embolism s. rep, j. fettich; nuk.med.department, ljubljana, slovenia. introduction: a pulmonary embolism (pe) is a blockage of a pulmonary artery caused usually by an embolus. this can be diagnosed using v/q scintigraphy showing absent perfusion and normal ventilation of the affected lung segment or using ct pulmonary angiography (ctpa). in this case iodinated contrast medium is injected i.v. and pe is shown as filling defect of the affected pulmonary artery. aim: the goal of our study was to detect relationship between absent perfusion showing with v/q scintigraphy and defect of the affected pulmonary artery showing with ctpa. patients and methods: our study includes patients with ctpa positive results for pe. ctpa and v/q planar scintigraphy was performed within hours all patients. for v/q scintigraphy we used xe ( mbq) for ventilation and mtc-maa ( mbq) for perfusion in four projections. lungs were divided into anatomical lobes (upper lobes, lower lobes, middle lobe and intermediate lobe). each lobe was evaluated as having normal perfusion, ventilation/perfusion defect mismatch or match on v/q scan, and partial or total occlusion of a segmental pulmonary artery on ctpa. the results of v/q planar scintigraphy and of ctpa were compared. results: analysis of ctpa perfusion showed normal perfusion in . % lobes, partial occlusion in . % lobes and total occlusion of pulmonary artery in . % of lobes. ventilation was not successfully performed in patient ( %). in % of segments ventilation was affected. perfusion results showed absent perfusion in %, decreased perfusion in . % and in . % of lung segments the perfusion was normal. results of both methods corresponded in % and did not in %. conclusion: according to our results abnormalities corresponded in the % of segments with both methods. in % of segments disparity of the results was due to the fact that pe can be caused not only by complete but also by partial occlusion of the pulmonary artery. in % of segments the results were false positive on v/q mainly due to ventilatory changes (indeterminate v/q results). in % of segments v/q results were false negative most probably due to better resolution of ctpa as compared with scintigraphy. asynchronous appearance of double parathyroid adenomas in a patient with primary hyperparathyroidism t. athanasoulis, a. fothiadaki, t. karianos, a. tsakmakli, v. makripoulias, f. athanasouli, c. zerva; "alexandra" university hospital athens, greece, athens, greece. during work up of a male patient years old with a discovered raised calcium level who demonstrated primary hyperparathyroidism (pth= pg/ml and serum calcium ca= mg/dl), a double phase parathyroid scintigraphy with mibi was performed. a large area of hyperactive parathyroid gland localized at the lower left lobe of the thyroid gland. the patient was operated and a giant parathyroid adenoma was removed at the indicated location of the study which was confirmed histologically. the patient was followed up for the following two years during which his calcium and parathyroid hormone levels were normal. during a normal check up seven years later an elevated serum calcium level was found (ca= , mg/dl). at that time a cervical ultrasound was performed and pth was measured. the value of pth was pg/ml confirming a mild hyperparathyroidism. a double phase sestamibi technique followed by a pertechnetate scan was used for further evaluation. an enlarged area of hyperactive parathyroid gland localized below and directly opposite of the lower right thyroid lobe extending to the upper mediastinum was discovered. an mri was performed which confirmed the appearance of a mass ( , cm x cm x , in dimensions) localized in the upper mediastinal area at the tracheo-esophageal groove with its lower border in contact with the aortic arch. a surgical removal was performed and the histological study confirmed that the removed mass was a huge parathyroid adenoma. this case report indicates that despite the fact that a parathyroid adenoma is discovered and removed, this does not exclude the possibility of asynchronous appearance of a second adenoma. bonescintigraphy -adjustment of administrated activity a. eriksson, centralhospital, karlstad, sweden background: diagnostic reference levels (drl) for nuclear medicine is established in sweden by the swedish radiation protection authority, ssi. drl is the given level of specific activity that shall not be exceeded. currently all patients that undergoe a bonescintigraphy in karlstad receive the same activity irrespective of weight and age. question: is it possible to individually adjust administrated activity by combination of age and bodyweight without loss of quality? method and material: adjustment of activity is done by creating an index of age divided by bodyweight. relation of activity to index is given by a prestudy of patients injected with mbq or mbq hdp-tc. results: patients received standard activity mbq and patients got individually adjusted activity. mean counts per image was , mcts respective , mcts. the decrease in administrated activity was , % for the adjusted group. variance of counts per image decreased from , to , . conclusion: individually adjusted activity by this model yields same quality in the image as a standard activity. the decrease in administered activity is positive both for the staff and the patient. radiation protection during two decades in a nuclear medicine department s. kristiansen, a. nielsen; department of nuclear medicine, aalborg hospital, aalborg, denmark. aim: the aim of this study was to follow the yearly radiation doses during two decades to staff working in department of nuclear medicine, aalborg hospital. we focused on the development in procedures, the number of examinations, and the physical working environment. this includes radiation protection in general nuclear medicine and pet/ct. materials and methods: data has been taken from list of examinations sent to the ministry of health since and measuring results of personal dosimetry from the same ministry since . until the department had very old and narrow quarters. when moving to new facilities in and when establishing pet procedures in december , our primary goal was to increase distance between the radiation source (the patient) and the technologists in order to reduce occupational exposure. the following was taken into consideration: •large, simple but functional rooms. •a new laboratory section with a direct hatch to the injection room. •a special waiting area for patients confined to bed. •improved shielding in preparation settings. •electronic personal dosimeters. •introduction program for new staff where the main topics are: radiation protection, personal dosimeter, receiving and registration of radioactive sources and pharmaceuticals, circumstances for pregnant and breastfeeding staff and handling of radioactive waste. •radiation protection is taken into consideration whenever changes are made or new procedures are implemented. •dosimeter measuring results are discussed at staff meeting. results: among the examinations giving the highest radiation dose to the staff are bone scintigraphy, myocardial scintigraphy and pet scannings. the number of bone scintigraphies has been almost stable since . the number of myocardial scans has increased from scans in to scans in . the department started pet/ct scans in and made scannings the first year. evaluating technologists working since in nuclear medicine the average occupational radiation dose has not increased. conclusion: we found that it is very important to develop the physical working environment currently while having focus on its functionality. furthermore the electronic personal dosimeter, updated guidelines for procedures and introduction of new staff is significance to keep radiation dose low. this has been introduced in our department, and despite an increase in the number of scannings, the radiation dose to the staff has not increased. cyclotrons are commonly used for production of radioactive isotopes for nuclear medicine purposes. as part of the site safety system, the nuclear process requires installation of a stack radiation monitoring system (srms) to determine the released activity during routine operation. this srms requires determination of a conversion factor for converting the radiation detector readings into concentration unit. defining the conversion factor is done mainly by calibration process of releasing a known amount of activity. it is important to have a precise estimation of the converting factor in order to enable the design of an optimal duct that shall provide maximum detection sensitivity. a computer program was developed for determining the stack conversion factor based on simulating the positron emitter isotopes free mean pass in the duct and the motion direction of the kev energy photons created by positron annihilation. the obtained conversion factor (by the software) is based on the radiation detector sensitivity for kev energy photons, the user definitions for the stack dimensions and the cross section of the duct. this algorithm is acceptable since all pet isotopes produce kev photons. a local calibration factor is designated to adjust the software conversion factor to the self-characteristics of the specified detector. adjustment is done by locating a calibrated radiation source in a pre-determined location and comparing between the expected reading calculated by software and the detector actual reading. the detector readings, converted into activity concentration along with the air flow data, are used to accumulate the total activity release through the duct. the software simulation has been performed on few square and round ducts of different dimensions and the results were compared to the actual calibration releases. results show a very high correlation between the software simulation and the actual releases. the conversion factors found to be in the range of cps per nci/m for duct with cross section of cm . due to the high correlation between the simulation and the calibration releases, the simulation may now be used to estimate the design ventilation system sensitivity in order to improve the minimum detectable activity and to be compatible with the restrict regulation of detecting concentration level as low as nci/m . this high correlation can reduce the amount of activity releases that are accumulated during the calibration process as part of the annual release activity under the site license and reduce the allowed released activity derived from the site routine operation. introduction: the nuclear medicine technologist(nmt) is the healthcare professional who is able to cover the whole range of nm procedures in the clinical routine. the period of education is a fundamental part of the educational process and for this purpose considerable resources investment is dedicated to it. the possibility of knowing how to confront the most varied situations in italy(i), in european(eu) and mediterranean nations, determines a professional growth in the sector. aim: the nmt is an important part of a team of healthcare specialists; the aim of this work is to identify nmt formative processes, working situations and economical capacities. in i, education and training is quite similar than in eu: during the initial months of the university course(average years), nmts acquire the basic theoretical elements, follow the courses which help to develop didactic, then anatomy, pathology, equipment in the radiology area( %); at the end, nmt deals with other fields of application of the ionizing radiations. the range of tasks permitted of nmt varies from country to country, and there is considerable overlap with other professional groups. results: according to several published reports, there are approximately radiological+nm technologist in the world; of them in europe ( %men+ %women). there are nmts operating throughout italian nm-pet departments. in addition to historical/cultural traditions, differences in teaching and the characteristics of university course programming create different technical procedures in nmt routine (diagnostic imaging, radiation protection, etc.); legislation is relative flexible in all countries, with - working hours per week with additional extramural nmt activity; the duties of chief-nmt are always dedicated to management of logistic problems( %) and financial resources( %). credit points must be collected by the exam for ce sessions in every countries. italian nmt salary is . times lower than % of eu. professional benefits (extra days off or special bonus) are taken into account only in the mediterranean area or intercontinental countries. conclusions: the training and the professional qualification of nmt represents a first step towards a governance of healthcare working activities; it's important to underline main nmt goal: one high standard of work for nmt in countries. fundamental for the changeover of nmts is the ability to acquire/process spet&pet-ct images, in addition to performing quality control of nm technologies. it's in the interest of healthcare quality that nmts take responsibility for providing of high quality service and performance in clinical routine, with professional competence and global competition. introduction: assuming that the modern concept of a nuclear medicine department should ideally include a positron emitting tracers (pet) production facility, there is a need to optimize the design of an integrated facility (here considered as the opportunity to build from the beginning) in order to allow the distinct patterns of functioning and circulation (patients, public, professionals, products, ) to occur in an harmonious and most efficient way. the purpose of this study is to integrate the ultimate concepts concerning aspects so crucial as radiation protection, ergonomics and the practicability and efficiency of the unit, considered as a whole. material and methods: starting with a bibliographic review, done according to the most recent developments on regulations and legislation, essentially at international level but also regarding eventual national particularities and following with practical knowledge, obtained from recent (real) implementation of similar units -and information shared by the responsible entities -we aim to build a complete and structured project, with an objective planning (blueprints), able to serve as basis for real implementation of an unit with an updated and optimized integrated vision of the current production and diagnostic processes. results and conclusions: the final blueprints of the unit are based on studies concerning not only the previous research on current legislation, but also the current assumption of best practices and fundamental principles related to radioprotection (as the alara principle), production (as the cgmp rules) and diagnosis (international guidelines). these blueprints demonstrated the practical result of that research and consist, briefly, on the obtained optimal structuring of the diagnostic side of the unit (as well as the production side) combined together in order to facilitate the necessary interaction, even if maintaining its respective independence and individual protection (compulsory condition to assure best practices) even in case of simultaneous operation. results: in the first patient tg level decreased from . ng/ml to . , . and . ng/ml after st and nd and rd ri application, respectively conclusion: there is a significant reduction of tg levels in esrf patients with dtc during the course of therapies using reduced activity doses. tg levels in all patients were lower then ng/ml after the nd therapy same-patient perfusion spect data were acquired by alternating between nr and bh every seconds. the ct protocol was standard breath hold. these data were transferred to the lungguide (nihon advanced biologic, japan) workstation via dicom where non-rigid spect/ct image co-registration and fusion were performed using lg-ifm. due to the small difference in displacements, bh-spect/bh-ct registration was taken to be the "gold standard" to which nr-spect/bh-ct registration was compared. the differences in the position of the the diaphragm and the bottom of the lungs and in bh ct and nr spect, respectively, were measured. after lg-ifm registration with, we evaluated the difference of bh-spect/bh-ct and nr-spect/bh-ct fusion images in the lung lower field. results: lg-ifm mis-registration was observed in of cases ( . ± . %) in nr spect/bh ct fusion images czech republic -the result of the questionnaire rd medical faculty rehling ; clinical physiology and nuclear medicine positive cd /weak glut- ( . ± . , n= ), negative cd /strong glut- ( . ± . , n= ) were significantly higher than those of negative cd /negativeglut- ( . ± . , n= ) using kruskal wallis test (p= . ), suggesting that fdg uptake variation is related not only glut- but also cd (thus muc ) we present synthesis, radiochemical synthesis, and preclinical data on a series of novel radiofluorinated alkyne agents as potential pet agents for the detection of amyloid plaques. one such pet agent, av- binds avidly to abeta (a ) with a ki = . ± . nm (vs. i-impy) and localizes specifically to a in ad brain tissue máthé , i. foldes ; nat is it possible, from stress images only, to decide if a myocardial perfusion rest study is needed? present our experience about the unwished effects that appear during the administration of i-ioflupano/fp-cit in patient with movement disorder. material and methods. a total of consecutives patients ( % male; mean age . y) were men are studied between xii/' to i/' . the patients were grouped according to the clinical prescription in / ( . %) patients were reported pain during the injection, red flush and irritation in the zone of puncture in spite of its reinjection in another vein assuring a correct canalization. in / ( , %) was observed slight headache with slight reddening face. three of these patients were referred for reevaluation in a follow-up protocol ( / ; , %) presenting similar reactions to the first time when the exploration was repeated. comments. the administration of i-ioflupano/fp-cit is a procedure of limited adverse reactions and if appear, are of slight intensity spect are inaccurate for both algoritims, and that degree spet recontructed with osem can offer an acceptable alternative. however, degree spect recontructed with fbp is superior for this purpose parisella , a. lenza , f. scopinaro ; ospedale sant'andrea the main component of paint thinner used in industry is toluene. toluene can diffuse into many body fluids and tissues; and causes formation of reactive oxygen species (ros) which are the main agents responsible for cellular damage. antioxidant enzymes such as sod, gsh-px and cat are part of the natural cell defense system against ros mediated injuries. matrix metalloproteinases (mmps) play an important role in physiologic and pathologic processes, including extracellular matrix turnover, tissue degradation and repair, cell migration and inflammation. an imbalance between the expression of mmps and tissue inhibitor of metalloproteinases (timps) is believed to cause some pulmonary inflammatory diseases. especially, the imbalance between mmp- and timp- expression may play an important role in airway inflammation. we aimed to investigate the alveolar clearance by tc- m dtpa radioaerosol inhalation scintigraphy in auto painters, to assess effects of exposure to toluene on clearance rate of alveolar epithelium and to determine the correlation between tc- m dtpa radioaerosol lung scintigraphy findings and mda, antioxidant enzymes, mmp- , mmp- , timp- levels. twenty eight auto painters, and control group were included in the study. tc- m dtpa radioaerosol inhalation scintigraphy was performed in all subjects. clearance half time (t½) and penetration index (pi) on the first minute image were calculated. the mean t½ values and pi of toluene exposed workers were significantly higher than those of control group (p= . , p= . respectively). the sod and gsh-px levels of auto painters were significantly higher than those of the control group (p= . , p= . , respectively). conversely, cat and mda levels was not significantly different between groups (p> . ). we observed a statistically significant increase (p= . ) in mmp- levels of toluene exposed workers compared with the control group, whereas the mmp- and timp- levels of painters were less than those of control group that not reached to statistical significance (p> . ). a positive correlation was observed between pi and gsh-px levels (p< . ) in the painters. there were no correlation between scintigraphic findings and other parameters in any subjects. our findings indicate that occupational exposure to toluene in auto painters has effect on bronco alveolar epithelial permeability, which is supported by prolonged tc- m clearance half time and increased penetration index. we also found increase in antioxidant enzymes and mmp- levels. in the light of these findings, it might be concluded that long lasting toluene exposure may lead into occupational lung diseases. study objectives: measur the synovial thickness after -holmium radiosynoviorthesis by sonography. methods: phases iii, prospectiv study. patients suffering from chronic synovitis, rheumatoid arthritis were examined. the protocol commenced with screening. the patients were selected according to inclusion and exclusion criteria. holmium phytate injectable suspension marked by mbq holmium phytate injectable suspension, and mg of ml triamcinolone acetonide and ml of lidocaine %. there were month follow-up period after the administration of the isotope. inflammatory activity of the affected knee-joint was tested prior to treatment, and the th and , , , and months after treatment. we measured the synovial thickness the following locations: in the midline, lateral and medial, by the condylus of femur medial and lateral. results: during the study period, inflammation decreased. in the first two years excellent and good results were recorded in . %. two years after radiosynoviorthesis . % of patients did not need another punction. the thickness of the synovia decreased significantly. we find a significant correlation between the synovial thickness and the clinical improvenes. conclusion: the -holmium-phytate is an effective new radiopharmacon in the treatment of synovitis. we detect the clinical improvement by sonography. the effective dose is - mbq. references: margit szentesi: radiosynoviorthesis with ho- phytate. first clinical results eanm post-congress scintific meeting. radionuclide therapy in theory and practice. györ, hungary. . szept. . szentesi m., környei j., antalffy m., törkö j. tóth gy., jánoki gy., balogh l., : study of intraarticular application of -holmium ihpp in rabbits. world journal of nucl. med. . suppl. . s . sept. . szentesi m., takács s., farbaki zs., nagy e., környei j., antalffy m., törkö j., tóth gy., jánoki gy., balogh l. géher p., comparitive study of applying increasing doses of ho-phytate injectable suspension in chronic synovitis. (comparative, randomized, single-blind, placebocontrolled study with increasing dosage). eur. j. nucl. med. suppl. . . . szentesi m., takács s., farbaky zs., nagy e., környei j., antalffy m., törkö j. tóth gy., jánoki gy., the first article on radiosynoviorthesis was published in by fellinger. the traditional isotopes cause whole body radiation of rad. isotope specialists have aspired to produce an isotope incurring lower radiation loads. (pirick, russel, sledge, junsing song) -holmium-phytate produced by us: radiation type beta energy maximum: , mev; radiation type gamma energy maximum: , mev; soft tissue penetration: maximum , mm; average: , mm; half-life: , hours; particle size: , - μm study objectives: examination of anti-inflammatory effect of -holmium-phytate injection. methods: phases iii, prospectiv study. patients suffering from chronic synovitis, rheumatoid arthritis were examined. the protocol commenced with screening. the patients were selected according to inclusion and exclusion criteria. holmium phytate injectable suspension marked by mbq holmium phytate injectable suspension, and mg of ml triamcinolone acetonide and ml of lidocaine %. there were month follow-up period after the administration of the isotope. inflammatory activity of the affected knee-joint was tested prior to treatment, and the th and , , , , and months after treatment. evaulation was based on the criteria as described by müller, rau and scütte the score system was developed by the authors. results: during the study period, inflammation decreased. in the first three years excellent and good results were recorded in . %. three years after radiosynoviorthesis . % of patients did not need another punction. administration of holmium- phytate is a safe procedure. we did not detect any symptoms of radiation sickness. we found no deviations in either haematological or chemical parameters during the study period. conclusion: holmium- phytate isotope is an effective radiopharmacy treating synovitis. due its adventageous features it produces less radioactive damage on the organism than the traditionally used isotopes . due to its physical parameters it is optimal to treat large joints (knee) and medium size joints (hips, shoulder, elbow, wrist, ankle) . effective dosage is - mbq. references: margit szentesi: radiosynoviorthesis with ho- phytate. first clinical results. eanm post-congress scintific meeting. radionuclide therapy in theory and practice. györ, hungary. . szept. . szentesi m., takács s., farbaki zs., nagy e., környei j., antalffy m., törkö j. tóth gy., jánoki gy., background: early and continuous prophylaxis in haemophilia is of paramount importance due to the susceptibility of the young and immature skeleton to repeated joint bleedings. in developing countries, financial aspects of clotting factor a or b replacement play a major role in patients' management. radiosynovectomy (rso) offers an alternative treatment option to surgical or chemical synovectomy and may reduce the need for clotting factor substitution. a. . . methods: in a multicenter effort patients from centers underwent rso of the knee following repeated bleeding episodes. rso was performed applying three radiocolloid formulations (y- -silicate, re- tin and p- chromic phosphate). average age was . (range - years). standard injected activities were mbq for y- , mbq for re- and mbq for p . the injected activity was tailored to patients' age; - one third, - one half and - years three quarters of adult dose. patients were referred by the haematological outpatient clinic. the frequency of bleeding episodes was documented. prior to the rso the frequency of knee joint bleeding was reported from patients' records. results: with exception of one case with circumscribed and reversible skin necrosis along the injection tract or reversible swelling of the knee joint, there were no other serious side effects. within the one month period prior to rso, all patients had at least bleeding episodes per month. following the rso, number of bleeding episodes dropped significantly (a total of bleeding episodes during the one month prior to rso dropping to at one month, at months and at months following the rso, x < . ). during a months follow-up period, % of the patients had no bleeding episodes ( % reduction), % had an % reduction and % had a % reduction. based on the feedback by the children and their guardians, there was a significant improvement of the life quality attributed to improved mobility and lesser drop-out days from school. conclusions: our results indicate that rso is effective in preventing joint bleeding in the paediatric population. in addition there is a significant cost benefit attributed to reducing the need for clotting factor substitution (medication cost to treat one bleeding episode - us$ vs. - usd for rso using p- or re- ). following an initial period of scepticism, the acceptance of the procedure improved significantly. results of an iaea led crp: e . . radiation synovectomy may be indicated for the treatment of chronic synovitis. a number of factors may affect its current use, including availability, limited evidense for its efficacy compared to intra-glucocorticoid, and concerns regarding the potential long term effects of radiation exposure, particularly in younger patients. specific chromosome-type abnormalities in peripherial lymphocytes can be useful indicators of whole-body radiation exposure. the frequency of these aberrations has been shown to increase in patients who have had radiation synovectomy using yttrium- /y- / by up to five times compared to baseline levers. -holmium-phytate / -ho/ is a new radiopharmaceutical currently on trial which appears to have less extra-articular leakage than y- compounds. the aim of this study was to indentify any increase in specific chromosome-type abnormalities, using published criteria, in patients following -ho synovectomy of the knee. patients / men, women/ in whom the analyses were performed had a mean age yr range / - yr./ results: there was no increase in scored chromosome-type abnormalities after -ho synovectomy. conclusion: this study further supporth the relative safety of -ho compared to oder radiopharmaceuticals. p -monday, oct. , , : aim: use of rhtsh aided rai therapy for differentiated thyroid cancers has increased over past few years. this study has been done to assess the clinical usefulness of rhtsh aided rai therapy for patients of differentiated thyroid cancers administered rai for either residual remnant ablation (rra) or irresectable and metastatic disease. materials and methods: patients ( females; males) - years (mean age . ); of differentiated carcinoma of thyroid given rhtsh aided rai therapy for either rra or irresectable and metastatic disease from october to february were included in the study. patients had papillary carcinoma while had follicular carcinoma. patients had stage i, stage ii, stage iii while had stage iv disease. patients were given rhtsh aided rai therapy for rra while had either irresectable or metastatic disease. patient's tsh did not rise adequately after surgery or due to functioning metastatic disease while opted for rhtsh aided therapy because of the problems associated with thyroxine withdrawal. rai given ranged from mci( mbq)- mci( mbq); mean dose . mci( . mbq). all the patient's baseline tsh, thyroglobulin (tg) and anti-thyroglobulin (anti-tg) levels were recorded. . mg i/m injections of rhtsh were given at day & and tsh levels recorded hours post injection. rai therapy was given if tsh level was > μiu/ml. all patients underwent whole body scan prior to discharge. patients were followed at months interval on outpatient basis. the mean follow up was . months. if the valid tg levels came down to negligible levels at months complete response (cr) was documented; if tg levels reduced significantly but not negligible, was termed as partial response (pr), if no significant difference noted; stable disease (sd) and if increased progressive disease (pd). results: patients had valid tg levels. the baseline tg levels ranged from . -> ng/ml. the baseline tsh levels ranged from . - . μiu/ml. after the rhtsh injection the tsh levels rose to ( . - . ) after first injection and ( . -> ) after the second injection. all patients are alive; patients had cr, had pr while had sd. patients were too soon to assess at the time of review. the overall response rate was %. conclusion: rhtsh aided rai therapy yields good results with an appreciable response rate, therefore it can be used for effective therapeutic administration of rai for both rra and in cases of irresectable or metastatic disease. detection of ectopic gastric mucosa in meckel´s diverticulum by m tc-pertechnetate disodium scintigraphy in patients with the lower gastrointestinal bleeding, retrospective study j. dolezal; teaching hospital, hradec kralové, czech republic.aim and background: to present our twelve-years experience with the perfusion m tc-pertechnetate disodium scintigraphy of meckel's diverticulum in patients with lower gastrointestinal bleeding. gastric mucosa may be presented in meckel´s diverticulum and associated with the peptic ulcer disease and the lower gastrointestinal (gi) bleeding and the m tc-pertechnetate scintigraphy can help to make diagnosis of ectopic gastric mucosa. material and method: one hundred patients - adults ( males, females, aged - , mean years) and children ( boys, girls, aged - , mean years) underwent m tc-pertechnetate scintigraphy. all patients had melaena or hematochezia with anaemia. the morphology imaging and the endoscopy were negative in all patients. the dynamic scintigraphy of the abdomen was started immediately after i.v. administration of mtc-pertechnetate. the static image of the abdomen was done after it. as necessary the spect was added to improve sensitivity, specificity and better spatial specification. results: four patients (two boys -two-and ten-years-old, one girl -four-years-old and -years-old male) had positive scintigraphy. all patients underwent surgery and meckel diverticulum with ectopic gastric mucosa (by histology) was detected. gi bleeding stopped spontaneously in patients with negative scintigraphy. these patients did not undergo intra-operative enteroscopy or surgery. conclusion: m tc-pertechnetate scintigraphy can help to detect ectopic gastric mucosa in the abdomen and improve a management of patients with lower gastrointestinal bleeding. aim: rapid detection and localization of the bleeding sites are important factors for the clinical management of patients with active hemorrhage. the aim of this study was to assess the accuracy of technetium- m (tc- m) labeled red blood cell (rbc) scintigraphy in patients with suspected gastrointestinal bleeding. material and methods: between december and august , we selected patients ( women and men, age range - years) with clinical suspect of gastrointestinal bleeding consecutively referred for tc- m rbc scintigraphy. the results of tc- m rbc scintigraphy were compared with those of oesophagus gastro duodenoscopy and angiography. results: tc- m rbc scintigraphy was positive for active gastrointestinal bleeding in ( %) patients and negative in ( %) patients. gastrointestinal bleeding was confirmed by other procedures in of the patients ( % true positive rate) with positive rbc scintigraphy (by oesophagus gastro duodenoscopy in patients and by angiography in patients). in ( %) of the true positive patients, rbc scintigraphy demonstrated active bleeding already in the early (within min) phase of the study. in the remaining patients ( %), rbc scintigraphy resulted positive only after delayed (between - hours) acquisition. therefore, the acquisition of delayed images increased the sensitivity of the method. in of patients with positive rbc scintigraphy, gastrointestinal bleeding was not confirmed by other procedures ( % false positive rate). among the patients with negative rbc scintigraphy, the lack of gastrointestinal bleeding was confirmed by oesophagus gastro duodenoscopy and/or angiography in patients ( % true negative rate). among the remaining patients with negative rbc scintigraphy, patients had gastrointestinal bleeding by oesophagus gastro duodenoscopy and by angiography. rbc scintigraphy had a sensitivity of %, specificity of %, positive and negative predictive values of % and %, respectively. conclusion: tc- m rbc scintigraphy is a useful and safe non-invasive test for the diagnosis and the management of patients with suspected gastrointestinal bleeding. in particular, the possibility to re-image patients over an extended period is helpful in identifying intermittent bleeding sites. radionuclide assessment of gastric emptying in relapsing-remitting multiple sclerosis b. g. chaushev, a. klisarova, p. bochev, n. deleva, b. ivanov; mbal st.marina -varna,bulgaria, varna, bulgaria. aim assessment of gastric motility disorderders in relapsing-remitting multiple sclerosis (ms) using dynamic scintigraphy of gastric emptying by mtc. material and method evolution of gastric emptying was performed in patients with ms ( males and females), aged , ± , years, with , ± , years of disease duration. the diagnosis ms was defined according to mcdonald's criteria. the clinical impairment was rated according to the expanded disability rating scale (edss). none of the patients have subjective complaints, suggestive of gastroparesis. at the time of the study all patients were in remission and free of corticosteroid treatment. dynamic gastroscintigraphy was carried out in the morning after evening fast, with - hours abstention of tobacco, drinks and medication influencing gastric motility function. the patients was took breakfast consisting of semi-solid food, labeled with mci / mbq / tc- m sc. parameters of the protocol included frames. the first image was achieved at minute and the next ones were achieved after minutes interval during two hours or until stomach evacuation goes above %. the time needed for semi-emptying of stomach was determined from all received images. we were drawing region of interest, which includes the whole stomach from all projections. time-activity curve that represents the movement of radioactivity in region of interest was generated and half emptying time was calculated (with up to minute's normal range). results our results demonstrate delayed gastric emptying in more than half of the patients ( %) with values ranging from , % to , %. we found gastric motility disorders in patients with more pronounced functional deficit, as assessed by edss. sex, age and disease duration have not a significant impact on gastric emptying. conclusion autonomic dysfunction is an integral part of the pathological process in ms with involvement of almost all somatic systems. dynamic scintigraphy of the gastric emptying in ms provides possibilities to evaluate the gastric motility. the evacuatory disturbances are an essential factor, impacting on the health status and on the quality of life. they appear even in patients without subjective complaints and with relatively mild neurological deficit. key words: multiple sclerosis, gastric emptying, dynamic scintigraphy introduction: tc- m mibi which is widely used in nuclear cardiology, is excreted via the hepatobiliary system thus enabling to make comments concerning this system of elimination. the nonalcoholic fatty liver disease (nafld) which is associated with mitochondrial dysfunction and has the potential to progress to cirrhosis has recently been drawing attention with its increased incidence due to predisposing factors such as obesity and diabetes (dm) . aim: in this retrospective study, mibi findings in normal and obese patients (pts) groups and the influence of accompanying risk factors on these findings were investigated using the rest images of myocardial perfusion scintigraphy (mps). method: regions of interest (rois) of the liver (l) and right lung (rl) were drawn in the anterior projection using the rest mps images of the pts referred to our department for coronary artery disease (cad) work up. the liver index (l/rl) was calculated using the ratios of average counts obtained from the related rois. the body mass index (bmi) was calculated with the help of the medical records at the time of the mps. the presence of dm and hyperlipidemia (hl) was investigated from the pts' medical records and history. the pts who had a known liver and/or lung disease, those who smoked or drank alcohol, with a low lvef or perfusion defects on rest mps images were excluded from the study. finding: the data of a total pts ( females, males, average age: , ± years, height: . ± . m, weight: , ± kg) were analysed. no significant change was observed in the l index with respect to an increase in bmi in the overall assessment of the study group (r: . , p: . ). the cases with bmi> and dm (n: , l index . ± . ) showed a significant degree of decrease in their l index (p: . ); while in the cases with bmi> and had only hl (n: , l index: . ± . ) a significant change was not detected (p: . ). conclusion: in the study group the liver uptake ratio of mibi was significantly decreased in the presence of both obesity and dm as compared to normal individuals. however, similar findings were not observed in the presence of only obesity or obesity and hl. although histopathological verification is a must, these findings suggest hepatocyte dysfunction in pts with nafld who has similar pts characteristics. the present findings need to be confirmed in prospective studies that enable kinetic analysis of hepatic function with simultaneous histopathologic analysis. p -monday, oct. , , : pm - the aim of this work has been to evaluate the results obtained by radioguided parathyroid surgery in patients diagnosed of primary hyperparathyroidism due to parathyroid adenoma (pa). methods. inclusion criteria: patients diagnosed of primary hyperparathyroidism, a previous positive mtc-mibi scan (including spect or spect/ct), pathological diagnosis and clinical/biochemical follow-up > months.according with these criteria we have included in our study patients. radioguided parathyroidectomy was performed between february and july . the day of surgery, a low dose ( - mbq) of mtc-mibi was injected and a planar scan was performed in order to draw a cutaneous mark in the localization of the pa. the interval between tracer injection and surgery was determined on the basis of the previous scan, ranged between m. and h. on surgical theatre an intraoperative hand-held gamma probe was used. in all cases we determined intraoperatively pth levels and performed a pathological diagnosis. a radioguided removal of the pa, reduction of intraoperative pth levels > % and a pathological diagnosis of pa were used as criterions for successful excision of the abnormal gland. results. in patients ( %) radioguided removal of the pa was achieved. in patients the pa was eutopic ( double adenoma) and in ectopic. scintigraphic localization of the pa was concordant with surgical localization in patients, in two was nonconcordant ( eutopic adenoma), and in the pa was non detected on surgery. radioguided surgical technique was minimally invasive in patients, unilateral or bilateral cervicotomy in ( previous cervical surgery, nodular goiter, double adenoma, four glands revision and non surgical detection) and sternotomy in (ectopic mediastinal adenoma). biochemical follow-up revealed normocalcemia in patients and persistent hyperparathyroidism in ( %). conclusions. radioguided parathyroid surgery is a safe and effective method in the surgical treatment of primary hyperparathyroidism due to pa. we achieved a % of surgical detection with a % rate of hyperparathyroidism persistence/recurrence. aim: although total thyroidectomy is accepted to be the main component of the therapy in differentiated thyroid carcinoma (dtc), completion thyroidectomy (ct) is a controversial issue due to its morbidity potential. the aim of this study is to evaluate the efficacy of ct with the aid of gamma probe, using i- . materials and methods: patients ( female, male; mean age: , range: - ) who had undergone ct, between april -january , with the help of gamma probe, after labelling with i- were enrolled in this study. the patients have undergone the primary operation with the diagnosis of either benign multinodular or solitary nodular goitre, and dtc was diagnosed in the operation specimen. the patients, while not under thyroid hormone replacement therapy in the th week or later after the operation and with tsh< mu/l, remnant thyroid tissue grams and/or suspicious malignant findings in the remnant tissue due to ultrasonographic examination, were evaluated by the council of thyroideal diseases of our hospital, and ct was decided. . - . mci. i- was given orally to the patients - hours prior to surgery, and thyroid scintigraphy were obtained on the operation day. ct were performed with the guidence of gamma probe. patients underwent bilateral, and unilateral remnant thyroid tissue resection. results: preoperative mean remnant thyroid tissue mass was measured ultrasonographically to be , ± , grams. intraoperative mean ratio of thyroid activity to background activity(t/bg) was detected to be , ± , and the mean ratio of thyroid bed activity to background activity after the excision (tb/bg), , ± , . (p< . ). mean operative time was ± minutes. tsh levels were > mu/l in all patients after the th week and no remnant thyroid tissue was detected in patients either by ultrasonography or scintigraphy. while the mean tsh level of the patients was , ± , mu/l preoperatively, it was , ± , mu/l postoperatively (p< . ). malignancy in the remnant tissue was detected in ( , %) patients. ( , %) patients had transient hypoparathyroidism and ( , %) had transient recurrent laryngeal nerve palsy postoperatively. none of the patients had persistent hypoparathyroidism and recurrent laryngeal nerve palsy.conclusion: in patients with dtc who had undergone subtotal thyroidectomy or lobectomy in the primary operation, ct with the guidence of gamma probe after labelling with i- , is a safe procedure with minimal complications. i- adam spet in athyreotic patients with and without suppressive thyroxine therapy. aim: to evaluate the added diagnostic value of spect imaging over planar imaging of parathyroid scintigraphy performed in primary and secondary hyperparathyroid (hpt) patients. materials and methods: patients with primary hpt (no. ) or secondary hpt (no. ) underwent pararathyroid localising imaging in our centre, and then were operated on by the same surgical equipe. parathyroid scintigraphy consistsed of a double-tracer m tc-pertecnetate ( mbq)/ m tc-sestamibi ( mbq) subtraction scintigraphy plus perchlorate per os ( mg) accordingly to rubello's protocol (ejnmmi, ; ( ) : - ); spect imaging was obtained immediately after planar imaging using the following parameters: acquisistion, elliptical orbit, x steps, sec./step, x matrix, processing, filtered back projection and butterworth filter using different cut-off levels and order calues depending on the location, depth and uptake of the parathyroid enlargement. high resolution - mhz -ultrasonography (us) was also routinely associated. results: sensitivity in localising parathyroid enlargements using double-tracer subtraction scintigraphy, spect alone, and us were: %, %, and % in primary hpt, and %, %, and % in secondary hpt. interestingly, combining double-tracer scintigraphy and spect information sensitivity rose up to % in primary hpt (instead, in this series, us did not improve sensitivity, even if allowed a better location of the parathyroid enlargement in some cases). on the other hand, us allowed a mild increase of sensitivity in patients with secondary hpt. this was related to the fac that us was able to detect some very small parathyroid enlargements which were not seen at scintigraphy. however, it has to be underlined that us gave % false positive results in comparison to % of scintigraphy, especially in secondary hpt patients. conclusions: on the basis of our data, it seems reasonable to argue that the combination of planar double-tracer subtraction scintigraphy and spect is an optimal pre-operative localising procedure in primary hpt patients. conversely, in secondary hpt patients, neither scintigraphy nor us showed a very high accuracy: a combination of all these methods in secondary hpt could be recommended. tc- m radio-guided completion thyroidectomy in patients with differentiated thyroid carcinoma aim: completion thyroidectomy (ct) is crucial in patients with differentiated thyroid carcinoma (dtc) who had either subtotal thyroidectomy or lobectomy as the initial operation. whether ct is associated with an increased complication risk is controversial. the aim of this study is to evaluate the efficacy of tc- m radio-guided surgery with gamma probe in performing ct. materials-methods: patients with the histopathological diagnosis of dtc after the initial operation, with the tumor diameter cm, tsh < mu/l, remnant tissue > g. in ultrasonographic examination and/or suspicious malignant foci in the remnant thyroid tissue, and undergone ct with the aid of gamma probe using tc- m were enrolled in this study retrospectively. on the operation day, - mci, . ml tc- m pertecnetate was injected through the forearm minutes prior to the incision, and bilateral remnant tissue resection was performed with the guidence of gamma probe. results: intraoperative mean ratio of thyroid activity to background activity(t/bg) was detected to be . ± . and the mean ratio of thyroid bed activity to background activity after the excision (tb/bg), . ± . . (p< . ). mean operation time was ± minutes. tsh levels of all patients one month after the surgery were > mu/l and no remnant thyroid tissue was detected either by ultrasonography or thyroid scintigraphy, except in two patients. preoperative mean tsh level of the patients was . ± . mu/l, while it was ± . mu/l postoperatively, (p< . ). malignancy in the remnant tissue was detected in ( . %) of the patients. transient hypoparathyroidism occured in ( . %) patient postoperatively. persistent hypoparathyroidism or recurrent laryngeal nerve damage occured in none of the patients. conclusion: in patients with dtc who had undergone subtotal thyroidectomy or lobectomy in the primary operation,tc- m radio-guided ct is a safe procedure with minimal complications. the diagnostic value of tc- m mibi gated myocard perfusion spect in detection of silent myocardial ischemia in asymptomatic patients with type ii diabetes mellitus aim: in this study, we aimed to evaluate the diagnostic value of tc- m mibi gated myocard perfusion spect (mps) in the detection of coronary artery disease (cad) and silent myocardial ischemia (smi) in the patients with asymptomatic type- diabetes mellitus (dm). material and methods: for this purpose, patients with type- dm and volunteers without any cardiac symptom as a control group were included in this study. exercise tolerance test (ett), echocardiography and tc- m mibi gated mps were performed to the patients and volunteers. computed tomography coronary angiography (ctca) was performed in the patients with coronary ischemia or infarct detected in tc- m mibi gated mps. biochemical analyses lipid profile of the patients and the volunteers were evaluated for the risk of cad. the results were analyzed and compared visually and statistically. results: the data of the present study revealed that silent myocardial ischemia was found at a high rate ( . %, n= ) in patients with type- dm. severe cad in ctca was detected in four of nine patients with ischemia or infarct in tc- m mibi gated mps ( . %). left ventricular diastolic dysfunction in echocardiography, ischemic pattern in ett and high risk of cad according to biochemical analysis were detected in the same four patients. at the end of statistical evaluation, we found that tc- m mibi gated mps showed significant correlations with ctca, echocardiography, ett, hba c, risk of cad and diabetic age in diabetic patients with cad. conclusion: in conclusion, we propose that tc- m mibi gated mps is a reliable and non-invasive method, which can be used to detect silent myocardial ischemia and cad in the patients with type- dm. were subjected to pet studies. all patients were treated previously with total thyroidectomy and i treatment. the routine protocol during the follow-up included i whole-body scan (wbs). thyroxin treatment was withdrawn (four weeks) and patients were on an iodine-free diet before wbs. tg, anti-tg antibodies, ft , ft and tsh were determined. patients with negative wbs and elevated tg or with suspicion of recurrence were subjected one week later to a pet study. pet findings were verified by pathology report or other imaging techniques (ct, mri, ultrasound) . results: at the time of the pet study, mean thyroglobulin values were ng/ml ( - ng/ml). in three cases, the value was < ng/ml but there was suspicion of recurrence based on clinical examination. tsh values were always > μui/ml and antithyroglobulin antibodies were negative. pet detected disease in / studies ( %), localized as follows: cervical lymph nodes, mediastinal lymph nodes, one lung metastasis and one bone metastasis. pet findings were verified by ct scan in cases and by ultrasound and mri in cases. in all cases, presence of disease was confirmed by postoperative pathology report. pet was negative in studies; four patients remained disease-free in the follow-up, and lymphatic metastasis was confirmed intra-operatively in one patient. conclusion fdg-pet localized the metastasis in / ( %) of the studies performed in patients of dtc variants with poor prognosis (tall cell or hürthle cell carcinoma), modifying the subsequent therapeutic approach to these patients. the role of mtc-pertechnetate thyroid scintigraphy in hyperthyroid hcv positive patients treated with interferon (ifn ) background: the occurrence of thyrotoxycosis in the course of therapy with ifn for hcv related chronic hepatitis is well known. however, a differential diagnosis between painless thyroiditis and graves disease is needed to provide a proper clinical management of patients with thyroid disfunction and liver disease. aim: to determine the value of pertechnetate uptake in the thyroid gland of patients with low tsh serum levels found in the course of treatment with ifn or within one months from drug withdrawal. patients and methods: thyroid scintigraphies of patients ( f; mean age yrs) treated with ifn and with low tsh values (mean tsh serum value: . ± . mu/l; normal range: . - . mu/l) were retrospectively evaluated. thyroid images were obtained at minutes after intravenous injection of mbq of m tc-pertechnetate and the tracer uptake value was calculated as percentage of injected activity (normal range: . - %). results: pertechnetate uptake values were out of normal range in / patients; of them had a low uptake value (a) and had an uptake over the normal upper limit (b). a normal uptake value was seen in the remaining patients (c) whose circulating hormone levels were into a normal range (see table) . discussion and conclusion: although hypothyroidism is considered the most frequent thyroid disease in the course of ifn therapy, the differential diagnosis of different forms of thyrotoxicosis has an important role in the clinical decision the aim of this study was to compare the effectiveness of fixed and calculated dose i- treatment efficiency in patients with graves disease. materials and methods: we retrospectively analysed patients with graves disease who treated with radioiodine in a manner of calculated or fixed dose approach between the years of - . study group consisted of male and female patients (range: - , mean age: ± , years old). mean follow-up interval was ± months. twenty four patients excluded from the study due to failure in follow-up. one hundred and fifteen patients received single dose i- . sixteen of these patients received i- via calculated dose and fixed dose approach. mean doses for both groups were as follows: ± . mci for calculated dose group (range - mci); ± . mci for fixed dose group (range - mci). the criteria for successful therapy was defined as euthyroidism or hypothyroidism after radioiodine therapy and, the existence of hyperthyroidism six months after therapy was considered as unsuccessful therapy. results: for patients who recieved calculated doses success ratio was % [hipothyroid (% ), euthyroid (% )] after treatment. success ratio was % [hipothyroid (% ), euthyroid (% )] for patients who recieved fixed doses. hipothyroidism occured - months (mean: ± , ) after treatment. patients recieved second doses and success ratio in this group was % [(hipothyroid (% ), euthyroid (% )]. one patient whose thyroid volume was g, recieved third dose and after total mci rai- finally patient was euthyroid. although the difference in success ratios and frequency of hipothyroidism weren't statistically significant, success rates and frequency of hypothyroidism was higer in fixed dose group. this statistical problem may be related to small number of patients in calculated dose group. low success ratio in the calculated group can be a consequence of low dose/gr factor ( mikrocurie per gram). conclusion: our results were in agreement with literature with respect to success rate and frequency of hipothyroidism in graves' disease with fixed dose of radioiodine. success rates can be improven by using higher dose/gr factors in calculated group. aim: i-mibg scintigraphy is shown to be useful in imaging of neuroendocrine tumours. a technique of in-house iodination of mibg, developed in our department in was found to be very cost-effective. our experience in i-mibg scintigraphy with the tracer prepared in-house was analyzed. materials and methods: records of i-mibg scintigraphy, carried out in our department between and were reviewed. results: a total of studies were performed during this period. there was a significant increase in the number of scintigraphy studies in the latter half of this period - during to , and during to . the clinical indications were pheochromocytoma and paragangliomas ( cases), carcinoid tumours ( ), neuroblastoma ( ), medullary thyroid carcinoma ( ) and others ( ), with more of neuroendocrine tumours in the latter half of study period. evaluation of aim: hiv patients receiving haart may develop body fat changes and low mineral density (bd), but whether these conditions are related is unclear. we further investigated whether a relationship exists between osteopenia/osteoporosis and lipodystrophy (ld)/lipoatrophy (la) in hiv patients on haart. methods: sixtyfive male patients, aged to yrs, with hiv infection haart (treatment duration: . ± . mths) were consecutively studied; all cases had normal bmi (range: to ); patients had ld, la while had no fat changes (nfc). there was no percentage difference between the groups in hiv infection and haart duration and in cdc stage, while the percentage of ld which included protease inhibitors (pi) in their haart regimen was significantly higher than both la and nfc patients. in all cases we measured by dexa (hologic qdr - a) bd (g/cm ) in lumbar spine, with t-score calculation according who criteria, and fat mass (fm; g) both in trunk (t) and appendicular (a) regions with t/a ratio calculation. results: globally, / ( . %) patients had low bd values, with osteoporosis in ( . %) cases and osteopenia in ( . %); the frequency of osteoporosis was higher in ld patients ( %), than in la ( %) and nfc ( . %), but with significant (p< . ) difference only between ld and nfc. bd was lower in ld than in la and nfc, but not significantly. t-fm was significantly (p< . ) higher in ld than in la and nfc, and a-fm was significantly lower in la than in ld (p< . ) and nfc (p< . ) with no difference between the latter two. t/a was significantly higher in ld ( . ± . ) than in la ( . ± . ) and nfc ( . ± . ) as well as it was in la than in nfc. t-fm correlated negatively with bd and t/a positively with pi therapy duration. conclusion: bone mass loss, even osteoporosis, may occur in hiv patients on haart with significantly higher frequency in pi treated patients who had lipodystrophy with t fat accumulation, in our cases. an inverse correlation seems to exist between t-fm and bd in haart patients, but it is unclear whether the pathogenetic mechanism leading to t fat accumulation and bone mass loss is common. aim: body fat changes are common in hiv infected patients receiving haart, mainly if protease inhibitors (pi) are present in their regimen, but the pathogenetic mechanism is still unclear. we evaluated quantitatively body fat composition in hiv patients treated with haart to ascertain both fat loss and fat distribution changes in order to identify possible therapeutic and host related associated risk factors. methods: we enrolled hiv patients receiving haart, m and f; according cdc stage, patients were stage a, stage b and stage c. at clinical examination, fat changes were present in / patients (fc) and absent in the remaining / cases (nfc). in all patients we measured by dexa (hologic qdr - a) fat mass (fm; g) in whole body (w), trunk (t), peripheral regions (p), arms (a), legs (l) and calculated t/p ratio and total weight (tw). we also measured bmi, cd counts and hiv rna and determined cd count nadir and rise from nadir and haart duration, including pi, nrti and nnrti. results: we found significantly lower values of wfm (p< . ), pfm and lfm (p< . ) in fc than in nfc; afm was also lower in fc, but not significantly. moreover, tfm and t/p were higher in fc than in nfc, but significantly (p< . ) only for t/p. no significant difference was ascertained in tw, bmi and in cdc stage between the groups of patients. fc patients had significantly (p< . ) longer haart duration in respect of nfc ( . ± . vs . ± . mths), in particular pi and nrti duration; significantly higher current cd count (p< . ) and cd rise from nadir (p< . ) were also ascertained in fc than in fnc, while nadir showed no difference. wfm, pfm and lfm negatively and t/p positively correlated to pi and nrti therapy duration. conclusion: in hiv patients on haart fat loss with distribution changes, mainly involving peripheral regions, may occur, significantly higher in fc and in nfc. the pi and nrti longer exposure and the better immune recovery, both conditions affecting adipocite metabolism, could represent probable risk factors for fat loss in our fc cases, to be considered in haart patient follow up. aim the glomerular filtration rate (gfr) is measured frequently in cancer patient receiving cytostatics, because some of the pharmaceuticals are excreted by filtration in the kidney and some may also be nephrotoxic. the treatment dose of a few specific drugs is adjusted and calculated in relation to gfr and may be discontinued if gfr decreases severely. in denmark, gfr is assessed by plasma clearance of cr-edta ( cr-labelled ethylenediaminetetra-acetic acid), which is a highly reliable method, but indeed also time consuming. due to the frequent need of gfr-estimation it appears relevant to look for a more simple method for estimating gfr. in this study we therefore explored the possibility of replacing cr-edta (gfr) by an estimate (egfr) from plasma creatinine, sex and age of the patients according to . material and methods cancer patients having a least four cr-edta measurements performed in were included in the study. information concerning gender, age, weight, diagnosis, chemotherapy, plasma creatinine and gfr were obtained from the files and egfr was calculated using the cockroft-gault formula. results in , patients ( women and men) were subjects to at least four gfr measurements. mean age was years (range - years) and the diagnostic profiles included: sarcoma ( %), cancer of the bladder ( %), germ cell tumors ( %), cervical cancer ( %), lung cancer ( %), unknown primary ( %) and various ( %). all patients were treated with nephrotoxic chemotherapy such as cisplatin, carboplatin and ifosfamide. on average, gfr decreased continuously from the first to the last measurement: , , and ml/min ( %). egfr, however, first increased and then decreased with no difference between the first and last values: , , and ml/min. as a consequence, the ratio gfr/egfr decreased significantly from . to . . conclusion: in patients receiving nephrotoxic cytostatics gfr and egfr agreeded at the first examination but a % fall in gfr was not detected by the egfr. consequently, plasma clearance of cr-edta can not be replaced by egfr from plasma creatinine and the cockroft-gault formula in these patients if the aim is to calculate the specific dose as accurate as possible in order to monitor the toxicity of the various treatment strategies and to ensure the highest efficacy. [ ] the variation in age, body habitus, glycemia level, duration of uptake period and partial volume effects are important factors that influence the suv level. the purpose of this study was to quantitavely assess the differences of suvbw (suv measurement based on body weight) in normal tissues (blood, hepatic parenchyma, spleen, kidney, bone marrow, muscle, stomach, brain) and to evaluated the degree of correlation with body weight and age. materials and methods consecutive patients having fdg-pet/ct studies were evaluated retrospectively ( m and f mean: ± . y.o. and body weights ranged from to mean: ± ). approximately h after injection of mbq/kg of f-fdg, whole-body ct images were acquired without contrast media. a whole-body emission pet scan was performed with min acquisition per each bed position (pet/ct: discovery ste, ge). roi were placed at the same level with no know abnormality. mean suvbw were compared, and the correlation between fdg uptake and body weight, patient age was assessed by using the pearson correlation coefficient test. results the mean suvbw values for cerebellum, kidney, stomach, liver, bone marrow, spleen, blood and muscle were . ± . , . ± . , . ± . , . ± . , . ± . , . ± . , . ± . and . ± . . body weight correlated well with mean suvbw (blood r = . , p < . ; kidney r = . , p< . ; spleen r = . , p = . ; stomach r = . , p = . ; bone marrow r = . , p = . ; liver r = . , p = . ; muscle r = . , p = . ; cerebellum r = . , p = . ) the suvbw showed no significant and very weak correlation with age ranged from r = - . , p = . (kidney) to r = . , p = . (spleen). discussion although there was a wide variance in the suvbw, it showed a strong significant positive correlation with body weight in blood, kidney, spleen, stomach and bone marrow. the best correlation between glucose consumption and body weight was observed when the suvbw was > . ( blood) with exception of cerebellum. the suv bw showed no significant correlation with age. conclusion suvbw are weight-dependent indice for fdg uptake in tissues. there are however some notable differences between the r correlation coefficient with regard to the selection of normal tissues. aim: to investigate the diagnostic potential of a new semiquantitative sacroiliac index in bone scintigraphy, as a method to distinguish chronic, non-infectious, inflammatory sacroiliac disease (cilbp) from low back pain of mechanical/non-inflammatory origin (mlbp) in young males. patients and methods: we studied a relative homogenous population sample of young males, aged - years, including the age when many sacroiliac diseases emerge. of these people, (group a) had cilbp, verified by clinicolaboratory and other imaging procedures, (group b) had mlbp similarly verified, and the rest (group c) had been scintiscanned for reasons irrelevant to sacrospinal disease. all of them were also subgrouped by age criteria. after planar static bone scanning, two rectangular and symmetrical regions of interest (rois) were drawn onto the bottom third of the sacroiliacs, as well as a third one which encompassed the whole l vertebra. finally a non-dimensional numerical value called "r" was created for all patients, by the equation r = total counts/total pixels of the "hottest" of the two sacroiliac rois divided by the counts/pixels corresponding to the l values (r = si/l ). results: the statistical analysis showed negative correlation of r with age in all three groups (p= . for group , . for group and . for group c). regardless of age, the mean value of r of group's b patients ( . +/- . ) appeared significantly lower (p= . ) than group's a ( . +/- . ) and unsignificantly higher (p= . ) than group's c ( . +/- . ), while group's a mean value of r also appeared significantly higher than group's c (p< . ). conclusions: the si/l ratio seems to decrease with ageing -at least in the young ages-, irrespectively of the presence of cilbp, and its clinical potential seems to be helpful in the distinction of patients with cilbp from both the normal people and from patients with mlbp. to our knowledge, there is no other study of this semiquantitative index in young male adults with cilbp using the above methodology, but a larger population sample would still be necessary so to accurately standardize the normal value range of si/l ratio. f. marafi, a. syed, a. esmail, a. elgazzar; mubarak al-kabeer hospital, jabriyah, kuwait.aim: post-polio syndrome causes new weakening in muscles previously affected by the polio infection and in muscles that seemingly were unaffected. patients present with musculoskeletal pain, weakness, and fatigue that probably result from overuse and misuse of muscles and joints. the objective of this study is to review patterns of poliomyelitis on bone scintigraphy. material and methods: bone scans of adult patients, five females and one male, aged to years, known to have paralytic poliomyelitis were studied. five patients had unilateral while one has bilateral disease. patients' complains included knee, shoulder, neck and/or back pain. all the patients underwent three-phase bone scan acquired minutes (blood pool) and hours (delayed) post-intravenous injection of mci of tc m mdp. studies were reviewed by two nuclear medicine specialists and findings were recorded. results:the following patterns were recognized: ( ) markedly decreased blood pool activity in all affected limbs particularly distal to the knee (both limbs in the patient with bilateral disease), ( ) deformed ipsilateral hemipelvis with relatively reduced radiotracer uptake in all patients with unilateral disease with minor degree of asymmetry in the patient with bilateral disease, ( ) stress changes in the contralateral lower extremity illustrated by relatively increased radiotracer uptake diffusely in the bones of the lower extremity and ( ) degenerative changes of multiple joints (shoulders, knees, ankle and spine). significant scoliosis was only noted in the patient with bilateral disease. conclusion: bone scintigraphy shows several poliomyelitis related findings predominantly due to skeletal asymmetry with unilateral disease. awareness of the characteristic scintigraphic findings is important to avoid misdiagnosis on bone scan which can help also in the follow up of post poliomyelitis changes. purpose: to examine the observer variation for bone scintigraphy in the detection of occult scaphoid fractures in daily practice, using only the early bone scanning images. methods: one hundred subsequent bone scans of patients with a suspected scaphoid fracture but negative initial radiographs were prospectively included to calculate the inter-and intra-observer variation. three nuclear medicine physicians independently evaluated all bone scans at two different points in time with a three months interval. the observers filled out a blinded scoring sheet for each patient. they scored if a scaphoid fracture was present or not. in addition they scored the presence or absence of another fracture. the inter-and intra-observer variation was analysed using the kappa statistic. results: the inter-observer variation showed substantial agreement for a scaphoid fracture and almost perfect agreement for another fracture. the intraobserver variation showed almost perfect agreement for both a scaphoid fracture and another fracture. conclusions: in the present study early static images of bone scintigraphy for suspected scaphoid fractures showed very little inter-and intraobserver variation. in addition, expertise does not seem to have a negative influence on the results. this enhances the possibility of using bone scintigraphy in daily practice. aim: to determine normal limits for quantitative m tc-hdp three phase bone scintigraphy regarding flow distribution at ankle and mid foot level. materials and methods: consecutive patients referred to bone scintigraphy and without known pathology in the legs or hips were included. patients were eligible, females and males. the population was divided into three groups according to age; less than years (n= ), between and years (n= ) and older than years (n= ). quantitative three-phase bone scintigraphy was performed in all patients. first phase consisted of a dynamic planar uptake in anterior projection immediately after a bolus injection of mbq m tc-hdp with a matrix size of by pixels with a legp collimator, dorsal view, and recording of frames at two frames per second. a processing protocol with standardised size rois was used to quantify flow distribution at ankle level and in the mid foot using the area under the curve for each roi during the first ten seconds of initial bolus passage. results: blood flow distribution at ankle and mid foot level for the three age groups is presented in table . conclusion: we suggest the normal range for distribution of blood flow at ankle level determined by quantitative three phase bone scintigraphy to be / (i.e. mean + sd). since variation in blood flow at ankle and mid foot level increases with age most probably because of uneven development of arteriosclerosis and various joint diseases, normal ranges for blood flow distribution at ankle level is wider among people older than years. at mid foot level the normal range for blood flow is as wide as / . the reference levels presented have been produced with the intention to quantify blood flow distribution at ankle and mid foot level among patients with various pathological conditions in particular charcot foot. aim: the aim of this study was to determine whether there is a difference between the left and the right proximal femur bone mineral densities (bmds) and, therefore, whether it is necessary to measure bmd of the femur bilaterally in determining bone loss. material and methods: this study was performed on subjects ( women, mean age ± years; and men, mean age . ± years). bmds of both hips (femoral neck, trochanter, intertrochanter and ward's area) were measured using dual energy x-ray absorptiometry (dexa) (qdr_ -hologic densitometer). the statistical software spss version for windows (spss, inc, chicago, il) was used for statistical analysis. a paired t-test was used to assess the right versus left (r-l) differences in bmds of the said regions. the results of bmd measurements were expressed in units of grams per square centimeter (g/cm²) as means (m) and standard deviations (sd). the -tailed pearson correlation was used for correlation analyses between r-l bmds. results: the mean femoral neck and trochanter bmds in total subjects were higher in the right leg than the left ( . ± . vs. , ± . , p< . ; and . ± . vs. . ± . , p< . , respectively). similar results were also obtained in females ( . ± . vs. , ± . , p< . ; and . ± . vs. . ± . , p< . , respectively). in males, a significant right versus left bmd difference was found only in femoral neck ( . ± . vs. , ± . , p< . ). there were significant correlations of bmd between all the right and the left femoral regions (p< . ). conclusion: although bmds of the right and the left femoral regions were strongly correlated, there were significant r-l differences of bmd in femoral neck (in males and females) and trochanter (in females). therefore, bilateral femur bmd should be taken into consideration in evaluating a possible bone loss.aim: the purpose of this series of cases was to describe clinical findings and patterns of the triple phase bone scans in young patients with clinical examination suggesting medial tibia stress syndrome (mtss) or "shin splint", term frequently used synonymously with this disorder. material and methods: this study included seven patients ( limbs) selected retrospectively with clinical examination suggesting mtss that underwent plain radiographs and triple phase bone scintigraphy (tpbs) with technetium- methylene diphosphonate dimmer (mdp) during the period from june/ to february/ . patients generally reported diffuse tenderness along the posteromedial edge of the tibia and complained of exercise-induced pain after starting physical activity. results: five patients had bilateral symptoms and two had unilateral pain. mean duration of symptoms was about . weeks. there were male and female. age ranged from to years old (mean value= . ). patients included runners ( military recruits and recreational runners), professional basketball player, recreational soccer player and recreational gymnast. all the patients related exercise-induced pain in the beginning of activity. one recreational runner related an unbearably pain when he continued the activity. radiographs were normal in all patients. perfusion and blood pool images of isotope bone scans were normal in all cases. delayed bone scintigraphy showed characteristic longitudinal linear uptake in limbs ( patients) and focal uptake (longitudinally spindle-shaped uptake) in limbs ( patients). conclusion: in this study, all patients with clinical examination suggesting mtss had scintigraphic abnormalities. most of them had focal uptake (longitudinally spindle-shaped uptake) in the bone scan. it was an unexpected finding once mtss pattern most usually found in other studies is longitudinal diffuse uptake (double stripe sign, tubular pattern or longitudinal linear uptake), more related to bone remodeling. in the current study, most patients were recreational athletes. this fact suggests that many of these problems result from poor or misguided training regimens. bone scintigraphy was an important tool to confirm the clinical diagnosis of mtss and exclude other causes of lower leg pain such as stress fracture, nerve compression syndrome and extertional compartment syndrome. accurate diagnosis is essential in early phase after the onset of pain to establish specific treatment and ensure return to sports activity. transiet osteoporosis of the hip (toh) is an uncommon condition. it presents with progressively worsening hip pain gradually increasing without history of trauma. there is a characteristic discrepancy between substantial clinical disability and minimal physical findings. this condition is characterized by a predictable bening course, with complete clinical recovery. unlike toh, avascular necrosis (avn) is a introduction-aim: early diagnosis of osteomyelitis (om) in the diabetic foot reduces the need for amputation, but detection is difficult. coexisting disorders such as soft tissue infection and charcot arthropathy (ca) may obscure the clinical and radiological manifestations of om and bone biopsy is not routinely performed. the aim of this prospective study was to evaluate the efficacy of tc m-hmpao-labelled leucocyte scan (hmpao-ls) for the diagnosis of om in the complicated diabetic foot, in comparison with other commonly used diagnostic modalities. patients and methods: forty five diabetic patients with clinical suspicion of om in pedal sites were enrolled in the study. all patients had pre-existing pedal abnormalities including pedal ulcers (n= ), ca (n= ), and toe or foot amputation (n= ). c-reactive protein levels (crp), esr and white blood cell count (wbc) were measured at inclusion. all patients underwent plain radiography, three-phase tc m-mdp-bone scan (mdp) and hmpao-ls. tc- m-sulfur colloid bone marrow scan (bms) was additionally performed in patients to interpret abnormal leucocyte uptake in ca. spatially congruent bone/leucocyte findings were interpreted as positive for om. incongruent hmpao-ls /bms indicated om superimposed on ca. diagnosis was confirmed by long-term clinical and radiological follow-up or bone biopsy. results: among the pedal sites investigated, foci of om, cases with acute charcot arthropathy (aca) and sites with simple soft tissue infection (sti) were diagnosed. patients with om had higher crp compared with those with aca or sti ( . vs . and . mg/l , p< , ). wbc and esr were not significantly different among the three groups of patients. plain radiography was insensitive ( . %), but very specific ( . %) while three-phase bone scan was extremely sensitive ( %), but not specific ( . %) for the diagnosis of diabetic foot om. the sensitivity, specificity and accuracy of hmpao-ls were %, % and . %, improved to %, % and . % respectively with the addition of bms. conclusion:among laboratory tests, elevated crp is better marker of om in the diabetic foot compared with leucocytocis or elevated esr. plain radiography is the least sensitive imaging method for early diagnosis of om and bone scan is the least specific method for detecting om in patients with pre-existing pedal abnormalities. tc m-hmpao-labelled leucocyte scan is the most accurate radionuclide method for the diagnosis of om in the diabetic foot. the addition of bone marrow scan improves the specificity of leucocyte scan for diagnosing om superimposed on ca. aim: in the large-vessel vasculitis, in particular takayasu arteritis (ta), clinical signs and laboratory tests are not good markers for evaluating the vascular disease activity. aim of this study is to evaluate if fdg-pet can have a role in assessing the inflammatory activity and the extent of the disease in patients (pts) with ta by a correlation between f-fdg uptake, acute-phase reactants and the clinical outcome. material and methods: we studied consecutive pts with large-vessel vasculitis in steroid treatment (m/f / ; age ± yrs; ta and giant cell arteritis). a total number of pet studies was acquired. fdg uptake was evaluated using a visual score ( - - - ), in different vascular areas and a total vascular score was calculated.pet was performed at the same time of the evaluation of acute-phase reactants [erythrocyte sedimentation rate (esr), c-reactive protein (crp) and interleukin- (il- )] and assessment of disease activity according to the kerr criteria. results: the frequency of elevated esr was higher (p . ) in presence of vascular fdg uptake ( %) than in absence of uptake ( %). esr was higher (p . ) in pts with vascular fdg uptake ( ± ) than in pts with no uptake ( ± ). the pet score was significantly (p . ) higher in pts with high esr ( . ± . ) than in pts with normal hsr ( . ± . ). the correlation of pet score was significant with ers (r=+ . p . ) and il- (r=+ . p . ) and not with crp (r=+ . ns). the pet score was significantly higher (p . ) in pts with active disease ( . ± . ) than in pts with inactive disease ( , colon carcinoma= , kaposi sarcoma= , lung tumors= , anal carcinoma= , myeloma= , cervical carcinoma= , hcc= , brain tumor= ) underwent fdg pet/ct studies to identify areas of hiv replication and/or tumor increase. all hiv-positive patients had a combined pet and ct body scan (discovery ls pet ct, ge healthcare, milwaukee, wi, usa) from the base of the skull to the pelvis with [ f]fluorodeoxyglucose (fdg) and patients also had brain studies with fdg. fdg accumulations (visual and quantitative) were rated, on a per patient basis, as true positive(tp) or true negative(tn), and false positive(fp) or false negative(fn), based on final clinical data. results: / ( %) hiv-positive patients had proven malignancies (nhl= , hl= , lung cancer= , anal cancer= , brain tumor= , hcc= ) in cytology/histology and conventional diagnostic imaging procedures (ct, mri, abdominal us, thorax x-ray). in this context, overall sensitivity (tp/tp+fn), specificity (tn/tn+fp) and accuracy (tp+tn/tp+tn+fp+fn) of pet/ct scanning with fdg was: %, %, % respectively for diagnosis of nhl diseases; %, %, % respectively for diagnosis of hl and %, % and % respectively for diagnosis of other neoplastic diseases. moreover, nodal fdg uptake showing active hiv replication areas was well identified in / hiv-positive subjects, and lung infections were correctly diagnosed in six more hiv-positive cases. the standardized uptake values (suvmax) over nodal lesions from lymphoma (nhl plus hl) were in the range of . - and in active hiv replication were in the range of . - . . conclusion: in our patient series, fdg pet/ct scan misjudged in the separation of malignancy from infection in some cases. however, pet/ct provided accurate localization of malignant and infective disease allowing biopsy of specific sites. even if abnormal fdg uptake occurs in subjects' nodes with detectable viral load, evaluating active lymphoid tissues during hiv infection from malignant lymphomas was possible. the effect of recent hemodialysis on invivo labeled m tc wbc lung retention in patients with end stage renal disease (esrd)aim: several clinical studies are evaluating the therapeutic potential of delivery of various progenitor cells (pcs) for treatment of injured hearts. the only noninvasive in vivo imaging method for evaluation of homing of transplanted haematopoietic pcs (hpcs) used so far was labelling the cells with in-oxine. the aim of our study was to evaluate radiolabelling of cd + haematopoietic pcs with mtc-exametazime and to examine use of radiolabelled cells to monitor myocardial homing. materials and methods: human hpcs were mobilized with granulocyte-colony stimulating factor and collected by aphaeresis. cd + cells were enriched with an immunomagnetic separation device (isolex i). amount of collected cd + cells per patient varied between to million. a fraction of of the cells ( - %) was radiolabelled with mbq of mtc-exsametazime and incubated for min at room temperature. to remove unbound radioactivity, the cells were washed with cell free media. cell viability was assessed by trypan blue exclusion assay before radiolabelling and and min after labelling. labelling stability of hpcs was assessed min after cell labelling. - mbq of radiolabelled cells was injected into open coronary vessel through a micro catheter. spect images were obtained and hours after hpc injection. results: labelling efficiency of hpcs was up to . % depending on the amount of cells available for radiolabelling. according to trypan-blue staining, viability of radiolabelled hpcs before and immediately after the labelling was . % and . % respectively, whereas viability min after labelling was %. labelling stability of hpcs min after cell labelling was . %. spect images obtained and hours after hpcs injection enabled us to evaluate the arrangement and percentage of transplanted hpcs accumulated in the heart muscle. additionally it was possible to evaluate their migration and accumulation in the reticuloendothelial system of the liver, spleen and bone marrow. conclusion: we can conclude that mtcexametazime labelling of hpcs is feasible, and in vivo imaging with spect provides a non-invasive method for sequentially monitoring cell trafficking with good spatial resolution. red cell mass, plasma volume, blood volume and their deviations from expected normal values in patients with end stage chronic renal disease. results: pvk was correlated (r : . p< . ) with pcv and bmi in all patients especially in men (r : . ). rcvk in all patients was also strongly correlated (r : . p< . ) with pcv and bmi. rcvk in men is affected only by bmi (r : . p< . ), while in females both pcv and bmi's influence reach statistical significance. in general, drcv and dpv are strongly related to bmi and pcv (r : . and . respectively). in men pcv and w predict drcv and dpv (r : . and . respectively) whereas in female subjects only drcv is strongly correlated (r : . p< . ) with pcv and w. serum fe seems to have a predictive role in drcv and dpv estimation. no other significant correlation among biochemical parameters (urea, creatinine, pth), total duration of dialysis and blood volumes was found. conclusion: not only radionuclide measurement of blood volumes but their promt estimation as well from the above equations has an important role in decision making in patients at esrd providing a applicable estimation of their anaemia. aim: to assess the contribution of an integrated spect-ct (infinia-hawekeye , ge healthcare) in patients undergoing m tc-radiolabelled blood cell imaging. material and methods: consecutive patients underwent m tc-radiolabelled blood cells imaging. among them, patients had m tc-red blood cell imaging (rbc) for suspicion of liver or spleen hemangiomas (n= ), and for suspicion of splenosis (n= ); additionally, patients had m tc-hmpao-white blood cell imaging (wbc) for detection of active crohn's disease (n= ), and for suspicion of infection (n= ). following the routine protocol, a low-dose unenhanced spect-ct study ( . ma, kv, eff.d msv) was performed. spect-ct findings were compared to planar and spect results. final reports were correlated to morphological imaging, clinical and surgical reports. results: in the rbc group, / patients had a positive study suggestive of liver or spleen hemangiomas (n= ) and splenosis (n= ). spect-ct was particularly useful for appropriate differentiation between physiological uptakes and pathological uptakes (vessel hot spots vs. liver lesions), as well as for precise anatomic localization of functional splenic remnants. all liver lesions > . cm were assessable on the low-grade ct, but liver or spleen lesions < cm were not always distinctly detected. in some patients, respiratory motion artifacts also impaired the ct quality. in the wbc group, patients had a positive study suggestive of infection on planar imaging. spect-ct was particularly helpful for a more accurate diagnosis of osteomyelitis vs. soft tissue infection (n= ), or for confidently ruling out a liver abscess (n= ). in patients with crohn's disease (cd), spect-ct allowed better anatomic localization of disease extent, and exclusion of intra-luminal bowel activities. in patient, spect-ct helped identify an entero-cutaneous fistula from ileostomy; in patients with active cd, the low-dose ct showed a colon wall thickening with a lumen narrowing matching a hot spot on the spect part. conclusion: in m tc-radiolabelled blood cell imaging, a low-dose multi-slice spect-ct, the infinia-hawkeye - , was found useful for improving the interpretation confidence, and thus, the diagnostic accuracy. aim: behcet's disease (bd) is a multisystem disorder characterized by vasculitis, and consists of a triad of recurrent ulcers of the oral and genital mucosa with relapsing uveitis. the prevalance of pulmonary involvement varies in the range of % - in various studies and its complications are severe and life threatening. we aimed in this study to investigate the changes of pulmonary epithelial permeability of patients with bd using m tc-dtpa aerosol scintigraphy. material and methods: twenty-one non-smoking patients with bd ( females, males; mean age: . ± . years) and healthy voluntary non-smoking controls ( females, males; mean age: . ± . years) underwent m tc-dtpa aerosol inhalation scintigraphy and pulmonary function tests. subjects inhaled mbq of m tc-dtpa for minutes in supine position. scintigraphic data were recorded dynamically ( frame/min) in posterior projection on a x matrix for a min period using with a double headed gamma camera (infinia, ge, tirat hacermel, israel) equipped with a low-energy all purpose parallel hole colimator. half time of m tc-dtpa clearance (t / ) were calculated by placing a mono-exponential fit on the curves. penetration index (pi) was also calculated by dividing the peripheral total counts by the sum of the peripheral and central total counts on the first minute image, in order to quantify the distribution of the inhaled aerosol. results: the clearance half time of m tc-dtpa radioaerosols in bd's patients ( . ± . min) were faster than in normal control group ( . ± . min) (p= . ). there was also a significant difference between pi of patients with bd ( . ± . ) and that of controls ( . ± . ) (p= . ). no correlation was found between the mean t / values of m tc-dtpa clearance and the spirometric measurements except fev in bd patients (r= . ; p= . ). pi were correlated with fev in bd patients (r=- . ; p= . ). conclusion: lung epithelial permeability of the patients with bd was found significantly lower than that of normal subjects. the result of this study demonstrated that the assessment of lung epithelial permeability using m tc-dtpa aerosol scintigraphy could predict the presence of lung involvement in patients with bd. . detect of pulmonary emobolism in patients with deep venous thrombosis using m tc -technegas/ m tc-maa lung scan s. l. chen, b. l. li, w. liu, y. gu; institution of nuclear medicine,zhongshan hospital,fudan university, shanghai, china. the existence and severity of pulmonary thromboembolism(pte) was still one of the major clinical concerns. the aim of this study was to assess the use of lung ventilation/perfusion (v/q ) scan in the investigation of pte, and compared the results of lung ventilation/perfusion (v/q ) scan with ct angiography (cta) or mr angiography (mra). methods: a total of patients with deep venous thrombosis (dvt) underwent v/q planar scan and chest x-ray , cta or mra were performed also. the modified prospective investigation of pulmonary embolism diagnosis(pioped) diagnostic criterion was used for interpretation of lung scintigraphy. according to the data of perfusion-ventilation scintigraphy, the patients was consider with a high pretest probability of pulmonary embolism, intermediate probability of pulmonary embolism, low probability of pulmonary embolism, lower clinical probability of pulmonary embolism or normal. the patients with a high pretest probability, intermediate probability and low probability were positive, lower probability and normal patients were negative. results: among the patients, patients with a high clinical probability of pulmonary embolism ( . %) by mtc -technegas/ mtc-maa lung scan, patients with a intermediate clinical probability of pulmonary embolism ( . %), patients with a low clinical probability of pulmonary embolism( . %), patients with a lower clinical probability of pulmonary embolism ( . %), another patients were normal( . %). pulmonary embolism was detected in of the patients ( . percent). compared with the data of lung v/q scan detect and cta or mra examination in the patients with clinical probability of pulmonary embolism, % patients showed different blood vessel abnormality findings between lung v/q scan defect and cta or mra. we found that in patients with partly pulmonary embolism, the blood flood could pass away the stricture artery. so the perfusion scan of the patients maybe was normal, the perfusionventilation scintigraphy couldn't found pathological vascular disease. moreover, when the small pulmonary embolism was in the laterale or outboard segment of the lung, cta or mra maybe mistake diagnosis and the perfusion-ventilation scintigraphy could found pathological vascular disease. conclusions: lung v/q scan was a considerably effective technique to detect pte. the combination of v/q scan and cta (or mra) could provide more comprehensive and accurate diagnosis information. and a larger outcome study is needed. comparison of ventilation-perfusion scintigraphy and contrast enhanced computed tomography in patients with pulmonary embolism k. f. wurm, t. zelesny, u. wacker, a. hentz, f. dammann; department of radiology and nuc. med., göppingen, germany.aim: ventilation-perfusion scintigraphy has been the main imaging modality used in the evaluation of patients with suspected acute pulmonary embolism. since the introduction of multi-slice devices computed tomography has been used as an equivalent imaging method. the aim of our study was to correlate the results of ventilation-perfusion scintigraphy with spiral ct pulmonary angiography. material and methods: we evaluated patients ( women, men, mean age years) with suspected acute pulmonary embolism (symptomatic patients and increased d-dimer blood test). all patients underwent computed tomography and ventilation-perfusion scan. scintigraphic examinations were obtained with two head gamma camera, using tc- m labelled human albumin microspheres. spiral ct scans were performed with the use of radiological contrast and multi-slice device. we compared the results of these three investigations. the sensitivity and specificity were evaluated. results: the ventilation-perfusion scintigraphy presented matching results in of cases. of them presented an identical issue in computed tomography. in of cases we found a mismatch of ventilation-perfusion study. in cases computed tomography could confirm a positive acute lung embolism. the sensitivity and specificity of lung perfusion scan in detecting lung embolism was % and %. computed tomography revealed a sensitivity and specificity of and %. conclusion: the results of ventilation-perfusion scintigraphy confirm a high sensitivity for diagnosis of lung embolism. in correlation computed tomography presented a similar sensitivity with additional specific informations. both modalities shall be accepted further on as an important diagnostic tool for patients with suspected lung embolism. pfeifer, n. millman, j.mortensen; rigshospital, universityhospital of copenhagen, københavn Ø, denmark.a -year old woman, suffering from stridor and dyspnoe was diagnosed with tracheobronchial amyloidosis of transthyretin type (attr). pulmonary involvement in attr is uncommon. according to the patient's symptoms and for prognostic reasons it was important to rule out cardiac amyloidosis as frequently seen in attr. the usefulness of m tc -aprotinine scintigraphy in detecting extra abdominal lesions of amyloidosis and especially early cardiac involvement has previous been shown ( ) . thus, the patient was evaluated with m tc -aprotinine whole body scintigraphy supplemented with single photon emission tomography (spect) and computer tomography of the chest using the vg hawkeye ge hybrid system. there was a close correlation between a) the scintigraphic findings of amyloid deposits in the central airways and b) the wall changes of the right upper bronchus as seen on the low quality ct (hawkeye) and c) the right upper lobe atelectasis shown on chest x-ray. no extra pulmonary amyloid deposits were found. conclusion: m tc -aprotinine scintigraphy with spect/ct detected amyloidosis in the central airways that correlated closely to the clinical and histological findings. reference: ( ) objectives: the purpose of this study was to evaluate the usefulness of tl- chloride/tc- m mibi, for the investigation of lung lesions, after comparison with ct and histological findings. methods: scintigraphy with tl- chloride and tc- m-mibi was performed in patients [ men, aged - years and women aged - years] with radiographic findings lung nodules, suspicious for malignancy. factors of the early and delayed static scans (hot, warm or cold uptake), the early and delayed retention indexes, the blood flow and the tumour retention index were obtained from tl- /tc- m-mibi scintigraphy. tumour retention indexes were classified into three grades; slightly (> . ), moderately ( . - . ) and severely (< . ) decreased. grade of tissue differentiation of tumour (well, moderately or poorly differentiated) and tumour size (t t ) were examined. scintigraphic indexes and tumour characteristics were compared. results: the early static scan and tumour size showed a correlation with the blood flow index. however, the delayed static scan did not show any relationship with blood flow index and tumour size. the tumour retention index with tc- m-mibi had a tendency to decrease in malignant tumours, and showed a significant correlation with the grade of tissue differentiation of the tumour. regarding tl- chloride we obtained a . % sensitivity, % specificity, % accuracy, a . % positive prognostic value and a . % negative prognostic value. conclusions: the tendency of the tumour retention index to decrease in tc- m-mibi scintigraphy might imply the malignancy of the nodule investigated and would be an additional useful parameter for the accuracy of the diagnosis. introduction: in patients with ctd, the early detection of the pulmonary involvement is mandatory. pulmonary function tests (pfts) are considered to be valuable noninvasive diagnostic modalities. among them, carbon monoxide lung diffusion (dlco) reduction that is consistent with pulmonary fibrosis and microvascular damage is widely considered as the earliest and most sensitive index for the evaluation of pulmonary involvement. in previous studies we proposed the usefulness of hig scintigraphy in the evaluation of lung involvement in ctd. the aim of our study was the evaluation of hig lung scintigraphy, in the early detection of the pulmonary involvement in ctd patients. methods: fifty-two non-smoking patients suffering from scleroderma, rheumatoid arthritis or systemic lupus erythematosus (males/females / , mean age . years, mean duration of disease . years) and referred to our institution for detection of possible pulmonary involvement were included in this study. patients were submitted to pfts (dlco, forced vital capacity [fvc] and total lung capacity [tlc]) and hig scintigraphy within a week. for semiquantitative interpretation of hig scintigraphy, a region of interest (roi) analysis was performed on the posterior view (sum of the mean activity for each lung divided by mean left ventricular activity / = average score). the average score was correlated with pfts. pearson's correlation coefficient r was calculated. a probability p< . (two-tailed) was considered to indicate statistical significance. results: pfts abnormalities were detected in patients (dlco reduction in , fvc reduction in and tlc reduction in patients). a statistically significant negative correlation was detected between hig scores and each one of the pfts [dlco (r=- . , p< . ), fvc (r=- . , p= . ) and tlc (r=- . , p= . )]. in patients isolated dlco reduction (normal fvc and tlc) was detected. hig scores were greater in these patients comparing to them with dlco within normal range ( . vs. . , p< . ). discussion and conclusion: dlco reduction was the commonest pulmonary function abnormality in our patients. the isolated dlco reduction might be attributed to pulmonary microvascular damage and increased membrane permeability, which constitutes one of the possible mtc-hig uptake mechanisms. by this pathway, hig lung scintigraphy seems to be useful in the early detection of the pulmonary involvement in ctd patients. aim: the aim of the study is to documentate intraoperative gamma probe applications in neck surgery in our hospital. material and method: between january -march with the guidance of intraoperative gamma probe patients underwent parathyroidectomy, well differentiated thyroid cancer patients; complementary thyroidectomy, medullary thyroid carcinoma patients; recurrent tumor exicion and carcinoid patient; tumor excision. before parathyroidectomy mci of tc m-mibi was injected and during hours static images were obtained every minute in order to detect maximum parathyroid/thyroid uptake. at the operation day according to this optimal timing mci tc m-mibi was injected. for complementary thyroidectomy μci i - was given per orally hours before the surgery and patients were imaged at - th hour following i- injestion. in medullary thyroid carcinoma patients mci of tc -dmsa(v) and in carcinoid patients mci tc m-mibi was injected minutes before the operation. results: in parathyroidectomy patients during operation except , ideal timing for peak parathyroid/thyroid uptake ratio was reached. obtained parathyroid/thyroid ratios were quite variable and changed between; . - . in complementary thyroidectomies thyroid/background ratios were between; - . tumor/background ratio was - . in medullary carcinoma and . in carcinoid. conclusion: optimization of injection time before surgery is very important in radioguided parathyroidectomy. this can be reached with the cooperation of departments of surgery and nuclear medicine. in parathyroidectomies, complementary thyroidectomies and in various tumor excisions beside a guidance potential, gamma probe help surgeons to instantly verify accurate removal of the targeted tissues. graft-versus-host disease (gvhd) is common compication of allogeneic bone marrow transplantation (bmt) in which functional immune cells in the transplanted marrow recognize the recipient as "foreign" and mount an immunologic attack. the chronic form of graft-versus-host disease (cgvhd) is defined as that which occurs after days. chronic gvhd demages liver, skin and mucosa, and the gastrointestinal tract like in acute gvhd (agvhd), but also causes changes to the connective tissue of the skin and exocrine glands. function of salivary glands, as exocrine glands, is very often observed in patients suffering from cgvhd. aim:the aim of this study was to evaluate the function of major salivary glands with dynamic salivary gland scintigraphy (dsgs) in hematologic patients suffering of cgvhd after allogenic bmt. methods: dsgs was performed after iv. injection of mbq tc mpertechnetate, with gamma cammera above parotid (pg), submandibular salivary glands (sg) and oral cavity (oc). dsgs lasted minutes (one frame-one minute), with per os stimulation in . minute with ascorbic acid tablete. time-activity curves (tac) were generated over pg, sg and oc as regions of interest. activity in oc was estimated on static scintigram . minutes after iv. injection.using tac and scintigrams, dsgs findings were graded from to according to shall at all. ( sct grade -normal finding, sct grade -moderate function damage, sct grade serious function damage, sct grade -very serious function damage). dsgs was performed in five patients, seven to ten months after allogenic bmt. two pts. were male and three female, aged from ninetheen to thirty nine years. three patients suffered from acute leucaemia and two from mielodisplastic syndrome. results: three pts. suffered from agvhd and all pts. were diagnosed as having cgvhd in skin, mucosa and liver. four pts. had feeling of dry mouth (xerostomia). all pts. with xerostomia had patological scintigraphic finding: two pts. had sct grade and the other two sct grade . in pts. without xerostomia scintigraphic finding was negative. conclusion: this preliminary results sugests that dsgs, as objective test, can detect disfunction of salivary glands in patients suspected of chronic graft-versus-host disease, improving diagnosis and forehand therapy of cgvhd. bone metastases are a frequent complication in oncological patients, and can deteriorate their quality of life by the appearance of bone pain, and, to a less degree, fractures or medular compression. bone pain treatment is multidisciplinary, aim: objective of this study is the evaluation of the staff radiation extremity exposure from preparation and application of y-zevalin (activity/patient< . mbq) in our hospital. material and methods: data from the first therapeutic administrations were considered. the chemists performed the radiolabelling at a high protection standard in a dedicated hot cell, using shieldings in plexiglas for vials and syringes, tele-tongs and an automatic dispensing system. technicians were involved in activity dose preparation only before buying the current dispensing system. physicians administered the radiopharmaceutical through slow activity infusion (duration nearly min). all operators wore both latex and anti-x gloves. thin-layer tlds (lif:mg,cu,p) were fixed to the fingertips to measure the local skin dose, hp( . ), at the position with the highest risk of exposure to adequately protect the hands. tlds were given to the chemist and the technician, while to the physician. results: as for the chemist fingertips, the th percentile of the dose distribution (hp( . )) is . msv/gbq, while the th is . msv/gbq. for each radiolabelling the sum of all fingertips adsorbed doses was performed. the mean of these values is . +/- . msv/gbq. the medians of the radiolabelling fingertips doses range from . to . msv/gbq, while the means range from . to . msv/gbq. the ratio between the highest and the lowest absorbed dose to the fingertips is extremely variable per radiolabelling, observing values from . to . . technician doses are lower than the chemist ones, ranging from . % to . % compared to the latter. as for the physician the medians of the fingertips doses range from . to . msv/gbq/administration, while the means range from . to . msv/gbq/administration. conclusion: when working at low radioprotection level, the exposure of the staff might exceed the annual skin dose limit of msv. it is due to carry out an extremity monitoring with fingertips dosimeters suitable to betaradiation, stated the high risk of the method. aim: radionuclides have been used worldwide for diagnosis and treatment. their use in brasil have started in and have been increasing progressively, benefiting thousands. scintigraphic methods have significant role in brazilian physicians practice. despite its great importance, nuclear medicine's image was tarnished by nuclear disasters as chernobil ( ) and goiania ( -brazilian disaster linked to radiotherapy). those events boosted fear in public opinion concerning the use of radiation in medical procedures, even those that utilize small amounts of it like nuclear medicine. this work aims to evaluate how widely spread is knowledge about nuclear medicine among its patients, to find out their personal view and fears about procedures and specially if fear of radiation is usual. materials & methods: after reading and accepting informed consent, adult patients underwent a multiple choice questionnaire. research took place in a private service of nm in teresina, brazil during january-march . results: patients were interviewed, women and men, ages ranging from to years old. most patients ( . %) have never undergone a nuclear medicine procedure before; ( . %) had never even heard about this medical field. from the ( . %) that already knew something about nuclear medicine, ( %) received information from relatives or friends. patients under years old were not asked to answer the questionnaire. a great majority ( . %) believe that the exam will be useful in solving their health problem. besides, % think it is a very advanced procedure and . % declared insecure due to their lack of information. only ( . %) patients reported to have some kind of fear; ( . %) from them said to be afraid of bad result; ( . %) feared it could be painful and only ( . %) were afraid of exam's radiation. others kinds of fears, as allergic reactions, injection, suffocation, distressed ( . %) of the patients. conclusion: although many had already heard about this kind of procedure, lack of information is still usual among them. therefore, greater efforts for public diffusion of social benefits of nuclear medicine are needed. fear of bad result is the most frequently mentioned, probably because it may represent life-threatening situations as bone metastasis and coronary insufficiency. twenty years after brazilian main nuclear accident (goiania), fears of radiation seem not to be very important among patients. m. gerhardt, t. pulawska, s. b. søndergaard, b. zerahn; herlev hospital, copenhagen county, herlev, denmark. to evaluate the effect of music composed with the purpose of being calming, on heart rate and motion artefacts during image acquisition in rest and stress myocardial perfusion scintigraphy. material and methods: patients referred for myocardial perfusion imaging on the suspicion of ischemic heart disease were included in a randomised cross over study. only studies with successful gating during both rest and stress image acquisition were included. patients listened to music during acquisition of rest images and not during stress image acquisition and patients did vice versa. the study comprised women and men. the music played is named musicure and composed with the purpose of creating a relaxed atmosphere. the music is non vocal, slow in tempo and performed with acoustic and electric instruments and nature sounds. heart rate was registered before and after each image acquisition. motion artefacts were evaluated by two independent specialists in nuclear medicine using a semiquantitative four point scoring system. after each image acquisition the patients filled in a questionnaire with their evaluation of the calming effect of music/no music, whether they liked the music played or if they would prefer to select the style of music played, and if they would prefer to listen to music during the acquisition or not. results: during stress image acquisition there was a significant decline in heart rate of - . (± . ) bpm, (p= . ) among patients who did not listen to music. this decline in heart rate was significant for women alone; - . (± . ) bpm, (p= . ) but not for men; - . (± . ) bpm, (p= . ). regardless of music being played or not there was no significant effect on heart rate during rest acquisition and there was no difference in the frequency or severity of motion artefacts. % of the patients preferred to listen to music during image acquisition, and % would prefer to select music of their own choice. % of the patients declared that the music had a calming effect, % no effect, and % found it to be distressing. conclusion: listening to music during acquisition for myocardial perfusion imaging after stress prevents a decline in heart rate in particular among women and has not any adverse effects on the frequency and severity of motion artefacts. a vast majority of patients preferred to listen to music during image acquisition, although half of the patients preferred to select the music style themselves. flood field uniformity quality control (qc) is an essential function that must be performed daily before a gamma camera can be placed into clinical service for that purpose. clinical audit (ec directive / /euratom): systematic examination or review of medical radiological procedures which seeks to improve the quality and the outcome of patient care through structured review whereby radiological practices, procedures and results are examined against agreed standards for good medical radiological procedures, with modification of practices where indicatedand the application of new standards if necessary. implementation of med directive. clinical audit shall be arranged to supplement the self-evaluation of practices. objective must be that clinical audit be carried out every years to cover all essential radiological practices in health care. ten points of interest to be covered by clinical audits are defined in the degree. introduction in any medical investigation the result standards in terms of sensitivity, specificity and accuracy are expressed. for stress myocardial perfusion scintigraphy (smps) in ideal non-selected population these values are all around . according to the references they can be much lower in compromised group of patients. to assure appropriate work quality every diagnostic laboratory should periodically perform the quality control of the whole laboratory as well as of every individual results interpreter . aim aim of the study was to control the quality of smps results reading in our nuclear medicine laboratory in a compromised group of patients. the whole laboratory as well as every individual interpreter was controlled. patients retrospectively the smps readings of pts, ( %) men, ( %) women, mean age of ± y ( - ), were compared to the results of coronary angiography. ( %) pts suffered recent mi, in ( %) pts cabg and in ( %) ptca was performed. methods the smps results, denoted as positive or negative, were compared to the results of coronary angiography. by their comparing, sensitivity, specificity and accuracy of smps were expressed for the whole group as well as for the individual readers of scintigrams. results conclusion: the great difference in diagnostic accuracy among the readers of scintigrams was found. these results were a good reminder of the whole group and especially of certain individuals for approving the quality of their work. advantages and problems of digital documentation and reporting in nuclear medicine o. nickel, a. helisch, m. schreckenberger; klinikum der j. gutenberg-universitaet, mainz, germany.aim: archiving and online reporting with digital documentation (without hardcopy) requires certain technical prerequisites and an adapted workflow. as well the image display on the workstations used for reporting as the image archive are to be optimised for easy and fast access, a good report quality and a safe long-term availability of the archived data. material and methods: all the image data from our modalities ( gamma cameras, pet scanner, ultrasound) are sent by dicom transfer immediately after acquisition to the department pacs system "tomomagine"(bs industrieelektronik, germany). the reporting physicians use windows workstations with two monitors for text and images. quality control of the image monitors is done by test images (e.g. smpte). all images can be displayed with the tomomagine viewer, which was developed especially for nuclear medicine: spect and pet slice data can be viewed interactively with d navigation in planes and mip projections; overlays of pet/ct or spect/ct can be displayed as well. all image data of a patient can be loaded online in a short time by using the archive database. hours after acquisition the images are sent automatically to the central pacs system of the hospital; this system distributes the patient studies to the department servers of the referring physicians. results: the image management of a digital archive has some problems compared to a conventional archive with film or paper hardcopies: the monitor and graphics mode for image display must be able to display all relevant levels of grey. some lcd monitors that we tested were bad or even useless in this respect. a document on paper or film can be easily removed, an electronic document, which has been sent to a ris/pacs, may have already been copied to several places; therefore its elimination can take very much effort. by the temporary storage of images in a local image archive and delayed transfer to a central pacs this problem can be minimized. the use of a local image archive improves the speed of access to the image data compared with a central pacs, the redundant archiving (local and central) increases the long term data security. conclusion: the use of a local image archive in nuclear medicine, together with a centralized pacs can improve the workflow during reporting and image archiving.aim: lactadherin binds with high affinity to phosphatidylserine exposed on the surface of apoptotic cells. it is the aim of this project to synthesize mtc-hyniclactadherin and to measure its ability to bind to apoptotic hl leukemia cells. materials and methods: bovine lactadherin was isolated from milk, conjugated with hynic and labelled with mtc using tricine as the coligand. the conjugate was separated on a biosep-sec-s hplc column and stability studies with and without bsa carrier was carried out by tlc. hl cells (human leukaemia cell line) were made apoptotic using etoposide. multiple cell aliquots were added different amounts of mtc-hynic-lactadherin. the procedure was repeated with untreated hl cells to evaluate mtc-hynic-lactadherin binding to non-apoptotic cells.results: the amount of conjugated hynic per protein molecule was determined spectrophotometrically to be . the relatively low yield of the hplc purification ( ± %, n= ) relates to the fact that lactadherin most likely adhered to the column. the stability tests showed that in the presence of bsa the rcp only decreased from % to % during a five hours period. the non-stabilized solution plunges from % to % rcp during the same period. a significant difference in binding activity between apoptotic and control cells ( ± . %) was achieved with a mtc-hyniclactadherin concentration as low as . nm. furthermore, the difference in binding to apoptotic and normal hl cells reached a plateau at . nm label resulting in an ± . % increase. when native lactadherin was added in excess the radioactivity in the pelleted apoptotic cells dropped to ± . %. this strongly suggests that the binding of mtc-hynic-lactadherin to apoptotic cells is mediated by the same mechanisms as for unlabeled lactadherin. conclusion: mtc-hynic-lactadherin has been synthesized, tested for stability and in vitro biological binding activity. the data clearly show that the compound is a potential imaging agent for apoptosis recognition. aim: annexin v is known to bind to phosphatidylserine which is exposed on the outer surface of the cell membrane of cells undergoing apoptosis. it has been shown that bovine lactadherin a milk fat protein isolated from milk has affinity to phosphatidylserine and apoptotic cells as well. in vitro binding studies of mtc-hynic-lactadherin indicate that it binds to apoptotic cells. we want to present the results of the biodistribution studies in mice and tracer kinetic studies in pigs of mtc-hynic-lactadherin and mtc-hynic-annexin v. materials and methods: normal mice were injected with approximately mbq in ul of mtc-hyniclactadherin or mtc-hynic-annexin v and sacrificed after min, h or h. the animals were dissected and major organs were collected in counting tubes and the distribution of radioactivity was measured. tracer kinetic studies in pigs were done by a combination of non-invasive scintigraphy and katheterisation. results: the biodistribution studies in mice showed a relatively fast blood clearance. the relative uptake of mtc-hynic-lactadherin (n = )/ mtc-hynic-annexin v (n = ) h post injection was . ± . / . ± . in blood, . ± . / . ± . in the liver, . ± . / . ± . in the spleen and . ± . / . ± . in the kidneys. accordingly, scintigraphy in pigs showed high liver uptake of mtc-hynic-lactadherin (n = ) and high uptake of mtc-hynic-annexin v (n = ) in the kidneys. renal extraction of mtc-hynic-lactadherin was about % whereas the extraction of mtc-hynic-annexin v fell from - % - min p.i. conclusion: these tracer kinetic studies in mice and pigs showed that mtc-hynic-lactadherin is mainly taken up by the liver in contrast to mtc-hynic-annexin v which is mainly taken up by the kidneys. these results combined to the apoptosis recognition ability of mtc-hynic-lactadherin makes this radiotracer a potential new imaging agent for apoptosis in different organs with an advantage to mtc-hynic-annexin v for imaging apoptosis in the kidneys. transport and phosphorylation of f- -deoxyglucose (fdg) in the tumor cells determine the kinetics of the tracer and the accumulation. however, experimental data gave evidence that other processes like angiogenesis may have an impact on the tracer kinetics. this study is focussed on the combined evaluation of pet and angiogenesis related gene expression. methods: dynamic pet fdg studies were performed in patients with colorectal tumors within two days prior to surgery. volumes-of-interest (voi) were used to obtain time-dependent tracer concentrations from the tumor region and a reference area. vois over the descending aorta were used to retrieve fdg total blood concentration data. a two-tissue-compartment model was fitted to the data and the transport constants k -k as well as the fracional blood volume (vessel density, vb) were calculated using the evaluation software pmod (pmod technologies ltd., adliswil, switzerland). tumor specimen as well as specimen from a reference area(normal colon) were obtained by surgery and quantitative gene expression data were obtained by gene array analysis using the u a gene chip (affymetrix inc., santa clara,ca,usa). pet and gene array data were evaluated with the genepet module of pmod. results: a quantiative data evaluation was performed in patients, comprising specimen of tumors and normal colon tissue. suvs were highly variable between . and . suv for this collective. angiogenesis related genes were enhanced by a factor of . , when tumors and normal colon were compared. classification analysis demonstrated that angiogenesis related genes provided the best discrimination between malignancies and reference tissue. the correlation/regression analysis demonstrated significant correlations (p< %) for the suv, fractal dimension (heterogenity of the tracer), k , k , and the fdg influx. summary: angiogenesis has a significant impact primarily on the kinetic data (k , k ), but also on the global fdg uptake. a detailed analysis of the fdg kinetics can help to classify the grade of angiogensis in primary colorectal tumors. fifteen patients between ages and years of age (mean yrs), with stage iia-iii recurrent cervical carcinoma treated with radiation therapy or chemotherapy and radiation therapy were enrolled. mr was performed on a . tesla scanner (ge scanner), the ct and pet was performed in a pet/ct scanner, (ge discovery st). mr scans were performed for radiation planning tumor delineation and pet ct's were performed for ruling out nodular metastasis. mr and pet/ct scans were done with a time interval less than days. pet and ct were coregistered during acquisition in the pet/ct scanner. mr volumes were co-registered with the ct part of the pet/ct using - internal anatomical fix points. the gtv were retrospectively delineated on transverse sections of ct (center hu; width, hu and tumor consistent criteria like contrast enhancement) and mr (t weighted) scans independently by two physicians with training in radiology and nuclear medicine, working in a blind fashion. gtv's were evaluated with different modalities on a single integrated eclipse planning system (varian medical systems). gtv was autosegmented on pet scans using a lower activity level defined as % of maximum activity corrected for regional background results: the preliminary results demonstrated that on average gtv defined in pet smaller than in both ct and mr.the final result will be demonstrated at the meeting. conclusion: the combined pet/ct scan demonstrates an easy and observer independent definition of gtv for radiotherapy. the size of gtv was found smaller compared to determination by mr and ct. aim: cd /neutral endopeptidase (cd ) and intestinal-type mucin (muc ) are known to associate with colorectal carcinogenesis and local invasion. the purpose of this study is to investigate the relationship between clinicopathological factors and fdg uptake in pet-ct in colon cancer, focusing on the expression of cd and muc . methods: in this study, patients ( . ± . year old women, . ± . year old men) with colon cancer were contiguously selected from april to september . preoperative pet-ct was performed in all of them. to determine the relationship between clinicopathological factors and standardized uptake values (suvs) in colon cancer, we analyzed the tumor differentiation, tumor size, lymph node metastasis, vascular invasion, lymphatic invasion, and the expression of muc and cd , in paraffinated tissue using immunohistochemial stain. in addition, the expression of hexokinase (hk-ii) and glucose transport (glut- ), and cell proliferating activity using ki- were evaluated. results: all of the cases studied were positive for glut- , specifically of glut- weak positive and of glut- strong positive. there were cases of cd positive, cases of muc positive. cd showed negative correlation with muc (rho=- . , p< . ). muc expression exhibited the positive correlation with ki- (rho= . , p= . ). there was no statistical significance among suvs and various clinicopathological factors such as tumor differentiation, size, lymphatic or vessel invasion, lymph node metastasis, ki- , and hk-ii. furthermore, no clear correlation was found between a very simple animal model of liver infection consists of the intraperitoneal injection of clamidia pneumoniae, which results in an activation of hepatic kupffer cells in % of the animals. this kupffer cells dis-regulation can be associated to primary biliary cirrhosis. aim of this study was to assess the predictivity of fdg small animal pet for the early identification of reactive animals, possibly identifying not only the peritoneal inflammation caused by the injection but also the liver kupffer cells activation and behaviour (are they originated from the peritoneum or from the liver itself?). we used adults balb/c mice ( - weeks) which were intraperitoneally injected with purified c. pneumoniae elementary body suspension (the inoculum preparation contained . x ^ inclusion forming units). , , and days after, the animals underwent a fdg small animal pet (ge, explore vista). we administrated mbq of fdg via the tail vein. uptake time was min, acquisition time min. images were reconstructed with osem d iterative reconstruction. animals were considered positive if a visual abnormal fdg uptake was present in the abdomen and/or in the liver. we found that / animals had a positive pet scan days after inoculum within the peritoneum. days after inoculum all these animals presented an increased peritoneal fdg uptake, which disappeared an days after inoculum. the other animals had negative scans , , and days after inoculum. no hepatic signs of inflammation were detected in any of the animals. these results reflect the biological behaviour of this animal model previously reported in literature (world j gastroenterol, oct ; ( ) ) which shows an inflammatory response in about % of the subjects. this inflammation, probably connected with the liver reaction, could be very early detected by fdg pet (those that were positive intraperitoneally). however, this imaging method was never able to identify the liver kupffer cells activation. these preliminary data indicates that, although predictive for reactive animals, fdg small animal pet is not the most appropriate technique to in vivo evaluate kupffer cells movements and behaviour. a reporter gene-reporter probe method or a in vitro cell labelling tracking method may be more accurate to fully in vivo understand the kupffer cells behaviour.aim: differentiation between cancerous growth and inflammatory reaction may be sometimes difficult. the glucose analogue, - f-fluoro- -deoxy-d-glucose ( f-fdg) accumulates in the areas of high glucose metabolism, such as rapidly growing tumours or active inflammatory foci. however, f-fdg is specific neither for cancerous growth nor inflammation, thus causing false-positive findings. vascular adhesion protein (vap- ) is a human endothelial protein whose cell surface expression is induced under inflammatory conditions, thus making it a highly promising target molecule for studying inflammatory processes in vivo. we hypothesized that positron emission tomography (pet) with gallium- -labeled , , , -tetraazacyclododecane-n',n'',n''',n''''-tetraacetic acid conjugated synthetic peptide targeted to vap- ( ga-dotavap-p ) could be feasible for differentiating tumours and inflammatory foci. we compared the biodistribution of ga-dotavap-p , f-fdg, c-choline and ga using experimental rat model. c-choline is a marker for cellular proliferation and it has been extensively used for pet imaging of prostate cancer. free ga also accumulates in both the tumours and inflammatory foci. to establish an in vivo model, athymic rats were s.c. implanted with human bxpc- pancreatic adenocarcinoma cells and sterile skin/muscle inflammation was caused by turpentine oil. dynamic h pet imaging and ex vivo organ distribution measures were performed h after induction of inflammation. results: our results revealed that the ga-dotavap-p was able to visualize inflammation better than tumour and it was more inflammation-selective than other tested tracers. the difference between ga-dotavap-p vs. ga and vs. c-choline was statistically significant (p< . ). the most tumour-selective tracer was c-choline. the difference between c-choline vs. ga and vs. ga-dotavap-p was statistically significant (p< . ). however, f-fdg showed the highest target-to-background ratios (table) . conclusion: our results indicate that ga-dotavap-p targeting vap- was capable of differentiating tumour from inflammatory foci in our animal model and it was almost as sensitive as f-fdg for inflammation imaging. a minority of tracers developed for scintigraphic detection of infection and inflammation could theroretically discriminate bacterial infection from sterile inflammation. however, for some of these tracers these claims could not be confirmed. recently, the radiolabeled thymidine kinase (tk) substrate -( '-deoxy- 'fluoro-beta-d-arabinofuranosyl)- -iodouracil (fiau) has been proposed as an agent to image bacterial infections, based on presence of endogenous tk in bacteria. in the present study, we investigated [i- ]fiau targeting in rats with bacterial and sterile inflammation. to prove that fiau uptake was tk-mediated, e. coli tk-negative bacteria were generated and inoculated intramuscularly (im) in rats and fiau uptake was studied. methods. fiau was labeled with i- using the trimethyl tin precursor. aim: angiogenesis is a prominent feature of rheumatoid synovitis. v integrin is expressed at high levels on the synovial formation of new blood vessels in rheumatoid arthritis. synovitis in rabbits could be suppressed by blocking this integrin with cyclic rgd peptide based v antagonists injected directly into the joint. the multi-pinhole (mph) single-photon emission computed tomography (spect) technique and in- labelled cyclic rgd peptide ( in-dota-e-[c(rgdfk)] ) allows to detect vascular joint alterations in arthritis-mouse-models. methods: mph-spect-measurements were performed under short general anaesthesia in collagen-induced-arthritis (cia) mice, which had arthritis of front and back paws. all mice were independently scored macroscopically before starting the studies. control mice were compared with the mph-analysis of arthritis-mouse-models. spect data was acquired with a conventional gamma camera (prism s, philips) which was outfitted with a new constructed mph-collimator ( pinholes with a diameter of . mm). after the injection of . ± . mbq (mean±sd) in- labelled rgd peptide, a dynamic measurement between and minutes p.i. was performed. results: the high sensitivity of the mph-technique allowed the dynamic visualisation in the uptake of rgd peptide in the ankles and other organs of the mice. mph-spect allows to detect all arthritic lesions (n= ) and a quantitative analysis. the regional evaluation showed that after minutes, the percentual accumulation h p.i. in the inflamed paws was . %± . % while in healthy control mice (n= ) a significant lower uptake of . %± . % was measured (p( )= . , mann-whitney). no significant difference was observable in the knee joints between healthy and arthritic mice. conclusion: the results of our studies suggest a correlation between arthritic inflammation and accumulation of cyclic rgd peptides in cia animals in vivo. the mph-spect technique in combination with a cyclic rgd peptide can be used as a diagnostic instrument for imaging joint pathologies and for an accurate and quantitatively precise monitoring of therapy studies. aim: image quality using the specific serotonin a-receptor radioligand i-r- is variable in dogs. since the p-glycoprotein is expressed in the blood-brain barrier, amongst many other organs, we wanted to evaluate the effect of ketoconazole, a pglycoprotein modulator, on the brain uptake of this radioligand in dogs. materials & methods: three -year-old healthy female beagle dogs were included. two spect scans were performed; one baseline scan and one scan after administration of ketoconazole. ketoconazole was administered orally during successive days; two days before scanning at a dose of mg/kg, one day before scanning and the day of scanning at a dose of mg/kg. the radioligand i- -i-r was injected (mean mbq) intravenously minutes prior to acquisition. acquisitions were performed under general anaesthesia (premedication with medetomidine, induction with propofol and maintenance with isoflurane in oxygen). acquisitions were performed with a triple head gamma camera (triad, trionix), equipped with lehr hole collimators. images were reconstructed with hosem iterative reconstruction and application of a butterworth-postfilter (cut-off, , cycles/cm, order ). roi's were drawn over eight cortical regions (left and right fronto-, temporo-, parieto-, and occipito-cortical area) and one global subcortical region. the uptake in the cerebellum (area void of serotonin a-receptors) was used as a reference for non-specific binding in addition to free ligand. radioactivity measured in the cortical areas was assumed to represent the total activity. the binding index was operationally estimated as (mean counts/pixel in regional cortex)/ (mean counts/pixel in cerebellum). results: on visual inspection a clear improvement was noted after administration of ketoconazole. the mean counts/pixel in the total brain was , ± , . after administration of ketoconazole the mean counts/pixel in the total brain was , ± , . the mean serotonin- a binding index of the baseline scan in the frontal cortex was , ± , . after administration of ketoconazole, the mean serotonin- a binding index increased to , ± , . this is a mean increase of , %. conclusion: the results of this study demonstrate a trend towards an increased brain uptake of serotonin a-receptor radioligand i-r- after use of ketoconazole. despite clear improvement of image quality, no statistic conclusions can be taken due to a low number included subjects. further investigations are necessary to confirm these preliminary findings. aim. to determine possibilities of quantitative imaging of the mouse thyroids using the nanospect/ct small animal imaging system. materials and methods. phantom and in vivo measurements were made with the nanospect/ct device. phantoms of two point sources distributed in homogenous flood source of cylindrical for were created. mtc and i isotopes were used to fill in radioactivity. mtc activities ranged from mbq in points to mbq, i activities ranged from . mbq to mbq. flood activities were between - mbq. in vivo imaging of - mice with the respective isotope was performed using activities of mtc of - mbq injected iv. or - mbq of i.imaging was done - minutes post inj. thyroids were then removed from mice and measured in a welltype counter and compared to standard activities to determine real activity. results. roi-quantified voxel activities were the same in the measured phantoms and the calculations of two digits post zero. in vivo results were the same with an error of % with mtc, with i the error depended on the signal intesity and count-noise ratio. conclusions. nanospect/ct allows the correct absolute quantification of activity located in voxels both in vitro and in vivo if a good signal-noise ratio can be obtained. objective: poor in vitro and in vivo delivery is limiting the use of oligomers for imaging and therapy. streptavidin (sa) may be used as a convenient link between biotinylated antisense radiolabeled oligomers and transmembrane carriers added to improve delivery provided that antisense and carrier function is not compromised thereby. methods: nanoparticles with mer uniform phosphodiester (po) or phosphorothioate (ps) dnas against the mdr mrna or a mer phosphorodiamidate morpholino (morf) against the survivin mrna were linked to sa along with cholesterol, a mer tat or mer polyarginine carrier. the m tc radiolabel was always on the oligomer. results: as evidence of unimpeded carrier function, the morf/sa/tat and morf/sa/polyarginine nanoparticles accumulated fold more than the morf/sa and the naked morf controls after h in survivin+ mcf cells while all po nanoparticles showed increased accumulations at all times with compared to without carriers in three mdr + cells but not so the ps dna nanoparticles because of its high protein affinity. evidence of antisense targeting were the statistically higher cellular accumulations of the antisense morf nanoparticle than the sense morf nanoparticle control and statistically higher accumulations of the po dna nanoparticle in the three cell types in order of their mdr expression levels. in xenografted mice, the ps dna/sa/tat and ps dna/sa/cholesterol nanoparticles were accumulated in all tissues including tumor much higher than the po nanoparticles. these results show that the high protein binding affinity of the ps dna was expressed despite the presence of the sa. conclusions: the preparation of oligomer carrier constructs was greatly simplified over covalent conjugations by using sa as a linker. the sa linker had no apparent detrimental influence on the function of the carriers or antisense oligomers. these observations suggest that sa provides a convenient means of linking oligomers, carriers and, eventually, antitumor antibodies without compromising properties. the aim of this study was to investigate the effect of food and time on intestinal activity in technetium m tetrofosmin stress myocardial perfusion scintigraphy. based on a pre-study sample size calculation, we estimate the study population to comprise a total of patients. patients were recruited at a single center and underwent a two day exercise-rest tc- m tetrofosmin single photon emission computed tomography (spect) imaging. patients were randomized to food or no food ( ml of water and two slices of white bread with butter versus no drink or food) versus early or late spect (within min from injection of tracer versus - min after injection of tracer) in a x factorial design. patients with abnormalities on their stress test also had a rest spect. the food/time allocation used for the stress test was used for the rest as well. rest data will be reported separately. patients were randomized in blocks of four. most patients received adenosine pharmacological testing with moderate ( w) bicycle exercise. frequency of intestinal activity was assessed visually on spect images on different planar projections. inferior myocardial wall and abdominal activity adjacent to the myocardium was evaluated visually on a -point semi-quantitative scale, ranging from no to severe intestinal overlay and a final accept/repeat spect decision. evaluation was performed by a trained observer blinded to the pre-spect details. the primary endpoint is the percentage of accepted first time spect in each cohort in the intention to treat population. secondary endpoints include proportion of approved first time scans in each cohort as per actual time and food (per protocol analysis), intestinal activity according to method of exercise testing, and time from injection to final acceptance of the scan (including repeat scans). an interim analysis has been planned at patients (estimated to be late april, ). the final results will be presented at the meeting. the aim of study was to explore the possibilities of the use of dicom standard (digital imaging and communications in medicine) in our department. we used it in comparison of new commercial software package ( dm spect) with the existing (qgs) for the quantification of left ventricular ejection fraction (lvef). lvef values obtained with dm spect, and frames/cycle were also compared. material and methods: twenty patients ( male, female, mean age ys) referred to stress and/or rest gspect study with mtc mibi, were enrolled. studies were performed with two detector camera system (ecam), first with frames/cycle, and immediately after that with frames/cycle for each patient, according to the recently published eanm/esc procedural guidelines for myocardial perfusion imaging (gspect, high count study), with total duration of minutes ( minutes for each study). after the reconstruction, the and frames/cycle data were processed with dm spect program. original frames studies were also copied from esoft to icon working station, using the dicom key, where reconstruction and qgs processing was performed. mean lvef values were compared, and statistical significances were checked with paired t test. results: dm spect- fr dm spect- fr qgs - fr mean lvef % (range%) % ( - %) * ** % ( - %) % ( - %) * p< . between and fr dm spect **p< . between fr dm spect and qgs mean lvef values obtained with frames dm spect were % higher than with frames qgs program. difference between and frame mean lvef values in dm spect was smaller, but both results turned to be statistically significant (p< . ). conclusions: dicom transfer from one to another working station was successful in all cases. significant differences between and frame dm spect study were found, and between frames studies obtained with two software programs. since more prominent differences were found with different programs, it can be concluded that lvef values should always be processed with the same software package, especially when follow up of patient is needed. the dicom successfully enabled the comparison of the two software packages. aim: both stress and rest examinations are usually performed to diagnose ischemia or infarction in the left ventricle. if the stress study is performed first and the images show normal findings, it might be unnecessary to perform the rest study. the aim of this study was to evaluate if it is possible to avoid rest studies in some patients without making false negative interpretations. material and method: the gated-spect studies performed using a two-day nongated stress/gated rest m tc-sestamibi protocol from consecutive patients were investigated. the patients had a mean age of ± years, and % were men. myocardial perfusion scan was performed for the diagnosis of cad in patients and for management of known cad in patients, previous myocardial infarction in patients and previous revascularisation in . visual interpretation by one experienced physician at the time of clinical reporting was used as the gold standard for the scintigraphic presence of myocardial infarction or ischaemia. rest, stress and gated images as well as clinical information were available for this interpretation. only the stress images (slice images and polar plots) were examined independently by physicians and technologists regarding the question if a rest study was needed or not. results: the clinical evaluation of the rest and stress images by the experienced physician showed normal findings, i.e. no signs of infarction and ischaemia, in cases. the five observers decided that rest was unnecessary in , , , and of these studies respectively. a false negative classification, i.e. rest study not necessary in a case were the gold standard interpretation was infarct or ischaemia, was found in , , , and cases respectively. conclusion: the results show that it is possible to avoid rest studies in a significant number of patients with no or only few false negative interpretations.technologists and physicians did not differ substantially in the interpretations. h. lehtinen, a. sonkki; university hospital of turku, pet centre, turku, finland.the aim of this poster is our practical experiences of cardiac cta and perfusion studies performed at turku pet centre, finland. coronary cta combined with the cardiac perfusion study is one of the best and most reliable non-invasic tests in diagnosis of cad. the study provides seamless team work with many occupational groups like medical laboratory technologists, physicians and the physicists. the radiographer's role is to prepare patients, inform them of the study and do the scan. materials and methods. at first we prepare the patient for the cardiac study. the patient fills an interview form where we will see his current medications, possible former reactions to contrast agents, allergies, diabetes and kidney diseases. while the patient lies down we observe heart rate, check blood pressure and set an intravenous cannula. optimal heart rate is stable and under bpm. if it's above bpm the physician gives beta-blockers intravenously. oral nitrate spray is given to each patient before the scan. cta demands breath holds so it's good to exercise this with the patient before the study. the scanner used is ge vct -slice pet-ct scanner. cardiac cta consists of a calcium score scan and a coronary scan with contrast media. we use an automatic dual head injector system for injecting contrast media and nacl bolus chaser. the cta scan is then followed by the perfusion studies with olabelled radio water, first basal perfusion and then adenosine stress perfusion. during the perfusion studies we monitor ecg and the blood pressure according to our protocol. after the study we observe the patient for awhile and advise him to drink a lot because of the possibility a nephrotoxic reaction due to iodine-containing contrast. conclusion. cardiac cta combined with pet perfusion is an excellent example of a multimodalitystudy, as the anatomic information of ct images is combined with the functional information of pet. it has been very challenging, exciting and rewarding to do these studies. standard indicator of sestamibi regional washout in the myocardium purpose: in recent years, it has been shown that washout of mibi is observed in myocardial ischemia lesions, and a method for its evaluation is discussed. we obtained the standard indicator for regional washout from early and delayed mibi images and evaluated its usefulness. method: in healthy volunteers without abnormalities, such as cardiac diseases, hypertension or electrocardiographic abnormalities, spect images were acquired one hour after intravenous administration of mbq of mibi of (early image), and subsequently, three times, up to five hours (delayed image , delayed image and delayed image ). to draw a polar map from each sequential spect image, the regional washout rate obtained from the mean count in three areas of the myocardium was plotted, and the gradient was calculated with the approximate equation. results: comparison of gradients in the linear approximation and exponential approximation from the early image to delayed image in each area showed no significant differences ( and rca=- . ± . , showed significant difference (p< . ) for the lad and lcx, but not for the other vessels (p=ns). the respective r were . , . and . , with no significant differences among the three (p=ns). as for correlation between the linear approximation and exponential approximation, the linear approximation approached more closely than the curve approximation, however, no significant difference was observed. conclusion:it was suggested that the regional washout of mibi in healthy myocardium would decrease with a gradient of linear or curve approximation. since there was no significant difference between the approximated line and curve, evaluation of the gradient with the linear approximate expression may provide a constant gradient, and therefore, it can be used as an indicator of the washout rate. t. iimori, t. fujibuchi, h. sato, k. sawada, y. uchida, t. kawata, m. fujita, s. shindo, y. kuwabara; chiba university hospital, chiba, japan.background and purpose: by m tc -mibi scintigraphy, a myocardial morphologic assessment (hypertrophy or enlargement) and functional assessment are also enabled as well as myocardial perfusion evaluation, and they contribute to the assessment of myocardial viability. recently, there are some reports that accumulation and clearance of mibi are related to severity of heart failure. therefore, we evaluated the utility of scatter correction for precise energy count in calculating h/m (heart/mediastinum) value of mibi in the planar image. method: ) phantom simulation study: in the phantom, myocardial region was filled by . mbq/ml with mibi, liver region was filled with . mbq/ml of mibi, and mediastinum was filled by water. we imaged the phantom with static collection (preset time; , counts, matrix; * ), and repeated with the different main window widths and sub window widths in order to determine the appropriate window width for scatter correction by tew. we used nmse (normalized mean square error) for their evaluation. ) clinical evaluation: with the appropriate windows determined by the phantom, we measured h/m value of mibi in patients with heart failure ( male, femail, mean age . ± . years), and compared with raw data for the relation with the clinical data such as ejection fraction (ef). since i-mibg imaging is well-established as a gauge of chf, effect of scatter correction by tew in mibi was also evaluated for the correlation with i-mibg. result: main window width with kev± % and sub window width with kev± . % were appropriate in scatter correction by tew by the phantom study, respectively. )correlation coefficient between h/m value and ef in patients with chf was r= . without scatter correction, and it improved to r= . with scatter correction. correlation coefficient with h/m value and i-mibg h/m value were r= . without scatter correction, however, it increased to r= . with scatter correction. conclusion: we proposed appropriate windows for the scatter correction in cardiac imaging by m tc-mibi by phantom study, and proved its utility by applying to the clinical cases. background: stem cells represent one of the new therapeutic possibilities for severe co ronarydisease, the effect being tested in many trials. most centers use intracoronary injections, but some recommend intramyocardial injection, to obtain maximal homing and retention of the cells in the ischaemic myocardium. details about differences between these administration techniques are completely unknown. the purpose of the present study was to examine the retention of in- labelled human stem cells injected into porcine, left ventricular (lv) myocardium. methods: in-labelling was performed as previously described by our group (ejnm (ejnm , : (ejnm - . the labelled cells ( ) ( ) ( ) were injected into the pigs ( - kg) via a cardiac catheter into the lv walls in small depots (total volume injected = cc). subsequent static gamma camera images were obtained ( and kev dual window, megp collimator) over the next days to monitor the clearance of the labelled cells from the myocardium. on the second day mbq sestamibi was given iv. after the planar image and cardiac spect performed min later. the energy windows for spect were % around and kev. results: it was easy to localize, in the homogenous sestamibi visualization of the lv myocardium, the remainder of - mbq in- , distributed in - hot spots, in the apex, posterior wall, septum etc. by the daily planar "pure" in- images the retention of the indium could easily be calculated after correction for physical decay: (day , , , ). discussion and conclusion: this technique with a lower energy window centered around kev during spect, permitting only part of the general myocardial activity uptake to be visualized as a background. it nicely demonstrated the myocardial localization of < mbq in- activity accumulations from labelled stem cells injected into the heart of - kg pigs. introduction lvef, edv and esv are good clinical indicators of left ventricular function and volumes, routinely measured by echocardiography (echoc). in former decade the emory cardiac tool box (ectb) was developed, a toll for assessing left ventricular function and volumes from gated spect myocardial perfusion scintigraphy (gspect). gspect myocardial function assessment provides an important incremental information. aim of the study the aim of the present study was to validate the accuracy of the ectb in assessing lvef, edv and esv from gspect using echoc as a reference values. patients and methods consecutive patients, males and females; mean age +/- y, range - y, with suspected or known coronary artery disease were examined using mtc-mibi gspect ( gates/cardiac cycle) min after tracer injection at stress. the gspet data were reconstructed using an automatic algorithm employing filtered back projection (fbp) and further analyzed by emory cardiac (ec) toolbox. all patients underwent two-dimensional ( d) m-mode echoc in the same diagnostic evaluation. optimization of myocardial fdg-uptake in f -fdg pet-ct by a standardised hyperinsulinemiceuglycemic clamp protocol and acipimox k. krommes, g. pleschberger, v. meyer, h. kässmann, c. pirich; salzburger landeskliniken, nuklearmedizin, salzburg, austria. the assessment of myocardial viability by f- fdg pet has become a standard procedure in nuclear cardiology. metabolic imaging of the heart requires designated protocols that reflect alterations in substrate metabolism under ischemic conditions. it was the aim of the study to analyse the efficacy and practicability of a standardised hyperinsulinemic-euglycemic clamp protocol in clinical routine. method: cardiac f- fdg imaging was studied in patients from till february . patients were non-diabetic ( %) and patients were diabetic (insulin and non-insulin dependent; %). every patient was given a dosage of mg acipimox on the study day. the hyperinsulinemic-euglycemic clamp protocol differentiates between non-diabetic, diabetic non-insulin-dependent and diabetic insulin-dependent patients. for each patient group, there is a predefined pattern for application of oral glucose or/and insulin (maximum single insulin dose iu) according to the blood glucose level. results: according to our protocol the following procedure was necessary in our patients: • no insulin / no glucose: patient • no insulin / glucose: patients • insulin / glucose: patients • insulin / no glucose: patients patients needed glucose, of whom patients ( %) got g glucose and patients ( %) got , g glucose. after glucose application, patients ( %) required no insulin, and patients ( %) needed insulin to lower the blood glucose level. of patients were given insulin, of them after glucose application and patients without glucose. in detail, , and patients received respective dosages of , and i.u. insulin. one patient was given i.u. insulin. diagnostically adequate imaging quality was achieved in cases ( %) and even in of diabetics ( %). cardiac fdg-pet imaging of patients was not successful due to vomiting of the oral glucose drink. conclusion: for metabolic imaging of cardiac glucose consumption by means of f -fdg pet-ct a strategy combining the use of acipimox and the hyperinsulinemic-euglycemic clamp protocol is feasible and results in adequate imaging quality in the vast majority of patients. the protocol is even successful in a diabetic population. aim: in our department, myocardial perfusion scintigraphy (mps) is usually performed using a -day rest-stress m-tc-sestemibi protocol. with more referrals and wishes of additional procedures for routine and research purposes there is a growing pressure on the staff and a waiting list seems inevitable. we examined if resource utilization could be improved by applying the lean concept originally introduced by toyota for optimizing automobile production. material and methods: implementations of lean has as its core five concepts: . specify value in the eyes of the customer; . identify the value stream and eliminate waste; . make value flow at the pull of the customer; . involve and empower employees; . continuously improve in the pursuit of perfection. in terms of mps, concepts - were applied. first, we established an "as-is" flow diagram, which required a) an interview guide, b) interviews of secretaries, booking, laboratory technicians, and physicians, c) sketching of a so-called swimming lane diagram, and d) the "as-is" flow diagram. from the "as-is" diagram it was easily seen which activities could be combined, reduced, or eliminated. based on these observations a "to-be" diagram eliminating all "waste" could be established in a process involving and empowering all relevant employees. results: the "as-is" diagram identified the following pre-scan steps as candidates for a change: i) non-appearance of patients, ii) measurement of body weight and height, calculation of body mass index and sestamibi dose, iii) preparations and check of patient dose, iv) positioning of intravenous cannula and dose injection, v) check of medication and withdrawal of relevant drugs before stress acquisition, and vi) entering of informations into a working sheet and the patient protocol. similarly, the following post-scan steps were candidates for a change: vii) information to the patient of preparations for the succeeding stress examination, viii) precautions on day- in case these instructions had not been followed. conclusion: these and other simple changes, which could eliminate or streamline the many extra procedures, lightened the pressure on the personnel, made the working rhythm more fluent and stable, and yielded extra time for patient care as well as the conductance, processessing, and finalizing of each single mps study. in this way, the "low hanging fruits" were collected. in addition, a further gain could be obtained in at least ¼ of the patients by converting the sequence rest-stress to stress-rest and leaving the rest study undone in case the stress study was normal. aim: gated myocardial spect provides an estimate of left ventricular ejection fraction (lvef). most commonly gating is performed with frames per cardiac cycle although frames per cycle may provide more accurate estimates of left ventricular function. the aim of this study was to compare same day repeatability of left ventricular ejection fraction using -frame or -frame gated spect. method and materials: in patients referred for routine myocardial spect a -frame gated spect study (study a) was performed hour after injection of mbq mtc -mibi. a second -frame gated spect study (study b) was performed immediately after without the patient leaving the gamma camera. frame studies were constructed from frame studies. gated studies were processed with qgs software. repeatability is reported as the mean difference (study a -study b) ± . sd. results: repeated studies ( stress and rest studies) were performed in patients. in study a, frame studies produced significantly higher lvef than -frame studies (mean lvef . %, vs . %, p < . ). repeatability of lvef in -frame and -frame studies were . ± . % and . ± . % respectively. the difference in lvef was not statistically significant in neither -frame nor -frame studies. in stress studies lvef was significantly lower in study b than in study a (repeatability . ± . % [p = . ] in -frame studies and . ± . % [p= . ] in -frame studies). in rest studies no change in lvef was observed (repeatability . ± . % in -frame studies and . ± . % in -frame studies). no correlation between difference of lvef and change of heart rate, perfusion defect size, edv or esv was observed conclusion: there is significant variability of same day left ventricular ejection fraction measured with gated spect. repeatability seems not to be affected by frame rate, but appears to be poorer in stress studies than in rest studies. these observations should be taken into account in serial evaluation of left ventricular function with gated spect studies. . recently there has been an increase in the number of acute chest pain and pre-surgical patients (pts) with cardiac risk factors treated at community hospitals in the u.s. many of these pts require immediate cardiac care which has significantly added to hospital stays and health care costs. yet both federal and state reimbursements for institutions seeing these patients have decreased. aim: to develop a patient care pathway and pacs ( picture archiving and communication system ) to maximize immediate care for cardiac and pre-surgical patients while reducing the patient's hospital stay when possible. length of hospital stay was recorded for all uncomplicated cases. method: this project was a cooperative effort among the cardiology department, hospital administration, stress laboratory, cardiac care floor and nuclear medicine. a tc- m gated myocardial perfusion imaging (mpi) was performed on all low and intermediate risk chest pain and pre-surgical patients within hours of admission and preliminary results were provided to the attending physician within hours of completion of the test. patients ( females, males) with an age range of to years (mean = ) underwent a one day rest and stress (exercise or pharmacologic stress with adenosine or dobutamine) gated spect mpi. a rest/stress dose of mbq/ . gbq ( / mci) of tc - m tetrafosmine was used. a siemens e-cam gamma camera with d ms spect software was used to reconstruct orthogonal views. results: pts ( %) had negative mpi findings and were discharged with hours of the exam. pts ( %) had positive mpi findings and were immediately sent to coronary angiography and discharged within to days post mpi. pre-surgical pts ( %) with negative mpi findings went to surgery within hours. pts ( %) with positive mpi results went on to have cabg. conclusions: all low and intermediate risk chest pain pts were discharged within hours of mpi which represents an improvement over past hospital stays for these pts. pre-surgical pts with negative mpi results were immediately sent to surgery. these data suggest a significant reduction in hospital costs and stays. introduction: even if filtered backprojection (fbp) methodology still has a very well established role in routine image processing in nuclear cardiology, actually, with the general improvement of computational power available, an increasing number of nuclear medicine departments worldwide tend/is interested on the use of iterative methods (im). with this paper, it is intended to expose some main considerations, always with clear practical purposes, sharing our own studies and experiences. material and methods: the first part of the study consisted on the analysis of the different possibilities available within the current software options brought widely available by the furnishers of equipment. once concluded, sessions of practical tests started: the main goal was to establish the relative practicability of the options predefined on the first part of the study. hence, we used one group of different myocardium perfusion scintigraphic studies, which had been processed with the distinct methodologies previously defined. we have compare data related with the processing operation itself for each case, with main focus on parameters as the time spent (from the operators as well as the system's immobilization, for instance) and complexity (here considered as essentially related with the degree of operator's intervention). in order to establish the clinical value of each methodological option, the resultant images were evaluated by independent physicians, according to different criteria, always based on its clinical value. conclusions: it had been clarified and justified what seems to be the best option for the use im in routine image processing, in the specific case of mpi. introduction: it is worldwide very common that patients who will undergo a myocardium perfusion scintigraphy are requested to be in fasting condition. even if this idea is generally accepted, the scientific evidence underlying this requirement seems to be far from objective and/or consensual. the main goal of this work is to contribute for the study of in vivo biodistribution and pharmacokinetics of mtcsestamibi with and without fasting. material and methods: the same normal volunteer was imaged twice under different physiological conditions: the first study was done without fasting and the second one in fasting condition. anterior projections of thoracic and abdominal regions were acquired during minutes, starting immediately after intravenous injection of the tracer. regions of interest in myocardium, liver, gallbladder and proximal intestine were drawn and a related timeactivity curve was then obtained. data was compared and correlated with the normal gastrointestinal tract physiology. results and conclusions: biodistribution and pharmacokinetics of mtc-sestamibi under those distinct physiological conditions had appeared slightly different, particularly in the case of organs such as the liver and the gallbladder. based on the obtained results, the authors assume first, the need to study further this subject and, secondly, maybe there is a need to review patient preparation procedures in the specific context of myocardium perfusion imaging. objectives: fdg-pet has suboptimal sensitivity in the diagnosis of brain metastases (bm). the presence of such metastases may result in cerebellar asymmetry (ca) of fdg uptake or crossed cerebellar diaschisis (ccd). previously, ccd has been studied qualitatively to describe the neuronal dysfunction of the cortico-pontocerebellar-system caused by supratentorial bm. we aimed to evaluate the potential added value of semiquantitative analysis of ca in the diagnosis of bm by comparing cerebellar uptake in patients (pts) with and without bm as well as in normal volunteers (nv) methods: a total of subjects studied: nv and cancer pts including without bm (g ) by mri and with bm (g ) as confirmed by mri, pet or histopathology. pet/ct scans of all subjects were retrospectively reviewed and one symmetric roi in bilateral cerebellar (cbl) cortex was drawn. differential values were calculated as -(suv /suv ), whereby suv /suv corresponds to the cerebllar hemisphere with the lower/higher suvmean, respectively. differential values of groups nv and g were used to determine the cut-off for ca determined as mean - x standard deviation. mann-whitney and t-tests were used for statistical analysis. results : differential values of nv and g showed no significant difference (mean . +/- . vs. . +/- . , p = . ) with values ranging from - . %. cut-off for ca was determined as differential values . %. / pts ( %) in g were found to have ca suggesting affection due to bm. / pts ( %) with unilateral supratentorial (st) metastasis showed contralateral ca consistent with ccd (frontal, parietal, occipital) which is compatible with published data. three pts demonstrated ca ipsilaterally to st foci (frontal, temporal/parietal occipital). despite bilateral st foci, / pts developed ca. / patients with cbl metastasis revealed ca caused by ipsilateral foci whereas pts with bilateral cbl foci showed no ca. bm could be identified by pet/ct in / pts ( %) as increased or decreased fdg-avidity. pet/ct failed to identify bm in / patients ( %) which however could have be decreased to ( %) if evaluation of ca was used. conclusions: detection of ca in fdg pet may indicate the presence of bm, and thus may have an added value in the diagnosis of bm, particularly if semiqunatitative measurement is used instead of subjective visual assessment. prospective validation of our findings is needed. measurement of suv as a means to evaluate glucose metabolism in solid tumours may aid in defining response to treatment. aim: we have evaluated fdg-suv changes during neoadjuvant chemo-radiotherapy in larc patients, in comparison with pathological response determined at surgery performed at the end of treatment. methods: thirty-three patients undergoing a novel treatment regimen have been evaluated with fdg pet during treatment. baseline pet studies were obtained from neck to pelvis for staging purposes. scans obtained after days of treatment and presurgically were carried out only on the pelvis. suv corrected for body weight was obtained for each study. maximum suv values and average suv values were obtained by drawing an irregular three-dimensional region of interest which semiautomatically defined the tumor area based on preset threshold values. values were recorded for the three studies and changes compared to treatment outcome which was defined on pathologic evaluation of surgical specimens at the end of treatment and scored on a five level tumor regression grade scale (trg). results: in % of tumours a complete or near-complete regression was observed at the end of treatment. in the remaining patients considered non-responders only partial or no regression was observed. baseline suv showed no correlation with the overall outcome. conversely, a strong correlation was observed between suv values measured days after the start of treatment and the pathological response (trg). the most important factor in predicting tumor response was found to be the early suv change (variation between the baseline and the day scan). the suv values measured on the pre-surgery scan were not as predictive of the overall outcome. we could define a cutoff value of the early average suv change that predicted treatment response in % of patients, whereas for early maximum suv change this was correct only in / patients. conclusions: fdg-pet is an effiecient and powerful tool for monitoring changes of tumour activity during the course of treatment. in particular, the early changes occurring shortly after beginning of treatment allow a very efficient evaluation of response which is more accurate for average suv compared to maximum suv. evaluation of dispersion of suv obtained by different pet system; preliminary cylinder phantom study h. otake , y. takahashi purpose: suv (standardized uptake value) is a useful tool for the evaluation of the uptake of fdg in tumor lesion, however, reliability of its accuracy in different condition such as different camera or institution has not been evaluated enough. in our study, suvs obtained by five pet systems with different acquisition condition and reconstruction method were compared by phantom study. materials and methods: five cameras, set- (shimadzu), acquiduo(toshiba), biograph lso(siemens), discovery (ge) and gemni (philips) were used. the same amount of radioactivity of f- was filled in a cylinder phantom with the size of mm tall and mm in diameter (type- , anzai-sogyo, tokyo, japan ). in phantom filled with same concentration of f- , different sized round spots ( , , , , , mm) filled with f- solution containing activity corresponding to suv . were placed in equal interval. suv of different spots were measured and compared with background. suv were calculated using formula by kubota et al. max suv obtained by roi methods was used as a representative value. d acquisition method and image reconstruction by fore-osem method was applied. results: minimum detectable size were different in each pet system. suvs by ct attenuation correction pet system were higher than those by external radiation source. in routine condition, maximum difference of suv was . %, whereas, . % in condition under image reconstruction. conclusion: for the early detection or follow up of cancer patients, contribution of fdg-pet is recently recognized and the number of study are increasing rapidly. however, we should pay attention about the follow up pet study by different pet camera, which may show different suv value. as shown in our study, maximum difference of suvs by different camera was . %, therefore, precise information of each pet study such as name of pet camera, acquisition condition and reconstruction method is recommended to be added to each results. aim: it is now a well know fact that the interpretation of abdomino-pelvic images in pet/ct can be altered by normal tracer fixation or accumulation in different organs and anatomic structures, such as the bowel, the ureters or the bladder. the purpose of this presentation is to show the advantages of the administration of furosemide and laxatives to the patient, as part of the preparation for a late second image acquisition when in presence of equivocal findings in first acquisition. methods: we present six examples of pet/ct (siemens biograph hirez) whole-body image acquisitions performed minutes after the i.v. administration of approximately mbq of f-fdg, adjusted according to the patient body weight. images were visually analysed after iterative reconstruction using the common parameters for these patients. when equivocal f-fdg foci were found along the course of urinary or intestinal tract, a second late abdomino-pelvic image acquisition (approximately h later) was performed after administration of furosemide ( - mg) and/or laxatives (sodium citrate and sodium laurilsulfoacetate). the second late images were then compared visually with the correspondent first acquisition ones. results: we show a comparative study of the images acquired before and after administration of furosemide and laxatives to remove equivocal f-fdg activity. as can be seen, the late images acquired post-furosemide and post-laxative administration, show enhanced information when compared with the first abdomino-pelvic pet/ct evaluation. this clearly allowed a more accurate distinction between physiologic and pathological f-fdg uptake, improving the diagnostic accuracy.conclusions: the administration of furosemide and laxatives and late image acquisition in pet/ct, after equivocal first diagnosis, due to retention of f-fdg along the intestinal and urinary tracts, proved to be of great utility in the above mentioned examples. in conclusion, this presentation shows the usefulness of this simple, non-invasive interventional procedures in ruling out suspected tracer fixation that is otherwise difficult to evaluate. objectives: to assess the value of a image fusion and change protocol for early detection of disease progression or recurrence. each patient underwent pre-surgery imaging with in- octreotide , i mibg and spiral ct and post surgery imaging with in- octreotide , i mibg and spiral ct at approximately monthly intervals post surgery. spect and whole body imaging (wbi) with in- octreotide is carried out at and hours pi . i mibg spect and wbi is performed at hrs and further wbi at hours pi. methods: a composite data set comprising the hr, hr octreotide, hr mibg and ct transaxial images is created by mutual information based image fusion for each patient's follow up imaging sessions. change detection is carried out between the octreotide spect hr and hr image sets to detect and eliminate significant changes corresponding to normal physiological excretion e.g. in the gut. remaining areas of stable, significant uptake are reviewed in the context of the co-registered hr mibg spect and ct data. pre -surgery and any previous post-surgery composite data sets are fused and compared to the current data to detect areas of significant change and potential areas of tumour recurrence or progression. results: of the patients included to date, exhibited stable disease, demonstrated disease progression and disease recurrence . conclusion: the advent of accurate image fusion software and ready availability of ct through pacs has enabled the development of comprehensive image protocols for follow up imaging in patients with neuroendocrine tumours. this image fusion and change detection protocol is also directly applicable to patient data acquired with new hybrid spect-ct systems. with the improvement of gamma cameras systems and software, spect has become a usual practice in most nuclear medicine departments. however, the development of other techniques in nuclear medicine conditioned the impact of new advances in spect methodology. spect provides significant technical challenges for the nuclear medicine technologist, concerning to data acquisition and image processing and reconstruction. many new advances in spect methodology are becoming available, such as whole body spect acquisition and iterative d reconstruction ( d osem). whole body spect acquisition is a new technique of image acquisition, allowing the d visualization of whole body. the application of this method is especially important in bone studies, excluding additional planar views, and improving the recognition and identification of lesions. the aims of this study are to describe the benefits of spect imaging based on whole body acquisition in bone studies and iterative d reconstruction (in relation to backprojection and the most widely used iterative reconstruction method, d osem) and analyse the impact, advantages and limitations of this methodologies, essentials to produce highest quality scans and reduce some image artefacts. material and methods: the acquisition of whole body spect was performed on a dual-head camera (siemens e.cam signature), using low-energy and high resolution collimators. a % energy window centered on kev was used for data acquisition. imaging was performed with the patient in supine position. images were acquired as × matrices with use of a º arc. for each of the positions considered, projections were acquired, each seconds in duration with a non-circular orbit, step and shoot mode. tomographic images were lately submitted to different reconstruction methodologies. results and conclusions: the whole body spect acquisition applied to bone studies is an effective, relatively cheap and easy to apply technique, that consume a short period of time ( minutes), allowing the d visualization of whole body, advantages that guarantees its superiority by themselves in relation to conventional whole body bone scan. in concern to reconstruction of the data, iterative d reconstruction algorithm provides significant improvements in image quality due to higher spatial resolution, lower noise, reduction of distortions and artefacts, improved image contrast and more accurate and easier to interpret images compared to backprojection and conventional iterative d reconstruction method. aim: oblique projections have been suggested to enhance sentinel node (sn) detection in breast cancer by supplementing anterior projection (ap) and lateral projection (lp). sn close to tracer depots can be especially difficult to detect. this may be remedied by moving the breast before acquiring ap or lp to increase distance between injection site and axilla. however, in some patients movement of the breast may be inadvisable, e.g. to avoid hook-wire displacement in patients with nonpalpable tumours. we wanted to compare a ° anterior oblique projection (ao- ) with ap and lp to investigate if this improved scintigraphic detection of sn in patients, where the breast could not be moved due to a hook-wire. furthermore, we wished to test the influence on observer confidence. material and methods: all women with non-palpable breast cancer scheduled for sn procedure and hook-wire implantation in were eligible (n= ). fifteen were excluded: reinjection of tracer s (n= ), contamination artefacts (n= ), bilateral tumours (n= ), non-available images (n= ), non-available surgery results (n= ) and multiple wire-implantations (n= ). mtc-nanocoll ( x mbq) was administered using both a peritumoral and a periareolar injection. scintigraphic images were obtained using a single-headed gamma camera (mediso, hungary) equipped with a low energy high resolution collimator. dynamic images in ao- were obtained for minutes after injection and a summed image from - minutes comprised the early ao- . following dynamic acquisi-tion, successive -minutes planar images were acquired in ap and lp. late images in ao- and ap were obtained successively starting minutes after injection. for each patient, the five images were reviewed randomly and independently without knowledge of other projections or the number reported and confirmed by surgery. results: in all patients, one or more sn were identified, in patients ( %), one or more were positive for metastases. in patients ( %), ap was sufficient. we found additional sn in ao- alone in of patients ( %); one was positive for metastasis. in another patients ( %), ao- also showed additional sn, but these were also visualized in lp. in the former patients, ao- improved observer confidence in ( %) and in the latter , observer confidence was improved with ao- in ( %). conclusion: adding oblique projections to standard ap and lp for sn detection in non-palpable breast cancer demonstrated a few more detected sn, and improved observer confidence in one third of the patients. to ascertain whether imaging patients at hours post injection will demonstrate sln(s) if the initial hour image is negative. method: sentinel lymph node (sln) images are usually acquired the day before surgery. four injections of mbq m tc nano-colloid in . ml are injected peri-areolar. the nipple area is then massaged for minutes. hours post injection anterior, lateral and oblique images are acquired on matrix with lehr collimator. a cobalt flood source is used to outline the patient. if no nodes are seen on the hour image a further minute oblique image is acquired at hours, again on matrix with lehr collimator. at surgery, ml of blue dye is also injected peri-areolar. results: out of patients (< %) demonstrated no nodes at three hours. patients went to surgery before delayed images could be acquired. of the remaining , ( %) images indicated nodes at hours. of the patients, with negative images at hours, had low activity nodes found at surgery using a gamma probe and in patient the nodes were detected with blue dye only. conclusion: imaging at hours post injection can improve the sln localisation if the hour image is negative. interdisciplinary databases for evaluation of nuclear medicine procedures m. móldrup , w. vach , p. hóilund-carlsen ; odense universitetshospital, odense c, denmark, university of southern denmark, odense c, denmark. we have established interdisciplinary databases the stem of which are nuclear medicine procedures in heart disease and cancer. using our database for breast cancer as an example we present its important characteristics and our experiences with it. material and methods: the database includes prospective and chronological data from mammography, nuclear medicine, surgery, pathology, oncology, and clinical genetics. its purpose is to ensure that all patients are included, check the quality of the sentinel lymph node (sln) procedure, evaluate its usefulness in terms of a constantly high identification rate, reliable detection, and treatment of extra-axillary slns, and long term follow-up with regard to axillary and distant recurrences. all parties agreed upon purpose, rules, and which data should be recorded for each patient. we created the questionnaire sheets with a common lay-out suited for typing of data, e.g., yes or no. all questions must be clear and unequivocal allowing simple answers only. each panel must have blanks for crosses or numbers, not text. spaces for "unknown" or "not done" are mandatory to ensure all questions are considered. in each department a contact person collects and controls data before submission to us, where they are checked once again by a controller before typing. in collaboration with the statistical research unit we have established an organization ensuring creation of proper webbased databases, relevant questionnaires, control of submitted data sheets, typing (twice) of data, error correction, etc. patient id is converted to a serial number to ensure anonymity. a set of basic data are available to all parties at all times. all can have their own data within a fortnight. interdisciplinary data are provided after application. an updated set of all data is available twice a year. results: the database has created a positive and unique collaboration between departments. all parties can check the entire patient course, including waiting and procedure times. it has become clear what is good and less good, if there are patterns of non-visibility of slns, reoperation, rates and appearance times of lymphedema, effects of treatment, new procedures, etc. conclusion: interdisciplinary databases yield closer collaboration and better understanding between parties. the fact that each department has its own questions means that data are much more comprehensive, detailed, correct, and up-todate than in nationwide cancer databases. datasheets and controllers are still necessary to ensure data reliability. nucl. med. , - ( ) ]. we use computer-controlled modules in connection with an automatic dose dispenser. the modules are installed in pharmaceutical class b cells surrounded by a class c laboratory. materials & methods: all the batches were analyzed according to the european pharmacopoeia (ep) to verify: •radiochemical purity (hplc, tlc); •ph (ph indicator strips); •sterility (all the batches has been sent to an external gmp compliance laboratory); •bacterial endotoxins (turbidimetric method); •chemical purity (hplc); •radionuclide purity (nai detector); •half-life (measuring the activity at different times in a dose calibrator); •residual solvents (gc-based method for measurement of residual methanol, acetone, ethanol and acetonitrile. detections limit was μg/ml for all solvents); • kryptofix . . (method developed by mock et al [nucl. med. biol. ; : - , ( ) ]; •bubble point of sterilization filters. depending on the requested amount of activity for in-house scheduled scans and of external costumers requests, we usually bombarded . ml of [ o] h o for to minutes at - μa beam current with a pettrace cyclotron and using alternatively two targets. [ f] fobtained by (p,n) reaction is transferred to the automated synthesis modules, which synthesise [ f] fdg within minutes. furthermore minutes are required to empty the target and additional minutes are necessary for the automatic dispensing unit to dispense activity in vials for qc, back-up and sterility in addition to vials for a variable number of costumers. all the samples are filtered (at . μm) into sterile evacuated collecting vials in pharmaceutical class a environment. results:the number of rejected batches over was and was due either to mechanical problems as leakage of fittings, tubes and valves or to solvent-/radiochemical impurities exceeding the ep limits. none of the batches was positive to sterility or pyrogenicity tests or presented problems due to the radiochemical purity or half life. conclusion: based on our experience we conclude that solvents impurities represent a crucial point in fdg production and great attention must be focused on an accurate method for residual solvents detection. background: immunoscintigraphy is an attractive tool for tumor and other imaging purposes, with iodine ( i / i) and indium(in) as popular isotopes for radiolabelling. i-labelling may be obtained by the iodogen and other methods, in needs some chelator, e.g. dtpa. the aim of this study was to produce and evaluate, in an experimental mouse model, a good labelling technique for in vivo use of a specific monoclonal antibodies (moab) against a human breast cancer (bc) antigen, muc- . materials and method: i and i labelled anti-muc- (muc) moab were synthesized by the iodogen method. after one sephadex purification step free i or i were < %. the i-muc was then injected into bc xenograft tumors in mice. as control a nonsense i-labelled moab, anti-tnp, was injected into other mice with the same bc tumors. by gamma camera monitoring and well counting of the tumors the retention of the moab were compared. in labelling of polyclonal igg ab modified with dtpa-anhydride were done times, before labelling muc. dtpa-anhydride was suspended in dichloro-methane (dcm) to avoid hydrolysis. just before adding the igg solution, dcm was evaporated with nitrogen. igg-dtpa was then separated from dtpa-anhydride by gel chromatography before adding in-citrate. results: iodine-: in the first series of bc xenografts i labelled muc was retained longer than anti-tnp (p< . ), both according to imaging and well counting. however, in the following identical mouse tumor series, radio-iodine was rapidly removed from muc anti-tnp in the xenografts, and high iodine uptake was noted in the thyroid gland. indium: labelling efficiency of igg-dtpa varied from to % (mean ). generally, but not always, purification with one sephadex column increased purity to > %. the in-muc has not yet been tested in an in vivo mouse model. conclusion: in vitro labelling with iodine is generally simple, but in vivo stability of i-labelled antibody must be carefully evaluated since de-iodination in vivo often occurs. inlabelled antibodies are, according to literature, usually stable in vivo, but chelatorbased in-labelling procedures may be a greater challenge for a reproducible production of a highly purified, radiolabelled antibody. aim: a radiation detection system for target monitoring was designed, developed and optimized for its use as a diagnostic tool for cyclotron startup, maintenance and operational needs. the system was installed for monitoring the radiation levels next to the cyclotron target during and after bombardment. the system permits a rapid assessment of the quality of any particular run in which isotopes are produced as radionuclides for pharmaceutical labeling. cyclotrons are produce short-lived positron-emitting isotopes that are used as research tools in identifying physiological mechanisms and in diagnostic procedures for numerous medical problems with the positron emission tomography (pet) instrument. the short half-lives characterizing the positron-emitting isotopes necessitate that they be produced at the desired activity, as rapidly as possible, so that they will be available for the scheduled procedure. this raises a need for automated control sensors that can monitor the production process. method: a computerized radiation detection system was developed for monitoring the radiation levels next to the cyclotron target, during and after the isotope bombardment in an attempt to show that a particular cyclotron run might be faulty. the system utilized a bgo scintillation detector focusing on measuring the photons at the energy window of kev; and a geiger muller detectors design for measuring the gross gamma radiation. the system monitored the radiation levels throughout the production run as well as the activity before and after the transfer procedure, when the measurement of isotope activity takes place. the installed system input on-line the results into computerized software, and used as part of an overall diagnostic and control tool of the bombardment run. results: the target radiation detectors provided an early warning of a malfunction or an irregular run. this information could lead to operational decisions in order to prevent delay in the production and availability of the isotope. the system predicted and quantified accurately the actual amount of radioactivity being produced, thus it assured quality control during isotope production. the system also helped in troubleshooting target problems immediately after their occurrence and identified the stage at which the malfunctioning took place. conclusion: the results obtained from the developed system indicated that such a measurement tool can serve as a powerful instrument for sensing various target conditions. this can be translated to an awareness of problems in the early stage during isotope production, and provide early notification to the cyclotron operator that a particular run is malfunctioning. aim at present, most nuclear medical departments have instrumentation that allows them to perform tommographic studies in a continuous circular method. with the present work, we aimed to compare quality of images obtained by simple photon emission tomography with two approaches, continuous circular and step-and-shoot circular acquisitions. material and methods for both methods, continuous circular acquisition and step-and-shoot circular acquisition, we tried to establish associations between acquisition parameters (independent variables) -number of projections for each detector, time for each projection; and measurements of image quality (dependent variables) -noise, contrast, resolution and sensitivity. the experimental series was defined using a non probabilistic method by convenience, with sixteen studies of a jaszczak fantom, model ecat/dlx/p, in which eight studies were acquired in a continuous circular mode and the other eight in circular step-and-shoot mode. the statistical analysis was performed with package spss version . results the percentage of noise was inferior in studies in continuous circular mode, the contrast measured with the spheres gave identical results in the two acquisition methods, the resolution was higher in step-and-shoot mode and the detection sensitivity was higher in continuous circular mode. conclusion we conclude that the tommographic acquisition in continuous circular mode presents identical image quality to the one in step-and-shoot circular mode. the quantification of low activity in plasma of a positron emission tomography tracer is performed in pet research to derive a kinetic model for a particular biochemical process. to define the kinetic model, the concentration of radioactivity in the parent compound present in the plasma must be measured at several time points. a radio-hplc is used to measure low levels of radioactivity in a compound throughout rapid sequential experiments with the nearby presence of another compound causing a high background level. both the measured compound and the background level are caused by compounds labeled by a positron emitter isotope. the time separation between the parent compound and the metabolite one is limited, therefore optimization of the measured volume and its geometrical configuration can improve the minimum detectable activity. improving of the mda is important for achieving a better reliability and validity in measuring biochemical processes with pet. the research was based on an analytical study, followed by software simulation and feasibility experiments for increasing the measuring sensitivity of an hplc metabolite radiation detector. as a first analytical step a mathematical model for the coincidence measurement probability from a pet tracer radioactive compound was developed. by using this model, an estimation of the number of coincidence counts was made, and its influence on detection sensitivity from the system configuration parameters was assessed. results of the mathematical model were compared to those obtained by software simulation.. finally an experiment was performed under similar conditions those in the mathematical modeling and software simulation. a high correlation between the mathematical modeling and the software simulation was found. the results indicated that an optimum for the measured volume and its geometrical configuration can be found. a curve representing the measured coincidence counts as a function of volume was obtained from the experimental results. the experiment validated the analytical study, showing that optimization can be achieved for each case based on the time separation between the parent compound and the metabolite one. a new method for improving the mda for the data acquisition during kinetic modeling, based on optimizing the measured volume seen by coincidence detection configuration is suggested. the mda is defined by both the signal and the background levels. the s reduction in the sensitivity for the signal measurement is negligible compared to the reduction in the background level, and is achieved by increasing the distance between the measured parent compound and the metabolite one. we have developed a simple image registration method for m tc-mdp planar bone scintigraphy and x-ray images in patients with suspected scaphoid fracture. this method is based on immobilisation of the wrist in a vacuum pillow equipped with three multi-modality fiducial markers ( co-source collimated by a punched coin, . cm) during image acquisition followed by computer assisted semi automatic image registration (casair). the aims of this study were to investigate the feasibility of the vacuum pillow to immobilize the wrist and to evaluate the accuracy of casair. materials & methods: wrist movement between two examinations was assessed in five healthy individuals. a small metal disk ( . cm) was taped radially to the volar side of the carpus. two x-ray images were acquired with the wrist immobilized in a vacuum pillow equipped with three fiducial markers. between the two acquisitions the subject walked around for about minutes. the two images were registered with casair and the distance between the centres of the metal disc on the carpus in the two images picture was measured. accuracy of multi-modality image registration with casair was estimated from clinical fusion images. the distance between the centres of each fiducial marker on the x-ray image and scintigraphic image was measured. results: mean wrist movement as evaluated by consecutive xrays was . mm (range mm to . mm ). accuracy of casair was . mm (range . to . mm). conclusion: the vacuum pillow provides a feasible and accurate method of immobilisation of the wrist and image registration with casair provides very accurate image registration of nuclear medicine and x-ray images. in consideration of the size of the scaphoid bone the magnitude of misregistration with the proposed method has no clinical impact. introduction:in routine practice of spect acqusition,the image acquisition time per projection is a cause of concern eventually leading to increased overall acquisition time of a clical study.the present study was therefore undertaken to optimize the overall aquisition time irespective of whether fbp or osem reconstruction technique is used.the objective of the study also included comparative evaluation of the images obtained by either reconstruction techniques. materials and methods:the raw image data were retreived from dst-xl sopha gamma camera work station and were then subjected reconstruction using both fbp and osem technique on xeleries work station.the aquisition time was also manipulated to seconds per view from seconds per view/projection.the reconstructed images were obtaine for reduced acquisition time keeping all other parameters identical nad by using both reconstruction techniques.the reconstructed images were blinded for independent evaluation by two nuclear medicine physicians in the nuclear medicine department of the institute. results and conclusions:the overall image information and quality remained unchanged even after reducing the acquisition time from seconds to seconds per projection irrespective of whether fbp or osem reconstruction method was used for skeletal images.in addition the intercomparison of fbp and osem reconstructed images revealed that the image information was better delineated in osem reconstructed images as compared to fbp reconstructed images. the image optimization in terms of reduction in acquisition time without any loss of image information would help reducing overall study time in spect aquisition.in addition use of osem reconstruction technique appears to be the order of the day in image processing and would provide improved image information delineation. the generally used filtered back projection(fbp)method is likely to be influenced by high accumulation, especially in the liver and biliary system, and it is often difficult to reduce the waiting time for imaging with a tc preparation. in this study, reduction of artifacts using the projection mask method was studied. method: a model was prepared to generate artifacts from the liver using a cardiohepatic phantom. mask processing of counts was applied to spect images acquired over degrees at intervals of degrees and the obtained projection data of slices other than the myocardium. a similar mask processing was also applied to clinical cases after ami and compared. for analysis, decreases and variations of the counts were measured with a polar map and a circumferential profile curve (cpr) on a short axial image. results: in the phantom, a significant difference in the count was observed (p< . ) between normal processing and mask processing, that is, the average count was . for normal processing and . for mask processing. variances in the area with visually observed artifacts with the cpr were . for normal processing and . for mask processing, indicating smaller variations with the mask processing. the counts and variances in an area with visually observed artifacts in clinical cases were . and . respectively, which were significantly reduced to . and . by mask processing (p< . ). conclusion: the projection mask processing method is an effective means for removing artifacts from the liver and the gallbladder, and imaging may be available from the early period after myocardial injection of the mtc tracer. aim: in pet study, the coincidence count rate (cr) in the imaging of standard image quality phantom (iq phantom) is different from that of the actual clinical data. therefore, clinically optimal injection dose cannot be estimated using the data of iq phantom. in this study, we made an anthropomorphic pelvis phantom (pelvis phantom) which can provide the cr equivalent to clinical data and investigated whether the optimal injection dose could be estimated using this pelvic phantom. materials and methods: the pelvic phantom was made by putting high radioactivity area imitating the urinary bladder in the iq phantom and by using bone-equivalent material for pelvic bone model. at first, the images of the pelvic phantom were acquired changing its radioactivity using both d and d acquisition modes. obtained crs were compared to those of pelvic images of actual patients. then, single photon ratio (spr) indicating the maximal necr was determined in the pelvic phantom imaging. using this spr, the spr obtained from patients' data was normalized. the optimal injection dose of fdg per kg of body weight was calculated according to the relationship between spr and the injected dose. results: the good correspondence was shown between cr of pelvic phantom data and that of clinical data when sprs were . to . mcps for d imaging, and . to . mcps for d imaging. the spr at the maximal necr in the pelvic phantom imaging was . mcps in d acquisition whereas no peak was found in d mode. the optimal injection doses calculated using spr in d imaging were mbq and mbq for the body weight of kg and kg, respectively. these results were empirically acceptable. conclusion: the imaging of pelvic phantom showed the cr similar to human bodies, indicating that the statistical quality of the obtained data in human studies can be estimated by this phantom. and, using spr of this phantom, the optimal injection dose per body weight could be simulated in d imaging. introduction: phantoms for the determination of the size of pixels should be big, rectangular, homogeneous and easily available. however, they must not "jut out". the nema homogeneity phantom can meet these requirements if its position is adjusted to whole body scanning. material and methods: the nema phantom was filled with gbq of m-tco and placed on the examination table with its long edges parallel to the examination table. a square tile of . cm was put on top of the phantom and was aligned to one of the short edges of the nema phantom to facilitate a comparison of the resulting defect with that of a static image. pixel numbers were determined by applying rectangular roi to the edges of the phantom and of the tile. by this, the numbers of pixels of the x-and y-axis could be determined and compared with the length and width of the phantoms. we compared the data of a prism camera with those of an lfov camera that had not been approved yet by our hospital at the time when we did the exams. we did a static scan and two whole body scans ( and cm) with both cameras. results tile the accuracy of osem and fbp reconstruction algorithm for the determination of the thyroid volume: a fantom study a. ergulen, g. durmus-altun, f. ustun, s. erol, s. cıldavil, s. berkarda; trakya university, edirne, turkey.background_individualised dosage models are frequently applied for radioiodine therapy in patients with graves' hyperthyroidism. in these dosage schemes the thyroid volume (tv) is an important parameter. iterative reconstruction algorithms produce accurate images without streak artifacts as in filtered backprojection. they allow improved incorporation of important corrections for image degrading effects, such as attenuation, scatter and depth-dependent resolution. the aim of this study was to compare the accuracy of osem and fbp reconstruction algorithm for the determination of the tv in fantom study, and to comparing estimted tv and anterior degree spect acquisition methods and results_the osem (it: , sbs: ) and fbp (bw cut-off: . , order ) algorithm was employed in reconstruction. at quantitative analysis and anterior degree -i thyroid spect , the volume of thyroid were calculated for %- %- % uptake levels of wather-filled thyroid fantom. for estimation of tv, linear regresion analysis was eployed and final regresion equations were generated for each acqusitions and filters. the thyroid images were filtered, and after applying a threshold method an automatic segmentation algorithm was used for the volume determinations. the best estimation of tv was observed on degree spect acquisition and fbp algoritims. estimated tv(ml)= +( . * calculated tv)-( . * average count of thyroid); r: . , r : . , p: . , se of estimation: . ). th predicted tv was . +/- . ml (min: . , max: . ) and see of ptv was . +/- . ml. conclusions_the comparisons with osem and fbp indicate that thyroid volume estimations with aim high resolution scintigraphy ( hrs) can be useful in radio-guided surgery (rgs) and small animal imaging. devices are generally based on arrays of sensible elements: room temperature semiconductor arrays or scintillating crystals arrays that can be coupled with position sensitive photomultipliers (pspmt). here we describe a small field of view (fov) portable cameras based on and inches pspmt. materials & methods these cameras show a peculiar crystal-collimator-pspmt matching that allows the exact positioning of all the scintillating elements inserted in the square holes of a parallel tungsten collimator. this arrangement ensures no crosstalk of rays or light among crystals. the scintillation light emerging from each crystal is revealed by a pspmt (h or r - -c ). the anodes allow event positioning through the reconstruction of the maximum of the multiplied charge distribution by the centroid algorithm. data are then selected with an appropriate energy window and transferred to a workstation. we studied the spatial resolution and the homogeneity of two cameras both equipped with . x . x mm csi (tl) crystals and a mm long collimator. a thin plexiglas container filled with m tc was used to check homogeneity and pixel identification. a derenzo phantoms with the diameter of the holes ranging from to mm was positioned at contact, at , , cm distance from the collimator and filled with m tc to assess the camera spatial resolution. results the energy resolution was . % fwhm of the m tc peak over the whole fov area. both cameras showed homogeneity within ± % between max and min pixel counts. pixel identification showed average peak to valley ratio of : . spatial resolution was . mm at cm, . mm at cm, . mm at cm and . mm at cm distance. conclusion measurement of resolution were performed to foresee the working conditions of hr cameras. actually when nuclear physicians show to surgeons sentinel nodes or parathyroid glands, they are on contact with the source or at few cm distance. both detectors were used for rgs and showed hot nodes less than mm large and distant . mm each other. in several instances a spot detected as single node by anger camera showed the presence of two near nodes. aim the aim of our study is to evaluate the correlation between the bone density measured with quantitative us technique (qus) and with dual x-ray absorbiometry (dxa). material and methods we studied patients ( - years; mean: ). bone status was assessed by quantitative ultrasound, using dbm sonic (igea, italy), which measures amplitude-dependent speed of sound (ad-sos [m/s]) and bone densitometry by the use of unigamma plus/compact (l'acn, italy), which measures bone mineral density. we correlated the t-score parameters obtained in qus e in dxa scan. "t-score" compares the patient's bmd with the young-normal mean bmd and expresses the difference as a standard deviation (sd) score. the qus was performed in menopausal ambulatory in gynaecology department, measuring the bone tissue at the metaphysic of the proximal phalanges of the last four fingers of the non-dominant hand. after the ultrasound bone densitometry, the women underwent the dxa scan of lumbar spine (l -l ). the bmd is calculated in g/cm . we had exposed t-score as diagnosis of normality, osteopenia and osteoporosis according to world healt organization normal range. results according the who definitions, osteopenia was found in patients and normal bone density in patients with quantitative us technique . with dxa method, osteopenia was found in patients, normal in patients and osteoporosis in patient . conclusions concordance was found between the bone density measured with qus and with dxa in patients, while patients results were discordant. some studies in literature showed an agreement of . - . between qus methods and dxa in our study the agreement between the diagnosis in qus and in dxa is . . it agree the literature data. our intention is to continue this study, extending the case study. aim: neuroendocrine tumors may be treated by peptide receptor radionuclide therapy. in order to target somatostatin expressing tumors dotatoc was coupled to a ßemitter yttrium- (y- ) or lutetium- (lu- ) which results in a high radiation dose in the tumor tissue. the elimination of the peptide occurs via the kidneys. y- -dotatoc shows tubular reabsorbtion and accumulates in the kidneys. therefore, a major complication of y- -dotatoc-therapy is the radiation-induced nephrotoxicity. in this study we determined the effects of y- -dotatoc-therapy on renal function with tc- m-mag- scintigraphy. methods: patients ( m; f) between and years (average: , years; median: years) have been examined. all patients received a minimum of three dotatoc-therapies in combination with a nephro-protective amino acid infusion according to the heidelberger standard protocoll. the dynamic scintigraphy was carried out from dorsal position (multispect , fa. siemens) with a weight dependent application of tc- m-mag . between the st. and th. minute p.i. a blood sample was taken at the opposite arm. the blood was centrifuged and ml serum was measured in a gammacounter using repeat determination. the evaluation of the tubular excretion rate (ter) was done on a xeleris workstation. the ter of any examination was normalized using a specific patient standard. the average after the second, third and forth therapy was verified with the t-test procedure and deviations from average were analysed. results: after the second and third therapy there was no significant change in renal function with a probability of p= , (n= ) after the second therapy and p= , (n= ) after the third therapy. a significant aggravation of the renal function was shown in patients p= , (n= ) after the fourth therapy. in of patients the ter was pathological. conclusions: three cycles of y- -dotatoc therapy are well tolerated by the kidneys, and a significant reduction of renal functions were not observed. however a significant reduction of the ter was found after the th cycle in some patients. however, the renal function dropped into the pathological range in . % of these patients. we conclude that the risk of a nephro-toxicity by a y- -dotatoc-therapy is negligible during the first cycles. after the th cycle of y- -dotatoc therapy, a reduction of renal function may occur, but the clinical relevance is low. this presentation will outline some of the additional duties that may be encountered by a nuclear medicine technologist (nmt) working in the field of rit research. radioimmunotherapy is being increasingly used, particularly in the treatment of haematological malignancies. a stem cell transplant with prior rit involves input from a range of specialities such as oncology, haematology, nursing, radiopharmacy, physics, imaging, and laboratory services. it is vital that the multidisciplinary team works in harmony to deliver this service. the large number of staff members involved adds complication to making patient appointments and has led to some overlapping of roles in order to offer a continuous service. rit is a complex and evolving technique and many procedures will be new to a nuclear medicine technologist entering the field. the additional duties performed by a nmt at southampton include coordination of patient appointments for rit clinical trials, performance of elisa assays, quality control of radio labeled antibodies by hplc and itlc, administration of dosimetric and therapeutic infusions, assistance with dosimetry calculations and bremstrahlung imaging. these duties will be illustrated with reference to a clinical rit trial currently being undertaken at this institution. aim the aim of this study was to determine the radiation dosimetry of no-carrieradded (nca) i-metaiodobenzylguanidine (mibg) compared to carrier-added (ca) i mibg, in the same subjects. materials and methods nine healthy subjects were injected with mbq nca i mibg and on a separate occasion with ca i mibg. anterior and posterior whole body (wb) scans were made with a dual-head camera at min, . , . , . , , and h post injection to obtain organ timeactivity data. blood samples were collected at the same time points in order to determine activity in the total blood volume. urine was collected in five portions up to h in order to monitor the excretion. one set of regions of interest (rois) was drawn for ten source organs and different background regions on the wb scans, and then applied to each wb scan. the counts in the rois were corrected for background. the geometric mean net counts were calculated, and corrected for attenuation, efficiency, decay, and expressed as a percentage of injected activity. curve fitting was applied to the time-activity data to obtain the total number of disintegrations in each source organ, from which the absorbed doses to all organs was calculated (olinda/exm software). the effective dose (msv/mbq) and effective dose equivalent (msv/mbq) were then determined. results the effective dose of nca i mibg was equal to ca i mibg ( . ± . msv/mbq vs. . ± . msv/mbq, respectively; p= . ). the effective dose equivalent of nca i mibg corresponded with that of ca i mibg ( . ± . msv/mbq vs. . ± . msv/mbq, respectively; p= . ). the myocardial wall showed % more uptake for nca i mibg compared to ca i mibg. the radiation dose to the myocardium was thus higher for nca i mibg compared to ca i mibg ( . ± . msv/mbq vs. . ± . msv/mbq, respectively). conclusion no essential differences were found in absorbed dose between nca and ca. the higher myocardial uptake of nca favours the use of nca over ca for the assessment of myocardial imaging. characteristic evaluation of a real-time semiconductor dosimeter and measuring finger dose in nuclear medicine departments t. fujibuchi , t. isobe , t. iimori , y. uchida ; chiba university hospital, chiba-shi, japan, kitasato university, sagamihara-shi, japan.background and purpose: workers who use radiation sources in the nuclear medicine field have the highest risk of exposures to their fingers. until now, tlds have been the only reliable dosimeter to measure finger doses. however, the usage of tlds is complicated, its procedure is time-consuming and it is used in other fields as well. in this study, we measured finger doses by using a semiconductor dosimeter for the nuclear medicine examination and evaluated its sensor characteristic. after having aim: the tracheo-bronchial inhalation is the most invalidating symptom shown by patients with neurological disease and it is the most frequent cause of death. oro-pharyngo-esophageal scintigraphy (ofes) allows both functional and semiquantitative study of the various stages of swallowing. material and methods: we studied with ofes a woman who underwent to high dosage radiotherapy treatment for rhinopharyngeal carcinoma. the patient developed progressive and ingravescent dysphagia, with ipomobility of the right arm. the patient, placed in a ° right anterior oblique upright position, in front of a large-field-of view gamma-camera, was given a single cc bolus o water labelled with mbq of m tc-nanocolloid. eight images/sec are acquired ( . sec/frame) for one minute, with dynamic acquisitions using a x matrix and zoom of the visual field from oral cavity down to epigastric area. two second after the beginning the patient is invited to swallow the liquid in a single time and a static image lasting seconds is then acquired at the end of examination, to evaluate the presence of tracheo-bronchial aspirate. for the presence of massive inhalation the study was completed with a spet-tc. the parameters analysed were: oral, pharyngeal and esophageal transit time, oro-pharyngeal and esophageal retention index, percentage of tracheo-bronchial aspirate. the study was performed at the time of diagnosis, after the treatment by positioning the low pressure cuffied tracheostomy tube and finally after functional laryngectomy. results: ofes shows a massive tracheo-bronchial inhalation at first study with ritention of bolus in the both lungs and a lengthier oral and pharyngeal transit times and an increase in the oro-pharyngeal retention index. a spet-tc confirms the pulmonary aspiration and shows a sovra-elevation of the right lung as consequence of inhalation. the ofes performed after positioning of the cuffied tracheostomy tube shows absence of inhalation in tracheo-bronchial tract after oropharyngo-esophageal transit of liquid bolus with a presence of small aspiration in the right lung in tardive acquisition. the cuffied tracheostomy tube was changed with a standard tracheostomy tube and the ofes shows again massive tracheo-bronchial inhalation. then the patient was submitted to functional laryngectomy. a scintigraphic study performed subsequentely shows absence of tracheo-bronchial inhalation. conclusion: ofes in neurological patient is a simple, inexpensive, non invasive and reliable technique that shows the presence of bolus inhaled and quantifies tracheobronchial aspirate. ofes is a useful and accurate tool to monitoring the response to medical and/or surgery therapy. ger on children with recidive bronchitis(rb) m. hudournik; general hospital celje, celje, slovenia.aim: in this examination we are finding how frequent ger as a cause for rb. materials and methods: in this examination have been included children ( men, women) in an age from mounts to years. doctor's notes for these children have: rb ( children), vomiting ( ), cough ( ) and allergy ( ). the images of these children has been taken in lying position after a normal meal. radiofarmac was tc- m-lyomaa (dose upon , mbq - mbq), which has been to apply through the nasogastric tube or to drink up. gamma camera was set up behind the patient. the field of view includes the mouth, sternum and abdomen. images are generated every s for h on x matrix. after - hours we have taken delay images of lungs to find out the aspiration tc- m-lyomma in to the lungs. results: from all ( ) in this examination included children has had ( , %) ger and from this has ha dan aspiration in the lungs. in examination has confirmed with diagnosis, rb %, vomiting %, allergy % and cough % ger. children average age with rb diagnosis has been , years . most children ( ) with rb has been - years old, % of them has had a ger. conclusion: frequency of ger on children with rb is %, especially with children at approximate age ( %). introduction: the collaboration problems that arise from the observation and care of patients could be codified to nursing interventions classification (nic), to obtain finally results codified agreed to nursing outcomes classification (noc). these collaboration problems, interventions (nic) and results (noc) applied to patients referred for treatment of hipertiroidism could identify and develop interventions to optimize ant obtain the wished results so the patient feels more comfortable in the visit to our service. methodology: since the nursing in our service are explore these aspects in the daily care of patients (approximately patients weekly), and have been identified the collaboration problems that usually presents this type of patients. the most frequent were: administration of radionuclides, informed consent, radioprotection advices, nursing registry, discard pregnancy in women in fertile age. once identified these collaborations problems an interventions, codified according the nic criteria are applied: administration of oral medication ( ), agreement with the patient ( ), support in making decisions ( ), identification of risks ( ), documentation ( ), advise before conception ( ). all patients fulfilled a report (survey form) about the satisfaction for the care received in the service. this form was complimented at % of patients. all patients facilitated a satisfaction survey when they left our service, which was answered for the % of them. results: after application the interventions we had a satisfactory results in % of patients. these results codified agreed the noc were: behaviour of fulfillment ( ), well-being ( ) , knowledge: prescribed activity ( ), knowledge: preconception ( ). conclusions: the use of the methodology according nanda criteria could diminish the collaboration problems in patients referred to treatment with i- . we acquired image that used orbiter gamma camera with pin hole collimator. also we acquired the thyroid phantom and the -q bar phantom image to compare resolution. the patient image aquired by sec or kcnts. and phantom image acquired by kcnts. we calculated thyroid/bkg ratio from the image that is setted with sec. and then compared scan time from the image that is setted with kcnts. additionally, we investigated that the time required of each diseases(hyperthyroidism, hypothyroidism, goiter, nodule). when we acquired image by time setting( sec), using mm pin hole collimator and mm pin hole collimator, that result of thyroid/bkg ratio was as low as . times in mm pin hole collimator(ratio - mm: . , mm: . ). and we the relative high number of persons who daily attend to nuclear medicine departments is an important factor regarding disease transmission. although the permanence of these people in the facilities is usually quite short in time, there is always the possibility to transmit or receive infectious agents (both through organic material or airborne transmission). the goal of this work is, firstly, to "make the diagnosis" of the present situation, identifying what kind of infectious agents are present at nuclear medicine departments (and if different nm departments present different profiles, according to their characteristic turnover of patients), and, secondly, to suggest appropriated technical solutions for their control/elimination, when possible (otherwise, at least, to obtain their minimization). this abstract relates with the first part of the work (as it is still on progress). material and methods: as a first step, it was performed the characterization of the present situation, via an adequate analysis/detection of the main pathological agents (focusing only on bacteria and fungi) present in the diagnostic equipment, as well as in other important "hot spots" in a nuclear medicine department, where the spreading of these agents was believed to be more prone to happen (such as keyboards). it had been collected and microbiologically analysed bacteriological samples from those pre-established spots in several distinct nuclear medicine departments. the information collected is actually being related to the different kind of scintigraphic studies that are performed in those departments (and/or the different "specific profiles" of the departments itselves). the cleaning methodology (agents used and respective frequency) used in these departments is being taken into account and related with the results obtained. results and conclusions: according to the results obtained, it had been possible to identify the main infectious agents and to make the "point of the situation" in distinct profiles of nm departments, being believed that this should be the starting point to further studies, now aiming to identify methodologies able to control the incidence of nosocomial infections related with nm departments. ben-gurion university of the negev, beer-sheva, israel. the o oxygen isotope is widely used in cyclotron targets for the production of the f positron emitting isotope. the latter's rapidly increasing use in medical imaging generated a need to improve the diagnostic tools for controlling the cyclotron production of f and o during the enrichment process. a highly reliable measurement of o concentration is important for the o manufacturer to validate its purity, and for the f producer, to assure that that it is produced with the required activity and quantity at the end of the cyclotron run. this work describes a process that can validate the concentration of these isotopes and that should prove useful to both parties. the manufacturing of o water involves several stages to obtain the final required concentration of o ( . %). by carrying out isotopic analysis repeatedly throughout these stages, the concentration of each isotope can be validated. a radiation detector was used to measure the gamma field for different levels of o enrichment during the production of f. the gamma radiation dose rate and the accumulated dose were measured for a target loaded with recycled water, or % enriched o water, or o water. the detector readings from the nuclear interaction in the cyclotron target were compared to the measured beam current, the existing indicator for the bombardment. the variations in the radiation level were calculated and compared to the different levels of o activity in the water, obtained repeatedly throughout the enrichment process, to establish a relationship. the isotope analysis test during enrichment enabled the manufacturer to maintain the o enriched water concentration level in the short run, and the o production quantity rate in the long run. the water enrichment was not reflected by the accumulated beam current when measuring cyclotron protons; however the calculated ratio between the radiation level and the accumulated beam current gave a factor of up to . during the target water bombardment at the various stages. this study presents a comprehensive solution for monitoring and validating o enrichment during the manufacturing stage, as well as the production of f. the isotopic analytical test enabled malfunction identification at the early stages of the o manufacturing process which assured quality and quantity. during the bombardment, the beam current did not indicate any difference in the level of enrichment. however, the radiation monitoring system provided a useful tool for distinguishing between different enrichment levels during the production runs. calibration of i- in dose calibrators routinely used in nuclear medicine departments s. tastan , n. kucuk , e. ibis , e. turkoglu , k. kir , a. soylu ; ankara university, ankara, turkey, monrol a.s, ankara, turkey.introduction: a dose calibrator is one of the most important instruments in a nuclear medicine center since it is crucial to give the right amount of activity to the patient. the calibrator is a well-type ionisation chamber, which has long term stability and can measure activity to the desired level of accuracy. however, it is sensitive to even small changes in geometry, container type, density and volume of samples. material & method: in this study ,which is part of a project supported by the iaea as a crp,performance tests of biodex atomlab- dose calibrator were performed according to " iaea technical report series no: " . the calibration was done by using an i- standard solution provided by the iaea to all participants of the project in various countries. the solution was mbq/ ml in a r schott vial with teflon-coated stoper and aluminium uncrimped seal,uncertainity ( %, k= ) . correction factors were calculated for the r vial, ml syringe and the vial which is routinely used in our laboratory . during the transfer to syringe/vial, necessary amount of carrier solution was added to bring final solution to original mass. results: calibration factors were . , . , . respectively r vial, ml syringe and routine vial. gum ( iso guide to the expression of uncertainty in measurement) were used to analyse all uncertainty components. the table demonstrates correction factors with the calculated uncertainities. conclusion: this study demonstrated that dose calibrator measurements are sensitive to small changes in container type and geometry altough total mass is the same. in many countries don't have national measurement laboratories. therefore, it is important that performance tests, calibrations and audits of radioactivity measurements in radiopharmacies and clinic so that measurement errors can be avoided.correction factor with uncertainities r vial . x activity ± , k= routine vial , x activity ± , k= ml syringe , x activity ± , k= introduction. usually the patients coming for the first time to our diagnosis unit for a pet study show a high degree of unknown about details of that. this fact induces a high degree of anxiety that could be assessed in nursing diagnosis according nanda classification. on basis this diagnosis could be planned nursing interventions (nic). objective: to evaluate nursing diagnosis of anxiety and the effectiveness of the application of interventions (nic) according to noc criteria in patients who are going to perform a pet study. material and methods: from i/' to vi/' patients have been studied for first time using pet, under suspicion of malignant disease. for this purpose, patients with alteration of conscience level are excluded. the degree of anxiety is evaluated by means a numerical scale likert type, before and after the application of the plan of care. results: after the application of the nursing care plan a % of patients reduce in points the anxiety level, in % this reduction is of points and in a % in point according likert scale. conclusions: the application of the nursing plan of care in patients, who first perform a study pet, diminished the level of anxiety in a significant proportion. high performance liquid chromatography evaluated the stability of levofloxacin and stannous chloride for injection x. q. zhou, g. x. cao, r. j. zhang, x. f. qin; jiangsu institute of nuclear medicine, wuxi, jiangsu province, china.aim: levofloxacin is a sort of broadspectrum antibiotic which is often used to treat infectious diseases at present. the method about determination content of levofloxacin tablet using spectrophotography was reported. m tc-levofloxacin is a new specific infect imaging. we prepared levofloxacin and stannous chloride for injection by freeze-dry. it is most important for radiopharmaceutical. we determined the concentration and evaluated the stability of levofloxacin in levofloxacin and stannous chloride for injection for the first time. methods:the concentration of levofloxacin and the concerned substance in levofloxacin and stannous chloride for injection were determined by reverse high performance liquid chromatography (hplc). the stability of levofloxacin and stannous chloride for injection and the radiochemical purity were examined under the different conditions of light, temperature, humidity. we used citric acid and acetonitrile ( : ) as mobile phase, adjusted ph to . using triethylamine. the mobile phase was pumped at ml/min through the lichrospher c ( . × mm, μm) at room temperature. the detective wavelength was nm and the sensitivity was . aufs .the number of theoretical plates was exceed using the model high performance liquid chromatograph and uv detection (waters aim: to guarantee presentation of all studies from pacs to a particular examination on a given imaging modality (in our case pet) after a query from his. material: pet ecat accel (siemens, erlangen, germany), dicom modality tool kit (the offis computer science institute, oldenburg, germany). method: his is interconnected with pacs via unique identifier (on pacs side with the seek key "accession number") for selecting all image data for particular examination on given imaging modality. the imaging modalities without the possibility to write down this unique identifier to a corresponding data item (most often if native image format is used -e.g. ecat for pet ecat accel) can usually use the data item only for a unique "study id". now there arises a problem if it was necessary to make additional studies for a particular examination, as the previous image study would be unwantedly overwritten. the only possible solution is simulated modification of "study id" for additional studies. for the purposes of proper archiving and selecting all the studies appertaining to a given examination on pacs it is necessary, after the conversion of the native image format to dicom, to write down backwards in the blank data item "accession number" the original unmodified value. on the basis of the above mentioned was for simulated "study id" generation modified before now designed dicom modality worklist in the form of an intranet application. after the conversion of the native image format ecat to dicom on the evaluating workstation esoft siemens are the image data going to pacs received by a temporally pacs running on hospital intranet server. here is reconstructed backwards the original value of the "accession number" from data item with simulated "study id" and is at once written into the corresponding blank data item in the format dicom. the data repaired in this way are resent to target pacs and after their successful archiving deleted from temporally pacs. results: such solution allows medical staff to make very simply additional studies on scheduled imaging modality for a given examination such that all of them could always be presented after a query from his. conclusion: the methods with the usage of free software tools may not always be easy to perform but sometimes are the only possible. moreover, they are in some cases the cheapest option. aim: vaccination using dendritic cells is a new therapeutic approach for patients with disseminated malignant melanoma. this phase i-study examines safety and migration of alpha-type i dendritic cells versus pge dendritic cells in patients with malignant melanoma. methods: the treatment consist of vaccination with the patients own dendritic cells, which are injected intradermally or directly into the lymph nodes. at the onset of treatment we are looking for the migration comportment of radiolabeled dendritic cells generated by differently preparation processes. at present six patients with malignant melanoma in stages iii and iv (ajcc, ) were included. alpha-type i dendritic cells and pge dendritic cells were radiolabeled with approximately . mbq in-oxin. thereafter, a minimum of x alpha-type i dendritic cells were injected intradermally of the right upper leg, and the same amount of pge dendritic cells into the left upper leg. migration was investigated by dynamic examination during min. furthermore, static scans were performed inguinal for another min. with and without shielding of the injection area. additionally, whole body scan, including radioactive standards (activities . mbq - . mbq) were performed with a scan speed of cm/min. late scans were acquired hours and hours after injection. results: scintigraphically, lymph nodes were visualized at and hours after injection. positive lesions were semi-quantitatively analysed by drawing regions of interest (roi) above the injection area, inguinal lymph nodes and radioactive standards. after correction for half-life, (± )% after h and (± )% after h of the initial activity was found in the injection area of both cell types. mean of ratios (counts in lymph nodes/ counts in injection area) of alpha-type i dendritic cells were . after hours and . after hours. for peg dendritic cells, the ratios were . after hours and . after hours. in all patients, differences in migration of both cell types were not significant (p= . ). conclusion: alpha-type i dc have a lower tendency to migrate than pge -dc in vivo, but the differences observed are not significant. our data do not provide information about the stimulating behaviour of dendritic cells for an antitumor tumor reaction. up to now, the optimal type of dendritic cells is not synthesized. however, the cells used in this study show potential for further clinical studies. key: cord- -y sfr c authors: nan title: scientific programme date: - - journal: pediatr nephrol doi: . /s - - - sha: doc_id: cord_uid: y sfr c nan the kidney plays an important role in ion homeostasis in the human body. several hereditary disorders characterized by perturbations of renal magnesium reabsorption leading to hypomagnesemia were described over the past years. only recently, mutations in renal ion channels and transporters have been identified in several of these diseases, following positional cloning strategies in families with these disorders. muations in the slc a gene have been identified in patients with gitelman syndrome, an autosomal recessive disorders characterized by hypokalemia, hypomagnesemia and hypocalciuria. slc a encodes the thiazide-sensitive na + , cl-cotransporter (ncc) in the distal convoluted tubule (dct), the nephron site of active renal magnesium reabsorption. the hypomagnesemia in gitelman syndrome has been shown to be secondary to the primary defect in ncc. mutations in the fxyd gene have been found in patients with autosomal dominant renal hypomagnesemia associated with hypocalciuria (idh). fxyd encodes the gamma-subunit of the na + , k + -atpase, which is expressed primarily in the kidney with the highest expression levels in dct and tal. hypomagnesemia in patients with idh can be severe (< . mm) and cause generalized convulsions. the molecular mechanism for renal mg + loss in this autosomal dominant type of primary hypomagnesemia remains to be elucidated. in patients with autosomal recessive hypomagnesemia with hypercalciuria and nephrocalcinosis (fhhnc) mutations in the cldn gene, and very recently also in the cldn gene, have been identified. these genes encode claudin and claudin respectively, which are essential components of the paracellular pathway for magnesium at the level of the thick ascending limb of henle's loop. mutations in trpm , encoding the epithelial mg + channel trpm in the apical membrane of dct cells, have been identified in patients with mg + wasting and secondary hypocalcemia (hsh). this autosomal recessive disease is due to defective intestinal and renal mg + (re)absorption, and affected individuals show neurologic symptoms of hypomagnesemic hypocalcemia, including seizures and muscle spasms during infancy. in my lecture, i will give an update on the proteins involved in magnesium reabsorption and the emerging pathophysiological understanding of hereditary disorders in which renal handling of this divalent ion is disturbed. transcriptional control of genes that regulate tissue patterning and the cell cycle is fundamental to normal renal development. the mammalian kidney arises from reciprocal inductive tissue interactions between the ureteric bud and the metanephric mesenchyme. these interactions result in growth and branching of the ureteric bud and its daughter collecting ducts, a process termed, renal branching morphogenesis, and formation of nephrogenic progenitors and mature nephrons. expression and activity of transcription factors in ureteric and metanephric mesenchyme cells determines the patterning of ureteric bud and metanephric mesenchyme derived tissue elements. this lecture will highlight transcription factors critical to renal branching morphogenesis and nephrogenesis, with particular emphasis on those factors that are mutated in humans with renal malformation. the regulation of transcription factor activity will be discussed in the context of growth factor signaling pathways downstream of wnts, bone morphogenetic proteins and sonic hedgehog and pathways such as notch that control cell differentiation. the complexity of transcriptional signaling will be highlighted in the normal and malformed kidney at the level of transcriptional factor interactions and target gene promoters that can be targeted by mutiple signaling pathways. t. benzing diseases of the glomerular filter of the kidney are a leading cause of end-stage renal failure. recent studies have emphasized the critical role of the slit diaphragm of podocytes for the size-selective filtration barrier of the kidney and revealed novel aspects of the mechanisms leading to proteinuria, both in inherited and acquired diseases. several critical structural protein components of the slit diaphragm have been identified. recently, it has been shown that slit diaphragm proteins, in addition to their structural functions, participate in common signaling pathways. this talk will focus on what is known about the importance of the podocyte for the function of the glomerular filter of the kidney. it will provide a snapshot of our current understanding of the signaling properties of slit diaphragm proteins and project a framework for further studies necessary to delineate the function and dynamics of the slit diaphragm protein complex and the pathogenesis of nephrotic syndrome. long-term survival of children with end-stage renal disease (esrd) has increased in the last years but the mortality rate remains high. cardiovascular disease accounts for to % of all deaths, infectious disease about %. a prolonged period of dialysis versus having a renal graft and persistent hypertension are mortality risk factors. the prevalence of all sorts of morbidities is high among those who have reached adulthood. nearly % of all these patients suffer from left ventricular hypertrophy and life threatening vascular changes; nearly one third has clinical signs of metabolic bone disease. this accounts for both dialysis and transplanted patients. the chance of getting cancer is times increased as compared to the general population; skin cancer and non-hodgkin lymphomas are most reported. a long period of dialysis at childhood is associated with impairment of both cognitive and educational attainment in adulthood. yet, despite all these negative outcomes, the health perception of young adults with childhood onset esrd is good. unemployment under young adults on chronic dialysis with pediatric onset of disease is higher than among healthy age related peers, but much lower than among dialysis patients of the same age with adult onset of disease. an impaired social development in childhood is associated with an impaired mental health perception at adult age. research and therapy in children with esrd should focus not only on prevention of graft failure but also on prevention of co-morbidity, especially cardiovascular disease, life threatening infections and malignancies. early transplantation, more extended forms of frequent hemodialysis in those who can not be transplanted, a more rigorous treatment of hypertension, avoidance of calcium-containing phosphate binders, reduction of the chronic inflammatory state, and tailor made anti-rejection therapy after transplantation may all be targets to improve outcome in future patients. psychosocial care should be more focused on attainment of independency and preparation for adult life, i. e. schooling and job career. applying regenerative medicine to combat organ shortage laboratory of regenerative nephrology, edmond and lili safra children's hospital, sheba medical center, tel hashomer, sackler school of medicine, tel aviv university, tel aviv, israel organ transplantation has been one of the major medical advances of the past years; however, it is becoming increasingly apparent that the supply of organs is limited and will not improve with current medical practice. regenerative medicine is focused on the development of cells and tissues for the purpose of restoring function through transplantation. when facing late stages of esrd, which necessitate whole kidney transplantation, organogenesis represents an alternative to combat organ shortage. indeed, previous data pinpoints a window of time in human and pig kidney organogenesis that may be optimal for transplantation into mature recipients. "window" transplants are defined by their remarkable ability to grow, differentiate and undergo vascularization, achieving successful organogenesis of urine-producing miniature kidneys with no evidence of trans-differentiation into non-renal cell types, lack of tumorigenicity and reduced immunogenicity compared to adult counterparts. in contrast, when dealing with earlier stages of esrd or acute renal disease, which allow for individual cell replacement, both bonemarrow derived and kidney specific stem cells, might be applicable. accordingly, we show in proof-of-principle experiments that a novel population of multi-potential stem cells derived from the adult murine kidney are capable of re-populating ischemically injured tubular cells, while hematopoietic stem cells (cd +cd +) or hemangioblastic progenitor cells can give rise to peritubular endothelial cells. thus, different types of biological materials (embryonic kidney, adult kidney, adult bone marrow) offer new and powerful strategies for future tissue development and regeneration in renal medicine. k. tory, É. kis, a. szabó, g. reusz st department of pediatrics, semmelweis university, budapest, hungary it is well known that chronic renal failure significantly increases the risk of cardiovascular mortality in adults. transplantation decreases this risk; however, it still exceeds that of the normal population. as the number of children on renal replacement therapy (including transplantation) has significantly increased in recent years, there has been a growing amount of evidence regarding the increased cardiovascular vulnerability of this specific patient group. one important factor of cardiovascular mortality in adults is the dysfunction of the autonomic nervous system, previously designated as autonomic neuropathy. in a series of studies using the conventional ewing tests as well as heart rate variability (hrv) monitoring we were able to show altered sympathovagal balance in children on peritoneal-and hemodialysis, that was at least partly reversible following renal transplantation. according to our data sympathetic overactivity plays a major role in the sympathovagal disequilibrium observed. correspondingly, beta-adrenergic blockade improves the decreased hrv in the young. early, accelerated arteriosclerosis is another important, recently recognized consequence of crf in children. arterial calcification leads to increased arterial stiffness deteriorating the cushioning function of the aorta. arterial stiffness can be assessed by the reproducible and non-invasive measurement of the pulse wave velocity (pwv). in adults, it was found to be a strong, independent predictor of cardiovascular mortality. hypertension, hyperphosphatemia/elevated serum calciumphosphate product and vitamin d deficiency are the principal factors associated with pwv. recently, pwv was also shown to be increased in children on dialysis. however, the difference to the normal population may only be apparent if a control group matched for body dimensions is used, because of the dependence of pwv on body dimensions and uremic children's significant growth deficit. furthermore, increased pwv could also be shown in children following renal transplantation (tx) indicating the persistence of these lesions even following successful tx. the data on the autonomic nervous system and arterial dysfunction in young patients point to the necessity of early prevention in order to avoid the cardiovascular complications of crf. this study was supported by grants otka-t -f -f and ett / . nitric oxide (no) production is reduced in ckd due to decreased renal and widespread decreases in endothelial no production. possible causes of no deficiency are: ). substrate (l-arginine) limitation; ). increased levels of circulating endogenous inhibitors of nitric oxide synthase (particularly asymmetric dimethylarginine [adma]); ). decreased nos protein abundance/activity. decreased l-arginine availability in ckd is likely due to perturbed renal biosynthesis secondary to damage to the renal parenchyma. in addition, inhibition of transport of larginine into endothelial cells and shunting of l-arginine into other metabolic pathways (e. g. arginase) will also decrease availability. elevated plasma and tissue levels of adma in ckd are functions of reduced renal excretion (minor), reduced catabolism by dimethylarginine dimethylamino-hydrolase (ddah) and possibly increased protein methylation. an increase in adma has emerged as a major independent risk factor in many forms of cardiovascular disease as well as end-stage renal disease (and probably ckd). decreased renal nos protein abundance and activity have been reported by us in multiple models of ckd in the rat. the neuronal (nos ) isoform is always reduced in the presence of injury, and is preserved in settings where there is protection from damage (female; wistar furth rat vs. sprague dawley). generalized and nnos specific inhibition accelerates underlying renal injury and in vulnerable animals will cause injury in the absence of underlying renal disease. we also find that relaxin (rlx) mediated prevention and repair of damaged kidneys requires an intact no system in order to function. in summary, no deficiency can cause cardiovascular and renal disease, and ckd results in no deficiency, contributing to a vicious cycle that promotes progression. an intact no system is required for rlxmediated repair of kidney damage. no deficiency in ckd is likely due to many causes: decreased arginine synthesis/availability and transport; increased endogenous adma functioning as competitive inhibitor; decreased enzyme abundance and activity will all lead to reduction in no generation. in addition, the oxidative stress of ckd will further reduce nos activity, switch the nos to become oxidant generators and will scavenge no to form the harmful peroxynitrite. selected glomerulopathies due to single gene defects such as finnish type nephropathy, diffuse mesangial sclerosis alport/thin membrane disease and inherited lipid disorders and will be discussed. finnish nephropathy is due to mutations of nephrin, a major structural component of the slit diaphragm. over nephrin mutations are known associated with variably absent slit diaphragms, originally thought to be specific for constitutional nephrin mutations. however, sporadic minimal change disease and membranous glomerulonephritis may have absent slit diaphragms suggesting that nephrin may participate in the nephrotic syndrome in nonhereditary diseases. dms is one cause of congenital nephrotic syndrome, characterized by podocyte proliferationis shared by wt (denys-drash syndrome), laminin α (pierson syndrome) and galloway-mowat syndrome mutations. alport nephritis is a paradigm in which only a subset of mutations may predict disease severity (col ivα )). heterozygous alport is similar to thin membrane disease (tmd), but % of tmd harbor col (iv) α mutations and a subset has col ivα . nail patella syndrome due to heterozygous loss of lmx b gene which regulates col ivα - expression during kidney development. in classic nail-patella pathology fibrillar collagen bundles within the gbm are identical in severe and mild disease. thus the mutation does not correlate with prognosis. a mutation overlap in factor h gene in lipid disorders such as dense deposit disease (ddd) and lcat underscores glomerular pathologies that ranges from classic ribbon-like deposits in ddd, to lucent gbm deposits characteristic of lcat, or subendothelial lipid pools in lipoprotein glomerulopathy. the importance of genetics underscoring the pathology is amply demonstrated but mutations may not determine prognosis. background genes, post-translational modification and or protein/protein interactions in podocytes or the gbm may act as phenotypic modifiers. acute renal failure (arf) has many different definitions. rifle criteria distinguish "risk, injury, failure, loss and end-stage renal disease" features of this event. classic forms include pathophysiological cases of renal hypoperfusion and direct parenchymal injury, as well as postrenal anatomical obstruction. microvascular mechanism is in general the effect of disturbed balance between vasoconstriction (in response to endothelin, angiotensin ii, thromboxane a , leukotrienes and increased sympathetic nerve activity) and vasodilatation (in response to nitric oxide, pge and bradykinin). endothelial and vascular smooth muscles cells may undergo structural damage and increased leukocytes-endothelial adhesion is a cause of inflammation. cytoskeletal breakdown, loss of polarity, apoptosis, necrosis, desquamation of viable and necrotic cells with tubular obstruction are underlying mechanisms of acute tubular necrosis. ischemic and direct tubular injury dominate as causes of arf, however specific epidemiology is strictly age-related. sepsis and major surgeryrelated events are the most common causes of arf in hospitalized patients. data on genetic background of certain genes polymorphisms and susceptibility to specific risk factors in newborns and infants are conflicting. several prophylactic and therapeutic techniques are available, however not of universal value. appropriate fluid management is crucial in ischemic arf, classic hemolyticuremic syndrome and rhabdomyolysis, however fluid overload is the one of major predictors of poor outcome in children admitted to icu. neither "renal dose" of dopamine, nor loop diuretics change the outcome. involvement of extrarenal organs worsens the overall outcome, which is the poorest in patients with multi-organ failure. early introduced renal replacement therapy is one of the key modalities in icu-treated patients. continuous techniques are of major value. in specific cases, such as hepato-renal syndrome, albumin ("liver") dialysis serves as an effective bridge to liver transplantation. hyperostosis-hyperphosphatemia syndrome (hhs) is a rare recessively inherited disease, manifested by persistent severe hyperphosphatemia and self-remitting episodic bone pain with radiologic findings of periosteal reaction and cortical hyperostosis. hyperphosphatemia in this patient population is not counter-balanced by pth or vitamin d, posing a mirror image of two hypophosphatemic states which result from increased activity of fibroblast growth factor (fgf ). the two hypophosphatemic disorders which result from enhanced urinary phosphate leak are: dominantly inherited hypophosphatemic rickets and tumor induced osteomalacia. this observation was the impetus to study the role of fgf in hhs. affected individuals were found to have low levels of the full length, biologically active fgf , but markedly augmented amounts of the cleaved inactive fragments. patients were found to be homozygous for a mutation in the galnt gene encoding a peptide involved in mucin-type o-glycosylation. decreasing the expression of the galnt gene by rna interference resulted in augmenting processing of the intact fgf . our research indicates that the primary defect in hhs is a state of underglycosylation of fgf- resulting from reduced expression of ppgantase-t , due to mutations in galnt , and leading to augmented processing at the cleavage site. these changes in fgf- would abolish its phosphaturic effect and lead to severe persistent hyperphosphatemia. this study provides the pathogenetic mechanism of the first mucin-type o-glycosylation defect identified. our observation lends further credence to the primary and essential role of fgf in phosphate homeostasis through a pth-independent pathway. this was substantiated most recently by several reports which showed that mutations in the fgf gene are responsible for familial hyperphosphatemic tumoral calcinosis (fhtc) . a further study showed that hhs and familial hyperphosphatemic tumoral calcinosis are allelic disorders with a founder mutation in our region. immune responses govern the outcome of many forms of chronic kidney disease. gene therapy offers the potential to modify immune genes to improve outcome. we will discuss the potential use of gene transduction as a therapy for chronic kidney disease. background: chronic proteinuric renal disease is a major cause of end stage renal disease in man. adriamycin nephropathy is a murine model of chronic proteinuric renal disease where initial chemical injury is followed by immune and structural changes that mimic human disease. foxp is a gene specifically expressed by regulatory t (treg) cells. forced expression of the gene foxp causes transduced t cells to develop a regulatory phenotype. we hypothesised that foxp transduced regulatory t cells could protect against renal injury in adriamycin nephropathy. methods: the retroviral vectors expressing foxp and green fluorescent protein (gfp) (foxp /migr) and gfp alone (migr) were transfected into package cell lines ecopack - , which produced the two retroviruses. cd + t cells were isolated from spleen of balb/c mice and stimulated by anti-cd mab and il- for hours and then were infected with either retrovirus. expression was confirmed and phenotypic and in vitro functional assays demonstrated a regulatory phenotype. one week after infection, the gfp+ positive cells were sorted. foxp and control vector (migr) transduced t cells were administered to adriamycin (adr)-induced progressive renal nephropathy in mice. results: adoptive transfer of the foxp transduced t cells protected against renal injury. urinary protein excretion was reduced; there was less renal injury as measured by glomerulosclerosis, and interstitial infiltrates. serum creatinine, glomerular sclerosis and tubulointerstitial alterations were significantly lower in adr-foxp group, compared to those without treatment (adr) and treated with control vector (migr) transduced group (adr+migr). the foxp transduced cd t cells also showed suppressive activity in vitro. we conclude that foxp induced t reg cells may have a therapeutic role in protecting against immune injury and disease progression in chronic proteinuric renal disease. the italkid project is a prospective, population-based registry that was started in . prevalent and incident cases of chronic renal insufficiency (cri) in children and adolescents were identified throughout italy (total population base: . million children). the inclusion criteria were: i) creatinine clearance (ccr): < ml/min/ . m bsa; and ii) an age of < years at the time of registration. as to december st, a total of patients had been registered. the incidence of cri was estimated . cases per million and the (point) prevalence . per million of the age-related population (marp). the probability of kidney survival at years of age was significantly different depending on the ccr at study entry, being % in patients with mild renal insufficiency (ccr - ml/min), % in those with moderate renal insufficiency (ccr - ml/min) and % in those with severe renal insufficiency (ccr < ml/min). the patients with normal (< . ) and low ( . - . ) upr/ucr compared to those with mild (> . ), showed a significantly slower decline in ccr (deltaccr + . ± . and - . ± . vs - . ± . ml/min/yr) and a higher kidney survival ( . and . vs . %). the incidence of renal replacement therapy (rrt) was . /year/ patients and the casefatality rate on conservative treatment . %. patients showed a significantly different slope of ccr before pubertal growth spurt as compared to after: - . ± . ml/min/ . mq/yrs and - . ± . . a non-linear pattern of decline in the probability of kidney survival, with a steep decrease during pubertal and early post-pubertal age was observed: the overall probability of rrt at age was estimated . %, while . % of the patients will eventually required rrt before the nd decade of life was over. suggesting that pubertal development triggers the progression of cri in children. treatment with angiotensin converting enzyme inhibitors did not significantly modify the naturally progressive course of hypodysplastic nephropathy. ambulatory blood pressure monitoring (abpm) is a relatively new technique of blood pressure assessment in children and adolescents that offers several distinct advantages over traditional methods of blood pressure measurement, including the ability to detect white coat and masked hypertension, as well as the ability to assess nocturnal blood pressure. the role of abpm in the diagnostic evaluation of pediatric patients with elevated blood pressure is well-established, and recent surveys have demonstrated that it is used quite often by pediatric nephrologists and other practitioners during the initial evaluation of elevated blood pressure. it is less well-established, however, what role abpm might play in hypertensive children and adolescents once hypertension has been diagnosed and treatment initiated. studies in adults have demonstrated that abpm can assess whether patients on antihypertensive medications have achieved goal blood pressure, or whether their hypertension has progressed in severity. abpm can be used to follow nocturnal blood pressure in patients with chronic kidney disease (ckd) and diabetes, facilitating early identification of non-dipping, which is a known risk factor for progression of ckd or development of diabetic nephropathy, respectively. abpm can also be incorporated into clinical trials of antihypertensive medications to help assess their efficacy and safety. while additional data supporting these applications of abpm to pediatric hypertension clearly need to be generated from well-designed clinical trials, we propose that there is ample justification to utilize abpm just as frequently after the diagnosis of hypertension as before. childhood obesity is increasing globally in epidemic proportions and affects children in both industrialized and non-industrialized nations. in the last years the percentage of overweight or obese children has increased from % to almost %. if current trends continue, as many as % of children may be overweight or obese by the year . obesity predisposes to development of the metabolic syndrome, which is defined in children as the presence of three or more of the following features: abdominal adiposity (bmi > %ile), serum triglycerides > %ile, serum hdl cholesterol < % ile, fasting blood glucose > mg/dl, and/or hypertension (systolic or diastolic blood pressure > %ile adjusted for age, gender and height). the metabolic syndrome occurs in about % of children, but in - % of overweight children. the presence of the metabolic syndrome increases the risk for cardiovascular disease and chronic kidney disease almost ten-fold in adults. adipose tissue does not just store fat, but also has important endocrine and immune functions mediated through adipocytokines, including leptin, adiponectin, resistin, apelin and visfatin, and classical cytokines such as tnf-a and il- . increased leptin, decreased adiponectin and increased inflammatory cytokines, which occur in obesity, are known to induce vascular endothelial dysfunction and increase blood pressure. increase in adipose tissue also leads to infiltration by monocytes, macrophages and lymphocytes, which are stimulated to produce additional cytokines that may contribute to the systemic inflammation associated with obesity and vascular inflammation associated with hypertension. screening for hypertension and metabolic syndrome in obese children is critical to allow early identification of the metabolic syndrome and aggressive early intervention to reduce the risks for progression to cardiovascular disease and chronic kidney disease in later life. therapeutic strategies must include lifestyle changes of weight loss, healthier diet and regular physical exercise as well as treatment of hypertension, hyperlipidemia or hyperglycemia. blood pressure (bp) regulation is affected by numerous physiologic, biochemical, genetic and environmental factors. it has been suggested that exogenous conditions affecting intra-uterine growth and development may pre-program individuals for hypertension, metabolic abnormalities and cardiovascular morbidity in later life. animal data and human autopsy findings support a link between intrauterine growth, nephron endowment and postnatal hypertension. conceptually, it appears increasingly unclear whether the association of birth weight and bp in later life is mediated by intrauterine growth retardation as suggested by various animal models, whether prematurity per se affects bp programming independent of the fetus, nutritional status, or whether postnatal circumstances statistically linked to low birth weight affect this relationship. we have designed a study to evaluate the relationship between gestational age, birth weight and bp abnormalities by applying abpm in a group of children born preterm with and without intrauterine growth retardation and a local control group of children born at term with appropriate weight. this study represents the first systematic assessment of -hour cardiovascular regulation in children and adolescents born preterm. our findings indicate that a fraction of these preterm born subjects has a selective nocturnal increase in systolic bp, resulting in an elevated prevalence of non-dipping. our analysis suggests that intrauterine growth retardation, rather than prematurity per se, is the major effector of the early cardiovascular abnormalities observed in preterm children. moreover, we have found that nocturnal systolic bp was closely linked to heart rate, pointing to a possible role of sympathetic hyperactivation. while little data is available regarding a link between low birth weight and/or prematurity and sympathoadrenal function in adult humans, a role of the sympathetic nervous system in the programming of adult hypertension has been consistently demonstrated in various animal models of fetal growth retardation. in conclusion, we detected subtle abnormalities of circadian bp regulation in those preterm born children who suffered from intrauterine growth retardation and this may reflect sympathetic hyperactivation. the intrinsic tendency of kidney disorders with reduced nephron mass to progress and the quest for renoprotective strategies are an ongoing focus of renal research. in adults, hypertension is not only a marker but also a major driving force of renal failure progression. renin-angiotensin system blockers (ace inhibitors and at receptor blockers) are preferred antihypertensive drugs in ckd due to their specific renoprotective effects beyond blood pressure (bp) control, mediated by their antiproteinuric, antiinflammatory and antifibrotic properties. it is less clear whether bp reduction to low-normal values has an additional salutory effect on gfr preservation. children suffer from a markedly different spectrum of renal diseases than adults, with a preponderance of hypo/dysplastic kidney malformations. hypertension and proteinuria are common but usually moderate. to elucidate the renoprotective efficacy of ace inhibition and strict bp control in children, the escape trial was launched by a consortium of european pediatric nephrologists. a total of children and adolescents with stage ii-iv ckd received a fixed dose of ramipril and were randomized to intensified (< th percentile) or conventional bp control ( th- th pct). h-bp, proteinuria and gfr were monitored over a -year period. h mean arterial pressure (map) was reduced by ramipril from to mm hg (i. e. from . to sds) on average. subsequently, mean map was lowered further to mm hg at months in the intensified arm, and maintained around mm hg ( . sds) in the conventional control arm (p< . ). on average . antihypertensive drugs were added to ramipril in the intensified and . in the conventional treatment arm (p= . ). treatment tolerability was excellent in both arms, with less than % dropouts due to side effects. in summary, ramipril was effective and well tolerated in children with ckd. it is possible and safe to target low-normal bp in children. final results regarding renal survival will be available in summer and presented at the ipna meeting. nephronophthisis and joubert syndrome: converging on convergent extension? nephronophthisis (nphp), an autosomal recessive cystic kidney disease, leads to terminal kidney failure in adolescence. nphp may be associated with retinitis pigmentosa (rp) in senior-loken syndrome (slsn) or with cerebellar vermis aplasia in joubert syndrome (jbts). we have identified by positional cloning genes as mutated in nphp. the gene product of nphp , nephrocystin- , acts in focal adhesion signaling. by positional cloning we detected mutations in the nphp /inversin gene as causing infantile nphp (type ) with association of situs inversus or rp. we demonstrated expression of nphp , in primary cilia of renal epithelial cells, supporting a new unifying theory for the pathogenesis of cystic kidney diseases (watnick et al. nature genet : , ) , stating that the products of all genes mutated in cystic kidney disease in humans, mice, or zebrafish are expressed in primary cilia, basal bodies, or centrosomes of renal epithelial cells (hildebrandt et al. nature rev genet : , ) . identification of nphp mutations in nphp type also revealed the cause of the renal cystic disease mouse model "pcy", for which treatment has been demonstrated. positional cloning of nphp led to the demonstration that its gene product, nephrocystin- , is conserved in c. elegans and expressed together with nephrocystin- in ciliated head and tail neurons of the nematode. the role of primary cilia function for retinal-renal syndromes was confirmed by identification of the novel nphp gene. recently, several signaling pathways have been implicated in the downstream signaling pathways that connect ciliary/basal body function to the renal cystic phenotype. these include the wnt signaling/planar cell polarity pathways, and the hedgehog signaling pathway. we implicated the planar cell polarity signaling pathway in nphp by positional cloning of mutations in the gene nphp /cep as causing joubert syndrome. abrogation of nphp function in zebrafish caused planar cell polarity (convergent extension) defects and recapitulated the human phenotype of joubert syndrome. further gene identification in nphp will result in the definition of functional networks of primary cilia, centrosomes, and planar cell polarity as they pertain to the pathogenic mechanisms of nphpassociated syndromes and other cystic kidney diseases. hnf b is a transcription factor that is expressed in bile ducts, intestine, pancreas and renal epithelia. germ-line inactivation of the mouse hnf β/tcf gene is embryonic lethal (e . ) due to defective differentiation of the extra-embryonic visceral endoderm. hnf β is later expressed in endoderm derivatives and in the mesonephros. to understand the function of hnf b at later stages of development and during organogenesis, we applied a conditional inactivation based on a (cre-loxp) strategy. with the use of a cre recombinase that is expressed in renal collecting ducts and henle loops (ksp-cre) we found that hnf b inactivation leads to polycystic kidney disease (pkd). this is reminiscent of the renal phenotype of patients carrying heterozygous mutations in tcf /hnf β. these patients suffer from maturity onset diabetes of the young type (mody ) and at the same time from renal cysts (renal cysts and diabetes or rcad). this cystic phenotype is linked to the defective expression of pkhd and pkd , two genes mutated in pkd patients. the cellular and molecular mechanisms underlying pkd are still poorly understood. it was recently speculated that planar-cell-polarity signalling (wnt) could be at the basis of cyst formation. maturation of nephrons during development is accompanied by a considerable lengthening of tubules. this process involves an intense proliferative phase without any increase in tubule diameter. interestingly, we discovered that the progeny of consecutive cell divisions are adjacent one another and oriented in parallel to the axis of tubules. this suggested that upon lengthening, cells divide according the tubule axis. in addition, d image reconstructions revealed that oriented cell division is due to the alignment of the mitotic spindle with the axis of the tubule. we hypothesized that oriented cell division could play an essential role in preventing tubular dilation during the massive proliferative phase that accompanies tubular elongation. indeed, our results indicated that both in ksp-cre-kidney-specific-hnf β-deficient pups and in the pck rats, lacking the expression of pkhd , the mitotic alignments were highly distorted. our results indicate that hnf β plays a crucial role in activating the expression of genes involved in the control of tubular size maintenance during tubular elongation. emerging evidence suggests that the intravenous injection of bone marrow-derived cells improves renal function after acute tubular injury. examination of human transplant biopsies of female kidneys that had been transplanted into male recipients have shown the presence of tubular cells that co-express the y chromosome and epithelial markers. however, controversy exists as to whether the protective effect is due to engraftment of the cells in the injured tubule or an endocrine/paracrine effect of the injected cells. our studies demonstrate that intravenous infusion of whole bone marrow from male mice into female recipients results in the appearance of significant numbers of y chromosome + cells in the kidney interstitium, and rare y chromosome + cells in the tubules. the majority of the interstitial cells express leukocyte markers such as cd . in addition, we have found that i. v. or i. p. injection of bone marrow stromal cells (msc, adherent non-hematopoietic marrow cells) into mice reduced the severity of cisplatin-or ischemia-induced aki. examination of these kidneys demonstrates that mscs enhance tubular cell proliferation and decrease tubular apoptosis after injury. examination of multiple tissue sections at or days after injury failed to reveal any examples of y chromosome cells within the tubules, and only rare examples of y chromosome cells within the renal interstitium. furthermore, exposure to conditioned medium from cultured mscs (msc-cm) significantly diminished cisplatin-induced death of cultured proximal tubule cells in vitro, while i. p. administration of msc-cm in the mouse markedly diminished the rise in bun associated with cisplatin injection. thus our data suggests that hematopoietic cells and their derivatives from adult bone marrow enter the kidney in response to injury where they are primarily localized to the interstitial space as inflammatory cells. in rare instances, these cells may differentiate into, or fuse with, tubular epithelial cells. in contrast, bone marrow mscs fail to enter the kidney in significant numbers, but can protect the endogenous tubular cells from toxic injury by secreting a factor or factors that limit apoptosis and enhance proliferation. renal hypodysplasia (rhd) is characterized by a reduced nephron number, small kidney size and disorganized renal tissue. a hereditary basis has been established for a subset of affected patients, suggesting a major role of developmental genes involved in early kidney organogenesis. gene mutations with dominant inheritance causing rhd, urinary tract anomalies and defined extrarenal symptoms have been identified in tcf (renal cysts and diabetes syndrome (rcad)), pax (renal-coloboma syndrome (rcs)), eya and six (branchio-oto-renal syndrome (bor)) for the most frequent of these syndromes. a recent study on a cohort of patients with rhd and consecutive renal insufficiency demonstrated that % of them had mutations in one gene encoding for a transcription factor. the majority of mutations were identified in tcf (hnf β) (especially in the subset with kidney cysts) and pax . this study demonstrates that subtle extrarenal symptoms in syndromal rhd easily can be missed. genetic testing in children with rhd should be preceded by a thorough clinical evaluation for extrarenal symptoms, including eye, ear, and metabolic anomalies. the presence of these anomalies increases the likelihood of detecting a specific genetic abnormality. in addition, mutations in genes that are usually associated with syndromes can occur in patients with isolated rhd. the ret receptor, its ligand gdnf and the co-receptor gfra play a pivotal role during early nephrogenesis and enteric nervous development. in humans, activating ret mutations cause multiple endocrine neoplasia, whereas inactivating mutations lead to hirschsprung disease. while ret deficiency also causes renal hypodysplasia (rhd) in the mouse model, genetic abnormalities in ret have not been characterized in human isolated renal malformations to date. the ret mutations, y f and s l, reportedly predisposing to medullary thyroid carcinoma (mtc) were found in one and six patients respectively in the same rhd cohort. none of the patients or their carrier relatives had clinical evidence of mtc at the time of the study. our findings suggest that ret mutations predispose to both mtc and rhd, with a low penetrance for either disorder. interestingly, a gdnf mutation was found in addition to a ret mutation and to an eya mutation in a patient with the branchio-oto-renal syndrome suggesting an oligogenic inheritance. mutations in clcn , the gene encoding the chloride/proton exchanger clc- , underlie most forms of dent's disease, an x-linked nephrolithiasis syndrome that is always associated with low molecular weight proteinuria. clc- belongs to the clc gene family of chloride channels and transporters and, in addition to other sites, is expressed in apical endosomes of the proximal tubule. in these vesicles, it co-localizes with the proton pump and with endocytosed proteins. previously thought to be a clchannel, it is now known to mediate electrogenic cl -/h + -exchange. this notion remains compatible with a role in supporting the acidification of endosomes by providing an electrical shunt for the h + -atpase. to clarify the pathogenesis of dent's disease, we created a knock-out mouse model. it displayed low molecular weight proteinuria due to a largely reduced endocytosis by proximal tubular cells (fluid-phase and receptor-mediated). the acidification of renal cortical endosomes was reduced in the ko. the failure of the pt to endocytose pth led to an increased luminal, but not systemic concentration of this hormone. this, in turn, resulted in hyperphosphaturia due to a retrieval of the phosphate transporter napi- a from the pt plasma membrane. nephrolithiasis can be explained by altered renal handling of pth and vitamind, all of which are secondary to the impaired endocytosis. there is an increased prevalence of nephrolithiasis in individuals with obesity, type ii diabetes, and the metabolic syndrome. in particular, uric acid constitutes a much higher percentage of stones in these patients compared to the general stone-forming population. we strived to examine the pathophysiologic connection between the metabolic syndrome and uric acid stones. in the vast majority of cases, the principal abnormality in uric acid stones is not hyperuricosuria but an excessively low urinary ph. uric acid nephrolithiasis is in fact a disease of 'urinary acidification' although there is no systemic metabolic acidosis in the classical sense because acid-base balance is achieved and no excessive acid is accumulated. however, the excretion of protons using low pk closed buffers rather than the high pk open buffer ammonia dictates a low urinary ph. since protonated uric acid has a sparingly low solubility compared to ionized urate, low urine ph promotes uric acid precipitation. thus uric acid nephrolithiasis is an innocent bystander of low urinary ph. the link between the metabolic syndrome and urinary ph as a continuous variable is explored by epidemiologic, human metabolic, and laboratory studies. in population-based studies in stoneformers, low urinary ph is associated with higher body weight. urinary ph is also lower with increasing number of features of the metabolic syndrome (waist circumference, high triglycerides, low high density lipoproteins, hypetension, hyperglycemia) and within each of the features, the severity of each parameter is inversely proportional to urinary ph. in metabolic studies in humans, low urinary ph is associated with low peripheral insulin sensitivity. when studied as in-patients on identical metabolic diets, patients with type ii diabetes and uric acid stone-formers have high net acid generation than normal volunteers. this alone lowers urinary ph although the reason for the elevated acid load is not clear at present. in addition to high acid generation, uric acid stone formers tend to use buffers other than ammonia to buffer protons in the urinary resulting in unduly acidic urine ph. when challenged with an acute acid load, the ammonium excretion response is markedly blunted in uric acid stone-formers. a similar urinary abnormally of acidic urine ph and underutilization of ammonia is seen in the zucker diabetic fatty (zdf) rat compared to their lean counterpart. these animals have peripheral insulin resistance, elevated serum free fatty acid and have significant steatosis in their kidneys. one abnormality in the kidney is reduced expression and activity of the na + /h + exchanger nhe which is the major transporter that excretes ammonium into the urine and its activity is stimulated by insulin. causality is supported by the fact that treatment of the animals with a thiazolidinedione partially reversed the fat infiltration, urinary acidification abnormality and reduced expressed of nhe . the direct effect of fat on the renal proximal tubule was tested in cultured cells. provision of fatty acids beyond the oxidation capacity of the tubule leads to dose-dependent impairment of nhe , generalized dysfunction and eventually cell death. a sub-cytotoxic dose of free fatty acid did not affect baseline nhe activity and expression but reduced the ability of insulin to activate nhe . in summary, the metabolic syndrome is associated with increase acid generation that is independent of diet. this increased acid load is effectively excreted by the kidney. failure to maximally utilize the ammonium buffer system results in lower urinary ph and titration of urate to its insoluble form as uric acid and results in uric acid nephrolithiasis. part of the pathogenic mechanism maybe lipotoxicity from fat infiltration of organs. uric acid nephrolithiasis is an "innocent bystander" which is a sentinel of a more generalized alteration in acid generation and excretion. genetic hypercalciuria recurrent kidney stone production is one of the most common diseases of the bipedal human condition, occurring in up to % of the population in western societies. unlike four-footed animals who likely perish in the wild from a selection disadvantage from a painful calculus, human beings continue to function, and have the ability to express the biologic defects repetitively that result in a stone. idiopathic hypercalciuria, where a specific gene defect has not yet been established, is a shrinking subpopulation of recurrent calcium stone formers, as specific mutations and functional polymorphisms of genes intimately or distantly related to calcium homeostasis arise from the sequencing of the human genome applied to clinical stone disease. other postulated mechanisms can be sought for in this manner as well, and may await larger population-based studies. the familial nature of nephrolithiasis is clear and robust for most calcium-based stone formers, and may have a gender-specificity for that inheritance. the role of environment in its expression remains controversial. the systemic nature of genetic hypercalciuria may be seen through its associated effects on skeletal health and biology. between - % of children with genetic hypercalciuria have abnormally low bone density measured by dual-energy absorptiometry that cannot be explained by correction for height or body mass. further, normalization of urinary calcium excretion with a variety of therapies is associated with improvements in bone density values over time. a proposal for re-classifying hypercalciuria pathogenetically will be presented, and linked to observational data across the world for successful therapeutic approaches. a call for a stone registry and more careful determination of etiology will be sought through the ipna congress. the systems that regulate blood pressure are plastic during development and can be permanently reset. experiments in animals show that it is surprisingly easy to produce lifelong changes in blood pressure by minor manipulations of the mother's diet before and during pregnancy. this phenomenon has been referred to as "programming". epidemiological and animal studies show that programmed effects operate within the normal range of growth and development, and influence the risk of hypertension, coronary heart disease and stroke in later life. a clinical study of people aged years from the helsinki birth cohort showed that two different paths of growth preceded the development of hypertension. people already diagnosed as having hypertension had small body size a birth and low weight gain from birth to two years but grew rapidly after two. at age eleven years their body size was around the average. as adults they tended to be obese and insulin resistant. a second group of people had not been diagnosed but their blood pressures were classified as hypertensive under current definitions. they were short at birth, had low weight gain from birth to two years and remained small after two. at age eleven years they were short and thin. as adults they tended to be overweight and have atherogenic lipid profiles. the first path of growth is similar to that which leads to coronary heart disease in this cohort. the second path is that which leads to stroke. this paper will present data on the maternal and placental influences through which these paths originate. nephron number is a key feature of the conceptual paradigm positing that cardiovascular and metabolic diseases that arise during childhood and adulthood have their origin in events that occur during fetal life. in mammals, nephrons are derived from a subset of cells resident within the metanephric blastema. blastemal cells participate in reciprocal inductive tissue interactions with the ureteric bud. these interactions induce the ureteric bud to grow and branch. in turn, ureteric bud branches induce discrete populations of the metanephric blastema to undergo successive transitions resulting in the formation of mature nephrons. a distinct population of metanephric blastema cells in the stroma modulates branching morphogenesis and nephrogenesis. identification of genes that control both branching morphogenesis and nephrogenesis is providing insight into the molecular pathways that could be targeted by environmental, nutritional and hormonal factors that control fetal programming. this lecture will highlight the morphologic and cellular events critical to renal branching morphogenesis and nephrogenesis, and the gene networks that regulate or counter-regulate these events. these gene networks will then be considered in the light of non-genetic factors that modulate their activities. it is now accepted that early life environment can modulate adult phenotype, including the blood pressure. the likely primary mechanism is epigenetic modulation of gene expression during a sensitive period of fetal maturation, but the pathogenesis of the later development of hypertension is unclear. participation by extrarenal factors such as central regulation and peripheral vascular function has been evoked; however, a strong body of experimental evidence suggests that the "setpoint" for renal regulation of na balance and extracellular volume is altered. because both humans and many experimental models with prenatally programmed hypertension appear to have a decrease in the total number of nephrons, impaired filtration of na has been hypothesized to be an important pathogenetic factor. more recent evidence has suggested that postnatal inflammation and accumulation of reactive oxygen species in the renal interstitium may contribute to the genesis of hypertension by upregulating distal nephron na transport. furthermore, the role of renal vascular function remains to be determined. the different mechanisms are not mutually exclusive; it is conceivable that both a prenatal "priming" and a postnatal "second hit" are required for hypertension to become manifest. j. ingelfinger epidemiological studies published in the late s by barker and his group -and since replicated in many populations -provide evidence of an inverse relationship between birthweight and risk of cardiovascular disease, hypertension, and renal dysfunction in adult life. both clinical studies and animal models have been used to investigate mechanisms underlying these observations [as cited in recent reviews. the concept that changes in the intrauterine milieu affect the growing fetus resulting in alterations in physiology and general health in later life has been termed perinatal programming or developmental origins of health and disease [dohad] . yet, despite a large and burgeoning literature about this phenomenon and its relationship to cardiovascular and renal disease, involved mechanisms remain elusive. maternal malnutrition or exposure to various medications or substances leads to an adverse in utero environment that may impair nephrogenesis, evident in experimental animal studies as well as in clinical reports in humans. nephron deficit at birth persists throughout life, creating "low glomerular endowment, " an important risk factor for hypertension and esrd in adulthood. for a number of years it has been hypothesized that nephron number may strongly influence blood pressure as well as susceptibility to renal disease in later life. recently clinicopathologic observations suggest that a relationship more directly. renal morphogenesis involves complex events in which many genes interact in the formation of the final kidney. when the normal pattern of nephrogenesis is interrupted, renal abnormalities may ensue. during renal development, two major events -ureteric bud (ub) branching and mesenchymal-to-epithelial transformation -greatly impact the outcome of renal morphogenesis. renal malformation accounts for approximately percent of childhood renal failure and represents the end result of failure of fundamental embryonic processes in ub and metanephric mesenchyme (mm) lineages. this presentation will review the data concerning renal responses to perinatal challenges as these occur and later evolve during childhood. we will consider the implications and the data available concerning screening, follow-up and management of at-risk persons. generation of oxidized lipoproteins in obstructive nephropathy -atherogenic or fibrogenic? children's hospital and regional medical center, division of pediatric nephrology, seattle, united states chronic kidney disease, regardless of etiology, is characterized by a relentless progression of fibrosis that gradually destroys the normal renal architecture, particularly in the tubulointerstitium. obstructive uropathy accounts for approximately percent of pediatric patients with chronic kidney disease (ckd) and end-stage renal disease (esrd). after post-natal relief of obstruction, the optimal treatment of children with obstructive uropathies remains unknown and for many the progression of ckd to esrd is inevitable. therapeutic options are limited by an incomplete understanding of fibrogenic pathways in the kidney. the major renal fibrotic pathways identified thus far can be broadly classified into those involved in transforming growth factor beta (tgf-b) activation, macrophage-mediated inflammation, angiogenesis, and extracellular matrix production/degradation. it is becoming increasing clear that key molecules have multiple roles in several of these pathways triggering fibroinflammatory events targeting specific cell types. oxidative stress represents an intersection of many of these fibroinflammatory pathways leading to cellular activation and tissue injury. oxidized lipoproteins accumulate in the circulation and renal interstitium in both experimental models and patients with ckd and esrd. many parallels have been drawn between atherogenesis and the pathogenetic mechanisms of progressive kidney destruction by fibrosis. although ckd is clearly associated with an increased cardiovascular risk, it is not clear whether oxidized lipoproteins amplify fibrogenic pathways in the kidney. research in our laboratory suggests that hypercholesterolemia increases injury severity in obstructed kidneys. scavenger receptors mediate the cellular effects of oxidized lipoproteins during atherosclerosis and activate both inflammatory and oxidative pathways. dietary and antioxidant therapies have clear benefits in animal models but limited efficacy in patients. our studies suggest that blocking key scavenger receptors leads to a significant attenuation of both oxidative and pro-inflammatory pathways during chronic injury by obstruction in hypercholesterolemic mice. interventions targeting scavenger receptor signaling may represent an alternative strategy to attenuate both the progression of ckd and cardiovascular disease. the resolution of injury and promotion of renal repair comprises a delicate balance between cell death and destruction of tissue architecture in relation to cell differentiation, maturation and extracellular matrix (ecm) remodeling. although many studies have focused on the cellular and molecular events leading to the development of renal fibrosis, less is understood about the process of renal repair and regeneration. this is despite the fact that the kidney has a significant capacity for regeneration and cellular replacement following acute damage. the present study describes the structural, functional, and expression profile analysis of endogenous renal repair and the regenerative potential of the kidney following reversal of ureteral obstruction (r-uuo) in the mouse. days after unilateral ureteral obstruction there is renal tubular cell loss, activation of an inflammatory cascade leading to widespread cortical interstitial fibrosis and the loss of normal medullary architecture. following to weeks after r-uuo there was marked tubular repair and regeneration of medullary components, ecm remodeling and decreased inflammatory cell infiltration. the structural repair observed at weeks post-release of ureteral obstruction was associated with a - % recovery of the glomerular filtration rate (gfr). expression profile analysis was performed to visualize patterns of gene expression that were differentially expressed in the repaired and remodeling areas following r-uuo. we are also interested in the regulation of cellular recovery and the processes involved in epithelial cell re-differentiation in regenerating tubules following injury. tubular epithelial cell cilia may play potential roles in directing the orientation of cell division and epithelial differentiation during the endogenous remodeling process. our results suggest that renal cilium lengthening may be an important factor in the response to injury and subsequent recovery of renal function. these studies propose that a lengthening of renal epithelial cilia increases their sensitivity to flow and reduces damaging epithelial dedifferentiation in the injured renal tubules. a better understanding of the key events involved in endogenous renal repair and remodeling may open the way to new interventions based on their manipulations aimed at acceleration of renal regeneration and prevention of scarring. soren nielsen has kindly agreed to present this topic, however was not able to submit an abstract. the final regulation of urinary k excretion in the fully differentiated kidney is accomplished in the distal nephron, including the cortical collecting duct (ccd), where cell k passively diffuses into the urine through apical k selective channels. the prevalence of the sk/romk channel and its high p o at the resting membrane potential has led to the belief that this channel mediates baseline k secretion. less easily detected is the bk channel which is characterized by a low p o at the physiologic resting membrane potential and [ca + ] i . bk channels are activated by membrane depolarization, elevation of [ca + ] i , and/or membrane stretch, and can be selectively blocked by iberiotoxin (ibx). we have reported that flow-stimulated net k secretion (jk) in the adult rabbit ccd is (i) blocked by ibx and (ii) associated with increases in net na absorption (jna) and [ca + ] i , leading us to conclude that bk channels mediate this process. recent studies have examined the acute and chronic regulation of bk channel-mediated flow-stimulated jk. we reported that flowstimulated jk requires an increase in [ca + ] i due to luminal ca + entry and er ca + release, microtubule integrity, and exocytic insertion of preformed channels into the apical membrane. channel expression is regulated long term during postnatal development and by dietary k intake. specifically, an increase in tubular fluid flow rate fails to elicit an increase in jk in the rabbit ccd until the th wk of postnatal life, coincident with appearance of immunodetectable bk channels, whereas flow-induced increases in jna and [ca + ] i in -wk-old ccds are "mature". a role for the bk channel in renal k adaptation has been suggested by the observation that dietary k loading leads to an increase in abundance of bk message in microdissected ccds with redistribution of immunodetectable channel proteins from an intracellular pool to the apical membrane. additionally, ccds isolated from k loaded animals demonstrate enhanced flow-stimulated jk compared to tubules from control fed animals. in sum, emerging evidence suggests that the bk channel plays a prominent role in distal k secretion in response to increases in urinary flow rate and dietary k intake. the late developmental appearance of this channel is compatible with the need of the growing animal to retain k early in postnatal life. recent advances in molecular genetics of hereditary hypomagnesemia substantiated the role of a variety of genes in human magnesium transport. this knowledge on underlying genetic defects helps to distinguish different clinical subtypes and gives insight into molecular components involved in magnesium transport. during the last four decades, numerous reports concerning inherited magnesium losing disorders have been published and their distinctive phenotypic features have been discussed. phenotypic characterization of affected individuals and experimental studies of appropriate animal models have contributed to a growing knowledge of renal magnesium transport mechanisms. the identification of the affected nephron segments, the different modes of inheritance and the observation of additional characteristic symptoms promoted a classification into different subtypes of inherited magnesium losing disorders. in general, primary magnesium wasting disorders are relatively rare. the prevalence of the more frequent entities, for example gitelman syndrome, has been estimated to be approximately : . . for most of the other disease entities, relatively few cases have been reported in the literature. depending on the genotype, the clinical course is sometimes mild or even asymtomatic. therefore, the disease prevalence might be underestimated for some of these syndromes. magnesium transport has been intensively studied in humans and various animal models leading to accepted concepts underlying the pathophysiology of the different forms of hypomagnesemia. however, the electrophysiological characterization of magnesium pathways has been complicated by unintentional simultaneous measurement of other cations so that the molecular correlates mediating mammalian magnesium transport components remained undefined. a different approach to study components of magnesium transport arises from genetic analysis of families affected with magnesium wasting diseases. linkage studies enabled the localization of several genes involved in hereditary hypomagnesemia and in the last decade, a number of genes have been identified by positional cloning. these genes have provided first insight into mammalian magnesium transport molecules. distal renal tubular acidosis may be inherited as an autosomal dominant or recessive trait. mutations in three genes -slc a , atp v b and atp v a -are associated with the various forms of disease, and give rise to a wide spectrum of clinical severity. in general, dominant mutations do not affect ion transport function per se and do not affect hearing, whereas recessive disease is characterized by loss of function and deafness. some unusual functional consequences of mutations in ae and a proteins are mistargeting and loss of protein-protein interaction respectively, and these will be discussed. the heart in pediatric nephrotic syndrome y. frishberg shaare zedek medical center, pediatric nephrology, jerusalem, israel in recent years, the molecular bases of several conditions which lead to steroid-resistant nephrotic syndrome (srns) have been identified. the common denominator shared by these clinical entities is that they all result from structural defects in the glomerular barrier, thus explaining their unresponsiveness to immunosuppressants. for instance, the congenital ns of the finnish type is caused by mutations in the nphs gene encoding nephrin. a recessive form of srns was found to result from mutations in nphs encoding podocin which is specifically expressed in podocytes. we have previously shown that a founder mutation in nphs (r x) is the prevalent cause of hereditary srns ( % of tested are homozygotes) among arab children in israel. interestingly, we noted that a number of patients who are homozygous for the r x mutation in podocin have a co-existing cardiac disorder. only a few case reports described an association between srns and cardiac defects. we questioned whether the glomerular-barrier disorders, which have been considered to be kidney-specific, have implications on other organ-systems. thus, we systematically reviewed the cardiac status of these srns patients at the time of diagnosis while they had normal blood pressure and preserved renal function ( ). cardiac anomalies were detected in % of children, the most common of which were cardiac hypertrophy and pulmonary stenosis. analyzing two control groups enabled us to conclude that cardiac disorders in homozygotes for mutations in nphs cannot be attributed to an association by chance or to a state of persistent ns. because human podocin mrna is expressed in fetal heart, we hypothesize that it may have a role in normal cardiac development and this will be an issue of further investigation. this is the first study showing a role for podocin in extra-renal tissues and therefore recommends early cardiac evaluation for timely medical management. cvd is the world-wide biggest obstacle to long-term survival of children and adolescents with ckd. mortality from cvd is excessively high on dialysis and continues to be a threat after renal transplantation. early diagnosis of the individual risk for cvd would enable preventive measures on an individual basis. however, prospective studies with hard end points -cardiac events -are difficult if not impossible to conduct in children and adolescents. on the other hand, the known high morbidity and mortality in elderly dialysis patients may largely result from pre-existing comorbidity (advanced atherosclerosis has been demonstrated in this age group at initiation of dialysis). for this reason, investigations in patients with childhood onset ckd may provide a diagnostic window to study the pathogenesis of cardiac and vascular changes in subjects without comorbidities. several studies using non-invasive measurements of surrogate markers for cvd have demonstrated a pattern of early systemic cvd, including changes in intima-media thickness (imt) of conduit arteries (aorta, a. carotis) and muscular arteries (a. femoralis), altered function of peripheral resistance arteries (venous occlusion plethysmography) and abnormalities in the heart (echocardiography). patients show a significant decrease in post-ischemic vascular reactivity with evidence of vascular stiffness and frequently have extraosseous calcifications often involving coronary arteries and heart valves. importantly, these studies have found little evidence for correlations with classical risk factors (except hypertension), but with abnormalities of calcium and phosphorus metabolism and their therapy, including the intake of active vitamin d preparations and calcium-containing phosphate binders. thus, patients with childhood-onset ckd are at high risk to develop systemic cardiovascular changes, which may represent a new disease originating from the survival of ckd, a previously deadly disease, and interventions for the prevention of renal osteodystrophy. this therapeutic challenge needs to be addressed with high priority to enable long-term survival of children with ckd. while their mere existence is still questioned by some investigators, lipid rafts have recently gained a large amount of attention because of their apparent involvement in various cellular processes, including signaling, membrane trafficking, polarization, and endo-as well as exocytosis of proteins as well as pathogens. membrane rafts have been defined as small ( - nm) heterogeneous, highly dynamic, sterol-and sphingolipid-enriched domains that compartmentalize cellular processes and that can sometimes be stabilized into larger platforms by protein-protein or proteinlipid interactions. rafts are of special interest for pediatric nephrologists for two reasons: . they play a critical role in immune cell activation, especially in the formation of the immunological synapse (is), and thus in many important disease processes affecting our patients, including -but not limited to -transplant rejection. beyond their participation in is formation, rafts also facilitate signaling through other immune cell receptors, such as the interleukin- receptors, where they may ascertain cytokine selectivity and specificity. . equally important, rafts serve as essential site for proper interactions between nephrin and podocin, thus establishing the integrity of the glomerular filter. general aspects of raft biology as well as their role in immune cell signaling will be reviewed in more depth in this presentation. raft involvement in glomerular filter formation and especially genetic aspects relevant to disturbances of this involvement and of the associated integrity of the filter, as seen in hereditary nephrotic syndromes, are discussed in subsequent presentations in this symposium. reports of familial forms of fsgs date back to , with the observation of an autosomal recessive disease primarily within the finnish population. it is characterized by massive proteinuria in utero, with up to to grams of protein loss per day. nphs encodes a gene product termed nephrin that localizes to lipid rafts within the slit diaphragm of the podocyte. steroid-resistant nephrotic syndrome (srns) is an autosomal recessive nephrotic syndrome and manifests between months and years of age, rapid progression to esrd, and with few cases of recurrence after renal transplantation. the gene product is podocin (nphs ), located on q - . podocin most likely functions in the structural organization of the slit diaphragm and regulation of its filtration function. it has been shown to interact in vivo with both nephrin and cd -associated protein (cd ap), a cytoplasmic binding partner of nephrin. mutations in the alpha-actinin gene (actn ), localized to chromosome q have been associated with autosomal dominant fsgs, characterized by adult onset disease of variable severity and rate of progression to esrd. fractions of the mutant protein have been shown to form large aggregates within podocytes ultimately compromising the function of the normal actin cytoskeleton, both through its abnormal function and toxic accumulation. recently, a disease-causing mutation for hereditary fsgs has been localized to chromosome q - , and identified as the transient receptor potential cation channel, subfamily c, member (trpc ). the missense mutation causes a highly conserved proline in the first ankyrin repeat of trpc to become a glutamine at position (p q). the trpc p q mutation causes increased and prolonged calcium transients in transfected cells. the mutant channel also significantly enhances cation signals triggered by at receptor activation. biotinylation and immunostaining studies reveal that the mutation also appears to cause mislocalization of the ion channel to the cell surface. whereas previously reported mutations such as nphs , nphs and actn have emphasized the importance of cytoskeletal and structural proteins in glomerular diseases, trpc related fsgs suggests an additional mechanism for renal disease pathogenesis. knowledge of trpc mediated calcium entry into cells may offer unique insights into therapeutic options for glomerular diseases. t. huber university hospital, department of nephrology, freiburg, germany the sense of touch relies on the ability of specialized sensory cells to convert mechanical stimulation into ionic currents. mechanoreceptor cells respond to external force by opening ion channels. recent findings highlight now a potential role for the mechanosensitive ion channel trpc at the glomerular filtration barrier. trpc localizes to the slit diaphragm and mutations of trpc cause familial glomerular disease. mutations of the phb-domain protein podocin are the most common cause of hereditary nephrotic syndrome and we demonstrate that podocin and mec- , the closest homologue of podocin in caenorhabditis elegans, bind cholesterol to regulate the activity of associated ion channel complexes: deg/enac channels for mec- and trpc channels for podocin. both the mec- -dependent activation of mechanosensation in c. elegans and the podocin-mediated activation of trpc channels requires cholesterol. our data suggest that the recruitment of cholesterol by podocin and mec- to ion channels plays an important role in regulating their activity. these findings promote the concept that podocin, similar to the function of mec- , may be part of a mechanosensitive protein complex at the slit diaphragm of podocytes. isidro salusky has kindly agreed to present this topic, however was not able to submit an abstract is there a role for bisphosphonates in pediatric bone disease? f. santos hospital universitario central de asturias, universidad de oviedo, pediatria, oviedo, spain bisphosphonates are being increasingly and successfully utilized to prevent bone fractures and treat bone pain in children with severe osteoporosis from different origins. a largest experience has been accumulated with the administration of cycles of intravenous pamidronate in children with osteogenesis imperfecta. in addition, to the bone resorption inhibition mediated by their effects on osteoclasts, bisphosphonates given in large doses inhibit normal and ectopic mineralization. thus, bisphosphonates have also been used in children with hypercalcemia and in the treatment of calcinosis and heterotopic ossification, bisphosphonates have been administered to renal transplanted adults to prevent or treat bone loss induced by chronic administration of glucocorticoids and might also be useful in the management of urolithiasis in selected hypercalciuric patients. the potential clinical utilization of bisphosphonates in the prevention and treatment of vascular calcification in patients with chronic renal failure is now being explored, although no data on children in this clinical setting are available. a number of questions as to the precise clinical indications to start bisphosphonates' administration, the type of bisphosphonate to be used, the duration of the treatment, the best way to monitor its effectiveness and the risk of longterm toxic effects remain to be answered. water is the solvent in which all metabolic reactions occur. body water moves between compartments with diverse compositions that are separated by semi-permeable lipid membranes. water exchanges also occur between maternal and fetal blood separated by several layers of tissue, the so-called placental membranes. the fetus appears to be dependent on placental flow and perfusion pressure for the bulk of his water requirements, and the prostanoids play a significant role in the control of ureteroplacental and umbilicoplacental blood flows. osmotic and hydrostatic forces control placental water flux. the amniotic fluid (af) appears early during gestation and its volume increases rapidly. the net af volume turnover approximates % per day. major sources of af production are represented by fetal lungs secretions, and by fetal urine. the af is initially isotonic, and becomes hypotonic when significant amounts of dilute urine are produced by the fetus. disposal of water is effected by fetal swallowing of af and by the intramembranous (im) pathway, that is the route of absorption between the fetal circulation and the amniotic cavity. this route appears to play an important role in the overall regulation of af volume and composition. the fact that water crosses the im pathway in excess of solutes suggests a role for aquaporin water channels in allowing this transport. circumstantial evidence indicates that the im water flow is regulated by aquaporin . homeostatic changes in placental permeability could thus be up or down-regulated by the number of aquaporin water channels in the membrane. systemic lupus (sle) is a multigenic and multifactorial disease, characterized by b lymphocytes polyclonal activation with decreased tolerance, autoantibodies production and immune complexes formation. dna was initially thought to be the mayor auto-antigen, however, it is not immunogen and injection of dna-anti dna does not induce lupus nephritis. the complex of dna and histones (nulceosome) is provided with a positive electrical charge which favours the binding to heparansulphates in the gbm. in sle high levels of nucleosomes are present in circulation due to accelerated lymphocytes apoptosis or defective removal of apoptotic cells. lupus nephritis (ln) is consequent to deposition of immune complexes, activation of lymphomononuclear cells and reactivity of renal cells. the who classification of lupus nephritis has been recently reviewed by the isn/rps. the new classification takes into account a distinction between forms without endocapillary hypercellularity (mesangial or subepithelial deposits) and others with endocapillary hypercellularity (involving less or more than % with segmental or global distribution). prognosis and treatment of ln need a flexible therapy, tailored on histological picture and clinical data. steroids must be given at high doses for induction therapy but have drawbacks of heavy morbidity and mortality. the addition of immunosuppressive drugs improves the therapeutic index. the nih protocol used cyclophosphamide (cyc) pulses in severe ln (monthly pulse for months followed by quarterly pulses for year). more recent studies, comparing low with high doses cyc pulses, failed to prove a significantly different effect. for maintenance therapy of ln, mycofenolate mofetil may be a good alternative to cya or aza. rituximab, a chymeric monoclonal antibody anti cd , which selectively and profoundly depletes b lymphocytes, has provided very interesting results in sle with poor response to classical therapy or in relapse. the possibility of rotating agents with different side effects may allow to lower the doses of steroids, to reduce drug-specific morbidity, and to improve the compliance of patients. efforts should be done to minimize steroids and cyc which are very effective but are the main responsible of invalidating and even lifethreatening complications. for half a century now, physicians have tried to classify vasculitic syndromes. classification of vasculitides is required to put in perspective the pathogenesis and therapeutic advances and to provide a uniform language, given the variation in the epidemiology of these diseases. the "american college of rheumatology" criteria have been used for classification and the chapel hill consensus criteria for definition purposes in children as well however they are based totally on adult criteria. taking into account the differences in children and the new developments in medicine a group of pediatricians have aimed to revise the classification of vasculitic syndromes encountered in children. the consensus group consisted of a multinational panel of experts who were pediatricians, pediatric rheumatologists and pediatric nephrologists. the delphi and nominal group techniques were used. this project has provided classification criteria for henoch-schönlein purpura, childhood polyarteritis nodosa, wegener granulomatosis and takayasu arteritis. this was an important task since appropriate classification criteria for vasculitis in children has been missing for far too long. we hope that the international and multispecialist composition of the expert group involved will facilitate the applicability of this classification for most vasculitic diseases in children seen around the world and will meet the needs of pediatricians. these criteria are now to be validated using a large registry for childhood vasculitides. anti-neutrophil cytoplasm antibodies (anca) are well established as a diagnostic marker for small vessel vasculitis, including wegener's granulomatosis and microscopic polyangiitis. there is increasing evidence that anca are directly involved in the pathogenesis of vascular inflammation in these disorders. in clinical studies, there is a clear relationship between levels of anca and the activity and extent of disease, and anca positivity confers an increased risk of relapse. rising titres of anca predict relapse, and two studies have shown that pre-emptive treatment of those with rising titres can prevent relapse. of great interest is the recent report of a newborn child who developed glomerulonephritis and lung haemorrhage after transplacental transfer of anca. in vitro experiments have shown that anca can activate cytokine primed neutrophils to release oxygen radicals, enzymes and inflammatory cytokines. this is achieved through both direct f(ab) binding and fc receptor engagement. in co-culture, anca can induce neutrophil mediated killing of endothelial cells. in flow chamber studies, anca can induce neutrophil adhesion and transmigration across endothelial cell monolayers. more recently, anca have been shown to be pathogenic in experimental models of disease. high titre anti-mpo antibodies induced by immunisation of mpo deficient mice can transfer glomerulonephritis and vasculitis to naive recipients. immunisation of rats with mpo induces anti-mpo autoantibodies which lead to crescentic glomerulonephritis. intravital microscopy in this model confirms that anca can induce leukocyte transmigration and microvascular haemorrhage in vivo. however, many questions remain unanswered. some patients may have high levels of anca without disease activity, and others may have typical disease without detectable anca. it seems likely that t cells may be involved, not only in providing help for anca synthesis, but also in mediating tissue damage. it is also possible that an additional inflammatory stimulus, for example an infection is required, to enhance the inflammatory effects of anca. greater understanding of the role of anca in vascular inflammation will hopefully lead to safer and more effective approaches to treatment. hacettepe university, faculty of medicine, department of pediatric nephrology, ankara, turkey the therapy of vasculitic syndromes poses a problem for the caring pediatrician. the treatment of anca associated vasculitides will be presented to cover microscopic polyangiitis, wegener granulomatosis and churg strauss syndrome. treatment of all anca-associated diseases are similar. steroids and cyclophosphamide are the mainstay of induction treatment. in severe patients with kidney involvement steroids can be given in the form of intravenous methylprednisolone for - days ( - mg/kg/d, max. gr), followed by daily oral corticosteroids ( . mg/kg/d, max. mg/d). cyclophosphamide may be given at mg/kg/d p. o. or monthly iv pulses . gr/sqm for at least months. for maintenance treatment there are again many different regimens for oral corticosteroids. along with corticosteroids for maintenance regimen there are a number of protocols suggesting the continuation of cyclophosphamide. the cycazarem study has shown that the replacement of cyclophosphamide with azathioprine at months was also as effective for disease control. methotrexate has also been shown to be an alternative for maintenance treatment. treatment of the childhood polyarteritis nodosa (pan) with systemic disease is similar to that of anca-related vasculitides. there are a number of non-anca associated vasculitides in childhood. the most frequent in childhood are henoch-schönlein purpura (hsp), kawasaki disease (kd) and takayasu arteritis (ta). the treatment of hsp is usually symptomatic. however, for severe kidney involvement with extracapillary proliferation and rapidly progressive disease severe immunosuppressive treatment is indicated. triple treatment with steroids, cyclophoshamide and dipyridamole have been given in various series. for kd intravenous immunoglobulin at a dose of g/kg still remains the first choice of treatment along with salicylates. for ta therapy depends on the extent of vessel invovlement: severe disease necessitates steroids and cyclophosphamide whereas for less intensive vessel involvement methotrexate and steroids may suffice. treatment period depends on the actiivty of the disease. lb. zimmerhackl haemolytic uraemic syndrome (hus) is the most common cause of acute renal failure in children. the syndrome is defined by the triad of microangiopathic haemolytic anaemia, thrombocytopenia and acute renal failure (creatinine over the th percentile). world wide hus is increasing. in a german/austrian multicenter study we follow children with hus occurring in the years to . year follow-up data are now available www. hus-online. at. from this study the following results are obvious. hus affects predominantly children of kindergarten age. the median age at onset is , years. the majority of hus is of infectious origin. shigatoxin (stx) producing escherichia coli (stec, ehec) are present in over % of patients. the predominant shigatoxin type is type ii. hus is classified into two clinical subgroups. "typical" hus usually occurs after a prodrome of diarrhoea (d+hus), and "atypical" hus (ahus), which is not associated with diarrhoea (d-hus). the majority of d+hus worldwide is caused by ehec type o : h , which is transmitted to humans via different routes. however non-o groups are emerging and are predominant in europe. transmission of disease in elder patients is predominantly through food poisoning and direct contact to farm animals. in infants and small children direct transmission from human to human seems to be more likely. currently there are no specific therapies preventing the disease course. anti-shigatoxin antibodies are being tested by several companies. if this may prevent hus is open to study. otherwise the therapy at present is symptomatic. parenteral volume expansion before hus in patients with positive stx or ehec stool culture may counteract the effect of thrombotic process before development of hus and attenuate renal injury. use of antibiotics, antimotility agents, narcotics and non-steroidal anti-inflammatory drugs should be avoided during the acute phase in particular during the prodromal phase. from our own study the prevention is best done by preventing primary ehec infection. however, patients with severe course and long term sequelae should be screened for genetic abnormalities in the complement system. if auto antibodies against complement proteins or the vwf play an relevant role is under discussion. patients under one year of age at onset have a significant worse outcome and should be kept under surveillance. patients below month of age are very likely to have an inborn error of complement or vwf and should be tested specifically. the european registry on hus and related disorders may help to determine these abnormalities: www. haemolytic-uraemic-syndrome. org. in order to improve long term outcome of these patients, increased awareness and an european (international?) task force is mandatory. in adults with chronic kidney disease, protein-energy malnutrition and inflammation are risk factors for death and accelerated cardiovascular disease. the "malnutrition-inflammation-cachexia syndrome" (mics); anorexia, increased basal metabolic rate, and loss of lean body mass is associated with low serum albumin, decreased protein intake, elevated c-reactive protein, and low serum cholesterol levels in adults. in children, mics manifests as growth retardation. clinical research focusing on the evolution of mics in pediatric ckd to understand its causes and consequences and how nutritional interventions alter its course may be the key to improving survival in ckd. baseline cross sectional data from the ongoing chronic kidney disease in children study, of children (n= ) aged - yrs (mean= . yrs) with estimated gfr ± ml/min/ . m (mean iohexol gfr ml/min/ . m ) shows substantial growth retardation in ckd with median height percentile= . greater height deficits are seen at lower gfr's. symptoms of decreased appetite and nausea are reported by % and % of those with gfr < respectively. mean ldl cholesterol is lowest in those with gfr < ( vs mg/dl in gfr ± ml/min/ . m group). serum albumin declines as serum creatinine increases (r=- . ). unlike previous reports in adult ckd, increases in crp were not associated with lower gfr at baseline. further exploration of the mics in pediatric ckd will be presented. the causes of growth failure in pediatric patients with chronic kidney disease (ckd) are multifactorial. it is an open question as to which factors play a key role in diminishing physical growth. it is also unclear which mechanisms may become pace makers for the therapeutic improvement of growth. furthermore, growth failure in children with ckd affects total body height, body proportions and composition as well as organ development. growth failure may also lead to disproportion which can only be identified by detailed anthropometric measurements. we were able to demonstrate that ckd patients have a specific age-dependent pattern of growth and distinct changes in segmental growth (trunk, arm and leg length) from birth to adolescence. leg growth in relation to other parameters of linear growth showed the most dynamic growth changes and emerged as the best indicator of growth in children with ckd. trunk growth had little synchronicity with leg growth. furthermore, we found that anthropometric measurements can be used as a diagnostic tool in distinguishing different sub-groups of ckd patients, for instance, children with syndromic ckd. in the heterogeneous group of patients with focal and segmental glomerulosclerosis, patients with schimke's disease were found to have a dramatically decreased sitting height/leg length ratio. as the disturbance in growth of ckd patients is a marker of the severity of the disease and of the quality of renal care, the annual analysis of growth failure from early childhood to adolescence should be used as a landmark information of the quality of medical care and as a helpful tool in differential diagnosis and of specific courses of ckd in sub-groups of patients. for example, patients with congenital or acquired renal diseases, dialyzed or transplanted patients and in gender differences. in addition, anthropometric measurements are able to identify specific growth patterns in children with ckd, which should be considered in the assessment of treatment efficacy such as in rhgh therapy. b. tönshoff, l. weber, b. höcker university children's hospital, st department of pediatrics, heidelberg, germany it is currently under debate whether steroid avoidance or late steroid withdrawal provides the best overall risk-to-benefit ratio in pediatric renal transplantation. late steroid withdrawal has the advantage over steroid avoidance that immunological high-risk patients and those with unstable graft function can easily be identified beforehand and be excluded from steroid-free immunosuppression. in order to further validate this approach, we performed a prospective randomized open-label multicenter trial in low-risk pediatric renal transplant recipients ( f, m; mean age . yrs; range, . to . ) on csa (target trough level - ng/ml), mmf ( mg/m per day) and methylprednisolone ( ) ( ) mg/m per day), who were randomly assigned > year posttransplant to continue steroids or to withdraw over a period of months. an interim analysis was performed at a mean observation period of mo after study entry; patients had been followed for at least mo. there were drop-outs ( reversible acute rejection episode, switch to sirolimus and to tacrolimus). transplant function as assessed by calculated ccr remained stable in both groups, no graft was lost. prepubertal children off steroids gained relative height from baseline - . ± . sds to - . ± . sds after yrs, while patients on steroids lost relative height (- . ± . sds at baseline, - . ± . sds after yrs); a comparable pattern was observed in pubertal patients. the standardized body mass in patients off steroids declined from . ± . sds at baseline to . ± . after yrs (p< . ), while it tended to increase in patients on steroids (baseline, . ± . sds; after yrs, . ± . ). the rate of adverse events, mainly infections, was comparable in both groups. patients off steroids required less frequently antihypertensive medication ( %) than patients on steroids ( %). a significant reduction of serum cholesterol (by %) and triglycerides (by %) in response to steroid withdrawal was observed. conclusions: this interim analysis indicates that late steroid withdrawal in selected pediatric renal transplant recipients on csa and mmf is safe, allows catch-up growth and ameliorates cardiovascular risk factors. at the ipna meeting, full month outcome data of all patients will be available. u. frei, j. noeldeke renal transplantation faces two major challenges: the organ shortage resulting in extended waiting times and an aging population resulting in increased death with a functioning graft. the eurotransplant senior program (esp) allocates kidneys within a narrow geographic area from donors aged > years to recipients > years regardless of hla. this analysis investigates the impact of the esp on waiting time, graft and patient survival. the esp group (n= , old to old) was compared to two groups allocated via the eurotransplant kidney allocation system (etkas) with either similar donor age [old to any (o/a), donor age > , n= ] or recipient age [any to old, (a/o), recipient age - , n= ]. all patients were transplanted between and . since initiation of the esp ( ), availability of elderly donors doubled and waiting time for esp patients decreased. local allocation led to shorter cold ischemia time ( . vs. > . hours, p< . ) and less delayed graft function (dgf, esp . % vs o/a . %, p= . ) but - % higher acute rejection rates. importantly, graft and patient survival were not negatively affected by the esp allocation scheme. the esp age matching of elderly donors and recipients is an effective allocation system for organs from elderly donors. the effect of age matching on the duration of the waiting time a. rahmel, m. slot, j. smits eurotransplant international, leiden, the netherlands in eurotransplant the proportion of children, i. e. patients aged under the age of at time of registration, with end-stage renal disease (esrd) on the renal waiting list amounts to only . %. despite this small proportion the eurotransplant kidney allocation system (etkas) specially addresses pediatric transplant candidates. in order to increase their chances of receiving a transplant in time children are assigned via etkas extra points for hla matching and receive an age bonus. in order to evaluate this allocation policy, the chances for receiving a kidney for patients in different age groups were evaluated. for the cohort of patients registered in the year , a year followup was obtained. for patients aged under at time of registration [n= ] % and % received a kidney from a post-mortem donor, within year and years after listing. for children aged to [n= ] these rates were at and years after listing % and %, and for children between age and [n= ] % and % respectively. adult patients were less likely to receive an organ: % and % of patients aged between and were transplanted within and years after listing. senior esrd patients can benefit from the eurotransplant senior program (esp), their chances for a transplant were % and % within and years, respectively. the life span of a renal allograft is limited in time. in the eurotransplant experience % of the post-mortem kidneys used for transplantation in children failed within years, compared to % for the living donor renal transplants (rtx). donor age is an important factor associated with long term renal allograft function. age matching between donor and recipient is hampered by the low number of pediatric donors. in the period - , heart beating kidney donors aged under were reported and used for rtx, donors were between and years of age, and donors were between and years old. in the same period adult donors were reported and used for transplantation. in the period - , % of the pediatric donor kidneys ultimately served a pediatric recipient. to improve the allocation of pediatric donors to pediatric recipients, et is in the process of implementing a rule giving pediatric recipients priority in case of pediatric donors. gender and sex hormones are playing a central role in the incidence and progression of different renal diseases. vascular tone, endothelial function and immune response are influenced by gender. in renal transplantation ischemic injury is always present. females are more resistant to postischemic renal failure than males. following ischemia/reperfusion injury renal vascular resistance decreases, allowing fast restitution of blood flow and oxygen supply in females. additionally, stabilization and preservation of tubular function following ischemia is achieved by the protection of na+/k+ atp-ase and heat shock protein activity contributing to the observed gender differences. posttransplant immune reactions also differ between genders. female gender predisposes to more severe acute rejection following kidney transplantation, partly due to differences in the effectivity of immunosuppressants used. ineffective immunosuppression in females, as well as different cytotoxicity profile of the drugs is contributing to more prone immune reactions shortly after transplantation resulting in more severe acute rejection. in contrast, similar to the slower deterioration of other renal diseases, progression of chronic graft failure is less pronounced in females in experimental and clinical settings. estradiol decreases profibrotic processes, preserves endothelial function and modifies influx of immune cells into the graft. the fine balance between alloantigen dependent immune reactions and alloantigen independent factors and its impact on longterm graft function is modified by gender. new evidences supporting the significance of sexual dimorphism following kidney transplantation may present the base of gender modified therapeutic approaches in the future. iga nephropathy: aetiology, incidence, and geographic distribution iga nephropathy (igan) is characterized by mesangial deposits of iga, proliferation of mesangial cells and expansion of matrix. the accumulation of iga and complement fractions within glomeruli was initially ascribed to deposition of iga immune complexes (igaic) due to mucosal immune response with predominant iga synthesis. this hypothesis has offered an explanation of the relationship between infections of the upper airways and gross hematuria. high levels of igaic have been detected in - % of patients, mostly of polymeric iga , and polymeric iga are detectable in renal deposits. this observation is consistent with hypothesis of either bone marrow or mucosal origin. however, no specific viral or alimentary antigens have been found in mesangial deposits, and the qualitative properties of polymeric iga have rather become of interest, particularly the glycosylation pattern of iga . human iga is o-glycosylated with carbohydrate chains of n-acetyl galactosamine (galnac) and galactose (gal) which may be covered with sialic acid (neu ac). patients with igan exhibit circulating iga with reduced gal and/or neu ac and increased exposure of n-galnac. such aberrantly glycosylated iga can circulate in monomeric form or participate in the formation of autoaggregates/true immune complexes. it likely escapes clearance by hepatic receptors and has a preferential renal deposition by virtue of enhanced reactivity with the mesangial matrix components. the role of a triggering event has not ruled out. in recent reports, antigens of bacterial origin and the secretory tract component have been found in renal deposits, making scientists reconsidering again the role of bacterial infections. tonsils recurrent infections may provide a suitable aetiology for igan, and the effect of tonsillectomy on the long term outcome of igan is under evaluation. the prevalence of igan varies in different areas, due to ethnic and environmental factors, being particularly frequent in mediterranean europe, northern europe, asia and australia. it is still debated whether differencies in frequency, clinical features and disease progression among patients with igan from different countries are actually due to uneven distribution of this diseases or these discrepancies are due to the different criteria for performing renal biopsy. definition. igan is characterized by the presence of dominant (or codominant) mesangial deposits of iga on immunofluorescence microscopy, frequently with c and sometimes with igg or igm. classification. the glomeruli display a broad spectrum of histologic changes, related in part to the differences in the indication for the biopsy of the referring nephrologist. a number of classification systems have been used to describe the histologic manifestations of igan. two will be referred to here: the system of m. haas (ajkd : - , ): ) minimal histologic lesion -the glomeruli exhibit no more than a minimal increase in mesangial cellularity, without segmental sclerosis or crescents. ) fsgs-like -the glomeruli display focal segmental sclerosis in a pattern resembling primary focal segmental glomerulosclerosis, with at most a minimal increase in mesangial cellularity and no crescents. ) focal proliferative glomerulonephritis (gn) - % or fewer of the glomeruli are hypercellular. the increase in cellularity may be limited to mesangial areas, or there may be obstruction of glomerular capillaries by proliferated endocapillary cells. crescents may be present. ) diffuse proliferative gn -more than % of glomeruli are hypercellular. the hypercellularity may be segmental or global, and crescents may be present. ) advanced chronic gn - % or more of the glomeruli are globally sclerotic, and/or there is % or more tubular atrophy or loss in the cortex. the system of s. emancipator (heptinstall's pathology of the kidney, lippincott-raven, philadelphia, , pp - ) : a -normal/minimal glomerular lesions b -focal mesangial proliferation c -diffuse mesangial proliferation d -focal segmental endocapillary proliferation superimposed on mesangial proliferation d -focal segmental endocapillary proliferation alone e -diffuse endocapillary proliferation f -diffuse extracapillary proliferation (crescents in > %), with or without endocapillary proliferation g -glomerulosclerosis (> % of the glomeruli are sclerotic) h -unclassifiable or combined lesions diffuse proliferative gn (c) and focal proliferative gn (d ) are the major patterns of expression of glomerular injury. indicators of a poor outcome. these include a high proportion of glomeruli with crescents, numerous sclerotic glomeruli, interstitial fibrosis and tubular atrophy, extension of the iga deposits into the peripheral glomerular capillary walls, and hyaline arteriolosclerosis. differential diagnosis. mesangial iga deposits are present in henoch-schönlein nephropathy, and may be present in lupus nephritis, chronic liver disease, coeliac sprue, certain dermatologic diseases, and some rheumatologic diseases. iga nephropathy [igan] is defined by the presence of mesangial iga, but otherwise the histopathological and clinical features are very variable. we do not yet know sufficient about pathogenic mechanisms to understand whether igan is a single disease. although traditionally called an 'immune complex' disease there is no direct evidence that mesangial iga deposition in igan occurs through classical antigen-antibody interactions. mesangial cells do carry receptors for iga, which may play a key role in iga deposition and subsequent injury, but these are not yet fully characterised. mesangial iga in igan is polymeric iga . there is no evidence of mucosal immune system overactivity, indeed there seems to be underproduction and abnormal t cell control of mucosal iga production, along with overproduction by the marrow of iga iga has a hinge region peptide structure which is a site for o-glycosylation. in igan circulating and mesangial iga both have abnormal o-glycosylation at the hinge region. the same defect is seen in henoch-schönlein purpura only when there is renal involvement. the glycosylation defect is not due to abnormal peptide structure of the hinge; the possibility that there is reduced activity of the key enzyme b , galactosyltransferase in b cells or plasma cells has not yet been confirmed. alternatively the glycosylation changes may reflect a shift in the production of mucosal type of iga to the marrow. while iga deposition is caused by disease mechanisms specific to igan, subsequent inflammatory and fibrotic events are probably driven by mechanisms common to other chronic glomerular disease. in some patients iga deposition is not followed by inflammation, in others inflammation resolves without fibrosis. cytokine and growth factor production by mesangial cells is a sufficient explanation for glomerular inflammation and fibrosis. however little is yet understood of any genetic or environmental influences which protect some patients from progressive renal injury. our recent controlled trials by the japanese pediatric iga nephropathy treatment study group demonstrated that treatment of children with severe iga nephropathy with prednisolone, azathioprine, heparin/warfarin, and dipyridamole for years early in the course of the diseaseprevents immunological renal injury and progression of the disease. the majority of patients with iga nephropathy in our series are diagnosed early in the course of the disease, and the asymptomatic period before the discovery of urinary abnormalities is short. early diagnosis and early treatment is very important in iga nephropathy. . combined therapy for severe childhood iga nephropathy (j am soc nephrol : [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ) . seventy-eight children with newly diagnosed iga nephropathy showing diffuse mesangial proliferation were randomly assigned to receive either the combined therapy of prednisolone, azathioprine, heparin-warfarin, and dipyridamole for two years (group ) or the combination of heparin-warfarin and dipyridamole for two years (group ). urinary protein excretion was significantly reduced in group patients, but remained unchanged in group patients. the percentage of glomeruli showing sclerosis was unchanged in group patients, but significantly increased in group patients. . steroid treatment for severe childhood iga nephropathy (clin j am soc nephrol, : - , ) . in this study we have compared the effects of prednisolone, azathioprine, warfarin, and dipyridamole (combination) with those of prednisolone alone in children with newly diagnosed iga nephropathy showing diffuse mesangial proliferation. patients were randomly assigned to receive either the combination or prednisolone alone for two years. the primary endpoint was the disappearance of proteinuria, defined as urinary protein excretion < . g/m /day. thirty-nine of the patients receiving the combination and of the receiving prednisolone completed the trial. thirty-six of the patients ( . %) receiving the combination and of the ( . %) receiving prednisolone reached the primary endpoint by the two-year follow-up point (p= . log-rank). the percentage of sclerosed glomeruli was unchanged in the patients receiving the combination, but increased in the prednisolone group (p= . ). the frequency of side-effects was similar in the two groups. long-term administration of recombinant human erythropoietin (epo) has become the most common way of treating anemia in chronic renal disease. standard amounts per unit body weight have been recommended for the initial dose. however, several authors have noted that the dose per unit body weight needed for a given response is higher in younger children than in older children or adolescents and that it is increasing with decreasing body weight. furthermore, for a given absolute dose of epo the outcome was investigated in adult hemodialysis patients, but no dependence was found in patients weighing - kg. a similar model to the hemoglobin-time data of children aged - years treated with epo for renal anemia did not find an impact of body weight on response when it was modelled in terms of absolute dose. in a similar analysis to the hemoglobin-time data children and adolescents aged - years were analyzed, in order to more definitively answer the question if, for given absolute doses the hematopoetic response to epo in children depends on body weight. neither the dose response parameter e max and ed showed dependence on body weight. the median hemoglobin response to a standard dose was similar to that reported for adults. it can be concluded that younger and smaller children need relatively more epo than older children. doses for children should be specified as absolute amounts rather than amounts per unit body weight. references: scigalla p. effect of recombinant human erythropoietin treatment on renal anemia and body growth of children with end-stage renal disease. in: baldamus ca, scigalla p, wieczorek l, et al, editors erythropoetic agents are the mainstay of treatment for renal anemia. although there are several different marketed forms of erythropoetin, they are not substantially different in their ability to stimulate erythropoesis. however, darbepoetin, which differs in one amino acid, and has additional glycosylation sites, has a longer half-life and therefore a presumed longer duration of action. this provides a theoretical advantage, suggesting that less frequent injections will be required. clinical experience and studies have confirmed that both erythropoetin (epo) and darbepoetin (dar) are effective to maintain hb values within the recommended range. also, though there is some experience with epo injected every couple of weeks, the overall evidence suggests that dar has a longer duration of action, and injections are required less frequently. for many children, particularly the pre-dialysis population, anemia is successfully controlled with dar injected every - weeks. however, this apparent advantage of dar is somewhat reduced because of the increased pain reported with dar injections compared to epo. both epo and dar have been used successfully in children of all ages. with epo, the doses required to maintain hb values appear to be increased in infants compared to older children; this may not be the case with dar, but there is much less experience with use of dar in infants. also, the administration of dar in infants is hindered by the need to inject portion of a unidose pre-filled syringe, which may introduce inaccuracies in dosing, is wasteful, and is not user-friendly. the side effect profile for each product is similar, and specifically each has been associated with development of hypertension, which is most likely with higher hb values. pure red cell aplasia has also been reported with each product. thrombocytosis has been reported with dar use. overall, there is little to recommend one product over the other. the need for less frequent injections may favor dar for use in most children beyond infancy, whereas it is easier to administer epo accurately in infants. how much iron is needed and how much is toxic? iron deficiency is the primary reason for ineffective erythropoiesis in patients with chronic kidney disease (ckd) who receive an erythropoiesis stimulating agent (esa). reasons for iron deficiency include inadequate dietary intake, blood loss from the gastrointestinal tract, frequent blood tests, loss of blood in the extracorporeal circuit of hemodialysis (hd), as well as the hepcidin related impairment of the intestinal absorption of iron and its release from the reticuloendothelial system. supplementation of iron can be by either the oral or intravenous (iv) routes, although the national kidney foundation-kidney disease outcomes quality initiative (k/doqi) strongly recommends the preferential use of iv iron in children and adult patients receiving hd. the k/doqi recommended target iron indices for all children on dialysis are a serum ferritin > ng/ml and a transferrin saturation (tsat) > %. while the serum ferritin should not regularly be > ng/ml, some such patients will achieve a higher hemoglobin value following an iv course of iron therapy. of the iv iron agents, the non-dextran products appear to be safest, and pediatric dosing recommendations exist for ferric gluconate and are currently being studied for iron sucrose. differences do exist for the clinical (e. g. proteinuria) and subclinical (e. g. oxidative injury) toxicities associated with the currently available iv iron products and should be taken into consideration when prescribed. until recently the major physiological function of erythropoietin (epo) was thought to be the induction of erythropoiesis. however, a growing body of evidence indicates that epo has tissueprotective properties and prevents ischemia induced tissue damage in several organs including the kidney. a main target of epo´s action is the endothelium, and one of the pivotal intracellular pathways mediating the beneficial effects of epo is the activation of akt, i. e. serine/threonine protein kinase b. as a result, akt phosphorylates the proapoptotic factor bad, which in turn causes inhibition of programmed cell death (apoptosis). moreover, experimental studies revelead that epo is a potent regulator of endotheial progenitor cell (epc) proliferation and differentiation. collectively, these data support the hypothesis that epo is a key molecule in the process of endothelial (vascular) repair and neoangiogenesis. treatment with rhuepo or analogues could therefore open new therapeutic strategies in regenerative cardiovascular medicine. introduction: africa as a continent is besieged by many health challenges including malaria, hiv (upwards of % of paediatric admissions), tuberculosis and malnutrition with an infant mortality rate (imr) ranging from (southern africa) to (mozambique). good health facilities are on the whole not available except in the extreme north and south of the continent with doctors/ population in south africa but in kenya only and even lower in other parts of africa. renal disease: renal disease in adults is an unknown quantity with no information being available regarding children's renal disease, where many babies do not even have access to antenatal ultrasounds. situation in south africa: in reality, there are only centres (cape town and johannesburg/ pretoria) doing paediatric dialysis and transplantation in significant numbers with small numbers interspersed in the rest of the country. this raises numerous issues: -accessibility for children to renal care -retaining minimum standards of care for children -both dialysis and transplantation -combined with adult units -central government funding in form of tertiary services grant for paediatric renal care -children not first priority on any transplant program in terms of organ allocation -private facilities vs state facilities -ethical decisions dialysis facilities: peritoneal dialysis (pd) first line therapy for acute renal failure, as can be performed in any setting with minimal equipment and expertise. in the setting at rxh, we have a greater than % survival in infants and children dialysed using pd even in a sophisticated intensive care setting. haemodialysis and chronic dialysis may not be easily available in most settings and realistically need transfer to one of the major centres. transplantation: again limited to only few centres, with at least % living related donations from family members. initial good year ( %) and year ( %) graft survival but results then deteriorating as patients enter their adolescent years often with little support and transfer to adult units in their early teens. controversial issues here include access to one kidney transplant only, no chronic dialysis if not suitable for transplant and transplantation in hiv positive recipients. conclusions: adequate resource allocation is required for paediatric renal care especially where resources are limited. immunosuppression remains the cornerstone of successful transplantation. in developing countries transplantation is mostly from living donors and transplant is thus a once in a lifetime chance. in this backdrop immunosuppression is a challenge as several issues have to be overcome. namely, non-availability of newer drugs, high costs and paucity of drug monitoring facilities. in most countries immunosuppression is based on a triple drug regimen of cyclosporin (cya), prednisolone (pred) and azathioprine (aza). in the last few years mmf and tacrolimus (tac) has been initiated in a few centres. several tailoring strategies have been employed taking into consideration costs, drug availability, tissue typing facilities and drug monitoring. firstly in hla identical transplants which constitute - % of the total, cya based regimen are used. marked reduction to - mg/kg at months and complete withdrawal at one year in rejection free transplants is safe with continuing of aza and pred. secondly several centres selectively use tac and mmf in cases with early rejection or transplants with > mismatches. it is possible to switch to cya or aza after months on individual basis. thirdly induction protocol with atg for days in transplants with > mismatches and in retransplants is cost effective. cost considerations have increased the use of generic calcinurin inhibitors with market share of - % in different countries. co administration of p competitors has reduced doses of cya by - % with considerable cost reductions. siut has been running a living related transplant program for more than years with dialysis and follow-up of recipients and donors. keeping in mind economic constraints a model of government public partnership was developed which provides all facilities including drugs free of cost. we adopted a number of tailoring strategies e. g. strict monitoring, tailoring by hla match and donor age and use of biological agents in risk groups. in first years we used parent drugs, however increasing costs necessitated use of generics after establishing bioequivalence in controlled trials. graft survival rates were maintained at % and % at and years. in conclusion, immunosuppression in developing countries require besides newer drugs, monitoring facilities, affordable costs and regular follow-up as transplantation for majority is once in a lifetime chance and failure equates with death. occurrence of infections following kidney transplantation is a major reason for hospitalization, and an important cause for renal dysfunction & mortality in developing countries. more than % renal transplant recipients get serious infections, with a - % risk of mortality. infections in the first month after transplantation are similar to those in surgical patients; opportunistic pathogens and cmv predominate between - months; and tuberculosis (tb) after months. the risk of tb in patients on maintenance dialysis & following transplantation is between - %. the onset of tb is usually within months of transplantation. clinical syndromes include pleuropulmonary tb, followed by disseminated tb, pyrexia of unknown origin and lymph node disease. demonstration of m. tuberculosis, on microscopy or culture might not be possible. nonrifampicin based treatment regimens (inh, pyrazinamide, ethambutol, fluoroquinolone for months, followed by hef for months) are used. inh prophylaxis ( - months) is advised in patients with tuberculin positivity or contact with active tuberculosis. cmv disease results in considerable morbidity & mortality; its timing is influenced by donor/recipient serological combination, state prior to transplantation, use of antilymphocyte induction therapy or preventive strategies. cmv disease is characterized by a non-specific febrile illness; features of enterocolitis, pneumonia, hepatitis, myocarditis, esophagitis, chorioretinitis & bone marrow involvement are variable; disseminated disease is rare. cmv disease exacerbates the net immunosuppression, increasing the risk for opportunistic infections. patients with cmv disease are also at risk for acute rejection and chronic allograft injury, atherosclerosis & vascular injury. diagnosis of cmv disease is based on a combination of viral serology, shell vial cultures, pp antigen assay and pcr. the cost of prophylaxis and treatment is a major limitation to the use of ganciclovir or valganciclovir. other infections in transplant recipients include malaria, p. carinii and fungi (cryptococcosis, candidiasis, mucormycosis, aspergillosis). infections are an important cause of morbidity & mortality in renal transplant recipients. their management continues to be challenging due to difficulties in diagnosis, unsatisfactory follow-up and cost of medications. ethical issues of renal replacement therapies n. orta, p. zibaoui, e. lara university of carabobo/insalud, pediatric nephrology, valencia, venezuela important ethical issues in pediatric nephrology (pn): genetic and molecular techniques, prenatal therapies for urinary anomalies, treatment of children with chronic renal disease (esrd). ecosonography can detect nephrourological anomalies and studies of amniotic fluid give information on chromosome alterations and renal function. particular situations, can lead to dilemmas related to pregnancy interruption and neonatal dialysis and transplantation (dt) possibilities. renal insufficiency (ri) presents at any age, and peritoneal, hemodialysis or hemofiltration could be applied. patients without structural abnormalities, ri secondary to toxics or isquemic nephropathies have better prognosis. these procedures are complicated and costly and increases, and may have secondary effects with ethical implications. treatment by dialysis developed in the 's and inclusion of children was not considered. this has changed with advances in dt. since 's dt programs were setup for children, but received criticisms and considered unethical, but were continued because of familiar and humanitarian demands and today it is clear that children benefit with that. scientific societies recommend: . children who receive dialysis must meet the following criteria: -diagnosis of esrd, legal authorization, possibility of transplantation, acceptable quality of life; may not be rejected for economic, social or psychological reasons, nor gender, age, race or mental conditions. biopsies are the current 'gold standard' for monitoring transplant patients, but it has been shown that even mild rejection episodes, based on pathology grading, can have poor outcomes and even biopsies with normal early pathology can progress rapidly with chronic allograft injury. there is considerable inter-observer variability of biopsy pathology readings that adds an additional confounder to this method of analysis. identification of non-invasive biomarkers in blood or other fluids would allow for the possible elimination of frequent biopsies. hence, the identification of diagnostic and predictive non-invasive genomic markers will be a worthy tool to aid in the clinical monitoring of transplant patients. the use of dna microarrays as a hypothesis generation tool for determining gene expression differences across thousands of genes in a data set is increasing. recently, the use of microarrays has been applied to the transplant field and holds great promise for unraveling the mechanisms at play in various transplant processes and for identifying new tissue specific and non-invasive biomarkers predictive of clinical outcomes. as microarrays produce large amounts of data, bioinformatics tools are being developed to determine gene expression patterns. gene clustering and class prediction tools aid in the discovery of molecular signatures in different disease processes while literature mining, gene family analysis and pathway analysis help in understanding the biological relevance of these signatures. initial studies in acute rejection and graft dysfunction have produced possible markers for risk stratification of the rejection event and have suggested underlying mechanisms at play, that may now allow us to test novel drugs for treating specific acute rejection episodes. the most exciting application of microarrays lies in our ability to predict clinical outcomes by non-invasive serial monitoring, eliminate the requirement of transplant biopsies and individualize patient management by accurately predicting the patient's sensitivity to immunosuppression-sufficient to suppress the allo-response, yet insufficient to abrogate the innate response. responsible array data handling and accessible reporting will open new doors for transplant researchers through increased use of computers and collaborations towards these kinds of novel insights and treatment options for transplant patients in the future. this talk focuses on dna microarrays, their application to transplantation, and discusses some of their limitations and recent applications, as well as some key research studies where dna microarrays are applied to understanding the molecular differences in acute transplant rejection that segregate and likely control the differences in rejection treatment responsiveness as well as decline in graft function, as well as gaining insights into the different biological processes that govern these differences. the molecular pathogenesis of vur is not well understood. uroplakins (ups) are expressed in the urothelium and are developmentally regulated by rab b and tbx genes. up ii and iiia-null mice exhibit a primary ( o ) vur phenotype. using microarrays and rt-pcr, we analyzed gene expression in surgically-discarded ureteric tissue from children undergoing reimplantation for o reflux, compared with adult living-related transplant donors as normal controls, as well as children with o reflux (megaureter, duplicated ureters, and posterior urethral valves) as age-matched disease controls. we also studied urine protein profiles using -dimensional electrophoresis ( d-page) followed by time-of-flight mass spectroscopy (q-tof-ms). rt-pcr showed partial expression of ureteric upia, upib, upii and upiiia genes in patients with o reflux. protein screening using western immunobloting confirmed that some uroplakins were undetectable. real-time rt-pcr revealed that ureteric up ia, up ib, upii, and up iiia gene expression decreased significantly, whereas upiiib gene expression increased at least -fold compared to controls. compared with patients with o vur, the decrease of upiiia expression in those with o reflux was highly statistically significant (p< . ). the expression of rab b and tbx genes also decreased significantly in patients with o and o reflux as well. total urinary protein concentration increased by -fold in the o vur patients without detectable renal scarring on dmsa scans; and increased further in patients with renal scarring, -fold for o vur and -fold for o vur patients. proteomic analyses of proteinuria revealed an overall increase of protein with mw> . kda in the pi range . to . in patients. q-tof ms identified one predominant urinary protein of ~ kda as sera-transferrin, which was confirmed by elisa quantitation. we hypothesize that the abnormal developmental expression pattern of the up, rab b and tbx genes in vur patients results in abnormal urothelial functions, which lead to leakage and/or secretion of proteins into the urine, and that this occurs in the absence of scarring from urinary infections. further identification of these protein biomarkers may lead to non-invasive diagnostic tests for vur. biomarker discovery in acute kidney injury p. devarajan cincinnati children's hospital medical center, department of pediatric nephrology and hypertension, cincinnati, united states acute kidney injury (aki), previously referred to as acute renal failure (arf), represents a common and persistent problem in clinical medicine. despite significant improvements in therapeutics, the mortality and morbidity associated with aki remain high. a major reason for this is the lack of early markers for aki, akin to troponins in acute myocardial disease, and hence an unacceptable delay in initiating therapy. fortunately, the application of innovative technologies such as functional genomics and proteomics to human and animal models of aki has recently uncovered several novel genes and gene products that are emerging as biomarkers. the most promising of these are chronicled in this symposium. these include a plasma panel (ngal and cystatin c) and a urine panel (ngal, . since they represent sequentially expressed biomarkers, it is likely that the aki panels will be useful for timing the initial insult and assessing the duration of aki. based on the differential expression of the biomarkers, it is also likely that the aki panels will distinguish between the various types and etiologies of aki. however, they have hitherto been tested only in small studies and in a limited number of clinical situations. it will be important in future studies to validate the sensitivity and specificity of these biomarker panels in clinical samples from large cohorts and from multiple clinical situations. such studies will be markedly facilitated by the availability of commercial tools for the reliable and reproducible measurement of biomarkers across different laboratories. a. watson children and young people's kidney unit, notthingham university hospitals, nottingham, united kingdom the achievement of adequate chronic peritoneal dialysis in children requires close attention to clinical, dietetic and psychosocial aspects of care. successful dialysis is dependent upon excellent peritoneal access and swan neck coil catheters with downward facing exit sites are increasingly favoured with many placed laparoscopically. automated peritoneal dialysis is employed in most developed countries but adolescents may be given the choice of capd which may be the only modality available in developing countries. training and support by committed nursing staff are of paramount importance as is regular review by a paediatric renal dietitian. growth parameters should be regularly monitored and supplemental enteral feeding introduced early. many infants are nasogastrically fed, but the preferred route for supplemental enteral feeding is via a gastrostomy which can be placed at the same time as the pd catheter. dialysis fill volumes should be assessed in terms of body surface area and intra-abdominal pressure measurements. there can be discrepancies between urea and creatinine clearances and adequate dialysis includes combining clinical parameters with regular growth measurements as well as biochemical data including phosphate, calcium and parathyroid levels. peritoneal function tests are useful in monitoring progress but the greatest challenges are in sustaining long-term dialysis, particularly in infants where transplantation is likely to be delayed. support for the families with a respite care 'package' may delay or prevent burnout and possibly reduce peritonitis rates. conventonal pd solutions are acidic, contain unphysiological concentrations of lactate and glucose and highly toxic glucose degradation products (gdp), which are substrates for advanced glycation end product (age) formation. repeated administration induces epithelial to mesenchymal cell transition, loss of the mesothel cell layer, progressive submesothelial fibrosis and angiogenesis, ultimately leading to ultrafiltration failure. meanwhile pd solutions with an improved toxicity profile are available. multi chamber pd solutions separate glucose from the buffer at a very low ph, which largely prevents gdp formation. after mixture ph is close to normal. they are equally effective with regard to solute-and water transport, reduce inflow pain and systemic age load. dialysate effluent markers indicate increased mesothelial cell mass, reduced peritoneal inflammation and reduced angiogenesis. animal studies demonstrate preservation of pd membrane morphology and function, respective human biopsy data however are pending. a european paediatric multi centre trial accomplished recently elucidates the impact of the lactate and bicarbonate buffer. a randomized cross over trial in adult patients points to an improved preservation of residual renal function; a korean registry suggests improved technique and patient survival. icodextrin solutions reduce glucose and gdp exposure, improve extracellular fluid status, left ventricular mass and stabilize membrane function in anuric adult capd patients and should be beneficial in children, too. amino acid based solutions achieve similar clearance and ultrafiltration rates, reduce glucose and gdp load and allow for a phosphate free amino acid supply. the nutritional benefit however is questionable. other, thus far experimental strategies include addition of locally active compounds to pd fluids such as gdp scavengers, inhibitors of age formation and antifibrotic agents. surface active phospholipids may increase peritoneal contact area and ultrafiltration. gene therapy appears highly promising but is still far from being clinically applied. in summary, there is substantial evidence for increased biocompatibility of the recently introduced multi chamber and icodextrin based pd solutions. they should improved long term morbidity and mortality of pd patients; this however still needs to be proven. the impact of the ippr on the treatment of peritonitis b. a. warady children's mercy hospital and clinics, pediatrics nephrology, kansas city, united states the international pediatric peritonitis registry (ippr) is an initiative that was established to evaluate the safety and efficacy of largely opinion based peritonitis treatment guidelines in which empiric antibiotic therapy ( st generation cephalosporin and ceftazidime or a glycopeptide and ceftazidime) was stratified by disease severity. forty-seven centers from countries contributed data on children and peritonitis episodes treated in accordance with the guidelines. culturenegative peritonitis accounted for % of all episodes, with a marked regional variability in the incidence of this disorder, as well as in the peritonitis causative organisms. overall, % of cases achieved full functional recovery, a portion following relapsing peritonitis ( %). in-vitro evaluation revealed only % sensitivity of gram-positive organisms to a st generation cephalosporin (eastern europe > north america) and % sensitivity of gram-negative organisms to ceftazidime. in contrast, % of gram-positive organisms and % of gram-negative organisms were sensitive to the combination of either a st generation cephalosporin or an aminoglycoside. whereas the risk of empiric treatment failure was associated with the presence of a gram-negative infection (p= . ), neither the risk factors assumed by the guidelines nor the choice of empiric therapy were predictive of the final functional outcome of the peritonitis episodes. the data collected by the ippr will serve as an important source of evidence to be incorporated into revised pediatric peritonitis treatment guidelines. ch. aufricht medical university, pediatrics, vienna, austria peritoneal dialysis (pd) is a safe, cost effective and widely used form of renal replacement therapy in patients with end stage renal failure. however, up to a third of patients on pd will suffer from technical failure during their course. identification of the patients at highest risk would be of high clinical relevance. cytotoxicity of pd fluids due to low ph, hyperosmolarity, and/or high concentrations of lactate, glucose and its degradation products causes mesothelial cell injury that ranges from minor cellular dysfunction to overt (apo)necrosis. the same physicochemical properties of pdf that cause such cellular injury also induce pathways leading to repair and recovery. this so-called cellular stress response results in a switch of the cellular machinery from routine procedures towards reaction against stressors. the complex machinery of the cellular stress responses not only counteract direct toxic injury caused by pdf but also attenuate inflammation or other potentially deleterious cellular processes. infectious, uremic and toxic injuries might converge in cellular inflammation. whereas inflammatory processes triggered by infection protect the peritoneal cavity against invading microorganism, chronic sterile smoldering 'cytotoxic' inflammation may result in aberrant healing processes and peritoneal fibrosis. recently, polymorphisms of many proteins involved in relevant cellular responses have been described and related to altered resistance and/or susceptibility to pathogenetic processes with potential influence in pd. in this review, we will focus on key effectors of stress responses, of cellular inflammation and of fibrogenesis such as heat shock proteins (hsp), cytokines (il- ), chemokines (il- ) toll-like receptors (tlr) and growth factors. given the recently shown role of these 'players' for the interplay between mesothelial injury, inflammation and cytoprotection, these polymorphisms will likely be relevant for mesothelial cell damage during pd. taken together, the ability to understand -and ultimately modify -the risk profile of a given patient will be essential for tailoring individual pd therapies. the pathologic diagnosis of chronic allograft nephropathy (can) was introduced in by the banff classification system for renal allograft injury. it originally included at least four entities that it was acknowledged could not always be distinguished by biopsy: ) chronic rejection; ) chronic calcineurin inhibitor (cni) toxicity; ) hypertensive vascular disease; ) chronic infection and/or reflux (solez, ki : ) . over the ensuing decade, the definition of can has expanded and fluctuated such that some pathologists have come to use the term to mean a specific pathologic entity comprising "…progressive graft dysfunction accompanied by chronic interstitial fibrosis, tubular atrophy, vascular occlusive changes and glomerulosclerosis. " (nankivell, nejm : , while others have suggested can should be used to describe all causes of renal allograft dysfunction involving fibrosis. the resulting confusion over terminology has in some ways hindered the growing awareness of the multiple discrete, diagnosable and often treatable diseases capable of causing chronic graft injury. these diseases include: ) chronic (primarily antibody-mediated) rejection; ) de novo and recurrent glomerular disease; ) calcineurin inhibitor toxicity; ) interstitial fibrosis and tubular atrophy without evidence of any specific etiology. to this list should be added other recognizable causes of late graft dysfunction such as polyoma virus infection and hypertension. in the new banff classification can will no longer be a diagnostic category (colvin, world transplant congress, ) . instead, the term sclerosis will be used to describe: "interstitial fibrosis/tubular atrophy, not otherwise specified, " or "if/ta nos. " the increasing use of protocol biopsies in clinically stable patients has dramatically increased awareness of the ongoing pathological changes almost every renal allograft appears to be undergoing almost from the first moments of engraftment. techniques are now available in most centers to reliably recognize the presence of chronic antibody-mediated rejection. these include: ) typical morphological findings: lamination of glomerular basement membranes, arterial intimal fibrosis, interstitial fibrosis/tubular atrophy; ) c d staining in peritubular capillaries or glomeruli; ) the presence of circulating donorspecific antibodies (takemoto ajt : . treatment of late, chronic antibody-mediated rejection is in its infancy and may include use of anti-b cell antibody (rituximab), ivig, and/or plasmapheresis. calcineurin inhibitor toxicity can be more reliably identified by focusing on blood vessels in the allograft, primarily the location of hyaline deposits in the arterioles. nodular, peripheral hyalinosis is found almost exclusively in cni toxicity, whereas sub-endothelial and transmural hyaline deposits are non-specific and can be seen in hypertension, aging and diabetic nephropathy. there is increasing concern that recent gains in short-term renal allograft survival and reductions in acute rejection rates have not resulted in improved long-term graft survival. while this is likely due to multiple factors, including infections and malignancies associated with over immunosuppression, unrecognized (sub-clinical) acute cellular rejection (moreso ajt : ), and noncompliance in some patients, much evidence points to the primary role of cni toxicity in many if not the majority of chronically failing allografts maintained on cni's. experience with conversion from cni to sirolimus in adult patients has been reviewed in a recent editorial (betard nephrol dial transplant : editorial comments) . in studies involving nearly patients, between % and % of patients with late allograft dysfunction failed to respond favorably to cni withdrawal and replacement with sirolimus. acute rejection episodes were rare, occurring in only six patients. common adverse effects included dyslipidemia, anemia and proteinuria. in one study, of patients developed proteinuria after conversion, in the nephrotic range. pediatric experience with cni withdrawal has been limited (kerecuk, pediatr nephrol : falger, pediatr transplant : , hocker, pediatr transplant . our recent experience at stanford with cni withdrawal in patients was not favorable, with % of patients experiencing an associated acute rejection episode (weintraub, wtc ) . prior history of acute rejection significantly increased the relative risk of acute rejection after cni withdrawal (rr= . ), and proteinuria was common. patients with advanced chronic graft dysfunction were at increased risk for graft loss. in summary, the use of the term can to describe all causes of chronically failing renal allografts is to be discouraged in favor of a search for specific etiologies whenever possible. antibody-mediated rejection and cni toxicity are major causes of late allograft dysfunction. protocol biopsies are helpful in identifying patients with treatable causes of late allograft dysfunction. cni withdrawal/avoidance may be successful, but optimum patient selection criteria and withdrawal/replacement strategies have not been determined. pediatric experience to date with cni withdrawal has been limited, but it appears that late withdrawal after cni injury and graft dysfunction have become well established may be associated with inferior outcomes. prospective trials in pediatric patients are needed to address these issues. which immunosuppression in pediatric transplantation? p. hoyer university children's hospital, essen, germany recent results in pediatric renal transplantation have reached one year graft survival rates better than %. current immunosuppressive drugs should be classified according to their interference with the immunesynapsis as signal , signal and signal blocking agents. the variety of immunosuppressive drugs does allow more treatment combinations than the potential number of large scale studies in children. the definition of current unmet needs should guide employment of drugs. calcineurin inhibitors (cni) are still the basis of immunosuppression. individual risk profile leads to preferences for cyclosporine or tacrolimus. while in adults cni reduction seems to be the major goal, the search for steroid sparing or avoidance protocols has attracted major interest in pediatric transplantation. growth and body configuration as well as cardiovascular risk factors should be in the focus of research. antibody induction protocols, mainly with il- receptor antibodies, are increasingly popular, but efficacy is less clear than concluded from adult studies and might depend on initial combination therapy. mmf (cellcept®) or mpa (myfortic®) are effective drugs with cni sparing potential. early adequate dosing seems to be of greater importance than the choice of the cni, but the price to pay may be an increase in infectious complications. mtor inhibitors are promising in avoiding nephrotoxic side-effects; specific side effects on male gonadal function and possible interference with growth should be considered before any recommendation can be given. fty would have been of especial interest for children because of maintaining viral infectious response, but phase- studies are on withhold. the vision of tolerance has stimulated research on regulatory t-cells; i. e. cd cd +t-reg cells and the mastergene foxp . the impact of lymphocyte depletion induction protocols with campath on operational tolerance needs further studies. newer drugs in development are isa , a cyclosporine analog without nephrotoxicity; a modified release form of tacrolimus which might improve compliance; the phosphokinase inhibitor aeb with the potential to avoid cnis; the jak inhibitor cyp , which might interfere with signal (il and il -receptor); and lea y (belatacept) with blocks costimulatory signals. according to the new european drug legislation some of these drugs will be subject for mandatory testing in pediatric patients to get marketing authorisation. the future might be a more tailored immunosuppression according to the induvidual needs of the patient. immunosuppression minimization strategies, under the umbrella of a newer generation of more powerful induction and maintenance immunosuppressants, are being increasingly applied to pediatric organ transplantation, with the greatest emphasis on minimization of steroids and calcineurin inhibitor agents. safe elimination of these steroids carry unprecedented advantages for reducing patient morbidity and chronic graft injury, but may also result in unanticipated changes in immunological homeostasis and drug pharmacokinetics, heralding closer surveillance for posttransplant infections and alterations in drug bioavailability and dosing, as well as break-through immunologic responses. in single center studies, pediatric renal transplantation appears safe without steroids. daclizumab first dose doubling and extended use for months replaces steroids effectively without evidence of over-immunosuppression, and may be the pivotal causative for the reduced acute rejection seen in the face of steroid avoidance. this pilot protocol has been tested in a prospective, multicenter randomized us and canadian study. b. maecker, c. klein department of pediatric hematology/oncology, hannover medical school, hannover, germany posttransplant lymphoproliferative disorders are severe complications of immunosuppressive therapy after solid organ transplantation causing significant morbidity and mortality. to define prognostic factors, we have analyzed pediatric solid organ graft recipients (kidney, liver, heart/lung) that were reported to the german ped-ptld registry. ptld was diagnosed at a median time of months post organ transplantation with sigifcantly shorter lagtime in liver versus heart or renal graft recipients. the five-year overall and event-free survival was % and %, respectively. stage iv disease with bone marrow and/or cns involvement was independently associated with poor survival. no differences in outcome were observed between early and late onset ptld, monomorphic or polymorphic ptld, and ebv-positive or ebv-negative ptld, respectively. patients with burkitt-like ptld and c-myc translocations had very short survival. these factors should be important to consider for future prospective interdisciplinary trials that are urgently needed to define rational treatment strategies. cystinosis is an autosomal recessive lysosomal storage disorder affecting children and adults all over the world. in cystinosis cystine is trapped in the lysosomal compartment due to a defect in its egress transport protein cystinosin encoded by the gene ctns. by mechanisms still not fully understood this leads to tubular and glomerular kidney and other organ failures (e. g., thyroid, muscles) if left untreated. kidney involvement is prominent from shortly after birth on as renal tubular fanconi syndrome with the clinical consequences of failure to thrive and rickets. cystinosis is the single most common cause of renal fanconi syndrome in childhood. therefore, any recognition of renal glucosuria, generalized aminoaciduria, phosphaturia, small molecular weight proteinuria, polyuria, and metabolic acidosis (due to renal bicarbonate loss) should lead to prompt consideration of cystinosis as possible cause. this can be done utilizing biochemical analytical methods measuring the cystine content of polymorphonuclear leucocytes. corneal cystine crystals, seen in slit lamp examination, are pathognomic as well, but may not be visible before months of age. left undiagnosed and untreated, patients will develop in addition to the existing tubular insufficiencies pronounced glomerular kidney failure often already present at diagnosis and inevitably leading to end stage renal failure typically at the end of the first decade of life. kidney failure in cystinosis presents differently from other forms of glomerular kidney failure because of the overlap of tubular and glomerular insufficiencies. kidney transplantation will be curative with respect to kidney function. specific treatment with cysteamine to lower the intralysosomal cystine content apparently is as important as before transplantation to prevent or attenuate other organ failures and therefore has to be continued after kidney transplantation. cysteamine treatment has been introduced in the s and has been approved in the s. early diagnosis and diligent treatment is able to prevent or ameliorate major organ complications. unfortunately, until now no newborn screening exists due to the biochemistry and cell biology involved. the high prevalence of a european founder mutation, i. e., a kb deletion in the ctns gene, makes molecular based methods not feasible. lowe syndrome and dent's disease: two ends of a spectrum d. böckenhauer great ormond street hospital for children nhs trust, nephrology, london, united kingdom lowe syndrome and dent's disease are x-linked disorders; the former is a systemic disorder characterized by cataracts, mental retardation and proximal tubulopathy whilst the latter was originally described as an isolated kidney disorder with tubular proteinuria, hypercalciuria/ nephrocalcinosis and progressive renal impairment. mutations in ocrl underlie lowe syndrome, whereas the majority of cases with dent's disease are caused by mutations in clcn . recently, mutations in ocrl have been identified in a subgroup of patients with dent's disease (also called dent- ). it is unclear, why some patients with ocrl mutations get dent's disease, while others develop lowe syndrome. however, careful clinical observation has revealed that dent- patients have evidence of systemic involvement. moreover, the degree of severity of symptoms in lowe syndrome is highly variable. thus, mutations in ocrl can cause a spectrum of symptoms, from tubular proteinuria and hypercalciuria to the full manifestations of lowe syndrome. here, we will review the clinical phenotype of the disorders, what is known about their pathophysiology and discuss genotype/phenotype correlation. fabry disease, the second most prevalent lysosomal storage disorder after gaucher disease, is an xlinked inborn error of the glycosphingolipid metabolic pathway and affects approximately : , live births. mutations in the gene encoding alpha-galactosidase a, lysosomal hydrolase, lead to systemic glycosphingolipid deposition, resulting in profound dysfunction of neurological, renal, cardiac, and cerebrovascular systems. the initial phase begins in childhood or adolescence and is characterized by neuropathic pain, angiokeratomas, and ocular deposits. the later phase is distinguished by progressive cardiac, cerebral, and renal involvement, leading to multi-organ dysfunction and death. few patients have historically survived past their mid s. although renal involvement usually becomes prominent in adulthood, adolescents may develop proteinuria and decreased glomerular filtration rate. timely diagnosis is critical, given that the enzyme replacement therapy likely delays progression of the serious complications of fabry disease and may have potentially preventive benefits. specifically, there is growing evidence that initiation of enzyme therapy slows progression of chronic kidney disease (ckd); it remains unknown whether enzyme therapy in the currently employed doses can prevent ckd. pediatricians have a particularly important role in making the diagnosis, since they are likely to be the first providers to encounter fabry patients and thus initiate therapy before irreversible tissue injury develops. nephrologists should consider the diagnosis of fabry disease when a patients present with ckd with nephrotic or subnephrotic proteinuria, often with skin lesions (but these may be limited in distribution), episodic extremity pain, and/or psychiatric problems. further research is required to determine the efficacy of enzyme replacement therapy to prevent organ damage in children, to identify optimal therapeutic doses and schedules, and to define efficacy of additional treatments for fabry kidney disease, include angiotensin converting enzyme inhibitors and angiotensin receptor blockers. w. van't hoff great ormond street hospital for children nhs trust, pediatric nephrology, london, united kingdom children with a complete deficiency of methylmalonyl coa mutase develop both renal tubular and glomerular dysfunction. the renal tubular dysfunction is characterised by renal tubular acidosis, defective urinary concentration and hyporeninaemic hypoaldosteronism. a chronic interstitial nephritis also develops leading to long-term glomerular renal damage. chronic kidney disaes is not evident on routine testing as muscle mass is reduced and protein intake is markedly restricted. formal measurement of gfr using chromium edta showed that of such mma patients have a gfr < mls/min/ . m ), and by years, of patients had a gfr < . most mma patients with ckd do not have excess proteinuria nor hypertension. although vit b responsive mma patients in general have a more favourable outcome, late onset renal complications have been seen. in addition to ckd, mma patients can develop cardiomyopathy, pancreatitis, gut dysmotility and chronic or acute encephalopathy. management is based on a protein-restricted, high calorie diet, allopurinol to control hyperuricaemia, supplements of carnitine and metronidazole therapy to reduce production of propionate. haemodialysis has successfully cleared plasma mma and improved the metabolic and nutritional status. liver transplantation has been performed in a number of younger children, as enzyme replacement therapy, but is associated with a significant morbidity and mortality (including late neurological deaths). renal transplantation has been reported in a small number of older patients but it is not yet clear how good the graft outcome will be. combined liver-kidney transplantation has been undertaken again in small numbers, with a high morbidity and significant mortality although there are a very few remarkable survivors. so far, there are only centre specific experiences and unfortunately reviewing the literature will not give a full picture of long-term outcome and complications, due to the bias of the reported results towards favourable outcomes. there is a clear need to share data on the management of these rare patients in order to better understand the best approach. estimations of the extent of hiv disease in sub-saharan africa are that million people are currently infected of which the total number of children is . million. worldwide it is thought that . million children are infected so it can be seen that the majority reside in africa. in south africa, we have a minimum of hiv infected children aged less than yrs of age with only on highly active anti-retroviral therapy (haart) at present. currently - % of all paediatric admissions to hospital may be hiv related. hiv associated renal disease, is not yet well documented among children -especially from africa -but now with the growing availability of haart, this information has become more important for appropriate management. hiv renal disease presents in many forms, including including hiv-assoc nephropathy (hivan) and hiv immune complex kidney disease (hivick) amongst others. questions have now been raised as to whether a screening program should be introduced as haart, despite side effects and drug interactions, has revolutionised management if hiv infection detected early enough. transplantation which was thought previously to be an absolute contraindication and potential waste of valuable resource is now possible, provided there is maintenance of haart, hiv viral load is undetectable for > mths and cd > cells/mul. there remains concern about feasibility in children with increased rejection, reduction of calcineurin inhibitors and infections such as recurrence of hepatitis c post-transplant. despite these concerns, studies in adherent adults have clearly shown that adult patients with hiv infection do better following transplantation than on dialysis. of concern, are some studies, showing that certain black patients may have a genetic predisposition to hiv infection. overall, transplantation can be successful in these patients provided the hiv disease is under control. however, hiv disease -including renal disease -remains a major problem in sub-saharan africa due to limited resources and lack of availability of drugs, where other health priorities may prevail. background. previous studies suggest that hiv- induces dysfunction and/or injury of endothelial cells, leading to the systemic release of fibroblast growth factor - (fgf- ). to date, the role that circulating fgf- may play in the pathogenesis of childhood hivan is not clearly understood. objective. here we sought to determine the potential role of circulating fgf- in the pathogenesis of hivan using wild type (wt) and hiv-tg mice. methods and results. to determine whether circulating fgf- induced ultrastructural changes in renal glomerular endothelial cells and podocytes, we injected human recombinant fgf- daily for days into fvbn wt and hiv-tg mice (n= in each group). by electron microscopy we found that fgf- induced endothelial swelling and mild fusion of the foot processes in wt mice. these lesions were more severe in hiv-tg mice, which showed enlargement of podocytes, protein reabsorption droplets, significant fusion of the foot processes, and collapsing glomerulopathy. subsequently, to confirm these findings in a different experimental model system, we used recombinant adenovirus carrying a secreted form of human fgf- (ad-fgf- ). four to five weeks old hiv-tg mice without evidence of abnormal protenuria (urine protein/creatinine ratio (up/uc) < ), and their wild type littermates were injected with x plaque forming units (pfu) per mouse of ad-fgf- or control ad-lacz vectors through the retro-orbital (r. o.) venous plexus (n= per group). all mice were followed for three weeks. all hiv-tg mice injected with rad-fgf- developed heavy proteinuria (up/uc > ). in addition, % showed elevated bun levels (> mg/dl) and renal histological lesions typical of hivan. in contrast, wt mice, developed transient and moderate proteinuria (up/uc < ), without renal failure or permanent renal damage. the number of animals with proteinuria in hiv-tg mice injected with ad-lacz group was consistent with the natural history of the renal disease progression. control wt mice injected with ad-fgf- developed mild proteinuria ( %) that returned to normal values - days after the injection. fgf- induced microcystic tubular dilatation and recruitment of mononuclear cells both in wt type and hiv-tg mice, although the changes were more significant in the later group. conclusion. taken together, these results suggest that the accumulation of fgf- in the circulation of hiv-tg mice induces glomerular endothelial and podocyte injury leading to the development of heavy proteinuria, renal failure, and the typical renal histological features of hivan. we conclude that the elevated levels of fgf- in the circulation of hiv-infected children may be a significant risk factor for the development and/or progression of hivan. human immunodeficiency virus associated nephropathy (hivan) is the third leading cause of kidney failure in young african american adults in the united states. the prevalence and natural history of the disease in children is not well documented. we have examined our experience in children, aged months to years (mean age . ± . years) with predominantly perinataly acquired hiv- infection from their mothers. since , of these children have been evaluated routinely for evidence of renal disease with quantitative assessment of proteinuria by random urine protein to creatinine ratios (upr/cr). renal functional studies included serum creatinine with estimation of glomerular filtration rate (egfr), urinalyses, renal scintigraphy, ultrasound and renal biopsy when possible. the patients were divided according to their level of proteinuria. those with nephrotic range proteinuria (upr/cr> . ) were designated as hiv-ns (n= ; %). those with persistent intermediate range proteinuria (upr/cr: . < . ) were designated as hiv-pp (n= ; %). those with no proteinuria (upr/cr< . ) were designated as having no nephropathy (hiv-non; n= ; %). the great majority of patients were treated with highly active antiretroviral therapy (haart), although those with hiv-ns had less time on treatment when their proteinuria was discovered. moreover, the virulence of the hiv infection as measured by viral load (vl) was significantly greater in those patients with proteinuria. also, viral load correlated positively with degree of proteinuria (r= . ; p< . ). mortality as shown by kaplan-meier survival curves was significantly greater in the hiv-ns group as compared to the pp and non groups. renal failure occurred only in the group with nephrotic range proteinuria. during the past years we have dialyzed children with hiv infection in our end stage renal disease (esrd) program for a total of patient dialysis months. since , all patients are managed on hemodialysis due to the high occurrence of fungal peritonitis in our initial experience. survival has improved remarkably during the past years with a median survival of months (range to months). the next stage is to begin renal transplantation in those patients with adequate control of the hiv infection. aim: to determine the spectrum of severe renal disease in our hiv infected children; excluding severe sepsis and septic shock syndromes. indications for their referral, renal biopsy and histology relating to outcome. methods: retrospective analysis of all children referred to the paediatric renal service from the general wards and hiv clinic from january to december . analysis includes age of presentation, sex, nutritional status, symptoms, renal function, histology, associated diseases including infections and follow-up. results: total of children with a mean age of . ± . years with a male: female ratio of : . . there was an overlap of symptoms but the commonest presenting symptom was haematuria in %, severe urinary tract infection and pyelonephritis in %, anasarca with or without any nephrosis in %, acute renal failure in %, chronic renal failure in %, severe electrolyte disturbances in %. renal biopsy was performed in ( . %) children. histogically % had immune complex disease (icd) of which . % had lymphoid interstitial pneumonitis (lip). . % had fsgs of which one had lip but also had icd, . % had severe interstitial nephritis, associated infectious changes in . % and atn in . %. one patient each had minimal change, mpgn, abdominal kaposi sarcoma and kidney/bladder stones. . % had or were treated for pulmonary tuberculosis. mean follow-up was ± . months. death occurred in . % ( ). all patients with fsgs with some renal dysfunction and severe sepsis demised. conclusion: despite the high burden of hiv disease, severe renal complications have a low prevalence. good correlation of icd and lip ( . %) but prognosis is good. pulmonary tuberculosis and infection is the main complications resulting in high mortality in nephrotic syndrome with fsgs. hiv associated nephropathy (hivan) is one of the most common causes of renal failure in hiv seropositive african americans. in the usa, hivan has become the third leading cause of end stage renal disease (esrd) in african americans over the age of . while the introduction of haart has decreased both the mortality and infectious complications of hiv infection, the incidence of hivan has reached a plateau and has not decreased. with reduced mortality, the prevalence of seropositive patients in the esrd program continues to increase dramatically. the histopathological findings of hivan include focal segmental glomerulosclerosis of the collapsing variant combined with microcystic tubule dilatation. the most common other diagnosis is mesangioproliferative glomerulonephritis associated with hepatitis c infection, a common comorbid condition. typical features of hivan include renal enlargement and echogenicity by ultrasound analysis. microscopic findings include coexistent microcystic tubule dilatation and glomerular involvement. usually there is mild to moderate tubulointerstitial inflammation, interstitial edema, and fibrosis as well. glomerulosclerosis is usually focal and segmental with collapse of the glomerular tuft and hypertrophy of visceral epithelial cells. hivan is caused by renal epithelial infection by hiv- in a susceptible host. clearly there are genetic factors, based on the racial predilection of this disease. patients with hivan are . times more likely to have a relative with renal failure. in susceptible individuals, hiv infection induces renal epithelial proliferation and apoptosis. the kidney represents a tissue-specific compartment in which hiv- can replicate in a previously unrecognized reservoir. while hivan is not currently considered to be an aids-defining condition, patients with hivan should be treated with haart. in some instances, haart has completely reversed the disease process, although it does not rid the kidney of virus. thus, in patients with hivan, the kidney is a true reservoir for replication competent hiv. whether this occurs in other forms of renal disease associated with hiv infection or in patients without renal disease remains to be determined. prenatal administration of dexamethasone causes hypertension in rats when they are studied as adults. renal sympathetic nerves directly innervate renal tubules and blood vessels and plays a role in the regulation of glomerular filtration rate and renal sodium excretion. we examined if renal nerves play an a role in mediating the hypertension in prenatal programming. pregnant sprague-dawley rats were injected daily with intraperitoneal dexamethasone between th and th day of gestation. renal norepinephrine concentration was measured at weeks of age. renal denervation was preformed at age weeks of age in control and prenatal dexamethasone treated rats and blood pressure was measured at age of weeks. renal norepinephrine concentration was ± ng/gr in controls and ± ng/gr in the group that received prenatal dexamethasone (p< . ). systolic blood pressure at weeks of age was ± mmhg in sham operated controls, ± mmhg denervated controls (p=ns). blood pressure was elevated to ± mmhg in dexamethasone treated sham operated group (p< . ), but was normal at ± mmhg in the dexamethasone treated denervation group. in conclusion, prenatal dexamthasone results in elevated renal norepinephrine levels. bilateral renal denervation normalized the systolic blood pressure in rats that received prenatal dexamethasone. these data are consistent with the renal nerve playing an important role in mediating the hypertension in prenatal programming by dexamethasone. objective: evaluation of clinical outcomes in surgically treated children with renovascular hypertension (rvh). methods: rvh patients treated surgically at a single centre between and were retrospectively reviewed: % were male, . - . (median . ) years of age, with systolic blood pressure (sbp) mmhg ( - mmhg). results: bilateral renal artery stenosis was present in %, midaortic syndrome(mas) in %, intrarenal disease in % and coexisting cerebral disease in % of patients. surgical procedures (n= ) included: a) nephrectomy (n= ), b) autologous surgery for both aortic reconstruction (n= ) and renal revascularisation (n= ) (renalartery reimplantation (n= ), renal bypass (n= ) and autotransplantation (n= )) and c) synthetic graft interposition for renal revascularisation (n= ), aortic reconstruction (n= ) or both (n= ). the majority ( %) of patients who received synthetic grafts had vascular anatomy too complex for autologous surgery. technical failure leading to secondary nephrectomy occurred in patients. postoperative complications were haemorrhage (n= ), septicaemia (n= ), and chylous ascites (n= ). there were no operative deaths. patients from the uk were followed up for . ( . - ) years. sbp post-surgery improved ( mmhg, range - mmhg, p< . ). outcomes were normal sbp without treatment ( %), improved ( %) or unchanged sbp ( %). reduction of sbp led to loss of contralateral kidney in patient. children required re-interventions ( angioplasties and surgical procedures) for progressive disease (n= ), narrowing of the synthetic graft (n= ) and re-stenosis of the autologous bypass (n= ). conclusion: rvh is a progressive disease of extensive nature. surgery benefited % of children when performed in conjunction with conservative therapy and, if indicated, interventional radiology. h. wong unlike adults with predominant primary hypertension (htn), the majority of children diagnosed with htn traditionally suffered from secondary forms of htn. however, substantial changes have occurred to the demographics of pediatric population over the past years. in addition, our definition, awareness and understanding of children with hypertension has also changed. we therefore retrospectively reviewed the current causes of htn in children followed in a single tertiary care pediatric nephrology referral center between january and december . patients who were either diagnosed with or treated for htn at the time of their last visit where included. gender, height, weight, age at the time of diagnosis, causer of htn and casual blood pressure were recorded. out of patients, ( . %) were diagnosed with htn. the majority were males (n= , %). median was years ( month- years) age at time of diagnosis and . years ( . months- years) at time of the last follow-up. secondary htn was the most common cause of pediatric htn (n= , %) followed by primary (n= , %) and then white coat (n= , %). renal htn was the most common cause of secondary htn ( / , %). for patients referred initially for assessment of htn (n= ), primary (n= , %) and secondary (n= , %) were the two most common diagnosis followed by normotension (n= , %) and white coat htn (n= , . %). twenty two ( . %) patients were diagnosed before the age of year. out of renal transplant patients, had htn ( %). renal htn remains the most common cause of pediatric htn overall and continues to represent a large portion of children referred for htn. all children suspected of having htn should continue to have thorough investigations of renal disease to identify the underlying cause. m. sinha , c. booth , j. simpson , n. dalton , s. qureshi , c. reid , s. rigden evelina childrens hospital, guys and st. thomas's nhs foundation trust, department of pediatric nephrology, london, united kingdom evelina childrens hospital, guys and st. thomas's nhs foundation trust, department of pediatrics cardiology, london, united kingdom king's college london, department of medicine, london, united kingdom background: hypertension (ht) is a frequent complication in paediatric tx patients. the evolution of end organ damage and its relationship to ht in these patients is not well described. aim: to study the predictive value of an abnormal -hour abp profile for end organ damage. methods: patients underwent simultaneous casual blood pressure (cbp), abpm, echocardiogram (lvh if lvmi > g/m . ) and ecg assessment, with measurement of several biochemical cardiovascular risk markers. cbp data for -months prior to study date was analysed as time averaged z-score. results: we present initial results of a -year prospective study. patients ( male) aged . y± . (mean±sd) and . y± . since tx were studied. on the day of study all patients had normal cbp. % had lvh of whom % had abnormalities on abpm. overall, % patients had both abnormal abpm and lvh. % had other findings: % abnormal abpm but no lvh; % normal abpm but no lvh; % normal abpm and lvh. data were analysed for differences between groups of patients, with and without lvh. bp alone was significantly associated with increased lvmi. time averaged cbp was normal in all patients although differed significantly between the groups: systolic bp z-score [mean (ci)] . ( . , - . ) with lvh; -. (- . , - . ) without lvh. there were significant differences by abpm criteria relating to several components of the abpm profile including mean arterial pressure, systolic and diastolic bp load. no difference was found between the groups for hb, ca*po product, ipth and cgfr. conclusions: we have found the majority of our renal transplant patients have normal cbp but have abnormal abpm in association with lvh. this suggests better control of hypertension should be achieved in patients who have abnormal abp profiles and lvh. a new group of patients with normal abpm but lvh has also been identified. background: obesity is an independent risk factor for renal failure. therefore, we compared the body composition of pediatric nephrology patients with the general child population over two decades. methods: , patients with a mean age of . ± . years were studied. in , patients ( . %), sufficient data were available to analyze body composition. body composition was measured as body mass index (bmi) z-score because of the age dependency, calculated on the basis of data from the national (usa) center for health statistics ( ) . results: enuresis ( . %), hematuria ( . %), recurrent urinary tract infections ( . %) and proteinuria ( . %) were the most common diagnoses. the bmi z-score of the pediatric nephrology patients increased significantly from . ± . in - to . ± . in - and . ± . in - . while the rate of this increase was not statistically different from that seen in the normal population, they consistently demonstrated a significantly higher bmi z-score (average + . ) over time. nephrotic edema, non-nephrotic proteinuria and hypertension were not confounding factors. conclusions: patients seen in our pediatric nephrology service over two decades had a higher bmi than the average child population. this implies that these patients are at even greater risk for development of chronic kidney disease later in life. we recommend therapeutic intervention to address this potentially modifiable risk factor. objective: b cell dysregulation is believed to be involved in the development of childhood-onset systemic lupus erythematosus (sle). there is limited evidence regarding efficacy and safety of interventions targeting b cell in children. in our study we evaluated efficacy and safety of b lymphocyte depletion therapy. methods: data of children ( % male) with sle aged . years ( . - . ) treated with rituximab in a single centre were retrospectively reviewed. biochemical parameters were evaluated before and after treatment, and the normalisation of the parameters was assessed as a primary outcome. results: prior to rituximab therapy all patients received extensive immunosuppressive agents. indications for rituximab therapy were chronic (n= ) or acute illness, in either relapsing sle (n= ) or first presentation (n= ). rituximab mg/m was intravenously administered twice within a -week period in combination with cyclophosphamide. patients were followed up for . years ( . - . ) . no serious side effects were seen, except for viral infections such as herpes zoster (n= ). all patients with high creatinine (n= ; ± mmol/l) prior to rituximab showed a decline within months (mo), achieving a stable level by mo ( ± mmol/l, p< . ). all patients with hypoalbuminaemia (n= ; . ± . g/l) improved ( mo: . ± . g/l, p< . ). low c level ( . ± . g/l) as seen in patients prior to treatment resulted in an increase up to mo ( . ± . g/l, p< . ). a decline of previously high anti-dsdna (n= ; ± iu/ml) was observed in all patients ( mo: ± iu/ml, p< . ). conclusion: rituximab is safe and effective when used in combination with standard immunosuppressive agents. further prospective studies are essential to evaluate the longterm safety of the drug. outcome of severe henoch-schönlein purpura nephritis treated with longterm immunosuppression m. shenoy, m. bradbury, l. lewis, n. webb royal manchester children's hospital, department of nephrology, manchester, united kingdom aims: to look at the long-term outcome of all children with severe henoch-schönlein purpura nephritis (hsn) treated with long term immunosuppression in a single centre over a ten year period. patients and methods: retrospective review of the records of children ( male) with iskdc grade b, , and hsn managed at our institution from / / to / / results: the mean age at presentation was . years (range . - . years). the median estimated glomerular filtration rate (egfr) at presentation was ml/min/ . m (iqr . - . ) and urine protein: creatinine ratio (up: uc) was mg/mmol (iqr - ). the indication for biopsy was nephrotic syndrome in , nephrotic range proteinuria in , sub-nephrotic range proteinuria in , acute nephritis in and nephritic-nephrotic syndrome in . a total of patients were treated with weaning dose of steroids, of whom were also commenced on long-term azathioprine (mean duration . months). of these children received an - week course of oral cyclophosphamide ( - mg/kg/day) prior to azathioprine therapy ( - mg/kg/day). outcome: after a mean follow-up period of years, ( %) have made a complete recovery, ( . %) have persistent proteinuria but normal egfr, ( . %) have persistent proteinuria and are on anti-hypertensive therapy with normal egfr and ( . %) have progressed to esrd. older age at presentation was the only independent risk factor for poor outcome ( . years vs. . years, p= . ). conclusions: despite treatment with cyclophosphamide, long-term steroids and azathioprine, a majority of children with hsn grade - b on initial biopsy have persistent renal abnormalities on long term follow-up. only older age at presentation was associated with poor outcome. background: resent advances in podocyte biology indicated that the main cause of the heavy proteinuria in nephrotic syndrome (ns) is a dysfunction of slit diaphragm. on the other hand, the classical charge selective barrier is not likely to have a place in slit diaphragm. therefore we reevaluated the charge selective barrier function in ns and chronic glomerulonephritis using recently established charge selectivity index (csi; takahashi et al, pediatr res : , ) in comparison with dent disease. patients and methods: csi is a clearance ratio of igg (stokes einstein radius - , pi . - . ) and iga (stokes einstein radius , pi . - . ) . the assay of serum and urinary igg and iga was performed using laser nepherometry and enzyme immuno-assay. in order to evaluate the csi of normal glomerular filtrate, we measured the csi of dent disease. the urine of dent disease is considered to be a concentrate of filtered protein from normal glomerulus, without having a process of tubular protein reabsorption. thirty eight patients with podocyte diseases (focal and segmental glomerulosclerosis , finnish type congenital nephrotic syndrome , steroid sensitive nephrotic syndrome ), patients with chronic glomerulonephritis (iga nephritis , henoch-schönlein purpura nephritis , mesangiocapillary glomerulonephritis , alport syndrome ) and patients with dent disease, were analyzed. results and conclusion: csi (mean±sd) of podocyte disesses, chronic glomerulonephritis and dent disease was . ± . , , ± . and . ± . respectively. the results apparently indicated that the charge selective barrier of gcw is working strongly in normal glomerulus, less strongly in podocyte diseases and not working in chronic glomerulonephritis. objectives: nphs mutations have been reported in familial and sporadic srns. we investigated the prevalence of nphs mutations among south-east asian chinese and their association with clinical outcomes. methods: genomic dna from patients with primary sporadic srns (mean age at onset . ± . years, range . - . years) and cord blood controls were screened on all exons and exonintron boundaries using direct sequencing. results: a missense heterozygous c>t mutation in exon was identified in only one patient. polymorphisms t>c and a>g in exon were detected in both groups. in the patient group, the genotypic frequency of tt, tc, cc at position was . , . and . , and aa, ag and gg at position was . , . and respectively, consistent with hardy-weinberg expectations. there was no significant difference in allele frequencies between patients and controls. using binary logistic regression analysis, individual polymorphisms did not appear as informative predictors of poor clinical outcome, defined as persistent proteinuria or renal failure (p> . ). on analyzing composite genotypes, carriers of at least a copy of the c allele were significantly associated with poor outcome (p= . , or= . , % ci: . - ), while heterozygotes for a>g were associated with good outcome (p= . , or= . , % ci: . ± . ), suggesting possible interactions between the polymorphic sites. further analysis showed that the genotypic combination of tc/cc with aa was more likely to have a poor clinical outcome. no significant linkage disequilibrium was detected between the two polymorphisms. conclusion: the concomitant occurrence of at least a copy of the c allele and the aa genotype may be associated with poor clinical prognosis in srns but larger studies are needed to confirm these findings. renal hypodysplasia (rhd) is characterized by a reduced kidney size and/or maldevelopment of the renal tissue following disturbed organogenesis. numerous deletion mouse models of developmental genes have been established presenting with anomalies of the kidneys resembling rhd, among these the knock-out of bmp and six . here, we report on the first human mutations in bmp and six identified in children with rhd, among these three different mutations in bmp in five unrelated patients (ser cys, thr ser, asn lys) and three different mutations in six also in five unrelated individuals (leu phe, pro leu, asp asn). overexpression assays in zebrafish demonstrated that ventralization and dorsalization caused by bmp and six overexpression, respectively, could be diminished after overexpression of mutant constructs expressing the human mutations identified. morpholino knock-down of zebrafish bmp and six . reveals specific roles of these genes for pronephric development, affecting the expression of wilms tumor- (wt ) and glomerular development. rna analysis of cos and hek transfected with different bmp constructs showed a lower level of mrna abundance in bmp mutants, indicating a possible negative feedback of the mutants on their own mrna expression and/or stability. nonreducing western analysis revealed that s c-bmp forms alternative protein complexes as compared to wildtype-bmp , due to the formation of extra disulfide bonds. these studies implicate six and bmp as important players in the development of the renal system, and suggest that defects in these proteins could affect kidney development at multiple stages leading to the congenital defects observed in rhd patients. apoptosis is important in normal renal development in which regulation of cell numbers is critical. studies have shown that apoptosis occurs in non-cystic tubules in pre-uremic pkd kidneys, thus providing the mechanism whereby expansion of cysts is accompanied by loss of normal nephrons. to date, it is unclear which initiating factors (intrinsic, through mitochondrial damage or extrinsic, through ligand activation of death receptors) are responsible for apoptosis in pkd and whether they are the same in ad-and arpkd. aim: to elucidate the sequence of activation of intracellular apoptotic pathway(s) in both ad-and arpkd. methods: proteins were extracted from tissues of human ad-and arpkd kidneys and normal adult (nhk) and fetal kidneys (hfk). quantitative western immunoblot analysis was carried out for markers of intrinsic and extrinsic apoptosis. immunohistochemical staining for these markers was performed on tissue sections of the same kidneys. results: markers of extrinsic apoptotic pathways, caspases and , were significantly increased in ar-and in adpkd tissue by comparison to nhk and hfk tissues. these increases were seen in early stages of adpkd and were more pronounced later in the disease. for the intrinsic pathway, caspase and bid were increased in hfk tissue, but unchanged in ad-and arpkd tissue compared to nhk tissue. staining for caspase was found in hfk, but was absent in all other kidney tissues. staining for caspase was seen in early adpkd and endstage (es) adpkd as well as in es arpkd. caspase was identified as the main executing caspase of fetal development and adpkd, but wasn't seen in arpkd, where caspase predominated. conclusion: induction of extrinsic pathways of apoptosis predominates in pkd and occurs early in the disease process in adpkd, but only later in arpkd. intrinsic apoptosis predominates during development. intrauterine growth restriction (iugr) is a risk factor for an aggravated course of renal diseases in later life. the influence of postnatal factors, eg. accelerated catch-up growth, is not well understood. we therefore analysed the influence of postnatal nutrition after iugr on the developement of later renal inflammation and fibrosis in the rat. iugr was induced by low protein diet ( % vs. %) in pregnant wistar dams. litter size was reduced to or male animals in iugr (lp , lp ) and control animals (np , lp ), respectively. animals were sacrificed on day . mean arterial blood pressure was similar in all four groups. lp -( . ± . ml/h/ g) and np animals ( . ± . ml/h/ g) showed reduction of endogen creatinine clearance by % (vs. np and lp ) (p< . ). renal mrna expression of il ( , x), tgfβ ( , x) , endothelin ( , x) und osteopontin ( , x) was significantly higher in lp than in np . lp showed the highest glomerulosclerosis-score (( . ± . ) (vs. np ( . ± . ), lp ( . ± . ) and, np ( . ± . )) (p< . ). as marker of extra cellular matrix expansion glomerular collagen-iv deposition was significantly higher in lp ( . ± . %) (vs. np ( . ± . %), lp ( . ± . %) and np ( . ± . %)) (p< . ). postnatal nutrition modifies the consequences of iugr in the kidney. increased postnatal nutrition of the individual animal is associated with aggravated renal inflammation and fibrosis after iugr. unilateral renal agenesis (ura): how intensively do we need to investigate and follow-up? s. rhodes, a. watson nottingham university hospitals, children and young people's kidney unit, nottingham, united kingdom a single kidney is one of the commonest urinary tract abnormalities in the general population. concerns remain about long-term outcomes with a reduced nephron mass and hence intensity of investigations and duration of follow-up. we identified cases with ura (ectopic and pelvic kidneys excluded) from our nephrourology database between and . ( %) occurred in males and ( %) had left ura. ( %) were detected antenatally with / ( %) recognised in the last years. median age of detection for postnatal ura was mths (range . - mths) with uti ( %) as the main indication for ultrasound scan (uss). % patients were classified as simple ura with no associated abnormality and % as complex with problems such as vesicoureteric reflux (vur)( %), hydronephrosis or scarring. all cases reviewed had uss which showed compensatory hypertrophy in / ( %). / ( %) had dmsa scan and / ( %) micturating cystogram. of those antenatally detected single kidneys with normal initial uss none had vur, scarring, hypertension or proteinuria. these patients were discharged from follow-up at the median age of mths (range - mths). all complex cases have continued under follow-up. conclusions: our data suggest that the incidence of antenatally detected ura may be increasing. investigations need to be individualised depending upon the initial uss. the value of routine dmsa and mcug in simple cases is questioned. most of these patients can be discharged after adequate documentation of compensatory hypertrophy of the normal kidney, absence of proteinuria, normal blood pressure and renal function. autosomal dominant pdk (adpkd) in childhood j. crocker, p. wornell, p. acott iwk health centre/dalhousie univeristy, division of nephrology, halifax, canada autosomal dominant polycystic kidney disease (adpkd) is the most common genetic kidney disease with in adults progressing to end-stage renal disease (esrd). a program for intervention in childhood at presentation with adpkd was developed and instituted in . our long-term objective is to modify clinical parameters that may contribute to risk of development of esrd in adulthood. seventy children with adpkd (average age . yr) were followed, of which ( %) had nephromegaly +/-cysts on antenatal ultrasound. modifiable risk factors were common including hypertension ( %), hyperlipidemia ( %), and proteinuria ( %). ace inhibitors were first line therapy for proteinuria and/or hypertension. ace inhibitors may modify cyst progression so they have been made available to non-hypertensive children as well. most patients with hyperlipidemia responded to dietary intervention with one patient developing gallstones. in the past years we have focused on renal calculi, as this is a known risk for a subgroup of adults with poor prognosis. we noted patients ( %) have glycinuria, which is a precursor to oxaluria. four patients have passed calculi with two of these being diagnosed by genetic linkage analysis for adpkd without radiographic cysts present. cerebral vascular studies of patients with severe headaches revealed two with vascular structural anomalies. all adolescent females received counseling regarding appropriate contraception and their pregnancy risks of hepatic cyst progression. an early intervention program targeting modifiable risk factors of adpkd patients during childhood and adolescence may modify adult renal failure risk in this population. background: techniques of chronic infant dialysis have evolved during the past decades but morbidity and mortality are not well described. methods: a retrospective review was performed on infants - months of age with end stage renal disease (esrd) treated with maintenance dialysis during the past years. the experience was divided into era ( era ( - (n= ) and era ( era ( - . dialysis modality, morbidity, and long term survival were assessed and compared between the eras. results: all patients were begun on peritoneal dialysis (pd). there were males and females. age at initiation of dialysis was , months. the predominant diagnoses were dysplasia/obstructive uropathy (n= ), autosomal recessive polycystic kidney disease (arpkd) (n= ), congenital nephrotic syndrome (cns) (n= ), other (n= ). overall survival is % ( / ) with current age of survivors ranging from months to years. mortality between era = % and era = % was not significantly different. fifteen ( %) survived to receive a kidney transplant. overall median survival is . years (era = . years; era = . years; p= . ). conclusions: although long term survival is possible in infants with esrd, mortality and morbidity remain high. improved technologies for automated pd should address the needs of the infant < kilograms. joubert syndrome and related disorders (jsrd) are a group of autosomal recessive conditions characterized by a complex neuroradiological malformation resembling a molar tooth on imaging. clinically, jsrd are characterized by overlapping phenotypes presenting neurological signs and variable involvement of other organs such as kidneys (mainly nephronophthisis -nph), retina and liver. seventy-nine italian jsrd patients from unrelated families were recruited in pediatric nephrology and neurology centers. medical records and brain mri were reviewed. patients without chronic renal failure (crf) underwent measurement of their glomerular and tubular function, a ddavp urine concentration test and a renal ultrasound. retinal examination was performed in most patients. seven patients younger then years had normal renal function but were not fully tested. of the remaining cases, had no evidence of renal disease, had developed crf mostly in their second decade of life, and were younger then years of age and had urinary concentration defects, of whom also had hyperechogenic kidneys by renal ultrasound. when comparing this latter group with age-matched jsrd patients, no other tubular function abnormality was detected. in multiplex pedigrees, no discrepancies in renal involvement between affected family members was observed. retinal involvement was significantly associated with renal disease. conclusions. evidence of interstitial renal disease was observed in one third of italian patients with jsrd. renal involvement should always be suspected in these patients, particularly if they have evidence of retinal dysplasia or other family members with symptoms related to nph. these patients should be assessed with a urine concentration test. we examined the course of children with primary obstructive megaureters (pom) treated in our hospital from - . pom occurred more often in boys ( %, p< . ) and on the left side ( %, p< . ). pom ( %) were only treated conservatively. four underwent immediate surgery following the first mag renography. one of these was nephrectomized after unsuccessful urinary diversion and persistent renal hypertension. of the kidneys primarily managed conservatively, needed a ureterocystoneostomy later on due to increasing obstruction. surgical correction of pom required a mean of days of hospitalization (incl. temporary urinary diversion, removal of catheters and treatment of complications). one child required surgical revision of early post-operative ureteric stenosis. urinary tract infections (uti) were a common complication (n= , mean . per patient). as utis occurred mainly in infants, hospital admission was commonly required ( %). only children never acquired a uti ( %). eight patients had a poor outcome as defined by partial kidney function < % on the affected side (n= ), atrophy on final ultrasound (n= ) or nephrectomy (n= ). the most potent predictor of reduced unilateral kidney function was a small kidney present from birth. secondary kidney growth failure occurred only in one case. the initial degree of obstruction on renography, but not the degree of hydronephrosis or size of megaureter predicted outcome. also, prenatal diagnosis of pom, surgical treatment and the occurrence of utis showed no association with outcome. in summary, the long-term prognosis of pom appears favorable. adverse outcomes were more closely related to congenital kidney size deficit than to the degree of obstruction. surgical interventions and the high uti incidence led to significant hospitalization times. r. bhimma, m. adhikari, k. asharam university of kwazulu-natal, maternal and child health, durban, south africa background: steroid resistant (sr) forms of ns have a poorer outcome in blacks compared to other racial groups. methods: children with srns - years old were analysed retrospectively for the period - . treatment schedules included oral cyclophosphamide with prednisone only (n= ); prednisone on alternate days with methylprednisolone and oral cyclophosphamide (n= ); oral prednisone on alternate days, doses of intravenous methylprednisolone on alternate days and monthly doses of intravenous cyclophosphamide (n= ) or cyclosporine adjusted to a trough level of - mg/ml (n= ). we compared the clinical, biochemical characteristics and outcome of these children using different forms of therapies. results: ( . %) underwent renal biopsy. ( . %) were indian and ( . %) were black. ( . %) had minimal change ns, ( . %) had focal segmental glomerulosclerosis (fsgs), ( . %) a proliferative form of ns, and ( . %) had other forms of ns. / ( . %) indian children biopsied were in complete remission and / ( . %) with mcd who were treated with oral cyclophosphamide and prednisone only achieved complete remission. / ( %) indian children not biopsied who received only oral prednisone and cyclophosphamide achieved complete remission. / ( . %) black children who were biopsied achieved complete remission. none of the eight black children who were not biopsied given only oral cyclophosphamide and prednisone achieved complete remission. conclusion: since % of indian children with srns responded to a trial of oral cyclophosphamide and prednisone but none of the black children did, we propose the use of oral cyclophosphamide therapy in non black children before embarking on renal biopsy. mj. kemper, c. moeller, n. rink, m. van husen, de. müller-wiefel university of hamburg, pediatric nephrology, hamburg, germany introduction: ssns is often complicated by a refractory clinical course with frequent relapses and steroid dependency despite aggressive alternative immunosuppressive regimens. since recent immunological findings suggest an alteration of not only t-but also b-cell immunity in ssns (kemper (kemper , we hypothesized that that immunological targeting of b-cells with antibodies directed against cd (rituximab) is able to maintain remission (rm) in treatment refractory patients with ssns methods: a total of six patients with complicated courses of ssns had severe steroid-dependency and toxicity. all patients had previously been treated with cyclophosphamide, two patients relapsed on maintenance therapy with cyclosporine, one relapsed on additional levamisole and one on mmf. treatment was initiated at a median age of (range - . ) years and rtx was given at steroid induced rm at a dose of x mg/m bsa within weeks. results: a complete b-cell depletion was induced for at least months in all patients. rm could be maintained in all patients and steroid treatment could be discontinued after a median of . months (range - . ) . also csa could be discontinued in the two patients on maintenance treatment. at current follow-up of . months (range - . ) the two patients after csa discontinuation relapsed after . and . months, respectively, but responded after steroid induced rm-to a second course of rtx. all other patients remained in remission off treatment so far. no significant clinical side effects were noted. conclusion: in summary and conclusion, rtx seems to be a therapeutic option in complicated ssns. long-term follow-up and future prospective studies are necessary to further define the role of rtx in the treatment of refractory steroid sensitive nephrotic syndrome. efficient control of secondary hyperparathyroidism can be achieved by calcimimetics. they increase calcium sensing receptor (car) sensitivity to extracellular calcium. in r- -treated uremic rats, proteinuria has been significantly reduced by calcimimetics. thus, we examined the potential direct effect of r- on podocytes. the car was expressed in cultured immortalized podocytes (quantative rtpcr, western blot) and in podocytes obtained from healthy and subtotally nephrectomized rats (immunohistochemistry). glomerular car abundance was increased by uremia and r- . the car colocalized with the plasma membrane and intracellular filaments in cultured podocytes, but not with the caveolin -and -rich membrane fractions. we then studied the effect of r- on the mitogen-activated protein kinase (mapk) family. jnk was not activated. p showed a biphasic response pattern, whereas erk / (and further downstream, p ribosomal s kinase) showed dose-( - nmol/l) and time-dependent phosphorylation, resulting in the activation of the transcription factor camp response element binding protein (creb). creb phosphorylation induced bcl-xl expression and bad phosphorylation, both of which have prosurvival activity. specificity was confirmed by addition of mek / inhibitor u , which completely blocked r- -induced creb phosphorylation. facs analysis revealed a significant, % decrease in puromycin-induced apoptosis in podocytes treated with r- for , and hrs. in conclusion, calcimimetics induced prosurvival gene expression in podocytes via mapk, protecting them from apoptosis. calcimimetics may have a direct renoprotective action beyond control of hyperparathyroidism in chronic kidney disease patients. we report our experience with plasma therapy in a family of three sisters from whom two are homozygous twins (patients b and c), presenting a missense mutation of the exon of the human complement factor h gene (hf- ). the factor h concentration has always remained normal and no systemic complement activation has ever been detected. in a ten years period, the followings have been observed: / no use of plasma exchange lead to immediate esrf of native kidneys (patient a); ) conventional plasma therapy ( sessions at presentation followed by repeated ml/kg plasma infusions when relapse of hemolysis and thrombopenia) could not impede esrf (patient b); ) the use of intensive pe at presentation (daily pe ( ml/kg ffp until plasma creatinine normalization followed by one pe/ w indefinitely) lead to a normal gfr years after presentation despite relapses (patient c); / no prophylactic pe for tx lead to immediate hus relapse and transplant loss (patient ); ) prophylactic pe allowed a successful tx in patient b (pl. creat mcmol/l after years); ) early and intensive pe allowed complete normalization of several hus relapses after tx (patient b). conclusions: in fh mutation-related atypical hus, ) intensive and indefinitely prolonged pe can allow a normal function of native kidney at long term; ) prophylactic pe allows successful kidney tx; ) early and intensive pe allow reversion of hus relapse after tx. the success of plasma therapy is bound to the followings: a/ the use of pe and not plasma infusion. b/ the prolongation of daily pe after normalization of hemolysis parameters, and further prophylactic pe. c/ the use of pe prophylaxis from before tx. d/ a minimum pes frequency of one/week in case of prophylactic treatment for tx. e/ immediate intensification of pe frequency in case of relapse. objectives of study: heparan sulfates (hss) are highly polyanionic sugar chains in the glomerular basement membrane (gbm) and have been reported to play an important role in the chargeselective permeability of the kidney. alterations in hs expression have been reported in a number of renal pathologies. in this study, we evaluated if degradation of hs in the gbm resulted in proteinuria in rats, using a controlled in vivo approach. methods: heparinase iii and neuraminidase were injected i. v. in -month old wistar rats at t= hr and t= hr, and kidneys were removed at t= hr. urine samples were taken at various time points. cryosections were stained for hs using specific antibodies, and for hs stubs (generated by heparinase). in addition, hs was evaluated at the electron microscopical level. neuraminic acid expression was analysed by peanut agglutinin lectin. the hs content in urinary samples was evaluated by agarose gel electrophoresis. urinary neuraminic acid was studied by an enzymatic colorimetric assay. presence of urinary albumin (proteinuria) was investigated by sds-page and by a competition elisa. results: injection with heparinase iii resulted in an almost complete absence of glomerular hs staining. cupromeronic blue staining was also greatly reduced in the gbm, further indicating that hs was largely degraded. staining for the hs proteoglycan core protein agrin was unaltered. in the urine a strong increase in hs was found, already at the first point in time of urine collection ( hr after the first injection). however, no urinary albumin or other proteins could be detected at any point in time analysed. injection of rats with neuraminidase resulted in a major increase of albumin in the urine. conclusion: in conclusion, removal of hs from the gbm does not result in acute albuminuria, whereas removal of neuraminic acids does. introduction and methods: children undergoing deceased ( ) or living ( ) donor kidney transplantation were randomized to receive tacrolimus, azathioprine, steroids and two doses of basiliximab (tas+b) or tacrolimus, azathioprine and steroids(tas). previously reported six month follow-up biopsy-proven acute rejection rates were . % (tas+b) and . % (tas). patient survival was % and graft survival % in both arms (am j transplant ; : - ) . in this investigator-driven follow-up study individual outcome data were submitted annually to the coordinating centre. results: two year follow-up data were obtained for ( . %) of the who completed the six month study. there was one death in the tas group occurring at month . there were graft losses in the tas+b arm and in the tas arm. all graft losses in the tas+b arm occurred within the first months. kaplan-meier estimates of year graft survival were . % for tas+b and . % for tas (p= . breslow generalised wilcoxon test). episodes of biopsy proven acute rejection occurred in in tas+b and in tas, kaplan-meier estimates of freedom from rejection being . % and . % respectively (p= . ). renal function did not differ significantly between the two arms; the median (iqr) plasma creatinine levels were ( - ) in tas+b and ( - ) in tas (p= . ). similarly there was no evidence of a difference in either systolic or diastolic blood pressure between the two arms. there was one case of b cell ptld in the tas+b arm at months in addition to two cases in the tas arm previously reported in the month study. conclusions: the addition of basiliximab to a regimen of tacrolimus, azathioprine and steroids does not appear to result in an improvement in either acute rejection rate or graft survival at two year follow-up. further data collection is ongoing. chronic renal dysfunction is a major complication after heart transplantation (htx). the pathophysiology is not yet fully understood but is thought to be in part due to calcineurin inhibitor (cni) toxicity, and reducing cni exposure has become one of the main strategies aimed at ameliorating renal outcome in htx recipients. we previously reported a significant improvement of renal function in htx children with biopsy-proven cni nephrotoxicity and chronic renal failure, year after the reduction of cni dosage with a concomitant replacement of azathioprine by mycophenolate mofetil. we ought to determine whether this improvement was persistent after years of follow-up, despite the histological lesions of chronic cni nephrotoxicity. gfr evaluated by annual inulin clearance had improved from a mean of . ± . ml/min/ . m (range - ) at time of the switch to . ± . ml/min/ . m (range - ) (p= . ) one year after ( % improvement), and remained stable at . ± . ml/min/ . m (range - ) (p= . ) years after the switch. maximal urinary osmolality followed the same increase profile from ± mosm/kg before the switch to ± at one year and ± after years (p= . ). meanwhile, the occurrence of serious adverse events such as infectious episodes, acute rejection and chronic allograft dysfunction as assessed by clinical examination, echocardiography and endomyocardial biopsies were not different from a control group of patients whose treatment was unchanged. no malignancy was observed in either group. in conclusion, reduction of cni dosage and replacement of azathioprine by mycophenolate mofetil lead to a safe and long-lasting improvement of renal function in children with heart transplants and cni-induced nephropathy. previous studies have demonstrated reduced bone mineral density (bmd) in some patients with idiopathic hypercalciuria (ih). reduced bmd during childhood may impact adult peak bone mass. bisphosphonates employed in adults with ih and reduced bmd resulted in conflicting outcomes. we evaluated the effects of oral bisphosphonate, alendronate (ale), in patients with persistent ih and reduced bmd. patients presented at ages , , yr, with hematuria/dysuria, had recurrent urolithiasis, and all had ih (uca > mg/kg/ hr). despite maximal traditional rx with low na/high k diet, thiazides, k-citrate, ih persisted ( . - mg/kg/ hr). at ages , and . yr, dxa showed reduced bmd, and ale , and mg/once weekly was given for , and months, respectively. after months of ale, uca decreased significantly compared to baseline (mean±sd, . ± . vs. . ± . mg/kg/ hr, p< . ). compared to baseline, bmd z scores year after starting ale improved at the spine (- . ± . vs. - . ± . , p< . ) and hip (- . ± . vs. - . ± . ) . the decline in uca during ale rx correlated with the increased bmd z scores in the spine (r=- . , p= . ) and hip (r=- . , p< . ). height z scores, serum creatinine, ca, p, electrolytes and pth remained normal throughout the rx period and no further hematuria or new stones occured. in summary, ale normalized uca previously resistant to traditional rx, eliminated urinary symptoms and improved reduced bmd in children with ih. the use of a single oral weekly dose appears adequate and safe. larger prospective studies are needed to confirm these preliminary results. in addition to its classical role in the regulation of calcium (ca) and phosphate (po ) homeostasis, vitamin d has important immunomodulatory and anti-inflammatory effects, that in turn can influence atherosclerotic vascular disease. we studied the impact of vitamin d levels and inflammation on vascular structure and function in children on dialysis. children (age . ± . yrs) on dialysis (mean duration . ± . yrs) were studied. all children received α-hydroxyvitamin d (alfacalcidol) . cumulative data on ca, po and pth, doses of po binders and alfacalcidol were recorded. , -dihydroxyvitamin d (vit d) and high-sensitivity crp (hs-crp) levels were measured by i radioimmunoassay and elisa respectively. all children had carotid intima-media thickness (cimt), pulse-wave velocity and cardiac ct for coronary calcification. ( %) children had vit d deficiency (levels< pmol/l), ( %) hadnormal levels ( ± pmol/l) and ( %) had high levels (> pmol/l). vit d positively correlated with serum ca, caxpo and alkaline phosphatase. both cimt and calcification showed a bimodal distributionpatients with vit d levels < or > pmol/l were significantly more likely to have calcification or raised imt than those with vit d levels in the normal range. hs-crp levels independently predicted cardiac calcification (p= . ) but not cimt. there was a strong inverse correlation between vit d levels and hs-crp (p< . , r=- . ). patients with vitamin d levels< pmol/l and hs-crp levels> mg/l had -fold greater calcification scores than subjects below these cutoffs. in conclusion, vit d deficiency is common despite treatment in children on dialysis. vit d may be an important mediator of vascular damage both through its hypercalcaemic and anti-inflammatory actions. severe growth failure remains one of the challenging problems in the care of children suffering from chronic renal failure (crf). although, rhgh has been proven to increase final adult height in prepubertal crf patients only limited data on its efficacy in the pubertal age-range are available. in addition, the impact of the underlying renal disease and the mode of renal replacement therapy on final height in these patients remain unclear. we report on final height data of ( female) severely growth-retarded crf patients (standardized height <- sds; database: kigs medical outcomes, pfizer). mean age at start of rhgh therapy was . ± . years, standardized height was - . ± . sds and duration rhgh therapy was . ± . years (range . to . years). at baseline % of the patients were on conservative treatment, % were on dialysis and % had a functioning renal allograft. in the whole study population mean standardized height was increased in the first treatment year and at attainment of final adult height by + . sds and + . sds, respectively (each p< . vs. baseline). prepubertal children aged less than years at start of rhgh therapy showed the best growth response (+ . sds). in pubertal patients mean increase in standardized height was + . sds, whereas growth response in patients with delayed onset of puberty (>+ sd) was significantly lower (+ . sds; p= . vs. other groups). the duration of rhgh therapy was positively associated with cumulative height gain. growth response was significantly lower in patients on long-term dialysis and in patients with nephropathic cystinosis. conclusion: rhgh therapy in severely growth retarded prepubertal and pubertal crf patients results in an increased final adult height. growth response is diminished in crf patients with markedly delayed onset of puberty. tightly regulated rankl/opg system is essential for normal bone remodelling. however, the exact roles of those osteogenic markers in uremic bone disease have yet to be defined. we therefore assessed the potential relationship of the rankl/opg system in bone biopsy proven secondary hyperparathyroidism (hpt) in dialyzed children. methods: patients aged ± years were on ccpd for ± months. s-ca, p, alk p'tase, pth, opg and rankl levels were measured. bone biopsies were obtained after double tetracycline labeling and none of the patients were treated with vitamin d for four weeks prior to biopsy. results: s-ca levels were . ± . mg/dl, p: . ± . mg/dl, alk p-tase: ± u/l, pth: ± pg/ml. bone biopsy findings revealed high turnover bone disease in patients, patients had normal bone formation rate (bfr). mean opg and rankl levels were . ± . and . ± . pmol/l, respectively (reference control=opg: . ; rankl: . ). opg correlated with bfr (r= . , p< . ) and adjusted apposition rate (r= . , p< . ), while inversely correlated with osteoid maturation time (omt) (r=- . , p< . ) and mineralization lag time (r=- . , p< . ). rankl/opg ratio was negatively correlated with mineral apposition rate (r=- . , p< . ) and positively with omt (r= . , p< . ). pth was correlated with bfr (r= . , p< . ) and resorption area (r= , , p< . ), but not with any mineralization markers. there were no correlations between pth and opg or rankl. conclusion: opg, in contrast to rankl, exerts a dual effect on the skeleton by promoting mineralization and increasing bfr. these osteogenic markers might be of benefit in characterizing the turnover, mineralization and volume of the skeletal lesions of secondary hpt as recently recommended by kdigo. "sevcan bakkaloglu was supported by tÜbitak (scientific and technological research council of turkey). this study was supported by usphs grants dk- , dk- and mo -rr . " pth values are widely used to guide therapy for renal osteodystrophy in patients treated with maintenance dialysis yet target values are based on cross-sectional studies and discrepancies between bone formation rates (bfr) and pth have been described during intermittent calcitriol rx. thus, we evaluated the relationship between serum biochemical parameters and bone turnover during treatment with intermittent vitamin d sterols. patients aged ± yrs with biochemical and bone biopsy (bbx) proven nd hpt received months of vitamin d ( , d or d ) given in twice weekly oral dosing and phosphate binders. dose of vitamin d was titrated upwards monthly to maintain st pth-ima(nichols r ) levels between - pg/ml. bbx was then repeated. s-ca, p, alk p-tase and pth by st and nd pth-imas were obtained monthly throughout therapy. baseline values were: p: . ± . mg/dl, ca: . ± . mg/dl, alk p-tase: ± iu/l, st pth-ima ± pg/ml, nd pth-ima: ± pg/ml. final values were: p: . ± . mg/dl, ca: . ± . mg/dl, alk p-tase: ± iu/l, st pth-ima: ± pg/ml, and nd pth-ima: ± . bone formation rate (bfr/bs) decreased from ± to ± um /mm /d (nl: - . ); % achieved normal bone turnover. nd pth-ima values were - % lower than st pth-ima levels; there was no difference in predictive capability of the two assays. patients achieving normal bfr/bs had st pth-ima values of ± pg/ml. the sensitivity, specificity and ppv of a st pth-ima range of - pg/ml for normal bfr/bs were % ( % ci: - %), % ( - %), and % ( - %) respectively. during therapy with intermittent vitamin d sterols, maintaining pth levels higher than currently recommended results in normal bfr/bs and prevents adynamic bone. maternal diabetes will induce abroad array of congenital malformation. consistently with these hypotheses, we observed the defects of renal development of diabetic pregnancy from late phase of embryogenesis to postnatal period in animal model (c bl/ j mice). histological analysis of phenotypes revealed decreased glomerular numbers, glomerular hypertrophy and hypercellularity, as well as renal tubular detachment in sequential late phase of kidney development in the offspring of diabetic female mice. tunel assay showed signficinatly increased cell apoptosis in fetal kidneys of hyperglycemic group. rt-pcr and fish study of kidneys of fetal and newborn mice revealed that gdnf and early growth response alpha (egr-α) are two of crucial genes inhibited in hyperglycemic ambience. in human, we presumed that children of gestational hyperglycemic mothers have the same defects of renal development as our animal model similarly, thus we measured and compared echogram of kidney/liver echoenic ratio in children born to gestational hyperglycemic mothers and health children. interestingly, our human ultrasonic study indicated that after age of months, the diabetic children had increased echogenic ratio of kidney/liver than the healthy age matched children (p< . ). we also found that . % of diabetic children had nonobstructive hydronephrosis. this simple sonographic procedure may provide a permissive was for clinicians to obtain the basis of long-lasting follow-up of these high-risk children as early as possible. keywords: diabetic embryopathy, renal development, glial cell line-derived neurotrophic factor, early growth response alpha, renal sonogram. genetic inactivation of spry in mice results in increased number of ub branches and expanded gdnf, c-ret and wnt- expression domains (basson et al., dev. cell, ) , indicating that spry is a negative regulator of the gdnf-ret-wnt pathway. ang ii induced ub branching morphogenesis, partly via stimulation of egfr tyrosine kinase activity (yosypiv et al. jasn, ) . we tested the hypothesis that ang ii stimulates the gdnf-ret pathway via repression of spry . cd mice metanephroi were dissected on embryonic (e) day e . , grown on filters in the presence or absence of ang ii ( - m, n= /group) for hours and subjected to whole-mount ish with digoexigenin-labelled spry , c-ret, wnt- and gdnf crna probes. spry mrna was expressed in ub branches and in condensing mesenchyme. c-ret and wnt- were expressed in ub tips, and gdnf-in the metanephron mesenchyme. ang ii downregulated spry expression in the ub. in contrast, c-ret and wnt- were induced by ang ii in the ub tip cells. gdnf expression in the mesenchyme was also upregulated by ang ii. in addition, ang ii stimulated ub tip cell proliferation, as determined by in vivo brdu in corporation ( . ± . vs. . ± . ; p< . ) compared to control. these findings suggest a model in which ang ii-mediated inhibition of spry gene expression releases. ret tyrosine kinase activity leading to upregulation of c-ret and its downstream target gene, wnt- . enhanced wnt- expression, in turn, induces gdnf in the adjacent mesenchyme. this causes focal bursts of ub tip cell proliferation and branching. these results support the hypothesis that abnormal collecting system development in angiotensinogen, renin, ace or at -deficient mice is at least partly due to aberrant regulation of the ub branching morphogenesis program. objectives of study: nephrogenesis requires a fine balance of many factors that can be disturbed by intrauterine growth restriction (iugr), leading to a low nephron endowment. our previous studies have shown that offspring born to mothers supplied low protein diets during pregnancy have fewer glomeruli than normal at birth in sd rats. the aim of this study was to identify the possible pathogenesis of abnormal nephrogenesis and decreased glomerular number in iugr by comparative proteomic approach. methods: iugr was induced in sd rats by isocaloric protein restriction in pregnant dams. kidney proteins were obtained from neonatal normal rats (control group) and iugr rats (iugr group) respectively. a series methods including -de, silver staining, mass spectrometry and database searching were used. the -de test was repeated three times in each group. results: after silver staining, the -de image analysis detected average ± spots in iugr group and ± spots in control group. the average matched rate was % and % respectively. the differential proteomic expression analysis found eleven protein spots were expressed only in iugr group and one in control group. seven protein spots were up-regulated more than folds and two down-regulated more than folds in iugr group compared with those in control group. these protein spots were preliminarily identified, which were structural constituents of cytoskeleton including vimentin, cytokeratin , perlecan and b-actin, transcriptional factors including splicing factor, rho gdp dissociation inhibitor alpha and cell division proteinkinase , enzymes including retinal dehydrogenase , transketolase and so on. conclusions: data from this study may provide, at least partly, valuable experimental evidence of proteins involved in the pathogenesis of abnormal nephrogenesis and decreased glomerular number in iugr. the aim of the study is to describe the natural history of tcf /hepatocyte nuclear factor- beta linked disease in children. prenatal and postnatal renal evolution and extrarenal manifestations of patients were reported. thirty one had prenatal diagnosis of developmental nephropathy: bilateral foetal hyperechogenic kidneys or a hyperechogenic kidney with a controlateral multicystic dysplastic kidney. % had cysts. the mean prenatal renal length was normal ( , sd) . intrauterine growth was normal with median birth weight of . kg (range . - . ) and % were small for gestational age. after a mean follow-up of months, the renal growth was impaired with a mean renal size of - . sd. patients with a solitary functioning kidney showed no compensatory hypertrophy. thirty one patients developed bilateral nephropathy and isolated unilateral multicystic kidney. twenty eight patients had cysts, mainly cortical bilateral microcysts. the mean gfr was . ± . ml/min/sc. sixteen patients had stage chronic kidney disease (ckd), four were classified as stage , eleven as stage or ckd and two were diagnosed with end stage renal failure. annual decline of the glomerular filtration rate was . ml/min. extrarenal manifestations included patients with diabetes, one with exocrine pancreatic insufficiency, one with pancreatic hypoplasia without clinical symptoms and with cholestasis. we found a complete heterozygous deletion of the tcf gene in patients and nine different point mutations. three patients had the g c mutation, with unilateral mcdk and with bilateral severe hypoplasia leading to early renal dysfunction. tcf gene anomalies are associated with low renal function decline but in some patients end stage renal failure appeared early in life. long term follow-up is needed to determine the incidence of extrarenal symptoms, particularly diabetes. objectives: although it has been observed more than one hundred years ago that the urinary tract is very resistant to infection, its antimicrobial mechanisms have not yet been systematically characterized. we sought to elucidate the expression and relevance of the antimicrobial peptide cathelicidin in this area. methods: in order to investigate the expression of cathelicidin in health, urine samples from healthy children, pieces of healthy renal tissue, and cell cultures were analyzed. to evaluate the expression of cathelicidin during infection, urine samples from children with urinary tract infection, a mouse model of ascendant pyelonephritis and cell culture experiments were employed. the relevance of cathelicidin production was tested by bacterial challenge of cathelicidin-deficient and neutropenic mice. in addition, we studied the in vitro effects of cathelicidin on the growth and multicellular behavior of bacteria as well as we tested sensitivity of clinical e. coli strains to the peptide. results: cathelicidin is expressed by epithelial cells of healthy urinary tract and excreted into urine in low concentrations. during urinary tract infection, the secretion of cathelicidin by epithelial cells significantly increases within minutes. invading neutrophils are the source of the second wave of cathelicidin. epithelial cathelicidin protects the urinary tract against bacterial infection while neutrophil-derived cathelicidin influences the severity of infection. cathelicidin displays multiple effects on bacteria. low concentrations of cathelicidin inhibit multicellular behavior, e. g. biofilm formation of e. coli, and high peptide concentrations kill bacteria. bacteria resistant to cathelicidin have an increased ability to invade the urinary tract. conclusion: the antimicrobial peptide cathelicidin is a key factor of the mucosal immunity of the urinary tract. the predictive value of procalcitonine (pct) plasma level for renal scarring after an acute pyelonephritis (apn) is still debated. during apn, the bacterial lipopolysaccharide of the membranes induce the release of tnf, il and il . these cytokines lead to inflammation syndrome and fibrosis sequellae resulting from cell apoptosis induced by nitric oxide (no) release that is catalysed by no-synthase. the aim of this work was to clarify the physiological role of pct in renal parenchyma apoptosis and fibrosis caused by apn. we conducted a prospective study in children with a first apn episode (fever> . c°, crp> mg/l, monomicrobial urine positive culture> . fcu/ml). we excluded patients with any concomitant infection, renal dysplasia or obstructive uropathy or grade - vur children were enrolled (age . m, median m). on admission, pct, crp and phospholipase a (pla ) were quantified in serum. scintigraphy with m tc-dmsa was performed on day and months later in case of initial abnormalities. fisher's test was performed and statistical significance was defined as p< . . results: on day , ( %) presented renal parenchyma alterations, at m underwent control scan and ( %) had renal scars. pla and pct levels were correlated with early dmsa lesion but not with renal scars at m. paradoxically, initial pct level was significantly lower in the presence of renal scars ( . vs . ng/ml, p< . ). significant pct increase was observed in favourable progress (recovery . vs aggravation . ng/ml, p< . ) and no difference between recovery and improvement evolution. these results suggest the protective effect of pct against apoptosis resulting from down-regulation of nitric oxide release; so high pct values could be interpreted with caution in apn. acute pyelonephritis (apn) may lead to renal scarring with later risk of hypertension and renal insufficiency. the aims of this study were to analyse prospectively renal scars progression with time and their impact on renal growth. methods: patients (pts), aged from to years who presented scars on dmsa at months after apn were included. in these children a second dmsa was done after years. evolution of scars was analyzed following pre-established criteria independently by observers. scar progression was classified as follows: =no change, =partial improvement, =total resolution. in addition a renal ultrasound was repeated to assess kidney growth using z-score. results: renal units ( pts: f, m) were studied. the incidence of vesicoureteral reflux (vur) was . % ( / ). per renal units, vur were observed in / ( %); ( % vur grade (g) i, ii and % g iii, iv). there were scars observed month after apn which evolution over years was as follow: = % ( / ), = % ( / ) and = % ( / ). incidence of vur was higher in children presenting scars; / ( %) against / ( %) in those with or scars. to identify factors interfering with renal growth, we analyzed potential confounding variables using robust linear regression. z-score was worsened with increased number of scars observed at month after apn p< . ) and improved with disappearance of vur ( . ci . - . ; p< . ). conclusion: between month and three years after apn, % of scars improved. in our population, the number of scars secondary to pna was the most important factor affecting renal growth. the second prognosis criterion was the correction of vur. prevention of pna and rapid treatment to avoid kidney scars seems to be the essential aim to preserve optimal kidney growth. v. smolkin , , r. halevy , , w. sakran , , y. kennes , a. koren , ha'emek medical center, pediatric b, afula, israel ha'emek medical center, pediatric nephrology unit, afula, israel ha'emek medical center, bacteriology and microbiology laboratory, afula, israel the ruth and baruch rappaport school of medicine, haifa, israel febrile urinary tract infection (uti) is a relatively common infection disease in childhood. children consider at risk for uti commonly receive prophylactic antibiotics to prevent recurrence of this urinary tract disease because of the risk of kidney scarring, which may lead to complications such as hypertension or end-stage renal disease. compliance with antibiotic prophylaxis after uti was assessed in children, using a parent questionnaire and a urine test for antibacterial substances. thirty six children ( st group) received prophylactic treatment during the period of months (range - months) and the other patients ( nd group) received antibiotic prophylaxis for a longer duration ( months, range - months). in the first group of patients, ( %) of parents reported giving the antibiotics every day in comparison with ( %) in the nd group. twenty nine ( %) of urine tests were positive for antibacterial substances in the st group but only ( %) in the second group. in the st group of patients the difference in recurrent infection between regular takers and non-takers was statistically highly significant. no significant difference was found in recurrent uti rate in takers and non-takers in the nd group. failure to understand the reason for prophylaxis and forgetfulness was found to be a main reason for non-compliance. imaging studies evaluating the kidneys and urinary tract are performed routinely after a febrile uti. evidence of their value in changing management or affecting long term outcome is limited. as part of a multicentre, rct (iris ) evaluating different antibiotic regimes in the treatment of first febrile urinary tract infections, we undertook as a secondary objective, an evaluation of the diagnostic protocol. the imaging modalities (ultrasound, dmsa scintigraphy within days and voiding cystogram within - months) were assessed for their ability to predict long term parenchymal damage. children of years of age or less at the time of investigation and who had normal renal function and antenatal ultrasound, were considered suitable for analysis of the diagnostic course. us was performed in children with ( %) normal, minor changes were noted in the remainder, apart from case requiring a change in management in the form of a pyeloplasty for pelvi-ureteric obstruction. the cystourethrogram was performed in of the children with ( %) demonstrating vur. the cystogram was a poor predictor of long term damage, being positive for reflux in only of the children who subsequently developed scarring. an acute dmsa scan performed in all children, exhibited findings consistent with acute pyelonephritis in ( %). a repeat dmsa scan at months in those with evidence of acute pyelonephritis demonstrated a scarring rate of %. the data did not demonstrate the clinical efficacy of routinely performing scintigraphy in the acute phase or a cystourethrogram. our recommendations for a reasonable diagnostic work up in small children with their first episode of uti are ) performance of a scintigram months following the acute infective episode, and ) close surveillance to identify eventual recidivists. introduction: focal segmental glomerulosclerosis (fsgs) has a high recurrence rate after renal transplantation (rtx). recurrence can lead to tx loss. disease recurrence (dr) seems to be influenced by genetic background. methods: patients with childhood onset of biopsy proven fsgs who were transplanted were evaluated. genetic investigations of the nphs gene were done in patients ( . %). results: mean age at diagnosis was . years. first renal transplantation was performed at age of . years. patients received a living related (lrd), a deceased donor (dd) graft. patients data under investigation. p ( . %) recurred after a mean time of , years, p with lrd ( . %) , p with a dd ( . %). patients ( . %) lost their graft after , years, patients due to recurrence. a second rtx was performed in patients, with dd, with lrd, patients data under investigation, with % dr. a third transplantation was performed in patients and a fourth in one patient. screening for nphs mutations revealed patients with mutation in the nphs gene, homozygot, heterozygot. all patients with a homozygote nphs mutation did not recur and only the one patient with a heterozygous mutation ( / ) recurred compared to / without a mutation (p< . ). conclusion: living related transplantation was advantageous to decreased donor transplantation. patients with nphs mutations had a lower risk of recurrence after transplantation compared to patients without mutations. patients with fsgs should be screened for nphs mutations. objective: prospective ebv surveillance post tansplantation reduces incidence of acute rejection and risks of post transplant lymphoproliferative disorders (ptld). methods: prospective screening of ebv by polymerase chain reaction (pcr) and serology in all patients transplanted between - . results: patients transplanted between may and september . were cadaveric and live-related transplants. recepient ebv serology status was known but not on donors. basiliximab was used for induction and maintenance comprised of tacrolimus/azathioprine (aza) until and mycophenolate (mmf)/tacrolimus from . all received corticosteroids. had mmf/tacrolimus, aza/tacrolimus. ebv screened within first week post transplant, weekly for a month, monthly for months. when ebv pcr lv > . , mmf/aza was withdrawn, tacrolimus levels kept between - ng/ml. pcr/ serology is checked weekly for months, monthly for , until lv falls < . and vca igg becomes positive. the mmf/aza is reintroduced. patients with ebv pcr lv < . are kept on full immunosuppression while viral load and vca igg monitored. ebv viraemia detected following prospective screening. was re-activation. were symptomatic. onset varied to . months post transplant (mean . months). were on mmf/tacrolimus received aza/tacrolimus. had pcr lv> . consequently maintained on tacrolimus an alternate day steroids for period of time. cmv patient and donor status was known and antiviral prophylaxis given to nonimmune. the use of antivirals made no impact on viral load. conclusion: no patient experienced acute rejection or ptld despite modification of therapy with our prospective screening programme. antivirals have no role in protecting or reducing viral load in already infected patients. graft attrition rate is highest in the first three months after renal transplantation. we analysed data in a recent cohort from all dutch centres for pediatric renal transplantation to determine incidence and causes of such early graft failure. methods: data from all pediatric renal transplants performed between - - and - - were analysed retrospectively. a common immunosuppressive protocol was used in all centres. thrombosis prophylaxis was given according to centre policy. early failure was determined as graft failure within months after transplantation. prevalence of possible risk factors of graft failure identified by literature search were extracted from patient charts. data were analysed with univariate and multivariate logistic regression. results: the cohort consisted of transplants. age of the recipients was - yrs (mean . ). there were early graft failures ( . %). major causes of graft failure were thrombosis ( . %) and are( . %). univariate analysis identified an association of early failure with complications during surgery (or . , p= . ), cold ischemia time (or . , p= . ), side of graft donation (or . , p= . ) and diuresis in the first hour after transplantation (or . , p= . ). multivariate regression analysis showed that complications during surgery were associated with the risk of early failure (or . , p= . ), as were side of graft donation (or . , p= . ) and diuresis in the first hour after transplantation (or . , p= . ) . only the occurrence of complications during surgery was significantly associated with early graft failure due to thrombosis (or . , p= . ). conclusion: thrombosis is the major cause of early graft failure after renal transplantation in dutch children, especially after surgical complications. prospective studies are needed to determine whether early failure can be decreased by more rigorous prophylaxis. background: interleukin (il)- is a major contributor to inflammation and cell death during ischemia-reperfusion (ir) injury and its deleterious effects are mediated mainly by nuclear factor-κb (nf-κb) activation. receptor binding and signalling of il- can be blocked by the il- receptor antagonist (il- ra). the aim of our study was to characterize the effects of il- ra administration on inflammation, apoptosis and infiltration in renal ir injury. methods: renal ischemia was induced in lewis rats (n= /group) by clamping of the left renal artery for min followed by reperfusion of h or five days respectively, when kidney were removed for histological and molecular analysis. results: treatment with il- ra ameliorated ischemic renal tissue injury and inflammatory infiltration. futhermore, the number of apoptotic tubular cells was lower in il- ra treated animals h after ischemia, which was paralleled by a bax/bcl- mrna ratio towards anti-apoptotic effect. il- ra reduced the expression of monocyte chemoattractant protein- (mcp- ) mrna h and days and that of intracellular adhesion molecule- (icam- ) expression h after reperfusion in the kidney. conclusions: our results indicate that il- ra treatment ameliorates renal ir injury and this protective effect might be mediated by reduced induction of nf-κb mediated mcp- , icam- and the decreased ratio between bax and bcl- mrna expression. k. satomura, y. santo osaka medical center for maternal and child health, pediatric nephrology and metabolism, izumi, japan many studies have reported that angiotensin-converting enzyme inhibitor (acei) and angiotensin receptor blocker (arb) show renoprotective effects in adult patients with acquired renal diseases. however, these effects have not been studied in children with renal hypoplasia or dysplasia (rhd). in this study, we explored the renoprotective effects of these drugs in children with rhd. patients and methods: participants of the study were patients with rhd aged less than years. a follow-up for more than one year was conducted in our outpatient clinic. the patients had chronic renal failure, and had not received acei or arb in the past. the change of glomerular filtration rate (gfr) per year, urinary protein/creatinine (up/cr) ratio, serum potassium levels, and blood pressure before the treatment with trandolapril or candesartan were compared with those of one year after the treatment. the estimated gfr was calculated by the schwartz formula. wilcoxon rank sum test was applied to evaluate the statistical significance. results: eleven patients were eligible for this study. the mean age of the patients was . ± . years and the estimated gfr was . ± . ml/min/ . m when trandolapril or candesartan was administered. the change in the estimated gfr for a year significantly improved after the treatment with trandolapril or candesartan compared with the pre-treatment period (- . ± . vs. . ± . ml/min/ . m /year, p= . ). the up/cr ratio significantly decreased at one year after the treatment compared with that before the treatment ( . ± . vs. . ± . , p= . ). the blood pressure and serum potassium level showed no significant changes. conclusion: these data suggest that treatment with acel or arb has beneficial effects on the renal function in children with mild to moderate renal failure due to rhd. objective of the study: postischaemic arf is influenced by sex hormones. dehydroepiandrosterone (dhea) pretreatment diminishes postischemic injury. previously we demonstrated that after renal ischaemia-reperfusion (i-r) injury the expression and activity of na, k-atpase (nka) is impaired in male rats. here we tested the impact of dhea on postischaemic survival, renal damage, mrna and protein expression of nka. methods: left renal pedicles of dhea ( . mg/kg/day) and propylene glycol, as vehicle (pg) treated male rats (g dhea and g pg , respectively) were clamped for min followed by (t ) and (t ) hours of reperfusion. survival rate, histological damage, serum creatinine (cn) and urea nitrogen (bun) were investigated. the mrna expression and protein level of nka α and β subunit were also determined. sham operated animals served as control. results: dhea treatment was associated with better postischemic survival (p< . g dhea vs. g pg ). postischaemic cn and bun were higher and renal histology showed more rapid progression vs. controls, however there was no difference between g dhea and g pg groups. mrna expression of nka α subunit was higher in g dhea vs. g pg at every time points, however it was decreased in i-r groups vs. controls (p< . ). similar changes were observed in nka α protein level (p< . , g dhea vs. g pg in controls, t , t ). mrna and protein expression of α subunit were different only at t (p< . , g dhea vs. g pg ). conclusions: our study indicates that nka is more protected from the detrimental effects of i-r injury in dhea treated animals, which might be a contributing factor of improved postischaemic renal function and could help to preserve cell and organ homeostasis even in male animals. the work was supported by otka f -t , bolyai and semmelweis grants. objective of study: recently bnp has been identified as a useful cardiac marker for risk stratification in adults. whether bnp has a similar diagnostic potential in pediatric population with ckd has to be established. the aim of the study was to assess the value of bnp to predict the cardiac dysfunction in children with ckd. methods: to test this suggestion, the relationship between plasma concentrations of bnp, echocardiographic parameters and cardiovascular risk factors (lipid profile, hypertension, secondary hyperparathyreoidism) has been evaluated. a cohort group consisted of children and young adults ( pts mean age x= . ± . years; controls mean age x= . ± . years). out of studied pts children were with ckd stage and k/doqi ( pts ckd stage ; dialyzed pts) and transplanted subjects with stable graft function (gfr= . ± . ml/s/ . m ). results: no association was found between bnp and gfr and/or s-creat (p= . ; p= . ; p= . ). the highest bnp plasma levels have been found in dialyzed children ( . pg/ml; resp. . pg/ml in tx; resp. , pg/ml in ckd stage group) as compared to controls ( , pg/ml p< , ). bnp was independently related to left ventricular mass (r= . ; p< . ) as well as to ejection fraction (r=- . ; p< . ) and preload (r= . ; p< . ). significant correlation between bnp and hypertension (r= . ; p< . ) has been observed. more over, bnp correlated with ipth (r= . ; p< , ) and diastolic dysfunction (r= . ; p< , ). plasma bnp concentrations did not significantly differ before/after dialysis procedure (p= . ). conclusions: bnp is a sensitive marker for cardiac dysfunction in ckd children. however, prospective studies in larger group of pts are needed to confirm our preliminary data. we have reviewed the data of patients with nephropathic cystinosis (nc) followed in our department since . overall, patients have died during the follow-up period. the mean follow-up was , ± , yrs (range , ) . / patients have initiated dialysis and / received a cadaveric renal transplant. univariate analysis showed that the time to reach a serum creatinine value of mg/dl was significantly associated with the patient's age at the last follow-up (o. r. , /yr; p< . ), the age at the beginning of cysteamine (mea) treatment (o. r. , /yr; p= . ), the dose of mea (o. r. , /g, p= . ) and the use of ace-inhibitors (o. r. , ; p= . ). by multivariate analysis, only the period of treatment (or , , p= . ) and therapy with ace-inhibitors (or , , p= . ) were significantly associated with better outcome. similar results were obtained when assessing the time to dialysis. there was a significant correlation between the dose of mea with intra-leucocytic cystine levels (ilc). by univariate analysis, the dose of mea expressed in mg/m correlated more with the outcome then the dose expressed in mg/kg. statural growth was significantly associated by multiple correlation analysis only with growth hormone (gh) treatment (p< . ). altogether, these results indicate that the renal prognosis of nc has been improving over the past two decades. this improvement may not be solely attributable to the introduction of mea for the treatment of nc. our data suggest that the overall management of these patients has improved, including more efficient symptomatic treatment of the fanconi syndrome and the use of medications such as ace inhibitors and gh. background: the chronic kidney disease in children (ckid) cohort study, targeted to enroll children aged - yrs with chronic kidney disease (ckd) by estimated gfr (egfr schwartz) of - ml/min/ . m aims to assess risk factors for kidney disease progression in children. objective: to describe the characteristics of the ckid cohort at study entry. design/methods: at the ckid baseline visit, gfr is measured by plasma disappearance of iohexol. children undergo physical exam, standardized bp measurements, blood and urine testing and parent and child interview. results: as of / / , children had completed the baseline visit, median age . yrs, % caucasian, % african american, % male and % hispanic ethnicity. median age-adjusted height and weight percentiles were % and %, respectively. underlying cause of ckd was urologic, cystic or hereditary in %, % had acquired glomerular disease. median egfr at study entry was . ml/min/ . m , % higher than the median iohexol-based gfr . ml/min/ . m . % of participants reported a history of hypertension, % anemia, % seizures, and % depression. symptoms of headache, nausea, loss of appetite and weakness steadily increased in prevalence with lower gfr. assessment of family history in parents and grandparents revealed: high blood pressure %, high cholesterol %, kidney disease %, dialysis %, and kidney transplant %. conclusions: children with stage iii ckd have significant height deficits, hypertension, anemia, and seizure disorders. cross-sectionally, increasing non-specific symptoms are associated with lower gfr. collection of plasma, serum and genetic material will facilitate understanding of novel risk factors and biologic mechanisms underlying kidney disease progression and associated morbidities. aim: increased glomerular filtration rate (gfr) has been implicated in the development of diabetic nephropathy. large normal interindividual variations of gfr hamper the diagnosis of renal hemodynamic alterations. we examined renal functional reserve (rfr) in children with insulindependent diabetes mellitus (iddm) to assess if hyperfiltration occurs. methods: the renal hemodynamic response following dopamine infusion was examined in iddm children ( . ± . y) with a mean duration of diabetes of . years and compared to controls. results: mean baseline gfr in diabetic children did not differ from control population ( . ± . vs. . ± ml/min/ . m ), whereas renal plasma flow was significantly lower ( . ± . vs. . ± ml/min/ . m , p< . ) and filtration fraction was increased ( ± vs. ± %, p< . ), compared to controls. the mean rfr was lower (p< . ) than in control subjects (- , ± vs. ± ml/min/ . m ). conclusion: the observation that rfr is reduced or absent suggests that all children are in a state of glomerular hyperfiltration with increased intraglomerular pressure regardless of the baseline normal values of gfr. while measurements of rfr may be helpful in diagnosing the presence of hemodynamic changes, the relevance to development of diabetic nephropathy remains unknown. only - % develops diabetic nephropathy, suggesting that glomerular hyperfiltration is only a concomitant risk factor. lp diet induces ischemic renal injury involving epithelial cells from osom. here, we tested whether hsp would stabilize renal na+k+atpase attachment to the cytoeskeleton during recovery from lp. after weaning, rats (n= ), were fed for days with a lp diet ( %), then were recovered by means of a normal protein diet ( %rp) each group had an age-matched control group ( %, np). tissues from cortex and osom were homogeneized in buffer plus . % triton x- . protein levels were measured by western blot. in vitro coincubation of solublen on cytoeskeletal and insoluble cytoskeletal-associated fractions in the presence or absence of anti-hsp antibody was performed. interaction between proteins was determined by coimmunoprecipitation. increased na+k+atpase dissociation was shown in soluble fraction from osom as a result of lp diet vs. np ( . ± . vs. ± . , p< . ). meanwhile, decreased hsp levels in the same fraction was shown (lp: . ± . vs. np . ± . , p< . ). translocation of hsp to the cytoeskeletal injured fraction associated with stabilization of na+k+atpase was shown in osom from lp, after in vitro coincubation of the cytoskeletal fraction of lp and non cytoskeletal fraction of rp. these effects were abolished by the addition of anti-hsp antibody. coimmunoprecipitation showed that the amount of hsp coprecipitating with na+k+atpase increased in lp osom, in rp results were similar to control. in cortex, absence of significant differences was shown in the na+k+atpase and hsp expression at in vivo and in vitro experiments among groups. in lp and rp cortex tissues, interaction of both proteins was similar to control. our results allow us to suggest that hsp has a critical protective role in the integrity of the cytoskeletal anchorage of na+k+atpase during recovery from ischemic lp injury in osom. tubular reabsorption of mg + occurs predominantly by paracellular flux in the thick ascending limb of the loop of henle. it is mediated by the, tight junction, mg + channel protein, paracellin- , which is encoded by the gene pcln- . cyclosporin a (csa), a widely used immunomodulatory drug, decreases tubular mg + reabsorption leading to urinary mg + wasting and hypomagnesemia. the exact molecular mechanisms of this modulation are unknown. in this study we examined the effect of csa on the paracellin- gene in renal cell lines and mouse kidney. the effect of csa on the pcln- gene promoter was examined. a plasmid, containing the human pcln- (hpcln- ) promoter ( . kb) upstream to a luciferase reporter gene, was transfected into opossum kidney (ok) and human embryonic kidney (hek ) cells prior to exposure to micrograms/ml csa for hours. mice received csa ( mg/kg/day) for up to days. at h intervals blood/urine mg + and ca + levels were determined and kidneys harvested for paracellin- mrna quantitation (real-timepcr) as well as protein quantification (western blot) and visualization (immunofluorescence). csa decreased hpcln- promoter activity by %- % in transfected ok and hek cells, compared to control cells. csa-treated animals displayed hypomagnesemia with increasing urine mg + and ca + levels paralleled by a - % decrease in pcln- mrna after and days of csa exposure. a similar effect on paracellin- protein expression inthe renal tubule was evident in response to csa treatment. csa may influence paracellin- -mediated mg + transport at the transcriptional level. involvement of the calcineurin-dependent tonebp pathway or the calcineurin-independent map kinase pathway in this response is subject to future research. this effect of csa on the paracellin- gene may play a role in the renal magnesium wasting and hypomagnesemia induced by csa. it is well established that proteinuria induces tubular injury, which is closely associated with progressive decline of renal function. megalin has an important physiological role in the reabsorption of a variety of low molecular weight proteins along the proximal tubule. in this study, we examined whether megalin mediates tubular injury secondary to glomerular diseases. we utilized megalin knockout (ko) mice, in which % of proximal tubular cells have mosaic nullmutation in the megalin gene. to induce glomerular injury, these were mated with a transgenic line, nep , in which selective podocyte injury can be induced by injection of immunotoxin, lmb . megalin ko/nep mice were injected with lmb ( . ng/g bw) and analyzed weeks later. they showed moderate proteinuria (upro/cr= , vs . before lmb ) and mild tubular injury, which were comparable to those observed in nep mice with intact megalin gene injected with the same dose of lmb . in the latter, megalin was still detectable in injured tubules. within each megalin ko/nep mouse, we compared megalin-intact (+) vs deficient (-) proximal tubular cells by immunostaining. the majority of megalin+ cells showed enhanced staining for albumin. in contrast, most megalin-cells were not stained for albumin. aquaporin- , which is highly expressed in normal proximal tubules, was diminished in . % of megalin+ cells, whereas it was diminished in only . % of megalin-cells. some proximal tubular cells expressed mcp- . in that, % of mcp- expressing cells were megalin+. the results suggested that megalin plays an important role in the reabsorption of massively filtered proteins in glomerular diseases, thereby contributing to proximal tubular cell injury. objectives of study: the hallmark of nephropathic cystinosis is lysosomal cystine accumulation, primarily leading to fanconi syndrome. although all tissues haveelevated cystine levels, it is not known why the kidney is first affected. it is postulated that decreased atp production in cystinosis results in defective proximal tubular reabsorption, a process driven by na, k-atpase. to study this hypothesis, we have monitored atp levels and viability in conditionally immortalized proximal tubular cells (ptc) of cystinosis and healthy controls. methods: urinary sediment of cystinotic patients and healthy controls was suspended ins supplemented culture medium. primary cultures were transfected with sv ts a t antigen allowing proliferation at °c and maturation at °c. to confirm the proximal origin of the cells ) expression of aquaporin- (aqp ) and dipeptidyl-peptidase iv (dpp-iv) was demonstrated using immunoblot technique and ) morphology was determined using em. ptc were matured at °c for - days, followed by cystine measurement using hplc and atp determination using luciferase assay. results are expressed as nmol/mg protein. results: colonies of cystinotic and control cell lines (n= ) with cobblestone morphology developed after weeks and expressed aqp and dpp-iv, confirming their proximal origin. in cystinotic ptc, cystine levels increased from . at °c to . after days at °c compared to . in controls. intracellular atp decreased in cystinotic ptc during days from . to . , while atp levels in controls remained stable (range . - . ). atp levels inversely correlated with cystine accumulation in cystinotic ptc (r=- . , p= . ). conclusion: decreased atp levels in conditionally immortalized ptc during days maturation suggest that alterations in atp levels are involved in tubular dysfunction in cystinotic patients. aquaporin ( aqps have been identified to date. aqp conveys % of the peritoneal water transport in pd. cell migration and angiogenesis are altered in aqp ko mice; erythrocyte pco depends on aqp . human peritoneal mesothelial cells (hpmc) from non-uremic patients and a human mesothelial cell line (met- a) were incubated with conventional (c-pdf), icodextrin (ico), bicarbonate (b-pdf) and lactate based double chamber pd solution (l-pdf). mrna was measured by real time rtpcr, and protein by western blot and immunocytochemistry. hpmc and met- a express aqp , , and . incubation of met- a and hpmc with c-pdf, ico and l-pdf did not change aqp and expression compared to medium. in contrast, incubation with b-pdf increased aqp and mrna and protein in both hpmc ( h aqp mrna: ± , aqp : ± %) and met- a (aqp : ± , aqp : ± %). the effect on aqp was in part explained by differences in ph, the effect on aqp was largely independent of ph. addition of mmol/l of bicarbonate to l-pdf increased aqp and mrna (l-pdf+bic: aqp : ± , aqp : ± %). aqp expression was suppressed by all three pd fluids (b-pdf: ± . , l-pdf: ± . , c-pdf %: ± %), aqp was up regulated by b-pdf ( ± %). b-pdf improved hpmc migration. we for the first time demonstrate the expression of four different aqps in peritoneal mesothelial cells. they are markedly regulated by pd-solutions. the upregulation of aqp , , and by bicarbonate based pdf may have important implications on long term peritoneal membrane function, wound healing and neoangiogenesis. the regulation of cx cl (fractalkine) by thromboxane a in inflammation there is marked leukocyte infiltration into the damaged tissue. chemokines recruit and direct leukocytes to the injured site. the chemokine cx cl is up-regulated in renal inflammation such as glomerulonephritis and allograft rejection. thromboxane a (txa ), a potent vasoconstrictor in the kidney, is also pro-fibrotic. txa is up-regulated early in inflammation and its effects are mediated by binding to the tp receptor. the aim of this study was to examine the effect of txa on cx cl expression. we previously showed that cx cl recycles between the cell surface and an internal compartment. cell surface cx cl is cleaved by the enzyme, tace, to yield the soluble species of the chemokine. we generated human ecv- cells stably expressing cx cl and treated cells with a tp agonist. levels of cx cl were quantitated by western blotting. cx cl decreased by - min after tp stimulation, but recovered by h. using flow cytometry, we found that cell surface levels of cx cl decreased by min, but began to recover before levels of total cx cl were replenished. to verify if early recovery of cx cl was due to redistribution from the internal to the plasma membrane compartment, we used fluorescence recovery after photobleaching (frap). after min tp stimulation decreased endocytosis of cx cl was seen. we postulated that loss of cell surface cx cl is due to cleavage by tace. accordingly, a tace inhibitor prevented early loss of cx cl after tp stimulation. in summary, txa induces rapid proteolytic shedding of cell surface cx cl by tace, but later increases expression of cx cl at the cell surface by inhibiting internalization of the chemokine. this could release the soluble chemotactic protein from the cell adhesive transmembrane protein, promoting leukocyte recruitment initially, whilst promoting leukocyte adhesion later in the time course. the response to steroid therapy is used to characterize idiopathic nephritic syndrome (ins) as steroid sensitive (ssns) or steroid resistant (srns). ssns pathogenesis has been associated with activation of t-cells and srns has been associated with activation of tgfb and progression to chronic kidney disease. our objective was to determine differences in the urinary excretion of inflammatory cytokines; opn, icam and tgfb , between ssns (n= ), srns (n= ), and controls (ctr, n= ) in an attempt to identify specific biomarkers of steroid sensitivity or lack thereof. for this purpose, we used a protein array high-throughput technique and confirmed the findings by elisa. in addition, we performed immunohistochemistry (ihc) for the above cytokines on renal biopsy samples. mean age, gender, race, body mass index, and estimated glomerular filtration rate were not statistically different among three groups. there were no statistically significant differences between ssns and srns in regard to the presence of hypertension, ace treatment, and renal histology (p= . , . , and . , respectively) . urinary excretion of icam , opn, and tgfb were statistically significantly higher in ins subjects vs. ctr. urinary icam and opn were higher in ssns than in srns (p= . and p= . , respectively). however, the urinary excretion for tgfb was similar in ssns and srns. the ihc failed to reveal differences in renal tissue expression of the studied cytokines. there was no correlation between urine and kidney tissue expression. in summary, our preliminary data suggest that urinary opn and icam may serve as biomarkers of ssns. this assumption needs to be tested prospectively. methods: this is an interim report of this single center study on proteinuria in hiv positive children. there are children aged - yrs. registered in our hiv clinic. all children attending the outpatient clinic or seen on admission are studied. questionnaires included bio and clinical data. blood pressure was measured in all children. a clean catch or bag urine is obtained from all and urine biochemistry done on an aliquot. patients found to have proteinuria + or above are referred to the nephrology unit. their urine is quantitated (timed urine collection), renal function, renal ultrasound and cd count estimated. anf, le cells, fbc including platelet count and genotype will be assayed. a renal biopsy will be performed for nephrotic range proteinuria. result: eighty children positive for hiv have been studied. there were males and females giving a ratio of . : . their mean and median ages were . yrs and . years respectively. all had normal blood pressures, renal ultrasound, and renal function. fifteen of the children ( . %) had - mg/dl proteinuria; ( . %) haematuria. their mean cd + cell count was . /mm , range - . there was no significant difference between low cd + count and the presence of proteinuria (p> . ). seventy seven of the patients had vertical transmission of hiv; two acquired the infection from blood transfusion; one from scarification marks. conclusion: there is a high prevalence of proteinuria among children with hiv infection in our region. hiv positive children should be screened and intervention instituted to avert or delay the onset of chronic renal failure. carotid intima media thickness (cimt) and brachial artery flow mediated dilatation (fmd) are novel indices of subclinical atherosclerosis. we studied these indices in children with nephrotic syndrome (ns) using high resolution ultrasonography (hrus). children with ns ( ssns; srns) of - months duration and normal sibling controls underwent cimt and fmd determination using a . mhz us probe. routine biochemistry, lipid profile and hscrp were carried out to look into associations with cimt and fmd. statistical analysis was carried out using epiinfo . . cases and controls were similar in age, sex, growth and egfr. mean maximum cimt (+- % ci) (in mm) was higher in the ns group ( . +- . ; range . - . ) vis-a-vis controls ( . +- . ; range: . - . ) (p< . ). srns and ssns cases were similar ( . +- . vs . +- . mm, p= . ). nephrotic children showed significantly lower fmd ( . +- . % vs . +- . %, p= . ). cimt and fmd varied with frequency of relapses in last months ( . + . mm, . +- . % (no relapses); . +- . mm, . +- . % (> relapses). children with ns had mean hscrp of . +- . mg/l. on univariate analysis, cimt correlated with disease profile at onset (r= . , p< . ), fmd (r=- . , p= . ), male sex (r= . , p= . ), bmi (r= . , p= . ), cyclosporine exposure (r= . , p< . ), total cholesterol (tc) (r= . , p< . ), ldl (r= . , p< . ), vldl (r= . , p< . ), triglycerides (r= . , p< . ), atherogenic index (ai) (r= . , p< . ) and creatinine (r= . , p= . ). fmd correlated with systolic blood pressure, age, bmi, weight, total cholesterol, vldl and triglycerides (p< . ). to conclude, hrus can detect early atherosclerosis using fmd and cimt as the indices in children with nephrotic syndrome with disease duration of years and more. a ten-year old girl, who presented with biopsy proven acute severe changes of type membranoproliferative nephritis (mpgn ) appears to have shown complete resolution of her disorder after nine months mycophenolate moffetil (mmf) (cellcept -roche) added to relatively rapidly reducing steroids. she presented aged nine years with incidental finding of significant proteinuria and upper tract haematuria when presenting with abdominal pain. blood pressure, chemical renal function and haematology were normal. c and total haemolytic complement were at the lower limit of normal. renal biopsy showed light microscopy (lm) changes of markedly enlarged glomeruli with significantly increased mesangial cellularity and matrix, together with 'double contours' of basement membrane. inmmunofluorescence (if) was strongly positive for igg and c . electron microscopy (em) showed mesangial cell interposition into the basement membranes. she was treated with iv pulse methylprednisolone, followed by high dose oral prednisolone (pnl). after one month, mmf mg bd was added as pnl was tailed to alternate day therapy. pnl was reduced more quickly than usual due to difficulty with side effects and excellent clinical response. within three months of mmf, proteinuria and haematuria had disappeared. blood pressure and renal function have remained normal throughout treatment. after nine months, while on . mg/kg alternate day pnl and mg bd mmf, repeat biopsy showed normal sized glomeruli on lm with no significant changes, no positive staining on if and normal em without mesangial interposition. this case suggests that mmf may be a key drug in management of mpgn . g. stringini, e. malagnino, f. emma bambino gesu children's hospital and research institute, department of nephrology and urology, rome, italy serum creatinine values may vary considerably between normal subjects. these variations are in part secondary to differences in muscle mass, body composition and creatinine tubular secretion. in addition, low nephron number, which is influenced by genetic and intrauterine factors, is associated with increased incidence of arterial hypertension, late-onset proteinuria and chronic renal failure. despite compensatory glomerular hypertrophy, autopsy data indicates that kidneys with fewer glomeruli tend to be significantly smaller. on these bases, we have hypothesized that a significant part of the variance of normal serum creatinine levels is related directly to individual differences in renal size. to test this hypothesis, we have reviewed the data of renal ultrasound examinations performed at our institution between and . patients were selected if they had conditions that should not influence renal size (low tract uti, enuresis, bladder instability, idiopathic hypercalciuria), if they had normal gfr and an ambulatory blood pressure measurement. analyses were performed after expressing renal length, serum creatinine levels and blood pressure values as standard deviation scores (sds) corrected for gender, age, height and weight, by multiple nonlinear regression analysis. a significant negative correlation was found between serum creatinine levels and renal length (p< . ). when renal length measurements were grouped in quartiles, serum creatinine sds was on average . sds higher in the st quartile (small kidneys), in comparison with the th quartile (large kidneys). no correlation was found between kidney length and single measurements of ambulatory blood pressure. these data indicate that renal size is accountable for a significant part of the variance in serum creatinine levels that is observed in the normal pediatric population. henoch-schönlein purpura (hsp) is the commonest small vessel vasculitis of childhood. henoch-schönlein purpura nephritis (hspn) is the major determinant of long term prognosis in hsp. the objective of this randomised controlled trial was to determine the effect of early prednisolone treatment on the development and progression of nephropathy in children with hsp. methods: children under years of age, with a diagnosis of hsp, presenting to secondary care centres in england and wales were randomly assigned to receive either placebo or prednisolone ( mg/kg/day (max mg) for days, followed by mg/kg/day for days (max mg)). patients, parents, paediatricians and investigators were 'blinded' to assignment of treatment or placebo. the primary outcome measure was the determination of the presence or absence of proteinuria, defined as urine protein: creatinine ratio (up: uc) > mg/mmol, months after initial presentation in treated and untreated patients. results: children with hsp were randomised. patients were assigned to receive prednisolone (group a) and patients were assigned to receive placebo (group b). patients in group a and patients in group b did not complete the study. there was no difference in the incidence of proteinuria at months, in patients receiving prednisolone ( / ) compared with those receiving placebo ( / ) or= . , % ci . - . , p= . . conclusions: this is largest prospective randomised placebo-controlled trial of the role steroids in hsp in the literature to date. this study provides compelling evidence of absence of a beneficial effect of early treatment with prednisolone in the development of nephropathy months after disease onset in children with hsp. while quality of life (qol) is generally assumed to be poor on dialysis and to improve markedly after kidney transplantation, systematic assessments of qol in children have not been performed to date. to date, we have examined general and health-related qol in children and adolescents with esrd aged - years treated by hemodialysis (hd; n= ), peritoneal dialysis (pd, n= ) or renal transplantation (tx, n= ), using a well-established instrument (kindl) comprising an ageadapted set of questionnaires (kindl). the obtained measures of overall and item-specific qol were transformed to standard deviation scores (sds). general qol was close to normal and did not differ significantly between hd (- . ± . sds), pd (- . ± . ) and tx (- . ± . ). psychological well-being was better in children on pd ( . ± . ) than after tx (- . ± . , p= . ) and on hd (- . ± . , p= . ). physical wellbeing did not differ between treatment groups (hd: - . ± . , pd: . ± . , tx: (- . ± . ). qol related to family life tended to be compromised in dialyzed (- . ± . ) vs. tx children (- . ± . , p= . ) . social interaction with friends was considered moderately impaired by all patient groups (hd: - . ± . , pd: - . ± . , tx - . ± . ). self-esteem was close to normal in all groups (hd: - . ± . , pd: - . ± . , tx . ±. ). in summary, our preliminary results suggest that subjective qol is remarkably good in children with esrd, with surprisingly small differences between treatment modalities. tx appears to be perceived beneficial with respect to the integrity of family life but provides poorer psychological qol than pd, possibly due to the constant concern with graft loss. background: gfr is determined in the ckid cohort study by plasma disappearance of iohexol (igfr). updated serum creatinine (scr)-based formulas (sgfr=k ht/scr) are needed for bedside clinical use. objective: derive formulas based on enzymatic scr to estimate gfr in the ckid study in children aged - yrs with sgfr of - ml/min/ . m . methods: from children, height (ht, meters), igfr, and scr & bun (mg/dl) by bayer advia were obtained. gfr was estimated from regression models: a(ht/scr) b ( /bun) c where a is gfr if ht=scr and bun= ; b and c are exponents. results: % (n= ) were male; median age= , scr= . , bun= and igfr= . formulas ranged from an updated schwartz formula (a= . , b= , c= ; r = . ), to sex-specific (a= . , b= . , c= in girls, and a= . , b= . , c= in boys), which yielded r = . , to the most complex (a= . , b= . , c= . in girls, and a= . , b= . , c= . in boys), which yielded r = . , higher (p< . ) than the r of the updated schwartz formula. by random selection of of subjects in independent trials, we assessed the predictive ability of each formula on the other observations. sex-specific formulas produced unbiased results and increasing precision with increasing complexity. the updated schwartz underestimated igfr in boys by % (p< . ) and overestimated igfr in girls by % (p< . ). conclusions: scr, ht, sex, and bun together provided unbiased estimates of igfr and explained % of its variability in children with igfr of to ml/min/ . m . extrapolation to ht/scr of (normal body habitus and kidney function) and bun of yielded predictions of ml/min/ . m for gfr in girls and boys. including cystatin c and broadening the gfr range to include normal levels are data being collected by ckid to extend the formulas and provide wider clinical utility. f. hussain, m. mallik, a. watson nottingham university hospitals, children and young people's kidney unit, nottingham, united kingdom considerable variation exists between units in terms of techniques used for renal biopsy. the bapn agreed an audit using published standards and a questionnaire was sent to all uk paediatric nephrology centres. agreed to a prospective audit between / / and / / . the survey revealed information leaflets are sent pre-biopsy in ( %) centres with only one using play preparation. ( %) routinely perform biopsies as daycase procedures (dc); ( %) use general anaesthetic (ga). realtime ultrasound is the favoured method in ( %) of centres. biopsies are performed by nephrologists only in ( %), nephrologists with radiologists in ( %) and radiology alone in ( %). of biopsies ( native), ( %) were performed as a dc with ( %) being done under ga. the mean age of patients was yrs (range . ± . yrs). the standard for the number of passes of native kidneys (< in %) was achieved in . % with no significant difference between grade of operator or nephrology/radiology speciality. standard number of passes in transplanted kidneys (< in %) was achieved in . %. adequate tissue was obtained for diagnosis in . % (standard > %). the significant complication rate (macroscopic haematuria and/or delay indischarge) was higher than the set standard of < % at . %. there was no significant difference in complication rates whether the biopsy was performed as a dc or inpatient procedure (p= . ) or whether ga or sedation was used (p= . ). conclusions: the survey highlights significant variation in practice with limited use of preparation materials and dc. the results may enable individual units to reflect upon their techniques and complication rates and has stimulated constructive debate about indications and training issues. objective: to characterize bp in children enrolled in the ckid study, an observational cohort study of children - y old with schwartz estimated gfr of - ml/min/ . m . design/methods: bp's were obtained using an aneroid sphygmomanometer. gfr was measured by iohexol disappearance. bp was classified according to the th report on bp in children. hypertension (htn) was defined as bp- th percentile (uncontrolled), or as self-reported htn plus current treatment with antihtn meds. pre-htn was defined as bp th- th percentiles. results: children (mean age ± y; % male) were studied. mean gfr was ± ml/min/ . m and mean ckd duration was ± y. for sbp, / ( . %) subjects had htn of these, subjects ( %) had uncontrolled htn. additional subjects ( %) had pre-htn. of subjects with systolic htn, only % had measured sbp< th percentile, and among the subjects with measured sbp> th percentile, only ( %) were taking antihtn meds. for dbp, / subjects ( . %) had htn of these, subjects ( %) had uncontrolled htn. subjects ( %) had pre-htn. of subjects with diastolic htn, just % had measured dbp < th percentile, and among the subjects with measured dbp> th percentile, only ( %) were taking antihtn meds. among children with gfr< ml/min/ . m , the prevalence of systolic or diastolic htn appeared to increase with decreasing gfr. conclusions: a significant proportion of children enrolled in the ckid study suffer from elevated bp. nearly % of children with ckd had measured bp> th percentile, and more than % of these children were not receiving antihypertensives, indicating that htn in pediatric ckd is frequently under-or even untreated. long-term follow-up of the ckid cohort should reveal the effect of elevated bp on ckd progression. background: we recently demonstrated elevated excretion of the putative urinary biomarkers tgf-β and et in a large cohort of children with ckd. tgf-β excretion was highest in kidney disorders associated with marked tubulointerstitial fibrosis, such as obstructive uropathy, nephronophthisis and pkd. aim: to investigate the course and predictive value of urinary tgf-β and et excretion in children with ckd undergoing ace inhibition (acei). methods: to date, patients have been followed for years and patients for years in a prospective, interventional trial investigating the nephroprotective efficacy of acei w/out intensified blood pressure control. results: average bp was reduced to the mid normal range. proteinuria initially decreased by %, but gradually reincreased to baseline levels within years. urinary tgf-β excretion, which was initially elevated -fold above healthy controls, continuously decreased during treatment from . ± . ng/g creatinine to . ± . , . ± . , and . ± . after , , and years, respectively (p< . ). in contrast, et excretion increased by % within the first years of follow-up. neither baseline nor the change in tgf-β and et excretion during treatment predicted the short-or long-term antihypertensive, antiproteinuric response to acei or ckd progression rate. conclusions: the marked reduction of urinary tgf-β excretion probably reflects the antifibrotic effect of acei but, at least over yrs of observation, does not predict the early and late course of proteinuria and ckd progression. hence, urinary tgf-β appears to be a biomarker of tubulointerstitial disease activity rather than of global disease progression. the surprising increase of et excretion may reflect the induction of compensatory hemodynamic mechanisms during acei. cardiovascular complications are the most important cause of death in pediatric patients with endstage renal disease. therefore early diagnosis and treatment are very important. brain natriuretic peptide (bnp) is released in response to volume overload or conditions that cause ventricular stretch. the aim of the study was to investigate whether bnp can be used for early diagnosis of cardiac complications in pediatric patients with esrd. twenty-four patients on peritoneal dialysis (mean age . ± . years), patients on hemodialysis (mean age . ± . years) and sex and age matched healthy children (mean age . ± . years) were included the study. plasma bnp levels were significantly higher in the patient group than those in the control group ( . ± . vs . ± . pg/ml, respectively, p< . ), but there was no significant difference between hemodialysis and peritoneal dialysis patients. in patients with hypertension, bnp levels, left ventricular systolic and diastolic diameters were significantly higher than those in the patients without hypertension. in patients with higher crp levels, bnp levels were significantly higher than those in the patients with low crp levels. bnp levels had a positive correlation with left ventricular mass index (r= . , p= . ) and a negative correlation with ejection fraction (r=- . , p< . ) and shortening fraction (r=- . , p< . ) significantly. there was no significant relation between bnp levels and anemia, dialysis duration, and dialysis modality. in conclusion, high plasma bnp level is significantly correlated with dilated left ventricle and it may be useful as a biochemical marker for identification of pediatric dialysis patients with cardiac dysfunction. we observed a high prevalence of left ventricular hypertrophy (lvh) and impaired lv contractility in children with stage ii-iii chronic kidney disease (ckd) (jasn , jasn . in a prospective, open-label assessment in children receiving ace inhibition (ramipril mg/m /d) with or without additional antihypertensive medication, we evaluated by echocardiography lv mass (lvm), geometry and myocardial mechanics at baseline and after (n= ) or mos (n= ) of treatment. lvh was defined by lvm index> g/m and concentric geometry by relative wall thickness> . ( th normal percentile). lv systolic function was assessed at the midwall level by circumferential shortening (ms). normalized h mean arterial blood pressure (bp) was reduced from . ± . at baseline to . ± . and - . ± . sds after and mos respectively. lvmi was reduced significantly after (from . ± . to . ± . g/m . , p< . ) and mos (from . ± . to . ± . , p< . ). of those patients presenting with lvh at baseline, lvm regressed to the normal range in / ( %) after mos and in / ( %) after mos. the prevalence of concentric lv geometry remained unchanged (baseline: %, mos: %, mos: %). age and afterload-corrected myocardial function increased from ± % to ± % at mos (p< . ). the changes in lvm and myocardial performance were independent of the randomized bp target and gfr. change in lvm was correlated with change in hemoglobin level (r= . , p< . ) and change in myocardial function with change in bp level (r= . , p< . ). in conclusion, fixed-dose ace inhibition and tight bp control induce regression of established lvh in the majority of children with stage ii-iii ckd. this is associated with a normalization of myocardial contractility. objectives of the study: periods with insufficient erythropoietic activity may occur during the erythropoietin (epo) treatment in chronic haemodialysis (hd). we determined the effects of a short-term suspension of epo therapy on various oxidative stress parameters during a -week follow-up in hd patients. methods: the antecedent epoetin beta (eb) treatment was suspended for days. after that, patients received eb two times a week and patients received darbepoetin alfa (da) once weekly. concentrations of whole blood oxidized and reduced glutathione (gssg, gsh) and various haematological parameters were determined weekly. erythrocyte malondialdehyde (e-mda) and the activities of erythrocyte superoxide dismutase, catalase and glutathione peroxidase were determined at weeks , and . results: the ratio gssg/gsh was increased in both groups after continuation of the suspended epo therapy (p< . and p< . week vs. the baseline in the da and eb group, respectively) and also at week (p< . and p< . vs. the baseline in the da and eb patients, respectively). the activities of the antioxidant enzymes were increased at week in both groups (p< . vs. the baseline for da and p< . vs. the baseline for eb), and returned to their week levels by week . the e-mda level decreased in both groups (p< . week vs. the baseline for da and p< . weeks and vs. the baseline for eb). conclusions: a short-term suspension of epo therapy caused characteristic time-dependent changes in the oxidative stress. the ratio gssg/gsh increased at weeks and . activities of the antioxidant enzymes were elevated at week , resulting in an improvement in lipid peroxidation. these results might have implications in certain conditions with transient alterations in the erythropoietic activity in hd patients. rrf has been associated with better nutritional status both in adults and children on peritoneal dialysis and in adults on chronic hd. there are no data on the influence of rrf on nutrition in children on chronic hd. three-days dietary reports and simultaneous urea kinetic monitoring of children, adolescents and young adults on chronic hd (age: . - . years) were retrospectively analyzed. protein catabolic rate, an index of nutrition adequacy, was normalized by body weight (npcr). in patients with rrf, total kt/v (kt/vtot) was calculated summing hd kt/v(kt/vhd) and rrf (evaluated by residual urea clearance ku-). in all patients, npcr and dietary protein intake (ndpi) were significantly correlated (p< . ). kt/vtot was correlated with npcr(p< . ) while correlation between kt/vhd and npcr was not significant (p: . ). in patients with rrf, ku resulted significantly associated with npcr (p< . ) while kt/vhd was not (p: . ). npcr was significantly higher in patients with rrf ( . ± . vs . ± . g/kg/day; p< . ). patients on recombinant growth hormone (rhgh) treatment showed npcr higher than those without rhgh ( . ± . vs . ± . g/kg/day; p< . ). however, in a multiple regression model including age, the use of rhgh, rrf, kt/vtot and kt/vhd, npcr resulted significantly associated only with rrf (b: . ; p< . ). inconclusion: in children, adolescents and young adults on chronic hd treatment, rrf is associated with better nutrition. rrf positively affects nutrition independently from hd efficiency and rhgh effects. possible hypothesis are a more selective (although decreased) depuration and the positive influence of water excretion maintenance on food intake. more efforts have to be made in order to maintain rrf in children on chronic hd. during the past three years, six women have undergone chronic haemodialysis during pregnancy at the pediatric renal unit of the adelaide women's and children's hospital. five have delivered normal infants at between and weeks gestation; one is presently at weeks gestation, with an apparently normal fetus. four were already receiving chronic haemodialysis at the time of conception; the others began dialysis at weeks gestation. the protocol includes six days per week dialysis for at least two hours per treatment. a number of practical and emotional issues have arisen, with major potential psychosocial hazards, including: unplanned pregnancy due to ignorance of fertility; precipitation onto the dialysis program; acceptance of increased dialysis time; concerns regarding effects of drugs and dialysis/kidney failure on the fetus; the likelihood of prematurity; the perceived difficulties of motherhood while on a chronic dialysis program; loss of income, social networks and independence. the program has been successful due to the cooperative approach from the multidisciplinary team consisting of nephrologists, obstetricians, obstetric physicians dialysis nurses, midwives, dieticians, physiotherapists, psychiatrists and social workers. the social worker has provided counselling and coordinated transport and assistance with housework, childminding and other day to day tasks. although the program has had overall success, there have been a number of pitfalls worth discussing, including those arising from the complex interactions between the members of the various disciplines, and those involved in maintaining the balance of clinical and psychosocial needs of the women. (median . ) , weight from . to . kgbw (median ). the vascular access was a central catheter (kt) in children, an arteriovenous fistula (avf) in , avf and kt alternatively in patients. duration of hd ranged from to m (median . ). dual lumen tunnelled cuffed kt were inserted in children through the internal jugular vein [ijv]), surgically in , percutaneously in . all kt have had an immediate good function. nine kt were exchanged over a guide wire for dysfunction. kt infections with positive blood culture were successfully treated in cases. duration of kt ranged from to m (median ). at the end of the follow-up, kt were still in function, removed for a mature avf, after renal transplantation (rt), for improved gfr and failed. patency of the venous network after withdrawal of kt was assessed in children (doppler , mri ) and showed normal patency in , ijv thrombosis in , brachiocephalic thrombosis in and stenosis in . thirty avf were created in children, distal in ( %). immediate patency was obtained in all cases except . the median blood flow ranged from to ml/min/m (median ). following the primary surgery, repeated surgical procedures included a superficialization of the vein in , refection for stenosis or thrombosis in , reduction of overflow in , nd avf creation in and ligation after rt in . percutaneous transluminal angioplasty was performed in children. duration of patency ranged from to m (median . ). in conclusion, hd is feasible in small children. nevertheless, kt are associated with risk of venous occlusion and obtention of a reliable avf frequently need several interventions, altogether leading to a limitation of hd indications in young children. - , ( %) were < years of age. the underlying disorders were congenital nephropathies in % (malformations %, hereditary %) and acquired diseases in %. living related donation (ld) was performed in % and preemptive tx in %. immunosuppressive (is) protocol varied considerably between the countries and over time. -year graft survival (gs) was % in ld and % in grafts from deceased donors (dd). gs improved significantly for dd grafts with time. the number of acute rejections (ar) during the first year posttx was significantly lower in ld recipients, in tac-treated children and during the second half of the study period. this improvement over time was also seen in separate analysis of cya-treated children. the proportion of rejection-free patients increased in all countries. median height sds at tx was - . (- . to + . )(boys - . , girls - . ). height sds increased to - . at years posttx. conclusions: gs results were excellent and the frequency of ar low, especially in children with ld grafts and tac treatment. interesting differences between the countries concerning donor source, preemptive tx, is and use of protocol biopsies were found. n. marcun varda, a. gregoric maribor teaching hospital, department of pediatrics, maribor, slovenia objectives: essential hypertension (eh), identifiable in children, is associated with cardiovascular (cv) diseases in adulthood. the aim of our study was to evaluate the presence of some traditional and non-traditional cv risk factors in our children and young adults with eh in the search for additional cv risk. the prevalence of metabolic syndrome (ms) was also investigated. methods: a total of children and young adults, diagnosed with eh, were included in our study. they were compared with a control group of healthy children, matched for sex and age, with regards to specific aspects in the history, body mass index (bmi), waist: hip ratio, full blood count, crp, serum cholesterol, hdl cholesterol, ldl cholesterol, triglycerides, uric acid, glucose, insulin, fibrinogen, homocysteine, apolipoprotein a , apolipoprotein b and lipoprotein (a). in addition, the prevalence of ms was calculated. ms was defined as having three or more ms components according to the national cholesterol education program's adult treatment panel iii criteria, tailored for children. results: the differences in values of bmi, crp, platelets, triglycerides, uric acid, apolipoprotein a , apolipoprotein b and homocysteine between the hypertensive patients and the controls were statistically significant. in all hypertensives positive family history of hypertension in the first or second generation was revealed. overweight (bmi > th percentile for age and sex) was identified in %, obesity (bmi > th percentile) in %, abnormal glucose homeostasis in %, high serum triglycerides in % and low hdl in % of the hypertensives. ms was present in % of these children and in % of our controls. conclusion: we demonstrated that children and young adults with eh differ from the population of healthy children in some specific cv risk factors, and are therefore at an increased cv risk. background: rtd is a rare autosomal recessive disease of differentiation of fetal kidneys with poorly developed proximal tubules. fetal and neonatal findings include oligohydramnios, preterm birth and neonatal death due to pulmonary hypoplasia, anuria and hypotension. mutations in genes in the renin-angiotensin system (ras), encoding for angiotensinogen, renin, angiotensin converting enzyme and angiotensin ii receptor type , have been revealed. we report the first rtd patients surviving the neonatal period and still being alive. both patients had affected siblings demised in utero or neonatally. case : oligohydramnios, birth at weeks, grams. neonatal course: pulmonary hypoplasia, pneumothorax, hypotension and anuria with ventilation ( weeks) and dialysis ( days) . current findings at years: creatinine umol/l, normal blood pressure. genetic and functional analysis: homozygous mutation of angiotensinogen gene ( g-a); very low angiotensinogen concentration ( . ng/ml; normal - ), absent plasma renin activity (normal . - . ng/ml/h) despite very high active renin ( pg/ml; normal - ). case : oligohydramnios, birth at weeks, grams. neonatal course: mild respiratory distress, hypotension and anuria with oxygen ( day) and dialysis ( months) . current findings at years: renal transplantation at age years, good graft function. genetic and functional (as neonate) analysis: homozygous mutation of renin gene ( g-a); very low active renin (< . pg/ml; normal - ). conclusions: rtd is caused by inactivating mutations in genes encoding the ras resulting in chronic low perfusion pressure of the fetal kidney. genetic and functional analysis of ras contributes to diagnosis of rtd. this observation extends the rtd phenotype from a uniformly fatal to a more favourable disease. objectives of study: to evaluate the relationship between serum uric acid (ua), new onset essential hypertension (eh) and endothelial dysfunction (ed) in the youth. methods: subjects with abpm proved new onset eh (aged , ± , years, bmi , ± , kg/m ), overweight/obese normotensive youth (oo) matched for age and bmi, and age matched healthy normotensive controls (nt) with normal weight were enrolled. ua, total cholesterol, hdl, ldl, triglycerides and creatinine were analyzed in blood, glomerular filtration rate (gfr) was calculated according to schwartz formula and endothelial function was assessed using flow-mediated dilation (fmd, %). results: new onset eh was associated with overweight/obesity in % of subjects. serum ua levels were significantly higher in eh than oo ( ± vs. ± umol/l, respectively, p< , ), in eh than nt ( ± vs. ± umol/l, respectively, p< , ), and in oo than nt ( ± vs. ± umol/l, respectively, p< , ). total cholesterol, hdl, ldl and triglycerides were significantly higher in eh and oo compared with nt (p< , ). no significant differences were found in lipidograms between eh and oo. serum creatinine and gfr did not differ significantly between the groups. fmd was significantly lower in eh comparing with oo and nt ( , ± , vs. , ± , vs. , ± , %, respectively, p< , ) and in oo comparing with nt ( , ± , vs. , ± , %, respectively, p< , ). conclusions: new onset eh in the youth is associated with overweight/obesity, higher serum ua and ed. ua may play a causal role in the pathogenesis of eh and commonly with eh and proatherogenic serum profile contributes to ed in overweight/obese hypertensive youth. objective of study: fibromuscular dysplasia (fmd) is a systemic arteriopathy of the small and medium sized vessels. it is the first cause of renal arterial stenosis (ras) in childhood. the aim of this study was to describe the natural history of fmd in children. we analysed all the data of children with fmd. results: mean age at diagnosis was years months old. hbp was discovered fortuitously in cases, after symptoms of malignant hypertension in . in all cases bp values corresponded to severe hypertension (mean bp of / mmhg). extra renal localizations were found in half of the patient, and the most frequent pathological arteries were the superior mesenteric and the carotida. the mean number of arterial stenosis at diagnosis was per patient. seven patients had a primary fmd with familial history for patient. in the others fmd were associated with polymalformatif syndromes: reported by grange ( ), moya-moya disease ( ), neurofibromatosis type i ( ). after a median follow-up time of months the number and severity of stenosis increase at arteries per patient. these lession, although to a lesser extend, were already observed as soon as months of follow-up. percutaneous transluminal renal artery angioplasty were proposed in cases when the bp was uncontrolled indeed a multi antihypertensive therapy with severe renal stenosis (> %) or when renal growth was impaired. prognosis is severe with cardiologic complications ( / ) and death. conclusions: intimal form of fmd accounts for the majority of multivisceral fmd. at diagnosis several hypertension is almost present. vascular ultrasonography imaging techniques is usefull in follow-up. a conservative treatment has to be privilegied. this disease is evolutive with increase of pathological arteries number, aggravation of stenosis degree and sometimes renal function impairment. objective: the effect of over weight on blood pressure elevation (bp) is more frequently present in childhood. several studies have demonstrated the efficacy of angiotensin-converting enzyme inhibitors (acei) therapy in obese hypertensive adults, but data on children are very limited. methods: obese (bmi: z score > . sd) primary hypertensive (systolic ordiastolic blood pressure > th) children (aged - years) were enrolled to this single centre prospective study. patients received ramipril ( . - . mg/bwkg/day) once daily. office and ambulatory bloodpressure measurements and serum biochemical analysis were performed at start and after and months of treatment. patients ( , %) hadimpaired glucose tolerance (igt) on oral glucose tolerance test (ogtt). results: ( , %) patients completed the six months ramipril therapy. reduction in -hour mean arterial pressure (map) was , mmhg (- , sd) after month and , mmhg (- , sd) months treatment respectively. bp was reduced with equal efficacy during day-and night time. / ( , %) patients were lost during the follow-up. ( , %) patients with high uric acid levels also were treated with allopurinol. eleven patients ( %) received second antihypertensive medication because of the blood pressure remained uncontrolled. ( pts metoprolol, pts amlodipine) ( , %) patients suffered recurrent cough, but otherside effect has not observed. the serum glucose and insulin levels havenot changed significantly during the follow-up. conclusion: oncea day given ramipril significantly decreases the blood pressure inobese hypertensive children. it is effective, tolerable and safe bloodpressure lowering monotherapy in childhood. further studies and longer follow-up are necessary to prove its long term beneficial effect in the childhood metabolic syndrome combined with hypertension. hw. zhang, j. ding, f. wang, yf. wang peking university first hospital, department of pediatric nephrology, beijing, people's republic of china objectives of study: females with x-linked alport syndrome (xlas) have variable phenotypes, from microscopic hematuria to chronic renal failure, which can not be clarified solely by mutation features of col a gene. x-inactivation has been suspected to be one of the responsible reasonsfor this phenomenon, but no definite correlation has been demonstratedso far. in order to confirm whether the phenotypes of xlas femalescorrelate with x-inactivation, we analyzed the xinactivation patternsin peripheral blood cells in xlas females and in skin fibroblasts in xlas females. methods: the x-inactivation analysis was performed using hpaiipredigestion of dna followed by polymerase chain reaction (pcr) of thehighly polymorphic cag repeat of the androgen receptor (ar) gene. results: results showed that the average x-inactivation levels of the mutant allele decreased while the degree of proteinuria increased, there was anegative correlation between the degree of proteinuria and thex-inactivation ratios of the mutant allele in blood cells (r=- . , p= . ). however, there was no correlation between the degree of proteinuria and the x-inactivation ratios of the mutant allele in skin fibroblasts (r=- . , p= . ). though of patients ( . %) had the similar x-inactivation ratios in both blood cells and skin fibroblasts, there was also no correlation between the x-inactivation ratios of the mutant allele in skin fibroblasts and that in peripheral blood cells (r= . , p= . ). conclusion: we concluded that the x-inactivation ratios in blood cells correlated with the degree of proteinuria, which might explain partially the diverse phenotypes in female xlas patients. more studies, including post-transcription regulation, environmental factors, and so on, are still needed. objective: to report frasier syndrome (fs) with wt mutation and abnormal expression of podocyte molecules which is the first case in mainland china. methods: peripheral blood cells were analyzed for chromosome karyotype and wt gene mutation. the ratio of +kts/-kts isoforms was quantified with genescan and genescan software. expressions of podocyte molecules were detected by immunohistochemical staining. result: the patient presented with steroid-resistant fsgs and male pseudohermaphroditism. the wt ivs + g>a mutation was found in one allele in the proband, but not in her parents. the ratio of +kts/-kts was . in the proband, and was . and . in her mother and father, respectively. podocyte molecules expression altered in normal-and abnormal-appearing glomeruli. wt expression showed diffuse nuclear staining with less obvious speckles compared with that in controls. wt (antibody against c-terminal) displayed strong, normal, faint and negative stained podocyte nuclei within the same glomerulus. the staining intensity of wt (antibody against the n-terminal) was very faint. conclusion: taking clinical data, pathology, karyotype analysis and genetic testing together, we diagnosed the first case of fs in mainland china, which prompts there might be more cases underdiagnosed. wt displayed diffuse nuclear staining with less visible speckles compared to controls, supporting the view of the differential nuclear localization of kts isoforms. our study further confirmed that wt mutation resulted in abnormal expression of podocyte molecules in glomeruli of fs, though we did not know whether this phenomenon directly or indirectly resulted from loss of wt regulation. dent disease is an x-linked disorder characterized by low-molecular-weight proteinuria, hypercalciuria, nephrocalcinosis, calcium nephrolithiasis and the development of renal insufficiency after the middle age. so far, two genes responsible for the development of dent disease have been identified, i. e., clcn and ocrl . ocrl was originally identified as a causative gene for lowe syndrome. in japan, igarashi et al. described for the first time that idiopathic tubular proteinuria in japan is identical to dent disease by mutational analyses. most of japanese patients with dent disease are identified by annual urinary screening as chanced proteinuria and several clinical phenotypes, such as incidence of nephrocalcinosis and long term outcome of renal function remains to be elucidated. furthermore, identification of ocrl as a second causative gene for dent disease has made the understanding of dent disease more complex. here we report patients with dent disease phenotype with the results of genetic analyses and clinical features. out of patients in different families, mutations ( %) in clcn were identified. in the patients with no clcn mutations, genetic analysis in ocrl is ongoing, and at the moment different mutations in ocrl ((i stop, r c, r w and r h) were identified. the remaining patients are now beeing investigated. among the patients in whom clcn mutations were detected, hypercalciuria are not always present. in several elderly patients, mild renal function impairment is present. there are similar clinical phenotypes between patients with clcn or ocrl mutations, but serum levels of ldh and ck are likely to be higher in those with ocrl mutations. in summary, we will present genotype and phenotype heterogeneity in japanese dent disease, and will discuss the clinical spectrum of dent disease. a. gulati , s. sethi , j. lunardi , m. kabra , n. gupta , p. hari , a. bagga all india institute of medical sciences, st department of pediatrics, new delhi, india hôpital de la tronche, genetics, grenoble cedex. france, france objectives: to study the clinical features and genetic basis of patients with lowe syndrome and identify female carriers. methods. case records of patients with lowe syndrome presenting to this hospital, between - yr old, were reviewed. the clinical features were recorded and glomerular and tubular functions assessed. a detailed genetic analysis was performed on dna extracted from peripheral blood of patients and their mothers, which involved sequencing of all exons of the ocrl gene. results: all patients showed failure to thrive, bilateral congenital cataracts, refractory rickets, delayed motor and language milestones and proximal renal tubular acidosis with fanconi syndrome. the mean schwartz gfr was ml/min/ . sq. m. genetic analysis showed distinct mutations of ocrl gene in all patients studied. we report new mutations having identified the variants c. a>g and c. g>t in exon , the variant c. _ ins t in exon and c. - a>g in intron in independent patients. we also found previously described mutations involving the region c. _ del tg and c. c>t in exon . four of mothers were heterozygous carriers. all genotypically proven carriers showed characteristic lenticular opacities. conclusion: the identification of mutations in the ocrl gene provides confirmation of the diagnosis of lowe syndrome. the new mutations described in north indian children expand the range of mutations that give rise to this condition. these observations have important implications for molecular diagnosis and genetic counseling in families with lowe syndrome. juvenile nephronophthisis (nph), an autosomal recessive nephropathy, is the most common genetic cause of chronic renal failure in childhood. in - % of known cases, nph is associated with joubert syndrome (js), a neurological disorder described in patients with cerebellar ataxia, mental retardation, hypotonia and respiratory dysregulation. mutations in three genes, ahi , nphp and nphp have been identified in patients with nph and js. as nphp mutations usually cause isolated nephronophthisis, the factors which predispose to the development of neurological symptoms in some patients are poorly understood. to determine such genetic factors and to assess the mutation rate of ahi , nphp and nphp in nph and js, a cohort of families with nph and at least one js-related neurological symptom was screened for mutations in these genes. thirteen ( %) and ( %) unrelated patients were homozygous or compound heterozygous for nphp and nphp mutations, respectively. in patients ( %) without nphp , nphp or ahi mutations, mutations in a novel gene (nphp /cors ) encoding a ciliary protein have been identified. interestingly, of the patients with nphp mutations carried either a heterozygous truncating mutation in nphp ( patient), a heterozygous missense mutation in ahi ( ) or the ahi variant r w ( ) . the variant r w affects an amino acid conserved in vertebrates and predicted to be 'possibly damaging' by polyphen software. in conclusion, nphp , nphp or nphp mutations can be found in % of patients with nph and js in our cohort. our finding that half of all patients with nphp mutations carry a mutation or a damaging variant in nphp or in ahi strongly supports the notion that epistatic effects provided by these genes contribute to the appearance of neurological symptoms in patients with nphp mutations. molecular cytogenetic techniques such as array-based cgh have been instrumental in the identification of microimbalances associated with syndromic phenotypes. we investigated patients with unclear syndromic nephropathies (e. g. urinary tract malformations, focal segmental glomerulosclerosis, and persistent hematuria/proteinuria) and additional clinical features, such as mental retardation, heart defects or growth abnormalities. array-cgh analysis was performed with a whole-genome array with large insert clones providing an average resolution of < . mb. results: in one -year old female patient presenting with microhematuria, proteinuria, mental retardation including severe speech impairment, senso-neuronal hearing loss, and recalcitrant focal epilepsy, we detected a microdeletion in chromosomal bands xq . -q . this deletion was verified by fish, found to be uniallelic, . - . mb in size, and not to be inherited from the mother. electron microscopy of kidney biopsy showed splitting of the lamina densa and a thin basal membrane, which is diagnostic for alport syndrome. high-resolution cranial magnetic resonance imaging including white fibre tracking revealed a severe neuronal migration disorder with subcortical band heterotopia (double cortex syndrome), i. e. a second band of cortical neurons within the white matter below the true cortex. conclusions: in patients with unclear syndromic nephropathies, we identified a female with a contiguous gene syndrome at xq . -q . the microdeletion includes the x-linked alport syndrome gene col a and the lisx gene associated with subcortical heterotopia, mental retardation and epilepsy. thus, the phenotype observed in our female patient combines features of the amme-complex (alport syndrome, mental retardation, midface hypoplasia, elliptocytosis) with x-linked lissencephaly. ( f, m; . ± . yrs, hemoglobin . ± . gr/dl, ferritin ± mg/dl) were enrolled. lipid profile, acute phase proteins (apps) were measured. renal tubular functions, plasma vegf level, urinary nag/cre ratio were determined. abpm and imt measurements were performed. the results were compared with healthy controls. results: mean -hour, day and night systolic-blood pressure (sbp), diastolic-bp (dbp) and mean arterial pressure values were comparable to that of control group. dipping in dbp was less in tm ( . % vs . %; p< . ). the ratio of patients with less than % dipping in sbp (non-dippers) was higher in tm ( . % vs . %, p< . ). mean plasma vegf level was . ± . pg/ml [ . - . ] in tm, was within normal range (< pg/ml) in controls. apps were normal. imt of common carotid artery (cca) was . ± . mm in tm group and . ± . mm in controls, (p< . ); imt of internal carotid artery (ica) was . ± . mm in tm group and . ± . mm in controls (p< . ). positive correlations were found between vegf and microalbuminuria, b -microglobulin and homosistein; between nag/cre and microalbuminuria; between cca-imt and age, and a negative correlation between cca-imt and ferritin. conclusions: renal tubular damage, abnormalities in abpm, increase in vegf and increase in cca-imt and ica-imt occur when the patients are asymptomatic and routine laboratory test are normal. optimal hemoglobin levels and deferoxamine therapy do not prevent the development of renal and vascular damage. l. sylvestre , e. santos , p. granzotto , e. siqueira , l. moreira , l. rispoli , n. mendes , r. meneses hospital pequeno principe, pediatric nephrology, curitiba, brazil centro universitario positivo unicenp, curitiba, brazil introduction: hypertension is frequently underdiagnosed in children. early diagnosis and a planned follow-up is helpful in detecting and preventing the harmful long-term consequences of hypertension. therefore, we created a specific outpatient clinic to have a better follow-up of these patients. material and methods: we reviewed the files of patients from the outpatient clinic of hypertension, from the dept. of pediatric nephrology in hospital pequeno principe, curitiba, brazil, followed for more than months, from march to december . we analyzed demographic and anthropometric data, diagnosis, staging of hypertension, presence of target-organ damage and treatment. results: patients were eligible, boys, mean age at the first visit . years old, mean follow-up of months. mean bmi= . ( % overweight and obese). secondary hypertension was present in % of the cases, predominantly due to parenchymal renal disease; essential hypertension associated to overweight and obesity in patients ( %) and there was no established diagnosis yet in other patients. fifty-five patiens performed at least one abpm of hours, showed hypertension. twelve from patients showed left ventricular hypertrophy and from patients had abnormalities of the retinal vasculature associated to hypertension. the most frequent drugs used to treat hypertension were ace inhibitors ( ) and calcium channel blockers ( ). conclusion: our data are in accordance that secondary hypertension is frequent in children, mostly associated to renal disease. furthermore, we could detect a large number of obese hypertensive children and adolescents. target-organ abnormalities are not as frequent as in adults but need to be monitored. intrauterine growth retardation (iugr) is characterized by low nephron number with or without reduced kidney size. leptin, an important hormone in the regulation of body fat massand weight, is decreased in fetuses with iugr. in the present study, weexamined the effects of leptin in a metanephric mesenchymal cell line ms . ms is generated from the metanephroi of embryonic day . homozygous mouse transgenic for h- kb-tsa. incubation of ms withleptin , , , or ng/ml for h did not affect either [ h]-thymidine incorporation or cell number. on the other hand, [ h]-leucine incorporation was significantly increased by leptin in a dose dependent manner ( ± %, ± %, ± %, and ± % of control by , , , and ng/ml, respectively). protein/dna was also increased . -fold by leptin ng/ml. leptin ng/ml activated both erk and p . the levels of phosphorylated-erk (p-erk) and phosphorylated-p (p-p ) , as assessed by western blot analysis, started to increase at min, peaked at min ( . -and . -fold increase respectively) remaining elevated at , , and h, and began to decrease at h returning to the baseline level at h. the levels of p-erk and p-p at min were increased by leptin in a dose dependent manner ( . -, . -, . -, and . -fold increase by , , , and ng/ml respectively). the levels of total erk and p remained unchanged. increase in [ h]-leucine incorporation stimulated by leptin ng/ml was completely inhibited by coincubation with a mek inhibitor pd μm or a p inhibitor sb μm. these results demonstrate that leptin induces hypertrophy of metanephric mesenchymal cells via erk and p . the hypertrophic effect of leptin may play a role in normal renal development and may explain reduced kidney size in a hypoleptinemic state, iugr. objectives of study: to investigate the mechanism of nephron deficit in rat model of intrauterine growth retardation (iugr). methods: a rat model of iugr was built by maternal low-protein ( %) dietthroughout pregnancy. newborn male pups were chose as our studyobjects. the proliferation and apoptosis in kidney was showed by ki- detection and tunel method. expression of wt , bcl- , bax, and p mrnas in renal tissue were examined by real-time pcr, and expression of wt and bcl- gene products in renal tissue were examined by immunohistochemistry and western blot. the final number of glomeruli was determined at weeks of age when nephrogenesis has finished. results: at weeks postnatally, iugr offspring had fewer glomeruli per kidney than those in controls (p< . ). in iugr newborns, tunel positive cells were more numerous in the nephrogenic zone. renalwt and bcl- mrna levels were significantly reduced in newborn iugrpups, and the bcl- mrna/bax mrna ratio was also decreased, but therewas no change in the expression of p mrna. in iugr newborns, the wt and bcl- protein expressions were significantly decreased, and the irimmunostaining were also suppressed in the nephrogenic zone. conclusions: these results suggest that reduction of nephron number in iugr rat may be associated with enhanced apoptosis in kidneydevelopment. decreased wt and bcl- expressions and reduction of the bcl- /bax ratio may contribute to the molecular mechanisms behind these findings. objective of the study: the aim of this study was to identify risk factors for urinarytract infection (uti) during follow-up of children with isolatedantenatal hydronephrosis. methods: between and , patients were diagnosed with isolated fetal renal pelvicdilatation (rpd) and were prospectively followed. after initialclinical and imaging evaluation, us scans, clinical examination, andlaboratory reviews were scheduled at -month intervals. the event ofinterest was time until occurrence of first episode of uti. cox's regression model was applied to identify variables that wereindependently associated with the uti. results: a total of patients were included in the analysis ( boys and girls) themedian fetal rpd was mm (iq range, . ± ) and patients ( . %) presented bilateral rpd. seventyeight ( %) infants presented urinarytract anomaly. the most frequent detected uropathy was upjo ( ), followed by primary vur ( ), and megaureter ( ). median follow-up timewas months (iq range, - months). during follow-up, uti occurred in ( %) of the children. the incidencerate of uti was episodes per person-month. the incidence rate of uti has decreased from . episodes per person-month in the first year of life to . in the second year, and to . after the third year. by survival analysis, the risk of uti for the whole series was estimated in . % at months, % at months, and % at months of age. after adjustment, two variables were independent predictors of uti during follow-up: female gender (rr= . , % ci, . - . , p= . ) and presence of uropathy (rr= . , % ci, . - . , p= . ). conclusion: according to findings, in a cohort of antenatal hydronephrosis, girls with vur or urinary tract obstructionhad a higher risk of uti during follow-up. objective of the study: to identify predictive factors of resolution of fetal renalpelvic dilatation (rpd) in a cohort of medically managed children. methods: between and , patients were diagnosed with isolated rpd and were prospectively followed. of infants, ( %) were clinically managed. after initial clinical and imaging evaluation, us scans, clinical examination, and laboratory reviews were scheduled at -month intervals. the event of interest was rpd resolution, regardedas renal pelvis < mm on two consecutive renal sonograms. cox's regression model was applied to identify variables that were independently associated with the event. results: a total of patients were included in the analysis and uropathy was diagnosed in ( %) infants. median follow-up time was months (interquartile range, to months). during follow-up, ( %) patients presented rpd resolution. by survival analysis, the estimate of rpd resolution for the whole series was % at months, % at months, and % at months of age. the median time for rpd resolution was estimated at months ( % ci, - ). in the survival analysis, three variables were found to be significantly associated with resolution of rpd during follow-up: mild fetal rpd, grades - (sfu grading system), and presence of uropathy. after adjustment, only absence of uropathy remained as an independent predictor of rpd resolution (rr= . , % ci, . - . , p< . ). conclusion: according to these findings, it was estimated that rpd resolution occurs in about half of the patients without uropathy at years of age. objective: to study clinical and pathological characteristics of antineutrophil cytoplasmic autoantibody (anca)-positive glomerulonephritis(gn). methods: clinical data of thirteen patients during years, with anca-positive gn were analyzed. results: of patients with anca-positive gn with an average age of . ± . ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) years, patients were female and were male. the average course was . ± . months. cases onset between december and february. there was , , cases whose chief complaint on admission was anaemia, swollen and hematuria respectively. the main clinical symptoms were: anaemia ( %), hematuria/proteinuria ( %), renal functional lesion ( %), edema ( . %), oliguresis ( . %), hypertension ( . %), arthralgia ( . %), rash ( . %), abdominal pain ( . %), fever ( . %). laboratory tests: bun, scr and esr were high while hemoglobin was low in all patients. mpo-anca was positive in cases c was normal in cases and low in cases. pathology features: all glomeruli are affected and show different degree of segment and glomus sclerosis. there was different degree of capsula glomeruli thickening. glomerulus capillary loop was necrotic, nuclear leukocytes and cell debris could be seen. inflammatory cell interstitial infiltration with lymphocyte and plasmocyte. endotheliocyte of small vessels of interstitial was swelling and vessel wall was edema, necrosis and glassy degeneration. immunofluorescence showed no or small immune complex deposition and showed pauci-immune gn. conclusion: onset of patients with anca-positive gn was hiding and there were nonspecific clinicalsymptoms in the early stage that reduced late diagnoses until esrd. female patients was predominant. renal pathology showed segment necrotic nephritis interstitial inflammation and polyangitis. the disease had unfavourable prognosis. background: renal function maturation isn't achieved at birth. vlbw infants exposed to intensive care have an increased risk of developing renal function impairment. moreover, we showed that ibu was associated with a significant impairment in renal function at one week of life in vlbw infants. objective: to evaluate renal function development in infants treated with ibu for pda closure as compared to infants not exposed to ibu, during the first month of life. methods: multicentric prospective cohort study of to weeks gestation (ga) infants exposed or not exposed to ibu within the first days of life. infants presenting with renal impairment at birth, urinary tract malformation, or contraindication to ibu were excluded. infants exposed to ibu were paired to controls according to ga, centre and crib score. creatinine clearance (ml/min/ . m ) was measured for glomerular filtration rate evaluation. fractional excretion of sodium (fena%), micro-albuminuria (mg/l) and alpha -microglobinuria/creatininuria ( /ucr: mg/mmol) were also measured once a week up to month of life results: infants were studied, half exposed to ibu. birth weight was ± g (mean±sd), and ga ± wks. results are presented in the table: *p= . ;**= . ;***< . . j. rouillard lafond, mp. morin, c. girardin centre hospitalier universitaire de sherbrooke, département de pédiatrie, sherbrooke, canada objectives of study: many studies have focused on the negative effects of low birth weight, especially caused by intra-uterine growth restriction, on adult renal function. however, few have addressed the impact of extreme prematurity (< weeks) on renal function of these children during their later childhood and adolescence. the aim of the present study is to estimate the renal outcome of this population, by determining blood pressure, glomerular filtration rate, fractional excretion of sodium and microalbuminuria in children ( girls and boys) aged to years old (mean age ) born between - weeks of gestation (mean: weeks). methods: during one encounter, height, weight and blood pressure were measured for each subject. blood tests were conducted to quantify creatinine, electrolytes and cystatin c. microalbumine, creatinine and electrolytes were dosed in one micturition. pertinent risk factors of renal damage in their perinatal history were noted. results: renal insufficiency, defined by a clearance of less than ml/min/ , m , was present in subjects ( %) when estimated by schwartz formula ( , - , ml/min/ , m ) and in ( %) when estimated by cystatin c ( , ml/min/ , m ). furthermore, ( %) children presented an elevated fractional excretion of sodium ( , - , %) . finally, children ( %) presented microalbuminuria, with albumin/creatinine ratio greater than , mg/mol ( , - , mg/mol) . those children presented more episodes of hypotension during neonatal period (p= , ) and have a tendency to have had neonatal asphyxia more than the others (p= , ). conclusions: these results suggest that children born extremely preterm may present renal insufficiency and sign of tubulopathy as early as adolescence, with microalbuminuria possibly announcing upcoming glomerulopathy. organogenesis isregulated by epithelial-mesenchymal interactions that take place in theembryonic kidney between the metanephric mesenchyme (mm) and theepithelium of the ureteric bud (ub). the mm expresses signals thatregulate ureteric branching while the ub signaling leads to inductionof nephrogenesis. as a response to the ub signals the mm cellscondense, aggregate, epithelialize and undergo simple morphogenesis togenerate segmented nephrons during kidney organogenesis in connectionto ureteric bud branching. we reported earlier that mutagenesis of fgf function from the whole embryonic mesoderm leads to kidney failure. activation of wnt- gene expression encoding another essential signal for nephrogenesis also depends on fgf function (perantoni et al., ) . given the important role of fgf in kidney development we targeted fgf roles in urogenital system (ugs) development with an ugs specific cre line pax cre. pax credeletion was expected to recombine the floxed genome in the nephronprecursors, ureteric bud and the wolffian duct derivatives. in crossesbetween fgf c/c and fgf n/+ ; pax cre mouse lines fgf gene was deleted successfully. as a result the whole ugswas affected. the kidney was severely reduced in size. newborn nullmice were born alive but died within hours likely due to kidneyfailure. in the deficient kidney the organization of theproximal-intermediate segments of the developing nephron was disturbed. marker analysis with in situ hybridization was consistentwith serious defects in nephrogenesis. we conclude that fgf functionis involved in the control of wolffian duct development andsegmentation of the assembling nephron. the zellwegerspectrum disorders (zsds) are characterized by a generalized loss of peroxisomal functions caused by deficient peroxisomal assembly. clinical presentation and survival are heterogeneous. although most peroxisomal enzymes are unstable in the cytosol of peroxisomedeficient cells of zsd patients, a few enzymes remain stable among which alanine: glyoxylate aminotransferase (agt). its deficiency causes primary hyperoxaluria type (ph , mim ), aninborn error of glyoxylate metabolism characterized by hyperoxaluria, nephrocalcinosis, and renal insufficiency. despite the normal level of agtactivity in zsd patients, hyperoxaluria has been reported in several zsdpatients. we aimed to determine the prevalence of hyperoxaluria in zsds and tofind clinically relevant clues that correlate with the urinary oxalate load. methods: we reviewed medical charts of dutch zsd patients with prolonged survival (>one year). results: urinary oxalate excretion was assessed in and glycolate in patients. hyperoxaluriawas present in ( %), and hyperglycolic aciduria in ( %). renal involvement with urolithiasis and nephrocalcinosis was present in five of whichone developed end-stage renal disease. the presence of hyperoxaluria, potentially leading to severe renal involvement, was statistically significant correlated with the severity of neurological dysfunction. discussion: zsd patients should be screened by urinalysis for hyperoxaluria and renal ultrasound for nephrocalcinosis in order to take timely measures to preventrenal insufficiency. menkes disease is a very rare x-linked recessivedisorder of copper metabolism. the frequency is : . live births. mutations in the atp a gene are described, which encodes for aintracellular copper-binding membrane protein. pathogenetically a defect in copper absorption is responsible for inadequate synthesis of copper requiringenzymes and causes multisystemic manifestations. the clinical picture ischaracterized by early neurodegenerative symptoms like muscular hypotony andcerebral seizures. the patients also present with the so called kinky hair, hyperelastic skin, and anomalies of the kidneys and the urinary tract. wereport on a patient of non consanguineous parents of german origin. theprenatal ultrasound did not show any malformations. birth at weeks ofgestation. postnatally a softening of the cranial bones and a vesicoureteralreflux iv° with dilatation of the renal pelvis combined with a subpelvicureteral stenosis had been observed, which were operated at the nd month of life. at the age of months the patient presented with seizuresand abnormal hair structure. within the diagnostic course menkes diseasehas been suspected and the nonsense mutation parg x has been identified inthe atp a gene. the mother is not a conductor, a mutation in thegermline cannot be excluded. conclusion: the combination of urinary tract malformations and neurodegenerative symptoms should let you think of the very rare menkes disease. introduction: primary hyperoxaluria type (ph ) is an inborn error of glyoxylate metabolism due to the deficient activity of the hepatic peroxisomal enzyme agt (alanine: glyoxylate aminotransferase). it leads to excessive endogenous oxalate production. patients develop urolithiasis and renal insufficiency. the contribution of specific precursors in the pathway leading to endogenous oxalate synthesis is not known. this is warranted to design appropriate treatments. we aimed to test the contribution of different precursors to oxalate synthesis. methods: wild type mouse hepatocytes were incubated with different potential precursors of glyoxylate, either in the presence or absence of alanine. in the absence of alanine flux through agt is deficient thereby mimicking agt deficiency. similar experiments were also performed in hepatocytes from agtdeficient mice. results: oxalate production was found to be highest with glyoxylate as substrate in the absence of alanine, whereas oxalate production was lower with glycolate, hydroxypyruvate, glycine, fructose, and ethylene glycol. the results obtained in wild-type hepatocytes incubated in the absence of alanine were comparable to those obtained in hepatocytes from agt-deficient mice. upon addition of alanine to wild-type mouse hepatocytes, however, resulted in % lower rates of oxalate production, in contrast to hepatocytes from agt deficient mice. discussion: hepatocytes derived from agt deficient mice represent a good model to study the contribution of different precursors to oxalate production in ph . s. grisaru , c. geary-joo , f. snider , j. cross university of calgary, department of pediatrics, calgary, canada university of calgary, department of biochemistry and molecular biology, calgary, canada gcm (glial cell missing), is a transcription factor necessary for the formation of placental syncytiotrophoblast in mice. gcm mutant mice die before nephrogenesis at embryonic day (e) . during early murine development gcm expression is limited to the placenta. however, immediately after birth, gcm is increasingly expressed in the kidney in proximal tubular cells in the outer medulla. we recently reported successful rescue the gcm null phenotype using a tetraploid aggregation approach (jasn vol. , ) . since our previous report, further analysis of the aggregation products confirmed only homozygous mutants ( males and a female) obtained from six hundred and twenty five transferred aggregate embryos resulting in live pups. abnormal cortico-medullary patterning was demonstrated by histology analysis of adult gcm null mice kidneys. this abnormality was further defined by immunohystochemical detection of known nephron segment-specific markers (aquaporin- , aquaporin- and tamm-horsfall protein) in gcm null kidney sections. to define the expression of gcm in human kidneys, commercially available anti-human gcm polyclonal antibodies were used to detect gcm protein in tissue sections of newborn kidneys obtained from autopsies. gcm was detected by immunohystochemistry in the renal cortex in tubular structures with cells having a brush border suggestive of proximal tubules. gcm signal was not detected in the renal medulla. conclusion: in humans, gcm is expressed in renal proximal tubules at birth whereas in adult mice its mutation is associated with abnormal renal cortico-medullary ultrastructure. this effect may represent a primary role for gcm in late renal development and patterning, or structural changes occurring postnatally secondary to alterations of tubular physiology caused by gcm inactivation. objectives: lupus nephritis (ln) in singapore children treated with cyclophosphamide and/or azathioprine has a poor prognosis with a reported -year renal survival of %. this study examined the long-term outcome of children with lupus nephritis using a new protocol comprising pulse intravenous methylprednisolone, mmf ± cyclosporine. method: twenty-one children with ln (age range at start of treatment . - . years) who were treated between the years to were included in this retrospective study. mmf dose was mg/m /day. mean duration of follow-up was . ± . (range . - . ) years. treatment outcome was defined by systemic lupus erythematosus disease activity index (sledai), renal function, proteinuria and serologic markers. effect of steroids on growth was assessed by height standard deviation score (htsds). statistical analysis was performed using wilcoxon signed rank test. results: at presentation, % had nephritic-nephrotic syndrome, % had nephrotic syndrome, while % had renal failure requiring dialysis. renal biopsy classification (who) was ii in %, iii in %, iv in %, and v in %. comparing pre-mmf treatment and current follow-up parameters respectively, sledai ( . ± . objectives of study: to understand the effects of response gene to complement (rgc- ) in tgf-β induced epithelial-mesenchymal transition (emt) on human renal proximal tubular epithelial cells (hptecs). methods: constructed rgc- expression plasmids and rgc- sirna hairpin plasmids, transient transfected them into hptecs in vitro, and then treated hptecs with tgf-β ( ng/ml) or vehicle alone for indicated time ( , min, h, h, h) . rt-pcr and western blot were used to determine the expression of a-sma, ecm (col-i, fn ). the mrna expressions of e-cadherin and sm a were detected by rt-pcr. results: ( ) the promoting effects of rgc- on emt. instead of stimulation with tgf-β , the hptecs, those overexpressed rgc- gene, de novo obtain the ability to produce markers of myofibroblast phenotype (a-sma, col-i and fn) and sm a gene, as well as lost the capability of expressing e-cadherin gene. ( ) the eliminating effects of rgc- sirna on emt that induced by tgf-β . after stimulation of tgf-β for hours, the expression of a-sma, col-i, and fn as well as sm a gene in hptecs, those rgc- genes were interfered with rgc- sirna, were significantly decreased than that in controls. conclusions: rgc- was an important regulator for tgf-β and its downstream signalling smad proteins on emt. background: low birth weight is associated with a low nephron endowment. this may predispose to hyperfiltration and cascading proteinuria particularly if obesity develops. our report relates to an emerging population of children with proteinuric kidney disease in our multiethnic community. methods: forty-two obese children (mean age ± years) with proteinuric kidney disease (kd) were studied. twenty-four were of normal birth weight (nbw> grams) and were of low birth weight (lbw< grams). there was a female ( / = %) and an ethnic predominance ( african, hispanic). degree of proteinuria was determined by the random urine protein (pr) and albumin (alb) to creatinine (cr) ratios (upr/cr and ualb/cr). renal function (egfr) was estimated from the schwartz formula. body mass index was used as a measure of obesity (> % centile). insulin resistance was measured by the homeostatic model assessment (homa). kidney tissue was obtained in of the patients for pathology and histomorphometry. results: average bmi was ± % tile. fasting insulin and homa scores were not significantly different in the obese nbw versus obese lbw children. renal biopsy specimens revealed focal glomerulosclerosis (fsgs) in the majority of patients ( / = %). progression to end stage kidney disease was significantly greater in lbw compared to nbw children with a median renal survival of years, p< . . glomerulomegaly as measured by glomerular diameter was similar in obese patients and significantly greater than non-obese controls with fsgs. conclusions: obesity appears to be a confounding factor in the development of glomerulosclerosis and progression of kidney disease in children. low birth weight and concomitant low nephron endowment may contribute to disease progression, especially in those of african and hispanic descent. objective: to determine long term outcome and prognostic factors of iga nephropathy in a large single center cohort of pediatric patients. patients and methods: we have reviewed the medical charts of patients with biopsy proven igan that have been followed at our institution from to , with a minimal follow-up of years. follow-up data, including proteinuria > mg/ h or the need for ace-is therapy, chronic renal failure (crf) and hypertension were analysed after years and years of follow-up. data from patients with follow-up longer than years were also available (mean follow-up . years, range - years). % of patients received therapy (cyclophosphamide in patients and/or steroid±ace-is in the remaining). clinical features at the onset, histology class (lee and haas) and treatment during the first years were analysed by multivariate analysis against the above mentioned dependet variables. results: the average follow-up was . years (range - years). presentation symptoms included macroscopic hematuria in % of patients. at the end of follow-up, renal function was normal in % patients, patients have reached end-stage renal disease and had chronic renal failure. proteinuria or the need for aceis at years was significantly associated with the age of onset (or: . [ . - . ] ) and proteinuria at the onset (or: . [ . - . ] ). crf was significantly associated with familial igan (or> ). hypertension at onset was significantly associated with persistent hypertension during follow-up (or: . [ . - ] . conclusion: taken together, these data indicate that the overall prognosis of igan is good during childhood and that the worst prognostic factor for development of crf is familial igan. overall, histological classification had a poor correlation with the outcome of the disease. this study was designed to compare three urinary protein expert systems for profiling proteinuria (pu) in children with kidney diseases. freshly voided urine was collected from children with glomerular diseases, children with tubular diseases and healthy children aged - years. out of children with renal disease had a glomerular filtration rate (gfr) < ml/min/ . m . the urinary protein expert systems were . albumin/total protein ratio (apr), . alpha- microglobulin/alpha- -microglobulin + albumin algorithm (aaa), and . the complex upes algorhithm (using serum creatinine, urinary total protein, alpha- -microglobulin, albumin, igg, alpha- -macroglobulin and dipsticks). apr correctly identified glomerular pu in of ( %) children with glomerular diseases, tubular pu in of ( %) children with tubular diseases and normal pu in of ( %) healthy children. aaa correctly identified glomerular pu in all ( %) children, tubular pu in of ( %) children, and all healthy children were characterized as having no pathological pu. upes differentiated the type of pu in children with glomerular diseases into glomerular ( / patients) and mixed glomerulo-tubular ( / patients). tubular pu in children with partial or complete renal fanconi syndrome was identified in / patients and described as mixed glomerulo-tubular pu in / patients. mixed glomerulo-tubular pu was only found in children with ckd stages - of glomerular and tubular diseases. in conclusion, urinary protein expert systems may be used to distinguish between glomerular and tubular pu. the aaa algorithm had the highest reliability when compared with the two other expert systems and the accuracy was not negatively influenced by a decrease of gfr. however, upes provided additional information on mixed glomerulo-tubular pu in patients with a low gfr. background: the three lmw proteins cystatin c (cys), β -microglobulin (β -m) and β-trace protein (β-tp) are useful markers of gfr. cys is particularly well suited for the detection of incipient renal failure. however, corticosteroid medication has been shown to stimulate cys production. aim of the study: analysis of the effect of corticosteroid therapy on the correlation between gfr and the three lmw markers. patients: patients ( f, m; median age . years, range . to . ) with malignant (n= ) or nephrological (n= ) diseases underwent a single-shot inulin clearance. the respective lmw proteins were measured by particle-enhanced immuno-nephelometry. children received corticosteroids (prednisone or dexamethasone) in a mean dosage of mg/m /d of prednisone equivalent (pred/bsa). multiple linear regression analysis was performed between the lmw markers as dependent and both gfr and steroid-dose as independent variables. results: mean gfr was . ± ml/min/ . m , mean cys . ± . mg/l, β -m . ± . mg/l and β-tp . ± . mg/l. cys was highly correlated with the reciprocal of gfr (p< . ) but not with corticosteroid-dose (p= . ), whereas both β -m and β-tp were highly correlated (p< . ) with both the reciprocal of gfr and the reciprocal of pred/bsa. discussion: using gold-standard gfr measurements, we cannot confirm earlier reports indicating an increase in serum cys during corticosteroid medication. by contrast, steroids significantly lowered both β -m and β-tp serum concentrations. we conclude that at least in patients with mild renal insufficiency cys -unlike β -m and β-tp -appropriately reflects gfr also during steroid therapy. this further supports the concept of cys being a superior marker of incipient renal failure. objective: to repeatedly follow kidney function since onset of type diabetes and evaluate whether gfr can predict development of micro-or macroalbuminuria or end stage renal disease. design: observational cohort study. methods: since , all diabetic patients undergo renal function tests every nd to rd year from onset. children, boys, have done clearance studies. healthy children and young adults, - years of age, served as controls. gfr was evaluated by clearance of inulin during water diuresis and continuous infusion. results: gfr during the first years after onset of diabetes was significantly higher than that of controls (mean - vs. ml/min/ . m ). at onset, and years after, boys had significantly higher gfr than girls (mean , , vs. , , ml/min per . m ) but after years no differences were found between sexes. the occurrence of microalbuminuria, albuminuria during the first - years was analysed and mean of gfr of , and years, and years, , and years and all those gfrs separately were compared between patients still normoalbuminuric, microalbuminuric and macroalbuminuric after and years resp. no significant differences were found between the groups. moreover the change in gfr from to , to and to and to years were also compared between the groups and no significant differences were found. young adults reached end stage renal disease (esrd) after - (median ) years and comparing their gfrs during the first - years with those still normoalbuminuric after years, no significant difference was found. conclusions: hyperfiltration is found in children with type diabetes during the first - years from onset and hyperfiltration was equally seen during the first - years in those children who in the future developed normo-, micro-, albuminuria and/or esrd. background: hiv associated nephropathy (hivan) remains an important entity despite the use of highly active anti-retroviral therapy (haart). our objectives were to determine the prevalence and severity of renal manifestations in a cohort of hiv infected children during the haart era. methods: a retrospective analysis was conducted on children infected with hiv. renal assessments included quantitation of proteinuria, radiologic abnormalities, and renal function. persistent proteinuria (pp) was defined by urine protein to creatinine ratio (upr/cr) > . detected on at least two measurements month apart. renal sonography and mag renal scintigraphy were categorized according to the presence of bilateral increased echogenicity and/or nephromegaly, and cortical retention and/or diffuse parenchymal disease, respectively. hivan was considered in those children that had pp associated with any radiological abnormalities. results: of the children, . % were perinatally infected. eighty-five ( . %) had pp. of these, had pp alone, while ( . %) developed hivan. the mean age of onset of hivan was . ± . years. overall mortality at the time of analysis was . % and it was highest in those with hivan. viral load (vl) > , copies was significantly associated with hivan. creatinine clearance was significantly decreased in patients with hivan. conclusions: the prevalence of pp in our population of perinatally infected children remains high ( . %), with at least half of them showing evidence of hivan. persistently high vl (> , copies) was associated with the presence of hivan. a spectrum of renal related disorders is a frequent occurrence in hiv infected children and should be sought with periodic urinalysis, quantitation of proteinuria and renal function, and imaging and/or histopathological studies. mmf has shown to be effective in adult ln, whereas only anectodical data are reported in childhood. we evaluated mmf in children with ln, f/ m, mean age: . ± . yrs, proteinuria > g/day, decreased c and increased anti-dsdna serum levels, normal renal function. renal biopsies, before mmf, showed the following classes (weening) : iv in cases, iii in , ii in , vi in . before mmf: patients have received i. v. cyp; more received aza and csa but were in flare-up of disease; the remaining were newly diagnosed patients. each patient received three i. v. metilprednisolone pulses and thereafter mmf (plus oral prednisone(p): mg/kg/day) was administered (mean dose: ± . mg/kg/day; through level: . ± . μg/ml). outcome was monitored by sledai score, renal function, proteinuria. in children p was tapered and, after . ± . month mean time, stopped; children were receiving p ( . mg/kg/day). the mean followup is ± months. sustained clinical remission was observed: proteinuria was absent in all, in patients an increase of serum c and c and a decrease of anti-dsdna levels was seen. significant steroid sparing effect was obtained: hypercorticysm dramatically improved. of the patients achieved years of mmf treatment and in them, at this time, a serial second renal biopsy was performed: histopathological activity indices reduced ( . ± . vs. . ± . , p< . ), whereas chronicity indices did not change ( . ± . vs. . ± . ). no haematological and/or gastrointestinal side effects were observed. our pilot study suggests that mmf represents a good alternative to traditional therapy in the treatment of sle in children, and in controlling disease activity and as steroid sparing agent without significant side effects over the entire period of therapy. mmf has shown to be effective, during treatment, in mantaining remission of childhood sd and csad ns, but few data are available on the mmf long term effectiveness after drug stopping. we report the results of two years mmf treatment in children with sd and csad ns. the characteristics of sd and csad groups were, respectively: patients, boys, mean age . yrs vs. pts, boys, mean age: . yrs (p< . ); first episode ns mean age: . yrs vs. . yrs; ns mean duration: . yrs vs. . yrs (p< . ); mean steroid therapy duration: . yrs vs. mean csa therapy duration: . yrs; histologic features: fsgs , mc vs. fsgs , mc . in both groups mmf was started after remission was achieved with prednisone administered at the last relapse. mmf treatment: lenght: months; mean dose: . ± , mg/kg/day; plasma through level: . ± . mcg/ml; non responder: patient presenting a ns relapse during mmf. in sd group ( %) and in csad ( %) subjects were responders. in patients of sd group and patients of csad group p could be withdrawn over a mean period of . months, so that ns remission was sustained just by mmf; remaining patients were receiving p at a mean dose of . mg/kg/a. d. two years mmf treatment was accomplished in / ( %) patients. at . ± months mean followup since mmf withdrawal, ( %) patients ( of sd and of csad group) relapsed after . months ( . - . ) mean time no haematological or gastrointestinal side effects were observed. our results demonstrate that two years mmf treatment in sd and csad ns children is effective not only in maintaining remission during therapy, but also in achieving persistent remission after withdrawal of drug in a significant rate (> %) of patients; the side effects and the rate of mmf dependence are negligible with respect to those of steroids and csa. information on long-term renal function following treatment for wilms tumor (wt) are relatively scanty. previous studies reported a worrying late development of microalbuminuria (uma), hypertension (hpt) and even reduction in glomerular filtration rate (gfr). the aim of the present study was to evaluate the long-term renal outcome in a cohort of patients who underwent uninephrectomy for wt. glomerular function (as creatinine clearance by cockroft-gault formula) was calculated and uma (as uma/ucr ratio) as well as urinary b microglobulin excretion were detected. -hours ambulatory blood pressure monitoring was also recorded. fifteen patients ( f) with a median age at wt diagnosis of . yrs (range . - . ) were studied. the median follow-up was . yrs ( . ± . ). eight patients had been classified as wt stage and as wt stage ii. all patients had been treated with unilateral total nephrectomy and chemotherapy. two of the children had also been addressed to radiotherapy. the primary disease did not recur in any of the patients. the median age at time of investigation was , yrs (range: , - , ). none of them had a gfr below normal limit (mean gfr was . ± . ml/min/ . m ). urinary b microglobulin excretion was normal (mean ub /ucr: . ± . ) in all of the patients. the mean uma/ucr ratio, was . ± , with only patient exhibiting higher then normal values (uma/ucr ratio: , ). the hr blood pressure was normal in all patients with a mean systolic and diastolic blood pressure sds of - . ± . and - . ± . , respectively. we conclude that as far as renal function, unilateral total nephrectomy combined with chemotherapy for low-stages wt can be look at as a safe treatment although it might be wise to monitor renal function at -year interval. classicaly, patients are divided into monosymptmatic enuresis (mne) and non-monosymptomatic enuresis, however, there is upcoming evidence that this subtyping might be artificial. the aim was to register the characteristics of nocturnal diuresis-rate and bladder volume in both subtypes. methods: retrospective analysis of consecutive patient-files, age - , primary consulting for enuresis in a tertiary center. registration of incontinentia diurna (id) and maximal functional bladder volume (vmax), hours urine-collections in day and nighttime-collections with uosmol and diuresis-volume (dv) and-rate. patients are divided into a mne and nmne-group. results: ) vmax is significantly lower than bladder volume for age, ) nocturnal polyuria is only present in / patients, ) nocturnal diuresis is >vmax, ) there is a significant linear correlation between nd and the nocturnal/daytime-diuresis-ratio, indicating fluid intake dependency. ) there is a negative correlation between nd and urinary osmolality. ) but the positive correlation between total nocturnal osmotic excretion and nd is much stronger. this unexpected observation cannot be explained by the classical primary vasopressin-theory. conclusion: our data show (almost) no statistical difference between the mne and nme-groups, suggesting a continuum instead of separate identities. both groups have a significant low vmax and nocturnal polyuria. the observation of the extremely strong correlation of nocturnal polyuria with the high osmotic excretion and high h urine-production suggests that nocturnal diuresis-rate is highly fluid-and nutrition-dependent, and therefore more attention should be given to this part of the urotherapy. a. deguchtenaere, a. raes, j. dehoorne, r. mauel, e. vanlaecke, p. hoebeke, j. vande walle there is increasing evidence that a subgroup of patients with nocturnal polyuria may have an abnormal circadian rhythm of tubular sodium which may result in vasopressin resistance. the pathogenesis of this phenomenon remains to be elucidated. however if the increased sodiumexcretion overnight results in the ddavp-resistance, decrease of the sodium-excretion-overnight may respond in subsequent ddavp response. aim of the study: retrospective study on the circadian rhytm of diuresis-rate and osmotic excretion in basal condition and subsequent during introduction of ddavp, diet and furosemide. results + discussion: ) baseline-values show significant lower uosmol and higher diuresis-rate overnight compared to controls. striking is the > % part of electrolytes to explain the high osmotic excretion. ) introduction of ddavp results in a normalization of nocturnal uosmol, but despite a significant decrease of uosmol overnight, nocturnal polyuria persists. ) protein-and sodium-restriction results only in slight differences, but of course we do not have data on the compliance. ) furosemide in the morning results in a significant increase of daytime diuresis, osmotic and sodium-excretion, but as compensation decreased nighttime diuresis, osmotic and sodiumexcretion. ) in / cases the antidiuretic effect results in an anti-enuretic effect. conclusion: this pilot study clearly demonstrates that introduction of early morning furosemide results in significantly lower nocturnal diuresis. because the urinary osmolality remains high, this correlates with decreased nocturnal osmotic excretion associated with increased osmotic excretion (sodium) during daytime. background: the elasticity of the vessel walls decreases with age, this process is dramatically speeded up by uremia. as an early indicator of arteriosclerosis pulse wave velocity (pwv) increases along with arterial stiffness. aim: to establish normal values for pwv in healthy children; to compare it with children on dialysis. patients, methods: pwv was measured with a pulsepen device in healthy children and young adults (age range - years) as well as in uremic children ( , ± years) (crf) treated by hemodialysis (n= ) or peritoneal dialysis (n= ). two control groups of - childrens were formed using the database of healthy children: one matched for age (a-c) and one adjusted for height and weight (h/w-c). blood pressure, heart rate, serum calcium (ca), phosphate (p) , and parathyroid hormone levels were also determined. results: a significant linear correlation was found between pwv and age (r= , ), height (r= , ), weight (r= , ), (p< , ), systolic blood pressure (r= , ) and heart rate (r=- , ) (p< , ). crf patients were smaller by , cm than a-c (p< , ), and younger than h/w-c by , years (p< , ). pwv in crf ( , ± , m/s) did not differ significantly from a-c ( , ± , ), however it was elevated in comparison to h/w-c ( , ± , p< , ). serum p, caxp and pth was increased in crf (p< , ) conclusion pwv is higher in children with crf as a sign of increased arterial stiffness. controls matched for height and weight should be used in states of severe growth retardation. a number of established risk factors potentially responsible for arterial dysfunction are present in crf. ngal has been identified as an early marker of acute renal failure (arf). sepsis in very low birth weight (vlbw) infants is associated with arf more often than recognized. the aim of this study is to determine whether ngal represents a marker of renal impairment in vlbw infants affected by sepsis. samples of urine of vlbw infants were prospectively collected for weekly measurement of ngal. after evaluation of the clinical course, groups were identified: group sepsis includes infants affected with septic events associated with some degree of renal impairment and group normal includes uncomplicated vlbw infants. a mouse model of sepsis was created in neonatal mice by intra-peritoneal introduction of salmonella lipopolysaccharide. kidneys were harvested hours after the challenge, and ngal mrna was quantified by real time pcr. ngal values of the normal group did not differ with gestational age or post-natal age of the neonates. the upper bound of the th percentile confidence interval was ng/ml. the median value of ngal in the sepsis group at days before the septic event was ng/ml and during sepsis was ng/ml: these values were not significantly different, but both were significantly higher (p< . ) than the median of the normal group ( ng/ml). once sepsis had been treated, the median value of urinary ngal was similar to normal ( ng/ml p= . ). changes in urine ngal concentration paralleled changes in serum creatinine. sepsis induced animal models showed a dramatic increase of ngal mrna in kidney tubules that paralleled acute renal failure. these neonatal animal and human data suggest that ngal may be an early marker of renal impairment in septic vlbw babies. further investigation is necessary to more exactly define the temporal relationship between the onset of sepsis/arf and rise in urine ngal concentration. we report cases of acute renal failure (arf) associated with orellanus syndrome, a cortinarius mushroom poisoning. grand-father, mother, father and son presented with arf week after gastrointestinal symptoms and weeks after repetitive ingestion of wild mushrooms. critically arf was observed for the year-old boy: anuria, severe metabolic disorders (hyponatremia mmol/l, hyperkaliemia mmol/l, serum creatinine mmol/l, blood urea mmol/l). renal biopsy was performed for the grand-father, father and son (day , and respectively after presentation) and showed similar lesions: severe tubulointerstitial nephritis (tin) with tubular necrosis and interstitial fibrosis. renal replacement therapy was necessary for the father and the son. the mother recovered completely in two weeks without dialysis while renal function improved slowly for the two men. the boy is still hemodialyzed months later. his main problem is uncontrolled hypertension. the diagnosis was confirmed weeks later since fungal spores of cortinarius orellanoides were observed in the contaminated meal by light microscopy. the severity of the disease seems to be related to the toxin quantity: the kg boy ate mushrooms as much as his father and grand-father, the mother ate much less. cortinarius spp poisoning is an exceptional paediatric cause of arf. gastrointestinal disorders are the main symptoms of the initial phase of the poisoning appearing days after the mushrooms ingestion. the renal phase is delayed (median . days) characterized by arf secondary to tin. the toxin effects are dose-related, explaining the severity of the boy's symptoms. the prognosis is severe with % of end stage renal failure. currently no treatment is available. although rare, mushroom poisoning should be considered in the differential diagnoses of arf with tin. l. mendels, ah. bouts, j-c. davin, j. groothoff emma children's hospital/academic medical center, pediatric nephrology, amsterdam, the netherlands background: inchronic dialysis, tertiary hyperparathyroidism (th) is clinically revealed by persistent combined high parathyroid hormone (pth), normalor high total serum calcium (tca) and normal phosphate levels. sincethe introduction of bicarbonate containing dialysate in peritoneal dialysis (pd), we have observed combined high tca and pth level sunusually early after onset of dialysis therapy. in most of the secases, ionized calcium (ica) levels were low. we aimed to investigate the extent of this discrepancy and its association with the mode of therapy. methods: serum ica, tca, pth, bicarbonate and capillary ph were assessed over years in pediatric pd, hemodialysis (hd) and in transplanted (tx) patients. associations between tca, pth and ica were analyzed. results: comparedto tx patients, we found in pd and hd patients a lower mean ica/tcaratio (both p< . ), an increased mean tca-ica (p< . and p < . , respectively), and a higher number of combined normal/increased tca and decreased ica and increased pth values ( . % and . %, respectively for pd and hd, vs. % for tx). alow ica/tca was associated with a high capillary ph (r=- . ; p< . ), a high venous bicarbonate (r=- . , p= . ) and a lowage (r= . , p= . ). conclusions: ica levels are warranted for monitoring calcium phosphate homeostasis in dialysis patients, especially in young pd patients. the use of only tca levels might lead to an inadequate treatment with vitamin d, and henceinduce the development of autonomous hyperparathyroidism in these patients. preterminal renal failure (prf)and end-stage renal disease in children and adolescents are associatedwith an increased risk of atherosclerosis and cardiovascular disease. oxidative stress is one of the pathogenetic factors that could possiblybe influenced by therapeutic interventions. we investigated biomarkers of oxidative stress in children (median age . years) with prf (median gfr ml/min/ . m , range - ) andin children (median age . years) under peritoneal dialysis (pd)and healthy age-matched controls (c). plasma samples wereinvestigated for malondialdehyd (hplc) and carbonyl groups in proteins(elisa) as biomarkers for oxidative stress as well as the plasmaantioxidative substances vitamin c (photometric), vitamin e (hplc), ubichinols (hplc), sulfhydryl groups in proteins(photometric), erythrocyte resistance to radicals and the total radicaltrapping antioxidant capacity (trap). in both patient groups prf and pdwe found a depletion of sulfydryl groups and ubichinol- and a reducedresistance of erythrocytes to radicals. malondialydehyd (p< . ) andcarbonyl groups (p< . ) were elevated in the pd group compared tocontrols. conclusion: from these studies we concludethat in children under peritoneal dialysis biomarkers of oxidativestress are elevated. moreover antioxidative defenses in preterminalrenal failure as well as under peritoneal dialysis are impaired. significant acute renal failure due to non-steroidal anti-inflammatory drugs: inpatient setting in united states non-steroidal anti-inflammatory drugs (nsaid) are freely available over-the counter. many children routinely use them without medical supervision. fourteen inpatients mean age of . ± . years ( males, females), were referred to nephrology for acute renal failure. based on history, biochemistry, imaging and urinalysis the diagnosis of acute renal failure due to nsaid was made. all patients admitted to taking ibuprofen and six also consumed naproxen. the exact doses of either could not be scientifically determined as none were prescribed by a physician. none of the patients had underlying renal diseases at the time of admission. nine patients had proteinuria and had hematuria (including one with gross hematuria). one patient had nephrotic syndrome but resolved spontaneously without steroids and has remained in remission for years. two patients required dialysis. only one of the dialyzed patient required steroid therapy for recovery of renal function. all data are expressed as mean±sd. the mean duration of hospitalization was ± . days. the mean serum creatinine at the peak of renal failure was . ± . mg/dl (range . - . ). all patients recovered renal function with normalization of serum creatinine to . ± . mg/dl (range . - , p< . ). however, the duration from onset to normalization of serum creatinine was ± days; indicating many patients had abnormal renal function for aprolonged period. in conclusion, nsaids pose significant risk of renal failure forsignificant duration and as an entity may be under recognized. objectives: treatment with growth hormone (gh) improves growth retardation of chronic renal failure. cdna microarrays were used to investigate gh-induced modifications in gene expression in the growth plate of uremic young rats, the organ where longitudinal growth takes place. methods: rna was extracted from the tibial growth plate from two groups (n= ) of young rats: uremic (nx) and uremic treated with . mg/kg/day of intraperitoneal gh for one week (nxgh). after reverse transcription, agilent technology was used to analyze differential gene expression by microarrays containing , rat probes (four hibridizations were performed). most expressed genes were detected using linear models and bayesian methods. to confirm gene expression changes shown by the chips, some genes known to play a physiological role in growth plate metabolism were analyzed by real-time quantitative polimerase chain reaction (qpcr). the ribosomal protein l (rpl ) expression did not show changes in the array and was used as the housekeeping gene. results. gh modified the expression of genes, being upregulated and down-regulated. the assay was validated by the qpcr results, which confirmed the sense of expression modification found in the arrays for insulin like growth factor i (down), insulin like growth factor ii (up), collagen alpha (down) and proteoglican type (up) . conclusions: this study shows for the first time the profile of growth plate gene expression modifications caused by gh treatment in experimental uremia. the further analysis of selected individual genes, whose expression is differentially modified by gh will contribute to explain the mechanism of the stimulating effect of gh on growth in chronic renal failure. objectives of study: children with chronic renal failure have an increased risk of cardiovascular disease. this is associated with endothelial dysfunction, a key pathophysiological factor in atherosclerotic disease. circulating endothelial progenitor cells (epcs) have the potential to repair endothelial damage and promote angiogenesis. in adults, the number of epc in peripheral blood correlates with endothelial function and reduced epc levels are associated with a higher incidence of cardiovascular events. we aimed to investigate if children on long-term hemodialysis (hd) therapy have reduced epc levels. methods: we quantified circulating epc in pediatric hd patients before a midweek hd session and healthy age-matched controls. epc are a subfraction of the haematopoeietic stem cells (hsc) expressing both hsc-marker cd and the vegf-receptor- kdr. using flow cytometry, epcs were identified as cd +kdr+ cells and quantified relative to the number of granulocytes in the sample. results: the number of epcs in the peripheral blood was significantly reduced in hd patients ( . ± . vs . ± . / granulocytes, % reduction; p= . ). the total number of circulating hsc also tended to be lower in hd patients ( . ± . vs . ± . / granulocytes, % reduction; p= . ). conclusion: the number of circulating epcs is significantly reduced in children on long term hd. reduced epc levels may contribute to endothelial dysfunction and accelerated atherosclerosis in children on long term hd. future studies are needed to identify the cause of this deficiency and to evaluate if increasing epc levels provides therapeutic benefit. objectives: darbepoetin alfa (aranesp ® ) is a novel erythropoiesis stimulating protein that has been shown in adult trials to have safety and tolerability equivalent to recombinant human erythropoietin. however, to date there is only limited published data on the use of aranesp inpaediatric patients. the objective of this study was to determine the safety and efficacy of darbepoetin in children with chronic and endstage kidney disease. methods: from to , children with either chronic or end stage kidney disease were enrolled in a prospective observational study. the initialdose of darbepoetin was . mcg/kg weekly (either iv or sc) and subsequent dose was titrated to achieve haemoglobin (hb) between and g/dl. results: data analysis to date includes patients ( male : female) whose agesranged from month to years (mean years). hb improved significantly with darbepoetin treatment from mean g/dl (range - ) at start of treatment to g/dl (range - , p< . ) at completion. the mean starting dose was . mcg/kg/week (range . - . ) which was not significantly different to the dose atthe end of the study ( . mc/kg/week, range . - . ). however, there was a significant change in the frequency of administration, with % commencing on weekly treatment, but only % still on weekly treatment at the end of the study (p< . ). the most common treatment interval in stable patients was fortnightly ( %) but a significant number tolerated even longer intervals ( % dosed every weeks or longer). injection pain was common, but there were no other significant adverse events. conclusions: darbepoetin alfa is a safe and effective therapy for anaemia associated with kidney disease. the majority of children will maintain satisfactory haemoglobin at a dosing interval of every weeks orgreater. high prevalence ( %) of left ventricular hypertrophy (lvh) and impaired systolic myocardial function in children with mild-to-moderate chronic renal failure (crf) were observed in previous studies (jasn , jasn ). in adult patients with uncomplicated arterial hypertension, lv mass (lvm) exceeding compensatory value for body size and cardiac workload (inappropriate or ilvm) is associated with poor prognosis, independently of lvh. we tested in crf children if increased lvm compensates or exceeds the expected values for individual cardiac load and if ilvm is associated with impaired cardiac function. complete anthropometrics, biochemical profile and doppler echocardiograms were obtained in children (age . ± . yrs; gfr . ± . ml/min/ . m ). ilvm was defined above % of the value predicted for individual body size, gender, and stroke work and lvh was defined as lvm/m . > g/m . . patients showed ilvm. children with ilvm had higher mean age and lower heart rate as compared to patients with appropriate lvm (both p< . ), without differences in blood pressure, bmi and gfr. after controlling for differences in age, gender distribution and presence of lvh, patients with ilvm showed similar cardiac geometry and diastolic function parameters compared to children with compensatory lvm (p=ns). in contrast, presence of ilvm was associated with lower lv ejection fraction ( . ± . % vs . ± . %) and lower midwall fractional shortening ( . ± . % vs . ± . %)compared to children with compensatory lvm (both p< . ), indicating impaired lv chamber performance and reduced systolic myocardial function. in conclusion, in . % of children with mild-to-moderate crf, lvm is inappropriately increased for individual cardiac workload and body size. presence of ilvm is associated with reduced systolic function, independently of age, gender and presence of lvh. pediatric nephrology centers were enrolled. age groups of the patients were as follows: . % newborn, . % - months, . % months - years, . % - years. underlying diseases were prematurity ( . %), malignancy ( . ), congenital heart diseases (chd, . ), urologic disorders ( . %). low fluid intake was noticed in % of cases. . % of cases developed arf after they have been hospitalized. time to diagnose arf was longer in the surgery department ( . ± . days) compared to pediatrics ( . ± . days), p< . . thirty-nine percent of patients were on mechanical ventilation (mv) before the diagnosis of arf, an additional . % needed mvl after the diagnosis of arf. arf was prerenal, intrinsic and obstructive in %, % and % respectively. hemodialysis and peritoneal dialysis was performed in . % and . % of cases. mortality was . %; and it was secondary to non-arf related causes in . % of cases; presence of mv, intrinsic arf, prematurity, chd, malignancy and being in intensive care unit were poor prognostic factors. conclusion: our nationwide data suggest that nephrologist, intensivist and pediatrician should focus on risk groups to prevent and to diagnose arf earlier. appropriate fluid intake and earlier consultation to a nephrologist are simple but may be effective measures to prevent arf.. hemolytic uremic syndrome is characterized by the triad of hemolytic anemia, acute renal failure, and thrombocytopenia. recent studies have shown that shiga-toxins (st) may stimulate apoptotic cell death in renal tubular cells, but the underlying molecular mechanisms remain to be elucidated. in the present study, confluent llc-pk cells were exposed to st and cell death was studied with morphological and biological assay. in llc-pk cells st was found to induce apoptotic cell death in a dose-and time-dependent manner. the expression of calpain and bax were significantly up regulated by st, while the expression of bcl- was down regulated. cell death was completely inhibited by a specific calpain inhibitor, but not by a broad caspase inhibitor, zvad-fmk, implicating a caspase-independent pathway via calpain. moreover, we found that serum factors could trigger a survival signal against st-induced cell death through pi k/akt pathway. in conclusion, activation of calpain mediates st-induced renal proximal tubular cell death, and the expression of bcl- and bax were oppositely altered. stimulation of pi k/akt signalling protects cells against death. verocytotoxin (vt)-producing e. coli (vtec) infection represents the main cause of hemolytic uremic syndrome (hus) in children. a nationwide surveillance system of hus was introduced in italy in may to follow the trend of vtec infections. for each patient, epidemiological and clinical information was collected by a standardized questionnaire. laboratory diagnosis of vtec infection was based on the detection of vtec and free vt in stools and of antibodies to the lipopolysaccharide (lps) of serogroups, o , o , o , o , and o in the sera. the immuno-detection of vt on circulating neutrophils was also performed on some patients. as of december , cases have been notified, accounting for a mean annual incidence of . x , in the - age group with a significant difference among the regions (from . to . ); median age of patients: months, % males. most cases ( %) occured in summer from june to september. seventy-nine per cent of the cases had prodromal symptoms such as bloody diarrhea ( %) and non-bloody diarrhea ( %). five patients ( . %) died from the disease. stools and/or sera were collected from cases. evidence of vtec infection was observed in cases ( %). the vtec serogroups most commonly detected were o ( % of the vtec-positive patients), followed by o , o , o and o . the number of cases associated with non-o infections increased over time: from the o -associated cases are the most frequent. during the surveillance-period epidemic clusters have been registered: -lombardia, -veneto, and campania. the role of vesico-ureteral reflux (vur) as a predisposition for acquired renal scarring with urinary tract infections (uti) has been questioned in recent years. few studies have investigated baseline factors associated with chronic nephropathy in severe reflux. we aimed to evaluate dmsa scans in children having any degree of primary vur associated with uti in order to identify variables that are predictors of the presence and/or development of renal scar. data of patients with proven uti who have primary vur were evaluated retrospectively. patients and renal units were classified as scar (+) and scar (-) by dmsa results. the following parameters were assessed with respect to their relation to presence of renal scarring: sex, age at diagnosis, grade (g) of reflux, number of subsequent utis (on new renal scars). there were patients (m/f: / , median age months) and refluxing units. variables increasing the likelihood of scar detection were: male gender ( / vs. / , p= . ; or . ), > months of age (for girls only; / vs. / , p= . ; or . ), g iv-v reflux (or . vs. g i-iii reflux and . vs. no reflux). all boys having g iv-v reflux and girls over months of age having g iv-v reflux had very high rate of scarring compared to the rest ( / vs. / , p= . , or . and / vs. / , p= . , or . , respectively). however, variables increasing the likelihood of new/progressive scar development were only the presence of previous scar (or . ) and uti number > (or . ). neither uti number nor new/progressive scar development was affected by vur grade. in conclusion, the most predictive variables for the presence of renal scarring among children presenting with a uti were male gender, age (being > months; only for females) and grades iv-v reflux, while new/progressive scar development was associated with presence of previous scar and uti number. d. hothi , e. harvey , c. goia , d. geary hospital for sick children, department of pediatric nephrology, toronto, canada hospital for sick children, educational, toronto, canada introduction: adequate ultrafiltration (uf) is necessary for good health in dialysis dependent patients. however uf can be hindered by development of intradialytic symptoms and hypotension. objectives: to determine whether sodium ramping, uf profiles and mannitol could improve uf without increasing intradialytic morbidity in children. method: a standardized hd practice was instituted in our unit. we prospectively analysed dialysis treatments from chronic patients with routine scheduled hd, hrs x - /wk. results: uf volumes between . to . % of the dry weight were achieved. mannitol reduced the risk of developing intradialytic symptoms by % (p< . ) without altering the risk of hypotension, with a mean uf volume of . % of the dry weight. a linear sodium ramp ( - mmol/l) increased the odds of intradialytic symptoms (p= . ) and hypotension (p< . ), with no difference in the mean uf volume. all uf profiles increased the risk of intradialytic symptoms but the effect was not statistically significant except with profile (stepwise reduction of uf during procedure). achievement of dry weight was least likely with uf profile (p< . ); there was no statistical difference in the mean uf volume between them all. conclusion: uf volumes higher than the traditional recommendations of % of the dry weight can be achieved in children. the use of mannitol increased the uf volumes and reduced symptoms without increased hypotensive episodes. objective: innate immunity and urinary tract response play a central role int he development of urinary tract infection (uti), in which heat shock protein (hsp) and toll-like receptor have a key position. patients and methods: hspa b a( )g and tlr a( )g genotypes were determined using allele-specific polymerase chain reaction in patients treated with recurrent urinary infection. allelic prevalence was related to reference values of healthy controls. clinical data were also reviewed and statistically evaluated. results: hspa b ( )gg genotype and hspa b ( )g allele occurred more frequently in uti patients versus controls (p= . ) and both were associated with a higher risk of renal scarring (p= . and . , respectively). tlr ( )ag genotype and tlr ( ) g allele had also higher prevalence among uti patients than controls (p= . and . , respectively). the combination of carrying ag genotype at both sites meant the greatest risk for uti (p= . ). conclusion: our data indicate an association between the carrier status of hspa b ( )g and tlr ( ) one of the major goal of hemodialysis adequacy is to achieve the fixed endsession body weight, so called dry weight, in order to limit overhydration and thereby cardiovascular risks. the prescribedultrafiltration, can induce hypotensive episodes and thereby limit thedry weight achievement. on line equipments offer the assessment of theblood volume (bv) and its relative variation. the bv is derived fromdirect measurement of the hematocrite. weroutinely use such an equipment (fresenius a c) over all thesessions since february , conducting to a clinical experience of bvm curves. these registered curves could be related to thehemodialysis prescription parameters (uf, nad, td, kt/v) to the dryweight, the blood pressure and to the clinical dialytic symptoms. thisexperience conducts us to define the normal bv curve over a sessionand its variations. starting dialysis induces an acute initial ( to min) decrease of bv, to %, mostly asymptomatic: extra corporeal circuit filling; this initialdecrease is a sign of normality. there after the normal bv curve should be flat; uf rate/amount being compensated by the plasma refilling rate: iso osmotic dialysis, no symptoms, no cramps, no hypotension, no vomiting. incase of no bv decrease over the dialysis session, the patient isoverloaded: reduce his dry weight. in case of a decrease of the bvhigher than %, there is a hypotensive risk: uf rate/amount, dryweight, sodium dialysate, sodium temperature and kt/v urea (cellular water shift) should be individually adapted conducting to arefilling curve. the effectiveness on the bv of these individual changein dialysis prescription can be directly, on line attested by the bvmcurve: plasma refilling capacity test. the bv changes reactivity is rapid, to min. renalscarring following acute pyelonephritis (apn) in children is a frequentcomplication which may impair renal growth. its pathophysiology includes host response, bacterial virulence, associated malformationand/or renal dysplasia. we prospectively studied virulence factors of e. coli isolates from children with a first episode of apn (fever > . c°, crp > mg/l, monomicrobial e. coli positive culture > * cfu/ml). we excluded patients with anyconcomitant infection, renal dysplasia or obstructive uropathy (us examination, renal length < sd) or grade - vur. renal scarring was evaluated by dmsa scan performed to months after apn. patients were included in a multicentre prospective randomized study comparing short vs long i. v. treatment with ceftriaxone as a first line antibiotic treatment [in press]; out of them fulfilled criteria for virulencestudy. six virulence genes were investigated by multiplex pcr (pap, sfa, afa adhesine genes; cnf , hly toxin genes, aeraerobactin gene) and the k capsular antigen was researched by latextest. we identified distinctive virulence profiles; % of e. coli strains had one or more virulence factors; % expressed the aer genewith at least one adhesin or one cytotoxic factor. renal scars occurredin % of cases and low grade ( - - ) vur was detected in %. statistical analysis did not show any correlation between the presenceof scars and e. coli virulence pattern. in addition, scarring was not correlated with the antibiotoc regimen but was correlated with grade vur (p . ). most e. colistrains associated with apn in children show several virulence factors, mainly adhesins and cytotoxins, but their profile was not correlated with renal scarring. background: acute lobar nephronia (aln), a severe renal parenchymal inflammatory disease, ranging between acute pyelonephritis (apn) and frank abscess formation, has been diagnosed with increasing frequency due to the advancement of non-invasive diagnostic modalities and the development of systematic diagnostic schemes. e. coli is the most common bacterialpathogen isolated from the urine samples of aln patients and the associated percentage is significantly higher than those among the patients with first time urinary tract infections. this prospective study was conducted to elucidate and differentiate the bacterialvirulence factors associated with aln and apn in pediatric patients. methods: patients included in the present study were those suspected of anupper uti and underwent a systematic scheme of ultrasonographic, ct and tc m-dmsa evaluation for the differential diagnosis of aln andapn. exclusion criteria were any evidence of underlying diseases orurinary anatomical anomalies except vur. the e. coli isolates from the urine samples of patients were screened with pcr analysis for various urovirulence genes. pulsed-field gelelectrophoresis was used to analyze the genetic association of theisolates. results: a total of patients were enroled. forty-six patients were diagnosed as aln, while the other cases were apn. diverse genotypes were found among the e. coli isolates in either group. among the pathogenetic determinants examined, multivariate logistic regress analysis indicating that a papg ii allele was the only significant urovirulence factor associated with aln (p< . ; odds ratio, . ). conclusions: while no specific genetic lineage was identified among the e. coli isolates studied, a papgii gene was found strongly associated with the cause of aln among pediatric patients without underlying disease other than vur. -< yr during - were sent to leading paediatric nephrologists of asian countries/regions. those having national renal registry were to use the registry data. results: data from countries/regions were returned (incl. national registries), namely china, hong kong sar, india, indonesia, japan, malaysia, pakistan, philippines, singapore, south korea & thailand. a total of esrd patients were reported: on peritoneal dialysis (pd), on haemodialysis (hd), & transplant (tx) of %, % & % respectively. chronic pd: capd and automated pd (apd) were the main modes of pd at ratio of . to . only countries had apd morethan capd. peritonitis rate ranged from episode in to patient-months, and seemed less common in those having more apd. chronic hd: hd comprised of % chronic dialysis, mostly adolescents. a-v fistula wasused in %, and permanent catheter % for vascular access. background: current data suggest the role of chronic inflammation and lipid disorders in atherogenesis. the aim of the study was to evaluate established and new markers of atherosclerosis in apd and hd pediatric patients and to assess whether the method of dialysis has an impact on those factors. methods: soluble(s) e-selectin, il- and il- concentrations were evaluated by elisa in sera of apd patients on, hd patients and controls. hscrp levels were assessed by nephelometry. the lipid profile (total cholesterol (chol), hdl-chol, ldl-chol, triglycerides (tgl)) was also estimated. results: se-selectin concentrations in dialyzed patients were higher than in controls (apd p< . ; hd p< . ) and in apd were increased vs. hd (p< . ). there were no differences in median values of il- , il- and hscrp between examined groups. chol levels were increased only in apd vs. controls (p< . ). hdl-chol concentrations were decreased in all dialyzed patients when compared to controls (apd p< . ; hd p< . ), without difference between apd and hd. ldl-chol in apd and hd were higher than in controls (apd p< . ; hd p< . ), but failed to differentiate between two dialysis modalities. tgl levels behaved in the same way. conclusions: the elevated se-selectin concentrations in all patients show the role of endothelium in atherogenesis in ckd children. thus, the se-selectin augmentation may serve as an early marker of endothelial activation, appearing prior to inflammation (unchanged hscrp, il- ). increased seselectin and cholesterol levels in apd patients prove that children on peritoneal dialysis are more prone to atherosclerosis than those on hemodialysis. background: end-stage renal disease (esrd) is associated with an increased risk of cardiovascular morbidity and mortality. according to recent data, arterial stiffness measured by aortic pulse wave velocity (pwv) and augmentation index (aix) is a strong independent predictor of cardiovascular mortality in adult esrd patients. few studies have been reported regarding arterial stiffness in the paediatric renal population. methods: aortic pwv and aix (difference between the first and the second systolic peaks on the aortic pressure waveform divided by the pulse pressure) were determined in haemodialysis children ( boys; age ± years) by applanation tonometry using a sphygmocor device. seven of the hd patients ( boys; age ± . years) received a renal transplant (tx) and were restudied ( ± months post tx). the immunosuppressive regimen included basiliximab induction, cyclosporine, mycophenolate mofetil, and steroids. results: in the hd population, aortic pwv ( . ± . m/s) was correlated with age (p= . ), weight (p= . ), height (p= . ) and systolic blood pressure (p= . ). in the transplanted cohort aix decreased in six children out of seven after transplantation ( . ± . % on hd versus - . ± . % after tx). no significant change was observed for aortic pwv ( . ± . m/s on hd versus . ± . m/s after tx). objective: to study the pathogenic role of host and escherichia coli virulence factors in the development of e. coli febrile urinary tract infection (uti) in children with acute cystitis (ac), acute pyelonephritis (apn) and renal scar. materials and methods: isolates recovered from children consecutively admitted to the hospital with e. coli febrile uti that diagnosed as ac (n= ) or apn (n= ) were retrospectively enrolled into this study. virulence genes of e. coli, that included papg genes (classes i-iii), aer, cnf , fimh, hlya, afa, sfa/foc, iha, usp, irone and ompt, were detected by polymerase chain reaction analysis. results: young age (=< months), male sex were more frequently associated host factors for patients with apn, but old age (> months) and female sex were more frequently associated with renal scar formation. after multilogistic regression analysis, with regard to e. coli virulence factors, the papg class ii gene might play a more important role in the development of e. coli apn. however, iha was significantly higher in young children with acute pyelonephritis. afterwards, age, gender, duration of fever before admission, and crp level were considered as potential confounders for the further multivariate analyses, specifically estimating the relative risks of e. coli genotypes to the incidence of acute pyelonephritis and renal scar by age group and the existence of vesicoureteral reflux. odds ratios with % confidence intervals for each variable were utilized to estimate the relative risk of acute pyelonephritis and renal scar. in addition, there were no differences between young children and old children, if we excluded the factor of vesicoureteral reflux (vur). conclusion: both host and e. coli virulence factors contribute to the development of febrile uti, apn and renal scar. since / we have started an acute peritoneal dialysis (duration - days) in infants (age days to months) with the use of the baxter acute set for children under constant warming of the complete dialysate inflow tract to °c (barkey system). as dialysate solutions we chose a glucose/bicarbonate/lactate solution (physioneal ) in all patients and in patients a mixture of this solution with a . % amino acid solution (nutrineal) in a : ratio. the body weight before the renal insufficiency was . to . kg. in patients the renal failure followed cardiothoracic surgery. the handling of the system was easy. because of obstruction by omentum and fibinous layers, respectively, the dialysis catheter had to be cleared surgically in patients. body temperature could be kept constant and in the normal range, even with low body weight and intensive dialysis (as measured by dialysate volume per kg body weight and day). in the infants dialyzed with the glucose/amino acid-mixture a decreased loss of albumin through the dialysate (as measured by the necessary intravenous albumin substitution), a better glucose homeostasis (less episodes of hyperglycemia and less need for insulin infusions) as well as a better acid-base control (less episodes of metabolic alkalosis) could be found. the detected tendency to a better homeostasis (concerning body temperature, serum albumin, blood glucose and acid-base) with this dialysis system and the used dialysate solutions could help to increase the survival chances of infants with renal failure. this will be evaluated prospectively. objectives: varicella-zoster-virus (vzv) infection can cause significant morbidity and mortality in the immunocompromised patient. since there is no clear correlation between antibody titers and protection monitoring after vzv vaccination is unclear. patients and methods: serum samples of nineteen pediatric transplant recipients were investigated for vzv igg antibody titers and avidity (elisa test). a relative avidity index (rai) < % showed evidence for low-avidity antibodies, an rai > % high-avidity antibodies, borderline avidity inbetween. the control group consisted of healthy children. had suffered from varicella infection after wild-virus contact, had undergone varicella vaccination. as there was no difference between diseased and vaccinated controls both subsets were treated as one group. results: median vzv igg antibody titers were u/ml (range - ) for transplanted children and u/ml (range - ) for control subjects (n. s.). median rai was % for transplant patients and % for controls (p= , ). there was no correlation between rai and antibody titers in either group. rai increased significantly with time after vaccination or infection in both groups. despite protective antibody titers after vaccination and an rai of % one transplant recipient showed a moderate vzv infection that required antiviral treatment. postinfectious course showed an increase of rai up to nearly %. conclusion: vzv igg antibody avidity might be a pathbreaking parameter regarding decision making for a second vaccination before transplantation or preemptive treatment in a transplanted patient in case of exposure. in japan, almost half of children with esrd received renal transplantation and more than % of those were living kidney transplants from their parents. burden of esrd during childhood frequently causes psychosocial problems in their families, including parental relationship problems. we investigated how parental divorce or death affected the choice of renal transplantation in children. patients and methods: in children younger than years old who started renal replacement therapy in our hospital, percentages of the children losing a parent or parents by divorce or death were investigated. we compared renal transplantation rates and percentages of fathers as kidney donors between those living with both parents and those without. results: in observation periods ( . ± . years), ( %) received renal transplants from living and deceased donors. nineteen children ( %) lost a parent or parents by divorce (n= ) or death (n= ). in all divorced families, mothers got parental authority. ten parents divorced during ckd period, after start of dialysis, and after transplant. of children living with both parents, ( %) transplanted with kidneys from fathers, mothers, and deceased donors. of children whose parents divorced, ( %) transplanted from fathers ( just before and after their divorce), mothers and other family members. however, in children at least one parent died, only ( %) transplanted from a deceased donor. conclusion: a high parental divorce rate from ckd period was observed in children with esrd, suggesting burden of the disease on their families. renal transplantation was preferred even in divorced families and divorced fathers still were willing to donate kidneys to their children. objective of study: to determine the importance of gastrointestinal evaluation in pre-transplantation phase in pediatrics with end stage renal disease (esrd). methods: twenty four children with esrd ( female, male) mean age . (± . ) years on maintenance hemodialysis were included in this study. upper gastrointestinal endoscopies were performed and four gastric antral and duodenal biopsy specimens were obtained for urease test and histological study for all patients. serum gastrin levels were measured in all patients, too. a control group was chosen to compare the rate of h. pylori infection using student's t. test. results: gastrointestinal symptoms were present in ( %) of patients. seventeen ( %) patients had abnormal upper gastrointestinal endoscopic findings. h. pylori was detected in % of patients and % in control group (p< . ). in symptomatic patients % had abnormal endoscopic findings and % had positive urease test for h. pylori infection. while, in asymptomatic cases these rates were % and %, respectively. seventy one percent of patients with gastrointestinal lesions and % of patients with normal endoscopic examination were infected. high serum gastrin levels in infected and non-infected patients were detected in % and . %, respectively (p< . ). conclusion: we demonstrated a significant number of patients with peptic ulcer diseases and h. pylori infection and secondary hypergastrinemia. this study showed that, clinical symptoms are not a reliable predictor of gastrointestinal problems. our results emphasize the importance of periodic, and also pre-transplant gastrointestinal evaluation in these patients to find out their problem and manage appropriately. key words: renal failure, hemodialysis, peptic ulcer disease, helicobacter pylori, hypergastrinemia. background: preservation of a stable allograft function in children following renal transplantation (rtx) depends on various factors including genetic variability. the gene of the angiotensin i converting enzyme (ace) has been shown to influence allograft function. we therefore analysed various polymorphisms of the renin-angiotensin system in children following rtx and kidney donors and associated genotypes with loss of renal function. patients and methods: children and adolescents ( male, female, mean age at transplantation . ± . years) with stable renal function and observation period exceeding months were included. mean follow-up time was . years ( . to years). dna was extracted from all recipients and donors and genotyped using rflp. the following polymorphisms were studied: renin g/a; ace i/d; angiotensinogen (agt) met/thr and angiotensin ii receptor type- (at r) a/c. the slope of glomerular filtration rate (gfr) was determined by linear regression analysis and correlated with the genotype. results: allelic frequencies were not different from healthy controls. genotypes of renin, agt and at r showed no significant association with the slope of gfr but patients homozygous for the ace-d-allele had a significantly steeper decline of gfr when compared to homozygous carriers of the ace-i-allele (slope dd: - . ± . vs. ii: - . ± . ; p= . ). the dd-genotype was also present in out of donors and in four cases a dd-recipient received a kidney from a dd-donor. those four patients showed a more pronounced decline of gfr (- . ± . ; p= . ). in addition, dd-recipients had a significantly increased systolic and diastolic blood pressure before rtx. conclusions: the dd-genotype is associated with a faster, non-immunological loss of graft function which has to be evaluated in prospective studies. year large single-center review b. warshaw, l. hymes, l. greenbaum, s. amaral from - , children received renal transplants at emory university/children's healthcare of atlanta of whom ( %) had nephroticsyndrome (ns) as their primary diagnosis ( fsgs, minimal change). all children received calcineurin-based immunosuppression. thirteen children ( %) developed recurrent ns within the first week post-transplant and received plasmapheresis (pp) - times weekly. nine ( %) had complete resolution of proteinuria. two who responded to pp suffered graft loss fromlate recurrences of ns at years. ns did not resolve with pp in children who suffered either delayed function ( ) or early cessationof function ( ); each of the latter lost their grafts within the first months. patients did not have recurrences of ns. comparison of these groups showed significantly increased riskfor recurrence with younger patient age (p< . ), interval < years from onset of ns to esrd (p< . ), and living donor source ( / = % ld vs / = % dd; p< . ). no differences were seenfor hla match, donor age, gender, or african american race. actuarial graft survival for children with recurrence was % at year and % at years vs. % & % for patients without recurrence. conclusions: ns recurred in % of children with ns as their primary cause of esrd. risk factors for recurrence included younger age, interval < years from onset of ns to esrd, and living donors. most recurrences responded to pp ( %); failure to respond was associated with delayed or early cessation ofrenal function & early graft loss. the incidence of recurrence was strikingly high ( %) among living donor recipients, suggesting a need to explore prophylactic strategies such as preemptive pp in this group. methods: a single-centre retrospective case-controlled study including children < yr (g ) and matched kidney tx recipients older than yr ofage (g ). patients were matched for donor type and tx period. kaplan-meier method was used for patient and graft survival. results: tx were performed using deceased donors in both groups. median recipient age, weight and height at tx in g were . [ . - . ] yr, . [ . - . ] kg and . [ . - . ] cm, respectively, while median age in g was . [ . - . ] yr. hypoplasia-dysplasia wasmore frequent in g ( vs %). median hla-dr mismatch, time ondialysis and number of blood transfusion before tx were not different. in g , kidneys were placed intraperitoneally and most of vascular anastomoses were done on distal aorta ( %) and inferior vena cava ( %). median follow-up was . [ . - . ] yr and . [ . - . ] yr ing and g , respectively. patient survival was % at yr and % at yr in g ; patients died in g ( ptld, recurrence of primary disease), none in g . fiveyear graft survival was % in g and % in g . acuterejection episodes occurred in % in g and in % in g (p . ). chronic rejection led to late graft losses in g ( . to . yrafter tx) vs in g . renal function did not differ between the groups during the first yr post tx. the average height gain was better in g at yr post tx (+ . sds vs. - . ). primary disease recurrence was observed in cases ( in g ) causing graft lossin cases. two arterial thromboses were observed in g causing earlygraft-loss. conclusion: the outcome after cadaveric kidney transplantation is as good in children under yr of age at transplantation as in older recipients in our experience. c. garcia, v. bittencourt, d. malheiros, a. tumelero, j. antonello, a. oliveira, v. garcia cancer is an increasingly recognized problem associated with immunosuppression. recent reports, however, suggest that sirolimus (srl) has anti-cancer properties that could address this problem. aim: to report a retrospective analysis of preliminary results of patients who received srl because of post-transplant de novo malignancies in a consecutive cohort of pediatric kidney recipients. patient and methods: we retrospectively evaluated the efficacy and safety of srl in pediatric renal transplantation recipients, who were ± years when converted to srl. the post-transplant de novo malignancies were: gall bladder and hepatic leiomyoma (n= ), wilms tumor in the native kidney (n= ), ptld (n= ) and hpv-associated neoplasia. the immunossupressive regimen at the malignancy diagnosis was tacrolimus/cyclosporin, mmf/azathioprin and prednisone. all were converted to double immunossupression with sirolimus at a standard dose of mg/day (tl - ng/ml) and prednisone. patients with ptld were also treated with rituximab, and the patients with wilms tumor received chemotherapy. mean follow-up after srl conversion is ± months. results: all patients were maintained with srl and pred without rejection, with good renal function and no cancer recurrence (follow-up to months). the patients with wilms tumor are still on chemotherapy. follow-up control after srl conversion in the patients: conclusion: although the intraperitoneal group had characteristics associated with increased surgical risk (they tended to be younger and smaller, with a higher incidence of aortic anastomoses and a higher incidence of multiple vessels), surgical complications were significantly lower than expected in the extraperitoneal group % v. %. objective of study: proteinuria is a frequent complication in adult patients after renal transplantation (r-tx) and is associated with poor graft survival. in children, there are no studies focusing primarily on proteinuria after r-tx. the aim of this study was to investigate the prevalence of proteinuria in children after r-tx and to evaluate changes of proteinuria during a -yr study on intensified antihypertensive therapy. methods: protein excretion was measured in -hr urine and proteinuria defined as > mg/m /day. proteinuria was investigated at baseline, and years after intensifying of the antihypertensive therapy in children with uncontrolled hypertension at baseline (i. e. additional antihypertensive drugs given to children with blood pressure > . pc). children ( . ± . yrs) out of from our center fulfilled inclusion criterias (> months after r-tx, no acute rejection (ar) in the last months, no recurrent fsgs). results: the prevalence of proteinuria was % at baseline, % after year (ns) and it decreased to % after years (p< . ). the mean protein excretion was ± mg/m /day at baseline, ± after year (ns) and it decreased to ± after years (p< . ). mean number of antihypertensive drugs increased from . ± . drugs/patient to . ± . after years (p< . ). mean nighttime bp decreased significantly after years. the number of patients on ace-inhibitors increased from % at baseline to % after years (p< . ). conclusions: this is the first study on proteinuria in children after r-tx. it showed that proteinuria is a frequent finding in transplanted children and that intensified long-term antihypertensive treatment using ace-inhibitors can decrease not only bp but also proteinuria in these patients. allograftrejection involves t cell activation and proliferation and multipleinflammatory components. monocyte chemotactic peptide- (mcp- ) is achemoattractant and activating factor for monocytes. interleukin- (il- ) may contribute to monocyte recruitment, results intubulointerstitial damage. cytotoxic lymphocytes induce target cell death by ligation of the fas-fasligand. allelic polymorphisms in recipient genes coding for them reported to beassociated with variations of outcome in renal transplantation. the aim was to investigate impact of mcp- - a/g and il - g/c, fas- a/g polymorphisms on acute allograft rejection (ar). there were males and females, ± . years meanly; of the graftscame from living-related donors, were from cadavers. the controlgroup consisted of unrelated, healthy individuals with similar ageand sex. ar group was composed by patients experienced at least one ar episode within the first months of transplantation. the non ar group was comprised by kidney transplant patients without ar. there was no significant difference between renal transplant patients and healthy controls in genotype distribution of allelic frequencies of il- , fas and mcp- polymorphisms. while il- and fas gene polymorphisms had no effect on the incidence of ar episodes, there was significant association with mcp- . the distribution of the genotypes for mcp- - a/g in ar group were aa/ag/gg , %, , %, , % respectively. the distribution of the genotypes for mcp- - a/g was aa/ag/gg %, %, % in nonar group respectively. the carriage of g allele at - position of mcp- gene has a significant association with ar (or: , , %, ci: , - , ). the il- and fas gene polymorphisms had no effect on the incidence of ar. mcp- - g allele carriage increases the ar risk in turkish renal transplant patients. the high recurrence rate of focal segmental glomerulosclerosis (fsgs) in transplanted kidney recipients suggests the hypothesis that such patients have a circulating factor that changes glomerular capillary permeability. serum from patients with fsgs increases glomerular permeability to albumin, and this permeability factor was partially identified as a protein. the removal of this protein by plasmapheresis (pp) decreases proteinuria. object: the aim of this paper is to provide data about the therapeutic effect of pp in fsgs children with recurrence in the transplanted kidney. methods and results: twenty eight pediatric kidney transplant recipients had fsgs as cause of renal failure from to in our center, confirmed by biopsy pre-transplant. seventeen of these ( . %) had a recurrence (proteinuria > g/m per day associated with hypoalbuminemia). the mean age was ± . years, , % were caucasians and , % were performed with living donor. since , patients who presented fsgs recurrence were treated with cycles of pp ( cycles/weekly), initiated immediately post-recurrence (n= ). immunosuppression comprised of cyclosporin in high doses (c levels of - ng/ml) or tacrolimus (tl= mg/dl), mycophenolate sodium or mofetil (until azathioprine was used) and prednisone. among patients who received pp (n= ), ( . %) achieved a complete remission. there were no cases of remission among those six patients who were not treated with pp. those who achieved remission after pp had no recurrence. the patients treated with pp had infectious complications: one patient had cytomegalovirus disease and two patients had varicella. conclusion: pp appears to be effective in treating recurrent fsgs following kidney transplantation. it should be started as soon as possible. because the calcineurin inhibitors (cni) cyclosporin a (csa) and tacrolimus (tac) are drugs with a narrow therapeutic index, individualization of cni dosage by therapeutic drug monitoring is indisputable. however, the optimal strategy for monitoring cni therapy is currently under debate. dosing of cnis according to the molecular effect of the drug on its target cells could optimize immunosuppressive therapy with cnis. for this purpose, we developed a reliable, precise, and robust whole blood assay based on the measurement of the expression of three nfat-regulated genes (il- , ifng and gm-csf) in pma/ionomycin-stimulated lymphocytes before and . (tac, c . ) or hrs (csa, c ) after oral drug intake. the inhibition of genes in this assay is independent from other commonly used immunosuppressive drugs and reflects calcineurin inhibition expressed as residual nfat activity. in a pilot study, patients (mean age yrs, mean time period posttransplant mo.) were analyzed. in csa-treated patients (n= ), a mean c concentration of ng/ml (range, - ng/ml) corresponded to a mean residual nfat-activity of % (range, - %) ; the correlation between individual residual nfat-activity and c was moderate (r= , , p< . ). at a csa-c of ng/ml, the residual nfat-activity varied between % and %. in tactreated patients (n= ), a mean c . concentration of ng/ml (range, - ng/ml) corresponded to a mean residual nfat-activity of % (range, - %); the correlation between individual residual nfat-activity and c . was also only moderate (r= , , p< . ). conclusion: these data indicate that there is a considerable inter-patient variability of residual nfat-activity at a given maximal cni blood concentration. ongoing studies are validating this assay regarding clinical outcome criteria of immunosuppression such as acute rejection and infections. hus due to antibodies against factor h (husafhab) is a very rare disease for which a limited experience in its management is available. we present a case of husafhab who was transplanted but lost her graft after only mos. in aug a -mos old child was admitted for a d-hus which did not go into remission and required chronic peritoneal dialysis. no fh and mcp gene mutation were detected nor adamst- activity was decreased. afhab were not searched at that time. in apr. the child underwent cadaver renal transplant (rtx). the immunosuppressive regimen was basiliximab-prednisone-cyclosporine-mycophenolate mofetil. fifteen days after rtx, following surgery for urinoma, the child exhibited an hus relapse with thrombocytopenia, haemolytic anemia and increased serum creatinine (scr). high afhab were detected ( au/ml). four plasma exchanges (pe) were performed over wks with a drop of afhab to control level ( au/ml) and a remission of hus. until the end of aug, afhab remained low (< au/ml) and the child was well (scr range: . - . mg/dl). in early aug, the patient was shifted to tacrolimus for severe hypertrichosis with a fluctuation of its plasma level (lower recorded value: . ng/ml) signs of acute rejection developed and metilprednisolone (mtp) pulses brought scr to baseline level. in oct. , following an urti, the child presented with severe proteinuria (upr/ucr: , ) without other clear signs of hus recurrence. since afhab were increased ( au/ml), pe was restarted but an acute hemorrhagic complication (hemotorax) occurred and pe had to be interrupted. septicemia followed and the child became anuric. the renal biopsy performed days later showed signs of glomerular and vascular thrombotic microangiopathy. renal function did not recover despite mtp pulses and pe. in nov the child was back to pd and in dec the graft was removed. background & aims: recently, the role of nitric oxide (no) in the pathogenesis of idiopathic nephrotic syndrome (ins) has been intensively investigated. however, its rapid turnover has made us impossible to investigate the quantity and the source. as we have developed a novel method for quantitative analysis for no by a new fluorescent indicator, , -diaminofluorescein (daf- ), its amount produced by both t and b lymphocytes in ins was studied. methods: five children with steroid-sensitive ins (mean age: . y) were included in this study, together with children with other renal diseases (mean age: . y) such as chronic glumerulonephritis and alport syndrome with significant amount of proteinuria, and healthy adults (mean age: . y) for the control. no production from cd + cell and cd + cell was investigated by a flow cytometry using daf- . results were expressed as mean fluorescence intensity and were compared among the groups. results: the amount of no produced by cd + cell and cd + cell in children with ins was significantly greater than those in children with other renal diseases and healthy adults (cd + cell: . ± . [mean±sd], . ± . , and . ± . , respectively; cd + cell: . ± . , . ± . , and . ± . , respectively, p< . ). additionally, both cd + cell and cd + cell during nephrotic relapse produced more no than in nephrotic remission (p< . ). discussion: patients with relapsing ins showed increased production of no by both t and b lymphocyte. these findings indicate that no plays some role in the pathogenesis of ins and suggest that an abnormal immune system may exist not only in t but also in b lymphocytes. a. bagga, a. sinha, s. menon, p. hari aim: the treatment of patients with srns is challenging. based on suggestions that b-lymphocytes are crucial in the pathogenesis of nephrotic syndrome, we examined the efficacy of rituximab (rtx) in patients with srns refractory to standard therapies. methods: six patients ( with initial, late resistance), - yr old, were included; biopsy showed minimal change & focal segmental glomerulosclerosis in each. all had previously received iv high-dose steroids, alkylating agents & calcineurin inhibitors (cni) for - yr with periods of partial (pr; urine - +) or complete remission (cr; urine trace/negative). all now had srns refractory to -months treatment with cni. rtx ( mg/sq. m) was infused iv every week for weeks. therapy with cni and/or alternate-day prednisolone, & cotrimoxazole prophylaxis was continued. patients were monitored for proteinuria and renal functions. results: at a median interval of wk following the last rtx dose, cr was seen in & pr in patients. remission was sustained in patients, despite tapering doses of steroids & cni. one case had relapse of nephrotic syndrome -months later, which responded to steroid treatment. at median follow-up of wk, cr, pr and recurrence of nephrotic proteinuria ( - +) were seen in , and patients respectively. mean urine albumin-to-creatinine ratio was . at baseline and . at followup; respective blood levels of albumin were . and . g/dl & cholesterol and mg/dl (all p< . , anova); difference in leukocyte counts and levels of igg were not significant and none had serious infections. conclusions: this is the first report on the efficiacy of rtx in sustaining remission in patients with srns. therapy with this agent appears promising for difficult srns, with a better risk/benefit profile than other medications. quantitative or functional deficiency of factor h results in uncontrolled complement activation and is an important cause of familial hemolytic uremic syndrome (ahus). factor h-related proteins (fhr) constitute a protein family which share structural and most likely functional similarities to factor h. we here describe complete deficiency of fhr- /- as novel cause of ahus. factor h and fhr- /- were quantified by elisa and were further analyzed by western blot using specific antibodies. complement activation was determined by measuring c and c . serial hgb (g/dl), platelet, creatinine (mg/dl), and ldh (u/l) were measured. a year old girl presented with a day history of lethargy, pallor, vomiting and hypertension. hgb was g/dl, platelets x /l and creatinine was . mg/dl. initial therapy consisted of packed red cell and platelet transfusion, followed by steroid therapy. representation occurred weeks later with hypertension, edema, persistent anemia thrombocytopenia and renal dysfunction (creatinine . mg/dl). renal biopsy demonstrated features of chronic thrombotic microangiopathy. low c levels indicated activation of the complement system. while western blot analysis showed normal factor h level, fhr- /- was absent. by repetitive plasma infusion and plasmapheresis, the cycle of hemolysis and thrombocytopenia could be disrupted. chronic periodical plasma infusion q days resulted in regression of renal impairment to a degree (current baseline creatinine . mg/dl). in conclusion, fhr- /- are thought to have co-factor activity and play a role in complement activation in ahus. deficiency of fhr- /- may lead to a subclinical form of ahus such that patients may initially present with features of chronic renal failure. however, factor replacement therapy may lead to regression of renal impairment. s. choudhry objectives of the study: the aim of the study is to investigate the long term prognosis ofsevere childhood iga nephropathy after years combined therapy. patients: we examined patients who had entered thejapanese pediatric iga nephropathy treatment study group between and , had been treated with years combined therapy (combinationof prednisolone, azathioprine, dipyridamole and heparin/warfarin) andhad been followed for more than years after the therapy. significantproteinuria is defined as more than . g/m /day. results: mean age at onset was . years ( - years), proteinuria at diagnosis was . ± . g/m /day, proteinuria after the combined therapy was . ± . g/m /day and mean follow-up period after the combined therapy was . years ( . - . years). proteinuria improved in all patients during thecombined therapy (p< . ). the final prognoses were as follows: patients ( %) showed no proteinuria, ( %) showed proteinuria withnormal renal function and ( %) proteinuria with decreased renalfunction. we compared the clinical and pathological parameters betweenpatients with proteinuria (n= ) and those without proteinuria (n= ) at the last observation. period between disease onset and start of treatment, glomeruli showing crescents before the combined therapy (%) and glomeruli showing pathological changes after the combined therapy (%) were the significant risk factors for the proteinuria at the last observation. logistic multivariable analysis revealed that glomeruli showing pathological changes after the combined therapy (%) was theonly independent risk factor for the proteinuria at the last observation. conclusions: pathological activity of nephritis at the end of the combined therapy might correlate well with the final proteinuria and the long term prognosis. s. arun, a. bagga, s. bhatnagar, p. hari, s. menon, s. saini aim: relapses in ssns of ten follow minor infections and are associated with perturbed t-cell function. based on data that zn supplements modulate t-cell function and reduce risk of infections, we examined its efficacy in reducing relapses in patients with ssns. methods: in this double blind rct, consecutive patients with ssns - yr old, stratified into frequent (fr= ) and infrequent (ifr= ) relapsers, were randomized to -months therapy with zn ( mg daily) or placebo. patients with fr also received long-term, alternate day prednisone. relapse and infection rates were monitored monthly. blood levels of zn, sil r, il and interferon (ifn) were measured at baseline, relapse andend of study. results: patientsin the zn (n= ) and placebo (n= ) groups had similar baseline clinical & laboratory features. the former showed % lower frequency of relapses (difference in means - . ; % ci - . , . ) with trend towards reduction from -months onward. a higher proportion ( . %) of patients in the zn group had sustained remission compared toplacebo ( . %). reduction in relapse rates was higher in fr receiving zn vs. placebo (- . ; ci - . , . ); respective sustained remission was seen in % and % patients (relative risk . ; ci . , . ; p . ). no differences were found in infection rates, and levels of zn, sil r & il ; levels of ifn were higher in those receiving zn compared to placebo (p= . ). conclusions: zn supplementation for -yr was effective in maintaining remission and reducing relapse rates. the effect was mediated not by reducing infections but perhaps through effect on th cytokines. while zn therapy appears promising, these results need confirmation in patients with frequent relapses and perhaps at a higher dose. background: n-glycosylation process in the endoplasmic reticulum (er) is tightly regulated and orchestrated by many factors such as chaperones and energy systems. we showed that adequate nglycosylation is crucial for nephrin to assemble to the plasma membrane (jasn, ) . additionally we recently demonstrated that the er stress evoked by glucose starvation induces hypoglycosylated nephrin retained in the er, which is rescued by dexamethasone (dex) (ki, ) and immunosuppresant: mizoribine (mzr) (submitting). in the present study, we tested whether other er stress inducer, hypoxia, could also interfere the alteration of nephrin n-glycosylation system and whether dex and immunosuppressants rescue its defective process. methods: nephrin-expressing cell line was cultured either in % o or % o for hours in the presence or absence of dex, mzr and cyclosporin a (csa), followed by western blot analysis with nephrin, cytochrome c. intracellular atp concentrations were measured by the highperformance liquid chromatography. protein expression of cyclophilin d (cyp-d), a component of mitochondrial permeability transition pore (mptp), was tested in the samples from human glomeruli and cultured podocyte. results: hypoxia induced hypoglycosylated nephrin. csa, but not dex and mzr, inhibited the formation of this hypoglycosylated nephrin and rescued mature form. csa inhibited the increase of cytochrome c in the cytoplasm caused by hypoxia. in addition, csa partially rescued the decrease of intracellular atp. cyp-d was distinctly observed in human glomeruli and located in podocytes. conclusion: csa inhibit the formation of hypoxia-induced hypoglycosylated nephrin through protecting the mptp opening via selectively binding to cyp-d in the mitochondria, resulting in a recovery of atp. csa may exert direct action on the alteration of nephrin biogenesis induced by the er stress. background and objectives: in two previous randomized controlled trials (rcts) we showed that treatment of severe childhood iga nephropathy (iga-n) with diffuse mesangial proliferation using prednisolone, azathioprine, heparin-warfarin, and dipyridamole reduced immunologic renal injury and prevented any increase of sclerosed glomeruli. in one of the two rcts we also showed that treatment with prednisolone alone did not prevent a further increase of sclerosed glomeruli. accordingly, the immunosuppressant is considered to play an important role in the combination therapy. often however, we were unable to complete the azathioprine regimen due to its severe side effects. therefore we considered that a different, but effective immunosuppressant would be worth trying. mizoribine, like azathioprine, is an antimetabolite that exerts its immunosuppressant effect by inhibiting lymphocyte proliferation. design, setting, participants, and measurements: in this pilot study, we administered mizoribine instead of azathioprine as part of the combination therapy for treatment of children with severe iga-n and evaluated the efficacy and safety of the regimen. results: eighteen patients reached the primary endpoint (urinary protein/creatinine ratio < . ) during the two-year treatment period. the cumulative disappearance rate of proteinuria determined by the kaplan-meier method was . %. mean urinary protein excretion was reduced from . g/m /day to . g/m /day (p< . ). after treatment, the mean percentage of glomeruli showing sclerosis was unchanged in comparison with that before treatment. no patients required a change of treatment due to side effects. the efficacy and safety of the mizoribine combination seems to be acceptable for treatment of children with severe iga-n. objectives of study: alport syndrome is a hereditary renal disease which is normally diagnosed by either histopathological studies or a genetical analysis. we attempted to diagnose alport syndrome by means of immunofluorescence staining of cultured cells with collagen type alpha chains obtained from voided human urine specimens. methods: the cells were cultured from the voided human urine of patient with x-linked alport syndrome, patient with sporadic alport syndrome, and patient with autosomal-dominant alport syndrome. for comparison purposes, controls cells were cultured from the voided human urine of patient with iga nephropathy, patient with fsgs, and patient with purpura nephritis. the cultured cells were stained by immunofluorescence techniques with collagen type alpha , , , , and chains. results: in the cultured cells of the controls staining for collagen type alpha and chains were observed both in the extracellular matrix and in the cytoplasm while for the staining of collagen type alpha , , and chains were observed in the cytoplasm. in cultured cells of xlinked and sporadic alport syndrome staining of collagen type alpha chain was lost or attenuated. in the cultured cells of autosomal-dominant alport syndrome the staining patterns of collagen type alpha , , and chains were observed. the staining patterns of the collagen type alpha chain in cultured cells of alport syndrome correlated with that observed in renal biopsies obtained from alport syndrome patients as reported previously. hence, the staining of cultured cells with the collagen type alpha chain obtained from voided human urine may therefore be a potentially useful means of diagnosing alport syndrome in a non-invasive manner. the aim of our study: was to examine zeta chain expression in cd +, cd + t cells and nk cells from ins children in active phase of the disease and in remission and to assess the effect of h and h anti-cd + ril- stimulation on zeta chain expression. we enrolled ins children in relapse before initiating the therapy, ins children in complete remission of proteinuria on prednisone for - weeks ( mg/kgbw/d) and age-matched controls. zeta expression was determined by flow cytometry as mean fluorescence intensity (mfi). results: cd +cells: mfi in relapse was higher than in remission and in controls. anti-cd + ril- stimulation had no impact on zeta expression in acute phase and in cotrols, but increased mfi values after h in pts with remission. cd +cells: zeta expression stayed unchanged irrespective of the examined group or antibody stimulation. nk cells: there were no differences between mfi values before stimulation and in relapse after stimulation. in remission and in controls antibody stimulation decreased zeta expression. in controls, mfi values for nk cells were higher than those for cd + and cd + populations, but this preponderance disappeared after h stimulation. in remission, that nk cell predominance vanished after h stimulation. in relapse, mfi values in all cells were comparable and stimulation had no impact on lymphocyte proportions. urinary protein, creatinine, and scd were measured. scd was measured using a elisa kit. scd was expressed as ng/g of urine creatinine. data were analyzed using anova and spearman rank correlation (src) tests. ) scd urinary concentrations in patients with mlns in relapse were higher than patients in remission, healthy controls and other patients with proteinuria (anova p . ) but similar to those seen in sle. ) in patients with mlns relapse, scd concentration did not correlate with urine protein/creatinine ratio (src, r: . , p: . ) ) in patients with mlns, serial urine scd concentrations were measured over a period a time. scd was increased at the time of relapse and decreased toward normal range weeks before patients went into remission. conclusion: urinary scd is elevated in mlns patients in relapse. this increased urinary concentration is not due to the proteinuria, since scd was not elevated in other patients with glomerulopathies and proteinuria. upregulation of podocyte scd during relapse may play a role in the pathogenesis of proteinuria in mlns. aim: patients with mpgn type ii/dense deposit disease (ddd) and atypical haemolytic uremic syndrome (ahus) secondary to defective complement control are found to have a high prevalence of y h polymorphism of factor h gene (cfh), which is linked to age-related macular degeneration (amd). however, no studies have looked into an ocular phenotype of children with complement based renal diseases, yet. methods: in two pediatric nephrology centres all patients with mpgn ii/ddd and ahus were identified and screened prospectively for the presence of y h polymorphism and drusen maculopathy. all patients have been on immunomodulatory therapy at the time of screening. results: four children were identified (male:female= : ) with mpgn ii/ddd and ahus. there were two children in either group. the median (range) age at examination was . years ( . to . years). of the four patients, all were found to have the y h polymorphism. none of the patients had evidence of drusen at the time of examination. two patients with mpgn ii/ddd and one patient with ahus had additional factor h mutations, which were thought to be responsible for the renal disease. conclusion: in our study of children with mpgn ii/ddd and ahus we found a % prevalence of the y h polymorphism of factor h gene, which puts these patients at higher risk for drusen maculopathy. therefore, all children with either mpgn ii/ddd or ahus should be screened for y h polymorphism; and if found positive have regular follow-up ophthalmologic examination. in the future, should y h be proven to be of functional significance with respect to complement control, there would be a role for plasma infusion or replacement of purified factor h for the treatment of both the renal and the ocular phenotype. we previously demonstrated that angiotensin-( - ) is an endogenous ligand for the g-protein coupled receptor mas. the aim of this study was to evaluate the role of angiotensin-( - ) mas receptor in kidney structure and function by using transgenic mice with genetic deletion of the receptor mas. mas -/-(knockout) mice were compared to mas +/+ (wild type) mice regarding renal function parameters and kidney histology. the animals were housed in metabolic cages to obtain -hour urine samples for measuring urinary volume, osmolality and microalbuminuria. at the end of the experiment, mas -/-and mas +/+ mice were sacrificed by decapitation to harvest the kidneys for histological analysis and immunofluorescence of collagen types iii and iv. the quantification of collagen expression was determined by confocal microscopy (zeiss lsm ). urinary volume was significantly reduced in mas -/-mice as compared to mas +/+ animals ( . ± . vs. . ± . ml/ hs in mas +/+ mice, p< . ). this change was associated with an increase in urinary osmolality ( ± vs. ± mosm/kg in mas +/+ mice, p< . ) and albumin excretion ( . ± . vs. . ± . mg/ hs in mas +/+ mice, p< . ). the histological analysis showed a significant reduction in the glomerular diameter in mas -/-mice as compared to mas +/+ animals ( . ± . vs. . ± . μm in mas +/+ mice, p< . ), where as any significant change was observed in tubular diameter. the immunofluorescence of mas -/-kidneys revealed a marked increase of the expression of collagen types iii and iv in periglomerular region as well as in external and internal medulla. collagen iv was also augmented in mesangial area of mas -/-mice. these results suggest that the receptor mas is critical for the regulation of renal structure and function. a circadian rhythm in calciuria is evident with a peak after : h, a lower excretion overnight and a nadir in the early morning. during the peak period both ca/creat ratio (figure) and calcium output frequently surpass the reference values of . mg/mg and mg/kg/day respectively. conclusion: a significant circadian variation in calciuria is evident in normal school age children, with peaks surpassing commonly used reference values for hypercalciuria. this peak excretion is independent from urine output, glomerular filtration and intake. the average h excretion of mg/kg is rarely surpassed despite this peaks. the management of children with secondary hyperparathyroidism is complicated and should start early in the course of renal insufficiency. in spite of an optimal management hyperparathyroidism is sometimes uncontrolled and calcimimetics like cinacalcet hydrochloride which directly stimulates calcium sensing receptors and potently suppress pth secretion are an alternative to parathyroidectomy. they are very promising agents, but paediatric experience is lacking. a years old girl with a bardet biedl syndrome without medical care came last year with end stage renal failure. thanks to daily hemodialysis, serum phosphate level was kept within normal limits and phospho-calcic product remains below . as recommended. in spite of this treatment, serum pth level increased to ng/l. this toxic hyperparathyroidism with optimal monitoring of serum calcium, phosphate, vitamin d levels led us to start calcimimetics. a , mg/kg cinacalcet dose was administrated and induced a decline of pth level to ng/l one month later. a years old boy with recessive polycystosis and chronic renal failure was treated with calciumbased phosphate binders and sevelamer hydrochloride but with a poor compliance and a free diet which led him to hyperparathyroidism (pth to ng/l). in addition, a parathyroid gland hyperplasia with two adenoma was individualized. start of calcimimetics treatment (less than mg/kg) led to a rapid decline in pth level from ng/l to ng/l. the two adenoma decreased in size. in case of hyperparathyroidism, with close monitoring of serum calcium, phosphate, alkaline phosphatase and vitamin d levels, calcimimetics are an excellent alternative to surgery, with safe use and low dose in these cases. preliminary favourable experience has been reported in children but paediatric experience is lacking. side effects result from chronic administration of steroids. the aims of this study are to analyze graft function and metabolic effects of low dose and withdrawal of steroid therapy. this is a single center pilot, one arm and prospective study. methylprednisone (mp) was decreased to . ± . mg/kg/day (low dose) after months. we studied changes in graft function, height velocity, lipid profile, body composition and bone mass after year of low dose mp and after a nd year following mp withdrawal. patients received daclizumab induction; tacrolimus and mycophenolate mofetil. the inclusion criteria was st living related graft and pra < %; patients were enrolled and total follow-up was . years. age at transplantation was . - years, females, prepubertal, postpubertal patients. patients and graft survival were %, acute rejection (ar) occurred after months of mp withdrawal in / ( %) prepubertal patients (banff , b). in prepubertal patients, at the moment of steroid withdrawal and year later creatinine clearance was . ± . and . ± . ml/min/ . m , p< . ; height velocity . ± . and . ± . cm/year, p: ns, with a height increment of . ± . sds, p< . during the last year of follow-up. graft function did not change in postpubertal patients. in all patients at the moment of steroid withdrawal and year later lipid profile was normal; fat body mass . ± . and . ± . kg, p: ns; lean body mass . ± . and . ± . kg, p< . ; total skeleton bmd - . ± . and - . ± . sds, p: ns and lumbar spine bmd - . ± . and - . ± . sds, p< . . this study demonstrates that low dose and steroid withdrawal allow catch up growth, normal lipid profile with no fat accumulation. steroid withdrawal prevents bone loss with increment of lean body mass, but with a concerning rate of ar and graft function deterioration in prepubertal patients. children with x-linked hypophosphatemic rickets (xlh) usually present with progressive disproportionate stunting. we therefore conducted a year randomized controlled trial on theeffect of rhgh therapy on body anthropometry ( parameter) in prepubertal children with xlh (each patients in rhghandcontrol-group). age at baseline was . ± . yrs (mean±sd), height was - . ± . sd, calcitriol dosage was ng/kg x day, and phosphate dosagewas mg/kg x day (each p> . rhgh-vs. control-group). results: within the whole study population longitudinal bodydimensions were more affected than transversal body dimensions aswell as circumferences (extremities/trunk). leg length (- . ± . sd; p< . ) was the most impaired longitudinal parameterexplaining % of the overall variability of total body height, whereassitting height (- . ± . sd) was the best preserved longitudinalparameter. longitudinal body dimensions were significantly increased after months rhgh-treatment (height + . ± . sd; sitting height + . ± . sd, leg length + . ± . sd; arm length + . ± . sd; each p< . ). in contrast, progressive stunting was noted in control patients (height - . ± . sd; sitting height - . ± . sd; leg length - . ± . sd; arm length - . ± . sd; each p< . vs. rhgh-group). rhgh treated patients showed a significant increase in all transversal body dimensions (each p< . ), as well as a decrease in skin folds (range - . up-to - . sd; each p< . ). one year rhgh treatment in severely growth retardedprepubertal children with xlh leads to improvement of longitudinal bodydimensions, harmonization of body (i. e. transversal body dimensions & body proportions), and decrease of body fat. thalassemia is an hemolytic anemia characterized by decreased production of β globin. the chronic hemolysis requires frequent bloodtransfusions that caused hemosiderosis, including iron deposition in the kidney. removal of excess iron via iron chelators, the most commonof which is desferal produce iron excretion in urine and stool. few studies have been published, the studied patients, mostly adults, exhibited proteinuria, aminoaciduria, low urine osmolarity and excess secretion of the proximal tubular function markers, n-acetyl-d-glucoseaminidase (nag) and β microglobulin. the iron accumulation may causes lipid oxidative peroxidation and this oxidative process cause's tissue damage. in this study we examined thalassemia major patients treated with desferal. the degree of hemosiderosis was determined by measuring serumiron and ferritin. children without iron metabolism disorders orrenal disease serve as controls. the renal and tubular function was analyzed. no differences in creatinine clearance, blood hco , na and k fe, tmp/gfr was found. serum uric acid was equal in the two groups but itsurine excretion was significantly higher in the thalassemic group probably due to persistent hemolysis. the nag level and its ratio to creatinine were significantly higher compared to the control group. the results of our work showed that most of the thalassemic patients have sub clinical disturbances in tubular function and high nag in theurine. these results raise the question of treating thalassemic patients with oral chelators which removes iron from cells preventing the oxidative process; moreover, and add antioxidants which may prevent the deposition of iron in tissues. in light of these findings, it would be advisable to routinely check glomerular and tubular function as part ofthe follow-up in these patients. objectives of study and methods: little information is available on the long-term follow-up in patients with biallelic mutations in the two genes slc a and kcnj , encoding the bumetamidesensitive na-k- cl cotransporter and the in wardly rectifying renal potassium channel, respectively. we evaluated the long-term follow-up (> years) in patients with these two forms of bartter syndrome. the slc a and kcnj genes were screened by dhplc and sequencing techniques. results: the long-term follow-up period was to years, median , after diagnosis, in patients with mutations in slc a ( homozygotes, compound heterozygotes) and patients with mutations in kcnj ( homozygotes, compound heterozygotes) genes. medical treatment with indo methacin at last follow-up control including supplementation with potassium in patients and medical treatment with indomethacin in patients (meandose . mg/kg/day). in two patients (one with slc a and another one with kcnj mutations) growth hormone (gh) deficiency was detected with specific tests. both patients were treated with recombinant human gh. at the end of follow-up, body height was < ° percentile for agein of the patients, of whom with gh deficiency and body weightwas < ° percentile for age in patients (none of them with gh decifiency conclusions: these data demonstrate that some patients with biallelic mutations inthe slc a and kcnj genes tend to present slight impaired glomerular kidney function after a median follow-up of years and that growth retardation and gh deficiency are often present in these patients. the cytosolic c-terminus of nhe does not mediate its apical localization or baseline activity -implications for blood pressure and ph homeostasis the epithelial sodium proton exchanger, nhe , is expressed in the apical membrane and subapical endosomes of the proximal tubule. apical localization is fundamental to proximal tubular na+, water and hco -absorption, a process necessary for the maintenance of plasma ph and blood pressure. moreover the redistribution of nhe between these compartments alters its activity. for example, acute hypertension leads to an increased endomembrane accumulation of nhe and pressure natriuresis. nhe is composed of a n-terminus with transmembrane helices and a cytosolic c-terminus. the former is necessary for sodium-proton exchange while the latter regulates activity. the goal of our studies was to evaluate the contribution of the cytosolic c-terminus to apical localization and therefore to nhe function. to this end we generated a series of nhe constructs with sequential deletions in the cytosolic c-terminus. all constructs contained an extracellular epitope tag to facilitate the delineation between cell surface and endomembrane nhe . stable renal epithelial cell lines were generated expressing each construct. surprisingly, even when the entire c-terminus was deleted nhe was still detectable at the apical membrane. we proceeded to evaluate the activity of the truncated exchangers and found they retained activity. finally, we assayed the attachment of nhe to the actin cytoskeleton (a process thought to be mediated by the c-terminus), by measuring their solubility in the weak detergent triton x- and by measuring their mobility in the plane of the plasma membrane. both assays confirmed that exchangers lacking the c-terminus retained their association with the plasma membrane. in conclusion, the cytosolic c-terminus of nhe is not necessary for apical localization nor baseline nhe activity. further studies will be needed to confirm its role in specific regulatory processes. background: ibu is used as a safer alternative to indomethacine for pda treatment. however, safety/efficacy balance has not been extensively studied. animal and a few clinical studies suggested that ibu might also have significant side effects. objective: to evaluate renal function at one week of life in infants treated with ibu as compared to infants not exposed to ibu, within the first days of life. methods: multicentric prospective cohort study of to weeks gestation (ga) infants exposed or not exposed to ibu. infants presenting with renal impairment at birth, urinary tract malformation, or contraindication to ibu treatment were excluded. infants exposed to ibu were paired to controls according to ga, centre and crib score. creatinine clearance (ml/min/ . m ) was measured for glomerular function evaluation; fractional excretion of sodium (fena) and microglobinuria/creatininuria ( /ucr) for tubular function evaluation. results: infants were studied: exposed to ibu for pda closure with . % efficiency and controls. birth weight was ± g (mean+sd), and ga . ± . wks. glomerular filtration rate (gfr) significantly decreased on day in ibu exposed infants. noteworthy, diuresis remained in the normal range, but was significantly lower after ibu treatment (given on day ) as compared to controls. antiresorptives, particularly bisphosphonates (bp), offer a promising treatment inpediatric bone disease. bp have been successfully used to treat childrenwith osteogenesis imperfecta (oi), secondary osteoporosis, fibrousdysplasia, hypercalcemia. concerns exist regarding bone mineralizationand bone growth and transient adverse reactions. according to available literature, bp were successfully used in ~ children, intravenous pamidronate (pm) being the most frequently used one (> children, mostly with oi), followed by alendronate (al) (~ patients with oi, secondary osteoporosis, hypercalcemia), risedronate, etidronate, zoledronate, clodronate, olpadronate. oi treatment with bp resulted in an increase in bmd, improved growth, relief from pain, mobility improvement, improved quality of life and a drop in fracture rate there are sparse data comparing oral and i. v. bp. oral and i. v. bp seem to have a similar effect in children with oi. daily al therapy seems to be safe and effective in children with oi, and daily or weekly administration of al led to increase in bmd in patients with secondary osteoporosis. there is scarcity of randomized, double blind, placebo-controlled or active comparator trials with bp in children. currently, double-blind, placebo-controlled study with risedronate andactive comparator trial with intravenous zoledronate in children with oi are planned. bp therapy should be used in context of a well-runclinical program with specialist knowledge in the management of pediatric metabolic bone disorders. other emerging antiresorptive agents include denosumab, glucacon-likepeptide- and calcitonin tablets. these drugs are tested in phase iii trials in adults. their applicability to children is likely to be discussed in the coming years. the current kdigo recommendations on classification or renal osteodystrophy recommend assessment of three areas of bone histology: turnover, mineralization, and volume. while lesions of bone turnover are prevalent in children treated with dialysis, little is know about the prevalence of mineralization defects and their response to therapy with vitamin d sterols and phosphate binders. we evaluated the skeletal mineralization (osteoid thickness (o. th.) and osteoid maturation time (omt)) in patients ages ± years treated with maintenance dialysis who were not receiving vitamin d sterol therapy. serum biochemical markers were: ca: . ± . mg/dl, p: . ± . mg/dl, pth: ± pg/ml, alk p'tase: ± iu/dl. % of patients with high turnover bone disease ( % ci: - %) and % ( - %) of patients with normal or adynamic bone had abnormal skeletal mineralization as reflected by both a prolonged omt and widened o. th. subsequently, a subset of patients underwent treatment with calcitriol and calcium carbonate. while serum pth levels decreased by % (p< . ) and bone formation rate decreased by % (p< . ) with therapy, there was no change in o. th or omt from baseline. indeed, % ( - %) of patients had abnormal mineralization after therapy. we conclude that mineralization defects are prevalent in children treated with dialysis and are not affected by current therapeutic options. further studies are needed to determine the pathophysiology and optimal treatment of these defects. introduction: clara cell secretory protein (cc ) is a protein synthesized primarily by non-ciliated bronchiolar epithelial cells, the clara cells. like other low-molecular size proteins, plasma cc is rapidly eliminated by glomerular filtration and reabsorbed by proximal tubular cells. this protein has been rarely studied in the paediatric age. the sensitivity of cc in urine was compared to that of b -microglobulin (b m) and n-acetyl-b-d-glucosaminidase (nag conclusions: cc is a good marker of the proximal tubular function. cc is related better with the urinary b m elimination, since both are low-molecular size proteins that are reabsorbed by the proximal tubule. sd. kim, bs. cho kyunghee university hospital, pediatrics, seoul, south korea background: many studies have demonstrated that arb prevents renal progression in patients with glomerular nephritis or diabetic nephropathy by inhibition of hmc proliferation and reduce of extracellular matrix expansion and glomerulosclerotic changes. however, the molecular effects of arb in cultured hmc have not been completely defined. we investigated differential gene expression by arb treatment on cultured hmc according to time sequence using cdna chip (affymetrix). methods: mc was grown in dmem with % fbs and then arb was treated on cultured mc. rnas of hmc at different time points ( , , and h after arb treatment and no treatment) were compared using affymetrix cdna chip. to validate the patterns of gene expression analyzed by the microarrays, some genes were selected and semi-quantitative rt-pcr was performed. results: among genes, humoral immune response, cytokine activity, il- receptor binding, chemotaxis, cell cycle arrest, and morphogenesis associated genes were down-regulated for , , and h after arb treatment. they also showed different clustering according to their changing patterns. conclusion: the present study demonstrates profile of gene expression as time goes by after arb treatment on proliferation of human mc. gene expression by arb treatment on cultured hmc showed sequential changes. our results showed that chemotaxis and immune response associated genes were suppressed by arb treatment on hmc. further evaluation of individual genes will be conducted to elucidate molecular mechanism. podocin is the major component of the slit diaphragm, the site responsible for size and charge selectivity of filtration. mutations in the nphs gene, which encodes podocin can lead to steroidresistant nephrotic syndrome (srns). in this work we studied whether genetic changes of podocin might predispose to the development of sporadic non-familial srns in childhood. we screened for podocin mutations children ( m/ f; mean age . ± . years) with sporadic srns and healthy controls. renal biopsy in srns patients revealed mesangial proliferative glomerulonephritis (n= ), focal segmental glomerulosclerosis (fsgs; n= ), membranoproliferative glomerulonephritis (n= ) and membranous nephropathy (n= ). the mean age of onset of srns was . ± . years. all exons of podocin gene of patients with srns and controls were amplified and direct dna sequencing was performed. there is one novel nonsense heterozygous mutation of c. g>t p. glu>stop was identified in the st exon of nphs gene in srns child with fsgs who has renal transplantation at the age of years without recurrence of fsgs in her graft. we found one kind of single nucleotide polymorphism c. + a>g in the th exon of nphs gene in % ( / ) srns patients ( with fsgs; with membranoproliferative glomerulonephritis) and % ( / ) children in controls. allele frequency of this polymorphism of the nphs gene in srns patients and controls was not different significantly. our results indicate that mutation-detected rate in the nphs gene in russian children with sporadic srns was %. the low mutation-detected rate and identified polymorphism c. + a>g in nphs gene unlikely predispose to the development of sporadic srns in russian children. further determining the slit diaphragm genetic profile of children with sporadic srns is warranted in order to improve disease classification and tailoring of treatment. for diagnose of essential hypertension is necessary except all causes of secondary hypertension (sh). case: family history of -year-old female patient was unremarkable for hypertension, incl. renal diseases. during last months she had often headaches with intermittent vertigo. she was not anywhere examined. at admission on intensive care unit patient had headache, her pulse rate was /min, respiratory rate /min, bp (right arm) was / mmhg and the lower extremity bp / mmhg. other physical examination was normal, incl neurological exam. fundoscopy of the eyes did not show any evidence of hypertensive retinopathy. cardiac ultrasound showed mild left ventricular hypertrophy. abnormal laboratory parameters (without medication) were: hypokalemia ( . mmol/l), metabolic alkalosis (ph . , hco . mmol/l), low urinary output of sodium ( mmol) and chloride (< mmol), high urinary output of potassium ( mmol). renal function tests were normal and no abnormalities were detected by renal ultrasonography, incl. doppler exam of renal blood flow. by large hormonal analyse were detected high plasma renin activity (pra; . ng/ml/hod; n.r. . - . ) and very mild increased serum aldosterone (ald; . nmol/l; n.r. - . ). during the ct renal angiography was found solid mass in the upper part of the left kidney. a partial left nephrectomy was performed and histological exam revealed juxtaglomerular cell tumor (so-called reninoma, re). after the resection we stopped subsequently patients antihypertensive therapy. in a -month follow-up our girl was normotens. re is a very rare cause of sh. re typically present during adolescence or young adulthood. this cause of severe sh should be considered along renal artery stenosis in adolescents presenting with secondary hyperaldosteronism or in causes with renin-secreting tumor of non-renal origin. we report our preliminary molecular findings in twelve turkish cystinosis patients. the patients were to years; male/female ratio was : . all presented initially with severe failure to thrive, polyuria and polydipsia. cystinosis was diagnosed at age month to years. six of the patients reached end stage renal failure at ages ranging from . to years necessitating renal replacement therapy; are currently on hemodialysis, one is on capd, and two were transplanted. while three of remaining have renal fanconi syndrome with proteinuria, had kidney failure in varying degrees. molecular analyses involve an initial multiplex pcr, checking for the presence or absence of kb founder deletion, and subsequent sequencing of the coding exons of ctns. interestingly, none of the nephropathic cystinosis patients carried the kb deletion. instead, one patient had a new homozygous kb deletion of exons to of ctns. one patient was homozygous for a known bp deletion in exon , i.e., c. del gact. two patients were homozygous for new missense mutations in exons and , i.e., c. g>a (r g) and c. a>g (y c), respectively. the most common mutation in our turkish patients was a new exonic splice site mutation in exon , i.e., c. g>a (e e). of alleles studied, carried this mutation, which is expected to disrupt proper splicing. two patients were compound heterozygous for one of the above-mentioned mutations and a known missense mutation in exon , i.e., c. g>a (g r). in two patients, we could not find any disease-causing mutation; in two patients, we could find only one disease-causing mutation. in summary, cystinosis patients of turkish ancestry show ctns mutations different from those of western european patients. these findings will be of relevance for molecular-based screening and diagnostic methods for cystinosis. introduction: the association of hypertension with bell's palsy in adults has been reported from - %, but there is few data in children. the presence of bell's palsy in children requires a complete evaluation for hypertension, solid tumors, leukemia, neurofibroma, and trauma. hypertensive children usually present with clinical manifestations of underlying disease, but with substantial elevation, symptoms of hypertension develop. although headache, dizziness, blurred vision and seizure are common neurologic symptoms of hypertension, but facial paralysis is not a wellrecognized presenting feature of hypertension in children. case report: this paper describes two severely hypertensive children who referred to children's hospital of tabriz with periferal hemifacial nerve paresis and initial diagnosis of bell's palsy. case : a years old girl who admitted with blood pressure of / mmhg on admission. renal ultrasound study revealed left small size kidney and renal scintigraphy followed by angiography confirmed renovascular hypertension. case : a years old boy with blood pressure of / mmhg on admission. sonography of kidneys was normal except for a small size ( mm) stone in left kidney. renal scintigraphy and angiography were normal. all other evaluations for etiology of hypertension including cardiac and endocrine investigations were negative. treatment of hypertension with antihypertensive drugs resulted in complete recovery of facial paresis in both cases within - months. conclusion: unilateral peripheral facial nerve paresis is a rare presentation of hypertension in children. unawareness of this presentation may result in delay in diagnosis of hypertension which may increase further with steroid therapy for bell's palsy. to uncover the frequency and the spectrum of nphs mutations in egyptian children with non familial steroid-resistant nephrotic syndrome (srns), patients were screened by pcr-singlestrand confirmation polymorphism analysis of nphs gene followed by direct sequencing. nphs mutations were evident in patients ( . %) who were bearing five novel mutations including two frame shift mutations ( - insg and - insg), two missense mutations ( a>c and t>a) and a silent mutation ( a>t). there were no phenotypic or histological characteristics of patients bearing nphs mutations, apart from the earlier onset of the disease, compared to those who were not bearing mutations. in conclusion, nphs mutations are prevalent in egyptian children with non-familial srns and this may in part explain the less favorable prognosis reported in these patients. , which is an inherited systemic disease of connective tissue primarily affecting the skin, retina, and cardiovascular system, also leads to rvh. these symptoms of pxe are usually apparent in adulthood and rarely observed in children. here, we describe a very rare pediatric case of rvh caused by pxe. case report: a -year-old boy was noticed to have severe hypertension ( / mmhg) when he was admitted to our hospital for an operation for exotropia. he had no previous or family history of pxe or hypertension. laboratory examination showed that plasma renin ( . pg/ml) and aldosterone ( . ng/dl) concentrations were markedly elevated. his systolic and diastolic blood pressure (bp) decreased . % and . % from baseline after administration of captopril, respectively. a computerized tomographic scan of his abdomen showed multiple calcified vessels in kidneys and spleen. yellowish papules on the bilateral axillary regions and inguinal area were detected. characteristic histological changes of pxe such as elastic fiber mineralization and calcification were noticed in the biopsy of affected skin lesions. conclusion: pxe is characterized clinically by high heterogeneity in the age of onset and extent and severity of organ system involvement. although its symptoms usually appear in the second or third decade of life, gastrointestinal bleeding and acute myocardial infarction have been reported in childhood. we should also consider pxe as one of the causes of rvh in children, because its prognosis depends largely on the extent of extracutaneous organ involvement. the clcnkb gene is rarely reported as having a large deletion mutation, but all cases reported previously were large homozygous deletions and a large heterozygous deletion is impossible to detect by direct sequencing. patients and methods: this report concerns a genetic analysis of japanese patients with type iii bs. to identify the mutations in the clcnkb gene, we used polymerase chain reaction (pcr) and direct sequencing to investigate all exons and exon-intron boundaries in the patients and their family members. to detect large heterozygous deletion mutations of the clcnkb gene, we conducted semi-quantitative pcr amplification using capillary electrophoresis. results: four mutations were identified, comprising novel bp deletion mutation (c. _ delct), an entire heterozygous deletion and a heterozygous deletion mutation of exon and of the clcnkb gene. the nonsense mutation w x in the clcnkb gene was detected in all patients ( of them were homozygous and were heterozygous) and this finding indicates that this nonsense mutation is likely to constitute a founder effect in japan. two patients had large heterozygous deletion of the clcnkb gene, which was proved by semi-quantitative pcr amplification. conclusions: capillary electrophoresis is a new method and extremely useful for detecting large heterozygous deletions, and should be employed to examine type iii bs cases in whom only a heterozygous mutation has been detected by direct sequencing. obesity defined as body mass index (bmi) above th percentile for age and gender is regarded as a risk factor for cardiovascular (cv) target organ damage (tod) in children and adults with ph. however, when using percentile-based definition of obesity one may miss children at risk of cv complications. the aim of the study was to compare sensitivity of traditional definition of obesity (bmi> th pc) and bmi thresholds (tbmi) for cv complications described by katzmarzyk et al. ( ) majority of children with idiopathic nephrotic syndrome (frequent relapsers, steroid dependent and steroid resistant) require adjunctive therapy. the response to cyclophosphamide (cp) in these children is variable and difficult to predict. there may be an effect of polymorphic expression of gst on the remission with cp. in this study, we have tried to evaluate the correlation of gst polymorphism and response to cp therapy in these children we studied gst polymorphism in consecutive children ( males, females) with steroid sensitive (n= ) and steroid resistant (n= ) nephrotic syndrome, receiving cp therapy. we evaluated the inter-relationships between gstm , gstt , and gstp genotypes and correlated it with the response to cp therapy in these children. the mean age of onset was . ± . years. out of children, % children responded to cyclophosphamide therapy. the null genotype of gstm and gstt was observed in . % and . % respectively while val genotype of gstp was seen in % children. there was no significant correlation among the various individual genotypic combinations. however, a trend was seen towards remission in children with a combination of gstp polymorphism with gstt null genotype (p= . ) or combination of gstp polymorphism with gstm wild type genotype (p= . ) another important finding in our study was that there was a significantly higher frequency of val allele of gstp in responders to cyclophosphamide as compared to nonresponders (p= . ). the results indicate that the presence of the val allele correlates with the response to cyclophosphamide in these children. gst gene polymorphism may be a significant therapeutic tool in the management of children with idiopathic nephrotic syndrome receiving therapy. objectives of study: primary vesicoureteral reflux (vur) is a common pediatric disease that may lead to reflux nephropathy and end-stage renal disease. the renin-angiotensin system (ras) was proposed to be associated with primary vur. the objective of this study was to investigate whether the gene polymorphisms of the ras are involved in primary vur and correlation with the severity of vur in taiwanese children. methods: we studied the angiotensin ii type receptor (at r) c a gene polymorphism for association with susceptibility to primary vur and disease severity in vur children and healthy controls. fifty four of the vur patients had low-grade vur (grade i-iii) and had high-grade vur (grade iv and v). to analyze the polymorphisms in the c a of at r gene, the snp genotyping assay were performed. the genotypic frequency and allele frequency for four ras genes were analyzed to detect the correlation between the patients with mild, severe vur, and healthy control. results: we found that the c a of at r gene was associated with the development and severity of vur. significantly higher c and lower a allele frequencies were presented in vur patients (c allele . and a allele . ) compared with controls (c allele . and a allele . , p< . ). the similar results were observed in both mild (c allele . and a allele . ) and severe (c allele . and a allele . ) vur compared with controls (p< . ). the cc genotype was higher in vur patients compared with controls (p< . ). conclusions: at r c a gene polymorphism was associated with the development and the severity of vur in taiwanese children. it raises the possibility to utilize the genotype of at r as a risk factor to evaluate the development and severity of primary vur. results: stone analysis led to diagnosis of cystinuria in patients ( % of all), but only were children ( . % of the paediatric stone patients). age at diagnosis in three patients was - years and in four - years. time from first manifestation (pain x, gross haematuria x, urinary retention x, uti x) until diagnosis was - years in seven, - in three and even and years in two. renal function was impaired in patient (ckd stage ii). the urinary cystine test was positive in all patients with cystine stones examined, but was negative in family members thus excluding cystinuria in them. family history of urinary stones was positive in two; the brother of one had died of renal failure due to bilateral urolithiasis. conclusions: delays in diagnosis of cystinuria in armenia are unacceptable. production of tablets containing nickel/dithionite which is non-toxic in contrast to brand test (cyanide/nitroprusside) is planned and could allow screening of all patients with stones of unknown origin. background: classically, childhood hypertension has always been recognized as secondary and frequently demanded an exhaustive etiological investigation. however, in the last two decades, many studies have been shown that pediatric patients also present primary hypertension and, sometimes, the adult disease probably begins during childhood. the aim of this study was to analyze a cohort of patients followed-up at a single tertiary unit (belo horizonte, brazil). methods: in this retrospective cohort study, the records of diagnosed with arterial and followed at our unit between and were analized. a data base was used for statistical analysis. results: of patients, . % were male and . % female. the distribution of patients according to the age at diagnosis was: - . years, ( . %), yr- . yr, ( . %), yr- . yr, ( %), and yr, ( . %). the causes for hypertension were: renal diseases in ( %), primary hypertension in ( %), renovascular disease in ( %) and ohers in patients ( %). the comparison between primary hypertensive subjects and patients with renal diseases showed that, although blood pressure was similar at admission, a better control was achieved in the first group (p< . ). the frequency of overweight and/or obesity was higher in primary than in secondary hypertension ( nephrnophthisis (nphp) is a very rare cause of crf in korea. identification of five genes mutated in nphp subtypes - has linked the pathogenesis of nphp. ten percent of affected individuals have retinitis pigmentosa, constituting the senior-löken syndrome. we experienced juvenile-onset crf with leber's amaurosis in two sibilings. case : a -year-old boy presented with pale appearance. he had severe renal impairment and visual disturbance, but no symptom of polyuria and polydipsia. his past annual school screening urinalysis was normal. his growth and development were normal except opthalmological findings and pallor. case : his -years-old sister also had a visual disturbance and was found to have crf. there was no specific problem during perinatal period. opthalmologic findings were similar to her brother's. nphp and on chromosome q was analyzed by direct sequencing. sequencing of mitochondrial dna-mbol digestion for mutation was analyzed by pcr-sequencing and rflp. electroretinogram revealed a decreased in amplitude of a and b waves. on the kidney biopsy, some of glomeruli were globally sclerotic. remaining showed no cellular proliferation or capillary wall thickening. interstitium was diffusely fibrotic and in which were scattered lymphocytes. most tubules were preserved well but a few dilated tubules were intermingled. no positive reaction for immunoglobulines or complements in if. by em, tubular membranes showed thickening, splitting and disintegration. nphp and genes were not identified. there was no transition mutation at mitochondrial dna nt. , , , . late-onset senior-löken syndrome were diagnosed in these cases even though there were no polyuria and polydipsia of initial symptoms of nphp and nphp and were not identified. we need to identify other known or novel mutation genes. nail-patella syndrome (nps) is an autosomal dominant disease characterized by classic tetrad of dysplastic nails, absent or hypoplastic patellae, elbow dysplasia, and iliac horns. some patients manifest nephropathy and adult-onset glaucoma. nps is associated with mutations in the lmxib gene. there is marked inter-and intrafamilial variability in the phenotypes. in this study, phenotype-genotype correlation was analyzed in unrelated korean children with nps. the probands were boys and girls. they manifested dysplastic nails ( / , %), absent or hypoplastic patellae ( / , %), elbow dysplasia ( / , %), iliac horns ( / , %) and nephropathy ( / , %) . four missense mutations/ in the lim-b domain (h q and l p) and in the homeodomain (r q and a p)/and frame-shifting deletion (c, dela) were identified in the lmxib gene.r q and a p are known to be common mutations, and r q was detected in patients in this study. autosomal dominant inheritance was identified in patients by phenotype and genotype analysis of the family members and in patients by phenotype analysis only. remaining patient had de novo r q mutation. one patient and her mother with r q mutation developed nephrotic syndrome, which progressed to end-stage renal disease (esrd). another patient with h q mutation had asymptomatic proteinuria with microscopic hematuria, and her father had esrd. galucoma was not detected in any patients or family members affected. there were inter-and intrafamilial variability of the phenotypes, but no genotype-phenotype correlation was identified. this is the first study to characterize mutations in the lmx b gene in korean patients with nps. r q is a common mutation in korean, also. the mechanism underlying the phenotypic variations and predisposing factors to the development nephropathy remain unknown. the pathological mechanism which would be responsible for higher production of digitalis similar compounds in essential arterial hypertension (ah), would be a genetically defect kidney, which causes difficulty in na + excretion. higher intake of salts can be an etiological factor inessential ah only patients with inherited abnormalities of thetransport mechanisms in the cell membrane.the objective of the studywas to establish the incidence and type of ah and frequency of genetic factor in the investigated population of school children (age - years). in children with essential and borderline ah we evaluated the activity of erythrocyte membrane na+, k+-atpase in the presence ofvarying atp concentrations. atp, adp and amp levels and lipid peroxides (as tbars) in the erythrocytes and tbars in plasma were measured. our data have shown that the prevalence of ah is lowest in - years oldchildren, while it is the highest in - years oldchildren. essential ah was established in ( . %) and borderline in ( . %) children. genetic factor were found in . % of children with essential ah and in . % of children with borderline ah. but, statistical analyses of the first and second degree relatives of children with essential and borderline ah suggested normal prevalence of hypertension. atp, adp and amp levels, as well as, lipid peroxides were not significantly altered compared to healthy children. kinetic profileof erythrocyte plasma membrane na+, k+-atpase activity revealed the presence of noncompetitive (allosteric) inhibition of enzyme activityin the children with essential and borderline ah. the differences in the kinetic properties of na+, k+-atpase between two investigated groups of children suggested that this dynamic model could be used as potential biological marker for early diagnosis and differentiation of these two type of ah. majority of these patients were obese and with increasing body weight nighttime hypertension became prominent in these patients. objectives: it has been shown that weight gain is directly related to increase inblood pressure. the objective of this study was to analyze the frequency of overweight/obesity in children/adolescents with primary hypertension (ph) and the relationship between the overweight/obesityand the stage of hypertension (h). methods: we analyzed the data of patients aged - . years (m ; f ) diagnosed with primary hypertension. overweight/obesity was defined asperc. of bmi - / c. the stage of hypertension was determined according to the th report on the diagnosis, evaluation,and treatment of high blood pressure in children and adolescents of the nhlbi working group. results: out of pts, prehypertension was found in pts ( . %), stage i h in ( . %) and stage ii h in pts ( . %). stage ii h was more frequentin boys ( % vs. % in girls). combined systolic/diastolic h was found most frequently, in pts ( . %), isolated elevation in systolic blood pressure (bp) was found in pts ( . %), while only pts ( . %) had isolated elevation in diastolic bp. sixty-one pts ( . %) were found overweight/obese; of which ( . %) above c bmi. theobese children were predominantly found to have stage ii h: . % ofthe obese children. none of the obese children had prehypertension. contrary to the general perception, boys were found more frequently overweight/obese ( . % boys vs. . % girls). conclusion: our data shows that stage ii ph is not rare also in theteen-age group. frequently it is accompanied with overweight/obesity, especially in boys. we can conclude that the roots of ph in the adultage are already set from the childhood. our efforts should focus onearly diagnosis of ph and include prevention of obesity as the possible contributing factor for the development of ph. objectives of study: alport syndrome (as) is a progressive renal disease characterized by hematuria, progressive renal failure, high-tone sensorineural hearingloss and ocular lesions. xlinked dominant alport syndrome (xlas) isthe major inheritance form, accounting for almost % of the cases, caused by mutations in col a genes. there are no good cures available for as at present, but there are some patients who requestfor prenatal diagnosis and genetic counciling. this study performed thefirst prenatal diagnosis in chinese as family. methods: the entire coding sequence of col a mrna of peripheral blood lymphocytes was amplified using nest pcr to screen mutations in a chinesexlas family. mutation analysis of the fetus was performed on both cdna-based level and dna-based level of amniocytes. fetus sex was determined by pcr amplification of sry as well as karyotypes analysis. maternal cells contamination was excluded by linkage analysis. results: mutation screen showed that there was a g to a substitution at position in exon of col a gene (c.g a), it was subsequently confirmed at genomic dna level by pcr amplification of exon of col a gene. the mutation was identified in the index case, family members aswell as the pregnant lady. the prenatal diagnosis showed that fetus didnot carry the same mutation as the mother detected by both cdna-basedand dna-based mutation analysis. pcr amplification product of sryas well as karyotypes analysis revealed a male fetus. linkage analysis of the three x chromosome markers showed that there was no contamination of maternal cells in amniocytes. conclusion: after mutation identification of col a gene in a large chinese as family, a successfully prenatal diagnosis was performed in one of the female members in this family based on both cdna as well as genomic dna level of amniocytes. objectives of study: alport syndrome (as) is a clinical and genetic heterogenousdisease. autosomal recessive as (aras) is caused by mutations in col a and col a genes, accounting for % of the cases. thin glomerular basement membrane nephropathy (tbmn), is also caused by mutations in col a and col a genes, inherited as an autosomal dominant trait. differentiation between early stages of aras and tbmn may be difficult in clinic, itdepends on gene mutation analysis of col a or col a . methods: the whole entire coding regions of col a and col a mrna of peripheral blood lymphocytes were analyzed using reverse transcription polymerase chain reaction (rt-pcr) and direct sequencing to screen mutations in three chinese aras families, the corresponding exon with flanking intronic sequence was further amplified to confirm the abnormality. results: both the entire coding regions of col a and col a mrna were successfully amplified and completely sequenced by seven overlapping pcr products, respectively. results showed that there were variations of col a and variations of col a , respectively. among the variations of col a ,three were snp reported previously, four were new snp, one nonsense mutation, one small insertions and one splicing mutation, the latter three were the pathogenic mutations for the three families, respectively. all the four variations of col a were snp reported previously. we concluded that rt-pcr and direct sequencing using peripheral blood lymphocytes rna is a practical, sensitive and feasible approach for analysis col a and col a gene variants in autosomal recessive alport syndrome patients, which offers a useful, inexpensive and timesaving approach for systematic gene analysis in patients with aras. objectives of study: gitelman syndrome (gs) is an autosomal recessive tubular disorder characterized by metabolic alkalosis, hypokalemia, hypomagnesemia and hypocalciuria. the majority of gs patients carry inactivating mutations of the slc a gene encoding the sodiumchloride cotransporter located in the distal convoluted tubule. this study aimed to detect mutations in a chinese family with gs. methods: two brothers presenting muscle weakness, hypokalemic metabolic alkalosis, hypomagnesemia and hypocalciuria were clinically diagnosed as gitelman syndrome. the two brothers, as well as their healthy brother and parents, were detected for mutations in slc a gene by direct pcr for each exon and then sequencing on genomic dna extracted from peripheral blood cells. results: the two patients were found to have the same compound heterozygous mutations (c. c>t and ivs - t>c) in the slc a gene. the two mutations were also detected in paternal and maternal genomic dna, respectively. the unaffected brother had one mutation (c. c>t) only. conclusion: a novel compound heterozygous mutation on the slc a gene was revealed in a chinese family with gs. the objective: to determine the clinical value of ambulatory blood pressure monitoring (abpm) in pediatric kidney disease. methods: patients with common kidney diseases aged from - yrs were enrolled. -hour abp were performed by welch allyn abpm . the number of cases whose ccr> mmol/l/ . m , ccr - mmol/l/ . m , ccr - mmol/l/ . m , ccr - mmol/l/ . m and ccr< mmol/l/ . m is , , , and , respectively. seven patients only took fosinoprilto control blood pressure did abpm again more than one weeks after therapy. healthy children performed in german in was used asthe normal data. casual bp was measured by sphygmomanometer. children took echocardiography to calculate left ventricular mass index (lvmi). results: the incidence of nocturnal hypertension was significantly higher than that of diurnal hypertension (p< . ).theincidence of non-dipper in children with kidney disease was . %. nocturnal dipping rate in the patients was significantly lower than that in the healthy children (p< . ). the incidence of masked hypertension and white coat hypertension inchildren with kidney disease were . % and . % respectively. nocturnal systolic and diastolic dipping rate of the children with lupus nephritis and acute glomerulonephritis were lower than those of the children with henoch-schönlein purpura nephritis (p< . ). lvmi hadpositive correlation with -hour diastolic blood pressure load (r= . , p= . ), but it had no correlation with casual bp. after taking fosipril, -h, diurnal and nocturnal average abp decreased significantly (p< . ). nocturnal dipping rate increased, but did not reach statistical difference (p> . ). conclusions: abpm was an effective tool for diagnosis and management of hypertension in childhood with kidney disease. identification of novel mutations in the col a gene of japanese patients with x-linked alport syndrome background: alport syndrome consists of nephritis, often progressing to renalfailure, and sensorineural hearing loss. x-linked phenotype (omim# ) is the result of mutation in the gene for the alpha- chain of collagen iv (col a ). objectives of study: to find mutations causing x-linked alport syndrome in japanese patients. patients and methods: diagnosis criteria of alport syndrome were proteinuria, familial history of renal failure andchanges of gbm in electron microscopy. to identify the mutations in the col a gene. results: for the time being we finished genetic analysis of patients with suspected x-linked alport syndrome, males and females. we identified mutations in of patients; of them were novel mutations. they comprise: nonsense mutations, missense mutations and mutations of splicing acceptor site resulting in exon skipping or truncation, and establishing of premature stop codon. in previous reports of x-linked alport syndrome, mutation detection rate was around %. the present study provides a detection rate of . %, although our number of examined cases is limited. conclusions: direct sequencing of rt-pcr and pcr products is efficient method of finding mutations in col a gene. we found mutations in high percentage of investigated patients. objectives of study: to make a genetic diagnosis of juvenile nephronophthisis for a chinese boy. methods: analyze the presentation, family history, laboratory investigations, and histological features of a patient suspected of juvenile nephronophthisis, make a clinical diagnosis. to confirm the diagnosis on genetic level by pcr amplification of satellite markers located within the known homologous deletion of nphp ,including del- , del- , del- , del- -( ) , del- and markers outside the deletions (ranbp / and d s )as control. results: the boy was nine years old, he was admitted becauseof renal failure for months. this case manifested by school age, negligible onset, anemia, polyuria, renal failure at years old,without hypertension and abnormal urine analysis. his sister presented with anemia at year old, and died of uremia at years old.laboratory investigations showed no proteinuria and hematuria. thekidney size is normal, and the cortical medullary boundary is obscure.the histological features consist of the disintegration of tubularbasement membrane, the atrophy and dilation of renal tubules, theinterstitial cell infiltration and fibrosis. he was suspected asjuvenile nephronophthisis. by pcr amplification, we found the missingof the satellite markers of del- , del- , del- -( ) and del- , which indicate that there is the common large homologous deletion ( kb) in the child's nphp . conclusions: nephronophthisis is the major hereditary cause ofchronic renal failure. the boy was suspected of nephronophthisis because of chronic renal failure, family history, normal kidney sizeand hitological features. according to the age of renal failure, he was suspected as juvenile nephronophthisis. the diagnosis was confirmed by gene analysis. it is the first juvenile nephronophthisis case for chinese confirmed by gene analysis. cutaneous small-vessel vasculitis is a rare condition in children and is commonly associated with a wide spectrum of systemic inflammatory conditions, malignancies, infections or drug hypersensitivities. enalapril is anangiotensin-converting enzyme inhibitor, commonly used for the treatment of hypertension. cutaneous vasculitis due to enalapril has very rarely been reported and only with adults. we report a case of an -yea-old boy presented with a pruritic eruptionover his lower legs that started hours after he had initiated treatment with enalapril at a dose of . mg/kg/daily. he had a history of hypertension due to a shrieked right kidney since infancy and he wason treatment with nifedipine and propranolol for the last three years. this medication was discontinued because it was ineffective, the day before initiation of enalapril. clinical examination revealed palpable purpuric lesions involving lower legs and ankles. he was otherwise well. a skin biopsy of the lesions showed leucocytoclastic vasculitis of small vessels. abnormal investigations were elevated c-reactive protein, esr and leucocytosis. further laboratory tests including creatinine, liver function tests, urineanalysis, antinuclear antibody, cryoglobulins, viral serology, complement levels, were normal or negative. enalapril was discontinued and he was started oral prednizolone and ceterizine over the next ten days. the skin eruption regressed rapidly. cutaneous vasculitis induced by enalapril is a rare adverse effect and it is essential a prompt recognition and withdraw of the suspicious drug. objectives of study: barttin, the gene product of the bsnd gene involved in bartter's syndrome with sensorineural deafness, is an essential b-subunit for clc-ka and clc-kb chloride channels, and it is expressed in the kidney as well as in the inner ear. one patient affected by deafness and renal bartter phenotype without bsnd mutations has been previously reported with simultaneous mutations in both clcnkb (responsible for classic bartter syndrome) and clcnka genes. we report here on a new case of a -months-old boy presenting such a disease. a severe polyhydramnios was detected during the pregnancy. he presented also polyuria, growth retardation, nephrocalcinosis and sensorineural deafness. laboratory studies revealed metabolic alkalosis (plasma hco , mmol/l), hypokalemia ( , mmol/l), hypercalcuria (cau/cru , mg/mg) and elevated plasma renin ( pg/ml). the aim of the study was to identify the cause of the severe renal salt wasting and sensorineural deafness in this patient. methods: dna sequencing analysis was performed on the bsnd, clcnkb, and clcnka genes. results: no mutation was detected in the bsnd gene. we identified a reciprocal partial homozygous deletion of exons - for the clcnkb gene and theloss of exons - for the clcnka gene. conclusions: the disruption of both clc-ka and clc-kb chloride channels leads to a syndrome clinically not distinguishable from bsnd, characterized by severe salt wasting and deafness. this digenic disorder is due to simultaneous mutations on the two genes clcnka and clcnkb respectively. the tight topology of the highly homologous clcnka genemight predispose to an unequal crossing over leading to partial orcomplete deletions of the clcnkb gene. we hypothesize that thischimaeric resulting gene interferes with the correct function of both the channels clc-ka and clc-kb, and leads to a bsnd-like phenotype. familiary hypomagnesemia with hypercalciuria and nephrocalcinosis (fhhnc) is a nautosomal recessive tubular disorder that is frequently associated with progressive renal failure. mutations in cldn which encodes the renal tight junction protein paracellin- were identified as the underlying genetic defect. in this work we present a gipsy family with fhhnc in which the mother and daughter both showed homozygous mutations in the cldn gene. a three-year-old girl was investigated after acute pyelonephritis and was found to have medullary nephrocalcinosis, hypomagnesemia ( , mmol/l), hypercalciuria ( , mg/kg/d), hypermagnesuria (femg %) and incomplete distal renal tubular acidosis. her renal function was normal. her mother demonstrated also bilateral medullary nephrocalcinosis, hypomagnesemia ( . mmol/l) with high femg ( %), moderate renal failure (creatinine umol/l) and high ipth levels ( pg/ml). as a child she had afebrile seizures, but serum mg levelwas not measured. index patient's uncle had history of recurrent passage of calculi in childhood, bilateral medullary nephrocalcinosis, normocalcemic hypercalciuria but his serum mg was not determined. he developed obstructive uropathy due to impaction of the calculus in urethra and eventually progressed to terminal uremia and later was transplanted. mutational analysis confirmed that the index case, motherand uncle were homozygous for the common mutation in the cldn gene (leu phe), while the father was heterozygous. we present a new family from macedonia with fhhnc with unusual presentation over two generation. mutational analysis confirmed also the diagnosis of fhhnc in the uncle although as a child he was considered to have idiopathic hypercalciuria. thus, serum mg should be routinely checked in children with nephrolithiasis/nephrocalcinosis. m. pan ' czyk-tomaszewska, j. s ' ladowska, j. so l /tyski, m. roszkowska-blaim arterial hypertension is one of the complications of reflux nephropathy. the aim of the study was to assess the risk factors of arterial hypertension in children with primary vesicoureteric reflux (vur). we studied children aged from to years mean ± . , with unilateral and with bilateral vur. in all children ambulatory blood pressure monitoring (abpm) and m tc dmsa renal scanning (dmsa) were performed and z score body mass index (z-score bmi) were calculated. the following criteria were examined as predictive risk factors: age, gender, age at diagnosis andat resolution of vur, period between diagnosis and resolution of vur,grade of vur, type of vur (unilateral or bilateral), treatment modality (medical, surgical), z-score bmi, grade of dmsa and birth weight. results: i grade of dmsa scan was diagnosed in children, iigrade in , iii grade in and iv in patients. hypertension (hp) was diagnosed in children ( %). the mean value of z-score bmi in children with hypertension was significantly higher in comparison withchildren with normal blood pressure ( . ± . and . ± . ). the multivariate discriminate analysis showed that zscore bmi and grades of dmsa scars were significant risk factors for developing arterial hypertension in children with vur. both parameters had the same influence on development of hypertension (standardized coefficient of discriminate analysis , and , respectively). conclusion: the development of hypertension in children with vur is associated with higher bmi and higher grades of renal scars in dmsa scan. grange syndrome comprises arterial stenoses with hypertension, brachy syndactyly, bone fragility, learning disability, and cardiac defects and it has been reported in the members of two families up to now. we report here a -year-old boy with hypertension, multiple arterial stenoses, microcephaly and brachysyndactyly. severe hypertension ( / mmhg) was detected on his routine control for acute rheumatic carditis and he was hospitalised for investigation. he had no complaints. his parents were first degree relatives. his physical examination revealed microcephaly, bilateral brachysyndactyly between the forth and the fifth fingers of hands and the second and the third fingers of feet. complete blood count, electrolytes, renal, thyroid, and hepatic functions and acute phase reactants were all in normal limits. echocardiography showed aortic and mitral insufficiency and left ventricular hypertrophy. renal and cerebral magnetic resonance angiographies demonstrated stenoses at bilateral renal, internal carotid, superior cerebral and posterior cerebellar arteries. association of hypertension with microcephaly and finger abnormalities and multiple arterial stenosis suggested grange syndrome. chromosomal analysis showed xy karyotype. hypertension persisted despite triple antihypertensive agents and percutaneous renal angioplasty was performed leading to a reduction of antihypertensive medication. with this case report we wanted to remind the recognition of this extremely rare syndrome in a hypertensive child with multiple morphological abnormalities and percutaneous angioplasty as a treatment modality in cases with persistent severe hypertension. hypertension is usually indicative of an underlying disease process in children. the combination of severe hypertension with hyponatremia is called hyponatremic hypertensive syndrome (hhs). in this report we present a case of hhs. the boy was referred to our hospital at the age of years old with generalized tonic clonic convulsion. his past history was insignificant and positive findins of the patients were as follows: hypertension ( / mm/hg), agressive behaviors after convulsive period, metabolic alkalozis (blood gases, ph: , , hco : , , pco : , ), hypocloremia ( meq/l), hypokalemia ( meq/l), hyponatremia ( meq/l), low urine density, polyuria and high serum aldosterone levels ( pg/ml, range: - ). the serum renin, cortisol, tyroid and antidiuretic hormones were within normal range. abdominal color doppler ultrasound were revealed double renal arteries in both kindneys. cranial and abdominal tomography examinations and cebrospinal-fluid examination were normal. the diagnosis of hhs was suggested based on these clinical and laboratory findins and therapy of nifedipine was started. the arterial pressure improved with this therapy. in hss due to renal ischemia, activation of renin angiotensin system which induce pressure natriuresis and thus, thence hyponatremia. we think that presence of renal arterial anomaly might be a cause of an ischemic condition and activation of renin-angiotensin-aldosterone system in our patient. also, activation of aldosterone could enhance with hyponatremia and it could be suppressed of renin secretion in our patient. [hadtstein et al. hypertension ] . the aim of this study was to analyze whether children with renal scars have altered rhythms of mean arterial pressure (map) and heart rate (hr). study design: ambulatory -hour blood pressure profiles of untreated patients with renal scars associated with recurrent urinary tract infections and vur were investigated and compared to healthy controls. results: pre-pubertal, but not pubertal patients with renal scars displayed a number of significant differences to controls. before puberty, the mesors of map and hr were significantly elevated, and the peak-trough difference of the h curve was blunted by . mm hg for map and . bpm for hr. the amplitudes of h and h map rhythms were blunted by . and . mmhg, and those of h and h hr rhythms by . and . bpm (all p< . ). pubertal patients did not display any abnormalities of bp or hr rhythms. we did not find any correlations of the degree of renal scarring, bmi or gfr with the abnormalities in cardiovascular rhythms. conclusion: in summary, pre-pubertal children with renal scarring due to vur show blunted circadian and ultradian rhythms of bp and hr. this phenomenon may reflect subtle alterations of autonomous nervous signaling in children with damaged kidneys; it remains to be addressed whether such abnormalities constitute an independent cardiovascular risk factor. mutations in the eya gene are associated with bor/bo syndrome and rarely with an isolated renal phenotype. we present a family from macedonia displaying a novel eya gene mutation. a six-year-old female was found to have bilateral grade iii vesicoureteral reflux (vur) after an episode of acute pyelonephritis. mutational analysis detected a novel eya gene mutation [an inframe bp deletion (c. _ delttg), resulting in l del of eya a]. she had no clinical stigmata for bor/bo syndrome. the paternal grandmother died due to end stage renal failure. all first grade relatives underwent detailed physical and ophtalmological examination, audiometry, ultrasound screening of the urinary tract and mutational analysis of the eya gene. the father and older sister were mutation carriers and both had normal ultrasound findings. the physical examination did not reveal abnormalities suggestive for bor/bo syndrome, except the sister had esotropia/ hypermetropia and horizontal nystagmus. the male sibling was found to have mild hydronephrosis on the left side. he was not a mutation carrier and cystographic study was not performed at that time. on repeat ultrasound examination he demonstrated dilatation of the right prevesical ureter. the cystography revealed presence of right sided vur grade iii. in conclusion: we present two siblings with vur; although eya gene mutation was found in one of them, it can not be incriminated for the renal phenotype in this family, as co-segregation of the mutation with the vur does not occur in all affected members of the family. decision to perform cystographic study should be still based on clinical grounds. associations asymmetric dimethylarginine (adma) is a novel predictor of cardiovascular (cv) outcomes in adults. aim: to evaluate adma in children with hypertension. subjects: children ( girls/ boys; median age: yrs) with primary (n= ) and secondary (n= ) hypertension. methods: adma levels were analyzed by elisa method. in study subjects antropometrical data, ambulatory blood pressure monitoring (abpm), left ventricular mass index (lvmi), carotid artery intimamedia thickness (cimt), -hour urinary albumin excretion (uae) and serum biochemical markers (lipids, uric acid) were also evaluated. results: adma concentration was positively correlated to serum uric acid (r= . , p< . ) and uae (r= . , p< . ). when analyzed in boys separately, more apparent correlation was found for uae (r= . ) and a tendency for adma to be associated with lvmi r= . , p= . ). interestingly, when analysis restricted to older children (above the median age), adma correlated to lvmi more significantly (r= . , p< . ). no relation was found of adma to cimt, lipids, and abpm parameters. moreover, patients with left ventricular hypertrophy ( %) and microalbuminuria ( %) had a tendency for higher adma values compared to those without these abnormalities ( . ± . vs . ± . μmol/l, p= . and . ± . vs . ± . μmol/l, p= . , respectively). when data analyzed on the basis of adma values, patients in the top quartile showed the worst profile. when compared to the lowest quartile, they had higher lvmi (p< . ), higher uae (p< . ; inter-quartile comparison p= . ), and higher uric acid concentration (p= . ). conclusions: the associations of adma with known factors of cv damage found in this study provide evidence that adma is closely linked to the early cv dysfunction in hypertensive children. nephrogenic diabetes insipidus (ndi) is a disease characterized by unresponsiveness of distal tubule and collecting duct to vasopressin. although ndi usually presents with polydipsia and polyuria, most infants do not have any of these symptoms and presentation is with features of dehydration like fever, constipation, vomiting, failure to thrive and developmental delay. so, the diagnosis is usually delayed until hypernatremia is noted. almost all infants go through a period of hypogammaglobulinemia at approximately the th- th months of age. at this time, the serum ig g level reaches its lowest point, and many normal infants begin to experience recurrent respiratory tract infections. the clinical findings of ndi and transient hypogammaglobulinemi of infancy (thi) may be seen at the same period. here, we report a five-month old boy with ndi. on his history, he was admitted because of recurrent fever attacks and was diagnosed as thi when he was three-months-old. on his follow-up, hypernatremic dehydration was detected and he was diagnosed as ndi. at the time of diagnosis, he had intracranial calcification secondary to delayed diagnosis of ndi. in infants with ndi, recurrent fever attacks due to dehydration may occur and incorrectly lead to think as an infectious disease. we think that this report can be an important warning for clinicians. we analyzed nphs , nphs and neph gene in japanese cns patients independent of the patients in previous report (k.i. ) from different japanese group which suggested that the mutation of nphs was not a major cause of cns in japanese patients. we extracted genomic dna from leukocytes and analyzed all exons and exon-intron boundaries for nphs , nphs and neph using polymerase chain reaction and direct sequencing after informed consent had been obtained. the study was approved by the ethics committees of okayama university medical school. results: we found compound heterozygous mutations of nphs in patients and homozygous mutations in patients. one of these homozygous mutations was already reported in paper from europe and was not found in more than healthy japanese. another one cause defection of trafficking to the membrane as we reported before (k.i. (k.i. , ajkd . the other patients have only heterozygous mutation in nphs that healthy parent also has. we could find any mutations in neither nphs nor neph in the patients with heterozygous mutation. one of these patients has mild form of cns. another one has neither expression of nephrin nor podocin protein on kidney tissue by immunohistochemistry. interestingly, patients out of have the same mutation in nphs as nt (delc). parents who have this mutation heterozygously were from neighboring prefectures. all mutations including this mutation but one have never been reported out of japan which was isolated from continent. all amino acids substituted by missense mutations which seem to be causative were preserved among mouse, rat and human. conclusions: our studies clearly demonstrated that nphs is a major cause of cns even in japanese patients. moreover, nt (delc) is a common mutation in japanese cns patients like fin major or minor. long-term survival of childhoodonset ckd is mainly limited by the manifestation of cardiovasculardisease (cvd). the development of early stages of cvd can be assessedby non invasive methods, e.g. flow mediated vasodilation (fmd) ofperipherial arteries and measurement of intima media thickness (imt) of the common carotid artery. wetherefore performed fmd and imt investigations in children and adolescents (mean age . ± . years) suffering from ckd (mean gfr ± ml/min/ . m ) on conservative treatment (n= ), dialysis treatment ( hd, pd) and after renal transplantation (n= ), and in sex-and age-matched healthy controls. ckdpatients showed significantly decreased fmd ( . ± . % vs . ± . %, p< . ), where as imt did not significantly differ between patients and controls ( . ± . mm vs . ± . mm, p= . ). within the ckd group the presence of arterial hypertension tended to be associated with increased imt ( . ± . vs . ± . mm, p= . ). in contrast, duration of ckd, mode of renal replacement therapy and degreeof renal dysfunction was not significantly associated with fmd and imt findings. conclusion: children and adolescents suffering from ckd show decreased arterial elasticity irrespective of the mode of renal replacement therapy, the rebycontributing to increased long-term cardiovascular morbidity and mortality. the genetic researches have shown the connection between the essential hypertension and angiotensinogen gene. the researches of preeclampsia also showed the connection with angiotensinogen gene. according to established connection of angiotensinogen gene with essential hypertension and also preeclampsia the aim of our research was to determine by the help of m t, g- a anda- c polymorphisms of angiotensinogen gene whether there is a genetic disposition for essential hypertension in those children whose mothers had preeclampsia. at the same time we wanted to establish whether the polymorphisms of angiotensinogen gene can be connected with preeclampsia in women in our population. two groups of children were studied: children of mothers who had preeclampsia and children of mothers without hypertensive disease in the pregnancy. we also studied two groups of mothers: mothers who had preeclampsia and mothers without hypertensive disease in the pregnancy. m t, g- a and a- c polymorphisms of angiotensinogen gene were performed using the pcr method. in investigating the differences between the two groups of children no statistically significant differences were found in m t,g- a and a- c polymorphisms of angiotensinogen gene. in investigating the differences between two groups of mothers no statistically significant differences were found in genotype distribution. the results of our study failed to confirm that with help of m t, g- aand a- c polymorphisms of angiotensinogen gene we might establish genetic disposition for essential hypertension in those children whose mothers had preeclampsia. we did not confirm the association between m t, g- a and a- c polymorphism of angiotensinogen gene and preeclampsia either. ( ) previously treated also with cyclosporine. before start of fosinopril treatment all had proteinuria . - . g/ h and gfr > ml/ . m /min. all active steroid and immunosuppressive treatment were discontinued. eleven children also were treated with calcium channel blockers to control hypertension. after twelve months of fosinopril ( . - . mg/kg) treatment a dna analysis for ace-gene polymorphism was performed. three patients carried ii, -id and -dd gene polymorphism of ace gene. no significant differencein proteinuria at start of fosinopril treatment between all polymorphism types was observed. all patients with ii polymorphism had a good antiproteinuric effect of fosinopril with more than -fold decrease in proteinuria in comparison with just , fold decrease in id polymorphism and no response in dd. renal function remained stable in all children except of with id and with dd gene polymorphism who demonstrated decrease in gfr. we suggest that ii polymorphism of ace gene may be associated with better antiproteinuric effect of acei while dd predicts poor response. wider study is required to confirm genetic predisposition for ace blockade efficacy in proteinuric diseases. introduction: dent disease is x-linked recessive proximal tubulopathy, due to mutations in the clcn gene. it is characterized by low molecular weight proteinuria, hypercalciuria, nephrocalcinosis and progresive renal failure. aim: case report of patient with short stature and proximal tubulopathy where dent disease is determined by gene analysis. method: seven-year-old boy is refered after endocrinological exemination where abdominal ultrasound showed nephrocalcinosis. there are anamnestic data neither of oedema, macrohaematuria, nor poliuria or hypertension. there are also no data of chronic renal failure in the family. we describe detailed diagnostic procedures performed in the boy and his family. results: we determined: proteinuria ( , g/day), elevated urinary excretion of beta- microglobuline, microscopic hemathuria, hypercalciuria ( - mg/kg/day), nephrocalcinosis, decreased tubular reabsorption phosphate ( - %). values of grow hormone, parathormone on thyroid hormone are normal. except hypercalciuria, which is registered in patient's mother, all other analysis performedin family members are betwen referent values. diagnosis is finalized by mutation analysis, which has showed s l substitution on cncl . mutation carrier is mother with normal fenotype. conclusion: dent disease is rare x-linked nephrocalcinosis. definitive diagnosis ofthis proximal tubulopathy which leads to progressive renal demage, is not possible without evidence of gene mutation in renal chlor channel. introduction: the segmental renal infarction is a rare disease, allthough it is more frequent in children than in adults and can be clinically veryrelevant. objective: we describe the clinical course of two children with idiopaticsegmental renal infarction who suffered severe arterial hypertension. cases description: the typical clinical picture of this disease, as seen in our twopatients, is characterized by metabolic alkalosis, hyponatremia, hypokaliemia, hyper-reninemia, hyperaldosteronism and renal salt lossfrom the contralateral enlarged kidney. hypertension was diagnosedduring the study of haematuria in the first case and due to ahypertensive emergency in the second case. the ethiology was found tobe renovascular in both patients, involving the occlusion of small renal arteries causing segmental renal infarction. our first patient was treated with partial nephrectomy, and the second patient wastreated with antihypertensive medication given the impossibility ofremoving the renal infarcted area. conclusions: in the clinical picture, the sodium depletion with increased urinary volume of the contralateral healthy kidney can be explained by the goldblatt model. the gold standard test for the diagnosis is theselective renal arteriography, which is the most sensible and specifictest for diagnosing renovascular hypertension secondary to a segmental renal infarction because it helps identifiing the segmentary artery ofthe infarcted area, this being the source of increased focal renin production. the definitive treatment is the surgical segmentectomy. if segmentectomy is not feasible because of the localization of the infracted area as inour second patient, a medical treatment is needed. conclusion: although an inverse association between birth weight/blood pressure has been suggested in several large studies, interpretation is still controversial. in our study, we have found only a weak inverse correlation between birth weight and pad (abpm): no statistical significance has been found among other variables, although graphs show a trend of low birth weight children towards hypertension. probably a long term follow-up is necessary. he took longer to have improvement, but his calcemia, phosphatemia and alkalinephosphatase are normal. the coding region of the vdr was amplified by pcr and directly sequenced. results: three mutations (two novels) were identified. two patients had anovel mutation in exon , changing the amino acid glutamine to glutamicacid at position (q e). one patient had a novel mutation in exon changing glycine to valine at position (g v). those mutations are in the ligand binding domain and belong to the patients with better control of the disease. one had mutation in exon , in the dna binding domain, changing arginine to a stop codon at position (r x) and it was from the patient with worse response to the treatment. conclusions: two novel mutations are presented in the vitamin d receptor and it could be possible to do a correlation between the clinical evolution and the localization of the mutations. we aimed to evalute the effects of intrauterine growth retardation (iugr) on blood pressure (bp) in small for gestational age (sga) children. sga children ( f, m) aged . ± . y ( preterm and term) and ( f, m) agematched control with appropriate for ga (aga) were included in the study. -hr ambulatory blood pressure monitoring (abpm)was performed using an oscillometric device (mobilograph). th centile limit was set according to published data sets, nocturnal threshold was % less than awake limits. bp was classified as normal if the mean sbp is < th percentile and sbp load is > %. nocturnal bp dip for sbp and dbp were evaluated. in sga and in aga case, office sbp were above th%, all dbp values were normal in both groups. according to the mean of abpm records, systolic, diastolic ht were determined in sga group, and systolic, no diastolic ht were in aga group. there were sga and aga children whose sbp load over %, and only of them remarked as hypertensive according to mean sbp values. children considered as hypertensive had significantly higher sbp loads than those that were not hypertensive( % vs %, p< . ). abpm records were not different between preterm and term sgas. sga group had lower nocturnal bpdip for sbp and dbp in comparison to aga group( . % vs . % for sbp, . %vs . %for dbp, p: . ). although it was not statistically significant, the frequency of non-dipper children was higher in sga group ( . %) than those in aga group ( . %). except the lower nocturnal bp dip and higher sbp loads in sga group which may be a marker for further hypertension, no clear association between being sga and hypertension could be found in our study population. pres is a rare clinico-radiological entity associated with acute hypertension, renal insufficiency and immunosuppressive therapy. it is typically reversible but cases with irreversibility had rarely been reported. we report contrasting cases of pres associated with renal disease, one with full recovery and the other subsequently had epilepsy. first patient had steroid sensitive nephrotic syndrome with acute hypertension, fluid overload and acute renal failure while the second patient had severe flare of lupus nephritis with malignant hypertension, renal failure and thrombotic thrombocytopenia. both had acute onset of drowsiness, blindness and seizures and mri findings of subcortical oedema in the parietal-occipital-temporal regions. while the second patient had full recovery, the first patient developed temporal epilepsy and repeat mri showed mesial temporal sclerosis. pres is attributed to capillary leak from functional cerebral vascular changes of hypertension, rather than infarction. prolonged vascular disruption may lead to ischemia resulting in neurological sequelae and chronic epilepsy. using mri, pres can be readily diagnosed and normalisation of blood pressure is imperative in patients at high risk of pres. efforts have been done to describe the significance of various genetic polymorphisms (snps) in acute renal failure (arf). available reports do not investigate the predictive value of snps in disease forecasting, because so many interacting factors influence arf that classical statistical methods become unstable. high-dimensional nonparametric methods such as random forest technique overcome this problem and help to identify each clinical and genetic factor that possibly contributes to disease. we tested the classification value of basic clinical data available at birth and snps in arf of preterm infants. we determined the relative importance score (ri) of each parameter in classification. low birth weight and gestational age had the highest ri; just few snps had medium ri, while the majority of snps had small ri. then we created variable-patterns and searched for pattern with the highest accuracy of classification. for each complication, the accuracy was . solely basic clinical data were considered. if snps were incorporated, the accuracy of classification for arf was not improved. in contrast with previous observations these findings suggest that the snps do not provide additional information about arf-risk of the general preterm population. conclusions: srbd in children with elevated blood pressure is higher than that of the general pediatric population. the prevalence appears highest in patients with pre-hypertension and may be higher in patients with essential and secondary hypertension than in patients with white-coat hypertension. the renal phenotype in lowe syndrome is similar to dent's disease a -month-old girl presented with heart failure due to severe hypertension ( / ). doppler ultrasonography (us) revealed a right renal artery stenosis. biological findings showed normal serum creatinine (scr) ( mmol/l), hyponatremia ( mmol/l) and hypokalemia ( mmol/l). aldosterone plasma level was increased as were epinephrine ( pg/ml n< ) and norepinephrine ( pg/ml n< ) plasma levels measured times. renal arteriography confirmed the presence of a nearly obstructive right renal artery stenosis with a normal left kidney. pta failed to improve signifcantly the renal artery flow. in the following hours after pta, her scr level increased, up to mmol/l. doppler us showed an unchanged right kidney but hypoperfused area in the left kidney confirmed by the tc -dmsa scan. both aspects were strongly in favor of focal ischemic events. secondarly, her renal function improved but hypertension remained difficult to control autotransplantation of the right kidney was then done, but unfortunately, thrombosis of the right renal artery occured in the following hours. six months later, her plasma creatinine level is of mmol/l. her cardiac function is normal but she has to remain on antihypertensive drugs. what exactly happened during arteriography in her left kidney, in order to provoke such ischemic injury, knowing that the left renal artery was not catheterized during arteriography and pta? one hypothesis is that arterial vasospasms occured, explained by a high vasospastic predisposition due to enhaced cathecolamines secretion. such increased has already been drescribed in patients with renal artery stenosis. this case raised the question of preparing patients in this condition with efficient antispasm therapy agents before radiological vascular investigations are done. rtd is a cause of oligohydramnios leading to potter's sequence and neonatal anuria. it is characterized by absent or hypoplasic proximal tubules. these lesions can be secondary to non genetic conditions involving renal hypoperfusion. genetic forms of rtd have autosomal recessive transmission. mutations of genes encoding for the renin-angiotensin system have been reported. evolution is most often severe with in utero or neonatal death. case report: this boy was born at weeks of gestation with oligohydramnios, arthrogryposis, large fontanels with poor calvarian ossification. he was referred to intensive care unit for respiratory distress, low blood pressure (bp) unresponsive to vasopressors and anuria (plasma creatinine μmol/l at day ). renal ultrasound (us) showed enlarged kidneys with bilateral cortical hyperechogenicity. weaning from ventilation and vasoactive drugs was possible at day . glomerular filtration recovered (plasma creatinine μmol/l at day ). at age , the child is well with normal growth and a mild chronic renal insufficiency (creatinine clearance ml/min/ , m ). bp is in the low normal ranges with plasma renin x over the upper range of normal values and normal plasma aldosterone. on renal us, kidney volume normalized with persistent cortical hyperechogenicity. genetic study revealed compound heterozygous mutation in the gene encoding angiotensin converting enzyme. one is a nonsense mutation (r p), the other is a truncating mutation (k fsx ). it is possible that the first mutation is less deleterious than the other and this could partly explain the unusually favourable evolution of this rtd. in conclusion, this is a rare report of a child with autosomal recessive rtd surviving after neonatal period. further functional studies are needed to explain this unusual phenotype. data on hbp in children are very limited, and it is unclear how much it is specific in pediatric patients. the objective of our study was to determine the reproducibility of hbp in children and adolescents. automatic omron -cp devices, which have been validated for use in children and adolescents, were provided to all families. hypertensive children measured blood pressure (bp) every minutes, three times consecutively in the morning or early afternoon, and three times in the evening during days. the reproducibility of hbp was quantified using repeated measures analysis of variance test and the sd of differences between average hbp values of consecutive days. confidence interval (ci) was calculated. we studied patients ( girls, boys); mean age was , year, range - years. there were measurements of systolic blood pressure (sbp) and diastolic blood pressure (dbp). in the morning or early afternoon the mean sbp and dbp were , mmhg (sd , ) ( % ci , - , mmhg) and , mmhg (sd , ) ( % ci , - , mmhg), respectively. in the evening the mean sbp and dbp was , mmhg (sd , ) ( % ci , - , mmhg) and , mmhg (sd , ) ( % ci , - , mmhg). the mean average difference between the daily measurements of sbp and dbp were analyzed with each period and were not statistically significant (p> . ). on the basis of these results, we conclude that self-monitoring of blood pressure at home in children has good reproducibility and is not influenced by white coat effect. case report: a -year-old caucasian girl presented with history of severe polyuria and polydipsia of few months duration. past history was significant for head injury and possible seizure activity at age yr. there was no history of headaches, vomiting, or visual problems. family history negative for di. physical examination was essentially normal. basal plasma and urine osmolality, and plasma vasopressin were and mosm/kg, and < . pg/ml, respectively. at the conclusion of water deprivation test these readings were and mosm/kg, and . pg/ml, respectively. however, urine osmolality increased to mosm/kg after desmopressin injection, confirming the diagnosis of cdi. mri scan revealed absence of the bright spot on t weighted images. genetic analysis detected avp gene mutation a t, where the normal alanine at amino acid position is changed to threonine. elevated levels of plasma vasopressin after water deprivation were misleading and intriguing. we believe that elevated plasma vasopressin, although immunoreactive was devoid of biological activity. conclusion: molecular genetic evaluation should be performed in all children with cdi without an identifiable cause, even in the absence of a positive family history of cdi. mutations of the nphs gene encoding podocin lead to autosomal recessive corticoresistant nephrotic syndrome, focal and segmental glomerulosclerosis (fsgs), and early end-stage renal disease (esrd). in mice, podocin inactivation by homologous recombination results in diffuse mesangial and glomerular sclerosis, esrd and death within the first weeks of life. this early demise precludes extensive study and elucidation of the molecular pathways engaged by podocin in the mature kidney. we have, therefore, generated a novel mouse model in which a tamoxifeninducible creer-loxp system allows for conditional inactivation in a temporal fashion in podocytes. following tamoxifen administration in nphs flox/-, cre+ mice, cre expression was noted in % of glomeruli and in - % of podocytes. two weeks after cre induction, podocin expression is decreased in podocytes correlating with the appearance of selective albuminuria at - days. this progresses to massive, nonselective proteinuria by weeks, along with high blood pressure and impaired renal function. optical microscopy of kidneys showed no lesion at week and fsgs progressively developed by weeks along with tubular lesions. however electron microscopy revealed a partial foot process effacement at week with no significant albuminuria that extends by weeks along with abnormalities of the basement membrane and development of albuminuria. no mesangial or vascular lesion has been noted, differentiating it from our previous podocin null model in which renal development may be affected by podocin loss or nephrotic syndrome. this model will allow a better understanding of the mechanisms underlying the development of nephrotic syndrome and the role of podocin in the mature kidney, and will be crucial to test new therapeutic approaches. glomerulonephritis is a group of diseases with complex etiology, pathogenesis, morphological features and clinical course. the renin-angiotensin and coagulation systems genes are important group of candidate genes involved in pathogenesis of chronic renal diseases. the purpose of our study was to analyze the association of genetic polymorphisms of these genes with glomerular kidney diseases. the study population consisted of patients with immunological glomerular kidney diseases and patients with renal failure with glomerulonephritis as primary disease. the control group consisted of healthy subjects. by means of the polymerase chain reaction (pcr) the following polymorphisms were evaluated: insertion/deletion (i/d) polymorphism in intron of the angiotensin-converting enzyme gene (ace), g/ g polymorphism of the plasminogen activator inhibitor- (pai- ). no significant association was found between the ace and pai- allele and genotype frequencies and the disease. more progressing of glomerulonephritis current was marked at patients with simultaneous has dd genotype of ace gene and g/ g gene pai- (c = , ; p= , ). our results suggest that ace i/d and pai- g/ g polymorphism is an important modifying gene in the progression of glomerulonephritis. captopril objectives: secondary causes of hypertension such as renovascular hypertension are more abundant in children unlike adult population. the objective of this retrospective study is to assess the use of captopril renography (cr), which provides a non-invasive approach in the differential diagnosis of hypertension. patients and methods: clinical, radiological and scintigraphic data of a total of patients were analyzed. there were girls and boys (mean age: ± years). none of the patients had parenchymal renal disease or reduced renal function. all patients were orally hydrated before scintigraphic study. cr was performed hour after orally captopril administration and iv furosemide injection was done simultaneously with - mci tc m-mag . when post-captopril study was normal, baseline scintigraphy was not performed. computed tomography angiography (cta) was performed in and gadolinium-enhanced magnetic resonance angiography (mra) was performed in children in addition to routine renal doppler ultrasonography (dus). results: nineteen out of patients had other comorbid diseases as follows: obesity n= , previosly-diagnosed fibomuscular dysplasia n= , n= neurofibromatosis, n= demyelinating diseases, n= bartter and n= turner syndrome. cr was normal in patients. in children abnormal cr findings in correlation with radiological methods were reported. correlation with radiological methods could not be done due to suboptimal technique in patients, of whom dus in obese children could not be interpreted. in the other patient, although cr was abnormal, radiological methods could not confirm scintigraphy. conclusions: captopril renography is a useful and simple-to-perform imaging modality in children suspected of having renovascular hypertension. takayasu's arteritis (ta) is a chronic, inflammatory, large-vessel vasculitis affecting the aorta and its main branches, which causes stenosis, occlusion, rarely aneurysm and distal ischemia. the disease is most common in young women, it is rare in inviduals before the age of years. clinical presentation may be heterogeneous. in this report, we present a pediatric patient with ta who had hypertension as the sole manifestation of multipl critical arterial involvement but no other symptoms. a -year-old boy was admitted with hypertension. the acute-phase reactants were moderately elevated with an erythrocyte sedimentation rate mm/h, and a c-reactive protein value of mg/l. serologic tests including ana, anti-ds dna, c and panca, complement c , and c were negative and other laboratory data were normal. mr angiography showed multiple severe stenosis or occlusions of the thoracic and abdominal aorta together with bilateral renal arteries, and saccular aneurysm in the abdominal aorta. immunosuppressive treatment including pulse steroid and methotrexate was prescribed. the patient underwent angioplasty of bilateral renal arteries and suprarenal aorta, and a stent was placed in the right renal artery. ta should be kept in mind in the differential diagnosis of hypertension in children, even if they do not have other associated symptoms of the disease. human urotensin ii is the most potent vasoconstrictor which circulates in the plasma of healthy individuals. it was suggested that it has an endocrine role in sodium handling and even in metabolic syndrome. the aim of this study was to investigate the role of u-ii in obese adolescents with hypertension. fourteen obese adolescents with essential hypertension (group ) were compared with thirteen age-and sex-matched obese adolescents with white-coat hypertension (group ). they underwent twenty-four hour abpm and echocardiographic investigation, complete physical examination, including adiposity indexes. plasma and urinary levels of u-ii were measured by ria. obese adolescents in group have significantly higher blood pressure measurements than those in group confirmed by abpm. there was no significant difference in left ventricular mass index between two groups. no significant difference was found in plasma u-ii concentrations (pg/ml) between group and group ( . ± . and . ± . , respectively), whereas mean urinary u-ii level (pg/mg urinary creatinine) was significantly higher in group than that of group ( . ± . , . ± . , respectively). considering the renal synthesis and vasoactive role of u-ii, these results suggest that u-ii may have a role in adolescents with white-coat hypertension. distal renal tubular acidosis (drta) and deafness is a rare autosomal recessive disease characterized by severe metabolic acidosis in childhood and inappropriately high urinary ph along with sensorineural hearing loss. the disease is caused by defects in the atp v b gene. the aim of the present study was to determine the molecular basis for drta with deafness in eight patients from four families (a-d) in israel. molecular testing was done by sequencing the coding exons of the atp v b gene in one affected child from each family. a population screen was performed for mutations found in family a. the results yielded a different mutation in the atp v b gene, as follows: families a and d: missense mutation, c>g (p r), in addition to a single nucleotide polymorphism ( t>c) in the first codon; family b: insertion mutation, - insc (i fs); family c: a novel nonsense mutation, c>t (r x). in conclusion, the phenotype of drta and deafness concurs with mutations in the atp v b gene. in the present study, four families of different origins with the same phenotype had three different genotypes, indicating that there is no single common mutation in israel. these findings have implications for genetic counseling during pregnancy and testing of families. the fact that all the patients that were examined have harbor mutations in the atp v b gene, pointed for the specific clinical phenotype. making correct and early clinical diagnosis is a fundamental step in finding the molecular basis of this rare disorder. delta f is the most common cystic fibrosis (cf) mutation worldwide. the prevalence is approximately % in caucasian and - % in asian while f l is demonstrated in only . %. homogenous delta f mutation is recognized as the most common genotype however there are small numbers of cf patients having delta f /f l. in the present study we report a year-old thai boy, originated from north india, presented with recurrent episodes of febrile illness, hyponatremia, hypokalemia and metabolic alkalosis since months of age. he was transferred to our hospital for further investigation. blood chemistry revealed serum electrolytes: sodium , potassium . , chloride . , bicarbonate . meq/l, and urine electrolytes: sodium< , potassium . , chloride< meq/l. after intravenous fluid administration, hyponatremia and metabolic alkalosis improved. dna sequencing analysis of his blood demonstrates compound heterogenous mutation for delta f and f l in cftr gene. t to g transversion at nucleotide and g to a transversion at nucleotide are found without altering amino acid encoding gene. in conclusion, we report a rare case of cf with delta f /f l genotype presented with recurrent hyponatremia and metabolic alkalosis. awareness of electrolyte abnormalities during febrile illness, proper genetic counseling and long-term follow-up are necessary in this patient. objectives of study: about % of families with congenital nephrogenic diabetes insipidus (ndi) have mutations in the aquaporin gene (aqp ), which codes for the vasopressin-sensitive water channel. only seven aqp mutations are known to cause a dominant form of the disease. in this study we performed genetic and clinical studies in a generation family with autosomal dominant inheritance of a partial di phenotype. methods and results: the proband (man, yrs old) was initially diagnosed with partial central diabetes insipidus due to antidiuretic effect of ddavp. his daughter ( . yrs old) also showed polyuria and polydipsia which was responsive to high doses of intranasal ddavp. the pedigree was consistent with an autosomal dominant inheritance pattern. sequence analysis of the entire coding region of the avp gene and aqp gene was performed in the proband and his affected daughter and in unaffected family members. the avp gene was normal in all subjects. in the two affected patients but not in the healthy subjects we identified a novel missense mutation in one allele of exon of the aqp gene (c. c>t) which predicts a substitution in the c-terminal part of the aqp protein (p.r w). conclusion: partial ndi can be caused by heterozygosity for a p.r w substitution of the aqp water channel. the substitution is likely to significantly alter the c-terminal tail of aquaporin which is important for proper trafficking to the apical plasma membrane. the preservation of some residual antidiuretic function indicates that some aqp tetramers are processed correctly. the study further illustrates the importance of molecular diagnostic tools in establishing a correct differential diagnosis in familial cases of di. a background and aim: dent's disease is a renal tubulopathy characterized by low-molecular-weight proteinuria, hypercalciuria, nephrocalcinosis and nephrolithiasis. mutations in the clcn gene encoding the chloride/proton exchange transporter clc- cause this disease. we have described an alu insertion in clcn that leads to exon skipping in the patient's mrna. in this study, we investigated the consequence of this mutation on the function of two putative exonic splicing enhancers (eses) in exon and the role of alu '-end sequences on splicing inhibition. methods: minigenes were constructed by inserting exon and exon -alu with their intronic flanking sequences into the exon trap vector. artificial mutations were introduced by site-directed mutagenesis. plasmids were transfected into cos cells by electroporation. pre-mrna splicing analysis was performed by rt-pcr. the ese finder web resource was used to predict the mutagenesis effects on the eses. results: alteration of one of the putative eses, the predicted binding site for srp , induced exon skipping. restoration of this site within the alu sequence promoted the incorporation of exon -alu in the mrna. however, restoration of both eses leaving the alu sequence intact resulted in exon skipping. furthermore, substitution of the eses for the first seven nucleotides of the alu element, and insertion of this sequence next to the eses increased exon skipping. deletion or modification of the alu '-end enhanced exon inclusion in the mrna. in the patient carrying the clcn alu insertion, dent's diseases is caused by disruption of an ese and by inclusion of splicing inhibitory sequences leading to exon skipping. this work was supported by grant pi from fondo de investigación sanitaria. factor h-associated hemolytic uremic syndrome (fhd-hus) is a rare disease with incomplete penetrance. it is not clear why and how carriers of the same mutation will eventually develop or not develop the disease and this uncertainty is sometimes responsible for anxiety in the carriers badly affecting their quality of life (particularly of parents with children carrying the mutation). in the attempt of estimating disease risk in subjects with factor h gene mutation, the families of fhd-hus patients (all of which had a documented mutation on the scr ) currently being treated at our center, were screened to identify the carriers after having been informed on the purpose of the analysis. twenty-eight subjects (age range - yrs), out of analyzed, revealed heterozygous mutations in the carboxy-terminal region of fh gene ( %). among subjects carrying the mutation, ( %) had exhibited the disease at a mean age of years (range . - ), of which ( %) before age , whereas the remaining subjects (mean age of yr -range - ) were healthy at time of the study. the figure shows the probability of carriers to be hus-free by age (no event occurred after age yrs). in the meantime that predisposing factor are identified, the presented survival curve (fig. ) can be an useful tool to estimate the residual risk of hus in individual carriers according to their specific age. cerebello-oculo-renal syndrome (cors) (also called joubert syndrome (js) type b) and meckel (mks) syndrome belong to the cilliopathy group of developmental autosomal recessive disorders associated with primary cilium dysfunction. nephronophthisis (nphp), the most frequent genetic cause of renal failure in children and young adults, is associated with retinal degeneration and cerebellar vermis aplasia in cors. mks is characterizd by renal cystic dysplasia, central nervous system malformations and hepatic developmental defects. these syndromes are genetically heterogenous: mutations in ahi and nphp can cause cors and mutations in mks can lead to mks, while mutations in mks and nphp are found in both syndromes. using snp mapping, we identified missense and truncating mutations in a novel genee, nphp , in both cors and mks. interestingly, all sequence changes were either nonsense or frameshift mutations in fetuses with mks whereas patients with cors had either only one or no truncating mutation. we then show that inactivation of nphp mouse orthologue recapitulates the cerebral and renal defects of cors/mks. we further demonstrate that nphp protein co-localizes at the basal body/centrosomes with nephrocystin- and nephrocystin- , the protein products of both nphp and nphp , known disease genes for nphp. in addition, missense mutations of nphp protein found in cors patients diminishes its interaction with nephrocystin- . taken together. our findings demonstrate that mutations of this novel ciliary gene can cause the multiorgan syndromes of either cors or mks, which therefore represent a continuum of the same underlying disorder. severe antenatal bartter's syndrome ga + , bw: g). both had classical signs of antenatal bs including very poor thrive, polyuria ( - ml/kg b.w./h) and responded to indomethacin treatment. direct sequencing was performed on pcr-amplified genomic dna. the entire coding region of both genes was analyzed. the kcnj gene was normal but both children were homozygous for a single base substitution ( t>a) in exon of the slc a gene predicting a premature stop codon (y x). the parents of both children and two siblings were heterozygous for the same mutation. by restriction enzyme analysis, the t>a substitution was absent among chromosomes from healthy subjects. conclusion: two children with severe antenatal bs were identified and the clinical phenotype was characterized. we identified in both children a novel mutation causing a premature stop codon of the bumetanide-sensitive-sodium-potassium-chloride co-transporter (nkcc ). despite large potassium supplements and indomethacin treatment, both children show persistent polyuria, vomiting, and insufficient thrive. background: mutations of nphs encoding the transmembrane slit diaphragm protein nephrin cause congenital nephrotic syndrome of the finnish type, characterized by massive proteinuria and the development of nephrotic syndrome before months of age. about different nphs mutations have been described. a large number of these are missense mutations resulting in single amino acid replacement mostly located in the extracellular domain. some nphs mutations have been associated with mild phenotypes responding to angiotensin-converting enzyme and prostaglandin synthesis inhibition. patient history: we report on a son of consanguineous turkish parents with a novel nphs alteration and steroid-resistant congenital nephrotic syndrome. after normal pregnancy and delivery at weeks of gestational age the boy presented with edema and proteinuria at the age of months. he responded to angiotensin converting enzyme inhibitor treatment reducing his proteinuria from a maximum of g/g creatinine to g/g creatinine and allowing him to develop normally until the age of months when cardiovascular insufficiency in the course of a hyperpyretic infection led to hypoxic encephalopathy. genetic testing revealed a homozygous in-frame -bp insertion in exon of nphs . both parents were found to be heterozygous. no mutations were found in nphs or in exons and of wt . the alteration results in an insertion of a glycine in an extracellular immunoglobulin domain of nephrin. the pathogenicity of this alteration is unclear. nephrin may be misfolded and mislocalized as in some missense mutations of the extracellular domain. alternatively the alteration might lead to an altered extracellular homo-and heterodimerization of nephrin. functional studies are currently underway to determine the effect of this novel alteration in nphs . objectives of study: interleukin receptor antagonist (il- ra) gene polymorphism has been found to affect disease susceptibility and activity in several inflammatory diseases. we investigated the association between il ra gene polymorphism and childhood nephrotic syndrome (ns) in a turkish population. methods: we analyzed the genetic polymorphism of il- ra gene in patients with childhood ns and healthy controls by using pcr. five alleles of the il- ra gene were identified and designated as il- ra* , il- ra* , il- ra* , il- ra* , and il- ra* , according to the variable number of tandem repeats in intron . results: in the ns group, the allele frequencies of il- ra* , il- ra* , il- ra* , il- ra* , and il- ra* were . , . , . , . , and . % compared with %, %, %, %, and % in the controls. a high allele frequency of il- ra* (x = . , p= . ) and a lower allele frequency of il- ra* (x = . , p= . ) were found in childhood ns. the other polymorphisms were not significantly different from normal controls. conclusions: a high allele frequency of the il- ra* allele may affect the disease susceptibility in childhood ns. objectives of study: congenital anomalies of the urinary tract (caut) are common in humans, and the incidence is increasing with recent advances in prenatal ultrasonographic examinations. interstitial fibrosis, which correlates with infiltration of inflammatory cells is common finding in the kidney with long-term ureteral obstruction. up-regulation of monocyte chemoattractant protein- (mcp- ), may be a common regulatory pathway involved in the progressive renal damage with any etiologies leading to interstitial fibrosis. mcp- gene polymorphism - a/g had been suggested to influence circulating mcp- levels and gene expression thus, might be one of the genetic markers for progression of renal damage. our aim was to investigate the frequency of mcp- genotypes and allele - g in patients with caut. objectives of study: congenital urological anomalies are well recognized as causing renal dysfunction. on the other hand, patients without congenital anomalies but with urinary bladder dysfunction (bd) could also develop renal parenchymal damage. it has been reported that angiotensin converting enzyme (ace) i/d polymorphism was a risk factor for renal parenchymal damage in certain renal diseases including vesicoureteral reflux. the aim was to determine i/d polymorphism as a potential risk factor for renal parenchymal damage in patients with congenital obstructive uropathy and to compare them to patients born with normal anatomy and innervation of bladder, sphincter and pelvic floor but which could develop upper urinary tract abnormalities. objectives od study: to determine the frequency of pyelocaliceal dilation (pcd) in asymptomatic infants and its connection with presence of other urinary tract anomalies (uta) and urinary tract infection (uti). methods: ultrasonographic screening (us) of urinary tract (ut) was performed on unselected population of healthy infants ranging between days and months of age ( boys and girls). kidneys were divided into two groups according to grade of pcd. group i consisted of kidneys with pcd, whose anterio-posterior diameter was - mm, while patients from the group ii had a-p diameter wider than mm.patients were followed up (ranging - months) by serial ultrasound examinations and with other methods for presence of uti and uta if necessary. results: in examined population , % had uta, and , % had uti. pcd was found in infants ( , %). in the group i, consisted of infants ( males and females) pcd increased during the time in , % infants, remained unchanged in , %, decreased in , %, and disappeared in , % patients. uta was found in ( , %) infants, and uti in ( , %) infants. in the group ii, consisted of male infants, pcd has not changed in ( , %) infants, decreased in ( , %), while dilation disappeared in ( , %) patients. uta was found in ( , %), and uti in ( , %) infants. conclusions: us of ut is useful and valuable method for detecting pcd. our results indicate that mild pcd in infants increases the risk for uta approximately times and uti times, while severe pcd raises the risk for uta approximately times, and uti times. early diagnosis and early treatment of uta and alertness for possible uti should be the final goal of the kidney damage prevention. therefore we recommend that us of ut should be done in all children in the first months of life. in order to determine factors involved in kidney development, the spatial and temporal expression pattern of intermediate filaments (cytokeratins, vimentin) , epithelial growth factor (egf) and transforming growth factor alpha (tgf-α), was investigated in developing kidneys (mesonephros and metanephros) of - week human embryos. immunohistochemistry for detecting specific antibodies was used on paraffin sections. in the - week human mesonephros, vimentin was moderately expressed in all mesonephric structures, while cytokeratins were seen only in the mesonephric nephrons. moderate to strong expression to egf and tgf-α detected in all mesonephric structures, decreased with advancing development. in the - -week metanephros, vimentin was mildly expressed in all metanephric structures. later on, its expression increased in collectin system and interstitium. in the th developmental week, first to appear were cytokeratins and in the ureteric bud and ampullae, while from the th week onward, both cytokeratins showed increasing expression in the collecting system and nehrons. at early stages, egf and tgfá showed moderate to strong reactivity in the collecting system, the metanephric mesenchyme and cups. from the th week onward, expression of both factors decreased in differentiating nephrons. expression of all investigated developmental factors was in line with subsequent mesonephric degeneration. expression pattern of intermediate filaments in the metanephros might be associated with mesenchimal to epithelial transformation of developing nephrons. some mutations of cytokeratins are lethal, while others might lead to some multifactorial disorders. egf and tgf-α expression patterns of the metanephros indicate their role in induction, proliferation and growth of metanephric structures. their disturbed expression might cause reduction in kidney growth. we have demonstrated that renin-angiotensin system (ras) and mitogen-activated protein kinase (mapk) family constribute to the renal development. growing evidences indicate that aldosterone, a final element or ras, is an independent and powerful mediator of various renal disease. purpose of this study was to evaluate the role of endogenous aldosterone in renal development including cell proliferation and apoptosis, and the expression of mapk family. newborn rat pups were treated with spironolactone ( mg/kg/d) in olive oil or vehicle for d. to identify cellular changes, kidneys were examined for proliferating cell nuclear antigen (pcna) by immunohistochemical (ihc) stain, and apoptotic cells by tunel stain. immunoblot, ihc stain and rt-pcr for mapks, phospho-mapks, and p gene were performed. spironolactone treatment resulted in decreased body weight, decreased pcna-positive proliferating cells and increased tunel-positive apoptotic cells, especially renal cortical epithelial cells (p< . ). in the spironolactone-treated group, c-jun n terminal kinase (jnk)- and phospho-jnk- protein expressions were significantly increased, whereas extracellular signal -regulated kinase (erk)- and p protein expressions were sigificantly decreased compared with the control group (p< . ) in immunoblot and ihc stain. expressions of erk- , phospho-erk- and , and p sere not changed by spironolactone treatment. in rt-pcr, erk- and p mrna expressions were significantly increased in the spironolactone-treated group (p< . ). we conclude that aldosterone inhibition in the developing rat kidney decreases cellular proliferation and increases apoptosis, and modulates the expressions of jnk- , erk- and p . mapk family expression may be implicated to differentially participate in aldosterone-related intracellular signaling pathways in the developing kidney. objectives: early detection of anomalies of the kidney and urinary tract (ut) helps to prevent complications but is hampered in moldova by diagnostic and logistic problems. to assess the extent of late diagnosis we studied the clinical data of all children referred to us for suspected ut infection (uti) in / and found to have renal or ut anomalies. methods: children ( males; age months- years) found to have anomalies of the kidney and ut and treated conservatively were studied (newborns and infants < months were seen elsewhere). work-up included ultrasonography in all, voiding cysto-urethrography (vcug) in %, urography in % and scintigraphy in % of patients. results: reasons for referral were febrile uti ( %); abdominal pain ( %), diarrhea and vomiting ( %), enuresis ( %) and dysuria ( %). uti was confirmed by urine culture in two thirds of cases. age at diagnosis of renal or ut anomaly was < year in %, - years in %, - years in %, - years in % and > years in %. renal hypo/dysplasia was found in , solitary kidney in and a horseshoe kidney in children. anomalies of the ut included hydronephrosis due to ureteral obstruction ( up and uv-obstruction), vesico-ureteral reflux ( ), duplex systems ( ) and bladder anomalies or mild infravesical obstruction ( ). serum creatinine was in the normal range in all children. urolithiasis was found in patients. conclusions: anomalies of the kidney and ut were diagnosed in nearly half beyond the age of years, thus with considerably delay. based on the results of this study a new strategy of renal ultrasound screening in newborns including prenatal diagnosis and of closer co-operation with referring physicians has been implemented. objective of the study: the purpose of this study was to report the outcome of infants with antenatal hydronephrosis. methods: between may and june , all patients diagnosed with isolated fetal renal pelvic dilatation (rpd) were prospectively followed at asingle tertiary renal unit. inclusion criteria were presence of rpd equal to or greater than mm on prenatal ultrasound after weeks gestation, at least six-months of follow-up, and at least two postnatalus scans. the events of interest were presence of uropathy, rpd resolution, urinary tract infection (uti), and hypertension. rpd was classified as mild ( - . mm), moderate ( - . mm) and severe (> mm objective of the study: the aim of this study was to compare the accuracy of ultrasound renal parameters to discriminate between significant uropathy and idiopathic renal pelvis dilatation. methods: neonates who were found to have isolated fetal renal pelvis dilatation (rpd) underwent systematic investigation and were prospectively followed. a us scan was performed after the first week of life and all infants underwent vcug. neonates with rpd larger than mm were examined by renal scintigraphy. receiver-operating characteristic (roc) plots were constructed to determine the accuracy of three indexes: fetal rpd, postnatal rpd, and sfu grading system. results: a total of infants were included in the analysis. ninety-five fetuses ( %) presented bilateral renal pelvis dilatation. seventy-nine infants ( %) presented urinary tract anomaly, corresponding to renal units. the most frequent detected uropathy was ureteropelvic junction obstruction ( ), followed by primary vesicoureteral reflux ( ), and megaureter ( ) conclusions: our data support the view that fetal and postnatal us renal parameters are useful markers to identify infants with clinically significant uropathies. there was no significant difference in performance among the indexes. objective of the study: the aim of this study was to evaluate the diagnostic accuracy of ultrasound (us) renal parameters to identify vur in infants withisolated antenatal hydronephrosis. methods: neonates who were found to have isolated fetal renalpelvis dilatation (rpd) underwent systematic investigation and wereprospectively followed. a us scan was performed after the first week of life and all infants underwent vcug. neonates with rpd larger than mm were examined by renal scintigraphy. receiver-operating characteristic (roc) plots were constructed to determine the accuracy of three indexes: fetal rpd, postnatal rpd, and sfu grading system. results: a total of infants were included in the analysis. seventeen infants ( . %) presented vur, corresponding to renal units. to discriminate between renal units with and without vur areaunder the curve (auc) was estimated by the roc curve, which was . ( % ci= . - . ), . ( % ci, . - . ), and . ( % ci, . - . ) for fetal rpd, postnatal rpd, and sfu grading system, respectively. there was no statistically significant difference between the indexes. the optimal threshold for fetal rpd was mm with a sensitivity of % ( % ci, - ) and specificity of % ( % ci, - ), for postnatal rpd the respective figures were: % ( % ci, - ) and % ( % ci, - ) for the cut-off of . mm. conclusions: our data shown that the magnitude of rpd is a poor predictor of presence of primary vur. there was no significant difference in performance among the indexes. objetive: we investigated the prevalence of renal calcification in children with autosomal ressecive polycystic kidney disease (arpkd) and studied the metabolic changes thats could cause this complication. methods: patients with arpkd. girls/ boys; range age m to y. criteria inclusion presence typical imaging findings: enlarged kidney and diffusely increased renal echogenicity and poorly defined renal margins on sonography; suggestive imaging features with positive results renal or liver biopsy, results patients, girls and boys, range of age - y, had ct scan renal clacification bilaterally. without renal clacifications < year. children renal calcifications, sistemic hypertension, portal hypertension and gastrointestinal bleeding and one renal colic. renal insufficiency patients, it was mild in (gfr > ml/min/ , mt ), moderate in (gfr - ), and severe in one (gfr< ). all with renal insufficiency had distal tubular acidosis. hypocitraturia urine patients. urinary calcium, uric acid, oxalates, and cystines normal in all. tuberoussclerosis (tsc) -an autosomal dominant inherited genetic disorder -is characterized by development of hamartomatous growths in many organs.two causative genes, tsc (chromosomal locus q ) and tsc (chromosomal locus p . ) have been identified. tsc gene is adjacent to pkd , the major gene for autosomal dominant polycystic kidney disease (adpkd) on chromosom p and contiguous germline deletion of both genes results in severe polycystic kidney disease phenotype at birth. at months of age bilateral abdominal masses were occasionally palpatedin a previously healthy girl. ultrasonography demonstrated enlarged (approximately cm) kidneys with multiple large cysts resembling those seen in adpkd. renal function and blood pressure was normal. suspicion of tuberous sclerosis was raised due to numerous hypopigmented cutaneous macules on the trunk and extremities. echocardiography demonstrated rhabdomyomas in the left ventricle with no hemodynamic significance. an isolated juxtapapillary astrocytoma was found in the left eye. her psychomotor development was normal with no history of seizures. cerebral magnetic resonance imaging revealed multiple subependymal nodules with noobstruction of the cerebral fluid pathways. by multiplex ligation-dependent probe amplification (mlpa) a large dna deletion was identified spanning from tsc exon to pkd exon permitting the diagnosis of tsc -pkd contiguous gene syndrome. cardiac rhabdomyoma and cutaneous manifestations were found in her father as well but no renal changes. at years of age the girl is doing fine with ace blockers against hypertension. renal function is still normal. the size of the cardiac rhabdomyomas is diminishing while the cerebral and ocular hamartomasare unchanged. this additional report focuses tsc in an infant presenting with polycystic kidneys and cutaneous lesions. improvements in ultrasound technology and the appropriate timing of antenatal ultrasound has led to refined prenatal diagnosis and enhanced accuracy of diagnosis of fetal renal anomalies and makes it possible to treat obstructive and/or refluxing uropathies before the onset of clinical symptoms.a retrospective review of patients; girls ( , %) and boys ( , %) admitted to our clinic between january -december with antenatal urinary anomalies were investigated to determine the urinary tract anomalies, and the follow-up results are presented. routine prophylaxis was started at admision and the imaging studies were performed. the mean gestational age at detection was , ± , weeks. the mean age of admittance was , ± , days and the average follow-up period was , ± , months. antenatal ultrasonoghrapy examination showed anomalies in / renal units. of these antenatally observed renal units, had postnatal urinary tract anomalies. of these postnatally observed renal units, urinary tract anomalies were detected (multiple urinary tract anomalies in patients) ( table ) . fifty-two ( , %) children had surgical interventions such as; ureteroneocystostomy, pyeloplasty, nephroureterectomy, puv resection. eighty-one ( %) of our patients had urinary tract infection during follow-up and renal scar was detected in ( %) patients. acute renal failure developed in patients and chronic renal failure developed in patients and three patients died. we conclude that all infants with fetal urinary abnormalities should be evaluated, so that we can recognize and treat congenital anomalies that may affect renal function or cause urinay tract infection, renal scarring. the majority of patients with fetal urinary anomalies can be managed safely with close conservative follow-up. fetal urinary tract obstruction at days gestation (e ) produces small kidneys with cysts, whereas obstruction at days (e ) generates large kidneys with cysts. in the present study, we investigated the mechanism for the generation of small kidneys by urinary tract obstruction at an earlier gestational age, e . fetal lambs underwent urethral and urachal ligation at e (n= ) or e (n= ). fetal lambs were delivered by c-section , , days after obstruction, or at term ( days gestation). unoperated kidneys of e , e , e , and at term served as controls. the percentage cystic area of kidneys obstructed at e and e was not different days after obstruction ( ± % vs ± %). after days, however the percentage of cystic area became larger in kidneys obstructed at e ( ± % vs ± %), and was significantly larger days after obstruction ( ± % vs ± %). proliferating cells, detected by pcna staining, were found in cysts and tubules of obstructed kidneys increasing toward term, and were more abundant in kidneys obstructed at e . on the other hand, pcna-positive cells in the nephrogenic zone were reduced in obstructed kidneys. the decrease was more prominent in kidneys obstructed at e . apoptotic cells, identified by tunel staining, were detected in the inner medulla of obstructed kidneys equally in kidneys obstructed at e and e during the fetal stage. at term, tunel-positive cells were rarely present in normal kidneys or kidneys obstructed at e , but were found abundantly in the interstitium and occasionally in cysts and tubules of kidneys obstructed at e . in conclusion, urinary tract obstruction at an earlier gestational age produces small kidneys by inhibition of mesenchymal cell proliferation, which may be due to compression by cysts. a. results: detrusor hyperreactivity, most commonly in i and iv or v grade was found in . % of vur children. the maximum detrusor pressure was above cm h . detrusor-external dyssymetry was found in % of children, most frequently in grade i and iv or v grades, and detrusor-internal dyssymetry was recognized in . % of children with vur, most frequently in grade i and iv or v. in . % of children with i-iii grade of vur cystometric capacity was reduced but child with v grade had increased capacity of the urinary bladder. glomerular filtration according to schwartz equation was normal and independent of vur grade. decrease in osmolality below mosm/kg h in nocturnal urine was only detected in the group of children with iv and v grade of vur,. there was no correlation between detrusor tension and osmolality of urine and glomerular filtration rate. conclusions: ). dysfunction of the lower urinary tract, with detrusor hyperactivity was detected, as the most frequent dysfunction in % of children below year old with i-v degree of vur, ). the maximun detrusor pressure in the voiding phase was highest in grade i and iv iv-v reflux children. hypomelanosis of ito was first described as a disorder characterized by unusual unilateral or bilateral macular hypopigmented whorls, streaks and patches. subsequently, neurologic, skeletal and ocular involvement were described. kidney involvement has only been exceptionally reported. herein, we describe a case of a male infant with hypomelanosis of ito and renal involvement. the patient was born at weeks of gestation by cesarian delivery. the ultrasound scan at weeks of gestation revealed bilateral enlargement of kidneys, decreased corticomedullary differentiation and cysts located in the cortical and subcapsular regions. these findings were confirmed at two months of life by ct scan. skin examination showed hypopigmented linear and round diffuse lesions located on the right leg and arms. the ophthalmological examination showed anterior capsular and posterior subcapsular cataract of the left eye. as previously reported in other cases of hypomelanosis of ito, the patient presented a transient leucocytosis (max . /mm ) during the first months of life.the renal biopsy showed a classic picture of glomerulocystic kidney disease, whereas the skin biopsy confirmed the clinical diagnosis of hypomelanosis of ito.three other cases of kidney disease in hypomelanosis of ito have been reported. of these, one case presented abnormalities of the glomerular basement membrane, and one case presented with polycistic kidney disease. the third case had renal cystic dysplasia with a histological picture containing glomerular cysts. alltogether these reports suggest that genes involved in hypomelanosis of ito are important for normal renal development and may be implicated in cystogenesis, when mutated. here we report on a male newborn (birth weight g, length cm) who presented with progressive edemas, oliguria and failure to thrive during the first week of live. on clinical examination he showed bilateral microcoria and decreased muscle tone. laboratory work-up revealed large proteinuria ( g/g creatinine), hypoalbuminemia ( g/l) and renal failure ( objectives. to investigate the incidence, nature, and management of associated genitourinary malformations in children with multicystic dysplastic kidney (mcdk). methods. in this retrospective study, we analyzed the medical records and imaging studies of children with mcdk. in children ( %) anomalies of the urinary tract were suspected prenatally in ultrasound studies. in the remaining children the diagnosis of mcdk was made postnatally. results. the male/female sex ratio was : . the left side was involved in ( %) children. voiding cystourethrography was done in ( %) children, the isotopic m tc-dmsa scan of the kidney in ( %). urogential anomalies were present in ( %) children. among them, contralateral urologic anomalies were found in patients (vesicoureteral reflux in and hydronephrosis in ), and ipsilateral in (vesicoureteral reflux in , ureterocele in , and hydroureter in ). genital abnormalities such as uterine didelphys and hydrocele were found in children. fourteen ( %) patients underwent follow-up examinations with ultrasonography (mean follow-up . years, range months to years). compensatory hypertrophy of the contalateral kidney was found in most children and decreased size of ipsilateral dysplastic kidney was found in out of children with follow-up. no cases of hypertension or tumor developed during the follow-up. conclusion. ultrasound can be used safely to diagnose unilateral mcdks and associated genitourinary malformation. although the risk of hypertension and development of malignancy is low, follow-up evaluation of contralateral renal function and genitalia will be needed. in cases of hydronephrosis and/or urinary tract infection, voiding cystourethrography is necessary and possibility of association with genital anomalies should be considered until the puberty. a. background: ectopic ureter is a rare anomaly. its incidence is at least four times higher in females and also more than % of the ectopic ureters drain duplicated systems in females. the most common presenting symptoms of an ectopic ureter are urinary tract infection and incontinence. diagnosis is often delayed and may remain undiagnosed until adulthood. case report: a -month-old girl was admitted to our hospital with the complaints of fever and discomfort. her mother recognized intermittent dribbling of urine while changing her napkin. physical examination revealed fever ( . °c), diaper dermatitis and intermittent dribbling of urine. urinalysis revealed leukocytouria, acute phase reactants were elevated (crp: . , esr: ) and renal function tests were normal. the patient was hospitalized with the diagnosis of acute pyelonephritis. tc m dimercaptosuccinic acid (tc-dmsa) scan revealed an increase in the size of the right kidney and decreased uptake in the upper half of the same kidney. ultrasound was performed with the suspicion of an ectopic ureter and it showed right duplicated kidney with marked dilatation of the upper collecting system. the ureter was also dilated in its whole length and ended ectopically distal to the bladder. contrast-enhanced magnetic resonance urography (mru) demonstrated right obstructed duplicated system with vaginal ectopic insertion of upper pole ureter. discussion: this case was presented to underscore the role of careful physical examination in the diagnosis of this rare anomaly that is by paying attention to the complaints of the family. ultrasound is the initial, important diagnostic modality in these patients especially if done by experienced radiologists. the diagnosis can be confirmed with mru by depicting the exact insertion of the ectopic ureter. objectives of study: to evaluate the occurrence and severity of vesicoureteral reflux (vur) in young infants with a history of mild prenatal hydronephrosis. the usefulness of voiding urosonography (vus) in the diagnosis of vur was also evaluated. methods: forty seven infants ( males, females) with a history of mild prenatal hydronephrosis, diagnosed between st to th week of gestation, were enrolled in the study. postnatal ultrasound was performed within the first month of life. voiding cystourethrography (vcug) and at the same time, contrast-enhanced harmonic vus was performed at the age of . - . months. results: the prenatal ultrasound revealed an anterior-posterior pelvic diameter of - mm in fetuses and - mm in . postanatal ultrasound showed an anterior-posterior pelvic diameter of - mm in infants and - mm in . vur was found in of ( . %) infants (grade i: , ii: , iii: ). the vur was detected by both vcug and vus in of children, only by vcug in and only by vus in of infants. the vur that was missed by vcug was more severe (grade ii and iii), compared with this one missed by vus (grade i). conclusions: even though prenatal hydronephrosis was associated with a quite important occurrence of vur, this was of mild or moderate severity. comparison between the two imaging modalities showed that the vur missed by vus were with no clinical significance (grade i), whereas the vur missed by vcug were more severe. although further study is needed, vus could be an alternative method, mainly in girls, in whom the imaging of the urethra is not necessary, thus avoiding the radiation exposure. early treatment with indomethacin in a neonate with a bartter syndromea case report neonatal bs is a rare genetic disorder characterized by sodium, potassium and chloride urinary wasting, hypokalemic metabolic alkalosis with hyperreninemia and hyperaldosteronism in the absence of hypertension and high level of urinary prostaglandins. indomethacin therapy is controversial because of toxicity for gut and kidney. a premature boy of unrelated couple was born by cesarean section at weeks because of early rupture of membranes and fetal distress. birth weight was g, length cm and apgar score / / . pregnancy was complicated by severe polyhydramnios. baby was mechanically ventilated for first hours and treated with antibiotics because of suspected sepsis. marked polyuria and dehydration were present from st week. metabolic parameters revealed hypokalemia, hyponatremia and hypochloremic metabolic alkalosis. serum creatinine was slightly elevated and gfr in normal ranges. blood pressure was normal with raised plasma renin activity and aldosterone level. sodium excretion via urine and level of renal and systemic prostaglandins were increased. nephrocalcinosis was detected on us from week. additonally to electrolyte supplementation indomethacin was started on the th day at a dose of mg/kg/day. in first months child experienced septic episodes, candida pyelonephritis and was operated because of bowel obstruction. dna analysis of affected child found new mutations in romk gene: p l and q x in herited from parents who carried one mutation each. at months height and weight are at and head circumference at percentile with slightly retarded psychomotoric development. he continues on . mg/kg/day indomethacin therapy. blood electrolyte profile is normal without supplements. us shows no progression of nephrocalcinosis. early treatment with indomethacin may prevent life-threatening complications and reduce the development of nephrocalcinosis. nimuselide, a cox inhibitor is widely used in india for relief of pain and fever. we describe cases of fetal renal abuse leading to neonatal renal failure due to maternal ingestion of nimuselide in the third trimester of pregnancy. results: all patients were diagnosed as having renal failure in the first few days of life.there were boys and one girl.. all the mothers had normal pregnancies except for oligohydramnios that was detected during the last months of pregnancy in all cases. children presented with anuria from birth. the remaining two had non-oliguric renal failure with metabolic acidosis as the presenting feature in one and poor feeding and lethargy in the other. usg revealed normal sized kidneys. one patient also showed increased echogenicity. out of the anuric children underwent peritoneal dialysis for a period varying from to weeks without recovery of renal failure. the remaining were managed conservatively. two of these patients are now in chronic renal failure at ages and years. only one patient recovered completely after days of anuria. all the mothers had taken nimuselide in the last trimester for periods varying from few days to several weeks for relief of pain or fever. some of them had taken multiple courses of short duration. the mother of the child who recovered completely had taken nimuselide in the last days before delivery. renal biopsy done in one baby revealed renal tubular dysgenesis. conclusion: nimuselide intake in the last trimester of pregnancy can be associated with oligohydramnios and neonatal renal failure that can be irreversible. renal tubular dysgenesis may be the underlying pathology. objectives of study: pkd is the most common inherited renal disease. aim of ours study was to analyse clinical and laboratory features of the different types pkd. patients and methods: we described the clinical presentation of children with pkd ( boys, girls) diagnosed in pediatric nethrology department between and . the patient's age range was from months till years. we retrospectively studied the family histories, clinical and biochemical data (physical examination, level of arterial blood pressure, blood and urine creatinine levels, serum levels of urea, glomerular filtration rate), ultrasonography, scintigraphy. results: the analysis of the family histories revealed adpkd in patients ( boys, girls), arpkd in ( boys, girls) and nondifferential pkd in ( boys, girls) children. pkd diagnosed by antenatal ultrasound in cases ( adpkd, arpkd). the mean follow-up adpkd were , year (range - years), arpkd - , year (range - , years). conclusion. patients with arpkd demonstrated the early beginning of an arterial hypertension and progressing chronic renal failure. one girl with neonatal form of arpkd died. chronic renal failure developed in ( , %) cases of pkd. objectives: this prospective study was to answer the question on the need of long-term follow-up and correlation of renal functions with the age at surgery and grade of o.u. prior to surgery in patients after surgery of obstructive uropathy (o.u.). methods: selected biochemical markers of glomerular and tubular functions and ultrasonographic findings in patients ( boys) who underwent surgery due to uni-or bilateral o.u. of grade iii. and iv. (age at surgery < months) in - were examined at mean age of . ± . years. the results were compared to healthy controls and/or to reference values according to age. consequently, patients were devided into groups according to the age at surgery ( - months, - months, - months) and grade of o.u. prior to surgery. results: serum concentration of cystatin c (s-cysc) was significantly higher in patients when compared to control group (p< . ). while s-creatinine was within reference interval in all patients, s-cysc was increased in . % when compared to reference interval. decreased tubular resorption and concentration ability was found in % and % patients, respectively. non-specific aminoaciduria was detected in . % patients. on ultrasound, . % kidneys after surgery had residual dilatation of renal pelvis. the differences in renal functions in patients according to their age at first surgery were not significant except for u-nag activity with significant negative linear trend with higher age at surgery. the grade of o.u. prior to surgery did not have significant influence on renal functions. conclusions: mild tubular dysfunction and slightly reduced gfr in the part of patients make longterm nephrologic follow-up reasonable. our results support the trend of postponing early postnatal surgical intervention in patients with positive ultrasound screening of o.u. and normocreatininemia. objectives of study: to evaluate, during almost five years of follow-up, the changes among preoperative and postoperative renal function in infants ( m/ f) with prenatal severe hydronephrosis (hn) and upj obstruction. methods: upj obstruction was diagnosed by a mag renal scan, performed at - weeks of age to establish baseline differential renal function; surgery was made if there was evidence of obstruction injury, and/or progression of hn and/or symptoms. the group was re-imaged months after surgery, after months, year and then annually. results: initial differential renal function was moderate in . % of males and in % of females and good in . % and in % respectively. also, % of kidneys required surgery because of declining function, with mean differential renal function in the affected kidney of % that improved to % already at months after pyeloplasty. there was no significant functional improvement, in the kidneys that underwent correction because of increased hn or symptoms and final renal function was > %. after pyeloplasty t was > min. in % and - min. in % of cases (p< . ) there was no statistically significant correlation between initial grade of hn and initial renal function. surgical treatment was performed between - months of age and there was no significant difference in postoperative results, ascribed to patient age at surgery. ma values, greater than controls at diagnosis, reduced at months after surgery in all, but % of children. during the follow-up, the mean ccr and bp values were in normal range for age in all children. conclusions: our findings showed improvement also in kidney with preoperative uptake less of %. this may be to explain in according to an inverse correlation between degree of renal dysplasia and gestational age. objective of study: is to determine the postnatal course and follow-up of children with fetal hydronephrosis. methods: in years period ( ) ( ) ( ) ( ) ( ) ( ) ( ) we followed infants with antenataly detected hydronephrosis. all infants were submitted to ultrasonographic examination of kidneys and bladder. if indicated, the isotope renography, micturating cysto-urethrography, i.v.urography and mr were performed. results: the diagnosis of hydronephrosis was established during - th weeks of gestation by obstetritian. first postnalat ultrasound investigation was performed during neonatal period in most children ( %). in ( , %) infants we diagnosed idiopathic hydronephrosis, in ( , %) vesicouretheral reflux (vur) grade ii-iv, in ( , %) hypofunction of one kidney, in ( , %) ureteropelvic junction obstruction (upjo), in ( , %) ren duplex and ureterocele, in ( , %) ampular pelvis and in ( , %) afunction of one kidney. after - months we found normal ultrasound in ( , %) children. the ultasound results were stable in ( , %) children and in ( , %) there was progression of hydronephrosis. four ( , %) infants underwent immediate surgery. conclusions: in a group of infants with antenataly detected hydronephrosis the diagnosis was confirmed postnataly in % infants. more than % of infants required long term follow-up. in , % the immediate surgey was required. this data support the need for antenatal detection of hydronephrosis. in the same period we followed up infants with urologic abnormalities which were not detected antenataly.the fetal ultrasound is reliable screening method in detection of urologic abnormalities. the considerable number of anomalies which were not detected antenataly are the result of insuffitient use of fetal ultrasound investigation. hemolytic uremic syndrome (hus) is defined by acute renal failure, microangiopathic hemolytic anemia, and thrombopenia. perinatal asphyxia (pa) may cause renal failure after birth and is often associated to disseminated intravascular coagulopathy (dic) with platelet consumption. however, no biological investigation permits to distinguish clearly neonatal hus from dic. we report three neonates with renal failure due to different degrees of pa. they presented biological features compatible with hus such as fragmentocytes ( %), thrombopenia (< , /mm ), anemia (< g/dl). serum creatinine on day was , , mmol/l respectively, requiring peritoneal dialysis in one patient. haptoglobin was undetectable for all three patients. factor h and i were in the lower normal range; components of the complement system (c , c ) and adamt activity were decreased. two patients received daily fresh frozen plasma infusions over the first weeks. renal function improved in two patients until day ; one patient has chronic renal failure. all other parameters suggestive for hus were normal on day , , and respectively. no severe neurological consequences were noted for either of them. pa may be responsible for multiorgan damage via ischemic lesions. ischemia may result in endothelial cell injury, the crucial event for the development of thrombotic microangiopathy. we hypothesize that endothelial cell damage concomitant with pa may lead to a vicious circle resulting in consumption of platelets and plasma factors involved in hemostasis and/or fibrinolysis. early use of fresh frozen plasma may correct these alterations. renal biopsies might have been useful but are technically difficult in newborns. in conclusion, pa and neonatal hus are difficult to distinguish and endothelial cell damage may be a common pathyphysiological aspect and might requirespecific treatments. a. medynska, m. nalesniak, k. kilis-pstrusinska, d. zwoliñska congenital posterior urethral valves (puv) are the most common cause of lower urinary tract obstruction in male neonates. we aimed to review our experience with puv children ( boys) in respect to retrospective analysis of the clinical course of disease. we analyzed: ultrasound during pregnancy, age of disease onset, clinical symptoms at admittance to hospital, outcome. average lenght of follow-up was , years, varying between month and years.obstruction of urinary tract was suspected by prenatal ultrasound in patients. the initial presenting symptoms were as follows: urinary tract infection boys, failure to thrive patients, increased abdominal circumference - , abdominal pain , enuresis - , acute renal failure , and chronic renal failure children. in association with puv renal dysplasia/hypoplasia in patients, undescended testis , bladder trabeculation were found. the diagnosis of puv was confirmed by voiding cystourethrograms and/or cystoscopy. primary vesicouretral reflux was documented in pts. hydronephrosis and/or megaureter were observed the most often in boys. the diagnosis of puv was established in pts at the age of less month, in pts between - months, and in between - years. surgery was performed in pts in neonates period including primary valve surgical ablation and/or cutaneostomy vesicostomy. chronic renal failure was diagnosed in boys in first year of live. of them progressed to end-stage renal disease. globally during the follow-up pts developed end-stage renal disease. pts have done a graft. only boys survive without progression to chronic renal failure. the presentation of puv is variable and currently antenatal detection is the most common mode. outcome boys with puv is poor. patients need nephrologic assesment from birth. background: furosemide is among the most frequently used drugs in the neonatal unit but few studies analyze the beneficial effect and complications in this patient group. objectives of the study: to analyze the therapeutic clinical effect and to document side effects of furosemide therapy in extremely preterm infants born < weeks gestational age (ga). methods: twelve infants born < weeks ga were prospectively included during the fall . the following parameters were documented prior, during and after furosemide administration: clinical status, serum/urine electrolytes, creatinine, albumin, blood gases and furosemide exposure. ultrasound of the kidneys and a wrist radiograph were performed at - weeks to rule out osteopenia/rickets and nephrocalcinosis respectively. no statistical analysis were done due to the small study size. results: general oedema, respiratory rate, apneic spells and oxygen supplementation decreased. arterial/venous pco decreased and partial oxygen saturation increased indicating improved lung function. hco increased and ph decreased. urinary excretion of sodium, potassium, chloride and calcium increased while phosphate excretion decreased. serum sodium and chloride decreased and potassium increased initially. six infants had electrolyte disturbances and metabolic alkalosis. one infant died during the study period. in the remaining infants, of had worsening of their patent ductus arteriosis, had osteopenia or rickets and had nephrocalcinosis. the total side effect score was increased in the infants with the highest furosemide exposure. conclusions: this small study suggests that furosemide is beneficial in extremely preterm infants born < weeks ga and that the associated side effects correlate to the total drug exposure. we recommend caution for long term administration of furosemide. conclusion: although children in our study suffered significant neonatal hie resulting in arf, glomerular and tubular function recovered sufficiently to cope with increasing body mass and metabolic needs. unlike reported studies, we did not find any significant evidence of cri in the survivors of neonatal hie and arf. one with marginal microalbuminuria will need further observation. c was born after a monozygotic monoamniotic twin pregnancy (gestational age= weeks). she presented with twin-twin transfusion syndrome with hypotrophy (birth weight= g, other twin= g), severe hypovolemia, anemia and acute renal failure. she required a blood transfusion, mechanical ventilation ( days), and peritoneal dialysis ( days). she recovered without bronchodysplasia but with chronic renal failure (creatininemia at months= μmol/l). the following months were uneventful but, as usual in tts, she exhibited growth retardation and slight mental delay compared to her twin. she reached terminal renal failure at years of age and was successfully kidney transplanted. after age of years, she presented with increasingly frequent and severe pulmonary infections predominantly in lower lobes of both lungs. after extensive explorations, the diagnosis of bilateral bronchiectasis was made. the search for classical aetiologies of such pathology was negative. the symmetric aspect and the absence of other etiologies lead to the consideration of bronchiectasis as a congenital pathology. numerous publications demonstrate the role of the renin-angiotensin system (ras) in renal and cerebral damages in tts. authors demonstrate the role or ras in development of vasculature in fetus but also of cartilage and muscle in different organs including lung. associations between tts and lung pathologies need to be further investigated. urofacial ( the urofacial (ochoa) syndrome (ufs) is a rare disease that occurs in both sexes and is more frequent when the parents are closely related. it has both urinary and facial abnormalities. ufs is a rare autosomal recessive disorder and a potential gene has been mapped to chromosome q -q . they present a bladder voiding dysfunction due to impaired neural communication between the bladder and the spinal cord, resulting in incomplete emptying of the bladder. this usually results in enuresis, urinary tract infection, hydronephrosis and in some severely affected patients, end-stage renal disease developed. the facial abnormality is a characteristic expression that, when these patients smile, their facial musculature inverts and they appear as if they are crying. we report a year-old girl who has inverted facial appearance, voiding dysfunction and vezicoureteral reflux. she had constipation and did the intermittan uretral cathaterization for five years. after a detailed evaluation, she was diagnosed as ochoa syndrome due to inverted facial expression. we report this case, because early diagnosis of ufs is very important for early assessment and management of urinary problems to prevent development of chronic renal failure. we think that only a smile can give a strong high light for this unusual 'inverted' facial expression and patients can be screened earlier for severe voiding dysfunction. tar syndrome is a congenital malformation syndrome characterized by bilateral absence of the radii and a thrombocytopenia. the known urinary anomalies with tar are duplex ureter, dilatation of renal pelvis, horseshoe kidney, and functional problems like vesicouretheral reflux and pyelonephritis. case: nine years old patient with tar syndrome was admitted with a complaint of bright red urine repeated three times. the microscopic hematuria without dysmorphism of erythrocytes accompanied with no proteinuria were determined in repeated urine sample microscopy. iga, ana, anti dna serology were negative. urine culture was clean. stone formation ( x mm) in the upper pole of the right kidney was established by the abdominal ultrasonography. postoperative chemical analysis of the stone, revealed that it was consisted of oxalate monohydrate and dihydrate. but the patient discontinued his follow-ups afterwards for a year. in this period, he had macroscopic hematuria attack once. when he applied for the second time, he reported macroscopic hematuria. cystoscopy was done for etiology. many tortuous and engorged vessels were seen by this evaluation in the bladder mucosa ( figure ). there was no active bleeding point. result: in this report, kidney stone and telangiectasia found co-incidentally in the bladder of a patient with tar syndrome during the examination of hematuria are discussed as there is no case report demonstrating nephrolithiasis and telangiectasia in tar patients in the literature. figure : many tortuous and engorged vessels in the cystoscopy. antenatal hydronephrosis (anh) is one of the common fetal abnormalities detected on ultrasound (us). the long-term renal prognosis for infants with mild to moderate postnatal hydronephrosis (hn) is unclear and controversial. a systematic review of the published literature was performed to determine an evidence based approach in infants with antenatally diagnosed hn and to identify those at risk of significant post natal nephro-uropathy (pnu). key questions were identified. does anh predict renal tract pathology in neonates? what is the value of prophylactic antibiotics in infants with anh? can postnatal us diagnose significant pnu? when is the optimal time to screen infants postnatally? which imaging modalities are necessary to diagnose the cause of the hn? how many neonates with anh would need to be investigated to prevent one case of esrf/crf? a search strategy was formulated. out of titles only seven studies met the validity criteria for inclusion. the results indicate that antenatal us is a valid screening test for pnu (sensitivity %, specificity %), but is not a predictor of pnu. the detection rate of hn by us is the same whether it is done early or late in neonates. two normal ultrasounds over a minimum of one month are required to screen for pnu. infants with a renal ap diameter over mm are at risk of a significant pnu and should be investigated further. us is not a substitute for cystourethrogram or dynamic isotope studies to determine the cause of hn. none of the studies addressed the role of prophylactic antibiotics. there was insufficient data to calculate the total number of cases that would need to be investigated to prevent one unfavourable outcome (esrf/crf). high quality population based cohort studies with long term follow-up into adulthood are required to determine the optimum postnatal management of mild to moderate hn in infants with anh. jeune asphyxiating thoracic dysplasia: a case report jeune asphyxiating thoracic dysplasia (jatd) is one of the congenital hepatorenal fibrocystic syndromes. it is characterized by renal, hepatic, pancreatic abnormalities with associated skeletal abnormalities including a long and narrow thorax, metaphyseal irregularities, and shortness of the ribs and long bones. this report describes a pediatric patient with jatd developed end-stage renal failure. a -year-old boy was admitted with complaint of vomiting and pallor. he had dysmorphic appearance including trigonocephaly, short stature, long thorax and short limbs and fingers, polydactyly and fascial dysmorphism. laboratory findings revealed severe anemia (hb . g/dl), high bun and creatinine levels ( mg/dl and . mg/dl respectively) and normal liver tests. abdominal usg showed a severe intrahepatic biliary tract dilatation and intraparenchymal cysts in liver, pancreas and kidneys. mr pancreatocholangiography was consistent with caroli's disease. jatd should be considered when caroli's disease exists with skeletal abnormalities. follow-up antenatal hydronephrosis: one centre experience the most common renal abnormality detected antenatally is hydronephrosis ( % to % of all pregnancies). in this paper, we report follow-up our patients with antenatal hydronephrosis (ah) between and . diagnosis of hydronephrosis was made > mm of antero-posterior diameter (ap) of the renal pelvis. ah was detected in patients on antenatal ultrasound examination. of the patients with ah, ( . %) were found to have hydronephrosis postnatally and ( . %) postnatal scans were normal. in of these patients ( . %) had bilateral and ( . %) of these patients had unilateral hydronephrosis. in these patients with ah, uretero-pelvic junction obstruction (upj) ( . %), reflux ( . %), uretero-vesical junction obstruction ( . %), posterior urethral valves ( . %) and mega-ureter ( . %) were identified. in follow-up period, ( . %) patients with reflux, ( . ) patients with upj were treated with surgery (p< . ). in conclusion, upj was most important cause of ah and most of them were treated with surgery. hyponatremia and renal tubular acidosis in severe vesicoureteral refluxa case report sahlgrenska academy, department of pediatric, gothenburg, sweden case report: st child to healthy parents without heredity for kidney or metabolic disease. antenatal bilateral hydronephrosis. postnatal examination showed bilateral vur grade v, normal urethra. antibiotic prophylaxis was started, no urinary tract infection (uti) occurred. normal s-creat and s-na + at weeks of age. the electrolytes remained normal during the next months. normal growth. the boy was thirsty with high urine volumes. at month of age feeding problems began with retarded weight gain. no vomiting or diarrhoea. at admission to the hospital the child was dehydrated, s-na + mmol/l, s-cl - mmol/l, s-ph . , bicarbonate mmol/l, s-creat μmol/l. crp mg/l, urine culture negative. u-na + mmol/l, u-ph . , u-osmolality mosm/kg. the anion gap was normal and there was no lactacidosis. the s-aldosterone was elevated , nmol/l, s-cortisone normal. treatment included intravenous rehydration, na + supplement and oral bicarbonate. blood chemistry normalised and the child's general condition improved rapidly. conclusions. children with severe reflux are at high risk for uti but may also develop impaired tubular function with diabetes insipidus, renal tubular acidosis and hyponatremia. the mechanisms include down-regulation of vasopressin receptors and impaired distal tubular function. close clinical monitoring of these children with regular blood chemistry and weight controls is important. purpose: we aim to prospectively study the natural history of minimal to severe grades of antenatal hydronephrosis (anhn) in our local chinese population and correlate the renal pelvic diameter (rpd) with the outcome. patients and methods: cases of anhn were prospectively followed up along a predefined protocol using us, mag and mcu in all. obstruction (pujo or vujo) was defined as a need for surgery based on symptoms and deteriorating function, not on mag drainage time. results: neonates were followed up for minimum of years. eighty percent had normal or minimal hn on postnatal scans (rpd - mm), . % had mild ( - mm) or moderate ( - ) hn and . % severe hn (> mm). seventy-eight percent infants had benign course; . % had partial obstruction which improved; . % had vesicoureteric reflux (vur) one of which required surgery. another . % required surgery for obstruction. the roc curve for obstruction requiring surgery showed optimal cut-off point of . mm (sensitivity %, specificity . %). prolonged diuretic t / was not predictive of surgery. severity of hn did not correlate with presence or grade of vur. fifteen patients developed uti despite antibiotic prophylaxis and had focal scars, all occurred in association with high grade vur or obstruction. the prognosis of infants with minimal or mild anhn is good. however rpd is poorly correlated with vur. the chances of obstructive lesions requiring surgery are high when the rpd is above mm. in those with high grade reflux or obstruction, urinary tract infection may lead to renal scars. objectives of study: cystinosis is a rare disease presented initially with renal fanconi syndrome, and renal glomerular failure develops later in childhood. without cysteamine treatment, patients affected with cystinosis uniformly died during childhood in the absence of renal replacement therapy (rrt). cysteamine is not available here and in some other areas of the world. the aim of this paper is to describe a beneficial effect of acacia gum in a patient with cystinosis and chronic renal failure. method: years old girl with cystinosis presented with symptomatic uremia as she didn't receive cysteamine. serum creatinine . mg/dl, blood urea mg/dl. the girl was hospitalized and vomiting controlled with intravenous fluid and pyridoxine. chronic dialysis was not available for her and the parents refused treatment with intermittent acute peritoneal dialysis. the girl was treated with a new therapeutic regimen (therapy ; ( ): ) combining the traditional conservative management of crf (dietary and pharmacologic) with addition of acacia gum (ag) g/day as an urea lowering agent aiming at improving her condition without dialysis. results: treatment was associated with amelioration of the uremic symptoms and improved general well being. after weeks of treatment, serum creatinine . mg/dl, blood urea mg/dl. during months of follow-up she continued in experiencing improved well being and urea levels was kept below mg/dl without dialysis. conclusion: it was possible to improve the health of patient with cystinosis despite the nonavailability of cysteamine and the appropriate rrt. objectives of study: the pattern of renal tubular disorder (rtds) has been infrequently reported in the literature, and the pattern of rtds in iraqi and arab children is not known. methods: from june to august , it was possible to evaluate children with suspected rtd to determine the type of their tubular defect. there was evidence of rtd in only patients; males ( %) and females ( %). their ages at referral ranged between months and years (mean . years). in patients with oculo-cerebro-renal syndrome, there was no evidence of rtd and one patient had hyperoxaluria which not a rtd. results: seven types of rtds were identified. the three most common disorders were: idiopathic hypercalciuria ( %), cystinosis ( %) and renal tubular acidosis rta ( %). four of the patients with rta have proximal rta, and four have distal rta. four of the patients with hypercalciuria have also significant hyperoxaluria > mg/kg/day. conclusion: the pattern of rtds in iraqi children differs from the previous studies: in germany the three most frequent disorders were cystinosis, xlhr, and idiopathic hypercalciuria. objectives of study: few literatures reported the incidence of ocular abnormalities in chronic renal failure (crf). the aim of this paper is to determine the incidence of ocular abnormalities in childhood crf. methods: from january to december , patients with crf (at the university hospital in al kadhimiyia) were examined to determine the presence of ocular abnormalitites. fifty patients were males ( . %) and ( %) were female. their age at referral ranged from months to years (mean year). they were followed for a period ranged from days to f years. results: corneal cystine crystals were the most common ocular abnormalities associated with childhood crf observed in patients with nephropathic cystinosis ( . %). congenital cataract & glaucoma were observed in patients ( . %) with oculo-cerebro-renal syndrome (ocrs). congenital cataract & chorioretinal hypoplasia were present in patient with ocrs. hypertensive retinopathy occurred in patients. acquired cataracts occurred in one patient with hinman syndrome in association with hypocalcaemia and non-compliance with calcium and onealphacalciferol supplementation. retinitis pigmentosa in one patient with laurence moon biedl syndrome. bilateral optic atrophy in one patient with familial nephropathy associated with club feet. proptosis in one patient with membranoproliferative glomerulonephritis. conclusion: ocular abnormalities are relatively common in childhood crf occurring in approximately %. objective: hypocalcaemia has been reported as a complication of phototherapy especially in neonates. we studied the relation between serum calcium level and urine calcium to creatinine ratio in neonates under phototherapy. method: icteric newborns ( males and females) treated by phototherapy entered into study by non accidental sampling. the consent was taken from parents on admission. all were breastfed healthy newborns. weight was checked and serum samples for calcium and bilirubin and urine aliquots for calcium, creatinine and osmoloality were sent on arrival (group i), after hour of starting (group ii) and hour after discontinuing phototherapy (group iii). hypercalciuria was defined by uca/ucr > . , hypocalcemia was defined by serum calcium < mg/dl in the term and < mg/dl in the premature. chi , anova, wilcoxon rank test and spearman were used to compare frequency, means, median and correlation. p< . was considered significant. two groups were designed, pateints whose therapy were finished at least months (group ) and those either on therapy or less than months passed from the last protocol of cytostat (group ). demographic data, cumulative dosages of anticancer drugs, history of other nephrotoxic agents, nephrectomy, radiotherapy and acute renal failure were recorded. we used ctc ( ) to evaluate renal function. chi and mann whitney u test and biniary logistic regression were used to compare percentage, scoring and correlation respectively. p value less than . was considered significant. result: out of patients were in group and ones were in group . the mean of age was . years (± . sd). the median (range) of therapy and termination was months ( - months) and month ( - month) in group and month ( - ) and months ( - months) in group respectively. the percentage of reversible renal failure, proteinuria, abnormal serum calcium and magnesium, metabolic acidosis and urinary concentration defect was higher in group . (table ) these differences were statistically significant (p< . ). we found no correlation between ctc score and dosage of drugs, age, sex, history of radiotherapy or nephrotoxic agents (p> . ). conclusion: mild to moderate tubular dysfunction has been observed in survivors of leukemia. routine follow-up of renal functions is recommended. v. tramma, k. giourtzis, v. fotoulaki, k. nousia-arvanitaki aristotle university, th pediatric clinic, thessaloniki, greece although cftr is expressed in the kidney, patients with cystic fibrosis (cf) have not been reported to have major renal abnormalities with the exception of urolithiasis. the aim of this study was to determine renal function and the potential risk factors for renal stone formation in cf patients older than years of age. the findings of metabolic evaluation of cf patients having confirmed urolithiasis (mean age: , ± , ) were compared with those of cf patients without urolithiasis (mean age: , ± , ) and those of healthy volunteers (mean age: , ± , ). evaluation included plasma sodium (na), potassium (k), chloride, bun, creatinine, uric acid, calcium (ca), phosphorus (p), magnesium (mg) and parathormone (pth). twenty-four hour urine collection for creatinine, uric acid oxalates, ca, mg, k + , na + and microalbuminuria was also performed. glomerular filtration rate (gfr) was calculated and fresh urine samples were examined for the presence of crystals, erythrocytes, glycosuria and microorganisms. patients with cf and urolithiasis showed significantly increased values of bun (p: . ), pth (p: . ) and gfr (p: . ), very low urine mg levels (p: . ) and microalbuminuria (p: . ) as compared to cf patients without urolithiasis. there was no correlation of urolithiasis with hypercalciuria and hyperoxaluria. furthermore, all cf patients showed significantly increased pth levels (p: . ), very low urine mg levels (p: . ) and microalbuminuria (p: . ) as compared to healthy volunteers. conclusions: renal dysfunction was demonstrated in older cf patients, probably, secondary to the primary defect of renal chloride channels. extracellular volume regulators, such as hormones, may also be implied. urolithiasis may be the result of renal dysfunction. conclusions: the morbidity of hsp had obviously increased in recent years. the familial cases, the initial symptoms of no palpable purpura at onset and the cerebral, pulmonary, cardiac and pancreatic involvement should be paid attention. objectives of study: systemic lupus erythematosus (sle) is an autoimmune disease affecting multiple organs and tissues including central nerve system, cardiovascular system and kidney. although etiologic mechanisms of sle are incompletely known, overproduction of immunoglobulin g autoantibody may contribute to onset of this disease. while still incompletely understood, the etiology of systematic sle is considered to involve both genetic and environmental factors. we encountered two boys with severe sle from unrelated families and analyzed polymorphisms of the gene that encodes cytotoxic t-lymphocyte associated (ctla)- , a protein important in t-cell activation and immune tolerance. abnormal function of the gene may participate in causation of autoimmune disease including sle, resulting in production of immunoglobulin against various self-antigens. case report: in family , a boy showed serious cardiovascular complications associated with heart failure while his mother also had clinically active sle including nephritis. a boy in family developed severe renal complications and peripheral vasculitis accompanied by disseminated petechiae in the lower extremities; his paternal grandfather had died from fibrinous pneumonia caused by sle. results: analysis of the ctla- gene indicated that the boy in family and his mother possess a gg genotype in ctla- exon at + together with a -bp fragment length of the ' untranslated region (utr) in exon . the boy in family also showed gg at + . no association with disease activity was found for polymorphism of the promoter region in exon at - in either family. conclusions: disorders of the ctla- gene, especially a gg genotype in exon at + and/or bp fragment length of the 'utr in exon , may be involved in early development of sle in japanese children such as the boys described here. this disorder is transmitted mainly as x-linked trait, and is caused by mutations in the col a gene encoding α chain of type iv collagen. in some families, x-linked as is associated with diffuse leiomyomatosis. we present clinical, pathologic and molecular-genetic findings in japanese family with this inheritance mode of as in association with leiomyomatosis. case report and results: as was diagnosed in a one-year-old boy with recurrent aspiration pneumonia caused by esophageal stenosis from leiomyomatosis. he had macroscopic hematuria and bilateral cataracts. diagnosis was confirmed by electron microscopy coupled with type iv collagen chain subtype staining in a renal biopsy specimen. thickening and irregular contours of the glomerular basement membrane (gbm) and splitting of the lamina densa were evident by electron microscopy. immunofluorescent staining for type iv collagen chains failed to show staining for α (iv), α (iv), or α (iv) in the gbm, associated with lack of α (iv) and α (iv) staining in the bm of bowman's capsule. his mother, who exhibited esophageal leiomyomatosis and is heterozygous for as, showed a discontinuous staining pattern for α (iv) along the epidermal bm. genetic analysis in the boy revealed the deletion of the first two exon of col a together with deletion of the ' end of col a . conclusion: identification of an as patient during infancy is extremely rare. clinical manifestations, including macrohematuria, cataracts and leiomyomatosis caused by the large deletion involved col a to col a , led to early presentation with as. functional voiding disorders of the bladder occur in the absence of any anatomic/neurological abnormality and present with wetting. invasive urodynamic studies are discomforting, not easily available in emerging countries and costly. this study aims to validate non-invasive urodynamics. children below years, with possible voiding disorders evaluated prospectively. non-invasive evaluation included history, examination, frequency volume charting, ultrasonography, urinalysis and renal functions. micturating cystourethrogram was carried out for children with urinary tract infection. all children underwent invasive urodynamic studies (uds) and the significance of association of the parameters of non-invasive assessment with invasive urodynamics was determined. the chi square test was used for statistical analysis using the epi software. children underwent invasive uds. the commonest abnormality was detrusor instability (di) in ( . %). dysynergic voiding (dv) noted in ( . %), lazy bladder in and an occult neurogenic bladder in . the study was normal in . repressing the disease progression may be . mg/kg/day or more background: henoch-schoenlein purpura is classified into the small vessel vasculitis. there may be no reliable indicator of the disease activity. steroid treatment ( mg/kg/day of prednisolone) has been thought of as a means with which alleviate abdominal pain. however, this dose seemed to be not effective to intervene the disease progression to nephritis. objectives: forty-three japanese children with henoch-schoenlein purpura were enrolled in this study. fibrinogen degradation product e-fraction (fdp-e) value was measured once or twice a week in the patients. coagulation factor xiii was simultaneously measured in of the patients in the early phase of illness. with an aim to alleviate abdominal pain, . - . mg/kg/day of prednisolone had been administered to of the patients. results: at presentation, only of the patients had low factor xiii activity. on the contrary, of them had elevated serum fdp-e value. longitudinal fdp-e measurement revealed that patients whose fdp-e value normalized within the second weeks of illness had minimal risk of nephritis. in this group, of had microhematuria. in the other patients group with prolonged (after fourteen days of illness) elevation of fdp-e values, of had nephritis. furthermore, of had proteinuria after three months of illness. these patients who had received prednisolone therapy with less than . mg/kg/day in the early phase of illness. the other patients with . mg/kg/day or more prednisolone therapy had no nephritis. summary: the disease activity of hsp and hspn might reflect the duration of elevated serum fdp-e. more than . mg/kg/day of prednisolone may repress the disease progression to nephrits. background: all major organs are involved more or less in thalassemia and most of them have been studied thoroughly in previous literature. renal system involvement has not been scrupulously scrutinized yet. method: in a randomized prospective study, renal findings of children and young adults, aged - years, with thalassemia major (group ) were compared to other cases of thalassemia intermedia (group ). blood urea nitrogen, serum creatinine, uric acid, calcium, phosphate, urinalysis, and sonographic findings were evaluated. results: mean age was ± . years in group and ± . in group . mean serum ferritin level was ± ng/ml in group vs. ± . ng/ml in thalassemia intermedia group (p< . ). % of subjects of group had received or was on hydroxyurea at the time of evaluation. serum uric acid was significantly higher in patients with thalassemia intermedia ( conclusion: significant renal involvement is not a frequent complication in children and young adults suffering from thalassemia. hyperuricemia and microscopic hematuria is more common in thalassemia intermedia than thalassemia major. case: a -year-old female patient was born at term (weight g, lenght cm) and for aspiration of amniotic fluid required resuscitation and mechanical ventilation for days. perinatal hypoxia was a cause of her acute renal failure but dialysis was not needed. patient's follow-up during next yrs showed mild form of chronic renal failure (crf) without hypertension: serum creatinine (scr; range during follow-up [rdf] - μmol/l), glomerular filtration rate (gfr; rdf - . ml/min/ , m ) and p (rdf - mg/ h). at the age yrs we performed renal biopsy (rb) because girl's p and scr increased ( mg/ h, μmol/l, respectively) and gfr decreased ( ml/min/ . m ). rb showed c q-nephropathy (c qn) with focal glomerular sclerosis and hyalinosis. c qn is a rare disease and as a first diagnostic step is differentiation against lupus nephritis. progression of c qn to crf is infrequent. probably two renal diseases were a cause of crf in our patient -hypoxic renal damage during neonatal period and c qn. objective: renal dysfunction has been reported in survivors of neoplastic disease. early diagnosis of renal damage may decrease the morbidity in those with partial or complete remission. we studied the frequency of nephrotoxicity in pediatric patients whose therapy were completed. method: pediatric cancer patients ( f, m) who were at least one year off therapy, enrolled in a prospective cross sectional study from to in oncology department of ali asgar children hospital. demographic data, cumulative dosages of anticancer drugs, history of other nephrotoxic agents, nephrectomy, radiotherapy were recorded. fasting blood and urine samples were collected to calculate fractional excretion of mg, ca, p, upr/ucr, clcr, urine osmolality and blood gas analysis. result: the mean of age was . years. out of patients had lymphoproliferative malignancies (group ) and had solid tumors (group ). the mean of therapy was . month. treatment was discontinued for . month in average. the median of blood ca, p, mg, bicarbonate,and cr were . mg/dl, . mg/dl, . mg/dl, . meq/l and . mg/dl, respectively. the median of fractional excretion of ca was . % this rate was . % for p excretion and . % for mg excretion. clcr was . ml/min/m in median. the medians of urine osmolality was mosmol/kg/h o. the median of urine protein to urine creatinine ratio was . mg/mg. these values were not different between two groups (p> . ) but urine concentration was defective in solid tumors group (p= . ). mild to moderate nephrotoxicity was seen in . % of cases. using binary logistic regression we found no correlated factor (p> . ). conclusion: mild to moderate tubular dysfunction has been observed in survivors of chemotherapy. routine follow-up of renal functions are recommended. the study is to discuss the treatment of hemolytic uremic syndrome (hus) after acute stage. methods: there were children who lived through acute stage of hus then continued treating. besides angiotensin converting enzyme inhibitors (acei) and early restriction of protein intake, the study was to use therapeutic schedule according to clinical classification, response to prednisone and pathological manifestation, which referred to clinical classification diagnosis and treatment of child with glomerulus disease (the program) established by nephrology group in pediatric branch of chinese medical association (cma). results: after months to years follow-up mild type children maintained the normal blood pressure and renal function and urine examination, except for recurrence. in gravis type children maintained the normal blood pressure and renal function and urine examination, another children who manifested as durative abnormality of urine examination developed into end stage renal failure (esrd) and died in the th, th and th month at last. another gravis type children untreated after stage of hus died in the th day to th day of the course. conclusion: it could improve the prognosis of children after acute stage of hus evidently to use therapeutic schedule according to clinical classification, pathological manifestation. objective: to find the prevalence of hematuria in patients with thalassemia major. methods: of total patients with thalassemia major under regular blood transfusion, cases were randomly selected. history was reviewed and physical examination was done. urinalysis was performed in all the patients. in those with hematuria ( or more rbc/hpf) or suspicious to hematuria ( - rbc/hpf) second urinalysis was done at the next transfusion time. more investigations were done in those with persistent hematuria. results: the patients had age range of months to years and male to female ratio was . . hematuria was detected in ( %) and suspicious in patients ( . %). sixty four percent of the patients with hematuria were female and it was persistent in urinalysis in % of cases. in % of the patients with hematuria, blood transfusion was started before the end of first year. in those with hematuria or suspicious to hematuria, % had sterile pyuria and % had proteinuria (these figures were . % and . % respectively, in those without hematuria). hypertension was not detected, but patients had secondary diabetes mellitus. conclusion: hematuria is not uncommon in patients with thalassemia major and is more prevalent in girls and in those with early transfusion. background: it has been widely recognized that cyclosporine a (cya) is a useful immunosuppressive drug in renal transplantation. although it has been also accepted that cya is an effective drug for pediatric nephrotic syndrome in the past two decades, the effective serum concentrations are not revealed. the functional roles of cya has been reported that cya inhibits the production of interleukin (il- ) in vivo and in vitro. aim: in this study, we investigated the correlation of serum concentrations of cya levels with il- levels in pediatric nephrotic syndrome cases. methods: seven children ( boys and girl, mean age . ± . years) with minimal change nephritic syndrome were enrolled in this investigation. cya (mean dose, . ± . mg/kg/day) was administrated in two divided doses before meal with or without administration of predonisolone. blood samples were collected just before, , , and hours after administration of cya. the serum concentrations of cya and il- were measured immediately. results: the peak blood concentrations of serum cya were observed at hour after administration. the concentrations of serum il- levels reduced at hour after administration of cya, and kept the same levels during hours afterwards. the serum concentrations of cya which inhibited more than % of the serum concentrations of il- required ng hr/ml. conclusions: we confirmed that cya inhibited the production of il- in children with nephrotic syndrome. these findings suggest that the necessary serum concentrations of cya to maintain the sufficient suppressive rate were more than ng hr/ml in pediatric nephrotic syndrome. this study aimed to evaluate the circulating angiotensins in female adolescents with type diabetes (dm ) and to compare with the results obtained in healthy age-matched adolescents to disclose possible changes in plasma peptide concentrations that could be related to microalbuminuria and metabolic control. patients were divided as female adolescents with dm (n= ) and adolescent age-matched controls (n= ). diabetic patients were evaluated at our endocrinology center and healthy adolescents were selected from our primary care unit. plasma levels of angiotensin (ang) i, ang ii and ang-( - ) were determined by radioimmunoassay. glycohemoglobin and microalbuminuria were also measured. results were expressed as medians or means and standard deviation. kruskal wallis was used for median comparisons and t-test for means. the level of significance was p< . . adolescent dm patients exhibited high levels of glycohemoglobin ( . ± . %). microalbuminuria was detected in ( %) patients with a disease duration of . ± . years. angiotensin concentrations were significantly increased in dm patients (p< . compared to controls) and ang-( - ) levels were -fold higher than control values. on the other hand, the levels of ang-( - ) in microalbuminuric patients were significantly lower than in non-microalbuminuric diabetic adolescents (p< . ). the comparisons between ratios of ang-( - )/ang i and of ang ii/ang i suggested a predominance of ang ii formation rather than ang-( - ) in microalbuminuric diabetics when compared to normoalbuminuric patients. our results showed an overall increase of angiotensins in a young female diabetic population, and further suggested a pathophysiological role for angiotensin-( - ) in dm . the pediatric nephrologist is often faced with the difficulty of determining adequate iron supplementation in children with chronic kidney disease (ckd). soluble transferrin receptor (stfr) and the stfr to log(ferritin) ratio (stfr-f index) have been proposed as markers of iron deficiency (id) independent of inflammation; however, their relationship with c-reactive protein (crp) and their age dependency have not been established. we therefore embarked on a prospective study of healthy children undergoing minor surgery to determine reference ranges for stfr (dade behring n-latex stfr analyser, dade behring bn prospec) and stfr-f index. we studied the relationship between crp and ferritin, transferrin, stfr and stfr-f index. we also compared the relationship between mean corpuscular volume (mcv) and ferritin, stfr and stfr-f index in children. results: for ages . . , . ) with mcv, which we used as a marker of id in the absence of a non-invasive gold-standard; however, only stfr-f index, but not ferritin, transferrin and stfr, was independent of crp. this study shows that ferritin, transferrin, and stfr, but not stfr-index, are dependent on acute phase reactions. it is therefore hypothesized that stfr-f index provides a more useful marker for monitoring the iron status in ckd patients. conclusions: low osmolality is a crucial factor to facilitate water absorption at least in the rat small intestine, while the absorption of sodium may be influenced by the concentration of sodium and glucose. (definition iccs). standard treatment consisted of general advice on voiding and drinking habits, alarm treatment and occasionally vasopressin. constipation was diagnosed on clinical considerations (history, stool charts, physical examination, occasionally x-ray). all patients received general instructions according to bowel habits. laxatives were prescribed when the patient was diagnosed as constipated. treatment goal was daily bowel movements. treatment results were evaluated months and years after discharge. results: patients were included. mean follow-up was . yrs. overall success rate (full response) was . % ( months) and . % ( years). laxative use: . % (n= ) of the patients received laxatives, % (n= ) did not. in patient information was lost. there was no significant difference in success rate between the laxative group compared with the non-laxative group (p= . , chi-square). treatment modality: . % (n= ) received general advice only without laxatives, all but one had a full response. . % (n= ) were treated with advice and alarm, ( . %) of them received laxatives. response to alarm treatment was . %. no significant difference in success rate between the laxative and non-laxative group (p= . , chi-square). patient was dry after vasopressin and laxatives. conclusion: the majority of patients with mse can achieve nocturnal continence without laxatives. constipation treatment with laxatives may be supportive, but is not essential in the treatment of mse. aim: hypocalcemic tetany is a known complication of plasmapheresis. we studied the changes in ionised and total calcium, and magnesium concentrations during plasmapheresis, with and without supplementing the replacement fluid with calcium and magnesium. methods: plasmapheresis was carried out by using . % human albumin solution (has) with or without supplements for the first % of the exchange, and fresh frozen plasma (ffp) for the last %. we measured ionised and total calcium and total magnesium at the beginning and end of the has, and after minutes of ffp infusion. results: we undertook pairs of plasmapheresis runs with and without supplements in children who had a variety of renal conditions. during the exchange with unsupplemented has, the total calcium fell from . to . mmol/l (ci . - . , p< . ), the ionised calcium fell from . have raised significant problems in minor surgeries. but the developmental mechanism of ponv is not clear until now. previously, we have experienced a case with ihn and ponv who showed extremely high plasma antidiuretic hormone (adh) level at the onset of ihn and that elevated adh level induced by minor surgery was supposed a trigger of ihn and ponv. in this study we investigated various values including plasma adh in cases taking kidney biopsy in order to clarify the mechanism of ihn and ponv. methods: fifteen patients taking percutaneous kidney biopsy were study subjects (mean age . years). plasma adh, serum electrolytes and osmolality were measured before and - hours after kidney biopsy. urine samples were collected to measure electrolytes and osmolality. results: high plasma adh level ( . ± . pg/ml) was observed in out of subjects ( %). serum sodium level dropped significantly in these cases. six of cases showed ponv, we divided all cases into groups: ponv group and non-ponv group. the result was that plasma adh level was significantly high in ponv group. conclusion: our study make it clear that elevated plasma adh level is frequently seen in children taking kidney biopsy and suggest that hydration with hypotonic saline solution after surgery is inappropriate because of the risk of developing ihn. it also become clear that high plasma adh level might lead to ponv as the same mechanism seen in motion sickness. it is suggested that adh secretion by stress after minor surgery is associated with not only ihn but also the onset mechanism of ponv. polyarteritis nodosa (pan) occurs more commonly in patients with familial mediterranean fever (fmf) and visceral hematomas are seen in almost half of the patients. we report here a year-old girl with pan and fmf presented with multiple visceral hematomas. the patient was on colchicine therapy for four years because of fmf but uncompliant to therapy. she addmitted with the complaints of fever, malaise, abdominal pain and artralgia lasting for two months. she was pale and extremely cachectic with atrophic muscles of extremities. she had fever, hypertension, hepatosplenomegaly and arthritis. she had anemia with normal renal and hepatic function tests, albumin levels, and electrolytes. multiple hypoechogenic mass lesions were detected on liver and bilateral kidneys on ultrasonography and computerised tomography and diagnosed to be hematomas by laparascopic examination. urinalysis, hematological tests for bleeding and blood marrow examinations were normal. bacterial cultures and serological tests did not reveal any infectious agent. serum complement levels were normal with negative antinuclear antibody, anti-dna, p and c antineutrophil cytoplasmic antibodies. renal angiography showed multiple aneurysms in bilateral renal arteries leading to the diagnosis of pan. she was successfully treated with intravenous pulse methylprednisolone followed by oral perdnisolone and oral cyclophosphamide together with colchicine and antihypertensive agents. she has been followed up for four years without any complaints and normal laboratory and radiological findings except multiple scar formations on kidneys on dmsa-renal scanning. results: the stone-free rate was % after one eswl session. the above rate increased to % and % after the second and the third session respectively. regarding surgical treatment with pcnl, the overall stone-free rate was %. in children initially treated with pcnl, an eswl session was performed later successfully, for residual calculi. open surgical removal was required in children with structural anomalies. the patients with staghorn calculi underwent nephrolithotomy combined with eswl in cases of residual fragments. patients underwent ureterscopic procedures to address ureteral stones and complete fragment removal was obtained. no major sideeffect were observed, during the above procedures. conclusions: it seems that the advances in instrument technology provide a variety of safe and effective methods in the management of paediatric urolithiasis. the incidence of open surgery has thus fallen. minimally invasive methods must form the first choice of treatment, while open surgery should be undertaken mainly in cases of coexisting congenital abnormalities. in all children the following parameters were estimated: a) timetable of ne, b) feeling/volume chart (frequency and biggest quantity of urination=functional capacity of bladder), c) ultrasound of urinary tract (size of kidneys, bladder capacity, bladder wall thickness, postvoiding residual urine) and d) urodynamic parameters (uroflowmetry and water cytometry). the ud bladder parameters were then correlated with the us and voiding diary findings. results: all children had sufficient data registered to allow reliable analysis. ud studies showed that children with mild pne had normal urodynamics findings, us parameters and voiding diary findings as well. ud studies reveal a relatively high incidence of instability in children with moderate and mainly in those with serious ne. conclusions: in children with pne, urodynamics did not have a significant additional value compared to baseline diagnostics and it should be avoided. on the contrary, findings from urodynamic studies in children with serious ne show that it has a useful role in this type of enuresis evaluation and management. objectives of study: hyperlipidemia, especially when started during early childhood will increase the risk of atherosclerosis. it is also a major risk factor for allograft nephropathy and post-transplant hyperlipidemia, so its diagnosis and treatment is highly suggested. in this study we have evaluated the effect of hemodialysis on the lipid profile of children with end stage renal disease (esrd). methods: twenty-two children with esrd who were on maintenance hemodialysis in shiraz pediatric hemodialysis unit were studied. they were asked not to take greater than % of their total daily calories as fat at least month before sampling. after a -hour overnight fasting and before starting dialysis, blood samples were taken for lipid profiles. for each patient with total cholesterol, tg or ldl-c levels more than th percentile for age and gender or hdl-c level less than mg/dl, was defined as dyslipidemia. results: nineteen out of children ( . %) had abnormal lipid profiles. atherogenic factor of tg/hdl-c ratio more than as a major risk factor for cardiovascular disease was in %. conclusion: dyslipidemia is common in hemodialysed children. so, hemodialysis set-up change and antilipimic medication, and replacement of l-carnitinine is recommended for correction of dyslipidemia in this group of patients. objectives of study: bipolar renal length measurement is an integral part of the assessment of urinary tract in childhood, and is routinely performed on ultrasonography and renal scintigraphy investigation. correlation between kidney size measurement on ultrasonography and dimercaptosuccinic acid (dmsa) scintigraphy is not well recognized. the purpose of this study was to comparison renal size measured by dmsa scintigraphy and ultrasonography to find if there is acceptable agreement between renal lengths by these two methods. methods: as cross sectional retrospective study, patients enrol in this study and their dmsa scan results and kidney ultrasonography reports compared. the agreement between renal size measured by two methods for left and right kidneys were evaluated separately using bland-altman plot. pearson's correlation coefficient was used to examine their correlation. statistical significance was calculated by paired-student t-test. the same tests were used to for kidneys with normal dmsa scans. results: correlation coefficient showed close correlation between kidney length measured by ultrasound and dmsa scan, but there were significant differences between two methods (paired t-test, p< . ). comparison between renal size measured by ultrasonography and dmsa scan using the methods of bland & altman plot in all patients and the group with normal kidneys showed a systematic bias of about + . mm for left and + . mm for right kidneys. conclusion: despite of close correlation between dmsa scan and ultrasonography for kidney length measurement; kidney size is overestimated by about percent in dmsa scan study and this matter must be considered in practice. medical treatment of cystinuria is often considered disappointing. patients undergo frequent surgery which is often followed by early relapse. the aim of our study was to prospectively evaluate, in a paediatric population, the efficacy of a conservative medical approach for long-term treatment of cystinuria, to prevent the formation of new renal stones and reduce the number and dimension of pre-existing stones. twenty-one stone former cystinuric patients were treated with a combined approach which included cystine-binding drugs. free and bound urine cystine levels were routinely measured every four months. drug dosage was adjusted in order to maintain a steady free urine cystine level below mmol/mmol creatinine (a three fold increase of normal level). in the patients who completed the study, renal stone episodes were reduced from . to . episodes/year, and in several patients the number and dimension of pre-existing renal stones were reduced. during the entire follow-up, percutaneous lithotripsy to remove an obstructive stone was required in only one subject. no relapse was observed months after treatment. the dosage required to achieve target levels was very closely correlated to patient body weight: older children required a lower dose to achieve target levels. in conclusion: medical management of cystinuria is feasible. the treatment must be personalised, at least in pediatric age. the amount of required drug is strictly depending from body size. it is mandatory to obtain a low free urine cystine level before any invasive procedure to reduce the risk of early relapse. objective: to study the pathophysiology of nutcracker syndrome (ns) and to assess the role of the upright position imaging and superior mesenteric artery (sma) angle measurement in the diagnosis. methods: doppler us findings in children with ns and in healthy control subjects were compared. the mesenteric angle, peak velocity (pv) and anteroposterior (ap) diameter of the left renal vein (lrv) at the hilar and aortomesenteric portions were measured in both the supine and upright positions. the means ±sd of the sma angle, ap diameter and pv ratio between the two portions were calculated and cut-off levels for the diagnosis of ns were established. results: the diameter and pv ratios were significantly different between the patient and control groups both in the supine and upright positions (p< . ). differences (d) between the supine and upright positions were also significant for the diameter of the lrv at the aortomesenteric portion, diameter ratio and sma angle in both groups. upright position imaging revealed comparatively narrower sma angles and more pronounced entrapment findings in patients with ns. the sma angle measurement had a sensitivity of . % and a specificity of . % in the supine position and . % and . % in the upright position when the cut-off values were set to less than ° and °, respectively. the upright position has significant effects on the lrv hemodynamics and angle of sma both in patients and healthy subjects. sma angle measurement may be a useful adjunct parameter in the diagnosis of ns. ). in addition, a statistically higher rate of pathological abnormalities on renal biopsy was noted in the group with microscopic hematuria combined with proteinuria and also in cases with more severe hematuria. conclusions: school urinary mass screening has greatly contributed to diagnosing chronic renal diseases. continuous medical observation is required when abnormal urinalysis is observed, and a more aggressive medical approach such as renal biopsy should also be performed if necessary. this study compared the outcome of children with proliferative ln (who class iii/iv) using a new protocol comprising pulse intravenous methylprednisolone, mmf +/-cyclosporine, with standard prednisolone and cyclophosphamide/azathioprine. method: twenty-three children with proliferative ln (age range at diagnosis . - . years) who were followed up for . - . (range . - . ) years, were included in this retrospective study. group i (n= ) received prednisolone with cyclophosphamide and/or azathioprine. group ii (n= ) received the combined mmf protocol with mmf dose of mg/m /day. poor outcome was defined as death or chronic renal failure. survival analysis was performed using the log-rank test. effect of treatment on growth at last follow-up was assessed using height standard deviation score (htsds). differences between the groups were analyzed using the mann-whitney and fisher's exact test. results: at last follow-up, significantly more group i compared to group ii patients had higher serological activity as defined by low serum complement c ( % vs % respectively, p= . ). in addition, -year actuarial survival was higher in group ii ( %) compared to group i ( %). all the group ii patients achieved complete remission of proteinuria compared to group i ( . ± . vs . ± . g/d/ . m respectively, p= . ). group ii patients also had lower htsds on long-term follow-up compared to group i (- . ± . vs - . ± . respectively, p= . ). conclusion: combination immunosuppressive protocol involving mmf +/-cyclosporine resulted in better renal outcome in children with proliferative ln without compromising on growth. this regimen allowed steroid tapering to alternate day dosing without increasing lupus activity. background: a full dose of corticosteroid is required to induce complete remission (cr) in steroidsensitive nephrotic syndrome (ssns), unless it is possible to taper and discontinue along with the course after cr. however, the mechanism of this change in steroid sensitivity remains unknown. p-glycoprotein (pgp) has a function to eliminate given corticosteroids from cytoplasm, which results in inducing corticosteroid resistance. therefore, we analyzed a drug delivery perspective using the real-time polymerase chain reaction (pcr) of multiple drug-resistant gene (mdr ; encoding pgp) messenger rna (mrna) expression. patients and methods: fourteen patients with steroid-sensitive nephrotic syndrome (ssns; male/ female: / , age: - years old; mean . ) were enrolled in this study. mdr mrna gene expression of peripheral blood nucleated cells (pbnc), before and after cr (a total of nineteen sets of blood samples), were quantified using real-time pcr and then carried for analysis. results: the mdr mrna levels before cr were variable in each patient. however, there was an apparent decrease in the mdr gene expression of pbnc after cr (p< . ). the results suggest that pgp may play a role in the ability to taper corticosteroids after cr in ssns. : week prednisone mg/m /day + weeks mg/m every other day). all other patients (b) received daily prednisone . - mg/kg/day for weeks and - % of initial dose for week, followed by alternate day steroids ( week) with tapering by . mg every - weeks down to . - mg. "frequent relapses" (less than months after discontinuation of initial steroid therapy or of first relapse therapy) were treated with chlorambucil . - . mg/kg/day for weeks and half of this dose for - months. results: seven patients (with long treatment) were lost to follow-up and were studied. six of ( %) of a had a relapse . ± . months after the end of initial therapy; became infrequent and frequent relapsers. of ( %) of b relapsed . ± . months after the end of initial therapy; became infrequent and frequent relapsers. frequent relapsers ( % in a and % in b) were treated with chlorambucil and all but one achieved long remission (> year). conclusions: first relapse occurred later after onset of ssns in patients with long ( weeks) as compared to short ( weeks) initial steroid therapy but the time interval between the end of initial therapy and the first relapse and the proportion of relapsers were similar. longer initial therapy may result in a lower number of frequent relapsers. nearly all patients had long remissions periods that were, however, achieved at the expense of early administration of chlorambucil. conclusions: the medium age of pts with metabolic stones was found to be higher than the medium age of pts with infectious stones. the familial occurrence of kidney stones was found to be important %. the ultrasonographic examination is the most important one. the stones composed by calcium oxalate and calcium phosphate were found to have the highest percentage. metabolic abnormalities were found in % of patients and hypercalciuria was the most common disorder. hypocitraturia is considered to be a risk factor the calcium stones. in an attempt to explore the new treatment for the childhood-onset intractable steroid-dependent nephrotic syndrome (sdns), we have recently performed the treatment with high-dose mizoribine (mzr), the inhibitor of inosine monophosphate dehydrogenase, and suplatast tosilate dimethylsulfonium std), a selective th cytokine inhibitor, which were both made in japan. mzr has been commonly used for the treatment of frequently relapsing sdns in japan at a dose of - mg/kg/day (maximally mg/day) divided into two doses (kidney int : , ). we used high-dose mzr (mean: . mg/kg/day) once before morning meal for adolescent patients with frequently relapsing sdns who had been treated with long-term cyclosporine (csa) resulted in moderate to severe csa nephropathy. with this treatment for years, seven out of patients weaned off csa and experienced less relapses without apparent adverse effects by high-dose mzr. std is a both il- and il- inhibitor and commonly used for childhood asthma. we used std at a dose which is for the treatment of asthma for children with sdns (mean . years) without previous csa treatment. after one year follow-up with std treatment, the relapse rate of nephrosis was decreased from . ± . to . ± . per year (p= . by wilcoxon signed-ranks test), where as the dosage of orally given predonisolone was also decreased from . ± . to . ± . mg/kg/day (p= . by wilcoxon signed-ranks test). objectives of study: to evaluate the efficacy and safety of long-term cya treatment for pediatric sle patients. pediatric sle patients in their teens suffer from many relapses and severe side effects caused by steroid and cyclophosphamide. there have hardly been any reports on the long-term cya treatment in children. methods: we retrospectively compiled cases of childhood-onset sle female patients (mean: . years) admitted to our department from to . the initial treatment was methylprednisolone pulse therapy followed by prednisolone (psl). at the onset, patients had class lupus nephritis and showed class . after several relapses, cya was added and used for to months. the dose of cya ranged from . to . mg/kg/day, and the target trough level from to ng/ml. results: under this low-dose cya treatment, patients had no relapse while had a relapse after months. in all patients, psl was reduced to alternate day treatment (mean: . mg/ days), and patients under years gained the target height. of all patients, developed hypertrichosis, gingival hyperplasia, transient elevation of s-cr with acute gastro-enteritis. although case had elevated s-cr after months of cya treatment, it returned to normal level within months after the cessation of cya. five patients had second biopsy after years, and showed mild tubulointerstitial (t-i) changes. two had third biopsy after years and both showed mild t-i changes only. the presence of t-i changes had no relation to s-cr, u-beta mg and u-nag. conclusion: low-dose cya treatment might be an effective and safe second line treatment for sle patients with many relapses in teens. it is also important to perform renal biopsy periodically to detect cya-induced renal damage which hardly shows any abnormalities in blood or urinary tests. hypersensitivity to inulin is rare; two cases of food allergy and some cases of allergy after inulin infusion have been reported. an -year-old boy suffering from severe iga nephropathy (igan) is reported with both anaphylactic reaction and concomitant relapse of his nephropathy due to inulin infusion, used for measuring gfr years after first symptoms. pruritus, sibilants and cough were observed during a first renal function test. prick and intradermal tests were negative for inulin. the patient presented with pallor and asthenia during a second inulin infusion performed under dexchlorpheniramin, leading to immediate infusion stop. he was read mitted because of fatigue and nausea; acute renal failure was diagnosed days after inulin infusion. a drug-induced acute interstitial nephritis was first suspected. however, due to the presence of macroscopic hematuria and proteinuria, a renal biopsy was performed and showed acute proliferative relapse of igan. few data are available about inulin-induced hypersensitivity. chandra described anaphylaxis and cardiorespiratory arrest immediately after administration of sinistrin. a retrospective study of all recorded cases of hypersensitivity associated with renal function tests was performed by our pharmacovigilance unit. , tests using inulin clearance were realized both in adults and children; patients experienced side effects which were divided into groups: respiratory symptoms, rash and general signs. most side effects were minor and no life threatening complication occurred. the underlying mechanism of inulin hypersensitivity is not well known. although % of patients with inulin-associated hypersensitivity underwent a first renal function test, we can speculate that presensitization with food inulin may occur, sometimes leading to severe problems such as in our patient with iga-mediated immunological dysregulation. . we have previously demonstrated a composite heterozygous nphs mutation of both v x and r h in a chinese patient with srns. however, it is not clear the molecular mechanisms of mutant podocinlead to proteinuria. some evidences proved the possible interaction between podocin and trpc . this study explored the effects of mutant podocin on the free cytosolic ca + and apoptosis of podocyte in order to clarify the possible causative mechanism of mutant podocin. methods: . the pdsred n -wild/mutant podocin was constructed by using site-directed mutagenesis. . mouse podocyte clone was cultured and transfected with pdsred n -wild/mutant podocin. . free cytosolic ca + was measured using the fluorescent indicator, fluo -am. results: the low level of free cytosolic ca + was detected in normal podocyte and the transfected podocytes with r h mutant podocin. the v x mutant podocin increased the free cytosolic ca +more evidently than the over-express podocin in transfected podocytes. podocyte apoptosis were not detected in the blank-vector (just pcdna . ) transfected podocytes and normal podocyte. the v x and r h mutant podocin increased the podocyte apoptosis more evidently than the over-express podocin in transfected podocytes. conclusions: the v x mutant podocin might induce podocyte apoptosis via the increment of free cytosolic ca +. however, whether the increment of free cytosolic ca + is induced by trpc and the involved signal pathway should be further investigated. y. xing, q. fan, j. ding objectives of study: podocytes slit diaphragm (sd) associated molecules (nephrin, podocin and cd ap) play a critical role on maintaining the integrity of glomerular filter. vegf is produced by podocyte, and acts on endothelium and podocyte itself. but, it is not clear whether there are some relationships between vegf and sd associated molecules. our study detected the expression of sd associated molecules and vegf in adriamycin (adr) nephrotic rats. methods: the adr rat was established by adr injection. distributions of sd molecules and vegf were detected by immunochemistry. the mrna and protein of sd molecules and vegf was examined by real-time pcr and western, respectively. nephrin phosphorylation were detected by immunoprecipitation. results: distribution of nephrin, podocin and cd ap changed evidently, and the staining intensity of vegf decreased evidently. nephrin mrna increased at day , and returned to the normal at day and ; podocin and cd ap mrna constantly increased from day until day . the protein of nephrin increased at day until day ; podocin was dramatically upregulated at day , and thereafter recovered again, but was downregulated at day ; cd ap prominently increased at day and day . tyrosine phosphorylation of nephrin was decreased evidently at day , and vegf mrna did not show significantly changes at any time points observed. however, vegf protein reduced significantly from the th day, and also reduced evidently at days and days . conclusion: the abnormality of nephrin, podocin and cd ap may be one of the mechanisms that lead to proteinuria in adr-induced nephrotic rats. the occurrence of proteinuria in adr rats may be also associated with the reduced vegf protein, which may be related with the reduction of nephrin phosphorylation. these results suggested there may be some relationship between vegf and sd molecules. the objectives of study: mutations in genes encoding structural proteins of slit diaphragm can lead to nephritic syndrome. just recently, another gene trpc mutation was identified in autosomal dominant fsgs. trpc encodes ion channel protein trpc , whose expression has not been clarified completely in kidney. this study aims to explore the expression and distribution of trpc in normal human, mouse and rat renal tissue and the mouse podocyte clone (mpc ). methods: distributions of trpc in normal human, mouse and rat renal tissue and cultured podocyte was observed with immunochemistry staining. the mrna expression of trpc , , , , and was detected by using rt-pcr. the protein expression of trpc in human, mouse and rat renal cortex and differentiated mpc was detected with western. results: trpc showed weak staining in glomeruli and strong in renal tubules and vessels in human kidney, however, strong in glomeruli and was mainly distributed along the capillary loops and mesangium in mouse and rat kidney. the staining of trpc was observed in differentiated mpc , which is distributed evenly on the cell membrane. the specific pcr band of trpc , , , , and was detected in mouse kidney and differentiated mpc . the sequence of the amplified pcr products is same as that published in genebank. the specific kda protein band of trpc was detected in normal human, mouse renal cortex and differentiated mpc . conclusion: the expression of trpc was verified in normal human, mouse and rat kidneys and in differentiated mpc . these results will benefit for further screening the possible mutation of trpc in acquired nephrotic syndrome, and investigating the relationship between trpc and the proteinuria-related podocyte molecules. methods: twenty children with kd ( boys and girls, aged from to months) were enrolled in our study. kidney sizes (including kidney length and kidney volume) were measured during acute stage in these patients. twenty age-and sex-matched healthy children and febrile children served as healthy controls and fever controls. left kidney length and age were used for correlation analysis and analysis of covariance. results: kidney lengths in patients with kd were significantly larger than those of healthy children (p< . ). the mean sd score of kidney length was . ± . for these patients (p< . , vs - . ± . in normal control). kidney volume analysis yields the similar result ( . ± . cm vs . ± . cm , p= . ). there was no kidney enlargement in the fever controls. up to % of the children with kd have absolute nephromegaly (>mean+ sd). this incidence is as frequent as that of lymphadenopathy and extremities change, the diagnostic criteria of kd. conclusion: these results confirm the presence of large kidneys in the children with kd and also provide another useful indicator for kd diagnosis if the diagnostic criteria is not yet well established. during renal inflammation macrophages infiltrate the renal parenchyma, and their number correlates with the intensity of inflammation. macrophage migration inhibitory factor (mif) was described originally to be a product of t-cells and macrophages. mif plays an important role in renal tissue injury. to our knowledge, the studies that assessed the role of macrophages in acute renal infection were few and the role of mif was not evaluated. the aim of this study was to assess mif in uti and compare the urinary excretion of mif in pyelonephritis, cyctitis and also control group to find a non-invasive and sensitive method to differentiate them. in this prospective case-control study pediatric patients with uti ( patients with acute pyelonephritis, patients with acute cystitis) and healthy children were recruited. urine mif concentration was quantitated by elisa and corrected for urine creatinine. the mean ratios of urine mif/cr were calculated as . (sem= . ) pg/μmol creatinine in acute pyelonephritis, . (sem= . ) in acute cystitis and . (sem= . ) in healthy individuals. urine mif/cr ratio was significantly higher in pyelonephritis than the ones in acute cystitis (p= . ) and control (p= . ). roc analysis was demonstrated that urine mif/cr ratio could considered potentially useful index to detect acute pyelonephritis [p= . , area under curve (auc)= . ]. the optimal cut-point of . pg/μmol creatinine for urine mif/cr ratio could potentially separates acute pyelonephritis patients from healthy individuals (sensitivity and specificity of % and . %, respectively). the underlying histopathological characteristics in biopsied renal diseases are of great importance in determining the long-term prognosis and provides useful information in clinical practice. ethnicity seems to play a critical role in the epidemiology of biopsied renal diseases the aim of this study is to provide data of clinical manifestations of biopsy-proven native renal diseases in iranian children. in this retrospective study, iranian children who were diagnosed as renal disease between and january , were evaluated. diffuse and focal mesangial proliferative glomerulonephritis was present in . % of all biopsies performed. mpgn, fsgs and mcd were observed in . %, . % and . % the most common clinical syndrome at any age is nephrotic syndrome ( . %), followed by nephritic syndrome ( . %), nephrotic-nephritic syndrome ( . %), recurrent macroscopic hematuria ( . %), asymptomatic urine abnormalities (aua) ( . %) and azotemia was seen in . % of patients. mesangial proliferatiove gn ( / = . %), poststreptococal gn ( / = . %) are the most frequent pathologies with acute nephritic syndrome presentation. the most frequent causes of aua were mesangial proliferative gn and hsp. thrombotic microangiopathy (hus) was the most prevalent cause of arf. inthis study, chronic tubulo interstitial nephritis ( . %) and alport ( . %) were the most common causes of crf presentation in our patients. in conclusion, mpgn remains the most common histopathological subtype in children with renal biopsied disease. the incidence of fsgs continues to be high in iranian children. the aim of this study is to assess postnatal kidney volume development and to compare the intrauterine and extrauterine kidney growth curves in premature infants. one hundred neonates were enrolled in this study. all infants had their kidney volumes measured by renal ultrasound examination. group ga consisted of neonates whom were evaluated within hours after birth, and their gestational ages were used in the analysis. group ca included premature infants born before weeks of gestation and was evaluated - days after birth, and their conceptional ages were used in the analysis. left kidney volume, body weight, body height and age were used in the correlation analysis. kidney volumes in group ca infants were significantly larger before weeks of age, but smaller after weeks of age than those of group ga infants (p= . ). there was a significantly better growth in body weight (p= . ) and body height (p< . ) in group ga infants. however, a larger kidney volume was noted in group ca infants with the same body weight (p< . ). conclusion: chart of postnatal growth of normal kidney volume before weeks of conceptional age in premature infants is presented. our data suggests that intrauterine growth may have a regulatory influence on kidney growth, and the reduced kidney volume in the premature infants may start from the early extrauterine period. objectives of study: to illuminate the role of prohibitin (phb), a tumor suppressor which inhibit cell proliferation by repressing e f-mediated transcription, in tubulointerstitial fibrosis (tif). methods: renal biopsy specimens were obtained from children with primary glomerulonephritis. phb and α-sma proteins expression were detected by immunohistochemistry. subcellular location of phb in nrk- f was detected by confocal microscope. changes of phb protein and mrna expression in cells upon tgf-β stimulation were detected. after transfected with phb plasmid, cell cycle and α-sma protein and mrna expression in cells treated with or without tgf-β were detected. results: phb protein was found at normal renal tissues, with a positive distribution in interstitial cells and tubular epithelial cells. phb was down-regulated in tissues with tif and negatively correlated with tif degrees (p< . ). phb is majority located at cytoplasm as well as at nucleus in nrk- f. phb protein and mrna expression in cells were decreased when treated with tgf-β , and the effects were both time-dependent and dose-dependent. extraneous phb inhibited cells proliferation induced by tgf-β , and phb over-expressing cells failed to enter the cell cycle compared with non-transfected cells (p< . ). α-sma was not expressed in control cells while de novo expression of α-sma in cells upon tgf-β stimulation was increased. overexpression of phb did not affect basic α-sma expression but dramatically repressed tgf-β -initiated α-sma expression (p< . ). conclusions: extraneous phb suppresses renal interstitial fibroblasts proliferation and cell phenotypic change induced by tgf-β , which indicates phb as a potential target to halt tif progression. results: the prevalence of urine abnormalities of first screening was over . %, and that of the second screening was about . %. the prevalence was different with various methods. the specificity of method b was higher than method a. testing two urine samples for each child had higher specificity. the direct cost of method a and b was - . and - . rmb, respectively. for screening twice, the corresponding cost was no more than - . and - . rmb, respectively. using method a to screen twice for each child was convenient and economical, which also reduced the false positive rate effectively. the prevalence of urine abnormalities of junior highschool children was significantly higher than that of elementary school-children in xh and the peak point was seen at the point of years old. however, there was no significant difference between children in ja and yp. more than months of follow-up diagnosed cases of iga nephropathy. conclusions: urine abnormalities of school-children could be detected through urine screening at school. for shanghai, method a with screening twice was convenient, economical, and could reduce the false positive rate effectively. objectives: angiopoietin-like protein (angptl ) is involved in lipid metabolism and angiogenesis. the present study was to examine angptl expression in human kidneys with proteiuria, in adramycin rats (adr), and in puromycin induced podocyte damage. methods: immunohistochemistry was performed on kidney biopsies from children with mcd, mn, fsgs, tbmn. in adr, angptl expression was determined by quantitative real-time rt-pcr in glomeruli and tubuli dissected from frozen section of kidneys with laser microdissection system. in mpc , a conditionally immortalized mouse podocyte cell line in vitro, angptl , perlecan and agrin were detected through real-time pcr with the induction of puromycin. detachment assay was performed in podocytes tranfected by angptl -pcdna . . results: in human kidneys, co-labeling showed angptl expressed in the cytosol of wt positive cells. quantitative computerized analysis showed that angptl in glomeruli in mcd and mn were significantly higher than that of tbmn, fsgs respectively (p< . ). in adr, angptl in glomeruli increased significantly at st or th day (p< . ) after adriamycin injection compared with control. and the expression of angptl in glomeruli was correlated with h urinary protein (r= . , p< . ). in mpc both protein and mrna expression of angptl on podocytes were up-regulated with the induction of puromycin. in podocytes transfected by angptl -pcdna . the expression of perlecan or agrin increased significantly compared with control (p< . ). the attachment ratio was shown . %± . % hs after puromycin treatment on podocytes transfected by angptl compared with . %± . % on normal podocytes, and . %± . % on untransfected podocytes. conclusions: angptl is predominantly expressed in podocytes which could be involved in podocyte damage and the development of proteiuria. ( ), iv ( ) and iii ( ), respectively. only one patient had microhematuria. we found that of them had a very low c serum levels. clq and c deposits were all strong positive in renal tissues. our findings suggest that biopsy should be strongly considered in this patient population. the significant renal involvement (class iii, iv, or v ln) could be found in sle patients with very lower proteinuria with or without hematuria. patients in bfb group received computer-assisted biofeedback program while those in ddavp group took minin. both therapies were carried out for month and then months follow-up was taken. parameters of follow-up included enuresis diary-urine flow rate and aqp in urine. results: pne patients were recruited ( boys, and girls), whose mean age was ( . ± . ) years. at the end of treatment and three months later, total effective rates in bfb group were significantly higher than those in ddavp group. uroflowmetry findings showed that in bfb group maximum flow rate, voided volume and ratio of coordinative detrusor-sphincter contraction increased after treatment. ratio of normal flow curve increased at second follow-up (p< . ). in ddavp group voided volume and voiding time decreased after treatment. ratio of normal flow curve and coordinative detrusor-sphincter contraction had no change after treatment. two bands of aqp ( and ) were detected in the morning urine. density of patients bands was significantly lower than that of the controls. density of bands in ddavp group after treatment were significantly higher than that before, but there was no difference between datas before and after treatment in bfb group. conclusions: bfb and ddavp are both effective therapies for pne in children. bfb is helpful in correcting voiding dysfunction and ddavp can increase aqp protein in the urine. with higher effective rate within four month, bfb is strongly recommended. objective: to describe the clinical course of non-parasitic chyluria in a thai pediatric case. this is the first report in children. results: the -year-old boy presented milky urine lasting for one year. urine tests showed heavy proteinuria (protein to creatinine ratio . mg/mg), lipiduria (triglyceride mg/dl). the proof of a pronounced hypertriglyceriduria led to the diagnosis of chyluria. his renal function was normal. numerous red cells and lymphocytes were observed in the urine, and postprandial cystoscopy revealed milky cloudy urine emanating from right ureteral orifices. retrograde pyelography demonstrated pyelolymphatic backflow. serum immunoglobulin g for wuchereria bancrofti and circulating filarial antigen in the peripheral blood were negative. chest x-ray, abdomen computed tomography and intravenous urography did not demonstrate abnormal mass or malformation. proteinuria and lipiduria ceased before sixth week of a medium-chain triglyceride-rich diet. there was no recurrent chyluria after weeks of mct-rich diet were completed. conclusion: in non-parasitic chyluria with unknown etiology, the low-fat diet with mct supplementation alone is effective. the prognosis is excellent. there was a significant improvement of waz comparing data at admission and at the end of follow-up (p< . ). there was also a significant improvement of whz comparing data at admission and at the end of follow-up (p= . ). only ( . %) patients presented with a whz less than - . at the end of the follow-up. conclusion: children with primary vur presented an improvement in somatic growth with medical management. objective: the aim of this study is to investigate the clinical practical value of using doppler ultrasound to detect renal blood flow in renal parenchymatous diseases of children. methods: the renal arteries, segmental arteries and interlobar arteries were detected by doppler ultrasound. the parameters were peak systolic velocity (vmax), minimum velocity in diastole period (vmin), vmax/vmin (s/d), resistive index (ri) and pulsatility index (pi). there were cases of healthy children, cases of acute poststreptococcal glomerulonephrits, cases of primary nephrotic syndrome and cases of chronic renal failure. results: the doppler renal blood flow in normal school children was high velocity and low resistant type. typical cases of acute nephritis with edema and oliguria appeared low velocity and high resistant type, ri, pi and s/d of all renal arteries were significantly increased, vmin are significantly decreased (p< . ). after to weeks all parameters returned to normal. during edema period and convalescence, the renal blood flow of primary nephrotic syndrome is low resistant type, ri, pi and s/d of segmental arteries and interlobararteries were significantly decreased (p< . ). the feature of low circulating blood capacity was not alleviated even though edema was vanished and urine output was increased. the doppler in chronic renal failure was high resistant and low velocity type. ri, pi and s/d were all significantly increased, vmin were significantly decreased (p< . ). when ri was great than . , the extent of damage in kidney function was serious and the prognosis was bad. conclusion: renal blood flow provided a new non-invasive method for clinic diagnosis and evaluation of the prognosis in children renal parenchymatous diseases. we concluded that the dms is an important cause of congenital nephrotic syndrome. the outcome of our patients was poor and most of our patients died before years old. objectives: the antiphospholipid syndrome is defined by the association of arterial/venous thromboses or obstetrical fetal loss with the presence of antiphospholipid antibody. this syndrome may be primary or secondary, particularly in association with systemic lupus erythematous. this study is to examine the frequency of anticardiolipin antibodies and the association between anticardiolipin antibodies with some symptoms in children with lupus nephritis. methodology: twenty-five children with lupus nephritis from / to / in department of nephrology, children's hospital o were included in the study. we find the relationship between anticardiolipin antibodies with hematologic and renal involvement. results: anticardiolipin antibodies was positive in patients ( %), for anticardiolipin igm antibody ( %), for anticardiolipin igg antibody ( %). there was a positive correlation between the presence of anticardiolipin antibodies and thrombocytopenia. in patients with positive anticardiolipin antibodies, patients had mta on renal biopsy. conclusion: anticardiolipin antibodies are associated with thrombocytopenia and mta. aim: the methodologies for quantitating urinary calcium excretion have not been standardized. the aim of this study was to compare urinary calcium/osmolality (uca/osm) ratio with calcium/creatinine (uca/cr) ratio and to assess the correlation of both ratios with daily urinary calcium excretion for the diagnosis of hypercalciuria in children. patients and methods: children aged - years (mean . ± . years) were included in the study. they were randomly selected from previous study's larger patient population. non-fasting, second morning urine samples were collected from all children. children were divided into two main groups: ) children with uca/cr < . (mg/mg) and ) children with uca/cr < . . -hour urine samples were collected from the second group, who were further divided into two subgroups: a) children with daily calcium excretion < mg/kg/day and b) hypercalciuric children (daily calcium excretion > mg/kg/day). results: mean uca/osm ratio was significantly lower in the first ( ) group than the second ( ) group ( . ± . vs . ± . mg/l/mosm/kg, p< . ); but there was no difference between a and b subgroups. the correlations of both uca/osm and uca/cr ratios with -hour calcium excretion were poor (r= . for both). conclusion: uca/osm ratio correlated with spot uca/cr ratio. but its superiority on uca/cr ratio in the diagnosis of hypercalciuria could not be shown. interestingly, values of -hour calcium excretion as a definite diagnosis test of hypercalciuria; did not correlate mathematically with those ratios of hypercalciuric or non-hypercalciuric children. using uca/osm ratio as a screening test would not separate hypercalciuric children. background: microalbuminuria is a biomarker of renal damage. the presence of microalbuminuria in patients with a solitary kidney has been described, but the pathophysiology leading to its occurrence is poorly understood. it is postulated that microalbuminuria is the early result of hyperfiltration. methods: we concomitantly measured inulin clearance, filtration fraction (ff) and microalbuminuria in children with a single kidney. correlation between the occurrence of microalbuminuria and a high filtration fraction was done. microalbuminuria was defined as an albumin/creatinine ratio (acr) > g/mol for boys and girls. normal filtration fraction was defined as < %, and normal inulin clearance as > ml/min x . m . during the same study, we also measured microalbuminuria in children with severe grade iii to v vesico-ureteral reflux (vur). results: children with a single kidney were evaluated. patients ( %) had a normal ff, and only one ( %) in that group had an abnormal acr. patients ( %) had elevated ff, and ( %) had an abnormal acr. the presence of an abnormal acr was highly correlated with an abnormal ff (p= . ). the mean gfr between the groups with normal or abnormal microalbuminuria did not differ significantly ( ± ml/min x . m vs. ± ml/min x . m , respectively). there was no significant association between microalbuminuria and a high ff in patients with severe reflux (p= . ). discussion: we found the presence of microalbuminuria to be significantly associated with an elevated ff in children with a single kidney. this finding goes in line with the pathophysiology of a reduced nephron mass, leading to hyperfiltration, and ultimately to glomerular sclerosis. the benefit of renin-angiotensin-aldosterone blockade in these patients remains to be proven. chyluria is the excretion of chyle from the urinary tract and indicates the presence of an abnormal communication between intestinal lymphatics and the urinary tract. it can be of parasitic or nonparasitic etiology. southern brazil is not an endemic region for filariasis. aim: report a case of a -yrs caucasian adolescent girl referred to our out-patient clinic. history: yrs before, she started to pass milky urine with white clots. no edema. normal blood pressure. she was investigated in another hospital and underwent a renal biopsy, that was normal. a diagnosis of nephrotic syndrome was made. she was treated initially with steroids and after changed to cyclosporin, lisinopril and simvastatin. conclusion: chyluria, although a rare conditione specially in children and adolescent in nonendemic areas, should beconsidered in the differential diagnosis of nephrotic syndrome. macroscopic examination of the urine, that is milky and cloudy, is simple and very helpful. also, triglycerides are found only in the urine of patients with chyluria. these simple tests will avoid unnecessary treatment, which is not without side effects. low-density lipoprotein apheresis (ldl-a) has been tried in the treatment of patients with steroidimmunosupression resistant nephrotic syndrome (ns) due to focal segmental glomerulosclerosis (fsgs). we would like to report a child case study of fsgs with ns and renal insufficiency due to mitochondrial abnormality treated by ldl-a and to clarify the therapeutic effects of this treatment. a -year-old boy was referred to our hospital with complaints of heavy proteinuria and edema. a routine examination revealed proteinuria of . g/day, serum albumin (alb) of . g/dl and creatinine clearance (ccr) of . ml/min. renal biopsy specimen showed fsgs and perceptive deaf nass was recognized, necessitating a hearing aid. the a g point mutation in mitochondrial gene was detected by using genomic dna isolated from peripheral blood leukocytes and by the molecular analysis using an allele-specific polymerase chain reaction (pcr). oral prednisone ( mg/kg/day for eight weeks), intravenous methyl-prednisone pulse therapy ( . g/day,three times a week on the consecutive days for three weeks) and oral cyclophosphamide ( mg/day for eight weeks) were not effective to reduce proteinuria. a protocol of ldl-a was designed for treatment twice-a-week for four weeks and then once-a-week for six weeks. following treatment by ldl-a, serum total cholesterol and ldl were markedly changed form to mg/dl and from to mg/dl, respectively. a small but significant increase in alb from . to . g/dl and a remarkable decrease in proteinuria from . to . g/day were also successfully obtained. conversely, no marked changes in ccr were detected. the results of the present study indicate that a rapid decrease in proteinuria and an excellent increase in alb by ldl-a provide a possible therapy for drug-resistant ns due to fsgs with mitochondrial abnormality. glomerular filtration rate (gfr) can be estimated in children by various formulas based on body height and serum creatinine (s cr ) measurements such as the schwartz formula (egfr sch =kxbh/s cr ). we evaluate the performance of egfr sch in estimating gfr in a pediatric cohort when compared to i-iothalamate clearance (igfr), used as the reference standard for measuring gfr. between and , we obtained igfr and egfr sch on subjects. for subjects who had more than one igfr, the first measurement was used for analysis. mean age was ± (range - , % age= ), % male. mean s cr was . mg/dl (median . ), mean igfr ± ml/min/ . m and mean egfr sch ± ml/min/ . m . figure shows a scatter plot of the data with a line representing perfect agreement. figure shows a residual plot comparing the difference between estimated and measured gfr to egfr sch . pearson r correlation between the two variables was . (ln scale). accuracy of egfr sch within % and % was % and %, respectively. the median difference between igfr and egfr sch was . ml/min/ . m (median % difference %). for igfr > , - , - and < ml/min/ . m , egfr sch overestimated gfr by %, %, % and %, respectively. however, the median difference between igfr and egfr sch for the same groups was , , and ml/min/ . m , respectively. in conclusion, agreement between egfr sch and igfr is poor. egfr sch overestimates igfr at all levels of gfr, but bias of egfr sch vs. igfr increases progressively with higher gfr levels. in clinical instances when an accurate estimation of gfr is critical for patient management, the use of egfr sch should be reconsidered. until a more applicable estimation equation is developed, isotope measurement of gfr remains the ideal method to determine gfr in this population. background: immunosuppressive therapies other than corticosteroids, potentially associated with serious adverse effects, are urgently required for children with frequently relapsing nephrotic syndrome (frns). this study evaluated the efficacy and safety of long-term treatment with a moderate dose of cyclosporine (cya) in children with frns. methods: in this prospective, open-label multicenter trial, patients, from to years old, were randomly divided into two groups. for the first months, both groups received cya (sandimmune) in a dose that maintained the whole-blood trough level between to ng/ml. during the next months, the dose of cya was adjusted to maintain a trough level between and ng/ml in group a, while group b received a fixed dose of . mg/kg per day of cya. the primary end point was the rate of sustained remission. results: at months, the rate of sustained remission was % in group a (n= patients), as compared with only % in group b (n= ) (p= . ). the hazard ratio for relapse was . ( % ci, . to . ) in group a as compared with group b (hazard ratio= . ). at months, the rate of progression (to frns)-free survival was % in group a and % in group b (p= . ). mild arteriolar hyalinosis of the kidney was found in ( . %) of patients in group a and ( . %) of in group b; no patient had striped interstitial fibrosis or tubular atrophy. conclusion: cya given for years in a dose producing a trough level between and ng/ml for the first months, followed by a trough level between and ng/ml for the next months is an effective and relatively safe treatment for children with frns. with this regimen, about % of patients are expected to remain relapse-free during years of treatment, without the most critical adverse effect of cya, i.e., interstitial changes of the kidney. renal stone disease has been regarded as an uncommon problem in children especially in the first year of life. we evaluated clinical findings and metabolic examination of children with urinary tract stone presenting in the first year of life. there were boys ( %) and girls ( %), the mean age of admittance was , ± , months. the average follow-up period was , ± , months. urolithiasis was diagnosed during evaluation for uti and incidentally. positive family history for urolithiasis was reported in ( , %) patients. in / ( , %) patients urinary metabolic examination was not normal (table ). in of patients ( %), stones were located in kidneys which was bilateral in ( %) patients and one patient had passing stone which had never seen in ultrasonographic examination. stones were examined in subgroups. in ( %) patients stones were measured mm or smaller (group ), in patients ( %) they were between - , mm (group ) and in only patient the stone (cystin) was larger than mm (group ). stones measuring mm and larger were found highly associated (in of children, %) with abnormal ultrasonographic findings mainly hydronephrosis. in group , stones disappeared spontaneously in / ( %) patients. urinary tract infections (uti) were present in ( %) patients. one fourth of cases had associated genitourinary tract abnormalities mainly vesicoureteral reflux in ( %) patients. we conclude that the presenting symptoms of urolithiasis in the first year of life show a wide spectrum so that high index of suspicion is important for early detection. stones measuring mm and smaller may have great chance to disappear. we also emphasize the importance of screening for uti in patients with urolithiasis under year of age. background: long term complications of glycogen storage diseases (gsds) include delayed puberty, hepatic adenoma and renal disease. in the present study we aimed to detect renal involvement in children with glycogen storage disease and to determine the most accurate laboratory test to be the gold standard for early detection of this renal dysfunction. methods: twenty-seven children known to have gsd were included in this study. fifteen healthy age-and sex-matched children were also included as controls. routine urine analysis, urinary β microglobulin and microalbumin were done for all patients and controls. renal function tests, serum electrolytes, alkaline phosphatase, urinary calcium, blood and urine ph, urinary and plasma aminogram, in addition to calculation of glomerular filtration rate (gfr), bone x-ray to detect rachitic manifestations and abdominal ultrasound to measure renal size were done for all patients. results: twenty-one patients had one or more renal abnormality. the most common was increased urinary β microglobulin ( / ) followed by abnormal gfr whether low or high ( / ) and microalbuminuria ( / ). sonographically there was nephrocalcinosis in one case and renal stone in another one. the auroc curve for β microglobulin was . , (p= . ) and . for urinary microalbumin/creatinine ratio (p= . ). the best cutoff level to predict renal abnormality for urinary β microglobulin was . mg/l with % sensitivity and % specificity and the best cutoff value for urinary microalbumin/creatinine ratio was . with % sensitivity and % specificity. in conclusion: renal abnormalities are common in patients with gsd. urinary β microglobulin can be considered the gold standard for early detection of renal dysfunction in these patients. the aim of this study was to investigate the role of neutrophil activation, protein oxidation and ceruloplasmin in the pathogenesis of hsp, which has been not investigated previously. serum activities of myeloperoxidase (mpo) and arylesterase (aryl) and levels of free thiol, ceruloplasmin (clp) and total oxidant status (tos) were measured in children with hsp ( boys, girls; mean age . ± . years) at the onset of the disease and during remission in comparison with matched healthy subjects. patients at active stage had significantly higher mpo activity ( ± vs. ± u/l, p< . ), higher clp ( ± vs. ± mg/dl, p< . ) and tos values ( . ± . vs. . ± . μmol h o /l, p< . ) than controls. patients had significantly lower aryl activity ( ± vs. ± u/l, p< . ) and lower free thiol levels ( ± vs. ± μmol/l, p< . ) than controls. there were patients with gis involvement, with joint and with renal involvement. no significant differences were found in the oxidant stress markers between patients with or without organ involvement (p> . ). significantly positive correlations were found between tos and mpo (r= . , p= . ), and tos and clp (r= . , p= . ) at the disease onset; while a negative correlation was found between mpo and thiol (r=- . , p= . ) during remission. in conclusion, protein oxidation and neutrophil activation may play important roles in the pathogenesis of hsp. gastrointestinal system, joint and/or renal involvements were not together with different magnitude of oxidant stress. further studies are required to identify oxidizing substances and to develop therapeutic strategies to reduce oxidant stress in hsp. , ) . if the first remission occurred after days, the median time to relapse after discontinuation of steroid therapy was significantly lower than in children with shorter remission time ( . vs . months; p< , ). in conclusion children who fail to achieve a prompt remission after a first episode of ns are more likely to have frns or sdns. these retrospective data provide the rationale for individualizing the initial steroid treatment of mcns according to the time to obtain a remission. a prospective study is needed to validate this approach. the aim of this study was to determine the influence of osmolality of the first morning urine (ofmu) to efficacy of the desmopressin therapy in enuretic (pne) children and to compare the values of ofmu in enuretic and non-enuretic children. methods: we investigated ofmu in group of children with pne and in group of control non-enuretic children. pne group was divided into subgroup i (ofmu < mosm/kg h o) and subgroup ii (ofmu > mosm/kg h o). additionally, we measured ofmu months after the initiation of desmopressin therapy and recorded the number of wet nights. regarding the number of wet nights we divided pne group to subgroups: subgroup a (< wet nights/month), subgroup b ( - wet nights/month), and subgroup c (> wet nights/month). results: the statistically significant difference between control group and pne group regarding ofmu was not found (p= . ). all children from subgroup i had < wet nights/month during desmopressin therapy. children from subgroup ii had < wet nights/month, and had > wet nights/month during desmopressin therapy. the difference between those two groups was statistically significant (x = . , p= . ). in children from subgroup a the difference between ofmu-s during and before treatment was mosm/kg h o, in children from subgroup b it was mosm/kg h o and in children from subgroup c it was , mosm/kg h o. there was the statistically significant difference among those subgroups. conclusion: children with pne had usually similar ofmu like non-enuretic children. low ofmu is a good prognostic factor for desmopressin therapy of pne, especially in patients whose ofmu is < mosm/kg h o. children with bigger difference of ofmu before and during therapy had better response to desmopressin therapy. we can conclude that ofmu can help in choosing the appropriate therapy for pne in children. yh. ng , kl. chan kk women's and children's hospital, pediatric nephrology, singapore, singapore singapore general hospital, neonatology, singapore, singapore aim: to evaluate the clinical course and outcome of primary vesicoureteric reflux (vur) in patients with antenatal hydronephrosis in a neonatal unit. method: a prospective observational study of neonates with antenatal hydronephrosis born between january and december in the neonatal unit of singapore general hospital. neonates with significant hydronephrosis postnatally underwent micturating cystourethrography (mcu). records were reviewed with regards to the clinical course and outcome of primary vur. results: of neonates with antenatal hydronephrosis, ( %) had significant hydronephrosis postnatally and underwent mcu. . % ( / ) were diagnosed with primary vur at median age of weeks. there were more male (n= ) than female infants with primary vur. ( %) infants had bilateral vur. % (n= ) of the renal refluxing units (rru) had low grade vur and % had high grade vur with the majority ( %) being grade iii vur. repeat mcu for rru at years showed that % (n= ) had spontaneous resolution of vur, % had improved vur grade and % had similar vur grades as before. infants develop vur in the contralateral kidney which was previously normal. infants ( rru) underwent dmsa with renal scarring noted in infants. all infants were noted to have renal scarring without a history of urinary tract infection (uti). interestingly, male siblings were found to have grade iii vur with renal scarring with subsequent spontaneous resolution. none of the study subjects underwent surgery. median age of follow-up was . years (range . - . years). conclusion: unlike neonates with vur detected after uti, infants with primary vur were predominantly male, had higher grade of vur with spontaneous resolution in the majority. early diagnosis of primary vur may provide the opportunity for reduced incidence of reflux nephropathy. t. neveus , g. läckgren , j. wahlberg , n. wahlin uppsala university children's hospital, uppsala, sweden uppsala university hospital, department of transplantation surgery, uppsala, sweden objectives and methods: loin pain hematuria syndrome is a rare entity consisting of recurrent macroscopic hematuria with debilitating loin pain. it has only been described in adults, etiology is unclear and treatment is controversial but the therapy with best recorded success is to remove the kidney and reposition it in the pelvis. our objective was to show that the condition exists in childhood as well. results: aj, a previously healthy -year-old girl, was admitted because of recurring cystitis-like symptoms with microscopic hematuria but without bacteriuria. ultrasound and urography were normal. the episodes continued during the following years with increasing hematuria, now macroscopic, and increasing loin pain that was somewhat exercise-dependent. a renal ct scan was normal, as was cystoscopy, urography and ultrasound, but during cystoureteroscopy dilated vessels were noted in the mucosa of the right renal pelvis. antegrade pyelography, high resolution renal ct angiography, invasive renal angiography, mag renogram were all normal, gfr . nephrological evaluation, including kidney biopsy and coagulation tests were also normal and during cystoscopy blood could be seen emerging from the right ureteral orifice. by this time the patient was years old and was dependent on opioids in order to be able to go to school. after long discussions with the nephrologist, urologists, pain specialist and transplantation surgeon, the family opted for autotransplantation as a last resort. this was performed january and the girl became almost momentarily pain-free. nowadays she does not need any analgesics, but after prolonged exercise (like several days of horseback riding) she may experience slight pain in the left loin and/or hematuria. conclusions: idiopathic loin pain hematuria syndrome exists in childhood and may possibly be treated with renal autotransplantation. j. van der deure, a. ockhuijsen, m. sondaar deventer ziekenhuis, st department of pediatrics, deventer, the netherlands objective: enuresis is a common pediatric problem. psychosocial factors (psf) influence the results of enuresis treatment in children. aim: to determine the short and long term effects of psf on enuresis treatment in a general pediatric population. methods: we reviewed the data of our enuresis patients treated from - . relevant contributing psf were categorized. initial follow-up was at months after training. a written questionnaire was sent years after training. treatment success was defined as > % improvement in dry nights. results: pts were included. in pts ( . %) contributing psf were recognised. categorized problems: family related n= ( %), behavioural problems n= ( %), motivation/support n= ( . %), learning disabilities n= ( . %). overall success rate was . % at months and . % at yrs (overall resp quest . %, psf . %, psf %, > psf %). success rate in the psf group was . % ( psf . %, > psf . %) at months and . % ( psf %, > psf %) at yrs. statistics: success rate in the group with psf is significantly lower as compared to no psf at months (p< . (chi-square), or . , % ci . - . ) and at yrs (p= . (chi-square), or . , % ci . - . ) success rate at months is significantly lower in pts with > psf, compared with psf. (p= . (chi square), or . , % ci . - . ) . no significance could be demonstrated at yrs (p= . , chi-square) but this may be due to the variety in response rates. t. papalia, r. greco, r. bonofiglio hospital annunziata, nephrology, cosenza, italy actually a new litholitic therapy includes the phytotherapy agents as phyllantus niruri (pn), a plant used for years in brazil to treat urinary stones. in this work we estimate the effect of pn intake (uristone gr/die) in children ( m/ f, ± years old) with urolithiasis. the pn has been administered for short term (from to months) in children wih caox urinary stones and for months in with struvite stones. besides all children treated with dietary intervention: high fluid intake, sodium restriction, normal calcium intake and a diet low in animal protein. urinary and plasma analysis, body weight, map, ph, creatinine clearance, urinary excretion of mg and citrate were determined at baseline, month and at the end of the study. the patients were studied by renal ultrasonography at baseline, , , months. nobody of them had been undergone extracorporal shock wave lithotripsy. there were no differences in the mean values of urinary and plasma parameters before and after pn intake, except for a significant reduction in the mean urinary calcium in hypercalciuric pts ( ± , vs , ± mg/kg/die). in this follow-up n° patients showed a faster stone clearance after a regular intake of pn and the others showed a smaller stone diameter. previous reports showed pn has a potent inhibitory effect on caox crystal adhesion and/or endocytosis by renal tubular cells and inhibitory effect on crystal growth, which might be related to the higher incorporation of gags into the calculi. our results suggest pn appears to represent a nontoxic and a low cost alternative for the prevention and treatment of stone disease, especially in the children. further studies are necessary to validate these preliminary findings. d. weitzel, c. schäfer, k. hohenfellner, u. pfeffer, m. neukirch german clinic for diagnostic, pediatrics, wiesbaden, germany objective: does sonographic quantification of the renal parenchyma allow estimation of isotopic renal function? method: sonographic kidney images of patients (age to months; mean ) were measured retrospectively. in all images of both kidneys taken from dorsal the volume on the base of length, width and depth was calculated. the parenchymal area (pa) in the longitudinal and cross section was calculated by planimetry. the distribution of renal function via mag was compared with sonographic values as volume and pa of each kidney in relation to whole kidney volume and pa respectively. patients with reduced global kidney function and time space of more than months between isotopic study and sonography were excluded. results: interrater variability regarding planimetry of pa in longitudinal section (from dorsal taken images) was as good as measurement of kidney length (correlation coefficient (k)= , - , and , - , respectively). all sonographic parameters correlated significantly with the isotopic parameters of renal function. the latter correlated best with the pa in longitudinal section (from dorsal taken images) k , . the combination with planimetry in cross section did not improve correlation (k , ). difference of the proportional pa of the left kidneys (in correlation to whole kidney pa) in comparison to isotopic proportional renal function lead to mean difference of - , % with a standard deviation , %. if only kidneys with split function of - % the mean difference of proportional pa was - , % and the standard deviation , %. conclusion: the distribution of total pa of both kidneys correlates significantly with the distribution of renal function (left and right) in isotopic studies. if sonographic planimetry might change the indication for isotopic studies in respect of renal function needs to be proofed in prospective studies. background: childhood incontinence is a common important urologic problem. especially daytime incontinence is often neglected by the parents until it turns out to be a significant clinical problem. the aim of this study was to evaluate the clinical characteristics of the patients with incontinence that were followed in our nephrology clinic. study design: patients were followed between the dates of . . - . . and they were admitted solely due to incontinence or with concomitant urinary tract infections were enrolled. results: the study comprised patients ( m, f; mean age . ± . years). fourty-two patients had only nocturnal enuresis (ne) ( primary, secondary). twelve patients had daytime incontinence (di) ( primary, secondary) and had both ne and di ( primary, secondary and both primary ne and secondary di). all, except two (neurogenic bladder), had functional incontinence. twelve patients had additional fecal incontinence and had constipation. sixty-two percent of the patients had one or recurrent urinary tract infections (uti) in their past history, % had accompanying vesicoureteral reflux and % had urinary stones. ultrasound revealed unilateral or bilateral dilatation in % and other anomalies in % of the patients. nineteen patients had abnormal dimercaptosuccinic acid scintigraphy findings. timed voiding schedule and double voiding were recommended to all patients with daytime incontinence, % of the patients received anticholinergic treatment and % received antimicrobial prophylaxis. discussion: overall, approximately / of our patients had associated uti and / had abnormal dmsa findings. therefore every patient with uti should be questioned about urinary incontinence and be treated carefully if present. the aim of the study was to determine early parameters of ultrasound and dmsa scanning diagnostics of reflux nephropathy (rn) in children. we examined children with rn and vesicoureteric reflux (vur). all children were comparable on gender and age. all patients underwent color doppler ultrasound (cdus), x-ray and dmsa scan. they were divided into two groups: ) children with unilateral rn a according to classification of smellie j. et all, (n= ) ; ) children with vur without renal damage (n= ). we established that data of cdus (diastolic velocities (vd) , ± , mm/sec, systolic velocities (vs) , ± , mm/sec, resistive indices (ri) , ± , , pulsatility indices (pi) , ± , ), dmsa scanning (time of the maximal accumulation , ± , sec, maximal activity , ± , sob/sec, mean velocities of accumulation , ± , mm/sec, the contribution to the common accumulation , ± , %) are characteristic for patients with rn a. data of cdus (vd , ± , mm/sec, vs , ± , mm/sec, ri , ± , , pi , ± , ), dmsa scanning (time of the maximal accumulation , ± , sec, maximal activity , ± , sob/sec, mean velocities of accumulation , ± , mm/sec, the contribution to the common accumulation , ± , %) are characteristic for patients with vur without renal scars. the ranges of cdus and dmsa scanning were significantly different between children from comparing groups (p< , ). our result suggest that data of cdus (vd, vs, ri, pi), dmsa scanning (time of the maximal accumulation, maximal activity, mean velocities of accumulation, the contribution to the common accumulation) can be used to early diagnostics of scarring in children with vur. the purpose of this study was to determine normal reference values for urinary uric acid/creatinine ratios in healthy turkish children. in this study, random urine specimens from children ( boys, girls) aged month to years were analyzed for uric acid and creatinine, and urinary uric acid/creatinine ratios were determined from each sample. uric acid/creatinine ratios were the highest in children aged - months and showed a significant decrease with age (p< . ). uric acid/creatinine ratios were not significantly different between the sexes except - years. girls between - years had higher urinary uric acid/creatinine ratios when compared with boys (p< . ). there was no correlation between urinary uric acid/creatinine ratios and protein intake. our results show that urinary uric acid/creatinine ratio changes with age. when assessing the urinary uric acid/creatinine ratio, a child's age should be considered. we provided normal reference values of urinary uric acid/creatinine ratio for using in our region. the aim of the study was to investigate microbiological marker of activity of uti. e. coli and s. aureus p were isolated from urine of children with uti. the children were divided into groups: . with pyelonephritis in the acute period (n= ); . with pyelonephritis in the period of remission (n= ); . with cystitis in the acute period (n= ); . with cystitis in the period of remission (n= ) healthy children consists the group of control. definition of bactericidal activity of urine (bau) was carried out by our original method. the essence of the method consisted in measuring of the optical density (od) of the bacteria after their contact with urine (experience) and isotonic solution of nacl (control) after minutes of endurance in meat peptone mediums with c during - hours. bau was calculated under the formula: bau (%)=(odc-ode)/odc* %, (odc -control group, ode -experience group). we established that the level of bau did not correlate with urine ph (r= , ), osmolality (r= , ), lysozymuria (r= , ), lysinuria (r=- , ). we established that the low level of bau was marked in children of control group ( - %). the patients in active period of uti had high level of bau (> %). the parameters of bau didn't depend from the level of uti (pyelonephritis or cystitis). the level of bau reduced in the period of remission of uti. we established that the level of bau correlated with bacteriuria (r= , ), leucocyturia (r= , ). the level of bau didn't depend from the degree of urine dissemination (r=- , ). so, the level of bau is correlated with laboratory parameters of uti and can be used as new additional microbiological marker of diagnostics of activity of uti. the evolution of the alport syndrome in brazilian children vesicoureteric reflux (vur) is common in children with urinary tract infections (uti). if vur coexisting with uti there is a high risk of progression to end-stage renal disease (esrd). the correct diagnosis is important. we observed children ( girls and boys) aged mo to yrs at the time they have been diagnosed as having vur. the follow-up period was mo up to yrs after the diagnosis. all children with vur grade have been operated. after antireflux operation incidence of uti dramatically decreased even this cannot prevent progressive kidney damage in some patients. children with less severe vur have been put on prophylaxis. controlled mcu was performed usually after year later. if vur disappeared medication have been stopped. vur grade - had a tendency of resolution under conservative treatment in . % of the patients. in children associated urinary tract malformations were found: duplicated system, dysplastic kidney, kidney agenesia, dystopic kidney, urethral stenosis and bladder outlet obstruction. in patients nonfunctioning kidney have been found. dysfunctional voiding was common finding. blood pressure and physical development have been controlled. kidney size, function and scar formation have been followed by dmsa scan. we observed kidney growth at mos intervals. during the follow-up period infants have had reversible renal insufficiency. one patient with bilateral vur grade went into renal failure at the age of yrs. conclusions: vur is still one of the most common leading causes to esrd in childhood. even the existing controversy concerning treatment modalities it is obvious that low grade vur does not need operative treatment. it is indicated in high grade vur to prevent repeated and severe uti but it cannot preserve progression of the disease because of high incidence of coexisting kidney dysplasia. results: from forty children with nephrolitiasis, ( %) were boys and ( %) were girls. the mean age was . ± . months. the youngest age was months old. the most common clinical presentation was abdominal discomfort ( %), followed by uti ( %), microscopic hematuria ( . %), macroscopic hematuria ( %), spontaneous urinary calculi ( %), flank pain ( %). nine of children were presenting with chronic renal failure (crf). statistical analysis showed that age had correlation with the present of crf in children with nephrolitiasis (p= . ). the clinical presentations of nephrolitiasis were varied. abdominal discomfort and uti were the major signs and symptoms. there was correlation that age may influence the present of crf in children with nephrolitiasis. objective: renal involvement is one of the most frequent and serious manifestations of sle. we analyzed the treatment and renal outcome of patients with lupus nephritis. methods: seventy-seven identified patients were retrospectively analyzed from jan. to dec. . the outcome was divided as complete remission ( -hour proteinuria < . g, plasma creatinine level normal and sledai < ), partial remission (abnormal renal damage index improved > %, -hour proteinuria > . g, sledai < ) and no response, respectively. results: fifty-four patients were biopsy proven ln ( %). fifty-seven patients followed up more than month. all the eleven patients with class i or ii achieved remission, using prednisolone together with either hcq, or tripterygium or mmf or cyclophophamide (ctx). in forty-three patients with class iii or iv or v, they were given prednisolone together with mmf or ctx. we found that remission was in cases, part remission cases and no response in cases. associations between methylenetetrahydrafolate reductase (mthfr) c t polymorphisms and several vascular diseases have been reported. this is a clinical study designed to investigate the possible effects of (mthfr) c t polymorphisms on the developement of henoch-schönlein purpura (hsp), renal involvement, and clinical course. fourty-one patients with hsp ( m/ f) mean age ( , ± , years) were included in the study. eighteen of the patients had renal involvement. the control group consisted of healthy children. blood samples were obtained for mthfr c t transition, homocysteine, folic acid and vitamine b in the patients and controls. the genotype frequencies (cc/ct/tt) of mthfr in the hsp group were , / , / , and , / , / , in the control group, respectively (ns). the genotype frequencies (cc/ct/tt) were , / , / , in the patients without renal involvement and , / , / , in those with renal involvement, respectively (ns). homocysteine levels were , ± , in the hsp patients and , ± , μmol/l in controls (ns). vitamine b levels were , ± , pg/ml in the hsp patients and , ± , pg/ml in the control group (ns). folic acid levels were , ± , in the hsp and , ± , ng/ml in the control group (p< , ). no significant relationship was present with the mthfr genotype and plasma homocysteine, folic acid and vitamine b levels. no association with mthfr gene polymorphism and homocysteine plasma levels could be detected in patients with hsp and hsp nephritis. although mthfr gene polymorphisms have been found to be associated with several vascular diseases, the results of this study indicate that other mechanisms should be operative in the developement of hsp and hsp nephritis. we report the symptoms, signs and laboratory values at onset and during month-follow-up of hsp in a prospective study of children ( girls, boys) with mean age of . years ( . - . y). the first sign of hsp was purpura in ( %), oedema or other joint symptoms in ( %), abdominal pain in ( %) and melena in ( %) patients. petechiae appeared on the average days after the first symptoms ( - d) if purpura was not the first sign (n= ). % of the cases were diagnosed between september and march. the mean delay from the first symptoms to the diagnosis was days ( - d our results based on an unselected and prospective patient material demonstrate that renal symptoms in hsp children develop early, are common and should be followed up at least months. the kidney is a metabolically active organ, so any alteration in kidney function might affect nutrient utilization. objective: analyze the nitrogen balance (nb) as a marker for adequate food consumption in children with chronic renal insufficiency (cri). material and methods: patients ( boys, girls) diagnosed and managed in the nephrology and nutrition departments. they were placed in two groups depending on age: group a: patients aged ± . years, follow-up ± . years, glomerular filtration rate (gfr) estimated by cr-edta: ± ml/min/ . m ; group b: patients aged . ± years, follow-up . ± . years, gfr estimated by cr-edta: ± ml/min/ . m results: group a had a worse weight and height evolution: weight: - . ± . sd in group a vs . ± sd in group b; height - . ± . sd vs - . ± . sd (respectively). group a showed a significant increase in tnf blood levels (p< . ) that was inversely related with weight and height. bn was significantly greater in group a ( . ± . gr/day) than in group b (- . ± gr/day) (p< . ) and this was related with higher calorie (p< . ) and protein (p< . ) intakes. there was no difference in alimentary nutritional breakdown. nb improved significantly over the follow-up (p< . ). there was no relation between nb and gfr. there was a significant increase in triglyceride levels and significantly lower blood urea levels in group a (p< . ). we conclude that nitrogen balance depends on protein and calorie consumption and is independent of the severity of renal affectation. we present a case of a months old boy, who was delivered to our intensive care unit because of high fever, acute renal failure and dilatation of the urinary tract. his hemoculture and urinary culture were positive for e. coli and a severe urosepsis was diagnosed. his urethral catheterization was unsuccessful, so a suprapubic puncture was performed to relieve the urinary system and provide sufficient urinary flow. after the urinary sepsis was cured with adequate board spectrum antibiotics, a voiding cystourethrography (vcug) was performed to reveal the suspected anatomical abnormality, vesicoureteral reflux (vur) respectively. meanwhile a continuously growing nodular tumor of the penis was observed. the vcug showed the signs of urethral stenosis, but posterior urethral valve and vur was excluded. the doppler ultrasound found a solid vascularised tumor, x . cm in its diameter. during the surgical operation the tumor couldn't been totally removed, as it was infiltrating the surrounding tissues and the urethra. the histopathological examination of the biopsy specimen confirmed a juvenile xanthogranuloma (jxg). this is an uncommon, benign, non-langerhans cell histiocytosis, primarily seen in infancy as a solitary cutaneous lesion, predominantly in males. systemic form of the disease is rarely seen. usually it resolves spontaneously without any further treatment, but the differentiation from a malignant neoplasm is essential. according to the authors' search, this is the nd reported case in the literature and the first pediatric report of the jxg of the penis. urine examination using x-ray diffractometry background and goal: x-ray powder diffraction analysis is widely used in chemistry and pharmacology and for other industrial purposes. in medical science it is used for analyzing kidney stones and investigating retained crystals in tissue sections. in the department of mineralogy and petrology we investigated urine samples, at first diagnostically to detect urinary amino acids, glucose and compounds and, secondly, to detect calcium oxalate hydrate, which can be employed for early detection of renal tubular injury when no significant differences in renal function values exist. materials and methods: after sedimentation and dehydration, authors investigated more than urine samples of children using x-ray diffractometry. results: of them were glucosuric due to diabetes mellitus; in these cases glucose could be detected in each of their urine samples. in cases different amino acids due to aminoacidopathy were detected. the urine samples of children -kidney stone problems in history -were examined, in one case struvit, in the other cases ca oxalate crystals were identified. also, samples of children were examined, hours after at least hours long anesthesia, ca oxalate hydrate appeared in their urine referring to renal tubular injury due to inhalational anesthetic agents. in cases urine samples of children treated in the intensive care unit were analyzed, in % ca oxalate crystals could be detected. in cases healthy children's urine were investigated, as control ones. conclusion: x-ray diffractometry, as a highly sensitive method can be used efficiently in clinical measurements. further investigations are needed in order to determine its place in clinical trials. authors emphasize the importance of collaboration of different sciences, as well. drug intake in the background of sudden death? microalbuminuria was significantly more in patients more than years of age as compared to younger patients on bivariate analysis (p= . ). on logistic regression analysis, though microalbuminuria was more in patients more than years of age, it was not statistically significant. the association between microalbuminuria and urinary specific gravity levels of < . was statistically significant (p= . ), similar results were seen on logistic regression analysis. there was no correlation between microalbuminuria and hospitalizations, crises, previous blood transfusions, hemoglobin electrophoresis and serum creatinine levels. conclusion: identification of risk factors for microalbuminuria may allow earlier intervention to prevent renal complications in patients with ssd. in developing countries at primary health care level urinary specific gravity should be done routinely in patients with ssd to identify cases at risk of microalbuminuria. m. bak, e. serdaroglu, y. bicilioglu aim: the aim of the present randomized-controlled study was to compare desmopressin (dp), alarm and combined treatments in nocturnal enuresis. the study included children ( boys and girls) with nocturnal enuresis. the mean age was . ± . years (ranged - years) and the mean wet-nights was . ± . day per month before treatment. the patients were followed for one month before treatment and randomized to dp ( patients), alarm ( patients) and combined ( patients) treatment groups. the dp group was received μg orally one-hour before sleep and alarm group was used wet-stop bedwetting alarm device after education of parents. the patients were followed months in treatment period and months after discontinuation of treatments. results: wet-nights per months was significantly reduced between before treatment and last month of treatment in dp ( . ± . to . ± . , p< . ), alarm ( . ± . to . ± . , p< . ) and combined treatment ( . ± . to . ± . , p< . ) groups. treatment success (> % decreasing in wet-nights) and complete response ( % dry) rates was %, %, % and %, %, % in dp, alarm and combined treatment groups respectively. the more rapidly decreasing in wetnights was observed between dp used and only alarm treatment group but this effect disappeared after months. relapse rates was %, % and % in dp, alarm and combined treatment groups respectively between successfully treated patients (p= . ). conclusion: alarm treatment is the best intervention with low relapse rates and no potential adverse effect in nocturnal enuresis. dp group has higher relpse rate but adding to dp may achieve more rapid decreasing in wet nights especially in patients and parents expecting rapid result. aim: it is often difficult to collect urine from infants. use of specifically designed urine collection pads gives reliable results for routine biochemistry tests in adult urine. their use for routine and metabolic tests in paediatric urine has not been investigated. the aim of this study was to evaluate whether the pads give reliable results for routine and metabolic biochemistry tests in paediatric urine. methods: urine collected by bag or clean-catch from infants < y without metabolic disorders was divided into two aliquots, one of which was added to a collection pad, incubated for min at °c, then recovered by aspiration. routine and metabolic analyses were performed on pad/non-pad aliquots. additionally, selected metabolic analyses were performed on pad/non-pad urine from patients with diagnosed inborn errors and urine spiked to simulate metabolic disorders. for quantitative analyses, pad/non-pad results were compared using bland-altman bias plots, passing and bablok regression and paired t-tests. results: routine tests (urea, electrolytes, creatinine, osmolality, calcium: creatinine, phosphate: creatinine, magnesium: creatinine, urate: creatinine, n= ) showed close concordance with no clinically significant pad/non-pad differences. in infants without metabolic disorders, aminoacids (n= ), organic acids (n= ) and mucopolysaccharides (n= ); and in patients with metabolic disorders -phenylketonuria (n= ), mucopolysaccharidoses ii (n= ) and iii (n= ), inborn errors of organic acid metabolism (n= ) and cystinuria (n= ), all showed excellent pad/non-pad concordance. sugar chromatography in urine spiked with glucose/galactose/fructose showed identical staining intensity in pad/non-pad samples. conclusion: urine collection pads give reliable results for a wide range of routine and metabolic tests in paediatric urine. a post-translational modification of arginine residues in proteins and subsequent proteolysis result in release of symmetric dimethylarginine (sdma). sdma is considered an end product of metabolism, excreted primarily by the kidney. several previous studies have reported a significant relationship between glomerular filtration rate (gfr) and plasma sdma. to determine the potential value of sdma in the assessment of gfr in children we have measured sdma in samples taken during routine measurement of glomerular filtration rate (gfr) using plasma clearance of inutest. patients ( male) requiring routine gfr measurement were studied. median (range) age . y ( . - . ) , height (ht) cm ( - ), and surface area . m ( . - . ). gfr was measured using the plasma clearance of inutest, and plasma sdma and creatinine (pcr) by liquid chromatography stable isotope dilution electrospray mass spectrometry-mass spectrometry method. estimated gfr (egfr) was calculated from the formula x ht (cm)/pcr (μmol/l). median gfr was ml/min/ . m ( - ), plasma sdma . μmol/l ( . - . ), pcr . μmol/l ( . - ), and egfr ml/min/ . m ( - ). as expected both plasma sdma and pcr increased with a decline in gfr. compared to gfr the correlation with /sdma, r= . (p< . ) was better than for /creatinine, r= . and similar to that for egfr, r= . . comparing sdma with inutest gfr for detection of gfr < ml/min/ . m the area under the roc curve was . (p< . ). the equivalent areas for pcr and egfr were . and . , respectively. in conclusion plasma sdma is an endogenous marker of gfr in children and is superior to pcr because it appears to be independent of body size. since the calculation of egfr requires accurate measurement of height, plasma sdma may provide a practical alternative for assessment of gfr in children. thrombotic microangiopathy (tma) consists of thrombocytopenia, microangiopathic hemolysis, and thrombi in the microvasculature of vital organs. broad categories of causes of tma include infectious (verotoxin-induced hus), hematologic (ttp), complement based (atypical hus), immune-mediated (sle, anti-phospholipid antibody syndrome), and drug-induced (cyclosporine). thorough investigation is required to detremine the underlying etiology in order to provide specific therapy and information about prognosis. a year girl presented with short stature and was found to have hypertension, proteinuria, renal failure (creatinine umol/l), and anemia (hgb g/l). platelets were normal. she also had spondylometaphyseal dysplasia, scoliosis, lymphopenia, mild pulmonary hypertension and aortic stenosis. on pulmonary function testing, her dlco was decreased. chest ct demonstrated small micronodules. a ventilation-perfusion scan was normal. renal biopsy showed features of tma. she was treated with dialysis and underwent renal transplantation one year later. there has been no disease recurrence months post-transplant. genetic and immunologic workups were negative, including anti-cardiolipin antibodies. a thrombophilia workup was negative apart from a heterozygous mutation in mthfr. c levels were mildly reduced. anti-neutrophil antibodies were negative. complement system studies, including factor h, and smarcal analysis for schimke immuno-osseous dysplasia are underway. although the descriptive diagnosis of tma can be applied here, the underlying pathophysiologic diagnosis has still to be defined. it is of particular importance that further efforts be made to identify the etiology given the potential risk of disease recurrence in the renal graft. background: long term outcome of renal functions after liver transplantation (lt) in wd is not studied yet. aim: the aim of this study was to determine the long term outcome of renal functions in children receiving lt for wd. patients and methods: renal functions were examined in (f/m: / ) liver transplanted patients for wd before and long after lt and compared with renal functions of patients (f/m: / ) with lt for a hepatic disease other than wd. the mean age of subjects was . ± . years in the patients group and . ± . years in the controls. the mean duration of follow-up was at least years. glomerular and tubular functions were assessed using the conventional equations for measured creatinine clearance (gfr), tubular phosphate reabsorption (tpr), daily protein and calcium excretion in both groups. results: mean gfr before lt was . ± ml/min/ . m in the study group and . ± . ml/min/ . m in the controls (p= . ). the mean tpr before lt was found to be . %± . % in the study group and %± . % in the controls (p= . ). daily protein excretion rate before lt was found to be high in both groups, as well as urinary calcium excretion. an increase in gfr was observed in the study group after lt (p> . ), while it was slightly decreased in the controls (p> . ). tpr increased significantly in the study group after lt ( . %± . %) (p= . ) and although it was found to be significantly lower in the study group than the controls before lt, in the long term follow-up the difference between the groups was disappeared (p= . ). conclusion: tubular dysfunction is frequent in patients with wd. liver transplantation for hepatic failure secondary to wd is a lifesaving procedure. it corrects the underlying hepatic defect as well as renal defects and leads to long-term survival. rather conflicting results are available regarding the neurocognitive development of children with ckd, due to small sample sizes, cross-sectional study designs, differing methodological approaches and historical trends in patient selection for renal replacement therapy. we prospectively examined in a standardized, multi-center effort children with ckd aged . - years. children were treated either conservatively (n= , gfr < ml/min/ . m ) or by dialysis (hd: n= , pd: n= ). a sub-sample of children underwent repeated testing after - months. bayley and snijders-oomen developmental tests were performed and the measured values normalized to standard deviation scores (sds). general cognitive development averaged at - . (± . ) sds. % of the patients scored <- . sds, i.e. below the th percentile of the normal population. no significant differences were observed between pre-dialysis (- . + . ) and dialyzed patients (- . + . ). impaired neurocognitive function was marked in infants (- . + . sds), whereas school children showed a distribution similar to healthy children ( . + . sds, p< . ). the global neurocognitive sds remained unchanged in the longitudinal sample (t =- . ± . ; t =- . ± . ). in summary, our preliminary results demonstrate a high prevalence of neurocognitive impairment in infants with ckd. we assume that this finding reflects the improved survival of children with complex disorders affecting not only the kidney but also brain development. the poor performance of this age group highlights the importance of close neurocognitive follow-up and early developmental interventions. objectives of study: to make a diagnosis of a girl with kidney subcapsular hydrops, abnormal urinanalysis and hypertension. methods: physical examination and laboratory investigations were analyzed. results: a years old girl was admitted because of kidney subcapsular hydrops, proteinuria without edema, and hypertension ( / mmhg) for days. no trauma or familial hypertension history were provided. no hydrops was found before the age of year. urinary rbcs were - /hp and protein was mg/kg/ hr. the serum albumin was normal. ultrasound examination revealed normal sized kidneys, increased echogenicity in both kidneys, and subcapsular hydrops on the upper pole of the right kidney connected with an old renal fissure. ucg and fundus examinations were normal. gfr of the right kidney was slightly decreased as compared to the left ( ml/min vs. ml/min, by dtpa scan). by puncture of hydrops, yellow clear fluid was drained, the analysis showed similar composition to that of original urine, so subcapsular urinoma was diagnosed. urine collection from two kidneys separately was performed by cystoscopy; nonselective proteinuria of + was found in urine from the right and + from the left kidney. analysis revealed urea . mmol/l, potassium . mmol/l, creatinine . mmol/l in the right kidney urine compared to urea . mmol/l, potassium . mmol/l, and creatinine . mmol/l in the left, which suggested that the right kidney function was compromised. according to proteinuria from both kidneys with microscopic hematuria, without edema and hypoalbuminemia, glomerulonephritis was diagnosed. the girl was diagnosed with glomerulonephritis and subcapsular urinoma. it was a rare case because of their co-incidence. reasons for the hypertension, if caused by the glomerulonephritis or the pressure by subcapsular urinoma, as well as reasons for subcapsular urinoma need to be clarified during the follow-up. the aim of this study was to detect factors that could interfere with the results of des treatment. methods: fifty-six patients . to . years old with des without improvement by previous therapies were randomly distributed into two voiding training programs: group (g ): patients submitted to kegel exercises training sessions for three months; group (g ): patients submitted to biofeedback sessions over a two month period. both groups adhered to a voiding and drinking schedule, received adequate toilet posture instructions and were reinforced through the maintenance of voiding diaries. clinical evaluation was carried out before each programs initiation and , , and months after end of the program. all patients were submitted to renal and dynamic ultrasound before and months after each program's conclusion. the following variables were analyzed: gender, age at diagnosis, treatment group type, vesico-ureteric reflux, constipation, urinary tract infection, asymptomatic bacteriuria, bladder wall thickening and post void residual (pvr) urine. the logistic regression model was applied to identify independent variables associated with response to treatment. results: urinary continence was improved after completion of either training program. success in diurnal urinary incontinence varied from . to % in g and from . to . % in g . success in nocturnal urinary incontinence varied from . to . % in g and from . to . % in g . in multivariate analysis three variables remained independently associated with bad response to treatment: constipation with soiling, bladder wall thickening and pvr urine (p< . ). conclusion: studies using multivariate regression analysis to identify predictors of response to behavioral therapy are important for the development of selection criteria for prescribing these therapies to children. we report the case of a four-year-old child born to consanguineous parents, who presented first at two months of age with respiratory failure. during the admission he developed panyctopenia, hypertension and nephrotic range proteinuria. the metabolic workup revealed methylmalonic academia and aciduria along with homosystinuria; highly suggestive of cobalamin deficiency. the renal biopsy showed chronic thrombotic microangiopathy (tma). the muscle biopsy showed the presence of nemaline rods on electron microscopy. cobalamin c deficiency was confirmed by genetic analysis as the patient was homozygous for the mutation c / . at the age of one, he was noted to be visually inattentive and developmentally delayed. on ophthalmology examination there was evidence of bilateral maculopathy and dysfunction of rods and cons on electroretinogram. he subsequently went on to develop bilateral bovine maculopathy. since his initial presentation he has been maintained on hydroxycobalamin, betaine and folate; with no further relapse of proteinuria or panyctopenia. however, despite adequate doses of hydroxycobalamin, the maculopathy progressed. to our knowledge, this is the first report of a child with both tma and bovine maculopathy. the aim of the study was to assess the rate of vesicoureteral reflux (vur) in patients with lower urinary tract dysfunction (lutd) of nonneurogenic origin. dysfunctional voiding may result in lower urinary tract symptoms in children and is commonly associated with urinary tract infections and vur. we investigated patients with voiding dysfunction during last three years: boys and girls, a mean age of . years, with a mean follow-up of months, all with normal renal function. mean pre and post treatment symptom scores were . and . respectively. vur was detected in % of the children with unstable bladders and . % of the children with stable bladders as detected by video urodynamic investigation, % of the children with urinary tract infection (uti) on admission, and % of the children with no history of uti on admission. the co-existence of vur in our group with voiding dysfunction was . % ( patients). all patients with vur had low grade reflux (grades i-iii) and of them bilateral, the remaining unilateral. renal us was performed in patients and revealed hydronephrosis in patients, while the remainder showed no abnormalities. vur was found to be present in % of the children with abnormal us findings, while only % of the children with normal us findings were affected. furthermore, the patients that had spontaneous resolution of reflux showed a markedly greater improvement in symptom scores. a significant portion of patients with lutd ( . %) have low grade vur. in detection of vur in patients with lutd, hydronephrosis is a good indicator of the presence of reflux, while utis and urodynamic findings were not found to be significant indicators. the overall spontaneous resolution rates of vur in patients with lutd and stable bladder following treatment was found to be . % and . %, respectively. - g) were grouped: group (n: ) was the sham group. group , and (n: for each) received mg/kg twice daily ptx intraperitoneally (i.p.), mg/kg/day gen i.p. and both ptx and gen at the same dosages for consecutive days, respectively. the rats were weighed at the beginning and than weekly during the study. after the last dose -hour urines were collected. then, rats were sacrificed and blood samples were obtained from the abdominal aorta. bun, serum creatinine (scr), creatinine clearance (ccr), renal superoxide dysmutase (sod), catalase (cat) and thiobarbituric acid reactive substances (tbars) levels were determined. all the parameters were compared between the groups. results: body weights were not different between the groups either at the beginning or during the study. bun levels were significantly higher in group than the other groups (p< . ). scr and ccr levels were similar between the groups and , but the levels were higher than those of groups and (p< . ). sod and tbars levels were similar between all groups. the levels of tubular cell apoptosis and caspase- expression were significantly higher in group than the other groups (p< . ). conclusion: we may conclude that ptx administration significantly reduced the apoptosis in gentoxicity, but we could not demonstrate any evidence of ptx-related reduced oxidative stress. the lack of evidence for the widespread use of antimuscarinics and holding exercises in mne prompted us to design a randomized controlled trial comparing interventions in four groups of children with mne: placebo (a) or oxybutynin chloride (b) in combination with a daily regimen of standardized fluid intake and holding exercises or as monotherapy (c) and (d). a fifth group, to be treated with alarm only, was planned as control. randomization was stratified for participating hospital, sex, age, tanner stage, family history of mne, previous treatment, and bladder capacity class, being the largest from either the maximum voided volume (mvv) from a h frequency volume chart or the volume after baseline holding exercises (hev). after weeks intervention with holding exercise (a and b) , hev had increased, both with oxybutynin ( ± (sd) ml to ± (sd) ml, p< . ) and placebo ( ± (sd) ml to ± (sd) ml, p< . ). without holding exercises, only oxybutynin (d) increased hev ( ± (sd) ml to ± (sd) ml (p< . ). mvv increased also in groups a and b (holding exercises), not c and d. cure rate (less than wet night in the last for weeks) was low: a / , b / , c / and d / . control group with alarm had / cure. cure was not related to hev, mvv or delta hev and mvv. this questions the relevance of increasing bladder capacity in mne. background: sickle cell disease (scd) is an inherited disorder of beta-globulin synthesis of haemoglobin, resulting in a tendency for haemoglobin polymerisation and consequent vasoocclusion, tissue hypoxia, and ensuing organ damage. the kidney is a particularly sensitive to hypoxia and renal failure is a major cause of morbidity and mortality in scd. children with scd commonly hyperfiltrate, the glomerular filtration rate (gfr) then typically falls back towards normal in adulthood. routine estimation of gfr in children is primarily derived from the height and plasma creatinine (pcr) measurements using k a constant dependent on the creatinine analytical method. this formula has reduced accuracy in children with a gfr > ml/min/ . m . it has never been validated in hyperfiltration or children with scd. recently, new gfr markers have been proposed including symmetrical dimethylarginine (sdma) that may be independent of body size. in this pilot study we tested the hypothesis that estimated gfr and/or sdma allow a reliable estimation of gfr in scd. methods: hbss patients, age range - yrs (mean age yrs) attending the evelina children's hospital were studied. the patients were on regular blood transfusions for stroke management and undertook a formal gfr measurement using plasma clearance of inutest. the plasma samples were also used for the measurement of pcr and sdma by stable isotope dilution mass spectrometry. egfr was calculated using k= . results: inutest gfr ranged from - ml/min/ . m . there was significant inverse correlation between sdma and inutest gfr (p< . )). there was no significant correlation between either pcr or egfr and inutest gfr. conclusions: this early data suggests that sdma might prove valuable in monitoring gfr in children with scd. introduction: the aim of this study was to identify the risk factors for renal scarring in children with lower urinary tract dysfunction (lutd) by using data available at the time of patient admission to the interdisciplinary management program of lutd at hospital das clínicas. material and methods: medical records of patients were assessed retrospectively concerning gender, presence of vesicoureteric reflux (vur), bladder capacity, detrusor overactivity, residual urine, urinary tract infection (uti), asymptomatic bacteriuria, constipation, detrusor-sphincteruncodination (dsu), high detrusor pressure at maximal cystometric capacity, low compliance, thickness and trabeculation of the bladder wall. renal scarring was diagnosed by dmsa scan. statistical analysis was performed by univariate and multivariate analysis. a p value < . , % confidence interval was considered significant. results: renal scarring was detected in patients ( %). abnormal bladder capacity, detrusor overactivity, residual urine, asymptomatic bacteriuria, constipation, dsu, high detrusor pressure and low compliance were not associated with renal sccaring. vur, uti, decreased bladder capacity, urinary residue, trabeculated and thick bladder wall were associated with scarring at univariate analysis. multivariate analysis showed vur (p< . ) and female gender (p= . ) as independent risk factors for renal scarring. thickness of the bladder wall was a marginal risk factor (p= . ). conclusion: urodynamic parameters didn´t predict renal damage in this study. uti was not a risk factor for renal scarring; however, it was associated with vur (p= . ). although vur was the main risk factor in our analysis, renal scarring was probably due to multifatorial causes as vur was associated with itu. results: comparison of test a and b demonstrates that a mild fluid load h before the administration of ddavp nasal spray ( puffs) results in major significant differences. ). maximal concentrating capacity (cc) is reached later than h after administration (p< . ). in / % cc at sleeping time is < % of max, thereby resulting in a persistent np in the first hour of the night. ) uosmol is significantly ( %) lower in the overnight collection (u ), correlating with a higher diuresis-rate ( %) ). the duration of the ddavp effect is shorter leading to an increase in diuresis-rate and to a decrease in the u osmolality in / children in the urine-collection between - h in the morning. this proves that in up to % of the patients the ddavp-effect does not cover the full night. conclusion: test b demonstrate sthat fluid intake prior to the ddavp-administration influences significantly the antidiuretic effect of ddavp (onset, maximum and duration). this might explain the partial response, suggestive for insufficient pd (and pk) effect of the spray. test a proves that fluid restriction h before ddavp administration, significantly reduces the nocturnal diuresisvolume. m. schmidts, c. schnakenburg, k. häffner, c. jacobi, k. schwab, m. pohl university hospital, center for pediatrics and adolescent medicine, freiburg, germany background: enteropathic hemolytic uremic syndrome (d+hus) is responsible for % of all hus cases. in addition to the nephrological and neurological complications, pancreatic damage resulting in diabetes mellitus is also possible and appears to be associated with more severe cases and elevated mortality. case report: a -year-old girl suffering from d+hus with severe colitis, acute renal failure, dyskinesia, dysarthria and agitation provoked by shiga-like toxin positive ehec infection in july, . the severe affection was characterized by partial thalamic infarction, prolonged leukocytosis (max. g/l) and the necessity of weeks of dialysis. days after the disease onset, hyperglycemia (max. mg/dl glucose) was noted. c-peptide was found to be low indicating reduced insulin secretion. months after hus the patient continues to be insulin dependent. clinically apparent exocrine pancreatic insufficiency has resolved spontaneously. gfr had recovered to ml/h/ , m , but then kidney function deteriorated and dialysis had to be resumed after months. kidney histology at this time showed severe nephron loss compatible with chronic changes after hus and ruled out other unrelated kidney disease. conclusion: in addition to the kidney damage, chronic pancreatic damage can occur in hus. therefore blood glucose levels should be monitored in all hus patients. it is tempting to speculate that patients after childhood hus might be at risk for diabetes mellitus later in life. objective: childhood nephrotic syndrome (ns) is characterised by a relapsing course resulting in significant corticosteroid burden or prescription of cytotoxic immunosupressive therapy. this randomised controlled study was carried out over years at a single centre in sri lanka to compare the efficacy and safety in children with steroid dependant ns treated with intravenous cyclophosphamide or intravenous vincristine therapy. methods: thirty-nine sequential children with steroid dependant ns with evidence of steroid toxicity were randomly allocated to receive either intravenous cyclophosphamide ( mg/m monthly for months) or vincristine ( . mg/m weekly doses followed by doses monthly). both groups received an identical tapering regimen of oral prednisolone for months. all children were reviewed on monthly basis for one year focusing on recurrence of proteinuria and side effects of therapy. finding of +++ proteinuria for consecutive days was diagnostic of relapse. results: there were ( m: f) children in the cyclophosphamide group (mean age . years) and ( m: f) in the vincristine group (mean age . years). during one year of follow-up / ( %) in the cyclophosphamide group suffered a relapse while / ( %) suffered a relapse in the vincristine group. p= . (comparison of proportions using standard error. ci . to . ). no serious adverse effects were encountered in either group. conclusion: in steroid dependant ns, intravenous cyclophosphamide therapy is superior to intravenous vincristine therapy in maintaining sustained remission. we present the clinical and biochemical features of a patient with antenatal bartter syndrome who was found to have a novel romk mutation. the patient presented antenatally with severe polyhydramnios. polyuria, hyponatraemia and hyperkalaemia were evident soon after birth. she had marked hypercalciuria and developed medullary nephrocalcinosis in early infancy. failure to thrive was evident from months. hypokalaemia was a late feature, developing gradually from months. serum chloride levels were consistently - mmol/l whilst urinary chloride levels were consistently < mmol/l, only reaching higher levels after treatment was commenced. alkalosis was not present and the patient did demonstrate some response to furosemide implying some functional capability of na-k- cl. renin and aldosterone levels were persistently elevated. treatment with indomethacin, nacl and kcl produced a good clinical response. mutational analysis revealed compound heterozygous mutations in kcnj , the gene encoding romk. both mutations, m t and l r are in the terminus of the protein thought to have a role in channel gating. similarities and differences from the classically described presenting features of antenatal bartter syndrome highlight the clinical heterogeneity in this condition. this relates to the different identified kcnj mutations which are likely to affect romk function in different ways. the m t mutation has been described, but past electrophysiological studies in sf cells transfected with the m t mutant have not identified any differences in k + conductivity from wild type romk. given that the mutation appears to be clinically relevant in this case, further functional studies are indicated. l r is to our knowledge a novel mutation. expression of these mutations in oocytes is now planned to enable evaluation their effects on channel function and regulation. a -year-old boy was admitted because of nephrotic syndrome. renal biopsy, performed after weeks of prednisone ( mg/m od) + methylprednisolone pulses ( mg/kg each), showed focal segmental glomerulosclerosis. prednisone was tapered (to mg/m od) and enalapril was introduced, without any significant improvement. two weeks later, the patient had transient hypoperfusive acute renal failure which required acei discontinuation. due to the persistence of proteinuria, cyclosporine was started ( mg/kg/day). proteinuria gradually decreased and ceased within the subsequent two weeks. in the meantime the boy had started to complain of low-grade fever without other symptoms and with normal physical examination. laboratory tests only showed leucocytosis (wbc x /ml) and increased c-reactive protein ( mg/l). a chest x-ray revealed an upper mediastinal enlargement and a total body ct scan confirmed the presence of several enlarged mediastinal lymph nodes, whose biopsy led to the diagnosis of hodgkin disease (hd) nodular sclerosis subtype, cd +; stage was iia. cyclosporine and the residual steroid treatment were discontinued and the patient was given six cycles of abvd (doxorubicin, bleomycin, vinblastine, dacarbazine), followed by radiation therapy. presently, months after stopping chemotherapy, both hd and nephrotic syndrome are still in remission. once again, this case points out both that fsg can be secondary to a lymphoproliferative disease and that chemotherapy for hd might have been effective to keep fsgs in long-lasting remission. several treatment methods including increased fluid intake and dietary modification, medical therapies such as potassium citrate and use of extracorporeal shockwave lithotripsy (eswl) and finally surgery methods are used for treatment of urolithiasis. the aim of this study was to evaluate the etiological and clinical characteristics and level of response to medical therapy with polycitra in children with urolithiasis. one hundred thirty-four patients had urolithiasis of which cases followed thetreatment instructions and fulfilled the inclusion criteria for this study. struvite stone were excluded from the study. all other patients who had an initial ultrasonography showing stone inurinary tract were treated with polycitra-k (potassium citrate grams, citric acid . grams in liter of distilled water) irrespective of the cause of the stone. at the end, complete resolution or passage or a decrease in the size of stone in later sonography was defined as response to treatment. hypercalciuria and hyperuricosuria were found to be etiological factor in % and % of patients respectively. the stone analysis was found that % of them were ca-oxalate. stone disease was more common between the age of - years. the most common complaint was hematuria ( %). eswl was performed in % of patients who did not respond to polycitra and had surgically active stones. calcium-oxalate stones were the most frequent stone which responded to polycitra. the response rate in girls and boys was equal and in different age groups the response rate was almost equal. methods: mmcs were expanded in culture and immunocytochemistry was used to characterize the cells. after gentamicin-induced atn, fluorescently-labeled cells were transplanted and traced in kidney tissues by fluorescence microscopy. kidney pathology was studied by hematoxylin-eosin staining, apoptosis was examined by the tunel assay, and ki- and bcl- expression were examined by immunohistochemistry and reverse transcription-polymerase chain reaction, respectively. results: ( ) mmcs (rimm- cells) were successfully expanded in culture. the phenotype of the cultured cells were vimentin-positive and kreatin-negative by immunocytochemistry. ( ) in the mmcs-treated group: the mortality rate decreased; renal function clearly improved; damage to the cell-treated kidneys was reduced and histopathologic lesion scores were lower; proliferation of renal tubular epithelial cells was improved; the apoptosis of renal tubular epithelial cells was reeuced; and the expression of bc - mrna and protein was upregulated. the subcapsular transplantation of mmcs could ameliorate renal function and repair kidney injury. atn is the most common reason for arf, and there is still an absence of effective therapies. this study was done to observe the effect of mobilizing bone marrow cells with stem cell stimulating factor (scf) and gm-csf on recovery from gentamicin-induced acute tubular necrosis (atn) in rats. atn was included in male sprague-dawley rats with five daily high dose intraperitoneal injections of gentamicin. subcutaneous injections of scf and gm-csf were administered simultaneously and these cytokines was observed at day , , , , and . leukocyte numbers, percent venous blood cd + cells, mortality rate, and concentration of the urine proteins, urine nag, bun, scr, and ccr, histopathogic lesion scores were determined. twelve hours after bone marrow ablation (bma) by lethal x-ray radiation, gentamicin-induced spf atn rats were given five daily injections of scf and gm-csf. bun, scr, and histopathogic lesion scores were evaluated at day , and . the effects and mechanism of scf and gm-csf on atn was observed. the number of leukocytes and the cd + cell percentage increased significantly in atn rats between and days after scf and gm-csf injection. in addition, mortality rates dropped, the peak value of renal function increased, renal function were rapid ameliorated and histopathologic lesions were reduced. there was no significant effect on atn rats after bma. this study demonstrates that scf and gm-csf effectively mobilized bone marrow stem cells in atn rats. rapidly improving renal function and decreasing mortality rate. these results suggest that bone marrow stem cell mobilization may be an effective therapy for atn. key words: acute tubular necrosis, bone marrow stem cells, stem cell factor, granulocytemacrophage colony stimulating factor, irradiation. objective of the study: the response to recombinant human erythropoietin (rhuepo), unit/kg twice weekly was studied prospectively in children and adolescents with end stage renal failure who were either transfusion dependent or had hematocrits (hct) < %. methods: rhuepo was given to haemodialysis (hd) patients and patients on conservative treatment, with mean age ( . ± . ) years, males and females with mean hct ( . ± . ). blood pressure, haematocrit, iron-indices, serum potassium, calcium, phosphorus, alkaline phosphatase, urea nitrogen and intact parathyroid hormone (ipth) were monitored serially. results: serum aluminum was measured randomly in patients, results were normal ranging from - ug/l. when serum ferritin was < ng/ml during therapy, they received iron supplementation. according to the response, patients were divided into groups, the non-responders group with hct< , mean age ( . ± . ) years, males and females with mean ipth ( . ± . pg/ml) and group of responders with hct > with mean age ( . ± . years), males and females with mean ipth ( increase of fatty acids such as nonesterified fatty acid (nefa) and triglyceride (tg) with oxidative stress and production of cytokine/chemokine occured during cisplatin (cp) toxicity. statin ( hydroxy- -mthylglutaryl coenzyme a reductase inhibitors) have been postulated to have pleiotrophic effects. we examined whether statin, pravastatin, would ameliorate renal damage induced by cp. male wistar rats (weight - g) fed standard chow were divided into groups: control-rats received tap water alone for days; cp treatment-rats that received cp ( mg/kg, i.v.) on the th day of the study; cp+pravastatin treatment-rats that received pravastatin ( mg/kg/day) in their drinking water for days and cp injection as indicated in the preceeding group. blood and urine samples were collected and the kidney were removed days after cp treatment. urinary excretions of protein and -hydroxy-deoxyguanosine ( -ohdg), serum levels of creatinine and fatty acids were measured. histology was evaluated by light microscopy with immunohistochemistry for pentosidine, n-carboxymethyllysine (cml), and heme oxygenase (ho)- . expression of ho- mrna in the kidney was also measured. pravastatin decreased urinary excretions of protein and -ohdg and ameliorated renal function diminishing areas of tubular damage and positive staining of pentosidine and cml compared with those of cp treatment alone. however, positive staining area and mrna expression of ho- were not significantly changed by pravastatin treatment. although pravastatin did not influence serum levels of total and low-density lipoprotein cholesterol, serum tg level decreased and was equivalent to that of control group. these findings suggest that pravastatin treatment partially protects against cp-induced nephrotoxicity in rats, through its antioxidant as well as lipid-lowering effect. n. bresolin, v. fernandes, f. carvalho, j. goes, l. araujo, m. simon, g. gamborgi, m. zanin hospital infantil joana de gusmo, nephrology pediatric department, florianópolis, brazil objectives: the objective is a report case of acute renal failure (arf) in a child contact with lonomia obliqua caterpillar in southern brazil. the accidents with lonomia oblique has increased in south of brazil in recent years. this increase can be related with reduction of caterpillar natural predators and deflorestation. the venom of lonomia caterpillar provokes hemorrhagic syndrome resembling disseminated intravascular coagulation (dic) and hemolytic anemia. arf could be an important complication of hemoglobinuria that has been recently described in adults. methods: a case report. results: the present is a first case described of arf in a child after contact with lonomia obliqua caterpillar. conclusions: the arf can occur in any age, however, the contributing factor to the development of arf remains obscure. there are mechanisms pointed out: fibrin deposition in glomerular microcirculation, ischemia in hemorrhagc shock with hypotension and venom direct action. the present article related a case of lonomia obliqua accident in a child who revealed coagulation disorder, hemolytic anemia, arf and always, she was hemodynamic stable. the treatment included antilonom serum, urine alkalinization, hyperhydration and peritoneal dialysis for four days. she was treated and followed per year when she recovered her normal renal function. introduction: secondary hyperparathyroidism develops in chronic kidney disease as a consequence of impaired phosphate, calcium and vitamin d homeostasis. the treatment includes phosphate binders and vitamin d analogues, but sometimes ineffective. we report two cases of refractory secondary hyperparathyroidism treated successfully with cinacalcet. case : a -month-old boy with end stage renal disease (esrd) due to posterior urethral valve started on peritoneal dialysis at months of age. he developed secondary hyperparathyroidism with serum parathyroid hormone (pth) level reaching pg/ml. serum calcium had been in the range of . to . mg/dl and serum phosphorus in the range of . to . mg/dl. despite treatment with phosphate binders and vitamin d analogues, pth levels kept increasing to pg/ml. x-ray showed the cupping and fraying of the distal ends of radius and ulna. we started cinacalcet mg daily and increased the dosage up to mg daily. eight months later, pth level decreased to pg/ml and bone changes resolved. case : a -year-old boy with esrd due to primary hyperoxaluria started on peritoneal dialysis at years of age. he developed secondary hyperparathyroidism with serum pth level of pg/ml. serum calcium had been in the range of . to . mg/dl and serum phosphorus in the range of . to . mg/dl. despite treatment with phosphate binders and vitamin d analogues, pth level kept increasing to pg/ml. x-ray showed the distal radius and ulnar fracture of left arm and right femur fracture. we started cinacalcet mg daily. five months later, pth levels decreased to pg/ml. conclusion: cinacalcet is effective in the secondary hyperparathyroidism resistant to phosphate binders and vitamin d analogues in children with chronic renal failure. rota virus (r) is a common pathogen as the cause of gastroenteritis in childhood. we experienced some cases with r infection who had the renal failure induced by uroammoniac calculi as well as dehydration. we examined the clinical feature and laboratory findings of the cases with viral acute gastroenteritis in r and non-rota virus (nr) groups for - . with rapid diagnosis test, we checked the patients that needed the hospitarization medical treatment from newborn to five-years old. in the cases of r group and cases of nr group, we campared the clinical findings, blood chemistry test and urinalysis of r groups in acute and convalescent a tage with those of nr group. r group had significantly (p< . ) lower in ph (vein blood gas test) and higher in blood uric acid (bua) compared with those of nr group. these findings suggest that the elevation of bua and acidosis in r group may induce the formation of renal calculus resulting in postrenal failure. our patient is white male y/o. at year of age, he was dx. with acute lymphocytic leukemia and was induced to remission on pog ; he presented tumor lysis syndrome during induction, acute renal failure with no recovery in renal function and rrt was started (ccpd) and continue on the same therapy. during the last years, he presented chronic pancreatitis, ards, sepsis. he had episodes of major vessel thrombosis probably due to central lines (several femoral lines and vascath placed in his thorax) and l-asparaginase. our patient did receive years of chemotherapy and radiation; and he is on complete remission. on / , , for pre-kidney transplant evaluation, a mri test was requested using gadolinium ml/kg for evaluating his vascular system (abdomen and pelvis) with inconclusive results. another mri test was requested months later using gadolinium . ml/kg. weeks later, his mother noticed brawny hyperpigmented, shiny, tightly bound-down, indurate plaques of his bilateral lower extremities, (more significantly on his lateral and posterior calves, and in his anterior and lateral thighs) a punch skin biopsy showed increasing number of fibroblastic cells and widened space between septa in the deep reticularis dermis compatible with nfd. nfd is a fibrosing disorder identified among patients with renal disease with cutaneous finding of skin thickening in extremities and trunk, very similar to those of systemic sclerosis. etiology, pathogenesis and clinical course remain unknown. the majority of cases have been reported in dialysis or kt patients and gadolinium has been identified as a trigger of nfd. in our case, there appears to be a link between the use of gadolinium and the developed of nfd. background: chronic renal failure (crf) is an independent cardiovascular risk factor. changes in calcium-phosphate homeostasis not only affect the quality of bones but also constitute the biochemical base for vascular calcification. aim: to find a method better describing factors of calcification using routine laboratory examinations and computed evaluation of complex equilibria. methods, patients: data of crf and of transplanted (tx) children were compared to a healthy control group of . tx children's parameters were taken before and and month following transplantation. three different strategies were used to analyse factors of calcification: ca x p product, ca-p activity value and the concentration of cahpo . the ca x p product and the ca-p activity value were not informative, because they didn't represent the direction of change in the complex chemical equilibrium. the cahpo concentration was increased in the crf and the tx group (before transplantation) ( . ± . mmol/l) compared to the healthy control group ( . ± . mmol/l) (p< . ). after and months to transplantation the cahpo concentration was in the normal range in the tx group. a negative correlation was found between the concentration of ica + (ionic calcium) and pth (parathyroid hormone) in the dialysed children (r= . ), but not in the transplanted group (r= . ). conclusion: according our findings the force driving calcification is better represented by the concentration of cahpo , the base compound of all primary calcification, than by measuring ca and p separately. follow-up study is needed to establish the predictive value of determination of cahpo . this study was supported by grants otka-t and ett / , the national office for research and technology (nkth) and szentágothai j. knowledge centre. introduction: acute renal failure is a rare complication of nephrotic syndrome and its cause is still unknown. several investigators reported that the most important factor for renal failure was acute tubular necrosis (atn); however, some cases did not have laboratory findings of tubular dysfunction paradoxically. patients and methods: we reviewed cases of nephrotic syndrome with acute renal failure (nsarf) since at metropolitan kiyose children's hospital. seven of cases had calcium deposition in the distal tubules predominantly. we analyzed the clinicopathological findings in these cases. results: the pathological diagnoses of these cases were as follows: minor glomerular abnormalities, mesangial proliferative glomerulonephritis (without iga deposition), and focal segmental glomerulosclerosis. interstitial nephritis was not documented in any case. the common characteristics of these cases were calcium deposits in the distal tubules. some cases had focal simplification of tubular epithelium. all cases were an initial episode of nephrotic syndrome, and cases were steroid resistant. almost all cases had hypertension. in addition, the range of urinary β microglobulin and fena were to and . to . %, respectively. discussion: in these cases, there was enhanced na reabsorption and urinary β microglobulin was only mildly elevated at the time of renal failure. these findings were not consistent with atn. additionally, pathological finding of severe tubular damages was not found on biopsy. contrarily, tubular obstructions due to ca depositions were consistent with these clinicopathological findings. conclusion: our findings suggest that tubular obstruction due to calcium deposition plays an important role in the etiology of nsarf except for atn. background: natriuretic factor was found in urine of chronic uremia for more than years. n-terminal pro-b-type natriuretic peptide (prontbnp) is postulated to be the natriuretic factor owing to its elevation in chronic kidney disease (ckd). however, salt wasting and non-saltwasting chronic kidney disease haven't been partitioned as different entities before. this study is designed to clarify whether prontbnp is different in salt wasting and non-salt wasting ckd and if it is the main causative factor of natriuresis. methods: patients with salt wasting ckd, which are mainly composed of congenital renal structure abnormalities, and patients with non-salt wasting ckd, which are mainly composed of glomerulonephritis, were collected. all of them are non-dialysis-dependent and without heart failure. serum prontbnp in these two groups and normal controls were sampled. fractional excretion of sodium (fena) and estimated clearance of creatinine (ccr) were also checked. results: prontbnp was elevated in salt wasting group compared to normal controls (p= . ). moreover, prontbnp was even significantly higher in non-salt wasting group than in salt wasting one (p< . ). in salt wasting ckd, prontbnp and fena were correlated (r= . , p= . ), but the same result was not observed in non-salt wasting group. prontbnp was significantly correlated to ccr and age using multiple regression analysis (p< . ). conclusion: prontbnp elevation was different between salt wasting and non-salt wasting ckd. volume expansion explained the difference and prontbnp elevation in salt wasting ckd resulted from other mechanisms. since salt wasting ckd, in which the influence of volume expansion was eliminated, had a good correlation between prontbnp and fena, prontbnp may be one of the major contributing natriuretic factor in chronic uremia. background: cidofovir is a new antiviral drug that has a broad spectrum of activity against a number of dna viruses. several observations reported its efficacy as topical treatment of resistant warts. we herein report a systemic complication of acute renal failure associated with such topical therapy. casereport: girl aged , received a renal transplant in and for end-stage renal failure secondary to haemolytic uremic syndrome. her initial immunosuppressive regimen consisted of prednisone, tacrolimusand mycophenolate. five years post transplant she developed chronic allograft nephropathy with mild renal impairment. as a consequence of long standing immunosuppression she also developed invalidating, widespread periungueal warts. a well conducted, aggressive, conventional management of her warts including reduction of immunosuppression failed to improve the symptoms. she subsequently received an intralesional injection of a mg/ml cidofovir solution. forty eight hours after the treatment she developed local swelling, inflammation and pain along with acute alteration of renal function. although cidofovir seric dosages performed on day , , and postinjection were negative we attributed this acute renal failure to a potential nephrotoxic side effect of cidofovir. renal biopsy showed no evidence of rejection but mild alterations of the tubes compatible with tubulo-interstitial nephritis. spontaneous recovery of renal function occurred within months. conclusion: we describe an acute renal failure as a consequence of topical cidofovir treatment of warts in the context of renal transplant with mild preexisting renal failure. topical administration of cidofovir needs as carefull use and monitoring as its parenteral administration, especially in patients with altered renal function. the hemolytic uremic syndrome (hus) is a disease characterized by microangiopathic hemolytic anemia and variable organ impairment with a predominat feature of renal failure in children. the aim of this study was to investigate the presence of plasma lipid peroxidation products in the acute phase of hus. we have analyzed the levels of lipid peroxidation, determined fluorometrically as thiobarbituric acid-reactive substances (tbars), in the plasma of patients (aged - months with a median of ) diagnosed with the shiga toxin-associated form of the disease. in all cases, tbars determinations were performed at hospital admission, during treatment and upon discharge. tbars values averaged . ± . and . ± . mm sem at admission and discharge respectively (reference value < . mm). of the patients examined, presented conserved diuresis during the course of the syndrome, while the other were anuric and required dialysis. maximum tbars values resulted significantly higher (p< . by anova followed by newman-keuls test) in the dialysis-requiring patients as compared to those that had conserved diuresis ( . ± . vs . ± . mm respectively) we also investigated a possible correlation between tbars and plasma creatinine, urea, lactate dehidrogenase (ldh) and platelet count. positive and highly significant correlations (r= . and . , p< . ) were observed when tbars values were plotted as a function of plasma creatinine and urea values respectively. no significant correlations were detected for tbars and plasma ldh values or platelet count. thus, patients affected by shiga toxin-associated hus exhibit increased levels of oxidative stress. also, there is a positive correlation between the magnitude of oxidative stress and the severity of renal failure. c. soares, j. diniz, e. lima, g. oliveira, c. camargos, b. sousa, e. oliveira objective of the study: the purpose of this retrospective cohort study was to report the clinical course of children and adolescents with chronic kidney disease (ckd) enrolled in a pre-dialysis program. methods: the records of patients with ckd admitted to an interdisciplinary pre-dialysis program from to were retrospectively analyzed. the program consisted of conservative management of children and adolescents with ckd and was conducted by an interdisciplinary team including pediatric nephrologists, pediatricians, nurses, psychologists, nutritionists, and social workers. the patients were admitted with a glomerular filtration rate (gfr) equal to or below % of the value expected for their age according to normal reference data. demographic, clinical and laboratory data at entry and at the end of the follow-up were analyzed. renal survival analysis was performed using the kaplan-meier method. results: the median age at admission was . years (interquartile range: . - . yr). the most frequent primary renal disease was congenital urological anomaly in patients ( %), following by glomerular diseases in ( %), cystic diseases in ( %), and others in children ( %). at admission, patients ( %) had ckd stage , ( %) had ckd stage , and ( %) presented ckd stage . median follow-up time was . years (iq range, . - . ). at the end of the follow-up, children presented ckd stage or ( %), patients were in stage ( . %), in stage ( %), and children were in stage ( %). it was estimated by survival analysis that the probability of ckd stage was % at years, % at years, and %at years after admission to the pre-dialysis program. conclusion: the long-term overall renal survival is relatively poor in a cohort of children and adolescents with ckd. objective: characterize the association between proteinuria and gfr in a cross-sectional study of children with mild to moderate chronic kidney disease (ckd). methods: first morning urine protein to creatinine ratios (up/c) and gfr (measured by iohexol blood-disappearance) for children enrolled in the ckid cohort study were examined using loglinear regression of proteinuria and gfr, adjusted for age, sex, body surface area (bsa), and ckd cause. conclusions: in children with mild to moderate ckd, there was a log-linear relation between proteinuria and gfr. the prospective cohort design of ckid will assess the risk of gfr decline associated with level of proteinuria in children with glomerular vs non-gn causes of ckd. objective: to study the clinical characteristics of chronic renal failure (crf) in children. the clinical data of children with crf in the last fifteen years were retrospectively analyzed. results: the first main causes of crf in children were still glomerular disease, and congenital deformities of urinary system and hereditary renal disorders were the second main causes. the initial age of children with crf which were caused by congenital deformities of urinary system and hereditary renal disorders were relatively younger than children with crf which were caused by glomerular disease. the symptoms of some crf in children were not typical. conclusions: glomerular disease were still the first main causes of crf in children. urine screening test, early renal function examination and kidney b-mode ultrasonic were attribute to early diagnosis and proper management of crf in children. the aim of the study was the evaluation of influence of clinical and biochemical parameters upon degree of impairment of cardiac function in dialysed children. methodology: chronically dialysed ( hd, pd) children participated in the study ( m, f), aged - , yrs (x= , ± . yrs). echocardiography examinations were carried out with a hp device. diastolic and systolic left ventricular (lv) dimension, ejection fraction (ef) and lv mass index (lvmi) were evaluated. mean values of estimated parameters in months preceeding echo were calculated. results: on the basis of echo examinations groups were singled out: a (n= ) of normal heart function, b (n= ) of impaired systolic and diastolic heart function and c (n= ) of normal systolic and impaired diastolic heart function. no differences between groups according age, bmi, dialysis and renal insufficiency duration were found. in group of children with severe cardiac lesion (b group) a higher lv mass (a vs b vs c: , vs , vs , g/m) and statistically significant lower ejection fraction ( , vs. , vs. , %) were ascertained. these children were anuric ( vs. vs. ml/d), their systolic ( , vs. , vs. , ) and diastolic ( , vs. , vs. , ) blood pressure were significantly higher, so was the number or hipotensive medications ( , vs. , vs. , ) . bioimpedance analysis showed overhydration in group b (tbw% vs vs . ; ecw/icw . vs . vs . ). conclusions: the vast majority of chronically dialysed children demonstrate an impairment of cardiac function mainly of diastolic parameters. anemia, malnutrition, hypervolemia, anuria and hypertension stand for a significant risk factors of cardiac impairment in dialysed children. we report here the clinical findings and prognosis of patients ( girls, boys) with infantile oxalosis diagnosed between june and december in order to remind this rare autosomal recessive metabolic disorder as the potential cause of acute renal failure in infancy. the mean age of the patients was . months (range: . - months). all patients had the complaint of vomiting since birth, had irritability, and had convulsions. seven of them had parental consanguinity ( %) and family histories revealed urolithiasis in four patients and infantile deaths in one. two patients were cousins without any other family history. all patients presented with anemia (hemoglobin: . - . g/dl), renal failure (creatinine levels: . - . mg/dl) and metabolic acidosis. abdominal x-rays showed bilateral nephrocalcinosis, renal ultrasonographies revealed normal sized kidneys with diffuse and intensive hyperechogenity and loss of corticomedullary differentiation in all patients. crystal deposition was demonstrated in fundoscopic examination of patients, bone marrow aspiration of patients, and renal tissues of patients that underwent renal biopsy. besides supportive therapy, peritoneal dialysis was performed on patients, but only one patient accepted to continue the therapy. four patients died within few months and were lost to follow-up, probably died. two patients have been followed up for months one on continuous ambulatory peritoneal dialysis. in conclusion, this rare disease with fatal outcome should be remembered and investigated in infants with renal failure and bilateral nephrocalcinosis since early combined renal and liver transplantation may be life saving if it can be performed. acute renal failure following halothane anesthesia in young child? case report we present here the case of renal failure and hepatocellular lysis that developed h after the exposure of halothane anesthesia during eye examination. previously a healthy months old boy had a cardiac arrest, during the above mentioned diagnostic procedure, therefore cpr was applied which all happened in another hospital. after a few hours he was transferred to icu at our hospital, consciousness, hemodinamic stabile. in the following hours he developed acute non-oliguric renal failure (maximal level of urea mmol/l, creatinine mmol/l), as well as hepatocellular lysis (alt u/l, ast u/l). plasmaferesis and continuous venovenous hemodiafiltration were immediately applied followed by conservative measures. the level of serum transaminase returned to the normal values within a week and the level of creatinine and urea within two weeks. fully recovered boy was released home. toxic effects of halothane anesthesia in children are reported in only few cases in the literature. objective of study: many cases of chronic aristolochic acid nephropathy (caan) in adults had been reported, but it had rarely been described in children. we reported children with caan to investigate its clinical and pathological characteristics. methods: three cases were studied retrospectively and relevant literatures were reviewed. results: three children received traditional chinese herb medicine containing aristolochic acid to months for different basal diseases including chronic aggressive hepatitis b, secondary hydrocephalus and purpura nephritis and suffered from caan from mouths to years after they began receiving the chinese medication. the main manifestations were renal failure of various degree accompanied with proximal and distal tubular dysfunctions. two of them began with anemia and suffered from serious renal failure. the onset of another case was glucosuria with renal function impaired mildly, and she presented secondary fanconi's syndrome simultaneously. their pathological characteristics were diffuse paucicellular interstitial fibrosis and marked tubular atrophy with mild glomerular impairment. after withdrawal of the chinese herb medicine, renal failure in two patients attenuated progressively. the clinical features of caan in children are progressive renal failure and renal tubular disfunction. its pathological characteristics are diffuse paucicellular interstitial fibrosis and marked tubular atrophy. therefore, we emphasize the recognition of the nephrotoxicity of traditional chinese herb medicine and prevent caan from happening in children. objective of study: recombinant human erythropoietin (rhuepo) treatment may cause pure red cell aplasia (prca), but it had been rarely described in children. in order to acquaint ourselves with this disease, we reported a boy with chronic renal failure developed prca following rhuepo treatment. methods: one case was studied retrospectively and relevant literature was reviewed. results: a -year-old boy suffered from chronic renal failure combining with renal anemia and received rhuepo treatment. two weeks later, his hemoglobin (hb) increased from to g/l, and maintained to g/l for weeks. subsequently his hb declined suddenly at a rate of g/l/day, despite rhuepo increased in dose. his reticulocyte count reduced to . /l without other cytopenias in peripheral blood. a series of laboratory examinations were performed, including bone marrow cell smear and culture to confirm his prca. because various of other factors such as parvovirus etc. induced prca was excluded, we considered the boy's prca was due to rhuepo treatment, although we didn't detect anti-epo antibodies for lacking of the reagent. the boy received erythrocyte suspension transfusion to correct his anemia and was waiting for renal transplant in the following period. conclusions: during the treatment of rhuepo, sudden and rapid reducing of hb might be a hint of rhuepo induced prca. the diagnosis should be based on the clinical presentation, the absence of red cell precursors in bone marrow and the detection of anti-epo antibodies. renal transplant and immunosuppressive therapy might be effective. m. zaniew, b. mroziñski, a. warzywoda, e. stefaniak, a. siwiñska, j. zachwieja among ambulatory blood pressure monitoring (abpm) parameters, pulse pressure (pp) provide an information on cardiovascular (cv) status. recently, a novel parameter i.e. ambulatory arterial stiffness index (aasi) has been proposed. aim: to investigate pp and aasi in relation to left ventricular (lv) geometry and carotid intima-media thickness (cimt) in children with chronic renal failure (crf). subjects: children ( f/ m; median age: yrs) with crf treated conservatively (n= ) and with dialysis (hd; n= /pd; n= ). methods: we studied demographic data, echocardiography data [left ventricular mass (lvm), left ventricular mass index (lvmi), interventricular septum (ivs), left ventricular posterior wall (lvpw), left ventricular end diastolic diameter (lvedd), relative wall thickness (rwt)], cimt and abpm. from abpm, we calculated pp [difference between systolic blood pressure (sbp) and diastolic blood pressure (dbp)] and plotted dbp against sbp (regression slope). aasi was defined as minus this regression slope. results: a positive correlation was found between aasi and pp (r= . , p< . ). aasi was correlated to lvedd (r= . , p< . ) and rwt (r=- . , p< . ). pp was related to: weight (r= . , p< . ), body surface area (r= . , p< . ), body mass index (r= . , p< . ), and lvm (r= . , p< . ), lvmi (r= . , p< . ), lvpw (r= . , p< . ), lvedd (r= . , p< . ), rwt (r=- . , p< . ). neither aasi nor pp was associated to cimt. children with lv hypertrophy had higher pp than without this alteration (p< . ). when data analyzed across quartiles of pp, children in the upper quartile showed higher lvm (inter-group comparisons p< . ), lvmi (p< . ), lvpw (p< . ) and lvedd (p< . ). conclusions: pp is a stronger predictor than aasi of lv geometry in children with crf.. acute renal failure in newborn period may be caused by prenatal, natal and postnatal factors. among them, obstructive lesions of the genital tract (e.g. imperforate hymen and vaginal atresia) are very rare. children with hydrometrocolpos due to distal vaginal atresia may present with severe obstructive uropathy and its consequences. hydrometrocolpos is the result of vaginal obstruction and can become an emergency in newborn period. acute renal failure associated with distal vaginal atresia appears to be rare, with only one report in the paediatric literature. here we report a -dayold infant with a hydrometrocolpos causing life-threatening renal failure. percutaneous drainage did result in dramatically improved clinical and laboratory findings of the patient. objectives of study: sympathetic overactivity is currently considered as an important mechanism of both development and progression of chronic renal failure. however, this statement was mostly based on the researches in which the participants were adult patients with terminal renal failure. little information is available on autonomic changes in pediatric patients with mild renal insufficiency. our aim was to determine whether there is sympathetic activation in children with chronic pyelonephritis in a stage of mild renal insufficiency. methods: patients met the inclusive criteria were selected and assigned into two groups according to the creatinine clearance. group i had patients with creatinine clearance between and ml/min/ . m while group ii have patients with normal creatinine clearance. baseline of age (from - years old), gender and diagnosis between the groups are comparable. time domain analysis of heart rate variability in short-term recordings of minutes was performed in both groups. as well vain questionnaire for assessment of autonomic state was performed in all participants with their parents help. results: the outcomes of heart rate variability analysis showed sympathetic overactivity of . % patients in group i vs . % in group ii, and the difference is statistically significant (t= . , p< . ). significant difference was also found in results of vain questionnaire: . % of patients in group i were estimated as "sympathetic", while only . % in group ii (t= . , p< . ). conclusions: based on the consistent findings of the two methods used in this study, we conclude that sympathetic overactivity may be found in children with even mild renal insufficiency, and it should be considered as an early event in the development of pediatric renal failure. the aim of this study was to describe the prevalence of myocardiopathy in pediatric patients with different stages of ckd (stages to ).methodology: inclusion criteria -gfr < ml/ . m , ckd treatment > months, age < years old. echocardiograms were performed using standard techniques. left ventricular mass (lvm) was measured by two-dimensional directed m-mode echocardiography according to the american society of echocardiography criteria. lvm index was assessed and when > g/m . it was considered severe hypertrophy. the relative wall thickness (rwt) was measured to assess the lv geometric pattern. age, high blood pressure (hbp), anemia, time and type of treatment were compared to the echocardiographic findings. results: we evaluated patients, mean age years old, % on pre-dialysis, % on hemodialysis (hd) and % on peritoneal dialysis (pd). patients on hd were evaluated in the interdyalitic period. twenty-seven patients ( %) had myocardiopathy, clvh in ( %), elvh in ( . %) and cr in ( %). severe hypertrophy ocurred in pacients ( . %). there was no significant difference in relation to age and high blood pressure. patients with clvh were on hd for longer time and had a lower hematocrite when compared to the patients without clvh ( ± vs ± months; p< . ) and ( ± vs ± ; p< . ) respectively. there was a significant correlation between hematocrite and left ventricular mass (r = . ). conclusion: we observed a high prevalence of myocardiopathy in this study population. the risk factors associated to clvh were anemia and time on hd. larger and prospective studies are needed to analyze the impact of myocardiopathy in the cardiovascular mortality in children as well as the results of interventions applied to correct these risk factors. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . urological problems such as vesicoureteral reflux ( , %), obstructive uropathy ( , %) and neurogenic bladder ( , %) were the leading underlying conditions causing cri with a total of , %. while majority of the patients were having gfr levels less than ( , %) or between to ml/min/ , m ( , %), gfr level was between - in only . %of the patients. patients with pth levels between - and more than pg/ml comprised the majority ( , and % respectively). the gfr levels correlated positively with hemoglobin/hematocrit and calcium levels and negatively with phosphorus and pth levels (p< . ). renal replacement therapies were initiated in , % of the patients. the most striking result of this study is the predominance of vur or related urological problems that are relatively preventable as the underlying causes of cri in children. early diagnosis and appropriate medical or surgical management of these conditions should be emphasized together with achieving broader coverage of the pediatric cri population in terms of supportive treatment. twin-twin transfusion syndrome (ttts) complicates up to % of monochorionic twin pregnancies. shunting of blood between twins through common placental blood vessels can cause growth restriction, oligohydramnios and anaemia in the donor twin. renal impairment in the donor twin has been reported as a transient phenomenon with full recovery. we describe a case series of three children with chronic renal failure due to ttts. all cases were monochorionic diamniotic twins. in cases and , growth discrepancy was noted on prenatal scanning. in the case anomaly scans were normal. gestation at birth ranged between and weeks. in all cases there was a significant birth weight discrepancy between twins. post-natal ultrasound appearances were variable: case had normal scans within the first month but echogenic kidneys at months; case had initial increased echogenicity but features consistent with cortical necrosis at weeks; case had small kidneys with no cortico-medullary differentiation. all children became dialysis dependent within the first year of life. age of commencement ranged from days to months. case was successfully transplanted at years. case had an unsuccessful transplant at years and remains on dialysis at years. case remains on dialysis at years. cases and are now at mainstream school with only mild learning difficulties; case has some gross motor delay but other wise normal development. with advances in neonatal intensive care and improved survival of low birth weight babies, this presentation may become increasingly common. even severe renal involvement can occur in the absence of other significant hypoperfusion injury. the management of survivors of ttts with established renal failure may present unique challenges and opportunities. introduction: endothelial heparan sulfate proteoglycans (hspg) play an important role in various biological processes in the renal glomeruli. it is involved in the inflammatory process by acting as a ligand for l-selectin. furthermore, leukocytes are able to interact with chemokines bound to hspg (examples are il- , rantes and mcp- ). this will lead to activation of the integrins on leukocytes and result in more stable leukocyte-endothelial wall adhesion. in this work, we have studied the effect of a subtoxic dose of shiga-like toxin (stx) and on the hspg and the possible implications on the pathogenesis of the hemolytic uremic syndrome (hus). methods: to study this effect, primary human umbilical venous endothelial cells (huvec) and primary human glomerular microvascular endothelial cells (gmvec) were incubated for hours with a subtoxic dose of stx or . then, cells were treated with the enzyme heparinase (which cleaves off hspg). non-treated cells were used as controls. after treatment with the enzyme, the endothelial cells were exposed to flowing human leukocytes in a parallel plate flow chamber. the amount of adherent leukocytes was calculated. -: not treated with heparinase , +: treated with heparinase conclusion: stx and cause an upregulation of the amount of adhering leukocytes on both endothelial cell types. treatment of the endothelial cells with heparinase decreases markedly this upregulation. the effect can not be detected without stx-incubation. this can be explained by a possible upregulation of hspg on endothelial cells by stx, resulting in a higher level of bound chemokines or an increased binding of released chemokines to hspg. this will lead to an increased adhesion of leukocytes and will induce a more severe inflammatory process in the renal endothelium. this effect will contribute to the devastating pathogenesis of the hus. c. soares, j. diniz, e. lima, g. oliveira, c. camargos, b. sousa, m. almeida, e. oliveira objective of thestudy: the purpose of this study was to identify clinical, nutritional and laboratory factors associated with the rate of progression of chronic kidney disease (ckd) among the children and adolescents admitted to a pre-dialysis interdisciplinary program. methods: one hundred eight children and adolescents aged months to years with ckd in conservative management were prospectively followed up from to . renal survival was analyzed by the kaplan-meier method and cox's regression model. a multivariate model was developed from the admission until occurrence of ckd stage (glomerular filtration rate < ml/min). the following data were obtained at admission: gender, race, age at admission, weight z score, renal primary disease, blood pressure, and laboratory data (serum creatinine, serum urea, glomerular filtration rate, hr urinary protein excretion, hematuria). results: median follow-up time was . years (iq range, . - . ) and patients ( %) progressed to ckd stage . in the univariate analysis the following variables were significantly associated with the event: non-white race (p= . ), age > years (p= . ), ckd stage at baseline (p= . ), renal primary disease (p< . ), severe proteinuria (p< . ). after adjustment, variables remained as independent predictors of ckd stage : severe proteinuria (rr= . , % ci= . ± . ), glomerular disease as renal primary disease (rr= . , % ci= . ± . ), and ckd stage at baseline (rr= . , % ci, . ± . ). conclusion: the combination of three factors -severe proteinuria, glomerular disease, and ckd stage at admission -was an independent indicator of adverse outcome in children and adolescents in a pre-dialysis interdisciplinary program. background: allogenic hematopoetic stem cell transplantation (allo-hsct) has gained world wide acceptance as a treatment for various diseases. renal dysfunction is one of the major complications that influences transplant related mortality (trm) rates following hsct. in this prospective study, we aimed to investigate the effect of allo-hsct on renal function in children. methods: renal ultrasonography, dmsa scintigraphy, analysis of renal and tubular function tests were performed before, shortly and -year after hsct. acute renal toxicity (art) was classified according to bearman criteria. grade =increase in creatinine up to twice the baseline; grade =increase in creatinine above twice baseline; grade =increase in creatinine above twice baseline and need for dialysis. chronic renal insufficiency (cri) was defined as gfr< ml/min/ . m and failure (crf) as need for dialysis. results: between april and june , children (median age: . years) underwent allo-hsct because of hematologic disorders (malignancy, ; hemoglobinopathy, ; aplastic anemia, ). all patients except one received nontbi conditioning regimen. six patients ( . %) were died because of trm but none of these patients had primary art. during the first days, patients ( . %) had grade art (csa nephrotoxicity in , vod in patients). grade art was defined in patients ( . %) (vod in , sepsis in , csa nephrotoxicity in patient). eleven patients had structural renal abnormalities before hsct, of them persisted and new patients had pathologic results one year after hsct. in long term period, ( . %) of evaluable children had cri and no patient had crf requiring dialysis. conclusion: renal dysfunction was found to be a frequent complication after allo-hsct in children. therefore, renal functions should be followed carefully in these patients. . years and at the end of follow-up, and compared between the three groups. there were no significant differences between groups in so far as gender, underlying disease, age at diagnosis, proteinuria, hypertension, hyperparathyroidism, use of ace inhibitors or renal size. erithropoietin use was significantly higher (p< . ) in group . gfr improved in all three groups during their first two years of life. the cut-off point on the roc curve indicating worse gfr long term evolution was ml/min/ . m at two years of life (sensitivity %, specificity %). g. zilleruelo, am. onder, j. chandar, o. nwobi, c. abitbol background: catheter-related bacteremia (crb) is a common complication of tunneled-cuffed hemodialysis catheters. our objective was to investigate the effectiveness of tissue-plasminogen activator-tobramycin locks (tpa-abl) in preventing crb in pediatric patients. methods: a retrospective analysis of pediatric hemodialysis patients was performed. patients with > crb/ catheter days (cd) were designated as high risk. those with < crb/ cd were of average risk. three eras of consecutive months were studied. in era , high risk patients were detected. during era , the high-risk group was placed on times weekly prophylactic tpa-abl. in era the high-risk group was given once weekly tpa-abl. results: there was a significant decrease in the rate of crb with prophylactic tpa-abl which was more pronounced when given three times/week. conclusions: the use of prophylactic tpa-abl times weekly significantly reduces the rate of crb in patients at high risk. prophylaxis once weekly may be less effective than thrice a week. l. was born after a normal pregnancy without a special personal or familial history, was seen at the age of years, after a days long ordinary oro-pharyngeal viral infection treated by symptomatic treatments. he presented with inflammation of the left cheek with slight fever ( °) and a sole purpuric lesion of the left leg ( cm) and some petechiae on the thorax. blood count showed haemolytic anemia (haemoglobin= g/dl, schizocyte= %, increased ldh), white cells ( % neutrophils) and platelets. no germs were found in hemoculture, lumbar punction, stools or urines cultures. creatininemia was μmol/l. in the following hours, despite immediate antibiotics administration and without any shock sign, several purpuric extensive necrotic lesions appeared, renal insufficiency increased (creatininemia= μmol/l), platelets count decreased to and markers of diffuse intravascular coagulation dramatically increased. in the following days, proteinuria, macroscopic hematuria and hypertension appeared. after days on anticoagulation therapy, renal function remained stable while anemia, thrombopenia and coagulation disorders persisted. coagulation factor tests demonstrated a heterozygote deficiency of factor v leiden (also found in the father) and an acquired protein s deficiency secondary to streptococcal infection. after protein s infusion and plasma exchanges, his state improved and necrotic lesions ceased. this initial hematologic and renal presentation could have suggest a hus but the large purpuric lesions remain unusual in such pathology. a in children on chronic peritoneal dialysis malnutrition is being diagnosed with an objective combined nutritional score (abn score) based on anthropometry and bioimpedance analysis indices (nephrol dial transpl ; : - ) . aim of this study was to investigate the prevalence of malnutrition and the main factors associated with it in children with ckd - . we planned a cross-sectional study of children with ckd - , mean age . ± . years, who underwent controls in our institution between september and december , . the data of abn score, age, primary renal disease, standard blood and urinary tests, and estimated gfr (schwartz formula) were collected.the prevalence of malnutrition (abn score < . ) in the whole population was %. the abn score was positively correlated with age, height sds, serum hemoglobin, total protein and albumin (p value from < . to < . ), while a negative correlation was found with serum phosphate and proteinuria (p< . ). patients with steroid-resistant nephrotic syndrome had lower abn score values than those with other primary renal diseases ( . ± . vs . ± . ; p< . ). the percentage of children with malnutrition in the different stages of ckd increased in parallel with the decrease of gfr, from % in the ckd group to . % in the ckd group. in conclusion, the prevalence of malnutrition in children with ckd - is not negligible. low hemoglobin, total protein and albumin levels and high serum phosphate and urinary protein excretion, particularly in small children with growth impairment, strongly suggest the need for an in depth nutritional assessment, in order to diagnose malnutrition and treat it accordingly. e.c. developed atypical hus at months of age. a heterozygous factor h gene mutation was found. despite plasma-exchange treatment numerous relapses led the child to ckd stage : creatinine clearance (ccr) . ml/min/ . sqm according to schwartz formula. at yrs we started a programme of fresh frozen plasma (ffp) infusions, - ml/kg bw. the child was poliuric and hypertensive, notwithstanding the treatment with ramipril, amlodipine, clonidine and furosemide. in the first months he received ffp every days. mean ccr during this period was . ± . ml/min/ . sqm. haptoglobin (hap) was still < mg/dl in / tests ( . %), ldh was increased ( . ± . u/l), hemoglobin and platelet count were always in the normal range. the treatment schedule was then changed to ffp every days for the next months. during this period, ccr was significantly higher ( . ± . ; p< . ) and ldh significantly lower than in the first months ( . ± . ; p< . ); haptoglobin was always > mg/dl. no differences between the two periods were found for hemoglobin, platelet count, proteinuria, microalbuminuria and blood pressure values. both in the first and the second period, ccr was negatively correlated with ldh (r . , p< . ) and with the bioimpedance analysis (bia) measure of resistance, which is an index of body hydration. in conclusion: . the only signs of disease activity in atypical hus can be minor abnormalities in laboratory tests, such as increased ldh and decreased haptoglobin levels; . ffp infusions are useful in maintaining hus remission and preserving kidney function, provided that the treatment schedule is optimized; . bia is useful in monitoring hydration status of children with ckd, especially those with poliuria and under ace-inhibitors, as it allows for the correct interpretation of serum cr values. analgesic-antipyretic agents are commonly used medications worldwide for the treatment of pain and fever in children. acute renal failure is commonly seen in adults after treatment with analgesicantipyretic agents. this complication has rarely been reported in children. two patients, ages and years were admitted with a diagnosis of acute, non-oliguric renal failure. one had symptoms of upper respiratory tract infection, and the other had been suffering from vomiting and abdominal pain. appropriate evaluations including detailed history especially the history of drug ingestion, physical examination, and measurement of serum creatinine concentrations were performed in the emergency department. both patient had ingested analgesic-antipyretic agents (mefenamic acid, and paracetamol) before the onset of acute renal failure. none of the patients had previous history of renal disease or concomitant treatment with other drugs. none had oliguria or anuria, dehydration, abnormal serum electrolyte concentrations, or evidence of glomerulonephritis. microscopic hematuria and leukocyturia were found in one patient. serum creatinine was . and . mg/dl at presentation. both of them recovered completely within a week. we emphasize that clinicians must be aware of renal toxicity of analgesic-antipyretic drugs with low doses. with the increasing use of over-the-counter analgesic-antipyretic agents, this association may become more prevalent. cardiovascular disease is a main cause of morbidity and mortallty in patients with chronic kidney disease (ckd). the pathophysiology of cardiovascular disease (cvd) in ckd remains uncertain but nowadays sympathetic hyperactivity is recognized as an important mechanism involved. this observational and transversal study of patients from five to years old, submitted to dialysis or at least four months after kidney transplantation (ktx), without signs of transplantations rejections, with definite ckd and creatinine clearance of ml/min or less. the subject (median age= years; . % female) were classified accordingly with treatment modality: conservative (n= ), peritoneal dialysis (capd) (n= ), hemodyalisis (n= ) and renal transplantation (n= ) submitted to l-metaiodobenzilguanidine ( l-mibg) planar and tomography scintigraphy and heart rate variability (hrv). comparisons among groups were made using anova and the association between variables was assessed using spearman's correlation coefficients and bonferroni correction was used during multiple comparisons testes. a p value < . was considered significant. hemodialysis patients presented increased cardiac washout (p= . ), heterogeneous pattern of l-mibg distribution (p= . ) and lower values of low frequency component of hrv (p= . ). capd subjects had reduced lung washout (p= . ). the cardiac washout had positive correlation with pth and negatives correlation with creatinine clearance. there was a significant negatives association between the rr interval in low frequency (lf) and cardiac washout. the uremic cardiac disautonomia might be characterized by decreased low frequency component of hrv and increased l-mibg washout and heterogeneous distribution pattern by left ventricular walls; these abnormalities subsided after ktx. d+hus is the main cause of acute renal failure in children. extrarenal manifestations are associated in more than % of the cases. hus causes toxin mediated endothelial cell damage, resulting in thrombotic microangiopathy and intraluminal thrombosis of small vessels, with subsequent tissue ischemia and necrosis of involved organs. a -year-old boy has been admitted for d+hus associated with escherichia coli o diarrhea. he presented with renal failure and hypertension requiring hemodialysis for days, hemolytic anemia ( g/dl, schizocytes %) requiring blood transfusions, severe thrombopenia ( g/l) and hyperleucocytosis ( /mm ). severe hemorragic colitis with duodenitis required prolonged parenteral nutrition. at days after onset, the child presented with confusion, slurred speech followed by loss of consciousness associated with major hyperglycemia ( mmol/l) and elevated corrected natremia ( mmol/l) without ketosis requiring transfer in intensive care unit (icu). continuous hemofiltration associated with insulin therapy ( . ui/kg) was then established with slow decrease of natremia and serum glucose within hours. neurologic condition rapidly improved. serum amylase and lipase were normal. insulinemia at the same time as the highest hyperglycemia was low ( , ui/ml), and search for human insulin, islet cell and glutamic acid decarboxylase antibodies were negative. insulin therapy could be discontinued within days. at the last follow-up, months later, neurologic examination, serum glucose and glomerular filtration rate were normal. in conclusion: / hyperglycemic hyperosmolar coma is a severe complication yet never reported in d+hus; / continuous hemofiltration with constant monitoring of biologic parameters could avoid permanent lesions due to rapid correction of this major metabolic unbalance. chronic renal failure (crf) can interfere with the regulation and time dependent secretion of multiple hormones. adrenocortical function in children with crf is examined in a few studies with a limited number of patients, and the results are controversial. in this study our aim is to evaluate adrenocortical function in basal and stimulated conditions, and to determine the relationship with the glomerular filtration rate (gfr), etiology and duration of crf in a larger group of patients. sixty-one patients with crf ( f, m; mean age . ± . years) were studied. the patients were grouped according to etiology [structural abnormalities (n: ), glomerulonephritis (n: ), others (n: )], duration of crf [ - (n: ) , - (n: ) and > months ( )] and gfr [ - (n: ), - (n: ), < ml/min/ . m (n: )]. cortisol levels were measured at : a.m. (basal cortisol) and : p.m. low dose acth test ( . micg/m synacthen iv) was performed. delta cortisol was calculated as peak cortisol minus basal cortisol during the acth test. diurnal rhythm is accepted to be preserved if : a.m. cortisol/ : p.m. cortisol is greater than two. basal cortisol levels and peak cortisol response to low dose acth is similar in all groups. median levels of delta cortisol found to be higher in the gfr< ml/min/ . m group; p= . . diurnal rhythm seems to be more preserved in the gfr - ml/min/ . m group (% ) compared to gfr< group (% ); p= . . no correlation was found between the basal, peak and delta cortisol, gfr and duration of crf. our preliminary results have shown that there is no difference in the basal and peak cortisol levels between all groups. this is the first study in children showing that adrenocortical function is preserved in groups with gfr levels between - ml/min/ . m . objective: this study was we evaluated bk virus and jc virus in urinary after renal transplantation. methods: because these polyoma viruses are excreted in urine, these patients ( females and males, . ± . years old) was analyzed by polymerase chain reaction. all patients were living donor renal transplantation from a parent. results: two patients have detected bk virus in urine. as the type of immunosuppressive treatment, one had tacrolimus and mycophenolate mofetil, and one more had methylprednisolone and tacrolimus. seventeen percent of the patients had quantifiable bk virus-dna in urine. thirty-three percent of the patients had quantifiable jc virus-dna in urine. there was non significant relationship between these polyoma viruses in urine and the type of immunosuppressive treatment. no patients developed interstitial nephritis during the study. conclusions: the activation of bk virus and jc virus does not seem to be related to the type of immunosuppressive treatment. the pathogenetic role of polyoma virus infection in renal transplantation recipients further researches are needed. background: urinary tract infection (uti) due to neurogenic bladder, secondary to large spina bifida as myelomeningocele, is well known, but the association of small occult spina bifida (sbo), having normal physical examination, with that of infection has not been reported. we studied the frequency of spina bifida occulta in children with urinary tract infection. method: the kub of voiding cystouretrography in patients ( f, m) with average of age year (± . sd), who referred to radiology department of ali asgar children hospital for uti, were observed for sbo. all patients had normal physical examination. chi were used to find the frequency of the level of sbo and the differences respectively. p< . was considered significant. result: out of patients had sbo. the order of frequency of the level of sbo was s ( %), l ( , %), s s ( , %), l s ( , %), and l s s ( %). patients had vesicoureteral reflux (bilateral in cases, at left and at right side). the severity of vur was % grade (g) ii, , % g iii, . % g iv, and . % g i. spina bifida occulta was detected in out of patients with vur. this difference was not statistically significant (p= . ): conclusion: the high frequency of lumbosacral sbo in the patients with urinary complaint may imply some lower urinary tract dysfunction in these patients although we need a control study in normal children. we evaluated interleukin- and interleukin- levels in the urine of children with renal scarring, with vesicoureteral reflux ( / , group a ) and without vesicoureteral reflux ( / , group a ) and in the urine of healthy children (group b). none of the children had urinary tract infection for the last ten months. interleukin- and interleukin- were determined using a commercially available human enzyme-linked immunosorbent assay kit. results: urinary interleukin- levels were below the lower detection limit in all samples. interleukin- levels were detectable in all urine samples of children with renal scarring and below the detection limits in the urine samples of healthy children. there were no statistically significant differences between urinary interleukin- levels in children with and without vesicoureteral reflux. there is a relationship between the grade of renal scars, the time past from their development and the urinary levels of il- . the introduction of mycophenolate mophetil (mmf) was an important advance in immunosuppressive therapy but its use is associated with gastrointestinal intolerability (gi) requiring dose reductions or drug interruptions. enteric coated mycophenolate sodium (ec-msp) was designed to improve mycophenolic acid (mpa)-related gi by delaying the release of mpa until reaching the small intestine. at present, its immunosuppressive activity in pediatric renal transplant with gi has not been clarified. we studied trough levels of active metabolite mpa (c ), changes in kidney function, mixed lymphocyte culture, cytotoxic antibodies as well as cytotoxic response before and after months of the conversion from mmf to ec-mps in renal transplant recipients with gi. in the immunosuppressive protocol used: mmf, tacrolimus and corticosteroid, mmf ± mg/m /day was replaced by ec-mpa ± mg/m /day. after months of treatment with ec-mpa, the incidence of gi decrease to . %. the levels of mpa were about % higher on ec-mps ( . ± . ug/ml) compared to mmf administration ( . ± . ug/ml). serum creatinine, creatinine clearance and urinary protein excretion did not change ( . ± . to . ± . mg/dl, . ± . to . ± . ml/min/ . m and . ± . to . ± . gr/ hr, respectively). also, during ec-mpa, proliferative response and cytotoxic antibodies showed no significant change. the release of il- was striking augmented with mmf or ec-mps therapy, but interferon-γ and tnf were low under both treatments. our data indicate that conversion from mmf to ec-mps leads to an improvement in gi without altering key elements of immunosuppression. however, the monitoring of mpa before and after conversion should be appropriated to the optimization of therapy efficacy. re. munarriz, ju. arakaki, ce. munarriz pediatric clinic, pediatric nephrology, buenos aires, peru objective: to describe the results of a program of chronic ambulatory peritoneal dialysis (capd) in children in peru by means of conventional indicators. methods: children ( , % male) were included in a longitudinal descriptive study. the average age was , ± , years (rank of , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . % were from lima (the capital city) and % came from other cities of the country. primary glomerulonephritis ( , %) was the main cause of the renal insufficiency. we evaluated the program from to . results: the average weekly kt/v was , ± , . the average dose of erythropoietin (epo) was ui/kg/week. % of the patients had average annual albumin of more than , gr./dl. the average annual protein catabolism index (icp) was , ± , gr/kg/d. the weight/age, height/age, weight/height z scores at the beginning and at the end were . / . , - . / . , - . / , - . / . , . / . - . / . , respectively. the average hematocrit was . ± . %. the rate of peritonitis adjusted for the period was , episodes/patients-year ( episode every months) and the mortality for the same period were %. conclusions: the indicators evaluated in our patients are according to the results of the international literature. is repeated urine culture essential after antibiotic therapy in uti in thai children? background: in , the american academy of pediatrics recommended for uti treatment, that urine culture be repeated only in children < years with fever > hours, since the chance of a positive urine culture in other children is very low. objective: to evaluate the cost-effectiveness of repeated urine culture after antibiotic therapy in childhood uti. patients and methods: a retrospective review of the records of children diagnosed with uti in songklanagarind hospital from jan -dec , . results: there were patients total, of which were excluded due to no repeated urine culture. patients with uti episodes were analyzed ( boys and girls). ( . %), ( . %) and ( . %) patients aged < , - and > years respectively. ( . %) had a repeated urine culture with significant growth. multivariate analysis showed that age < year, etiologic agents psuedomonas aeroginosa or enterococci spp., fever > hours and kub anomalies were the most significant risk factors for positive repeated culture, while vur and recurrent uti episodes were not significant risk factors. if we consider that a child who has at least one of the above risk factors should have a repeat urine culture, then cases ( . %) will require repeating urine culture and x . =$us . will be saved and ( . %) positive repeated urine culture will be missed. conclusion: our study in a group of thai children indicates that repeated urine culture after antibiotic therapy is still recommended. our aim was to find out if there are any signs of renal scarring and reduced renal function without recurrent uti in patients with obstructive pyelonephritis. there were investigated children ( - y) with - years passed after diagnosis of obstructive pyelonephritis. these patients were investigated during years long period without uti. all the children had a treatment with nitrofurantoin during season viral infections. we investigated excretion with urine of the collagen product (hydroxyproline) and activity of lisosomal enzymes (b n-acetilglutamase, elastase, pseudocholiesterase). as a control group, healthy children of the same age were investigated. our result demonstrates the decrease of the level in urine of collagen product and lisosomal enzymes and normalization of tubular and glomerular functions during years remission of pyelonephritis. prevention of recurrent uti and maintenance of the remission of pyelonephritis leads to the decrease of sclerosing processes on kidney. regular dialysis induces insecurity and special psychological problems associated with staff-, machine-and artificial material-dependence. the more severe the child's physical problems are the more probable is developing of emotional disorders, a sense of loneliness and an exaggerated dependence on the parents and staff. a psychological and social study of children on regular dialysis was performed. there were girls and boys, aged - (mean: ) ys. two children ( %) are exclusively treated with haemodialysis, ( %) are on peritoneal dialysis and in ( %) both methods interchanged. somatic concomitant disorders are present in ( %) of children. among psychological disorders, an inclination to unsociability, autoaggression or aggression towards the immediate environment has developed in children ( %), ( %) do not like talking about disease while ( %) are communicative and sociable. psychosocial characteristics showed: emotional difficulties (anxiety, mild depression) in %, feeling of being physically different from peers (short stature, less physical ability) in %, lowered self-esteem and social isolation as a result of school absenteeism in %. overprotection of parents was presented in %. different psychological changes were present in some children. of the children are of school age: ( %) attend special schools and the remaining follow regular education programs. with the help from their teachers, children on dialysis can master regular school programs, in spite of the time spent on dialysis. a good and continuing co-operation of dialysis staff and sick children and their parents as well as a more intensive co-operation with psychologists and teachers are necessary to reduce psychological disorders and promote a better adaptation to the life of their healthy coevals. we report a -year-old girl with syndrome frasier who developed b cell lymphoma within nine month after live related kidney transplantation. in induction therapy we applied atg up to days, mycophenolate mofetil and cyclosporine. routine abdominal ultrasound revealed multifocal hypoechogenic changes in liver and spleen. computed tomography showed diffuse focuses of changed liver tissue in length up to . cm, precontrast density of - hu and postcontrast of - hu. in spleen there were three similar changes (up to . cm). after surgical biopsy of liver, patohistological examination confirmed diffuse large cell b lymphoma (cd positive, moderate risk). pcr ebv was positive. we immediately started with ganciclovir intra venously and decreased cyclosporin and mmf (within two weeks) up to completely exclusion from therapy. in the same time we increased prednisolon on mg daily. after weeks from beginning ganciclovir she treated with rituximab, one dose of mg every week (five weeks). repeated abdominal ultrasound and two controls computed tomography showed markedly regression of tumorous lesions. after . months of last rituximab doses scan showed normal spleen and liver findings. all lesions were resolved. in two occasions she developed severe leucopenia without any infection complication. she still has got moderate lymphopenia due to continual ganciclovir therapy. during this period ( months) of illness course she treated with ganciclovir intravenously due to repeated ebv reactivation (positive pcr). despite enormous reduction in immunosupressive therapy renal function remain stabile without episodes of acute rejection. - . years) . the most of them, % ( patients) received graft from live related donor. % of patients had preoperative dialysis and % were preemptive. the mean waiting period for transplantation was months (range to months). congenital anomalies of kidney and urinary tract were the most common underlying diseases ( patients), then nephrotyc syndrome ( patients), hereditary nephritis ( patients), polycystic kidney disease ( patients) and others. daclizumab was the most commonly used as immunosuppressive induction agent and the maintenance immunosuppressive therapy consisted of azathioprine or mycophenolate mofetil (mmf), cyclosporine or tacrolimus and prednisone. two patients had immediate postoperative surgical complication and graft loss due to thrombosis of a. renalis and donor tubular necrosis respectively. three patients had delayed graft function; two of them underwent cadaveric transplantation. one patient had recurrence of primary kidney disease only few days after transplantation and graft loss after one year. other patient lost the graft after years due to noncompliance and chronic cellular rejection. after one year of follow-up graft survival rate is % and patient survival rate %. at the end of follow-up (mean range . months), patients had normal, patients slightly decreased renal graft function. catch-up growth was seen during the first year after transplantation from mean height sds of - . to . . the mean goal of our further intention is improvement of cadaver renal transplantation. j. lee, y. shim, s. lee objectives; although the variable risk factors of urinary tract infection (uti) in children such as virulence factors of the pathogenic bacteria and vesicoureteral reflux are already well known, the role of normal flora clononizing the intestinal tract and genitourinary tract is not fully understood. the change in colony forming units (cfu) of lactobacillus in chidren with uti is primarily investigated to explore the role of lactobacillus, one of the human normal flora, in development of uti. methods; lactobacillus was cultured from stool, urine, and periurethral or vaginal discharge of febrile infants with uti. those with confirmed uti by the suprapubic urine culture were classified to uti group (n=- ), and those with negative urine culture and confirmed viral illness were classified to control group (n= ). lactobacillus was anaerobically cultured in dico rogosa sl agar (becton, dickinson and company, usa) for hours at °c. results: the cfu of lactobacillus in stool was correlated with those in periurethra, vagina and urine (p< . ). the cfu of lactobacillus in stool was significantly lower in uti group than in control group ( , ± , vs , , ± , , , p< . ) . the cfu of lactobacillus in periurethra or vagina was significantly lower in uti group than in control group ( , ± , vs , ± , , p< . ). the cfu of lactobacillus in urine was significantly lower in uti group than in control group ( ± vs , ± , , p< . ). the cfu was distributed mostly at low level in uti group, which was significantly different from that in control group (p< . ) conclusions; the cfu of lactobacillus in stool, periurethra, vagina and urine is low in infants with uti. it is suggested that lactobacillus has a role in the development of uti. pediatric small bowel transplantations are associated with pronounced electrolyte inbalances in the posttransplant period. we investigated the sources of possible electrolyte losses. our hypothesis was that electrolyte inbalances after intestinal transplantation might be augmented by fk (tacrolimus) mediated renal toxicity rather than short bowel syndrome alone. we retrospectively reviewed eleven living-related small bowel transplantations between october and december . the data collected included frequent serum and urine electrolyte profiles, renal function parameters, enterostoma electrolytes, and fk levels in the postoperative period up until either discharge or graft loss. we analyzed pearson's correlations between fk levels, serum electrolytes, renal function parameters, and also fractional excretions (fe). in order to investigate possible delayed nephrotoxic effects of fk , we correlated all values of the same day as well as with fk levels of , , and hours earlier. furthermore, we analyzed our data stratified by fk dosing ranges. our results show decreased gfr and prominent increase of renal sodium, phosphorus, and magnesium losses along with rising fk levels, suggesting this pathway as a major contributor to their imbalances. furthermore, fk levels were associated with serum calcium and phosphorus decline, though urinary calcium excretion was not significantly changed. signs of renal toxicity are apparent within the first hours of fk challenge. our data suggest that fk mediated nephrotoxiticy is a significant contributor to electrolyte imbalances observed after small bowel transplantation. objectives of study: urinary tract infections (uti) are common in children and c-reactive protein (crp) in serum is often used to evaluate the severity of the renal inflammation. recently it was demonstrated that crp can be produced locally in the kidney. we therefore measured the crp concentration in both serum (s-crp) and urine (u-crp) from children with uti to evaluate the extent of local production and the usefulness of measuring u-crp for diagnosis of inflammatory kidney disease. methods: children ( boys) with uti were studied (median age . years, range days- years). children had fever . °c or more. the uti was caused by e.coli in patients. all children were examined within a few days of diagnosis by dmsa scan for evaluation of renal function. as controls were used children with respiratory infection (pneumonia in most) and elevated s-crp in whom uti was ruled out by negative urine culture. u-crp was measured in a commercial hscrp elisa. normal value was < mg/l results: in the uti patients, the median s-crp was mg/l (range - ) and u-crp mg/l (range - ). there was a significant correlation between the s-crp and u-crp concentrations (< . ). dmsa scans were abnormal in ( %) uti patients. the proportion of abnormal scans increased significantly with the crp concentration in both serum (< . ) and urine (< . ). all control patients had increased s-crp concentrations (median mg/l, range - ) but the median u-crp was . mg/l (range - ). the u-crp in the patients with uti was significantly higher than in the controls with other infections (< . ). conclusions: our data strengthens the concept that crp can be produced locally in the kidney during uti. the usefulness of measuring u-crp to evaluate inflammatory kidney disease needs to be tested further. s. paunova, a. kucherenko, i. smirnov, g. serova, i. donin, l. revenkova, n. goltsova in order to reveal the role of cytokines in renal tissue damage in infants with urinary tract infection (uti) patients aged from to months were examined. in all of them inflammatory markers (esr, crp, leukocyte count), urine concentration of tumor necrosis factor-α (utnf-α) and transforming growth factor-β (utgf-β) standardized to urinary creatinine concentrations were evaluated. two groups of patients were determined: ) with uti and normal urodynamics (n= ), ) with uti and urodynamic disorders (vur, hydronephrosis) (n= ). healthy infants were used as controls. as a result, all the patients demonstrated significantly elevated utnf-α, utgf-β creatinine ratio in comparison with controls (p< , ) with no difference between groups. but children with normal urodynamics (from the st group) presented with severe uti ( st -a) showed urine tnf-α tgf-β creatinine ratio in , times higher than other patients of st gr and close to nd gr. data ( st gr.-utnf-α/ucr= , ± , , utgf-β/ucr= , ± , , st gr.-utnf-α/ucr= , ± , , utgf-β/ucr= , ± , ; nd gr -utnf-α/ucr= , ± , , utgf-β/ucr= , ± , , p , - < , ) . to conclude, tnf-α and tgf-β are responsive for renal tissue impairement in infants with uti. elevated tnf-α tgf-β creatinine ratio in a part of infants with normal urodynamics suggests that renal damage begins early in infection mostly due to inflammation. one may suspect a predisposition of that subgroup of patients to fibrogenic process and subsequent scar formation. prompt diagnosis and localization of pyelonephritis are of great importance in treatment and prognosis of the patients. the urinary excretion of enzymes, in particular n-acetyl-beta-dglucosaminidase (nag), is considered a relatively simple and non-invasive method in the detection of renal tubular function under various conditions such as pyelonephritis. this study was performed to determine the diagnostic value of urinary nag in acute pyelonephritis and to compare it with other indices traditionally used for this purpose in children. this is a quasi experimental study conducted from april to may on children with pyelonephritis. diagnosis of pyelonephritis has been based on standard criteria. seventy-two patients between month and years were recruited. fresh random urine samples were obtained on the admission time and at th hour of treatment and were tested for nag and creatinine. there was a significant difference in pre and post-treatment urinary nag/creat ratio (p< . ) and the sensitivity and specificity of urinary nag in diagnosis of pyelonephritis were % and % respectively. there was a significant correlation between urinary nag level and kidney ultrasonography results. patients whose ultrasonography showed hydronephrosis, had the highest level of urinary nag and patients who showed urinary stone in their ultrasonography had the lowest level of urinary nag. in addition, there was a reverse correlation between urine culture results and urinary nag level; patients who had negative urine culture had higher level of urinary nag in comparison with patients with positive urine culture. we conclude that urinary nag is elevated in children with pyelonephritis especially in the presence of urinary tract abnormality and the absence of renal stone. type- hyperoxaluria (ph- ) is an autosomal recessive disorder caused by the impaired activity of the hepatic peroxisomal alanine-glyoxilate aminotransferase. the disease leads to end stage renal disease (esrd) and combined liver-kidney transplantation (clkt) is required. we report cases diagnosed with ph- who received clkt. case- : she had attacks of dark urine without any pain and renal stones were determined on sonography when she was . years old. she was diagnosed with ph- and received peritoneal dialysis (pd) at the end of the first year and cadaveric clkt was performed when she was yearsold. at the age of , she had chronic allograft nephropathy and began to have hemodialysis (hd). recently, . year after hd, cadaveric renal transplantation (tx) was performed. she is well after the second tx. case- : he was admitted with polyuria, polydypsia, stomachache and renal stones were determined on sonographic examination. he had esrd and pd was started when he was years old. at the age of , cklt was performed from his mother. his liver and renal functional tests are well months after cklt. case- : he was evaluated because of having an older brother diagnosed with ph- when he was . years old. he had no complain, but sonography showed multiple calculi. within years he experienced flank ache, hematuria attacks and anuric phases due to obstruction and esrd appeared and he received hd and clkt was performed from his full-match sister at the age of . . he is doing well years after tx. here, we present the favourable clinical outcomes of our patients with cklt to indicate the validity of this treatment of choice in ph- . tenascin (tn) is a glycoprotein component of extracellular matrix (ecm) which is not present in the normal kidney tissue. tissue plasminogen activator inhibitor- (pai- ) regulates fibrinolysis and the plasmin mediated matrix metalloproteinase activation and it is also not expressed in the normal kidney. recent studies focus on the pathogenesis of advanced renal diseases. in this study we evaluated tn and pai- staining in the renal tissues of pyelonephritic rats using immunohistochemistry (ihc) as to understand if these markers may be served as histological parameters of pyelonephritis like fibrosis, tubularatrophy or vascular changes. seven rats were injected . ml solution containing e. coli atcc cfu/ml into left renal medullae. seven rats were designed as sham group and were given . % nacl. rats were sacrificed days after injections. renal tissues were studied histopathologically by hematoxylin and eosinand scored for the parameters of pyelonephritis. tn and pai- expressions were studied semiquantatively by ihc by tenascin novocastra (ncc-tenas-c) and pai- (h- ) santa cruz biotechnology. both tn and pai- expressions increased in the pyelonephritic groups. we observed acorrelation between tenascin and fibrosis, vascular changes and tubular atrophy and pai- expression showed a correlation with only fibrosis. we conclude that increase in renal tn and pai- expression shown in experimental pyelonephritis are the responsible factors for the fibrotic changes of persistent renal damage. introduction: urinary beta microglobulin (β mg) urinary excretion is a good index of proximal tubular cell dysfunction. objective: to determine β mg excretion significance in determining the outcome in respect to scar and renal insufficiency. patients and methods: urinary β mg and creatinine (cr) was measured in urine samples of whom proceed to do dmsa renal scan at the time of admission and months later to detect scar. β mg was measured using radioimmunoassay method using β mg -test kit (radim company). twenty children had various grades of renal scars. results were compared with ratios of children with low uptake and normal scanning and normal children. student t test, anova, and unpaired t-test was used for analysis and differences considered significant if p< . . results: the mean urinary β mg/cr was significantly higher in the scarring group ( . ± . ) than in the normal group ( . ± . ) and in low uptake group ( . ± . ) (p< . ). patients with grade iii had higher values ( . ± . ) than grades i ( . ± . ) and ii ( . ± . ) (p< . ). patients without renal scar had β mg/cr ratio below . microgram/mg. the mean β mg/cr was higher in patients with vur grades and ( . ± . ) than patients with vur grades to ( . ± . ) (p= . ). maximum β mg/cr was detected in patients with grade vur ( . ) and the minimum was zero in non-refluxing patients and normal children. two patients with high grade vur and the highest levels of β mg/cr ratio ( . and ) progressed to renal failure in years time, the first patient was treated by hemodialysis and the second underwent renal transplantation. conclusion: measurement of urinary β mg is useful in the early detection of tubular damage in patients with renal scars. introduction: chronic allograft nephropathy refer to the progressive decline of renal function seen in some renal transplant recipients in association with alloantigen-dependent and alloantigenindependen factors. hyperlipidemia is a risk factor for chronic allograft nephropathy in adult pts, where no data exist in pediatric transplant population. methods: in this cross sectional study, patients ( can/ non-can) that aged - yr and - mo (mean: mo) after transplantation, were evaluated for lipid profile and renal function tests. results: hyperlipidemia has high prevalence in our patients both pre and posttransplantation and hypercholesterolemia and increased ldl had significant correlation with chronic allograft nephropathy (p= . ) and p= . respectively. conclusion: in pediatric patient as in adults hyperlipidemia and particularly hypercholesterolemia has significant correlation with chronic allograft nephropathy and as adults may need specific therapy. results: pre-transplantation renal replacement therapy time ranged from to months. eleven children underwent pre-emptiverenal transplantation. / transplants were from living related donors. donor age ranged from days to years. grafts were from donors < year of age and of these grafts were transplanted en-block. hla mismatches ranged from to antigens. primary disease was: focal segmental glomerulosclerosis in , rapidly progressive glomeluronephritis in , reflux nephropathy in , nephronophthisis in , iga nephropathy in , congenital nephrotic syndrome in , dysplasia-hypoplasia in , idiopathic membranous glomerulonephritis in , henoch-schönlein purpura in , hemolytic-uremic syndrome in , nephroblastoma in , polycystic kidney disease in and of unknown origin in children. patient survival at five years was %. allograft survival with living related transplants at one, two and five years was %, % and % respectively and with cadaveric transplants at the same periods was %, % and % respectively (p< . ). regarding en-block grafts, they functioned immediately and satisfactory and presented excellent graft function years later. most kidneys were lost due to acute or chronic rejection (n= ). other causes were renal artery thrombosis (n= ), infections (n= ), withdrawal of immunosupressive regime (n= ). conclusions: results of this single center series of pediatric renal transplants are encouraging from the standpoint of patient and allograft survival. conclusion: in infants with hn, the incidence of uti was higher especially in those with ou, hn of higher sfu grade or hun. the antibiotic prophylaxis may be recommended during year after birth in infant with hn because the incidence of uti was high in these period. results: the underlying diseases were: sepsis with mods ( . %), septic shock ( . %), severe intoxication ( . %), trauma with sirs ( . %), drowning ( . %), abdominal compartment syndrom ( . %) and inborn metabolic disorders ( . %). children ( %) had acute renal failure, ( %) patients met non-renal crrt criteria. cvvh was performed in ( %) children, cvvhdf in ( %) children. crrt duration was to hours (median . hours). dynamics of blood urea, creatinine, c-reactive proteine (crp) and white blood cells (wbc) were evaluated. significant decline (p< . ) of creatinine along the treatment with cvvh as well as during cvvhdf was observed. blood urea levels showed significant decrease only in children treated with cvvhdf (p< . ). significant decrease of wbc and crp was observed only using cvvh. children from the study group survived (overall mortality . %). in non-survivors was time from crrt initiation to its termination compared to time interval from crrt initiation to the death of children with - organs failure significant (p< . ) where as in non-survivors with - failured organs it was not. conclusion: cvvh is efficient at removing urea and creatinine as well as inflammatory mediators (crp, wbc). cvvhdf is more potent to blood urea elimination. authors suggest preferring cvvh to cvvhdf in critically ill children to affect basic inflammatory parameters. to analyse hd and pd prescription (pr) adopted in chronic dialysis children, were viewed data of pd regimens in patients ( . - years) and hd regimes in patients (age . - years) treated in pediatric centres in . pd patients were on automated pd: -nightly intermittent pd (nipd; pr): . ± . ( - ) hrs; . ± . ( - ) cycles/night; dwell volume (dv) ± ( - ) ml/m bsa; -tidal pd ( pr): . ± . ( - ) hrs; . ± . ( - ) cycles/night; dv ± ( - ) ml/m ; tidal volume . ± . ( - )%; -continuous cycling pd (ccpd; pr): . ± . ( - ) hrs; . ± . ( - ) cycles/night; dv ± ( - ) ml/m ; daytime dv ± ( - )% of night dv. in % of pr dialysis fluid (df) glucose concentration was > . %, and in % buffer was bicarbonate. df of daytime dwell was . % glucose ( pr) or icodextrin ( pr). patients with residual diuresis were . % of those on nipd, % on tidal pd, and . % on ccpd. hd was performed as bicarbonate hd ( %), hemodial filtration ( %) and acetate-free biofiltration( %). patients received sessions/week in % of cases, /week in %, and /week in % of cases; oxalosis patients were on daily hd. session duration was hrs in pr, hrs in , and . hrs in . dialyser membrane was: polysulfone ( %); hemophane ( %); polyamide s ( %); cellulose acetate ( %); polyacrylonitrile ( %); cellulosediacetate ( %); cellulose triacetate ( %); polymethylmetacrylate ( %); polyether/carbonate ( %). ratio between dialyser surface area and patient bsa was . ± . ( . - . ) and was - . in %, . - in %, > . in %, and < . in % of cases. isoniazid (inh) is widely used in most prophylactic and therapeutic anti-tuberculosis regimens because of its effectiveness and low cost. acute intoxication by isoniazid is known to cause symptoms of seizures, metabolic acidosis, coma, and even death. we present a case of acute isoniazid poisoning in a seven years old patient who ingested tablets ( mg) of isoniazid. she was admitted unconscious, with ventilatory insufficiency and convulsions. renal and liver function tests were in normal ranges. she was intubated and mechanically ventilated. despite parenteral midazolamand pyridoxine (vitamine b ) treatments convulsions went on. then hemodialysis was performed and after hemodialysis convulsions and ventilatory insufficiency were disappeared and the patient was conscious and she was extubated. hemodialysis may be an effective treatment alternative for the patients who doesn't respond pyridoxine treatment. the aim of this study is to analyse children under two years of age, with their first febrile urinary tract infection (uti), identifying bacteriological etiology, antimicrobial resistance, urologicalabnormalities and renal damage. this is a prospective study including children ( % girls) with their first febrile uti. mean age was months ( - ), ( %) patients were younger than months ( % of them were boys). urine was obtained by suprapubic aspiration ( . %) or transurethral catheterization ( . %). % had positive nitrite on urinalysis and . % had leukocyturia. they were submitted to ultrasonography (usg), dmsa scan (within months) and voiding cystourethrography (vcug). the most frequent microorganism found in urine culture was escherichia coli, ( . %). in this study high bacterial resistance to antimicrobials was observed in relation to the following antibiotics: ampicillin ( . %), first generation cephalosporyn ( . %), sulfamethoxazole/ trimethopin ( . %). resistance to second generation cephalosporyn, aminoglycoside, nitrofurantoin and nalidixic acid was lower than . %. renal ultrasound was abnormal in . % of the infants. vesico-ureteral reflux (vur) was observed in . %, although only . % had vur grade iii or more. the dmsa scan showed that ( %) patients had renal parenchymal damage. fourteen of these ( . %) had normal esr. there were ( . %) reinfections within a months period, even under prophylactic treatment, and the presence of vur grade iii or more was the only one with a significant relationship. conclusion: there were high levels of bacterial resistance to frequent used antimicrobials. this finding points toward a need for reviewing criteria of choosing initial blind therapy. investigation with dmsa scan is important in the detection of renal parenchymal scars, irrespective of the reflux grade. purpose: urinary tract infection (uti) has a risk of renal damage and is associated with vur. vur is investigated only by vcu. however, vcu is an invasive, painful study and many patients hesitate to be taken the study. we studied the correlation of vur in vcu and defect of dmsa scan and investigated the possibility of substitution of vcu by dmsa scan. material and methods: from to , the medical records were searched for children admitted to cheongju st.mary's hospital with the first uti who had been evaluated with both dmsa scan and vcu within months of the infection. the value of several clinical signs, laboratory findings, the resultsof dmsa scan and vcu were investigated. bacteriuria was defined as , or greater colony-forming units in urine from a bag, midstream or catheter sample. results: there were patients underwent both studied at the first uti. mean age of the patients was months old. the male patients were ( %). the vur was found in of the patients ( %), grade i-ii in and grade iii-v in patients. there was no significant correlation with the presence of vur in sex, fever duration, blood white cell count and the level of serum creactive protein (crp). but the patients with vur grade iii-v were significantly older than the patients with grade i-ii reflux or without vur. there were abnormal dmsa scan findings in of ( %). of these patients, were without vur, with vur grade i-ii and with vur grade iii-v. the abnormal dmsa scan was correlated with the presence and severity of vur. but vur was found in % of patients with normal dmsa scan. conclusions: abnormal dmsa scan is correlated with the presence of vur, so the patients with abnormal dmsa scan require vcu. in order to prevent missing a quarter of patients with vur shown normal dmsa, vcu should be recommended in all children with first febrile uti. cuba is the largest of the carribean islands with its , millions inhabitants. cuba is considered as a developing country and is classified in the group of: "lower middle income countries and territories". despite low financial resources, cuba has succeeded to develop an efficacious health care system with comparable results to those of west europe and usa (who data) ccl: ) hd is the most prominent form of pediatric dialysis (automated night pd is in progress); ) the no of transplantations is relatively low because of no participation to an international transplantation network; ) high no of pediatric nephrologists; ) high quality of patients care. background: inborn errors of metabolism in neonates are often characterised by hyperammonaemic coma within the first days of life and require prompt diagnosis and specific treatment such as toxin removal and nutritional support. cvvhd seems to be the optimal modality for extracorporal ammonium detoxification, however, little experience with small numbers of children has been accumulated. patients and methods: from to , patients with hyperammonaemia ( male, female) were admitted for dialysis treatment: neonates (mean age . ± . days, range - days) with a mean birth weight of ± g and infants (mean age . ± . years, range to years). in neonates and infants we inserted venous double lumen shaldon catheters (predominately femoral or jugular vein) for cvvhd treatment while neonates and infant underwent capd treatment. results: plasma ammonia levels (range - μg/dl before dialysis and - μg/dl after dialysis) were reduced by % within . ± . h by cvvhd and within . ± . h by capd (p< . ). total dialysis time was . ± . h for cvvhd patients. no major mechanical complications were observed with cvvhd and stable blood flows ( - ml/min) and dialysate flows ( - ml/m /h) were achieved. due to severity of underlying disease, out of neonates ( %) undergoing cvvhd died on day - while out of neonatal capd patients ( %) died on day and one infant patient died after days of capd treatment. twelve out of neonates ( %) survived with no or moderate mental retardation. conclusions: cvvhd is an effective modality to eliminate plasma ammonia within few hours. however, vascular access and blood flows are critical restrictions. mental retardation has to be evaluated in larger scale studies. r. vilalta, e. lara, a. madrid, s. chocron, j. nieto hospital materno-infantil vall de hebron, nefrologia pediatrica, barcelona, spain background: transplant nephropathy is the main cause of renal failure in kidney transplanted children. until this situation is proved by biopsy, sometimes the progressive raise of creatinine leads to raise the anticalcineurinic (cni) drugs with added nephrotoxicity. sirolimus (sir) plus an anticalcineurinicin less dose and mycophenolate (mmf) could offer in kidney-transplanted children an immunosuppressive regime with less toxicity and even an improvement of renal function. methods and patients: paediatric kidney-transplanted patients developed biopsy-proved chronic allograft nephropathy (age - y, mean ) a follow-up post-transplant of y and exhibit also tubular involvement and acute cni toxicity. sir was added in all patients as a rescue therapy at . mg/kg/d. results: after a follow-up period of months, creatinine level diminished (p< . ) in patients ( in group tac, in group cya, with no significant differences). creatinine level did not show a significant change in the other patients ( group tac, group cya, basal creatinine . mg/dl. serum cholesterol changed from ± mg/ ml to ± (ns) and serum tryglicerides from ± mg/ ml to ± (ns). proteinuria also did not show changes ( ± to ± mg/m /h (ns). conclusions: a poly-drug approach with less dose of anticalcineurinic added to the antiproliferative effect of sirolimus and the inhibition of purine synthesis based on mycophenolate mofetil could suppose an improvement of the renal function in children graft nephropathy an even in the graft survival. steroids have been a cornerstone in renal transplant immunosuppression. several strategies have been used to minimize their side effects. new immunosuppressive drugs have allowed steroid withdrawal or total avoidance. aim: to evaluate a new protocol with steroid-free maintenance immunosuppression in pediatric renal transplant. patients and methods: a prospective, non-randomized study in consecutive first renal allograft recipients, followed-up to months. patients received prednisone the first days, two-dose basiliximab induction and maintenance therapy with tacrolimus (tac) and mycophenolate mofetil (mmf). no steroids were given after d posttransplant. controls were historical-matched steroid-based children receiving basiliximab, tac and mmf. all patients gave informed consent. anthropometric, biochemical variables, acute rejection and cmv infection were compared using student-t test and regression analysis. results: a better growth pattern was seen in steroid-free maintenance group reaching a normal growth at months. gfr and serum glucose were similar in both groups. total cholesterol levels were significantly lower in the study group. the incidence of acute rejection was . % in steroidfree maintenance vs . % in steroid-based group, no differences in cmv infection and blood pressure were observed. hematocrit levels were lower during the first months after transplant in the steroid-free group, increased after months post-transplant. patient and graft survival was % at two-yr post transplant in the two groups. conclusions: this steroid-free maintenance immunosuppressive protocol was efficacious, safe, with a lower incidence of acute rejection, not increased risk of infection, preserving optimal growth, renal function and reducing cardiovascular risk factors. objectives of study: to evaluate the lipid profile and its possible implications in children with end stage renal disease (esrd) or renal transplantation. methods: children ( boys, girls) aged from . to years, on peritoneal dialysis (group i) and with renal transplantation (group ii) were studied. in all children were examined: serum creatinine, total cholesterol, triglycerides, high density lipoproteins (hdl) and low density lipoproteins (ldl). a cardiac and liver ultrasonography were also performed. the body mass index (bmi) and blood pressure were evaluated in all children. / children received also a triplex carotid study. the median values of blood creatinine, cholesterol, triglycerides, hdl, ldl as well as the number of children with bmi over th percentile in both groups were shown in table i . all children had normal findings in triplex carotid study. cardiac ultrasonography was abnormal in child of group i and in children of group ii. only child presented lipoid invasion in liver ultrasound. / children of group i and / children of group ii presented hypertension, well controlled, with antihypertensive therapy. conclusions: frequent evaluation of lipid profile is recommended in all children with esrd or renal transplantation independently their bmi. in our study, children with renal transplantation presented better lipid profile compared with children on peritoneal dialysis. group i with < months (n= ; , ± , months) and group ii > months (n= ; , ± , months). results: serum albumin, serum lipids values and the distribution of the categories of the peritoneal membrane did not present significant differences between the groups. hypertension, renal residual function (p= , ), the renal urea kt/v (p= , ) and the weekly renal ccr (p= , ) were significantly higher in group i, while the weekly peritoneal ccr (p= , ) and the total weekly ccr (p= , ) were significantly higher in group ii. catch-up was not observed in any group. control of the cholesterolemia, trigliceridemia and albuminemia were maintained with the dialysis time in both groups. the goals of adequacy of the doqi for kt/v and ccr were gotten respectively in , % and , % of the group i and in , % and , % of the group ii. the longer time in dialysis was associated with the lowest values of renal residual function, renal kt/v and renal ccr. the capacity of transport of the membrane was similar in both groups. objectives of study: to explore the characterize of peritoneal transport in chinese children with chronic peritoneal dialysis. methords: pet was carried out times for six children (mean ages . ± . , aged from to years) who were maintained by capd, and the infusion volume of dialysate was ± ml ( ml/m ). the peritoneal solution transport rate was evaluated by the standards of twardowski's and ppdsc's criteria. results: in our study, the initial pet was performed at . ± . days following initiation of pd, the -hours of peritoneal creatinine clearance ( h-d/p) and glucose absorption ( h-d/d ) was . ± . and . ± . , respectively. according to the standards of twardowski's and ppdsc 's criteria, the peritoneal transport categories were divided into high transport (h) ( / ), high average transport (ha) ( / ), low average (la) ( / ) for peritoneal solution transport, and h ( / ), ha ( / ), la ( / ), low transport ( / ) for glucose absorption. no low transport type of solution was uesd in our patients. the coincidence rate of peritoneal creatinine and glucose transport types were % and % between the twardowski's and ppdsc's criteria, respectively. the different changes of peritoneal transport type were found in two patients with continuous pet. the value of h-d/p increased after peritonitis episodes. our results showed that the pet in % of capd children fall into high and high average transport categories elevated by ppdsc's and adult standards. the peritoneal solute clearance was adequacy in the children, but net water ultrafiltration was lower. standard pediatric pet and its criterie are consistent with the adult criteria. the capability of peritoneal solute transport increased after peritonitis episodes. verapamil (vp) is known to alter cyclosporine (csa) bioavailability. the impact on immunoregulators (il- , tgf-β , and tgf-β ) in allograft recipients remains unresolved. a prospective open study to examine the impact of vp on peripheral blood cell mrna encoding il- , tgf-β , and tgf-β and serum il- , tgf-β , tgf-β protein levels was performed. parental written informed consent was obtained in all cases. children with stable renal allograft function (< months), and receiving immunosuppression (csa, pdn, either with aza or mmf) were included. in the first visit, a clinical examination, two-point ( and h) csa pharmacokinetic profile, serum creatinine, serum for il- , tgf-β , and tgf-β protein levels (by elisa) were obtained; peripheral mononuclear cells were collected for measurement of transcripts for s rrna (house keeping gene) and mrna for il- , tgf-β , and tgf-β (by real time quantitative pcr assay). after the visit one, patients were either withdrawn of vp (if the subject was already receiving vp) or started on vp mg/kg/day (if the subject was not receiving vp). two weeks after, a repeat clinical evaluation and blood collection, as in the first visit, were performed. pediatric recipients of renal allografts were included ( were from ld, mean post-transplant time . years, mean csa dose . mg/kg/day). the c h and calculated auc - h were significantly higher in those receiving vp, but there was no difference in csa trough levels. protein and mrna levels of il- tgf-β , and tgf-β were not different. were previously seen by a nephrologist. logistic regression was performed on anemia (hgb< . g/dl) and showed relative risk in blacks was . vs. whites. relative risk in those who did not receive epo was . vs. those who did. of black patients, were anemic and previously seen by a nephrologist. of white patients, were anemic and previously seen by a nephrologist. in summary, blacks and patients not receiving epo at the time of dialysis initation were more likely to be anemic. despite being seen previously by a nephrologist, nearly % of patients were anemic when starting dialysis. further analysis is needed to determine causality to improve anemia control in incident dialysis patients. of the avf were in whites with in a black patient. the avg was in a black patient, with a cvc distribution of whites and blacks. patients with cvc had been previously followed by a nephrologist and of these had been followed for > months. in summary, incident pediatric hemodialysis patients are primarily having cvc as initial access type. with . % having been previously seen by a nephrologist and % of these for greater than months, the reasons behind not having an avf or avg as primary access need to be explored and improved upon. this high incident cvc use is consistent with data reported in the united states, but not with other european and asian countries. an effort to have a permanent avf or avg in incident pediatric hemodialysis patients needs to be made by the patient's nephrologist. to find the preventive measures for recurrent uti in infants with first febrile uti and normal urinary tract (ut), the incidence of recurrent uti and its risk factors were investigated. method: from june, to june, under months of age (- mon: , - mon: ), who were diagnosed as the first febrile uti and proved to have normal ut, were enrolled to the retrospective study. for all infants with nonretractile prepuce, topical application of hydrocortisone for - weeks and physiotherapy was recommended. during the following year, the incidence of recurrent uti and the well-known risk factors such as female, young age, phimosis, vaginal reflux, and initial mtc-dmsa(+) pyelonephritis were evaluated. result: the incidence of recurrent uti in infants with normal ut was . % and recurrent uti episode was . /patient-year. the recurrent incidence in male infants was . %, which was not significantly different from . % in female infants (p= . ). the recurrent incidence in younger infants was significantly higher than in older infants [- mon: . %, - mon: . %, p= . ]. this age-related difference was significant in male infants [- mon: . %, - mon: . %, p= . ], but not in female infants (p= . ). in infants with persistent nonretractile prepuces, recurrent uti developed in . %, which was higher than . % in infants with retractile prepuces (p= . ). the presence of the vaginal reflux (p= . ) or initial mtc-dmsa(+) pyelonephritis (p= . ) showed no significant difference in the incidence of recurrent uti. conclusion: in uti infants with normal ut, younger infants under months of age and nonretractile prepuces of male infants were the risk factors for recurrent uti. objective: vascular endothelial growth factor (vegf) appears to play a central role in the process leading to peritoneal angionesis and increased level of vegf may conrtibute to high peritoneal small-solute transport rate (ptsr) in continuous ambulatory peritoneal dialysis (capd) patients in adult. vegf-c is related to lymphogenesis, but its role in peritoneal solute transport rate is not known. in this study, we evaluated possible relationship between dialysate vegf and vegf-c levels and pstr in children. method: twelve children with no apparent inflammation process or disease, who had been on capd, were enrolled. standard peritoneal equilibration test (pet) was done to evaluate pstr. d/pcreat and d/d gluc were calcualted at hr of pet. overnight dialysate levels of vegf and vegf-c were measured using commercial elisa kit. correlation between dialysatevegf (or vefg-c) and d/pcreat (d/d glu) was analyzed. results: mean peritoneal dialysis duration was . ± . months. mean overnight dialysate vegf and vegf-c level were . ± . pg/ml and . ± . pg/ml, respectively. a significant correlation was noted between the dialysate vegf-c and vegf level (r= . , p= . ). dialysate vegf level had negative correlation with d/d glu of hr pet (r=- . , p= . ). vegf-c had no correlation with d/d glu or d/p creat. conclusion: there was significant relationship between dialysate vegf and vegf-c levels in children and significant correlation was also noted between dialysate vegf and ptsr. it seems that vegf contribute to high ptsr also in children on capd. m. feldkötter, l. stapenhorst, b. beck, u. bangen, b. hoppe we currently use sirolimus as a second line medication in transplanted patients with a distinct nephrotoxicity of calcineurin-inhibitors. as our short term experiences were not as positive as expected, we performed a short term meta-analysis in our renal transplant recipients under sirolimus treatment: we give an account of seven kidney transplant patients who were either directly started or were switched to a medication with sirolimus during september to february . the reasons for this action taken were calcineurin-inhibitor side effects like severe arteriolopathy with lossof gfr, atypical haemolytic-uraemic-syndrome, seizures after the first dosages of cya and a tacrolimus induced exanthema. in four of seven patients switched to sirolimus we observed severe side effects, exaggerating those of the calcineurin-inhibitor and hence, in three patients the latter treatment was installed again. findings were distinct proteinuria in two patients, hyperlipidemia in three patients, wound healing disorders and, most strikingly, treatment resistant severe pancytopenia in one patient and severe interstitial pulmonary fibrosis in another patient, both with amelioration after termination of the medication, but still the need of oxygen therapy in the latter patient. in addition we noticed a slightly faster reduction of the gfr calculated with the schwartz formula in five patients compared to the previous immunosuppressive regimen. based on these findings we strongly feel that a more critical discussion of each case is necessary before changing the immunosuppressive medication. also, the question arises on whether sirolimus can really be valued as an equivalent alternative to a calcineurin-inhibitor based immunosuppressive regimen in pediatric kidney transplantation. y. kovalski, r. cleper, i. krause, m. davidovits schneider children's medical center of israel, nephrology and dialysis unit, petah tiqwa, israel background: despite significant technical improvements, haemodialysis in infants with end-stage renal disease (esrd) is still associated with significant morbidity and mortality. methods: the files of patients weighing less than kg with esrd who were treated with haemodialysis at our institute between and were reviewed for background and treatment characteristics, morbidity and outcome. results: the study group included patients aged - months (mean . months) weighing . - . kg (mean . kg). mean duration of dialysis was . months. vascular access posed the major problem. ten patients were dialysed through a central venous cuffed catheter and one through an arteriovenous fistula. an average of three different vascular accesses was required per patient (range - ). mechanical difficulties were the most common cause of central line removal ( . %), followed by infections ( . %). major complications causing significant morbidity were intradialytic haemodynamic instability, hyperkalemia, coagulation within the dialysis set, anaemia, hypertension, inadequate fluid removal and recurrent hospitalisations. analysis of outcome revealed that patients underwent successful transplantation, one returned for haemodialysis after . years due to graft failure, and died. conclusion: haemodialysis is a suitable option for low-weight paediatric patients with esrd awaiting transplantation, when performed in highly qualified centers. the importance of antibiotic prophylaxis in management of vur vesicoureteral reflux (vur) cause urinary tract infection (uti) and renal scarring is a common condition in children. the detection and treatment of vur before renal scarring is vital. recently, optimal management of low grade vur is controversial. the aim was to explore the kidney outcome in a cohort of patients with vur. the patients were divided into five subgroups according to vur grades. all of them were treated with low dose prophylactic antibiotics until the age of years. urine culture was repeated monthly. background: anemia is a common complication in patients on hemodialysis. treatment of anemia with recombinant human erythropoietin (rhuepo) may lead to iron deficiency. intravenous sodium ferric gluconate complex (sfgc) therapy improves iron stores. objectives of study: aim of our study was to assess effects of maintenance sodium ferric gluconate therapy in pediatric patients on hemodialysis on mean hemoglobin (hb), hematocrit (hct), transferrin saturation (tsat), serum ferritin and rhuepo dose, as well as safety of therapy with sfgc. methods: intravenous sfgc therapy was administered for months in mean dose of . mg/kg/week to eight pediatric patients on hemodialysis. patients were from to years old ( males and females, aged . ± years). all patients were prescribed rhuepo before start of study. results: sfgc therapy was successful in maintenance of mean hb (increased from . to . g/dl), mean hct (improved from % to %), mean tsat (from to %) and mean ferritin level (from to ng/ml). high ferritin levels in two patients were due to inflammatory disease rather than the sign of iron overload. the mean weekly rhuepo dose decreased from to iu. no significant adverse event due to intravenous sfgc therapy occurred. conclusions: intravenous maintenance sfgc use in pediatric patients on hemodialysis was safe and successful in maintenance of iron indices, thus allowing reduced use of rhuepo. the the viral hepatitis b still remains a serious problem, especially actual in patients with end-stage renal disease (esrd) on renal replacement therapy (rrt). the high frequency of hbv infection transmission in hemodialysis units and immunodeficiency modify hepatitis clinical course and outcomes and worsening vaccination results and renal graft survival. we have analyzed the results and influence on transmission of hb -infection of hepatitis b vaccination in children aged from to years with esrd on chronic hemodialysis. majority of children were boys ( . %) older than years ( . %). an assessment of hbs-ag has been conducted prior and during the vaccination (engerixb) by scheme - - months. after first vaccination hbv infection was detected there after in . % of children, after second vaccination in . %. in all patients ( ) which have received three tours of vaccination, an active immune response was developed. thus, vaccination against viral hepatitis b is effective and prevents hbv infection in children with end stage renal disease on chronic hemodialysis. renal transplantation (tx) represents the best treatment for the patient with crf. scientific advance has been able to optimize the immunosuppressive treatment however the adherence to treatment has been not maintained. aims: to identify the factors that influence in non-adherent behavior with the purpose of designing effective educational strategies. methods: the qualitative focus was carried out through patients and tutors interviews. the quantitative aspect applies for epidemic variables, time post-tx, percentages and frequency of the sentences coming from the analysis of the interviews. nurse, psychologist and a social worker were incorporated with the purpose of elaborating an instrument based on seven questions related to the transplantation, risk and/or loss of the graft; besides the events happened as consequence of this, allowing that interviewed manifested with freedom their opinions. the interview was recorded in a microcassette and later transcribed. analysis was determined by categories containing the answers of each question granting the agreement sentences according to the frequency which was repeated in each interview. informed consent was obtained. results: tx ( - ; non-adherent, % of them were interviewed. mean age: . ys. loss the graft: %, time post-tx: . months, dd: % ld: %. the lack of supervision in the taking of medications, numbers/schedules medications, family conflicts and the poor communication with the parents/medical team seem to be the main factors for non-adherence. conclusion: it is necessary to modify the pattern of the patient's attention transplanted under the pattern of chronic suffering that allows the sick person's and their family active incorporation to the process in an integral way to the multidisciplinary group. infantile results: patients ( females, males) < kg, / -< kg at pd start were treated. they consisted % of our center's pd patients ( pts). age at pd start: . ± months (median ), / pts < mo. pd therapy duration: - mo (median ), pts > mo. esrf cause: congenital nephrotic syndrome pts, dysplastic kidneys , cortical necrosis . pts were fed by gastrostomy, pts received gh (growth hormone). / pts had hypertension (ht) treated with > drugs and - cv events. pd type: / cycler-assisted, / capd (continuous ambulatory pd), / both. pd adequacy targets (kt/v> . ) were reached in / . peritonitis: . episodes/patient-month, pts had > episodes. / pts had > pd catheters and / > pd-related surgery. outcome: / -kidney transplantation, / switched to hd for infections or uncontrolled ht. height ±sds median , weight ±sds median + . . conclusions: small infants with esrf can be successfully treated by pd despite high rate of infectious, cv and surgical complications. pd therapy main target is optimal growth towards kidney transplantation. hyperlipidemia is a well recognised complication of renal transplantation. it is a fairly common problem in the paediatric renal transplant population. its prevalence ranges from % to % though the mechanism is not clear. steroids, calcineurin inhibitors and rapamycin are the main culprits in inducing hyperlipidemia, which is a potential risk factor for cardiovascular heart disease and graft dysfunction. long term effects of these immunosuppressive drugs in children have not been adequately studied. of the calcineurin inhibitors cyclosporine (csa) was found to induce hyperlipidemia compared to tacrolimus (tac). post-ransplant hyperlipidemia is well described in adults; the same cannot be said in children. in adults, post-transplant hyperlipidemia increases risk of cardiovascular disease to fold. screening and management of hyperlipidemia has therefore become an important part of current long term management of transplant patients. there is a limited data on prevalence of hyperlipidemia in renal transplant in children and even more so locally here in south africa. most of the known studies have been conducted in the first world, there was therefore need to determine prevalence locally. this information would ultimately assist in the overall management of our renal transplant recipients. majority of the patients had normal lipid profile. % of the patients had high cholesterol levels, while % of the patients had high tg levels. / ( %) of the patients on csa had hypercholesterolemia compared to only / ( %) on tac (p= . ). / ( %) of the patients on csa had high tg compared to / ( %) on tac (p= . ). the study concluded that the prevalence of hypercholesterolemia and hypertriglyceridemia in renal transplant pts is high, comparable to other studies and that there is a tendency towards having more lipid abnormalities in transplant pts on csa. grade vur in ( %) and . the incidence of abnormal findings was significantly higher in children with uti and vur than in those with uti without vur ( . % vs %; p< . ). in children with no vur, grades - vur, grade vur and grades - vur, renal scarring rates were %, %, % and %, respectively. the patients with higher grades vur tended to have more than scars on their dmsa scans (p< . ). our findings suggest that renal scarring resulting from uti is mostly related to vur, but sometimes is caused by the infection itself. we can conclude that vcu is essential for diagnosis of vur, but mtc-dmsa scan shouldn't be avoid in the management of children with uti. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] years. seventythree ( . %) of them were on triple immunosuppressive therapy, one on double therapy, and one didn't use any medication. overall, subjects ( %) had at least one episode of uti. twenty-four episodes of urinary tract infection occurred in children: episodes in two girls with neurogenic bladder (ngb), episodes in two boys with posterior urethral valve (puv), four episodes in an obese girl with laurence-moon-biedl syndrome, episode of uti in girl with unknown primary renal disease and episodes in girl, one with polycystic kidney disease and one nephronophthisis. conclusion: uti following kidney transplantation was more common in children with known lower urinary tract abnormalities. key words: urinary tract infection, kidney transplantation. background: in japan, the severe shortage of cadaveric kidneys led clinicians to attempt performing abo-incompatible living kidney transplantation (tx). some reports demonstrate successful results of the combination of plasmapheresis (pp), strict immunosuppression and splenectomy. however, we should concern about a great risk of surgical invasion and postoperative serious infection in younger patients who underwent splenectomy. recently, a few reports suggested anti-cd monoclonal antibody (rituximab) can be an alternative to splenectomy. patient and method: a years old boy with bilateral hypoplastic kidneys had been treated with peritoneal dialysis for years. since his blood type o was incompatible with paternal blood type a, we arranged to perform tx using pp and rituximab without splenectomy. a single pp was performed on days - , - , and - to reduce anti-a antibody (ab) titer. rituximab was administered in a single dose of mg/m on day - . basiliximab, tacrolimus, mycophenolate mofetil and methylprednisolone were used for immunosuppression. results: before tx, the anti-a ab titer was reduced from : to : , and cd level was suppressed from % to %. tx was performed without splenectomy and he had excellent initial graft function. we observed anti-a ab titer rose up to : on day + , but it decreased spontaneously to : . there were no side effects and severe infections during the perioperative period, but the neutropenia treated by gcsf appeared months after rituximab administration. the protocol biopsies were performed in month and months, which revealed no signs of rejection. conclusions: abo incompatible tx using pp and rituximab without splenectomy can be a therapeutic option in children to avoid a invasive surgery and infectious risks. further establishment of optimal protocol for children are necessary to obtain excellent outcomes safely. . . , . . , and . . , . . , in hivan, and od, p= . , p= . , respectively. serum p levels were . . , . . , and cap were . . , and . . , in hivan and od, p= . , p= . the aim of this study is to identify the outcome of the physically or socially handicapped children with end stage renal disease (esrd) receiving chronic peritoneal dialysis (cpd). among patients commenced on cpd, handicapped children with esrd receiving cpd were identified in our unit during the period between november and february . age at cpd initiation ranged from . to . years (median age: ; girls, boys). underlying diseases were neuropathic bladder and vesicoureteral reflux (in patients), chronic pyelonephritis (in patients), vesicoureteral reflux (in patients), amyloidosis (in patients), and alport syndrome (in patient). causes of handicapped status against cpd were inadequacies of indoor resources (in patients), cerebral palsy (in patients), down syndrome (in patient), inadequate psychosocial status (in patient), surgically corrected rectovesicale fistula and ectopic anus (in patient), blindness (in patient), ventriculoperitoneal shunt and paraplegia (in patient), colostomy (in patient). all catheters were implanted percutaneously by the same pediatric nephrologist. median duration of dialysis was (range - ) months. during a total of dialysis months, episodes of peritonitis ( episode/ . patient-month), episode of exit-site infection, and episode of tunnel infection occurred in of children. except for an inguinal hernia in patient, we did not observe any mechanical complication related to catheter. cpd was terminated in children (death in , renal transplantation in , switch to hemodialysis in ). before initiation of renal replacement therapy, some negative baseline factors may not be really contraindications for cpd. the socioeconomic and geographic factors greatly influence the prevalence and outcome of renal disease in children. the subspecialty of pediatric nephrology in sudan was established few years ago and the facilities for the management of renal problems are limited. the aim of this study is to review the demographic profile, complications and outcome of capd after nineteen months of treatment. all children who underwent capd from june to january were studied. there were children ( males), the mean age was years (range from months to years). the majority of children has undetermined cause of esrd ( children). the most common complication was peritonitis (peritonitis rate was / . patient/months. patients had refractory peritonitis that necessitate catheter removal, exit-site infection was documented in children and catheter block in children. there were drop out of the program were due to deaths, changed modality and one family withdraw treatment. in conclusion this analysis has stimulated improvement in nurses training and supervision as well as attempts to improve catheter survival and microbiology monitoring. the - ) , looking for symptoms of hypovolemia (cramps, abdominal pain or headache) during or at the end of hd treatment. bioimpedance measurements were performed at the end of each session according to the khz tetrapolar technique; resistance and reactance values were plotted on the age and gender specific th , th and th percentiles of the vector distribution in the healthy population (reference tolerance ellipses) as a resistance-reactance graph. hypovolemia (hv) was indicated by a vector shifted to the upper pole, out of the % tolerance ellipse; normovolemia (nv) by a vector inside the ° ellipse. patients complained of one or more of the above-mentioned symptoms in % of hd sessions, while biva suggested hv in . % of the sessions. symptoms were significantly more common (p< . ) in sessions with hv ( / cases; positive predictive value . %) than in those with nv ( / cases; negative predictive value . %). biva suggested hv in / sessions with symptoms (sensitivity . %) and nv in / sessions without symptoms (specificity %). no significant differences in the accuracy of biva were found between patients either younger vs older than years, or with height sds <- vs >- , or taking vs not taking antihypertensive drugs. in conclusion, biva can be useful in assessing dry weight in children and young adults on hd: since patients with a vector shifted to the upper pole, out of the reference % tolerance ellipse, are at high risk of hypovolemia during the next hd treatment, the increase of the dry weight is then indicated chronic antibody-mediated rejection can occur as a de novo complication in renal allograft recipients and is associated with c d deposition in peritubular capillaries in the renal graft and positive circulating anti-hla antibodies, although the sensitivity and specificity of positive c d staining for chronic humoral rejection requires further study. renal outcome appears to be worse in c d positive patients. current treatment strategies to manage c d-positive chronic humoral rejection are poorly defined. various protocols with enlarged doses of tacrolimus, mycophenolate mofetil, plasmapheresis, ivig and rituximab have been reported in adult patients. we investigated four pediatric patients (mean age . yrs; range to yrs) after renal transplantation that developed c d positive chronic rejection. in of patients, maintenance immunosuppression with calcineurin inhibitors had previously been minimized because of severe toxicity. in of patients, an elevated anti hla class ii antibody titre could be detected; donorspecific antibodies were positive in patients. all patients experienced a progressive deterioration of graft function. treatment with repeated intravenous immunoglobulin (ivig) ( g/kg body weight per week over four consecutive weeks) followed by a single dose of rituximab ( mg/m ) was therefore initiated. three of four patients showed an improvement of graft function with a mean increase of gfr by %. one patient with advanced chronic transplant nephropathy lost his graft after months. this pilot study demonstrates that the combination of high-dose ivig and rituximab can stabilize or improve transplant function in chronic antibody-mediated rejection without major side effects. the use of ivig and rituximab appears to reduce the active immunologic process, but larger trials are needed to support these observations. cardiovascular diseases are some of the most important causes of morbidity and mortality in children with end stage renal disease (esrd). chronic inflammation has been suggested to be a risk factor for cardiovascular diseases. the aim of this study was to investigate the relation between crp and cardiac changes in children on hemodialysis. this study was conducted on patients ( patients were hypertensive & were normotensive), males ( %) and females ( %) on regular hemodialysis due to esrd. their ages ranged from to years (mean . ± . ). sixty age-and sex-matched controls were also included. significantly higher velocity of circumferential fibre shortening (vcfs), tei index, interventricular septum thickness in diastole (ivsd), left ventricular mass index (lvmi) and isovolumetric relaxation time (ivrt) and significantly lower e/a ratio were found in all patients as well as in hypertensive & in normotensive groups as compared to the controls. significantly higher ivsd and lvmi were found in hypertensive patients than normotensive patients. significantly higher high sensitivity crp (hs-crp) & crp latex were found in all patients as well as in hypertensive & in normotensive groups when compared to the controls. crp was significantly higher in both study groups with cns symptoms and cardiac symptoms in comparison to those without. it was also significantly higher in patients with increased lvmi & than in those with abnormal e/a ratio. hdlc showed a significantly direct negative effect on crp. s. ca + , se. p and ca x p had a significantly direct positive effect on it. we can conclude that the cardiac affection in children with esrd appears in the form of lv hypertrophy with early diastolic affection. crp could be correlated to these changes and to cns symptoms and cardiac symptoms in these patients. is. lim, hs. lee, dw. kim, wh. choi chung-ang university, pediatrics, seoul, south korea purpose: urinary tract infections are common clinical problems occurring in infants and pediatric patient groups, most frequently caused by uropathogenic e. coli. urinary pathogens almost always infect the host through ascension from the rectum, vagina to the urethra and bladder. recurrent urinary tract infection is a disorder involving repeated or prolonged bacterial infection of the bladder or lower urinary tract. in this study, we examined the substitusion effect of probiotics in the high risk group of recurrent urinary tract infection. objectives & methods: patients diagnosed as recurrent urinary tract infection were administered probiotics for six months, and urine cultures were checked during the period. probiotics in this study were selected among the products commercially saled in korea, namely lactobacillus acidophillus, bacillus subtilis, and bifidobacterium infantis. single blind study was done for selection of probiotics for patients. result: the separated bacteria from the urinary tracts of the patients were the same as administered probiotics in some patients. conclusion: in recurrent urinary tract infection, there seemed to be a substitution effect of probiotics for uropathogenic bacteria, and it is reasonable to administer probiotics for long period in the high risk group of recurrent urinary tract infection. renal insufficiency therapy in children: quality assessment and improvement: the rich q study objectives: outcome studies in children on chronic renal replacement therapy (crrt) have revealed a -time increased mortality and % co-morbidity in adult survivors. information on the quality of care of treatment centers and on the impact of advised quality indicators on outcomes in children are lacking. no data exist on the impact on these outcomes of the different treatment modalities, peritoneal dialysis, hemodialysis & transplantation either. until now, no structural corporation and consensus on general guidelines with respect to crrt exist between the dutch (nl) and belgium (b) centers for pediatric crrt. aim of the study: . assessment of the current quality of treatment crrt in children (qt) in nl & b and of the effect of recurrent peer review of the achieved outcomes on the qt. . the assessment of the effect of different treatment modalities on outcomes. . the creation of a format for multicenter trials. methods: all prevalent patients on chronic dialysis aged < years at onset of the study & all incident patients during the study period with onset of crrt< years of age, from b & nl will be included. treatment characteristics and quality indicators of crrt with respect to physical and psychosocial outcomes will be collected of all patients. operational data collection and management will be performed by members of the dutch institute for quality care in dialysis patients (hans mak institute). each months, all data will be revealed and actively discussed by representatives of all centers (peer review). the effect of registration and peer review on the qt will be analyzed after & years. comparison will be made between the effects of cumulative periods of different rrt models on outcomes. the study will be performed between august & . on estimation, patients will be analyzed. renal renal transplantation in patients with lower urinary tract dysfunction (lutd) of different origin is a challenging issue in field of pediatric transplantation. we report our single centre experience to evaluate the patient and graft survival as well as risks of the surgery and immunosupressive therapy. among pediatric transplant patients patients had severe lower urinary tract dysfunction. videourodynamic test was performed in all patients preoperatively and postoperatively. the cause of urological disorders was secondary to neurogenic bladder (n: ) and valve bladder (n: ). clean intermittent cathatetization (cic) was needed in patients to empty the bladder. pretransplant augmentation ileocystoplasty was created in four patients and gastrocystoplasty in one patient to achieve low-pressure reservoir with adequate capacity. three of the patients received kidneys from cadaveric and of them from living donors. the mean age at transplantation was ± . years. the median duration of transplantation was months (range - months). at their last visit median creatinin levels were . mg/dl ( . - . ) . three patients had recurrent symptomatic urinary tract infections who had augmented bladder and on cic. one of them had creatinine levels of . mg/dl. one patient with ileocystoplasty who developed urinary leak and ureteral stricture in early postoperative period was treated by antegrade j stent. severe lutd reserves high risks for graft kidney. however our data suggests that renal transplantation is safe and effective treatment modality if the underlying urologic disease properly managed during the whole course of transplantation period. since surgery and follow-up of these patients is more complicated, patient compliance and experience of transplantation team will have significant impact on the outcome. r. meneses, l. sylvestre, j. sousa, d. ribeiro hospital pequeno principe, pediatric nephrology, curitiba, brazil introduction: in july , we started a systematic evaluation program of each patient on chronic pd. the aim of this study was to analyze the long-term outcome of children on pd program. material and methods: we evaluated all the patients on pd between july and may , who performed complete protocols, with a minimal interval of months between them, consisting of: anthropometric measurements, blood pressure and cardiological status, standardized laboratorial evaluations, pet test, clearance and kt/v, measurement of the intra-peritoneal pressure (ipp), occurrence of infections, hernias or constipation and need to change the catheter. we then compared all the evaluations using the graphpad prism software, a p value < . was considered significant. results: out of patients were eligible, mean age ± years old at the first evaluation, % boys, primary renal disease: % uropathies, % glomerulopathies, % tubulopathies and % other causes. there was an improvement on bmi and weight/height z-scores and worsening of height/age z-score, but none was significant. there was also no significant decrease in residual renal function (p= . ), adequacy parameters remained stable: clearance (p= . ) and kt/v (p= . ). most patients were converted from capd to ccpd and nipd, and some had to increase daytime dwells (p= . ).constipation and the number of infections improved but not significantly. laboratorial evaluations, peritoneal membrane characteristics, ipp, need to change the catheter and occurrence of hernias did not change over the time. conclusion: a long-term maintenance of children in peritoneal dialysis program is possible, but reaching a satisfactory clinical condition is a great challenge. several points need to be checked for planning a better adequacy and survival of dialysis technique in children waiting for a graft. a rigorous follow-up protocol seems helpful in precocity of prescription strategy modifications. we observed a stable long-term outcome observing these adequacy tools. outcome the recurrence of primary disease in transplants is a well-known problem. we report our single centre experience to assess the frequency of the recurrence of primary glomerulonephritis in children after renal transplantation. medical reports after of children with primary glomerular disease were evaluated. the grafts were nine from living related and four from cadaveric donors. eight of them were diagnosed as fsgs, of them mpgn and of them pan. the mean age was . ± . years. however the median transplantation duration was months, one of the fsgs patient had hyperacute rejection. five years later she had second graft with the serum creatinine . mg/dl at th year of second transplantation. and all recipients were immunosuppressed with either cyclosporin a or tacrolimus, azothioprine or mmf and steroid based regimens. mutational analysis was available in two patients, they had homozygous podocin mutations. post transplant recurrence of fsgs was confirmed in one patient. glomerular tip lesion was the only histologic abnormality on graft biopsy. he has treated with plasmapheresis with no improvement of proteinuria. two of the fsgs patients had thromboses after transplantation. one of them had cardiac thrombosis with heterozygote mthfr mutation and one of them had renal artery thrombosis and loss of graft with prothrombin a mutation. both of them have had additional risk factors for thrombosis. they have all functioning grafts except one. we have not observed any recurrence in patients with pan and mpgn. although the number of our patients quite small, renal and patient survival seems to be more favourable in our experience but we strongly recommend the evaluation of all risk factors of thrombosis and give appropriate anticoagulation. skin involvement in factor h deficiency (fhd) associated to hemolytic uremic syndrome (hus) has never been reported. we describe the case of a young adult on regular hemodialysis (hd) for fhd-hus who developed microangiopatic skin lesions and was successfully treated with plasma exchange (pe). the patient developed end stage renal disease secondary to fhd-hus (scr ) in , when she was . after one year of hd she complained of severe night pain in the perimalleolar areas, followed by skin lesions which evolved into superficial ulcers (fig ). in august , due to the worsening of the skin lesions, the patient started hd and pe ( litres of fresh frozen plasma per session twice a wk) based on the hypothesis that skin lesions were expression of thrombotic microangiopathy. after wks of pe there was a skin improvement (fig. ) and a pain relief. pe was discontinued. wks later she started to complain of the usual pain in the right foot. pe program combined to hd was restarted and the symptoms ceased again. pe was gradually discontinued and she was addressed to regular plasma infusion of . litre per wk. so far, after months the pain and the skin lesions did not show up again. m. belingheri, s. cristino, p. basile, v. bianchi, a. leoni, s. testa, l. ghio, a. edefonti, g. ardissino ospedale maggiore policlinico irccs, mangiagalli e regina elena, pediatric nephrology, milan, italy background: in rapidly growing children on hemodialysis (hd), the determination of dry weight still remains troublesome. bioimpedance analysis (bia) is potentially helpful in quantifying the fluid to be removed but its specific role, in routine clinical practice, is not yet clearly set. the aim of the present study was to test the feasibility of prescribing ultrafiltration (uf) exclusively based on bia parameters. methods: differences in body weight, resitance (rx) and reactance (x-c) between pre-and post-hd were calculated in order to derive the equivalence between uf and bia parameters in a years old girl over a period of months. for consecutive hd sessions, uf was prescribed exclusively based on the derived uf-bia equivalence. this period was compared with hd sessions where uf was prescribed by the conventional approach. results. xc correlated with ultrafiltration better (r: . ) than rx (r: . ). bia-based compared with weight-based uf prescription showed a significantly lower number of hd sessions complicated by hypotension ( % vs. %), need of fluid reinfusion ( % vs. %) and a better quality of the hd sessions ( % vs. %). conclusion. prescription of uf solely based on xc is feasible and provides a better outcome compared to the conventional modality of uf prescription. we believe that this approach could be useful for any patients with low tolerance to uf or with problems in setting the correct dry weight. aim: the aim of the present prospective study was to determine the incidence of urinary tract infection (uti) and related abnormalities in children ages between - years. material and methods: all children between - years old whose admitting to first step health offices (routine controls and immunization) was screened for uti with urine dipstick test after education of minimum two persons from first step health offices according to protocol with two tertiary child care center and health directorate of izmir province in turkey between july and july . all patients with urine dipstick test abnormalities were referred to tertiary child care centers for evaluation. urine microscopic evaluation and urine cultures and other further investigations were performed in tertiary care centers after obtaining urine with urinary catheterization. results: . children ( % boys) were screened with urine dipstick test. the children's mean age was . ± . mo (median mo). screening test was found normal in . ( %) children. of ( %) of referred child were admitted to tertiary care centers and evaluated for uti. uti was demonstrated in children ( . % of screened and % of evaluated children's). uti incidence was found . % in girls and . % in boys. urinary tract abnormalities were found in children ( . % of screened and . % of evaluated children's). the most common urinary abnormality was vesicoureteral reflux ( patients). conclusion: the uti incidence was . % in children ages between - years, uti more common in girls than boys in this age group and only small group of children has urinary tract abnormality which is determined with routine urine screening. knowledgement: thank you for this opportunity to health directorate of izmir province. we describe ds post-peldrt in children with no known neurologic problems and discuss potential predisposing factors. a . kg girl with renal dysplasia was started on a calcineurin inhibitor (cni) one week pre-t and when her blood urea nitrogen (bun) was mg/dl. on admission for t, the bun had increased to , and her serum sodium (na) was mmol/l. post-t, she remained intubated and paralyzed to permit generous volume supplementation, including : replacement of her vigorous urine output (uop), initially with . % nacl in water. five hours post-t, her bun was and her na . after modification of uop replacement, her na normalized. on the morning of post-t day , paralysis was discontinued, but she did not awaken and had sluggish pupillary reactions. computed tomography of the head (cth) revealed diffuse cerebral edema, and brain death occurred. a kg adoloescent with polycystic kidneys was started on a cni days before peldrt. his bun and na then were and , respectively, and had not changed on the day of t. post-t, the patient was immediately extubated. with uop replacements as described above, his bun and na decreased from to and to , respectively, over hours despite adjustments in the na content of his intravenous fluids based on urine na levels. the patient then had a -second tonic-clonic seizure, followed by a -hour post-ictal state. cth was negative, and the patient recovered completely. we conclude that ds, caused by a rapid decrease in serum bun and thus osmolality, may complicate peldrt in settings even with older pediatric recipients or without excessive elevation of pre-t bun. other factors contributing to this ds may include relatively mild hyponatremia and cni effects on both pre-t uremia and seizure threshold. results: patients, predominantly males, ages between months and years old. the mean incidence of peritonitis was . episodes/patient months. fifty-seven patients ( %) had at least one episode of peritonitis.there were peritonitis, % percent from all episodes began at home, % caused by gram negatives, % by gram positives, % by fungus, % had a negative culture and in less than % it was not performed. the mean treatment time was days, % had a good response to initial empiric antibiotics (cefazoline and amicacine). the interval between the beginning of dialysis and the first peritonitis episode varied from to days, occurring in the first months in % of the patients. successful treatment occurred in % of the cases, % were transfered to hemodialysis, % had a consecutive peritonitis episode, and patient died due to mesenteric artery trombosis. conclusion: peritonitis occurred early in our patients. even though most of them have a good initial response, there is still a great amount that have complications leading to technique failure. continuous education for the patients and health team, aiming early diagnosis and treatment, are useful to preserve the technique and decrease morbidity and mortality associated to peritonitis. d. davis, j. emancipator, x. zhu, c. rosen objective: to assess for sd in p chronic kidney disease (ckd) patients before and after rtx. methods: we assessed symptom (sx) domains of sleep disorders: ) sleep-disordered breathing (sdb); ) insufficient sleep (is) (shortened sleep time or nap); ) excessive daytime sleepiness (eds); and ) restless leg syndrome (rls) using a set of standardized questionnaires in patients with ckd (age - yrs) including non-d non-tx (ndntx) (n= ), d (n= ), rtx (at least months post-tx) (n= ), and age-matched sibling controls (c) without known ckd. the presence of an overall sd was defined by positive responses in any of the sx domains. results: mean age (se) ranged from . ( . ) to . ( . ) in the pt groups (p> . ) without significant differences in gender, race, or congenital ckd. estimated mean gfr (ml/min/ . m ) (se) was significantly higher in the rtx group [ . ( . ) methods: in a prospective design, renal transplanted children, who had renal transplantation at least months before, at namazee hospital, were enrolled in our study. immunosuppressive regimen consisted of cyclosporine and prednisolone plus mycofenolat mofetil or azathropin. data regarding gfr, serum creatinine, electrolytes, lipids and c and c levels was collected at beginning, in one-month, and five-month intervals. cyclosporine was adjusted to - ng/ml based on c level. patients were divided into two c (< and > ng/ml) and two c (< and > ng/ml) subgroups. discussion: similar creatinine levels, drug dosage, and complications of c and c subgroups may be due to dependence of renal function to several factors other than cyclosporine dosage. regarding coefficient of variation, c was more accurate and reliable than c level. as there was no significant difference in mean c and c levels, and renal function at beginning and the end of the study, there seems to be no need to check c levels after renal transplantation. purpose: preparation is necessary in order to effectively meet the critical needs of the post-operative pediatric kidney transplant patient upon their arrival to the icu following transplantation. the increasing number of children requiring liver transplantation services has made it evident that it is important to have guidelines in place for their initial and often specialized post-operative care. methods: the main goal is to provide the child with appropriate post-operative care and to recognize and quickly address complications. therefore the icu nurse will: · monitor the patient continually and conduct full assessments a minimum of time/hour (airway, breathing, ventilation, perfusion, neurological status, etc) . · observe the incision for signs of bleeding, evisceration, and dehiscence. · treat post-operative pain. · update family with findings, etc. · see that appropriate post-operative studies (ultrasound, laboratory studies, etc) are completed. outcomes: nurses in the icu monitor the pediatric post-operative kidney transplant patients very closely as outlined. this allows for quick recognition of problems and immediate intervention. it is the practice of these nurses to be fully aware of the patient's status as well as any changes that might be problematic. conclusions: nurses are prepared to care for pediatric kidney transplant patients and very carefully follow established guidelines for assessment. following guidelines for assessing and caring for pediatric kidney transplant patients upon admission to the icu has proven to be affective in allowing nurses to quickly recognize complications and notify the appropriate clinician. background: uremia is an independent cardiovascular risk factor. transplantation increases life expectations of patients with crf, however there is still an increased risk of accelerated arteriosclerosis. the pulse wave velocity (pwv) is a non-invasive marker of arterial distensibility, it increases along with arterial stiffness, as an early indicator of arteriosclerosis. aim: to evaluate pwv values of transplanted (tx) children. patients, methods: pwv was measured with a pulsepen in tx (age , ± , years). two control groups were formed using a database of healthy children ( - years): one matched for age (a) and one adjusted for height and weight (h/w). blood pressure, heart rate, serum calcium (ca), phosphate (p) , and pth were also determined before transplantation and at the time of the pwv measurement. results: tx patients were smaller by , cm (p< , ) than a and younger by , years than h/w (p< , ). pwv in tx ( , ± , m/s) did not differ significantly from a ( , ± , ) , however it was elevated in comparison to h/w ( , ± , p< , ). serum p, caxp and pth was increased before transplantation, all the values returned into the normal range except for creatinine ( ± micromol/l) at the time of the study. there was no correlation between pwv and the actual values of ca, p and pth. conclusion: pwv is higher in transplanted children as a sign of increased arterial stiffness. controls matched for height and weight should be used in states of severe growth failure. although a number of established risk factors potentially responsible for arterial dysfunction were present before transplantation, they were normal at the time of the study. the long lasting effect of uremia before transplantation could be in part responsible for the increased pwv in children after transplantation. supported otka-t -fo -f and ett / . d. derakhshan , h. jalaeian , a. derakhshan department of pediatric nephrology, shiraz, iran shiraz organ transplantation center, nemazee hospital, shiraz, iran backgrounds: bartter syndrome is an inherited recessive autosomal tubulopathy characterized by hypochloremia, hypokalemia, metabolic alkalosis associated with potassium renal leakage, and normal blood pressure despite increased plasma renin activity. patients with this syndrome may have proteinuria or hematuria, but most of them have normal gfrs. here we report on a child with bartter syndrome who developed esrd (end stage renal disease) and underwent successful cadaveric kidney transplantation. case presentation: a -year-old girl presented to the pediatrics nephrologist with failure to thrive, severe hypokalemia, hypochloremia, metablolic alkalosis, and normal blood pressure and the diagnosis of bartter syndrome was considered for her. however, due to poor compliance, she did not receive any medications, did not give consent for kidney biopsy and did not attend her opd follow-up visits for about years, when she developed esrd and went on chronic hemodialysis ( /weeks) . her little sibling also was diagnosed to be suffering from bartter syndrome at this time. after months, she received a cadaveric renal allograft. afterwards, her kidney function, serum electrolytes, and growth have improved dramatically. discussion: in this case, we postulate that long-term hypokalemia due to bartter syndrome led to chronic interstitial nephritis and renal dysfunction. successful renal transplantation, even after the onset of esrd, for severe clinically bartter syndrome results in correction of metabolic abnormalities and excellent graft function. we propose that bartter syndrome should be considered as a possible cause of esrd and an indication for early renal transplantation, a procedure that results in a cure for the underlying disease and significant improvements in patient's quality of life. h. jalaeian , a. derakhshan , d. derakhshan , m. fallahzadeh , z. bazargani , m. basiratnia shiraz organ transplantation center, nemazee hospital, shiraz, nemazee hospital, shiraz, iran fasa university of medicine, pediatrics, fasa, iran shiraz university of medical sciences, pediatric nephrology, shiraz, iran background: obesity is a major issue in the end stage renal disease population. while studies evaluating the effect of obesity on transplant outcomes in adults have yielded varying results, this issue is even still more controversial in children. methods: in a cross-sectional design, pediatric recipients, aged - at transplantation and with normal graft function for at least months after transplantation, were evaluated. we grouped the data with regard to the body mass index (bmi) percentiles as group i (bmi > th), group ii (bmi < th), group iii (bmi > th), group iv (bmi < th). we compared the clinical and laboratory findings between groups i and ii and between groups iii and iv. obesity was defined as bmi > th and being overweight was defined as bmi > th. results: there were children ( males, females) with mean age at time of transplantation of . ± . years (range, [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , and mean follow-up of . ± . years. . % of children were overweight and . % were obese. no difference was found regarding age, height, duration of pretransplantation dialysis, or age at transplantation between groups i and ii and between groups iii and iv. (p> . ). further more, no difference was found in regard to serum creatinine, bun, glomerular filtration rate, and -year graft survival rates among obese and/or overweight and other children. no correlation was found between bmi and gfr (p> . ). conclusion: obese and overweight recipients can have excellent graft function and survival rates that are comparable to their non-obese counterparts. denying patients access to renal transplantation on the basis of obesity per se does not appear to be justified. d. derakhshan , h. jalaeian , a. derakhshan , b. sabet , m. fallahzadeh nemazee hospital, shiraz, iran shiraz organ transplantation center, nemazee hospital, shiraz, iran introduction: tb is an important cause of morbidity and mortality in renal transplant recipients, especially in developing countries. this study was done to identify the incidence of tuberculin test positivity before transplantation as well as the influence on outcome of graft function and patient survival in children who receive renal allografts. methods: all children with esrd who received a renal allograft between and were evaluated. as a routine pre-operative measure, a tb test was administered, using ppd. the ppdpositive recipients were compared with ppd-negative subjects, regarding age, gender, graft function, graft outcomes and patient survival rates. patients were divided into < mm versus > mm induration. results: the mean age of recipients was . ± . years (range, - ) with a male/female ratio of . : . the majority of children were on chronic dialysis with mean duration on dialysis of . ± . months. the tuberculin test was positive in . % of children; all of them received isoniazide prophylaxis on diagnosis of latent tuberculosis. overall, the -year, -year, and -year survival rates were . ± . %, . ± . %, and . ± . %. three year survival rate was not different among ppd positive or ppd negative individuals. ( . ± . vs. ± . %; p> . ) in addition, no difference was found for -year or -year graft survival rates (p> . ). also serial serum creatinine levels at -month, -month, -year, -year, and - year interval after transplantation was not statistically different (p> . ). conclusions: detection of latent tuberculosis infection is an important step in the control of tuberculosis among asymptomatic pediatric kidney transplant. with proper management, latent tb does not affect transplantation outcome among children. h. xu, q. shen, ss. ruan, yl. bi, yq. lu, x. wang children's hospital of fudan university, department of nephrology, shanghai, people's republic of china objectives of study: we have started the first pediatric renal transplantation project in children hospital in china from . survival of patients and grafts for the patients are %. the clinical features were analysed and specific problems related to drugs and infections were reviewed. methods: children ( ~ years old) underwent rtx. the duration of follow-up was months to months (average of . months). results: all the patients were on automated peritoneal dialysis prior to rtx. the transplanted kidneys came from cadaveric donors (one were a -year-old brain-dead boy). patients received il- receptor antibodies as induction therapy and the other one with alg due to high level of population reactive antibody. after the rtx, all the patients were on triple immunosuppressive treatment (prednisolone, mmf, fk or csa) . no patient developed postoperative complication and delayed graft function occured. during the follow-up, case suffered from calcineurin inhibitor renal toxicity and changed to rapamycin treatment, from acute respiratory distress syndrome due to infection and from elevated liver enzymes owing to drugs. one had acute rejection at months after the operation. a severe anemia appeared on him after the rejection recovered. the cause of the anemia was found by the positive of serum anti-parvovirus b igm and completely recovered from the ivig treatment. at latest follow-up, the mean serum creatinine level of the patients was . ± . umol/l and egfr was . ± . ml/min/ . m . some patients received a support from "shanghai child renal failure trust fund". conclusions: the improvement of surgical technique, adequate dialysis prior to rtx, rational use of medicine, financial support and regular follow-up are all important for improving the outcome. h. bunker-wiersma , , j-c. davin the area under the curve (auc) of cyclosporine is strongly related to the efficacy and toxicity of the drug and its variability is mainly determined by the absorption phase. close therapeutic drug monitoring (tdm) is warranted to optimise therapy, using more appropriate methods to estimate the auc, than trough concentration measurement. from july we started auc guided monitoring of cyclosporine therapy based on two concentration measurements, c and c . the results of this method are reported. methods: all paediatric renal transplant recipients treated with cyclosporine were included in the analysis. bayesian, model based estimation of auc values was performed at each out-patient visit or during hospital admission. calculated pharmacokinetic parameters, treatment efficacy data and side effects were collected over the month period after introduction. target auc values were derived from previous studies in adult patients: ng/h/ml in the first three months after transplantation and ng/h/ml after three months. results: early or stable post renal transplant patients were evaluated, divided in two groups (group i: < months after transplantation; group ii: > months after transplantation). in patients with trough concentrations below the therapeutic range, more than % auc's were in the therapeutic range in both groups. conclusion: auc guided monitoring of cyclosporine after kidney transplantation in children using c and c is practically feasible and presents the major advantage that c has not to be determined precisely hours after csa administration. it is more closely related to the total drug exposure as compared with trough concentration monitoring and isolated c . this method may facilitate the use of lower doses of cyclosporine and by this way limitside-effects. objectives: there is no satisfying data about reproductive functions after kidney transplantation in adolescence who have end stage renal disease (esrd) during childhood. we analysed the reproductive functions of kidney transplanted male adolescences. patients and methods: nine patients who followed between - were enrolled in the study. except one preemptively transplanted patient, all were on hemodialysis/peritoneal dialysis before transplantation. mean dialysis duration was ( - ) months. their ages ranged between - years (mean . ) at transplantation. at the urologic examination, their mean age was years. all patients had normal renal functions. results: all patients had normal testicular volume, libido and erectil functions. except one all patients had normal serum levels of lh, fsh, total and free testosterone. seven of the patients semens were available for analysis. / patients had normal sperm parameters. transplantation had been performed before adolescence period in these patients. one of these patients had been treated with intensive cyclophosphamide before. oligospermia was detected in , defective morphology in , low sperm motility in / patients. conclusion: although adult transplanted patients mostly have normal semen profiles; male children with end stage renal failure would not have normal spermatogenesis at the adolescence period; even after successful renal transplantation. in our study only patients had normal semen profile, even hormon levels were normal. renal transplantation age seemed to be more crucial than the duration of esrd, of primary diagnosis or previous cyclophosphamide usage. r. vilalta, j. nieto, e. lara, a. madrid, s. chocron hospital materno-infantil vall de hebron, department of pediatric nephrology, barcelona, spain background: inhibition of il- receptors by basiliximab is irreversible and extended in time (mean days). basiliximab (anti cd receptor) is used usually in the induction regime in our first cadaveric-donor kidney transplants. its re-use when chronic allograft nephropathy (can) develops could be useful. however some concern could exist related to possible adverse reactions (anaphylactic shock) linked to re-exposure to this drug because is an heterologous protein. less adverse reactions as lymphokine release syndrome has been described with the use of other monoclonal antibodies as the anti-cd receptor rituximab. objective: to describe our experience in the treatment with basiliximab of seven children with banf ii can. patients: seven children ( - years old (means . y.), boys, girls) showed biopsy-proved banf ii can. its period post-transplant ranged from to years (mean . y.) and their creatininine level from to mg/ ml (mean . ). all of them had been received at the transplant time basiliximab, tacrolimus or cyclosporine, mycophenolate and tapered steroids to reach . mg/kg/day in the third month post-transplant. when can developed, sirolimus was used in two patients, but was withdrawn due to increase of proteinuria. results: one dose of basiliximab ( mg/ . m ) was administered after steriod pulses ( mg/kg/day) in all patients. their basal immunosuppression was not changed. plasma creatinine diminished by % in four patients in the second week post-treatment and this improvement was sustained in two patients after one year follow-up. proteinuria did not change in any patient. in the course of this treatment no adverse reactions were observed. conclusion: ) use of basiliximab in can is safe and possibly useful. ) exposure to different monoclonal antibodies in paediatric kidney transplantation could be usual in the future; in the induction time, in the treatment of humoral rejection if exists (rituximab) and in the treatment of can. ) it is necessary to establish that exposure and re-exposure to different antibodies is safe and without major adverse effects as our limited experience supports. r. vilalta, e. lara, a. madrid, s. chocron, j. nieto hospital materno-infantil vall de hebron, department of pediatric nephrology, barcelona, spain background: there are limited knowledge of kinetics and pharmacodynamic effect of sirolimus in paediatric renal transplantatation. provided that sirolimus is effective and safe in combination with tacrolimus and mycophenolate (mmf), the initial dose needed, the evolution of blood levels and the steady state should be studied in order to optimise its clinical use. objective: to establish a possible correlation between dose/level ratio of rapamune and other parameters as age, gender or puberal state. patients and methods: between and , paediatric patients ( girls, boys) received a cadaveric kidney transplant. age ranged from to years (mean y.), and all of them received mmf and steroids. sirolimus were used from . to . mg/kg/day, to obtain levels between to ng/ml. results: dose/level ratio obtained allowed us to describe three types of patients: an infant-type i dose-level patient (age - y), a prepuberal type ii (age - y) and an adult-type iii dose-level patient (age - y). type i needed sirolimus between . and . mg/kg/day (sd± . ), type ii between . and . mg/kg/day (sd± . ) and type iii between . and . mg/kg/day (sd± . ) to obtain all of them a constant blood levels between and ng/ml. the same positive correlation was obtained regarding the puberal status. no correlation were observed regarding the gender. introduction: developing of diabetes mellitus after renal transplantation is one of the determining factor in the survival of the patient and the graft. in present study we assessed the carbohydrate metabolism status of ntx. methods: we analyzed patients' data about recently developed carbohydrate metabolism failure after ntx. children underwent ntx between - were investigated. thirty-nine children ( girls/ boys) underwent ogtt, who had no ptdm. we analyzed the incidence of ptdm/igt, the combination of immunsuppressive therapy, the number of transplants, the proportion of cadaver/living donor, hcv, blood pressure, lipid metabolism, bmi, graft function parameters and the time since ntx. results: ptdm developed in children ( %). four of patients required insulin therapy. we diagnosed igt in of with ogtt investigated patients ( %). all ptdm/igt patient got tacrolimus and continous steroid therapy. the dose of steroid was . mg/day in the ptdm/igt group vs. . mg/day no ptdm/igt (p< . ). during ogtt the trough level of tacrolimus was higher in the ptdm/igt group . ng/ml vs. . ng/ml (p< . ). in the other parameters we did not find any significant differences between ptd/igt and no ptdm/igt patients. discussion: the most important reasons in the development of ptdm and igt after transplant are steroid therapy and higher tacrolimus trough level. in transplant children we recommend the regular fasting glucose and ogtt examimation, the reduction of steroid and tacrolimus in case of stable graft function. otka f- , otka-t , ett / , ett / the introduction: measurement of plasma bnp is a novel noninvasive approach in the assessment of cardiovascular status. in our study we investigated the role of bnp in the monitoring of cardiovascular status of children with crf or renal transplant (ntx). methods: we examined children with crf (n= , boys/ girls, age: , year ( , - )) or ntx (n= , boys/ girls, age: , ) ). patients underwent echocardiographic investigations (ivs, lvedd, lvesd, pw and fs) and their bnp levels were measured (age matched normal values were used). other cardiovascular risk factors, such as hgb, htk, ca, p, creatinine and blood pressure were also evaluated. a correlation between bnp and echocardiographic results was calculated. results: the values of lvesd, fs and bnp levels of renal transplant patients were significantly better than those of crf patients (p< , ). the other parameters did not show significant differences. bnp levels were significantly higher in all age groups of crf patients as compared to the normal levels. in younger ntx patients this value was within normal limits. in older ntx patients, and in those that had their transplants a long time ago we measured higher bnp levels, which correlated significantly with graft function as well (p< , ). bnp showed a significant positive correlation with lvesd and a significant negative correlation with fs only in crf patients. the elevated bnp levels showed the worsening of cardiac function even when the echocardiographic parameters were still normal. the hgb, htk, ca, p and creatinine values were significantly better in ntx patients and showed no correlation with bnp. summary: bnp is an early, easily usable marker in diagnosing and following decreased cardiac function of both crf patients and after ntx. otka f- , otka-t , ett / , ett / c. garcia , v. bittencourt , s. vitola , e. didone , e. guerra , f. pires , a. tumelero , d. malheiros , v. garcia department of pediatric nephrology, porto alegre, brazil complexo hospitalar santa casa, department of nephrology and kidney transplantation, porto alegre, brazil complexo hospitalar santa casa, department of surgery, porto alegre, brazil the objective is relate the results of consecutive kidney transplants carried out in children in a single center. patients and methods: analysis of kidney transplants performed in patients less than years old, carried out from may to december . results: kidney transplants were performed. % of the patients were female, % were caucasian and % were african-brazilian. the mean age at the transplant was . ± . years. the most frequent etiology of renal failure was vesico-ureteral reflux/obstructive uropathy ( %), followed by glomerulopathy ( %). the donor was deceased in % and living related in % (parents %). the initial immunosuppression was cya+aza+pred in . %, cya+mmf+pred in , %, tac+aza+pred in . %, tac+mf+pred in . %, tac + mf without pred in . %. sirolimus was employed initially in cases. induction with okt /atg occurred in patients and received anti-il receptor antibody. the graft losses during years of follow-up were secondary to chronic allograft nephropathy in ( %), vascular thrombosis in ( . %), acute rejection in ( . %), recurrence of original disease in ( . %). there were transplants in patients with focal segmental glomerulosclerosis, ( . ) had a recurrence after transplant. eight were treated with plasmapheresis and % obtained a total remission. the survival of graft in the first, fifth and tenth year was: %, % and % respectively. the graft survival in the th year according the immunosuppression was % using azathioprin and prednisone, % with cya/aza or mmf and % with tac/aza or mmf. the patient survival in the first, fifth and tenth year was: %, % and % respectively, infection was the main cause of death. j. feber , p. geier , b. chaudry , h. wong , g. filler children's hospital of eastern ontario, division of pediatric nephrology, ottawa, canada london health science center, departments of pediatrics, london, ontario, canada successful pediatric renal transplantation (tx) should fully correct the metabolic abnormalities of end-stage renal failure. however, ckd may persist because of only half of the normal nephron endowment and other factors (ischemia, nephrotoxocity etc). height, bmi and blood pressure (bp) z-scores, cystatin c-gfr, hemoglobin (hb), serum pth, hco , cholesterol, mycophenolic acid (mpa) and sirolimus (sir) levels were analyzed retrospectively in tx recipients ( males, age . ± . years) at months post tx (t ) and at . ± . years (median . ) post tx (t ). data are expressed as mean±sd. height z-scores remained significantly lower than controls (t : - . ± . ; t : - . ± . , ns), growth failure occurred in % of pts at t and % of pts at t . bp z-score did not change from t to t , but hypertension was diagnosed in % pts at t and % pts at t . gfr (ml/min/ . m ) was . ± . at t and . ± . at t (ns), mean decline of gfr was . ± . %/year. hb z-score remained below normal at - . ± . at t and - . ± . at t (ns) and anemia was diagnosed in % and % of pts at t and t respectively, despite trough levels of both mpa ( . ± . mg/ml, pts) and sir ( . ± . mg/ml, pts) that would be considered adequate. hypercholesterolemia was detected in . % pts at t and % pts at t , whereas only . % of pts at t and . % of pts at t were labeled as obese. bone disease was diagnosed in . % pts at t and . % pts at t . we observed suboptimal growth, hypertension, hypercholesterolemia, bone disease and persistent anemia in a significant proportion of tx children despite iron supplementation, adequate mpa and sir levels and good kidney function. these ckd complications require careful monitoring and intervention. a. al midani , g. koffman , j. john , s. stephen , s. suzanne , r. lord royal free hospital, transplantation, london, united kingdom great ormond street hospital for children nhs trust, transplantation, london, united kingdom objectives: to document factors predisposing towards surgical complications over years in a single pediatric renal transplant centre. methods: we retrospectively analysed consecutive renal transplants between jan and dec . patients were divided into group , without complications, and group , with complications. we compared variables previously identified as risks for surgical complications between the two groups: live/deceased donor, donor and recipient age, gender and weight, side of organ donation, cold ischaemia time, single/multiple vessels, intraperitoneal/extraperitoneal approach, anastomosis to aorta/iliac vessels, thrombosis prophylaxis (changed from heparin to aspirin in oct ). results: / ( %) were complication free; % patients developed one or more surgical complication: wound infection / ( . %), wound dehiscence ( . %), prolonged ileus ( . %), lymphocoele ( . %). patients were re-explored: ( . %) for bleeding, ( . %) for graft repositioning. we observed ( . %) cases of renal artery stenosis. overall, ( . %) graft loss occurred secondary to thrombosis, % ( / ) prior to changing our prophylaxis from heparin to aspirin ( . % on aspirin). urological complications occurred in ( . %): ureteric leaks and ureteric stenoses. the variables between group and group were as follows: under kg: % v %, less than yrs old: % v %, intraperitoneal approach: % v %, anastomosis onto the aorta: % v %, no aspirin prophylaxis: % v %, other variables were the same in both groups. conclusions: % of patients developed surgical complications. a higher rate of surgical complications was seen in recipients under , using the intraperitoneal approach onto the aorta. the introduction of aspirin prophylaxis reduced graft loss due to thrombosis from % to . %. other variables did not affect the complication rate. m. medeiros , v. sharma , r. ding , s. valverde , am. hernández , p. garcía , y. fuentes , m. suthanthiran hospital infantil de mexico federico gomez, departamento de nefrologia, mexico, mexico weill cornell medical college, immunogenetics and transplantation center, new york, ny, united states the forkhead transcription factor foxp is highly expressed in cd +cd + regulatory cells (tregs). the foxp +cd +cd + cells play a central role in immune tolerance and tgf-β is reported to induce foxp expression in vitro. whether there is an in-vivo association between foxp and tgf-β is not known. we investigated the hypothesis that there is a positive association between foxp and tgf-β in children with stable renal graft function. parental written informed consent was obtained before enrollment in all cases. children with stable renal allograft function for a minimum of months were studied. a complete clinical examination was performed; peripheral mononuclear cells were collected for measurement of transcripts for foxp , tgf-β , tgf-β , and s rrna (house keeping gene) using by real time quantitative pcr assay. correlation between transcript levels was performed using pearson r. results: pediatric recipients of renal allografts were studied. tgf-β and foxp were highly expressed in peripheral blood mononuclear cells, and there was a highly significant and positive correlation between levels of mrna for foxp and tgf-β (r= . , p< . )), whereas no significant correlation was found between tgf-β vs. tgf-β (and tgf-β vs. foxp ). conclusion: foxp expression in vivo is strongly correlated with tgf-β expression in peripheral mononuclear cells of stable renal transplant recipients. introduction: studies suggest that pre-emptive lamivudine therapy improves survival in hbv renal transplants. however, long-term outcome is not well established. method: four chinese adolescents with chronic hbv infection were transplanted. they were put on cyclosporin a, mycophenolate mofetil and prednisolone. prophylactic lamivudine was given just before transplantation and was continued afterwards. hbv status and liver enzymes were monitored serially. results: four patients were transplanted at the age of . ± . ( . - . ) yrs old. they were followed up for . ± ( - ) months and no mortality was reported. alanine transaminase (alt) was only transiently elevated in the first months post-transplant in all cases and became normal afterwards. there was no hepatitis flare and liver function was normal at the last follow-up. hbeag and hbv dna were positive in patient before transplantation and remained positive at the latest follow-up. mutation in the ymdd motif of the hbv genome was detected in the same patient and undeterminable in the other three due to low virus load. this patient remained clinically stable with normal liver function except there was a rise of viral load from baseline. all grafts were functioning and there was one late acute cellular rejection which responded to treatment and there was no hepatitis flare. latest mean serum creatinine was ± ( - ) umol/l. conclusion: ymdd mutation and resistance to lamivudine treatment may happen but appear to have little clinical significance. our long-term results showed that renal transplant seems feasible and safe in this population up to yrs follow-up. there are no studies in mexican children (mx) . the aim of the study was to determine tacrolimus pharmacokinetics (pk) in mexican renal transplant children and compare it wih reported pk in aa and ca. methods: a seven point pharmacokinetic profile ( , . , , , , and h) was performed in ten children receiving tacrolimus as part of the immunosuppressive therapy, mean age was . ± . years, mean post transplant time . ± months. c and cmax were obtained directly from experimental points, the auc and t / was obtained with a non-compartmental model using winnonlin version . . results: in cyclosporine (csa) is widely used for immunsuppression in transplant recipients and for treatment of srns. however, patients can develop csa associated cutaneous side effects, e. g. hypertrichosis, skin cancer, and viral warts due to human papillomavirus infection. here we report on a -yearold boy suffering from a microdeletion syndrome ( q-) and srns (histology: minimal change nephropathy) starting at the age of years. since the initial combination therapy with corticosteroids and cyclophosphamide was associated with severe side effects (sepsis, leukopenia) and did not lead to sustained remission csa therapy was initiated. csa-treatment resulted in rapid clinical remission. however, after months the patient developed viral warts (hands, trunk and head), although csa trough levels were kept below μg/l. therefore, immunosuppression was switched to mmf ( x mg/day) resulting in sustained remission of srns and rapid disappearance of viral warts within months. conclusion: conversion to mmf may be a usefull treatment strategy in srns showing csa associated side effects like viral warts. - . were live related (lrd) and the remaining cadaveric (cad). were pre-emptive(pet). all received basiliximab induction hrs prior to surgery. in addition, induction immunosuppression consisted of tacrolimus and methylprednisolone. in all but patients, basiliximab was re-administered at day . patients, aged and yrs (one cad and other lrd respectively) developed acute noncardiogenic pulmonary oedema - hrs after transplantation. both children had renal dysplasia as primary cause of renal failure. both required delayed ventilation and were ventilated for to days respectively. there was a rapid rise in c reactive protein in both patients. both grafts had primary function, but the cad transplant subsequently developed acute tubular necrosis, and was eventually lost within weeks due to thrombotic micro angiopathy and severe acute antibody mediated rejection despite immunosuppression with sirolimus, mycophenylate, steroids and plasma exchange therapy. conclusion: we report a rare but serious side effect of basiliximab. to our knowledge, this is the first report of basiliximab induced non-cardiogenic oedema so early post transplantation and in such young children. early recognition and aggressive appropriate supportive therapy is vital for patient and where possible, graft survival. ( ); cmv seroconversion ( ); seizures ( ); hypertension ( ), uti ( ), adverse reaction to basiliximab ( ), delayed graft function ( ), acute rejections ( ), chronic allograft nephropathy ( ). patients had well matched kidneys ( or less mismatches), were poorly matched. grafts were lost from latter group, both were cad, had acute tubulointerstitial nephritis and tacrolimus toxicity and the other thrombotic microangiopathy and eventually acute antibody mediated rejection. chronic allograft nephropathy (can) is a complex phenomenon caused by underlying kidney disease and superimposed by environmental and genetic factors. we investigated the association of polymorphism in the genee nos with the can. nitricoxide is synthesized from l-arginine in vascular endothelial cells by nitric oxide synthase. endothelial nitric oxide plays an important role in endothelial dysfunction and involved in the inflammation. the gene encoding enos maps to chromosome q q . . a missense variant of the enos gene in exon shows a transversion of g to t at nucleotide position (g t) that results in a replacement of glu by asp at amino acid residue (glu asp). the aim was to investigate the association between can and g t polymorphism of the endothelial nitric oxide synthase gene. the g t mutation at exon of the endothelial nitric oxide synthase gene, enos gene polymorphism, was analyzed in turkish children with renal transplantation. the g t polymorphism of the endothelial nitric oxide synthase gene was determined by polymerase chain reaction and restriction fragment length polymorphism. were grouped according to stages of chronic kidney disease (ckd) as estimated by the calculated glomerular filtration rate (gfr, schwartz formula). measurements of structural and functional surrogates for cardiovascular disease (cvd) included intima-media thickness (imt) of the common carotid artery (cca), pulse wave velocity (pwv) and augmentation index (aix). aix and pwv reflect the degree of arterial stiffness and were calculated from pulse wave recordings at the arteria carotis and arteria femoralis (sphygmocor device). results: patients and healthy control subjects had a mean age of years. imt was not significantly different in patients and controls. significant differences were found in the aix, which was increased by %: the mean aix was in healthy subjects was - , % and in transplanted subjects - , %. pwv was increased by % ( , m/s vs. , m/s). both aix and pwv increased in parallel with the degree of renal impairment (stages of ckd). table . discussion: weight gain post transplant is multifactorial, like cultural, psychological and associated to steroids. weight gain was observed in general, patients with overweight or in risk of overweight didn't loose weight postransplant even they were aware of the consequences. introduction: tacrolimus is metabolized by cytochrome p a and has a narrow therapeutic range. we report a kinetic interaction between tacrolimus and amlodipine, a potent cytochrome p inhibitor, resulting in anuric acute renal failure. case report: a -year-old male renal transplant recipient received amlodipine, a calcium channel blocker as antihypertensive treatment while he was on tacrolimus ( . mg/kg per day). he presented first with diarrhea and developed subsequently, dizziness and fatigue, related to acute anuric renal failure, requiring hemodialysis for days. tacrolimus trough levels were in the desired therapeutic range ( - ng/ml) until recently. three days after introduction of amlodipine, tacrolimus trough levels increased to a toxic level of . ng/ml. after discontinuation of amlodipine, tacrolimus levels returned to the normal range in seven days and renal function recovered progressively. no polymorphisms in the expression of cyp a and p-glycoprotein were detected. discussion: tacrolimus is known to be a substrate of p-glycoprotein, responsible for drug secretion into the intestinal lumen and metabolized by enterocytic cyp a. amlodipine is a competitive inhibitor of cyp a. as no abnormalities of cyp a and p-glycoprotein were found, we suspect that drug interaction due to competitive inhibition of tacrolimus metabolism by amlodipine was responsible for these toxic effects. concomitant diarrhea might have played an additional role for increased tacrolimus serum levels, presumably in relation to diarrhea associated dysfunction of enterocytic cyp a and p-glycoprotein. conclusions: amlodipine and diarrhea increase tacrolimus blood concentration by inhibiting its metabolism. amlodipine should not be used in patients on tacrolimus. careful monitoring of tacrolimus blood levels is recommended in case of concomitant diarrhea. urinary tract infection (uti) remains a significant cause of infectious complications in renal transplant recipients. the aim of the study was to determine the frequency of uti following renal transplantation in our center. the records of patients (f/m: / ) who underwent renal transplantation were evaluated retrospectively. among them patients (f/m: / ) were found to have at least one episode of uti during follow-up. the records were examined for the age, sex, primary disease, and duration of chronic renal failure, donors, posttransplant follow-up and recurrence of uti. biochemical analysis of blood for renal functions, complete blood count, creactive protein and sonographic examination of patients were also recorded and results were compared with renal transplanted patient who did not develop any episode of uti (group ). the mean age of the group was . ± . years, while it was . ± years in the group . mean duration of post-transplant follow-up was . ± . years for group and . ± . for group . four patients ( . %) in group and patients ( . %) in group had vesicoureteral reflux (p> . ). five patients had single uti while patients had more than one uti. though we did not find any difference between girls and boys in terms of presence of vesicoureteral reflux, frequency of uti in girls was found to be significantly higher than in boys (p= . ). ultrasonographic examination of patients during uti in group revealed pyelonephritis in and hydronephrosis in patients. the most frequent microorganism causing uti was e. coli. age, donor source and etiology of chronic renal failure did not influence the incidence of urinary tract infection. our data suggests that urinary tract infection remains a frequent but mostly benign complication in the pediatric transplant population, especially in female gender. the growing population of transplanted patients requires the consideration of the potential side effects of the different treatment regimens. experience of the last decade with calcineurin and nucleoside reverse transcriptase inhibitors revealed important renal side effects. we describe a years old girl who was known to have liver failure related to wilson's disease (wd). she had orthotopic liver transplantation from her mother years ago and treatment with tacrolimus and mmf was initiated. although she was known to have proximal renal tubular acidosis secondary to wd, renal tubular functions were found to be normal within the three months of transplantation. two years after the transplantation lamivudine was initiated because of de novo hepatitis b infection in transplanted liver. a couple of months later she developed renal fanconi syndrome with metabolic acidosis, hypophosphatemia, glycosuria and aminoaciduria. she needed high doses of sodium bicarbonate and phosphate supplementation. tacrolimus was suspected to be the cause of late post transplant renal acidosis and was replaced by sirolimus. however, months later, at the th month of lamivudine treatment, she was hospitalized because of metabolic acidosis, mild hyperglycemia and inability to walk. electromyographic examination revealed myopathic changes while liver biopsy was normal with a normal tissue copper level. renal biopsy showed findings of karyomegalic nephropathy which could be the result of the action of antimitotic agents. we suspect that our patient's tubular dysfunction, myopathy and hyperglycemia may have resulted from mitochondrial dysfunction which is triggered by tacrolimus and augmented by lamivudine. however, randomized and prospective studies with large groups of patients are needed for definite results about mithocondrial side effects of these drugs. recombinant factor viia (rfviia, novoseven) is a new hemostatic agent that was initially indicated in hemophiliac patients. recently it has been used successfully for the treatment of bleeding in patients with thrombocytopenia, and acquired and congenital platelet dysfunction. epstein syndrome, also known as alport-like syndrome, is a rare autosomal dominant disease characterized by proteinuria, chronic renal failure, hearing loss, and thrombocytopenia with giant platelets. our group previously reported functional alterations of giant platelets of boy with epstein syndrome, who rapidly progressed to end stage renal disease during adolescence. the first nonheartbeating kidney transplantation at age was failed because of the severe postoperativebleeding irresponsible for traditional therapy (packed red cells, platelets, and fresh frozen plasma), result in immediate graft failure and the need for transplant nephrectomy. the second kidney transplantation was years later, after a single intravenous bolus injection μg/kg body weight rfviia, which was repeated one and hours after the surgery. rfviia successfully controlled the bleeding in the peri-and postoperative phase and no side effect and thrombotic complication occurred and his graft function is still stable after years. recombinant factor viia may have a potential role in the treatment of phenotypic bleeding associated with chronic kidney disease. cyclosporin a (csa) and mycophenolic acid (mpa) have a wide interindividual variability in their pharmacokinetics (pk). among others, intestinal p-glycoprotein (p-gp) expression and cyp a activity have been held to be responsible for that variability. in adult kidney transplant (rtx) patients, an influence of these gene polymorphisms has not been shown; however, there are no data in pediatric patients. we reasoned that such an influence might be masked in adults by confounding environmental factors accumulating over the decades of life. we therefore investigated a possible influence of gene polymorphisms of p-gp and cyp a on defined dose-adjusted pk-parameters in children with rtx (age . ; range, . - . yrs). pk parameters (auc, c ) were assessed , , , and weeks after rtx. real-time, rapid-cycle pcr methods were used for genotyping. the allele frequencies for the mdr c t allele (expression and in vivo activity of p-gp) of % and for the cyp a -v allele of % were comparable to those reported for caucasian populations. dose-adjusted pk parameters of csa and mpa were not significantly different in patients with and without the cyp a -v allele or patients with different mdr c t genotypes. along with that finding, neither of the polymorphisms investigated into was associated with renal function or the incidence of acute rejection episodes. we studied how the il- r β-chain becomes enriched in lipid rafts of activated human t cells, isolated by ficoll gradient and sheep red cell rosetting, and how its tyrosine phosphorylation, which requires its heterodimerization with the common cytokine r β-chain (βc), occurs there. imunoblots (ibs) of sucrose gradient fractions of cell lysates obtained during a -hour activation with phytohemeagglutinine (pha) showed the gradual, largely selective, translocation of the β-chain into rafts. as dimerization or lipid modification can be mechanisms underlying raft enrichment, we assessed lysates of pha-activated cells in ibs under non-reducing versus reducing and crosslinking conditions but did not see evidence of β-chain dimerization. however, exposure to cycloheximide to interfere with post-translational acylation, or to the palmitic acid analogue -bromohexadecanoic acid substantially diminished raft enrichment of the il- r β-chain. we next performed ibs of il- r β-chainand βc-immunoprecipitates from raft and non-raft fractions of activated t cells before and after il- treatment. we found that il- exposure triggers the translocation of small amounts of βc, accompanied by il- r β-chains, into rafts, resulting in its heterodimerization with the il- r β-chain and their tyrosine phosphorylation. all of these processes were attenuated in the presence of the il- r β-chain-blocking antibody daclizumab. we conclude that the raft enrichment of the il- r β-chain requires palmitoylation and provides the focal point for the formation of the highaffinity il- r via il- r β-chain-mediated "chaperoning" of few βcs into these domains, establishing novel raft-dependent mechanisms underlying cytokine r specificity and selectivity in human t cells. iga nephropathy (igan) is an immunecomplex disease resulting from a defect in mucosal iga response. food antigens have been implicated in the pathogenesis. gut permeability to antigenic substances is immature at birth and its maturation is delayed by early administration of antigenic foods while breast feeding accelerates this process. we aimed to evaluate if exposure to antigenic foods in early life is associated with a predisposition for igan in childhood. three groups including children with igan (group , n= ), primary non-iga glomerulopathies (group . n= ) and healthy controls (group , n= ) were formed. their parents filled a questionnaire regarding the age at diagnosis, gestation time, birth weight, feeding by breast milk, formula, cow's milk and complementary foods. all groups were similar for age, sex, gestation period, birth weight and the rate and duration of breast feeding. in addition, the rate of formula feeding was also similar in all groups. however, cow's milk consumption rate was higher in group and than in group . introduction of formula was earlier in groups and than in group . in addition, the children in group were younger than the other groups at the onset of feeding by cow's milk and weaning. roc curves predicted . , . and . months as the best cut-off age values for formula feeding, cow's milk feeding and weaning for predicting the presence of igan, respectively. ors for igan with respect to these cutoff levels were ( % ci: - ), . ( % ci: . - . ) and . ( % ci: . - . ), respectively. the results of this preliminary study indicate that early introduction of antigenic foods might increase the risk of future primary igan. results: they were males and females, with a male: female ratio of : . their ages ranged from months to years (mean . years), with a peak age of - years. the common presenting complaints were generalised oedema ( %); oliguria ( %) and hypertension ( % we report nine patients (three males) with mesangiocapillary glomerulonephritis (mcgn) from a single paediatric nephrology centre. the average age at presentation was . years (range . to . ). all had nephrotic syndrome. seven had mcgn type and two had mcgn type ii. six of seven tested had positive c nephritic factor. three patients responded well to steroids and ace inhibitors and received no further therapy. five had a good response initially but relapsed when steroids were tapered and one patient had a poor response to steroids. these six patients received calcineurin inhibitor (ci) therapy. four responded well with resolution of proteinuria. one patient relapsed when tacrolimus was withdrawn after months of therapy but proteinuria resolved after re-introduction of therapy. two patients had a poor response to ci therapy. one remains stable but with heavy proteinuria. the second patient (with mcgn type ii) initially had a complete remission of proteinuria on steroids but relapsed months after presentation while on prednisolone mg on alternate days. repeat biopsy showed % crescents. treatment with pulsed intravenous steroids, cyclosporin and mycophenolate mofetil was ineffective and she progressed rapidly to end stage renal failure. we conclude that ci treatment might be useful in mesangiocapillary glomerulonephritis. prospective, randomised controled trials are required to determine their place in the management of this disease. iga nephropathy (igan) is caused by a primary defect in mucosal iga response leading to increased antigenic stimuli reaching to bone marrow. enteric flora is important for mucosal and systemic immunity, and probiotics regulate specific and innate immunity by maintaining microbial balance in the gut. saccharomyces boulardii (s.boulardii), a probiotic, increases intestinal siga production, protects enteric infections and also prevents atopic and immunoinflammatory diseases. we aimed to evaluate the effect of s.boulardii on experimental igan, induced by oral polio virus vaccine (opv) administration to the mice. four groups of male balb/c mice (n= for each) were formed. groups i and ii were immunized enterally by opv at the onset, nd and th weeks. group ii was also given s.boulardii in drinking water throughout the study. group iii was given only s.boulardii, while group iv received no treatment. two weeks after the last opv dose, all the animals were sacrificed to obtain their kidneys for histopathological evaluation and all four groups were compared with respect to the severity of histopathological changes. while there was mild to moderate mesengial proliferation and widening, tubular atrophy, interstitial inflammation and fibrosis in group i, no remarkable histological changes in the other groups were noted. immunofluorescence microscopy revealed universal deposition of iga and some c in group i, while there was no iga or c deposition in the other groups. electronmicroscopy revealed mesengial proliferation along with matrix expansion, focal basement membrane thickening and electron-dense deposits in the mesengial area in only opv group and the other groups were normal. in conclusion, enteral s.boulardii administration prevented experimental igan development in mice. the aim was to assess the correlation of renal histopathological findings with clinical diagnosis in order to recognize the pattern of kidney diseases in our pediatric population. methods: a total of renal biopsies performed on children who presented to the surgical kidney hospital in damascus during a period of years were retrospectively reviewed. results: nephrotic syndrome alone accounted for % of all cases, followed by hematuria in %, mild to moderate renal impairment including allograft dysfunction in %, nephritic syndrome in %, and hsp in %. the most common histologic lesion was mcd in ( %). fsgs was the second most common lesion ( %) followed by mesangial gn ( %), mpgn ( %), post-infectious gn ( %), iga nephropathy ( %), membranous gn ( %), cns of finnish type ( %), alport syndrome ( %), interstitial nephritis ( %), nephronophthisis ( %), hsp ( %), acute rejection ( %), chronic rejection ( %), nephrocalcinosis ( %), crescentic gn of undetermined origin ( %), and lastly, % were completely within normal limits. familial and inherited diseases were encountered in %. histopathologic diagnosis was mostly useful in nephrotic cases. while in hematuria cases, the usefulness of the histologic findings in terms of therapeutic and/or prognostic point of view was definitely less. one of the reason for that in our series is perhaps because we still do not have facilities to perform electron microscopic evaluation of the renal tissue. however, controversy about the usefulness of renal biopsy in such cases is still there. conclusion: this study provides an important data on the pattern of pediatric renal diseases in our center and highlights the usefulness histologic findings in guiding the therapeutic plan especially for nephrotic children. aim: the aim of this study was to determine the efficacy of tacrolimus in the management of sr fsgs in children. study design: this was a prospective study of children with sr fsgs treated with tacrolimus ( . - . mg/kg per day in divided doses over hours adjusted to a trough level between - ng/ml) for months in combination with low dose steroids. other therapies included angiotensin converting enzyme inhibitors, folic acid, multivitamins and lipid lowering agents. results: the mean age at study entry was . years (range . - . ). the mean duration of nephrotic syndrome before initiation of tacrolimus therapy was . years (range . - . ). at the end of the treatment period ( %) children were in complete remission, ( %) children were in partial remission and ( %) failed to respond. the average period of follow-up following cessation of tacrolimus treatment was . months (range . - . ). at last hospital follow-up ( %) of children were in complete remission, ( %) in partial remission and ( %) in relapse. children demised from dialysis related complications following cessation of tacrolimus treatment. adverse events included sepsis ( ), nausea ( ) diarrhea ( ), anaemia ( ) and worsening of hypertension ( ) . conclusion: tacrolimus is a safe and effective treatment for sr fsgs. however, like cyclosporine some children tend to relapse following cessation of treatment. it has been rarely reported in association with graves-disease. now we present a previously healthy -year-old japanese girl who had proteinuria due to stage i mn and graves disease. patient: she was found to have + proteinuria and a goiter at her school medical examination simultaneously. serum free thyroxine was . ng/dl (normal range . ~ . ), thyroid-stimulating hormone (tsh) less than . microu/ml ( . ~ . ), anti-microsomal antibody t (~ ), anti-thyroglobulin antibody t (~ ), and tsh-receptor antibody % (~ ) consistent with graves' disease. the electron microscopy finding of her renal biopsy specimen showed the presence of electoron-dense deposits located in the subepitherial and intramembranous spaces. with immunofluorescence microscopy, the bright granular staining of igg along the gromerular capillary wall was found. these findings were characteristic of mn. objectives of study: to investigate whether graves disease caused mn in this patient. methods: we examined the presence of thyroid microsome and thyrogrobulin in glomeruli by immunofluorescence study using anti-thyroid microsomal antibody and anti-thyrogrobulin antibody. result: glomerular granular staining of thyroid microsomal antigens was demonstrated corresponding to igg granular deposits, but that of thyrogulobulin was absent. conclusion: mn in this patient is presumed to be caused by immunecomplexes mediated by thyroid microsomal antigens. objective: to explore the role of oxidative stress reaction on the injury of glomerular podocyte slit diaphragm molecular barrier. methods: thirty-two male spraque-dawley (sd) rats were randomly divided into control, low dose ( . mg/kg), nephrotic ( . mg/kg), overdose ( . mg/kg) groups by the dosage of adriamycin (adr) injection.the levels of malondialdehyde (mda) glutathione peroxidase (gsh-px), hydroxy radical ( . oh) and superoxide dismutase (sod) in renal cortex were measured; the expression of podocin was measured with immunohistochemistry. results: ( ) compared with control group, the levels of mda in renal cortex and -hour urinary protein were increased, the levels of sod in renal cortex was decreased in adr-treated groups, especially in nephrotic group (p< . ). ( ) in control group, podocin staining was a sable linearlike pattern along the capillary loops of glomerulus; in nephrotic group, podocin staining was a light tan discontinuous punctiform or short linear-like pattern along the capillary loops of glomerulus. compared with control group, the score of podocin immunohistochemical staining was decreased in adr groups, especially in nephrotic group (p< . ). ( ) there were some significant negative correlations between the score of podocin immunohistochemical staining and the levels of mda in renal cortex. there were some significant positive correlations between the score of podocin immunohistochemical staining and the levels of sod in renal cortex. conclusion: ( ) there was close relationship between podocin and the development of proteinuria. ( ) there were significant correlations between the reduction of podocin in glomerular podocyte slit diaphragm and oxidative stress reaction, especially lipid peroxidation. lupus nephritis (ln) remains an important problem in patients with sle. to evaluate the clinical course, histopathology and the efficacy and safety of high-dose pulse cyclophosphamide (ctx) in children with ln. retrospectively, children with ln were studied; all patients underwent renal biopsy and were followed up for at least years. the clinical and serologic data at the time of renal biopsy were recorded. five of them were excluded because of short period of follow-up or defective laboratory data. based on renal biopsy (who classification for ln), patients were treated with the following regimens: one patient (class i) with low-dose prednisolone (pred), (class ii, iii) with high-dose of pred, (class iv) with high-dose pred and received intermittent intravenous (iv) ctx pulses (monthly for months, then every months) followed by mycophenolate mofetil (mmf) as maintenance therapy. there were girls and boys. the mean age at the time of diagnosis of sle was . years. eighteen patients were more than years old. sixty percent of the patients were presented as nephritic-nephrotic syndrome. there was with class i, with class ii, with class iii, with class iv and none with class v based on biopsy. eighty-five percent of cases went in remission, one was hemodialytic and died due to renal failure and cns involvement. among cases with class iv, responded to pred and iv ctx pulses. there was no evidence of side effects. it seems that iv pulse ctx does induce remission of clinical and renal disease in the majority of early diagnosed children with severe ln. furthermore, it appears that mmf is an appropriate drug for maintenance therapy. however, this study was based on a small number of subjects. further studies to confirm the long-term efficacy and safety of ctx pulse therapy on larger numbers of patients are needed. forming group i were compared with children on short course steroid therapy (iskdc regime) (group ii). children were examined for steroid side-effects and underwent blood tests, ophthalmologic evaluation and radiological examination. results: though remission was achieved in < weeks by % in group ii against % in group i, the total dose received ( - mg/kg) was lower in group i ( % vs %). forty-six % had - relapses, % had - relapses and % had - relapses. the proportion of children having > relapses was much higher in group ii ( % versus %). mean relapse/patient/ year was . (sd . ) in group i against . (sd . ) in group ii. delayed bone age ( %), radiological evidence of osteoporosis ( %). cushingoid facies ( %), posterior subcapsular cataract ( %), decreased growth velocity ( %) and hypertension ( %) were the side effects and were almost equally distributed in the two groups. more patients from group ii received a higher cumulative dose/ kg/year of > mg ( %versus % in group i) and these had higher risk for hypertension, delayed bone age and osteoporosis. conclusion: alternate day, prolonged therapy (soyka regime) compared to short course, daily therapy (iskdc) resulted in lower cumulative dose to the patient. acute side effects and severity of infections were less. mean relapse/patient/year were lower. group ii patients receiving higher cumulative dose had osteoporosis and delayed bone age. objetive: to assess urinary protein excretion decrease in patients with primary srns treated with ec-mps methods: cohort of patients, mean age: years with primary srns. inclusion criteria: primary sncr with of focal segmental glomerulosclerosis (fsgs). exclusion criteria: glomerular filtration rate (gfr) % than baseline level, leukopenia, absence of decrease of proteinuria excretion by month of treatment with ec-mps. mean time after the initial diagnosis of ns until the introduction of ec-mps was calculated in patients who decreased urinary protein excretion below nephrotic range and in non-responsive patients and the glomerular damage, interstitial fibrosis and tubular atrophy were classified as: absent, mild, moderate, severe ( to , risk grade> ). ec-mps dosing: - mg/m /day. complete response was considered a reduction in the urinary protein excretion lower than or equal to mg/m /hour; partial response: urinary protein excretion ranging from to mg/m /hour and absence of response: urinary protein excretion in the nephrotic range. laboratory monthly assessments: serum creatinine, urea, hemoglobin and blood cell counts, lipids, serum proteins, amilase, hours urinary protein excretion. . no significant differences in the frequency of both alleles were observed among patients with different grades of hypertension or proteinuria. in conclusion, drb * , and possibly alleles confer susceptibility to psagn. however the severity of the disease is not determined by these two alleles. methods: fifty children who diagnosed as biopsy-proven fsgs were studied retrospectively by medical records. response to treatment and pathologic slides, we compared normal renal function group (n= ) and decreased renal function group (n= ), assessed the factors affecting renal survival and progression to renal failure. results: the mean age at onset was / years, gender ratio m: f was . : and the mean duration of follow-up was / years. the overall renal survival rate was % at years, % at years. five-year survival rate was % in normal renal function group, but % in decreased renal functin group. between the two groups, there were no significant differences in age at onset, gender ratio, amount of proteinuria, incidence of hematuria, hypertension and mesangial hypercellularity. decreased renal function group showed higher serum creatinine level, poor response to treatment, higher percent of glomeruli with sclerosis, moderate to severe tubulointerstitial change and vascular change (p< . ). the prognostic factors of renal survival rate were same as above (p< . ). there were no significant factor has shown relations with the progression rate to renal failure. conclusion: we reviewed the factors affecting long-term outcome of fsgs. serum creatinine level, steroid responsiveness and the degree of glomerulosclerosis were significant prognostic factors. but, age at onset, gender, amount of proteinuria, incidence of hematuria and hypertension were not considered as a prognostic factor. a background: several studies have suggested that cyclosporine (csa) and methylprednisolone pulse therapy (mpt) may be effective for idiopathic steroid-resistant nephrotic syndrome (isrns) in children; however, the optimal regimen has yet to be established. the present study evaluated the efficacy and safety of years' treatment with csa (neoral) combined with mpt and prednisolone (psl) in such patients. methods: in this prospective study, children with biopsy-proved isrns were enrolled. all patients received csa and psl ( mg/kg every other day). patients who had focal segmental glomerular sclerosis (fsgs) additionally received mpt (methylprednisolone at a dose of mg/kg per day for consecutive days at weeks , , , , and ) . the dose of csa was adjusted to maintain a trough level from to ng/ml for the initial months, followed by to ng/ml for months to , and to ng/ml for months to . results: twenty-six patients were enrolled. their mean age was . ± . years. two-year follow-up was completed in patients. histological examination at study entry revealed minimal changes in patients, diffuse mesangial proliferation in , and fsgs in . at the end of the therapy, patients had complete remission, including who had occasional relapses of steroid-sensitive nephrotic syndrome, and had partial remission; the remission rate was . %. nephrosis persisted in patient. disease progressed to end stage renal failure in patient. serial renal biopsy at the end of the study showed mild signs of csa-related renal toxicity, including tubulointerstitial fibrosis in ( . %) of patients. conclusion: combination therapy with csa, mpt, and psl for years was clearly effective and produced a high remission rate without serious csa-related renal toxicity in children with isrns, in contrast to previous reports. objectives: patients with hemolytic uremic syndrome who do not require dialysis in acute stage usually have a good prognosis. however the spectrum of renal compromise is wide. we believed non-anuric patients with higher creatinine values in acute stage could have different evolution when compared to patients with lower values. aims: ) to analyze the outcome after a year and ) to determine if peak serum creatinine values in acute stage would be a prognostic marker. methods: patients, aged . months at hemolytic uremic syndrome, were analyzed. they were classified into groups: group i, complete recovery; group ii had subgroups: iia, microalbuminuria, and iib, proteinuria and/or high blood pressure, both with normal renal function; group iii, chronic renal failure; and group iv, end stage renal disease. peak creatinine value was definided as the highest value of at least determinations in acute stage. these data were available in patients and they were divided in those with creatinine equal to or higher than , mg/dl ( patients) and those with lower values ( patients). the relationship between creatinine and final outcome was analyzed. we applied fisher's test. results: after a mean follow-up of years, patients were in group i, in group iia, in group iib ( with hypertension, with proteinuria and with both) and in group iii. eight out of patients ( %) with creatinine equal to or higher than . mg/dl in acute stage and out of ( . %) with lower values were in groups iib and iii in the last visit (p= . ). conclusions: ) after years, % developed proteinuria, high blood pressure or chronic renal failure and % microalbuminuria. ) peak creatinine values in acute stage were a prognostic indicator. objective of study: the aim of this study was to assess the serum concentration of hs-crp in children with nephrotic syndrome (ns) treated with prednisone and cyclosporine a (cya). methods: patients were divided into groups: i - ns children ( - years) in relapse, examined twice: a -before treatment and b -after proteinuria regression (a - week course of prednisone therapy), ii - children with steroid-dependent or steroid-resistant ns, treated with cya, also examined twice: d -before treatment with cya, e - months after therapy. control group (c) consisted of healthy children. serum hs-crp level was determined using a nephelometric method with behring nephelometer analyzer, dade behring. results: it was shown that median hs-crp concentration was the highest in children with relapsing steroid-sensitive ns before treatment (ia). after proteinuria regression (ib), the hs-crp level decreased and did not differ from healthy controls (c) (p> . ). in group ii, before cya administration (iid) the level of hs-crp was normal, but increased after months of treatment (iie) up to a level six times higher that of the control group (p< , ). conclusions: in children with steroid-sensitive nephrotic syndrome in relapse, the serum hs-crp level is increased but returns to normal values after a - week glucocorticoid treatment course. in children chronically treated with cya due to ns, serum hs-crp level increases significantly during the therapy. slit diaphragm connecting adjacent foot processes of podocyte is the final barrier of glomerular capillary wall to prevent proteinuria. both podocytes and neuronal cells are terminally differential cells and they share many common features. nurexin is a presynaptic adhesion molecule that plays a role in synaptic differentiation, and they have been understood to be specifically expressed in neuronal tissue. we found that neurexins are expressed not only in neuronal cells but also in several organs including kidney. our immunofluorescence study shows that neurexins are restrictedly expressed in glomeruli in kidney. dual-labeling immunofluorescence studies show that neurexins are localized close to a cd ap. we also detected some portions of neurexin staining are coincident with that of rab a, a synaptic vesicle associated molecule. we found that a single splice variant of neurexin- is expressed in glomeruli. the staining intensity of neurexin in the glomeruli clearly reduced and their staining pattern shift to more discontinuous patchy pattern in puromycin aminonucleoside nephropathy and anti-nephrin antibody induced nephropathy. the alteration of neurexin in these models was detected more clearly and rapidly than nephrin. we confirmed that neurexin is expressed in podocyte also in human kidney section. these observations suggest that neurexin is involved in the development of proteinuria and that neurexin could be an early diagnostic marker of podocyte injury. to further elucidate the clinical relevance of t-cell abnormality in minimal change nephrotic syndrome (mcns), and to predict the consequences of mcns, we studied t-cell receptor (tcr) diversity by analizing cdr size distribution and the frequency of v repertoire usage. thirty-six pediatric patients with mcns were enrolled. eighteen were frequent relapsers and/or steroiddependent (fr/sd) and were non-frequent relapsers (nfr). the study was performed to analyze serial changes of tcr v repertoires in the two groups of patients. frequencies of v repertoire usage were determined by flowcytometry, and tcr cdr length distribution was analyzed by genescan. in nfr patients, abnormalities in the distribution of v repertoires were few in both cd + and cd + t cells. in fr/sd patients the patterns were normal in cd + t cells, while selected v repertoires were significantly increased in cd + t cells in some patients. furthermore, tcr diversity was significantly reduced in both cd + and cd + t cells in fr/sd patients as shown by marked skewing of cdr size distributions. it is noteworthy that in some fr/sd patients the initially abnormal tcr diversity improved as the clinical symptoms improved such that they became nfr over the years. analysis of tcr diversity may delineate the subgroup of patients with fr/sd and provide a rationale for early intervention with immunosuppressive therapy for these patients. background: transforming growth factor-β is known to play a role in the interaction between metabolic and homodynamic factors in mediating accumulation of extracellular matrix in the diabetic nephropathy. tgf-β gene polymorphism was associated with circulating tgf-β levels and influenced the pathogenesis of fibrotic diseases including diabetic nephropathy. in this study, we examined the relationship between tgf-β gene codon polymorphism and type diabetic nephropathy with more than -year history of disease. methods: we conducted a case-control study, which enrolled type diabetes. a total of patients with diabetic nephropathy were compared with patients without diabetic nephropathy. tgf-β codon genotyping was determined using polymerase chain reaction with sequence specific primers method. results: distribution of tgf-β codon genotype in the patients either with nephropathy or without nephropathy is confined to hardy-weinberg equilibrium. methods: nzb/w f female mice were distributed into three experimental groups (n= per group) according to age: , . and months. at specific time-point for each group, -hour urine and blood samples were collected to determine proteinuria, osmolality and creatinine levels. after sacrifice, kidneys were removed to measure chemokines and cytokines levels by elisa (pg/ mg of tissue). results: urinary flux was significantly lower at . than at and months. a significant reduction in creatinine clearance and an increase in proteinuria were detected at . and months when compared to months. no significantly changes were observed in serum and urinary osmolality. regarding inflammation, mcp- significantly increased at . ( . ± . ) and remained elevated at months ( . ± . ) when compared to months values ( . ± . ). kc was also higher at than at months ( background: nephrotic syndrome (ns) is related to immunological factors and renal inflammatory mechanisms. many studies showed that inflammatory mediators, especially interleukin- (il- ) and monocyte chemoattractant protein- (mcp- ), have a role in kidney injury. changes in their urine concentration were found in lupus nephritis and iga nephropathy. thus, the aims of this study were to evaluate il- and mcp- in serum and urine samples of pediatric patients with primary ns and to verify the relation between these measurements and protein excretion. methods: patients were divided according to current -hour proteinuria into two groups: lower than mg/ hours (group , n= ) and higher than mg/ hours (group , n= ). blood and -hour urine samples were collected and stored at - °c. il- and mcp- were measured by elisa standard methods. results: blood il- and mcp- did not differ between the groups. urinary il- levels (pg/mg of creatinine) were significantly elevated in patients of group when compared to group ( . ± . vs. . ± . , p< . ). although group also exhibited higher values of urinary mcp- ( . ± . pg/mg creatinine) than group ( . ± . pg/mg creatinine), they did reach statistical difference. conclusion: the inflammatory process in ns seems to be a local phenomenon, since blood levels of these chemokines were similar in all groups. moreover, our findings showed a relation between il- and the presence of proteinuria and suggested a role for this local inflammatory mediator in disease activity. the characteristics of iga nephropathy detected in school urinary screening iga nephropathy (igan) is one of common types of glomerulonephritis in children. however, progression to esrd in patients with igan is not as rare as originally thought. in korea, school urinary screening (sus) program, an useful tool to find out abnormal urinary findings, initiated in . igan was the most common histopathological change in children with isolated hematuria and/or proteinuira in sus. we studied to clarify the clinical and pathologic characteristics of iga nephropathy detected by sus in korea. we investigated patients (symptomatic group= vs sus group= ) had been diagnosed with igan following renal biopsy at the yeungnam univ. hospital between may and may . these patients were analyzed clinical nature, laboratory data and histopathologic findings (haas classification in lm) and progress, retrospectively. their mean age were . ± . and . ± . , respectively, at the time of kidney biopsy. gross hematuria and edema apt to be common in symptomatic group. there were no significant difference in serum iga level, estimated ccr, -hours protein amount, light microscopic class and electron microscopic findings between two groups. mesangial iga deposition was significantly more intense in symptomatic group with gross hematuria. in addition to iga deposition in capillary and immune dense deposition in intramembrane is significantly common in symptomatic group with nephrotic range proteinuria. however, progression to chronic renal failure was not noted in both groups during . ± . and . ± . months respectively. also there were no difference in outcome according to treatment modalities. a longer follow-up period is needed to obtain more information on progression of igan with nephritic range proteinuria by disclosing iga deposition in capillary and immunedense deposition in intramembrane. outcome of srns is uncertain and especially patients unresponsive to treatment have a high risk to develop esrd. prognosis has improved with the introduction of csa, however but long-term follow-up data are scarce and response to csa in patients with genetic forms of srns is uncertain. we report on patients with srns, that was diagnosed at a median age of . (range . - . ) years. treatment with csa was initiated on concomitant prednisone therapy, however steroids were discontinued after due course in all patients. median follow-up is . ( . - . ) years. patients had fsgs on renal histology and patients had mcns. complete remission (cr) was defined as reduction of proteinuria < mg/m /d. partial remission (pr) was defined as reduction of proteinuria of at least % and cessation of edema with serum albumine levels > g/l. results: patients ( fsgs, mcns) reached cr with csa treatment. in of these ( fsgs, mcns) csa could be tapered and discontinued successfully after a median time of ( . - . ) years. eight patients showed ( fsgs) a pr while patients ( fsgs) showed no repsonse (nr). of patients going into esrd had podocin mutations (pm). only one patient with pm showed partial remission on csa. our data indicate a positive effect of csa treatment in srns, especially in sporadic cases. in patients with cr tapering and even discontinuation of csa is possible. prognosis of srns has improved with csa treatment. objective: we planned to investigate the effects of rsv on the proteinuria and glomerular structure of rats and to explore the role of rsv in the pathogenesis of minimal change nephrotic syndrome. methods: sd rats were inoculated with , , and pfu rsv respectively, and sacrificed on days , , , and postinoculation (rsv , rsv , rsv , rsv , rsv ). renal histology was observed by light microscopy and electron microscopy. meanwhile, the proteinuria and serum parameters were measured. the rsv rna and rsv titer were determined by in situ hybridization and plaque assay respectively. immune complex deposits were detected by immunofluorescence microscopy. results: after inoculation, the urinary protein excretion was increased, especially in pfu rsv , , (p< . ). the serum albumin of pfu rsv , , and different-titer rsv decreased, but no significant differences in cholesterol, urea nitrogen and creatinine were found among all. slight hypercellularity in minority glomeruli and swelling of partial tubular epithelial cells were observed in rsv , of different-titer, whereas a relief of the above changes and no abnormalities were detected in rsv and rsv respectively under a light microscopy. extensive foot process effacement was observed in pfu rsv , , under an electron microscope. rsv rna signal and rsv titer of renal and pulmonary tissues, depending on the dose of inoculum, reached their climax on day postinoculation, especially in pfu rsv . no immune complex deposits were detected in the renal tissues. conclusion: our study reports for the first time that rsv can lead to nephropathy in rats on day - postinoculation, especially in pfu rsv-inoculated rats, which may be a new exploration of the pathogenesis of mcns. objectives of study: podocytes play an important role in maintaining the glomerular filtration barrier structure and functions, which associates with several podocyte-specific proteins. our previous study indicated the antiproteinuric effects of dexamethasone were achieved by changes the expression of certain podocyte molecules in vivo. the extracellular signal-regulated kinases regulates a wide range of cellular processes. the aim of the present study is to analyze the potential effects of dexamethasone on podocytes in vitro and to investigate its associated signal transduction pathway. methods: immortalized mouse podocyte clone was divided into three groups: the dexamethasonetreated group (dex-group), the dexamethasone with puromycin aminonucleoside-treated group (dex-pangroup), and control. in dex-group, cultured podocytes were treated with dexamethasone, while in dex-pan group, cells were treated with dexamethasone for min first, then added puromycin for different time periods. changes of the protein expression of podocyte-specific proteins and phosphorylation of erk were analyzed by western blotting analysis. result: compared with the control group, in dex-group, the expression of nephrin, podocin, cd ap, α-actinin proteins and vegf protein started to elevate at hr, while neph showed no obviously change. erk signaling pathways was activated. increased phosphorylation of erk was marked but transient, which increased from min to min, then decreased. at min the level of phosphorylation of erk returned to the baseline. the phosphorylation of erk level was significant raised in dex-pan group, and lasted to min. conclusion: dexamethasone alters the expression of certain podocyte-specific proteins not only in vivo but also in vitro, and in part, through the activation of the erk signal pathway. kh. kim minimal lesion in the renal biopsy of idiopathic nephrotic syndrome (ns) patients (pts) generally predicts a benign course. fsgs lesions in nspts, on the other hand, are associated with increased risk of steroid resistance and progression to renal failure. fsgs may be observed in follow-up biopsies despite being initially undetectable. whether this represents sampling error or the true natural history of this condition, earlier markers of steroid resistance and poorer prognosis could prove helpful. renal morphometric analyses was performed in ns pts, ages to years, initially diagnosed with minimal lesion, with (n= ) or without(n= ) subsequent progression to fsgs or end stage renal disease (esrd), along with controls ages to years. the age of patients in progressive and non-progressive group and controls were similar. gbm width in patients with minimal lesion ( ± nm) who subsequently progressed, was significantly greater than that in non-progressive group ( ± nm, p< . ). gbm width in both groups was not significantly different compared with the controls ( ± nm). average foot process width was increased in patients both with progression and non-progression as compared with controls, but there was no significant difference between progressive and nonprogressive group. the length density of podocyte detachment per gbm surface was not significantly different between progressive, non-progressive groups and control groups. there were no significant differences in the mean glomerular volume and cortical interstitial volume fraction between progressive and non progressive group. in conclusion, gbm width may help to differentiate between progressive and non-progressive groups in minimal lesion nephropathy. this may be a pathogenetic clue and needs further study. objective: our study is to investigate the correlation between clinical features and pathological characteristics on henoch-schönlein purpura nephritis (hspn) and the therapeutic methods. methods: fifteen boys and five girls aged - years (median . years) with hspn were analyzed retrospectively. the clinical characteristics, laboratory data, pathological findings and therapeutic methods were investigated. results: the patients with isolated hematuria and isolated proteinuria, the pathologic patterns were lighter then gradeii b ; eight patients with hematuria and proteinuria and seven patients with nephrotic syndrome, the pathologic patterns of injury is more severe then gradeii b , whose pathologic patterns injury exceeded gradeii b is . %. twelve patients with nephritic-range proteinuria (> mg/kg.d) and nephrotic syndrome received corticosteroids, cyclophosphamide, heparin and dipyridamole treatment. nine of twelve patients received intravenous pulse methylprednisolone (mp) and pulse cyclophosphamide (ctx). fourteen of twenty patients obtained stable remission after months to years, and five of twenty patients have asymptomatic microscopic hematuria, another one only has minimal proteinuria. conclusions: if the clinical features showed nephritic-range proteinuria or nephrotic syndrome, the renal pathologic changed markedly as well. for patients whose pathologic exceeded grade iii b or have renal tubule and interstitial damage, our study suggests that mp pulse therapy have satisfied curative effect. materials and methods: in experiment , higa mice, c bl/ mice and balb/c mice were inoculated intravenously with live cb and inactivated cb once a month from to mo of age. in experiment , higa mice, c bl/ mice and balb/c mice were inoculated intravenously with live cb and inactivated cb once at wk of age. mice in the control group were inoculated with vehicle. the kidneys were extirpated from mice of each group killed with time after inoculation for histological evaluation. experiment : we examined prostaglandin (pg) synthetic activity of cultured human mesangial cells. results: the scores for mesangial iga deposition, pcna-positive and matrix scores at weeks were higher in higa mice with live cb than in higa mice with inactivated cb or without cb . on em examination, swelling and detachment of endothelial cells from hours after inoculation and increase of serum ifn-gamma concentration were found in mice with live cb . the scores for mesangial iga and igg depositions, pcna-positive and matrix scores at weeks were more frequently found in balb/c mice with live cb . production of pge and txb significantly increased in cultured human mesangial cells damaged by live cb . conclusion: these results suggest that cb provokes exacerbation of renal pathological findings in higa mice via endothelial injury and ifn-gamma production, and may play important roles in igalike glomerulonephritis pathogenesis. rapidly progressive glomerulonephritis (rpgn) is a rare occurrence in alport syndrome (as). this report describes the case of a -year-old malewith as who developed rpgn and considers the cause of rpgn in this patient. he had a history of persistent hematuria and proteinuria since birth. at the age of years, he was diagnosed with as based on a renal biopsy. he developed nephrotic syndrome at the age of years. before administration of cyclosporine (cya), repeated renal biopsy was performed at the age of years. the biopsy specimen showed pathologic lesions characteristic of as without crescents. using immunofluorescence (if) staining, the expression of alfa- chains of collagen iv was found to be absent in the glomeruli. therefore, cya was administered for eight months. although he recovered from nephrotic syndrome, the effect of cya was limited. after the cessation of cya, his renal function slowly exacerbated. at the age of years, the administration of angiotensin receptor blocker was started. no subsequent anti-proteinuric effect was noted and his renal function improved to cr . mg/dl. however, by the age of years, he showed macrohematuria and acute deterioration in renal function to cr . mg/dl. subsequently, he underwent a third renal biopsy. on light microscopy, the biopsyspecimen showed diffuse cellular crescentic glomerulonephritis. if findings indicated pauci-immune type and electron micrography showed a few subepithelial deposits. a serological study revealed negative results for mpo-anca, pr -anca, and anti-glomerular basement membrane antibody. despite immediate treatment with pulses of methylprednisolone, cyclophosphamide, and plasma exchange, he progressed to end stage kidney disease. the patient reported here presents either a super imposition of rpgn upon a preexisting case of as or a new morphologic and clinical presentation for as. the wt gene encodes a zinc finger transcription factor involved in kidney and gonadal development. mutations of the wt gene have been shown to cause denys-drash syndrome (dds) and frasier syndrome (fs). the association of early onset nephrotic syndrome progressing to renal insufficiency, xy pseudohermaphrodism and wilms' tumor characterizes dds. renal biopsy shows diffuse mesangial sclerosis (dms). fs is also characterized by xy pseudohermaphrodism and nephropathy, but patients have delayed kidney failure characterized histologically by fsgs. this report examines three girls with nephrotic syndrome related to mutations in the wt gene, but with normal female karyotype and development. two girls with early-onset steroid-resistant nephrotic syndrome presented classical wt mutations coding for an amino acid change (d n) and (r w) at exon that is typical of dds. both children were phenotypically and genotypically females. they developed end stage renal failure within years. one girl had a wilms' tumor on the right kidney. the third child was identified with heavy proteinuria at years of age. laboratory investigations revealed a protein level of . g/dl ( - g/dl), albumin . g/dl ( . - . g/dl). proteinuria worsened to g/ h and she failed to respond to prednisone. renal biopsy demonstrated fsgs in % of glomeruli. the splice site mutation ivs + g >a, known to be associated with fs, was found in this patient. karyotype was , xx and she had normal uterus and adnexae on ultrasound. angiotensin-converting enzyme inhibitors were prescribed but she still has heavy proteinuria without renal failure. the classical clinical presentation of dds and fs is out dated. pediatric nephrologists need to consider the possibility of these genetic syndromes in evaluation of females with steroid-resistant nephrotic syndrome. we aimed to compare the effects of cyclosporine (csa) or mmf with or without combination of vitamin a,d,e or n-acetyl-l-cysteine (nac). the study included rats in eight groups: control, nephrotic syndrome without treatment, treatment with csa, mmf, vitamin a,d,e, combination of csa and vit ade, combination of mmf and vit ade and combination of nac and vit ade. all rats except the control group were given adriamycin. blood samples were drawn and -h urine were collected on day and at weeks and . at the th week, -h urinary protein excretions in the treatment groups were higher and serum albumin levels were lower than that of th week and control groups (p> . ). at the th week, urinary protein excretions in group csa&ade was lower than of the groups of csa, mmf, mmf&ade, ade and nac&ade with non-significance (p= . , p= . , p= . , p= . , p= . ) . serum albumin in group mmf&ade and group ade were significantly higher than of control group (p= . , p= . ). serum albumin in group ade was significantly higher than that of groups of csa and csa&ade (p= . , p= . ). serum triglyceride in group mmf&ade was significantly lower than that of groups csa and csa&ade. serum creatinine in group mmf&ade was lower than that of the groups of csa, csa&ade, mmf, ade and nac&ade and was significantly lower than that of control group (p= . ). serum creatinine in group csa was significantly higher than of groups of csa&ade, mmf, mmf&ade (p= . , p= . , p= . , respectively). in group nas+ade, total oxidant was significantly higher and total anti-oxidant was significantly lower than other treatment groups (p< . ). we showed that the better effect on proteinuria, serum triglyceride and albumin and lower serum creatinine by adding vitamin a, d, e in the treatment of experimental nephrotic syndrome with csa or mmf. conclusion: ht is associated with known risk factor of progression of biopsy-proven gn such as s-cr or proteinuria. the crb is an important tool for studies focusing on the epidemiology of gn in the czech republic and serves as a basis for cooperation in this field. ( ), lupus-nephritis ( ), iga-nephropathy ( ), minimal change disease and membranous nephropathy (by ) were observed. the distinction of morphological variants of the fsgs was started recently (last months). among the patients with fsgs, which were biopsied during this short period ( ), all have had a tip-lesion. these patients were started cyclosporine a mg/m /day with complete ( ) and partial ( ) remission achievement after - months. thus, the focal and segmental glomerulosclerosis is the most frequent cause of the nephrotic syndrome in children. the focal and segmental glomerulosclerosis with tip-lesion is characterized by favourable course and good response to therapy with cyclosporine a during the short-time period. objectives of study: molecules of monocyte chemoattractant protein- (mcp- ), β-catenin and cytokeratin (ck ) express increased in cellular crescent, which is a severe pathological change in renal diseases. however, it is unknown whether these molecules in urine correlate to the number or extent of cellular crescents. methods: urinary molecules mentioned above were detected in healthy subjects and patients with renal diseases by elisa. the expressions of these molecules and macrophage (cd positive) in biopsy specimens were also investigated. results: significant higher levels of these molecules in urine were demonstrated in all patients with renal diseases compared with healthy subjects (p< . ), but the highest level in patients of the cellular crescent group. the significant correlations were revealed between these molecules in urine and the index of cellular crescents (r= . , r= . , r= . , p< . ), between these molecules in glomeruli and the index of cellular crescents (r= . , r= . , r= . , p< . ), and between these molecules in glomeruli and in urine (r= . , r= . , r= . , p< . ). conclusions: this study suggested that the detection of urinary mcp- , β-catenin and ck might become potential biomarkers for clinical diagnosing cellular crescent lesions and assessing cellular crescent extent in renal diseases. this study aims to evaluate the benefits and harms of levamisole in steroid dependent (sd) and frequent-relapsing (fr) nephrotic children. material and methods: a total of steroid-sensitive nephrotic children were recruited prospectively from january to december . females and males, ( %) fr, ( %) sd. mean age at the beginning of levamisole was , years. twelve didn't receive any alternative drug before, received cyclophosphamide. renal biopsy was perfomed in patients, had minimal change disease (mc), one patient had mc at the first biopsy and fsgs in the second. the patients were divided in two groups according to their steroid response: sd and fr. levamisole was started at a dose of , mg/kg/ h as a second line drug in order to try to prolong periods of remission. clinical and laboratorial controls were performed monthly. patients were evaluated as: total responders: when steroid withdrawal was possible, partial responders: when steroid reduction was possible, non-responders: no steroid modification in months. the responders used levamisole for one year. results: the response of frequent-relapsing patients was: % of total response, % of partial response and % of non-responders. steroid-dependent patients had % of total response, % partial and % non-responsers. only one patient developed leukopenia. now % ( ) are out of levamisole and in remission, % ( ) are still using levamisole(alone or low-dose of prednisone), % ( ) are using cyclosporin, one used cyclophosphamide and one is using low-dose prednisone. conclusion: levamisole is a promising alternative drug for nephrotic syndrome. the major advantage of levamisole is its steroid-sparing effect with minimal toxicity. conclusions: hypertension and renal insufficiency were less frequently seen in chinese children with fsgs, isolated hematuria as unique clinic presentation was common in fsgs. all pathological variants had tubular-interstitial lesions, but vascular lesions were rarely seen. most fsgs children with nephrotic syndrome were sensitive to steroid at initial stage, and easy to develop frequent relapse gradually, immunosuppressive agent may be helpful to elevate remission rate. the aim of the study was to assess whether the serum index iga/c can be a usefull marker of activity igan and hsn in children. twenty children with igan (mean age . ± . years) and children with hsn (mean age . ± . years) were retrospectively analysed. in all children urine analysis, gfr were checked and the levels of serum iga and c were measured before therapy, serum iga/c was than calculated. at the onset of illness, igan and hsn was diagnosed based on the renal biopsy in mean time . ± . years. changes in light microscopy were graded i-v according to the classification of who (cwho). all biopsies were scored for activity and chronicity index (ai max score , ci max score ) (pediatr.nephrol. , , heparan sulfate proteoglycans are present both as structural components of the gbm and as modifiers of growth factor signaling on the cell surface. in mcns the presence of certain hs epitopes inthe gbm is decreased. hsulf and hsulf are recently identified endosulfatases, that can remodel the sulfation pattern of hs and thereby control the availability and presentation of factors such as fgf and hgf to their high affinity receptors. sulfatase activity requires posttranslational modification by formylglycine-generating enzyme or sulfatase modifying factor (fge/sumf ) that is counteracted by its paralogue pfge/sumf . we demonstrated that podocyte, endothelial and tubular epithelial cell lines express mrna for sulf , sulf , sumf and sumf . we investigated the in vivo distribution patterns of these enzymes in human kidney specimens by in situ hybridization. in histologically normal kidneys (n= ) expression of hsulf mrna was largely restricted to peritubular and glomerular endothelial cells, where as hsulf mrna was weakly expressed in all glomerular resident cell types. expression of sumf and sumf mrna was present in a minority of mesangial cells and podocytes, as well as in avariable number of glomerular and peritubular endothelial cells and invascular smooth muscle cells. in mcns (n= ), the glomerular expression patterns of hsulf , sumf and sumf mrna did not differ significantly from that in controls. in contrast, hsulf mrna expression was increased in podocytes. increased hsulf expression by podocytes is a novel factor to be considered in the pathogenesis of mcns. the onset and duration of ins, histopathological changes in renal biopsy, results of corticosteroid therapy and proteinuria selectivity reflecting the alteration of glomerular capillary wall were analysed. materials and methods: children with ins aged - , followed up to month, and healthy children were studied. in all patients stage of ckd were diagnosed. ins children were divided in two groups regarding to serum cystatin c levels as a marker of gfr: group i (n= )children with unchanging gfr, ii (n= ) -patients with impairment renal function over the study period. serum total protein, albumin, cholesterol, cystatin c, creatinine and immunoglobulin igg, and urinary protein, albumin, igg and creatinine were measured. results: serum cystatin c levels were higher in both groups of ins patients compared to healthy children (gr. i: . ± . , gr. ii: . ± . vs . ± . mg/l; p< . ). in group ii amount of -hour proteinuria was significantly higher than in group i ( . ± . vs . ± . g/l; p<. ), however other biochemical parameters (including igg excretion, albuminuria, selectivity index) were not different. in group ii higher age of onset was found. in this group mesangial proliferation and focal segmental glomerulosclerosis more often were observed. conclusions: the age of onset, histopathological diagnosis and proteinuria can be considered as important markers of ckd progression in children with ins. probably, longer follow-up of children with ins is necessary to find other prognostic factors. k. kilis-pstrusinska, k. fornalczyk, d. zwoliñska cyclosporine a (csa) has been used as a therapeutic option for steroid-dependent and steroidresistant nephrotic syndrome (ns). the aim of the study was to assess the effects of long term csa treatment in children with ns. methods: we performed retrospective study to evaluate safety and efficacy of csa therapy in children with ns ( girls and boys), aged - years. results: before introducing csa, in patients steroid-dependent ns and in -steroid-resistant ns were observed. children presented symptoms of steroid toxicity. pre-treatment renal biopsy was performed in patients ( children without biopsy because of renal agenesia). minimal change disease was diagnosed in ( %) children, focal segmental glomerulosclerosis (fsgs) in ( %), mesangial glomerulonephritis (gn) in ( %) and membranoproliferative gn in ( %) cases. all children were taking csa (target blood trough levels - ng/ml) more than months, mean months (range - ). complete remission was achieved in ( %) children, partial in ( %). in ( %) patients csa treatment was continued with mild dose of steroids. patients ( %) did not respond to the therapy and one of them end stage renal failure developed. following side effects have been observed: hyperuricuria ( % of patients), hyperuricaemia ( %), hypomagnesaemia ( %), hypertension ( %), hypertrichosis ( %), gingival hyperplasia ( %), hepatotoxicity ( %), gastritis and ileitis symptoms ( %). in patients control renal biopsy was performed after - months of csa therapy. in patients progression to fsgs was seen. only in one case histological findings of csa nephrotoxicity occurred. conclusion: long-term csa treatment in children with steroid-dependent and steroid-resistant nephrotic syndrome can be consider as an effective and safe therapy. introduction: membranous nephritis represents a rare disease in childhood with an incidence of . to % in renal biopsy specimens among various types of glomerulonephritis. although in many cases the disease is considered as idiopathic the association of membranous nephritis and infectious agents it is also well known. aim: we report a case of a months old baby girl of asian origin, presented with macroscopic haematuria of glomerular origin, proteinuria, - gr/ hours, hyaline and granular casts, maculopapular rash on the legs and microcephaly. methods: renal function tests in terms of plasma urea and creatinine were normal. the renal biopsy showed membranous nephritis. tests for infectious diseases (torch screen) showed a primary cmv infection. this diagnosis was based on the presence of high level cmv specific igm antibodies, increased igg antibodies and low avidity of cmv specific igg antibodies. a real-time-pcr of the renal biopsy specimen was positive for cmv as well, confirming this virus as the causative agent of membranous nephritis in the presented case. treatment with gancyclovire per os was introduced and it was most impressive since proteinuria disappeared in the following two to three weeks. two years after the diagnosis the child remains well and asymptomatic. in summary: to our knowledge, among various infectious agents, there is no case of congenital or secondary nephropathy described so far due to cmv infection in children. objective of study: pulse methylprednisolone therapy (pmt) has been shown effective in proteinuric renal diseases. but its exact effect in children with steroid-sensitive relapsing nephrotic syndrome still has no definite conclusion. to evaluate the effect and adverse effects of pmt, we performed a retrospective study. methods: there were cases of steroid-sensitive relapsing nephritic syndrome received pmt. they all had been treated with oral prednisone in similar condition previously. a self control design was used to compare the effect of pmt and oral prednisone. results: the average age was . ± . years. ten cases attained complete remission after the first course of pmt, and the average duration of pmt until remission was . ± . days. one case attained complete remission after the second course of pmt. compared with the effect of oral prednisone previously, seven cases attained complete remission more rapidly. paired-samples t-test was performed to compare the effects of pmt and oral prednisone in six cases with very similar state, however, the difference between them was not significant (p= . ). during the treatment of pmt, adverse effects were found in cases. conclusion: compared with oral prednisone, the superiority of pmt had not been definitely confirmed, and adverse effects might appear during the treatment. therefore we should be very strict with administering pmt in children with steroid-sensitive nephrotic syndrome. the study we performed was retrospective, so it was necessary to design a prospective clinical randomized controlled trial to further evaluate its effect. objective of study: pulse methylprednisolone therapy (pmt) has been shown effective in proteinuric renal diseases. but the exact effect of pmt in children with steroid sensitive nephrotic syndrome (ssrn) still has no definite conclusion. to evaluate the effect and adverse effects of pmt, we performed a prospective study. methods: a prospective clinical randomized controlled trial was conducted to compare the effect and adverse effects of pmt with oral prednisone (op) in children with ssrn. thirty-one children were enrolled with only suitable for evaluation including patients in the pmt group and in op group. results: there was no significant difference between both groups in complete remission rate. the average durations of therapy until remission were . ± . days in pmt group and . ± . days in op group, respectively. complete remission was more rapidly attained in pmt group (p= . ; < . ). during the treatment and the following months, no significant difference of adverse effects was found between both groups. there was no significant difference between both groups in relapse rate during months follow-up. conclusion: compared with oral prednisone, pmt could induce complete remission more rapidly and did not company with more adverse effects in children with ssrn. pmt had no effect on the reduction of relapse rate in the following months after administration. outcome of childhood henoch-schönlein purpura nephritis with nephroticrange proteinuria in a single center objective: the majority of children with henoch-schönlein purpura nephritis (hsn) only with hematuria and/or mild proteinuria have good chances for recovery. however, it is still unclear how we should treat hsn with persistent massive proteinuria. the aim of this study is to evaluate the outcome of childhood hsn with nephrotic-range proteinuria treated with angiotensin converting enzyme inhibitor (acei) and corticosteroids. methods: patients with henoch-schönlein purpura ( boys, girls) ranging from . to . ( . ± . ) years old at onset visited our hospital between april and december . thirty seven ( . %) developed hsn. mean age of ( boys, girls) hsn patients with nephroticrange proteinuria (> mg/h/m ) at the time of diagnosis was . ± . years old. two developed nephrotic syndrome, but none had renal insufficiency at onset. one patient suffered moderate proteinuria and renal dysfunction years after the onset. renal biopsies were done in cases and showed for grade i, for grade ii and for grade iii respectively (classification by international study of kidney diseases in children). results: eleven of the patients received acei and no patients were treated with immunosuppressive agents except for corticosteroids and methylprednisolone pulses. after a mean follow-up of . years, patients showed complete remission, had mild proteinuria or microscopic hematuria, only one postpartum patient presented with nephrotic-range proteinuria, and none developed renal insufficiency. conclusions: our results suggested that the short-term outcome of childhood hsn with nephroticrange proteinuria but not renal insufficiency was relatively favorable. thus, the degree of proteinuria is not a sole prognostic factor for childhood hsn. therefore, the indication for corticosteroid therapy should be clarified. recent observations determined a r x specific exon mutation in the gene encoding nephrin (nphs ) which evidenced an unexpectedly mild finnish-type congenital nephrotic syndrome (cns) phenotype. the long-term follow-up of patients with this mutation is actually known only in a few patients. we reported the long term follow-up of a girl originary of sicily (italy) presenting such a mutation. the first years of her life were previously reported (s.guez et al pediatr nephrol ). in brief the child was pre-term born from related parents and she presented proteinuria ( - g/day) from birth. renal biopsy was consistent with the diagnosis of cns and molecular evaluation demonstrated a homozygous exon r x nonsense mutation in the nphs gene. in the first years she was treated by human albumin without a regression of proteinuria that decreased up to . - . g/day with enalapril treatment ( . mg/kg/day); clearance of creatinine at years of age ranged between and ml/min/ . mq. during the following years (at the last control the girl was year old) she had continued enalapril treatment ( . mg/kg/day). creatinine clearance was ml/min/ . mq/day, serum total protein g/l; serum albumin g/l and proteinuria ranged between . - . g/day. both height and weight were at th for age and pubertal stage was normal; blood pressure was / mmhg. in conclusion, this is the first reported long-term follow-up in an italian patient affected by finnishtype cns with the specific r x nonsense mutation in the nphs gene: even if proteinuria persisted there was no worsening in gfr. serum total protein, albumin and growth were normal confirming the milder phenotype in comparison with the typical finnish forms. long-term enalapril treatment may also have contributed to the prognosis in this specific form of congenital nephrosis. atypical hemolytic uremic syndrome (ahus) frequently results in end-stage renal failure and can be lethal in many cases. recently, it has been recognized that many cases of ahus are associated with a defective control of the complement activation cascade. more than sixty different mutations in complement factor h gene (cfh) have been reported so far. guidelines for treatment modalities are yet to be established although plasma infusions and exchanges are often advocated. we describe a patient who presented at months of age with ahus (anemia, thrombopenia, acute renal failure requiring hemodialysis) associated with heterozygous combined de novo complement factor h mutations (s l and v a) on the same allele. laboratory investigations showed normal levels of complement c , c and factor h. during the first episode, daily plasma exchanges (pe) using cryosupernatant (cr) as replacement fluid resulted in a resolution of hemolysis and complete normalization of renal function. two ahus recurrences were successfully treated with daily pe and subsequently pe were weaned to twice weekly. one year after the first episode, pe were stopped and pi regimen ( ml/kg twice weekly and weekly thereafter) was started. at the present time, the patient has been receiving weekly pi ( ml/kg) for one year. transitory falls in haptoglobin levels or platelet counts are observed periodically and successfully treated by intensification of pi ( ml/kg) twice weekly for one or two weeks. renal function remains normal.although our observation demonstrates the effectiveness and good tolerance of large volumes of pi ( ml/kg), long-term efficacy of such a therapy remains to be evaluated. because of the possibility of secondary failure of plasma therapy, it is important to investigate alternative approaches such as combined liver-kidney transplantation. common variable immunodeficiency (cvid) is characterized by reduced serum immunoglobulin levels and recurrent bacterial infections. there have been only previous case reports of renal granulomas in cvid and only one of them was associated with immune complex glomerulonephritis. we present a case of renal granuloma and glomerulopathy in a patient with cvid. a -year-old girl, with a past history of uveitis, presented with cardiac tamponnade and bilateral pleural effusions. investigations revealed nephrotic syndrome (serum albumin of (normal - ) g/l and proteinuria > g/l), microscopic hematuria and reduced serum igg levels ( . g/l, normal . - . g/l). lupus nephritis and serositis were first suspected and corticosteroids were initiated. no serum anti-nuclear or anti-dna antibodies, nor complement activation were detected. a renal biopsy was performed and showed global glomerular endocapillary proliferation. intratubular calcium deposits were present. in the interstitium, a noncaseating epithelioid granuloma was found. immunofluorescence studies showed significant mesangio-parietal igm deposits with few c and c q. as igm-immune complex glomerulonephritis has been reported in sarcoidosis, this diagnosis was highly suspected. further investigation revealed normal lung parenchyma and mediastinum, normal serum angiotensinconverting enzyme, . oh d , calcemia and calciuria. the nephrotic syndrome gradually improved, but serum igg levels remained persistently low ( . g/l). the diagnosis of cvid was confirmed and iv immunoglobulins were initiated. this is the first report of concomitant renal granuloma and igm-immune complex (without igg) glomerulonephritis in a cvid patient. in summary, cvid must be included in the differential diagnosis of renal granuloma and should be differentiated from sarcoidosis to ensure appropriate therapy. o. nwobi, c. abitbol, j. chandar, w. seeherunvong, g. zilleruelo background: rituximab, an anti-cd antibody, has been proposed as therapy for refractory systemic lupus erythematosus (sle), although its use in children remains anecdotal. we present our initial longterm experience on the safety and efficacy of rituximab for treatment of sle in children. methods: pediatric patients with sle refractory to standard treatment protocols were treated with rituximab for - doses ( mg/m ). all had proliferative nephritis and systemic manifestations of vasculitis. clinical disease activity was scored using the sle-disease activity index (sledai). proteinuria is reported as the urine protein to creatinine ratio (upr/cr). patients have been followed an average of . ±i. years. results: b cell depletion occurred within month and remained suppressed for up to months. clinical course, renal function and proteinuria improved in the majority of patients as summarized below: objective: to assess efficiency and safety of treating crns patients with srl. subjects: patients, mean age . years old ( yrs- yrs) ( females) affected by crns. inclusion criteria: histological diagnosis of focal and segmental glomerulosclerosis, glomerular filtration rate (gfr) above ml/min/ . m , negative plasma pregnancy test, signed child and parents informed consent. exclusion criteria: secondary nephrotic syndrome, white blood cells (wbc) count below /mm , chronic hepatopathy, coagulopathy, tumoral or infection processes. discontinuation criteria: sustained decrease in gfr by more than % of the initial rate, decrease of the wbc count to less than /mm , occurrence of lymphoprolipherative and tumoral processes, severe infection, alterations in coagulation parameters, positive pregnancy test or inflammatory process or lack of changes in proteinuria or its increase after four-month treatment. methods: srl dose and dosage: dose of to mg/m /day (up to mg/day) administered once a day. expected dosage range: to ng/ml (hplc-uv method). treatment duration: months. results: patients showed nephrotic syndrome remission; average srl dose: mg/m /day; average srl dosage: . ng/ml (range . - . ). average proteinuria prior to treatment: mg/m /hour (range - ); average proteinuria after treatment: mg/m /hour (range . - ); average time of remission: months and days, none of patients showed adverse events that would have lead to the treatment discontinuation. if these data are representative of the universe of patients we are dealing with, the confidence interval (p= . ) of the percentage of patients with not proteinuria after treatment is going to be between % and % if patients are assessed. conclusions: srl caused crns remission in patients who were refractory to traditional immunosuppressive treatments. background: retinoic acid-inducible gene-i (rig-i) may play an important role on inflammatory and immune processes by regulating the expression of various genes, and has been reported to be expressed in various inflammatory diseases. we studied the expression of rig-i in human lupus nephritis and evaluated the correlation between its expression and the histological activity of the renal disease in these cases. methods: expression of rig-i in the glomeruli was assessed by indirect immunofluorescence method; frozen sections of ten kidney tissue specimens obtained from eight patients with lupus nephritis were stained with a monoclonal antibody for rig-i. kidney tissue specimens from eight patients with minimal-change (mc) disease were used as controls. results: expression of rig-i was detectable as granular immunofluorescence in a mesangial and capillary distribution in all the patients with lupus nephritis, but was absent or only trace-like in the patients with mc disease. the glomerular immunoreactivity for rig-i was correlated with the histological activity and severity of the renal disease in the patients with lupus nephritis. conclusions: rig-i expression occurs at levels detectable by indirect immunofluorescence and may be potentially useful as a parameter reflecting the renal histological activity in cases of lupus nephritis. cyclophosphamide pulse therapy for crescentic, proliferative iga nephropathy in children iga nephropathy is one of the most common glomerular kidney diseases in europe, up to % of affected adults need dialysis after years. therapy of crescentic, proliferative iga nephropathy in children is not well examined. between / and / seventeen children (main age years ( - ), male/female= / ) with biopsy-proven mesangioproliferative glomerulonephritis as manifestation of iga nephropathy were enrolled. nine patients (male/female= / ) had severe clinical manifestations (renal failure, nephrotic proteinuria or cerebral vasculitis) with extracapillary glomerular proliferations (crescents). this children were treated by intravenous methylprednisolone pulses ( / / / mg/m body surface area over days) followed by monthly intravenous cyclophosphamide (cph) pulses ( x mg/m body surface area) with gradually tapered oral prednisolon ( - mg/m body surface area/ h over months) and aceinhibitor (enalapril . - . mg/kg/d). after months of treatment a significant reduction of proteinuria ( . ± . to . ± . g/m /d; p< . ) and improvement of kidney function (gfr ± . vs. ± ml/min/ . m , p< . ) was observed. no notable adverse events were recorded. six patients had a second renal biopsy after completing cph-therapy; only crescent was found in examined glomeruli (initial findings: crescents in glomeruli). after follow-up of ( - ) months all children have unaltered renal function, further episodes of macrohematuria or gross proteinuria did not occur. intravenous cph pulse therapy seems to be an effective therapeutic option in paediatric patients suffering from crescentic iga nephropathy. eye involvement in children with primary fsgs distinct eye abnormalities have been described in children with nephrotic syndrome, particularly in diffuse mesangial sclerosis (pierson syndrome). the aim of the study is to investigate whether there are any associated ocular anomalies in childhood primary focal segmental glomerulosclerosis (fsgs). demographic characteristics, age at onset, drug therapy and duration of the disease were defined in patients ( girls, boys, mean age . ± . years) with biopsy proven fsgs. standard steroid therapy was prescribed to the patients. a detailed ophtalmological examination was performed in all patients. the median age at diagnosis was years ( - years). mean followup time was months ( - months). eleven patients ( . %) reached to chronic renal failure during follow-up period. overall, patients ( %) showed various eye abnormalities. nuclear opacity was found inone child and posterior subcapsular opacities probably due to corticosteroid therapy were present in two cases. two patients had myopic astigmatism and two had exotrophia. importantly, patients had anisometropic ambliyopia, had mittendorf spots and had pigmentary changes in macula, which had never been described in the literature. mutational analysis for nephrin, podosin, wt and lamb genes are still going on. we don't know whether particular mutations are related to particular eye findings like pierson syndrome, yet. however our findings emphasize that ophtalmological evaluation should be performed in all patients with primary fsgs at the time of diagnosis. regardless of the underlying disease, the proteinuric condition demonstrates ultrastructural changes in podocytes with retraction and effacement of the highly specialized interdigitating foot processes. to investigate whether high glucose and advanced glycosylation endproduct (age) induce podocyte phenotypical changes, including quantitative and distributional changes of zo- protein, we cultured rat glomerular epithelial cells (gepc) under ) normal glucose ( mm,=control) or ) high glucose ( mm) or ) age-added or ) high glucose plus age-added conditions. high glucose plus age-added condition could increase the permeability of monolayered gepcs and induce ultrastructural separation between confluent gepcs. zo- moved from peripheral cytoplasm to inner actin filaments complexes by both age-added and/or high glucose condition in cutured gepc by confocal imaging. high glucose plus age-added condition also decreased zo- protein amount and its mrna expression to statistically significant level compared to normal glucose or osmotic control conditions. we could also confirm the activation of pkb/akt signaling pathway in gepc by age, high glucose and insulin in pi k-dependent manner. in addition, an inhibition of pi kinase by ly was able to prevent quantitative and distributional changes of zo- protein induced by high glucose and age. these findings suggest that both high glucose-and age-added condition induce the cytoplasmic translocation and suppresses the production of zo- at transcriptional level and these changes may be mediated by pi k/akt signaling. this pathway could explain the role of zo- in the phenotypic changes of podocytes in diabetic conditions. henoch-schönlein purpura (hsp) is common in the pediatric population, while wegener's granulomatosis (wg) is rare. although both diseases are classified into the vasculitis syndrome, their clinical symptoms, the treatment and the prognosis are considerably different. the classic clinical triad of wg consists of upper and lower airway disease, renal involvement and small vessel vasculitis. we present a rare childhood case in whom hsp-like symptoms were developed prior to wg symptoms. a -year-old girl developed ankle joint pain and swelling and purpura on bilateral legs and hands in the absence of abdominal pain. she was diagnosed as hsp and treated with oral prednisolone (psl) therapy. although high dose psl temporarily rescued these symptoms, purpura and joint swelling and pain reappeared in parallel with a reduction of psl dose. at this moment, because microscopic hematuria, mild proteinuria and hoarseness were also noticed for the first time, serum proteinase- antineutrophil cytoplasmic antibody (pr- anca) was evaluated and detected to be high. moreover renal pathology showed necrotizing pauci-immune glomerulonephritis, leading to the final diagnosis as wg. after methylprednisolone pulse therapy followed by oral psl combined with cyclophosphamide, her clinical symptoms with wg were resolved together with the reduction of serum pr- anca titer. taken together we emphasize that pr- anca should be evaluated even in the patients who only develop hsp symptoms. background: short-term efficacy of steroid therapy for pediatric patients with iga nephropathy (igan) has been reported. however, there are a number of cases in whom their igan recurs after stopping the steroid therapy. recent japanese study indicated that tonsillectomy had a significant impact on renal outcome. also, another japanese study showed mizoribine was effective for igan in children. in this study, we examined the effects of a treatment regimen consisting of tonsillectomy and steroid pulse therapy followed by mizoribine (tx) for chronic relapsing igan in children. method: ten cases who showed chronic relapsing igan were included as the subjects (mean age at onset: . yrs, mean age at initiation of tx: . yrs). they were divided into two group, a normal renal function group (group a, n= ) and an impaired renal function group (group b, n= ). the changes in hematuria, proteinuria, renal function, and adverse events were prospectively examined for more than months. result: a negative of hematuria was observed in % of group a and % of group b. a negative of proteinuria was seen in % of group a. in addition, in group b, deterioration of renal function was not observed during the observation periods. there were no serious adverse events associated with this treatment regimen. conclusion: a treatment regimen consisting of tonsillectomy and steroid pulse therapy followed by mizoribine treatment seems to be effective to control of acute inflammation coexisting with chronic glomerular lesions, and can be a valuable addition to therapeutic options for treating patients with chronic relapsing igan in children. objective of study: to present a case of silent stenosing ureteritis in a boy with henoch-schönlein purpura (hsp). case report: a -year-old boy was admitted with a typical hsp. urine findings were normal on admission. a gastrointestinal bleeding on the th day of illness suggested corticosteroid treatment. the ultrasound on the th and th day revealed a normal urinary tract. on the th day he developed non-painful macroscopic haematuria, followed by microscopic haematuria and proteinuria, which reached the nephrotic range on the th day. thus, the boy was treated with methylprednisolone pulses and cyclophosphamide for weeks. renal biopsy was not performed because of his parent's refusal. microscopic haematuria and proteinuria gradually subsided, with complete disappearance at the th month. during this time he was asymptomatic, with no episodes of macroscopic haematuria or colicky flank pain. at the th month of illness a new ultrasound revealed a major left hydronephrosis. computer tomographic urography showed a complete ureteropelvic junction obstruction. the mtc-dmsa scan revealed a % relative function ipsilaterally. a left pyelostomy was performed. during the next four months after draining, the urine volume of the affected kidney was . - . ml/kgr/hour, the creatinine clearance - ml/min/ . m and the mtc-dmsa scan showed a % relative function. based on the above findings a nephrectomy was decided. conclusions: although rare, stenosing ureteritis should be considered in hsp. the typical clinical presentation with haematuria in association with colicky flank pain may not always occur, as in the present case, or may be confused with the symptoms of hsp itself. thus, the repetition of an ultrasound during the process of the disease may be necessary, in order for this complication to be diagnosed and treated early, preventing serious renal outcome. mitochondrial diseases are either due to sporadic or inherited mutations mainly in mitochondrial dna located genes. with regard to renal manifestations, tubular dysfunctions are common; however, the existence of solitary glomerulopathy has recently become apparent. in such case, the pathomechansim of the glomerular proteinuria is still obscure. wepresent a year-old girl who was found to have asymptomatic proteinuria (up/cr . ) in the absence of hematuria, azotemia, tubular dysfunctions, lacking any neurological manifestations. her family history showed maternal inheritance with mild proteinuria of grandmother and renal insufficiency of young uncle. light microscopy revealed glomeruli of normal appearance and of global sclerosis. electron microscopy showed swollen mitochondria in podocyte of normal appearance glomerulus. pointmutation rate of mitochondrial dna, a g, was detected as less than % in grandmother, % in mother and % in the patient examined byperipheral blood cells. the proteinuria completely disappeared months after treatment with combined therapy of arb and acei. to determine the responsible molecule for the pathomechanism of proteinria, immunostaining followed by conforcal microscopy with slit diaphragm associated molecules (sdm) (nephrin, podocin), gbm associated molecules (type iv collagen alpha chains, laminin isoforms, perlecan) and podocalyxin was studied and compared to the controls. interestingly distinct decrease of expression with sdm was observed even in normal appearance glomerulus of the patient. taken together, a g mutation itself may lead to depletion of atp and/or increase of free radicals in podocyte, which predominantly affect the biogenesis of sdm, result in pathological glomerular proteinuria. the mechanism of antiproteinuric effect of arb/acei therapy should be evaluated by serial biopsy specimen. objectives: to report the effectiveness of pulse cyclophosphamide induction therapy in children with diffuse proliferative lupus nephritis. to identify predictors for unresponsiveness to the treatment. methods: thai children under years of age with biopsy-proven diffuse proliferative lupus nephritis who were admitted to chiang mai universityhospital between and were retrospectively studied. responsiveness to treatment, defined as urinary protein to creatinine ratio of less than . , was assessed at the end of induction period. the clinical characteristics and laboratory data including gender, age at diagnosis of sle, duration of disease before treatment, hypertension, clinical nephrotic syndrome, amount of proteinuria, serum creatinine, creatinine clearance, serum c level and presence of crescentic formation in renal biopsy were compared between the two groups who responded and did not respond to the treatment. results: a total of patients ( % female) with the mean age at diagnosis of sle of . ± . year were studied. nineteen patients ( %) achieved remission at the end of induction therapy. there were no significant differences in all parameters studied between responsive and nonresponsive groups. despite the indifference in the amount of proteinuria, the proportion of patients with nephrotic-range proteinuria was higher in unresponsive group. conclusions: pulsecyclophosphamide is an effective regimen for induction therapy in children with diffuse proliferative glomerulonephritis. although no definite predictor was detected in this study, higher proportion of patients with nephrotic-range proteinuria in the unresponsive group wasnoted. born small for gestational age, but not early postnatal weight gain aggravates the course of idiopathic nephrotic syndrome in children clinical and animal studies have shown a higher risk of an aggravated course of renal disease in childhood after birth small for gestational age (sga). fast catch-up growth after sga seems to support the development of later disease. in a retrospective analysis of cases with idiopathic nephrotic syndrome treated between and in a university centrefor paediatric nephrology we identified children as sga and asappropriate for gestational age (aga). we related the course of disease to birth weight and catch-up growth. median age of manifestation in sga was . ( . - . ) years vs. . ( . - . ) years in aga children. in all sga children renal biopsy was performed, while only % of the aga children underwent renal biopsy showing nodifference in renal histology. in the sga group, % patients developed steroid resistance (vs. % aga, p< . ). the number of relapses was not different. % sga children needed antihypertensive treatment inthe course of the disease compared to % of aga children. catch-up weight gain between birth and months of age did not influence the course of disease. in conclusion we could find evidence for an aggravated course of idiopathic nephrotic syndrome in former sga children, but weight gainduring the first two years of life did not influence the course of disease. the mechanisms of perinatal programming in later renal disease need further investigation. wilson's disease(wd) is a disorder of copper metabolism that affects numerous organsystems including kidneys. besides renal tubular dysfunction as a result of excessive storage of copper, renal manifestations due to therapeutic complications can also develope specially with d-penicillamin. in this study we investigated the frequency and spectrum of renal manifestations during d-penicillamin therapy in wd. of patients receiving d-penicillamin for wd, patients( . %) ( boys, girl) developed findings of glomerulopathy within month to year after initiation of therapy and all were histologically diagnosed to have membranoproliferative glomerulonephritis (mpgn). the patients were between - years old, and they had normal urinalysis and renal function tests in their first presentations. two siblings developed hematuria and proteinuria below nephrotic range while the other two developed nephrotic syndrome. one of these latter patientsalso had acute renal failure needing temporary peritoneal dialysis. three patients had low complement (c) levels, had antinuclearantibody (ana) positivity, two had c-antineutrophil cytoplasmic antibody (anca) and one p-anca positivity. d-penicillamin therapy replaced by zinc sulphate in all patients. all renal findings improvedin patients within - months with normal renal functions and complement levels, and negative ana, p and c-anca tests. after years all were clinically in remission of mpgn confirming the role of d-penicillamin in development of renal disease. objectives of the study: the use of tacrolimus in steroid-resistant (sr) focal segmental glomerulosclerosis (fsgs) has been reported in single and small series. the aim of this report is to exhibit experienceon the management of children with sr fsgs in whom tacrolimus had been started on due to the therapy resistance. methods: fk combined low-dose oral steroid was started on three male patients ( , , -yearold) with sr fsgs who had been following for three years. all of them had failed various cyclosporin a, cyclophosphamide and steroid regimens prior to treatment with fk . the application was . mg/kg/day in two divided doses over h adjusted to a trough blood level between and ng/ml for months. other therapies included angiotensin-converting enzyme inhibitors, vitamin d and calcium analogues, and lipid-lowering agents. results: a reduction in proteinuria to normal levels was noted between - weeks following the initiation. the remission was achieved overall during the treatment. the relapse was recorded following cessation of tacrolimus in - weeks. the drug was generally well tolerated with no sideeffects and adverse reactions. the ratio of infectious events did not differ from the former regimens. conclusion: tacrolimus may be effective in controlling the proteinuria of patients with srfsgs during the therapy. there is a trend of relapse following cessation of treatment. the duration for drug uptake is a topic of debate. further study in larger population is warranted. introduction: histological features of focal segmental glomerulosclerosis are found in % of pediatric patients with steroid resistant nephrotic syndrome. upto % (between - %) children with fsgs progress to esrd. objective: to study the clinical course of childhood fsgs and determine the possible predictive factors of chronic kidney disease. method: case records of children who had biopsy proven fsgs and had presented to the sindh institute of urology and transplantation between - , were retrieved. clinical and laboratory parameters at baseline, response to steroids and cyclosporine, development of crf (as defined by a gfr of < ml/min/ . m ), and histopathological details were analysed. result: a cohort of children with a mean age of . ± . years and a m: f ratio of : was identified. after a mean follow-up time of years, / ( . %) developed crf. on univariate analysis, male sex ( % vs %, p- . ), > years age at onset ( % vs. %, p- . ), hypertension ( % vs. %, p- . ) and microhematuria at presentation ( % vs. %, p- . ) were significantly associated with risk of developing crf. steroid resistant course ( % vs. %, p= . ) was more prevalent in those who developed crf. the crf group was also more likely to have an elevated creatinine at baseline ( . % vs. %, p< . ). moderate tubular atrophy and a high percentage of segmentally and globally sclerosed glomeruli were found in those who developed crf. patients progressing to crf were more likely to have a partial response to cyclosporine ( % vs. %, p= . ) conclusion: factors such as age, microhematuria, hypertension, elevated baseline creatinine, steroid resistance, tubular atrophy, percent global sclerosis and partial response to cyclosporine are likely predictive of progression to chronic kidney disease in children with fsgs presenting to our center. chronic glomerular nephropathies in children are marked by an often unfavourable evolution, so that the establishing of a prognosis at the time of the diagnosis is both a professional and a moral duty for the pediatric nephrologists. purpose: the estimation of the current practice renal survival prognosis in children with chronic glomerular nephropathies, by using clinical and laboratory elements in different histological forms of primitive chronic glomerulonephritis (cgn), with a minimum period of observation of one year. we analyzed parameters that may intervene in the duration of renal survival: type of cgn, age at the debut of the illness, histological scores of activity and chronicity, the presence of tubular atrophylesions and that of interstitial fibrosis, renal failure (rf) installment time, in cases with normal renal function at the beginning, the time until the initiation of dialysis in cases with esrf, respectively. the statistic analysis of data has been carried outwith epi soft (fishcer test). the results have been as follows: unfavourable evolution has been taken into consideration in the cases which have presented fixed nitric retention or which required the initiation of dialysis. the initiation of dialysis was necessary in cases ( %), out of which ( %) having associated between and of the considered risk factors. if the histological type (sfgs, dgs, mpgn) is added to the obtained score, the accuracy of the estimation increases to %. in conclusion: the usage of prognosis scores composed of current elements of diagnosis that have proven to have statistical significance, as far as the renal survival prognosis is concerned, may allow the invoking of a medium-term prognosis in the evolution of children with cgn. introduction: the srns can lead to a progressive deterioration of the renal function and therefore needs an aggressive therapy. one of the alternatives of treatment is the association described by mendoza et al which consists of prolonged use of methylprednisolone with cyclophosphamide (cp), which has a remission rate of %. the objective of this study is to evaluate retrospectively the clinical evolution of children with srns treated with mendoza's protocol. method: between and , children, male and female, with srns were subjected to a renal biopsy and later treated with mendoza's protocol. cp was used in children that had not responded to pulses of methylprednisolone and presented a relapse. all of the patients received supplemental calcium. the clinical evaluation included stature, weight, ophthalmic fundus examination, proteinuria in urine recollection of hours and/or protein to creatinine ratio and blood chemistry. results: eleven patients ( %) had fsgs. nine ( %) presented complete remission, two ( %) had partial remission, four ( %) did not respond to treatment, of which evolved to terminal kidney disease. nine patients received cp. of the complications secondary to treatment with steroids, % had a linear growth suppression and an increase in their bmi and patient presented cataracts with visual impairment. conclusion: the prolonged treatment with boluses of methylprednisolone and cyclophosphamide is a good alternative in patients with srns. the prolonged use of high doses of steroids can cause linear growth suppression and other adverse reactions, so it is advisable torealize a genetic study in all of the patients with srns to be able to exclude the patients that have a genetic mutation and so avoid unnecessary treatment. objectives: to study the clinicopathological profile and outcome of lupus nephritis (ln) in indian children. methods: clinical and histopathological features and outcome of children with ln was retrospectively reviewed. patients were included if they fulfilled the acr criteria for the diagnosis of sle and had either of persistent proteinuria, active urinary sediments or renal dysfunction. outcome was analyzed at years and at last follow-up. results: ofthe children studied, were boys. the mean age (sd) at diagnosis was . ± . (median . , range - . ) yr; children were youngerthan years of age. the mean age at presentation and renal biopsy was . ± . (median . , range . - ) years. the mean duration of follow-up was . ± . (median . , range . - . years) years. . % patients were followed for more than years. commonest clinical manifestations were fever ( %), hypertension ( %) and malar rash ( %). and % of patients presented with nephrotic and nephritic syndrome respectively before the diagnosis of sle. the commonest pathology was class iv nephritis ( %) followed by class ii ( %). hypertension, hematuria, nephrotic syndrome and decreased egfr were significantly associated with class iv ln. at last follow-up . , . and % patients were in ckd stage ii, iii, and iv respectively. the patient survival rate at year and at last follow-up was and % respectively, while no patient developed esrd at years. infections were seen in % cases that resulted indeath in patients; died of hepatic encephalopathy. conclusion: sle nephritis has a varied presentation and high morbidity. a significant proportion of patients developed infections during the course of disease. clinical, pathological features and outcome in our study do not differ markedly from those in most pediatric series. background: atypical hus has a frequently relapsing course and a poor renal prognosis. low c plasma concentration suggests alternate complement pathway regulatory abnormalities: factor h (fh), factor i (fi) and membrane cofactor protein (mcp). case report: we report an year old girl with atypical hus due to acquired fh deficiency caused by anti-fh antibodies (abs). hus was diagnosed on the basis of acute renal failure, microangiopathic hemolyticanemia and thrombocytopenia. past history: recurrent fever with culturenegative pharyngitis (suspected pfapa syndrome). decreased c ( mg%, normal> ) with normal c . adamts activity was depressed, no cleaving protease abs. hemodialys (hd) and plasma exchange (pex) were started days later. severe urticaria and angoiedema during pex was treated with methylprednisolone and chlorpheniramine. hematological and renal improvement were observed after the rd pex session. relapses occurred in months: -controlled by pex; -(with suspected pfapa) with single dose corticosteroids, -with prednisone therapy, terminated with single dose ivig mg/kg. elevated anti fh ab titer- au with decreased fh functional activity were found in pre-pex plasma. fh, fi, factor b and c antigenic levelsnormal. hematological remission and renal function improvement without hus relapse ensued while tapering corticosteroids. two years after presentation, onprednisone mg/day anti fh titer dropped significantly with restoration of functional fh activity, gfr ~ ml/min/ . m . conclusions: in cases of atypical hus, active search for anti fh ab iscrucial for implementing specific and effective therapy: plasma exchange, iv ig and steroids for improving course and longterm prognosis. research centre for child health rams, department of pediatric nephrology, moscow, russian federation children aged , - years with idiopathic biopsy-proven steroid-resistant focal and segmentary glomerulosclerosis (fsgs) were treated with cyclosporine a (csa) , - , mg/kg as initial dosage, oral prednisolone , mg/kg every other day tapered to the -th month and methylprednisolone pulses (mp) - mg/kg every other day for the first - weeks in of patients. serum creatinine level was controlled once a month. after months of csa treatment complete or partial remission of proteinuria was in ( %) of children, no effect in ( %). serum creatinine level increased in % on an average in the group remission of proteinuria. in the group of non responded patients the creatinine elevation was significant same - %. after year of csa treatment complete or partial remission observed in ( %), no effect in ( %). elevation of serum creatinine level in children with remission was , % (without significant difference compared to month's csatreatment). increasing of the creatinine level more than % in two patients leaded to double tapering csa dose resulted in normalization of serum creatinine level. in the group of csa non responders the significant increasing of serum creatinine level ( %) was revealed (compared to month's csa treatment). in cases the elevation ofcreatinine level was more than % and these patients turned into esrd eventually. in all of non-responders csa was discontinued. we concluded that serum creatinine level in csa respondrers was stable without significant elevation during the year of treatment. csa therapy for year without any effect influenced on renal function decreasing. clinical objective: to describe the clinical course and outcome of pediatric patients with cgd treated with iv mpt ( mg/kg x doses monthly for months, then dose monthly for the next months) methods: patients' medical records were reviewed. pre, post-treatment and follow-up hr urineprotein, creatinine and gfr were compared using paired t-test; and proteinuria, hematuria and blood pressure using mcnemar's chi square. outcome measures were analyzed usingmean ± sd and frequency distribution. results: patients were included, male, female. mean age at disease onset is . ± . years. mean duration of follow-up is . ± . months. % achieved complete remission after a mean of . cycles, % partialremission after a mean of . cycles and % were treatment failures. mean relapse rate is . ± . on treatment and . ± . at follow-up. renal survival rate is %. hour urine protein and the proportion of patients with proteinuria, hematuria and hypertension significantly decreasedafter treatment and remained stable at follow-up. serum cr/gfr were also stable pre, posttreatment and at follow-up. no serious side effects were noted. conclusion: this protocol induced a high and early remission rate ( % after . cycles)among the patients. majority demonstrated stable renal function and blood pressure over time. relapse rates were low and treatment is generally safe. recommendation: the protocol can be offered to oral-steroid or alkylating agent-resistant patients with satisfactory remission rates. objectives of study: nestin, an intermediate filament protein which has a role in regulating cellular cytoskeletal structure, is restrictedly expressed in the podocytes of human kidneys. in the present study nestin expression was investigated in biopsy specimens of children with focal segmental glomerulosclerosis (fsgs). methods: kidney biopsy specimens taken from children with diagnosis fsgs were investigated. diagnosis was performed on light microscopy, immunofluorescence microscopy, taking into account clinical data. for immunomorphology monoclonal anti-nestin antibody from mouse (sc- , clone c . a , santa cruz biotechnology) diluted : , was applied on cryostat or paraffin sections using labeled streptavidinebiotin (lsab+ dako) method. visualization was performed by dako aec substrate. kidney biopsies of patients without nephrotic syndrome, mainly with mesangioproliferative gn were used for control staining. results: the mean age at the time of biopsy was . ± . years, and all patients had nephrotic syndrome. half of them revealed some focal tubulointerstitial changes: tubular atrophy, slight interstitial fibrosis and lympho-monocytic infiltration. in two cases mutation of wt gene and in one case mutation of nphs gene was detected. four cases had familial character of fsgs. nestin expression was variably present in different cases of fsgs. decreased expression was detected in glomeruli with segmental mesangial sclerosis and capsular adhesions. conclusion: fsgs revealed heterogenity concerning nestin expression. nestin expression was diminished in affected glomeruli. background: renal effects of altered ob/ob-r pathway may contribute to obesity, and diabetesassociated proteinuria. in the kidney ob/ob-r stimulates collagen type i and iv synthesis and upregulates tgfβ and tgfβ receptors. objective: to determine ob/ob-r and its downstream (jak/stat/socs) pathway expression in nephrotic syndrome (ns) and fsgs. design/methods: microarray analysis of kidneys of -week ( w) and -month ( m) old transgenic mice (tg) and controls (ctr) was performed, and confirmed by quantitative pcr. kidney sections were analyzed by immunohistochemistry (ihc) and western blot analysis (wb). urinary ob/ob-r of children with ns classified as steroid sensitive (ssns) or steroid resistant (srns), were measured by elisa. results: ob, ob-r, and jak , , mrna expressions were not statistically different at w and m between ctr and tg. stat and socs mrna were increased . -fold (sem ± . ), and . fold (sem± . ) at m in tg, p= . and p= . respectively. ihc and wb (p= . ) of kidney sections showed no significant difference between the groups. we examined ctr, ssns, and srns patients with comparable bmi, age, race and gender. urinary protein to creatinine ratio in ssns and srns was . (sem± . ) and . (sem± . ) respectively, p= . . urinary ob (p= . ), ob-r (p= . ), and tgfβ (p= . ) were not statistically significantly different between the groups. conclusions: ob/ob-r was not upregulated in tg at the onset of proteinuria and fsgs. however, advanced fsgs ( m tg) showed significant activation of socs , an ob/ob-r negative regulatory pathway. pediatric patients with early srns had no significant increase in urine ob/ob-r. this data suggests the role for ob/ob-r regulatory pathways in the development of advanced fsgs. primary fsgs presents clinically with steroid-resistant (srns) or steroid-dependent (sdns) nephrotic syndrome or proteinuria. the data shows, that % patients with fsgs progress to esrd in years follow-up. objectives: the aim of the study was to analyze the long-term outcome of patients with primary fsgs diagnosed in kidney biopsy. material: the study group consisted of children ( males, females) followed from . all patients were treated with immunosupression and renoprotection. the clinical data were analyzed after follow-up lasting for mean ± , years ( , - years) . children presented with nephrotic syndrome ( srns and sdns) and with proteinuria. the age ranged from , - years mean , ± , at the time of diagnosis. more then kidney biopsy was performed in children -in progression from mcd (n= ) and mes (n= ) to fsgs were observed. results: the clinical remission was observed in / patients ( %) and was not correlated with initial proteinuria (mean , ± ). in / patients crf was observed, of them progressed to esrd ( were successfully transplanted). among patients, who had fsgs as their initial glomerular lesion (n= ), the percentage of glomerular sclerosis was significantly higher in a group in which remission was not obtained after long-term follow-up ( , vs. %, p< , ). in out of patients with follow-up over years progression to esrd was observed ( , %), / were transmitted to adult centers with persistent proteinuria. conclusions: immunosuppression and renoprotection in patients with fsgs can prevent the progression of crf. extensive glomerular sclerosis is a predictor of unfavourable outcome. further clinical and genetical studies are needed to establish the effective therapy modalities. mycophenolate and who had previously undergone a renal biopsy, recieved mg twice daily (maximum gram twice daily) during six months. prednisone was concurrently prescribed at at dosage of mg/kg/every other day, during weeeks and . mg/kg/every other day during the subsequent weeeks. results are expressed as mean±sd. results: seven chidren, boys and two girls were enrolled. oncet of their ns was at age . ± , yr (range - yr) and mmf was initiated at . ± . yr ( . - . yr) . six were sr and one sd. two patients had previously recieved cyclosporine, two patients cyclophosphamide and one chlorambucil. renal histology displayed: focal segmental glomerulosclerosis (n= ), minimal change (n= ), mesangial proliferation (n= ) and membranous glomerulonephritis (n= ). at the end of the follow-up: three patients were in partial remission, two were in complete remission and two had no response to mmf. initial and final serum creatinine concentration . ± . vs . ± . mg/dl), estimated gfr ( . vs. ± ml/min/ . m ) and serum albumin ( idiopathic nephrotic syndrome is the most frequent glomerular disease in childhood. most patients are steroid responsive but half of them relapse and often become steroid-dependent. they are exposed to long term steroid complications on the one hand and relapses due to insufficient disease control on the other hand. our aim is to determine predictive risk factors for high degree steroid dependence. in france, steroid-resistance is defined as persistent proteinuria after one month of daily oral prednisone ( mg/m ) and pulses of methylprednisolone (mpn) ( g/ . m ). we included steroid responsive children with disease onset between and . the mean age at diagnosis was . years (range . - ). all patients initially received prednisone mg/m per day. the following parameters were analysed: age at onset, gender, days to remission with initial steroid therapy, mpn pulses, numbers of relapses, steroid dependency, immunosuppressive drugs. twenty of the patients were steroid-dependent; among the steroid dependent patients, received mpn pulses. % of those patients ( / ) were treated by cyclosporine during follow-up. on the other hand, only % ( / ) of the patients who did not receive mpn required cyclosporinebased therapy during follow-up (chi-square test, p= . ). interestingly, there was no correlation between treatment days until remission during the initial prednisone course and the risk for later steroid dependence. conclusion: the need for mpn pulses, but not the time interval until remission helps to predict steroid dependence. patients, necessitating mpn pulses to obtain remission are at risk to require cyclosporine for disease control. by identifying these children, we could eventually / avoid multiple relapses by earlier use of adequate immunosuppression and / avoid side effects related to long term high dose steroid therapy. membranous nephropathy (mn) with antitubular basement membrane antibodies is a rare condition. relapse of tubular dysfunction in renal transplant recipients has been published in one case, but relapse of mn in the renal graft has not yet been reported. a -year old boy presented first with steroid resistant nephrotic syndrome associated to tubular dysfunction. renal biopsy revealed mn associated to interstitial fibrosis and granular deposits of iga, igg, and c along the tubular basement membrane. indirect immunofluorescence (if) revealed circulating anti-tubular basement membrane antibodies. he received a renal allograft at the age of years. an acute rejection episode on day required three steroid pulses and okt- . renal biopsy revealed the presence of interstitial and vascular rejection (banff iii) and relapse of tubular basement membrane deposits. renal function normalized within days and remained stable (gfr estimated by schwarz formula= ml/min per . ). proteinuria remained negative and urinalysis normal over years under the immunosuppressive regimen including fk, azt, and prednisone. at the age of years, proteinuria increased progressively over weeks reaching . g/day, whereas serum creatinine remained stable. renal biopsy revealed the presence of granular deposits along the glomerular basement membrane suggesting a late relapse of mn in the transplant. rituximab therapy (day , , , and ) followed by switch from azathioprine (aza) to mmf resulted in a complete biological remission with negative proteinuria. indirect if revealed progressive decrease of antitubular basement ab level during rituximab treatment and a negative signal was obtained months after the switch from aza to mmf. this is the first report of glomerular relapse of mn with anti tubular basement antibodies in a renal transplant recipient. nephrotic children are at risk for severe pneumococcal infections. the best moment for antipneumococcal vaccination is controversially discussed. we investigated the serologic response after pneumo vaccination in children ( girls) with nephrotic proteinuria and hypoalbuminemia, immediately after initialisation of prednisone therapy at mg/m (group ) and in children after tapering down of prednisone to < . mg/kg eod (group ). there was no difference in both groups concerning antibody (ab) response, relapse frequency, or number of steroid dependent forms. in group , pneumo ab levels at presentation (m ) were . ± . (mean±se) . at m antibody levels increased -fold to . ± . (p< . ). serum levels at m were . ± . . one year after vaccination ab levels ( . ± . ) decreased compared to m (p< . ), but remained increased compared to m (p< . ). there was no increased delay until remission in both groups compared to a retrospective control group. severe hypoalbuminemia (< g/l) at the time of vaccination was not related to a lower serological response on m . during relapses, antibody levels decreased significantly compared to levels before relapse (p< . ), but increased again once remission was obtained. even during relapses, ab levels remained higher (> -fold) than pre-vaccination levels. conclusion: nephrotic children on high dose glucocorticoid therapy respond to anti-pneumococcal vaccination and their ab levels remain elevated during relapses. vaccination at disease onset may be beneficial as those patients with relapses during the tapering down of steroids already have increased anti pneumo ab at the time of relapse. crescentic glomerulonephritis with isolated c deposits associated to complement abnormalities: a new entity? introduction: several progressive renal diseases present proteinuria, as a result of glomerular and tubulointerstitial injuries. thus, some studies prove that proteinuria is an important predict factor for progression of renal failure. angiotensin converting enzyme inhibitors (acei) are efficient in reducing proteinuria and preserve renal function in patients with diabetic or non-diabetic nephropathy. the purpose of this study was to evaluate the efficacy and security of acei in children. material and methods: the acei (enalapril) was used in normotensive and hypertensive patients with chronic renal disease, with microalbuminuria/proteinuria. results: we studied patients ( girls), for at least months, mean age was . ± . years ( month to years). / patients had glomerulopathy, / chronic pyelonephritis, / systemic disease, / renal hypoplasia/ dysplasia, / cystic renal disease and / arterial hypertension. the mean dose of enalapril was , mg/kg/d ( , to , ) and it was used during , months (mean). we observed a normalization of proteinuria/microalbuminuria in , % of cases. in seven patients, the drug was discontinued due to: / irregular use, / vertigo, / hypercalemia and acute renal failure recovered after withdrawn the drug. during the use of enalapril we did not observe significant difference in potassium or creatinine serum levels, as well as blood pressure measurements. conclusions: the use of enalapril in pediatric patients with renal disease and proteinuria/ microalbuminuria showed security and efficient. therefore, we suggest it as a antiproteinuric and renoprotective agent in children. a. filleron, al. adra-delenne, l. ichay, f. dalla-vale, h. valette, d. morin chu montpellier, pediatric nephrology, montpellier, france in order to evaluate the long-term efficacy of oral cyclophosphamide (cp) in children with sdns, the outcome of patients ( girls) treated in our unit for steroid sensitive ns were studied retrospectively. median age at diagnosis was . years (range . to ). initially, they received oral prednisone (p) : mg/m /d for weeks and p dosage was then tapered for the next weeks (totale dose p: mg/kg). relapses of proteinuria were treated with p ( mg/m /day) and, in case of steroid dependency (sd), p was maintained on an alternate day regimen. one single child had no relapse, while had a relapse rate of less than /year. the remaining frequently relapsed and received oral cp - mg/kg/day for weeks, totale dose mg/kgbecause of their high relapse rate with steroid toxicity. median duration of p treatment was . years (range . to ) before cp was given. in one case cp had to be stopped because of hemorragic cystitis. follow-up after cp treatment was, at least, years. p was stopped in the following months after cp in / children, but has to be continued in the remaining because of early relapse of proteinuria. among those children, only one had no more relapse years after cp. in children, relapse of proteinuria occured . ± months after cp. in those patients, / had to receive another steroid sparing drug such as cyclosporine or mycophenolate mofetil (mmf) because of recurrence of sd. in our experience, cp treatment in ns with steroid toxicity is associated with a significant change in the relapse rate in only / children and in the remaining , improvement was transient. our results suggest that alternative treatment, such as mmf, has to be evaluated as first-line steroidsparing agent in those patients with sdns and steroid toxicity. interleukin - the aim of our investigation is to compare the concentration of total ige, specific ige, interleukin- (il- ) and gamma-interferon (gamma-ifn) in serum of children with initial and relapsed steroid-sensitive mcns and of children with atopic dermatitis at the age from to years. the concentration of total ige was measured by immunoenzymatic method and il- , gamma-ifn by immunoassay technique using monoclonal antibodies. the result showed that % of children with atopic dermatitis had the increased concentration of total ige; specific ige was increased to alimentary allergens- , %, household- , %, inhaled- , %. the concentracion of il- was , ± , pg/ml, of gamma-ifn was ± , pg/ml. the result showed that % of children with mcns had increased concentration of total ige; specific ige was increased to alimentary allergens- , %, household- , %, inhaled- , %. the concentration of il- was , ± , pg/ml, of gamma-ifn was , ± , pg/ml. according to our investigation, the concentration of il- and gamma-ifn in children with mcns were not significantly different then in children with atopic dermatitis. conclusion: the fact that there were not significant differences in serum total ige and specific ige, il- and gamma-ifn in children with mcns and atopic dermatitis gives us a reason to suppose that these diseases have identic mechanisms of pathogenesis with ige reaction i-type with activation of t-limfocyte. to clarify the pathogenesis of mcns, comprehensive studies for these cells would be worthwhile. there are several lines of evidence that the slit diaphragm (sd) not only serves as a structural framework for filtration barrier but also has an essential role as a signaling platform. nephrin is tyrosine phosphrylated by src-family tyrosine kinase, fyn. phosphorylated nephrin recruits nck to sd, and regulates assembly of actin filament. the crucial roles of tyrosine phosphorylation in podocyte is also indicated by renal malfunction observed in fyn knockout mice. neph has a longer cytoplasmic domain and a larger number of tyrosine residues in its cytoplasmic region than nephrin. but knowledge about tyrosine phosphorylation of neph is limited. here we characterize neph as a substrate of fyn. fyn interacted with and phosphorylated cytoplasmic domain of neph in vitro and in cultured cells. peptide mass fingerprinting of neph cytoplasmic domain phosphorylated by fyn in vitro identified at least five tyrosine phosphorylation sites. site-directed mutagenesis confirmed that these tyrosine residues were indeed phosphorylated in cultured cells. in pull-down analysis with neph from rat glomerular lysate, neph specifically bound to an adaptor protein grb and a tyrosine kinase csk in a phosphorylation-dependent manner. coimmunoprecipitation experiments revealed phosphorylation of y and y were crucial in neph -grb binding. furthermore, tyrosine phosphorylated neph suppressed erk activation elicited by fyn, and also inhibited fyn-induced ap- transcriptional activation. these inhibitory effects required the intact binding motif of the grb sh domain, and both y f and y f mutants failed to inhibit erk activation. these results indicate that fyn orchestrates a wide spectrum of protein-protein interactions at sd by phosphorylating neph as well as nephrin, and neph modulates downstream signaling by phosphorylation-dependent association with adapter proteins. celiac disease (cd) is a common disorder in southern europe and has a protean clinical presentation. hla class ii aplotypes dq and/or dq are present in % of cd patients and in % of the normal population. the observation of three patients with both cd and nephritic syndrome (ns) prompted us to study hla class ii aplotypes in our patients with ns. in all children with ns admitted to our unit we determined the presence of dq /dr , dq /dr , dq /dr e dq /dr aplotypes and anti-transglutamidase antibodies (ab-httg). hla typing was done by dna extraction and pcr amplification and electrophoresis in agarose; ab-httg determination was made by elisa. as control groups we examined children with cd and first degree relatives (of theirs). in so far we have studied children with ns ( males, females, age ranged - years); are steroid sensitive (ssns), steroid resistant (srns). a renal biopsy was done in and showed minimal lesions in , focal and segmental sclerosis in , membranoproliferative gn in , membranous gn in and iga deposition in . corticosteroids or other immunosuppressant were administered in when blood was drown. dq and/or dq aplotypes were present in out of patients ( . %), in out of ssns ( . %), in out of cd relatives ( %) and in all cd patients. dq /dr combination was present in a smaller percentage of ns compared to control groups. ab-httg were detected in one patient out of ( . %). purpose: to investigate activity of antithrombin and a protein c at children with mcns: at active period (proteinuria more g/m /d; hypoalbuminemia < g/l), at in incomplete remission (the third day of absence of proteinuria, hypoalbuminemia < g/l), at in proof remission. methods: activity of natural anticoagulants in blood was defined by a clotting method with use of reactants "roche" and "behring". results: activity of antithrombin in blood in the active period of disease sharply decreased ( , ± , %, p< , ), and already in the period of incomplete remission came back to norm ( , ± , %), characteristic for the period of full remission ( , ± , %). activity of a protein c in blood in the active period of mcns was high ( , ± , %, p< , ), during incomplete remission decreased ( , ± , %, p< , ), in the period of proof remission was in norm ( , ± , %, p< , ). at children with mcns dependence of decrease in activity antithrombin from weight hypoalbuminemia (r= , , p< , ), hyperfibrinogenemia (r=- , , p< , ), hypercholesterolemia (r=- , , p< , ) and hyper-lipoproteinemia (r=- , , p< , ) is established. authentic distinctions of factor of the attitude of activity of protein c/ activity of antithrombin depending on the period (the active period - , , incomplete remission - , , proof remission - , ) are received. conclusion: at children with mcns changes in system of natural anticoagulants: decrease in activity antithrombin below % and increase of factor of a parity of anticoagulants (more than , ) testify to hypercoagulation and risk of thrombosis. varicella objectives: the pattern of steroid responsiveness of nephrotic syndrome may change during the course of the disease in children with steroid sensitive nephrotic syndrome (ssns) and/or in different populations. patients and results: a prospective cohort study was conducted in centers. patients who were initially diagnosed as ssns in and followed for five years were included. standard questionary forms from children( boys) with a mean age of . years ( months- years) at presentation were submitted for entry to data coordinating center. / patients who showed initial steroid sensitivity with a follow-up period of at least one year ( - years) were included in the study. seventy three ( . %) children remained in sustained remission at year; nine patients showed steroid resistance. / patients were followed for years, whose clinical course were sustained remission in ( %) and steroid resistance in ( %). steroid response rate from to years remained stable ( - %). eight children out of totally patients who were steroid sensitive initially, became steroid resistant in the first year. the remainder showed steroid resistance at the nd year ( ), at th year ( ) or at th year ( ) . renal biopsy was performed in children who developed steroid dependency or steroid resistance. nine patients revealed fsgs, minimal change disease, mesangioproliferative gn, membranoproliferative gn, one igm nephropathy. only two patients who had minimal change nephropathy in initial biopsy progressed to fsgs after and years. conclusion: steroid response rate was between - % and steroid resistance was - % in years follow-up. secondary steroid resistance within the first year of presentation seemed to be predictive for their subsequent courses. the need of biopsy was not high. ssns seemed still as a relatively benign condition in our population. the aim of this study was to asses the changes in coagulation/fibrinolysis system in chronic renal disease (crd) by measuring plasma levels of von willebrand factor (vwf) and plasminogen activator inhibitor - (pai- ). we studied children ( - years old) with nephrotic syndrome (ns): minimal change disease (n= ), focal segmental glomerulosclerosis (n= ), mesangioproliferative glomerulonephritis (n= ), membranoproliferative glomerulonephritis (n= ). relapse of the disease was observed in patients. healthy age matched children served as controls. serum levels of pai- : ag and vwf were measured by elisa. results. pai- and vwf levels were elevated in all morphological forms of ns in relapse and remission compared with controls (p< , ) except the mcd remission in which they were the same as controls (p> , ). the highest levels of pai- and vwf were discovered in relapse of proliferative forms (mespgn, ± ng/ml and , ± , me/ml, respectively; mpgn, , ± , ng/ml and , ± , me/ml, respectively) compared with nonproliferative (mcd , ± , ng/ml and , ± , me/ml, respectively; fsgs , ± , ng/ml and , ± , me/ml, respectively, p< , ). conclusion. these data suggest activation of coagulation/fibrinolysis system in relapse of ns and the absence of normalization in the remission phase. our results confirmed that more severe fibrin formation via activation of intraglomerular coagulation and fibrin accumulation is characteristic for mpgn, likely by deficiency of the fibrinolysis system. introduction. several recent case reports suggest that rituximab (rtx) could be an effective treatment for idiopathic nephrotic syndrome. in a retrospective study, data were collected from patients (mean age: . years) treated with rtx for steroid dependent nephrotic syndrome (mean duration of the disease: months). four of were treated during a remission period. eight of were treated in association with one or several other immunosuppressive (is) treatments (prednisone, anticalcineurin, mycophenolate mofetil). rtx efficacy was admitted when the previous is treatment was withdrawn or significantly tapered-off, or when the proteinuria disappeared with no other change than rtx treatment. a complete b-cell depletion was confirmed in all patients when assessed ( / ) even when rtx was infused during a period with nephrotic proteinuria. rtx was considered to be effective in cases especially when given in association with other immunosuppressive treatment during a period with remission of proteinuria ( / success, follow-up to months). conversely rtx failed to induce remission among patients who were treated during a proteinuric period with no other immunosuppressive drug ( / failures). finally rtx was considered to be effective among of patients treated in association with other is drugs during a proteinuric period (follow-up and months). there was no significant side effect during rtx infusion. delayed side effects were observed for patients: case of neutropenia and pneumocystis pneumonia and case of hypogammaglobulinemia. conclusion. rtx is an effective treatment in a subset of patients with severe steroid dependent nephrotic syndrome. further prospective data are necessary to determine if rtx could become an alternative to other immunosuppressive drugs in patients with toxic side effects. infections are leading causes of death in lupus patients. disseminated histoplasmosis has been commonly documented in immunocompromised patients including lupus patients. we report a case of lethal cerebral histoplasmosis in a child originating from french guyana. lupus disease was revealed by typical malar rash. she developed a class ii lupus nephritis treated with prednisone and azathioprine. then she developed restrictive lung disease, recurrent arthritis and pericarditis. later on, nephrotic syndrome revealed a class iii lupus nephritis treated with methylprednisolone pulses and mycophenolate mofetil. four years following the onset of the disease, she was admitted because of febrile seizures and five months later for a febrile coma. repeated lumbar punctures displayed hypercellularity with depressed levels of glucose and elevated protein concentrations but sterile cultures. according to the presence of high titers of lupic specific antibodies and cerebral mri suggesting vasculitis, neurological flare of lupus was considered and immunosuppressive treatment was increased (methylprednisolone and cyclophosphamide pulses, plasma exchanges). a repeated lumbar puncture evidenced presence of histoplasma capsulatum. despite antifungic treatment the child died. our report emphazises the difficulty to discriminate opportunistic infections from the wide spectrum of lupus clinical features. symptoms of infection may mimic those of lupus, or conversely, may be masked by immunosuppressive drugs. infection screening should take in account clinical feature as well as endemic context. our report is the first case of isolated cerebral histoplasmosis in a child with systemic lupus. renal manifestations of mitochondrial cytopathies have been described, but nephrotic syndrome with respiratory chain disorders (rc) was described extremely rarely in infancy. we report a months-old boy with a mitochondrial cytopathy preceded by months history of steroid-resistant nephrotic syndrome. on admission his clinical condition was deteriorating rapidly with gross oedema, ascites, hypertension and oliguria. fundoscopic examination revealed salt-pepper sign which was thought to be consistent with intrauterine infection (iui) at that time. however, serologic and microbiologic investigation of iui was inconclusive. a sensorineural hearing loss was found to associate his findings. podocin mutation was negative. a percutaneous renal biopsy was undertaken and revealed diffuse mesengial sclerosis. a significant decrease in mitochondria was observed on electron microscopic examination. the child progressed to end stage renal failure and was successfully managed by peritoneal dialysis. during his follow-up a fine tremor was observed in his hands and cranial mri revealed demyelinisation in left thalamus and occipital lobe. steroid resistant nephritic syndrome, sensorineural hearing loss, ocular and neurologic findings has led us to be suspicious about mitochondrial cytopathy and muscle biopsy was done. though muscle biopsy was normal, the results of biochemical analysis showed a deficiency of the respiratory chain complex iv (cytochrome c oxidase) (rc iv). the clinical phenotype and the deficiency of respiratory complex iv thought to be compatible with deficiency of the cytochrome c oxidase deficiency protein cox . nephrotic syndrome with rc disorder were described extremely rarely in infancy. based on these observations, we suggest that rc disorders should be considered in patients with early onset nephritic syndrome. human parvovirus b (hpvb ) was identified as the cause of a self-limited childhood febrile illness with rash, namely erythema infectiosum. most of hpv-b infections are usually mild or asymptomatic, but in some cases infection is associated with serious systemic complications. renal involvement in patients with hpvb infection was discussed in recent, mostly anecdotal, case reports. the majority of these reports were described in adults, whereas only a few cases of childhood were defined whom presented with mesangiocapillary proliferative glomerulonephritis, fsgs or tubulointerstitial nephritis. a literature search revealed no cases of acute endocapillary proliferative glomerulonephritis in childhood. a -year-old girl was admitted with fever, cough, maculopapuler rash, hemoptysis, dark-colored urine, multiple lymphadenopathies, hepatosplenomegaly. she developed acute nephritic syndrome during the course of this complex clinical features. laboratory data showed proteinuria, hematuria, hypocomplementemia, the presence of igm and igg antibodies to hpvb and positive reaction of serum hpvb dna using a polymerase chain reaction. renal biopsy showed acute endocapillary proliferative glomerulonephritis with coarse granular c depositions in a "starry sky pattern" which is more peculiar to poststreptococcal glomerulonephritis. electron microscopy revealed subendothelial and hump-shaped subepithelial dens deposits. there was no evidence of either a mycobacterial or a streptococcal infection and the diagnosis of goodpasture syndrome and connective tissue disorders were excluded by clinical and laboratory investigations. based on the literature review, this case represents, to our knowledge, the first time that a direct relationship between parvovirus infection and acute endocapillary proliferative glomerulonephritis has been demostrated in a child. objective: the purpose of this retrospective cohort study was to report the clinical course of children and adolescents with focal segmental glomerulosclerosis (fsgs) according to steroid response. methods: the records of patients with biopsy-proven fsgs admitted between and were retrospectively reviewed. demographic, clinical and laboratory data at entry and at the end of the follow-up were analyzed. the patients were classified according to the initial prednisone response into two groups: group (g ): response (complete or partial remission) (n= ) and group (g ): non-response (prednisoneresistant) (n= ). renal survival analysis was performed using the kaplan-meier method. results: the median age at admission was . years (iq range: . ± . yr) in g and . years (iq range: . ± . yr) in g . seventeen patients ( %) of g , and patients ( %) of g presented with hematuria at admission, and ( %) children of g and ( %) of g presented blood pressure levels above the th percentile. g presented a higher h proteinuria ( . mg/ h) at admission when compared to g ( . mg/ h, p= . ). median follow-up time was . years in g and . years in g . the renal survival rate was % at years and % at years in g , % at years and % at years in g . conclusion: progressive renal insufficiency was more frequent in patients with fsgs who have initial resistance to prednisone therapy. objectives of the study: adults with chronic kidney disease (ckd) show impaired immune status. in this study, the profile of mononuclear cell subsets was related to the age and actual gfr in children and compared to healthy controls. methods: the expression of lymphocyte surface antigens was evaluated on peripheral blood (pb) mononuclear cells using three-color flow cytometry in children with ckd (stage - ) on conservative treatment. we analyzed absolute and relative numbers of total leukocytes, total lymphocytes and subsets: cd +, cd +, cd +cd +, cd +cd +, cd -cd / +, cd +hla-dr+, cd +cd +, cd +, cd +αβ+, cd +γδ+, cd ra+, cd ra+cd +, cd ra+cd +, cd ro+, cd ro+cd +, cd ro+cd +, cd +cd +. results: in younger ckd children (below years) absolute numbers of cd +, cd +cd +, cd +cd +, αβ+t, γδ+t cells and cd /cd ratio was higher, the percentage of cd +cd +, cd ra+cd +, cd ro+cd +, cd ro+cd +, αβ+t cells and the absolute number of cd ro+cd + cells was lower than in the oldest group. in children with the lowest gfr (below ml/min) the percentage of cd +, cd + was lower, the absolute number of cd +cd +, cd +, and the percentage of nk-cells, cd +cd +, cd +, cd ro+cd + cells was elevated as compared to ckd stage group. the absolute number of cd +, cd +cd +, cd ra+cd +, αβ+t, γδ+t cells and percentage of total lymphocytes, cd +, cd +cd +, cd + was lower in ckd children than in controls. conclusion: impaired immune status is observed already in early stages of ckd. progressive disturbances in pb lymphocytes percentage mostly in the naive and memory t cells and the shift in the cd /cd balance were found in pre-dialysis children with ckd. with progressive loss of renal function, we observed an increased expression of activation markers on t cells such as cd or cd . introduction: relapse of steroid resistant nephrotic syndrome (srns) after renal graft occurs iñ % of the pediatric patients. medical management is based on increased immunosuppression with the use of iv cya and plasma exchanges (pe). however, this strategy fails in ~ % of the treated patients. new immunosuppressive agents may improve the outcome of relapsing srns post transplant. case report: a -year-old boy with srns reached esrd and received a cadaveric kidney transplant after two years on hemodialysis. the immunosuppressive regime was cya, mmf and steroids. seven days post transplant gross proteinuria ( g/day) reoccurred. iv cya was administered over two months (blood level: ~ ng/ml) associated to pefloxacine and pe (n= ), and followed by oral cyclophosphamide (cyp), resulting in partial disease control. cyp was discontinued due to haematological toxicity after one month. proteinuria increased again from to g/day within months, despite high dose oral cya ( mg/kg/day) and mmf. etanercept (a tnf blocking agent) was introduced at a dose of mg twice weekly (combined with three steroid pulses) and maintained over two months: proteinuria decreased to . g/day over days. etanercept was discontinued followed by a relapse of the ns and re-introduced eight months later, with, again a significant decrease of proteinuria to a baseline level of . g/day. conclusion: treatment with anti-tnf agents in nephrotic children has been reported once in a boy with high degree steroid dependent ns; a spontaneous decrease of disease activity over time cannot be excluded in this patient and might jeopardize data interpretation. our case is the first report of successful antiftreatment despite a constantly high activity of the nephrotic syndrome, demonstrated by relapse after discontinuation of etanercept while the patient was on post transplant immunosuppression. fournier´s gangrene (fg) is defined as a specific, quick and progressive form of synergic necrotizing fasciitis of multi-bacterial origin that affects perineum muscular fascia, genital region and surrounding areas with skin gangrene due to thrombosis of subcutaneous blood vessels. it describes the clinical case in a male preschooler of four years of age with idiopathic nephrotic syndrome (ns) that subsequent presented fg of the scrotum. broad-spectrum antibiotics, intravenous albumin and surgical cleaning of the scrotal necrotic tissues were indicated. pseudomona aeruginosa was isolated from necrotic tissue cultures. the later evolution was satisfactory with healing of the affected area and remission of the ns subsequent to the steroidal treatment. fg is an uncommon in children, rapidly progressive infection of the genital, perineal and perianal regions. it is characterized by a synergistic necrotizing fasciitis leading to thrombotic occlusion of small subcutaneous vessels and development of gangrene. until now few cases have been report fg in children, and still less associate to the kidney diseases. et all ( ) described a -year-old boy presenting with steroid resistant ns developed fg of the scrotum so that to our knowledge, this patient seems be the second case reported in medical literature with both pathologies. high index of suspicion, prompt diagnosis, broad spectrum antibiotics followed by wide debridement is the key to successful treatment. objectives of study: to evaluate a long term experience on iga nephropathy (igan) presenting in childhood and investigate clinical and histological factors that may act as early markers of renal disease progression. methods: retrospective review of data from children and adolescents with biopsy proven igan in the last years. demographic and clinical data at presentation and severity of renal histological involvement were recorded and related to renal dysfunction markers identified at the last review. results: twenty-five patients were studied ( m/ f) with median age at onset of ( - ) and follow-up of ( - ) years. on presentation recurrent macroscopic hematuria was present in patients, microscopic hematuria (mh) in , proteinuria in ( nephrotic), hypertension in and transient acute renal failure in . renal histology findings were focal mesangioproliferative in , focal proliferative in , diffuse proliferative in and focal sclerosing glomerulonephritis in . six patients showed tubulointersticial and extraglomerular vascular lesions (tevl) with glomerular crescents in . on follow-up, patients remitted ( spontaneously, with ace inhibitors). of the remaining, were kept on ace inhibitors due to proteinuria ( ), hypertension ( ) or both ( ). one patient (with focal glomerulosclerosis and tevl) developed esrd within a year after diagnosis, despite treatment. at last review, patients presented progressive renal disease with a mean decrease of ml/min/ , m in gfr per year. these ( m/ f) showed mainly mh and proteinuria at onset and tevl. conclusions: early renal function impairment in childhood igan can occur and may be associated with mh and proteinuria at presentation and with focal glomerulosclerosis and tevl on renal histology. proteinuria persistence in a number of patients emphasizes the need for long term followup into adulthood. adhesion molecules, il- +p and cd +cd + and cd +cd + lymphocyte subsets in childhood nephrotic syndrome background: parathyroid hormone (pth) can modulate t cell activation and proliferation through as yet incompletely identified mechanisms. since the pth receptor (pthr) is a g protein-coupled receptor and thus a candidate for association with lipid rafts, and since pth has been shown to alter membrane phospholipid metabolism, we explored the relationship of the pthr with lipid rafts in human t cells. methods and results: we found by flow cytometry that neither physiologic nor pathologically elevated concentrations of pth affect the up-regulation of the raft marker gm- or of the partially raft-associated activation marker cd in purified t cells stimulated with phytohemagglutinin (pha). moreover, we detected the pthr exclusively in non-raft fractions of these cells after sucrose gradient separation. conclusions: these data indicate that in human t cells, the pthr does not associate with lipid rafts and that pth does not modulate these domains. accordingly, other mechanisms underlying the actions of pth on human t cells need to be sought. the direction and magnitude of potassium transport in nephron segments depend on the sitespecific distribution of transporters in tubule cell membranes. potassium depletion has been demonstrated to be associated with altered sodium reabsorption in renal tubule segments. we examined whe her potassium transporters protein expression is associated with altered abundance of major renal na + transporters, that may contribute to the development of hypokalemia in lp. after weaning rats (n= ) were fed days with lp diet ( %), then they were recovered with a normal protein diet ( %, rp), each group had a control group ( %, np). we examined the changes in the abundance of the na + /h + exchanger (nhe ), na + k + atpase, na + k + clcotransporter (bsc- ), na + clcotransporter (tsc), epithelial sodium channel (enac) subunits and romk in kidneys of lp, np, rp rats. controls were normalized to . results reduced clcreat (ml/min) in lp vsnp ( . ± . vs . ± . ), hypokalemia ( . ± . vs . ± . meq/l) and increased fe k+ ( . ± . vs . ± . %) were demonstrated. immunoblotting revealed that the abundance of nhe in cortex was severely decreased. the amount of bsc- ( . ± . , p< . ) and tsc ( . ± . , p< . ) protein levels were enhanced in the inner stripe (isom) and outer stripe of the outer medulla (osom), respectively. romk protein levels were increased in lp ( . ± . , p< . ), the protein abundance of the enac subunits α, β and γ was increased near . fold each in response to lp. na + k + atpase protein levels showed no differences in cortex and osom. after rp, na + transporters expression returned to control values. conclusion: increased expression of bsc- , tsc, enac subunits and romk, contributing to distal potassium secretion was shown in hypokalemia from lp. a role of aldosterone may be suggested. v. belostotsky , mz. mughal , j. berry , n. webb royal manchester children's hospital, pediatric nephrology, manchester, united kingdom st. mary's hospital, pediatrics, manchester, united kingdom manchester royal infirmary, vitamin d laboratory, manchester, united kingdom aims: to describe the prevalence of vitamin d deficiency in south asian and white uk children with renal disease. to establish how decreased levels of vitamin d affect pth in patients with a normal gfr. methods: children aged - years were enrolled in the study: were of white uk, of s asian and of other ethnic origin. were on dialysis, had chronic renal failure, had various renal disorders with normal gfr (> ml/min/ . m ), had a transplant ( with anormal gfr). blood samples were collected to establish the levels of -vitamin d ( -ohd); pth; creatinine. -ohd concentration < ng/ml was defined as vitamin d deficiency; levels between - ng/ml as vitamin d insufficiency. serum pth of . - . pmol/l was defined as normal. results: the prevalence of vitamin d deficiency/insufficiency was higher in s asian ( %) than white ( %) children (p< . ). ofthe ( s asian, white and other) children with normal gfr / s asian and / white children had pth concentrations > . pmol/l. of these / s asian, / white children had low levels of -ohd (p= . ). of transplant patients with reduced gfr, of with a high pth had low -ohd levels, compared with of with a normal pth (p= . ). conclusions: many s asian children attending our renal clinic are vitamin d deficient/insufficient and the prevalence of this problem is significantly higher than that in the white population. high pth values in the setting of a normal gfr can often be explained by vitamin d deficiency and should result in serum -ohd levels being measured. nephronophthisisis a rare recessive autosomal disease which may be either limited to progressive chronic tubulointerstitial nephritis or associated with extrarenal involvement (eye, liver, central nervous system, etc.); mutations/deletions have been found in at least nphp genes. fibrous dysplasia is a benign skeletal lesion due to an activating mutation inthe gene that encodes the α subunit of stimulatory g protein and occurs after fertilization in somatic cells; it involves one or several bones and may be part of mccune albright syndrome. we report on a boy with fibrous dysplasia of bone diagnosed at yrs of age, who underwent protocol renal function tests at yrs of age in the follow-up of pamidronate treatment. inulin clearance was ml/min/ . m and potassium reabsorption rate was . % where as there was neither urinary phosphate wasting nor hypercalciuria. serum magnesium was decreased ( . mmol/l) without reabsorption abnormality and serumuric acid progressively increased with age. in addition, due to increasing microalbuminuria, a treatment with acei was started at yrs of age. renal ultrasonography at yrs of age showed hyperechoic reduced-sized kidneys with few microcysts. a renal biopsy (light and electron microscopy) was performed at yrs of age, which showed nephronophthisis-like lesions, i.e., diffuse interstitial fibrosis and focal thickening of tubular membrane basement. dna analysis revealed no nphp gene deletion but is still under investigation.nephronophthisis has been reported in association with skeletal involvement (coneshapedepiphyses) and fibrous dysplasia with hypophosphatemic rickets or fanconi syndrome. however no association between fibrous dysplasia of bone and nephronophthisis-like lesions has been described and may be a new picture of the nephronophtisis/medullary cystic kidney disease complex. m. bald, m. holder, h. leichter olgahospital, pediatric nephrology, stuttgart, germany puumalaviruses belong to the group of hanta viruses and are transmitted by inhalation of aerosolized particles of the red bank vole (cletriomonysglareolus) which is endemic in the alb-danube region of southern germany. infections with puumala virus were first described as "nephropathia epidemica" in scandinavia with the clinical symptoms of fever, thrombocytopenia and acute renal failure. over the last seven years three boys with acute renal failure were admitted to our hospital after vacationing in the region endemic for puumalavirus. all three presented with high fever, influenza like symptoms aswell as pronounced abdominal or flank pain. they showed a decreased gfr ( , and ml/min/ . m , respectively) with hematuria and proteinuria. cbc revealed no leucocytosis or anemia, but thrombocytopenia in of the patients. they had no oliguria, but patients had marked polyuria in the recovery phase of renal function. arenal biopsy in the boy with the most severe presentation showed diffuse tubular damage. puumala virus infections were confirmed in all patients by serological tests, and renal function normalized within - weeks. nephropathia epidemica due to puumala virus infections have to be included in the differential diagnosis of acute renal failure in patients from endemic regions. severe abdominal or flank pain are common symtoms in these patients; renal failure is transient and the general prognosis is good. aims: the objective of this study is to determine the relationship of urinary calcium excretion (uca) with sodium and protein intake in a pediatric population of families with low income. methods: children, f and m, ages to years from families with income <$ /month were studied. protein intake was estimated with a -day dietary record. a nonfasting urine sample was collected for dipstick, calcium, creatinine, sodium, potassium, urea and uric acid. urinarycalcium/creatinine (ca/cr), sodium/potassium (na/k), uricacid/creatinine (au/cr) and urea/creatinine (u/cr) ratios were calculated. children with a urinary ca/cr > . mg/mg, were submitted to a day period of high sodium foods restriction after which a second urine sample was collected. results: mean (x) and standard deviation (sd) for ca/cr, na/k, au/cr and u/cr ratios were: . ± . mg/mg, . ± . meq/meq, . ± . mg/mg and . ± . mg/mg respectively. the th percentiles for ca/cr, na/k, au/cr and u/cr were . , . , . and . respectively. x±ds for protein intake was . ± . g/kg/day. the incidence of hypercalciuria was . % in the initial urine sample and . % in the second. correlation was significant between ca/cr ratio and na/k ratio (r: . , p< . ), acu/cr ratio (r: . , p< . ) and u/cr (r: . , p< . ), not significant between ca/cr ratio and protein intake. conclusions: the incidence of hypercalciuria in this serie is lower than previously reported values in venezuela for the general pediatric population and decreases further when sodium intake is controlled. although no correlation was found between uca and protein intake, we could speculate that protein intake near to the daily recommended requirements of g/kg/day, could be a possible reason for the lower incidence of hypercalciuria in this population. -year old girl presented with rapid onset of muscular weakness and a short history of severe dysphagia, dysphonia nad significant wasting. on examination, she was dystrophic (bmi , ) and had signs of myopathy. laboratory findings confirmed myopathy (cpk , ukat/l, ast , ukat/l, myoglobin ug/l). there was striking hypokalemia (s-k , mmol/l) suggesting hypokalemic paralysis. diagnosis of distal renal tubularacidosis (drta) was based on confirmation of hyperchloremicmetabolic acidosis, severe hypokalemia, high urinary ph and positive value of urinary anion gap (s-cl mmol/l, ph , , be , urinary ph , ). there was evidence of other signs of renal tubular impairment (urinary beta- -microglobulin mg/l, glomerulo-tubular proteinuria , g/ h). autoimmune tests (high positive rheumatoid factor, anf, ena ss-a/ro, ss-b/la, high circulating immunocomplexes) and low values of sialometric measurements ( , ml/ x minutes) revealed primary sjogren´s syndrome as the underlying cause of drta. the renal biopsy confirmed chronic tubulo-interstitial nephritis compatible with this diagnosis. full recovery of muscle weakness and laboratory findings of hypokalemia and acidois followed potassium and alkali replacement. corticosteroids were administered with subsequent addition of cyclosporine a because of disease activity. conclusion: primary sjogren´s syndrome is a rare diagnosis in childhood and adolescence and should be considered in patients presenting with hypokalemic paralysis due to drta. m. caletti, h. lejarraga, s. caíno, a. jiménez introduction: ndi is a chronic, genetic disease caused by an inability to effectively conserve urinary water, due to a lack of response of distal renaltubule to antidiuretic hormone. the main symptom is polyuria, polydipsia and growth impairment. objective: to evaluate long term growth in height and weight of children with ndi. patients and methods: sixteen patients with ndi attending hospital for a median period of . years (range . / . yrs) were studied. treatment consisted of indometacine, hydroclorotiazide and amiloride (iha). height and weight was measured with standardized anthropometric techniques. z scores(sds) for all measurements were calculated according to national standards. results: all children responded favourably to treatment. mean birth weight sds was not different from zero; mean height and weight at diagnosis was ± . and ± . sds respectively, and at the end of follow-up was ± . and ± . respectively. the majority of patients´s growth curves evolved below the th centile. ten out of children experienced some catch up in height (mean height gain: . sds (r: - . / . )). mean weight gain during follow-up was . sds (r: . / . ) . mean gain in body mass index was . sds (range . / . ). in the two patients who attained adult height, adolescent growth spurt was normal, and final height was within normal limits for standards and for parental height. correlation coefficient between gain in height andage at diagnosis was ± . . conclusion: although mean height at follow-up was below the expected normal value, combined therapy with iha is compatible with some catch up growth in height and weight. the lower the initial height, the greater the height gain. adherence to treatment is essential for normal growth in children with ndi. body growth of children with steroid-responsive idiopathic nephrotic syndrome m. noer, i. irwanto, n. sumiarso, m. chalim soetomo hospital, school of medicine airlangga university, department of child health, surabaya, indonesia objectives of study: the present study was designed to evaluate the statural growth of children with steroid-responsive idiopathic nephrotic syndrome, attending the pediatric nephrology unit department of child health, school of medicine airlangga university, soetomo hospital, surabaya, indonesia, with a minimum follow-up of years. methods: anthropometrice valuation included weight, height, and growth velocity expressed as mean and standard deviation scores (sds), relative to the normal population (nchs/cdc ). these indices were analyzed at admission and then every months of follow-up. all patients were treated with prednisone, according to indonesian consensus of management of idiopathic nephrotic syndrome in children. results: of children ( boys and girls), patients ( boys) aged / years to years (mean . years) were analyzed. initial mean height and z score (height for age) were . ± . cm and - . ± . , respectively. mean height and z score (height for age) of the last follow-up were . ± . cm and - . ± . , respectively. mean growth velocity were . ± . cm/year where boys ( . %) had growth velocity less than cm/year. total cumulative dose of steroid during years of follow-up were . ± . mg or . ± . mg/kgbw. conclusions: the cumulative dose of steroid up to . mg/kg body weight in children with nephrotic syndrome during years of treatment did not influence their growth velocity. background: recently it has been reported in adult patients (pts) that deterioration of renal function was associated with the lost of nocturnal blood pressure (bp) dip and enhanced urinary sodium (una) and protein (uprt) excretion during night. objectives of study: to investigate the circadian rhythms of bp, una and uprt in children with chronic kidney disease stage i (ckd i). methods: in pts ( boys) aged . ± . years with ckd i (chronic glomerulopathy confirmed by renal biopsy in % pts), hour bp was monitored during daytime (d) and nighttime (n) and urinary samples for uprt, urinary creatinine (ucr), and una, were collected for both periods. results: serum creatinine-based gfr was ± ml/min/ . m , uprt ranged from to (median ) mg/ h, and una from to (median ) mmol/ h. in general we found a highly significant nocturnal decrease in systolic bp (from to mmhg), diastolic bp ( to mmhg), mean arterial pressure ( to mmhg), heart rate ( to /min) urinary output (uo), una and uprt. the regression equations were as follows: uod (ml/m /h)= + . xuon (ml/m /h); unad (mmol/l)= . + . xunan (mmol/l); uprtd (mg/m /h)= . + . xuprtn (mg/m /h) and urinary osmolality (us) d= + . xusn. nocturnal decrease of uo correlated with nocturnal decrease of ucr and uprt, and nocturnal decrease of uprt correlated with nocturnal decrease of uo. more than half of the patients were classified as non dipper. they differ significantly from dipper only in night/day changes of us. conclusion: night/day changes of uo, una and uprt in pts with ckd i may be calculated from the given regression equations. these changes are not correlated with nocturnal bp decrease. non dippers have greater nocturnal change of us compared to dippers. follow-up of these parameters will clarify their importance in progression of ckd. autosomal autosomal dominant proximal renal tubular acidosis (prta) it is described l. g. brenes ( ) at seven members of one family. we diagnosed seven members of the afghani family with prta: mothers and children ( girls, boy from , till years) with hyperchloremic metabolic acidosis. pedigree analysis suggested an autosomal dominant inheritance pattern. observable patients did not have ricket and nephrocalcinosis. deafness and ocular abnormalis are absent. the plasma hco concentration is decrease in the range of , to , mm/l, minimal urine ph is < , . parameters of blood creatinin and glomerular filtration rate were normal. urine calcium excretion was normal. therapy strategy of prta at observable patients provides high dozes of citrates/bicarbonates - mmol/kg per h. all india institute of medical sciences, division of nephrology, department of pediatrics methods: retrospective case-search. data of previously reported prospective trial (n= ) was also included. results: all except patients had previously been treated with both levamisole and cyclophosphamide. forty-two cases qualified for the study and were administered mmf for a mean duration of . months ( % ci, . , . /patient in the first months of treatment and . episodes (n= ) in next six months of mmf treatment (p< . ), an average reduction of % ( % ci, . , . ) from the pre-mmf phase. nine ( . %) patients had no relapses while on mmf therapy we present sibling cases of as with heavy proteinuria at early childhood. a boy ( year-old) and a girl ( yearold) were diagnosed as x-linked as. since a boy developed persistent heavy proteinuria (up/cr . ) with macrohematuria andresistant to arb/acei therapy, we treated him with cyclosporina (csa) that could lead to complete remission. to investigate pathomechanism of proteinuria, we tested immunostaining for slit diaphragm associated molecules (nephrin, podocin), gbmassociated molecules (laminin, perlecan, agrin) and podocalyxin using frozen sections from his firstand second biopsy and girl's one (up/cr . ). in the specimens from boy's first biopsy and girl's one, light microscopy revealed mild mesangial proliferation and no differences ofthe expression with perlecan, agrin and podocalyxin compared with controls. however, when determined laminin isoforms, fetal type laminin (alpha beta gamma ) wasdistinctly observed in the gbm, whereas that was localized only inmesangium with controls. interestingly when compared mature laminin isoform (alpha beta gamma ), beta chain was specifically less expressed in the gbm. however there were no differences of expression of these molecules in the specimens between pre-and post-treatmentwith csa. in boy's second biopsy, % glomeruli were detected to becollapsed. together with the recent report showing that laminin beta mutation causes congenital nephrotic syndrome factor v leiden mutation and steroid resistant membranous glomerulonephritis: a case report m. buyukcelik , m. karakok turkey renal compications of d-penicillamin therapy in wilson's disease sami ulus children's hospital, department of pediatric nephrology sami ulus children's hospital, department of pediatrics sami ulus children's hospital hass classification), treatment and outcome. thirty-nine patients; boys ( . %) and girls ( . %) time of the last examination (median months, min< year) after the admission as a long term follow-up. clinically, group i; while microscopic hematuria was detected in patients, patients had repeated attacks of hematuria, had isolated mild proteinuria/hematuria, group ii; patients had nephritic, had nephrotic syndrome and had both. biopsy grades in the patients: %, % had grade i, . %, % had grade ii, %, % had grade iii, %, % had grade iv in group i and ii, respectively. group i and ii patients recovered completely (no hematuria and proteinuria) . %, . % as well as %, %, short-term, longterm, respectively. while recovery rates in fish-oil and/or ace-inh treatment group was . % and . %, in corticosteroids group, it was %, % short-term, long-term,respectively. no patients who received immunosuppressive treatment had improved. however, ( . %) patients would suffer from esrd. initial presentation, severity of renal involvement and type of the treatment were not found to have a prognostic value (p> . ). in children, igan is characterized by extreme pathogenetic, clinical and histological polymorphisms radojevic university of belgrade, faculty of medicine, institute of pathology, belgrade, serbia institute of mother and child health of serbia, belgrade, serbia university children's hospital, department of nephrology, belgrade, serbia celiac disease hla aplotype in children with nephrotic syndrome s i (if) or mcp or with anti-cfh autoantibodies. varicella hasn't been described as a triggering event of ahus. we report two cases of ahus associated with complement dysfunction revealed after varicella infection. case . a five year-old boy presented with non post-diarrheal hus, days after varicella. serum creatinine was μmol/l, hemoglobin . g/dl, schizocytes %, platelets g/l. glomerular filtration rate normalized within days. search for shiga toxin-producing e coli in the stools and serum anti-lipopolysaccharides antibodies were negative. plasma c , cfh and if levels were normal. no mutations of cfh and if were found. mcp cell-surface expression was decreased and a c f mutation in mcp exon was demonstrated. case . a four year-old girl had ahus days after varicella at that time, complement system study showed normal c level ( mg/l, normal to mg/l), normal cfh level ( %, normal - %), but the presence of anti-cfh autoantibodies. no mutations of cfh, if or mcp were found. in conclusion, these cases outline that varicella can be the triggering event of ahus associated with complement dysregulation about ( . %) children had relapses after initial remission. various infections were responsible for relapsed with in / ( . %) who had relapses. about children ( . %) relapsed with out cause where as poor compliance was observed in ( . %). overall infection and relapse rate was . and . /pt/yr respectively. among children with infections, most common types of infections were acute respiratory infections (ari), diarrhea and uti seen in ( . %), ( . %) and ( . %) of cases respectively. other types of infections like malaria, peritonitis, skin infection and pulmonary tuberculosis were seen serum pai- and tgf-beta levels in profliferative forms of glomerulonephritis in children russian federation research centre for child health rams, department of pathology, moscow, russian federation we aimed to investigate serum levels of plasminogen activator inhibitor - (pai- ) and transforming growth factor-beta (tgf-beta ) in children with proliferative forms of glomerulonephritis (gn). children were examined ( - years old) with gn (steroidresistent ns, n= ; steroidsensitive ns, n= , isolated haematuria, n= ) and healthy age matched controls. mesangioproliferative gn (mespgn) was detected in patients, membranoproliferative gn (mpgn) in cases. serum levels of pai- : ag and tgf-beta were measured by elisa. results. the highest levels of pai- : ag and tgf-beta were observed in relapse of mpgn: , ± , ng/ml and these results confirm prosclerotic effects of pai- and tgf-beta via increased fibrin deposits and extracellular matrix accumulation in the renal tissue and promotion of disease progression rituximab treatment for idiopathic nephrotic syndrome: a retrospective study of cases v. guigonis , a. dallocchio , m. dehennault urinary and serum annexin v levels in children with steroid sensitive and steroid-resistant nephrotic syndrome hôpital robert debré-aphp, pediatric intensive care unit indonesia this study was aimed to evaluate the efficacy of pulse dose of cyclophosphamide in children with srns admitted in child health department faculty of medicine university of indonesia/cipto mangunkusumo hospital jakarta between - . -month period, one child died, and the rest ( children) did not complete the regimen. five out of children who finished the treatment had remission, while others were still experiencing heavy proteinuria. remission was achieved in various time, children were in remission after the first dose, in children it was achieved at the third and sixth dose. in further follow-up time; one child remained in remission, one child had relapse when still receiving cpa, children got relapse one month after stopping cpa, and one child had relapse after months ceasing cpa. nausea and vomiting were found in children indonesia this study is to evaluate the anthropometric measurements of children with nephrotic syndrome methods: a descriptive retrospective study at child health department, cipto mangunkusumo hospital, jakarta. data were collected from medical records of nephrotic syndrome %) irns; body height and body weight of <p was found in none of frns/sdns, / ( , %) srns, and / ( , %) irns; bmi >p was found in / ( , %) frns/sdns, / ( , %) srns, / ( , %) irns. conclusion: the percentage of children with frns/dsns and srns with body height <p il- ) during active stage (as: urinary protein > mg/m per hour, serum albumin < . g/dl) and remission stage (rs) in ss-mcns. a total of patients with ss-mcns ( of patients with as and of patients with rs) and healthy children were recruited for studies. the mean±sd of serum il- , se-selectin and sicam, levels were significantly higher in patients with as than in patients with rs ( ± . / . ± pg/ml; . ± . / . ± . ng/ml and . ± . / . ± . ng/ml respectively, p< . ). in spite of, higher levels of il- , se-selectin and sicam in patients with as than controls, difference was not statistically important. the percentage of cd +cd + lymphocyte subsets were statistically grater in patients with as severe proximal renal tubular acidosis in pearson syndrome birth weight was g. pallor was initially noted during the neonatal period and referred to our hospital with anorexia, vomiting, diarrhea, weakness, and increased pallor at wk of age. on the physical examination she was pale and the other systems were unremarkable. investigation showed hypoplastic anemia, and bone marrow examination showed cytoplasmic vacuolization of both myeloid and erythroid precursors, and maturation arrest of granulopoesis. family history was negative for hematological disease. the diagnosis ps was considered on the basis of early severe refractory anemia associated with vacuolization of bone marrow precursor cells and ring sideroblasts. treatment was started consisting of vitamine b and folic acid. she was followed with growth retardation, moderate anemia and leucopenia up to age . . at that age, the girl was readmitted with severe vomiting and dehydration. on admission, she had moderate metabolic acidosis, hypokalemia, high plasma lactate, and hypophosphatemia. further investigations showed tubuler proteinuria, glucosuria, aminoaciduria, and defective bicarbonate reabsorbtion in the proximal tubule. she developed refractory metabolic acidosis resulting in a cardiac and respiratory failure and death. to confirm the diagnosis of ps, molecular studies were performed bp common deletion was found medial calcification in intact human arteries from children with chronic kidney disease is associated with apoptosis and osteogenic differentiation -clinical and laboratory correlations r using intact human vessels we studied the phenotypic changes in medium sized arteries ex vivo and in vitro after exposure to ca and po . arteries were retrieved during insertion of pd catheters or at transplantation from children: dialysis (n= ), ckd stage iv (n= ) and compared with mesenteric vessels from controls. vessel rings were incubated with graded concentrations of ca and po upto days. calcium and alkaline phosphate (alk) were measured by cresolphtalein complexone and colorimetry. immunohistochemistry for bone marker proteins, inhibitors of calcification and apoptosis were performed. laboratory findings were related to patient's clinical and biochemical parameters, carotid intimamedia thickness (cimt) and coronary calcification. vessels from ckd or dialysis patients had increased baseline vessel wall ca compared with controls (p= . ). when exposed in vitro to ca and/or po , dialysis vessels showed greater calcification than those from controls or ckd patients (p< . ). in the presence of elevated po even a small increase in ca increased calcification (p< . ). calcification was associated with apoptosis (tunel +) and could be inhibited using apoptosis inhibitor zvad. alk in ckd and dialysis vessels and along with upregulation of bone-markers suggests an osteogenic conversion of vsmcs using our unique in-vitro model, we have shown for the first time that vascular damage induced by elevated ca-po as well as factors specific to dialysis primes vessels for rapid progression of medial calcification altered expression of major renal na + and k + transporters c. ruete , p. vallés , university of cuyo, department of pathology turkey the effect of corticosteroid therapy on bone metabolism in nephrotic syndrome was examined. sixty-nine patients with idiopathic nephrotic syndrome (age: . ± , years) and healthy controls (age: . ± , years) were divided into groups: group : patients who were on remission but still receiving steroid therapy, group : patients who were on remission and free of steroids within the last year and group : patients with active nephrotic syndrome and receiving steroid therapy. serum total calcium, ionized calcium, phosphorus, alkaline phosphatase, magnesium, parathyroid hormone, (oh)d, serum cystatin c, urine protein, urine creatinine and urine cystatin c levels measured in all patients including the control group. in addition, lumbar spine bone mineral density z scores were measured in the patient group objectives of study: we evaluated the clinical, laboratory and urinary tract echosonographic findings in patients with ah and rh. methods: there was prospective clinical study, included patients (mean age . ± . ) with ih (normocalcemic, normophosphatemic, with hours urinary calcium excretion greater than mg/kg/day) all analyzed parameters (dysuria, positive family history of urolithiasis, microscopic hematuria, urinary tract microlithiasis) showed low sensitivity and specificity, and none of the parameters could be considered reliable in differentiating ah versus rh. average value of una/cr was greater in patients with rh conclusion: none of the analyzed clinical parameters, laboratory and echosonographic parameters except values of urinary excretion after calcium deprivated diet could be considered reliable in differentiating ah versus rh. patients with rh have higher level of hours urinary calcium excretion than patients with ah. patients with rh have significantly greater excretion of urinary sodium compared with patients with ah idiopathic hypercalciuria (ih) is defined as hypercalciuria with no detectable cause. low bmd with increased fracture rate and tendency to short stature has been reported in ih patients. we aimed to perform calcaneus qus in children with ih and relate to u-ca, body height and number of prevalent fractures (fx). children ( girls, boys; patient. body height was recorded and qus was measured on both heels with cuba clinical. the -h u-caexcretion (u-ca/ h) was assessed and calculated in mmol/kg/ h. results were expressed as z-scores ±sd. czech anthropometric parameters from a survey and previously obtained qus values of the healthy czech pediatric population served as reference data. qus results were also calculated as height adjusted values with the use of heightmatched standards. u-ca/ h was matched to healthy european paediatric population values we found no correlations between fx and bua (either age-related orheight-adjusted) or fx and vos (age-related or height-adjusted). neither were there any correlations between u-ca and fx, or u-ca/ hand bua or vos, respectively. in conclusion, children with ih had normal height, normal values of bua and low vos (fc) (p) (p) (mr) (fc) (fc) (op) (p) alpay h. (p) (p) amann k. (fc), (p), (p) amanullah f. (p) (op) amaro a. (op) (op) amore a. (sy) (p) anarat a. (fc) (mr) (p) (op) (fc) (op) (p) (p) bael a. (op) (p), (p), (p) (fc) (fc) (p) balat a. (p) (p) (fc) bayazit ak. (p) (p) (p), (p), (p) (p) (p) (p) (p) bensman a. (op) (sa), (p) (p) (fc) bereczki cs. (op) (fc) (op), (fc) (op) (sy) bi yl. (p) (fc) (p) (op) (p) biyikli n. (p) (p) (fc) bocanegra v. (fc) (fc) (p) boh m. (fc) bökenkamp a. (op) (fc) (fc) (op) (op) (op) bourrier t. (p) bouts ah. (op), (fc) (op) (p) bubic-filipi lj (p) (op), (fc) (op) (p) (p) caropreso m. (op) (fc), (p) (fc) (p), (p) chartapisak w. (p) (p) (p) chaves a. (op) (p) chemodanova m. (p) (p) chen j. (op) (p) (p) (p) (p) (op) (p) (p), (p), (p) clermont mj (p) (fc), (p) (sy) codoceo a. (p) coelho g. (op) (sy), (fc) (sy) (p) (fc) (fc) (p) (fc) (p) coutinho s. (p) coviello d. (p) (fc) craig j. (op), (p) cransberg k. (fc) (p) (p) cristino s. (p) (fc) (p) cross j. (op) cruz mr (fc) (p) (fc), (p), (p) (sy) deanfield j. (fc) (p) decena-galvez a. (p) (fc) (p) (p) deguchtenaere a. (op) (p) (p) (sa), (p) (p) delucchi a. (p) (p) (p) (p) (p) (p) (fc), (p) (fc) dinda a. (p) (p) (p) (p) dittrich k. (fc) (fc) (p), (p) dötsch j. (fc), (p), (p) dragon-durey ma (p) (fc) (p) (fc) (p) (p) (p) (p) dursun i. (p) (p) (p) edefonti a. (p) (p) eke f. (fc), (p) (p) (fc), (fc), (p), (p) (fc) (p) (p) (p) evim m. (p) f faerch m. (p) fallahzadeh mh. (p) (p) (sy) feig d. (p) (p) (p) fella a. (op) feneberg r. (op) (op) (p) filler g. (fc) (p) (op) fischbach m. (op) sy) fitoz s. (p) (fc) (p) (p) fujita h. (op) (p) fujita t. (p) (p) fukuhara d. (p) (op) (p) (p) (op) (op) garnier a. (p) (p) (op) (sy) geary-joo c (fc) (fc) (op) (sy) (fc) (p) gross ml. (fc) (p) (p) (fc) (fc) (p) (p) guo w. (op) (p) (op) (p) haberal m. (p) (fc) (op), (fc) (fc), (p) (fc) (fc), (p) (fc) (p) (mr) (p) (p) (op) (op) hernández am. (p) (op) (op) (fc) (op), (fc) (p) hou jr. (p) (p) (op) (p) (fc) (fc) (p), (p) iharada a (op) (op) (p) (fc), (fc) (p) (p) (sy) (p) kathiravelu a. (fc) (op) (op) (op), (fc) (p) (p) (p) (p) (p) (p) (mr) (p) (op) (p) kondo y. (fc) (p), (p) kosuljandic-vukic d. (p) (fc) kovalski y. (p) (op) (p) (p) (p) kru èic d. (p) krylova-olefirenko a. (p) (p) (p) (p) (sy) (fc) (p) (p) kurayama r. (op) (p) (fc) lalatta f. (op) (p) (sy), (p) (op) (p) lau yw (op) (op) (p) llanas b. (op), (fc), (p) llewellyn-edwards a. (fc) (fc) (p) (fc) luis-yanes m (p) (p) (sy) maeda a. (p) maekawa k. (p) (p) (p) (p) (p) (p) (p) mak r. (sy) (op) (op) (p) (fc), (fc) (fc) (p) (sy) (fc) (p) (p) (p) medynska a. (p) (p) mehls o. (fc) (p) (fc), (p) (op) (op) (op) (fc), (p) (p) (fc) (p) molnár-varga m. (p) (fc) (fc) (p) montini g. (fc) (p) (p) (op) (p) (p) morimoto t. (op) (p) (op) (p) morita t. (p) (p) mortazavi f. (p) (fc) moscaritolo e. (p) (p) mosig d. (p) (op) (fc) (p) moxey-mims m. (fc) (op) (p) mudun a. (p) (fc) mughal mz. (p) (p) müller t. (op) müller v. (fc), (sy) müller-esterl w. (p) müller-wiefel de. (fc) (sy), (fc) (op) fc) (op) (fc) (p) nghia h. (p) niaudet p. (mr) (p) (p) nuzzi f. (op), (op), (p) nwobi o. (p) (op) (op) (p) (op) (p) (sy) (p) ostalska-nowicka d. (p) (p) otukesh h. (p) (p) (p) (p) ozen a. (p) (sy), (p) (p) (p) paik kh. (p) (p) pan'czyk-tomaszewska m. (p) (p) (fc) paripovic d. (p), (p), (p) (fc) pasqualini t. (op) fc) pastori a. (p) pászka d. (op) (op) (p) pereira a. (op) (fc) (fc), (p) (p) fc) (op), (p) raes a. (op), (op), (fc) (fc) (p) rigden s. (fc) (fc) ring e. (p) rink n. (op) (op) ristoska-bojkovska n (fc), (p) roszkowska-blaim m. (p) (p) (p) ruffo gb. (p) ruhlmann a. (op) ruiter j. (op) rumeau r. (fc) rusai k. (fc) rusnak f. (p) rüther u. (p) rutjes n. (p) rybarova s. (p) rychlik i. (p) ryckewaert-dhalluin a (p) sabasiñska a. (p) (p) sabolic-avramovska v. (p) (p) (op) safouh h. (p) saha a. (p) sahin h. (p) (op) saint-cyr c. (p) saito a. (p) (fc) sakalli h. (p), (p), (p) sakalli ercoban h. (p) (sy) (p) salusky i. (fc) (op) (p), (p) sarkissian a. (p) (p) (fc) (p) (fc) (op) sayili a. (p) schäfer b. (p) (fc), (fc), (fc), (sy), (fc), (fc), (fc), (fc) (fc) schmidt-gayk h. (mr) schmidts m. (p) schmitt cp. (fc) (op) (p) (fc) schneider-maunoury s. (p) (p) (sy), (fc) (fc) (op) (p) seeherunvong w. (fc) (p) (op) (p) semama d (op) (p) (p) (p), (p) shin yh (p) (p) (fc) (p) (p), (p), (p) siwiñska a. (p) (fc) (op) (p) spasojevic b. (p), (p), (p) spasojevic-dimitrijeva b stanic m. (p), (p), (p) stankovic a. (p) (p) (mr) (fc) (op) (mr) (p) (p) (p) (p) (p) (p) szteblich a. (op) t (fc) (p) taha g. (p) (p) taheri derakhsh n. (p) (p) (p) (fc), (p), (p) tan ph (p) (p) (fc) (p) (op) (p) (p) (p) tizard e. (fc) (p) toenshoff b. (fc) (p) tönshoff b. (fc) (p) (op) (fc) (fc) (op) (op) (p) (op) (fc) urdaneta-carruyo e. (p), (p) urdaneta-contreras a (fc) (p) (p) valverde s. (p) (p) van den heuvel l. (fc) (p), (p) van't hoff w. (sy), (p) (p) (fc), (p) (sy) (sy) (fc), (fc) (p), (p), (p) waters a. (op) (fc), (fc), (fc) (mr) (op) (fc) (fc) (op) (fc), (p) (fc) wingen a. (op) (sy) (fc) (sy), (fc) (fc), (p) (fc) (sy) (p) (fc) (p) (p) (p) (op), (p) (fc) (p) yap hk. (fc) (p) yata n. (p) (op) (p) (p) yilmaz a. (p) (op) (op) (p) (p) (p) zhou jh (fc) (op), (fc), (sy) zingg-schenk a (p) (fc) zurowska a. (fc) (op) the il (- g/c) polymorphism is associated with initial peritoneal transport status in children commencing chronic pd acknowledge: this study was from iran university of medical science. atypical hemolytic uremic syndrome: an unsolved case of complement dysregulation (p) aim: we have shown that rats overexpressing il- gene developed a mcn with proteinuria, hypoalbuminemia and hypercholesterolemia. this study aimed to determine the role of il- on hypercholesterolemia in this model. methods: recombinant rat il- gene in a mammalian expression vector was transfected into quadriceps of wistar rats by in-vivo electroporation. serum il- , albumin, cholesterol, creatinine and urine albumin were measured serially. after sacrifice on day , hepatic gene expression of hmg-coa reductase (hmg-coar), acat , cholesterol- a-hydroxylase (ch ah), ldl-receptor (ldlr) and il- receptor subunits were determined by rt-pcr. results: compared to control rats (n= ), il- -transfected rats (n= ) showed significant albuminuria ( . ± . vs . ± . mg/day, p< . ), hypoalbuminemia and hypercholesterolemia ( . ± . vs . ± . mmol/l, p< . ) at day . serially, this rise in serum cholesterol preceded the increase in proteinuria and fall in serum albumin. serum cholesterol correlated significantly with il- levels (r= . , p< . ). in of the il- -transfected rats with serum cholesterol> . mmol/l, hepatic gene expression (mean±sem) was significantly upregulated compared to controls for hmg-coar ( . ± . vs . ± . , p= . ), acat ( . ± . vs . ± . , p= . ), ch ah ( . ± . vs . ± . , p= . ) ldlr ( . ± . vs . ± . , p= . ) and il- ra ( . ± . vs . ± . , p< . ). conclusion: the increased cholesterol synthesis in il- -induced mcn was associated with increased hepatic gene expression of hmg-coar and acat , which are important enzymes for cholesterol synthesis. associated increased hepatic gene expression of ch ah and ldlr involved in cholesterol metabolism could be a negative feedback response. e. bordador, f. anacleto philippine general hospital, pediatric nephrology, manila, philippines general objective: to formulate a clinical scoring system that will predict the presence of glomerular crescents in patients with severe nephritis. specific objectives: ( ) to describe the profile of children with acute nephrotic-nephritic syndrome ( ) to correlate clinical parameters with renal histopathology. methods: this is a retrospective study. twenty six charts from the philippine general hospital, admitted between january -march were retrieved. included in the study were children with acute nephritic -nephritic syndrome who underwent kidney biopsy. excluded were patients with small/contracted kidneys on renal ultrasound. statistical tool used were univariate analysis, pearson's product moment method and chi -square test. results: profile variables of the subjects were analyzed. afterwhich, each clinical parameter was tested using univariate analysis, if significantly correlated with the renal biopsy result using pearson's product moment method at critical value= . at p< . . out of parameters, only parameters were noted to be significant, these were serum creatinine, blood urea nitrogen and glomerular filtration rate. further analysis was made by separately treating male from female population using a chi-square test with critical value x ( ,. ) = . . the test identified another three clinical features among female which were significantly associated with renal biopsy results, these were blood pressure, anemia and hematuria. from these significant parameters associated with renal biopsy results, a clinical scoring system was then conceptualized in order to identify patients with high probability of crescents on renal biopsy. conclusion: cresent maybe use as an accurate screening tool to predict presence of glomerular crescent in patients with severe nephritis. heterogeneous effect of acei therapy in children with proteinuric nephropathies b. kranz, s. diepenbruck, u. vester, r. buescher, a. wingen, p. hoyer university of duisburg-essen, pediatric nephrology, essen, germany background: chronic proteinuric nephropathies are at high risk of developing progressive renal insufficiency. the renin-angiotensin-aldosteron-system blockade is a well documented strategy to reduce proteinuria in adult patients. the efficacy and risks of renal-protective therapy with angiotensin-converting-enzymeinhibitors (acei) in children with proteinuric kidney diseases is of concern. method: in this retrospective study the efficacy of acei as antiproteinuric therapy in children with chronic proteinuric nephropathies is evaluated. patients: sixty-three children (mean age . ± . years) have been treated with acei for a mean of . ± . years (range . ± . years) because of proteinuria (hus n= , alport syndrome n= , psh n= , others n= ). results: proteinuria in all patients declined from a median of . g/d to . g/d after years (p= . ). there was a drop out of patients because of end stage renal failure during the followup. one-third of patients showed a continuous reduction in proteinuria from . g/d to . g/d (median) within years while a second third had a transientimprovement followed by a reincreasing proteinuria later. patientswith hus showed a good response (decrease of proteinuria from . g/d to . g/d) in contrast to patients with alport syndrome who developed increased proteinuria ( . g/d to . g/d) despite of acei and patients with psh who had no change in proteinuria.interpretation: it has to be discussed whether biological compensation mechanisms may bypass the ace inhibition in single patients and whether the underlying illness may predict the efficacy of acei.aims: to determine the clinicolaboratory renal manifestations; glomerular, extra-glomerular histopathologic lesions; renal tubular dysfunction (rtd) frequency, and outcome of a short-term renal follow-up in nigerian children with systemic lupus erythematosus (sle). methods: a non-randomized prospective study of consecutive cases of childhood-onset sle with nephropathy. baseline/follow-up clinicolaboratory data were collected. each patient was followedup for months. results: seven of children studied were girls (f:m, . ). median age at diagnosis was . years. median diagnosis time interval ( . years) and median time of renal disease onset ( . year) were similar. hypertension, nephrotic syndrome, and acute renal failure occurred in . %, . % and . % of the patients, respectively. the glomerular lesions were non-proliferative lupus nephritis (ln) in . % (class ii ln); focal (class iii ln) and diffuse (class iv ln) proliferative ln (pln) in . % and . %, respectively. tubulointerstitial nephritis (tin, . %), and rtd ( . %) were common. arf (p= . ) and rtd (p= . ) were significantly associated with severe tin. complete renal remission rate at end-point was . %. relapse and renal survival rates were . % and . %, respectively. rtd was persistent in . %. conclusion: renal function disorders, diffuse pln, and extra-glomerular lesions were frequent. significant association of arf and rtd with severe tin in this series suggests the need for early renal tubular function (rtf) assessment in our sle patients. deranged rtf may be marker of severe tin in sle warranting early confirmatory renal biopsy and aggressive interventional treatment.we report two cases of children with crescentic glomerulonephritis (gn) associated to isolated c deposits. patient . a year old girl was admitted for macroscopic hematuria, nephrotic range proteinuria (proteinuria/creatininuria= mg/mmol) and renal failure (serum creatinine μmol/l). anca and other antibodies were negative. c , c and ch activity were normal but c nef was detected. the patient was treated by prednisolone and cyclophosphamide pulses followed by oral corticotherapy. renal function normalized, but proteinuria persisted (proteinuria/creatininuria= mg/mmol). a relapse occurred ten months later. corticotherapy and cyclophosphamide pulses were reinitiated and were successful, followed by mmf maintenance therapy. patient . a year old girl was admitted after viral infection for macroscopic hematuria and fever. proteinuria was of nephrotic range (proteinuria/creatininuria= mg/l). the search for autoimmunity was negative. c nef was detected but c , c and ch activity were normal. serum creatinine increased to μmol/l. after three pulses of prednisolone followed by oral prednisone, renal function normalized. histological examination of the two renal biopsies revealed endo-and extracapillary gn with numerous granulocytes in the capillary lumen. cellular crescents involved % of the glomeruli. immunofluorescence demonstrated isolated c deposits in the mesangium and along the glomerular basement membrane (humps). c q, igg, iga and igm staining were negative. background: the risk of end stage renal disease (esrd) is low in unilateral wilms tumor, although patients with wagr or associated genitourinary anomalies are at higher risk. esrd is attributed mostly to hyperfiltration in the remnant kidney. immune complex glomerulonephritis (icg) has not been previously reported in wilms tumor patients. objectives: to report cases of icg in unilateral wilms tumor. methods: retrospective chart review. patient # a boy with cryptorchidism, diagnosed with unilateral wilms tumor at y of age. patient # a girl with wagr and unilateral wilms tumor diagnosed at y of age. both had chemotherapy after tumor resection. results: patient # : within mo of tumor resection, a proteinuria of . g/ hrs and rising creatinine were noted. renal biopsy was consistent with icg. within mo of surgery the patient developed esrd requiring chronic hemodialysis. patient # : within y of tumor resection, the patient developed progressive, asymptomatic proteinuria up to g/ hrs. the renal biopsy revealed changes typical for icg. the patient was treated initially with enalapril and prednisone. due to no response, mycophenolate mofetil (mmf) was added and prednisone was weaned. after mo of therapy, her proteinuria improved to . g/ hrs. her serum creatinine continued to be normal at . mg/dl, with calculated gfr of ml/min/ . m . conclusions: this is the first report of icg in patients with unilateral wilms tumor with rapid progression to esrd in the first patient, but successful response to mmf in the second patient. despite low risk for progressive proteinuria in wilms tumor patients, it is prudent to monitor these patients for proteinuria and perform a renal biopsy if proteinuria is progressive. mmf therapy may be attempted to decrease proteinuria and to delay the onset of esrd.aim of the study: to present our first results of rhgh treatment mainly in children on hemodialysis. patients and methods: sixteen children, aged . - . years (mean age . ± . ) with height below - . standard deviation score (sds) for age or height velocity below - . sds for age, were selected to receive rhgh therapy at our nephrology and hemodialysis department. most of them were on hemodialysis ( children) with mean spent time . ± . years ( - years) before an initiation of rhgh therapy. one half of patients were prepubertal ( children) and second half were in early puberty (testicular volume between and ml for boys and breast development b or b in girls). all received - iu/ml per week by daily subcutaneous injection for months to years. the year before rhgh therapy served as a control period. results: during the first year of treatment, mean height velocity in hemodialysis patients increased from . cm/year to . cm/year (p< . ) and in the second year was . cm/year (p= . ). the mean height sds in hemodialysis children did not improved significantly during the first year of rhgh treatment (from - . sds to - . sds, p= . ). neither weight, nor the body mass index varied compared with the pretreatment period. no change was observed in glucose, total proteins, albumins, cholesterol and triglycerides levels. the mean increment in bone age was . years. pubertal status had no influence on response to rhgh. conclusions: therapy with rhgh improved height velocity in children with esrd. no significant side effects were observed in children during the . treatment years. two patients developed secondary hyperparathyroidism but the relationship with rhgh remains uncertain. in our treatment group rhgh therapy was safe. a. waters , a. trautmann , p. zipfel , e. harvey , ch. licht hospital for sick children, department of pediatric nephrology, toronto, canada university children's hospital, department of pediatric nephrology, heidelberg, germany atypical hemolytic uremic syndrome (ahus) is characterized by the absence of a diarrheal prodrome, the tendency to relapse and a poor outcome. functional and quantitative deficiency of complement regulatory proteins or inhibiting autoantibodies result in uncontrolled complement activation, which eventually causes ahus. -we report a case of ahus with complement dysregulation associated with a progressive refractory response to plasma infusions. factor h and factor h-related proteins (fhr) were quantified by elisa and were further analyzed by western blot. complement activation was determined by measuring c . serial hgb (g/dl), platelet, creatinine (mg/dl), ldh (u/l) were measured. initial presentation was at months of age with thrombocytopenia, hemolytic anemia and increased creatinine. ahus was suspected as e coli infection was ruled out. disease remission followed several plasma exchanges. monthly plasma infusion maintained remission. therapy intervals exceeding month promoted relapses. nine years later, the relapse interval decreased and over the subsequent years, thrombocytopenia persisted as plasma infusion requirements increased. a concomitant decline in renal function (creatinine . mg/dl) occurred with the development of persistent proteinuria and hypertension. at years of age, she deteriorated acutely with hypocomplementemia and thrombopenia. quantitative factor h was normal. autoantibodies to platelets and factor h were negative. intravenous immunoglobulin combined with oral steroids resulted in normalization of platelet count. complement dysregulation is associated with ahus. hereditary defects can be treated with factor replacement therapy. refractory responses may subsequently arise due to the development of autoantibodies against complement regulatory proteins. complement dysregulation requires further analysis in our patient. objectives: angiopoietin-like protein (angptl ) is involved in lipid metabolism and angiogenesis. the present study was to examine angptl expression in human kidneys with proteiuria, in adramycin rats (adr), and in puromycin induced podocyte damage. methods: immunohistochemistry was performed on kidney biopsies from children with mcd, mn, fsgs, tbmn. in adr, angptl expression was determined by quantitative real-time pcr in glomeruli and tubuli dissected from frozen section of kidneys with laser microdissection system. in mpc , a conditionally immortalized mouse podocyte cell line in vitro, angptl , perlecan and agrin werer detected through real-time pcr with the induction of puromycin. detachment assay was performed in podocytes tranfected by angptl -pcdna . . results: in human kidneys, co-labeling showed angptl expressed in the cytosol of wt positive cells. quantitative computerized analysis showed that angptl in glomeruli in mcd and mn were significantly higher than that of tbmn, fsgs respectively (p< . ). in adr, angptl in glomeruli increased significantly at st or th day (p< . ) after adriamycin injection compared with control. and the expression of angptl in glomeruli was correlated with h urinary protein (r= . , p< . ). in mpc both protein and mrna expression of angptl on podocytes were up-regulated with the induction of puromycin. in podocytes transfected by angptl -pcdna . the expression of perlecan or agrin increased significantly compared with control (p< . ). the attachment ratio was shown . %± . % hs after puromycin treatment on podocytes transfected by angptl compared with . %± . % on normal podocytes, and . %± . % on untransfected podocytes. conclusions: angptl is predominantly expressed in podocytes which could be involved in podocyte damage and the development of proteiuria. purpose: we present cases of a previously undescribed pattern of membranoproliferative glomerulonephritis, in children with neuroblastoma on chemotherapy. the pattern of injury shows unusual focal capillary loop proteinaceous deposits possibly related to toxic chemotherapeutic drugs. the resultant hypertension and renal impairment made bone marrow transplant a challenging prospect. method: case series results: case : this boy with stage neuroblastoma, developed severe renal impairment and hypertension during treatment. thus there were difficulties in administration of chemotherapy and he required early surgery. at tumor resection a nephrectomy was necessary. he received an autologous stem cell transplant. he became unwell at transplant and required haemofiltration. he made a good renal recovery and did not relapse. case : he was diagnosed at months with stage s neuroblastoma. he completed treatment but later relapsed. during treatment his gfr reduced and he developed severe hypertension. this lead to restrictions in chemotherapy. renal biopsy was carried out at tumor resection. at bone marrow transplant he was very unwell and required haemofiltration. he has chronic hypertension and low gfr. light microscopy findings in both -global diffuse membranoproliferative pattern of injury -large numbers of proteinaceous resorption droplets -features of a protein deposition disease electron microscopy findings common to both -large number of differently sized protein droplets in the endothelial cells -no obvious immunecomplexes/deposits -protein deposition disease with a membranoproiferative pattern of injury conclusion: both cases showed deposits in the kidneys which may be tumor protein in origin and the resultant glomerulonephritis, hypertension and renal impairment lead to challenges in transplant. the long term consequences are yet to be revealed. methods: establish the cultured glomerular mesangial cells of rat in vitro, ~ generations of cells were used in the experiment after identification. the experiment included five groups: ctrl, lps, high, middle and low dose fos groups. gmc proliferation were detected by mtt. the changes of ln, fn and col protein secretion were detected by the elisa. the changes of lnbeta mrna expression were detected by semi-quantitative real-time pcr. results: ( ) fos can inhibit the effect of proliferation induced by lps. ( ) mesangial cells can secrete some ecm protein in normal culturing medium, ecm protein secreted by mesangial cells was significantly higher in lps group than that in ctrl group (p< . ), while ecm protein was significantly lower in all fos groups than that in lps group (p< . ). ( ) lnbeta mrna expression was significantly higher in lps group than that in ctrl group, while that in fos group was significantly lower than in lps group. conclusions: lps can induce the increase of secretion of the ecm, including ln, fn, col fos can inhibit the secrection of ecm in gmc as dose-dependent manner at the mrna and protein levels. the conclusion supplies the theoretical evidence for the renal protection of fos. h. hong, w. na, y. li, w. qiang guangzhou first municipal people's hospital, department of pediatrics, guangzhou, people's republic of china objective: to observe the effects of fosinopril (fos), the new generation angiotensin-converting enzyme inhibitor (acei), on protein and mrna expression of tgf-β of rat glomerular mesangial cell (gmc) induced by lps; to demonstrate the preventive mechanism against glomerular sclerosis by applying fos. methods: culture rat gmc in classic way. the cultured cell were divided into groups, namely ( ) control group, ( ) lps group, ( ) lps+fos group. detect tgf-β concentration in gmc supernatant fluid by elisa; estimate tgf-β mrna expression by semiquantitative real-time rt pcr. results: lps group is obviously higher than control groups in tgf-β secretion and mrna expression, while lps+fos group drops distinctively in tgf-β secretion and mrna expression compared with lps group. conclusions: fos has obvious inhibited on tgf-β expression of rat gmc both at protein level and mrna level, which reveals that it might be an important mechanism by fos on restraining the development of glomerulosclerosis. r. kahn , n. akbari , j. wieslander , w. müller-esterl , a. christensson , k. westman , t. hellmark , d. karpman lund university, pediatrics, lund, sweden wieslab ab, lund, sweden institute of biochemistry ii, frankfurt, germany lund university, nephrology, lund, sweden vasculitis is an inflammation with neutrophil influx in and around blood vessels. patients may have elevated plasma levels of neutrophil-derived proteinase and anti-neutrophil cytoplasmic antibodies (anca) directed to proteinase , suggested to be involved in the pathogenesis of disease. we have previously shown that the kallikrein-kinin system (kks) is activated in vasculitis. in vivo the kks is activated on endothelial cells and neutrophils when high-molecular-weight kininogen (hk) is cleaved by kallikrein thus liberating bradykinin. bradykinin is a potent mediator of inflammation. in the present study we investigated if neutrophil-derived proteases, and proteinase in particular, could induce activation of the kks and bradykinin release. purified neutrophils from ten vasculitis patients ( adults, children) and thirteen controls were treated with triton-x to induce lysis. proteinase was immunoadsorbed from the neutrophil extracts. bradykinin and proteinase levels were measured by elisa. hk proteolysis was detected by immunoblotting. proteinase incubated with purified hk induced physiological breakdown of hk and bradykinin release. this was inhibited by preincubation of proteinase with anti-proteinase . triton-x treated neutrophil extracts from both patients and controls induced hk proteolysis and bradykinin release whereas the neutrophil extracts from which proteinase had been immunoadsorbed did not. levels of proteinase in the neutrophil extracts from patients and controls did not differ. these findings suggest that neutrophil derived proteinase can proteolyse hk in a physiological manner thus liberating bradykinin, thereby initiating kallikrein-independent activation of the kks. introduction: this is a prospective study to evaluate the safety and efficacy of tacrolimus in consecutive children with steroid-resistant nephrotic syndrome (srns). methods: all of them were subjected to kidney biopsy. tacrolimus was given in dose of . - . mg/kg/day in two divided doses to attain trought levels of . - . ng/l. these patients were followed-up every weekly initially for the first month, followed by monthly visits. urine spot protein creatinine estimation was done at each visit. besides blood glucose, serum creatinine, urea, electrolytes, albumin, and complete blood count were done once a month. results: the mean age of onset was . ± . yrs. of the children, had mcd, had fsgs and another had dmh on histopathology. tacolimus had to be withdrawn in children: of the rest children who received adequate therapy, complete remission was seen in ( %) children, ( %) attained partial remission and was non responsive. the mean time to achieve remission was . + . days and the mean dose of tac was . + . mg/kg. the mean urine spot protein/creatinine ratios were significantly lower ( . ± . vs . ± , p= . ) and mean serum albumin significantly greater ( . ± . vs . ± . , p= . ) as compared to those prior to tac. of the children who attained complete remission, patients are off steroids and tac and in sustained remission, while the rest are still on tac therapy. conclusions: this is the largest study so far on the safety and efficacy of tacrolimus therapy in children with srns. we conclude that tacrolimus is a useful therapeutic alternative in children with srns who are unresponsive to cyclophosphamide and cyclosporine. objectives: to describe hiv infected paediatric patients from our centre with pathology proven renal disease. methods: retrospective review of biopsy data base and case notes of patients with hiv referred with renal problems. results: patients were identified who had biopsy confirmed renal disease. the mean age of the patients was , yrs (range: months to years). twelve of the patients were african and two were of mixed race. renal pathology was divided into three groups: ) hiv associated nephropathy (hivan): five patients. ) mesangioproliferative nephropathy: patients ) other: acute pyelonephritis in , mesangial proliferation plus interstitial nephritis in , renal tuberculosis in , hiv immune complex disease (hivick) in one. conclusion: there is a high degree of variability of renal pathology in children with hiv and renal disease which upholds the need accurate diagnosis when confronted with these patients. background: acute poststreptococcal glomerulonephritis (apsgn) is the most common glomerular disease of children in our country. it has not been studied well in this region yet. here, we report our experience with psgn in a tertiary referral center during a five-year period. method: hospital records of all children who had been admitted from mar. to mar. to nemazee hospital with diagnosis of acute glomerulonephritis (agn) were reviewed. all demographic, clinical, paraclinical data and consumed medications were obtained. results: among children diagnosed as agn, ( %) had apsgn. other ( %) children had mpgn (n= ), mespgn (n= ), iga nephropathy (n= ), lupus nephritis (n= ), rpgn (n= ), and fsgs (n= ). mean age in children with apsgn was ± . (range, years. children ( %) developed apsgn following a sore throat or upper respiratory infection while ( %) cases developed after impetigo. ninety-five ( %) patients developed apsgn during the cold seasons of the year. periorbital edema was found in children ( . %), hypertension in ( %), gross hematuria in ( %), oliguria in ( %), generalized edema in ( %), azotemia (bun> ) in ( %), and nephrotic range proteinuria in ( . %). aso titer was high in ( %). low c was detected in ( %) and low c in ( %). dilutional anemia in ( . %), hyponatremia in ( %), and hyperkalemia in ( %) children among whom, required hemodialysis. regarding medications, patients had received only furosemide, cases took furosemide and nifidipine and for patients furosemide+nifidipine+another antihypertensive medication was prescribed. conclusion: acute psgn is the most common type of glomerulonephritis in this region. it follows sore throat in the majority of cases. it usually has an uneventful course. y. guo, zh. wang, x. liu west china second university hospital, sichuan university, department of pediatrics, chengdu, people's republic of china objective: we planned to explore the mechanism of glomerular basement membrane (gbm) damaged by rsv, through investigating the effects of lmwh on proteinuria and glomerular structure of rsv nephropathy. methods: sd rats were inoculated with pfu rsv and lmwh iu/kg. group a: rsv was given in the first days, and lmwh was given for the following days; group b: the mixture of rsv and lmwh was given in the first days, then lmwh was given for other days; group c: lmwh was continuously given throughout days and on the th - th day rsv was also given; group rsv and the control were respectively inoculated by rsv and dmem for days. renal histology, urinary protein excretion and serum parameters were observed. rsv rna in renal and pulmonary tissue was determined by in situ hybridization. results: there was no significant increase in urinary protein excretion of the lmwh-treated groups (a . ± . , b . ± . , c . ± . , mg/ h) compared with the control, but that of group rsv ( . ± . mg/ h) gradually increased after rsv inoculation. there was just a decrease in albumin ( . ± . g/l) and an increase in urea nitrogen ( . ± . μmol/l) of group rsv only. no change of the glomeruli detected in all lmwh-treated groups, while congestion and swelling in glomeruli of group rsv were observed significantly. glomerular microstructures of the lmwh-treated groups were almost normal, while extensive foot process effacement was observed in group rsv. rsv rna signal expressed weaker in the lmwh-treated groups than in group rsv. conclusion: rsv damages hs on gbm by electrostatic interaction. lmwh, as the analog of hs, charged with anion, competes with hs to combine with rsv to keep gbm from being destroyed, and then reduce the proteinuria. s. zhai, zh. wang west china second university hospital, sichuan university, department of pediatrics, chengdu, people's republic of china objective: the study is to explore the relevance among gags, hpa and ela in the steroid responsive nephrotic syndrome (srns). methods: ( ) children with srns were selected, including the active (n= ), the convalescent (n= ), the remissive (n= ). purpuric nephritis and healthy children were served as the control.( ) using the improved whiteman process detected the urinary gags. ela activities in plasma were determined by the amount of -nitroaniline released per unit time. immunocytochemistry and image analysis method were used to detect the expression of hpa of peripheral blood leukocyte. results: . gags of the active were the highest ( . ± . ) of all (p< . ). in contrast with the healthy, the active and the convalescent ( . ± . , p< . ) were significant difference, but the remissive no difference ( . ± . , p> . ). . all of ns showed higher level of hpa than the healthy (p< . ). comparing with the healthy, hpa was significant difference both in the active (iod . ± . , p< . ) and in the convalescent (iod . ± . , p< . ),but no difference in the remissive (iod . ± . , p> . ). by contrasting the active and the purpuric, their difference of hpa was no statistic significance (p> . ). . all of ns showed higher levers of ela than the healthy (p< . ). the healthy was strikingly different, contrasting with the active ( . ± . ) and the convalescent ( . ± . , p< . ), but no difference with the remissive ( . ± . , p> . ). .there was a significant correlation among the urinary protein, urinary gags, hpa and ela with simple linear regression analysis. conclusion: in the srns, proteinuria may be resulted by the spallation of hpa and ela for gags on gbm. ( ), combination withhaematuria, hypertension and/or renal insufficiency ( ), extrarenalsymptoms ( ), and familial mediterranean fever (fmf, ) . of the non-nephrotic patients, had extrarenal symptoms, were nephritic, had rapidly progressive glomerulonephritis (gn), renal failure and isolated urinary abnormalities. biopsy samples were evaluated by light microscopy in yerevan and zurich and by electron microscopy (except for amyloidosis) and immunohistochemistry (last ) in zurich. results: the most common histological lesion was renal amyloidosis ( %), followed by focal segmental glomerulosclerosis (fsgs, %), lupus nephritis ( %),systemic vasculitis/hus and minimal change disease (mc, . % each),mesangioproliferative gn/iga-nephropathy and membranous nephropathy(mn, % each), hereditary nephritis and membrano-proliferative gn typei ( % each), acute postinfectious gn (apgn, %), and dense deposit disease (ddd, %). the miscellaneous group includes,apart from interstitial nephritis ( %), unclassified or inadequate biopsies and specimens with mostly sclerosed glomeruli( %). the majority of patients with amyloidosis of fmf, fsgs/mc andmn were nephrotic, but % of patients with amyloidosis had non-nephrotic proteinuria. conclusions: several glomerular lesions were considerably more frequent than in other studies, particularly amyloidosis of fmf, mn and lupus nephritis, and to lesser extent membranoproliferative gn type and ddd. apgn is underrepresented because less than % of all patients (> ) had a biopsy. this study would not have been possible without international collaboration. henoch-schönlein purpura in children: an epidemiological study amongst dutch pediatricians on incidence and diagnostic criteria j. aalberse , , k. dolman , g. ramnath , r. rodrigues pereira , j-c. davin the aim of the present study on the incidence of henoch-schönlein purpura (hsp) in dutch children is not only to give some insight in the epidemiology of hsp in the netherlands but also to record the diagnostic criteria used by dutch pediatricians and to evaluate the accuracy of the latter using the presence of iga in the skin when biopsies are available. methods: in , all dutch pediatricians received monthly a card asking to mention new diagnosed hsp. pediatricians reporting one or more new patients with hsp were sent a list of questions concerning symptoms, blood and urine parameters, skin biopsy, diagnostic criteria and follow-up duration needed. results: two hundred and thirty-two patients from - of age ( . / ) were reported as having started hsp in . twenty nine % presented with renal symptoms. in accordance with the classification criteria of the american collegeof rheumatology (acr), eighty percent of pediatricians consider that isolated purpura (without hematological abnormalities) is sufficient to allow the diagnosis of hsp in children. from the skin biopsies performed, only ( %) presented with iga deposits. the follow-up duration considered as necessary was longer in case of renal symptoms at presentation. however, % of patients without renal symptoms would be followed for more than one year. conclusion: considering the recent ( ) eular/pres endorsed consensus criteria for the classification of childhood vasculitides, hsp should have been diagnosed in only of the patients of our study. the use of isolated non-thrombocytopenic purpura as only criterian to diagnose hsp in children might therefore lead to over diagnosis and unnecessary follow-up. noteworthy, the eular/pres criteria remain to be validated by a prospective study. the clinical presentation and response to therapy of childhood pan in johannesburg, south africa. method: retrospective record review of twelve children with a clinical diagnosis of pan treated between and . results: there was unequal number of males and females; average age at presentation was . ± . - . years, all were black children. eight children had more than acr criteria and sufficient clinical criteria (eular/pres consensus criteria). musculoskeletal and cardiac diseases were the commonest finding at presentation ( %), cutaneous, hypertension ( %), renal and gastrointestinal disease ( %), central nervous system disease ( %) and constitutional features ( %). two children had bone involvementwith periosteal reactions on plain x-ray. angiographic abnormalities were found in ( %), and ( %) had positive histology (skin/renal biopsies). tuberculosis was diagnosed in ( %), and had positive streptococcal titers. all patients were ana and hepatitis b negative, but there were five patients anca positive ( =p-anca, =c-anca, =both) ( %). the crp was elevated in / ( %), esr also in / , while % had both elevated. all patients received oral glucocorticoids, methylprednisolone ( - pulses- mg/m ), ivi cyclophosphamide ( - pulses, mg/m ), oral azathioprine, and required i. conclusions: children with pan in johannesburg present at a younger age with multi-organ disease. they require aggressive therapy with both glucocorticoids and cytotoxic therapy to ensure good outcomes. objective of the study: in order to evaluate the predictive factors of chronic kidney disease (ckd), the records of children with biopsy-proven mesangioproliferative nephrotic syndrome (mpns) admitted between and were retrospectively reviewed. methods: renal survival was analyzed by the kaplan-meier method and cox's regression model. two multivariate models were developed: ( ) from the onset of symptoms to the occurrence of ckd and ( ) from the time of renal biopsy to ckd. the following data were obtained at admission an dat the time of renal biopsy: gender, race, age at the onset ofnephrotic syndrome symptoms, age at admission, blood pressure, laboratory data (serum creatinine, serum urea, glomerular filtration rate, -hr urinary protein excretion, hematuria). patients were classified according to the response to the initial course of prednisone: ( ) a complete response was defined as a proteinuria < . g/day; ( ) a partial response was defined as urinary protein excretion of < g/day and > . g/day, and ( ) no response was defined as urinary protein excretion of > g/day. results: median follow-up time was years (iq range, . ± . ) and patients ( %) progressed to ckd. at baseline, after adjustment variables remained as independent predictors of ckd: creatinine > . mg/dl (rr= . , ci %= . ± . ) and non-response to steroids (rr= . , ci %= . ± . ). at the time of renal biopsy, after adjustment variables remained as independent predictors of ckd: age> . yr (rr= . , ci %= . ± . ) and creatinine > . mg/dl (rr= . , ci %= . ± . ). conclusion: serum renal function at baseline and initial response to prednisone were strong predictors of progression to ckd in our cohort of children with mesangioproliferative nephrotic syndrome. methods: an illustrative case history of a boy with sle and vhd in the absence of antiphospholipid antibodies was described. results: a -year-old boy with a history of sle for about five years was admitted to our hospital due to intermitted arthralgia, facial erythema, increased serum creatinine and oliguresis in october . he had been treated irregularly with prednisone and immunosuppressants. however,the disease was not always controlled well. during thishospitalization, the problems of hypertension, renal failure and anemia had been resolved and maintained, but the problem of intolerance to increased circulation volume was obvious, and three times echocardiography (ecc) showed moderate to severe mitral valve insufficiency. reviewed his history, suspected mitral leaflets vegetations was revealed by ecc four months after onset, he complained of chest pain, chest distress and breathholding several times without causes since eighteen months after onset and manifested with heart failure once, and ecc showed moderate to severe mitral valve regurgitation four months ago and twenty days ago respectively. ruling out the possibility of infective endocarditis, rheumatic heart disease and congenital heart diseases, vhd were considered secondary to sle. since the vhd becomes hemodynamically significant, valve surgery is needed. conclusions: vhd is generally asymptomatic and omitted easily, so routine cardiac evaluation of children with sle using electrocardiography, echocardiography and chest x-ray is recommended to early detect and treat cardiac abnormalities, which may lead to better survival. objective: we have previously reported that deleted in esophageal cancer (dec ), a potent tumour suppressor gene, was specifically upregulated in cd + cells of patients with relapse of mcns, using differential display rt-pcr. this study aimed to further characterize the potential function of dec in mcns. methods: semi-quantitative rt-pcr was used to verify the dec gene expression in children with relapse and remission of mcns. jurkat cells were transfected with plasmid containing dec gene or vector alone. gene expression was regulated by tet-on/off system. the effect of dec on jurkat cell proliferation was assessed by h-thymidine incorporation. cell cycle analysis was performed following propidium iodide staining. protein localization was determined by immunofluorescent staining with anti-dec antibody. results: we confirmed that dec gene expression was significantly increased in children with mcns in relapse ( . ± . ), as compared to remission ( . ± . , p< . ), normal controls ( . ± . , p< . ), patient controls with viral infections ( . ± . , p< . ) and nephrotic patients with other forms of glomerulonephritis ( . ± . , p< . ). in dec -transfected jurkat cells, cell proliferation was inhibited by . %, compared with vector control. cell cycle analysis indicated that dec arrested jurkat cell cycle progression by blocking its entry into the g /m phase. immunofluorescent staining with anti-dec antibody suggested that dec was a cytoplasmic protein, which was in agreement with psort. conclusion: dec gene expression was significantly upregulated in children with relapse of mcns. our results showed that dec acts as a t-cell proliferation suppressor and arrests cell cycle progression, and thus may be important in mediating the number or function of cd + cells during relapse of mcns. objective of study: the aim of the study was to assess plasma and urine concentrations of vascular endothelial growth factor (vegf) in nephrotic syndrome children (ns) depending on the total dose of glucocorticoids (gc) and the percentage of lymphocytes with glucocorticoid receptor expression (cd /gcr). methods: we examined children ( - years) , allocated to three groups: group i: children with the first ns onset, group ii: children with ns relapse, group c: healthy children. the ns patients were examined: a: before treatment and b: - weeks after prednisone administration at a dose of mg/m / h. plasma and urinary vegf levels were determined using the immunoenzymatic elisa method. flow cytometry was applied to assess cd /gcr expression. results: higher plasma and urinary vegf concentrations were noted in ns children before treatment (a), as compared to control subjects (c). following prednisone therapy (b), vegf level was reduced but it was still higher than in the control group. positive correlation was observed between vegf and protein in the urine (group i r= . , p< . , group ii r= . , p< . ) and a weak positive correlation between vegf in plasma and urine (group i r= . , p< . , group ii r= . , p< . ). cd /gcr expression was lower in group ii. in both groups, the correlation between plasma vegf and cd /gcr was positive (p< . ). conclusions: . plasma and urinary vegf levels increase during nephrotic syndrome onset. . glucocorticoid treatment reduces plasma and urinary vegf levels in ns children. objective of study: the aim of the work was to determine the expression of p-glycoprotein (p-gp) on peripherial lymphocytes (cd ) in children with steroid-dependent nephrotic syndrome (sdns) during cyclosporine a (cya) and ace-inhibitor (ace-i) treatment. methods: the study group (i) consisted of children with sdns aged - years, with a subsequent proteinuria relapse at the time of prednisone dose reduction. all ns children were examined three times: a: at proteinuria relapse, before cya treatment, b: after months, c: after months of cya administration. control group (ii) consisted of healthy children. cd /p-gp was measured using a flow cytometry assay. serum cya level was assessed by means of the immunofluorescence method. results: the expression of cd /p-gp in ns relapse, prior to cya+ace-i administration was much higher (median . %, range . - . %) when compared to healthy controls ( . % range . - . %). the absolute number of cd /p-gp in this examination was almost times higher when compare to healthy controls (p< . ). after months of cya+ace-i therapy the expression of cd /p-gp decreased dramatically and was similar to the controls. similar results were obtained after -months of treatment. when analysing the correlation between cd /p-gp and serum cya concentration a strong negative correlation was found in both examinations. the correlation was stronger in group ib (during the treatment with higher cya doses): (r=- . , p< . ) than in ic (after reduction the cya dose: (r=- . , p< . ) conclusions: the results of our studies indicate that cya in sdns inhibits the expression of p-gp. cya is an alternative therapy that may lead to optimization of glucocorticoid doses, thus reducing the risk that goes along with treatment. backround: hemolytic uremic syndrome is considered as the main cause of acute renal failure in childhood. it is characterized by microangiopathic hemolytic anemia, thrombocytopenia and acute renal failure. the epidemiology of the disease varies between counties. aim of the study: to describe demographic and epidemiologic aspects of hus, presented in a years period at the biggest children's hospital in the country. material-methods: patients aged days - years, mean age . years, ( boys, girls) were diagnosed with the syndrome. of them , . %, presented as d+ cases, with preceeded respiratory system symptoms and with no preceeded symptoms. treatment consisted of fresh frozen plasma (ffp) and whole blood transfusions in all cases. peritoneal dialysis was necessary in cases, haemodialysis in , while plasmapheresis was performed in cases. three children, all boys, suffered from recurrent type of syndrome. a girl required treatment with peritoneal dialysis for months followed by recovery of renal function. one-five years follow-up: one baby months old died, children received renal transplantation, in renal function remained mildly reduced (gfr - ml/min/ . m ) and suffered of hypertension. the rest recovered fully. summary: hus represents a rather minor public health problem with low mortality rate in greece. methods: three children with pauci-immune ln were retrospectively reviewed. results: the reported cases fulfilled the american rheumatism association criteria for sle. at admission, all had a -month history of glomerulopathy without intensive therapy. case presented with nephrotic proteinuria, macroscopic hematuria and progressively deterioration of renal function. laboratory data included a positive antineutrophil cytoplasmic antibodies (anca) on myeloperoxidase immunoassay. she was positive for lupus anticoagulant (la) but negative for anti-cardiolipin (acl) and anti-beta- glycoprotein i (β gpi) antibody. renal biopsy showed pauciimmune necrotizing and crescentic ln. case manifested with proteinuria, microhematuria and hypertension. anca was negative. case had nephrotic proteinuria, microhematuria and hypertension. the case had positive la, acl and anti-β gpi antibody. anca was negative. the biopsy findings of both case and case indicated pauci-immune mesangial proliferative ln. electronic microscopy revealed segmental and diffuse foot process effacement respectively. all three ln remitted following the treatment of steroid and immunosuppressive agents. conclusions: these atypical ln were considered to be associated with the distinct pathogenesis, rather than immune complex-mediated glomerular injuries. we supposed the possibility of ancaassociated necrotizing and crescentic glomerulonephritis for the first case. for the others, primary or secondary podocytes lesions might alter the glomerular permeability. the nephrotic syndrome is a clinical picture that characterized by proteinuria, hypoproteinemia, oedema and hyperlipidemia. although the primer nephrotic syndrome is the most common type of nephrosis in children, it may also develop during the course of infections including hepatitis b and c virus infections, whereas hepatitis a virus infection related nephrotic sendrome is very rare in children. in this paper, we present a case of who had suspected diagnosis hepatitis a virus infection related nephrotic syndrome. the boy at the age of years was referred to our hospital due to vomiting, abdominal distension and oliguria. physical examinations were revealed palpebral and tibial oedema, hepatomegaly, decreased breath sounds and mat percussion on right hemithorax. icter were not detected. laboratory examination were showed proteinuria, hyperlipidemia, hypoalbuminemia, high alt and ast levels with normal levels of bilirubin, alkaline phosphatase, complement c /c , urea and creatinine. in viral serologic examinations, hepatitis b and c related antibody were found negative, but anti-hav igm was found positive. chest radiography and ultrasonography examination were revealed right pleural effusion and abdominal ultrasonography examination was revealed ascites. based on these findings, we thought that the nephrotic syndrome could be developed due to anicteric hepatitis a virus infection in our patient. low dose steroid treatment was started (prednisolon mg/kg/day, month). edema was improved, negative urine protein was seen, and liver functions were not deteriorated during this therapy in our patient. hepatitis a virus may be cause of nephrotic syndrome by forming of immune-complexes. in conclusion, although hepatitis a virus infection is rare cause of nephrotic syndrome in children, it should be investigated as a seconder casuse. membranoproliferative glomerulonephritis (mpgn) is a rare, chronic glomerulonephritis, and its prognostic factors and outcome are not known very well in childhood. in this retrospective study, we reviewed the clinical, laboratory and histopathological features of children with primary mpgn. thirty-three children ( boys, girls) presented at a mean age of . years (range - years). they were followed for a median of months (range - months). the clinical presentation in children was nephritic-nephrotic syndrome in children ( . %), nephritic syndrome in ( . %) and nephrotic syndrome in ( . %). nine patients had renal failure at presentation. at the end of study, patients ( . %) had complete remission and patients had abnormal findings ( proteinuria, microscopic hematuria, hypertension, esrd). all of patients were treated with steroid. eight patients were given another immunosuppressant drug (cyclophosphamide , azathioprine ) in addition to steroid therapy. the interval between appearance of symptoms and admission, durations of microscopic hematuria and proteinuria, and systolic blood pressure at presentation were higher in children with abnormal findings when compared with children with complete remission. there were no significant differences in clinical presentation type or histopathological features between children with abnormal findings and children with complete remission. our results showed that delayed detection and treatment, uncontrolled hypertension and unresponsiveness to steroid in early period were poor prognosis predictors. we did not determine any correlation between histopathological findings and outcome. we need further investigations including larger patient population. partial lipodystrophy (pl) is a rare condition of unknown etiology, with childhood onset. it is characterized by progressive loss of subcutaneous fat of face, neck, trunk and upper extremities together with c hypocomplementemia. usually, patients do not have clinically evident renal disease or abnormalities until they have had the disease for or more years. but, the case we reported here, firstly presented with membranoproliferative glomerulonephritis (mpgn), and during follow-up pl was observed. a six years old girl was presented with sore throat, vomiting and loss of appetite for the last fifteen days. her development was normal and the child was asymptomatic till years of age. the parents were relatives of the third degree. there was no history of similar cases in the family. the physical examination of the patient was normal. urinalysis revealed hematuria and pyuria. proteinuria was not present. renal function tests were normal. laboratory examination revealed low serum complement c but normal serum c . the lipid profile was also normal. patient was followed with the diagnosis of poststreptococcic glomerulonephritis. because of persistent low complement c and nephrotic range proteinuria renal biopsy was performed at the rd month of follow-up. renal histology revealed mpgn consistent with type . c nephritic factor was negative. at the same time it was observed that the face took on a cadaverous look with prominent malar bones, chin and zygoma because of the loss of buccal fat. according to these findings, partial form of lipodistrophy, which is frequently associated with mpgn, was considered in the patient. during two years of follow-up she had two recurrences of nephrotic range proteinuria and she is now in remission with prednisolone therapy. as far as we know this is the first example of pl which is developed during follow-up of mpgn. central nervous system abnormalities in children with acute post-streptococcal glomerulonephritis (apsgn) are rare and are considered to be secondary to acute severe hypertension, electrolyte imbalances and uraemia. cerebral vasculitis associated with acute post-streptococcal glomerulonephritis has been rarely reported in pediatric literature. a -year-old girl with a severe headache, vomiting, edema and macroscopic heamaturia is presented. she had history of upper respiratory infection before two weeks. so, the patient was diagnosed as apsgn. on admission, she was normotensive and biocemically well balanced. two hour later, she experienced a grand mal seizure. mri examination of brain showed not only multiple areas of increased density in white and gray matter, and cerebellum but also subarachnoid bleeding, consistent with vasculitis. during follow-up, abducens nerve palsy was detected. histopathological features on renal biopsy specimen, an elevated antistreptolysin level and fallen c complement level were compatible with apsgn. all clinical and laboratory abnormalities improved with steroid therapy (pulse and oral methylprednisolon). in conclusion, children with apsgn may present central nervous system abnormalities without hypertension, uraemia and electrolyte disturbances. results: hsp was diagnosed in patients, median age years old. all had the skin manifestations, . % abdominal pain and % arthritis. patients developed hsp nephritis ( . %), mean presentation time was . months after phs diagnosis. renal biopsy was performed in patients, and the most common histopathological finding was hsp nephritis grade iii a. age of onset older than years was statistically significant for nephritis development (chi square < . ). chronic renal insufficiency incidence was . %. conclusions: the main complication of hsp is nephritis. follow-up should include evaluation by a pediatric nephrologist. age of onset older than years is an important risk factor for hsp nephritis. objectives of study: acquired abnormalities of coagulation and fibrinolysis in nephrotic syndrome have been implicated in the pathogenesis of deep vein and arterial thrombosis. resistance to activated protein c due to amutation in the gene for factor v, the commonest inherited risk factor for venous thrombosis, could contribute to risk of both arterial and deep vein in patients with nephrotic syndrome. we report an arterial thrombosis in a young girl with idiopathic membranousglomerulonephritis (mgn) and factor v leiden mutation. case report: a year-old girl was admitted to our hospital with swelling of both legs and cyanosis of her toes. her mother had history of abortion in the second trimester of gestation, and parents were second-degree relatives. physical examination showed peripheral edema in both extremities and peripheral cyanosis in toes. laboratory study showed the nephrotic range proteinuria. serum albumin was . g/dl, and cholesterol was mg/dl. creatinine, electrolytes, prothrombin/partial-thromboplastin times, c , c , fibrinogen, protein s, c, antithrombin iii and homosistein levels were within normal limits. ana, anti-dsdna, p-anca, and c-anca, antiphospholipid igg/igm, anticardiolipin igg/igm were all negative. genetic study showed the heterozygote mutation of factor v leiden (fv/g a). in arteriography, there was complete occlusion on the posterior tibiaartery of left leg, occlusion of mid portion of right femoral artery and the posterior tibia artery of right leg. renal biopsy findings werefelt to be compatible with mgn. conclusions: we postulate that patients with concurrent nephrotic syndrome and factor v leiden mutation may have an increased risk of thrombosis. screening for factor v leiden mutation may be indicated in patients with idiopathic nephrotic syndrome. introduction: hus (d+) is the nd cause of chronic renal failure (crf) in children in argentina. proteinuria is the main predictor of progression to crf. patients with renal failure, when treated with restricted proteinin take show slower progression to end-stage of rcf. proteinuria appeared in patients with hus sequelae subject to an overload of protein intake. objective: to evaluate the effect of a controlled protein intake on proteinuria in patients with renal disease due to hus and normal renal function (> ml/min/ . m ). patients and methods: within a multicenter, randomized, double blind, controlled trial, carried out inorder to study the effect of iace on the development of renal disease*, proteinuria before and after a controlled diet was measured in patients with proteinuria due to hus and normal renal function. protein intake was indicated according to rda for age. protein intake was estimated with a questionnaire on former hours, and with hrs urea excretion. proteinuria was measured in hours urine collection at the beginning of the study and at , and days after onset of the study. results: median age at onset was . months (r: . - . ); mean of length of follow-up after hus onset was . months (r: . - ). in sixty five ( , %) patients, proteinuria reduced to normal values; in the remaining ( , %) there was no change. median of initial and final proteinuria in the children whose proteinuria became normalised, was . mg/k/day (ds . ) and . (ds . ) respectively < . . conclusion: controlled protein diet (rda) normalizes proteinuria in patients with significant proteinuria secondary to hus and normal renalfunction. * a trial financed by roemmers laboratory, argentina. differential diagnosis of hematuria is the significant task of any nephrologist while most common reasons for hematuria demand histopathological diagnosis. iga-nephropathy is the progressive glomerular disease which is known to be a common reason for hematuria. the diagnosis ofiganephropathy is often missed because of variability of clinical presentations, long-term asymptomatic course and therefore waiting tactics in prescribing renal biopsy. the aim of the study was to evaluate the incidence of iga-nephropathy and to define its characteristic clinical and morphological features in children in belarus. we present results of immunohistochemical staining for iga mesangial deposition of kidney biopsy preparations. the mean age of the patients enrolled in the study was , ± , years. at the moment of biopsy patients clinically presented isolated hematuria ( %), hematuria with proteinuria ( %), nephrotic syndrom ( %), nephrotic syndrom with hematuria and hypertension ( %), isolated proteinuria ( %) and others in less than % each. iga mesangial deposition was detected using immuno histochemical staining with polyclonal rabbit anti-human iga. we found diffuse mesangial deposition of iga in patients ( % of all). two of them had nonnephrotic isolated proteinuria, one nephrotic syndrom. vast majority of patients were hematuric (either isolated or combined with proteinuria). iga nephropathy incidence among hematuric patients was %. in histopathological examination we found mild segmental mesangial hypercellularity in patients, mild to moderate global and segmental mesangial proliferation in (in two of this patients we also found cellular and fibrous crescents in less than % glomeruli). one patient had focal-segmental glomerulosclerosis secondary to diffuse mesangial proliferative glomerulonephritis and clinically presented heavy proteinuria. we analyzed nphs mutations in chilean pediatric patients with srns due to fsgs, diffuse mesangial sclerosis (dms) and minimal change disease (mcd). nphs mutation analysis was performed in patients (sporadic cases n= , familial cases n= ). nphs exons and were amplified by pcr and subjected to automatic sequencing or enzyme restriction analysis using clai (c. g>a) and hin i (c. c>t) respectively. patients median age at disease onset was months (range , % of which were male. histological diagnosis were fsgs (n= ), dms (n= ) and mcd (n= ). ten of patients ( . %) had mutations in nphs ( / fsgs, / dms, / mcd). eight of patients bearing mutations were sporadic cases. seven patients were compound heterozygous for r q and a v. patients with mutations were significantly older than those without mutations (median age versus months, p< . ). resistance to cyclosporin was observed in of cases with mutations and of cases without mutations (ns). we studied the frequency of r q and a v in healthy volunteers with similar ethnic background. only one control individual was heterozygous for r q. no a v mutation was detected. our study demonstrated that nphs mutations are a major cause of srns in chilean pediatric patients. since most of the srns patients bearing nphs mutations were cyclosporin resistant, it is advisable to perform nphs mutation screening before starting immunosuppressives. in this study we aimed to investigate the long-term prognosis of henoch-schönlein nephritis (hsn) in childhood. between and , patients with hsn were investigated retrospectively. there were males and females with a mean age of . years. they were graded according to the degree of renal involvement. grade : isolated microscopic hematuria (n: ); grade : hematuria and mild proteinuria (n: ); grade : acute nephritic syndrome (n: ); grade : nephrotic syndrome/hematuria (n: ); grade : acute nephritic and nephrotic syndrome (n: ). renal biopsy was performed on patients in grade and . twenty patients had extensive crescent formation (> %) on renal biopsy, and were given triple therapy [iv pulse methylprednisolone (mpz) mg/kg/d for days, followed by oral prednisolone (op), oral cyclophosphamide- mg/kg/day for - months and dipyridamole]. the other patients with < % crescent formation were given mpz followed by op and dipyridamole. the patients in grade and were given op and dipyridamole. grade and were not given any immunosupressive agent. during the follow-up period (mean ± . ; range - months), patients in grade , patients in grade , patients in grade , patients in grade and patients in grade showed complete remission ( %). of the patients with extensive fibrosis on renal biopsy, had persistent nephropathy ( %) and developed endstage renal failure ( %). the remaining patients showed near-complete recovery with minimal urinary abnormalities ( %). in conclusion, although initial presentation of renal involvement determines the prognosis in hsn, intensive treatment with triple therapy appears to be effective in severe renal disease especially if started before the development of fibrotic changes in crescents and tubulointerstitial tissue. aim: the bacterial infection in nephrotic syndrome (ns) is still the big problem and is one of the leading death causes in ho chi minh city, vietnam. we did this study with aims to overview this complication in children with ns. methods: our study population consisted of children with nephrotic syndrome during one-year prospective cohort. twenty seven out of patients who developed severe bacterial infection including pneumonia, peritonitis, urinary tract infection, bacteremia or cellulitis were recorded. results: from june to june , there were children with nephrotic syndrome recruited to the study. the severe bacterial infection stood at . % (n= ). in these children, children were first ns, children were relapsing ns. the percentages of pneumonia, urinary tract infection, cellular infection and peritonitis were . % (n= ), . % (n= ), % (n= ) and . % (n= ), respectively. no patients with bacteremia were recorded. in patients with uti, e.coli wasin patients, proteus in and enterococus in . ns children with uti were asymptomatic. ns children with peritonitis had typically clinical manifestations of fever, abdominal pain, tenderness. one out of four patients with peritonitis cultured streptococcus pneumoniae inperitoneal fluid. some factors associated with severe bacterial infection were increase in weight ( . vs . %, p= . ), very low serum albumin ( . vs g/l; p= . ), rise in serum a globulin level ( . % vs . %; p= . ) and hyperfibrinogenemia ( . vs . g/l; p= . ). conclusions: bacterial infection has still been a common problem in children with nsin ho chi minh vietnam. it is important to investigate and manage this complication early to reduce mortality rate. primary nephrotic syndrome (ns) is the most common glomerular disease in children which mainly responds to corticosteroids. however, > % of children experience a relapse with recurrent episodes. the aim was investigation of outcome in ns patients, retrospectively. clinical, histological data and treatment responses of children presenting with ns from to were reviewed. all patients were treated with steroid treatment firstly and classified as steroid sensitive ns (ssns) and steroid resistant ns (srns) according to clinical or laboratory responses. there were patients, male and female, had followed-up for . ± . months. age at onset ranged from - (median ) months. seven patients were admitted with hematuria and ns ( mpgn, mgn) that excluded from this study. patients were treated by only classical steroid treatment. thus, ( . %) patients were ssns and classical steroid therapy was successful in this group. of all ssns patients were evaluated with biopsy ( fsgs, dmp) because of frequently recurrent ns. in srns group ( patients) with one cytotoxic agent, complete and stable remission was induced in patients ( in fsgs, in mlh, in dmp) while patients ( in fsgs) who responded to more than one cytotoxic agents had partial remission with symptomatic relief. five children ( in fsgs) were refractory to all cytotoxic therapies. cyclophosphamide (cp) was used as the first cytotoxic agent in patients and induced complete remission in ( . %). the patients who relapsed following cp and patients who failed to respond were treated with further cytotoxic therapies such as cyclosporine a (cs) or mmf. in patients, cs was used as the first cytotoxic agent and induced remission in patients ( . %). steroid must be the initial drug in childhood ns. cp could be used successfully as an immunosuppressive agent in srns patients. aim: annexin v has a molecular weight of - kda and has been reported to possess anticoagulant activity, inhibition of phospholipase a , regulation of membrane transport, proliferation and signal transduction. it is reported that urinary annexin v concentration may be an indicator of apoptosis and acute renal injury related to the urinary protein level. the aim of this study is to define the role of urinary annexin v, serum annexin v concentrations as new prognostic tools and follow criteria in children with steroid sensitive and resistant ns. methods: annexin v concentrations were measured in serum and hour urine samples in steroid sensitive nephrotic syndrome (ns) patients in both relaps and remission periods (group and respectively) and in steroid-resistant ns (group ) and sex and age matched healthy controls (group ). total protein, albumin, cholesterol concentrations and hour urinary excretion of protein and creatinine were measured in all groups. results: in steroid resistant ns group (group ), median of urinary annexin v/creatinine ratio was significantly higher than all the other groups ( . ng/g creatinine (min-max: . - . ) vs . ng/g creatinine (min-max: . - . ) in group (p: . ); . ng/g creatinine (min-max: . - . ) in group (p: . ), and . ng/g creatinine (min-max: . - . ) in group (p: . )). serum annexin v concentration was significantly higher in group (median . ng/ml) than in group (median . ). no significant correlation was found between urinary protein excretion and urinary annexin v/creatinine ratio. conclusion: remarkably increased urinary annexin v/creatinine ratio could be used as a determinant factor in children with steroid resistant ns, and it may be a prognostic factor in these children. v. baudouin , f. bernaudin , a. garnier , t. kwon , m. peuchmaur , g. deschenes , c. loirat hôpital robert debré-aphp, service de néphrologie pédiatrique, paris, france chic, service de pédiatrie, créteil, france cgvhd is the most common late complication of hsct. clinical manifestations mimic lupus disease but renal involvement is unusual. a year-old boy underwent hsct from an hla-identical sibling donor for sickle cell disease. he received myeloablative therapy (cyclophosphamide, busulfan, antithymocyte globulin). prophylaxis of acute gvh consisted in prednisone and mmf until month . moderate skin and mucosa cgvh appeared at month so that prednisone and mmf were restarted. at month prednisone was stopped and mmf decreased to half dose. at year, while clinical features of cgvh intensified, fortuitous diagnosis of ns was done. glomerular filtration rate and blood pressure were normal. biopsy showed membranous glomerulonephritis and mesangial hypercellularity. immunofluorescence confirmed granular immune deposits of igg and c treatment consisted in prednisone ( . mg/kg/d for month, progressively tapered to . mg/kg/e.o.d at month ) and cyclosporine ( mg/kg/d, trough levels - ng/ml). proteinuria decreased to < . g/l in months. cyclosporine was progressively stopped between month and without relapse of proteinuria. ns associated with cgvhd had been reported in about patients ( patients < yr-old). retrospective studies estimate occurrence around % of patients with cgvhd. it was secondary to membranous glomerulonephritis in % of cases, minimal changes disease in %. strengthening of immunosuppression led to complete remission in % of patients with minimal changes disease and % of those with membranous glomerulonephritis ( % partial remission). usual treatment consisted in prednisone ( %) and cyclosporine ( %). this manifestation of cgvhd is probably underestimated and can occur at the same time or later than other clinical features. early detection of proteinuria in patients with cgvhd is recommended to adapt immunosuppressive treatment. objectives: to see if cyclosporine a (csa) is safe and effective in reducing proteinuria in children with the iga nephropathy (igan) or the henoch-schoenlein purpura nephritis (hspn). methods: the biopsy proven patients ( with igan, with hspn) who showed increased proteinuria (> +) for longer than months were included. the blood level of csa, serum chemistries, urine analysis and complete blood cell counts were carried out every other month along with the physical exams. results: csa was given at an amount of . . mg/kg/day for . . months in average. complete remission of proteinuria in ( . %) and partial remission in ( . %) were achieved by csa treatment. five ( . %) non-responders were discontinued for csa treatment in the middle of the trial. the ration of urine protein to creatinine was initially . . and reduced gradually with time to . . , . . , . . at , , months after csa treatment, respectively. twenty eight patients showed hypertrichosis, three experienced transient elevation of serum creatinine, and two complained difficulties in taking the medication due to severe nausea. for . months after completion of the csa treatment, patients redeveloped proteinuria and had to receive the nd csa trial. no clear difference was observed in the pharmacokinetic profiles of csa attributable to the non-response or recurrence. follow-up renal biopsies were carried out in patients after completion of the csa therapy and no csa toxicity was found. there was no alteration of linear growth pattern. conclusions: this study has a limitation of lacking the control group but the csa treatment is assumed to be very effective and a safe method to attain the remission of proteinuria in pediatric patients with the igan or hspn. j. madrigal , e. fernandez , p. noguera , p. carranza the aim of this retrospective study was : ) to correlate the histopathological diagnosis with steroid response,persistent hematuria, hypertension and or abnormal renal function tests (gfr) ) to evaluate the response of the patients with srns and sdns to the oral cytotoxic drugs , in a period of consecutive years. ) to correlate the response of this group of patients to the oral cytotoxic drugs with their histopathological diagnosis ) to observe the incidence of fsgs in costarrican children during a period of years. ) based on these observations, reevaluate the indications of the kidney biopsy in our patients . we reviewed all the clinical records of patients with the diagnosis of ns and in whom a kidney biopsy have been done. patients with incomplete data were excluded. two consecutive reviews were made: the first included all patients diagnosed between january and december (group a) and the second, between january and december (group b). a total of medical records were analyzed; patients were excluded, and the remaining were studied. results: all patients had been referred for edema or new onset nephrotic syndrome before treatment had been initiated. in our patients the steroid response was also the most important factor to predict the histological diagnosis and the response to the treatment with cytotoxics. the presence of hematuria and abnormal serum creatinine at the time of diagnosis were a predictive factor for the steroid response but not for the histological diagnosis. arterial hypertension achieved statistical significance only between mcns and fsgs but it was useful as a predictive factor for the hystological. in our group of patients with srns treated with cytotoxics, . % with mcns responded, versus . % of the patients with dmgn p< , . a. guersoni, v. mello, v. benini, s. laranjo children with srns are exposed to prolonged and high doses of steroid therapy and other immunosupressants that can lead to a variety of serious side effects. these include statural growth impairment, obesity, osteoporosis, cataract, hypertricosis and psychological disturbances.we carried out a prospective single-center study to evaluate the efficacy of mycophenolate in children with steroid-resistant disease, female and male, aged . ± . years. histological findings were: minimal change disease (mcd) in children, focal segmental glomerulosclerosis (fsgs) in and membranous nephropathy in one. all patients had been treated with at least one course of cyclophosphamide, metil-prednisolone in , while had also been treated with cyclosporine before mmf. the initial dose of mmf was mg/m per day, together with a minimal reduction dose of corticosteroids associated with angiotensin ii receptor blockers (arbs) and sinvastatin.three patients went into complete remission, into partial remission and showed no remission. partial remission was described as loss of edema and improvement in symptoms, despite persistence of significant but improved proteinuria, that was classified either as moderate or low proteinuria according to the level. side effects were: diarrhea (n= ), neutropenia (n= ), infectious disease (n= ). mmf is an important new therapeutic option when associated with angiotensin ii receptor blockers (arbs) and sinvastatin for srns with mcd or fsgs, providing improvement in edema and symptoms despite persistence of proteinuria, with no compromise of physical appearance or risk of nephrotoxicity. background: primary focal segmental glomerulosclerosis (fsgs) that is resistant to steroids and other immunosuppressive agents has a guarded long-term prognosis. patients who fail to respond to current treatment may benefit from therapies that inhibit renal fibrosis and retard progressive loss of kidney function. objective: the font study (novel therapies in resistant fsgs) is a phase i clinical trial designed to test the safety, tolerability, and pharmacokinetics (pk) of novel agents that reduce renal fibrosis in patients with resistant fsgs. methods: patients, age - yr and egfr > ml/min/ . m , with resistant fsgs who fail treatment in the nih supported trial evaluating cyclosporine vs. dexamethasone plus mycophenolate mofetil or who are screen failures due to prior exposure to these drugs are eligible. patients are assigned to receive rosiglitazone mg/m per day po or adalimumab mg/m every other wk sc. the treatment phase is wk and patients undergo an initial (wk ) and steady state (wk ) pk assessment. results: patients have been screened and have been randomized to each test therapy. patients have completed rosiglitazone therapy and have completed adalimumab. four serious adverse events have occurred in patients receiving rosiglitazone, none related to the study drug. fatigue ( %), gastrointestinal complaints ( %), and headache ( %) were the most common adverse events in patients given rosiglitazone. the outcomes in the adalimumab group have not been analyzed. conclusion: these preliminary results indicate the feasibility of performing phase i assessments of novel agents that can target renal fibrosis in patients with resistant fsgs. the findings will be used to design phase ii randomized clinical trials in this cohort of patients at high risk of progression to end stage renal disease. supported by grant niddk r . object: to study the effect of fty on glomerulosclerosis and expression of cell cycle regulatory proteins in subtotal nephrectomized rats. methods: rat were divided into sham-operation group, glomerulosclerosis model group and fty treated glomerulosclerosis group, rats in each groups. the rats in later two groups were subjected to / nephrectomy. after operation, the treat group was fed with fty for weeks. the expression of collagen, fibronectin, and cycline, p , p were determined by immunohistochemistry methods. results: after treatment with fty , up began to decrease from w after operation, significantly lower than in model group (p< . ). the model group showed higher level of scr from w, which was much higher than in control group (p< . ). in fty treated group, scr level were much lower than in model group. fty could obviously inhibit the expressionof col-and fn in glomeruli and attenuate the extent of glomerulosclerosis. moreover, fty could upregulate glomerular expression of p and downregulate glomerular expression of p and cycline. the expression levels of p and cycline were significantly lower in treatment group than in model group (p< . ), but still higher than in control group (p< . ). p expression in glomeruli was stronger in treatment group than in model group (p< . ), and lower than in normal group but without significant statistic difference. conclusion: fty can diminish urine protein excretion and prevent glomerulosclerosis in subtotal nephrectomized rats. this protective effect is presumed to be associated with its role in downregulation of cycline expression and upregulation of p expression in glomerular cells, and inhibition of extracellular matrix accumulation in glomeruli. the authors illustrate severe side effect of steroid therapy ulcerative gastroduodenitis-and rare complication (multiple cerebral thrombo-embolism) in the case of a year old girl with steroid resistent nephrosis. in childhood occurence of thrombosis in steroid sensitive nephrosis syndrome is . %, while it comes up to . % in steroid resistant cases. on admittance she presented the classic symptoms of nephrotic syndrome. one month after the initiation of steroid therapy haematemesis, melaena occurred, and after appropriate therapy was cured. due to the progression of the nephrotic syndrome, steroid shot and later immunesuppressive therapy was started. eight weeks after onset she became unconscious for a shortwhile and had a transient episode of right hemiparesis. at the same time ct and mri disclosed bilateral parieto occipital ischemic territorial vascluar lesions, with relative sparing of the cortical ribbbon. following icu observation her state rapidly improved and after a two week period she became free of symptoms. renal biopsy disclosed the pattern of minimal change nephrosis with diffuse mesangial hypercellularity and a slight amount of igm positivity. immunological evaluation-with the capacitiy to reveal systemic immunological diseases remained negative. having been put on an evidence based protocol the patient's present nephrological state was unremarkable, with proteinuria less then g/day. in the present work the authors discuss the factors predisposing to thrombo-embolism with special emphasis on the possible preventive measures and therapy. igg autoantibodies to c q (antic q) have been reported to play a pathogenic role in immunecomplex mediated diseases (sle, apsgn, membranoproliferative gn, etc). the occurrence of antic q in adult patients with sle has been shown to correlate with disease activity and some immunological parameters (hypocomplementemia, anti-dsdna) and may be useful in the early diagnosis of lupus nephritis (ln) or even as a predictor of renal flares. the presence of antic q in children with apsgn was associated with more severe disease manifestations and a lack of spontaneous recovery. associations between antic q, c and c complement levels and disease manifestations in children with gn were investigated and compared with healthy controls. antic q were measured by elisa and c and c by immunoturbidimetry, respectively. of patients with gn were positive for antic q compared to / healthy controls. antic q were associated with active ln and hypocomplementemia: / patients with sle were found to be antic q-positive. nine of these had active renal disease at the time of blood sampling compared to / being antic q-negative. / antic q-positive patients had low c level and / had low c level. in children with apsgn, / were positive for antic q. antic q positive patients had significantly higher proteinuria, more often hypertension and c -hypocomplementemia. all patients in which apsgn did not resolve spontaneously were antic q-positive. antic q were associated with active nephritis and hypocomplementemia in patients with sle. in children with apsgn antic q-positive patients have more severe disease and stronger c -hypocomplementemia then those being antic q-negative. m. zahrane , l. fawaz , l. nesseim cairo university hospital, pediatric nephrology, cairo, egypt cairo university hospital, pediatrics, cairo, egypt cairo university hospital, cell pathology, cairo, egypt objective of the study: growth hormone (gh) and insulin-like growth factors are essential for normal growth and development. chronic renal failure (crf) results in major changes in the circulating growth hormone/insulin-like growth factor (igf) system. our aim is to study clinical and laboratory parameters of growth and osteodystrophy including igf and igfbp as part of the somatotropic hormone axis in egyptian children suffering from crf on conservative therapy. methods: egyptian children ( boys and girls) with a mean age of . y ( . to . y) suffering from crf on conservative therapy and controls were included in the study. ht, wt and tsf were measured and followed up for a period of months. at the end of the follow-up period serum for igf and igfbp , renal function, electrolytes, ca, p and alkaline phosphatase and acid base balance were measured and an x-ray of the left hand and wrist was done to determine their bone age by tanner and whitehouse. results: our study shows that children suffering from crf in egypt on conservative therapy have growth retardation with a mean ht of . sds, a mean wt of - . sds. tsf mean was - . sds. on the average the patients had a delay of . y (± . ) in their bone age. their height was retarded more than their bone age with a height age/bone age of . (± . ). alkaline phosphatase as a markers of renal osteodystrophy is significantly correlated to the height, height age, bone age and to the ph. the mean igf sds (- . ± . ) did not differ from that of controls while the mean igfbp sds ( . ± . ) was significantly higher in patients with crf than in controls. height and weight were significantly correlated to igf but not igfbp . there is a significant correlation between igfbp level and the glomerular filtration rate. conclusions: the imbalance between normal insulin-like growth factor-i (igf-i) and markedly increased igfbp plasma levels plays a pathogenic role for growth retardation in children with chronic renal failure. the lower the gfr the higher the igfbp level. the latters inhibitory action may provide hope for improving growth in cases of crf by reducing the level of igfbp or displacing igf from it. s. sultana , h. rahman , m. hossain bangladesh medical college, pediatric department, dhaka, uttara, bangladesh bangabandu sheikh mujib medical university, pediatric nephrology, dhaka, bangladesh objective: to find out the impact of different etiology of chronic renal failure on growth in children. methods: this prospective study was carried out in the department of pediatrics, bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh, from october to october . fifty children of both sexes under years of age with clinical and biochemical evidence of chronic renal failure (crf) with creatinine clearance (ccr) of < ml/min/ . m were included in the study. on the basis of underlying causes of crf, the children were divided into congenital (n= ) and acquired (n= ) groups. all patient's height and weight were measured. radiographs of hands, digits, ankle and knee joints, lumbar spine & skull were obtained to evaluate the presence of renal osteodystophy (rod) and for assessment of bone age. serum intact parathormone (ipth) level was also assayed in all patients. growth parameters and presence of radiographic and biochemical features were evaluated in two groups. results: crf children due to congenital anomalies had stunting and wasting in ( . %) and ( . %) cases respectively and the difference between two groups of crf patients was highly significant (p< . ). alkaline phosphatase ( . ± . u/l) and ipth ( . ± . pg/ml) were also significantly higher than acquired group (p< . and p< . respectively). radiographic features of rod were present in ( %) cases in congenital group in comparison to ( %) in acquired group and the growth zone lesion was the commonest type of rod in congenital group ( . %). conclusion: all efforts should be made to diagnose the presence of crf as early as possible, especially in infants and in children with early onset crf who seem to lose growth potential. introduction: in patients with thalassemia major the most important cause of morbidity and mortality is organ failure due to iron deposits, desferioxamine toxicity and anemia. this study was designed to define renal abnormalities associated with thalassemia and to find early marker (markers) of renal dysfunction. patients & method: thlassemic children ( female and male) with mean age of . ± . yr. were studied. all of them were received desforioxamine. age and sex matched healthy children were involved in the study. blood and timed urine sample were obtained for hematologic and biochemical tests. the results were compared between case and control group. results: mean value of bun, serum creatinine, creatinine clearance, serum electrolytes, urine osmolality, fractional excretion of sodium and potassium were not statistically different between two groups. level of urinary nag (n-acetyle-beta-d-glycosaminidase) was significantly higher in patients than in controls (p: . ). there was a positive relation between urinary nag and duration of disease (p: . ). the was no statistically significant relation between urinary nag and serum ferritin. tubular function was not altered by hypertransfusion. conclusion: proximal tubular dysfunction is found in thalassemic patients. measuring urinary nag can guide the physician to find the early tubular abnormality in patients without frank renal dysfunction. severity of the abnormalities is correlated with the duration of disease. the present study aimed to investigate the effects of isolated ma and ma associated with mild renal function impairment on fracture healing in rats. ma was induced by chronic ingestion of % ammonium chloride solution as the unique source of liquid and renal dysfunction was produced by unilateral nephrectomy. thirty male holtzman rats ( - g) were divided into six groups: control group (c,n= ) non-operated rats receiving tap water, acidotic group (ac,n= ) non-operated rats ingesting % ammonium chloride; sham water (s,n= ) sham-operated animals receiving tap water; sham acidotic (sac,n= ) sham-operated rats ingesting % ammonium chloride; nephrectomy water (n,n= ) nephrectomized rats ingesting tap water; and nephrectomy acidotic (nac,n= ) nephrectomized rats ingesting % ammonium chloride. after one week, blood samples were obtained to measure ph and gases, and a fracture of the right tibia was manually produced. four weeks later, fracture healing was evaluated by radiological and histological parameters. blood ph and gases, serum electrolytes and creatinine were also determined. data were compared by anova followed by newman keuls or fisher's exact test. fracture healing in nac, ac, sac animals was significantly altered as compared to c group. there was an additive effect of metabolic acidosis and unilateral nephrectomy in fracture healing process as shown by the comparison of sac and ac rats using radiological and histomorphometrical parameters. there was no difference between electrolytes and creatinine levels in all groups at the end of the experiment. this study showed a higher frequency of delayed fracture healing and nonunion in the presence of ma, which is worsened by unilateral nephrectomy. our data indicated an important interaction between bone and kidney in acid base homeostasis. introduction: dent disease, an x-linked recessive tubulopathy, is historically characterized by lowmolecular weight proteinuria, hypercalciuria, nephrocalcinosis/lithiasis and slowly progressive renal failure. most cases are caused by mutations in the clcn gene (dent disease , omim # ), some patients with dent like phenotype have defects in the lowe syndrome gene ocrl (dent disease , omim # ). patients: male patients from families with urinary findings resembling dent disease are reported. in patients, mutations in the clcn gene were found, in patients ocrl mutations. all children have increased values of urinary alpha- -microglobuline, but also unselective glomerular proteinuria. / have mild hypercalciuria, / demonstrate mild renal insufficiency. amost all patients have increased echogenicity of renal parenchyma, but mild medullary hyperechogenicity is found only in of patients. metabolic acidosis or renal phosphate wasting is not found. interestingly, of children have increased values of creatinine kinase of unknown origin, clinically asymptomatic and independant of clcn or ocrl mutations. conclusion: the phenotype and genotype of dent disease is very heterogeneous. diagnostic criteria of dent disease and of lowe syndrome should be discussed. e. sahpazova, d. kuzmanovska, l. spirevska, n. ristoska bojkovska pediatric clinic, nephrology, skopje, macedoniathe nutritional condition of children ( males and females) mean age . ± . (range - years) with moderate renal failure have been followed for three year. glomerular filtration rate (gfr) was measured by creatinine clearance calculated with schwartz formula and was ranged from . to ml/min per . m . the nutritional condition was determined by anthropometrics and nutritional measurements. the patients were divided in four groups depending of their protein intake, primary disease, ages and glomerular filtration rate. all patients were following an -ad libidum -diet. nutritional intake was determined by minimum of two -day prospective dietary diaries. % of children received significantly lower protein intake. the mean protein intake (% of who recommendation) determined by dietaries of patients with -sub-optimal intake -was . % vs. . % in patients with -adequate protein intake -(p< . ). all patients have a calorie intake of at least % of the who recommendations. the relative distribution of calories was . % from proteins, . % from carbohydrates and . % from lipids. nitrogen balance in patients was positive and correlated most significantly with increasing energy intake (r= . ). average values for height, weight, triceps skin fold, mid-arm muscle circumference, and body mass index were within sd of the mean of the normal population. the protein intake, primary disease and age of the children did not have any effect on growth and development. only patients with more advanced renal disease showed small score for height and growth velocity. key words: chronic renal failure; uremic children; nutritional status; nutritional intake; u. aslanova , t. morimoto , e. farajov , n. kumagai , n. sugawara , a. ohsaga , y. maruyama , s. tsuchiya , s. takahashi , y. kondo tohoku university, pediatrics, sendai, japan tohoku university, medical informatics, sendai, japan tohoku university, physiology, sendai, japan nihon university school of medicine, pediatrics, tokyo, japan the extracellular calcium-sensing receptor (casr) located in either luminal or basolateral cell membranes of various types of renal tubules including proximal tubules, henle's loop and collecting ducts has been thought to play a fundamental role in electrolyte metabolism. to further identify the physiological roles of the casr, we examined the effects of ca + and calcimimetics neomycin (neo), gentamicin and gadolinium chloride gd + on the intracellular ph (phi) of in vitro microperfused mouse medullary thick ascending limb (mtal) cells of henle's loop, by loading the cells with fluorescent ph indicator ', '-bis-( -carboxyethyl)- -(and- )-carboxyfluorescein and measuring the ratio of fluorescence emission at nm after exciting the dye at and nm. in a steady-state condition in hepes-buffered solution, the phi in the mtals was . ± . (n= ). a concentration of micromol/l neo in the basolateral side decreased the phi after min by - . ± . (n= , p< . ). the other calcimimetics showed similar effects on phi, whereas none of these calcimimetics in the lumen affected phi. na + removal or the inhibition of na + and proton transport with amiloride, bumetanide, or bafilomycin did not eliminate the effect of neo on phi. on the other hand, clremoval clearly eliminated the neo-induced phi decrease (- . ± . vs - . ± . in clremoval, n= , p< . ). thus, we have demonstrated for the first time that the casr is involved in the regulation of the phi in the mtal and requires clto exert its effect. background: paediatric nephrologists are often consulted for atypical rickets of renal or non-renal origin. the comeback of vitamin d deficient (classical) rickets in armenia and elsewhere is not only a public health problem but also a new diagnostic challenge for nephrologists. the aim is to analyse all paediatric patients seen in with bone deformities and suspected rickets at the arabkir hospital in yerevan. patients and methods: patients with bone deformities came spontaneously or were referred by one of us (gk). routine serum chemistry was done in yerevan. further investigations, if needed, and urine chemistry were performed in zurich. patients with rickets due to renal insufficiency were excluded. results: in we have seen patients ( males) with rachitic bone deformities aged - months (mean ± . ) at diagnosis. of these, patients had florid vitamin d deficient rickets and had sequelae of rickets but were radiologically and biochemically cured. these children with classical rickets had to be distinguished from patients with other forms of rickets: x-linked hypophosphataemia (xlh; ), vitamin d dependant rickets type ( ), and renal fanconi syndrome ( ) due to fanconi-bickel syndrome and idiopathic. conclusions: (i) the rising number of vitamin d deficient rickets is of concern and due to neglected prophylaxis, (ii) children with classical rickets came late and were in the same age range as patients with atypical rickets, (iii) hence, and because of the larger number of rachitic children, an increased awareness of nephrologists -including a full diagnostic work-up -is needed in order not to overlook rare forms of rickets, (iv) polar vitamin d metabolites should not be used before the precise type of rickets is known. b. spasojevic-dimitrijeva, m. kostic, a. peco-antic, d. kruscic, d. paripovic, m. stanic university children's hospital, nephrology department, belgrade, serbia t. porowski , w. zoch-zwierz , j. konstantynowicz , k. taranta-janusz medical university of bialystok, st department of pediatrics, bialystok, poland medical university of bialystok, department of pediatrics and auxology, bialystok, poland there are no published data on calcium oxalate (caox) crystallization and therewith associated kidney stone disease in children. the aim of this study was to determine bonn risk index (bri) in children with urolithiasis in relation to healthy age-and sex-matched controls and to assess possible associations between bri values and the size of renal stones. methods. in this cross-sectional study, we compared bri in caucasian children and adolescents ( girls, boys) aged - years (median: . ) in whom kidney stones were newly diagnosed and healthy age-and sex-matched controls ( girls, boys) without urolithiasis. urinary ionized calcium [ca + ] was measured using a selective electrode, while the onset of the spontaneous crystallization was determined using a photometer and titrating with mmol/l ammonium oxalate (ox ). the calculation of bri value was based on [ca + ] to (ox ) ratio. high resolution renal ultrasonography was done to estimate the size of renal stones. results. our results showed that bri values in children with renal stones were greater compared with healthy children without stones. bri was -fold greater, bri/kg body weight - -fold greater, bri/per . m b. s. - -fold, whereas bri/bmi was even -fold greater in cases with stones than in controls. no significant association was observed between bri and the size of stones. interpretation. children with kidney stones demonstrate increased bone risk index compared with healthy subjects without urolithiasis. an increased bri during growth, although unrelated to renal stone size reflects the risk for crystallization of calcium oxalate and may suggest early metabolic disorders leading to urolithiasis. this simple method appears to be accurate and cost-effective, thus bri may be widely used for discrimination between stone-formers and healthy children. m. dixit, n. dixit florida children's hospital, florida children's kidney center, orlando, united states acute tubulo-interstitial nephritis (atin) is an important cause of acute renal failure resulting from a variety of insults including rare immune complex-mediated tubulo-interstitial injury. drugs including non-steroidal anti-inflammatory drugs (nsaids) are far most frequent cause of atin, but overall as an entity it remains under-diagnosed as symptoms resolve spontaneously if the medication is stopped. we present a -year-old male who developed acute renal failure weeks after aortic valve surgery. he was put on aspirin following surgery and took ibuprofen for fever for nearly a week prior to presentation. he then presented to the emergency department feeling quite ill and was found to have bun of mg/dl, creatinine of . mg/dl and serum potassium of . meq/l. dialysis therapy was immediately initiated. a kidney biopsy showed inflammatory infiltrate consistent with atin. however, very intense tubular basement membrane (tbm) granular deposits of polyclonal igg and c were noted. he needed dialysis for nearly two weeks and was treated successfully with steroids. his renal recovery and disappearance proteinuria took almost a year. in conclusion, we present an unusual case of tbm immune complex-mediated atin due to nsaids with severe but reversible renal failure. the effect of corticosteroid therapy on bone metabolism in nephrotic syndrome background: nephropathic cystinosis is characterised by lysosomal cystine accumulation leading to generalized fanconi syndrome. defective tubular reabsorption of proteins, mainly by the multi ligand receptors megalin and cubilin, is considered to be the cause of proteinuria in cystinosis. whether increased glomerular permeability contributes to proteinuria in cystinosis is investigated in this study by evaluating ) urinary protein pattern in cystinotic patients and healthy controls ) expression of megalin, cubilin and their ligands transferrin, albumin, a -microglobulin (a m) and b -microglobulin (b m) in renal tissue. methods: urine of cystinotic patients and controls (n= ), aged - , were immunoblotted using antibodies against megalin, cubilin, transferrin, albumin, a m and b m. additionally, urinary levels of igg, albumin, a m and creatinine were measured. results are expressed as mg/mmol creatinine (median, range). presence of proteins in semithin paraffin sections from cystinotic and control kidneys was evaluated using antibodies mentioned before. results: cystinotic patients had increased urinary excretion of , p < ) and all tested ligands of megalin and cubilin. immuno histochemistry showed comparable expression of megalin, cubilin and their ligands in convoluted proximal tubules (pt), while the ligands in straight pt were only present in cystinotic patients. conclusion: a selective proteinuria with high molecular weight protein excretion such as igg indicates increased permeability of glomerular filtration barrier in cystinosis already at an early age. the presence of the megalin and cubilin ligands in endocytic vesicles suggests functional endocytosis. however, the enhanced staining of the ligands in cystinotic straight pt may be a result of incomplete reabsorption in convoluted pt. background: dent's disease and lowe syndrome are the most frequent x-linked tubulopathies. dent's is characterized by lmw proteinuria, hypercalciuria and nephrocalcinosis. in ca. %, this phenotype results from mutations in the clcn -gene. lowe syndrome (congenital cataract, mental retardation and generalized fanconi syndrome) is due to mutations in the ocrl gene. stunted growth is another typical finding in lowe patients. recently, in a subgroup of dent patients ocrl gene mutations have been demonstrated (dent- disease). aim of the study: comparison of the growth pattern of patients with clcn and ocrl mutations. patients: boys with proven mutations in clcn (n= , mean age . ± yrs) were compared with those with dent- disease (n= , ± yrs) and those with ocrl mutations and a lowe phenotype (n= , . ± . yrs). comparison of z-scores for height, weightand bmi. results: clcn positive boys had a significantly higher height-sds (- . ± . ) than ocrl positives (dent- : - . ± . /lowe: - . ± . ). there were no significant differences in bmi-sds and weight-sds. the difference between weight and height sds as a parameter for obesity in these small-statured children was higher in lowe than in classical dent patients, with intermediate values being found in dent- . discussion: although the renal phenotype of dent- patients is identical with classical dent, the former are more stunted. therefore, the abnormal growth pattern in dent- patients cannot be ascribed to renal dysfunction. taken together with other findings (elevated ck and ldh, mild mental retardation) our findings illustrate that dent- is indeed a mild variant of classical lowe syndrome. quantitative ultrasonometry of the calcaneus in children with idiopathic hypercalciuria lesch-nyhan syndrome is a very rare x-linked recessive disorder characterized by mental retardation, spasticity resembling cerebral palsy, choreoathetosis, self-mutilation and hyperuricemia. self-mutilation behavior is a hallmark of the disease. hyperuricemia leads to hyperuricuria and uric acid nephrolithiasis. we report on a -year-old boy with lesch-nyhan syndrome with no self-mutilation behavior who was erroneously diagnosed as having athetotic cerebral palsy. besides, he had no renal stones, the only renal abnormality detected were hyperechoic renal medullary pyramids, sonographicaly indistinguishable from medullary nephrocalcinosis. bone disease is frequently observed in children with homozygous beta-thalassemia (thal). we have observed an increased prevalence of renal stones in these patients. in order to understand the cause of this predisposition to renal stone formation we investigated markers of bone metabolism in our thal children. we studied thal children (age range - years; females and males) with no eviodence of renal stones. thal was diagnosed with haemoglobin hplc study and genetic typing. all received blood transfusion and iron chelants on a regular schedule. serum levels of pth, osteocalcin, telopeptide c-terminale (cross-laps) were determined with eclia technique; serum vitamin d ( ohd ) with elisa technique. serum calcium, phosphate, uric acid, bicarbonate, creatinine, alkalin phosphatase and sodium, calcium, oxalate, citrate and creatinine in hours and fasting urine were determined with common methods. as controls we studied children with comparable age. serum pth and vitamin d were increased in % of our patients, serum osteocalcin in % and telopeptide c-terminale (cross-laps) in %. hypercalciuria was observed in %, hyperoxaluria in % hypocitraturia in %. significant correlation were found between pth and osteocalcin (p< . ) cau/cru (p< . ); osteocalcin and cross-laps (p< . ) and vit d and cau/cru (p< . ). bone disruption due to bone marrow expansion may produce an increase in vit d and pth production with hypercalciuria producing renal stones. losartan is an angiotensin ii subtype (at ) receptor antagonist used for controlling blood pressure and urinary protein excretion in patients with hypertension and chronic renal disease. there are a few reports about the clinical implications of at- receptor antagonism that may interfere with the kidney's defense against an acid load and may thereby exacerbate metabolic acidosis in the literature. the suggested mechanism is that at- blockade by losartan exacerbates acidosis by inducing a distal-tubular acidification defect.we observed metabolic acidosis and hyperkalemia in five patients ( females/ males, age ranged - years) whom were given losartan. during the second week of the therapy all patients revealed a metabolic acidosis with (ph; ranged , to , and hco ; ranged , to mmol/l) hiperkalemia (ranged , to , mg/dl). the etiologies of chronic renal disease in the patients were focal segmental glomerulosclerosis (fsgs) in one, lupus nephritis in one and three had undergone renal transplantation according to different etiologies. glomerular filtration rate was higher than ml/sec/ , m in all patients. immune suppressive regimen of renal transplanted patients was based on tacrolimus in two patients and on cyclosporine a in one. both renal transplanted patients and other two patients with fsgs and lupus nephritis were all receiving steroid, enalapril and mycophenolate mophetil at the same time during the losartan therapy. metabolic acidosis and hyperkalemia were recovered within a week following the exclution of the losartan. in conclusion, we think detailed and controlled studies are necessary to determine the pathogenesis of the metabolic acidosis due to losartan and patients must be followed up very closely for the adverse effects of metabolic acidosis and hyperkalemia during the treatment. objectives of study: bartter's syndrome is a rare renal tubular disorder characterized by hypokalemia and metabolic alkalosis. it is also known to be effectively treated with potassium supplement, potassium sparing diuretics and indometacin. we experienced two sibling cases whose problems were incompletely solved with above mentioned conventional treatment, but rather completely with adjunctive therapy of regular hemodialysis with dialysate of low bicarbonate concentration. case : this male patient was diagnosed of bartter's syndrome when he was months old. he was treated with potassium supplement, aldactone and indometacin with marked improvement. but he still had some problems of retarded growth, severe headache and episodes of marked hypokalemia which needed repetitive admission. when he was years old, we put him weekly hemodialysis with dialysate of low bicarbonate concentration ( meq/l). with hemodialysis, he has been in good condition for years with stable blood ph and serum potassium levels. case : this female patient, the elder sister of case , was diagnosed of bartter's syndrome at one year of age. with those therapy on conventional medications, she seemed to grow out of failure to thrive, but needed repeated admissions due to episodes of dehydration and hypokalemia. after start of weekly hemodialysis with low bicarbonate dialysate, for one year she has been on good control of blood ph and serum potasium level, and was never admitted with those episodes. conclusion: regular hemodiaysis with dialysate of low bicarbonate concentration can be considered as effective adjunctive therapy in intractable bartter's syndrome. a. deguchtenaere, a. raes, j. dehoorne, c. vande walle, r. mauel, j. vande walle university hospital gent, pediatric uro-nephrologic center, gent, belgiummonosymptomatic enuresis nocturna (mne) may be associated with nocturnal polyuria (np) and low urinary osmolality during the night. besides vasopressin, recent studies have stressed the possible role of renal sodium-handling, hypercalciuria, prostaglandins and/or osmotic excretion.the aim: was to study circadian rhythm of gfr and diuresis in a highly selected group of children with persistant np. methods: population existed of children with mne and np, age - y, males. controls n= children, - y with mne, but no np. (=b). renal function during h concentration-prophyle, with timed urine samples, and measurement of p and u for na, k, osmol, creatinin. calculation of gfr by creatinine, uosmol, feosmol, diuresis vol (ml/min), fena, fecl, fek, u k /u k +u na %. statistics: paired t-test p< . between d and n, unpaired t-test, between the groups. conclusion: children with nocturnal polyuria have not only lost their circadian rhythm of diuresis and sodium-excretion but also of gfr. another observation for a reanl involvement in mne. sarcoidosis is a systemic disorder of unknown etiology, rare in children, characterized by the presence of noncaseating granuloma in affected organs. we report a -year-old boy of french african origin who presented with left hearing loss followed by bilateral deafness within months. a history of bilateral uveitis was secondarily unveiled. mild renal insufficiency (creatinine level μmol/l ; clearance: mmol/min) was diagnosed prior to cochlear implant surgery. a percutaneous renal biopsy evidenced a granulomatous interstitial nephritis with widespread interstitial fibrosis. complementary explorations showed elevated lysozyme activity at μg/l (normal < ) with elevated cd /cd ratio in bronchoalveolar lavage specimen. pulmonary function test was notable for mild diffusion impairment. cerebral mri demonstrated abnormal enhancement involving the periventricular white matter and the intracanalicular portions of both viii cranial nerves. cerebrospinal fluid showed abnormal hyperlymphocytosis ( lymphocytes per mm ) while protein was normal. three weeks after admission, bilateral uveitis recurred and was cured by local steroid therapy. despite intensive treatment with intravenous prednisone g/ , m /j per day, successive days per month associated with oral prednisone during months, glomerular filtration rate did not improve. in conclusion, sarcoidosis may apparently be revealed by acute bilateral deafness, and prompt diagnosis is needed to avoid permanent lesions. gfr cystcin= . cystc - . , formgfr= *height (cm)/s-creat (mmol/l). d difference between c inulin and tested method. conclusion: none of the tested methods seems to reveal hyperfiltration in type diabetes patients as clearance of inulin. the best correlation was found to clearance of iohexol and second best gfr estimated by /cystatin c. creatinine clearance overestimates and formula clearance underestimates gfr in diabetic patients without nephropathy. objective: to study the effects and mechanism of fty on the renal interstitial fibrosis in unilateral ureteral obstructic rats. methods: fouty-five males sd rats were randomly divided into sham-operated (sham), unilateral ureteral obstruction (uuo) and uuo treated with fty (uuo+fty ) group. . mg.kg - .d - of fty or vehicle was administrated through daily gavage and begun from two days before the operation till being sacrificed. -hour urine protein, blood urea nitrogen and plasma creatinine were determined. the renal tubular interstitial fibrosis lesion and the expression of α-sma,col-i, cd , ed were scored semi-quantitively. results: the amount of hours urine protein was much lower than that in uuo group, (p< . ). serum creatinine in fty treated group were significantly lower than those in uuo group (p< . ). the scores of renal interstitial fibrosis were lower in fty group than that in uuo group. α-sma expression was limited to vessels in sham group, but extended to renal tubule and interstitium in uuo and fty treated group, while relatively weaker expression was observed in fty group than in uuo group. some collagen expression was found in sham group, which was much enhanced in uuo group and mainly distributed in renal interstitium, the expression in fty group was also increased compared to sham group, but much lower than that in uuo group. obvious lymphocyte and macrophage infiltration were found in tubular interstitial area in uuo group but significantly less in fty treated group (p< . ).conclusion: novel immunomodulator fty can obviously inhibit renal interstitial lymphocyte and macrophage infiltration, renal tubule cell transdifferentiation, and interstitial fibrosis, thus prevent renal disease progression. background: the mesangial cell, especially as a fundationtal component in normal mature glomeruli, is essential to keep glomerular capillary lumen open and to maintain efficient ultrafiltration. loss of mesangial cells due to pathologic conditions such as glomerulonephritis leads to impaired renal function. the exact developmental origin of mesangial cells is unknown. it has been established that mesenchymal stem cells, which are derived from bone marrow, have a potential to differentiate into different lineages in response to different environments. the purpose of the study is to examined the effect of platelet-derived growth factor (pdgf) in the differentiation of bone marrow-derived cells into mesangail cells. method: isolated bone marrow cells were cultured in the medium containing collagen type i within hours, and then transferred to collagen type i.-coated dishes. the cells attached to collagen type i. in the following days were maintained in the differentiation medium containing % horse serum, μmol/l, and μmol/l of pdgf and all-trans retinoic acid. results: after cultivation under the above condition, approximately % of cells expressed β actin and desmin, which highly resembled cultured mesangial cells in rat. the induced cultured cells changed into a wide range of shapes from spindle to stellate. the results indicate that bone marrow-derived stem cells could differentiate into mesangial-like cells in vitro. key: cord- -uftc inx authors: nan title: abstract of th regional congress of the isbt date: - - journal: vox sang doi: . /vox. sha: doc_id: cord_uid: uftc inx nan in the fin de siecle was heavily concentrated in vienna. freud, boltzmann, schr€ odinger and mach might be the first names to find, whenever one cites austrian scientists. but more related to transfusion are the noble prize winners max perutz and karl landsteiner. landsteiner s fate illustrates the brain drain beginning in the early s escalating in with the "anschluss", which lead to the forced emigration of many scientists. a loss which was not regenerated in the post war years and was further aggravated by dubious and often undisclosed relations and scandals in the nazi-era. all together this leads to a severe loss of credibility and productivity of universities across decades. opening university access in the early s and intensive historical work-up of scandals transformed the austrian universities to open and effective scientific institutions driving innovation in the country. austria has achieved a great economic deal in recent decades, which was accelerated by the eu membership in . as a result of strong long-term economic performance, the country's gross domestic product (gdp) per capita is the eighth highest among oecd countries and fourth in the eu . levels of poverty and income inequality are both below the oecd average. investment in research and development (r&d) increased since the eu accession, when austria's r&d intensity (aggregate r&d expenditure as a percentage of gdp) was well below the oecd average and significantly far lower than switzerland -a country to which austria prefers comparison. the eu target of % r&d intensity was first met in and is the sixth highest among oecd countries and the second highest in the eu . austria showed the second highest increase in r&d intensity of all oecd countries, exceeded only by korea. the rapid expansion was matched by a similar increase in human resources and scientific output of universities. austrian science in quantum mechanics, quantum communication and information is world renown. vienna is a major biotech hub, as is linz in mathematics and mechatronics and graz in automotive and production technologies. austria has been a net resource recipient in the horizon and the preceding th framework programme. small and mediumsized enterprises show a high propensity to co-operate with universities and other research organisations and more and more included in scientific grant schemes. vienna is the largest student city in the german-speaking world and consistently ranks among the top cities in the world on quality-of-life indices. as austria possesses globally recognised cultural attractions ranging from famed salzburg festival to the vienna new year concert its inhabitants are not aware of the progress made in r&d and how thriving innovation is going on in their country. they still love to show their cultural heritage and events and impress the world with some kind of eternal sound of music. patients with refractory b-cell malignancies as non-hodgkin lymphomas (nhl) resistant to standard therapies have a dismal prognosis. the outcome is even poorer in patients relapsing after autologous stem cell transplantation. most of these patients do not qualify for an allogeneic hematopoietic cell transplantation (hct) due to refractory disease, lack of a suitable allogeneic donor, higher age or cumulative toxicity of previous chemotherapy. despite patients undergoing allogeneic hct normally profit from a graft-versus -lymphoma effect, overall survival in patients with nhl after hct remains short. a similar situation can be observed for patients with acute lymphoblastic leukemia (all). therefore novel treatment modalities are urgently needed. chimeric antigen receptor (car)-t cells, a new class of cellular immunotherapy involving ex vivo genetic modification of t cells to incorporate an engineered car have been used in clinical trials. in the majority of studies b-cell malignancies treated with cd targeting car-t cells have been analyzed. austria had the advantage to participate in two international trials in the past and is currently involved in further car-t studies. recently, results from cd directed car-t cell trials with an increased follow-up of patients led to fda (food and drug administration) and ema (european medicines agency) approval of tisagenlecleucel and axicabtagene ciloleucel. common adverse events (aes) include cytokine release syndrome and neurological toxicity, which may require admission to an intensive care unit, b cell aplasia and hemophagocytic lymphohistiocytosis. these aes are manageable when treated by an appropriately trained team following established algorithm. in this presentation, results of four large phase ii cd car-t cell trials for patients with nhl and all and focus on aes is summarized. preoperative anemia is a known risk factor for increased perioperative morbidity and mortality in patients undergoing major surgery. previous studies have not only shown higher in-hospital mortality, but also an increased hospital length of stay, greater postoperative admission rates to intensive care and prolonged use of mechanical ventilation and intensive care resources in patients with anemia compared to those with normal preoperative hemoglobin concentrations. about % of patients scheduled for major surgery suffer from preoperative anemia. this figure is even higher in patients requiring orthotopic liver transplantation, where up to % of all patients are diagnosed with anemia prior to surgery. transfusion of packed red blood cells (prbcs) is commonly used to correct anemic hemoglobin values. however, transfusion of prbcs has been associated with increased morbidity and mortality in patients undergoing cardiac, orthopedic, and abdominal surgery. additionally, transfusion of prbcs is associated with a greater incidence of postoperative acute kidney injury in patients undergoing orthotopic liver transplantation. as preoperative anemia might increase the perioperative use of prbcs, negative effects observed after prbc transfusions might even be augmented. data on the influence of preoperative anemia on morbidity and mortality after orthotopic liver transplantation are limited. thus, we retrospectively analyzed the association of preoperative anemia and mortality in adult patients undergoing orthotopic liver transplantation at our institution. in addition, we examined the influence of anemia on perioperative parameters such as transfusion requirements, surgical complications, early allograft dysfunction, acute kidney injury, and the need for renal replacement therapy. based on the results obtained in the retrospective analysis, an ongoing prospective randomized clinical trial was initiated. the two suspensive treatments in sickle cell disease (scd) are hydroxycarbamide, inducing the production of the functional hbf, normally repressed at birth, and red blood cell (rbc) transfusion, a critical component of scd management. however, rbc transfusion is not without risk. repeat exposure to allogeneic rbcs can result in the development of rbc alloantibodies which can make it difficult to find compatible rbcs for future transfusions. however, the main concern of alloimmunization is the development of hemolytic transfusion reaction, with in the most severe cases, hyperhemolysis, leading to multi organ failure and death in % of the cases. the prevention of this life threatening condition must be based on risk factors. however, although some risk factors, such as alloimmunization, have been identified, much of the mechanism underlying dhtr remains a mystery, particularly in severe cases presenting hyperhemolysis. here we will describe the current and future development to prevent and treat this severe syndrome in order to decrease exposure to transfusion in scd but also improve red blood cell quality, some new products are developed. oxidative damage is one of the parameter that could be diminished. some work is also ongoing to prevent filter blockage during leucodepletion of precious rbcs units from afro-caribbean donors carrying the sickle cell trait. finally, in countries with higher risks of transmission of infectious disease, treatment of red blood cell units against infectious agents can be discussed. the only current curative treatment of scd is hematopoietic stem cell transplantation (hcs). however, the occurrence, frequency, and effects of immune hematologic complications in hcs remain and will be discussed. finally, gene therapy is a real hope as a definitive curative treatment. clinical trials are ongoing in france and will be discussed as well as the remaining place of transfusion in this therapeutic. in the context of the chronic myeloid leukemia (cml), we have hypothesized that quiescent leukemic hematopoietic stem cells (hsc) compartment, escaping to the current tyrosine kinase inhibitors (tkis) treatment, in part associated in the molecular relapse, may be targeted by cart-cells immunotherapy. gene expression profiling studies have established that a cell surface biomarker il- rap is expressed by the leukemic but not by the normal cd + /cd -hsc. this talk will focus of the whole process of development of a cart-cells starting from recombinant il- rap protein mice immunization to produce a specific monoclonal antibody (mab), to the proof of concept demonstration, before moving into the clinic. we produced and selected a specific anti-il- rap mab (#a c clone, diaclone sa, besanc ßon, france). after molecular characterization of antigen-binding domain, nucleotide sequences were fused with rd generation t cell activation coding sequences and cloned as a single chain into a lentiviral backbone comprising a safety switch suicide gene icasp (inducible caspase ) and a monitoring/selection cell surface marker Δcd . we demonstrated in-vitro and in an in-vivo xenograft murine model that il- rap car t cells can be activated in the presence of il- rap+ cell lines or primary cml cells, secrete pro-inflammatory cytokines, degranulate and specifically killing them. we also demonstrated that multi-tkis treatment over a -year period does not affect transduction efficiency of cml patient t-cells by il- rap car vector and that autologous cart-cells are able to target il- rap+ leukemic primary hsc. "off-tumor-on target" toxicity prediction, by studying il- rap expression on a tissue macroarray comprising normal human tissues ( donors) , with #a c , detected various il- rap intensity staining in only few tissues. regarding the healthy hematopoietic system, #a c flow cytometry staining did not detect hematopoietic cells, except monocytes that express poorly il- rap. as expected, monocyte subpopulation is targeted by autologous il- rap cart cells (ratio e: t = : ), but at a lower level that il- rap cml cell line. in-vivo investigation of specific toxicities of autologous il- rap cart-cells against hsc and/or immune cells on a human-cd + cord blood cell engrafted/nog murine model, but also by an in-vitro cd + colony forming unit assay didn't reveal any significant toxicities in immunocompetent cell subpopulations, suggesting that healthy cd + hsc are not affected. finally, to overcome potential toxicity, functionality of the icasp / rimiducid â safety switch was demonstrated in-vitro but also in-vivo in a nsg tumor xenograft model, showing that, when activate, the system is able to eliminate more than % of cart-cells, after exposure to ap . in conclusion, based on cml model, we demonstrated that il- rap is an interesting target for cart-cell immunotherapy, with a limited "on target, off tumor" predictable toxicity. next step will be the up-scaling of the process in order to match with the use in human regarding also the regulatory requirements. this strategy may be applied, in the future, in other hematological malignancies. mortality ranges from to % for trauma victims with severe bleeding and is largely dependent on the transfusion therapy from which they can benefit. the nature of this therapy has an impact on prognosis with a halving of mortality when the plasma/prbc ratio is greater than ½ and a decrease of about % when the proportion of platelets transfused is close to that of whole blood. the speed with which such therapy is actually administered has a major impact as well with an increase in mortality of % for each minute of delay in making the entire therapy available. this can be explained mainly by the fact that the probability of death of these patients is greater within minutes of their admission to hospital with a median time to death of h after admission. to allow plasma, platelets and prbc to be made available in a timely manner, north american trauma centers have mandated that trauma centers have massive transfusion packs at the patient's bedside within min. to further simplify and speed up logistics from distribution to transfusion, several trauma centers now use whole blood stored at °c. this return of an "old" product is largely inspired by military experience where whole blood is mainly used "warm" immediately after collection with compelling evidence of its effectiveness. its return to civilian practice requires the ability to deleukocyte it while preserving platelets and to store it while maintaining their hemostatic functions. good quality data shows this is achievable and several clinical studies are planned to begin in the coming months. in france, the french blood establishment and the french army are cooperating to initiate the prospective randomized non-inferiority storhm trial (sang total pour la r eanimation des h emorragies massives) which will be comparing whole blood to separate blood components in an / / ratio in severely bleeding trauma patients. the primary endpoint will be a thromboelastographic parameter (maximum amplitude) assessed at the th hour after admission. secondary endpoints will include early and overall mortality, lactate clearance (reflection of the effectiveness of resuscitation) and h organ failure. this trial will be recruiting patients in french trauma centers and is planned to be initiated second half of . local/neighbours day: innovation in germany c- - mesenchymal stromal cells for regenerative therapy bm-msc / asc obtained from these protocols have been characterized in detail in preclinical evaluations. manufacturing licenses for msc and asc and a platelet-derived growth factor concentrate have been obtained and they have been explored in several clinical trials for treatment of bone defects (ortho-ct : eudract number: - - ; ortho-ct : eudract number: - - ; maxillo : eudract number: - - ) . we will summarize results of completed clinical trials which confirmed feasibility and safety of autologous msc /asc treatment and provided evidence for efficacy (gjerde et al, stem cell res. introduction: in vitro produced megakaryocytes (mks) may serve as source to produce platelets (plts) ex vivo or in vivo. we have established a strategy to differentiate mks from induced pluripotent stem cells (ipscs) in bioreactors. this study aimed at the large-scale production of mks using microcarriers to increase the mk yield and to characterize their phenotype and functionality after irradiation as a method to decrease possible safety concerns associated to the ipsc origin. methods: ipscs were cultured in an aggregate form in presence or absence of microcarriers using ml stirred flasks. cells were differentiated into mks using tpo, scf and il- in apel medium for a period of days. non-irradiated or irradiated ipsc-derived mks were analysed for polyploidy, phenotype and proplt production using flow cytometry and fluorescence microscopy. also, plt-production was investigated in vivo. non-irradiated or irradiated mks were transfused to nod/ scid/il- rcc-/-mice and blood was analyzed for human plts. results: differentiation of mks in presence of microcarriers resulted in an -fold increase of mks per ipsc in comparison to only aggregates. this resulted in mean of total mk harvest of . ae . in microcarrier-assisted bioreactors in comparison to . ae . mks collected from bioreactors containing only aggregates. interestingly, mks produced in microcarrier-assisted bioreactors showed higher proplt formation capacity than mks derived from only aggregates bioreactors. mk phenotype and dna content was comparable between mks derived from both types of bioreactors. irradiation of mks did not affect their phenotype and capability to form proplts or plts after transfusion into nod/scid/il- rcc -/mice. conclusion: microcarriers showed to significantly increase the yield of ipsc-derived mks in stirred bioreactors to clinically relevant numbers. this may facilitate the use of ipsc-derived mk for ex vivo production of plts, direct transfusion or for innovative mk-based regenerative therapies. although the rosetta stone, found by the troops of napoleon in egypt near the city of rosetta (rashid) contains only a small amount of text in three languages it was key in deciphering hieroglyphs. the rosetta mission tried to achieve something similar: by looking at a tiny body its goal was to decipher the origin of the solar system, planets including earth and life. after more than years the rosetta spacecraft softly crashlanded on comet churyumov-gerasimenko on september , . it has travelled billions of kilometers, just to study a small ( km diameter), black boulder named p/ churyumov-gerasimenko. the results of this mission now seem to fully justify the time and money spent in the last decades on this endeavor. where are we from? where are we going? are we alone in the universe? these are some of the big questions. in this talk i will show which answers we got from rosetta and comet chury. we follow the pathway of the material which makes up our solar system from a dark cloud to the solar nebula and finally to planets and life. i will show that indeed we are the result of stardust and that what happened here may happen elsewhere in the universe. cells, tissues and entire organs can collectively be seen as "living drugs". genetically unaltered cells are routinely used in clinical practice to treat diseases as diverse as anemia, bleeding disorders, leukemia and organ failure. ground-breaking advances in genetic and genome engineering technologies are propelling cell therapies to the frontline of medical research and practice. the hematopoietic system is particularly amenable to genetic engineering because specific cell types can be purified based on the expression of specific surface proteins and the ability to culture and expand cells ex vivo. the recent unprecedented clinical success of killer t cells reprogrammed by chimeric antigen receptors (cars) to attack cd expressing tumor cells demonstrates the power of immunotherapy with genetically engineered immune cells. however, given the rapid development of novel genome engineering and synthetic biology tools we are likely only at the beginning of a new era of engineered cellular therapies. i will present recent progress in immune cell reprogramming, gene correction, safety aspects and remaining challenges such as manufacturing. d- - cell free nucleic acids (cfna) circulate in the plasma of all individuals and are thought to be released by host and foreign cells into the circulation. after fractionation by centrifugation, cfnas can be extracted from the supernatant of whole blood samples or manufactured blood products. these dna or rna sequences can be of human, bacterial, viral or fungal origin. most of them are human double stranded dnas. research on cfnas is increasing, thanks to technological advancements in molecular biology. some of their results are already implemented in clinical practice in the areas of prenatal diagnosis, oncology and infectious diseases. the latter investigation focuses on the exploration of non-human cfnas, the field of metagenomics. high throughput sequencing associated with bioinformatics, the so-called new generation sequencing (ngs), has sped up the investigations of non-human cfnas. this tool provides the opportunity to classify cfnas into a human or non-human category, and then to identify them. it is thus possible to explore simultaneously the whole landscape of bacterial, viral and fungal populations. presently, ngs of human blood has already proven its feasibility and its value in identifying emerging viruses or investigating clinical cases of fever of unknown etiology. ngs of cfnas is also particularly effective in analyzing the different genotypes of a virus in case of a co-infection (e.g. hepatitis c virus). studying cfnas with the new molecular technologies is therefore of great importance in transfusion medicine, especially regarding security and clinical transfusion reactions. first, transfusion transmitted infections are the most feared adverse complications. second, febrile non-hemolytic transfusion reactions are also the most frequently reported adverse events in hemovigilance systems and their physiological mechanism -if only one-remains not clearly elucidated. investigating cfnas could thus improve our understanding and strategy aiming at reducing those two clinical adverse events. surveying comprehensively the composition of circulating infectious agents in a blood product by ngs technology could be very interesting for investigating a severe febrile transfusion reaction. moreover, when the costs of analysis will be reduced, it might be possible to screen prospectively and regularly the whole metagenomics of asymptomatic blood donors, in addition to the classical epidemiological surveillance. for instance, in a study testing a ngs method on manufactured fresh frozen plasmas, an astrovirus (mlb ) has been identified. finally, it is the responsibility of transfusion physicians implicated in the manufacturing of blood products to ensure that cfnas within a blood product do not have a clinical impact on the innate immunity of the recipients. according to recent research in vitro, cfnas purified from blood products can induce the transcription of inflammatory cytokines by mononuclear cells. as nonhuman cfna have an effect on toll-like receptors (tlr-linked inflammatory pathways), it would be also relevant to insure that donor's cfnas have no significant effect on the immune system of the recipient. in conclusion, cfnas are very diverse molecules contaminating blood products. technological progress makes now their investigation more available. besides being useful markers of infection in asymptomatic donors, their impact on the recipients' immunity should be further investigated. an active life and regular training is part of a healthy life style and for many this includes participation in endurance exercise competition at different levels. thus, it is highly relevant to know how a blood donation affects exercise performance and how close this can done to an endurance competition. endurance exercise performance is determined by many factors, but three of the primary are maximal oxygen uptake, the relative load that an individual can sustain over time and finally the efficiency of movement in the given discipline. over the years, a number of studies have sampled blood volumes ranging from - ml and applied different methodological approaches to measure maximal oxygen uptake over a recovery period ranging between - days. overall, the general finding is a reduction in blood haemoglobin and an attenuated maximal oxygen uptake as well endurance performance after blood donation. in normal to well-trained men maximal oxygen uptake and performance was normalized after two weeks in one study after a normal blood donation ( / ml), but remained attenuated after four weeks in another study, despite the change in blood haemoglobin concentration was similar and the design and methodology also similar in the two studies. in addition to maximal oxygen uptake the relative load that can be tolerated during exercise is probably also attenuated, through a decreased arterio-venous oxygen extraction, but the available data is very limited. the first part of this talk will highlight the major findings and discuss some of the methodological issues that complicate interpretation and conclusions. there are sex differences in circulating blood volume, haemoglobin concentration, haematocrit and hormone levels and thus it is entirely possible that there is a sex difference in the effect of blood donation on physical performance and the recovery after blood donation. in addition to the basic physiological sex differences, there is also a higher prevalence of iron deficiency in premenopausal women, physically active women and women donating blood. therefore, we studied the influence of a standard ml blood donation on maximal oxygen uptake and endurance performance and the subsequent recovery in physically active women. we observed that in iron sufficient women blood haemoglobin concentration and maximal oxygen uptake were back to baseline days after blood donation, but endurance performance was normalized already after days. the second part of this talk will discuss the sex differences in the effect of blood donation on maximal oxygen uptake and endurance performance. overall, the available data suggest that, with a careful conservative approach, - weeks are needed after a normal blood donation to be fully recovered to participate in endurance exercise competitions. more than one in ten attempts to donate blood result in a temporary deferral, due to concerns about the impact of the donation on the donor or recipient. there is well established evidence that temporary deferrals impact negatively on donors, with a large proportion of those deferred failing to return at the end of the deferral period. this presentation provides an overview of deferrals from the donor perspective, describing the likelihood of receiving a deferral for different donor subgroups. the impact of temporary deferrals on the future donation of donors, considering both short-term and longer-term donation patterns, will also be reviewed, outlining which donors are at highest risk of non-return following a deferral, and what is known about the accumulative impact of multiple deferrals on donors. several hypotheses have been proposed to account for the strong negative impact of deferrals on donor behaviour, and there is preliminary evidence of psychological factors, such as emotional reactions, predicting intention to return. research is also beginning to emerge on the effectiveness of tailored interventions to mitigate the impact of deferrals on donor behaviour. the evidence for these preventative interventions, and for strategies to reactive donors once they have lapsed post-deferral, will be reviewed. recommendations for blood centres will be made, as well as suggestions for future research to address continuing gaps in knowledge. in his influential study "the gift relationship" ( ) , richard titmuss coined the idea of voluntary, non-paid, blood donation being the gift of life for a fellow citizen. this metaphor has been powerful in mobilizing donors (busby ) . it conveys a direct relationship between blood donation and patients' vitality, as well as a difference between gains and costs. as the gift of life, blood donation is seen to symbolize pure altruism and promoting solidarity between strangers. but can we apply the metaphor as successfully into donating blood for research? we asked a group of finnish blood donors what they would think if the frc blood service invited them to give a blood sample and personal information for research. the blood donors were usually willing to contribute to research for the public benefit, because they saw great potential in science to create solutions to help patients in the future. however, based on our interview data and previous research, we suggest that the analogy between gift of life and donation for research did not work all the way. the metaphor fails to address donors' questions on new types of relationships, interests and risks related to the use of personal data for research. left unanswered these could discourage donating for research. hence, we argue that the gift of life metaphor is not applicable to donor recruitment at the research context. in this presentation we wish to look for a better metaphor for donation for research that blood services collecting research data could apply. academy day: transfusion challenges in patients with sickle cell disease a- - immunohaematological features of patients with sickle cell disease (lfa) should be considered as polymorphic antigens in the african population and these lfa are not present in most commercial panels. the situation is even more complicated when recipients lack high-frequency antigens, the most common ones being hr-, hr b -, sec-, u neg , u+ var , js(b-), (hy-), and jo(a-). finally, there is a high rh diversity among people of african descent. because they harbor variant alleles and/or partial rh antigens, they are at risk of developing alloantibodies. in this setting, screening for partial rh antigens makes sense. the figures illustrating this diversity vary with the approach used. one of them is to take into consideration rhd or rhce*ce variant alleles. in several american studies, their prevalence was estimated to be - % and - %, respectively. other teams take into consideration d, c and e partial antigens. their prevalence was estimated to be . - %, . - . %, . - . %, respectively, and the alloimmunization rates were . %, . - %, . %, respectively. as a result of these phenotype discrepancies, scd patients are more likely to be alloimmunized. an overall immunization rate of - % is commonly admitted in the general population. depending on the unit selection policy and/or the study design, the immunization rate in scd patients varies from % to %, the highest figures being established when an abo/rh -only matching policy is implemented. in a meta-analysis of publications, the overall alloimmunization rates were around %. alloimmunization is thought to be enhanced by an inflammatory state, which is often present in scd patients. they are more prone to develop a new alloantibody. using a stochastic modeling of alloimmunization, they have a % increased risk of producing additional antibodies versus % in the general population. autoantibodies have been identified as a risk factor of alloimmunization. as a result, scd patients often have complex mixtures of allo and autoantibodies. rh antibodies and those considered as irregular natural antibodies are present in a significant proportion. another characteristic of the antibodies in scd patients is their evanescence; up to % of alloantibodies become undetectable within a few years of their initial development. relatedly, about a third of dhtrs are reported to happen in patients with no previous history of immunization. in addition, a third of patients will not develop an antibody after a dhtr. identifying patients at risk of developing a dhtr is key to managing them properly. alloimmunization is a serious risk of red blood cell transfusion in patients with sickle cell disease (scd) and can result in severe (delayed) haemolytic transfusion reactions, exacerbation of clinical symptoms and life-threatening hyperhaemolysis. once alloimmunized, the presence of alloantibodies in the patients' blood further complicates pretransfusion testing and hampers the selection of compatible blood products. numerous studies have shown that scd patients have a relatively high risk of alloimmunization as compared to the 'general' population. this is not only explained by the large number of transfusions given but also by the increased exposure to foreign antigens as a result of differences in the antigen make-up of the scd recipients and the blood donor population. other factors involved in the immune response such as age at first transfusion, inflammatory state, hla typing are under investigation and are starting to unravel. because blood transfusion is still one of the main treatment modalities for scd and some patients have a life-long transfusion dependency it is important to minimize the alloimmunization rate. theoretically, complete matching for all relevant blood group antigens would prevent alloimmunization. this however, is only possible when all donors are comprehensively. matching strategies should be developed to minimize alloimmunization while balancing patients' need and donor availability and is cost effective. to develop a (preventive) matching strategy some factors need to be established; ) which antibody specificities are clinically relevant ) which antigens are most immunogenic ) what is the availability of specific antigen typings in the donor population ) how should recipients (and donors) be typed, phenotypically and/or genotypically and to what extent. the latter is especially important in scd patients since they are of african descent and the prevalence of genetic variations in this population is relatively high. rhd and rhce variants are common and can remain undetected when serological typing is used but can be discovered with high resolution molecular typing. patients with partial rh phenotypes are at risk for alloimmunization. apart from special rh phenotypes in individuals from african descent, the fy(a-b-) phenotype related to the gata-box mutation in the fyb allele and the u-or u var phenotype resulting from genetic variations in the mns alleles are also common. several studies have shown that in scd patients antibodies directed against rhd, rhe, rhc and k are most frequently found when unmatched transfusions are given. preventive matching for these antigens has proven successful in reducing alloimmunisation. extended matching for all rh antigens fy(a), jk(a) and jk(b) can further decrease the alloimmunisation rate. currently, different countries have preventive matching strategies in place for this vulnerable patient group. as genotyping is more and more available and within reach, optimal antigen typing approaches for patients and donors, combining serology and genetics are being developed. in this lecture several aspects of antigen typing approaches and preventive matching strategies that will most benefit scd patients of will be discussed. artificial intelligence has become a buzzword that will appear about anywhere in the media. we can forget that ai, or the subfield in this computer science field machine learning, has been around for over years. improvements in computing power, abundance of data, progress in computer science, and the arrival of affordable cloud solutions have now brought it to our daily lives. also in health care news about ai has become omnipresent. and some landmark papers have come out on algorithms outperforming (teams of) physicians in the diagnosis of all kinds of skin disease, eye disease from retina scans, and detect cancer in ct scans. however, little of these solutions have actually shown up in our clinical practice yet. in anaesthesia, we worked with the first algorithm to come to anaesthesia practice; hypotension during surgery is associated strongly with poor outcome like myocardial ischemia, surgical complications, renal failure and even mortality. we worked on a machine-learning trained algorithm that predicts hypotensive events using the arterial blood pressure curve up to - min before the actual event. to get fda and ce approval, however, mere mathematic validation is required. this can be achieved on retrospective datasets. in reality, we need more before we can use these algorithms to support our decision-making; after internal (retrospective) and external (prospective but passive use) validation steps, clinical (i.e. rct validation is needed. moreover, we will need to assess the economic impact too. ultimately this tool has now reached clinical practice and is starting to help us go from reactive to more proactive hemodynamic management. like this, we have started to work on machine-learning tools to predict the incidence of specific types of patients coming into a&e and predicting infections after surgery. we will discuss our approach, essentials to start with machine learning, practical learnings. we will also discuss a first project design to use machine learning in managing bleeding patients to get the best therapy advice for blood product use like plasma, fibrinogen et cetera. how can we start using this tool in unison with our existing tools to improve science and clinical practice in our respective (bio)medical fields? thrombocytopenia is a very common hematological abnormality found in newborns, especially in preterm neonates. two subgroups can be distinguished: early thrombocytopenia, occurring within the first h of life, and late thrombocytopenia, occurring after the first h of life. early thrombocytopenia is associated with intrauterine growth restriction, whereas late thrombocytopenia is caused mainly by sepsis and necrotizing enterocolitis. platelet transfusions are the hallmark of the treatment of neonatal thrombocytopenia. most of these transfusions are prophylactic, which means they are given in the absence of bleeding. however, the efficacy of these transfusions in preventing bleeding has never been proven. in addition, risks of platelet transfusion seem to be more pronounced in preterm neonates. because of lack of data, platelet transfusion guidelines differ widely between countries. in a recent randomized controlled trial (planet- /matisse study) among preterm infants with severe thrombocytopenia, we found that those randomly assigned to receive platelet transfusions at a platelet-count threshold of /l had a significantly higher rate of death or major bleeding within days after randomization than those who received platelet transfusions at a platelet-count threshold of /l. this presentation summarizes the current understanding of etiology and management of neonatal thrombocytopenia. transfusion-associated circulatory overload (taco) is a severe transfusion adverse reaction that is associated with increased mortality and morbidity. the incidence of taco in adults varies from % to %, but is probably underdiagnosed and underreported. the incidence in the pediatric population is undetermined. taco usually occurs in patients who receive a large volume of blood product over a short period of time. it is more common in patients with known risk factors such as cardiovascular disease, renal failure, and older or younger age (> years or < years). hospitalised patients and intensive care patients are also more at risk. the typical presentation of taco is respiratory distress (dyspnea, tachypnea) occurring within h of a blood transfusion. associated signs and symptoms are hypoxia, hypertension, tachycardia, positive fluid balance, high central venous pressure, and acute or worsening pulmonary edema on chest x-ray. echocardiography and measurement of brain natriuretic peptide (bnp) or its n-terminal prohormone (nt-probnp) is helpful for diagnosis. several definition criteria have been proposed for taco, but none are adapted for children, particularly critically-ill children who are more at risk. this is probably the main reason why taco is even more underdiagnosed and underreported in the pediatric population. in a recent study, we compared the incidence of taco in a pediatric intensive care unit using the international society of blood transfusion (isbt) criteria, with two different ways of defining abnormal values: ) using normal pediatric values published in the nelson textbook of pediatrics; and ) using patients as their own controls and comparing pre-and post-transfusion values with either a % or % difference threshold. we monitored for taco up to h post-transfusion. a total of patients were included. taco incidence varied from . % to %, depending on the definition used. with such wide variability, we conclude that a more operational definition of taco is needed in pediatrics, particularly for critically-ill children. differential diagnosis from other dyspnea-associated transfusion adverse reactions (e.g. transfusion-associated lung injury, anaphylaxis) is important because treatment differs, as do guidelines to the blood bank. treatment for taco is similar to that of any other cardiogenic pulmonary edema: oxygen, diuresis, ventilatory support. prevention is possible by avoiding unnecessary transfusions, transfusing only the necessary amount of blood product, avoiding rapid transfusions, and using diuretics. background: the risk and importance of transfusion-transmitted hepatitis e virus (tt-hev) infections by contaminated blood is currently a controversial discussed topic in transfusion medicine. in particular, the infectious dose is a not finally determined quantity. the different countries have chosen different approaches to deal with this pathogen. one central question is the need of individual nat screening (id) versus minipool nat screening (mp) approaches to identify all relevant viremias in blood donors. aims: comparison and evaluation of the available screening strategies in relation to the infectious dose to minimize the risk of tt-hev infections. methods: we systematically reviewed the presently known cases of tt-hev infections and available routine nat-screening assays. furthermore, blood donation screening strategies for hev ehev in effect in the european union were compared. we also describe our own experiences of hev screening utilising an id-nat-based donor screening algorithm compared to mp-nat in pools of samples. from november to january , a total of , blood donations were screened for the presence of hev rna using a mp-nat (in house, realstar hev rt-pcr kit) and an id-nat (cobas platform). results: the review of the literature revealed a significant variation regarding the infectious dose causing hepatitis e. in the systematic case review, all components with a viral load (vl) greater than . e+ iu caused infection (definitive infectious dose (difd) . the lowest infectious dose resulting in tt-hev infection observed in general was . e+ iu (minimal infectious dose (mifd). the infectious dose of the different blood products is mainly influenced by the remaining plasma content. our data comparing the two different hev screening algorithms revealed eight hev rna positive donations using a mp-nat (incidence : , ) , whereas hev rna positive donations were identified by id-nat (incidence : ); all id-nat only positive donations had vl < iu/ml. summary/conclusions: taken into account the current knowledge on the required mifd, the difd, and the analytical sensitivities of the screening methods, we extrapolated the detection probability of hev-rna positive blood donors using different test strategies (nat assay, id vs. minipool with different pool sizes). we also considered the amount of plasma in the different blood products and calculated the infectious doses needed to be detected. only id testing would be sufficient to detect the minimum vl in the donor to avoid tt-hev infections based on the currently known mifd, but a highly sensitive mp-nat should be adequate as a routine screening assay to identify high viremic donors and avoid tt-hev infections based on the difd. we have also determined that the incidence of hev infection was approximately % higher if id-nat was used. however, vl were below iu/ml and will most likely not result in tt-hev infection taken into account the currently known mifd or difd. the clinical relevance of and need of identification of these low level hev positive donors still require further investigation. in the last years several pathogen inactivation (pi) technologies have been developed to be applied to blood components. technologies for inactivating pathogens in plasma and platelets are available in the european union, and some others are currently under development. the first pi technology introduced in the market was for plasma, and was based on the addition of methylene blue and the illumination with light (theraflex mb-plasma, macopharma and gr ıfols). for platelets and plasma two technologies are licensed, one is based on the addition of amotosalen and the illumination with ultraviolet light (uv) (intercept â , cerus) and the other one combines the addition of riboflavin (vitamin b ) and the illumination with uv light (mirasol â , terumo bct). currently another technology for platelet inactivation, based on the illumination with uvc light and strong agitation is under development (theraflex, macopharma). for red blood cells one technology based on the addition of one molecule (amustaline, cerus) is being developed. the mechanism of action, and the spectrum and level of inactivation of pathogens varies among the different technologies. in addition, the number of studies with clinically relevant endpoints and the number of patients included in the studies is not homogeneous. there is published evidence for most of them that show that the treated blood components are safe and efficacious for the patients although, for treated platelet concentrates some decrease in the posttransfusion recovery and survival of the transfused platelets occur, with differences between the different technologies. however, cumulative experience on the use in routine, for some of the technologies for almost years, support the concept of the safety and efficacy of the blood components treated with pathogen inactivation technologies without a significant increase in utilization. the use of pathogen inactivation for blood components is not widespread. differences in epidemiology between countries, infectious risk perception, concerns about potential adverse effects associated with its use and economical considerations might explain the differences observed in its implementation. the history of the p and p k antigens is complicated and sometimes confusing because of several changes to the nomenclature. the association between the antigens and their genetic home has raised many questions as well as the longstanding enigma regarding the molecular mechanism underlying the common p and p phenotypes. the system (isbt no. ) currently includes three different antigens, p , p k and nor. the p antigen was discovered already in by landsteiner and levine while p k and nor were described in and , respectively. as for the abo system, naturally-occurring antibodies of igm and/or igg classes can be formed against the missing p /p k carbohydrate structures. anti-p is usually a weak and cold-reactive antibody very rarely implicated in hemolytic transfusion reaction (htr) or hemolytic disease of the fetus and newborn (hdfn). however, some antibodies against p have been reported to react at °c, bind complement and cause both immediate and delayed htrs. the p k antibodies can cause htr and anti-nor is regarded as a polyagglutinin with unknown clinical significance. a higher frequency of miscarriage is seen in women with the rare phenotypes p and p k /p k . the rbc of the fetus as well as of the newborn express low amounts of p , p and p k antigens but the placenta shows high expression and is consequently a possible target of the antibodies and the cause of the miscarriages. the p k and p antigens have wide tissue distributions and can act as host receptors for various pathogens and toxins. furthermore, altered expression of p k antigen has been described in several cancer forms. a longstanding question has been why individuals with p phenotype not only lack p k and p expression but also p . recently it was clarified that the same a galtencoded galactosyltransferase synthesizes both the p , p k and nor antigens and in addition the p and p phenotypes was confirmed to be caused by transcriptional regulation. transcription factors bind selectively to the p allele in the '-regulatory region of a galt, which enhance transcription of the gene. it has been debated whether the p k and p antigens exist on glycoproteins in the human rbc membrane or if glycolipids are the only membrane components carrying these epitopes. a recent publication shows that the p antigen can be detected on human rbc glycoproteins and thus glycosphingolipids can no longer be considered as the sole carriers of the antigens. the blood group system which started out with one antigen, p , has now gained two more members namely p k and nor. step by step the biochemical and genetic basis underlying the antigens expressed in this system has been revealed but still many questions remain to be solved. neither gata nor klf represent a blood group system but mutations in the genes encoding these transcription factors (tfs) have been shown to result in simultaneous altered expression of blood group antigens in certain rare blood group phenotypes. in particular, mutations in the klf gene are responsible for the dominantly inherited in(lu) phenotype, commonly referred to as lu(a-b-) because of the gross reduction in lutheran antigens expression. red cells from in(lu) individuals, though, have also weakened expression of other blood group antigens, like the high-incidence antigen anwj, the antigens of the indian blood group system (cd ) and p , among others. since the first description of klf variants associated with the in(lu) phenotype, many other variants of this gene have been reported with an impact on blood group antigen expression and they are listed on the klf table of blood group alleles. other than klf , a mutated gata gene has also been found associated with the x-linked form of the lutheran-mod phenotype and has likewise been registered in the gata allele table. besides the effect of tf variants on blood group antigen expression, there are transcription factor-binding site polymorphisms in regulatory regions of blood group genes, which also have an impact on the expression of the encoded antigens in red cells. the first example of such type of polymorphisms was described in , when the disruption of a gata motif in the ackr gene promoter was found to abolish erythroid gene expression in fy(a-b-) individuals of african descent. the impact of mutations affecting gata binding sites has also been described in some abo subgroups, like the am and bm phenotypes. a regulatory element with gata binding sites in the first intron of the abo gene has been found to be altered in individuals with these phenotypes, either by deletion or by a point mutation disrupting the gata motif. recent findings have also revealed that xga expression on red cells is dependent on gata binding to a control element located . kb upstream of the xg gene. a single nucleotide polymorphism (snp) within this region was shown to correlate very well with the expected distribution of the xga negative phenotype in different populations. further work has demonstrated that this g>c snp disrupts a gata binding site and consequently abolishes erythrocyte xg expression. overall, these investigations have allowed to elucidate the underlying genetic basis for xga expression and have made xga genotyping possible. similar to xga, the p antigen has been known for a long time to be determined by the a galt gene but the molecular basis underlying the common p /p phenotypes has remained elusive till recently. several cis-regulatory snps had been identified in non-coding sequences around exon a, which showed a very good correlation with p antigen expression. interestingly, potential binding sites for several hematopoietic tfs were identified in the same region. finally, recent investigations have demonstrated the role of the runx tf in the expression of p antigen, by selective binding to a regulatory site present in p but not in p alleles. to summarize, variation in blood group antigen expression may result from mutations or polymorphisms in the regulatory region of blood group genes. recent reports have unravelled the molecular mechanisms underlying the expression of p and xga blood group antigens, which involves tf binding to allele-specific regulatory elements. similar mechanisms may also regulate antigen expression in other blood group systems. c- - clinical immunology, copenhagen university hospital, copenhagen, denmark since the discovery of cell-free fetal dna (cffdna) in pregnant women's blood, the development of noninvasive prenatal testing (nipt) has provided new diagnostic applications in prenatal care. in transfusion medicine and clinical immunology, cffdna is extracted from maternal plasma to predict fetal blood groups with the purpose of ) guiding targeted rh prophylaxis in non-immunized rhd negative women and ) assessing the risk of hemolytic disease of the fetus and newborn (hdfn) in immunized women. i will give an overview of noninvasive prenatal testing of fetal blood groups. based on the literature, i will summarize the current experience with noninvasive prenatal testing of fetal rhd and other blood groups. for rhd negative pregnant women, routine clinical testing is available in several countries world-wide to assess the risk of hdfn in d immunized women, and routine testing to guide rh prophylaxis is now implemented as nationwide service in - european countries. noninvasive prenatal testing for fetal rhd is highly accurate with sensitivities of . %, as reported from clinical programs. in general, the sensitivity is challenged be low quantities of cffdna, especially in early pregnancy. the specificity is challenged by the polymorphic rh blood group system, where careful attention is needed to navigate among the many rhd variants. rhd variants may complicate cffdna analysis and interpretation of results, especially in populations with mixed ethnicities. despite these challenges, fetal rhd testing is very feasible when implemented with careful attention to these issues. for blood groups that are determined by snps, such as kel or rhc, the main challenge has been interference from the maternal dna when analyzing the fetal dna which has resulted in low accuracy and lower sensitivity, when using qpcr. with the application of more novel techniques such as next generation sequencing and droplet digital pcr, accurate noninvasive prediction of these fetal blood groups has been demonstrated. the success of predicting fetal rhd and its successful clinical implementation into national programs should encourage wide-spread use of cell-free dna based analysis. future work on noninvasive prenatal testing of fetal blood groups determined by snps may consolidate the application for cell-free dna testing for such targets, including human platelet antigens. at isbt, the newly formed cfdna subgroup of the red cell immunogenetics and blood group terminology working party will work to facilitate clinical applications, implementation and evaluation of cell-free dna testing. blood banks in most of the nordic countries all share a vein-to-vein approach which in short means that the collection of blood, the preparation of blood components, testing/release and storing is served by a single actor. on top of that recipient and donor blood grouping, crossmatching, delivery, registration of transfusion and of any complications is usually handled in a single blood banking information system (bbis). this means that blood banks in the nordics are traditionally operated by a single vendor. the needs for process control in a single vendor bbis, the present solutions, unsolved challenges and untapped possibilities of streamlining processes have been scrutinized with the intention to describe separate processes and to acquire best of breed or best of suite it-systems. the aim for integrations, rather than building an integrated it-system, to support the need for a vein-to-vein process is a precondition in the nordic countries. with multiple it-systems supporting isolated processes, we intend to facilitate development in these and furthermore increase the flexibility in the whole process. we set out to reveal any existing knowledge in the literature on it vendor strategies for blood banks, but we didn't succeed in identifying any relevant literature. however, a systematic literature study on vendor strategies when choosing health it was based on the prisma method, and identified studies, but only was eligible for full text review and met the inclusion criteria. even this broader literature study reveals very little evidence. two studies find single vendor strategies poor and conclude "best of suite" solutions to be optimal. one study was not able to correlate vendor strategies to the investigated productivity, but concludes that best of suite and best of breed strategies requires larger organizational changes than a single vendor strategy. in summary, the existing research is contradictory. this paper adds basic knowledge for breaking down the process control of blood banking in smaller processes. this adds the possibility for identifying best of breed or best of suite vendors, instead of relying on single vendor it solutions. furthermore it is a call for more research in the field of vendor selection strategies which this study didn't succeed in identifying. d- - applying drones to supply blood to remote areas: rwanda's experience biomedical services, rwanda-ministry of health-national blood services, kigali, rwanda background: in rwanda, blood transfusion services started in . during the genocide against the tutsis almost all the socioeconomic fabric of rwanda was destroyed as well as its health infrastructure. the healthcare system was suffering in its aftermath, and there were health inequalities between urban and rural areas, including access to blood for transfusion. from , the government started to rebuild all courses of life including the health system and the blood service in particular. the national center for blood transfusion (ncbt) was then mandated to provide safe, effective and adequate blood and blood components to all patients in need. this was pivotal in achieving health related mdgs , and . today, rwanda has an ambitious vision to put all million citizens within minutes of any essential medical product. while every second matters in emergency management, the use of drones was the perfect solution to many of the last mile challenges that have been traditionally difficult to overcome. it is impossible to forecast accurately down to the need of a single patient. the government has provided an easy solution by centralizing supply and providing on-demand, emergency medical deliveries by drone. doctors are now empowered to provide the quality care with all the supplies on hand, patients can now be treated close to home, and we eliminate waste from potential overstocking when health workers know that they have a quick and reliable source of supply. description: in , the government of rwanda started to operate the world's first national drone delivery program for blood and other lifesaving medical products. these drones can carry two to six units of blood at a time and deliver in - minutes depending on a hospital's location. the average duration was between - hours round trip with the vehicle system, before the use of drones. drones currently deliver blood to health facilities throughout the country and are set to reach % of transfusing health facilities outside kigali by the end of the year. within the first year, healthcare workers saved an average of . hours per delivery and a total of , hours of lost time on road pick up they could instead dedicate to patient care. by march , over , deliveries have been made, with % of those being emergency deliveries. a total of more than , blood units have been delivered. in february , zipline obtained the highest rating from the health facilities being served in a performance evaluation conducted by the national center for blood transfusion. when a doctor or medical staffer needs blood, they place an order through the hemovigilance order portal. they are then sent a confirmation message saying a drone is on its way. the drone flies to the health facility at up to km/h. when it is within five minutes of the destination, the medical staffer receives a notification. the drone then drops the package, attached to a parachute, into a special drop zone. conclusion: supply is not a developing country problem, it is a global issue. rwanda was just the first one to recognize the potential of this technology and decided to do something about it first and fast, to ensure access to universal access to all blood products. d- - scottish national blood transfusion service, edinburgh, united kingdom supporting the provision of viable transfusion services in remote/rural areas is more than just a geographical challenge. limited qualified blood bank resource; small throughput volumes; increased regulation are only three of the additional factors combining to threaten safe and sustainable transfusion service delivery. inventory management and out of hours service provision were identified as essential areas where it was thought that technology, in the form of a remotely controlled blood fridge, could provide a key element of the overall solution. a radio frequency identification (rfid) fridge racking system was installed in a standard blood bank fridge and connected to the laboratory information management system (lims) common to both the remote and central blood bank. the central blood bank was enabled to test patient samples from the remote laboratory, identify components located in the remote fridge suitable for the patient and allow correct component issue, even when qualified staff were unavailable in the remote laboratory. testing has concluded that installation of remote fridge management can play a major role in helping to maintain a remote inventory permitting patient compatible components to be issued. by sustaining transfusion services in remote communities we can avoid transportation of patients who require transfusion support to locations miles from home. antibodies to hna- b, fcgriiib and hna- have been reported, too. neonatal alloimmune neutropenia results from maternal antibodies transferred transplacentally to the fetus and is caused by all known hna-antibody specificities, i.e. hna- a, - b, - c, - d, hna- , hna- a, - b, hna- a, - b and hna- a specificity. hna and hla antibodies can induce mild febrile transfusion reactions and trali. since the introduction of the male only plasma strategy, in many countries the trali incidence decreased but it is still one of the most common causes of severe transfusion reactions. especially hna- a antibody containing plasma from female donors is responsible for severe or even fatal reactions. but also hna- a, - b, hna- and hla class i and class ii antibodies were reported. the latter activate monocytes to secrete soluble factors that act on the primed neutrophils in the narrow lung capillaries. laboratory testing: laboratory work-up requires the knowledge of the patient's clinical condition and the methods that are appropriate to detect the relevant antibodies. the classical granulocyte agglutination test (gat) in combination with the granulocyte indirect immunofluorescence test (gift) can detect nearly all relevant antibodies. hna- , - , - , - and hla class i antibodies are clearly detectable in the gift while hna- antibodies strongly agglutinate neutrophils in the gat. the monoclonal antibody-specific immobilization of granulocyte antigens (maiga) test detects all hnaantibodies except for hna- with high glycoprotein specificity and sensitivity but is time consuming and requires highly skilled personnel. for trali diagnostics laboratory testing is completed by methods like the indirect lymphocyte immunofluorescence test (lift) or elisa for hla class i antibodies and hla class ii specific elisas. since several years fluorescent bead based assays (luminex) enable faster and more automated hna antibody detection but to date not all specificities, especially hna- , can be reliably detected so that still the classical gift and gat have to complete the methodological spectrum. serological typing today is mostly reduced to the determination of hna- in the gift because the molecular reason for the hna- -null phenotype is not completely understood. establishing only one pcr-asp reaction for the main cd * a>t polymorphism would comprise the risk to miss other molecular causes. however, for all other hna allelotyping by pcr methods is the first choice. summary/conclusions: granulocyte serology still today is widely based on a variety of manual methods and will be reserved to specialized laboratories as it requires experienced laboratory staff and profound knowledge of granulocyte immunobiology. d- - norwegian national unit of platelet immunology, laboratory medicine, university hospital of north norway, tromso, norway maternal alloantibodies against antigens on human platelets can cause severe thrombocytopenia and bleeding in fetus or newborn, identified as fetal/neonatal alloimmune thrombocytopenia (fnait) . although most cases the thrombocytopenia is selfresolving within the two first weeks of life, some infants present bleeding symptoms and thus require platelet transfusion. a set of laboratory analyses are required to confirm the fnait diagnosis. in addition to guiding compatible platelets to the affected newborn, the correct diagnosis will be valuable to assess the risk of fnait in subsequent pregnancies. in addition, platelet alloantibodies may also complicate platelet transfusions by immune-mediated platelet refractoriness, and require proper identification of the patient's antibody specificities prior to selection of donor platelets. the algorithm for laboratory investigations include both serological and molecular assays, and depend on the objective and timing: whether there is an urgent need for platelet transfusion, follow-up of a pregnancy with known risk, or to do full-scale laboratory testing to confirm diagnosis. molecular genotyping should include all hpa systems relevant for the local population (in caucasians hpa- , - , - , - and - ), preferably with optional extended panels for systems for low frequency populations due to immigration/mobility and for less frequently seen alloantibodies (hpa- , - to - are most commonly included). serological testing of antibody binding to platelets is often initially tested by flow cytometry analysis (direct test and/or cross-match). however, the detection of platelet-specific antibodies is often complicated by the presence of anti-hla class i antibodies and thus require sensitive platelet glycoprotein-specific assays. serological testing for platelet-specific antibodies includes as a minimum panels of antigens on gpiib/iiia, gpib/ix, gpia/iia and cd and preferably additional targets for populations with asian/african origin. several methods are available; i.e. bead-based assays and elisa based methods. however, most reference laboratories perform variants of the monoclonal antibody immobilization of platelet antigens assay (maipa), as reported by the th international platelet immunology workshop of isbt ( ) . the investigations also include measurement of the anti-hpa- a by quantitative maipa if present, as this is reported to potentially predict the severity of fnait. for pregnancies with known risk of fnait, there are methods available to perform non-invasive prenatal typing from maternal plasma. the most feasible and so far appropriate for routine testing is fetal hpa- typing with quantitative pcr or by melting curve analysis. other sophisticated, yet resource-demanding techniques have also recently been reported -importantly also for typing of other hpa-systems. d- - molecular basis of hna- expression justus liebig university, institute for clinical immunology and transfusion medicine, giessen, germany human neutrophil antigen (hna- ) is a neutrophil-specific antigen located on gpi-anchored glycoprotein cd (also known as nb ). hna- is absent on the neutrophil surface of - % of the healthy individuals that divided the population to hna- positive and hna- null individuals. exposure of hna- null individuals to hna- positive neutrophils during pregnancy, after transfusion or transplantation, induces immunization against hna- and consequently the production of iso-antibodies. the hna- iso-antibodies are involved in the mechanism of neonatal alloimmune neutropenia (nain), transfusion-related acute lung injury (trali) and graft failure following bone marrow transplantation. presence of cd on a neutrophil surface of hna- positive individuals follows a bimodal expression that categorizes the circulating neutrophils to hna- positive and negative subsets. the cd gene contains exons encoding a protein of amino acids. the lack of hna- (in hna- null individuals) is associated with the presence of a missense mutation, cd *c. a>t in exon of cd gene inducing a premature stop codon in codon . this mutation alone or in combination with cd *c. delg has been introduced as the main reason for the absence of cd in hna- null individuals. a pseudogene (cd p ) highly homologous to exons - of cd gene is located downstream of the cd gene. conversion of exon of cd p into cd gene is responsible for the generation of cd *c. a>t missense mutation. in addition, the heterozygosity or homozygosity of cd *c. a>t is accounted for regulation of hna- negative and positive neutrophils subpopulations. genotyping has revealed the hna- null individuals, heterozygous for cd *c. a>t mutation without cd *c. delg, indicating the presence of a complementary mechanism regulating cd expression. newly in hna- null individuals and individuals with atypical cd expression a cd * g>a polymorphism in combination with cd * a>t is described. altogether these data indicate a complex compound mechanism(s) for regulation of cd expression on the neutrophil surface. this presentation will summarize recent findings on cd expression and highlights the potential genotyping methods for genetic assessment cd expression of donors and patients. blood products ordered, transfusion start and end times, whether patients experienced a reaction to the transfusion as well as vitals measurements taken before and during the transfusion, including temperature, oxygen level, blood pressure and heart rate. for the validation process, transfusion nursing notes were sampled and reviewers assessed the accuracy of the information regarding ) blood product ordered, ) whether the patient experienced a reaction, and ) the start and end times of the transfusion. for each of these fields across all sampled notes, the claritynlp tool reproduced these data points with percent accuracy. in addition, the tool supplied transfusion end times for numerous structured records that were missing this key data point. summary/conclusions: claritynlp can very efficiently digest a large number of transfusion nursing notes simultaneously and also does an excellent job of extracting the main characteristics of a transfusion, which can be used in partnership with structured data to produce a more accurate and more complete picture of patient transfusions. immunohematology and genomics, new york blood center, new york, united states antibody-based typing, with a positive result reflected in agglutination of the red cells (rbcs), has served the profession for nearly a century enabling safe and effective transfusion therapy. the power of rbc typing by serologic methods lies in the availability of standardized antibody reagents which target many of the specificities of significance for transfusion, and the ability to directly detect antigen expression on the rbcs. hemagglutination has historically been relatively inexpensive, particularly for abo and rhd as the most important blood groups in most populations. serologic rbc typing is reliable, requires no sophisticated equipment, is generally straightforward to perform, and is fast requiring less than h to results. hence, antibody-based testing has been considered the "gold standard" for blood group typing. with the age of genomics, dna-based genotyping is increasingly being used as an alternative to antibody-based methods. most antigens are associated with single nucleotide changes (snps) in the respective genes. genotyping has been validated by comparison with antibody-based typing and has been shown to be highly correlated. the power of genotyping of rbcs lies in the ability to test for antigens for which there are no serologic reagents, and to type numerous antigens in a single assay using automated dna-arrays. this increases accuracy and weak antigen expression can be revealed. fresh rbc samples are not required for dna extraction, and there is no interference from transfused rbcs or igg bound to the patient's rbcs. dnabased typing is economical in that it provides much more information, but testing requires special equipment, training, and -h turn around. what then is the best approach to use? will serologic typing be replaced by dnabased typing? indeed, genotyping will increasingly be used in the practice of transfusion medicine, especially with the growth of whole genome sequencing (wgs). however, because serologic typing for abo and rhd is fast and accurate and often relied on for sample identification, genotyping will not be the sole means for routine typing. genomic sequencing approaches will certainly reveal unrecognized changes and genetic variability in rbc membrane proteins, but not all variation will be immunogenic. a genetic polymorphism must be associated with antibody production to be considered a blood group antigen. the importance of an antibody, and antibody reactivity, then will continue to be the central defining principal in transfusion. as two sides of a coin, both are key to safe and effective transfusion therapy. since the mid- s, research in the molecular basis of structural and functional aspects of proteins carrying and producing the antigens has led to an upgraded and modern understanding of blood group variation. most commonly, single nucleotide polymorphism (snp) based basic molecular typing techniques were utilized to test new findings on a smaller subset of samples, and resulted in concordant sero-and genotyping results in general. however, quite commonly a small number of all samples delivered discrepant results, triggering consecutive rounds of analysis and resolution, finally resulting in a better knowledge with respect to the underlying blood group variation. such rounds of repetitions represented the synergistic incremental process of learning, learning for serologists and molecular biologists. inheritance of public, presence of high frequency, or low frequency, or partial antigens and notice of weakly expressed, or almost undetectable antigens marked the path of incremental learning and may best be exemplified by discoveries within the blood group systems abo, rhd and kell. naming for pheno-and genotypes coevolved alongside the permanent discovery of new antigens. at present, antigens and their antithetic counterparts (if tested and if existent), are more commonly reported independently, as exemplarily shown for the following kell phenotype consisting of three antithetic antigen-couples: kk, kp (a+b+), js(a+b+). alternatively, the same phenotype could be stated as: kel:- , , , , ( ), , . genotypes, on the other hand, rather mirror the actual biological background, e.g. display the two parental alleles (or "haplotypes") present in an individuals' sample. genotype of the above mentioned example would read: kel* . / . (italicized). in an idealized diagnostic environment and for most blood group systems encoded by proteins, every single blood group allele would be defined by its full genomic sequence, derived from one parental chromosome (including "some" 'and '-untranslated regions). thereby, every such "ideal allele" would fully declare presence or absence of all its public, low-and high-frequency antigens and possess its "ideal name". by trend, biallelic snps and their immediate relation to antithetic antigen couples might have distracted from the originally intended meaning of "blood group alleles", more recently. finally, genotypes only dependent on (ideal) allele names, and considering mendelian inheritance patterns (dominant, recessive), would allow for fully comprehensive phenotype predictions. more recently, blood group serology, e.g. the "second side of the coin", seems to gain momentum. since the advent of whole genome sequencing and access to many more than human genomes, it seems that dozens of new blood group alleles are discovered, almost on a daily basis. beside the challenge of naming this multitude of alleles, respective discoveries are frequently made in samples lacking any phenotypic blood group pre-values. clear procedures will be needed to address naming and analyzing the phenotypes resulting from previously unknown alleles. as a consequence, questions asked years ago have changed: today, molecular biologists looking at hundreds of newly discovered blood group alleles find themselves not being asked by serologists any more: "can you confirm my serology?", but instead, pose their question to the experts for the blood group phenotype: "can you confirm my genotype?" a-s - background: the screening of blood donors and returning travelers from active transmission areas have highlighted the importance of diagnosis of acute arboviral infections. in the context of co-infections and similar clinical signs in endemic zones, the differential diagnosis of arboviruses is essential to discriminate the causative agent. the detection of viral nucleic acids in serum or plasma provides a definitive diagnosis, however, in most instances, viremia is transient within less than two weeks after the onset of clinical illness. in addition, the cross reactivity due to the high degree of structural and sequence homology between zikv and other flaviviruses is a significant concern. the combination of molecular (identification of viral genomes) and immunological assays (detection of the immune response) is a key challenge to follow the natural history of these infections and to improve the patient management and the epidemiological surveillance. aims: in this context, we have developed an innovative platform based on agglutination of superparamagnetic nanoparticles (npmag) covalently grafted either with nucleic or proteic probes to face the continuing emergence of arboviruses. methods: dengue (denv) and zika (zikv) viruses are selected as models in this study. a pan-flavivirus rt-pcr is used for the molecular assay to amplify the viral genomes. then, biotinylated viral amplicons are captured specifically on complementary original polythiolated probes coated on npmag. for the immunological assay, npmag are grafted with viral ns proteins to capture anti-denv or anti-zikv antibodies potentially present in the plasma samples. both tests are performed in disposable cuvettes in a homogeneous format. a magnetic field generated by an electromagnet is applied to the reaction medium to align the npmag into chains to enhance the capture of the targets between two npmag. aggregates formed are detected when the field is turned off. the optical density is measured in real-time at nm during several cycles of magnetization / relaxation. results: in this study, molecular analytical performances were evaluated on human samples from blood donors with no history of infections as negative controls, on viral standards and on clinical samples. using viral references standards, we have observed sensitivities of - tcid /ml for zikv and denv (serotypes / / / ) after a detection phase of around min. the first results obtained on zikv (+) clinical samples previously tested by commercial real-time pcr (ct < , altona) showed an % correlation between the two detection methods. no false positive results or cross reactions were observed. concerning immunological assays, commercial human plasma from donors tested positive for denv or zikv antibodies were detected positive with our innovative approach in less than min (sampling + detection) instead of h with classical elisas. further assays on clinical samples are planned to confirm these preliminary results. summary/conclusions: this innovative strategy combining molecular and immunoassays on the same analytical platform offers new opportunities for rapid blood testing to improve the surveillance and the prevention of arboviral infections. background: zika virus (zikv) caused a dramatic epidemic in puerto rico (pr) during , with up to~ % of blood donors reactive for zikv rna in id-nat testing at the peak in june . aims: perform a serosurvey for anti-zikv igg using six panels of donor specimens each collected in march , at the beginning, peak and end of the epidemic, and from march and april . methods: we employed a commercially available zikv igg elisa antibody (ab) assay based on the zikv ns antigen from bio-techne to characterize zikv seroprevalence in the cross-sectional sample sets (anonymized with selected demographic information). results: pr donor samples collected in april were initially evaluated using the manufacturer supplied cut-off to confirm that the zikv ab results were largely negative ( positive, equivocal) despite the high dengue virus seroprevalence (> %) in pr that could potentially lead to false positive zikv ab results. we then used this dataset, together with known positives collected - months postdetection from zikv nat yield donors, to set a population-specific cut-off based on receiver operating characteristic (roc) curve analysis. this cut-off yielded sensitivity and specificity values of > %, and an area under the curve (auc) of . , demonstrating a highly accurate assay. we used this new cut-off to calculate final rates of seroreactivity in the additional sample sets ( samples) and estimate seasonal incidence. rates of reactivity, together with mean net od for only the reactives (shown in parentheses), were calculated for each sample set: background: sex hormone intake in blood donors occurs in three demographic groups: premenopausal women who take contraceptive drugs (progestins with or without estrogens), postmenopausal women who receive estrogen replacement therapies that may be combined with progestins, and testosterone therapies in men. we hypothesized that sex hormone therapies may modulate the quality of red blood cell (rbc) products via alterations of rbc function and predisposition to hemolysis during cold storage. aims: the objectives of this study were to evaluate the association between sex hormone intake and rbc measurements of hemolysis, and to examine possible mechanisms by which sex hormones interact with rbcs. methods: self-reported sex hormone intake and menstrual status were evaluated in , female blood donors from the national heart, lung and blood institute's rbc-omics study. the associations between hormone intake and donor scores of spontaneous storage, osmotic, or oxidative hemolysis were determined in all women and by menstrual state. the interactions between sex hormones and rbcs were determined by sex hormone (progesterone, b-estradiol, or testosterone) potency to inhibit calcium influx or hemolysis during incubations or cold storage. the calcium fluorophore, fluo- am, was used to define rbc calcium influx in response to treatments with sex hormones or drugs that modulate transient receptor potential cation (trpc) channel activity including hyp (a selective trpc activator). results: sex hormone intake by menstrual status was higher in premenopausal women ( . %) than in postmenopausal women ( . %). female hormone intake was significantly (all p < . ) associated with reduced storage hemolysis in all females ( . ae . % versus . ae . % in controls), enhanced susceptibility to oxidative hemolysis ( . ae . % versus . ae . % in controls), and reduced osmotic hemolysis in postmenopausal women ( . ae . % versus . ae . % in controls). in vitro, supraphysiological levels of progesterone ( or lmol/l), but not b-estradiol or testosterone, inhibited spontaneous or hyp -induced calcium influx into rbcs, and were associated with lower spontaneous hemolysis after day cold storage ( . ae . % versus . ae . %, progesterone lmol/l versus solvent control (dimethyl sulfoxide, . %), p < . ). co-incubations ( . h, °c) of rbcs in the presence of progesterone and a trpc activator (hyp , lmol/l) suggested that progesterone protected against hyp -induced hemolysis ( . ae . % and . ae . % versus . ae . %; hyp + progesterone at or lmol/l versus hyp alone, p < . by one-way anova). summary/conclusions: this study revealed that sex hormone intake in blood donors is capable of modulating rbc predisposition to hemolysis and led us to propose new mechanistic pathways by which progesterone regulates calcium influx and hemolysis in human rbcs. pre-and postmenopausal women respond differently to hormone intake and its effects on rbc responses to osmotic or oxidative stress. progesterone modulates calcium influx into rbcs via a mechanism that may involve interactions with membrane trpc channels, activation of which is associated with pre-hemolytic events such as senescence and eryptosis. a-s - international cooperation, swiss red cross, wabern, switzerland background: red cross and red crescent societies were playing an important role in setting up blood transfusion establishments in many low resource countries. by the mid- s, the red cross was active in the national blood programs in approximately % of countriesmostly in blood donor recruitment and education. today, major organizational developments in blood transfusion services were made in high income settings, where nearly % of all worldwide donations take place (home to only % of the population). who data shows that the median annual blood donation rate in high-income countries is . % of the population compared to . % in low-income countries. the factors for this low turnout are multilayered, but it is well-known that most resource poor settings suffer from a low rate of regular donors and challenges to set-up and financially sustain a national blood donor program. the red cross and red crescent (rc) societies assume a key role by reaching and retaining donors from the communities and contribute significantly to better safety and availability of blood. partnerships and international collaboration, such as the swiss red cross (src) program, are aiming to strengthen national structures to improve blood safety and to face today's epidemiological, demographical, and technological challenges. aims: the present work aims to review the role, the mandate and the impact of rc societies in improving blood safety through systematic "voluntary non-remunerated regular blood donor" (vnrbd) programming and international partnerships. methods: data and evidence is drawn from the src international cooperation projects over the last years, more specifically partnering with three rc societies, and the data from the global advisory panel (gap) of the ifrc including their global mapping. results: the promotion of vnrbd has been a specific objective in all src supported programs. through the engagement of the rc society, the training of volunteers and partnering with the health authorities, the projects significantly increased the blood donor rate by recruiting and retaining donors from the communities. for example, the rc societies increased total donations by % in lebanon; vnrbds by % annually in kirgizstan, and from practically zero to ' in south sudan. the importance of rc societies was also underlined in the published global mapping of gap, which showed that ( %) of them provide level a (full blood service), ( %) are level b (systematic blood donor recruitment) and ( %) are level c (vnrbd blood promotion) blood services. gap has also commenced a new three year vnrbd support program aimed at establishing tools and materials for national societies. summary/conclusions: the red cross / red crescent movement has a unique mandate and position in improving global blood safety at all levels; with its huge network of volunteers, even blood donors in remote communities can be reached and retained. rc societies in low resource settings with a level b or level c role should further capitalize on partnerships with local and international actors to leverage technical assistance and funding for their activities. background: it is essential to motivate and encourage the public to donate blood and be eager to help saving lives, in order to maintain safe and adequate national blood supply. aims: "technical assistance for recruitment of future blood donors (europeaid/ /d/ser/tr)" project aimed to avoid problems in supplying the safest blood to contribute to the improvement of public health by (i) increasing the knowledge of primary and secondary school students regarding blood donation, (ii) creating sensitivity in school principals and teachers regarding voluntary non-remunerated blood donation (vnrd), (iii) motivating family members of the students for blood donation and (iv) creating public awareness through media. methods: an effective coordination is established between ministry of health (moh), ministry of national education (mone) and turkish red crescent (trc). the existing curricula and textbooks of primary and secondary schools were reviewed and revised, and corresponding materials on the importance of blood donation were created. the human resources capacity of moh, mone and trc to support raising awareness on blood donation were developed. to raise public awareness on blood donation nationwide, education and recruitment campaigns on were organized in pilot schools. additionally, media and public relation campaigns on blood donation were organized throughout the country. results: ( ) existing curricula and textbooks relevant to promoting blood donation were reviewed, revised and reported to the board of education of mone. ( ) corresponding educational materials for students and teachers were developed and distributed. ( ) blood donation clubs were established in pilot schools. ( ) trainings were conducted for personnel of moh and trc on blood donation regarding their responsibilities. ( ) cascade trainings were conducted for personnel of transfusion centers and school principals in provinces. ( ) information seminars were delivered to . students and . teachers and family members of students during school campaigns. ( ) four animation films on blood donation were produced and broadcasted on the national tv channel (trt). ( ) three different computer games targeting different age groups were developed and uploaded to the web portal of the project and distributed to the pilot schools. ( ) media spots were produced and broadcasted . times in different tv and radio channels. ( ) billboard posters and brochures were prepared and distributed to provinces for raising public awareness. ( ) advertisements about the project and the importance of vnrd were displayed times on national and local newspapers, . times on online news, and broadcasted on national tv channels. ( ) during the campaigns, . units of whole blood were collected in pilot schools. ( ) visibility kits to recruit future blood donors are prepared and distributed throughout the project activities. ( ) awareness and knowledge level of students and their teachers/parents on the importance of blood donation are increased to . % and . % respectively, assessed through pretest and posttest. voluntary non-remunerated donation rate of national demand increased from . % to . in two years. summary/conclusions: training and campaign programmes successfully increased the knowledge on blood donation. to achieve national self-sufficient safe blood supply, efforts for recruitment should be continued. background: despite % of pakistan's population being under years, only % of blood supplies come from voluntary donors while remaining blood is collected from 'family replacement donors'. in pakistan the system has outsourced the mobilization of blood donors to the patient families. as a result many people reach out to their networks including on facebook to locate blood donors. there are thousands of posts each month in pakistan seeking blood donors on facebook. to facilitate needy families, the global social media giant facebook launched a special blood donation feature for pakistan in collaboration with sbtp, pakistan. the feature makes it easier for people to sign up to become blood donors and helps connect these voluntary donors with people and organizations in need of blood. similar features have been launched by facebook in india, bangladesh and brazil to address the problem of blood shortages in those countries. however, among these four countries pakistan has unique position because of the existence of a national counterpart, sbtp which can facilitate facebook in promoting its feature and provide the feedback on the impact of this innovative effort for continuous improvement of the feature. aims: to promote voluntary blood donations and blood safety in pakistan through facebook. methods: the facebook and sbtp teams launched a pilot to study the impact and effectiveness of the facebook blood donation feature as a tool of community engagement. a six months plan has been chalked out to measure the impact of this tool in five selected blood centres. a checklist called "p checklist" was shared with these blood centres to fulfill some basic requirements for an official blood bank page including a display picture, cover photo, contact information, directions, etc. regular skype meetings are held between the teams of sbtp, facebook (san francisco and singapore) and the blood centres to monitor the progress of the pilot and generate feedback. results: the facebook blood donation feature has recorded remarkable success with over one million signups within few months in pakistan. the blood centres participating in the pakistan study have experienced enhancement in the voluntary blood donations trend with - walk-in donors and an average of more than telephonic queries regarding voluntary blood donation per month in each center. the trend is gradually surging as the feature is being refined on the basis of feedback received. the pilot will end in june . the statistics generated since january are very encouraging and underscore the importance of social media in reaching out to the untapped potential blood donors. the study will be used to plan an effective nationwide strategy to increase donor mobilization, recruitment and retention. background: in our region, an increasing number of patients of african or asian origin with sickle cell disease (scd) or transfusion dependent thalassemia (tdt) require red blood cell (rbc) transfusions, and many have rbc alloantibodies. selecting optimally matched rbc units for these patients is essential for preventing not only acute hemolysis but also further alloimmunisation. beside antigen-matching for abo, rh d, c, c, e, e and k, patients with scd and tdt should ideally receive rbc units matched also for m, s, s, fya, fyb, jka and jkb (extended phenotype). this is the policy at our center, which currently provides rbc products to patients with hemoglobinopathies. because the vast majority of our blood donors are caucasians, the selection of matched rbc units for patients of different ethnic origin can be difficult. therefore, expanding the number of available african and asian blood donors is becoming increasingly necessary. aims: hereby the recruitment strategy of non-caucasian blood donors introduced at our center is described and the results obtained during six years are reported. methods: since . . , whenever a first-time blood donor of non-caucasian origin is registered, an alert is entered in the donor file to trigger the determination of the extended rbc phenotype along with routine testing. rbc antigen determination is performed in our laboratory with serologic methods. in selected cases (i.e. suspected rhd or rhce variant), samples are sent for molecular analysis (ssp pcr). rare rbc phenotypes relative to ethnicity are, among others, fy(a-b-), s-s-, lu(b-) and those with uncommon rh phenotypes. if a rare rbc phenotype is detected, a coded comment is entered in the donor data and the donor is listed in the national rare donor file. results: from . . until . . , an extended determination of rbc antigens was performed in subjects presenting for blood donation. twenty-nine rare donors ( %) were identified and included in the rare donor file: fy(a-b-), lu (a-b-), lu(b-), fy(a-b-) and s-, ccddee (r'r'). overall, these donors provided rbc units (range . to date, all donors are still active and are reserved for dedicated donations. the internal price of rbc antigen testing per donor is approximately . -chf, resulting in a total financial effort of around , .-chf in the time since the project was started. summary/conclusions: in our experience, a "passive" recruitment of non-caucasian blood donors based on ethnicity has an overall low efficiency from a logistic and financial point of view. moreover, african and asian blood donors may require investigations for hemoglobin variants and serology for malaria in addition to routine testing. nevertheless, a targeted determination of extended rbc antigen phenotype does allow the identification of persons with rare phenotypes. currently, measures for the active recruitment of potentially rare blood donors are being implemented at our center. after a pilot phase, a project for a nationwide recruitment strategy will be elaborated. a further goal is to build a national registry of patients with hemoglobinopathies requiring transfusions. blood transfusion is an essential treatment. transfusion safety consists of several components. although all are important, ion richer countries the order of priority is typically: .) avoidance of transfusion transmittable infections; .) quality of the blood product with a strong focus on component therapy; .) prevention of severe transfusion reactions; .) avoidance of clerical errors; .) sufficient availability of blood. the keynote of this lecture will be that the order of priorities on transfusion safety should probably be different in resource limited environments. .) sufficient availability of blood and proper utilisation; .) avoidance of transfusion transmittable infections; .) avoidance of clerical errors; .) prevention of severe transfusion reactions; .) quality of the blood product. most important, in regions with limited resources patients suffer from under-transfusion because not enough blood is available. all efforts should be made to reduce wastage of the available blood either by inappropriate storage, handling, or nonindicated transfusions. in addition, prevalence and number of pathogens transmittable by transfusion is much higher than in the richer parts of the world. this is aggravated by the fact that rejection of blood donors based on their history is problematic when the blood bank is empty. the aim to develop centralized national blood services with few sites manufacturing cost effective (low personnel costs) high-quality blood products, which are distributed to regional hospitals is not matching the reality of infrastructure, governmental support, and functionality. in healthcare systems with limited resources usually available personnel (hands) is not a problem, while reagents, equipment and even electricity are precious resources. the lecture will propose to focus on staff training and education, establishing local hospital-based transfusion services, which provide the blood products for the region, based on donor recruitment campaigns adjusted to the available technology, local culture, including replacement donor programs, with retention of safe donors as highest priority. fractionation of blood into components had been standard in transfusion medicine, but recently whole blood has experienced revival for patients with acute blood loss. given main transfusion indications such as postpartum hemorrhage, or severe trauma, in regions with limited infrastructure, whole blood might be the more appropriate product. most patients requiring transfusion in these regions are younger and volume overload by whole blood is not a major issue. in addition, frequent electricity failures do not allow prolonged storage of plasma at - °c (this is therefore mostly wasted), although this issue can be overcome by solar powered freezers. ideally whole blood should be pathogen inactivated for which two methods are currently available. to reduce frequencies of acute hemolytic transfusion reactions again education and training to minimize clerical errors in the transfusion process are most important. extended testing for other rhesus antigens and k beside abo and rh-d in transfusion dependent hemoglobinopathy patients may help to reduce delayed hemolytic transfusion reactions. currently a leukodepleted pathogen-inactivated whole blood product might mostly serve the needs for blood transfusion in regions with limited infrastructure . the developed world should invest research efforts to develop such a product available at affordable costs. background: in modern transfusion medicine, serological investigations for blood cell antigens are complemented by genotyping arrays and pcr assays. whilst these platforms are informative in the majority of reference investigations, they are limited in their ability to define nucleotide variants associated with rare antigens and unable to detect novel variants potentially affecting antigenicity. next-generation sequencing is increasingly being employed in reference settings, providing information that cannot be obtained through these methods. whole genome and whole exome sequencing have been successfully employed in many investigations of novel and rare antigens, however concerns remain regarding the collection of genomic data unrelated to reference investigations, and reporting clinically significant incidental findings. these concerns can be addressed through the use of targeted sequencing panels. we report on the design, testing and efficacy of a panel providing a comprehensive genotyping profile for red cell, platelet and neutrophil antigens in a single test. aims: design a customised targeted exome sequencing panel for red cell, platelet and neutrophil antigen genes, and benchmark the efficacy against a commercial medical sequencing panel (illumina trusight one -tso). -test the panel and in-house genotype prediction script on sequence outputs from samples with known red cell, platelet and neutrophil genotypes and phenotypes and determine whether predictions are concordant. methods: the panel was designed with probes covering exons of genes associated with red cell, platelet and neutrophil antigens. using illumina nextera rapid capture technology, samples were tested over five sequencing runs, on standard and micro chemistries, to determine optimal sample plexity per standard run, and the efficacy of smaller flow cells for lower throughput applications. an in-house python script was used to predict star-allele genotypes based on variants listed in isbt and embl databases. these predictions were compared to results from serology, snp array and previous tso data. results: coverage consistently averaged > , with % of target at a quality of q . optimal sample plexity for a standard run was determined to be samples, allowing for sufficient coverage of all clinically significant variants. for red cell samples with previous typing data (excluding rh structural variants), the script correctly predicted . % of snp based red cell genotypes. script predictions were % concordant for platelet genotypes, and four of five neutrophil antigen genotypes. hna genotypes defined by cd could not be reliably determined. the increased target coverage of the panel allowed for detection of a clinically significant heterozygous variant in scianna system, previously undetected by the tso panel due to extremely low coverage. additionally, a variant defining a potentially novel null allele was detected in the p pk system. summary/conclusions: the panel demonstrates considerably higher coverage, quality and throughput compared to the tso and allows for detection of variants previously overlooked due to low sequencing coverage. up to samples can be reliably sequenced in a single run. our script correctly predicts over % of snp based alleles; however, rh structural variants require further manual analysis. background: to ensure the safety of a transfusion it is critical to identify the blood type of both donor and recipient. serological methods for typing abo, rh and kel use monoclonal antibodies, however, typing reagents for rare blood groups are expensive, unavailable or unreliable. dna-based identification of human blood groups has been used to overcome these limitations and its application has reduced rates of alloimmunisation in chronically transfused patients. however, to date, the cost per sample has prevented the universal application of dna-based donor typing aims: to achieve universal adoption of dna based donor typing, the blood transfusion genomics consortium (bgc) set out to develop an affordable dna based platform, capable of typing all red cell antigens, hla class i and ii and human platelet antigens. methods: the uk biobank axiom array, previously used to type , uk citizens, was redesigned for donor typing using three approaches: i) mining transfusion medicine knowledge, e.g. isbt allele tables; ii) inclusion of loci associated with donor health; iii) extraction of all coding variants in relevant genes with a frequency > : , identified in large-scale sequencing data. samples from nhsbt and sanquin blood donors (n = , ) were used for performance assessment. red cell and platelet antigens for each donor were inferred from genotypes using the bloodtyper algorithm and concordance with clinical serological typing results assessed. results: concordance between genotypic and serological typing results was . % for , comparisons; of the discrepancies were serologically negative and genotypically positive for a given antigen (k/k, fy[a/b], lu[a/b]). in all cases dna variants known to modify or weaken antigen expression were detected, displaying the power of genotyping to detect variant 'weak-antigen' expression. across antigens for which serology was available, genotyping provided a . -fold increase in the number of typing results available per donor ( . vs . ). furthermore, genotyping provided data on an additional clinically relevant antigens, allowing identification of antigen-negative donors and blood group identification for which antibodies are not commercially available. the power of a genotyped panel of donors to support patient management was demonstrated by a retrospective analysis of clinical cases referred to nhsbt. from , patient referrals with > alloantibodies between and , unique alloantibody profiles were identified. we found that there was a . -fold greater likelihood of finding o negative compatible donors for these patients when using genotyping data from the , nhsbt donors. importantly, the number of alloantibody combinations for which no compatible antigen-negative donor could be identified fell from to , representing an additional patients that could be provided with directly compatible blood using the same donors. summary/conclusions: through the bgc efforts an affordable fully automated genotyping platform, including the processes for quality assurance and data analysis, has been developed. furthermore, we have demonstrated the real-world benefits more extensive donor characterisation can provide when selecting blood for patients with multiple antibodies. the results of this international collaboration provide opportunities to introduce fully-automated genotype-based donor typing in a safe and cost-efficient manner in blood supply organisations. c-s - biobank performs whole-genome sequencing (wgs) from individuals nation-wide. these data are suitable for allele frequency analysis to demonstrate gene expression and genetic profile in our population, also to estimate the significance of each antigen in transfusion practice. aims: we aim to provide and verify population-based blood group antigen profile using wgs and dna samples from taiwan biobank. methods: a near wgs and demographic data were analyzed. annotations of blood group antigen were performed according to variants from isbt allele tables, including transcription factors; variants for the lewis system were obtained from previous studies. annotations of blood group variants were verified by dna samples with targeted sequencing on illumina miseq, and specific variants were verified by dna samples with the commercial genotyping kit or sanger sequencing. allele frequencies from wgs analysis were compared with population serology data using two-proportion z test. results: population-wide blood group antigens were analyzed, revealed in-depth antigen expression profiles in all systems (except ch/rg). the antigen frequencies from wgs were similar compared with published serology data, except for the antigens and possible explanations listed as follow, ) m, n: insufficient sequencing reads, ) c, c: identical rhce exon with rhd exon for c allele, ) mur: insufficient read length/depth for gypa/gypb hybridization calling and individuals from high prevalence of mur antigen in aboriginal tribes were not enrolled. blood group antigen predictions and variants from wgs were accord to dna verification. furthermore, systems shown no genetic variations, predicting uniform antigen expression in our population, and we can manage transfusion with minimum concerns for antigen mismatch in these systems. moreover, we found weak and null alleles in our population for blood group systems that we had previously no knowledge of, such as lan, jr, and vel. these variants were helped to identify a patient with anti-jr a carrying homozygous jr a null alleles. summary/conclusions: taiwan biobank wgs is suitable for full blood group antigen profile determination with few adjustments required for specific antigens. the population antigen allele frequency provides valuable insight to antigen significance in transfusion practice, matching strategy for our patients, and estimation of the likelihood to obtain for specific antigen negative blood from mass population. also, the genetic variants revealed in this study can help us to locate rare donors, and to integrate variations into routine donor blood group screening to provide suitable blood at a low cost efficiently. background: providing adequate amounts of safe, appropriately matched blood to meet the demands of an expanding and aging patient population presents a challenging global problem. for these reasons, sustainable in vitro sources of red cells may offer a desirable alternative to reliance on donor blood. the first stable immortalized early adult erythroblast cell line, bel-a , has been shown to differentiate efficiently into mature, functional reticulocytes (trakarnsanga et al., nat commun. : , ) and consequently could provide a readily available tool for diagnostic use and proof of principle for future therapeutic use. aims: at ibgrl, next generation whole exome sequencing (wes) has been used previously to accurately predict blood group phenotype in a number of blood group systems, including abo, rh and mns (tilley & thornton, transfusion medicine (suppl. ) : , ). here we have used it to analyse and document bel-a blood group-related genotypes and predict blood group phenotypes. additional genes involved in cell-growth and enucleation were also analysed in order to further elucidate the characteristics of the bel-a cell-line. methods: bel-a cells (day ) were cultured in expansion medium and genomic dna (gdna) was isolated from cells on day . for wes, gdna libraries were prepared using nextera â rapid capture exome enrichment and sequenced on illumina â miseq. sequence alignments for genes encoding all known blood group systems and further genes encoding transcription factors and cell enucleation-associated proteins were visualised using integrative genomics viewer, whilst illumina â variant studio was used to identify observed mutations. mutations in coding regions were used to determine bel-a genotype and predicted phenotype. results: good coverage of most of the selected genes was achieved. alignment of homologous blood group genes including rhd/rhce, gypa/gypb and c a/c b was problematic and additional analysis of coverage of these genes was required for accurate interpretation. despite a number of polymorphisms observed across the tested genes, bel-a did not express any novel or rare blood group antigens. genotyping results predicted a common antigenic profile, in agreement with previous serological and genotyping results where available. although a number of missense single nucleotide variations were detected in analysed genes, including cr , cdan and tmx , these were common polymorphic variants and unlikely to be of any functional significance. summary/conclusions: wes was used to determine bel-a genotype in relation to blood group genes and selected genes encoding transcription factors and proteins associated with cell enucleation. wes allowed accurate prediction of blood group phenotypes, showing full concordance with available serological data (trakarnsanga et al, ) . a small number of mutations were identified which are of unknown significance and require further work to determine any potential phenotypic effects. this complete record of the bel-a blood group-related exome will enable reliable gene editing strategies for future diagnostic and therapeutic purposes. additionally, knowledge of the full cell line exome will allow analysis of any emerging genes of interest and provide better insight into the mechanisms of erythroid differentiation and enucleation. background: emerging evidence, especially in neonates, has shown potential harm associated with liberal platelet transfusion strategies. very little evidence exists regarding optimal platelet transfusion thresholds in critically ill children. randomized controlled trials may be difficult due to lack of equipoise from providers. if regional variation in practice exists, comparative effectiveness studies may be an alternative approach. aims: to describe regional variation in platelet transfusion practices in critically ill children. methods: secondary analysis of a prospective, observational study. subjects were grouped according to region (north america, europe, middle east, asia and oceania) and nation. transfusions were analyzed as prophylactic (given to prevent bleeding) or therapeutic (given to treat bleeding). the primary outcome was the total platelet count (tpc) prior to transfusion. sub-groups analyses were performed in children with an underlying oncologic diagnosis and those supported by extracorporeal life support (ecls). the dosing and processing of the platelet transfusions were analyzed as secondary outcomes. results: five hundred and forty-nine children from countries were enrolled ( % in north america, % in europe, % in oceania, % in asia, and % in the middle east). overall, the median (iqr) tpc prior to prophylactic transfusions (n = ) differed significantly on a regional basis (p = . ) and ranged from ( - ) x cells/l in the middle east to ( - ) x cells/l in asia. the median tpc prior to prophylactic transfusions did not significantly differ between countries (p = . ), nor did the tpc prior to therapeutic transfusions (n = ) differ on either a regional (p = . ) or national (p = . ) basis. for children supported by ecls (n = ), there were no regional (p = . ) or national (p = . ) differences for prophylactic transfusions. however, significant differences in the tpc prior to therapeutic transfusions were observed on both a regional (p = . ) and national ( . ) basis with the middle east, in particular israel, transfusing at the lowest median (iqr) tpc [ ( - ) x cells/l]. for children with an underlying oncologic diagnosis (n = ), no differences were seen in the tpc for prophylactic transfusions (n = ) on a regional (p = . ) or national (p = . ) basis. nor were differences seen in the tpc prior to therapeutic transfusions on a regional ( . ) or national (p = . ) basis. there was significant variability in the dosing of platelet transfusions on both a regional (p < . ) and national basis (p < . ). the median (iqr) dose based on volume ranged from . ( . - . ) ml/kg in north america to . ( . - . ) ml/kg in europe. the vast majority of transfusions were leukoreduced and irradiated but significant variation exists in storage duration on both a regional (p < . ) and national (p < . ) basis. summary/conclusions: regional and national variation exists in platelet transfusion practices among critically ill children, especially in those given therapeutic transfusions while supported by ecls. considering this variation, comparative effectiveness studies may be an appropriate approach to gain evidence to optimize platelet transfusion thresholds. background: the optimal threshold for prophylactic platelet (plts) transfusion in pediatric patients with cancer is still controversial and current clinical practice comes from studies on adults and on inpatient setting. the international guidelines (icmtg, ) recommend, for all age patients, a prophylactic platelet transfusion when plts count is ≤ /l and a platelet dose of . per square meter (sm) of body-surface area (bsa) in inpatient and . /sm in outpatient setting. aims: in january we started in our children's hospital a prospective protocol in order to evaluate the impact on bleeding risk of current clinical practice of prophylactic platelet transfusion in inpatients and outpatients onco-haematological patients. methods: bsa was calculated from age-standardized weight. inpatients received a dose per transfusion of . /sm and outpatients a dose per transfusion of . /sm. platelets were transfused when the count was ≤ /l or in presence of bleeding signs; pediatric aliquots were obtained from buffy coat derived pooled platelet concentrates or apheresis platelet concentrates, according disponibility. results: from january to december a total of platelet pediatric aliquots were transfused: ( . %) were obtained from apheresis platelet concentrates and ( . %) from buffy-coat-derived pooled platelet concentrates. the majority of platelets pediatric aliquots ( - . %) were transfused to onco-hematological patients undergoing hematopoietic stem cells transplant (hsct) or conventional chemotherapy. among them, aliquots were transfused in inpatient setting: ( %) in the hematology unit, ( . %) in the oncology unit and ( . %) in hsct unit. a total of ( . %) aliquots were transfused in outpatient setting: ( . %) to patients affected by hematological malignancies and ( %) to patients with solid tumors. five major bleeding events (who grade ≥ ) were observed during the study period and all of them occurred in hospitalized patients. two patients with solid neoplasm developed a who grade bleeding event. two patients with hematologic malignancies and a patient with neuroblastoma (n = , . %) developed intracranial bleeding (who grade ). the platelet count at the time of the event was /l, /l and /l, respectively. summary/conclusions: our results showed the efficacy, in onco-hematological pediatric patients, of a prophylactic platelet transfusion protocol based on international guidelines: a very low incidence of who grade bleeding has been observed in inpatients setting only ( . % vs % of plado trial, sj slichter, nejm, ) , while in outpatients setting the double platelet dose prevents the major bleeding event (who grade ≥ ) occurrence. background: the problem of blood-borne infections remains relevant in transfusion medicine. pathogen reduction technologies (prt) provide a preventive approach to a wide range of transfusion-transmitted infectious diseases. to date, prt widely used for platelet concentrates and blood plasma, however, the use of these technologies for the treatment of red blood cell-containing blood products undergo research. aims: the aim of our study was to evaluate the safety and efficacy of transfusions of pathogen-reduced (test group) red blood cell suspensions (rbcs) and compare these data with gamma-irradiated rbcs (control group). methods: the technology based on the combined action of riboflavin and ultraviolet (mirasol prt, terumo bct, belgium) was used to reduce pathogens in whole blood. subsequently, the rbcs of the test group were derived from pathogenreduced whole blood. the control rbcs were irradiated at the gammacell elite (best theratronics, canada) at a dose of gray. all rbcs were used for transfusion for days from the harvest day. pediatric patients with various oncological and hematological diseases were randomized to groups of members in each group. the test group of patients received transfusions of a pathogen-reduced rbcs; the control group received transfusions of a gamma-irradiated rbcs. the next day after transfusion were assessed hemoglobin and hematocrit increment, the level of potassium and haptoglobin in the patients' serum, the frequency and severity of transfusion reactions. - days after the transfusion, the direct antiglobulin test (dat) was performed and after - days the indirect antiglobulin test (iat) was performed. the interval to the next need for transfusion was also evaluated. results: the increase in hemoglobin and hematocrit (p = . ), as well as the concentration of potassium (p = . ) and haptoglobin (p = . ) in the patients' serum after the transfusion did not differ between groups. none of the patients in both groups had hyperkalemia after transfusion. in each group, two patients had febrile non-hemolytic transfusion reactions of comparable severity (p = ). all dat and iat tests were negative in both groups. the interval between transfusions were not significantly different between groups (p = . ). only in the test group was found the correlation between the increase in the hemoglobin and hematocrit values with the volume of transfusion, with the dose and the adjusted dose of hemoglobin obtained for the transfusion on body weight. and in this group was found inverse correlation between the hemoglobin and hematocrit increment with the level of hemolysis in the rbcs. summary/conclusions: we found that the clinical efficacy and safety of rbcs of the compared groups did not differ. there was no evidence of immune elimination and allo-sensitization caused by pathogen-reduced rbcs. according to our data, the spectrum of efficiency and safety indicators of pathogen-reduced rbcs is no worse than that of gamma-irradiated rbcs, provided that rbcs is used for days of storage. the founded correlation suggests that the efficiency of pathogen-reduced rbcs transfusions is more dependent on the characteristics of the rbcs. background: patient blood management (pbm) programs are expanding at an international level. a recent nationally representative study from united states observed pediatric age group as the only age group showing lack of objective evidence of pbm initiatives (goel et al, jama ) . aims: this study aims to identify trends in peri-operative blood utilization in children undergoing elective and non-elective surgeries over years duration from to . methods: using years data ( ) ( ) ( ) ( ) ( ) perioperative transfusions decreased steadily per year from . % in to . % ( % cumulative decline) in for children of all ages (or . ; % ci . - . ; p trend < . ). the cumulative change in elective procedures was . % versus . % decrease in urgent/emergent procedures (p trend < . ). summary/conclusions: in this large prospective registry study of > , children undergoing elective/non-elective surgeries, a statistically significant decrease in utilization of peri-operative rbc transfusions was seen across years from through with more significant decrease in urgent/emergent procedures than elective procedures while these findings need evaluation for non-surgical indications of transfusion, these results may provide first evidence of peri-operative pediatric patient blood management strategies being implemented to optimize transfusions in pediatric population. adverse events -tti, immune interactions and risk c-s - transfusion-transmitted infections (tti) are a long-standing and well recognized concern in medicine, which is tackled on the highest level to guarantee the safety of the transfusion procedure for all stake holders. these include the recipient patients, the donating volunteers, the health care workers involved, and their respective contact persons. accordingly, current national and international guidelines including expert societies and the who provide medical, technical, and legal frameworks, which are the basis for the standard operating procedures. nevertheless, there are important challenges, which render tti a "moving target", and reflect the dynamics in three main areas. first, a change in the type and number of recipient patients with past or ongoing immunomodulatory / immunodeficiency component (examples being hiv/aids, sot, allogenic hct, monoclonal antibody therapies, small molecule inhibitors). second, changing exposure to known agents in donors due to global travel, migration and displacement, as well as environmental/climate change. third, discovery and diagnostics of old and new agents with their known or presumed impact as tti. these aspects will require careful review of data and studies, and judicious discussion of the potential action such as selection versus close monitoring to keep tti rates as low as possible, to deliver maximal safety of patients and stakeholders. background: the implementation of nucleic acid testing (nat) and the development of sensitive and specific serologic assays to detect hbsag and anti-hbc antibodies significantly reduced the risk of hbv transfusion-transmission. the apparent redundant testing for two direct viral markers prompted debates on maintaining hbsag screening, particularly in low endemic countries where blood donations are screened for anti-hbc. however, frequencies of - % of hbsag-confirmed positive/nat negative donations have been reported depending on the sensitivity limit of the molecular assays used. the nature of this discrepancy between hbsag and dna remains largely unknown and it is essential to evaluate any potential negative impact on blood safety before considering removing hbsag testing. aims: the prevalence in blood donors and the molecular mechanisms responsible for a persistent undetectable or barely detectable level of viral replication in the presence of a sustained hbsag production were investigated in a collaborative study including five laboratories/blood centers in europe and south africa. discrepancy between viral dna and hbsag levels suggested the presence of mutations that may negatively affect hbv replication and/or infectious viral particle production. methods: donor samples from france, south africa, poland, and croatia were selected for having hbsag levels ≥ iu/ml and being id-nat (procleix-ultrio plus tm [ % lod: iu/ml]) non-reactive/non-repeatable reactive (nr/nrr) with undetectable viral load (vl) or < iu/ml (n = ) or nat repeat reactive (rr) with vl < iu/ml (n = ). french samples initially tested nat nr/nrr with procleix-ultrio (lod %: iu/ml) were retested with ultrio plus prior inclusion in the study. hbv dna load was quantified (cobas taqman hbv [loq: iu/ml]). hbv dna was purified from to ml of plasma after ultracentrifugation. the whole hbv genome, pre-s/s, precore/core and bcp regions were amplified and sequenced. results: following viral concentration, hbv dna presence was confirmed in % of all samples with undetectable or vl < iu/ml. hbv genotypes were a ( . %), a ( . %), a ( . %), b ( . %), c ( . %), d ( %), and e ( %). all samples were anti-hbc positive and % of ultrio-negative samples tested positive with ultrio plus. unusual - nt insertions/deletions identified in bcp regulatory elements (tata boxes, pginr, epsilon domain) suggest altered viral replication. amino acid substitutions (n = ) or deletions (n = ) at positions reported involved in nucleocapsid formation, particle envelopment and virion formation were observed in the core protein of samples. the replicative properties of the bcp and core variants are currently evaluated in vitro as a surrogate model for direct infectivity testing. preliminary results indicate that the variants tested so far have replicative capabilities similar to those of control viruses. analysis of pol, s, and hbx proteins is ongoing. summary/conclusions: these data confirmed the presence of extremely low level of circulating dna-containing viral particles in id-nat non-reactive or nonrepeated reactive blood donations with concomitant high hbsag levels and anti-hbc reactivity. despite the presence of mutations in the viral genomes potentially affecting virion production, preliminary data indicate that some of the viruses in plasma retain the ability to replicate in vitro and to constitute a potential infectious risk. c-s - background: in switzerland highly sensitive nucleic acid screening in an individual donation format for hepatitis b virus (hbv id-nat) and hepatitis b surface antigen (hbsag) detection is mandatorily performed (guidelines of swiss transfusion src, switzerland). since , hbv (hb) vaccination is recommended in switzerland for children and adolescents until the age of and for adults belonging to known risk groups. aims: to highlight that low anti-hbs titers several years following hbv vaccination still confer protection and enable the host immune system to clear hbv dna without development of serologic markers of disease. methods: a retrospective donor interview was conducted to complete information not covered by the questions included in the standard donor questionnaire. routine hbv serological donor screening was performed on a quadriga system (diasorin, former siemens) with the enzygnost hbsag assay (diasorin, former siemens). further hbv tests were performed on the abbott architect i analyser (hbsag neutralisation, hbeag, anti-hbc igg/igm, anti-hbc igm, anti-hbe and anti-hbs). routine id-nat screening for hiv/hcv/hbv was performed with the roche cobas mpx test on a roche cobas platform. hbv id-nat positive samples were confirmed with a quantitative hbv nat assay (abbott). background: hepatitis b core-related antigen (hbcrag) is a structural antigen of hbv, consisting in hbcag, hbeag and the p cr precore protein. quantitative hbcrag measurement is a sensitive marker of viral replication reflecting the cccdna content and persistence of disease. hbcrag positivity was found to be a significant risk factor of hbv reactivation in hbsag-, anti-hbc+, hbv dna-patients (occult hbv infection, obi) undergoing immunosuppressive therapy. aims: no data about hbcrag status in apparently healthy subject with obi are available. the aim of this study was to analyse this marker in our cohort of obi blood donors. methods: hbcrag was measured in blood donors confirmed to be carriers of obi (hbsag-, hbv dna+). of them, / ( . %) donors were anti-hbc positive, and ( . %) negative. donors had both anti-hbc and anti-hbe reactivities. a group of young blood donors vaccinated for hbv infection (hbsag-, hbv dna-, anti-hbc-), and patients with chronic hbv infection (hbsag+, hbv dna+) were used as negative and positive controls group, respectively. serum hbcrag was measured using a chemiluminescent enzyme immunoassay on the lumipulse g automated analyzer (fujirebio, tokyo, japan). the lower limit of detection (lod) of the quantitative assay is logu/ml and the lower limit of quantification (loq) is > logu/ml, due to nonlinearity results between and logu/ml. levels of hbcrag were tested in the three groups and analysed in comparison to the presence of anti-hbc and anti-hbe. statistical analysis was performed by the ibm statistics spss . . . results: all donors in the negative control group had undetectable hbcrag levels, whereas all patients in the positive control group have detectable hbcrag (mean value: . logu/ml, range . - . ), confirming that individuals without prior exposure to hbv would not have detectable hbcrag. hbcrag was detectable in / obi donors ( . %), with a mean value of . logu/ml (range . - . ). hbcrag could be measured only in obi donors ( . and . logu/ml), being below the loq of the test in the majority of obi ( / ). considering the presence of anti-hbc, hbcrag was detected in / ( . %) anti-hbc+ and in / ( %) anti-hbc-obi, with no significant difference in their mean levels ( . ae . vs . ae . ; p = . ). interestingly, the presence of anti-hbe ( / ) was independently associated with higher hbcrag levels ( . ae . vs . ae . ; p = . ). summary/conclusions: identification of donors with obi is critical to prevent the risk of hbv transfusion-transmission. being hbcrag associated with the cccdna content and replication, our results suggest that the presence of hbcrag, even if not quantifiable, could be useful marker to confirm the occult infection status, even in anti-hbc negative donors. the association between hbcrag, anti-hbc and anti-hbe could also be a useful marker to identify obi donors with a higher risk of hbv reactivation. c-s - hc group. human peripheral blood mononuclear cells (pbmcs) from blood donors were stimulated with hbv polypeptides pool in vitro. t cell proliferation assays (cfse) was used to detecting t cell proliferation, enzyme-linked immunospot assay (elispot) was used to detecting the frequency of hbv-specific ifn-c secreted t cells. spss . statistical analysis software was used for statistical analysis. the measurement data of normal distribution were tested by two independent samples t test; and the comparison between multiple groups was analyzed by one-way anova. mann-whitney u test was used for comparison between non-normal data sets. p < . was considered statistically significant. results: . proliferation characteristics of t cells. the proliferation of cd + t lymphocytes was mainly stimulated by specific hbv polypeptide pool, and the proliferation rates of obi group and chb group were significantly higher than those of hc group ( . %, . % vs. . %), with significant difference ( . % vs. . %, p = . , . % vs . %, p < . ). . the frequency of specific ifn-c secreted t cells. the response intensity of the obi group ( sfc/ pbmcs) and chb group ( sfc/ pbmcs) was higher than that of the hc group ( sfc/ pbmcs) under the stimulation of hbv polypeptide pool, and the positive rate of t cell response to the stimulation of hbv polypeptide pool was the highest in the obi group ( . %). summary/conclusions: both obi and chb had higher rates of hbv-specific t effector cell proliferation and ifn-c secretion than the healthy control group. compared with the chb group, obi group had a higher positive rate of t cell response, which may be one of the causes of host immunity resulting in obi. further studies on other immune factors are required. background: western blood transfusion practices are currently changing due to various drivers such as blood management policies, ongoing technological developments, and new therapeutic options. in the netherlands, as in many high-income countries, these have resulted in a diminishing trend of red blood cells. therefore, it is important for blood bank management to anticipate the future demand of blood products for the sake of medium and long term decision making. to support this decision making, we have employed scenario development, which is used in many other sectors (such as finance and transportation) and can also be applied to blood transfusion. building upon a prior literature review and semi-structured interviews of international experts, we gathered experts together for scenario sessions to assess the opportunities and threats for sanquin's medium-term ( - years) strategy using an online platform and face-to-face discussions. aims: to assess for opportunities, threats, and the organizational implications thereof for the medium-term future of sanquin, the dutch national blood bank. methods: twenty-one multidisciplinary experts in blood transfusion agreed to participate and were separated into two groups for half-day interactive sessions. using an iterative process through an online platform, experts brainstormed opportunities and threats for sanquin, which were categorized into themes. these themes were ranked according to importance and certainty, and through consensus, experts chose two themes with high impact and high uncertainty. for these chosen themes, specific actions for the blood bank were listed to mitigate and/or enhance the threat or opportunity. discussions were ample throughout. results: with regards to opportunities and threats for sanquin's medium term strategy, experts brainstormed many ideas and categorized them under themes: political context/ changing legislation, novel products and alternative applications, donors, international markets, commercialization, digitalization, change in perceptions, research, demand, and organizational structure. after ranking for importance and certainty, six themes were chosen: change in perceptions, international markets, political context (opportunities), demand (opportunities), research (vulnerabilities), and donor (vulnerabilities). for each of these themes experts provided specific actions for the organizations to mitigate threats or stimulate opportunities accordingly. these actions included increased transparency and improved communication with the (donor) public, lobbying in political spheres, increased activities in educational institutes and large funding organizations, and creating and collaborating on novel blood products on an international level, to name a few. summary/conclusions: these results show that mapping and assessing a blood bank's future using a multi-disciplinary group of experts is conducive as an effective means of collection a diverse range of opportunities and threats. this provides an opportunity for blood bank management to become proactive towards these potential opportunities and threats and possibly evolve future strategies for the organization. showed that iron-deficient female blood donors were more likely to have depressive symptoms than non-iron deficient female blood donors. among participants with depressive symptoms, females with low plasma ferritin levels had significantly increased odds for reporting a "feeling of lacking energy and strength" (or = . ; % ci: . - . ). as it is known that blood donors are at an increased risk of iron deficiency, it is important to determine whether those genetically predisposed to lower plasma ferritin levels have a higher risk of experiencing the tiredness/lack of energy symptom. aims: to investigate whether there is an association between polygenic risk scores (prss) based on plasma ferritin levels and the tiredness/lack of energy symptom in blood donors. methods: the dbds is an ongoing nationwide blood donor cohort, of which genome-wide genotype data are available for , participants. genotyping was performed using the infinium global screening array (illumina â ) and imputation was achieved based on a scandinavian reference genome. ferritin prss, based on an icelandic ferritin gwas (n = , ), were calculated for all dbds participants. , female donors were available for the analysis. data on depressive symptoms were obtained using the validated major depression inventory scale (mdi), a selfreport mood questionnaire, which assesses the presence of depressive symptoms. a donor was classified as "tired" if they responded "all the time" or "most of the time" to the question "how often do you feel that you lacked energy and strength?". logistic regression analysis was performed, adjusting for age. for generating the quantile plots, the participants were distributed evenly into six quantiles based on their prs, whereby quantile contained the donors with the lowest prss (genetically predisposed to lower ferritin levels) and was set as the reference quantile with or = from the age-adjusted regression analysis (tiredness~quantile). results: prss in females ranged between - . and . (mean . ). a total of , female donors were classified as "not tired" and ( . %) were classified as "tired". no significant difference in ferritin prs was found between "tired" and "not tired" female donors (tired mean prs: . ; not tired mean prs: . ). an age-adjusted logistic regression model found this to be insignificant (or: . , % ci: . - . ), p = . ). to visualise the lack of association, a quantile plot was created, separating the female donors into six equal quantiles based on their prs. no clear trend was observed; donors with the highest prss (in quantile ) had or = . (p = . ) of being tired when compared to those in quantile (or set as ). summary/conclusions: no significant association was found between the ferritin prss of female blood donors and the tiredness/lack of energy symptom. further studies are needed to understand the effect of blood donation versus genetic constitution on tiredness among female iron-deficient blood donors. background: antiretroviral therapy (art) is critical for the control of clinical progression of human immunodeficiency virus (hiv) infections. however, the outcome of art could be limited by drug resistance-associated mutations (drms), even lead to the transmission of drug-resistant hiv to treatment na€ ıve patients such as blood donors, which is a huge concern to art. drms surveillance in hiv infected groups is strongly recommended by world health organization. characteristics of genetic diversity and drms of hiv among blood donors may provide comprehensive data to monitor viral evolution and optimize art, play important roles in blood safety. aims: limited data concerning the epidemic of hiv- subtypes and drms of blood donors is available in china. this study is to investigate genetic characteristics and drms of hiv- infected blood donors. methods: from - , blood donations collected from blood centers, covering almost the whole of china, were confirmed as hiv- positive by national centers for clinical laboratories using abbott realtime hiv- assay or cobas taq-man hiv- test, version . . then hiv- gag ( bp, hxb : - ), pol genes ( bp, hxb : - ) (encoding the whole protease (pr) and a part of reverse transcriptase (rt)) was sequenced after viral rna extraction and amplification. hiv- subtype based on gag and pr-rt regions was determined by comprehensive analyses of los alamos hiv blast tool, rega hiv- subtyping tool, phylogenetic trees and online jphmm program. drms analysis was performed in the stanford hiv drug resistance database. results: among donations, gag and pr-rt regions of samples were sequenced successfully. the distribution of hiv- genotype was as follows: crf_ bc = ( . %), crf_ ae = ( . %), b = ( . %), crf_ bc = ( . %), crf _ b = ( . %), crf _ b = ( . %), crf _cpx = ( . %), crf _ b = ( . %), crf _ = ( . %), crf _bc = ( . %), urf_ = ( . %) and urf = ( . %). of hiv- isolates were identified to have drms. there were ( . %, / ) protease inhibitors (pi) accessory drms, pi major drms and ( . %, / ) non-nucleoside reverse transcriptase inhibitors (nnrti) drms. most of blood donors with drms were crf _ae and crf _bc ( . %, / ). of pi accessory drms were q e. the pi major drms included m l, m i and n s. n s could result in hlr to atazanavir (atv) and nfv, llr to indinavir (idv) and saquinavir (sqv). v d/e is main nnrti drm ( . %, / ). a combination of v d and k r among two samples acted synergistically to reduce efavirenz (efv) and nevirapine (nvp) susceptibility. furthermore, two blood donors with k n mutation in reverse transcriptase gene had high level-resistance to efv and nvp. summary/conclusions: overall, the most prevalent subtypes among blood donors in the study were crf _bc ( . %), crf _ae ( . %). besides, other rare crfs and several urf_ and urfs were also found in these hiv- isolates, which suggested the epidemic of hiv has been shifted from high risk populations into general populations, including blood donors in china. drms were observed in . % donors in the study, which may result in resistance to pis and nnrtis, especially the hiv- variants with n s mutation in pr gene and k n mutation in rt gene. in summary, our findings indicate that increasing diversity of hiv- in blood donors and remind us the necessity of timely genotypic drug resistance monitoring and molecular epidemiology surveillance of hiv- among blood donors. background: labeling of platelets is required to measure the recovery and survival of transfused platelets in vivo. currently a radioactive method is used to label platelets. however, its' application is limited, due to safety issues and the inability to isolate transfused platelets out of the circulation. biotin-labeling of platelets is an attractive non-radioactive option, however, no validated protocol to biotinylate platelets is currently available for clinical purposes. aims: the aim of this study is to develop a simple, standardized, reproducible method to label platelets with biotin as a non-radioactive alternative to trace transfused platelets in vivo. methods: six pooled buffy coats derived platelet concentrates (pcs) stored in % plasma were biotinylated at day and day of storage. to distinguish the effect of the processing steps from the effects of biotin incubation, 'sham' samples were processed. for the biotinylation procedure, ml of pcs was washed twice and incubated with mg/l biotin, dissolved in phosphate buffered saline-pas-e ( : ), for min. stability of the biotin labeled platelets after irradiation was tested. annexin v and cd p expression were assessed as measures of platelet activation. applicability of this method to other platelet products was assessed in three pooled pcs stored in % pas-e and three single donor apheresis pcs. results: the method was reproducible performed in a closed system. after biotinylation, . % ae . % of platelets were labeled. platelet counts, ph and 'swirling' were within the range accepted by the dutch blood bank for standard platelet products. the number of annexin v positive cells was not significantly altered by the biotinylation procedure in both fresh and stored platelets. in contrast, cd p expression was increased in biotinylated platelets . % iqr( . - . %) compared to the control samples . % iqr( . - . %) on day of storage. however, biotinylated platelets were not more activated compared to sham samples % iqr( . - . %). thus only the procedural steps led to increased cd p expression and not the biotin label itself. all samples showed maximal response to thrombin receptor-activating peptide. for platelets labeled at day , a similar pattern was observed. irradiation of biotin labeled platelets did not alter the stability of the biotin label nor cell quality. furthermore this method is also applicable to pooled pcs stored in pas-e and apheresis pcs, with similar patterns in annexin v and cd p expression. summary/conclusions: we developed a standardized and reproducible protocol according to good practice guidelines (gpg) standards, for biotin-labeling of platelets for clinical purposes. the procedural steps, which are similar to the steps used for production of hyperconcentrated platelet products, led to an increased cd p expression, but did not alter the annexin v expression. this method can be applied as non-radioactive alternative to trace and recover transfused platelets in vivo. blocking activity over the prototypic chs insulator in cell lines and substantially reducing genotoxicity in a c-retroviral vector-mediated carcinogenesis mouse model. in contrast to chs , these insulators are small-sized ( - bp vs . kb) and can be easily accommodated in gt vectors without detrimentally affecting vector titers. aims: we aimed to test whether a , one of the newly discovered cis, could reduce vector-mediated genotoxicity in the challenging context of sin-lvs, by insulating a therapeutic globin-vector. methods: we tested the genotoxicity effect in the il- -dependent d cells, which upon transduction with oncogenic vectors become il- -independent, leading to transformation. d cells were transduced with sin-lvs: the b-globin-ΤΝs . . -, the insulated b-globin-a -tns . . and the oncogenic sffv-gfp-vector. transduced cells were expanded in % il- and transduction efficiency was determined by vector copy number (vcn). transduced d cells were seeded in methylcellulose with % or - % il- to detect the il- -independent and potentially transformed clones. the il- -independent clones were further expanded in % il- and infused in partially myeloablated and il- -treated c h/hej mice. wbc analysis, blood smears and bone marrow(bm) cytospins were performed. results: the a insulator did not negatively affect vector titers (ΤΝs . . , a -tns . . , sffv-gfp: . , . , . x ^ iu/ml, respectively). d cells were successfully transduced with all vectors (%vcn positive colonies: - %) and expanded up to -fold. the a -insulator decreased the number of il- -independent colonies by - % over the uninsulated vectors. the uninsulated vector-transduced, il- -independent colonies, were greatly expanded in culture with % il- over the a -transduced colonies (sffv, ΤΝs . . , a -tns . . : , , fold change, respectively). il- independence as a transformation event was confirmed in vivo by the development of overt leukemia (hyperleukocytosis, splenomegaly, bm-and extramedullary site-infiltration) in mice transplanted with the il- -independent and expanded colonies. summary/conclusions: under forced oncogenic conditions, the a insulator effectively protected a therapeutic vector from vector-mediated genotoxicity. a may serve as a safety feature in the construction of globin-sin-lvs. background: novel rare nucleotide substitutions are frequently identified in rhd, the gene encoding the immunogenic d antigen of the clinically-relevant rh blood group system, resulting in d variant phenotype. so far, it has been commonly accepted that substitutions of amino acids located either in a transmembrane or intracellular domain of the rhd protein induce weak d phenotype, i.e. reduced d antigen density at the surface of red blood cells. recently we showed by functional analysis using a "minigene splicing assay" (msa) that a decrease in d antigen expression may be due also to alteration of cellular splicing. aims: here we pay attention to the general disruption of this mechanism and the related phenotypic consequences in novel and previously reported single-nucleotide variations in rhd. we then sought to characterize functionally by msa novel candidate splicing variants in rhd. then we extended the project by studying prospectively all single-nucleotide variations reported in rhd exons, in order to assess globally the correlation between in silico prediction and functional analysis and to gain insights into the reliability of bioinformatics tools in line with the available phenotypic and/or clinical data. methods: seventeen novel or uncharacterized rhd variations, including missense, synonymous and intronic substitutions, were selected for functional analysis by msa in human cell models. a second set, including missense variants reported in rhd exons and , was further analyzed. functional data were compared with an algorithm derived from the quepasa method and tools available in the alamut suite. a published d protein model was used to visualize the location of missense amino acid substitutions and to assess potentially their respective phenotypic consequence. results: a novel "universal" minigene was validated and used successfully to characterize eleven novel splicing variants. those variants include six intronic and four missense substitutions close to the consensus dinucleotide splice sites, as well as the c. c>t synonymous variation associated with a weak d phenotype, which creates a de novo splice site. very interestingly, c. g>t (gly val; d-negative) disrupts totally normal splicing, while c. g>c (gly ala; weak d) and c. g>a (gly asp; d-negative) only partially alter the mechanism. further visualization of amino acid changes in a d model suggests that gly asp, but not gly ala, dramatically impair rhd protein structure/folding. subsequently the global analysis of mutations in rhd exons and by msa showed that inclusion of whole exon sequence in the mature transcript is significantly reduced in / ( . %) variants, which correlates well with the quepasa-like prediction (sensibility = . , specificity = . ). additionally, while normal exon inclusion is affected by c. c>g (weak d type ), the associated leu val substitution does not seem to be deleterious to the protein. summary/conclusions: on the basis of our functional data, this work shows that splicing disruption in the presence of rhd variants is a common and general mechanism that may act independently or synergistically with alteration of protein structure through amino acid substitutions, resulting in a weak d phenotype. it also illustrates the potency of combining functional tests and in silico tools towards the phenotypic/clinical interpretation of rare variants. background/aims: monetary and non-monetary incentives may support blood services in recruiting blood donors but have also been criticized for violating ethical principles and threatening blood safety by attracting donors with a high risk for infectious diseases. although incentives for blood donors have been discussed extensively over the past decades, empirical research on this topic remains limited. the aim of this study was to describe attitudes towards incentives for blood donors in europe and show donor return rates of compensated and non-compensated blood donors in south-west germany. methods: first, we present results of a secondary analysis of the eurobarometer, a nationally representative survey in all member states of the european union. in , participants were asked to evaluate eight potential incentives for blood donations as acceptable or unacceptable. these incentives were refreshments (e.g. coffee), physical check-ups (e.g. blood pressure), free (testing) laboratory parameters, free medical treatment, complimentary items (e.g. first aid kits), monetary travel reimbursements, additional cash reimbursements, and release from work. second, we conducted a retrospective analysis of donor return patterns of . compensated and . non-compensated donors who started donating blood at mobile and fixed donation sites. compensated donors received either eur as a regular reimbursement for their expenses (at a fixed donation site), in accordance with the german transfusion law, or a singular free entrance for an amusement park (at a mobile donation site). these compensated donors were compared with noncompensated donors who started either at a fixed or mobile donation site. chisquare statistics were used to test for differences in regular donor status after , , and months between compensated and non-compensated first-time donors. results: among german participants of the eurobarometer, physical check-ups ( . %), refreshments ( . %) and free (testing) laboratory parameters ( . %) showed the highest acceptance as an incentive for blood donors. travel reimbursements and free medical treatment were rated as acceptable by . % and . %, respectively. the lowest acceptance was for release from work ( . %), complementary items ( . %) and additional cash reimbursement ( . %). interestingly, the acceptance of potential incentives varies considerably across europe. in south-west germany, donor return of first-time donors differed significantly by type of compensation. among compensated first-time donors, who received eur as a monetary reimbursement, the proportion of regular donors after months ( . %) was significantly higher than among comparable non-compensated donors ( . %). however, a non-monetary compensation (free entrance) did not increase donor return rates. conclusion: the eurobarometer survey indicates that in most european countries monetary incentives are only accepted by a small minority. refreshments, checkups, free (testing) laboratory parameters and free medical treatment were most popular as incentives for blood donors. however, results of our four non-randomized donor samples from south-west germany suggest that monetary compensation may increase the likelihood of donors returning to fixed donation sites. regular monetary reward may therefore help to recruit regular donors especially in urban settings. incidentally, non-monetary compensation by a free entrance, however, may not affect donor return. background: previous research showed that whole blood (wb) donors that are temporarily deferred on-site are at higher risk of lapsing, yet very little studies have focused on differentiating the effects that different deferral reasons (e.g., travel, hemoglobin [hb]) may have on donor lapse. in addition, donor experience (i.e., firsttime or repeat donor) has also previously been found to affect donor lapse, yet novice ( - prior donations) and reactivated donors (returning after years of not donating) may respond differently. finally, it is currently unclear how and why different deferral reasons and donor experience interact in influencing donor lapse. aims: our aims were to understand ) how deferral reasons and donor experience jointly affect donor lapse, and ) why donors may lapse after temporary deferral. methods: a mixed methods approach was used. first, we used sanquin's donor database for a quantitative analysis of return behavior of all dutch wb donors between and (n = , ). the first wb donation for each donor was identified as the target donation. lapse was defined as non-return within a followup period of two years after the target donation. target donations included % new donors, % novice donors, % experienced donors, and % reactivated donors. deferral reasons included travel, hb, medical short-term (< days duration), medical long-term (> days duration), and miscellaneous. next, we interviewed temporarily deferred donors to understand the deferral process from their perspective. semi-structured interviews were used to understand how these donors cognitively and emotionally experienced on-site temporary deferral. we analyzed the interviews (using the framework approach, cf. hillgrove et al., bmc public health, ) to identify key topics and underlying themes. results: of target donations, % were deferred, mostly for travel ( %), medical short-term ( %), and hb ( %). survival and time-to-events methods showed that the different deferral reasons and donor experience levels differentially impacted donor return or lapse. importantly, experience and deferral interacted in influencing return (rate). for instance, deferred new donors were more likely to lapse than eligible or experienced donors (ors < . , p's< . ). even though deferral also affected return of experienced donors, this effect was smaller or even non-existent for certain deferral reasons (e.g., travel-and hb-related deferrals). qualitative results showed that almost all donors experienced temporary deferral as disappointing, particularly when it was unexpected (e.g., first-time deferral). not all donors (fully) understood the aims of deferral or how to prevent on-site deferral. donor beliefs about why deferral would lead to lapse were related to recurring deferrals, (mistakenly) interpreting deferral as permanent, or feeling all the effort did not pay off. summary/conclusions: reasons for temporary deferral differently impact risks of donor lapse at different levels of donor experience. for new donors all reasons for deferral are related to higher risks of lapse, whereas some reasons for deferral seem not to affect lapse among more experienced donors. unexpected or recurring deferrals may explain why donors lapse after temporary deferral. blood banks may tackle disappointment after deferral by explicitly showing that the donor is still valued, for instance by using personalized communication or offering an alternative good deed. background: blood donors experience a temporary reduction in their hemoglobin (hb) value after whole blood donation. in the netherlands, the hb value is measured before each donation, and a too low hb value (cut-off values: . mmol/l ( g/l) for men and . mmol/l ( g/l) for women) leads to a deferral for donation, in order to prevent iron deficiency and anaemia. the minimum interval between two donations is internationally set at weeks, but over time donors exhibit iron deficiency so that blood donors are temporarily deferred from donation each year. in the us % - % of deferrals are due to low hb, especially in women (editorial, transfusion, ) . due to the recovery process after each donation and the unobserved heterogeneity of donors, advanced statistical methods are needed to model the longitudinal data of hb values of blood donors. aims: to estimate the shape and duration of the recovery process of hb until the hb value has returned to its pre-donation level, to assess whether one can distinguish between donors with fast and/or slow recovery of their hb level and to predict future hb values. methods: the study is based on data of the donor insight study, which was a prospective cohort study performed by sanquin in the netherlands from to . we employed three statistical models for the hb value: (i) a mixed-effects models, (ii) a latent-class mixed effects model, and (iii) a latent-class mixed-effects transition model. in each model, a flexible function was used to model the recovery process after donation. the latent classes identify groups of donors with fast or slow recovery times, and donors whose recovery time increases with the number of donations. the transition effect accounts for possible state dependence in the observed data. all models were estimated in a bayesian way, using data of a sample of new entrant donors ( males and females). prior information from the clinical literature (boulton, vox sanguinis ) about the recovery process three days after blood donation was incorporated into the analysis since these values were not identified in the observed data. results: the results show that the latent-class mixed-effects transition model fits the data best. we also found that the recovery process shows a concave process (initially fast followed by slower recovery). the estimated recovery time is much longer than the current minimum interval of days between donations. namely, depending on the subgroup that the donor belonged to, males showed a recovery time of to days, while the estimated recovery time for females varies between to days. these results suggest that an increase of this interval may be warranted. summary/conclusions: the analysis shows the usefulness of the sophisticated statistical models that make use of historical information to model complex processes in time, in this case the hb trajectory over time across repeated donations. in addition, our results suggest a (much) longer time lag between subsequent donations to avoid anemia. background: complications of blood donation are known to reduce donors' return for future donation. the episode study (experience success in donation) showed that water drinking shortly before donation had an effect of % reduction of selfreported vasovagal reactions (vvr) in younger novice whole blood donors (wiersum-osselton, transfusion, ) . aims: in this study we analysed the return for a subsequent donation of the donors participating in the episode study. this was a predefined secondary outcome of the episode study. methods: the episode study was conducted in young (< years) whole blood donors making their first, second, third or fourth donation in geographically selected collection centres. the study interventions were: ml water drink, ml water drink or squeezing a ball (placebo intervention) during the wait after the screening interview and before phlebotomy, and a control group without intervention. participating donors were sent an online questionnaire about their experience within a week following their donation attempt. in the netherlands donors are usually invited for blood donation in accordance with hospitals' needs; the aim is to invite eligible donors at least once a year. donors were included in the return analysis if they had received at least one invitation within days after the index donation and we analysed their return for a donation attempt within days. associations with the interventions and donors' donation status, gender and reported symptoms at their index donation were analysed by calculating return percentage of eligible donors and by binomial logistic regression. results: out of the episode participants who had received an invitation, ( . %) returned within the study period. there was no difference in donor return between the two water groups. the likelihood of return was significantly increased in both water and placebo intervention donors compared to the questionnaire group (or . , % ci . - . and . , . - . respectively). return was slightly lower in women (or . , ) and lower in first-time donors (or . , . - . ) than after a nd - th donation. a staff-recorded or self-reported vvr at the index donation reduced donor return (or . , % ci . - . and or . , . - . respectively). other symptoms following donation were also associated with a lower return percentage. summary/conclusions: in this cohort of younger new and novice blood donors, . % returned for a subsequent donation. a vvr (either staff-recorded or selfreported) reduced donor return. donors who received a study intervention, either water or placebo, were more likely to return, whether or not they had suffered a vvr. it is conceivable that the mere fact of study participation could also have increased donor return, even in de questionnaire group; this will be examined in the total population of target group donors. background: the contribution of older blood donors to the blood supply is substantial. in australia, donors aged > years contributed % of all donations made in . however, with ageing, the general health status of older donors changes relatively faster, thus progressively affecting their ability to donate. an indepth understanding of the relationship between older donors' health status, future donation patterns, and risk of iron-deficiency could be of a great value to inform the blood service to predict the number of future donations, and manage the risk of iron-deficiency. aims: to understand the relationship between self-reported health, blood donation patterns, and the management of identified iron-deficiency in older blood donors. methods: we linked the sax institute's and up study baseline data collected between and to the blood service donation records, inpatient records, and medicare records*. the data-linkage was conducted by centre for health record linkage. using these linked data, we examined the relationship between health, donation patterns, and iron-deficiency and its management. results: we followed up , active whole blood donors for , eligible person-years (average age at recruitment . years, . % female, average follow up . years per-person). after adjusting for the effect of age, sex, body-mass index, education, non-english language spoken at home, country of birth, smoking, physical activity, regular use of multivitamins, alcohol consumption at enrolment, and total number of whole blood donations in the years prior to enrolment, participants with better self-reported health at recruitment showed significantly higher rates of donation. excellent, very good, good, and fair/poor health status donors made ( % ci - ), ( - ), ( - ), and ( - ) donations per person-years, respectively. iron-deficiency was identified in . % of donors in the study (n = , % ci . - . ) . sixty percent of those with iron deficiency (n = , , % ci . - . ) visited their general practitioner (gp) within days of the identification of irondeficiency, and . % ( % ci . - . ) of those visiting gp underwent further iron status examination and monitoring. after adjusting for several potential confounders including the total number of donations made during the follow-up period, excellent self-reported health status was independently associated with lower risk of iron-deficiency (p for trend = . ). summary/conclusions: information on self-reported health status can be an effective indicator to estimate the future donation yield of an older blood donor panel, and risk of developing iron-deficiency. donors with better self-reported health had a higher number of future whole blood donations and a lower risk of iron-deficiency. donors referred to gps for management of their iron status utilised the health services as expected, however there is an opportunity to improve their contact with their gps. * medicare records was provided by australian government department of human services. anaemia is a major public health issue, affecting % of the population worldwide according to the world health organization. iron deficiency is responsible for approximately half of all cases globally, with other causes including anaemia of chronic disease, other nutritional deficiencies, haemoglobinopathies, renal impairment, malignancy and bone marrow disease. in the elderly, where anaemia is even more common, the cause is frequently multifactorial. anaemia is associated with increased mortality, decreased cognitive and physical function, depressive symptoms and fatigue, particularly in older adults. poor outcomes have also been reported in anaemic patients with underlying comorbidities such as cardiac and renal disease, and cancer. within a hospital setting, anaemia is highly prevalent. preoperative anaemia, affecting up to % of patients, is associated with poor clinical outcomes including higher in-hospital mortality, longer length of stay and higher icu admission rates. anaemia management requires a proactive and multi-faceted approach, typically involving a multi-disciplinary team in which the transfusion practitioner plays a vital role. this includes screening of high-risk patients and pre-admission clinics to identify and manage patients at high risk of peri-operative anaemia. implementation of patient blood management (pbm) guideline recommendations has been shown to be effective to prevent and optimally manage anaemia within the community and hospital settings. the transfusion practitioner has key roles in the coordination, monitoring and auditing of pbm programs. active patient involvement and engagement of all members of the multidisciplinary team, including primary care clinicians, are also key to enhance the success of such programs. tp - the role of the transfusion practitioner in anaemia assessment and management: processes, tips and resources for creating background: patient blood management (pbm) is an evidenced based integrated multi-disciplinary approach aimed to improve clinical outcomes by effectively managing and conserving the patient's own blood, thus reducing unnecessary exposure to transfusion. pbm has the patient as the central focus with the aim being to improve their outcomes and include them in the process. pbm includes three pillars: ) optimising the patient's own blood, ) minimising blood loss and ) optimising a patient's physiological tolerance of anaemia. delayed assessment/management of anaemia contributes to increased health costs and unnecessary blood transfusions, and transfusion has been recognised to be associated with increase morbidity and mortality. the term transfusion practitioner (tp) includes those known as transfusion nurses, transfusion safety officers, haemovigilance officers, or patient blood management (pbm) coordinators. a key aspect of the role is driving and influencing clinical blood management activities to help align practice to internationally recognised guidelines and standards, including pbm. aim: to demonstrate the tp role in anaemia assessment & management and discuss strategies, processes, tips and resources for creating organisational and cultural change to implement pbm. context: literature outlines the importance of a multidisciplinary team to implement pbm related changes, and tps play a fundamental role within these teams to support 'buy in'. tps are seen as enablers, pulling resources together, engaging with those involved, providing education and facilitating change. they are often the ones to conduct audits, collating data and evaluating outcomes. approaches to implement pbm should be tailored to suit individual organisations. the authors will outline different approaches, highlighting where the tp can support or lead activities. one approach to anaemia assessment is to undertake an audit, examples of available tools will be shown. with this data, the tp along with the pbm team can explore options for corrective action. these could include interventions such as developing a pathway where all or a specific group of patients are assessed and or treated either at a preoperative clinic, or with their local general practitioner; through to more complicated strategies such as establishing anaemia clinics. the skills of the tp are a valuable asset to analyse clinical specialties/patient mix who should be targeted to achieve best outcomes, they know the organisation and as such are well placed to help develop a process/concept that will suit, and they can provide education and support to promote and embed these practices. conclusion: appropriate assessment and management of anaemia requires a multidisciplinary approach. the tp plays an active and crucial role in this team. examples of processes, tips and resources to support change and embed a pbm culture across the clinical spectrum will be shared. d-s - department of hematology and central hematology laboratory, inselspital bern, bern, switzerland immune haemolytic anaemia (iha) is characterized by an increased breakdown of red blood cells (rbcs) due to allo-and/or autoantibodies directed to rbc antigens with or without complement activation. clinical and laboratory signs of haemolysis in concert with the presence of a positive direct antiglobulin test characterize iha. alloantibodies formed during pregnancy and/or after prior transfusions may cause acute or delayed haemolytic transfusion reaction after transfusion of a rbc product incompatible with the specificity of the alloantibody. autoantibodies to rbcs reduce the survival of endogenous and hamper the recovery of donor rbcs after transfusion. lymphoproliferative disease, autoimmune disease, infection or drugs often cause autoantibodies to rbc, but frequently no obvious cause can be identified. besides the antigen specificity, the isotype critically determines the biological activity of rbc antibodies in vivo. the isotype defines the affinity to fc-gamma receptors on cells of the reticuloendothelial system as well as the capacity to activate the classical pathway of complement, igm being the most effective. antibody-mediated complement activation results in the opsonisation of rbc with c bc/c d with subsequent complement receptor-mediated removal by phagocytes (extravascular haemolysis). occasionally, complement activation proceeds via the activation of c to the formation and insertion of the membrane attack complex resulting in intravascular haemolysis. there is growing evidence that the innate immune system plays an important role in the pathogenesis of iha. the process of complement-mediated haemolysis results in systemic inflammation, which contributes to morbidity and mortality of patients suffering from iha. complement activation results in the release of anaphylatoxins, which are strongly vasoactive and mediate chemotaxis, inflammation and formation of radical oxygen species. release of cell-free haemoglobin and cell-free haeme upon haemolysis induces endothelial cell activation, no-depletion, cytotoxicity, ros formation and neutrophil activation. natural plasma scavengers, such as haptoglobin and hemopexin complex with their target molecules, cell-free haemoglobin and haeme, with subsequent removal of the complexes via cd and cd -mediated phagocytosis. although being positive acute phase proteins due to consumption the plasma scavengers become exhausted during chronic haemolysis thereby failing to prevent the adverse biological effects of cell-free haemoglobin and haeme in the circulation. inducible haeme oxygenase- (ho- ) is an efficient cellular scavenger by breaking down haeme into biliverdin with subsequent formation of bilirubin, co and ferrous iron with subsequent oxidation to ferric iron and storage by the ferritin h chain. ho- has an established role in the systemic protection from systemic inflammation induced by haemolytic and non-haemolytic diseases. the lecture will emphasise the role of innate immunity with a special focus on different plasma-and cellular systems involved in the pathogenesis of systemic inflammation in patients suffering from iha. d-s - understanding erythrocyte clearance c roussel, p amireault, p ndour and p buffet research and teaching, institut national de la transfusion sanguine, paris, france the clearance of erythrocytes is essential in physiology, disease and transfusion. elimination of erythrocytes altered because of senescence or pathological processes is expected to protect the microcirculation from obstruction by adhesive or rigid erythrocytes. it also contributes to the harmful consequences of anemia and hemolysis in hereditary and acquired red blood cells diseases as well as in conditions associated with auto-or allo-immunization. immunobiology has explored in great details antibody-mediated clearance of erythrocytes but conventional approaches may not be fully operational to explain delayed hemolytic transfusion reactions. some important clearance processes are independent from the recognition of molecules or antigens on the erythrocyte surface. increased erythrocyte stiffness triggers their clearance in hereditary spherocytosis, malaria and possibly also in the context of autoimmune anemia. knowns and unknowns on the mechanisms and sites of erythrocyte clearance will be presented based on a critical review of old and recent contributions. d-s - cardiovascular and endocrine-metabolic diseases and aging, istituto superiore di sanit a, rome, italy existing literature indicates that red blood cells (rbcs), beyond gas transport, exert a complex role in human physiology, being involved in many functions essential to maintain ion, metabolic and immunological homeostasis. rbcs display an immunomodulatory activity on adaptive immune cells by promoting t cell growth and survival and inhibiting activation-induced cell death. the balance between cell death and survival controls t cell homeostasis and anomalies in this balance account for diseases linked to excessive or faulty t cell growth. rbcs are able to modulate innate immunity by binding endogenous molecules such as chemokines and mitochondria-derived dna, as well as external agents such as pathogens. rbcs can also directly modulate innate immune cell activation or tolerance by controlling the maturation of the circulating pro-inflammatory subset of dendritic cells (dcs). these cells are potent inducers of primary antigen-specific t cell responses, produce tnf-a when stimulated by lps and are the principal il- p -producing cells among leukocytes. the pro-inflammatory capacity of circulating dcs is controlled by rbcs that are able to inhibit their maturation and il- production. in diseases characterized by local th inflammatory response such as psoriasis vulgaris and rheumatoid arthritis, pro-inflammatory dcs play a role in the induction and perpetuation of inflammation. collectively, literature data indicate that rbcs exert important modulatory functions that may result in immune activation or quiescence, depending on the environmental conditions. when rbcs encounter a microenvironment characterized by an intense production of ros, the rbc defenses get overwhelmed or are unable to counteract the new pro-oxidant status and become themselves a source of ros, which cause the generation of senescent signals on rbcs. the major feature of oxidized rbcs is the clustering and/or the breakdown of band . other features are the complexation of hb with spectrin, the loss of glycophorin a, the externalization of phosphatidylserine and the reduction of the "marker of self" integrin-associated protein cd . a similar senescence phenotype has been documented in rbcs during the storage period. oxidized, senescent or stored rbcs, due to surface antigen modification and to the release of pro-inflammatory molecules, fail to control immune cell homeostasis thus contributing to the perpetuation of inflammation and to the pathogenesis of immune-mediated diseases associated to oxidative stress, such as autoimmune diseases and atherosclerosis. our research group demonstrated that rbcs from patients with carotid atherosclerosis presented a senescent phenotype similar to that acquired by rbcs from healthy subjects following to in vitro oxidation. oxidized erythrocytes fail to control t lymphocytes apoptosis and lipopolysaccharide-induced monocyte-derived dc maturation, thus representing dangerous signals for adaptive and innate immunity and contributing to the pathogenesis of atherosclerosis. in conclusion, the crosstalk between rbcs and the immune system represents a mechanism to maintain immunological homeostasis. however, in high oxidative stress conditions, that can take place during a prolonged storage period or in particular diseases, rbcs can acquire a pro-oxidant behaviour and lose their functional and homeostatic features. by interfering in immune system homeostasis, rbcs become a potential tool that can be manipulated to improve or reverse pathological situations characterized by anomalies in the control of adaptive and innate immunity. transfusion therapy remains an important treatment modality for patients with sickle cell disease (scd). transfusions are given to lower the percentage of circulating sickle rbcs, and to decrease blood viscosity and have been shown in clinical trials to reduce the risk of stroke by %. however, many indications for transfusion in scd remain controversial partly due to insufficient randomized clinical trials data and in part because of our limited understanding of the complex pathologic networks leading to diverse disease complications in scd despite the common single mutation. similarly, we have incomplete mechanistic understanding of why chronic transfusion protocols must be continued for those indications supported by clinical data. the beneficial effects of transfusion therapy in scd need to also be weighed against potential transfusion risks including alloimmunization associated with lifethreatening delayed transfusion reactions, increased iron stores associated with increased oxidative stress and exposure to infectious agents. we believe that a deeper understanding of the benefits as well as harmful effects of transfusions is crucial to optimize our current transfusion therapy protocols in scd. this knowledge may provide highly needed guidance, which is currently lacking, for expansion or limiting existing indications for chronic transfusions in scd. d-s - treatment of thalassaemia department of pediatric hematology, ege university, faculty of medicine, bornova/ izmir, turkey thalassaemia is a devastating blood disease with a significant worldwide burden. annually, , children are born with a major thalassemia. life-time rbcc transfusions and iron chelation remain standard of care treatment in thalassaemia. transfusion therapy still account for significant iron overload related morbidity and mortality despite chelation therapy which is associated with poor adherence, safety concerns and varied efficacy. higher risk for transfusion transmitted infections (ttis) exists for thalassemia patients whose transfusion exposure sustains lifelong. although, the risk of transmission for traditional viruses is exceedingly rare in the modern era, emerging infectious diseases continue to be recognized as potential threats to transfusion safety. the inadequacy of blood safety points to the necessity for an additional layer of security for the blood supply in the developing world. pathogen reduction technologies for rbcc may imply a proactive, more generalized approach against new and re-emerging pathogens in the developed world and may be an ultimate safeguard for transfusion safety in the developing countries. rbc alloimmunization may become a major challenge in thalassaemia management. prevention is the key reducing the burden of alloimmunization. while the recommendation is to transfuse thalassaemic patients with c/c,e/e,kell compatible blood, it is not universally practiced. extended molecular rbc typing may be an appropriate adjunctive test in addition to serological typing before embarking on transfusion therapy. if a complete rbc antigen profile has not yet been performed in an alloimmunized patient, genotyping is the only option for accurate detection of rbc antigens that may guide the antibody identification. allogeneic stem cell transplantation (a-sct) is the only available curative therapy in children with hla matched sibling which is available to approximately % patients. in the absence of msd, mud transplant with high compatibility criteria has still limited experience. mismatch related, cord blood and haploidentical donor scts are considered experimental. a-sct carries a substantial risk of saes and mortality, both increasing with recipient age and disease severity. dfs is % in paediatric and % in adults. gene therapy for correction of the a-globin chain imbalance overcomes the problems of donor availability and immunologic complications associated with a-sct. multicenter clinical studies on gene addition therapy by using self-inactivating lentiviral vector are currently underway. recently, gene editing by either gene disruption or gene correction emerged as a potential alternative to gene addition therapy in beta-thalassaemia. a new era of novel therapeutics is unfolding in thalassemia management. several targets have been identified that can improve alpha/beta chains imbalance, ineffective erythropoiesis, or iron dysregulation and a number of those now have agents in preclinical and clinical development. hydroxyurea may improve globin chain imbalance and be beneficial for reducing or omitting transfusion requirement in selected group of patients. ruxolitinib has shown the limited effect on pretransfusion haemoglobin and reduction in transfusion needs, but allowed steady decrease in spleen volume that may serve for avoiding splenectomy in beta thalassaemia. luspatercept may restore normal erythroid differentiation and improves anaemia and hepcidin mimetics or tmprss inhibitors may modulates ineffective erythropoiesis by iron restriction and improves anaemia and organ iron loading. background: thalassaemia major (particularly b-type) and sickle cell disease (scd) are the commonest clinically important haemoglobinopathies, representing major sources of morbidity. recommended therapy is regular transfusion of safe, good quality blood, and monitoring of related complications. thalassaemia international federation (tif) guidelines, in place since , include strategies for precautionary measures and use of scientific progress in detection, inactivation and elimination of transfusion transmissible pathogens. antigen-matching strategies to avoid alloimmunization against rbc antigens and other measures including haemovigilance are key components for safe blood, alongside voluntary, non-remunerated blood donation and laboratory quality assurance programmes. aims: we present the contribution of tif and the greek experience in ensuring safety and availability of blood for thalassaemia patients applying internationally accepted standards and recommendations. methods: tif -a non-profit, patient-driven organization with national thalassemia associations in countries -promotes national control programmes for prevention and management contributing to the achievement of final cure. the main working methods are provision of education, expert support, networking, communications and projects to support improvements in the quality of health, social and other care. in greece, technical standards for blood donor selection and testing are applied in compliance with directive / /ec as well as haemovigilance programmes and traceability procedures for recording adverse reactions and events associated with the transfusion of rbcs (directive / /ec). pre-transfusion and transfusion measures recommended by the council of europe are applied. in particular, measures for transfusion of "the right blood at the right time for the right patient", leucodepletion, rbc washing and accurate cross-matching and antigen and antibody screening for an extended matching policy are practised. fresh (up to days old) rbcs are used. molecular testing for abo and rh d is performed in cases with blood group discrepancies. haemovigilance in greece covers % of total blood supply. data on ttis in , patients with thalassaemia and scd-thalassaemia in - are analysed. results: tti prevalence in thalassaemia syndromes was: hbv . % (occult type . %), hcv %, hiv . %, htlv . %, wnv . % and hev %. most frequent adverse reactions in - were allergic (incidence : ), non-haemolytic febrile reactions : , , "other" : , , alloimmunisation : , , taco : , , tad : , , tt-hev : , . hyperhaemolysis was diagnosed in two scd patients, delayed haemolytic transfusion reaction in one thalassaemia intermedia patient. trends in - show reduced incidence of alloimmunisation against rbcs. rates of allergic and pyrexial ars remained stable. no major abo incompatibility case was reported and no fatal transfusion reaction of transfusion has been recorded. summary/conclusions: blood safety in transfusion has significantly improved in high and upper-middle income but unfortunately not in lower and low income countries. blood shortages and lack of stringent protective measures for thalassaemia patients is the reality for many developing countries. tif focuses particular attention on the provision of support and the promotion of initiatives promoting the safety and adequacy of blooda key component of the lifelong management of patients with transfusion-dependent thalassaemia. background: b thalassemia is the most common group of hereditary hemoglobinopathy diseases. affected people with major thalassemia are dependent on regular blood transfusion which leads to iron overload. hepcidin is a peptide and an important regulator of iron homeostasis. expression of this hormone is influenced by polymorphisms within the hepcidin gene, hamp. aims: this study aimed to analyze the association of three polymorphisms in promoter of hamp, rs , rs , and rs with iron overload in major b thalassemia patients who do not respond to iron chelating therapy. materials and methods: a total of samples from major b thalassemia patients were collected. genomic dna was extracted and sequenced for snps rs , rs , and rs . statistical analysis was performed on ibm*spss* statistic using independent t test and fisher test. results: our analysis revealed statistically significantly difference between the level of cardiac iron concentration and c.- a>g variant (p = . ). for rs statistical analysis was on the edge of significant relationship between minor allele and serum ferritin (p = . ). all samples were homozygous for allele t of rs . summary/conclusions: different factors affect iron overload in thalassemia. our findings and others emphasize the role of hepcidin polymorphism as a key component in iron homeostasis. ten to twenty years ago, countries in south eastern africa faced the peak of the devasting hiv/aids epidemic leading to an up to years drop in general life expectancy. with the burden of hiv/aids falling mainly on the economically active population of young and medium-aged adults, the epidemic endangered social and economic stability in nations most heavily affected. today, despite aids still being a major cause of death in south eastern africa, the epidemic has become an example of public health gains that can be achieved through programmatic, evidencebased approaches that are endorsed by globally aligned policy and funding strategies. based on his work from lesotho, where one out of four among adults is infected by hiv, niklaus labhardt will take the auditors through the history of hiv programs in south eastern africa and show how innovative, pragmatic and evidence based implementation brought the region to a stage where the goal to end the aids epidemic by might be in reach. background: in france, the deferral for men who have sex with men (msm) was reduced from permanent to months in july . since this change has not impacted the residual risk (rr) of undetected hiv among blood donations, the ministry of health is considering a greater access of blood donation to msm. two scenarios have been studied: s . deferral of msm during the months preceding the donation; s . deferral of msm who have had more than one sexual partner in the months preceding the donation, similarly to all other blood donors in france. aims: to assess the impact of these two scenarios on the hiv rr estimated over the period july -december which is the baseline rr with the current month deferral for msm. methods: baseline hiv rr was calculated with the classical incidence-window-period method, where hiv incidence was derived from a detuned assay (eia-ri) detecting recent infections (≤ days) since all hiv- antibodies positive blood donations are tested with this test. the assessment of the impact of both scenarios on the baseline hiv rr was based on (i) data obtained from surveys among msm in the general population and in blood donors (compliance survey), to estimate the number of additional msm who would give blood in each scenario, and on (ii) hiv incidence estimate among these additional donors. this incidence was estimated: for s , from msm blood donors with the current deferral policy ( months) and for s , from monogamous msm of the general population. results: from july to december , / ( %) hiv- positive blood donors tested with the eia-ri were identified as recently infected, allowing to estimate the baseline hiv rr at . in million donations [ % ci: . - . ], or in , , donations. for s , the number of additional msm donors was estimated at and the number of additional hiv positive donations at . , resulting in an hiv rr of . in million donations [ % ci: . - . ] or in , , donations. for s , the number of additional msm donors was estimated at , and the number of additional hiv positive donations at . , resulting in an hiv rr of . in million donations [ % ci: . - . ] or in , , donations. sensitivity analysis shows that if both the number of msm and the hiv incidence were multiplied by . , the risk would be in , , donations for s , and in , , for s . summary/conclusions: for both scenarios, the hiv rr remains very low. for s ( -month deferral), the risk is identical to the baseline rr and is very robust to variations in the model parameters. for s (no more than one sexual partner, months), the risk is . higher than the point estimate of the baseline rr and sensitivity analysis shows that this estimate is less robust than for s , since the risk could be times higher than the baseline rr. for both scenarios, there was a modest increase in eligible msm donating. d-s - background: recruiting safe blood donors amongst the largest hiv-positive population in the world is a major challenge for south african blood transfusion services. south african donor deferral criteria and deferral periods for perceived high risk activities have evolved over time, but current risk factors for infection have not been formally assessed. in addition, most studies have reported risk factors for prevalent hiv infection whereas risk behaviours for incident infection are more informative as donations with these infections could occur during the window periods of available screening assays. aims: to identify the demographic and behavioural risk factors associated with incident hiv infection among blood donors in south africa. methods: we conducted a case-control study with incident hiv-infected blood donors compared to infectious marker negative controls. incident hiv cases and controls seronegative for hiv, hepatitis b and c viruses and syphilis were accrued from a donor pool covering of provinces in south africa. controls were frequency matched at a : ratio to cases on race, age and geography. incident hivinfections were hiv rna positive by individual donation nucleic acid amplification testing (id-nat; procleix, grifols) but antibody (ab) negative (prism, abbott) as well as those rna+/ab+ donors with recently-acquired hiv based on limiting antigen avidity (lag) assay results with normalized optical density values of < . . eligible cases and controls completed a confidential audio computer assisted structured interview (acasi) on motivations for blood donation and behavioural factors, including behaviours in the months before donation. frequencies and measures of statistical association for risk behaviours comparing cases and controls are reported after adjusting for multiple comparisons. results: from november to january , we enrolled incident hiv cases and controls; ( . %) cases and ( %) controls were ≤ years old. there were significantly more female cases ( . %) than female controls ( . %) (p < . ). significant hiv risk factors (all p < . ) reported within the -months before donation included: having a primary sex partner who is male; reporting increasing numbers of male sexual partners for both females and males; frequency of vaginal sex; frequency of vaginal sex without condoms; use of methods to clean, dry, or tighten one's anus before sex; and having visited a traditional healer for medical care. lack of medical aid (private health insurance) and reports of injury or accident with blood loss were also associated with an incident hiv infection. summary/conclusions: our study has identified a set of novel, putative risk factors for incident hiv infection among south african blood donors while confirming a number of previously known sexual risk behaviours. not having private health insurance and being injured may be markers of socio-economic context that place individuals at higher risk rather than behaviours that directly increase hiv transmission risk. the detection of risk behaviours by acasi in donors who passed predonation questionnaires and interviews suggests that acasi has the potential to improve risk behaviour identification. background: in france from to , among male blood donors (mbds) found hiv- positive at blood donation screening, % did not disclose any risk factor for hiv infection during post-donation interviews, while % reported having sex with men (msm), and % and % reported heterosexual sex (hts) and other risk factors, respectively. aims: in order to gain new insights into the risk factors for hiv- infection in mbds, we performed an hiv- genetic network analysis, including hiv- positive mbds and patients included in the french primary hiv infection anrs co primo cohort (pc). methods: mbds, who donated blood between and , and pcs, included between and , were studied. epidemiological data were collected by the french blood service (efs) upon blood donation or post-donation interviews for mbds, and upon inclusion for cps. viral strains were sequenced and genotyped in pol gene, and a recent infection assay was performed to date infection in mbds (recent: < months). a partial transmission network was computed based on tamura-nei nucleotidic distance (threshold for hiv- s/t b = . %; for non-b s/ t = . %) and assortative mixing was evaluated for mbds epidemiological data, including risk factors for hiv infection (msm, hts, others and unknown). selfreported data were then compared to assortativity-enhanced data. results: hiv- strains from mbds and pcs were linked into clusters including at least one mbd. primo-only clusters were excluded from the analysis. compared to mbds who did not cluster, those found linked to the network were younger ( vs. year-old; p < . ) and were more likely to have a recent infection ( % vs. %; p = . ). assortative mixing indexes showed that paired individuals were more likely to live in the same area (p < . ) and to have the same risk factor for hiv infection (p < . ) compared to a random distribution. imputing msm risk factor to non-msm individuals paired with msm changed the distribution of risk factors as follows: msm: % vs. %, hts: % vs. %, other: % vs. % and unknown: vs. %. summary/conclusions: after validating the assortativity of risk factors between paired individuals, and imputing msm risk factor to individuals self-reported as non-msm (including those with no identified risk factor), up to % ( / ) of mbds could be reclassified as msm. this is a worst-case scenario, as the network analysis does not exclude the possibility of one or several persons between two paired individuals (missing link). altogether, these results could help reevaluate the hiv residual risk linked to msm mbds, especially in the frame of the evolution of blood donor deferral criteria. background: although most individuals remain asymptomatic, htlv infection can lead to adult t-cell leukaemia/lymphoma (atll) and htlv- associated myelopathy (ham). the serious nature of these diseases, evidence of transmission via non-leucodepleted blood, and concern about a high prevalence among donors originating from endemic areas led to the uk blood services introducing universal blood donation screening in . monitoring through routine surveillance commenced and htlvinfected donors were invited to participate in the htlv national register cohort study to assess disease progression. these data together with evidence from lookback to previously untested donations and cost-effectiveness analysis were reviewed by an expert working group in and . aims: to describe the epidemiology of htlv among uk blood donors and evidence of disease progression from long term follow up of asymptomatic donors. methods: uk blood donations screened, and infected donors identified are reported to a national surveillance scheme. these donors are contacted, their results explained and information about clinical history and possible sources of infection are collected. where appropriate, htlv-infected donors are consented to the register, with participants completing a baseline questionnaire about their health, flagged in registries for cancer or death, and followed up about every - years. results: in the uk - , htlv-infected donors were identified. prevalence among new donors was steady around / donations. prevalence among repeat donors peaked in ( . / donations), with most in previously untested. from to , prevalence of . per , donations (average of one positive/year) was recorded. in , prevalence among new donors increased to . / , donations ( positives), with increased numbers associated with asian ethnicity and coinciding with an increase in collections from bame groups. overall, most were women ( / , %), uk-born ( / ; %) and htlv- infections ( / ; %). mean age was years. almost all positive donations were from previously untested donors ( / ), with seroconversion within a year of previous donation confirmed for only of the previously tested donors. typically, infections were associated with endemic countries (including caribbean region, west africa, iran, india and japan), acquired through breast feeding or from their heterosexual partner originating from these countries. interestingly, three were thought to have been infected through self-flagellation. a total of htlv-positive asymptomatic blood donors have already been recruited to the htlv national register, and during over -person years follow-up, none had developed atll or ham. summary/conclusions: over years of testing, few seroconverters were identified, suggesting very little ongoing transmission among uk blood donors. the lack of disease among the cohort study was also reassuring, although it is likely too early to detect associated symptoms of a slow progressing disease. recruitment to this unique dataset continues, also outside of the blood donation setting. as a result of these surveillance data, evidence from lookback, and cost-effective analysis, in nhsbt ceased to test donations from previously tested donors unless the donation was being used to manufacture a non-leucodepleted component. finland lies in northern europe between the °and °n latitude. the length of the country is km and width km. by surface area it is the fifth largest country in eu. the population of the country is . million resulting in the lowest population density in eu ( . inhabitants/km ). the whole country is inhabited, although most of the population is packed in the south. the climate of finland is influenced mainly by its latitude, but the warm waters of the gulf stream and the north atlantic drift current also play a role. due to finland's northern location, winter is the longest season. the southern portions of the country are snow-covered about three or four months of the year, and the northern regions for about seven months. long distances, low population density and the extreme climate give logistical challenges. it is estimated that these logistical costs can be as much as - % of gdp in finland. the finnish red cross blood service (frc bs) has been the nationwide blood service provider in finland since . frc bs collects annually about whole blood units of which % are collected in fixed sites and % in mobile sessions around the country. central activities (donor recruitment, medical support, production, testing, supply chain management, digital services and administration) are located in helsinki. management of transfusion is highly dependent on the logistical arrangements from blood donation sites to the central facilities and from the central inventory to the hospitals. the logistics is outsourced to three major partners all of whom have their roots in nationwide public transportation and logistics services. posti ltd is a state owned company having its roots in the national postal and telecom office. today it is the leading postal and logistics service company having the widest network coverage in finland. blood units collected at different fixed sites and mobile sessions are transported overnight by posti ltd to the frc bs central facilities by am on the day following the blood donation. posti ltd is also used for the regular deliveries of blood products to the hospitals. the other important partner is matkahuolto ltd, which was founded in the s to maintain bus stations and to serve as a common marketing company for the bus and coach services in finland. it maintains a nation-wide package delivery system based on the scheduled bus route network. matkahuolto ltd is used to transport donor testing samples from the donation sites to the central laboratory. by this arrangement it is possible to obtain most of the donor samples to the laboratory around midnight, which significantly speeds up the completion of laboratory results. the third logistics partner is jetpak finland ltd, which operates the air freight for the national flight company finnair. blood transfusion services can be managed centrally in a large sparsely populated country in a manner that is of high quality, safe and cost effective. however, the supply chain has to be planned carefully. background: elearning is a divisive topic. it is often criticised as an inferior form of education while simultaneously being promoted as a means to provide education to large numbers of people in a consistent, cost-effective manner. bloodsafe elearning australia (bea) is a government-funded blood transfusion education program that commenced in and provides courses in clinical transfusion practice and patient blood management (pbm) including: -clinical transfusion practice ( courses) -pbm: general ( courses) -pbm: medical ( courses) -pbm: acute care and surgical ( courses) -pbm: obstetrics and maternity ( courses) -pbm: neonates and paediatrics ( courses) aims: to determine the engagement, outcomes and impact of learning of bloodsafe elearning australia courses. methods: a retrospective analysis of user registrations, course completion records, course evaluation data and red cell usage in australia to determine learner demographics, and the impact on acquisition of knowledge and application to clinical practice. results: in the period from july to january : - , people registered as learners - , , courses were completed -these learners came from countries, with , ( . %) of them from outside of australia. analysis by profession shows that: - . % are nurses and/or midwives - . % are medical - . % are laboratory, anaesthetic technicians or other. analysis of user evaluation data (n = , ) from april to january shows that these courses have a positive impact, with . % of respondents stating they gained additional knowledge, . % able to make changes to clinical practice, and . % reporting that these changes will improve patient safety and outcomes. analysis of international participants shows greater benefits with . % gaining knowledge, . % able to change their clinical practice and . % believing this will improve patient outcomes. analysis of red cell usage in australia shows that since there has been a . % reduction in red cells issued. this has been achieved through a number of pbm activities including development of guidelines, research and audits, education, waste reduction strategies, and promotional campaigns. bloodsafe elearning australia courses on pbm were released in and are one part of this pbm activity, and it is notable that these courses have the widest reach as they are undertaken by a large proportion of doctors, nurses and midwives in australia who are not directly involved with the blood sector. stakeholder feedback shows that the program provides credible, consistent education that is cost-effective, reduces duplication, is 'best-practice' elearning, is readily accessible, and allows institutions to focus on the development of practical transfusion skills. summary/conclusions: this analysis shows that elearning is a well-accepted, wellutilised form of education for healthcare workers to learn about clinical transfusion practice and patient blood management, and learners gain knowledge that can change their clinical practice and improve patient outcomes. it is also likely that these courses have contributed to better utilisation of a scarce, freely-donated resource. this approach has global reach and availability, and is a cost-effective model for improving transfusion practice in the developing world by providing education for millions of healthcare workers. d-s - prospective platelet auditing: analysis of trainee compliance with guidelines pathology, columbia university, new york, united states background: apheresis platelets are a component product with high cost and limited supply. furthermore, there is a potential for severe transfusion reactions associated with this product such as transfusion related lung injury (trali), and sepsis due to bacterial contamination. therefore, transfusion guideline compliance is closely monitored by many centers. this quality assurance analysis describes our experience with prospective platelet auditing performed by physicians in pathology residency training. aims: this study aims to evaluate the ability of physicians in training to perform prospective auditing and compare policy compliance for different levels of experience. methods: this is a quality assurance analysis of a prospective platelet audit program for a -month period (january -december ). the blood bank paged the on call physician any time an order was placed for a patient with a platelet count of > , /ll, ≥ doses of platelets with no interim repeat count, or an unknown platelet count. audit records created by physician trainees in their first post graduate year (pgy ) were compared to subsequent years (pgy > ). information collected included the total number of doses requiring approval, number of products approved, training year for the approving physician, and transfusion indication. cost analyses assumed $ for a dose of platelets. descriptive statistics and comparative analysis using a pearson's chi-square were used with a difference of p < . considered statistically significant. results: there were platelet doses requiring approval with ( %) routed to the pgy group and ( %) to the pgy > group. there were ( %) ordered doses that were in compliance with hospital transfusion policy and ( %) that were not in compliance with hospital policy. of the appropriately ordered doses, the pgy group declined release of necessitating the clinical team to insist upon release without approval, and there were zero such instances in the pgy > group. when paged by the blood bank, pgy physicians approved product release not in compliance with policy for / ( %) doses while pgy > physicians approved not indicated products for / ( %) of doses (p < . ). products not indicated by hospital policy were held from release by pgy physicians for / ( %) doses and / ( %) doses by pgy > physicians (p < . ). the ordered doses not in compliance with hospital policy had an estimated cost of $ , . of this cost, there was a calculated $ , savings of products not released due to prospective auditing. there was an additional potential savings of $ , for products not indicated but released ($ , from the pgy and $ , from the pgy > group). summary/conclusions: despite a higher number of requests being routed to the more senior pgy > group, there were a disproportionately higher number of out of compliance platelet orders being released by the pgy group in addition to withholding needed products on several occasions. potential mitigation strategies for this could include a closer level of oversight for pgy physicians, and the potential monetary savings could justify a hiring a dedicated patient blood management team or quality assurance manager to monitor compliance and provide feedback to clinicians. d-s - what can we learn from how adverse events are detected? norwegian directorate of health, oslo, norway background: the primary aim of reporting systems, such as haemovigilance systems, should be learning and improvement and to identify risk areas, not simply counting errors. to understand and learn from adverse events the description of how, where and why they occur, and how they are detected, is important. to support our understanding, we use a predetermined classification that is required for reporting to eu, supplemented by classification suggested by ihn, who and ourselves. in we started asking the blood establishments what steps they would take to prevent recurrence of the event, and we added a simple classification to tell how the adverse event had been detected. aims: this study aims to analyze how different types of adverse events reported to the haemovigilance system were detected, whether the current quality management systems used in norwegian blood establishments had effective barriers and whether new barriers should be considered. methods: adverse events reported to the norwegian haemovigilance system in and were analyzed with focus on how the adverse event had been detected. in all cases classification had been performed by the reporter of adverse events and were confirmed, or reclassified if necessary, by the haemovigilance team before analysis. for analysis based on classification we used powerbi (microsoft). results: a total of adverse events were reported from norwegian blood establishments. all had been classified according to how the adverse event had been detected. twenty ( . %) adverse events were detected because of alarms or warnings from it-systems or equipment. routine checks by blood establishment staff detected ( . %) events and formal internal or external reviews detected one event. seven ( . %) events were detected because the donor became ill shortly after donation, but the illness was not caused by the donation. sixty-four percent of events were detected in a way that did not fit our present classification and hence were classified as "other". twelve out of wrong blood in tube were detected by an alarm from the it-system or routine check, as were six of events related to blood ordering, two of seven errors in testing, six of events where incorrect blood had been transfused, and eight of events related to donor selection. in reports human error was listed as the cause of the event and of these were detected by alarms or routine checks. summary/conclusions: detection of adverse events by alarms or routine checks are highly efficient when the blood establishment has historic data to check against, as exemplified with wrong blood in tube or a patient require irradiated blood components. when no historical data exists or when the quality management systems do not require routine checks, events are usually detected by chance. further analysis is needed to see if and where the quality management systems should be improved. the wide variety of adverse events can make it difficult to select which area to prioritize in the improvement work. results: the hb measurements from the finger prick were on average . g/l ( . %) higher than from the venous blood samples. the range of the difference was - -+ g/l. these results were used in order to add novel information to determine the measuring uncertainty of hb measurement in frcbs. in . % ( / ) of the donors in this study the venous hemoglobin measurements were below the cut-off point of donor eligibility. in those measurements the difference of the finger prick and venous hemoglobin measurement was at most + g/l. % of the hemoglobin results from the finger prick were in the range ae g/l compared to the venous hemoglobin results. % of the results from the finger prick were between ae g/l (the precision of the device) compared to venous hemoglobin results. in cases the difference between finger prick and venous measurements was outside standard deviations from the mean i.e. . % from the bottom (n = ) or top (n = ) of distribution. systematic errors were seen in some nurse's results both towards too low or too high hb result in the finger prick measurement and some nurses had random errors in both directions. the batch of cuvettes, donors' age, gender or the time of sampling were not detected to have an impact on the difference between finger prick and venous hb measurements in this study. summary/conclusions: the results of the poc measurements compared to the cell counter were in agreement with published data and with manufacturers' information on the device. the practical skill test is a workable way to develop competence and operations to measure the hemoglobin from the finger prick. it offers an opportunity to give personal feedback to nurses concerning their personal performance in the use of the current hb measurement technic. it also provided data on the accuracy of the poc method in the everyday donor selection process. background: whole blood donation has frequently been related to iron deficiency. a blood donor loses per donation about % (men) to % (menstruating women) of iron stores. to replenish the iron lost by blood donation in a donation interval of days, a donor needs to absorb . mg iron per day. this amount exceeds the reported maximal amount of absorbed iron of - mg/day, eventually leading to iron deficiency, with consequences such as donor deferral and possibly iron deficiency-related symptoms (decreased physical endurance, fatigue, pica, restless legs syndrome, and cognitive functions). since hb levels do not reflect donors' true iron status, measuring ferritin is a better way to detect low iron stores in whole blood donors. studies from usa and denmark showed that on the introduction of ferritin measurement with either extension of donation intervals or iron supplementation in case of low iron stores, deferral percentages for low hb declined in both male and female donors. aims: to gain more insight in iron status of whole blood donors during their donor career, how this affects donor health and which measures may prevent low iron stores in donors. methods: in the netherlands, sanquin blood bank is currently implementing a policy with ferritin-guided donation intervals. in brief, ferritin levels are measured in all new donors and in repeat donors every th donation or in case of an hb below the deferral threshold. donation intervals are extended if ferritin levels are < lg/ l, or ≥ and ≤ lg/l (for and months respectively). we anticipate that routine ferritin measurement will ultimately result in a lower prevalence of iron deficiency, less hb deferrals and improved donor retention. this will be further evaluated in a stepped wedge cluster-randomized trial 'find'em', which may also identify subgroups of donors prone to develop (symptoms of) iron deficiency. in addition, implementing ferritin screening may lead to a decreased donor availability. for this purpose, we modeled the impact of the implementation of our ferritin deferral policy on donor availability over time, which provides insight for both the expected size of the impact of the ferritin deferral policy and the time and rate at which this impact is expected to occur. this allows the blood bank to timely plan actions to counterbalance possible donor shortage and ensure an adequate blood supply. lastly, iron supplementation can be an alternative measure instead of donation deferral. as the used and recommended dosage of iron supplementation varies widely across blood services, sanquin is planning to start a new study in whole blood donors to gain evidence on the dosage and frequency of iron supplementation and its effect on ferritin and hemoglobin levels and donor health. results: the before-mentioned studies are ongoing and results will be expected from onwards. summary/conclusions: iron deficiency is a frequent side effect of whole blood donation. to prevent iron deficiency and its consequences, like donation deferral and health issues, more evidence-based insight in iron management of whole blood donors is being generated. d-s - superdonors -genetic risk profile and risk of low hemoglobin deferral background: no reliable method exists for stratifying new blood donors into those who can maintain sufficient hemoglobin (hb) levels and those who will be deferred because of a low hb (< . mmol/l [< . g/dl] for women and < . mmol/l [< . g/dl] for men). polygenic risk scores (prss) have shown great promise in predicting complex disease risk. prss could also prove useful for identification of donors genetically predisposed to low hb levels, and, thus, to an increased risk of deferral. aims: the objective of the study was to evaluate the association between prs (modelled to predict hb level as a quantitative trait) and risk of deferral as a binary outcome. methods: the danish blood donor study (dbds) is an ongoing nationwide blood donor cohort since with more than , participants. extensive genotyping has been performed on approximately , dbds participants using the infinium global screening array (illumina â ) and extended by use of imputing based on the pan-scandinavian reference genome. based on hb and genetic data on more than , icelandic individuals (an independent discovery cohort), we constructed different weighted prss for individuals from dbds. information on the donors' whole blood donations following inclusion into dbds unto end of was obtained from a nationwide donation database, scandat. the best predictor of hb among the nine prss was chosen and used in all subsequent analyses. we performed multilevel mixed-effects linear regression analysis with hb as outcome, and prs as factorized explanatory variable with cutoffs at , , , , , , , and th percentiles, respectively. moreover, the models had a two-level clustering on donor id and donation site and an id-specific random intercept; and further adjusted for: sex(binary), age(continuous), year of donation(factorized), and time since last donation (continuous). lastly, risk of deferral was evaluated in random effects logit models with similar covariables and clustering structure. results: mean number of donations per donor after dbds inclusion was . donations. generally, we observed a statistically significant positive association between prs(hb) and current hb levels. compared with donors in the - prs percentile group, donors below the th percentile had lower (- . hb mmol/l ( % ci: - . ; - . )) and donors above the th percentile higher (+ . hb mmol/l ( % ci: . ; . ) hb levels. in the random effects logit models we observed a marked increase in deferral risk with decreasing prs percentile strata. with the - prs percentile stratum as reference, donors below the th percentile and donors above the th percentile had odds ratios of deferral of or = . ( % ci: . ; . ) and or = . ( % ci: . ; . ), respectively. summary/conclusions: we found a statistically significant positive association between prs(hb) and hb levels and a markedly increased risk of deferral with decreasing prs(hb). from a scientific point of view, it is unsurprising that a genetic score for hb from an independent cohort is associated with hb in another cohort. however, from a practical perspective, prss may be the first step in a personalized donation approach to donors and their risk of deferral. background: individually calibrated inter-donation intervals for repeat blood donors have the potential to minimize the risk of iron related adverse outcomes (e.g., hemoglobin deferral or collecting a donation from a donor with low or absent iron stores) without unduly impacting the donated blood supply. machine learning has shown promise for personalized clinical risk assessment. aims: our aim is to use machine learning to develop donor-specific, personalized inter-donation intervals that minimize the risk of adverse outcomes while maintaining or improving the adequacy of the donated blood supply. methods: using a public use dataset from the reds-ii donor iron status evaluation (rise) study (cable, transfusion, ) we defined donor profiles with physiological measures including hemoglobin, ferritin and soluble transferrin receptor along with questionnaire responses regarding diet, reproductive health indicators, and demographics. we used these profiles ( features, , donations from , repeat donors) and the time until the next donation attempt to predict iron-related outcomes of the next donation attempt. possible outcomes were no adverse outcome, hemoglobin deferral, low-iron donation (ferritin < ng/ml for women and < ng/ml for men), or absent-iron donation (ferritin < ng/ml for men and women). we trained multiple machine learning models on , of the donations and selected the model with the best performance (lowest cross-entropy loss in cross validation). we assessed the best model's performance on a hold-out test set of donations, which were not used to train or select the model. we then used our model to generate risk estimates for these test donors as a function of days since their last donation, which varied from days to days. to show individual variation, we generated graphical representations of individual donors' risk over time. results: ferritin, log ferritin, body iron, and time since last donation were most useful for predicting iron-related adverse outcomes at the next donation attempt. the estimated risk of adverse outcomes at the next donation attempt varied considerably across donors. as expected, the risk of adverse outcomes days after the last donation was lower than the risk days after the last donation for most donors (risk of hemoglobin deferral decreased for % of donors; risk for low-iron donation decreased for %; and risk for absent-iron donation decreased for %). summary/conclusions: the risk of iron-related adverse outcomes as a function of time since last donation varies considerably between donors. machine learning models trained on relevant donor profiles can effectively estimate how an individual's risk will change over time. individual risk estimates could allow blood centers to protect highrisk repeat donors while continuing to allow more frequent collections from low-risk donors. further study is needed to ensure this approach works well for donor classes that are not well-represented by the rise dataset, to assess risk prediction outside of the physiological measures collected in the rise study, and to determine the viability of assigning an optimal inter-donation interval to a first-time donor using this approach. background: iron depletion is common among repeat blood donors, who contribute a large proportion of the blood supply in many countries. exogenous iron from multivitamins with iron or iron-only supplements helps prevent donation-induced iron depletion, but whether dietary iron protects against iron depletion in repeat donors has not been rigorously evaluated. available data from the reds-ii rise study in the us (cable, transfusion, ) and from the danish blood donor study (rigas, transfusion, ) suggest minor impact of dietary iron consumption on blood donor iron status in multivariable regression models. both studies, however, analyzed food items singly, such as beef or fish, rather than in aggregate, so precision was limited. aims: to evaluate whether a composite measure of dietary heme iron consumption, weighted for frequency and iron content, was associated with incident iron depletion among repeat blood donors. methods: a re-analysis of the rise cohort was undertaken to test the hypothesis that reported levels of animal protein consumption was associated with lower risk for incident iron depletion among repeat blood donors. the six blood centers participating in rise enrolled first-time and frequent donors for - month follow-up of donation frequency and iron status. a brief checklist of food categories was administered at baseline to assess frequency of consumption of several categories of animal protein that are rich in heme iron, the biochemical form of iron most readily absorbed. an iron composite score (ics) weighted for frequency and heme iron content was derived and subjects were grouped into tertiles (thirds) of ics. iron status was assayed at enrollment and study completion and at roughly one-third of donation visits in between. modified poisson regression with generalized estimating equations was used to generate risk ratios controlling for donation frequency and other covariates. results: of enrolled donors, were iron replete at baseline and completed the food checklist. the median value of the ics for each tertile (lowest to highest) was . , . , and . mg of heme iron weekly. these values are equivalent to approximately , , and servings of beef per week, or alternately twice as many servings of chicken or pork. across follow-up visits with iron outcomes assayed, almost % of donor visits were associated with intermediate iron depletion (serum ferritin < ng/ml) and . % with complete depletion of iron stores, representing serum ferritin < ng/ml. after controlling for demographic factors and donation frequency, the lowest tertile of ics was associated with a greater than fold higher risk for complete iron depletion during all follow-up visits (rr . , % ci . , . , compared to the highest tertile). summary/conclusions: in this longitudinal evaluation of dietary iron and iron status, blood donors with low intake of heme iron had an elevated risk for developing advanced iron depletion. these results suggest that blood centers should continue to recommend iron-rich diets to repeat blood donors. background: blood donors lose approximately mg of iron with every blood donation. as a result, frequent blood donors are at risk of iron deficiency and low hemoglobin (hb) levels, which may affect their health and eligibility to donate. lifestyle behaviors such as dietary iron intake and physical activity, may influence iron stores and thereby hb levels. gaining insight into associations between lifestyle behaviors and hb levels is valuable for blood supply organizations, as lifestyle behaviors can potentially be considered to prevent hb deferrals. examining the mediating role of ferritin, a measure reflecting iron stores, in these associations will help to gain insight into whether iron stores could be the limiting or enabling factor that links lifestyle behaviors to hb recovery after donation. aims: to investigate associations between lifestyle behaviors (dietary heme and non-heme iron intake and physical activity) and hb levels, and whether ferritin mediates these associations. methods: donor insight-iii (dis-iii) is a dutch cohort study of blood and plasma donors and included , donors. participants who were pregnant, had hemochromatosis, used iron supplements/medication, got a hysterectomy or bilateral oophorectomy were excluded (n = ). hb levels were measured in edta whole blood samples using a hematology analyzer (xt- , sysmex, japan) and ferritin was measured in plasma from lithium heparin tubes (architect ci , abbott laboratories, u.s.a.). dietary heme and non-heme iron intake (grams/day) were assessed using a food frequency questionnaire adapted to measure iron intake. moderate-tovigorous physical activity (mvpa, minutes/day) was assessed using the international physical activity questionnaire (ipaq)-short form. results: in total, , ( , female) participants were included. donors with higher intakes of heme iron had significantly higher hb levels (regression coefficient (b) ( % confidence interval ( % ci)) in men and women respectively: . ( . to . ) and . ( . to . ) mmol/l), independent of age, smoking, menstruation, number of donations in previous two years, donation interval, sedentary behavior, the other lifestyle variable (i.e. (non-)heme iron intake or mvpa), and initial hb level. non-heme iron intake was negatively associated with hb levels (- . (- . to - . ) and - . (- . to - . ) mmol/l for men and women respectively). ferritin mediated associations between dietary iron intake and hb levels (indirect effect in men and women respectively: . ( . to . ) and . ( . to . ) lg/l for heme and - . (- . to . ) and - . (- . to - . ) for non-heme). more mvpa was negatively associated with hb levels in men only (- . (- . to - . )), which was not mediated by ferritin. summary/conclusions: in conclusion, higher heme and lower non-heme iron consumption are associated with higher hb levels in donors via higher ferritin levels, indicating that donors with high heme iron consumption may be more capable of maintaining iron stores to recover hb levels after blood donation. more mvpa was associated with lower hb levels, although effect sizes were small, independent of ferritin. taking a donor's lifestyle behaviors into account may be useful in preventing low hb levels in blood donors. immune thrombocytopenia (itp) is still diagnosed by exclusion of other causes for thrombocytopenia. sensitive and specific detection of platelet autoantibodies may support the clinical diagnosis and prevent misdiagnosis of itp. for example, the direct monoclonal antibody immobilization of platelet antigens (maipa) assay, performed with in vivo sensitized patient platelets, offers platelet glycoprotein specific autoantibody detection with high accuracy. a drawback is that low platelet counts demand a large blood sample to have sufficient patient platelets available for analysis. circulating platelet autoantibodies are more difficult to detect by maipa; and may demand more sensitive detection platforms, such as those using surface plasmon resonance. in general, the presence of anti-gpiib/iiia, anti-gpib/ix and anti-gpv platelet autoantibodies is investigated. all these antibody specificities have been found in patients with itp. in itp, platelet autoantibody-mediated destruction via the spleen has been proposed; but also other mechanisms leading to low platelet counts in itp may play a role. inhibition of megakaryocytopoiesis by autoantibodies or by t cells has been suggested. in mice, gpib-directed antibodies induce loss of platelet-sugar epitopes, inducing hepatocyte-medicated platelet destruction. platelet autoantibodies can cause complement activation, which may contribute to platelet autoantibodymediated destruction. interestingly, we recently found that lack of detectable platelet autoantibodies is correlated with non-responsiveness to rituximab (cd moab) treatment in itp patients. in children with newly diagnosed and often transient itp, platelet autoantibodies of igg class or not often found, but of igm class are present for short duration. in conclusion, testing for platelet autoantibody characteristics and their pathologic effect may be helpful in establishing the diagnosis of itp and in choosing the best individualized therapy for itp patients. a-s - thrombopoietin receptor agonist (tpo-ra) treatment raises platelet counts and induces immunomodulation in immune thrombocytopenia (itp) jw semple , r aslam , e speck , j rebetz and r kapur lund university, lund, sweden st. michael's hospital, toronto, canada background: itp is an autoimmune bleeding disorder in which autoantibodies and/ or autoreactive t cells target the destruction of platelets and megakaryocytes in the spleen and bone marrow. several therapeutic options e.g. corticosteroids, intravenous immunoglobulins (ivig), rituximab and splenectomy are available for patients but inadequate efficacy, side effects and/or expense can make them undesirable. for the last years, tpo-ra e.g. romiplostim and eltrombopag have made a substantial contribution to the treatment of itp patient's refractory to first-line treatments. of interest, approximately % of patients that are tapered from tpo-ra therapy show a sustained response (e.g. a stable higher platelet count than before treatment). the mechanism of how tpo-ra induce these sustained responses is unknown. aims: to analyze the efficacy and immunomodulatory properties of a murine tpo-ra (amp , amgen) in a well-established murine model of itp that demonstrates both antibody-and t cell-mediated thrombocytopenia (chow l et al., blood ) . methods: platelet glycoprotein (gp) iiia (cd ) knockout (ko) mice were immunized with cd + platelets and itp was initiated by the transfer of their splenocytes into mice with severe combined immunodeficiency (scid). the scid mice were treated with either placebo or tpo-ra weekly and platelet counts and serum anti-platelet antibodies were measured weekly. results: in an initial pilot dose escalation study, control na€ ıve scid mice treated with a single subcutaneous bolus of different concentrations of murine tpo-ra ( , and ug/kg) had significantly higher platelet counts by h post infusion. in addition, compared with untreated mice, bone marrow histology revealed significantly increased numbers of megakaryocytes. maximal platelet count increases were observed with the highest tpo-ra dose and this dose was chosen to treat scid mice suffering from itp. when scid mice were treated with weekly injections of tpo-ra, platelet counts began to increase after weeks and were fully rescued to control levels after weeks post splenocyte transfer. of interest, compared with non-treated itp mice, serum igg anti-platelet antibody production in the tpo-treated mice was significantly reduced starting from two weeks post splenocyte infusion. summary/conclusions: these results suggest that murine tpo-ra is not only an efficacious therapy for murine itp but also induces immunomodulation indicative of immunosuppression. thus, this model may be able to elucidate the mechanism of how tpo-ra's induced immunosuppression in patients with itp. background: desialylation, the loss of sialic acid content on platelets (plts) glycoproteins (gps) was recently identified to contribute in immune thrombocytopenia (itp). however, the potential impact of autoantibodies (aabs) on megakaryocyte sialylation remains unclear. aims: to investigate the effect of itp aabs on plts and megakaryocytes (mks) sialylation and the subsequent impact on plt survival. methods: aabs from well-characterised itp patients induced gp-modifications were tested using a lectin binding assay. after incubation of mks or plts with itp or control sera, glycan changes were analysed by flow cytometry (fc). to investigate the impact of desialylation on plts life-span, the nod/scid mouse model was used. results: itp sera were investigated in this study. ( %) sera induced a significant increase in rca signal on plt surface compared to control sera from healthy donors (rca-mean fold increase (rca-fi): . , range: . - . , p = . ). in addition, ( %) sera caused higher ecl binding to test plts (ecl-fi: . , range: . - . , p = . ). injection of desialylating aabs resulted in accelerated clearance of human plts from the circulation of the nod/scid mice which was significantly reduced by a specific neuraminidase inhibitor that prevents background: autoimmune hemolytic anemia (aiha) is a rare autoimmune disease characterised by hemolysis associated with the presence of immunoglobulins (igg, igm, or iga) and/or components of complement system on red blood cells (rbcs), which is usually demonstrated by a positive direct antiglobulin test (dat). depending on the presence of an underlying disorder, aiha can be subdivided into primary and secondary and, by the temperature at which autoantibodies bind optimally to rbcs, into warm antibody aiha (waiha), mixed aiha (including both warm igg and cold igm antibodies), cold agglutinin disease (cad), paroxysmal cold hemoglobinuria (pch) and dat negative aiha. a frequent finding in immunohematology is the presence autoantibodies on rbcs without clinical symptoms of hemolysis that may later develop. aims: the aim of this study was to analyse serologic findings and transfusion support in patients with aiha and also to analyse dat positive patients without clinical symptoms. methods: we included data for all adult patients with aiha and dat positive patients without clinical symptoms diagnosed and/or treated at the university hospital centre (uhc) zagreb, croatia in the period between and . the diagnosis of aiha was defined by anemia with features of hemolysis (elevated bilirubin and/ or elevated lactate dehydrogenase and/or low haptoglobin level) and a positive dat. results: the data from patients ( % women) meeting the inclusion criteria was analysed. the mean age at the time of aiha was years (range - years). the mean hg level at diagnosis was . g/l. dat results were positive mostly with igg+c d ( %) or igg ( %). most patients had warm aiha ( %). other types of aiha diagnosed were mixed aiha ( %), cad ( %), pch ( . %) and dat negative aiha ( . %). in cases alloantibodies were detected with autoantibodies in the patient's plasma. patients were treated with corticosteroids as st line therapy and some with intravenous immunoglobulins (ivig). in severe or refractory patients rituximab and/or splenectomy was applied. a total of % of patients were transfused at a mean hemoglobin level of . g/l. during this period we detected dat positive patients without clinical symptoms. summary/conclusions: most patients from our study were diagnosed with warm type of aiha, followed by mixed type aiha and cad. on the other hand, pch and dat negative aiha were very rare, which is in concordance with relevant literature. most patients were transfused despite therapy used, which is not desirable in patients with aiha and should be better controlled, especially in moderate cases of anemias, where this is rarely necessary. a significant number of patients that were dat positive without clinical symptoms may later develop aiha and should be closely monitored. background: autoimmune haemolytic anaemia (aiha) is a decompensated acquired haemolysis caused by the host's immune system acting against its own red cell antigens. aiha is a rare disorder and although british society of haematology (bsh) guidelines for diagnosis and treatment were published in february , there is little evidence for clinical practice in the united kingdom. aims: to investigate the approach to diagnosis, investigation and management of patients with aiha in english nhs trusts. methods: a survey of diagnostic and management practice was designed, piloted and disseminated to clinical transfusion leads in all english acute nhs trusts from november to march . completion was by a consultant haematologist treating patients with aiha but a response that represented a departmental consensus was encouraged. results: responses represented % ( / ) of english acute trusts. median number of adults with aiha diagnosed annually was - . in the preceding years, % ( / ) recalled at least one patient who had died due to aiha. although % ( / ) undertook a bone marrow biopsy in all patients, % required additional features, mainly: neoplasia, age over or being treatment-refractory. for patients with suspected drug-induced immune haemolysis, % ( / ) would not organise confirmatory tests, either because it was considered unnecessary ( / ), or because clinicians were unsure how to access tests ( / ). when determining aiha subtype, % ( / ) indicated there were no circumstances in which they would undertake cold antibody testing (antibody titre and/or thermal amplitude), with considering this unnecessary and unsure how to access tests. in clinical scenarios of patients with aiha and dat positive to c d ae igg ae cold associated symptoms, up to % ( / ) of respondents would not test for cold antibodies. for first line treatment of primary warm aiha, mean duration of prednisolone mg/kg given before judging the patient refractory and reducing the dose was . weeks (sd . , range - weeks). second line treatment of choice was rituximab for % ( / ) of respondents and splenectomy for %. intravenous immunoglobulin and splenectomy were the most cited rescue therapies. for primary cold haemagglutinin disease (chad), first line treatment was rituximab-based for % ( / ) but single agent steroid for %. we also explored the potential for future audit and research. % ( / ) of respondents were able to identify patients with aiha who previously required transfusion. % ( / ) of respondents would consider supporting a registry of patients with aiha requiring transfusion. the key questions that respondents thought a registry should address were: morbidity and mortality, treatment response, and differences in the diagnosis and treatment of aiha subtypes. there was uncertainty over access to cold and drug-induced antibody tests and clinicians do not always conduct bshrecommended cold antibody tests for aiha with c d positive dat. initial treatment of primary warm aiha and chad broadly matched bsh guidelines although % ( / ) would continue prednisolone at mg/kg beyond the recommended days before starting a taper, with greater toxicity risk. summary/conclusions: the findings support the need for a range of research initiatives, including creation of an aiha registry. preoperative anemia is common and is associated with adverse outcomes in the peri-operative period. preoperative anemia also increases the risk of allogeneic blood transfusions, which may lead to increased perioperative mortality, increased hospital length of stay and infections. diagnosis and treatment of anemia is one of the tenets of patient blood management (pbm), along with reduction in unnecessary transfusions and diagnostic phlebotomy, as well as use of hemostatic agents to reduce bleeding among many others. effective pbm is multi-disciplinary, multi-modal, timely, individualized and patient-centered. early referral to pbm and multi-modal pbm interventions are associated with greater improvement in pre-operative hemoglobin. pbm has been shown to reduce transfusions and cost, while system-wide, multi-modal programs may also be associated with improvement in mortality. using examples from our local research and practice, i will discuss three aspects of pbm. iron and erythropoiesis stimulating agents (esa) are effective, safe and used extensively in management of pre-operative anemia. previous studies have questioned whether esa leads to increased risk of thrombosis, however, recent systematic reviews do not support these concerns. another pbm approach is to reduce bleeding during surgery by using hemostatic agents such as tranexamic acid (txa). txa reduces transfusion requirements in knee and hip arthroplasty, and is safe, widely available and relatively cheap. txa is effective in both anemic and non-anemic patients, making it an attractive universal pbm strategy. finally, recommendations and evidence-based guidelines on pbm exist, including the most recent international guidelines developed by the pbm international consensus conference. however, knowledge translation in pbm has been a problem and a number of barriers to its implementation have been identified. these include perceived or actual lack of expertise, time, and resources, as well as lack of physician and patient engagement. one way to address patient engagement is education through character driven animation and we are currently trying this approach. a-s - low vs . high hemoglobin trigger for transfusion in vascular surgery (tv): a randomized clinical feasibility trial (the tv trial) background: current guidelines advocate to limit red-cell transfusion during surgery, but the feasibility and safety of such strategy remains unclear as the majority of evidence is based on postoperative stable patients. aims: we assessed the effects of a protocol aiming to restrict red-cell transfusion during elective vascular surgery. methods: fifty-eight patients scheduled for lower limb-bypass or open surgery of abdominal aortic aneurysm were randomized to a low-trigger (hemoglobin < . g/ dl, mmol/l) vs. high-trigger (hemoglobin < . g/dl, mmol/l) for red-cell transfusion throughout hospitalization. intraoperative change in cerebral-and muscle tissue oxygenation was assessed by near-infrared spectroscopy. we used a nationwide registry to collect data on death and major cardiovascular events, which encompassed ( ) severe adverse transfusion reaction, ( ) acute myocardial infarction, ( ) stroke, ( ) new-onset renal replacement therapy, ( ) vascular reoperation, and ( ) amputation of the lower limb. results: the primary outcome, mean hemoglobin within days of surgery, was significantly lower in the low-trigger group: . g/dl vs. . g/dl in the hightrigger group (mean difference . g/dl; p = . , longitudinal analysis) as were units of red-cells transfused ( background: controlled non-hemato-oncological studies have consistently demonstrated a single-unit red blood cell (rbc) transfusion policy as well as a stringent hemoglobin (hb) rbc transfusion threshold to be safe and reduce blood product utilization. yet, it is unclear whether these conclusions also apply to the hemato-oncological patient population. aims: to quantify reduction of rbc blood product utilization by the introduction of a restrictive single-unit hb-triggered rbc transfusion policy among the inpatient hemato-oncological population. methods: under the liberal transfusion protocol, applied up till november , , standard double-unit rbc transfusion was indicated with a hb threshold ≤ . g/dl and/or anemia-related symptoms. following this date, the restrictive transfusion protocol was introduced involving a lowering of threshold to . g/dl and single-unit transfusion. for patients with an asa-score of ii-iii and iv, a hb threshold of respectively ≤ . g/dl and ≤ . g/dl applied. we evaluated rbc blood product utilization over a month period starting december , (liberal protocol) and december , (restrictive protocol) in all hemato-oncological patients admitted for chemotherapeutic treatment including hematopoietic stem cell transplantation (hsct) with an expected duration of neutropenia of ≥ days. analysis of categorical and continuous data was performed using the chi-square and mann-whitney test, respectively. results: during both observational periods, patients were admitted who in total received therapy cycles, including acute myeloid leukemia (aml) induction cycles and autologous hscts. distribution of indications of admittance, median age, duration of hospitalization and duration of neutropenia did not differ between both periods. during the restrictive period, in / ( . %) of transfusions the assigned hb trigger was adhered to. the percentage of single-unit transfusion episodes increased from / ( . %) to / ( . %) with the introduction of the restrictive protocol. overall, rbc blood product utilization per admittance did not reduce under the restrictive protocol (cumulative number of transfused rbc units . (interquartile range (iqr) . - . ) during the liberal versus . (iqr . - . ) during the restrictive period (p = . )). however, rbc blood product utilization per neutropenic day demonstrated a trend towards reduction: . (iqr . - . ) versus . (iqr . - . ) units per day during the liberal versus restrictive period, respectively (p = . ). this reduction was mainly attributed to autologous hscts during which rbc blood product utilization decreased from . (iqr . - . ) to . (iqr . - . ) units (p = . ), corresponding to a reduction from . (iqr . - . ) to . (iqr . - . ) (p = . ) units per neutropenic day. moreover, / ( . %) patients during the liberal versus / ( . %) during the restrictive period did not require rbc transfusion during admittance. consequently, stringent hb thresholds as compared to single-unit transfusions seem to more strongly impact rbc blood product utilization. summary/conclusions: a hb-triggered single-unit transfusion policy results in a strong reduction of rbc blood product utilization in the setting of autologous hsct. no utilization reduction was observed among other hemato-oncological inpatient populations receiving intensive chemotherapy. further improvement of protocol adherence rates could potentially increase the benefit of this blood saving strategy. a-s - assessment of hb content of packed red cells (prbc): is it time to label each unit with hb content? r jain , n marwaha and s sachdev transfusion medicine, aiims, new delhi transfusion medicine, pgimer, chandigarh, india background: in the current era of evidence based medicine and individualized care of patients, rbc transfusion continues to be administered on the basis of conventional wisdom and the notion of an average benefit per unit. the existing blood transfusion practice based on the "number of units transfused" ignores the fact that the total hb varies markedly among the individual rbc units. aims: the present study was aimed at estimating the hb content in packed red cell unit prepared by three different protocols from ml and ml whole blood collection in three types of blood donors: replacement blood donor (rd), first time voluntary donor (ftvd) and regular voluntary blood donor (rtvd). methods: a total of prospective blood donors were included in this study. three hundred whole blood collections were performed in each of the three groups of donors (rd, ftvd, and rtvd). within each group collections were done in double ml, triple ml and quadruple ml blood bags respectively. a pre-donation venous sample was drawn from sample collection pouch for analysis in hematology analyzer as reference method for hb concentration of donor. the hb content of packed red cell units were estimated after collection of representative sample from the blood unit. volume of prbc unit was estimated by the formula of weight of blood in prbc divided by specific gravity. the hb content in unit was estimated by the formula: hb content in unit = hb value of the prbc unit (g/dl) volume of prbc unit (dl). results: in this study the hb concentration (g/dl) was comparable among three types of blood donors except that rtvd had lower hb values when compared to rd (p = . ). hemoglobin concentration of prbc ranged from . - . g/dl; mean hb was . ae . g/dl. net hb content of prbc bag was lower in prbc prepared from rd as compared to ftvd (p = . ) and rtvd (p = . ). the hb content of prbc units prepared from ml collection ranged from . - . g and from ml collection ranged from . - . g. we observed a wide range of net hb content in the prbc units and the correlation coefficient showed the strongest association of net hb content of the prbc unit with the overall volume of prbc (r = . , p = . ).higher volume prbcs have more hb content. volume of prbc bags in the study ranged from ml to ml (including both and ml collections). summary/conclusions: the present study shows that labelling hb content of the prbc unit help in better inventory management for patients. the hb content may help in decision making for release of units for paediatric/low weight versus adults/ higher weight patients. adopting a policy of optimizing dosage of rbc transfusion could have the potential to significantly improve rbc utilization and decrease patient exposure to allogenic blood. this would help further in the clinical transfusion practices based on evidence. a-s - nv more, p desai, s rajadhyaksha, a navkudkar and n deshpande transfusion medicine, tata memorial centre, homi bhabha national institute, mumbai, india background: red blood cell (rbc) transfusion is an important medical therapy benefiting the patient in a wide spectrum of clinical setting. critically ill intensive care unit patients in particular, as well as medical and hemato-oncology patients, are among the largest group of the user of rbc. periodic review of blood components usage is essential to assess the blood utilization pattern in any hospital or health care set up. our institute is a bedded tertiary care oncology centre with approximately , to , rbc transfusions annually. these transfusions are required in various stages of patient treatment like chemotherapy, radiotherapy, surgical and palliative care and there are established guidelines by the institute to be followed by clinicians. aims: to study clinical practices of rbc transfusions based on indications and to evaluate appropriateness of rbc utilization practices at the institute. methods: this was a prospective observational study, started after approval from institutional ethics committee. total of rbc transfusion events in adult patients over a period of four months were included and analyzed as per institutional guidelines for their appropriateness. details of transfusion events in form of pre transfusion hemoglobin, indication of transfusion, type of request, number of unit requested and issued, time of issue, site of transfusion and adverse reactions, etc were obtained from department of transfusion medicine records. overall statistical analysis was descriptive using spss software. chi-square test in cross tables was applied to see the relationship between different variables and considered significant if p-value was < . . results: total rbc transfusion events for patients were analyzed. there were ( %) events in patients of medical oncology and ( %) in patients of surgical oncology. maximum transfusions were received by patients in age group of to years ( %). total % of transfusion events were appropriate as per institutional guidelines. all transfusions administered in operation theatre were found to be appropriate with p value < . . inappropriateness was more %( / ) and significant in daycare setup (p < . ). anemia was the most common indication of rbc transfusion observed in % of events ( / ). total % rbc transfusions were given as planned and % as urgent transfusions. most common adverse transfusion event observed was allergic reaction in . % of total transfusion reactions. summary/conclusions: clinical practice of rbc transfusions in our hospital was largely found to be appropriate and rational with adherence to institutional guidelines. blood utilization audits should be conducted regularly by transfusion services and results should be discussed with clinician for ensuring judicious use of the scarce resource. the concept of transfusion safety officer (tso) can be introduced for better coordination between clinicians and blood transfusion services to improve practices. a-s - paul-ehrlich-institut, langen, germany on a global scale, blood services are quite diverse in regard to aspects like organisational structure, regulatory background, donor populations, donation rates or pathogen epidemiology. the world health organization (who) recognizes blood and blood products as essential medicines and provides guidance to member states for various aspects like blood regulation, best practices in blood collection and transfusion, or screening parameters. more recently a who guideline on residual risk of transfusion associated infections has been established which may facilitate decision-making for the most appropriate screening algorithms. it emphasizes the need for regional evaluation of screening assays and regulatory control of blood-associated ivds. background: babesia, a protozoan parasite that infects red blood cells, is a leading infectious cause of mortality in u.s. transfusion recipients. babesia is usually transmitted through the bite of an infected tick but may be transfusion transmitted (tt) or transmitted from mother to child during pregnancy. babesiosis is a world-wide disease; the ticks that carry babesia have a global distribution. babesiosis has been reported throughout europe and in canada, korea, india, and japan. prospective testing of blood donations in endemic areas of the u.s. revealed . % of donors were positive for babesia dna or antibodies (moritz, nejm, ) aims: -to report results of ongoing babesia clinical trial -to explain significance of babesia as a tt infection methods: in cobas â babesia for use on the cobas â / systems, is a qualitative polymerase chain reaction nucleic acid amplification test, developed to detect in whole blood (wb) donor samples the babesia species that cause human disease: b. microti, b. duncani, b. divergens, and b. venatorum. testing began in october under a u.s. fda-approved investigational new drug application. wb was collected into a proprietary medium that lysed red blood cells and stabilized babesia rna and dna. donations were collected in states with high, low, and no babesia endemicity and screened as individual blood donor (idt) samples. reactive index donations were retested in simulated minipools of (mp ), plus idt replicates with cobas â babesia. reactive index donations were also tested with validated alternate babesia nat and for b. microti igm and igg antibodies. donors with reactive results were invited to enroll in a follow-up study to test for additional evidence of infection. results: to date, , valid donations have been screened with cobas â babesia, and ( . %) were reactive. of ( %) initially-reactive donations were confirmed to be positive for babesia with a positive alternate nat or serology result. of ( %) confirmed-positive donations was collected in a state with low babesia endemicity (pennsylvania), and ( %) was collected in a state where babesia is not considered endemic (iowa). of ( %) confirmed positive donations were collected in states with high endemicity. of ( %) confirmed babesia-positive donations were detected in late fall or winter. all ( %) confirmed babesia-positive donations were reactive in mp . serology results are available for of confirmed-positive donations: at index, of confirmed babesia-positive donations were only igg-positive, while none were only igm-positive; were positive for both igg and igm. of the confirmed-babesia positive donations were negative for both igg and igm antibodies. cobas â babesia showed an overall specificity of . % ( , / , ; % exact ci: . %> %). summary/conclusions: the cobas â babesia test successfully identified babesiapositive donations, including confirmed-positive donations with no igm or igg reactivity. donations were collected in states considered low-or non-endemic for babesia. confirmed-positive donations were collected outside of the summer babesia season, when most clinical cases occur. screening with cobas â babesia continues in several laboratories. cobas â babesia is not fda licensed or available commercially. background: babesiosis in humans is caused by the erythrocytic protozoan parasite, babesia microti which is transmitted by tick bites, but is also transfusion transmitted. although frequently asymptomatic or presenting with flu-like symptoms in a normal host, if immunocompromised infection can lead to severe complications and death. b. microti is endemic in the north eastern/upper midwest united states where partial testing of donations has been implemented. in canada, a study of~ , donors did not identify any b. microti antibody-positive samples, suggesting low risk at that time, but risk should be monitored. aims: to evaluate the prevalence of b. microti-positive donations in potentially atrisk areas in canada. methods: between july and november , , blood donor samples were selected from sites near the us border. minipools were tested for b. microti nucleic acid by transcription mediated amplification (tma) using the procleix â babesia assay on the panther â system with individual testing on reactive pools. reactive donations were also tested by b. microti-specific: american red cross (arc) igg immunofluorescence assay [ifa] and imugen ifa/pcr. a subset of , tma-negative samples, primarily from the province of manitoba and eastwards to nova scotia, were tested for b. microti antibody using the arc ifa and if positive, the imugen ifa/pcr. donor age, sex, donation status, residential location and collection site location were recorded. donors who tested reactive/positive were informed, deferred and asked about risk factors (possible tick exposure and travel within canada, the usa and elsewhere, history of symptoms) and a follow-up sample was requested for supplemental testing (tma, arc ifa). reactive donations were removed from inventory. results: the , donor samples were proportional to collections in target geographic regions. age group, sex and donation status were also similar to the donor base in the collection areas. one sample from winnipeg, manitoba was tma reactive and antibody positive on supplementary testing. the donor did not remember symptoms or spending time in wooded areas. he visited the city of fargo, north dakota, usa. the subset of , samples tested for antibody were also proportional to collections in the targeted areas. four antibody-positive samples were identified from mid-september to october , all in south western ontario near lake erie. none were tma reactive. three were interviewed and none remembered any symptoms, any likely tick exposure, or relevant travel within canada or the usa. summary/conclusions: this is the largest b. microti prevalence study in canada. the results indicate very low prevalence with only tma-confirmed-positive donation of , tested. the donor was from the only region in canada where one autochthonous human case has been reported and active tick surveillance identified b. microti positive tick populations. seropositive donations in south western ontario may suggest low prevalence in that region, but interpretation is less certain due to lack of corroborating supplementary results or case history. given the close proximity to the us border, forgotten us travel should not be ruled out. a-s - background: the protozoan parasite toxoplasma gondii is prevalent in animals and humans worldwide. wild and domestic felids are the definitive hosts, and homoeothermic animals serve as the intermediate ones. after primary infection, the parasite persists lifelong within latent tissue cysts. transmission is by ingestion of undercooked or raw meat infected with cysts, by ingestion of food or water contaminated with oocysts, or transplacentally. however, it can also be acquired by blood transfusion and organ transplantation. toxoplasmosis can be a severe disease in immunosuppressed people and neonates whose mothers have acquired primary infection during pregnancy. aims: there is no information about the specific epidemiology of t. gondii infection in blood donors in portugal. therefore, we sought to determine the seroprevalence of t. gondii and associated risk factors in the population of blood donors in portugal. methods: between september and july , blood donors who attended the portuguese blood and transplantation institute blood banks located in oporto, coimbra and lisbon, and also at regional blood collection meetings, were invited to participate in the study. a written informed consent was obtained and a questionnaire about socio-demographic and behavioural variables was answered. sera were assessed for igg antibodies to t. gondii by a modified agglutination test (mat) commercial kit (toxo-screen da â biom erieux, lyon, france). results: of the blood donors (mean age . ae . ; range - years old), . % were positive for antibodies to t. gondii. when questioned about toxoplasmosis, almost half the blood donors did not have any knowledge about the disease. the centre of portugal had the highest seroprevalence ( . %) followed by the north ( . %) and the south ( . %). blood donors living in rural areas had a significantly higher seroprevalence (p = . ) than those living in urban areas. seroprevalence increased with age, with the highest seroprevalence ( . %) found in the age group of - years old (multiple logistic regression [mlr]: or = . ; ci: . - . ; p < . ), and decreased with educational level (p < . ). engaging in soil-related activities (gardening or agriculture) was significantly related to t. gondii seropositivity (p = . ). regarding water consumption, untreated sources (even though including mineral and tap water) was confirmed as a risk factor (mlr: or = . ; ci: . - . ; p = . ). other behavioural and eating characteristics, including cats in the household, eating raw or undercooked meat, processed pork products, or not washing raw fruit and vegetables before eating, were not associated with t. gondii infection. summary/conclusions: the risk of t. gondii transmission through blood transfusion is low, and serologic testing of antibodies, with exclusion of blood donors, appears not to be feasible. immunosuppressed individuals, organ transplant patients and pregnant women, should receive t. gondii antibody-negative blood components for transfusion. this study explored the epidemiology of t. gondii in portugal thus providing useful information on the seroprevalence and potential risk factors for t. gondii transmission. information regarding toxoplasmosis and its prevention could be promoted by medical and public health authorities among blood donors, and also the general population, when addressing policies, and designing screening programs, for monitoring and controlling infection and disease in portugal. a-s - who is syphilis testing excluding? c reynolds , c pearson , k davison and s brailsford nhsbt/phe epidemiology unit, nhs blood and transplant nhsbt/phe epidemiology unit, public health england, london, united kingdom background: screening for treponemal antibodies to detect syphilis in blood donors has been in place in england since the s. there have been no reported syphilis transfusion transmissions in england since records began in part due to sensitivity of the organism to cold storage. since we have specific tests in place for other sexually transmitted infections such as hiv and hepatitis b virus (hbv), the utility of syphilis screening is often questioned. however, it may be a useful proxy for higher risk behaviours particularly following shortening of deferrals for higher risk sexual behaviours from to months in november and against a background of increasing infectious syphilis in the general population. aims: here we describe the epidemiology of recently-acquired syphilis in blood donors in england compared with hiv and acute hbv infection between and . methods: monthly donation testing results are collected from the nhs blood and transplant (nhsbt) screening centres and reference laboratory. the demographics, possible sources of infection, and compliance to donor selection in confirmed positive donors are collected by proforma at post-test discussion with the nhsbt clinical team. recent syphilis is classified as igm positive and/or recent history including a negative donation within months for regular donors. results: between and there were recent syphilis cases, hiv and acute hbv infections identified by donation screening. recent syphilis rates per , donations increased from . to . whereas hiv decreased from . to . with less than positive donations in . acute hbv rates rose slightly from . to . in . males outweighed females accounting for . %, . % and . % of cases of recent syphilis, hiv and acute hbv respectively. nearly a quarter of cases of recent syphilis and hiv were seen in donors below years old. of the male donors with recent syphilis, . % reported sex between men and women (sbmw), . % sex between men (sbm) and . % did not report a risk. this contrasted with hiv where . % of male donors reported sbm, just . % not reporting a risk. overall , and males with recent syphilis, hiv or acute hbv respectively were non-compliant to the sbm deferral in place at the time of donation. in , donors with recent syphilis aged - years (median years) were excluded from the donor pool, including non-compliant to the sbm deferral. there were fewer than hiv cases identified in , all over years old, all compliant, reporting sbmw. of the hbv acute cases in , were male, all but one in the and over age-group. summary/conclusions: over the year period demographics of recent syphilis cases appeared similar to hiv with highest rates in young males, albeit lower proportions reporting sbm. following the switch to a month deferral, hiv case detection continued at low level, while syphilis screening continued to exclude higher numbers spanning all age-groups, potentially at risk of other sexually transmitted infections, including non-compliant donors. background: globally, an estimated million blood donations are given annually. in the blood service we are obliged to monitor donor health and ensure that blood donation is safe. in recent years, large-scale blood donor cohort studies in several countries have increased our knowledge on health effects of blood donation. health concerns relate both to immediate side effects like fainting and to possible long-term health issues related to repeated blood or plasma donation. the studies have provided us with data that can now help us introduce an evidence-based individualised donor care -a parallel to personalised medicine. individualised donor care in the management of iron depletion: studies have shown that a large percentage of our frequent whole blood donors, especially young women, are iron depleted. iron depletion is a strong predictor of deferral for low haemoglobin but has also been associated with e.g. restless legs syndrome and lower birth weight in children of frequent donors. the risk of iron deficiency can be mitigated by ferritin-guided prolongation of interdonation intervals or by iron supplementation. prolongation of interdonation intervals can challenge our inventories. iron supplementation, on the other hand, may give gastrointestinal side effects and other effects have been proposed as well, e.g. the masking of malignant disease and increased iron availability with subsequent risk of infection. in a large study we found that iron supplementation is not associated with increased risk of infection. what is the optimal balance between iron supplementation and prolongation of interdonation intervals? a growing number of blood services have implemented various flavours of iron management regimens generating more results. moreover, genetic studies in e.g. the uk, us, holland, and denmark can help us to find donors at high risk of iron depletion or low haemoglobin. we can use all these data in a big data approach in the pursuit of an individualised risk assessment model. other risks for blood donors: the presentation will also cover other risks associated with donation. new studies identify predictors of fainting after blood donation and also new interventions to prevent fainting. the global demand for plasma derived medicinal products has increased severalfold the last years. plasma donors are bled up to times per year in the us. very little is known about the health effects of frequent plasma donation. we know that immunoglobulin levels decrease with frequent donation but how does this affect health? summary/conclusions: the precautionary principle mitigates risk through early intervention prior to evidence. we tolerate next to no risk of transfusion-transmitted infectious diseases. the health of the blood donors, however, has not been protected similarly. we owe to our whole blood and plasma donors to investigate health effects of blood donation and ensure their safety. while the first attempts may not be perfect, we now have the tools to construct models for individualised donor care. background: in , the isbt, aabb, ihn and eba jointly issued the standard for surveillance of complications related to blood donation which categorized donor adverse events (dae) into categories ( subcategories) defined by specific criteria. severity and imputability were briefly described but were optional. subsequent validation of these categories demonstrated consistency in categorizing reactions, but wide variation in assignment of severity. in , with international input, the aabb donor biovigilance committee developed a severity grading tool (sgt) using a recognized medical adverse event grading system in which neutral grades replace subjective terms (mild, moderate, severe). aims: a large us blood collection establishment (bce) applied the draft sgt to assess its use in real cases of dae. methods: we performed retrospective analysis of all allogeneic and apheresis needle-in donations between / / to / / . severity grading was assigned based on criteria defined by the sgt. database review of dae was performed, and each event was assigned a grade based on the type of outside medical care (omc), and on specific key search terms. search terms for omc included emergency room, emergency medical response, urgent care, healthcare professional, and hospital admission. additional specific key search terms included fracture, concussion, laceration, dental injury, surgery, and hospitalization. since duration and activities of daily living (adl) limitations were not captured in our dae database, cases in our dae claims' database were reviewed. case files of events classified as grade or higher were individually evaluated by a physician for grading accuracy. results: in , , needle-in collections, , dae were graded for severity. the majority ( , , . %) were vasovagal reactions (vvr), followed by , apheresis-related ( . %), , needle-related ( . %) and allergic ( . %) events. the majority of dae were grade accounting for . % of all dae, followed by grade ( . %), and grade ( . %). there were grade and no grade dae. among the vvr, . %, . %, . % and . % were grade , , , and respectively. grade vvrs included concussions, fractures, dental injury, and pre-faint and fainting events requiring hospitalization for work-up. two grade vvrs involved falls resulting in intracranial hemorrhage requiring immediate medical intervention. for allergic and apheresis dae, there were only and grade reactions respectively, and no grade or events. needle-related dae included . % grade , . % grade , . % grade , and no grade events. of the six grade needle-related dae, were nerve irritations lasting > months, and were dvts requiring hospitalization. summary/conclusions: the sgt provided consistent assignment of severity for the majority of dae, based on outside medical care and specific key search terms. assignment of severity based on impact on activities of daily living or on duration of injury/condition requires tracking over time making such assignments more difficult; modification of our dae tracking database and claims database to capture adl and duration should improve severity assignment for such cases. background: the international haemovigilance network (ihn) has collected aggregate data on complications of whole blood and apheresis donations from member national haemovigilance systems (hvs) since . aims: we analysed the data collected in - in order to learn from the data and consider future improvement of data collection. methods: national hvs entered annual data on donor complications in the passwordprotected "istare" (international surveillance of transfusion adverse reactions and events) online database. from the donor complication spreadsheet allowed entry of separate data for whole blood donation (wbd) and apheresis, but also provided an option for entering data for all donation types. annual numbers of whole blood and apheresis donations were also collected. the harmonised international standard definitions were implemented in . reactions were captured according to severity level (mild, moderate, severe) but without distinction between donor sex or first time vs repeat donation. extracted data were used to calculate national and aggregate donor complication rates (generally per donations). results: twenty-four hvs provided figures for donations and donor complications for one or more years (median years per country was , iqr - ). the total number of country years (cy) was , covering million donations. the overall complication rate was . / donations and the median country rate was . complications/ donations (iqr . - . ). rates were generally consistent within a hvs from year to year but showed considerable variation between hvs; this was also the case for reactions classed as severe. not all countries differentiated between mild and moderate reactions and some reported all reactions under a single severity level. vasovagal reactions were the most commonly reported complication: overall . / donations, median country rate . / donations (iqr . - . ). rare and apheresis-related types of complications such as generalized allergic reaction ( . per , , cy), and major blood vessel injury (category available since ; overall . per , , cy) were only reported occasionally. eighteen of the hvs provided separate data for complications of whole blood and apheresis donations in one or more years (total cy, . million wbd and . million aphereses, total million donations). for these hvs the median rate of vasovagal reactions was . / wbd (iqr . - . ) and . / apheresis procedures ( . - . ) . reported haematoma rates were higher for apheresis than for wbd: the median per hvs was . / wbd (iqr . - . ) vs . / aphereses ( . - . ); rates of arm pain and/or nerve injury (not separated in - ) also tended to be higher: median . / with wbd, iqr . - . , vs . / with apheresis, . - . . summary/conclusions: international reporting allows hvs to study rates of blood donation complications, to distinguish between wbd and apheresis complication rates and capture information about very rare events. variability of reporting and of severity assessment between countries impairs the feasibility of comparisons between hvs. work is needed to improve harmonisation of classification of donation complications and severity assessment for data comparison and research. background: to prevent iron related hb loss, screening with ferritin testing was implemented in stockholm county (approx. registered blood donors) during a two-year roll-out. iron supplementation is offered to blood donors but has not prevented hb deferrals resulting in control visits per year. ferritin testing is hypothesized to increase iron compliance. aims: implementation of ferritin testing for surveillance of iron levels for the entire blood donor population with specific attention to new donors, women returning after pregnancy, donors with low hb and at return visit after low hb. yearly testing of plasma and platelet donors. methods: ferritin testing, following a staff education program, was implemented for applicant donors, donors with low hb, women after pregnancy, apheresis donors, followed by screening of registered blood donors per donation site. after initial screening, donors will be tested at each th (women) or th (men) donation, and with yearly testing of young adult blood donors below years. six nurses were educated to process ferritin and blood count results. donors with aberrant ferritin were contacted by letter. results: establishment of cut-off levels and algorithms for ferritin testing and iron treatment was evidence based but met practical limitations such as number of analyses and results that could be processed per week, limitations in liss set-up, blood demand contra preferred cut-offs, iron supplementation compliance. for applicant donors, hb testing show that % of female and % of male applicants cannot be registered because of low hb ( and mg/l respectively). adding ferritin testing, a preferred cut-off level of lg/ml (male reference level), would result in additionally % female and . % male applicant donor loss. as this would threat the blood demand, cut-off was set to lg/ml for women, above the female reference lg/ml, with an acceptable % loss of female applicant donors. for registered blood donors, mg of extra iron tablets were offered at low ferritin ( - lg/ml). this was sometimes combined with prolonged intervals and often repeated before ferritin was restored above lg/ml. donors with ferritin below lg/ml (in . % applicant donors, . % registered donors) or above lg/ml ( . % applicant donors, . % registered donors) were deferred and recommended to see their physician. for hb deferral, the interval was prolonged from to months, irrespective of ferritin levels. this, together with iron supplementation, resulted in an increase from % to % approved hb at return. the team of nurses processing ferritin and blood count results ( ½ nurse fulltime weekdays) reacted to approximately donor results daily, representing % of test results. summary/conclusions: many female donor applicants have suboptimal ferritin levels although they meet required hb for donation. iron treatment was added to retain donors with low ferritin as only prolonged intervals may danger the blood supply. for implementation of ferritin testing, it is necessary to have a well-functioning and agile organization to create and apply algorithms for testing, extension of intervals and iron treatment. background: since november a new donor screening regime is introduced in the netherlands where serum ferritin levels in whole blood donors are measured periodically to further control potential iron deficiency in donors. donor deferral thresholds are set at and ng/ml, and donors are deferred for six and twelve months respectively if ferritin levels are below these values. as limited information is available on ferritin recovery in whole-blood donors, the policy is introduced in parts such that adaptations to the implementation may be considered based on intermediate results and the impact of the measure on donor well-being can be evaluated. aims: to assess the effect of donor deferral on donor ferritin levels. methods: ferritin levels are measured in new donors and at every fifth donation in repeat donors. donors with ferritin levels below the indicated thresholds are deferred and ferritin is re-evaluated at their return for donation after six or twelve months. the policy allows estimating long term trends in ferritin levels post donation in repeat donors. as ferritin levels are measured in all new donors a reference distribution of ferritin levels in healthy individuals is obtained as well. results: among repeat donors % ( % of , male donors, and % of , female donors) have ferritin levels below ng/ml and are deferred for their next donation. furthermore, the distributions of ferritin levels in repeat male and female donors are similar and each has an average ferritin level of ng/ml. in contrast, we found that only % of new female donors (n = , ) and . % of new male donors (n = , ) have a ferritin levels below ng/ml. the average ferritin level in new donors was ng/ml for males and ng/ml for females. comparing the ferritin levels in new and repeat donors, a reduction in average ferritin levels between . and . was observed in female donors and between . and . in male donors. both ratios increased with donor age. at the end of december donors with low ferritin levels returned for donation after six or twelve months deferral. repeat ferritin measurements show that on average the ferritin levels in female donors increased by ng/ml per year whereas average ferritin levels in male donors increased by ng/ml per year. summary/conclusions: in line with earlier findings in literature our results show that repeat donations substantially reduce ferritin levels in repeat donors. these range from . to . in female and from . to . in male donors, who generally have higher ferritin levels. deferral of donors with low ferritin levels seems to be effective in increasing ferritin levels in donors, however, further monitoring of follow-up in repeat donors is warranted to see whether the proposed scheme allows for sufficient donor recovery over time. there are~ different rare diseases and the genes for half have been identified. approximately . million uk citizens experience premature ill-health because of a rare disease. a conclusive diagnosis is generally not reached and on average the diagnostic odyssey lasts . years. the main aims of the , genomes project are to reduce the diagnostic delay by embedding whole genome sequencing (wgs) to accredited standards in the care path of patients with undiagnosed rare diseases. the project started in and dna samples from , nhs patients and their close relatives have been analysed by wgs. here we review the results from the nihr bioresource pilot study for the , genomes project comprising phenotype and genotype data from , individuals recruited at hospitals using approved eligibility criteria for rare disease domains. we determined the population structure including ethnicity and relatedness estimation, high level phenotypes collected using human phenotype ontology (hpo) terms and quality control and summary metrics for samples and variants. the sequence resource contains over million unique variants in the , genetically independent samples, with % of variants previously unobserved in other large scale publicly available genome datasets. we summarise the curation of gene lists and pertinent findings in , unique diagnostic-grade genes for the domains. over , reports assigning pathogenic or likely pathogenic causal variants have been issued with diagnostic yields varying between domains from . % to %, while the proportion of novel causal variants ranged between % and %. we show the power of the bayesian association test, bevimed, to recapitulate decades of clinical genetics discoveries and by identifying > novel genes and novel diseasecausing variants in the non-coding space of the genome. we show how typing data for all red cell, hpa and hla class antigens can be extracted from wgs data. we mined the data from the , genomes project and similar sequence resources to re-version the probe content of the uk biobank axiom array. we genotyped donors from england and the netherlands with this new array and observed a . % concordance when comparing , blood centredetermined antigen typing results with genotype-determined ones. for the red cell and hpa antigens that were available for , donors, the array typing provided a . -fold increase in typing results per donor ( . vs . ) and rare donors were identified. using the genotyping data we identified . times more compatible units among this cohort of donors when blood demand was modelled using referral data from , english patients with more than three red cell alloantibodies. in conclusion the , genomes project has shown the feasibility of using wgs across a universal healthcare system to deliver a diagnosis for patients with rare diseases. based on these results the nhs has commissioned the analysis of another , dna samples from patients with cancer and rare disease. with analysis of dna by wgs and arrays becoming part of routine clinical care, blood services must develop competencies to extract transfusion and transplant relevant information from clinical-grade genotyping data. next-generation sequencing (ngs) enables the sequencing of thousands of genes, the exomes, and even entire genomes by single experiments at a reasonable price. there have also been advances in cytometry: use of antibodies with different fluorescence tags enables simultaneous monitoring of the expression of dozens of antigens. however, immunological methods cannot detect every variant discovered by ngs. genome sequencing reveals not only the exome but also the regulatory elements of transcription/translation, such as promoters and enhancers. rna sequencing determines which genes and spliced transcripts are expressed. it is amazing to realize how much this novel technology has been contributing to the better understanding of various biological phenomena. since the initial cloning of the human blood group a transferase cdnas in the early s, we have been studying the abo genes, a and b glycosyltransferases, and a and b oligosaccharide antigens. various scientific disciplines including genetics, immunohematology, biochemistry, enzymology, and glycobiology have been applied to their study. we have made several important scientific contributions. we demonstrated the central dogma of abo: the a and b alleles at the abo genetic locus encode a and b transferases, which synthesize a and b antigens, respectively. we elucidated the allelic basis of the abo system. we found amino acid substitutions between a and b transferases and inactivating mutations in o alleles. we became the first who succeeded in the abo genotyping, discriminating the aa and ao genotypes, as well as the bb and bo, which was impossible by the immunological approach. we have taken a simple experimental strategy: preparation of eukaryotic expression constructs of a/b transferases and their derivatives, dna transfection to human hela cells or their sublines, and immunological detection of the a/b antigen and/or biochemical examination of the enzymatic activity. we used this to show that the codons and are crucial in determining the sugar specificities of galnac/galactose of a/b transferases. we also identified mutations in several subgroup alleles causing restricted substrate use and diminished transferase activity. we also showed that cis-ab and b(a) alleles specifying the expression of both a and b antigens by single alleles encode a-b transferase chimeras. since then, other scientists have characterized more than abo alleles. recent human genome sequencings have identified many more single nucleotide polymorphism variations. the genome sequences of many species are also available. taking advantage of those sequences and associated information, we have expanded our research to include evolutionarily related a , -gal(nac) transferases and their genes and scaled it up from the genetic to genomic level. in this talk, i would like to present the followings. : our elucidation of the molecular genetic basis of the abo blood group system (as requested by the organizer); : identification of novel abo alleles by others; : more snp data from genome sequences and potential problems for abo genotyping; : findings obtained from analysis of abo genes from other species; bacteria, vertebrates, to primates; : a , -gal(nac) transferases and their genes and the crosstalk between a transferase and forssman glycolipid synthase (fs); and : the potential causes of generation of abo polymorphism and of species variations of the gbgt gene specifying the fors polymorphism. in recent years, there has been a concerted effort to improve our understanding of the quality and effectiveness of transfused blood components. the expanding use of large datasets built from electronic health records allows the investigation of potential benefits or adverse outcomes associated with transfusion therapy. together with data collected on blood donors and components, these datasets permit an evaluation of the effect of donor and blood component factors on transfusion recipient outcomes. large linked donor-component recipient datasets provide the power to study exposures relevant to transfusion efficacy and safety, many of which may not otherwise be amenable to study for practicality or sample size reasons. analysis of these large blood banking-transfusion medicine datasets allow for characterization of the populations under study and provide an evidence base for future clinical studies. knowledge generated from linked analyses has the potential to change the way donors are selected and how components are processed, stored and allocated. however, unrecognized confounding and biased statistical methods continue to be limitations in the study of transfusion exposures and patient outcomes. results of observational studies of blood donor demographics, storage age, and transfusion practice have been conflicting. this review will summarize statistical and methodological challenges in the analysis of linked blood donor, component, and transfusion recipient outcomes. c-s - a large deletion spanning xg xg and gyg gyg constitutes a genetic basis of the xg null phenotype, underlying anti-xg a production background: the xg blood group system comprises the homologous antigens xg a and cd . the cd gene resides within pseudoautosomal region on the short arms of the sex chromosomes and thus mimics autosomal inheritance. xg, on the other hand, is x-linked and straddles the pseudoautosomal boundary; a truncated pseudogene composed of only the first exons remains on the y chromosome and therefore males carry a sole full-length copy of xg. this phenomenon manifests as asymmetric frequencies of the xg(a+) phenotype between the sexes: roughly % of women and % of men are xg(aÀ). also, whilst xg a immunization is rare, the vast majority of all anti-xg a makers reported are men. recently, we reported that the rs c variant disrupts a gata motif between xg and cd . this abolishes erythroid xg a expression and causes the common xg(a-) red cell phenotype. however, rare individuals who produce anti-xg a cannot be accounted for by this finding. we hypothesized that a structural defect in the xg coding region causes the true xg null phenotype underlying anti-xg a production. aims: we undertook to determine a genetic explanation for anti-xg a production. methods: genomic dna (gdna) was extracted from two whole blood samples and cell-free dna (cfdna) from archived plasma samples from donors producing anti-xg a ; one cfdna sample was from a female donor and the rest from males. polymerase chain reaction (pcr) experiments, sanger sequencing, and database searches were performed to identify and confirm the deletion. aliquots of gdna from four males reported to carry a similar deletion in the genomes project were also tested. results: in one gdna sample, exon-specific pcr identified a deletion involving part of xg and the downstream gene gyg . database searches indicated that the most likely deletion was the infrequent genomic structural variant esv reported in the genomes project. further analyses with a short ( bp) and a long ( bp) pcr amplicon across the suspected breakpoint determined that this deletion was approximately kb and corresponded well with esv . this finding was confirmed in the second gdna sample. given the rarity of anti-xg a producers, we decided to test for the same deletion in cfdna extracted from old archived plasma samples. of the cfdna samples, poor quality in four samples prevented amplification even from control reactions and one was contaminated with bacterial dna. in the remaining nine samples, eight could be amplified for the deletion-specific -bp short amplicon while one was negative for the deletion. sanger sequencing of the amplicons revealed a heterogeneous repetitive dna element, ltr b, hinting at a previously-reported recombination event. this deletion was not detected in the samples from the genomes project which reiterates the previously identified deficiency in data interpretation and reporting for deletions. summary/conclusions: a large deletion disrupting the xg and gyg genes accounts for the xg null phenotype underlying the majority ( of ) of anti-xg a makers. one sample remained unexplained, indicating further heterogeneity to be explored. our data help to explain why anti-xg a production is rare and has primarily been reported in men. background: s and s antigens encoded by gypb differ by one nucleotide (nt), c. c>t, p.thr met. two different genetic backgrounds are associated with silencing of s antigen and a u+ w phenotype. these include the nt change c. c>t (p.thr met) causing partial exon skipping and designated gybp* n. (gypb*ny) and c. + g>t, an intron change causing complete skipping of exon , designated gypb* n. (gypb*p ). aims: samples from three individuals, a previously transfused african american sickle cell patient (p ), a blood donor of unknown ethnicity (p ), and an african american patient (p ) (lapadat r. aabb abstract) were investigated for discrepant serologic and molecular results when determining s and s phenotype. methods: standard methods were used for rbc typing with licensed s and s reagents and rbcs from donor p were also tested with monoclonal and polyclonal anti-s and anti-s. dna was isolated from wbcs and hea precisetype performed on p and p . p was also tested by gypb*s/s as-pcr, exon pcr-rflp for c. + g>t and as-pcr for c. c>t. p was tested for gypb*s/s and c. c>t and c. + g>t changes by a real-time pcr-fluorogenic ' nuclease taqman chemistry. for all, gypb exons - were amplified and sanger sequenced and aligned to consensus using clustal x. results: rbcs of all three probands typed s-and strongly s+ while dna testing indicated c. t/c (gypb*s/s). assay for the two common gypb*s silenced alleles, c. c>t and c. + g>t, indicated all three samples had both silencing mutations previously reported to be independently associated with a sÀu+ w phenotype. hea precisetype could not interpret this novel allele combination and indicated gypb*s as pv (possible variant). samples were confirmed to be heterozygous for c. c/t, c. c/t and c. + g/t by exon specific sequencing and as-pcr, pcr-rflp and real-time pcr. by long range sequencing of gypb, all three were heterozygous c. t/g and c. a/g (p. leu/trp), c. a/t (p. thr/ser), c. a/g and c. g/t (p. glu/gly), c. c/t (s/s), c. g/t (p. val/leu), c. c/t (p. thr/met), and c. + g/t. all samples were also c. g/g (p. ser) and heterozygous for several previously recognized silent changes in exon , c. t/c, c. t/c and c. a/g. summary/conclusions: we report a novel silenced gypb*s allele that can confound gypb genotyping interpretation. the allele was found in three probands associated with a sÀs+ phenotype. in these samples, two changes previously reported to be inherited independently and both associated with silencing of s antigen are carried on the same allele. dna-based testing could not rule out that c. t or c. + t are separate and that gypb*s was also silenced. robust s+ rbc typing indicates both changes are on gypb*s. gene sequencing confirms the c. + t change is on a gypb* n. [gyp*he(ny)] background. c. c>t (rs ) and c. + g>t (rs ) have a frequency of . respectively . in the african population (exac). although we identified samples, the frequency of this novel allele is unknown. background: the lutheran blood group system currently consists of antigens. these antigens are of low immunogenicity and may cause mild-to-moderate transfusion reactions and hemolytic disease of the fetus and newborn. the activation of lu-glycoprotein/bcam on red blood cells (rbcs) and its interaction with laminin- a is thought to play a role in vaso-occlusion in sickle cell disease and other hematological disorders. the two glycoprotein isoforms lu-glycoprotein and bcam are encoded by the bcam gene which consists of exons located on chromosome q . . a number of rare lutheran phenotypes have been previously recorded in israel, including lu:- , observed among iranian jews, lu:- in one thalassemia patient and one case of lu:- . in this report, a previously transfused pregnant arab patient with b-thalassemia intermedia was investigated because she presented with an antibody to an unknown high frequency antigen (hfa), potentially related to the lutheran system. aims: to characterize a novel lutheran antigen through serological and molecular investigation of a patient with a lutheran related antibody. methods: initially, the red cell phenotype and the presence of a lutheran related antibody in the serum of the patient were detected by standard serological techniques, utilizing enzyme treated and chemically modified cells and rare cells and sera from the nbgrl collection. further serological investigations were carried out using standard iat (liss tube and bio-rad gel) technique. plasma inhibition studies were performed using soluble recombinant lu protein (srlu). eluates were prepared using acid elution method (gamma elu-kit ii). genomic dna was isolated from whole blood and all exons of the bcam gene were amplified by pcr and directly sequenced by sanger sequencing. the impact of the identified mutation on lutheran glycoprotein structure was studied by molecular dynamics calculations. results: the patient's plasma reacted with all cells tested, except for three examples of in(lu) cells and cells treated with -aminoethylisothiouronium bromide, trypsin and a-chymotrypsin. inhibition studies with srlu protein showed complete inhibition of the antibody, thereby confirming the antibody to be directed toward an epitope on the lu-glycoprotein. in addition, testing of inhibited plasma revealed the presence of underlying anti-e and anti-fy a . an eluate was prepared to isolate the patient's lu-related antibody and this eluate was found to be incompatible with examples of lu:- , lu:- , lu:- , lu:- , lu:- , lu:- , and lu:- cells, whereas in(lu) were compatible. results of serological typing of the patient's cells, for lu system hfas, could not be conclusively determined due to the patient having been recently transfused. however, results suggested (through absence of mixed field reactivity) the patient's cells to be lu: - , , , , ,- , . bcam sequence analysis confirmed the patient to be lu* , lu* and revealed a novel homozygous mutation c. a>c in exon , encoding p.lys gln in the lutheran glycoprotein. summary/conclusions: a novel homozygous mutation c. a>c (p.lys gln) in exon of bcam was identified in a patient with an antibody to a lutheran hfa. serological and genetic evidence presented here indicates discovery of a novel antigen of the lutheran blood group system, which we propose to name lura. background: lutheran glycoprotein and basal cell adhesion molecule antigen b-cam are two isoforms of a type i membrane glycoprotein residing on red cell surfaces. both isoforms are adhesion molecules with the main function of laminin binding, and both carry antigens of the lutheran blood group system (lu). the system currently comprises antigens, all encoded by mutations in the alternatively spliced single gene bcam located on chromosome . currently, isbt lists high incidence antigens in the system. aims: we report a case study of an individual with an unidentified alloantibody to high incidence antigen present in her plasma. samples from the patient and her family were investigated. we provide here serological and molecular evidence for a novel high incidence antigen of the lutheran blood group system. methods: serological investigations were performed by standard iat (liss tube and bio-rad gel) technique. plasma inhibition studies were completed with soluble recombinant lu (srlu) protein. genomic dna was isolated from whole blood of the patient and her family members; all the exons of the bcam gene were amplified by pcr and analysed by direct sanger sequencing. the impact of the identified mutation on lutheran glycoprotein structure was studied by molecular dynamics calculations. results: presence of a lu-related antibody in the patient's plasma was confirmed, reacting moderate strength by liss iat with untreated and papain treated cells. cells from the patient's mother, father and two siblings were all incompatible with her plasma, though weaker than panel cells, reflecting dosage. only in(lu) cells were compatible with patient's plasma. the antibody was successfully inhibited with srlu protein, thereby confirming the epitope recognised by the antibody resides on the lutheran glycoprotein. the patient's cells were found to be lu: - , , , , , , , , . bcam sequencing revealed a novel homozygous mutation c. g>a in exon , encoding p.val met in the lu glycoprotein. the c. g>a change appears to be an extremely rare mutation, listed in gnomad database with a frequency of . - and with no known homozygous examples. homology model of the novel lutheran glycoprotein was subjected to all-atom molecular dynamics calculations to analyse potential conformational changes. summary/conclusions: we report serological and genetic evidence for a novel antigen of the lutheran system, which we propose to name lunu. the evidence will be submitted to the isbt red cell immunogenetics and blood group terminology working party for consideration for allocation of antigen status. the absence of this high incidence antigen arises from a rare single amino acid change p.val met in the lutheran glycoprotein and the presence of anti-lunu in the patients' plasma was presumed to have been made in response to previous pregnancy. on native, papain-treated (diagast) and trypsin-treated (sigma) rbcs. genomic dna was extracted from peripheral blood cells by an automated method, amplified by sema a exon-specific primers and sequenced. results: the proband was a -year-old female patient of moroccan origin, group a, d+c+e-c+e+, k-, without transfusion history. she was hospitalized at weeks gestation for a blighted ovum requiring a manual vacuum aspiration, with a significant hemorrhage risk. a rbc antibody screening was performed by a first laboratory. the antibody reacted + by iat on all native reagent rbcs, with negative autocontrols, but was nonreactive on papain-and trypsin-treated cells. an anti-ge was initially suspected, due to the pattern of reactivity and ethnic background. new blood samples were referred to our national immunohematology reference laboratory. the antibody showed the same profile. anti-ge and anti-ch could be ruled out. the serum was nonreactive with two jmh:- and positive with two jmh:- samples. the patient was found to be jmh positive. in addition, a soluble recombinant jmh protein (jmh imusyn/inno-train) fully abolished the reactivity of the panagglutinating antibody. the antibody was an igg . overall, these results were consistent with a probable jmh variant and prompted us to perform sema a sequencing. three nucleotide changes were found, in homozygous state: a rare nonsynonymous change in exon , c. g>a (p.asp asn, rs , maf < . , sift score = ); a common synonymous change in exon , c. a>g (p.gln gln, rs , maf = . ); a rare non-synonymous change in exon , c. g>a (p.arg his, rs , maf < . , sift score = . ). the analysis of surface accessibility of asp and arg using the d structure of sema a (rcsb pdb- nvq https://www.rcsb.org/structure/ nvq) showed that only arg was predicted to be an exposed-epitope. interestingly, all other reported jmh variant phenotypes correspond to an arginine substitution. of note, we retrospectively found another individual of algerian ancestry (pregnant woman) with a pan-agglutinating igg antibody showing a similar pattern of reactivity, and with the same three changes in sema a. we unfortunately could not perform a cross-compatibility testing with the proband (no material left and unsuccessful contact). summary/conclusions: serological and molecular studies allowed us to provide evidence for a novel high-prevalence antigen in the jmh blood group system, very likely encoded by the p.arg his substitution in sema a. we propose to provisionally assign the name jmh for this antigen. interestingly, our two unrelated jmh:- individuals were from north african ancestry. background: the abo system was discovered almost years ago and the underlying structures later elucidated as carbohydrates carried by glycoproteins and glycolipids. the terminal trisaccharides galnaca (fuca )gal and gala (fuca )gal constitute the clinically important a and b epitopes, respectively. clausen et al. (pnas, ) showed that the a antigen could be extended to a repetitive glycolipid a epitope, galnaca (fuca )galb galnaca (fuca )galb glcnac-r. however, extended forms of b antigen have not been described. we encountered two related situations with unexplained serological reactivity. firstly, enzyme-conversion to group o treatment of group b (b-eco) red blood cells (rbcs) with a -specific gh family exogalactosidase (bzyme) abolishes b antigens as detected by hemagglutination and flow cytometry with all monoclonal anti-b tested. despite this, % of group o plasmas have been reported to give positive crossmatch results with b-eco rbcs. secondly, plasmas from ab and b individuals of the globoside-deficient p k phenotype contain anti-p and anti-px but react stronger with bpp-rbc than with app/opp-rbc. based on these findings, we hypothesized the presence of a bzyme-resistant, b-related glycolipid. aims: to identify the molecular basis of the enigmatic serological observations outlined above. methods: plasma and eluates from an a b individual with the p k phenotype were investigated by hemagglutination and flow cytometry, as were eluates from b p k and o plasma. rbc membrane glycolipids were extracted from two batches of pooled, expired group b-rbc units (frozen -litre reference preparation and confirmatory preparation from freshly collected units). native or enzyme-treated glycolipid fractions were analysed by liquid chromatography electrospray ionizationmass spectrometry (lc-esi/ms) and immunostaining of thin layer chromatography (tlc) plates. antigen expression in the h+bÀ human erythroleukemia (hel) cell line was analysed by flow cytometry following overexpression of selected glycosyltransferases. results: anti-p-depleted eluates made from a b p k plasma contained anti-px and antibodies of unknown specificity that reacted stronger with native or papaintreated bpp-rbcs compared to app/opp-rbcs. anti-px was removed by adsorption onto opp-rbcs but reactivity (here designated anti-extb) remained against b/bpp/b-eco rbcs. lc-esi/ms of glycolipid fractions from group b units revealed an unknown hexnac-hex-(fuc-)hex- hexnac-hex- hex heptasaccharide. upon b-nacetylhexosaminidase treatment of this candidate structure, a group b type hexasaccharide was produced, demonstrating that the terminal hexnac of the hexnac-gala (fuca )galb glcnacb galb glc heptasaccharide was b-linked. since the discovery of the anti-platelet effects of aspirin platelets have been a major therapeutic target for pharmaceutical companies and also a very profitable target. however, the effectiveness of aspirin has also been a challenge as it is an inexpensive drug and any new agent needs to show clear benefit over aspirin. furthermore the risk of bleeding from anti-platelet agents, especially cerebral bleeds, has also presented challenges. in the 's orally active gpiib/iiia antagonists were considered to be the 'super aspirin' but clinical trials showed increased mortality and ultimately this class of drugs was relegated to iv use only in high-risk patients. gpib/ix/v antagonists were also a promising drug target but no agent made it to market. the real breakthrough was the discovery of the p y antagonist clopidogrel which, in conjunction with aspirin, proved to be very effective at preventing thrombotic events and as a result it became the biggest selling drug in the world at the time. with clopidogrel now offpatent the combination of aspirin and clopidogrel is a formidable challenge to any new agent both in efficacy terms and pharmacoeonomic terms. so is there a future for new anti-platelet agents? with the growing awareness of the role of platelets in inflammation and an understanding of how the immune activation of platelets differs from the classical haemostatic activation of platelets it is now possible to develop novel anti-platelet agents that target inflammation without compromising haemostasis. it is here that we should look for the next generation of anti-platelet agent. c-s - university hospitals of geneva, geneva, switzerland platelet function defects, either congenital or acquired, are associated with increased bleeding risk, particularly in a perioperative setting. the use of platelet function assays is therefore tempting in order to tailor transfusion and limit platelet transfusion to those bleeding patients with impaired platelet function, as assessed by those assays. however, the current guidelines provide only weak recommendations supporting the routine use of these assays. indeed, there are numerous platelet function assays on the market that differ in their method of evaluation of platelet function and agreement between their results is at best moderate. the threshold values beyond which procedure-associated bleeding risk becomes worrisome is not standardized. moreover, observational studies addressing the predictive value of platelet function testing in perioperative or spontaneous bleeding are not consistent. finally, management trials with randomized patients assessing the benefit of platelet function testing are scarce. more recent data identified selected situations where platelet function testing may be useful though. i will review the different platelet function assays as well as selected clinical studies addressing the impact of platelet function testing to improve bleeding and transfusion-related outcomes. the latest recommendation will be addressed too. background: platelet refractoriness complicates the provision of platelet transfusions in management of thrombocytopenia in oncology patients. platelet refractoriness poses challenge due to alloimmunization to hla and human platelet antigens and is associated with adverse clinical outcomes. aims: a prospective study was undertaken to analyse result of platelet compatibility with post-transfusion platelet count increment and to ascertain presence of platelet antibodies as causative factor in platelet refractory oncology patients. pulmonary complication after blood transfusion is the leading cause of transfusionrelated morbidity and mortality, with an incidence reported between . - % of all transfused patients. the most important transfusion related pulmonary complications are transfusion associated circulatory overload (taco), transfusion related acute lung injury (trali) and transfusion associated dyspnea (tad). in this presentation the recent changes in the international definitions will be presented and discussed. furthermore, insights in the different underlying pathophysiologic mechanisms will be highlighted. in the past decades only for trali prevention strategies have successfully been designed and implemented. currently no evidencebased treatment strategy is available for any of these life-threatening syndromes. insight in the pathogenesis of pulmonary complications after transfusion should pave the way for future prevention and treatment studies. the issue of the impact of iron overload / toxicity on the hematopoietic stem transplantation (hct) outcome has been firstly addressed in the field of transfusion dependent thalassemia. today the concept has been extended to other diseases characterized by periods of variable duration of transfusion dependence such as myelodysplastic syndrome (mds) and myeloproliferative diseases. patients requiring regular blood transfusions certainly develop iron overload leading to tissues and organ damage. iron burden before transplant significantly impacts outcome and long-life posttransplant. it is well known that iron overload is deleterious for organs such as liver, heart and endocrine glands and it has been postulated could also increases the risk of infections and severe graft versus host disease early after hct. recent preclinical data has shown how increased production of reactive oxygen species (ros) resulting under iron overload condition, could impair the stem cells clonality capacity, proliferation and maturation. also, microenvironment cells could be affected through this mechanism. for this reason, iron overload is becoming an important issue also in the engraftment period early post-transplant. high baseline ferritin levels before hct have been shown to negatively influence clinical outcome, but nowadays, ferritin is considered a steady and not biologically active form of iron, while free iron forms as non -transferrin bound iron (ntbi) and labile plasma iron (lpi) are considered the main trigger of cell damage more representative of the dynamic tissue damage. the scientific community is moving the iron disease from a "bulky" disease, such as classically in thalassemia (based on quantitative iron parameters as ferritin, red blood cell transfusion number, mri) to a "toxic" disease (based on active and dynamic biological markers as ntbi/lpi). at this time in all the studies published on hct setting, only the correlation between direct or indirect estimates of iron overload (mainly serum ferritin) and outcome parameters has been explored, while the duration of exposure to toxic iron species has not been taken into account. the first study that explored the lpi role in relationship with outcome was published by wermke and colleagues in malignancies. they investigated the predictive value of both stored (mri-derived liver iron content) and non-transferrin-bound-iron, defined as enhanced labile plasma iron (elpi) on post-transplantation outcomes in patients with acute myeloid leukemia or mds. their prospective, observational all-ive study showed that patients who had raised elpi concentration at baseline, also had significantly increased incidence of non-relapse mortality at day ( %) compared with those who had normal elpi at baseline ( %) (p = . ). reinterpreting transplant predictive factors in the light of the current advances in understanding iron homeostasis further supports the concept that the key to successful transplantation is regular and life-long chelation therapy to consistently suppress tissue reactive iron species and prevent tissue damage in the years before hct. in transfusion medicine, the role of donor sex was long considered to be limited to the increased risk of trali observed after transfusions from female donors. this risk has been shown to be limited to female donors with a history of pregnancy and to plasma rich products (i.e. excluding red blood cell products, typically containing < ml plasma). until, in , we found that sex-mismatched red blood cell transfusions were associated with increased recipient mortality. since then, several other studies have confirmed these findings, but some studies also did not find an association. all of these studies relied on the analyses of routinely collected health care data, which was not primarily intended to be used for research. as a result, analyses are complex and often difficult to properly appraise based on published descriptions. therefore, the discussion about possible reasons for these discordant findings has largely focused on the methodological approaches of the different studies. other potential explanations include differences in donor or patient populations, production methods, or storage time of blood products. the different potential explanations are expected to be associated with different underlying biological mechanisms. therefore, further delineating which donor, patient, and product characteristics modify the observed association could provide more insight into the underlying mechanism. in , we observed that only transfusions from female donors with previous pregnancies were associated with increased mortality and only in male recipients under years. this leads us to postulate that pregnancy induced long term changes in the female immune system are transferred during red cell transfusion, with negative consequences for young male recipients. the low amount of plasma present in red cell products further lead us to assume a cellular component, like passenger leukocytes, to be involved. it has been shown that micro-chimerism of passenger leukocytes can persist for decades after transfusion, even of leuko-reduced blood products, suggesting long term immune-modulation could play a role. we hypothesized that passenger leukocytes would die during storage of blood products and the negative effect of ever-pregnant female donors, on the survival of young male red cell recipients, would therefore be attenuated by increased storage time. however, our data seem to indicate the opposite. the risk of death was increased over three-fold for young male recipients of old (> days storage) red cells from ever-pregnant donors, compared to for young male recipients of fresh (< days storage) red cells from ever-pregnant donors ( -year cumulative incidence of death . % versus . %). the negative control group (i.e. young male recipients of red cells from male donors) showed a much weaker association of mortality with storage time (i.e. . % versus . %). these findings seem to falsify our hypothesis that mortality could be caused by passenger leukocytes, establishing long term immune-modulatory effects. another potential mechanism that has been suggested could be the presence of cellfree dna in transfused blood products. this cell-free dna increases during storage. however, more research is needed both to establish if cell-free dna can also be linked to previously pregnant blood donors and by which mechanism it could negatively affect young male transfusion recipients. clinical trials (cts), the gems in clinical research for generating robust evidence in medicine and public health, are costly and complicated undertakings. in resource limited setting like sub-saharan africa (ssa) where the health systems are sub-optimal and where capacity for research is limited, the conducting of cts can be a daunting challenge. the challenges of undertaking cts in rls may be categorized based on the occurrence of the bottleneck(s) in relation to the ethics and regulatory approval process: pre-approval: protocol development: in order to develop a context-specific protocol which is subsequently subjected to an ethics and regulatory approval process, investigators need to review and ensure that the protocol is pragmatic and feasible with respect to implementation. this results into a time-consuming reiterative process of reality-checking the protocol. site selection: in light of the limited research infrastructure, investigators in rls and their developed world partners spend considerable time reviewing and selecting suitable sites for participation in the anticipated protocol for the cts. suitable sites are usually very few and with competing on-going studies. approval: institutional review board (irb) approval: the irb approval process can be quite lengthy ( - months) with considerable unpredictability in the periods between the initial and subsequent irb reviews. national regulatory approval: the requirements by national regulators are unusually innumerable with limited flexibility to accommodate specific cts. post-approval: the key post-approval challenges for cts implementation in rls are attaining appropriate participant enrolment and maintaining high retention rates. specifically, for participant enrollment, the challenge may be unforeseen competing cts targeting the same participant pool or community perspectives that may discourage participants from getting screened for the cts. retention may also be a challenge particularly where participants view enrollment as a chance to access healthcare services may therefore not have any incentive to keep in a study after the initial study visits. in conclusion, cts are complex undertakings wherever they are conducted but are doubly challenging in rls like sub-saharan africa. the bottlenecks at the preapproval, approval and post-approval stages are considerable. nevertheless, it is rewarding to perform ctus in rls given that the data generated therein is highly valued by national regulators and may hasten the registration process for medical products. background: interest in an appropriate and effective whole blood (wb) pathogen reduction technology (prt) is growing, especially in sub-saharan africa where the residual risk of transfusion-transmitted infections (ttis) remains unacceptably high and wb is still frequently used. cerus corporation, manufacturer of the intercept tm blood system, and swiss transfusion src are collaborating on a clinical development program to adapt intercept prt using amustaline (s- ) and glutathione (gsh) for red blood cells (rbcs) into an appropriate prt for wb in resource-limited settings in africa. treatment with amustaline/gsh has been shown to inactivate a broad spectrum of transfusion-transmissible pathogens in rbcs. studies with amustaline/gsh in wb have shown effectiveness against a duck hepatitis b virus (> . log reduction) and plasmodium falciparum (> . log reduction), with future studies planned. a wb prt system with amustaline/gsh also has the potential benefit of minimal electricity requirements. aims: to describe the safety and clinical objectives for a phase clinical trial using the amustaline/gsh prt system for wb in africa, and describe research and development efforts to adapt the intercept prt system for rbcs into a robust and appropriate wb system for settings with high burdens of tti and limited resources. methods: the protocol for a phase clinical trial using pathogen-reduced wb treated with amustaline/gsh in an african country is presented, as are current research and development activities related to the development of a prt system for wb. results: in the planned phase clinical trial in africa, clinically stable patients with anemia who require wb transfusion will be randomized into two study arms at a large medical center in a sub-saharan african country. enrolled patients will receive one unit of non-leucocyte-reduced wb treated with amustaline/gsh, or a unit of untreated control wb or rbcs. the primary safety endpoint will be the incidence of high-imputability transfusion reactions (swissmedic ≥grade ) within the first hours of transfusion. data will also be collected on all adverse events and transfusion reactions (all grades) and the development of treatment-emergent antibodies to pathogen-reduced wb or auto-antibodies within (ae ) days of the study transfusion. clinical efficacy will be characterized by hemoglobin increment hours after transfusion adjusted to hemoglobin dose and body weight. summary/conclusions: a prt system for wb is being developed based on the intercept prt for rbcs that is in advanced development in europe and the united states. intercept-treated rbcs have met efficacy and safety endpoints in phase clinical trials. the amustaline/gsh prt system used to treat intercept rbcs has demonstrated effective inactivation against a broad spectrum of agents that may result in ttis. a phase clinical trial using an adapted prt system for wb in africa is the first step in a clinical development program that includes additional pathogen inactivation efficacy studies and improvements to the wb prt implementation process. together, these developments and evaluations represent progress toward a realistic and appropriate prt for wb in africa and other resource-limited settings. background: in australia, demand for plasma-derived products has increased dramatically, and there is a need to increase plasma collections. first-time donor retention, including the rate at which first-time donors return, is a pressing issue. a quick return is optimal as this increases the overall plasma yield and is associated with long-term retention. however, we lack evidence of effective interventions to encourage first-time donors, particularly those donating plasma, to return and to establish a higher frequency donation routine. working from schultz's ( ) framework, this intervention study was based upon insights from interviews with first-time plasmapheresis donors. participants identified barriers such as time and lack of knowledge about plasmapheresis. facilitators included being able to help more people and to donate more frequently than allowed with whole blood. participants generally favoured donating at a frequency of every weeks. aims: the aim of this study was to test the effectiveness of three intervention conditions compared with the business-as-usual (bau) procedure on the proportion of donors returning to donate plasma and the number of plasma donations. we report on the data from months post-donation. methods: donors were randomly assigned to one of four study conditions. in conditions and , donors received an email one day after their initial donation. in the first condition, donors received the bau 'thankyou' email. donors in the second condition received an alternative email with content derived from the interview study. donors in the remaining conditions received either the bau email (condition ) or the revised email (condition ) coupled with a telephone call. the phone call was scripted to provide additional information about plasma, including how often plasma can be donated, a suggestion to donate every weeks, and a prompt to forward-book appointments. results: the final sample (n = ) comprised women ( %) and men ( %) aged - (mean = ). after two months . % of donors returned to donate plasma at least once. after controlling for gender, age, and blood group, donors in each of the intervention conditions were more likely to return to donate plasma than were donors in the bau condition. the greatest effect was found between donors randomized to condition (revised email + phone call), or = . , ci = . - . , and bau. donors assigned to the two telephone conditions (condition and ) donated plasma at a higher frequency than bau. summary/conclusions: this study tested the effectiveness of interventions designed to encourage first-time plasma donors to return to donate plasma and to establish a routine of donation. early indicators suggest that the evidence-based email and phone call elements are more effective than bau in bringing donors back to donate plasma, and the revised email combined with a phone call had the greatest positive effect on short-term plasma yield. background: healthy individuals with hereditary hemochromatosis (hh defined as hyperferritinemia and homozygous p.c y mutation), but also carriers of other hfe mutations (p.c y/p.h d or homozygous h d) with elevated serum ferritin (sf) are accepted as blood donors, if allowed by local regulations and if eligibility is fulfilled. generally, blood components are released for transfusion at normal sf levels (< ng/ml in females, < ng/ml in males). aims: prospective, two-center, randomized study comparing the efficacy and tolerability of double-erythrocyte apheresis ( rbcaph) and whole blood phlebotomy (wbph) for iron depletion in asymptomatic subjects with hh or hyperferritinemia and other hfe mutations in the setting of routine blood donation. methods: eligibility criteria included age ≥ - years, total blood volume ≥ l, bmi < kg/m , hb ≥ g/l, elevated sf levels and no end organ damage due to iron overload. rbcaph ( ml rbc) were scheduled every days and wbph ( ml) every days until sf was < ng/ml. a complete blood count and sf were measured at baseline, at every visit and at follow up weeks after completion of the study. adverse events were systematically recorded. the treatment effect was tested by poisson regression, with gender, hfe mutation, bmi and baseline sf as covariates. results: subjects ( females; mean age years) were randomized to wbph (n = ; female) or rbcaph (n = ; females). hfe mutations were p.c / p.c y in subjects, p.c y/p.h d in , and p.h d/p.h d in . at baseline, mean hb was g/l (sd . ) and median sf was ng/ml (iqr - ng/ml). procedures (wbph n = , rbcaph n = ) were completed; were interrupted (local hematoma, insufficient flow); ( wbph, rbcaph) were postponed because of low hb and for non medical reasons. there were drop-outs in the wbph arm due to depression and poor compliance, respectively. anemia (hb < g/l in males, < g/l in females) occurred after visits in wbph subjects and after visits in rbcaph subjects. fatigue was reported after phlebotomies and aphereses. only participants ( %) completed the study per protocol. blood components ( rbc concentrates and plasma units) for transfusion were obtained. overall, a median of . wbph (iqr . - . ) was needed to reach sf < ng/ml, corresponding to . times of rbcaph (median . , iqr . - . ) (p = . ). analyzing separately p.c /p.c y and p.c y/p.h d carriers, the relation wbph to rbcaph was . and . , respectively. treatment arm and hfe mutation were the covariates with significant effect on the primary endpoint (p = . and . , respectively). summary/conclusions: rbcaph is more efficient than wbph for iron depletion in healthy subjects with hh or other hfe mutations and moderate hyperferritinemia. intensive treatment schedules, generally recommended for hh, are difficult to keep because of hb drop and compliance. less intensive treatment in asymptomatic individuals with hh and their inclusion in blood donation would avoid negative effects on quality of life and benefit blood collection centers in the long term. background: serum ferritin (sf) measurements in whole blood (wb) donors demonstrated that female sex and intensity of donation are major risk factors for iron deficiency. approximately ml red blood cells (rbc) and - mg iron are lost with wb donation. double unit rbc ( rbc) collections of ml (ca. ml less than the rbc amount of two wb donations) lead to a loss of about mg iron. in switzerland, the maximal allowed donation frequency for male donors is once every months for rbc and once every months for wb donation. aims: to describe and compare the course of hemoglobin (hb) and sf in male subjects donating wb and rbc at our institution. methods: we included wb and rbc donors (n = ) who donated with the maximal allowed donation frequency over months between and , yielding , wb and , rbc donations. we excluded subjects with hyperferritinemia and known hfe mutations. hb limits were g/l for wb and g/l for rbc donation. with rbc apheresis ml rbc were collected. sf was measured on a predonation serum sample; hb was determined from finger prick samples. the donors received no iron substitution. we used generalized estimating equation models for hb and sf trajectories. results: mean age at the first blood donation was (wb) and years ( rbc), respectively. at the first donation, mean hb was g/l (sd ) in wb and g/l (sd ) in rbc donors; mean sf was (sd ) and lg/l (sd ), respectively. on average, hb and sf were higher in rbc donors ( . g/l and lg/l, respectively; p < . ). there were subjects with sf < lg/l in wb and in rbc group, and with sf < lg/l (but > lg/l) and , respectively. in rbc donors, between the first and the last donation, mean hb declined from g/l to g/l (p < . ) and mean sf from lg/l to lg/l (ns). in wb donors, mean hb dropped from g/l to g/l (p < . ) and sf from lg/l to lg/l (p < . ). similar results were found when adjusting for age and season. hb values dropped from baseline until the th donation for wb donors and until the th donation for rbc donors with an upward trend thereafter. in both groups, no hb value below the limits of blood donation and no anemia were observed. sf reached a nadir at the th donation in both wb and rbc donors ( lg/l and lg/l) and increased thereafter in rbc donors. in wb donors, sf followed a parabolic trend that peaked at the th donation, and then declined until the last donation. summary/conclusions: the maximal allowed blood donation frequency for wb and rbc male donors in switzerland is not only protective for the development of anemia, but also for deferral of blood donors because of low hb. this was observed even in subjects with low sf at baseline. background: granulocyte concentrate transfusion is a potentially lifesaving option for patients without functional neutrophils. however, recent studies have failed to demonstrate the anticipated clinical effectiveness of this procedure. granulocyte concentrates are manufactured using sedimentation agents to separate granulocytes from red blood cells and enhance granulocyte collection efficiency. high-molecularweight hydroxyethyl starch (hes) is most commonly used for this. however, authorities recently restricted the use of hes due to its unfavorable risk-benefit-profile. modified fluid gelatin (mfg) is an already used alternative sedimentation agent. as the granulocyte product contains these substances, any impact of the sedimentation agent on granulocyte function may affect the clinical effectiveness of granulocyte transfusion. aims: we tested the hypothesis that mfg is not inferior to hes in terms of the functionality and viability of granulocytes. methods: granulocytes from ten healthy donors were isolated, aliquoted and incubated in parallel for hours with either % (control), . %, % or % mfg (gelafundin %, b. braun melsungen ag) or hes (hespan %/ / . , b. braun medical inc.), respectively, and granulocyte migration, chemotaxis, reactive oxygen species (ros) production, neutrophil extracellular trap formation (netosis), antigen expression of cd b, cd l and cd b, and viability were subsequently investigated in vitro. testing was performed using live cell imaging of the cells embedded into a collagen i matrix for parallel testing of migration, ros production and netosis. in addition, flow cytometric (facs) analysis was utilized for surface marker expression, viability and respiratory burst measurement. results: granulocyte migration decreased in a dose-dependent manner in response to hes and mfg. relative to the controls, all three concentrations of hes lowered migration distances (p < . respectively), whereas only the higher concentrations ( % and %) of mfg showed lower relative migration distances (p < . respectively). track straightness was reduced with both sedimentation agents at % and % to the same extent (p < . respectively). hes resulted in lower cd b expression (p = . ) and higher cd l expression (p = . ) compared to the controls, whereas the differences for cd b did not reach statistical significance. mfg did not affect the expression of any investigated surface antigen mediating endothelial adhesion and transmigration in comparison to the controls. no significant differences in the timing of ros production or netosis, or in neutrophil viability or respiratory burst were observed. summary/conclusions: these results indicate that mfg is not inferior to hes in terms of granulocyte phenotype and function in vitro when used at equal concentrations, and that potential impairment of granulocyte function can occur with hes. background: plateletpheresis donation leads to a well-known transient decrease of donor's platelets. the question of long-term effects raised with the development of regular donations by some donors in order to satisfy a growing demand. a seminal work (lazarus, transfusion, ) stated that there is a sustained thrombopenia in frequent plateletpheresis donors, correlated with the total number of donations. aims: french regulation authorizes up to plateletpheresis donations per year, with a minimum weeks interval between them. we tried to evaluate the risk of sustained thrombopenia under these conditions. methods: we retrieved all plateletpheresis donations occurring between / / and / / from the french civilian blood donors' base and then selected a cohort of donors with at least donations during that period. in order to minimize measurement errors, platelet counts analysed were means of three consecutive donations, i.e. measures for each donor. results: the cohort includes , donors ( women and , men). mean platelet counts fluctuate between . and . platelets/ml. analysis of variance does not show any statistically significant difference (f = . ), even taking donor's sex or age in consideration. there is no difference if we consider the total duration of the donations, either. donors with the lowest first counts show a significant rise in subsequent measures and donors with the highest counts show a decrease trend, exhibiting a classical regression toward the mean. summary/conclusions: plateletpheresis french regulation does not seem to be at risk of sustained donor thrombopenia. this conclusion is in agreement with recent literature data. the primary biological role of the human leukocyte antigen (hla) system is the regulation of the immune response to foreign antigens. because of this role, hla genes and molecules have an important role in transplantation, etiology of many autoimmune, non-autoimmune and infection diseases, but also in transfusion medicine. an increasing probability of an hla non-compatible blood products, tissues or organs exists due to the extremely high polymorphism of hla genes, with more than , described alleles to date, and their different frequency distribution in various worldwide populations. the hla system, originally discovered as a result of a transfusion reaction in the s, can cause detrimental immune reactions in transfusion therapy. hla antibodies present in the patient are responsible for some of these reactions, while in other cases hla antibodies or hla reactive cells present in the transfused product are accountable for the immunoreactivity. hla antibodies form as a result of exposure to foreign hla antigens during pregnancy, transplantations and blood transfusions and can cause platelet immune refractoriness, febrile transfusion reaction, transfusion-related acute lung injury, and transfusion associated graft versus host disease. in order to avoid or reduce the development of these transfusion-related events, hla antibody negative or compatible products should be used. almost all existing methods presently used for molecular typing of hla polymorphisms are based on polymerase chain reaction, but with different resolution levels (low resolution -two digits or high resolution -four digits). in addition to providing a more precise detection of polymorphisms at hla classical loci (e.g. hla-a, -b, -c, -drb , -dqb ), molecular methods can also determine polymorphisms at hla loci which previously could not be typed by serology (e.g. hla-drb , -drb , -drb , -dqa , -dpa ). the most commonly used method for the detection of hla antibodies was until recently complement-dependent cytotoxicity (cdc) technique, but it is increasingly being replaced by a more sensitive, solid phase based method (luminex technology). in conclusion, an accurate and precise determination of both hla gene polymorphism and hla antibodies presence is essential for the safe and efficient administration of transfusion products. background: in only a minority of pregnancies complicated with anti-hpa a antibodies serious fetal/neonatal disease develops. the difficulty in predicting which mothers should be treated with ivig hampers implementation of fnait screening. we found that fc-core fucosylation and galactosylation are highly variable in anti-hpa a igg, and that these glycan features strongly affect binding to fccriiia receptor. the level of fc-core fucosylation of anti-hpa a alloantibodies was found to correlate with platelet count and outcome of the newborn, suggesting that antibodyspecific fucosylation might serve as a biomarker in fnait screening. however, at present the fc-glycosylation pattern can only be determined by complicated methods involving purification of the antigen-specific igg, and analyzing trypticly released -igg-derived-glycopeptides by tandem liquid chromatography-mass-spectrometry (ms) techniques. these methods, although powerful, are not yet suited for high throughput clinical screening. aims: our aim was to provide a simplified method to quantify the biological activity of anti-hpa- a antibodies, and possibly other alloantibodies against blood cells. methods: here we explored if cellular surface plasmon resonance (spr) imaging can replace ms, resulting in less complicated handling of patient sera and donorantigen-bearing cells. the strength of the binding of platelets to fccr on spr sensor was monitored under flow. the spr sensor was equipped with both wt fccriiia (sensitive to fc-glycosylation status) and mutant fccriiia-n a (insensitive to fcglycosylation status). in addition, the biosensor was prepared with anti-platelet cd (c ) and anti-igg to calibrate the number of injected platelet as well as to quantify igg-opsonization. the quality of the anti-hpa a glycosylation was monitored as the ratio of the binding of opsonized platelets to the wt and the mutant n a-fccriiia. platelets opsonized with recombinant glycoengineered anti-platelet antibodies with different levels of fc-fucosylation were used as standards. for validation, plasma samples with anti-hpa a antibodies, already analyzed by mass spectrometry and with known clinical outcome were tested (sonneveld, bjh, ) . results: we found that the ratio between the binding to the wt fccriiia and to the mutant n a-fccriiia correlated with the level of fucosylation of the hpa a antibodies, as measured by mass-spectrometry (r = À . ; p < . ). overall, a similar predictive value for disease severity was obtained as we previously reported for this retrospective cohort. in addition, quantitative information on antibody concentration can also be extracted using the fccriiia-n a receptor as sensor on the chip, while anti-igg gave aspecific signals, presumably because it recognized cytophilic platelet-fccriia-bound antibodies as well. summary/conclusions: in conclusion, the combined use of wt and mutant fccriiia in a label free spr assay provides both quantitative and qualitative information of platelet bound anti-hpa a antibodies, which circumvents the need for purification of specific antibodies and laborious mass spectrometric analysis. this approach might be generally applicable to determine the biological activity of cell bound antibodies not only for anti-hpa a in fnait, but also for anti-rhd alloantibodies in hdfn or anti-platelet antibodies in itp. background: immunization against the human platelet hpa- a alloantigen is the most common cause of severe fetal and neonatal alloimmune thrombocytopenia (fnait) in otherwise healthy term newborns. the screening for hpa- a antigen in pregnant women is an important tool for identification of pregnant women at risk of having a fetus/neonate with fnait. any targeted intervention depends on efficient screening methods as well as sensitive and specific methods for detection of anti-hpa- a. within the framework of the polish-norwegian project (prevfnait) we have performed hpa- a screening program in poland. aims: our aim was to assess the frequency anti-hpa- a antibody detection and the clinical outcome of newborns identified through the study. women who joined the program due to the fnait in the previous child or in the current newborn are not analyzed in this study. methods: hpa- a screening of pregnant women in - gestational weeks was performed by facs phenotyping or rq-pcr genotyping at ihtm in warsaw. hpa- a negative/hpa- b/ b women were tested for hla drb * : and for anti-hpa- a antibodies by maipa (followed up at week - , , , - and weeks after delivery). if anti-hpa- a were detected, quantitative maipa was performed. all hpa- a negative women were contacted for information concerning the newborn. if the baby had thrombocytopenia and anti-hpa- a were not detected by maipa, the look back samples were tested retrospectively by paklx test (immucor). results: hpa- a negative women were identified ( . %). anti-hpa- a was antibodies were detected by maipa in women (two delivered tweens). in addition, anti-hpa- a antibodies were later detected by paklx in further women who delivered baby with severe thrombocytopenia and/or ich. total number of immunized mothers was ( . %). they delivered babies; were boys. three women were treated by ivig: two by and injections since th and th gw respectively. the anti-hpa- a concentration in the st one was . ; . ; . iu/ml in , , gw respectively and in the nd < . iu/ml in all examined samples. the decision on treatment was based on the low plt count~ g/l in the fetus in cordocentesis. their newborns (one delivered tweens) were healthy. the rd treated woman entered the program in gw (anti-hpa- a concentration was high . iu/ml). she obtained one injection of ivig. her baby was born with mild thrombocytopenia with no ich. severe fnait occurred in / newborns: in with anti-hpa- a detected in paklx only and in with antibody concentration in maipa - st : . / . / . at / / th gw respectively; nd : . / . at / th gw respectively. ich was observed in all of them; plt count was < x in four, / in one. summary/conclusions: / the severe thrombocytopenia due to anti-hpa- a alloimmunisation in our prospective study occurred in / pregnancies / the paklx could improve anti-hpa detection in the screening program and should be considered as an additional diagnostic test, if maipa result is negative / the hpa- a alloimmunisation frequency is higher in pregnancies with male than female fetus. background: foeto-maternal platelet alloimmunization (fmpai) is mainly characterized by foetal and / or neonatal thrombocytopenia (fnait), sometimes revealed by intracranial hemorrhage (ich) or even by foetal death in utero (fdiu). the experience of the pnil milwaukee (usa) reported in that the diagnosis of alloimmunization was carried in only % of neonatal thrombocytopenia cases with a clinical symptomatology highly suggestive of an alloimmune etiology. aims: the aim of this two-year study was i) to determine the frequency of platelet incompatibilities in fnait, ich and fdiu and ii) to evaluate the frequency of detectable platelet alloantibodies (alloab) and their specificity in cases of incompatibility. methods: platelet genotyping was performed by hpa beadchip genotyping kit (bioarray solutions, immucor, warren, nj). serology investigation was carried out by different methods: complete maipa kit (apdia bvba, turnhout, belgium), pack lxtm assay (immucor gti diagnostics, waukesha, wi) and « in house » maipa. all and data were collected using the laboratory information management system. results: patient files were analyzed. no incompatibility is demonstrated in hpa- to - , - and - systems in . % (n = ). hpa- and / or and / or incompatibilities were found in cases ( . %), hpa- and / or in cases ( %). platelet alloimmunization was globally confirmed in only . % of the cases. platelet alloabs were identified regardless of clinical manifestations: anti-hpa- a ( . %), anti-hpa- b ( . %), anti-cd ( . %), anti-hpa- a and anti-hpa- b ( . % respectively) and anti-hpa- b and anti-cd ( . % respectively). alloabs were found in the context of neonatal thrombocytopenia, in ich and in fdiu, and in a follow-up of pregnancy. even if no anti-hpa- alloab could be identified, the incompatibility in this system was highly associated with fnait, ich and fdiu (n = , n = and n = on cases). summary/conclusions: this study strongly confirmed the known immunogenicity of some hpa systems and highlighted overall the severity of hpa- and hpa- incompatibilities. the definite diagnosis of fmpai is difficult to make due to the present technical difficulties in the detection of antibodies against the hpa- and hpa- systems. however, our results suggest that special attention should be paid to the management of pregnancies with these incompatibilities due to the frequency of severe foetal/neonatal adverse events. background: fetal and neonatal alloimmune thrombocytopenia (fnait) is a potentially life threatening disease caused by maternal alloantibody formation against fetal human platelet antigens (hpas), of which anti-hpa- a is accountable for the fast majority of the cases. population-based screening for fnait has been topic of debate for over decades. logistically as well as financially, the major challenge of such a screening is the typing of pregnant women to recognize the % hpa- a negative women. at present, hpa- a typing is mostly done by genotyping. for costeffective implementation of anti-hpa- a screening there is need for a high-throughput, quick and low-cost phenotyping assay. aims: the aim was to develop a high-throughput, quick and low-cost phenotyping assay in order to identify hpa- a negative pregnant women. methods: an automated sandwich elisa was developed to perform hpa- a phenotyping using a murine monoclonal anti-gpiiia as coating antibody and horseradishperoxidase-conjugated recombinant igg anti-hpa- a as detecting antibody. to ensure the applicability for high-throughput testing in a potential screening setting, ll of the uppermost plasma of - days-old stored edta anticoagulated blood tubes was used, without first swirling or spinning them. in two phases, samples of pregnant women were tested and compared to an allelic discrimination polymerase chain reaction assay as golden standard. in the first phase, samples from unselected consecutive pregnant women were tested. the second phase was part of a prospective screening study in pregnancy and confirmatory genotyping was restricted to samples with an arbitrary set od < . in the hpa- a elisa. the developed elisa was optimized to require no additional handling (swirling or spinning) of stored tubes. during phase i, consecutive samples were tested. in phase ii, the hpa- a elisa was performed in another , consecutive samples, with confirmatory q-pcr in , . the two phases combined, samples from in total , hpa- a negative and hpa- a positive pregnant women were genotyped. the assay reached a % sensitivity with a cut-off od between . and . , leading to a specificity of . %. summary/conclusions: a quick, low-cost and reliable assay for hpa- a phenotyping was developed that can be used in a population-based screening setting to select samples that has to be tested for the presence of anti-hpa a antibodies. because plasma from non-mixed or spinned tubes of three to six day-old samples can be used, this assay is applicable to settings with suboptimal conditions. background: cytomegalovirus (cmv) sero-prevalence in ireland is lower than that which is reported in many other european countries. a study of pregnant women in found that . % of irish women were cmv seropositive in comparison to % from western europe and % eastern europe and % from africa. an internal study carried out by the irish blood transfusion service (ibts) in indicated the rate of cmv seropositivity in irish blood donors was . %. therefore a significant proportion of the irish donor and recipient population are susceptible to primary cmv. this is of particular concern for patients for certain at-risk groups such as very-low birthweight cmv seronegative neonates, cmv seronegative patients undergoing transplantation and other cmv seronegative immunocompromised patients. this results in a demand for the provision of cmv sero-negative blood components. in the ibts evaluated the abbott alinity s cmv igg assay as a replacement for the cmv mastazyme eia (total ab eia). aims: to assess the performance of the abbott alinity s cmv igg screening assay in comparison to the cmv mastazyme eia (total ab eia). methods: diagnostic sensitivity was determined by testing confirmed cmv igg positive donors from an external laboratory. sensitivity was assessed using three seroconversion panels (n = ). analytical sensitivity was calculated using linear regression analysis of the who first international standard for anti-cmv igg. diagnostic specificity was determined by testing donors. further evaluation of discordant results was carried out using the architect anti-cmv igg and igm assays and vidas anti-cmv igg and igm assays. results: the diagnostic sensitivity of the alinity s anti-cmv igg assay was determined to be %. the seroconversion sensitivity reported out of samples reactive. the analytical sensitivity of the alinity s cmv igg assay was determined to be . iu/ml. the validation reported discordant results from donor samples tested with both the alinity s cmv igg assay and the current mastazyme total assay. discordant results were observed (alinity s anti-cmv igg positive/mastazyme total negative). further testing of these samples classified discordant results as positive, as negative and as indeterminate. discordant results were observed (alinity s anti-cmv igg negative/mastazyme total positive). further testing classified these samples as negative. overall the diagnostic specificity was determined to be . %. summary/conclusions: both the seroconversion and analytical sensitivities are comparable between the alinity s cmv igg assay, the cmv mastazyme total ab assay, the architect cmv igg assay and the vidas igg assay. the slight variations can be attributed to the individual assay cut-off definitions, which can vary greatly between cmv assays. it must be noted that the determination of the diagnostic specificity ( . %) does not include indeterminate discordant results. further testing will be carried out to try to characterize all discordant samples in collaboration with abbott. this evaluation did not identify any donors with isolated confirmed cmv igm antibodies in a pool of donors. based on this evaluation the abbott alinity s cmv igg assay is a suitable replacement to the mastazyme total ab assay for blood donor screening. background: africa has a unique set of challenges regarding safe blood transfusion. two of the largest contributing factors are: ) the most common disease states in sub-saharan africa (ssa) require large amounts of blood as lifesaving interventions e.g. malaria, ) the highest burden of infectious diseases transmissible through transfusion (tapko, toure, & sambo, ) is found in ssa. this has often led to the binary donor base that exists in ssa, consisting of voluntary non-remunerated blood donors (vnbd) and family or replacement donors (frd) as transfusion centres are unable to supply the demand when relying only on vnbd. voluntary non-remunerated donors are the safest blood donors as they have no incentive (other than altruistic motives) and are not under social pressure to donate, both factors that may induce individuals knowing or suspecting themselves to be infected with a blood-borne agent to donate blood. nucleic acid testing (nat) in conjunction with serological testing is the gold standard for testing, however, the vast distances and high temperatures of africa makes transport of traditional plasma samples a logistical challenge. many publications evaluating the stability, suitability, and ease of use of dried blood spots (dbs) for nat have been published. generally, results have been shown to be comparable to traditional plasma samples. dbs is being used successfully in the early infant diagnosis (eid) programs for hiv by means of pcr testing, especially in africa. aims: . to demonstrate that dbs and/or dried plasma spot (dps) testing is suitable for blood donor screening and can make nat testing more widely available in africa . to determine the diagnostic sensitivity and specificity of testing dps and dbs samples, in comparison to testing of plasma samples. methods: negative new donor samples and confirmed positive donor samples, as defined by routine blood safety screening done at western cape blood service, were screened using a dried blood spot kit. after routine testing was completed, one dbs sample and one dps sample for each blood donor were prepared and analysed with the ultrio elite assay on the panther analyser. summary/conclusions: dbs/dps can be used as a sample for screening blood donors as the invalid rate was . %, and only found on dbs samples. logistically dbs/dps is well suited for the resource-poor countries as samples are: -easy to obtain (fingerpick samples could be used.) -transport is simplified as samples will not leak or haemolyse due to high temperatures. -samples can be stored at room temperature dbs/dps demonstrated acceptable specificity. the ultrio elite performed well with regards to hiv and hcv sensitivity. sensitivity with regard to hbv was not as high but this could be due to very low and erratic viral loads. background: sanquin blood supply is responsible for the blood transfusion services in the netherlands. at the national screening laboratory sanquin (nss) annually more than . blood and plasma donations are tested, on average . samples per day. for more than years, infection serology testing was performed using the prism (abbott diagnostics), but since mid of july , serological testing for the hbsag, hiv ag/ab, anti-hcv and anti-hbc is done with abbott's alinity s system. aims: to compare the numbers of initially and repeatedly reactive results of whole blood and plasma donation samples and the rate of non-specific results leading to deferral of donations and donors for prism and alinity s assays using data from months before and months after implementation of the alinity s systems at nss. methods: initial and repeat reactive rate of the assays run by either prism (hbsag, hiv o plus, hcv) or alinity s (hbsag, hiv ag/ab combo, anti-hcv,) were calculated for january to june (prism) and august to december (alinity s). due to the lack of a true confirmatory method for anti-hbc, we only compared the rate of repeatedly reactive results for prism hbc and alinity s anti-hbc. results: the rate of repeat reactive results for prism (p) and alinity s (a) assays were as follows: ) hbsag p . % ( / . ) versus a . % ( / . ); ) hiv p . % ( / . ) versus a . % ( / . ); ) anti-hcv p . % ( / . ) versus a . % ( / . ). the rate of anti-hbc reactive samples was not significantly different between prism ( . %) and alinity s ( . %). over the study period, the rate of initially reactive samples for the three main screening assays (hbsag, hiv, hcv) was also comparable between alinity s ( . %) and prism assays ( . %), mainly attributable to a rather high number of initially reactive alinity s hiv ag/ab results. this was due to initial issues with blood collection tubes that were resolved. as a result in december, the rate of initially reactive samples decreased to . %, which was significantly lower than for the three prism assays ( . %). summary/conclusions: the introduction of the alinity s assays lead to a decrease of the average repeat reactive test results (hbsag, hiv, hcv) by . % as compared to the prism, mainly due to a lower false reactive rate of the alinity s anti-hcv assay. this will be further investigated for first time and multiple time donors. with the implementation of the alinity s at sanquin we aimed to improve not only the operational efficiency but also to further minimize unjustified disapproval of donors. these first data show that the low initial and repeat reactive rates of the alinity s assays indeed have a positive impact on unnecessary deferrals of donations and donors. background: in blood banks, testing all blood donations for markers of infectious diseases plays an important role in maintaining the safety of blood transfusions. mandatory serological testing in switzerland is performed for anti-hcv, hiv ag/ab, hbsag and syphilis. highly specific and sensitive tests with corresponding automation are essential for this purpose. aims: a comparative study was carried out to evaluate the usability of the newly launched alinity s system (abbott) and the specificity of the infectious disease parameters hbsag, anti-hcv, hiv combo and syphilis (abbott) with the currently used elisa methods on the quadriga befree system (all diasorin, formerly siemens healthcare diagnostics). methods: the study took place at the interregional blood transfusion service in berne, switzerland. the specificity of the parameters was studied on , blood donor sera from both first time and repeat donors. the samples were tested first on the quadriga be free system with enzygnost hbsag . , enzygnost anti-hcv . , and enzygnost hiv integral assays and on the pk with the newbio-pk tpha assay (newmarket biomedical). all samples were retested on the same day with hbsag, anti-hcv, hiv combo and syphilis on the alinity s. initial reactive samples were repeated in duplicate. discriminatory tests were carried out for repeatedly reactive samples using alternative screening tests and neutralisation (for hbsag) on an abbott architect i system and immunoblots (hiv-, hcv-, syphilis-inno-lia, fujirebio). for all samples, results from our routine individual donation nucleic acid testing (hcv, hiv, hbv, roche cobas system) were available. results: based on the results from testing , blood donations, the observed specificities of alinity s assays (a) and enzygnost assays ( summary/conclusions: the alinity s system was easy to use by the operators after a very short introductory training and provides good operational efficiency such as high throughput even when selective testing for samples is needed. the observed specificity of abbott alinity s versus siemens enzygnost assays is comparable in a blood donor screening setting. unfortunately, we were not able to analyse statistically the specificity data due to the insufficient number of donor samples tested in parallel. it is worth mentioning that around % of the samples included in the study derived from repeat donors who had been previously tested with the enzygnost assays but were "first time donors" for the alinity s assays. all four assays from both systems exhibit a very good specificity and are highly suitable and practicable for routine blood donor screening. background: effective screening for transfusion-transmissible infections is essential to ensure safe blood transfusions. the world health organization recommends mandatory serological testing of blood donations for human immunodeficiency virus (hiv), hepatitis b (hbv)/c (hcv), and syphilis. due to increasing demands on clinical laboratories, there is a need for reliable and accurate automated blood screening tests. the fully automated cobas e analyser can be used with elecsys â infectious disease parameters to screen donor blood samples. aims: to compare the performance of elecsys â infectious disease parameters on the cobas e analyser (roche diagnostics) with other commercially available assays for routine first-time blood donor screening. methods: we provide results from etablissement franc ßais du sang (montpellier), a blood bank which participated in a large, multicentre study of the cobas e analyser. the following infectious disease marker assays were compared: hiv, elecsys â hiv duo versus prism hiv o plus; hcv, elecsys â anti-hcv ii versus prism hcv; hbv surface antigen (hbsag), elecsys â hbsag ii versus prism hbsag; hbv core antigen antibodies (anti-hbc), elecsys â anti-hbc ii versus prism hbcore; syphilis, elecsys â syphilis versus newbio pk tpha assay. specificity was tested using residual fresh serum samples from unselected first-time blood donors, and calculated according to assay package inserts and site-specific cutoffs. samples were tested using comparator assays, then retested the same day using elecsys â assays. initially reactive samples were repeated in duplicate; confirmatory tests were conducted on repeatedly reactive samples. confirmatory tests: hiv, nucleic acid testing (nat), architect hiv ag/ab and inno-lia â hiv i/ii score assays; hcv, nat, archi-tect hcv and inno-lia â hcv score assays; hbsag, nat, architect hbsag and elecsys â /prism hbsag confirmatory assays; anti-hbc, nat, hbsag, anti-hbs, and architect anti-hbc assays; syphilis, architect syphilis tp and inno-lia â syphilis score assays. sensitivity was tested using preselected, anonymised, positive, citrate-phosphate-dextrose-plasma samples (plasmatec laboratory products) and compared with archived data for comparator assays. sensitivity was calculated according to the final nat result. results: across all infectious disease markers, specificity to detect repeatedly reactive samples using elecsys â versus comparator assays was similar ( . - . % versus . - . %; n ≥ ). in specificity analyses, there were discrepant results for hiv testing, for hcv, two for hbsag, eight for anti-hbc, and five for syphilis. sensitivity of the elecsys â hiv duo assay ( . %; % ci . - . ) was higher than the prism hiv o plus assay ( . %; % ci . - . ), but the difference was not statistically significant. sensitivities of elecsys â and comparator assays were the same for hcv ( . %; % ci . - . ), hbsag ( . %; % ci . - . ), anti-hbc ( . %; % ci . - . ), and syphilis ( . %; % ci . - . ); three hcv and six anti-hbc samples were classified negative/ indeterminate and excluded from the analyses. in sensitivity analyses, there were two discrepant results for hiv testing, three for hcv, and five for anti-hbc. summary/conclusions: elecsys â infectious disease parameters on the cobas e analyser demonstrate high specificity/sensitivity for screening first-time blood donor samples, with similar clinical performance to other commercially available assays. background: individual plasma and serum specimens from whole blood or plasmapheresis donors are tested for absence of infectious agents by serological assays prior to use for transfusion or production of blood derived therapeutics. the department of plasma analytics (pa), takeda (austria), and haema ag, grifols (germany), both labs with high throughput and a high level of automation, were seeking for alternatives to replace their current serological test systems (abbott prism next). aims: to allow a direct comparison of the two final candidate analyzers alinity s (abbott) and cobas e (roche diagnostics gmbh), a side by side evaluation was carried out by the pa and haema with support from abbott and roche (provision of instruments and reagents). the aim was to compare assay specificities as well as handling and performance of the instruments. the outcome should be used to better understand potential specificity differences and practical handling aspects (throughput, etc.) of a next generation serological analyzer. methods: the two candidate instruments were installed in the pa. from march to june , close to , aliquots from routine preselected repeat donors, provided by haema, were run on both study instruments in parallel. plasma samples were tested for hbs antigen (ag), hcv antibody (ab), hiv ag/ab, and partially for syphilis ab. serum samples were additionally tested on hbc ab. samples with repeat reactive results ("rr", two reactive results out of three tests) not confirmed by confirmatory tests were counted as false reactive. the necessary sample size was calculated based on a one-sided comparison of proportions with the aim to detect potential specificity differences (a = %) in the size of those specified by the manufacturers' instructions. two different lots were tested for the three main assays. results: out of , plasma and , serum samples, test results representing individual donations were found rr on one or both instruments. two samples were confirmed positive ( hbsag, hcv), two others were indeterminate. the sample containing low level antibodies against hcv was pcr negative and only detected by the roche system. the percentage of false reactive results for the five assays on the two systems were (alinity s/e ): hbs ag: . / . % in a total of / samples tested; hcv ab: . / . % in / , p < %; hiv ag/ab: . / . % in / , p < %; syphilis ab: . / . % in / ; hbc: / % in / . no significant difference was found between the calculated specificities in our study and the manufacturers' data. a potential influence of sample matrix and kit lots was assessed. a trend towards more false reactive results in serum vs plasma was found for nearly all assays. no clear-cut statistical difference was seen between lots. summary/conclusions: the study results are in line with the manufacturers' specificity data, showing that the alinity s hcv ab and hiv ag/ab assay show a slightly higher specificity in a population of plasma and serum samples from repeat donors prescreened by prism. a possible influence on the test specificity by the sample matrix was detected but needs further investigation. the possibility to edit complex genomes in a targeted fashion has not only revolutionized basic research but biotechnological and therapeutic applications as well. with the rapid development of genome editing tools, in particular zinc-finger nucleases (zfns), transcription activator-like effector nucleases (talens), and the crispr-cas system, a wide range of therapeutic options have beenand will bedeveloped at an unprecedented speed. therapeutic genome editing in hematopoietic cells enable new interventions in the blood and immune system, including novel approaches to treat immunological disorders, infectious diseases, and cancer. we have developed gmp-compliant protocols to manufacture gene edited cd + hematopoietic stem and precursor cells (hspcs) as well as chimeric antigen receptor (car) t cells, with the final goal to provide novel cell therapies for patients suffering from primary immunodeficiencies, chronic infection with human immunodeficiency virus type (hiv- ), and some tumor entities. despite great success in improving their specificity, engineered designer nucleases can induce genotoxic side effects by introducing mutations or chromosomal aberrations. we have established novel genome-wide assays that enable us to detect chromosomal aberrations induced not only by off-target activity but also by on-target activity, such as micro-aberrations and translocations, with unparalleled sensitivity. in toto, our developed protocols allow us to achieve genome editing in hematopoietic cells with high efficiency and to assess the genotoxic risk associated with the expression of crispr-cas nucleases and talens in clinically relevant human cells, so forming the basis for planned phase i/ii clinical studies. adoptive t cell therapy (act) has proven a potent means to treat blood-borne tumors and solid tumors. adoptive cell therapies include t cells that are genetically engineered with tumor specific t cell receptors (tcrs), or with chimeric antigen receptors (cars). in addition, tumor infiltrating cells (tils) can be isolated from tumor lesions, which are then expanded and reprogrammed in vitro prior to transfusion into the patient. the anti-tumoral efficacy of act products depends on several parameters, including the capacity of cd + t cells to produce cytokines, chemokines and granzymes, a feature that is critical for effective anti-tumoral responses. here i will discuss our efforts to develop and improve act products for future clinical use. i will present pre-clinical work on developing til therapy for non-small cell lung cancers. in addition, i will show that human cd + t cells can be divided into different subsets, and that only one of those subsets is highly cytotoxic. this finding may help improve the quality of genetically engineered t cell products, like tcr and car t cell products. background: the baltic states -estonia, latvia and lithuania have a lot in common. we are located side by side, share the baltic sea as a gate to the west, and more importantly, a common history. we were members of the ussr and suffered years of soviet occupation. we held hands in a km long human . . .chain" across the three states to express our mutual support, and later on, even joined the european union on the very same day -june st , . the three differ a bit in size, population and more in the languages spoken in each one, but that does not explain why the path towards voluntary unpaid donation varies as it does. aim: the aim is to describe the journey towards voluntary non-remunerated blood donation in the baltic states after regaining independence from the soviet union. methods: the information was collected from published and unpublished memories, annual reports and written interviews with latvian and lithuanian colleagues. results: in soviet times, all orders came from moscow and quality control was conducted from the capital city of latvia, riga. donors were mostly paid and given an extra vacation day. big factories were the best places to collect blood and people were queuing to donate. in , the soviet union fell apart and the baltic states suddenly got the freedom and responsibility to decide. in estonia the first edition of "guidelines for the preparation, use and quality assurance of blood components" was taken as guidance in . a lot of advice came from finnish colleagues. in , it was decided to move towards non-paid voluntary donations. the process took years. the first couple of years were economically difficult for the reborn state, as money had less value than food. instead of cash, donors were given rapeseed oil, sugar and pasta, for example. as the situation improved, food items were replaced by small symbolic gifts that carry sentimental value. it has been this way for more than years by now. in lithuania, the process started later, the first program for developing a framework for voluntary non-remunerated donations being carried out in - . it resulted in % of the donations being unpaid. the second program initiated in is still ongoing, aiming towards % non-remunerated donations by . by the end of , they had reached . %. in the beginning, the main obstacle was a private blood center creating unfair market conditions. in latvia, monetary compensation for blood donations still exists, but the younger generation has been encouraged to donate blood for free and some results can already be seen. summary/conclusions: a common starting point does not guarantee the same results, at least not at the exact same time. examining the circumstances leading to the different outcomes could benefit countries yet to start moving towards non-remunerated donations as well as those considering the opposite. haemoglobin (hb) was as expected significantly different between women and men (meanaesem: . ae . vs . ae . g/dl; p < . ). percentage of females with low hb < . g/dl were . %, . %, . %, . % and . %, percentage of males with hb < . g/dl were . %, . %, . %, . % and . % for the age groups - respectively. ferritin values were higher in males compared to females (median; th - th %>tile: ; - vs ; - lg/l; p < . ) and in older age groups compared to younger age groups (median; range in age groups - in females: ; - , ; - , ; - , ; - , ; - and in males: ; - , ; - , ; - , ; - , ; - respectively) . percentage of females with ferritin ≤ lg/l were . %, . %, . %, . % and . %, while percentage of males with ferritin ≤ lg/l were . %, . %, . %, . % and . % for the age groups - respectively. white blood cell counts (wbc) were slightly higher in females compared to males (meanaesem: . ae . vs . ae . ; p < . ). percentage of females with wbc > x /l were . %, . %, . %, . % and . %, while percentage of males with wbc > x /l were . %, . %, . %, . % and . % for the age groups - respectively. none had wbc < x /l. platelet counts (plt) were higher in females compared to males (meanaesem: ae . vs ae . ; p < . ).percentage of females with plt < x /l were . %, . %, . %, . % and . %, while percentage of males with plt < x /l were . %, . %, . %, . % and . % for the age groups - respectively. among the low plt counts most were caused by edta-dependent pseudothrombocytopenia. extreme deviations from normality were seldom and referred to gps for further investigations. summary/conclusions: first time donors are young with % younger than years of age and the female/male ratio was / . of the first time donors with data on ferritin available, % had low ferritin (≤ lg/l). the typical male first time donors neither had low hb nor low ferritin, even with a significantly lower ferritin in younger donors. in female first time donors the prevalence of low hb ( %< . g/dl) and low iron stores ( %≤ lg/l) is high. in all, while all first time donors are highly appreciated, campaigns could target the male population to even out the gender imbalance. blood centers must be aware of the higher prevalence of low iron stores in the youngest donors. background: the aim of assessing suitability of prospective blood donors is protection of their health and the safety of transfused patients. selection process is not always effective in obtaining all relevant information from blood donors in a timely manner. for several reasons, some risks remain undetected or they are disclosed at a future donation(s). therefore, recording and management of post-donation information (pdi) are of great importance for improvement of transfusion safety, donor counselling and education as well as overall improvement of the selection process. aims: the aim of the study was to present results of pdi management at croatian institute of transfusion medicine (citm) and the effect of education activities on their trends. methods: we have analyzed reports on pdi recorded in two-year period ( - ), according to the types of information obtained, age and sex of blood donors, total number of their donations preceding pdi, and the time of receiving the information. the effect of an information leaflet on pdi launched in november was assessed by comparing results in two study years. results: a total of pdi were recorded: in ( / donations) and in ( / donations) with the following distribution: nonsexual risk as tattoo and piercing ( . %), surgical procedures ( . %), travel history ( . %), infections/ contact ( . %), other medical reasons ( . %), endoscopy/invasive diagnostic procedures ( . %), malignancy ( . %), autoimmune diseases ( . %) and sexual risks ( . %). majority ( . %) were late pdi, revealed on the future donation(s): . % on the first next donation, . % on the second and . % after more than subsequent donations. the mean age of blood donors associated with pdi was ae years (median years), while the mean age of all donors in / was years (median years). of all pdi, . % were related to male donors ( % in total pool of citm donors). using chi-square test there were no significant difference between female and male donors in total pdi frequency and in their distribution to early and late pdi (p > . ). the median number of all donations preceding pdi was for female donors and for male donors. implementation of education leaflet for blood donors resulted in . % reduction of pdi in compared with (p > . ). the effect is more pronounced (p < . ) when comparing second and first half of (- . %). reduction is observed in all types of pdi with the exception of infections/contact (because they are mostly early pdi) and malignant diseases. the share of early pdi increased from . % in to . % in , which may suggest better awareness of blood donors on the importance to inform blood bank on changes in their health status. summary/conclusions: our study points to the importance of systematic recording and management of pdi, including education of blood donors about the need of providing all relevant facts related to their health and the safety of donated blood in a timely manner. we are planning further improvements by providing information on this topic on posters and screens on donation sites. background: currently, the transfer of data between organizations and/or computer systems is very limited, and where present is typically proprietary. in the absence of a standardized reference format individual organizations and vendors attempting to integrate disparate databases must develop unique solutions. aggregation of information from multiple sources is complex and costly, constituting a significant barrier to effective analysis of data to improve practice and inform policy. aims: to standardize the definitions and facilitate integration of key data items used in blood donation and transfusion. we report here on an initial effort to map internationally harmonized critical steps in the blood collection/donation process in order to test the approach. methods: through a collaborative process of serial conference calls and correspondence, an informal multi-national consortium of experts across the transfusion industry are attempting to create a vocabulary with sufficiently precise definitions to be usable by automated systems and that can be the foundation of a blood collection/transfusion medicine common data model (cdm), using the following steps: -define the scope of activity to be addressed and segment into key processes. -identify the set of data elements in each segment that are common to all systems. -review and consider existing standards and definitions for each data element. -develop draft definitions for each data element. -release draft to public domain for critical review and refinement with long-term goal of gaining widespread endorsement. results: a standardized approach to blood donation was mapped through identification of common pathways and core mappable data elements. denominator data associated with donor characteristics and blood collection was selected as the first segment to address. a dictionary (or vocabulary) of common terms has been created and will be presented for international comment. summary/conclusions: developing an international consensus on the core elements and their definitions across the transfusion chain is critical for data integration and automation efforts. the expected benefits of this endeavor include that it allows the establishment of algorithms to automate reporting and thus reduce hands-on staff time; reduces time and resources needed to integrate new databases; allows systems to continue to use existing concepts and definitions internally while also providing data output in a standardized format; supports the ability to consistently analyse, interpret and present information regardless of the data source; establishes data definitions against which new systems can be developed; helps to improve comparability of results by providing a common data model for researchers and policy makers; improves confidence in data integrity and reliability of the derived information as a © the authors vox sanguinis © international society of blood transfusion vox sanguinis ( ) (suppl. ), - basis for rational decision making; and reduces data gathering effort and cost thus improving opportunities for more efficient/complex data analysis. standardizing the transfusion medicine dataset is the first step in achieving the automation of data transfer and analysis needed globally to drive patient safety, research innovation, and best business practices. further steps must address the precise methods of data exchange, identification of responsible entities for maintenance and further development, and engagement of computer system developers. red blood cell (rbc) alloantibodies develop in a subset of individuals following exposure to non-self rbcs through transfusion, pregnancy, or other activities; these antibodies can lead to difficulty locating compatible rbcs, acute or delayed hemolytic transfusion reactions, or hemolytic disease of the newborn. alloimmunization is underestimated due in part to antibody evanescence, the random nature of posttransfusion antibody screens, fragmented medical care, and the lack of widespread antibody registries. factors that influence who will develop detectable alloantibodies are not well understood. transfusion burden is one risk factor for alloimmunization, though many highly transfused individuals never form alloantibodies despite exposure to many rbc units (and many non-self abo blood group antigens). individuals with sickle cell disease (scd) and myelodysplastic syndrome (mds) are more likely to form rbc alloantibodies than most other patient populations. individuals with rheumatologic and other forms of autoimmunity, though not chronically transfused, are also at higher than average risk of forming rbc alloantibodies. inflammation, in a broad sense, is one common thread among these diagnoses associated with high prevalence rates of rbc alloimmunization. reductionist murine models support some types of inflammation (including viral-like stimuli) around the time of rbc exposure as being associated with an increased likelihood of alloantibody formation. strategies other than transfusion avoidance or extended antigen matching beyond abo/ rh would be beneficial to prevent new rbc alloantibody formation, especially in patients at highest risk. background: the unique genetic makeup of the omani population makes them rich in the genetic blood disorder. % of omani populations are Àa/Àa gene carriers, % Àa/aa, and % of the population are aa/aa. around % of omani nationals carry the gene for hbs, and - % carry the gene for b-thalassaemia. recent statistics show that there are around patients with thalassaemia major and with scd in oman. the other rbc abnormality that is common in oman is g pd deficiency which is found in % of males and % of females. omanis are known to have the highest frequency of a thalassaemia and g pd reported so far in any race. although blood transfusion is one of the supporting treatments of scd, it can cause some serious complications for the patients. alloimmunization of red blood cells is one of the consequences of blood transfusion. alloimmunisation of the rbcs can cause haemolytic transfusion reactions and may trigger hyperhaemolysis, in which transfused and patient's own rbcs are destroyed. alloantibodies can cause delay in the process of transfusion, it can be costly and time consuming. high number of patients developing alloantibodies may indicate a major difference in the patient and donor population. it may also indicate lack of a controlled, generalised sickle patients management policy. in oman the decision of transfusing scd patient is left to physicians attending the patient. aims: this study is aimed to highlight the increasing number of alloimmunised sickle cell patients. in the royal hospital we get new cases of sickle patient with alloantibodies each year. the acknowledgement of these cases may help in is assessing the current practice of transfusing scd patients, or will help to define the donor and patient population difference. methods: patients were recruited in the royal hospital for this study. edta blood samples were taken for antibody screening test and in the positive cases antibody was identified, all tests done by capture technique using immucor neo machine. results: of the scd patients, % of the patients were male and % female, mean age was years, in the range of - years. % of the scd cases were positive for the alloantibodies, % were female and % were male, the age range was from - years. % of the positive were scd, % s trait and % were s/ bthal. most of the patients developed one antibody, however cases of multiples antibodies were also detected. % of the patients were with single alloantibody, % of them with two antibodies, % with three antibodies, % with four antibodies and % with five antibodies. the majority of the cases were igg against rh antigens anti-e is being the majority %, followed by anti-d %, anti-k %, anti-c %, anti-c %, anti-jk a %, anti-jk b %, anti-fy a %, anti-e %, anti-s %, antis %, anti-kp a . %, anti-fy b . % and igm being %. summary/conclusions: rbc alloimmunisation rate is high in oman majority of the patient affected are female. interestingly sickle trait patients were also transfused and % of them developed alloantibodies. the practice of transfusing rh and kell matching blood unit is implemented four years ago and still high alloimmunization percentage is achieved. background: in ghana, routine pre-transfusion investigations for patients with sickle cell disease (scd) involve only abo-d typing and immediate spin crossmatch, without screening for irregular rbc antibodies aims: determine the prevalence and specificities of and risk factors for rbc alloantibodies in multi-transfused patients with scd methods: in , a cross-sectional study in multi-transfused patients with scd, from two tertiary hospitals in ghana was performed. participants' data on demography, transfusion and medical history were recorded. antibody screening and identification tests were done at sanquin, the netherlands, with standard serology using liss as enhancer and with papain treated rbc panel cells ('enzyme only'). characterization of rhd genes was done by multiplex ligase amplification assay. logistic regression was used to determine the association of patient characteristics, i.e. sex, age at enrollment (continuous), age at first transfusion (categorized as ≤ , - , - and ≥ ), previous pregnancy, number of transfused units ( , - and - and > ), and years after last transfusion (< , - , - , > y) with presence of alloantibodies results: patients ( males and females, median age years, range . - ) were included. the median number of transfusions was (range - ). the median years after last transfusion was (range weeks- . years). in patients, anti-rbc antibodies were detected. in of them the antibodies were weakly reactive with enzyme treated cells only or pan-reactive, possibly some of them representing autoantibodies or antibodies against high frequency antigens. in seven patients enzyme-only anti-le a was demonstrated, likely naturally occurring antibodies. thus, in at least patients ( . %) alloimmunization was demonstrated or suspected; in patients the alloantibodies were 'enzyme only'. besides, the alloantibodies of known specificity ( anti-d, anti-d+c, anti-e, anti-c, anti-e, anti-k, anti-s, anti-le a , anti-go a ), three antibodies reactive only with fy(a-b-) cells and two antibodies of yet unidentified specificity were detected. in six d-patients ( had been pregnant) anti-d (together with anti-c in two patients) was found. in three out of four d+ patients with anti-d, an rhd variant gene was demonstrated ( dau-alleles and diii type or diva- ). logistic regression revealed that none of the risk factors analysed was associated with the presence of antibodies in the patients. immunobiology -red cell alloimmunity fifty-eight patients, had experienced an adverse reaction during or shortly after transfusion ( patients had dark urine). adverse reactions were associated with the number of units received (or . ( % ci, . - . ; p = . ), but not with the presence of antibodies (p > . ) summary/conclusions: in at least % of multi-transfused patients with scd alloimmunization could be demonstrated, mainly ( %) directed against rh antigens. the enzyme only reactivity, coupled with absence of antibodies in seven of patients with probable haemolytic reaction and known evanescence of especially non rh antibodies suggest possible low titre and disappearance of some clinically relevant antibodies. given the high immunization rate together with the high frequency of adverse transfusion reactions, pre-transfusion screening for rbc antibodies should be considered for patients with scd. background: rh blood group system and mainly antigen d is one of the most immunogenic, diverse and clinically important protein-based blood group. antibody anti-d may induce hemolytic transfusion reactions and hemolytic disease of the fetus and newborn. anti-d prophylaxes become ineffective if an anti-d immunization has occurred. approximately % of the d+ population carries rhd alleles associated with reduced d antigen expression. qualitative variants, in which some epitopes are lacking and can produce anti-d antibody, are usually termed partial d. by contrast, d weak is commonly defined as a quantitative variant that have all d epitopes and should not make anti-d. del is a very weak form of d antigen and cannot be detected by routine serological tests. because some of del individuals have already developed an anti-d antibody whereas others did not this group contains both qualitative and quantitative changes. aims: investigation was prompted by finding discrepant results in typing of d antigen in a pregnant woman / rd pregnancy, st delivery, abortions in st trimester/. routine serological techniques detected d negativity and the presence of antibody allo-anti-d in clinically significant titre. the non-invasive testing of d status of the foetus from maternal peripheral blood was indicated, but this was not applicable due to presence of the rhd gene in the woman's dna sample isolated from buccal swab. our aim was to investigate the discrepancy and determine the underlying rhd genotype. methods: blood samples, dna from peripheral blood and buccal swab of the pregnant woman were investigated. routine blood grouping and antibody testing were performed by column agglutination. two anti-d sera (id-diaclon anti-d igg (cell line esd ) by biorad and anti-d duo igm+igg, clone: th + ms by immucor) were used for adsorption/elution test for identification of del phenotype. initial rhd genotyping was performed by rt-pcr (exons , , ) with the dna from buccal swab; further resolution was performed using pcr-ssp (fluogene; inno-train diagnostik gmbh); sequencing was performed by sanger analysis (inno-train diagnostik gmbh). results: genotype was identified as rhd positive by ce-certified pcr-ssp kits (fluogene). sanger sequencing of rhd from exon to revealed presence of a nucleotide deletion in position c. dela, which is specific for allele rhd* el. . this nucleotide change results in the amino acid change p.val leufs* causing the del phenotype. presence of antigen d was proved by adsorption/elution technique. titre of the anti-d was rising during the pregnancy to the level two weeks before the delivery. the newborn was delivered by s.c. without a sign of hemolytic disease. blood grouping of the newborn revealed blood group a, d negative, dat negative, testing for del was not performed. summary/conclusions: the case reported here shows that females with rhd* el. allele are able develop strong anti-d immunization, so this type of del phenotype belongs to the "partial del subgroup". presence of variant rhd gene in mother disabling antenatal fetal genotyping from maternal blood by current methods requires a more attentive approach to care for such pregnancies. supported by mh cz-dro uhkt and rvo-vfn . a-s - ea scharberg , s rothenberger , a st€ urtzel , n gillhuber , s seyboth , e richter , g rink and p bugert institute for transfusion medicine and immunohematology, drk-bsd ba-w€ u-he, baden-baden institute for transfusion medicine and immunology, heidelberg university, medical faculty mannheim, mannheim, germany background: rb a (di ) is a low prevalence antigen of the diego blood group system. it has been found in few families only. the clinical significance of anti-rb a is unknown so far. the slc a *c. c>t (p.pro leu; isbt allele name: di* . ) allele is the molecular basis of the rb a antigen. in the gnomad database this gene variant was found in only one of , sequenced genomes (allele frequency: . ). aims: to prove the frequency of the allele in our population and gain an rb a positive donor we performed a molecular screening for di in , blood donors. after our antibody screening test accidentally contained an rb a positive test cell we found out that anti-rb a is a very common antibody specificity. the frequency of the antibody in patients and blood donors was proved. methods: for the molecular screening of the blood donors we developed a pcr-ssp method. the antibody screening test in , patients and in blood donors was performed in the gel technique (biorad ahg id-cards) using a cell screening panel (drk-bsd src) including an rb a positive test cell. positive reactions with the rb a positive cell were confirmed by an additional rb a positive test cell of different source. additional antibodies were excluded or identified in the same method using an antibody identification panel (drk-bsd irc). results: the molecular screening for the di* . allele in , blood donors revealed no single positive individual. within the first weeks of usage of our antibody screening test which accidentally contained the rb a positive test cell patients with anti-rb a were found. it was . % of , patients tested in laboratories in different parts of germany. some laboratories stopped using the rb a positive lot to avoid expensive and time consuming identification and conformation tests. in of randomly tested blood donors ( . %) anti-anti-rb a was also present. summary/conclusions: despite the very low frequency of the di* . allele, anti-rb a is a very frequent unexpected antibody in patients and blood donors in germany. it is obviously naturally occurring and is even more frequent than anti-wr a and anti-vw we found in previous studies in around % of patients and donors. a-s - national blood center, ministry of health and sports, yangon, myanmar hemovigilance which detects every event not only for patient' reactions and donor's complications but also incidents and near misses definitely improve quality of blood transfusion services especially for those situations where implementation of all the standards in one time is not possible. healthcare system in myanmar is still in the stage of requiring priority for clinical professions and has limited resources for supportive roles. supportive services including transfusion service are still not a center of interest from prioritization of health care system. blood transfusion service has been practiced in myanmar since . real essence of transfusion service is hidden behind laboratory practice and transfusion is regarded as part of laboratory investigation. hospital laboratories take care of testing of blood donated by replacement donors. this kind of transfusion services under laboratory umbrella is still being practiced in myanmar except national blood center (nbc) which was established in in accordance with blood and blood product law. this law was formulated cohesively with who strategies of blood safety. in , who global data-based study sent questionnaires for assessment of safety status of transfusion service. nbc noticed that there was no data which can support corrective actions for safety. from that time onward, active retrospective review of existing data and introduction of records, prospective finding of process errors and any events from hospital blood banks were recorded and taking into actions at local level. cost of every unit of blood is supported by government. in , national blood and blood product committee was established. the steering committee is working hard to get cooperation from every service by aiming to prevent those undesirable events before establishment of national level policy, standards and guidelines for sustainable service quality. in conclusion, by using essence of hemovigilance as a tool, quality of transfusion service can be improved step by step to fulfil the gap in spite of limited resources. the system started in local, extends to regional level by getting agreement of importance from hemovigilance results and is finally approaching to national level endorsement. background: erroneous transfusion of abo-incompatible(aboi) blood almost always reflects a preventable breakdown in transfusion protocols and standard operating procedures and can have disastrous consequences, with significant morbidity and mortality. these incidents need to be investigated in a systematic manner to identify system vulnerabilities to mitigate risks and improve patient safety. since , reporters to shot have been asked to score( - ) the extent to which the cause of incidents can be attributed to key factors: staff, environmental, organisational and government/regulatory which helps recognise the key factors identified whilst investigating these incidents. aims: to understand why unintentional transfusion of aboi blood components continue to happen despite standard procedures and national guidance available. methods: retrospective analysis of unintentional transfusion of aboi blood components reported to shot between - (inclusive) was done to identify common themes and recognise areas of improvement. information provided using the shot human factors investigation tool (hfit) between - was reviewed to understand more about why the errors occurred. results: sixty-seven unintentional aboi transfusions were reported between - ; majority ( / , . %) were red cell transfusions but aboi plasma ( / ) and platelet transfusions ( / ) were also seen. most errors occurred in the clinical area ( / , %), and could have been detected at point of administration. in ( %) cases, the error could not have be detected at the point of administration with a primary laboratory error in / ( %) incidents. reviewing data from hfit for cases in - ( aboi cases), the total score for staff culpability was , compared to a total score of for all the other three organisational and system factors. this disparity is most obvious for the aboi red cell cases, all of which scored the maximum for staff culpability, i.e. / compared to / as the combined total score given to the other factors. in the preceding years ( to ), there were no hf scores available; however, the emphasis on staff-related culpability is demonstrated by cases that included an outcome of the local case review and ( . %) mentioned staff-related retraining or disciplinary procedures. the risk of haemolysis and serious harm is more likely with aboi red cells than with other components with / ( %) that resulted in death, / ( %) major morbidity and / ( %) no or minor adverse reaction. of these cases, one resulted in conviction for manslaughter and at least two staff dismissals. summary/conclusions: transfusion never events continue to occur, and it is evident that investigations into such incidents focus mainly on staff failings and do not consistently identify system wide changes that need to be incorporated to address prevalent issues. national recommendations and a safety alert to 'use a bedside checklist' immediately prior to administration were issued between - to support prevention of such errors but never events continue to persist. current approach is ineffective because it often leads to apportioning blame, rather than understanding the often-complicated and multidimensional factors contributing to the error. this must be replaced by a holistic approach which addresses local work pressures and embraces advances in automated technology like electronic prescribing and barcode scanning. of the confirmed trars, n = were possibly related to treatment, n = trars were probable, and n = were definitely related to treatment; n = trars were grade , n = were grade , and none were grade . in recipients of conventional wb, there were n = ( . %) ars, n = ( . %) fnhtrs, n = ( . %) taco, n = trali, and n = ( . %) unclassified transfusion reactions. of the confirmed trars, n = were possibly related to treatment, n = trar was probable, and n = were definitely related to treatment; n = trars were grade , n = was grade and n = was grade . there were mirasoltreated wb transfusions in pregnant women and trars ( . %), both grade and probably related. there were transfusions of mirasol-treated wb and transfusions of conventional wb in patients < years old resulting in n = ( . %) trars in recipients of mirasol-treated wb and n = ( . %) in recipients of conventional wb. summary/conclusions: timely data reporting of trars and expanding the hv infrastructure has helped to improve the hv system in ghana. of wb transfusions in routine use in ghana, there were . % trars in recipients of mirasol-treated wb and . % in recipients of conventional wb. additionally, mirasol-treated wb was safely transfused in pregnant women and pediatric patients. haematology, monash health, melbourne, australia background: transfusion-associated graft-versus-host disease (ta-gvhd) is rare and usually fatal. it can be prevented by provision of irradiated blood products to at-risk individuals, such as those receiving nucleoside analogues, alemtuzumab, bendamustine or with hodgkin lymphoma (hl). duration of risk is uncertain, so ensuring these individuals correctly receive lifelong irradiated blood components, as currently recommended by anzsbt and bsh guidelines, is challenging. in australia, platelets are routinely irradiated, but red blood cells (rbc) are not. aims: to determine whether patients receiving fludarabine, cladribine, bendamustine, alemtuzumab, or dacarbazine (for hl), appropriately received irradiated rbcs. secondary outcomes included rates of ta-gvhd after unintended exposure to non-irradiated components, factors influencing correct issue of irradiated rbcs such as transfusion management plans, and provision of adequate clinical information on blood requests. methods: we performed a retrospective audit to identify patients receiving therapies indicating risk for ta-gvhd using pharmacy dispensing records from january to october at monash health, a multi-campus university hospital in melbourne, australia. diagnosis, treatment dates, group and hold (g&h) requests, rbc transfusions, and follow-up information were sourced from laboratory and medical records. results: we identified patients who received fludarabine (n = , %), bendamustine (n = , %), cladribine (n = , %), dacarbazine for hl (n = , %) and alemtuzumab (n = , %). the median age of patients was years (range - ) and ( %) were male. median follow-up was months (range - ). post-exposure, patients ( %) received transfusions with % correctly receiving irradiated rbcs. the remaining , all from haematology/oncology, received a total of unirradiated rbcs. in patients, this was rectified on subsequent transfusions. there were no cases of ta-gvhd at median follow-up of . months (range - ) from first rbc transfusion. after medication administration, patients had g&h requests after a median of months (range - ). only % of requests had sufficient clinical information to prompt irradiation, such as hl or medication details, and only % asked for irradiated components. preventive strategies have now been employed. transfusion management plans for haematology patients were implemented in march . for audited patients, these were written from days prior to days after medication exposure. two were written following inadvertent unirradiated rbc transfusion. patients identified in this audit will have a laboratory flag generated and prospectively, pharmacy dispensing records will be sent to blood bank to identify at-risk patients. our hospital is transitioning to electronic medical records (emr). an alert will be generated in emr when ordering transfusions if there has been exposure to these medications. however, clinical awareness and documentation remain vital. additional measures include patient education, alert cards, and ongoing collaboration with medical staff to encourage transfusion planning. summary/conclusions: recognition of patients at risk for ta-gvhd remains low, even among haematology units. we are making progress on ensuring provision of lifelong irradiated blood components in patients exposed to nucleoside analogues or alemtuzumab, as well as hl patients. implementation of an emr and additional strategies in this domain is important to prevent ta-gvhd. background: blood transfusion is considered an essential element in the management of patients globally. it might be risky and transfusion related adverse reactions may occur with the less adherence of transfusion policies. standard guidelines regarding the screening of blood for infectious disease, genuine need of transfusion and abo compatibility are followed and monitored drastically. however, patient assessment during transfusion especially at patient bedside and post transfusion is also equally important. aims: we are a newly established hospital and are working towards the best possible management of patients. in this regard to minimize the transfusion errors and to highlight if any lacking being practiced during transfusion, we conducted this study to observe the compliance rate of documentation of transfusion form by the healthcare staff and also to observe the compliance of line of action taken in case of occurrence of transfusion reactions. methods: this was a observational study conducted at nibd and bmt, pechs campus from february to february . ethical approval was obtained prior to the study. transfusion form for each transfusion was filled. the form provided information on documentation of blood product receiver name, employee identity number, date and time of receiving blood product, patient name, medical record number on units, on patient's wrist band and on transfusion form. abo compatibility on the unit and on form, medical record number from wrist band, name and employee identity number of two healthcare staff started transfusion, transfusion start and completion time. time, temperature, blood pressure, pulse and initials of staff at the time of order, onset, after minutes and at the completion of transfusion were also included. transfusion reaction form was also filled by the healthcare staff. data was analyzed by using spss version . . results: a total of transfusions forms were analyzed. over all compliance rate was %. out of , ( %) forms were available in source notes and of , ( %) were partially and completely filled. higher compliance was seen in the initial months of hospital establishment than later months (p-value = . ). highest non compliance was seen in documentation of initials of duty doctors on transfusion form at the completion of transfusion( %) and highest compliance was seen in documentation of name by healthcare nursing staff at the start of transfusion( %). a total of ( . %) adverse events were reported from red blood cells and platelets. mean time of start of symptoms was hours and minutes for red blood cells and for platelets it was hour and minutes. transfusion was instantly stopped as the symptoms appeared with no delay of time and actions were taken to resolve the reactions. time of appearance of symptoms and time of start of medication were documented and error free. all blood bags were returned to the blood bank and discarded after hours as per the policy of hospital. summary/conclusions: the study was conducted to highlight the scarce practices that are being implemented by healthcare staff in context of documentation and reporting of transfusion reactions at our hospital. stringent actions should be taken for the adherence of compliance by healthcare staff to avoid morbidities and mortalities. we believe that it will also be helpful to provide baseline information in the process of preparation of a national guidelines and protocol on blood transfusion procedures. a-s - as buser, a holbro and l infanti regional blood transfusion service, swiss red cross, basel, basel, switzerland to make blood supply safer, pathogen inactivation (pi) technologies have been developed. they are based on photochemical (amotosalen/uva or riboflavin/ uv) or uv-c light treatment to reduce potential pathogens in blood components. this gain of safety might however be offset by "off target" effects of these technologies. in virtually all clinical platelet transfusion trials, it has been demonstrated that post transfusion increments with pi platelet (plt) components are lower as compared to conventional components, indicating different biological behaviour such as survival/ clearance of nontreated and treated plt. published studies have also suggested shorter survival of platelets in vivo in animal studies. additionally, data of the rates of alloimmunization and refractoriness after transfusion of pi platelets are show discrepant results. animal studies suggest a reduction of the rates of alloimmunization when transfusing (leukoreduced) pi plt as compare to conventional plt. in the clinical setting, published data, including very recent reports, showed different rates of hla class i and ii alloimmunization with the two currently available photochemical based pi technologies. while pi of plt components surely benefit patients regarding pathogen safety, the impact of potential off target effects possibly impairing efficacy of pi plt transfusions need more investigation. background: brucellosis is an endemic disease and still a major health problem in saudi arabia. ministry of health in saudi arabia listed brucellosis as a notifiable disease due to its endemicity. in the last ten years, the incidence has decreased significantly to approximately cases per , but is still higher than that in developed countries. human-to human transmission is extremely rare including breast feeding, transplacental, sexually and blood transfusion. five cases of brucellosis through blood transfusion have been reported in the literature. brucella transmission through blood transfusion is likely underreporting due to the long incubation time of - weeks (range, days to months),vagueness of clinical presentation and lack of hemovigilance systems in endemic areas. (allohsct) and ( . %) autologous (autohsct) hsct patients, with mean corrected count increments (cci) of . , . and . , respectively. mean cci decreased in a linear fashion between day ≤ and day pcs ( . , . and . at ≤ days; . , . and . at days, respectively), although the number of pc transfused on day to autohsct patients was small (n = ). background: nipah virus (niv) is a paramyxovirus (genus henipavirus) that emerged in the late s in malaysia and has since been identified as the cause of sporadic outbreaks of severe febrile disease in bangladesh and india. niv infection is frequently associated with severe respiratory or neurological disease in infected humans with transmission to humans through inhalation, contact or consumption of niv contaminated foods. nipah virus (niv) belongs to the list of pathogens identified by the who to have the potential for a global pandemic. aims: this study aimed to investigate the efficacy of the theraflex uv-platelets system to inactivate niv in platelet concentrates (pcs). the theraflex uv-platelets system (macopharma) uses uvc light without the need of any additional photoactive compound. methods: plasma reduced pcs from bcs ( % plasma in additive solution ssp+) were spiked with virus suspension ( % v/v). pcs (n = , ml) were then uvcirradiated on the macotronic uv machine (macopharma) and samples were taken after spiking (load and hold sample) and after illumination with different light doses ( . , . , . and . (standard) j/cm )). the titre of the niv (malaysia) was determined as tissue culture infective dose (tcid ) by endpoint titration in microtitre plate assays on vero cells (atcc â crl- tm ). the results of the infectivity assay demonstrated that uvc irradiation dosedependently inactivated niv. after spiking a niv titer of . (bag no. ) and . (bag no. ) log tcid /ml was received in the pcs. at a uvc dose of . j/cm and higher niv was inactivated down to the detection limit of the system ( . log tcid / ml), resulting in log reduction factors of ≥ . (bag no. ) and ≥ . (bag no. ). summary/conclusions: our results demonstrate that the theraflex uv-platelets procedure is an effective technology to inactivate niv in contaminated pcs. vs. ae . e platelets/unit, p < . ), whereas the platelet content of apheresis pc did not change ( ae . vs. , ae . , p = . ). summary/conclusions: pathogen reduction resulted in the transfusion of older pc on average, but without altering the number of pc ordered or the use of pc per patient. pathogen reduction has improved pc stock management without an increase in platelet demand, despite lower platelet content of buffy coat pc after pr implementation. donors and donation -donor adherence -are we doing the right thing? the transfusion procedure is the last step in a multi-process supply chain. the task of matching supply with demand requires donor managers to consider average consumption rates on a weekly or monthly basis, but to also have insight into variability in order distribution and possible attribute (blood groups) requirements. since hospitals and blood banks are usually not deeply interwoven and often only ex-post data is available, forecasting methods should be implemented. a thorough analysis of order pattern to set weekly target inventories and safety levels is required to close the information gap. a collection plan needs to identify possible bottlenecks which can be prevented through the planning of inter-shipping, changes in message urgency and building of reserve donor pools. constant analysis of collection and mobilization kpis allows donor managers to implement the rolling-wave planning approach and continually adapt to changing requirements, unexpected events and overall systematic variability. the variability happens on the demand side, as order quantities and their attributes, such as blood group distribution, are subject to change. however, also the supply is subject to significant variation, as donor response rates, attrition, deferrals and overall availability of donors are not constant. the data was collected with the face-to-face interview method right after the donation. first-time donors has attended to the study in regional blood centres in cities in turkey. the survey included items in accordance with the standard tpb predictors of attitude, self-efficacy, and intention. self-identity, anticipated regret, donation anxiety, paraphernalia anxiety, personal moral norm, descriptive norm, satisfaction, motivation also assessed for the first-time donors. the relation between the predictors and intention confirmed with correlation analyses. the predictors' distribution analysed by multiple linear regression. a number of goodness-of-fit indices were calculated and examined for each tested models (ibm, amos spss). the results of goodnessof-fit tests for proposed model provided a better fit to the data than these models (cmin/df = ). moreover, this result indicated that the fit between the proposed model and the data could be improved with further modifications with the inclusion of paths between motivation and attitude, self-identity and intention. moreover, inclusion the paths between donation anxiety and intention and between self-efficacy and attitude, on contrary to recent analyses suggesting opposite paths. evaluation of goodness-of-fit tests showed good result for revised model with a value of cmin/df = . , close to perfect fit. the revised model revealed that attitude was the strongest positive direct predictor of intention followed by personal moral norm, self-identity, motivation and anticipated regret (path coefficients: . , . . . , . , and . , respectively). donation anxiety was the negative direct predictor of intention (- . ). satisfaction was the strongest positive indirect predictor of intention via attitude and followed by self-efficacy ( . and . ). paraphernalia anxiety was the negative indirect predictor of intention (- . ). descriptive norm did not show any significance. our model accounted for . % of the variance in intention. summary/conclusions: these findings suggest several potential avenues for enhancing donor retention. the results obtained with this study provide important data from the standpoint of donor retention, which should be, implemented in the future strategies of turkish red crescent. background: transpose-transfusion and transplantation: protection and selection of donors, is a european consortium project, including partners from countries, reviewing donor selection and protection policies for substances of human origin (soho).one of the main issues in the current donor selection system, which transpose aims to tackle, is that for many, if not most criteria, is not evidence based. the transpose consortium therefore tries to re-assess selection criteria, revised them where needed and provide recommendations as evidence-based as possible. transpose additionally adds to the current european directorate for the quality of medicines & healthcare (edqm) guidelines by emphasizing donor safety. aims: the aim is to compare existing donor eligibility criteria throughout europe, and to compile a list of risks to consider, with evidence-or consensus-based deferral criteria to provide more uniform donor screening criteria. methods: there are three horizontal work-packages (wps); wp coordination, wp dissemination, and wp evaluation of the project, and four technical ones with specific deliverables and milestones to be regularly produced: -wp inventory of donor selection & protection practices; -wp development of risk-based guidelines for donor selection and protection; -wp development of a standard donor health questionnaire (dhq); -wp training course/workshop on the use of the guiding principles, guidelines and the dhq. the transpose project launched in september and will complete in spring . wp has completed its work in october, wp will complete its work in june , and wp and wp have recently commenced. results: with the use of the deliverables created by wp , we have created an indepth inventory of current practices in donor selection and protection, including overview of similarities and differences across european countries and across soho types. there is an agreement amongst experts that existing guidelines are often based on the precautionary principle rather than on risk assessment. consequently, in the development of wp 's guidelines for donor selection and protection, we now make an effort to also emphasize donor safety, in a more evidence-based way via the use of risk-based assessments. this will result in a standardized dhq with a common trunk and more in -depth questions per soho. summary/conclusions: the impact of the outcomes of transpose will be threefold. first, outcomes are expected to be of help in revising donor selection and protection related eu directives. second, the set of guiding principles and donor selection & protection guidelines will facilitate eu member states to take a next step in implementing donor selection and protection policies in a consistent and clear-cut way to the benefit of both donors and recipients of soho. third, a standard donor health questionnaire with carefully guided local/regional/national adjustments will become available per soho which can be used widely and will consequently enable comparisons of the prevalence of certain risks and risky behaviours throughout europe. background: transpose-transfusion and transplantation protection and selection of donors is a european consortium project, including partners from countries, that reviews donor selection and protection policies for blood, plasma, tissues, assisted reproductive technology (art) and stem cells (together soho). donor selection criteria (dsc) in europe are based on eu-directives, guidelines and countries' own additional criteria. literature shows that particular criteria are outdated or not risk-based, often leading to unnecessary donor deferral or an underestimation of risks for donors. aims: to ) provide a comprehensive inventory of current systems for selection and protection of donors and donations, ) critically review them and ) recommend an over-arching donor health questionnaire (dhq) including all necessary criteria currently used by different eu-member states (eu-ms). methods: in-depth semi-structured interviews with key stakeholders in blood collection were conducted to identify main topics for improvement in the current dsc. these formed the basis for a survey sent to professionals from collection institutions of all soho to get feedback on current systems from as many eu-ms organisations as possible. questionnaires were sent to a total of experts ( blood; plasma; tissues; stem cells; art) and ( %) completed questionnaires were received. where information was lacking, additional experts were asked to recommend upon dsc. results: for blood and plasma donation four main areas of concern in dsc were identified: risk-based selection, adaptability, flexibility and consistency. the stakeholders agreed that dsc are often outdated and lack evidence, hence leading to unnecessary deferral of donors and underestimated risks for donors. they suggested to base dsc on group risk-assessment (risk-based selection) and on conducting more research to achieve standardized risk perceptions and evidence-based deferrals, either for safety of recipient or donors. criteria could be made more detailed to fit specific groups to defer less donors (adaptability). furthermore, implementing criteria was considered easy, but abolish criteria when not regarded as a risk anymore seems almost impossible (flexibility). additionally, deferral periods are perceived too long, seen as both negative, i.e. jeopardizing donor return intention and positive, i.e. no risk for safety (consistency). changing legislation into guidance was an often-mentioned suggestion to improve dsc. specific feedback on plasma donations revealed that many whole blood topics are not applicable to plasma-only donors, e.g. parasite infections such as malaria (no deferral needed); travel history (no deferral needed), and recent bacterial and viral infections (deferral periods currently too long). a clear need for more research on plasma collection-related issues was identified. summary/conclusions: dsc are perceived redundant on a substantial number of aspects by most stakeholders. besides achieving the goal of save and sufficient soho for patients, many regulations could be improved to diminish deferrals and decrease donor risks. transpose will add to reviewing, improving and harmonising these regulations and criteria. furthermore, transpose will provide suggestions to improve directives and guidelines and a dhq, focusing on both donor health protection and safety of donations, but also removing deferral criteria that are not relevant (anymore), and offer a future research agenda to make dsc more evidence-based. background: transpose -transfusion and transplantation: protection and selection of donors, is a european commission co-funded project with participation of stakeholders from both not-for-profit and private blood collecting organizations as well as researchers and officials. the project aims to create new evidencebased donor selection criteria as well as guiding principles for risk assessment of threats to the safety of all substances of human origin (soho) except solid organs. as part of this, an inventory of current donation-related risks was performed, including an investigation of both type and number of adverse events reported. aims: we here aim to present an overview of reported adverse events in plasma and whole blood donation in europe and to compare this to the anticipated risks rated by transpose stakeholders. methods: national or local data on adverse reactions from the years - , both serious and mild, in whole blood and plasma donors was collected from the relevant stakeholders (eighteen and nineteen respectively). stakeholders were also asked to grade the most important anticipated donor risks according to severity, level of evidence and prevalence. we then compared the relevant risk categories as evaluated by the stakeholders with the categories of the provided data, as well as the heterogeneity of category numbers. results: thirteen stakeholders provided data on adverse events during whole blood donation in a given year, including in total thirty-three different categories of adverse events, ranging from only one unspecified reaction to seventeen different categories, with an average of nine categories per stakeholder. the most frequently used categories were hematoma (included by %), arterial puncture ( %) and nerve damage ( %). vasovagal reactions were also frequently included ( %); however, this was being done variably as vasovagal reactions unspecified, and acute and/or delayed vasovagal reactions. only one stakeholder reported iron deficiency. for plasma donation, seven stakeholders provided data on adverse events. a total of twenty-seven different categories were reported, ranging from one to seventeen per stakeholder, with an average of nine. the most frequently reported adverse events were hematoma ( %), citrate reactions ( %) and arm pains and nerve damage (both %, respectively). anticipated risks in blood donation were rated by nine stakeholders rating iron deficiency, vasovagal reactions and hematomas the greatest risks to donors. for plasmapheresis, six stakeholders rated vasovagal reactions, hematomas and citrate reactions as highest risk. summary/conclusions: as shown, categories used to describe adverse events in blood donation vary tremendously across europe, with some countries only being able to provide total numbers of adverse events without further specification. furthermore, there is a gap between perceived high donor risks and reported adverse reaction categories in donor vigilance for whole blood, as reports on iron deficiency are virtually absent despite being considered the most significant risk. our findings show the need for international collaboration on creating an international standardized donor vigilance system, to gather more insight into donor risks to protect the health of donors. plenary session -a glimpse of the future pl- - modern transplantation medicine has made significant progress within the last decades due to a better immunological understanding of rejection and advances in immunosuppression. however, the severe side effects of long-term, typically lifelong, immunosuppression and the shortage of donor organs remain the major restrictions in transplantation. the idea behind all research to improve transplant outcome has always been the modification of the recipient's immune system to ideally induce a specific tolerance towards the donor's graft. in fact, the immunological blindness of the recipient towards the donor's graft is achieved by a general reduction of the immune system's competence and represents a major burden for transplant patients. the idea of invisible organs is an entirely different approach to solve the problem: instead of inducing an immunological blindness of the recipient's immune system an immunological invisibility of the donor's organ is created. this is achieved by genetically engineering the transplant to eliminate the organ's immunogenicity defined by the gene products of the major histocompatibility complex (mhc) and minor histocompatibility antigens. in addition to manipulating the expression of mhc genes required for immune recognition, immune cloaking strategies are used to evade immune rejection. these approaches take advantage of creating an immunosuppressive environment and expressing immune suppressive molecules by immunomodulatory transgenes. mhc engineering and immune cloaking in an entire organ is achieved during ex vivo perfusion by lentiviral transduction of gene expression modifiers and transgenes to induce a permanent immunological invisibility of the organ. importantly, mhc engineering also prevents the presentation of minor histocompatibility antigens, which usually are not possible to match between donor and recipient, but which trigger potent immune responses and graft rejection. eliminating the targets of cellular and humoral rejection as well as creating an allograft-specific immune environment through immune cloaking camouflages the organ and equips it with a powerful set of defense weaponry. immune-engineering of transplants achieved during the inevitable ex vivo period of the allograft after explantation without the need to accept off-target effects allows keeping the recipient's immune system fully functional and capable to combat infections and cancer. in pre-clinical in vivo studies from rodents to minipigs a clear survival advantage of ex vivo engineered transplants could be demonstrated. this approach has the potential of eliminating the burden of organ rejection and immunosuppression, thereby sustainably increasing transplant survival, organ availability and quality of life. gene editing for sickle cell disease: re-expression of the fetal c-globin genes (hbg / ) could be a universal strategy to ameliorate the severe b-globin disorders sickle cell disease (scd) and b-thalassemia by induction of fetal hemoglobin (hbf, a c ). we have previously identified bcl a erythroid enhancer sequences, marked by hbf-associated common genetic variants, that are required for repression of hbf in adult-stage erythroid cells but dispensable in non-erythroid cells. recently we have optimized conditions for selection-free on-target crispr-cas editing in human hscs as a nearly complete reaction without detectable genotoxicity or deleterious impact on stem cell function. we demonstrate that cas :sgrna ribonucleoprotein (rnp) mediated cleavage at core sequences of the + bcl a erythroid enhancer results in highly penetrant disruption of gata binding motif, reduction of bcl a expression, and induction of fetal c-globin. erythroid progeny of edited engrafting scd hscs express therapeutic levels of hbf and resist sickling, while those from b-thalassemia patients show restored globin chain balance. moreover we find that hscs preferentially undergo nonhomologous as compared to microhomology mediated end-joining repair. nhej-based bcl a enhancer editing approaching complete allelic disruption in hscs appears to be a feasible therapeutic strategy to produce durable hbf induction. in this presentation, i will compare and contrast bcl a enhancer editing to other autologous curative gene therapy and gene editing approaches at various stages of clinical and pre-clinical evaluation. oxygen is vital for life. without oxygen death is assured for aerobic organisms. although everybody knows this fact a lot of medical acts forget to take care of it, leading to a lot of potential troubles. indeed, during cell respiration the glucose oxidation by oxygen gives carbon dioxide, water and energy. this energy also called atp is necessary for cellular metabolism and consequently for life. we have identified an extracellular hemoglobin coming from a marine worm, called arenicola marina, which is able to deliver oxygen to this animal living in the intertidal areas on the atlantic coast in france between the north sea and biarritz. this molecule called m was developed in the medical device named hemo life â . we have showed that this product was very efficient to protect organs before transplantation. a multi centers clinical trial performed under the supervision of pr. le meur from the chu of brest, on patients waiting kidney grafts showed a delay graft function reduced roughly by three between the two kidneys harvested on the same donor with and without hemo life â and grafted on recipients. in , a world first was realized in france by the pr. lantieri to georges pompidou hospital in paris, france. indeed, it was the first time that a patient received a second graft face. this surgery was realized with hemo life â and showed a very nice result according the pr lantieri, the anastomosis were very easy and no edema was observed. furthermore, we have developed dressing incorporating m making a product called hemhealing â . preclinical data on diabetic mice showed an increase of healing process. hemoxycarrier â , a therapeutical oxygen carrier, is also in progress of development in order to address ischemic diseases such as the sickle cells disease, myocardiac infraction and stroke. this universal oxygen carrier without blood typing, which is the ancestor of our red blood cell containing hemoglobin showed that it is able to deliver oxygen at different biological levels, cellular, tissues and organs and could address a multitude of medical applications. background: main goal of transfusion is saving life and/or improve the health status of human by "safe blood" which needs regular, voluntary, unpaid blood donors. donor recruitment is being more sensitive and challenging part of the blood supply system in actual global socio-economic conditions. achievement to enough voluntary non-remunerated blood donation (vnrbd) can be established by an efficient donor recruitment. efficiency of the donor recruitment has still close relation with blood donor recruiter although there are so many new tools. occupational specifications, rights and responsibilities of blood donor recruiter have wide range differences between countries which cannot be explained completely by the specific conditions of each country. also, a concrete document which has an international consensus was not existing on this subject. turkish blood foundation (tbf) has been organizing an international workshop since ; anatolian blood days (abd). "who is a blood donor recruiter?" was the topic of abd-vii at - march . aims: main aim of the workshop was to check and evaluate the existing systems of the participant countries. than create a model for clearly defining occupational specifications, responsibilities and rights of blood donor recruiter. methods: experts from countries participated in the workshop. those countries are albania, algeria, bosnia-herzegovina, estonia, france, germany, hungary, india, kazakhstan, lithuania, macedonia, montenegro, oman, portugal, qatar, romania, russia, saudi arabia, serbia, slovenia, sri lanka, tajikistan, turkey, uganda, uzbekistan. these countries reflect almost all religious, ethnical, social, cultural and economic situations of the world. a questionnaire which was analyzing existing systems at participant countries sent before the workshop. after country presentations different discussion groups were organized. below listed topics were announced at final declaration. results: donor recruiter: . should have university degree preferably in marketing and business administration field. . should have a certificate and/or professional experience in public relation . should have efficient skill in conversation, sociability, independence, self-confidence, reliability, resilience and conscientiousness as well as to work in a team . should get a special training which includes not only social topics such as public relation, marketing, etc. and medical topics related bb&tm before practicing alone as a donor recruiter . should be a permanent staff . should have basic salary and performance bonus might be given . is eligible to monitor and modify mobile team working period at blood drive . should participate the mobile blood drive which he/she has organized . should participate the group who will create promotional materials for national blood service . number at each blood establishment should be defined based on annual blood collection such as staffs for , whole blood collection annually in germany. summary/conclusions: in conclusion; both donor recruitment and retention are not easy tasks to undergo while public are aging, and birth rates are decreasing all around the world. dedicated blood donor recruiter whose occupational specifications, rights and responsibilities are clearly defined will be the corner stone of the success for providing enough safe blood for transfusion. ct smit sibinga and j emmanuel background: africa is a large continent with independent states and a total population of , , , (february ) . healthcare policies and strategies are developed through who's advocacy, guidance, and support from hq in geneva and the who regional offices; eastern mediterranean regional office (emro) supporting arabic speaking countries and the african regional office (afro) responsible for sub-saharan countries. population distribution is approximately . % urban. there are a large number of different local dialects and languages spoken. the main languages spoken are english, french, portuguese, spanish and arabic. countries are mainly classified by undp as being of low and medium human development index the africa society for blood transfusion (afsbt) has members in most countries, advocates for the development of sustainable and effective blood services, and has developed a stepwise level accreditation program. in emro held a consensus meeting developing a "strategic framework for blood safety and availability for - " with a set of priority interventions focusing on leadership and governance, cooperation and collaboration, provision of safe blood and blood products, appropriate clinical use of blood, and quality system management. in all member states of the african union (au) countries, in abuja, nigeria, pledged that national budget for health should be at least % of the national fiscal budget. in ministers of health of who member states endorsed that blood and blood products be included in the essential medicines list; these endorsements and who's universal health coverage (uhc), have yet to be fully implemented. aims: to analyze (gap-analysis) to what extend countries in africa implement the world health assembly resolution wha . on availability, safety and quality of blood products, which urges governments to ensure safe, accessible, affordable and available supplies of blood and components from voluntary non-remunerated blood donors, which meet clinical transfusion requirements and achieve national self-sufficiency, following who guidelines and recommendations. methods: to provide an overview of the current status of the blood supply in africa strengths and weaknesses, data from who's global status report on blood safety and availability were analyzed and used. the study has been descriptive and explorative. results: the report identified a number of areas requiring attention; principle amongst these were -inadequate funding; -lack of governance and leadership; -ineffective public education on blood donation; -absence of capacity building for clinicians on rational use of blood; -lack of haemovigilance and implementation of quality management systems; -the need for regulatory or oversight mechanisms. summary/conclusions: national authorities should address areas requiring attention if progress towards ensuring a sustainable safe and sufficient supply of blood products is to be achieved. key is the commitment and support of national governments, which should implement resolutions and recommendations agreed by ministers of health at wha and african union. background: the core function of the blood donation testing (bdt) laboratory is to screen every unit of blood collected from a donor for blood group type and infectious disease markers to ensure safety of the national blood supply prior to transfusion. the lab operates daily on two work shifts, comprising of staff on the morning (am) shift (from : to : ) and staff on the afternoon (pm) shift (from : to : ) on weekdays and staff on the am shift and staff on the pm shift on weekends. bdt lab has a staff strength of to be rostered for the work shifts. each staff is on a five-day work week and has to work pm shift and am shift per month on average. the higher number of pm shift leads to staff feedback that they do not get sufficient time in the evenings for family and social or leisure activities. a lean six sigma project was initiated to review the work rostering to improve the work-life balance of the staff. aims: the project aims to reduce the number of staff working on the pm shift without affecting the downstream processes and continues to meet the timely release of blood supply to the hospitals. methods: lean six sigma tools were used to study the bdt lab workflow process and to identify factors that contributes to the higher number of pm shifts that the staff has to take on. data on the turn-around time and the man-effort required for each screening tests performed was analyzed. a survey was also conducted to understand the preference of the staff on the acceptable number of pm shifts per month. results: the main contributing factor for more staff required to perform the pm shift is due to majority of the daily donation samples being received only in the evening. as this factor is beyond the control of the bdt lab, redeploying work from the pm shift to the am shift was eventually selected as the solution to reduce the number of staff needed for the pm shift. the screening test that was shifted was determined based on the test system that has the shortest turn-around-time and is able to allow continuous release of results. at the same time, most of the staff must be trained for that test system. a trial on the new roster involving staff on am shift and staff on pm shift was conducted. the total number of pm shift per month was reduced from to using the re-defined process. the % reduction translates to fewer number of pm shifts that the staff has to undertake and was able to meet the staff's expectation. summary/conclusions: with the adoption of the new process workflow, bdt lab was able to reduce the number of pm shifts that the staff needs to be rostered using evidence based process improvement method. most importantly, the lab has a satisfied team of staff with better work-life balance. background: preparedness of blood transfusion services for emergencies and crisis situations is an important issue concerned with patient and transfusion safety. aims: having an experience of delay in blood component supply in an emergency situation due to partial interruption of hospital information system (his), it is aimed to create a crisis kit and constitute an alternative work flow for emergency in crisis situations. methods: it is stipulated that the failure of his which is normally conducts all process for transfusion would be disabled in a disaster or crisis situation. a brain storm was made on possible challenges associated with disability of his during transfusion emergencies. according to the scenarios a kit was developed for the process management of transfusion emergencies. results: a flow chart was designed in proper with transfusion emergency definitions of who and instructions were written to explain the flow chart. all forms categorized with different colour codes are designed to fill with handwriting. the kit consists of flow chart and instructions, analysis request forms (blue coloured), blood component request forms (pink coloured), proceeding forms (green coloured), pens and blood sample tubes with edta were put into a plastic folder labelled as transfusion emergency disaster & crisis (tedc) kit. additionally, the kit is placed in a sealed clear plastic bag and delivered to all inpatient and intensive care units of pediatrics and pediatric surgery. a training programme concerned with transfusion emergency situations and usage of the tedc kit was developed for health care workers involved in blood transfusion process. pre and post-assessment tests were developed for the evaluation of effectiveness of the training programme. summary/conclusions: it's challenging to improve the response capacity of blood transfusion services during emergencies and crisis situations. abstract withdrawn. background: india is a developing country having licensed blood banks majority have manual documentation which causes inaccuracies and errors in blood bank activities. monitoring is a herculean task. computerisation is the need of the hour but this goal involves many hurdles and challenges aims: the aim of this study is to discuss the challenges faced during computerisation of blood bank activities and the remedial solutions for it methods: department of transfusion medicine, king george medical university, lucknow is one of the biggest blood bank of the country with annual collection of , blood units. two years ago, the blood bank worked on totally manual system. computerisation involved challenges associated with hardware and software installation and personnel training. hardware was installed in two phases. initially hp system but later shifted to apple imac due to frequent breakdowns. with hp server. software installation (easy software) involved erratic internet connectivity hence changed to lan. customisation involved radical changes according to our needs. at times we had to change our way of working to suit the software. biometrics linking, medical registration, cash id generation, donation, serological crossmatch, automated blood grouping, labelling, chemiluminescence & nat testing, blood component preparation and camps were all included with challenges at every level. remedial actions were taken from small to big. training of the staff was the most essential part of the implementation of computerisation who initially showed considerable resistance and at time faking ignorance due to apprehension that their mistakes will be highlighted and they will be penalised for it. it was a herculean task in creating their password protected identity and enforcing them to use it. gradually the staff realised that computerisation made their task easier as it cut down on paper work and repetition and also prevented serious mistakes from happening. hard copies at certain essential areas were still maintained to continue work in the event of major breakdown of computer results: computerisation aided us in regulating the movement of the donor which at times was repetitive due to manual entry. transfer of data ensured a safe supply and the mistakes could be retraced very easily. implementation which included installation, training and enforcement took a period of months. after overcoming all the challenges we minimised hard copies to registers and started taking printouts of the other necessary details. the turnover time for the employees due to computerisation decreased by %. waiting time for attendant decreased by %. traceability of all the units became %.supervision of the activities being carried out was % accurate. identification of the donors was easy due to biometrics which included thumb impression and iris scanning. the decision making time for donors decreased by % thus making the system more efficient. summary/conclusions: manual to computerisation involves involvement from source to supply and it is essential to anticipate the challenges and be prepared for solutions in order to make its implementation successful p- ct smit sibinga , y abdella and f konings iqm consulting, zuidhorn, netherlands who eastern mediterranean office, cairo, egypt background: who defined essential medicines (ems) as medicinal products that satisfy health-care needs of the majority of a population. they should be available at all times, in adequate amounts, in appropriate dosage forms, with assured quality and affordability. in blood and blood products (whole blood, red cells, platelets, plasma, and plasma-derived products) were added to the who model list of ems. appropriate and effective regulatory framework (legislations, regulations, etc.) and a functioning regulatory authority (ra) is crucial for management of blood products as ems. however, particularly in the less developed world, these prerequisites have barely been implemented. aims: to analyze and advise on existing legislation and regulations. existing legislative instruments of the member states of who eastern mediterranean region (emr) were collected and analysed for relevance and appropriateness for preparation and use of blood and blood products as well as use of associated substances and relevant medical devices. a literature search was done on matching combinations of regulatory system, regulatory framework, legislation, regulation, with production and use of blood and blood products, which resulted in almost exclusively references with respect to national and international legislation. benchmark: who recommendations (aide m emoires) and eu directives. methods: existing legislative instruments of the member states of who eastern mediterranean region (emr) were collected and analysed for relevance and appropriateness for preparation and use of blood and blood products as well as use of associated substances and relevant medical devices. a literature search was done on matching combinations of regulatory system, regulatory framework, legislation, regulation, with production and use of blood and blood products, which resulted in almost exclusively references with respect to national and international legislation. benchmark: who recommendations (aide m emoires) and eu directives. results: various formal legislative documents of only / countries are put in force by governments [ (egypt) till (pakistan -sindh)]. most are detailed descriptions of ra, operational establishments, and specific requirements. however, none of these legislations complies with who and eu recommended formats and contents, and will not support effective regulatory oversight to promote and enhance quality, safety and availability of these ems. summary/conclusions: government should provide effective leadership and governance in developing a national blood system (nbs, fully integrated into the national health-care system. essential functions of a nbs include an appropriate regulatory framework with legislations, regulations and other non-legislative instruments administered by a ra. these documents should spell out principles and cadres, standard setting, and organization of the blood system to ensure an adequate supply of blood and blood products and safe clinical transfusion for which a model was designed. the structure of nbs will depend on organization and level of development of the health-care system. however, all critical activities within nbs should be coordinated nationally to promote uniform standards, economies-of-scale, consistency in staff competency, quality and safety of these ems, and best transfusion practices. key is formulation of an appropriate regulatory framework administered by a ra responsible for regulating the vein-to-vein chain in the preparation and use of these ems. background: the capacity of blood transfusion service to provide adequate supplies of blood components is the issue of concern for health providers worldwide; longer term observations of trends in this respect are therefore of crucial value. aims: the study aim was analysis of some basic activities of the polish blood transfusion service in - including organizational changes, numbers of donors, donations and blood components as well as activities directed at increasing their safety. methods: retrospective analysis of data supplied by the regional blood transfusion centers (btcs). results: in the discussed period, blood and blood components were collected in regional btcs and local collection sites as well as during mobile collections. although the number of local collection sites decreased from in to in in favor of mobile collections, which increased from , to , , the former is still the number one location for donating blood. on average . % of all donations were performed in local collection sites. the total number of blood donors both at the beginning and the end of the discussed period was similar ( , in and , in ); over % of all donors were non-remunerated. however, the number of first-time donors dropped significantly (from , in to , in ). the total number of donations increased from , , in to , , in ; most frequent were whole blood collections (from , , in to , , in ) . some blood components (mostly plasma and platelet concentrates) were also collected by apheresis. most frequently prepared blood components were red blood cell concentrates -rbcs ( , - , , units per year), fresh frozen plasma -ffp ( , , - , , units) and platelet concentrates -pcs ( , - , units, with significant increasing tendency). additional processing methods such as leukocyte depletion and irradiation were more frequently applied to pcs ( - . % in respective years irradiated, . - . % leukocyte-depleted), than to rbcs ( . - . % irradiated, . - . % leukocyte-depleted). in , the pathogen reduction technologies in plasma and the pcs were implemented. up to date however the use of these technologies is limited in most btcs. in approximately . % of pcs and % ffp units issued for transfusion were subjected to pathogen reduction technologies. summary/conclusions: our study data may contribute to the assessment of some long-term tendencies observed in polish blood transfusion service and may serve practical-benchmarking. this in turn may prove beneficial to the transfusion community as a whole. background: in poland % of hospitals depend on blood for the treatment of patients; over . mln units of blood components are annually transfused. it is therefore purposeful to expand the knowledge on factors impacting on blood transfusion service (bts). the institute of hematology and transfusion medicine (ihtm) as competent authority is responsible for collection of data related to the activity of all polish blood transfusion centers (bcts). this data is exploited to a much lesser degree than the recently available statistical methods and data processing tools would allow. moreover, survey of research in the field of public health indicates a negligible share of issues related to bts. it seemed therefore necessary to "fill in the gap" with true assessment of performance of the polish bcts for improvement of bts activity. st stage of our investigation refers to collection, merging of data from different sources, their unification and preparation (big data) for further analysis to be performed using multidimensional statistical analysis and data mining methods. aims: assessment of the activity of the polish btcs over the year-period in two stages. goals at st stage: . data digitalization; scanning of paper documents. . development of a uniform template for collecting digital data from various sources. . standardization, unification and quality improvement of available data: filling in missing data, elimination of errors, duplicate records etc, that may distort the outcome of analyzes. . selection of data for analysis. methods: digitalization and big data methods for processing various types of data: a) stored in paper form ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) , b) digital stored in two file types (.doc and .xls, for the years - and - , respectively). for each data-type, a separate excel file model was created. the models were then merged into one analytical table with data processing methods. results: . pages of paper documents were scanned. . models developed for data from different sources: a. paper-data were rewritten and ascribed to its model; outcome - tables, columns, , rows. b. .doc and .xls. filesdata were ascribed to other models; outcome - tables, columns, rows. . the models were merged into analytical table to create a mb database (comparable to approx. min of music). . the data was subjected to standardization, unification and quality improvement: filling in missing data, elimination of errors and duplicate records that may distort the results of analyzes. . selection of data for analysis at nd stage. summary/conclusions: the st stage provided a set of selected data for analysis in the nd stage which will rely on multidimensional statistical analysis and data mining methods. the outcome of such analysis will contribute to optimal realization of objectives: a) gaining in-depth knowledge about the fundamental phenomena that shape polish bts, b) identification of potential changes bcts, c) development of overall guidelines for change management. aimed to touch untouched or less touched topics of bb&tm. so far workshops were organized and each year around countries were participated from almost all religious, ethnical, social, cultural and economic situations of the world. . supported realization of major changes in bb&tm in turkey; a convincing medical individuals and agencies mainly moh to give the deserved consideration to bb&tm b encouraging the recognition and establishment of national blood program c issuing a new blood act and numerous necessary bylaws, etc. d creating an appropriate standard donor questionnaire form e changing blood transfusion practice from % whole blood (at ) to %. f changing donated blood screening criteria; while anti-hcv screening became obligatory malaria, screening cancelled g preparing national guidelines h promoting haemovigilance nurse post i promoting patient blood management . around , blood bankers attended national courses, , attended national congresses, , attended nationwide symposiums. summary/conclusions: bbtst can be accepted as a sample how a scientific nongovernmental organization may give a very positive impact on developing and progressing bb&tm activities with close collaboration moh and other related organizations abstract withdrawn. background: globally there is growing investment in information technology (it) in business. this similar trend has been observed in blood establishment computerized systems (becs). the it investment can be high hence it decisions need to be properly informed. the africa society for blood transfusion (afsbt) encourages the use of its in african blood services as this optimize quality blood services, thereby improving patient's outcomes. afsbt established in an it working group (afsbt itwg) with the support of the swiss red cross (src) to spearhead the it standards among member blood services. a number of priority it thematic areas were identified. these includes it governance which focuses on creation (strategic alignment) and preservation (risk management) of business value. there is absence of published literature on how a structured it governance framework can be implemented in a resource constrained setting. a review of the national blood service zimbabwe (nbsz) it governance was done based on published it governance framework. aims: to explore how a structured it governance can be developed, implemented and monitored in a resource constrained setting. methods: a published mit-cisr framework which has six components was used to assess the strength, gaps and opportunities of the it governance. results: nbsz has been implementing an evolving structured it governance system. in terms of service strategy and organization there is a well-established it function which is reflected in the nbsz strategic plans. this ensures it annual budgetary support, which averages . % of the total budget. the it governance arrangements are such that decision rights are assigned to different it staff (executives, it specialist, and users). a range of it solutions have been embedded within the nbsz operations such as becs, financial, donor mobile application, social media, temperature monitoring, and human resources. the business performance goals are defined and are congruent across the various business units. it organization and desirable behaviors are documented in the ict policies and procedures and were needed remedial actions are available through the code of conduct. the it metrics are included within the nbsz monitoring and evaluation system which use a four colored traffic lighting reporting system. it was noted that the it accountabilities are undesirably tilted to the it specialist only hence some ict projects tend to have delayed deliverables. the it governance mechanisms are supported with tools such as service level agreements and established communication approaches. simple excel based solutions are used to track critical performance metrics such as on the interactive blood supply management status, which averages . % ( ) based on a -day projected stocking and supply levels. nbsz need to properly document the return on investments on all these ict initiatives, which is estimated ( / ) to be at . % of annual savings. summary/conclusions: blood services in resource constrained settings can implement a properly structured it governance and this will ensure maximum return on it investments. the nbsz approach will be shared and further developed in the afsbt itwg to support other blood services in improving their it governance. haematology/blood transfusion, alfred health, melbourne, australia background: in october , an integrated electronic medical record (emr) was implemented at an australian metropolitan multi-campus heath service using cerner millennium tm , aiming to achieve himss (healthcare information and management systems society) level . prior to implementation, large numbers of blood specimens were collected from patients unnecessarily and sent to pathology without a test request attached (no blood test requested -ntr). these specimens required additional processing in the laboratory. electronic specimen collection using cerner specimen collect tm allowed streamlining of specimen processing by eliminating paper requests. as part of the new workflow, individual specimen labels are printed with the specified blood test and correct tube type. this helps prevent the practice of collecting additional specimens due to uncertainty of the collection requirements. aims: • to quantify the expected reduction in ntr specimens following introduction of electronic specimen collection, and outline the benefits • to determine the impact on collection errors and wrong blood in tube (wbit) events methods: data was obtained directly from cerner millennium tm using a ccl (cerner command language) query which is run monthly by pathology it staff. this data includes all specimens registered for the month with indication of rejected specimens, wbit & ntr samples. 'rejected specimens' includes incomplete specimen and/or request certification, unlabelled specimens/requests and mismatched specimens. further information about wbit events was collated from riskman reports and staff interviews. results: data from the months prior to emr implementation was compared with months post. ntr numbers reduced from /month to /month ( % reduction), freeing up more storage space in fridges. rejected specimens due to inadequate patient request labelling reduced from a mean of /mth to /mth. wbit numbers have increased slightly: before having median (range - ), after with median (range - ). although it was hoped that wbit incidence may reduce with the new emr, of the post implementation wbits involved electronic specimen collection. departure from planned protocols involving a lack of working printers, causing staff to print patient labels away from the patient's bedside, as well as multiple patient labels printing on individual printers appear to be a main cause of the emr wbits. summary/conclusions: emr implementation has led to a reduction in ntr, and rejected specimens due to inadequate request labelling, as well as increased storage space in laboratory refrigerators. associated benefits include: • decreased financial costs of the wasted equipment • decreased staff time collecting and processing unusable specimens • decreased environmental impact of manufacture and disposal of unused specimens • decreased potential of iatrogenic anaemia work in preventing the occurrence of further wbits is ongoing, by ensuring that label printers are in working order, are in plentiful supply and easily accessible to staff; and also ensuring positive patient identification and blood collection by the patient's bedside remains a priority. jm mustaffa , k teo , s tsai , p heng , r sagun and m wong laboratory medicine khoo teck puat hospital, singapore, singapore background: khoo teck puat hospital (ktph) is a -bed general and acute care hospital, opened in , serving more than , people living in the northern sector of singapore. the blood bank of ktph department of laboratory medicine provides specimen testing and blood transfusion services for ktph as well as the neighbouring yishun community hospital (ych), one of the largest community hospitals in singapore providing intermediate care for recuperating patients including rehabilitative services. the process of ordering transfusion-related test requests in both hospitals is through printed forms. aims: in line with the hospital directive to move towards electronic patient management, the ktph blood bank intended to implement an electronic type and screen (e-t&s) system. the goal of the project is to ensure zero patient identification errors and maintain full traceability and accountability for the blood collection process in all transfusion-related testing. another aim of the system is to reduce repeated venepunctures when specimens are rejected due to missing essential patient information on the printed forms by implementing mandatory fields in the e-t&s form. methods: the e-t&s was implemented in phases. phase : an online version of the printed form was signed electronically by the ordering doctor and a witness within the electronic medical record system, sunrise clinical manager (scm) system with the doctor counter-checking by signing on the specimen label to ensure correct patient identification. phase : the ordering doctor is not required to sign on the specimen label since fingerprint biometrics are required for the electronic signin. phase : elimination of the witness step for blood collection. specimen collection and rejection data from to was analysed. specimen rejection rate was presented as percentage of rejected specimens (mislabelled, unlabelled and clerical errors) over total specimen count for each month. results: between january and march , before the implementation of the e-t&s phase , the average rejection rate for blood bank specimens was . % and . % for identification and clerical errors respectively. during phases and of implementation, rejection rate increased due to unfamiliarity to the new work processes. by february , with the implementation of the final phase of the e-t&s system the specimen rejection rate was . % and . % for identification and clerical errors respectively. rejected specimens were mostly from the few locations that had to use paper requisition due to workflow or infrastructure limitations. summary/conclusions: the e-t&s system was implemented successfully in ktph. full traceability and accountability of the blood collection process was maintained with the fully electronic system. the adoption of electronic documentation has also reduced the number of preventable repeated venepunctures that were due to incomplete order information on the printed forms. future developments in technology and full implementation of e-t&s system in all hospital locations may make zero patient identification error achievable and ensure transfusion safety in all patients in the near future. background: blood component administration represents a critical phase due to the possible occurrence of errors during the different steps from the identification of the patient to the infusion of the product. error occurrence can be reduced by the implementation of validated information systems. we tested the scweb â system at the bedside in a transfusion outpatient clinic. aims: the aim of the study is to validate a system designed to assist and to control blood administration step by step using electronic devices to ensure traceability and documentation of the process methods: the scweb â system is based on it monitored checklists which guide the personnel to follow the procedure, according to best practices; the system must initially be activated by the operator which is recognized by an auto-signing system based on bluetooth low energy which avoids the operator having to identify himself/herself beforehand. appropriate privacy protection is provided. thereafter the system takes up the task to give instructions and to verify the adherence, by asking an active confirmation of the proper fulfillment of the activities; a continuous registration and documentation is made by the system. standards and specifications for each step of the procedure have been configured on scweb â system to track in detail operator and patient identification, presence of informed consent to transfusion, blood pressure, pulse and temperature recording, vein access, verification of the blood unit. an alarm has been set after min, to ensure the control of patient's conditions. for each step, an active confirmation of the action is required and nurse and doctor direct involvement must be actively confirmed on the device by both operators. the system has been tested at the bedside on patients admitted to the outpatient clinic for red cell concentrate transfusion; compliance of the personnel and organizational impact has been recorded. results: the system required a very short training: ease of scweb â system allows its implementation without negative impact on organization of transfusion outpatient clinic and without difficulties by operators (nurses and doctors), who appreciated the help given by the it check system. the registration of the electronic check list offered a reliable tool for the traceability of the transfusion procedure, also granting a paperless and timely available documentation of the entire process through a registration in electronic format of all the operator's action in every single phase of the transfusion process. when prescribed, confirmation of the checklist was only possible in the presence and with the active confirmation of two operators (doctor and nurse). summary/conclusions: the scweb â system is useful as a barrier against the mismatch of transfusion (preventive measure), as a traceability and documentation measure and as a tool for training of personnel in blood transfusion administration; it avoids paper registration during the transfusion process, due to the timely registration of the activities performed by operators recognized by the system thanks to the bluetooth low energy auto-signing device. the scweb â system will be connected to the transfusion data management system, to monitor all the process from the arrival of the unit from the blood bank. background: he blood banks aims at reducing cost and increasing customer satisfaction by providing quality in service. the quality in service can be attained by streamlining the processes and restructuring the supply chain of the organization by implementing it tools. aims: aim is to understand the complex flow of information and processes within the supply chain of the blood bank. the requirement of such a study is a part of the integrated erp modeling for the integrated functioning of a blood bank. methods: he approach used to understand and map the sequence of processes, and the work responsibilities of each process and the operational decisions involved at each step is process mapping and data flow diagrams for front end system modeling and analysis. the processes are mapped and represented in a schematic diagram. dfd (data flow diagram) are constructed for representing the system. a context diagram is also constructed for understanding the entities interacting with the system. the emr systems aim at replacing (or supporting) the paper based medical records. the whole model of the system is divided into two parts-front end and back end. the front end design and analysis is done using epc (event-driven process chains), resource views, data flow diagram for data view. reporting was on donor selection, finance and collection of blood bag, blood collection process, component preparation, blood testing and blood distribution results: process mapping using event driven process chain generated a whole view of the processes involved. the resource view gave an organizational structure and the personnel involved. the data view using context diagram and data flow diagram gives a flow of data and amount of data involved. this framework can be used for business process reengineering for the blood banks by conducting a time study and removing non value added activities. data view helps analyze redundant data in each process. it also helps in staff training and orientation within the department. summary/conclusions: a systematic overview presented in this paper facilitates in removal of non value added processes, duplication of data, bottlenecks, reduction of cycle time and thereby improving service quality in blood banks. background: the transfusion of blood components, one of the most prevalent interventions in clinical practice is a major expenditure item in healthcare services which tend to increase in recent years. aims: it is intended to investigate the impact of transfusion associated costs to hospital costs in pediatric intensive care unit (picu) patients. methods: during a year period (january -december ) patients, females and males receiving transfusion with blood components along the stay in picu were included in the study. transfusion associated costs and total costs for healthcare services for children treated in picu was collected by using hospital information system (his). statistical analysis of data was performed by spss software (version . , spss inc., chicago, il, usa). mann-whitney u test and kruskal-wallis test was performed for comparison of independent categoric variables and numeric data; chi-square analysis was performed for comparison of two numeric variables and spearman correlation analysis was performed for associations. results: the median age of patients was . months (interquantile range-iqr ). the median length of stay was days (iqr ). in total blood components were transfused in which of red blood cell concentrates, apheresis platelet concentrates, granulocyte concentrates, fresh frozen plasmas, and cryoprecipitate and whole blood. the ratios of transfusion associated expenditures to hospital costs were categorized in intervals of percentages as < %, - %, - % and > %. most of the patients ( . %) were ranked in the lowest interval. the medians for hospital cost and transfusion associated cost were . euros (iqr = . ) and . euros (iqr = . ), respectively. a significant strong positive correlation between numbers of transfusions and hospitalization cost of picu was detected (r: . , p < . ). while it was found a significant weak positive correlation between transfusion associated cost and hospital cost (r: . , p = . ) there was also a significant weak positive correlation between the age and transfusion associated cost (p = . , r: . ). a significant difference was found between the patients with and without hematological malignancies (p < . ) for transfusion associated cost. the reason why pediatric dosages are mostly prefer is that the hospital provides healthcare for only children and splitting of the blood components was common in the hospital. but unexpectedly a significant increase on the transfusion associated costs which is related to split blood components was detected (p < . ). summary/conclusions: studies on the economics of blood transfusion have been conducted mostly in patients who require chronic or multiple transfusions. picus, specialized facilities that provide care for patients with severe life-threatening diseases are major departments often necessitate multiple transfusions. there are many variables to evaluate the impact of transfusion associated cost to hospital cost in picu patients, but the major factors are underlying conditions, admitting diagnoses and transfusion strategies. although there are unexpected data in our study demonstrated the increasing impact on transfusion associated cost originated from blood components split for pediatric usage no significant relationship was determined to explain this situation. further studies on the economics of blood transfusions have to be carried out to clarify the variables of transfusion associated costs. background: approximately . % of the transfused blood component is packed red cell (prc). over ordering of prc unit is a common practice and excessive pretransfusion testing was being wasteful of resources and have adverse consequences on cost. high crossmatch to transfusion (c/t) ratio as quality indicator of blood bank implies that crossmatches were performed unnecessarily. aims: the aims of this study were to evaluate the cost effectiveness of strategies for limiting the number of pretransfusion testing of ordering prc. methods: all prc units who ordered from dr. hasan sadikin hospital from january to december were collected in this retrospective study. number of ordering prc unit, completed pretransfusion testing of ordering prc units, and prc units that were transfused were recorded. restrictive pretransfusion testing strategies were done based on the hemoglobin level and diagnosis as transfusion indication criteria. cost effectiveness was measured by multiplying the unit cost of pretransfusion testing and number of prc unit. results: out of total , ordered prc unit, , ( . %) were subjected to pretransfusion testing and . % ( , ) of ordering prc unit which are pretransfusion testing were transfused. this means that . % ( , ) of ordering prc unit were not subjected to pretransfusion test. this showed savings of , , , rupiah. c/t ratio was . which demonstrate a good ordering pattern. however, . % ( , ) of completed pretransfusion testing of ordering prc unit were not transfused, leading to blood bank loss of , , , rupiah. summary/conclusions: strategies for limiting the number of pretransfusion testing on the good c/t ratio was still associated with saving cost effective background: blood is a precious resource for saving patient lives. the purpose of blood and blood component therapy is to provide suitable and safe blood products to achieve best clinical outcomes. nurses have an important role in ensuring safe blood transfusion. it is crucial for nurses to have sufficient knowledge about blood donation and collection, storage, component preparation, possible adverse effects of blood transfusion and necessary management and care. aims: the aim of this study was to assess the impact of an educational intervention on knowledge and awareness of nurses regarding blood transfusion services and practices. methods: the baseline study to assess the knowledge and awareness regarding blood transfusion services and practices of the nurses posted at various areas of the hospital including wards, operation theatres and critical care areas was carried out at our institute hospital which is a tertiary care teaching centre. the nurses were then sensitized and educated regarding blood transfusion services and practices during their day to day activities by referring them to the blood transfusion guidelines of the institute. subsequently, a self-developed questionnaire which was used for the baseline assessment of knowledge and awareness of the nurses was again used to reassess them. a total of questions were included in the questionnaire pertaining to: general awareness (two questions), blood donation (two questions), testing and blood component preparation related (two questions), storage of blood/blood components (two questions) and pre-transfusion checks and bed side transfusion practices (eleven questions). fifty nurses each were included for both the baseline as well as post-sensitization assessment. for different category of questions, the correct response rates were compared with those obtained in the baseline study using mann-whitney test. the entire study duration was spread over a period of three months (december, to february, . results: the overall mean percentage of 'correct' responses for questions in the baseline study was . %, whereas post sensitization it was . %. the mean percentage increase in general awareness related questions was . %, . % for storage of blood/blood components related questions, . % for pre-transfusion checks and bedside transfusion practices related questions, . % for testing and blood component preparation related questions and . % for blood donation related questions. the percentage increase in correct response was found to be statically significant for each of the five categories of questions. the overall mean percentage increase in correct response rate was also statistically significant (p < . ). summary/conclusions: this study revealed that after sensitization and educational intervention there was a significant improvement in the knowledge and awareness of nurses regarding the blood transfusion services and practices. abstract withdrawn. background: tact, introduced in the uk in to support managers, provides resource-saving, continual, 'real-time' monitoring of knowledge-based competency of staff in transfusion laboratories. tact is available online / , complementing existing practical competency schemes and external quality assessment. multiple variations on a standard pre-transfusion testing scenario are generated using constrained randomisation; logic rules for automatic assessment of sample acceptance, abo/d, antibody screen and identification (as/id), and component issue are based on bsh guidance. during , tact was offered internationally to transfusion laboratory managers to trial, and saw uptake in five countries. the core tact programme, based upon uk guidelines, is under review for programming conversion, to be customisable for the international community. aims: to assess the feasibility of tact programming conversion to meet the requirements of country-specific pre-transfusion testing guidelines, and to direct future programming in line with feedback from international users. methods: guidelines from / international users were obtained and translated where necessary. these were compared against the core assessment elements of current tact programming. international users were approached for their feedback on the current version of tact, as it compared to their local policies and practices. results: the following criteria were cross-referenced: specification of transfusion request forms, sample label acceptance criteria, reagents used for abo/d and as/id, resolution of grouping anomalies, alloantibody confirmation/exclusion, and selection criteria of blood components for transfusion-dependent patients and women of child-bearing potential. apparent differences included:-australia:--selection of red cells for patients with immune anti-d. greece:--inclusion of the name of the patient's father on the transfusion request. italy:--testing of all new patients with an anti-a,b reagent and two different monoclonal anti-d reagents. international users in the same three countries supplied feedback. this included suggestions for:-greater complexity of cases presented, provision of patient history, inclusion of follow-on tests e.g. phenotyping and cells for antibody confirmation/exclusion, broader range of reaction strength grading, and official professional cpd credits. the following differences were noted:-nomenclature used, the format and content of the request form, use of english abbreviations of patient clinical details, and the availability, provision and specification of blood components. summary/conclusions: this analysis has shown very few instances where the current tact iteration differs from the guidelines reviewed, and that it is feasible to expand the use of tact on a more international basis. the current iteration of tact has been developed to represent an abbreviated scope of pre-transfusion testing practices, which can be applied to laboratory practice outside of the uk without difficulty. further work is required to enable international users to configure tact such that the system represents all laboratory practice on an international basis. aims: these courses provide education to clinicians on patient blood management and safe transfusion in neonatal and paediatric settings in order to improve patient outcomes and increase awareness of the national patient blood management guidelines. this analysis aimed to investigate the uptake, practical use, and perceived value of the courses by learners. methods: a retrospective analysis of course completion statistics and course evaluation data. results: there have been , paediatric and neonatal courses completed from march to february with . % of learners being nurses and/or midwives. analysis of course evaluation data (n = ) showed that these courses: -provide knowledge ( . %) -improve patient safety and outcomes ( . %) -result in change to clinical practice ( . %) -are relevant to clinical practice ( . %) -are easy to use ( . %) -are readily accessible ( . %). examples that learners provided of how they can apply this learning to their clinical practice include: -"[i am now] more aware of special requirements for neonatal blood transfusion" -"[i] feel more confident especially when talking with parents" -"[i will now be] checking the patient's blood results and will speak up for unnecessary blood sampling" -"[it's good that] when there is ambiguity in clinical practice [this is] very well shown by explanation from experts in the field" -"we don't do a lot of transfusions [and this is] a reminder that transfusions are not always the first answer to the baby's clinical picture". summary/conclusions: analysis of course and user evaluation data demonstrates that these courses are being used by nurses and doctors working in the neonatal and paediatric settings and that they provide knowledge of pbm that can be applied to clinical practice, thereby contributing to improved patient care. background: blood transfusion is a high-risk clinical activity that must be mastered both theoretically and practically in order to guarantee the required result without any incident or complications. the mastery of transfusion knowledge among nurses represents a very important link in the transfusion chain. the objective of this work is to compare the theoretical and practical knowledge of transfusion among two groups of nurses divided according to their seniority. aims: this is a cross-sectional descriptive study conducted over a period of month [ st april- th april] . we selected two groups of care staff: the st group consists of students at the end of their training at the higher institute of nursing sciences. the nd is made up of nurses working in university hospitals of tunis, currently practicing blood transfusion. the evaluation's tool used was a questionnaire of simple or multiple choice questions, were related to theoretical knowledge of labile blood products and to transfusion practice. ten questions were considered "life-threatening" if their answers were false. a comparative study was made between the two groups. methods: this is a cross-sectional descriptive study conducted over a period of month [ st april- th april] . we selected two groups of care staff: the st group consists of students at the end of their training at the higher institute of nursing sciences. the nd is made up of nurses working in university hospitals of tunis, currently practicing blood transfusion. the evaluation's tool used was a questionnaire of simple or multiple choice questions, were related to theoretical knowledge of labile blood products and to transfusion practice. ten questions were considered "life-threatening" if their answers were false. a comparative study was made between the two groups. results: the participation rate in the survey was %. the nd group participants had an average seniority of years . more than half of them ( %) had seniority of less than years. only % had more than years of experience. the rate of correct answers for all items combined was . % for students versus . % for practicing nurses. the theoretical knowledge part was more mastered in the st group than that of practicing nurses ( . % vs . % of correct answers). on the other hand, the control of the transfusion act was better in nd group ( % vs . %). the overall "dangerous" response rate was % for students and . % for practicing nurses. false practical knowledge was more common in group ( . % vs. . %). summary/conclusions: the theoretical as well as the practical knowledge remains not well mastered by the care staff. our study highlighted the best theoretical mastery for young students and practical for practicing nurses. this could be explained by the freshness of knowledge in the first group and the daily practice in the second group. background: the european commission (ec) directive / /ec on blood donor selection criteria is years old. in the meantime, knowledge on risks related to blood donor selection has progressed and challenged several obligatory rules. transpose -transfusion and transplantation: protection and selection of donors, is a european commission co-funded project with participation of more than stakeholders from both not-for-profit and private organizations providing substances of human origin (soho). the project aims to provide evidence-based donor selection criteria and guiding principles for risk assessment of threats to the safety of soho. as part of this work, an inventory of current blood donor selection criteria in europe and an evaluation of the evidence behind current practice was performed by experts working on this project. aims: to identify the gap between the ec directive / /ec on whole blood donor selection criteria and a current evaluation of the clinical relevance of the criteria based on scientific literature by a panel of european experts within the transpose project. methods: in , we performed an inventory of blood donor and transfusion recipient risks in participating european countries. project members were asked to provide the existing donor selection criteria related to these risks and to carry out a risk-based evaluation for each of them. the evaluation was based on the available scientific literature and on a risk assessment template based on the abo risk-based decision-making framework, developed by transpose. all risks with divergent assessments within the panel were resolved through discussion; in all cases an expert consensus was established. subsequently we compared the results with the content of the ec directive / /ec for every risk, thereby identifying discrepancies and missing items in the directive. results: the panel identified risks considered to be significant, distributed between donors and recipients. for / ( %) of them the expert evaluation deviated from the content of the ec directive, or the ec directive provided no information about the decision making. in particular, a discrepancy was observed for / criteria concerning general health and medication, / for transfusion transmissible infections, / for high-risk behaviour and travel, and / for other diseases. summary/conclusions: our results highlight a significant gap between the whole blood donor selection criteria stated in the ec directive / /ec and the scientific evaluation performed by a panel of transpose participating experts. this gap includes both new risks not addressed in the ec directive and addressed risks that are however evaluated differently. this involves both blood donor and transfusion recipient safety, and various medical and epidemiological topics covering several aspects of the blood donation criteria. we strongly recommend a change in the european legislation, allowing a procedure to guarantee that blood donor selection criteria are updated regularly within the framework of the european institutions, to keep aligned with scientific progress, epidemiology and changes in medical practice, in order to enable an updated risk-and evidence-based framework for donor selection criteria. the risk-assessment method elaborated in the transpose project is a valuable instrument for this purpose. background: the brazilian health regulatory agency -anvisa has developed the method for assessment of potential risk in hemotherapy services (marpsh) which is based on the data collected during the inspections of blood services carried out by regulatory authorities. using marpsh any blood service can be classified in one of possible potential risk categories: high, medium-high, medium, medium-low and low risk. each category represents a different potential risk level, according to the proportion of compliance with the established regulatory requirements. marpsh has been used since , showing a trend of risk reduction on blood services evaluated all over the country. aims: this work aims to describe the utilization of marpsh as a tool for an integrated risk management model. also, it shows the main results obtained after years of data monitoring and coordination of regulatory actions and policies by anvisa, targeting quality and safety of blood products. methods: the utilization of marpsh follows a network risk management model since the inspections are carried out by decentralized organs in all states and some municipalities. the inspectors fulfill a standardized inspection guide containing the regulatory requirements, where each item is associated with a level of risk, varying from i to iii as the risk increases. at the end of the inspection, after a statistical calculation, the service is categorized. this classification gives an estimate of its quality profile, guiding the adoption of suitable measures for risk management by local authorities and services. these data are send to the states (if realized by municipalities) and to anvisa that perform consolidation in a national level. either states or anvisa use data to coordinate risk management measures in a broader spectrum. data are continuously monitored by anvisa as part of its strategical panel of indicators. anvisa follows up specially blood services in high and medium-high risk with the aim of helping or complementing local authorities' actions. additionally, anvisa periodically sends this information to the brazilian ministry of health and local governmental organs from brazilian national blood system that also support actions to improve quality in their blood services networks. results: since , when the assessment covered blood services, marpsh reached blood services in ( % of the blood services registered) what corresponded to almost % of the inspection cover in this year. over this period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) it is possible to notice a dramatic decreasing in trend for proportion of blood services classified as high and medium-high risk, varying from % to %. summary/conclusions: marpsh generates data necessary to the categorization of blood services into five levels of potential risk. as a result, the regulatory actions are applied by local organs with the purpose of reducing or eliminating risks involved in the production and use of blood components. data have shown a significant risk reduction over years of marpsh's utilization. additionally, monitoring of this data at a national level has been permitting appropriate planning and prioritization of integrated strategies directed to risk management and strengthening of blood services in brazil. background: sub-saharan africa has the highest need of blood transfusion in the world, mainly for childbearing women and children suffering from malaria. meeting basic quality and operational requirements to provide patients with safe blood remains a challenge in these settings. aims: the aim was to identify and prioritize potential hazards for patients in blood bank practices in the democratic republic of the congo (drc). we focused on two subsets: (i) sensibilisation and selection of donors, and (ii) qualification and production of blood products, using failure mode effect analysis (fmea). methods: two risk analysis workshops were organized at the national blood transfusion centre in kinshasa, the democratic republic of the congo. in both workshops, a multidisciplinary team was invited to represent different hospitals and profiles in transfusion management in drc: quality coordinators (n = ), training coordinator (n = ), medical doctor for donor selection (n = ), hemovigilance officer (n = ), laboratory technicians performing donor sampling, blood qualification and production (n = ), biomedical scientists (n = ), microbiologist (n = ), clinical biologist (n = ), nurse (n = ). the principle of fmea was applied, which implies identification of possible hazards (failures) in a process flow, followed by scoring each hazard according to their impact, probability, detection and feasibility. in the both workshops, participants were guided by an external facilitator who guaranteed common understanding of the methodology. main focus of the risk analysis was potential harm to the transfused patient in the process of (i) sensibilisation and selection of donors, and (ii) qualification and production of blood products. all ideas were written on coloured cards and mapped on a chart according to their impact, probability, detection and feasibility score. hazards were ranked according to their final risk score by multiplying these four scores. results: in the process of sensibilisation and selection of donors, the three hazards with the highest final score for impact, probability, detection and feasibility were: (i) a paid donor is recruited after sensibilisation by family members of the patient, (ii) donor selection staff approves a non-eligible donor for blood donation because of personal/financial motivation, (iii) blood donors are not correctly informed about blood donation during sensibilisation by family members of patients. in the flow of qualification of blood products, highest scores were made for: (i) no double check for validation and sorting of qualified blood products, (ii) stock-out of reagents, (iii) no check for match between registered test result and tested blood tube. regarding production of blood products, the top three consisted of: (i) transport time between blood collection and processing is > h, (ii) storage of qualified and quarantined blood products in the same fridge (some sites only), (iii) power cuts. summary/conclusions: the risk analysis resulted in three prioritized hazards in the process of donor selection/sensibilisation and blood product qualification/production. some are very specific to the sub-saharan african setting and have been described before (power cut, family and paid donors, stock rupture,. . .). an action plan needs to be put in place to reduce their final risk score. the risk analysis needs to be continued for the remaining blood transfusion flows. background: . million of germany's population, so just under a quarter of residents, have a migration background. the majority of these has roots in regions where the population has a distribution pattern of blood group and hla-antigens that differs considerably from the predominant one in the german population. sufficient supply of these individuals with red blood cell (rbc) and platelet concentrates (tc) will continue to be a major challenge in the future, as blood donors with compatible blood group antigens are dramatically underrepresented in the local donor pools. many migrants suffer from severe hematological disorders such as b-thalassemia or sickle cell disease and will not only need compatible blood transfusions, but an allogeneic stem cell transplantation in the foreseeable future. as healthy family donors often are not available, at present suitable stem cell donors with a similar genetic background can only be found in international donor registries. aims: this project was initiated to recruit new donors with a migration background for blood donation and to increase the number of blood stem cell donors among this group. methods: serological extended blood group phenotyping was performed by automated gel card technique (fa. grifols, erytra) and included ab , rh (ccdee), kk, fy (ab), jk(ab), lu(ab), m, n, s, s. hla typing for hla-a, -b, -c, -dr, -dq, and -dp was performed by next generation sequencing. allele frequencies were analysed using genepop version . ; the rare and very rare alleles were defined according to the allele frequency database (www.allelefrequencies.net) rbc genotyping using next generation sequencing is currently being established and will include additional antigens with the most frequent distribution pattern differences between migrant and resident populations according to literature. results: so far, more than blood donors with a migration background have been recruited for a blood donation in this project. amongst this group, over blood donors from more than non-european countries enrolled as potential stem cell donors. an initial evaluation of the data revealed a very similar distribution of blood groups compared to the current blood donor population in north rhine-westphalia. of migrant donors, ten fy(a-b-) donors were identified, which corresponds to a percentage of . %. amongst hla-typed potential stem cell donors, we found ( . %) with rare and very rare alleles. summary/conclusions: blood donors with rare blood group and hla phenotypes (e.g. null types such as fy(a-b-)), are in demand for adequate medical care of people with a migration background. the technological development of blood group determination by next generation sequencing will significantly improve the supply for all blood transfusion recipients in germany. this project is funded by the european development fund - (erdf) and the european union. background: mortality due to uncontrolled haemorrhage following trauma is the most important cause of potentially preventable deaths. trauma care systems in low and middle income countries like india, are still in developing phase. also, the role of blood component therapy in improving patient outcomes has been mostly derived from combat settings. application of these protocols in an urban setup has not been well established and marked variation in practice exists. hence this study aims to identify the key components of transfusion practices to optimize the transfusion protocol in trauma settings. aims: to study the current transfusion practices in severely injured trauma patients, admitted to the red area/resuscitation bay after initial triage in ed methods: this prospective observational study was conducted over a period of year starting from june to may at the department of transfusion medicine in collaboration with emergency department at jpnatc, aiims, new delhi. the study included severely injured patients (iss ≥ ) that were admitted within h to the red area/resuscitation bay after triage. data collected included the demographics, injury, laboratory and transfusion details for these patients results: during the study period patients ( . % males) were enrolled. mean iss scores was . . mean time to hospital admission after injury was : (iqr . - : ) hours. mean time to first rbc transfusion following admission was : (iqr : - : ) hours. approximately . % ( ) patients were in shock (sbp < mm hg &/or pulse rate > /min). whereas, ( . %) patients were coagulopathic (pt ≥ . times of normal). during initial h of admission, these patients were transfused with ( . %) rbc, ( . %) ffp, ( . %) rdp and ( . %) cryoprecipitate of total blood components utilized for these patients. massive transfusion (defined as transfusion of ≥ units/ h) was given to ( . %) patients. summary/conclusions: significant quantity of blood components were required during initial resuscitation in severely injured patients. pre-hospital transfusion can significantly reduce the time to transfusion. further studies are needed to assess utility of pre hospital transfusion in severely injured patients. background: allogenic stem cell transplantation recipients are known to be the main consumers of platelet concentrates (pc). the geneva university hospital is one of the three allogeneic hematopoietic stem cell transplantation (hsct) centers in switzerland. since the blood center is also part of the hospital, data of pc consumption are easily available. as needs rose steadily since several years, with an average increase of % per year, pc supply is a serious concern for our center. aims: in this study we tried to evaluate if any pre-transplant indicator could help to forecast the number of pc needed after an allogeneic hematopoietic stem cell transplantation. methods: this observational retrospective study was conducted in geneva hospital on patients suffering from various inherited or acquired disorders of the hematopoietic system who were treated by hsct in . pc consumption was examined from january to december . the five indicators were: gender, stem cell source (bone marrow (bm) vs peripheral blood stem cell (pbsc)), donor type (hla matched ( - / ) vs haploidentical), conditioning regimen (standard vs reduced intensity), and cmv serology of the recipient. results: data for a total of patients aged from to years were analyzed; ( %) were male and ( %) female; ( %) were cmv-negative and ( %) were cmv-positive. out of a total of transplants, ( . %) were haploidentical and ( . %) hla-matched. according to the stem cell source, bm was transplanted in cases ( . %), and pbsc in cases ( . %). two patients also received a cd + stem cell boost. our analysis showed that, with a mean follow-up of days, the number of pc transfused to our patients treated by hsct ranged from to units, with an average of and a median of , illustrating a high variability. the results indicated that gender, stem cell source (bm vs pbsc), conditioning regimen (standard vs reduced intensity), and cmv serology of the recipient do not have any statistical impact on platelet consumption. however, we observed a tendency of an increased need for platelet transfusion when patients were cmv positive. our results also showed a statistically significant (p = . ) higher number of pc transfused for patients treated with a haploidentical ( ) versus hla-matched ( ) transplant. summary/conclusions: this study points out the high variability of platelet consumption after hsct, which limits the forecast of platelet production needed to support allogeneic hsct recipients. a larger cohort would be required to confirm a potentially higher platelet consumption in cmv positive patients, and to consolidate our results showing a higher pc consumption for patients treated with haploidentical transplant. abstract withdrawn. background: historically at our institution, a minimum of four red blood cell (rbc) units were crossmatched for all cardiac surgery cases regardless of surgical case-type or patient characteristics. two rbc units were packed in validated blood product coolers and brought to the operating room (or); the balance of crossmatched units remained in the blood bank. a retrospective review revealed that very few rbcs were transfused ( : % ( / ), : % ( / )). moreover, approximately products were wasted each month as a direct result of this practice. thus, we recognized an opportunity to improve inventory management in terms of personnel activities and blood component utilization. aims: the goal of this study was to reduce advance preparation of coolers in cardiac surgery cases without compromising patient care and safety. we limited our intervention to those patients who were eligible for electronic crossmatch. we maintained the aforementioned historical practice for those patients with history of and/ or those who currently demonstrated clinically significant red blood cell alloantibodies. methods: a multidisciplinary group consisting of representatives from the blood bank, cardiac surgery, cardiac nursing, cardiac anesthesia and surgery quality department was assembled in october to determine whether a modification of practice was reasonable and safe. group members evaluated site specific society of thoracic surgery (sts) cardiac surgical data between july and december to establish intraoperative red cell transfusion rates classified by type and urgency of surgery. the group's main goal was to discontinue preparation of default coolers for patients eligible for electronic crossmatch who were scheduled for all types of non-emergency cardiac surgery cases in which ≤ % of historical cases required at least one red cell transfusion. additionally, team members simulated the multiple protocols by which red blood cells could be prepared and delivered to the or and estimated the time for each scenario. results: review of sts data showed that the following cases met the criteria of ≤ %: elective primary coronary artery bypass graft (cabg), urgent primary cabg, elective mitral valve repairs, and elective aortic valve replacements. simulation showed that, in patients eligible for electronic crossmatch, preparation from receipt of order to completion of unit packing for delivery took . min using the pneumatic tube system (maximum of units per tube) and . min using delivery of a cooler using a human courier. summary/conclusions: based on the simulation results, and with consensus agreement from the multidisciplinary group, default cooler preparation for elective primary cabg, urgent primary cabg, elective mvr, and elective avr was discontinued in december . one year following implementation of the change in policy rbc units were issued to the or (a % reduction); % ( ) were transfused, compared to % in . wastage rates decreased from products a month to per month on average. summary/conclusions: the most obvious drawback of pabd is the higher cost in running the program in comparison with collection of allogeneic blood in the areas of additional patient attention and clerical input in labeling, separate storage and so on. in this audit, % of the autologous blood components were not transfused into the intended recipients and wasted; in this context, the pabd program could not be considered as a cost-effective approach in protecting blood safety. background: the national blood service zimbabwe (nbsz)'s blood supply management status (bsms) is an integral process of ensuring the availability of a safe and sufficient blood supply provision. nbsz introduced a new daily blood bank statement with improved metrics from may . the new analytics approach focuses on three interactive components of the blood bank statement; the available stock, quarantine stock (as per the desired -days stocks level), and the demand versus supply. it is imperative to have a closely monitored blood supply chain because blood has limited shelf life with uncertainties in both supply and demand. the 'blood-for-free' proclamation by the government of zimbabwe in july set more pressure on the blood demand. these metric-based analytics seek to assess if the nbsz's improved blood bank statement is a realistic model for the bsms. aims: to assess the use of the interactive metrics in monitoring the blood supply management status. methods: a prospective cross-sectional study was conducted. a total of daily blood bank statements which were submitted between may and december from each of the five branches were analyzed. the bsms which is calculated as the average of the three interactive measures of quarantine stock, available stock and demand versus supply was determined. sub-analysis of branches was done to determine individual branch performance. analysis by month was done to assess seasonal variations. findings and recommendations were shared among key stakeholders to validate the bsms methodology. results: overall the quarantine stock average was . % (sd +/- . ), the available stock was . %: (sd +/- . ) and the demand versus supply was at . % (sd +/- . ).the overall bsms was . %; (sd +/- . ) for the study period. gweru and masvingo nearly supplied all the demanded blood with . %, overall bsms of . % and . %, overall bsms of . % respectively. bulawayo supplied . % of the blood demanded with an overall bsms of . %. mutare supplied . % with a bsms of . % and harare . % and a bsms of . %. there were monthly variations but the service could supply above % of the blood demand. in the month of may the service met . % of the demand and a bsms of . %. in november and december it supplied . %, bsms of . % and . %, bsms . % respectively. august also had a below average supply of %, bsms - . %. june, october and september recorded above the average values; . %, bsms of . % and . %, with a bsms of . % respectively. summary/conclusions: the overall bsms performance was satisfactory and it was noted that branches capacitated according to demand. the new interactive analytics approach is appropriate for showing the blood bank status and assessing the performance of the branches. this new approach has optimized the decision-making process in blood supply management. the metrics are tracked using excel based model hence this approach is suitable for resource constrained settings with limited ict infrastructure . st vincent's hospital melbourne (svhm), a tertiary hospital supporting medicine, surgery and non-major trauma emergency and itu services implemented a mtp in . subsequent mtp reassessment has led to implementation of regular multi-disciplinary review of all mts to identify areas for improvement in transfusion and other aspects of support for critically bleeding patients. aims: to implement a systematic service-wide stakeholder review of mt events at svhm aiming to identify deficiencies and implement improvements in mt management. methods: a multi-disciplinary mt review team was established as a subcommittee of the hospital transfusion committee (tc) to update the organisational mtp in and subsequently continued to meet quarterly as the mt review subcommittee (mtrs) of the tc, systematically reviewing all aspects of mts at svhm. instances where or more red cell units are transfused in < h are identified from the laboratory information system and reviewed by the mtrs which includes representatives from accident and emergency, intensive care, operating suite (os) and transfusion laboratory staff; the head of the patient's treating unit is also invited to contribute. reviews include: demographics, clinical details, comorbidities, time from patient arrival to pre-transfusion specimen collection/receipt, time from blood request to release/transfusion, regularity of full blood examination (fbe)/coagulation (coag) testing, timing of blood component transfusion, total component provision/ratios, component waste, patient outcome, and communication between various clinical areas and also the laboratory. a discussion summary with actions/ recommendations is provided to the tc and some cases referred to the hospital mortality/clinical review committee. results: cases reviewed: from treating units including cardiothoracic surgery ( ) hepatobiliary/gastrointestinal/colorectal surgery ( ), vascular surgery ( ), neurosurgery ( ), orthopaedic surgery ( ), endocrine ( ) and "other" (encompassing general surgery, urology, general medicine and oncology - ). areas for monitoring/improvement identified: transfusion documentation, regularity of fbe/coag specimen submission, reducing time between patient arrival and specimen collection, reducing specimen transport time, interfacing point of care bloodgas analysers to the central pathology result management system as well as component management/waste reduction and the introduction of viscoelastometry assessment in the os. of reviewed cases involved the transfusion of emergency uncrossmatched o rhd negative red cell units. the appropriateness of the use of this precious resource is also reviewed by the mtrs. summary/conclusions: the svhm mtrs meets regularly to review mt events and formalise multidisciplinary collaboration in identifying possible improvements to support these often critically ill patients. matters highlighted include communication issues, delays in specimen delivery and blood component waste minimisation. areas for further work include minimising delay between mt events and review, and formalisation of key performance indicators for mts. background: the use of radio frequency identification (rfid) technology to manage the blood supply chain is recognized as a major enhancement to the operations of blood banks and hospital transfusion services. to facilitate optimal blood supply management, it is crucial to guarantee the integrity of rfid tags throughout the transfusion chain. since rfid tags can be affixed to blood products very early in the process, these tags undergo the same process-steps as the blood products themselves (e.g. centrifugation, label printing, shock-freezing and irradiation). aims: the goal of this study was to validate the mechanical and functional resistance of biolog-id rfid tags through different blood related processes: centrifugation, label printing, shock-freezing, intensive reading at À °c, and irradiation. biolog-id tags are passive hf ( . mhz) tags. they are compliant with is , iso - and follow the guidelines for the use of rfid technology in transfusion medicine (vox sanguinis, ). methods: biolog-id tags were evaluated using a series of rfid encoding and reading tests. before each of the processing steps, each tag was encoded with donation number, site id, product code, blood group and expiry date. the data was encoded using the isbt format. the different processing steps and conditions tested were: -centrifugation: quintuple whole blood bags, filled with ml water. centrifugation at , rpm for min. tags processed, tags per kit affixed at different positions. -shock-freezing at À °c: shock-freezer (angelantoni, sf ), units processed, reading immediately after removal from shock freezer. water, tags irradiated at gy and tags at gy results: all biolog-id tags were encoded and read with a % success rate in all series of tests. summary/conclusions: biolog-id rfid tags can be encoded and read through common processes used throughout the blood transfusion chain. their mechanical and functional integrity is not affected by centrifugation, shock-freezing, intensive reading at À °c, printing, eto sterilization and irradiation. background: the provisioning of compatible red blood cells by international cooperation is presented. the units were meant for an -year old female, with homozygous sickle cell disease (scd) and multiple complications. patients' blood group was a positive with anti-c, -e, -wr a and an antibody to a high prevalence antigen in the rh system, anti-hr b possibly combined with anti-hr b (rh ). the antibody was not reactive with rh null , -d-or hr b negative cells. the donor center put out an international request for group a or o, rh null or -d-units lacking wr a and possibly k, fy a , jk a , wr a , do a and s (the latter antigens for prophylactic matching). the patient sample had been genotyped for rhd and rhce using mlpa and sanger sequencing and the patient was found to carry rhd* /rhd* n. and rhce*cevs. / rhce*cevs. . aims: the request was sent to the american rare donor program (ardp). the ardp working with the american red cross national molecular laboratory, used the rh genotype information to identify donors carrying the same or similar rh variant alleles using the rh allele matching approach described previously (keller et al. transfusion ( s): a). methods: a recent blood sample was used to confirm anti-hr b ; no anti-hr b was detected. the patient rhd and rhce alleles were used to build punnett squares for both genes with donors carrying the same and similar alleles that would be predicted to be compatible. tier donors are those predicted to carry the same combination of rhd and rhce alleles as the patient. tier donors are those predicted to be homozygous for one of the allele combinations carried by the patient. tier donors are those predicted to carry alleles similar (but not identical) to those carried by the patient, with similar predicted phenotype. the database of donors in the ardp carrying rh variant alleles was queried against the alleles in the patient-specific punnett square. results: donors of group a or o and matched for rh alleles were identified as follows: tier , tier and tier donors. after the clinical team agreed to drop one or more of the prophylactic antigen matches, one tier unit lacking s and jk a was identified at the american red cross. while the request was being processed, the patient experienced a sickle cell crisis, red cell aplasia and recurrent aiha and her hemoglobin level dropped from to . g/dl. at that time, she was transfused the only compatible units available - of the rare -dphenotype and her hb increased to . g/dl and eventually to g/dl. the tier rh allele matched unit was shipped to amsterdam where it was frozen, and reserved for the transfusion care of this patient. summary/conclusions: this case illustrates how rh allele matched blood can be found for a highly rh alloimmunized patient, and can avoid use of the exquisitely rare -d-or rh null blood. background: blood transfusion has been a complicated and high-risky clinical procedure. any error could cause serious injuries to patients. to better assure the procedure safety. aims: we enhanced and built a blood transfusion database platform and develop inventory management strategies to better guarantee the patient transfusion safety. methods: we designed six new features of the platform ( ) assuring the patient identification with barcode techniques; ( ) designing a structured order entry; ( ) proactively reminding the physicians with patient's previous blood transfusion reaction with related precautions including the use of leukoreduction filter; ( ) automatically reminding physicians the happening of reaction and suggesting relevant test; ( ) building a complete traceability log system; and ( ) supporting data analysis. the blood transfusion safety team includes medical technologists, nurses, physicians, system analysts, and blood transporter and the whole process is electronic management. the new blood transfusion platform integrated the workflow, reduced the incidence of abnormal blood samples collected ( % after implementation, p < . ), reduced the time of call for medical technologists with blood component preparation and improved the achievement rate of emergency -min blood crossmatch ( . % after implementation, p < . ). the barcode correctly identified patients and monitored the entire transfusion process to reduce the error rate of blood component supply ( % after implementation, p < . ). summary/conclusions: after the transdisciplinary team approach with e-monitoring and a better design of clinical decision support module with barcode technology, blood transfusion database platform improve the blood supply efficiency and assure blood transfusion safety. background: in the modern world, terrorist acts are characterized by a multiplicity of combined injuries to a large number of victims. qualified medical care is urgently required for a large number of patients in one locality at the same time. it leads to increase in emergency demand for blood components, mostly red blood cells. the desire to donate blood to the victims is a natural manifestation of society's solidarity in response to tragic events. however, donor activity and patient needs do not always correlate. aims: to analyze the donor activity during the terrorist attacks. methods: a retrospective analysis of donation activity in periods of terrorist attacks in moscow ( moscow ( - . the average daily blood donations' number (dbdn) before ta compared with the number of donations in day after ta and with the dbdn during days after ta. also the number of delivered rbc units (d-rbcu) daily before ta and daily in days after were compared. results: in - , terrible ta occurred in moscow: people died and more than were injured. with the explosion in subway in / people died, were injured. the number of d-rbcus increased by % on ta-day, and by % during next days. dbdn in the st day after ta increased , times, and in the next days - , times. second explosion in subway in / resulted in died, injured. the number of d-rbcus increased by % on ta-day, and by % during days. dbdn in the st day after ta increased , times, and in the next days - , times. in (explosion on market) resulted in died, injured. d-rbcus delivery increased by % on ta-day, and by % during days. dbdn in the st day increased , times, but decreased to , times during the next week. with subway explosion in people died, were injured. the number of d-rbcus increased by % on ta-day, and by % during days. dbdn in the st day after ta increased , times, and in the next days - , times. with the explosion in airport in people died, were injured. rbcus delivery increased by % on ta-day, and by % during next days. dbdn in the st day after ta increased , times, and in the next days - , times. summary/conclusions: an increase in donor activity is observed already the next day after ta and usually lasts for days, but does not correlate with the number of victims. the rbcs' delivery from blood bank increases in all cases on the day of the ta. therefore, the guarantee for patients is the maintenance of rbcs' stock, including cryopreserved ones. it is also necessary to promptly send excess of red blood cells harvested at the peak of activity to the cryobank. background: rh system is the major blood group system besides abo system. even after proper blood grouping and cross matching there is a possibility of alloimmunisation in recipients against the rh or minor blood group antigens like kell, mnss, duffy etc. in medical colleges which cannot bear the financial burden of complete phenotyping of patient and donor, implementation of rh & kell phenotypes match blood transfusion can play a major role in preventing alloimmunisation and adverse events in multitransfusion patients aims: to evaluate the efficacy of rh & kell phenotyping as a cost effective measure instead of extended phenotyping in multitransfused patients methods: study was carried out in the department of transfusion medicine, one of the biggest blood bank of the country with annual collection of , blood units. patients of thalassemia, aplastic anemia and leukemia were taken who required multiple transfusions. complete phenotyping was done initially of all the patients before transfusion. patients were taken as control and the other were taken as cases. blood units of healthy donors were chosen ( were males and were females). in all the donor units, identification of rh & kell phenotyping was done by the antigen antibody agglutination test by the erythrocyte magnetize technology on fully automated immunohaematology analyzer qwalys. these blood units were transfused to patients who had been selected as cases. in the control group, patients were transfused blood units which were not phenotyped for rh & kell but gel crossmatching was done. follow-up was done on these patients for transfusion reactions and at the end of six months they were evaluated for any alloimmunisation. results: at the end of months, no reactions were reported in cases receiving rh & kell phenotype blood and no alloimmunisation was seen on repeat phenotyping. the control group on the other hand reported reactions in cases ( . %) and phenotype at the end of three months showed alloimmunisation with 'e' antibody. the phenotypic frequencies of rh & kell blood groups in the population were comparable with other published studies. amongst the rh antigens (e) was the most common ( . %) followed by d ( . %), c ( . %), c ( . %) and e ( . %). thus 'e' was the most common and e was the least common of all the rh types. background: the prevalence of a particular blood group has an uneven distribution in different geographic areas and is largely determined by the national composition of the population. moscow is one of the largest city of europe with population of . million. the understanding of prevalence of red blood cells antigens (rbc-ag) among the population has great importance for blood banking planning. aims: to determine frequency and distribution patterns of transfusion-significant rbc-ag among donors in the moscow region. methods: the results of immunohematological studies on ab , rhesus and kell systems were analyzed retrospectively in blood donors for years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) in moscow. data collection and processing was carried out using the regional information system for transfusiology. rbc-ag detection (ab , rh, kell) systems was performed using microplate method (automatic immunohematological analyzer "galileo neo" (immucor, inc., usa)) and "ih- " (bio-rad laboratories, usa) with diagnostic cards. results: the most frequent blood group is a (ii) . %, (i) blood group . %, b (iii) . %, ab (iv) . % (n = ). rh(d+) was established as positive in the presence of antigen d and as rh(d-) negative in its absence. donors with weak variants of antigen d (du) were determined as rh (d+) positive. the ratio of rh (d+) and rh (d-) was . % and . %, respectively. donor's phenotype detection was routinely conducted from the year, therefore the number of donors was . the most common phenotype among donors ccdee ( . %), the second in frequency ccdee ( . %), the third in frequency rhesus negative phenotype ccddee ( . %) in the studied population. the ccdee and ccdee phenotypes were . % and . %, respectively. the most rare are ccdee ( . %), ccdee ( . %), ccddee ( . %). other options: ccddee, ccdee, ccdee, ccddee, ccddee, ccdee, ccddee were detected in single cases and amounted to a total of . % (n = ). cw antigen was tested in donors and was detected in . %. cw is most commonly found in donors with ccddee phenotypes ( . %), ccdee ( . %) and ccdee ( . %), with other variants of the data phenotype, the antigen was detected in . % of the examined (n = ). antigen k was detected in . % of donors, in . % of this antigen is absent (n = ). summary/conclusions: the study of transfusion-relevant antigens distribution in population is necessary for building of effective and flexible model for blood service managing. a differentiated approach in choosing a strategy to form a long-term bank for storing blood components, taking into account the frequency of various antigen variants, contributes to improving the quality, accessibility and safety of medical care. of dislocated division of our blood establishment in orthopaedic hospital valdoltra (obv) in the number of outdated units at the hospital side dropped considerably. results: since when the issued number of red blood cell units (rbc) was the amount of issued units rose to in and then dropped more or less steadily to in . in this period the hospitals' programmes rose for % in all areas. number of donated units declined from in to in . after reorganization in the number of outdated units fell from % of stocked units to . %. after setting a dislocated unit of ctdiz on obv location the number of discarded rbc fell from to in . for transfusion specialist who is constantly in contact with the clinician in the hospital the most important day routine is when the stock availability is displayed. it happens times a day; at a.m. when the previews' day collection is released and another three times a day when the updates occur. the central base is led in ljubljana (the capital) and all centres are able to control and order the stock for the blood banking. blood wastage remained low and the traceability of the blood usage in south-western region remains high ( %). though it is not supported by an informational system the traceability form the blood bank to the patient is done on paper. this issue demands a big effort by the staff in blood bank and in hospitals. summary/conclusions: reorganization enabled better stock utilization and traceability of issued units. sometimes it is impossible to predict the peak demand of rbc especially during the summer season when the population of the area doubles and car accidents as well. transfusion specialist's effort in assuring the optimal blood stock represents the crucial daily routine. blood bank, grande international hospital, kathmandu, nepal background: voluntary non-remunerated blood donor consists of % blood donor's population in nepal. therefore demographic about the distribution of blood donors according to the age group is important to achieve % voluntary nonremunerated blood donors in nepal. aims: to explore the demographic distribution of the blood donor in different age group in the kathmandu nepal. methods: this is retrospective study conducted at nepal red cross society central blood transfusion service. data from january to january were collected from donor management software. the data includes socio demographic data. data has been process with spss version - results: during years study period, total of , blood donation happened from both mobile blood collection and in-house blood collection. out of , collection, ( . %) are from - age group; ( . %) are from - age group ( . %) are from - age group; ( . %) are from group - age group; ( . %) are from age group - and ( . %) from age group above respectively. summary/conclusions: the distribution of abo blood group varies regionally and from one population to another. in kathmandu, nepal - years age group is the most common age group encountered donating blood. the data generated in the present study and several other studies of different geographical region of india will be useful to health planners and future health challenges in the region. background: the information system on hemovigilance sihevi-ins©, coordinated by the national health institute was available in to all blood banks in the country. this software allows to centralize and record the identification data of a donor, its infectious and immunohematological tests, as well as the fractionation and final destination of each blood component obtained from a donor. aims: to describe the abo and rhd typing discrepancies in blood donors found in the blood group variables registered by each blood bank to sihevi-ins©. methods: retrospective analysis of the information registered by of the blood banks authorized nationwide between january and december . results: sihevi-ins© received information of , accepted donors, % of them with more than one donation in the same blood bank in a period of months. a total of abo or rhd discrepancies were identified in people, who made donations in blood banks (estimated risk: one discrepancy per , accepted donors). five of the blood banks implicated in these discrepancies are hospital-based (annual average collection of , ae , units, representing . % of the national collect). the remaining blood banks are distributors (average collection: , ae , units per year, representing % of the national collect). % of blood group typing discrepancies (n = ) were related to the abo group. the most common discrepancy was between a typing group and ab typing group ( %) . in % of the cases, the same blood bank initially registered in the same donor, an o blood type donation and later an a blood type (n = ) or b type (n = ). rhd typing discrepancies account for % (n = ) of the total. additionally, in three donors, a simultaneous discrepancy between abo and rhd typing was detected in the same blood bank. the results could be due to: a) failure in the warning mechanism before the release of the blood component; b) errors in typing the information of the donor registered in the system or c) failures in the identification of the donors at the time of selection. the above shows risk in the process of control of blood components release, which can impact patient safety unless abo and rhd typing blood groups are systematically verified before transfusion. summary/conclusions: despite blood banks have a verification and validation process through software to release blood components, flaws were detected. although sihevi-ins© is not a software to validate the information before the release of blood components, it was through this program that abo and rhd typing discrepancies were identified in donors who attended the same blood bank multiple times. this finding implies increasing the controls that should be used in each blood bank, to avoid lose traceability of the processes and to put at risk the life of the recipients. blood donor testing department, blood transfusion institute of nis, nis, serbia background: the ability to automate blood grouping and antibody detection procedures is a requirement for blood donor testing laboratories. mistakes in the sample identification and testing procedures could be prevented by testing on automated immuno-hematology systems. irregular antibody screening and abo/rhd grouping of blood donors are tests performed routinely in blood transfusion institute of nis. neo iris (immucor, usa) is a fully automated instrument for the abo and rh d grouping using microplate hemagglutination technique and antibody screening and identification using solid phase red cell adherence (sprca). aims: evaluation of the automated neo iris system for abo and d grouping and irregular antibody screening of blood donors in blood transfusion institute of nis. methods: during the evaluation period a total of edta-anticoagulated samples for abo and d forward and reverse grouping using microplate anti-s, anti-s, anti-jka and anti-k. in one case ih- failed to identify anti-c antibody in very low titer in sample with anti c+d antibody presence. in two samples ( . %) false-positive result were observed both on ih- system and neo iris and in two cases ( . %)only on neo iris due to nonspecific reasons. summary/conclusions: abo/rhd grouping results obtained on neo iris system, using microplate method, have a good correlation with results on ih- system as our routine column agglutination method. for antibody screening and identification neo iris showed high sensitivity for detection of clinically significant antibodies which is important step for increasing blood transfusion safety. background: continuing improvement of laboratory quality to provide accuracy test results for precise diagnosis and treatment is the mission of advanced laboratory. immunogenetic testing for histocompatibility including human leukocyte antigen (hla) typing, hla antibody detection and cytotoxicity test is critical for diagnosis and evaluation of transplantation and prognosis monitoring. in order to improve the quality of experiment competency, an external quality assurance schemes with review and education per year program was established and performed during the period from to in taiwan. aims: the proficiency testing (pt) held semiannually from to were reviewed to investigate the outcome of competency improvement of laboratories participated in the program. methods: the test items in the exercises were classified into groups, hla genotyping (including pharmacogenetics hla typing), cytotoxicity test, hla and platelet antibody. the methods of hla genotyping include ssp (sequence specific primer), sso (sequence specific oligonucleotide), sbt (sequence based typing) and either ssp+sso or ssp+sbt were used, the methods of hla antibody including elisa, flow cytometry and luminex were used and the methods of platelet antibody including sprca and elisa were used. there are four shipments of exercise materials in two years and each shipment include two positive and one negative samples for antibody detection, two each of whole blood and serum for cytotoxicity of t and b cell and three whole blood for hla genotyping. aims: this study aims to survey transfusion related laboratory tests for the quality improvement of hospital's blood bank management. methods: we analyzed survey results of kinds of routine work categories of blood banks that were registered on korean association of external quality assessment service. blood bank worker voluntarily replied this electronic survey. the categories were as follows: . characteristics of institution . the equipment of blood bank . the kinds of tube in blood bank . the present kinds of blood bank tests . abo and rh type tests . the cross-match tests . the irregular antibody tests . hemovigilance system . other blood bank tests . massive transfusion protocol . quality control issues we analyzed and compared each category data according to considering characteristics of hospitals. results: there were consensus and some differences of current blood bank tests. we presents the result of a pilot survey. especially the cross-match tests were divided by saline phase method added with irregular antibody tests or completion of rd step anti-human globulin phase according to institutional environment. automated typing machines or automated irregular antibody test devices were more increased in large-scale hospitals than small-scale hospitals. different kinds of tubes were used such as edta tube for abo and rh typing, plain tube for cross-match test. the retention segments of rbc were reserved for minimum days. most blood bank were registered and regularly listed up transfusion events to korean hemovigilance system for safety transfusion. also, a lot of institution have none or underdeveloped massive transfusion protocol. more specific survey results will be analyzed in further poster presentation. summary/conclusions: this survey will show the current status of transfusion related blood bank test. this institutional blood bank comparison will be helpful to assess the currency of individual blood bank environments. abstract withdrawn. background: we know that quality management is a continuous process, involving implementation, maintenance and improvement. aims: our purpose is to show our experience in implementing the quality management system in the whole institution and our first steps in achieving the jacie accreditation in the stem cell collection facility in order to provide our patients and donors the best possible care. methods: the institute for transfusion medicine of the republic of macedonia (itm) is the main institution in charge of blood transfusion service (bts) in the whole country, which is the national unified system. the stem cell collection facility is a part of the itm. this facility is operational since year with collections of stem cells ( in patients and collections in sibling donors) till now. we are obtaining the implementation and maintenance of qms through the establishing of the iso standardization for the whole institution (itm), as well as of implementing jacie standards in the stem cell collection facility. the two of our colleagues became the jacie inspectors and the standard operating procedures (sops) were developed, followed by regular meetings, trainings and self-evaluation of the personnel. we asked for the orientation visit from the independent jacie inspector in order to come one step closer to the jacie accreditation and to improve our overall qms. results: the institute for transfusion medicine of rm was a part of the ipa project "strengthening the blood supply system". this project aimed to ultimately bring the blood transfusion service to european union standards allowing the exchange of blood components and all other types of collaboration with other european union countries in future. the project put the basis for unification of blood transfusion standards and operating procedures in the whole country as well as set up essential education of blood transfusion personnel. although a lot of strengths were found during the orientation visit from jacie inspector, there are still a lot of areas for improvement. our strengths are motivated team and supportive institutional leadership including macedonian ministry of health. areas for improvement are: labeling of cellular therapy products and lack of laboratory for quality control. there is a national regulatory framework in place and who and world bank initiatives in macedonia which support quality in health care and accreditation. summary/conclusions: our institution has in plan to implement isbt standards for labeling of cellular therapy products and to establish a laboratory for quality control of cellular therapy, as well as to meet all the requirements to become jacie accredited facility. working by standards, following the rules and regular self-evaluations will help us to maintain the strong quality management system. every institution will benefit from a quality management system that brings you into line with international standards. ensuring the quality of our services and products is essential to keep safe and strong blood transfusion service. background: implementation of robust quality assurance program is key to high performing blood establishments. quality control and quality assurance systems together constitute the key quality systems and are parts of quality management. effective and efficient quality control policies not only provide guidance that help to increase the reliability of results but also maintains the laboratory's consistence performance overtime. aims: therefore, we established a set of qc limit using historical data which can timely identify unexpected variation in the testing systems and trigger a review of test processes in blood screening laboratories as part of quality assurance system. methods: last two consecutive years (jan, to dec, ) qc data from archi-tect i sr (abbott laboratories, chicago) was extracted using abbottlink for philippines red cross tower national blood center total of data points ( data points in & data points in ) were obtained for different qc levels for four serological blood screening assays (hiv combo, hbsag, anti-hcv, syphilis). the data was sorted for each assay/lot and qc level combination by year. qc limits were calculated using simple mean, standard deviation (sd) and coefficient of variation (cv%) and were validated and compared with manufacturer's recommendation. results: all the six positive quality control levels cv% ( . - . ) were within manufacturer's precision recommendation (within lab precision hbsag ≤ %, anti-hcv ≤ %, syphilis ≤ %, hiv ≤ %) in . five out of six positive quality control levels cv% ( . - . ) showed within manufacturer's precision recommendation (within lab precision hbsag ≤ %, anti-hcv ≤ %, syphilis ≤ %, hiv ≤ %) in except syphilis tp positive control ( . %). all four negative quality control levels showed the sd values within . - . in and . - . in respectively. summary/conclusions: excellent qc performance was observed in philippines red cross tower national blood center blood screening laboratory based on historical data and evidence-based laboratory qc limit for blood screening assays were established using historical data which takes into account total variation expected in a test system and offers a more robust and meaningful mechanism for setting control limits, for the first time. background: quality indicators (qi) in transfusion medicine (tm) are 'critically important aspects of transfusion medicine practice that are measured and utilized to gain insight for continuous quality improvement, into the degree to which the tm is capable of providing quality tm care, products or services for the aspect of practice measured following comparison of the measurement against acceptable local or international reference thresholds, benchmarks, standards, or practice guidelines'. the critical control point (ccp) selected for this study is 'administration techniques and monitoring of key elements'. this has been selected since the clinical fraternity plays a larger role in ensuring quality services in administration of blood components. there was a need to follow up compliance to standard protocol for bedside transfusion practices hence was decided to study the same with four selected quality indicators and introduce corrective measures if necessary. aims: . to assess the existing transfusion practices in the institute with specific quality indicators . to introduce corrective reforms to improve the existing practice . to assess the transfusion practices after interventions using the same quality indicators methods: to assess the existing transfusion practices in our centre, transfusions were prospectively followed up with a structured checklist. the quality indicators used were (i) verification of blood components prior to transfusion (ii)initiation of transfusion within min of release from the blood bank (iii) close observation of transfusions for the first min (iv)completion of transfusion within the right time frame for each component. as a corrective measure, a transfusion monitoring format was designed which was distributed in every ward and the nursing officers were informed to monitor and document transfusions using that. in addition, the blood bank staff was made to call up the wards and ensure that the transfusions of every component had been initiated within min of issue. transfusion practices were once again monitored by following up transfusions using the same quality indicators. results: there was significant difference in all the four variables between the two phases. . % transfusions were verified in phase i while . % were verified in phase ii (p < . ). . % transfusions were started within half an hour of issue while in the second phase, it rose to . % (p < . ). . % transfusions were observed in the first min in phase i and . % were observed in the second phase (p < . ). in phase i, . % transfusions were completed within right time while the same in phase ii was . % (p < . ). summary/conclusions: we recommend the following as quality indicators for bedside transfusion practices: background: antibody titration consists in performing antibody detection with selected red cells of different sample dilutions. the titer is reported as the reciprocal of the highest dilution that induces macroscopic agglutination. the usual applications of titration are prenatal studies and complex antibodies identification. some publications have demonstrated that more variation in antibody titer and titration score are noted upon repeat testing of the same sample when testing was performed in tubes as compared to repeat testing in gel. aims: to evaluate the efficacy of automated antibody titration versus manual method by using gel microcolumn technology. methods: edta-anticoagulated whole blood donors' and plasma frozen samples containing a known irregular (rh, kidd, duffy, mns, etc.) and regular (a & b) antibodies were selected. the titers of samples were determined in parallel by using grifols analyzers (erytra and erytra eflexis) and compared versus grifols gel manual method by using grifols gel microcolumn technology and grifols red blood cell reagents. sixty of these also processed in parallel in erytra and erytra eflexis analyzers for comparison. for the precision study, of these samples were tested in the automated systems for times ( datapoints for each analyzer) on different testing days. the hands-on (manual intervention) average time required to complete a titration was measured ( expert technicians) in different sample workload ( and samples testing). these results were compared with the same number of independent titrations performed in grifols analyzers. for the walk-away time, different sample workload ( and samples testing) were assessed in manual method ( expert technicians) and compared to timings obtained when reproduced in grifols analyzers. results provided by analyzers were reviewed and compared to manual method. results: titer obtained by erytra or erytra eflexis was equivalent to the titer obtained manually (differences ≤ titer: % ≤ . titer). the results proved that both instruments were equivalent in performing titration (differences ≤ titer; % ≤ . titer). the precision results showed no difference between titers obtained through the % of the runs performed with the grifols analyzers (differences ≤ titer: % ≤ . titer). the manual hands-on in automated system was reduced in a % compared to manual method for sample. when the number of samples was increased ( samples), the difference in hands-on in was even more reduced ( %). in addition, the walk-away was % higher in automated system compared to manual method. furthermore, when the number of samples was increased ( samples), the walk-away difference was increased even more ( %). finally, automated system software demonstrated to increase the standardization of the test as all samples, results and reagents traceability were automatically managed. summary/conclusions: grifols gel system including erytra and erytra eflexis analyzers provided a scalable and efficient solution to perform standardized titrations in the immunohematology lab. the study proved that using grifols gel system, titrations can be run in an automated reliable way (less than one-fold differences versus manual gel), thus reducing at least % the hands-on, increasing at least % the walk-away, rising the standardization and automating all testing traceability. , and fourth case of use (results) scenarios, tasks were considered "very easy" by %> % of users and "easy" and by - % of users; %> % of the users considered "sufficient" the design to ease the interaction; and %> % of users never founding any situation of not knowing how to proceed. for the fifth case of use (user roles), % of users considered tasks "very easy" or "easy"; % of users considered "sufficient" the design to ease the interaction; and % of users never found any situation of not knowing how to proceed. for the sixth case of use (maintenance plan), % of users considered tasks considered "very easy" or "easy"; % of users never found any situation of not knowing how to proceed; and % of users considered the maintenance plan similar or better than other instruments. reliability analysis ( background: quality control procedures in blood group serology for reagents, techniques, personnel working and automated equipment are essential for the accuracy of the laboratory results. the observation of high number of uninterpreted results during blood donor grouping was a motive for investigation and possible targeting the problem. aims: to identify blood group interpretation problems by analyzing the testing results obtained with the commercial quality control samples routinely used during blood grouping. methods: a microplate (mp) system for performing abo and rhd, as well as rh phenotype and kell blood group determination with two automated analyzers techno ( and ) and correspondent two mp-readers lyra ( and ) using maestro software from diamed is currently in use for blood donor typing. three types of mp are being used such as: a, b, ab, dvi-, dvi+, ctl/a , b profile for first time donors, then a, b, d ctl for repeat donors and finally, the c, c, e, e, k, ctl profile. the accuracy and safety of the blood grouping results is ensured by using the diamed q.c. system which consists of + tubes of whole blood and tubes containing serum with known specific antibodies. we analyzed and compared the interpretation of the q.c. whole blood samples' results from both of the analyzers after a new optic camera was installed on the techno /lyra system. ward to ward. methods: a prospective observational pilot study was done for around prbc unit issues which were followed in real time for understanding the tat within blood bank & from ward to ward. as per the definitions, the areas where the times are documented perfectly are understood and considered for calculations. based on the conclusions of pilot study a monitoring form has been designed and utilised to monitor the tat within bb & wtw. the data is analysed monthly and an avg tat for bb & wtw is calculated. the common causes of delay in providing the blood components were analysed and strengthened to both reduce & control the tat. results: in pilot study, total wtw tat averaged to min, with highest time taken min, where there were additional processings like leukodepletion, irradiation, saline washing of red cells and holding the transfusion. lowest wtw tat was found to be min where there was a prior information for crossmatch. after the surveillance form has been started, the average time taken for wtw tat came down to min, maximum being min (jan ), the areas where delay happened were identified as internal courier delays, technician delays, billing & other logistics delay. the concerned staff are put on regular training to maintain the tat. summary/conclusions: although ethically all the staff work for providing better care for patients, there will be few areas that delay the life supporting blood transfusion. monitoring using tat surveillance forms help in avoiding the delays and hence provide better & timely transfusion support. blood donation -blood donor recruitment p- hematological and physiological characteristics of regular blood donors with beta-thalassemia traits background: according to recent evidence, the physiological variability observed in the hematological characteristics of regular blood donors (linked -in certain caseswith genetic factors or the donor's lifestyle) may affect red blood cell (rbc) storage lesion. beta-thalassemia heterozygous (b-thal-het) blood donors represent a group of particular interest because of a) the high frequency of thalassemia mutations in specific geographical areas b) the physiology of the b-thal-het rbcs, which predisposes towards more effective management of storage-associated stress. aims: the goal of the present study was the comparative examination of the hematological and rbc physiological features of regular blood donors with or without beta-thalassemia traits before blood processing for transfusion purposes. methods: healthy blood donors of greek origin ( - years old), who met the blood donation criteria were recruited in this study. plasma/serum (uric acid, electrolytes, extracellular hemoglobin, antioxidant capacity), cellular (rbc indices) and biological parameters (corpuscular fragility, proteasomal activity etc) were measured. the results were statistically analyzed and topologically represented in biological networks for both donor groups (+/-b-thal-het). significance was accepted at p < . . results: b-thal-het represented % of the donor cohort. no differences in lifestyle (smoking, alcohol consumption, physical exercise) were observed between the two groups. nevertheless, regardless of sex and sex-dependent parameters (e.g. hct, hb concentration), b-thal-het demonstrated: a) reduced hct, mcv and mch ( % p = . , % p = . and % p = . , respectively) and b) increased rbc count ( %, p = . ) compared to the average donors. moreover, mpv platelet index was found slightly elevated (p = . ) and serum total protein concentration slightly reduced (p = . ) in the same group. a trend for higher plasma antioxidant capacity (p = . ) was evident in the group of b-thal-het, in addition to statistically significant lower levels of osmotic fragility (by %, p = . ) and hemolysis (by %, p = . ) compared to controls. finally, analysis of the three proteasome-associated enzymatic activities (n = per group) in the rbc cytosol and the membrane, revealed similar levels in the two groups (p > . ). the b-thalhet and control biological networks showed insignificant variations in respect to the amount of connections and their hub profiles. however, differences were observed regarding the number or type of connections, or even their topology in the network, in the cluster of lipids (triglycerides, ldl etc), nitric oxide, clusterin, carbonylated plasma proteins and rbc osmotic fragility (correlated with the concentration of electrolytes selectively in b-thal-het donors) between the two groups. summary/conclusions: b-thal-het who meet the criteria for blood donation are a non-negligible sub-group of the total donor population in greece. they exhibit several similarities to the general cohort, but differ in fine characteristics of rbc physiology, including resistance to hemolysis and extracellular antioxidant capacity. the differential network profile of hematological and redox parameters may be important in respect to the subsequent blood processing and storage of b-thal-het erythrocytes for transfusion purposes. background: blood service in poland is based on voluntary and non-remunerated donations. regional blood donor centre in poznan as well as other regional centres (total of ) are the only entities authorized to collect, process, store and distribute blood and its components to hospitals in the region of their activity but they are also responsible to provide sufficient amounts of blood and its components. regional blood donor centre in poznan is one of the largest blood centers in poland with the total number of donations exceeding , per year. in the recent years we have observed a growing popularity of tattoos among various age groups as well as among people registering to donate blood (first time and repeat donors) hence, it is critical to introduce suitable measures to ensure the safety of blood and its components. aims: the aim was to analyse the correlation between the increasing number of donors deferred from donating blood due to having tattoos made and the number of recorded confirmed hcv infections and the effect it may have on the safety of blood and its components. methods: the analysis was made using the data for the years - obtained from the computer system 'blood bank' which is in operation in regional blood centre in poznan, poland. we have analysed the total number of deferrals of donors due to recently acquired tattoo and the total number of recorded confirmed hepatitis c infections. we must note that the category of temporary deferrals due to tattoos is a broad one: it includes so called regular 'artistic' tattoos, permanent make-up procedures as well as medical tattoos. results: we have recorded a significant increase in number of deferrals due to tattoos from in to in (+ %). in the group of male donors this trend remained rather stable with a slight decrease: from in to in (À . %). in the group of female donors the growth was more prominent: from in to in (+ %). in terms of the recorded confirmed hcv infections a downward trend can be observed: from in to in (À . %). in the group of male donors from in to in (À %), in the group of female donors from in to in (À %). summary/conclusions: as we can conclude from the analysis the applied policy of temporary deferrals of donors with recently acquired tattoos (in the last months) proves to be a reliable method of increasing the safety of blood and its components. nevertheless, the current conduct of the qualification of the donors which requires a month deferral following the new tattoo must be complemented by various and numerous educational activities regarding the means of hcv transmission (and other bloodborne viruses such as hbv, hiv) and ways of protection from possible infections. special emphasis must be put on the group of female donors as the growth of deferrals was more prominent among them. at the same time it is vital to ensure for constant availability for all donors of well designed, concise educational materials (hard copies on the premises, articles, infographics, downloadables etc. on the website). background: a temporary deferral has a negative impact on donor retention, with many donors failing to return at the end of their deferral period. anecdotal evidence collected by the australian red cross blood service suggested that many donors do not know when they are eligible to return to donate, suggesting that a reminder message may be effective at promoting donor return once the deferral has ended. aims: the aim of this study is to evaluate the effectiveness of a reminder message on the return rates of deferred donors at the end of their deferral period. this reminder message notified donors that their deferral period was ending and encouraged them to make an appointment to donate. this study also aimed to determine the most effective time to send the message, message content, and mode of communication (sms vs email) in optimising donor retention post deferral. methods: three separate randomised controlled trials were conducted to answer these questions. data on donors' attempted return behaviour and subsequent deferrals, appointments and donations made one month after the deferral end date were collected and analysed. results: overall, . % of donors who received a reminder message attempted to return compared to . % of donors in the control group (p < . ). looking at each time point, donors who received the message week before their deferral ended were % more likely to attempt to return compared to the control group (p < . ). the week prior reminder message was particularly effective with males, with . % attempting to return to donate, compared with . % of females (p < . ). there were no significant differences in the return rates of donors who received the recipient versus non-recipient focused message, or donors who received the message via email or sms. summary/conclusions: a reminder message sent to deferred donors at the end of their deferral period is a simple, cost-effective way to promote donor retention, providing clear information regarding the date on which the donors can return to donate as well as a prompt to make an appointment background: our challenge is to provide % voluntary donation for safe blood, thus taking into account the current history of family donation, promotion of blood donation, level of awareness and voluntary donations from various institutions, the opinion of interviewees will give us a clearer idea of what we want to achieve and what needs to be improved in the future. aims: . provide % voluntary donation for safe blood. . establishing a special department within the national blood transfusion center responsible for marketing and promotion of voluntary blood donation. methods: this study was conducted as a combination of qualitative and quantitative methods. the study was a combination and identification of existing data, direct interviews with persons of different age groups, preparation and dissemination of questionnaires and analytical processing of the collected information. the study questionnaire with questions in total was divided into sections out of which questions on blood practices were answered by all interviewees. people answered questions on the blood transfusion service. questions on blood knowledge were answered by people. questions on the knowledge of the blood transfusion were answered by people, questions on blood donation were answered by people and questions on the communication channels were answered by people. results: out of interviewees, % have never donated and did not intend to donate, due to the fact that most of them were afraid of needles and infections, while the smallest part didn't donate blood because it was not allowed by the religion, % did not donate, but expressed the readiness to donate in the future, % have donated voluntarily only once, % were family donors, % regular volunteer donors, and % have donated voluntarily several times and did not want to donate anymore. from those who have donated, % have donated for one of their relatives, % have donated for thalassemic children, % have donated to benefit free check-up and % have donated because it was valuable for their health. the question as to whether they would voluntarily donate again, % have answered yes, % no and % were still not sure. this means that donation of those who have donated once did not leave a positive impression, did not increase the desire to repeat the donation once again, rather it has restrained or made it unsafe for them to repeat donation. among the causes mentioned by the interviewees were bad conditions in the donation facilities, staff behavior, inadequate treatment, they did not feel good after donation and had hematoma at the venipuncture. summary/conclusions: based on the results obtained from the study, the national blood transfusion center needs the establishment of a genuine promotion department where there is a need for a transfusion doctor who should be an active part of it. the national blood transfusion center should build up and implement a rigorous retention policy for voluntary blood donors, as the study found out that around % of donors who have donated once would like to donate again. their attraction through a donor retention policy will surely lead to self-sufficiency with safe blood. the safe blood is a public good and for this reason it is the duty of all state instances, the media and non-governmental organizations to give their support in the promotion of voluntary blood donation. background: smoking, unhealthy diet, sedentary behavior and inability to maintain adequate exercise have significant consequences for several chronic disorders, including obesity. a balanced and equilibrate nutrition may prevent the negative consequences associated to the status of obesity. in italy, overweight and obesity is increasing with adults of overweight and of obese in with a higher frequency in the south. blood centers can play a public health role in obesity surveillance and interventions. aims: since the quality of life, self-reported by the patient, related to health and adequate quali-quantitative nutrition, are becoming necessary and relevant in the field of nutrition, we conducted a demographic study to evaluate the health status of the blood donors by monitoring the nutritional habits and lifestyle. methods: a descriptive cross-sectional face-to-face questionnaire was developed. it included a item dietary assessment, reporting semi-quantitative food frequency, dietary behavior and questions on self-rated health status. normal weight was established with bmi < kg/m , overweight with a bmi ≥ and < kg/m , and obesity with bmi ≥ kg/m . obesity prevalence was standardized by sex. donors were repeat blood donors, who had made at least donations in the last years, and were eligible to donate. results: of the blood donors enrolled between july and january , were regular repeat donors, did not wish or chose not to respond at survey for several reasons (i.e. lack of time or privacy) and accepted, of which were deferred from blood donation and were excluded from the analysis. among the included participants . % (n = ) were male, age ranged from - years with a mean age of . ae . sd and . % (n = ) were female age ranged from - years with a mean age of . ae . sd. data showed that donors followed mainly a mediterranean diet and had more awareness to lifestyle, women more than men, in comparison with general population. the prevalence of overweight was found . % in men and . % in women. our survey showed that . % of the participants evaluated their health as "good", without gender difference (men, . % vs women, . %). besides, . % reported their health as "very good". summary/conclusions: overweight and obesity are common among regular blood donors and it is more frequent in men than women. our preliminary data showed that women have a better knowledge of the nutritional properties of food and consequently adopt a more balanced and proper diet. furthermore, it is clear that they are aware about the relationship between lifestyle and health putting into practice their information. unfortunately, the survey structure, of observational nature, does not make it possible to establish whether women are more alert to health to participate more in donation programs or if, on the contrary, the status of regular donor could help the improvement of knowledge and healthy lifestyle. background: donor recruitment pose an ongoing challenge to blood banks worldwide. one approach to improve the effectiveness of donor recruitment is to target influencing factors. a yearly league is conducted at the sultan qaboos university (squ) to encourage university students and faculty to donate blood. during this, the colleges are evaluated based on different measures including the number of donors recruited from each college and the efforts made by the students in increasing the awareness of blood donation in the colleges and in the society via different means including the utilization of the social media. the whole competition is organized and ran by an independent group of students. aims: this study aims at studying the impact of the yearly squ college competition on the perception of blood donation among squ students. methods: a comprehensive anonymous voluntary survey was developed and used to assess perception of students aged - attending squ and other universities (non-squ) over a two years' period. analysis was performed using ibm spss statistics . . categorized variables were presented in numbers with percentages and associations between the groups were analyzed using chi-square test. a p-value of < . was considered statistically significant. results: a total of students were surveyed ( squ, non-squ). there was no statistical difference between squ and non-squ students with regard to past history of blood donation and the number of donations made. when comparing between both cohorts, % of the squ and % of non-squ students reported the university as the main source for information (p < . ), while % of squ and % of non-squ students reported that the social media was the main source respectively (p = . ). there was no statistical difference between male and female donors on their perception of level of self-knowledge on blood donation (p = . ). about % of the youth agreed that blood donation is one of the duties toward the community. squ students reported higher rates of respond to specific requests for blood donation ( . % vs . %, p < . ). squ students reported greater influence of peers ( % vs . %, p < . ), personal knowledge ( % vs . %, p = . ) and personal experience ( . % vs %, p = . ) when compared to non-squ students. they also reported more feeling of commitment to the society ( . % vs %, p < . ). squ students reported lower influence of parents ( % vs %, p = . ), lower rates of fear from needles ( % vs %, p < . ) and lower rates of fear from blood ( % vs %, p < . ). there was no difference between male and female genders in any of the discouraging factors. summary/conclusions: these results highlighted the positive impact and important rule of the youth in the promoting blood donations among themselves through this yearly college competition; in recruiting blood donors and in the dissemination of the knowledge of blood donation. distinct promotion strategies should be adopted to increased first time and repeated blood donation among the youth. we advocate for similar initiatives in encouraging blood donation and disseminate knowledge among individuals in the community. dubai blood donation center, dubai health authority, dubai, united arab emirates background: dubai is multicultural city in united arab emirates. only about % of the population consists of uae nationals with the rest comprising expatriates from various countries all over the world. approximately % of the expatriate population (and % of the emirate's total population) are asian, chiefly indian ( %) and pakistani ( %). dubai blood donation centre is the only centre providing blood donation services in dubai. arabic is the national and official language and english is used as a second language. in order to have good quality screening, it is important that blood donors understand the educational material and questionnaire properly. aims: dubai blood donation centre receives donors (nationals, residents and gcc card holders) from various countries. the aim of this study is to analyze the multinational profile of donors and to find out the need to add any third language to meet the customer needs and expectations. methods: a cross-sectional study of blood donors was conducted in dubai blood donation centre in . the donors were asked about their country of origin, languages which they can read & understand and about the preferred mode of communication. results: a total of donors were surveyed and asked about the languages which they can read and understand and responses were obtained. the most common languages which can be read and understood by blood donors in dbdc are english (n = ; %), arabic (n = ; . %), hindi (n = ; . %) and malayalam (n = ; . %). the donors come from different countries, most common ( . %) donors are indian and ( . %) are from uae. it was found that % donors can read and understand only one language. majority ( . %) donors can read and understand either of the official languages arabic or english. however, ( . %) donors can't read and understand these two official languages, the other common languages being hindi and malayalam. the donors were asked about the preferred mode of communication, responses were obtained. the most common mode of communication were sms and telephone ( % together). summary/conclusions: based on the above findings, it can be concluded that the blood donor profile in our centre is multinational which is a unique and almost similar to the population profile of dubai. as . % donors can't read and understand arabic and english, so it has been decided that the educational material and questionnaire need to be prepared in one more language. hindi has been decided as the third language in the centre and donor questionnaire and educational materials in hindi will also be made available to the donors. further,the donors will be communicated through sms for routine messaging and disease notification while telephonic calls will be done only when the blood is urgently required. background: metabolic disorders (metds), including hypertension, dyslipidemia, hyperglycemia, and central obesity, are tightly associated with cardiovascular diseases and type diabetes mellitus. due to the sedentary lifestyle and increased consumption of high-calorie diet in modern society, metds have become serious health problems worldwide. to have a better understanding and possible improvement on blood donors' health condition, we conducted a survey of the prevalence of metds among blood donors in a blood donation station located in the hsinchu science park in taiwan. participants with metds will be provided with health education materials about metabolic risk reduction, in order to prevent the development of future complications. aims: the aims of this study were to determine the prevalence of metabolic disorders among blood donors, and to calculate how much money would be paid to identify a case of hyperglycemia, hyperlipidemia, or undiagnosed diabetes. methods: this study was approved by the institutional review board of taiwan blood services foundation (tbsf). the body weight, body height, waist circumference (wc) and blood pressure (bp) of participants were measured. blood samples were obtained to determine the values of hemoglobin a c (hba c) background: the law on blood donation supports the development of the blood service and guarantees the protection of the donor's rights and the maintenance of health during blood donation in the russian federation. national criteria for donor selection for blood donation are used in the activities of blood service establishments and are aimed at ensuring the blood products safety. the study of the characteristics of blood donors allows to predict the development of blood service and to plan the volume of blood products for transfusion and plasma fractionation. aims: the aim of this work was to study the characteristics of whole blood and apheresis donors in the blood service in the russian federation. methods: indicators of activity in the blood service establishments in the russian federation in sectoral statistical observations over the period - and the calculation of indices characterizing the whole blood and apheresis donors were analyzed. data are presented according to the administrative division of russian federation into federal districts (fd). results: the proportion of whole blood donors was . %, plasmapheresis donors - . %, blood cell apheresis, including plateletapheresis, donors - . %. for the period - , the percentage of repeated and regular whole blood and apheresis donors increased from . % to . %. the percentage of first-time donors ranged from . % to . %. the largest proportion of plasmapheresis donors was observed in the volga fd ( . %). about . % of the total plasma was collected by apheresis from donors. the percentage of plateletapheresis donors increased from . % to . %. the largest percentage of plateletapheresis donors was observed in the central fd ( . %), where a significant part of medical centers of cardiac surgery, hematology and bone marrow transplantation are located. the proportion of platelet concentrate collected by apheresis increased to . % in . actions to recruit young donors for blood donation and its components were regularly carried out in all federal districts. summary/conclusions: in the russian federation, the structure of donation is characterized by an increase in the proportion of plateletapheresis donors, stabilization of the percentage of plasmapheresis donors and an increase in the proportion of repeated and regular whole blood and apheresis donors. there are significant regional variations of donor's characteristics in the federal districts. background: shortage of blood supply despite continuous blood donation campaigns especially during local festive seasons has been a major issue in our country. thus, our faculty initiated blood donation drives in collaboration with national blood centre in order meet the demand for the blood requirements. however, the pre-donation deferral rate was relatively high among our young blood donors leading to loss of valuable blood units. understanding the causes of donor deferral provides direction on strategies for young donor recruitment and retention of future blood donation. aims: the aim of this study is to evaluate the young donor deferral pattern and to identify factors which could help in minimizing the preventable deferrals. methods: this is a retrospective study of voluntary young blood donors age between to years old recruited during mobile blood donation in faculty of medicine, universiti teknologi mara, malaysia. the study was conducted between january to december . the data were retrieved from the official reports of each mobile blood donation. results: a total of young blood donors had attended mobile blood donation during the study period. the overall pre-donation deferral rate is . %. the main causes of deferral are low haemoglobin (hb) level ( . %) followed by low blood pressure ( . %), upper respiratory tract infection ( . %) and sleep less than h ( . %). summary/conclusions: low haemoglobin and low blood pressure are the two common reasons for blood donation deferral among our young blood donors. in our study a significant proportion of deferrals are due to sleep less than h whereby this could be prevented if the donors are aware of the donor selection criteria. strategies to mitigate preventable deferrals and improve blood donor retention particularly young blood donors as source of motivation for future blood donation are urged to avoid additional stress on the blood supply. background: in the modern world, donating blood has become a humane manner for saving of patients life. but there are barriers to blood donation which are designed to ensure both donor and blood recipients' safety. anemia is one of the most common health problems in the world. based on the who estimation, nearly a quarter of the world's population are suffering from anemia, its prevalence varies among the populations and age groups. the prevalence of anemia among men is . % and in non-pregnant women is . %. aims: the aim of this study was to determine the status of hemoglobin in volunteer blood donors referring to fars province blood transfusion service and to determine the demographic status of them during the last two years. our study included blood donors for all blood donors during the last two years. methods: the study is descriptive cross-sectional and our sampling was non-random and simple sampling method. all parameters related to the donors, including age, sex and type of donation were investigated and analyzed in spss software. results: the total number of referrals for blood donation was . repeated blood donors was . % of total population and had the highest number of referrals, followed by first and lapsed donors with . % and % respectively. in terms of gender distribution, . % were female and . % were male. the highest rate of hemoglobin level less than . g/dl was found in first-time donors with . % and the lowest prevalence was observed in lapsed donors, followed by repeated donors with . %. . % of the repeated blood donors have hemoglobin higher than . . there was a significant difference between blood donation type and hemoglobin level. summary/conclusions: according to our findings, low hemoglobin levels are more common among first-time and female donors, and this requires a special training among these groups. because the high share of first time donors in blood supply and the positive impact of female donors on the blood safety, corrective action for that groups is recommended. finnish blood donor biobank j partanen, t wahlfors, m arvas, j clancy, k l€ ahteenm€ aki, e palokangas and n nikiforow background: the increasing need for large, well-characterized cohorts of healthy individuals for modern biomedical research, such as genomics or phenomics studies typically including tens or even hundreds of thousands of subjects, has posed the possibility of using blood services as an option for collecting samples and related data. the possibility to re-contact blood donors for repeated sampling or asking for additional data has further increased interest in collecting large biobanks from blood donors. there is also a need to study more thoroughly the effects of blood donation on donor health. aims: the first-phase goal is to recruit , blood donors with broad biobank consent for the finngen (https://www.finngen.fi/) project, a large publicprivate effort aiming to collect genome and health-related registry data of % ( , ) of the finnish population. ( . %), dental examination ( . %) and medication history ( . %). permanent deferral namely, risk factor involving transfusion transmitted infections and chronic disease were ( . %) and ( . %) respectively. the prime cause of permanent deferral was risk factor involving transfusion transmitted infections while the temporary deferral was bed side hypertension. gender wise, the leading cause of donor deferral in male was bed side hypertension and anaemia was the major cause in female. summary/conclusions: the findings of the survey aid to evaluate the significant causes of blood donor deferral. this study suggests that the restrictive criteria can be used for blood donor selection. this will in turn increase the blood supply of tertiary care hospital. background: donor selection is the first step towards safe blood but retaining blood donors is also very important for the blood supply. donor questionnaire and the medical interview should provide optimal doctor deferral. aims: to evaluate deferral rate in blood donors in order to identify the main reasons and to target eventual corrective activities. methods: we analysed the data concerning blood donors who were registered in the period of three years ( - ). we used data from the information system e-delphyn. background: iron deficiency (id) in blood donors is an underestimated issue in many countries and may cause symptoms to blood donors even without anemia. id prevention is mainly based on the prevention of anemia in whole blood donors, which is done by deferring donors whose haemoglobin level is under defined threshold ( g/l in women, g/l in men in france). efs (french blood establishment) studies has observed that the rate of deferral for anemia is significantly higher in women than in men, either in french west indies ( . % versus . %) or in continental france ( . % and . %). assessing the prevalence of id is of great interest since strategies to counteract it must deal with donor health and self-supply. however, data on id are missing in france. aims: to estimate the prevalence of id in french whole blood donors and to identify risk factors associated with id. methods: this non-interventional, cross-sectional, multicenter study is performed in blood donors of efs and ctsa (blood center of the french military health service). all whole blood donors who met selection criteria are potentially included. donors coming for bloodletting and donors who refuse to participate to the study are excluded. no additional sample is taken for the study, ferritin is tested after blood qualification on surplus amount. samples are selected at random within all the geographical areas and all mobile blood drives and blood centers between march and march , . results: this study ferridon has been approved by ethical research committee. nine thousand ( ) whole blood donors will be included in efs centers in continental france. to have information on donors of afro-caribbean origin and comoros origin, donations should be included in the french west indies and in reunion island. additionally, whole blood donors will be included in ctsa centers. in this study, id is defined by ferritin lower than ng/ml and iron overload is defined by ferritin higher than ng/ml. all donors with iron deficiency or overload will received a letter advising to consult their general practitioner. weights will be calibrated on age, sex and geographical area so the sample will be representative of the french whole blood donors. estimation of id prevalence will take into account the weights and logistic regression model will be used to analyze risk factors associated with id. data will be analyzed during april and may to get result at the end of may. summary/conclusions: ferridon will be the first study on id in the french blood donors. considering the french health care system and diet, it will be interesting to compare those results to results from other countries. mostly this study will allow to consider various strategies dealing both with donor safety and self-supply. background: in portugal, with an aging population of around million people, only . % are blood donors. the country has a national center of blood supply and some central hospitals with a blood donation center. despite the growing practice of the excellent concepts of patient blood management, it is imperious to attract new donors. this need has been our inspiration to use new approaches towards people, in a constant work of promotion. aims: reach the majority of our local population using radio and telecommunication as well as social networks in an attempt to raise the number of new blood donors in a central hospital of the north of portugal. methods: active communication with the population of our reference area, via the social networks facebook tm and instagram tm , through educational digital posters and messenger service to answer any kind of questions. establish contact with radio and television stations as well as with the mayor of the city, journalists, schools, town hall deputies and celebrities, through email and telephone calls. design posters, flyers and public advertising to distribute in the city. results: through the social networks it has been possible to reach a population of dozens of thousands in our city, in a daily basis. the national and world donor days were celebrated with success, in our health facility, with city mayor and journalists, and also in three television stations with national broadcast, reaching millions of people. celebrities (sport, television, music, stand-up comedy, journalists and a magician) have accepted our challenge through videos or donating blood, appealing to blood donation and sponsoring our cause. these projects and continuous availability to innovate have given our hospital a self-sufficiency of % in , instead of % in , which implied receiving less blood unities from the national center of blood supply. our most recent project involves high schools, in an attempt to educate our next generation of donors, with meetings in the town hall with deputies and district school delegates. summary/conclusions: the aging population and the low percentage of blood donors are an important issue concerning public health. nevertheless, the good will and continuous advertising and educative work towards the population, appealing to the ethical and civil responsibility since young ages have shown to improve our capacity of response as a central hospital, increasing the auto-sufficiency of blood unities and the interest of younger donors. it is of the utmost importance to understand that this is a continuous and a hard work of the professional team of our hospital, involving countless calls, emails and hours to obtain some positive response, in an endless job. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the mean interval between donations is shorter for former regular donors ( . months, p < . ) whereas donors with an interval of to months are more likely to be regular (aor ; % ci . - ). summary/conclusions: at the provincial blood transfusion centre of bukavu, the percentage of regular donors is low and there is a substantial loss of former regular donors. some factors identified to be linked to fidelity are unique to our study: female gender and a longer interdonation interval. other factors that are similar to those found elsewhere have a particular significance in our donor population which consists mainly of young people and people without income. efforts must be undertaken to ensure a supply from voluntary donations; recruitment strategies and target groups must be refined. future qualitative studies are needed to explain the various associated factors and better understand the motivations of regular and non-regular donors to improve donor retention. results: in kazakhstan, the proportion of donors is higher, especially primary. the number of blood and especially plasma donations is higher, which can be explained by the presence of several albumin and immunoglobulin production sites. increased evidence of blood transfusion rules, the development of a patient's blood management in combination with an increase in the quality of blood components cause a reduction in clinical need for red blood cells and plasma for transfusion. at the same time, the need for platelets is growing. it is difficult to assess the correctness of comparing the amount of banked whole blood. it is equally difficult to compare the number of received and distributed donor red blood cells and plasma: in russia they are measured in liters, and in kazakhstan in doses. with a certain degree of conditionality platelet extraction can be compared. in russia, they are counted in equivalent doses isolated from a dose of whole blood (at least cells per dose), and in kazakhstanin therapeutic doses (at least cells per dose). in , the estimated consumption of platelets in kazakhstan exceeded the russian indicator by . %. % of platelets in kazakhstan and . % in russia are harvested by the apheresis method. inactivation of pathogens is performed in % of platelets in kazakhstan and in . % in russia. pathogen inactivation with amotosalen allows us to abandon the examination of donors for cytomegalovirus and irradiation of platelet concentrate. the main modern trend in the use of cryoprecipitate is using it as a source of fibrinogen, a blood coagulation factor that is first depleted in coagulopathy associated with injury and massive bleeding. its production is growing in both countries, endowment in kazakhstan in exceeded the russian indicator by . %. a significant plasma percentage in both countries does not pass quarantine due to repeated non-appearance of the donor and is subject to destruction. inactivation of pathogens is performed in % of plasma in kazakhstan and in . % in russia. despite the instruction and selection of donors, laboratory screening of infection markers remains effective: russia more often identifies hiv and viral hepatitis c from potential donors, and viral hepatitis b and syphilis are detected in kazakhstan. . % of donors in kazakhstan are exempted due to the results of multiplex screening of nucleic acids of three hemotransmissive viruses. summary/conclusions: the blood services of russia and kazakhstan perform tasks to provide medical organizations with effective blood components. in conditions of decreasing demand for red blood cells and plasma, it is advisable to focus on the efficiency of resource use and improving the quality of blood components produced. blood collection including apheresis p- finnish red cross blood service, helsinki, finland background: skin disinfectant must effectively reduce microbes from the arm of the donor. as a result of poor disinfecting microbes may be transferred from skin via venepuncture to the collected blood and contaminate the blood components. aims: to ensure the efficiency of the skin disinfectant used for donor arm disinfecting by validation. the validation has two criteria which the post-disinfection samples must achieve: . no bacteria growth near the puncture spot (result cfu) in ≥ % of the samples. . total amount of bacteria on average is at most cfu/ cm . at most % of samples are allowed to have - cfu/ cm . methods: microbiological samples were taken with contact plates from voluntary persons' elbow folds before and after skin disinfection. the disinfecting was performed according to normal procedure by five nurses altogether with ethanol based disinfectant used in blood donation. on the sample plates an x was marked and this was directed to the puncture spot pointed by nurse. post-disinfection sample was taken at the moment the skin would be punctured with needle. results: the amount of bacteria varied from to above cfu/ cm in the pre-disinfection samples. disinfection reduced bacteria very well; the critical puncture spot was totally clean ( cfu/ cm ) in . % of the samples and . % of the samples had or only cfu/ cm . the average number of bacteria after disinfection was , cfu/ cm and the maximum number was cfu/ cm . most of the remaining bacteria were single colonies at the edges of the plates. summary/conclusions: both main criteria are fulfilled. the sub criteria of the second main criteria is also full filled if the not so critical colonies at the edges of the plates are not taken into account. the skin disinfectant in question is shown to be effective and can still be used in blood donation paying attention to thorough procedure performance according to the instructions and sufficient drying time of the disinfectant. background: research questions involving blood donation and recipient data often require advanced statistical methodologies. while such methodologies may appear in other medical research areas, specific tailor-made statistical tools and approaches are required for the analysis of blood-related data. these toolkits, which often require collaboration, are not always readily available to blood services, especially so in resource-limited settings. an international network of statisticians, epidemiologists and clinical researchers has been established for this purpose, which started with an invited session at the meetings of the international biometric society. aims: to exchange ideas, experience and knowledge to further improve the quality of blood sector research. methods: currently our network covers four major blood services and members from five different countries. the network has monthly conference calls about past and current research topics. we wish to extend this network further, and establish a subcommittee on statistical and epidemiological methodology with regular face-toface meetings at an international organization such as isbt. results: the monthly meetings have already demonstrated that the members share common problems and interests. for example, we are discussing techniques to analyze data with repeated measurements, e.g. eligibility haemoglobin tests, ways to assess the healthy donor effect, e.g. determining appropriate controls groups, and predictive models of blood supply and demand, e.g. stochastic processes and queuing models. the network also aims to organize training sessions in methodology either on site and/or by developing web lectures. summary/conclusions: an international network on statistical methodology for the analysis of blood donation and recipient data will improve the quality of research in the field of transfusion medicine research. expanding the network to include countries and blood services in research limited settings needs to be actively pursued. background: blood donor hemoglobin concentration (hb) is commonly measured from a skin-prick sample at the donation site, and low hb is the most common reason for temporary donor deferral. while a proportion of the deferrals do reflect true low hb, the skin-prick sample is prone to preanalytical error and variation resulting in false deferrals. aims: we assessed the applicability of a venous blood sample for second-line hb screening in blood donors failing the initial skin-prick test. methods: initial hb was measured from a skin-prick sample with the hemocue hb + (hemocue ab) point-of-care (poc) device. donors with hb < g/l for females or < g/l for males or with a decrease > g/l from latest donation were included in the study. in the study group, a venous blood sample was collected for hb measurement with the poc device at the donation site. donation eligibility was based on this hb result. venous hb was also determined with a hematology analyzer (sysmex xn, sysmex co.). the blood service's current workflow served as the control group: two more skin-prick samples were collected and the donor's final hb and donation eligibility assessed with an algorithm based on all three skin-prick hb results. results: in the study (n = ) and control (n = ) groups, the proportion of male donors ( % and %) and the mean initial skin-prick hb ( g/l and g/l) were similar. significantly less donors were deferred from donation in the study group ( %) than in the control group ( %; chi-square test p = . ). the mean difference in venous hb with the poc device versus the hematology analyzer was À g/l (range À to + g/l). two donors were incorrectly accepted based on venous sample poc result; however, in both, hb measured with the hematology analyzer was only g/l below the limit of donation eligibility ( g/l for a female and g/l for a male). interestingly, a further donors ( % of all deferred in the study group) would have been eligible for donation based on the hematology analyzer result. summary/conclusions: utilizing a venous blood sample for second-line screening of donors failing the initial skin-prick hb test significantly decreased low hb deferrals without compromising donor health. blood donors' and blood service nurses' reactions to the new workflow have been favorable. we conclude that valuable donations can be recovered and donor satisfaction increased by implementing a second-line hb screening model utilizing venous sample analysis at the donation site. background: there is a paucity of literature on haemoglobin (hb) reference values for adults above years of age. this age group has been reported to use up to % the blood supply. some studies report a decline of mean hb with age, but others have found no change with age. conflicting findings of hb levels in the healthy elderly population may be associated with challenges in accessing data from healthy older adults, small sample sizes, selection bias and recent health population data. to donate blood, each individual is assessed as 'healthy' and must meet the minimum hb criteria. however, the hb criteria across countries vary and many blood collection services have an upper age limit for donors. as many populations around world are aging, restricting the upper age limit for blood donation may potentially affect the size of the donor pool and consequently the nation's blood supply. aims: to explore the hb levels of healthy older adults, through a multi-centre retrospective observational study of blood donors aged years or older. methods: over a one-year period, hb values were collected from blood donors aged ≥ years from blood centres of four countries. the estimated proportion of blood donors aged ≥ years old for each country was . % in south korea (sk); . % in hong kong (hk), < . % indonesia (indo) and % in japan (jap). the minimum hb criteria varied between each country and ranged from . - . g/dl for women and . - . g/dl for men. hb levels were determined using point of care testing (hemocue, compolab, hemcontrol) or the xe- d sysmex dependant on the country of origin. statistical analysis of the mean, standard deviation and cumulative distribution of hb were determined by gender and age. background: medication usage is assessed to determine donor eligibility from the perspective of both recipient and donor safety. different time frames since last taken apply to different medications. assessment of medication use varies by jurisdiction, but most european centres use multiple questions. these often include a general question about recent medication use whereas the usa does not. at canadian blood services there are medication questions on the donor history questionnaire (dhq), including any medication use in the last days, vaccination and specific medications over different time frames (high teratogenicity medications). the name of each medication taken and reason for use are documented by staff at each donation attempt. assessment of the frequency with which this process occurs is the first step in improving efficiency of this aspect of donor screening. aims: to determine the percentages donors answering yes to medication questions by demographic variables. methods: all whole blood donors who completed the dhq (full length or abbreviated) in were included in the analysis. donors' answers to each of the medication questions were extracted from the national epidemiology donor database, as well as sex and age. the number and percentage of donation attempts in which a donor answered yes to each medication question were calculated. donors who answered yes to any medication question were sorted by sex and by age group, the totals and percentages calculated. results: there were , donation attempts with a completed dhq. overall, % of donors answered yes to medications in the last days, % to vaccination, and less than . % to others ( % any). slightly more were female ( vs %) of those who answered yes to any medication question, as well as by individual question. the percentage of donors answering yes to any medication question increased progressively in each age group from % of - year olds to % aged + (p < . for trend). summary/conclusions: more than one third of all donation attempts answer yes to a medication question and require further questioning and documentation. this is more common in older donors and follows a similar trend to general population medication use. comparison of ways of assessing medication use in different countries may help identify effective but more efficient approaches. in addition, the contribution to donor and recipient safety of assessing all medications should be assessed. blood center experience with trima accel and tomes software j schreier , a davison , j gambarte , y l opez , c calonge and e herranz terumo bct, lakewood, united states centro de transfusi on de la comunidad de madrid, madrid, spain background: in the madrid community, more than apheresis platelet collections were completed in , of which almost were completed in the blood transfusion center and the remainder in several hospitals in the region. trima accel was implemented to meet the productivity needs of the blood transfusion center while improving the donation experience. tomes (terumo operational medical equipment software), which enables bidirectional communication with trima accel devices, was used to connect and centrally manage all trima accel devices with automated data capture and reporting. aims: the aim of this study was to evaluate operational improvements using trima accel with tomes compared to trima accel version . methods: this was a retrospective study analyzing apheresis procedures on trima accel version during the control period from january to september compared to apheresis procedures on trima accel during the test period from september to december . this was not a paired study. operator interventions, and completed procedure rate comparisons, were analyzed using a -proportions test, whereas donor demographic data were analyzed using a -sample t-test. results: trima accel was used to collect single and double platelet products stored in platelet additive solution. operators selected either a single (target platelet yield = . or . ) or double (target platelet yield = . ) platelet donation based on desired procedure time not the maximum number of products that could have been collected per donor. no statistically significant differences were observed for donors in the test arm compared to donors in the control arm for total blood volume (control = ml, test = ml, p = . ), hematocrit (control = . %, test = . %, p = . ), or platelet pre-count (control = / ll, test = /ll, p = . ). females represented % of donors in the control arm compared to % of donors in the test arm. platelet split rate (platelet products per procedure) increased from . with trima accel version to . with trima accel ; procedure time decreased from . min to . min for single collections and from . min to . min for double collections with trima accel (these differences were not statistically significant). the percentage of procedures that completed with no operator interventions due to access alerts increased from . % to . % (p < . ) and the rate of completed apheresis procedures increased from . % to . % (p = . ) with trima accel . manual transcription of data during the procedure was discontinued with the implementation of trima accel with tomes. tomes captured procedural data and operator steps with barcode scanning and tracking of configured events. this information was transferred to tomes post procedure and printed as a final report. summary/conclusions: trima accel significantly decreased operator interventions, and automated data capture with tomes eliminated manual transcription of data. both outcomes freed operators to complete other tasks and focus on donor well-being. background: the european committee (partial agreement) on blood transfusion (cd-p-ts) of the council of europe (coe) has appointed a working group (wg) to focus on issues with plasma supply management (psm). the task of the wg is, among others, to collect and analyze data in order to fill knowledge gaps concerning donor safety in plasmapheresis. in doing so, the working group will gather evidence base data to support the upcoming revision of the th edition of coe's "guide to the preparation, use and quality assurance of blood components", the blood guide. an international survey was conducted sept-dec , distributed to blood establishments (bes) by the cd-p-ts representatives to coe's member and observer states. the questionnaire included sections covering collection practices (volume and frequency), management of red cell loss, donor panel demographics and data on donor adverse events. aims: the aim of this study was to investigate whether collection practices following the recommendations published in the blood guide for maximal collection volumes and number of donations per year were indeed associated with higher levels of donor safety and improved donor base sustainability. methods: from the total of respondents, bes collected plasma for fractionation (pff) by apheresis and the study had a dataset covering , , plasma donations in the latest fiscal year (lfy). the parameter used as marker of donor safety was the rate of immediate vasovagal reactions with loss of consciousness (vvr with loc) per , plasma collections. the parameter used as marker of donor base sustainability was the retention rate of donors, ie % donors active in the previous year returning to make a donation in the lfy. results: in the blood guide, the collection volume per apheresis is limited to % of the estimated total blood volume but maximally ml, including anticoagulant. respondents had differing practices and scale of collection program be were aligned or lower, and be had higher collection volumes. altogether reported the immediate vvr with loc rate, which mainly was lower than / collections. there was a small trend towards reduced rate with larger collection volumes than allowed by the current blood guide. saline compensation during or after collection did not affect the rate of vvr with loc. no correlation was observed between the annual donor retention rate and the rate of vvr with loc or saline compensation practices, as reported by respondents. the retention rate banded in the range of %> % (mean = %, min = %, interquartile range = %, max = %). the association between maximum allowed yearly plasma collection ( l) appears to be reasonably constant and showed no clear association with the donor retention rate. summary/conclusions: restricting the maximum collection limit according to the current blood guide was not associated with either lower vvr with loc or with higher donor retention rate. this study supports reassessment of current blood guide s limits for collection volume of maximum of ml per donation and l per year per donor. methods: serum ferritin concentrations were established from sera stored at À °c from repetitive platelet donors between and , using architect â ferritin assay chemiluminescent microparticle immunoassay (cmia). the hematimetric parameters were evaluated in a total blood sample using the celldyn â . sixteen samples were obtained from women (age: . ae . years, range: - ) and samples from men (age: . ae . years, range - ), corresponding to . % and . % of the total female and male repetitive donors of platelets by apheresis using trima accel â terumo-bct and amicus tm fresenius-kabi. the difference in the concentration of serum ferritin between the last and first donation was established, as well as the change in the predonation platelet count between the last and first event. results: in the study population, . % of women and % of men performed repetitive donations of platelets by apheresis with an interval of less than three months. the change in ferritin concentration was evaluated according to the interval between donations. in women ferritin delta was À . ae . ng/ml when the donations had an interval less than three months, vs . ae . ng/ml when the time between donations was higher (p = . ). in men the change in the ferritin levels was À . ae . ng/ml with donation times less than three months vs © the authors vox sanguinis © international society of blood transfusion vox sanguinis ( ) (suppl. ), - À . ae . ng/ml with prolonged donation times (p = . ). in women, the change in platelet count was À ae . /ul, when the donations had an interval less than three months vs À ae . /ul when the time between donations was greater (p = . ). in men, the delta of the platelet count was À ae . /ul in donation times less than three months vs À ae . with higher donation times (p = . ). no correlation was found between the concentrations of serum ferritin and the platelet count (r = . , q = . for males, and r = . , q = . for females). summary/conclusions: the data obtained suggest that repetitive donation of platelets by apheresis with intervals between donations of less than three months, significantly reduce serum ferritin concentrations in women and men, although normal levels were maintained in both groups. there was no correlation with platelet count. therefore, it is proposed to develop prospective studies to establish the minimum time interval safety for platelet apheresis donor procedures. background: the demand for platelets concentrates is increasing continuously and becomes a challenge for the blood establishments. apheresis platelet collections may be a solution for this challenge. improving apheresis collection efficiency while maintaining blood donor safety is an important goal for the service du sang of the belgian red cross. aims: our establishment evaluated the improvements of the trima accel automated blood collection system version (ta ) by comparing its routine performance with that of the previous software version . (ta ). methods: prospective, multi-site, controlled, non-randomized trial. apheresis collections were performed in three sfs sites: liege, mons and namur using the two trima software versions ta and ta sequentially. data were collected from december to april on ta and from june to july on ta . simple and double doses of platelets (respectively . , . and . , . ) were collected in platelet additive solution (ssp+, macopharma) with concurrent plasma from the same cohort of donors in accordance to donor's eligibility and preferences. in order to maintain the same final platelets content in platelets concentrates, the trima accel's tool yield scaling factor (ysf) was subsequently adjusted from . (ta ) to (ta ). platelet yield, duration of procedure, number of alarms requiring operators' interventions were recorded and evaluated. donor's hypocalcemia was avoided by giving preventively oral or intravenous calcium which was documented by the operators. results: five hundred ninety ( ) collections with ta and with ta were recorded, with % and % complete procedures respectively. mean duration of procedures was min on ta against min on ta , p < . . the mean alerts number per procedure on ta was . against . on ta , p < . whereas the maximum alerts number per procedure was and respectively. on ta , % procedures did not require operator's intervention against % on ta ,. with ta the inlet flowrate was automatically adjusted in . % procedures. the inlet flowrate was increased in response to access pressure in . % of procedures, for % of the procedures the inlet flowrate was decreased and for . % of the procedures the inlet flowrate was increase and decreased on the same procedure by the ta autoflow system. summary/conclusions: ta with its autoflow function improves apheresis donors experience while decreasing operator' interventions through a significant reduction of access draw alerts. as expected from the trima accel platform, post-donation safety remains high. a weak increase in procedure duration was observed for the same platelet yield which may be resolved with further adjustments. background: trima accel system is an apheresis platform relying on continuous flow centrifugation to collect from a donor platelets, plasma or rbcs based on donor qualification. the latest software version -trima accel (ta ) introduced the autoflow feature which allows for automated flow rate adjustments. moreover, ta leverages the mobilization capacity of the spleen increasing potential platelet productivity while maintaining high post-donation safety standards characteristic of trima accel. aims: the objective of this evaluation was to assess the impact of ta software by retrospective comparison of procedure data and potential for increased productivity with those of trima accel version (ta ) in the same cohort of platelet donors. methods: eight hundred twenty one procedures, started on ta from th january to th october were compared to procedures, started on ta from th october to st december . procedural data from the trima devices were captured using the cadence system (terumo bct, lakewood co). parameters investigated were the number of machine access pressure alerts per procedure, the potential for higher platelet yield collections and the actual collected yields within the same cohort of platelet donors. results: both donor populations (ta vs. ta respectively) were comparable and were characterized by: tbv - vs. ml; platelet count pre-procedure - ³/ll vs. ³/ll; hematocrit pre-procedure - % vs. %. gender distribution was % female with ta vs. % with ta . venous access pressure alerts were significantly improved by ta with an average of . alerts per procedure as compared to . with ta , i.e. % decrease. this decrease went down to % if only male procedures were analyzed. the maximum number of pressure alerts went down by % from alerts in one particular run in the ta cohort to alerts in one ta procedure. procedure time for single platelet products was reduced from to min and for double platelet products from to min (ta and ta respectively). donor qualification possible was % of procedures yielding single products and % of procedures yielding double products with ta . the percentage of procedures qualifying for doubles increased to % with ta . in terms of split rates, i.e. how many platelet doses could be produced per apheresis collection, potential split rates increased from . to . from ta to ta , respectively. in fact, the observed split rate rose modestly from . to . , as shorter procedures were generally selected according to donors' preferences. summary/conclusions: in comparable donor populations, implementation of ta decreased the number of access pressure alerts significantly compared to previous trima versions. the average procedure duration was also found to be slightly reduced. implementation of ta has the potential to increase productivity significantly. the observed modest actual rise in split rate suggested that factors related to donor and inventory management will determine at which extent the potential of the new software will be used. donor compared experience on trima accel to trima accel version august to october or trima accel during the test period from november to january . this was not a paired study. donors completed the survey while recovering from the apheresis procedure in the cantina. results from the paper survey were transcribed into excel for analysis. results: donors completed the survey during the control period whereas donors completed the survey during the test period. the mean number of previous donations for the control period was . (min max ) and for the test period was . (min max ). there were no first time donors during the control period and first time donors during the test period. % of donors rated their overall donation experience as good on trima accel compared to % on trima accel version . zero ( ) donor rated their experience on either trima accel device as poor. % of donors who responded to the question said they would donate on trima accel again. summary/conclusions: no significant difference was observed in donor experience between trima accel version and trima accel as both versions receive high marks. background: the trend on growth of query for donor platelet concentrates is observed in russia for past few years. as reported by edqm in , a higher number of the platelets was consumed compare to by . %. patients' with hematological malignancies treatment requires platelet concentrates transfusions during chemotherapy, immunotherapy and hematopoietic stem cells transplantation. according to the data collected in national research center for hematology (nrch) in , ( . %) of the , patients, treated within facility, received platelet transfusions as transfusion therapy. the total number transfused units is , , which is higher (by . %) comparing to . platelet concentrates production can be performed either by apheresis process or by pooling individual units recovered from the whole blood. taking into account that the nrch produces blood units for its own needs, the pooling is not suitable method for production because its implementation doesn't cover require for platelets and overproduces rbcs. that is why platelet concentrates in nrch are obtained by apheresis only. in summary, the growth on requirement for platelet concentrates and their safeness explains the need for a comparative study for effectiveness of platelet production using various apheresis systems. aims: the aim of the study is to compare effectiveness of platelet concentrate production using mcs + (haemonetics), upp and trima accel (terumo bct) version . protocols. methods: the data for protocols of platelet donations performed in were analyzed: on trima accel and on msc + . all donors were voluntary and non-paid donors with previous experience of blood donations. the choice of the platelet collection device was random; analysis of the main characteristics of donors did not reveal any significant differences between the groups. the median age of the donor was years old, height - cm, weight - kg, platelet count before donation - /l, hematocrit - %. detailed data are presented in table . student's t-test for unrelated sets was used for statistical analysis of the data. a value p of less than . was considered as significant. results: the data obtained showed significant difference (p < . ) between average number of platelets collected on trima accel ( . ae . /l) and on mcs + ( . ae . /l). while cost of consumables are comparable, trima accel demonstrated . % higher efficiency. procedure duration also was comparable and averaged within min for both devices. detailed data are presented in table . it is crucial to mention that proportion of trima accel's donations was significantly increased in nrch during and reached , % in total ( - . %). a flexible usage of trima accel's consumables for different procedures (regular platelet collection and collection in pas) allowed to change the pas/regular platelets collection ratio from . % up to . %. summary/conclusions: obtained results proved the effectiveness of the trima accel's use for platelets concentrates production. it allowed to increase the average count of platelets obtained for one procedure by . % compared to mcs + while the cost of consumables and procedure duration are comparable. the donor's comfort during procedure did not affect either. in long terms increasing of number of platelets collected is reducing the cost of platelet concentrates production. abstract withdrawn. background: apheresis collected platelet concentrate is preferable in terms of reducing the risks of adverse reactions in platelet transfusion when compared to random donor platelet concentrates. aims: the aim of our study is to present our experience in collection donation of single donor platelets with apheresis. methods: this is a retrospective study performed in the institute for transfusion medicine from till . all donors were fully informed on the donation procedure and signed an informed consent for donation. the optimal platelet count that we want to achieve was ≥ . equal to random donor platelet doses. minimum preapheresis platelet count in donors requested to start the apheresis collection was . /ll. platelet collection was performed using flow cell separators haemonetics mcs+ and trima accel. acid citrate dextrose formula a was used for anticoagulation. median precollection platelet count of donors was . /ll, with range from . /ll to . /ll. male were % of the donors and females were %. the single procedure usually took - min. the median platelet count collected was . , range - . . the median processed blood volume was ml and median used acd-a was ml. mean total volume of collected product was ml. the adverse effects included vein perforation and the numbness of the extremities as reaction of acd-a (hypocalcemia), which occur rarely and was very mild. summary/conclusions: the collected platelet count was more than the wanted optimum platelet count. the number of apheresis donors is increasing and we are working on expanding our voluntary platelet donors registry and increasing the number of typed donors in the registry. background: to determine value of hemoglobin in blood donors, there are some tools or methods used, such as: cyanmethemoglobin method that can detect of hemoglobin quantitative and methods cupric sulfate solutions (cuso ) can detect of hemoglobin qualitative. according to who (world health organization) to determine the level of hemoglobin in blood donors enough used cuso solutions with specific weight (y) . can to detect value of hemoglobin above or same with . gr/dl. but, cuso solution specific weight . can not to detect and elimination value of hemoglobin above gr/dl or polycythemia sick. because it, central blood transfusion unit (utdp) as the central of blood service in indonesia to manufacture cupric sulfate solution (cuso ) with a specific weight (y) to detect value of hemoglobin below gr/ dl and determine value of hemoglobin above gr/dl. because it, do the testing the accuracy of the solution cupric sulfate in detecting and eliminating donor with value of hemoglobin above gr/dl with the test of samples. aims: to determine accuracy and effectiveness by blood donors unit in indonesia red cross to use cuso solution with specific weight . in to detect and elimination value of hemoglobin donors above gr/dl. methods: used the method cyanmethemoglobin and cuso (y) . determination value of hemoglobin donor. test results were analyzed with spss software version using nonparametric analysis wilcoxon test. results: this research testing the accuracy and effectiveness of using a cuso solution with specific weight (y): . in detecting and eliminating hemoglobin value donors above gr/dl. from data processing using spss with the wilcoxon test p value . . summary/conclusions: it was found that the cuso solution (y): can detect hemoglobins value above gr/dl and more effective in checking the hemoglobin in blood donors. it can be seen from the data processing with spss version with the wilcoxon test p value < . . it is important to monitor the precise course by which repeated blood donation affects hb and the probability of low hb deferral. zinc protoporphyrin (zpp) is a functional indicator of body iron levels and is hypothesized to predict hb levels among blood donors. advanced statistical methods are necessary to properly analyze the longitudinal associations between zpp and hb in data with repeated donations per donor. aims: to determine whether predictions of future hb levels using current hb levels can be improved by taking zpp levels into account, and to illustrate the use of statistical models for repeated measurements of blood donors. methods: we used data from the zpp and iron in the netherlands cohort (zinc) study. we identified previous zpp levels (log-transformed) as the main predictor and adjusted for previous hb level, age, day and time of donation, donation history, bmi, blood volume and blood pressure. we used linear mixed models, which take into account missing data in the outcome and associations between repeated measurements, to investigate the longitudinal association between previous zpp and current hb levels. the longitudinal analysis with linear mixed models was contrasted with a simpler analysis based on the area under the receiver-operating-characteristic (roc) curve for the probability of low hb deferral. results: in total, whole blood donors ( , whole-blood donations) were included in the zinc study, % being female donors. previous zpp showed a statistically significant association (p < . ) with hb levels in females, but the size of the association was quite small (regression coefficient, b = À . , % confidence interval À . to À . ). the same was true for males, but the size of the association was even smaller. blood volume and age for women were significant secondary predictor variables; blood volume, age and donation interval for men. by comparison, the roc analyses showed relatively larger, but less statistically significant predictive effects of zpp on hb. summary/conclusions: zpp is a statistically significant predictor of hb levels, but the size of the effect after adjustment for previous hb and other variables is small. the results cast doubt on whether zpp is an effective predictive marker for hb level and low hb deferral, and suggest that zpp should not be included in prediction models for hb levels. by properly adjusting for associations between repeated measurements and by using all available data, longitudinal models provide less biased and more precise estimates than simpler cross-sectional analyses. background: finnish red cross blood service (frcbs) is a national blood service and is responsible for all blood collection and component production in finland. the highest age for blood donors was years until the end of year and since beginning of donors between and years have been able to donate blood. blood donation after the age is possible if the donor has donated within the last months. the upper age limit was raised up based on adverse event data from frcbs donors up to years and on published data from other blood establishments. aims: the aim of this study is to find out if the new policy from with upper age limit of years is safe. therefore donor adverse event data was analyzed in order to evaluate if the blood donors older than years have more adverse events compared to other donors. the most common donor adverse event for donors over years, haematoma, was registered times ( . %). in the other age groups haematoma was registered times ( . %) and the difference between the oldest age group compared to all other donors was statistically not significant (chi , p = . ). vvrs with loc were registered times ( . %), vvrs without loc times ( . ), and the total number of all daes was ( . %) in the age group years or older. the respective numbers in the other age group were: , . %; , . %; ( . %). the number of vvrs with and without loc, and total number of all daes in the age group years and older was smaller than in the other groups and the difference between these groups was statistical significant (chi , p < . ). summary/conclusions: donors over the age of years have less donor adverse events than other age groups. decision to raise the age limit from to seems proven to be right as the older age group has even less donor adverse events than other donors. background: deep vein thrombosis (dvt) of the donor's phlebotomy arm is a rare, but serious complication of blood donation that needs to be recognised and managed appropriately in a timely manner. post donation dvt will be classed as a 'serious adverse events of donation' (saeds)these are events that either result in donor death, hospitalisation, intervention or significant symptoms persisting for more than one-year post donation. aims: to review cases of dvt post donation reported in uk in - years and identify any common themes for improving practice methods: all data relating to saeds from the four uk blood services reported to shot in the last years ( - inclusive) were reviewed to look for reports of dvt post donation results: a total of saeds were reported in uk from approximately . million donations (whole blood and apheresis) collected during this period. three cases of upper limb dvt were reported during this time accounting for % of the saeds reported and rate of dvt of in . million donations collected. -case : a regular male whole blood donor in his early s reported worsening arm pain days following blood donation, had a painful venepuncture and a small bruise at site of donation. he was diagnosed to have an upper limb dvt extending to the subclavian and brachiocephalic vein and started on oral anticoagulants. no other contributory factor was obvious -case : a female donor in her mid- s gave her sixth whole blood donation without event. days after donation, she developed worsening arm pain in the donation arm and was diagnosed with an upper limb dvt and commenced oral anticoagulation. there was no other identifiable risk factor for the thrombosis -case : a female donor in her s developed pain, swelling, redness and itchiness in her donation arm and chest wall two days after donation. she also described prominent veins on the affected side compared to her other arm. she contacted the transfusion service one week after donation; by this time she was also breathless on minimal exertion. she was admitted to hospital and commenced on anticoagulant therapy. a diagnosis of dvt and associated pulmonary embolus was confirmed. the donor's only risk factor for thrombosis was use of the oral contraceptive pill. summary/conclusions: rare complications of blood donation, like dvt, can occur. superficial venous thrombosis may occasionally progress into the deeper veins of the donor's arm but dvt can also occur without signs and symptoms of superficial thrombosis. none of our patients had any overt evidence of superficial thrombosis. one patient in our series reported using oral contraceptive pill. no other risk factors for thrombosis was forthcoming. transfusion services should encourage donors to make early contact with the blood service if they experience arm complications so that they can be investigated and managed in a timely manner. staff dealing with such donors must recognise the possibility of this rare complication, explore other additional contributory factors and initiate prompt and appropriate management. background: voluntary blood donation is widely considered to be safe with very minimum chance of adverse reaction, which may occur during or after the end of phlebotomy procedure. aims: to find the adverse blood donor reaction among voluntary blood donors in tertiary care hospital in kathmandu methods: this is a prospective study done among voluntary blood donors at grande international hospital, kathmandu, nepal from february to march . the outlines of reported and communicated adverse donor reaction were also collected after the blood donation from voluntary blood donors in different locations including outdoor and in-house blood donation drive results: in the present study , whole blood donors were included, during the period of years, ( . %) adverse donor reactions were reported. majority ( . %) of adverse donor reactions were mild in nature such as, sweating; ( . %), light headedness; ( . %), nausea and vomiting; ( . ), allergy and bruises; ( . %), sore arm; ( . %) and hematoma; ( . %) while ( . %) were severe adverse reactions similarly, anaphylaxis; ( . %), loss of consciousness; ( . %) and convulsive syncope; ( . %). markers of the adverse donor reaction were age, sex, pulse, weight, blood pressure and donation status. age and first time status were related with significantly higher risk of adverse reaction with - years old at higher risk compared to - years old. first time donors were at higher risk compared to repeated volunteer donors. summary/conclusions: the results of the study are helpful to identify and understand the complication of adverse donor reactions though the incidence of reactions in the blood donors is lower than in other studies. donor age and donation status were strong possibilities of complications. background: blood donors with pollen-induced allergy and asthma must often refrain from donation in pollen season despite medication, because of symptom severity or similarity to airways infection. extracts of the medicinal mushroom agaricus blazei murill (abm) given orally have been found to reduce ige anti-ovalbumin levels and ameliorate the skewed th /th cytokine balance in mice sensitized to ovalbumin (takimoto, immunopharm immunotox, ; ellertsen & hetland, clin mol allergy, ). aims: the objective was now to examine whether supplementation with the abmbased extract that we used in the mouse model for allergy, could alleviate allergy and asthma in blood donors by reducing specific ige levels and basophil sensitization. methods: sixty donors at oslo blood bank with self-reported birch pollen allergy and/or asthma were recruited and randomized in a double-blinded, placebo-controlled study with oral supplementation for weeks before the birch pollen season with the abm-based extract andosan tm (immunopharma, oslo, norway). this is a water extract of the bacidomycetes mushrooms abm ( %), hericeum erinaceus and grifola frondosa. the participants filled in questionnaires for allergic conjunctivitis & rhinitis, asthma and medication. serum ige (immunocap â , immunodiagnostics, sweden) and bet v -induced basophil activation in whole blood determined by cd expression in a flow cytometer (flow cast â , b€ uhlmann lab ag, switzerland), were analyzed before and after the pollen season. (trial record: nct , clinical.trials.gov). results: there was significant reduction in allover allergy-related ailments and types of allergy medication used in the abm extract compared with placebo group during the pollen season and no side effects. also, abm treated asthmatics had fewer symptoms and used less medication than controls. in the abm group, serum levels of specific ige anti-bet v and anti-t , were significantly reduced during the pollen season as compared with levels in the placebo group. whereas the maximal allergen concentrations needed for eliciting basophil activation before the season changed significantly to lower concentrations (i.e. enhanced sensitization) after the season in the placebo group, these concentrations remained similar in the group given the mushroom extract. summary/conclusions: oral pre-seasonal supplementation with an abm-based extract for months reduced general allergy ailments, asthma symptoms and medication in blood donors with birch pollen-induced allergy and asthma during the pollen season. this was due to reduced specific ige levels and basophils rendered less sensitive to allergen activation. the study suggests that supplementation with abm mushroom extract can have prophylactic effect on aeroallergen-induced allergy and asthma in blood donors. it may therefore reduce such ailments in affected blood donors and impact blood donations in the pollen season. results: dhv started in / / . the data presented in this abstract is till / / . data is collected from total of blood donors ( . % male donors and . % female donors). repeat donors accounted for . % against . % of first time donors. of the total number of donor adverse events recorded, . % ( ) reported for male donors and . % ( ) for female donors when the donor adverse events stratified age-wise, the highest incidence reported in age group - years (male . % and female %). among age group - years, (male . % and female . %), whereas in age group - years, (male . % and female . %) data analysis of total reported and registered donor adverse events, are categorized as hyperventilation ( ), sweating ( ), dizziness (pre-syncopal ), loss of consciousness ( ), vomiting ( ), convulsions ( ), hematomas with re-bleed ( ), nerve irritation ( ) and off-site reactions ( ). many donors showed multiple forms of reactions. summary/conclusions: evaluation of donor side effects helps to improve donation process and donor compliance. most frequently recorded reaction remains dizziness (pre-syncopal). our donor vigilance data show reactions occurred more frequently in younger age, female and first time donors. repeat donation and age are predictors for low rates of adverse events. participation in dhv implies an effort to improve donor care and safety infrastructure and a desire for national and international comparisons to determine best practices and also to look into effectiveness of risk reduction strategies and follow-up trends. pre-donation hydration was implemented as an interventional tool to test the effects of hydration on pre-syncopal reactions to blood donation, specifically targeting those at highest risk such as female, first-time, high school donors. the results are awaited. background: descriptions of deferral categories and a knowledge in the percentage of deferrals in each category are of value in formulating recruitment and retention strategies. this can also help in planning more efficient recruitment strategies and thereby assist in reducing the shortage in blood supply. aims: the aim of the study is to categorize all donors who were deferred during medical checkup and find out the donor deferral rate in dubai blood donation center from january st to december st and also to find out whether there is any yearly or seasonal trend in any of the categories of deferral criteria's which can aid in forecasting and managing donor pool. methods: a retrospective study of donors deferred during last three years from january st to december st was done in dubai blood donation centre. the donors deferred during pre-donation medical check-up were categorized into categories including low hemoglobin, high and low bp, intake of antibiotic, fever and flu, taking other medications, travel history etc. the deferrals were analyzed monthly and yearly and then were compiled to find any yearly trend or seasonal trend in the donor deferral rate in any of the categories. the data were analyzed using the spss software and a p value of < . was considered significant. the assessment of donor suitability is in accordance with aabb standards and is consistently applied in every blood donation setting on each occasion of donation to all blood donors. results: during this study, , donors were registered from january st to december st and , ( . %) donors were deferred. the common reasons of deferral were low hb, high bp, travel history, intake of antibiotics and cough/flu symptoms. there was a significant decrease in deferral rate from . % ( / ) in to . % ( / )in and further to . % ( / ) in (p < . ). the specific deferral rate due to low hb also significantly (p decreased during these three years ( / in , / in , / in ), though no change was seen in the deferral due to other reasons. the reduction in the rate of deferral due to low hemoglobin may-be linked to the change in the staff performing the hemoglobin testing in dbdc (nurses instead of phlebotomist were assigned to perform hb estimation of donors). there was a seasonal variation in the deferral rate in all the three years-lowest in june ( / ) and then increasing with a peak in october ( / ) and plateauing till january. this pattern of deferral corroborated with the rate of deferral due to flu/fever and cough and antibiotics with an average of / in june and increasing to / in october (p < . ). summary/conclusions: staff competency is pertinent in accurately deferring donors. there is also a significant seasonal pattern in flu/fever and intake of antibiotics deferral rate that is reflected in the total donor deferral pattern. seasonal variation of specific category of donor deferral should be taken into account for donor recruitment and retention efforts. background: west nile virus (wnv) is a mosquito transmissible flavivirus. it has been shown (vogels thesis) that the common mosquito in the netherlands can transmit wnv in laboratory circumstances but presently does not lead to effective transmission. however, the number of outbreaks of wnv is increasing and moving from the eastern and southern european borders towards the traditionally more colder western and northern parts of europe. in order to prevent wnv transmission to blood transfusion recipients, dutch donors that travelled to regions with wnv risk are deferred for a period of days for whole blood, platelet donations and quarantine plasma in order to exclude potentially infected asymptomatic donors. aims: to assess numbers of dutch donors who are deferred for travelling to wnv risk areas within europe, and the return after onsite and offsite deferrals of donors. methods: data from to on donation attempts and deferral were retrieved from eprogesa, the blood bank information system. onsite deferral is defined as a donation that was attempted in the deferral period or in the days prior to deferral, all other deferrals are considered as offsite. a generalized estimating equation model was used to assess the association between onsite versus offsite wnv risk deferrals in - and subsequent return rates within two years (after which a donor is inactive according to domaine). results: in - , , donation attempts led to onsite deferral for wnv risk; % at whole blood donation attempts, % at new donor examinations. in total , offsite deferrals could not be traced directly to a donation, but based on the next donation more than % were probably whole blood donors. the number of deferrals peaks each year during august, the major holiday period in the netherlands, and increased from in august to in august . this increase is probably caused by the expansion of wnv risk regions. the return rate of wnv deferred whole blood donors is slightly lower than for donors who are not deferred ( % versus %); for wnv deferred new donors the return rate is % (versus % for no deferral). thus wnv deferral resulted in approximately - extra lapsing donors during these years. however wnv deferred donors, that are older (odds ratio (or) . ; % confidence interval ( % ci) . - . ), of male sex (or . ; % ci . - . ) and whole blood donors as opposed to new donors (or . ; % ci . - . ) were more likely to return to donate. there was no difference in return rate by offsite and onsite deferral. summary/conclusions: travel-related wnv deferrals are increasing with expanding risk regions, especially in the holiday season where the availability of donors is already low. although the numbers of donors who are permanently lost after wnv deferral are limited, the increasing numbers of lost donations make it important to consider alternatives to donor deferral such as wnv nat testing. background: low haemoglobin due to iron deficiency is increasingly recognized as a serious problem in many blood centers. donor education, iron supplementation, ferritin monitoring, and lengthening of inter-donation interval are currently the main mitigation measures. however, a number of factors in particular donor knowledge could impact their success. locally, iron supplementation programme was implemented since with target group of donors who have given blood within the last six months. aims: here we look at an online donor survey to gain insight on their view of the programme and knowledge. methods: donors with successful blood donation in the past six months would be given days of one tablet of iron supplementation ( mg elemental iron) since . an electronic questionnaire was sent to blood donors in to assess their view on the programme and knowledge which focused on iron store and absorption, compliance and any side effects occurred. results: donors (male to female was : . ) replied to the questionnaire. of them, received iron supplementation (male to female was : . ). most of the respondents ( %) had one or more donations in the preceding months. of the donors received iron tablets, only ( %) took all; ( %) took more than % but not all; ( %) took some but less than % and ( %) did not take any. gastrointestinal upset was reported in ( %) donors and constipation seen in ( %) among those who took at least some of the iron supplementation. most respondents answered correctly to the questions on the knowledge on iron store and absorption. when comparing those with better compliance (took more than %) to those who did not (took less than %), significantly more donors in the former knew vitamin c could enhance iron absorption (p < . ). on the other hand, no difference was seen when they were asked if ) iron can only be absorbed from meat; ) tea and coffee consumed during meal can enhance iron absorption; ) everyone can take iron supplementation on their own; and ) iron store in male is always more than female. summary/conclusions: the results suggested that there is definitely more room to enhance the blood donors' knowledge on iron store and absorption in order to improve the effectiveness of iron supplementation programme. besides, the side effects reported by the donors could be an important limiting factor that better alternatives should be explored and considered. background: vasovagal reactions (vvr) are a well-established deterrent to donor return. however, the correspondence between vvr experience and donor lapse is not perfect. in australia, for example, vvrs only reduce two-year return rates by % for whole blood donors and % for plasma donors. the elements of a vvr and the donor's interpretation of this event that protect against or encourage lapse have not yet been identified. aims: in this study we explored the views of donors on donating following a vvr, with a particular interest in their emotional reaction to the vvr, their understanding of what caused the reaction, and their intentions to return. methods: semi-structured telephone interviews were conducted with whole blood and plasma donors who had a recent vvr experience. data were analysed using the framework approach. results: donors are generally motivated to give blood to help others and to positively impact on those in their communities. they anticipate feeling good after their donation but in contrast, for many, a vvr leaves them feeling anxious, embarrassed, and disappointed. for donors, the experience of a vvr negatively influences their perceived ability to donate successfully, and many fear it will happen again. however, this effect appears minimised among donors who at least partially attributed their reaction to their own behaviour, such as poor hydration. for donors already juggling multiple demands, a vvr may tip the balance with donating becoming too much of an effort and perceived risk. however, donors appeared more confident to return if they felt supported by staff or if they could donate with family or friends. summary/conclusions: this study provides valuable insight into the vvr experience, which will aid in the improvement of donor safety and retention. the findings highlight the need to improve communication at the time of and following a vvr, to educate donors on how to reduce their vvr risk, and to intervene to help donors maintain their perceived ability to give blood in order to maximise retention following a vvr. background: frequent blood donation depletes the iron stores of blood donors. iron depletion might have negative effects on the health of the general population, but its effect on the blood donor population is not well known. aims: to investigate the iron status of finnish blood donor population and how it relates to donor health, the finnish red cross blood service set up the findonor , study in . we investigated whether there were changes in donors' selfrated health and if these possible changes could be associated with differences in iron biomarkers (ferritin and soluble transferrin receptor -stfr) or hemoglobin levels during the first study visit. methods: participants were recruited in three donation sites in the capital region of finland between may and december . participants filled out an electronic questionnaire about their health and lifestyle at the donation site during their enrollment visit. participants were asked by letter to fill out the same questionnaire electronically during the summer . we included the participants ( men and premenopausal and postmenopausal women) who completed both health questionnaires. to evaluate self-rated health we used the well-validated single question: "how would you rate your health in general?". participants were able to evaluate their health status on a five-point scale: excellent, very good, good, moderate, and poor. iron biomarkers and venous hemoglobin were measured from blood samples collected at the first study visit. we first computed the odds-ratios of reporting poorer health depending on demographic group. we then compared iron biomarker and hemoglobin levels between donors who reported improved, similar or poorer health rating. results: donors who rated their health in the first questionnaire as moderate (n = ), good (n = ), very good (n = ) or excellent (n = ) health tended to report improved ( %), similar ( %), similar ( %) or poorer ( %) health ratings respectively in the second questionnaire. pre-menopausal women reported their health poorer in the second questionnaire compared to the first questionnaire more often than post-menopausal women (pre-menopausal %, post-menopausal women %), or = . % ci . - . ). there were no differences between other groups. there were no significant differences in iron biomarkers levels (ferritin and stfr) or hemoglobin levels between donors whose health ratings were improved, similar or poorer. summary/conclusions: in this cohort, pre-menopausal women rated their health poorer at the end than at the beginning of the study more often than post-menopausal women. no association was found between changes in self-rated health and iron levels (ferritin, stfr) or hemoglobin levels. further studies about the factors relating to blood donors' self-rated health need to be carried out. background: in recent years, the blood donation business has made great achievements, but it still cannot avoid the occurrence of adverse reactions to blood donation which not only brings certain obstacles to the blood donation work, but also affects the enthusiasm of blood donors. aims: to understood the causes and other relevant factors of adverse reaction among blood donors, the information of blood donors at dai autonomous prefecture of xishuangbanna were analyzed in . methods: the data of volunteers from january to december were analyzed. the causes of adverse reactions were classified, and the incidence of adverse reactions was compared in terms of gender, frequency, age and blood type of blood donors. results: there were blood donors in , ( . %) of whom had adverse reactions and causes were induced, among which mental stress was the most common factor that accounted for . % ( cases). there was no significant difference in the incidence of adverse reactions between men and female (p > . ). from the frequency of blood donation, the incidence in the first donor was significantly higher than that in the second donor (p < . ). when it comes to age, the incidence was different and the - age group was the highest ( . %). among different blood group donations, there was no significant difference (p > . ). summary/conclusions: adverse reactions of blood donation is closely related to the psychological state and age of the blood donors. the staff of the blood center should further optimize the service, strengthen the communication and publicize the knowledge of blood donation. the ultimate goal is to increase the blood donation rate on the basis of reducing adverse reactions. background: blood loss due to repeated blood donation can lead to iron deficiency or anemia, but currently there is no management plan for the prevention of iron deficiency in korean blood donors. female and male donors are required to wait at least weeks between blood donations in korea, which is the shortest period among all northeast asian countries. female and male donors are allowed to donate whole blood up to five times per year and platelets up to times per year (if spaced more than days apart for the latter) due to the chronic blood supply shortage. these facts induce concern about the impact of blood donations on the donors' iron status. aims: this study aimed to evaluate the effect of oral iron supplementation in repeat donors based solely on donation history. methods: the high-risk group included male donors with ≥ whole blood donations or plasmapheresis or plateletpheresis donations, and female donors with ≥ whole blood donations or component donations, both within the previous year. the control group consisted of first-time or reactivated (ft-ra) donors who had no history of blood donation in the past years. the hemoglobin (hb) level, ferritin level, total iron binding capacity (tibc), transferrin saturation, and soluble transferrin receptor (stfr) of repeat donors at high risk for iron deficiency were compared to those of ft-ra donors. iron deficient erythropoiesis (ide) is defined as present if the log of the ratio of soluble transferrin receptor to ferritin was ≥ . . the repeat donors took iron supplements for weeks and the same tests were repeated after and weeks to evaluate their effects and the side effect and compliance was assessed. results: a total of male and female repeat donors were recruited, and each male and female ft-ra donors were recruited to the control group. after week iron supplementation, among male donors, the prevalence of: low hb level (< . g/dl) decreased from . % to . %; low ferritin level (< . ng/ml) decreased from . % to . %; high tibc level (> lg/dl) decreased from . % to . %; low transferrin saturation (< . %) decreased from . % to . %; and ide (stfr/ferritin ≥ . ) decreased from . % to . %. among female donors, the percentage of: low hb level (< . g/dl) decreased from . % to . %; low ferritin level (< . ng/ml) decreased from . % to . %; high tibc level (> lg/dl) decreased from . % to . %; low transferrin saturation level (< . %) decreased from . % to . %; and ide (stfr/ferritin ≥ . ) decreased from . % to . %. in total, male ( . %) and female ( . %) blood donors reported undesirable side effects related to iron supplementation. a total of male ( . %) and female ( . %) blood donors were administered iron supplementations for days. participants ( . %) answered that they were willing to take a complimentary iron supplementation. summary/conclusions: ferritin level, considered a reliable indicator of iron status, increased and ide decreased significantly after iron supplementation in female donor group, but not in male donor group, compared to the ferritin levels and ide of control donors. iron supplementation in repeat donors at a high risk of iron deficiency was shown to reduce their risk of iron deficiency or anemia irrespective of gender; however, -week oral iron supplement was not enough to restore iron storage level in the male donor group. background: c-reactive protein (crp) is an acute-phase protein and a non-specific maker of inflammation and tissue damage produced by the liver. several prospective epidemiologic studies have demonstrated that high-sensitivity c-reactive protein (hs-crp) is a predictor of future coronary events among apparently healthy men and women, hs-crp level greater than mg/l has been independently associated with a % excess risk in incident of coronary heart disease (chd) as compared with levels less than mg/l. frequent blood donation has been associated with a lower incidence of coronary artery disease (cad); however, there is a dearth of information on serum levels of crp in the nigerian donor population. aims: to investigate whether regular blood donation is associated with lower serum hs-crp level in nigerian blood donors. methods: a descriptive cross-sectional study carried out to measure serum levels of high sensitive c-reactive protein (hs-crp) and ferritin among blood donors attending the donors' clinic in lagos university teaching hospital (luth). subjects who did not meet criteria for blood donation were excluded. additional data on sociodemographic characteristics was collected using interviewer-administered questionnaire. serum ferritin was analysed using chemiluminescent microparticle immunoassay performed on the abbott architect ci (abbott laboratories, abbott park, il, usa). serum concentration of hscrp was estimated by immunoturbidimetry method using analytical kits from erba diagnostics mannheim gmbh in semi-autoanalyzer (xl , erba mannheim). data was analysed using stata version (stata corp) statistical software. results: in total of blood donors, ( . %) were males and ( . %) were females, the mean age was . ae . years. two hundred and thirty four ( . %) were first time donors and ( . %) were regular donors, serum levels of hs-crp was slightly higher in regular donors compared to first time donors ( . ae . vs . ae . mg/l, p = . ) though the difference was not significant. serum levels of ferritin was significantly higher in first time donors compared to regular donors ( . ae . vs . ae . ng/ml, p = . ). interestingly, levels of serum hs-crp were significantly higher in male than female population ( . ae . vs . ae . mg/l, p < . ) and smokers than non-smokers ( . ae . mg/l vs . ae . mg/l, p = . ). correlation analysis showed no correlation between serum hscrp and serum ferritin levels in both categories of donors while there was a weak positive correlation between hs-crp levels and white blood cells among the first time donors. summary/conclusions: this present study did not reveal any decrease in baseline levels of serum hs-crp with regular blood donation; smoking status and gender were however associated with an increase in baseline hscrp. this finding suggests that hs-crp level might not be a useful marker of future coronary events in healthy blood donors in nigeria. background: because the blood donation removes mg of iron from the donor, iron deficiency, frequently occurs in regular blood donors leading at a long term to the anemia. aims: to determine the effect of blood donations on ferritin levels in regular blood donors. methods: all prospective donors have been submitted to a physical examination and a health history assessment intended to ensure that the prospective donor is in a good general health and eligible to donate blood. the acceptance criteria are: • hemoglobin > or = . g/dl for male and > or = . g/dl for female • inter donation interval = days • donations/year for male and /year for female all eligible donors and deferred donors for all reasons except for low hemoglobin who accepted to enroll in this study and signed a consent. in addition to the medical exam, two samples have been collected one for cbc and another for ferritin. donation history, sex, age and weight have been documented. results: first time and regular donors accepted to enroll in this study. only female donors ( . %) participated to this study. . % of the participants were first time donor. % of male and % of female frequent donors are iron deficient out of male blood donors were iron deficient ( %) with serum ferritin < ng/ml. . % were repeat donors. out of female donors were iron deficient ( . %) with serum ferritin < ng/ ml, all were repeat donors. . % of repeat donors were iron deficient / of the deplete donors were first time donors summary/conclusions: frequent blood donors have higher prevalence of iron deficiency than first time donors. female donors have a slightly higher prevalence of iron deficiency than male donors. prevalence of iron deficiency in abu dhabi donor population is lower than the published data. changes need to be done on: increase inter donation interval or restrict the total number of allowable donations in a -month period for whole blood and red cells modifying donor hemoglobin requirements testing for serum ferritin iron supplementation donor education abstract withdrawn. background: haemovigilance procedures aim to guarantee not only the safety of the recipients of blood and its components but the safety of the donors as well. every adverse reaction that occurs during the donation of blood or its components can potentially be a threat to the health of the donor which can subsequently lead to the decision of the donor to resign from donating blood. aims: the aim is to analyse the type and the frequency of occurrence of adverse reactions among the donors donating blood or its components independently of the method of the donation. methods: we have analysed the number of collected donations and the number of adverse reactions in the years - in the group donors of aged - . we have specified following adverse reactions: vasovagal response without fainting, vasovagal response with fainting, vascular reactions (bruises) and other (e.g. allergic reaction to the anticoagulant, loss of blood pressure due to hypovolemia). the analysis was made using data obtained from computer system blood bank which is in operation in blood center in pozna n, poland. results: in years - the total number of adverse reactions among the donors was recorded which is . % of the total number of collected donations. % of the adverse reactions occurred in the group of donors aged - . vasovagal response without fainting was the most common adverse reaction in the total number of reactions and totalled . % of all adverse reactions. in the group of donors ages - it totalled % of all adverse reactions. the second most common type of adverse reactions was vasovagal syncope that totalled . %, in the analysed group of donors . %. vascular reactions (bruises) totalled . % of all adverse reaction, in the analysed group . %. the remaining adverse reactions totalled . %. summary/conclusions: . vasovagal reactions (with and without fainting) were proved to be most common adverse reactions in the group of donors aged - i.e. in the groups of donors just starting to donate blood. it seems reasonable to continue with further research into the reasons for the occurrence of this psychosomatic reactions. . it seems beneficial to provide constant educational activities of young donors regarding the preparation for the process of donation of blood and its components (proper nourishment, hydration as well as planning the time for scheduled donation long enough for a safe and pleasant procedure. . it seems beneficial to provide constant training for the medical staff involved in the process of donation regarding active observation of donors, proper conduct in the situation when the adverse reactions occur during the blood donation, ways to minimize the fear of donors, effective communication with the donors (explaining the process of blood donation, proper behaviour after the donation e.g. avoiding physical exercise or straining the arm). blood products -blood processing, storage and release background: the accumulation of microvesicles (mvs) in rbc concentrates during storage may be responsible for clinical symptoms such as inflammation, coagulation, and immunization. aims: our aims was to determine whether any of cd molecules responsible for important functions are present on the microvesicles, and if their expression level is dependent on the storage period of rbc units. additionally, by using cytometric analysis and phagocytosis visualization in a confocal microscope, we examined the interactions of donor monocytes with erythrocyte microvesicles, depending on their time of storage. methods: erythrocyte microvesicles were isolated from "fresh" ( nd day) and "old" ( nd day) stored rbc units. qualitative and quantitative cytometric analysis of these membrane structures was performed using the annexin v-fitc, anti-cd a-pe antibody, and calibrated beads. the microvesicles were also visualized under a confocal microscope. the expression of the molecules cd a, cd , cd , cd , cd , and of phosphatidylserine was analysed using flow cytometry. measurements of microvesicle phagocytosis by human monocytes were carried out using a flow cytometer and a confocal microscope. results: the analysis of the microvesicles with calibration beads allowed us to identify these structures with a diameter of about . lm in the "fresh" and "old" blood samples. we observed a statistically significant increase in the number of microvesicles in the "old" units ( ae mvs per ll), as compared to the microvesicles in the "fresh" ( ae mvs per ll). at day , the microvesicles had elevated expression levels of cd and reduced expression levels of phosphatidylserine. significant changes were also observed in the case of cd and cd molecules. the expression of these molecules of vesicles isolated from "fresh" rbcs was lower than in the case of -day vesicles. the phagocytosis index was significantly higher ( . %) for the microvesicles isolated from -day stored rbcs than for microvesicles from the - background: platelet concentrates (pcs) are conventionally stored at room temperature with a limited shelf-life of - days. alternative storage methods, such as cold storage and cryopreservation are attractive options due to the potential for extended storage, reduced bacterial growth and improved hemostatic function. cryopreservation of human pcs has been associated with formation of more microparticles and elevated procoagulant activity compared to liquid-stored (room temperature-and cold-stored) pcs. microparticles are submicron plasma membrane particles that have been postulated as potential mediators of adverse transfusion outcomes. similarities in the size and storage-related changes up to days suggest that sheep may be a suitable model in which to investigate the effects of pc transfusion. previous research has established that room temperature stored sheep pcs contain fewer microparticles than human pcs. however, nothing is known of the effect of other storage conditions. aims: this study aimed to determine whether cold storage and cryopreservation contribute to variation in concentration and size of sheep platelet derived microparticles compared to conventionally stored sheep pcs. methods: sheep buffy coat derived pcs in % plasma/ % ssp+ were prepared with minor modifications to standard procedures for preparation of human pcs. sheep pcs were split into units (n = of each) on day and stored either at room temperature (rt; - °c with agitation) for days, cold stored for days ( - °c no agitation) or cryopreserved (À °c with the addition of - % dimethyl sulfoxide) for - days and sampled post-thaw. platelet supernatant, prepared by double centrifugation, was stored at À °c. the mean size and concentration of microparticles were measured using nanosight ns nanoparticle tracking analysis system (malvern instrument). results are mean ae standard deviation. storage associated changes overtime were determined using a one-way analysis of variance with bonferroni's post-test. paired t-tests were applied to determine the effect of cryopreservation. a p-value of < . was considered significant. results: at day , sheep pcs had a microparticle concentration of . ae . microparticles/ml with a mean size of . ae . nm. storage duration at rt sheep pcs was not associated with significant changes to microparticle concentration or size. cryopreservation of sheep pcs significantly increased the concentration ( . ae . microparticles/ ml; p = . ) and the mean size ( . ae . nm; p = . ) of microparticles post-thaw. the mean size and concentration of microparticles in the cold-stored pcs at day was comparable to room temperature pcs stored for days ( . ae . nm vs. . ae . nm; p = . and . ae . microparticles/ml vs. . ae . microparticles/ml; p = . respectively). summary/conclusions: cold storage of sheep pcs did not impact formation of microparticles over the days storage period; however, cryopreservation increased microparticle concentration and the size post-thaw. further investigation is required to determine whether these findings are influence hemostatic function. a pre-clinical sheep model of cold-stored and cryopreserved pc transfusions can facilitate mechanistic studies and complement clinical trials. background: during storage, the properties of rbc in storage solution change ("storage lesion"). for instance, ph, atp and , -dpg concentrations decrease upon prolonged storage. these changes can affect oxygen delivery by the cells. the capacity to deliver oxygen is defined as p : the oxygen tension (po ) at which % of the hemoglobin is saturated with o . an oxygen dissociation curve (odc) represents the non-linear relationship between saturated hemoglobin and po . this relationship is dependent on temperature, ph, pco and , -dpg. due to changes in these factors, the curve will shift along the x-axis. in whole blood, p is at a po of about mm hg. not much is known about p of rbcs in storage solution, and the changes during storage. aims: to determine the oxygen dissociation of rbcs stored in standard red cell additive solution sagm and in pagggm (an experimental red cell additive solution, transfusion. ; : - ). methods: rbcs were prepared in sagm (n = ) or pagggm (n = ). pagggm is designed to better maintain both atp and , -dpg during storage. rbcs were stored at - °c and sampled on day , and for (internal) ph, atp, , -dpg and p . p was determined by hemox analyzer (tcs scientific corp.). the principle of the hemox is based on the measurement of spectrophotometric properties of hemoglobin at different oxygen pressure. rbc samples were brought from oxygen-rich environment to oxygen-poor environment ( %) using n gas. p was determined from the obtained odc. results: the whole storage period, ph i of pagggm-rbcs was higher compared to sagm-rbcs. , -dpg content of sagm-rbcs decreased during storage and was below the detection limit after day . , -dpg content of the pagggm-rbcs increased the first days of storage and slowly decreased from day on. at day , pagggm-rbcs still contained . -dpg ( . lmol/g hb). p values decreased during storage from mmhg at day to mmhg at day for sagm-rbc and from mmhg to mmhg for pagggm-rbc. p values of pagggm-rbcs were higher during the entire storage period. summary/conclusions: during storage, the p decreased in all rbcs. the p was higher for the pagggm-rbcs during the whole storage period. the higher p in pagggm-rbcs seems to correlate with the higher , -dpg content in these cells. background: in belgium % of the platelets are pathogen inactivated (pi) and legislation requires a minimum platelet content of . per platelet concentrates (pc). therefore routine pools are produced with buffy-coats (bc). facing increased demand of pc and stable to slightly declining red blood cells (rbc) demand, production of whole blood (wb) derived platelets must be adapted to switch flexibly from to bc per pool. this dual pooling strategy should allow alignment between wb collection forecast, pc inventory, pc demand and pc production. aims: first develop a pooling procedure with bc and ml platelets additive solution (pas) instead of ml for bc, without changing the settings of our wb separators and platelets separators. maintain a content of ≥ . platelets with a ratio plasma/pas between to % required for pi. after validation, deploy a dual pooling strategy ( or bc/pool). methods: wb is collected with top and bottom kit (composelect; fresenius kabi) and separated (macopress; macopharma) to produce ml bc with % haematocrit (htc) and > % platelets recovery with average platelets content of . random bc are pooled with ml or bc are pooled with ml of pas-e, platelets are then extracted on tacsi pl (terumo bct) and pc are treated for pi (intercept blood system; cerus). each pc is sampled and platelet content is determined (abx pentra xl ; horiba). results: during the study bc were processed into pools ( ( . %) with bc and ( . %) with bc). before tacsi separation, bc mixture with pas-e had volumes of ae ml ( bc) and ae ml ( bc) with respectively htc of ae % and ae %. the plasma/ pas ratio was ae % in both cases. tacsi separation was performed with one same program for both types of pools. after pi, platelets content of the pools was . ae . with bc and . ae . with bc (average ae standard deviation). pools below the limit of < . were / ( . %) with bc and / ( . %) with bc. the platelets concentrations ( /ll) were ae ( bc) and ae ( bc). platelets recovery was % ae for bc and % ae for bc. summary/conclusions: bc could theoretically produce pools of bc or pools of bc. this means a maximum potential gain of + % pc. in practice during shortage periods we switched from to bc when dictated by the actual inventory levels and hospital needs. the advantage of this dual pooling strategy was a gain in production capacity to cover these shortage periods ( pc, + %). the disadvantage of pooling randomly bc is that pools contained less than . platelets per pool potentially limiting their usage to low weight or paediatric patients. a preselection of the bc based on platelet count could optimize the bc pooling procedure. background: apheresis-derived platelet concentrates (apcs) is a standard medical therapy indispensable to contrast bleeding or hemorrhage. however, bacterial infection caused by storage at room temperature (rt) still remains the major drawback. recently, we showed that cold-stored apcs are associated with better plt functionality but with accelerated clearance (haematologica , pmid: ). cold-induced apoptosis was identified as a potential mechanism of the shorter plt survival aims: to investigate the protective effect of apoptotic inhibitors during cold storage of apcs methods: apcs were collected and stored at rt and °c in the presence or in the absence of caspase- inhibitor. the phosphatidylserine exposure and the mitochondrial membrane potential (mmp) (tetramethylrhodamine ethyl ester perchlorate [tmre ] staining) were measured using flow cytometry. the protein expression was quantified by western blot results: a higher expression of the apoptotic marker phosphatidylserine was detected in cold-stored apc compared to rt (% apoptotic events meanaesem: ae % vs. ae % p = . ). to verify if the apoptotic signal, observed with phosphatidylserine, specifically involved the intrinsic pathway, the mmp was analyzed as a marker of alive cells. interestingly, after cold storage a decrease of the mmp was observed compared to rt indicating the activation of the intrinsic pathway (mean fluorescence intensity tmre meanaesem: . ae . vs. . ae . , p = . ). accordingly, a decrease of the procaspase- level after cold storage was detected by western blot analysis. however, when plts were stored in the presence of caspase- inhibitor a significant rescue of the cold-stored cells viability was observed (tmre staining: % alive cells meanaesem: ae % vs. ae %, caspase inhibitor vs. ionomycin, p = . ). this indicates that the activation of the apoptotic pathway, induced during cold storage, can be prevented using caspase inhibitor summary/conclusions: our results show that the reduction of cold-stored plt viability can be prevented by a specific caspase inhibitor. consequently, cold storage, associated with a better plt functionality, may become an efficient strategy for apc storage in combination with apoptotic inhibitors background: gamma-irradiation is used to treat red blood cell (rbc) concentrates (rccs) for patients who are immunosuppressed. this treatment is known to damage rbcs and to increase storage lesions. one of the causes of the storage lesions is the presence of oxygen. several studies have shown, based on different strategies to reduce o , a reduction of storage lesions related to metabolism, protein modifications and cell morphology. aims: the present research work investigated the effect of gamma-irradiation on rccs stored under normal condition and hypoxia/hypocapnia. methods: saturation of o (so )-and abo-matched rccs from whole blood donations, leukoreduced and prepared in paggsm (macopharma, france) were pooled and split in two identical rccs within h post-donation. one bag (treated) was submitted to oxygen and carbon dioxide adsorption (oxygen reduction bag, hemanext, usa) for h on an orbital shaker ( rpm) at °cae and then transferred to a storage bag impermeable to gas. the other one (control) was left as it is. the two bags were then stored at °c. a g-irradiation treatment ( gy, gammacell elan, theratronics) was applied at day or and the rccs (expiry dates at day or day , respectively) were stored until day . hematological parameters, glycolytic metabolites, extracellular potassium level, antioxidant power, morphology and deformability were measured. results: starting so values were of . %ae . (n = ) in control and of . %ae . (n = ) in treated bags, and reached . %ae . and . %ae . at day , respectively. as expected, an increase in glycolysis rate was observed during deoxygenation without any influence from the irradiation. potassium levels were identical in treated and control, and reached around mm at expiry with an irradiation-dependent kinetic release. antioxidant power and deformability were identical in both conditions. no difference in hemolysis was observed after irradiation on day and the values stayed equivalent through end of storage (at day , hemolysis (control) = . %ae . , hemolysis (treated) = . %ae . , p-value > . ). when irradiated at day , hemolysis was lower (p-value = . ) in treated rccs at the end of storage (day , . %ae . ) compared to control ( . %ae . ). seven days post-irradiation, two-third of the control rccs were above the limit of . % whereas all the treated rccs remain below the limit. quantification of microvesicles and morphological analysis confirmed these data. summary/conclusions: the storage under hypoxia has a beneficial effect on rbc storage thanks to a decrease in o content and to an improvement of metabolism. this benefit provided equivalent storage when rccs were irradiated at day and was an advantage when irradiated at day . importantly, the results show that combining irradiation with hypoxia/hypocapnia retained the improved hemolysis profile of o depleted rbc. in summary, the reduction of o level in rccs enables a better storage of rcc when a late irradiation is applied. background: in vitro blood circuit machines require a constant monitoring of blood flow rate which have to be maintained at a constant value. also, measuring the hematocrit of flowing blood in such machines is essential for performing real-time diagnostics. recently, acoustophoresis has emerged has a promising blood separation technology capable of replacing centrifugation for the preparation of platelet concentrate. to avoid damaging blood cells, the technique is used without infusing pumps thus increasing the need of flow monitoring. however, acoustophoresis chips performs at low flow rates, outside the range of available commercial flow meters. in addition, hematocrit measurement is of a particular interest for acoustophoresis since it is a direct indicator of the separation efficiency. aims: in this study, we present a straightforward doppler ultrasound system designed for measuring blood flow rate and hematocrit in an acoustophoresis chip [bohec et al, platelets, ] . we show that the stability of the in vitro environment can be used to obtain high level of accuracy of the doppler method using a basic and low-cost experimental set-up. this improvement allows a precise measurement of flow rates as low as . ml/min in sub-millimeter tubing. furthermore we evaluate the capability of the system to measure hematocrit of human blood samples coming from different donors. methods: the experimental set-up was constituted of an ultrasonic continuous wave doppler probe mounted on a d printed support. the accuracy of flow rate measurements between . ml/min and . ml/min was evaluated as well as the optimal measurement time. for different blood bags, the relationship linking the total energy of doppler signals and hematocrit was derived. hematocrit in a range under % was estimated from doppler signals for each blood bag. results: the system is able to acquire exploitable doppler signals for the whole flow rate and hematocrit range. flow rate estimation from the signals shows a high accuracy with a mean measurement error under % for a measurement time of s. the mean error is still under % for a measurement time of . s. hematocrit estimation from doppler signals shows a good linear correlation with reference measurements for bags , and . hematocrit estimation for bag diverges from reference for values above %. summary/conclusions: the proposed doppler ultrasound system is capable of measuring low blood flow rate in narrow medical tubing with a high accuracy. it is particularly suited for an acoustophoresis device but the versatility of the system makes it easily applicable to any in vitro blood circuit. we furthermore demonstrated that the system can be used for measuring hematocrit under % without additional developments. this finds interesting applications in blood sorting technologies but also demonstrates that doppler ultrasound is a potential simple and low cost method for measuring hematocrit of flowing blood in vitro. background: hereditary hemochromatosis (hh) is the most common genetic disorder in populations of northern european descent manifesting with high levels of storage iron (ferritin) in blood and tissues. the standard treatment is serial therapeutic phlebotomy to decrease iron overload. the collected blood is frequently discarded but some blood banks allow "healthy" hh patients to donate blood for patient use. red cell concentrates from hh donors have been reported safe for transfusion, but little or no data is available on platelet concentrates from hh donors, including the potential contribution of surplus iron to the "platelet storage lesion". aims: the aim of this study was to compare platelet quality, activation and aggregation over seven-day storage in platelet-rich plasma from patients with newly diagnosed hh and from healthy controls. methods: whole blood ( ml) was drawn into compoflow blood bags containing cpd and sag-m from healthy controls and newly diagnosed hh patients. platelet-rich plasma (prp) was prepared from whole blood and split into four compo-flex bags each containing ml prp (range - platelets/l). platelet quality tests were performed on days , , , and of storage. platelet aggregation was tested using a chrono-log aggregometer and four agonists (adp, arachidonic acid, collagen, and epinephrine). platelet expression of cd , cd b, and cd p was measured with flow cytometry while ph and metabolites were measured with a blood gas analyzer. scd l and scd p in the supernatant were quantified using enzyme-linked immunosorbent assays. results: both hh and control groups included males and females. the mean age was significantly lower in the control group, years ( - years), than in the hh group, . years ( - years) (p = . ) while ferritin levels were significantly higher in hh patients (median . , range - ) than in controls (median . ng/ml, range . - ng/ml) (p < . ). in the hh group, each had the c y/c y and c y/h d genotypes. results of prp quality control tests were comparable between the two study groups over seven days of storage (p < . ) with the exception of glucose (higher in hh patients on all time points, p < . ). platelet aggregation and the expression of activation markers (cd p and cd b) on platelets and in the supernatant (scd p and cd l) were comparable between hh and control prp units over all seven days of storage. the analysis revealed comparable and expected alterations in metabolic and platelet activation markers over seven-day storage in both groups. ph increased, glucose decreased, and lactate increased over time while cd b expression decreased and cd p increased. platelet aggregation responses decreased during storage but to a varying degree depending on the agonist, however, the decrease was comparable in cases and controls. summary/conclusions: these results suggest that high iron stores in hh do not adversely affect the quality of platelet units produced from hh patients. furthermore, the data also suggest that blood from hh patients, including platelets, can be donated for patient use. background: platelets are often shipped over long distances from collection centres to blood processing centres and subsequently to hospitals. platelet agitation facilitates oxygen transfer, thus promoting aerobic metabolism, and maintaining platelet ph. during shipment, platelets cannot be agitated continuously, which may promote anaerobic metabolism. previous studies have examined the effects of prolonged periods without agitation on apheresis platelets collected in plasma, but not platelets in platelet additive solution (pas). it is therefore important to determine whether platelet quality and function are maintained during prolonged transport or hold time in a shipper. aims: the aim of this study was to evaluate the effects of prolonged storage without agitation on the in vitro quality of apheresis platelets in pas. methods: triple dose apheresis platelets (n = ) were collected using a trima accel platform in % plasma/ % pas (ssp+). after resting for h, platelets were split equally into three components, packed into a shipper and transported immediately to the blood centre. upon arrival, one of the platelet components was removed (< h; t ), and the others remained within the shipper, without agitation. the second component was removed at h post-collection (t ), and the third was removed at . h post-collection (rounded up to h; t ). platelets were tested on day , and post-collection and in vitro quality and function were monitored. data were analysed using a two-way repeated measures anova, where a p-value of < . was considered significant. results: platelets held without agitation for h consumed significantly more glucose than those removed at h or immediately upon arrival (p < . ), even on day post-collection. this was accompanied by increased lactate production (p < . ), indicating increased anaerobic glycolysis. consequently, the ph was significantly lower in t platelets (p < . ), and on average it was . ph units lower than in platelets held in the shipper for h or less. however, the ph remained above . in all components. mean platelet volume was also reduced in t platelets (p < . ), suggesting acceleration of the platelet storage lesion. phosphatidylserine exposure, surface expression of cd p and microparticle generation were significantly higher in the t platelets throughout the storage period (all p < . ), suggesting platelet activation. release of scd p was also increased in t platelets (p = . ), whereas extended storage in a shipper did not affect release of rantes (p = . ). adp-induced activation of glycoprotein iib/iiia, measured by pac- binding, was decreased in t platelets (p < . ), indicating reduced platelet responsiveness to agonist stimulation. additionally aggregation in response to collagen (p = . ) and adp (p = . ) were significantly lower in t platelets, suggesting a decrement in platelet function after prolonged storage without agitation. summary/conclusions: significant in vitro changes were observed in platelets held without agitation for h. these results suggest that the length of time that platelets are held in a shipper should be minimised where possible. background: the shelf-life for platelet products has been restricted to days. this very limited window of time is intended to sustain the quality of platelet and to reduce the risk of bacterial growth. we have recently demonstrated that in suitable platelet bags, the platelet product quality remains high after days of storage. this was proved by examining in vitro, the quality parameters of platelets such as platelet concentration, glucose, ldh, and ph (alexopoulos k. et al., haema, , ) . our new target is to extend this research in extra days of storage. we also want to determine if there is any bacterial development in this period. aims: the goal is to investigate the capability of storage period for platelet units, from to days. methods: in this study, platelets were collected from normal blood donors in the blood bank department of general hospital of patras "agios andreas". a total of ae ml of whole blood was drawn into triple cpd/sag-m top-top bags blood container systems, lmb technologie (gmbh). the platelet concentrates were prepared by platelet rich plasma (prp) method and then they were placed in a platelet incubator with agitator (helmer pc ). samples were drawn aseptically with a needless access coupler (cair-lgl) on days , , and . platelet count was done by ceeldyn ruby (abbott all data shown are reported as mean ae standard deviation (sd). the swirling effect remained positive (+) during the seven days storage period. the bacterial screening was found negative. summary/conclusions: platelet concentration in the bag remained constant between day and day , maintaining platelet yield. the decrease in glucose and increase in lactate, along with the decreased ph, show that the platelets remain metabolically active between days and of storage. the ph remained well within the acceptable range. no bacterial contamination was reported. thus, we conclude that platelet concentrates in these specific bags may be used with an extended shelf life of days. further studies are needed with other platelet bags to confirm our hypothesis. abstract withdrawn. aims: we introduce rt-dc as a fast, robust and unbiased quality control tool for pc, rcc and hpsc. utilizing the interdependency between cell deformation and the molecular state of the cytoskeleton, we demonstrate that rt-dc is capable to assess the quality of blood products. methods: by rt-dc we assessed: i) platelets after storage at °c or room temperature (rt) over days for apheresis pcs in addition to standard in vitro platelet function assays; ii). red blood cells before and after gamma irradiation in addition to hemolysis; and iii) hpsc after cryopreservation with % or % dmso in addition to cell count, and in vitro viability. in addition we compared the regeneration time of patients' platelets and leukocytes after transplantation of hpsc products containing either % or % dmso. results: for pcs standard quality assurance tests did not show a major difference between °c and room temperature storage while rt-dc showed a highly significant difference between both start conditions (day - , p < . and day , p < . ). for red cells, we found by rt-dc no impact of gamma irradiation with gy over the entire storage period of days assessing different rcc. for hpsc, rt-dc showed that cryopreservation in liquid nitrogen resulted in a significant increase in deformation ( . for % dmso versus . for the control without dmso; p < . ). however, this did not differ to high extent whether % or % dmso were used for cryopreservation ( . and . , respectively; p < . ). hpsc viability was lower after cryopreservation using % dmso in comparison to using % dmso. overall, blood cell regeneration is comparable between % and % dmso. summary/conclusions: studying platelet and red blood cell concentrates as well as hematopoietic stem cells under different, clinically relevant, storage conditions our results demonstrate that intrinsic material properties reveal insights into cell function and allow to predict cellular state in a robust way and using small sample volumes. in order to offer more flexibility to the production process, the storage of bcs overnight ( h) has been validated in our blood center. aims: the aim of the study was to assess the platelet quality in platelet concentrates derived from overnight stored buffy coats. methods: whole blood collected at day was separated into plasma, bc and red cell concentrates either at day or at day . bcs were then stored until the pooling step at °c without agitation and pcs were prepared at day by pooling isogroup bcs. seven " h-pcs" were prepared from bcs stored for h (whole blood separation at day ) and six " min-pcs" from bcs stored for min (whole blood separation at day ). standard quality control measurements were performed during the process and the storage. in addition, the quality of the platelets into the prepared pcs was assessed throughout the period of storage by measuring the hypotonic shock response (hsr) and by measuring by flow cytometry the proportions of platelets in apoptosis (marked with annexin v), of functional platelets (marked with cd ) and of activated platelets (marked with cd the changes observed during the -h storage period appear to be limited and compatible with a further pr process using a photochemical treatment (amotosalen and uva) with intercept. summary/conclusions: leukocyte-depleted "double dose" buffy coat platelets with a high platelet content and ready for pathogen reduction can be obtained with the ipp pooling and leukodepletion set developed by kansuk. a storage period of h before applying the photochemical treatment is feasible without significantly altering the biological quality of platelets. methods: dd-bc-pc were prepared with bc and ml of pas (intersol, fresenius kabi (germany) are sterile docked to the octopus harness and combined into a ml pooling bag. the pool is centrifuged and the pc supernatant expressed through a bioflex cs leukodepletion filter into a temporary platelet storage container. the obtained dd-bc-pc were tested within h of preparation and after storage for h in the platelet storage container for volume, platelet content, residual leukocytes (wbc), plasma ratio and biological parameters, ph, po , pco , glucose, lactate, mpv, ldh, p-selectin and swirling. results: the platelet content of dd-bc-pc (n = ) was on average . ae . . in a volume of ae ml. the mean of plasma ratio was % [min: . max: . ]. all pc contain < . wbc [min: <lq; max: . ]. po decreased from ae mmhg after separation ( h) to ae mmhg after h, ph (+ °c) and pco was stable during the same time period. glucose decreased from . ae . mmol/l ( h) to . ae . mmol/l ( h) while lactate increased from . ae . mmol/l ( h) to . ae . mmol/l ( h). the vpm was stable with . ae . at h and h. ldh increased from . ae . u/l at h and . ae . u/l at h as p-selectin . ae . ng/ml at h and . ae . ng/ ml. all units have maintained swirling. the changes observed during the -h storage period appear to be limited and compatible with a further pr process using a photochemical treatment with intercept. summary/conclusions: leukocyte-depleted "double dose" buffy coat platelets with a high platelet content and ready for pathogen reduction can be obtained with the platelet pooling and leukodepletion set developed by fresenius. a storage period of h before applying the photochemical treatment is feasible without significantly altering the biological quality of platelets. background: the irish blood transfusion service (ibts) is the statutory body with the responsibility for ireland's national blood supply. in the ibts collected , whole blood units and performed , platelet apheresis procedures. blood is collected in three fixed and six mobile sites and is returned overnight in temperature controlled vans to a single processing site. in september , the ibts implemented the tacsi automated system for the preparation of buffy-coat derived platelets as an alternative to the orbisac system. aims: the aim of this study is to compare operational aspects and quality data of buffy-coat derived platelets prepared by the tacsi (t-pcs) and orbisac (o-pcs) automated systems. methods: qc data of t-pcs and o-pcs from years to were analyzed. in , the ibts prepared , orbisac platelet pools of which , were qc tested. in , orbisac and , tacsi platelet pools were prepared and tested. in , tacsi platelet pools were prepared of which were qc tested. qc data comprised pc volume, platelet content ( /unit), residual leucocyte content ( /unit) and ph at expiry. feedback from the processing laboratory operators was collected comparing operational aspects of preparation of t-pcs and o-pcs. results: from the , o-pcs tested in and , mean pc volume was ae ml. initially the t-pcs mean volume was ae ml but more recently the volumes were increased by addition of a larger volume of additive solution to ae ml. platelet content ( /unit) was significantly improved in t-pcs ( ae ) compared to o-pcs ( ae ) [p < . ] as well as residual leucocyte content ( /unit) which was lower in t-pcs ( . ae . ) compared to o-pcs ( . ae . ) [p < . ]. ph at expiry was lower in t-pcs ( . ae . ) compared to -pcs ( . ae . ) but remained within the quality requirements. from an operational perspective with two tacsi devices, five operators produce approximately t-pcs per hour compared to a lower throughput of o-pcs per hour with five orbisac devices. the tacsi system is more compatible with batch processing which aligns with our staffing arrangements in routine production and has resulted in greater productivity since its introduction. with tacsi implementation, we reverted to manual pooling of buffy coats and new staff had to undergo training to achieve optimal platelet recovery. once staff were trained during validation, we observed a % increase in platelet recovery. processing laboratory staff indicated that tacsi devices were easier and simpler to maintain in comparison to orbisac, but highlighted that some improvements to tacsi system boxes could be made to make the system more robust. summary/conclusions: pcs prepared with tacsi and orbisac automated systems both met national and european quality requirements, however we observed a significant improvement in quality markers of pcs prepared with tacsi. processing staff reported easier maintenance and processing with tacsi compared to orbisac. throughput is higher with tacsi and there is greater additional capacity to increase production in the future if required. a perez aliaga , f puente , a aranda , j domingo , l call en and a bah banco de sangre y tejidos de arag on, aragon, spain terumo bct europe n.v., zaventem, belgium background: the blood bank and tissues of arag on (bsta) is responsible for the collection, processing and distribution of blood in the region of aragon in spain. with five fixed and five mobile sites, the bsta collects and processes , whole blood units per year. to improve quality of processed units and working conditions of personnel, the bsta decided to implement the reveos automated system. validation studies were carried out in november and routine use started in july . in parallel, the bsta initiated pathogen inactivation of platelet concentrates (pc) in november to improve transfusion safety. in november , the mirasol prt system was implemented due to simplicity of this platform. aims: the aim of this abstract is to (i) describe the results of the validation studies carried out during reveos implementation (ii) present routine use data of products processed with reveos and (iii) provide information on mirasol implementation. methods: in , whole blood units were processed using reveos. quality parameters for red cell concentrates (rcc), such as: hemoglobin (hb), hematocrit (hct) and volume; plasma: volume and residual platelet content; and pcs: volume and yield, were analyzed. a control group consisting of units processed with a semiautomated platform was used as comparison. a survey was sent to the collection and processing staff for feedback on operational aspects of the use of reveos. from to , qc data of rccs (n = ), plasma (n = ) and pcs (n = ) processed with reveos were collected. number of mirasol treated pcs and hemovigilance data from to were collected. results: volume, hb and hct of rccs processed with reveos were significantly higher compared to control rccs (volume: ae ml vs ae ml; hb: . ae . g/ unit vs . ae . g/unit; hct: . ae . % vs . ae . %). control plasma units had higher volume ( ae ml) and lower residual platelet content ( ae /l) compared to reveos plasma units (volume: ae ml; residual platelet content ae /l). for pcs, volume was higher for units processed with reveos compared to control ( ae ml vs ae ), but no statistical difference was observed in platelet content (reveos: ae /unit; control: ae . /unit). we observed either an increase or stabilization in qc parameters of rccs, plasma and pcs during the years routine use of reveos. for example, percentage of rccs units hemolyzed dropped from % to % between and and platelet content in pcs increased from /unit (first six months in routine) to /unit. plasma volume increased from ml during validation to ml in . survey results from staff highlighted the user friendliness of the reveos device. number of mirasol treated pcs increased from % in to . % in with no pathogen transmission nor serious adverse events reported following transfusion of these products. summary/conclusions: with implementation of two user-friendly systems, the reveos whole blood automation system and mirasol prt system, we observed an increased standardization of our processes enabling us to provide higher quality and safer blood products to hospitals and the patients they serve. background: white blood cells (wbc) may be regarded as contaminants in blood components and potentially reduce transfusion safety. there is currently enough evidence showing that wbc reduction through pre-storage filtration reduces the incidence of three major complications of allogeneic blood transfusions: febrile nonhemolytic transfusion reactions (fnhtr), refractoriness to random-donor platelet transfusions and transmission of cmv. leukodepletion is now mandatory in canada and several european countries. aims: the aim of this study was to evaluate leukoreduction performance and the quality of the resulting red blood cell concentrate (rbc) produced with new quadruple system top & bottom imuflex crc with an integrated red blood cells filter which was used in whole blood fractionation under routine conditions of san paolo asl blood bank methods: twenty-seven whole blood donations ( ml) were collected with using quadruple blood bags top & bottom system with an integrated rbc filter (imuflex crc, terumo bct). centrifugation and processing (using t-ace ii + -terumo bct) of whole blood units followed the blood bank sop to obtain rbcs, plasma and buffy coat. rbcs were diluted with sagm ( ml) and then filtered by gravity in average - h after blood collection to obtain leukoreduced rbc. average temperature during filtration was °c. samples were collected before and after leukoreduction for calculation of hemoglobin loss through the filtration process. filtration time was recorded. final hb, hematocrit (hct), residual platelets and white blood cells were determined after filtration using standard laboratory methods (blood cell counter) results: wb donations (n = ) were performed. rbc characteristics post-filtration and separation were as follows: volume ( . ae . ml), hematocrit ( . ae . %) hemoglobin ( . ae . g/dl) and hemoglobin per unit ( . ae . g); residual platelets ( . ae . x ³/ll); residual wbcs ( À . ³/ll). the mean filtration time was ae min and no filter blocks were observed summary/conclusions: the usability and performance of the new quadruple system top & bottom imuflex â crc with integrated rbc filter was evaluated. all quality parameters complied with italian and european guidelines and requirements. in conclusion, the set was found to be a reliable and efficient collection and separation system that performs consistently background: novel devices for automated whole blood processing (reveos tm terumo bct) have been installed in regional center for blood donation and blood treatment in katowice to modernize and automate production of blood components. this system allows to separation of four whole blood units into four buffy coat depleted red blood cell concentrates (rbc), four units of plasma and four interim platelet concentrate (ipu) units in one automatic cycle. an ipu is the starting blood component for the production of pooled, leucoreduced platelet concentrates (lpc). residual leukocytes (wbc) are obtained as a byproduct and discarded. the use of this system shortens production time because it combines otherwise two separate steps: centrifugation and blood separation in press. aims: to evaluate the quality of the blood components obtained with the newly developed reveos nlr kits, which are a whole blood collection kits containing no leucocyte reduction filter for the rbcs. methods: blood [wb] was collected into nlr reveos set (terumo bct), and processed between and h from collection using the c protocol. quality control was performed on rbc, plasma and ipu. rbc were tested for hemoglobin (hb) content, hematocrit (ht), residual white blood cells (wbc), volume and hemolysis level on the last day ( nd day) of storage. the content of wbc and platelet count (plt), protein, factor viii on the day of production and after one month of storage were determined in plasma. for ipu, platelet and leucocyte counts, volume and average platelet yield index (pyi) were displayed at the device after processing was recorded. furthermore, a comparison between fully automated and semi-automated whole blood processing was done, by comparing the amount of time necessary to fractionate whole blood units using the two different processes. background: direct, single step automatic blood separation devices (reveos tm terumo bct) was installed in regional center in katowice in . the system allows for full automation of whole blood fractionation. one of produced blood components is an interim platelet unit (ipu), containing most of the platelets and limited of white blood cells (wbcs). it is then pooled through a filter to form a therapeutic unit of leucoreduced platelet concentrate (lpc). a rough estimate of the platelet yield in the ipu, the so-called platelet yield index (pyi) is calculated and displayed by the device after the end of the separation phase. it is a useful tool to optimize selection of ipu for pools to produce lpc. aims: to determine the quality of polled lpc obtained on the basis of ipu from whole blood processed up to h after collection and the usefulness of this method in daily practice. methods: ipus used for production of lpc were obtained using fully automated whole blood processing single step system -reveos tm (terumo bct). from the beginning of the application of the method, therapeutic units of lpcs were produced after overnight hold: pools of ipus and of ipus were made using platelet pooling set (terumo bct), using ml ssp+ solution (macopharma). results: therapeutic units of lpc were analyzed. the mean volume of lpc was ae ml, platelet content was . ae . x , and white blood cells (wbc) count was . ae . x , % all lpcs had wbc below . ph measurements were made on the fifth day of storage, the ph was determined in units of lpc and was . ae . . summary/conclusions: the use of interim platelet units in daily practice increases the possibility of producing high quality blood components for patients and is a great alternative to the laborintensive manual methods of lpc's production. background: the development of cold-stored platelets has been hampered by the rapid removal of blood after transfusion by apoptosis and desialylation due to platelet storage lesions caused by refrigeration. previous studies have shown that antioxidants inhibited the activation and desialylation of cold-stored platelets for days and also inhibited rapid elimination after transfusion in animal models. aims: it was tried whether in long-term ( days or longer) storage conditions, antioxidants showed similar effects inhibiting the activation and desialylation of cold-stored platelets. methods: platelet-rich plasma (about ml) were obtained from a healthy blood donors of type o blood group and divided into a ml platelet storage bag manufactured by the manufacturer, and the conditions including room temperature and refrigerated condition and various kinds of antioxidants were prepared, (ph, glucose, lactic acid) and activation index (cd p, gpiba (cd b), annexin v), degree of reactive oxygen species and sialidase activity on the th, th and th day, and phagocytosis using the hepg cell line and platelet recovery after in vivo transfusion using scid mice were compared and compared. results: cold-stored platelets showed autoaggregation on the nd day of storage, and apparent aggregation on the fifth day of visual observation but not in the antioxidanttreated group. as expected, the ph, glucose and lactate levels of the cold platelets were maintained and the platelets at room temperature changed significantly. nac (n-acetylcysteine) -treated platelets were less active on day and sialidase activity was maintained lower than that of control group on day . the degree of phagocytosis by the hepg cell line remained at the same level during the storage period, and the in vivo recovery rate in the animal model was superior to that of the antioxidanttreated cold platelets for h and h after transfusion. summary/conclusions: cold platelets could be developed as clinically effective agents for up to two weeks if appropriate preservatives were added, and antioxidants, especially n-acetylcysteine, were effective. background: the reveos c procedure produces the following three blood components for transfusion: plasma, rbcs, and a single interim platelet unit (ipu). whole blood is collected into the reveos blood bag set and held at room temperature a minimum of h before processing on the device. after processing on the reveos device, the plasma product is ready to freeze. the rbc product is ready to combine with sag-m additive solution and leukoreduce using the integrated leukoreduction filter. the ipus are rested and agitated for the recommended time. for example, when whole blood is processed within h of collection, the ipu is agitated overnight before pooling. because the ipu is made from one unit of whole blood, approximately to ipus are pooled together and leukoreduced by filtration prior to storage in a platelet storage bag. this leukoreduced platelet pool ( units) can be supplied to the demand of hospitals like a platelet apheresis product. aims: to assess the usability of the reveos automated blood processing system to collect units of whole blood and to process the units on the reveos device, producing blood components that meet product quality specifications. methods: this study will evaluate approximately units of whole blood using the reveos system and approximately units of pooled platelet products. a total of units of whole blood (wb) have been collected into the reveos blood bag set and then held at room temperature without the use of an active cooling system (or temperature control system), such as cooling plates, or in this case, ice packs. of the units, units have been processed on the reveos device using the fresh procedure (within h of collection). nine units have been processed using the overnight wbhold procedure. all units have processed successfully without alarms, resulting in three components (rbcs, plasma, platelets). we also evaluated four platelet pools created from eighteen interim platelet units (ipus). one ipu has been discarded due to a -min whole blood collection time. the leukocyte count on all component using the automatic sysmex-xn cell blood counter. results: the red blood cells meet the criteria for hematocrit, hemoglobin and residual wbc counts are less than million per unit. the plasma units meet the criteria for displayed volume accuracy compared to measured volume and also for factor viii levels. the average residual platelets in plasma levels meet the criteria. the platelet pools meet the acceptance criteria for platelet yield and volume. limited data (n = ) suggests that this criteria will be easily met, provided that wb hold conditions are suitable for platelets. summary/conclusions: final results indicate that products produced from the reveos system meet or exceed product quality expectations. staff report that the reveos system is very easy to use. abstract withdrawn. background: thorough manual mixing of overnight-held whole blood (wb) units prior to centrifugation to separate red cell (rc) from platelet-rich-plasma (prp) is currently practised at the hong kong red cross blood transfusion service (hkrcbts). the mixing step is crucial to maximise platelet yield but laborious, and may cause elbow and wrist injuries in operators. a laboratory shaker, reax (heidolph instruments, schwabach, germany), originally designed for mixing solvents, was modified to allow mixing source wb units by the supplier. to enhance the well-being of the operators in the context of occupation health and safety (oh&s) management, feasibility of the application of such blood mixer to replace the manual mixing steps in blood component preparation was explored. aims: to evaluate the in vitro quality control (qc) parameters of the blood components prepared with the use of the modified mixer. methods: fifty-eight wb collections, including units in ml quadruple bags ( q) with/without integrated leucofilter and units in ml quadruple bags ( q), were processed in accordance with hkrcbts' prevailing component processing protocols except using the motor-driven mixer in lieu of manual mixing. wb collections were divided into groups, mixed at revolutions per minute (rpm) for min (n = ) and min (n = ), then processed into rc, prp platelet and plasma components. in vitro qc assessments including haematocrit (hct), haemoglobulin (hb) and haemolysis at expiry for rc; absolute platelet count and ph for platelet concentrates (plt); volume and residual platelet count for plasma units were evaluated and compared. results: all components derived from both q and q processed with the blood mixer fulfilled the qc requirements stipulated by aabb standards and council of europe (coe) guidelines. there were no significant differences for all the qc parameters in rc and plasma components produced when mixed for or min. summary/conclusions: the overall performance of blood components processed with the motor-driven mixer met the acceptance criteria at the hkrcbts in accordance with the aabb and coe standards. higher platelet yield was observed with prolonged mixing for min. however, prolonged mixing will much delay routine component processing. further evaluation on intermediate mixing time such as , or min may help determine an optimal mixing duration to maximise platelet yield without compromising processing workflow. to conclude, using the modified blood mixer to replace laborious manual mixing in components preparation is promising to improve the oh&s for blood component preparation operators. background: leukocyte reduction is widely used to reduce the risk of non-hemolytic febrile transfusion reactions and alloimmunization by multiple blood transfusions. around and after year , universal leukocyte reduction was adopted in many developed countries. there are mainly two types of filter, one to filter whole blood and the other to filter red cell concentrate (rcc) used during pre-storage blood processing. aims: in this study, we conducted the filtration tests with sepacell tm rs for rcc in comparison with sepacell tm r-s and sepacell tm pure rc widely used in the world. background: the cardarelli hospital blood bank processes over , whole blood units yearly. in order to constantly cope with the huge demand for platelets from oncohematology and intensive care departments, a progressive review of the processing protocols for platelet concentrates (pc) from buffy-coat (bc) pools has recently been implemented to reduce the number of units assembled, from (routine in italy) to . the -bc pc units have slightly lower volume and plasma content, factors that further limit the transfusion risk. in addition, the -bc assembly allows to facilitate the production of the pc units obtained from the same blood type, in order to minimize both the adverse reactions related to the abo/rh incompatibility and the amount of bcs not used. finally, the described innovation also impacts on the workload, with reduction of assembly, centrifugation and separation time. aims: the aim of this work is to define an optimized protocol for the preparation of pc units from -bc pools, so that the platelet yield is always higher than the minimum value required by current regulatory ( . cells/unit). background: blood is a basic component for human life and hence blood transfusion is an integral intervention in the treatment of patients. the need of blood transfusion is increasing with decreasing blood supply due to limited blood donations. conversely wastage of blood products is also a topic for discussion. to ensure the availability of blood products when they are needed, wastage of blood products should be controlled and minimized. aims: the study was designed to investigate the quantity and reasons of wastage of blood products at our hospital. methods: this was an observational study based on the statistical data available from blood bank department of nibd and bmt, pechs campus, karachi, pakistan. the study period was from february to february . study was approved from institutional review board. for all the blood products wastage and reasons of wastage were evaluated. frequencies were calculated by using spss version . results: a total of blood products were available at our institute including each of platelets, pack red cells and fresh frozen plasma(ffp). the overall wastage rate was . %. pack red cells and platelets were fully consumed yet shortage of supply was observed. however, highest wastage was observed in ffp in our blood bank i.e. ( %). results of investigating the common causes of blood product wastage at the hospital revealed that it was highly associated with common causes, including the expiry of unused products ( %) followed by broken bags ( %). summary/conclusions: this study showed over all diminutive wastage rate. ffp wastage was highest among all the blood products. wastage of blood products is a genuine issue in a hospital setup, strategies and plan of action should be discussed and implemented including enhanced collaboration with other centres to outsource the blood products or even donate at times, education and training of staff for better clinical use of blood products and ensure the availability when and where they are needed most. background: in the early s, the blood service of the republic of kazakhstan functioned along the lines of the soviet period: donation of blood was approached to the place of its use (carried out at hospitals), screening of donor blood was carried out at one stage (enzyme immunoassay) on analyzers of semi-automatic type, there was no mechanism calculating the cost of blood components, the activity of blood centers was funded at the rate of liter of whole blood. donation was not popular in society, household fears of infection were common when donated. aims: research objective is to study the main stages of reforming of blood services of the republic of kazakhstan (rok). the research methods are based on the system analysis of the condition of the rok's blood services based on the indicators of production activity for the period of - . results: in order to effectively reform the blood services, the following steps were taken. the blood supply was centralized and optimized. blood collection at hospitals was terminated, more than blood collection subjects were closed. the result was a more efficient use of technical, human and financial resources, as well as ensuring the high quality of the blood components produced. today, there are blood centers in the republicone for each of the administrative territorial units of the republic. the screening of donor blood for transfusion infection markers has been transferred into a two-step principleimmunological analysis and nat testing. a fully automated analytical equipment of a closed type is used for screening, unified for all blood centers of the republic. unification of the equipment choice allowed to provide centralized service maintenance of complex equipment and its uninterrupted operation. since , the national reference laboratory has been operating in the blood service, which conducts an external assessment of the quality of laboratory research in blood centers, as well as research in controversial and complex cases. introduced pathogen inactivation of platelet concentrates in % of cases of platelets. erythrocytes are used only in the weighing solution and only after leukoreduction. the use of resource-saving blood harvesting technologies, as well as methods to further enhance the infectious and immunological safety of components, are expanding annually. the foundations for the development of applied scientific research in the field of transfusion medicine were laid, and an own school of transfusiologists was created. as a result of reforming the blood services, the mechanisms of reimbursement of blood services costs from the budget of the republic have been changed, uniform tariffs have been defined by type of blood components for all blood components suppliers in the country. summary/conclusions: the transformations made it possible to create a blood service in kazakhstan that corresponds to the best international practice and ensures the quality, efficacy and safety of transfusion therapy. further development of the blood service is aimed at deepening reforms, studying and developing cellular technologies, new properties of plasma blood components, and improving the clinical practice of using donor blood components. background: reconstituted platelet concentrate (rpc) is a component that contains platelets (thrombocytes) resuspended in plasma that is blood group compatible with the recipient. it is used when transfusion of platelet concentrate is necessary but the fresh platelet concentrates of the specific blood group are not available. group rh-(negative) platelets resuspended in the ab group plasma are of universal use as such components can be used for all recipients independently of their blood group. in the area of activity of regional blood center in poznan rpc is used most often for patients after stem cell transplant incompatible with their blood group. aims: the aim of the analysis is to evaluate the loss in the number of platelets in the reconstituted platelet concentrates in order to determine their quality and usage. methods: we used for the analysis units of pooled platelet concentrate derived from buffy coats and units of pooled platelet concentrate derived from the apheresis. for the reconstitution group ab plasma was used. we investigated the number of platelets prior to and after the reconstitution. following measures were calculated: number of platelets in pooled platelet concentrates derived from buffy coats, number of platelets in pooled platelet concentrates derived from apheresis; average values and the standard deviation as well as the loss in number of platelets due to the reconstitution. the number of platelets was calculated with impedance method using horiba pentra xl analyser. . pooled platelet concentrates derived from buffy coats the number of platelets before the reconstitution: . /unit ae . the number of platelets after the reconstitution: . /unit ae . the loss in the number of platelets: . % . platelet concentrates derived from apheresis the number of platelets before the reconstitution: . /unit ae . the number of platelets after the reconstitution: . /unit ae . the loss in the number of platelets: . % summary/conclusions: . reconstitution results in the loss of . % of platelets in comparison to the initial value of pooled platelet concentrate derived from buffy coats. . the average number of platelets after the reconstitution is . /unit, which fulfils the quality requirements. . reconstitution results in the loss of . % of platelets in comparison to the initial value of pooled platelet concentrate derived from apheresis. . the average number of platelets after the reconstitution is . /unit, which slightly deviates from the quality requirements. . the results that we obtained show that the process of reconstitution always results in the loss of number of platelets and that the quality of platelet concentrates that have not been reprocessed is always higher. because of that we recommend that the reconstitution should only be performed in special cases such as for patients after stem cell transplant incompatible with their blood group and that hospitals should be supplied with platelet concentrates derived from buffy coats and apheresis. methods: pf was extracted from human pcs by using immunoaffinity chromatography and specific anti-pf antibody on the column. hereafter, pf was purified with concentration tubes having kda molecular weight cut-off and dialyzed via dialysis tubing with . kda cut-off. pf concentration was measured by bradford method. specific enzyme-linked immunosorbent assay (elisa) and dot blot analysis were used to determine the pf specificity. molecular weight of obtained pf was determined by polyacrylamide gel electrophoresis (page). results: our data confirmed clearly that separated pf had kda molecular weight which is corresponding with a tetramer pf . in addition, elisa showed that the pf qualified true antigenicity. dot blot analysis helped us to assure the specificity of pf . summary/conclusions: we used and optimized a homemade protocol to isolate and purify the pf . nevertheless, there was no any scientific report among the databases that utilized the similar purification method. recombinant pf is more feasible and ready-to-use, but its price may discourage the researchers to study the biology of pf . unused human pcs and specific anti-pf antibody can considered as an alternative to separate the pf particularly in labs with the shortage of resources. background: whole blood is increasingly used in civilian hospitals as an alternative to blood components in trauma resuscitation with massive bleeding. however, the hemostatic effect of whole blood depends on the initial platelet content and decreases rapidly within the first weeks of storage at °c. consequently the problem arises of how to provide wb to trauma centers without losing valuable low titer group o units if the units are not used within the expiry date of use. aims: to assess the in-vitro quality of red cell concentrates (rcc) produced from days cold stored leucodepleted whole blood units filtered with a platelet-sparing whole blood filtration filter in order to save the rcc once the wb units has reached the expiry date. methods: units of whole blood were leucodepleted within h using a platelet sparing filter (imuflex wb-sp/terumo bct) and stored for days at ae °c. on the th day of storage, units are centrifuged and the rcc is supplemented with sag-m additive solution for an additional storage of days at ae °c. in vitro parameters such as hemoglobin, hematocrit, residual leucocytes, platelet content, hemolysis, glucose, lactate, atp, . dpg were tested during storage. results: the imuflex wb-sp provided satisfying leucodepletion of the wb units ( . ae . . e /u)) while maintaining % of the initial platelet content ( ae . e /u). mean volume ( ae ml), hemoglobin content ( ae g/u) and hematocrit ( ae %) was within conformance range. after days of storage, % of the initial platelet content at collection is maintained and mean hemolysis is . ae . %. rcc processing at day was uneventful, without loss of hemoglobin or noticeable hemolysis. mean volume ( ae ml), hematocrit ( ae %), hemolysis ( . ae . %) were in conformance with mandatory standards at day . after days of storage (i.e. day after collection), rcc quality parameters were maintained with however an increase in hemolysis ( . ae . %) which was above usual values routinely observed with rcc produced from day processed units. rcc out of were above the maximum limit of . % at day after collection such increased hemolysis was more pronounced at day after collection ( . ae . %) with a proportion of rcc with a non-conforming hemolysis ratio above the accepted threshold ( % of the tested units). summary/conclusions: rcc units can be readily obtained from leucodepleted wb units with spared platelet contents after days of cold storage. in vitro quality attributes of such rcc are within conforming ranges for hemoglobin, hematocrit, volume and hemolysis. hemolysis increases more rapidly than in standard rcc, thus limiting the possibility of use within days after collection. additional studies are being initiated to reduce hemolysis during storage. g hetland , , f mahmood , l nissen-meyer and i nentwich immunology and transfusion medicine, oslo university hospital immunology, university of oslo, oslo immunology and transfusion medicine, akershus university hospital, lørenskog, norway background: allergen-specific ige in donors' plasma can be transferred from blood donors to recipients via plasma-containing products and consequently sensitize recipient's effector cells bearing receptors for ige (mast cells, basophils, thrombocytes etc.). these cells can then degranulate after exposure to allergen. this can cause allergy symptoms of various degrees (johansson, allergy, ) . food allergen-specific ige antibodies, although causing mild or no symptoms in blood donors, can be of clinical importance to plasma recipients due to varying sensitization and activation grade of recipients' effector cells. aims: the aims of the study were ) to assess sensitization profiles against an array of allergens in randomly selected blood donors and ) to identify donors with high concentrations of food-specific ige antibodies that could bear risk of clinically important sensitization of plasma product recipients. methods: we tested serum samples from blood donors randomly selected on one donation day outside the pollen season. we used ll serum per sample in a multiplex ige line-blot enzymoimmunoassay for analytes (euroline atopy screen, euroimmun, germany), which comprised food allergen extracts and single allergens, inhalant allergen extracts, insect venom extracts and one carbohydrate allergen ccd. this high-throughput method enables scanning of serum samples for ige against allergens in less than h. results are expressed as east (enzymoimmunoassay) classes: class (no sensitization), - (weak sensitization), (moderate sensitization), - (strong and very strong sensitization). results: east class, allergen, number of samples. food allergens: class none detected. class , sesame seed: . class , apple ; hazelnut . class , apple ; almond ; hazelnut ; sesame seed ; soybean ; cow milk alpha-lactalbumin . class : donors weakly sensitized to one or more allergens as kiwi, apple, almond, hazelnut, sesame, soybean, wheat, mutton, beef, cow milk beta-lactoglobulin and alpha-lactalbumin. we did not find any donors sensitized to apricot, peanut, rice, rye, yeast, cow milk casein and carbohydrate allergen ccd. insect venoms: class , and none, class , wasp venom ; honey bee . lower classes ( - ) not reported in this abstract. summary/conclusions: we found considerable sensitization to inhalant allergens but such sensitization probably represents low risk of clinical allergies due to passive transfer of antibodies. sensitization to insect venoms was negligible. we disclosed only one blood donor ( %) with high ige to sesame seed with a potential to transfer clinically relevant ige antibodies via plasma products. the need for a broad screening of donors for ige sensitization remains still questionable. background: the platelet storage lesion (psl) is one of the key factors that limit the platelet shelf-life to days. the mechanisms mediating the psl are not well understood, but it is becoming increasingly evident that platelets from some donors do not store as well as others. similarly, assessment of many in vitro quality parameters has been used to predict transfusion outcomes, with varying degrees of success. donor attributes such as age, and body mass index (bmi) may contribute to these differences. aims: to characterise the variability in the quality and function of apheresis platelet donations and to examine associations between donor attributes and platelet characteristics. methods: apheresis platelets (n = ) were collected, stored at °c with agitation, and tested at day , day and post-collection. vwf and fibrinogen binding (indicators of platelet adhesion; ae ristocetin stimulation), phosphatidylserine (ps) exposure (annexin v binding) and microparticles (cd + /annexin-v + ) were measured by flow cytometry. platelet aggregation was initiated with collagen, thrombin or arachidonic acid. thromboxane a (txa ) was measured by elisa. the proportion of procoagulant platelets (% coated platelets) was assessed by fibrinogen binding following collagen/thrombin stimulation. platelet-attached glycans were measured using flow cytometry and lectins ricinus communis agglutinin- (rca- ; detecting galactose-residues) and wheat germ agglutinin (wga; detecting sialic acid and nacetyl-d-glucosamine, glcnac-residues) ae stimulation with ristocetin. donation time, donor age, blood pressure (bp) and bmi were recorded. linear regression was performed using graphpad prism software. results: for many of the parameters measured, there was high inter-donor variability. platelets from subsets of donors showed up to -fold higher vwf and fibrinogen binding, formation of coated platelets and microparticle numbers. binding of lectins was also highly variable between the donors, indicating variability in sugar cleavage. following ristocetin stimulation, binding of all lectins increased, and again there was high variability in the responses, with up to -fold higher binding in platelets from a subset of donors. of particular interest, aggregation in response to arachidonic acid was observed in only % of platelet donations tested; although platelets from non-responders aggregated in response to the collagen and thrombin. txa was also higher in the arachidonic acid responders (p = . ). there were few associations between platelet parameters and donor attributes, and these associations were typically weak. ph at day was weakly associated with donor age (p = . , r = . ) but not bmi (p = . , r < . ), with a trend towards lower ph in younger donors. summary/conclusions: these data indicate that apheresis platelet products are highly variable. whilst donor characteristics may have some influence on the quality of the donated platelet product, there is a high level of inherent inter-donor biological variability. a much larger sample size is required to confirm these findings, and determine whether they have clinical implications. background: the frequency of beta thalassemia mutations, and thus, of beta thalassemia heterozygotes (b-thal-het) is particularly high in certain geographical regions. it has been reported that a significant proportion of donors (occasionally more than %) are b-thal-het that meet the criteria for blood donation (hb > . g/ dl). red blood cells (rbcs) of b-thal-het donors are characterized, in vivo, by particular geometry and redox status. despite sporadic indications that the rbc storage lesion may be milder in b-thal-het, targeted research on this donor group is still missing. aims: the aim of this study was to investigate whether b-thal-het rbcs storage at blood banks leads to a distinctive hemolytic, physiological and redox profile, thus, making b-thal-het a unique blood donor group. methods: blood samples from healthy non-smoker donors ( b-thal-het carriers and controls) were analyzed before and after preparation and storage of leukoreduced packed rbc units in cpd/sagm at various time intervals. susceptibility in hemolysis (in the presence/absence of oxidative, mechanic and osmotic stimuli), redox status (lipid peroxidation, reactive oxygen species (ros) accumulation, antioxidant capacity), intracellular ca + and proteasomal activities were determined. for statistical analysis, significance was accepted at p < . . samples from the red cell units were collected aseptically, processed (dual centrifugation at , g for min) and stored at À °c. processed samples were thawed, and then analysed using the nanosight ns nanoparticle tracking analysis system (malvern instruments). samples from all time-points from each unit were analysed on the same day. data were analysed by one-way anova with bonferroni's multiple comparisons test. results: at d , red cell units contained an average of . ae . mvs/ ml. the mean size of these mvs was . ae . nm and the mode size was . ae . nm. the concentration of mvs increased gradually throughout storage (p = . ), reaching a maximum at d of . ae . mvs/ml. both the mean (p < . ) and mode (p < . ) size of the mvs increased during storage; however, this size increase primarily occurred in the first week of storage (d vs. d : p < . for both mean and mode). by d , mean and mode size of mvs was . ae . nm and . ae . nm summary/conclusions: nanoparticle tracking analysis demonstrated the presence of mvs smaller than nm in red cell units. both the concentration and size of mvs present in red cell units increased during the days of routine storage. the concentration of these mvs was approximately -fold higher than we had previously detected using flow cytometry (aung, pathology, ) indicating the advantages of more sensitive techniques in characterisation of mvs. background: the lack of availability of sterile saline in a format suitable for use in blood centers for manual washing has led to an urgent need for blood services to consider alternative methods. for operational flexibility it would be desirable to be able to produce a washed rbc unit that had a shelf life longer than h. aims: the aim of this study was to validate the manual method for washing rbcs using sagm solution both as wash and storage solution and to ascertain whether an extended storage period for washed rbcs may be feasible. methods: six day old leukocyte depleted red blood cells (ld-rbc) and six day old ld-rbcs were manually washed and stored in sagm, and half of the units were pre-stored irradiated ( gy). a volume of ml wash solution (sagm) was added to the ld-rbss by sterile connection. after mixing the units were centrifuged for . min at g at °c (hettich roto silenta rs) before removing the supernatant using compomat g extractor. wash procedure was repeated twice using ml sagm solution, and after removal of the last supernatant, ml of sagm solution was added. all units were immediately measured for volume, haematocrit, albumin, iga, potassium, haemolysis, haemoglobin, ph, glucose and lactate and tested again after h, days and days storage at ae °c. results: all washed ld-rbcs met european specification for haematocrit ( . - . ) and all but one for hb content (≥ g/unit). hemolysis increased during storage. the rate of hemolysis in irradiated ld-rbcs was greater over time than in nonirradiated units. all units, both irradiated and nonirradiated, met european specification for hemolysis (less than . %) days after washing. after wash, potassium levels were low and then increased during storage; increase was greater in irradiated than nonirradiated units. potassium concentration days after washing and irradiation did not exceed those levels found at the end of shelf life (day ) of standard ld-rbcs. ph decreased during storage due to the metabolic activity of red blood cells converting glucose to lactate. the ph level of the supernatant depends on the age of the unit and not on the irradiation. the glucose concentration of the supernatant after washing is high due to sagm solution. the concentration of glucose decreased and lactate increased due to the metabolic activity of red blood cells. there is currently no specification in europe or finland for iga in washed rbcs. aabb and american red cross rare donor program stipulate that level of iga should be less than . mg/dl ( . mg/l). our iga method s lower limit for detection is . mg/l and all results were below this level. total albumin were well below finnish specification (< mg/unit). background: room temperature has been the standard storage condition for platelets since the s, when it was shown that this improved in vivo survival compared to when stored at °c. however, storage at room temperature has several disadvantages, including risk for bacterial contamination and short outdating. recently, the interest in cold-stored platelets increased, especially for patients with a hemostatic need. using extensive analysis techniques, we evaluated the in vitro quality of cold stored platelets in additive solution. aims: investigation of the in vitro quality of platelets stored at - °c in pas-e. methods: three experiments were performed, in which two platelet concentrates, prepared from buffy coats and ml of pas-e (pcs) were pooled and split in equal pcs. pcs were stored for days at - °c, one of each pair with agitation on a flatbed shaker and the other without agitation. various parameters were analyzed to study the in vitro quality during storage and compared to routine room temperature storage. results: during cold storage, the swirling phenomenon disappeared within one day. due to the lower temperature, metabolism of the platelets was lower as compared to room temperature storage. the metabolic conditions were acceptable with ph d -d : . - . with platelet count /u and glucose still at mm at least until days of storage. platelet activation maintained acceptable levels with cd p expression < %, while ps exposure increased rapidly; > % after days of storage. aggregation tests showed functional platelets until days of storage. agitation during storage had no effect on any of the tested parameters. summary/conclusions: during storage of platelets at - °c, the hematological parameters and ph met routine requirements, while swirling phenomenon disappeared already at the first day. the functionality of the platelets did not decrease during cold storage, indicating that the swirling phenomenon is not a good surrogate marker under these conditions. the strong increase of ps exposure might be involved in the observed short survival of cold-stored platelets. platelet concentrates stored at - °c are potentially suitable as a hemostatic agent for patients with a bleeding in need of platelets, but more studies are needed. aims: the goal of the study is the reinforcement of platelet reserves for case of emergency events and increasing their availability for treatment, preferentially in patients with massive bleeding. methods: we performed a comparative study with cpp and fp in vitro. buffy coatderived pooled leukoreduced platelets rhd negative were frozen in - % dmso and stored at À °c for months. cpp were thawed at °c, then reconstituted in platelet additive solution ssp+ and compared to fp. we measured these parameters: platelet content, platelet concentration, platelet loss during preparation process, coagulation properties, volume, ph, dmso concentration, titres of anti-a and anti-b antibodies. results: the average platelet loss after the process of freezing and reconstitution was %. the amount of platelets and platelet concentration in unit was lower in cpp compared to fp, but high enough (amount /unit, concentration . /unit). both types of plts (either pcc or fp) maintained an acceptable ph during storage. swirl was on value in fp and on value in cpp. the average plasma content in fp was % compare to . % in cpp after reconstitution. measured titres of igm anti-a and anti-b antibodies were very low ( - : ). cpp had faster clot initiation (rotem clotting time (ct) in cpp . s, fp . s). cpp contributes to a sufficient clot (rotem maximum clot firmness (mcf) in cpp . mm, fp . mm). summary/conclusions: our results shows, that cpp have higher procoagulation activity and simultaneously lower clot firmness. thawing and reconstitution of platelets are easy and fast processes if platelet additive solution is used. this method helps to increase the availability of platelets in emergency medicine. low plasma content in cpp enables their use as washed platelet product in specific groups of patients. methods: after donation, the whole blood was stored in room temperature overnight before separating next morning by reveos â system. seven abo compatible ipus, each with a target volume of ml, were selected and then they were connected to the pooling set provided by terumo bct. prior to the pooling of ipus, ml of additive solution (t-pas+ provided by terumo bct) was added and distributed evenly between the ipu bags. the pooling set was then kept h on bench in room temperature followed by h on agitator at ae °c. after filtration, the pool might be manually adjusted if its volume exceeded the maximum of ml to meet the requirements by the intercept tm blood system. the final products were two pathogen-reduced platelet units with a shelf life of days. results: during validation of the method, pathogen-reduced platelet units were controlled, in addition to the platelet count, for ph, glucose, po , pco and lactate on day , and of storage. the platelet count was . ae per unit on day . the ph value was . on day , . on day , and . on day . the glucose concentration decreased from . to . and . mmol/l on day , and , respectively. the mean po level was . , . and . kpa while the mean pco was . , . and . kpa and the lactate concentration was . , . and . mmol/l on day , and , respectively. since routine implementation of the method in april , regular quality controls showed an average of platelet count of . ae (n = ) with a volume of ae ml per unit. summary/conclusions: the validation of the method and the following two years of experience in routine shows that the pooling of ipus processed in reveos â system meet the requirements needed for intercept tm ds processing set for pathogen reduction of platelets. the results from the quality controls of the final platelet units were in accordance with the local and eu guidelines. methods: data was analyzed from published and unpublished clinical studies that performed both primary and secondary testing of platelets using the bta system. the studies included apheresis and whole blood derived buffy coat platelets and tested - ml sample volume per culture bottle. the studies classified results based on aabb bulletin - definitions with some modifications. the following assumptions were made including: • data was summarized as total number of positive tests, observed by the total number of tests performed on each day post collection; • it was assumed that one test was performed per platelet unit; • all units eligible for secondary testing were negative by the primary test the data needed to demonstrate a benefit for the use of the bta d systems for detecting contamination that was not revealed by previous bacterial testing as well as clinical specificity. results: a total of , platelet units from the studies where secondary testing of platelets was performed were analyzed. platelets were tested on day , , or ≥ , and represented . %, %, and % of the units tested, respectively. true positives were detected in platelet units representing . % of the total platelets tested. the majority were reported from platelets tested on day ≥ with a total of . data showed the bta d system used for secondary testing detects the most prevalent contaminates reported, staphylococcus spp., in ≤ h with the majority detected in ≤ h after incubation, allowing for interdiction of the units prior to transfusion. instrument specificity was reported in of the studies for platelets tested at days and ≥ days with a total false positive rate of . % (range of - . %). instrument sensitivity when used for secondary testing could not be determined since subculture of negative bottles is not performed during routine use. during previous validation testing of lrap and lrwbpc, , culture bottles were confirmed true negatives by subculture. summary/conclusions: data from the studies that tested platelets at to days post collection provided evidence that the bta d with bpa & bpn detects contaminants missed in previously tested platelet units. the data supports that the bact/alert d system is an effective safety measure for secondary testing of platelet products to extend platelet dating beyond day and up to day when testing is performed using the test parameters described in the bpa and bpn bottle ifus and according to the fda draft guidance. background: magnetic nanoparticles have recently shown great potential in nonradioactive labeling of platelets. platelet labeling efficiency is enhanced when particles are conjugated with proteins like human serum albumin (hsa). however, the optimal hsa density coated on particles and the uptake mechanism of single particles in platelets remain unclear. aims: we characterize the interaction between single particles and platelets and determine the optimal hsa amount required to coat particles. methods: ferucarbotran iron oxide nanoparticles were coated with hsa in different amounts ( . - mg/ml) and we confirmed successful hsa coating by addition of a crosslinking hsa antibody (dynamic light scattering). we labeled platelets from pooled platelet concentrates with mm ferucarbotran coated nanoparticles and analyzed labeled platelets for iron content (atomic absorption spectroscopy) and particle localization (transmission electron microscopy). single-molecule force spectroscopy was used to determine binding forces of nanoparticles to platelet compartments. we applied hsa-particles via linkers of different length (i.e. short~ nm, medium nm and long~ nm) on the cantilever tip and let them interact with a platelet provided on a collagen surface. after interaction we determined the rupture force required for platelet retrieval. results: the iron content per platelet reached a maximum at . - . mg/ml hsa coated particles with . ae . and . ae . pg/platelet, respectively. however, the . mg/ml hsa coating resulted in~ -fold higher binding affinity to platelets than particles coated with . mg/ml hsa. depending on peg length between tip and particle, particles interacted differently with platelets as shown by one, two or three force distributions of , , and pn, which correspond up to three different binding pathways, respectively. the results indicate that a particle can interact with three targets including platelet membrane, open canalicular system, and platelet granules. summary/conclusions: our results reveal mechanism of platelet-particle interaction on a single particle level and provide an optimal hsa concentration coated on particles to gain maximal platelet labeling efficiency. labelling of platelets by magnetic nanoparticles may substitute radioactive labeling. results: the activation/lesions on total platelets and small and medium-sized platelets platelet population was detected on storage day , by the increased expression of cd . the percentage of cd -positive cells among the population of large platelets did not change during storage. on the day , increased expression of cd b and cd p was detected, but only on large platelets. small and medium-sized platelets had increased cd p expression only on day . the expression of cd a on total platelets increased significantly on day , and stayed unchanged until day . the same pattern of cd a expression was detected for small and medium-sized platelets, whereas on large platelets the expression continued to increase until the end of storage. a decreased percentage of cd -positive cells was detected among the total platelets and populations of medium-sized and large platelets. the storage induced externalization of phosphatidylserine on total platelets or on any of the platelet populations was not detected. the levels of tgf-b and p-selectin in the pc-bc supernatants were unchanged during the -day storage period. increased annexin and pf concentrations were detected on day . the concentration of b-tg increased on day of storage, and continued to rise until the end of storage. summary/conclusions: the evaluation of expression of activation markers on different platelet populations could be used as an additional analysis in quality control of platelet concentrates, and in the assessment of novel approaches to platelet concentrate manipulation i.e. for testing new additive solutions, cryoconservation protocols, and cryoprotectants. background: the primary goal of autologous blood transfusion is to reduce the risks related to allogeneic blood transfusion, including transfusion-associated graft-versus-host disease (ta-gvhd). although downward trends in rates of autologous blood transfusion have been reported in europe and the americas, it still plays a role in eliminating risks related to allogeneic blood transfusion in japan, especially ta-gvhd. since february , the transfusion service in our hospital has managed autologous blood conservation techniques and helped to prevent mistransfusion by employing a bar code-based electronic identification system. aims: the objective of this study was to determine the use of types of autologous blood components in a single institution over an approximately -year period. methods: between february and december , we retrospectively analyzed autologous blood transfusion, including perioperative autologous cell salvage (pacs), pre-operative autologous blood donation (pad), and acute normovolemic hemodilution (anh). we investigated the use of autologous blood components and the rate of complying with electronic pre-transfusion check at the bedside in the operating rooms. we also determined the adverse reactions to autologous blood transfusion, which were categorized according to the definitions proposed by the international society of blood transfusion (isbt) working party on haemovigilance. results: a total of , patients ( % of whom received operations) received blood transfusion, of which , ( %) received autologous blood transfusion alone, , ( %) both autologous and allogeneic blood transfusions, and , ( %) allogeneic blood transfusion alone. the rate of autologous blood transfusion among patients who received blood transfusion was %. pacs units were transfused to , patients ( %), pad units to , patients ( %), and anh units to patients ( %), and multiple blood conservation techniques were used for one patient. the overall compliance rate with electronic pre-transfusion check at the bedside in autologous blood components was . %. adverse reactions were observed only with pad transfusion and not pacs nor anh. the number and rate of adverse reactions to pad transfusion were and . %, respectively, of which the most common was febrile non-hemolytic transfusion reaction at ( %), followed by allergic reactions at ( %), and hypotensive transfusion reaction at ( %). the severity of adverse reactions to pad transfusion was grade (non-severe) in all cases, and no serious adverse reactions were observed. among pad units, the rate of adverse reactions to whole blood pad units was . %, that to frozen pad units was . %, and that to autologous ffp units was . %. summary/conclusions: our observations indicate that the rate of autologous blood transfusion among patients who received blood transfusion was %, when all types of autologous blood conservation techniques were included. to accurately determine the rate of autologous blood transfusion in a hospital, it may be better for the transfusion service to manage all types of autologous blood conservation techniques. they are now clinically available as a blood product. the residual plasma level of this product, which is prepared using the automated cell processor acp (haemonetics corp.), is approximately %. recently, a retrospective multicenter study was reported that this product was effective and safety for prevention of recurrent or severe transfusion reactions. plt products are generally stored with continuous agitation to maintain their quality. the interrupted agitation of plt suspended in additive solution (plasma carryover: - %) for up to h was previously found to have only a slight impact on in vitro plt properties. however, in some small hospitals with no agitator, if the initiation of transfusion is delayed by an emergent change in a patient's condition, the interruption of agitation may be prolonged. aims: the aim of this study was to evaluate the effects the interruption of agitation for h (shelf life of wpc in japan) on the in vitro qualities of plt. methods: leukoreduced apheresis platelet concentrates in % plasma were washed on day one after blood collection using the automated closed-system cell processor acp (n = ). wpc, which were rested h after preparing, were divided equally into control and test units using polyolefin containers on day one. control units were agitated from days one to seven. test units were stored without agitation from days one to three, and agitation was subsequently performed until day seven. both units were stored at - °c. in vitro plt quality was examined on days one, three, four and seven. results: the plt concentration of prepared wpc was . ae . ( /l) and the volumes of the control and test units after the division were ae and ae (ml). the ph values of the test units on day three were lower than those of the control units; however, the ph of both units were maintained at higher than . during the seven-day storage period. swirling was well maintained and no clumping was visible in both units during storage period. no significant differences were observed in plts concentrates, mpv, hsr, aggregation response. the pco , po , bicarbonate, glucose and lactate mean values of test units were slightly lower or higher than those of the control units on days three or four. the levels of cd p expression were significantly higher in the test units than in the control units on days three ( . % ae . vs . ae . , p < . ); however, this difference decreased in a time-dependent manner after agitation resumed. the levels of cd b expression of test units were relatively lower than those of the control units until day seven, but no significant difference between the two units. background: monitoring residual white blood cells (rwbcs) is a requirement for quality monitoring (qm) the production of leucocyte depleted blood components. although flow cytometry is widely used for monitoring rwbc, there are no widely accepted methods to accurately and consistently measure rrbcs in blood components. sysmex have developed a novel algorithm, termed the blood bank (bb) mode for their xn-series of haematology analysers which is specifically designed to quantitate the levels of rwbcs and rrbcs in blood components. aims: we have previously assessed the linearity, accuracy and reproducibility of the bb mode on spiked samples in an r+d lab. we sought to further assess the performance of the bb software in a routine, high throughput blood component manufacturing department. methods: units of plasma, platelets (pcs) and red cell concentrates (rccs) were produced according to standard uk specifications within nhs blood and transplant (nhsbt). qm of residual cells was tested using the bb mode whilst rwbc was additionally analysed by flow cytometry using bd leucocount kit. results: during a -month field trial over , data points were collected representing all types of manufactured component. for some pcs, bb mode results from some sample tubes that did not contain edta gave very high rwbc values, indicating a potential large number of ld failures. the results were significantly different from those obtained from pcs using edta samples (p < . ) which did not show the same high values. for rccs or plasma, the range of results from plain and edta tubes were not significantly different (p ≥ . ). the analyses of ld platelet and plasma concentrates by either bb mode or flow cytometry both show more than > % of ld components have less than rwbc/unit. for ld failures (n = ) there was a good correlation (r = . ) between flow cytometry and bb mode measurements. spiking studies suggested that the limits of detection and quantitation of rrbc were around and rrbc/ll respectively. residual red cell counts from manufactured components showed a wide variation in their numbers between units. as expected platelet production methods also showed a significant difference (p < . ) in rrbc contamination, with lower levels in apheresis platelets (median = rbc/ll, n = ) compared to those produced from buffy coats (median = rbc/ll, n = ) in our hands, although the time taken to analyse samples is similar for flow cytometry and bb mode, considerable time can be saved on manual handling and the processing of samples for flow cytometry (approximately - h for - samples). summary/conclusions: we have been able to embed the sysmex bb mode into a routine production environment and confirm that its performance in spiked samples is mirrored in routine use. for platelets, sample collection in edta is essential. the bb mode offers an opportunity to reduce operator time compared to flow cytometry whilst gaining additional information on rrbc. abstract withdrawn. results: in our experiment, the typical size of a spectrin matrix section (l) was to nm (without oxidation). the heights (h) of dips were to nm. due to oxidation, the junctional complexes between spectrin and membrane proteins can rupture. only % to % of the spectrin surface has the same structure as in the control group. the values of l and h vary significantly depending on the intensity and time of exposure. we observed significant changes in the spectrin matrix after exposure to uv radiation in a model experiment. the local topological defects in the membrane arise from the action of oxidizing agents on the red blood cells. the mechanism of their appearance is connected mainly with the distortion of the spectrin matrix. as a result of oxidation processes, the spectrin molecules can be damaged. there is a transformation of tetramers to dimers. additionally, it can be easily seen with the afm, that spectrin network structure was essentially destroyed. most parts of the spectrin matrix have damaged structures with mesh breaks and dips after uv irradiation. also the results of network distortions in response to temperature changes were obtained. there are presented preliminary results of spectrin matrix change during long-term storage of prbc. summary/conclusions: atomic force microscopy in direct biophysics experiment allows to observe and to quantitatively measure the disturbances in the spectrin matrix nanostructure in response to oxidation processes in rbcs. these studies are important for the fundamental research of interactions of rbcs on the molecular level during redox processes and the consequences to their structure and function on the cellular level. this is important for the advancement of transfusion medicine, intensive care medicine, and molecular and radiation biology. methods: blood samples were taken from donors during a prophylactic examination and collected with edta-filled microvettes (sarstedt ag and co., germany). all experiments were carried out in accordance with the institute guidelines and regulations. the polylysine-coated glass was used to perform the sedimentation method for formation of native rbc smears. it is important that any fixatives weren't used. the stiffness of rbc membranes was studied in native rbcs (control) and native cells after the application of modifiers: glutaraldehyde, hemin, zn + (heavy metal ions). local stiffness was studied by atomic force spectroscopy (afs) (ntegra prima, (nt-mdt, russian federation). results: experimental kinetic curves i(z) were measured. nonlinear fitting method was used to determine the young's modulus. the experimental dependences of membrane bending were approximated by the hertz model to a depth up to nm. the young's modulus e = ae kpa for control rbc. it was shown that some natural oxidants (hemin), membrane fixatives (glutaraldehyde) modifiers, heavy metal ions (zn + ) significantly increased the absolute value of the young's modulus of rbc membranes up - times. the biophysical parameter hertz depth (h hz ) was determined for each curve. under the influence of modifiers the hertz depth h hz was changed from nm to nm. there are presented preliminary results during long-term storage of blood. summary/conclusions: the blood rheology is determined by rbc deformability, associated with membrane stiffness. the young's modulus can be used as a quantitative criterion to estimate the membrane state of a native cell. the results of the work can be used in clinical practice, in assessment of the quality of donor blood during storage before transfusion, in biophysical studies of rbc state. abstract withdrawn. immunohemotherapy, centro hospitalar universit ario são joão, epe, porto, portugal background: transfusion of blood and blood components is an essential resource in modern medicine. a proper use of human blood, being an irreplaceable resource, is necessary in order to achieve minimal wastage. blood wastage may occur for a number of reasons, like expiry date, haemolysis, seroreactivity or low volume. monitoring wastage of blood product during collection, testing and processing of blood is used as a quality indicator. aims: to determine the annual rate of discarded blood components due to expiry date in a portuguese university hospital blood bank (bb) from january to december , in order to implement appropriate measures to minimize the number of discarded blood to a reasonable rate. methods: we retrospectively analysed the rates of blood components discarded after meeting their expiry date of a portuguese university hospital blood bank from january st to december st . results: a total of , whole blood units and , apheresis platelets were collected during the study period. of the , blood components (packed red cells, whole blood pooled platelets and apheresis platelets) prepared during the study period, a total of , ( . %) blood components were discarded, of those . % due to expiry date. the rate of discarded packed red cells, according to this component production, decreased considerably over the years, in was . %, in was . % and . % in . similar tendency was shown in the pooled platelets for consecutive years with . % ( ) and . % ( ), but with an increase in ( . %). the rate of apheresis platelets had a more variable behaviour from to with rates of . %, . %, and . % respectively. summary/conclusions: blood transfusion is an essential part of patient care. for this reason, the implementation of a quality system and continuous evaluation of all activities of the bb can help to achieve maximum quantity and quality of safe blood. we identified that date expiry was the main reason of discarded blood components, although there was a significant decrease in the rate of discarded packed red cells over these three years. properly implemented blood transfusion policies, donor screening and training staff as well as implementation of automation also helps to improve the process, reducing the discarding rates of blood and blood component. background: storage performance of platelets (plt) is associated with age of the donor. the risk for plt with poor storage performance, characterized by high lactate production and rapid acidification of a plt concentrate (pc), shows a positive correlation with age. we wished to explore whether high lactate production was associated with donor health issues. aims: to investigate high lactate production by stored platelets in relationship to donor health. methods: single-donor pc were collected by apheresis or prepared from buffy coat and donors were evaluated who could be marked as 'rapid acidifiers'. in total, apheresis pcs and pcs from whole blood were included in four studies. information about donor health was obtained either from the blood bank information system or using questionnaires. in some donors, the lipid profile was measured from plasma, and the diabetes marker hba c from red cells. triglyceride levels > . mmol/l and hba c levels > mmol/mol were defined as high. results: twenty two percent ( / ) of the donors were marked as 'rapid acidifiers' and % ( / ) of these donors had health issues. 'rapid acidifiers' were of age , - (median, range) years. three groups of donors can be distinguished: a) donors affected by metabolic syndrome, prediabetes and type diabetes, indicated by high cholesterol and/or triglycerides, high hba c and/or the use of medication to treat diabetes. b) donors affected by vascular diseases who reported or used medication to treat high blood pressure. c) "other" donors who used other medication to treat various other conditions. the remaining 'rapid acidifiers' ( %) did not have high triglyceride or hba c levels and did not report health issues. summary/conclusions: pcs with rapid acidification by high lactate production are mainly collected from older donors with health issues. we postulate that high lactate production by stored plts is associated with health issues, and we will combine detailed donor information (health and behavior) with in vitro quality for a significant number of donations. background: the development of applied biotechnologies requires a search and creation of new methods of cells' functional completeness analysis. the instrumental assessment of platelets quality for the selection of the most effective donors, quality assessment of platelet concentrates for short and long-term storage and for the selection of platelets for cryopreservation is in demand in blood service. assessment of platelets morphofunctional status is possible using morphological studies of various platelet granules fractions (makarov, med. alfavit, ). among the biologically complete platelets there is a special population of cells, the so-called granule-rich platelets (grp). these cells contain the largest number of cytoplasmic granules (more than visually distinct granules). it is established that grp have increased viability and functional activity. earlier we found a correlation between the grp level in blood plasma and shift of the redox potential value in blood plasma after cryodestruction of platelets (tsivadze et al., doklady physical chemistry, ). it was suggested that the shift of the redox potential may be partly due to the release of the low molecular weight antioxidants contained in functionally complete platelets outside the cell. in turn, the concentration of low molecular weight antioxidants can be estimated using the cyclic voltammetry. aims: the aim of the study was to estimate of cyclic voltammetry method possibilities for quality assessment of platelets. methods: the functionality of platelets was examined in platelet concentrate (pc) obtained by apheresis ( . ae . /ll). voltammetric analysis in pc before and after the platelets cryodestruction was carried out on platinum electrode in the potential range from À mv to + mv using a potentiostat ipc pro l and saturated ag/agcl electrode as reference. for the morphofunctional analysis platelets were vitally stained with fluorochrome stains trypaflavin and acridine orange. microscopic examination of platelets was carried out using confocal microscope nikon eclipse i. the following parameters were evaluated: concentration and percentage of platelets with granules and concentration and percentage of grp. results: voltammetric studies in pc show that there are two oxidation peaks of low molecular weight antioxidants on voltammogram at potentials + mv and + mv. analysis of pc before and after the cells cryodestruction showed that changes in the height of oxidation peaks occur, indicating an increase of antioxidant content in blood plasma. at the same time a correlation between the changes in the height of oxidation peaks and the grp content in the sample was found. in samples with reduced initial grp content (less than %) after the cells cryodestruction significant changes in the height of oxidation peaks were not observed, regardless of the total number of cells in the pc. summary/conclusions: in conclusion, voltammetric analysis allows to indirectly estimate the population of functionally active platelets that in combination with other methods of analysis can serve to assess the quality of platelet products. background: determination of hemoglobin derivatives in blood is one of the most important studies in clinical laboratory diagnostics, especially during the storage of donor blood and its transfusion. concentration of hemoglobin derivatives can be changed during redox process. aims: to show the possibility of using non-linear fitting method to calculate concentrations of hemoglobin derivatives during reduction-oxidation processes. methods: for this we performed model biophysical experiment, in vitro. blood samples were collected into edta microvettes from healthy donors (sarstedt ag and co., germany) during prophylactic examinations. all the donors gave their consent to participate in the study. a suspension of erythrocytes was prepared in pbs buffer with ph . . we used ultraviolet (uv) irradiation of blood or nano as oxidizing agent. the drug cytoflavin (stpf "polisan", russian federation) was used as an antioxidant. in our study we used digital spectrophotometer (unico , usa) to measure the absorption and scattering of light ( . nm step). the method of nonlinear fitting was used to find the concentrations of hemoglobin derivatives. the empirical spectrum d l (k) exp was approximated by the theoretical curve d l (k l ) theor , which fits the experimental curve in the best way. under approximation the light absorption by different hemoglobin derivatives was considered in model. simultaneously effects of rayleigh light scattering on structures with size d<< k (coefficient s) and light scattering on particles with size d≥ k (coefficient k) were taken into account: d l (k l ) theor = e hbo ,l c hbo l+ e hb,l c hb l+ e methb,l c methb l+ e hbno,l c hbno l+ e methbno -,l c methbno -l+ e methbno,l c methbno l+k+s/k l ( ), where e h,l is the molar absorption coefficient for each hb h derivative at given wavelengths k l , c h is the concentration of the derivatives hb h , l is the thickness of the solution layer, d l (k l ) is the optical density of the substance, k and s are the parameters of the model. results: we determined the concentrations of hemoglobin derivatives without any additional chemicals in blood. there were measured experimental spectra for different agents action on blood. it was shown that concentration of methb increased after uv irradiation and nano action (up to %). there were calculated c h for each hb h derivative. it was established that theoretical curves coincide with experimental data with good accuracy (r = . ). incubation of rbcs with cytoflavin leads to reduction of methb to hbo . summary/conclusions: the determination of hemoglobin derivative concentrations by the method of nonlinear fitting (without adding special chemical agents to blood) can be used for measurement of carboxyhemoglobin in blood during toxic state of organism. also it is important for assessment of rbcs quality before blood transfusion. background: the use of in line leukoreduction filters have been highly expanded in iranian blood transfusion centers within the last decade in order to provide sufficient leukoreduced blood fractions from healthy safe frequent blood donations to be supplied to the leukocyte sensitive patients. leukoflex lcr , the dominant brand of such filters procured by iranian blood transfusion organization, is the most updated generation of the filters used around the world. aims: in this study, it is tried to recover the trapped leukocytes from this novel filter by different buffering systems and having optimized the elution mode, the cell differential of the viable recovered white blood cells were determined by flow cytometry. methods: having passed the routine virological tests, eight leukoflex lcr leukoreduction filters freshly used in tehran blood transfusion center were daily collected and each were back flushed by a self-designed mechanical system (a peristaltic pump, a triple junction with regulator part and an air pump) using various conditions and additives for pbs buffer at different phs in order to find the highest recovery yield for leukocytes. the optimized elute was characterized by flow cytometry for subcellular profile to be determined. results: it was illustrated that a system consisting of pbs (without cacl and mgcl ) in ph . containing mm edta and %(w/w) dextran without additive amounts of triton x was the most optimized buffering system for lcr filter back flushing. total cell content was also determined as . * granulocytes, . * lymphocytes and . * monocytes using auto hemoanalysis and flow cytometric methods. summary/conclusions: in addition to partly compensating of the overhead expenses inflicted by application of leukoreduction filters on healthcare system, the results will assist blood organization system to be more classified in rational profile design, future cell therapy strategies and exceptional blood management. also, the recovered cells could be of significance in stem cell science, cellular interaction studies as well as novel molecular developments in drug discovery. vox sanguinis ( ) results: three lines of strategy are in place to pursue self-sufficiency of the largest number of pdmps. first strategy line: maximizing the yield of driving proteins, represented by immunoglobulins (ig) and albumin; this was assured by csl behring with a yield of . g ig ( % intravenous -privigenand % subcutaneous -hizentra) and g albumin (alburex) per kg plasma fractionated, corresponding to . g ig and . . g albumin; based on present demand, this represents % and % self-sufficiency, respectively, for naip regions. second strategy line: ensuring other products from plasma fractionation; the fractionator granted . g fibrinogen (riastap) and . . iu vwf/fviii (haemate p) per year, which corresponds to the present demand of naip regions for both products, but it is under the full potential of plasma, thus providing a high margin of safety in case of increased demand (now the case of fibrinogen). third strategy line: exchanging cryoprecipitate, fibrinogen and vwf with italian regions whose plasma is fractionated by other companies to obtain prothrombin complex concentrates (pcc -kedcom) and antithrombin (atked) as to satisfy naip regions demand; this strategy allowed a supply of . . iu at and . . iu pcc, capable of ensuring self-sufficiency for naip regions until . summary/conclusions: in italy, differentiation of plasma contract manufacturing among companies with different portfolios allowed naip regions to obtain a significant contribution to self-sufficiency from vnrd plasma for a variety of pdmps by different and complementary strategies consisting in maximizing the yield and the portfolio of proteins from the fractionator and exchanging products among regions for other pdmps at high demand but not included in the portfolio of a single fractionator. plasma check system: a valuable tool for plasma freezing validation and monitoring. background: the validation of plasma freezing processes may result problematic in the monitoring/control of critical process parameters (cpp). in in italy , litres of plasma were produced and frozen. aims: in order to assist plasma freezing validation and cpp monitoring, of the italian bes performing plasma freezing utilize the plasma check system (pcs), a system able to record, store and certify the temperature (t) detected at the core of "surrogate" bags during the entire freezing session, consistently with gmp requirements. pcs is patented and commercialized by expertmed srl, verona, italy (http://www.expertmed.it). methods: pcs consists of parts: a) "surrogate" bags (check-bags) of and ml corresponding to the average standard volumes of the real products, containing a fluid validated to simulate the thermal behaviour of plasma; b) a mobile probe (cryo-med) positionable at the core of the check-bags; c) a dedicated software (memo-track). plasma freezing session data are tracked via barcode/rfid and can be consulted by the pcs that associates blast freezer code, operator code, cryo-med and check-bag. data on plasma freezing are stored in a shared folder and transferred to the be information system. the pcs can also be used to check and monitor the out-of-storage variations of core t of frozen plasma unit, i.e. during labelling and packaging procedures, thus allowing to establish optimal timeframes and operations and suitably validate these procedures. in the period - , at the pievesestina be of emilia romagna region , plasma units were frozen so as to allow complete freezing within to a temperature below À °c, in , freezing sessions, using the pcs both for process validation, change control and for the systematic monitoring of core t at each freezing session. furthermore, at the bologna be tests on the out-of-storage conditions of plasma units were carried out to revalidate the procedures of labelling and packaging. results: out of , freezing sessions carried out at the pievesestina be, ( . %) were detected to fail to reach À °c at the core of the check-bags within . of the latter, in most cases ( %) a technical error in the activation of the cryo-med was identified. in addition, the pcs was systematically utilized for periodical revalidation of the freezing procedures. the tests performed at the bologna be to validate the out-of-storage procedures of frozen plasma labelling and packaging allowed to modify the operating procedures in place so as to establish optimal timeframes and operations. this prompted corrective actions regarding: i) number of units to be taken out of storage sites at each labelling session (< units), ii) labelling time (< ), iii) optimal storage t (À °c vs. À °c), iv) optimal time between two openings of storage sites (> ). summary/conclusions: the pcs is a valuable system for plasma freezing validation and monitoring, as well as to perform monitoring and control of the whole pathway of frozen plasma in the be. it is a technologically advanced, easy-to-use and costeffective tool that can efficiently replace other traditional methods commonly used for the above-mentioned purposes. assessment of blood group matching quality using six sigma metrics background: six-sigma metrics provides a general methodology to evaluate a process performance on a sigma scale. implementation of six-sigma for quality assurance can benefit the health care sectors. one of the most important health care sectors is blood transfusion service. for that reason, maintaining a high quality in blood transfusion service is required. pathogen in activated plasma is one of the main products that are provided by the blood transfusion service. the process of producing pathogen inactivated plasma involves blood group matching step. the quality of this blood group matching is extremely significant for the delivery of plasma that satisfies the recipient need. aims: the aim of this study is to assess the quality of blood group matching of pooled plasma units using six sigma metrics, and to clarify the potential implementation of six sigma metrics as a quality management tool. methods: this retrospective study was conducted in the component preparation lab of kuwait central blood bank. the twelve months (january -december ) data of pooled fresh frozen plasma units were recruited and examined. the data was separated to data without double check ( months) and data with double check ( months). data statistics and analysis were conducted by the use of six sigma metrics. results: in a sample size of from the first six months a mismatch was found which equals dpmo and . sigma metric. and in a sample size of from the second six months a mismatch was found which equals dpmo and . sigma metric. out of the whole pooled units were found to be mismatched. some of which were found to be discarded as abo discrepancy, broken, or expired. other was still available in the system, while the rest of the mismatched units were issued. summary/conclusions: using the six sigma principle the study presents a successful assessment of blood group matching quality. as a . sigma metrics obtained from the first months, were shifted to a sigma metrics of . in the second months, after the addition of a double-checking step to the blood group matching of pooled plasma process. the implementation of these metrics in our laboratory quality management has been shown to be very beneficial. in which six-sigma metrics were able to clarify the reduction in blood group matching errors. although six-sigma benefits in major quality improvements and helps to reach an error free laboratory services, yet it presents a new challenge to laboratory practitioners. currently, the hemophilia a patients treated with factor viii concentrated as the first line of therapy but it is more expensive and the supply is not sufficient so for now they have not used factor viii concentrate as prophylaxis therapy. for some cases, hemophilia patients in indonesia depend on subsidy from the world federation of hemophilia. the first handicapped concentrated case is just for therapy not for prophylaxis. big blood centers in indonesia produce routinely fresh frozen plasma (ffp) and cryoprecipitate-anti hemophilic factor (ahf) as replacement therapy for hemophilia a, but its content and safety of factor viii from ml ffp need to be improved. nowadays, there is an available kit for producing minipool cryoprecipitate (mc) that has better safety and quality but it is available as liquid products, stored in very strict and specific temperature (À °c). prophylaxis therapy for hemophilia patients needs a stable product, easy to use and convenient treatment for patients. aims: to analyze the content and safety of f viii with minipool cryoprecipitate (mc) and lyophilized mc for home therapy. methods: we produced mc; mc as the control, mc were lyophilized with excipient and mc without excipient. we analyzed the number of factor viii, the safety, and stability. we count the erythrocyte, leukocyte and platelet residual in mc using flow cytometry. we also measure the ph, osmolality, solubility to learn its stability after storage at days at room temperature ( - °c) and blood bank refrigerator temperature ( - °c) at central blood transfusion services (cbts). results: we found the content f viii with excipient is higher ( . iu/ml) than without excipient ( . iu/ml) and the storage at blood bank refrigerator ( - °c) is better than at room temperature ( - °c) . in both group, there were no residual cells and bacterial found in mc. no significant difference in the ph, osmolality and solubility in both groups. summary/conclusions: the lyophilized mc with excipient stored at blood bank temperature ( - °c) is better than room temperature. this experiment will be continued to know its stability in extended storage time. background: peptic ulcer disease (pud) is a multifactorial and complex disease, and it affects a wide range of people in the world. however, a perfect therapy for pud has not yet been available at present. therefore, we provided a novel therapeutic approach for pud patients and observed its effect in this study. aims: we provided a novel therapeutic approach for pud patients and observed its effect in this study. methods: in this randomized controlled trial, pud patients residing in chongqing were enrolled from to . they were randomly assigned to two groups: (a) a control group used only rabeprazole, and (b) a platelet-rich plasma (prp) group that received a combined therapy of autologous platelet-rich plasma (aprp) and rabeprazole. the aggregation rate of aprp was measured via aggregation remote analyzer module. the therapeutic effect was assessed via the ulcer size and the symptom score. all data were recorded and analyzed statistically using spss. results: a total of patients were included ( patients as control group) and ( patients as prp group) in the analysis. we found that the aggregation rate of aprp is not affected in ph . after treatment with pepsin. our results showed that there were no significant differences between the prp group and control group before the treatment, and there was also no significant difference in healing time between the two groups in different variables. however, regression analysis revealed that the healing time was . d less in the prp group than in the control group, and the patients with higher symptom scores in the initial examination need more time to heal in treatment. summary/conclusions: this study showed an encouraging preliminary result that aprp has a positive result in the peptic ulcer patients, and it seems to be a better choice for refractory pud patients. despite the further follow-up studies are needed to determine the duration of efficacy of aprp, the approach will be helpful for improving the pud treatment in clinical. background: the croatian institute of transfusion medicine (citm) collects, produces and distributes blood components in an area of . million habitants. annually, it collects about , whole blood and , apheresis donations. platelet concentrates (pcs) are more inclined to bacterial contamination due to storage conditions that favor bacterial replication. the citm decided to evaluate the mirasol pathogen reduction technology (prt) system as it offers the possibility to work with a non-toxic, non-mutagenic compound that upon uv illumination induce nucleic acid damage, reducing the risk of septic transfusion. aims: the study objective was to evaluate quality of pcs treated with the mirasol prt system for platelets and stored in tpas+ for days at °c on a platelet shaker. methods: pcs were produced according to the citm's s.o.p., either through pooling of bc with tpas+, "wbd", or through apheresis collection using two devices: the fresenius amicus, "ad" and haemonetics mcs+ system, "mcd". pcs were stored in % plasma and % pas and mcd were subsequently evaluated also in % of plasma and % pas. identical pcs were produced with a pool-split protocol to be prt-treated or serve as untreated control. pcs were treated with the mirasol system according to manufacturer's instructions. qc parameters, such as yield, ph and swirl were measured at days , and . bacteria sterility test was performed at day for a sample of all treated platelets. protein content of pcs produced routinely at the citm was determined to assess accuracy of plasma carry-over calculations for all processed pcs. results: mirasol-treated wbd (n = ) and ad pcs (n = ) stored in % plasma showed at day an average ph ≥ . ; swirl ≥ . and yield = . . their untreated counterparts showed average values for ph ≥ : , swirl ≥ . and yield . - . . mcd stored in % plasma (n = ) that underwent prt showed at day average values for ph = . , swirl = . and yield = . . control mcd showed average values for ph = . , swirl = . and yield = . . mcd stored in % plasma (n = ) that underwent prt showed average values for ph = . ., swirl = and yield = . . their untreated counterparts had average ph = . , swirl = . and yield = . . total protein content in pcs derived from wbd (n = ), ad (n = ) and mcd (n = ) was g/l, g/l and g/l, respectively. while the coefficient of variation of wbd and ad ranged from % to %, plasma products respectively, the one of mcd reached %. all prt-pcs were negative for bacterial growth at day . summary/conclusions: mirasol treated wbd and ad produced according to citm current s.o.p. were quite similar to untreated controls at expiry, on day and passed the requirements of the eu guidelines ( th edition). quality of mcd units met eu criteria at day ; swirl decreased significantly at day which might be explained by the variability in plasma content of mcs+ -derived platelets, challenging the accurate calculation of illumination index for the mirasol treatment. all mirasol treated pcs showed minimal platelet loss at the end of storage. as the implementation of pr had to be cost-neutral it could only be implemented for~ % of the annual produced buffy coat platelet concentrates (bcp) (~ . bcp/year) and required a change in the bcp production method. the primary aim of the implementation was to offer increased blood safety to our most vulnerable patients. the secondary aim was to ensure that we built-up enough routine experience with pr to enable us to quickly ramp-up the production of pr-bcp to % if there were an outbreak of an emergent pathogen in the madrid region. aims: to verify if we could produce~ % pr-bcp without increasing the overall production cost (opc) for bcp. also evaluate the impact of pr on overall scrap rates of bcp, outdate rates and usage of other safety measures. methods: we compared opc for bcp between the pre-pr period ( ) . this cost was offset by substituting a semi-automated production method for bcp, which was used in to produce . % of bcp-units. a manual double dose buffy coat production method (dd-bcp) in combination with pr enabled us to reduce the bcp-disposables cost by . %. despite the moves from a semi-automated to a manual production method the overall scrap rates during production decreased in by . %. the extension of max. storage time from to days for % of the bcp-units that were pr resulted in decreasing our overall outdating rates by % (versus ). this reduction in outdating rates reduced our opc in by . %. in we gamma-irradiated . % fewer bcp-units, but this had only a minimal impact on the opc. summary/conclusions: results of this study confirmed that we reached our initial objectives of producing~ % pr-bcp without increasing the overall production cost (opc) of bcp. it enabled us to offer increased blood safety to the most vulnerable patients. we built-up enough routine experience with pr so we could quickly rampup the production of pr-bcp to % if there were an outbreak of an emergent pathogen in the madrid region. background: irradiation of red cell units is undertaken to prevent transfusion-associated-graft-versus-host-disease (ta-gvhd) in immuno-compromised patients. while irradiators using radioactive c-ray sources are primarily found in blood establishments, they require regular recalibration and supplementary safety measures. xirradiation has been shown to have similar biological effectiveness to c-irradiation and does not require a radioactive source. there is international interest in moving away from gamma sources to reduce vulnerability to terrorism. although damaging, impacts of irradiation on red cells are well recognised. only a limited number of studies have compared red cell component quality following cand x-irradiation for both standard volume red cell concentrates (rcc) and neonatal red cell splits (rcs). aims: to compare the in vitro quality of rcc and rcs when subjected to cor xirradiation on day of storage then stored for a further days. rcs were also irradiated on day of storage as that is most common practice in nhs blood and transplant (nhsbt). methods: four rcc were pooled and split into arms on day of storage, with units in each arm. all units received an irradiation dose of . - . gy. two arms remained as standard volume rcc and were either cor x-irradiated on day of storage. the other two arms were both split into rcs on day of storage before being irradiated on day (early arm) or day (late arm) of storage. for each replicate in these arms, splits were c-irradiated and splits x-irradiated. all arms were tested a day prior to irradiation and , and days post-irradiation for red cell quality parameters: haemolysis, intracellular atp and , dpg, supernatant potassium, glucose and lactate, ph and red cell microvesicle release. the rcc arms were sampled over storage; while for the rcs arms, split was tested on each testing day post-irradiation. a -way anova was used to detect statistical differences over storage between cand x-irradiation for the same components. results: all components produced were within nhsbt specification for volume, haemoglobin and haematocrit. there were no significant differences in red cell in vitro quality parameters studied over storage between cand x-irradiated units, for standard volume arms or neonatal arms and whether rcs were irradiated early or late in storage. moreover, all arms were within haemolysis specification for the end of storage (> % of units with < . % haemolysis) and % of units had atp levels above the recommended minimum for acceptable post-transfusion survival ( . lmol/ghb). both haemolysis and potassium levels at the end of storage for the standard c-irradiated rcc were comparable to our laboratory's historic data for the same component. summary/conclusions: in summary, the storage quality of rcc and rcs post-xirradiation did not differ from c-irradiation in this study, providing reassurance that either method could be used in routine manufacturing. a pajares herraiz , c coello de portugal , m morales , f solano , c perez parrillas , a rodriguez hidalgo , t diaz rueda and m flores direccion, regional transfusion center toledo-guadalajara transfusion service, toledo hospital complex, toledo transfusion service, general university hospital of guadalajara, guadalajara transfusion service, hospital nuestra señora del prado de talavera de la reina, talavera regional transfusion center, regional transfusion center toledo-guadalajara, toledo, spain background: the regional transfusion center of toledo-guadalajara (rtc) manages the collection, processing and distribution of blood components for the hemotherapy area of castilla la mancha (spain) that serves general hospitals (hospital complex of toledo (hct), university general hospital of guadalajara (ughg) and hospital nuestra señora del prado de talavera (nspt)) and the needs of , inhabitants. by also managing the hct transfusion service, it facilitates the handling of stocks. since , rtc has initiated pathogen inactivation (pi) for a part of its platelet components(pc) with the intercept blood system (cerus) using a photochemical treatment with amotosalen and ultraviolet-a. this system allows the inactivation of a broad panel of pathogens and leukocytes, extending the shelf-life of the cp from to days. this affects the expiry and discards of this blood component, allows a better management of the inventory and has an influence on production costs. aims: the objective was to evaluate the influence of pi in the production of cp at rtc and the expiry in the hemotherapy area during the last years divided into four periods ( results: pc were predominantly obtained from whole blood collections with % of bc platelets/ % of apheresis platelets. % of the available bc were used in production for period a and % for periods b, c and d. after wastes of approximately . %, the distribution of pc was stable for the periods studied. pc were distributed for period a, pc for b, pc for c and pc for d. the % of pi platelets with -day shelf life available in the hospitals was limited to % during period a. it was then increased to . %, . % and % for periods b, c and d respectively. the percentage of wastes was stable at . - . % but the discards due to expiry went down from . % (period a) to stabilize at . % in periods b and c and . % in period d. in the general hospitals the expiry went down from % to . %(hct), . % to . % (ughg) and . % to . %(nspt) respectively. summary/conclusions: greater control of pc stocks through historical analysis and consumption projection, together with it tools and the use of pi pc with -day shelf life allowed reducing discards for expiry from . % to . % in the last period analyzed at rtc and the major hospitals of the hemotherapy area. this has a great value in cost-reduction and improves inventory management and the efficiency of the processes. background: blood centers are faced with many challenges including availability of concentrate platelets as well as ensuring highest quality of the product. overcoming the shortage of platelet apheresis by using pooled platelet derived from whole blood units separated using automated standardized system, which can assist blood banks to meet the increase demand in platelets. the pathogen inactivation (pi) technology can improve the quality of the product by mitigating the risk of transfusion-transmitted diseases (ttd) and residual white cells, resulting in minimizing non -hemolytic transfusion reactions. however, the pathogen inactivation treatment must not impact the platelet quality and functionality significantly, as well as the patient safety. aims: evaluate the quality of pooled platelets derived from whole blood (five interim platelet units), separated using reveos automated blood processing system (terumo bct), pooled in % donor plasma and pathogen inactivated by amotosalen/uva technology. methods: five interim platelet units (ipus) produced with reveos device (terumo bct) from single whole blood donations, were pooled with a platelet pooling set (terumo bct) and leucodepleted with a lrf-xl filter (haemonetics). thirty pools have been included in this study, the units were treated using a large volume cerus intercept processing set for platelets according to the manufacturer's instructions and stored until day . the swirling was determined by visual inspection. the volume and yield content were assessed preinactivation and after treatment by pathogen inactivation with a cell counter (dxh- , beckman coulter), rbc contamination was also measured preinactivation with a cell counter (beckman coulter), bacterial contamination was assessed by automated blood culture with a bact/ alert system (biomerieux). the ph of the platelet units was assessed with a phmeter (jenway), and residual amotosalen levels were assessed by an hplc assay. results: the impact of amotosalen/uva pathogen-inactivated pool platelet products quality were assessed. the pre and post-inactivation of the units showed a swirling score of - . the average volume per unit of the pre-inactivation was ml ( - ml) and post inactivation was ml ( - ml), with average volume loss during inactivation was ml ( - ml), corresponding to % ( - %). the average platelet yield per unit pre-inactivation was . ( . - . ) and post inactivation . ( . - . ) with an average platelet loss of % ( - %) . the average rbc contamination per unit ( . - . rbc/ml). the culture tests were negative, the average ph at day was . ( . - . ), average ph at day / was . ( . - . ). the average residual amotosalen concentration post treatment was . lm ( . - . lm). summary/conclusions: the quality of pathogen-inactivated pool platelets tested, met the criteria set by aabb guidelines. the volume and platelet loss were in acceptable range, in alignment with previously published data. a residual amotosalen concentration below lm is considered safe and acceptable by french and german authorities. the evaluated data support the reasonable assurance of quality and effectiveness of the device when used in accordance with indication for use. background: the implementation of a pathogen inactivation process (pi) allows the redesign of processes to obtaining safe blood components by reducing the need for additional testing for pathogens detection, minimizing the residual risks (such as the infectious window period for those pathogens that are detected as usual), eliminates the need for selective tests (eg cytomegalovirus serology test) and complements gamma irradiation given its ability to inactivate white blood cells. in addition, the routine implementation of pi reduces the incidence of bacterial infection in recipients of blood components and allows blood services to proactively protect the blood supply against future emerging infections. aims: to verify the functional integrity and viability of platelet concentrates after being inactivated of any pathogenic agent, to be used as safe and functional components for transfusions. methods: a total of independent platelet concentrates were studied. platelets are donated through a process called plateletpheresis according to the established norms, after the process, platelet concentrates were submitted to pi on the intercept blood system tm platform with uv-a illuminator; an immediate sampling of each donation of platelet concentrates was carried out taking a sample of ml pre-inactivation and another sample post-inactivation ( h after pi). the platelet viability of each sample was evaluated by demonstrating the cd p expression marker by flow cytometry. once processed, platelet concentrates were released as safe components for donation. compiled the experimental data of the platelet count with platelet activation marker with respect to the total platelet, a comparative, nonparametric test of wilcoxon was carried out between two measurements (pre vs post) and the platelet viability after pi was determined. results: a total of independent platelet concentrates were studied, where the average percentage of pre-inactivated platelets with expression of the cd p marker, was %, while the percentage of functional platelets post inactivation was %, this result only shows that the functionality of the platelets is not being altered after the inactivation process. the wilcoxon test confirms that there is no significant difference between platelet activity pre-and post-inactivation, with a % confidence level. summary/conclusions: the process of photochemical treatment with amotosalen hydrochloride and long-wavelength ultraviolet light (uva) applied to platelet concentrates provides functional products without alterations in platelet function to be transfused. background: treatment of platelet concentrates (pcs) with pathogen reduction technologies is widely implemented in blood establishments to reduce the risk of bacterial contamination and to face the presence of new emerging agents in blood components. aims: the reduction of antioxidant power (aop) could be a quality control test to prove the complete viro-inactivation treatment. this evaluation has the goal to study the feasibility of the method from "abonnenc et al., transfusion, " in another blood service, assessing the aop of platelet units treated by intercept technology. methods: the aop is expressed in edel value, one edel being equivalent to lmol/l ascorbic acid. repeatability, intermediate precision and accuracy were determined. linearity was evaluated using the linear regression and the calculation of pearson's coefficient (r²). limit of quantification (loq) was determined by measuring aop using nacl samples to define the background. roc curves were used to determine a threshold to discriminate pcs before and after treatment. a distinction was realized between men and women and between apheresis (a) pc and buffy coats (bc) pcs. a one-year evaluation was assessed on pcs before and after treatment on the routine production. results: the coefficient of variation for the repeatability was less than %. for the intermediate precision, the coefficient of variation was less than %, but for the pcs after treatment, this result rose up to %. the r² value for the linearity was . %. the detection limit corresponded to a result of edel and the loq (equal to xsd) is edel. concerning roc curves, the men apcs threshold was . edel compared to women apcs with . edel. the threshold for bcpc was edel. all of these results had % of specificity. below this threshold, intercept treatment was considered to be executed. about the one-year experience on routine pcs production, apcs ( women and men) and bcpcs were tested. all of the bcpcs and women apcs were under the threshold after treatment. concerning men apcs, . % of the pcs after treatment were not under the threshold. summary/conclusions: the device validation was satisfied. for the one-year evaluation and concerning men group apcs, the threshold found by abonnenc et al. was edel. our study showed a threshold with % specificity and % sensitivity at . edel which is much lower. specificity was favored compared to sensitivity but the analysis should be revised to adapt the threshold to get higher sensitivity. this can lead to reduce the non-conformity and allows measuring the aop only after treatment. for women, our threshold was found at . edel compared to . edel for abonnenc et al. concerning sex in apcs, results were statistically lower in women group than men group before and after treatment. and for bcpcs, the two populations (before and after treatment) were very distinguishable and our threshold ( edel) was lower than abonnenc threshold which was at . edel. in conclusion, edel threshold enables the segregation and depends on the preparation process adapted in each blood service. aims: this study has the goal of measuring antioxidant power (aop) level in plasma units treated by mb technology. the aim is to use such a test as a quality control assay for documenting the execution of pathogen inactivation treatments during the preparation of plasma units. methods: aop measurements were performed using a potentiostat electrochemical analyzer. a -ll volume of sample is deposited over the electrodes on a single-use microship. the aop is expressed in edel value, one edel being equivalent to lmol/l ascorbic acid and reflects the redox status of the plasma units. different protocols were established to understand the role of mb, the illumination and the filtration on the aop variation measure: ) complete treatment, ) plasmas with mb without illumination, ) plasmas without mb with illumination and ) plasmas without mb without illumination. ten dosages on men donor samples, except for protocol where n = , were realized during the viro-inactivation process, t corresponds to a dosage of plasmas before treatment, t the plasma after the mb dry tablet passage, t is the time after illumination and t corresponds to the final product (after filtration). results: in each protocol with mb, an increase was observed after addition of mb before illumination. after illumination, the edel values decreased for about less than %, which was expected because of the degradation of mb in its photoproducts during the illumination. in the series and , the illumination seemed to have an effect by itself, with or without mb because the aop increased. the final filtration has the goal to eliminate the residual mb and its photoproducts. after this step, the aop values fell down. the series was a confirmation of the efficacy of the filter to remove the mb as shown by the decreased aop in t ( ae edel at t and ae edel at t ). however, in the absence of mb (series and ), the results at t and t were not statistically different. summary/conclusions: the filtration decreases the aop rate, except when there was no mb. the results of non-complete viro-inactivation treatment allow concluding that the measure of aop rate may not indicate that the treatment was completed or not since significant differences before and after treatments were found in the non-complete treatment series. vox sanguinis ( ) background: the intercept blood system (ibs), a photochemical treatment with amotosalen and uva, is used to inactivate pathogens and leukocytes in plasma. the intercept tm plasma processing set (cerus bv, netherlands) was modified to incorporate plastic containers in non-pvc materials sourced from alternate suppliers and connecting parts and accessories in non-dehp pvc formulations, making the system dehp-free. the final storage container was modified with a higher contact surface with plasma to limit the thawing time. proportion of units with a fibrinogen concentration ≥ . g/l was % (> % required). mean recovery fviii fibrinogen after ibs treatment and frozen storage were % and %, respectively. residual platelets were < /l, leucocytes < /l and red blood cells < /l. all units had a protein content > g/l. residual amotosalen was below lm in all post-cad samples. the concentration of tat complexes was slightly reduced after treatment and frozen storage. concentrations of c a and c a were significantly reduced with the cad treatment. the plasma thawing time in a water bath at °c was consistently short ( - min). summary/conclusions: pathogen inactivated plasma units (ffp-a-ibs and ffp-wb-ibs) prepared with dehp free intercept processing sets retained in vitro characteristics which meet the quality standards for therapeutic plasma. the process did not activate coagulation or complement. reducing ffp thawing time from routine - to - min is an important benefit for emergency use. background: plasma coagulation factor concentrations usually differ for individual donors, therefore pooling of whole-blood derived plasma units moderates high or low coagulation factor concentrations and ensures transfusion of more standardized blood components. moreover, pooling contributes to dilution of reactive antibodies and may reduce the risk of non-hemolytic transfusion reactions and trali. additionally pathogen inactivation reduces the risk of transfusion-transmitted infections, and non-hemolytic transfusion reactions as well as gvhd through inactivation of residual lymphocytes. aims: assessment of the impact of plasma pooling and pathogen inactivation on the standardization of blood components and plasma quality. methods: the study included experiments. for each experiment male-donor, abo-compatible whole-blood derived plasma units (≥ ml) were collected from different donors and pooled using the donopack optipool plasma pooling set (cerus europe b.v.). each of the -unit pools were split into equal minipools which were subsequently treated with the in intercept blood system (cerus europe b.v.). then, each minipool was split into (≥ ml) therapeutic units. samples were collected before and after pooling as well as after inactivation to assess the coagulation factor content (fviii, fix, fibrinogen, vwf antigen using elisa) and coagulation time (aptt, pt). the study-analysis included samples from five pools from single plasma units respectively ( background: biotin (bio) is an alternative to radioactive red blood cell (rbc) tracers which allows one to concurrently track in vivo multiple cell populations labeled at different bio densities. in american clinical trials, multi-labeled biorbc have been transfused in man to assess their survival (mock et al, transfusion, ) . in these studies, the different biorbc populations were monitored by ex vivo flow cytometry analysis using streptavidin. so far, the biotinylation reagents biosulfonhs was not complying with good manufacturing practices (gmp). moreover biorbc, with bio ≥ lg/ml, have induced immunization of the recipient, in rare cases (schmidt et al, transfusion, ) . this represents an obstacle regarding the regulatory european authorities. aims: the aim of this study is to describe a procedure of biotinylation of rbc intended for clinical trials while refining the levels of bio ≤ lg/ml. methods: sterile status is met throughout the process. rbc are taken from standard rbc concentrates and treated with biosulfonhs of gmp-grade ( to lg/ml) recently commercialized. washing buffer is of injectable-grade. biotinylation efficacy is controlled by flow cytometry with streptavidin conjugated to different fluorochromes: phycoerythrin (pe) or brilliant violet (bv ). results: labeling with biosulfonhs of gmp-grade or non gmp-grade is comparable and populations of rbc could be easily distinguished between themselves and from unlabeled blood cells. biosulfonhs (lg/ml): (mfi . ), (gmp mfi ; non gmp mfi . ), (gmp mfi ; non gmp mfi ), (gmp mfi ; non gmp mfi ). streptavidin-bv brighter than streptavidin-pe is a promising tool because it amplifies by . the signal of fluorescence and allows a good differentiation of the populations of rbc treated with only , , and lg/ml biosulfonhs. summary/conclusions: this preliminary study explores the feasibility of multilabeled biorbc production for clinical trials. the benefits of this approach are to overcome the need for non-radioactive tracers, to follow simultaneously various populations of rbc and consequently to limit the number of volunteers, and to reduce the risk of immunization using bio ≤ lg/ml. background: rejuvenation is aiming to revert ageing-related disease development. heterochronic parabiosis studies revealed eotaxin in young and old murine blood as a regulator of brain aging and neurogenesis. umbilical cord blood (ucb)-borne factors including tissue inhibitor of metalloproteinases (timp ) and neonatal immune cells also contributed to rejuvenation in animal models. human platelet lysate (hpl) is commonly used by us and others for highly efficient cell propagation in vitro (burnouf et al., biomaterials, ) . published data indicate only limited differences between adult and ucb-derived hpl, partly questioning enigmatic rejuvenation effects. aims: to verify candidate regenerative factors in neonatal blood products we compared protein contents of neonatal and adult plasma and platelets, respectively. methods: heparinized ucb samples (n = ) were centrifuged within h to collect neonatal platelet rich plasma. aliquots from apheresis platelet concentrates (n = ) were used as adult counterpart. platelet concentration was adjusted to - / l. plasma supernatants and platelets were obtained by centrifugation and platelet pellets were re-suspended in saline. after two freeze/thaw cycles at À °c/ °c for platelet lysis (npl; apl) the platelet fragments were removed by centrifugation. the protein content was analyzed with a proteome profiler tm array. nine samples of each group were pooled to avoid individual donor variations. a threshold of , au spot density was defined as cut-off. data were analyzed by graphpad prism using two-way anova. results: semi-quantitative evaluation of analytes per array revealed significant differences. in plasma samples and platelets and analytes were detected above cut-off, respectively. in neonatal plasma we found more highly prevalent proteins (> , au spot density) compared to adult plasma ( / vs. / ). thirteen proteins were significantly elevated in neonatal plasma including growth/differentiation factor (gdf ), platelet derived growth factor aa (pdgf-aa) and serpin e (p < . ). more highly prevalent proteins were detected in npl ( / ) compared to apl ( / ), and proteins were significantly elevated including vascular cell adhesion molecule- (vcam- ), platelet factor (pf /cxcl ), epidermal growth factor and lipocalin- (p < . ). in adult samples only proteins were significantly higher in plasma and three proteins in apl compared to the neonatal groups (p < . to p < . ). summary/conclusions: we detected significant differences in regenerative growth factor and cytokine contents of neonatal and adult plasma and platelet samples, respectively. additional experiments are underway to further characterize their impact in distinct functional readouts. background: the production and storage conditions of platelet (pl) products intended for transfusion are constantly evolving and need sometimes in vivo evaluations in clinical trials to ascertain whether the platelets have retained their ability to survive in the circulation. this requires that the transfused platelets can be distinguished from the recipient's circulating platelets. labeling of platelets with biotin (bio) affords to track in vivo and concurrently, multiple cell populations covered with various biotin densities as already described for red blood cells (mock, transfusion, ) . surprisingly, there is only one study describing the transfusion of human biopl (stohlawetz, transfusion, ) . so far, the biotinylation reagent bio-sulfonhs was not complying with good manufacturing practices (gmp), which represents an obstacle regarding the regulatory authorities. aims: the aims of this study are ) to describe a procedure to label injectable human platelets with densities of biotin, ) to evaluate the impact of biotinylation on platelet functions, ) to track human biopl in the circulation of the mouse. methods: platelets are taken from standard platelets concentrates and treated with . and lg/ml biosulfonhs of gmp-grade, recently commercialized. main platelet functions are assessed in vitro. human biopl survival is evaluated in immunodeficient nsg-mice treated with liposome-clodronate to eliminate macrophages and to prevent rejection. circulating human biopl are detected ex vivo by flow cytometry with streptavidin phycoerythrin. results: using trap ( lm), p-selectin externalization reveals a normal capacity of secretion for all biopl. gpiba and gpiibiiia expression is not affected by the biotinylation process. biopl have the ability to aggregate: using arachidonic acid ( mm), amplitude of aggregation is . ae . % (bio ); . ae . % (bio . lg/ ml); . ae . % (bio lg/ml). using collagen ( . lg/ml), amplitude of aggregation is . ae . % (bio ); . ae . % (bio . lg/ml) . ae . % (bio lg/ml). the biopl populations could be easily distinguished between themselves and from unlabeled blood cells in the mouse circulation during more than h. after h, the mean fluorescence intensities are . ae . for unlabeled circulating mouse platelets, . ae . and . ae . for circulating human biopl covered respectively with . and lg/ml biotin. summary/conclusions: this labeling approach should be helpful to evaluate new platelet products in vivo and represents an alternative to radioactive tracers. it allows to follow simultaneously different platelet populations and consequently limits the number of volunteers in clinical trials. background: severe ocular surface diseases, dry eye syndrome, persistent and recurrent corneal epithelial defects and diabetic or neurotrophic keratopathy are mainly successfully cured by standard treatment protocols. however, not rarely does refractory to these usual treatments appear, especially with serious forms of disease. in military medical academy, autologous serum eye drops -auto seds and autologous platelet lysate -apl eye drops have been being applied in the treatment of ophthalmological patients in these categories, who were previously resistant to standard therapy. aims: to show the achieved results of therapeutic use of autologous blood products (auto seds and apl) in the treatment of ophthalmological patients who previously had not responded to conventional therapysingle center experience. methods: auto seds are prepared by taking autologous blood into tubes (bd vacutainer, cat, ml) and apl in tubes with anticoagulants (greiner bio-one, acd-a, ml). control on tti of every patient and sterility of every series has been conducted. before and after the treatment, subjective ocular discomfort (ocular surface disease index -osdi), objective parameters of the tear film (schirmer's test, rose bengal, tear breakup time -tbut) and measuring of epithelialization zone were analyzed. apl, obtained from platelet-rich plasma which had been frozen, unfrozen and diluted with nacl solution, up to %. auto seds were administered in the form of % eye drops. results: auto seds have been applied to ophthalmological patients ( men and women), previously resistant to standard therapy. in total treatments were performed (each lasted days). for successful curing, one or two treatments per patient, in average, were applied. apl has been used multiple times to one patient with sj€ ogren syndrome and severe multiple tropical corneal changes. all ophthalmological patients had subjective improvements (the average pre and post treatment osdi scores were . and . respectively). also, objective progress was present in % of all patients (p < . ). summary/conclusions: the use of auto seds and apl in the treatment of ophthalmological patients, previously resistant to standard therapy, is in constant increase, because of its simplicity and low expenses. apl has turned out to be better than auto seds for patients with severe trophic changes, because apl contains larger amounts of the nerve growth factor, tgf-b, vegf and platelet derived growth factor. however, a larger number of clinical cases is needed for future conclusions. background: whole blood (wb) has recently regained favor in treatment of massively bleeding patients in military and civilian settings. platelets (plts) are a vital component in clot formation. as a component of wb, it is critical that they maintain functionality throughout storage. red blood cells (rbcs) stored in hypoxic/ hypocapnic conditions preserve high level of , -dpg while reducing storage lesions stemming from oxidative stress. , on the other hand, effects of steady hypoxia (pco ~ - mmhg) on plts contained in leukoreduced wb is poorly characterized. aims: examine the effects of hypoxic conditions on plt function and microvesicle (mv) formation in wb stored hypoxically (h) and conventionally (c) for -week storage at - °c. methods: units of wb were collected at mayo clinic rochester blood donor center from normal healthy volunteers into ml cp d. wb was leukoreduced using plt-sparing filter (terumo wb-s) then split into control (c) and hypoxic (h). h-wb was processed by the oxygen-reduction bag (hemanext, lexington ma) and unit was stored in o -free bag. ml of wb were collected from each unit at day , weeks , , . plt counts, agonists (thrombin receptor agonist peptide (trap), adenosine diphosphate (adp) and collagen stimulated platelets aggregation, nonactivated and agonists activated plt surface expression of phosphatidylserine (ps, annexin-v binding), p-selectin, fibrinogen receptor (pac- binding), and microvesicles (mv) were measured by coulter counter and digital flow cytometer. paired student t-tests were used to analyzed differences in degradation rates; significance: p < . . results: h-plt counts declined to~ % by the o -reduction process, while similar decline was observed after week in c, and thereafter remained steady. plt activation (ps) increased over time (h >> c after processing; c increasing more rapidly during storage). p-selectin increased over time (h < c), while pac- showed large increase after week, then remained steady (h << c). plt activation by trap or adp declined modestly over weeks (~ %) while h-plt showed additional~ % reduction for all time points. collagen activation for c-plt increased after week ( %) and gradually increased to % after weeks (~ % reduction with h compared to c). plt-derived mv (cd and cd /annexin v) increased~ -fold over storage time; day mv levers were significantly higher for h, but subsequent increase rates were similar or lower. total number of plt-derived mv (cd a) in wb supernatant increased -fold after weeks for c, while h suppressed increase to -fold. (majority of the trends described above showed significant differences between h and c.) summary/conclusions: plts were activated over -week period when stored at - °c in leukoreduced wb, accompanied by a modest loss of agonist-induced activation. oxygen reduction treatment initially activated h-plts, while subsequent increase in activation rates were suppressed compared to c-plts. wb plts retained activatability, and hypoxic condition showed only modest further reduction on the activatability. hypoxic wb may provide higher quality wb for trauma patients if the levels of initial plt activation can improved during oxygen reduction procedure. methods: after informed consent, eligible patients were randomized to either first receive autologous followed by allogeneic seds or first receive allogeneic followed by autologous seds. each sed treatment phase was one month, separated by one month of patient's standard treatment (wash out period) between sed treatment phases. the patients each donated ml whole blood from which the autologous seds were prepared. allogeneic seds were prepared from blood from never-transfused male donors with blood group ab. all serum was diluted : by adding saline, and aliquoted in an eye drop dispensing system (meise, schalksm€ uhle, germany). at each visit, the osdi was determined using a validated questionnaire, with higher scores reflecting poorer outcomes. the results were analyzed intention-to-treat, and a random effects linear mixed model for cross-over design was used. results: in total, patients were enrolled, of whom were excluded because they failed the autologous blood donation. background: the following blood components for non-transfusional use (bcntu) are produced in our transfusional center (tc): ) allogeneic platelet gel (pg), derived from buffy-coats (bc) and human cord blood platelet gel (cbpg); ) autologous serum eye drops (sed). the creation of both types of platelet gel started in but only in we confirmed the process for daily production: these blood components are used to treat pediatric patients with epidermolysis bullosa. the sed, produced from , is dedicated to treat patients with dry eye syndrome. aims: production and storage bcntu. methods: the whole process production of bcntu is traced on the transfusional informatic system (emonet-insielmercato), under the same conditions of another blood transfusional components. the process takes place in closed circuit using the laminar flow hood. ) pg production starts from the bc resuspended in plasma that are not used for daily platelet concentrates, instead the cbpg is produced using cord blood units that are not used for hematopoietic transplant. both have a platelet concentration between - /ll and negative blood cultures, required by the italian law; the units are frozen at À °c and last -year. pg and cbpg must be activated with calcium gluconate or batroxobin to be used. ) the ophthalmologist's patients, with dry eye syndrome, donate ml of autologous blood; the serum is separated and after the dilution with a balanced saline solution ( %) are divided in boxes containing single-dose vials each: they are stored at À °c and they last one year. negative blood culture was evaluated. results : background: candida albicans is the most common pathogen detected in fungal infections. aims: in this study, we aimed to evaluate the in vitro antifungal activity of volunteerderived platelet rich plasma (prp) against c. albicans atcc strain and the possible effects of certain chemokines, kinocidins that might play a role in this activity. methods: prp from nine volunteers were derived by using magellan prp â kit. % calcium gluconate was used to obtain autologous thrombin. c. albicans isolates with a final yeast concentration of cfu/ml and cfu/ml were inoculated on sabouraud dextrose agar at the st , nd , th , th and th hours of incubation to reveal the antifungal activity of autologous thrombin-activated prp. the colonies were counted after - h of incubation at °c. chemokines and kinocidins (platelet factor- , interleukin- and thymosin-b ) were also measured simultaneously by elisa method. results: compared with the pbs-control group, the prp- group showed that the antifungal activity was still going on at the th hour. the difference in colony production between the two groups at th hour was statistically significant (p < . ). it was observed that the antifungal activity continued at the th hour, decreased at the th hour in the group prp- group. although the same amount of prp was used and the same amount of chemokine and kinocidins were released in both groups, the concentration of c. albicans was considered to be important in the detection of more effective prp- group. although there was an increase in il- levels by hours in the two prp groups by elisa method, no antifungal effect was detected against c. albicans. it was observed that decrease in tmsb values results from the antifungal activity on the advancing hours in the prp groups. whereas pf- did not act an antifungal activity on prp- and prp- . summary/conclusions: even in our study group where the highest platelet counts were obtained at the lowest concentration, c. albicans reproduction could not completely eliminated as mentioned in the literature. repeated doses of prp applications, such as drugs used in patients, may have longer duration of action and even complete repression of reproductive outcomes. background: generally, blood is available in developed countries for transfusion. sometimes, transfused or previously pregnant patients form alloantibodies to red cell antigens and rarely, to antigens of high prevalence. this case focuses on a twoyear-old girl, of pakistani descent, diagnosed with neuroblastoma stage iv with anti-in b and -e. although the publications indicate that % of the pakistani, indian or iranian populations are in(b-), it was discovered that this blood type is exceedingly rare. an international search was required to ensure blood product availability for chemotherapy and autologous hematopoietic progenitor cell transplants aims: illustrate the response of the public to a powerful story of a child needing rare blood for treatment and international collaboration for provision of very rare units. methods case report: a two-year-old patient's sample was referred for antibody identification. the patient had received four transfusions ( ml of red cells) in the preceding -day period. hgb level fluctuations were consistent with decreased transfused red cell survival. following the last transfusion of ml, the hemoglobin decreased from . to . . anti-in b , and a ficin-only reactive anti-e was identified in the serum and anti-in b in the eluate. the monocyte monolayer assay predicted the anti-in b to be clinically significant ( % reactivity). transfusion of antigen neg units once obtained, resulted in a stable transfusion response. although it was expected that in(b-) blood would be more easily sourced, only two donors in the usa were in (b-) e-. as - units of blood were requested for the post-transplant period, a national and international search was initiated, as was a robust media appeal to donors resulting in many donors for an intense domestic screening effort in the usa. the search of the who international rare donor panel by the international blood group reference laboratory revealed three known in(b-) e-donors; two british and one australian. they were contacted, recruited, collected and shipped to the usa with the work of the american rare donor program (ardp) staff and the isbt working party on rare donors (isbt wprd) members in each of the countries. results: the intense media coverage of oneblood (the florida blood center collaborating on treatment with the hospital) included online news outlets (youtube, facebook) resulted in over , responses from national and international potential donors to be tested for in b . isbt wprd members were sent the web information of potential donors identified in their countries by the ardp. over , samples from blood centers and associated laboratories tested with anti-in b by oneblood. two new in(b-) donors were discovered ( . %); but both typed e+, thus were not a match for the child. summary/conclusions: this intense media coverage and the overwhelming donor response was unprecedented in our experience. the coordination and cooperation among the numerous blood centers reflect the deep dedication of the blood banking community to the well-being of special patients in need. this case illustrates the response potential that a powerful story and a medical appeal for exquisitely rare blood utilizing social media and other online news outlets can generate. background: blood platelet units are generally stored in blood banks for - days, afterwards they are discarded. prepared infusible platelet membrane (ipm) from fresh or outdated human platelets correct the prolonged bleeding times in thrombocytopenic animals such as rabbits. infusible platelet membrane (ipm) as a platelet substitute may be the most feasible approach to reach the target market. our previous experiments have shown that ipm has a hemostatic efficacy to shorten bleeding time without any adverse effects in rabbits. aims: abnormal toxicity is the european pharmacopoeia standard for assessment of biological products which the test material is administered to the mice. in this study, abnormal toxicity of ipm was evaluated in experimental animal model such as mice to assure the safety of ipm without any evidence of serious toxicity. methods: in this experimental study, infusible platelet membrane (ipm) was prepared from outdated platelet concentrates. platelet concentrates were pooled, disrupted by freeze-thaw procedure, pasteurized for h to inactivate the possible viral or bacterial contaminants with a sodium caprylate stabilizer, formulated by sucrose and human serum albumin and finally lyophilized. at first, the test for sterility is carried out under aseptic conditions for ipm vials and then we injected . ml of ipm ( mg/kg) intravenously between to seconds into each health mice, weighing - grams. these tests were performed according to eu pharmacopeia monographs. results: in the sterility test no evidence of microbial growth in our product is found. the abnormal toxicity test will be passed if none of animals die during h after injection. if more than one animal dies, the preparation fails the test. if one of the animals just dies, the test is repeated. in our experiment all five mice were alive after h of ipm injection. summary/conclusions: in this research the results showed that ipm as a platelet substitute is free of abnormal toxicity with adequate safety and it may be used in human clinical trial studies as a feasible approach to develop a platelet substitute in the future. however, further studies are required to confirm the different aspects of its safety as well. the success of such investigations may affect patients' care in transfusion medicine in the future. a substantial number of infants, especially premature infants, are unable to receive adequate amounts of their mothers' milk for a variety of reasons. the world health organization recommends that infants, especially preterm and ill infants are fed with quality-controlled donor milk if they cannot be fed with their own mother s milk. due to the possible transmission of the human immunodeficiency virus many human milk banks closed in the s, therefore the availability of donor milk has decreased. aims: we analyzed the processing of donor milk and the required laboratory tests to establish a human milk bank within our blood donation service in cooperation with the department of neonatology at the frankfurt university hospital. methods: based on the recommendations for promoting human milk banks in germany, austria, and switzerland (efcni) we evaluated the manufacturing steps and the quality controls require to establish a human milk bank. background: for patients suffering from severe ocular surface disorders treatment with blood derived serum eye drops (sed) is a highly effective therapy. autologous sed, prepared from the patient's own blood, is used preferably. for this approach we have more than years of experience. if auto-sed cannot be manufactured due to medical reasons allogeneic sed present an alternative. since years, the allogeneic approach is well established in our center. aims: retrospectively evaluation of our experience with allo-sed. methods: in germany manufacturing of allo-sed is only possible as an "individual healing attempt". for each patient experienced regular ab -identical male donors without blood borne disease, who never received blood products and not taking any kind of medication are selected. additionally, donors must pass a questionnaire excluding any form of dry eye syndrome. allo-sed are manufactured directed for each individual patient according to the process for auto-sed in a closed system. patient files of our serum eye drops donors were screened for patients receiving an allogeneic treatment. data concerning indication for allo-sed, contraindication for phlebotomy, problems with donor selection and manufacturing, as well as serological and microbiological testing results were obtained. clinical results were evaluated © the authors vox sanguinis © international society of blood transfusion vox sanguinis ( ) (suppl. ), - by ocular surface disease index (osdi) and patient's questionnaire, asking for subjective benefit, symptom reduction, possible side effects, consumption and comparison with artificial eye drops or, if applicable, with auto-sed. furthermore patients are undergoing regular ophthalmologic examination within a special consultation for dry eye syndrome at our hospital. results: patients were identified receiving allogeneic sed, patients had been treated autologous previously. in total, allogeneic sed have been produced times since june . indications were ocular gvhd (n = . %), neurotrophic keratopathy (n = . %), mucous membrane pemphigoid (n = . %), sj€ ogren syndrome (n = . %) and secondary keratoconjunctivitis sicca by virtue of chemotherapy, meige syndrome, rosacea, morbus bruton (n = . %). contraindications for autologous donation were underlying disease (n = . %), poor venous access (n = . %), low haemoglobin (n = . %), low body weight (n = . %), very young age (n = . %), circulatory disturbances (n = . %) and lack of response to auto-sed (n = . %). some patients presented more than one contraindication. manufacturing problems were: lipemic donor plasma (n = . %), high donor haemoglobin (n = . %) and unspecific positive serological findings (anti-hbs n = . %). microbiological testing was sterile every time. as side effects one case of allergic reaction, suspected as serum protein allergy, appeared. clinical outcome can be considered equivalent to ased. subjectively, all patients benefited from the therapy and reported an alleviation of their symptoms. for some indications (highly active gvhd) allo-sed might even be the better option. summary/conclusions: considering our previous experience, allo-sed seem to be a safe and equally effective alternative to auto-sed for patients unable to donate blood. in case of urgent indication, timely supply can sometimes be difficult. to overcome this disadvantage licensing allo-sed as a new blood product with the possibility of production and storage in advance would be a desirable goal. in addition supply would become even safer by preparing allo-sed according to a quarantine principle like ffp. abstract withdrawn. background: vernal keratoconjunctivitis is a chronic, recurrent bilateral inflammation of the outer ocular layer. mostly affected are children and young people and the condition is more common in boys. the disease presents with eye pruritus (itching eye), photophobia (sensitivity to bright light), excessive tearing and foreign eye syndrome. severe cases manifest with diffusion of overgrown papillae usually of the upper eyelid, bursting of the connective tissue barriers and appearance of giant papillae that press on the cornea. corneal ulceration is a severe complication of vernal keratoconjunctivitis that may induce scarring, corneal neovascularization and occasionally perforation. treatment of keratoconjunctivitis mainly relies on steroids, mast cell stabilizers, antihistamines, immunosuppressive drugs (cyclosporine), artificial tears, contact lensdressing, cryotherapy and surgical papillae removal. we present the case of a year-old girl with corneal ulceration who was applied artificial tears after traditional methods of treatment proved unsuccessful. aims: the aim was to share our experience on artificial tears therapy applied in ophthalmic disorders. methods: autologous blood ( ml) was collected into disposable, sterile transfer bags used for routine blood component preparation (no anticoagulant) and incubated for h at °c. the clot was then removed by centrifugation and the serum containing erythrocytes was press extracted. centrifugation was applied again to obtain serum free of cellular components. the serum was then divided into . ml segments (capsules)and the artificial tears applied to the left eye daily. results: ulcer healing was reported after weeks of therapy with artificial tears. the dosage was reduced to daily. no recurrence of corneal ulceration was observed after subsequent weeks. summary/conclusions: artificial tears are a safe and effective therapy for ophthalmic disorders in children. background: arv non-disclosure among hiv-positive donors who tested hiv antibody (ab) positive but rna negative (ab+/rna-), so-called false elite controllers, was previously described by our group in south africa, with > % of ab+/rnadonations since testing arv positive. the extent of undisclosed arv use at time of donation represents a significant risk to blood safety in a country with a growing treated hiv population. aims: to establish the prevalence of arv non-disclosure among four subgroups of hiv-positive donors in south africa along with demographic correlates of non-disclosure. methods: south african blood donors are screened by a self-administered questionnaire, which includes questions on current hiv status and arv use, followed by a semi-structured personal interview. specimens for hiv, hepatitis b and c testing are collected at time of donation. based on id-nat (procleix, grifols) and antibody (prism, abbott; western blot) testing, hiv-positive blood donations were classified as acute (ab-/rna+), recent (ab+/rna+, limiting antigen avidity [lag] odn ≤ . ), longstanding (ab+/rna+, lag odn > . ) and potential elite controller (ab+/rna-) cases. stored plasma from these donations were tested for four arv drugs using qualitative liquid chromatography-tandem mass spectrometry (detection limit . lg/ml). chi-square tests were used to assess associations of hiv case type, gender, ethnicity, age, donor type, and donor clinic (fixed, mobile) type with arv non-disclosure. results: during , donors tested hiv-positive of whom had samples available that were tested for arvs. the overall prevalence of undisclosed arv use was . % (n = ) with efavirenz most frequently detected ( ), followed by lopinavir ( ) and nevirapine ( ) . potential elite controller cases had the highest proportion of detectable arv ( / ; %) (p < . ) followed by longstanding ( / ; . %) and recent ( / ; . %) infections. none of acute hiv cases tested positive for arvs. there were no associations between arv use and gender or ethnicity. however, older ( to years) hiv-positive donors ( / ; . %) were significantly more likely to test positive for arv than younger ( to years) donors ( / ; . %) (p < . ). arv use was more frequent among first time ( / ; . %) than in lapsed ( / ; . %) or repeat ( / ; . %) donors (p < . ). donors at mobile clinics had significantly higher arv non-disclosure than donors at fixed sites ( . % vs . %; p = . ). summary/conclusions: the . % prevalence of undisclosed infection and arv use among hiv-positive south african blood donors is alarming. higher rates of nondisclosure among first-time donors was expected, but non-disclosure among repeat and lapsed donors suggests failure in donor education and assessment. the . % prevalence among concordant ab+/rna+ cases may suggest sub-optimal viral suppression. lack of detection of arvs in acute cases should be qualified because the samples were not tested for tenofovir, the most common drug used in pre-exposure prophylaxis. donor motivation for non-disclosure of known hiv infection and arv use needs further investigation, since early arv initiation or infection while on prep could lead to low ab and rna levels, failure to detect hiv-infected donations and transfusion-transmission of hiv. blood bank, rotary blood bank, new delhi, india background: voluntary blood donation ensures safe blood transfusion. careful blood donor selection is of importance to provide safe blood to patients, although new methodologies have also been adopted by blood centers for blood safety and to minimize risk of transmitting infections through blood transfusion. the quality and the availability of blood components depend on the willingness to donate and reliability of the information given by the donors about their own health, including risk behaviour. blood donor history questionnaire is designed to evaluate donor's history in accordance with the guidelines laid down by the fda. donors, once deferred by the blood bank, will be less motivated to return for donation if he is not counseled effectively. it is important to reduce the number of deferrals by good donor comprehension and the centre should have a mechanism to recall temporarily deferred donors aims: the aim of the study is to analyse donor history and test results of those who donated blood with past history of jaundice. based on their history which suggested the type of viral infection they had, these donors were accepted or deferred. data was collected from voluntary blood donors who were screened for blood donation in the year . methods: in this study, donor history was analysed with reference to history of jaundice. jaundice in donors after the age of yrs, history of surgery, blood transfusion, body tattoos and acupuncture treatment within past one year of donation, history of multiple sex partners and related history and intravenous drug abuse history was taken into consideration. donors who revealed past history of jaundice were asked in detail about their illness and recovery. blood was donated by donors from whom the history of jaundice was elicited and it was understood that the type of virus which caused jaundice was not hepatitis b or c. those who could not give the correct history or were not sure of the cause of hepatitis, those individuals were deferred. aims: to assess the performance of this follow-up program in terms of donor participations, successful confirmed positivity rates, and potential reentry rates. methods: eligible donors were tested for hbsag, hcvab, hivab/ag, and tpab with two eias for each marker. samples reactive with at least one assay were tested further with electro-chemiluminescence assay (eca) and reactive samples were considered repeated reactive (rr). tpab reactive donations were re-tested with particle agglutination assay (tppa). samples eca or tppa non-reactive were considered non-repeatable reactive (nrr background: the blood donation service in suhl processes more than . samples annually from whole blood and apheresis donations, testing on average around samples per day. for the last years, serology screening was performed on the architect instruments (abbott) (arc), but will be changed to the alinity s system (aly) by middle of . although the design of the aly assays is based on those of the arc assays, we undertook a thorough evaluation of the four mandatory screening assays detecting hbsag, hiv ag/ab, anti-hcv and anti-hbc. aims: to validate the mandatory screening assays on the new aly system in our lab in terms of sensitivity and specificity, also including samples with known falsereactive results. determine the rate of false reactive results for hbsag, anti-hcv and anti-hiv that may lead to deferrals of donations and donors. methods: for sensitivity, we used known positive samples confirmed by immunoblot or nat. known unspecific positive samples for arc not confirmed by immunoblot or nat were testes for aly also. close to . unselected samples (edta plasma) from routine blood and apheresis donors were tested in parallel on both systems, arc and aly to determine the rate of initial and repeat reactive results. results: all known confirmed positive samples were identical detected by aly. samples with known unspecific reactive results were retested by aly with the following results: / anti-hcv, / hiv ag/ab and / hbsag were found reactive by aly to. one donation from an acute hiv infection in the early seroconversion period was detected by both methods in routine testing. there are no reactive results for aly not already known for arc. the specificity for the screening assays on aly versus arc assays were as follows: ) hbsag aly . % ( % ( / % ( ) vs arc . % ( % ( / ; ) hiv aly and arc . % ( / ); ) anti-hcv aly . % ( % ( / % ( ) vs arc . % ( % ( / . the number of anti-hbc reactive samples did not differ between aly and arc. summary/conclusions: while the switch to the new system is mainly driven by operational efficiency, obviously, the high specificity of the alinity s assay will reduce unnecessary deferrals of donations and donors. abstract withdrawn. background: blood donor selection is the cornerstone for blood transfusion safety, designed to safeguard the health of both donors and recipients. donor safety is targeted by reducing the risk of complications associated with blood donation and transfusion safety by reducing the risk of transfusion-transmitted infections (tti) and other preventable transfusion reactions. there is always a compromise on blood donor safety as well as blood safety during outdoor mega blood donation drives due to various reasons, mainly due to more number of donations within a stipulated time. aims: to compare the blood donor selection patterns between in house blood donations and donations at mega blood donation drives and its influence on donor safety and blood safety in a tertiary care hospital in india. methods: a retro prospective study was done to audit and compare blood donor safety and blood safety over a period of years from january to december . blood donor safety was analyzed by two indicators: donor health questionnaire (dhq) monitoring and blood donor reaction rates and blood safety through tti positivity rates. ( ) during mega blood donation drive. summary/conclusions: a good donor selection is a lengthy process which involves pre-donation information and advice: this is usually provided in a leaflet, especially about transfusion-transmitted infections (and the associated risk factors) and the potential risks of donation, filling of dhqs by the donor himself, donor interview: conducted by a qualified medical specialist trained in donor selection process and health assessment at the end of the interview to declare if the donor is eligible to give blood or deferred temporarily or permanently. it was observed that seroprevalence rates, number of donor reactions and incompletely filled dhqs were more among blood donations at mega blood donation drives when compared to blood donations during in house collections. this is mainly due huge number of blood donations with in a stipulated time where there is limited time spent on proper donor selection. stringent implementation of who strategy: "safe donor safe blood" is the only way for blood donor and transfusion safety. background: safety of blood transfusion is a great concern especially in crisis countries and during humanitarian emergencies. transfusion transmitted infections (ttis) are one of the major health problem in yemen that are associated with blood transfusion complications. aims: the aim of this study is to determine the prevalence of ttis among blood donors at national blood transfusion and researcher center (nbtrc this contributed to an additional reactivity of . %, thereby total reactivity being . %. % ( / ) of these were hcv reactive & % ( / ) for hbv. the nat yield was in and the viral loads of nat reactives ranged from - x iu/ml for hcv & all the hbv yields had an extremely viral load of < iu/ml. / nat reactive showed sero-conversion after - months with follow-up eclia screening, and of these were hcv reactive and hbv reactives. summary/conclusions: incidence rate indicate that the current risk of transfusion transmitted viral infections attributable to blood donation is relatively high in our country. parallel use of both serology and nat screening of donated blood in countries that have high seroprevalence can improve the blood safety. at our centre, by using best in class serology and nat technologies, we were would add an extra layer of safety to blood supply by interdicting samples from donor with recent infections. abstract withdrawn. abstract withdrawn. ( / , ) . the both hiv-rna and hcv-rna detected donors by nat were identified in the window period. summary/conclusions: in this study, we found that nat could detect infected cases with hbv-dna, hiv-rna and hcv-rna which were forgotten by serological methods therefore, nat is a sensitive screening method to detect low viral load and shorten the window period of the virus infection to ensure the safety of blood transfusions. service du sang, croix rouge de belgique, namur, belgium background: due to enhancement of kits specificity and machines throughput, roche elecsys â technology is a potential partner for blood donations screening laboratories. aims: the aim of the study was to assess the performance of the elecsys serology assays on a cobas e equipment for clinical specificity, analytical sensitivity and reproducibility. background: deceased donors are the primary source of organs and tissues for transplantation but the risk of infectious complications in the recipient is high and is the main cause of morbidity and mortality after transplantation. to minimize the risk of infections by organ or tissue transplantation, donors should be tested for anti-hiv- / , hbsag, anti-hbc, anti-hcv, and syphilis. further laboratory tests may be required depending on the history of the donor and on the tissue properties. certain grafts can be donated after circulatory death of the donor; however, the absence of the heartbeat may change dramatically the blood composition by e.g., haemolysis and proteolysis. this may have an impact on test performance and lead to false results. therefore, an assay validation is needed for testing of cadaveric samples. aims: a validation study was performed to demonstrate the suitability of elecsys hbsag ii, anti-hbc ii, anti-hcv ii, hiv combi pt, hiv duo, syphilis, htlv-i/ii, and chagas for the use in cadaveric samples from non-heart beating donors. methods: as the basis for validation, we followed the recommendations of the paul-ehrlich-institut (pei) "proposal for the validation of anti-hiv- / or hiv ag/ ab combination assays, anti-hcv assays, hbsag and anti-hbc assays for use with cadaveric samples". comparison of spiked samples from living donors and cadaveric donors was used to demonstrate accuracy. to determine precision, two cadaveric specimens were tested in several replicates. acceptance criteria were implemented according to the pei recommendations. results: results were found to be within specifications requested by the pei recommendations for all tested assays summary/conclusions: the evaluated results support the extension of the use of these assays with cadaveric specimens. background: in developed countries, blood donors are routinely screened for a range of blood borne viruses (hiv, hbv, hcv and htlv) using highly sensitive screening tests. this has dramatically improved the safety of blood supply. however, transmission by transfusion of unknown or unsuspected viruses remains a continuing threat. this is particularly relevant considering that a significant proportion of transfused patients are immunocompromised and more frequently subjected to fatal outcomes. in developed countries, blood donors are routinely screened for a range of blood borne viruses (hiv, hbv, hcv and htlv) using highly sensitive screening tests. this has dramatically improved the safety of blood supply. however, transmission by transfusion of unknown or unsuspected viruses remains a continuing threat. this is particularly relevant considering that a significant proportion of transfused patients are immunocompromised and more frequently subjected to fatal outcomes. aims: in this context, metagenomic analyses of viral content in blood donations collected in geographical zones recognized as "hotspot" for viral emergence represents a suitable approach without any a priori for the identification of a potential emerging viral risk that may compromise blood safety. methods: in the framework of a viral discovery program founded by the french national agency for medicine security (ansm in french), more than plasma samples collected in sub-saharan africa countries ( ) ( ) and the amazon region of brazil ( ) have already been analysed by metagenomics. results: although no viral sequence could be described as novel (i.e. new species or even a new genus), we unexpectedly identified a feline bocavirus in two donors from mauritania. a large diversity of known viruses that are not part of the regularly monitored agents were also observed, among which anelloviruses, hpgv- (formerly known as gbv-c), papillomaviruses, herpes viruses, parvovirus b , chikungunya virus, enterovirus, and various small circular viruses (circo-, cycloand gemycircularviruses). while no significative differences was observed in the higher classification of detected virus (above families/genera) between africa and brazil, we observed variations at the sequence level allowing better resolution of the genetic diversity for several viruses (for example characterization of hpgv- genotypes). summary/conclusions: overall, the absence of novel viruses in blood samples collected across countries of two distant continents is reassuring regarding threats emergence. however, continuous monitoring of prospective blood banks should be continued. summary/conclusions: after the high peak observed in during the first period, this study shows that the decrease in the seroprevalence of viral markers is continuous over the next five years. the second period is marked by an irregular evolution of seroprevalence but with lower levels than the first period. the recruitment of new donors allows a quantitative increase in donations. however, improving the quality of blood products essential condition of transfusion safety is achieved through retention of recruited blood donors. background: in blood screening laboratories, samples may be transferred between automated serological and molecular instruments, and the potential for sample contamination is a serious risk to the integrity of nucleic acid testing (nat) results. the sensitive limit of detection (lod) for hiv and hcv nat assays combined with the high viral titers encountered in specimens from patients with acute infections presents a challenge for maintaining the sample integrity of negative specimens. at additional cost per test, this risk can be reduced with single-use filter pipette tips. aims: we evaluate the efficacy of applying induction heated washes to a non-disposable pipettor on serology instruments-alinity s, alinity i, and architect i sr (abbott diagnostics)-to preserve the integrity of samples transferred to a downstream molecular instrument, the m realtime (abbott molecular diagnostics), which amplifies viral nucleic acid targets exponentially. methods: in this application of induction heating, the metallic pipettor warms under its own resistance to coil-induced electrical currents. by sweeping the pipettor through an induction coil, temperatures on the pipettor are elevated throughout its length. single donor high viral titer hiv genotypes a ( . log iu/ml), b ( . log iu/ml), c ( . log iu/ml), crf ( . log iu/ml), crf ( . log iu/ml), and urf ( . log iu/ml), as well as single donor high viral titer hcv genotypes a ( . log iu/ml), b ( . log iu/ml), a ( . log iu/ml), ( . log iu/ml), q ( . log iu/ ml), and t ( . log iu/ml) were used as potential sources of contamination; these genotypes account for the majority of hiv and hcv infections worldwide. on serology instruments, one high viral titer hiv or hcv specimen and three consecutive susceptible negative samples (hiv/hcv rna negative human plasma, abbott molecular diagnostics) were tested on an hiv ag/ab combo or anti-hcv immunoassay (abbott diagnostics), and this schema was repeated four times per positive specimen. induction heated washes occurred between all samples processed on the serology instruments. the first susceptible negative from each testing block, with approximately ml of residual sample volume, was then tested using the . ml abbott realtime hiv assay (lod copies/ml) or . ml abbott realtime hcv assay (lod iu/ml) and an hcv ag immunoassay (lod . fmol/l; abbott diagnostics). study acceptance criteria required that any susceptible negative sample had no detectable level of hiv or hcv rna. results: all first susceptible negative samples (n = per platform per virus schema) run on alinity s, alinity i, and architect i sr using induction heated washes after a high viral titer hiv specimen or hcv specimen were hiv ag/ab combo nonreactive (< . s/co) and reported no detectable level of the hiv rna target, or were anti-hcv nonreactive (< . s/co) and reported no detectable level of the hcv rna or core antigen targets. summary/conclusions: while precautions should continue to be taken for samples run on molecular instruments, the integrity of samples originally tested on the alinity s, alinity i, and architect i sr was preserved for downstream molecular testing through the use of induction heated washes. aims: increasing the safety of blood and blood products -motivating the blood donors to be regular donors methods: national reporting system showed the high prevalence of ttis among first blood donors in compares with the regular donors. in per . . donations, % % of confirmed positive hiv, % of hcv, and % of hbv cases has been reported among first blood donors. in the end of a national program named "pre-donation screening tests "has been developed and has been implemented in high prevalence provinces in whole country. based on this program, all first blood donors who accept in donation sites, if after donor selection process are eligible to donate blood, they refer to give just a blood sample for screening ttis tests. after months, the invitation letters and smss send to the donors who have negative results for all screening ttis tests, and they can be eligible to donate blood after another donor selection process. in , about . % of all donations have been rejected because of at least one of hiv, hcv, or hbv confirmed positive results, while this reject rate in was . %, which shows a significant decreasing the ttis prevalence among blood donation from to . the prevalence of hiv, hcv, and hbv among donations has been decreased significantly in compared with the . prevalence of hiv among donations reduce from . % in to . % in , for hcv and hbv the same results have been experienced, respectively from . % and . % in reduce to . % and . % in . it seems this applied study could effectively scale up the safety of national blood supplies. in addition this intervention could support iranian blood transfusion service to increase the proportion of regular blood donors from . % in to . % in . it means that with increasing the regular blood donor population sizes, the safety of iranian blood and blood products will be more and more scaled up. summary/conclusions: evidence based reports show there is a high rate of prevalence of transfusion transmitted infections (ttis) among first blood donors. so an effective intervention which can reduce the risk of unsafe first blood donation can effectively increase the safety of blood and blood products. pre donation screening tests program in iran can support the national program to decrease the rate of ttis among blood donations from . % in to . % in . abstract withdrawn. abstract withdrawn. background: despite the universal application of viral inactivation and elimination technologies during the preparation of plasma-derived products, the exclusion of infectious donations before any other procedure remains the first essential step as well as the major determinant for the safety of untreated labile blood products. current selection and screening techniques have reduced the risk of viral transmission to very low levels, but there is still a very low but quantifiable risk of transmission through donations beyond routine detection, particularly during the " seroconversion window". "of an infection in a blood donor that is to say during the period when the recently infected donor has not yet developed a serological response. the level of residual risk, which must be as low as possible, is mainly conditioned by the rates of the infections concerned (hiv and hepatitis b virus (hbv) and c (hcv)) to blood donors. summary/conclusions: the evolution of serologic markers is generally satisfactory with continued regression, which has improved particularly for hiv. on the other hand, hepatitis b is still a concern because of its still high rate among new donors. it is desirable to initiate a regular donor vaccination program to protect against hepatitis b. background: blood centres require high throughput assays with a high level of reproducibility to assure consistent results and minimize unnecessary retesting of samples and deferral of donors. in addition, continued economic pressures on laboratory operations demand that assays perform on platforms capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. aims: evaluate the reproducibility of hcvab, havab igm and havab igg essays using abbott alinity s when compared to architect i sr. determine repeatability of these tests in alinity s essays. methods: during months a study was conducted where several samples (minimum samples per test) were randomly sorted and tested using alinity s and architect i sr, results were compared using ibm spss statistics â . in order to evaluate repeatability, at least samples with different reactive degrees (high, intermediate and low) per test were repeated, using alinity s, an average of times per sample and it was determined the percentage of coefficient of variation (%cv). results: a total of samples were tested ( for hcvab, for havab igm and for havab igg) using alinity s and architect i sr, and it was ensured that there were no statistically significant differences between results (p > . ). using samples and a total of essays we found the %cv hcvab ranged from to . %. samples were tested for havab igm in a total of essays and the %cv ranged from to . %. havab igg was tested in samples during essays and the %cv ranged from to . %. summary/conclusions: the new automated equipment alinity s system demonstrated no statistically difference when compared with architect i sr and repeatability was ensured. this demonstrates the precision of results generated by this fully automated blood screening analyzer, which helps assure consistent results for the testing and retesting of blood specimens for hcvab, havab igm and havab igg. background: blood centres require high throughput assays with a high level of reproducibility to assure consistent results and minimize unnecessary retesting of samples and deferral of donors. in addition, continued economic pressures on laboratory operations demand that assays perform on platforms capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. aims: evaluate the reproducibility of hbsag, hbsab, hbcab, hbeag and hbeab essays using abbott alinity s when compared to architect i sr. determine repeatability of these tests in alinity s essays. methods: during months a study was conducted where several samples (minimum samples per test) were randomly sorted and tested using alinity s and architect i sr, results were compared using ibm spss statistics â . in order to evaluate repeatability, at least samples with different reactive degrees (high, intermediate and low) per test were repeated, using alinity s, an average of times per sample and it was determined the percentage of coefficient of variation (%cv). results: a total of samples were tested ( for hbsag, for hbsab, for hbcab, for hbeag and for hbeab) using alinity s and architect i sr, and it was ensured that there were no statistically significant differences between results (p > . ). using samples and a total of essays we found the %cv hbsag ranged from - . %. samples were tested for hbsab in a total of essays and the % cv ranged from - . %. hbcab was tested in samples during essays and the %cv ranged from - . %. using samples and a total of essays we found the %cv hbeag ranged from . - . %. samples were tested for hbeab in a total of essays and the %cv ranged from - . %. summary/conclusions: the new automated equipment alinity s system demonstrated no statistically difference when compared with architect i sr and repeatability was ensured. this demonstrates the precision of results generated by this fully automated blood screening analyzer, which helps assure consistent results for the testing and retesting of blood specimens for hbsag, hbsab, hbcab, hbeag and hbeab. background: blood centres require high throughput assays with a high level of reproducibility to assure consistent results and minimize unnecessary retesting of samples and deferral of donors. in addition, continued economic pressures on laboratory operations demand that assays perform on platforms capable of increased walk away time and enhanced automation in areas of reagent management, retest options, and commodity/waste management. aims: evaluate the reproducibility of hivag/ab, syphilis and htlv i/ii essays using abbott alinity s when compared to architect i sr. determine repeatability of these tests in alinity s essays. methods: during months a study was conducted where several samples (minimum samples per test) were randomly sorted and tested using alinity s and architect i sr, results were compared using ibm spss statistics â . in order to evaluate repeatability, at least samples with different reactive degrees (high, intermediate and low) per test were repeated, using alinity s, an average of times per sample and it was determined the percentage of coefficient of variation (%cv). results: a total of samples were tested ( for hivag/ab, for syphilis and for htlv i/ii) using alinity s and architect i sr, and it was ensured that there were no statistically significant differences between results (p > . ). using samples and a total of essays we found the %cv hivag/ab ranged from to . %. samples were tested for syphilis in a total of essays and the %cv ranged from to . %. htlv i/ii was tested in samples during essays and the %cv ranged from . to . %. summary/conclusions: the new automated equipment alinity s system demonstrated no statistically difference when compared with architect i sr and repeatability was ensured. this demonstrates the precision of results generated by this fully automated blood screening analyzer, which helps assure consistent results for the testing and retesting of blood specimens for hivag/ab, syphilis and htlv i/ii. , human immunodeficiency (hiv) and hepatitis c (hcv) viruses' infection in blood donors were . %, . % and . % respectively. consecutive positive results for hbv were . % ( / ), for hcv were . % ( / ) and nil for hiv. there was no sample carry over in this. out of consecutive reactive donors were donated for same patients and were related with infected patient which were statistically significant (p < . ). summary/conclusions: among all tti reactive donors . % ( / ) were consecutive reactive. the reason for the same may be process related like sample carry over or reagent carry over or donor related. donor related reasons may be, one of the close relative is reactive for virus and that is transmitted to other family members. in our study reactive donors either had close contacts with persons with history of infective disease or were their first degree family relatives. these findings were found statistically significant (p < . ). this study recommends that in analysis of consecutive positive results in elisa along with looking for procedure/sample error, there is also a need to take retrospective history of donors for close contact with infected patient. background: screening for transfusion-transmitted infections (ttis) is critical in ensuring safety of blood products. transmission of infections through transfusion remains a major source of viral hepatitis especially hbv and hcv. the effectiveness of rapid immunochromatographic test (ict) devices for screening of blood is a concern and needs validation through advanced methods like chemiluminescence immunoassay (clia) and polymerase chain reaction (pcr). aims: the current study was conducted to evaluate the performance and screening effectiveness of commercially available rapid screening kits in comparison with clia and pcr. methods: this single centre, cross sectional study was conducted at the department of blood transfusion services, shaheed zulfiqar ali bhutto medical university, islamabad, from january -june . a total of ten commercially available ict devices and one clia kit (liaisonr xl) were tested for their sensitivity, specificity, positive predictive value (ppv), negative predictive value (npv) and accuracy using positive and negative samples each for hbv and hcv respectively, in comparison with the values determined by pcr. the ict kits included hightop, rightsign, wondfo, accu-chek, fastep, abon, immumed, insta-answer, biocheck and ctk. results: the sensitivities and specificities of ict kits for hbsag were % and % (hightop), % and % (rightsign), % and % (wondfo), % and % (accu-chek), % and % (fastep), % and % (abon), % and % (immumed), % and % (insta-answer), % and % (biocheck) and % and % (ctk) respectively. similarly the sensitivities and specificities of different ict kits for hcv were % and % (hightop), % and % (rightsign), % and % (wondfo), % and % (accu check), % and % (fastep), % and % (abon), % and % (immu-med), % and % (insta answer), % and % (biochek) and % and % (ctk) respectively. the sensitivity and specificity of diasorin liaison murex assay for both hbv and hcv were found to be %, when compared with pcr. the ppv, npv and accuracy were determined accordingly. summary/conclusions: rapid testing ict devices for both hbv and hcv available in pakistan were found to have a variable degree of sensitivity and specificity, when compared with pcr. comparatively expensive but quality methods are more reliable as compared to rapid devices. the data generated will help policy makers to prepare future plan of action and introduce the concept of quality control in blood centres. the analysis has shown that the population of blood donors also included people infected with syphilis. in reference to the number of the tested samples this number is quite significant. the analysis proved the increase in the number of syphilis infections among the blood donors which is consistent with the general trend in the population. summary/conclusions: we have proved that testing blood donors for the treponema pallidum infection increases the safety of recipients of blood and its components and that obligatory testing of donors is fully justified. , and , the use of third or fourth generation serological assays is mandatory for screening of blood donor units for hbv and hcv infection before transfusion. routinely, blood banks in india screen the units by the elisa testing. nat is not very common due to cost constraints. aims: the aim of this study is to determine the frequency and load of hbv dna and hcv rna in hbs and hcv reactive blood donors respectively, and hence it was intended to contribute to determining whether routine hbs and hcv screening of blood donors, using elisa method alone, provides any concrete benefits with regard to hbv and hcv risk reduction or whether the implementation of nat will be of great benefit to low-resource countries like india, which has high prevalence of hbv and hcv. abstract withdrawn. , donors were routinely tested for hbv dna by using cobastaqscreen mpx- and mpx- (roche) or procleix ultrio and ultrio plus id (grifols) assays. obi was confirmed by repeat dna testing and by performing additional serological and molecular investigations on index and follow-up samples. anti-hbs concentrations were determined and anti-hbc antibodies were tested with three distinct commercial clia assays (anti-hbc elecsys roche, architect anti-hbc ii abbott, and hiscl anti-hbc assay sysmex). hbv pre-s/s, precore/core and bcp regions were pcramplified after viral particle concentration and viral amplicons were sequenced. results: hbsag-/dna+ donors ( : , ) including confirmed obi were identified ( : , prevalence). among obi donors, ( . %) tested anti-hbc+/anti-hbs-, ( . %) were anti-hbc+/anti-hbs+, ( . %) were anti-hbc-/anti-hbs+, and anti-hbc-/anti-hbs-primary obi ( . %). anti-hbc-/anti-hbs+ obi donors were significantly younger (mean: years [range: - years]) than those with anti-hbc+/anti-hbs+ (mean: years [range: - years]) and anti-hbc+/anti-hbs-(median: years [range: - years]) profiles (p < . ). hbv vaccination was documented for ( %) of these donors and was reported in one donor but without definitive evidence. extremely low hbv dna loads (range: < - iu/ml) were transiently detected in seven donors during follow up. genotypes identified were genotype b (n = / ) and genotype c (n = / ). preliminary analysis of core protein (n = ) and bcp (n = ) sequences showed no particular genetic feature that could be associated with altered antigenicity or core gene expression. follow-up was available for / anti-hbc-/anti-hbs+ donors ( - samples/donor; range: - months). anti-hbc remained undetectable with all clia assays in these donors except one. low transiently detectable levels of hbv dna were observed overtime with anti-hbs levels fluctuating between and , iu/l. no significant difference in hla-a, -b (except hla-b* more frequently detected in anti-hbc negative obi), and -drb *. summary/conclusions: overall, the . % prevalence of anti-hbs-only in hbv dna positive obi carriers ( : , of total donors) in dalian blood donors confirmed previous reports from south east asia. this phenomenon was not related to core antigenic variations but was significantly associated with younger age of carriers. a particular route and natural history of the infection may be considered. the hypothesis of acute-phase vaccine breakthrough was ruled out in / donors by the over months stability of this serological profile. breakthrough in immunized donors may still be suspected. further studies are needed to evaluate the potential infectivity of anti-hbs-only/hbv dna+ obi carriers, and to characterize the potential viral and immunological mechanisms responsible for this unusual hbv infection profile. confirmatory laboratory, hungarian national blood transfusion service (hnbts), budapest, hungary background: vaccination against hepatitis b virus (hbv) is an effective tool to avoid the infection. in hungary, population born after is considered to be immunized, because inoculation has been mandatory for children as campaign vaccination since . hbv vaccine is strongly recommended for healthcare workers, moreover trips to endemic countries and awareness of individuals could also be reasons of vaccination in immunologically na€ ıve age-groups. since the hbv vaccine contains surface antigen, a recent inoculation can cause reactivity of hbsag screening assays and positivity of confirmatory tests for several days resulting in deferral of donors from blood donation. the former regulation of hnbts, which was valid until december , , allowed the re-entry of donors whose immunization records and negative hbv confirmation of the second blood samples proved that the previous vaccination had resulted in the hbsag confirmed positivity. aims: the aim of this study was to strengthen that vaccination against hbv before blood donation had resulted in the reactivity of hbsag screening and confirmatory assays between and . background: in brazil, the introduction of nucleic acid tests (nat) for hbv-dna detection in the routine screening at public blood banks is relatively recent. at fundac ßão pr o-sangue/hemocentro de são paulo (fps-sp), about , blood donors are submitted to serological screening tests (hbv, hcv, hiv- / , chagas disease, syphilis and htlv- / ) and nat for hiv, hcv and hbv per year. approximately % of the blood donations are discarded due to some reactive result; of these, the hbv discard rate was . % in . aims: our study aims to determine the potential infectious cases among samples that had one or more hbv-reactive screening results (anti-hbc, hbsag and mp-nat-hbv) and verify the different categories of hbv infection (acute, chronic, occult hepatitis b infection (obi) and immunological window). furthermore, to characterize the distribution of hbv genotypes, drug resistance and escape mutations and analyze the risk factors. methods: we carried out a cross-sectional study of roughly , donations from may to december . hbv antibodies and antigen screening were performed using cmia kits architect â -abbott/hbsag and architect â -abbott/anti-hbc. nat screening was performed in minipools (mp) of six samples using kit nat hiv/hcv/ hbv -bio-manguinhos (sensitivity % lod iu/ml for hbv). reagent samples (n = ) that presented one or more hbv-reactive screening results (anti-hbc, hbsag and/or mp-nat-hbv), were submitted to individual nucleic acid extraction and "in house" quantitative real-time pcr-hbv (id-pcr-hbv) targeting the hbsag region (sensitivity - ui/ml). the hbv genotypes and mutation analyses were determined by direct sequencing of the hbv pol-gene/surface-gene and use of the online analysis tool geno pheno [hbv] . . socio-demographic and epidemiological data were also analyzed. financial support: fapesp / - . results: among the hbv reactive samples, were reactive for anti-hbc only ( . %), for hbsag only ( . %) and were reactive for both markers and hbv dna ( . %). routine testing and id-pcr-hbv identified ( . %) samples of active infections that had all hbv reactive/positive tests results. no hbv dnayield samples or hbsagyield or obi were observed. viral loads for active infections samples ranged from . e+ to . e+ cop/ml (median, . e+ cop/ml). hbv sub-genotypes a , a , c , d and f were found in %, %, %, %, and % of the donors, respectively. no reverse transcriptase inhibitor-resistant variants were detected. escape mutations in small hbsag protein shb region were detected in % ( / ), with the following main substitutions c ( x), r, n and g. the mean age of donors with active hbv infection was years, mostly donors were males ( %), mixed ( %) or white ( %) and had concluded high school ( %). summary/conclusions: discard rate due to isolated anti-hbc is high but no obi was found in the blood donor population studied. in addition, no case of immunological window for hbv or hbsagyield was detected. there was a predominance of subgenotype a and mutations associated with escape were found in % of hbv-dnapositive samples. continuous research and surveillance about hbv prevalence among blood donors are needed to maintain and evenly increase blood safety in brazil. background: screening for anti-hbcore antibodies in blood donors is considered to contribute significantly to blood safety, since it reveals donors with occult or probable occult hepatitis b, with variable results in molecular screening, due to very low viral load. however, universal anti-hbcore testing in blood donors, might exclude a considerable number of blood donors in countries with high hbv prevalence and even in countries with low to moderate prevalence, like greece. aims: the aim was to investigate the percentage of blood donors with natural hbv infection (confirmed positive anti-hbcore) or hbv immunization due to vaccination (anti-hbs+ only, due to vaccination) and predict the impact of generalized anti-hbcore testing. methods: during the period - november , all blood donors were asked to give their consensus for additional screening for hepatitis b anti-hbcore and anti-hbs antibodies, besides the obligatory serological and molecular screening, the samples of few donors who disagreed, were not examined. all samples with repeated positive anti-hbcore results, were further examined for anti-hbcore igm and anti-hbe antibodies. furthermore, a new donor sample was requested, to confirm reactivity. the serology results were recorded in an excel spreadsheet. additional data, including age, sex, nationality, number of previous blood donations, abo blood group, family history of hbv infection, hbv vaccination, were also recorded and statistically evaluated. donors were informed of the positive results. results: a total of edta samples were tested using the architect anti-hbcore, anti-hbs, nti-hbcore-m and anti-hbe assays (chemiluminescent microparticle immunoassay (cmia). repeated anti-hbcore(+) occurred in ( . %) samples, among which ( %) were also anti-hbe(+), while anti-hbs was found > m iu/ml in ( . %), between and miu/ml in ( . %), and < miu/ml in ( %). among anti-hbcore positive donors, / were foreigners ( . %) and were greeks, while foreigners consisted , % ( / ) of donors examined. so, anti-hbcore was found positive in , % of foreigners ( / , all from countries with high prevalence for hepatitis b infection) and in , % of greeks ( / ). in total, ( . %) samples had anti-hbs > miu/ml (considered seroprotective for the donor). summary/conclusions: almost half of our blood donors ( . %) were immunized, by vaccination and ( . %) by natural infection. the incidence of natural infection was significantly higher in foreigners ( . % versus , %). if not all anti-hbcore+ donors, % with anti-hbs < iu/ml, might be potentially infectious, especially for immunocompromised patients. if we choose to screen all blood donors for anti-hbcore and reject those with positive results, regardless of the anti-hbs levels, we would probably lose a significant number of donors and jeopardize blood sufficiency. alternatively, we could reject only those with anti-hbs < or < , or choose to selectively screen pre-donation blood donors from countries with high prevalence of hbv infection. following this pilot study, the prevalence of immunization against hbv in large numbers of blood donors from various parts of greece, must be investigated, in order to decide whether to introduce such screening. aims: the aim of this study was to perform phylogenetic analysis of the donor samples with hcv found in the neighbouring villages to determine the nature of transmission. methods: altogether, approximately million blood donor samples were screened with anti-hcv immunoassay (architect anti-hcv, abbott gmbh, wiesbaden, germany) and reactive results were confirmed with anti-hcv line-immunoassays (inno-lia hcv score, fujirebio europe, gent, belgium). based on lia positivity, in samples an association of hcv infection was supposed, because the residence places of donors were in three neighbouring villages situated less than km to each other. pcr was positive in samples. from these samples, hcv sequencing and phylogenetic analysis were performed. fourteen hcv infected samples of general population and of ivd users were also included into the study. results: phylogenetic analysis detected genetic relationship among the hcv virus sequences in donor samples. the most abundant was the a subtype, and it formed two different groups on the phylogenetic tree. according to their genetic distance, a more distant mutual ancestor could be supposed. two samples with b subtype originated from the same village, and their difference was only nucleotides. three hcv from the ivd user control group showed close genetic relationship with the viruses detected in the donor samples. summary/conclusions: based on our phylogenetic analysis, hcv transmission in blood donors could be the consequence of the ivd use and the origin might be related to or primary human sources. during and , a significant increase in the hcv seroprevalence among the ivd users was observed, which was approximately threefold in the rural areas of hungary. our recent findings highlight the importance of the proper donor selection, which can identify the typical signs of the ivd use. moreover, enhancing awareness of blood donors with education is a further significant issue in order to reduce the risk of transfusion transmitted infections. abstract withdrawn. background: in china, the residual risk of transfusion-transmitted hcv has been declining since screening of blood donors for anti-hcv and/or hcv nat from . however, many high sensitivity reagent, using to test blood donors' samples, lead to false-positive results and donors loss. aims: this study intended to establish a donor reentry procedure for hcv screening reactive donors in china. methods: from march to december , there were blood donor samples which were screened reactive or belonged to "grey zone" by elisa and/or reactive by nucleic acid test(nat) at the local blood centers were collected from chinese blood centers. all these samples were sent to institute of blood transfusion (ibt) national reference laboratory where anti-hcv and hcv individual nucleic acid test (id-nat) were conducted. if the results were reactive for anti-hcv, then the samples were tested with a recombinant immunoblot assay (riba). results: based on this study, of donors in the study who could be classified into two categories for hcv status: ( . %) true positive and ( . %) false positive. a total of of donors lost to follow-up, their hcv status cannot be determined with certainty. based on these data, a reentry procedure for hcv screening reactive donors was proposed. summary/conclusions: based on our proposed donor reentry procedure for hcv screening reactive donors, a majority of screening false-positive donors ( . %) can re-entry safely. abstract withdrawn. background: providing safe blood for transfusion in sub-saharan africa (ssa) is a particular challenge due to a combination of factors; limited resources and infrastructure, suboptimal diagnostics and a high prevalence of the major transfusion-transmissible infections (ttis). average seroprevalence data estimates from the ugandan and kenyan blood transfusion services (bts) for hepatitis c (hcv) currently stand at . % and . % respectively. between january and december , in mbale (eastern uganda) the hcv prevalence amongst blood donors was an alarming . %. with no provision or funds for confirmatory testing, the bts are unable to confirm or refute a diagnosis of active hcv. this results in large quantities of blood wastage, unnecessary anxiety in potential donors and high donor deferral rates limiting the donor pool. aims: we aim to determine the true prevalence of active hcv infection amongst seropositive donors in bts in uganda and kenya. in addition, we aim to compare the performance of locally used serodiagnostics and best available alternative tests and to examine the feasibility of cost-effective additional or alternative tests to help provide accurate results on the infectious status of blood. methods: hcv seropositive blood samples from bts study sites (kampala, mbale, mombasa) will be re-tested using the local serology screening test (abbott architect anti-hcv), an alternative who pre-qualified rapid antibody test (sd bioline) and a confirmatory test (hcv core antigen test). where there is discrepancy in the results or need for clarification, samples will be tested on the cepheid xpert platform by reverse-transcriptase pcr to obtain a quantitative rna result. s/co (specimen to cut-off) values for false positive samples (by screening serology) will be analysed and presented. pre-analytical factors (centrifugation speed, haemolysis check, time delay between collection and testing) will be controlled for and documented. results: pilot data from re-testing quarantined hcv seropositive donor blood (mbale bts) in uganda demonstrated that / seropositive blood ( %) was rna pcr negative. in december , / ( %) of seropositive samples (by screening anti-hcv serology) in kampala bts had s/co values between . - . ( . is the cut-off indicating a positive sample). data from the re-testing of seropositive samples as true representation of active hcv will be demonstrated and s/co values for the study period concomitantly with a retrospective analysis of january to december . preanalytical factors, cost analysis comparisons of the diagnostic platforms coupled with costs of the donor deferral process in false positive cases will be presented. summary/conclusions: for the bts in ssa there are significant resource and financial implications, as repeat testing and donor deferral counselling is required. evaluating and introducing new and appropriate diagnostics and algorithms in the screening of hcv is crucial in improving the supply of safe blood transfusion services in east africa. background: in november , the blood services of england, scotland and wales reduced donor deferral to three-months for commercial sex workers and individuals with higher risk sexual partners, including sex between men. the change was recommended after a detailed review by an external expert committee (sabto) which recommended that a shortened deferral of months would allow detection of recently acquired infection and maintain residual risk (rr) at a tolerable level. recommendations were accepted by government but with a government commitment to explore a more individualised approach. aims: to assess the impact of a -month deferral on blood safety in terms of epidemiology of infections in blood donors and compliance with donor selection criteria, and to explore evidence required to develop a more individualised approach to donor selection policy methods: routine uk blood donation surveillance data for - ( : preliminary) were reviewed. annual prevalence and incidence of hbv and hiv infection were estimated, with a poisson regression models to test for trends. incidence was calculated from donors seroconverting within -months, and/or microbiological and clinical evidence of recent infection. for donors positive in , compliance with the -month deferral was determined. uk hemovigilance data were scrutinised for evidence of transfusion transmitted infections (tti) associated with newly eligible donors. results: from to among new donors, annual hiv prevalence decreased significantly by an average of . % each year (p = . ) to . / , donations in ; no significant trend was observed for hbv. annual hiv incidence among repeat donors also decreased significantly by an average of . % each year (p = . ) to . / , -person years (pyrs) in (based on seroconverters). there was no significant trend in hbv incidence over the study period, however between and incidence increased from . / , pyrs to . / , /pyrs (based on and seroconverters respectively). with the information available to date, none of the seroconverting donors were non-compliant, and there was no reported confirmed ttis associated with the policy change. summary/conclusions: hiv prevalence and incidence has continued to decline. hbv incidence in repeat donors increased in although initial analysis suggests this is not associated with the policy change. monitoring continues, and residual risks will be re-estimated as data post-change accumulate. these data are reassuring, and therefore it is appropriate to scope the evidence for, and feasibility of, a more individualised approach to selection policy. a multidisciplinary steering group has been convened including representation from patient and stakeholder groups. gaps in knowledge are being defined, and a package of work is in development under the project of fair (for the assessment of individualised risk), using the abo rdf for guidance. background: permanent deferral of men who have sex with men (msm), established in the s, primarily to minimise the risk of hiv transfusion-transmitted infections is increasingly challenged. accordingly, blood services in many countries have changed to time-based deferral. in canada, a -year deferral was implemented in , reduced to -months in ; a -month deferral is now being considered. aims: to estimate the risk of undetected hiv among screened blood donations under a -month deferral since last sex between men. methods: the applied model combines features of previously published english and canadian models to estimate hiv risk under a -month deferral. three scenarios varying hiv incidence, prevalence and non-compliance under a -month deferral were modelled. assumed constants were the hiv nucleic acid window period, testing procedure error rate and assay sensitivity. model inputs were incidence under the current -month deferral, calculated as hiv positive donors with a previous negative within months divided by number of person years, numbers of hiv positive donations, hiv positive msm, hiv msm incident cases and newly eligible msm donors (from donor surveillance and compliance surveys). the risk with a -month deferral was estimated for three scenarios, one determined "most likely", where msm donor non-compliance, hiv incidence and hiv positive donations do not change and msm newly eligible to donate are estimated from compliance surveys. this scenario is based on data from two sequential policy changes in canada. an "optimistic" scenario where non-compliance halves and a "pessimistic" scenario where msm hiv incidence, hiv positive donations, non-compliance and new msm donors double were also used. the median hiv residual risk was used as the final estimate. the uncertainty in this estimate was assessed with the . th and . th percentiles over the simulation ( % ci). results: incidence, per , donations, was estimated to be . , . and . for the "most likely" "optimistic" and "pessimistic" scenarios, respectively. for the month deferral "most likely" scenario, hiv residual risk was predicted to be in . million donations ( % ci: in , million to in . million). for the "optimistic" scenario, hiv residual risk was estimated to be in . million donations ( % ci: in , million to in . million). finally, for the "pessimistic" scenario, hiv residual risk was estimated to be in . million donations ( % ci: in , million to in . million). with these residual risk estimates, based on the number of donations in canada, one hiv infectious donation would be in inventory every years for the "most likely" scenario, every years for the "optimistic" scenario and every years for the "pessimistic" scenario. summary/conclusions: the risks of hiv entering the blood supply in canada for a -month msm deferral are predicted to be very low for all modelled scenarios, including a "pessimistic" doubling of hiv incidence post change. background: safety of blood and blood products is a major concern in pakistan. the prevalence of transfusion transmitted infections among multi-transfused thalassaemia patients is high (above %). the hiv epidemic in pakistan is following the asian epidemic model where after establishment among the high risk groups, its transmission to general public is rapid. fear, stigma and ignorance have contributed heavily to hiv transmission in pakistan. the hiv detection among blood donors is on the rise and reports occur in media repeatedly. aims: to investigate the possible transmission of hiv through blood transfusion in punjab, pakistan and to highlight the steps being taken to reduce further transmission of infections methods: in september , a report of hiv transmission through blood transfusion was reported in the media where a mother and her newborn acquired hiv after blood transfusion from a hiv positive donor (confirmed later). the case was referred to and investigated by the punjab blood transfusion authority (pbta). the pbta team took blood samples of both recipients (mother and her newborn) and the blood donor who was a family relative. the samples were tested by highly sensitive chemiluminescence immunoassay (clia). the clia results confirmed the presence of hiv in both recipients and the blood donor. due to maternal hiv antibodies transfer through the placenta, the infection status of the newborn was not re-confirmed as he died within two weeks. the donor informed that he had donated times in the past few years. the pbta was able to trace only one earlier donation three months ago. the recipient (a female) was found, tested by clia and was found to be hiv positive. all these cases occurred in unlicensed private blood banks that were screening for hiv on rapid manual devices. the blood banks were sealed by the authority and infected cases were registered by the provincial aids control programme and are being treated. summary/conclusions: the main reasons for hiv spread through blood transfusion is the use of sub-standard rapid screening devices which are not evaluated and validated at a national level. in addition, the existing system relies on the family/replacement donors. the national safe blood transfusion programme, is implementing blood safety system reforms as recommended by who. under the reform agenda, the blood transfusion authorities have been made functional and grant licenses to only those blood banks with proper systems to ensure quality and safety of blood products. the programme is developing a national system for the evaluation, selection and validation of all assays used for screening of blood in close coordination with the drug regulatory authority of pakistan. to promote the culture of voluntary blood donations, the programme has taken concrete steps initiating with the formulation of a national blood donor policy, interaction with celebrities, celebration of world blood donor day and more recently the launch of blood donation feature through 'facebook'. the promotion of voluntary blood donation concept along with regulation of blood sector will reduce the risk of hiv transmission through blood transfusions in pakistan. mianyang blood center, mianyang urumqi blood center, urumqi, china rti international, rockville national heart, lung, and blood institute, bethesda stanford university, stanford, united states background: the incidence of hiv infections has increased substantially over the past decade in china, especially among young people, who represent nearly half of the chinese blood donor population. this upward trend in hiv infections underscores the importance of monitoring hiv prevalence and incidence in chinese blood donors. aims: to estimate hiv prevalence and incidence rate (ir) among chinese blood donors using blood donation data from five geographically-disperse blood centers in - participating in the recipient epidemiology and donor evaluation study-iii (reds-iii) china program. methods: western blot confirmatory testing was done on samples of blood donations reactive for hiv- / on one or both rounds of routine elisa tests or positive by nucleic acid amplification testing (nat). multiple imputation was used for samples with missing confirmatory test results. hiv prevalence was calculated among first-time donors. to estimate hiv ir in first-time donors, single-well lag-avidity eia testing was conducted with first-time hiv recent (incident) infections defined as being infected within approximately days based on avidity of hiv antibodies. a novel model was derived to estimate hiv ir among infrequent repeat donors who had provided only one donation in the - estimation interval. to derive an overall hiv ir for repeat donors, this estimate was combined with the classical-model ir estimated for repeat donors who had given at least donations in the estimation interval. multivariable logistic regression model was used to examine factors associated with hiv infection. results: a total of , , whole blood and apheresis platelet donations with postdonation screening results were collected at the five blood centers between and , including , donations from first-time donors and , donations from repeat donors. hiv prevalence among first-time donors was . per , donors ( % ci, . - . ). hiv ir was estimated to be . per , person-years ( % ci, . - . ) among first-time donors and . per , person-years ( % ci, . - . ) among repeat donors. hiv prevalence and ir varied across regions with an increasing trend observed at some blood centers. among first-time donors, being male, older than years, minority ethnicity, less than college education, and certain occupations (commercial services, factory workers, retired, unemployed, or self-employed) were associated with positive hiv confirmatory testing results. summary/conclusions: although hiv prevalence and incidence remain low among chinese blood donors, it is important to monitor hiv epidemiology in blood donors on a continuous basis, especially among populations and regions of higher risk. further donor screening and education strategies need to be developed and evaluated to reduce these risks. the ir methods used in this study for first time donors as well as repeat donors who donate very infrequently is readily applicable to other countries who have similar donation patterns. background: in thailand, the national blood centre is responsible for blood donation service which includes follow-up and blood donor counseling in order to indicate the infection status, especially hiv-positive blood donors. currently, although the epidemic of hiv infection in thailand is in decline, the hiv-positive cases still have been found in blood donors screening. thus, monitoring of hiv infection status in blood donors and post-blood donor counseling are important for providing the hiv-positive infected donors lead to access the hiv treatment immediately. aims: to study the hiv follow-up cases on serological testing over years for assessment of the hiv infection in thai blood donors. the retrospective analysis of hiv follow-up cases on serological testing (cmia, ics and western blot) was conducted during to at thai national blood centre. results: a total of , , voluntary blood donations over years, the repeated reactive results on hiv serological screening were , ( . %) cases and only half of these hiv reactive donors returned to follow-up testing for ascertaining their hiv status. for hiv follow-up process, the hiv reactive screening donors must be followed for months and tested by using the different three principles of hiv serological testing. a total of , hiv reactive results were separated to three patterns including hiv positive results, inconclusive results and negative results which the number of each group was , ( . %) cases, ( . %) cases and , ( . %) cases respectively. out of , hiv positive results, we found that , ( . %) cases were positive with all hiv serological testing for the first-time follow-up and ( . %) cases were tested and become to positive results after follow-up more than one time. in cases of inconclusive results, ( . %) cases were reactive only or testing(s) which these donors did not return to confirm again leading to temporarily deferred donors in blood donor system. in addition, ( . %) cases of inconclusive results could not conclude the hiv result although they were repeated several times. for the last pattern, , negative results cases showed ( . %) cases were negative results after follow-up over months while ( . %) cases were inconclusive results before changing to negative results which almost cases of this group were reentry as blood donor after deferral period is over. summary/conclusions: the number of repeated reactive results on hiv screening was constant over years of which returned to follow-up only half of hiv reactive donors leading to accumulation of temporarily deferred donors in blood donation system. hiv follow-up positive cases were informed and counseled immediately then referring to anonymous clinic for treatment. the problem and challenges of hiv follow-up were inconclusive results that were unclear and some of these did not return to retest lead to loss of re-entry donor who might be changed to negative result afterward. hence, the effective counseling and follow-up system need to be taken urgently to encourage the temporarily deferral donors returned to retest for reducing stigma of deferred donors in hiv follow-up cases. . we only analyzed the information that had non-reactive results for infectious markers reported by blood banks to sihevi-ins©, because they represent a risk for blood recipients. results: when loading the information of sivigila in sihevi-ins©, donors were found ( % men); of these people donations were obtained ( % whole blood). donors ( %) had a reactive result for hiv being subsequently reported in sivigila. in addition, five of them were reactive simultaneously for hbv in blood banks and took on average ae days to be reported in sivigila. donors ( . %) had an hiv reactive result notified by sivigila and subsequently they were reactive in blood banks. this behavior may suggest an attempt to spread the disease. donors ( % men) despite being initially reported in the sivigila database, presented a non-reactive result in a blood bank for hiv; one of them was reactive for syphilis and hbv and only one for hbv. this pattern may suggest false positive or negative results in one of the two databases analyzed. fourteen donors had negative test in blood banks for hiv and in a range of up to months they were reactive by sivigila ( % of them donate whole blood). this conduct may suggest that accepted donations were in a window period and therefore warrant further investigation. considering that two blood components could be obtained on average from each donor, a potential risk is estimated for recipients. summary/conclusions: the donors reported first in the blood banks through sihevi-ins© and later in sivigila allow to estimate an adequate orientation to the health services. the information from general epidemiological surveillance programs could improve the selection of donors and transfusion safety. background: it is assumed that bacterial contamination of blood products most often takes place during the donation process. the number of bacteria at this time point is estimated to be around - cfu per bag. little is known about the growth behavior of different bacteria species in whole blood (wb) units during storage and the distribution of bacteria to the different blood products. aims: aim of the current study was to determine the growth of different bacteria species in contaminated wb units and to study the distribution of the bacteria to the different blood components. methods: whole blood (n = - per species) was inoculated with approximately cfu of different bacteria species (escherichia coli, klebsiella pneumoniae, pseudomonas fluorescens, staphylococcus aureus, staphylococcus epidermidis, streptococcus dysgalactiae, streptococcus pyogenes) and stored for to h at room temperature before centrifugation and separation into red blood cells (rbc), buffy coat (bc) and plasma. bcs from spiked wb were each pooled with random bcs to prepare plasmareduced platelet concentrates (pc). samples were taken from wb after storage and from the blood products (rbc, bc, plasma and pc) right after preparation, and the bacterial titer was determined. sterility of pcs was tested by bact/alert after seven days of storage. results: bacterial growth in wb varied remarkably between donations and bacteria species. the highest titers in wb were detected for the streptococcus species, whereas staphylococcus aureus, staphylococcus epidermidis, escherichia coli and pseudomonas fluorescens did not multiply. bacteria preferably accumulated in the bcs during separation, reaching titers of up to . cfu/ml in bcs and up to . cfu/ml in the corresponding pcs right after preparation. in total, out of pcs tested positive for bacteria at the end of storage. the results were dependent on the species used: e.g., / pcs tested positive after spiking with streptococcus pyogenes, while only / pcs tested positive after spiking with escherichia coli. bacterial contamination of rbc and plasma units was much less frequent and associated with higher bacterial titers in the parental wb units. summary/conclusions: the growth and distribution of bacteria during processing of wb into the different blood products is species-dependent and remarkably varies between donations. results: both patients were male ( yo and yo) with a history of acute myelogenous leukemia status-post haploidentical stem cell transplant. the patients were thrombocytopenic and underwent simultaneous transfusion of irradiated, non-pr, day platelets stored in platelet additive solution, from a single apheresis collection. the blood supplier's primary pre-release bacterial cultures were negative, and the on-site point of release secondary safety measure pan genera detection (pgd) testing was negative for both gram positive (gp) and gram negative (gn) organisms. both apheresis units also passed visual inspection prior to release from the blood bank. during transfusion, both patients displayed signs of septic transfusion reaction including rigors, fever, hypoxemia, tachypnea, tachycardia, and hypotension. transfusion reaction evaluations were initiated, and both patients were admitted to the medical intensive care unit and started on broad-spectrum antibiotics. gram stain of one platelet unit demonstrated gram negative rods (gnr) and gram positive cocci (gpc) in clusters, and the second platelet unit demonstrated gnr only. repeat secondary safety measure pgd testing of both units was negative for both gp and gn organisms. direct bacterial cultures of both platelet units grew both gnr and gpc identified as a. baumanii and s. saprophyticus after h of incubation. colonies on the initial bacterial plates were too numerous to count (tntc), and subsequent re-plating of the platelet units showed: unit : a. baumanii tntc and s. saprophyticus with . cfu/ml unit : a. baumanii . cfu/ml and s. saprophyticus . cfu/ml blood cultures collected from both patients became positive within h with gnr on gram stain, and both blood cultures ultimately grew both a. baumanii and s. saprophyticus. the primary pre-release cultures at the blood supplier remained negative. after days on antibiotics and pressors, both patients stabilized and were discharged home. the blood donor was interviewed, and he was well. no cultures were collected. summary/conclusions: this case documents failure of both primary pre-release bacterial testing and secondary on-site point of release pgd testing to identify two pathogenic organisms. a. baumanii and s. saprophyticus are unusual causes of septic transfusion reactions, and it is possible that these organisms have different limits of detection in the pgd assay compared to other organisms. rapid attention to clinical signs during transfusion and prompt initiation of antibiotics is critical for the management of septic transfusion reactions. we are currently evaluating ways to further reduce septic transfusion reactions, including increasing the utilization of pathogen reduced platelets. background: transfusion-associated infections due to the transmission of bacteria still represents a major risk in developed countries nowadays. despite the refrigerated storage of red blood cells (rbc), fatal reactions of patients receiving contaminated rbc units are repeatedly reported. in order to further increase the safety of blood transfusions, new strategies and measures have to be developed. in this context, transfusion-relevant bacteria reference strains can serve as a valuable tool for the validation, comparison and interpretation of these new developments. aims: conducting a collaborative study to establish the first repository for red blood cell transfusion-relevant bacteria reference strains. methods: six bacterial strains (serratia liquefaciens, serratia marcescens, pseudomonas fluorescens, listeria monocytogenes, yersinia enterocolitica a- and yersinia enterocolitica a- ) were distributed from the paul-ehrlich-institut to laboratories in countries for enumeration, identification and growth measurement in a -day interval for a total of days after low-count spiking of rbc bags ( - colony-forming units (cfu)/rbc bag). results: except for s. marcescens, all other strains showed good-to-excellent growth in rbc. s. liquefaciens, p. fluorescens, y. enterocolitica a- and y. enterocolitica a- achieved > cfu/ml at day and cfu/ml at day . growth of l. monocytogenes was lower reaching a maximum concentration of > cfu/ml at day . in out of laboratories, s. marcescens showed no growth at all. summary/conclusions: five of the six tested strains showed robust growth in rbc independent of donor variability and are promising candidates to be adopted as official rbc transfusion-relevant reference strains by the world health organization. background: the samplok sampling kit (ssk), itl biomedical, is used by nhs blood and transplant (nhsbt) for sampling of platelet components (pc) for bacterial screening using the bact/alert d system. inoculation of bact/alert bottles is performed immediately after sampling. validation of delayed inoculation, with retention of the sample within the ssk devices, would allow a contingency for transport to other screening sites in the event of an incident that prevented testing at the sampling site. ssk maintain a closed system for sampling of pc and are compatible with standard blood collection bags. a graduated chamber ( or ml) ensures that only the required sample volume is collected and an integrated needle allows inoculation into bact/alert bottles. aims: the national bacteriology laboratory, nhsbt, evaluated the impact of prolonged storage of pc samples in ssk devices with regard to bacterial viability and detection. methods: four reference species were assessed: staphylococcus aureus (atcc ), streptococcus agalactiae (atcc ), escherichia coli (atcc ), clostridium perfringens (atcc ). a pool and split method was used with apheresis pc suspended in plasma. units were screened using bact/alert d prior to spiking to prove the absence of contamination. pc were spiked with a single species (range - . cfu/ml) and tested on bact/alert with a ml inoculation into anaerobic and aerobic bottles (positive control). enumeration was performed to confirm the bacterial concentration. each unit was sampled using two ml ssk, which were held for a period of h at - °c. the process was repeated with a -h period. once elapsed, ml of each ssk was inoculated into an aerobic and anaerobic bact/alert bottle, one ssk per atmosphere per species and the remaining sample was enumerated. all bottles were incubated on the bact/ alert system for a maximum of days ( ae . °c) and subcultured if positive. results: positive controls had detectable growth by bact/alert, excluding aerobic bottles with c. perfringens. this was expected as it is an anaerobic organism. after the storage periods, all bottles had detectable growth by bact/alert. s. aureus showed an increase of . -log after h ( . to . cfu/ml) and . -log after h ( . cfu/ml to . cfu/ml). s. agalactiae increased by . -log after h ( . cfu/ml to . cfu/ml) and . -log after h ( . cfu/ml to . cfu/ml). c perfringens increased by . -log after h ( . cfu/ml to . cfu/ml) and . -log after h ( . cfu/ml and . cfu/ml). for e. coli, the concentration after h was reduced by . -log ( . cfu/ml and . cfu/ml), however this was possibly a result of inherent counting errors. at h, an increase in growth by . -log ( . to . cfu/ml) was obtained. summary/conclusions: storage of pc samples in ssk devices for up to h does not have a negative effect on bacterial viability and detection using the bact/alert d system. background: the intercept tm blood system for platelets efficiently inactivates pathogens and leukocytes in platelet concentrates (pc). the system utilizes amotosalen and uva light and is available for the treatment of apheresis and whole blood (wb) derived platelets (mostly buffy coat pools) in europe in plasma or platelet additive solution (pas), and the treatment of apheresis platelets in the us (trima tm in % plasma or amicus tm for % intersol pas/ % plasma). acinetobacter baumanii and staphylococcus saprophyticus strains were isolated from a saline flush taken h after successful and complete transfusion of an apheresis intercept-treated pc in % pas/ % plasma, from a patient with a suspected septic reaction that occurred h post transfusion. bacterial isolates, and a sample of a gram stain-negative and culture-negative sister split pc were submitted for evaluation. we report here the in vitro inactivation of the fast growing, gram negative bacterium a. baumanii and slower growing gram positive s. saprophyticus. the sister unit was assessed for amotosalen break down products as an indication of successful inter-cept treatment. aims: the objective of the study was to evaluate bacterial inactivation of a. baumanii and s. saprophyticus in apheresis platelets, assessed immediately after treatment and with re-culture at the end of a day shelf-life. methods: a double apheresis pc collected in % pas/ % plasma was split into three equal components, yielding approximately ml of platelets/pc. a. baumanii and s. saprophyticus were grown in lb broth and each pc unit was inoculated with either bacterial strain or the combination of both strains, each at~ log colony forming units/ml (cfu/ml). after inoculation, the contaminated units were treated in small volume (sv) intercept kits. samples were taken: pre and post-inactivation treatment, and at , and days of storage. the samples were analyzed by plating on lb plates ( ll- ml). residual amotosalen levels were assessed by hplc. results: initial bacterial titers were . - . cfu/ml. following the inactivation treatment, no viable bacteria were detected by plate culture. no bacteria were detected after , and days of storage, corresponding to > . log inactivation of both bacterial strains. performance of the intercept treatment process was confirmed in the sister pc unit as evidenced by levels of amotosalen and its byproducts characteristic of intercept treatment, as well as by review of the process documentation. summary/conclusions: amotosalen/uva effectively inactivated a. baumanii and s. saprophyticus individually and together below the limit of detection after days storage. no bacteria in the sister pc by gram stain and culture, and the presence of amotosalen byproducts suggested that the pc collection involved in the septic reaction was sterile at the time of intercept treatment and was successfully illuminated. the possibility of only one-of-two split pc being contaminated due to biofilm formation is minimized in the intercept system which decants platelets into virgin storage bags at the end of treatment. contamination of the source pc container likely occurred after intercept treatment, possibly at the time of spiking for transfusion. background: studies in sub-saharan africa have documented bacterial contamination of blood products for transfusion varying between , %> , %, up to times higher than in the north. published data from central africa are lacking. aims: the aim of this study was to determine the proportion of blood products contaminated with bacteria in three hospitals in the democratic republic of the congo (drc). to assure aseptic sampling, we used a closed system of sampling bags. in addition to the presence of contamination, we assessed semi-quantitative colony counts. methods: from july to december , a total of blood products were sampled, of which in hôpital provincial g en eral de r ef erence, kinshasa (hpgrk), in hôpital p ediatrique kalembe lembe, kinshasa (hpkll) and in hôpital saint-luc, kisantu (hslk). after compatibilization of blood products, ml of blood was transferred from the primary blood bag to an attached sampling bag. sampling bags were sealed off, stored in the fridge and transported once daily to the bacteriology laboratory. using the adapter connected to the sampling bag, ml of blood was inoculated in a blood culture (bactalertpf, biom erieux) and incubated at °c for days. cultures were checked daily for signs of growth. in addition, ml of blood was equally distributed on the cled and macconkey agar-coated sides of a dipslide (meus s.r.l.). dipslides were incubated h for semi-quantitative culture, expressed as colony-formingunits (cfu) per ml. in case of blood culture growth, bacteria were identified and a second blood culture was inoculated to exclude contamination during processing. bacteria grown on semi-quantitative culture were also identified. results: a total of . % ( / ) of whole blood and red cell concentrates were contaminated with bacteria. in hpgrk, . % ( / ) of blood products were contaminated, in hpkll . % ( / ) and in hslk . % ( / ) . the proportion of contaminated blood products was significantly higher in hpgrk compared to hslk (p = . ). there was no significant difference between the other sites (p = . and p = . ). majority of isolated bacterial species were coagulase-negative staphylococcus spp./micrococcus spp. ( . %) and bacillus spp. ( . %). the remaining % of bacterial isolates were identified as non-fermentative gram-negative rods, klebsiella pneumoniae, staphylococcus aureus, mould, listeria spp., corynebacterium spp./coryneform bacteria. the concentration of all isolated bacteria was lower than ³ cfu/ml, except for one coagulase-negative staphylococcus spp. found in hpgrk at ³ cfu/ml. summary/conclusions: to our knowledge, we were the first to reach a sample size of more than blood products for bacterial culture and the first to use a closed system of sampling bags in sub-saharan africa, which guarantees aseptic sampling of blood cultures. this might explain the low bacterial contamination rate ( . %) of blood products in three hospitals in drc compared to previous studies in other sub-saharan african countries. moreover, bacterial concentrations in the contaminated blood products were low (< ³ cfu/ml). the different proportions of contamination between study sites suggest that different environments and practices play a role in the risk for bacterial contamination. background: although the screening of the treponema pallidum (tp) is mandatory in blood donations, its necessity is controversial, because there have been no transmissions by blood products documented in the developed countries in the last few decades. aims: based on laboratory markers, active and early tp infected donors (aeid) were determined. the demographics of aeid and the frequency measures of cases were compared with that of early infected syphilis cases (syc) notified from the to -year-old general population registered at the nphc. methods: altogether, , to -year-old donors were screened with anti-tp immunoassay (architect syphilis tp, abbott, wiesbaden, germany) between and . reactive results were confirmed with immunoblots (viramed biotech ag, planegg, germany), which discriminated both specific anti-tp (igg, igm) and non-specific vdrl antibodies in five dilutions. meeting the criteria of anti-tp igg positivity with a vdrl titer of ≥ : and anti-tp igm positivity, donors were considered as aeid. they were stratified by age, gender and residence regions. the proportion of aeid (paeid) and syc (psyc) were calculated in first time (ft), and repeat tested (rt) donors and in the to -year-old general population, respectively, in each year studied. the period prevalence (pp) of aeid and syc was estimated in the populations at risk , across - . statistics: weighted proportions and one-way anova with tukey post-hoc test and z score test were applied. statistical significance was defined as p < . . results: anti-tp reactivity was confirmed in blood donors. aeid was proved in cases with ft and rt donors. in that period, syc were notified. both in aeid and syc, the age group of - years with approximately % and % of individuals was the dominant. the proportion of men was % and % (p = . ) in the aeid and syc, respectively. paeid estimated in ft donors was significantly higher ( . %; . %; . %, p < . ) than that of rt donors ( . %; . %; . %) and the proportion of syc ( . %; . %; . %) in the general population. pp of aeid showed a roughly homogenous distribution in the regions ( . %- . %), however, pp of syc had a significant ( . %; p < . ) central hungary dominance in relation to the other regions ( . %- . %). comparing the pp of aeid to syc, central hungary indicated a significant difference ( . % vs. . %, p < . ), however, other regions showed no substantial differences. summary/conclusions: donors with anti-tp confirmed positivity are referred to the healthcare system. based on the laboratory markers tested, aeid could be separated and their demographical characteristics are pretty similar to that of syc notified from the general hungarian population. the proportion of early and active infection in ft donors is significantly higher than that of rt donors and the proportion of syc in the general population. given the considerable number of tp infection in background: quality assurance and safety of hematopoietic stem cells (hsc) with emphasis on prevention of bacterial and fungal contamination are the prerequisites for any transplantation procedure. bacterial contamination is of particular significance as it occurs relatively more frequently and bacteria are gradually gaining more antimicrobial resistance. aims: the aim was to determine the incidence rate of bacterial and fungal contamination during processing of transplantation material at the institute of hematology and transfusion medicine (ihtm) taking into account the hsc sourceperipheral blood (pbsc), bone marrow (bm) or cord blood (cb). methods: analysis involved both autologous and allogenic components collected at ihtm and other hospitals and dedicated for ihtm patients. in all, the analysis comprised donations, including bm ( . %), pbsc ( . %) and cb ( . %) donations processed in our laboratory in the years - . bm was collected in operating theatre-conditions, pbsc with cell separators -cs- (baxter), cobe spectra (gambro) and trima accel (terumo bct) and cb was acquired from umbilical vein at obstetrics and gynaecology wards. aerobic and anaerobic bacteria contamination was determined at various incubation temperatures (room temperature and °c) using a variety of culture media. pbsc and bm were tested using samples with trypcase-soy broth (tsb-t) and with schaedler + vit k (biomerieux). cb was tested using bactec peds plus/f and bactec lytic/ /anaerobic/f (becton-dickinson). results: in the - period contaminated products were found: pbsc ( . % of all tested pbsc units) and cb ( . % of all tested cb units). no infected bm products were determined. the overall percentage of contaminated products was estimated at , %. in , three ( ) products were found contaminated with staphylococcus epidermidis; all came from one patient with central venous catheter and were collected on consecutive days. other products were contaminated mostly with staphylococcus epidermidis ( . %). detailed results to be presented on the poster. summary/conclusions: according to ihtm policy no contaminated product is admitted to clinical use. the outcome of our study identifies processing experience of the staff as the main indicator of product quality. important is also proper assessment of donor health and condition of the injection site as products are usually collected from central venous catheter. the closed system is an additional safeguard against contamination during processing. the sample collecting procedure should help to avoid false positive results. background: syphilis is considered a global public health problem. the world health organization (who) estimates that there are annually around million new cases of syphilis in the world, more than % occurring in developing countries. despite significant decrease in syphilis transfusion transmission. the recent increase in worldwide incidence associated with the risk of transmission through platelet concentrates (cp), which are stored at room temperature, have called attention to the potential residual risk of syphilis transmission by transfusion. between and we observed in our institution a significant increase of % in positivity of syphilis among blood donors from . % in to . % in and . % in (p < . ). aims: to determine the prevalence of active syphilis in blood donors and characterize the serological profile of syphilis positive donors. methods: each positive sample in a treponemic chemiluminescence assay (cmia, abbott architect) performed during blood donor screening in was submitted to a treponemic elisa anti-treponema pallidum igm (euroimmun) and a non-treponemic test (antigen-omega diagnostics). samples with positive results for one or two of these tests (indicating recent syphilis) were submitted to a real-time pcr for syphilis. the inno-lia syphilis-fujirebio immunoblot test was also performed for samples that presented a positive result for elisa-igm alone. financial support: fapesp / - . results: among , samples screened in , ( . %) presented a positive result for cmia -syphilis. of these, ( . %) were included in the study. a total of samples ( %) showed vdrl+/igm+; ( %) vdrl+/igmand ( . %) vdrl -/elisa igm+. the inno-lia syphilis test was performed as a confirmatory test in ( . %) samples that presented positive results for elisa igm and vdrl negative with ( . %) positive results, ( . %) undetermined and ( . %) negative. none of the samples showed the presence of treponema dna by real-time pcr. the prevalence was . %, the incidence was . % in the year , and the incidence in relation to the total positivity was . %. both, prevalence and incidence were higher in men, white, not married, aging - years and high school educational level. we observed a % a-hbc seroprevalence in the elisa igm-syphilis positive samples and a prevalence of . % htlv coinfection. summary/conclusions: we observed a significant increase in prevalence of syphilis in ( . %) with an incidence of . % of the total of cases initially positive in the cmia test. according to our data, we could identify a risk of syphilis transfusion transmission in blood banks that exclusively use the vdrl for donor screening, once we found ( . %) cases with negative vdrl and elisa igm and inno-lia positive. continuous monitoring of the profile of donors infected with syphilis at this time of reemergence of the disease is useful and important not just for blood banks, as it reflects the epidemiological situation of disease in community, and can contribute to the definition of health policies. background: transfusion related sepsis is a serious concern limiting platelet storage time to days at room temperature. while most units are screened for bacterial contamination when collected, bacterial monitoring methods can take up to days to detect contamination. thus, cold storage of platelets represents an attractive alternative for improving platelet safety. in this study, we assessed bacterial growth in platelets stored either at room-temperature (rt; °c) or refrigerated (cs; °c). aims: the aims of this study were to ) assess the effect of storage temperature on platelet function and bacterial growth in "contaminated" platelet units, and ) identify factors contributing to bacterial growth during rt storage. methods: apheresis platelets in plasma (plt) were obtained from healthy donors using the terumo trima accel automated blood collection system (terumo bct). fresh plasma (fp) was collected similarly. aliquots of plt or fp were transferred to ph safe minibags (blood cell storage, inc) and "contaminated" with acinetobacter baumannii, escherichia coli, pseudomonas aeruginosa, staphylococcus aureus, staphylococcus epidermidis, or pbs (uninfected control). minibags stored at rt were agitated using an orbital shaker set to rpm while cs aliquots were stored under static conditions. bacterial growth was monitored daily through dilution plating. lactate levels were assessed by istat (abbott) cg + test cartridges. plasma glucose levels were assessed using blood glucose testing strips (germaine laboratories). platelet activation and aggregation were assessed on days , , , and by flow cytometry and multiplate platelet aggregometry, respectively. results: bacterial growth progressed rapidly over the first - days post-collection in all plt aliquots stored at rt except those challenged with s. epidermidis. significant growth of s. epidermidis was not detected until day . bacterial numbers remained unchanged in refrigerated aliquots through day . rt storage resulted in significantly (p < . ) decreased platelet aggregation over time which was exacerbated by bacterial challenge. plt function was largely preserved with refrigeration regardless of challenge. bacterial growth was significantly reduced, or at least delayed, in fp. fp challenged with gram-negative pathogens exhibited a significant (p < . ) delay in bacterial growth at day . while growth of e. coli and p. aeruginosa recovered by day , growth of a. baumannii was significantly (p < . ) inhibited throughout. fp challenged with gram-positive pathogens exhibited significant (p < . ) reduction in bacterial growth relative to plt aliquots. bacterial growth correlated with plt lactate production. lactate levels in plts challenged with e. coli showed diminished significantly after day , indicative of lactate utilization. with exception of fp challenged with s. aureus, bacterial growth was restored in fp supplemented with lactic acid in all challenge groups. summary/conclusions: refrigeration preserved platelet function while both inhibiting bacterial growth and lactate production. conversely, the opposite was observed with rt storage. these data demonstrate that bacterial growth can be controlled through refrigeration without loss of function and rt storage may potentiate growth of certain bacterial strains through accelerated plt metabolism. background: bacterial contamination of peripheral blood progenitor cell (pbpc) for transfusion has been the cause of serious sepsis and life-threatening infections. however, a standard procedure or choice of test sample(s) has not been established to screen pbpc products for microbial contamination, because these products are not large enough to facilitate inoculation of the recommended volume for the automated blood culture systems. samples taken from by-product plasma and low volume pbpc product were cultured in routine sterility test. aims: to evaluate the residual risk of microbial contamination in pbpc products for transplantation, we cultured sufficient post-thaw inoculation volumes from pbpc products which were discarded for various reasons in our blood center. methods: in routine sterility test, a -ml sample of by-product plasma collected with pbpc product was inoculated into bact/alert bpa and bpn culture bottle ( ml each) within h after collection. the bottles were then placed in the bact/ alert system and incubated for at least days or when a positive reaction was indicated by the automated liquid-media culture system. moreover, a -ml postthaw sample would be cultured before transplantation performed. in the residual risk investigation, discarded pbpc products were thawed, and then a -ml and a -ml aliquot were taken and cultured with the same method. all positive bottles were subcultured for bacterial isolation and identification. results: in september and march , after maintaining in liquid nitrogen for to years, pbpc products collected from patients, which was preserved in a volume between and ml, were discarded. all of these products had been cultured negative in routine sterility tests with plasma samples. these final products were thawed and cultured with both the -ml and the -ml aliquot. one of these pbpc products had the positive culture result with the -ml retested samples. nevertheless, the same pbpc product had the negative result with the -ml post-thaw pbpc sample and the -ml by-product plasma sample. propionibacterium acnes was isolated from the bpn positive bottle. summary/conclusions: the residual risk of microbial contamination in pbpc postthaw products still exist after routine sterility test with the plasma sample and the -ml volume of pbpc sample. the bacterium isolated from pbpc product was normal skin flora bacterium. an optimal screening method of pbpc products merits further study to increase the safety of the blood supply. background: hospital hygiene tools that serve as a proxy for assessment of microbial contamination are increasingly used. they include adenosine triphosphate (atp) bioluminescence and air particle counting. however, their use for microbial monitoring of blood banks remains underexplored. they could be of particular interest in a sub-saharan african setting (temperatures, dust) to circumvent bacterial culture and provide direct results usable for monitoring over time. aims: the aim of this study was (i) to quantify environmental bacteria in the air and on surfaces that are regularly in contact with blood products, and (ii) to evaluate atp bioluminescence techniques and particle counts as a predictor for bacterial contamination, in three blood banks in the democratic republic of the congo (drc). methods: samples were taken in three blood banks in the democratic republic of the congo: hôpital p ediatrique de kalembelembe (hpkll) ( surfaces, air), hôpital provincial g en eral de r ef erence (hpgrk) ( surfaces, air) and the national blood transfusion centre (cnts) ( surfaces, air). surfaces that are regularly in contact with blood products were selected (sealer, fridge, donor chair,. . ..). regular surfaces were sampled using rodac contact plates ( . cm²) containing cled and macconkey agar, irregular surfaces using swabs (nrsii, medicalwire). atp was measured on the same surface (pd , kikkoman), expressed as relative light units (rlu) per cm². air was sampled by active sampling ( liter; spinair, iul) on cled and macconkey medium. in parallel, particles > . lm and > lm were counted using a particle counter ( , liter; metone a). culture media were incubated for h at °c before counting colony forming units (cfu). results: for regular surfaces, the median (range) viable bacterial count was ( - ) cfu/rodac, ( - ) cfu/rodac, ( - ) cfu/rodac for hpkll, cnts and hpgrk, respectively. at hpkll, highest viable counts were found in the sink (plain growth) and cool boxes ( and cfu/rodac). in cnts the blood processing bench, the donor chair arm support and washing basin showed the highest counts (plain growth). whereas in hpgrk, most bacteria were found in a fridge (plain growth), blood bag trolley (plain growth) and manual separator ( cfu/ rodac). gram-negative bacilli were isolated from water basins and sink in cnts and hpkll, but also surfaces close to donor chairs at hpgrk. the median (range) of atp per cm² was . ( - . ) rlu at hpkll, ) rlu at cnts and . ( . - . ) at hpgrk. atp results and total viable count were not correlated (n = , p = . ). median (range) bacterial count in the air was ( - ) cfu/ l for all sites together. there was no correlation found between total bacterial count and particles > . lm or > lm (r = . and r = . respectively; p < . ; n = ) summary/conclusions: total viable bacterial count of surfaces varies over blood bank sites. according to our results, atp and particle counts did not correlate with bacterial counts on surfaces and in the air, respectively. bacterial isolates from blood bank environments in drc need to be identified and seasonal variations need to be evaluated. background: the risk of transfusion-transmitted hepatitis e virus (tt-hev) infections in line with the question of the necessity of hev-nat screening of blood products is currently subject to an ongoing debate on the importance of timely introduction of hev screening of blood donors and the impact of blood safety. different countries have chosen different regulatory approaches. just recently, the german federal authorities have introduced mandatory testing of all therapeutic blood products beginning from january st . however, we already decided to voluntarily test all our blood products since january . aims: in this study, we present our results of a % screening of therapeutic blood products for hev rna including four years of active surveillance of hepatitis e infection among blood donors in germany. methods: from january to december , a total of , allogenic blood donations from , individual german blood donors were screened in a minipool format of samples of for the presence of hev rna (realstar hev rt-pcr kit, altona diagnostic technologies (adt), hamburg, germany). nucleic acids were extracted from . ml plasma using the chemagen msm-i extractor (viral k, perkin elmer chemagen gmbh). the % lod of the assay was determined to . iu/ml ( iu/ml per single donation). the presence of hev-specific igm and igg antibodies was determined using the anti-hev igm/igg elisa (euroimmun, luebeck). hev rna concentrations were quantified using the first who international standard for hepatitis e virus rna for nat-based assays. all hev rna positive donors were deferred from donation for months. follow-up samples were tested for the presence of hev rna and hev-specific antibodies. genotyping was performed by sequencing of the hypervariable region (hvr) and orf . results: in total, hev rna positive donors were identified. of these, hev rna-positive donors, were nat-only positive donations ( . %, negative for anti-hev igm and anti-hev igg), three donors had a positive igm titer ( . %), donors showed reactive igm and igg titers ( . %), donors already had isolated igg titers ( . %). median values of viral loads were approximately twice as high in index donations that were antibody negative. merely donors showed elevated alt levels ( . %), mostly within a double increase within the reference range ( . %), only . % of donors had even further elevated alt levels. significantly higher alt values were found in donors with a viral load > , iu/ml compared to the group with viral loads between and iu/ml. available follow-up samples confirmed igg seroconversion for all donors, however we also observed long-term igm positivity in some donors. genotyping revealed genotype in all cases. the month-dependent incidence ranges from : to : , blood donations with a peak in june and july. summary/conclusions: the high number of identified hev rna positive donors emphasizes the need for hev-nat screening to increase the safety of blood products. this study further confirmed that hev infection is common in german blood donors. background: zika virus (zikv) is a mosquito-borne virus that has caused outbreaks in central and south america in february , and has threatened the safety of blood transfusion globally. there is a high risk of zikv transmission by whole blood and blood components transfusion. it was reported that, zikv rna in infected patients plasma can only be detected within to weeks. however, in whole blood, zikv rna might present positive up to day after the symptoms appear in some patients, even if the clinical symptoms disappeared with zikv rna negative in plasma. this phenomenon suggested that the presence of zika is associated with red blood cells (rbcs). moreover, another report showed that viral load in whole blood of type a west nile virus (wnv) patients was higher than type o, implying that the binding of virus to rbcs may be related to blood group glycoprotein. both of zikv and wnv are member of the flavivirus genus. the study is intended to explore whether zikv have the same adherence mechanism to rbcs as wnv. aims: to investigate the distribution of zikv in blood components and adherence of zikv to different blood types of rbcs in whole blood. methods: five units for each blood type of a, b, o and ab whole blood were randomly selected. each unit of ml whole blood was divided into two half-unit. zikv was added to one half-unit in a certain proportion, and incubated at °c for days. each component of whole blood was collected for viral load detection. in the other half-unit,rbcs were suspended in the same type pools of plasma with equal volume after the plasma removed from the whole blood after centrifugation. zikv was added with the same certain proportion, and then incubated at °c for days. the whole blood samples and the upper plasma by centrifugation were collected detected for zikv rna. meanwhile, rbcs were washed and resuspended with normal saline followed by viral load detection. results: zika rna of these samples which extracted from whole blood, rbcs, and plasma were determined in a quantitative reverse transcription pcr, and viral rna of each component was all up to copies/ml. although, zikv rna loads did not show significant difference in distribution between rbcs and their corresponding plasma components, zikv rna quantification were significantly higher than those in plasma (p < . ) in type o rbcs and lower than those in plasma (p < . ) in type ab rbcs. summary/conclusions: in our study, we detected high viral rna loads in rbcs. it was demonstrated that zikv adheres to erythrocyte in whole blood, and the blood type may have influence on the adherence. background: hong kong is not endemic for dengue virus (denv) with most of the documented cases being imported. the presence of sufficient number of mosquito vectors, aedes albopictus, in the territory has led to two self-limiting indigenous outbreaks affecting residents from to . during august to september , another outbreak of confirmed cases of autochthonous dengue fever were reported to the department of health, linked to two epidemiological clusters, one in lion rock park near wong tai sin (wts) district ( cases) and the other in cheung chau, an outlying island ( cases). aims: we assessed the risk of dengue transmission from blood donors during the outbreak using a simplified version of the probabilistic model developed by biggerstaff and petersen (b-p) and the european up-front risk assessment tool (eufrat) model (oei, transfusion, ) . methods: patient demographic and general population data were obtained from the centre for health protection and the department of census and statistics of the hong kong government for the number of -to -year-old patients in the outbreak and residents of the same age range in hong kong and wts district as at mid- respectively ( - years old being the eligible age range for first time donation). to apply the b-p model, we estimated denv incidence among donors in hong kong territory and in wts with confirmed denv infection during august to september after correction for clinical:subclinical infections ratio, the mean length of asymptomatic viraemia and the probability of collecting blood from asymptomatic donors as described previously (seed, transfusion, ). to estimate the risk using eufrat model, outbreak and blood donation variables were entered into eufrat's web-based interface (https://eufrattool.ecdc.europa.eu/), which provided automatic calculation of risk-related output parameters. results: while using the b-p model, the estimated risk of collecting a denv viraemic donation was one in , ( , - , , ) territory-wide for the -day study period but increased to one in , ( , - , ) in wts. similarly while applying the eufrat model, the risk of encountering a viraemic donor was in , ( , - , ) territory-wide and in , ( , - , ) in wts during the same period. the eufrat also predicted a territory-wide issue of . unit of denv-contaminated labile blood component during the outbreak period. summary/conclusions: like many mosquito-borne infections such as denv, the risk is characteristically localised and varies geographically and seasonally during outbreaks. the average predicted risk of collecting a denv-viraemic donation territory-wide is low at in , during the outbreak based on the b-p model, which was generally considered as tolerable. however, the risk increased by folds when blood donations were collected from wts residents, who had higher chances of paying visits to lion rock park in close proximity. it was then justifiable to institute risk mitigation policies such as geographically-based deferral and/or fresh component restriction, enhanced post-donation reporting, etc. to protect against blood safety. background: hev is a developing threat to blood safety following the reporting of several cases of transfusion transmission hev (tt-hev). transfusion-related hev infection has been reported in several countries but its true frequency is probably underestimated because it is often asymptomatic and testing of blood donors is infrequent. pakistan is classified as a highly endemic region; with sporadic cases of hev occurring throughout the year, mainly affecting the adult population. to the best of our knowledge, no studies have been reported from pakistan on the epidemiology of hev in blood donors. aims: to assess the epidemiology of the hev specific antibodies and serum alt levels in blood donors of capital twin cities of pakistan. methods: this cross sectional study was conducted from july to december at three blood banks in the capital twin cities (rawalpindi and islamabad) of pakistan. the blood donors were equally distributed across the three blood banks. only donors who tested negative for hiv, hbv and hcv were included in the study. serum alt levels were analyzed by using automated clinical chemistry analyzer (selctra pro m) using merck kits. all samples were tested for hev-specific antibodies (igm and igg) by using enzyme linked immunosorbent assay (elisa) kits (adaltis, italy). statistical analyses were performed using spss software version . (ibm). results: in our study population there were ( . %) males and ( . %) females. the mean age of recruited blood donors was . (sd ae . ), with a range of - . younger donors were more common with a frequency of - year olds of ( . %). we found an overall hev igg prevalence of . % and an hev igm prevalence of . %. there were ( . %) blood donors who were positive for both igg and igm antibodies. our results revealed that the hev specific antibodies (igg, igm) prevalence increased with age. the mean value of serum alt was . (sd ae . ) with a range of - iu/l. the serum alt levels were elevated (> iu/l) in ( . %) blood donors. there was significant correlation (p=< . ) between serum alt level and hev specific antibodies for igg and igm. summary/conclusions: this study shows that a significant proportion of blood donors at our blood centers have been infected with hev and may be able to cause tt-hev. as we have not yet measured hev rna, we have used igm antibodies as a proxy for donors who have active infection. hev is generally asymptomatic, so it is debatable whether mandatory hev screening in blood donors should be required. results of this pilot study show that there is a need to conduct a larger study at national level with highly sensitive assays before making screening for hev mandatory in pakistan. background: hepatitis e virus (hev) is a zoonotic virus. who estimates that there are million hev infections, million acute hev cases and thousands hevrelated deaths worldwide each year. in recent years, the prevalence of hev in european and american countries has increased significantly. the survey results show that the positive rate of hev igg in blood donors is respectively . % in new zealand, . % in britain, . % in denmark, % in the united states and . % in the netherlands. hev has become a global public health concern. in addition to the food route of infection, several cases have been reported that hev can be transmitted via blood products. aims: to investigate the prevalence of hepatitis e virus (hev) infection among voluntary blood donors and potential impact on blood safety in guangzhou china. methods: blood samples from blood donors were collected from april to april at the guangzhou blood center and were tested for anti-hev igg antibody (hev igg), anti-hev igm antibody (hev igm) and hev antigen (hev ag)by enzyme linked immunosorbent assay (elisa). hev rna detection was performed on hev antigen positive samples by rt-pcr. the association of age, gender, ethnicity, occupation and alt with hev igg and igm were analyzed by chi-square test. multivariate logistic regression analysis was applied to identify the independent risk factors of hev infection. results: the positive rates of hev igg, igm and hev ag were . % ( / ), . % ( / ) and . % ( / ), respectively. no positive hev rna was detected. age and ethnicity were independent risk factors for hev igg and hev igm. the rate of hev antibody increased significantly with age (igg or = . , p < . ; igm or = . , p < . ). donors who were zhuang minority ( . %, . %) showed higher anti-hev than those who were han ethnicity ( . %, . %), and the difference was statistically significant (igg or = . , p = . ; igm or = . , p < . ). in addition, we found that occupation was an independent risk factor for hev infection, where students showed the lowest anti-hev rate. summary/conclusions: the results indicate that the positive rate of hev antibody among blood donors in guangzhou is high, and the infection status differs in different populations. our study provides basic data for the estimation of risk of transfusion-transmitted hev. background: human cytomegalovirus (hcmv) belongs to the viral family of herpesviridae. it is an enveloped double-stranded dna virus, widely distributed in the human population ( - % seropositive subjects worldwide) and cause of severe disease in immunocompromised patients and upon infection of the foetus. in normally healthy subjects, hcmv persists lifelong without clinical manifestation undergoing alternating phases of active viral replication and latency. since hcmv can be readily detected in blood, as free virus as well as associated to neutrophils and monocytes, hcmv transmission is a complication of blood transfusion. even though leukoreduction of blood products has been shown to significantly reduce the risk of hcmv transmission, higher inactivation standards may be required for high-risk, immunocompromised groups of patients. aims: in this study, murine macrophages infected with murine cytomegalovirus (mcmv) were used as a model to study the inactivation cell-associated cmv in human plasma using the theraflex mb-plasma system (macopharma). methods: mcmv expressing the green fluorescent protein was used to infect murine macrophages. infected macrophages were harvested h after infection, washed and used for spiking of plasma. plasma units (n = , ml) were spiked with infected cell suspension ( % v/v) and treated with the theraflex mb-plasma system according to the manufacturer's protocol using the macotronic-b illumination device (macopharma). samples were taken after spiking (load and hold sample), after illumination with different light doses ( after addition of mb, , , and [standard] j/cm ) and after blueflex filtration. mcmv titers were determined by endpoint titration and large volume plating on murine fibroblasts. infectious virus, which expressed gfp in infected cells, was detected using a fluorescence microscope. results: the results of infectivity assay showed that the treatment of human plasma by the theraflex mb-plasma system inactivated cell-associated mcmv in a dosedependent manner. after spiking with mcmv infected macrophages a mcmv titer of . (bag no. ) and . (bag no. ) log tcid /ml was achieved in the plasma units. in hold samples, a mcmv titer of . (bag no. and bag no. ) log tcid /ml was determined. the illumination step of the theraflex mb-plasma treatment procedure efficiently inactivated mcmv. already three-fourths of the standard light dose decreased infectivity of cell associated and remaining cell-free mcmv to infectivity levels below the limit of detection (≥ . log). further investigations would be needed to evaluate the log reduction capacity of the blueflex filtration step for cell-associated mcmv. summary/conclusions: the results with the murine model virus suggest that the theraflex mb-plasma system is an effective technology to inactivate cell-associated cmv in human plasma units. background: the use of pathogen inactivation (pi) technologies for platelet concentrates and plasma is slowly but steadily increasing. methods for treatment of red blood cells (rbcs), the most commonly used blood component, are still under development. aims: a novel approach for pi in rbc units employing uvc light was developed. methods: pi treatment was applied to full-scale rbc units after leukodepletion. the pi capacity of the uvc-based method was evaluated by bacteria and virus infectivity assays. a panel of in vitro assays to measure quality, metabolism, functional, morphologic, and blood group serology variables was applied to a pool-and-split approach in which pathogen-reduced rbcs were investigated in comparison to untreated rbcs. results: uvc treatment caused dose-dependent inactivation of bacteria and enveloped and non-enveloped viruses in rbc units. at a full dose, the mean log reduction factors ranged from . (bacillus cereus) to . (serratia liquefaciens) for the tested bacteria, and from . (emcv) to ≥ . (vsv) for the tested viruses. uvc treatment did not alter rbc blood group antigen expression. quality of uvc-treated rbcs was maintained during storage, e.g. hemolysis in uvc-treated and untreated rbcs were well below . % until day of storage. summary/conclusions: the data obtained until now show that uvc irradiation is a potential new method for pi in rbcs and justify further development of this process. background: histo-blood abh antigens are the mayor allogeneic antigens in human and they are widely distributed in almost all tissues. the expression of a- , -fucosyltransferase (fuct ), encoded by fut gene, determines the secretor status of an individual. about % of caucasian population have a functional copy of fut (secretor gene) expressing abh blood group soluble antigens in organic fluids such as saliva and seminal plasma. this individuals are known as "secretors". soluble abh blood group antigens have been associated with several metabolic and infectious diseases as well as reproductive failures. the incidence of infertility related of both male and female factors continues to rise despite many advances in reproductive technologies. it is well known that abo antigens are expressed on sperm membrane and in seminal fluid of secretors as well as abo antibodies are present in cervical mucus. in previous studies we observed significant loss in progressive motility of spermatozoa of non-secretors compared to secretor ones caused by specific cervical mucus antibodies in abo-incompatible couples. in addition, sperm cells are haploid cells, so that a heterozygous individual has two sperm subpopulations, each expressing the corresponding allele. the specific antibody of cervical mucus will attack only its complementary sperm. aims: to evaluate the prevalence of secretor character in men belonging to fertile and infertile couples in order to investigate a possible association with reproductive success. methods: samples of semen, from infertile men and from fertile controls were studied. comprehensive infertility evaluation was performed in all patients according to who criteria. secretor phenotype was evaluated in seminal plasma by inhibition of hemagglutination assay using saline erythrocyte suspensions, monoclonal antibodies anti-a, anti-b and lectin from ulex europaeus (anti-h). to distinguish between abo genes, genomic dna was extracted by an enzymatic digestion method. pcr was designed with two sets of oligonucleotides that allow to amplificate two different regions of the transferases without use of restriction enzymes. by comparison of bands of the pcr products, the individual genotype was determine. cervical mucus antibodies of their female partners were titrated with the corresponding red blood cells. results: results were analysed in both groups. in infertile couples with abo incompatibility, the frequency of non-secretor phenotype of male partners ( . %) were significantly higher than those from fertile couples ( . %) (p < . ) the results obtained by pcr in sperm cells correlated % with red cells phenotypes. summary/conclusions: incidence of infertility continues to increase. several factors have a negative impact on men's reproductive health. immunological implications are now being studied and considered as a cause of failure in sperm-egg interaction, even among normal gametes. secretor phenotype in male partners could help reproductive success by blocking cervical abo antibodies. furthermore, if the male is heterozygous, cervical mucus antibodies will only affect the corresponding sperm. we propose to evaluate abh antigen expression on sperm membrane and seminal plasma as well as abo antibodies in cervical mucus to contribute to the diagnosis and treatment of human infertility. background: the h blood group contains one antigen, the h antigen, which is present on virtually all red blood cells (rbc) and is the acceptor substrate of both a and b gene-specified glycosyltransferases. in blood group o the h antigen remains unmodified and therefore its rbcs show the highest and the rbcs of blood type ab the least amounts of h antigen. individuals with the so called bombay phenotype carry homozygous h null alleles (h | h) and do not produce any h antigen. the para-bombay phenotype retains some h antigen on rbcs either induced by a weakly active (h+ w | h+ w ) or completely silenced fut gene (h | h), mandatory linked with an active fut gene. aims: in this study, we aimed to develop an adapted flow cytometric method to quantify the relative amount of h substance present on rbcs in order to distinguish different abo phenotypes in routine diagnostics as well as to capture rare h-deficient phenotypes. methods: analyses were performed on a flow cytometer (facs canto ii, bd biosciences, ch) and measured with identical instrument settings. list mode data were evaluated and visualised using bd facsdiva software. rbcs were incubated with increasing concentrations of monoclonal anti-h antibodies (bric -pe and a : mixture of bric -pe/bric , ibgrl, uk). after rinsing the cells with pbs, micro-aggregates were mechanically dissolved. rbcs from blood donors with different abo phenotypes (o ( ), a ( ), a ( ), b ( ), a b ( ), a b ( )) and patients with genetically confirmed bombay and para-bombay phenotype were assessed. results: saturation of h antigen binding sites on type o rbcs was achieved only upon use of a : antibody mixture (bric -pe/bric ) covering approx. half of the h-binding sites by unconjugated bric . in contrast, non-o type rbcs reached saturation of h-binding sites using pure bric -pe. rbcs coated with bric -pe at saturation revealed a distinct pattern of mfi (mean fluorescence intensity) depending on the abo phenotype. in addition, mfis of rbcs upon staining with bric -pe did discriminate bombay-and para-bombay type rbcs, respectively. summary/conclusions: adapted flow cytometry is able to distinguish variant expressions of rbcs h antigen. thus, our flow cytometric method may complement traditional serological and genetic analyses in routine abo phenotype cases or, more intriguing, when the bombay or para-bombay phenotype is suspected. it will be of interest to further prove this method by investigating additional rare h-deficient phenotype cases. s chen , , x xu , , x hong , , k ma , , j he , , j chen , and f zhu , blood centre of zhejiang province zhejiang provincial key laboratory of blood safety research, hangzhou, china background: weakened a and b antigen expression results in abo typing discrepancies. h gene controls the development of h substance from which a and b antigens develop. depressed a and b antigen expression and strengthened h antigen expression are always simultaneously observed in abo subgroups. there are other possibilities for weak antigen expression of abo system such as leukemic change and pregnancy. it is undiscovered whether abnormal expressions of a, b and h antigen stand for abo subgroups in hemopathic patients. aims: the aim of this study is to explore the role of enhanced reactions with anti-h in direction to abo subgroups of hemopathic patients. methods: samples from blood donors and hemopathic patients with nonconcordant abo typing by serological tests were collected after consent information. the agglutination strength of these rbcs with anti-h reagent was recorded. enhanced reactions were determined by comparison with the results from normal abo groups. the genomic dnas of samples were extracted and genotyped for abo system. this work was sponsored by the medical science research foundation of zhejiang province ( rc ). results: samples in blood donors showed increased expression of h antigen, of which were identified as abo subgroups. there were enhanced reactions in hemopathic patients. however, were finally confirmed as normal abo genotypes. no statistical significance ( . % vs . %, p > . ) in the frequency of strengthened h antigen expressions was observed between donors and hemopathic patients. the total number of subgroups is and respectively in blood donors and hemopathic patients. extremely significant statistical differences ( . % vs . %, p < . ) existed in the frequency of subgroups with enhanced h antigen, which meant the possibility of subgroups in hemopathic patients samples was less. summary/conclusions: the expression of h antigen is comparably enhanced in subgroups and hemopathies. but most of hemopathic patients with strengthened h antigen expression present normal abo genotypes. as a result, the enhanced reaction with anti-h is necessary but not sufficient for serological identification of abo subgroups in hemopathic patients. background: although the use of automated blood bank analyzer with the advantages of speed and efficiency has recently increased, the abo discrepancies in automated blood bank analyzer have caused the reporting delays of the results and increase of the task. aims: we analyzed the causes of abo discrepancies in automated blood bank analyzer and suggested a solution strategy based on the causes. methods: from november to january , cases ( . %) of abo discrepancies among , abo blood type tests performed using the -min reaction mode of ih- in chonbuk national university hospital blood bank were identified. we compared the test results of -min mode with results of immediate mode using different red cell reagents, and analyzed the causes of discrepancies by performing additional tests such as microscopy, auto-control, antibody screening and identification, anti-a and abo genotyping. results: in the immediate reaction using different red cell reagents, cases ( . %) of discrepancies disappeared and cases ( . %) remained discrepancies. all abo discrepancies observed in the -min reaction were due to serum side causes, and one case ( . %) was due to both of serum and red cells side cause. nonspecific response ( cases, . %), cold antibody ( cases, . %), rouleaux formation ( cases, . %), cis-ab ( cases, . %), and abo subtype ( case, . %) were analyzed as causes of discrepancies. one discrepancy due to cis-ab was disappeared in the immediate reaction using different red cell reagents, abo subtype was changed to totally different blood group, a. on the other hand, in cases of the discrepancy corrected by the immediate reaction using different red cell reagents, the intensity of the positive results still observed in immediate reaction was not different from the -min reaction. summary/conclusions: ih- , an automated blood bank analyzer, was considered useful for automation of abo blood typing, and some observable abo discrepancies are expected to be mostly addressed by reexamining with immediate reaction mode using different red cell reagents. abstract withdrawn. background: abo blood group antigens mainly expressed on red blood cells, but along with that they also present on many organs and tissues like epithelia, platelets, vascular endothelia and neurons etc. the importance of abo antigens extends beyond transfusion medicine by association with various systemic diseases like cardiovascular diseases, gastric diseases, cancers, infectious diseases etc has been proven previously. previous researchers also tried to find out the involvement of abo antigens in neurological diseases like alzheimer's disease, parkinson diseases etc. but association with neurological tumours is less explored. aims: this study aimed to analyse the association of abo blood group antigens with neurological tumours. methods: a retrospective study in a tertiary care institute in india analysed the years data from jan to dec . the carcinoma patient's admitted in neurosurgical department during study period were included in our study. their diagnosis and abo blood groups were collected from hospital information system. data were analysed into microsoft excel and spss (version ). results: during study period a total of patients with neurological tumours were admitted in our hospital. the blood group frequency of these patients were . %, . %, . %, . % for a, b, o and ab respectively. the common neurological tumours found in our study were glioma ( . %) followed by pituitary adenoma ( . %), meningioma ( . %), schwannoma ( . %), cavernoma ( . %), neuroma ( . %) and space occupying lesions ( . %). the prevalence of abo antigens was almost similar in all neurological tumours except in neuroma. neuroma was found in . % o group patients as compared to other blood groups which was found statistically significant (p < . ). summary/conclusions: in this study we tried to analyse the association of neurological tumours with abo blood groups antigens. we found there is no association of neurological tumours with abo blood groups because the prevalence on abo group in general population is almost similar in patient with neurological tumours except neuroma. neuroma group of tumours like neurofibroma, neuroblastoma, nerve tumours etc. were more common in o group of patients while in our population frequency of b blood group antigen ( . %) is more common as compared to o blood group( . %). background: rhd and rhce represent homologous genes in head-to-head position on chromosome (chr , p . ). they encode for the proteins rhd resp. rhce which compose together with rhesus associated glycoprotein (rhag), band and ankyrin the ankyrin complex (ac) linking the red blood cell (rbc) membrane to aspectrin of rbc cytoskeleton (s.e. lux, blood, ). cooperatively, the proteins of ac are important for maturation and physiologic properties of rbcs. many proteins of the rbc membrane express blood group antigens on their extracellular surface and are therefore of concern in transfusion medicine. cepellini et al. described weakened hemagglutination reactions of rhd+ rbcs in the presence of an rhc+ antigen (cepellini et al, pnas, ) . we attempted to further elucidate the expression of rhd/rhag proteins in various rhce/rhce pheno-/genotypes using a sophisticated flow cytometry approach. aims: in this study, we investigated a flow cytometric method for measurement of the antigen-density of various rhce-phenotypes. methods: analysis was performed on a flow cytometer (facscanto ii, becton dickinson (bd)) using bd facsdiva software and identical instrument settings for all samples. optimized number of rbcs was incubated with saturating concentration of pe-conjugated anti-rhd antibodies brad- /brad- /fog- (ibgrl, bristol, uk). debris was excluded by rbc gating in fsc/ssc plot. quantibrite-pe beats (bd) were applied according to manufacturer's instruction to quantify the relative expression of rhd epitopes. in addition a representative number of samples from common phenotypes were assessed for expression of rhag using bric- pe (ibgrl). results: a total of samples from healthy blood donors with serologically defined rhcde phenotypes were included into this study (rr( ), r r( ), r r ( ), r r( ), r r( ), r r ( ), r r ( )). variant expression of rhd by different rhce phenotypes using brad- -pe was shown. rhd was weakly expressed in presence of rhc antigen (cepellini effect). effect of rhd gene dose on rhd protein expression is mitigated by rhc/c genotypes. when only samples with molecularly confirmed phenotypes were assessed, the rhdce genotype predicts consistently the strength of rhd protein expression. outlier samples ( ) were retrospectively genotyped and revealed rhdce genotypes as expected from the strength of rhd expression falsifying serological rhcde phenotypes. in contrast, rhe/e polymorphic site does not correlate with rhd expression. in addition, rhag protein is equally present across all rhcde phenotypes. similar results were obtained by using alternative anti-d antibodies such as brad- -pe and fog- -pe, although different antibody's avidity precludes quantitative comparison of antigen expression on rbcs. summary/conclusions: sophisticated facs methods reveal different expression of rhd on rbcs according to rhce/rhce phenotype/genotype. rhc/c polymorphic sites (c. g>c, c. a>g, c. a>g of exon , exon resp. and intron ) are in linkage with rhd expression, confirming the observation by cepellini et al. in contrast, rhe/e (c. c>g, exon ) is not in linkage with rhd expression. based on epigenomic signature it is conceivable that altered transcription factor binding sites (tbs) of rhd mirrored by homologous rhc/c may cause variant rhd expression. rhe/e snp mirroring the homologous sequence of rhd in exon is not recognised as tbs. in addition, although ac comprises all three rh proteins (rhd, rhce, rhag), their transcriptional regulations seem to be distinct. red cell reference laboratory, australian red cross blood service, perth, australia background: the rh antigen was first described when an antisera thought to contain a potent anti-c did not react with all c+ cells. these non-reacting c+ cells were classified as c+, rh:- , and the antibody specificity anti-rh . most polyclonal anti-c contain anti-c and anti-rh . previous studies have shown of monoclonal anti-c reagents are actually anti-rh . these reagents will not detect the c antigen where the red cells are rh:- . aims: the australian red cross blood service investigated a phenotype discrepancy in a blood donor. the donor's historic phenotype c+ (r r) was inconsistent with the current donation phenotype c-(r r ). we aimed to investigate the cause of the discrepancy so the donor could be assigned the correct phenotype, identify the root cause of the discrepancy and implement any corrective actions. methods: the donor's red cells were phenotyped with all available anti-c reagents as per the manufacturers product insert across both manual and automated testing platforms. following variable results and weaker reactions with some reagents, dna was extracted from the edta sample and was genotyped using immucor bioarray tm hea precise and rhce beadchip tm . targeted dna sequencing of rhd and rhce was also performed using the trusight tm one sequencing panel. a review of the historical phenotype results, including the testing platform and reagents used at the time was also performed. results: on the current sample the donor's red cells gave a + reaction by tube with bio-rad seraclone â ( ) [clone ms ] and immulab epiclone tm [clone anti-c reagents. the sample tested negative on the beckman coulter pk using beckman coulter anti-c [clone ] blood grouping reagent and tested positive ( ) reaction on the immucor neo using immuclone â ( ) anti-c [clone . immucor bioarray tm hea precise beadchip tm predicted a c+ phenotype and no variants were detected with the bioarray tm rhce beadchip tm . the trusight tm one sequencing panel genotyped the donor as rhd* /* n. and rhce* . /* with a predicted phenotype of c+, c+ w , d+, e-, e+, rh: (locr+), rh:- . a review of the donor's historical records indicated the donor tested as c+ on the pk , which at the time was being used with an in-house bromelain preparation (sigma-aldrich) and diagast olymp pheno anti-c reagent [clone ms ]. summary/conclusions: results indicated the phenotype discrepancy was caused by the c+ rh:- variant associated with the rhce* . allele. reagents containing clones ms- and ms correctly phenotyped the donor as c+, with the manual tube reagents showing a weaker reaction which may alert the operator to a possible variant which is important in the patient setting. the beckman coulter pk and associated anti-c [clone ] failed to detect the c antigen. this reagent appears not to detect the c antigen where it is associated with the rh:- phenotype, which is in contrast to the previous report by faas et al, transfusion, where it was demonstrated that clone reacted with c+ rh:- bromelain treated red cells. abstract withdrawn. background: although serological rhd typing has always been challenging due to variation of techniques and variable sensitivity of anti-d reagents, most individuals are unequivocally typed as either rhd positive or rhd negative. however, variants of d (weak d and partial d phenotypes) may present typing difficulties. individuals with partial d (missing epitopes of the d antigen) must be typed as rhd negative as blood receivers, but as rhd positive, as blood donors. aims: the aim of our study was to evaluate the algorithm used since at ahepa university blood center, to resolve rhd typing problems among first time donors. methods: since automatic analyzers may type variants of rhd as rhd+, our practice is to routinely perform two different typing methods in first time donors: an automated microplate method on the neo analyzer (immucor) and the slide test, using a potent reagent (anti-d blend-immunodiagnostika). in case of negative, weak, slow or mixed-field reaction, further testing with an automated microplate weak d method [immucor-modified indirect antiglobulin (anti-igg) test] follows. the next step of the protocol consists of testing with the commercial id-partial rhd typing kit (bio-rad) comprising a panel of monoclonal anti-d reagents, in an indirect coombs gel test assay. the patterns obtained with this kit can distinguish between d weak and partial d and can also differentiate between categories ii, iv, v, vi, vii dfr, dbt and dhar. the last step of our algorithm consists of molecular testing (immucor bioarray rhce and rhd beadchip assays) at the hellenic national blood transfusion center, in case of remaining uncertainty. results: we applied the above algorithm in samples: a) by using the partial d kit, samples were typed: four samples were characterized as "partial d" ( dfr, diii) and as "weak d". four of the weak d samples (all from women of reproductive age) were confirmed by molecular typing ("weak d type " three samples, "weak d type . or . " one sample). b) the nine ( ) remaining samples that showed atypical serological pattern, were sent for molecular testing, which characterized samples as "weak d type ", one sample as "weak d type " and another as "weak d type ". results are pending for samples. summary/conclusions: in our experience some partial rhds may be mistyped as rhd+ if the technologist does not inspect the pattern of the reactions and only takes into account the assignment by the automatic analyzer as d+ or d-. by use of our algorithm, serological characterization was sufficient to distinguish between weak d and partial d in , % of cases. molecular typing was necessary in the rest. the integration of molecular techniques improves the quality and accuracy of d typing of blood donors. if applied to patients, it also allows administration of d positive blood without compromising safety to those carrying prevalent weak d types that have not been reported to produce anti-d. furthermore, it permits withholding rhig in case of pregnant women carrying such weak d types. background: rhd antigen is one of the most clinically significant blood group antigens. except d positive and d negative phenotypes, there are over rhd variants, which represent as serologic weak d phenotypes (swd). patients with certain swd can make anti-d alloantibodies. by serology testing it is not possible to clearly distinguish among different swd. in croatian institute of transfusion medicine (citm) patients and pregnant females with swd are mostly reported as rhd negative and generally did not refer for confirmation, because molecular testing was not part of the algorithm. that remains the risk of shortages of rhd negative blood and overuse of anti-d immunoprophylaxis for pregnant females. according to uk guidelines patients with swd who are likely to require chronic transfusion support and females ≤ years are treated as d negative and refer for confirmation of d type. people who are rhd genotyped as weak d type , or are not susceptible for rhd alloimmunisation. one study showed that in croatian population the most frequent variants are weak d type , and . aims: the aim of this study is to estimate the prevalence of swd in patients and pregnant females and to find out serologic and molecular characteristics of swd referred for confirmation. methods: from / / to / / we analysed . samples of patients and pregnant females. rhd typing was performed by anti-d igm monoclonal reagents in direct agglutination micromethod on tango (bs , bs ) (biorad, dreieich, germany), swing maestro [lmh / (ldm ) + - and th- + rum- + ldm ] and ih- [lmh / (ldm ) + - ] (id-card, biorad, cressier, switzerland). cut-off value for tango was determined as ++ and for gel microtyping as +++. the samples with results below the cut-off were reported and treated as rhd negative, all except those which gave discrepant results at current testing or with historical data. these were sent to rhd genotyping for confirmation. dna extraction was done by qiaamp blood mini kit (qiagen, hilden, germany) and rhd genotyping by pcr-ssp kits ready geneweak d and ready genecde (inno-train, kronberg im taunus, germany). results: from . samples ( , %) were swd. / ( %) were referred to rhd genotyping. / ( %) samples were weak d type , or , while / ( %) were weak d type and partial d variants vii and va. serologic reactions with monoclonal igm anti-d reagents showed different pattern for weak d types , and . clearly negative serologic reactions were given in / samples with bs and bs , in / samples with lmh / (ldm ) + - and in / samples with th- + rum- + ldm . summary/conclusions: the prevalence of swd in this study is rather low ( , %). after rhd genotyping % of referred samples were finally reported as d positive. serologic determination of d variants is inconsistent and only rhd genotyping can resolve rhd status in swd. to define the permanent rhd status of swd female of childbearing potential and patients who are likely to be chronically transfused we will introduce rhd genotyping in the new algorithm. background: among all blood group systems, the antigens of the abo system are by far the most clinically significant. comes second in importance is the antigens of the rh system, which comprise d, c, e, c, and e antigens. another clinically relevant antigen is the k of the kell blood group system, which is known to be involved in both htr and hdfn. the distribution of the major blood group antigens, such as rh, and kell, is well-studied among populations of developing countries. in contrary, a relatively few studies have addressed their frequencies in saudi arabian population this is also the case in jazan province, where only two published studies have analysed the prevalence of abo and d antigens, while the frequency of other clinically important antigens, such as rh and kell antigens, is yet to be explored. aims: to determine the frequency of the following clinically relevant blood group antigens; rh(d, c, e, c, e) and k among saudi blood donors in king fahd central hospital in jazan province. methods: a retrospective, cross-sectional study was carried out in the blood bank of king fahd central hospital in jazan province. the red cell phenotyping records for blood donation of randomly selected saudi donors, who donated blood between january and june , were reviewed to identify the prevalence for the following antigens: d, c, e, c, e and k. the hospital blood bank routinely performs rh/k phenotyping for all blood donation using either bio-rad or ortho diagnostic column agglutination technology (cat) platforms. phenotype frequencies were expressed as percentages. results: this study included a total of saudi voluntary as well as family replacement blood donors. the d antigen was found to be positive in . %, while k antigen was positive in . %. among other studied rh antigens, e was the most common ( . %) followed by c ( . %), c ( . %) and e( . %). dce/dce ( . %) and dce/dce ( . %) were the most common phenotypes amongst d-positive and dnegative donors, respectively. surprisingly, dce/dce phenotype was significantly prevalent ( . %) with almost times higher frequency compared that reported in caucasians ( . %). the rare phenotype dce/dce was found in donors ( . %), while dce/dce and dce/dce phenotypes were found in only one donor each. summary/conclusions: this study is the first to determine the frequency of rh and k antigens in saudi blood donors in jazan province. determination of the frequency of these clinically significant antigens in our geographical area will facilitate the selection of antigen-matched red cell units for transfusion in recipients with multiple alloantibodies. it will also help in the management of blood donation processes and planning the estimated need of blood stock of different blood group phenotypes to meet the patient's needs. abstract withdrawn. background: the gerbich (ge) blood group system includes several high-frequency antigens located on glycophorin c and d. with only few reports published on the clinical significance of antibodies directed against these antigens, it is unclear whether blood transfusions have to be antigen negative in the presence of an anti-ge antibody. the monocyte monolayer assay (mma) is an in-vitro method used to estimate the clinical significance of alloantibodies. aims: to illustrate the role of the monocyte monolayer assay (mma) in the transfusion management of a patient with an anti-ge alloantibody. methods: the clinical and transfusion history was retrospectively retrieved from the patient's medical records. serological investigations were performed by indirect antihuman globulin test. papain and trypsin treated cells were also used. the clinical significance of the antibody was assessed by mma. genomic dna was isolated from whole blood and the samples were further characterized by pcr. results: a -year-old male patient with lung cancer without previous transfusions was admitted ( / ) for surgery. his hemoglobin was . g/l. an anti-ge antibody was detected and it was decided to transfuse ge-positive packed red blood cells (prbcs). however, no blood transfusion was needed. in july , the patient was admitted for colon cancer surgery with a hemoglobin of , g/dl. the anti-ge alloantibody was still detectable and a ssp-pcr revealed the genotype ge* .- . an mma performed on the pre-transfusion sample revealed a monocyte index (mi) of . % and the antibody was considered not to be clinically relevant. the mi was interpreted as following: - % not significant; - % inconclusive; > % clinical significant. however, due to the clinical background of the patient it was decided to transfuse ge-negative prbcs, which were obtained from etablissement francais du sang (efs), paris, france. two days after surgery, the patient received units of ge:- ,- prbcs without any transfusion reaction. one and a half year later ( / ), peritoneal carcinomatosis, as a complication of colon cancer, was diagnosed. the patient's hemoglobin was g/l and he had a passage disorder, symptoms of deterioration and an adynamia. based on the mma results from july indicating no clinical significance of the antibody, it was decided to transfuse ge-positive prbcs. in the following days the patient received a total of units of gepositive prbcs no immediate or delayed transfusion reaction were observed following these transfusions. two further mma's, performed on samples drawn on december th and th ( days after transfusion of a total of three and two days after two further prbcs respectively), showed a mi of . % und % respectively and the anti-ge antibody was considered still not to be clinically significant. summary/conclusions: we report the case of a patient with an anti-ge antibody transfused with ge-positive prbc. as ge-negative prbc are not available in switzerland and not easy to obtain internationally the mma can help in the decision on how to transfuse. in this case, the clinical course confirmed the mma-based prediction. transfusions of ge-positive prbcs were tolerated without signs or symptoms of immediate or delayed transfusion reactions. background: abo grouping discrepancies occur when the results of forward grouping are not corroborative to those of the reverse grouping. these may be due to weak subgroups of a and b, missing or weak abo antibodies or red cell alloantibodies. determination of correct abo blood group of a donor is essential for preventing abo incompatible transfusions and to avoid hemolytic transfusion reactions in the recipient. aims: to determine the frequency of abo discrepancies and their resolution to correctly identify the blood group of the donors. we also determined the frequency of 'weak d' positivity in rhd negative donors. methods: this was a retrospective study on donor samples collected from st april, to th september, (two and a half years). for discrepant samples, the abo and rhd grouping was repeated using tube technique using commercial antisera {anti-a, anti-b, anti-ab and anti-d (igm), anti-d blend (igm+igg), anti-h and anti-a lectins}. adsorption-elution testing was done for detecting weak subgroups of a and b. antibody screen ( -cell) and identification ( -cell) was done by gel technique (bio-rad, switzerland). 'weak d' testing in rhd negative donors was also performed by gel technique. antibody titration was done using tube technique. the donor details including name, age and the registration/unit number of the donation were also checked for all the discrepancies to avoid repetition while data analysis. results: we detected ( . %) abo discrepancies out of the total donor samples tested during the study period. out of these, ( . %) were rhd positive. the most common cause of abo discrepancies was weak anti-b antibody ( / ; . %), followed by weak anti-a antibody and weak subgroups of a ( / each; . % each) and weak subgroups of b ( / ; . %). the remaining . % ( / ) discrepancies were due to agglutination with o cells in reverse grouping. the overall frequency of weak subgroups of a and b collectively was . % ( background: detection of unexpected red blood cell (rbc) antibodies before transfusion is critical for prevention of hemolytic transfusion reaction. ideally, unexpected rbc antibody detection is carried out within days after receiving a patient's sample. however, in some cases, retests could be performed after more than days for evaluation of any transfusion reaction, quality control or research. therefore, it is necessary to determine the stability of antibodies after refrigeration or freezing for a certain period of time. aims: we carried out antibody identification test with fresh, refrigerated and frozen samples using automated analyzer ih- and manual tube methods to evaluate the stability of antibodies after storage and compare the results between the two methods methods: antibody identification tests were performed using ih- (bio-rad, cressier fr, switzerland) and manual tube methods. fifty samples showing positive results in antibody screening test by both methods were divided into three and tested immediately, week after storage at °c and month after storage at À °c. the specificities and reactivities of antibodies at each storage state were recorded and compared between the two methods. results: specificities of antibodies identified were concordant between ih- and manual tube methods irrespective of the storage state. the results were as follows: anti-e/e+c, ; anti-le a , ; anti-di a , ; anti-c+e, ; anti-m, ; anti-d, ; anti-c, ; anti-k, ; anti-jk a , : anti-xg a , ; unidentified antibody, ; autoantibody, cases. with regard to the changes in reactivity owing to storage, ( %) samples (anti-e+c, ; anti-m, ; anti-di a , ; anti-d, ; anti-c+e, ; anti-le a , ; anti-c, : autoantibody, ; unidentified antibody, ) showed identical reactivities after week and month storage by both ih- and tube methods. however, ( %) samples, comprising unidentified antibodies, anti-le a , anti-c+e, anti-e, anti-e+c, and autoantibody, showed decreased reactivities after storage in both methods. three samples, comprising anti-di a , anti-e+c and anti-k antibodies, showed increased reactivities after storage. one sample with anti-jk a showed increased reactivity only after month storage, while one sample with anti-xg a showed decreased reactivity only after month storage. higher reactivities were observed in all samples detected using the ih- analyzer than manual tube methods (p < . , wilcoxon rank sum test). summary/conclusions: the specificities of unexpected antibodies detected by ih- and tube methods were the same in all storage states; however, reactivities were higher in ih- than in the tube method. twenty-six ( %) of samples showed identical reactivities after week refrigeration and month freezing. nineteen ( %) samples showed decreased reactivities after storage; however, ( / , %) of them were nonspecific antibodies, unable to identify using commercial id panels. therefore, it is suggested that retests for evaluation of transfusion reaction, quality control or research could be reliably performed after more than days, if stored appropriately in refrigerated or frozen states. abstract withdrawn. t gleich-nagel , d huber-marcantonio , n rufer , g canellini and c niederhauser unit of transfusion medicine, interregional blood transfusion src, lausanne laboratory diagnostics, interregional blood transfusion src, bern, switzerland background: a positive direct antiglobulin test (dat) is mainly found in patients with warm/cold autoantibodies or alloantibodies directed against transfused erythrocytes. the identification of antibodies fixed on red cells is important for the clinician, allowing the further evaluation of a patient's clinical situation including their current medication. in immunohematology the elution of a positive dat remains a tedious and expensive procedure. the blood transfusion service src (bts src) has derived a flow chart that indicates in which situation an elution of dat positive samples should be performed. in order to follow the bts src guidelines, it is mandatory to obtain additional data related to the patient's condition, such as haemolytic parameters and recent transfusion history. currently, our laboratory is not always able to apply the recommended flowchart, since information is often unavailable. aims: here, we performed a comparative study between the algorithm provided by bts src and our in-house strategy, which is based on the qualitative changes of a positive dat, without the need for additional patient and biological information. methods: details of dat positivity and the patient's transfusion history was taken from the software eprogesa (mak-system) and analysed in excel. we analysed a total of ' dats and evaluated them for their positivity, whether an elution was performed or whether antibodies were detectable in the eluate. furthermore, we performed an additional analysis on those samples, that were derived from recently transfused patients (< days). results: a positive dat was found for igg and c d in out of ' ( . %) samples, a level similar to previous reports of positive dats for hospitalized patients. among these positive samples, ( %) were eluted because of a qualitative change in their positivity according to our in-house algorithm. identification of warm autoantibodies or alloantibodies occurred in only . % ( / ) of the cases. from the patients transfused within the last days and having a positive dat, ( %) were eluted according to our in-house algorithm. the same samples would have been analysed if the swiss transfusion guidelines had been applied. however, this comparative study reveals a significant discrepancy in regards to overall sample numbers that should have been eluted according to the two algorithms ( versus samples). this is mainly due to the fact that the swiss transfusion based algorithm does not recommend an elution of positive dats from patients who did not receive a transfusion within the last -days, except if there is a significant clinical suspicion (e.g. haemolysis). summary/conclusions: this comparative study indicates that our elution-based algorithm was performed on all clinically relevant samples as recommended by the bts src guidelines. qualitative changes in the dat positivity represent our main parameter for selecting those samples to eluate. besides ensuring that no clinically relevant samples were missed, this strategy also led to a large number of unnecessary elution analyses. in conclusion, a significant reduction in the laboratory workload and economical savings arises if the relevant clinical information and patients history is known prior to laboratory analysis. background: novel anti-cd monoclonal antibodies, such as daratumumab (dara) and isatuximab, used in treatment of multiple myeloma, interfere with routine blood bank serologic tests. as part of the strategies to manage these patients, it is recommended to perform extended phenotyping to provide matched units (aabb association bulletin # - ). many investigations have focused on the interference with iat for the screening and identification of underlying alloantibodies and how to overcome them, but less has been published on the potential interference with extended phenotyping techniques. aims: the purpose of this study is to compare different technologies to type the most important antigens in myeloma patients before and during the treatment with therapeutic anti-cd antibodies. vox sanguinis ( ) (suppl. ), - methods: edta-anticoagulated whole blood samples coming from patients in different stages of treatment with daratumumab and with isatuximab have been typed in parallel with dg gel microcolumn (grifols) and mdmulticard technology (grifols). the results are also compared with genotyping results obtained with id core xt (grifols). direct coombs, autocontrol and antibody screening has also been performed as complementary tests. results: the study provides that four patients had positive dat and/or ac before therapeutic cd antibodies treatment. in these cases, of negative antigens (fy / jk and/or s) turn to positive in gel technology but mdmulticard showed % agreement with genotype id core xt results. focusing in the data obtained during the treatment, negative antigens were type as positive in gel technology ( % of the tests). mdmulticard agreed with genotype in % of the analyzed antigens. as complementary data, of patient-treated samples had dat or ac positive and showed panagglutination. summary/conclusions: the results demonstrated that mdmulticard is an effective method to type cd -directed cytolytic antibodies treated samples in addition to dat and or autocontrol positive samples. background: antibody titration is a semi-quantitative method to estimate the strength and concentration of antibodies present in plasma or serum sample. titration methodology should be validated together with clinical data to evaluate the relevance of the titer value in each application. the titer of an antibody depends on different parameters: the antibody concentration in the sample, the density of the corresponding antigen expressed on the red blood cells used, the affinity constant of the antibody-antigen and other parameters regarding the technique used (e.g. gel cards or tube test). gel cards technology reduces the intra and inter-laboratory variation in titration studies comparing with the tube technique. aims: to evaluate the suitability of dg gel coombs, dg gel anti-igg and dg gel neutral (grifols) for titrations using two sample volumes ll and ll. methods: twenty frozen plasma samples containing unexpected antibodies from different specificities (anti-jk a , -fy a , -k, -d, -e and -c) were titrated in dg gel coombs and dg gel anti-igg cards and donor fresh plasmas with natural occurring antibodies (anti-a and -b) were titrated in dg gel coombs and dg gel neutral (saline technique). the titer of the antibodies was determined by testing two-fold dilutions of the plasma with selected red blood cells depending on the antibody tested. plasma samples were diluted in dg gel sol. selected red blood cells serascan diana, serigrup diana or donor blood were added into the card ( ll at . %). further, sample dilutions were dispensed into the card ( ll or ll). subsequently, cards were incubated min, °c (coombs technique) and min, - °c (saline technique), centrifuged in dg spin and the results read. agglutination intensity was graded visually according to the instructions for use of dg gel cards. the reciprocal of the highest plasma dilution that gives macroscopic agglutination was interpreted as the titer. results: titers obtained with dg gel coombs and anti-igg (n = titrations, titer ranged - ) were compared for each sample with unexpected antibodies. no differences were found between gel cards types (differences were ≤ . titer in the % of the cases). differences between dg gel coombs and neutral (saline technique) (n = titrations, titer ranged - ) were observed when anti-a and -b antibodies were titrated using the same sample. the titer was similar or higher in coombs in comparison to the saline technique. coombs titers may be a mix of igm antibodies reacting at °c and igg antibodies. differences were > titer in % of the comparisons and ≤ titer in the rest of the cases ( %). comparing sample volumes of ll and ll in all cards (n = titrations), higher titers were observed using ll, as expected. differences were titer in the % of the comparisons, < titer in % and > titer in the % of the cases. background: autoimmune haemolytic anemias (aiha) are characterized by production of antibodies directed against red blood cells and destruction by the mononuclear phagocytic system or complement system. aiha observed in paediatrics is usually self-limiting and often precipitated by viral infections. in some, the condition is secondary to autoimmune diseases, drugs, infections or underlying primary immune deficiencies. appropriate immuno hematological evaluation to characterise the underlying autoantibody can help identify the type of aiha to aid in diagnosis & treatment of these cases. aims: retrospective analysis of immune-hematological evaluation, treatment and outcome of aiha in paediatrics. methods: patients aged - years, diagnosed with aiha, between april -december ( months) were included in this analysis. aiha was defined as positive direct coombs' test (dct) with anemia associated with corroborative evidence of haemolysis in the form of raised indirect hyperbilirubinemia, raised ldh, raised reticulocyte counts or red cell agglutination on peripheral smear. further monospecific dct and evaluation for the specificity of autoantibody was done for all patients using biorad gel cards and panel cells. steroids were given as first line in all; second line agents included cyclosporine and rituximab. red cell transfusion was given in those with severe anemia with cardiac decompensation. results: patients were diagnosed during the study period with autoimmune haemolytic anemia. haemoglobin at presentation ranged from . to grams/dl. the initial presentation was severe anemia in children and mild-moderate anemia with thrombocytopenia (evan's syndrome) in . the trigger for haemolysis was infection in children. rheumatological evaluation was performed for children out of whom were diagnosed as evolving lupus. primary immune deficiency evaluation was advised for and one child was diagnosed as suffering from combined immunodeficiency. dat was positive in out of aiha patients as one of the infant had dat negative iga mediated aiha secondary to viral infection. two out of dat positive cases had igg & c d positivity on monoclonal dat testing whereas rest had only igg coating the red cells. dat titration was more than : in patients; where only of these patients had both igg and igg coating and rest had only igg . alloantibody screen was negative in all. specificity of autoantibody was found only in one case, which was against rh blood group antigen (anti e). all patients received prednisolone as the primary treatment. three children attained remission following a - weeks of steroids. in those who were steroid dependent, cyclosporine was used as the second line agent in and rituximab was used in . out of these children children are in sustained remission and off any medication, whereas the rest are on low dose steroids with cyclosporine. summary/conclusions: aiha is not an uncommon problem in children and can vary in its clinical severity. the proper diagnosis and management involves efficient immuno-hematological evaluation, as detailed characterization of the autoantibody coating the red cell is very important in guiding the clinician for management and prognosis. abstract withdrawn. background: drug-induced immune hemolytic anemia (diiha) is rare and has only been described once with dexchlorpheniramine (polaramine tm), an antihistaminic agent widely used in the treatment of a variety of allergic reactions. we report a case of diiha complicated with acute renal failure associated with antibodies to dexchlorpheniramine. a -year-old woman with no history of transfusion, was treated semimonthly with a combination of chemotherapy and targeted therapy for metastatic colorectal adenocarcinoma. her chemotherapy regimen consisted of oxaliplatin and -fu with leucovorin rescue (folfox). panitumumab (monoclonal antibody anti-egfr) was used as targeted therapy. premedication with dexchlorpheniramine iv was systematically given at the beginning of each cycle of treatment to reduce the risk of perfusion reactions mainly associated with panitumumab. the patient developed chills and febrile agranulocytosis during the first and second infusion respectively. the third infusion was not performed due to pyrexia, chills, general discomfort experienced by the patient at the beginning of chemotherapy. probabilistic antibiotherapy was administered and the patient recovered rapidly. during the next infusion (day ), following premedication with dexchlorpheniramine, a more "impressive" reaction including all the above mentioned symptoms occured along with back pain and dark colored urine. the infusion was halted and no chemotherapy was delivered. bacterial infection at the implantable port was first thought to be the cause of this adverse event but was not confirmed. additional laboratory findings revealed biological signs of inflammation associated with iha and acute renal failure. the patient was treated with hemodialysis (day ), two units of rbcs (day ) and was discharged one week later in stable condition. dexchlorpheniramine was then suspected and samples collected on day were sent for a diiha laboratory workup. aims: the aim of this study was to support a clinical diagnosis of diiha. methods: laboratory workup included direct and indirect antiglobulin tests (dat and iat). drug antibodies investigation was performed by incubating patient's serum and eluate from patient's rbcs in the presence of drug against normal donor rbcs that had not been previously treated with the drug (i.e., by the so-called "immune complex" method). control tests were performed in parallel. drug was diluted in pbs and tested at and mg/ml. results: dat was positive (anti-igg + , anti-c d + ) and no unexpected rbcs antibodies were detected by iat in patient's serum and eluate without the in vitro addition of the drug. an antibody directed against untreated (titer ) and enzymetreated (titer ) normal donor rbcs was demonstrated only in patient's serum in the presence of the drug tested at mg/ml by the gel method. the pool of normal sera did not react in the presence of the drug. summary/conclusions: the multi-drug treated patient described in this study was demonstrated to have dexchlorpheniramine dependent antibody detected by the "immune complex" method. the key to the diagnosis was the observation of positive dat with negative eluate tests which prompted a reexamination of the medications administered in temporal relationship with the hemolytic event. although rare, this case report should alert physicians to the need to investigate the possibility of dexchlorpheniramine induced hemolytic anemia in any patient who develop unexpected anemia after hematologic or oncologic procedures p- singapore, singapore, singapore background: daratumumab is a monoclonal antibody against cd used in the treatment of multiple myeloma and has been known to bind to cd on rbc's and interfere with indirect antiglobulin based serologic tests such as red cell antibody screens and crossmatch compatibility testing. in order to negate the interference of daratumumab, our reference laboratory follows the daratumumab protocol recommended by the aabb which uses dithiothreitol (dtt) treated reagent red cells in red cell antibody screening and identification test in patients known to have received daratumumab. aims: the objective of this study is to determine the impact of daratumumab in the turnaround time (tat) for red cell antibody screening and identification. methods: a retrospective review of the tat for red cell antibody screening and identification samples of patients known to be treated with daratumumab from october to december was performed. turnaround time is defined as the time the sample is received up the time the results were reported. the tat for routine red cell antibody screen and identifications were also reviewed during the same period and was compared with the tat of samples from patients treated with daratumumab. results: a total of patients on daratumumab had samples sent to our reference laboratory for red cell antibody screen and identification during the study period. information on daratumumab treatment was not provided to the reference lab prior to the start of testing in of the patients while the use daratumumab was mentioned in the serology request form of the other patients. the median tat for red cell antibody screen and identification is min (range: - ) if information on daratumumab was provided prior to start of testing and min (range: - ) if information was not provided prior to testing. the median tat for routine testing is min (range: - ). using wilcoxon rank-sum test, turn-around time for antibody screening and identification for daratumumab treated patients was observed as statistically not significant when compared to routine samples (p value . ). however, tat for serologic tests requests with appropriate medical history compared to the testing requests without relevant information was also observed to be significantly difference (p value . ). summary/conclusions: there is no significant impact in the tat of red cell antibody screen and identification in patients known to receive daratumumab as compared to routine testing. however, there is a significant difference in the tat if information on daratumumab treatment is not provided prior to testing. this highlights the importance of providing the relevant medication information in the request form in order to prevent delays in testing and provision of blood to patients on daratumumab, which can result in improved organizational efficiency and have positive impact on cost and resource savings. background: daratumumab, an anti-cd monoclonal antibody, has been shown to be highly efficacious in the treatment of multiple myeloma (mm). cd is a glycoprotein highly expressed on plasma cells and, to a less extend, on the surface of red blood cells (rbc). when bound to cd on rbc, daratumumab interferes with the pretransfusion tests, with positive antibody screening and crossmatch. anti-cd interference is an important challenge as many mm patients will require blood transfusions during their treatment. dithiothreitol is a reducing reagent with multiple applications in blood bank testing. treatment of rbc with dithiothreitol irreversibly removes cell surface cd tertiary structure, avoiding the binding and testing interference by the anti-cd daratumumab. aims: to demonstrate the efficacy, safety and celerity of the protocol between the blood bank (bb) and haemato-oncology of our institutions, using just the crossmatch. methods: a retrospective research was used for the evaluation of the results obtained from the implemented protocol. this comprehends a previous contact by haemato-oncology that leads to a study of the patient before the beginning of daratumumab treatment, and consists in: abo/rhd grouping; rh and kell phenotyping, and other clinically significant antigens; antibody screening; and direct antiglobulin test. genotyping may be required for some patients who received previous blood transfusions. before the beginning of the therapy, a blood sample of the patient is sent to the bb to perform laboratory tests and frozen after. this frozen sample is used for crossmatching in patients that already started therapy, did not have a blood transfusion in between, and have a positive antibody screening and/or crossmatch. in further transfusions, in case of positive tests, the dithiothreitol-treated donor rbc is applied. the donor rbc antigens are always selected accordingly to patients negative clinically significant antigens, when transfusional support is needed. the laboratory tests are executed in gel column agglutination technique. results: since , patients were studied, from which were transfused with blood units, according to the protocol. there were no immunizations or adverse reactions to transfusion registered within the transfused patients, neither delay on the availability of blood units. patient blood sample collected and frozen prior to the beginning of the treatment, has shown to be a good strategy by reducing significantly the waiting time for the blood unit in the first transfusion. summary/conclusions: this protocol, which defines the communication among the involved professionals, has shown to be a secure and effective way of reducing interferences caused by daratumumab. it ensures the previous study of the patients and their transfusion with rbc respecting the patients negative clinically significant antigens. if not adopted, the mitigation measures described in this protocol, delays in the availability of the rbc requested and alloimmunizations, may and will possibly occur. a good communication between the bb and the haemato-oncology is crucial for a good time management when a transfusion is requested for these patients. three methods were used to resolve this dara interference. reagent rbc's were treated with dtt, which know to denature cd and then tested with patient plasma. allo-adsorption study was performed using a certain ratio of red cells to plasma. in addition, a selection of phenotyped cord cells were used as an antibody screening panel. results: dtt treatment of reagent red cells was successful at eliminating dara interference and allowing for the presence of underlying antibodies to be identified. in this case, underlying antibodies were not detected by using reagent dtt treated red cells or phenotyped cord cells. adsorption technique was ineffective at elimination the reactivity. summary/conclusions: dara is the first commercial fda-approved therapeutic monoclonal antibody used in treating multiple myeloma patients. • since cd is weakly expressed on normal red blood cells, dara attachment to red blood cells can interfere with pre-transfusion iat testing. • dtt treatment of reagent red blood cells and cord cells can abolish the interference of dara to test for the presence of underlying alloantibodies. • to prevent delays in issuing red blood cell units to patients, hospitals should send patient samples to be tested before receiving dara treatment to ensure that clinically significant alloantibodies are not being masked. background: antibody screening (as)is considered superior to antihuman globulin (ahg) cross match during pretransfusion compatibility testing. in spite of knowing the utility and superiority of as, it has not been adopted uniformly in india. therefore, scarce data is available from this subcontinent in terms of optimisation of red cell antibody detection during pretransfusion testing in form of "type and screen" aims: the main objective was to study the benefits of performing simultaneous antibody screening along with the blood grouping during the first hospital visit to the hospital. other objectives were to study the prevalence of clinically significant antibody among the indian population and to follow up the patients who were transfused antibody screen negative but cross match incompatible blood. we also studied some other relevant quality indicators related to efficiency of blood transfusion services methods: this prospective study was carried out at a tertiary healthcare centre in india between july and dec ( months). the study protocol was submitted to institutional review board and permission was granted. blood grouping and as were done during patients' first hospital visit, which we called "type and screen". when the patient got admitted to the hospital and required blood transfusion, a blood request form was generated by the user and sent to blood bank. depending upon the results of antibody detection, further course of action was chosen. if patient was found to have no antibody, immediate spin test (ist) cross match compatible blood was issued and transfused. in such cases the procedure of ahg crossmatch testing was continued even after issue of blood. cases where ahg cross match test was found negative no further follow-up of the patient was done whereas when ahg cross match was found positive, patients were followed after the transfusion results: a total of patients were "type and screened". majority were from hemato-oncology, bmt, liver transplant, paediatric cardiac surgery, and medical icu units. clinically significant allo-antibody was detected in patients and autoantibody was detected in patients. alloantibody was detected mainly against rh and kell blood group systems. in diagnosed aiha cases, majority were in the form of warm aiha ( %) and % of aiha cases were having hidden single or multiple alloantibody. significantly higher proportion of patients in as positive group required blood transfusion than as negative group ( % vs %, p < . ). in both the groups, in planned cases, most of the time blood was issued immediately within the defined turnaround time except in where either transfusion was delayed or surgery was postponed. it happened only in trauma or surgical bleed cases. expiry of blood was decreased significantly due to no usage of blood ( . % vs. %, p < . ). during the period of study we obtained cases where the ist cross match was compatible but the ahg cross match was incompatible. during follow up none of the cases demonstrated any sign of hemolysis summary/conclusions: in developing countries like us, optimization of as during pretransfusion testing increases operational efficiency and significantly decreases the expiry of blood. results: during the period when absc was performed on pk , , donation samples were tested and , ( . %) were found absc positive. antibodies to red cells were identified in donations out of , ( . %) absc positive samples and in the rest, no irregular antibodies were detected. the prevalence rate for atypical antibody was . %. the top most frequent antibody specificities were: nonspecific cold antibodies ( . %), anti-e ( . %), anti-mi a ( . %), anti-m ( . %) and anti-le a ( . %). a total of , donations were screened for atypical antibodies by ih- and , ( . %) were screened positive. among these, anti-red cell antibodies were identified in , samples ( . %), which was significantly higher than those identified in pk screened positive samples (p < . ). the prevalence rate for atypical antibody as screened positive by ih- and with confirmed red cell specificities was . %, which was also significantly higher (p < . ). the top most frequent antibody specificities were: anti-mi a ( . %), anti-m ( . %), anti-le a ( . %), anti-e ( . %) and non-specific cold antibodies ( . %). anti-fy b was detected in cases, which would be missed detection by enzyme treated reagent cells on pk system. summary/conclusions: the performance of the ih- system using a -cell screening panel including one cell with mi(a+) expression and column agglutination technology with iat phase was superior in comparison with that of pk in the context of higher sensitivity in detecting more true positive results and higher specificity in detecting more true negative and less false positive results. this has translated into the advantages of reduction in workload of reference laboratory in performing less antibody identifications in those false positive samples as well as enhanced transfusion safety by removing more irregular red cell antibody positive plasma-containing components from the issuable inventory, which may potentially lead to haemolytic transfusion reactions. the prevalence of irregular red cell antibodies of . % in healthy blood donors in hong kong reflects more the true statistical figure. background: chronic red blood cell (rbc) transfusion is the upfront therapy for thalassaemia patients, however this therapy is featured by several adverse events including rbc alloimmunization. phenotype matched products transfusion policy can prevent alloantibody formation, but it makes routine transfusion more difficult for both the donor center and the transfusion service. a recent systematic review (franchini et al, blood transfus ) reported a rbcalloimmunization prevalence of . %, with a higher incidence against rh and kell systems in thalassemia intermedia patients. aims: the aim of our retrospective study is to evaluate the rbc alloimmunization prevalence in thalassemia patients transfused in a single center over a years period with limited phenotype matched rbc (rh and kell system antigens) units. methods: from to thalassaemia patients, with a minimum follow up of year and transfused with more than > rbc units, were included in our study. patients were studied for: blood group and rh / k phenotype determination, direct antiglobulin test (dat), irregular antibodies research (abirr). cross-match and detection of alloantibodies were performed using the indirect antiglobulin test by the column agglutination method. six-monthly dat and antibody screening were performed using the indirect antiglobulin test and enzymatic papain-treated rbc test. results: overall patients ( females, males) were included in our retrospective analysis: patients were affected by thalassaemia major and by thalassaemia intermedia. rbc alloimmunization prevalence was . % ( patients): patients were found to be positive for rbc alloantibodies, four with alloantibodies and autoantibodies. eleven alloantibodies were detected ( anti-h, anti-cw, anti-e, kpa, anti-jka, anti-jkb, anti-m and anti-lua). in out of alloimmunized patients we found an anti-e antibody reactive in enzymatic papain-treated rbc test only, in the third alloimmunized patient anti-kpa and anti-lua antibodies were detected, while in the remaining patients, in which auto and alloantibodies were detected, a severe autoimmune hemolytic anaemia (aea) requiring therapy was diagnosed. in these cases the appearance of alloantibodies is concomitant with the presence of autoantibodies. among the patients positive for alloantibodies, were affected by major thalassemia and one by intermedia thalassaemia summary/conclusions: in our experience a limited phenotype matched rbc transfusion policy showed a rbc alloimmunization prevalence similar to literature data: . % vs . %; we didn't find higher alloimmunization prevalence in thalassemia intermedia patients may be due to the low patients number. we believe that introduction, in our department, of an extended-phenotype matched transfusion, including antigens of the main group systems (fy, jk, mns) and the main rare antigens (cw, kp, lu), could reduce the risk of red blood cell alloimmunization in thalassemia patients. abstract withdrawn. background: undoubtedly, preventing alloimmunization has an advantage over overcoming its consequences. however, the high cost of technical and organizational aspects of preventive measures requires their scientific substantiation confirmed by clinical and laboratory data. selection of donors of the rhesus (d, c) and kell (k) antigens for the red blood cell transfusions to hematological patients has been regulated in the russian federation since . recipients with the phenotype c+c-transfuse red blood cell only with the same antigenic combination. for transfusions red blood cell obtained from k-negative donors are used. the compatibility of the donor and recipient with the antigens c, e, e, c w (rhesus system) and k (kell system) is additionally taken into account from april . that is, transfuse red blood cell that do not contain antigens in the phenotype that are not in the recipient's phenotype. aims: to evaluate the efficiency of red blood cell donor selection using antigens of rhesus (c, c, e, e, c w ) and kell (k, k) systems for the prevention of the recipient alloimmunization. methods: immunohaematological studies using equipment and reagents of biorad (usa) were performed in patients of the hematology clinic. non-hodgkin lymphoma was diagnosed in patients, acute leukemia in , multiple myeloma in , chronic lymphatic leukemia in , chronic myeloid leukemia in , aplastic anemia in , hemophilia in , myelodysplastic syndrome in , and other hematological diseases in . the frequency of detection of antibodies to antigen c ( . % vs . %) and to antigen e ( . % vs . %) decreased four times. the frequency of detection of antibodies to the c w antigen has not changed significantly ( . % vs . %, respectively). selection of antigens c (rhesus) and k (kell) has been carried out in the clinic since , therefore the immunization index for these antigens remained unchanged and amounted to . % vs . % for anti-c antibodies; . % vs . %for anti-k antibodies. alloantibodies to the antigens e (rhesus) and k (kell) were not detected for the entire observation period. summary/conclusions: research verified the effectiveness of alloimmunization prevention of recipients by selecting red blood cell for antigens c, c, e of the rhesus system and k (kell). the study concluded that selection of red blood cells for the antigens c w , e (rhesus) and k (kell) does not affect the level of alloimmunization of patients and is not clinically justified. background: in the russian federation, there is an order according to which patients requiring multiple transfusions, who are at high risk of immunological complications are to typed for red blood cell antigens: abo, d, c, c, e, e, cw, k, k. selection of erythrocyte-containing blood components is carried out taking into account the donorrecipient compatibility according to all the listed antigens. aims: analysis of results of immunological evaluation of patients of hematological clinic. methods: the study included first time patients of hematology clinic in - . typing of antigens of abo, rhesus, kell systems, screening and identification of antibodies were carried out using equipment and reagents from bio rad (usa). results: interpretation of results of immunohematological screening was complicated in ( . %) patients. the total number of complex cases was . the double population of red blood cell was most often determined in antigens of the rhesus system ( . % of the total number of patients) as a result of previous transfusion therapy. of those, chimera for the antigen e was detected in cases ( . % of patients with the chimera for rhesus and kell antigens), cin ( . %), sin ( . %), e - ( . %), cw - ( . %), k - ( . %). in such cases, donor red blood cells were chosen not carrying chimeric antigen for transfusions, in the presence of chimeras in both paired antigensred blood cell transfusion with the cc phenotype and / ee. chimera for abo antigens was detected in . % of the examined individuals. the discrepancy between the direct and reverse blood grouping of the abo system in patients ( . %) was due to a decrease in the production of antibodies - cases and the appearance of extra agglutinins - case. autoantibodies were detected in . % of all patients, including . % of patients, when they caused panagglutination phenomenon. upon detection of autoantibodies that complicate the individual selection of donors, transfused red blood cells that are compatible with antigens of abo, rhesus, kell, duffy, kidd, mns systems. alloantibodies were detected in . % of patients, including specific anti-din ( . %), anti-dcin ( . %), anti-kin ( . %); antibodies of unidentified specificityin ( . %), polyspecificin ( . %). summary/conclusions: the complexity of interpreting immuno-hematological tests in hematological patients is due to intensive transfusion therapy, changes in red blood cell antigens and appearance of nonspecific antibodies due to underlying disease. red blood cell for transfusion in these patients should be selected taking into account the expanded red blood cell antigen profile. abstract withdrawn. background: blood transfusion is an essential part of therapy for many patients. although life-saving for many patients, blood transfusion is not without risk. the main goal of blood transfusion services is that transfused blood should be compatible with the patient. the clinical and serologic evaluation, which allows for the transfusion of the most compatible (or "least incompatible") blood, requires a joint effort between the clinician and the transfusion medicine physician. aims: root cause analysis of incompatible cross matches in patients. methods: in this prospective study, total of , , crossmatches were performed over period of last four & half years, out of which units were found incompatible by column agglutination method-cat in polyspecific (anti-igg+ c d) gel media. a root cause analysis protocol was formulated to resolve incompatibility to ensure safe transfusion. results: on the evaluation of , , crossmatches, only units were found to be incompatible ( . %). the major cause for incompatibility found in patients was aiha-( . %). other causes of incompatibility were infections ( . %), multiple transfusions ( . %), trauma ( . %), evan's syndrome ( . %), rh negative mother ( . %), sca ( . %) & incompatibility due to dat positive packed red cells ( . %).the most common antibody found were anti-'c', anti-'s' & anti-'m'. summary/conclusions: the rca protocol involves a thorough evaluation of the patient's clinical condition and underlying pathology to identify the cause. a logical stepwise approach will enable provision of safe transfusion to the patient. background: antibodies to high-frequency antigens (hfas) are a transfusion hazard, as compatible blood is often very difficult to obtain. other clinically significant alloantibodies represent an additional transfusion risk. in patients treated with allogeneic bone marrow transplantation (bmt) recipient red cell alloantibodies may cause acute or delayed haemolysis of donor red blood cells (rbc) and contribute to morbidity and mortality. aims: the aim is to present the case of a patient with myelodysplastic syndrome (mds), multiple "common" alloantibodies and an additional alloantibody to a highfrequency antigen, treated with allogeneic bmt. methods: a forty-one-year-old caucasian patient with mds (raeb- ) was admitted to our hospital in january for unrelated allogeneic bmt. she previously received myeloablative conditioning therapy according to the flu / bu / atg protocol ( days of mg iv. fludarabine, days of busulfan mg iv, days of mg iv. antithymocyte globulin). the indirect antiglobulin test (iat), done in august and december of , was negative. according to anamnestic data, the patient had two pregnancies. she received red cell transfusions during childbirth and platelets in december . results: the patient's blood group was o rhd positive, iat positive. the donor blood group was a rhd positive, iat negative. phenotype of the recipient's rbcs, as well as the donor rbcs, was also determined. anti-e and -c w were found in the patient's plasma, but an additional alloantibody was suspected. the autocontrol was negative. column agglutination technology (cat) and tube technology were used to identify rbc antibodies. plasma was tested with pheno-matched rbcs, papain-and . m dithiothreitol-treated rbcs, as well as cord and autologous rbcs. adsorption and elution tests were done, excluding other "usual" clinically significant alloantibodies, and the patient received three incompatible (xm in iat, cat) yt(a+), e-, c w -, k-red cell units. the sample was urgently sent for an antibody investigation at the international blood group reference laboratory (bristol, uk). in the reference laboratory, anti-e, -c w and an alloantibody to a high-frequency antigen were confirmed, whose specificity was determined to be anti-yt a . anti-jk b was also suspected and later confirmed. before the patient was discharged from the hospital, she received eight more red cell units (yt(a+), e-, c w -, jk(b-)), during which she was serologically closely monitored. summary/conclusions: the results of the antibody investigation in this case study indicate the presence of multiple alloantibodies in a patient who has previously received immunosuppressive myeloablative conditioning therapy. in addition to the "common" alloantibodies (anti-e, -c w , -jk b ), an alloantibody to a high-frequency antigen (anti-yt a ) was detected in the patient. this patient was transfused with incompatible red cell units (yt(a+)) in an emergency, with no ill effects. although anti-yt a is rarely a clinically significant antibody, according to literature, it can cause immediate haemolytic transfusion reaction. additional risk were "common" clinically significant alloantibodies, especially anti-jk b , which was in this case extremely difficult to detect and had further complicated the selection of blood. background: the identification of an antibody against a high-incidence antigen always introduces a challenge due to the difficulty in finding compatible units of red blood cells (rbcs). in patients needing surgery it is important to minimize their transfusional needs by implementing patient blood management programs (pbm). tests that predict the clinical significance of antibodies, such as monocyte monolayer assay (mma) are also useful in guiding clinical decisions. kell blood group system contains highly immunogenic antigens. antibodies against these antigens are immunoglobulin g, and can cause severe hemolytic transfusion reactions and fetal anemia. results: case report we report the case of a -year-old female, with non-hodgkin lymphoma, chronic anemia and scoliosis with severe neurological compromise, proposed for lumbar spinal stabilization surgery. she had a total hip replacement surgery in , with unknown transfusion history. her obstetric history was g p a . the patient had no history of thromboembolic or hemorrhagic events. during pre-transfusional tests, she was typed as a rr and had a positive antibody screening test. the identification studies were suggestive of an antibody against a highincidence antigen, so the surgery was delayed until clarification of these results. she was also referred to a pbm appointment where her hemoglobin was improved from . g/dl to . g/dl by administration of ferric carboxymaltose iv and darbepoetin sc. the patient was phenotyped as kp(a+b-) with anti-kpb, an antibody against a highincidence antigen (> % prevalence worldwide). it is a rare antibody with variable reactivity, causing from none to moderate/delayed transfusion reactions. to access the clinical significance of this antibody, a mma was performed, resulting in a reactivity of . %, suggesting no clinical relevance, however it could be altered after transfusion of kpb+ blood. in order to find compatible rbc's, several family members were phenotyped, however they were all positive to the kpb antigen. in portugal there were no rr kp(b-) blood donors, as it is extremely rare, so we searched in the international rare donor panel (irdp) and two donors were found in spain. two units of compatible rbc's were requested prior to the surgery, which was performed successfully four months later without transfusional support. summary/conclusions: anti-kpb is a rare antibody that in some cases can cause hemolysis of the transfused kp(b+) red blood cells. the combination of kp(b-) and o rr, an extremely rare phenotype, presented a challenge in finding compatible rbcs. this case illustrates not only the complex transfusional and logistic problems that an antibody against a high-incidence antigen can pose, but also the importance of an efficient pbm programme to mitigate the transfusional needs in these patients. background: blood transfusion is an integral part of the supportive care for patients with sickle cell disease (scd). allo-immunization is a recognized complication to red blood cells transfusion (rbc) in those patients. this may result in difficulties in providing compatible blood, and may be associated with the risk of acute of delayed hemolytic transfusion reactions. aims: to describe transfusion management in a patient with scd who has multiple alloantibodies with difficulty in obtaining compatible blood, in order to highlight the importance and clinical consequences of this complication and suggest a possible management approach methods: an -years-old female patient with scd presented to our hospital with hemoglobin level of g/dl secondary to acute splenic sequestration. she had a history of multiple previous admissions and many previous rbc transfusions. blood grouping and pre-transfusion compatibility testing were performed in addition to phenotyping of the patient's red cells. screening was done using column agglutination technique by automated machine (ortho; usa) and antibody identification was performed manually using commercial cells identification panel. phenotyping for the patient was done using haemagglutination technique with mono-specific anti sera (bio-rad; switzerland). results: the patient was of group o rhd (positive). antibody screening was positive and antibody identification revealed probable anti-e and anti-fya with possible development of anti-k allo-antibodies, in addition to recent development of autoantibodies; giving pan-positive reactivity with the identification panels. phenotyping of the patient's rbcs was found to be r r and k-negative. other masked allo-antibodies of undefined specificities were suspected and no compatible blood was found. the clinical condition warranted a blood transfusion, so least incompatible phenotypically matched rbc unit was released. the patient developed acute hemolytic transfusion reaction with drop of the hb level to . g/dl. despite screening hundreds of rbc units, no compatible units were identified, and no transfusion was given. the patient was managed conservatively using hydration, analgesics, hydroxyurea, erythropoietin, intravenous immune globulin (ivig), steroids, and rituximab. hb level increased to g/dl in weeks, and the patient was discharged from the hospital. the sample of the patient was sent to a reference lab (institut fur klinische chemie und laboratoriumsmedizin-regensburg -germany) for further investigations, clarifications and advice for compatible transfusion in case of need. the report of the reference lab revealed the development of additional anti-m and anti-s with confirmation of the presence of anti-fya, anti-k and warm auto-antibodies. phenotyping of rbcs was confirmed by molecular diagnostic testing done in the reference lab; as r r, k-neg. summary/conclusions: finding compatible blood may be extremely difficult in patients with scd who develop multiple alloantibodies. it is therefore essential to perform an initial extended red cell phenotyping for the patients at diagnosis and to have on shelf ready phenotyped blood units for issuing to the patients, to minimize allo-immunization. transfusion may occasionally be avoided in allo-immunized patients, utilizing alternative options of treatment and reducing the risk of serious complications such as hemolytic transfusion reactions. background: red blood cell (rbc) antigens that are present on less than % of most populations are known as low incidence antigens and those present on more than % are known has high incidence antigens. the mns blood group system consists of antigens carried on glycophorin a (gpa), glycophorin b (gpb) or on hybrids of these glycophorins. there are low incidence and high incidence antigens in the mns blood group system. an individual that is homozygous for gp.mur will be negative for the high incidence jenu (mns ) antigen. anti-jenu was first described in a thai patient with thalassemia where only compatible units were found following screening of units. the jenu negative phenotype is a rare phenotype with an estimated frequency of . %. a male patient with a history of previous transfusion presented with an anti-e and a weak auto antibody with no apparent specificity. a donor unit selected for cross match (group o rhd positive, c+e-c-e+, k-) was incompatible with a reaction grade of + by column agglutination technology. the patient's sample and donor unit were referred to the red cell reference laboratory for investigation for a possible antibody to a low incidence antigen. aims: we aim to characterize the phenotype of the incompatible donor unit. methods: standard serological procedures were used to identify the antibody specificities in the patient's sample. blood group phenotyping of the patient and donor was performed by standard serological procedures. genotyping and zygosity testing was performed using polymerase chain reaction (pcr) high-resolution melting (hrm) assay. gp.mur is a gp(b-a-b) hybrid glycophorin resulting from a gene conversion event between gypa and gypb . this disruption to gpb impacts s expression. the donor was negative with anti-s moab (albaclone), positive with anti-s polyclonal (immulab) and negative with anti-s monoclonal antibody (immulab). this s and s phenotype was consistent with the previously reported examples of gp.mur homozygote jenu negative individuals. molecular testing was consistent with serology supporting gp.mur homozygosity and jenu negative phenotype. summary/conclusions: this donor has been added to our rare donor panel and their red cell donations are cryopreserved for future use in our rare donor frozen inventory. there is limited anti-jenu antiserum available to confirm the jenu negative phenotype. we currently rely on the serological profile of red cells presenting with the gp.mur phenotype, s negative and the discrepant s phenotyping to identify jenu negative donors. this case has highlighted the importance of following up unexplained serological incompatibilities. the development of a monoclonal antibody directed against jenu antigen would provide an opportunity to screen for suitable donors for this rare phenotype. background: molecules expressed on tumor cells are a target of interest for drug development by the use of monoclonal antibodies or blocking proteins. however these drugs have the potential to interfere in pretransfusion testing when the target molecule such as cd is also expressed on red blood cells (rbcs). recently, many drugs targeting cd have been developed but appropriate mitigation strategies and approach to selecting rbcs for safe transfusion is still an obstacle. aims: we describe a case of delayed hemolytic transfusion reaction (dhtr) by anti-jk a in a patient treated previously with cd targeted high affinity sirpa fusion protein alx . methods: a -year-old woman diagnosed with nasal cavity squamous cell carcinoma was enrolled in an alx clinical trial. her blood type was group ab, rhd positive, and the antibody screening test was negative for the past months. she had no previous transfusion history during the past two years. after two infusions of alx , two units of apheresis platelets were requested for transfusion. the blood bank noticed that the antibody screening was positive and further investigation was proceeded. results: antibody screening showed trace positivity in both panel cells (i & ii) at room temperature (rt) and °c albumin phase, and + at anti-human globulin (ahg) phase by tube method. the auto control was negative at rt and °c albumin phase, but + at ahg phase. antibody screening ( cells) and identification ( cells) all showed + at ahg phase using gel cards. direct antiglobulin test was + for anti-igg and + for anti-c d using gel cards. two units of rbcs were requested for transfusion after hemoglobin decrease to . g/dl. rbc genotyping was unavailable at the moment. as her previous antibody screening was negative (anti-jk a not detectable), e-, c-, fy b -rbcs were given as a second best option, considering the phenotype distribution of major blood groups in the korean population. the hemoglobin level was well sustained between . - . g/dl but it decreased again to . g/dl twenty days after rbc transfusion. further laboratory investigation was consistent with a dhtr. the patient was no longer being given alx , and antibody screening and dat decreased to - + reactivity. we presumed that antigen typing results would be reliable after chloroquine dissociation and cell washing using antisera that did not require ahg for testing. serologic phenotyping showed that the patient's cells were c+, e+, c+, e+, jk a -, jk b +, fy a +, fy b -, s-, s+, m+, n + . antibody identification using papainized panel cells revealed anti-jk a antibody. we concluded that the dhtr was due to anti-jk a , and jk a -, fy b -, s-rbcs were issued for further transfusion requests. the patient's hemoglobin level recovered to . g/ dl. the patient's genotype was later identified to be the same as serologic typing. summary/conclusions: communication with the physician and blood bank to perform adequate pretransfusion testing before administration of drugs targeted to cd is important to achieve safe transfusion for patients. serologic phenotyping using antisera which do not require ahg for testing can be used as a second option when genotyping is unavailable in a timely manner. background: transfusion is still a key treatment for sickle cell disease (scd) patients. as a result, these patients are much more exposed to transfusions' risks, the most feared one being a delayed hemolytic transfusion reaction (dhtr). we investigated a female scd pediatric patient with no known antibody, who was referred to us for a suspicion of two dhtrs. three transfusion episodes were reported (a total of four units collected from four donors). for the last transfusion, a premedication with rituximab was done. the patient was planned to undergo a bone marrow transplant with her brother as her donor. aims: to describe the molecular and serological workups needed to investigate a dhtr in a scd patient. methods: antibody identification and crossmatches were performed by iat gel testing with red blood cells/panels, which were used raw, papain-treated and trypsintreated. rbcs' phenotypes were determined by conventional techniques. semi-quantitative phenotypes were conducted by serial dilutions with a monoclonal anti-jk a (ms /seraclone â ). dna was extracted using the magna pure compact instrument (roche). sequencing of jk exons - was carried out by in-house techniques. results: the antibody identification showed a very weak anti-jk a , which was only reactive on papain-treated rbcs. autologous control was also only positive in this technique. dat and the eluate were negative. as the patient had recently been transfused (less than four months earlier), on this first sample we were neither able to perform autologous adsorptions, nor verify her jk a /jk b phenotypes. in order to rule out the imputability of an anti-lfa in the dhtr outcome, crossmatches with her donors' rbcs were undertaken. three out of the four donors were tested. apart from the anti-jk a reactivity, none of them was reactive. because the patient had previously been phenotyped as jk(a+b+), her jk gene was sequenced. her genotype was determined as jk* ( a, a, a, g)/jk* . to confirm this jk a variant allele, a family study was conducted. all her siblings were found to harbor the same genotype. her mother's and father's genotypes were jk* ( a, a, a, g)/ jk* and jk* /jk* , respectively. subsequently, autologous adsorptions were performed, which proved the anti-jk a to be an autoantibody. considering the weakness of this antibody, internal controls were used, in order to evaluate a possible dilution effect of this technique. finally, serial dilutions with the anti-jk a reagent showed a weakened jk a expression encoded by the jk* ( a, a, a, g) variant allele. this finding is consistent with the fact that the crossmatches between the proband's serum and her brother's rbcs were weaker than those performed with (jka+b+) rbcs. summary/conclusions: about a third of dhtrs are reported to happen in patients with no previous history of immunization. performing sensitive serological techniques in order to identify antibodies is necessary to select the most appropriate units. molecular work and extra serological testing can be useful to determine whether an antibody is an allo or autoantibody. even though in this case the anti-jk a was the only antibody identified, because it was proven to be an autoantibody, it is difficult to conclude if it was the cause of the dhtr. nevertheless, jk(a-b+) blood was issued, and no adverse events have been reported. luckily, the patient's bone marrow donor harbors the same variant allele. background: according to the aabb, a pre-transfusion sample must be obtained within days of transfusion if a patient has been transfused or pregnant in the preceding months. despite this safeguard, high risk patients (i.e. those recently transfused with a history of pregnancy or transfusion) may develop antibody during this day window. to avoid issuing incompatible red blood cells (rbcs) to these patients, a new antibody screen (abs) sample should be drawn and tested shortly before anticipated transfusion. aims: we report a case of a y/o man who presented to the ed (hospital day , hd ) with a post-fall intracranial hemorrhage and multiple fractures. anti-e and anti-jka were identified after admission on a new specimen prior to current specimen expiration (< days). methods: specimen # (s ) was sent on hd for type & abs (t&s) and crossmatch (xm) of rbcs. abs and immediate spin xm were negative; there was no patient history. by hd , he had negative t&s specimens (hd : s ; hd : s & ; hd : s ) and had been transfused rbcs (hd : ; hd : ) via electronic xm (exm). at hr on hd , rbcs were requested and could have been issued via exm since s was not expiring until midnight. however, given recent transfusions, bb staff first called the patient's nurse to review history. patient was uncommunicative, but had scars suggesting past trauma or surgery. s was requested and received at hr. results: s showed anti-e and anti-jk a in plasma and eluate. his hemoglobin/hematocrit (h/h) decreased from . ( . - . g/dl)/ . ( . - . %) on hd to . / . on hd . during this period, he underwent several surgeries without unexpected bleeding, documented jaundice or dark urine. two e-jk(a-) rbcs were transfused on hd , which he tolerated well with an increase of hemoglobin from . g/dl to . g/ dl. he did well post transfusion with stable h/h between . / . . to . / . . he was discharged on hd . repeat abs on s was negative. of the rbcs transfused before s , one was e+ and four jk(a+). the family reported that he was injured years prior and had been admitted to hospitals, but was unaware of transfusion. hospital # (h ) reported admissions years ago ( rbcs transfused) and years ago; all abs were negative. h admission was years ago with positive abs and inconclusive workup. h admission years ago showed negative abs. summary/conclusions: the patient developed a significant antibody response in less than days from the specimen collection, likely a secondary immune response to sensitization from a transfusion years earlier. a new specimen was requested prior to transfusion even though the existing sample (which was abs negative) had not expired. this approach identified new antibodies, preventing transfusion of incompatible rbcs, and a potentially serious hemolytic transfusion reaction. this case suggests that for high-risk patients, abs more frequently than every days may be beneficial. it is important to increase clinicians' and laboratorians' awareness of this issue. background: red cells with partial d antigen have historically been classified as such, based on the fact that the red cells type as d positive, but individuals make anti-d antibody when exposed to conventional d antigen. a definitive confirmation of the variant of d antigen is obtained after the rh d genotyping. aims: to present a case study of the patient's alloimmunisation with the present d partial antigen type dnb, most likely on previously received transfusions. methods: the patient's pretransfusion testing included the determination of the abo blood group and rhd type (id card diaclon abo/d dv+, dv-, reverse grouping, monoclonal antibodies, gel method), antiglobulin crossmatch, additional phenotyping (gel and tube methods), antibody screening, identification of the specificity of irregular anti-erythrocyte antibodies by commercially available red cell panels (id dia-panel bio rad gel method, panocell immucor, tube method) through an indirect antiglobulin test (iat) and enzymes. after routine rhd typing we continued further characterisation of the rhd antigen by serologic assay (bio-rad id-partial rhd typing),and finally by rhd antigen molecular genotyping (fluogene method on fluo vista machine). results: our patient is a year old woman with a diagnosis of tu mammae who was preparing for total mastectomy surgery. she had a history of blood transfusions twenty years ago, and she also had two births. the blood group typing was: o, ccdee, k-, fy (a-b +), jk (a+b +), ss, mn, le (a+b -). the agglutination reactions that we tested with anti d serums were strong ( +). the compatibility test with rhd positive donated blood units was positive. the presence of anti-d and anti-fya antibodies in the serum of the patient was determined. we prepared one compatible blood unit, rhd negative and fya negative, for a surgery. interpretation of the id-partial rh d typing set indicated that this is a diii category of d partial antigen. a sample of blood of our patient was sent to the blood transfusion institute of serbia, where molecular typing of d antigen was performed and the presence of partial form of antigen d, dnb type, was found. summary/conclusions: rhd positive patients or donors with anti-d antibody presents in their serum should be tested for d genotyping. the recommendation for further transfusions of our patient with dnb d partial and her alloimmunisation is to prepare d negative, fya negative erythrocytic blood components, and as a possible blood donor it would be labeled as rh d positive. background: the jr blood group system consists of jr a (jr ), a high frequency antigen expressed by the abcg gene. the individuals with jr(a-) phenotype are mainly found in the japanese population and may develop anti-jr a when stimulated by blood transfusion or pregnancy. anti-jr a is a dangerous antibody for pregnancy, but also could cause mild or moderate neonatal jaundice. aims: to conduct the antibody specificity identification of the high frequency antibody in a pregnant woman with history of pregnancy but no transfusion. methods: abo, rhd and some special blood group antigens were identified by tube method in saline. antibody screening and blood group specific antibody identification were performed by indirect antiglobulin test (iat) in gel column. the reagent cells treated with trypsin, chymotrypsin and papain, were used to test the antiserum to obtain the characteristic of antibody reaction. the antibody titer in the patient's serum was detected. dna sample was extracted and exons and adjacent intronic sequence of the abcg gene were sequenced. the sample of one family member was collected for testing. results: the blood groups of the patient were b, rhd(+), lu b (+) and kp b (+). the negative reaction of the serum reacted with all reagent cells were tested in saline, but positive ( +) in iat test, while the self-control was negative. the antiserums reacted strongly ( + in iat test in gel card) with the papain-treated cells, but kept the same reaction strength ( +) with trypsin-and chymotrypsin-treated cells, which indicated the possible existence of anti-jr a . the titer of igg antibody in serum was . in cross matching test, the red blood cell of the patient's brother with the same abo and rhd blood group with the patient was successfully matched with the serum of the patient. the sequencing analysis of the abcg gene in the patient and her brother revealed one homozygous nonsense mutation in exon (c. c>t, p.gln x). after the delivery of the pregnant women, no pathological jaundice was seen in the newborn. summary/conclusions: in the condition of the anti-jr a reagent was unavailable for the identification of jr a antigen in the patient, having an indication with anti-jr a by serological test, the alternative genotyping method was used. the most common silencing jr allele reported in asian population, especially in japanese population, was identified to indicate jr(a-) phenotype. immunohemotherapy, centro hospitalar vila nova de gaia/espinho, vila nova de gaia, portugal background: if the investigation of irregular/unexpected antibodies reveals a pattern in which all or most screen and panel cells are positive, with reactions in the same phase and with the same strength, along with a negative autocontrol, an irregular antibody to a high-prevalence antigen may be suspected. high-prevalence antigens are those that are present in almost all individuals ( % or more). fortunately, because these antigens do occur so frequently, it is not common to find a patient with an antibody to one of them. however, when it happens, it may become a troubling situation. aims: clinical case report of panagglutination in assessment of irregular antibodies. methods: collection of clinical data in scl ınico â and sibas â applications. results: woman, years old, o rhd+, previously transfused with red blood cells concentrates in , was proposed to a correction surgery of a periprosthetic hip fracture. pretransfusion serologic tests were requested and irregular antibodies were detected ( + in all the screening cells). in order to identify the specificity of the antibody, a panel of cells was tested; the result was considered inconclusive, due to positive reactions ( +) with all test cells in liss/coombs and atypical positivity with dragging in all cells in enzymatic environment. autocontrol and direct antiglobulin test were negative. it was decided to send two blood samples to the reference laboratory for a more complete immunohematological study. compatibilization of red blood cells to this patient was also requested. during the waiting period, haematopoiesis was optimized. although the patient did not present anaemia at admission, the analytical study revealed iron deficiency; therefore, supplementation with intravenous iron was performed. the reference laboratory also obtained a panreactive panel ( + with all cells) in liss/coombs and weak positivity in papain. after allo-adsorption, the search for irregular antibodies was negative. an anti-yt a , apparently without clinical significance (negative igg and igg ) was then identified. transfusion was not needed either during or after the surgery, with a good recovery of the haemoglobin value in the postoperative period. summary/conclusions: yt a , which belongs to cartwright system, is a high-prevalence antigen in all populations. anti-yt a , an igg antibody stimulated by pregnancy or transfusion, is not as uncommon as we may think, which suggests that it is reasonably immunogenic. these antibodies are not generally considered clinically significant, but there are reported cases of acute and delayed haemolytic transfusion reactions in which anti-yt a has been implicated. therefore, although the described pattern of panagglutination in assessment of irregular antibodies may suggest the presence of an alloantibody directed against a highfrequency antigen, it is very important to confirm that hypothesis, recurring to a reference laboratory if necessary, to identify the antibody and to determine its clinical relevance. even if the identified antibody is associated with rare haemolytic transfusion reactions, it is crucial to optimize haematopoiesis when it is not an emergent procedure, in order to minimize transfusion and its associated risks. both for emergent and elective procedures, the creation of a national database of patients with already identified irregular antibodies would facilitate the administration of red cells concentrates without the implicated antigen. aims: to investigate the frequency and explore the genomic characterization of jk (a-b-) phenotype in blood donors in harbin, china. methods: all samples were screened for jk(a-b-) phenotype using a direct urea lysis test. and the results were confirmed with by iat using anti-jka and anti-jkb with a standard tube test. additionally, polymerase chain reaction amplification and sequence analysis of the jk gene were performed. results: from blood samples, four donors with jk (a-b-) were selected, at a frequency of . %. among these four samples available for sequencing jk gene, a total of two genotypes were discovered: heterozygote of ivs - g>a combining with heterozygote of g>a (gly glu) and heterozygote of g>a (gly glu) combining with heterozygote of c>t(thr met). summary/conclusions: the frequency of jk(a-b-) phenotype in blood donors in harbin area was lower than the reported data from the populations in other areas of china and in finland, but higher than that in japan. ivs - g>a, g>a and c>t were common mutations in the before reports, while g>a was reported first time. in addition, it is an effective measure which establish the jk(a-b-) phenotype donors in this region, to solve the blood transfusion problem in patients with anti-jk . background: blood types, indicating the type of blood group antigen expressed in the red blood cells, is determined by the type of allele at the blood group gene locus. therefore, when allele frequency of each blood group gene is determined, it is possible to predict the frequency of a specific blood type donor with a homozygous allele. it is also possible to estimate the proportion of donors within a particular blood type through combination of specific alleles. and because the ratio of blood group allele differs between ethnicity and race, this can be used as basic data for population genetics and anthropology. therefore, we present a study that examined the allele frequencies of blood group systems in the korean population through blood group genotyping. aims: the purpose of this study is to determine the frequencies of blood group alleles in the korean population, to predict the proportion of homozygous donors, and to obtain the basic data of population genetics. methods: , blood donors from age to were recruited at korean red cross blood centers located nationwide. acquired samples were examined by blood group genotyping methods using the rbc genotyping system id core xt (progenika biopharma). for each donor, genotypes of blood group systems, excluding abo and rhd, were identified. calculation of the frequencies of blood group alleles in the korean population was done. results: we conducted molecular genotyping of the rhce, kell, kidd, duffy, mnss, diego, dombrock, colton, cartwright, and lutheran blood group systems. the allele frequencies of these blood group systems in the korean population were estimated as follows. -rhce*ce . %, rhce*ce . %, rhce*ce . %, rhce*ce . % -kel*k_kpb_jsb allele % -jk*a allele . %, jk*b allele . %, jk*b_null allele . % -fy*a allele . %, fy*b allele . % -gypa*m allele . %, gypa*n allele . % -gypb*s allele . %, gypb*s allele . %, gypb*mur allele . % -di*a allele . %, di*b allele . % -do*a allele . %, do*b allele . % -co*a allele % -yt*a allele % -lu*b allele % summary/conclusions: the significance of this study is accumulation of data on the allele frequencies of blood group genes through highly accurate genotyping method in the east asia region. this enables the prediction of the proportion of donors with a combination of specific blood group alleles in the korean population, which accounts for a decent percentage of the population in this region. background: in donors from arabian countries only little is known about blood groups other than abo and rhesus. during the last years increased migration to central europe has put a focus on the question how to guarantee blood supply for patients from these countries, particularly because hemoglobinopathies with the need of regular blood support are more frequent in patients from that region. aims: blood group allele frequencies should be determined in individuals from syria, other arabian countries, and iran by molecular typing. methods: as most blood groups are defined by single nucleotide polymorphisms (snps) we introduced a maldi-tof ms assay to detect alleles encoding blood groups including kk, fy (a/b), fy null , c w , jk(a/b), jo(a+/a-), lu(a/b), lu ( / ), ss, do (a/b), co(a/b), in(a/b), js(a/b), kp(a/b), rhce*c. c>g, and rhce*c. c>g. additional blood groups and polymorphisms like yt(a/b), s-s-u-, vel null , co null and rhce*c. g>t were tested by pcr-ssp. a total of probands including individuals from syria, from iran, from the arabian peninsula and from northern african countries were included. results: % of the donors were homozygous for the fy null (fy*- t>c, fy* n. ) mutation, . % carried the heterozygous mutation. . % of the syrian probands were heterozygous for the do* c>t mutation (both, do*jo and do*jo ; jo(a+/ a-)) that is virtually unknown in caucasian donors. . % of the syrian donors heterozygously carried the kel* . allele coding for js(a) (phenotype js(a+/ b+)) that is very rare in caucasians. however, no homozygous kel* . carriers were identified. . % of the syrian and . % of all donors were negative for yt*a, which is definitely more frequent than in europeans. one donor from northern africa homozygously carried the gypb*c. c>g, intron + g mutation, inducing the s-u+ w phenotype. . % of all and . % of northern african donors were heterozygous for the rhce*c. c>g substitution, . % of the syrian donors carried rhce*c. c>g (heterozygously) and . % of all donors were heterozygous for rhce* g>t. heterozygosity for vel deficiency (vel*- ) was detected in individuals ( %; of them from syria) whereas only one syrian donor carried the homozygous mutation. none of the donors carried the aqp *c. delg (co* n. ) mutation that induces the co null phenotype. summary/conclusions: the study provides a first overview on a number of different blood group alleles in blood donors from arabian countries. some blood group alleles that largely are lacking in europeans but had been described in african individuals are present in arabian populations at a somewhat lower frequency. in single cases it could be challenging to provide immunized arabian patients with compatible blood. methods: three unrelated individuals ( blood donors and one pregnant woman) of polish origin who were typed as ab group with a very weak a antigen and normal b antigen expression were subjected to extended abo typing. in one case family studies were performed (blood samples from donor's mother, father and sister). sequencing analysis of this donor dna was performed three times (from two blood samples and buccal swab). serologic investigations were performed with standard methods: /gel cards diaclon id abo/d (anti-a: clone a , anti-b: clone g / , anti-a,b: clone es , es + birma + es ; bio-rad) and diaclon id abd-confirmation for donors (anti-a: clone m / = la- ; bio-rad); /tube techniques with: anti-a (birma ; a- h , a s.pa m , c. d ), anti-b (lb- , b- f , c. a ). genotyping was determined by rbc fluogene abo basic kit (inno-train, germany) and by sequencing of + . -kb site of abo gene to cover sequences ranging from the end of intron to utr of the abo gene. additionally sequence of exon of the abo gene was analyzed. results: abo typing showed normal b and a very weak a antigens on rbcs of all three individuals ( blood donors and one pregnant woman). the a antigen was detected by tube technique only using anti-a clones: birma ( + to +), a- h ( + to +) and c. d (weak+ to +); negative reaction of a antigen typing by gel cards was observed. the sera of all individuals contained anti-a antibodies. commercial pcr-ssp kit revealed three heterozygous a/b genotypes (absence of delc typical for abo*a alleles). in all these individuals abo sequencing of . -kb fragment confirmed the heterozygous genotype with polymorphisms characteristic for abo*b. allele ( a>g; c>g; c>t; g>a; c>a; g>c; g>a) and detected a novel abo*a allele sequence with duplication-based insertion of bp after position (abo*a c.dup _ ; gcaggacgtgtccatgcgccg). as a consequence, the online protein translation predicts an in-frame duplication of seven amino acids after codon (p.dup_ _ qdvsmrr), with synonymous change of the repeated codon (cgc>cgg) and (cgg>cgc) but both coding arginine (r). inheritance of abo*a c.dup _ allele was confirmed by family studies of one donor: his father and sister had a/b genotype associated with normal a and b antigens expression; his mother had normal a antigen expression. she carried abo*a . allele and the same abo*a c.dup _ allele as a son. summary/conclusions: a novel a weak allele at the abo gene detected in three unrelated polish individuals is an in-frame insertion of seven amino acids to the wild-type glycosyltransferase a. the stability of the encoded protein may be affected causing the weak a phenotype. the inheritance of this mutation was confirmed in the family studies. background: since the cloning in of cdna corresponding to mrna transcribed at the blood group abo locus, polymorphisms and phenotype-genotype correlations have been reported by many investigators. although many subgroups have been explained at the genetic level, unresolved samples are still encountered in clinical practice. we report here the result of an abo investigation of a sample from a swedish blood donor that showed a very weak agglutination of rbcs with anti-a in routine forward typing. aims: to elucidate the genetic basis of the apparent weak a subgroup. methods: routine abo genotyping by pcr-asp and pcr-rflp including pcrbased analysis of the upstream cbf/nf-y-binding enhancer region was carried out. further genetic analysis was performed by dna sequencing of abo exons - (including base pairs of the adjacent introns) and the proximal promoter. flow cytometric testing of rbcs was performed with monoclonal anti-a, anti-b and anti-h. results: the weak agglutination of erythrocytes with anti-a was accompanied by the expected lack of anti-a and anti-a in plasma. abo genotyping gave the genotype abo*a . /o . usually consistent with normal expression of a antigen. enhancer analysis resulted in an amplification product corresponding to the expected single cbf/nf-y binding motif. flow cytometric testing of the sample showed a antigen expression with an almost chimeric pattern where the majority of the cells (approximately %) expressed the a antigen at a very low level, marginally distinguishable from the group o control. the remaining approximately % of the cells displayed an a antigen level ranging from normal to very weak. genomic abo sequencing showed an abo*a . -like allele except for a novel mutation located in intron , c. + g. the o allele had an additional snp, c. g>a, consistent with the abo*o . allele variant summary/conclusions: a previously unreported variant, c. + a>g, likely effecting the -donor splice site of intron was found in an a weak sample. this type of mutations is expected to decrease mrna stability and/or cause skipping of the preceding exon in the mrna. however, small amounts of full-length enzyme might still be made, being able to give rise to the weak a antigen expression seen in this individual. interestingly, this mutation is very similar to the genetic variant underlying the weak a subgroup a finn . in this case, however, the c. + a>g mutation is located in the -end of intron and is predicted to cause partial skipping of exon . strikingly, the a finn phenotype also results in a pseudochimeric pattern by flow cytometry but with only approximately % positively staining erythrocytes. due to the well documented lack of a-allele-derived mrna in peripheral blood, further transcript studies could not be undertaken. further studies are needed to investigate the exact mechanisms underlying the pseudochimeric pattern observed by flow cytometry in these two interesting genotypes/phenotypes abstract withdrawn. background: abo is the clinically most relevant blood group system in transfusion and transplantation medicine. abo genotyping is potentially useful in clarifying serologic blood grouping discrepancies. this scenario includes inherited subgroups alleles, temporary acquired variant abo phenotypes in disease or pregnancy, and chimerism due to exchange of progenitor cells early in fetal life or after blood progenitor cell transplantation. aims: to investigate the molecular basis for abo discrepancies detected in clinical samples, including donors and patients, sent to our reference laboratory during the past years. methods: if routine abo grouping showed weak agglutination or forward vs reverse typing discrepancy, further abo typing studies were performed manually. adsorption-elution tests were also performed in some cases with polyclonal anti-a and anti-b to confirm whether a or b antigens were weakly expressed on the rbcs membrane. a pcr approach using sequence specific primers for a , b, o and o alleles was used for initial genotype determination. the full abo coding region was analysed as previously described in selected samples for which abo discrepancy was still unexplained. allele specific fragments spanning exon , intron and exon were amplified using a forward primer targeting the g nucleotide (to exclude o alleles amplification) in combination with either b, a or a generic reverse primer. analysis was carried out by sanger sequencing. results: a total of samples with suspected inherited abo subgroup alleles were selected for further molecular studies by sequence analysis. a subgroup alleles: in out of samples with suspected a subgroup alleles, the c. insg insertion was detected corresponding to the abo*ael. allele. the abo*aw . - variant, a hybrid a -o v allele, was found in cases. in case we found the c. g>c change, previously reported associated with weak a antigen expression. finally, a novel c. c>g change was detected in an a allele. b(a) or cis-ab suspected alleles: the abo*b(a) variant carrying the c. a>g change was found in of samples with bo genotype but a weak antigen expression. in the remaining cases, a consensus b allele was detected, thus pointing to a potential chimerism as the cause of the results observed in abo grouping. finally, we have identified an abo*b . allele carrying the nucleotidic change c. a>g in the context of an abo phenotype vs genotype discrepancy. summary/conclusions: the sanger sequencing approach applied in this study have proved to be informative and helpful to determine the molecular basis of abo grouping discrepancies with suspected inherited subgroups. we found mutations, within exon of the abo gene, in out of samples, including novel alleles. chimerism was suspected in cases of a antigen expression in samples with b o genetic background carrying an apparent normal b allele. we are evaluating at the moment a deep sequencing approach by next generation sequencing to determine the presence of a small amount of a minor allele in the presence of a large surplus of the other two alleles. background: recently, the multiple pregnancy rate has been increasing due to advances in artificial fertilization including in vitro fertilization-embryo transfer. most dizygotic twins have dichorionic placenta, but % of them share the placenta. monochorionic dizygotic twins can have blood chimerism, leading to double rbc populations in routine abo serologic typing. recently, more sensitive and objective column agglutination tests with automated systems are being widely used. therefore, blood chimerisms in dizygotic twins can be detected more easily by routine abo blood typing. aims: we report congenital blood chimerism in monochorionic dizygotic twins of triplets, found incidentally during abo serological testing and confirmed by abo genotyping and str marker analysis. methods: a -year-old male (one of triplets) was admitted to the hospital for medical checkup. he did not have any history of transfusion or bone marrow transplantation. routine abo blood grouping test was performed using automated blood bank system ih- ; however, it showed abo discrepancy. the red blood cells showed double cell populations in a gel column with anti-a and anti-b. we carried out abo genotyping both from the blood and from a buccal swab. for the further evaluation, we performed abo serologic testing, abo genotyping, and str marker analysis in his family members. results: among the triplets, blood chimerism was demonstrated in the patient and his brother. they both showed a b phenotypes in the serologic test and tri-allelic abo genotypes in the blood, a /b /o . however, in buccal swabs, the patient showed a /o and his brother showed b /o . other members of the family (father, mother, and dizygotic sister) had regular abo blood types in the serologic test. we performed str analysis in the triplets and parents. eleven loci (d s , d s , d s , csf po, th , d s , d s , d s , d s , d s , and fga) revealed more than one additional allele in the blood sample, apart from those in the buccal swabs. str marker analysis showed that his brother too had blood chimerism. summary/conclusions: we found blood chimerism in monochorionic dizygotic twins of triplets during routine abo blood typing, and this was confirmed by str analysis. as the application of assisted reproductive technology increases, the incidence of blood chimerism will also increase. blood chimerism can often create confusion during abo serologic typing and microchimerism can be overlooked in routine methods. therefore, it is helpful to use an automated blood bank system to improve sensitivity and blood chimerism should be considered if abo blood grouping reveals double populations. background: expression of abo transferase genes can be affected by genetic variants located within the coding sequence, at splice junctions, in the proximal promoter and in the intron enhancer. here we describe five new alleles with singlenucleotide substitutions found in samples with discrepant or unusual abo serology. aims: to resolve serological discrepancies or unusual serological findings in the abo blood group system by molecular methods, in particular by sanger sequencing. methods: forward and reverse abo phenotyping was performed by the gel or tube methods. genomic dna extracted from whole blood was pcr amplified to cover the entire abo coding sequence, splice junctions, proximal promoter and intron enhancer. amplification products were sanger sequenced directly or after cloning in a bacterial host. results: case # is a patient with an unclear abo phenotype: forward type b, reverse type ab. sequencing of genomic dna and cloned abo exon detected variant c. - t>g in heterozygosity on an otherwise common a allele, and in trans an abo*b. allele. case # is a caucasian donor with an abo discrepancy: forward type aweak/o, reverse type a. sequencing also detected variant c. - t>g in heterozygosity on an a background, and in trans an abo*o. . allele. given that this variant is located near the intron splice acceptor site, abo* - g transcripts are postulated to undergo altered splicing, leading to an aweak phenotype. case # is a prenatal sickle-cell disease patient with an abo discrepancy: forward type aweak, reverse type a. dna sequencing detected variants c. c>t (pro leu) and c. t>a (tyr asn), both in heterozygosity on an otherwise common a allele, with an abo*o. . allele in trans. thus, the data establish an association of allele abo* t, a with an aweak-like phenotype. case # is a donor with an abo typing discrepancy: forward type o, reverse type a. sequencing detected variant c. c>g (pro arg) in heterozygosity on an a background, and in trans an abo*o. allele. an interpretation of the data is that variant c. c>g weakens the activity of the a transferase, with allele abo*a ( g) encoding the aweak-like phenotype detected by serology. case # is a year-old patient with an abo discrepancy: forward type o, reverse type ab. sequencing of genomic dna and cloned abo exon detected variant c. g>c (gly ala) in heterozygosity on an a background, and in trans an abo*o. . allele. the serology and molecular results suggest that allele abo*a ( c) encodes a cisab weak phenotype. case # is a caucasian donor with an abo typing discrepancy: forward type o with a weak agglutination with anti-ab, reverse type o. dna sequencing detected variants c. g>a (glu lys) and c. g>a (asp asn), both in heterozygosity, in trans, and on a backgrounds. variant c. g>a by itself constitutes allele abo*a . . the phenotype encoded by abo* a is uncertain. summary/conclusions: molecular characterization of abo alleles can help in their future identification and discrepancy resolution. background: expression of abo transferase genes can be affected by genetic variants located within the coding sequence, at splice junctions, in the proximal promoter and in the intron enhancer. here we describe five new alleles with singlenucleotide substitutions found in samples with discrepant or unusual abo serology. aims: to resolve serological discrepancies or unusual serological findings in the abo blood group system by molecular methods, in particular by sanger sequencing. methods: forward and reverse abo phenotyping was performed by the gel or tube methods. genomic dna extracted from whole blood was pcr amplified to cover the entire abo coding sequence, splice junctions, proximal promoter and intron enhancer. amplification products were sanger sequenced directly or after cloning in a bacterial plasmid vector. results: case # is a year-old pregnant female with an abo typing discrepancy: forward type o, reverse type a. pcr-rflp predicted abo*a /abo*o . sequencing detected variant c. insg (val gly>fs ter) in heterozygosity on an otherwise common a allele, and in trans an abo*o. . allele. it is unclear how the early truncation of the a transferase encoded by allele abo* insg still allows for some residual enzyme activity, as suggested by the reverse a type. case # is a recently-transfused year-old black patient with an unresolved abo type. sequencing detected variant c. a>g (silent) in homozygosity and variant c. c>t (ala val) in heterozygosity, both on an o background, with an abo*b. allele in trans. although variants c. a>g and c. c>t are likely of no consequence to the abo phenotype of this patient, they are reported here as components of a new abo*o ( g, t) allele. case # is a year-old prenatal female with a rhd typing discrepancy. failure to yield an abo genotype on blood-chip (progenika), a genotyping microarray that interrogates polymorphic positions in rhd and abo, prompted dna sequencing. sequencing of genomic dna and cloned abo exon detected variant c. c>t (arg cys) in heterozygosity on an abo*b allele background, and in trans an abo*o. . allele. the phenotype encoded by allele abo*b( t) is predicted to be b, as evidenced by forward typing on immucor neo and reverse manual typing. case # is a prenatal black patient with an abo typing discrepancy: forward type o in gel, a + mixed field (mf) in tube. reverse type on a cells + in gel, / + in tube. sequencing of genomic dna and cloned pcr products covering exons - detected variant c. g>c (asp his) in heterozygosity, and in trans an abo*o. . allele. case # is the newborn baby of case # , with a forward type a + mf in gel, a + mf in tube. sequencing of the baby's dna detected variant c. g>c (asp his) in heterozygosity, and in trans an abo*b. allele. from these results it is inferred that the phenotype encoded by allele abo* c is a -like. case # is an year-old hispanic donor with an abo typing discrepancy: forward type a, reverse type o. sequencing of genomic dna and abo exons - and - detected variant c. c>t (gln ter) in heterozygosity, and in trans an abo*o. . allele. the truncation of the a transferase at such a relatively late position is consistent with the retention of some enzyme activity, explaining the forward a type encoded by allele abo* t. summary/conclusions: molecular characterization of abo alleles can help in their future identification and discrepancy resolution. background: expression of abo transferase genes can be affected by genetic variants located within the coding sequence, at splice junctions, in the proximal promoter and in the intron enhancer. variants reported to date in the intron enhancer include large deletions, small deletions and single-nucleotide substitutions. here we describe four new alleles with single-nucleotide substitutions found in samples with discrepant or unusual abo serology. aims: to resolve serological discrepancies or unusual serological findings in the abo blood group system by molecular methods, in particular by sanger sequencing. methods: forward and reverse abo phenotyping was performed by the gel or tube methods. adsorption-elution by the heat elution method and testing for h and a substances in saliva were performed by following the procedures in the aabb technical manual. genomic dna extracted from whole blood was pcr amplified to cover the entire abo coding sequence, splice junctions, proximal promoter and intron enhancer. amplification products were sanger sequenced directly or after cloning in a bacterial plasmid vector. background: inactive alleles of the fut could be decreased or aborted the activity of the fucosyltransferase, which results in to form the bombay or para-bombay phenotype with weak or no h antigen expression on erythrocytes. now many para-bombay individuals have been found in the chinese population. according to names for h blood group alleles v . of red cell immunogenetics and blood group terminology working group of the isbt, fut alleles were identified for bombay or para-bombay phenotype around the world. aims: the study was explored the distribution of fut alleles for the chinese individuals with para-bombay phenotype. methods: the samples were come from the blood donors or the patients. the a, b, h antigens were determined using conventional serological method according to the manufacture's instruction. the sequences of the full coding region for fut was amplified, then amplicon was purified with enzymes digestion and used as template for sequencing bidirectionally. all nucleotide sequences obtained were analyzed and compared with standard fut sequence. results: nineteen chinese individuals with para-bombay phenotype were identified. ten of them were the donors and nine individuals were come from the hospital. the rbcs had a very weak agglutination reaction with anti-h in the most of the individuals. fut homozygous mutations were found in the individuals and fut heterozygous changes were existed in individuals after bidirectionally sequencing. . %, . %, . %, . %, . %, . %, . %, . % respectively in the individuals with para-bombay phenotype. according to our previously reports, the fucosyltransferase activity of fut * n. (c. _ delag), fut * w. (c. c>t) and fut * w. (c. c>t) were abolished in vitro assay, while fut mrna levels of them had no effect compared with wild type. summary/conclusions: the fut mutations in the para-bombay individuals were various. the most common fut allele in the chinese individuals with para-bombay phenotype was fut * n. (c. _ delag). background: the regulatory mechanism of the abo gene is complicated and has been investigated extensively.variation in a antigen expression was recognized very early in the twentieth century and the a blood group was divided into a and a . later the a blood group was subdivided further based on characteristic reactivity with human polyclonal antisera, i.e., strength of reactivity and presence of mixed field agglutination; presence of anti-a , and whether a or h blood group substance was present in the saliva of secretor subjects. mutations critical for abo blood group phenotypes have predominantly been found in exons and of the abo gene, both of which encode the catalytic domain of abo glycosyltransferase. in our case report we show how mutation ranging from single nucleotide in the intron enhancer element can alter the efficacy of enzyme and alter antigen expression. aims: this study aims to investigate the molecular basis of discrepant results of abo forward/reverse typing in blood donor. methods: the abo typing was performed using tube technique and column agglutination tests (bio-rad, grifols). standard tests were completed with adsorption-elution study using o plasma as a source of anti-a, and with saliva testing for presence of a and h substances. we performed quality control for these methods. abo group genotyping was performed using pcr with sequence-specific primer by commercial kit (abo-variant; bag healthcare, lich, germany). pcr-amplified exons and intron enhancer were subject to bi-directional dna sequence analysis using standard sanger dideoxy chemistry. seqscape software (abi) was used to analyze sequence data by comparing the obtained sequence to a reference sequence from ncbi. results: standard serological forward tests identified blood group o, however, only anti-b iso-agglutinins were present. anti-a in adsorption-elution study was successfully adsorbed and eluted from the investigated cells. a and h substances were detected in saliva. abo genotyping using pcr-ssp indicated genotype o v/a . dna sequence analysis showed result abo*a ( + a), abo*o. . . the specimen was revealed as an a subgroup, probably a m with an unusual genetic variant in the intron region of the abo gene, the enhancer of the gene expression. summary/conclusions: we report the first case of abo*a ( + a), the mutation located in the enhancer region of gene expression in allele a, that causes discrepant results not only in abo forward/reverse typing but also in molecular blood grouping tests. based on our serological findings, this subgroup is considered as a m . background: a chimera is a single organism composed of cells with distinct phenotypes and/or genotypes. several different types of chimeras are described: artificial, twin and dispermic. the artificial chimerism can be seen following hematopoietic stem cell transplantation, or more transiently following blood transfusion. the second type may also be inherited most commonly through blood exchange in utero between twins. dispermic chimerism is induced by the fertilization of two maternal eggs with two spermatozoa and their fusion into one body. this one is also called tetra-gametic chimerism. in transfusion medicine, chimeras are often detected when mixed field reactivity is observed in abo/d typing or, less commonly, when phenotyping for other blood group antigens. aims: this investigation was prompted by finding a double population of erythrocytes in a surgery patient with no transfusion history. our aim was to investigate the chimera and determine the underlying abo genotype of this patient. methods: routine blood grouping was performed by column agglutination. separation of the double cell populations was performed by differential agglutination with igm anti-d (immuclone, anti-d fast igm, clone: d - , immucor). initial abo genotyping was performed by pcr-ssp (fluogene; inno-train diagnostik gmbh); further resolution was performed using in-house pcr-asp and pcr-rflp methods. next generation sequencing (monotype abo; omixon using illumina sequencing platform) and sanger sequencing analysis were also performed. identification of reference alleles was investigated by fragment analysis of short tandem repeats (str) polymorphisms. results: double population was found in column agglutination in tests with anti-a and anti-ab, and subsequently when typing for d and c antigens, with approximately % of o d+c+ cells. the patient's genotype was identified as abo*o. /*a by ce-certified pcr-ssp kit (fluogene). routine pcr-asp and pcr-rflp could not resolve the patient's genotype possible abo*a /*o genotype was detected by pcr-rflp, but the pcr-asp analysis gave an apparent abo*a homozygote result. sanger sequencing of abo exons and also gave anomalous reactions: no abo*a allele was detected. homozygosity for c. delg was observed as well as heterozygosity for c c/a. this result therefore suggests the patient's genotype is abo*o. /*o. . . next generation sequencing (omixon) revealed the same result. however, when pcr amplification of the cbf/nf-y enhancer vntr -region was performed, possible heterozygosity was observed, i.e. a weak band representing a single copy, and one representing copies of the enhancer region were present. presence of a single copy of the -bp cbf/nf-y enhancer vntr region is unique background: del is a very weak form of d antigen with low density expression of d antigen on the surface of red blood cell, which is generally typed as d-blood group as couldn't form agglutination in routine rhd blood group testing and could only be detected by the non-routine adsorption-elution test. in the east asian and southeast asian population, - % of the individuals with serologically apparent d-phenotype are not these with truly d-phenotype, but del phenotype, which is very rare in caucasian and black ethic groups. and the rhd* el. (rhd* a) is most prevalent (> %) in del people in these regions, so the del carried this allele was commonly known as "asia type" del. in previous studies, no alloanti-d was observed in a large cohort of chinese "asia type" del pregnant women with d+ fetus to indicate no occurrence of alloanti-d immunization against d+ red cell in "asia type" del individuals. aims: to conduct genotyping analysis in the chinese patients having serologically apparent d-phenotype simultaneous with alloanti-d to confirm the existence of the "asia type" individuals to produce alloanti-d or not. methods: from to , the blood sample of the patients or pregnant women identified with alloanti-d in our reference lab were collected. d antigen was confirmed again using the blend anti-d reagent (clone th- /ms- , igm/igg) by tube method in saline and indirect antiglobulin test (iat) in gel card. the zygosity of rhd gene was detected by hybrid rhesus box pcr with psti digestion. for the samples with d or dd genotypes obtained by rhd zygosity analysis, multiplex ligation-dependent probe amplification (mlpa) genotyping was conducted for rhd genotyping analysis. results: a total of serologically apparent d-chinese patients (female, n = ; male, n = ) with alloanti-d were identified. different titers of alloanti-d from : to : (≤ : , n = ; > : , n = ) were detected including few cases with mixed antibodies (anti-d mixed with anti-c, n = ; anti-d mixed anti-e, n = ). serological rhd typing confirmed the serologically apparent d-phenotype. rhd* n. / n. (homozygous rhd gene deletion) genotype was identified in majority of them ( / , . %) by rhd zygosity analysis, while rhd* n. / n. genotype (n = ) and rhd* n. / n. genotype (n = ) carried the rhd non-functional hybrid alleles were detected by mlpa. summary/conclusions: compared with the distribution of average % frequency of "asia type" del in serologically apparent dpopulation in guangzhou of china, no one case of "asia type" del was identified in the cohort of serologically apparent d-patients with alloanti-d in this study. this also provides evidence to confirm no occurrence of alloanti-d immunization in "asia type" del individuals. aims: a serologically rhd-negative donor was found to be rhd-positive in the routine rhd screen. to solve the discrepancy between serology and molecular screen, the sample was sequenced on dna and rna level. methods: phenotyping on id/iat-cards (bio-rad) was done using commercial anti-d antibodies. the adsorption-elution analysis was performed using an in-house pool of polyclonal anti-d antibodies. furthermore an antibody d-screen was performed (diagast). for rhd genotyping rh-type and partial d-type assays (bag health care) were carried out. the sample was further characterized by exon sequencing including flanking intronic regions. rna was extracted from whole blood, reverse transcribed and the cdna sequenced. for amplification and sequencing, both published (gassner, transfusion, ; legler, trans. med., ; richard, transfusion, ) and in-house primers were used. results: repeated phenotyping of the sample with commercial as well as, in-house anti-d antibodies confirmed the rhd negativity. in addition, the adsorption-elution analysis showed a negative result. however, genotyping, using commercially available kits, yielded a rhd positive result and no variants were detected. to investigate this discrepancy, all rhd exons were sequenced. the sequencing data revealed the mutation c. + delt in the splice donor site of exon . to confirm the effect of the splice site mutation on transcription, rna from a fresh whole blood sample was analysed. as a positive control, gypb was amplified and sequenced from the same cdna. wild-type gypb (mns ) was found. with rhd specific primers, no product could be amplified. summary/conclusions: we present a serologically rhd negative case, that was identified as rhd positive by standard commercial genotyping kits. sequencing revealed the new splice site mutation c. + delt. rna sequencing yielded no detectable product. the donor was classified as rhd negative. this case of a discrepant result between serology and genetics shows the importance of a profound and highly sophisticated genetic investigation of conflicting laboratory results. j stettler, s lejon crottet, h hustinx, c von arx, f still, j graber, c niederhauser and c henny interregional blood transfusion src berne ltd., berne, switzerland background: one of the most immunogenic and clinically significant blood group antigens in transfusion medicine is the rhd antigen. variant rhd phenotypes with weakened or absent antigen expression pose a challenge for rhd status assignment in blood donors. to ensure patient safety, it is necessary to fully characterize these variants at the molecular level. aims: samples from two donors were investigated in our laboratory due to discrepancy in rhd typing. methods: rh blood group phenotyping was done by standard serological column agglutination testing (id-system, biorad). further rhd characterization was performed by an anti-d antibody panel containing monoclonal antibodies (d-screen, diagast) and an adsorption-elution test using an in-house pool of polyclonal anti-d antibodies. molecular investigation was initially performed by ssp-pcr detecting common rhd variants (rbc-ready gene cde inno-train; rh-type bag health care). rhd sequencing was done on either dna or rna using published and inhouse primers for amplification and sequencing. results: by tube testing, the rbcs of donor were predicted to be rh:- ,- ,- , , . however, all ten exons of the rhd gene could be detected by routine genotyping. sequencing of rhd revealed a homozygous mutation c>g at position which is the second last nucleotide of exon and thus might have an influence on exon splicing. by cdna analysis a transcript with a correctly spliced exon was identified. the mutation c. c>g leads to the amino acid substitution t r located in the twelfth transmembrane domain of rhd using the model of flegel (transfus apher sci., ) as reference. adsorption-elution testing using a pool of polyclonal anti-d showed a weak positive reaction, re-classifying the donor as rhd positive. this novel allele, rhd* g, could thus be categorized as a del allele. serological results displayed an almost normal rhd antigen expression for donor . further serological determination of the rhd antigen with different antisera, however, showed a reaction pattern typically observed with a weak d variant. with commercial available kits no rhd variant could be detected. rhd sequencing revealed a novel homozygous mutation c. g>c in exon . this mutation causes a p.a p exchange in the sixth membrane-spanning domain of rhd. based on serological data, the donor is rhd positive and in case of transfusion the patient would be treated as rhd negative. summary/conclusions: here we report two novel rhd missense mutations c. c>g and c. g>c harbouring an amino acid substitution within a transmembrane segment. the c. c>g variation displayed an unusual low rhd antigen reactivity and would have been mistyped as rhd negative without extensive genotypic testing. molecular analysis of variant c. c>g suggests that the t r exchange causes a del phenotype rather than a miss splicing event. this was also confirmed by adsorption-elution testing. interestingly, variant c. g>c could only be detected due to comprehensive serological and genetically investigation. background: the rh blood group system is highly polymorphic and one of the most clinically relevant systems in transfusion. actually d antigen is of critical importance due to its involvement in hemolytic transfusion reaction and hemolytic disease of the fetus and newborn. rhd gene variants are common in africans and mostly related to partial d phenotype. aims: rhd gene sequence was investigated in two african brazilian samples. we further attempted to take advantage of combining the molecular data and the available in silico tools for the functional interpretation of the variations, in order to get insights into the clinical phenotype that may be predicted a priori from genotyping. methods: sample #id is a d-negative donor self-declared as african descent. sample #id is a patient with sickle cell disease (scd) typed as d-positive with anti-d in his serum. serologic d typing was determined by manual gel test and by microplate in an automated instrument. sample #id was also submitted to adsorption/elution test. after genomic dna extraction, all ten rhd exons and flanking intronic regions from sample #id were pcr-amplified with rhd-specific primers and analyzed by sanger sequencing. sample #id was investigated by next-generation sequencing on the miniseq platform (illumina) by using a previously published, custom (selected blood group genes) ampliseq panel. a reported three-dimensional ( d) structural model of the rhd-rhd-rhag heterotrimer was used to visualize the position of variations and predict their putative functional/clinical effect. results: in sample #id , a single nucleotide missense change, i.e. c. c>g in exon , was identified. this transversion is thought to replace a threonine by an arginine residue at amino acid position (p.thr arg) of the rhd protein. analysis in the d model clearly suggests a dramatic impact of the p.thr arg substitution occurring in a functionally-critical, conserved motif in terms of interhelix interaction, which is supposed to be highly deleterious to the stability of the protein, and potentially impairs totally its expression at the red blood cell plasma membrane. this predicted functional effect is definitely in accordance with the d-negative phenotype reported in sample #id . in sample #id , the single c. a>g transition was found in exon leading to a threonine-to-alanine substitution at amino acid position (p.thr ala). amino acid is located in rhd protein extracellular loop , and is thus thought to alter d antigen structure, resulting in a partial d phenotype. this hypothesis is in accordance with anti-d found in the serum of sample #id . summary/conclusions: for the past years, due to the advent of next-generation sequencing and the subsequent identification of numerous rare variants, bioinformatics prediction and modelling tools have evolved and currently help physicians in diagnostics, clinical management and genetic counselling. we took advantage of some of those in silico methods to predict retrospectively the effect of two novel variant rhd alleles, including one d-negative and one partial d alleles. although phenotype and clinical symptoms remain definitely the standard determinants to assess the effect of genetic variations, use of those approaches may soon become valuable for guiding subsequent investigations in immunohaematology. abstract withdrawn. alleles of the weak d type and diva cluster. in africans, the most frequent were typically associated with alleles of the weak d type (including dol and rhdpsi), diva and dau clusters with f v occurring in > % of alleles; in addition the key mutations of weak d type and dii and two inactivating mutations (c. _ inst and c. delg) not reported in rhb were among the first polymorphisms. in east asians, rhd( g>a) at . % was most frequent, followed by dfv, weak d type , dbo- , key mutations of diva and weak d type cluster as well as rhce-like substitutions and the mutations of weak d type , type , type , rhd(a v), dvl- , weak d and rhd(n s). weak d type and rhd(t r) were frequent in south asia but not elsewhere. summary/conclusions: data from tgp and gnomad add relevantly to the knowledge on rhd alleles; tgd discloses linked intron polymorphisms, gnomad frequency data not biased by the likelihood of serologic detection. current typing strategies usually start with serology later complemented by molecular typing. in the future, molecular methods will gain importance and frequent alleles currently not distinguished from "standard rhd" may need a rational transfusion strategy. in this respect, the high frequency of weak d type and type in europeans was surprising, might warrant confirmation by alternative methods and should trigger discussion on rational transfusion strategies for these alleles. consistent with an r haplotype and probable dc-. two siblings that were abo compatible including the dc-sibling were incompatible at iat phase. reactivity could be completely adsorbed from the serum using r r , r r , and rr rbcs indicating the antibody is probably a single specificity. the donor returned in and to continue autologous donations. the aim of this case study was to examine the genetic framework of the rhd and rhce genes and to characterize the rh epitope recognized by the antibody. aims: the donor returned in and to continue autologous donations. the aim of this case study was to examine the genetic framework of the rhd and rhce genes and to characterize the rh epitope recognized by the antibody. methods: serologic testing was performed by manual tube testing using ahg in the indirect antiglobulin phase. rbc phenotyping was performed by standard tube hemagglutination testing from edta anticoagulated blood. rhd and rhce exons were sequenced using genomic dna and standard sanger dideoxy method with the bigdye terminator v . cycle sequencing kit. sequence data was aligned to rhd_ng_ . . rhd zygosity was performed using pcr-rflp with mspi. background: according to recent findings in molecular immuno-hematology, rhd genotyping is strongly indicated in rhc+ and rhe+ donors classified in routine as d-negative. among these, one could find a non-negligible share of entirely new genetic alterations or even del alleles, which are often not identifiable with routine serological methods due to the low number of antigenic sites. aims: the present study reports the genotyping data of rhd on rhc+ and rhe+ caucasian donors classified serologically as d-negative, all enrolled by a single transfusion center in italy methods: rhd serological typing was carried out in microplate direct agglutination tests (iris, immucor) by using different anti-d igm clones (clone , dvi+: ldm +esd m; clone , dvi-: rum- , th ) and different anti-d igg clones (clone : ms ; clone : d e ). all donors with d-negative results (n = , divided into subjects with rhc+, with rhe+ and with both rhc+ and rhe+) were addressed to genotype analysis with rhd beadchip molecular test (immucor), pcr-ssp (bagene, inno-train) and/or rbc-fluogene (inno-train). the discrepant results between serology (d-neg) and molecular biology (wild-type or full-length rhd gene) were further investigated by bi-directional sequencing of the rhd coding regions. results: one-hundred donors have been analyzed retrospectively, as part of a pilot study. following the data obtained in this first phase, the analysis methods described above have been implemented in routine, allowing to include further donors, studied prospectively. in . % of donors (n = ), the molecular analyses showed the complete deletion of the rhd locus, while in cases ( . %) a genetic status was found with "non-deleted" rhd. over all, bi-directional sequencing on these donors revealed the presence of negative and weak-d variants. the list of rhd alleles we have identified at the molecular level is as follows: rhd* n. ( cases), rhd* n. ( ), rhd* n. ( ), rhd* n. ( ) , rhd* n. ( ), rhd* el. ( ), rhd* el. ( ), rhd* el. ( ), rhd* w. ( ) . moreover we found a donor with a lack of signal encompassing exons - of the rhd sequence (bioarray rhd beadchip), while additional cases are currently under investigation. summary/conclusions: our study confirms that a non-negligible number of caucasian subjects, classified serologically as d-negative, present rhd gene alterations that differ from the common total deletion. in line with the literature data, we also found a frequency of about in cases ( subjects out of ), in which a donor re-classification as d-positive (weak d type) was necessary. hence, a wider use of molecular typing methods is desirable in order to achieve the correct genetic characterization and the appropriate phenotypic classification of "apparently" d-negative donors. background: without evidence of abnormal serological d antigen expression there will be no quest for weak d, partial d or d variant on the red blood cells. according to our blood donor registry we found that out of serologically typed donors, . % were d+, . % d-and . % weak d. aims: to compare different weak serological reactions of the d antigen to the rhd genotyping. methods: molecular rhd typing using isolated dna and rbc-ready gene cde and rbc-ready gene d weak kits was performed in blood donors, who were serologically typed as weak d using monoclonal blended igm/igg and dvi-and dvi+ anti-d reagents by slide and microplate (mp) technique respectfully, as well as by the antiglobulin test (iat) in gel and with the set of monoclonal partial d typing reagents (biorad). in addition, rhccee phenotyping and genotyping was also performed. results: all of the donors with serologically weak reactions were confirmed to be weak d variants by genotyping except one donor whose iat was false positive due to rbc autoantibodies. the frequency of d variant genotypes was as follows: % weak d type , % weak d type , one donor was typed as weak d type and another one as weak d type . these weak d types were associated with different degrees of serologically determined weakness ranging from negative to weak positive reactions concerning slide and mp. all of them gave positive reaction ranging from + to + with iat, except for the weak d type with the score of < + which gave negative reaction by slide and mp and inconclusive result with the set of monoclonal anti-d reagents for partial d typing. the percentage of donors, who, at serological typing were only found to be d positive in the iat was %. one of the weak d type donors was negative with dvi-and positive with dvi+ reagent in the mp. the additional rh phenotype (genotype) was ccee in all of the donors except in the one who was genotyped as weak d type , as well as in the d negative donor, being ccee. summary/conclusions: further rhd genotyping is required to estimate the actual frequency of d variants in our blood donors. in practice, current serological methods are sufficient to detect almost all variant d phenotypes. there is a consensus that routine molecular d antigen screening in d negative donors in order to detect del variant when ddccee phenotyped red blood cell transfusion is practiced in all d negative patients does not seem to be cost-effective. background: rh null or rh mod -the so-called rh-deficiency phenotypes-are characterized by a null or severely reduced rh antigen expression (including d, c/c and e/ e), respectively. molecular genetic studies showed that these phenotypes are transmitted in an autosomal recessive manner. rh null phenotype originates from two different molecular events giving rise to the amorph type and the regulator type. the former is caused by homozygosity for silent genes at rhd and rhce loci, caused by inactivating mutations in rhce and deletion of rhd. on the other hand, the regulator rh null type as well as the rh mod phenotype are attributed to mutations in rhag gene when in homozygous state or when in heterozygosity with another rhag allele containing an inactivating mutation. a functional rhag is essential both for the correct rh complex assembly and rh antigen expression in the erythrocyte membrane. aims: the aim of this study was to investigate the molecular genetic basis of an argentinean proband with no detectable d, c, c, e and e antigens by standard serological techniques. methods: blood samples were collected from the proband, her parents and sister. the proband was a year-old young woman with parameters of hemolytic anemia: low hemoglobin level ( g/dl), reticulocytosis ( %), hyperbilirubinemia, increased ldh and marked spherocytosis. the d, c, c, e and e status was determined by standard serologic hemagglutination techniques using specific monoclonal antibodies. genomic dna was isolated using a modified salting-out method. dna samples were initially screened for the presence of intron and the untranslated region of the rhd gene using pcr strategies. rhc/c, and rhe/e alleles were studied by allele-specific pcrs to determine the rhce genotype. rhd zygosity was analyzed by pcr-rflp. rhd exon polymorphisms were studied by rhd exon scanning procedure based on pcr-ssp. rhag gene was investigated by exon-specific pcr amplification and sanger sequencing. results: no d, c, c, e and e antigens were detected in the proband's erythrocytes. the father and sister rh phenotype was: d+, c+, c+, e+, e+ whereas the mother rh phenotype was: d+, c+, c-, e-, e+. rh genotyping confirmed the rh phenotypes for all family members except for the proposita who genotyped rhd+, rhc+ and rhe+. all samples showed an homozygous status for the rhd gene and all rhd exons were detected by exon scanning. sequencing analysis revealed an homozygous c. c>t mutation in rhag exon in the proband whereas the rest of the family showed an heterozygous state in the same nucleotide position. the c. c>t mutation is responsible for the p.ser phe amino acid substitution predicted to be in the th rhag glycoprotein transmembrane segment. summary/conclusions: this study described the molecular background responsible for an rh-deficiency phenotype in an argentinean proband. we identified the novel missense mutation c. c>t in the rhag gene which results in the ser to phe single amino acid substitution that shows to be critical for rh antigen complex assembly within the erythrocyte membrane. further studies are being performed in order to determine whether the proband is rh null or rh mod . background: rh blood group system is the most immunogenetic blood group system and blood donor typing should account for all expressing antigens in order to prevent anti-d alloimmunization. aims: the objective of this prospective study was to investigate rhd alleles among blood donors who typed d-by serologic methods and positive for c and/or e. for this reason we developed an easy-to-perform dna-based screening method for the detection of rhd gene and positive samples were further characterized by two commercial pcr-ssp kits. methods: of individual blood donors within a month period, ( . %) typed as d-with standardized immunohematologic methods including the indirect antiglobulin test (iat). residual edta-anticoagulated blood samples were used to isolate genomic dna using the qiaamp dna blood kit (qiagen, germany) from out of ( . %) c/e+ and serologically d-donors. all dna samples were tested individually for the presence of rhd-specific dna sequences in the rhd promoter, intron , exon and exon by a multiplex pcr-ssp method. the reaction was conducted in a final volume of ll with primers that were applied as described by f. wagner et al. (bmc genetics, ) except antisense primer for exon and the two primers amplifying an hgh gene fragment as internal control, designed by our laboratory. pcr products were visualized by electrophoresis on a % agarose gel with ethidium bromide staining. in case of a positive reaction the sample was analyzed by pcr-ssp d weak and pcr-ssp cde (inno-train, germany). results: out of d-individuals analyzed, were ddccee, ddccee, ddccee and one had a ddccee phenotype. molecular analysis showed that ( . %) were negative for all four rhd dna regions. among the other samples, all of ddccee phenotype, three were found to be positive for rhd promoter, intron , exon and exon , three for rhd promoter and exon , and two for exon alone. further genotyping revealed five hybrid rhd-ce-d alleles [ rhd-ce( - )-d and rhd-ce( - )-d], one allele represented the del(m i) genotype, while the remaining two samples did not show an allele that could be determined with the pcr-ssp kits. summary/conclusions: serotyping is the standard method to assign transfusion strategies but it is not always capable to correctly define all samples that show weak reactions in d. a rhd genotyping strategy is needed to confirm d-blood donors and thus to avoid anti-d immunizations. for these reasons we suggest the implementation of an easy and possible cost-effective method. background: more than weak d types have been described to date. transfusion recipients with weak d type , , or are not at risk for forming allo anti-d when exposed to conventional rh d-positive rbcs. molecular analysis of weak d offers a more reliable basis than serotyping to determine the prevalence of weak d types and optimal d transfusion strategies. background: the d antigen, which consists of a mosaic of epitopes, is determined in all the blood donors and patients. most people are either rhd-positive or rhdnegative, but there is a certain number of people who have a variation of the d antigen, which are called weak d, partial d and del phenotypes. aims: the objective is to use molecular methods to determine whether blood donors in republika srpska (with whom a serological weak d antigen has been detected) really have the weak d antigen. in addition, determine whether blood donors, who have been determined as persons who are rhd-negative, with the phenotypes c and/ or e, who have the rhd gene and d antigen on the erythrocyte membrane, so weak that it could not be determined by serological techniques. methods: blood samples were used from regular blood donors, who have been determined as persons with a weaker d antigen, as rhd-negative or as c and/or e positive (based on the agglutination strength) using serological techniques, the test tube method, the microplate method and the gel method. gp.mur was also modelled and shown to closely resemble the tertiary structure of glycophorin a. the predicted structure is anti-parallel b sheets arranged in a "b barrel" also referred to as an ob-like-fold. the regions in which blood group antigens were identified in the predicted stable dimeric structure. summary/conclusions: ob-like-fold structures typically to bind oligonucleotides or oligosaccharides and are associated with cold shock proteins. further modelling is in progress to predict the structure of gpa/gpb heterodimers as a basis for understanding the presentation of blood group antigens. of interest, this finding is consistent with a previous report showing that this gpa binds to carbohydrates. this model serves as a foundation for future work regarding the properties of gpa, which includes identifying locations of specific interactions between gpa and other rbc surface proteins such as gpb and band , as well as identifying structural features of antigenic regions on gpa. . even though no significant differences were found among the groups studied, haplotypes containing the mcc b and sl polymorphisms were identified in d samples but were not found in tb and l groups. summary/conclusions: this preliminary data obtained suggests that cr polymorphisms and haplotypes, especially those containing mcc b and sl snps, could be involved in the disease pathogenesis of tuberculosis and leprosy. the entrance of mycobacteria into macrophages is mediated by complement receptors that facilitate their uptake by host cells so the combined haplotypes could be enhancing parasite phagocytosis and inflammation. further studies are being carried out to establish whether cr polymorphisms are risk or protective factors and whether other genetic variations in this receptor are also involved. abstract withdrawn. background: the dombrock blood group system consists of two antithetical antigens, do a and do b , and three high-prevalence antigens, gregory (gy a ), holley (hy), and joseph (jo a ). the rare do null or gy(a-) phenotype lacks all dombrock antigens, and the do null alleles vary with both do* and do* backgrounds. here we report the molecular basis of a novel do null allele in a gy(a-) brazilian patient with anti-gy a . aims: case presentation: an alloantibody to a high-prevalence antigen was detected in the serum of a year old woman from the northeast brazil with a history of pregnancies but no history of previous transfusion. she required transfusion because of a schedule for total thyroidectomy surgery due to a large compressive nodular goiter. the antibody did not react with the autologous rbcs but reacted by the indirect antiglobulin test in liss with all panel rbcs and other rbc samples tested except with the gy(a-) phenotype. the corresponding antigen was resistant to treatment with papain but sensitive to dtt and trypsin. these results suggested that the antibody recognized an antigen in the dombrock blood group system. the purpose of this study was to identify the antibody specificity and to determine the molecular basis of the phenotype detected. methods: the red cells phenotype and the presence of the dombrock related antibody in the serum were detected by standard hemagglutination techniques. rbcs and antibodies were from our in-house collection of rare samples. genomic dna was prepared from peripheral blood of the patient. dombrock genotyping was performed by id-core xt platform (grifols, spain). the exons of the do gene were amplified by pcr and directly sequenced. experimental immunohematology and diagnostic immunohematology diagnostic immunohematology experimental immunohematology, sanquin, amsterdam, netherlands background: typing of blood group antigens is essential to prevent transfusion reactions or haemolytic disease of the foetus and newborn. to date, the isbt recognises blood group antigens. most antigens ( ) belong to one of the blood group systems. since the genetic basis of these systems is known, genotyping of these antigens is possible. the molecular background of antigens is unknown and can only be determined serologically. one of these antigens is sd a (sid), first reported in .~ % of the population carry sd a on erythrocytes, but this frequency might be higher since identification is difficult due to variability in expression. in % of individuals sd a is present in urine. cells with a high expression of sd a (cad/sda++) are used for detection of antibodies. recently, a -cells antibody detection panel of bio-rad contained a sda++ cell and many individuals with anti-sd a were detected. the b galnt gene has been implicated in the synthesis of sd a . we collected individuals with and without anti-sd a to elucidate the genetic background of the antigen. aims: elucidation of the genetic basis responsible for loss of the sd a antigen on red blood cells. methods: routine diagnostics to identify antibodies in patients was performed using a bio-rad -cells panel, containing donor with high expression of sd a . additionally, pregnant women were screened for anti-sd a . dna of eight samples with anti-sd a and eight samples without anti-sd a was isolated for further analysis. sanger sequencing was performed on b galtnt exon - . results: sequencing of b galtnt revealed two homozygous mutations which are present in all eight individuals with anti-sd a , but not present in controls. the remaining two controls are heterozygous for these mutations. the first mutation within exon , c. t>c (enst . , rs ) changes a cysteine to arginine at position of the protein. the second mutation in exon c. a>g (rs ) does not change an amino acid. both snps have a maf of . and therefore we expect that . % of the population is homozygous for the minor allele. genotyping of a large population of pregnant women and the serological detection of anti-sd a in women with a homozygous mutation is in progress. summary/conclusions: the high frequency antigen sd a has not been linked to a blood group system because the molecular basis for loss of the antigen has not been elucidated. the b galtnt gene has been associated with sd a synthesis and therefore we analysed this gene for mutations in individuals with antibodies against sd a . a single homozygous mutation within exon causing an amino acid change was found in all individuals with anti-sd a , and no individuals without antibodies were homozygous for this snp. from population studies we expected~ % sd a -negatives, but either this frequency is an overestimation because of difficulties to detect low expressed antigens or mutations in other genes are interfering with sd a synthesis. a larger study of individuals with homozygous mutations in b galnt and linkage to sd a -negativity and presence of antibodies will be performed before sd a can be assigned to a new blood group system. abstract withdrawn. abstract withdrawn. background: erythrocyte duffy blood group antigen can scavenge chemokines in whole blood. duffy blood group gene consists of two major alleles: fy*a and fy*b. however, little is known regarding the association of duffy blood group polymorphisms with the red blood cell (rbc) chemokine scavenging. aims: the aim of this study was to determine the association of duffy blood group polymorphism with the rbc chemokine scavenging. methods: the duffy blood group were genotyped by ˊ-nuclease assay in healthy chinese han individuals, while erythrocyte chemokine scavenging function and duffy antigen expression from the same samples were measured using erythrocyte chemokine binding assays and quantitative flow cytometry respectively. results: rbc chemokine scavenging of cxcl was significantly lower in the individuals with the fy*a/fy*a genotype compared to those with fy*a/fy*b genotype (p = . ). similar result was also observed in rbc chemokine scavenging of ccl (p = . ). the expression of duffy antigen on rbc surface in the individuals with the fy*a/fy*a genotype was significantly higher compared to those with fy*a/ fy*b genotype (p = . ). summary/conclusions: duffy blood group polymorphism is associated with the differential rbc chemokine scavenging. it is probable that a change in duffy antigen structure caused by duffy blood group polymorphism is responsible for the differential rbc chemokine scavenging. background: individuals with p-phenotype can develop a naturally occurring anti-pp pk and has clinical significance, causing hemolytic transfusion reactions or hemolytic disease of the fetus and newborn. finding and procuring blood units of pphenotype is a challenge because of its rarity throughout the world. therefore, acute normovolemic hemodilution (anh) can be an on hand tool in the perioperative successful management of patient with rare blood group. however, this approach has not been commonly used aims: n/a. methods: n/a. results: a -year-old korean woman was referred to samsung medical center for surgical management for gallbladder malignancy. her blood type was group a, d-positive. the patient had no known history of transfusion. however, antibody screening and identification test using the column agglutination method (bio-rad, cressier, switzerland) showed panagglutination with negative reactions to autologous red blood cells, indicating the presence of alloantibodies to high frequency antigens. the specimen obtained from the patient was sent to the central laboratory of the swiss red cross (bern, switzerland) and confirmed as anti-pp pk. at first, the transfusion team of our hospital recommended the surgical team to postpone the surgery. however, anh was planned because postponing surgery was not preferred and the patient's preoperative hemoglobin was . g/dl. ml of blood was withdrawn through a radial arterial catheter in two ml blood bags containing citrate-phosphate-dextrose-a solution after anesthetic induction. equal volume of % hydroxyethyl starch solution was infused during the procedure. the patient underwent radical cholecystectomy and liver wedge resection with lymph node dissection, and two units of autologous blood were returned to the patient during surgery. she was then discharged h later with a hemoglobin level of . g/dl. later, the family study was performed with the standard serologic method using the proband's plasma containing anti-pp pk and sequencing of the a galt gene, which were conducted according to the protocols by koda et al.(transfusion. ) . the proband and her brother were homozygous for c. dupc, indicating a rare p phenotype. summary/conclusions: we experienced that autologous blood transfusions via anh is an alternative to allogenic rbc blood transfusion in patients who have no blood available because of high alloimmunization antibodies against rare blood groups. " and the third sample as "gypb*s_gyp*[ a], gypb*s_null(ivs + t)" with a predicted phenotype: s-s+ mi a + and s+s-mi a +, respectively. the gypa specific primers used for discrepancy resolution detected the nucleotide substitution, gyp.c. c>a, in gypa-b-a hybrid associated to gp.hut allele, thus confirming the id core xt result. the expression of mi a for one of these samples was confirmed using non-commercial anti-sera. hence, these three samples were not gp.mur but gp.hut phenotype. both alleles codify for the expression of mi a antigen since it is expressed on several hybrids between the usual forms of glycophorin a and b. two of these three gp.hut samples are african-american donors. gp.hut was reported in white people with a frequency about . % and in thais with . %. these three gp.hut cases found by id core xt in this study point to a higher frequency of this glycophorin variant and also to the presence in african american population. summary/conclusions: id core xt was able to detect two glycophorin phenotypes, gp.mur and gp.hut, which codify for the expression of mi a antigen. standard molecular methods should be implemented in pre-transfusion testing and obstetrical care routine to detect the most clinically relevant glycophorin variants in mns system. background: serf(+) is a high prevalence antigen in the cromer blood group system, which is encoded by a crom* allele. the lack of the serf antigen, serf(À) on red cells is caused by a single nucleotide polymorphism, c. c>t in exon of the decay-accelerating factor, daf gene. alloanti-serf has been found in thai pregnant woman with serf(À) and a serf(À) individual was found among thai blood donors. anti-serf is not a marketed product; hence, a molecular technique has to be implemented to genotype for the crom* allele among blood donors. aims: this study aimed to identify the crom* allele among thai blood donors leading to predicted serf(+) and serf(À) phenotypes. methods: dna samples obtained from , central thai blood donors were genotyped for serf allele detection using in-house pcr with sequence-specific primer (pcr-ssp) and confirmed by dna sequencing. results: the allele frequencies of crom* (+) and crom* (À) among , central thais were . ( , / , ) and . ( / , ), respectively. the homozygous of crom* (À/À) alleles was not found in this study. additionally, the pcr-ssp technique was validated by dna sequencing using randomly chosen samples together with heterozygous crom* (+/À) samples and the results were in agreement. summary/conclusions: our results confirm a high frequency of the crom* (+) allele in the thai population and their frequencies were similar to those formerly reported among thai blood donors. this study would be beneficial to predict the serf antigen from genotyping results due to unavailability of commercial antiserum. background: there is increasing interest in the use of molecular methods for predicting abo grouping. though nextgen and sanger sequencing have both been used to predict abo type, predicting abo type from buccal swab-derived dna and from deceased donors benefits from a quick and reliable method. besides a pcr-rflp that has been used by many labs for more than years, there is a commercially-available research use only (ruo) kit, and both interrogate nucleotides associated with o , o , a and b with a representing the ancestral allele. aims: the aim of this report is to compare two low-resolution polymerase chain reaction (pcr)-based methods, for investigation of samples submitted to a reference molecular immunohematology laboratory for abo typing discrepancies. fifty-six peripheral blood samples were tested, from patients and from blood donors. methods: genomic dna was isolated from peripheral blood mononuclear cells. background: del is the weakest known d positive phenotype in the rh blood group system and detectable only by adsorption and elution tests. the rhd g>a change is an important marker for del phenotype in east asians. a rapid and efficient pcr method for rhd gene g>a genotyping is useful in east asian countries. aims: the aim of this study was to develop a method for rhd g>a genotyping by using single-tube pcr with melting temperature(t m )-shift primers. methods: two allele-specific primer for rhd g>a and a common primer were designed and synthesized. two gc-rich tails of different lengths were attached to ends of the allele-specific pcr primers. single-tube pcr with t m -shift primers was carried out with the three primers. after pcr, melting curve analysis was performed. rhd g>a could be genotyped by differences of the t m s of the pcr products. all of genotyping results were compared with those obtained from conventional pcr-ssp. for the discordant results, rhd exon sequencing was performed to determine rhd g>a genotype. results: a total of samples were genotyped for rhd g>a by pcr with t mshift primers. samples were typed as a+/g-, samples were typed as a-/g+, samples were typed as a+/g+ and samples were typed as a-/g-. two samples typed as a+/g+ by pcr-ssp but a+/g-by pcr with t m -shift primers were confirmed as a+/g-by rhd exon sequencing. summary/conclusions: the single-tube pcr with t m -shift primers for rhd g>a genotyping is simple, rapid, accurate, and it is superior to conventional pcr-ssp. abstract withdrawn. background: the rh blood group system has numerous variant alleles, which may affect rh antigen expression, including rhd-rhce (d-ce) hybrid genes. these variant alleles are frequently found in people of african descent, and typically result in either d-negative (d-) phenotype, or partial d antigen expression, including silencing of high-frequency antigens and/or expression of low-frequency antigens. patients carrying those alleles are particularly at risk of alloimmunization, suggesting that their identification is important in diagnostics. quantitative multiplex polymerase chain reaction (pcr) of short fluorescent fragments (qmpsf) has proven successful for genotyping those dna samples carrying d-ce hybrid genes by assessing both qualitatively and quantitatively rhd and rhce gene exons. aims: the aim of this project was to genotype both rh genes in a cohort of brazilian patients with sickle cell disease (scd), which are known to be of african descent, by using the qmpsf approach and report hybrid gene variability in this population. methods: one-hundred fifteen dna samples were selected for the study and analyzed prospectively by the rhd-qmpsf and rhce-qmpsf approaches to investigate the copy number of all exons in both rh genes. genotypes were further confirmed or investigated by sanger sequencing and conventional pcr-rflp assays. results: in the dna samples, ( . %) exhibited a "wild-type" profile by qmpsf analysis. hybrid genes involving exon , which is functionally not relevant as reported before, was found in samples, including and samples carrying respectively rhd-ce( )-d and rhce-d( )-ce (two homozygous each). except two samples that require additional studies ( . %), rhd zygosity was resolved successfully: (n = rhd gene copies; . %), ( ; . %) and ( ; . %). clinically relevant, i.e. partial d, genotypes were identified in four hemizygous samples ( / , . %) carrying rhd*dau , rhd*dv. , a rhd*diiia-like allele, and a novel rhd*d-ce( :g h-y s-n i)-d allele, as confirmed by sequencing. other hybrid alleles, such as rhd* n. and rhd*diiic, were also found in trans with a normal rhd* allele. in rhce, c/c genotype could be resolved. the rhce*ce (rhce*ce ( c)-d( )-ce) allele, which is commonly cis-associated with rhd*Ψ, was observed in four samples. however the clinically relevant polymorphisms in variant rhce alleles, such as those involved in cemo, cear, ceag, and ceti, were mostly identified by other standard methods. summary/conclusions: although most of the brazilian patients with scd investigated in this study did not carry rhd-rhce hybrid genes, qmpsf analysis has been shown to be an efficient tool in the whole genotyping process to investigate rh gene variation. as previously reported, it has been conclusive for characterization of rhd zygosity and identification of rare, as well as novel, variant alleles. additionally, our results show a large diversity of hybrid genes among the brazilian patients with scd. therefore, we suggest that qmpsf may be used as a complementary screening approach for assessing rh genotype in selected patients and donors. = ) vs. non-bleeding (n = ) patients. platelet, pmp and cp phenotype and function were evaluated by flow cytometry: activation and granule release were examined by antibodies against granulphysin (cd ), p-selectin (cd p), activated gpiib/iiia (pac- ) and phosphatidylserine (ps) (lactadherin) unstimulated and adp, trap or collagen stimulated. coated platelets were identified as a highly granulated independent cell population appearing following collagen stimulation, gated on side scatter and gpiba (cd b). normal healthy reference levels were available. results: the platelet count in bleeding ( /l) and non-bleeding ( /l) patients was comparable (p = , ). bleeding patients had a higher bat score compared to non-bleeding patients ( vs. , p < , ). the proportion of cps was normal in all patients. however, in non-bleeding patients the proportion of ps+cps and per cell ps expression (mfi) ( , % and , mfi) were higher, compared to bleeding patients ( , % and , mfi, both p < , ), and the proportion of ps+cps correlated negatively with bat score (r = , , p < , ). cd + cp was higher in non-bleeding ( , % and , mfi) compared to both bleeding patients ( , % and , mfi) and significantly higher than the reference level ( , % and , mfi, both p < , ). finally, the proportion of ps+pmps was normal in bleeding patients, but their pmps expressed higher than reference ps per cell, both unstimulated and for all agonist ( , mfi unstimulated vs , mfi reference, p < , ). summary/conclusions: patients with it exhibited different bleeding tendency despite comparable thrombocytopenia. in non-bleeding patients the proportion and per cell level of ps+ were higher, indicating that generation of cps with high ps expression is a critical factor determining bleeding phenotype. the finding of high pmp ps per cell level in bleeding patients could represent an inadequate compensation for lack of cp function, indicating that procoagulant pmps may be less important than cps for thrombocytopenic bleeding. quantification and characterization of cps may be a useful tool for future assessment of bleeding risk as well as a therapeutic target in it and other conditions with bleeding diathesis and/or thrombocytopenia. more studies investigating this field are warranted. background: alloantibodies against human platelet antigens (hpas) and human leukocyte antigen (hla) are implicated in several immune-mediated platelet disorders. detection of these antibodies is crucial in the diagnosis and management of these disorders. aims: to establish a method detecting hpa- , hpa- , hpa- , hpa- and hla antibodies using luminex bead technology. methods: monoclonal antibodies specific for platelet glycoproteins and hla class i molecules were separately coupled to the luminex microbeads. positive anti-hpa- a, anti-hpa- b, anti-hpa- a, anti-hpa- a samples were used to validate the specificities of the luminex assay. the anti-hpa- a, anti-hpa- a standard samples were used to evaluate the sensitivities of the luminex assay by serial dilutions (from neat to / ). results: samples collected from patients or isbt platelet workshop were tested by the luminex assay. the results showed that luminex assay could detect antibodies against hpa- a, hpa- b, hpa- a, or hpa- a successfully from the known samples. the sensitivities of the luminex assay detecting anti-hpa- a, and anti-hpa- a were : and : , respectively, using the standard samples. no cross-reactivity was observed in the samples containing multi-platelet antibodies, or mixture antibodies against hpa and hla. the results of samples with platelet disorders were agreement with those of monoclonal antibody immobilization of platelet antigens (maipa) assay. summary/conclusions: luminex beads coupled with monoclonal antibodies could be successfully used to detect hpa and hla antibodies with high sensitivity. background: platelet transfusion is important in clinical treatment. the expression of abo antigen on platelet surface is differential, so it is usually need to ensure the consistency of the abo antigen in clinical transfusion. but in many cases, it is difficult to find the platelets that the abo blood type matched between the recipient and donor, and abo-incompatible platelet infusion is required in these cases. to data, the expression of abo antigens on platelets in normal blood group individuals is rarely reported in chinese population. aims: to understand the differential expression of abo antigen on platelet surface in population of zhejiang province, china. methods: total of individuals with normal abo groups ( group a, group b and group ab individuals, and group o as negative control of abo antigens on platelets) were analyzed. the expression of abo antigens on platelets was determined by flow cytometry using monoclonal antibodies: fluorescein isothiocyanate (fitc)-conjugated mouse antihuman blood group a and pe-conjugated murine igg anti-b antibody ( pe bgrl ). flow cytometric parameters were statistically analyzed by the mann-whitney test or the kruskal-wallis test to observe the difference in two or more groups using graphpad software v . . the correlation and regression analysis between a and b antigen in the platelets and rbcs were also performed by the software. population studies were reported as the mean and standard deviation (sd), and p values less than . were considered statistically significant. results: according to mfi values of abo antigens expression on platelets, the samples were divided into three groups: low expression (le), high expression(he) and moderate expression (me) according to the background mfi observed in group o samples. it was found that about . % of the individuals had a weak expression of abo antigen on the platelet surface in zhejiang province. there was a significant difference in the intensity of antigen expression between these three different groups of the same blood group. for each blood group, there was a positive correlation between the intensity of abo antigen expressed on the platelet membrane and red blood cells of the individuals. results: cases were found with antibody positive. among them, cases ( %) were only anti-hla-i positive, cases ( %) were only anti-hpa positive, cases ( %) were both anti-hla-i and anti-hpa positive. cases were found without anti-hla-i or anti-hpa. among the cases with anti-hpa positive, the distributions of anti-gpiib/iiia, anti-gpia/iia, anti-gpib/ix, anti-gpiv were . %, . %, %, . %, respectively., hla antibody positive rate in the female patients was higher than that in the male and hpa antibody positive rate in the female was lower than that in male, but there was no significance difference between them (p > . ). summary/conclusions: in ptr patients, the platelet antibody was mainly hla-i antibody combined with hpa antibody. background: human neutrophil antigens (hna) are polymorphic structures located on surface membrane of human neutrophils. alloantibodies against hna are implicated in a number of clinical conditions, including immune-mediated neutropenia and transfusion reactions. genotyping for human neutrophil antigen (hna) systems is an important in the diagnosis of disorders involving alloimmunization to hna. aims: the aim of this study was to investigate the hna allele frequencies among blood donors and hematological patients undergoing blood transfusions and to estimate possible hna incompatibilities and risk of hna alloimmunization. methods: a total of blood donors and hematological patients from the north-west region of the russian federation were recruited. dna samples were obtained and typed for hna- , - , - and - systems using polymerase chain reactions with sequence-specific primers (pcr-ssp). specific primers for hna were designed and the polymerase chain reaction amplification conditions were optimized. the v test was used to test for the hardy-weinberg equilibrium for the hna systems. the probabilities of the incompatibility and the potential risk for alloimmunization against different hna systems after random transfusions were estimated based on the hna allele and genotype frequencies. results: in blood donors, the frequencies for the fcgr b* (hna- a), fcgr b* (hna- bd), and fcgr b* (hna- bc) alleles were . , . and . ; for the slc a * (hna- a) and slc a * (hna- b) alleles, . and . ; for the itgam* (hna- a) and itgam* (hna- b) alleles, . and . ; for the itgal* (hna- a) and itgal* (hna- b) alleles, . and . , respectively. in hematological patients, the gene frequencies for hna- a/ bd/bc, - a/ b, - a/ b, and - a/ b were . / . / . , . / . , . / . , and . / . , respectively. no statistic significant difference between genotypes in these groups was observed. since the allele frequencies of hna - , - - for hematological patients and donors did not have statistically significant differences, possible hna incompatibilities and risk of hna alloimmunization were estimated based on the obtained data on the allele and genotype frequencies of hna in a group that combines donors and hematological patients (n = ). the predicted risk of hna- , - , - , - incompatibilities in this cohort were . %, . %, %, and . %, respectively. the possible risk of hna- a, - bd, and - bc alloimmunization were . , . , and . , respectively; of hna- a and - b alloimmunization, . and . ; of hna- a and - b alloimmunization, . and . ; of hna- a and - b alloimmunization, . and . , respectively. summary/conclusions: the information about hna gene frequencies can be used not only in blood services for detection and identification of hna alloantibodies in donors and assessment of alloimmunization risk but also for anthropological studies. background: non-invasive fetal rhd genotyping is performed using circulating cell-free fetal dna from maternal plasma sample and real-time polymerase chain reaction. this antenatal routine dna test is used to target rh-ig administration to prevent hemolytic disease of the newborn. aims: the aim of this study is to characterize maternal rhd variants responsible for indeterminate results during fetal rhd genotyping due to early amplification of at least one of the exons ( , or ) of the rhd gene. methods: samples were tested from / / to / / using free dna fetal kit â rhd. samples ( , %) yielded a premature signal for one or more exons of the rhd gene. after extraction of maternal cellular dna, the maternal rhd was characterized using rhd beadchip assay (immucor/bioarray). rhdiiia-ce( - )-d summary/conclusions: greater diversity is observed in the caucasian population rather than in the afro-caribbean. % of the identified variants are rhd negative alleles including alleles leading to partial rh antigen expression. unexpected alleles are found such as weak d type , , or . these data underline the benefits of maternal rhd genotyping when abnormal early signals are detected during noninvasive fetal rhd genotyping. background: a considerable number of rhd alleles responsible for weak d phenotypes have been identified. serologic determination of these phenotypes is often doubtful and makes genetic analysis of rhd gene highly desirable in transfusion recipients and pregnant women. dna-based methods are useful for enhancing immunohematology typing in doubtful d phenotypes at pregnant women. aims: determination of the rhd gene in a cohort of pregnant women with doubtful d phenotypes. methods: determination of the rhd phenotyping was performed with microagglutination technique biorad and ortho diagnostic simultaneously. rhd genotyping was performed on cases with d typing serological discrepancies with ready-to-use inno-train rbc-ready gene cde and rbc-ready gene d weak test kits based on polymerase chain reaction with sequence-specific priming (pcr-ssp) to unclear serologic findings. results: molecular analyses showed of ( %) pregnant women were rhd*weak d type and not at risk for anti-d. rhd*weak d type were typed in cases ( %) and case was rhd*weak partial . and potentially at risk for being alloimmunized producing anti-d allo-antibodies. summary/conclusions: appropriate classification of rhd phenotypes is recommended for correct indication of rhig in pregnant women. however, the serologic differences between rhd-negative and rhd-positive pregnant women is a real problem for unnecessary application of rhig prophylaxis in pregnant women with d variants. conclusion: antenatal rhig prophylaxis is useful in rhd negative pregnant women. with genotyping we found that % of serological doubtful rhd negative women was d variants that not produce anti d antibodies. in that cases those rhig prophylaxis was unnecessary and harmful as a product of human origin. on other hand there is a save up of a stock of rhig which is any way in deficit. is it time to think about cost benefit of rhig prophylaxis and genotyping in pregnant women. background: in may , uk neqas (btlp) created an external quality assessment (eqa) sample designed to mimic a feto-maternal haemorrhage (fmh) bleed of ml. all material used passed pre-acceptance serological testing; samples were dispatched to participants in countries. post-dispatch testing by flow cytometry (fc) using an anti-d marker showed a bleed volume of . ml so an investigation was initiated. aims: to determine the cause of the unexpectedly low bleed volume and what lessons could be learnt. methods: production methodology and results of pre-acceptance testing were reviewed. fc testing was repeated, plots examined, and the fmh scientific advisory group consulted for advice. further fc testing was performed at wbs using alternative markers, and the material used was investigated at ibgrl. participant results were examined to determine if the sample should be withdrawn from scoring. a questionnaire on how results were managed was sent to the participants using fc with an anti-d marker. results: a material production methodology review showed no obvious cause of the erroneous in-house result. review of pre-acceptance testing images showed no issues, further d-typing of the cord showed + reactions vs. two reagents by tube, cf. + with two different reagents by column agglutination technology. repeat fc testing using the anti-d marker gave similar results; however, closer examination of the plots showed a left shift in the positive peak, indicating reduced fluorochrome binding, possibly due to reduced d antigen density on the cord cells. further fc testing at wbs demonstrated a marked reduction in fluorescence intensity with an anti-d marker. further investigation using an anti-hbf marker showed a bleed volume of . ml, indicating the correct proportion of cord material had been used during sample production. additional serology at ibgrl on the cord material showed reactions which were weaker than the control with / anti-d reagents. overall, the investigation supported the hypothesis that the cord material was d variant. a review of results submitted by participants mirrored the fc investigation and the sample was withdrawn from scoring, as the fc median result is used to calculate scores and the d variant cord was clearly affecting testing with an anti-d marker. the questionnaire showed that all respondents examine fc plots and the gating used, but not all act on them before reporting results, and not all have a back-up plan for anti-d ig dosing in a similar situation. later sequencing of the d gene revealed the cord donor to be dvii which can have a lower than normal d antigen density. summary/conclusions: the use of a d variant cord in an eqa sample was not planned, but allowed uk neqas to highlight some important learning points: -thorough examination of fc plots is essential to avoid underestimation of fmh; a controlled procedure should be in place if modification of gates is required -access to cord/neonatal blood to allow serological investigation may be useful in a similar clinical situation -it is important to have a back-up plan for issuing anti-d ig in the event of an uninterpretable fmh result background: allo-antibodies against fetal blood group and platelet antigens produced by antigen-negative pregnant women can cause hemolytic disease of fetus and newborn (hdfn) and fetal and neonatal alloimmune thrombocytopenia (fnait). prediction of the fetus antigen status in immunized women is important for making decisions concerning further management of pregnancy. nipt is widely used for determination of fetal blood groups but determination of proper specificity in the real-time amplification of a single nucleotide polymorphism (snp), such as k or hpa- a, requires modified protocols. droplet digital pcr (ddpcr) permits detection of low-grade fetal chimerism in maternal plasma dna with higher specificity using allelic discrimination pcr protocols. aims: to establish ddpcr protocols for non-invasive prenatal diagnostics (nipd) of clinically important blood group antigens. methods: dna was isolated from plasma samples of pregnant women and donors with known genotypes (easymag, biomerieux). allelic discrimination protocols for determination of k/k (n = ), s/s (n = ), hpa- a (n = ), hpa- (n = ), hpa- (n = ), hpa- (n = ) genotypes were performed using ddpcr method with droplet digital tm (biorad). the results of allelic discrimination performed using ddpcr were concordant with the already known phenotype/genotype of donors and pregnant women. ddpcr enabled the detection of - , reads for total dna from plasma in tested samples. all fetal results were in agreement with antigen positive genotype of the neonates and the fetal chimerism was from , % to , % (one case was for advanced pregnancy - week of gestation). in / tested samples false positive results were detected at the level of or unspecific reads. summary/conclusions: the implementation of allelic discrimination protocols for ddpcr allowed detection of fetal-maternal incompatibility in k/k, s/s and hpa- a, - a/b, - a/b, - a/b antigens encoded by snp. background: in france, for pregnancies complicated by anti-d (rh ) and anti-c (rh ) allo-immunization, the tests currently used to quantitate maternal antibodies are tube method titration and continuous flow analysis determination of the antibodies concentration. recently, an automated assay was developed using the column agglutination technology on the ih- system (bio-rad â). aims: we wanted to evaluate the score, calculated from the agglutination profile of the antibodies on the ih- system, as a quantitative data to appreciate the level of maternal antibodies. methods: titers from samples containing anti-d and containing anti-c have been established using the semi-automated tube method performed since decades in our lab and the fully automated gel method on the ih- system. scores were calculated manually in both cases. antibodies concentrations were also determined for all samples by continuous flow analysis on our auto-analyzer device (evolution iii ams alliance). we looked for a possible correlation between anti-d and anti-c scores and the corresponding concentrations using the spearman correlation test. results: anti-d tube and gel scores were significantly correlated with the anti-d concentration values (p < . , r = . and p < . , r = . respectively). anti-c scores were also significantly correlated with anti-c concentration values (p < . ) but gel scores have a better correlation coefficient than tube scores (r = . versus . ). it was easier to extrapolate gel score thresholds than tube score thresholds from the autoanalyzer values, with the aim of triggering fetal monitoring by ultrasounds and measurements of the peak systolic velocity in the middle cerebral artery only for risk pregnancies. the determined gel score thresholds were and , corresponding respectively to ui/ml ( uchp/ml) of anti-d and . ui/ml ( uchp/ml) of anti-c. conclusions: calculating the score from the hemagglutination profile displayed by the ih- system provides added values compared to the sole reading of the titer. for anti-c immunization, gel scores are more discriminant than tube ones and better correlated to the concentration values established by continuous flow analysis. the proposed score thresholds to trigger fetal antenatal monitoring need, however, to be confirmed on more samples and to be clinically documented. background: hdnf is due to maternal igg alloantibodies directed against fetal antigens that cross the placenta during pregnancy, causing hemolysis in the fetus, anemia that can lead to edema, ascites, hydrops and, in some cases, death. the diagnosis and management of hdnf is based on maternal screening, and middle cerebral artery (mca) doppler monitoring. in severe hdnf intrauterine blood transfusions (iuts) and or exchange transfusion (et) after birth are necessary to correct anemia, to prevent and treat fetal hydrops. aims: we report eight years of experience in our immunohematology reference laboratory (irl) to highlight the importance of red cell antibody detection as a fundamental parameter to identify pregnancies with high fetal risk and to drive a correct treatment. methods: we report laboratory data from pregnant women with a positive indirect antiglobulin test (iat) referred to our irl from january to december . we performed antibody screening and identification by indirect antiglobulin test (iat) in microcolumn method with biovue system (ortho-clinical diagnostics, raritan, usa), and the title of antibodies in iat by tube method without additive. follow-up tests were also performed in the presence of significant red cell antibodies in order to check antibody title and begin clinical monitoring. threshold values were ≥ : for anti kell antibodies and ≥ : for other specificities. results: out of women, ( . %) displayed clinically significant antibodies, ( . %) clinically insignificant antibodies and ( %) natural antibodies of different specificities. among women with clinically significant antibodies the most frequent was anti-d ( . %) also in combination with other rh antibodies ( . %), while anti-k accounted for %, anti-e for % and antibodies against high-incidence antigens for . %. anti-m and anti-le a antibodies were also found ( . % and % respectively) but they were not clinically significant. among women with clinically relevant antibodies, showed a critic antibody title and they underwent gynecological and obstetric monitoring. fetuses resulted affected by hdfn, displaying anti-d in cases and anti-kell in . fetuses with severe hdfn (anti-d in and anti-kell in ) required iuts, were treated with et, received red blood cells units at birth. summary/conclusions: the mother screening program led to important improvements in the outcomes of hdfn. the identification of women with clinically significant antibodies allowed an appropriate monitoring program and therapy. background: the hemolytic disease of the fetus and newborn (hdfn) is a severe disease, resulting from maternal erythrocyte alloantibodies directed against fetal erythrocytes. alloimmunization in pregnant women has been found to range from , % to , % worldwide. there are over erythrocyte surface antigens, of which more than have been reported to be associated with hdfn. although anti-rhesus d was once the major etiology of hdfn, the universal introduction of antenatal and postpartum rh immunoglobulin has resulted in a marked decrease in the prevalence of alloimmunization to the rhd antigen in pregnancy. consequently, alloantibodies other than anti-d emerged as an important cause of severe hdnf, in particular anti-k and anti-c. however, there are other antigens that have also been found to be associated with hdfn. aims: retrospective identification of erythrocyte antibodies in pregnant women in hospital de braga in and . methods: this study was planned to assess the prevalence of erythrocyte antibodies responsible for alloimmunization, excluding abo-immunizations, in pregnant women attending the antenatal clinics of hospital braga during years, from january to december . in this study, we retrospectively evaluated the erythrocyte antibody screening results of pregnant women. women with positive erythrocyte antibody screening also underwent identification with gel card system following the manufacturer's instructions (diamed â ). the outcomes of infants, whose mother's indirect antiglobulin tests were found to be positive, were examined. direct antiglobulin tests, jaundice and phototherapy history, transfusion and mortality of the newborns were recorded. results: during the study period, pregnant women were attended in hospital de braga. the laboratory registered positive erythrocyte antibody screening tests. the prevalence of positive erythrocyte antibody screening was , %. anti-d was the most common antibody found ( , %). anti-d prophylaxis given during pregnancy was responsible for of cases and maternal antibody titer levels did not exceed among these cases. the prevalence of non-rhd immunization was %. anti-e ( , %) was the most frequent alloantibody other than anti-d followed by anti-m ( , %) and anti-c ( , %). multiple maternal antibodies were found in pregnant women. four women had types of alloantibodies: anti-c and anti-e; anti-c and anti-d; anti-k and anti-cw; anti-e and a non-identified antibody. one pregnant had types of alloantibodies: anti-d, anti-c and anti-e. of all cases of newborns whose mothers had a positive antibody screen tests, icterus occurred in % of them and phototherapy was given in %. summary/conclusions: the prevalence of positive erythrocyte antibody screening in hospital de braga was , %. the erythrocyte antibody screening showed that anti-d was the most common antibody found ( , %) in most of the cases because of anti-d prophylaxis. the prevalence of non-rhd immunization was %. the other most frequent alloantibodies were anti-e ( , %), anti-m ( , %) and anti-c ( , %). an increasing prevalence of non-anti-d alloimmunization was found and there are currently no preventive strategies. in contrast to rhd alloimmunization, the main risk factor for non-anti-d alloimmunization is a previous transfusion therapy. thus, it is important to minimize the exposure of women to incompatible erythrocyte antigens through unnecessary transfusions when possible. background: the mns blood group system is one of the most complex blood group systems. although alloanti-m is a common antibody observed in pregnant women and could also be found in the serum of individuals who have not been exposed to m positive erythrocytes, it is rarely clinically significant and has been regarded as an unimportant antibody to cause hemolytic disease of the fetus and newborn (hdfn), especially in caucasian and black ethnic groups, for a long time. however, an increasing number of cases of severe hdfn resulting in fetal hydrops and recurrent abortion caused by alloanti-m have been reported mainly in the asian population, especially in the japanese and chinese populations. aims: to summarize the characters of serological testing in preterm twins newborns suffered with severe hdfn. methods: the blood sample of two newborns with severe hdfn and the mother, who had the history with three hydrops fetus, were collected. abo, rhd, rhce, and mn blood group typing of the twins newborn and their mother were performed in saline with tube or gel card. direct agglutination test (dat), elution test, antibody specificity identification and antibody titer detection were conducted by iat method in gel card. results: o, rhd(+), and ccee blood groups were identified both in the mother and the twins newborn. background: in france, since may , the legislation does not promote anymore the use of the reference tube method for titration of anti-red blood cells antibodies. this opened the way to the use of newly developed automated anti-red blood cells antibodies quantitation by column agglutination technology. aims: we wanted to assess the performance of titration and scoring by the id-gel test on the ih- system (bio-radâ) and to compare it with the performance established for the reference tube method, used in our lab since decades. another objective of the study was to determine titer thresholds for the gel method, to trigger fetal monitoring by ultrasounds and measurements of the peak systolic velocity in the middle cerebral artery. methods: an home-made internal quality control (iqc) prepared and calibrated using the international anti-d standard ( / ) was used to determine the intraassay and interassay imprecisions, regarding the score and the titer results. patients samples for testing were chosen during the -months assay period, regarding the specificity of the antibodies and the tube titer in order to cover a wide range of have lower values. the highest differences (more than to dilutions higher) were seen for antibodies directed against rh system antigens. among the other specificities, anti-k (kel ) and anti-m (mns ) antibodies show the most samples with equal or lower titers compared to the tube method. conclusions: automated anti-red blood cell antibodies titration by column agglutination technology on ih- system shows better intra and interassay cvs compared to the tube method. it is explained by the fully automated process that includes the reading step. titer results are almost always higher with the gel technology. thus, it seems possible to safely extrapolate the titer thresholds defined for anti-red blood cells antibodies by the tube method to the gel method. however, based on future clinical studies and fetal/neonatal outcomes, it would probably be necessary to increase these thresholds, at least for anti-rh antibodies, in order to avoid heavy, expensive, stressful and useless monitoring of some pregnancies. results: the first case was a -day-old female infant, yellowish skin developed the next day after birth. her capillary bilirubin level was mg/dl, the evidence favored neonatal hyperbilirubinemia and the clinical manifestation revealed hemolysis symptoms. her laboratory findings showed elevated reticulocytes ( . %), ldh ( iu/l) and g pd ( . u/ghb); dat (+/-), iat (-), anemia (hb . g/dl, hct %), and blood smear showed anisocytosis, spherocytes, and polychromatic rbc. her mother blood typed o, d positive, while her blood type was b, d positive and anti-b was found from her elution rbcs ( + ). due to rarely severe anemia with abo incompatibility, maternal plasma was analysed for abo igg antibodies and showed high antibody a and b titre with : and : . the female infant received one unit washed-prbcs for anemia and intensive phototherapy for hyperbilirubinemia. her clinical condition improved significantly, hb rose to . , bilirubin level was within normal range, she was discharged. another -days-old male infant was our second case. on the third day after birth, yellowish skin discoloration developed and bilirubin level was mg/dl. two days later, his transcutaneous bilirubin (tcb) measurement data was high and laboratory findings also showed raised reticulocytes ( . %), dat (+/À), iat (À), hb . background: anti-indian b is a rare alloantibody against the high frequency antigen in b . individuals with the in: ,- phenotype (in(a+b-)) are observed with a frequency of < . % in the indian population and have not been described in caucasians. the majority of anti-in b antibodies have been reported in individuals without previous transfusions, indicating the possibility of a naturally occurring antibody. anti-in b is considered clinically significant and haemolytic reactions after in b -incompatible transfusions have been reported. haemolytic disease of the foetus and newborn (hdfn) due to anti-in b has not been described. however, a positive direct antihuman globulin test (dat) may be observed. aims: to describe the challenges of managing a pregnancy and childbirth of a woman with an anti-in b . methods: serological investigations were performed by iat (tube and column agglutination). papain and trypsin treated cells were also utilised. soluble recombinant in blood group proteins (in-rbgp) (inno-train, germany) were used in neutralization tests. the clinical significance of the anti-in b antibody was determined by monocyte monolayer assay (mma). genomic dna was isolated from whole blood and the samples were further characterized by pcr amplification and sanger sequencing of exon of cd . results: in a -year-old pregnant (para ) woman of indian origin without previous transfusions, an alloantibody of the specificity anti-in b with a titer of : was detected by iat (negative with papain-treated cells) at gestational week (gw) and . the mma, performed in duplicate on samples taken at these dates, showed a mi of . %/ . % and . %/ . % respectively. the mi was interpreted as follows: - % not relevant; - % inconclusive; > % clinical significant. the patient's parents were typed heterozygous, in: , whereas her husband was homozygous, in:- , . due to the husbands phenotype, the fetus was predicted to be in b positive. doppler flow measurement of the peak systolic velocity in the middle cerebral artery of the foetus was normal. delivery took place at gw without increased bleeding. the neonate presented no clinical manifestation of hdfn. neither the mother nor the baby required blood transfusions. summary/conclusions: we report the case of a pregnant woman of indian origin with an anti-in b alloantibody. the first mma, performed in gw , was inconclusive whereas the second mma, performed in gw , indicated that the antibody was clinically significant. if the mi-increase is only due to the pregnancy or has also a clinical significance, cannot be stated. in b negative blood components were not available and the patient's relatives were all in b positive. therefore, measures to avoid transfusions, including optimised peripartal management of haemostasis, was of utmost importance. with only few cases published, the risk of hdfn could not be excluded with certainty. an intrauterine investigation by doppler was performed to exclude relevant anaemia of the fetus. no transfusion was needed at delivery as there were no haemorrhagic complications. the neonate presented no clinical signs of hdfn. background: hemolytic disease of the fetus and newborn (hdfn) is a disease which if untreatedcan cause perinatal mortality and morbidity with a substantial risk for long-term sequela. in albania we lack of studies in this field. aims: the aim of this study is to determine the predictive value and the reliability of the "critical titre" during the evaluation of red cells alloantibodies ability to cause the hemolytic disease of fetus and newborn. methods: we conducted a descriptive, cross-sectional study. the data were collected in the university hospital for obstetrics and gynecology in albania. in the study were included immunized pregnant woman for anti-d antibodies and their newborns which were affected from the hemolytic disease of fetus and newborn. the data belong to the period and . results: the "critical titre" in our study was , meaning that this was the minimal value of the titre antibodies that could cause hemolytic disease of fetus and newborn. our study concluded that only newborns were born without the hemolytic disease of fetus and newborn and the titre values were less than . moderate hemolytic disease of fetus and newborn were caused between the titre values - . the summary/conclusions: the titre values of the mothers are a predictive option of the high risk of giving birth to a child with the hemolytic disease of fetus and newborn. it is recommended that in this cases the mother should be followed with doppler ultrasonography to measure the blood flow of the middle cerebral artery. also the doctors should recommend in pregnant women with positive coombs test not only the identification of the anti-d antibodies but also the identification of the other antibodies such as anti-e, anti-c, anti-k. background: rhd-negative pregnant women with allo-anti-d are at risk of having a fetus affected by haemolytic disease of the fetus and newborn (hdfn) where the fetus is rhd-positive. the rhd allele is highly polymorphic and many rhd variants give rise to an array of partial d phenotypes. the clinical significance for many partial d phenotypes is not well-established. rhd genotyping by non-invasive prenatal testing (nipt) to assess the fetal rhd status determines whether the fetus is at risk for hdfn. nipt tests also include strategies for detecting maternal rhd variants to provide for accurate reporting. however, the presence of a paternal rhd variant, while having the potential to confound nipt interpretation, is often not recognised. we report a "trio" family study triggered by a request for nipt for an rhd-negative pregnant mother, weeks gestation, who presented with allo-anti-d and anti-jk a antibody. subsequent paternal and fetal rhd genotyping was conducted and revealed a novel variant rhd allele. aims: we aim to characterise the paternal rhd allele and review clinical case features. methods: rh phenotyping was performed by standard serological procedures. nipt tested for fetal rhd exons , and . rhd genotyping on whole blood/cord blood dna was performed on the immucor bioarray rhd beadchip kit which predicts a rhd phenotypic variant of best fit. dna sequencing was performed using the illumina trusight one sequencing panel. copy number variation (cnv) analysis was used to assess the rhd exon structure and zygosity. results: the paternal red cells typed as group o rhd+c-c+e-e+, (ror). nipt genotyping detected fetal rhd signals for all exons, predicting rhd-positive. no maternal rhd sequences were detected consistent with homozygosity for the rhd deleted haplotype. for both paternal and cord genomic dna (gdna), beadchip genotyping predicted a rhd variant "diiia/cehar". furthermore, signal drop out was observed at nucleotide positions (c. , c. , c. ) located in rhd exon suggesting exon was either deleted or rhce-replaced. paternal and cord gdna sequencing detected out of snps (c. g>t, c. c>t, c. a>c, c. c>g) associated with diiia phenotype plus additional snps (c. g>a, c. g>c) on the rhd gene. both were rhd hemizygote by cnv analysis. no rhce variants were detected. clinical case features: the maternal anti-d quantitation increased from . iu/ml ( weeks gestation) to iu/ml ( weeks gestation). the fetus required intrauterine transfusions during the pregnancy to manage the hdfn. summary/conclusions: both father and fetus carry an rhd allele that does not align with alleles encoding diii phenotypes. this putative novel rhd variant allele comprises snps associated with diiia and with a possible exon deletion/rhcereplaced. a similar allele was reported in literature, although based on sequence analysis only, with no phenotype data. the variant allele here encodes rhd-positive phenotype and we predict that there may be a loss of d-epitopes. notwithstanding, the clinical presentation shows that maternal anti-d against this rhd phenotype (presumed partial) is associated with a severe hdfn and that such rhd blood group phenotypes are of clinical significance for alloimmunised pregnancies. abstract withdrawn. background: cd is a glycosylphosphatidylinositol (gpi)-anchored protein with apparent molecular mass of kda. in addition to being expressed on human plts, cd is expressed on activated t-cells, endothelial cells, cd + hematopoietic stem cells as well as on progenitor cells. in the chinese population, the calculated allele frequencies of hpa- a and - b are . and . , respectively. based on these data, the risk of alloimmunization against hpa- alloantibodies due to incompatible plt transfusion or pregnancy is expected to occur in relatively high frequency. however, until today there is no report of hpa- alloimmunization in the chinese population. in this study, we analyzed sera from hydrop fetus cases by maipa technique and icfa. aims: to detect the anti-hpa b alloantibodies by maipa and icfa. methods: a -year-old mother, gravida /para . the mother in the first pregnancy was diagnosed hydrop fetus at pregnancy weeks by ultrasound. in the second pregnancy, fetal hydrops was observed by ultrasound at pregnancy weeks. the mother's irregular antibody test was negative. the maternal platelet specific antibodies and hla antibodies were negative. blood routine and morphological examination of fetal umbilical cord blood showed that plt count dropped to . /l, wbc count dropped to . /l, including neutrophil %, lymphocyte %, mononuclear %, eosinophil %, basophil %, red blood cells were normal, hb was g/l. screening for hla and plt-specific antibodies was performed using a elisa-based plt antibody kit (pakplus, gti diagnostics) as recommended by the manufacturer. plt antibodies were detected by icfa and maipa.hpa genotyping was detected by cpr-ssp. results: the fetus's genotype was hpa- a/a, - a/a, - a/a, - a/a. - a/a, a/a, a/a, a/b, naka (+) and the maternal was hpa- a/a, - a/b, - a/a, - a/a. - a/a, a/a, a/ a, a/a, naka (+). the paternal genotype was hpa- a/a, a/b, a/a, a/a, a/a, a/a, a/a, a/b, naka (+), which was the only incompatible antigen compared with the maternal hpa. samples were tested using the fresh plt panels consisting of hpa- aa and - bb homozygous donors. the reactivity of the negative control and the mother's sera with the plts from hpa- a/a (donors ), hpa- a/b (donors ) and hpa- b/b (donors ) donors by maipa. the mother's serum showed no reactivity against a/a plts, weak positive reactivity against a/b plts (od values . ), but strong reactivity against b/b plts (od values . ).this finding could be confirmed by one of the reference plt laboratories (japanese red cross kanto-koshinetsu block blood center, japan) using freshly isolated plts from hpa- genotyped donors (anti-hpa- b average value . ). summary/conclusions: in this study, we found anti-hpa- b in a case of fnait (patient hpa- aa, blood group o) using the maipa technique. we were able to detect the presence of hpa- b alloantibody in one case of nait. background: fetal and neonatal alloimmune thrombocytopenia (fnait) occurs in : live births in caucasians. serological and molecular human platelet antigens (hpa) genotyping tests are performed to investigate and conclude to fnait diagnosis. however, in few cases and particularly in case of suspicion of private platelet antigen, some specialized analyzes must be performed in the laboratory (lab). these analyzes can range from sanger or ngs sequencing to platelet serology with transfected cells. aims: the aim of our study was to explore where the frontier between research and care takes place in the field of platelet immunology through the prism of the fnait investigations carried out by the platelet immunology laboratories. methods: a two-part electronic survey have been sent to foreign platelet immunology experts (pie) from platelet immunobiology working party (piwp) members and espgi board members (n = ). the first part focused on the lab practices and regulatory environment regarding to accreditation, contact with patient, informed consent and patient results. the second part stressed on the investigations performed to discover new platelet antigen and more precisely on the perceived status of these analyzes ( background: haemolytic disease of the fetus and newborn (hdfn) can occur when maternal red cell antibodies, directed against red cell antigens present on the fetal red blood cells, cross the placenta and enter the fetal circulation. in a "traditionally" conceived pregnancy, when hdfn occurs, it is as a result of maternal antibodies directed against fetal red cell antigens in the heterozygous state, whereby the antigen is inherited from the father only. with the advent of donor oocyte (do) in-vitro fertilisation (ivf), the addition of a third person into the reproductive equation allows for the possibility of a more severe form of hdfn when fetal red cell antigens are present in the homozygous state (one copy from father and one copy from donor) and maternal antibodies are directed against these. antigens expressed in the homozygous state will have more antigens sites per red blood cell and therefore are at an increased risk of red cell destruction from the maternal derived cognate antibodies. aims: to raise awareness of increased severity risk of hdfn in donor oocyte conceived pregnancies. methods: we describe two unusual cases of hdfn in our institution of two women whose pregnancy was induced using a donor oocyte and their offspring requiring transfusion support in the postnatal period to treat hdfn. results: the first is a case previously reported (doyle, quigley, fitzgerald et. al. transfusion medicine, ) of protracted hdfn due to anti-c, managed with phototherapy initially, then intervention with red cell top-up transfusion at weeks post-delivery. the second is an unusual case of severe abo hdfn requiring exchange transfusion therapy (pre-publication). summary/conclusions: given the increased number of pregnancies conceived using do we recommend that antenatal guidelines are reviewed to create awareness regarding the potential increased risk of hdfn in do pregnancies complicated by allo-immunisation. critically, antenatal testing guidelines should highlight that the predicted outcomes associated with quantitation/titres can only be used when do has not been used to obtain the pregnancy. it is also essential that clinicians inform the blood transfusion laboratory when do has been used. abstract withdrawn. %) are deceased due to organ rejection, and / patients ( %) are deceased due to disease not related to rejection. summary/conclusions: the use of therapeutic plasma exchange for the treatment of antibody mediated rejection in solid organ transplant is safe and effective when used along with other treatment modalities. further studies will help determine whether it can be reproduced in larger cohorts and whether it is more effective in certain organs. background: extracorporeal photopheresis (ecp) is an important cellular therapy for the treatment of several (auto-)immune diseases such as graft-versus-host disease. the international standard for the ex vivo treatment of the leukapheresis product is the application of -methoxypsoralen ( -mop) and irradiation with uv-a light. however, the addition of -mop to the illumination bag is associated with a potential risk of contamination. aims: the basic principle of the ecp is the induction of apoptosis in the leukocytes. our aim was to find an alternative for the conventional apoptosis induction without the need of external substance application. the objective of the study was the investigation of the apoptosis levels and kinetics in leukocytes after treatment with -mop+uv-a compared to uv-c treatment without additional -mop. methods: we used an in vitro h cell culture approach with human mononuclear cells from healthy blood donors. untreated control cells were compared with , lg/ ml -mop plus j/cm uv-a treated cells and j/cm (effective dose) uv-c treated cells. apoptosis in several leukocyte sub-populations was detected daily with annexin v and -aad flow cytometry standings. results: the apoptosis analysis of cd cd t-helper cells, cd cd cytotoxic tcells, cd b-cells, cd monocytes, cd neg cd nk-cells and cd cd nkt cells revealed no statistical differences in almost all of these cell types after treatment with -mop/uv-a or uv-c light. the apoptosis kinetic as well as the final apoptosis after h were similar in both treatment groups. summary/conclusions: the addition of -mop to the photopheresis irradiation bag is a risk for potential infections. the main effect of the -mop/uv-a treatment is most probably the induction of apoptosis in the leukocytes. here, we provide information that this induction of apoptosis can also be achieved with uv-c irradiation without the need of -mop addition. the apoptosis patterns in most leukocyte subpopulations are very similar after treatment with uv-c compared with -mop/uv-a treatment. future in vivo studies are needed to prove the therapeutic effect of uv-c treated cells in the ecp setting. abstract withdrawn. background: therapeutic plasma exchange (tpe) is performed to remove the implicating substances from the plasma causing the disease. a periodic appraisal of tpe data is important to get insight into the procedural related effects and toxicities and overall outcome in order to have a guided future approach. aims: the purpose of this study is to observe the overall profile and outcome of the patients receiving the tpe in the medicine intensive care unit (micu) of a tertiary care hospital in south india. methods: a record based audit was conducted for the all the patients who were admitted to our tertiary care hospital of south india with bedded micu and received tpe therapy between june, and december . all the tpe procedures were performed using haemonetics multicomponents system (mcs) + ln apheresis system based on intermittent flow centrifugation. we audited our tpe for: number of treatments, clinical indications, treatments prescribed and administered, any procedural or patient complications, and adherence to current best practice recommendations. results: sixty nine patients had undergone tpe procedures. among them, thirty were female patients ( %). the median age ( - ) years. guillain-barre syndrome (gbs) was the most common indication ( %) followed by cases of thrombotic thrombocytopenic purpura, diffuse alveolar hemorrhage, myasthenia gravis, autoimmune encephalitis and hypertriglyceridemia respectively. the tpe regimens received by patients in this icu were not always prescribed in accordance with current best practice recommendations. there were ( %) episodes of patient related complications during the tpe treatments. in ( %) procedures, technical error in the machine was encountered. summary/conclusions: the findings of this audit have identified differences between the current prescription recommendations for tpe and those applied. the infrequency of the therapy and the different indications may present a challenge for medicine intensive care clinicians to provide best care in all cases. background: microangiopathic hemolytic anaemia (maha) encompasses a spectrum of disorders characterised by widely disseminated thrombosis in small blood vessels resulting in formation of schistocytes and concomitant thrombocytopenia. plasma exchange (pe) needs to be considered as empirical and urgent life saving therapy in these disorders irrespective of waiting for specific testing like adamts levels in thrombotic thrombocytopenic purpura (ttp) or complement levels or factor h antibodies in atypical hemolytic uremic syndrome (ahus). aims: to assess the efficacy and safety of plasma exchange in patients diagnosed as having microangiopathic hemolytic anaemias. methods: a retrospective analysis of all pe procedures performed in patients diagnosed as having maha was done over a period of years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . procedures were done on apheretic device (cobe spectra, terumo bct, lakewood co. usa). patients' pre and post procedural hematological and renal parameters were analyzed by applying paired t test. adverse event if any was recorded. results: pe was performed in patients with diagnosis of maha ( -ahus, -ttp, each of post stem cell transplantation drug induced thrombotic microangiopathy (tma), post thyroidectomy tma and post-partum tma). the mean age of patient was . ae . years with m:f as . : . number of procedures per patient varied from to . post pe recovery was observed within - days with statistically significant increase in mean platelet count from . ae . to . ae . /l (p = . ) and significant decline in mean lactate dehydrogenase level from . ae . to . ae . lkat/l (p = . ). there was also significant decline in mean percentage of schistocytes in peripheral smear from . ae . % to . ae . % (p = . ). the mean serum urea changed from . ae . to . ae . mmol/l and creatinine from . ae . to . ae . lmol/l (p = . and . respectively) with significant increase in urine output from . ae . to . ae . ml/kg/h (p = . ). adverse events were observed in patients ( %), allergic reaction to replacement fluid (n = ) being the commonest followed by hypotension (n = ), rigors and chills (n = ). overall survival rate at months was %. summary/conclusions: pe had proven its safety and usefulness as life-saving first line treatment modality in maha. prompt and aggressive treatment helps in achieving early and complete remission in these patients. background: neuromyelitis optica (nmo) also known as devic's disease or devic's syndrome is a rare demyelinating disease of the central nervous system that most often results in selective involvement of the optic nerves (optic neuritis) and spinal cord (myelitis)and has female preponderance. neuromyelitis optica (nmo) attacks are poorly controlled by steroids and evolve in stepwise neurological impairments. assuming the strong humoral response underlying nmo attacks, therapeutic plasma exchange is an appropriate technique in severe nmo attacks. aims: to study the effect of tpe in neuromyelitis optica. methods: a year old female in the medicine department, civil hospital, ahmedabad admitted with chief complains of weakness and numbness in the arms and legs, blurred vision, reduced sensation, difficulty in controlling bladder and bowels, uncontrollable vomiting and hiccups since - days in the medicine department, civil hospital, ahmedabad. attacks were treated with short courses of high doses of intravenous corticosteroid -methylprednisolone intravenous. but there was no clinical improvement. results: clinician advised for the trial of tpe in this patient. the procedure was performed by automated device with continuous flow centrifuge machine fresenius kabi-com.tec using double lumen femoral catheter. after obtaining informed consent from the relative of the patient, cycles of tpe were performed on daily basis. after cycles, both subjective and objective clinical response to tpe was estimated by three different sources (the patient, a transfusion medicine physician, and the treating neurologist). [ ] for motor performance, patient was assessed on a disability scale ( = healthy; = minor symptoms; = able to walk meters without support; = able to walk meters with support; = confined to bed or wheelchair; = requiring assisted ventilation; = dead).patient's motor performance was increased to scale (upper limb) and (lower limb) from scale , deep tendon reflexes were normal. visual function began to improve week after the treatment. visual acuity was / after weeks. summary/conclusions: assuming the strong humoral response underlying nmo attacks, therapeutic plasma exchange is an appropriate technique in severe nmo attacks. this suggests that tpe is beneficial in nmo patients during acute attack if there is no response to corticosteroid treatment. background: babesiosis is a tick borne infectious disease caused by the protozoa babesia. while most infections with babesia are asymptomatic, some patients present with a symptomatic infections and rarely this can be a severe life threatening illness. treatment is primarily with antibiotics but red cell exchange (rce) has been used in the more severe cases which are characterized by high grade parasitemia, evidence of severe hemolysis and or multi-organ failure involving the kidney, lung or liver. a threshold parasite level of % has arbitrarily been applied as an indication for rce, however, this threshold is not evidence based. aims: to report on patients with babesiosis and high grade parasitemia who were treated with antibiotics only without rce methods: data were collected from july to july . a case was defined as a patient diagnosed with babesiosis for whom rce was requested on the basis of a parasitemia of > % but on clinical evaluation it was considered that rce could be withheld and the patient monitored awaiting response to antibiotics. results: three cases of severe babesiosis in which the use of rce was requested on the basis of a parasite level of greater than %, but was not performed. the rce was deferred on account of the good clinical state of the patient and the absence of renal failure. levels of parasite at diagnosis were . %, % and %. all patients were followed daily until discharge. two of these patients had been splenectomized and each received a single unit of red blood cells during the hospitalization. the third patient had a long history of refractory lymphoma and was pancytopenic requiring multiple transfusions during the years before the diagnosis of babesiosis. she had transfusion transmitted babesiosis from a red blood cell transfused days prior to the diagnosis. all three patients responded well to antibiotics and were discharged between - days with undetectable parasites. summary/conclusions: this small case series suggests that requests for rce solely on the basis of an arbitrary level of parasitemia should be questioned and the clinical state and evidence of organ failure considered in the decision to perform rce. abstract withdrawn. chronic transfusion program (ctp) remains the gold standard therapy for stroke prevention and for patients with a severe disease who have inadequate response to hydroxyurea treatment. aims: to evaluate the safety, efficacy and cost between scd patients on ctp that underwent both aet and partial manual exchange transfusion (pmet) procedures. methods: retrospective observational cohort study of patients with scd on ctp that have switched between pmet and aet. this study was carried out from / / to / / in a hospital in portugal. data on patient history, haematological values, duration of the procedure, intervals between them, adverse events as well as the cost of material and working hours were collected and compared between both procedures. results: a total of patients met the inclusion criteria described. however, patient was excluded from our study because of the lack of attendance to the ctp. during the study, we recorded exchange procedures ( pmet and aet), both on peripheral venous access. from all those procedures the major concern was the poor venous access, which was the reason why patients had returned to pmet. no major complication or alloimmunization was observed. the indications for ctp were cerebral vasculopathy (n = ), stroke (n = ) and recurrent vaso-occlusive crisis with multiorgan failure (n = ). for both procedures, target values were to obtain a pre-exchange hbs level ≤ % for stroke and cerebral vasculopathy and ≤ - % for other indications. the median hbs level before pmet was , % ( , - , ) and , % ( , ) before aet. we documented a higher hbs level prior to the next procedure in , % of patients (n = ). despite that all patients remained stable without any major scd related event. both procedures were well tolerated and iron overload was well controlled (median ferritin level pmet: , vs. aet: , ng/ml). the duration of the exchange procedure was longer and the intervals between procedures were shorter with pmet (median pmet: vs. aet: min and pmet: vs. aet: weeks, respectively). annual rbc requirements per procedure were superior (median vs. units) and the overall costs related with aet were , times higher - . , € and . , € aet and pmet, respectively (estimated cost per session aet: , € and pmet: , €). summary/conclusions: our study shows, that the hbs level before both procedures, performed during the same interval, was similar. we verified that pmet has a comparable efficacy with aet in terms of preventing the development or progression of chronic complications and that the cost per procedure is significantly higher with aet. however, in a clinical situation where it is important to rapidly reduce the hbs level, and/or where the control of the target hbs is stricter so that the patients are clinically controlled without an increase in hospital visits, aet is preferred. we conclude that aet is more effective in the rapid reduction of hbs and ferritin levels, as well as being less time consuming. despite this, for the reasons described above, it is more cost-effective to maintain both aet and pmet procedures. background: erythrocytapheresis/red blood cell (rbc) exchange, involves removing of a large number of rbcs from the patient and returning the patient's plasma and platelets along with compatible allogenic donor rbcs. typical indication for rbc exchange is sickle cell disease and its related complications. however, one of the miscellaneous indications of rbc exchange is for the patients of methemoglobinemia who are refractory to treatment by methylene blue. acquired methemoglobinemia is more common than any genetic causes. acquired methemoglobinemia is caused by toxins that oxidize heme iron, notably nitrate and nitrite-containing compounds. for patients failing to respond to standard treatment with methylene blue or in whom its use is contraindicated; hyperbaric oxygen or rbc exchange is indicated aims: case reports on use of rbc exchange in methemoglobinemia are few and indications are based on anecdotal reports. methods: exchange was performed on the cell separator machine, com tec by fresenius kabi. results: we report a case of acquired methemoglobinemia where patient was admitted with peripheral capillary oxygen saturation (spo ) of % on air. the patient did not show improvement in spo level with effective emergency treatment of methylene blue. since, the patient was refractory to treatment with methylene blue, the decision was made by clinician to proceed with rbc exchange. the patient improved significantly after two cycles of one rbc volume automated rbc exchange, and was discharged with spo of % on air. summary/conclusions: automated rbc exchange can be used in patients of acquired methemoglobinemia successfully when methylene blue is ineffective, and may be superior to manual one. background: therapeutic plasma exchange (tpe) is known to disturb the ph and electrolyte status. patients with compromised liver functions may be at a higher risk of electrolyte imbalance due to metabolic abnormalities. aims: the aim of this study was to analyze the variation in ph, ionized calcium, sodium, potassium, and bicarbonate in liver disease patients undergoing tpe. methods: patients with liver disease undergoing tpe during the period from july to august were included in the study. data on patient demographics, details of the tpe procedure, blood gas analysis report and adverse effects of tpe (if any) were collected and analyzed. results: one hundred and seven procedures were done during the study period; of these ( %) were done on the mcs plus (haemonetics corporation) and rest ( %) were done on the spectra optia (terumo bct). the percentage change in ionized calcium, sodium, and potassium due to the procedure was found to be statistically significant (p = . ). the systolic (p = . ) and diastolic ( . ) blood pressure also changed significantly with the procedure. the predictors for the change in ionized calcium were found to be pre-procedure ionized calcium (p < . ), the age of the patient (p < . ) and the pre-procedure ph (p = . ). procedurerelated complications occurred during procedures of which complications ( . %) were categorized as features of hypocalcemia. no association was found between hypocalcemic manifestations and pre-procedure calcium, change in calcium, age or gender of the patient. summary/conclusions: the tpe procedure in liver disease patients causes remarkable changes in ionized calcium, sodium, potassium and bicarbonate ions. the decrease in ionized calcium during the procedure is predicted by pre-procedure ionized calcium levels, ph and age of the patient. monitoring of these parameters and appropriate corrective measures are imperative to patient safety. background: therapeutic plasma exchange (tpe) in pediatric age group is technically demanding because of low blood volume, difficult venous access and poor cooperation of the patient during the procedure. we here present our experience of tpe in pediatric patients from our centre. aims: to assess the challenges during tpe in pediatric patients and formulate appropriate strategies. methods: we did retrospective analysis of all tpe procedures performed in pediatric patients over a period of years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . tpe procedures were done on two different apheretic devices (cs plus, fenwal usa and cobe spectra, terumo bct lakewood, colorado) daily or on alternate days depending on clinical condition of the patient. for all procedures, kit was primed with compatible packed red cells. adverse events during the procedure were noted and analyzed. results: a total of tpe (range - /patient with mean of . procedures) were performed for pediatric patients with different indications like atypical hus (category i as per american society for apheresis (asfa) in total patients, neuromyelitis optica (category ii) in patients, rapid proliferative glomerulonephritis (category i), c glomerulopathy in patients each and one patient of infective hemophagocytosis. the average age of patient population was . yrs ( . - years) . the male:female ratio was : with an average weight of . kgs. adverse events were observed during ( . %) procedures. most commonly observed adverse events were allergic reaction to replacement fluid ( . %) followed by hypotension ( . %), line occlusion ( . %), vasovagal, endotracheal tube blockage and symptomatic hypocalcemia was observed in one procedure each ( . %).there was no corelation observed between physical parameters of patient with adverse events. all adverse events were managed as per departmental standard operating procedures (sops) and procedures were completed successfully except in one where the procedure was abandoned. no mortality was observed during the procedures. background: the hemoglobin (hb) content of packed red blood cell (prbc) units is heterogenous. the patient's blood volume is also variable which can be calculated based on the weight, height and body surface area (bsa) of the patient. the efficacy of a transfusion episode can be assessed if the hb content of prbc is known and the patient's post-transfusion hb increment is determined. aims: this prospective study was performed to compare the efficacy of the transfusion of prbcs based on hb content versus the standard transfusion practice in thalassemia major patients. we also determined the correlation between hb increment and the hb content of prbc units transfused. methods: a total of registered thalassemia major patients of our institute were included in the study after excluding the patients who had allo-or auto-antibodies. the study was approved by the institute ethics committee. the enrolled patients were randomly divided into two groups: group i (n = )they received abo/rhd identical prbcs suspended in additive solution (saline, adenine, glucose, mannitol: sagm-prbcs) after determining its hb content (units with hb content ≥ g); and group ii (n = )they received randomly selected abo/rhd identical sagm-prbcs. the hb estimation of the randomly selected units in group ii was blinded. following tests were done on pre-transfusion sample: hb estimation using the hematology analyzer (orion , ocean medical technologies, india), blood grouping using tube technique, anti-human globulin (ahg) crossmatch and direct antiglobulin test (dat) using gel technique (biorad, switzerland), antibody screening (abs) using a fully automated immunohematology analyzer (neo, immucor, usa). on the posttransfusion sample collected h after transfusion, hb estimation and dat were performed. results: there was no significant difference among the patient characteristics of the two groups. the mean hb content of the sagm-prbc units was significantly higher (p = . ) in group i (mean ae standard deviation: . ae . g; range: . - . g) than group ii ( . ae . g; range: . - . g). the mean hb increment in group i patients ( . ae . g/dl) was significantly higher (p = . ) than the group ii patients ( . ae . g/dl). in both the groups i and ii, there was a significant negative correlation between hb increment and weight (p = . in groups i and ii), age (p = . for group i; p = . for group ii), body surface area (bsa) (p = . for group i; p = . for group ii) and blood volume (p = . for group i; p = . in group ii). in both the groups i and ii, there was a significant positive correlation between hb increment and hb dose adjusted for bsa and the hb dose adjusted for blood volume (p = . in both groups i and ii for both the parameters). summary/conclusions: the efficacy of transfusion is more when patients are transfused with sagm-prbcs having hb content of g or more as compared to those who are transfused with randomly selected units. for optimal hb increment in thalassemia major patients, the transfusion strategy should be based on the hb content of the sagm-prbcs. background: in male transfusion recipients under years of age, receiving red blood cells (rbcs) from an ever-pregnant blood donor has been associated with increased mortality, compared to receiving a product from a male donor. although it has been suggested that older units of rbcs could be associated with increased mortality, there are significant methodological challenges in these studies. other studies indicated the freshest units of rbcs could be associated with increased mortality among transfusion recipients. we hypothesize both the association between ever-pregnant donors, and fresh units, with mortality could be caused by passenger leukocytes in the transfused rbc units, which decay during storage. aims: to quantify modification of the effect of ever-pregnant donors on mortality in young male rbc transfusion recipients, by storage time. methods: data on transfusion recipients receiving their first-ever rbc transfusion in one of six major dutch hospitals between / / and / / was collected. for the current study, male transfusion recipients under years receiving only transfusions from one donor sex exposure category were selected and followup was censored at three years after transfusion. differences in storage time between groups were estimated by linear regression, adjusted for total number of transfusions, patient age, blood group, transfusion year and month. in a single-unit, single-transfusion cohort, cumulative mortality was estimated separately for patients receiving transfusions from ever-pregnant or male donors and for 'fresh' (< days storage) or 'old' (> up to days storage) rbcs. results: for recipients of only blood from male donors, the storage time of the freshest unit was . day shorter when comparing the patients who died, to , patients who survived (ci: À . to . ). for recipients of only blood from ever-pregnant donors, the storage time of the freshest unit was . day longer when comparing the patients who died, to patients who survived (ci: À . to . ). in the single-transfusion cohort, , patients received a fresh rbc transfusion from a male donor, of whom died; patients received a fresh transfusion from an ever-pregnant female donor, of whom died. patients received an old transfusion from a male donor, of whom died; patients received an old transfusion from an ever-pregnant female, of whom died. the -years cumulative incidence of death among young male recipients was . % (confidence interval (ci): . % to . %) after a fresh transfusion from a male donor and . % (ci: . % to . %) after a fresh transfusion from an ever-pregnant female donor. the -years cumulative incidence of death was . % (ci: . % to . %) after an old transfusion from a male donor and . % (ci: . % to . %) after an old transfusion from an everpregnant female donor. summary/conclusions: prolonged storage of rbcs from ever-pregnant donors was not associated with decreased mortality at years. contrary to our expectations, our results indicate older units may potentiate the effect of ever-pregnant donors. however, due to limited sample size the observed differences were not statistically significant. background: according to the literature review, there was limited impact of premedication (antipyretics, antihistamines and steroids) before transfusion on the prevention of adverse transfusion reactions (atrs). however, the necessity of premedication remains controversial. the premedication before transfusion is still a common clinical practice in pacific-asian countries, along with the premedication rate ranging from to %. in our previous investigation, we found that premedication rate was . % in the outpatients in , which was much higher than the reported rate in asia. aims: to investigate the incidence of atrs and decrease premedication rate without increasing the rate of atrs via education and evidence-based clinical practice. methods: the incidence of atrs from april to december, was retrospectively surveyed. evidence-based clinical practice was initiated since january, . clinical data of the outpatients receiving transfusion therapy were requested and analyzed from january to september, . the incidences of atrs and premedication rates in and were compared using chi-square test. a p value less than . was statistically significant. besides, feedback of the incidence of atrs and premedication rate was given quarterly to the clinicians during the investigation. results: from april, to september, , a total of , blood units were transfused in the outpatients with , transfusion events. of these, cases of atrs, including febrile nonhemolytic transfusion reactions (fnhtr) and minor allergic reactions were reported. the overall premedication rate in the outpatients was . % in , and was significantly decreased to . % in (p < . ). it was reported that the incidences of atrs in and were . % and . % per unit, respectively. there was no remarkable difference between the incidence of atrs in and (p = . ). summary/conclusions: via education and evidence-based clinical practice, we successfully reduced premedication rate without increasing the rate of atrs in the outpatients. furthermore, introduction of computerized provider order entry (cpoe) and clinical decision support system (cdss) could be considered and be expected to prevent unnecessary premedication before transfusion, increasing the compliance with optimized transfusion strategies in the future. methods: a retrospective analysis was done over a period of one year to evaluate clinical efficacy of granulocyte transfusions in hemato-oncology patients with febrile neutropenia. mobilization of granulocyte donors was done as per standard protocol, which included subcutaneous injection of granulocyte colony stimulating factor (g-csf) - lg/kg and tablet dexamethasone mg, - h prior to granulocyte harvest by apheresis. all granulocyte products were gamma irradiated before transfusion. patient parameters like white blood count (wbc), absolute neutrophil count (anc), hemoglobin and platelet count were recorded pre-and post-granulocyte transfusion. infection related mortality (irm) within days of granulocyte transfusion was also recorded. results: minimum adequate granulocyte yield of per unit was fulfilled in % of granulocyte harvests. clinical indications for granulocyte transfusions were fever, an absolute neutrophil count (anc) < /ll, evidence of bacterial and/or fungal infections (i.e. clinical signs of infection, positive cultures and radiological evidence) and unresponsiveness to appropriate antimicrobial therapy for at least h. effects of clinical, microbiological and granulocyte transfusion related variables on infection-related mortality were investigated. the post transfusion anc (within h) increased significantly (median value: /ll) as compared to baseline levels (median value: /ll) (p < . ). infection related mortality was observed in only % ( out of ) of patients. patients became afebrile within - days and culture negative within - days after granulocyte transfusion. for analysis purpose granulocyte transfusion episodes were grouped according to doses of granulocyte transfusions, based on european guidelines (standard dose: . - . cells/kg and high dose: > . cells/kg background: hsa's blood services group (bsg) is singapore's national blood service. in , we conducted our pilot national pbm audit to promote pbm practices. it was agreed that the audit would be performed annually with incorporation of a new indicator to continue promotion of pbm and sharing of good practices. aims: to provide an update on the second national pbm audit for . results are compared to the pilot audit and summarized below. methods: we collected data on performance indicators from acute public care hospitals for weeks each in march and august (the pilot audit covered weeks in ). the performance indicators were: ). percentage compliance to documentation of red blood cell transfusion indications ). percentage of patients screened for pre-operative anaemia, to days before surgery ). peri-operative transfusion rates ( days before to days after surgery) for commonly performed surgeries: coronary artery bypass graft surgery (cabg), total knee replacement (tkr), total hip replacement (thr), nephrectomy, colectomy and hysterectomy. the first two indicators assess pbm efforts and were measured in the pilot audit. indicator ) was added to the second audit to assess impact of pbm practices on transfusion in surgical patients. it was an appropriate time to incorporate this indicator as the hospitals would have been familiar with pbm since its introduction in . results and recommendations were shared with the senior management and hospital transfusion committees of the participating hospitals. results: for indicator ), hospitals had a compliance of - %, the remaining had a compliance of - %. all hospitals incorporated electronic blood ordering but the usage was not compulsory in some. hospitals which mandated electronic ordering performed better as doctors could only order blood products after entering the transfusion indication. we saw compliance increase from % in to % in a hospital that had newly mandated electronic ordering. for indicator ), results ranged from % to %. hospitals made notable improvements when compared to , achieving % and % respectively. they had implemented pre-operative workflows screening all elective surgical cases for anaemia at least weeks before surgery. one hospital also started an outpatient intravenous iron service which reduced pre-operative anaemia rates. for indicator ), mean number of transfused units for each surgery ranged from . to . units per patient, lowest being thr and highest being cabg. this suggests that some transfusions were potentially avoidable with more robust pbm practices. the rate of perioperative transfusions was highest for cabg at % and lowest for tkr at %. summary/conclusions: the annual national pbm audit increases pbm awareness, allowing hospitals to share and learn good practices and implement measurable improvements. based on this audit, a recommendation to mandate electronic ordering of blood products to improve adherence to red cell transfusion indications and implementing pre-operative workflows with consideration for intravenous iron support was made. this audit was more representative than the pilot, with a longer duration of data collection and incorporation of indicator ) showing impact of pbm practices. background: autoimmune haemolytic anaemia (aiha) is a decompensated acquired haemolysis caused by the host's immune system acting against its own red cell antigens. aiha is a rare disorder and although british society of haematology (bsh) guidelines for diagnosis and treatment were published in february , there is little evidence for clinical practice in the united kingdom. aims: to investigate the approach to the diagnosis, investigation and management of patients with autoimmune haemolytic anaemia (aiha) in english nhs trusts. methods: we designed and distributed a survey to the clinical transfusion leads at all english nhs trusts between november and march . the survey requested information on detailed, simulated clinical scenarios. the first simulated scenario described a young patient with active aiha months after an allogeneic stem cell transplant, who has received multiple transfusions in the last weeks and is hypotensive, tachycardic, with a falling haemoglobin (hb), currently g/l. the second scenario describes a young man with a new diagnosis of warm aiha who has an initial hb of g/l and returns to clinic at a -week interval with symptoms of fatigue. he is actively haemolysing and commenced on mg/kg prednisolone. results: there was a % ( / ) response rate by trusts. faced with a - h delay for allo-adsorption studies, % ( / ) of respondents would instead transfuse acutely with abo, rh and k matched red cells negative for any previously detected alloantibodies, % ( / ) would transfuse with o rh d negative red cells and % ( / ) would wait for completion of allo-adsorption studies before transfusing. in this first scenario, a quarter of respondents appeared to delay a potentially lifesaving blood transfusion. british society of haematology guidelines recommend that when anaemia is life-threatening in the time required for full compatibility testing, abo, rh and k matched red cells should be transfused. in the serious hazards of transfusion (shot) report, the most serious and fatal of cases of preventable delayed transfusion was a patient with aiha who died untransfused with an hb of g/l, while awaiting alloadsorption studies. a key shot message was that if clinical harm to patients from withholding blood outweighs safety concerns over a possible delayed haemolytic transfusion reaction, emergency blood is essential and should be offered. the second scenario also identified considerable variation in transfusion practice. it can take several weeks for patients with aiha to respond to prednisolone so a transfusion threshold < g/l after an hb fall of at least g/l in the previous weeks is perhaps overly conservative. summary/conclusions: the overall findings support a need for studies to explore barriers to uptake of guidelines, and to identify areas for further audit and research to guide safe and appropriate transfusion practice in aiha. background: balance between supply and demand of o d negative red cells remains a challenge for almost every blood service. with this re-audit, we wanted to collect objective and comprehensive information regarding usage of o d negative red cells supplied by nhs blood and transplant (nhsbt) to private and nhs hospitals in england. aims: the aim was to understand hospital practices, actual needs and possible avoidable usage of o d negative red cells. where possible, comparisons were made with two previous audits ( ) ( ) ( ) . methods: participating hospitals were asked to determine the fate of all group o d negative red cells they received between th and th may excluding substitutions and complete an organisational survey regarding activities, policies and stockholding practices with respect to o d negative blood. participating hospitals were asked to provide (if available) the prevalence (as a percentage) of o d negative patients in their population. this information, in conjunctions with hospital activities, will be used to estimate appropriate o d negative stockholding levels. background: o rhd-negative (neg) red blood cells (rbcs) are a precious resource, are often in short supply and transfusion of these units in emergency settings carries the potential risk of transfusion-related adverse outcomes such as haemolytic reaction due to minor blood group incompatibility. as such, their use should be closely monitored within health services. most recent australian guidelines ( ) for their use in emergency settings include pre-menopausal females of unknown blood group (mandatory indication) or while the blood group is being established; use should be limited to or less units where possible before a switch to group-specific rbcs (acceptable indication). aims: audit of use of emergency uncrossmatched o rhd-neg rbcs against national guidelines in our institution (an australian tertiary metropolitan public hospital providing acute medical and surgical, emergency and critical care services). methods: use of emergency uncrossmatched o rhd-neg rbcs units over a six-year period was retrospectively reviewed. we collected information about rbcs transfused and discarded, adverse outcomes, patient characteristics, clinical indications and whether use met national guidelines or could have been avoided. results: episodes of emergency uncrossmatched o rhd-neg rbcs were identified, encompassing transfusion of rbc units to patients and the discard of rbcs (due to incorrect transport). of the episodes, episodes ( %) involved an eventual switch to group-specific rbcs (range of emergency units, - units). the main requester was the emergency department ( %). the most common clinical indication for transfusion was acute gastrointestinal bleeding ( %). of the episodes, episodes ( %) did not meet the guidelines for emergency use because > units of emergency uncrossmatched o rhd-neg rbcs were issued. episodes ( %) were flagged as potentially inappropriate as the patients were clinically stable according to documentation in the medical records. episodes ( %) were identified as potentially preventable due to delay in pre-transfusion sample collection (defined as > h elapsed between patient arrival and group and screen sample collection) in the setting of acute bleeding ( %), receipt of an unsuitable pretransfusion sample requiring sample recollection ( %), delay in pre-transfusion sample processing ( %), no valid pre-transfusion sample being available at the time of the bleeding episode despite having a planned elective procedure or being an inpatient with recent clinical bleeding ( %). only one patient was investigated for potential transfusion-related adverse outcome ( %) which was thought likely due to concurrent sepsis. summary/conclusions: over six years, episodes utilising emergency uncrossmatched o rhd-neg rbcs were identified with rbcs issued and rbcs discarded. a significant proportion of episodes ( %) were potentially avoidable if there had been a valid pre-transfusion sample available in the transfusion laboratory at the time of the episode. efforts to minimise use of this precious resource are ongoing, and include feedback to clinical units regarding importance of valid pretransfusion samples prior to applicable invasive procedures and in bleeding patients, ongoing education to medical and nursing staff, and continuing audit of use of this blood component in the hospital haemovigilance programme. abstract withdrawn. abstract withdrawn. background: platelet transfusions are often given prophylactically to thrombocytopenic hematology patients. to which extent platelet function improves after transfusion, and how this improvement correlates with an increase in platelet count, is not well studied. flow cytometry has been used to evaluate platelet function after transfusion in a few studies and can be performed even at low platelet counts. rotational thromboelastometry (rotem) represents a more physiological measure of platelet function in whole blood that has not been extensively used in transfusion settings. we used these methods to investigate if platelet transfusion improves platelet function in hematology patients and if improvement correlates with increased platelet counts. aims: the aim was to evaluate the relationship between response to platelet transfusion, measured as corrected count increments (cci), and platelet function in thrombocytopenic patients with hematological disorders. methods: blood samples (sodium-citrate anticoagulated) were collected from unselected hematology patients receiving prophylactic platelet transfusions, after informed consent had been obtained. samples were taken at three time-points: within h before transfusion, h after and - h after transfusion (via a central venous catheter or a subcutaneous venous port). for each time-point, platelet response to adenosine diphosphate (adp) and thrombin receptor-activating peptide (trap- ) was assessed by flow cytometry by measuring p-selectin and pac- expression on single platelets. rotem analysis was also performed on all samples, using intem and extem reagents. results: an interim analysis was performed after inclusion of patients. the mean platelet count before transfusion was /l (range - /l). h cci was /l and - h cci was /l, but response was highly variable. pselectin expression after stimulation with adp and trap was significantly higher at h after and - h after transfusion compared to before transfusion (p < . ). pac- expression after stimulation with adp was significantly higher at - h after transfusion (p < . ), but not at h after transfusion. in rotem, clot amplitude at and min (a and a ) as well as maximum clot firmness (mcf) improved after transfusion (p < . ). a significant correlation between absolute platelet count and p-selectin expression after trap and adp stimulation was found (r s = . and . respectively, p < . ). absolute platelet count was also significantly correlated with mcf (r s = . , p < . ), where % of patients with a platelet count of more than /l reached mcf values within the reference interval. summary/conclusions: platelet function generally improves after transfusion and was in our patient population correlated to the absolute platelet count, but was also seen at the single platelet level in flow cytometry. a post transfusion platelet count of more than /l might be sufficient to significantly improve coagulation in heavily thrombocytopenic patients, but larger studies are needed to confirm this conclusion. abstract withdrawn. abstract withdrawn. background: sickle cell disease (scd) is a genetic disorder that is frequently referred to as a hypercoagulable state. hydroxyurea (hu) is known to decrease the frequency of vaso-occlusive complications and need for blood transfusions in severely affected individuals. although cross-sectional studies show that treatment with hu is associated with decreased coagulation activation, there are no prospective studies evaluating the effect of hu on coagulation activation. aims: to assess the effect of hu on markers of fibrinolysis (d-dimer) and endothelial activation (soluble vascular cell adhesion molecule- [soluble vcam- ]) in patients with scd in their non-crisis, "steady state." methods: patients, at least years of age, with documented hbss or hbsb-thalassemia, eligible for treatment with hu were studied in this prospective, observational study. laboratory investigations were obtained at baseline, prior to commencement of therapy with hu, with repeat evaluations at three and six months of therapy. non-parametric test was applied to observe the association between hu therapy and the biomarkers of interest. results: twenty-five patients with scd (hbss: , hbsb thalassemia: ) were enrolled (females: [ %]), with a median age of years (iqr: ). following months of hu, median values for wbc count ( . /l vs. . /l, p = . ) and d-dimer ( . ng/ml vs. . ng/ml, p = . ) were significantly lower than baseline values, while the mean corpuscular volume ( . fl vs. . fl, p = . ) was significantly higher than the baseline value. no significant differences from baseline were observed in the median values for hemoglobin ( . g/ dl vs. . g/dl, p = . ), platelet count ( /l vs. . /l, p = . ), lactate dehydrogenase ( u/l vs. . u/l, p = . ) or soluble vcam- ( . ng/ ml vs. . ng/ml, p = . ) following months of hu therapy. summary/conclusions: this exploratory study confirms that treatment with hu is associated with decreased coagulation activation in patients with scd, although no effect on endothelial activation was observed. by decreasing coagulation activation, hu may decrease the risk of thrombotic complications in scd. abstract withdrawn. abstract withdrawn. transfusion medicine, apollo gleneagles hospitals, kolkata, india background: reduction of immune responsiveness through blood transfusion has been documented by previous authors. breast cancer is considered as one of the commonest cancer globally and the second main cause of death in females transfusion of allogeneic blood in breast cancer surgery is variable and differences of transfusion incidence have been observed in the literature. where the maximum surgical blood ordering schedule (msbos) dictates cross matching and reservation of blood before surgery, factors deciding their utilization are varied and numerous. our hospital protocol guides that every patient planned for elective breast cancer surgery should routinely have a blood sample sent for reservation of one unit of compatible packed red blood cell (prbc) in the blood bank. aims: in this prospective study we aimed to audit the blood utilization in patients undergoing elective breast surgery and thereby optimize the blood ordering schedule, economic burden and loss of clinical resources. methods: the study included confirmed breast cancer patients planned for elective breast surgeries from january to december . patient and disease details like age, stage, tnm status, estrogen receptor (er) and progesterone receptor (pr) status, human epidermal growth factor receptor (her - ) expression, triple negative breast cancer (tnbc) status, reproductive and treatment status were documented. patients were divided into younger group [≤ years] and older group (> years). before surgery blood samples for compatibility testing were sent to blood bank for blood reservation. details of test, blood issue and blood transfusion were documented in the blood bank. approximate loss of time in minutes and wastage of resources in terms of money (inr) in the blood bank were noted. all results were calculated as mean ae sd and a 'p' value of < . was considered statistically significant. results: of the total patients most underwent wide local excision of the breast and modified radical mastectomy. a total of patients received units of blood and blood components in all categories of surgeries. only were younger women (≤ years) with mean age of years. non-transfused patients were significantly more than transfused ones (p < . ). frequency of blood transfusion was more in young patients ( . %). seven ( . %) of the total stage iv patients received blood transfusions. frequency of blood transfusion was more in patients undergoing surgery after chemotherapy ( . %). a significant loss of time and loss of revenue was observed. summary/conclusions: we conclude that routine compatibility test is not justified for all patients undergoing breast surgery. a more targeted approach is needed to reduce blood demand and associated cost to patient and blood transfusion services. background: blood transfusion guidelines are not only essential for the optimal use of blood products, but also help reduce transfusion-related adverse reactions and improve patient outcomes. the korean national transfusion guidelines were developed in and fully revised in by the korean centers for disease control and prevention and the korean society of blood transfusion. in our hospital, which is a -bed university hospital, a transfusion-indication data-entry program based on the national transfusion guidelines was developed in . it was applied to the electronic medical record system and all transfusion orders, except emergencies, have been performed through this program since then. aims: we planned to record and analyze the reasons for transfusion in order to monitor blood product usage and provide feedback to clinicians. furthermore, we intended to contribute to patient safety through the appropriate use of blood products. methods: we classified transfusion-indications by the blood product requested and created a pop-up window listing these indications, which would appear at each regular transfusion order. indications for transfusion with each blood product were as follows: red blood cells (rbcs)acute blood loss, chronic disease (sub-classified as hb ≤ g/dl, cardiovascular disease, cerebrovascular disease, peripheral vascular disease, respiratory disease, age ≥ years, age ≤ months, chemotherapy), surgery/ procedure, transplantation and 'other'; platelets (plts)present bleeding, bleeding prevention (sub-classified as hematologic disease, solid tumor, peripheral blood stem cell transplantation, disseminated intravascular coagulopathy, infant), surgery/procedure, massive transfusion and 'other'; fresh frozen plasma (ffp)bleeding in coagulopathy, bleeding prevention in coagulopathy, massive transfusion, plasma exchange and 'other'. transfusion indications entered into the data-entry program from sep to feb were analyzed. results: the number of transfusion-indications analyzed was for rbcs, for plts and for ffps. the most common indications for transfusion were chronic disease for rbcs ( / , . %), bleeding prevention for plts ( / , . %) and 'other' for ffp ( / , . %). 'hb ≤ g/dl' was the most frequent sub-indication of chronic disease ( / , . %), and hematologic disease was the most frequent sub-indication of bleeding prevention ( / , . %). many clinicians entered transfusion indication as 'other': rbcs ( / , . %), plts ( / , . %) and ffp ( / , . %). however, the free-text supplied by the clinician when 'other' was selected, often corresponded to an indication already categorized in the transfusion-indication data-entry program; . % of rbcs and % of plts. of the indications entered as 'other' in ffp, . % were surgery/procedure-related. summary/conclusions: in our hospital, the release of blood products has been dependent on the data-entry of transfusion indications (except in emergencies) since sep . transfusions of rbcs and plts were most common for chronic disease and bleeding prevention, respectively, but many cases entered as 'other' could have been categorized as existing indications in our data-entry program. therefore, we conclude that additional training is needed for clinicians regarding the determination of transfusion-indications and correct use of the transfusion-indication dataentry program, in order to use blood products more appropriately. methods: this was a prospective cohort designed study. subjects were children aged - years with indication of platelet transfusions in sardjito hospital yogyakarta indonesia. the patient samples were collected before and h post-transfusion, the expression of cd p on platelet was determined by flow cytometry method. results: there were subjects who were divided into two groups. fifty-one subjects received non-leukodepleted pcs and the other fifty-one transfused by pre-storage leukodepleted pcs. the mean of pre-transfusion platelet cd p for nonleukodepleted and leukodepleted groups were . % and . %, and the mean increase of post-transfusion platelet cd p for non-leukodepleted was . % and the mean decrease of leukodepleted groups was . %. it was shown the increase of post-transfusion platelet cd p for non-leukodepleted group, and it was significantly (p < . ) higher than in the leukodepleted groups. summary/conclusions: there was an increase of post-transfusion platelet cd p expression in patients received non-leukodepleted, but a decrease in leukodepleted pc transfusions. background: preoperative anaemia is a common finding in patients undergoing surgery and often neglected in our country. aims: the objective of this study was to evaluate hb(values and the identification of cardiac patients who entered operation with anaemia. and also to study the correlation between hb values and the number of rbc (red blood cell) transfused unit methods: this is a retrospective, descriptive and analytical study. the data for this study was collected from the files in the statistic's service at qsut (university hospital center "mother teresa"). the object of our study were the files of patients hospitalized in the period january -may in the cardiac surgery ward, which were subjected to cardiac surgery. from the files were collected data on age, gender, primary diagnosis, accompanying diseases. we also collected hb, rbc, htc (hematocrit), mcv (mean corpuscular volume), mch (mean corpuscular hemoglobin), mchc (mean corpuscular hemoglobin concentration). from the transfusion service at qsut and from the files were pulled out the transfused patients and the number of transfused units. results: based on the who definition for anemia (females < g/dl and males < g/dl), from the patients included in the study, ( %) were anaemic. from males in the study, ( %) of them were anaemic based on hb lab values, whereas from women in the study anaemic were found to be ( %) of them. from the anaemic patients in the study, ( . %) of them with mild anaemia, ( . %) with moderate anaemia and ( . %) with severe anaemia. in the total of anaemic female . % are under , while . % are over/or years old. in the total of anaemic males, % are under , while % are over/or years old. it is noticed that most of them are with normochromic normocytic . %, normocytic hypochromic anaemia . %, hyperchromic microcytic anaemia . %, macrocytic normochromic anaemia and macrocytic hypochromic anaemia respectively . % and microcytic normochromic anaemia . %. the average value of preoperative hb decreased from . g/dl before surgery to . g/dl after surgery, so there is a decrease of approximately . g/dl of hb value. in our patients, % ( ) were transfused and the remaining % ( ) were not transfused. from transfused patients ( %) patients were anaemic. the correlation between the values of hb, rbc, htc and the number of transfusions shows that with the decrease of these values the number of transfused units increases. summary/conclusions: the diagnose of anaemia is underestimated before surgical intervention in our country and investigation of hb low values do not take the proper importance to find probable cause and correct it before surgical intervention. the lower the hb values, the greater the chance to be transfused and the number of rbc transfused units. failure to correct hb values before surgery results in unnecessary transfusions for the patients or which could have been avoided, eliminating also the risk of transfusion complications. background: alloimmunization after red blood cell transfusion is affected by various factors. it is known that the incidence of alloimmunization increases in certain diseases. extended red blood cell matching can be used to prevent the development of alloimmunization in diseases which the rate of alloimmunization is increased. in asia, extended red blood cell matching is not actively implemented. aims: we tried to investigate whether there is a difference in the disease categories between unexpected red blood cell antibody positive and negative groups. methods: from january, to december, , the diseases of the patients who had undergone unexpected red blood cell antibody identification test at dong-a university hospital was examined through medical records. from january to december , the diagnosis was made on patients who had two or more unexpected antibody screening tests. we analyzed the frequency difference of disease category between two groups. results: a total of patients were performed with unexpected antibody identification tests. of patients who underwent more than screening tests, ( . %) were positive. were consistently unexpected antibody negative. the patients with solid tumors (n = , . %) and those with hematologic diseases (n = , . %) had a higher incidence in unexpected antibody positive group. the patients with myeloid malignancy had a significantly higher frequency than lymphoid malignancy (p = . ). the frequency of patients with liver cirrhosis was significantly higher in the unexpected antibody positive group ( / , . %) than in the negative group ( / , . %) (p = . ). the incidence of non-hodgkin lymphoma was significantly higher in the unexpected antibody negative group ( / , . %) than in the positive group ( / , . %) (p = . ). summary/conclusions: there was a difference in the distribution of diseases between unexpected antibody positive group and negative group. the patients with liver cirrhosis were more frequent in unexpected antibody positive group, suggesting that extended red blood cell matching would be considered. background: in hematological patients with multiple platelet transfusions (pc) often develop immune response to human leukocyte associated antigens (hla-i) and human platelet-specific associated antigens (hpa). besides, platelet associated immunoglobulins (paig) and complement components (pac) are found on platelet. this leads to increased platelet destruction and development of refractoriness to transfusions of donors' platelets. transfusion therapy using an individual selection of platelets and plasmapheresis, contribute, in the majority of cases, to the realization of efficient transfusion by pc. but, in difficult cases, there is a need to use intravenous immunoglobulin, which may promote the efficient transfusion of pc. aims: evaluate the algorithms of using the complex therapy of refractoriness to transfusions of donors' platelets with additional application of intravenous immunoglobulin (ivig). methods: in there were three female patients in the clinics of the centre for observation, age between and years (me = ) with the ineffectiveness of complex therapy for overcoming refractoriness to transfusions of donors' platelets due to selection and plasmapheresis. the diagnoses were as follows: aplastic anaemia (aa)- , acute myeloid leukemia (aml)- . individual selection of platelets was carried out by the adhesion method on the solid phase (immucor "galileo neo"). paig and pac / were evaluated by the method of flow cytometry (bd facscanto ii) by the method of double staining with cd a. the density of fixed paig, pac was © the authors vox sanguinis © international society of blood transfusion vox sanguinis ( ) (suppl. ), - evaluated by the median fluorescence intensity (mfi). the two patients with aa received ivig-igg therapy in the standard dose , g/kg per day, for days. one patient with aml received ivig-iggam therapy in the standard dose , ml/kg/day for . results: under pressure of the complex therapy with the use of ivig in the standard dose there was are decrease in mfi over time in the case of two patients: aa- mfi-paigg reduced from to ; while the patient with aml: paiga reduced from to , and paigm from to , pac from to , pac from to . the patient with aa- over time, regardless of the treatment, there was an increase of mfi, but the effect of pc transfusions was achieved under pressure of complex therapy. under pressure of complex therapy all the patients also reduced the frequency of reaction of alloantibodies when resorting to an individual selection and increasing the frequency of compatible couples "donor-recipient". summary/conclusions: delivery of complex therapy and the additional application of ivig enables an adequate transfusion therapy of pc, neutralize hemorrhagic syndrome and continue the treatment of the main disease. detection and monitoring of paig/pac during the development of refractoriness to transfusions of donors' platelets are additional markers for prescription of ivig therapy. anaesthesia, tan tong seng hospital, singapore, singapore background: blood transfusion is quite prevalent in paediatric cardiac surgical procedures. we hypothesized that the routine use of rotational thromboelastography (rotem) to guide transfusion decisions would reduce the overall proportion of patients receiving transfusions in paediatric cardiac surgery aims: the aim of the study was to find if the use of blood and blood products in pediatric cardiac surgical cases in a single centre is affected due to rotem. methods: sixty paediatric cardiac surgical patients undergoing cpb were included in this study. thirty patients (study group) were prospectively included and compared with thirty procedure and age-matched control patients (control group). in the study group, rotem, performed during cpb guided intraoperative transfusions. perioperative transfusions of blood and blood products, postoperative blood loss and hemoglobin levels were compared between the two groups. results: the patients in the control group received fewer transfusions of packed cells ( % vs %) and fresh frozen plasma ( % vs % p<o.oo ). more patients in the study group received platelets ( % vs %) and cryoprecipitate ( % vs %). the postoperative blood loss was lower in study group compared to the control group. the postoperative hemoglobin did not differ between the two groups. summary/conclusions: the results suggest that the routine use of rotem in paediatric cardiac surgery to guide transfusions is associated with reduced proportions of patients receiving transfusions and is evidence based practice. abstract withdrawn. abstract withdrawn. abstract withdrawn. background: mycoplasma pneumonia (mp) infection has often been implicated in respiratory tract infections. although this agent has also been associated with other non-respiratory diseases, hemolytic anemia is the most common hematologic complication of mp infection. episodes of sudden onset of severe anemia are rarely seen in beta thalassemia. we report a -years-old female with beta thalassemia major who was diagnosed to have severe anemia secondary to autoimmune hemolytic anemia induced from mp infection aims: to report a case of patient with beta thalassemia major who was diagnosed to have severe anemia secondary to autoimmune hemolytic anemia induced from mp infection and how it was managed with minimal transfusion. methods: a -year-old female case of beta thalassemia major who developed autoimmune hemolytic anemia following mycoplasma infection. the patient is on monthly blood transfusion since the age of years at dubai thalassemia center. she was admitted to the hospital with days history of dizziness, severe low back and joint pain and her travel history indicated a four-week visit to pakistan. initial investigations showed a hemoglobin level of . g/dl the direct and indirect coombs test were positive. patient was transfused with two units leuko-depleted compatible prbc (o, rh +, negative for e and kell antigens.) and discharged next day. three weeks later, the patient was still with lower limbs pain and the hemoglobin was . g/dl with a positive dat with both igg+ and c + , patient was not transfused as it was difficult to find matching blood; therefore she was given one week follow up. four days later, patient reported to the center with fever, generalized body pain and fatigue. she had significant drop in hemoglobin . g/dl, mcv . , platelets count , crp . , retic count . , blood culture no growth, total bilirubin . , malaria parasite smear was negative, urine culture and microscopy were normal. mycoplasma pneumonia antibody showed positive with igg . and igm . , she was started on azithromycin for days and received units prbc least incompatible leuko-depleted (o, rh +, negative for e and kell antigens.). after which her hemoglobin increased to . g/dl. she did not show any improvement in her condition over the following weeks and repeat mycoplasma pneumonia antibody showed an increased titer, which denoted resistance to azithromycin; hence, we started her with second line of treatment levofloxacin for days. screening for collagen disease were all negative apart from high esr of mm/hr. patient remained afebrile and transfused with least incompatible available blood, post transfusion hb was . g/dl. three weeks later, during her routine follow up, she was doing well with esr dropping to mm/hr and hemoglobin . g/dl, which indicated gradual settling of hemolysis, although the last dat remained positive. subsequent visits showed hb drop of . g/dl/week which is acceptable for transfusion dependant thalassemia. results: with conservative management patient condition improved. summary/conclusions: hemolytic anemia associated with mycoplasma pneumonia is usually self-limited and resolves spontaneously after mycoplasma infection elimination. packed red cell transfusion in transfusion dependent patient may be troublesome and can aggravate the condition; therefore it should be utilized and limited to significant symptomatic anaemia background: early plasma transfusion in women with severe postpartum hemorrhage is often instituted to prevent and treat coagulopathy, but whether maternal outcomes improve with this treatment is unclear. aims: to quantify the association of plasma transfusion within the first min after diagnosing persistent postpartum hemorrhage and adverse maternal outcome. methods: we performed a retrospective cohort study of women with persistent postpartum hemorrhage, defined as postpartum hemorrhage refractory to first-line measures to control bleeding. women were enrolled from january , to january , in dutch hospitals. in a time-dependent propensity score-matched analysis, women with transfusion of fresh frozen plasma within min following the diagnosis of persistent postpartum hemorrhage were matched to women without plasma transfusion or plasma transfusion at a later time point during hemorrhage. plasma transfusion was not guided by coagulation tests. the main outcome measure was adverse maternal outcome, defined as a composite of mortality, hysterectomy and arterial embolization to control bleeding. we performed sensitivity analyses with initiation of plasma transfusion within and within min following diagnosis persistent postpartum hemorrhage, compared with other plasma transfusion strategies. results results: the cohort consisted of women with persistent postpartum hemorrhage, with uterine atony as cause of hemorrhage in women ( . %). in this cohort, seven maternal deaths ( . %), hysterectomies ( . %) and arterial embolizations ( . %) were observed. plasma transfusion within min in women was matched on time-dependent propensity scores with women with no or later plasma transfusion. rate of adverse maternal outcome was similar between women with and without early plasma transfusion, . % versus . %, adjusted odds ratio . ( % confidence interval . - . ). results of sensitivity analyses were comparable to the primary results. summary/conclusions: among women with persistent postpartum hemorrhage, initiation of plasma transfusion within min following this diagnosis was not associated with improved maternal outcomes, compared with no or later plasma transfusion. whether other transfusion strategies or identification of women with high risk of coagulopathy will improve maternal outcomes remains to be studied. background: preoperative evaluation of increased risk for perioperative bleeding is essential for cardiac surgery patients. platelet aggregation, as a laboratory test for assessment of platelet function, is very efficient for optimal antiplatelet treatment and also for assessment of the increased risk of postoperative bleeding and perioperative application of allogenic red blood cell transfusions. aims: the aim of this study was to establish whether preoperative platelet function testing for the presence of residual effect of acetylsalicylic acid (asa) on platelet aggregation can be correlated with an increased risk for intraoperative bleeding during cardiac interventions. methods: a retrospective study included patients who underwent surgical procedures (cabg ii and cabg iii) at the department of cardiovascular surgery, clinical center in ni s in period november -july . patients were previously taken asa at a dose of mg per day, but therapy was discontinued days before surgery. platelet aggregation was measured on the day of surgery using impedance aggregometer multiplate (multiplate platelet function analyzer, roche), using trap and aspi tests. patients were divided into two groups: control group (cg), which included patients with preserved function of platelets (aspi - au*min), and examined group (eg), which included patients with inhibited platelet aggregation in aspi test (< au* min background: hemophilia b is an x-chromosome-linked inherited bleeding disorder resulting from reduced levels or an absence of factor ix clinically represented by recurrent prolonged bleeding. mutations can be inherited or acquired de novo. de novo mutations arise in about one-third of patients with haemophilia. the disease affects primarily males, but approximately % of carrier females have factor ix clotting activity lower than % and are at risk for bleeding. aims: case report of a hemophilia b carrier. methods: the clinical history of the patient was thoroughly studied by analyzing medical records and analytical results using the software available in the health institution and paper records. results: year old woman, with no history of abnormal haemorrhage, healthy, up to when, after a dystocic delivery, presents with subcutaneous and ocular haemorrhage and dispersed bruises. a basic coagulation study is performed and a level of % fix is found. genetic analysis reveals a mutation in fix gene and she is diagnosed as a carrier of hemophilia b. except for a son, no other direct family members carry the mutation. in , after total hysterectomy with bilateral adnexectomy due to an invasive carcinoma in the uterine cervix, the patient suffers a haemorrhagic shock with multiple transfusion support and around six months later undergoes an ureteronephrectomy also with the need for post-surgery transfusion support. the patient is referred to the immunohemotherapy department where she has regular appointments as an outpatient since . in , she requires surgery for the removal of a thyroglossal duct cyst, which is performed under prophylactic treatment with iu recombinant fix (rfix) daily, for four days, and up to h after discharge maintaining basal levels of fix of % and with no major complications reported. in , the patient is admitted to the er in haemodynamic shock and a history of black stools and syncope. at admittance, she receives a bolus of iu of rfix and requires severe transfusion support due to active bleeding. she is diagnosed with colonic angiodysplasia and undergoes surgery. daily doses of iu rfix are administered from day (d ) and up to d maintaining fix levels around - %. the patient is operated at d under the cover of iu of rfix, twice per day, and up to d after surgery reaching fix levels of around - %. at d the dose was diminished to iu of rfix daily and at d she is discharged with no rfix replacement therapy necessary in ambulatory. since then, no complications or new occurrences have been reported. the patient is under prophylactic administration of rfix prior to minor invasive procedures (nodule biopsy, dental extractions and colonoscopies). summary/conclusions: hemophilia b carriers usually do not require any major health care for their daily routine or invasive procedures. however, in the case reported, basal fix levels conditioned any minor intervention to be performed. thus, this carrier must be considered as a moderate hemophilia b patient and mandatory prophylaxis with rfix must be performed prior to any invasive procedure. background: blood transfusion is a life saving procedure but transfusion associated complications are equally important that need to be addressed. with limited resources of blood donations and screening, excessive transfusions must be avoided to prevent risk and economic burden on patients. on the other hand discussion on appropriate use of blood product is a matter of debate in medical literature. it is recommended to restrict the liberal use of transfusion. aims: in this regard we aimed to observe the frequency of genuine and non genuine transfusion at our hospital and also to compare the outcomes of liberal and restrictive transfusions. methods: it was a cross sectional study carried out at nibd and bmt, pechs campus, karachi, pakistan, from february to january . the study was approved from institutional review board. pack red cells (prc) transfusion in case of < g/dl hemoglobin (hb) with cardiac history and < g/dl hb with symptomatic anemia was considered genuine. platelets transfusion in case of sepsis and count < /l, sepsis with bleeding and < /l, patients on active chemotherapy without bleeding but platelet count < /l and in patients presented with bleeding was considered genuine. patients who were presented with bleeding, deranged coagulation profile and with sepsis + bleeding considered genuine for fresh frozen plasma (ffp) transfusion. spss version . was used for descriptive and inferential statistics. results: a total of transfusions were evaluated for genuine and non genuine transfusion. male predominance was high in our data ( %). out of , ( %), ( %) and ( %) prcs, platelets and ffp were transfused respectively. out of platelets, ( %) were platelet apheresis. / ( %) prcs and / ( %) platelets were non genuinely transfused as per the criteria described in methods. however, ffp and platelet apheresis were genuinely transfused. in non genuine group of platelet transfusion, all patients received more than unit platelet and the increment of platelet count post transfusion was found statistically non significant (p = . ). thirty six ( %) of transfusions were done with more than units of prcs in non genuine group. the mean hb level of patients received unit and more than units prcs was statistically same (p = . ) and it was found out that there was same increment in hb in both the groups post transfusion. (p = . ). summary/conclusions: we concluded that although blood transfusion is an integral procedure for saving life yet correct use of blood products is necessary in the era where blood donations are scarce and blood transfusion has its potential associated hazards. the approach towards the appropriate use of blood products will not only minimize the risk of transmission of infectious diseases but also will reduce the economic burden. longitudinal studies on large sample size are needed to validate this study. uncertain. an ovine model enables comparisons of; (a) invasive and non-invasive methods to measure oxygen delivery and utilisation at a tissue level, and of (b) the efficacy of various resuscitation fluids and transfusion protocols in treating haemorrhagic shock. aims: to develop an ovine model of haemorrhagic shock. methods: sheep (n = ) were anaesthetised, ventilated and instrumented. instrumentation included blood flow, perfusion, and microdialysis probes placed in the brain, kidney, liver and skeletal muscle. haemodynamic, tissue oxygenation, tissue flow and respiratory data were recorded continuously by data capture software. non-invasive assessments, including brain and muscle oxygen saturation by nirs, and visualisation of sub-lingual microvascular perfusion, as well as arterial blood gas measurements and plasma/serum/urine collections were made at specific timepoints. after a baseline period ( h) sheep were bled~ % of their estimated blood volume (estimated at ml/kg) to a mean arterial blood pressure (map) of - mmhg. sheep were then resuscitated with either plasmalyte â (up to ml/kg/ hr; n = ) or transfused with sheep red cells (n = ) to achieve a map > mmhg. sheep were euthanised h after resuscitation. data are presented as mean ae standard deviation. results: sheep were haemorrhaged an average of . ae . ml blood which combined with iatrogenic blood loss (~ ml) corresponded to an average . ae . % blood loss. two out of the four sheep met clinical criteria for haemorrhagic shock (map = - mmhg, lactate > mm, svo < %). across all four sheep the nadir map averaged . ae . mmhg, lactate peaked at . ae mmol/ l, and nadir svo was . ae . %. all sheep survived to the end of the experimental protocol. summary/conclusions: these data demonstrate the successful induction of haemorrhagic shock in an ovine model. further experiments are planned to improve the protocol and to achieve % incidence of haemorrhagic shock, and then to compare invasive and non-invasive measures of oxygen delivery and utilisation as well as the efficacy of different resuscitation fluids and red cell transfusion. adverse events, including trali p- bilirubin were recorded within the -day period. the clinical parameters were compared against the reaction strength of the antibody reactions. the automated strength was measured by solid phase. the manual testing consisted of a -min incubation using liss and adding monospecific igg. the dat was performed manually by adding poly-specific igg and then testing with monospecific igg and c d. the rh group and non-rh group had and cases performed manually, and results were + or weaker further indicating the manual strength did not correlate with the clinical hemolysis. likewise, in / ( %) the dat was negative, and did not show any correlation with clinical hemolysis. however, when ldh and bilirubin were measured, the two parameters increased as the automated strength of the antibodies increased. summary/conclusions: most of the dshtr investigation was not associated with overt accelerated red cell destruction. a strong correlation was observed only between the automated immunohematology testing results and other laboratory markers of hemolysis. in our experience, the direct antiglobulin test and manual strength showed no correlation. background: numerous transfused patients present severe, sometimes critical clinical conditions. the occurrence of adverse transfusion reactions (atr) may induce deterioration in the clinical condition with a worsened clinical course and a lifethreatening or fatal outcome as is the case with nervous system impairment. in france, in , out of , notified atrs, ( . %) and ( . %) were life-threatening and death respectively. aims: our aim was to evaluate the notified atrs with neurological signs that occurred in transfused patients over a period of six years and six months in hospitals in the auvergne rhône alpes area. the study included patients with reported atrs in hospitals in this area from january st to june th . each atr was registered in the national haemovigilance database system. two signs observed at the time of the atr were analyzed: unconsciousness and convulsions. stroke was excluded. the type of atr, its severity, the blood product involved and its imputability were studied. results: during the period under study, , atr were reported, of which included unconsciousness and/or convulsions ( . %). of these patients, were females ( . %) and males ( . %). unconsciousness alone was frequently observed ( reports, . %). convulsions were notified in reports ( . %) and were associated with unconsciousness in of them. the diagnosis of seizure, with no other clinical signs, was established in cases ( . %). unconsciousness and/or convulsions were present in allergic reactions ( . %), cases of transfusion-associated circulating overload ( . %), cases of suspected transfusion-transmitted bacterial infections and hypertensive reactions. in allergic atrs, unconsciousness was notified in cases and unconsciousness associated with convulsions in one. twelve atrs were severe ( . %), were life-threatening ( . %) and in cases, they resulted in the death of the recipient ( . %). of the allergic atrs, were severe and life-threatening. red blood cell concentrate was involved in atrs ( . %) and platelet concentrate in ( . %), including cases with apheresis platelet concentrate and cases with pooled platelet concentrate. fresh frozen plasma was involved in atrs ( . %). nevertheless, the imputability of the blood product was excluded or unlikely in atrs ( . %). in the suspected transfusion-transmitted bacterial infections, the imputability of the transfusion was ultimately excluded after a negative result was obtained in the bacterial culture of the blood product. the imputability of the blood product was probable or possible in and atrs respectively, but was certain in only atrs. summary/conclusions: unconsciousness and/or convulsions were rarely observed in atrs notified in transfused patients. nevertheless, the presence of these signs highlights the seriousness of the atr ( ars, . %). lastly, the imputability of the blood product was often excluded or unlikely. in the multivariate cox model for the effect of lpi on overall survival, adjusted for age and ipss-r category, elevated lpi levels were associated with inferior overall survival (hr . , % ci . - . , p = . ). this effect was most pronounced in the td-rs subgroup (hr . , % ci . - . , p < . ). similarly, elevated lpi levels were associated with inferior pfs (hr . , % ci . - . , p < . ) for the whole study population and the td-rs subgroup (hr . , % ci . - . , p < . ). in total patients received iron chelation during the sample collection period ( patients deferasirox, patients desferrioxamine). lpi levels were normal in out of the samples collected during deferasirox treatment and in out of samples collected during desferrioxamine treatment. summary/conclusions: transfusion dependency is associated with the presence of toxic iron species and inferior overall and progression-free survival in lower-risk mds patients. in td-rs patients the effects were most pronounced indicating ineffective erythropoiesis leading to additional iron toxicity. background: post-transfusion immunomodulation has been reported to contribute to poor patient outcomes. clinically relevant transfusion models are needed to improve our understanding of underlying mechanisms. sheep transfusion models are of increasing importance in blood transfusion research as they provide several advantages over small animals, including their size, anatomy, physiology and similar blood volume compared to human. a current limitation of sheep transfusion models is the lack of characterisation of the sheep immune system. understanding the sheep immunology is necessary to advance sheep transfusion models, identify mechanisms that contribute to post-transfusion immunomodulation and facilitate the translation of findings into clinical settings. aims: to characterise the sheep leukocyte inflammatory responses to in vitro lipopolysaccharide (lps) challenge in edta and heparinized whole blood. methods: edta and heparinized sheep whole blood (n = of each) was cultured with rpmi media ( °c, % co ) alone or with the addition of lps ( - lg/ml; derived from escherichia coli : b ). the inflammatory response was assessed after h (h), h, h, h, h and h. supernatant was harvested at each time point and stored at À °c. inflammatory cytokine/chemokine production was determined using sheep specific in-house elisa (il- b, il- , il- and il- ). twoway analysis of variance with bonferroni's post-test was used to measure the effect of incubation time and concentration compared to no lps matched samples. results: when edta was used as an anticoagulant, addition of lps resulted in production of sheep il- b and il- but not il- or il- . il- b production was significantly increased following stimulation of lg/ml lps for h (p = . ) and declined following h incubation. release of il- was significant h post-lps stimulation with lg/ml (p = . ) and reached a maximum at h. the use of heparinized blood resulted in a different immune profile as all inflammatory markers tested were detected following stimulation with much lower concentrations of lps ( lg/ml), although the incubation times differed. il- b was significantly increased following h incubation (p = . ), with increasing levels observed up to h post-lps stimulation. il- production was evident from h and reached significance at h post-lps stimulation (p = . ). il- was significantly increased following stimulation of lg/ml lps for hr (p = . ) with lower concentrations of lps resulting in il- production at h (p = . ). release of il- was significant after h of lg/ml lps stimulation (p = . ), with lower concentrations of lps resulting in il- production at h (p = . ). in heparinized whole blood an lps concentration-dependent effect was evident for all cytokines. summary/conclusions: using a time-and concentration-approach our findings indicate that sheep are more tolerant and have a delayed response to lps stimulation compared to previous research using similar human in vitro whole blood culture models. in addition, data suggest that sheep have greater immune responses using heparin as anticoagulant for the collection of blood samples. improving our understanding of sheep immunology and development of relevant sheep transfusion models will provide a bridge between sheep models of transfusion and clinical settings. . rhdig inappropriately administered (unnecessary exposure) (n = , %) administered to: -rhd positive woman (n = ) -rhd negative mother with rhd negative neonate (n = ) -woman with immune anti d (n = ) -administered in error (instead of other ig) (n = ) rhdig delayed/omitted/wrong dose (risk of sensitisation to the d antigen) (n = , %) -omitted (n = ) -delayed (n = ) -inadequate dose (n = ) administration without correct patient identification (n = , %) storage & handling (n = , %) failure to check the maternal and neonatal blood groups prior to administration was identified as a source of error. misinterpretation of blood results also led to women receiving product inappropriately. e.g. reading a negative antibody screen as the mother being rhd negative. patient identification was raised as an issue. rhdig is often stored in satellite blood fridges for easy access. collection from these areas did not always require confirmation against patient identifiers and there was no register of women who received product or link to the batch number to ensure traceability. two incidents involved the administration of rhdig when the prescription for other immunoglobulin products was not clear, leading to a child and a baby receiving rhdig instead of the intended immunoglobulin. summary/conclusions: these incidents indicate problems with the processes of appropriate identification of women who need rhdig, the use and interpretation of pathology tests and requirements for prescription and administration. these resulted in omitted and inappropriate doses of rhdig. blood matters has made a number of recommendations regarding rhdig administration: -all health professionals involved in rhdig administration should be appropriately trained in the use of rhdig -confirmation of the maternal rhd status is essential prior to prescription or administration -positive patient identification must be used prior to administration of rhdig -health services should consider regular auditing to identify areas for improvement relating to rhdig blood matters continues to work with maternity care providers to improve practice. centro comunitario de sangre y tejidos de asturias, oviedo agencia gallega de sangre, organos y tejidos, galicia banco de sangre y tejidos de cantabria, cantabria banco de sangre de la rioja, la rioja banco de sangre y tejidos de navarra, navarra banco de sangre y tejidos de arag on, aragon fundaci on de hemoterapia y hemodonaci on de castilla y le on, castilla y leon fundaci on banco de sangre y tejidos de las islas baleares, islas baleares, spain terumo bct europe nv, zaventem, belgium background: hemovigilance, a long-term monitoring process made mandatory by national and supranational regulations, begins with a systematic whole blood or blood component collection and ends with an examining period after transfusion of blood components into the patients. in spain, organized in autonomous regions, the hemovigilance system is structured in three levels: ( ) the local level comprised of transfusion centers and hospital based transfusion services that monitor and collect all transfusion related adverse events (ae) and level them up to ( ) the regional hemovigilance coordinator, who communicates all the region's data to the ( ) spanish ministry of health which issues an annual report and corresponds with european institutions. to ensure safer blood supply, pathogen reduction technology (prt) was approved and implementation started in spain in . the mirasol prt system for platelets and plasma was introduced in and is currently being used in of the spanish regions. aims: to monitor the safety of the system, a passive hemovigilance study on mirasol treated products was initiated in the region of asturias and collaboration was extended to other regions (baleares, galicia, la rioja, cantabria, navarra, castilla y leon and aragon). methods: collected data included allergic and febrile reactions, trali and all other adverse event observed. severity of the event and level on imputability of the transfusion were also assessed using the who grading scale. hemovigilance data of mirasol treated products (platelets or m-pc and plasma or m-p) are included from to as blood centers started to apply the technology in routine. results: increase adoption of the mirasol system is observed between , when , mirasol treated blood products were issued to hospitals and with , mirasol products issued. due to low number of transfusions of mirasol-treated blood components in and , notification rates began to be analyzed in , showing ae rates of . %, similar to reports at the national level. stable transfusion reaction rates were observed with m-pc (around . ). rate of ae after transfusion of m-p is fluctuant between . and . . this fluctuation could be due to the inconsistent numbers of m-p transfused from one year to the other. most of transfusion reactions (around %) were of grade i severity and grade ii level of imputability. allergic reactions accounted for most of the adverse events, with g&i > reactions in and of respectively . and . no bacterial nor viral transfusion transmission was recorded on mirasol products during the study period ( ) ( ) ( ) ( ) ( ) ( ) . at the national level, nine cases of bacterial transfusion transmission (with g&i > ) were reported. these transmissions were probably due to transfusion of non-pathogen reduced products. summary/conclusions: the observed notification rate of ae is similar to the national rate but allergic reactions with g&i > is inferior with mirasol treated products. also, we found no reports of transfusion transmission infections nor cases of transfusion associated graft-vs-host disease, demonstrating safety of mirasol treated products. were attributed to human error ( %) with the lowest frequency in equipment failure ( %), compared to % and %, respectively, in the following three years. root cause analysis demonstrated failures in the quality management system including failures in administration, inadequate staffing for blood collection as well as in distribution and processing, and failures arising from institutional constraints and system failures in hospital management. high numbers of "other" aes ( %) in distribution and whole blood collection call for further investigation to indicate measures necessary for prevention and correction. errors related to incorrect blood component transfused (ibct) in - were in , , blood units ( / , ) issued for transfusion. these resulted in serious reactions ( %) ( fatal, life-threatening) . another ( %) were related with ibct that did not cause a reaction. near misses (component not transfused) were ( %) summary/conclusions: our data demonstrate increasing compliance with reporting requirements. questions about the initial factors for deviations in certain activities specifying failures in equipment and materials due to system as well as human errors, highlight the need for further specifications beyond "other" and "human error". background: the weakest link in the transfusion chain currently is the handling of blood components after their issue and the bedside blood administration practices. aims: to evaluate compliance with standard procedures for bedside blood transfusion practices by analysis of the "transfusion feedback forms" in a tertiary care multi-specialty hospital setting. methods: during the study period of months, the transfusion feedback forms received from various clinical areas of the hospital were studied with special reference to the transfusion times. the data was categorized based on the patient's location as well as the time of transfusion, whether done in routine or emergency hours. results: , blood components were issued during the study period, while transfusion feedback forms for , components ( . %) were received in the transfusion medicine department. delay in starting the transfusion (more than min after issue) was observed in transfusion events ( . %). the component transfusion time exceeded the permissible limits for component ( . %).the overall total permissible time for completion of components exceeded permissible limit in ( . %) of transfusion events. the pediatric ward ( . %), icu and ot complex ( . %) were found to be the most non-compliant delay in transfusion, transfusion time and total transfusion time. amongst the delayed transfusions after issue, ( . %) were during the routine hours i.e. between am to pm and ( . %) were in the non routine hours i.e. between pm to am. summary/conclusions: the audit of bedside blood transfusion practices has given us a good insight into various areas of noncompliances as well as the predominant locations in the hospital where the practices need to strengthened further. focused training program on safe blood administration practices for all staff involved in handling and transfusion of blood components is now planned to combat this issue. background: the international surveillance of transfusion adverse reactions (ars) and events (aes) (istare) of the international haemovigilance network (ihn) collects aggregate data from member national haemovigilance systems (hvs) in order to estimate the morbidity and mortality of blood transfusion in a holistic approach. the ultimate goal is to contribute to improving the safety of transfusion by close monitoring throughout the chain "from vein to vein". aims: we analyse recent istare data on suspected transfusion transmitted infections (sttis) for - in comparison to previous years of surveillance, [ ] [ ] [ ] [ ] [ ] [ ] [ ] methods: annual aggregate data from ihn member hvs on transfusion associated bacterial, viral and parasitic infections collected online in istare are analyzed by incidence in blood components (bcs) issued for transfusion, by severity and imputability as well as by blood component. ars with definite, probable or possible imputability were included in the analysis. trend analysis is performed to allow comparisons and to collect information on established and newly emerging infectious threats of blood transfusion. results: for - sets of annual aggregated data from countries covering , , bcs issued were analyzed. all ars totalled , and infectious ars amounted to ( . %). the overall incidence of the infectious ars was . / , units of bcs issued. bacterial infections were the most frequent ( , %), next viral ( , . %) and then parasitic ( , . %). serious were % and there were fatalities ( . %, incidence . / , ). nine deaths were attributed to sepsis and the other two were associated with non-malarial parasitic pathogens. one geotrichum clavatum fungal infection associated with apheresis platelets was reported as a free text comment. this very rarely recognized fungal pathogen caused a very severe infection in a patient but the route of transmission is inconclusive. the viral sttis included hbv ( %), hcv ( %) and hiv ( . %). the recorded as "other" ( . %) including cases of hev, one case of parvovirus b , one cmv and one ebv. no case of tt-malaria was reported. other stt-pi were (two fatal). the prevailing bcs were in general rbcs followed by platelets. comparison with corresponding data for - shows a consistent overall incidence in total sttis ( . vs . / , ). however, considerable differences were seen in separate categories, such as bacterial infections (significantly increased rate in - , p < . ) and an almost doubled rate of parasitic infections (p < . ). compared to the earlier period, there were many fewer hbv infections ( vs ) and many more hev. a similar reduction in the rate of hcv and hiv was observed in - in comparison with previous years. this may be explained by the fact that nat testing for hcv/hiv/hbv has been implemented in many countries in the last decade. summary/conclusions: the infectious risk of transfusion overall remains very low. the rate of bacterial cases has increased and among other viral sttis the frequency of hev is increasing. the mortality of transfusion due to sttis is lower than in the previous period of surveillance. abstract withdrawn. background: one of the main aspects of haemovigilance system in hospitals is following of adverse events and reactions related to blood transfusions. aims: it was intended to analyse the adverse reactions related to transfusion of blood components in pediatric patients. methods: over a four year period (january -december ), the haemovigilance records of all patients receiving blood transfusions procedures were reviewed and transfusion reactions were analysed. statistical analysis of data was performed by spss software (version . , spss inc., chicago, il, usa). majority of blood components were provided by regional blood center organized by national red crescent society. but granulocytes collected by apheresis after donor mobilization and reconstituted whole blood for exchange transfusions were prepared in the transfusion center of the hospital. results: the median age of patients who developed transfusion reactions was months (interquantile range-iqr ). the median for the numbers of individual transfusions in children in a year was (iqr ). the median for the numbers of blood components individually transfused to patients was (iqr ). patients, anaphylactic transfusion reactions in patients and transfusion-related lung injury (trali) in a patient. the overall incidence of transfusion reactions was estimated at a rate of . per units. summary/conclusions: it was reported that adverse effects related to blood transfusion, especially allergic reactions and fnhtrs are common in pediatric patients than adults. in a multinational study concerned about the transfusion reactions related with red cell concentrates, allergic transfusion reactions and fnhtrs were reported at a rate of and in units and in units, respectively. while the incidence of transfusion reactions in children was found . % in a study from the u.s.a., the overall incidence of transfusion reactions in our study which was estimated at a rate of . per units represents a lower rate. hospital gran canaria dr. negr ın, gran canaria hospital general universitario, ciudad real, spain hospital nostra senior de meritxell, andorra, andorra banco sangre y tejidos, santander banc de sang i teixits, barcelona, spain fundaci on hematol ogica colombia, bogot a, colombia centro regional de transfusi on de almer ıa, almeria complejo hospitalario de navarra, pamplona fundaci on banc de sang i teixits illes balears, palma de mallorca hospital de cabueñes, gij on, spain background: root analysis cause is defined as the cause of an error that, if it is treated, eliminates the repetition of the error aims: describe types of human and latent errors detected by a work group in the root analysis cause of transfusion incidents, analyze the concordance between the individual responses of the members and propose recommendations in order to improve transfusional safety. methods: in fifteen participants (nurses and hematologists dedicated to transfusion and component preparation) studied some incidents of administration of nonirradiated components and tried to approach the root causes by applying the classification of errors in mers-tm transfusion medicine. they transferred the answers to a questionnaire (simple or chain error, initial process affected, human and latent errors and measures derived from the analysis to correct the errors). the communication was made by mail and by the spanish transfusion society web forum, which contained the consultation documents. data and percentages are exposed for each type of error and the answers of the participants are tabulated. results: cases corresponded to patients. two patients of years of age diagnosed of acute myeloblastic leukemia (case and ) and chronic lymphatic leukemia (case ). in one case, the hematologist of the transfusion service canceled an irradiation prescription; in another, a patient with fever was transfused in the emergency room without the irradiation requirement and it was later discovered that he had received a transplant of hemopoietic progenitors month earlier; in the last case, neither the requesting doctor nor the laboratory technician nor the following doctor (prescriber) detected the alerts located in their respective computer applications. in all cases, the story was judged as sufficient for analysis. the majority of reviewers ( %) diagnosed a chain of errors. there was agreement of % with respect to the initial process affected. the initial error was communication ( %), monitoring ( %) and compliance ( %), in cases , , and . - human errors were detected per case (average: . , . and . errors respectively) and - latent errors per case (average: . , . and . , respectively). the latent errors most punctuated were: failures in the quality of the protocols ( %), in the transfer of important knowledge ( %), in the available technology ( %) and in the information to the patient ( %). all the participants contributed feasible measures of improvement according to root causes: ) improve the quality and drafting of work procedures and their compliance, including procedures of effective communication between professionals, ) train staff in knowledge important for safety, ) communicate with computer application providers to improve the effectiveness and visibility of the alerts and ) involve the patient with essential information to ensure transfusion safety. the measures were processed later as recommendations. summary/conclusions: the root analysis shows agreement between participants and allows the elaboration of useful recommendations to increase patient safety. this strategy can contribute to the comprehensive prevention of errors. background: in transfusion-associated circulatory overload (taco), pulmonary oedema develops primarily due to volume excess. data from the uk haemovigilance scheme, serious hazards of transfusion (shot) suggest that either the incidence of taco, or the recognition and reporting of taco, has increased over time. from to , reports of taco increased from to ; deaths from to , major morbidity from to . known risk factors include pre-existing cardiac and/or renal dysfunction, low body weight, extremes of age (eg, < years, > years), concomitant fluid administration, positive fluid balance, peripheral oedema and hypoalbuminemia. in a small subset of cases reported to shot, taco developed following transfusion for severe anaemia in the absence of other risk factors. this may be an under-recognised independent risk-factor. aims: to raise awareness of severe anaemia as an under-recognised risk factor for taco and is potentially life-threatening transfusion. methods: cases of taco submitted to shot over the last years were reviewed to identify cases where transfusion for severe anaemia was a key identifiable patient risk factor. results: the following are illustrative cases: -case : a patient in their s weighing kg was prescribed six units of red cells for iron deficiency anaemia after being admitted with hb g/l. the patient had no risk factors for taco except for profound anaemia. during transfusion of the fifth unit the patient became dyspnoeic, hypoxic and hypertensive. the patient recovered after diuretic therapy and had a post-transfusion hb level of g/l. -case : a patient in their s presented with a -week history of weakness and dizziness and had felt unwell for months. the hb was g/l, ferritin lg/l and ecg showed cardiac ischaemia. two units of red cells were transfused. after the second unit oxygen saturations fell despite supplemental oxygen, post-transfusion hb of g/l. a third unit was transfused over min and the hypoxia worsened with dyspnoea and crackles on chest auscultation. the chest x-ray showed an enlarged cardiac silhouette and pulmonary congestion. the patient improved with diuretics. -case : a patient in their s with severe megaloblastic anaemia, hb g/l and peripheral oedema developed taco after transfusion of units and recovered with diuretic therapy. summary/conclusions: chronic and acute anaemia are associated with compensatory cardiac changes irrespective of the aetiology of anaemia. this is further compounded by the underlying cause of anaemia particularly haematinic deficiencies (iron/b deficiency) that independently affect myocardial function. hyperdynamic circulation related to anaemia increases the load on the heart, causing myocardial ischaemia and hypoxia and if the anaemia is not corrected, eventually leads to heart failure. clinicians need to make an accurate diagnosis and avoid excessive transfusion in patients with severe anaemia with or without other additional risk factors. patients with chronic iron/folate/b deficiency without haemodynamic instability should be given the appropriate haematinic replacement. haematinic deficiency responds rapidly to appropriate vitamin/mineral. blood transfusions are to be given only when clinically indicated and even then, only the minimum volume needed for symptomatic relief transfused with consideration for diuretic therapy. methods: legal forms for reporting transfusion reactions were used in the retrospective analysis, which were adjusted by the department of quality assurance and quality control in the electronic form and distributed to clinics using blood components. clinicians were trained to report transfusion reactions through the hospital's transfusion board and through the "service for improvement of the quality and safety of health services" at the clinical center of sarajevo. analysis of the reported reactions in the institute include immunohematological and microbiological examination based on which the guidelines for further treatment with blood components are being made. users of registered services are obliged to report since . results: total of , different blood components were applied in the period between - . department for quality assurance and control has received serious adverse reactions, serious adverse event, reports of transfusion reactions, of which ( %) were inadequately filled, in the same period. from the above, ( . %) were transfusion reactions to erythrocyte blood components which were applied, ( . %) to platelet components and ( . %) were transfusion reactions after the application of fresh frozen plasma. the analysis has shown that the most frequent were febrile non-haemolysis reactions ( or . %), followed by allergic reactions ( or . %). two transfusion reactions ( . %) were characterized as circulation overload. summary/conclusions: the frequency of serious adverse reactions and events was . % ( of , ) and . % were reported transfusion reactions ( of , ). with the establishment of the hospital transfusion board and with the increase of collaboration with the clinical center, significant progress has been made. it is necessary to increase awareness among clinicians in regards to the safe transfusion practice. reporting transfusion reactions should be a mandatory procedure, a path to the proper selection of blood components, monitoring adverse reactions, and for us, transfusiologist, guide to the safest, most efficient blood components. j garc ıa-gala, e martinez-revuelta, a caro-g omez, c castañ on-fern andez and i fern andez-rodriguez hospital universitario central de asturias, oviedo, spain background: elderly patients are the main group of transfusion recipients in our country. given their comorbidities are a risk group for the development complications related to transfusion. aims: analyze the incidence of adverse effects related to transfusion in the elderly population and to assess what factors may influence its appearance methods: transfusions were reviewed in patients > years old. the variables analyzed were: sex, age, diagnosis/reason for transfusion, pre-transfusion hemoglobin (hb), number of transfused units, infusion rate and transfusion side effects, as well as the measures used to prevent or treat the transfusions. effects of circulatory overload results: a total of patients were analyzed ( women, men), with a median age of years ( - ). in total, ch were transfused. patients received ch, patients ch, patients received ch. patients were transfused at two different times. the median hb prior to transfusion was . g/dl. in the patients who received ch was . g/dl, those who received ch: g/dl and those who received ch: . g/dl. the infusion time could be estimated in % of the patients. in those who received ch was . min; . min in those who received ch and . min in those who received ch. patients ( % of the total) suffered some type of adverse effect related to the transfusion. in patients there was an increase in posterior ta, in an increase in hr, in an episode of hypotension and in another one episode of acute respiratory failure. % of those who had an adverse effect were older than years. patients with aht after transfusion, % received ch and the remainder ch. among their background, % had a history of ischemic heart disease. % also had a positive balance. the average previous bp was / mmhg and the subsequent one was / mmhg. % of patients did not receive diuretic treatment. in the case of the patient with acute respiratory failure was in oligoanuria, with positive balances. ch was transfused in total. she was treated with oxygen therapy and with intensification of the diuretic treatment, recovering later. summary/conclusions: -patients > years have a higher risk of suffering some type of adverse effect related to transfusion because they have pre-existing risk factors such as ischemic heart disease or heart failure. -we see that the risk of suffering some type of adverse effect in the elderly population is greater when we transfuse ch than ch. -we have appreciated that in those patients receiving ch, the infusion rate is higher. -the study highlights the lack of methods to prevent the development of circulatory overload. background: iron deficiency anemia is the commonest cause of anemia worldwide. weakness, fatigue, reduced physical activity and difficulty in concentration are the symptoms which are associated with its deficiency. the forefront treatment available is oral iron replacement therapy which is convenient, cost effective and has substantial outcome. another option is intravenous (i/v) iron when oral is not tolerable. despite of potential transfusion associated hazards and limited availability of blood due to shortage of voluntary blood donations, it is insisted by the patients prior to iron therapy. aims: the aim of conducting this study was to observe the impact of administration of oral iron, i/v iron and transfusion on hemoglobin levels in patients presented with iron deficiency anemia. methods: this was an observational study carried out at nibd and bmt, pechs campus, karachi, pakistan from february to december . the study was approved by the institutional review board. diagnosed ida patients presented at our hospital were recruited for analysis who were given oral iron, i/v iron and transfusion for the correction of anemia. informed consent was taken from the participants. descriptive and inferential statistics was applied by using spss version . . results: a total of ida patients were analyzed in which ( %) were females and ( %) were males. the most common symptom in females and males was fatigue followed by body aches in females ( %) and pallor in males ( %). menorrhagia was present in ( %) of females of reproductive age. surgical history was present in ( %) of females while there was no surgical history in males. mean hemoglobin, mch and mcv of females at baseline was . ae . , . ae . , and ae . while in males it was . ae . , ae . and . ae . respectively. sixty two ( %) females were advised oral and i/v iron and ( %) received transfusion. however, in males ( %) received transfusion and ( %) were advised oral and i/v iron therapy. it was observed that the increment of hemoglobin after oral/iv iron at average of months follow up in males and females was same as that the transfusion (p > . ). summary/conclusions: in our society where blood donations are scarce especially voluntary blood donations that are considered to be the safest type of blood donation. we would like to draw attention towards the alternatives to correct anemia such as oral and i/v iron replacement therapy as our results revealed that there was no difference in the increment of hemoglobin between the two groups. we need to educate our society especially the older age adults and young women who are more vulnerable of getting ida to opt oral and i/v iron therapy. it will be cost effective, convenient and also has less risk than transfusion. cellular therapies -stem cell and tissue banking, including cord blood background: the differentiation of megakaryocytes plays an important role in the production of platelets. however, the underlying mechanisms regulating megakaryocytes differentiation have rarely been studied. aims: to identify candidate genes involved in megakaryocytes differentiation and investigate the potential regulatory mechanisms of megakaryocytes differentiation from human cord blood hematopoietic stem cells in vitro. methods: cb-derived cd + cells were isolated using density gradient centrifugation and magnetic activated cell sorting (macs). cultures were stimulated with only recombinant human tpo ( ng/ml). after , and days, the mk fraction was selected by immunomagnetic sorting from the non-mk fraction using an anti-cd a monoclonal antibody. rna-seq-derived gene expression data was performed on uncultured samples (day ), cultured but unselected samples (day ), and cultured, selected samples (day , and ) by using the next-generation sequencing (ngs) platform, and rq-pcr technology was used to verify the expression of transcription factors. results: the comparison of the transcriptome profiles among the five stages showed that a massive gene expression change occurred in megakaryocytes differentiation. a total of genes were detected, of which showed up-regulation and down-regulation. among these genes, differentially expressed genes (degs) (fold change ≥ ; false discovery rate < . ) were selected were further validated with rq-pcr, including gabre, cdhr , wasf , pkhd l , thbs , pf v , lrrc and lgals . the rq-pcr result indicated that the mrna expression level increased with the prolongation of culture time. however, pf v mrna expression level was highest at day , lgals was highest at day . summary/conclusions: conclusion: our study identified a series of genes that may participate in the regulation of megakaryocytes differentiation. these results should serve as an important resource revealing the molecular basis of megakaryocytes differentiation and thrombocytopoiesis. preoperative anemia and blood transfusion requirement during hip and knee surgery rambam health care campus, haifa, israel background: blood transfusion (bt) is independently associated with increased morbidity, mortality and hospitalization length across different patient populations. due to bt-related risks, the concept of "patient blood management" (pbm) has been introduced to clinical practice. the three pbm pillars are: optimizing red cell mass, minimizing blood loss and optimizing physiological reserve. bt indications during orthopedic surgery include excessive bleeding or hemodynamic instability and not the hemoglobin (hb) level. in most clinical scenarios, a restrictive transfusion threshold (hb level: - g/dl) appears to be non-inferior to the liberal transfusion strategy in terms of blood use, morbidity and mortality. similar results are observed in highrisk patients after hip surgery. we hypothesize that preoperative anemia may lead to blood product overuse and its complications. aims: evaluating potential correlation between preoperative anemia and bt requirement during hip or knee surgery. methods: we reviewed medical files of patients who underwent hip or knee replacement surgery at rambam between - . patients with hb level measurement within days pre-surgery were included. receiving > blood unit was considered a surgery complication and such patients were excluded. patient demographic and clinical data, including comorbidities, surgery type, length of hospital stay, were collected. we created a synthetic data cohort using mdclone healthcare data sandbox, an environment enabling fast data extraction and producing synthetic data for analysis that does not require irb approval. results: during the evaluated period, patients underwent hip or knee surgery; were excluded from the analysis due to receiving > blood unit. hb measurement within days pre-surgery was available for patients. hip or knee surgery was performed in ( %) and ( %) patients, respectively. women comprised % (n = ) of patients who underwent hip surgery. in the hip-surgery group, . % of patients required bt, with this need being slightly higher among women ( . % vs. . %; p-value=ns). only ( %) patients were transfused during knee surgery and this cohort was not further analyzed. patients receiving bt had a significantly lower mean hb level than those who didn't require it ( . g/dl versus . g/dl for women and . g/dl vs. . g/dl for men; p-value < . ). hospitalization was longer in transfused patients compared to non-transfused ones (mean . vs. . days, p-value = . ) and in patients with a low hb level (female < , male < . ) than in those with a high hb level, irrespective of receiving bt (p-values < . ). patients with at least one of the following diagnoses: diabetes, renal failure, ischemic heart disease, were significantly more likely to have a lower preoperative hb level (p-value < . ). no other factors (e.g., patient's weight, rdw value or blood pressure) were predictive of transfusion need. the probability of a need for blood unit was . in the hb g/dl group and . in hb g/ dl group ( %>reduction). summary/conclusions: anemia presence before elective hip surgery is a risk factor for bt requirement and longer hospitalization. diagnosis and management of anemia using timely pre-surgery consultations may minimize intraoperative bt, particularly in women and patients with comorbidities. real-patient data and prospective trials are warranted. abstract withdrawn. abstract withdrawn. background: cd , known as platelet glycoprotein iv, belongs to type b scavenger receptor and is related to the pathogenesis of many diseases. type i cd deficiency was cd not expressed on platelets and monocytes. individuals with type i deficiency can produce homologous antibodies and cause related immune diseases. in recent years, it has been reported that cd deficient individuals cause fetal immune thrombocytopenia with fetal edema syndrome in asia. cd is not expressed in mature rbc, but exists in hematopoietic stem (progenitor) cells. anemia is an important cause of edema. in view of the phenomena of clinical and animal experiments, cd + hematopoietic stem (progenitor) cells were cultured in vitro to observe the effect of anti-cd monoclonal antibody on cd + hematopoietic stem (progenitor) cells. aims: to investigate the effect of anti-cd monoclonal antibody on proliferation and differentiation of human cd + hematopoietic stem (progenitor) cells in vitro. methods: choose healthy full-term maternal women without various obstetric complications, take cord blood ml. after density gradient centrifugation of ficoll cell separation solution, cd + hematopoietic stem (progenitor) cells were sorted by flow cytometry and cultured for - generations. mtt was used to examine the effect of anti-cd monoclonal antibody on the growth of hematopoietic stem (progenitor) cells. flow cytometry analysis was used to detect the apoptosis and cell cycle of cd + hematopoietic stem (progenitor) cells. the effect of anti-cd monoclonal antibody on the formation of cfu-e/bfu-e in hematopoietic stem (progenitor) cells was analysis by cfu-e/bfu-e account after - days culture. results: after umbilical cord blood was isolated by ficoll to obtain mononuclear cells, the hematopoietic stem (progenitor) cells of cd + were sorted by flow cytometry, and about . % of cd + hematopoietic stem (progenitor) cells were isolated. different concentrations of anti-cd monoclonal antibody and hematopoietic stem (progenitor) cells were cultured in vitro. the od value of value ( . ae . ) of anti-cd monoclonal antibody group ( mg/ml) was decreased than normal group ( . ae . ) (p < . ), and the od value ( . ae . ) was significantly decreased at the cd monoclonal antibody concentration of mg/ml (p < . ). there was no significant difference between the hematopoietic stem (progenitor) cells culture group and the igg control group (p > . ). in the annexin v flow detection, the apoptotic rate of anti-cd monoclonal antibody group ( mg/ml) was statistically increased than the normal group (p < . ). anti-cd monoclonal antibody significantly induced hematopoietic stem (progenitor) cells to undergo s phase cell reduction, g phase cells increased, and g /s phase cell arrest occurred. the number of cfu-e/bfu-e clones in the normal group was ae , the number of cfu-e/bfu-e clones in the control group was ae , and the number of cfu-e/bfu-e clones in the anti-cd monoclonal antibody culture group was ae . the number of colonies formed by hematopoietic stem (progenitor) cells in the anti-cd monoclonal antibody culture group was significantly lower than that of the other groups (p < . ). summary/conclusions: anti-cd monoclonal antibody can reduce the proliferation of human cd + hematopoietic stem (progenitor) cells and reduce the ability of erythroid differentiation. background: recently the new modern collection techniques were introduced in the apheresis procedures. cobe spectra system was replaced with spectra optia, and it was necessary to verify the efficiency of spectra optia in pbpc collections. aims: the aim of the study was to evaluate and optimize the new cmnc protocol spectra optia v. (terumo) for pbpc collections in patients with haemato-oncological malignant diseases. methods: the results of autologous pbpc collections were evaluated in: (a) well mobilized patients with precollection cd + cells concentration in blood higher than /ll, (b) from only the first collections, which were performed either by the use cmnc spectra optia v. or cobe spectra v. , v. , terumo (c) collections were performed in the standard and large volume leukapheresis regimen, lvl. engraftment data in transplanted patients were assessed. results: standard collections were performed in patients. the yield of cd + cells was high, and no significant differences were found between the numbers of cd + cells prepared from spectra optia , ( , - ) and cobe spectra , ( , ) /kg b. w. (a = , ; pval , ). the dependence of cd + cell yield on the precollection concentration of cd + cells in blood can be considered as linear with high correlation coefficients in cmnc spectra optia r = , , and cobe spectra r = , . lvl collections were performed in of patients, and there were no significant differences between the numbers of cd + cells prepared by cmnc spectra optia , ( - , ) and cobe spectra , ( , - ) /kg b.w. (a = , ; pval , ). the relations between the precollection cd + cells concentration in blood and the numbers of cd + cells from collections can also be considered as linear with the correlation coefficients in cmnc spectra optia r = , , and cobe spectra r = , , respectively. in lvl, the median platelet loss was significantly lower in cmnc spectra optia ( %) than in cobe spectra ( %). a group of patients was transplanted by means of pbpc prepared in the standard regimen. median time in the neutrophil reconstitution was in cmnc spectra optia as well as cobe spectra days, while in platelets from cmnc days, and from cobe spectra days, respectively. the number of patients obtained pbpc from lvl. the median time in neutrophils and platelets reconstitution was in cmnc spectra optia as well as cobe spectra the same, and corresponded with and days, respectively. summary/conclusions: cmnc protocol spectra optia is a modern, efficient and the safe system, which can be used for both standard and lvl procedures. in well mobilized patients the sufficient dose of cd + cells for transplantation could be prepared from one standard or one lvl procedure. no serious adverse reaction have been observed. background: peripheral hematopoietic stem cells are collected from patients/donors after mobilization with g-scf. the aim of the collection is a fixed number of cd + cells/kg. this number depends on the pre-apheresis cd + number, the blood processed and the collection efficiency of the procedure. the aim should be to collect all the requested cells in day, whenever possible. this is in order to reduce the dose of g-csf given to donor/patient and the resources used in the collection centre. the only parameter that can be adjusted is the volume of blood processed, if this is increased, the likelihood of collecting the requested amount of cells is increased, but only if the pre-apheresis cd number is high enough. therefore, you need to know, when it is feasible to increase the volume and thereby increasing the time of the procedure with the intention to collect all the requested cells in day. it can also show if it is possible to reduce the volume of blood processed, thereby reducing the time of the procedure. aims: to develop an easy tool to calculate the volume of blood processed in order to collect the requested cells in day. methods: the mean collection efficiency (ce) was calculated. ce is calculated as cd + cells collected/(pre-apheresis cd + number*processed volume)* %. based on the mean ce, an excel sheet was generated to calculate the volume of blood that should be processed in order to collect all the requested cells. the excel sheet is designed so the user enters the pre-apheresis cd + number, patient weight and the requested number of cd + cells. the ce is fixed according to the mean ce calculated. the result is the volume of blood processed in order to collect the requested yield. based on that result, the apheresis machine will provide time for the procedure, thereby it is possible to evaluate if the collection can be finished in day or not, e.g. by increasing the volume of blood processed. spectra optia â was used for all collections, cmnc for allogeneic donors and mnc for autologous patients. results: mean ce = % (n = ). a ce of % was chosen as the cut-off for the cd calculation tool. using the cd calculation tool: allogeneic donors (n = ): mean ce = %, mean blood volume processed = . tbv, mean time: min, donors were finished in day collection ( %) autologous patients (n = ): mean ce = %, mean blood volume processed = . tbv, mean time = min, patients were finished in day ( %). the calculation failed in only case ( . %). in this case the volume of blood processed was reduced according to the calculation, but because of unexpected low ce, the requested number of cells was not achieved. summary/conclusions: the cd calculation tool based on an excel sheet has shown to be simple and easy to use in order to personalize the stem cell collection. immunotherapy products: blood product, pharmaceutical, or a new category all together? from till . all donors were hla typed and matched; they were fully informed on the donation procedure and signed an informed consent for donation. minimum dose required to ensure successful and sustained engraftment was /kg cd + cells and /kg mono-nucleated cells (mnc). pbsc harvesting was performed with continuous flow cell separator baxter c , cobe spectra and spectra optia using conventional-volume apheresis processing the - . total blood volumes per apheresis. a femoral catheter was used for harvesting and acid citrate dextrose formula a is used for anticoagulation. recombinant human granulocyte colony-stimulating factor (g-csf) is used to mobilize pbpc for collection. harvesting of pbsc is usually performed after to days of g-csf subcutaneous administration at a dose of lg/kg body weight. results: all the donors were siblings of the patients treated at the university hematology hospital. there were apheresis procedures performed in healthy sibling donors. there were males and females, aged - . one to two apheresis procedures were required to collect adequate graft. the single procedure usually took - h and the volume of collected stem cells was - ml. the needed number of mnc and cd + cells was successfully collected by . apheresis. there were abo incompatible donors. procedures for mobilization and collection of pbpc from healthy donors are generally well tolerated. the only adverse effects of the apheresis procedure were bone pain as reaction of g-csf and numbness of the extremities as reaction of acd-a (hypocalcemia), which occur rarely and were very mild. the collected pbsc were used in allogeneic stem cell transplantation in patients with: acute myeloid leukemia - patients ( . %), acute lymphoblastic leukemia - patients ( . %), chronic myeloid leukemia - patients ( . %), myeloproliferative disorders - patients ( . %), myelofibrosis - patients ( . %), severe aplastic anemia - patient ( . %), non-hodgkin lymphoma - patient ( . %), multiple myeloma - patient ( . %), chronic lymphoblastic leukemia - patients ( . ), hodgkin disease - patient ( . %). summary/conclusions: the apheresis collection of pbsc in healthy donors is an effective and safe procedure. we are developing our national stem cell donors registry as a part of bone marrow donors worldwide. in that way we hope we will help widen the world network of stem cell donors and enlarge the possibility for each patient to find the right match. background: leukocyte-removing filters for blood are being used widely as a universal leukocyte reduction policy is being adopted progressively throughout the world. filtration is one of the most effective methods for preventing various adverse transfusion effects caused by leukocytes included in blood components, such as febrile reaction, alloimmunization, and transmission of leukotropic viruses. aims: the goal was to evaluate whether the new domestic blood filter finecell, developed by kolon industries, gumi, korea, is appropriately suited to the international standards. and to reveal its efficacy and safety in the settlement of leukocyte reduction system in korea. methods: thirty-two units of packed red blood cells obtained from ml whole blood collected from healthy donors were used. this was done by analyzing the filtration time, residual leukocyte count, rbc recovery, and hemolysis rate during a storage period of days after leukoreduction. results: the standards commonly used for the evaluation of leukocyte-removing filters are set by the food and drug administration of the usa and the council of europe. the results of our study satisfied these international standards. summary/conclusions: the newly developed domestic leukoreduction filter was, thus, found to be efficient and will contribute to the improvement of the quality of isolated blood components used in korea. faculty of science, humanities and education, technical university of liberec, liberec, czech republic background: as polymeric fibrous scaffold fabrication techniques strive to create structures that more closely replicate tentative extracellular matrix form and function, the need for increased scaffold bioactivity becomes more pronounced. the fibrous structure made from biocompatible and nontoxic polymers ensures mechanical stability, however cell proliferation requires further stimulation. platelet-rich plasma, which has been shown to contain over bioactive molecules, has the potential to deliver a combination of growth factors (gfs) and cytokines capable of stimulating cellular activity. aims: the presented work deals with the preparation of nanofibrous materials with platelet growth factors incorporated into the internal fiber structure. polyvinyl alcohol (pva) was used for the preparation a material providing a progressive release of native gfs without need of subsequent crosslinking. methods: materials were prepared from pva (mw , , % of hydrolysis) using electrospinning technology (nanospider tm ws u). platelet lysate (pl) was prepared from thrombocyte rich solution (obtained from regional hospital in liberec, the concentration of - x plt/ml, freeze-thaw method with subsequent centrifugation). nanofibers were electrospun from % pva solution using water: ethanol ( : ) solvent system. materials with proteins were electrospun from solution containing % of pva and % of pl. morphological analysis was performed by scanning electron microscopy. protein release was monitored using spectrophotometry (bradford method) and chromatography. results: the prepared fibrous materials consisted of random oriented end-less fiber with smooth surface with minimal defects in structure. the morphology of materials was not altered by the addition of proteins. the average fiber diameter was: ae nm for pristine pva fibers and ae nm for pva with incorporated proteins (pva/pl). pva/pl layers contain - mg of protein per gram of pva. % of the proteins are released during the first day (burst release) followed by a gradual release of up to weeks. summary/conclusions: nanofibrous pva-based nanofiber materials were prepared with native growth factors. the process used for the preparation of solutions and subsequent spinning does not affect the activity of the incorporated proteins, which are being gradually released. therefore, we believe that the developed material has great potential for use in tissue engineering e.g. to promote healing of chronic wounds. acknowledgements: supported by the czech health research council, project no nv - - . background: human a-defensins are small cationic peptides with antimicrobial and anticancer activity. up till now, six a-defensins have been described in humans. they include the human neutrophil peptides (hnp) , and which present in large amounts in neutrophil azurophilic granules and differed from each other only in the first amino acid. a fourth defensin, termed hnp- , comprises less than % of the total defensins in neutrophils and has a distinct sequence from hnp - . the other two, human defensin and , are synthesized mostly by intestinal paneth cells. neutrophil defensins (hnp - ) are . kda peptides that are characterized by three disulfide bridges. the pattern of disulfide bonds in the mature forms is crucial for the functional properties. due to this structural feature, synthesis of defensins using the chemical and recombinant approach presents quite a challenge. moreover, purification from the natural source can be very difficult because the large number of neutrophils is needed to obtain a sufficient amount of protein. in blood banks, leukocyte reduction filters are used to remove leukocytes from blood components in order to prevent adverse transfusion reactions. leukofilters contain high numbers of normal human cells and discard after use. aims: the aim of this study was to purify a-defensins from neutrophils trapped in leukocyte reduction filters. methods: blood bags from healthy blood donors were collected after written consent. all donors were screened for infectious diseases (hbv, hcv and hiv) and negative samples were included in the study. blood bags were filtered at °c by leukoflex lst- filters. the cells were extracted from the filters by back-flushing with cold phosphate buffered saline (pbs), ph . , without mgcl and cacl , containing mm edta and . % sucrose. the pbs was homogenized with the filter content and then collected in a sterile tube. neutrophils were separated from mononuclear cells by ficoll. isolated neutrophils resuspended in pbs x at a concentration of cells/ml. for degranulation, cells were stimulated with nm of formylmethionyl-leucyl-phenylalanine (fmlp) for min followed by stimulation with lm of cytochalasin b for min. supernatant was collected by centrifugation at g for min. supernatant was incubated with mouse monoclonal antibody to hnp - and purification of hnp - was performed by lmacs protein g microbeads system. the presence of protein was confirmed by western blot. results: the presence of the . kda band was confirmed by western blot, which corresponded to the size of the a-defensins. summary/conclusions: the development of defensins as therapeutic products requires access to a steady supply of neutrophils. our results indicated that lst- filters are economical source for purifying a-defensins. anatomical sciences, abadan school of medical sciences, abadan, iran background: epigenetic reprogramming of terminally differentiated cell can modify somatic cells to a pluripotential state. there are several approaches that induce pluripotency in somatic cells. exposure the cells with the embryonic stem cell extract is an easy way, and some investigations were done on fibroblast cell line. however, its efficiency was low aims: the purpose of this study was to increase the number of reprogrammed granulosa cell as a full differentiated cell into pluripotential state methods: the human granulosa cells were cultured in the medium containing -aza-deoxycytidine and trichostatin a. then, the cells were exposed to mouse escs extract and co-cultured with mouse embryonic fibroblast in the presence of leukemia inhibitory factor (lif). alkaline phosphatase test and also immunohistochemistry staining for oct , sox and nanog were performed after and h and week results: the results indicated that after h the granulosa cells were revealed a round and expanded morphology. the cells in all groups except in negative control, were showed alkaline phosphatase activity. the cells that were cultured in medium containing -aza-deoxycytidine and trichostatin a and exposed to the extract had the most numbers of alkaline phosphatase positive cells. immunocytochemistry showed the granulosa cells that were cultured in medium containing -aza-deoxycytidine and trichostatin a with extract expressed oct with weak intensity after h. no expression of oct , sox and nanog were observed in other groups at the same time. after h, oct , sox and nanog were over expressed in the cells that were treated with -aza-deoxycytidine, trichostatin a and extract. furthermore, there was high expression of oct in the granulosa cells that were cultured in medium containing dmso and exposed to the extract. after one week, the expression of oct and sox in the granulosa cells that were cultured in medium containing dmso and exposed to the extract was continued while its expression ceased in the other groups. the expression of nanog were ceased in all groups after one week summary/conclusions: present study revealed that the inhibitors of the methyl transferase ( -aza-deoxycytidine) and histone deacetylase (trichostatin a) could delete the epigenetic markers and improved cells reprogramming by administration of the extract abstract withdrawn. abstract withdrawn. abstract withdrawn. background: mesenchymal stem cells (mscs) are adherent spindle shape cells expressing different surface markers. they show special criteria including, paracrine effects, differentiation to several tissue cells, migration, immunomodulatory and regenerative potentialities. mscs are isolated from different sources and employed as therapeutic tools to treat several diseases and injuries. however, some of mscs properties including secretion of growth factors and migration ability are controversial especially during remission or in presence of tumor. interestingly, msc-derived compartment could be used as practical tools in term of diagnosis, follow up, management and monitoring of disease instead of intact mscs. exosomes are kind of extracellular vesicles (evs) characterized via their size and releasing mechanism. usually they defined as less than nm in diameter vesicles. they secreted from different cells and are also found in urine, blood, breast milk, cerebrospinal fluid and other body fluids. exosomes contain genetic material including dna, mrnas, micrornas (mirnas) and other biomolecules. mirnas are single stranded non-coding rnas transcribed from dna. immature mirnas are subjected to two known cleavages to modify to mature mirna that involve to either mrna degradation and gene expression process or cell-cell interaction and communication via secretion as the part of exosomes. aims: this study was aimed to discuss some aspects of exosomal micrornas derived from mscs in progression, diagnosis and treatment of some diseases. methods: different scientific data bases including pubmed, google scholar and scopus were used to find and review related articles. results: evs play important role either in intercellular communication related to pathological and physiological situation or intracellular communication, angiogenesis, immune system modulation and metastasis progression. mirnas could regulate expression of multiple mrnas then they play important role in different biological processes and contribute cell-cell interaction as well as influence in the progression of different disease. exosomal mirna-derived mscs are involved in cancer procession, tumor growth, angiogenesis and metastasis. they are used as diagnosis and therapeutic tools to treat different diseases such as renal failure, liver fibrosis, myocardial infarction. summary/conclusions: due to controversial aspect of using of intact mscs especially during remission or in presence of tumor, msc-derived exosome could be used as practical tools in term of diagnosis, follow up, management and monitoring of disease instead of intact mscs. aims: the aim of study try to use sybr green i based real-time pcr to identify homozygous, heterozygous, gene deletion or wild type for rhd exon , , and a. methods: for this study, we used real-time pcr with high resolution melting curve mode, and matrix mix containing sybr-green i were used for sequence specific primers of g>a and rhd exon , , . samples with rhd gene deletion homozygous/heterozygous, g>a heterozygous with rhd gene deletion and normal rhd, normal rhd homozygous/heterozygous and rhd -rhce( - )-rhd homozygous/heterozygous were enrolled in our study. all samples were screened using rhd exon genotyping, sanger sequencing and rhesus box analysis. concentration and mass of dna samples were in alleles of normal rhd/rhd gene deletion. the tm ratio of rhd exon ( °c) to internal control ( °c) were . in alleles of normal rhd/rhd -rhce( - )-rhd , . - . in alleles of rhd gene deletion/normal rhd, . - . in alleles of normal rhd and < . alleles of rhd gene deletion. the tm ratio of rhd exon ( °c) to internal control ( °c) were . in alleles of normal rhd/rhd -rhce( - )-rhd , . - . in alleles of rhd gene deletion/normal rhd, . - . in alleles of normal rhd and < . alleles of rhd gene deletion. the tm ratio of rhd exon ( °c) to internal control ( °c) were . in alleles of normal rhd/rhd -rhce( - )-rhd , . in alleles of rhd gene deletion/rhd -rhce( - )-rhd . - . in alleles of rhd gene deletion/normal rhd, . - . in alleles of normal rhd and < . alleles of rhd gene deletion. summary/conclusions: using the tm ratio of sequence specific primers to internal control is an effective way to detect the rhd gene deletion or rhd weak d types , and not detected") were tested with a method based on next generation sequencing (ngs) using the illumina miseq platform to detect a possible rhd variant not interrogated by id rhd xt. results: in total dna samples were tested in pools. fifteen ( ) pools ( samples) gave rhd deletion genotype and seventy two ( ) pools ( samples) resulted to the presence of rhd gene. the positive pools were also analyzed individually. the genotype results obtained were: rhd exon no amplification ( ), rhd exon and the genotype results obtained with id rhd xt (in pools and individually) were concordant with the results provided by the centers. hence, % accuracy was obtained using id rhd xt with dna pooled samples. the results of rh ngs for the samples with inconclusive results by id rhd xt showed rhd variants previously described: sample rhd* - inst (del), sample rhd*ivs + g (del), samples rhd*weak d type (partial d), sample rhd*weak d type (weak d), sample rhd*weak d type (weak d) and not described: sample rhd*del - (unknown) summary/conclusions: id rhd xt is a high accurate tool for genotyping the most common rhd alleles associated to weak d and d negative phenotype in up to pooled dna samples. use of rhd genotyping improve rhd typing in blood donations variant rhd alleles generate qualitative/quantitative alteration in serological expression of d antigen such as weak and partial rhd phenotypes which are clinically important in transfusion setting. population studies have shown varied distribution of the variant d alleles in caucasians, africans, east asians and indians. many countries have developed their own population-specific strategy for identifying d variants. our previous study in indian population showed absence of weak d type , , and which are commonly found in caucasians d variant individuals. instead, a novel population-specific pattern i.e.~ -kilobase duplication event, including exon , was predominantly identified in . % d variant samples. functional analyses showed that this genetic variation results in the expression of several transcripts, including a wild-type product. commercial genotyping assays available, mainly detect common d variants found in caucasians and africans, thus limiting its usefulness in india. hence, based on our findings we have designed a multiplex pcr assay specific for indian population that can be easily implemented at the laboratory level for genotyping variant rhd. aims: to characterize rhd variants using "indian-specific, rhd genotyping assay". methods: seventy samples referred to our laboratory for molecular characterization of rhd variants were included in this study. all rhd variant samples were serologically typed for results: out of the rhd variants included in this study, samples ( %) showed presence of indian specific allele i.e. exon duplication. seventeen rhd variants samples showed presence of both exon and . qmpsf analysis of these samples excluded involvement of rhd-rhce-rhd hybrids. sixty of the seventy d variant individual had r r genotype this assay thus can be used routinely in indian laboratories to identify and characterize rhd variants. - non-invasive fetal kel genotypes from allo-immunized anti-kel women were done ( positive confirmed fetuses, undetermined, positive non-confirmed, negative non-confirmed and negative confirmed). - non-invasive fetal rhc genotypes from allo-immunized anti-rh women were done non-invasive fetal rhe genotypes from allo-immunized anti-rh women were done ( positive foetuses, undetermined for , % of the allo-immunized women, the pregnancy was compatible and no specific antenatal monitoring was necessary summary/conclusions: non-invasive fetal red blood cell genotype is a powerful tool to diagnose a feto-maternal red blood cells incompatibility and allows to legitimize a costly and heavy specific antenatal monitoring s purchla-szepioła , m krzemienowska , m pelc-kłopotowska , m jurkowska , m debska , m uhrynowska and e brojer the test developed by ihtm has been offered to clinicians and pregnant women since but it is not covered by the health care system. rhd nipt is not informative for mothers with rhd variant. in such cases further analysis of the molecular background is offered to exclude from immunoprophylaxis the women with weak rhd type , and . aims: summary of a -year period of routine rhd nipt available at ihtm. methods: cffdna isolated using easymag, biomerieux from plasma of pregnant women determined with standard serology as rhd-negative (in - week of gestation) was examined for the presence of exons and of rhd and ccr by realtime pcr using lc ii (roche). maternal dna from whole blood was tested for identification of rhd variant using rbc fluogene rbc-dweak/variant (inno-train, germany) or the home-made protocol. results: in cases the rhd gene was not detected in cffdna and the administration of rhig was not recommended. in seven cases ct-values for rhd and ccr indicated a maternal d variant (d ct ccr -rhd > ); the genetic follow-up of six of them identified: rhd* w. in cases, rhd* w. and rhd* . in cases the rhd nipd results indicated that a fetus is rhd positive and rhig administration was recommended it was recommended in the remaining % of mothers. in . % cases with maternal d variant rhd nipt was not possible. however, in / such cases the test is unnecessary because follow up analysis revealed maternal rhd variant of the weak d type and in switzerland extended antigen-matching for duffy, kidd and mnsbesides rhesus and kell -is recommended for sickle cell disease (scd) patients. the ethnic diversity of red blood cell (rbc) antigen polymorphism engender that these patients are often transfused with rbcs from donors of african origin. this strategy, however, increases the likelihood of being exposed to certain low-prevalence antigens, such as rh (d w ), as these are almost exclusive to african populations. rh is encoded by several types of rhd*dv as well as by dau- . anti-rh is associated with delayed hemolytic transfusion reactions (htr) aims: here we report a specific low-prevalence antibody newly formed by the same patient, meanwhile gravida , para , causing positive crossmatches with the rbcs of two of the four selected donors. subsequently, advanced serologic and genetic workup and close international collaboration enabled optimal patient care. methods: standard serological methods were used for antibody specification (biorad, cressier, ch and in-house). crossmatches were carried out by indirect antiglobulin test at °c. molecular typing of donors' and parental blood group antigens was performed by further serological analysis (institute national de transfusion sanguine, paris) revealed an anti-rh in addition to anti-fy , anti-e and anti-jk a . genotyping of the two donors causing positive crossmatches presented heterozygosity for rhd* . which encodes rh . the newborn's phenotype was a r r k-, fy(a-b+) and most likely rh -and jk (a+b+), considering both maternal and paternal (a r r, k-k+, fy(a-b+), jk(a+b-), rh -) predicted phenotypes. the neonatal serum contained maternal anti-a , anti-rh and anti-e. the direct antiglobulin test was positive but elution only showed nonspecific reactions with papain-treated cells. latter might have been caused by anti-fy during her present pregnancy we were able to demonstrate that two positive crossmatches of two former compatible donors were caused by a new alloantibody against a low-prevalence antigen, namely anti-rh , derived from several rh + rbc transfusions during the previous pregnancy. despite this challenging blood supply we were able to support the patient with a total of ten antigen compatible and crossmatch negative rbc units from french and swiss donors until delivery with increasing age, the relative number of women in the study population raise from % in the patients younger than years to % in the patients older than years. our study showed that cardiovascular diseases were the commonest indications for warfarin use in older patients with %. only , % achieved target therapeutic range while the risk of thromboembolism and the subsequent need for proper anticoagulant therapy increases sharply with age, the bleeding risk rises as well. older patients are more sensitive to any given dose of warfarin and need a significantly lower total weekly dose. a well-informed patient provides one of the best defenses against bleeding complications. recent data demonstrate doacs advantages over warfarin, especially for older population: more predictable dosing, fewer drug interactions and reduced risk of intracranial bleeding although vast majority of fh cases are caused by mutations in ldl-r gene %- % patients do not harbor genetic cause in the known loci. patients with homozygous/severe heterozygous fh are unresponsive (ldlc above mg/dl with diet and drug therapy) and require additional extracorporeal therapy to reduce ldlc concentrations to prevent the development/progression of cad. ldl apheresis techniques remove apolipoprotein b-containing lipoproteins from blood and include heparin-induced extracorporeal ldl precipitation(help), immunoadsorption, dextran-sulfate adsorption methods: a y iraqi male visited cardiac-opd. ct coronary angiogram showed cad-dvd. he had multiple tendinous xanthomas and xanthelasmas. family history was significant for death of elder brother from coronary event at y, a sister with similar profile age y and one sister apparently normal. he was taking medical treatment for dyslipoproteinemia (ecosprin mg od, ticagrelor mg bd, rosuvastatin mg od). despite dietary and medical treatment his dyslipoproteinemia was refractory. therefore cascade-filtration was planned with evaflux a plasma fractionator. one procedure of cascade plasmapheresis was done on com.tec apheresis system (fresenius kabi, germany) separating patient's plasma as the first step and passing it through a pore sized based filter column a (evaflux, kawasumi, japan) as the second step. a total of . x plasma volume( ml) was processed. the patient was given continuous calcium infusion. the flow rate of ml/min was maintained immunoglobulins) were not assessed. summary/conclusions: the procedure successfully met the requirement of reduction of cholesterol by %. the patient became responsive to the medical treatment. follow up of the patient up to a year has been uneventful with no additional procedure requirement actions included development of major haemorrhage protocols with improved communication and required instances of delayed transfusion to be reported to the uk national haemovigilance scheme (serious hazards of transfusion, shot) methods: delayed transfusion data have been collected from . hospitals identify incidents and report them via an online database. mh may also result in avoidable or overtransfusion. reports are analysed and collated data published in the shot annual reports in july each year. results: the total number of reports of delayed transfusion has increased with time: , , in the last years. delayed transfusion in relation to mh was reported for cases - contributing to death in patients %) miscommunication was noted between clinical different teams, between emergency departments, porters and the transfusion laboratory, failure of bleeps, failure to communicate the urgency, failure to confirm the patient location. failures to follow mhp correctly occurred in / ( . %): incorrect activation including failed alerts to porters, wrong contact telephone details and wrong components in the mhp packs most transfusions included red blood cells (median, units); % of women were transfused with fresh frozen plasma (median, units) and % with platelets. mean pre-and post-transfusion hemoglobin levels were . g/dl and . g/dl, respectively, representing an increment of . g/dl per rbc unit transfused ( . g/dl in soweto and . g/dl in durban). indications for transfusion included obstetric hemorrhage ( %), chronic anemia ( %), surgery or anesthesia ( %), other ( %) and not specified ( %). transfusion for chronic anemia (vs. hemorrhage) was associated with gestation ≥ weeks (odds ratio = . , % confidence interval . - . ). surgical blood loss was a common indication in trimester ( %) that declined to % then % in trimesters and . summary/conclusions: hemorrhagic complications accompanying spontaneous abortions and ectopic pregnancies in the first and second trimesters were the most common reasons for antenatal transfusion surveillance and analysis of blood transfusion reactions represents inseparable part of hemovigilance. aims: summarization of data on reported cases of transfusion reactions. methods: analysis of serious undesirable reactions to blood products administration in the czech republic (cr) during period - . results: there were evaluated , of blood products administrations in , patients in the cr during defined three years period. announced , ( , %) transfusion reactions including severe transfusion reactions ( adjudged with grade ). the most frequent types of severe transfusion reactions: anaphylaxis , trali x, taco x, hcv x, hbc x, bacterial infection x, delayed hemolysis x. transfusion reactions incidence according to administered bp: red blood cells products: , administrations, transfusion reactions (fnhtr x, allergy x, circulatory overload x, anaphylaxis x, trali x, hbv x, hcv x) platelets: , thrombocyte administrations, including transfusion reactions (allergy x, fnhtr x, anaphylaxis x, circulatory overload x, delayed immune hemolysis x, acute circulatory overload x. granulocytes: administrations, transfusion reactions plasma: , administrations, reactions reported (allergy , fnhr , circulatory overload , anaphylaxis x, trali x, hbv x, ards x. summary/conclusions: conclusions: comprehensive analysis and data processing help to appropriate prospective setting of blood products (bp) production and hemotherapy. concrete outputs from processed data triggered undermentioned changes in many departments in the cr: . plasma for clinical uses from male blood donors, . prestorage of leucocyte reduced blood products, . production of platelets in additive solutions, . implementation of pcr testing method for blood donors screening. background: skae's basic activities include epidemiological surveillance of all adverse events (aes) associated with deviations in the collecting, testing, processing, storage and distribution of blood and blood components that may affect quality and safety near misses" and "uneventful transfusion errors" are collected to identify preventable causes. incorrect blood component transfused (ibct) events are reported following ihn instructions. results: a total of they were mainly associated with deviation in processing ( . %) and attributed to equipment failure and materials ( %) whole blood collection, materials and distribution, as a result of product defect, equipment failure, human error and other. trend analysis showed a significantly increasing (p < . ) annual rate of total aes by % ( % confidence interval - ) ) % fibrinogen-depleted phpl or ( ) % fibrinogen-depleted phpl plus heparin. internalization of fluoresceinamine-labeled heparin in stcs was investigated by flow cytometry and immunocytochemistry. all stromal cells were subjected to whole genome expression analysis (affymetrix human gene . st array) and data were analyzed using r/bioconductor and panther analysis tools. confirmative qrt-pcr was performed and protein levels of selected pathways were analyzed by a bead-based western blot system (digiwest â ). immunophenotyping, in vitro differentiation, longterm proliferation and colony forming units (cfu) assays were done for all cell types. results: in vitro exposure of heparin induced differential internalization and lysosomal accumulation in stromal cells, as well as regulation of distinct gene sets, both in a tissue-source dependent manner. affected signaling cascades were mainly involved in proliferation, cell adhesion, apoptosis, inflammation and angiogenesis. the influence of heparin on protein expression and phosphorylation of four pathways (wnt, pdgf, notch and tgfbeta) was further analyzed, revealing most alterations in bm-stcs. independent of origin and medium composition, flow cytometry analysis revealed the characteristic fibroblastoid phenotype profile (cd +/ +/ + and cd -/ -/ -/ -/hla-dr-). in addition a comparable osteogenic and adipogenic differentiation capacity was found summary/conclusions: internalization of heparin in lysosomes by stromal cells, differential gene and protein expression and phosphorylation changes were observed in a tissue-source dependent manner. however, stromal cell characteristics as immunophenotype pattern, long-term proliferation, clonogenicity and in vitro differentiation were unaffected, putatively by post-translational protein modifications. in this respect, application of porcine heparin is compatible with efficient manufacturing of stromal cell based medicinal products abo incompatibility may have no effect on the clinical outcome after allogeneic hematopoietic stem cell transplantation. however, it carries additional risks of hemolytic reactions, delayed red blood cell (rbc) engraftment and incidence of graft-versus patients were categorized according to abo compatible and mismatched groups; these were further sub-categorized into major, minor and bidirectional. direct coombs test (dct) was performed when hemolysis was suspected in the post-transplantation period along with serum lactate dehydrogenase (ldh) %) were male and ( . %) female. mean age of abo matched and mismatched groups were ( . ae . ) years. most common indications for transplant included beta thalassemia major ( . %), aplastic anemia in ( . ) and pure red cell aplasia ( . %). source of stem cell was bone marrow in and peripheral blood patients abo matched while abo mismatched group comprised of ( . %) patients with further subdivision into major (n = ), minor (n = ) and bidirectional in the post transplantation period, packed red blood cell and platelets were transfused in matched group (n = ) and (n = ) comparably(n = ) and (n = ) in mismatched group. primary and secondary graft failure in matched group was . % and . % patients while in mismatched group graft failure was observed in ( . %) patients respectively. positive dct in abo matched group in ( . %) patient, whereas ( . %) patients with major and minor abo mismatch group with raised ldh levels and deranged lfts were found. episodes of acute and chronic gvhd in abo compatible and incompatible groups were insignificant. overall survival in abo summary/conclusions: these results indicate that abo incompatibility does not seem to influence outcome of the patients undergoing allogeneic hematopoietic stem cell transplantation. careful monitoring of patients can help detect problems early and treat them efficiently, thus, reducing the number of life threatening events a picascia , c sabia , f cavalca , g nicoletti and c napoli in our routine work with one lambda sab class ii reagents, we observed non-specific reactivity with some beads bearing dr and dr in patients without sensitizing events. this pattern was not confirmed by testing same sera with screening-and pra-beads suggesting non-specific reactions. aims: here, we sought to determine if fetal bovine serum (fbs) treatment would be effective in reducing/eliminating non-specific reactivity. methods: we tested sera pre-treated with fbs from non-sensitized patients that showed the dr /dr pattern. in particular, ll of fbs was added to ll of patient serum; incubated for min at °c; centrifuged and subsequently tested in the sab assay. as controls, we treated sera from patients with documented dsa including dr /dr and patients without hla antibodies. results: dr /dr non-specific reactivity was eliminated or significantly reduced after fbs treatment. we found that patients with dr and dr dsa had no change in mfi values and additional reactivity was not observed in negative fbs treated sera transfusion medicine, national blood transfusion centre transfusion medicine, national blood transfusion center transfusion medicine, national blood transfusion centre, tirana, albania background: abo blood group, has been associated with many diseases, although the explanation for abo's blood group association and some illnesses is still unclear. aims: to find the distribution of cases by blood groups in patients with malignant pathology compared to donors in order to assess the presence of the abo blood group as an epidemiological indicator to identify populations exposed to different malignant pathologies methods: we conducted a case-control study. abo blood group and diagnosis of all patients have been studied. the control sample was collected from , healthy donors from which group a ( , %), group o ( , %), b ( , %) and group ab ( , %) resulted. the study was conducted in patients who have been transfused and submitted a request to determine the blood group at the blood bank at qsut during the period - results: among the patients, when all malignant pathologies were taken together, the highest frequency was seen in blood group a ( . %), followed by ( . %), b ( . %) and ab ( . %). group a frequency was higher and o was lower compared to controls. a high incidence of blood group a is seen in: pancreatic cancer a ( %), in gastric cancer a ( %), colorectal cancer a ( , %), breast cancer a ( %), cervical cancer a ( %) and ovarian cancer a ( %) versus a ( . %) in the control group. a high incidence of blood b is seen in multiple myeloma b ( %) and cervical cancer b ( %) versus b ( . %) in the control group. blood group ab has a high incidence in malignant lymphoma ab ( %) versus ( . %) in the control group summary/conclusions: it appears that individuals with blood groups a, b and ab are more at risk of developing malignant pathologies and individuals with blood group o are more protected. background: the high homology and opposite orientation of rh genes promote many rearrangements between them and generate a large number of rhd and rhce variants which can be inherited together. several studies have shown that those rh variants in patients with scd represent an additional risk for alloimmunization and delayed hemolytic transfusion reactions (dhtrs), but little clinical or biological evidence related to alloimmunization and dhtr are presented for all the rh variant alleles. it is well established that transfusion recipients with the most common weak d types , and , are not at risk for forming alloanti-d when exposed to conventional rhd-positive rbcs. aims: we report here a case of a -year-old patient typed as weak d type , receiving d+ rbc units who presented anti-d in his plasma detected three weeks after the last transfusion. methods: rhd beadchip (immucor, nj, usa), was performed to identify the rhd variant allele associated with the weak expression of d. rhce genotyping was performed by laboratory developed tests. sequencing of rhd, rhce and rhag were performed to determine if there were other mutations that could explain the production of alloanti-d. serologic testing was by standard hemagglutination methods. the clinical significance of the antibody was evaluated by monocyte monolayer assay (mma). results: serological analysis showed a negative dat and the presence of anti-d in plasma ( + by gel). anti-lw was ruled out. rhd genotyping revealed the patient was rhd*weak d type . rhce genotyping predicted the d+c+c+e-e+ phenotype. sequencing of rhd, rhce and rhag found no additional changes and confirmed the presence of rhd*weak d type . mma showed the anti-d was clinically significant (> %). summary/conclusions: we report the production of alloanti-d in a scd patient with rhd*weak d type allele. weak d type patients are not considered to be at risk for allo anti-d but our results show that there are exceptions and that these anti-d can be associated with clinically significant rbc destruction. background: the mns blood group system is located on glycophorin a (gpa), glycophorin b (gpb) and hybrid glycophorins on the surface of the red blood cell (rbc). these glycoproteins are involved in complex structures interacting with other rbc surface proteins including the band /diego protein. the glycophorins are heavily glycosylated and contains multiple clinically significant blood group antigens. it has proved difficult to model the gpa extracellular structure due to its heavy glycosylation, and lack of homology with existing modelled proteins. aims: to develop an in silico model of gpa as a basis for improved predictions of structure function relationships methods: prediction of secondary structure and disorder: . . predictprotein (https://predictprotein.org); . . spider (http://sparks-lab.org/server/spider /); . . dsc (discrimination of protein secondary structure class): using an in-house implementation; . . jpred (http://www.compbio.dundee.ac.uk/jpred /); . . raptorx (http://raptorx.uchicago.edu). prediction of secondary structure: . . robetta (http://robetta.bakerlab.org/submit. jsp); . . falcon (http://protein.ict.ac.cn/treethreader/); . . itasser (https://zha nglab.ccmb.med.umich.edu/i-tasser/) threading methods to evaluate the quality of protein structures: . . verify d (http://servicesn.mbi.ucla.edu/verify d/); . . prosa (https://prosa.services.came.sb g.ac.at/prosa.php) protein-protein docking: . . gramm-x protein-protein docking web server (http://vakser.compbio.ku.edu/resources/gramm/grammx/); . . gramm (http://va kser.compbio.ku.edu/main/resources_gramm . .php) results: using in silico modelling we derived a stable tertiary glycosylated structure for gpa both as an individual protein and a homodimer. the hybrid glycophorin background: non-invasive prenatal testing of fetal antigen using cell-free fetal (cff) dna from maternal plasma of immunized women is widely implemented into clinical routine but the sensitivity and specificity of the method, especially for genotyping antigens encoded by single nucleotide polymorphisms such as k antigen, is limited by low proportion of cffdna in maternal plasma dna. according to literature reports detection of circulating tumour (ct)dna can be improved by selection of short ctdna fragments using automated electrophoresis methods. aims: the aim was to assess the feasibility for enrichment of cffdna fraction in maternal plasma dna by size selection using the pippin prep gel selection system. methods: plasma dna isolated using easymag (biomerieux) from rhd negative and k-negative pregnant women (n = ) carrying fetuses with known genotype was loaded into % agarose gel casette ( % df marker q , sage bioscience) and size selection of fraction was performed on a blue pippin tm (sage bioscience) with the elution from min to h min of electrophoresis. results for real-time pcr detection of fetal rhd, kel* and ccr (as a marker of total plasma dna) in dna fraction after gel selection were compared to results obtained from non-processed plasma dna. results: the total dna level (measured by ccr ) was significantly lower in dna samples tested after gel selection (from . to . geq/pcr) versus the level obtained from non-processed plasma dna (from to geq/pcr). the results for fetal fraction (measured by rhd) from dna samples of rhd-negative pregnant women carrying rhd positive fetus tested after gel selection were from , to . geq/pcr versus . - . geq/pcr for non-processed plasma dna. results for kel* detection in plasma dna from k-negative pregnant women carrying k-negative fetus were kel* -negative in dna samples tested after gel selection comparing to nonprocessed dna samples were false kel* positive amplification was observed. however, kel* detection in plasma dna from two k-negative pregnant women carrying k-positive fetus gave false kel* -negative results in dna samples tested after gel selection comparing to non-processed dna samples were kel* positive genotype was obtained. the total dna level in samples from k-negative women was from . to . geq ccr /pcr after gel selection versus from to geq ccr / pcr in non-processed dna samples. summary/conclusions: using the pippin prep gel selection system increases the proportion of cffdna fraction in total plasma dna by retaining long maternal dna fragments in the gel cassettes, but the protocol of gel separation dilutes the separated material decreasing the concentration of fetal dna and leading to false negative results of nipt. anti-rh quantification assay using ih- (bio-rad â ): promising results for monitoring rh:- pregnant women j beaud, h delaby, c toly-ndour, a mailloux and s huguet-jacquot centre national de r ef erence en h emobiologie p erinatale (cnrhp), hôpital saint-antoine, paris, francebackground: the generalization of immunoprophylaxis by anti-rh immunoglobulins since complicates the interpretation of the anti-red blood cell antibodies screening during pregnancy. to distinguish an alloantibody from a passive one, many laboratories in france use anti-rh microtitration. it is a column agglutination technology using red blood cells rh: , - , - , , (r r) . it permits to quantify low levels of anti-rh in comparison to a range of an anti-rh standard. performed since at the cnrhp and automated on evo clinical base tecan in (dilutions and distribution), anti-rh microtitration is well adapted to rh prophylaxis. aims: the aim of this study was to evaluate this technique on the ih- system from bio-rad â . methods: on ih- , the reactivity of the bio-rad â reagents was compared with the cnrhp reagents (red blood cells r r, anti-rh standard). the performances of the method were evaluated using three internal quality control (icq) ( cnrhp home-made at and ng/ml and bio-rad â at ng/ml) on papainized r r (plc) and native r r (nlc). a comparison of results from patient sera ranging from . to ng/ml was done between ih- and evo clinical base tecan. results: the results of the qci are similar between the different reagents used. there is no significant difference between the types of red blood cells except for the limit of detection: . ng/ml in plc - ng/ml in nlc. for the qci, the intra and interassay imprecision based on the dilution degree show coefficients of variation between and %, similar to those found with the evo clinical base. the correlation with the cnrhp technique performed on samples in plc and samples in nlc was satisfactory (deming plc: r = . y = . x + . -nlc: r = . y = . x- . ). summary/conclusions: the anti-rh microtitration on the ih- offers similar performances to the method conducted at the cnrhp. the ih- allows automated reading of gel cards. however, it does not have a calculation or interpretation algorithm and does not directly give the concentration of anti-rh . this final part remains manual and requires trained staff. background: haemolytic disease of the foetus and newborn (hdfn) due to maternal-foetal incompatibility has been perfectly framed for decades from the etiologic, pathogenetic and therapeutic point of view. the anti-d alloantibody is most frequently responsible for the most serious form of hdfn due to rhd incompatibility (rhdi hdfn). although immunoprophylaxis (ip) has reduced the number of cases of rhdi hdfn, this disease continues to occur and red blood cell alloimmunization still remains the most common cause of foetal anaemia. hdfn due to abo incompatibility (ab i hdfn) is currently the most common neonatal haemolytic disease in the western world. however, only in about . - % of cases haemolytic disease demands transfusion support. aims: analysis hdfn from to . methods: the hdfn's transfusional support is: intrauterine transfusion (iut) in the antenatal period; exchange transfusion (et) for severe hyperbilirubinaemia and neonatal transfusion of small volumes red cells for the newborn's late anaemia in the postnatal period. our policy for iut, for et and for the neonatal transfusion requires the use of a concentrated blood cells (ec) preferably group rh negative (cde/cde) or negative for any red cell antigens if the mother has antibodies, fresh (< days), preferably cmv safe. for iut, the ec must be compatible with mother's plasma, must have hematocrit + %, and irradiated. the unit for et must be compatible with the newborn's plasma, whit hematocrit % - % and irradiated. the ec used in post-natal transfusions is usually divided into rates of ml, hematocrit ae %. results: in last years, we calculated neonates with hdfn ( males and females): with rhdi hdfn, with ab i hdfn and with hdfn due to incompatibility for other red blood cell antigens. we have produced iut: for our hospitalized patients and for patients located in other hospitals. of these patients, who received iut, were immunized: showed anti-d antibody and antibodies different from anti-a and anti-b. , of the infants with rhdi hdfn, were transfused in utero. neonates on ( . %) have performed et: with ab i hdfn and with rhdi hdfn; the latter had also been transfused in utero. neonates on were transfused after birth: with rhdi hdfn, with ab i hdfn and with hdfn due to incompatibility for other antigens. summary/conclusions: our case studies reflect the literature data. neonates with rhdi hdfn are the most numerous ( . % of the total) and are those who have requested the highest blood supply both in the antenatal period ( . %) that postnatal ( . % performs et, . % performs postnatal transfusions). neonates with aboi hdfn are . %: nobody has received iut, only one has been subjected to et, and % has transfused after birth. patients with hdfn due to other antigens are %, have undergone iut . % and were transfused after birth . %. background: according to british guidelines on neonatal transfusion, since we shared with neonatologists a transfusion protocol for preterm babies. patients are anemic premature newborns with a gestational age ≤ weeks and/or a birthweight lower than g, until months of age. aims: reduce the incidence of iatrogenic anemia. methods: pre-transfusion tests were based on ab direct test, rh phenotype, direct and indirect antiglobulin test (dat, iat). a second blood sample was required for ab /rh confirmation. blood transfusions were performed with negative kell negative ( cde/cde/kk) cmv negative irradiated erythrocyte concentrates (ec) of less than days. ec were subdivided in ml aliquots with a hematocrit of ae %. according to the definition of "small volume transfusions", our protocol established that further four transfusions had to be delivered free of testing. after the fifth ec transfusion the supplementary release of ec was provided of type and screen (t&s) test with h of validity. serological investigation and full compatibility testing were applied in the presence of a iat and/or dat positivity and in the case of mother alloimmunization. results: from october to the end of , premature newborns received ec transfusions within their first months of life. in % of cases (n = ), transfusion requirement was comprised within the 'small volume transfusions'. another % of cases (n = ), requiring further ec administration, was requested of a blood sample for t&s determination and % (n = ) for a cross-match test. in . % of newborns (n = ), being transfused within the " small volume transfusions", blood requirement of ec was fulfilled by the initial blood test ( blood samples). . % of newborns (n = ) received more than transfusions ( - ; median = ) accounting for ec released and for this group blood samples were required. summary/conclusions: with the exception of babies requiring crossmatch test, blood tests were performed to sustain infants transfused with units. the alternative option of omitting crossmatch test (otherwise suggested by italian directives), allowed a reduction of % of blood drawn without any adverse effect or incident reported. due to the relevance of anemia in premature babies, we suggest the application of this transfusion policy in all newborns in the first months of life. background: glucose- -phosphate dehydrogenase deficiency (g pdd) is a sexlinked enzymopathy which is usually asymptomatic unless individuals are exposed to oxidative stress agents. the g pd genotype is the most common g pd genotype in sub saharan africa (ssa). some studies have linked blood from g pdd donors to poor outcome of a transfusion. however, there are no genetic screening programmes for blood donors in the region hence the contribution of g pdd to the donor pool in the ssa setting had not been described.aims: this study aimed to describe the prevalence of g pdd genotype among donors in two regions in uganda. it also described the effect of g pdd and the coinheritance of haemoglobin s and a-thalassaemia on the haematological quality of blood. methods: , blood samples from donor packs were utilized in a transfusion trial conducted in uganda, were genotyped for g pd , haemoglobin s and a-thalassaemia. haemoglobin and haematocrit measurements for the donor units (packs) at the time of transfusion were used to describe the effect of g pd and co-inheritance with a-thalassaemia (n = , ) and haemoglobin s (n = , ) on the haematological quality of blood packs. a subset of donor blood packs was utilized to determine the sensitivity and specificity of the carestarttm rapid diagnostic kit (rdt) for g pdd. results: based on g pd genotyping, . % (n = ) of the blood samples used in the trial were deficient for g pd enzyme while . % (n = ) were heterozygous. significant lower hemoglobin values were observed in red cell concentrates (p = . ) and whole blood (p = . ) donations of heterozygous g pd genotype. co-inheritance of g pdd and a-thalassaemia resulted in significantly lower haemoglobin levels. the carestarttm rdt test was . % sensitive and . % specific for detecting donor blood packs with g pdd. summary/conclusions: the prevalence of g pdd among ugandan blood donors was similar to that in the general population. the heterozygous genotype resulted in lower haemoglobin concentration of the blood units. the use of carestarttm rdt for screening of stored blood units was not as efficient in this study hence further testing for the determination of g pdd needs to be done on fresh samples from donors. transfusion medicine, jaypee hospital, noida, india background: during last two decade there has been a continuous remarkable improvement in desensitization therapy in high risk hla sensitized kidney recipients. in india there has been a tremendous increase in the number of kidney transplantations in patients having anti-hla antibodies (hla sensitized) with excellent success rate. aims: in present study, we are describing successful role of desensitization in hla sensitized patients having preformed donor-specific hla antibody (dsa). methods: all patients were preconditioned with combined modality of a standard dose of rituximab, therapeutic plasma exchange (tpe) and low dose ivig. tpe was started using com. tec (fresenius kabi, germany) after days of administration of rituximab. complement dependent cytotoxicity cross match (cdc-xm), luminex cross match with donor lysates (lm-xm, immucor inc., ga, usa) and flow cytometry cross match (fc-xm, bd facs canto ii).) was done in all cases. if any of the three tests was positive, single antigen bead assay (sab) was performed. desensitization therapy was given in all cases where dsa was detected. pretransplant tpe procedures were done until dsa (mfi < ) and cdc-xm became negative. cdcxm labeled positive at ≥ %. t-cell fcmx was considered positive above mfi and b-cell fcmx was considered positive above mfi. lmxm was considered positive above mfi. sab was performed using lifecodes single antigen (lsa) class i and class ii kits (immucor, usa). if the specificity of anti-hla antibodies was against donor hla antigen(s) it was called as donor specific antibody (dsa). results: present study demonstrated the diagnostic and clinical superiority of adding fc-xm and lm-xm in pretransplant compatibility testing algorithm over cdc-xm. cdc-xm alone was not able to detect anti-hla antibody in patients ( . %). among the three pretransplant compatibility tests, fcxm demonstrated highest sensitivity. among the cases initially screened showed dsa positivity in sab. desensitization was done in those cases only. in our study, sab was positive for class ii alone in ( %) while in remaining ( %) cases it was positive for both class and class ii. the number of pre transplant tpe procedures required was . ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the mean number of post-transplant tpe sessions required was . (range, - ). during pretransplant and post transplant tpe procedures, five ( . %) patients presented with allergic or hypotensive reactions which were managed conservatively. most of the patients were discharged after seven days of hospital stay whereas patients who required post-transplant tpe were discharged after a relatively longer hospital stay (mean- . , median- days). after three months, protocol biopsy was done in those cases only where post transplant tpe was required. protocol biopsy showed normal findings. in present study, the mean duration of follow up was approx months with the longest duration of follow up of months. summary/conclusions: in a country like india where there is a huge gap in the demand and supply of kidney and a large no. of patients waiting for a suitable organ, transplant across hla barrier could a good doable option. thorough pretransplant compatibility and tpe are essential tools to make these transplants program successful background: most transfusion-dependent chronically anemic patients are managed by simple red cell transfusions. however, some patients are not able to tolerate the additional volume associated with simple transfusions and are at a high risk of developing transfusion associated circulatory overload, if transfused with multiple red cell units. plasma-to red cell exchange (prx) is a modified procedure wherein an apheresis machine is used to remove patient's plasma, while simultaneously replacing with donor rbcs. this procedure allows for a rapid euvolemic transfusion of rbcs to patients that are severely anemic and intolerant to excess fluid volume. others as well as our group have previously described this procedure. we now summarize our institutions nearly seven years of experience performing this procedure on a routine basis. aims: to document patient experience with prx. methods: we performed a retrospective chart review of all patients that underwent prx at our institution in the last seven years. our protocol for prx has evolved during this period. currently, we perform the procedures using spectra optia (terumo bct, lakewood, co) machine using the plasma-exchange program and tubing set. if the patient's pre-procedure hematocrit (hct) is < %, we custom prime the tubing set with % albumin. the number of red cell units transfused to the patient depends on their pre-procedure hematocrit and is individualized to the patients. results: we have treated four patients with prx procedure. patient # is a -year-old transfusion-dependent male with beta-thalassemia major. the patient had experienced multiple congestive heart failure exacerbations secondary to simple transfusions and we consequently performed prx procedure, every weeks, starting in . the patient has completed procedures with - units of washed red cells transfused to achieve a target hct goal of to %. he tolerated all procedures without any volume overload issues. he continues on this transfusion regimen. patient # was a -year-old female who had symptomatic anemia secondary to sickle cell disease (hb ss complicated by end-stage renal disease (esrd). she had progressively become intolerant to simple transfusions, including an episode of severe dyspnea, which required intubation. she underwent prx procedures with - units of washed red cells. patient tolerated the procedures without any significant complications. however, during a different surgical procedure, she experienced cardiac arrest and subsequently passed away. patient # is a -year-old transfusion-dependent male with severe anemia secondary to sickle cell anemia (hb ss). he was intolerant to excess fluid because of esrd and congestive heart failure. he has undergone prx procedures with - red cell units transfused to achieve a hct goal of %. he tolerated all procedures without any volume overload issues. he continues on this transfusion regimen. patient # is a -year-old male with a sickle cell disorder (hb ss) complicated by esrd, heart failure and chronic hypoxemic respiratory failure. the patient has undergone two prx procedures with - red cell units. other than an episode of non-bloody emesis that was symptomatically treated, he tolerated both procedures. he continues to be managed on this regimen. however, the patient remains noncompliant with treatment. summary/conclusions: prx is a safe and efficient method to transfuse multiple red cell units to volume-intolerant anemic patients. background: transplanted organ failure due to antibody mediated rejection in abo-compatible organs is a serious complication with a bad prognosis. the goal treatment in these cases encompasses the following strategies: adjustment of the immunosuppressive medications, ivig infusion, antibody removal by therapeutic plasma exchange, and/or the use of target-specific monoclonal antibody medications to lymphocytes, plasma cells, and/or complement. the american society for apheresis has assigned a category i to the use of therapeutic plasma exchange for the treatment of abo-compatible antibody mediated rejection in kidney, but a category iii to all other abo compatible organs: liver, lung, and heart. at our institution, a standardized approach for the use of therapeutic plasma exchange as a supportive intervention for abo-compatible immune mediated rejection, regardless of the organ type, has been in place since . aims: a retrospective review was performed to evaluate our patient outcomes using therapeutic plasma exchange for the treatment of antibody mediated allograft rejection in abo-compatible solid organ transplantation. methods: patients used for the retrospective review were selected from an existing therapeutic apheresis list. the therapeutic plasma exchange protocol consists of: adjustment of the immunosuppressive medications, ivig infusion, antibody removal by therapeutic plasma exchange, and/or the use of target-specific monoclonal antibody medications to lymphocytes, plasma cells, and/or complement. it is performed as follows: one plasma volume exchange is performed on days , , , , , along with one or more of the above strategies followed by an ivig infusion. cases with allograft rejection in which plasmapheresis was not used were excluded. and t devos aims: this study aimed to explore the possible causes of the decreased transfusion rate for all adult cardiac surgery patients. methods: data were collected from adult cardiac surgery patients during the mentioned time frame and were extracted from electronic patient files and a database of the department of cardiac surgery. a set of variables was defined as possible confounders by a panel of experts. after discussion, global variables (age, gender, duration of surgery, use of cpb (cardio-pulmonary bypass), american society of anesthesiologists (asa) risk score, type of surgery, urgency, attending cardiac surgeon and attending anesthesiologist) and cpb-related variables (administration of cardioplegia yes/no (cpg), duration of cpb, circulatory arrest, hypothermia, duration of aortic cross-clamp, baseline hemoglobin and cpb-priming volume) were retained. negative binomial models for counts were used for data analysis. all analyses were performed with spss. results: patients were extracted from databases and further analyzed. the mean age of this group was , years (sd +/- , years) and . % of them were male. the mean duration of surgery was min (sd +/- , min). the decrease of perioperative rbc transfusion rate over four years was statistically significant (p < . ). in , the mean use was , units per operation (sd +/- , ), which changed to , units (sd +/- , ) in . three variables (urgency, attending cardiac surgeon, attending anesthesiologist) changed significantly over years and were used in a multivariable model as confounders together with rbc transfusions and year. even after adjustment for these factors, the decrease in rbc transfusion rate was still statistically significant (p < . ). in the specific group of patients undergoing cardiac surgery with cpb (n = ), the use of rbc was also significantly reduced (p < . ). in , the mean use was , units per operation (sd +/- , ) and this changed to , units (sd +/- , ) in . after correction for the cpb variables that notably changed over the years (cpg, priming volume and hypothermia) and the three previously defined confounders (urgency, attending cardiac surgeon and attending anesthesiologist) the reduction of rbc transfusions over years still remained statistically significant (p < . ). summary/conclusions: our study shows evidence for a decreased rbc transfusion rate in adult patients undergoing cardiac surgery between and . this tendency was also seen in the subgroup of patients undergoing surgery with cpb. possible explanations of the decrease are implementation of various established parts of patient blood management. however, a unique reason could not be identified in this study. background: growing worldwide demand for immunoglobulin products such as intravenous immunoglobulin (ivig) and subcutaneous immunoglobulin (scig) is driving plasma collection. patients with primary immunodeficiency (pid) or secondary immunodeficiency due to haematological malignancy or its treatment (sid) rely on these products to maintain therapeutic serum igg levels to minimise recurrent infection. efficacy of immunoglobulin replacement therapy (irt) in pid is well established but information on sid is limited. the different aetiologies of hypogammaglobulinaemia between pid and sid raised the question of whether sid patients on irt experience similar clinical and quality of life (qol) benefits as reported in pid patients. aims: to assess whether sid patients experience similar clinical and qol benefits while on irt as pid patients. methods: following ethics approval, data on dosage, serum igg trough levels and infection (bacterial, viral and fungal requiring treatment such as antibiotics) was collected from adult pid and adult sid patients from medical records and pathology reports, for their last months of ivig and their first months of scig. the starting and maintenance dose was . g/kg/month for ivig, transitioning immediately to . g/kg/week for scig without a washout period. a study specific questionnaire was developed to gather data on patient perceived side effects, treatment satisfaction and impact of irt on social/family life, work/study and their overall qol. paired t-test was used for parametric data and the wilcoxon signed-rank test for non-parametric data. results: sid patients were significantly older with a mean age of . years versus . years in pid patients (p = . ). a mean of three training session was required to reach competency in scig administration in both cohorts. there was a trend of reduced side effects on scig for pid and sid patients compared to ivig, with a significant reduction of headaches in the pid cohort (p = . ). the majority of patients experienced infusion site reactions, which were predominantly perceived as manageable. % of infections were respiratory tract infections. pid patients had slightly higher mean serum igg trough levels with scig ( . g/l) compared to ivig ( . g/l), and fewer infections on scig than ivig (mean annual infection rate of . vs . respectively). sid patients had higher mean serum igg trough levels on scig ( . g/l) than ivig ( . g/l) (p = . ) but experienced more infections while on scig versus ivig (mean annual infection rate of . vs . respectively). the number of hospitalisation due to infection decreased in both cohorts with scig. pid patients perceived that switching from ivig to scig improved their health and qol. in contrast sid patients perceived no improvements in health and qol. summary/conclusions: data from this pilot study suggests that the clinical and qol impact of irt in sid patients is different to that of pid patients. to support evidence based irt management and effective use of this limited and expensive blood product in sid, larger studies which account for different stages of malignancy and associated treatment regimes are required. background: there is an increasing platelet transfusion for treatment and prophylaxis of bleeding in patients with hematologic disorders and malignancies. because of limited resources, leukoreduced platelet concentrates is not yet implemented in most indonesian hospitals. in vitro platelet activation may cause morphology, functional, and ultrastructure changes. those changes will reduce the platelet viability, in vivo functions, and clinical efficacy. high platelet cd p expression is the cause of faster platelet destruction in the reticuloendothelial systems. post-transfusion in vivo hemostatic efficacy can be determined by the measurement of corrected count increment (cci), recovery, and platelet cd p expression. aims: to analyze the increase of platelet cd p expression in patients of non-leukodepleted compared to pre-storage leukodepleted pc transfusion.background: haemorrhage is a leading cause of preventable death not only in the military trauma care, but also for civilian population suffering accidents or bleeding injuries in regions with low population density where health services should reach people in remote areas. resuscitation using blood products and limited infusion of normal saline improves survival for critically bleeding patients. nowadays there are hems programs (helicopter emergency medical system) carrying blood products around the world. the hems in castilla-la mancha, with physician and nurse, is the first out-of-hospital emergency service in spain that provides packed red blood cells (prbc) transfusion where the accidents happen without delaying the transport to the proper hospital for definitive treatment. this program has been developed between the blood center of ciudad real and the hems team ('gigante ', emergency service castilla-la mancha). the goal of the designed protocol was to preserve the properties of the product to be transfused in out-of-hospital environment by hems teams. aims: to describe the process for out-of-hospital prbc transfusion in hems of ciudad-real. the protocol for out-of-hospital blood transfusion was developed according to criteria of medical indications and security, monitoring, and tracking of the product. methods: data for the observational retrospective study were collected from june to august . the medical helicopter (ec t ) was provided with two prbc o rh(d) negative. the shock index was selected for the indication for transfusion according to the literature revised and as a simple rate to obtain out-of-hospital data. to achieve the feasibility and preservation of the prbc a prospective monitoring of volume was established, haematocrit, haemoglobin, leucocytes, coulter, hemolysis and microbiological culture. blood center established two groups: the case group for the prbc kept in the hems base and helicopter and the control group for the units remaining in the blood center with standardized blood conservation. for both groups, control and comparison of immediately obtained hematologic analyses, and days after collection, were performed. the statistical analysis used spss . version (significance p < , ). results: prbc samples were evaluated, , % ( ) from case group and , % ( ) from control group. analyses were tested day and day after collection. haemolysis was not observed. all cultures were negative. although significant differences were found between the parameter in the value of before-after in the value of the hematocrit, leukocytes and coulter, there are no differences between the prbc that flew and those conserved in the transfusion-service. all results comply with current legislation and blood transfusion standards. there have been administered prbc transfusion to patients during out-of-hospital advanced medical assistance. no post-transfusion reactions have been registered. prbc units have a -day rotation to allow the use of the units in the hospital after achieving their optimal status. summary/conclusions: the out-of-hospital transfusion protocol designed to transport blood (prbc) in the helicopter for hems has demonstrated to keep the standard conditions and properties of the product to be considered useful in the treatment for critically bleeding patients in the out-of-hospital. background: early and adequate treatment of major bleeding is important for survival and a good outcome. blood and plasma are given increasingly early including before hospital admission in trauma based on successes reported from combat experience. in the national patient safety agency issued a rapid response report requiring national health service hospitals in england to take actions to improve provision of blood in an emergency including provision of major haemorrhage protocols (mhp) and drills. the national reporting and learning scheme had identified reports of deaths and instances of harm due to delay over a -year period. aims: the aim of the study was to monitor the acid-base status of the patient by means of abg and to administer the blood component therapy based on teg results. methods: this study was a prospective observational study of adult patients over a period of months. serial monitoring of the abg in the intra-operative period was done. teg guided resuscitation was performed in all cases. results: the abg analysis of all patients showed decrease in the ph, increase in pco , decrease in serum bicarbonate level and elevation in negative base excess. these components of metabolic acidosis can be attributed to massive transfusion. increased lactate, an independent parameter, which reflects poor tissue perfusion or shock and predicts need for massive transfusion was observed in all patients. all the cases showed a decrease in ionized calcium levels which could be a result of citrate related toxicity. increased glucose was observed in all patients which may be due to increase in the catecholamine release as a response to haemorrhagic shock. electrolyte correction was given depending on results of the abg analysis wherever appropriate. two out of cases showed an increase in r time indicating deficient coagulation factors, which was corrected with fresh frozen plasma (ffp). three cases showed elevation in k time indicating deficient fibrinogen levels, which was corrected by ffp. fresh frozen plasma was also given in cases, which showed decrease in the alpha angle, indicating deficient fibrinogen, and cryoprecipitate was given in cases. platelets were transfused in patients showing a decrease in the maximum amplitude (ma), which indicates deficient platelets. summary/conclusions: teg as poc testing is an important tool in appropriate blood component therapy in massive transfusions. serial monitoring of abg helps in monitoring acid-base status of the patient and therefore is a guide in the correcting electrolyte level in patients undergoing massive transfusion. background: massive blood loss is encountered in various situations like trauma, major surgeries, gastrointestinal bleeds and obstetric haemorrhages. haemorrhage is an important cause of mortality and morbidity in massively bleeding patients. early recognition of haemorrhage and intervention is essential for survival. massive transfusion (mt) of blood is required to replenish blood losses and is a lifesaving treatment in these patients. a variety of haemostasis and pathophysiological changes occur during massive haemorrhage and massive transfusion. all of these changes contribute to the vicious cycle of progressive coagulopathy due to the 'lethal triad' of refractory coagulopathy, progressive hypothermia and persistent metabolic acidosis. aims: the aims of the study included understanding management of cases of massive blood transfusion in surgical patients, impact of mt of blood components on patient outcome, evaluating post-operative complications of massive transfusion and the development of institutional massive transfusion protocol (mtp).methods: this prospective observational study commenced after institutional ethics committee (iec) approval. it comprised of adult surgical oncology patients who received massive transfusions and was conducted for a period of months. every case of a massive transfusion was studied under the following headings ( ) patient's details ( ) patients base-line laboratory tests ( ) resuscitation with transfusion ( ) intra-operative laboratory tests ( ) thromboelastography (teg) ( ) post-operative complications ( ) duration of stay in the hospital ( ) day mortality rate. results: complete blood count, serum electrolytes, arterial blood gases, coagulation profile and teg were used to monitor transfusion therapy in the intraoperative period. intraoperative laboratory parameters of patients showed dilutional coagulopathy, metabolic acidosis, hypocalcaemia, hypomagnesaemia, hyperkalaemia and hypokalaemia, increased lactates and glucose. electrolyte correction was done based on the derangement. the derangements were on a decreasing trend in the postoperative period and returned to baseline level by nd or rd post-operative day with no requirement of correction in the post-operative period. the post-operative outcomes were evaluated in terms of the surgical site infection (ssi) as per the centers for disease control (cdc) criteria, surgical complications as per modified clavien-dindo classification and respiratory complications. a total of ( . %) patients had ssi, ( %) had surgical complications and ( %) patients had respiratory complications. the length of the stay in the hospital was longer for patients who had postoperative complications. despite complications, owing to excellent peri-operative care, ( %) patients were discharged alive. summary/conclusions: surgeries associated with massive transfusion are at an increased risk of ssi as well as morbidity and mortality. complications associated with rapid transfusions of blood, acute haemorrhage and associated risk of the surgery lead to a prolonged icu stay and increased length of stay in the hospital. a well-developed massive transfusion protocol optimizing the ratio and dose of the blood component therapy results in excellent patient outcome with minimal postoperative morbidity and mortality. background: despite the introduction of new oral anticoagulants (dabigatran, rivaroxaban, apixaban), vitamin k antagonists (vka), such as warfarin and acenocoumarol are still the most widely used oral anticoagulants for the treatment of non-valvular atrial fibrillation (nvaf). the use of vka must be regularly and often laboratory controlled in order to ensure the adequacy of therapy and to avoid subdosing or drug overdose. the most commonly used test for the control of oral anticoagulant therapy is the prothrombin time (pt), expressed in inr system, which provides an internationally standardized monitoring of the treatment. time in therapeutic range (ttr) represents a measure of the quality of the anticoagulant effect of vka and estimates a percentage of time a patient's inr is within the desired therapeutic. aims: the aim of this study was to evaluate of the effectiveness of vka therapy in patients with nvaf and to identify factors affecting the anticoagulation efficacy. methods: a retrospective study was conducted on a population of outpatients with nvaf, treated with vka and followed in blood transfusion institute of ni s from january to december . laboratory control of inr was done from capillary blood of patients on thrombotrack solo (axis shield, norway) and thrombostat (behnk elektronik, germany). targeted ae . %, but . % of patients had a ttr less than %. patients were at high risk of thrombosis in . % of time (inr < . ) and high risk of bleeding in . % of time (inr > . ). the most significant independent factors affecting the quality of vka therapy are gender, arterial hypertension, diabetes mellitus and the use of amiodarone and antiplatelet drugs (aspirin, clopidogrel). summary/conclusions: the ttr is undoubtedly useful indicator of the effectiveness of vka treatment. the most important predictors of poorer efficacy of vka therapy are arterial hypertension, diabetes mellitus, patients' gender and the use of amiodarone and antiplatelet (aspirin, clopidogrel) drugs. to improve the quality of vka therapy, education of patient and better collaboration with them, as well as a successful teamwork with clinicians are also imperative. background: an estimated . million deaths per year result from haemorrhagic blood loss. at a cellular level, haemorrhagic shock develops when oxygen delivery is insufficient to meet oxygen requirements to maintain aerobic metabolism. successful resuscitation prevents further oxygen debt and repays the prior oxygen debt. this includes the administration of fluids and blood components (e.g. plasma, red cells and platelets). measurement of oxygen delivery and utilisation at a tissue level requires invasive monitoring not possible clinically, meaning that surrogate markers such as lactate and venous oxygen saturation (svo ) are used instead. new technologies such as incident dark field imaging and near-infrared spectroscopy may offer a non-invasive alternative; however their utility in haemorrhagic shock remains background: transfusion-induced red cell alloimmunization is still a major challenge in transfusion practice. besides logistic problems for the transfusion laboratory, it may compromise available blood supply, and when undetected and unanticipated, it may risk haemolytic transfusion reactions. knowledge about risk factors can help to optimize preventive matching strategies. severe renal failure and subsequent renal replacement therapy influence the immune system and could therefore modulate the risk of alloantibody formation against foreign red cell antigens subsequent to transfusion. aims: this study aims to quantify the association between renal failure, according to its degree and its treatment with renal replacement modalities, and transfusioninduced red cell alloantibody formation. methods: we performed a multicenter case-control study within a source population of patients receiving their first and subsequent red cell transfusion between and in the netherlands (risk factors for alloimmunization after red cell transfusion, r-fact study). using a conditional multivariate logistic regression, we compared first-time transfusion-induced red cell alloantibody formers (n = ) with two similarly exposed non-alloimmunized control recipients (n = ) during a five-week alloimmunization risk period. degree of renal function was categorized as: 'no renal failure' i.e. glomerular filtration rate (gfr) > ml/min/ . m , 'moderate renal failure' i.e. gfr ≥ - ml/min/ . m during a continuous period of minimally seven days, 'severe renal failure' i.e. gfr < ml/min/ . m and/or use of any type of renal replacement therapy during at least one day of the alloimmunization risk period. odds ratios were interpreted and presented as relative risks (rr). adjusted rrs were conditioned on the matching variables and identified confounders. results: no renal failure was observed among ( . %) cases versus ( . %) controls; moderate renal failure among ( . %) cases versus ( . %) controls; and severe renal failure among ( . %) cases versus ( . %) controls. among the latter, cases and controls underwent renal replacement therapy. moderate renal failure and severe renal failure without renal replacement therapy were not significantly associated with red cell alloimmunization (adjusted rr . , % ci . - . and adjusted rr . , % ci . - . , respectively). however, patients undergoing renal replacement therapy had a two-fold lower alloimmunization risk (adjusted rr . , % ci . - . ) as compared to transfusion recipients without renal failure, unrelated to type and duration of renal replacement therapy. summary/conclusions: these findings suggest that patients undergoing renal replacement therapy have strongly diminished red cell alloimmunization risks. further research should confirm these results and elucidate the underlying pathophysiological protective mechanism. background: the ability of allogeneic hematopoietic stem cell transplantation(allo-hsct) to prevent relapse depends partly on donor natural killer (nk) cell alloreactivity. nk effector function depends on specific killer-cell immunoglobulin-like receptors (kir) and hla interactions. thus, it is important to identify optimal combinations of kir-hla genotypes in donors and recipients that could improve hematopoietic transplantation outcome. aims: to obtain the optimal combinations of inhibitory kir and its ligand between donor and recipient which is helpful for the guidance of selecting donors and recipients in hsct. methods: the pcr-sbt method was used for kir dl , kir dl /kir dl , kir dl , kir dl and hla-a, -b, -c, -drb , -dqb genotyping. pairs of hla / identical donor/recipients matching samples were retrospectively analyzed. three different models of kir were established. there were kir-kir gene model, kirligand model and haploid model. in kir-ligand model, patients were divided into three groups: c /c homozygote group ( cases), c /c heterozygote group ( cases) and c /c homozygote group ( cases). according to the expression of dl , cases were dl positive and cases were dl negative. there were cases of bw /bw , cases of bw /bw and cases of bw /bw in the dl positive samples. according to the expression of a /a , they were divided into three groups: a /a negative group ( cases), a /a heterozygous group ( cases) and a / a homozygote ( cases). according to kir genotyping, kir haploidentical group ( cases) and kir haploid mismatched group ( cases) were divided. the clinical data on neutrophil and platelet remodeling time, gvhd and os of cases were statistically analyzed by the mann-whitney test or the kruskal-wallis test using graph-pad software v . . results: there was no significant difference in the time of neutrophil and platelet remodeling, the incidence of agvhd and the survival time after transplantation in the kir genotype model. in haplotype model, there was no significant difference in neutrophil and platelet remodeling time and survival time after transplantation. the incidence of agvhd was low when the kir haploid mismatched and kir dl was positive. it was conducive to neutrophil and platelet remodeling when bw /bw and a /a was heterozygosity. summary/conclusions: it is important to establish the three different models of kir genotypes, haplotypes and receptor-ligand mismatches for analyzing the effect on the prognosis of allo-hsct. kir-ligand model plays an important role in hla unre-background: transfusion of platelet concentrates (pcs) has been associated with adverse outcomes including transfusion-related acute lung injury (trali). the underlying mechanism of trali has been related to the accumulation of immunomodulatory mediators (e.g. lipids, cytokines/chemokines) present in pcs. current room temperature storage limits the shelf-life of conventional pcs to - days. alternative storage conditions, including cryopreservation, offers extended storage and a solution for blood banking logistics. cryopreservation of human pcs has been associated with higher concentrations of immunomodulatory mediators compared to room temperature stored pcs and it has been suggested that cryopreserved pcs may be immunomodulatory. to investigate the effects of cryopreserved pcs, a transfusion sheep model would be a beneficial approach. aims: to characterize immunomodulatory mediators in supernatants of sheep conventional and cryopreserved pc and to investigate whether storage duration and cryopreservation impacts the accumulation of these mediators. methods: buffy coat pooled sheep pcs (n = ), prepared in % plasma/ % ssp+ with minor modifications to standard human procedures, were stored room temperature (rt) for days (d) and sampled on d , d and d . cryopreserved sheep pcs (n = ), prepared by the addition of - % dimethyl sulfoxide, were stored at À °c and sampled pre-freeze and post-thaw. supernatant was prepared at each time point with double centrifugation and stored at À °c. concentrations of pro-inflammatory cytokines (interleukin (il)- , il- b, il- a), anti-inflammatory cytokine il- and chemokines (il- , monokine induced by gamma interferon (mig) and interferongamma induced protein (ip)- ) were measured using sheep specific in-house and commercial enzyme linked immunoassays (elisa). levels of non-polar lipid mediators, such as arachidonic acid (aa), -hete and -hete were assessed in the stored sheep pc-and cryo-pc supernatant using commercial elisa. results shown as mean ae standard deviation. the effect of storage was determined at p < . using paired t-test. results: in rt stored sheep pc supernatant il- , il- b, il- a, il- , il- , mig, ip- , -hete and -hete were detected at d , d and d . storage duration significantly increased accumulation of ip- at d ( . ae . pg/ml compared to . ae . pg/ml, p = . ) and further increased at d , and il- at d ( ae . pg/ml compared to ae . pg/ml, p = . ). cryopreserved sheep pc supernatant pre-freeze and post-thaw contained equivalent or higher concentrations of il- , il- b, il- a, il- , il- , mig, ip- , -hete and -hete than rt stored d pcs. however, cryopreservation did not impact levels of any of the platelet derived mediators. summary/conclusions: several platelet-derived cytokines/chemokines, including high concentration of il- with neutrophil priming activity, and non-polar lipids were found in stored sheep pc supernatant. these immunomodulatory mediators may contribute to adverse outcomes associated with pc transfusion. storage at rt, but not cryopreservation was associated with increased accumulation of immunomodulatory mediators in sheep pcs. most importantly, similar to human pcs, sheep cryopreserved pcs contained at least if not higher concentrations of majority of cytokines as pcs stored at rt, therefore making sheep a suitable model in which to investigate immunomodulatory effects of cryopreserved pc transfusion. background: transfusion, despite being a lifesaving therapy, has been associated with adverse transfusion outcomes. transfusion related acute lung injury (trali) remains one of the leading causes of transfusion-related mortality. accumulation of immunomodulatory mediators (e.g. lipids, cytokines/chemokines) present in blood products, including packed red blood cells (prbcs), have been implicated with the development of non-antibody mediated trali. however, how specific mediators contribute to the underlying mechanism is yet to be defined. during routine storage of human prbcs fewer than cytokines/chemokines and several biologically active lipids have been identified. a sheep model of trali has successfully been developed using human prbc supernatant, however transfusing sheep prbc has not been investigated. to support the use of sheep prbc in the trali model and to better understand the precise mechanism, characterization of the potential mediators in sheep prbc is required. aims: to characterize immunomodulatory mediators in sheep prbc supernatants and to investigate whether storage duration impacts the accumulation of these mediators. methods: sheep prbcs (n = ), prepared according to standard human procedures with minor modifications, were stored ( - °c, days (d) ) and sampled at d and d . supernatant was prepared by double centrifugation and stored at À °c. concentrations of pro-inflammatory cytokines (interleukin (il)- , il- b, il- a), antiinflammatory cytokine il- and chemokines (il- , monokine induced by gamma interferon (mig) and interferon-gamma induced protein (ip)- ) were measured using sheep specific in-house and commercial enzyme linked immunoassays (elisa). levels of potential non-polar lipid mediators (arachidonic acid (aa), -hydroxyeicosatetraenoic acid (hete) and -hete) were assessed in the sheep prbc supernatant using commercial elisa. paired t-test was used to compare fresh and stored prbc supernatant (p < . ). results are mean ae standard deviation. results: at day , aa ( , ae , pg/ml), -hete ( . ae . pg/ml), -hete ( . ae . pg/ml) and il- b ( . ae . pg/ml) were detectable in sheep prbcs supernatant. at day , storage duration significantly increased concentrations of aa ( , ae , pg/ml, p = . ) and -hete ( . ae . pg/ml, p = . ) in sheep prbcs supernatant. summary/conclusions: similar to reported findings of human prbcs, the predominant type of immunomodulatory mediators present in sheep prbcs were non-polar lipids. the concentration of these non-polar lipids increased during storage. these immunomodulatory mediators may contribute greatly to adverse outcomes associated with prbc transfusions. further investigation is required to determine whether stored sheep prbcs supernatant induce immunomodulation in sheep in vitro and in vivo transfusion models. background: dshtr incidence is reported as in , transfusions, presenting days to months after the transfusion. the published data addressing the correlation between the strength of the antibodies detected after a dshtr has taken place and the corresponding clinical symptoms as measured by laboratory parameters that assess the presence of hemolysis is limited. aims: the aim of this study is to evaluate the correlation between the results of the dat, automated and manual antibody reactivity strength with the corresponding clinical parameters of hemoglobin, lactate dehydrogenase (ldh), bilirubin, and haptoglobin. methods: a dshtr is defined as discovering a new antibody within days of a transfusion. for all positive antibody screens, a work-up is initiated consisting of identification panels, dats, antigen typing of the red cells transfused, and eluates at the discretion of the transfusion medicine physician. additional laboratory testing for hemolysis is requested when indicated. a retrospective review was conducted of patients who were identified as having a dshtr. levels of hemoglobin, ldh, and transfusion safety background: rhd immunoglobulin (rhdig) has been available for years in australia. since its introduction for routine antenatal and postpartum prophylaxis, alloimmunisation has decreased from % to . %, reducing the number of australian deaths from haemolytic disease of the newborn over a hundred-fold, to approximately . deaths per . blood matters serious transfusion incident reporting (stir) system has been collecting transfusion incidents and adverse events across four australian jurisdictions since . since january , rhdig administration errors have been reported. aims: to understand incidents relating to the administration of rhdig and increase safety and awareness of risks. methods: health services registered with stir (n = ) were notified of the inclusion of reporting rhdig incidents. when an incident is identified, the reporter sends an online notification to stir, prompting the appropriate investigation form to be sent for completion. the completed incident data are reviewed and validated by an expert group. data is de-identified and collated for reporting. results: during the period january -december , reports were received; reports were validated, with reports excluded (reactions rather than administration errors). reports were categorised as below: background: following the nice transfusion guidelines, recommending offering iron before and after surgery to patients with iron-deficiency anaemia (ida), we worked collaboratively with the anaesthetic and pre-operative team to implement a clear and robust anaemia pathway for pre-operative haemoglobin (hb) optimisation. oral iron was started, where appropriate, and our anaemia pro-forma was sent for review in a virtual clinic to assess eligibility for intravenous iron. we performed a retrospective evaluation of the patients who received iv iron during the anaemia pathway. aims: the aim of this retrospective evaluation was to look at the cohort of patients who had received iv iron in and assess the effect of iv iron on haemoglobin levels for different defined groups. methods: we classified patients, as described in munting and klein, , depending on their iron parameters as having either: -idaserum ferritin < mg/l -chronic inflammation with idaserum ferritin - mg/l with transferrin % of < %/crp > mg/l -anaemia of chronic inflammationserum ferritin > with transferrin % of < %/crp > mg/l patients were considered eligible for iv iron if the following criteria were met: . an inadequate response to oral iron, or were unable to tolerate oral iron or the interval between diagnosis and surgery was short . the anaemia pro-forma was completed . hb was ≤ g/l . they were classified as either having ida or chronic inflammation with ida or anaemia of chronic inflammation hb was measured prior and on average, days following the iv iron infusion. we excluded patients who had their post iv iron follow up blood tests done after surgery. results: this retrospective evaluation included patients. patients were classified as having ida and patients classified as having chronic inflammation with ida. those classified with ida had a mean hb of g/l ( - ), a mean mcv of . fl and a mean serum ferritin of lg/l. those with chronic inflammation with ida had a mean hb of g/l ( - ), a mean mcv of . and a mean serum ferritin of lg/l. follow-up hb was measured on average twenty days post iv iron infusion in both groups. the average hb post iv iron infusion in the ida group was g/l ( - ) with an average increment of g/l and in the group with chronic inflammation with ida the average post iv iron hb was g/l ( - ) with an average increment of g/l. summary/conclusions: in conclusion the group with ida had, on average, a lower starting hb that the group with chronic inflammation with ida and the average increment in hb days post iv iron infusion was greater in the group with ida. however, the group with chronic inflammation with ida cases also responded to iv iron and therefore we strongly consider the use of iv iron in both groups. further studies to evaluate the ongoing effect of iv iron would help assess whether the same level of increment seen with ida can also been seen for the group with chronic inflammation with ida over a longer period and how long the increment was sustained. background: the expansion of personalized genomic medicine has led to the development of targeted therapeutic approaches for patients. one example is sipuleucel-t, an autologous cellular immunotherapy product used to treat prostate cancer manufactured from the patient's white blood cells. this study describes our experience with incorporating autologous cellular immunotherapy products into the workflow of the blood bank. the policies supporting the workflow are outlined and compliance with them is assessed. aims: this study aims to evaluate the process and method used to dispense and track the infusion of sipuleucel-t. methods: this is a retrospective analysis of the dispensation and administration of sipuleucel-t from january -august , which was handled exclusively by the blood bank. standard operating procedures and hospital policies were reviewed and compliance with these policies evaluated. included were patients who had the sipuleucel-t product dispensed and administered. information collected included the total number of products dispensed, patient age, adverse reactions/incidents, premedication, and patient outcome. descriptive statistics were used for data analysis. results: there were products dispensed to patients. the recipients were male patients diagnosed with prostate cancer with a mean age of years. there were doses (a complete course) administered to / ( %) recipients and a partial course ( - doses) administered to / ( %) recipients, for a total of products. the blood bank workflow treated sipuleucel-t as a derivative in the computer system, listing the manufacturer (dendreon corporation) as the supplier. health care providers were instructed to follow the nursing policy for the administration of blood products and derivatives for the infusion of sipuleucel-t. this policy required documentation of the infusion in a transfusion nursing note and reporting adverse events to the blood bank as transfusion reactions. there were no adverse events reported to the blood bank, yet there were adverse events described in provider notes; of them necessitating transfer to the emergency department, and requiring hospital admission. of the infusions, infusions were documented in a chemotherapy note rather than a transfusion note ( %), and ( %) were documented as both a transfusion and a chemotherapy administration. there were additional deviations from the blood product administration policy: cases where the consent check was not performed, case where the product was infused with ringer's lactate rather than normal saline, and cases where the -person -way check erroneously indicated the product was irradiated. summary/conclusions: this study describes one approach to managing cellular therapy products as an extension to existing blood products dispensed by a blood bank. the findings demonstrate noncompliance with hospital policy with this new product as evidenced by failure to report adverse events and failure to follow hospital practices regarding administration. although sipuleucel-t is a product manufactured from an autologous blood product donation, the administration and perceptions of this product may be more similar to a pharmaceutical. as the field of immunotherapies derived from blood product donations continues to expand, these products may necessitate an entirely new approach to ensure proper management. abstract withdrawn. (ref ) . while the mnc procedure is fully automated, cmnc requires frequent interface checks to ensure the collection of the correct cell layer. at the rambam health care campus, a tertiary care center, solely the mnc procedure had been employed till , at which point, the cmnc has been introduced for the use in patients with a white blood cell (wbc) count of ≥ , /ll on the collection day. aims: the current study aimed to compare various parameters of peripheral blood stem cell (pbsc) collection, using the cmnc protocol in allogeneic donors and patients undergoing autologous stem cell (autosc) transplantation. additionally, data on autosc collection using mnc (n = ) and cmnc (n = ) procedures were compared. methods: data were retrospectively obtained from pbsc collection reports in consecutive cmnc procedures, including autologous and allogeneic donors. the following comparisons were made: cmnc results of allogeneic versus autologous donors, a sub-analysis of cmnc results for autologous donors with a pb cd + count ≥ /ll versus allogeneic donors as well as mnc versus cmnc results in autologous donors. the collection efficiency- (ce- ) was defined as the total cd + amount in the collection bag divided by the amount of cd + cells in the pb processed by the collection apparatus. results: in the cmnc, the following parameters significantly differed between autologous and allogeneic donors: mean collection time ( ae and ae min, respectively; p = . ), the total blood volume processed ( . ae . and . ae . , respectively; p = . ) and the final volume in the collection bag ( ae and ae ml; p = . ). the mean ce- in autologous versus allogeneic donors was ae and ae , respectively (p = . ). using cmnc, the collection was effective in % of allogeneic and % of autologous donors. in autologous donors, a significantly lower collection bag volume ( ae and ae , respectively; p < . ) and increased total wbc in the collection bag ( ae versus ae , respectively; p < . ) were obtained using cmnc compared to mnc protocol. thirteen patients were treated with plerixafor due to a low pb cd + count following g-csf therapy; of them achieved a cd count ≥ and their collection was considered effective. summary/conclusions: the cmnc protocol is highly effective in terms of the cell yield in both allogeneic and autologous donors with a pb cd + count ≥ /ll. significantly superior collection results are obtained in allogeneic donors versus autologous ones. cmnc provides a significantly higher wbc and a lower final collection volume than mnc. similar total cd + cell counts are obtained with both methods. . tbv processed ranged from - . tbv with mean of . , average was . tbv for females and . tbv for males mean pre-apheresis cd + count was . cells/ll (range . - . ). mean postapheresis cd + count was . cells/ll ( . - . ). mean cd + cells x / kg recipients body weight was . (range: . - . ). our target yield was ≥ cd + cells/kg body weight of the recipient and in only / ( %) cases, the yield was < . / ( . %) procedures were lvl and / ( . %) were svl. summary/conclusions: most of our pbsc were done for haematological indications ( . %) and the target dose was cells/ll in single leukapheresis. in cases ( %), target yield was achieved, only cases had < but > yield. in our study donors < years have shown to mobilize better than the older children. hematocrit (hct) and weight showed correlation with cd + cell yield but they cannot be taken absolute predictors. wbc count cannot be taken as a predictor for cd yield as high wbc count did not convert into high cd yield or vice versa. high prepheresis cd + count gave higher postpheresis cd + count. large volume leukapheresis (lvl), > tbv gave higher yield as compared to standard volume leukapheresis (svl). blood volume processed related to prepheresis cd + count and/or the weight difference between the donor and recipient. other parameters like hematocrit, wbc count, age etc did not show correlation to the volume processed. in our study, younger age and prepheresis cd + count were found as the most relevant predictors for stem cell yield. background: allogeneic hematopoietic stem cell transplantation is an established therapy for many hematologic disorders. since the discoveries of the potential of peripheral blood stem cells (pbsc) in the hematopoietic reconstitution mid s and early s pbsc gradually replaced bone marrow as the preferred source of stem cells. the introduction of hematopoietic cytokines that can mobilize large number of progenitors into circulation accelerated pbsc usage. aims: the aim of our study is to present our year experience with apheresis collecting of pbsc in donors. methods: this is a retrospective study performed in the institute for transfusion medicine of republic of macedonia and university hematology hospital for period background: obtaining unambiguous results of hla typing plays an important role in the transplantation of hematopoietic stem cells. appropriate selection of alleles in the level of hla between recipients and unrelated bone marrow donors reduces the risk of transplant rejection and graft-versus-host disease. new generation technology ensures the highest possible resolution and obtaining unambiguous genotyping results due to the high complexity of the hla system. currently, this is the selection method for obtaining hla test results at the high resolution level. aims: the aim of this study was to determine hla loci (hla-a, -b, -c, drb / / / , dqb , dpb , dpa , dqa ) in potential bone marrow donors from poland. the research included , potential bone marrow donors registered between and . a novelty of this paper was that the amplification of all hla loci was performed by using multiplex pcr primers in a single tube. that solution completely eliminated the need to pool amplicons. methods: the typing of the hla loci (hla-a, -b, -c, drb / / / , dqb , dpb , dpa , dqa ) of potential bone marrow donors was made by using the alltype tm ngs -loci amplification kit (one lambda). genomic dna was isolated from peripheral blood of , donors. hla genotypes were determined according to the manufacturer's protocol on the miseq illumina platform. the obtained sequencing data was evaluated by using the typestream tm visual ngs analysis software. results: the ngs method allowed to obtaining unambiguous results of genotyping of potential bone marrow donors, and also provided the identification of rare alleles, such as: c* : , c* : , c* : , c* : , drb * : , c* : , b* : , c* : , dqb * : , drb * : , drb * : . summary/conclusions: . new generation sequencing technology (ngs), which is based on pcr, ensures the highest possible resolution. . the ngs method allows to obtain more accurate sequencing results compared to the conventional methods. . the research has confirmed the superiority of the ngs method over conventional methods in obtaining unambiguous hla genotyping results at the high resolution level. background: the accurate results of hla typing are significant for ensuring the success rate of hematopoietic stem cell transplantation. currently, hla typing is mainly based on sanger sequencing, which has a high proportion of ambiguous combination results indicating potential errors for hla typing. it is necessary for finding a more accurate typing method to reduce the risk. next-generation sequencing (ngs) method could provide clonal sequencing of single molecules, which has been used for hla genotyping and improved the scope and precision of hla study. aims: to establish a full-length precision sequencing platform for hla-i gene (hla-a, -b, -c) based on ngs technology and be evaluated by classical sangersequencing method, which can effectively improve the accuracy of hla typing for donor and recipient in hematopoietic stem cell transplantation. methods: hla-i (hla-a, -b, -c) gene-specific primers were screened, and the amplification parameters were optimized to obtain full-length sequences of hla-i gene under the same condition. the sample library for the amplicon was prepared with transngs tn dna library prep kit and the sequencing step was carried out with illumina miseq platform according to the manufacturer' protocol. all the sequencing data in fastq format were analyzed by typestream visual software version . . (one lambda inc.)with the default setting. cord blood samples were collected for hla typing with the mentioned above next-generation sequencing method in our study. in parallel, all the sample were also tested with the sanger sequencing method according to the previous study in our laboratory. results: samples were successfully tested with two methods and the coincidence rate between two sequencing methods was %. with the next-generation sequencing method, the probability of ambiguous results among samples in our study is . %( / ) for hla-a, . % ( / ) for hla-b and % ( / )for hla-c. however, the probability of ambiguous results with the sanger sequencing method is . % for hla-a, . % for hla-b, % for hla-c. summary/conclusions: the full-length precision sequencing platform for hla-i gene (hla-a, -b, -c) based on ngs technology was established, which could greatly reduce the probability of ambiguous results and effectively improve the accuracy of existing hla typing techniques. key: cord- -atbjwpo authors: nan title: poster sessions date: - - journal: febs j doi: . /febs. sha: doc_id: cord_uid: atbjwpo nan ** each poster has been given a unique number beginning with the letter p; the next part relates to the session in which the poster will be presented. moreover, klf is also acting on cellular processes such as cell migration, apoptosis, inflammation, angiogenesis and differentiation. previous studies showed a novel role for klf as a regulator of proliferation and differentiation in skeletal muscle stem cells. detecting klf at the protein level harbored technical obstacles. commercially available antibodies exhibited low affinity, low specificity and failed to recognize post-translationally modified forms that are directly relevant to the function. thus, these obstacles prevent further functional protein studies such as western blots, protein co-immunoprecipitation and chromatin immunoprecipitation (chip) assays. therefore, we used crispr/cas system to establish a stable cell line which carry v epitope tag into the n-terminal of klf gene. insertion into the target side of klf gene via crispr-cas system provided an opportunity to overwhelm the above mentioned obstacles. v epitope tag would not interfere with the function of the klf and also enable us to recognize endogenous klf via anti-v antibody in the mouse myoblast cell lines (c c ). we confirmed the targeted insertion into the exon of the klf gene both at the dna and protein levels. the conformational dynamics of structural domains plays an important role in functioning of many proteins. the reca proteins from e. coli are known to be the central catalyst of homologous recombination and repair in bacteria. it forms a helical filament on ssdna capable to bind homologous dsdna and catalysis of the exchange of the complementary strand. significant mobility if its c-terminal domain has been observed experimentally by cryo-electron microscopy. however its potential significance for reca protein activities still remains unclear. in this work we investigated this question by construction of a mutant reca protein with artificial disulfide bridge between central and c-terminal domains. the wild type protein has no disulfide bonds, and therefore its native mobility can be restored in vitro, by addition of b-mercaptoethanol. our data suggest that the s-s bridge decreases both the rate of atp hydrolysis in vitro and the e. coli resistance to uv in vivo. thus, our experimental results indicate that the flexibility of the c-terminal domain significantly affects recombination activity of reca protein in vivo and in vitro. hydroxiurea (hu) is an inhibitor of ribonucleotide reductasethe enzyme that catalyzes the process of free dntps synthesis in living cells. treating cells with hu causes diminishment of the nucleotide pool. as a result, single-stranded dna regions are generated, which leads to s-phase checkpoint activation. the progression of replication forks is blocked and the completion of dna replication is prevented. this results in s-phase cell arrest. nevertheless, our results demonstrate that after prolonged hu treatment, the saccharomyces cerevisiae cells seam to escape the arrest and continue the progression of their cell cycle. we show that when cells re-enter the cell cycle, mrc , but not ctf is detached from chromatin. our data also shows that meanwhile, rad checkpoint activity is diminished in order to allow s-phase checkpoint escape and completion of the cell cycle. moreover, cells not only continue the cell cycle, but steadily surmount in the presence of hu. all this data indicates that cells have made the decision to compromise s-phase checkpoint and to adapt to the novel environmental conditions in order to survive. as both mrc and ctf are known to be responsible for polymerase and helicase harmonization during replicative arrest, our data indicates that mrc has a more specific role in the process of adaptation. our data demonstrates that mrc is a leading protein to regulate the stability of s-phase checkpoint arrested replication forks. zinc finger domain is the most common dna binding domain in metazoa. almost drosophila proteins with c h zinc fingers also have zinc finger associated domain (zad). several proteins with zad (zw , pita and zipic) were found to interact with cp and act as insulator proteins. for some of the zad-containing proteins (for example, weekle and grauzone) it was shown that their zad domains can form dimers with each other. the ability of these proteins to dimerize appears to be especially important in the light of the model suggesting that dna-binding insulator proteins can support genome looping and organization of chromatin structure via interaction with each other. in this work we aimed to understand the role that zadmediated protein-protein interactions play in maintenance of dna loops, focusing on proteins: zw , pita, zipic and cg . first, we performed co-precipitation and yeast two hybrid assays to confirm dimerization of isolated zads in vitro. we observed that only zads from the same protein can specifically interact with each other (homodimerization) and they are unable to interact with zads from different proteins (heterodimerization). we confirmed homo-but not heterodimerization of zads in vivo with coimmunoprecipitation experiments in s cells. furthermore, we found that zad proteins can support longdistance interactions in transgenic constructs in flies. using model system with cg protein, we demonstrated that zad is essential for these interactions. proteins without zad cannot maintain loop formation. finally, analysis of chip-seq experiments for zw , pita, zipic and cg revealed that binding sites of zad proteins often overlap with regions of inter-chromosomal contacts known from hi-c experiments. we conclude that zad-containing proteins can support longdistance genomic interactions and dimerization of zads is necessary for these interactions. this study was supported by the russian science foundation (project № - - ). over the years a large body of clinical knowledge has accumulated on pharmacological effects of drugs on thyroid function. antipsychotics are administered over long periods in humans; therefore their possible adverse side effects should be taken into consideration. the aim of this study is to evaluate the effects of haloperidol and clozapine on plasma t and t concentrations in adult male wistar rats. fifty rats aged between and weeks ( ae g) were divided into five groups (n = in each group), and drugs were administered each day intraperitoneally (ip) for days. the first group was a sham group. the other four groups were considered as low and high treatment doses of the drugs. after a one-week habituation period, animals was administered haloperidol ( . mg/kg, n = and mg/kg, n = ) and clozapine ( . mg/kg, n = and mg/kg, n = ). the rats were anesthetized with ether, and bloods were collected by direct cardiac puncture hours after the last injection. the t and t plasma concentration levels were analyzed with chemiluminescent immunoassay. statistical analysis was performed with ibm spss v . . kruskal-wallis and bonferroni tests were used. t plasma concentration levels significantly differ between sham (median= . mg/kg) and haloperidol ( mg/kg) (median= . mg/kg), haloperidol ( . mg/kg) (me-dian= . mg/kg) and clozapine ( mg/kg) (median= . mg/ kg), haloperidol ( mg/kg) (median= . mg/kg) and clozapine ( mg/kg) (median= . mg/kg) groups (p < . ). however, no significant differences between the groups regarding to t plasma levels were observed. in conclusion, haloperidol and clozapine increased the t plasma concentrations, but didn't have any significant effect on t plasma concentrations. p- . . - isolation of lipase producing strains of bacillus obtained from olive wastewater and screening for substrate specificity in this work, wastewater samples of an olive factory from yusufeli (artvin, turkey) were collected carefully. after a centrifugation period of samples, supernatants were applied to a . lm filter and incubated on lb agar medium for hours. based on differencies of colony morphologies, isolates were selected and purified for identification. s lipase activity assay was carried out by rhodamine b. all of the strains exhibited lipase activity. for determining the substrat specificity of isolates, different substrates were used; nitrophenyl-butyrate, -nitrophenyl-caprylate, -nitrophenyl-laurate, -nitrophenyl-myristate, -nitrophenyl-palmitate. results were measured spectrophotometrically at nm. all of the strains hydrolyzed -nitrophenyl-butirat, while there was no activity with -nitrophenyl-palmitate. bacillus sp. l was the most efficient strain that hydrolyzed all of the substrates. the gene encoding for lipase of bacillus sp. l will be cloned and expressed for more analyses and industrial applications. p- . . - some quantitative aspects of hair follicle layers differentiation e. vsevolodov , , v. golichenkov , a. mussayeva , , i. latypov llc "kazcytogen", almaty, kazakhstan, "institute of general genetics and cytology" sc mes, almaty, kazakhstan, lomonosov's moscow state university, moscow, russia in the course of stable hair growth the differentiation of hair bulb cambium cells to several layers with dissimilar cytochemistry and morphology takes place. this means the activation of different genes in the cells of different layers. depending upon the hair diameter some layers may be absent (medulla in the thin hairs). the hair diameters of the carpet sheep breeds vary widely even within the same square mm of the skin. we compared the different layers thicknesses proportions for the follicles with varying hair diameters. the follicle layers were measured on microphotos of transverse histological sections of the follicles made under the standard magnification. all follicles belonged to the same skin biopsy. the measurements were made at the levels just below the fissure separating the hair and inner root sheath appeared. the empirical regressions of the layers thicknesses and of ratios of different layers against hair diameters were counted. the computer model was made on the basis of these regressions which allowed to obtain the absolute parameters of the layers as well as ratios of these parameters for every chosen hair diameter. using this model we found an essential trend in changing the proportions in relative layers dimensions as we choose the follicles with more and more thick hair. when we change the follicles with mcm hair diameter for those with the hair diameter mcm the ratio of hair medulla diameter to hair diameter increases from . to . . the ratio of hair diameter to the diameter of inner root sheath increased from . to . . it means that the thicker is the hair the higher proportion of cells produced by cambium are spent to build innermost layers (medulla layer within the hair or hair within the complexinner root sheath + hair). these data may throw some light on positional information mechanism of layers differentiation. lignin is a heterogeneous polymer that constitutes % of woody plant cell walls. microorganisms that degrade lignin are fungi, actinomycetes and to a lesser extent, bacteria. in case of industrial applications, the use of fungi is not feasible due to the structural hindrance caused by fungal filaments, requirement of particular culture conditions such as humidity, aeration which are not compatible with industrial processing environments. bacteria are worthy of being studied for their ligninolytic potential due to their immense environmental adaptability. environmental concerns and increasingly stringent emissions standards have led the pulp and paper industry to devise ways to decrease the level of chlorinated lignin residues in its effluents through both production process changes and improved treatment technologies. bleaching with the enzymes is the most promising because the enzymes may be very efficient, and can be used under industrial conditions. the main objective of this study was to investigate the adequency of klebsiella pnuemonia gst (glutathione-s-transferase) pretreatment for bleaching of calabrian pine kraft pulp. for this purpose the following conditions were investigated: enzyme loadings from to u/g pulp basis and the consistecy of the pulp was between and %. enzyme at the desired concentration was added to the pulp and the mixture was incubated at °c for hours. after the enzymatic pretreatment to determine the optimum conditions the kappa number of all reactions were analyzed according to tappi standarts. as a result of this study we determine the optimum conditons as % pulp consistecy, u/g enzyme for pulp treatment. after the enzymatic treatment carried out under optimum conditions we are planning to submit a short bleaching sequence and analyze for physical properties such as viscosity and brightness. owing to this bleacing sequence we are going to able to compare the enzymatic and chemical treatments of pulp in bleaching prosess. p- . . - biochemical characterization of lipase from bacillus subtilis strain a from olive waste water f. ay sal, m. kac ßagan, s. c ß anakc ßi, a. o. beld€ uz karadeniz technical university, trabzon, turkey lipases (triacylglycerol acyl hydrolases, ec . . . ) are regarded as mild and environment-friendly biocatalysts for triacylglycerols hydrolysis. in addition to this hydrolytic reaction, they also catalyze reverse reactions of esterification, transesterification, and interesterification in non-aqueous environments. substrate, stereo-, regio-and enantio-specificities, and chiral selectivity are certain unique attributes of lipases that make them industrially attractive. these properties are often exploited in the manufacturing of detergent formulations, synthesis of fine chemicals, useful esters and peptides, food processing, paper manufacturing, degreasing of leather as well as in bioremediation. in this study, lipase from bacillus subtilis strain a is partially purified and characterized. bacillus subtilis strain a is isolated from olive factory from soke (aydin, turkey) and identified with s rrna analysis. lipase activity is screened on petri supplemented with rhodamine b. bacteria was grown in lb medium supplemented with % olive oil (vol/vol) for hour at °c. after incubation, cells were harvested by centrifugation at , rpm for minutes, resuspended in mm tris-hcl (ph . ) buffer, followed by sonication with sartorius labsonic m to release intracellular proteins. q-sepharose is used as ionexchange column chromatography for lipase purification. effects of temperature on activity and stability were determined spectrophotometrically using p-nitrophenyl laurate as the substrate. effects of ph on activity and stability were also determined. the effects of various metal ions and other reagents on the hydrolytic activity were assayed at °c. the enzyme was active and stable in the broad ph range of . - . and temperature range of - °c. bacillus subtilis strain a have high lipolytic activity. after cloning this enzyme to an expression vector and detailed characterization, this may suggests its usefulness in industrial applications. p- . . - investigation of pin as a nuclear factor one binding partner s. saritas, a. e. yilmaz, a. kumbasar department of molecular biology and genetics, istanbul technical university, istanbul, turkey the nuclear factor one (nfi) proteins are important regulators of gene expression in the developing embryo and in adult stem cell niches. this transcription factor family has four members: nfia, nfib, nfic, and nfix. nfi proteins bind a consensus sequence on gene regulatory regions as homo or heterodimers. each member of nfi family has a highly conserved n-terminal dna binding and dimerization domain and a diverse proline rich c-terminal transcriptional activation/repression domain. as knockouts of nfi genes display distinct developmental phenotypes, we hypothesized that specificity of nfi protein function may arise from their interactions with binding partners. a yeast-two hybrid screen identified protein interacting with never in mitosis a (pin ) as a potential nfib interactor. pin is a ubiquitously expressed protein that specifically recognizes and binds to a phospho-serine or a phospho-threonine followed by a proline (ps/pt-p motif), and catalyzes isomerization of peptidyl-prolyl bonds. interestingly, both n-terminal and c-terminal domains of four nfi isoforms contain several conserved putative ps/pt-p motifs and some of these are reportedly phosphorylated. we looked for nfi pin interactions in vitro by gst-pulldown and co-immunoprecipitation assays. while gst-pin fusion protein interacts with all of four nfi isoforms, it binds nfib most strongly, nfia and nfic moderately, nfix most weakly. moreover, deletion of the cterminal domain leads to loss of nfi affinity for pin implicating this domain in nfi-pin interactions. co-immunoprecipitation assays where we co-expressed various epitope tagged nfi and pin proteins in hek t cells showed that pin precipitates nfib, as well as other nfi isoforms and nfib can, in turn, precipitate pin . we are currently carrying out site-directed mutagenesis on nfib to identify the specific residues that pin recognizes. we will further explore if this interaction regulates nfi function during embryonic development. that pre-adapt migrating fish to the life in seawater. among others, smoltification induces intense growth of fish that enter the ocean at a size where risk of predation is significantly reduced. skeletal muscle growth depends on a tightly controlled balance between protein synthesis and degradation. protein synthesis driven by hormone regulation is well studied in smoltified atlantic salmon; while less is known on protein degradation occurring via a number of pathways including cytosolic ubiquitin-proteasome system and calcium dependent calpains. the aim of this study was to compare calpain and proteasome enzymatic activities in the skeletal muscles of s. salar parr, pre-smolts and smolts. calpain and proteasome activities were determined by casein or suc-llvy-amc hydrolysis in the skeletal muscles of s. salar from indera river (kola peninsula, russia). our results demonstrated the significant differences in studied protease activity levels between parr and smolts. calpain and proteasome activities in s. salar smolt muscles showed a significant drop compared with that of parr. the negative correlation between proteases activity levels in the muscle tissue and overall fish growth rate was shown. so, our data indicated life stage specificity in skeletal muscle protein degradation capacity in migrating fish. we suppose that intense muscle growth in s. salar pre-smolts is supported by various mechanisms including accelerated muscle protein accretion through the reduction of protease activities. obtained results enhance our knowledge in the mechanisms of atlantic salmon smoltification. the work was supported by the russian scientific foundation, project no. - - . p- . . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the sociodemographic characteristics of the pregnant women who double and triple prenatal screening test h. d€ ulger, s. yabanci€ un meram medical faculty, n.e.university, konya, turkey double and triple prenatal screening tests which are applicable during first and second trimesters of pregnancy predict existent abnormalities at early stage. the aim of this study is to investigate the relationship between positive results of double and triple tests, further confirmatory tests during prenatal phase, postnatal status of babies and maternal age. in this study, double and triple test results of pregnant women who were admitted to meram faculty of medicine during - period were scanned from archive and test results indicating risk were detected. from these results, those which were above cut-off values for down syndrome, trisomy , open spina bifida were determined. a questionnaire was carried out with voluntary participants by reaching to these individuals. positive-negative result ratio of all double and triple test results and sociodemographic features such as age, occupation, presence of consanguineous marriage were investigated. all data from archive and answers from survey questions were assessed statistically. participants of the study were to years old and their average age was . ae . . ofthem ( . %) were under years of age whereas of them ( . %) were above years of age. number of pregnancies were scaling between to with an average of . ae . . of mothers ( . %) were not undergone amniocentesis, whereas babies with chromosomal abnormalities were detected among mothers who were undergone amniocentesis. in conclusion, there may be regional, sociological and such that reasons for those who were not undergone amniocentesis despite positive double and triple test results. ( . %) chromosomal abnormalities were detected among pregnancies with increased risk assessment with positive double and triple results. p- . . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the effects of oil on the growth and development of amphibians l. sutuyeva, t. shalakhmetova, a. ondassynova al-farabi kazakh national university, almaty, kazakhstan currently, the pollution of ecosystems by oil and oil products is increasing everywhere. the oil gets into water and ground during oil production, transportation and accidents. as a result, terrestrial animals and hydrobionts are exposed to oil contamination. thus, populations of animals decline. it can be assumed that the most sensitive to the effects of pollutants are animals in early stages of development. amphibians have established themselves as the most convenient bioindicator species. since lake frog (rana ridibunda) and green toad (bufo viridis) are the bioindicator species in kazakhstan, the study of the effects of oil on their larvae was carried out. we used water-soluble fraction of the oil from zhanazhol field (aktobe region) in our test. the larvae of control group were kept in pure water, and larvae of test groupsin aquariums with . , . and % concentrations of the oil fractions. the concentrations were chosen in accordance with the level of pollution of kazakhstan's water bodies with oil. mortality of larvae, morphometric parameters and morphogenesis were studied. it was found that high mortality of larvae is the most visible reaction when exposed to oil. this indicator rose noticeably depending on the doses ( . , . % and %) in both species with percentages %, % and % in r. ridibunda and %, % and % in b. viridis, respectively, while in the control group it was about %. furthermore, delayed larval development was detected. thus, the larvae from the control and . % oil group reached gosner stage (gs) , tadpoles from . % and % groups were at gs- and gs- , respectively, by the th day of life. moreover, behavioral abnormalities (sluggish movements) and decreased sensitivity to mechanical stress (touch) were observed under the influence of high concentrations of oil fractions. thus, oil in low concentrations alters the growth and development of tadpoles of anurans, and causes their increased mortality in high concentrations. p- . . - effect of catechin loaded plga nanoparticles on glioma cell line histone h t is a linker histone which binds to dna and contribute in chromatin condensation as well as regulation of specific genes through spermatogenesis. replacement of this histone h subtype and hyperacetylation of histone h tail, facilitate the replacement of histones with sperm chromatin condensing proteins of tnps and prms. ethical approval and informed patient consent was gained from infertile men referred to royan institute. testicular biopsies were collected from patients through assisted reproductive techniques (art) procedure. based on pathological results samples were classified into the following three subgroups: obstructive azoospermia (as positive control), complete maturation arrest and sertoli cell only syndrome (negative control). chromatin of tissues evaluated for presence/absence of histone h t protein in regulatory regions of tnps and prms genes using chip-real time pcr. results showed lower incorporation of h t protein on regulatory regions of tnps and prms genes in two spermatogenic failure group versus positive control. in this study, it can be concluded that the decreased levels of h t histone variant in testis tissues and failure in chromatin condensation have significant association with male infertility. p- . . - serum dickkopf- levels in obese children and adolescents that obesity is detrimental to bone health despite potential positive effects of mechanical loading conferred by increased body mass on bones. the wnt/b-catenin pathway is essential for normal osteogenesis. serum dickkopf- (dkk- ) is one of the most important inhibitors of the wnt//b-catenin pathway. the aim of this study was to investigate the serum dkk- levels in obese and non-obese children and adolescents. materials and methods: the study included obese children and adolescents ( males and females) aged from to years and healthy normal-weight controls ( males and females) aged from to years. serum dkk- levels were measured by elisa method using commercially available kit. results: body mass index of the obese children was significantly higher than that of non-obese children (p = . ). however, there was no significant difference between dkk- levels of the groups. (these results are preliminary and the study is continuing). discussion and conclusion: our result showed that serum dkk- levels were not changed in obese children and adolescents. p- . . - transcriptional regulation of cdo by nuclear factor one proteins b. kutay, c. lektemur, v. g€ uler, a. kumbasar department of molecular biology and genetics, istanbul technical university, istanbul, turkey nuclear factor one (nfi) transcription factors play important roles in regulation of central nervous system development. three of the four members of nfi family, nfia, nfib, and nfix are expressed in neural progenitors, as well as neurons and glia in the embryo. inactivation of these genes in mice show that they function in development of neocortex and hippocampus in the forebrain, cerebellum, spinal cord and precerebellar nuclei of the hindbrain, regulating neurogenesis, gliogenesis, as well as neuronal migration, axonal outgrowth and guidance. all three neural specific nfis are expressed in precerebellar neuroprogenitors, however, only deletion of nfib leads to a delay in development of precerebellar neurons. investigation of misregulated genes in nfib À/À precerebellar neuroprogenitors identified cell adhesion associated, oncogene regulated (cdo) as a potential downstream target of nfib. interestingly, this gene has been reported to be upregulated in nfia À/À hippocampus as well. cdo, a cell surface glycoprotein of the ig superfamily, has been found to regulate neurogenesis in vivo, is highly expressed in the developing brain and can induce neural differentiation by promoting heterodimerization of basic helix loop helix transcription factors with e proteins. bioinformatic analysis of the kb human cdo promoter region identified five nfi binding sites: one cluster in the first kb region, another in the . kb upstream region. electrophoretic mobility shift and supershift assays showed that nfib binds to all five sites. furthermore, nfib, along with the other neural nfis, inhibits the proximal cdo promoter driven luciferase activity by up to % in hek t cells. preliminary data indicate that nfis bind to sites in both clusters in human neural stem cells (hnscs) suggesting that these sites are functional in vivo. we are currently investigating this possibility through nfi overexpression and silencing experiments that will examine regulation of cdo in hnscs. differentiation. the aim of this study is to investigate bdnf and drd /ankk gene variants in eos development. in this study, eos patients and healthy controls were used. genomic dna extraction was performed from peripheral blood leukocytes. drd /ankk taq a (rs ) and bdnf val met (rs ) polymorphisms were determined by real-time polymerase chain reaction (rt-pcr). positive and negative syndrome scale (panss) was used to determine eos severity. for drd /ankk rs polymorphism, there was a significant difference in the genotype frequencies between patients and controls for the co-dominant model (p = . , or = . ; % ci: . - . ). however, no significant relationship was observed in the genotype frequencies of bdnf val met polymorphism between eos patients and controls (p = . ). these results indicate that, drd /ankk rs genotypes may affect eos development. however, bdnf val met polymorphism may not be associated with eos. lack of association of bdnf val met polymorphism may be due to limited number of patients. our findings need to be confirmed by further studies. various dyes used in the textile industry are discharged in large quantities to the receiving environment in the manufacturing process. this is the beginning of a process that is difficult to compensate for environmental and human health. therefore, contaminated areas should be cleaned. in addition, technologies with high polluting potential should be integrated with biological approach and thereby the impurities consisting of dyes should be reduced. in this experiment; burdirect black meta konz (c.i. direct black ) was intended to decolorization using laccase. firstly, enzymatic decolorization of the dye was determined using spectrophotometry. the wavelengths of maximum absorption of burdirect black meta konz (c.i. direct black ) was determined between and nm. then, optimization studies have been done. for optimization studies; dye concentration, laccase activity, ph, buffer concentration, temperature, mediator effect, mediator concentration and time parameters were determined. lastly, in optimal conditions, atr-ftir and gc-ms analyzes of ensuring decolorization of dye were analyzed. decolorization of burdirect black meta konz (c.i. direct black ) was performed successfully and the absence of any metobolite in the decolorization medium has been provided by atr-ftir and gc-ms analyzes. assessing in terms of application, it can be easily applied by provided the reaction conditions in textile factories. laccase is a tool of decolorization of dyes in environmental friendly process. thus for the development of spermatids into mature sperm able to fertilize the oocyte.one of the causes of male infertility is in fact impaired sperm fertilization capacity due to sperm chromatin abnormalities and aberrant protamine replacement.recent research has focused on protamine biology,including protamine gene and protein structure,mechanisms of protamine expression regulation and involvement of the protamines in male fertility.various studies reported abnormal expressions of protamine (prm) genes in sperm of infertile men.the aim of the study is to investigate the gene expression of prm , prm and their relationship with defective spermatogenesis. materials and methods: this study has been performed on infertile and fertile turkish men.total rna was extracted from the sperm pellet using trizol reagent.after rna extraction and cdna synthesis,real-time quantitative polymerase chain reaction (rt-qpcr) was used to determine the expression of prm and prm . results: distinct levels of spermatozoal prm and prm mrna were found in infertile patients compared to fertile control groups.we found that the mrna levels of prm was reduced in (% ), and the mrna levels of prm was reduced in (% ) out of infertile patients.in the current study,we found statistical significant association between the prm expression and infertility (p < . ).although prm gene expression was decreased in most of infertile patients compared to fertile control groups,the differences between the groups were statistically insignificant (p > . ). discussion: the results of the study suggested that, the protamine expressions which were associated with spermatogenesis may be important in infertility treatment. further studies are required in a large series of different populations to clarify the role both prm and prm themselves and their mrna expression on male fertility. the study was conducted to characterize the processes of muscle growth in atlantic salmon (salmo salar l.) of different ages inhabited rivers indera and varzuga (kola peninsula, russia) in summer and autumn. the expression levels of genes myosin heavy chain myhc, myostatin (mstn), and myogenic regulatory factors myf , myogenin) in white muscle were studied in salmon parr of age groups +, +, + in june and october. the changes in expression levels of mrfs, myhc and mstn indicating the extent of hyperplasia, hypertrophy, and restriction of muscle growth at different ages of parr were revealed. the pattern of age-related changes differed between seasons. especially, the expression of genes myod, myogenin and myhc peaked in yearling parr ( +) in summer, that indicated the high rate of hyperplastic and hypertrophic muscle growth in yearlings ( +). at the same time, the mstn expression level, the negative regulator of muscle growth, was highest in parr at age +. possibly, it is the necessary regulation mechanism to attenuate hyperplasia and hypertrophy and control muscle growth. in autumn, the expression level of myhc and myogenin were higher in salmon of age + and + then in +, indicating the higher intensity of hypertrophy in parr at both first ages in comparison to +. there was no differences in expression level of myod, myf and mstn between age groups in autumn. moreover, the expression levels of genes studied were lower in autumn than in summer. thus, it indicated the decrease of muscle protein synthesis and muscle growth rate in autumn. these findings expand knowledge on age-and season-related features of muscle development in young atlantic salmon in their natural habitat. the study was supported by the grant of the russian science foundation no. - - . p- . . - lmp and lmp gene polymorphisms in the southeastern anatolia population of turkey d. mihc ßioglu , f. ozbas gerceker sanko university, gaziantep, turkey, gaziantep € universitesi, gaziantep, turkey introduction: the low molecular weight polypeptide (lmp ) and low molecular weight polypeptide (lmp ) genes are located in the class ii region of the major histocompatability complex (mhc) locus on chromosome . these genes encode peptides forming the large components of the proteosome complex which degrades short-lived cytoplasmic proteins. due to the significant role of lmp products antigen presentation, these genes can be accepted as strong candidates of susceptibility factors for different diseases. population genetic studies can also contribute to understanding of the possible role of lmp gene polymorphisms. the aim of this study was to determine the allele and genotype frequencies of the lmp and lmp gene polymorphisms in southeastern anatolia population and to compare these with the frequencies in other populations previously reported. material and methods: a total of healthy and unrelated individuals participated in this study. polymorphism analyses were done by polymerase chain reaction (pcr)-restriction fragment length polymorphism (rflp) method and allele/ genotype frequencies of lmp and lmp genes were determined. results: a deviation from the hardy-weinberg equilibrium (v = . ,p < . ) was found for the genotype distribution of lmp gene polymorphism, while the lmp genotypes found to be distributed (v = . ,p > . ). discussion: available allele frequency data for different populations were used to calculate genetic distances and to construct a neighbor-joining tree. among the included populations, nahuas (mexico) population was found to have the lowest genetic distance from the southeastern anatolia-turkey population. conclusion: it can be concluded that, more studies using different types of genetic markers are needed to clarify the filogenetic relationships of southeastern anatolia population with other populations and also the number of population studies on lmp and lmp genes should be increased to understand their effects as a genetic marker. p- . . - investigation of in vitro antioxidant activity of quercetin loaded plga nanoparticles pharmacological effects. but its usage is restricted because of low aqueous solubility, poor bioavailability, poor permeability and instability in physiological medium. these problems can be overcome with encapsulation of quercetin into nanocarriers such as biodegradable plga based nanoparticles. polymeric nanoparticles which have - nm particle size and providing controlled released of biological active agent are prepared by using biodegradable and biocompatible polymers. in this study, encapsulation of quercetin molecules into plga nanoparticles was carried with using the single emulsion (w/o) solvent evaporation method. size measurements of the obtained nanoparticles were performed by zetasizer and their size were found . ; . ; . nm respectively. the morphological features were examined by sem images. antioxidant activities of q , q ve q nanoformulations have been investigated by dpph and no (nitric oxide) methods. it is thought that the nanoparticular formulations that is developed in this study can be useful model for the other antioxidant molecules and will provide a significant contribution to the food and pharmaceutical industry. "this research has been supported by yıldız technical university scientific research projects coordination department. project number: - - -gep ". p- . . the effect of environmental enrichment on spatial memory and certain nmdars, and ht a expressions in rat pups introduction: the aim of the study was to investigate the effect of environmental enrichment exposed during whole childhood on spatial learning and memory and certain nmdars, and ht a in the hippocampi of pups. materials and methods: four-weeks old, male, weaning rats were randomised into groups as enviromental enrichment (ee, n = ) and standard cage control (scc,n = ) groups. eeg housed in an enriched environment and sccg were kept in standard cages for weeks. following the experiment the rats were trained and tested in the morris water maze (mwm) , open field test (oft) and forced swim test (fst) in order to assess the neurobehavioural effects of ee. nr a, nr b, ht a protein levels were analyzed by western blotting from hippocampi of rats. results: the positive effect of ee was seen at the learning phase in the mwm as 'latency to locate the hidden platform' between groups thoughout the training days showed that eeg located the hidden platform significantly earlier than sccg on days , (p = . , p < . ). also eeg significantly spent lower time in the outer zone of the maze on days , which was the sign of low anxiety level (p = . , p = . ). the parameters of oft which indicated increased locomotion, exploration and low anxiety were significantly higher in eeg (p < . ), in fst comparison of groups showed no difference (p > . ). the levels of nr b and ht a were significantly increased as compared to sccg as well (p < . , p = . ). discussion & conclusion: these findings showed that exposure to ee throughout the whole childhood causes several neurobehavioural effects like increased exploration and low anxiety. these effects may lead to improvement in speed of learning. increase in the nr b and ht a concentrations which are the receptors that are related to learning and memory in the hippocampi accompanied these changes which may be basis of the neurobehavioural improvements or may provide contribution to positive neurobehavioural effects. p- . . - effects of monosodium glutamate exposure during prepubertal term on several biochemical parameters in rats h. i. b€ uy€ ukbayram, d. kumbul doguc ß, i. ilhan, a. y. ismail s€ uleyman demirel university, isparta, turkey monosodium glutamate, which is commonly used in processed foods as flavor enhancer, is considered 'generally recognised as safe' by fda; however many studies have revealed the negative effects of msg.we aimed to evaluate the effects of msg in childhood on several serum parameters. sixty-six rats, ( weeks old) were divided into groups as control (cg, n = ; + , male+female) , experiment (msg-low dose, e g, n = ; + , male+female) and experiment (msg-high dose, e g, n = ; + ) groups. msg was administered at mg/kg/d to e g, . g/kg/d to e g for weeks by oral gavage. the rats were sacrified and blood samples were collected from aorta. the blood samples were centrifuged, the serum samples were separated and glucose, alt, total protein, albumin, creatinine, cholesterole and triglyceride levels were analysed by beckmann au autoanalyser. level of total protein was significantly increased in e g and e g groups when compared to cg (p < . ). level of alb€ umine was also increased in both egs but significant difference was seen in e g as compared to cg. creatinine levels were significantly increased in egs when compared to cg (p < . ). although the glucose levels in both egs were increased, the increase in e g was statistically significant (p < . ). the alt levels of in egs were also increased but the significant increase was seen in e g (p < . ). the effect of msg seem to be dose dependent and especially effect on carbonhydrate metabolism. increasing doses caused increase in glucose level, and tendency to glucose intolerance. increasing doses of msg also caused increase in creatinine and urea. another apparent effect of msg was detected on alt activity. in conclusion the negative effect of msg on glucose level, liver and kidney functions depends on daily dose intake. consumption of msg seem to be inevitable it has to be restrained in children otherwise early metabolic problems may be future problems for these children. ( mg/kg) + tartrazine ( mg/kg) + brilliant blue fcf ( mg/kg) + ponceau r ( mg/kg) + azorubine ( mg/kg) + indigotine ( mg/kg) + erythrosine ( mg/kg). artificial food color mixture were administered to g and g and drinking water was applied simultaneously to g by oral gavage per day for weeks. after application all rats were sacrificed, the total oxidant (tos)/antioxidant (tas) capacity were analyzed in rats' brain, liver, kidney homogenate and serum with rel tos-tas diagnostics assay kit.the statistical analysis was carried out by using kruskal wallis test. tas and tos levels in liver homogenate were not found significantly different between all groups (p > . ). in serum and kidney and brain homogenate, tas levels were not significantly different between all groups. tos levels in g were higher than g and g in serum and kidney and brain homogenate (p < . ). exposure to synthetic food colors may increase oxidative stres in vitale organs such as brain, kidney in female rats. these alterations differ according to organ and dose. parallel with increasing trends on healthy eating habits, consumption of prebiotics and probiotic microorganisms have been popular due to their benefits on human health. functional dairy foods such as probiotic yoghurt and cheese are the most common foods including probiotic microorganisms. due to some considerations such as standardization and quality in bulk production, starter cultures are used in industrialised fermentative food production to start fermentation. starter culture basically refers the microorganisms which induce and maintain fermentation of the fermentative foods and starter cultures including probiotic microorganisms are called as probiotic starter cultures. in this study, probiotic cheese starter cultures as a microbial community were investigated using computational systems biology tools. a metabolic network model of probiotic cheese starter culture was reconstructed using microbial community network modeling approach. literature-based genome-scale metabolic models of commonly used lactic acid bacteria were used for the microbial community metabolic model. the microbial community metabolic model simulated metabolic interactions of the microorganisms in the probiotic starter culture. metabolic flux values computed by the metabolic network model also predicted the metabolic pattern of the glycolysis (conversion of lactose), lipolysis (conversion of fat) and especially amino acid catabolism which are associated cheese flavor metabolism. simulations obtained by metabolic network-based analysis of cheese starter cultures can also be used for other fields like genetic engineering, upstream processing of the functional cheese production. p- . . - er quality control protein network in cf to modulate f del-cftr rescued phase ii xenobiotic metabolizing enzymes convert parent compounds into more hydrophilic metabolite by catalyzing conjugation reactions including glutathione and amino acid conjugation, glucuronidation, sulfation and acetylation. this study was aimed to describe the best cell line model for studying phase ii xenobiotic metabolizing nqo and gst-pi enzymes. for this purpose, mrna and protein expression of nqo and gst-pi enzymes were analyzed in ht and sw (colon); hepg and huh (liver); pnt a and pc (prostate) cell lines by qrt-pcr and western blotting techniques, respectively. protein expression analysis revealed that nqo protein was expressed in all cell lines and relative protein expression is highest in the hepg ( %) and pnt a ( %) while huh ( . %) showed relatively low expression of nqo . in addition, nqo mrna expression was relatively high in ht ( . fold) and pnt a ( . fold) when compared with liver cell line hepg ( . fold). gst-pi protein expression was found very high in huh ( %) while there was no expression in hepg . gst-pi mrna expression was relatively higher in pnt a ( . fold) and ht ( . fold) when compared with huh ( . fold). according to these results, choosing the best cell line as model depends on the purpose of the research. for studying metabolism of a chemical by nqo and gst-pi or effect of a chemical on translational regulation of these enzymes, it is better to consider protein expression of the cell lines for choosing best model. however, if the aim is to study effect of a chemical on transcriptional regulation of these enzymes, it is better to choose a cell line that expressing highest mrna of gene of interest. in conclusion, considering both mrna and protein expression levels together, the best model cell lines for studying phase ii xenobiotic metabolizing nqo and gst-pi are ht and huh , respectively. p- . . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the studies on the pancreatic cells' surface glycoconjugates profiles in rats fed with high fat with lectin labelling methods by flouresans microscopy y. mater, s. beyhan ozdas gebze technical university, kocaeli, turkey in this study, the backbone of the cellular adhesion-recognition mechanism, located in the cell membrane. the study material selected pancreas tissue, has a privileged structures. the pancreas is one of the main organs to aid in digestion. the pancreas functions as an exocrine gland and role in digestion. in addition, the pancreas also functions as an endocrine gland, secreting several hormones into the blood that control the blood levels of glucose and other nutrients. due to the pancreas have been selected for this unique feature. thus, different types of cells in the same sample will be able to study the structure of the surface glycoconjugates. generally researches about determination of carbohydrates in the cell, glycoproteins or/and glycolipids are cut with enzymes. next step, the oligosaccharide mixture obtained, than establishing the complete structure of oligosaccharides and polysaccharides requires determination of branching positions, the sequence in each branch, the configuration of each monosaccharide unit, and the positions of the glycosidic links. this is a more complex problem than protein and nucleic acid analysis. these processes are indispensable for the understanding of the chemical structure of the sugar. whereas in cells using labeled lectins specific sugars, it is possible to accurately determine. in this study, was used triticum vulgaris (wga) labeled with fluorescein (fitc). thus, the cells located on the cell surface and neu ac (sialic acid) for wga sugar residues were investigated. according to preliminary results of this study, wga labeled with fitc is specifically binding of these sugars. when this study is completed, the differences of sugar on the surface of different type of cells in the pancreas can be distinguished in micrographs. thus, in the cells of the pancreas, the sugar units involved in adhesion-recognition can be possible to determine specifically. large scale gene networks could be topologically analyzed in order to obtain possible global system-level structure cancer gene co-expression networks can have lower connectivity as compared to normal samples. using colorectal tissue gene expression datasets, we observed that tumor specific networks are less connected than normal networks. functional enrichment analysis suggested that cell cycle genes and methylation-associated cell adhesion genes can specifically play a role in the connectivity loss of carcinoma samples. literature confirmation provided a gene network including significant genes playing roles in the intersections between cell cycle, cell adhesion, and cell skeleton dynamics. this network can provide novel insight to our understanding of the molecular mechanisms of colorectal cancer. p- . . - tf-mirna circuits specific to epithelial cancers y. oztemur, a. aydos, b. gur dedeoglu ankara university biotechnology institute, ankara, turkey cancer is the most common cause of death in the world but there are still a lot of uncertainties about the exact mechanism taking roles in regulation of it. cancers can be classified according to cell type; in which they start. carcinomas are the most prevalent types of cancer and start in epithelial tissues. they are also named as epithelial cancers (ecs) and make up about out of every cancers. over the past few years, many studies are concentrated on mirnas, which have emerged as important regulators of gene expression like transcription factors (tfs). tfs are regulators at transcriptional level while mirnas are post-transcriptional regulatory key-elements. otherwise the transcription of mrnas and mirnas are known to be regulated by tfs and tfs are the targets of mirnas. therefore, it is crucial to characterize the relation of tfs, mirnas and their targets by building circuits in diseases such as in ecs. for this study, mirna and mrna expression studies including epithelial tumors and normal samples searched in geo and array express microarray databases. mrna studies and mirna study, which were designed for different ecs (breast, lung, ovary and colorectal) were selected to be analyzed. differentially expressed (de) mrnas and mirnas between epithelial tumors and normal samples were extracted (p ≤ . , fold change). among de genes, transcription factors and mirnas were identified and listed for epithelial tumor vs. normal comparison. circuit analysis resulted with remarkable circuit, which was common for all the types of ecs that includes klf transcription factor and hsa-mir- . in the literature hsa-mir- and klf are known as important regulators in different types of cancer, which indicated that the motifs involving tfs and mirnas might be useful for understanding the regulation of ecs. as a conclusion finding out new and common circuits may aid us in predicting new or alternative diagnostic and/or prognostic biomarkers for ecs. mesenchymal stem cells (mscs) are multipotent stromal cells that can differentiate into a variety of cell types which are used in cell therapy. although they are the most attractive cell type for cell therapy studies, primary mscs lose their differentiation potential with increasing time in culture and passage so they are of limited use. due to this disadvantage, msc lines are more suitable for in vitro researches owing to their immortality. in this study we compared primary bone marrow-derived msc (bm-msc) with bone marrow derived msc line (rcb ) in terms of cell characteristics and gene expression profiles to determine the functional differences among mscs types. firstly, mscs were identified by using cd , cd , cd and cd as positive markers and cd as a negative marker. gene expression profilling was investigated using affymetrix hg-u -plus arrays. the significant go biological process terms and kegg pathway enrichment analyses of the identified degs were performed using david (p < . , fold change≥ ). the analysis showed similar pathway clustering in both cell types. the resulting quantitave transcriptome of genes were identified that differentially expressed in msc line versus primer mscs ( upregulated and down-regulated). functional classification of changed genes was mainly clustered in cell cycle, cell death and mismatch repair. kegg pathway analysis revealed that the genes were significantly enriched in pathways including "cell cycle, dna replication and focal adhesion" pathways. in conclusion, our results indicate that msc lines can be used instead of primary mscs. these quatitative results provide an important basis to adapt cell lines to more closely resemble physiological conditions as oppossed to animal experimentation. this could help to minimize the use of animals in research. p- . . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] association between loss of q , gain of q . and progression in sporadic colorectal cancer n. belder , b. savas , m. a. kuzu , i. pak , h. s€ umer c ß elebi , a. ensari , h. € ozdag biotechnology institute, ankara university, ankara, turkey, school of medicine, ankara university, ankara, turkey, ankara oncology training and research hospital, ankara, turkey colorectal cancer (crc) is one of the most diagnosed cancer and the third leading cause of cancer deaths throughout the world. identifying of copy number variation (cnv) profiles between early and late stage cancers can be useful to understand the progression and aggressiveness of cancer. the main goal of this study was to construct a comprehensive insight of association between cnv and sporadic crc stages in order to identify novel candidate targets which may contribute to tumor progression. affymetrix . genechip snp arrays were used for characterization of cnvs in tumor and matched normal formalin-fixed, paraffin-embedded (ffpe) tissues from stage i, stage ii and stage iii samples. paired cnv analyses were performed using partek genomic suite . and genomic segmentation algorithm was performed using a minimum of markers per segment, a signal-to-noise ratio of . and the cut-off value for the gain and loss was set of ae . . the adjusted p-value ≤ . were considered to be significant. whole genome cnv analysis revealed that amplification of q . with genes was found the most frequent ( . %) in stage ii tumors. the most frequent ( %) amplifications were q . and p . in stage iii tumors. while deletion of chromosome q . in stage iii with a frequency of % was found the most frequent loss, deletion of q . was seen the most frequent ( . %) in stage ii tumors. two tumor suppressor genes smad and smad which are found in these deletion regions were common genes between stage ii and stage iii. our results showed that gain of q . might have a significant role in the progression of cancer. loss of q comprising two tumor suppressor genes is also another important finding. q loss can be a significant prognostic value in colorectal cancer even though validation of target genes requires additional study and larger sample size. this work was supported by tubi-tak project no: s . p- . . - meta-analysis based mirna signature discriminates cervical cancer from normal samples a. yucel polat, y. oztemur, a. aydos, b . gur dedeoglu biotechnology institute, ankara university, ankara, turkey gynaecological cancers are common problems in female health. squamous cell carcinoma (scc) is a type of these malignancies. this tumor type is derived from pre-cancerous lesions, which is called cervical intraepithelial neoplasia (cin). cin is classified as cin , cin and cin according to their dysplasia grade in the cervical tissues. mirnas are small non-coding rnas that were shown to have important roles in the development and progression of various cancers. the aim of this study is identifying mir-nas, which are playing a part in progression of cervical lesions by a ranking based meta-analysis approach. two mrna and three mirna expression studies, which include normal, cin , cin and scc samples were selected from arrayexpress and gene expression omnibus (geo) databases. three mirna studies were combined with anova dependent ranking based meta-analysis program which was developed in our laboratory to find out a mirna signature that can discriminate cin , cin and scc samples from normal samples. the top five mirnas with the highest ranks in meta-list were selected for further analysis. predicted targets of these mirnas were identified by mirdb target prediction tool. additionally two mrna datasets were selected for mirna-target validation studies. common genes, which were obtained from meta-mirna targets and differentially expressed genes between normal and cin , cin and scc groups from two independent studies, were identified and they were subjected to pathway enrichment analysis. pathway enrichment analysis that was performed with common genes showed that these targets were significantly enriched (p < . ) in especially cell proliferation, cell survival and cell cycle pathways, which are the key players of cancer development and progression. the meta-analysis results together with validation analysis of their targets may point out the potential roles of mirnas as biomarkers for the diagnosis and the treatment of cervical cancer. p- . . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the hypoglycaemic and regenerative activity of thymbra spicata in alloxanized-diabetic rats thymbra spicata (labiatae), a carvacrol and thymol containing plant, is one of the medicinal herbs used by diabetic individuals to reduce blood glucose in turkey. we investigated the hypoglycaemic and anti-lipemic effects of the aqueous extract prepared from dried leaves and flowers of this plant in alloxanized-diabetic rat model. rats were divided as: diabetic control (group ), dia-betic+glibenclamide (group ), diabetic+plant extract (group ), untreated control (group ) and control+plant extract (group ) groups (n = for each group). serum glucose, lipid levels and body weight changes were mesasured and pancreas and liver histology of the rats were examined. each rat in all groups were administered the plant extract ( mg), and the reference drug glibenclamide ( mg/kg) by gastric gavage every day for weeks. in group , blood glucose, serum alt, ast, triglyceride, cholesterol and ldl cholesterol levels increased while body weights decreased. in group , serum glucose, alt, ast, triglyseride and hba c levels decreased compared to group while cholesterol and ldl levels were high. in group , serum alt, ast, trigliserit, cholesterol, ldl levels decreased significantly but serum glucose and hba c were higher compared to group . body weights increased except group and hdl levels were not altered. histologically degenerative changes observed on pancreas of group were decreased in groups and . there was no difference on liver histology of the groups. in conclusion, thymbra spicata showed a protective and regenerative effect on diabetic pancreas. the hypo-lipidemic effect of the plant extract was also more effective than glibenclamide possibly due to the flavonoids, saponins and triterpenoids contents in the extract. its hypoglycaemic and protective activity should be tested for different doses and extract preparations and for longer periods. our study suggests that thymbra spicata is an excellent candidate for future studies on diabetes mellitus. with three different transcriptome data sets from the public gene expression omnibus database: time dependent data of dphop mutant, dargr mutant and wild type strain. the dynamic data spanned both primary and secondary phases of the metabolism. statistical results of transcriptome data were used for reporter metabolite analysis and reporter pathway analysis, which identify the metabolites (or pathways) with a significant coordinated transcriptional change in response to gene deletion perturbation in phosphate and nitrogen metabolisms. further, the production of actinorhodin, a pharmaceutically important compound, was modeled in the two deletion strains by calculating the metabolic fluxes subject to transcriptional level constraints on enzyme-coding genes. the metabolic switch from primary to secondary metabolism was highlighted in terms of the activity of pathways and fluxes as a result of the computational analyses in this work, leading to a better understanding of the role of phosphate and nitrogen metabolisms in increasing production levels. introduction: as a member of legume family licorice (glycyrrhiza glabra l.) has been widely used by human kind for many years as food constituent. especially by folks in rural sites licorice consumed widely. beside food constituent licorice has been used for medical purposes as well. licorice found effective with scientific datas on peptic skin infections, ulcers, inflammation, eczema, alzheimer disease, liver disease, and cancers. it also has been used as natural sweetener and food additive for preparing candies, chewing gum and beverage since ancient times. like all other medicine it has not been free of adverse event or toxicological effects. material and methods: alcoholic extracts of plant obtained by maceration process. for in vitro examination of anti-oxidant profile of licorice dpph free radical scavenging, abts cation radical scavenging and cupric ion reducing antioxidant capacity assay applied. application of extract made by oral route to rats for a week. anti-oxidant profile has been evaluated by myeloperoxidase (mpo), arylesterase (ares), total oxidative stress (tos) and total antioxidant status (tas) of serum levels. determination of toxicological effects alt, ast, ldh and alp values studied. histological investigation applied on liver and kidney tissues. results and discussion: results compared with control and standarts. antioxidant potential of licorice has been observed by in-vitro assays. serum mpo and ares values also compared with in-vitro results and correlation between them has evaluated. toxicological investigations made after evaluation of ast, alt, ldh and alp values. conclusion: in vitro assays has showed that licorice has potential anti-oxidant effect. investigation revealed that a mild toxic effect of licorice by biochemical tests. toxicological profile compared with control group and alt, ast values found slightly decreased and a mild elevation has been seen in ldh and alp values. for further and detailed investigation is needed. p- . . - on the applications of a metabolic network model of mesenchymal stem cells h. fouladiha, s. a. marashi, m. a. shokrgozar, m. farokhi mesenchymal stem cells (mscs) have several applications in tissue engineering and regenerative medicine. mscs can be very useful in stem cell therapy, because they can be isolated bone marrow or adipose of an adult. these cells have also been used as gene or protein carriers. therefore, maintaining them in a desire metabolic state has been the subject of several studies. here, we have used a genome scale metabolic network model of bone marrow derived mscs for exploring the metabolism of these cells. then, we try to validate the computational results by experimenal tests. we analyzed metabolic fluxes in order to increase stem cell proliferation using the metabolic model. consequently, the experimental results were in consistency with computational results. in the present work, the applicability of the metabolic model was successfully approved. therefore, this metabolic model can be useful in biomedical researches of stem cells. p- . . - qtl analysis for body weight and fatness in bxd recombinant inbred mouse strains a. dogan , c. neuschl , r. alberts , g. a. brockmann school of medicine, istanbul kemerburgaz university, istanbul, turkey, department for crop and animal sciences, humboldt-universit€ at zu berlin, berlin, germany, helmholtz-zentrum f€ ur infektionsforschung, braunschweig, germany genetic variation in body weight and composition is under the influence of many genes and have different genetic architectures. in the present study, the genetic factors contributing to body weight and fatness were examined under energy rich feeding conditions. growth traits, lean and fat weight, fat mass gain were analyzed to map qtls in a set of bxd ri strains. genome-wide analyses were revealed several genomic loci that control body weight and associated bodily changes in a sex and age-specific manner. the genetic data provided evidence for significant qtls on chromosome (chr) , , , and . most likely candidate genes within or near the regions with the highest significance levels were identified. the genes f rik, gbe , a n , and four genes cenpc , stap , uba , gnrhr for example, are suggested as most likely positional candidates accounting for the qtl effects on chr for fat mass, on chr for fat mass gain and on chr for lean weight, and chr for body weight, respectively. our results showed that body composition and fatness are highly complex that many genetic factors regulating and suggested candidate genes, which may help for studies of human fatness. related to serotonergic and gaba systems in response to hormonal changes. the nutrients involved in neurotransmitter synthesis may be the cause of relationship between diet and premenstrual syndrome. therefore, the aim of this study was to investigate the effect of various nutrients and premenstrual syndrome. this study was conducted to healthy women aged - years. participants were asked to fill in premenstrual assessment form. dietary intakes (three days in each phases) were recorded during premenstrual, menstrual and postmenstrual phases. energy, protein, amino acids, iron, calcium, and magnesium intakes were estimated. statistical analyses were performed using the spss software. friedman tests were conducted and differences were considered to be statistically significant for p-values lower than . . . % of the participants reported premenstrual symptoms and premenstrual symptoms related nutrient intake were increased in these women. it was determined that energy (p = . ) and protein (p = . ) intakes were higher in the premenstrual phase. during premenstrual phase; tyrosine (p = . ), isoleucine (p = . ), leucine (p = . ), lysine (p = . ), methionine (p = . ), cysteine (p = . ), tryptophan (p = . ), and glutamic acid (p = . ) intakes were higher than other phases. likewise, iron intake was higher on premenstrual phase (p = . ). on the other hand, intake of other potential premenstrual syndrome related nutrients like fat, cholesterol, calcium, magnesium, and vitamin b were not significantly different within the menstrual phases. amino acids including tyrosine, tryptophan, glutamine, and vitamin b are involved in neurotransmitter synthesis and might be related to premenstrual symptoms. consequently, elevated intakes of dietary protein and some amino acids during premenstrual phase may be related to premenstrual syndrome symptoms. until now far uv cd spectra of only two potexviruses were published. the papaya mosaic virus (papmv) spectrum, measured by leclerc and co-authors contained no obvious anomalies and was similar to the spectrum of isolated papmv coat protein (cp). but measured years earlier by homer and goodmanfar uv cd spectrum of potato virus x (pvx) itself had anomalous character and differed strongly from the spectrum of isolated pvx cp. in the present work we measured far uv cd spectra for two more members of potexvirusgenus: alternanthera mosaic virus (altmv) and potato aucuba mosaic virus (pamv) and their free cps. the altmv virion and altmv cp spectra were similar to each other and to the spectra of papmv and its cp. the pamv spectrum resembled the pvx spectrum in anomalously low ellipticity of the negative band at nm, but in contrast to pvx, did not have additional peak at nm. homologous modeling showed that cp of the three viruses is very similar in the core structure, and the observed difference may be explained by differences in disordered parts of proteins. possible reasons of potexvirus structural variability are discussed and it is suggested that the intravirus potexvirus cps may assume different conformations in different virions of the same preparation or even along the length of one virus particle. this work was supported by the russian science foundation (grant - - ). the antimicrobial potential of different phenolics was tested on pectobacterium in search of possible mode of action. in this respect, biofilm formation, exoenzyme activity, gene expression and virulence on its natural host (potato, cabbage, calla lily) were performed. also computational approach to show interaction between phenolic compounds and target protein was carried out using docking tools. the virulence determinants of pectobacterium were significantly impaired, at compound concentrations that did not affect bacterial cell growth. these observations suggested a mechanism which specifically interferes with bacterial virulence. since, these virulence determinants in pectobacterium are controlled by quorum sensing (qs), we focused on the effect of phenolics on the qs system in pectobacteria. the study revealed an inhibiting effect of the tested compounds on the expression level of central qs system and controlled genes, using qrt-pcr. also, there was a prominent reduction in the level of qs signal molecules n-acyl-homoserine lactone (ahl) accumulation. in addition infection capability was also practically blocked, which was completely recovered by application of exogenous-ahl. these results were supported by a potential interaction of plant phenolics with qs targets, as shown by molecular docking tool. collectively, results suggest the potential interference of phenolic compounds with qs central components (expi/expr proteins). moreover, it holds potential for future development of control measures against pectobacterium, and possibly other pathogens with similar mode of virulence. saccharomyces cerevisiae has been a key experimental organism for the study of infectious diseases, including double-stranded rna (dsrna) viruses. the l-a dsrna virus family of s. cerevisiae is widely distributed in nature. several versions of l-a virus are described and new ones continue to be discovered. some s. cerevisiae strains along with l-a dsrna possess smaller dsrnas, called m satellites. these dsrnas encode a sole secretable protein, known as k , k , k and k-lus toxin. l-a genome encodes the gag major structural protein and gag-pol fusion protein, formed by ribosomal frameshifting. gag-pol has transcriptase and replicase activities are necessary for maintenance of both l-a and m satellite dsrnas. so far, it's not known whether certain l-a virus has evolved to maintain a distinct type of satellite dsrna or this phenomenon lacks inherent specificity. we developed universal strategy to obtain full length l-a and m dsrna genomes from s. cerevisiae. complete viral dsrna genomes can now be cloned, as evidenced by l-a- dsrna, analyzed and sequenced directly from any yeast strain by means of enzymatic manipulations on total or fractioned rna content. we have identified previously undescribed l-a variant from different yeast strains specifically associated with certain type of m satellites. moreover, we identified for the first time full -utr and -utr sequences of m satellite. highly conserved sequence regions along with variable fragments were discovered at protein level, revealing clear trend to form clusters among different l-a gag-pol proteins. the obtained data suggest that each l-a virus variant can specifically maintain a distinct type of satellite dsrna. p- . . - physic-chemical characterization of plga adjuvants for immunization per os t. chudina, d. kolybo palladin institute of biochemisry of the national academy of sciences of ukraine (nasu), kyiv, ukraine antibodies against diphtheria toxin play the most important role in the immunity against corynebacterium diphtheriae. all current diphtheria vaccines have parenteral route of administration. undoubtedly, oral administration of antigens would be the most patient-friendly way of immunization. however, the efficacy of free antigens oral administration is limited by their degradation in the gastrointestinal tract and poor absorption by m-cells. biodegradable and biocompatible polymers, like poly (d,l lactide-co-glycolide) (plga), are widely used for the design of mucosal immunizing agents. importantly, that the way of particle preparation plays an important role in plga biodegradation and antigen release. the aim of this work was to characterize the main physic-chemical properties of two types of plga particles: with immobilized antigen (plga ) and with encapsulated antigen (plga ) . we have prepared two types of plga particles containing egfp-sbb proteins (non-toxic recombinant fragment b of dt fused with egfp). the antigen loading efficiency of particles was determined based on the ratio of protein concentration in solution before and after loading and shown better results for plga particles (plga - . %, plga - . %). the flow cytometry results demonstrated that % of plga particles conjugated with egfp-sbb, and only . % of plga particles conjugated with protein.the particle sizes had the slight difference by the results of two different techniques (ntanumber based, the software tracks individual particles; dls -scattering intensity weighted), however demonstrate similar patterns. dls data showed that the mean plga particles size was . nm and plga - . nm. nta data also showed that mean plga particles size a little smaller than plga ( . nm and . nm respectively) . demonstrated differences in the properties of synthesized particles may have an influence on the immunogenicity of the used for oral immunization antigen. p- . . - a suitable system for studying the functionality of a plasmodial protein in mammalian cell lines cho-mt , a mutant cell line was proved to be an appropriate tool for investigating intracellular function of cct. in this cell line, the endogenous cct activity decreases dramatically at °c, blocking membrane synthesis and ultimately leading to apoptosis. we have studied the rescuing potential of pfcct in cho-mt cells with the isogenic cho-k cells as a control. cells after transient transfection were incubated at °c and then analysed by facs using the fluorescence of egfp fused to pfcct. the proportion of cells undergoing apoptosis was determined by propidium-iodide staining. we have demonstrated for the first time that heterologously expressed pfcct is able to complement endogenous cct activity in mammalian cells. thus, a suitable system has been established for functional investigation of structural elements of pfcct. in order to reveal the role of different protein sequences in enzymatic function, we redesigned the structural gene of pfcct obtaining a modular system where different domains are easy to be removed or exchanged. here we designed a series of different truncation and deletion constructs to reveal the role of plasmodium specific sequences. in parallel, heterologous expression experiments of different constructs in the mutant cho-mt and the wild type control cell lines are performed to validate the reported model system. p- . . - host-pathogen interactions: is there a relationship between tlr polymorphisms and tuberculosis in a group of turkish patients? introduction: tuberculosis (tb) is a global health problem and according to world health organization (who) each year more than million individuals die from tb and each year , cases of tb are notified in turkey. malatya is the third largest city in east anatolian region of turkey and tb incidence rate is higher ( . / , ) comparing to the general population of the country. for this reason it is important to determine the factors that lead to tb in this population. disease agent can stay in the latent phase for long periods of time after infecting the individuals. while some infected individuals show the symptoms some others never do and even % of these never develop clinical disease. various mechanisms take place during the host response to infectious agents. toll-like receptor (tlr) genes are shown to be candidate genes in these responses. materials and methods: in this study tb patients and healthy controls were included. tlr genotyping for rs , rs was performed by using a commercial taqman snp genotyping assay kit. data were summarized by count and percent. hardy-weinberg equilibrium was tested by chi-square distribution with df. differences between groups due to allelic and genotypic distributions were analyzed by pearson's exact or fisher's exact tests. in all comparisons significance level was considered to be . . results: the single nucleotide polymorphisms (snps) which were subject of this study haven't been screened in turkish population earlier. no significant association was found between tb and the snps we screened in our group of patients. discussion and conclusion: unlike other populations results we couldn't find a significant association between the disease and the genotypes of our patients. the study should be performed in bigger populations in order to confirm the results. p- . . - lytic action of bacteriophages as a tool for the obtaining of images p. boltovets , r. radutny , t. shevchenko institute of semiconductor physics nas of ukraine, kyiv, ukraine, scientific and technical center of advanced technologies nas of ukraine, kyiv, ukraine, taras shevchenko national univercity of kyiv, kyiv, ukraine obtaining of images by different types of bacteria now became a very special branch of skill at the interface between science and art. however the authors did not found any scientific article, where bacterial lawn was used as the background and the image was formed by the lytic action of the virus (bacteriophage). whereas the mentioned approach could be used not only with artistic aims but for the practical use. the aim of this work was to demonstrate a possibility to obtain the image on the bacterial lawn by the lytic action of the bacteriophage. the bacterial lawn was obtained by the standard metod using the . % agar with the nutrient medium and the . % agar containing escherichia coli culture. stencils with the preparation of the bacteriophage t were applied. samples were incubated during the twenty-four hours at + °c. after that stencils were removed and the samples were stained by coomassie blue r- or fuchsine (with further fixation by the % acetic acid). several approaches to obtain the image by the lytic action of the virus were applied. first of all stencils made from printing paper and filter paper were compared. it was demonstrated, that the use of filter paper stensil allows to obtain more accurate and controllable images, than the use of the printing paper stensil. in the next series of the experiment the possibility of the reversed stencil use (where the image is formed not by the lytic zone but by the zone of bacterial growth) was demonstrated. also the possibility of the partial staining of the obtained image was explored. it gives an opportunity to obtain polychrome images using available colorants. summarizing the above it should be noted, that it was the first time when the graphical image was obtained by the lytic action of the virus on bacteria. this approach could be used not only for the artistic aims but as well for the practical use, for example, for the restriction of the action of microorganisms in out-of-theway places. burgdorferi the identification and characterization of possible antigens is essential for the improvement of current laboratory diagnostics for lyme disease and vaccine development. in this study, several recombinant b. burgdorferi outer surface proteins have been obtained and their antigenic properties have been evaluated in an effort to characterize novel immunodominant antigens. because b. afzelii and b. garinii are the most prevalent species in latvian ticks, proteins with conserved domains were included in this study. a panel of serum samples of lyme disease patients with early and disseminate disease stage was used. the controls were matched by age and sex to the patients and represented the same geographic area. the results show that proteins of several b. burgdorferi gene families have properties with respect to their candidacy as a subunit assay for a novel lyme disease immunodiagnostic. especially, the difference in their size in a range on the western blot assay may provide good discrimination between protein bands. however, they have potential for diagnosis if used in combination with other antigens but not as a "stand alone" test. in conclusions, this study showed the existing challenges in serological testing of early lyme disease. the conservation of the sequence of antigen between species of b. burgdorferi complex is essential for the most successful serodiagnostic marker candidate. the presence of homologous proteins in treponema species could lead to the cross reactivity in syphilis patients, and should be carefully evaluated. antimicrobial resistance is one of the greatest challenges in modern medicine. there is a pressing need for better understanding of the specific mechanisms that contribute to resistance to optimize existing therapies. in in georgia extended-spectrum beta-lactamase (esbl)-producing e. coli strain was isolated from the post-surgical sample obtained from gallbladder of the patients with chronic calculous cholecystitis which belongs to the sequence type (st ) complexes with ctx-m gene. is this strain characterized by other differences on a proteome level? are antibiotics against which the strain is resistant inducing the changes in bacterial proteome? the present work was aimed (i) to study the differences on a proteome level (i) between e. coli - / -g and attc e. coli-reference strain and (ii) to compare the proteomes of strain at two conditions: with and without antibiotics. strain was grown in the presence of three antibiotics: rocephin (ceftriaxone), fortum (ceftazydym) and claforan (cefotaxime sodium) together. proteomic expression was analyzed using two-dimensional gel electrophoresis and mass spectrometry. significant differences were found for several proteins, including putative abc trnsporter arginine protein , cystine-binding periplasmic protein, fkbp-type peptidyl-prolyl cis-trans isomerase, outer membrane protein a, d-galactose binding periplasmic protein and some others. the importance of these differences for anti-microbial resistance will be discussed. p- . . - molecular characterization of resistance and virulence features in staphylococcus aureus clinical strains isolated from cutanaeus lesions in patients with drug adverse reactions i. lupu , i. gheorghe , , m. popa , , a. ion , m. mihai , v. lazar , , m. c. chifiriuc , carol davila" university of medicine and pharmacy, bucharest, romania, research institute of the university of bucharest-icub, bucharest, romania, faculty of biology, university of bucharest, bucharest, romania patients treated with epidermal growth factor inhibitors often experience cutaneous adverse reactions. however, the infectious complications of these toxic effects and the contribution of specific pathogens, such as the community emergent methicillin resistant staphylococcus aureus strains. the present study was aimed to identify the types of sccmec and virulence genes profile in clinical s. aureus isolated from cutaneous lesions of different severity degrees in patients with dermatologic toxic effects. this study was conducted on a total of s. aureus clinical strains isolated in from acneiform reactions pustulae and periungual lesions in patients with drug cutaneous adverse reactions. multiplex pcr was performed on genomic dna from isolates in order to identify the sccmeccentral elements and the virulence genes: bbp (bone bound sialoprotein), ebps (elastinbinding protein), fnbb, fnba (fibronectin-binding proteins), fib, clfa, clfb (clumping factors a and b), cna (collagen-binding protein), luk-pv (panton-valentine leucocidin), hlg (haemolysin), tst (toxic shock toxin). the mrsa phenotype was genetically confirmed by the presence of meci gene in case of . %, meca in . %, sscmec type ivd element in . %, ccrb in . % and sccmec types i, iii, iv in . % of the studied s. aureus strains. regarding the virulence genes encountered in s. aureus strains, the most frequent was clfa ( . % of the isolates), followed by clfb ( . %), fib ( . %), hlg ( . %) and bbp ( . %). these results confirm the high prevalence of mec i and sscmec type iv elements, usually encountered in communityacquired mrsa strains, in cutaneous isolates from patients with dermatologic toxic effects. more data on the virulence and genetic background of these local strains are needed to appropriately assess the risk of such infections and avoid the inappropriate administration of beta-lactams. p- . . - analysis of toxicogenic properties of staphylococcus aureus strains isolated from cows with subclinical form of mastitis in the central area of russian federation. pore-forming toxins and enterotoxins), which are present in s. aureus strains isolated from clinically healthy cows. staphylococcus strains were isolated from cow's milk. disk diffusion method was used to determine the sensitivity to antibiotics. pcr analysis was used for detection of meca, mecc genes and genes of toxins. investigated strains were resistant to oxacillin ( %), vancomycin ( %) . it was found that all strains, which contain meca and mecc genes, showed resistant to more than antibiotics. it was determined that among the investigated strains % contained meca, % -mecc, % contained both meca and mecc. some strains contained genes of panton-valentine leukocidin (pvl) or alpha-hemolysin and several strains contained both types of genes. enterotoxin a (sea) gene was detected in . % of cases, sed - %, seg - %, sei - %. genes of staphylococcal toxins b, c, e, h were not found. the presence of phenol soluble modulin biosynthesis genes was determined: genes of alpha peptide synthesis were found in % of strains, beta peptide toxin genes in %, delta toxin gene in %. it was determined, that clinically healthy animals are carriers of s. aureus strains that cause mastitis. high level of antibiotic resistance was found in strains containing meca and mecc genes. the major part of the strains carried genes of phenol soluble modulin biosynthesis. the role of phenol soluble modulins as well as of pvl and alpha-hemolyzin in the development of mastitis is not completely clear. we conclude that pore-forming toxins have dominant role in the latent form of mastitis. p- . . - impact of lactoferrin on the hydrophobicity and adherence to the inert substratum of staphylococcus aureus strains isolated from patients with cutaneous drug reaction skin healing is a complex biological process that requires the involvement of different cell types and humoral effectors. one of the main factors are aggravating and delaying the healing process is represented by the supra-infection with pathogenic or opportunistic microorganisms that grow in specialized consortia embedded in a self-produced extracellular polymeric matrix, called biofilms, which are extremely resistant to any antimicrobials and host immune response. lactoferrin (lf) is an ironbinding glycoprotein which promotes skin healing by enhancing the initial inflammatory phase, but also by inducing an overabundant immune response. the aim of this study was to investigate the influence of lf, one of the main components of innate, humoral anti-infectious immunity on some microbial features, involved in the first steps of the infectious process, such as hydrophobicity and adherence of staphylococcus aureus strains isolated from maculo-pustular lesions in patients with adverse reactions to epidermal growth factor inhibitors. for hydrophobicity measurement the bacterial suspensions were grown in the presence or absence of lf, and then, the "microbial adherence to hydrocarbons test" (math) was performed. the capacity to develop biofilms on inert substrata and the influence of lf on this feature was spectrophotometrically quantified using an adapted microtiter method, after crystal violet staining. our results showed that lf decreased the hydrophobicity and limited the biofilm development of all s. aureus tested strains, in a dose and time dependent manner. the decreasing effect on the microbial hydrophobicity was accompanied by a lowering effect on the adhesion of microbial strains to the inert substratum. in conclusion these observations indicate that lf exhibits a wound pro-healing effect, by limiting the microbial colonization and biofilm formation and thus, the occurrence of infectious complications of skin lesion. p- . . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] host-specificity determinants of bacteriophage vb_ecom_fv considered vehicles of s.aureus intoxication in humans throughout the world. the objective of the present study was to assess the presence of enterotoxigenic and methicillin-resistant s. aureus in water buffalo milk and dairy products. a total of water buffalo milk and dairy products ( water buffalo cream and water buffalo cheese) were collected from different dairy farms, smallholders and local bazaars in samsun, turkey. all samples were analyzed using the standard procedure en iso - and isolates were confirmed for the presence of the s rrna and nuc gene by polymerase chain reaction. s. aureus was identified in of water buffalo milk ( %), of water buffalo cream ( %), and of water buffalo cheese ( %). a total of isolates were confirmed as s. aureus by pcr. genotypic methicillin resistance was evaluated using pcr for the meca gene. out of isolates, ( %) were found to be methicillin resistant (meca gene positive) by pcr. the enterotoxigenic s. aureus was identified in out of ( %) isolates by the mpcr technique. five isolates produced staphylococcal enterotoxins sea ( / ; . %), two isolates produced sec ( / ; . %), one isolate produced ( / ; . %) sed, one isolate produced ( / ; . %) see and three isolates produced sec+sed ( / ; %) . none of samples were positive for seb. in conclusion, the presence of enterotoxigenic and methicillin-resistant s. aureus in milk and dairy products is of significant for public health concern and also these enterotoxin genes sea and sed are predominant toxins that can cause staphylococcus intoxication in humans. this study was funded by ondokuz mayıs university, samsun, turkey, scientific research project programs (project no: pyo. vet - . . ) and this article was part of a phd thesis. p- . . - identification and biochemical characterization of an immune modulating protein from helicobacter pylori b. kaplan t€ urk€ oz faculty of engineering, department of food engineering, ege university, izmir, turkey helicobacter pylori is able to achieve persistent infection with minimal immune response. the first line of defence during h.pylori infection is through gastric epithelial cells which present toll like receptors (tlr). a family of bacterial proteins which share homology with the toll/il- receptor (tir) domain were identified. the structure of btpa from brucella showed that bacterial tir proteins (btp) mimick human tir domain proteins and act on myd signaling pathways to suppress tlr signaling. h.pylori might also produce a similar protein. a putative h. pylori tir protein was found based on sequence homology and the corresponding gene; hp ; was cloned in fusion with an n terminal cleavable his-tag. the recombinant protein, his- was purified using nickel affinity chromatography. was subjected to limited proteolysis and the bands were analyzed by peptide mass fingerprinting (pmf). oligomerization of was investigated by in vitro pull-down and size-exclusion chromatography. , a amino acid protein, has a predicted c terminal tir domain similar to other btps and sequence alignments verified the presence of tir domain signature regions. recombinant his- was produced with a yield of mg/l culture. a structurally stable kda fragment was obtained from limited proteolysis which contained the tir domain as verified by pmf. in vitro pull down assays showed interacts with itself forming dimers as shown by size-exclusion chromatography. tir domain proteins function by interacting with themselves and other tir domains. our results showed that also form dimers, supporting that it is a btp. current research is focused on solving the structure of and investigating its interaction with myd . might play a direct role in reduced immune response against h.pylori by binding to myd analogous to other btps. further characterization of will provide the first solid evidence of presence of a tir domain protein in h.pylori. p- . . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] lipopolysaccharides with different lipid a acylation status from vibrio cholerae and campylobacter jejuni contribute differently to il production by bone marrow-derived macrophages k. korneev , , e. sviriaeva , lipid a is a biologically active part of lipopolysaccharide (lps) from gram-negative bacteria that is responsible for the activation of the innate immunity through interaction with toll-like receptor (tlr ) and subsequent production of proinflammatory cytokines. bacteria frequently transform their lipid a so that its recognition by tlr is not sufficient for induction of effective antibacterial immune response. we compared biological activity of various lps from pathogenic bacteria vibrio cholerae and campylobacter jejuni. we purified r-form lps for each strain by hydrophobic chromatography. the biological activity of lps preparations was evaluated by their ability to activate production of proinflammatory cytokine il by bone marrow-derived macrophages from c bl/ mice, using tlr -deficient macrophages to control for specificity of tlr signaling. lps from e. coli and inactive lps from f. tularensis were used as positive and negative controls. lps from v. cholerae demonstrated biological activity similar to that of lps from e. coli, consistent with the presence of highly acylated lipid a in both strains. however, the former was a slightly weaker activator than the latter, because lipid a from v. cholerae had on average shorter acyl chains. lipid a from c. jejuni had on average longer acyl groups than in e. coli, while degree of acylation was lower, and as a result its lipid a displayed significantly lower biological activity. our study demonstrates importance of functional groups of lipid a in the ability of lps to activate production of il by macrophages. in line with our previous reports, we confirmed a direct correlation between biological activity of various lps species with their lipid a acylation status: the biological activity increases with increase in the length and in the number of the acyl chains. excess proinflammatory cytokine production through tlr activation can cause sepsis, while inefficient activation may result in the failure to clear bacteria. clostridium perfringens phospholipase c (cpplc) is the most toxic extracellular enzyme produced by this bacterium and it is an essential virulence factor in the pathogenesis of gas gangrene. cpplc may lead to cell lysis at concentrations that causes extensive degradation of plasma membrane phospholipids. however, at sublytic concentrations it induces cytotoxicity without causing evident membrane damage. the results of this work demonstrated that the cytotoxic effect of cpplc requires its internalization and the activation of the mek-erk pathway. cpplc internalizartion occurs through a dynamin-dependent mechanism and in a time progressive process: first, cpplc colocalizes with caveolin both at the plasma membrane and in vesicles, and later it colocalizes with early and late endosomes and lysosomes. the results also showed that cpplc requires endocytosis in order to activate mek-erk, because treatment with the dynamin inhibitor, dynasore, prevents cpplc endocytosis, erk / activation and cytotoxcity. cholesterol sequestration as well as inhibition of actin polymerization also prevents cpplc internalization and cytotoxocity, involving endocytosis in the signaling events required for cpplc cytotoxic effect. once internalized, cpplc induces reactive oxygen species production through the activation of pkc, mek/erk and nfjb dependent pathways. inhibition of either of these signaling pathways prevents cpplc's cytotoxic effect. in addition, it was demonstrated that nfjb inhibition leads to a significant reduction in the myotoxicity induced by intramuscular injection of cpplc in mice. these data provide new insights about the mode of action of this bacterial phospholipase c, previously considered to act only locally on cell membrane. understanding the role of these signaling pathways could lead towards developing rational therapeutic strategies aimed to reduce cell death during a clostridial myonecrosis. p- . . - apoptosis induced by clostridium perfringens phospholipase c is mediated by reactive oxygen species m. flores-d ıaz , l. monturiol-gross , m. j. pineda padilla , c. araya-castillo , a. alape-gir on bacterial phospholipases are lipolytic esterases surface associated or secreted by a wide variety of bacterial pathogens. clostridium perfringens, the most broadly distributed pathogen in nature, secretes a prototype phospholipase c (plc), also called a-toxin, which plays a key role in the pathogenesis of gas gangrene. this toxin causes death to cultured cells and extensive myonecrosis when injected intramuscularly in experimental animals. the results of the present study showed that c. perfringens plc ( - ng/ml) induces morphological and biochemical changes characteristic of apoptosis in cultured cells, as determined by scanning electron microscopy. nuclei condensation and fragmentation were observed by fluorescence microscopy and a typical ladder fragmentation pattern of genomic dna was detected by dna in agarose gels. cell death was prevented by the caspases inhibitors z-devd-fmk and z-vad-fmk. c. perfringens plc induces oxidative stress in cultured cells as determined by fluorescence microscopy and flow cytometry using the membrane permeable probe dcfda. different antioxidants including the gluthation precursor nac, several iron chelators and the free radical scavengers tiron and edaravone prevent cell death induced by c. perfringens plc in cultured cells or in mice challenged intramuscularly with . lg of that toxin. thus, this work provides compelling evidence that superoxide, hydrogen peroxide, and the hydroxyl radical are involved in the cytotoxic and myotoxic effects of c. perfringens plc. furthermore, the data demonstrated that edaravone, a clinically used hydroxyl radical trap, reduced the myonecrosis and the mortality caused by c. perfringens in a murine model of gas gangrene, induced by intramuscular bacterial injection of bacteria. this knowledge provides new insights for the development of novel therapies to reduce tissue damage during clostridial myonecrosis. lectins are ubiquitous proteins able to recognize mono-and oligosaccharides with high specificity and low affinity. lectins do not have any catalytic activity, unlike enzymes, and they are not products of the immune system in contrast to antibodies. lectins play a crucial role in cell interactions on molecular level showing their importance in various physiological and pathophysiological processes as well as both mutualistic and parasitic interactions between microorganism and hosts. photorhabdus luminescens is a gram-negative bacterium from the family enterobacteriaceae. the bacteria have a complex life cycle that involves mutualistic and pathogenic interaction with two different invertebrate hosts. it is highly pathogenic towards insect larvae. in addition, p. luminescens lives in the intestine of infective juveniles of nematode heterorhabditis bacteriophora, together forming an effective entomopathogenic complex. we have identified several soluble lectins produced by p.luminescens. in this study, we focus on proteins from p. luminescens, which show a high sequence homology with each other. a wide range of methods was used for structural and functional studies of photorhabdus lectins, e.g. surface plasmon resonance, isothermal titration calorimetry, analytical ultracentrifugation and x-ray crystallography. all lectins from p.luminescens recognize l-fucose and d-mannose. despite being closely related, they differ in fine binding specificities. to determine their biological function, knock-out mutants of p. luminescens are being prepared to study its interaction with axenic nematodes and insect larvae. breast cancer is the major disease of women in developed countries occuring predominantly after the age of . triple negative breast cancer (tnbc) is a typical subtype of epithelial breast cancer which lacks estrogen receptor (er), progesterone receptor (pr) and human epidermal growth factor receptor (her ) all together. although various researches have been focused on characterizing tnbc and enlightening different molecular markers with the aim of improving the overall outcome, currently the sole affective therapy action for tnbc is chemotherapy. thus chemoresistance is the main clinical challange and accounts for % of failures in terms of treating the disease. multidrug resistance (mdr) is defined as simultaneous resistance towards the drugs which do or do not demonstrate structural resemblance and have different effects on their molecular targets. p-glycoprotein (p-gp) is a membrane protein coded by abcb (mdr- ) gene. p-gp is an atp-dependent pump which pumps a wide range of drugs out of the cells including chemotherapeutic agents such as doxorubicin (dox) and pactilaxel. in the present study, tnbc cell line mda-mb- was treated with increasing doses of dox, cell viability was examined with srb assay and development of mdr was investigated through mdr assay and rt-pcr. results demonstrated that cell viabiliy decreased significantly with the treatment of higher doses. mdr was shown to be increased when cells were treated with , and nm of the drug respectively along with lm of p-gp inhibitor verapamil. rt-pcr results were obtained to be consistent with mdr assay results and indicated increased mdr- gene expression with the treatment of dox. especially after nm of dox treatment, mdr- was overexpressed to be fold when compared to control. in conclusion, it was demonstrated that mda-mb- cells have shown to display elevated resistance to higher doses of dox. p- . . - targeting dna damage response pathway in cancer cells under heat stress and the mechanical effect of ultrasound y. furusawa , t. kondo toyama prefectural university, imizu-shi, japan, university of toyama, toyama, japan ultrasound (us) has been widely utilized for diagnosis and therapy in many medical fields. the biophysical modes of us are divided into three classes, thermal, cavitation and non-thermal non-cavitation effects. in clinical use for cancer therapy, the thermal effect was utilized for hyperthermia therapy with focusing us on cancer to rise the temperature from °c to °c, or further which could induce thermal ablation of cancers. cavitation leads to a variety of mechanical stress such as shear stress, shock wave, high pressure, and chemical stress such as free radical formation, both of which have been inferred to act simultaneously on all biological materials. it has been indicated that us induces cell killing, cell lysis, loss of viability, and loss of clonogenicity. recently, we found that heat stress as well as us without thermal effect induce not only dna single-strand breaks but also dna double-strand breaks, a most cytotoxic region of dna, in chromatin dna detected by both gammah ax staining and neutral comet assay. in response to the stresses which induce dna damage, the dna damage sensor protein kinase, ataxia telangiectasia mutated (atm), atm and rad related (atr), and dna-dependent protein kinase (dna-pk) become activated form to initiate signal transduction pathways activating cell-cycle checkpoints, dna repair, and apoptosis. the molecules consisting of dna damage response pathway were expected as therapeutic targets because defects in the response to dna damage agents can be lethal. this work was designed to explore the possible therapeutic targets of the molecules in dna damage response pathways for future us-aided therapy. finally, several kinases (e.g., checkpoint kinase) on dna damage response pathway seems to be the targets for hyperthermia and us therapy. (ural branch) , ekaterinburg, russia, shemyakin and ovchinnikov institute of bioorganic chemistry, russian academy of sciences, moscow, russia based on the recently synthesized (s)-( -aminopurin- -yl) amino acids (gly, ala, val, phe, pro), we obtained a series of novel modified nucleosides using the transglycosylation reaction. for the first time, it has been demonstrated that the corresponding nucleobases are good substrates for the genetically engineered recombinant e. coli purine nucleoside phosphorylase (conversion to nucleosides reached - %). nucleosides, such as ribosides, -deoxyribosides, and arabinosides were obtained in high yields ( - %). it has been found that yield in the transglycosylation reaction does not depend on the structure of the amino acid fragment. the nucleosides synthesized are considered as potential inhibitors of intracellular adenosine deaminase (ad), the increasing activity of which is observed in hepatitis, cirrhosis, hemochromatosis, obstructive jaundice, prostate and bladder cancer, hemolytic anemia, rheumatic and typhoid fever, gout, and cooley's anemia. cytotoxicity of the synthesized nucleosides was tested in the jurkat (model of human t-lymphoblastic leukemia) and el- (model of mice t-lymphoblastic leukemia) cell lines. the compounds studied did not exhibit cytotoxic activity compared to the activity of the known antitumor agent nelarabin. the work was financially supported by the russian science foundation (grant - - ). p- . . - dna binding, dna cleavage, antimicrobial activities, antimutagenic and anticancer studies of a schiff base and its complexes n. yildirim , n. demir , m. yildiz health services vocational school, c ß anakkale onsekiz mart university, c ß anakkale, turkey, department of biology, faculty of arts and sciences, c ß anakkale onsekiz mart university, c ß anakkale, turkey, department of chemistry, faculty of arts and sciences, c ß anakkale onsekiz mart university, c ß anakkale, turkey schiff bases are considered as favored and the most widely used ligands, due to their metal complexes having variety of applications as antibacterial and anticancer agents. the rational design and synthesis of new schiff bases and their metal complexes have been drawing great interest because of their diverse biological and pharmaceutical activities. so, exploring and designing novel molecules that have biological activities and capable of interacting with nucleic acids has a great significance for disease defence and to discover new dna-targeted anticancer drugs for chemotherapy. in this study, we report the synthesis and characterization of a novel schiff base and its ni(ii) and cu(ii) complexes. the minimal inhibitory concentration (mic) of the compounds was screened in vitro against bacteria and yeast cultures using broth micro dilution test. dna binding and dna cleavage activity of the compounds were investigated by uv-vis spectroscopy and agarose gel electrophoresis. antimutagenic activity of compounds were tested in the absence of microsomal enzymes (s -). also, cytotoxicity of the compounds against hepg cell lines was assayed by the mtt ( -( , -dimethylthyazolyl- )- , -diphenyltetrazolium bromide) method. consequently, uv-vis spectroscopy studies indicated that the compounds interact with calf thymus dna (ct-dna) via intercalative binding mode. dna cleavage activity studies showed that the cu(ii) complex can effectively cleave pbr plasmid dna. compounds inhibited the base pair mutation with high inhibition rate in the absence of s . also, schiff base complex had cytotoxic activity towards hepg cell line, that it was found to be more potent than the control cisplatin. p- . . - single particle electron tomography of rnap elongation complex, stalled at position + genome in vivo is constantly exposed to the damaging effects of the environment. single-strand breaks (ssbs) are the most frequently occurring dna lesions. accumulation of unrepaired ssbs can interfere with the cells metabolism and increase genomic instability. in vivo, ssbs are repaired in specific pathway, but, in eukaryotic nuclei, dna is organized in chromatin that could affect the accessibility of lesions to sensor proteins. breaks in a template strand induce arrest of rna polymerase ii (polii) in vitro and in vivo and can be revealed in a transcription-dependent manner. our recent biochemical studies identified two key intermediates formed during transcription through a nucleosome by rnap that are nearly homogeneous, active and stable by biochemical criteria (complexes stalled after entering or bp into the nucleosome; ec+ or ec+ , respectively). hear we produced two complexes, both stalled in the + position, one without break in the dna, and the other with introduced ssb at position + of a non-template dna strand. complexes were purified using affinity chromatography and applied to a carbon-coated, glow-discharged em grid. tomographic studies were performed at ae °in a jeol microscope at kv accelerated voltage. images were recorded using a gatan ccd camera. image analysis was performed using the imod software. the resulting structure of the ec+ complex with no break in dna consist of two domains, connected by a single dna string. the complex with a break introduced into the dna has a more compact appearance and its two domains were connected by two dna strings, thus forming an intranucleosomal dna loop. our data suggest that ssbs in a non-template strand can induce the formation of stable non-productive transcription intermediate. the inhibitory effect of ssbs onto transcription may suggest a possible mechanism for their recognition in vivo with a transcription-dependent pathway. this work has been supported by the rsf grant # - - . colorectal cancer (crc) is one of the leading causes of cancerrelated deaths in the developed countries. according to who report new incidence rate of crc in turkey is . % among other cancer types. owing to difficulty of the low allele frequency variations detection, genetic association profiles of crc have not been entirely identified. low allele frequency variations mlh À g>a (rs ) promotor substitution, mlh g>c (rs ) exonic substitution, mthfr c t (rs ) and apc t>a (rs ) were investigated in this study. these snps "rs , rs , rs , rs " are located on p . , q , p respectively. colonoscopic investigations were performed on both cancer and control group. the snps were genotyped using kompetitive allele specific pcr technology in cases and healthy controls. statistical analysis was carried out with cochran-armitage chi-square test. in this study these of the snps in mlh , mthfr genes were examined for the first time in turkish sporadic crc cases. statistical analysis showed no significant association within our turkish sporadic crc population. percentage of mlh À aa genotype in group aged ≥ was found to be . % in cancer versus % in control group. moreover apc a, mlh c alleles were detected only and allele respectively. previously, apc a allele was determined in . % of a turkish cohort. however in the present study apc a allele was detected on allele only. studies showed mlh À promoter variation as a risk factor for microsatellite instabile crc but for the current study this data is not available. in spite of literature mthfr c t and mlh g>c snps were not found to be associated with sporadic crc in turkish population. this research demonstrates that importance of population based studies in multifactorial disease. p- . . - excision of damaged bases from transcription intermediates by fpg/nei superfamily dna glycosylases k. makasheva, d. zharkov sb ras institute of chemical biology and fundamental medicine, novosibirsk, russia oxidative lesions are abundant due to constant presence of reactive oxygen species in living cells. repair of oxidative base lesions is initiated by dna glycosylases. for example, bacterial fpg and nei dna glycosylases excise oxidized purines and pyrimidines, respectively, from dna. their human homologs, neil and neil , have been reported to show preference towards oxidized lesions in dna bubbles. from these observations, it had been hypothesized that neil proteins may be involved in the repair of lesions in dna bubbles generated during transcription. however, it is not presently clear how neils would behave on bubbles more closely resembling transcription intermediates (e. g., containing the rna strand), and bacterial homologs fpg and nei had never been investigated with bubble substrates. we have studied excision of either -oxoguanine ( -oxog) or , -dihydrouracil (dhu) by e. coli fpg and nei and human neil and neil from single-strand oligonucleotides, perfect duplexes, bubbles with different number of unpaired bases ( to ), d-loops with dna or rna and from complexes with rna polymerase. fpg, neil and neil efficiently excised dhu located inside a bubble. fpg and neil was generally more active than neil in excision of -oxog from ssdna and bubbles. nei, on the other hand, was active only on dhu located in dsdna (either perfect duplex or dna/dna d-loop). fpg and neil also have shown activity in d-loops with rna. the presence of an additional unpaired -tail of the third strand of d-loops didn't affect the glycosylases activity. the activity of fpg was observed in pre-assembled transcriptional complexes with e. coli rna polymerase and depended on the position of the lesion in the transcription bubble, possibly reflecting local accessibility of the lesion within the elongation complex. this work was supported by rsf ( - - ). nucleotide excision repair (ner) is a multistep process that eliminates a wide range of lesions in dna, including uv photoproducts and base modifications by many carcinogenic and chemotherapeutic agents. one of the advanced approaches to ner process investigation is based on reproducing the repair reaction by mixing protein extracts from mammalian cells with model linear dnas, bearing lesions. long linear dnas ( bp) containing efficiently recognized and processed by ner system lesions (fluoro-azidobenzoyl photoactive lesion fab-dc, nonnucleoside lesions nflu and nant) in both strands have been synthesized. we have demonstrated that dnas containing closely positioned lesions in the both strands represent difficult-to-repair (fab-dc/nflu(+ ), fab-dc/nflu(À )) or unrepairable (nflu/nflu (+ ), nflu/nflu(À ), nant/nflu(+ ), nant/nflu(À )) structures. besides, it has been shown that model dnas bearing bulky lesions in opposite positions (fab-dc/nflu( ), nflu/nflu( )) represent unrepairable structure as well. the model substrates with increasing distance between lesions in the duplex demonstrated the full recovery of substrate properties in ner process (fab-dc/nflu(+ ), fab-dc/nflu(À ), fab-dc/nflu(À ), nflu/nflu (+ ), and nant/nflu(+ )), whereas the level of specific excision from nflu/nflu(À ), nflu/nflu(À ) and nant/nflu(À ), nant/nflu(À ) was approximately % of the nflu/dg or nant/dg dna respectively. it has been shown that modified dna-duplex ( bp) with fab-dc has decreased structurally dependent affinity for xpc-hr b compared to duplexes containing lesions in both strands being analyzed (fab-dc/dg, fab-dc/nflu(+ ), fab-dc/nflu (À ), fab-dc/nflu(+ ), fab-dc/nflu(À ), fab-dc/nflu(- )) and increased compared to umdna. the data provide an argument that the ner system of higher eukaryotes recognizes and eliminates injured dna fragments on a multi-criteria basis. it is well known that dna plays crucial role in the biological system because of including all the genetic information for cellular function. therefore, the interaction of molecules with dna has gained interest in the medicinal chemistry to explore new anticancer agent. photodynamic therapy which is alternative cancer treatment method depends on free radicals and singlet oxygen to destroy tumor tissue via necrosis and apoptosis. phthalocyanines (pcs) are used for photodynamic therapy because of their absorption of high wavelength light ability and they have high triplet quantum state yields and long lifetimes in triplet states. also they do not have any toxic effect without light. in this study the novel synthesized - [ -( morpholin- -ylethoxy) ethoxy]phthalonitrile substitued zinc(ii), manganese(ii) and copper(ii) phthalocyanines were used. the potential properties of phthalocyanine compounds for photodynamic therapy were purposed to reveal by the preliminary work. for this aim, the mode of dna binding, photocleavage and topoisomerase i inhibition of these compounds were investigated. - [ -( -morpholin- -ylethoxy) ethoxy]phthalonitrile substitued zinc(ii), manganese(ii) and copper(ii) phthalocyanine compounds have been synthesized. the interaction of novel pcs compounds with calf thymus (ct) dna was investigated by using uv-vis spectroscopy, thermal denaturation studies and viscosity measurements. additionally, dna photocleavage and topoisomerase i inhibition studies were performed to pbr dna by using agarose gel electrophoresis. the interaction studies indicated that pcs compounds powerfully bound via an intercalation mechanism with ct-dna. these compounds showed efficiently dna photocleavage under irradiation at nm. the all of pcs inhibited topoisomerase i in a dose-dependent manner. all the experimental studies showed that pc compounds might be used agents for photodynamic therapy. p- . . - target search by base excision repair dna glycosylases e. dyatlova, g. mechetin, d. zharkov institute of chemical biology and fundamental medicine, novosibirsk, russia the problem of rapid target search in dna is faced by transcription factors, restriction endonucleases, dna repair enzymes and other sequence-or structure-specific dna-binding proteins. theoretically, the fastest target search in dna can be achieved by combining one-dimensional diffusion along the dna contour (processive search) and three-dimensional diffusion (distributive search). the balance between these search modes depends on many factors affecting dna-protein interactions, such as the presence of mono-and divalent cations, competing proteins, crowding effect, etc. presently, the mechanisms of target search are understood only for a handful of enzymes. we have recently developed an assay to study target search by dna repair enzymes, based on cleavage of oligonucleotide substrate containing two targets. thus, the distance between the targets can be precisely controlled, and any modification can be introduced into dna. subsequently, the probability of correlated cleavage (p cc ) is estimated, reflecting the efficiency of enzyme transfer between the specific sites. in this work, we have investigated five repair enzymes: e. coli endonuclease viii (nei), its human homologs neil and neil , and uracil-dna-glycosylases (ung) from e. coli and vaccinia virus. as expected, p cc of all enzymes depended on the ionic strength of the solution and the presence of mg + . ung from vaccinia virus was the most sensitive to these factors, raising questions about its proficiency as a suggested processivity factor of viral dna polymerase. nei, neil and neil showed a peak of p cc at low but non-zero ionic strength indicating that nonpolar interactions contribute to binding of these proteins to nonspecific dna. this conclusion was also supported by analyzing amino acid conservation in the catalytic core of nei. introduction of bulky fluorescent group between two specific sites greatly reduced the ability of glycosylases to slide along dna. this work was supported by rsf ( - - ). p- . . - does causes mhz magnetic field application kras and p mutations in colon?: occurences histopatologically and microbiologically changes in colon determination of kirsten rat sarcoma (kras) and p gene mutations in colon. materials and methods: in this study, three groups were prepared as control,sham and electromagnetic field (emf) group. mhz radiofrequency (rf) radiation was produced by using an electromagnetic energy generator.the emf group rats were exposed to electromagnetic field for weeks as minutes per day.at the end of experiments, rats were sacrificed under ethyl ether anesthesia and the rat colons were dissected.fecal speciments were collected.fecal dna (for detection of fusobacterium and bacteroides) and colonic dna (for detection of kras and p mutations) were isolated.rt-pcr tchnique was used for detection of bacterias and mutations. results: no any differences was observed histopathologically between control and sham groups.erosions and partial losses were observed at mucosal epitelium in the emf group.the corrupted gland structure, the mucosal edema and the inflammatory cell infiltration were observed.the amout of collagen was increased and fibrosis was detected in emf group.goblet cell number decreased statistically significant when compared to control and sham groups (p < . ).the amount of fusobacterium increased significantly in emf group compared to controls.the difference was not detected between groups in the amount of bacteroides.all the samples analysed for kras and tp mutations in the colon tissue were found to be wild type.no significant difference was observed between the control group and the emf applied group. discussion and conclusion: in conclusions,for weeks minute/day exposure to mhz emf caused histopatological damage in rat colon.the amount of fusobacterium is increased.emf exposure did not caused to kras and p mutations in colon tissue. p- . . - synthesis, antimicrobial activity, genotoxicity, dna binding and dna cleavage studies of new glycine methyl ester derivative schiff base there has been an increasing focus on the binding study of small molecules to dna during the last decades, since dna is an important genetic substance in organisms. therefore, the current growing interest in small molecules that are capable of binding and cleaving dna is related to their utility in the design and development of synthetic restriction enzymes, new drugs, dna agents, and also to their ability to probe the structure of dna itself. in recent years, schiff bases have found increased application in pharmaceutical research, organic synthesis, and bio-processes. schiff bases are considered as favored and the most widely used ligands, due to their metal complexes having variety of applications as antibacterial and anticancer agents. in this study, we report the synthesis and characterization of a novel glycine methyl ester derivative schiff base. the minimal inhibitory concentration (mic) of the compound was screened in vitro against bacteria and yeast cultures using broth micro dilution tests. antimutagenic activity of compound was tested in the absence of metabolic activation. also, dna binding and dna cleavage were investigated of compound by uv-vis spectroscopy and agarose gel electrophoresis respectively. consequently, this compound differs significantly in its activity against tested microorganisms. this difference may be attributed to the fact that the cell wall in gram-positive bacteria is a single layer, whereas the gram-negative bacteria cell wall is a multilayered structure, and the yeast cell wall is quite complex. the compound inhibited the base pair mutation in the absence of s with high inhibition rate. uv-vis spectroscopy studies of the interactions between the compound and calf thymus dna (ct-dna) showed that the compound interacts with dna via intercalative binding. to date a large number of the sequences in the human genome (g motifs) with the potential to form a spatial structure, gquadruplexes is known. g motifs were found in the promoter regions of most of the known oncogenes. recent experimental studies have shown that genome instability directly related to the non-canonical dna structures, including g-quadruplexes. in this work we study the distribution of somatic snvs within the g motifs in tumor samples with the aim to identify involvement of the motifs in the process of mutagenesis in pancreatic cancer. using the access kindly provided by the international icgc consortium to the database, we analyzed samples of pancreatic ductal adenocarcinoma and samples of pancreatic endocrine neoplasms. we considered only the promoter regions as the richest with g-quadruplex motifs. we found that quadruplex sequences have the ability to focus somatic snvs. this could be explained by the errors of polymerase during replication through secondary dna structures. furthermore, the snvs occur much more often in loops of g motifs than in g blocks, without changing the motive. in addition, t>g(a>c) and t>c(a>g) substitutions occur significantly more likely in loops which in turn stabilize the g-quadruplex structure. the cancer-related mutations tend to increasing the length of g blocks. the conservation of g motifs may indicate an important functional significance of g-quadruplex structures in human genome. supported by project no. - - of the russian science foundation. background: multiple myeloma (mm) is a rare, leading to bone destruction and marrow failure, largely incurable malignant disease of plasma cells. anemia (mostly normocytic normochromic) is seen in most patients. mean platelet volume (mpv) is a laboratory marker of platelet function and activity, the most accurate measure of platelet size. the aim of this study was to investigate the mean platelet volume (mpv) values in this disease. materials and methods: whole blood samples were collected from healthy controls and patients with mm. the mean age for controls and patients were . ae . and . ae . years, respectively. mpv levels were calculated with cancer is a chronic disease in the world which is the second leading cause of death, after cardiovascular diseases. benzimidazoles have been known to act as antiproliferative or anticancer agents in chemotherapeutic drug research area. in this regard we aimed to investigate the cytotoxic and apoptotic properties of novel benzimidazole derivatives bearing pyridyl/pyrimidinyl piperazine moiety against a lung adenocarcinoma cells. a lung adenocarcinoma cell lines were used in the studies. the cytotoxic activities of the tested compounds were determined by mtt assay. detection of apoptosis was performed using annexin v-fitc apoptosis detection kit bd, pharmingen according to the manufacturer's instruction. all measurements were performed on a facs-calibur cytometer. the ic values of the compounds were determined for a cell line. compounds , and which were including -chlorophenyl, -nitrophenyl on pyridine ring; -fluorophenyl on pyrimidine moiety, had significant cytotoxic activity with ic values lower than . ae . lg/ml. compound showed the highest cytotoxic activity with a ic value of . ae . lg/ml, whereas cisplatin ic values were . ae . lg/ml lg/ml against a cells. cytotoxic activity of compound and with a ic value were . ae . and . ae . lg/ml, respectively. also, compound showed the highest population of early apoptotic cells ( . %) of the tested compounds which was . -fold higher than for cisplatin. compound produced a comparable population of apoptotic cells with a percentage of . %, respectively according to cisplatin's percentage of . %. it was determined that synthesized compounds , and had considerable anticancer activity against a cell lines compared to cisplatin. compound including -florophenyl on pyrimidine ring was the most cytotoxic compound against the a cell line. our study results demonstrated that compound , also induced apopototic pathway on a cells. p- . . in vitro/in vivo antimitotic activity and structure-activity relationships of new glaziovianin a isoflavone series glaziovianin a (gva), isolated from the leaves of the astelia glazioviana, demonstrated cytotoxicity, disrupting microtubule structure and dynamics of hl- cells. the aim of the present work was to devise a concise synthetic route toward gva and its derivatives in order to expand structure-activity relationship studies and to investigate their anti-mitotic effect. a concise six-step protocol for the synthesis of gva and its alkoxyphenyl derivatives starting with readily available plant metabolites from dill and parsley seeds was developed. the sea urchin embryo tests confirmed that gva directly affects tubulin/ microtubule dynamics and structure. the b-ring substitution pattern of gva derivatives exhibited strong effects on activity. according to the assay results, the anti-mitotic activity decreased in the following order: gva > myristicin ≥ , , -trimethoxyphenyl = -methoxyphenyl > dillapiol > -methoxyphenyl> , dimethoxyphenyl > , , , -tetramethoxyphenyl derivatives. a methylenedioxy moiety was essential for the activity of compounds substituted with four b-ring alkoxy groups. the mts assay of the limited panel of cancer cell lines shows that gva displayed the highest inhibitory activity, with ic values ranging from . (a cells) to . lm (mda-mb- cells). compounds, containing , , -trimethoxy and apiol-derived b-rings, respectively, were less active. other isoflavones did not affect cancer cell growth up to lm. anti-proliferative effects of isoflavones observed in both the sea urchin embryo model and human cancer cell lines correlated well. importantly, none of the synthesized isoflavones demonstrated cytotoxicity in human pbmcs, up to lm. in summary, gva and its analogues were synthesized via a scalable six-step reaction sequence. the gva and its analogues containing , , -trimethoxy and apiol-derived b-rings were found to be promising anti-mitotic microtubule destabilizing agents with low toxicity against human pbmcs. bag- is a multifunctional protein which has interactions with a number of cellular proteins; nuclear hormone receptors, bcl- , hsp /hsc family, growth hormone receptors, raf- , ubiquitin machinery and dna to regulate cell survival. for this reason, bag- is a critical molecular player in the regulation of cell survival signaling and apoptosis mechanism. elevated expression levels of bag- are associated with progression of cancer. in the treatment of breast cancer, silencing tools as a promising combined therapy strategies in the presence of classical chemotherapeutics gain importance to investigate interaction networks of cell death and survival signaling pathways. therefore, we aim to understand potential role of bag- silencing in the treatment of breast cancer cells with apoptotic agents; cisplatin or paclitaxel. our results showed that, silencing of bag- enhanced cisplatin or paclitaxel-induced apoptosis in mcf- cells by down-regulating antiapoptotic and upregulating proapoptotic bcl- family proteins, changes on cell cycle, upregulation on subg phase, activating caspases and cleavage of parp. in addition, knockdown of antiapoptotic bag- has a suppressive role in pi k and akt signaling pathway in mcf- breast cancer cells through inhibition of akt phosphorylation and downregulation on pi k. investigation targets of akt pathway showed that mtor cell survival pathway also affected through bag- silencing. bag- silencing inhibited mtor signaling via downregulating both rictor and raptor proteins which are the members of rapamycininsensitive mtorc and rapamycin-sensitive mtorc complexes, respectively. knockdown strategies of bag- is important to enlighten the network interactions of bag- and clarify its interaction partners in the cells. therefore utilization of bag- targeted strategies might further increase therapeutic efficiency of drugs through inhibiting cell survival machinery in the treatment of metastatic breast cancer. p- . . - biological activity evaluation of new , , trisubstituted triazine derivatives bearing different heterocyclic rings against lung cancer cell lines l. yurttas, g. akalin c ß iftc ßi, h. e. temel, b. demir anadolu university, eskisehir, turkey cancer is one of the major death causing disease worldwide. among the various cell types occurs on different organs, lung cancer is one leading cause of cancer death accounting for approximately % of all female and % of all male cancer deaths in . the resistance development, cytotoxicity and inadequacy are the main encountered problems by the treatment with existing chemotherapeutic agents. therefore, there is continuous need to discover new active and non-toxic molecules. -[ -( , -bis( -substituted phenyl)- , , -triazin- -yl)piperazin- -yl]- -[benzimidazole/benzoxazole/benzothiazole- -yl)thio]ethanone ( - ) derivatives were synthesized with a four-step synthetic procedure using toluil, anisil and -chlorobenzil as starting materials. the anticancer activity of the compounds was evaluated using the methods mtt ( -( , -dimethylthiazol- -yl )- , -diphenyltetrazolium bromide), brdu (bromodeoxyuridine) assays and flow cytometric analysis against lung cancer cell lines. the lipoxygenase enzyme inhibition activity of the compounds were also investigated using the method described by baylac and racine. compounds was found to have (inhibition concentration) ic values between - lg/ml. the early and late apoptotic cell percentage was determined as . for compound by flow cytometric analysis. the lox inhibition activity was found . ae . for compound . compound bearing -chlorobenzil and benzoxazole moieties was found as the most active compound when we evaluate anticancer potential of all compounds. the lox enzyme inhibition was indicated for the compound including methyl substituent on phenyl rings. the dna synthesis inhibition of the compounds has been still studied at the concentrations ic / , ic and ic x . p- . . - single amino acid substitutions and deletions modulate the drp-lyase activity of human dna polymerase iota n. miropolskaya, i. petushkov, a. kulbachinskiy, a. makarova institute of molecular genetics, moscow, russia dna polymerase iota (pol ι) is a y-family dna polymerase that possesses an unusual combination of properties. due to the special organization of the active site pol ι has a very low accuracy of dna synthesis but possesses an ability to bypass a variety of dna lesions. in addition to the dna polymerization activity, human pol ι also possesses an intrinsic -deoxyribose phosphate (drp)-lyase activity. removal of the drp group is a pivotal step in base excision repair (ber) in vivo. although pol b plays a key role in the drp group cleavage and dna synthesis during ber, pol ι was shown to complement the in vitro single-nucleotide ber deficiency of pol b null cell extracts and was suggested to be involved in ber under oxidative stress. the drp-lyase active site in pol ι is still not known. to address the mechanism of the drp-lyase activity of pol ι we obtained a series of pol ι mutant variants including point mutations of conserved lysine residues and deletions in different locations. we purified human pol ι variants from yeast saccharomyces cerevisiae and tested the effect of mutations on the cleavage of an internal -drp group in oligonucleotide dna substrates in the presence or absence for me + ions. the experiments revealed several point amino acids substitutions that significantly affected the drp-lyase activity of pol ι, thus suggesting a possible location of the drp-lyase active site. furthermore, we showed that deletions in the n-terminus of pol ι and metal ions modulate its drp-lyase activity, which may play an important role in the regulation of pol ι activities in vivo. this work was supported by russian foundation for basic research grants - - -a and - - -mol-a-mos and by the russian academy of sciences presidium program in molecular and cellular biology. rosmarinus officinalis, commonly known as rosemary, is an aromatic plant belongs to lamiaceae family. from past to now, rosemary have been used as a traditional medicine to cure for various illnesses such as diabetes, rheumatism and cancer. recent studies have shown that rosemary is effective for various cancer types. in this study we aimed to investigate the effect of rosemary in glioblastoma cells (gbm) by comparison with etoposide and the effect of rosemary by concurrent application with the etoposide. gbm cells (u mg) were seeded into the well plates and cultured with dmem supplemented with % fetal bovine serum. rosmarinus officinalis tea was prepared just as traditional usage and filter sterilized. at the second day of the culture rosemary in / (v/v) dilution ratio was given to first group, lm etoposide was given to second group, / (v/v) diluted rosemary and lm etoposide together were given to third group. after one day incubation cell viability was measured by neutral red assay. it was observed that rosemary reduced the viability of gbm cells by nearly % , etoposide reduced the viability by nearly % and rosemary with the etoposide reduced the viability by nearly % . the results showed that rosemary was able to reduce the viability of gbm cells but hadn't got an increasing or inhibiting potential over the etoposide's cytotoxic effect. from our previous studies we know that rosemary increases the proliferation of mouse embryonic fibroblasts. it is considered that rosemary might have a protection potential from dna damages and when rosemary is used with etoposide during the cancer treatment, it might reduce the side effects on healthy cells. in conclusion rosemary promises hope for developing new cancer treatment strategies and reducing the side effects of chemotherapeutics. for further studies it is aimed to examine the effects of rosemary with other chemotherapeutics and if rosemary has got a protection potential from the genotoxic stress. morpholine moiety has been found to be an excellent pharmacophore in medicinal chemistry and a number of molecules possessing morpholine skeleton are the clinically approved drugs. in this present study, we aimed to investigate the possible underlying apoptotic mechanism for the cytotoxicity of new morpholine dithiocarbamate derivatives bearing -( -aryl- -oxoethyl)- -substituted benzimidazole moiety on c glioma. c glioma cell lines were used in the studies. the cytotoxic activities of the tested compounds were determined by cell proliferation analysis using standard ( -( , -dimethylthiazol- -yl)- , diphenyltetrazolium bromide (mtt) assay. detection of apoptosis was performed using annexin v-fitc apoptosis detection kit bd, pharmingen according to the manufacturer's instruction. all measurements were performed on a facs-calibur cytometer. the ic values of the compounds were determined for c cell line. compounds , , , , and , which were including hydrogen, -methyl, -methoxy, -chloro and -floro substituents on phenyl acetyl moiety, had significant cytotoxic activity with ic values lower than lg/ml. compound showed the highest cytotoxic activity with a ic value of lg/ml, whereas cisplatin ic values were lg/ml against c cells. cytotoxic activity of compound , , , and with a ic value were , , and lg/ml, respectively. compound , and showed the highest population of early apoptotic cells as . , . , and . % respectively compared to cisplatin ( . %). also, compounds caused dna synthesis inhibition depend on their ic values by brdu assay. conclusions: it was concluded that synthesized compounds had considerable anticancer activity against c cell lines. however, compound , and including -methyl, -chloro and -floro substituents were the most active compounds against the c cell line. also our study results showed that compound , , induced apoptosis in c glioma cells. rutin is a glycosided flavonoid and known to have antioxidant and anti-inflammatory properties.trail induces the apoptosis of tumor cells and has no significant toxic effect on normal cells. although trail is a promising anticancer agent, trail resistance is a major barrier to effective cancer therapy. this study was conducted to examine the utility of the combined use of rutin and trail in prostate cancer cells. pc- and du prostate cancer cells were treated with rutin ( - um) and/or trail ( ng/ml), cell viability and migration were examined. cell viability was determined by trypan blue exclusion and mtt assay. cell migration was determined by wound healing assay. furthermore, lactate dehydrogenases (ldh) levels of medium were determined as biochemical markers of cell viability. pc- and du- prostate cancer cells were treated with rutin for and hours incubation and ic doses for hours incubation were determined um and um respectively. treatment with rutin, pc- cells is more sensitive than du cells. rutin and rutin plus trail inhibit prostate cancer cell growth in a dose-dependent manner. treatment with trail has no effect at inhibiting growth of pc- and du prostate cancer cells. the combination of rutin and trail elicit a synergistic antitumor effect on pc- and du prostate cancer cells. there is a significant increased in rutin and rutin+trail treatments group of ldh activities with respect to control and trail group. conclusion: present data show that rutin efficiently enhanced trail effects in prostate cancer cells. combined treatment with rutin and trail is more effective than the individual treatments of trail at inhibiting growth of prostate cancer cells. p- . . - determination of antigenotoxic, proliferative and cytotoxic properties of ellagic acid since ancient time, people use plant for traditional treatment. plants or fruits are produced different type of secondary metabolites. particularly phenolic phytochemicals from plants play an important role in the prevention and treatment of radical damage by inactivating the reactive oxygen compounds due to their antioxidant properties. however, the structure and the activities of many herbal products are not fully elucidated yet and there are several studies about the toxicity of herbal antioxidants and their possible risks to human health. ellagic acid, phenolic compounds, is an important substance. ellagic acid is a naturally occurring plant phenol found in numerous fruits, including blackberries, raspberries, strawberries, cranberries, walnuts, pecans, pomegranates and wolfberries. different researchers give some information about the biological activities of ellagic acid. in this study, we aimed to determine the cytotoxic, proliferative and antigenotoxic effects of ellagic acid, which is phenolic compounds found in natural products. cytotoxic effects of ellagic acid on huvec is investigated by lactate dehydrogenase (ldh) and cell proliferation (wst- ) methods; and antigenotoxic effects against ccl on human lymphocytes is investigated by single cell gel electrophoresis (comet) methods. the rusults showed that high concentration ( and lm) of ellagic acid has cytotoxic and mutagenic effects, but showed antiproliferative effects. on the contrary, low concentrations ( , , . lm) of ellagic acid has anticytotoxic and antimutagenic effects. as a conclusion, low concentrations of ellagic acid might be use treatment of some disease. but high concentrations of ellagic acid constitute a risk factors for people. keywords: cytotoxicity, antiproliferation, wst- , ldh, rtca-sp the constitutive nuclear factor kappa b (nf-kb) activation is widely found in diverse types of hematologic malignancies such as acute myeloid leukemia (aml) and chronic myeloid leukemia (cml) as well as solid tumors. inhibition of nf-kb signaling via proteasome inhibitors such as bortezomib can induce apoptosis in myeloid leukemia cell lines. however it is not clear whether the cytotoxic effects of bortezomib on myeloid leukemia cell lines is due to direct inhibition of nf-kb or another pathway, such as dna damage. in this study, cml cell line k and aml cell line hl- were treated with bortezomib (bor) , etoposide (eto) and camptothecin (cpt) alone or in dual combination with these drugs, following by measuring the effects on cell viability, apoptosis and signal pathways. the effect on cell viability was determined using the mtt assay. the data were used in combination index and isobologram analysis. the expression levels of apoptototic genes (bcl , bax and caspase ), the related dna damage genes (atm and atr) and the involved genes in nf-kb signaling (rela and p ) were determined by real time rt-pcr. we showed that combinations of bor with topoisomerase inhibitors (cpt and eto) exhibited synergistic cytotoxic effect in k cell line but not in hl- cell line. the combination treatment increased apoptosis and dna damage response. dnadamage-sensing kinases were detected in k and hl- cells following treatment with bor as similar as topoisomerase inhibitors. bor increased the mrna levels of atm and atr dramatically, which indicated active dna damage in the myeloid cell lines. furthermore, bor induced apoptotic cell death by decreasing bcl and increasing bax and caspase levels. these effects of bor were observed to correlated with increasing the p expression levels. this study on the mechanism of action of bor indicates that this compound affects several pathways involved in the control of cell cycle progression, apoptosis and dna damage. p- . . - analysis of molecular cytogenetic alterations in gastric and colon carcinoma by array-based comparative genomic hybridization (array cgh) introduction: genomic dna regions are frequently lost or gained during tumor progression. we aimed to evaluate tumor samples of patients with gastric cancer and colorectal carcinoma to show these genetic alterations by array-based comparative genomic hybridization (array cgh) method. materials and methods: dna isolation was performed from the tumor samples obtained from sixteen patients with primary gastric adenocarcinoma and twelve patients with colon adenocarcinoma. then, agarose gel electrophoresis was performed in those dna samples. following electrophoresis of dna, array cgh procedure was performed to four patients with gastric adenocarcinoma and three patients with colon adenocarcinoma who had dna breaks with - kb. results: after array-cgh study, many common genetic changes in gastric and colon cancer genome were determined. in gastric cancer dna samples, common losses were detected in chromosome p . , p . , q , q , p . , q . , q . , q . , q . , p , q . , q . , q . , q . , q . , q . , and q . , and also common gains were detected in chromosome p . , q , q . , q . and xq . in colon cancer dna samples, common losses were detected in chromosome p . , q , p . , p . , q . , q . , q . , q . , p . , p . , q . , and q . , and also common gains were detected.in chromosome q . , xp . , xp . , xp . , xp . and xq . both in gastric and colon cancer dna samples, common losses were detected in chromosome q . , q . , and p . , and common gains were detected in xq . discussion and conclusion: we think that these common changes, generally in dna loss areas harboring tumor suppressor genes and dna gain areas harboring oncogenes, may important in gastrointestinal tumorigenesis. the dna of every cell is under a constant attack by various mutagenic factors which damage the dna and can cause cell cycle arrest and even cell death. accumulation of dna damage is the basis for cancer development and one of the reasons for aging of the organisms. in order to preserve the integrity of its dna cells have evolved an impressive array of dna repair pathways, which are precisely coordinated with the progression of the cell cycle. one of the first events at the site of dna damage is poly(adp-ribose) polymerase (parp ) recruitment which is a sensor for single strand breaks in dna. parp catalyzes the synthesis of poly(adp-ribose) or par which is needed for the recruitment of many other dna repair proteins by means of par-binding domains. we used high speed confocal spinning-disk microscopy of living cells to obtain precise kinetics of recruitment of par-dependent proteins to the sites of laser induced dna damage. our results show that the investigated par-dependent proteins are recruited to dna damage sites in the matter of seconds, they reach peak intensities for to seconds after damage infliction and start dissociating. the recruitment of the proteins is entirely dependent on par because addition of parp inhibitor abbrogated their recruitment. the use of spinning-disk microscopy of living cells allowed us to obtain the kinetics of recruitment of the studied proteins to the sites of dna damage. the results are consistent with the fact that parp and par-dependent proteins are quickly recruited to damage sites and generation of par is essential for other dna repair protein recruitment. the precise kinetic curves may serve as a basis for investigating how they will change or if they will change at all when cells are put in different conditions or treated with various chemical substances affecting dna metabolism and repair. introduction: chronic myeloid leukemia (cml) is a myeloproliferative disease associated with reciprocal translocation between chromosomes and . bcr-abl fusion gene which exhibits constitutively active tyrosine kinase activity has a main role in cml. the tyrosine kinase inhibitor imatinib is used as a first line treatment in cml patients, but imatinib resistance leads to failure in therapy. the application of imatinib in combination with other anticancer agents may be a strategy to increase the antileukemic effect of imatinib. in this study, we have investigated the antiproliferative effect two novel agents: a benzamide derivative xt and a benzoxazole derivative xt b in combination with imatinib. these molecules were investigated in imatinib-sensitive (k s) and imatinib-resistant (k r) cml cell lines. materials and methods: antiproliferative and apoptotic effects were assessed by mtt assays and flow-cytometry, respectively. we also evaluated the effects of these compounds on the expression of apoptosis-related genes bax, bcl- , bad, bim, bcl-xl and mcl by real-time quantitative pcr. results: treatment of k cells with xt increased the expression levels of the pro-apoptotic genes bax, bad and bim in both sensitive and resistant cells. however, xt b was not found to have similar effects on k r and k s cells. combined application of xt increased cell death in the mtt assay. mtt assay demonstrated that ic for xt treated cells in k r with imatinib (ic = . ) is lower than k r without imatinib (ic = . ). discussion and conclusion: our results showed that combining xt with imatinib has more antiproliferative and apoptotic effect on a cml cell line. as a result combination of xt with imatinib can be an alternative approach to overcome imatinib resistance. introduction: the mmr(mismatche repair) system recognizes base-base mismatches and insertion or deletion loops in doublestranded dna, and it degrades the error-containing region of the newly synthesized strand, allowing the polymerase to correctly resynthesize the second strand according to the template sequence. the human mmr system includes the mlh and msh . alteration in expression or a defect in mlh or msh can cause resistance to anti-cancer drugs used in chemotherapy. the attempt of the mmr system to detect drug induced dna damage, triggers the activation of apoptosis, a mechanism which may enhance the cytotoxicity of chemotherapy. loss of the mmr system would make the neoplastic cell less able to initiate apoptosis. inability to initiate apoptosis could be a mechanism of resistance to drugs. chronic myeloid leukemia (cml) is a clonal disease originating from aberrations in hematopoietic stem cell. imatinib, a tyrosine kinase inhibitor has significantly improved clinical outcome for cml patients. however, patients develop resistance when the disease progresses to the blast phase (bp) and there are several mechanisms involved in imatinib resistance. in this study we investigated the role of mmr system in imatinib resistance. materials and methods: k s (sensitive) and k r (resistance) were grown in rpmi- . k r cells were maintained in rpmi- medium supplemented with lm imatinib rna isolation, cdna synthesis, rt-pcr was performed respectively. results: the results demonstrated that expression of mlh in k r cells is dramatically lower than equal amount of imatinib treated k s cells, whereas msh expression level did not change in both cell lines. conclusion: it can be suggested that alteration and down-regulation of mlh genes leads to imatinib resistance. p- . . - characterization of interaction between rad inhibitor dids and human serum albumin d. velic, s. henry, c. charlier, m. popova, p. weigel, j. masson, i. nabiev, f. fleury cnrs/university of nantes, nantes, france -diisothiocyanostilbene- , -disulfonic acid (dids) has been largely used during the last years for its inhibitory effect on anion transporters and channels. more recently, ishida and colleagues have described a possible mechanism by which dids inhibits rad -mediated homologous pairing and strand exchange, key processes in dna repair by homologous recombination. thus, dids could act as a potential revertant of radioand chemo-resistance in cancer cells, which is the major cause of failure during therapeutic protocols. new drugs targeting rad protein have since been developed with potential use for medical applications. in this context, we attempted to determine the behaviour of dids towards blood and plasma proteins such as serum albumins. firstly, we analysed the effects of several environmental factors such as solvent polarity, which may affect the stability of the molecule. secondly, we analysed the spectroscopic properties of dids in the presence of human or bovine serum albumin proteins. uv-visible absorption, circular dichroism, fluorescence spectroscopy and isothermal calorimetry were used. here we show for the first time that dids can interact with both serum albumins. we have also determined the characteristics of these interactions. the comparison of several dids derivatives led us to identify the essential chemical moiety of this compound involved in the interaction. moreover, by using site competition approaches we show that the main binding site for this molecule is in subdomain ib of the protein. these findings show that the binding of dids to serum albumin proteins may change the equilibrium between the free and bound dids forms, thereby affecting its bioavailability and efficiency against the rad recombinase protein. p- . . - mechanism of tap beta-mdm autoregulation p is a transcription factor which is the member of a p family. it regulates many cellular processes, such as apoptosis, cell cycle, and senescence. in contrast to p , p is rarely mutated in tumors and elevated p expression is observed in many types of cancers including hepatocellular carcinoma, neuroblastoma, and lung. defining regulatory mechanisms which control p protein abundance and activity will be crucial for the development of new therapeutic strategies for cancers. mdm is known as the key player in regulation stability and activity of p . in addition, p induces mdm transcriptional activity, and caspase- , activations which cleave mdm n-terminal at asp . cleaved form of mdm binds p and promotes its stabilization. mdm suggested as a candidate to modulate p activity and stability too. however, an interaction between p and mdm has not defined well. in this study, we aimed to analyze the role of mdm in p stability. to define this relationship, firstly, we overexpressed the tap beta isoform using trex system in hep b. tap beta and mdm protein levels were determined by western blot. to examine whether mdm mediate tap beta protein degradation by the proteasomes, cells were treated with proteasome inhibitor, mg for hours prior to analysis. previous studies showed that p -induced caspase- and caspase- activation cleaves mdm . considering this, we firstly examined caspase- activation by western blot in hep b tap beta cells. then we analyzed expression of cleaved mdm and tap beta levels following caspase inhibitor, z-vad-fmk treatment. as a conclusion, tap beta-induced full-length mdm- expression. furthermore, tap beta enhanced cleavage of mdm via increased caspase- activation. in addition, inhibition of caspase- activation caused a decrease in cleaved-mdm levels in parallel with tap beta expression repression. our results suggested positive regulation between mdm -tap beta. hepatocellular carcinoma (hcc) is one of the most common type of liver cancer and third leading cause of cancer related deaths in worldwide. discovery of new targets is important in survival of hcc patients. p is a transcription factor which is the member of p family. it has two promoters; while p promoter expresses apoptotic ta isoforms, p promoter expresses anti-apoptotic dn isoforms. in addition, alternative splicing in c terminal creates many isoforms of ta and dn p . it has been shown that both tap and dnp isoforms are expressed in hcc patient tissue and cell lines. the ratio between tap and dnp affects the apoptotic response, drug response and prognosis. accordingly, identification of the role of p and its targets are important in discovery of new treatment strategies in hcc. to understand the role of p isoforms in hcc, firstly we performed mtt assays following dna-damaging drugs and multikinase inhibitor, sorafenib treatment to categorize hcc cell lines as resistant or sensitive. after that, we analyzed the expression levels of tap isoforms via western blot in all hcc cell lines. then we overexpressed the tap beta isoform using trex system in hep b and snu cells. these two clones were analyzed for dna damaging drug response by mtt, cell cycle and apoptosis by flow cytometry, and tumor formation by in vitro and in vivo experiments. in scope of our study; . only tap alpha isoform is expressed in a few hcc cell lines. . there is no correlation between basal expression of p isoforms and drug responses in hcc cell lines. . there is no change in expression of p isoforms after treatment of drugs. . we showed that the ectopic expression of tap beta in hep b arrested the cell cycle in g / s and decreased the colony formation. therefore, the capacity of tumor formation of the cells dramatically decreased in scid mice. as a result, we revealed that tap beta play role in tumor formation, cell cycle arrest, dna damage responses in hcc. p- . . - biochemical characterization of exonuclease iii-family ap endonuclease point mutants reveals role of conserved amino acid residues in the nir-specific enzymes a. mursalimov, z. koshenov, t. yeleussizov, m. redrejo-rodriguez, a. ishchenko, b. t. matkarimov, m. saparbaev national laboratory astana, astana, kazakhstan oxidative dna damage caused by reactive oxygen species is believed to be a major type of endogenous cellular damage. oxidatively damaged dna bases are substrates for two overlapping repair pathways: dna glycosylase-initiated base excision (ber) and apurinic/apyrimidinic (ap) endonuclease-initiated nucleotide incision repair (nir). in the ber pathway, an ap endonuclease cleaves dna at ap sites and -blocking moieties generated by dna glycosylases, whereas in the nir pathway, the same ap endonuclease incises dna to a number of oxidized bases. majority of characterized ap endonucleases possess classic ber activities and about half of them are able to catalyze nir activity. at present, the molecular basis of dna substrate specificities of various ap endonucleases remains unclear. here, we examined amino-acid sequence requirement of the nir activity of human major ap endonuclease (ape ). amino acid sequence alignment of various ap endonucleases including e coli exonuclease iii (xth), human ape and archaeal mth revealed conserved amino acid residues in the nir-specific ap endonucleases ape , mth and exoa that are absent in xth. based on these data, we constructed four ape point mutants y h, n q, g s and t d and examined their dna substrate specificities. results obtained from biochemical characterization of ape mutants are discussed in the light of the evolutionary conserved dna repair functions of ap endonucleases and whether these functions can be mutationally separated from. since its discovery some years ago, cisplatin has evolved for its efficacy in one of the most used drugs in treatment of various cancer types. huge effort was invested in understanding the action of cisplatin and development of more potent drugs. they target mainly neighboring purine bases of nuclear dna forming covalent intra-or inter-strand cross-links that affect inhibition of replication and transcription, cell cycle arrest, and attempted repair of the damaged nucleotides. if such damage cannot be removed the cell dies. we have studied the details of the binding site of the short oligonucleotide modified by a platinum compound using complementary solution techniques used in modern structural biology, including raman spectroscopy with dft calculations aided interpretation of the obtained vibrational spectra. moreover, the calculated structure of the dna duplex was verified using saxs (small angle x-ray scattering) curve. in our contribution, we will present an nmr structure of a dna cross-linked with a cisplatin derivative containing a cyclohexane ring. at this atomic level resolution, structural features probably influencing cytostatic effects are described and compared with previously published structures. common structural features of previously determined structures are: a significant roll ( - °) of the guanine bases involved in the cross-link, bending and unwinding of the double helix at the site of cross-link and orientation towards the major groove. also, the platinum-guanine plane angle varies between and °. although the experimental structures were often used as the starting models for molecular dynamics (md) simulations, results of these md still leave many questions unresolved. the results of this research have been acquired within ceitec (lq ) project with financial contribution made by the ministry of education, youths and sports of the czech republic within special support paid from the national programme for sustainability ii funds. p- . . - ercc /xpd polymorphisms and colorectal cancer risk: a case control study in a north eastern iranian population j. mehrzad islamic azad university, neyshabur, iran excision repair cross-complimentary group (ercc ) is one of the important dna repair genes.ercc codon and polymorphisms has been shown to modulate cancer risk. we therefore assessed the relationship between the ercc polymorphisms and the susceptibility to colorectal cancer in a case-control study. there were lung cancer cases and matched healthy controls in this study. information concerning demographic and risk factors was obtained, each person donated ml blood for biomarker testing. ercc genotypes were determined by t-arms-pcr method. all of the statistical analyses were performed with spss (v . ). there was significant difference between the frequencies of ercc polymorphism in cancer cases and controls (p < . ). the frequencies of ercc gln allele were . % in controls and . % in cancer cases. the individuals with lys/gln+gln/gln combined genotype were at an increased risk for lung cancer as compared with those carrying the lys/lys genotype (adjusted or= . , %=ci . À . ). the above findings indicate that the genetic polymorphism in the ercc codon is associated with the risk of colorectal cancer in an iranian population (neyshabur citizenship). peptide pore blockers are potent tools to study structure and function of potassium voltage-gated channels (kv). kcsa-kv .x chimeras, in which a ligand-binding site of eukaryotic kv-channel is inserted into bacterial kcsa channel, mimic properly the pore domain of kv-channels. a fluorescence-based approach to study the binding of peptide blockers with kcsa-kv . -kcsa-kv . chimeras was developed by us. this approach rested on high-level expression of kcsa-kv .x chimeras in e.coli inner membrane, binding of fluorescently-labeled toxin at the surface of the spheroplast and analysis of competitive binding of studied ligands by laser scanning confocal microscopy (lscm). here we report on a new analytical system for search and study of kv . -channel blockers that combines bl (de ) cells expressing kcsa-kv . and rhodamine-labelled agitoxin (rh-agtx ) as a fluorescent probe. by tuning cultivation conditions, the high-level of membrane expression of kcsa-kv . was achieved. it was found that lowering both the growth temperature and the concentration of inducer resulted in significant increase in membrane-embedded kcsa-kv . . for system validation, wellknown kv channel blockers were studied by the method of competitive binding, and equilibrium dissociation constants were estimated for agtx , osk , and kaliotoxin. a new system was applied to study molecular determinants of peptide-kv . channel binding using a number of agtx mutants constructed by us, whose affinities to kcsakv . were measured. a new bioengineering fluorescent system is a robust and sensitive assay for assessing the binding activity of kv . channel blockers. it can be used to study interaction interfaces of toxinchannel complexes, to search for novel peptide blockers and to develop new potent and selective kv . -blockers for scientific and medical purposes. the work was supported by the grant - - from russian science foundation. asparagus racemosus root extracts (ar) have been exhibited to show a wide range of pharmacological benefits. in this study, liposomes of ar were developed and assessed their physicochemical properties and anti-inflammatory activity in monocytic leukemia cell line (thp- ). liposomes containing ratios of ar to lipid and phosphatidylcholine to cholesterol ratio were synthesized by thin-film hydration (tf), reverse-phase evaporation (rev), and polyol dilution (pd). the in vitro anti-inflammatory activity was assessed in terms of inhibition of tumor necrosis factor alpha (tnf-a) in lipopolysaccharide activated thp- by elisa. the size of ar liposomes prepared by tf were larger, whereas those prepared by rev and pd were smaller. ar to lipid ratio was shown to have no influence on particle size, whereas zeta potential enhanced with increasing ar to lipid ratio. ar liposomes with lipid ratio of : achieved the highest value of entrapment efficiency and were at the highest with polyol dilution method. ar was found to have no toxic effects on thp- cells. the anti-inflammatory activities of ar and ar liposomes in terms of tnf-a in thp- cells were was exhibited to possess the highest values of around % at ar concentration of lg/ml and % tnf-a inhibition tended to decline with the increasing amount of ar. this result may be attributed to the increased amount of liposomal particles being uptaken into the cells as a result of the increasing ar concentrations. it can be suggested that ar liposomes could be an alternative choice of topical/transdermal drug delivery for anti-inflammatory activity. p-mis- inhibition of ire signaling enzyme increases the expression of tumor suppressor genes and modifies their hypoxic regulation in u glioma cells d. tsymbal, o. minchenko palladin institute of biochemistry of the national academy of sciences of ukraine (nasu), kyiv, ukraine gliomas constitute one of the most aggressive groups of malignant neoplasms with poor survival prognosis and scarce therapeutic options. plentiful studies have proven the connection between endoplasmic reticulum stress and malignant growth. we have studied the effect of inhibition of ire (inositol requiring enzyme ), which is a central mediator of endoplasmic reticulum stress and controls cell proliferation and tumor growth, on hypoxic regulation of the expression of different proliferation related genes in u glioma cells. it was shown that inhibition of ire leads to up-regulation of the expression of krt , cd , mest, cenpu, myl , ing , ing , mybl , and mybl genes at the mrna level in u glioma cells, with more profound changes for mest, mybl , and cd genes. hypoxia leads to up-regulation of the expression of cd , ing , and ing genes and to down-regulationof krt gene in glioma cells. at the same time, inhibition of ire modifies the effect of hypoxia on the expression of all studied genes: suppresses effect of hypoxia on ing gene, eliminates hypoxic regulation of krt , cd , and ing genes in glioma cells. the present study demonstrates that inhibition of ire enhances the expression of all studied genes and modifies the hypoxic regulation of these gene expressions in gene specific manner and thus possibly contributes to slower glioma cell proliferation, but several aspects of this regulation remain to be further clarified. amplification and clonig of dna polymerase (pol ) of thermus scotoductus k isolated from an armenian goethermal spring a. saghatelyan, h. panosyan, a. trchounian, n. birkeland yerevan state university, yerevan, armenia the most important enzyme ''mined'' from thermophilic microorganisms is dna polymerase, which widely used in molecular biological studies. although dna polymerase produced by thermus aquaticus (taq polymerase) was launched into the market long back, isolation of more processive, reliable and stable dna polymerases from other species is a demand. the purpose of this work was to amplify and clone the pol gene of t. scotoductus strain k recently isolated from an armenian geothermal spring. the draft genome sequence of strain k was deposited under accession number ljjr . . genomic dna was isolated using genelute bacterial genomic dna kit. primers for the pol gene were designed manually. the gene was amplified using pfu polymerase, and amplicons (~ . kb) were ligated into the pet- b(+) vector (novagen) and transformed into chemically competent top escherichia coli. inserts were sequenced with t prom and t term primers, which showed that the gene sequence was correct and in the right reading frame and could be expressed in mesophilic e.coli. dna polymerases patented form different species of thermus are mostly comparable, suggesting that only limited natural variations in taq-like dna polymerase may be discovered. the pol gene from k shares % and % similarity with pol of t. scotoductus sa- ( . kb) and t. aquaticus, respectively. although the difference is not huge at sequence level, possible functional differences (e.g. stability, proofreading activity, resistance to different pcr inhibitors etc.) may occur. therefore, it is important to express and purify dna polymerase from strain k for further investigations. peptide ligands of the immunoglobulin g fc region identified by screening phage libraries and site-directed mutagenesis n. kruljec, p. molek, t. bratkovic young researcher, ljubljana, slovenia affinity chromatography based on immunoglobulin (ig)-binding proteins, such as staphylococcal protein a and streptococcal protein g, typically represents the initial step in therapeutic antibody purification process. however, this approach suffers from high cost, poor ligand stability and the requirement for relatively harsh elution conditions that can negatively impact activity and immunogenicity of antibodies. compared to protein ligands, peptides represent an interesting alternative due to higher stability and less expensive production. furthermore, the expected lower affinity for immunoglobulins should allow for elution under milder conditions. the aim of our research was to identify short peptide ligands for the fc region of human iggs. we have screened three commercially available phage display libraries of random cyclic and linear peptides for binding to human fc region in solution using an optimized biopanning approach. five non-homologous linear peptides were shown to specifically interact with the fc portion of immunoglobulins as verified by a set of phage elisa assays. individual phage-displayed peptides were able to recognize specific subclasses of igg. the highest-affinity peptide ( l- fc), which competed for fc binding with protein a, was subjected to mutagenesis studies. we displayed on phage several variants of l- fc with individual amino acid residues exchanged for alanine as well fragments of the parent peptide of different lengths and evaluated binding to fc with phage elisa to identify the minimal binding motif. binding characteristics of the minimized peptide were further analyzed using spr biosensor. the details will be disclosed at the meeting. diverse effects of ganoderma lucidum in combination with tamoxifen citrate and doxorubicin in mcf- breast cancer cells ganoderma lucidum, an edible medicinal fungus, has been known with its anti-metastatic, anti-carcinogenic bioactivities and widely used in asian countries in complementary and alternative medicine. however, there is no information regarding its combined usage with tamoxifen and doxorubicin in breast cancer treatment. we investigated the interactions between ganoderma lucidum and tamoxifen or doxorubicin in mcf- human estrogen receptor positive breast cancer cell line. anti-proliferative properties of six extracts were assessed by wst- method. the most effective extract in inhibition of mcf- cell viability was then evaluated in terms of its anti-metastatic activity by boyden chamber assay. apoptosis and cell cycle assays were performed by flow cytometry. ganoderma lucidum ether extract (g.ether) was the most effective extract on inhibition of cell viability among others with ic ( ) values of lg/ml and . lg/ml at h. and h. respectively. we found that g.ether is capable of inducing apoptosis and changing cell cycle dynamics. however, incubation with g.ether did not affect mcf- cell motility significantly. we then assessed the interactions between g.ether and tamoxifen or doxorubicin in mcf- cells. the interactions between g.ether and cancer therapeutics were examined by combination index analysis and macsynergy ii software. interestingly, g.ether increased the anti-proliferative effect of tamoxifen although exhibited strong antagonism with doxorubicin in mcf- cell line. testing the best matrix/analyte combination for maldi tof mass spectrometric detection of steroid hormones, amino acids, vitamins and carbohydrates in spite of numerous advantages, there are serious drawbacks of the application of matrix assisted laser desorption/ionization time-of-flight mass spectrometry (maldi tof ms) for smallmolecule analyses (below da) and quantification. the main problem is the background interference from commonly used maldi matrix materials. the aim of this work is to evaluate maldi tof mass spectra of physiologically relevant small molecules: steroid hormones, vitamins, amino acids and carbohydrates, acquired with several organic, traditional matrices. small volume, . ll, of each sample solution (testosterone, progesterone, estradiol, l-cysteine, l-alanine, dl-methionine, glutathione, d-(+)-glucose, d-(+)-maltose, vitamin a, vitamin e) was mixed on the sample plate with the same volume of organic matrix solutions (dhb, thap, chca, -aa). for each molecule/matrix pair, we determined quantitative and qualitative parameters of ms analysis. to calculate within day and day-today variation we used excel tools (anova tests). in addition, homogeneity of the sample/matrix distribution on the target was also calculated and expressed as the coefficient of variation of a series of measurements. our results show selectivity of the detection of individual molecules related with the matrix applied. the statistical analysis of certain molecule/matrix pairs gave within and day-to-day variations less than %. additionally, homogeneity of the sample/ matrix mixture distribution on the target plate was with some matrices, also less than %. some of the used matrices have a great potential for the analysis of small molecules with good analytical parameters, with low variations and high homogeneity of samples on the maldi target plate. these results hold potential for quantification of metabolically-significant small molecules and are very promising for future applications of maldi tof ms analyses. stress causes different expression of mitochondrial biogenesis markers in rat steroid-producing cells of adrenal gland and testes i. starovlah, s. radovic, t. kostic, s. andric faculty of science univeristy of novi sad, novi sad, serbia functional mitochondria of steroid producing cells of adrenal cortex and leydig cells of testes are essential for steroid hormones biosynthesis and regulation. the aim of this study was to determine transcriptional profile of mitochondrial biogenesis markers in adrenal cortex and leydig cells by applying in vivo and in vitro studies. immobilization stress (imo), was performed for hours daily for one ( ximo), two ( ximo) or ten ( ximo) consecutive days. in in vitro studies, primary cultures of purified leydig cells from undisturbed rats were stimulated with stress hormone adrenaline, propranolol (nonselective b-adrs-blocker) and prazosin (the selective a -adrs antagonist). rq-pcr results showed that the transcription of the main regulator of mitochondrial biogenesis, ppargc a and ppargc b, significantly decreased in adrenal cortex of ximo rats. oppositely, the significant increase of the same transcript was registered in leydig cells from the same rats. in parallel, transcription of ucp , the mediator of regulated proton leak, decreased in adrenal cortex, but increased in leydig cells of the same group of rats. incubation of leydig cells with adrenaline, increased transcription of the main markers of mitochondrial biogenesis (ppargc a, ppargc b, nrf and nrf a). nonselective b-adrsblocker attenuated this effect. the selective a -adrs antagonist did not change adrenaline-induced stimulation of ppargc a, ppargc b, nrf and nrf a transcription in leydig cells, indicating that the most of the effects are probably mediated by b-adrenergic receptors, not by a -adrs of leydig cells. in summary, the results suggest that reduction of transcription of mitochondrial biogenesis markers could be a possible mechanism that protects body from excessive glucocorticoid production from adrenal glands in stress conditions, while at the same time stimulation of mitochondrial biogenesis markers transcription in leydig cells could serve as mechanism to preserve testosterone production. p-mis- generation of new mitochondria is possible protection mechanism of basal steroidogenesis in leydig cells s. radovic, i. gak, t. kostic, s. andric faculty of science, university of novi sad, novi sad, serbia mitochondria are the most important component of stress response in all cells and for steroid-hormones-producing cells they are the starting point for steroid biosynthesis. here we investigated the parameters of mitochondrial biogenesis in these cells from rats exposed to the psychophysical stress by immobilization (imo). imo stress was applied for hours daily for one ( ximo), two ( ximo) or ten ( ximo) days.hormone levels were measured employing eia, elisa kit or ria. mitochondrial membrane potential (Δwm) was measured by tmre fluorescence, mitochondrial mass was detected by quantitative analysis of mitotracker-green fluorescence as well as relative intensity of fluorescence, since number of mitochondria and mitochondrial architecture were defined using transmission electron microscopy. relative gene expression and proteins analyses were performed by rq-pcr and western blot. there was positive correlation between Δw m of leydig cells and androgens production of leydig cells. both of them were reduced in all stressed rats but partially recovered in ximo group. the mitochondrial mass in leydig cells from ximo group was increased. transmission electron microscopy analyses showed that acute and two times repeated stress altered architecture of mitochondrial cristae, while ximo increased number of mitochondria and recovered mitochondrial architecture. there was significant increase in the expression of the all markers of mitochondrial biogenesis in leydig cells from ximo rats compared with other groups. accordingly, stress-triggered mitochondrial biogenesis represents an adaptive mechanism and does not only correlate with but also is an essential for testosterone production, being both events depend on the same regulators. supporting the evidence that stress, a constant factor in life of humans, induces mitochondrial biogenesis in leydig cells, our results indicate this mechanism probably protects the basal steroid production in stress conditions. targeting survival pathways in leukemic cells through synergism of metformin and thymoquinone u. glamoclija, m. suljagic international university of sarajevo, sarajevo, bosnia and herzegovina generation of resistance to current treatment options is common problem in the therapy of many hematological malignancies. combined therapies utilizing compounds with low toxicity that act synergistically, are proposed to overcome this problem. metformin and thymoquinone (tq) are two molecules which have proven safety profile and represent potential candidates for treatment of hematological malignancies. there are more than clinical trials, at different stages, exploring metformin anticancer activity. metformin activates amp activated protein kinase (ampk) leading to inhibition of the mammalian target of rapamycin (mtor) and induction of apoptosis in different cancers. however, human leukemic cells with increased basal protein kinase b (akt) phosphorylation were shown to be resistant to metformin-induced apoptosis. it was found that activity of metformin can be enhanced by combination with akt and/or nuclear factor 'kappa-lightchain-enhancer' of activated b-cells (nf-jb) inhibitors. tq is phytochemical compound that has shown inhibitory capacity on both of these targets. wst- assay was used to evaluate the effects of metformin and tq in dhl (b cell lymphoma) and k (chronic myelogenous leukemia) cell lines. compusyn software was used in order to calculate the combination index (ci). the ci value indicates whether two drugs have synergistic (ci< ), additive (ci= ) or antagonistic effects (ci> ). we have shown that separately, metformin and tq, exhibit dose dependent inhibition of dhl and k cells. in combinatorial study with fixed constant ratio and simultaneous drug exposure, in dhl and k cell lines, ci values were . and . , respectively. to our knowledge, this is the first report showing synergistic effects of metformin and tq in lymphoma and chronic myelogenous leukemia derived cell lines. these promising data are currently being investigated in order to obtain the insight into their molecular mechanisms. for the last decade many methods of calculating and analysing the physical characteristics of dna has been developed. these methods allow to estimate distributions of free energy, propensity to bend, stress-induced duplex destabilization (sidd), electrostatic potential (ep) etc. and most of them have been used for prediction of genomic regulatory site positions. the main idea of such approach is that proteins recognize genome regulatory sites by these physical and chemical properties, so the physical characteristics are used to predict the location of regulatory sites. most of the characteristics mentioned above describe properties of dna at equilibrium or steady state, but we propose to use characteristics of internal dna dynamics. in this work we used the coarse-grained model of dna, developed recently, to simulate dynamics of the dna open states. with this model we were able to calculate trajectories of the open states moving along the molecule and their dynamical characteristics, such as: open state activation energy, size, half decay time and sound velocity in dna. we use distribution of four dynamical characteristics around transcription start site of experimentally found e.coli promoters taken from regulon db to organise them in stable clusters. clusterization was made with ward method and consensus clustering technique was applied to clusterization results for analysis of its consistency. the same procedure was applied to equilibrium dna characteristics for comparison. distribution of go functions among clusters was also analysed. stable promoter clusters obtained with different physical properties share some similarity. it was not surprise that clusters obtained with dynamical characteristics of dna more similar to sidd clusters then to ep clusters. the data highlights the possible role of dna dynamical properties in transcription initiation and its applicability to promoter identification together with other physical and textual properties of dna. chromium complex with -hydroxyflavone acts on metabolic pathways the development of novel therapeutic strategies for obesity treatment are urgently required as obesity is currently the main leading cause in type ii diabetes and insulin resistance. among natural compounds, flavonoids have recently gained interest due to their positive role in maintaining blood glucose levels and insulin secretion. their association with trace elements, wellknown for their capacity in increasing the efficiency of insulin, might potentiate flavonoids biological effects. in this context, the aim of our study was to investigate the in vitro changes in energetic metabolism related genes expression profile in the presence of a chromium complex with -hydroxyflavone. dna microarray technology was used for a large scale screening of differentially expressed genes in human adipose stem cells (hascs) after weeks of adipogenic induction in the presence of the chromium complex with -hydroxyflavone. moreover, perilipin expression was assessed by flowcytometry. the chromium complex with primuletin negatively regulates the expression of key genes involved in adipogenesis and also modulates the expression of the genes associated with triglyceride synthesis and subsequent fat storage in mature adipocytes. consequently, the chromium complex with -hydroxyflavone can be further employed in studies on animal models to investigate the possible improvement of metabolic disorders. deinococcus radiodurans is a highly radioresistant and stress-resistant bacterium. despite extensive studies, the mechanisms of transcription regulation that contribute to the stress-resistance are still poorly understood. d. radiodurans encodes multipe stress-related proteins including three members of the gre-family of transcription factors: grea, gfh and gfh . while grea is a universal bacterial factor that stimulates rna cleavage by rna polymerase (rnap), the functions of lineage-specific gfh proteins remain unknown. we cloned, expressed and purified d. radiodurans rnap and gfh factors and their mutant variants and analyzed their properties using various in vitro transcription approaches. we tested gfh effects on rnap activity in promoter, elongation and termination complexes assembled on natural and synthetic dna templates under different conditions. we found that the gfh factors strongly enhance site-specific pausing and intrinsic transcription termination by d. radiodurans rnap but do not act on active transcription complexes and do not compete with the grea factor. uniquely, the pause-stimulatory activity of gfh is greatly enhanced by manganese ions, which are accumulated in d. radiodurans cells under stress conditions, and is modulated by the secondary rna structure. we revealed functionally important regions in the gfh factors and the rnap active site involved in transcriptional pausing. we propose that gfh factors inhibit rna extension in paused complexes through binding within the secondary rnap channel, coordinating metal ions in the rnap active site and stabilizing an inactive enzyme conformation. this may serve as a sensitive mechanism to regulate transcription under stress conditions and coordinate it with dna repair and replication. our data suggest that gre and gfh proteins target different structural states of the transcription elongation complex and reveal functional diversity of the factors that bind within the secondary channel of rnap. from planktonic to biofilm state of growth, flagella formation is turned off, and the production of fimbriae and extracellular polysaccharides is activated. bola protein is widespread in nature and has been associated with several cellular processes. using high-troughput techniques we showed that bola protein is a new bacterial transcription factor, which regulates the switch between motile and sessile lifestyle. it negatively modulates flagellar biosynthesis and swimming capacity in escherichia coli. moreover, bola overexpression favors biofilm development, involving fimbriae-like adhesins and curli production. our recent results show that bola action in these pathways is related with cdi-gmp a relevant intracellular signaling molecule involved in biofilm formation. we demonstrate that bola contributes to a fine-tuned expression of different diguanylate cyclases and phosphodiesterases and c-di-gmp has a negative influence in the bola mrna transcription. herein we propose that bola is a key player in motile/adhesive transcriptional switch, contributing to a fine-tuned regulation of these important pathways. background: deep venous thrombosis (dvt) is an important health problem worldwide. its pathophysiology is multicausal and involves environmental, genetic and acquired factors. factor v leiden (fvl), prothrombin g a (pt g a), and methylenetetrahydrofolate reductase (mthfr) gene mutations are to predispose to venous thrombosis. the aim of this study was to compare the frequency of fvl, pt g a and mthfr polymorphisms between patients with dvt and healthy controls. methods: this study was conducted at the bozok university hospital. total participants were included in this study, patients with dvt and healthy blood donors. in order to identify fvl, pt g a, mthfr c t and mthfr a c, the polymerase chain reaction (pcr) method was utilized combined with the amplification refractory mutation system. results: in patients fvl was present in ( . %) patients while in controls fvl was present in only ( . %). frequency of fvl was significantly higher in cases as compared to controls (p < . ). pt g a mutation was present in patients ( . %) and in healthy participants ( . %). mthfr c t and mthfr a c polymorphisms were almost equally distributed among patients and healthy participants. however, the concomitant presence of fvl and double heterozygous polymorphisms of mthfr c t/a c was found in patients ( . %) and in healthy controls ( . %), showing significant association with deep venous thrombosis. conclusion: in this study, the frequencies of fvl and pt g a polymorphisms were found significantly higher in patients with dvt than those in healthy participants. thus, fvl and pt g a polymorphisms have a contributory role on the development of dvt in contrast, mthfr c t and mthfr a c genotypes were not associated with a predisposition to development of dvt. but, a combination of double heterozygous polymorphisms of mthfr c t/a c with fvl may be associated with increased risk of dvt. p-mis- self-assembling micellar clusters comprising drugs, nanoparticles and fluorescent compounds for bilogical applications when designing drug carriers, the drug-carrier ratio is an important consideration, because the use of wrong drug-carriers relation can result in toxicity as a consequence of poor metabolism and elimination of the carriers. solubility problem of various substances also plays an important role in many aspects of fundamental science and practical field. specifically, it is an important parameter as well as bioavailability, which determines the required concentration of drug in the body needed to achieve a pharmacological response. among the variety of solubilization methods micellar solubilization is widely used as an alternative to the dissolution of poorly soluble drugs. here, we show a specific approach based on sequential selfassembly of nonionoc detergent micelles (t , tx ) followed by enacpsulation of various nanoparticles (noble metals, magnet etc.), drugs, fluorescent compounds leads to the formation of stable micellar nano-amd microcomplexes. we propose ways of micellar clusterisation. in the first one micelles are modified by semi-hydrophobic chelator followed by addition of metal ion to make cross-linking. the second way is similar to the first one and suggests application of the metal complex with incresed denticity instead of naked metal ion, and the third one involves micelles clusterisation by semi-hydrophobyc metal complex directly. therefore, one can stabilize micellar network by means of 'interactions on interface': semi-hydrophobyc metal complexes are embedded inside micelle due to hydrophobyc interactions. hydrophobic fluorescent compounds-loaded micellar complexes demonstrates better optical response in aqueous media without crystallization. such obtaining clusters are also very flexible and can be modified by nanoparticles to obtain various nanocomposites, such as fluoromagnetic clusters. this work was supported by russian foundation of basic research grants no. - - r_center_a ( no. - - r_center_a ( - no. - - r_center_a ( ) and - - mol_a_ved ( no. - - r_center_a ( - . lamellipodia and membrane blebs utilize different signalling pathways to induce directional movement of walker carcinosarcoma wc cells in a physiological electric field clear if those reactions are mediated by similar mechanisms. to establish that, we performed proteomic analysis and subsequent investigation of the role of differential signalling pathways in electrotaxis of cells representing various strategies of movement. cells were exposed to ef in galvanotaxis apparatus and their reaction was recorded. in some experiments cells were pre-incubated with erk / or btk- inhibitors. the phosphorylation of erk / and btk- was determined by western blot analysis. proteomic analysis was performed by ultimate rs lc nanosystem coupled with a q-exactive mass spectrometer. both blebbing (bc) and lamellipodial (lc) cells show cathodal migration in a physiological ef ( v/cm). comparative analysis of bc and lc cells proteomes revealed about differential proteins. functional analysis in ingenuity analysis pathway allowed to determine the statistically significant signalling pathways in which these proteins are engaged. among the most distinctively regulated pathways are tec kinase and erk/ mapk signalling activated in lc but not bc. it was found that btk- is required for directional movement of lc but not for bc cells. moreover, ef induced stronger and faster btk- phosphorylation in lc than bc cells. in contrast erk / activity was not necessary for electrotaxis of lc cells and ef did not induce erk / phosphorylation. our results reveal that both lamellipodia and membrane blebs can efficiently drive electrotactic migration of wc cells but it is mediated by different signalling pathways. this work was supported by a grant from the national science centre / /b/nz / , poland. newborn screening for congenital hypothyroidism in turkey: a regional evaluation € o. demirelce , n. y. saral , f. b. aksungar , , a. coskun , , m. serteser , , i. unsal , acibadem labmed, istanbul, turkey, acibadem university, istanbul, turkey congenital hypothroidism (ch) is the most common congenital endocrine disorder and the most important cause of preventable mental retardation. it is important to begin the treatment within weeks before the development of brain damage. tsh based newborn screening programs are shown to be useful for implementing early treatment of ch. in this study, regional results of ch screening program in turkey between and were assessed retrospectively. we have evaluated the results of marmara, central anatolia, aegean and mediterranean regions in which our laboratories are located. screening was based on tsh determination in dried blood spot specimens. tsh limits determined to be lu/ml for cut off point and lu/ml for clinical decision point. tsh was measured using enzyme immune assay (eia). blood spot tsh data for newborns during this time period were evaluated. permanent or transient ch was determined according to the results of thyroid function tests. confirmed ch cases were based on local endocrinologists' report and initiation of thyroxine treatment. the frequency of neonatal tsh levels were found to be under the cut off level of lu/ml in ( . %), between and lu/ml in ( . %) and above the level of lu/ml in ( . %) babies, respectively. recall rate was . %. ch cases of neonatal tsh levels greater than lu/ml were . the incidence of ch of this group was : . there were no significant differences in the number of congenital hypothyroidism between males and females (p > . ). the preliminary results of our study indicate that the incidence of ch in our region is higher than the worldwide reports as has been proved by preceding studies. iodine deficiency, dyshormonogenesis, highly consanguineous population, may contribute to the high incidence of ch in turkey. newborn screening of ch must be developed for detecting true cases and tsh cut off point must be reviewed for decreasing redundant recall rate. in silico analysis of the first complete genome sequence of lactobacillus acidipiscis species k. papadimitriou , m. kazou , v. alexandraki , b. pot , e. tsakalidou agricultural university of athens, athens, greece, institut pasteur de lille, lille, france introduction: lactic acid bacteria (lab) constitute a significant group of microorganisms for the food industry, as they play a key role in food fermentation and consequently in human health. lactobacillus acidipiscis aca-dc is a gram-positive, motile, rod-shaped lab isolated from traditional greek kopanisti cheese. here we present the in silico analysis of the first complete genome sequence of l. acidipiscis in order to explore the biology of the species. materials and methods: sequencing of l. acidipiscis genome was performed using the hiseq and pacbio rsii sequencing platform technologies and the genome assembly was validated against an nhei optical map of the l. acidipiscis genome. protein-coding sequences were predicted by glimmer, rrna genes by rnammer and trna genes by the trnascan-se server. potential genomic islands were detected using the island-viewer software tool, prophage regions by phast and the subsystem-based annotation by rast server. finally, the circular representation of l. acidipiscis genome keyed to the cog groups was constructed by cgview server. results: the sequencing analysis resulted in one continuous genomic scaffold of , , bp with a g+c content of . %. the genome contains , protein-coding genes on the chromosome covering up to . % of the genome sequence, trna and rrna. according to the subsystem-based annotation, , protein-coding genes were assigned to metabolic subsystems. the most abundant of the subsystems are related to carbohydrates (n = , . % of total protein-coding genes) and protein metabolism (n = , . % of total protein-coding genes). furthermore, three prophage regions were detected; one intact ( . kb), one incomplete ( . kb) and one questionable ( . kb). discussion and conclusion: the whole genome analysis of l. acidipiscis aca-dc provided interesting information about a not well-studied species. investigation of serum irisin levels of patients with metformin taking new onset type diabetes mellitus increases glucose tolerance and energy expenditure and improves carbohydrate homeostasis. metformin is a biguanidine class antidiabetic drug which inhibits liver gluconeogenesis and decreases insulin resistance and is frequently recommended in treatment of new onset type diabetes mellitus (t dm). irisin has a role in the regulation of energy metabolism pathways and its level in blood of persons with t dm has been reported to decrease. regarding this relationship, it was aimed to reveal the effect of metformin on serum irisin levels. patients with impaired oral glucose tolerance test were included to this investigation. they were recommended to take metformin and to change their life style, such as exercise and diet. their blood were taken at the beginning and after month. also, a healthy control group (n = ) was formed from persons with similar age and sexual distribution as the patient group. irisin levels of their sera were measured by enzyme-linked immunosorbent assay (elisa) method. statistical evaluation of the measurements showed no significant difference (p = . ) between the irisin levels of the patients at the beginning and after month treatment. a similar result was found between the control and the treated groups (p = . ), while a significant difference (p = . ) was observed between the control and untreated patients groups. the results obtained from this study do not show a clear and significant change in the blood irisin levels of the patients with new onset t dm taking metformin together with life style change. a longer period of treatment and a higher number of patients may be needed for more reliable results. thermodynamics of dna ligands binding at specific sites of telomeric g-quadruplex dna g-quadruplexes are a perspective target for anticancer therapy. for example stabilization of the telomeric g-quadruplex dna formed by single-stranded ends of the chromosomes leads to inhibition of telomerase, which is active in % of cancer cells. similarly, small molecules targeted to a specific g-quadruplex would inhibit various cellular processes. stoichiometry and affinity of interaction of these compounds to dna is determined by specific structural motifs within a g-quadruplex. rational design of novel chemical compounds requires an in depth knowledge of interactions between known ligands and g-quadruplex structures. experimental methods that are used for determination of thermodynamic binding parameters, such as isothermal titration calorimetry, differential scanning calorimetry, ultraviolet absorption and circular dichroism spectroscopy provide a collective characteristic for all of the ligand molecules bound to dna, while the information on ligand affinity to individual dna binding sites is lost. we propose a complimentary method for detailed analysis of thermodynamic parameters of ligand binding based on the introduction of fluorescent probes in the structure of g-quadruplex. monitoring fluorescence quenching of the fluorescent labels allows to derive binding constants of the dna-ligand interaction at a specific binding site. temperature dependence of the fluorescence quenching determines the thermodynamics of the dnaligand complex formation. since only a proximal ligand is able to quench the fluorescence, this method allows characterization of the ligand binding to a particular site the g-quadruplex structure. the study was supported by project no. - - of the russian science foundation. the correlation between biochemical and dynamic surface tension parameters of calves blood serum during the animal ontogenesis, as well as by various pathologies or poor diet, the imbalance of protein, mineral, lipid components is observed (the changes in all parameters of biological liquids are accompanied of these metabolism peculiarities). the dynamic surface tension (dst) of serum essentially depends on these factors and (in combination with the biochemical parameters) can provide the valuable information for evaluation of the physiological and biochemical status of the organism (can be used as an express test for animal diagnostics in future). the aim of the work was to study dst and biochemical parameters of calve serum, as well as their correlations, as the main indicators of the animals. ) of calve serum were in the range of the normal values for healthy animals and can be considered as reference data for animal science and practice. the obtained results enable us to establish correlations between the dst and biochemical parameters of calves serum. this work was supported by the russian scientific foundation (grant - - ). the middle strong correlations of dst values of calves serum with the level of total protein, albumin, billirubin, some enzymes and cholesterol, whereas only weak correlations with the other biochemical parameters (urea, calcium, magnesium, phosphorus, etc.) were found. in the veterinary science and practice such correlations are important for the estimation of the organism physiologicaland biochemical status, for general inspections of cattle before vaccination (immunization) or slaughter, for "quick separation" of healthy and ill animals in the case of infection, etc. role of protein kinase c in the regulation of astrocytic glutamine transporter sn in ammonia-exposed mouse cortical astrocytes (bisi; lm). total pkc activity was analyzed by a direct pkc assay and phosphoserine detection by western blot (wb) analysis. protein level of sn and sn , second astrocytic gln transporter belonging to system n, in a membrane fraction was also analyzed. the total uptake and system n-mediated (l-ala and l-leu-inhibitable) gln uptake was tested. treatment of astrocytes with ammonia resulted in a decrease of pkc activity, whereas pma treatment increased pkc activity in ammonia-independent way. bisi treatment reversed fully, and ammonia partially, the pma-induced pkc activity. pma treatment resulted in only a slight decrease in sn protein level in both control and ammonia-treated astrocytes, while a decrease of total and system n-mediated gln uptake were noted in control astrocytes, an effect not exacerbated by ammonia. in turn, cotreatment with pma and bisi reversed the decrease of total gln uptake and showed tendency towards increase in system nmediated gln transport. the results suggest that: a) ammonia changes the dominating direction of system n transport from release to uptake, which may be related to decreased phosphorylation or to alterations in relative phosphorylation by different pkc isoforms. this inference remains to be verified in further studies; b) changes in system n transporter function induced by ammonia appear to involve mechanisms other than changes in transporter expression. evidence for human ghrelin ghs-r a and orexin ox heteroreceptor complex formation in a heterologous system ghrelin and orexin are two peptides implicated in the regulation of energy balance and modulation of food-related motivation at the level of the midbrain dopamine reward system. their function in the hypothalamic arcuate nucleus and the ventral tegmental area (vta) has already been described, but the modulation at the level of receptors remains unclear. the action of these peptides is mediated by g-protein-coupled receptors (gpcrs): ghrelin a and b (ghs-r a , ghs-r b ) for ghrelin, and orexin and (ox , ox ) for orexin. traditional approaches to know the mechanism of neurotransmission of dopaminergic neurons in the mesolimbic system have focused on targeting neuronal receptors as single entities. from the discovery that gpcrs for neuromodulators may form heteroreceptor complexes, our hypothesis is that ghrelin and orexin receptors may interact and form novel functional units that may specifically participate in the central regulation of food intake and energy balance. as a proof of concept we have investigated the potential of human ghs-r a and ox receptors to form heterocomplexes. formation of ghs-r a -ox receptor heteromers in transfected hek t cells was detected by bioluminescence resonance energy transfer (bret) and proximity ligation (pla) assays. furthermore, a negative crosstalk was identified in cells co-expressing both receptors by assessing mitogen-activated protein kinase (mapk) and adenylyl cyclase (camp) pathways, and by a label-free dynamic mass redistribution assay. experiments in sources endogenously expressing ghs-r a and ox receptors are needed to know the functional relevance of the heteromer. from the negative crosstalk here identified, it is tempting to speculate that ghs-r a -ox receptor heteromers are important players in mediating the response to the combination of different orexigenic signals. lysosomal storage diseases which are related to deficiency of specific lysosomal hydrolases resulted to clinical aspects due to accumulation of substrates in different tissues. since dried blood spot (dbs) is non-invasive, low-cost, easy transportable, acceptable enzyme stability compared to leucocyte and/or fibroblast culture, it's recommended as a first screening test. however the false positive rate with dbs sample is higher compared to other samples. we aimed to investigate any possible effect of leucocyte number on enzyme activity in dried blood samples in a retrospective study. we re-evaluated the lysosomal enzyme activity results in regard to leucocyte number among data within last year. enzyme activities had measured by using fluorometric and lc msms method. we determined the correlations between the lysosomal enzyme activities of alpha glycosidase, glycocerebrosidase, alpha galactosidase, sphingomyelinase, galactocerebrosidase and alpha-l-iduronidase in healthy population (n = ). while glycocerebrosidase and galactocerebrosidase positively correlated with the number of neutrophils, alpha galactosidase, sphingomyelinase and alpha-l-iduronidase positively correlated with the number of lymphocytes. alpha glycosidase activity showed a correlation both lymphocytes and neutrophils. the patients having the glycocerebrosidase enzyme activity which was lower than . nmol/ml/hour (which is accepted as the cut off value to recall the patients) existed significantly lower number of leukocyte, lymphocyte and neutrophil compared to those of patients having higher enzyme activity than . . our data indicated that the enzyme activity in dried blood samples including low leucocyte number might be found lower than reference intervals resulting in false positive diagnosis. therefore we suggest that the laboratory scientists should evaluate the number of leucocyte levels while they were interpreting data. using dna-markers for estimation of genetical variability of two kazakh sheep breeds a. mussayeva , , b. bekmanov , , a. amirgalieva , k. dosybaev , , z. orazymbetova , , r. zhapbasov , a. zhomartov , n. zumadillaev , n. zumadillaev llp "kazcytogen", almaty, kazakhstan, "institute of general genetics and cytology" sc mes, almaty, kazakhstan, branch "scientific research institute of sheep" llp "kazakh research institute of animal husbandry and feed", almaty, kazakhstan to compare the frequencies of different microsatellite loci in sheep breeds subpopulations genomic structure of edilbay and kazakh archaromerinos was investigated. different methods for homogeneity testing of two breeds were elaborated. inter simple sequence repeats (issr) pcr analysis of the breeds studied displayed species and breed specific fragments with different frequencies (population frequency more than . ) there were found rarely met fragments (frequency lower than . ). the combinations of these fragments present the specific issr-spectra which arrange genofond profiles of breeds. using panels of microsatellits (recommended by isag) breeds ( populations) were characterized. informative value and resolving capacity of the sum of str-loci were estimated. wide polymorphism of alleles length was demonstrated both when the breeds were compared and within the breeds. informative markers were chosen for both two breeds, markers being used for both breeds, while other markers were informative for one of the breed only. when the animals of one breed were compared unique alleles which were met only within one of populations were of much interest. for example the allele of bm was met in birlik population of edilbay breed as often as in % of animals while in two other populations there were no this allele. in kumtekey population one can meet % animals having particular locus (dyms ), while in the other population (cf ablay) this locus was not met at all. basing on genetical distances obtained using fragment analysis phylogenetic relationships between populations were estimated. so for example edilbay population of cf ajar has the larger distance from two other populations (birlik and bayserke-agro) than each of them from one another. two subpopulations of kazakh arkharomerinos breed (cf kumtekei and cf ablay) also have the genetical difference. how preeclampsia affects oxidant status and antiinflammatory potential of breast milk? preeclampsia is a pregnancy syndrome associated with hypertension, proteinuria and edema, leading to maternal morbidity/mortality and preterm delivery. in this study we aimed to investigate if the breast milk of preeclamptic mothers is effected in oxidative status and anti-inflammatory activity in comparison to the breast milk of mothers with healthy pregnancies. for the aim of the study, hyaluronidase and myeloperoxidase activities (mpo), total oxidant status (tos), total antioxidant status (tas), oxidative stress index (osi) and tbars levels were measured in breast milks of preeclamptic mothers and mothers with healthy pregnancies as control group. when the control group and preeclamptic group were compared, hyaluronidase activity, tas, tos and osi levels showed statistically significant differences in the preeclamptic group. hyaluronidase activity was significantly higher in the preeclamptic mothers' breast milk ( vs u/ml, p = . ). while tos levels were significantly higher in the preeclampsia group ( . vs . lmol/l, p = . ), the tas levels were significantly higher in the control breast milks ( . vs . mmol/l, p = . ). as expected osi levels (tos/tas ratio) were significantly higher in the preeclampsia group. even though the mean levels were higher in preeclamptic group, the difference in mpo activities and tbars levels did not show statistic significance. oxidant status parameters also suggest that preeclampsia effects in both ways by increasing oxidant status and also decreasing antioxidant capacity shifting the balance to the increased oxidant stress side. as the results showed that the preeclampsia group had higher hyaluronidase activity, this can be interpreted as preeclamptic mothers' milk have higher inflammatory potential as this enzyme enhances inflammation by catalyzing the depolymerization of certain acidic glycosaminoglcans. p-mis- investigation of relationship between postprandial lipemia and erythrocyte membrane cholesterol level postprandial lipemia is a metabolic condition related to an increase in plasma triglycerides. remnant-like lipoprotein particles are predominant in postprandial phase and they play an important role in development of atherosclerosis. cholesterol is a prominent component of erythrocyte membranes and regulates the membrane functions such as viscosity and permeability. free cholesterol derived from erythrocytes is thought to participate in the atherosclerotic plaque formation. in the current study, it was aimed to investigate the relationship between postprandial lipemia and erythrocyte membrane cholesterol level in healthy subjects. study group included subjects ( female and male with age range of - years). then these individuals were divided into three groups according to the values of area under curve (auc) calculated by using triglyceride levels at the fasting state and at nd, th and th hours after the high fat diet (ottt). lipid and erythrocyte membrane cholesterol (emc) values were compared between groups with low and high ottt response. while tc, tg, ldl-c and emc were significantly higher, hdl-c was significantly lower in high ottt response group than low ottt response group. it was not observed any statistically significant difference when compared emc values between women and men study groups. on the other part, it was seen positive correlation between emc and auc (r = . , p = . ), tg (r = . , p = . ), tc (r = . , p = . ), ldl-c (r = . , p = . ) in the total study group. it was concluded that, postprandial lipemia may show atherosclerotic tendency not only with atherogenic lipid profile but also with increasing emc. p-mis- eu-openscreen: the european infrastructure for chemical biology b. stechmann, p. gribbon eu-openscreen, fmp leibniz institute for molecular pharmacology, berlin, germany small molecules that can be applied as chemical 'tool' compounds (or 'probes') have become indispensable in basic research for the elucidation of fundamental biological mechanisms. they act directly with the protein-of-interest and often allow for the interrogation of biological processes that cannot be properly studied with traditional genetic or rna interference approaches. eu-openscreen (www.eu-openscreen.eu) is the largest emerging academic chemical biology research infrastructure initiative in europe and will provide access for molecular and cell biologists to screening infrastructure, well-characterized highquality chemical libraries, and facilities for medicinal chemistry services for compound optimization. molecular biologists who have a robust and suitable biological assay and are interested in collaboratively developing chemical tool compounds to validate their targets-of-interest are welcome to work with eu-openscreen. selected assays are screened against a collection of more than , compounds, incl. confirmatory and counter screening, ic/ec determination, sar (structure-activity relationships) and qc of confirmed hit compounds. eu-openscreen will start operations in , but it can already look back on a growing number of transnational activities: joint screening projects, exchange of local compound libraries, development of new design principles for its compound collection; exchange of experimental data through its pilot database etc. steps towards an arthrobacter nicotinovorans based biotechnology for production of hidroxy-nicotine as the archetypal agonist of nachr, nicotine stands up as a powerful scaffold for developing new alzheimer disease therapeutic agents in form of nicotine derivatives. in this context, arthrobacter nicotinovorans pao and its wide range of nicotinederivatives produced when grown on nicotine have a huge biotechnological potential. indeed, the metabolic intermediate -hydroxy-nicotine ( hnic) produced by a. nicotinovorans pao was shown to bind to the nachrs, and by modulating their function, to sustain spatial memory formation in a rat model of ad. the current work presents the first attempts to produce and isolate hnic by using a genetically engineered a. nicotinovorans strain. the growth and the hnic accumulation were compared for two strains: . a. nicotinovorans pao wild type strain and . a genetically engineered a. nicotinovorans pao strain (part ndh) containing the nicotine-dehydrogenase (ndh) genes cloned in the nicotine inducible part vector. the growth curves were followed spectrophotometrically. the consumption of nicotine and accumulation of hnic were monitored by hplc using a mn nucleodur - c ec column and . m sulfuric acid at a flow rate of ml/minute. the growth curve of the part ndh strain shows that the bacteria grow slower when compared with the wt. as a result, in the wt strain, the nicotine is quickly depleted from the medium and only low amounts of hnic are observed. although the sds-page analysis of the total protein extracts from the part ndh strain did not show clear signs of ndh overexpression, the enzyme is produced and is active, allowing a fold accumulation of hnic in the growth medium. the first attempts to purify ndh from the part ndh strain using imac were nevertheless unsuccessful. in conclusion, using the part ndh strain for hnic production is feasible. further improvements of the growth condition and strain are envisioned (i.e. knocking the ndh downstream genes; adding inhibitors for the downstream enzymes). studies on the impact of butyrylcholinesterase (bche) on the symptoms and progression of cognitive impairments like alzheimer's disease (ad) or other neurodegenerative disruptions speak in favour of selective bche inhibitors as a new approach in future ad pharmacotherapy. some derivatives of quinine and quinidine, present in the cinchona species bark, have already been identified as selective bche inhibitors with respect to acetylcholinesterase (ache); therefore, further investigation of these compounds might result in promising leads for enhanced anti-ad drugs. we synthesised ten quaternary derivatives of cinchonines and their corresponding pseudo-enantiomeric cinchonidines. quaternization of quinuclidine moiety was carried out with groups diverse in size: methyl and differently meta and para substituted benzyl groups. all of the compounds were prepared in good yields, characterized by standard analytical spectroscopy methods, and were tested for their bche and ache inhibition potency. the inhibition potency of the compounds was defined by the dissociation constants of the enzymeÀinhibitor complex (ki). all of the tested compounds reversibly inhibited both human bche and ache. the compounds inhibited bche with ki constants in the range of . - lm, and ache in the range . - lm. five cinchonidines displayed a - times higher inhibition selectivity to bche over ache, and four of them were potent bche inhibitors with ki constants up to nm. bche affinity toward the studied compounds depended on the size of the substituent on the nitrogen of the quinuclidinium part of the molecule and on the resonance stabilization of the substituent at the quaternized nitrogen. based on the presented results, cinchonidine cd-(pbr) can be pointed out as a potent and selective bche inhibitor that could be considered for further research in alzheimer disease pharmacotherapy. exposure to nmda ( lm) for h increased the expression of kir . mrna and decreased that aqp -and gs mrna. the expression of kir . was decreased by h exposure to glu ( mm) and tnfa ( ng/ml). at h incubation, nmda induced a decrease of kir . expression in the presence but not in the absence of calcium in the medium. nmda did not alter the expression of nmda receptor subunits. tnfa increased the expression of the nr subunit, and decreased that of nr b mrna. glu decreased the expression of out of subunits. the study demonstrates, to our knowledge for the first time, that prolonged exposure of astrocytes to nmda alters the expression of mrna coding for critical astrocytic proteins. the dependence of the decrease of kir . mrna expression on extracellular calcium suggests the ionotropic nature of nmda receptor stimulation. the effects of nmda receptor stimulation occurred by a mechanism bypassing changes in subunit composition of the nmda receptor. experiments are under way to establish whether the tnfa-induced changes in the expression of nmda receptor subunits contribute to modulation of nmda receptor stimulation by inflammation. the importance of education in reducing preanalytical errors the preanalytical phase includes the request of test, the preparation of patient, the obtaining of sample from the patient, the transport of the sample to the laboratory, and the pretreatment of sample. the preparation of patient and the obtaining of sample are considered as the most common error sources. in order to reduce preanalytical errors, we aimed to provide training for phlebotomists and to also determine their knowledge level about the preanalytical phase before and after these training. it was given the training related with preanalytic phases to pediatric nurses and adult nurses, other phlebotomists in march. the surveys which are made before and after the training were consisted of questions that are related with demographyic features and preanalytic phases. in order to determine the effects of training to the preanalytic phase, the preanalytic error rates before (in february) and after (in april) traning was calculated with the formula of: (the number of rejected samples/the number of total samples)x . the average age of participants was ae years. it was not found significant difference between their correct answers rate before the training and the education degree of the participants. the correct answer rate before the training was % and after the training it was %, which showed an increase of %. the preanalytic error rates which were . % in february were decreased to . % in april. in our study, the positive results were obtained through the training aimed to reduce the preanalytical errors. by providing regular training to the phlebotomists and also providing pretraining to the beginners, the updating of their information about preanalytic phase can be achieved. in this way, the loss of labor and economic related to preanalytical errors can be avoided and the accurate results can be obtained in short time. curcumin, the active compound of turmeric (curcuma longa) has antiinflammatory, antioxidative and antitumour effects. unfortunately, curcumin has a poor absorption and low stability. both can be solved by encapsulation of curcumin using a proper technique like electrospray. it was reported that piperin, the active compound of black pepper, enhances the intestinal absorption of curcumin and thus its bioavailability. due to these facts it was aimed in this study to nanoencapsulate turmeric extract in order to enhance its absorption and stability. for that purpose, it was encapsulated with the maize protein zein, chitosane and black pepper extract by varying the voltage and flow rate of electrospray and the concentration of the compounds. the nanocapsules were characterised by measuring their particle size and with help of sem photographs. the particle size of the final nanocapsule formulation was nm and had a sufficient stability over a period of months, visually determined. by encapsulating turmeric extract into double layer nanocapsules with help of black pepper extract, zein and chitosane, the turmeric extract could be protected from degradation, which was observed for the pure turmeric extract in form of clearing its yellow colour. analysis of the human genome reveals that potential g-quadruplex sequences are enriched in promoters of the oncogenes. growing body of evidence suggests that g-quadruplexes (g ) may play putative roles in various biological processes, such as the regulation of gene expression. consequently, targeting the oncogenic g-quadruplexes using small molecules is an alternative strategy for the potential treatment of cancers. porphyrin derivatives are promising class of drug in this respect, being nucleic acids binders and generators of reactive oxygen species under visual light irradiation. interaction between porphyrin derivatives and g dna from oncogene promoter region has been studied in vitro. we applied chemical probing, circular dichroism spectroscopy and uv melting techniques in order to map the oxidized bases, monitor structural rearrangements and evaluate stability of the resulting dna structures. specifically, we observed that g dna is considerably more susceptible to lightinduced modification than duplex dna; -terminal tetrads of the g dna are preferably oxidized; structural changes induced by oxidation result in decrease of the thermodynamic stability of the g dna. irreversibility of these effects on dna make porphyrin derivatives perspective lead compounds for rational design of ligands targeting human oncogenes. the study was financially supported by project no. - - from the russian science foundation. resistin levels in denervated obese rats n. saglam , t. ahmedi rendi , c. kahraman , a. alver department of medical biochemistry, faculty of medicine, karadeniz technical university, trabzon, turkey, school of health, d€ uzce university, d€ uzce, turkey the sympathetic nervous system is an important factor affecting the metabolic and secretory function of the white adipose tissue. resistin is mainly expressed by mononuclear cells, also it is expressed by adipocytes, pancreatic cells, and muscle. resistin induces insulin resistance and glucose intolerance in mice. resistin plasma levels depend on fat depots size and sex. resistin levels decrease in short-term fasting in mice, then it increase refeeding. also, it increase as a response to fed with the high fat diet. in our study we aimed to determination of the effect of high-fat diet and denervation on serum resistin levels in rats. in this study experimental groups were formed each consisted of rats. during weeks, first two groups are fed with high-fat diet and other two groups are fed with standart diet which they purchased from research diets company. at the beginning of the feeding periods, retroperitoneal fat tissiues of animals assigned to the first and the third groups were denervated. second and fourth groups were not denervated. at the end of the week feeding periods, blood collected from rats and blood resistin concentration was determinated by elisa. in denervated and fed with high fat diet groups serum resistin levels higher than control groups (p < . ). according to our literature research, there are no studies demonstrating the relationship between resistin and the sympathetic nervous system. also, denervation may lead to increase in serum resistin levels. the amount of resistin is possibly reduced by b -adrenergic activation. in conclusion, it was concluded that there is differences on serum resistin levels depending on diet in bilateral denervation of retroperitoneal fat tissues of rats. stress activated protein kinases regulates the ribosomal frameshift rate in est gene, encoding subunit of telomerase s. t€ urkel, s. sarica uludag university, bursa, turkey est gene (ever shorter telomere) of s. cerevisiae encodes one of the essential subunits of telomerase enzyme. expression of est gene is regulated at the translation level by + programmed ribosomal frameshift (prf). it is known that the physiological stresses affect telomere length. in this study, we have investigated the effects of stress activated protein kinases snf p (ampk) and gcn p (eif kinase) on the prf rate in est gene. prf rate of est gene was quantified in plasmid based expression system. expression vectors were transformed in to the wild type and mutant yeast strains that deleted for snf , or gcn genes. yeast cells were grown in normal conditions or subjected to acid stress, osmotic stress, or glucose limitations to activate protein kinases gcn p, and snf p, respectively. prf rate of est gene was measured as % in the normal growth conditions in the wild type cells. but, the prf rate of the wild type strain grown in glucose limited conditions decreased more than -fold, giving less than % prf rate. contrary to glucose limitation, osmotic or acid stress activated frameshift rate by -fold in the wild type cells and prf rate increased to %. when the prf rate was analyzed in gcn and snf mutants, frame shift rate of est was - % in normal growth conditions. when these mutants were subjected to acidic or osmotic stress, prf rate activated slightly. we have also shown that gcn p and gcn p, positive regulator of gcn p, is also essential for the regulation of prf in est in response to stress conditions. it is clear that the basal level expression of est is highly dependent on the gcn p kinase complex. gcn p is also associates with ribosomes, indicating that gcn p might have a significant function in connecting the stress signals to biosynthesis of the full length est peptide. this regulation might also link the biosynthesis of functional telomerase and telomere replications to cell physiology through protein kinases such as snf p and gcn p. inflammation might have a role in erosive esophagitis but not in non-erosive reflux disease the relationship between inflammatory activation mechanisms and acid-peptic injured esophageal tissue is not clear. we evaluated whether there are differences between inflammation and tight junctional proteins such as e-cadherine among subtypes of gastroesophageal reflux disease. the aim of this study was to investigate any possible role of inflammation in pathologic mechanism of reflux disease by determining the inflammatory markers in injured esophageal tissue as well as serum of patients. three groups (erosive-ee, n = ; nonerosive-nerd, n = ; healthy controls-hc, n = ) were evaluated with upper gastrointestinal endoscopy. the esophageal biopsies and blood samples were collected. serum e-cadherine levels, nfkb, chitotirosidase (chit), myeloperoxidase (mpo) activities in serum and homogenized tissues were determined. nkfb levels in tissue was significantly higher in subjects with ee ( . ae . ng/mg.prt) versus hc ( . ae . ng/mg.prt, p = . ). mpo tissue activities in ee group were significantly lower ( . ae . u/mg.prt) than hc ( . ae . u/mg.prt, p = . ) while mpo serum levels were higher in ee ( . ae . ul) versus hc ( . ae . ul, p = . ). tissue chit levels were three fold increased in ee versus hc (p = . ). none of these measurements showed any differences in nerd group. nfkb and mpo levels had a negative correlation (r=À . , p = . ) in tissue. nfkb and ecad levels had a positive correlation in serum (r = . , p < . ). inflammatory process might play a pivotal role in injured mechanism only in erosive esophagitis but not in nerd. noninflammatory mechanisms might be responsible such as hypersensitivity in patients with non-erosive reflux disease. d-dimer (a fibrin degradation product) test is used to aid in the diagnosis of intravascular coagulation. the aim of this study is to investigate the correlation between d-dimer levels and other inflammatory markers including procalcitonin. anonymized data on d-dimer, fibrinogen, hscrp, wbc, neutrophil% (neut%) and procalcitonin levels from , patients (mean age ae sd, . ae . ) were used for the correlation (excel analyze-it v . . ) and linear regression (pasw statistics v . ) analysis between the measured parameters. there was a significant (p < . ) age-dependent increase in d-dimer levels between different age groups. patients with the highest d-dimer levels were also found to have an increased frequency of hscrp levels. d-dimer levels showed a significant correlation with hscrp, wbc and neut%. a model describing the positive association between these parameters were built. the resulting equation is as follows: d-dimer = (hscrp* . ) + ( . *age) + ( . *wbc) + ( . *neut%)À . . correlation analysis between procalcitonin and d-dimer levels gave pearson's correlation coefficient of . . our results suggest that the age-dependent variations should be taken into account while interpreting d-dimer test results. in addition, neut% ratio was found to be the most important parameter for estimating d-dimer levels. our equation can be used when the d-dimer test is not available or for control purposes only. in the field of cancer research great hope lies in finding more powerful and selective way for the direct elimination of cancer cells. this task can be solved by means of nanobiotechnology. recent progress in this field has arisen interest in a carbon nanostructurefullerene c . fullerene exhibits not only unique physico-chemical properties and biological activity but also a significant potential to serve as a nanocarrier for selective drug delivery into cancer cells. the aim of this study is to analyze a unique tool for cancer therapy. the main idea is realized by the non-covalent conjugation of c with the well-known anticancer drug -doxorubicin (dox). two types of conjugate with different c -dox ratio ( : and : ) were studied. conjugates absorbance and fluorescence, size distribution as well as a mass data were recorded utilizing optical and analytical equipment (microplate reader, zetasizer, lc-ms/ms and maldi-tof). in vitro studies were performed including evaluation of c -dox conjugate effects on human leukemic cells (jurkat, ccrf-cem, thp ad molt- ) viability. conjugates accumulation and distribution within cancer cells was monitored using fluorescent microscopy accompanied with fluorescence-activated cell sorting. it was evidently proven that both c -dox conjugates were stable and could be used as reliable candidates for biological application. cellular accumulation and distribution studies showed that conjugation of dox with fullerene promoted its entry into leukemic cells. accumulation of dox in the form of conjugates within cancer cells was intensified compared to the free drug. the results show that conjugated dox is more cytotoxic and the value of its ic are lower compared with the free dox. obtained results confirm nanocarrier function of fullerene c and the perspective of its application for optimization of doxorubicin efficiency against leukemic cells. comperative investigation of protective effects of tea and tea-related wastes on reducing potaential of h o -induced erythrocytes tea processing waste (tpw) formed during the tea production process in tea factories is up to , tones/year in turkey. tpw is one of the abundant available phenolic biomass among plantal wastes. in this study, black and green teas and their wastes were used. the aim of the study is to determinate the phenolic content and the radical scavenging activities of the samples, and to measure their effects on hydrogen peroxide-induced erythrocyte damage due to analyzing the reducing potential of erythrocyte involving glutathione reductase (gr), glutathione peroxidase (gpx) activities and reduced glutathione (gsh) content. total polyphenol content of samples was determined as mg catechine per dry mass by using folin-ciocalteau reactive and dpph radical scavenging activity was estimated by cuendet method as equivalent catechine standard. in erythrocyte, gsh level was measured by method of sedlak and lindsay while gr and gpx activities were assayed by the methods of bergmeyer and beutler, respectively. the highest phenolic content was observed in green tea and its wastes (p < . ) whereas black fiber waste had the lowest phenolic content. therefore, the highest radical scavenging activity and gsh level were detected in green tea and its wastes (p < . ). erythrocyte with the extracts of the teas and their wastes had the similar enzyme activities for both gpx and gr. in sum, the teas and wastes have antioxidant activity but, green tea and its leaf waste hade higher antioxidant activity than other samples. the tea wastes might be evaluated as many of protective health products, particularly in cosmetic fields thus, these by-products no application for any area is expected to become an economical value. fluorouracil ( -fu) is a chemotherapeutic drug classified as an "antimetabolite". it works through irreversible inhibition of thymidylate synthase. chemical derivatization of -fu with carbohydrtates is being investigated widely in order to enhance its bioavailability, therapeutic efficiency and to reduce its toxicity. however, water solubility of the newly derived compounds is usually very low. so, in order to obtain a pharmaceutically relevant formulation they need to be formulated appropriately. in this study, we prepared micellar delivery system for the new tetra-o-acetylglycose derivative of -fu synthesized via "click reaction", namely f -[{ -( ″, ″, ″, ″-tetra-o-acetyl-b-dglycopyronosyl)- h- , , -triazole- -yl}methyl] -fluorouracil. since the water solubility of this compound is very limited, we tested its solubility in several pharmaceutically relevant solvents by visual estimation after stiring increasing amount of the compound in ml of solvent for h. to estimate the carcinogenic potential of this compound, salmonella/microsome mutagenicity assay (ames test) was performed in four histidine-requiring strains of s. typhimurium, tester strains ta , ta (for the detection of frameshift mutations) ta and ta (for detection of base pair substitutions) according to the oecd guideline . the drug was solubilized ( lg/ml) with no precipitation in lutrol Ò -f /ethanol/water ( . : . : . , wt/wt) micelles ( . ae . nm). the results of ames test were negative so the compound neither produced frame shift mutations nor base pair mutations in s. typhimurium strains. the results imply that the new compound can be dissolved in aqueous micellar delivery system in order to be used for further studies, and that it was not mutagenic in the tested s. typhimurium strains. in conclusion, the formulation of the newly synthesized compound is not carcinogenic, and can be evaluated for anticancer activity in vitro and in vivo. integral metabolism parameters of dairy goats during reproductive cycle periods d. solovyeva, e. zarudnaya, s. zaitsev moscow savmb, moscow, russia study of the goat metabolism at different periods of the reproductive cycle allows to correct feeding ration, to increase the age of the productive use of animals and to receive high-quality products. the aim of the work was to determine the metabolic parameters of blood serum of goats, expressed in terms of biochemical parameters and interfacial tensiometry and study their relationship to metabolic processes in the body goats depending on the age and the period of the reproductive cycle. the healthy goats were divided into groups. the dynamic surface tension (dst) parameters were obtained from dependences of a surface tension (r) vs. time (t): at t? (r ), at t = . s (r ), t = s (r ) and t?∞ (r ). this work was supported by the russian scientific foundation ( - - ). all animals had - % fat content. the contents of total protein ( . %), albumin ( . %) and urea ( . %) are higher for the lactating animals as compared to the normal goat values. the levels of total cholesterol ( . %) and creatinine ( . %) are higher for the lactating animals. in lactating animals have the highest level of, which along with high phosphorus level talks about the intensification of energy processes during lactation. the correlations were found between the biochemical and dst parameters of the goat blood: lipids or cholesterol levels with r (r = À . ), r (r = À . ), r (r = À . ); total protein or albumin levels with r (r = À . ), r (r = À . ), r (r = À . ); aminotransferase activity with r (r = À . ), r (r = À . ). the correlations were found between the total protein and albumin levels with k (r = . ), k (r = . ); glucose levels and r (r = . ), r (r = . ). thus, the dst and biochemical parameters of goats have strong correlation relationships that are important for biomedical and veterinary applications. the relation of the severity of atherosclerotic disease with oxidative stress in patients with stable coronary artery disease h. sezen harran university, sanliurfa, turkey introduction: because, to the best of our knowledge, the relationship of total oxidant status (tos) and total antioxidant status (tas) with the severity of stable coronary artery disease (cad) has not been investigated in the literature so far, the present study was conducted to address this issue. materials and methods: this study consisted of consecutive patients and controls who underwent coronary angiography. for each patient, the total gensiniscore (gs) was calculated andthose with a gs of > were classified as the high gs group (hgg), and those with a gs less than were defined as the low gs group (lgg). the total oxidant status (tos) and total antioxidant status (tas) levels were measured using the erelmethod. the osi, which is an indicator of the oxidative balance, was calculated as the percentage ratio of tos to tas. results: the tas was lower in the hgg than lgg. the tos and osi were higher in the hgg than lgg. the correlation analysis showed that gs was negatively associated with the tas and positively with the tos and the osi. the multivariate analysis showed that age, tos, and hdl-c were independent variables for a high gs. the cut-off level of . lmol h o equiv./ l for serum tos levels predicted high gs with a sensitivity of % and a specificity of %. discussion: information on the severity of atherosclerosis is requiredtopredicttheprognosis of an individualpatientandtodetermine the proper treatment modality. the gs system has beenproventodemonstratethe severity of atherosclerotic disease. inthepresentstudy, thepatientswith a high gs had increasedlevels of oxidants. inaddition, tos was an independentindicator of theseverity of atherosclerosis. the optimal cut-offvaluefor tos topredict high-gens score was . (sensitivity % and specificity %). conclusions: the results suggest that the severity of atherosclerosis in stable cad is associated with increased oxidative status. evaluation of roemerine as a multidrug resistance pump inhibitor f. g. avci , c. velioglu , e. recber , c. unsal , g. gulsoy , b. sariyar akbulut marmara university, istanbul, turkey, istanbul university, istanbul, turkey efflux by multidrug resistance (mdr) pumps is a common defense mechanism used against antimicrobials. by pumping the drugs out, these pumps significantly reduce the efficacy of drugs. one approach to overcome this limitation is offered by the combinatorial therapies where drugs are co-administered with together with pump inhibitors. by simply preventing the efflux of the drug, the presence of inhibitors enhance drug efficacy. (-)-roemerine is an aporphine type alkaloid with significant antibacterial (against bacillus cereus, escherichia coli) and antifungal (against candida strains) activities. interestingly, (-)-roemerine was also found to enhance the cytotoxic response mediated by vinblastine in multidrug-resistant kb-v cells. in the same study, this finding was linked to its possible interaction with p-glycoprotein, a eukaryotic mdr pump. taking this finding as the starting point, the current study investigates the potential of roemerine as an inhibitor of the p-glycoprotein homologue pump, bmra, in bacillus subtilis . the antimicrobial agent berberine was used as the model agent since its efficacy is reduced by efflux through mdr pumps. to this end, bacillus subtilis cells were subjected to lg/ml berberine, a value well below the mic. this concentration only slightly retarded growth for hours but then cells resumed their regular growth. upon addition of lg/ml (-)-roemerine to the bacillus subtilis cells treated with berberine, growth pattern changed, indicating possible interaction with bmra. further investigation for the change in the expression of bmra was achieved with real time pcr analysis. glucose oxidase is an enzyme that catalyzes the oxidation of glucose to d-glucono- , -lactone and hydrogen peroxide. we hypothesized that enzyme would cause a double negative effect on cancer cells, by reducing the presence of glucose in cancer microenvironment and producing reactive oxygen species. to increase enzyme stability and enhance cellular uptake we encapsulated the enzyme with a thin acrylamide layer. the purpose of this work was to optimize the synthesis of these glucose oxidase nanoparticles and investigate their effect on cancer cells. nanoparticles containing single glucose oxidase were synthesized in two steps; first by introducing the vinyl groups onto the surface of enzyme by acyloylation followed by polymerization step with acrylamide monomers. encapsulated enzymes are approximately nm in size and retain most of their activity. after the optimization of nanoparticles, the anticancer potency of these nanoparticles was in vitro tested in mcf- breast cancer cell line. according to results, both nanoparticles and free enzyme are capable of inhibiting viability of cancer cells in a similar manner at very low concentrations. currently we are investigating mechanisms involved in this viability inhibition. initial results demonstrated that glucose supplement does not rescue cells from death induced by the activity of glucose oxidase, suggesting an oxidative stress related cause of inhibition. further studies are required to elucidate the exact mechanism. until now there is no determined advantage of glucose oxidase encapsulation against proteolysis. however, encapsulation may induce the accumulation of enzyme in cancer microenvironment. furthermore results suggest that glucose oxidase has a high effect on the viability of mcf- breast cancer cells indicating that this enzyme may have a potential use in cancer treatment. studies on the interaction of human phospholipid scramblase with c-terminal domain of topoisomerase iia u. sivagnanam, s. n. gummadi applied and industrial microbiology lab, bhupat and jyoti mehta school of biosciences, indian institute of technology madras, chennai, india human phospholipid scramblase (hplscr ) is a multifunctional protein that plays key roles in several cellular processes including apoptosis, tumorigenesis, anti-viral defense, cell signalling and several protein-protein interactions. it has been shown that hplscr interacts with the c-terminal domain of topoisomerase iia (topo iia) and enhances its decatenation activity in vitro. the interacting region in topo iia was identified but till date, no reports exist on the binding region in hplscr . this study aims to identify the region of hplscr that interacts with topo iia. to identify the topo iia interacting sites in hplscr , nterminal deletion constructs of hplscr viz Δ -hplscr , Δ -hplscr , Δ -hplscr , Δ -hplscr and Δ -hplscr were generated by pcr, cloned, overexpressed and purified to homogeneity using ni + -nta purification. the cterminal domain (ctd) of topo iia was cloned in pgex p- and was expressed as a gst fusion protein. gst pull down assays will be performed with the deletion constructs of hplscr and the gst-ctd-topo iia. the binding region in hplscr will be confirmed by peptide competition assays. our initial results show that the decatenation activity of topo iia was enhanced when the topo ii was pretreated with hplscr . Δ -hplscr did not show any enhancement of the decatenation activity compared to full length hplscr . hence, the binding region could be in the - region of hplscr . further deletions were done in the - region of hplscr as described earlier. gst-pull down assays and decatenation assays will be performed for the deletion constructs to narrow down the region of hplscr that binds to topo iia. we conclude that hplscr interacts with and enhances the activity of topo iia and the - region of hplscr is critical for enhancement of decatenation activity. further work is under progress to identify the exact topo iia binding region of hplscr and the physiological relevance of this interaction in the cell. a. ugur kurtoglu , v. aslan , e. kurtoglu department of biochemistry, antalya education and research hospital, antalya, turkey, department of hematology, antalya education and research hospital, antalya, turkey beta-thalassemia is a common autosomal recessive disorder resulting from over different mutations of the beta-globin genes. our aim was to creat a mutation map of beta thalassemia in province of antalya, turkey. in this study, mutation analysis of a total of beta-thalassemia patients followed up at the thalassemia center of the antalya education and research hospital, antalya, turkey, were included. according to our results, the ivs . is the most frequent mutation type in our province same as other geographical regions of turkey. the most frequent mutations in heterozygous or homozygous patients are ivs . , ivs . , ivs . and ivs . . our results indicate the importance of micromaping and epidemiology studies of thalassemia, which will assist in establishing the national prevention and control program in turkey. keywords: beta-thalassemia, beta-globin gene, mutation p-mis- investigation of the in vitro effects of some antibiotics on the purified beta-glucosidases from the rat liver n. t€ urkmen , h. kara karadeniz technical university medical biochemistry department, trabzon, turkey, balikesir university veterinary faculty biochemistry department, balikesir, turkey beta-glucosidases catalyzes the hydrolysis of the glycosidic bonds to terminal non-reducing residues in b-d-glucosides and oligosaccharides.b-glucosidases are widely distributed in the living world.b-glucosidases which in mammals, primarily found in the liver and kidneys;lysosomal b-glucosidase (gba ),non-lysosomal b-glucosidase (gba ), cytosolic b-glucosidase (gba ),intestinal lactase-phloriz the hydrolase (lph). liver tissues of wistar-albino rats were homogenized with homogenizer in the extraction buffer and crude extract was obtained after centrifugation.ammoniumsulfate precipitation range designated crude extract was purified by sepharose b-ltyrosine- -naphthylamine hydrophobic gel.commercially availabled antibiotics were prepared with substrate buffer.it was investigated inhbition effects of cefuroximesodium, ampicillin-sulbactam, amoxicillin trihydrate/potassium clavulanate, cefazolin sodium, gentamicin sulfate and ceftriaxone disodium antibiotics onto gba .inhibition types and k i values of related antibiotics were determined with p-npg substrate.lineweaver-burk plot was used for that purpose. rat liver gba was purified at . -fold with . % yield.gba was illustrated and kda at sds-page.ic value of ampicillin/sulbactam antibiotic for gba was found . mg/ml with competitive type inhibition and other antibiotics didn't inhibit. purfication methods are being used in the literature for the purified b-glucosidase from different sources.purified gba was illustrated and kda at sds-page.about molecular weight of bglucosidases is presented different information in the literat€ ure. this has been reported because of acid beta glucosidases are abnormal migration at the acrylamide or agarose gels.it was investigated inhbition effects of various antibiotics onto purified gba .ampicillin/sulbactam antibiotic inhibited to purfied gba at the competitive type.similiar antibiotics studies have been made in the literature for different enzymes. effect of glutamine on insulin resistance and endoplasmic reticulum stress g. aydogdu , p. b. sermikli , a. abbasi taghidizaj , e. yilmaz ankara university, institute of science, ankara, turkey, ankara university, biotechnology institute, ankara, turkey obesity and diseases are one of the most important public health problems of the world.excess fat storage in adipocytes leads to the release of increased amounts of non-esterified fatty acids, glycerol, hormones, cytokines, which are factors involved in the development of insulin resistance that cause type diabetes. one of the major differences between obese and lean individuals is the amino acid concentration in the circulation. although there are many studies about the amino acid metabolism associated with insulin resistance in obese individuals, the effect of glutamine metabolism in insulin resistance mechanisms are not well understood yet. glutamine can be used as fuel and its levels in tissues and circulation can regulate cell responsiveness to insulin and cellular metabolism. therefore, glutamine is a potentially important factor that might help us better understand insulin resistance and type diabetes. to determine whether glutamine effect on insulin resistance and endoplasmic reticulum stress, t -l cell is treated with different concentration of glutamine and analyzed by western blot for er stress markers. our results indicated that glutamine reduced endoplasmic reticulum stress and related with that attenuated insulin resistance. in case of transport of amino acids, insulin resistance, how it is affected when we have the information about the important tips on energy requirements and metabolism reach insulin resistance and type- diabetes treatment is likely to reveal a possible new targets. how does different lead levels affect tsh, ft , ft , vitamin b and folate? e. ozkan ankara occupational disease hospital, ankara, turkey exposure to heavy metals is increasing with the industrialization of society. one of the most intense exposure to heavy metals is pb on this issue. this study was aimed to determine the relationship between different blood pb levels and serum thyroid hormones (th), vit b , folate. the cases were - years old, male individuals who admitted to our hospital between april -march for periodic inspections because of occupational exposure to pb. the parameters of the cases were retrospectively retrieved. according to their pb levels, exposed workers (n: ) were divided into four subgroups; group (g) : - . lg/dl, g : - . , g : - . , g : ≥ . from these, the number of cases whose th levels were measured (n: ) given respectively; g : , g : , g : , g : cases. also the number of cases whose vit b and folate levels were measured (n: ) given respectively; g : , g : , g : ,g : cases. levels of pb were determined by icp-ms. th, vit b , folate were determined by cmia. between the groups formed according to pb levels, there was no significant difference in terms of average t , tsh and vitamin b (p > . ). on the other hand there was statistically significant difference between t and group , , (p < . ) but there was no difference between group (p > . ). the average folate belongs to the first group was about % higher than the other groups, and found that the difference was statistically significant (p < . ). there are many publications which have various results between pb levels and t ,t , tsh. but this study is important to compare the effect of different levels of pb. up to day there was no publication about the relation between different pb levels and vit b , folate. it was seen that there was no significant clinical relation between different pb levels and thyroid parameters, vit b . but the low levels of folate in the high pb levels groups shows us that we need further studies about this relationship. fluorescent study of in meso crystallization of membrane proteins with the introduction of membrane protein in meso crystallization years ago by landau and rosenbusch, a new era of membrane protein structural research has emerged ( ). since that time this method became associated with a number of major breakthroughs in the field ( ) including exceptional successes in structural studies of microbial rhodopsins and g-protein coupled receptors ( ) . here we used fluorescence microscopy to study in meso crystallization process of bacteriorhodopsin. several observations provide new insights into the in meso crystallization process. the crystallization starts with formation of microcrystals, followed by growth of a dominating crystal at the expense of smaller ones and formation of a depletion zone around it. these observations demonstrate an ostwald ripening mechanism of the in meso crystal growth. the depletion zone formed around the growing crystal is consistent with the previously proposed analogy relating in meso crystallization with the crystallization in a microgravity convection-free environment. this work is supported by rsf - - . ( ) landau, e. m.; rosenbusch, j. p. proc. natl. acad. sci. u. s. a. , , À . ( ) caffrey, m. acta crystallogr., sect. f: struct. biol. commun. , , - . ( ) katritch v., cherezov v., stevens r.c. ( ) . annu rev pharmacol toxicol , - . p-mis- stamp is critical for both ar and mtor signaling in prostate cancer cells x. sheng, y. jin, f. saatcioglu university of oslo, oslo, norway androgen receptor (ar) signaling plays a central role in the initiation and progression of prostate cancer (pca), including when the disease progresses to castration-resistant pca (crpc). the second central signaling pathway in pca, similar to various other cancers, is the pi k-akt-mtor signaling. importantly, these two oncogenic pathways cross-regulate each other in pca cells by reciprocal feedback, thereby maintaining tumor cell survival even when one is suppressed. we have previously identified that the six transmembrane protein of prostate (stamp ) promotes pca cell proliferation as well as inhibits apoptosis through, at least in part, regulating the erk mapk signaling. human pca cell lines lncap and vcap were used in the study. colony formation, soft-agar growth, prostatosphere formation assays were performed. for in vivo xenograft experiment, the cells were implanted subcutaneously into the flanks of nude mice. here, we show that stamp knockdown caused defects in colony formation, anchorage-independent growth and prostatosphere formation in lncap and vcap cells both in vitro, as well as tumor formation and growth in vivo. this may be due to the impaired ar and mtor signaling in these cells upon stamp knockdown. interestingly, in the crpc cell line rv , where-stamp knockdown did not affect mtor signaling, there was a remarkable repression of tumor take rate and growth. these results clearly indicate that stamp is essential for both ar and mtor signaling, and is crucial for pca growth in vitro and in vivo. however, the detailed molecular mechanism requires further investigation. taken together, these data unveil a critical role for stamp in coordinating the ar and mtor signaling pathways in pca cells, solidifying the basis for its pro-survival effects in pca, including in advanced disease. quantification of d thin layer chromatograms using d gel analysis software and gel documentation system o. kaynar, m. ileriturk, d. kaynar, s. kurt ataturk university, erzurum, turkey introduction: thin layer chromatography (tlc) is an important chromatographic technique that is widely used as a cost-effective method for rapid-sensitive analysis of compounds in plants, animals, and humans. however, one dimentional ( d) tlc is not sufficient for the separation of complex compounds. therefore, two-dimentional ( d) tlc was developed. the quantitative evaluation of plates are performed with tlc scanners or documentation systems. however, these systems specific for d plates, and cannot be adapted to quantitative evaluations of d plates. in this study, the applicability of the gel documentation systems and d analysis software for the analysis of d tlc plates were examined. material and method: d tlc of lipids: st dimension: methyl acetate/n-propanol/chloroform/methanol/ . % kcl ( / / / / v/v); nd dimension: chloroform/methanol/acetic acid/ water ( / / / v/v); detection: charring. d tlc of aminoacids: st dimension: . % (v/v) formic acid; nd dimension: toluene/glacial acetic acid ( : v/v); detection: uv. phospholipid and aminoacid standards, each include different classes were developed by d tlc. plates visualized with biorad geldoc xr, and band volumes on plates were calculated with biorad pdquest d gel analysis software. for the method validationa) plates containing same lipid classes were developed in the same day, and results were used for the calculation of intra-assay cv;cv% = average of each sample standard deviation/mean of sample b) plates containing same lipid classes were developed in different days, and results were used for the calculation of interassay cv; cv% = standard deviation of each sample average/mean of the plates results: volume of each phospholipid and aminoacid had less than % intra and inter-assay cv. conclusion: gel documentation system with d gel analysis software can be used for the quantitative analysis of the d tl plates both at uv and visible light. the role of na + k + atpase activity in the vasodilatory effect of n-acetylcysteine introduction: spasm occurred at the stage of and after the preparation of arterial grafts used in coronary artery bypass surgery (cabg) is effective on morbidity and mortality in the first hours of postoperative patients. n-acetyl cysteine (nac) that vasodilatory effect is known,may be considered as a suppressor agent for vasospasm developing during cabg. however, for the prevention of complications that may arise during or after cabg mechanism of these vasodilatory effects should be described. this study was aimed to investigate the role of atpase enzyme on the vasodilatory effect of nac. materials and methods: in this study, adult male wistar albino rats were used. rats were separated into four groups as control rats (g ), mm nac (g ), mm nac (g ) and mm nac (g ). a portion of the thoracic aorta isolated from rats was used for the relaxation response recording, and the other portion was used for measurement of nakatpase activity. isolated smooth muscle rings are suspended in the ml organ bath containing krebs solution for relaxation responses. in all groups, level of smooth muscle contraction were allowed to reach a plateau by adding mm kcl to the organ bath. then, in the first minutes of application relaxation responses which created by adding nac to the medium were recorded and the maximum relaxation responses were measured. nak atpase activity was determined using the mazzanti method. groups means were compared by one-way analysis of variance (anova). the threshold for statistical significance was set at . . results: the contraction force decreased in all nac dose groups compared to control group and this reduction was statistically significant (p < . ). similarly, nak atpase activity is also decreased in a dose dependent manner (p < . ). the findings obtained in this study suggest that vasodilator effect of nac formed in thoracic aortic smooth muscle was associated with the activity of the enzyme na k atpase. in the presented study, we isolated and characterized a novel feather-degrading bacterium that shows keratinolytic activity. a bacillus uk , which was isolated from the soil samples taken from farmland on kahramanmaras sutcu imam university campus, showed high keratinolytic activity when cultured on feather meal medium. the enzyme activity was studied in the ph range of . - . . the optimum temperature for keratinase activity was investigated by varying the incubation temperature between °c and °c. optimum keratinolytic activity was observed at °c and ph . . the enzyme was stable at °c. the activity was investigated in the presence of some chemicals, including sds, tween , dmso, triton x- , edta, nacl, zncl , cacl , glucose. the keratinolytic activity was inhibited by all chemicals tested to some degree. the molecular weight of keratinase was determined by polyacrylamide gel ( %) using standard molecular weight marker and estimated about kda by sds-page. the keratinase isolated from bacillus uk could be used in biotechnological processes i.e. feather degradation, wastewater treatment and in industrial processes, such as detergent, food and leather industries. introduction: hemoglobinopathies, including thalassemia, abnormal hemoglobins, constitutes a major group of inherited disorders of hemoglobin synthesis. the reduced or absent of the beta (b) or alpha (a) globin chains of the adult human hemoglobin molecule results beta or alpha thalassemias, leading to imbalanced a-globin/non a-globin chains. the aim of this study was to give a quik desicion with a/b-globin mrna ratio for sequencing of a or b gene, when the anemia is not detectable. materials and methods: mrna and cdna extraction of bthalassemia and a-(including two of . kb del./hbs) thalassemia subjects and normal controls were accomplished using the high pure rna isolation kit and transcriptor first strand cdna synthesis kit, respectively, following the manufacturer's instructions. we used cdna as a template in the real-time pcr amplification using primers specific for a, b globin genes. amplification was performed in a lightcycler Ò instrument. the a/b-globin mrna ratio of each sample was calculated based on the Àddct method. results: a/b-globin mrna ratios calculated in a-thalassemia subjects relative to normal control as a result of numbers of defective a-globin genes. the a/b-globin mrna ratio was found higher in b-thalassemia subjects. coinheritance of a-thalassemia in hb s subjects concluded a stabile a/b-globin mrna ratio as per a-thalassemia or b-thalassemia subjects. discussion and conclusion: instability in a/b-globin chains is a significant factor of thalassemia disease severity and can be used before deciding type of gene sequencing when the anemia is not detectable. this study indicates that imbalance in globin gene expression could be demonstrated by measuring a/b-globin mrna ratio, which was conveniently and accurately determined by qrt-pcr and give an information about globin gene function which gene should be correct to investigate an individual for globin gene mutation. p-mis- self-assembling peptides mimic supramolecular biochirality r. garifullin , , m. o. guler bilkent university unam, institute of materials science and nanotechnology, ankara, turkey, kazan federal university, institute of fundamental medicine and biology, kazan, russia supramolecular chirality is rooted in asymmetric spatial arrangement of structural elements (e.g. molecules or units with higher hierarchy). self-assembled systems giving rise to this kind of chirality are of great importance because they closely resemble natural biological systems and potentially can lead to new advanced functional materials. in the process of self-assembly, both molecularly chiral and achiral structural units can organize into chiral nanostructures. chiral arrangement of chromophore molecules in space is known to result in emergence of chiroptical properties of a chromophore. organization of pigment-protein complexes into macrodomains in green plants gives rise to biochirality emanating from long-range chiral order of complexes. owing to this order, macrodomains start to absorb circularly polarized light intensively and thus exhibit huge circular dichroism (cd) signal. in our study, a simple approach which was aimed at mimicking the biochirality phenomenon makes use of self-assembling peptide amphiphiles and their interactions with pyrene chromophore. designed peptide amphiphiles are capable of self-assembly into nanofibers with chiral interior, which in principle gives an opportunity to achieve long-range chiral order. two modes of interactioncovalent and noncovalentwere utilized in order to induce supramolecular chirality. covalent interaction mode included direct covalent attachment of pyrene to peptide sequence. upon self-assembly of peptide amphiphile into nanofibers intense circular dichroism phenomenon was observed. noncovalent interaction mode envisioned encapsulation of pyrene molecules in the hydrophobic core of nanofibers of another peptide amphiphile. co-assembly of peptide amphiphile and pyrene molecules led to chiral order and intense cd signal. in addition, it was possible to control the sign of cd signals by using either of peptide isomers, l or d. p-mis- pon activity in hdl subgroups of obese, overweight and normal weight subjects objective: the aims of this study were isolation of hdl-c subgroups by using precipitation method, determination of pon- activity in both total and hdl subgroups, and evaluation of performance characteristics of pon- activity measurement method in newly diagnosed obese, overweight and normal subjects. material and methods: the study population consists of newly diagnosed obese, overweight and normal subjects. fasting morning blood samples were taken from all study groups. hdl subgroup was obtained by heparin-mn-dextran sulphate precipitation method and cholesterol was measured with direct (homegenous) hdl-c method. hdl -c concentrations were calculated with the subtraction of hdl -c from total hdl-c. hdl -c and total pon- activity were determined by using eckerson method. non-hdl pon- activitiy was calculated with subtraction of hdl pon- activity from total pon- activity. results: total hdl-c, hdl -c and hdl -c concentrations and the activity of total pon- and hdl pon- were found lower in obesity according to overweight and normal subjects (p < . ). negative correlations were found between body mass index and hdl -c, total pon- and hdl pon- (r = À . , p < . ; r = À . , p < . ; r = À . , p < . , respectively). conclusion: our findings indicated that hdl-c metabolism and lipoprotein associated antioxidant defense mechanisms were adversely affected with obesity. in conclusion we think that precipitation method using for separating hdl subgroup, is simple and cost effective for routine applications in clinical laboratories. besides hdl -c measurements, pon activity, measurement of total and hdl -c subgroup might be helpful to evaluate the atherosclerotic process in obese subjects. keywords: obesity, body mass index, paraoxonase, hdl subgroup, cholesterol p-mis- hepatitis e virus antibody prevelance among persons who work with animals in north cyprus introductions: hepatitis e infection is a major cause of viral hepatitis in many developing countries. the objectives of the present study was to determine the seroprevelance of hev infection in peoples who work with animals in northern cyprus. materials and methods: prevelance of hev infection were determined in study group population: persons without occupational exposure to animals; persons who work with animals; veterinarian and butcher. a total of blood samples were collected. all serum samples were tested elisa using a commercially available kit according to the manufacturer's instructions. ti-test were used for istatistical analyses. p > . was accepted as significant value. results: in a study of blood donors ( male, female), the overall prevelance of anti-hev igg antibodies were . %. the blood samples were collected different areas. the prevelance of anti-hev igm antibodies was . % and he was years and acting a butcher during years. the prevelance of anti-hev igg of women were approximately two fold higher than men. no significant difference in anti-hev prevelance was observed between the age of the blood donors. according to the anti-hev igg prevelance, the without occupation expose to animal animal were %, the animal husbandry were % and the veterians and the butcher were % were found. discussion: the prevelance of anti-hev in the north cyprus ( %) was found low such as the prevelance of the turkey ( %). the prevelance of anti-hev igg in animal husbandry were higher that the other groups because of they may be more spend of time and contact with animals. the prevelance of igm results suggested that the possibility of outbreaks may be low in north cyprus. conclusion: this study was the first seroprevelance analysis of north cyprus according to the population number.the further studies could be included the seroprevelance of anti-hev from the animals. most errors in the clinical laboratory occur in the preanalytical phase the aim of this study was to investigate the causes and rates of rejected samples, regarding to certain test groups in our laboratory. this study was designed on the rejected samples between january and january . clinical chemistry, coagulation, hormone, cardiac markers, total urine evaluation and other (ethanol level, hba c, hb electrophoresis, neonatal bilirubin, drug level, blood gas, fecal occult blood) test groups were included. the total number of specimen and rejected samples was obtained from the hospital information system retrospectively. types of inappropriateness were evaluated as follows: erroneous coding, clotted specimen, hemolysis, insufficient volume, incorrect patient, incorrect tube and inappropriate specimen. it was determined that blood samples were sent to our laboratory in one-year period. . % of them were rejected because of preanalytical errors. erroneous coding was found as the most common rejection cause ( %). rejection rates of clotted specimen, hemolysis, insufficient volume, incorrect patient, incorrect tube and inappropriate specimen were found to be %, %, %, %, % and % respectively. in our study, erroneous coding was the most common cause of preanalytical errors. education of medical secretaries is relevant and important as can be seen in the decrease of sample errors and the resulting quality improvement. glycosylated hemoglobin test (hba c) is important for screening, diagnosing, and monitoring diabetes and prediabetes. however, hba c levels may dependent on patient ethnicity suggesting that the diagnostic cut-offs should be evaluated for specific populations. therefore, our aim in this study was to evaluate the efficiency of hba c for predicting diabetes in comparison to oral glucose tolerance test (ogtt) results for turkish population. the study included anonymous lab results (acibadem labmed laboratories in turkey) of patients ( female, male) aging . ae . years ( - ) who had an initial diagnosis of diabetes. glucose and insulin levels during ogtt were measured after the initial administration of g sugar ( hour), -hour and -hour. these parameters were statistically analyzed in comparison to simultaneous hba c results. glucose measurements at hour had better distinction power (p < . ) between these individual groups than initial and -hour glucose measurements. the average hba c (%) levels for healthy, pre-diabetic and diabetic individuals were . ae . , . ae . and . ae . , respectively. roc curve analysis showed . % sensitivity and . % specificity for the clinically accepted hba c cut-off value of . %. hba c cut-off value of . % had a higher sensitivity of . % and comparable specificity of . %. the highest discrimination power between healthy, pre-diabetic and diabetic individuals was observed at glucose concentration at -hour after sugar administration in ogtt test as opposed -hours generally used for diagnosis. low sensitivity was observed for the clinically adapted . % cut-off value of hba c. the cut-off value of . % for hba c was found to be more sensitive with comparable specificity than the . % cut-off values for diabetes screening in our population. our results suggest that . % for hba c should be considered for diabetes cutoff value for turkish population. induction of the glutathione-dependent detoxification capacity is involved in the hepatoprotective effect of silymarin against acetaminophen-induced hepatotoxicity y. kim, d. kwon, c. ahn seoul national university, seoul, south korea recent findings in this laboratory showed that silymarin was capable of promoting hepatic glutathione (gsh) synthesis via a modification of the transsulfuration reactions in the liver. to investigate its pharmacological significance, we examined the hepatoprotective effect of silymarin against liver injury induced by acetaminophen (apap). adult male mice were treated with silymarin ( mg/kg, po) every hours for a total of doses prior to an apap challenge ( mg/kg, ip). the apap-induced liver injury was assessed by histopathological examination and measurement of changes in plasma enzyme activities, lipid peroxidation and formation of nitrotyrosine protein adducts in the liver. plasma levels of apap and its major metabolites were monitored for hours to estimate the metabolic transformation of apap. also protein and activity of the major cyp subtypes involved in the metabolic activation of apap into a toxic metabolite were determined in liver of the mice treated with silymarin only. silymarin pretreatment attenuated the apap-induced liver injury significantly when determined hours later. plasma concentrations of apap, apap-glucuronide or apap-sulfate in plasma were not changed, but thiol conjugates of apap, such as apap-glutathione, apap-cysteine and apap-n-acetylcysteine, were elevated significantly in the mice pretreated with silymarin. however, silymarin treatment did not affect protein expression of cyp e , cyp a , or cyp a in the liver. also hepatic microsomal enzyme activities measured using p-nitrophenol, ethoxyresorufin and erythromycin as substrates, were not increased by silymarin, indicating that the elevation of apap-thiol conjugates should be attributed to an augmentation of the gsh conjugation capacity. it is suggested that silymarin may protect the liver against an electrophilic substance-induced toxicity by increasing gsh availability which would enhance the detoxifying capacity of liver cells. prostate cancer (pca) is the second leading cause of death among men in western countries. we have previously found that the six transmembrane protein of prostate (stamp ) promotes pca cell proliferation as well as inhibits apoptosis through, at least in part, regulating the erk/mapk signaling. we also found that stamp is highly mobile in pca cells and shuttles between the plasma membrane and the golgi, often found in vesiculotubular structures in the cytosol. using advanced imaging techniques, we have now characterized the trafficking of stamp from the plasma membrane to early endosomes in lncap cells, by analysing its dynamic targeting to the three main endocytosis pathways: clathrin-mediated endocytosis, caveolae/lipid rafts, and the arf -dependent pathway. we found that stamp fused to cyan fluorescent protein (cfp-stamp ) is present at the plasma membrane where it accumulates in punctate structures. live cell confocal imaging showed that these puncta were dynamic over time indicating that stamp may be constitutively delivered to the plasma membrane and removed from it by endocytosis. co-expression of cfp-stamp with various fluorescent protein markers revealed that cfp-stamp puncta corresponded to lipid rafts that were labelled with caveolin- -rfp or antibodies against flotillin. live cell imaging showed that cfp-stamp and caveolin- -rfp disappeared at the same time from the same region of the plasma membrane suggesting that lipid rafts are likely to be responsible for stamp internalization. notably, stamp was absent from other endocytosis structures such as clathrin-coated pits/vesicles. further work is needed to determine whether stamp internalization is required for its function, such as its link to erk signaling, and whether interference with lipid rafts influences stamp effects on pca cell proliferation and survival. antithrombin-iii, mpv and plasma total homocysteine levels in behcet's disease introduction: behcet's disease is a multi-systemic and chronic inflammatory vasculitis of unknown etiology characterized by recurrent oral and genital ulcers, uveitis, arthritis, arterial aneurysms, venous thrombosis and skin lesions. platelet indices such as mean platelet volume (mpv) is a standart indicator of platelet function in disease pathophysiology. antithrombin, a glycoprotein synthesized in the liver, is the major plasma inhibitor of thrombin thus modulating blood coagulation. antithrombi-iii (at-iii) is a enzyme even moderate deficiency significantly increases the risk of thrombosis. homocysteine (hcy), that is formed during the metabolism of methionine. several clinical studies have clarified that elevated blood hcy levels are related to atherosclerotic disease. in our study, we investigated ovocystatin is one of the best characterized members of cystatin superfamily of protease inhibitors, and it has been frequently used for pathophysiological studies as the model protein, representative for this superfamily. its application has been supported by high structural similarity to human cystatin c as well as several common biological activities. as regard to biological activity, cystatins, including ovocystatin, are best characterized as inhibitors of cysteine proteases of papain family (c ), such as cathepsins b, h, l and s. these inhibitors participate in intra-and extracellular control of proteolytic events, both in physiological and pathological states. in the recent decade also new activities of cystatins, not assigned to inhibition of papain-like cysteine cathepsins, were found. these activities are associated with an alternative active center for legumain-type proteases in the molecule. here we report a chemical modification of ovocystatin that disables the anti-papain activity of the inhibitor but does not affect its anti-legumain activity. the chemical knockout has been obtained by reaction with -hydroxy- -nitrobenzyl bromide (hnbb) that covalently modifies the trp residue in the molecule. the reaction has been monitored by uv-vis and fluorescence spectroscopy. the anti-papain activity of the inhibitor has been measured colorimetrically against bana as a substrate. the anti-legumain activity was assessed fluorometrically using z-ala-ala-asn-amc. the reacted inhibitor exhibited an additional, characteristic for hnbb, band at nm in uv-vis scan. accordingly, an ablation of trp fluorescence was also observed. the molecule fully retained the anti-legumain activity, while only residual antipapain activity ( %) was observed. the modified ovocystatin can be a useful molecular tool for studying the physiological and pathological processes specifically associated with legumain activity. departments of medicine (hematology/oncology) and biochemistry and molecular biology, university of louisville, james graham brown cancer center, louisville, ky, united states -phosphofructo- -kinase/fructose- , -bisphospatase (pfkfb) family of enzymes are responsible for the conversion of fructose- -phosphate (f p) to fructose- , -bisphosphate (f , bp) and vice versa, and f , bp is an allosteric activator of phosphofructokinase- (pfk ), a rate-limiting enzyme of glycolysis. among the four identified pfkfb isozymes (pfkfb - ), pfkfb is the least studied isozyme in human cancers. there exists two different splice variants of pfkfb , variant- and variant- , coding two different isoforms, isoform a and b, respectively. in this study, we first analyzed the effect of k-ras(g d)induced oncogenic transformation on pfkfb expression in pancreatic duct cells. we found that oncogenic k-ras induction in immortalized pancreatic duct cells (ipde) was associated with decreases in total pfkfb mrna and protein expressions (mrna; ipde: ae . ; ipde+kras: . ae . and protein; ipde: ipde+kras: . ). we then, checked individual expressions of splice variants and observed that while pfkfb splice variant- (p -v ) expression was reduced by k-ras induction (ipde: ; ipde+kras: . ), pfkfb splice variant- (p -v ) expression was increased (ipde: ; ipde+kras: . ). then, we checked effects of p -v and p -v on glycolytic phenotype of ipde and ipde+kras cells. over-expression of pfkfb variants increased f , bp concentration (p -v : . ; p -v : . fold; compared to empty vec), glucose uptake (p -v : %; p -v : %) and glycolysis (p -v : %; p -v : %) in ipde+k-ras cells. we next analyzed the subcellular localizations of pfkfb isoforms and observed that both pfkfb isozymes localize to the nucleus, with more prominent nuclear localization of p -v compared to p -v . also, nuclear localization ratio of p -v increases after oncogenic transformation with mutant k-ras. taken together, these results suggest that pfkfb may have a role in the glycolytic phenotype of pancreatic cancers characterized with hyperactive k-ras signaling. effects of p map kinase inhibitors on mda-mb- cell line introduction: p mapk phosphorylates serine and/or threonine residues of the target proteins. the activation of p mapk leads to cell growth, differentiation, survival or apoptosis. in this study, we tested the effect p mapk sb and sb on mda-mb- cells to further elucidate the controversial role of p mapk on cell proliferation or cell migration. materials and methods: mda-mb- cancer line was cultured in rpmi- supplemented with % fbs. the cytotoxic and cell migration effects of sb and sb inhibitors were tested by mtt assay and wound assay, respectively. the effects of both inhibitors on proliferation and adhesion of md-mb- cells were determined by icelligence system. results: it was found that sb p map kinase inhibitor was more effective than sb . however, no significant effects of low doses of lm and lm of both inhibitors were seen on cell proliferation as compared to the dmso-treated control cells for up to hours as determined by icelligence system. on the other hand, both sb and sb significantly prevented cell proliferation at a concentration of lm. both sb and sb significantly reduced cell migration in a time-dependent manner at a concentration of lm. then, we tested whether each p mapk inhibitors have any effect on cell adhesion during a treatment period of hours using icelligence system. only lm concentration of sb reduced cell adhesion for about . hour (p < . ). conclusion: p mapk inhibitors sb and sb differentially affect cell proliferation, survival and migration. acknowledgements: this study is financially supported by dumlupınar university, scientific research project no - . mutagenicity of a series efficacious benzoxazine derivativesa new approach to evaluate ames test data e. foto , f. zilifdar , s. yilmaz , t. sarac ßbasi , i. yalc ßin , n. diril hacettepe university, ankara, turkey, ankara university, ankara, turkey testing safety of drug candidates is as crucial as evaluating their efficacy in early drug development. we previously synthesized a series of , -benzoxazine- -one derivatives showing significant antimicrobial, in vitro anticancer, topoisomerase i inhibitory activities and studied their several mechanisms of action. in this present study, we have evaluated mutagenic activities of these compounds and their potential metabolites. moreover, we aimed to develop a new statistical algorithm available for structureactivity relationship analysis to identify the regions responsible for the activity. to evaluate mutagenicity of the compounds, ames salmonella/microsome test was used. salmonella typhimurium ta and ta strains were used to detect for frameshift and basepair substitution mutagens, respectively. additionally, mutagenicity of potential metabolites of them were evaluated by adding metabolic activation system (s ) which was prepared from a pool of male sprague dawley rats. results were evaluated with student's-t test. following regression model estimation analysis, we detected minimum mutagenic doses of all tested compounds for generating a d-common features pharmacophore model with hiphop method. according to the results, only bs , bs , bs and bs exhibited strong mutagenic effects on both strains in the presence and absence of s . additionally bs , bs , bs and bs (in the absence of the s ), bs , bs and bs (in the presence of the s ) showed weak mutagenic effects on ta . hiphop analysis results revealed that mutagenicity was increased in the presence of aromatic desactivating groups which might form hydrogen bonds at the position of r and hydrophobic groups at the position of r of the benzene ring in the structure of benzoxazine. the new statistical approach developed in this study can be useful for assessing the ames test data available for structure activity relationship analyses. background: recently more than thirty different diseases can screen simultaneously with expanded newborn screening (nbs) programs by tandem ms.expanded nbs with tandem ms is performed routinely at akdeniz university hospital central laboratory since .the aim of this study was to evaluate our nbs results with some second-tier and confirmatory tests. materials and methods: nbs results (n = ) were evaluated in dried blood samples which sent to our laboratory for the study between august and august . electrospray ionisation (esi)triple quadrupole mass spectrometer (shimadzu lc-ms/ms ,japan) was used for nbs analysis,acylcarnitine and amino acid profile were screened with mrm (multiple reaction monitoring) spectrum within minutes.second-tier tests were performed as urine organic acid analysis by gas chromatography-mass spectrometry (gc-ms),plasma and urine quantitative amino acid analysis by high pressure liquid chromatography (hplc).pathological nbs results were assessed in three separate groups as amino acid metabolism disorders, fatty acid oxidation defects and organic acidemias. results: metabolic diseases were found in ( . %) patients by the second-tier tests performed.there were detected amino acid metabolism disorders in ,organic acidemia in ,fatty acid oxidation defects in patients. conclusions: the reason of high positive results in our laboratory could explain that our study includes both screening and monitoring of previously diagnosed metabolic patients.nbs is performed in only a few centers in turkey although there were the national screening programs included nbs in many foreign countries.more expanded nbs programmes in our country is required to start treatment of patients before irreversible damage is not occured. although many reports indicate the involvement of calpain in several human pathologies, it is not yet clarified how the protease can recognize the substrates to digest and how can escape to its natural inhibitor calpastatin. answers to these questions have been obtained by identifying specific intracellular localizations of calpain and its substrates and analyzing the interactions of the protease with calpastatin. these studies were carried out using human sknbe neuroblastoma cells. protein-protein interactions and intracellular localization of calpain and the related proteins were determined by immunoprecipitation and isolation of membrane microdomains. we have observed that small amounts of calpain- are localized in lipid rafts microdomains together with n-methyl-d-aspartate receptor (nmdar) containing nr /nr b subunits. immunoprecipitation experiments have demonstrated that nmdar containing nr /nr b subunits, calpain- , hsp and neuronal nitric oxide synthase (nnos) but not calpastatin and calpain- are present in specific protein complexes. thus, in this localization calpain activity is regulated by hsp that reduces the affinity for ca + of the protease. cell stimulation with nmdar agonists induces calpain activation that specifically cleaves the subunits nr b of the receptor promoting changes in lipid rafts organization and internalization of nmdar without affecting cell viability. moreover, in these conditions, also nnos is digested and converted in the active form by calpain- . our data suggest a physiological role of calpain- at specific cell sites. the protease inserted in lipid rafts microdomains is in strict contact with its targets and escapes to calpastatin which is not inserted in these structures. following an increase in ca + influx, the activated protease regulated by hsp , promotes the removal of nmdar from the plasma membranes, decreasing ca + entrance through this receptor-channel and protecting cells from ca + overloading. tissue transglutaminase (tg ) is a multifunctional protein complex that can act as a crosslinking enzyme, gtpase/atpase, protein kinase and protein disulfide isomerase. at the cell surface, tg was shown to be involved in adhesion, migration, invasion, growth, epithelial mesenchymal transition and hence implied in the metastatic development of many different tumor types. renal cell cancer (rcc) is one of the most common type of cancer in adult males that generally grows as a single tumor within a kidney. our previous findings indicate that the increased expression of tg in rcc results in tumor metastasis with a significant decrease in disease-and cancer-specific survival outcome. herewith, the role of tg in cell migration of rcc was investigated in this study by transducing the model rcc mouse cell line renca with a series of tg mutant constructs. renca cells were transduced by lentiviral particles encoding wttg , transaminase-defective tg -c s form with low gtpbinding affinity, gtp-binding deficient form tg -r a, and transaminase-inactive tg -w a. in order to investigate the role of tg transamidating and gtpase activity in cell migration, scattering assay was used where colonies for each mutant clone was followed for a time interval of hours. our results showed that non-transduced control and tg -c s mutant renca cells demonstrated a similar migration pattern with a % of scatter activity. on the other hand, % colonies formed by renca cells overexpressing wttg and tg -w a mutant scattered away from each other. a small insignificant increase in scattering was seen in % of the total number of colonies for renca cells overexpressing tg-r a construct. data from this study supports that gtp-binding activity of tg is the drive force in migration driven scattering of renca cells, suggesting that inhibitors targeting the gtp-binding activity of tg may serve as a new therapeutic approach in the treatment of rcc. background: in this study, we aimed to investigate the relationship between level of vitamin d with subclinical hypothyroidism and subclinical hyperthyroidism. material and metod: study groups planned as three groups such as euthyroid (n = ), subclinical hypothyroid (n = ), subclinical hyperthyroid (n = ). serum tsh, free t (ft ) and free t (ft ) levels were determined by chemiluminescence immunoassay and serum -hydroxy (oh) vitamin d (oh) d level were determined by liquid chromatography-tandem mass spectrometry. euthyroidism was defined as a normal level of tsh (range, . to . miu/l), ft (range, . to . ng/dl) and ft (range, . to . ng/dl). subclinical hypothyroidism is defined as an elevated serum tsh level associated with normal total or free t and t levels. subclinical hyperthyroidism is defined as low serum tsh levels associated with normal free t and free t levels. results: subclinical hyperthyroid group had significantly higher (oh) vitamin d levels compared to the euthyroid and subclinical hypothyroid groups (p < . ). (oh) vitamin d levels in subclinical hypothyroid group was not statistically significant when compared with the euthyroid group. food processing wastes provide carbon sources in high amounts for fermentative microorganisms to produce energy. converting carbon-rich biomass into bioethanol through fermentation by microorganisms both provides energy requirement for humankind and also decrease pollutant gases like co , no x and so x (ghorbani et al., ) . fermentation processes for bio-ethanol production could be achieved by saccharomyces cerevisiae, zymomonas mobilis, and escherichia coli. bacterial hemoglobin (vitreoscilla hemoglobin, vhb) is the first and best characterized prokaryotic hemoglobin molecule. the function of vhb is supporting the cellular respiration through binding to oxygen at microaerobic environment, transferring it to the terminal respiration oxidases (geckil et al., ) and thus improving growth and productivity of the microorganisms. in this study, e.coli strains fbr , ts and ts were used as ethanologenic microorganisms. expression of vhb in ts is lower than in ts strain. for the efficient ethanol production effect of different inoculum sizes, sugar species and sugar concentrations in the growth medium were investigated. vhb expression increased effectively the viability of ts strain by up to . x cfu per ml of fructose ( %, w/v) supplemented lb medium starting with small inoculum for fermentation. this indicates that vgb expression should be at the certain level to maintain sufficient the cell growth for ethanol production. geckil h, gencer s ( ) . production of l-asparaginase in enterobacter aerogenes expressing vitreoscilla hemoglobin for efficient oxygen uptake. applied microbiology and biotechnology : - . ghorbani, f., younesi, h., sari, a. e., najafpour, g. ( ) . cane molasses fermentation for continuous ethanol production in an immobilized cells reactor by saccharomyces cerevisiae. ethanol production from dairy industry by product using bacterial hemoglobin t. sar, g. seker, a. g. erman, m. yesilcimen akbas gebze technical university, depertment of molecular biology and genetics, kocaeli, turkey bioethanol production from biomass has a great potential to reduce greenhouse gases emissions. ethanol has several applications in industries (chemical, medical, pharmaceutical, food etc.) in the form of raw material, solvent and fuel. one of the most abundant liquid wastes is cheese whey generated from dairy industries. whey powder is concentrated form of whey and contains lactose and also protein, lipid, minerals and vitamins. vitreoscilla hemoglobin (vhb) is the first bacterial hemoglobin. the main function of this molecule is to improve oxygen transfer to cellular oxidases and thus supporting cellular growth and productivity at low oxygen levels (kallio et al. ) . in this work, e. coli strains fbr , ts (low level vhb expressing) and ts (high level vhb expressing) were used as ethanol producing microorganisms. fermentation medium containing whey powder supplemented with lb material was inoculated with these strains and incubated for hours at °c and rpm in a ml erlenmayer flask. the ethanol production was improved over % by using lower vhb expressing strain. the ethanol levels (v/v, %) were determined as . , . and . for fbr , ts and ts strains respectively. it is shown that the certain levels of vhb could be useful tool to increase the growth and productivity of ethanol from dairy industry wastes. kallio p.t., kim d.j., tsai p.s. and bailey j.e. ( ) . bioethanol is usually produced from cellulose, hemicellulose and lignin. the lignocellulosic wastes should be hydrolysed into fermentable sugars by using enzymes or dilute acids before microbial fermentation. acidic hydrolysis methodology is cheaper than enzymatic hydrolysis but it can cause production of some inhibitors like aliphatic acids, which affect the growth of microorganisms. vitreoscilla hemoglobin (vhb) is the first described prokaryotic hemoglobin. the recombinant strains carrying vgb gene (e. coli, p. aureginosa) which encodes vhb showed increased bacterial growth, productivity of metabolites compared to untransformant counterparts under low oxygen concentrations [nasr et al., ; geckil et al., ] . in this study, ethanologic e. coli strains fbr , its derivative strains ts (vgb+) and ts (vgb+) were used. ts was constructed in such that it could express more vhb than ts . bioethanol production by these strains in presence of lignocellulosic hydrolysates derived inhibitors was investigated. different acetic acid concentrations ( . - mm) were used as inhibitors from lignocellulose hydrolysate. . mm acetic acid was used as an inhibitor. the growth of vhb expressing ts and ts strains was inhibited about % after hours fermentation time. strain fbr was inhibited as high as % by using the same inhibitor including growth medium. it was shown that the expression of vhb could improve growth and productivity in presence of lignocellulosic inhibitors. differentiation of preadipocyte, also called adipogenesis, leads to the phenotype of mature adipocyte. however, excessive adipogenesis is closely linked to the development of obesity. thus, any drug or chemical that can inhibit adipogenesis may have preventive and/or therapeutic potential against obesity and related diseases. azd , an inhibitor of the family of pim kinases, is known for anti-cancer activity. here we investigated the effect of azd on adipogenesis in t -l preadipocytes. notably, azd treatment led to a concentration-dependent inhibition of both lipid accumulation and triglyceride (tg) synthesis during the differentiation of t -l preadipocytes into adipocytes with no cytotoxicity. on mechanistic levels, azd strongly reduced not only the expression levels of ccaat/enhancer-binding protein-a (c/ebp-a), peroxisome proliferator-activated receptor-c (ppar-c), fatty acid synthase (fas), and perilipin a but also the phosphorylation levels of signal transducer and activator of transcription- (stat- ) during adipocyte differentiation. furthermore, azd largely decreased leptin, but not adiponectin, mrna expressions during adipocyte differentiation. collectively, these results demonstrate that azd inhibits adipogenesis in t -l preadipocytes and the inhibition is largely attributable to the reduced expression and/or phosphorylation levels of c/ebp-a, ppar-c, fas, perilipin a, and stat- . effect of intrauterin exposure to artificial food colourings on dna damage in rats in many research genotoxic potential of food additives has been investigated. however there are few findings about the effect of artificial food colourings (afc) on dna. in this experimental study, we aimed to analyze whether in utero exposed artificial food colourings would have effect on dna and cause damage.thirteen female rats were included to the study which were equally divided into two groups as control (cg, n = ) and food colouring (fcg, n = ) groups. a mixture of nine food colours were given daily to fcg by oral gavage from preconception to birth. no adverse effect level (noael) of artificial food colourings for each colouring was administered to fcg. three months after the birth, offspring from each group were selected randomly as control (cg) and experiment (eg) groups. then they were sacrified under anesthesia. for performing the alkaline comet comet assay leukocytes were seperated from whole blood samples. the alkaline comet assay was performed. the extent of dna damage was assessed from the length of dna migration derived by subtracting the diameter of the nucleus from the total length of the image and graded into categories and these grades were converted into arbitrary unit (au). differences between the means of data were compared by independent samples t test. the results were given as the meanaesd, p values of less than . were considered as statistically significant. although the extent of dna damage was higher in eg, the comparison of experiment ( . ae . ) and control ( . ae . ) groups showed no statistical difference (p = . ). relationship between glucocorticoid receptor gene polymorphisms and recurrent depression l. aydogan, i. benli, z. c. ozmen, i. butun gaziosmanpasa university medical faculty, department of biochemistry, tokat, turkey objective: sensitivity to glucocorticoids varies between individuals and these differences have been implicated in the etiology of psychiatric diseases such as depression. recent studies have found relationship between common glucocorticoid receptor (gr) gene (nr c ) polymorphisms and unipolar or bipolar depression. the nr c gene is a candidate gene affecting depressive disorder risk and management. the aim of the present study was to evaluate the relative distribution of specific polymorphisms of nr c (bcl and rs ) in recurrent depressive disorder (rdd) patients. methods: our study included volunteers with recurrent depressive disorder and healthy individuals without any mental illness. depression was assessed by hamilton and madrs depression scale. nr c gene polymorphisms were detected by real-time pcr, with hybridization probe method. allele and genotype frequencies at two loci (bcli and rs ) were investigated in rdd patients and controls. results: genotype distribution among rdd patients and the control group for bcl- (g/c) were as follows: cc % and %, gc % and %, gg % and %, respectively. there was not a significant difference when the frequency of the allele (p = . ) and genotype frequency (p = . ) were compared between the patients and the control. genotype distribution in the rs region (a/t) of the patients and controls were tt % and %, ta % and %, aa % and %, respectively. allele frequency (p = . ) and the genotype frequencies (p = . ) were not significantly different among the groups. conclusion: numerous nr c gene polymorphisms were previously reported in association with modification of depressive disorders. the results of our study showed no association between gr genotype and recurrent depressive disorder. nr c polymorphism does not play a role in the development of recurrent depressive disorder. thymoquinone (tq) has been shown to supress the proliferation of various tumor cells, while it is minimally toxic to normal cells. the aim of this study is to investigate the potential therapeutic effects of tq on cell proliferation, apoptosis, invasion, migration, colony formation and wound-healing in sh-sy y human neuroblastoma cell line. sh-sy y cell line treated with - lm tq by solving medium for , and h considering a time-and dose-dependent manner. the cytotoxic effect of tq was determined by mtt method. total rna was isolated by trizol reagent. cdna synthesis was performed by using commercial kit. mdm , p , p , akt, pten, cdk , cyclin d , caspase- , - , - , - , bcl- , bax, parp, bcl-xl, bid, dr , dr , puma, noxa, mmp- , - , timp- , - and gapdh gene expression profiles were analysed by real-time pcr method. effects of tq in sh-sy y cells on invasion, colony formation and cell migration were detected by matrigel-chamber, colony formation assay and woundhealing assay, respectively. statistical analysis were performed with rt profiles array data analysis by using student's t test. ic value of tq in sh-sy y cells was detected as lm at th hours. by rt-pcr results, it was determined that tq caused a decrease in the expression of mdm , akt, cdk , cyclin d , bcl- and mmp- . it is also observed that tq caused a significant increase in the expression of p , pten, caspase- , - , bid, dr , puma, noxa and timp- . it was also found that tq in sh-sy y cells suppressed invasion, migration and colony formation by using matrigel invasion chamber, wound healing and colony formation assay, respectively. in conclusion, we demonstrate that tq significantly effect cell cycle, apoptosis, invasion, migration and colony formation of sh-sy y cells. tq may be a potential candidate as chemotherapeutic agent for the treatment of neuroblastoma. more studies have to be performed to profile the mechanisms and genome wide effects of tq to prove its therapeutic potential. dna aptamers can achieve a very high affinity to the target due to the potential of developing broad target-binding interface. however, classic strategy selection of aptamer binders is a challenging task requiring multiple rounds of panning and post-selection optimization. we have developed fast and convenient technique for the selection of dna aptamers based on the offrate selection and tandem affinity purification (tap). we constructed and produced in e.coli recombinant chimeric protein, comprising two affinity tags (his and gst) separated from each other and from the target protein (anthrax protective antigen domain iv, padiv) by sumo protease recognition polypeptide and synthetic cleavage site for the anthrax lethal factor (lf). the protein bound to aptamer library is first captured by imac resin, cleaved by sumo protease, captured by gst resin and eluted by lf following the lines of the tap method. the gst-captured aptamer-target complexes were subjected to the off-rate selection using soluble padiv as the competitor. multiple selection rounds are cumbersome and can result in carryover. high abundance of moderate affinity aptamers in the resulting pools obtained by classic selection approaches suggests that the procedure to counter-select them at the beginning of panning is needed. reduction of the contact duration between the aptamer library and the target was crucial for efficient selection of high-affinity binders. on the other hand, tap prevents contamination, and bundled with the off-rate selection, allows for clean isolation of high-affinity binders with affinity in the low nanomolar range. the developed technique is applicable for efficient selection of high affinity dna binders to soluble recombinant proteins and their fragments. dna aptamers obtained will be further used for the development of diagnostic and therapeutic tools for the detection and treatment of anthrax. the work was supported by russian science foundation research grant no. - - . the role of macab efflux pump in protection of serratia marcescens against antibiotics and oxidative stress the emergence of bacterial multi-drug resistance is a growing problem of public health worldwide. bacterial drug efflux pumps are membrane protein complexes that function to expulse drugs from the cell. they play a crucial role in the rising rates of antibiotic therapy failures. the homolog of macrolide-specific pump macab was identified in opportunistic pathogen serratia marcescens and was used in this study to characterize its role in protection against antimicrobials and other processes beyond the active efflux of antibiotics. here we used method of serial dilutions to determine minimum inhibitory concentration (mic) for s. marcescens sm wild type (wt) and its isogenic Δmacab mutant strains. we also used h o survival assay to evaluate the ability of wt and the mutant strain to withstand an oxidative stress. finally, we used b-galactosidase assay to evaluate macab promotor activation in the reporter strain and followed macab expression by western blotting analysis using macab- xhis strain. we show that in contrary to its e. coli homolog, macab pump in s. marcescens is not involved in the protection against macrolides but instead it is required for protection against aminoglycosides. we further show that similar to its salmonella typhimurium homolog, s. marcescens macab is essential for protection of bacteria against h o . transcriptional analyses demonstrate that while low level of macab promotor activity can be detected after hours of growth in lb-broth there is at least -fold increase in expression in response to the presence of h o . on the protein level macab can be detected starting from hours of growth in lb-broth and it reaches maximum expression on hour of growth. our data suggest that macab pump in s. marcescens is involved in protection of bacteria against aminoglycoside antibiotics and is crucial for protection against reactive oxygen species. we are currently working on identification of macab substrate with anti-h o properties. antiproliferative and apoptotic effects of noscapine on mcf- and mda-mb- human breast cancer cell lines approximately - % of breast cancers are negative for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor . these are most aggressive tumor and a clinical problem because of lack of targeted therapies. noscapine is an alkaloid from opium. noscapine is a microtubule-interfering agent. it causes mitotic arrest, induces apoptosis. in this study, we aimed to investigate the effects of noscapine in mcf- and mda-mb- human breast cancer cell lines. the cytotoxic effects of docetaxel, tamoxifen, and noscapine on the mcf- and mda-mb- cell lines were analyzed by roche xcelligence system. the cells were cultured in % fetal bovine serum containing dulbecco's modified eagle medium at °c in a humidified atmosphere containing % co . h after seeding, the cells were treated with different doses of docetaxel ( . to nm), tamoxifen ( . to lm), and noscapine ( . to lm). cultured cells were harvested, fixed with % formalin, and centrifuged. pellet was blocked, fixed, and embedded in paraffin. paraffin-embedded cells blocks were sectioned at lm thickness and stained with h&e, ki- , bcl- , cyclin-d , and bax. sides were assessed under a light microscope. quantification of the analyzed proteins were evaluated by the percentage of positive cells. all drugs showed cytotoxic effects on both cell lines. all drugs inhibited the proliferation of breast cancer cells, but effects were dependent on time and dose. all drugs were especially more effective on mcf- cells. immunohistochemical examinations revealed that tamoxifen was more effective on mcf- cells, hovewer docetaxel and noscapine were more effective on mda-mb- cells. tamoxifen has more apoptotic and antiproliferative effects on mcf- cells. docetaxel and noscapine showed more apoptotic and antiproliferative effects on mda-mb- cells. noscapine may be an effective anticancer agent due to antiproliferative and apoptotic effects on breast cancer cells. negative selection of dna aptamers to reduce non-specific binding in solid-phase-based selection procedures carryover by binders specific to the components of the selection system can be a serious issue in hampering the aptamer selection campaign. solution-or "mass"-based techniques still cannot substitute classic phase-separation strategies. one approach to prevent selection of "passenger" phase-specific (plastic, beads) or blocking agent specific aptamer species is their depletion from the initial library pool. our aim was to develop the universal technique for removal of such aptamers exemplified by bsa-and casein-specific binders, while preserving the initial library complexity. the dna aptamer library was subjected to three rounds of depletion using magnetic beads with covalently attached casein and bsa. to ensure high depletion efficiency, beads were pelleted in a -ml centrifuge tube by a neodymium magnet through a -cm cushion of % sucrose, thus preventing weakly bound aptamers from re-populating the library. high complexity of the input library helped to avoid pcr amplification after depletion rounds preventing the library bias introduced by dna amplification. the depletion effciency was confirmed by real-time pcr. resulting oligonucleotide sub-library was analyzed for binding to the targets using solid-phase real-time pcr assay. we have shown that three rounds of panning under the conditions employed provided full depletion of the initial dna pool from nucleic acid structures capable of binding to protein competitors and hampering the process of aptamer selection. we compared selection efficiency of aptamers specific to type a botulinum neurotoxin light chain in depleted vs undepleted library. the yield of the target-specific aptamers was -fold higher in the library subjected to the depletion procedure. removal of undesired binders from aptamer libraries appears an important step of solid-phase selex procedure. it can become a useful approach in optimizing solid-phase selex. the work was supported by russian science foundation research grant no. - - . epithelial mesenchymal transition (emt) is a critical trans-differentiation program driving cancer metastasis. patients showing signs of emt or presence of distant metastasis have poor prognosis. another well-known feature of decreased cancer-associated survival is the lack of anti-cancer immune responses. thus we hypothesized that the emt and anti-tumor response should be linked via altered secretion of soluble factors by metastatic cells. all cell lines were grown in dmem. emt status of crc cell lines were assessed by investigating canonical markers of emt. cytokine/chemokine expression of crc cells was performed using r&d systems antibody arrays and validated using ccl sandwich elisa and rt-pcr. the mechanism of action of zeb / on ccl promoter has been studied by luciferace assay and chip. ccl coding region was cloned into pcdna . and stably transfected into dld- cells. ccl deficient ct cells were generated using lentivirual shrna transduction. cells overexpressing or knock/down ccl were injected orthotopically into mice. t lymphocyte (til) infiltration in respect to ccl and sip expression was studied using ihc or flow cytometry. emt status catagorised crc cell lines into epithelial, intermediate epithelial, intermediate mesechymal and mesenchymal. cytokine/chemokine antibody arrays showed a significant increase in ccl in induced dld-sip cells. elisa, multiplex assays and rt-pcr confirmed a significant increase of secreted ccl in the induced dld-sip cells as well as mesenchymal crc cells as compared to epithelial ones (p = . ). promoter studies showed that zeb / bind to ccl promoter and and activate ccl gene expression. no metastasis was observed for dld- cells overexpressing ccl but significant alterations of tumour associated lymphocytes were identified in syngeneic orthotopic crc models. our data shows that ccl is up-regulated by emt inducing transcription factor sip , and mesenchymal (metastatic) crc cells secrete significantly more ccl compared to epithelial (non-metastatic) ones. ccl did not induce emt per se but abundant secretion of ccl by metastatic crc cells was a crucial regulator of immune infiltrate in crc. inhibiting ccl in metastatic crc may have a therapeutic potential. barley (hordeum vulgare l.) belongs to the grass family, poaceae (gramineae). it is the fourth most important cereal crop after wheat, maize and rice and is among the top ten crop plants in the world. talbina was used to be recommended for the sick and for one who is grieving over a dead person. talbina is made by adding one or two tablespoon of barley flour (must be percent wholegrain barley flour) to one-and-a-half cups of water and placed on low heat for - minutes (optional: add milk or yoghurt and sweeten with honey). the main objectives of this investigation were determine the a-tocopherol contents and antimutagenicity activity of talbina (hordeum vulgare l.). our results showed that the total tocopherol content was in the range of . to . lmol/g fw. talbina extract was shown to have greater antimutagenic activity observed in the lg/plate concentration s. typhimurium ta . at all the doses antimutagenic response was significant at (p < . ) against both the strains with a percent mutagenicity decrease from to for ta followed by ta with percent antimutagenicity from to . the results of the study concluded that talbina is a better antimutagenic agent than vitamin e and combination of vitamins did not produce any synergistic activity. the compounds containing thiadiazoles have diverse applications as antifungals, anticancer agents, antibacterial, antiinflammatory drugs, antidepressants and carbonic anhydrase inhibitors according to literature. in this study some novel thiadiazole compounds [( , , , )-tetrathia[ . ] ( , )- , , -thiadiazolophane; ( , )dioxo- , , , )-tetrathia[ . ]( , )- , , -thiadiazolophane; ( , , , )-tetraoxo- ( , , , )-tetrathia[ . ]( , )- , , -thiadiazolophane and ( , , , , , )-hexaoxo- ( , , , )-tetrathia [ . ] ( , )- , , -thiadiazolophane] were used to evaluate the cytotoxicity on healthy human lymphocytes and the antibacterial activities. cytotoxicity tests were perfomed using mts assay and the trypan blue test. cells were incubated with the compounds for hours. at the end of the each hour, cell vitality was assessed by measuring the absorbance ( nm) of each well using a microplate reader for mts assay. in addition, viability percents of the cells were determined after trypan blue test. as a result, the compounds showed cytotoxicity in a dose dependent manner. for the concentrations of : of . mg/ml, the cytotoxic effect was eliminated. also, antioxidant capacity was determined using , -diphenyl- -picrylhydrazyl (dpph) reagent. moreover, the antibacterial activities of the compounds were analyzed using a microdilution test against e. coli and s.aureus. compounds having various concentrations showed different antibacterial effects against these two bacteria. arabidopsis thaliana ecotypes vary in their ability to utilize organic p substrates insufficient quantity of inorganic phosphorus in soil is an evergrowing problem that affects many fields of agriculture. unlike inorganic phosphates, organic phosphorus compounds are very common in many soil types, but plants are often unable to efficiently utilize them. to better characterize the extent of natural variation in the ability of the model plant arabidopsis thaliana to grow on organic phosphorus compounds, we grew arabidopsis ecotypes on several organic and inorganic sources of phosphorus. plants were grown in liquid or solid media containing naphosphate, phytate and atp as the sole supply of phosphorus or in absence of any phosphorus source. after several weeks of growth, plants were assayed for changes in their morphological and physiological characteristics. phytate was shown to be the least preferred source of phosphorus compared to inorganic phosphate and atp. the rate of biomass accumulation in all ecotypes decreased in the following order from inorganic phosphate to atp to phytate. lateral root formation was markedly reduced in the absence of any phosphorus source or in the presence of phytate. we also showed that phosphomonoesterase activity in intact roots increased when plants were grown on atp and phytate. overall phosphorus content in leaves and roots was similar when plants were grown on atp or inorganic phosphate, but it was markedly reduced on phytate. substantial differences between ecotypes were also observed in root length, p content in ash and phosphomonoesterase activity in intact roots. our analysis of the ability of arabidopsis ecotypes to grow on several different phosphorus sources provides a unique opportunity to investigate the degree of natural variation in this plant's ability to adapt to different nutritional environments. analysis of many important morphological and physiological changes observed in these plants can further extend our understanding of the full range of plant responses to phosphorus availability. laboratory tests are important in terms of confirmation of diagnosis given by clinics and implementation of appropriate treatment protocols for patients. laboratory tests used by the clinics have been increased in parallel with time.there are many reasons for increased use of the test such as increase of elderly population, increase in standard of care, lack of information and shortening of turn around time. unnecessary laboratory testing also constitute one of the reasons for increased use of laboratory tests. in our study we aimed to investigate the unnecessary laboratory testing for fpsa test. fpsa tests which are ordered with total psa tests that values of less than ng/ml or greater than ng/ml were accepted as inappropriate initial testing. fpsa tests were evaluated as unnecessary laboratory testing. the clinic which ordered the maximum unnecessary laboratory testing with was urology within all the clinics. although to the restrictions about the ordering of total psa and fpsa tests there were no decrease in the number of unnecessary laboratory testing. unnecessary usage of laboratory testing may cause increase of false positive results, increase in the use of invasive testing, unnecessary drug consumption and increase of healtcare costs. some precautions may be effective in reducing unnecessary tests such as to inform clinicians about the cost of laboratory tests, to increase the clinician education programs and to develop usage of disease specific diagnostic algorithms about test ordering. local clinical validation of blood collection tubes although the tubes with gel and clot activator are widely used due to the advantages, there are ongoing discussions about the effects of the blood collection tube on clinical outcomes in the analysis of biochemical parameters. therefore, we aimed to prove the local clinical validation of the new produced blood collection tubes with low-volume. the blood samples of patients who referred to the hospital phlebotomy unit were collected using holder into the different tubes. first tube was ml glass tube and with no additive, second was ml tube with gel separator, third was ml tube with gel separator. serum was separated and immediadiately analysed for biochemical parameters. the difference between the analyte amounts in the different tubes was evaluated using paired t-test. the clinical significance was evaluated using significant change limit. bias (%) between the other tubes with the reference tube was also evaluated according to the ''allowable total error". when we compared the other test tubes to a glass tube which was assumed reference tube, total protein, albumin, amylase, calcium, triglyceride, cholesterol, hdl-cholesterol, total and direct bilirubin, iron, gamma glutamyl transferase, magnesium, phosphorus results were statistically significant. but the results of all the analytes were within the significant changes limit and the allowable total error was not significant. while a biochemical parameters have analysed, it may be absorbed into the gel and this may caused from factors such as the chemical structure of the gel, analyte itself, the residence time in the gel, storage temperature and volume of the sample e.g. as well as the leaking of gel material to the sample was reported to be another factor for affecting the analysis. despite these factors, we observed that neither gel-clot activator tube with low nor high volume affect the clinical results. the research of the frequency of interference in thyroid function tests interference is defined as the effect of substance in the sample which changes the correct value of laboratory results. the frequency of interference in immune techniques is varied. the frequency of interference depends on population of the study, technique for detecting the reaction and researcher's method. unexpected or inconsistent results with clinical findings should suggest the possibility of interference. in this study it is aimed to investigate the frequency of interference in thyroid function tests (tsh, ft , ft ) which are the most common requested laboratory tests. thyroid function tests of patients are analyzed in ankara numune education and research hospital in october -may . five samples which had the incompatible results with clinical findings are re-evaluated just because of the suspicion of interference. the detection of interference included; repetition of test via different immune techniques, serial dilution, polyethylene glycol (peg) precipitation and incubation with heterophilic blocking tubes (hbt). the results of two different immune techniques and before/ after incubation with hbt showed no significant difference. linear curves had observed in serial dilution. after peg precipitation; below % of recovery had obtained in one sample, therefore it is interpreted as macro-tsh. the frequency of interference in thyroid function tests for -month study period was . %. no information is found about the best test for defining the cross reaction. it is also aforethought that interference should not be excluded by using any single procedure. p-mis- development of polyclonal and monoclonal antibodies against fatty acid binding protein (fabp /ap ) a. abbasi taghidizaj, g. aydogdu, b. p. sermikli, e. yilmaz ankara university, ankara, turkey recombinant proteins and antibodies can be use for therapeutic or diagnostic purposes which produced in many different host organisms. the technique for the production of immortal cell making single antibody, fusing target antibody-forming b lymphocyte precursor with a suitable myeloma cells. the fused hybrid cells (called hybridomas), as a cancer cell will reproduce rapidly and will produce large amounts of the desired antibodies. fatty acid binding protein (fabp ) is a well characterized intracellular lipid transport protein and plays a key role in the intracellular fatty acid transport and adipose tissue metabolism. fabp as a adipokine that regulates glucose homeostasis and has various features for metabolic syndrome associated with obesity. in this study, production of monoclonal antibodies against immunogenic fabp protein made by recombinant dna technology. recombinant his-fabp was expressed in e.coli and purified. balb/c mice used for immunization and serum anti-fabp antibodies determined by enzyme-linked immunosorbent assay (elisa). hybridoma cells created by fusion of splenocytes and myeloma partner cells. after selection of antibody producing cell clones, injecting hybridomas into the peritoneal cavity in balb/c mice ascites fluids was obtained. we have selected fifteen hybridoma clones that produced antibodies specific for fabp , as shown by western blotting and immunocytochemistry. as a result we produced mabs that will be useful for the scientific community working on fatty acid binding proteins and lipid metabolism. in near future, therapeutic approach for this antibody maybe a possibility in metabolic syndrome. thioridazine, an anti-psychotic drug, inhibits migration, invasion and epithelial mesenchymal transition in breast cancer cell lines thioridazine (thz), an antipsychotic drug, exhibits anti-angiogenic effects on breast cancer cell lines. however the mechanistic insight in exerting antiangiogenic effect is not clearly understood. the objective was to investigate the role of thz in epithelialmesenchymal transition (emt) by using cell migration assay, scratch assay, western blot (wb) and immunocytochemistry. thz treatment reduced cell viability on mda-mb- , mcf- and cd + /cd -cells and ic values of thz were found to be lm, . lm and lm respectively, at hours. invasion potency of mcf- , cd + /cd -and mda-mb- cells were determined as %, %, . % when compared to relevant treatment controls. migration potency of mcf- , cd + /cd -and mda-mb- cells was determined as . %, . %, % respectively. among the three cell lines mda-mb- cells display enhanced invasive and migration ability when compared to other cell lines. western blotting results demonstrate that thz significantly increases e-cadherin, cytokeratin- , b-catenin, while inhibiting n-cadherin, vimentin, fibronectin. immunocytochemistry studies revealed decrease in e cadherin and a concomitant increase in vimentin level for all three cell lines upon treatment with thz. moreover thz significantly inhibited the cell migration, invasion and emt in mda-mb- , mcf- and cd + /cd cell lines by suppressing mesenchymal markers. in conclusion, these data suggest that thz might be a novel anti-proliferative and anti-metastatic agent for treatment of breast cancer. effect of seasonal temperature and humidity on urine density in children environmental heat and humidity are important factors affecting hydration status in childhood. hereby, we aimed to investigate the effects of seasonal climate changes on urine density of children living in mediterranean climate, cyprus. healthy - year children's ( girls, boys) age, sex and urine density results were collected retrospectively for three consecutive years. the correlation of urine density with each seasonal and months' average temperature and humidity has been analysed. the urine density results had a positive correlation with temperature (r = . , p = . ) and a negative correlation with humidity (r= À . , p = . ). mean urine density in spring was higher than that of autumn (p = . ) and winter (p = . ). mean value of summer was higher than autumn (p = . ) and winter (p = . ). - months age group had lower urine density. evaluation of urine density based on gender and puberty revealed no statistically significant difference. seasonal mediterranean climate changes have an impact on urine density in children which may affect hydration status especially in infants < yrs of age. during high temperature seasons ensuring adequate water intake is essential in this age group in mediterranean climate. p-mis- implementation related to the use of antibiotics and data sources by community pharmacists in north cyprus as the resistance to antibiotics is gaining importance in today's world;the solution to this problem is possible through a common consciousness of the doctor who prescribes antibiotics,the pharmacist who sells and the patient who consumes antibiotics. irrational use of drugs is an economic and medical problem in many developed and developing countries around the world.the aim of this study is to determine the sales ratio of non-prescription antibiotics in pharmacies which is the biggest category of the antibiotic group sold as well as the indications that lead to its' prescription. eighty-four pharmacies out of pharmacies located in north cyprus were involved in the study with %stratified systematic sampling, questionnaires were filled and a consent form was signed by the participating pharmacists. the pharmacists involved in the study stated that non-prescribed antibiotics were demanded from the pharmacists and all except two ( . %),responded positively to this demand. it has also been identified in the study that . % of the daily sale of antibiotics in the first half of the year was non-prescribed. the most purchased antibiotics either with or without prescription was found to be the penicillin and its derivatives with . % and upper respiratory tract with . %. when the level of selfawareness of the pharmacists was examined, the rate is found in north cyprus to be ( . %),compared with the studies conducted in greece,italy,malta and spain % and egypt . %that designated the non prescribed antibiotics purchased from the public pharmacies. the rate of sale of non-prescribed antibiotics in north cyprus has been found to be at a higher level compared to the rates in many developed and developing countries. furthermore, the upper respiratory tract infections are amongst the most common viral causes which lead to a high consumption of both prescribed and non-prescribed antibiotics. this study was supported by turkish viral hepatitis prevention society. acrylamide has cytotoxic, antiproliferative and apoptotic effects on human lung adeno carcinoma cell line a acrylamide (aa), a widespread substance in many fields, forms in foods during high temperature processing such as baking, roasting, frying. aa is a potent neurotoxic, genotoxic and clastogenic agent being a strong electrophile and forming adduct with biological molecules or potent nucleophiles. up to now, several studies confirmed the toxicity of acrylamide to several organs. on the other hand, aa is reported to have inhibition effects both on proliferation and differentiation of different cancer cells in a time and dose-dependent manner. in addition, natural and synthetic acrylamide derivatives are also used as potent anti-cancer agents. moreover, inhibition concentration (ic ) values of aa against these cancer cells have not been investigated in detail yet. thus, the goal of this study is to investigate the cytotoxicity of aa on a cells including with ultrastructural and morphological effects. ic value of aa on a cells for h was detected with mtt ( -( , -dimethyl- -thiazolyl)- , -diphenyl- h-tetrazolium bromide) colorimetric assay. we evaluated morphological changes under confocal microscopy and ultrastructural changes under transmission electron microscopy (tem). our results demonstrate that aa inhibits the proliferation of a cells in dose-dependent manner and ic on a cells was found to be . mm for hours. confocal microscopy evaluations showed that aa caused nuclear condensations, fragmentations, cytoskeleton lacerations and membrane blebbing. tem results revealed membrane blebbing, chromatin condensations and cell shrinkage. although aa is a probable carcinogen substance, it drastically inhibited cell viability in dose-dependent manner. from microscopic assessments, aa is suggested to induce apoptosis in a cells. in conclusion, the present study confirms the high potential of aa for cytotoxic, antiproliferative and apoptotic activity on a cells. however, appropriate aa dose is critical to prevent its possible adverse effects. effect of hemolysis and lipemia on some immunochemical tests in beckman coulter unicell dxi immunoassay analyzer c. yilmaz, s. yildiz, m. senes, v. fidanci, d. y€ ucel ankara training and research hospital, ankara, turkey the aim of the study was to investigate the effects of in vitro hemolysis and lipemia on immunoassays studied by the beckman coulter unicell dxi immunoassay analyzer. we prepared a serum pool without hemolysis, lipemia and icterus. baseline serum pool concentrations of tests were measured by the beckman coulter unicell dxi . d _ ifferent serum pools, six for hemolysis and five for lipemia, were spiked with increasing concentrations of hemoglobin ( . , . , . , . , . and . g/l hemoglobin) and intralipid ( . , . , . , and g/l intralipid). the hemolysate was prepared by osmotic shock method. intralipid ( %, baxter, deerfield, il) was used to mimic the effect of lipemia. the hemolysis (h), lipemia (l) and icterus (i) indices were measured on beckman coulter au . after spiking the pools, the tests were measured again in duplicate on beckman-coulter dxi analyzer. a change of % from baseline results was taken as evidence of interference and the interfered tests were also evaluated according to total analytical error based on analytical imprecision and intraindividual biological variation. we observed a positive interference due to hemolysis for folat, vitamin b , testosterone and by lipemia for cortisol. there was a negative interference of hemolysis for ca . , ca , ca . , insulin, pth and e , and of lipemia for progesterone, ca . , vitamin b and pth. we found clinically significant effect (>total analytical error) of hemolysis on folate and insulin, and lipemia on cortisol. investigation of the effect of two different p mapk inhibitors in rats subjected to isoproterenol-induced acute myocardial injury: an experimental study objective: acute myocardial infarction is a serious acute condition. in the current study, we aimed to investigate the possible effect of two different mitogen-activated protein kinase (p mapk) inhibitors in rats subjected to isoproterenol (iso)induced myocardial injury. materials and methods: a total of male wistar-albino rats were equally and randomly seperated into four groups as follows: control, iso, iso plus sb andiso plus tak- . treatment agents were orally administered and myocardial injury was induced by subcutaneous injection of iso. serum cardiac troponin-i (ctni), ischemia modified albumin (ima), heart fatty acid binding protein (hfabp) levels and paraoxonase- (pon- ) activity, tissue tos (total oxidant status), tas (total antioxidant status), tt (total thiol), tumor necrosis factor-a (tnf-a) levels, superoxide dismutase (sod) and glutathione peroxidase (gsh-px) activity levels were measured. tissue mrna levels of nf-jb, p mapk and nuclear factor erythroid -related factor (nrf ) were analyzed. heart tissues were also immunohistochemically and histopathologically evaluated. results: both compounds have led to a decrement in myocardial damage, apoptosis, ctni, ima, hfabp, tos, and tnf-a levels, nf-jb, p mapk, phosphorylated c-jun n-terminal protein kinase (pjnk / ) expressions. on the other hand, the applied treatment increased sod, gsh-px, tas and tt levels, as well as phosphorylated extracellular signal-regulated kinase (perk / ) and nrf expressions. conclusion: data established from the current study suggest that administered agents have protective effect against cardiac injury induced by iso, which was more prominent in rats received sb treatment. p mapk inhibitors may constitute a useful choice as cardioprotective agents due to their antiinflammatory, antioxidant and anti-apoptotic effects. keywords: _ isoproterenol, myocardial infarction, myocardial ischemia, p mitogen-activated protein kinases, sb , tak- . silicosis composes the vast majority of occupational lung diseases. silicosis, caused by inhalation of crystalline silica, is a chronic lung disease characterized by parenchymal nodules and pulmonary fibrosis. the susceptibility of patients with silicosis to infection is thought to be due to toxic effects of silica on pulmonary macrophages. ada activity is considered as a nonspecific marker of t cell activation and cellular immunity. this study aimed to compare the serum ada activity in silicosis patients with spirometric values. in this study there were males in each groups which contained patients with silicosis (group ), individuals having similar symptoms with silicosis from same occupational area (group ) and healthy subjects (group ). routine hematological and biochemical parameters were also measured. the serum ada activity and spirometric values (fev , fev %, fev /fvc, fev / fvc%, fef - and fef - %) were compared. the average age of group , and are . ae . , . ae and ae . years, respectively. there was a significant difference between group and in terms of the ada level (p < . ). there was a negative correlation between ada activity and fev , fev %, fev /fvc, fev /fvc%, fef - values. elevated serum ada activity has been shown in many diseases with induced cellular immunity. despite initially toxic effects were lead to a little immunological reaction in patients with silicosis, continuation of this immunological response is important in some chronic manifestations of silicosis. the release of chemotactic factors and inflammatory mediators cause the migration of polymorphonuclear leukocytes, t lymphocytes and macrophages. in this study, the ada activity was significantly higher in patients with silicosis than others. increased immunity in patients with silicosis is being considered, increasing ada activity might be help of earlier recognition of these patients and to take better quality of life. atlantic salmon (salmo salar l.) is an important model system in evolutionary and conservation biology that provides fundamental knowledge into population persistence, adaptive response and the effects of anthropogenic change. the role of behavioral and body size variation in environmental adaptation of atlantic salmon is well known, by contrast, the underlying biochemical mechanisms are largely unknown. intracellular proteases, such as cathepsins b and d in lysosomes and calpains and proteasome in cytosol, due to their metabolic and regulatory role may contribute to phenotyping speciation of salmon young. we examined the activity of intracellular proteolytic enzymes in skeletal muscles of atlantic salmon parr from two local habitats of the varzuga river (the main channel and small tributaries) differing in hydrological and feeding parameters. calpain and proteasome activities were determined by casein or suc-llvy-amc hydrolysis in the skeletal muscles of s. salar from varzuga river (kola peninsula, russia). it is known that salmon parr originated from a common hatch became phenotypically divergent during the settle in the biotopes. reliable difference in studied enzyme activities in the salmon parr from two local habitats was found; furthermore, calpain and cathepsin b proteolytic activities were found to negatively correlate with parr body size. muscle proteolytic activity data support an idea on protease contribution to environmentally-driven adaptation and speciation process in fish. the work was supported by the russian scientific foundation, project no. - - . the phylogenetic analyses of anthriscus (apiacea) species from turkey based on non-coding "trn" regions of chloroplast genome p. yilmaz sancar , m. tekin , s. civelek firat university, elazig, turkey, cumhuriyet university, sivas, turkey anthriscus pers. (apiaceae) species belongs to apiaceae family and is represented by genus on the world and by genus in turkey. anhriscus species are used extensively for treatment various disease such as asthma, alzheimer and show anti-tumoral, anti-microbial, antioxidant features. for determining exact species which treat disease it is necessary sorting species correctly with molecular markers to support morphological features. anthriscus species were defined by examining insufficient quantity of samples in turkey flora. besides, no detailed study was found in our country after flora study. for this reason a revision study was made with the aim of solving some systematical problems in by tekin. the result of the study provided important contribution to the systematic of the species in turkey. however a molecular study was also required for building the obtained results on a more solid ground. in this study, the aim to reveal systematic and phylogenetic relationship among species of anthriscus in turkey, by using trnl-f region in chloroplast genome. dna was isolated by ctab method and amplified in pcr by using e-f primaries. the obtained data was evaluated by mega . program and phylogenetic tree was prepared by using maximum likelihood method. according to the phylogenetic tree that we prepared by using the sequence line up of trnl-f section, it was observed that a. cerefolium, a. caucalis and a. tenerrima species completed their speciation and an isolation with other species in terms of speciation was provided. it was also observed that a. kotchi, a. sylvestris subs. sylvestris, a. sylvestris subs. nemarosa and a. lamprocarpa'nın provided hybridization among themselves but they did not complete their speciation. it was determined that a.lamprocarpa var. chelikhii which is one of the two different varieties of a. lamprocarpa is actually a new sub-species. this fact was supported by molecular data obtained from the study we made after morphologic data. introduction: excessive production of androstenedione can becaused by defects of adrenal steroid biosynthesis, tumors of ovarian and adrenal origin, polycystic ovarian syndrome, increased peripheral sensitivity to androgens, and increased peripheral production of androgens. most epidemiologic studies use enzyme-linked immunosorbentassay (elisa) to measure sex steroid hormones because they have acceptable turnaround times and arerelatively inexpensive. mass spectrometry-based methods are currently the most specific quantitative analytical methods for steroid determination. mass spectrometry methods are independent of matrix effects or cross-reactivity. in this study, a new liquid chromatography-tandem mass spectrometry (lc-ms/ms) method was developed. materials and methods: for serum androstenedione measurement, ll of internal standard (d - deoxycortizol) in methanol was added to ll standart or serum and centrifuged at . rpm for minutes to remove the precipitated proteins. supernatant was transferred to clean tubes and this procedure was performed twice. the supernatant was collected and dried under a nitrogen gas flow at • c and dissolved in mobile phase. ll was injected in to the ultra performance liquid chromatography analytical column for chromatography. elisa study was conducted with drg (lot. no. k ) brand kit. results: method comporison between lc-ms/ms and elisa was found slope value , , intercept value À . and r² value . . the regressione quation was elisa= À . + . lc-ms/ms. discussion and conclusion: method comparison study presented higher results in elisa compared to lc-ms/ms. in our opinion, this might due to the interference in elisa systems. our lc-ms/ms method allows rapid, sensitive and specific determination of androgens in plasma and serum.the specificity of liquid chromatography-tandem mass spectrometry (lc-ms/ ms) offers advantages over immunoassays. heparins play an important role in cell growth, differentiation, migration and invasion. however, the molecular mechanisms of heparin mediated cellular behaviors are not well defined. to determine the effect of heparin on gene expression, we performed a cdna microarray in a hepatocellular carcinoma cell line and found that heparin regulates transcription of genes involved in glucose metabolism. in this study, we showed a new role of heparin in the regulation of thioredoxin interacting protein, which is a major regulator of glucose metabolism, in hepatocellular carcinoma cell lines. we determined the importance of a unique carbohydrate response element located on its promoter for the heparin-induced activation of thioredoxin-interacting protein and the modulatory role of heparin on nuclear accumulation of carbohydrate response element associated proteins. we showed the importance of heparin mediated histone modifications and downregulation of enhancer of zeste polycomb repressive complex expression for heparin mediated overexpression of thioredoxininteracting protein. when we tested biological significance of these data; we observed that cells overexpressing thioredoxininteracting protein are less adhesive and proliferative, however they have a higher migration and invasion ability. interestingly, heparin treatment increased thioredoxin-interacting protein expression in liver of diabetic rats. in conclusion, our results show that heparin activates thioredoxin-interacting protein expression in liver and hepatocellular carcinoma cells and provide the first evidences of regulatory roles of heparin on carbohydrate response element associated factors. this study will contribute future understanding of the effect of heparin on glucose metabolism and glucose independent overexpression of thioredoxin-interacting protein during hepatocarcinogenesis. prolidase activity in chronic obstructive pulmonary disease and asthma t. g€ uc ßl€ u , h. s€ urer , g. bilgin , d. y€ ucel ankara training and research hospital, medical biochemistry department, ankara, turkey, ankara training and research hospital, chest diseases department, ankara, turkey chronic obstructive pulmonary disease (copd) is a consequence of an underlying chronic inflammatory disorder of the airways that is usually progressive and causes dysregulation in the metabolism of collagen. and asthma is a disease where there is an accumulation of collagen in the reticular basal membrane of the airway leading to chronic inflammation. prolidase has an important role in the recycling of proline for collagen synthesis and cell growth. we measured and compared prolidase activity in healthy individuals with copd and asthma patients to find out that whether its activity might reflect disturbances of collagen metabolism in the patients. patients with copd, patients with asthma and healthy control subjects with similar age range and sex were included in our study. the patient and control groups do not have any other chronic disease. serum prolidase activity was measured in the patient and control groups. ferritin and alpha- antitrypsin concentrations were also compared. there was no significant difference between serum prolidaz activities of asthma and copd patients. serum prolidase activities of both copd and asthma patients were significantly lower than those of the control subjects (p < . ). there was no significant difference for ferritine and alpha- antityripsin levels between the groups. the prolidase activity is significantly lower in asthma and copd patients comparing with control subjects. the collagen metabolism may be undergone to a change in these patients. hence, there may be an effect on the accumulation of collagen in the reticular basal membrane. the results suggest that collagen turnover are altered by the development of copd and asthma in human lungs, and prolidase activity may reflect disturbances of collagen metabolism in these pulmonary diseases. monitoring serum prolidase activity may be useful in evaluating fibrotic processes and in the chronic inflammatory lung diseases in human. acyclovir molecule in the active site of e. coli purine nucleoside phosphorylase (on the basis of x-ray study) i. kuranova , , v. timofeev , , n. zhukhlistova , y. abramchik , t. muravieva , r. esipov shubnikov institute of crystallography of fsrc "crystallography and photonics" ras, moscow, russia, national research centre "kurchatov institute", moscow, russia, shemyakin-ovchinnikov institute of bioorganic chemistry, russian academy of sciences, moscow, russia e. coli purine nucleoside phosphorylase (pnp), which catalyzes the reversible phosphorolysis of purine ribonucleosides, belongs to the family i of hexameric pnps. due to key role in the purine sulvage pathway pnps are attractive targets for drug design against some pathogens. they also used widely in biotechnology for the synthesis of nucleoside analogues as well as for the activation of the prodrugs in anti-cancer gene therapies. the acyclovir (acv), acyclic derivative of guanosine, is antiviral drug for the treatment of some human viral infections. the crystalline complex of e. coli pnp with acyclovir was prepared by co-crystallization using counter diffusion in capillary through the gel layer. the set of x-ray data at k from single crystal grown in space (sp. group p ) was collected on the spring- synchrotron-radiation facility (japan) and the structure was solved at . a resolution, using the molecular replacement method (pdb id i c). acv molecule was located in the nucleoside binding pocket of the enzyme in two conformations. the phosphate binding site was occupied by so ion. the hydrogen bonds network and hydrophobic interactions stabilising acv molecule in the active site as well as the conformational changes upon ligand binding were described. the comparison of e. coli pnp/acyclovir complex and the similar complexes of bacillus subtilis pnp (pdb id da ) and human pnp (pdb id pwy) allowed to establish the peculiarities of acv binding of in the e. coli enzyme. gonadotropins are glycoprotein hormones that regulate normal growth, sexual development, and reproductive function. these are large, up to kda proteins, which are synthesized and secreted by the gonadotropic cells of the anterior pituitary gland. these hormones may vary in the level of glycosylation depending on the tissue and the metabolism cycles. follicle-stimulating hormone (fsh) and upon binding to fsh receptor, a g-protein coupled receptor (gpcr), regulates the development, growth, pubertal maturation, and reproductive processes of the body. human chorionic gonadotropin (hcg) and luteinizing hormone (lh) act via a shared gpcr (lh receptor) and regulate mechanisms essential for ovulation, early pregnancy and placental function in females as well as spermatogenesis and testosterone production in males. activation of gpcrs by these hormones can be measured by monitoring formation of cellular cyclic adenosine monophosphate (camp). the level on camp was measured using a f€ orster resonance energy transfer (fret)-based biosensor tepacvv (h ) kindly provided by dr, kees jalink. the biosensor was expressed using the developed bacmam gene delivery system (recombinant baculoviruses carrying the transgene under a strong mammalian promoter). kgn cells expressing the fsh receptor and cos cells expressing the lh receptor served as study objects. monitoring of specific gpcr activation in living cells, allows detection of only the biologically active agonists, which has real impact in quantification of large hormones. differences in levels of hormone glycosylation may affect their biological function. investigation of this phenomena is planned for near future. detection of biological activity of gonadotropins is of importance for pharmaceutical industry, where today the concentration of recombinant proteins is mostly estimated using immunological assays only. development of a colorimetric aptasensor for the detection of peanut allergen protein ara h in food samples b. bora ege university, izmir, turkey food allergy, especially peanut allergy is a life-threatening problem, and severe reactions against these foods can be observed. since unintnded consumption of non-labeled foods is the most dangerous risk, any residual allergen protein should be tested and labeled by the manufacturers. an aptamer based colorimetric test is a powerful alternative to commercially available rt-pcr and elisa test kits. the main objective of this study is to develop an aptamer based colorimetric test fort he detection of major peanut allergen protein ara h . ara h aptamer was used to recognize any residual peanut major allergen protein ara h in food samples. recombinant ara h protein was produced and puirifed to be used as a target. ara h aptamer was used in combination with a blocking sequence, to prevent non-specific binding event, a biotinylated complementary strand to the blocking sequence, and finally strp-hrp interaction in order to facilitate colorimetric reaction. optimal blocking sequence length was optimized and introduced to the site of aptamer sequence to construct an aptamer-hairpin structure. liberation of the blocking sequence allows biotinylated complementary strand to bind to the blocking sequence and consequently str-hrp conjugate to achieve color development that is proportional to the target concentration. since, the aptasensor will be used for the detection of ara h in food samples, total protein extraction from chocolate samples was also optimized. in order to lower the detection limit of aptasensor, aptamer coupled magnetic bead based pre-enrichment assay was aslo optimized for the total protein extraction. as a result, a sensitive, fast and reliable aptamer based colorimetric assay was developed for the detection of peanut allergen protein from food samples. moreover, the assay has the advantages like ease of application and low cost which makes the assay a promising and a powerful alternative to commercially available rt-pcr and elisa tests. the association between lipid parameters and waist circumference in female university students in turkey s. ozen, a. cort sanko university, department of nutrition and dietetics, gaziantep, turkey a high waist circumference is associated with an increased risk for type diabetes, dyslipidemia, hypertension, and cvd in patients with a bmi in a range between and . kg/m . monitoring changes in waist circumference may be helpful, in addition to measuring bmi, since it can provide an estimate of increased abdominal fat even in the absence of a change in bmi. objective of the study was to find an association between plasma lipid profile and anthropometric parameters (waist circumference percentage of body fat and body mass index (bmi)) in abdominal obesity in turkish university students. lipid profile and anthropometric parameters of obesity were studied in a sample of women. students with high bmi (> ) had higher values of low-density lipoprotein (ldl), triglycerides (tg) and cholesterol (c) than students with low bmi (< ) but these differences were not significant. high-density lipoprotein (hdl) levels were non-significantly higher in low bmi (< ) student group. waist circumference, percentage of body fat was higher in high bmi (> ) group than low bmi (< ) group. waist circumference, percentage of body fat was positively correlated with bmi in both samples (bmi (> ) and bmi (< )). students were grouped depend on their waist circumference. healty individuals who had lower than cm waist circumference had decreased tg levels compared to cardiovascular risk group who had higher waist circumference than cm. this study shows an association between waist circumference, percentage of body fat, body mass index and lipid parameters in young female university students. with regard to the relationship, the screening females for central obesity to prevention of cardiovascular disease are recommended. a new biotechnological product from propolis with low allergen: anti-inflammatory effect propolis is extensively used in food industry due to its special medical properies (antioxidant, antimicrobial, antiseptic, antibacterial, anti-inflammatory and antimutagenic effects). even these positive properties it may cause some allergic reactions in consumers with allergic predispositons. previously, we demonstrated that biotransformation of propolis by some special strains of lactobacillus plantarum ( , , aatc strains) might decrease the allergenic molecules in propolis. in this study, we aimed to investigate the effect of biotransformation of popolis on it's antiinflammatory activities. before biotransformation, propolis samples were treated with different solutions ( % ethanol and polyethylene glycol -peg %) and different method (ultrasonic treatment w/ o c/ minutes) in order to facilitate solvation of solid samples which are very dense and not suitable for fermentation. fermantations were performed at o c/ hours under constant agitation conditions. the anti-inflammatory activity was determined in-vitro conditions using hyaluronidase's analysis and the xanthine oxidase activity. the highest inhibition (%) of radicals produced by xanthine oxidase was determined in solid samples treated by peg prior to biotransformation and using of l.plantarum strain during fermentation ( . %), followed by liquid samples treated by ultrasonic method prior to transformation ( . %). concernig the results of hyaluronidase activity (%) inhibitions, the best value were determined in the solid sample treated by peg prior to biotransformation and using of l.plantarum strain during fermentation ( . %). results indicated that the anti-inflammatory activities of analysed samples are quite high and depending of used extraction methods prior the biotransformation and used specific strain of l.plantarum could be optimized in terms of other required parameters. faceanti-mullerian hormone is not predictive for poor neonatal outcome aim: anti-mullerian hormone (amh) is a growth factor specific to ovaries. it is commonly used to predict ovarian reserve and outcomes of fertility treatments. recently, low levels of amh have been shown to be related to hypertensive diseases of the pregnancy and the risk of preterm labor. the aim of this study was to investigate the diagnostic performance of amh levels of mothers to predict poor neonatal outcome in term pregnancies and the relationship between amh and birthweights of the newborns. materials and methods: patients, having delivery beyond weeks, and who did not have any other medical problems were included in the study. the patients had normal g. oral glucose tolerance test results. they were divided as groups, based on their newborns' birthweight as " g. and g.". level of amh was determined by elisa method. results: there was not any relation with the amh of the mothers and the poor neonatal outcome of the newborns, in all groups. also no siginificant difference was observed in amh levels of the patients having delivery in early term and late term periods. when the patients of the same group were evaluated; amh levels were irrelevant to age, gravidy, delivery week, body mass index, the weight gain during pregnancy, and poor neonatal outcome. conclusion: amh is not a predictive factor for poor neonatal outcome and it is not a determinant of the weight of the newborn. objectives: the aim of the study was to investigate the effects of differing amounts of hemolysis on serum high sensitvity troponin i (hs-tni), ck-mb mass and myoglobin measurements. materials and methods: we prepared serum pools having troponin i, ck-mb and myoglobulin concentrations at low ( . ng/l, . ng/ml and . ng/ml respectively), normal ( . ng/l, ng/ml, . ng/l respectively) and high ( ng/l, ng/ml, g/ml respectively) values. the osmotic shock method was utilized to prepare a hemolysate. hemolysate was added into serum pools increasing concentrations of hemoglobin ( . , . , . , , . and . g/l hemoglobin). troponin i, ck-mb (mass) and myoglobin concentrations were measured in duplicate by beckman coulter access analyzer. the hemolysis indices were measured on beckman coulter au . a change of % from baseline results was taken as evidence of interference and the interfered tests were also evaluated according to total analytical error based on analytical imprecision and intraindividual biological variation. results: we found a positive interference due to hemolysis for ck-mb (mass) at low concentrations ( . ng/ml), and a negative interference for myoglobin at low concentrations ( . ng/ml) and high concentrations ( ng/ml). conclusions: ck-mb increase and myoglobin decrease in hemolyzed samples with hemoglobin ≥ . g/l, but the bias might not be clinically significant (< total analytical error) in samples. a retrospective study to determine a reliable marker for selective screening of pompe disease lysosomal storage diseases (lsd) are rare inherited metabolic disorders caused as consequence of a deficiency in a specific enzyme required for lysosomal function. pompe disease is one of these disorders with deficiency of a- , glycosidase enzyme with an incidence of : , - : , . as enzyme replacement therapies are available nowadays, early diagnosis is crucial and selective screening is a rational method to reach pompe patients among people who administer to healthcare with lsd suspected symptoms. this study aims to examine the relationship between basic biochemistry parameters and a- , -glycosidase activities retrospectively, in order to find a key parameter for selective screening of pompe disease. for this reason a- , glycosidase, creatine kinase (ck), creatine kinase-mb (ck-mb) activities calcium, phosphate levels of those who had been suspected to be lsd patients and administered to our laboratory for analysis are examined retrospectively. out of patients's examined, of them were diagnosed with pompe disease depending on clinical findings & low a- , glycosidase activity. enzyme activities of pompe patients were . nmol/ml/hour as lsd suspected patients'activities had a mean of . nmol/ml/hour (p = . ).comparison of ck activity was compared results showed significant difference between pompe patients and lsd suspected patients. even though ck activity levels of the lsd suspected patients were much higher ( vs - u/l) than reference interval, the levels of the pompe disease patients' were still more than twice of the lsd suspected group ( vs u/l, p = . ). ck-mb, ca, p levels didn't show a significant difference. a strong (-) correlation (p = . r=À . ) was observed between a- , -glycosidase and ck activities (n: ). selective screening is a rational way to diagnose rare diseases. this study's results show that ck activity can be used as a key parameter to determine patients for selective screening of pompe disease within lsd suspected population. the functional effect of stem cells on the reproductive organs infertitility is considered as a major health problem of recent century. importance of stem cell is increasing so it is searched new features and supposed to be involved in the infertitility treatment where oxidative stress and apoptosis play importany role. we aimed to investigate the beneficial effect of the stem cells related to free radicals and cell death on testis and ovary. biopcy model of wound healing was created in the rat testis and ovary with ppd syringe where stem cells were delivered by injection. rats were divided into four groups including controls, sham, wound healing and wound healing with stem cell. after the creation of the wound, bone marrow-derived mesenchymal stem cells from the tibia of the mature rats and medium were administered to ovaries and testes. following the applications, ovary and testis samples were investigated for oxidative stress and apoptosis by immunohistochemistry. in comparison with the medium and stem cell applications without a medium support, it was meaningfully determined that healing effect in testicles and ovaries were spotted specifically on the seven day. tissues were analysed for these staining by h-score and h-score results were determined using one-way anova test statistically. our results show the positive effects which clinic applications can bring by displaying the great contribution of the stem cell application in the treatment of testicle and ovary damage. these findings suggest that transplantation of the mesenchymal stem cells may help to promote better enviroment for the reproductive organs by the effect on oxidative stress and apoptosis. the further studies of these results in the molecular level can lead the way to solve the problem of infertility, to increase the percentage of success in the ivf and icsi techniques and more importantly to perform a differentiation from a somatic cell to a germ cell. the antimicrobial activity of ( h)-furanone derivative on staphylococcus aureus nosocomial infections caused by methicillin-resistant staphylococcus aureus strains are known to be a reason of many infectious diseases like osteomyelitis, endocarditis, sepsis etc. being organized in biofilms these bacteria become extremely resistant to antimicrobials and host immune system leading to difficulties in treatments. here we report the effect of ( h)-furanone derivative possessing sulfonyl group and l-menthol moiety (f ) on biofilms formed by s. aureus atcc and mrsa cells. while exhibiting relatively high minimal inhibiting concentration -mic ( mg/l), clear synergy with a number of antibiotics was found in the checkerboard assay. thus, in the presence of mg/l of f the mic of kanamycin was decreased -fold, and the mics of both erythromycin and ampicillin were lowered -fold. at the concentration of mg/l f also completely inhibited the biofilm formation by s. aureus; the cell growth was suppressed by two orders of magnitude as judged by differential fluorescent staining with syto and propidium iodide. the addition of f to preformed h-old biofilms increased the fraction of red-stained (dead) cells of both s. aureus atcc and mrsa strains uniformly throughout the whole profile of the biofilm. the quantitative analysis of clsm microphotographs revealed that f at concentration of mg/l led to death of up to % of biofilm-embedded cells. this fact suggests that f efficiently penetrates into the biofilm matrix and kills the cells without visible damage of biofilm structure. in summary, furanone f seems to be a promising compound for drugs design to treat biofilm-embedded s. aureus. this work is supported by the russian science foundation, project № - - and the german academic exchange service (№ ). pneumonia is an inflammatory lung disease which can be associated with inadequacy of host defense system and the proliferation of various pathogenic microorganisms into the lower respiratory tract. community acquired pneumonia (cap) is one of the leading causes of death in elderly. the incidence of pneumonia in people aged and over is - times more than young adults. creactive protein (crp) is an acute-phase protein of hepatic origin that increases following interleukin- secretion by t cells and macrophages. procalcitonin (pct) is a peptide precursor of the hormone calcitonin, the latter being involved with calcium homeostasis. it is composed of amino acids and is produced by parafollicular cells (c cells) of the thyroid and by the neuroendocrine cells of the lung and the intestine. the level of pct rises in a response to a proinflammatory stimulus, especially of bacterial origin. the aim of this study was to compare crp and pct levels in young and elderly patients with pneumonia. recently diagnosed young and elderly patients with pneumonia and their respective aged matched controls (n = , n = ) were enrolled this study. crp and pct levels were by immunoturbidometric and by elisa methods respectively. crp and pct levels for young control and patients and elderly control and patients respectively are . ae . mg/l, . ae . ng/ml, . ae . mg/l, . ae . ng/ml, . ae . mg/l, . ae . ng/ml and . ae . mg/l, . ae . ng/ml. young patients with pneumonia have significantly higher crp and pct levels than their controls (p < . and p < . ). elderly patients with pneumonia have significantly higher crp levels than their controls (p < . ). crp and pct are important markers in the diagnosis of pneumonia. effect of serum albumin concentration on total and ionized calcium z. adiyaman, c. yilmaz, s. a. peker, d. y€ ucel ankara training and research hospital, ankara, turkey objective: the aim of the study is to investigate in vitro effect of albumin concentration on total and ionized calcium concentrations. materials and methods: a serum pool with low albumin ( . g/dl) and normal calcium ( . mg/dl) concentrations was prepared from leftover sera. from this serum pool, two parts, each of ml were aliquoted. purified albumin, . g, was added to one of these pools and albumin concentration was determined as . g/dl. the low and high albumin pools were mixed at different ratios and pools with . , . , and . g/dl albumin concentrations. total calcium and albumin concentrations of these pools were measured at a beckman-coulter au analyzer and ionized calcium was measured at a radiometer abl blood gas analyzer in triplicate. total and ionized calcium concentrations were evaluated as compared to those of the original pool with an albumin concentration of . g/dl. results: total calcium concentrations are increased with the increasing albumin concentrations: . %, . %, . %, and . %, respectively. whereas, ionized calcium concentrations were decreased with increasing albumin: . %, . %, . %, and . %, respectively. conclusions: when total allowable error limits based on biological variation were considered, total calcium concentrations are significantly increased at > g/dl albumin concentrations. ionized calcium is significantly affected by . g/dl and over albumin concentrations. a regression equation based on albumin concentration may be useful for corrected ionized calcium concentrations. relationship between lipoprotein (a) and hba c in patients with type ii diabetes , is a complex lipoprotein consisting of ldl and apolipoprotein(a). lp(a) is a risk factor for coronary artery disease and stroke. the relationship between lp(a) and diabetes mellitus is not clear. in this study, the relationship between lp(a) and glycemic parameters such as hba c and fasting glucose concentration was investigated. lp(a), hba c, fasting glucose, triglyceride, total cholesterol, ldl-and hdl-cholesterol concentrations were screened retrospectively from july to july . there were patients with these test results at the same time. the patients were grouped according to hba c values: group i < . % (n = ), group ii . - . % (n = ), and group iii > . % (n = ). the relationship between these parameters were statistically within each group and all groups. there was not a statistically significant difference between the lp(a) concentrations of group i and group ii. lp(a) concentrations of group i and ii were significantly higher than those of group iii.. _ in total, lp (a) was negatively correlated with hba c (r = . ; p < . ), but there was not a significant correlation with fasting blood glucose. _ in groups, there was a significant and negative correlation between lp(a) and fasting glucose in only group i. the negative correlation between lp(a) and glycemic parameters is interesting in patients with diabetes. despite lp(a) is an independent risk factor for cardiovascular diseases, on the contrary to expectations, lp(a) concentrations are decreased in diabetes. effect of blood collection through intravenous lines on hemolysis erroneous results are one of the most important causes of medical errors and may lead to unnecessary investigations or inappropriate interventions. total testing process consists of preanalytical, analytical and postanalytical phases. hemolyzed specimens that one of the most common source of preanalytical errors are frequently observed in laboratory practice and associated with incorrect laboratory results. blood collection through intravenous lines frequently results in hemolysis especially at eds and icus. in this study, we aimed to compare the effect of blood drawing by using bd luer-lock adapters and injector on the hemolysis rates at the ed. patients who has been admitted to the ed were included in this study. all samples were drawn from newly inserted iv lines. the first blood sample was drawn with injector and the second one was drawn with luer-lock adapters to vacuum tubes. after the centrifugation routine chemistry tests and hemolysis indices were analysed on a beckman coulter au analyzer for each serum tube. the statistical significance of differences between two tubes was calculated with paired samples t test and statistical significance was accepted as p < . . there were statistically significant differences between the two groups of tubes for the following parameters: ldh, ck, ast, k + , total bilirubin, protein, albumin, alp, calcium and hemolysis index (p < . ). the use of luer-lock adapters instead of injector could reduce the hemolysis rate. because of it reduces false results and unnecessary investigations, this approach will be more appropriate and cost-effective in ed. hemolysis and test rejection: are we following a reliable process? introduction: in laboratories, some blood samples are rejected due to hemolysis. we usually cancel only some of the tests that are affected by hemolysis. however, the frequency of the test cancellation may be relative. each test is affected in different degrees of hemolysis; some of them are not even affected at all. in this study, we aim to investigate unnecessary cancellations and explain the relationship between hemolysis and test results according to their kit inserts. materials and methods: we measured hemoglobin levels of hemolyzed serum using drabkin method (abbott). interference studies are conducted using clsi protocol nccls ep -p is written in kit inserts. target values ( %) and their change due to different degree of hemolysis have been defined. results: hb concentration ranges of hemolyzed sera were found from to mg/dl. according to kit inserts, aspartate aminotransferase (ast) test results deviate . % from the target when the degrees of hb are mg/dl. when the degree of hemoglobin is mg/dl, the test strays about . %. potassium levels increase ( %) at mg/dl hb while this increase reaches to . % at mg/dl hb. sodium, calcium, ck, crea, total bil, lipase are not significantly affected even at mg/dl. in lactate dehydrogenase (ldh) tests, test reporting is not allowed at any hemolysis level. alt increases %, at the mg/dl hb. ast and potassium results were excluded from patients' reports even though those samples had low hb. some of them were reported despite of excess hemolysis. some tests are even blocked without ever being studied. discussion: prior to the approval of the lab specialist, technicians decide whether to cancel the tests affected by the hemolysis according to the visible hemolysis based on their personal knowledge. conclusion: we should use the hemolysis index, in which standards would be defined via guidelines. this way, all technicians and specialists could know which results are false. the dna-binding hu-proteins are present in all bacteria and belong to the family of nucleoid-associated proteins. these proteins can be considered precursors to eukaryotic histones. gene knockout of hu-proteins partially inhibits the growth of bacteria, their ability to resist various stressing factors and in some cases leads to their death. since the spatial structure of hu-proteins is highly conserved it is possible to create inhibitors that will affect them in a broad spectrum of pathogenic bacteria. in the present work the preparation of the recombinant hu protein from mycoplasma gallisepticum, crystallization of this protein, and x-ray diffraction study of this protein has been reported. the crystallization conditions for studying protein were found by the hanging-drop vapor-diffusion method. found conditions have been adapted to the counther-diffusion method in the capillary. the x-ray diffaction dataset from grown crystals have been collected using synchrotron radiation. d-structure of the hu protein from mycoplasma gallisepticum have been determined with a resolution. structural features of the investigated protein are described. this work is supported by russian scientific fund ( - - ). a novel sensitive disposable indium tin oxide (ito)-based electrochemical immunosensor was developed for simple, rapid and sensitive biomonitoring of sox . sox is a cancer biomarker and used for detecting of small cell lung cancer, lung adenocarcinoma, squamous cell carcinoma, skin cancer, prostate cancer, and breast cancer. in this study, indium thin oxide (ito) thin film was used as working electrode. carboxyethylsilanetriol was also used for electrode modifying so as to obtain self-assembled monolayers. the formed self-assembled monolayers were activated with -ethyl- -( -dimethylaminopropyl) carbodiimide (edc)/n-hydroxysuccinimide (nhs) chemistry. edc was used as a heterobifunctional crosslinker. nhs was used in conjunction with the crosslinker edc. anti-sox antibody was used as a biorecognition element and it was covalently immobilized onto the ito electrode modified with carboxyethylsilanetriol. immobiliztion steps were characterized by cyclic voltammetry (cv), electrochemical impedance spectroscopy (eis), and scanning electron microscopy (sem). the optimal immobilization conditions for the best sensitivity of the new immunosensor were investigated. under optimal conditions, this immunosensor demonstrated a wide linear range ( . - pg/ml) with a detection limit as low as . ng/ml sox . furthermore, the developed sox immunosensor had good storage stability, repeatability and reproducibility. in this work, we successfully fabricated disposable ito thin film based electrodes for sensing the interaction between sox antigen and anti-sox antibody by electrochemical impedance spectroscopy and cyclic voltammetry. and our developed immunosensor has an acceptable performances for the detection of sox antigen, exhibits low detection limit, has selective and reproducible results in immunoreaction analysis. we are thankful for the support from t € ub _ itak (the scientific and technological research council of turkey, project number: z ). applying multiple linear regression model to determine the relationship between anti mullerian hormone with age, luteinizing hormone, follicle stimulating hormone and estradiol: a data mining study introduction: anti mullerian hormone (amh) has a widely used in our life because it is a good indicator of reproductive age to estimate the time of menopause. the purpose of this retrospective data mining study is the estimate of ovarian reserve by using amh and determines relationship between other indicators which are luteinizing hormone (lh), follicle stimulating hormone (fsh), estradiol and age. materials and methods: . women members were included this retrospective data mining study who were applying to acıbadem labmed laboratory. multiple regression analysis of age related changes of amh ( - ) and lh, fsh and estradiol were investigated. beckman gen ii elisa kit was used for amh and the technique of electrochemiluminescence and roche elecsys cobas analyzer were used for the measure of other hormones. results: amh shows meaningful correlation between lh, fsh, estradiol and age but also seen there is no correlation between progesterone. after the multiple linear regression analysiz amh= . -( . age)À( . fsh) + ( . lh)À( . estradiol) is detected and the model's r = . is also detected. conclusion: nowadays there are lots of methodology were developed the estimate the function of ovary and biological age of ovarian. age, fsh, lh and estradiol show ovarian reserve by indirectly. this study shows the mathematical relationship between amh and the other indicators and results are thought to lead to future developments. antioxidant and anticancer effect of artemisia absinthium extract on colon and endometrium adenocarcinoma cells plants have always been among the common sources of medicines that have many phytochemicals with various bioactivities, including antioxidant and anticancer activities artemisia absinthium (ar) has been used as an antipyretic, antiseptic, anthelmintic, tonic, diuretic, and for the treatment of stomachaches in turkish folk medicine. this study aimed to investigate antioxidant, cytotoxic, genotoxic and apoptotic effect of methanol extracts of ar activities on the human colon (dld- ) and endometrium (ecc- ) adenocarcinoma cell line. total phenolic, flavonoid content, and antioxidant activities were determined using suitable methods (abts, cuprac i.e). cytotoxic effects of ar on cells were determined by mtt and neutral red uptake assays. genotoxicity was evaluated by comet assay and, apoptosis induction were detected by apoptosis elisa and acridine orange staining methods at the half maximal inhibitory concentrations (ic ) levels. it was determined that extract have shown antioxidant activity in all tests and that they could be considered as a source of natural antioxidants. cytotoxic effects were concentration-time dependent. specifically, apoptotic and genotoxic effect increased at and lg/ml concentrations by hours. we found that ar extract had antiproliferative, genotoxic and apoptotic effects on the human cancer cell lines dld- and ecc- . however, further studies at molecular level are required to support our findings and to elucidate chemopreventive and chemotherapeutic effects of ar on colon and endometrium cancers. keywords: artemisia absinthium, antioxidant, anticancer, apoptosis, genotoxicity introduction: colorectal cancer is considered as a major gastrointestinal. this cancer is the second cancer related cause of death after lung cancer in worldwide. we designed a vaccine chimeric including cea and ca - against colorectal cancer (ce-ca). materials and methods: the construct were analyzed by bioinformatics softwares. in this study, the ce-ca gene was optimized using the codon bias of e.coli and synthesized by biomatik company. then construct (ce-ca) was cloned into an expression vector and recombinant constructs transferred to e.coli bl de bacterium and desired recombinant protein was expressed. recombinant protein was purified using ni-nta affinity chromatography. the content of secondary structures was obtained by circular dichroism (cd) spectrum. then recombinant protein was confirmed using western blot analysis and indirect elisa method. results: sds-page analysis showed that the recombinant protein was highly expressed and purified. western blot analysis confirmed recombinant protein. also cd spectrum confirmed predicted structures by bioinformatics tools. the elisa results showed significantly high affinity toward recombinant ce-ca protein. discussion: based on many studies, cea as potential immunogenic candidate could be considered in vaccine studies. also ca - is a cell-surface antigen that has significant increase of expression in colorectal cancer, thus as marker of colorectal cancer. based in available data, these two antigens, in combination can provide specificity for production of colorectal cancer vaccine. conclusion: these findings suggest that ce-ca as potential immunogenic candidate which could be considered in future vaccine studies and detection of colorectal cancer. flow cytometric cell cycle and apoptosis analyses of some wild animal species a. tas, e. koban bostanlar tubitak, marmara research center (mrc), genetic engineering and biotechnology institute (gebi), animal genetic and reproductive biology laboratory, kocaeli, turkey cell biobanking; more specifically cryopreservation of biological diversity, is promising as a tool to preserve wild animals as well as domestic ones via nuclear transfer. in this study, we investigated the viability and cell cycle characteristics of wild animal species (fallow deer, red deer, wild sheep, wolf, wild goat). auricular tissue samples were maintained in pbs+ %psa. tissues were seeded on mm petri dishes containing dmem/high glucose supplemented with % (v/v) fcs and incubated %co in air at % relative humidity and at °c. after seeding, the medium was unchanged for days and then it was changed in every days for days at maximum. once the cells were obtained; flow cytometric cell cycle and apoptosis analyses were done. in terms of apoptosis, all the groups showed high viability rates (over %) in culture when compared with the negative control ( %). the cell cycle comparisons were made between serum-starved cells and roscovitine treated cells, both for which untreated cells were used as control, which revealed different results for different species. there was no difference found between serum-starved cells and roscovitine treated cells for red deer and wolf. the serum-starved cells resulted in higher g /g phase for fallow deer and wild goat. on the contrary, roscovitine treated cells resulted in higher g /g phase for wild sheep. as a result; the cells obtained from wild animals had high viability and g /g phase rates. therefore, they may serve as a donor cell source for nuclear transfer studies.(grant: tubitak kamag, turkey, g ). the interaction of different types of antibiotics with endothelial cells in the presence of nanoparticles the interaction of nanomaterials with cells and lipid bilayers is critical in many applications such as phototherapy, imaging, and drug/gene delivery. the aim of this study was to investigate the interaction of nanoparticles (fe o ) or nanoparticles fused with different antibiotics with cell membranes in order to reveal changes in the membrane organization. endothelial cells were used to determine the effect of different antibiotics (gentamicin, kanamycin, amikacin, penicillin, polymyxin, neomycin, cefotaxime, bacitracin, moxicillin, erythromycin, streptomycin and vancomycin) on the membrane organization. for recording the anisotropy of cell suspensions treated with antibiotics or nanoparticles fused with antibiotics we used - -trimethyl- -phenyl , , hexatrien p-toluenesulfonate (tma-dph). we decided to use nanoparticles fused with antibiotics because they contain small amounts of antibiotics which makes them less toxic than simple antibiotics,which is very important in patients with genetic diseases such as cystic fibrosis, that should be treated with antibiotics for a long time. our results showed that at temperatures between and °c simple nanoparticles decreased the membrane fluidity. at physiological temperatures ( - °c) nanoparticles fused with antibiotics (gentamicin, vancomicin, cefotaxim, bacitracin, amoxicillin) increase more the membrane rigidity compare with simple antibiotics or nanoparticles.erythromycin, polymyxin and penicillin increase the membrane rigidity at °c, and at °c the same effect was obtained in the presence of nanoparticles fused with these antibiotics,suggesting that the nanoparticles are dependent to temperature for penetrating the membrane. in conclusion the membrane fluidity does not depend on antibiotics types, the modification are present in many antibiotics irrespective of class type.the presence of nanoparticles fused with antibiotics is very important for long term treatment. objectives: hypertension is an important cardiovascular risk factor for the development of atrial fibrillation (af). increased atrial electromechanical coupling time interval measured by tissue doppler is accepted as an important factor for prediction of af development in hypertensive patients. monoamine oxidases (maos), are enzymes which catalyze the oxidation of monoamines. -isoprostane is considered as an indicator of oxidative stress. mao activity and -isoprostane levels were measured in some diseases. however, there are no information on -isoprostane levels and mao activity in newly diagnosed patients with stage hypertension has not been observed in a study of literature. aim: this is the first study, we aimed to evaluate the levels of mao and -isoprostane in newly diagnosed patients with stage hypertension. the study included newly diagnosed stage hypertensive patients with no other systemic disease. patients were selected as randomized ( women, men; range of age - years) and healthy individuals as control ( women, men; range of age - years). all the underwent tissue doppler echocardiographic examination. blood samples were taken from patients and controls and, the levels of mao and -isoprostane in serum samples were measured by elisa. results: baseline blood pressures, electrocardiographic and echocardiographic findings, and atrial electromechanical coupling were similar in both groups (p > . ). compared to the control group, the activity of mao and -isoprostane levels were found significantly higher in patients (p < . ). conclusion: increased -isoprostane level indicate that there is oxidative stress in newly diagnosed patients with stage hypertension. also, increased mao activity may be biochemical biomarkers for the diagnosis of hypertension. keywords: hypertension, monoamine oxidase, -isoprostane p-mis- determining the indirect reference intervals for complete blood count parameters in bursa, turkey reference intervals (ris) for laboratory test results are defined as the most commonly used diagnostic tool in medicine. therefore, careful determination of ris by the laboratory for use is a very important task. although c -a guideline recommends the direct ris (dris) calculated from healthy subjects, ris can be calculated from laboratory data which are called as indirect ris (iris). the study was carried out at the central laboratory for clinical chemistry, teaching and research (uludag university, bursa, turkey) . the results of the laboratory analyses from , males, , females, stored for approximately one year, were used for statistical analysis. data for hospitalized patients and for ambulatory patients from the intensive care unit were eliminated. furthermore, we used evidence based criteria to enrich the health-related values. a modified bhattacharya procedure was used to estimate the iris from hospital patient data. the nested anova was used to evaluate variations among genders and ages. cell dyn analyzer (abbott diagnostics, il, us) was used for the measurements of complete blood count. the obtained iris were also compared the dris determined in our previous ri study and the ris suggested by the manufacturer. we found that the ris of rbc, hb and hct required strong gender partition and calculated the ris of rbc, hb and hct separately. the observed iris for wbc, sub-fractions of wbc and plt in both genders are in good accordance with the dris reported in previous study. age-related changes were noted for rbc, hb, and hct. the calculated iris for rbc, mcv and rdw are different from the ris suggested by the manufacturer. we believe that, using this relatively easy technique, every laboratory can produce its own iris, divided, where possible, according to sex and age and according to local conditions. these ranges can be complementary to dris obtained for reference individuals according to the ifcc recommendations. the principal sigma subunit, involved in transcription of most house-keeping genes in escherichia coli, was also shown to induce rnap pausing during transcription elongation, by interacting with promoter-like motifs in the transcribed dna. such pauses were proposed to play important roles in the regulation of phage and cellular genes. e. coli contains six alternative s subunits but little is known about their ability to induce transcriptional pausing. we expressed and purified alternative s subunits of the sigma family and tested their effects on transcription elongation in vitro on natural and synthetic dna templates containing consensus promoter motifs. the structure of the paused complexes was analyzed by dna footprinting methods. in vivo analysis of transcription was performed using reporter genes placed under the control of corresponding promoters. we demonstrated that the stationary phase sigma subunit induced efficient rnap pausing on both synthetic and natural dna templates containing promoter-like motifs in initially transcribed regions. in contrast, the sigma and sigma subunits did not affect rna elongation. we showed that the sigma -induced pausing depends on sigma contacts with both nontemplate dna strand and rnap core. the pausing results in formation of backtracked transcription elongation complexes which can be reactivated by gre factors that stimulate rna cleavage by rnap. our results for the first time reveal transcriptional pausing induced by an alternative s subunit. analysis of sigma -dependent promoters shows that a substantial fraction of them contains potential pause-inducing motifs suggesting that such pausing may be a widespread phenomenon. we propose that sigma -dependent pauses may play important roles in genetic regulation and modulate the binding of transcription repressors or activators to promoter regions. the crosstalk between streptococcus pneumoniae rnase r, ribosomes and translation c. b arria, s. domingues, c. arraiano instituto de tecnologia qu ımica e biol ogica, lisbon, portugal ribonucleases (rnases) are enzymes that ensure maturation, degradation and quality control of rna thus, contributing to the maintenance of the optimal amount of each transcript in the cells. escherichia coli rnb family of enzymes is present in all domains of life and includes rnase r, rnase ii and the eukaryotic rrp /dis , dis l and dis l proteins. in streptococcus pneumoniae only rnase r was identified. rnase r, encoded by the rnr gene, hydrolyzes rnas starting from the end. rnase r level is increased in several stress conditions such as heat shock, stationary phase or cold shock, conditions in which most of the proteins translation is blocked. moreover, rnase r is the only exoribonuclease able to degrade highly structured rnas without the help of a helicase which is critical at low temperatures. here, we investigated the role of this enzyme by comparing the wild type strain with an rnr mutant strain. for that purpose we performed northern blots analysis of transcripts involved in translation. also, we investigated rnase r connection to the ribosome and polysome fractions using sucrose gradient polysome separation and western blots. in this study, we highlight the importance of s. pneumoniae rnase r in translation. we show that this enzyme interacts with ribosomes mostly with the s subunit at °c. moreover, in the absence of this enzyme we have observed a decrease in the amount of the s ribosomal subunit, concomitantly with the increase of s and s subunits. rnase r seems also to modulate the amount of the elongation factors ef-tu and ef-g transcripts. nevertheless, preliminary results further suggest other roles of rnase r in translation. modified nucleotides are present in many rna species in all domains of life. the biosynthetic pathways of such nucleotides are well studied. however, much less is known about the degradation of rnas and the salvage of modified nucleotides, their respective nucleosides or heterocyclic bases. using an e. coli uracil auxotrophic strain, we screened the metagenomic libraries for genes, which would allow the conversion of -thiouracil to uracil and thereby lead to the growth on a defined synthetic medium. we show that a novel gene encoding previously uncharacterized domain of unknown function (duf) is responsible for such phenotype. we have purified this recombinant protein and demonstrated that it contains a fe-s cluster. the substitution of cysteines, which have been predicted to bind such clusters, with alanines abolished the growth phenotype. we conclude that this domain is required for conversion of -thiouracil into uracil in vivo. this work is supported by the research council of lithuania (lmt, mip- / modified nucleotides are present in almost all classes of rna. they have great chemical diversity and are critical for rna folding, stability, interaction with cellular proteins and thereby for various cellular processes such as translation, stress response, and signaling pathways. biosynthesis of pyrimidine nucleotides and their modified derivatives in rna is well studied. nonetheless, not much is known about the cellular degradation of these compounds and the enzymes catalyzing such processes. using an e. coli uracil auxotrophic strain, we screened metagenomic libraries for genes encoding isocytosine deaminases. three novel genes were obtained, one of which encodes a protein similar to oxoguanine deaminases. the other two encode proteins resembling hydroxydechloroatrazine ethylaminohydrolases. we confirmed that these proteins are functional in vivo, allowing growth of e.coli on minimal medium with isocytosine. we also demonstrated that such purified recombinant enzymes catalyze the conversion of isocytosine, but not cytosine, into uracil in vitro. natural products display special attributes in the treatment and prevention of various human diseases, including cancer. a significant number of organic compounds from plants exhibit anticancer properties as attested by in vitro and in vivo studies. emerging evidence supporting the antineoplastic activity of natural compounds has rendered them promising agents in the fight against cancer. in this study, skin from limnio grape, a red greek grape variety that is indigenous to the greek island of lemnos, was extracted using mixtures of methanol, water and acetone; the apoptosis-inducing properties of these extracts were studied in the human ovarian malignant adenocarcinoma cell lines tov- g and tov- d. for this purpose, tov- g and tov- d cells were treated with limnio grape skin extracts at a range of concentrations, at °c, for , and hours. untreated cells incubated for the same time intervals served as controls. cell viability was determined by measuring metabolic activity (colorimetric mtt assay) and observing cell membrane integrity (cell staining with trypan blue). after the determination of the optimal concentration of the extract, total rna was extracted from treated and untreated (control) tov- g and tov- d cells. after determination of rna concentration and subsequent first-strand cdna synthesis, mrna expression analysis of apoptosis-related genes was performed with rt-pcr using gene-specific primers. an increasing percentage of non-viable cells was observed by increasing cell exposure time and extract concentration. distinct modulations of the expression of apoptosis-related genes at the mrna level were also observed, mainly concerning bcl , bclx, bax, bak and bcl l , along apoptosis induction. in conclusion, the cytotoxic properties of limnio grape skin extracts against ovarian malignant adenocarcinoma cells merit further investigation. the intrinsic apoptotic pathway seems to be the major mechanism of action induced by these plant extracts. almost all eukaryotic mrnas are polyadenylated by a complex machinery that recognizes the poly (a) signal, cleaves the mrna and adds the poly (a) tail. % of human genes harbor multiple poly (a) signals. alternative polyadenylation (apa) generates transcript isoforms with different utr (untranslated region) lengths due to the use of proximal or distal poly (a) signals. hence, tightly regulated apa has been observed in normal physiological settings as well as in diseases. considering that utr shortening cases have been linked to increased protein levels, we hypothesized deregulated apa to be one of the potential cancer related mechanisms. we investigated the utr alterations in er(+) breast cancer patients and cell models compared to normal breast tissue, using gene expression data and a probe-based quantification tool, apadetect. based on means of proximal to distal probe sets, slr (short-long ratio) were calculated as an indication apa. significance analysis of microarrays (sam) determined significant genes. the gse numbers of the datasets are gse , gse and gse . we analyzed two datasets of er(+) breast cancer patient samples (n = , n = ) compared to normal breast tissue (n = ) using apadetect and sam. a total of utr shortening and utr lengthening events were detected in breast cancer samples compared to normal breast tissue. ontology analysis suggested almost all the utr shortening genes were proliferation related and were indeed reported to be upregulated in breast cancer. to further investigate the connection between apa and era status, we used data from a cell line model; wild type or era transfected mda-mb- cells that are otherwise of triple negative nature. our results suggested that most of the genes are utr shortened or lengthened via direct binding of era to dna. our results suggest involvement of apa mechanisms in era action mechanisms. possible link between era regulated transcription and apa remains to be elucidated. contamination of nucleic acids (na) as a result of na extraction protocols may result an inaccurate measurement of dna copy number. agarose gel electrophoresis and spectrophotometric methods are commonly used to check dna purity. however, the resolution of these methods may not be good enough for special applications such as determination of dna copy number and separation of base pairs (bp) that are close in their bp number. in this study, we have developed a new method for separating na's ranging between - bp also detecting the impurities in dna solution in %, % and % ratios to the dna of interest. the developed method was validated using the in-house dna fragments of , and bp. the dna mixture analyzed using analytical hitachi elite lachrom hplc using the guard and analytical columns tskgel dna-npr, . lm, . mm id . cm and tskgel dna-npr, . lm, . mm id . cm, respectively. the validation of the analysis was performed by running each sample five times on three different days. the linearity of the detector response was established by plotting a graph to quantity versus area of bp dna. the lod and loq were then measured by calculating the minimum level at which analyte can be readily detected and quantified. the ratios calculated with hplc were compared to the ratios calculated by quant-it kit. recovery values were calculated for each measurement and the uncertainty were calculated for each ratio. the method was found linear for bp in the range of . ng to ng dna with the regression coefficient of r = . . lod and loq for the bp dna was found to be . ng and . ng, respectively. the recovery values for the %, % and % impurity ratios were found . . . and . , respectively. the purity of the synthetic dna was determined by hplc and related uncertainty was calculated. the developed method is a simple alternative to electrophoresis and spectrophotometric methods with higher resolution and separation range. physical and chemical factors can disturb the conformation of proteins maturing within the cellular secretory pathway. in response to unfolded proteins the cell activates several stress signaling and adaptive response mechanisms. the aim of our study was to investigate small non-coding rnas as the potential regulators of cellular response to unfolded proteins (upr). for this, we conduct the next generation sequencing of small rna and transcriptome analysis of mrna from jurkat cells exposed to dithiothreitol (dtt), which reduces protein disulfide bounds. analysis of mirnas reveals the differential expression of mirnas. we observe a decrease in the normalized amount of reads aligned to mirna loci in stressed cells. affymetrix analysis with subsequent gsea reveals downregulation of reactome mirna biogenesis pathway (fdr = . ). the length distribution of small rnas revealed nt-peak corresponding to trna-derived fragments, amount of which was increased by . -fold under dtt treatment. the trna isotypes that gave rise to almost % and % of all nt rna fragments in stressed and control cells, respectively, include glycine, glutamic acid, aspartic acid and valine. the vast majority of nt fragments produced from these trnas are precisely phased halves with the characteristic cleavage patterns generated by rnase a angiogenin (ang). observed upregulation of tirna in stressed cells is accompanied with upregulation of ang mrna and down-regulation of angiogenin inhibitor (rnh ). we speculate that translational repression, associated with observed tirna, is an additional mechanism of reducing global protein synthesis in response to dtt-induced stress. collectively, our findings reveal the increase in tirna, the differential regulation of mirna expression together with the global mirna downregulation as the most prominent small rnome reprogramming events and possible fine-tuned levels of post-transcriptional regulation upon dtt-induced cellular stress response. global gene expression changes after spinal cord injury j. k. hyun , , , j. kim , , j. y. hong dankook university, cheonan, south korea, institute of tissue regeneration engineering (itren), cheonan, south korea, the neuronal regeneration is hardly achieved spontaneously after spinal cord injury (sci), and the restoration of somatic and autonomic functions after sci is also challenging in the clinical field. the pathophysiology of sci is extremely complex and many in vitro and in vivo studies continued to report opposite results each other in spite of the same treatments, therefore a fundamental analysis such as an extensive assay of global gene expression is required to find a way for spinal cord regeneration. in this study, we aimed to detect the changes of global gene expression after spinal cord contusion in rats according to the time sequence. the spinal cord tissues at contusion site were sequenced after spinal cord contusion in rats using rna-sequencing technology. for time sequence analysis, five time points was determined; hour, day, week, month and months after spinal cord contusion, and sham operated rats at each time point were used as controls. quantitative rt-pcr analysis was also performed to validate expression changes of candidate genes in each category. we found that the pattern of changes in gene expression at acute and subacute stages was quite different from that at chronic stage, especially genes associated with with neurotrophin signaling and apoptosis pathways. most of gene expression levels of inflammatory cell markers were increased and peak during acute stage ( hour to week) and maintained until chronic stage. some of regeneration-associated genes (rags) including brain derived neurotrophic factor, glial cell derived neurotrophic factor and ciliary neurotrophic factor were increased at hour or day after sci. we concluded that the information of gene expression level according to the time sequence after sci might be useful to determine treatment strategies for spinal cord regeneration especially in chronic stage. p- . . - utr length isoform generation profile in a differentiation model alternative polyadenylation (apa) is the regulated selection of a specific poly(a) signal among other proximal and/or distal signals on the utrs (untranslated region) for the endolytic cleavage and addition of a poly(a) tail to form the mature mrna. consequently, position of the poly(a) site determines the length of the utr which is known to harbor microrna and rna binding protein sites. such apa isoforms have already been linked to altered protein levels and even functions. therefore we hypothesized apa to be one of the mechanisms to generate isoform diversity in proliferating and differentiated cells to better understand the molecular basis of cancer. we used a combinatorial in silico and in vitro approach to analyze a well known enterocyte differentiation model; caco- cells. initially we analyzed gene expression datasets for the proliferative and differentiated caco- cells using a probe based apa detection tool. to better understand the significance and to validate these results, we used proliferating and differentiated (day ) caco- cells and tested sample apa events by rt-qpcr. utr isoforms were identified by using race pcr. we identified genes ( % of all apa events) to undergo utr shortening in differentiated cells compared to proliferating cells. on the contrary genes ( % of all apa events) went through utr lengthening events. several genes have been validated to follow the pattern that was seen in apa detection tool so far. to begin understanding the mechanism behind these observations, we are investigating potential inducers of apa during the complex events of differentiation. our next aim will be to further validate and investigate the consequence of such isoform generation events both in the context of differentiation in colon cancer cells. recognition of phosphorylated threonine- of rna polymerase ii c-terminal domain by end processing apparatus o. jasnovidova, m. krejcikova, k. kubicek, r. stefl central european institute of technology, masaryk university, brno, czech republic rna polymerase ii has evolved an array of heptad repeats with the consensus sequence y -s -p -t -s -p -s at the c-terminal domain (ctd) of its largest subunit, rpb . phosphorylation of serines (s , s , and s ) and tyrosine- orchestrate the binding of rna processing and transcription factors in the site of transcription. several recent studies showed that also threonine- site can be phosphorylated which has a number of functional consequences. to reveal the structural basis for the recognition of threonine- phosphorylated ctd, we set out to investigate several proteins factors that were implicated with a high levels of threonine- ctd phosphomarks using integrative structural biology. one of them, a factor involved in the -end processing and transcription termination, showed a high affinity to the phosphothreonine ctd. using nuclear magnetic resonance spectroscopy (nmr), we determined its structure bound to the ctd phosphorylated at threonine- that reveals a direct read-out of the phosphothreonine. altogether, our data provides the first insights into the recognition of this poorly understood ctd mark that plays important role in the ctd code of rna polymerase ii. the results of this research have been acquired within ceitec (lq ) project with financial contribution made by the ministry of education, youths and sports of the czech republic within special support paid from the national programme for sustainability ii funds. introduction: the treatment of brain tumor glioblastoma (gbm) is still one of the greatest challenge. anti-inflammatory drug indomethacin (ind) mainly acting through the inhibition of cyclooxygenase (cox) has also anti-cancer activity including brain tumors. the aim was to investigate how ind effects an immortality enzyme telomerases' activity. materials and methods: monolayer and spheroid cultures of t g human gbm cell line were used to evaluate the effects of ind ( lm) on cell proliferation, viability, apoptosis, cell cycle, camp levels, the levels of apoptotic and anti-apoptotic proteins, morphology (sem) and ultrastructure (tem) for hours. results were analyzed using the student's t-test. results: ind decreased cell proliferation (p < . ), cell viability (p < . ), cell rate at s phase (p < . ) and g + m phase (p < . ), camp levels (p < . ), the levels of pdgfr-a (p < . ), mrp- (p < . ), nf-jb (p < . ) and cox- (p < . ) in comparison to control group. ind mildly increased apoptosis (p < . ) and caspase- levels (p < . ). interestingly, ind increased htert levels ( %, p < . ; %, p < . ). sem evaluation showed that ind led to decreased and shortened microvilli, the lost of cell interactions and the conversion of many cell shapes from spindle to oval. many cell remnants in the intercellular area, intact cell membranes, many dense lipid droplets and few autophagic vacuols in the cytoplasm were observed under tem. discussion and conclusions: the effect of ind on telomerase activity can only be found in publications at pubmed research that they only showed its' inhibitory effect in colon, gastric, head and neck cancers. in contrast to previous studies, it was shown for the first time that ind increased telomerase activity in gbm cells and this increase was independent from cox- and other tested factors. p- . . - interaction between fibrinogen and insulin-like growth factor binding protein- under physiologic conditions and influence of diabetes mellitus type on this interaction n. gligorijevic, o. nedic institute for the application of nuclear energy, university of belgrade, belgrade, serbia fibrinogen is plasma glycoprotein and principle participant in blood coagulation. it interacts with many proteins, including insulin-like growth factor binding proteins (igfbps). one of them, igfbp- , is controlled by insulin. metabolic changes due to diabetes mellitus (dm) affect igfbp- . besides glucose regulation, igfbp- stimulates wound healing. we have investigated complexes formed between fibrinogen and igfbp- , their change in dm type (dm ) patients and involvement in fibrin clot. samples from adult healthy persons and dm patients were studied: plasma, isolated fibrinogen and fibrin. the amount of igfbp- /fibrinogen complexes was determined using immunoblotting. immunoprecipitation and lectin affinity chromatography were used to confirm interaction between fibrinogen and igfbp- . in vitro incubation of fibrinogen with excess glucose or methylgyoxal (mgo) was employed to demonstrate influence of glyco-oxidation on complexes. results have shown that igfbp- /fibrinogen complexes can be differentiated from igfbp- oligomers and igfbp- /alpha- macroglobulin complexes. the amount of igfbp- /fibrinogen complexes was lower in patients with dm . complexes participated in fibrin clot formation, the amount being significantly lower in patients' samples. the quantity of igfbp- monomer in fibrin clot was greater in patients' samples. in vitro experiments revealed that complexes undergo glyco-oxidative modifications leading to their reduced formation, cross-linking and increased acidity (faster electrophoretic movement). isolated fibrinogen from patients with dm was additionally able to bind exogenous igfbp- . since igfbp- stimulates wound healing, directly and by delivering igfs, igfbp- /fibrinogen complexes may be seen as igfbp- storage instrument, ready to participate in fibrin formation and to assist in damage repair. reduction of complexes due to glyco-oxidative stress in patients with dm may be part of the mechanism responsible for impaired coagulation process. human interferon gamma (hifnc) is a proinflammatory cytokine involved in the regulation of nearly all phases of immune and inflammatory responses. its abnormal expression is associated with the aetiology of many inflammatory and autoimmune diseases. recently we have been exploring the idea to counteract the over-expression of the endogenous hifnc by competitive inhibition with inactive hifnc mutants. they are designed to have preserved affinity to the hifnc receptor, but to be deprived in their capability to trigger the intracellular signal transduction. to this end a library of mutants was created and two potential hifnc antagonists were selected for further investigations: a single point mutant k q (q substitution for k in position ) and a double mutant with additional substitution in the n-terminus. both mutants and the wild type hifnc were expressed in e. coli employing the established by us methodology for large scale production of aggregation-prone proteins in soluble native form. the purified mutants were screened for interferon activity (antiproliferative assay), binding affinity (isothermal titration calorimetry) and ability to compete with the wild type for the hifnc receptor (competition assay on wish cells). the selected mutants demonstrated (single mutant) and (double mutant) times lower antiproliferative activity than the wild type. measuring the binding thermodynamic parameters, we proved that the receptor binding affinity of both mutants was preserved, which is an indication for their potential to compete with the wild type hifnc for its receptor. finally, the biological assay performed on wish cells showed a distinct dose-dependent competition between the wild type hifnc and the mutants. based on the results presented in this study we conclude that the two hifnc mutants are potential candidates for autoimmune therapy based on selective suppression of the endogenous hifnc activity. mesencephalic astrocyte-derived neurotrophic factor (manf) is an er (endoplasmic reticulum) stress-inducible protein and widely expressed in mammalian tissues. it has been identified as a secretory protein that protects cells against er stress-induced damage. er-stress is one of the main mechanisms that play a role in ischemia/reperfusion (i/r)-induced renal injury. recent studies demonstrated that manf can protect cardiac myocytes and cortical neurons against i/r-induced injury. moreover, it has been suggested that it has a restorative effect in ischemic injury. nevertheless, the function of manf in i/r-induced renal injury is still not known. in the present study, we investigated the function of manf by manipulation its expression level in ischemic acute renal failure model established in proximal tubular kidney cells (hk- cells). for this purpose, the cells were transfected with either manf sirna or manf encoding plasmids for silencing or over-expression of manf, respectively. then, the cells were exposed to hypoxia-reperfusion (h/r) induction for indicated times. evaluations of cell viability were determined with wst- reagent. the changes in protein levels of h/r-induced stress markers were analyzed byimmunoblotting. the results showed that the overexpression of manf has provided a significant resistance to h/r-induced cell death, whereas silencing of manf has rendered the cells more susceptible to death. it was also determined that the pretreatment of cells with manf conditioned medium caused a decrease in cell death. additionally, oxidative/nitrosative stress (os/ns) and er stress levels were decreased with over-expression of manf and increased by silencing of manf in hk- cells. taken together, our study suggests that manf may have a protective role against h/r-induced renal cell injury, possibly through the reducing effects on os/ns and er stress. p- . . - his-flag tag as a fusion partner in insect expression systemgain or loss? e. krachmarova , m. tileva , k. maskos , i. ivanov , g. nacheva institute of molecular biology "roumen tsanev", sofia, bulgaria, proteros biostructures, martinsried, germany human interferon gamma (hifnc) is a glycoprotein playing major role in the regulation of innate and adaptive immunity. glycosylation is not essential for hifnc activity but is important for its stability, half-life and protease resistance in blood. the commonly used hifnc in therapy and research is produced in e. coli and therefore is not glycosylated. bearing in mind the above mentioned shortcomings of the non-glycosylated hifnc we expressed it in mammalian cells and transgenic mice, however very low yields were achieved. to obtain glycosylated hifnc, here we employed a secretory expression of n-terminal his-flag fusion protein in baculovirus-infected insect high five Ò cells. this small hydrophilic tag is designed to not affect the proper folding of the target protein and to facilitate the detection and purification procedures. in parallel the same fusion was expressed in e. coli cells. the fusion proteins were purified to high degree of purity by affinity and size-exclusion chromatography. bioassay carried out on wish cells showed that the antiproliferative activity of both fusion proteins was times lower than that of the native hifnc. this result shows that, in contrast to the generally hold view, the n-terminal his-flag tag interferes with the biological activity of hifnc despite of the protein glycosylation. in order to restore the biological activity we attempted to remove the his-flag tag enzymatically. surprisingly, we found that the fusion protein obtained from insect cells was resistant to enterokinase, independently of the enzyme source and experimental conditions, whereas the protein isolated from e. coli was susceptible and the tag-free protein showed fully restored biological activity. we are prone to explain the enterokinase resistance of the fusion protein from insect cells with either the specific conformation of the glycosylated protein or with the interaction of the carbohydrate residues with the enzymatic activity of the enterokinase. p- . . - development of fluorescence assay for highthroughput screening system based on flow cytometry for directed evolution of cellobiose dehydrogenase cellobiose dehydrogenase (cdh) is an enzyme produced by phanerochaete chrysosporium and it has been already successfully cloned in other organisms. one of the most important roles of cdh is removing products of cellulose degradation. cdh is very important for biofuel and biosensor industry. for improvements of enzyme properties we have used directed evolution. the most important step is to develop screening system that reflects properties of interest. screening in microtiter plates (mtp) is expensive, time-consuming and has low throughput with a small number of variants detected ( - in months). the aim of this work was the development of screening system for mutant libraries of cdh expressed on surface of yeast cells based on fluorescent enzymatic assay and flow cytometry. the screening method should be capable of screening cellobiose dehydrogenase variants mutated for higher activity and higher thermostability by error prone pcr. the fluorescent assay was beta-galactosidase (ec . . . ) also known as lactase is the enzyme that typically catalyzes hydrolysis of beta- , -d-galactosidic linkages in beta-d-galactosides, including disaccharide lactose, with glucose and galactose as end reaction products. this enzyme is able to catalyze synthesis of oligosaccharides, in particular galactooligosaccharides via galactosyl transfer reaction. arthrobacter sulfonivorans beta-galactosidase of unique for prokaryotes extracellular localization may find application in food industry for manufacturing lactose-free dairy products and in pharmacology as bioactive principle of medicines prescribed for patients suffering from lactase deficiency. the study was aimed at cloning of the gene encoding a. sulfonivorans beta-galactosidase, purification and characterization of the enzyme. a novel extracellular beta-galactosidase from a. sulfonivorans was recovered with an overall -fold purification, a . % yield and specific activity uÁmg À protein. the subunit molecular mass of the enzyme determined by sds-page analysis equalled kda. it was found that the enzyme displays pi . , prefers ortho-nitrophenyl-beta-galactoside as substrate (km mm) and shows maximum activity at °c and at ph . - . . the beta-galactosidase gene was isolated from the genomic dna library of a. sulfonivorans, sequenced, cloned and deposited in the genbank database under accession number km . . it was established that the gene carries an open reading frame consisting of bp ( amino acids) and encodes beta-galactosidase referred to glycosyl hydrolase family (cazy database). p- . . - different splice-forms of tdrd protein mutated in cataract's and glaucoma's interacts with s k / o. skorokhod, v. filonenko department of cellular signalling, institute of molecular biology and genetics nas of ukraine, kyiv, ukraine ribosomal s kinases (s k) are important players in cellular pi k/mtor signalling network, deregulation of which has been associated with methabolic disorders, inflammation and cancer. previously we had identified a novel binding partner of s k -tdrd (trap). tdrd is a scaffold protein detected in complexes involved in the regulation of cytoskeleton dynamics, mrna transport, protein translation, non-coding pirnas processing, transposons silensing. it was reported recently that mutations in human tdrd result in cataract and glaucoma formation, defined by elevated intraocular pressure (iop) and optic nerve damage. the aim of our study was to confirm s k-tdrd interaplay and study its role in cells. bioinformatical analysis of tdrd sequence revealed the presence of potential phosphorylation sites of s k . using in vitro kinase assay, we have demonstrated that recombinant s k phosphorylate from fragments of tdrd . formation of s k -tdrd complexes in vivo was further confirmed by coimmunoprecipitation using anti-s k and anti-tdrd antibodies generated previously in rat brain lysates. this interaction was further confirmed by confocal microscopy, oleksandr had shown that tdrd co-localize with s k in hepg cells, predominantly in perinuclear region, enreached for one of the tdrd isoforms identified previously. moreover, we have detected that c-terminal synthetic peptides of s k with methylated arg interfere with tdrd from hepg lysates. the physiological characteristics of s k -tdrd interaction and the role of this complex formation in neuropathology's development need further investigation. many biological function of placenta are performed not just a set of individual proteins, but also different oligomeric structures and complexes. herewith, activities of complexes may considerably differ from activities of individual proteins. therefore, identification and characterization of placental multi-protein complexes is an important step to understanding the placenta function. the aim of the present work was to investigate a composition and biological functions of the very stable high molecular mass multi-protein complexes (spc) from placenta of healthy mother. we isolated spcs (~ kda) from the soluble fraction of three human placentas. light scattering measurements and gel filtration showed that the spc is stable in presence salts, acetonitrile and triton x- in high concentrations, but efficiently dissociates in the presence of m urea and mm edta. such a stable complex is unlikely to be a random associate of different proteins. it was shown the spc includes a number of proteins with molecular weights of to kda. several protein components of the spc were identified, including serum albumin, transferrin, iggs, annexin a and other proteins. serum albumin, transferrin and protein with molecular weight , kda are the main proteins of the complex. it was shown high the spcs from three placentas possesses dnsase and catalase activities. an addition, investigation of cytotoxic effect on human cancerous cell lines has shown that the spcs reveal high cytotoxicity. antibody-cytochrome b fusion protein, characterization and applications for antibody development process antibodies have recently become an essential tool being a part of immunodiagnostics, therapeutics and as a valuable instrument in life science research. an enormous number of options utilizing a various tags were used to create a universal antigen-binding domain, which can be easily detectable, highly soluble and might be produced in high yields with low costs, but no multipurpose solution exists yet. we addressed the question whether a single tag could be found for enhancing solubility of recombinant fab antibody fragment and providing its detection and accurate quantification by rather simple method. a new application for hemeproteincytochrome b as the antibodies fusion partner were proposed. we have constructed of recombinant fab antibody fragment cytochrome b fusion protein. we have shown that cytochrome b enhance expression of fab antibodies fragments in bacterial system, and could be a versatile tool for recombinant proteins folding, redox (oxidation) state studies and for their precise concentration determination in the turbid solutions. fusion fab-b protein has a stable red color and characteristic absorbance spectrum with the maximum absorbance at nm in oxidized environment. cytochrome b change its spectrum maximum depending on environmental redox potential and its folded state, so one can track these events in real time spectrophotometrically. binding activities of fab-b fusion protein and hybridoma secreted immunoglobulin were measured by biolayer interferometry and elisa. no significant difference between them was revealed. due to this feature we can distinguish the chimeric protein of interest in complex mixtures and control the process of recombinant proteins expression and purification in real-time. besides, cytochrome b fusion tags multiples recombinant antibody yield (from to times) and doesn't affect antigen-binding properties. the bb - site of fibrin molecule is the site of fibrin protofibrils lateral association l. urvant palladin institute of biochemistry nas of ukraine, kyiv, ukraine previously we showed that fibrin-specific monoclonal antibody i- c (monab i- c) inhibited the fibrin protofibrils lateral association. we suggested that the epitope of monab i- c in bb - of coiled-coil region of fibrin molecule coincides with the site involved in fibrin protofibrils lateral association. the aim of this study was to localize the site of protofibrils lateral association in fibrin molecule using the synthetic peptides bb - , bb - and both their scrambled version, and bb - peptide. monab i- c was isolated from hybridoma culture medium by affinity chromatography on fibrin-sepharose. turbidity analysis was used to study the effect of synthetic peptides on fibrin polymerization. the interaction between peptides and monab i- c was investigated by spr method using plasmon- device. we investigated the effect of synthetic peptides which corresponded to amino acide sequences of fibrin molecule bb - , bb - , bb - , and the scrambled versions of bb - and bb - peptides on a binding to monab i- c and on the fibrin polymerization process. in spr analysis was showed that bb - and bb - peptides, but not their scrambled version, binds to monab i- c, immobilized to a chip. turbidity data showed that only bb - and bb - peptides caused the -fold decrease of the rate of the lateral association of protofibryls at the concentration . À m and . À m, respectively. both of them decreased the final clot turbidity. our data let us to suggest that the bb - site is the site that involved in protofibryls lateral association. it has been recently shown that irisin immunoreactivity was altered in gastrointestinal cancers. as known hematological malignancies was one of the most common malignancies through world, but no study was present how irisin was changed in this type of cancers. therefore, purpose of this was to investigate how immunoreactivity to irisin was altered in hematological malignancies (blood cancers). we used an antibody from phoenix to demonstrate how a kda band after deglycosylation of irisin altered in hematological malignancies. here we first time showed that irisin tissue immunoreactivity from acute lymphoblastic leukemia (all) and acute myelogenous leukemia (aml) patients was increased when compared with unaffected biological tissue parts. from the immune-histochemical (ihc) investigations it is concluded that hematological tissue and blood cells may be another source of irisin and increased with cancer, thus this finding might help to enlighten pathophysiology of hematological malignancies. the value of urine neutrophil gelatinaseassociated lipocalin (ngal) in acute heart failure n. serdarevic clinical centre, sarajevo, bosnia and herzegovina introduction: renal dysfunction is very common in heart failure (hf) and neutrophil gelatinase-associated lipocalin (ngal) is used as an early marker of acute renal tubular injury. recent studies have been reporting that ngal is inhibitor of inactivation of matrix metalloproteinases (mmp- ) which results in enhanced proteolytic activity with prolonged effects on collagen degradation. due to its relation to extracellular matrix degradation in myocardium and infammation, we hypothesized possible increased ngal expression in hf besides it renal dysfunction etiology. patients and methods: in study were included patients hospitalised with signs and symtoms of ahf. urine samples for ngal analysis were collected at admission and analysed by the chemiluminescent microparticle immunoassay (cmia) for the quantitative determination of neutrophil gelatinase-associated lipocalin in human urine (abbott, architect analyzer). refferent range for urine ngal is - ng/ml. on admission blood samples for bnp (brain natriuretic peptide) analysis were drawn and tested by architect bnp chemiluminescent microparticle immunoassay (cmia), abbott laboratory. results: the mean age of the patients (male= , female= ) was . years (sd . years). among them ( %) patients was diagnosed as a hf-pef (hf with preserved ejection fraction) while ( %) as a hf-ref (hf with reduced ejection fraction). mean bnp values was . pg/ml (sd . pg/ml) and mean lvef was . % (sd . %). mean urine ngal was . ng/ml (sd . ng/ml). we found significantly positive, but weak correlation among ngal and bnp only by pearson correlation test (r = . , p = . , wilcoxon signed rank test z = À . p < . ). conclusion: bnp levels are elevated in hf with reduced and preserved ejection fraction. urine ngal is not elevated in acute heart failure, but it is slightly positively correlated with serum bnp values. converging evidence implicates the intermediate and medial mesopallium (imm) of the domestic chick forebrain in memory for a visual imprinting stimulus. a number of learning-related changes have been found in plasma membrane and mitochondrial proteins of imm. for broader analysis of these changes we employed two-dimensional gel electrophoresis/mass spectrometry approach and identified differentially expressed proteins in membrane-mitochondrial fraction of the imm across chicks with different estimated levels of imprinting h after training. we further inquired whether the amounts of those proteins in the imm and a control region (posterior pole of the nidopallium, ppn) are correlated with memory for the imprinting stimulus. learning-related increase in the amounts of the following proteins was demonstrated in the left imm, but not in the right imm or left and right ppn: (i) membrane cognin;(ii) a protein resembling the p subunit of splicing factor sf ;(iii) voltage dependent anionic channel- ;(iv) dynamin- ; (v) heterogeneous nuclear ribonucleoprotein a /b . obtained results indicate that the molecular processes involved in learning and memory of imprinting cover a wide range of cellular activities, including stabilization of protein structures, increased mrna trafficking, synaptic vesicle recycling and specific changes in the mitochondrial proteome. the aim of this work is to study the substrate and inhibitory properties of uridine derivatives in the reactions catalyzed by e.coli up in order to shed some light on the substrate's conformation in the productive complex with the enzyme. we studied the e.coli up-catalyzed phosphorolysis of uridine and its derivatives modified in the heterocyclic base and the sugar moiety. the kinetic constants (km, ki, kcat ) of the phosphorolysis reaction of near uridine derivatives were determined. the combined kinetic (nnna, , ) and structural data (acta crystallogr., d , , ) provide clear evidence that up binds uridine in the most energetically unfavorable conformation, which, to the best of our knowledge, has no precedents in the enzymes of nucleic acid metabolism. this is possible due to multiple interactions between the substrate and the protein environment (active site residues) mainly through hydrogen bonds. these results are important for understanding the mechanism of action of this class of enzymes. an analysis of the conformations of nucleosides in solution and rotational barriers suggests that the energy difference between the ground state of uridine and uridine complexed with up may be high as - kj/mol. the binding in a high-energy conformation results in the weakening of the glycosidic bond. the observed conformation of uridine complexed with sulfate (mimetic of phosphate) may be very similar to its conformation in the transient state. until now, foxp (forkhead box p ) has been identified as a tumor suppressor in several correlation studies in breast cancer. although, foxp is defined as a transcriptional repressor that interacts with other transcription factors in various mechanistic studies, there is no study that explains its repressor functions in breast cancer biology. here we demonstrate the repressor function of foxp on nfat (nuclear factor of activated t cells) and the migratory effect of this repression in mda mb breast cancer cells. we performed co-immunoprecipitation experiments for the investigation of protein-protein interaction between two transcription factors. protein-protein interaction on dna was investigated with emsa and transcriptional effects of foxp on nfat, lusiferase reporter assay was performed. wound healing assay was used to analyse the effects of overexpression of foxp on tumor cell migration. our results showed that foxp has protein-protein interaction with nfat on dna and enhances breast cancer cell migration by repressing nfat transcriptional activity and foxp shows oncogenic function by regulating breast cancer cell motility. introduction: phosphodiesterase (pde ) is one of phosphodiesterase lead to hydrolyzing cgmp.the cgmp signaling pathway has an important role in proliferation of cells. previous studies showed pde was increased in cell lines cancers thus pde inhibitors can used as efficacious therapeutic option for treatment of cancers. the current study was to investigation the effect of hydroalcoholic achillea.wilhelmsii extract (hawe) on the pde gene expression and cgmp signaling in the mcf- er + and mda-mb- er À . methods and materials: the ed of the hawe on both cell lines were examined by using mtt viability test then the expression of pde and cgmp concentration were measured in timedependent manner (in the ed ) by real-time rt-pcr and colorimetric assay respectively. results: treatment with the hawe showed, lg/ml is ed for both cell lines and the hawe lead to reduction in pde mrna expression and evaluation of intracellular cgmp showed an increase pattern in the time-dependent manner. conclusion: our results showed that the hawe has anti-proliferative property in the mcf- and mda-mb- , cell lines of breast cancer through the cgmp pathway, these data suggested that the hawe can be potential source for the isolation of effective anti-proliferative molecules. keywords: achillea.wilhelmsii, breast cancer, anti-proliferative, phosphodiesterase, cgmp signaling pathway. outer membrane protein g (ompg) is a stable monomeric porin having -stranded beta barrel form from e.coli. its exact function is not fully understood; however, it allows the passage of molecules up to da in neutral ph but the pore is closed by going through a conformational change under ph . . as being monomeric and having ph-dependent gating characters, it is suitable for biosensor and targeted drug delivery applications. an attempt on ompg is to create a larger pore while its stability is undisturbed. ompg- s is obtained by adding amino acids to the primary chain in order to have a -stranded beta barrel porin. ompg- sl is formed by further adding amino acids to loop l and by replacing lysines with arginines. ompg- s and ompg- sl mutants are investigated by fourier transform infrared spectroscopy (ftir) and compared with ompg-wild type (wt) in terms of ph-dependent conformational changes and thermal stability. each mutant is prepared in na-phosphate buffer pd . / . and infrared spectra are recorded. further, temperature profiling are recorded for the range between to °c. results show that both mutants are responsive to ph changes. while turning the ph from acidic to neutral, beta sheet signals shift to lower wavenumbers showing difference in secondary structure, implying the existence of closed and open states. on the other hand, mutant proteins show structural differences compared with the wt protein. porins are known for their remarkable thermal stability. the mutans retain this character by having transition temperature of $ °c, although this is less than the wt transition at $ °c. in conclusion, two mutants show signs of open and closed states as ompg-wt and even if the mutants are less stable than ompg-wt. this study shows that the attempted alterations in ompg structure are successful in terms of ph-response but it needs improvement in terms of stability when necessary. nad is a key factor in the regulation of mitochondrial metabolism. besides its vital role as redox carrier, nad serves as substrate for protein adp-ribosylation and deacetylation, modifications which modulate enzyme activities in mitochondria. these functions depend on how nad levels are maintained in this organelle. in human cells, mitochondrial nad is segregated from the cytosolic pool and can be synthesized from nmn, which is probably imported into the matrix. here, we tested whether the nudix pyrophosphatase nudt participates in the regulation of the mitochondrial nad pool. this enzyme has a predicted nadh pyrophosphatase zinc ribbon domain and a mitochondrial targeting sequence at its n-terminus. however, it has not yet been functionally characterized. we overexpressed nudt endowed with a c-terminal flag-epitope in human cells. to evaluate changes in the mitochondrial nad concentration, we used a reporter system which includes the overexpression of the catalytic domain of poly(adpribose) polymerase (parp ) within the organelles (mitoparp). thereby mitochondrial nad is converted into protein-bound poly(adp-ribose) (par). the extent of par formation correlates with the mitochondrial nad availability and is detected by western blotting. our results established that nudt is indeed a mitochondrial protein, as it was localized exclusively to these organelles. moreover, when nudt was overexpressed along with the mitoparp detector system, a dramatic decrease of par was observed. the obtained results indicate that nudt is enzymatically active upon overexpression in the mitochondrial matrix and that it might cleave nad, thereby modulating its organellar level. however, at this point we cannot exclude the possibility of direct par cleavage by nudt . further characterization of nudt will define its substrate specificity and clarify its role in mitochondrial metabolism. the incidence of increase in colorectal cancer (crc) worldwide has become a major health problem. early diagnosis and treatment of crcs are of importance for improving survival. in the present study, it was aimed to investigate chemopreventive effect of rosmarinic acid and evaluate the angiogenesis process in azoxymethane (aom)-induced crc model. male sprague-dawley rats were randomly divided into a control group, aom-induced rat colorectal cancer group ( mg/kg body weight aom; ip, weekly for four weeks), and rosmarinic acid ( mg/kg body weight; oral, daily for four weeks)-treated group. in addition to the standart diet of the all groups . % peanut oil was added throughout the experiment. the all rats were sacrificed at the end of weeks. biochemical examinations were performed in rat plasma. histopathological adenocarcinoma rates were observed in . % of aom group. the incidence of adenocarcinoma was showed a reduction in the treatment group. significant increases in plasma tos and mcp- levels were found in the aom group compared to controls. these increases were reduced in the treatment groups but no significant. a significant increase was detected in tas levels in the treatment group when compared to the aom group. significant decreases in plasma adiponectin levels were found in the aom and the treatment groups compared to controls. in conclusion, treatment with rosmarinic acid reduced the occurrence of inflammation and was helped to maintain the oxidant-antioxidant balance in the model of aom-induced rat colon cancer. mitochondrial genome, while being strongly reduced in course of evolution, still codes for several proteins. the vast majority of them are components of the respiratory chain complexes. to produce these proteins, the system of mitochondrial translation is presented in the organelles, which is in common close to that in bacteria. translation initiation in bacterial cells is orchestrated by three protein factors called if , if and if . the orthologs of the two latter proteins are commonly found in mitochondria. however, mitochondrial if could not been identified in several groups of organisms, including s.cerevisiae, for a long time. recently we have shown that baker's yeast protein aim p possesses a function of mtif . however, the mitochondrial translation has not been stopped in the yeast strain without aim p which is surprising taking into account the fact that if is obligatory for the translation in bacterial systems. instead of blocking of mitochondrial protein synthesis in absence of aim p, we observed the translational imbalance: the synthesis rate of the complex v subunits was increased while the synthesis rate of the complex iv subunits was repressed. thus, in addition to its general role in translation initiation, aim p might specifically affect the biosynthesis of individual mitochondrial-encoded protein species. our genetic experiments have revealed that, indeed, aim p is almost indispensable for cox p synthesis, and that it affects the translation of cox mrna through its -utr, like classical mitochondrial translational activators. this is in accordance with our measurements of complex iv activity which is several times less in yeast lacking aim gene than in the wild-type. taken together, our results point on the multiple role of aim p in mitochondrial translation: in addition to its function as mitochondrial if , it specifically regulates the amount of complex iv subunits and its activity. p- . . - the circulating betatrophin and irisin levels in polycystic ovary syndrome patients with and without insulin resistance introduction: polycystic ovary syndrome (pcos) is the most common endocrine/metabolic disease in women around the world, characterized by oligo-or anovulation, polycystic ovary, and/or hyper-androgenism. insulin resistance (ir) and obesity are common findings in patients with pcos. irisin is a recently identified myokine secreted from skeletal muscle in response to physical activity. irisin has been postulated to induce the differentiation of white fat tissue into brown fat tissue. betatrophin is a currently discovered new hormone proposed to stimulate b-cell proliferation. in this study we investigated the levels of irisin and betatrophin in pcos patients. materials and methods: our study group was consisted of patients with pcos and healthy volunteers. patients group was divided into two subgroups according to presence of ir. (pcos+ir and pcos-ir). the oral glucose tolerance test (ogtt) and the homeostatic model assessment (homa-ir) were performed to assess glucose tolerance and insulin sensitivity. irisin and betatrophin levels were measured by elisa method. results: circulating irisin was significantly higher in the pco-s+ir subgroup than the control group (p < . ). circulating betatrophin was significantly lower in both patients subgroups than the control group (p < . ). there was no negative or positive correlation between irisin and betatrophin levels. discussion: these data suggest that irisin and betatrophin may act a role together in the ir mechanism in pcos patients. butyrylcholinesterase (bche) synthesized in liver has long been associated with hyperlipidemia, type diabetes and obesity. there are also reports on bche knockout mice becoming obese. the exact involvement of how bche interacts with lipids is still not clear. previously we displayed a correlation between leptin, waist circumference, fat mass and bche levels. recently, we have also shown that bche overexpression in hepg cells is regulated by alpha linoleic acid. as the next approach on the analysis of lipid metabolism and bche interaction, we considered the capability of bche to hydrolyze lipids. human serum bche was purified by subsequent deae-tris-acryl m and procainamide chromatography. the purified bche was utilized in a modified acid lipase assay with the acid lipase substrate -methylumbelliferyl palmitate ( -mu-palmitate). as the second alternative substrate trioleic acid was utilized. the triolein hydrolysis was measured by the nefa kit. verification that bche hydrolysis of these lipid substrates was not due to another esterase was done by iso-ompa inhibition studies. also, lectin binding studies with bche and rca were carried out to rule out non-specific esterase activity. using purified human serum bche and hepatic lipase as control enzyme we found that bche is able to hydrolyze the acid lipase substrate -methylumbelliferyl palmitate ( -mu-palmitate). we found that bche hydrolyses this molecule at ph rather better than at ph . . at ph values, purified human bche has a km value that was times bigger than that of human pancreatic lipase. with the bigger molecule the triolein, the difference between the km values of bche and pancreatic lipase was smaller. bche seems to hydrolyze triolein with an efficacy comparable to approximately % that of human pancreatic lipase. our results display that another function of bche may be its lipid hydrolyzing activity. p- . . - determination of regional reference ranges for erythropoietin with laboratory data mining serum erythropoietin (epo) levels are the main regulator factor of erythrocyte production and increase in response to hypoxia. our region is a location dominated by hypoxic conditions due to the high attitude. in this study we aimed to investigate the mean serum epo levels in the living conditions of our region. two hundred and eighty epo results from our laboratory data whose hemoglobin levels were normal were evaluated in the study. mean serum epo levels were analyzed via chemiluminescence method in beckman coulter dxi auto analyzer. the epo levels of samples was . ae . mul/ml (ranged between . and . ) mul/ml. when we performed ae sd for the studies population we determined normal serum epo levels were as . - . mul/ml. the upper limit determined by our results was % higher than that of determined by the manufacturer as . mul/ml and the lower limit determined by our results was % higher than that of determined by the manufacturer as . mul/ml. normal serum epo levels were considerable for our region and the upper and lower limits were higher than those of determined by the manufacturer. more detailed studies considering the physical properties of participants including a higher number participants are necessary. subclinical hypothyroidism is the precursor to hypothyroidism because it has a tendency to transform into hypothyroidism. subclinical hypothyroidism is considered one of the risk factors causing metabolic syndrome. metabolic syndrome can be characterized by plasma level of apelin released from adipocytes. in the present study, we aimed to measure serum apelin level of patients with subclinical hypothyroidism and compare them with serum apelin level from healthy individuals. our study group included patients diagnosed with subclinical hypothyroidism and healthy volunteers. serum samples were obtained from each participant for the measurement of apelin. these were then stored at À •c until the time of analysis. serum apelin concentrations were determined using an enzymelinked immunosorbent assay. the mean serum apelin levels of subclinical hypothyroidism and control groups were ng/l, control group ng/l respectively. there was no statistically significant difference in terms of the mean apelin levels between the groups (p > . ). apelin levels didn't show significant correlation with bmi (p > . ). in the present study, no significant difference of serum apelin level was observed between patients with subclinical hypothyroidism and healthy control subjects. however, the apelin levels were higher in the patients with subclinical hypothyroidism than in the control group. the possible relationship between thyroid hormones and apelins is critical to understanding the etiopathogenesis of metabolic disorders. the mitochondrial erv /mia import system does not impact cytosolic fe-s cluster protein maturation and iron regulation erv is a sulfhydryl oxidase that partners with the import receptor mia to import small cysteine-rich proteins into the mitochondrial intermembrane space. it has also been suggested that erv has an additional role in maturation of cytosolic fe-s cluster proteins and regulation of iron homeostasis in s. cerevisiae. however, these studies were performed on one particular erv mutant strain (erv - ) that we discovered has additional defects in glutathione (gsh) metabolism. since gsh is required for iron regulation and cytosolic fe-s cluster assembly, this complicates our understanding of erv s role in these processes. we discovered that the erv - strain originally tested for fe-s cluster defects was the only strain to exhibit defects in the cytosolic fe-s enzymes. mitochondrial and cytosolic fe-s protein activities in the other erv and mia mutants tested were similar to the wt control. in addition, while all the erv and mia mutants tested exhibit temperature-dependent defects in mia oxidation, only the erv - strain has significantly reduced gsh levels and more oxidized gsh: gssg redox state. we determined that the cause of gsh depletion in the erv - strain is an additional mutation in the gene encoding the glutathione biosynthesis enzyme (gsh ) that compromises gsh protein folding and/or stability. to address whether gsh deficiency in the erv - mutant is the underlying cause for the cytosolic fe-s cluster defects and iron misregulation for this strain, we measured fe-s protein activity, iron-regulated gene expression, and iron accumulation in erv and mia mutant strains. only the erv - strain exhibited iron misregulation and accumulation of mitochondrial iron, while exogenous gsh rescued these defects. these results demonstrate that the defects in cytosolic fe-s enzymes and iron homeostasis in erv - are due to gsh depletion and neither erv nor mia play significant roles in cytosolic fe-s cluster assembly and iron homeostasis. human c-peptide is a amino acid polypeptide, which is secreted into blood from b-cells in the pancreas where pro-insulin undergoes a post translational modification and cleaved into insulin and c-peptide. human c-peptide concentrations in blood plasma and urine reflect the level of insulin resistance associated b-cell function and can point out insulin secretory failure. the reference intervals in blood plasma and urine are . - . ng/ml and - ng/ml respectively. c-peptide measurement in urine and plasma provides a guide for therapy in diabetes. this study describes a method for the development and validation of picaa (peptide impurity corrected amino acid analysis) method for the determination of the purity of the human c-peptide which could be used as a reference material to measure cpeptide concentrations in plasma. two different methods were performed for the picaa; aaa-id-ms/ms for quantification of constituent amino acids following hydrolysis of the material and rp-hplc-esi-tof ms for determination of the peptide related impurities. the result of the aaa id ms/ms method was corrected for the amino acids originating from the impurities. id ms/ms-aaa was performed with zivak Ò hplc and zivak Ò tandem gold triple quadrupole ms equipped with a phenomenex ez:faast l aaa column ( mm i.d). the mobile phase was composed of, a: mm ammonium formate (af) in water, b: mm af in acetonitrile (acn). the intact peptide analysis was performed by a hitachi lachrome elite hplc and bruker microtof-q mass spectrometer equipped with a capcell pak mg-ii c column ( mm i.d., mm particle size). the purity of the synthetic c-peptide was determined by picaa analysis and related uncertainty was calculated. traceability to si was established using the amino acid standards of which the purity was determined by tub _ itak ume using qnmr analysis. picaa is a simpler alternative to the full mass balance approach which requires large quantities of the peptide material. p- . . - heat shock proteins: complementary therapies in brain tumors with viscum album e. onay-ucar, s. n. biltekin istanbul university, faculty of science, department of molecular biology and genetics, vezneciler, istanbul, turkey cancer is one of the lethal diseases in the world. different cancer types possess overexpressed hsps levels. viscum album extracts with their anticancer and antioxidant properties are being used in cancer therapies. biochemical composition of this plant is known to vary its features depending on the host trees and time of harvest. in our previous study, it has been found that v.album inhibited hsp expression and induced caspase-dependent apoptosis in c rat gliomas. the aim of the current study is to find out whether different v.album extracts have different effects on hsps expression level and apoptosis in c glioma cell line or not. in this study, three different extracts of v.album were compared for their potential inhibition effects on hsps. the cytotoxic effects of extracts have been determined via mtt test. different experiment groups were set up subjected to heat shock and/or incubated without any heat shock application. overexpression of hsps was induced by heat shock at °c for h in c cells. expression levels of hsps were determined by western blot analysis. the apoptosis inducing effect was also evaluated via caspase- activation in c glioma cells. pretreatment of the cells with non-toxic dose ( lg/ml) of v.album extracts prior to heat shock, reduced significantly the expression levels of hsps. similarly, pretreatment with the extracts prior to heat shock increased apoptosis via caspase- activation in c glioma cells. these results will be utilized in the determination of the relation between extract composition and stress protein expressions. these results suggest that different extracts of v.album are able to down regulate expression of hsps, and induce apoptosis. this warrants further exploration as a potential resource of bioactive compounds that can be used in cancer therapy. future studies targeting hsps for the development of chemosensitizers may help improve the treatment of cancer in combinational therapy. biological drugs (biologics) are the fastest-growing category of therapeutics among those approved by the agencies for drugs regulation. most biologics are proteins designed for parenteral use. however, proteins are characterized by poor pharmacokinetic and safety profiles. peg-coating (poly-ethylene glycol coating) of biologics provides several benefits, including an increased half-life related to reduced renal clearance, an increased stability to degradation, and a reduced immunogenic/antigenic response. preservation of the three-dimensional structure and activity of the pegylated form is a strict requirement for human use. the recombinant proteins used for this studies (as-sod, superoxide dismutase; mmp , matrix metalloproteases ; ansii, l-asparaginase ii) were cloned and then over-expressed in escherichia coli. pegylation reactions were performed using commercial reagents. all the protein samples were purified and analyzed by solution and solid-state nmr (fields from mhz to mhz). we developed new protocols to prepare samples of pegylated proteins, demonstrating that solid-state nmr spectra of exceptionally good quality can be obtained for pegylated proteins in the sedimented state (obtained by either ultracentrifugation or rehydration of freeze-dried samples); surprisingly, sedimentation of pegylated proteins to this end has never been attempted. the spectral quality is comparable toor better thanthat of the corresponding crystalline samples. the excellent quality of the solid-state nmr spectra would make it possible to perform extensive resonance assignment and even a conventional full structure determination of biologics. the proposed method is based on the comparison of a standard twodimensional solid-state nmr spectrum of the sedimented pegylated protein with that of the crystalline state of the native proteinfor which the x-ray structure is available. all eukaryotic creatures hereditarily have natural defense mechanisms and are protected from the infections with this defense mechanism. antimicrobial peptides (amp) contain - amino acid content, are positively charged with amphipathic feature. the antimicrobial activities of amps are thought to be depended on the microbiocidal effects by binding to the surface of microorganisms and creating pores in their membranes. defensins are both effector and mediator small antimicrobial peptides of the immune system. these peptides in cationic and amphipathic structure have broad spectrum antibacterial, antifungal and antiviral features. defensins regulate the innate and acquired immune systems by suppressing proinflammatory responses during infection. mammals have three structural subfamilies of defensins. these show differences according to the trisulfide arrays in their structure and are classified as a,b, h defensins. human beings have tissue-specific six functional a defensins. human hnp- and hnp- encoded by defa , defa and defa genes are firstly expressed in neutrophils. human hdp and hdp encoded by defa and defa are firstly expressed in paneth cells in the intestines and play important role in the defense and homeostasis. human beings have many pseudogenes such as defap and deftp in addition to these functional genes. according to literature data, defensins play an important role in defense against microbial placements on mucosal surfaces. in addition, the antimicrobial spectra of defensins include gram negative and gram positive bacteria, fungi and viruses. in addition to their antimicrobial efficiency, they can accelerate the wound healing due to their mitogenic effects on epithelium cells and fibroblasts. bile salt hydrolase (bsh) enzyme catalyzes the hydrolysis of glycine and/or taurine-conjugated bile salts into amino acid residues and the free bile acids that reduce cholesterol. however, some intestinal bacteria have an excessive deconjugation of tauro-conjugated bile salts and production of secondary bile acid having potential harmful side effects to the host. the catalytic mechanism and substrate preference of such bsh enzyme is not clear. in this study, bsh gene from lactobacillus plantarum gd strain was cloned, expressed, characterized in escherichia coli blr(de ) strain, and then val- and phe- amino acids, supposed to be responsible for substrate preference, were substituted for met- and ile- amino acids respectively by site directed mutagenesis. the hydrolysis activities and stability of the mutant recombinant bsh (mrbsh) enzymes were examined along with six different bile acids by ninhydrin assay and sds-page respectively. ninhydrin test results indicated that wild-type recombinant bsh (wrbsh) hydrolyzed six major human bile salts with an apparent preference towards glycine-conjugated to tauro-conjugated bile salts. however, the activities of mrbsh/phe ile enzyme are %, %, %, %, % and % of the activity of wrbsh against to glycocholic acid (gca), glycodeoxycholic acid (gdca), glycochenodeoxycholic acid (gcdca), taurocholic acid (tca), taurodeoxycholic acid (tdca) and taurochenodexycholic acid (tcdca) respectively. the activities of val met mrbsh enzyme are %, %, %, %, % and % of wrbsh against to gca, gdca, gcdca, tca, tdca and tcdca respectively. our findings support the suggestion that bsh enzymes recognize their substrates predominantly at the amino acid moieties and not at the cholate moieties. however, further pcr-based site-directed mutagenesis and structure-driven computational and theoretical approaches are required for the precise determination of their substrate specificities and the selection of probiotic bacteria. we deposited bacteriorhodopsin in purple membranes under applied electrical field onto ito (indium tin oxide) support. purple membranes film, highly oriented in one direction, was placed between two ito electrodes. we studied dependence of electrical properties of these films on light illumination. we argue that this setup can be used for functional studies of microbial rhodopsins. in opposite to already published results where this system was used as a photocondensor for studying functional properties of bacteriorhodopsin, we studied electric properties of such systems and we found strong light dependence of resistivity of bacteriorhodopsin in purple membranes films. optogenetics is already used in study of neuronal cells cooperation in vitro and in vivo by means of microbial rhodopsinsion pumps and channels incorporated in membranes of neurons changing their electrical potential while receiving a light quantum by laser or led source. best perspectives optogenetics will give after successful transfer to medical applications, such as the treatment of blindness, treatment of disorders like parkinson's disease etc. but to achieve these we need a broad set of tools, optogenetics tools, highly specialized to solve specific problems of neurophysiology. to the creation of such tools our work is dedicated. new optogenetic tools can be made by mutations in existing ones altering their properties (mainly spectral characteristics, selectivity and conductivity) or some promising mutations in conserved residues can be found in existing organisms. a halophilic archaeon halosimplex carlsbadens is a host of protein of our interest. according to the theoretical data based on the alignment with br and the d structure model of this novel protein, we suppose this protein functions like the light-driven h+ pump: all the key residues are the same or at worst have the similar properties, except one in the position leucine instead of the aspartic acid. a gram-positive bacteria deinococcus-thermus phylum syntheses rhodopsin with substitution of this aspartic acid to alanine. sphingomonas paucimobilis has rhodopsin where aspardic acid in position is changed to serine residue. and one yet uncharacterised guillardia theta rhodopsin even has the same as br motif (d , t , and d ) but according to alignment is closer to chr even the last one motif is e , t , n . it is expected that all of them will show us new properties. though the further experimental data are essential. the work is supported by rsf - - . evaluation of some thymus proteins in patients with crimean congo hemorrhagic fever i. b€ ut€ un , s. sahin , f. duygu university of gaziosmanpasa, department of biochemistry, tokat, turkey, oncology education and reasearch center, ankara, turkey crimean congo hemorrhagic fever (cchf) is a tick-borne viral zoonotic disease. it has a high fatal rate (% - ). tokat is one of the cities having the most reported cchf cases, in turkey. clinical presentation of the disease varies widely among patients. thymic peptides are small molecules synthesized by thymic epithelial cells. they play role in the immune response, as well as anti-inflammatory process. fourty patients referring to the hospital with tick-contact history and/or presenting clinical manifestations consistent withcchf and with positive pcr results for cchf virus in blood samples were included to the study. the wbc and platelet values at application and before the patients were discharged were recorded. the healthy control group consisted of age and gender matched healthy volunteer adults free of any chronic disease. thymosin alpha (ta ), thymuline and thymosin beta (tb ) were studied by the elisa method in this study. biochemical parameters were also analysed. ast and alt values were significantly higher (p < . ) and plt and wbc levels were significantly lower in the cchf group (p < . ). levels of tf, ta and tb were found to be significantly higher in cchf (p < . ). there was no mortality during the study period. duration of hospitalization was . ae . days. levels of tb were significantly correlated with duration of hospitalization (r= À . , p = . ). alt levels were significantly correlated with tf levels (r = . , p = . ). patients received ffp and apheresis for the supportive treatment, while patients received only ffp and patients got only apheresis. patients did not get any of these blood products. there was not a statistically significant differences in thymus peptides among these treatment groups (p > . ). we report survived cchf patients with elevated thymic peptides. pathogenesis of cchf has many points to be highlighted. thymic peptides may play role in the clinical situation of the patients with the disease. the effect of methocarbamol on the peroxiadse activity of human erythrocyte hemoglobin hemoglobin is released to blood circulation, after red blood cells lysis. it is carried in circulation by binding to haptoglobin. in normal persons, no free hemoglobin is observed in the blood, because most of hemoglobin is in the form of haptoglobin complex. in some diseases that are accompanied by hemolysis, the amount of released hemoglobin is higher than its complementary haptoglobin. as a result, free hemoglobin appears in the blood, which is a toxic compound for these patients. free hemoglobin has been showed to have peroxidase activity and considered a pseudoenzyme. in this research, the effect of methocarbamol on the peroxidase activity of human hemoglobin was studied. our results showed that the drug inhibited the pseudoenzyme by un-competitive inhibition. both k m and v max decreased by increasing the drug concentration. k i and ic values were determined as and mm, respectively. molecular docking results showed that methocarbamol did not attach to heme group directly. a hydrogen bond connected nh of carbamate group of methocarbamol to the carboxyl group of asp side chain. two other hydrogen bonds could be also observed between hydroxyl group of the drug and ser and ser residues of the pseudoenzyme. p- . . - dca reduces viability and down regulates mapk protein activations in human malignant mesothelioma cells and pericardium. microarray analyze results performed in mm patients revealed that one of the most prominent changes is upregulation of many genes involved in glycolysis and the krebs cycle. dichloroacetate (dca) is an inhibitor of pyruvate dehydrogenase kinase (pdk) that enhances the oxidative activity of cells by activating pyruvate dehydrogenase (pdh) in mitochondria. dca has shown as a promising anti-neoplastic agent that re-sensitizes cancer cells to apoptosis. the aim of this study is to elucidate the coupling between pdk inhibition and mm cell proliferation and cell cycle. human malignant mesothelioma (spc ) cell line was used as a model for dca treatments. cell viability was measured by mts assay; mapk protein activations and expressions were assessed by western blotting; cell cycle profile was analyzed by flow cytometry. statistical analysis was performed by utilizing one-way anova test. results showed that dca reduced viability of spc cells in a concentration and time dependent manner. protein analysis indicated that mapk pathway was down regulated at concentrations greater than mm. moreover, primary cell cycle analysis has indicated arrestment at g /m phase in hours. our findings corroborate with recent reports where dca treatments resulted in reduction of viability and g /g and g / m arrest in other cell lines. abnormalities in mapk signalling play a critical role in the progression of cancer. here, we showed for the first time that dca decreased mapk activation in h. our results suggest that dca is an anti-prolifertive agents for mm cells in vitro. however, it requres extra analysis with other mesothelial cells. future study will focus on investigating relation between mapk and mitochondrial apoptosis. adrenomedullin (adm) is a vasodilator peptide consisting of amino acids. adm is synthesized in many tissues. and is a biologically active peptide that has various effects including vasodilatation, the regulation of vascular endothelial function and adjusting adipogenesis. hypoxia inducible factor alpha (hif a) is a subunit of a heterodimeric transcription factor hypoxia inducible factor . it is the master transcriptional regulator of cellular and developmental response to hypoxia. the dysregulation and overexpression of hif a by either hypoxia or genetic alternations have been heavily implicated in cancer biology as well as a number of other pathophysiologies. in our research, the adm and hif -a levels in heart, kidney and lung tissues of rats were investigated in control, hypoxia, control+adm and hypoxia+adm groups. rats in hypoxia groups were provided hypoxic environment containing of - % oxygen and - % nitrogen for week. rats in adm groups were injected intraperitoneally in a dose of . nmol/kg for four days before the collection of the tissues. the control group was oxygenated with normal air. the control and treatment groups were formed from - animals and adm, hif -a levels were measured in taken tissues with immunoassay method. the aim of this study was to investigate the reaction of the organism when exposed to hypoxic conditions and the effect of adm over hif -a level. adm levels and hif -a in heart tissue were found decreased in hypoxia group, and adm levels increased in hipoxia+adm group. hif -a levels decreased in hypoxi+adm group. adm levels in liver tissue were found decreased in hipoxia and control+adm groups than control group. hif -a levels were higher in control+adm group. adm has a role in angiogenic process, and our experiment showed that adm reacts earlier than hif -a, and affects its synthesis. organism increases its vascularization as a reaction to hypoxic condition, and adm treatment may provide a rapid adjustment. p- . . - covalent conjugation and characterization of immunogenic protein of toxoplasma gondii and polyacryclic acid as vaccine candidate r. c ß akir koc ß yildiz technical university, department of bioengineering, istanbul, turkey toxoplasmosis is a major medical and veterinary disease caused by toxoplasma gondii which infect approximately half of the world's population. this infectious disease especially gains importance in pregnant women and immunodeficient individuals. also t. gondii infection has economic importance. however, there are only one attenuated-live t. gondii vaccine for veterinary uses and no vaccine against t. gondii is available for humans. therefore development of an effective vaccine would be extremely valuable for preventing disease in human and veterinary medicine. subunit vaccines are very attractive vaccine candidates but there is low antigenicity problem when they are used alone. polymers themselves don't stimulate immune response while they used with antigenic structure of various infective agents enhance immune response because when proteins are covalently conjugated with hydrophilic polymers, ( ) their circulatory-lives and stability (in different ph and temperature values) enhance ( ) binding to proteases and clearance by the reticuloendothelial-system decreases. in this study, immunogenic protein of t.gondii and polyacrylic acid with immune stimulant properties was covalently conjugated and conjugation was demonstrated by size-exclusion chromatography (sec) and fluorescence spectroscopy. it is significant to detect time of death in case of a sudden death for medical and legal concerns. there is no known method that can be used for post mortem time detection. based on this deficiency pmi detection in narrow time frame is a big problem. in this study, we aimed to investigate and determine timedependent expressional changes of apoptotic markers by western blot technique. postmortem skeletal muscle were analyzed hour periods in first -hour after death. nd and rd -hour periods were statistically significant (p < . ). keywords: post mortem interval, time of death, apoptosis. hyaluronidases are excessively found in nature and involved in numerous biological functions. hyaluronidases primarily degrade hyaluronic acid (ha) and have significant role in fertilization during acrosomal reactions. therefore, the measurement of hyaluronidase enzyme activity may provide valuable information about acrosomal function and the fertilizing ability of the sperm. the aim of this study was to investigate the semen hyaluronidase enzyme activity changes among four different sheep breeds (akkaraman, suffolk, merino, and kıvırcık). in this research, ten ram testis tissues from each sheep breed, a total of , were cut and collected on ice. ovine testicular hyaluronidase of four different sheep breeds was purified from a crude ammonium sulfate-precipitated fraction of an extract of ram testis. the semen hyaluronidase enzyme activity differences between the sheep breeds were examined by spectrophotometrically monitoring the appearance of ha at nm. analysis of variance test was used to examine the possible mean differences among the four different sheep breeds. the observed mean differences in enzyme units for kıvırcık, suffolk, akkaraman, and merino were as follows . , . , . , and . , respectively. the observed mean differences in absorbance values for kıvırcık, suffolk, akkaraman, and merino were as follows . , . , . , and . , respectively. the results showed that the observed mean differences in enzyme units and absorbance values among the four different sheep breeds were not statistically significant. despite that, in average kıvırcık had higher values for the activity of each sample and yet it had the smallest values for standard deviation. therefore, in order to achieve higher enzyme activity and more homogenous samples kıvırcık breed should be preferred. what is extra to learn from protein drying measurements? hydrations of soluble proteins are crucial for their functionality. therefore elucidating the details of protein hydration is still of interest in the proteins' action mechanisms. this is the motivation of the present study. in order to study protein hydration, changing concentrations of the well-studied serum albumin protein was measured with the spectroscopic techniques like uv-vis and ft-ir spectroscopy. spectral data is analysed and calculations were performed on the data to extract the relevant changes in the protein. experimental parameters' variation in association with the spectral changes implies the involvement of protein structure and hydrogen bonding in the drying process. the protein's reactions may not be merely a feature of the protein structure in the common sense but it could be related directly to the protein hydration states as well. this is understandable since it is already known that enzymatic proteins lose their functionality when they are dried while this drying may or may not involve dramatic structural changes. on the other hand, here it is claimed that the role of water in gaining the functionality that was lost in the dried state is not just about enhanced diffusion processes and the dynamicity but could be related to the functionality of water in the energy transfer processes as well. investigating the cellular effects of the aldoketo reductases akr b and akr b in hct- colon cancer cells b. taskoparan, e. g. seza, m. s. ceyhan, s. banerjee middle east technical university, ankara, turkey aldo-keto reductases (akr) are nad(p)h dependent oxidoreductases are best characterized as glucose reducing agents, and have been implicated in diabetic pathophysiology. increased expression of akr has been associated with tumors of lung, breast, prostate, cervix, ovarian and colon. two members of the akr superfamily that have been associated with different cancer types are akr b ; aldo-keto reductase family , member b , and akr b ; aldo-keto reductase family , member b . both are -kda cytosolic reductases that are similar in both amino acid sequence identity ( %) and tertiary structure with the (a/b) barrel topology. while hct- , a colorectal cancer cell line, cells expresses akr b robustly, there is no expression of akr b . in this study, we have stably knocked down akr b through shrna technology and overexpressed akr b in hct- cells. comparisons were made with a known akr inhibitor sorbinil. with the knock down of akr b , we have observed reduced cellular proliferation, enhanced apoptosis, delay in cell cycle progression, reduced expression of mitogenic proteins and a decrease in activation of the inflammatory transcription factor nuclear factor kappa b (nf-kappab). interestingly, although akr b overexpression did not affect cell proliferation, apoptosis or cell cycle, some effect was observed with nf-kb signaling. our data indicate that, although closely related, akr b and akr b have very different contributions towards signaling pathways in colorectal cancer. comparison of different nisin quantification methods and optimization of nisin production by lactococcus lactis z. girgin ersoy, g. demir, m. f. cesur, s. tunca gedik gebze technical university, kocaeli, turkey nisin, which is produced by certain strains of lactococcus lactis, is the only bacteriocin approved by world health organization (who) as a food additive. it prevents the growth of foodborne bacteria which cause food spoilage. nisin research and applications necessitates developing an accurate and reproducible method for its quantification. the agar diffusion bioassay is the most widely used method for quantifying nisin, although it has limitations especially diffusion-related difficulties of the active substance. in the present study, "agar diffusion bioassay", "enumeration of colony forming units", "colorimetric assay" and "flow cytometry" methods were compared with each other to determine antibacterial activity of nisin on micrococcus luteus. moreover, this study also covers the results about the effect of different cultural conditions to optimize nisin production by l. lactis. galactose, lactose and their combination in m medium (ph ) boosted nisin production at °c, as the addition of . lg/ml hemin into the fermentation broth. to our knowledge, this is the first study showing the usage of "flow cytometry" method to determine nisin activity of fermentation broth filtrates. p- . . - coronaviral nucleocapsid protein is an antiviral target for drug development institute of genomics and bioinformatics, national chung hsing university, taichung, taiwan between and , the severe acute respiratory syndrome (sars)-cov caused a worldwide epidemic and had a significant economic impact in the countries affected by the outbreak. recently, the middle east respiratory syndrome human coronavirus (mers-cov) was found in patients with severe acute respiratory tract infections in the middle east and south korea. as is true for all coronavirus infections, there are no efficacious therapies currently available against coronaviral diseases, making the development of anti-coronavirus compounds a priority. the cov genome consists of positive-sense, single-stranded rna approximately kb, and it contains several genes encoding several structural and non-structural proteins that are required for progeny virion production with a conserved order. the n proteins exist in the center of the viral particle and represent a helical structure complex. nucleocapsid protein is most abundant structural protein of covs, binds the viral rna genome to form the virion core, leading to the formation of a ribonucleoprotein (rnp) complex or to a long helical nucleocapsid structure, that is important for maintaining the rna in an ordered conformation for replication and transcription. the cov n protein is also involved in the regulation of cellular processes, such as gene transcription, interferon inhibition, actin reorganization, host cell cycle progression, and apoptosis. two strategies to inhibit oligomeric n protein function have been reported. the first strategy is to discover antiviral agents that target the rna-binding site. the second one is to impair normal n protein function by interfering with monomer-oligomer equilibrium. our recent studies suggest that n proteins in infections caused by coronaviruses will be useful antiviral drug targets because they serve many critical functions during the viral life cycle. post-translational modification of vascular endothelial growth factor (vegf) in colon cancer cells s. tunc ßer, e. solel, s. banerjee middle east technical university, ankara, turkey vascular endothelial growth factor a (vegf-a), commonly referred as vegf, is a potent secreted mitogen crucial for tumor initiation and progression. the gene for vegf is translated into a number of splice isoforms that lead to , , and amino acid proteins, with different receptor-binding and matrixbinding properties. in the present study, we discuss the functional significance of post-translational modification/processing of vegf isoform in hct- colon cancer cells. we also focus on the role of calcium in the post-translational modification of vegf . we show that vegf undergoes n-linked glycosylation in hct- cells. perturbation of cellular calcium may affect vegf driven malignant phenotypes. p- . . - novel methods for modulating the activity of bcl family proteins in apoptosis p. rowell, j. miles, a. wilson, t. edwards apoptosis, also known as programmed cell death, is an essential cellular process, but is implicated in several human diseases, including diabetes and cancer, when it is up-or down-regulated respectively. bcl- family proteins are major players in the control of intrinsic, or mitochondrial apoptosis; they respond to intracellular stress signals, function through protein-protein interactions and converge on the mitochondrial outer membrane to cause membrane permeabilisation, release of cytotoxic molecules, and initiation of an apoptotic cascade that leads to cellular demise. our work aims to identify molecules able to bind and modulate the activity of several key players in the bcl- family, including the pro-survival members bcl- , bcl xl and mcl , and the death promoting family member bax. adhirons, novel non-antibody peptide display scaffolds developed at the university of leeds, have been used to construct a phage display library containing over clones, and form a key part of the strategy to identify such molecular modulators. adhirons able to selectively bind individual bcl- family members have been identified, in vitro assays carried out to test for modulatory activity, and xray crystallography used to elucidate details of how they interact with their target proteins. more recently, studies have been carried out to identify adhirons able to target multiple bcl- family members, with the aim of selectively inhibiting defined groups of proteins in cells. this work provides opportunities to differentiate the activities carried out by different bcl- family proteins in apoptosis, enabling us to better understand how their dysregulation contributes to human disease. biophysical and evolutionary study of the structural flexibility of adp-dependent sugar kinases from mesophilic and psychrophilic archaea r. zamora , v. castro-fern andez , c. a. ramirez-sarmiento , e. a. komives , v. guixe facultad de ciencias, universidad de chile, santiago, chile, department of chemistry and biochemistry, university of california, san diego, united states of america the capability of extremophiles microorganisms to live at low temperatures is mainly attributed to the high structural flexibility of its enzymes. several sequence and structure features have been associated to a high structural flexibility that enables metabolic processes to occur at low temperatures. during evolution, the general mechanism adopted by these enzymes has been to reduce the free energy of the transition state rather than the michaelis constant, k m . increased structural flexibility and decreased affinity for its substrates in psychrophilic enzymes is compensated by an increase in the catalytic rate, k cat . few psychrophilic enzymes have been reported to performance the optimization of their catalytic efficiency (k cat /k m ) by decreasing k m values. we use the adp-dependent kinase sugar family of archaea as a model, to identify particular structure and sequence features of a psychrophilic enzyme that would make this enzyme more flexible than their thermostable homologues. we characterize the bifunctional psychrophilic enzyme phosphofructokinase/glucokinase from methanococcoides burtonii (mbpfk-gk) and the bifunctional mesophilic enzyme phosphofructokinase/glucokinase from methanococcus maripaludis (mmpfk-gk) by spectroscopic, biophysical and computational techniques. the comparison showed that the absence of two ion pairs is primarily responsible for the increased structural flexibility accounted in the psychrophilic model. this increase in structural flexibility is reflected in the exponential increase in the k m values with temperature. additionally, we reconstruct the sequences of all ancestral enzymes between the current enzymes and their last common ancestor, which was used to trace the occurrence of these electrostatic interactions during evolution in the adp-dependent sugar kinase family. our results suggest that electrostatic interactions are a dominant feature in the transition from psychrophilic to thermophilic environments. fondecyt . elucidating the domain swapping mechanism of the forkhead domain of human foxp fox transcription factors control gene transcription during key processes, such as embryogenesis and immunity, and feature a conserved dna-binding domain known as forkhead. while most forkhead domains are monomeric, solved structures of members from the p subfamily (foxp) show that they can oligomerize by domain swapping (ds), a mechanism where protein segments are exchanged between subunits leading to an intertwined dimer. the biological relevance of ds in foxp has been stressed by disease-causing mutations that impair this process. however, for many proteins ds takes days to occur and requires global protein unfolding. thus, the current mechanism impedes a conciliation of the occurrence of ds of foxp in a biological context. here, we elucidate the biological feasibility of this process by biophysically characterizing the ds mechanism of the forkhead domain of foxp using size exclusion chromatography (sec), circular dichroism, and hydrogen-deuterium exchange mass spectrometry (hdxms). our results show that ds of foxp occurs at micromolar protein concentrations, within hours and is energetically favored. remarkably, dimeric foxp follows a threestate n « i « u folding mechanism, where dimer dissociation into a monomeric intermediate (i) precedes protein unfolding, in contrast to other ds proteins. using sec and hdxms, we show that the i state of foxp largely resembles the native state, but has a larger hydrodynamic radius and a higher deuterium uptake in regions that maintain the compact monomer, suggesting that the i state is an 'open' conformation en route of ds. finally, we compared the local flexibility of the dimer and monomer of foxp , showing that only the hinge region connecting ds segments exhibits different deuteration rates. our results show that ds in foxp follows an unusual threestate folding mechanism that proceeds through transient structural changes rather than needing protein unfolding as in most ds proteins. (fondecyt , ). p- . . - the sustained release of growth factor proteins following their implantation in tissue engineering j. jang bone tissue engineering has become a promising approach for bone regeneration. however, insufficient vascularization during bone regeneration, particularly with large bone defects, results in poor and unsustainable bone formation due to central necrosis. therefore, vascularization following implantation in vivo is essential to the successful formation of new bone tissue. we evaluated the release profile of vegf from bgs using a novel fluorescence-based retention assay, which revealed that vegf loaded on bgs can be released in a sustained manner without an initial burst (near zero-order cumulative release) with a controlled release rate of . % per week for up to weeks. in contrast, an elisa-based release assay showed vegf to have an early burst-release profile for the first week. however, the biological activity of vegf released from the bgs was preserved over the -week release period, which is consistent with the sustainedrelease profile observed in the fluorescence-based retention assay. we developed a novel fluorescence-based retention assay to evaluate the release of vegf from bgs. this fluorescence-based retention assay, which detects the vegf that remains on bgs, reveals that vegf loaded on bgs can be released in a sustained manner, with a minimal initial burst, for up to weeks. these results indicate that the sustained biological activity of the vegf released from bgs over the full -week period promotes bone regeneration, and suggest its potential use for bone tissue engineering. irisin is a recently discovered myokine which regulates energy metabolism and is associated overweight. we aimed to evaluate serum irisin levels in the patients with morbid obesity. a total of sixty patients with morbidly obese and thirty healthy control subjects were included in this study. all participants were measured body weight and height, the lipid profile, and plasma glucose, hba c, insulin and irisin levels. irisin levels were measured by elisa method. serum irisin levels were significantly lower in morbidly obese patients than healthy controls (p < . ). there was no statistically significant difference in terms of age or gender. serum irisin was negatively correlated with bmi, insulin levels, and homa-ir (p = . , p = . , p = . , respectively). our study revealed lower irisin levels in morbidly obese patients with respect to control subjects. the lower irisin levels observed in morbidly obese patients might suggest a loss of browning of subcutaneous adipose tissues. p- . . - pka inhibition restores adenosine uptake in renal tubular epithelial cells under high d-glucose conditions w. garrido, j. catal an, s. alarc on, r. san mart ın universidad austral de chile, valdivia, chile introduction: diabetic nephropathy (dn) is the leading a cause of end-stage renal failure whose pathogenesis must to be elucidated. the progression of dn has been associated with elevated levels of adenosine. extracellular adenosine availability is regulated by the activity of the equilibrative nucleoside transporters (ents). due to the ents have putative sites of phosphorylation our objective was to evaluate the role of pka and ck kinases on ents activity. methods: adenosine uptake ( lm adenosine, s, °c) was assayed in hk cells preincubated with mm or mm d-glucose for h and exposed to lm -br camp, lmh or lm tbb for h. plasma membrane and intracellular proteins were fractionated by the biotinylation method and ent and ent contents were quantified by western blot. results: high d-glucose in hk cells inhibited the uptake of adenosine. this effect was reversed using a pka inhibitor (h ) through an increased ent uptake activity. we noticed this pka inhibitor did not regulate the plasma membrane localization of ent or ent under normal d-glucose ( mm) or high d-glucose conditions ( mm). also, we saw that tbb (ck inhibitor) decreased the activity of ent and ent under normal glucose conditions, decreasing the localization of ent at cell surface, while the membrane localization of ent decreases under the effect of tbb and high d-glucose conditions. conclusions: pka inhibition reversed the effect of high d-glucose, increasing the uptake of adenosine mediated by ent . this could be a new target for the restoration of adenosine levels in dn. relation between serum lipo (a), plasma fibrinogen, red cell distribution width and mean platelet volume in healthy adult men the aim of this study was to investigate the relationship between the serum lipo (a) and plasma fibrinogen, red cell distribution width (rdw) and mean platelet volume (mpv) in healthy adult men. for this purpose, healthy adult men have normal physical examination and laboratory findings and not use any drug were included to the study. serum lipo (a) levels and hematologic parameters (fibrinogen, rdw-sd and mpv) were measured by autoanalyzer and commercial kits. the mean of the age of the persons was . ; body mass index was . ; serum lipo (a) level was . and plasma fibrinogen level was . . there was significant positive correlation between the serum lipo (a) and plasma fibrinogen levels (r = . ; p = . ), significant positive correlation between the serum lipo (a) and rdw-sd (r = . ; p = . ) and significant negative correlation between lipo (a) and mpv (r= À . ; p = . ). the plasma fibrinogen and the serum lipo (a) levels have been known as the risk factors for cad (coronary artery disease) increase together in healthy adult men. similar findings have been reported in cad patients. it has reported that elevated rdw is associated with intracoronary thrombotic burden and may be associated with the severity and instability of acute myocardial infarction. in addition, mpv is predictor of severe atherosclerosis and may be used for the prediction and identification of cardiac risks in cad patients. our findings show that elevated rdw and decreased mpv may predict to increased risk of cad in the future, in healthy adult men. follicular fluid is rich in peptides, which significantly influence the growing oocyte. due to existence of a link between kisspeptin (metastin) cells and gonadal steroids kisspeptin might manipulate the gonadotropin axis and folliculogenesis. in this context, the study was planned to investigate for the first time that the follicular fluid (ff) and serum concentration of kisspeptin in high and poor responders undergoing in vitro fertilization (ivf)/intracytoplasmic sperm injection (icsi). biological samples were collected from twenty infertile women with polycystic ovary syndrome (pcos) and poor responder participants undergoing controlled ovarian stimulation (cos) with gonadotropin-releasing hormone (gnrh) antagonist protocol for ivf/icsi treatment. kisspeptin concentrations were measured in serum and follicular fluid by using elisa, whereas fsh and lh levels were detected by routine laboratory methods. it was found that kisspeptin levels were significantly lower in serum and follicular fluid of infertile women with pcos. kisspeptin levels were correlated with fsh and lh level in infertile women with pcos. it can be concluded that low level of kisspeptin might inhibit gnrh release that might cause to the inhibition of fsh and lh release and might disrupt folliculogenesis. decline in serum and ff levels of kisspeptin might be possible cause of anovulation and subfertility in pcos subjects. cryptococcus albidus d is a newly identified yeast isolates from petroleum area in _ izmir as a lipase producer. the molecular weight of the enzyme is . kda as found. optimum temperature was °c and half-life times were , , and . min at , , and °c, respectively. optimum ph value was . . however, it shows significant ph stability at ph values . and lower. the existence of acetone in the solution as a solvent enhanced lipase activity. cryptococcus albidus d lipase was able to catalyze the esterification reaction between fructose and palmitic acid to produce fructose palmitate using acetone as the solvent. due to its stability in organic solvents, we propose that in order to increase the yield of fructose palmitate, we could immobilize d lipase. therefore, the effect of immobilization on kinetic parameters of d lipase was investigated. different immobilization materials and methods were used to find efficient support materials for d lipase immobilization. additionally, fructose palmitate production processes will be optimized with immobilized lipase. introduction: the diagnosis of osteoarthritis (oa) is based on clinical symptoms and radiographic findings. it is known that the pathologic changes at the molecular level in the joint cartilage tissue start before symptoms appear in oa. c q tumor necrosis factor-related protein (ctrp- ), c q tumor necrosis factor-related protein (ctrp- ) and kallistatin are related to many different cellular processes including bone and cartilage tissue metabolism. the aim of this study was to investigate any probable association between the serum ctrp- , ctrp- and kallistatin levels and diagnosis and radiologic staging of knee oa patients. materials and methods: this study included patients with knee oa and healthy individuals for control purposes. the patient group was divided into four stages radiologically. ctrp- , ctrp- and kallistatin levels were measured in serum samples of patient and control groups with elisa method, and the differences between the groups were analyzed with statistical methods. results: the levels of serum ctrp- in the patient group were significantly higher than in the control group (p = . ), serum ctrp- and kallistatin levels were not statistically different (in order of p = . , p = . ). in the patient group, there was not a significant difference between serum ctrp- , ctrp- and kallistatin levels and radiologic stages (respectively p = . , p = . , p = . ). there was a significant positive correlation between the radiologic stage and patient's age, body mass index, western ontario and mcmaster universities arthritis index and visual analogue scale values (respectively p = . , r = . ; p = . , r = . ; p = . , r = . ; p = . , r = ). discussion and conclusion: serum ctrp- levels were detected significantly increased in patients with knee oa, but there was no significant difference in ctrp- and kallistatin levels. there was not a significant association between the radiologic stage and levels of ctrp- , ctrp- and kallistatin. enzymes in microorganisms, especially termophilic bacteria are more attractive in biotechnology and molecular biology due to the higher catalytic activity. turkey is rich in geothermal resources and it is important to determine unknown microbial content of geothermal sources. in this study, water and sludge samples were taken from ayder, kizilcahamam and gonen hotsprings. firstly, ph, temperature, salt concentration, gram reaction, mobility, endospore formation, oxidase and catalase tests were carried out as conventional characterization. molecular characterizations of isolates were achieved by fames, rep-pcr and s rrna sequencing. finally, test isolates were evaluated according to enzyme production capability by petri dish. as result of conventional tests, isolates were determined as gram positive, mobile-rod shaped, aerobic, oxidase, catalase and endospore positive. the growth range for ph and temperature of the isolates were determined as - and - °c. in consequence of the salt test, the test isolates were grown at - % nacl. of thermophilic isolates were selected by rep-pcr and according to s rrna sequencing analysis test isolates were belonging to bacillus, geobacillus, anoxybacillus and brevibacillus genus at a range of - %. enzyme tests showed that, some of the isolates were able to produce protease (f , f , f , f , f and f ), amylase (f , f , f , f and f ), cellulase (f , f , f , f , f and f ), xylanase (f , f , f , f and f ) and lipase (f , f , f , f and f ). it can be concluded that, geothermal regions are rich in bacillus and related genera. fame analysis was particularly insufficient for diagnosis of thermophilic microorganisms, but rep-pcr was successful in separation of organisms at species and even subspecies levels. most of our bacterial isolates have industrially important enzyme production capacities. it is a pioneer result to use bacteria for industrial applications which need higher temperatures. p- . . - warburg effect was investigated by studying various metabolic molecules and assays in mammalian cell lines z. i. kanbagli, b. kiratli, h. cimen yeditepe university, istanbul, turkey majority of the different cancer cells switch their metabolism from oxidative phosphorylation pathway to glycolytic pathway; in order to meet excessive energy requirement, which is also called warburg effect. acetylation is one of the most crucial post-translational modifications playing key roles in metabolic reprograming. in this study, the relationship between acetylation dependent changes in energy metabolism and apoptotic pathways were investigated in pnt a, du , hela, hep b, hek t, shsy y. immunoblotting experiments were applied by using antibodies against acetylated-lysine to examine the changes in overall acetylome. candidate proteins displaying elevated acetylation was identified with mass spectrometry based-proteomic analysis. glucose transporter (glut ) was used to detect insulin-stimulated glucose transport, total oxphos rodent antibody cocktail to identify variations in complexes which are responsible for most of the atp production. caspases (casp- , - ) to unreveal different activation levels of apoptotic pathway among the cell lines. mitochondrial membrane potential was measured by using rho-damine by employing confocal microscopy. the expression level of respiratory chain complex iv subunit mtco and casp- was higher in hek t compared to other cell lines. casp- was upregulated in cancer cell lines, mostly in hep b. glut- levels were downregulated in cancer cell lines in contrast to healthy cell lines. findings imply that these proteins might have significant roles leading to variable metabolic and apoptotic activity of each cell line during energy production. due to the results, mtco might be important in adaptation of different cell lines to regulate the overall respiratory chain complex activity. reduction in glut level demonstrates insulin desensitization in cancer cell lines, which might lead to metabolic defects in these cells. besides, since p has a repressive effect on glut , it also can lead us to study about p levels. the effect of inhibition of pi k/akt/mtor signaling pathway on receptor tyrosine kinase expression in breast cancer cells g. tunali, a. l. dogan department of basic oncology, hacettepe university cancer institute, ankara, turkey the increased expression and activation of receptor tyrosine kinases (rtk) (egfr, her , her ) play important roles in breast cancer pathogenesis. her /her interaction is the most potent heterodimer and it causes oncogenic pi k/akt activation. inhibitors of pi k/akt pathway (akt inhibitor and pi k/mtor dual inhibitors) lead to increase in rtk levels and activities while blocking signaling pathway. in this study, the time dependent effect of dual pi k/akt inhibitor pi- on receptor tyrosine kinase expressions' in breast cancer cells was investigated. two breast cancer cell lines, mda-mb- cells (which has egfr overexpression and pten deficiency) and skbr- cells (which has her overexpression) were evaluated for the effect of dual inhibitor. these cells were treated with dual pi k/akt inhibitor pi- for different time periods ( - h) . egfr, her her total rtks expression and pi k/akt pathway inhibition (p-akt and p-p s k expression) were evaluated by western blot. in mda-mb- cells, there were significant decrease in p-akt and p-p s k proteins' expression during the first h. this inhibition was followed by reactivation of the signaling pathway after h. in skbr- cells, p-akt and p-p s k proteins' expression were significantly decreased during the first h. the pi k/ akt signaling pathway in these cells were reactivated after h. basal expression of egfr and her in mda-mb- cells and basal expression of her and her in skbr- cells were found to be very high. transient inhibition of akt and mtor protein kinase activation in tumor cells followed by reactivation of signaling pathway did not result in a time-dependent difference on egfr, her and her expression levels. these results suggest that dual pi k/mtor inhibiton by pi- may trigger receptor tyrosine kinase reactivation due to the signal distruption without affecting total protein expression level. site-specific bioorthogonal reactions are one of the significant tools for discovering different aspects of biological systems in live cells. the reactions should be highly stable and rapid in physiological conditions. various chemical tools can be used in bioorthogonal reactions to monitor biological systems, therapeutics, microscopy and diagnostic applications in live cells. synthetic covalent chemistry in the study of biological systems has been used to label biomolecules selectively in their native environment. for example, small synthetic fluorophores can be added to biomolecules without disturbing other molecular biological pathways. aldehydes or ketone-based functional handles can be attached onto protein at specific sites via chemoenzymatic reactions. labeling of carboxy terminus of a-tubulin has been successfully studied in our previous studies by replacement of wild type tyrosine with unnatural amino acid -formyltyrosine in the presence of tubulin tyrosine ligase enzyme (ttl)-as its role can suggest whether certain cancer cells might grow more aggressively than others. in this work, we highlight the synthesis and spectroscopic properties of azacoumarin chemical probes to study tubulin-tubulin tyrosine ligase (ttl) system in live cells. significant increase in fluorescence quantum yield or a red shift on absorption and emission maxima is observed when the conjugated product is formed. bioorthogonal fluorescent labeling is such a favorable reaction to perform rapid kinetics, localization and high site-specificity in cell environment. newly synthesized azacoumarin fluorophores should therefore not only be useful for studying ttlbased biological systems, but also would enable broad range of high-yielding and fast diagnostics for future biolabeling applications in biochemistry, cell biology and beyond. binase is an extracellular ribonuclease from bacillus pumilus which shows antiviral and antitumor activities in cell cultures. however, the action of binase on intracellular functions and processes has not yet been identified. here, for the first time we report the whole transcriptome analysis of binase-treated human lung adenocarcinoma epithelial a cells. a plasmid-based reverse genetics system and colorimetric cell viability assay were used to identify the binase internalization and binase cytotoxicity towards a cell line, respectively. for the whole cell transcriptome analysis a cells were treated with lg/ml of binase for h followed by mrna extraction and library preparation. sequencing was performed on solid xl wildfire next-generation sequencer. we found that binase internalized into a cells after h of incubation. the binase at lg/ml was absolutely non-cytotoxic towards a cell line and was active in the cell culture medium during h incubation. the analysis of rna-seq data showed that among thousands of protein coding transcripts transcripts were up and down regulated by binase, among them transcripts were induced and repressed. binase repressed the production of s a and tnxb which act cancer biomarkers, scn a and drd which play a crucial role in cancer metastasis and responsible for pediatric tumors, respectively. the induction of transmembrane protein transcript abcb by binase can help binase to internalize into the cell as abc transporters are often account for transporting drugs across the cellular membrane. binase induced the production of nlrp , rasgrp and alpk transcripts which can activate apoptosis, cytokine or t cell activation in cancer cells. thus, binase exerts different effects in cancer cells. the rnaseq data obtained will help to understand the mechanism of binase anticancer action. . ) is a specific group of phosphatases capable of hydrolyzing myo-inositol , , , , , -hexakisphosphate (phytate) with the formation of less phosphorylated inositol derivatives (from mono-to pentaphosphate). three major types of phytases are recognized on the basis of the first phosphate group hydrolyzed by the enzymes: -phytase, / -phytase, and -phytase. due to the stereospecific way of phosphate release from the phytate molecule by the action of phytases, these enzymes by themselves and their composition may serve as a potential alternative for production of myo-inositol phosphate isomers with therapeutic properties. chemical synthesis of these compounds is inefficient and costly. pantoea sp. strain . . showing high phytase activity was isolated from the forest soil sample of the republic of tatarstan, russia. in this study the main objective was the cloning and expression of pantoea sp. . . phytase gene in e. coli. first, we amplified the phytase gene (agpp) from the genomic dna of the bacteria using specific primers phmh_dir and phmh_rev. size of phytase gene corresponded to base pairs. during the optimization of amplification conditions it was found that the optimum temperature for primer annealing was °c. this temperature increases the specificity and efficiency of annealing. then the pcr-product of agpp gene was cloned into the pbad myc/ his vector first. on the next step we carried out subcloning of the agpp into a pet a expression vector. multicopy plasmid pet a/agpp contained the sequence of the phytase gene of pantoea sp. . . under t promoter. the corresponding recombinant protein was expressed in e. coli as a fusion with a his-tag and was detected by western blotting. recombinant phytase was purified via affine chromotography on the ni-nta column and displayed high phosphomonoesterase and phytase activities. bag- (bcl- associated athanogene) is a multifunctional protein that interacts with diverse array of cellular targets and modulates a wide range of cellular processes, including proliferation, cell survival, transcription, apoptosis, metastasis and motility. in human cells bag- exists as three major isoforms (bag- s, bag- m and bag- l) derived by alternative translation initiation from a single mrna, which allows interactions with various molecular targets such as hsp /hsc molecular chaperones, components of the ubiquitylation/proteasome machinery, bcl- , raf- kinase, nuclear hormone receptors and dna. our work aims to investigate how altered bag- expression levels affect cell survival in mda-mb- (er, pr and her /neu negative) breast cancer cell lines. we first cloned bag- l gene to a cloning vector, later we transfected mda-mb- cells for overexpression of bag- . we also used bag- sirna to silence bag- gene. western blot analysis was applied to demonstrate relative expression levels of bag- , its interacting partners and certain proteins which are important for apoptosis pathway. we performed xtt cell viability assay for bag- overexpressed cells to checkbag- 's impact on cell survival, and observed enhanced survival rates on cells compared to that of the untreated cells with bag- overexpression. in addition, our study revealed that once bag- forms a complex with c-raf/b-raf/hsp /akt/bcl- , modulation of cell survival was observed. we believe that once the exact localization and involved molecular mechanisms of bag- and its isoforms are found, the role of each bag- isoform in cell survival can be understood better. this can further provide routes to study tumor development. the aim of this study is testing the recombinant glp encapsulation into a biocompatible material. we also tested if it can be a therapeutic candidate drug for type diabetes. the incretin hormones, which are also named as endogenic peptide hormones have become a more attractive therapy for type diabetes because of different physiological effects. in circulation, glp is cleaved by ddp in a very short time. if glp can be protected from cleaving, the effective time of glp would be increased and by this way it can replace the therapy of insulin. chemical synthesis methods of peptides are limited because of low efficiency and high cost. the production of peptides by recombinant e. coli is an alternative way because of effective production, simplicity and low cost. however, the major disadvantage derived from the recombinant e. coli is the frequent formation of inclusion body. for that reason, extra methods are needed for obtaining soluble recombinant peptides. glutathione s-transferase (gst) tag is commonly used as affinity and solubility tag to improve the solubility of recombinant peptides. in this study, we cloned and heterologously produced glp using the gst fusion system in e. coli. affinity purification of recombinant protein was achieved by using glutathione immobilized columns. characterization of the gst-tagged glp was performed by sds-page. the purity of fusion protein was found to be %, as confirmed by glp elisa kit. then, the fusion protein was encapsulated in a chitosan coated polygalacturonic acid. the different ph stability and in vitro release tests also in different phs was studied. morganella morganii is an opportunistic pathogen capable of causing a wide range of clinical infections. it is known that microbial metalloproteases play an important role in the development of bacterial infections. thus, investigation of m. morganii metalloproteases has a particular interest. bacteria were grown in lb medium at °c. as a bioinformatics tool blast was used. for molecular biological experiments, thermo scientific kits and sibenzyme enzymes were used. pbad/myc-his plasmid was used as an expression vector. bacterial transformation was carried out by heat shock method. bacterial cells were disrupted by sonication. gene expression products were analyzed by western blotting. to analyze the actinolytic activity of bacterial extracts sds-page electrophoresis was used. the putative metalloprotease gene (an cp . ) has been found in the genome of annotated strain of m. morganii kt. its amino acid sequence has partial homology ( %) with actin specific metalloproteases grimelysin from s. grimesii and protealysin from s. proteamaculans. using specific primers the gene with % homology was identified in the genome of clinical isolate of m. morganii . rt-pcr analysis showed that this gene had the maximum expression at h of growth. in addition, the cellular extract of m. morganii had small actinolytic activity. cloning of the gene into e. coli dh a cells led to the synthesis of the kda protein. it is known that the highest expression of serratia proteases is observed at h of growth, and the molecular weight of the mature proteins is kda. it was shown that metalloprotease gene of m. morganii expressed at the same time of growth. moreover, the recombinant e. coli cells synthesized protein with the similar weight ( kda) which perhaps is a mature form of the metalloprotease from m. morganii. as a result, in the genome of m. morganii the metalloprotease with similar properties to grimelysin and protealysin proteases was identified. the preliminary characterization of p-ii like protein glnk from lactobacillus brevis z. iskhakova , d. zhuravleva , a. laykov , k. forchhammer , a. kayumov kazan federal university, kazan, russia, eberhard-karls university tuebingen, tuebingen, germany the p-ii proteins in bacteria, archaea and plants regulate the activity of a variety of proteins in response to specific metabolic signals which affect their structural state and interaction ability. among various bacteria belonging to lactobacillus only some species have genes encoding pii protein in the genome. here we report the preliminary characterization of pii-like protein lbrglnk from lactobacillus brevis. while the amino acid sequence alignment revealed only - % homology of lbrglnk with other well studied pii proteins, lbrglnk also has the atp binding motive gdgk. trimeric structure of lbrglnk was confirmed in vitro by size exclusion chromatography, suggesting possible similarities of lbrglnk properties with pii proteins. the isothermal titration calorimetry revealed a preferential binding of adp (kd = lm) over atp (kd = lm) suggesting that they compete for binding to lbrglnk. neither -oxoglutaric acid nor other nucleotides were interacting with lbrglnk in itc measurements. the mutation gly ala in the atp binding motive completely abolished the interaction with both adp and atp. the pull down of lbrglnk with l. brevis cell extract allowed identification of chaperonin grol, transketolase and glnr-like transcriptional regulator from merr family as most probable partner proteins for interactions with lbrglnk. this work was supported by the russian foundation for basic research (project no. - - a background: hemophilia is a bleeding disorder due to the deficiency in coagulation factors viii (hemophilia a) or ix (hemophilia b). hemophilia patients are essentially treated with intravenous replacement of the missing or dysfunctional factors fviii or fix by recombinant proteins. these therapies often induce the generation of acquired antibodies, and thus, novel approaches are needed. most recent hemophilia strategies target the tissue factor pathway inhibitor (tfpi), which is the major inhibitor of the coagulation cascade, particularly of the extrinsic tenase complex. anti-tfpi agents have been empirically developed such as aptamers, peptides, monoclonal antibodies. we have followed a structure-based strategy, to design a mutated fxa that would show more affinity for tfpi, and thus trap this inhibitor. tfpi exists as two isoforms are folded as multi-kunitz domains related by linkers. the second kunitz type domain of tfpi (tfpi-k ) is known to bind the catalytic site of fxa. methods: the molecular complex of tfpi-k -fxa was modeled and submitted to molecular dynamics (md), allowing the identification of low-spots interaction. modified fxa with theoretically stronger interaction with tfpi-k were predicted using md. the mutants and wild type proteins were expressed in hek cells, and their processing status was checked. they were tested by western blotting, by chromogenic activity using a specific substrate of fxa, by thrombin generation assay in fviii depleted plasma. finally, their binding to a tfpi-k peptide array was compared. results: the mutants showed better efficiency to restore thrombin generation in plasmas from hemophiliacs and displayed stronger binding to tfpi-k than the wild type fxa. conclusions: the proof of concept of the synergistic approaches of md and mutagenesis was obtained and an efficient tfpi trap was designed. the mutated fxa is a candidate for a new hemophilia therapy. organophosphorus acid anhydride (op) nerve agents are potent inhibitors which disrupt the mechanisms of neural transmission. organophosphorus acid anhydrolase (opaa; e.c. . . . ) is a class of enzyme that potentially acts on phosphorus anhydride bonds, reported intracellularly in diverse organisms, albeit notably the enzyme belongs to alteromonas species are more extensively studied. whereas mass-transfer problem is a major issue in native whole cell biocatalysis, new anchor system derived from the n-terminal domain of ice-nucleation protein from pseudomonas syringe inav (inav-n) was used for the first time to display opaa onto the cell surface. tracing of the recombinant protein and its activity assay showed a successful presentation of opaa and its significant ability for biodegradation of organophosphorus compounds. further studies on bacterial fractions confirmed that opaa is remarkably located on the outer membrane. the specific activity of recombinant bacteria to degrade diisopropylfluorophosphate (dfp) was measured at u/mg of cell wet weight, which almost all was observed in the outer membrane fraction. recombinant cells could also degrade chlorpyrifos (cp) compound in . u/mg activity. it can be concluded that inav-n anchor is efficient for targeting opaa on the cell surface and can effectively eliminate the masstransfer problem in native whole cell bioconversion system. proper spatial and temporal organization of proteins involved in cell signal transduction is crucial for the specific and efficient information transfer. scaffold proteins coordinate the action of signaling molecules by their physical binding and organization in multiprotein complex assemblies. multiple protein binding is often mediated through intrinsically disordered regions of the scaffold, where the interaction epitopes are defined by linear peptide motifs. using a hub scaffolding protein axin as a paradigm, we have employed peptide microarray technique to identify the binding epitopes for axin interaction partners at high resolution. this enabled us to design axin-derived peptides corresponding to the respective binding epitopes that compete for the interaction in vitro. by transfection of chemically stabilized competitive peptides directly into the cells, we have shown the effect of specific interaction blocking on axin-mediated signaling in vivo. our data demonstrate a proof of concept for a rational design of inhibitors of protein-protein interactions that allow specific intervention with single function of the targeted protein (i.e. recruitment to the axin complex). contrary to the inhibitors that completely disrupt the protein function (e.g. inhibition of a kinase catalytic site), this approach provides a tool for investigating specific action within the axin complex, while the other cellular functions of the targeted protein remain preserved. the results of this research have been acquired within cei-tec (lq ) project with financial contribution made by the ministry of education, youths and sports of the czech republic within special support paid from the national programme for sustainability ii funds. de novo design of an artificial biocatalyst using immunoglobulin template became rather routine procedure due to the achievements of molecular biology and crystallography. recently the 'reactibody' approach was developed based on the chemical selection of catalytic repertoires from immunoglobulin library followed by expression of these biocatalysts in eukaryotic system. in this study we structurally characterize the a antibody, its kappa and lambda variants, in order to understand the difference on the active site between a and a which although there are two antibodies sharing very high homology and sequence identity their active residues are located in a different region of the antibody. the structures of the a antibody kappa and lambda variants have been already determined, there was no structural information though about the a antibody. the structural analysis revealed dramatically different angle in position of nucleophilic residue tyr and area of solvent accessible surface. the structural difference of active center reflects on kinetics of the a organophosphate modification. both variants of antibody bind with organophosphate throw induce-fit mechanism, but rate of the step of induce fitting is different (k obs are s À and s À for a kappa and a lambda respectively). this observation may hint at novel means of regulation of velocity and specificity of artificial biocatalysts. this study was supported by grant #rfmefi x . translation elongation factor ba (eef ba) is a component of a heavy form of translation elongation factor (eef h). it functions as a catalyst of gdp/gtp exchange in translation elongation factor a (eef a) restoring its active conformation appropriate for aminoacylated trna binding. eef ba forms a tight complex with translation elongation factor bc (eef bc) via the n-terminal domain, while its c-terminal domain executes the catalytic activity. eef bc has been shown to enhance the attributed to the c-terminal domain catalytic activity of eef ba. this suggests that the eef ba n-terminal domain may influence the guanine nucleotide exchange process. to test this hypothesis we prepared a set of n-terminal truncated forms of human eef ba and checked their activity in the guanine nucleotide exchange assay on both isoforms of eef a, eef a and eef a . we showed that recombinant eef ba is a non-globular monomeric protein in solution with an elongated shape by analytical ultracentrifugation approach. the truncation of the dispensable for the catalytic activity n-terminal domain of eef ba resulted in significant acceleration of the rate of guanine nucleotide exchange in eef a comparing to full-length eef ba. similar effect on the catalytic activity of eef ba was observed after its interaction with eef bc. in contrast, the effect of full-length eef ba and its truncated forms on the rate of guanine nucleotide exchange in eef a was similar but relatively modest compared to eef a . this can be explained by higher rate of spontaneous gdp dissociation from eef a comparing to eef a and lower affinity of eef a to eef ba. thus, we propose that the n-terminal domain of eef ba via flexible linker region may interfere with eef a binding to the cterminal catalytic domain that results in a decrease of the overall rate of guanine nucleotide exchange reaction. the formation of a tight complex between eef bc and eef ba n-terminal domains abolishes this inhibitory effect. p- . . - assessment of quantitative proteomics results in large-scale data-independent with fragmentation spectra reproducibility measure reduces variation and allows to use lowintensity signals organisms with reduced genomes that lack the vast majority of transcriptional or translational regulation systems tend to adapt to changing environment with a variety of subtle changes in protein abundances. as soon as relative changes for most proteins fall below %, the power of traditional label-free proteomic analysis rapidly becomes insufficient for robust profiling of hundreds of samples. intoduction of frament-by-fragment and sample-by-sample signal quality assesment in mrm and dia experiments helps to increase accuracy of methods and at the same time reintroduce cases which could have been excluded during bulk quality assessment due to lower signal-to-noise ratio for several fragments. samples of mycoplasma gallisepticum were acquired in data-independent manner on sciex tripletof + mass-spectrometer (swath acquisition) during the year. the samples were produced from mycoplasma gallisepticum culture cultivated at different temperatures. the signals for each fragment were extracted with vendor-supplied software with the theoretical fragment ions for each peptides instead of spectral library. the results were used for relative protein quantitation in two manners the first conventional method included direct use of peptides with top most intense signals. the second included selection of peptides and ions for quantification for each pair of samples based on the reproducibility of fragmentation patterns after computing the areas of chromatographic peaks for each ion. spectral angle was used as a distance measure for fragmentation patterns for clustering. further, a base set of detected ions was selected for each peptide and a subset for comparison of each pair of runs. the first method resulted in quantitation of proteins across all samples with variation across lc-ms replicates was % on average, and the second approach led to quantitation of proteins in total, of them across % of samples, all with the variation about % on average. p- . . - interaction of plasminogen fragments k - and k with fibrin fragment dd t. yatsenko, v. rybachuk, l. kapustianenko, s. kharchenko, o. yusova, t. grinenko palladin institute of biochemistry of nas of ukraine, kyiv, ukraine introduction: plasminogen interaction with specific binding sites in c-terminal d-domains of fibrin molecule initiates the activation process of proenzyme and subsequent fibrin clot lysis. the sites are exposed under fibrin polymerization. plasminogen kringle domains ensure the proenzyme interactions with fibrin clot. in this study, we investigated the binding of human plasminogen kringle fragments k - and k with human fibrin fragment dd and their effect on glu-plasminogen interaction with dd. results: kringle-containing fragments k - and k reduce plasminogen activation by tissue-type activator on fibrin fragment dd. the level of glu-plasminogen binding to dd is decreased by - % in the presence of k - and k . fragments k - and k have high affinity to fibrin fragment dd (dissociation constant is . lm for k - and . lm for k ). analysis of k - and k binding to fibrin fragment dd with reduced disulfide bonds showed the interaction of both plasminogen fragments with c-c-chains of fragment dd. k - interacts with complex of fragment dd-immobilized k as well as k with complex of fragment dd-immobilized k - . the plasminogen fragments do not displace each other from binding sites located in fibrin fragment dd, but can compete for the interaction. analysis of k - and k binding to fibrin fragment dd with reduced disulfide bonds showed the interaction of both plasminogen fragments with aand c-chains of fragment dd. conclusions: widely known specific plasminogen-binding site located in aa - region of fibrin molecule is not a single binding sequence of fibrin peripheral domains or plasminogenbinding site is not linear and contains amino acid residues from other polypeptide chains of fibrin d-domains. fibrin fragment dd contains different binding sites for plasminogen kringle fragments k - and k , which can be located close to each other. possible plasminogen kringle-binding sites are located in aand c-chains. p- . . - implementation of budded baculovirus particles for characterization of ligand binding to g protein-coupled receptors a. allikalt, a. rinken university of tartu, tartu, estonia g protein-coupled receptors (gpcrs) constitute the largest class of membrane receptors involved in regulation of signal transduction into the cell in response to various extracellular stimuli. for that reason, gpcrs have become important targets for variety of drugs. as these receptors are present in native tissues at very low concentrations, efficient recombinant expression systems are needed to produce sufficient amounts of protein. we have shown that budded baculovirus particles, which display gpcrs on their surfaces can be used as a source of receptors for the investigation of ligand-receptor interactions. this expression system can be used for radioligand binding assay as well as for fluorescence anisotropy-based assay (fa). we have validated the system with budded baculovirus particles produced in spodoptera frugiperda (sf ) cells expressing human dopamine d receptors using [ h]sch- and bodipy-fl-skf- as reporter ligands for corresponding assays. this system has many advantages, for example good signal to noise ratio, homogeneity of the receptor, high expression levels and long-term stability of the receptor preparation. fa method allowed real-time monitoring of reporter ligand binding in the absence and presence of different dopaminergic ligands, giving information about their kinetic properties. association, as well as dissociation of the bodipy-fl-skf- itself were rapid with an apparent half-life of t / = . ae . s for association ( nm) and t / = . ae . s for dissociation. we determined the pharmacological profiles of different dopaminergic ligands in displacement binding assays with membranes of sf cells or budded baculovirus particles. the data were in good agreement for both membrane preparations tested in radioligand binding as well as in fa assay. obtained results indicate that budded baculovirus particles can be proposed as a source of gpcrs for performing fluorescence anisotropy as well as radioligand binding assays. gastrointestinal (gi) cancer includes a variety of cancer types affecting the structures and functions of the gi system, encompassing the gi tract and the accessory organs of digestion, from the esophagus, stomach, biliary system and pancreas to the intestine, rectum and anus. despite the significant advances however, much remains to be learned in the spectrum of gi cancer. several investigators have shown that both gas and its receptors, axl, sky, and mer are expressed in various types of cancers. however, the expression level of gas in gi cancer remains unclear. the aim of the study was to determine and compare plasma gas levels in gi cancer patients. female and male patients were included in the study (n = ): colorectal, gastric, pancreatic, liver, ampullary, gall bladder and esophageal. from all gi cancer patients, ml venous blood was collected in citrate tubes before surgery. blood samples were centrifuged at g for min, and plasma samples were carefully removed and stored in À °c prior to use. the level of plasma gas was measured using a commercial developmental elisa kit (r&d systems, minneapolis, mn) which is validated by our laboratory. plasma gas levels in cancer patients were determined as follows: . ae . ng/ml in colorectal; . ae . ng/ml in gastric; . ae . ng/ml in pancreatic; . ae . ng/ml in liver; . ae . ng/ml in ampullary; . ae . ng/ml in gall bladder and . ae . ng/ml in esophageal cancer. preliminary findings indicate that there is a relation between gi cancers and plasma gas levels. taken together, these results suggest that gas may be a candidate biomarker for diagnostic use in gi cancer. inhibition of gas would be an attractive therapeutic target for slow down the progression of gi cancer. monday september : - : computational biology p- . . - computational approaches as an assay for blactam hydrolysis in class a b-lactamases c. tooke university of bristol, bristol, united kingdom b-lactam hydrolysing enzymes, in particular carbapenem-hydrolysing enzymes, are an increasing clinical threat. herein we show that molecular dynamics (md) and combined quantum mechanics/molecular mechanics (qm/mm) approaches are a predictive tool of carbepenemase activity in class a b-lactamases. b-lactam drugs are the most prescribed class of antibiotics worldwide, especially in the treatment of gram-negative pathogens such as klebsiella pneumoniae and escherichia coli. these organisms produce b-lactamases, enzymes which hydrolyse the b-lactam ring, a key resistance mechanism. class a b-lactamases have the ability to hydrolyse carbapenems, termed 'last resort' antibiotics. in particular, the kpc (klebsiella pneumoniae carbapenemase) family are the most clinically important, and recently identified natural kpc variants show increased hydrolytic activity against ceftazidime, a third generation cephalosporin. here we use computational simulations of b-lactam hydrolysis by b-lactamases. in particular, molecular dynamics (md) combined with qm/mm approaches have been used to model the deacylation of the carbapenem meropenem across class a b-lactamases. this method has been extended to model cephalosporin hydrolysis across class a b-lactamases, including kpc variants. these approaches calculated the free energy barriers and correctly distinguished carbapenemases from carbapenem-inhibited enzymes. preliminary results suggest this protocol is also a predictive tool for ceftazidime hydrolysis. further, md simulations of kpc variants (single and double amino acid changes) were analysed to identify structural changes in the active site, highlighting that variants differ in the size of the active site opening, corresponding with experimentally derived kcat values. these computational assays provide a predictive tool of b-lactam hydrolysis and has potential to provide insights into important mechanistic differences both across class a b-lactamases and within the same families. p- . . - computational design of a novel polyglutamic dendrimer-based platform as an anticancer therapeutic approach poly (glutamic acid) (pg)-dendrimer as potential nanocarriers for cancer therapies, to specifically deliver tumor associated antigens (taa)mannosamine and melanato target cells and to modulate cancer antigen intracellular trafficking within the cytoplasm to promote an efficient and selective antitumor immunotherapeutic effect. the theoretical structures were obtained using x-plor software. the molecular dynamics simulation of pg-g -dendrimer and taas was performed using desmond. the electronic properties of the structures were determined by semi-empirical methods using mopac. docking studies of taa to pg-g -dendrimer to mannose receptor (mr ) were performed using hex . . software. taa lumo atoms were conjugated to homo atoms of pg-g dendrimer using maestro software. results showed that pg-g -dendrimer displays carboxylic end groups available for covalent interaction with taas. the homo molecular orbitals of the dendrimer was located on the a-carbon of the carboxylic acid groups from backbone chain and it preferentially interacts with lumo molecular orbitals of amine group from taas. no differences in the gap energy of homo/lumo of all pg-g -conjugates. taas bind preferentially to a-carbon of cooh of backbone chain instead of cooh from side chain. docking results showed that majority of taa conjugated pg-g -dendrimer binds to the core of the mr receptor. increasing of the number of mannosamine conjugated to pg-g -dendrimer more close and stable is the conjugated to the receptor. this system shows promising results as a novel functionalized pg-dendrimers for cancer therapy. theileria parva is one of the the economically important protozoan of the theileria genus belong to apicomplexa phylum which include plasmodium spp. and toxoplasma gondii, causative agents of malaria and toxoplasmosis respectively. this parasite is the disease agent of tick-borne east coast fever (ecf) ranks first among the tick-borne diseases of cattle in sub-saharan africa. the disease caused by the parasite affects a large proportion of domestic and wild animals and leads serious economic losses in the world. major problems in dealing with this illness are the high cost of drugs, development of resistance, and absence of effective vaccines. thus, it is important to develop an efficient and affordable antitheilerial agent. for this aim, -deoxy-d-xylulose- phosphate reductoisomerase (dxr) which subjected to identify novel drug aganist malaria and toxoplasmosis, of theileria parva was selected as potential target for improving novel inhibitors aganist ecf. a computational molecular modeling approach was conducted to determine the d structure of tpdxr by phyre . energy minimisation and root mean square deviation (rmsd) was performed by drefine and superpose servers. to ensure the quality of modelling, stereochemistry, energy profile and residue environment of modelled structure were checked by different servers and possible ligand binding pockets were identified by metapocket . server a reliable d model for dxr from t. parva was modeled by using au as a template. the ca rmsd and the backbone rmsd deviations for the model and the template crystal structure were found to be . and . a, respectively. the ramachandran plot for the predicted model by rampage reveals that model shows an acceptable stereochemistry. top three considered possible binding pockets have been identified. these results have important implications for future screens aimed at finding new and safe molecular entities active against tpdxr through docking studies. p- . . - molecular binding profile of protoberberine alkoloids on amyloid precursor proteincleaving enzyme (bace ) as a drug candidate for alzheimer's diseases g. yalcin , i. yildiz biotechnology institute, ankara university, ankara, turkey, department of pharmaceutical chemistry, faculty of pharmacy, ankara university, ankara, turkey alzheimer's disease (ad) is the most prevalent neurodegenerative disorder that leads to dementia and nowadays over million people live with dementia worldwide. because of the prevalence and economic burden of the disease, drug development studies have picked up speed and scientists especially focused on natural products. ad is basically characterized with tau hyperphosphorylation and accumulation of amyloid b (ab) proteins. ab proteins are generated from sequential cleavages of amyloid precursor protein (app) by b and c secretases, and b-site app cleaving enzyme (bace ) is a b secretase essential for ab production. the alkaloids represent a very extensive group of secondary metabolites, with diverse structures, distribution in nature and important pharmacological activities. protoberberine alkaloids, which belongs to isoquinoline alkaloid class, are widely arranged in many species of the berberidaceae, annonaceae, fumariaceae, papaveraceae, and other plant families. recent searches showed that some of the protoberberine alkaloids such as berberine, palmatine, jatrorrhizine, columbamine, magnoflorine prevents the progress of neurodegenerative disorder. however, the mechanisms of them are not absolutely clear. therefore, we have aimed to elucidate the binding and affect mechanism of these alkaloids on the bace open and closed forms in here. for this purpose, molecular docking studies were applied for these natural products to the both forms of bace by using autodock vina and it was subjected to explicit solvent simulations by amber molecular dynamic package. our preliminary studies indicate that gly , thr , gln , phe , tyr , lys , thr , arg , thr residues of binding pocket have affiliations with all of the mentioned alkaloids and the binding of them generates alterations on closed form of bace . the complexity of animal milk needs to apply numerous approaches and methods for its investigations. an understanding of the processes occurring in the milk can be used, for example, for quality control of the products. fat and protein are main components of milk which have a significant influence at its colloid properties, such as dynamic surface tension (dst). the application of regression-correlation analysis to milk data enables to develop a reliable quantitative model. the aim of our investigation was to perform the regression analysis to establish the relationship between above-mentioned parameters. for this purpose, we used a statistical software packages r version . . . dst was determined by bpa - p tensiometer. milk fat (f) and protein (p) contents were measured by analyzer bentley . this work was supported by the russian scientific foundation (grant - - ). obtained formulas characterized the degree of influence of fat and protein contents of a milk sample for each of the dst parameters (r , r , r , r , k , k ): r = . + . * p À . * f r = . + . * p À . * f r = . + . * p À . * f r = . + . * p + . * f k = . + . * p + . * f k = . À . * p À . * f these formulas show that the maximum total effect of fat and protein contents influences at r and r . a significant coefficient (> ) before the fat is observed in the formula, which describes the value of the tilt of final part of the tensiogram (k ). the resulting regression equations have fundamental importance. with their help it is possible to calculate the dst parameters without their experimental determination, positioning fat and protein contents data. obtained dst parameters promote more complete characterization of the properties of the milk that may be used for dairy products. p- . . - molecular studies of scorpion toxin and its mutants interactions with voltage-gated potassium channels the voltage-gated potassium kv . channel is mostly expressed in neurons and immune cells. its blockage has a high therapeutic potential, for example, specific inhibitor shk toxin is undergoing clinical trials on psoriasis. goal of the current study was an interface analysis in complexes of hybrid channel kcsa-kv . with peptide blockers agitoxin and its mutant forms. d structure was generated by homology modeling method using complex of mutated kcsa channel with charybdotoxin (pdb-code a h) as a template and equilibrated by molecular dynamic simulation in gromacs software. analysis of hydrophobic and stacking interactions, hydrogen and ionic bonds of the toxin and potassium channels was performed for representative frames with optimal toxin orientations using program platinum and apbs software package. we performed contacts energy characteristics estimation to predict key toxin residues for binding process and possible mutation sites for changing selectivity against kv .x channels. the results of investigation are in good agreement with the experimental values of binding constants, obtained by competitive binding assays. results of the conducted investigation may find an application in fundamental science and drug design. the research was supported by the russian science foundation grant no. - - . simulations were performed using the supercomputing center of lomonosov moscow state university. p- . . - homology modeling and molecular docking study of the paraoxonase- and its polymorphic variants q/r and m/l for non-statin lipid lowering drugs paraxonase- (pon ) enzyme is an hdl associated ester hydrolase exhibiting paraoxonase, arylesterase and lactonase activity, and reduces the formation of atherosclerosis blocking the ldl oxidation and reducing levels of oxidized lipids. in this study, molecular docking approach and molecular dynamics simulation were applied for finding the affinity of non-statin lipid-lowering drugs to pon and its polymorphic structures pon q/r and m/l . fibrates (bezafibrate, ciprofibrate, clofibrate, fenofibrate, gemfibrozil), phytosterols (beta-sitosterol, brassicasterol, campesterol, stigmasterol) and other lipid lowering drugs (ezetimibe, niacin, orlistat, probucol, and sibutramine) was obtained from pubchem database. x-ray crystallographic structure of human pon and its polymorphic variants pon q/r and m/l was generated via 'modeller', homology modelling software, from human-rabbit hybrid x-ray crystal structure of pon (pdb code: sre). ns molecular dynamic simulation analysis was performed using gromacs . . . affinity of lipid lowering drugs to pon and its polymorphic variants was predicted by molecular docking approach using autodock . suite. unlike other lipid lowering drugs that they have negative Δg values for affinity, probucol, orlistat and betasterol was calculated by positive Δg values ( . , . and . kcal/mol). these values suggest that they may have no affinity to pon q/r polymorphic structure. in all drug groups, brassicasterol and stigmasterol to pon -m/l and sibutramine to pon q/r were calculated as the highest affinity. in generally, phytosterols predicted by high affinity to pon and m/l polymorphic structures in comparison to other lipid lowering drugs. our study demonstrated that phytosterols predicted as high affinity compounds on pon structures may reduce the activity of antioxidant pon enzyme. this study need to be supported by in vitro and in vivo detailed studies. prolactin and its cognate receptor, prolactin receptor (prlr), are involved in over distinct functions in mammalians. the mammalian prlr gene consists of - exons and several and regulatory sequences. in this study, gaps and annotation errors in the rat prlr gene were corrected by comparing the genomes of mammals and rodents and new putative exons were identified. the rat prlr gene sequences from two different sources (rnor_ . , nc_ . and rn_celera, ac_ . ) were used and primary analysis showed that both sequences contain several gaps (varying from . to kbp), corresponding to about . % ( - kbp) of the gene. using the rat known prlr mrna exon sequences, it was found that the rnor_ . prlr gene has two exon- (one is about kbp long and the other immediately after this). comparisons of mammalian and rodent prlr gene structures showed that the kbp stretch is an assembly artifact. by comparing both gene sequences (and also other available rodent prlr genes), the gaps in the rat prlr gene were reduced from . % to . % (from kbp to kbp). functional annotation of the gene revealed that r. norvegicus prlr gene could have two more additional exons, exon- and - , similar to mus musculus prlr gene. in mammals, prlr mrnas contain non-protein coding exons in the utr (exon- and - ). in rats, there are exon- variants, resulting from alternative promotor usages. studies on the rat and mouse prlr genes revealed that both rodents share common non-protein coding exon- variants. in conclusion, it is found that the rnor_ . version of the prlr gene has the highest number of unidentified base pairs (corresponding to . % of the gene) and the second exon- is the assembly artifact. the rat prlr genes in both databases have several gaps and our corrected version is the best available and characterized form of the rat prlr gene. in silico affinities of some statins to paraoxonase- enzyme the structure of the statins (atorvastatin, fluvastatin, lovastatin, mevastatin, pitavastatin, pravastatin, rosuvastatin and simvastatin) was obtained from pub chem database, and x-ray crystal structure of pon (pdb id: sre) from protein data bank. modeller software was used for homology modeling of pon and its polymorphic variants that's called as pon q/ r and m/l . amino acid sequence of human serum pon (uniprot: p ) was used as the modeller template. all molecular dynamics simulations were carried out with gro-macs . . software. molecular docking calculations on each of the polymorphic structure of the pon was performed with auto dock . . suite. for each substrate, y residue showed open conformation in pon and m/l polymorphic structures while q/r polymorphic structure showed closed conformation. in comparison between structures of pon variants, in most cases statins had lower affinity to q/r polymorphic structure than to the other variant. in this study, among statins, atorvastatin showed lowest but simvastatin highest affinities to pon . by considering that the high affinity drugs can have reducing effect of pon activities, it may be more appropriate to use the low affinity statins in hyperlipidemia treatment. however, these findings need to be supported with in vivo and in vitro studies. p- . . - self-assembly of lipidoids for sirna uptake and release mechanisms studied by molecular dynamics simulations o. acar , d. alpay , a. r. atilgan , c. atilgan sabanci university, istanbul, turkey, northwestern university, evanston, united states small interference rna (sirna) has the ability to bind a specific mrna which provides silencing of selected genes. nanocarriers made out of self-assembled lipidoids encapsulate sirna and deliver them into target cells effectively. in this study, a library of lipidoid structures is constructed and studied by molecular dynamics (md) simulations in different solvents, including sodium acetate, to ferret out their self-assembling mechanisms. the effect of the protonation state of the head group of lipidoids on the final shape of the self-assembled carrier is also studied. we further examine the role of the size of hydrocarbon tails in the packing. we study the final topology and the geometry of the self-assembled lipidoids both in the presence and in the absence of sirna. we find that stable clusters form with as few as chains. for lipidoids having neutral head groups, clusters are in the form of dense bundles, while those with charged head groups form spherical capsids which are depleted of the salt on the inside and having a salt rich phase on the outside. in the self-assembled structure, lipidoids are arranged so as to expose the nitrogen and oxygen atoms to the solvent. while partial capsids with these properties also form at lower lipidoid numbers, chains are necessary to form a fully closed capsid. in the presence of the sirna, the capsid assembles around the nucleotide. the free energy to remove the sirna from the assembly is calculated via repeated steered md calculations utilizing jarzynski's equality relating it to the irreversible work along and ensemble of trajectories. we therefore determine an optimal tail length for the most stable nanostructure, paving the way for designing nanocarriers with high efficacy. milk is one of the most valuable products for humans and attracts a lot of interest of researchers in various fields such as biochemistry, biology, food science and technology. the methods of milk study are quite varied. we chose the combination of the ultrasonic and dynamic surface tension (dst) measurements with the possible correlations among the obtained parameters. the aim of this work is to study the correlation between the parameters of milk, such as a content of fat, protein, lactose, minerals, dry milk solids and dst parameters. for this purpose we used milk analyzer 'klever- m' and tensiometer 'bpa- p'. three groups of animals were formed from clinically healthy holstein cows at the age of - years according to the fat content in the milk sample. group i - cows (milk fat content . ae . %), group ii - cows (milk fat content . ae . %), group iii - cows (milk fat content . ae . %). this work was supported by the russian scientific foundation (grant - - ). the biochemical parameters of the milk samples of all three groups are in the range of the 'normal' values for healthy holstein cows: protein content varies from . % to . %, lactose and mineral content varies from . % to . %, respectively. the dst parameters (r , r and k ) for the group i have strong positive correlations with the fat content in the studied milk samples. at the same time for the groups ii and iii the fat content in the milk indicates only medium positive and weak positive correlations with the r , r and k . obtained absolute values of the dst parameters of the milk samples showed some differences between all three groups. thus, the dst parameters are changing in direct proportion to fat content in the milk sample that can be explain by the primarily role of the milk lipids in the formation of the water/fat surfaces (such as fat globules, lipid-protein particles, etc.). p- . . - exploration of allosteric paths in caspase molecules using energy dissipation e. n. bingol, o. sercinoglu, p. ozbek sarica marmara university, istanbul, turkey caspases are highly regulated aspartate-specific cysteine proteases that have major roles in programmed cell death; apoptosis. effector caspases are at the terminal step of the pathway, hence they are considered as death switches. with the discovery of the presence of allosteric sites, these molecules attracted the attention of the pharmaceutical studies and became drug targets. as a result of the binding of small molecules to the dimeric interface, active site loops are shifted to an unfavorable position. this is associated with a network between distal allosteric sites and the active site loop. an energy dissipation model was applied in order to analyze this matter in further detail. perturbation of specific residues enable us to determine a possible signaling network in proteins using external energy as an input, while focusing on the dispersion of this energy between residues throughout the structure. molecular dynamics simulations were performed with and without energy perturbation using namd software with charmm force field. energy perturbation was applied by increasing the velocity of a chosen residue at the desired time step of the initial md simulation. energy change of each residue was calculated upon the application of perturbation. as a result, residue response times, corresponding to the time of the response of a residue after the perturbation of another chosen residue, are obtained. combining reponse time data with a residue interaction network, it is possible to construct a final network that shows the communication started by perturbation within the molecule. it is shown that perturbation of allosteric sites result in the disruption of the catalytic sites given in literature. our findings support this and also gives a little detail of the possible communication between distal allosteric site and the active site loops. this finding enables the usage of this methodology for similar structures where the exact allosteric mechanism is yet not known. p- . . - effect of complex mammalian membrane models with multiple membrane components on ras protein nanoclustering a. farcas , , l. buimaga-iarinca , c. floare , l. janosi faculty of physics, babes-bolyai university, cluj-napoca, romania, national institute for research and development of isotopic and molecular technologies, cluj-napoca, romania ras proteins are essential for the cellular signal transduction that regulates cell proliferation and differentiation and act as binary switches between gdp and gtp forms. a wide range of human tumors are associated with defective ras protein signaling. the production of permanently activated ras proteins is correlated with mutations in ras genes. experiments and computer simulations have shown that membrane-bound ras proteins form nonoverlapping dynamic nanosized subdomains (nanoclusters) in activation state-/isoform-dependent manner. we performed coarse-grained molecular dynamics simulations to investigate the effect of complex mammalian membrane models on formation and evolution of ras nanoclusters. a fundamental part of the plasma membrane is the phospholipids bilayer, which contains phosphatidyl-choline (pc), phosphatidylethanolamine (pe), phosphatidyl-serine (ps), sphingomyelin (sm) and cholesterol (chol). the nature of lipid-lipid and protein-lipid interactions was studied in binary (pc:chol) and quinary mixtures (pc:pe:ps:sm:chol). because the polar lipids are not uniformly distributed between the two leaflets of the membrane, the construction of the plasma membrane with five-component lipid mixtures took into account the asymmetry between the outer and inner mono-layers. the phospholipids chain saturation (combined with the presence of cholesterol) constitute the dominant factor in phase separation and was, therefore, modeled in different lipid tail combinations for various headgroups. using microsecond timescale simulations of membraneembedded ras proteins, we have shown that the nanoclusters are spontaneously forming dynamic structures whose behavioral characteristics is modulated not only by the ras isoform, but also by the complexity of the membrane model. furthermore, we showed that variations in the plasma membrane lipid composition have important implications in the localization of ras protein nanoclusters. optogenetics comprises biological methods to achieve gain or loss of function of well-defined events in specific cells of living tissue by means of targetable control tools that respond to light and deliver the effector function. microbial rhodopsins (mrs) have been established as powerful light-sensitive tools for optogenetics. acting as ion pumps or channels, mrs are used to induce cell (de)polarization to control neuronal activity in a wide range of living organisms. mrs are membrane proteins found in a large clade of organisms, including eukaryotes, bacteria, and archaea. they share a common architecture of transmembrane a-helices and a covalently linked retinal, which is employed to absorb photons for energy conversion or the initiation of cellular signaling. major efforts are put into screening of natural and generating of synthetic mrs with desirable properties for optogenetics, e.g. ion selectivity. however, experimental study of mrs is difficult and resource consuming owing to, among other factors, low expression levels and protein stability. thus, there is a need in developing of computational tools for identification of mrs with desirable properties. we used non-redundant atomic structures of mrs taken from protein data bank to develop a set of numerical descriptors that reflects functional properties of mrs. then, we calculated the descriptors for non-redundant sequences of mrs with known function taken from the uniprot database, resulting in the feature matrix. we applied the support vector machine and the fold cross-validation procedure, using the feature matrix as the training set. as a result, we obtained the classifier that discriminates mrs in terms of the ion selectivity, e.g. na + , h + , or cl À pumps, with high precision. finally, we used the derived classifier on a test set of proteins and identified mrs for the further experiment in vivo. rational design of peptides with required stability and functional activity properties becomes a real instrument for the new generation drug development. the reca bacterial protein (and human rad homolog) is considered to be the central catalyst of homologous recombination, a mechanism essential for the accurate repair of double-strand dna breaks. dna repair via homologous recombination requires reca nucleoprotein filaments assembly. using seqopt (http://mml.spbstu.ru/seqopt/), a novel method for a-helix sequence optimization we present the successful design of peptide sequences capable to maintain a very stable a-helix structure and to inhibit reca activity. novel a-helical amino acids peptide is constructed based on reca-dna complex structure. we observed in vitro inhibition of reca atp hydrolysis, dna strand exchange reaction and reca filament formation. also, we observed lower e. coli resistance to uv and sos-response suppression in vivo. computational identification of promiscous enzyme activity for the morita-baylis-hillman reaction k. ozturk, s. sayin, n. celebi olcum yeditepe university, istanbul, turkey enzyme promiscuity attracts considerable attention in terms of enzyme evolution, protein engineering and biocatalysis. especially, development of highly efficient novel biocatalysts starting from promiscuous enzymes that have the catalytic machinery to perform desired chemistry is an intense area of research in recent years. in this work, we computationally explored the catalytic promiscuity of natural enzymes for the synthesis of morita-baylis-hillman (mbh) adducts, which display antitumoral activity against human cervical cancer cells, by mining structural protein databases using quantum mechanically optimized theoretical active site models (theozymes). catalytic interactions in the active sites of selected hit proteins with potential mbh activity were evaluated in solvated dynamic environment using molecular dynamics simulations. computational screening of the protein data bank for the quantum mechanically determined optimal arrangement of catalytic functional groups for the target mbh reaction successfully identified an enzyme with experimentally determined promiscuous mbh activity. ras proteins mediate a wide variety of signal transduction pathways that regulate cell growth, proliferation and differentiation. these proteins are small gtpases that act as binary switches between gdp-bound 'off' and gtp-bound 'on' states. oncogenic point mutations of ras are associated with~ % of all cancers and up to % in specific tumors and many developmental disorders. both experimental and in silico results showed that the membrane-bound ras proteins form non-overlapping dynamic nanosized subdomains called nanoclusters in an activation state-/ isoform-dependent manner. we performed coarse-grained molecular dynamics simulations in order to investigate the formation and evolution of ras nanoclusters in mammalian model membranes. ras proteins were inserted into the cytoplasmic side of the plasma membrane model (di-c : -phosphatidyl-choline: di- : -phosphatidyl-choline: cholesterol : : ) where they formed highly dynamic nanoclusters, both in size and in composition. furhermore, we found that the presence of ras protein nanoclusters has a significant impact on the model membrane behavior. properties such as phase behavior, diffusion coefficient, surface tension and lipid tails order parameter are also influenced by the temperature variation of the model membrane. we have investigated dynamics in three different crystal forms of ubiquitin, as well as ubiquitin in solution, with particular emphasis on (i) conformational exchange between b turn type i and ii in the region - and (ii) rocking dynamics where protein molecules as a whole undergo subtle reorientational motion within the confines of the crystal lattice. experimentally, both motional processes have been probed using relaxation dispersion techniques, including recently developed near-rotary-resonance dipolar relaxation dispersion experiments. thereby it has been determined that rocking motion in one of the crystal forms (pdb id n ) occurs on the time scale of tens of microseconds, whereas the conformational exchange has characteristic time constant of ca. ls. using molecular dynamics simulations, we have shown that the similarity of motional time scales is not accidental: bi↔bii exchange and rocking motion appear to be coupled. we have investigated the mechanisms of this coupling and predicted a number of point mutations that are expected to abrogate (or enhance) rocking. the crystals of ubiquitin containing these mutations have been modeled in silico. we have also investigated the interactions (in particular, crystal contacts) that control the balance between bi and bii conformations in different crystal forms. finally, we have used md simulations as a basis for chemical shift calculations and illustrated how relaxation dispersion effects can emerge as a function of bi↔bii exchange in conjunction with the rocking motion. the md simulation study was supported by rsf grant - - . serine/threonine kinases are attractive targets in targeted cancer therapy due to their overexpression in several forms of cancer. flavonoids are highly bioactive plant secondary metabolites that are important in human health due to their antioxidant property. quercetin, a natural flavonoid derivative, has been shown to regulate several signal transduction pathways and is in phase i clinical trial as an anticancer drug. this study explored the inhibitory potential of quercetin and its derivatives using in silico methods like molecular docking and molecular dynamics simulations. quercetin and its derivatives were observed to bind to several serine/threonine kinase family proteins with binding energy significantly better than other known inhibitors and commercially available drugs. this study thus sheds light on the atomic level interactions that define the polypharmacological nature of quercetin and its ability to interfere with a number of cancer pathways. introduction: noninvasive prenatal diagnosis (nipd) of the fetal rhd status by rhd genotyping of the maternal plasma was initially applied in alloimmunized pregnant women. fetal rhesus d status detection for management of rhd incompatibility using circulating cell-free fetal dna from maternal plasma or serum is now accepted by many obstetricians in europe as reliable and useful. the aim of the study was to detect fetal rhd specific antibodies in maternal plasma using a nanopolimer based electrochemical biosensor. materials and methods: a three-electrode system, consisting of a gold electrode, an ag/agcl reference electrode and a pt counter electrode, was accommodated in a -ml electrochemical cell. anilin and jelatin were used for immobilization of rhd antibody. the polimerization was occured at nm uv light. antibodies of rhd antigen were detected using differential pulse method at between . and . v potentials by observing the differentiations in the current values. results: the rhd status of the fetus was predicted in rhdnegative pregnant women ( - th week of pregnancy). rhd antibody were detected in maternal bood using biosensor in of the fetuses. the results were confirmed with real-time pcr. the fetuses found rhd (+) for exon and of rhd gene by multiplex real-time pcr. discussion and conclusion: biosensors based studies might be useful, because they allow to monitor the molecular interactions in real-time providing qualitative and quantitative information, through kinetics, affinity and concentration analyses. we found that more advantages in comparison to other methods reported in the literature so far; it was determined that the method is sensitive, specific, economic, practical and less time-consuming. fetal rhd detection at low concentrations and in the early week of pregnancy is possible with this method. p- . . - investigation of phylogeography of cricotopus sylvestris (diptera: chironomidae) using mitochondrial and nuclear molecular markers the family chironomidae is one of the most widely distributed insect families of diptera, and this family is distributed in all continents and all habitats from the tropics to the arctic in lakes, streams and puddles. in this study, we aimed to determine the dispersal of c. sylvestris using molecular phylogenetic markers not only in turkey but in the world and to reveal from where this species may have entered to turkey in the past. c. sylvestris larvae were collected from lakes across turkey. after total genomic dna extraction from body of larvae, fragments of two mitochondrial genes, cytochrome c oxidase subunit i (coi) and cytochrome b (cytb), and one nuclear gene, carbomyl phosphate synthase domain (cps) of cad, were amplified and sequenced. in addition, several sequences of these three genes of c. sylvestris from different countries of different continents such as south corea, japan, canada, denmark, and sweden were obtained from genbank. all sequences were aligned using mega and bioedit version . . . and were used for phylogenetic analyses. neighbour-joining (nj) tree was created in mega and paup . b with bootstrap replicates. maximum likelihood (ml) analysis was performed in raxmlgui . using gtrgamma model with bootstrap replicates. beast v . . was used for bayesian analysis. our phylogenetic analyses indicated that the japanese, south corean and american c. sylvestris were different from european and turkish members. turkish members of c. sylvestris were closely related to european ones according to our bayesian, nj and ml analyses. in turkish members, c. sylvestris collected from hazar and c ß ıldır lake was more ancient than those from marmara, sapanca, c ß ıldır, aygır, beys ßehir, e girdir and sıhke lakes. in conclusion, our results clearly suggest that several transoceanic dispersal events among the continents may have occurred and that the entrance of turkish c. sylvestris to turkey may have been from southeast and northeast of the country. metagenomics is providing great help to explore world of unculturable microorganisms in the natural samples to enhance our knowledge about microbial diversity. here, we have performed metagenomic analysis of fresh water lake bacterial community using pyrosequencing techniques. we have observed a wide array of bacteria from phylum proteobacteria and family enterobacteriaceae as well as very few viruses from podoviridae, siphoviridae and unclassified phages. we have conducted a metagenomics analysis with the primary focus on the examination of the community of bacteria in a fresh water lake ecosystem. roche gs flx software gave us total reads (with an average read length of . bp). there were contigs having > bp sequence length whereas contigs with > bp sequence length. for further analysis we have taken contigs with > bp only. further, we have analyzed the microbial community composition using blastn/blastx against nt/nr databases with e-value cutoff of À . ≥ % of total contigs were mapped to the reference with ≥ % contig match coverage. the community analysis revealed that domain bacteria is predominantly present ( . %) in the water sample, followed by eukaryota ( . %), viruses ( . %) and other sequences ( . %). most abundant phyla was proteobacteria ( . %) and the most dominant family was enterobacteriaceae ( %) followed by xanthomonadaceae ( %), vibrionaceae ( . %), pasteurellaceae ( . %), shewanellaceae ( . %). we performed functional analysis of all contigs using rapid annotation using subsystems technology (rast) which detected coding sequences and rnas in subsystems. among the classified cds from rast showed major cds hits for enzymes involved in the subsystems amino acids and derivatives and the carbohydrate metabolism. the great diversity of microorganisms present in the lake may reflect the human activity in the area. maldi-tof mass spectrometry is a ubiquitous and widespread tool for protein identification. once the protein sequence is unavailable, unambiguous identification cannot be performed, and predictability is limited by the presence of sequenced homologous proteins. we present a statistical approach to predict a number of structural, localization and functional properties of unknown proteins by direct analysis of mass distribution shapes of their post-cleavage fragments obtained from maldi-tof mass spectrometry data. secondary structure of proteins is best predicted by their specific cleavage at the inertial hydropathy group amino acid residues (filmv), with thermolysin (afilmv) being the closest commercially available reagent, leading to distinguishing between proteins with presumably ahelixes or b-sheets with % accuracy. cellular localization of proteins is best predicted by their specific cleavage at the external hydropathy group amino acid residues (dehknqr), exemplified by gluc(phosphate)+lysc(dek) cleavage. protein location in the cell membrane and its localization character (monotopic/ transmembrane, single-pass/multi-pass transmembrane) are predictable with~ % accuracy by this single cleavage, with optimal combination of - cleavages improving the accuracy tõ %. functional prediction of proteins is the best among membrane-associated proteins with characteristic structural conformations. we attribute the differences in the mass distribution shapes to the characteristic clustering of amino acids residues with respective hydropathy properties that are involved in the formation of d structural conformations of proteins. the suggested approach allows for a non-parametric statistical prediction of uncharacterized proteins from their maldi-tof mass spectrometry data without knowledge or reconstruction of their primary sequence. potential applications include proteomic studies of organisms with unavailable genomic sequences and highly variable proteins analysis. the cancer genome atlas (tcga) represents a comprehensive database of genomic, transcriptomic and epigenetic alterations across more than tumor types. earlier we developed cross-hub tool aimed at multi-way analysis of tcga data in the context of gene expression regulation. in the present work, the software was updated with new features that are described below. crosshub is a python-based application. one of the features of crosshub is the combining tcga rna-seq co-expression analysis to encode chip-seq data in order to reveal most possible transcription factor (tf) targets and coupling mirna-mrna co-expression to several algorithms of mirna target prediction in order to enhance its efficacy. the key feature of the updated crosshub version is the analysis of the associations between expression ratio of tf to its targets and tf mutation status. this allows identification of tfs that are functionally (in)activated with driver mutations in a particular cancer type. the second novel feature of crosshub is the analysis of associations between 'tf-to-targets' expression ratio and tumor characteristics (tnm classification, pathological stage), patient follow-up, etc. in turn, this analysis may result in the identification of 'tf-targets' functional relations that are important for disease progression, tumor invasion, response to chemotherapy. thus, crosshub was supplemented with new features that can be useful for comprehensive tcga data analysis. the updated version of crosshub is freely available at http://sourceforge.net/ projects/crosshub/. this work was financially supported by the russian foundation for basic research (grants - - , - - and - - ) and ras presidium program 'molecular and cellular biology'. p- . . - mutations leading to increased rnase production and streptomycin resistance in bacillus pumilus bacillus pumilus strain - which was derived from soil-isolated b. pumilus p using chemical mutagenesis is characterized by resistance to streptomycin (str, up to lg/ml) and ability to produce extracellular enzymes in quantities almost -fold higher than the parent strain. these features make the - strain suitable for industrial production of rnase (binase) which is known for its antitumour and antiviral properties and can be used as an rna-degrading tool in molecular biology. the whole genomes of both mutant and wild-type b. pumilus strains were sequenced recently. to reveal the exact genetic features responsible for rnase overproduction and str resistance we have fulfilled comparative genome analysis of b. pumilus p and - strains. facilities of rast server, edgar platform and additional bioinformatics tools (plasmid finder, prophinder, bl seq) were used. it is found that both b. pumilus genomes under study contain an intact prophage, while only wild-type strain bears a kb cryptic plasmid. none of the systems is inactivated in mutant strain according to the results of metabolic reconstruction. . % of total cdss differ in - strain in comparison to p one, % of them are hypothetical. the altered genes are involved in membrane transport, cell wall composition, chemotaxis, spore formation, carbohydrate metabolism, dna metabolism, translation and transcription regulation. mutation (k n) leading to str resistance is identified in s ribosomal protein s p. regulatory and coding regions of binase gene have no modifications. candidate genes which can account for binase overproduction are selected. mutation k n is classical in str resistance and leads to enhancement of decoding accuracy while decreasing elongation speed. rnase overproduction is brought about by non-specialized mechanism since other hydrolases are also overproduced in mutant strain. genes encoding extracellular serine protease, sporulation initiation phosphotransferase f, gnat-family acetyltransferase and cell wall modifying enzymes are reported previously to increase production of degradative enzymes. the action of encoded by them proteins lead to increase of stability and release of secreted proteins to environment and to derepression of their transcription from negative regulators bacillus pumilus strain p has been identified on its ability to produce ribonuclease and different extracellular proteases. in order to increase inherent biosynthesis of proteases the p strain was screened on culture medium supplemented by streptomycin. derivative b. pumilus strain - gains the resistance to streptomycin and also shows the increased ribonuclease activity. we used genomes of both these strains to explore streptomycin susceptibility and increased activity of hydrolytic enzymes. whole-genome shotgun sequencing was performed using a combination of pyrosequencing and ion semiconductor sequencing, which provided x ( p) and x ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) overall genome coverage. assembled genome sequences of p and - strains included and scaffolds > bp with a calculated genome size of bp and bp, respectively. the gc content was %. both draft genomes have been deposited at genbank (jojx . for p and jhud . for [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . detailed comparative genomic analyses of strains have been performed. we calculated average nucleotide identity (ani) values between the genomes of our strains and completed b. pumilus genomes deposited in ncbi database. two b. pumilus strains (sh-b and safr- ) revealed the max. ani value ( . % and . %, respectively). b. pumilus sh-b strain has been used as a reference for snp calling in strains p and - . snps for the p strain and for the - strain were classified as nonsynonymous variants. radical nucleotide substitutions from the - genome were not found in p genome. among them, the mutation in the codon of rpsl gene (coding s ribosomal protein s ) is probably associated with resistance to streptomycin. also, two mutations in rpob and nusa genes (coding rna polymerase and transcription termination factor rho, respectively) may be related to increased enzymes activity. both our strains contain protease-coding genes. twelve of them are encoding extracellular proteases. here we propose an algorithm that can predict an antibodies mutant forms with desired specificity. this algorithm allows to determine the position and type of amino acid residue for mutagenesis. approach is based on a hybrid method of quantum and molecular mechanics (qm/mm) that allows to understand the reaction mechanism and the role of active center amino acids. catalytic antibody a , that is able to hydrolyze pesticide paraoxon, was selected as a model. however, the hydrolysis efficiency of paraoxon by a antibody is only m À min À , that is insufficient for using this antibody as antidote. the main fundamental goal of our study is to determine the necessary conditions for improving the binding reaction of paraoxon by catalytic antibody a . the hybrid qm/mm method allows to study the reaction mechanism of interaction of a with paraoxon. it was shown that the reaction proceeds via the classical s n mechanism. the key step of the reaction is the proton transfer from the catalytic residue tyr- to paraoxon. qm/mm approach determines position for mutagenesis -leu- in light chain. for one of the mutant in this position -leu argwere predicted (i) increased probability of formation of a hydrogen bond between the catalytic moiety and paraoxon compared to the wild type antibody and (ii) smaller value of the diffusion coefficient, which reflects the best positioning of paraoxon in the active center. steady-state kinetic analysis shows that leu arg exhibits a -fold increase in k /k d compared to a ( m À min À vs. . m À min À ). double mutant leu arg/ser ala also has improved constants of interaction with paraoxon in comparison with the wild type antibody, however, a single mutant leu arg still binds paraoxon three times better, that may be due to the fact that the serine in position increase the nucleophilicity of tyr . thus, our results are in line with our computed predictions. this work was supported by rfmefi x . due to high prices of meat and meat products, low quality raw materials like offal tissues are commonly used in turkey. in the retrospect of the studies for evaluating and detection of unwanted tissues in the sample is basic histological examination. the light microscopy techniques are very strong method if a researcher qualification is enough. a new researcher-independent method must be developed. therefore, different tissues and organs constitute of unique mrna and protein. our method is based on this event, so the antigenic sites of the tissues can be detected by selected antibodies. the first set of the antibodies are for detecting muscle and adipose, consist on muscle actin and adipose triglyceride lipase. this set is used for calibration on standard meat sample. the second set of the antibodies are detecting of offal tissues, consist on trrap and casein. anti-casein antibody is selected because the mammary gland usage in grinded-meat is very common. immuno-staining started with hier (heat mediated epitope retrieval), then classical ihc method applied to slides with dab-chromogen. after all process completed the slides were photographed by las (leica application suite) on microscope. the capture settings were remained same on both sets. image capture size is x pixels and field of view (fov) is lm. all the image files were converted to binary for threshold operation. the threshold values of first set and second set were calculated and their ratios were compared. the formula is based on the distribution (dst) of pixel intensity (int) over threshold (thrs) values on all fov (axis: the results are good enough to detect the unwanted micro-structures on % raw meat and % offal tissue. calculations proofed with imagejÒ. future application of this method and opencv-based software algorithm is to port the source code to a single board computer (sbc) with a digital microscope connected. monday september : - : mechanisms of pro-inflammatory diseases p- . . - the effects of raas inhibition in rate limiting step by aliskiren on testicular torsion injury in rats testis torsion is a urological emergency condition that results in necrosis of the testis if the condition is not treated. unfortunately treatment of testis torsion is not fully understood, therefore clinical and experimental studies are performed continuously. reninangiotensin-aldosterone system (raas) contributed to pathophysiology of several diseases. aliskiren (als) inhibits the renin on the first step of this system. our aim is to investigate the protective effect of aliskiren on unilateral testis damage caused by experimental testis torsion and detorsion. the forty-eight rats were separated into eight groups of six animals: sham, sham+als mg/kg (oral) group, torsion group (tor), torsion/detorsion group (tor/det), tor+als mg/kg (oral) group, tor+als mg/kg (oral) group, tor/det+als mg/kg (oral) group, tor/det+als mg/kg (oral) group. in the tor and tor/det groups, the left testes were rotated °clockwise together with the spermatic cord and tunica vaginalis in the scrotal space. the left testes of the rats were subjected to torsion and detorsion during h. after experimental procedures, testicular tissues were examined by histopathologic and molecular analyses. the il- b and inos mrna expressions were increased in tor and tor/det groups when compared with sham group. both doses of aliskiren administration decreased these expressions in tor/det groups. the stereological results revealed that aliskiren administration promote the numerical density of mature spermatids in tor and tor/det groups. the numerical densities of tor/det+als and tor/det+als groups were similar and these two groups have significant difference when compared to the tor and tor/det groups. the administration of als may be useful for preventing ischemic damage on unilateral testes injury in rats. this study supported by a tubitak project, coded s . ) has recently been recognized as a potent immunomodulator which acts through regulation of gene expression involved in immunity response thus affecting various inflammatory and autoimmune diseases. the study was aimed at investigating hepatoprotective role of d in vdr-mediated regulation of pro-inflammatory factors in diabetic liver. materials and methods: type diabetes was induced in male c bl/j mice by i.p. injection of high-dose stz ( mg/kg b.w.). after weeks of stz-induced diabetes animals were treated with/without d ( iu/mouse per os) for weeks. blood serum ohd was assessed by elisa. rel-a, vpf, inos and vdr expression was measured by qrt-pcr and/or western-blot. results and discussion: diabetes caused two-fold reduction of serum ohd level, indicative of d deficiency. significant alterations in d -endocrine system were found as is evident from reduced expression of cyp a , cyp r , vdbp and vdr at transcriptional and translational levels. these changes were accompanied by a marked increase in mrna and protein levels of inflammation markers rel-a, vpf and inos in hepatic tissue of diabetic mice. diabetes also led to structural lesions in liver tissue. complete restoration of ohd content and partial normalization of liver tissue structure were achieved after d treatment. d administration partially normalized expression of cytochromes involved in d metabolism and hepatic pro-inflammatory factors. d treatment prevented overexpression of rel-a and phosphorylated p /rel-a translocation to hepatocellular nuclei that is most likely mediated through , (oh) d and vdr. conclusion: study confirmed that diabetes-induced liver abnormalities are associated with chronic inflammation that can be linked to impaired d metabolism and deficiency. our findings demonstrate protective vdr-mediated effect of vitamin d against diabetes-induced liver injury. p- . . - lavandula stoechas extract increased glucose uptake and protein levels of key signaling molecules in insulin resistant c c muscle cells s. savranoglu , h. ipek , s. arslan , h. delig€ oz , a. r. t€ ufekc ßi , i. demirtas , t. boyunegmez t€ umer graduate program of biology, institute of natural and applied sciences, c ß anakkale onsekiz mart university, c ß anakkale, turkey, graduate program of bioengineering, institute of natural and applied sciences, c ß anakkale onsekiz mart university, c ß anakkale, turkey, deparment of biology, faculty of arts and sciences, pamukkale university, denizli, turkey, department of chemical engineering, faculty of engineering, pamukkale university, denizli, turkey, department of chemistry, faculty of sciences, c ß ankiri karatekin university, c ß ankiri, turkey, department of molecular biology and genetics, faculty of arts and sciences, c ß anakkale onsekiz mart university, c ß anakkale, turkey introduction: the aim of this is to identify remedial effects of lavandula stoechas, anatolian traditional medicine, against metabolic disorders developed on the ground of insulin resistance. ethyl acetate extract (eae) of l. stoechas was investigated in c c myotubes which were made insulin resistant by free fatty acid (ffa) treatment, for its effects on glucose uptake and as well as on the activation of akt- (by pakt/ akt ratio) molecule which plays a central role in insulin signaling through serine ( ) phosphorylation. in addition, the protein level of lipoprotein lipase (lpl) enzyme was also evaluated. material and methods: c c cells were made insulin resistant by palmitic acid (ffa) and effects of eae on p-akt (ser )/akt ratio and lpl level were determined by sds-page/western blot. the effect of eae on glucose uptake in insulin resistant cells were determined by the -deoxyglucose uptake assay. results: eae at and lg/ml significantly increased the glucose uptake and % compared to insulin resistant control cells. metformin at mm increased this parameter up to %. eae increased pakt ser /akt level - % and lpl expression - % for and lg/ml, in insulin resistant myotubes, respectively (p < . ). discussion: eae of l. stoechas improved impaired insulin sensitivity through both enhancing glucose uptake and activation of akt molecule through ser phosphorylation. in addition, it also considerably increased lpl level which has very important function in lipid metabolism. conclusion: overall, results demonstrated that l. stoechas contain phytochemicals which can be effective for the prevention and also treatment of insulin resistance and associated conditions. our research group is on the way for the identification of these 'bioactive' molecules with bioassay guided fractionation studies. tubitak (projectid: t ) supports this study. achievement of complete pain control is very difficult task, which requires a search for new molecular targets during the analgesic substances development. considering the importance of glial cells and their signaling molecules, development of new gliotropic therapeutic methods is a promising direction in pain treatment. polyunsaturated fatty acids, including docosahexaenoic acid demonstrating anti-inflammatory and antioxidant activity are of considerable interest. docosahexaenoic acid (dha, : n À ) analgesic activity was studied using a chronic constriction injury (cci) rat model. animals were subcutaneously injected with dha emulsion at a dose of . mg/kg ( mm/kg) daily during weeks after surgery. collection of material for subsequent immunohistochemistry investigation was performed on day . we clearly demonstrated that the activation of neurokinin neurotransmission and nnos synthesis are coincided with the astroglial activation in the spinal cord dorsal horn (scdh) superficial lamina during neuropathic pain development. however, the detailed mechanisms of interaction between substance p (sp)-, no-ergic systems and astrocytes in the spinal cord remain to be elucidated. systemic administration of dha to cci animals reduced neurogenic pain intensity and duration, leading to an earlier stabilization of paw weight distribution and preventing the development of degenerative changes in denervated limb. this drug treatment reduced the level of the sp-and no-ergic neurotransmission and decreased astrocytosis in the scdh superficial lamina. thus, the ability of dha to affect nociception is a promising and safe alternative to current pharmaceutical therapeutics. immunohistochemistry studies carried out with the russian science foundation financial support (agreement no. - - ), obtaining dha and all manipulations with animals of the material was funded by rfbr according to the research project no. - - mol_a. p- . . - circulating endothelial-derived apoptotic microparticles and aopps are related to highsensitive troponin t in patients with chronic hepatitis c infection the aim of this study was to evaluate non-standard risk factors for cardiovascular events, such as endothelial dysfunction assessed by endothelial-derived microparticles (emps) (cd +/ cd + ), advanced oxidation protein products (aopps), and low-grade inflammation, that are potentially associated with elevated levels of high-sensitivity troponin t (hs-tnt) and n-terminal pro-brain natriuretic peptide (nt-probnp) in patients with chronic hepatitis c (chc). methods and results: eighty-six chc patients and healthy control subjects were enrolled in the study. circulating levels of hs-tnt, nt-probnp, aopps-albumin (the ratio of aopps to albumin content), emps (cd +/ cd + ), hs-crp, and tnf-a were assessed. compared with chc patients, the chc patients with diabetes mellitus (dm) had higher levels of emps (cd +/ cd + ) and aopps-alb, which were associated with elevated hs-tnt levels (≥ . pg/ml). nt-probnp positively correlated with tnf-a level in all chc patients and this correlation was stronger in diabetic patients. in multivariate logistic regression analysis, the independent factors associated with the presence of elevated hs-tnt levels were the presence of dm (p < . ) as well as high levels of aopps-alb, apoptotic emps (cd + /cd + /an-v + ), and nt-probnp (p = . , p = . , p = . respectively). conclusion: the prevalence of elevated hs-tnt were increased significantly in the diabetic patients with chronic hepatitis c. hs-tnt was related to non-standard risk factors for cardiovascular events, and circulating endothelial-derived apoptotic microparticles (cd + /cd + /an-v + ) level was an independent predictor for elevated hs-tnt levels, potentially indicating some abnormalities in the myocardium. apnea; and healthy individuals; and assessing the connection between the pain and the dimension of the sleep disorder. material and methods: patients who were diagnosed with obstructive sleep apnea and healthy individuals who were similar in terms of age and gender were included in this study. the patients, who were diagnosed with obstructive sleep apnea with the examination and sleep tests, were assessed according to the american college of rheumatology (acr) criteria in terms of fms. serum d vitamin level was measured by using the ultra performance liquid chromatography method. findings: when the fibromyalgia syndrome and obstructive sleep apnea and pure obstructive sleep apnea patient groups are compared with the control group, the vitamin d level was found to be low at a significant level (p = . , p = . , respectively). no significant difference was found between the vitamin d levels in fibromyalgia syndrome, obstructive sleep apnea and pure obstructive sleep apnea patient groups. a negative correlation was found between the number of the sensitive points and vitamin d levels in fibromyalgia syndrome patients (p = . ). results: it has been concluded that the obstructive sleep apnea and fibromyalgia syndrome patients have low vitamin d levels, and this situation must be considered in treatment modalities. on the other hand, the results obtained in the study make us consider that vitamin d metabolism is not influential in the pathogenesis of the fibromyalgia syndrome and obstructive sleep apnea togetherness. p- . . - decreased chitotriosidase activity and levels in familial mediterranean fever discussion: familial mediterranean fever is an inflammatory disease. several cytokines and inflammatory mediators are playing role on pathogenesis of the disease. although ıt has been demonstrated that the increased concentrations of cht in patients with fmf. we found lower cht activity and concentrations in patients with fmf. conclusion: serum cht enzyme activity and concentrations may not be considered as a biomarker in fmf patients taking colchicine. new studies are needed to evaluate the changes of the enzyme activity, concentration and the role of cht in patients with colchicines negative patients. chronic hyperglycemic state leads to an increase in subclinical systemic inflammatory response in diabetes mellitus type (dmt ) patients. inflammation-based scores, neutrophil to lymphocyte ratio (nlr), platelet to lymphocyte ratio (plr) and red blood cell distribution width to platelet ratio (rpr) are biomarkers able to quantify systemic inflammation. the aim of the study was to investigate association of the inflammation-based scores with short-and long-term glycemic control markers, and whether they could be used as indicators of glucoregulation in dmt patients. the cross-sectional study included dmt patients, treated at the primary health care centre zenica from december to april , distributed into groups according to glycated hemoglobin (hba c) values: a (n = , hba c ≤ . %) and b (n = , hba c > . %). complete blood cell count, fasting blood glucose (fbg) and hba c measurements were determined at the primary health care centre zenica and at the department of laboratory diagnostics, cantonal hospital zenica by standard laboratory methods. all statistical tests were performed using spss . . p values fasting blood glucose and hba c were significantly higher in the group b compared to the group a (p < . ). there was no significant difference of nlr, plr and rpr between the groups (p = . ; p = . ; p = . , respectively). significant correlation of inflammation-based scores with fbg and hba c was found only between plr and hba c in the group a of dmt patients (r = . , p = . ). inflammation-based scores could gather meaningful clinical information, either diagnostic or prognostic, on a variety of hyperglycemic, inflammatory, cardiovascular and thrombotic disorders. since there was no statistically significant difference of nlr, plr and rpr between dmt patients with good and poor glycemic control, we conclude that these scores could not be used as indicators of glucoregulation in dmt patients. chronic inflamation plays a central role in the development and progression of diabetes and in the pathogenesis of its comlications. the neutrophil-lymphocyte ratio (nlr) and platelet-lymphocyte ratio (plr) are indicators of subclinical inflamation. mean platelet volume (mpv) is one of the platelet function indices that reflects the platelet production rate and stimulation. we investigated the association of nlr, plr and mpv with prediabetes and type diabetes mellitus (t dm) and determine whether or not these are reliable markers for diagnosis. we evalueted people's results who were carried out oral glucose tolerance test (ogtt). acording to -h values of plasma glucose in the ogtt; . group (normal glucose tolerance: ngt): under mg/dl (n = ), . group (prediabetic: impared glucose tolerance (igt)): ranging from mg/dl to mg/dl (n = ), . group (firstly diagnosed diabetic by ogtt): above mg/dl (n = ). . group is clear diabetic without complication (taking treatment) group (n = ). we compered nlr, plr, mpv and some biochemical markers between four groups. there are significantly differences between all groups in nlr (p = . ) and plr (p = . ) values. nlr values are significantly higher in prediabetic ( . it is recognized that a chronic low-grade inflammation and an activation of the immune system are involved in the pathogenesis of insulin resistance and type diabetes mellitus (t d). this study aimed to analyze the long-term impact of altered metabolism in female t d patients at the level of mediators of inflammatory response. this study included femalet d patients and control subjects, which were recruited at the clinical center university of sarajevo and the general hospital tesanj. in this study the effects of glycemic control on markers of the inflammatory response crp, fibrinogen, leukocytes, sedimentation, and cytokine il- , were analyzed. all subjects included in this study were free of evidence infections, surgery, thyroid disease, polycystic ovarian syndrome, active liver and kidney damage. all biochemical analyses were performed by employing standard ifcc protocols. results from this study demonstrated significant increase of fibrinogen (p = . ), crp (p = . ), il- (p = . ), leukocytes (p = . ) and sedimentation rate (p = . ) in female t d population compared to control subjects. interestingly, a significant correlation was shown between crp and hba c (p = . ), il- and glucose ( . ), il- and bmi ( . ). in our study, female t d compared to the healthy population had significantly higher levels of fibrinogen, leukocytes, il , crp and sedimentation. other studies conducted in female population associated elevated levels of il- and crp with t d independent of other risk factors for diabetes. crp being most robust predictor of diabetes. studies have shown that crp is an important predictor of t d for the female but not the male population. thus, our data suggest that inflammation play an important role in the pathogenesis in female diabetic population. a more detailed study on a far larger number of subjects should point out fact if they can effectively be used as biomarkers in the primary prevention of t d in this population. objectives: bone and mineral metabolism disorders hold an important place among the complications after renal transplantation. the purpose of this study was to demonstrate the relationship between vitamin d, calcium, phosphorus metabolism with graft function and to measure , (oh) d levels with lc-ms/ ms in renal transplant recipients. design and methods: this study included renal transplant recipients ( female, male; mean age: . ae . ) from living related donors were transplanted. blood samples were collected immediately before and after transplantation at month . serum creatinine, bun, calcium, phosphorus, alkaline phosphatase, glucose, albumin, pth, (oh)d and , (oh) d levels were measured. gfr values were estimated by ckd-epi. plasma , (oh) d levels were determined in a lcms- triple quadrupole tandem mass spectrometer (shimadzu corporation, japan) by mrm. spss . software was used for statistical analysis. results: although plasma , (oh) d levels significantly increased (p = . ), we did not find any significant differences for serum (oh)d levels after transplantation. when posttransplant levels of serum phosphorus, pth, creatinin, bun and alp levels were found to be significantly decreased (p = . , p = . for alp), we observed significantly higher calcium and gfr values (p = . ). vitamin d insufficiency was present . %, deficiency . %, severe deficiency % before transplantation, insufficiency was also seen . %, deficiency %, severe deficiency . % after transplantation at month . conclusions: in our study, all patients were found to vitamin d deficiency and insufficiency. determination of vitamin d deficiency and consequently treatment with vitamin d supplements could lead to better graft surveys. free fatty acids (ffa) represent important link between obesity, insulin resistance, type diabetes (t d), and dyslipidemia. increased adiposity, as approximated by body mass index (bmi), correlates well with increased serum levels of leptin-adipocyte derived hormone implicated in the regulation of adipose mass and alterations in insulin action and secretion. the main objective of the present study was to investigate the potential association of serum ffas with leptin levels in healthy and newly diagnosed type diabetic subjects. this study involved newly diagnosed type diabetics and healthy subjects. all participants in the study were free of evidence of hepatitis, viral infection or active liver and kidney injury. for biochemical analyses of glucose, glycosylated hemoglobin (hba c), and lipid profile, standard ifcc protocols were used. analysis of free fatty acids (ffas) was done by gas chromatography, while serum leptin levels were determined by the elisa kit. in addition to the expected differences in glucose, hba c, and bmi, our results also showed significant differences in leptin, myristoleic, palmitic, linolenic, arachidic, and arachidonic acids between t d and control subjects. in healthy subjects, a significant correlation was demonstrated between glucose and lauric, arachidic, arachidonic acid levels, body weight, and bmi. newly diagnosed diabetics showed significant association between glucose and lauric, myristoleic and linolenic acid levels; with leptin being associated with myristic and palmitoleic acid levels. interestingly, in all participants, significant association was found between glucose and hba c, glucose and leptin, myristoleic, arachidic, and bmi as well as between leptin, arachidic acid, and bmi. thus, our data point out association of different types of ffas with leptin levels in newly diagnosed type diabetics. however, further studies should be done in larger number of patients to confirm our results. rheumatoid arthritis (ra) and ankylosing spondylitis (as) are chronic inflammatory diseases with distinct clinical manifestations in many ways. the aim of this study is to evaluate the serum levels of molecules which may be used as markers for angiogenesis and vascular leakage in the processes of two clinically different pictures, ra and as. ra patients, as patients and healthy volunteers with mean age of - were included in the study. serum levels of vegf, angiopoetin- and tie- were measured by enzymelinked immuno-sorbentassay (elisa) using a commercially available kit. serum nitricoxide levels were evaluated by the griessreaction. serum vegf, ang- and no levels were significantly higher in the as group ml, p < . ; p < . ; p < . ). no differences were found between as and ra for tie- (p > . ). vegf, ang- , tie- and no levels were positively correlated in both as and ra patients (p < . ), but no correlation was detected between clinically activation index das- , basda _ i scores and laboratory measurements such as sedimentation, crp and anti-ccp (p > . ). when the diagnostic performance of the parameters were evaluated with the roc analysisonly the performance of the ang- in as patients was sufficient (auc ( % cl): . , p < . ). elevation of angiogenic factors in the serums of as and ra patients supports the role of angiogenesis in the etiopathogenesis of these diseases. however, lack of relationship between disease activity leads to not to use these factors as a marker for clinical follow-up. only ang- measurements may be useful for the differantial diagnosis. the evaluation of ischemia modified albumin as an early biomarker of acute myocardial infarction introduction: acute myocardial infarction (ami), remains a leading cause of morbidity and mortality worldwide. early diagnosis of ami is very important because early treatment may reduce the extent of injury to the myocardium. currently, biomarkers of myocardial necrosis such as myoglobin, ck-mb and troponins are highly sensitive and exhibit good specificity. however, these biomarkers increase after tissue injury, approximately - h after the cardiac event and detect only the consequences of prolonged ischemia. recently, ischemia modified albumin (ima) has been assessed and found to be very useful for the diagnosis of myocardial ischemia and it is considered as a serum biomarker. the aim of the present study was to evaluate the serum level of ima and determine the relation between patients with ami and control group, in order to verify its potential as a novel marker for early detection of mi. materials and methods: the study was performed with patients and healthy controls. blood samples from all subjects were collected by venipuncture in plain tubes, and immediately centrifuged at g for min at °c. the serum samples were stored at À °c until analysis. the serum levels of ima were determined using the cusabio biotech human ischemia modified albumin, elisa kit according to manufacturer's instructions. the results are given as international units/milliliter (iu/ml). results: our findings revealed that ima showed no significant difference between the groups. conclusion: our results suggest that ima assay is not a sensitive marker for early detection of ischemic hearth disease and cannot be used alone for the diagnosis of ami. prospective studies are needed to identify ima's potential as a biomarker for ami. p- . . - neutrophil-to-lymphocyte ratio and platelet-tolymphocyte ratio in polycystic ovary syndrome polycystic ovary syndrome is a complex and multifactorial disease with metabolic dysfunction and the etiopathogenesis is not well established. emerging data suggest that adiposity and chronic low-grade inflammation are involved in the development of the metabolic dysfunction. neutrophil-to-lymphocyte ratio (nlr) and platelet-to-lymphocyte ratio (plr) have recently been investigated as two new inflammatory markers used in the assessment of systemic inflammation in many diseases. the purpose of the study was to investigate their relation with pcos patients. the study population consisted of patients with polycystic ovary syndrome and healthy women controls. nlr and plr obtained by dividing absolute neutrophil to absolute lymphocyte count and absolute platelet count to absolute lymphocyte count, respectively. the neutrophil count ( . ae . vs. . ae . , p < . ) and platelet count ( . ae . vs. . ae . , p < . ) were higher in patients with pcos compared to the control group. lymphocyte count was . ae . in pcos patient and . ae . in control group. the nlr and plr of pcos patients were significantly higher compared to those of the controls ( . ae . , . ae . p < . , . ae . , . ae . p < . , respectively). in this study we found nlr and plr were significantly increased in patients with pcos compared to healty control. nlr and plr were two useful inflammatory markers for assessment of patients with pcos. imbalance in neurotransmission in conjunction with neuroinflammation contribute to neurological dysfunction observed during acute liver failure (alf). own observations indicate that alf in a mouse model is associated with altered expression and/or intracellular distribution of synaptic proteins. since neutralization of tgf-b appears to improve the neurological score in alf mice, we examined the possibility that increased levels of tgf-b , caused by liver damage, may affect the expression of selected synaptic proteins. expression and/or cytoplasmic vs. membrane distribution of a number of functionally critical synaptic proteins in cerebral cortex and blood tgf-b were measured in c bl mice with alf induced by single i.p. injection of aom ( mg/kg of b.w.) and after neutralization of tgf-b induced by single i.p. injection of ab-tgf-b ( mg/kg) h before aom injection. in alf mice, blood tgf-b was increased, and the expression of presynaptic proteins: synaptophysin and synaptotagmin was increased in the cytosolic (s ) fraction by~ % and %, respectively, but was slightly depressed in the membrane (p ) fraction by~ % and~ %. aom induced an increase of postsynaptic proteins: psd- and nnos by~ % in p fraction. tgf-b neutralization resulted in a reduction in the expression of presynaptic proteins by~ % in s fraction and~ % in p fraction, in control animals and normalized their amount in the cytosolic fraction after aom injection, but was ineffective with regard to psd- and nnos. the results indicate that in alf mouse, neutralization of cytokine tgf-b normalizes synaptophysin and synaptotagmin expression in the synaptoplasm, without affecting their synaptic membrane content. effect of tgf-b neutralization appear to be confined to the presynapse. % of acute pancreatitis (ap) patients develop severe acute pancreatitis (sap), which is is resulted in multiple organ dysfunction syndrome. an extensive inflammatory response occurs due to inflammatory mediators synthesized and secreted during sap. since preventing the inflammation in sap is important in the prognosis of the disease, new drug candidates having strong antiinflammatory effects will provide a new concept for therapeutic strategies against acute pancreatitis. non-steroidal anti-inflammatory drugs (nsaids) show their effects by inhibiting cyclooxygenases (cox- and cox- ) and they play an important role in the pathogenesis of acute pancreatitis. since conventional nsaids inhibit both cox- and cox- , they have serious side effects on gastrointestinal system. therefore, new highly selective cox- inhibitors having fewer side effects are needed. in the present study, selective cox- inhibitory activities and cytotoxic effects of new series of -benzoxazolinone and thiazolo [ , -b ]- , , -triazole derivatives previously synthesized as specific cox- inhibitors with no side effects on gastrointestinal system were investigated. permeability of the compounds was tested by pampa using caco- cells. compounds were found highly selective, non-toxic and permeable. ap was induced in rats via retrograde injection of stc into the pancreatic duct system. rats were pre-treated with saline or celecoxib or the new compounds before stc injection and sacrificed h later. the severity of ap was evaluated using biochemical and histopathological analyses. edema, inflammation, hemorrhage and acinar cell necrosis were detected in the pancreatic tissue of sap group. sap was remarkably increased serum lactate dehydrogenase, ast, alt, lipase and amylase activities and serum tnf-a, il- b, il- , il- and il- levels. tissue myeloperoxidse activity was also increased. pretreatment with the novel compounds reserved all these biochemical and histopathological parameters. alopecia areata (aa) is an inflammatory disease which is affects hair follicles, and sometimes nails. it is suggested that cytokinemediated immunity plays an important role in etiopathogenesis of aa. this study was planned to evaluate the serum ykl- and tgf-b levels of patients with aa. patients with aa and healthy volunteers were recruited into the study. fasting venous blood samples were collected from the participants and serum was obtained by centrifugation. serum ykl- and tgf-b levels were measured by enzyme linked immunosorbent assay (elisa). serum tgf-b levels in the patient group were significantly lower compared to the control group whereas serum ykl- levels were significantly higher in patient group. tgf-b levels of men and women with aa were found to be significantly lower than that of controls. while serum ykl- level of male control group is higher than the male patients, there were no significant differences between women groups. the increased serum ykl- levels in aa patients suggests that ykl- plays a crucial role in the pathogenesis of aa. arterial immune mediated inflammation participates centrally in all stages of the development of atherosclerosis, from the initial lesion to the end-stage thrombotic complications. although emerging evidence supports augmented cardiovascular morbidity and mortality in cutaneous psoriasis (psc) and psoriatic arthritis (psa) as compared to the general population its underlying mechanism is poorly understood. here we analyzed the inflammatory burden in recent onset of psa patients without traditional cardiovascular risk factors (cvrf) in a transversal study measuring carotid intima media thickness (cimt) (measured with ecodoppler), and proatherogenic inflammatory molecular markers like c-reactive protein (crp), interleukin (il- ), and soluble intercellular adhesion molecule- (sicam- ) in comparison with control patients. cimt values are similar in psa ( , ae . *) and psc ( , ae . ) patients. however, both of them were significant increase compared with control ( . ae , ). regarding inflammatory markers il- serum levels in patients with aps was higher than pcs ( ae . ) and healthy controls ( , ae . ) but the difference did not achieve statistical significance (*p > . ). on other hand mean of sicam- , value from patients with recent onset of psa is significant higher than controls. psc remain without significant changes compared to control (*p > . ). in addition mean value from patients with recent onset of psa is significantly higher than in controls (*p < . ) and psc group. overall, preliminary findings suggest for the first time that patients with early psa, without evident traditional cvrf have significant increased values of cimt, sicam- crp against the general population control group. this data strongly supports that early cv molecular markers are increased after the first symptoms and signs of this disease even in the absence of traditional cardiovascular risk factors. furthermore, this give new windows for a proper treatment. p- . . - protective effect of trail against proinflammatory cytokines on pancreatic beta cells correlated with decrease in dr and increase in dcr expressions universitesi, antalya, turkey introduction: proinflammatory cytokines are known to have destructive effects on beta cells, which contribute to type diabetes (t d) development. the combinatory effects of three of these cytokines in particular, namely tnf-alpha (tnf-a), ifngamma (ifn-c), and il- beta (il- b), are claimed to render beta cells prone to t cell-mediated destruction. the recently identified anti-inflammatory feature of tnf-related apoptosis-inducing ligand (trail), its possible protective role in this process. in this study, the effects of applications of trail with tnf-a, ifn-ᵞ, and il- b on beta cell viability and correlation of these effects with trail receptor expression patterns were investigated. methods: glucose-responsive insulin-secreting nit- mouse beta cell lines were treated with tnf-a, ifn-ᵞ, il- b, and soluble trail (strail) individually and in various combinations. cell viabilities were determined at and h by mtt assay. trail ligand and receptor expression profiles on nit- cells, and alterations in receptor expression levels following cytokine applications were determined by western blotting analysis. results: trail treatment did not have any cytotoxic effects on nit- beta cells at h, while increasing cell viability following il- /ifn/trail and il- /tnf/trail combined applications. substantial levels of death receptor (dr ) expression were detected on nit- cells before applications, yet it displayed decreased levels at h of trail treatment. lower levels of decoy receptor (dcr ) expression detected prior to treatments increased significantly in contrast. discussion: the fact that trail co-treatment with tnf-a, ifn-ᵞ and il- b increased cell viability in nit- beta cell lines along with reduction in dr death receptor expression and an increase in the decoy receptor dcr expression, points out to a possible protective effect of trail in insulitis, and strengthens its potential as a putative therapeutic molecule in prevention of beta cell loss. behc ßet's syndrome (bs) is a multisystemic inflammatory disorder with a strong and complex genetic background. being a prevalent disorder both in turkey and also in the ancient trade road 'silk road' countries, bs is an important cause of impairment and disability owing to its chronic and relapsing nature. besides, bs is reported to be an important cause of mortality among the young male patients. while the epidemiology of bs is substantially well documented, currently, the etiology, the molecular mechanisms underlying its pathogenesis, and the classification of the disorder remain to be elucidated. our aim was to disclose the disease mechanisms at molecular level in turkish bs patients by obtaining, comparing, and analysing the transcriptome data of bs patients with age and gender matched healthy controls. for this purpose, by using the affymetrix hg u plus . microarrays, peripheral blood cell mrna profiles of bs patients (b) and matched healthy controls (c) were obtained. following bioinformatics, gene ontology, and pathway analysis, validation experiments of the identified prominent mrnas were performed by qrt-pcr methodology. the comparison of b vs. c yielded differentially expressed gene numbers of and for the chosen fold changes of . and . respectively (p ≤ . for both). during gene ontology and pathway analysis, immune system process, immune system diseases, systemic lupus erythematosus, arthritis, and intestinal immune network for iga production categories/pathways were significantly enriched. clustering analysis revealed a molecular signature which accurately distinguished b and c samples, while the qrt-pcr analysis successfully validated the chosen mrna transcripts. this study documented differential expression of a large number of immune system and immune disease related genes in bs patients. the uncovering of the molecular disease mechanisms of bs will point to novel candidate molecules to be targeted for the treatment of the disorder. obesity is a public health problem in developed countries and worldwide with increasing prevalence through a relationship primarily with atherosclerotic cardiovascular diseases as well as several metabolic disturbances such as increased insulin resistance and diabetes. although several studies identified obesity as an independent risk factor for atherosclerotic cardiovascular diseases, the mechanism underlying the increased cardiovascular risk in obese patients has not been clearly delineated. adma, no, endothelin- and homocysteine are an indicator of endothel disfunction that plays an important role in the pathophysiology of atherosclerosis. in our study, obese children and the control group were compared in terms of adma, no, endothelin- and homocysteine, we also investigated whether there is a correlation between these parameters. obese and healthy children, participated in the study. when the obese group was compared to the healthy controls, the adma level of the obese group were significantly higher than those of the control group but there was no statistically significant difference in no, endothelin- and homocysteine. increased adma level might trigger the pathogenesis of atherosclerosis starting from the childhood years onward. that is why controlling obesity in this age group with diet and other treatment modalities will prevent the mortality and morbidities that will be seen in adult years. inh deficiency leads to the formation of bradykinin causing to dilation of blood vessels. furthermore, the study conducted by shagdarsuren, on the damage done by c -esterase, demonsrates that the complement system and triglyceride levels are affected. we investigated lipid oxidation and fetuin a levels in patients with c _ inh deficiency. materials and methods: people with c _ inh and people without any illnesses were taken into the study. fetuin a was studied using an el _ isa kit from raybio (usa). ferrous ion oxidation-xylenol orange test was used to find looh serum levels. sh (free thiol groups) test was studied with regards to ellmans method modified by hu. _ ibm spss . was used for statistical results. results: in assessments made between the healthy and the illness groups, there was significant differences in the levels of fetuin (p = . ), looh (p = . ) and sh (p = . ). when pearson correlation analysis was performed, we detected a significant positive correlation between fetuin a and looh levels (r: + . ) discussion and conclusion: in these patients, lipids is secreted from the adipose tissue. in response, anti-atherosclerotic fetuin a levels were risen. patients also possessed increased lipid peroxidation, this increase shows positive correlation with fetuin a levels. in conclusion, we identified that sh with antioxidant properties have increased levels. aim: high fructose corn syrups are found in soft drinks, juice beverages, breakfast cereals, most of the processed foods. it has been shown that high dose of fructose intake may lead to a reduction in the number of hepatocytes, deterioration of liver function, increasing reactive oxygen species and liver steatosis. the aim of this study was to explore whether caffeic acid phenethyl ester (cape) has any potential protective effect on high fructose diet-induced fatty liver model. materials and method: totally fifty rats were divided into five groups. control group, % fructose administered group, cape group, % fructose + cape administered group and ethanol group. after weeks, liver oxidant and antioxidant status, and blood tnf alpha, il- , and il- , tissue nfkb levels were quantified. protein levels were investigated against, nfkb and p-nfkb antibodies and normalized and analyzed against b-actin antibody by western blotting. results: serum tnf-alpha, il- , il- levels were found to be increased in fructose group compared with the control group (p < . ). in liver tissue of % fructose administered group, mda, protein carbonyls and no levels were higher than control group. however sod activity did not show any difference among the groups. in the fructose administered group, caspase showed liver apoptosis and was considered as positive. acquired data revealed that nfkb protein level was decreased in the presence of cape while increment in nfkb protein level was observed in the fructose administered group compared with control group. in case of pnfkb antibody, increment observed in fructose only and both cape and fructose administered groups, respectively. in cape only administered group, there was a decrement in the level of pnfkb protein. conclusion: depending on further analysis, experimental findings are expected to implicate the role of cape as a protective agent on high fructose diet-induced fatty liver model in relation of inos, nfkb and p-nfkb pathways. the investigating association of hepcidin levels with iron homeostasis and inflammation variables in pregnant women with intrauterine growth restriction a. g. agg€ ul , n. uzun , e. c ß inar tanriverdi , h. € un agri ibrahim cecen university, agri, turkey, nenehatun maternity hospital, erzurum, turkey this study was designed to investigate hepcidin levels and their associations with iron homeostasis and inflammation variables in pregnant women with intrauterine growth restriction (iugr). a total of pregnant women were included in this study. pregnant volunteers were divided into two groups ( healthy pregnant women and pregnant women with iugr). serum hepcidin, total free iron, ferritin, transferrin, transferrin receptor and interleukin- (il- ) levels were measured by elisa. also, hemoglobin (hb) and c-reactive protein (crp) levels were determined in serum samples from the healthy pregnant women and the pregnant women with iugr. there were significant differences in hepcidin, ferritin, transferrin receptor, crp and il- levels between healthy pregnant women and pregnant women with iugr. hepcidin, ferritin, crp and il- levels in pregnant women with iugr were significantly higher than healthy pregnant women (p). the mediators of systemic inflammation in lipopolysaccharide-induced neonatal sepsis rat model sepsis is an excessive inflammatory response that causes shock, multi-organ failure and high mortality. foreign bacterias and lipopolysaccharides lead to stimulation of endothelial cells to produce biologically active mediators such as proinflammatory cytokines and chemokines, cell adhesion molecules, and growth factors. then these mediators could be act on targets, which were involved in the initiation of systemic inflammation in neonatal sepsis. our aim was to indicate a protective role of thalidomide and etanercept, which have anti-tnf-a activity on systemic inflammatory response in lipopolysaccharide (lps)-induced neonatal sepsis rat samples. thirty -day-old wistar rats were randomly divided into five groups: a control group that received normal saline, a sepsis group that received lps, thalidomide, etanercept and both thalidomide and etanercept treatment group that were administered with therapeutic agents hrs after lps injection. the rats were sacrificed at hrs after lps or normal saline injection (n = ). hepatic tissue tnf-a, il- , icam- and pdgf levels were determined by enzyme-linked immuno sorbent assay (elisa) method in all groups. in sepsis group, tissue tnf-a, il- , icam- and pdgf levels were statistically significantly higher than in controls (p < . ). at same time, pretreatment with both thalidomide and etanercept were found statistically dramatically decreases the levels of tnf-a, il- , and pdgf when compared to sepsis group (p < . ). there were no significant differences in the icam- levels between the all treatment groups and the sepsis group. higher liver tissue tnf-a, il- , icam- and pdgf levels are associated with severe bacterial infection. these proinflammatory cytokines and angiogenic factors may be important in the endothelial dysregulation seen in sepsis. therapeutic agents used in the present study can be help to avoid devastating effects of neonatal sepsis. n-stearoylethanolamine (nse)is saturated minor compound of natural origin that represents the large family of signaling lipids n-acylethanolamines, which belong to endocannabinoid system. considering the crosstalk between obesity-induced inflammatory response and its key role in synaptic dysfunction and neurodegeneration, our current study aimed to investigate the biological effect of nse on brain tissue under high fat diet-induced insulin resistance. previously we found that nse administration to insulin resistant rats caused normalization of liver and pancreas lipid composition followed by the improvement of glucose tolerance and insulin sensitivity (decline in serum insulin level and homa-ir value). moreover, this effect of nse correlated with inhibition of nf-kb translocation into the nucleus of peritoneal macrophages and decreased pool of serum tnfa level in obesity-induced insulin resistant rats. further experiments showed that fat overload triggered significant reduction in the level of main phospholipids (phosphatidylethanolamine, phosphatidylcholine and sphingomyelin), while there were no changes in cholesterol content. nse at a dose of mg/kg during weeks of administration to insulin resistant rats showed a tendency to restore the phospholipid level that was accompanied by increased neural cell survival ( %) compared to rats without treatment ( %). neuroinflammation accompanied by intensive reactive oxygen species (ros) production impairs neurotransmission in a wide range of neurodegenerative pathologies. flow cytometry is used for quantitative analysis of global dna methylation, but fluorescence microscopy is mostly preferred to qualitatively reveal intranuclear localisation of dna methylation and its copattern with other markers. both methods use a similar immunostaining protocol. in this study, we aimed to compare these methods concerning the detection of the global amount of dna methylation. for this, mouse embryonic fibroblasts were cultured either with or without phenol red and then stained for dna methylation or positive controls (histone, betaactin, phosphoakt) by specific antibodies, or nonspecific control antibodies. some cells were incubated with trypan blue before or after the addition of antibodies. fluorescence intensities were measured by the green fluorescence channel ( / nm). autofluorescence spectrum of cells was analysed, and fluorescence channel used for dna methylation detection was changed to red ( nm lp). a poor discrimination between signal and noise was detected due to cellular autofluorescence interfering with specific detection of dna methylation by flow cytometry but not by microscopy. it was also the case for the other markers examined. conventional advances to reduce autofluorescence such using phenol red free culture media or trypan blue quenching were not effective, but using the red channel regarding autofluorescence spectra allows detecting specific staining of dna methylation by flow cytometry. but, green channel did work well for microscopy analysis. findings show that flow cytometry detection of dna methylation requires much attention to quench cellular autofluorescence compared to detection by fluorescence microscopy. one reason could be that flow cytometry detects all cellular content, but manual image-based analysis can exclude cytosolic components. these results suggest the usability of flow cytometry and microscopy as complimentary methods for dna methylation detection, but optimisation to reduce autofluorescence is crucial for flow cytometry. objectives: lung cancers are divided in two main groups as small cell lung cancer (sclc) and non-small cell lung cancer (nsclc) . docetaxel (dtx) and cisplatine are chemotherapeutic that has an anti-tumor activity against various solid tumors. the growing resistance against dtx and cisplatine (cis) still continues to be the biggest obstacle for the treatment success of nsclc patients. deguelin (deg.) is a natural plant derivative and has an encouraging activity against a lot of human cancers. the comparison of the treatment activity of the separate and combined usage of deg., which is a potential chemotherapeutic agent, and dtx, cis which are used in standard treatment, is aimed in this study. material-method: the ic doses of dtx, cis and deg. on the a and h nsclccell lines were determined via the cell vitality tests in our study. the active concentrations determined were applied to nsclc cell lines as deg., dtx, cis and their combinations. the impacts of the medicine are studied by applying flow cytometric analyzes (apoptosis, cell cycle), glutathione and reducted glutathione, colony formation, migration and angiogenesis analyzes on the treated cells and measuring the oxidative stress index (osi). statistical analyse program, rstudio (v. . . ) and the r-script language were used to examine the differences between the agents. the states in which the pvalue was lower than . were accepted as statistically meaningful. results: we found that deg. has pro-apoptotic, anti-migratory and cytotoxic potential on lung cancer cells. deg. amplified cis and dtx-related anti-cancer efficacy (increased apoptotic cell content and cytotoxicity, reduced migration). also, deguelin pretreatment sensitized the cells dtx-treatment (reduced ic values). these effects were remarkable in p -mutant cells. conclusion: deguelin, solely, has anti-cancer potential on nsclccells. both deguelin pre-treatment and combinantion with standart chemotherapeutics result in enhanced anticancer efficacy. the % of the lung cancers are non-small cell lung cancers (nsclc). despite docetaxel (dtx) and cisplatine (cddp) are agents used in the standard treatments of these patients and the recent improvements in the treatments, the response and remission rates observed on the patients are relatively nominal. selenium (se) is an essential diet component and is introduced to have a preventive impact on different levels of cancer. the aim of our study is to investigate the impacts of selenium addition on anticancer feature and tumor prevention before or/and during nsclc standard treatment. the ic doses of dtx, cddp and selenium on the a and h (p mutant) nsclc cell lines were determined via the cell vitality tests in our study. the active concentrations determined and the stipulated available concentrations were applied to cell lines as dtx, cddp, se combinations. the impacts were compared by applying flow cytometric analyzes (apoptosis, cell cycle), glutathione and reducted glutathione, western blot analyzes on the treated cells and measuring the oxidative stress index (osi) and thioredoksin reductase activity. selenium pre-treatments reduced dtx-related ic concentrations at lower doses in both nsclc cells. however, cddprelated ic concentrations reduced dose-dependent manner. selenium supplementation also altered cell-cycle charactheristics at several concentrations and combination regimens. the remarkably higher osi values were observed after dtx treatment and osi levels were found to be lower in selenium pre-treated nsclc cells. selenium sensitizes nsclc cells to dtx treatment at lower concentrations. however, this effect is obtained dose-dependent fashion for cddp regimen. breast cancer is the most common female malignancy worldwide. human epidermal growth factor receptor (her ) is overexpressed in % of breast cancers in association with aggressive phenotypes. the prognosis of metastatic breast cancer remains poor in spite of advances in therapy. as such, her has long been studied as a potential target for anticancer drugs. the modulation of intracellular signaling pathways leads to altered cell metabolism that triggers tumorigenesis and adapts cells to cancer cell metabolism. this characteristic hallmark of cancer metabolism is known as warburg effect meaning energy production via enhanced glycolysis. despite of several studies in breast cancer metabolism, little detail exists on the link between her overexpression and warburg effect. we have committed examining the nature of aerobic glycolysis in her overexpression. in breast cancer cell line mcf , her overexpression (mcf-her ) results in mitochondrial dysfunction with low mitochondrial membrane potential (Δᴪm) and ros accumulation. intracellular iron levels are also higher in mcf -her cells than vector control (mcf -vec). additionally, mcf -her cells show enhanced levels of atp and lactate in association with increase in glucose levels. we have found that complex i activity increases in mcf -her and decreases in knockdown of her in hcc cells that is her positive breast tumor cell line. based on these results, we conclude that there is a link between her overexpression and metabolic indicators of warburg effect. expression and methylation analysis revealed microrna genes deregulated by methylation and new potential target genes of mir- and mir- - p in breast cancer micrornas (mirnas) and methylation of mirna genes play a great role in epigenetic deregulation in malignant tumors. the aim of our study was to assess the contribution of methylation to expression level alterations of mirna genes and to search for novel potential targets of these mirnas. to analyze alterations in expression we used qpcr technique with references (rnu , rnu ) and paired (tumor/normal) breast cancer (bc) samples. for methylation analysis a methylation specific pcr and the same set of bc samples were used. significant downregulation was shown for mir- b- p, - - p, - - p, - a- p, - b- p, - - p, - - p, and - - p (p ≤ . , fisher's exact test) in bc. we observed mirna genes to be hypermethylated and mir- hypomethylated. hypermethylation for of these mirna genes was shown for the first time: mir- , - , and - ( - % of bc cases). a significant correlation between methylation and expression alterations was revealed for mirnas with downregulation: mir- b- p, - - p, - - p, - a- p, and - b- p (spearman's correlation coefficient (rs) was in the range À . to À . , p ≤ . ), and for mirnas with both scene (down-and upregulation) as well: mir- a- p, - a, and - (rs = À . to À . , p ≤ . ). comparative analysis of the data on expression alterations of mirna genes and protein-coding genes, which were predicted as targets by mirwalk . , revealed the negative correlation between expression levels for some potential mirna-mrna interaction pairs. for example, for pairs mir- /rhoa, mir- /rassf (a), mir- - p/dapk (rs = À to À . , p ≤ . ). thus, both mirnas and methylation affect regulatory networks in bc. novel potential mirna-mrna interaction pairs could be useful in the development of bc therapy approach. this work was financially supported by grant - - from the russian science foundation. the authors thank the n.n. blokhin cancer research center for tissue samples. clear cell renal cell cancer (ccrcc) with metastases has pour prognosis: -year survival is about %. micrornas (mirnas) and methylation of mirna genes play a great role in epigenetic deregulation in malignant tumors. the aim of our study was to find out mirnas which methylation contributed to ccrcc progression, including metastasis, and to reveal potential target genes of these mirnas. to analyze methylation status, we used a methylation specific pcr as a method and a representative set of paired (tumor/ normal) ccrcc samples. we also used post-mortal renal tissues from individuals without cancer history as additional control. for expression analysis we used qpcr method and paired ccrcc samples. we observed mirna genes (mir- a- /- /- , - - , - - , - b/c, - - , - a, - ) to be hypermethylated, (p ≤ . , fisher's exact test), mirna genes to be hypomethylated and mir- a with both scene (hyper-and hypomethylation was detected). methylation of mirna genes (mir- a- /- , - b/c, - - , - , - a, - a) correlated with advanced stage and/or tumor size and/or dedifferentiation. hypermethylation of mir- - , mir- a, and mir- significantly correlated with metastasis presence (p < . , fisher's exact test). besides, preliminary data revealed the positive correlation between hypermethylation of mir- - and up-regulation of p protein-coding genes: rarb( ), rhoa, nkiras , and chl , which were predicted as targets by mirwalk . (spearman's correlation coefficients (r s ) was in the range . - . , p ≤ . ). in conclusion, novel supposed interactions of mir- - with target genes could be useful as missing chains in signaling pathways. tests for hypermethylation of mir- - , mir- a, and mir- could be suggested as markers of metastasis and pour prognosis of ccrcc. because of difficulty in diagnosis and treatment hc is a clinical problem: early symptoms of hc are often non-specific and surgical resection is the only curative treatment for hc. it is well known that epigenetic alterations are linked to cancer development. the purpose of this study was to determine potential mechanisms of epigenetic regulation of genes related to energy metabolism in hc. we have performed bioinformatics analysis of the cancer genome atlas (tcga) project rna-seq data with crosshub software and found a number of genes involved in glycolysis and differentially expressed in cholangiocarcinoma. qpcr analysis revealed significantly decreased expression of pgm and eno genes in a majority of hc samples which were known as up-regulated in other human cancers according to the literature date. on the basis of tcga methylation dataset ( k illumina microarrays) we supposed that cpg methylation of pgm and eno promoters may play a role in their inactivation. using bisulfite sequencing study we identified several regions within the gene promoters (pgm :~ bp and bp upstream tss; eno :~ bp downstream tss) that are frequently methylated in hc samples (up to %, / ) with down-regulated pgm and eno expression. thus, we demonstrated frequent and significant pgm and eno down-regulation associated with hypermethylation of the specific regions within the gene promoters in hc. the pattern of pgm and eno gene promoter methylation suggests a possibility of ones to be used for the hc diagnosis and development new strategies for therapy. this work was financially supported by grant mК- . . from the president of the russian federation. the work was performed using the equipment of eimb ras 'genome' center. introduction: the development of stomach cancer is a multifactorial and complex process and includes multiple epigenetic, genetic alterations and dietary/non-dietary factors. iodine as an antioxidant may play a protective role against gastric cancer. the aim of this study was to investigate the changes in iodine level in rat with stomach cancer induced by n-methyl-n -nitro-n-nitrosoguanidine (mnng). materials and methods: a total of sprague dawley rats were randomly divided into six groups. rats were administered with mnng ( lg/ml) by oral gavage on days , and to initiate stomach cancer. during the experiment, rats died and those surviving were sacrificed in the rd, th, th, th and th months of the experimental period (group i, ii, iii, iv, v, respectively). the control group (group vi) contains rat which are given only food and water for months. the stomach tissue was examined histopathologically. and also, iodine levels in stomach tissue was determined using the foss method. results: a decrease in iodine level was determined in stomach cancer tissue of rats in group i-v compared with normal healthy stomach tissue in group vi. when the control (group vi) iodine level was taken as % baseline, the % iodine levels of all groups were determined as follows . , . , . , . and . for groups i-v, respectively. the pathological diagnosis of gastric cancer was adenocarcinoma. discussion and conclusion: the iodine levels of group i were higher than those of group ii (p < . ) and of groups iii, iv and v (p < . ) and also were lower than in the control group (p < . ). iodine deficiency as one of the risk factors of stomach cancer strongly supports the necessity for the application of effective iodine prophylaxis in the areas with iodine deficiency. iodine supplementation might be useful in stomach cancer therapy and therefore, further research is warranted. this study was supported by ataturk university (project number: / ). effect of water extract of turkish propolis on mitochondrial membrane potential in human laryngeal epidermoid carcinoma cell lines propolis is the generic name for the resinous substance collected by honeybees from the buds of various plant sources and it is used by bees to seal holes in their honeycombs, smooth out the internal walls, and protect the entrance of bee hive against intruders. the aim of this study is to investigate what kind of changes the turkish propolis cause on mitochondrial membrane potential (mmp) of human laryngeal epidermoid cell lines (hep- ), by considering its anticancer features. water extract of turkish propolis (wep, - mg/ml) and ethanolic extract of turkish propolis (eep, . - mg/ml) were prepared and incubated with hep- cell lines ( , , and h). mmp was investigated with a flourometric method by using dioc ( , -dihexyloxacarbocyanine iodide). the most significant mmp decrease was seen on rd hour. both wep and eep extracts at all concentrations decrease mmp according to that of control. the recent studies have shown that propolis extracts have induced apoptotic cell death by decreasing mitochondrial membrane potential in various cancer cells. it was concluded that both wep and eep decreased mitochondrial membrane potentials on hep- cell series according to control ( concentration) depending concentration and time. there are numerous transcription factors involved in the regulation of the inducible gene expression. thus, transcription of proinflammatory genes, steroid hormone receptors, etc. is controlled by the group of factors triggering gene expression which includes nf-kb. another group of factors is involved in the formation of the structure of the chromatin of the inducible genes regulatory regions, providing competence for gene expression. it is expected that this group of factors includes the proteins of nf (nuclear factor ) family. there are few data suggesting that the nf factors maintain potentially active state of the chromatin of the hormone-dependent gene promoter regions. these findings initiated studies of the correlation between presence of the nf transcription factors on the chromatin of a gene regulatory region and the functional state of the gene in vivo. as a model we chose the rat tryptophan dioxygenase (tdo) gene which is expressed tissue-specifically in the liver under control of glucocorticoid hormones. three constitutive dnase i-hypersensitive regions are identified in the regulatory region of this gene. to conduct the study we used rat liver and kidney. the basic methods were electrophoretic mobility shift assay (emsa), immunoblotting assay and chromatin immunoprecipitation combined with real-time pcr (chip-qpcr). using emsa we found that the proteins of nf family interact with the constitutive dnase i-hypersensitive regions in vitro. immunoblotting assay of the protein fraction from rat liver used in emsa experiments showed the presence of the nf -b isoform. chip-qpcr revealed statistically significant differences in the level of the factor nf enrichment of the tdo gene regulatory region between the rat liver and kidneys at p < . . these data suggest the involvement of the nf proteins in the formation of the chromatin structure of the rat tdo gene promoter region. reciprocal ( ; ) translocation and bcr-abl fusion protein that is responsible for developing leukemia are observed in more than % of chronic myeloid leukemia (cml) cases. epigallocathecin- -gallate (egcg) is a green-tea flavonoid and egcg is proposed as a natural anti-cancer agent. histone modifications which contain histone deacetylases (hdac) and histone acetyltransferases (hat) are parts of epigenetic regulations. hdacs play important roles in different human malignancies including leukemia via activation of abnormal signaling pathways. hdac inhibitors have become remarkable therapeutic molecules for malignancies. the aim of this study is to determine the expression changes of leukemia-related hdacs with the treatment of egcg in k- cells. the cytotoxic effect of egcg on k- cells was determined in time and dose dependent manner by wst- analysis. total rna was isolated from k- cells. reverse transcription procedure was performed for cdna synthesis and gene expressions were detected by rt-qpcr. the expression level of hdac , hdac , hdac gene that supports cell proliferation was down-regulated . , . , . folds in k- cells treated with ic dose of egcg, according to control, respectively. our current findings suggest that is a polyphenol egcg may be a hopeful agent in treatment of cml by hdac inhibitory effect. chronic lymphocytic leukemia (cll) is a disorder of morphologically mature but immunologically less mature lymphocytes and is manifested by progressive accumulation of these cells in the blood, bone marrow, and lymphatic tissues. carbonic anhydrase (ca) is a metalloenzyme which is widely distributed in the living world, and it is essential for the regulation of acid-base balance. anti-ca antibodies have been reported in many disorders, such as systemic lupus erythematosus, sj€ ogren's syndrome, rheumatoid arthritis, endometriosis, idiopathic chronic pancreatitis, type diabetes and graves' disease. the goal of this study was to investigate carbonic anhydrase i and ii (ca i and ii) autoantibodies in cll. patients with cll and healthy controls were included in the study and ca i and ii autoantibody levels were investigated by elisa. the ca i autoantibody levels of cll group were significantly higher than the healthy group (p = . ) while there was no statistical difference between serum ca ii autoantibody levels of the groups (p = . ). we found a significant positive correlation between hemoglobin and hemotocrit levels in patients with cll (r = . , p = . ). cut-off value of . absu for anti-ca i was associated with % sensitivity and % specificity and a cut-off value of . absu for anti-ca ii was associated with % sensitivity and % specificity for predicting cll. the ca i autoantibody levels in patients with cll were found higher compared to control group and the results suggest that ca i autoantibody may be involved in the pathogenesis of cll. genetic and epigenetic aberrations can lead to the activation of oncogenes and inactivation of tumor-suppressor genes (tsgs) followed by the development of malignant tumors. in the present work we evaluated the frequency of alterations of cpg island methylation and dna copy number in paired (tumor/normal) breast cancer (bc) samples using comparative dna hybridization on noti-microarrays and original niman software. the microarrays contained noti-clones associated with chromosome genes. expression alterations were assessed with the use of qpcr technique, ddct method and original atg software. in total, noti-sites with high ( - % of cases) hypermethylation/deletion (hm/d) frequency were revealed in bc. among genes associated with these sites, there are both known tsgs and tsg-candidates (aldh l , vhl, ctdspl, etc.) as well as genes, which involvement in breast oncogenesis was shown for the first time (lrrn , foxp , prickle , etc.). noti-microarray data were verified selectively using bisulfite sequencing for vhl, nkiras , itga , lrrc b, and ctdspl genes. several genes with high hm/d frequency (aldh l , ephb , itga , and ropn ) were tested for expression alterations using qpcr. frequent ( - % of cases) and significant (> -fold) down-regulation was shown for all of them in bc. the most significant expression loss was observed for aldh l geneon the average -fold mrna level decrease in % of samples. the involvement of the majority of genes with high hm/d frequency in breast oncogenesis was shown for the first time. these genes are novel tsg-candidates in bc. functional hypermethylation associated with expression loss was shown for aldh l , ephb , itga , and ropn genes thereby strengthening the speculation on tumor suppressor abilities of these genes. methylation and expression analyses of genes, that were revealed by noti-microarrays, were financially supported by grant - - from the russian science foundation. functional hypermethylation of a number of chromosome genes was revealed in colon cancer using noti-microarrays cancer is a disease of genome caused by genetic and epigenetic aberrations. noti-microarrays, that were developed by prof. e.r. zabarovsky, is a unique tool that allows us to simultaneously detect hypermethylation of cpg islands and dna deletionstwo major reasons of inactivation of tumor suppressor genes (tsgs). in the present work, the frequency of chromosome genetic and epigenetic alterations in colon cancer (cc) was evaluated. noti-microarrays, that contained noti-clones associated with chromosome genes, were used for comparative (tumor/normal) hybridization of dna from paired cc samples. data analysis was performed using original niman software. expression alterations were evaluated using qpcr technique and original atg software. in total, noti-sites with % and above hypermethylation/ deletion (hm/d) frequency were revealed in cc. among genes associated with these sites, there are several known tsgs and tsg-candidates (for example, vhl, ctdspl, and itga ), but for the majority of genes, involvement in colon oncogenesis was shown for the first time (for example, lrrn , nbeal , and ube e ). the highest hm/d frequency was observed for ankrd , nkiras /rpl , itga , cmtm , and gor-asp /ttc a genes - - %. expression alterations were evaluated for genes with high hm/d frequency (plcl , prickle , and ppp r a) and significant mrna level decrease (> -fold) associated with hypermethylation was shown for all of them in the majority of samples. a number of novel potential tsg-candidates was revealed in cc. functional hypermethylation associated with expression decrease was shown for plcl , prickle , and ppp r a genes thereby enhancing the suggestion on tumor suppressor function of these genes. this work was financially supported by in many countries, radon is the second leading cause of lung cancer, which accounts from % to % of cases. it is obvious that the population of all the developed and industrial countries in the world spend most f their time, almost %. therefore it is necessary to explore the obtained radiation dose, because of the presence of radon in a room due to the radon emanation from the soil and exhalation from a variety of building materials. the developed countries solve this problem of radon pollution as well as create a special monitoring services. the paper presents some data of genes molecular-genetic analysis from patients with lung cancer who live in almaty located in a foothill area of tectonic faults. the object of research were blood samples obtained from patients diagnosed with lung cancer who are receiving a treatment at the almaty oncology center and living in the city of almaty, where the level of radon activity exceeds the norm approved by the international commission on radiation safety. as a control group relatively people living in the plains, characterized by a lower radon emanation have been considered. to determine mutations in the genes polymerase chain reaction with a subsequent analysis of restriction fragment length polymorphism has been conducted. the pcr products were subjected to hydrolysis by bstni restriction endonucleases haeiii, ras i. disturbances in the genes under consideration to variour types of cancer development. the analysis showed that examinees do not have mutations in the kras gene codons - , which corresponds to a control group consisting of people living in the city of balkhash. on the whole, molecular genetic studies have shown that examined patients do not have mutations in the kras gene. one mutation was been found in the egfr gene. aim: polyps are abnormal growths of tissue that can be found in gastro intestinal system. they are most often found in the colon and rectum. most polyps are noncancerous (benign) however, because of abnormal cell growth, they can eventually become cancerous. the aim of this study is to determine the concentrations of trace element contents in colon and rectum polyp tissues and whether there is any relationship between polyp tissue element levels and the disease. material and method: the present study was conducted on total of individuals including patients and healthy subjects. while receiving normal intestinal tissue from healthy control group; from the patient group both normal tissue and polyp samples were taken during colonoscopy procedure. the concentrations of the elements (al, cr, mn, fe, co, ni, cu, zn, as, se, ag, cd, hg and pb) were determined with induced coupled plasma-mass spectrometer. results: the mean concentrations of cr, mn, ni, se and ag in colorectal polyp tissues of patients were significantly higher than in colorectal tissues of control subjects (p is less than . ). on the other hand the mean concentration of cd and pb in colorectal polyp tissues of patients were significantly lower than in control colorectal tissues of control subjects (p is less than . ). there was no any significant difference between the groups in terms of concentrations of al, fe, co, zn, as and hg (p is more than . ). conclusion: the differences found in some elements between polyps and a control tissues may provide an indication about the role of trace elements in the early stage (polyps) in the colon carcinogenic process and encourages further studies to confirm the involvement of such elements in neoplastic processes. the use of herbal medicines is steadily growing, with approximately % of the population use herbs to treat various illnesses in the western world. vitex agnus-castus has been used since ancient times as a remedy. the aim of this study was to investigate the in vitro anticancer activities of vitexagnus-castus oil. for this purpose, the cytotoxicity of vitexagnus-castus oil in sh-sy y cells was investigated by crystal violet staining. ec was found to be . %(w/w) vitexagnus-castus oil for this cell line. this dose was applied to the cell for h, and the cells were harvested for further studies. vitex agnus-castus oil treatment increased bax and p mrna levels. on the other hand, bcl- , bcl l , erk- , jnk, caspase and mrna expression levels were reduced significantly withvitexagnus-castus oil treatment while p and pten remained unchanged. these results indicate that another effector caspase such as caspase or may be involved apoptosis process which remains to be elucidated. moreover, mapk pathways, p and erk, may be involved in vitexagnus-castus oil induced apoptosis in sh-sy y cells. these initial observations suggest that this agent might not be useful in treating cancers. further detailed studies should be carried out to elucidate the exact mechanism of vitexagnus-castus oil in neuroblastoma cell lines. melanoma is a skin cancer with a melanocyte origin that can occur in any part of the body that contain melanocytes. while melanoma is less common than other skin cancers, it causes the majority of deaths related to skin cancer. several gene expression databases have shown that interferon regulatory factor (irf ) is upregulated in melanomas, and genome wide association studies linked variation at irf locus with skin cancers. irf was first identified to have roles in lymphocyte development and function. studies have identified a 'non-oncogene addiction' of malignant cells to irf in various hematopoietic cancer types. the aim of this study is to investigate the role of irf in melanoma cell lines. lentiviral vectors were used to reduce irf levels in melanoma cell lines. a gfp competition assay was performed to study the competitive fitness of melanoma cells with irf knockdown (gfp positive cells) over melanoma cells with normal irf levels (gfp negative cells). cell cycle profiles were investigated in melanoma cells with irf knockdown by propidium iodide staining. migration potential was assessed as well by wound healing assay. our preliminary data showed a decreased competitive fitness for cells with decreased irf levels. cell cycle profiling showed increased g /g and decreased g /m levels in irf knockdown cells compared to controls. wound healing assay results showed no difference between controls for cells with reduced irf levels. taken together, these results indicate that irf knockdown affects the melanoma cell lines' survival and cell cycle profile, suggesting a non-oncogene addiction of melanomas to irf . these observations are largely similar to previous observations in hematopoietic cancers. unravelling the role of irf in melanoma will increase our knowledge about melanoma development and progression and thereby may lead to targeted therapy in melanoma treatment. humans are exposed to various chemicals having beneficial or toxic effects at a time in their daily lives. , -dimethylbenz[a] anthracene (dmba) is a carcinogenic compound produced during the incomplete combustion of carbon-containing compounds. endosulfan is an organochlorine pesticide used against insects on food. morin is an antioxidant, antiinflammatory and chemoprotective flavonoid. this study is aimed to determine the effect of morin in the presence of dmba and endosulfan. for this purpose, adult wistar male rats weighing - g were randomly selected and divided into eight groups. mg/kg body weight (b.wt.) morin and . mg/kg b.wt. endosulfan were given to morin and endosulfan treated groups three times in a week. the rats in dmba treated groups were gavaged with . mg/kg b.wt. dmba three times during the administration period ( days). cytochrome p a (cyp a) associated -ethoxyresorufin o-deethylase (erod) and glutathione s-transferase (gst) activities were measured in rat liver cytosols and microsomes. in addition, liver tissues were evaluated by histopathological analysis. erod activities of control, morin, endosulfan, dmba, morin+endosulfan, morin+dmba, dmba+endosulfan and morin+dmba+endosulfan groups were ae , ae , ae , ae , ae , ae , ae and ae pmol/min/mg protein, respectively. all treatments increased erod activities. gst activities of these groups were ae , ae , ae , ae , ae , ae , ae and ae nmol/min/mg protein, respectively. histopathological studies showed that endosulfan and dmba induced inflammation in the liver tissues and morin reduced their effects. in conclusion, morin treatment increased the metabolism of dmba and endosulfan by inducing cyp a activity. gst activities of morin+dmba+endosulfan group were not significantly different from those of dmba group. histopathological studies indicated that morin administration reduced the toxic effect of endosulfan and dmba in the liver cells. hepatocellular carcinoma (hcc) is the sixth most common cancer and third most frequent cause of cancer-related death worldwide. molecular mechanisms of hepatocarcinogenesis is still unclear. the impairment of epigenetic mechanisms is implicated in the development of multiple cancers, including hcc. transforming growth factor-beta has been shown to play both tumorsuppressive and tumor promoting roles. transforming growth factor-beta signaling pathway involves activation of smad and smad by the type i receptor and formation of smad / / heteromeric complexes that enter the nucleus to regulate transcription. -deazaneplanocin a is an inhibitor of the histone methyltransferase ezh . we aimed to reveal the effect of -deazaneplanocin a on transforming growth factor-beta /smad pathway in hepg cell line. hepg , a human liver cancer cell line cultured in dulbecco's minimal essential medium supplemented with % fbs. the cells were seeded the day before -deazaneplanocin a administration and then the cells were treated with lm -deazaneplanocin a for days. expression levels of genes were analyzed by roche lightcyclerÒ . gapdh was used as housekeeping gene. apoptosis assay was performed by the muse annexin v and dead cell assay kit. the unpaired t-test was used to compare variables and p < . was accepted as statistically significant. -deazaneplanocin treatment was significantly reduced transforming growth factor-beta, smads - in hepg cells (p < . ). we also found that -deazaneplanocin induces apoptosis in treated cell line (p < . ). as a result, -deazaneplanocin a may take place in treatment of hepatocellular cancer by its inhibitory effect on transforming growth factor-beta /smad pathway and inducing apoptosis in liver cancer cells. brefeldin a (bfa) is a lactone antibiotic first isolated from the fungus eupenicillium brefeldianium. bfa inhibits the transport of secreted proteins from endoplasmic reticulum (er) to golgi apparatus, leading to disruption of golgi function, accumulation of unfolded and not fully incompletely processed proteins in er. bfa also inhibits cell proliferation, phosphorylation and migration of cancer cells. therefore in this study, we investigated the effects of bfa on breast cancer cell proliferation of various phenotypes. in we observed that bfa inhibited the proliferation of all three phenotypes of breast cancer cells, but the effects of bfa were seen at different times and doses. according to time and dose, bfa was observed more effective to mcf- compared to other cell lines. physiological, pathological and physical factors. moreover, nlr may represent the two opposing inflammatory and immune pathways that exist together in cancer patients. we aimed to investigate nlr in breast cancer in our population. methods: using data retrieved from the medical records, women diagnosed primary breast cancer met our study inclusion criteria as they had a complete blood count with leukocyte differential performed before any anti-cancer therapy. and women with benign mammary neoplasm/disease, followed up in the outpatient clinics of mammary disease and confirmed with sonographical/histopathological examination, made up our controls. exclusion criteria included laboratory evidence of white blood cells count (wbc) > . /l. differential leukocyte counts were obtained by bc (mindray medical international ltd., china), we examined wbc, neutrophil, lymphocyte, platelet counts, and hematocrite, nlr, mean platelet volume values. results: although there is lack of evaluation of tumor-associated neutrophils and lymphocytes, higher nlr median values and lower lymphocyte mean counts (lymphopenia) were shown in women with breast cancer (p < . ). there was a weak negative correlation in breast cancer between nlr values and platelet counts (r s = À . ; p = . ). holmboe] is distributed throughout southern mediterranean europe from spain to the eastern mediterranean on anatolian peninsula of turkey. present study was designed to investigate the in vitro anti-cancer activities of turkish black pine essential oil. the essential oil was extracted by steam-hydrodistillation and its chemical composition analyzed by gc-ms. the major components of the essential oil were a-pinene, b-pinene and trans-b-caryophyllene, respectively. the crystal violet staining method was used to investigate the cytotoxicity of essential oil in sh-sy y cells. ec was found to be . % (w/w) essential oil for sh-sy y cells. neuroblastoma cells were incubated at °c for h. after h, cells were harvested for further studies. bax and p mrna levels were significantly elevated in essential oiltreated cells. on the other hand, bcl- , bcl l , casp- , casp- , erk- and jnk expression were significantly downregulated. unlike these proteins, p and pten mrnas were not changed. in this study, apoptosis was enhanced by turkish black pine essential oil treatment which was activated by the involvement of another effector caspase subfamily, like casp- and casp- . additionally, erk and p mapks may be associated with upregulation of the level of bax. based on these results, we suggest that p. nigra subsp. pallasiana essential oil might not be well-suited in cancer treatment. however, further detailed research is necessary to establish the exact role of p. nigra subsp. pallasiana essential oil in sh-sy y cells. p- . . - the protective effect of newly derivatized compound naringenin-oxime and relative to naringenin against cisplatin-induced nephrotoxicity and genotoxicity in rat background: the aim of this study was to evaluate the possible protective effect potentials of newly derivatized compound naringenin-oxime (ng-ox) relative to efficacy of free naringenin (ng) on cisplatin (cis) induced nephrotoxicity and genotoxiticity in rat. methods: totally, fifty six male wistar albino rats were equally divided into eight groups as follows: control; cis treatment ( mg/kg b.w., i.p.), ng and ng-ox ( mg/kg b.w., i.p daily for days) alone treatment; cis + ng ( or mg/kg b.w., i.p daily for days) and cis+ng-ox ( or mg/kg b.w., i.p daily for days) combination treatment. at the end of the study total antioxidant capacity (tac) levels, total oxidant status (tos), lipid peroxidation (lpo), total thiol, catalase (cat) were studied in homogenate kidney. peripheral lymphocyte cell dna damage was investigated with comet assay results: the results suggest that cis induces oxidative stress resulting in increased tos and lpo reduction thiol, tac and cat in kidney and increased peripheral lymphocyte cell dna damage. the treatment with naringenin and naringenin oxime alone or with cis treatment showed a protective effect against the toxic influence of cp on peroxidation of the membrane lipids and an altering of the total thiol status in the kidney of rats. from our results we conclude that naringenin and naringenin oxime functions as a potent antioxidant and suggest that it can control cp-induced nephrotoxicity and genototoxicity and ng-ox was found more protective than that of ng on cisplatin induced toxicity in rats. keywords: naringenin, naringenin-oxime, antinephrotoxic, antigenotoxic, comet assay. introduction: oxidative damage is considered to play a pivotal role in ageing, several degenerative diseases, and carcinogenesis. lung cancer is the most common type of cancer, resulting in over . million deaths each year worldwide. accurate and reliable determination of superoxide radicals has been widely investigated using spectrophotometric, electrochemical, amperometric, polarimetric, piezoelectric technologies. among these methods, electrochemical detection is a most promising approach to achieve accurate, separate and rapid superoxide radicals monitoring with using biosensor system. materials and methods: we used a new technic for detecting superoxide radicals in samples. superoxide dismutase (sod) enzyme immobilized on the surface of gold electrode with the help of gelatin, bovin serum albumin (bsa) and glutaraldehyde (ga) crosslinker. for the biosensor preparing benzoquinone selected as a mediator in working buffer and measurements were carried out at À . v. result: for the optimization studies, effect of the bsa, gelatin, glutaraldehyde, ph, buffer concentration on biosensor response. characterization of the biosensor commitment to the work process and answer reproducibility were evaluated. the analytical characteristic of the biosensor were evaluated by measuring the steady state current response to superoxide radical concentrations. the electrochemical response of the enzyme electrode was linearity gradually leveled of at higher concentration. we found that crosslinking of the sod (e.c. . . . ) with glutaraldehyde could be achieved over a wide range of relative mole ratios in mm phosphate buffer at ph . , glutaraldehyde concentration of % . . discuss and conclusion: in this study, a new technique for developed sod biosensors has been developed, which features effective combination of sod/gelatin/bsa/ga modified electrode, trapping of sod and glutaraldehyde cross-linking. this technique is reliable and cost effective. the effect of astaxanthin on apoptosis and cell arrest in u brain cancer cell line f. s€ og€ utl€ u, b. € ozmen yelken, c ß . kayabasi, a. asik, s. gonca, r. gasimli, s. yilmaz s€ usl€ uer, c ß . biray avci, c. g€ und€ uz department of medical biology, izmir, turkey a brain tumor is a collection, or mass, of abnormal cells in your brain. brain tumors can be cancerous (malignant) or non-cancerous (benign). the brain is one of the least accessible organ that active pharmacological compounds cannot be delivered. the two physiological barriers control and block the entry and exit of endogenous, exogenous compounds. one of these is the bloodbrain barrier and the other is the blood-cerebrospinal fluid barrier. this structures maintain protection of the brain. when there is a cancer case, it can lead to problem. astaxanthin with potent antioxidant properties can cross blood-brain barrier. in our study, we aimed to evaluate the effects of astaxanthin on apoptosis, cell cycle and also migration in brain cancer cell line. in present study, xcelligence real-time cell analyzer was used so as to determine cytotoxic effect of astaxanthin in u cell line. changes of apoptosis and cell cycle in u cell line exposured to ic dose of astaxanthin ( . nm- lm) are detected with annexin v-egfp apoptosis detection kit and cycle test plus dna reagent kit with facs, respectively. the result of apoptosis and cell cycle test was analysed in flow cytometry. the group to which active substance was not treated was used as controlled. the wound healing assay performed in order to measure migration ability of u cell line to which astaxanthin was treated or not. ic dose of astaxanthin was calculated as . lm at h by xcelligence rtca sp based on time and dose. astaxanthin decreased the migration ability at rate of % in u cells treated by ic dose of astaxanthin. astaxanthin had no apoptotic effect on viability in u cell line and astaxanthin caused an increase of g /m phase arrest ( . fold) and s phase arrest ( . fold). astaxanthin has cytotoxic effects in brain cancer. it determined that astaxantin decreases cell cycle potential at g /m even a little. the effect of anticancer of astaxanthin should be researched further. interferon regulatory factor (irf ) is a critical transcription factor in development and survival of different cell types including immune cells and melanocytes. furthermore, it has been demonstrated that irf expression levels are elevated in several lymphoid cancers, and irf is one of the key transcription factors for the survival of these cancers. several genome-wide association studies identified irf -linked genetic variants to increased melanoma incidence. in addition results from our lab and elsewhere have shown high levels of irf expression in melanoma cell lines. furthermore our preliminary results suggest melanoma cells are sensitive to irf expression levels. however, there are no published studies about irf target genes in melanoma cells. in this study, we are investigating the genome-wide target genes of irf in melanoma cell lines via high-throughput sequencing of immunoprecipitated chromatin (chip-seq). we have identified possible irf binding regions in loci with known key roles in development of melanocytes from neural-crest cells. one such key factor is mitf, which is the master regulator in melanocyte development and also plays critical roles in melanoma. integrating chip-seq and rna-seq data suggests irf as a transcriptional regulator of genes related to progression of melanoma. objectives: aim of this study was to evaluate prognostic importance of selected laboratory parameters (c-reactive protein (crp), gama glutamiltransferaz, ferritin (fer), potassium, chloride, calcium, phosphorus, magnesium, total protein, aspartat aminotransferaz, alanin aminotransferaz (alt), ifn-c, il- , tnf-a) in non-small cell lung cancer (nsclc). material and methods: patients with nsclc who were treated with chemoradiotherapy (crt) prospectively evaluated. all patients were newly diagnosed tumour. heparinized blood samples were taken from the patients before and after the completion of crt. fer analyzed by chemiluminescence method on beckman coulter dxi ; ifn-c, il- , tnf-a were analyzed with elisa kits (boster biological technology) and other biochemical parameters analyzed on abbott architect c . post-crt and pre-crt levels compared with survival. results: the lr cox regression analysis revealed that pre-crt ferritin was significantly associated with survival of patients with nsclc (hazard ratio (hr) = . , p = . , %ci; . - . ). it was also demonstrated by lr cox regression analysis, high levels of pre-crt crp was associated with worse outcome of patients (hr = . , %ci; . - . , p = . ). after crt, mean alt level was determined as . . there was survival difference in nsclc patients with high post-crt alt (hr = . , %ci; . - . , p = . ). conclusions: there exists a clinically relevant relationship between pre-crt fer concentration and the prognosis of survival in patients with nsclc. elevated fer is the result of inflammation rather than body iron overload. ferritin showed negative correlation with survival so it could be a useful biomarker to indicate bad prognosis of the patients with nsclc. additionally, crp which is easy to detect and feasible for the use in the routine clinical practice should be considered in the prognosis of nsclc patients. keywords: ferritin, nonsmall cell lung cancer, survival, c-reactive protein. epigenetic therapy tries to reverse the aberrations followed to the disruption of the balance of the epigenetic signaling ways through the use of natural and synthetic compounds, active on specific targets, such as dna methyltransferases (dnmts). we previously synthesized some benzoxazole and benzamide derivatives which might have anticancer activities on account of their heterocyclic structure. our studies showed that not only these compounds caused selective cytotoxicity towards cancer cells (hela) with little or no toxicity on normal cells (l ) but also were not genotoxic. in this study, we aimed to test whether these compounds changed global demethylation profile of normal and cancer cells. we used methylation specific comet assay (msc assay) to determine global methylation levels of cells. cells were treated with the tested compounds at ic concentrations for h. slides were prepared as did in alkaline comet assay, then they were incubated with methylation specific restriction enzymes (mspi, hpaii) before electrophoresis. differences in global methylation levels between nontreated control cells and cells treated with compounds were compared by using tail moment data. -aza-c, a demethylating agent, was used as reference drug. msc assay results revealed that none of the tested compounds caused hypermethylation on both cell lines. however, global methylation levels decreased statistically (p < . ) through both cells treated with c- and c- . only c- decreased methylation level on l but not on hela. consequently, c- and c- caused demethylation on hela cells similarly with -aza-c at low concentrations. for the reason that dna methylation is regulated mainly dnmt enzymes in the cell, c- and c- might cause global demethylation in the cell by inhibiting dnmt activity. further studies will be done to support this prediction. overall, macrophages and some subtypes of lymphoid cells are found in tumour stroma. these cells secrete a variety of growth factors, proinflammatory cytokines and chemokines, esp. tnf-a, il- b and il- , causing the formation of inflammatory microenvironment around tumour cells. tnf-a and il- b signaling increases activity of nf-kb pathway. at the same time, il- , triggers jak-stat signaling pathway, which effector is stat . nf-kb and stat activity facilitates hyperexpression of mir-nas mir- , mir- and mir- as well as down-regulates expression of mirnas mir- / , mir- and let- . this investigation aims to identify in what way these shifts in mirnaome can lead to epigenome reorganization supporting the cell transformation. mirna targets within gene transcripts were predicted in silico using targetscan software. transcripts of hdac / / / and sirt / genes encoding histone deacetylases carry targets for at least one of up-regulated mirnas mir- , mir- or mir- . also, these mirnas can silence ezh , mll, mll , nsd , setd / / , smyd , suv h genes encoding histone methyltransferases. mirna mir- suppresses gene encoding de novo dna methyltransferase dnmt b. at the same time, down-regulation of mirna mir- / can allow hyperexpression of gene encoding acetyltransferase elp . these shifts impair dna and histone methylation, cause the increase of overall level of chromatin acetylation and expression and, therefore, create epigenetic background for reactivation of silent transposons, oncogenes as well as other genes important for cell transformation. immune system can paradoxically facilitate the tumour growth instead of healing. cancer-related inflammation leads to the mir-naome and epigenome shifts contributing to the tumour promotion and progression. lysine acetylation is one of the key mechanisms to regulate chromatin structure and transcriptional activation. acetyl-lysine modifications are recognized by bromodomains, which are small interaction modules found on diverse proteins including histones. among these acetyl-lysine reader proteins is the family of the bet (bromodomain and extra-terminal) proteins which contain tandem bromodomains (bd and bd ). the recent discovery of potent and specific inhibitors for the bet family proteins has stimulated intensive research activity in diverse therapeutic areas, especially in oncology, where bet proteins regulate the expression of key oncogenes and anti-apoptootic proteins. several bet inhibitors are currently in clinical trials and reported to exhibit promising clinical activities. however, pleiotropic nature of bet proteins regulating tissue-specific transcription has raised safety concerns and suggested that attempts should be made for domain-specific targeting. here, we report the recent progress in the development of bet inhibitors in korea research institute of chemical technology (krict). we have identified the bet inhibitors with a novel scaffold different from the previously reported diazepine and azepine scaffolds and specific for first bromodomains (bd s). a medicinal chemistry effort is currently made to optimize the pharmacokinetic properties of these lead compounds for further drug development. the experimental data from the biochemical and cell-based assays for these bd -selective bet inhibitors will be presented. family of small c-terminal domain serine phosphatases (scp), which includes ctdspl, ctdsp , and ctdsp , plays a regulatory role in a number of vital processes. in particular, it is shown that ctdspl is capable to activate the retinoblastoma protein (rb) which is well-known tumor suppressor and one of the key cell cycle regulators. although the question on whether ctdsp and ctdsp dephosphorylate rb is open, high similarity of sequences and three-dimensional structures of phosphatases may indicate the similar function of these enzymes. in the current study expression of scp genes was evaluated by quantitative pcr in non-small cell lung cancer (nsclc) samples. using original crosshub software, that combines an analysis of high-throughput sequencing data of the cancer genome atlas project (tcga) and databases of mrna-mirna interactions (targetscan, mirtarbase, etc), the involvement of mir- - - microrna cluster in co-regulation of ctdspl/ / genes in nsclc was predicted. the significant ( -fold on the average) and simultaneous decrease of mrna levels of ctdspl/ / genes was revealed in the majority of nsclc samples ( %, / ). such unidirectional expression change and strong positive correlation between phosphatase expression levels (r s = . - . , p ≤ . ) allowed us to suggest a common mechanism of their inactivation. we evaluated the expression of predicted co-regulators of scp gene expression, mir- - - family, in examined nsclc samples. as a result, the simultaneously increased levels of all three mir-nas in most nsclc samples ( %, / ) and negative correlation with phosphatase gene expression was shown. the results suggest the ability of investigated phosphatases to exhibit tumor-suppressive activity and the involvement of mir- - - micrornas in the regulation of rb protein activity via inactivation of ctdspl/ / in nsclc. cancer is one of the leading causes of death in all around the world. cancer is defined as a disease involving abnormal cell growth with the potential to invade or spread to other parts of the body. tumor markers are substances that are produced either directly by the tumor or as an effect of the tumor on healthy tissue. tumor markers can be used for screening, determining prognosis and monitoring effectiveness of therapy and disease recurrence. the aim of this study is to investigate the frequency of tumor markers orders and the appropriateness of these requests. laboratory information systems data for were reviewed. for , a total of patients and tumor marker requests were included. carbohydrate antigen - , cancer antigen , cancer antigen - , prostate specific antigen, alphafetoprotein and carcinoembryonic antigen were measured by chemiluminescence method. according to the data from the year of , both positive tumor markertest resultsratio and the positive patient ratio were %. in the patients group with increased marker levels, % of the patients had no history of cancer. in the patients group with tumor marker levels in referenceranges, % patients with diagnosed cancer history in remission. the ratios of positive tumor markers were % forca - , % for ca , . % for psa, %for ca - , . %for afp, and . % for cea. in conclusion; unnecessary test requests increase laboratory work load and health expenses. laboratory and clinical staff collaboration is crucial to increase the appropriate use of tumor markers. dna methylation is an epigenetic modification that is involved in both normal biological and disease states. hypermethylation of promoter regions of tumor suppressor genes have a role in tumor development. therefore, the measurement of promoter methylation of genes can be used for diagnosis and prognosis purposes of cancer. to detect dna methylation alterations in a sample (biopsy, blood, saliva, etc.), sensitive detection systems and optimization of the methods are needed. as a part of a collaboration project between national metrology institute of korea (kriss) and national metrology institute of turkiye (tubitak ume). dna methylation status of apc and gstp genes were studied. dna methylation measurements were performed using stepone real-time pcr system and results were analyzed using hrm (high resolution melting) software. the parameters effecting the quantification of dna methylation were found as primers, annealing temperature, pcr cycle number, fluorescence dye and the commercial dna methylation standards used for quantification of dna methylation. since, the accurate measurement of dna methylation is very critical in early diagnosis of cancer and choosing the right therapy, optimization of the method is required. cancer is a disease that includes heterogenic and complex molecular changes. anti-carcinogenic effects of resveratrol, a natural polyphenol, have been proved in a variety of cancer cells. considering the effects of resveratrol, the influence of the signal transduction pathways in the presence or absence of p of colon cancer cells is gaining importance. our aim was to investigate the effects of resveratrol in the presence or absence of p on cell viability, apoptotic cell death ratio and fold changes of proliferative or anti-proliferative gene expressions, which may have important effects on colon cancer, in hct colon carcinoma cells. ic doses of resveratrol were determined by wst- assay. the apoptotic cell death ratios in treatments of resveratrol were determined by annexin-v-fitc/pi assay for flow cytomety . the changes of ccnd , fra , ppard, egfr, birc , pcna, mcl , stat , fos, jun, p , atf , trail, puma, gadd a, rb , faslg, tnf, socs , stat gene expressions were evaluated by real time pcr. all data were statistically analyzed by student's t test. our research has revealed that resveratrol ( lm) causes decrease in cell viability and increase in apoptotic cell death in hct p (+/+) and hct p (À/À) cells significantly (p < . ). the fold changes of the gene expressions have shown that resveratrol has significant (p < . ) and different effects on the expressions of the genes related with the existence of p in hct cell lines. therefore we proposed that resveratrol might show proliferative or apoptotic effects related with p mutation of colon cancer cells and we predicted that unconscious consumption of resveratrol in colon cancer patient might cause adverse effects. introduction: colorectal cancer (crc) is the third most common cancer worldwide. alterations in methylation profiles of tumor suppressor genes (tsgs) have been recognized as a key mechanism in colorectal cancers. in the current study, we investigated the hypermethylation status of tsgs in colorectal cancer tissues. materials and methods: formalin-fixed paraffin-embedded (ffpe) tissue samples obtained from patients with crc. methylation specific-multiplex ligation dependent probe amplification (ms-mlpa) technique was used to assess the methylation status of tsgs. the findings were evaluated in terms of age, mortality, survival, positive lymph node status, lymphovascular invasion, and perineural invasion. results: hypermethylation-detected patients and hypermethylation-undetected patients were called as group and group , respectively. hypermethylation was detected in atm, cdkn a, and gata genes. mortality rate was ( . %) in group and group (p > . ). mean -years survival rate in group was ae months and mean -years survival in group was ae months (p > . ). positive median lymph node count was ae for group and ae for group and the difference was statistically significant (p < . ). frequencies of perineural invasion and lymphovascular invasion rate in two groups were % (p > . ). discussion and conclusion: our findings suggest that tsg hypermethylation found in crc patients may increase the lymph node metastasis. further investigations with larger sample size are required to support our results. boron (b) is known to be important for cell replication and development, but the underlying mechanism remains obscure. recently b has also become important in some specific anticancer processes. some recent reports advise using of some boron compounds for the treatment of specific forms of cancer. for instance, boron-based drugs (bortezomib) are now being developed for use as therapeutic agents with anticancer activities and several other boron-based compounds are in various phases of clinical trials. it has been shown that bortezomib disrupts the regulation of cell cycle and induces apoptosis in both hematologic and solid tumor malignancies except for colon carcinoma. colorectal cancer (crc) is the third most common cancer in men and the second in women, accounting for % of all tumour types worldwide. cytotoxic effects of boron compounds on crc cells and changing of its effects related with p mutation, which is mutated % of cancer cases, have not take part in literature yet. for this purpose; the aim of the study was designed to investigate the effects of borax pentahydrate and disodium pentaborate decahydrate compounds on cell viability, apoptotic cell death ratio and parp protein expressions in p (+/+) and p (À/À) hct colon carcinoma cells lines. the effects of the boron compounds on cell viability were assessed by xtt assay and apoptotic effects and parp protein expression of the compounds were evaluated by flow cytometry and western blot analysis respectively. our results showed that borax pentahydrate ( mm) and disodium pentaborate decahydrate ( mm) significantly causes nearly % reduction of cell viability at h (p < . ). apoptotic cell death ratios and parp expressions revealed that both of the compounds might have a potential for a candidate of anticancer agent. epithelial-mesenchymal transition (emt) is a significant event for metastasis, and could be mediated by several pathways such as pi k/akt, map kinases and many epigenetic regulators. satb is an epigenetic regulator involved in emt and osteoblastic differentiation. since preliminary results indicate that there is a crosstalk between p and akt pathways in nsclc cells, we aimed to determine whether this crosstalk has a regulatory effects on emt and satb expression in nsclc cells. we used a and h cells as a model to evaluate the effects of the crosstalk between p and akt on emt of nsclc cells. therefore, cell culture, inhibition of p activation via sb , transient expression assay for (ca-akt), western blot analysis, sirna transfection for satb , wound healing and invasion assay were performed in this study. firstly, the expression statues of e-cadherin, satb , p-p , p , p-akt and akt was examined in a and h cells by western blot analysis. we observed that e-cadherin and satb are downregulated in a cells (highly active p , lowly active akt) compared to h cells (lowly active p , highly active akt), suggesting that e-cadherin and satb are associated with the crosstalk between p and akt pathways. our results demonstrated that p inhibition in a cells leads to decreased pten expression and subsequently increased akt activation. then, we found that p inhibition upregulated satb expression, and reversed emt in a cells. furthermore, alone satb knockdown is sufficient to induce emt, and prevented the effects of p inhibition on emt. all these results strongly indicate that the crosstalk between p and akt pathways might determine satb expression and epithelial characters of nsclc cells, and satb is a critical epigenetic regulator for emt in nsclc cells. therefore, it is also need to explore how p and akt signalling pathways could regulate satb expression. this work was supported by tubitak ( s , z ). introduction: lung cancer is a disease characterized by uncontrolled cell growth in the lung tissues. the most common causes of lung cancer are tobacco smoke, radon gas, asbestos, air pollution, and genetic factors. nitric oxide (no) has potential mutagenic and carcinogenic activity and may play important roles in lung cancer. endothelial no, synthesized from l-arginine by endothelial no synthase (enos), inhibits apoptosis and promotes angiogenesis and tumor cell proliferation. the aim of the present study was to examine the possible relationship between enos gene intron vntr and exon -g t (glu asp) the stressful ecosystems exert strong adaptive pressure and proteins that facilitate these adaptation processes are candidate drug targets. nucleotides are the core of biochemical pathway required for cancer cell growth and replication and genetic changes will lead in oscillation in their pools. although it is questionable whether the warburg effect actually causes cancer, impairing dglucose uptake and metabolism induces oxidative metabolism. lproline (lproline) homeostasis is critical in a constellation of human diseases, in parametabolic linkage between cancer, epigenetics (phang et al. ) and bioenergetics (pallotta ) where degradation and biosynthesis are robustly affected by oncogenes or suppressor genes that can modulate intermediates involved in epigenetic regulation. lproline-fueled mitochondrial metabolism involves the oxidative conversion to l-glutamate by a flavin dependent lproline dehydrogenase/oxidase and a nad +dependent l-d -pyrroline- -carboxylate dehydrogenase. in saccharomyces cerevisiae an important test tube, put p and put p respectively help cells to respond to changes in the nutritional microenvironment by initiating lproline breakdown after mitochondrial uptake (pallotta ) . in this preclinical study, low molecular weight compounds were tested for inhibiting lproline mitochondrial transport and put p/put p catalytic activities. thus, in seeking for natural bioactive compounds targeting lproline pathway and its substrate channeling (becker's group ), we report data using in silico screening and in vitro researches in saccharomyces cerevisiae with genetic background atcc but different phenotypic landscape induced by nutritional stress/ ph changes. cells vitality, dΨ measurements, nad(p) + /nad(p) h pool and flavine turnover were determined in spectrofluorimeter microplater reader and via hplc (pallotta et al. (pallotta et al. , (pallotta et al. , pallotta ; di martino pallotta ) thus in supporting of future cancer therapies with decreasing side effects. evaluation of lymphocyte to monocyte ratio (lmr) in patients with colorectal cancer introduction: inflammation may play an important role in cancer progression and a high neutrophil to lymphocyte ratio (nlr) has been reported to be a poor prognostic indicator in several malignancies. the aim of this retrospective study was to evaluate the prognostic value of nlr, lymphocyte to monocyte ratio (lmr) and platelet to lymphocyte ratio (plr) in patients with colorectal cancer (crc). : patients who were diagnosed with colorectal cancer between january and january ; were evaluated retrospectively. the cutoff value was determined using receiver operating characteristics curve analysis. survival analysis was performed using the kaplan-meier method and log-rank test. the cox proportional hazard model was used to identify the influence of factors related to survival. (tnm stage, tumor differentiation, age, tumour size and lmr) results: receiver operating characteristic curves showed that lmr was superior to plr and nlr as a predictive factor in patients with colorectal cancer. the cutoff value for lmr was . . cancer-specific survival was not significantly different between the high-and low-lmr groups (p = . ). age was identified as independent prognostic factor in colorectal cancer (hazard ratio: . ; % confidence interval: . - . ; p = . ). discussion and conclusion: our preliminary study showed that the lmr was not an independent prognostic factor in crc patients, but additional large sample sized prospective studies will be needed to confirm these findings. the aim of this study is to investigate the effects of luteolin treatment on enzymatic activity of arginase, and ornithine and polyamine levels (putrescine, spermidine spermine) in serum and cancer tissues of ehrlich ascites breast cancer model. balb/c female mice were divided randomly into following groups: healthy control, healthy treatment, cancer control, treatment and treatment . . ml ehrlich ascites tumor cells was inoculated subcutaneously to medial part of left hind leg. healthy treatment and treatment groups, and the treatment group were given mg/kg and mg/kg dose of luteolin, intraperitoneally, for a days period, respectively. luteolin has a hydroxylated flavonoid structure and shows potent antioxidant, anti-inflammatory, and anticarcinogenic properties. luteolin not only leads to cell death in various tumors by suppressing cell survival pathways and stimulating apoptotic pathways, but also sensitize them to cytotoxic therapy. supporting various previous studies, tumor implantation to healthy mice resulted in statistically significant elevation of serum arginase and polyamine levels (p < . ) indicating the tumor cells as the main source of this production. furthermore, luteolin treatment abolished this increase in serum arginase and polyamine levels (p < . ). tissue measurements of arginase and polyamine levels indicated that luteolin treatment resulted with an increase in these parameters of tumor tissue while the serum levels of them showed a significant decrease. our results revealed that increased tissue arginase and polyamine levels might be related with estrogenic agonistic effect of luteolin on utilized tumor model in this experiment; and decreased serum levels of these parameters while there is a significant increase of them in tissue levels might be a result of a suppression of polyamine efflux from the tumor tissue by inhibitory effect of luteolin on plasma membrane polyamine transporters. hepatocellular carcinoma (hcc) is the third most common cause of cancer-related deaths. around - % of hcc patients are diagnosed at an early stage of the disease. hepatic resection, liver transplantation are common strategies in hcc treatment. even if, most of the patients present advanced-stage tumors and have a restricted survival rate. for the reason, resistance against existing tumor stress conditions have been demonstrated in hcc. hypoxia, hyperglycemia are general stress sources in hcc and result in aggressive cell phenotype, resistance to apoptosis and therapeutic drugs. thioredoxin interacting protein (txnip) regulates cellular responses under stress conditions. over-expression of txnip results activation of oxidative stress and apoptosis. in cancer models txnip is considered as a tumor suppressor gene. however, its role in the development, progression of hcc and mechanisms behind it warrant further investigation. in this study expression levels of txnip were examined in hcc cell lines by rt-pcr and western blotting. txnip expression was significantly high in poorly-differentiated snu- , snu- and snu- than the well-differentiated hcc cell lines such as huh- , hepg and plc/prf/ . besides, expression of txnip was examined in non-hcc and hcc tissue samples by immunohistochemical staining. txnip positivity was observed in % of well and % of poor differantiated hcc tissues. however, no txnip positivity was observed in non-hcc tissues. to investigate whether txnip might be involved in biological responses such as cell proliferation, motility and invasion, we used overexpression and silencing strategies. overexpression of txnip minimally inhibited adhesion and proliferation, whereas boyden-chamber motility and invasion assay showed that invasiveness of cells were increased. our findings suggest that txnip expression is increased in hcc and txnip over-expression is important for invasive phenotype during hepatocarcinogenesis. cardiovascular diseases are the leading cause of morbidity and mortality in the western world. it was shown that ischemic tolerance of the heart can be enhanced not only by ischemic or pharmacological conditioning (pre-and postconditioning), but also by adaptation to chronic hypoxia. different studies have indicated that these cardioprotective phenomena may at least partly share the same signaling pathways. the jak/stat signaling pathway has been demonstrated to participate in the development of cardioprotection by conditiong apparently through the inhibition of gsk- b. the aim of our present study was to determine whether this pathway also takes part in cardioprotection induced by adaptation to chronic hypoxia. we investigated the effect of inhibitor of jak kinase (ag- ) on myocardial infarct size and the jak /stat signalling pathway and other effector molecules that may participate in cardioprotection conferred by adaptation to hypoxia. adult male rats were adapted to intermittent normobaric hypoxia ( % o , weeks, h/day) and part of them recieved ag- ( mg/kg) min before ischemia. control rats were kept under normoxia. infarct size was assessed in isolated perfused hearts. relative expression of the key components of the jak /stat signalling system and other proteins was detected using western blotting. preliminary data indicate that administration of the jak inhibitor ag- caused a significant increase in infarct size in hypoxic rats. western blot analysis revealed changes in phosphorylation of jak , stat and some other proteins involved in cardioprotection (akt, erk / , gsk b). these results suggest that the jak/stat signaling pathway could participate in the development of a cardioprotective phenotype in rats exposed to chronic hypoxia. however, further research will be needed to clarify in more detail the role of this signalling pathway in the cardioprotective mechanism. p- . . - detrimental effect of hypertension on myocardium was reversed by liver x receptor agonist gw hypertension is a cardiovascular disease that causes functional and structural changes in the heart. nuclear liver x receptors (lxrs) are involved in the control of cholesterol and lipid metabolism. however, effect of lxr activation on the hypertensive heart is not well characterized. in this study, the effects of lxr agonist gw on hypertension-induced damage of myocardium were investigated. hypertension was induced by deoxycorticosterone acetate (doca) injection ( mg/kg, twice a week) following the unilateral nephrectomy in male -week-old wistar albino rats for weeks. blood pressure was measured by using tail-cuff method. gw ( mg/kg/day, i.p.) was administered last week. expression of various markers (grp , perk, p-perk, ikb-a, nf-kb p , tnf-a, bax, bcl- , mmp- ) in the ventricular tissue were examined by western blotting. inflammation and fibrosis were evaluated in histopathological examination. gw treatment reduced systolic blood pressure of hypertensive animals. expressions of endoplasmic reticulum stress markers grp and p-perk were increased by hypertension and gw treatment reversed them. hypertension-induced increase in nuclear nf-kb p expression and decrease in ikb-a expression were reversed by gw treatment. while bcl- expression was lower, bax level was higher than control in the hypertensive animals. in hypertensive group, fibrosis marker mmp- expression was augmented and gw treatment reversed this elevation. hypertension-induced increase in interstitial and perivascular collagen deposition and inflammatory cell infiltration in left ventricle were prevented by gw treatment. these results suggest that lxr activation by gw restored the hypertension-induced structural changes of heart in the doca-salt hypertension. methylphenidate (mph) is a psychostimulant prescribed for the treatment of attention deficit hyperactivity disorder (adhd), one of the most common neurobehavioral disorders of childhood and adolescence. in fact, despite the widespread use of mph the full comprehension of its cellular/molecular mechanisms is still elusive, including its effect on blood-brain barrier (bbb). this barrier is a key structure in the central nervous system since it protects the brain and its dysfunction has been described as a critical event in several brain diseases. thus, the aim of the present study was to clarify the effects of mph on the bbb function in both physiological and adhd conditions. for that, we used a rat model of adhd, the spontaneously hypertensive (shr) rats, and wistar kyoto (wky) animals as inbred comparator strain. also, to mimic a clinical dosing schedule for adhd treatment, rats were administered for monday-friday with vehicle or mph ( . mg/kg/day or mg/ kg/day, per os) from p -p . chronic mph treatment ( mg/kg/day) promoted cortical bbb permeability in both wky and shr animals; however, more prominent in wky rats. this effect can be explained by the downregulation of claudin- and collagen-iv, tight junction and basal lamina protein, respectively. noteworthy, wky animals also showed an increase in the expression of caveolin- and in both vascular cell and intercelular adhesion molecules. these bbb alterations led to subsequent infiltration of peripheral immune cells, including cd + macrophages. furthermore, hippocampal bbb disruption was only observed in wky rats with mg/kg of mph. here, mph decreased collagen iv expression and upregulated caveolin- , with no alterations in claudin- . overall, our results show that chronic exposure to mph can led to brain vascular alterations particularly under physiological conditions. this highlights the importance of an appropriate mph dose regimen for adhd, and also that mph misuse can have a negative effect. regulators of g proteins signaling (rgs) serve several cellular functions varying from tolerance, dependence, neuroprotection, transcription and tumorgenesis. despite their initial role as gtpase activating proteins, evidence suggests that rgs proteins are localized in the nucleus, interact with transcription factors thus regulating transcriptional responses. it was shown that rgs directly interacts with and interferes in opioid receptor (or) signaling. rgs is mostly expressed in brain and is implicated with brain structural alterations; however, the molecular mechanisms of how rgs could be involved in cellular differential functions remains unclear. based on these observations we examined whether rgs can regulate transcriptional responses mediated by the stat b transcription factor. isolated neural stem cells from rgs À/À mice were immunostained for the mitosis marker ph and the mrna levels of antiapoptotic genes were determined. proliferation assays were performed with brdu staining in neuro a cells stably expressing rgs . the functional assays of stat b transcriptional activation were performed in hek expressing either the erythropoietin receptor (epo-r) or the delta opioid receptor (d-or). the present data demonstrate that rgs blocks stat b phosphorylation and transcriptional activation by interfering in stat b heterodimerization upon epo-r or d-or activation triggered by cytokines or opioids administration. lack of functional rgs results in increased mrna levels of stat b target genes such as the members of the bcl anti-apoptotic family bcl- , bcl- and bcl-xl. this upregulation of stat b inducible gene transcription results in an increased proliferation rate of neural stem cells. this study demonstrates for the first time a non-canonical function of rgs in stat b mediated transcriptional responses and a novel selective role of rgs in transcription. role of the pre-molten globule structure in amyloid fibril formation a. eshaghi department of biology, faculty of science, islamic azad university, mashhad branch, mashhad, iran the major factor that caused extensive research on the protein fibrillation is their crucial roles in important diseases known as the amyloidosis diseases. neurodegenerative diseases, including alzheimer's, parkinson's, diabetes and huntington are the most important types of this disease. understanding the mechanisms of fibril formation and ways of treatment can be useful in reducing this type of disorder. in this project, the fibrillation of carbonic anhydrase protein was investigated as a model. carbonic anhydrase creates two stable intermediated known as pre-molten and molten globule, in different ph solution. this protein at ph between ph - molten globule structures was formed while the pre-molten form took place under ph . in our tests at ph . when the protein in molten globule structures only the amorphous aggregates were formed. instead, at ph . in pre-molten globule structure amyloid fibrils formed in the protein. there some reports, indicated the protein from pre-molten globule structure go toward amyloid assembly. even intrinsically unstructured proteins such as alpha-synuclein first took a structure similar to pre-molten globule and then made amyloid fibrils. it seems pre-molten globule structure have the major role in promoting to amyloid fibrils. perhaps drugs that prevent the formation of premolten globule structure have an important role in inhibiting amyloid fibrils. identification of compounds preventing the biochemical changes that underlie the epileptogenesis process and understanding the mechanism of their action is of great importance. we have previously shown that myo-inositol (mi) daily treatment for days prevents certain biochemical changes that are triggered by kainic acid (ka)-induced status epilepticus (se), [ , ] . however in these studies we have not detected any effects of mi on the first day after se. in the presented study we broadened our research and focused on ka induced other early molecular and morphological changes and influence of mi treatment on these changes. the increase in the amount of voltage-dependent anionic channel- (vdac- ), mitochondrial-plasma membrane cofilin and caspase- activity was observed in the hippocampus of ka treated rats. administration of mi h later after ka treatment abolishes these changes, whereas under the same time schedule diazepam treatment has no significant influence. the number of neuronal cells in ca and ca subfields of hippocampus is decreased after ka induced se and mi post-treatment significantly lessens this reduction. no significant changes are observed in the neocortex. obtained results indicate that mi post-treatment after ka induced se could successfully target the biochemical processes involved in apoptosis, reduces cell loss and can be successfully used in the future for translational research. references . r. . neuroscience letters, vol. , no. , pp. - . . r. solomonia, et al; . cell. mol. neurobiol. vol. , no extracellular deposits of amyloid-b peptide (ab) in brain parenchyma via proteolytic processing of amyloid precursor protein (app) are one of the typical characteristics of alzheimer's disease (ad). these aggregates mainly occur as a result of an increase in ab production or a decrease in its degradation. it was found that the neurotoxicity of ab aggregates is accelerated by acetylcholinesterase (ache). besides, ab-ache complex has a prominent neurodegenerative effect in brain. thus, cholinesterase inhibition and preventing ab production are current treatment strategies for ad. recent studies have shown that methylene blue (metb), a cholinesterase inhibitor with phenothiazine structure, inhibits the formation of amyloid plaques and neurofibrillary tangles. azure b, the major metabolite of metb, has been shown to inhibit ache and bche with ic values of . lm and . lm, respectively. in the present study, we tested whether azure b, may effectively lower the levels of ab / . we treated chinese hamster ovary cells, which stably express human wild type app and presenilin- (ps ) with - mm azure b or vehicle for h. to determine the effect of azure b treatment on ab / levels, we used separate sandwich-based elisas and normalized to total protein levels, determined by bca protein assay. azure b treated ps cells were also assessed by propidium iodide in flow cytometry for cellular toxicity. we observed a significant decrease in both extracellular ab and ab levels with a dose range treatment of azure b in ps cells. ab levels were reduced by . % in lm and . % in lm azure b-treated cells when compared to control. additionally, ab levels were decreased by % in lm and . % in lm azure b-treated cells when compared to control. overall, these preliminary results suggest that azure b may have beneficial effects for the treatment of ad. the effect of green silver nanoparticles (agnps) on the amyloid formation in alphalactalbumin and chaperone action of alphacasein a. ghahghaei, m. dehvari, j. valizadeh formation and deposition of protein fibrillar aggregates in the tissues is associated with several neurodegenerative diseases such as alzheimer's and parkinson's disorders. molecular chaperones are a family of proteins that are believed to have ability for inhibiting protein aggregation. in the present study the effect of different concentrations of green synthesis silver nanoparticles (agnps) from pulicaria undulate l. on the amyloid formation of a-lactalbumin (a-la) and chaperone action of a-casein have been investigated. the effects of the agnps were determined using light scattering absorption, tht binding assay, intrinsic fluorescence assay, ans binding assay, cd spectroscopy and sds-page. light scattering and tht assay results showed that agnps have the ability in preventing aggregation of a-la in a concentration-dependent manner. consistent with these results, sds-page results represented that by increasing the concentration of agnps the adsorption and interaction between agnps and protein have increased. light scattering and tht assay results, also, revealed that the amyloid fibrilation decreased in the presence of both agnps and a s -casein compared to presence of a s -casein alone. fluorescence results, however, show that agnps have no effect on the chaperone ability of a-casein and in fact they perform their protection of protein aggregation action independently. consistent with the above experiments, cd spectroscopy also revealed that agnps have decreased structural changes in reduced a-la in absence and presence of a-casein, both the tertiary and the secondary structure of the proteins. our finding represented that agnps have preventing effects on protein aggregation and have no effect on the chaperone ability of a s -casein. in the main, results of this study show that biosynthesized agnps mediated by >pulicaria undulate l. maybe could be affective as a therapeutic agent for inhibiting aggregation in treatment of amyloidosis disorders. pink is a mitochondrial kinase with multiple cellular functions. while loss-of-function mutations of pink gene lead to early onset parkinson's disease, its over-expresion is associated with cancer development. parkinson is a multifactorial neurogenerative disease, with a complex aethiology including various cellular stressors. it is now known that genotoxic stress also triggers the release of soluble factors able to induce changes in neighboring cells enhancing the initial lesions, process known as bystander phenomena. althrough the mechanisms are still unclear, recent studies point towards a role for mitochondria in this process. our work investigates pink role in intracellular and intercellular stress response, comparatively in various models: fibroblasts (mefs) and neuroblastoma (sh-sy y) used as a tumoral model or differentiated to a neuronal phenotype. pink role in this process was analyzed using genetically engineered pink deficient cells exposed to a genotoxic agent, bleomycin. the modified cell lines showed a reduced level of basal atp production. pink proved to be involved in cellular vulnerability to stress. despite differences in cellular sensibility between our models, genotoxic treatment of pink deficient cells induced consistently higher lesions compared to corresponding wild type variant. pink deficient cells showed altered intercellular signaling of stress, impairing bystander phenomena induction, by suppression of signal formation in treated cells, but also by altering the capacity to respond to the signals in neighboring cells. our hypothesis is that pink contributes to the management of cellular stress being involved in bystander transmission of detrimental effects through intercellular communication. this is determined mainly by its role in maintaining mitochondrial homeostasy and atp levels, pink deficient cells lacking the amount of energy required for rapid dna repair and stress signaling transmission. p- . . - intranasal administration of synthetic fragments from receptor for advanced glycation end products prevents memory loss in olfactory bulbectomized mice the receptor for advanced glycation end products (rage) is a member of the immunoglobulin protein superfamily. activation of rage causes brain inflammation, oxidative stress and secretion of beta-amyloid that has been recognized as an essential phase in the development of alzheimer's disease. it is known that the receptor soluble isoform (srage) which lacks the transmembrane and cytosolic domains binds to ligands and prevents negative effects of the receptor activation in in vivo and in vitro experiments. we proposed that potential ligand-binding peptide fragments from srage would demonstrate the same biological activity. we have selected and synthesized peptide fragments from unstructured surface-exposed regions of rage. synthetic peptides were intranasally administrated into olfactory bulbectomized (obe) mice with neurodegeneration of alzheimer's type. we have found that only administration of rage fragment ( - ) effectively prevents the obe murine memory from impairment, leads to decrease of beta-amyloid level and blocks the development of neuronal pathology in the brain of experimental mice. six overlapping fragments of rage ( - ) peptide were synthesized in order to find a site, responding for the therapeutic effect. tests in obe mice carried out with these fragments showed that only the n-terminal part of the molecule is responsible for preventing obe mice memory from impairment. all fragments which do not include n-terminal - dipeptide have been fully inactive in these experiments. we have proposed that active peptides can interact with beta-amyloid or s b protein preventing these ligands from binding with rage. this interaction can inhibit the development of neurodegeneration. the aim of this study was to examine effects of social isolation, enriched environment and exercise on learning in rats. the study included female day old wistar rats. the rats were randomly divided into four different groups; control, exercise, social isolation and the enriched environment groups. the social isolation group and the enriched environment group were housed under their specific conditions and the exercise group and the control group were housed in standard conditions during weeks. the rats in the exercise group swam for weeks. after weeks, the rats were evaluated in the morris water maze. brain and blood samples were taken and the hippocampus tissue was dissected. bdnf and ngf levels were measured in these samples. in conlusion, while enriched environment was a positive effect on spatial learning, social isolation was a negative effect on spatial learning and increase thigmotactic behaviors. according to the analysis results ngf and bdnf levels in the hippocampus and plasma did not change with environmental conditions and exercise. time of exposure to social isolation, procedures of the enriched environment, time of exposure to the environment, type and duration of exercise and gender may affect the results. alzheimer's disease (ad) was characterized by dementia that typically begins with subtle recognition failure and poor memory. it slowly becomes more severe and, eventually, incapacitating. the cholinergic system seemed particularly susceptible to synapse loss, especially in cortical regions associated with memory and executive function ( ) . recent studies showed that the main cause of the loss of cognitive functions in ad patients was a continuous decline of the cholinergic neurotransmission in cortical and other regions of the human brain ( ) . acetylcholinesterase (ache) and butyrylcholinesterase (bche) are hydrolytic enzymes that act on acetylcholine (ach) to terminate its actions in the synaptic cleft by cleaving the neurotransmitter to choline and acetate. both enzymes are present in the brain and detected in neurofibrillary tangles and neuritic plaques. it was suggested that ache predominates in the healthy brain, with bche considered to play aminor role in regulating brain ach levels. however, bche activity progressively increases in patients with ad, while ache activity remains unchanged or declines. both enzymes therefore represent legitimate therapeutic targets for ameliorating the cholinergic deficit considered to be responsible for the declines in cognitive, behavioral, and global functioning characteristics of ad ( ). we initiated a study to screen their acetylcholinesterase (ache, ec . . . ) inhibitory activities, which are the key enzymes taking place in pathogenesis of ad. newly synthesized chiral benzimidazole derivatives with thioure structure showed ic values in the range of . - . nm for ache. this study was financed by turkish research council-tubi-tak (kbag z ). p- . . - f -a h, novel fingolimod derivative, activates camp-dependent signalling pathway in sk-n-sh cell line g. celik turgut , a. sen , d. doyduk , y. yildirir department of biology, faculty of arts and sciences, pamukkale university, denizli, turkey, department of chemistry, faculty of sciences, gazi university, ankara, turkey fty , a sphingosine -phosphate (s p) receptor modulator, is the first oral disease-modifying therapy to be approved for the treatment of relapsing-remitting multiple sclerosis. in this study, we have synthesized and characterized novel derivative of fty , namely f -a h, and have determined its underlying camp regulation in sk-n-sh cell lines. for this purpose, we first determined the regulation of the camp response element (cre) activity and camp concentration by f -a h along with fty using pgl . luciferase reporter assay and camp immunoassay, respectively. then, we have determined their effect on camp/pka-related gene expression profiles using custom arrays along with fty treatment at non-toxic doses. it was found that f -a h significantly activate cre and increase camp concentration in the sk-n-sh cell line, indicating that it activates camp pathway through cell surface receptors as fty does. furthermore, f -a h modulates the expression of the pathway related genes that are important in camp signaling pathway. in summary, our data demonstrate that the novel fty derivative act as a modulator of camp ultimately by influencing the gene expression via the camp and downstream transcription factor cre pathway. in conclusion, f -a h might contribute future therapies for multiple sclerosis. alzheimer disease (ad) results in memory impairment and accompanied by neuroinflammation, cholinergic deficit and amyloid-beta (ab - ) accumulation in brain. we found that bacterial lipopolysaccharide (lps) injections or mice immunizations with extracellular a nicotinic acetylcholine receptor (a - nachr) domain resulted in astrogliosis, decrease of a nachr density, accumulation of ab - in brain and episodic memory impairment. the aim was to reveal main event triggering ad-like symptoms development. c bl/ mice were injected with lps, immunized with recombinant a - or a - endoglycosidase treated to remove carbohydrates. two immunizations with week interval were performed. control mice obtained complete freund's adjuvant injections. mice were tested for memory performance, blood sera were examined for presence and fine specificity of a - -specific antibodies and brain preparations were studied for a nachr, ab - and il- levels. the original a - ('glyc') was more immunogenic than 'deglyc', and their epitopes were recognized with different efficiency. in contrast to lps and 'glyc' a - immunization with 'deglyc' a - did not stimulate il- elevation in brain and had no proinflammatory effect. immunizations with 'glyc' or 'deglyc' a resulted in similar a nachrs decrease and ab - accumulation in brain and significant episodic memory decline comparable to those after lps injections. a nachr interacts directly with amyloid-beta precursor protein and facilitates its proper processing and metabolism. our data indicate that decrease of a nachr density caused by a - -specific antibody is critical for ab - accumulation and episodic memory impairment while pro-inflammatory capacity of a - -specific antibody plays secondary role in ad-like symptoms development. in vitro antioxidant and antiacetylcholinesterase activity of achillea millefolium alzheimer diseases (ad) is a neurodegenerative condition without a current effective treatment. increase in reactive oxygen species and lipid peroxidation or decrease in total antioxidant capacity causes oxidative stress-induced tissue damage. it has been suggested that decrease in oxidative stress and inhibition of acetylcholinesterase (ache) activity play a major role in the prevention and slowing of cognitive symptoms of ad. recently, studies have been directed for the discovery of medicinal plants and natural substances that are known to have natural antioxidants. achillea millefolium (a. millefolium) is a traditional herbal medicine that contains natural compounds with antioxidant activity and has been used as a carminative, diuretic, menstrual regulator and wound healer, however the mechanism of its actions are unclear. the aim of our study was to investigate the effects of a. millefolium extracts on free radical production, acetylcholinesterase (ache) activity and lipid peroxidation in vitro. methanol (me) and ethanol (ee) extracts of a. millefolium were prepared to determine (a) in vitro antioxidant capacity (by using , -diphenyl- -picrylhydrazyl assay, radical scavenging activity, phosphomolibdenum-reducing antioxidant power, ferricreducing antioxidant power, and total phenolic-total flavonoid contents), (b) effects on ache kinetics (by using a colorimetric assay) and (c) effects on sodium nitroprusside-induced lipid peroxidation in mice brain homogenates. me showed a higher antioxidant activity compared with ee in the biochemical assays tested. similarly, me demonstrated significant inhibition of ache activity that was potent than ee. both extracts dose-dependently decreased malondialdehyde content in mice brain homogenates suggesting a strong inhibition of lipid peroxidation. these results showed that a. millefolium has a high antioxidant capacity and antiache activity, indicating a potential use as an adjuvant therapy in ad. b-cells are known to play a key role in multiple sclerosis (ms) progression and autoimmune response. cxcr is the main b-cell chemokine receptor that under normal conditions directs their migration to specific areas of secondary lymphoid organs. in ms, areas of demyelinating lesions have been reported to attract bcells due to overexpression of cxcl , the cxcr ligand. we aimed to determine whether snp rs located in the promoter of cxcr gene and associated with high risk of multiple sclerosis could have a direct effect on of cxcr promoter activity. mef c binding to dna was assessed using pull-down assay. b-cell stimulation was performed using lps, pma and ionomycin. activities of variants of cxcr promoters containing different rs alleles were estimated using luciferase reporter assay. we determined that minor rs allele creates functional mef c-binding site within one of the regions required for the basal activity of the cxcr promoter. cxcr promoter containing minor rs variant that is statistically associated with low risk of ms showed significantly decreased activity in stimulated human b-lymphoblastoid cell lines. mef c has been reported to play an essential role in b-cell survival and b-cell responses. we determined mef c as the main regulator of rs -dependent modulation of cxcr promoter activity in b-lymphoblastoid cell lines. this link may be directly related to pathogenic b-cell activities in multiple sclerosis. introduction: parkinson's disease (pd) is the second most common neurodegenerative progressive brain disease with increasing prevalence in aging population. the etiopathogenesis involves many cellular procesess, but is not fully elucidated yet. treatment of pd is based on levodopa and dopamine agonists, but mao-b inhibitors, comt inhibitors, amantadine or anticholinergics may be used as initial monotherapy or as adjuvant therapy. treatment related adverse drug reactions (adrs) are frequent, but cannot be predicted and/or prevented. non-motor adrs, such as nausea, somnolence, hallucinations and hypotension are frequent in dopamine agonist therapy, while dyskinesias along with motor fluctuations are the most common late adrs with levodopa. the aim of our study is to combine clinical data with genetic and epigenetic biomarkers in the algorithm for personalized approach to pd management. materials and methods: we are planning a clinical study to assess the combined impact of selected clinical, genetic and epigenetic factors on the progression of pd, adrs and treatment response. our study will have a retrospective and prospective arm. we will collect peripheral blood samples of pd patients and clinical data. single nucleotide polymorphisms (snps) in the genes involved in dopamine, neurotransmitter and drug metabolism and transport, receptors and signalling pathways will be genotyped. snps within inflammatory, neurodevelopmental, antioxidative defense, synaptic transmission and immune response pathways will also be analysed. in the prospective arm we will isolate the exosomes and check their mirna content at the time of diagnosis and after the treatment initiation. the combined effects of clinical, genetic and epigenetic factors will be analyzed using lasso penalized regression analysis. conclusions: we hope to identify genetic and/or epigenetic biomarkers that may predict progression of pd, adrs and treatment response and may support personalized tratment of pd. most evidence indicates that g protein-coupled receptors form heteromers between them and with other receptors. by allosteric mechanisms, them acquire a multiplicity of unique pharmacological and functional properties. recently, we discovered that dopamine d receptors (d r) and histamine h receptors (h r) form heteromers through which h r ligands can inhibit d r function. d rs also physically interact and modulate ionotropic glutamate nmda receptors (nmdar). in the present work, we investigated if nmdar, d r and h r form a heterotrimeric complex in brain. the heteromer expression was studied in slices from both rat and mouse brain cortex by co-immunoprecipitation (co-ip) and proximity ligation assays (pla). the ability of d r and h r to interact with nmdar in transfected hek cells was analyzed by bioluminescence resonance energy transfer (bret) with bimolecular fluorescence complementation (bifc) experiments. heteromer properties were studied by analyzing erk / phosphorylation and cell death in cortical slices. endogenous d r-h r heteromers were detected in rat and mouse cortical slices, where h r ligands decreased d r signaling (erk / pathway) and were also able to block the cell death induced by overstimulation of either d r or nmdar. by bret experiments in transfected hek cells, we demonstrated that both d r and h r form heteromers with nmdar subunit a in the presence of subunit b. d r-h r-nmdar heteromers were detected by bret with bifc. endogenous d r-h r-nmdar heteromers were observed in rat and mouse cortex by pla. many systems, including the glutamatergic and dopaminergic, are involved in neurodegeneration. our innovative finding is that d r, h r and nmdar form heteromers that may be a point of intervention for cognitive disorders in neurodegeneration. d r-h r-nmdar heteromers are expressed in brain cortex and a complex interaction exists between protomers in the heteromer, where h r ligands act as a 'molecular brake' for d r and nmdar signaling. studies conducted on obesity and hfd (high fat diet) revealed hypothalamus have crucial roles on development of metabolic diseases. after chronic over nutrition or high fat diet, as a neurodegenerative condition, premise inflammation, neural stress and development of functional impairments are observed. these studies generally focused on changes in neurons, but it's effects on brain vessels are still unknown. in this study, as a neuronal damage infrastructure, changes in hypothalamic vascularity investigated. experiment initiated with weeks old total male wistar rats. in order to acquire obese phenotype, the rats were fed either cafeteria diet as hfd, or normal/chow (standard diet, sd) for months. intravenous glucose tolerance tests performed before sacrification. animals were exposed for s to co and then decapitation was performed with guillotine. isolated brains were directly immersed into liquid nitrogen and stored at À °c. the hypothalamic sections were acquired with the cryostat instrument at different. immunofluorescence was performed on serial sections through the hypothalamus using the antibody smi- and cd . changes in tight junction (tj) proteins (occluding and zone occludin- ) are evaluated via western blot (wb) analysis. the hfd-treated consumed significantly more food than did control animals, when examining average food consumption per day and rats that received the hfd diet weighted significantly more at the end of month diet treatment. there were no differences acquired for glucose tolerance tests. however, after hfd treatment, wb analysis have shown that tj proteins decreased even if hypothalamic micro vessel number increased and smi- staining have shown that increased. our primary results have shown that hfd diet can affect hypothalamic vascularity and such changes might initiate neurodegenerations and functional impairments as observed in neuroretinal degeneration in relation to vasculopathy in diabetic patients. defects of mitochondrial trafficking are common problem in many neurodegenerative diseases. its dysregulation can contribute to changes in bioenergetics profile of the cell and can lead to cell death. in our study we investigate distribution of mitochondria and their transport in primary fibroblasts derived from patients with sporadic form of alzheimer's (ad) and parkinson's (pd) diseases. our data revealed that in the most cases the velocity of mitochondrial movement is lower in ad and pd cells in comparison to the control. the most intense differences between ad, pd patients and control group are observed in the case of movement of large mitochondria. owing to the fact that mitochondrial trafficking depends on mitochondrial state, we investigated the 'age' of mitochondria. we observed a diminished mitochondrial turnover in ad and pd fibroblast. evaluation of the mitochondrial distribution within the cell in all groups (ad, pd and control) showed that in the perinuclear area are accumulated 'old' and 'worn out' mitochondria, probably dedicated to remove from the cell. because mitochondrial biogenesis, shape and size depends on fusion/fission proteins we assessed their level within the cell. to summarise, our results revealed alterations in mitochondrial trafficking in fibroblasts derived from patients with alzheimer's and parkinson's diseases in comparison to the healthy control cells. carbonic anhydrases (cas, ec . . . ) is a zinc metalloenzyme that catalyzes the reversible reactions of co and water. carbonic anhydrases (cas, ec . . . ) form a family of metalloenzymes that play an important function in various physiological and pathological processes. therefore, many researchers work in this field in order to design and synthesize new drugs. carbonic anhydrase activators are important as much as inhibitors. caas have polar groups to make hydrogen bond in the main body and the activation property of enzyme increaase in this way. caas are have polar groups to make hydrogen bond in the main body and the activation property increaase in this way. furthermore, recent studies suggest that ca activation may provide a novel therapy for alzheimer's disease. in this study ca activators are determined. human carbonic anhydrase isozymes ca i and ca ii are isolated from human blood erythrocyte. hca-i and hca-ii isoenzymes were purified using sepharose- b-l tyrosine-sulfanilamide affinity colum. finally, hca-i and hca-ii isoenzymes were eluted with appropriate elution buffers. enzyme purity was checked by sds-page. the enzyme activity system contained . m tris-so ph . , r-nitro phenol in ml total volume. effects of some macrocyclic thiacrown ethers derivates were investigated. enzyme activities were measured at constant substrate and different activator concentrations to find ac value. these compounds are thought to be useful for treating alzheimer's disease. introduction: gender differences in stress models are not studied in detail. we compared different stress conditions on brain bdnf levels, in social isolation (sit) and predator scent tests (pst) in rats. bdnf levels in cortex, hippocampus and amygdala were compared, effects of chronic fluoxetine (flu) treatment were evaluated. methods: rats were used. for sit, animals were kept individually for month and for pst, rats were exposed to dirty cat litter for min at the first day of month stress. flu was given ( mg/kg, ip) through stress. controls, stress and treated groups were evaluated in elevated plus maze (epm), anxiety scores were calculated. brain bdnf levels were determined in cortex, hippocampus and amygdala by western blot. p < . were considered significant. results: sit and pst induced anxiety in both male and female rats, females having greater anxiety scores than males (p < . ). flu restored anxiety scores in both sexes (p < . ) in two settings. male and female rats exhibited reduced cortical bdnf levels in sit (p < . ). pst reduced cortical bdnf in females, but increased in males. hippocampal bdnf expression was lowered in sit (p < . ) and pst (p < . ) in both sexes. female rats had % lower bdnf expression than males in amygdala in sit. flu did not restore cortical bdnf in females in both tests, but reduced incresed bdnf levels in males (p < . ). flu did not restore reduced brain bdnf in males in hippocampus and amygdala, but restored in hippocampus, in females. discussion: our findings indicate that sex differences must be considered in studies related to mood disorders of animal models, and suggest that bdnf expression in different brain regions are altered differentially in a gender-dependent manner in rats. antianxiety effect of flu is not mediated through increasing bdnf activity in cortex in both genders. increased bdnf in hippocampus and amygdala may reflect its antidepressant effect in female rats, but not in males. perineuronal nets (pnns) are special forms of neural extracellular matrix found around neuron bodies and neurites. hyaluronan and proteoglycan link protein (hapln ) is one of the major elements of pnns. hapln interacts with tenascins and aggrecan which are other essential pnns components. in most of neurodegenerative disorders caused by neuritogenesis defects, disrupted pnns structure and decreased expression of hapln were observed. however, the role of hapln in neural differentiation is unknown. the aim of this study is to determine mrna and protein levels of hapln during differentiation using pc cell line as a neural differentation model, derived from rat pheochromocytoma. after pc cells were stimulated to differentiate into neurons by nerve growth factor on days , and ; cells were collected, qrt-pcr and western blot were performed. also, in order to find out whether there is a physical interaction between hapln and proteins related to neuritogenesis defects, spinal muscular atrophy (sma) was used as a neurodegenerative disease model. therefore, a detailed hapln and survival motor protein (smn ) network analysis were performed in-silico. as a result, we analyzed fold increase in hapln mrna level compared to undifferentiated state. on the other hand, a decrease in protein level was detected. this decrease in cellular hapln level suggests that, hapln is required for formation of pnns structure, thus secreted to extracellular environment at early stage of differentiation. in addition, according to in-silico analysis, an indirect path between hapln and smn through fibulin (fbln ) was detected. fbln was also found to be an interaction partner between different matrix molecules such as aggrecan and hapln which form a macromolecular meshwork. the results of this study will pave the way for investigating the role of hapln and fbln in neurodegenerative disease models. also it will help us to understand the mechanism of neuritogenesis defects. determination of properties of bone marrow and tissue-derived mesenchymal stromal/stem cell population in neurofibromatosis type patients neurofibromas, complex tumors deriving from schwann cells and containing fibroblasts, vascular structures and mast cells, are part of the clinical picture in nf . the risk of malignancy is increased in nf , wound healing is delayed and keloid formation is frequent. because multiple tissues are involved in malignant and non-malignant manifestations of nf , we considered the mesenchymal stem/stromal cells (msc) carrying the nf mutation might play a role in the microenvironment. mscs affect the biological behaviour of other cells: they alter their proliferation, apoptosis and migration through various secreted growth factors, cytokines, chemokines, or by direct contact. we examined the msc of nf patients. methods: the adipogenic and osteogenic differentiation potential of mscs from nf and healthy subjects was examined in vitro and by rt-pcr. msc's migration potential was measured in the scracth assay. mscs' interaction with schwann cells and their effect on tumorigenesis was examined in co-culture by apoptosis markers on flow cytometry. results: nf -mscs' adipogenic and osteogenic differentiation potential was lower than healthy controls as assessed by staining aizerin red s and oil red o and rt-pcr for osteopontin and collagen . mscs cultured from dermal neurofibroma showed faster closing of the scratch compared to the same patient's normal and caf e au lait skin. on the other hand, mscs obtained from plexiform neurofibroma healed late, while mscs derived from the same patient's caf e au lait skin showed the fastest healing. hepatic encephalopathy with ammonium ions accumulation is accompanied by some disorder in the brain due to toxic material concentration being usually detoxified in the liver. one of the reasons for hyperammoniemia could be some imbalance in brain glutamine metabolisation induced by the key enzymes glutamine transferases (gts), which catalyze the reaction of glutamine transamination resulting in neurotoxic product of a-ketoglutaramate (akgm). akgm is hydrolyzed to a-ketoglutarate and ammonia by x-amidases. in the study, the dynamics of the enzymes activity in the tissues and biological liquids of experimental animals with hepatic dysfunction induced by thioacetamide (taa) was under investigation. white laboratory rats of wistar line (female, weight of g) chronically intoxicated with hepatotrophic toxine of taa. every weeks, some biological samples were collected to assess gt-k and x-amidase activities. x-amidase activity was the highest in the kidney tissue in the control and decreased by % in the experimental group. in the experimental hepatic x-amidase activity decreased by % compared to those in the control. the average x-amidase activity in the blood serum ( . nmols/ mg/min) and in the brain ( . nmols/mg/min) differed faintly. maximal gt-k activities were revealed in the kidneys; in the controls, it was about % higher than those in the experimental animals. the difference between average enzyme activities in the liver of the control and experimental animals reached %. the average gt-k activities in the blood serum and brain of the control and experimental animals were rather similar. the decrease in x-amidase and gt-k activities obtained in the study during hepatic pathology development could testify to imbalance of glutamine metabolism, possibly aimed at declining the level of akgm neurotoxicant under the hepatic dysfunction. acknowledgments: supported by the russian federation ministry of science and education (grant no rfme-fi x ). wilson disease is an autosomal recessive disorder of copper metabolism characterized as neurodegeneration and liver abnormalities. it is caused by defects in the atp b gene. atp b is responsible for the sequestration of cu into secretory vesicles, and this function is exhibited by the orthologous ccc p in the yeast. we aimed to characterize clinically-relevant novel mutations of p.t i, p.v i and p.r g-fsx in yeast lacking the ccc gene. the patients with these mutations have copper storage abnormalities in different parts of their bodies; p.t i mutation mainly affects the liver and the nervous system, p.v i mutation affects the nervous system, and p.r g-fsx mutation causes damages to the liver. to better understand the effects of these mutations on normal functions of atp b, we cloned human atp b gene onto a yeast expression vector and created the same mutations by site directed mutagenesis. then, wild type and mutated forms of atp b genes were transformed into yeast cells lacking the homologous ccc gene for functional comparison. first, we analyzed the expression of atp b and its variants in yeast cells by a real time pcr approach and western blot to make sure that transformed cells express the plasmids. expression of human wild type atp b gene in ccc d mutant yeast restored the growth deficiency and copper transport activity, however, expression of the mutant forms did not restore the copper transport functions and only partially supported the cell growth. our data support that p.t i, p.v i and p.r g-fsx mutations cause functional deficiency in atp b functions and suggest that these residues are important for normal atp b function. in recent years, attempts were made to develop miniaturized potentiometric biosensors which is particularly important to reduce the amount of enzyme and reagents needed. the miniaturization of a biosensor is possible by using an all solid-state polymer membrane ion selective electrode which is cheap, easy to prepare and allow micro-sized construction. the use of all solidstate polymer membrane ion selective electrode as the basic sensing element also has the advantage of providing biosensors that are easy to fabricate, exhibit rapid response and have long life-times. they are also mechanically stable and allow flow-through configuration. genetical and chemical modifications for the alteration of enzyme molecule characteristics are gained considerable importance. enzymes can be modified chemically by using water-soluble polymers or some chemicals. conjugates of natural and synthetic macromolecules with enzymes provides wide usage in medicine and in many fields of biotechnology. in this study, enzyme-polymer conjugates with different molar ratios were synthesized using urease enzyme. in this study micro sized potentiometric urea sensitive biosensor has been developed in which urease-polymer conjugates were immobilized on polymeric membrane ammonium ion selective electrodes whether pvc or derivatized-pvc via glutaraldehyde cross linking reaction. biosensor is not include inner reference electrode and inner reference solution. potentiometric performance of biosensor will be examined with a computer-controlled measurement system designated. the most important features of the obtained micro sized urea biosensor by using enzyme-polymer conjugations were being highly sensitive, having long life-time, easily built at a low cost, and having short response time when compared with conventional potentiometric urea biosensor. also, these biosensors were easily built at micro-construction. this study was supported by grant from the tub _ itak research fund (project number: z ). creative drama technique as a new tool to increase enthusiasm and to achieve learning objective for medical students e. y. sozmen , , e. erem faculty of medicine, ege university, izmir, turkey, center for continuing education, ege university, izmir, turkey, recently drama in education techniques have been implemented successfully in education program of primary and secondary high school and positive effects of these techniques on learning ability and attitude of students have been shown. the aim of this study was to organize an education program based on drama in education techniques in a special module of ege university medical faculty and to test any effect of this technique on achievement of learning objectives and student's perspectives on drama. the special module program was on the oxidative stress and antioxidants. the program covered the drama in education sessions (improvisation, role play, game) linked with learning objectives (understanding of free radical generation and free radical reactions in body, evaluation of the effect of free radical reactions in diseases as well as increase the ability usage of scientific information), laboratory work (antioxidant activity determination) and searching a special scientific topic on literature. students (in rd year of faculty) who had taken theoretical lecture on this subject a year ago, participated in this special module. the opinions of the students on the program were obtained through a questionnaire form and the increase in knowledge was evaluated via pre/posttest. the mean of pretest point was . / , that increased to . / in the posttest evaluation. % of students pointed that they enjoyed participating in drama activities in the pre-questionnaire, this rate was % in the final questionnaire. they all remarked that implementation of drama in education was beneficial for their communication skill, helping them to learn more about science and increased their enthusiasm to learn and discuss the scientific information. although the preparation process might take more time and need to hard work for teachers, we concluded that the drama methods as a new tool to increase of participant's interest might be proposed for students in higher education. laboratory-based performance assessment in medical education: an opportunity for connection between scientists and medical students h. tuncel cerrahpasa medical faculty, istanbul university, istanbul, turkey number of medical students who interested in basic medical sciences is declining and medical sciences literacy is falling, it is crucial to develop ways for students and scientists to connect. students need to know that science is an intensely human endeavor, and scientists need mechanisms to bring that truth to the community at large. based on continued interest and experience on the part of faculty, and on student feedback, the development of a more effective and stimulating interactive learning tool was undertaken. an in-depth knowledge of laboratory medicine principles is vital to all practicing physicians. great variation exists in the ways that medical students learn the principles of laboratory medicine. there are a number of programs for electronic media that emphasize laboratory-related skills. some of these are appropriate for medical students in the clinical years. programs that teach skills in common laboratory procedures, such as interpretation of peripheral blood smears and microscopic examination of urine sediment, have been shown to improve student performance. to ensure that important principles are addressed, medical schools should establish goals and objectives specifically related to laboratory medicine and experiment with optimal teaching and assessment methods. we also hope that this study will inspire dialogue among primary care and specialist physicians as to the proper degree of education in this area. ideally, it will encourage scientific studies that address evidence-based possibilities for improving critical laboratory medicine educational outcomes, that is, the training of physicians who optimally use laboratory diagnostics and therapeutics. engaging medical students in scholarly scientific activities and producing clinically competent and research-oriented medical workforces are essential demands, particularly in developing countries. an experimental special study module for medical undergraduate students: learning western blot analysis and detection of b-actin protein expression in tissue and cell culture samples learning, introduce basic principles of laboratory research and to present the results.b-actin is one of six actin isoforms which is mainly expressed in all eukaryotic cells. western blotting is a widely used laboratory technique to determine specific proteins and to evaluate protein expression in tissues and cells. in our study, different concentrations of rat spleen homogenates ( , , lg/well) and lg protein/well of human lung and ovary cancer cell lysates were used. the proteins were seperated by % sds-page, transferred to pvdf membrane, incubated with specific b-actin antibody and then with hrp-conjugated antibody. protein bands were detected with ecl and densitometric analysis of proteins was quantified by imagej software. differences in protein band intensities were compared using one way anova.a value of p < . was considered statistically significant. we detected b-actin expression in rat spleen homogenates, human lung and ovary cancer cell lysates, as a kd protein. the protein band intensities were in correlation with protein concentrations. the highest concentration resulted in the highest signal intensity in rat spleen homogenates.b-actin level was higher in ovary cancer cells than in lung cancer cells, although both proteins were loaded equally. the feedback showed that students were very satisfied with this laboratory ssm. they developed their independent study skills, planned a research, worked in a laboratory, learned and performed a technique, western blotting. the hands-on experience is very important for medical undergraduate students for their future scientific career. three-dimensional structure of truncated human kv . voltage-gated potassium channel kv . belongs to the ether-ago-go family. it has been proved that its mutants are involved in development of neurological diseases and some types of tumor. directed drug design needs knowledge of details of the threedimensional channel structure. the members of the kv - subfamilies are characterized by extremely long n-and c-terminal intracellular tails, which possess a number of structural domains. the n-terminal pas domain in kv plays an important role in activation, and is thought to alter the rate of deactivation, possibly by binding at or near the s -s linker at the inner mouth of the pore. here we present an improved d structure of the truncated human kv . channel, obtained by single particle em. this channel lacks its cytoplasmic pas domain but it still forms tetrameric particles. earlier we showed that the full length kv . channel is build according to the 'hanging gondola' type, and its cytoplasmic and transmembrane parts are connected by linkers. the cytoplasmic part includes the interconnecting pas and cnbd domains. deletion of the pas domain leads to the conformational change in the cytoplasmic part of the channel. for interpretation of the d structures we used homology modeling and molecular dynamics simulation. there are several templates available to the moment including eag domain-cnbhd complex of the mouse eag channel, full-length shaker potassium channel kv . , c-linker/cnbhd of zelk channels and others. but there are still no templates for many fragments that led to necessity of partial de novo modeling. analysis of molecular trajectory allowed estimating dynamical characteristics of channel, supposing interdomain interactions. results of the conducted investigation have a great interest at both the academic and the industrial levels. the objective of this task program is to enable students to gain scientific attitude and skills for them to be able to deal with the problems they'll confront in future research careers. it's been emphasized in various studies that medical students are keen on conducting scientific research, and it's been stated that they need to be supported in this respect, as they lack the adequate fund of knowledge. this study aims to share information throughout a -year performance of the research training program (rtp) conducted at ege university, faculty of medicine. rtp is an educational program applied in addition/parallel to the bachelor's degrees for establishing scientific thought, attitude, proceeding and knowledge of the willing medical students, and enabling them to adopt study skills. the dynamic program produced by the rtp committee in has been developing each and every year via feedback received from the students. an operating principles, a manual for advisor and an introductory booklet have been laid out. applications are being accepted at the end of first academic year, making announcement to the freshmen in advance. students are being admitted to the program, taking the assessment criterias into consideration. second and third year medical students attend the didactic part of the program during the terms devoted to special study modules. thereafter, they go through the project management phase, and accomplish their projects under supervision of a faculty member until their graduation. first graduates of the program, accomplishing their projects, received their certificates at the graduation ceremony of graduation. currently, there are students in total from all classes who perpetuate their studies within the program. an inventive training pattern of ege university faculty of medicine, rtp experience is being maintained as a dynamic process and successfully keeps the students advised of conducting scientific researches, cultivating scientific awareness. objectives: objectives selection and verification of blood collection tubes is an important preanalytical issue in clinical laboratories. in this study comparison with the reference glass tube of ayset plastic tubes containing separator gel and assessment for routine clinical chemistry laboratory testing in samples were aimed. materials and methods: thirty-four volunteers were included in the study. samples were taken into two different tubes by two experienced technologists according to the clsi protocol [tube : z (becton dickinson and company, franklin lakes, nj, usa); tube : ayset (lot , turkey)]. glucose, urea, creatinine, ast, alt, total-cholesterol, triglycerides and high density lipoprotein-cholesterol were analyzed subsequently (olympus au ) and randomised samples stored at - °c for and h. th hour sample was analyzed immediately after collection and accepted as the reference for the comparison of the other samples. a paired t-test and wilcoxon signed rank sum test were used to test the significance of differences between the reference tube and test tubes. results: the difference between the results of reference tube and test tubes for glukose, urea, creatinine, ast, alt, total cholesterol, tg and hdl-cholesterol at , and h were statistically no significant (p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , p = . , respectively). conclusions: no significant difference was observed between ayset tubes' results and the reference tube's results. e. akin c ß akir d€ uzen laboratuvarlar grubu, istanbul, turkey insulin resistance underlies the development of obesity which is a global health problem. obesity is a main concern of scientists because it's associated with type diabetes, hypertension and some cancers. recently, inflammation centered mechanisms are deeply investigated as well as the effects of anti-inflammatory diets which are highly rich in vitamins, minerals, fibers and healthy oils. these diets are proposed to inhibit or supress the secretion of the inflammatory mediators and also improve the intestinal microflora. the aim in this study is to highlight the increasing trend of publications in regard to insulin resistance and inflammation based obesity along with the effects of antiinflammatory diets used for its treatment in the last decade. we performed a pubmed search with key words of 'obesity and insulin resistance and inflammation' ( / / - / / ) (search # ). besides, we performed another search with key words of '(anti-inflammatory diet or dietary supplement) and (obesity or insulin resistance)' (search # ) to highlight the value of anti-inflammatory diets and dietary supplements in combating inflammation based obesity and insulin resistance. search # revealed articles; of these were clinical trials, were observational studies. human studies were while animal studies were . overall, there were review articles and meta-analysis in the field. search # revealed articles of which were clinical trials, were review articles, were meta-analysis. human studies were and other animal studies were . the relationship of metabolic diseases with a low grade inflammatory state has opened a new area of research to understand the consequent causes of inflammation in the human body. the increasing scientific data in the field indicates that antiinflammatory diets may serve as powerful tools to solve the inflammation and the consequent insulin resistance and obesity. medical and biological illustrations for life sciences education: is 'a picture worth a thousand words' in visualizing medicine and science? medical and biological illustrations (mbi) convey complex ideas with just an image and they are powerful intersections of science and art. the clarification of complex pathways via illustrations can be effective means in education as they help the student to visualize the biomolecular world and understand the mechanisms. our aim is to illustrate how a mbi is developed over the example of mechanism of insulin action, via the phosphoinositide (pi) kinase-protein kinase b (akt) pathway. organising one's thoughts and clarifying relationships and then using the optimal complexity level to illustrate the pathway most clearly are the basics of mbi. thus, we made a thorough investigation of insulin mechanism on glucose uptake in skeletal muscle and adipose tissue; a biochemical process that includes insulin receptor (ir), ir substrate, pi kinase, pi-dependent kinase and akt. then, we found the d structures of molecules via protein databanks and accordingly created drawings and diagrams of each component in both molecular and macrolevels by adobe photoshopÒ software. graphics tablets and a compatible pc were also used in the production phase. the use of computer hardware/software enables unlimited detail in images and provides the flexibility that classical drawing techniques can not. thus, the final diagram clarifies the underlying molecular mechanisms of a biochemical pathway along with the physiologic actions. recent improvements of computer technology have resulted in the creation, and reproduction of high-quality lower cost medical art. mbi's can be used in education to explain concepts/pathways to students to enhance learning. similarly, mbi's are great tools to show mechanism/procedures to enhance patients' understanding of their medical condition. considering their unquestionable contribution to education, research and patient care, the creation of mbi's should be promoted as a graduate level course and the discipline should be represented at academic level. biochemistry is a compelling field with broad applications in many disciplines like medicine, dentistry, pharmacy and bioengineering. biochemical research increasingly combines ideas from genetics, molecular biology, etc. and collaborates with many disciplines. our objective is to conduct a scientometric analysis of the last decade's postgraduate theses in the field of biochemistry (ptb) in regard to number, collaborations, subject area distribution, etc. to discover the characteristics and trends in turkey. we searched the turkish higher education council's theses database ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) which includes master of science (msc.), doctorate (ph.d.) and specialization (s) theses in all disciplines. an electronic search with the keyword of 'biochemistry' (in the thesis subject area) was conducted, thus it brought all theses either in the biochemistry discipline or theses in other disciplines but have a biochemistry component. we performed data cleaning and further quantitative analyses in excel. we also executed word count analysis on the titles of theses to derive the main subject areas in ptb. of the total of ptb ( s, msc, phd theses) . % was in natural sciences while . % was in health sciences. the theses output-growth measured by the compund annual growth rate was % over the -years. the top clinical disciplines in collaboration with biochemistry were pediatrics, surgery and cardiology, and the top science disciplines were biotechnology, bioengineering and biology. oxidants-stress and antioxidants ( ), endocrine-metabolism ( ) and enzymology ( ) were the top research areas in ptb, followed by genetics ( ) and cancer ( ). scientometrics is a powerful tool to understand the direction of science and research. our ptb analysis indicated that prominent areas like stem cell, biosensors, geriatrics are somewhat lagging in turkish biochemistry research while postgraduate education and research in total is growing fast with sound collaborations. the st turkish in vitro diagnostic symposium evaluation objective: in vitro diagnostic (ivd) medical laboratory tests and the equipment are closely related the public health, patient safety and the safety of all who utilize these tests. it depends on auditing of the process from the production to the consumption of these materials, that they do not pose a risk to individuals and society. upon these basic requirements; 'turkish in vitro diagnostic symposium: medical laboratory tests' was held in february , organized by the cooperation of turkish biochemical society branch of izmir, and dokuz eylul university health sciences institute. it was intended to shed light on some questions such as, what is the place and importance of ivd in turkey? what are the responsibilities of educational institutions?, what is the role of ministry of health? to put across the conditions of preparing a substructure that may provide achieving success in producing ivd medical devices and in this sector, in our country. material-method: invited speakers attended the symposium, along with the participation of both as lecturers and attendees; ministry of health, turkish standards institution; representatives of manufacturer enterprises; representatives of enterprises manufacturing in turkey; scientists conducting considerable researches on health technology; students and representatives from some of the non-governmental organizations. in addition to the presentations, gathering up the written opinions of the participants, a report was prepared. results: the symposium that lasted for days was realized with participants in total, of which from universities; representatives of their companies; from chamber-institute-public establishments and of which from public hospitals. of the participants were from izmir, of them were coming from out of izmir. conclusion: at the end of the symposium, % of the participants gave feedback. among the feedback selected; . % of the participants evaluated the symposium overall, as successful. . % of them found the symposium successful with regard to its scientific content. their feedback were . % positive in terms of the symposium's contribution to the situation assessment on ivd in turkey, and . % of them stated they would consider participating in the second of the ivd symposium if it is to be organized. perceptions of molecular life science master's students on their scientific and academic competencies and prospective plans for professional development the master's education (me) in molecular life sciences (mls) is aimed at strengthening the knowledge and skills base of the young scientist, preparing him for the competitive academia/industry positions. the rapidly developing pace of science and research forces the master's student (ms) to play a central role in monitoring and guiding his scientific education and professional development (pd). thus, the aim of our study was to examine the perceptions of ms of mls, regarding their scientific and academic competencies. with this data, we planned to analyse if this awareness channels ms to take action and/or matches with their prospective plans. we developed a item online survey with sections (demographic data, current data-contributions of me, competencies and prospective data-action for pd, future plans) and distributed it via e-mail to various postgraduate institutes. at the end of the -day period, ms students (in the thesis phase) answered the questionnaire (female: . %, male: . %). the most highly rated activities that contributed to their scientific knowledge and skills gained in the me were laboratory work ( %), visits with their mentors ( %) and theoretical lessons ( %). ms expressed low levels of sufficiency both in theoretical scientific knowledge and laboratory skills (only % and % sufficiency, respectively). communication skills ( %) and team work ( %) were rated as the highest professional competencies followed by literature search and research planning (both %). it was striking that ms perceived themselves as quite insufficient in scientific writing ( %), data analysis ( %) and project writing ( %) while proficiency in english ( %) was the first area they wanted to take action. despite their perceptions of insufficiencies in many areas, a majority ( %) wanted to continue to phd education. these and similar surveys may lead to an increase in selfawareness in ms and the data may contribute to the revision of me. the report of the st turkey in vitro diagnostic symposium results the following aspects and suggestions took place in the results report prepared after the symposium: about the national ivd-tc r&d, production, forming quality assurance and innovation strategy and policy the cooperation of the university and the industry is not sufficient most of the industrialists cannot take enough advantage of the support provided by the institutions like tubitak, the ministry of science, technology and industry and the ministry of development the statistics on the ivd-tc in turkey should be carried out as soon as possible national standards should be determined in parallel with the international standards the vat rate of the exported raw materials that would be used in ivd production should be decreased. about the education and training, the job titles and positions the related graduate programs, which would focus on all steps of the whole life cycle related to the ivd-tcs one by one, are not widespread there is no 'postdoc' application in turkey. 'postdoc' staff is needed for insufficient component human resources the lecturers should not be restricted to one discipline only graduate programs on laboratory medicine are needed to be established and spread, in order to train component labor specified on the ivd-tc about research and development there are almost no researches related to product development. this should be associated with the education and training institutions about the research centers currently, there is a real infrastructure on health technology in turkey, but there are difficulties in its instituonalism the insufficient cooperation of the university and the industry does not allow the inventions to turn into products the cooperation supports of r&d, being restricted to tech-nopark and r&d centers, are open fields for improvement p-edu- phd training in medical education: career profiles and satisfaction levels of graduates from dokuz eylul university graduate school of health sciences this survey was carried out within the scope of special study modules that is entitled 'phd training in medical sciences' by a group of medical students in deu. the purpose of the survey to investigate the members of health sciences that have successfully completed their phd training in terms of the levels of satisfaction and the status of their career. from this scope we generated two hypothesis: we expected that graduate phd graduates are mostly involved in academy and find their satisfaction levels at moderate level as to phd education. the study was designed as cross-sectional. we reached phd graduates who had graduated from deu graduate school of health sciences between and from different departments via e-mail. the survey was included questions, which were prepared in the light of the existing literature. among the phd graduates, ( %) participated in the study. through this survey, perception of phd students on supervisors' scientific and educational abilities, opinions on phd training, productivity of phd training, number of articles published, their position and related satisfaction levels after graduation were investigated. according to the results, more than half of the graduates (% . ) are well satisficed from the education they had taken. beside this, interestingly we found that % . of graduates prefers staying in the academic positions and % . of them sustains their communication with their supervisors. in conclusion, most of phd graduates were contented with phd training and their career profiles. as a result of this survey, we produced a novel and precise contribution to the literature. in a further study, this survey may extend to other parts of turkey and compile the results in order to get more accurate and inclusive data. phd is an international degree that is reached by conducting an original research after finishing bachelor or master's degree. doctoral degree (phd) can open the door of academic career; on the other hand, a person with a doctoral degree is equipped to carry out important work in research, industry, or public sector. today, gradually increasing number of phd students have brought some problems in phd training. the purpose of this study is to investigate and review activities that have been done by the following international organizations: orpheus: (organization for phd education in biomedicine and health sciences) eua-cde: european university association-council on doctoral education. febs education committee: federation of european biochemical societies these three organizations have done workshops on phd training to pay attention to the following points: *a phd student must take some courses and trainings outside her/his institute, should not be limited to the institute. *the phd training programme should include transferable skills courses. *clinicians, if involved in phd training, should be given free time from their clinic duties. *with regards to potential problems with the supervisor, the institute should provide the student an advisory system. *students should be encouraged to participate in the management of doctoral programmes in the institute. *the students should be given be opportunity to select their own supervisor (thus their thesis area). the phd training has gained quality thanks to these organizations. it is advised that graduate school of health sciences should follow the recommendations and report from these organizations. itsn and itsn are genes encoded adaptor proteins with multiple isoforms participating in clathrin-mediated endocytosis (cme), mapk signaling and reorganization of actin cytoskeleton. changes in itsns expression can lead to different neurodegenerative disorders and cancers. to date little is known about regulation of itsn genes on posttranscriptional level. the aim of our work was to predict and experimentally confirm target sites for micrornas that could potentially regulate itsns expression. using web servers we analyzed utrs of short and long isoforms of human itsn mrnas and found conservative target sites for mir- , mir- , mir- , mir- / , mir- , mir- and mir- in utr of itsn -s, predicted by servers, mir- predicted by servers for itsn -l, and mir- , mir- / , mir- , mir- and mir- predicted by - servers for itsn -l. to elucidate potential impact on cme, mapk signaling and actin cytoskeleton regulation by these mirnas we performed enrichment analysis by diana-mirpath server and found that mir- , mir- , mir- / , mir- , mir- and mir- were highly enriched for all analyzed pathways. using regrna . and scan for motifs services we predicted types of different regulatory elements in utr of itsn and itsn : k-box and brd-box, musashi binding element for rbps musashi and musashi , gu-rich element (gre) and au-rich elements (are) that regulate mrna decay. to confirm itsn -s regulation by micrornas we cloned utr of itsn -s into luciferase reporter vector and transfect hek cells by this construction and mir- a, mir- a and mir- a. for mir- transfected cells, we found - % decrease of expression of itsn -s utr-bearing construction. for other mirs we did not obtain strong reproducible effect in luciferase assay. these data may confirm mir- target site in utr of itsn -s mrna but needed additional research. objective: stroke is an acute neurological disorder that is mostly caused by ischemia in central neural system. % of stroked patients lose their life in year, and remaining / of the living patients continue to their lives as dependent to others. nihss and mrs are two scales which are used in prognosis studies because they can show stroke intensity and after stroke functional recovery. microrna's which have effects on transcription and posttranscription gene regulations are small rna molecules. their roles have been investigated on pathophysiology and treatment of diseases. in this study, it was aimed to detect changes in blood serum levels of mir- a, - , - , b, - , , - a and let- f of ischemic stroke patients and to investigate role in predicting prognosis methods: patients diagnosed by acute ischemic stroke admitted to neurology service of g€ oztepe hospital and healthy individual were included in the study. after stroke patients' blood samples were taken periodically in st day, st week, and rd month, and at the same time nihss and mrs scores were determined. set mirna blood serum levels were measured by rt pcr results: when compared to the control group, we found that after stroke st day peripheric blood levels of mir- a,- ,- a and let- f were significantly low; when st week and st day serum records were compared there was a significant increase in mir- level; and when st week and rd month records were compared we noted that there was a significant increase in mir- a,- and let- f levels. from prognosis point of view; after ischemic stroke measurements showed that mir- b in the st day, mir- a and mir- in the st week showed positive significant correlation with rd month mrs scores (p = . , p = . , p = . , respectively) conclusion: according to the outcomes of this study, after stroke st day mir- b, st week mir- a and st week mir- levels can be stipulated to use in predicting patients' rd month prognosis p- . . - inhibitory rna aptamer against lambda ci repressor showed the transcriptional activator activity s. ohuchi, b. suess tu darmstadt, darmstadt, germany because of the variety of functionalities on gene regulation and the easiness of molecular engineering, functional rnas are promising parts for the construction of genetic circuits. artificial affinity rna, or rna aptamer, is one of such genetic parts. in the previous study, an inhibitory rna aptamer against a repressor protein, tetr, was developed as a transcriptional activator [ ] . the expression of this aptamer abolishes the repressor activity of tetr, resulting in the elevated gene expression under the control of tetr. because of simplicity of the mechanism, similar transcriptional activators can be generated by using rna aptamers against other repressor proteins. here, we examined the generation of an activator based on an rna aptamer against one of the most frequently applied repressor proteins, lambda phage ci. in vitro selection (selex) was performed targeting a recombinant ci protein employing an rna pool containing -nucleotides of a random region. after rounds of selex, the pool rna showed the affinity, as well as the inhibitory activity, against ci in vitro. then, rna aptamers with the transcriptional activator activity were screened from the enriched pool in vivo employing a reporter plasmid on which the expression of a reporter gene, lacz, is repressed by ci. when the variants of the rna pool were transformed to e. coli cells harboring the reporter plasmid, about half of the transformants showed the elevated reporter expression. interestingly, all of these desired rna clones shared the same sequence. quantitative analysis indicated that -fold induction of the reporter expression was achieved upon the aptamer expression. our results suggested that diversity of artificial transcriptional activators can be extended by employing rna aptamers against repressor proteins to broaden parts for the construction of genetic circuits. [ ] hunsicker, et al. ( ) an rna aptamer that induces transcription. chem. biol., : - . p- . . - microrna expression signatures between non-atherosclerotic plaque and atherosclerotic plaque in cad with humans, and parallels whole blood rnas and represent a new important class of gene regulators. the present study was designed (i) to investigate the mirna expression profile in human atherosclerotic plaques from peripheral arteries aorta as compared to non-atherosclerotic left internal mamary artery (lima); (ii) to examine the expression levels of mirna in whole with correlation mirnas of aorta tissue. material and methods: thirty-one patients with cad were enrolled in study. lima and aorta tissue samples were obtained during coronary artery bypass surgery. whole blood samples were collected before cabg surgery. each patient with cad was obtained from whole blood, aorta and limas tissues. these tissue samples were immediately soaked in rnalater solution and homogenized using a magnalyser. the rna was extracted using the trizol reagent and the mirneasyÒ mini-kit. the expression profiles of mirnas were evaluated using highthroughput qrt-pcr. results: we found that mir- - p was expressed only in aorta. mir- - p and were expressed both aorta and whole blood. mirnas were significantly up-regulated in aorta when compared to lima tissue (fc > ). mirnas were significantly down-regulated in aorta compared to lima. conclusion: in conclusion, our study suggests that mir- - p, mir- - p and might be a potential for cardiovascular disease development. also mir- - p and might serve as novel non-invasive biomarkers for cad p- . . - mir b regulates cell proliferation and colony formation in pancreatic ductal adenocarcinoma n. gurbuz, e. isildar due to the strong metastatic potential, pancreatic cancer has the highest mortality rate of all major cancers. therefore, the investigators are in urgent need of developing the new alternative therapeutic approaches for the prevention of pancreatic cancer. mirnas, small noncoding rnas, regulates as an inducer or inhibitor in expression of key mediators related molecular mechanisms in cancer promotion. to investigate the effect of mir b on pancreatic ductal adenocarcinoma cells, we performed the cell viability and clonogenic assays by mts and crystal violet dye, respectively, in panc- and miapaca- cells transfected with mir b mimic. our data revealed that mir b led to decrease the cell viability depending on enhanced mir b doses, which are , , and nm, as the ratio of % , , and , respectively, in miapaca- cells and as the ratio of % , , and , respectively, in panc- cells compared with control condition of each cell. this inhibition mediated by mir b was also obtained in colony formation both of pancreatic cancer cells. when the induced effect of mir b on the death of pancreatic cancer cells was compared with gemcitabine, which is currently used as a clinical drug for pancreatic cancer patients, we determined that mir b was more effective than gemcitabine. based on our findings, it is clearly shown that mir b serves as a tumor suppressor in pancreatic ductal adenocarcinoma cells. we strongly believed that mir b gene therapy might be more effective and targeted approach than classical gemcitabine therapy for pancreatic cancer patients. *this work was supported by tubitak (the scientific and technological research council of turkey) grant s . breast cancer is the most common cause of cancer death in women. trastuzumab is a therapeutic agent frequently used against her + breast cancers, which has role in approximately % of invasive breast cancers. with the discovery of their activity in cancerogenesis, micrornas (mirnas) have become potential candidates to mediate therapeutic actions by targeting genes that are effective in drug response. recent studies have showed that mirnas are induced by targeted therapies. in this study, we aim to find out mirna-mediated mechanism, which is driven by common trastuzumab responsive micro-rnas in her + breast cancer. for this purpose, the common trastuzumab responsive mirnas were determined in treated bt and skbr cells by microarray profiling. two datasets were intersected to find out common mirnas for both cell lines. the overlapping predicted targets of common mirnas were provided by two different mirna-target prediction databases and then a mirna-gene network was built in cytoscape by using networkanalyzer plugin. the most shared target genes were chosen to be analyzed in the ebi-embl gene expression atlas for their expression patterns in breast cancer. common mirnas were found to have overlapped targets in two target prediction algorithms that were used to build the mirna-gene regulatory network. overlapped targets were determined as the most shared genes in the mirna-gene network. expression pattern of each shared gene in the gene expression atlas showed that out of the most shared target genes were strongly dysregulated in several breast cancer types. our results suggest that mirnas might show a common response to the targeted therapies and network analysis can be profitable to have a better explanation of the regulatory mechanisms between drug responsive mirnas and their target genes. revealing the mirna-potential target interactions might provide novel key players that mediate the mechanisms of action in drug treatment. chronic myeloid leukemia (cml) is a clonal disease of primitive pluripotent stem cells that identified with a specific t( ; ) reciprocal translocation that encoding bcr-abl oncoprotein. resveratrol (res) is a natural phytoalexin found in grapes and induces apoptosis, erythroid differentiation and autophagy in leukemic cells. micrornas are small, single strand, non-coding rna molecules that regulate post-transcriptional gene expression via disrupting the stabilization of target transcripts or inhibiting protein translation. in our study we aimed to determine cytotoxic effect of res in k human cml cell line and to evaluate the expressions of mirnas that are associated with genetics of leukemia after treatment with res; to investigate target genes of mirnas which show significant expression alterations and molecular mechanisms of res treatment. k cells were treated with lm (ic dose) res during h and cytotoxicity was evaluated by using wst- assay. the rt-qpcr is used for mirna and gene expression analysis. results showed that; res up-regulated tumor suppressor mir- - p level . fold and significantly downregulated hdac gene expression (p = . ) and upregulated p / sqsmt gene expression (p = . ), according to the control cells.p /sqstm interacts with lc and plays role as a critical player in the autophagic degradation of the bcr-abl fusion protein. our findings showed that resveratrol acts as a hdac inhibitor targeting hdac and p /sqsmt gene expression level. treatment with hdac inhibitors results apoptosis, cellcycle arrest, cell differentiation, anti-angiogenesis and autophagy. downregulation of hdac provides post-translational modification for expression of tumor supressor genes and leads to cell cycle arrest and increases apoptosis. these results could be linked to hdac dependent induction of gene associated with autophagy like p /sqsmt and resveratrol could be a therapeutic candidate as a hdac inhibitor for cml treatment. the mirna used in this study are hsa-mir- , hsa-let- a, hsa-mir- b and hsa-mir- . thereafter, we bought pre-mirnas and their mirnas commercially. we apply them to the a cell line in different combination and different concentrations. these mirnas applied solely onto cells or in combination as; four of them, let + , let + b, let + , + b, + , + let + b, + let + b. the cell viability was detected by wst- kit in a well plate elisa reader. cells were seeded as per well, mirnas incubated with cells for h in an appropriate atmosphere. according to our results some combinations and mirnas didn't alter viability, however + b and + combination increased the cell viability dramatically. on the other hand let + b and only applications decreased the cell viability. the other applications' viability results are not different from the control cells significantly. in this study, we used a cell line also called non-small lung cancer (nsclc) cell line and possibly effective mirnas on lung cancer. it is important to exhibit the mirna combinations should be effective on cancer cells' viability. the prospect combinations were determined which is crucial to develop new strategies for cancer treatment. competing endogenous rnas (cernas) act as molecular sponges for the same pool of micrornas through their mirna response elements (mre), titrate mirna levels and thereby regulate gene expression post-transcriptionally. smad interacting protein (sip ), a member of the zeb family is a regulator of epithelial-to-mesenchymal transition (emt) program, which is active during embryogenesis and tumor invasion and metastasis. hence, we investigated the regulation of sip by cernas in hepatocellular carcinoma (hcc) cells. among hundreds of sip cernas listed at competive endogenous mrna database (cerdb), transcripts (pten, zeb , ptch , creb , acvr b, enah, robo , erbb , e f , foxo , rictor, klf , ets , cdk ) sharing at least common mre sites with sip were selected and their expression in hcc cell lines were determined by qrt-pcr. ets was found to be highly correlated with sip in hcc. furthermore, repressing sip expression by shrna in hcc cells resulted in decreased expression of ets , pten and zeb . our results suggest a possible bidirectional and post-transcriptional regulation of sip and its cer-nas in hcc. a meta-analysis for the identification of common microrna signatures in colorectal cancer n. sahar , , n. belder, h. ozdag biotechnology institute, ankara university, ankara, turkey, comsats institute of information technology, islamabad, pakistan colorectal carcinogenesis (crc) has quite frequent incidence and mortality rates worldwide, despite being studied for decades now. new biomarkers are needed to be identified in addition to the existing ones, due to heterogeneous nature of this disease. the regulatory molecular machinery of a cell, including micrornas (mirnas), contributes to this heterogeneity upon aberrant expression. herein, for a mechanistic understanding of differential gene expression in crc tissue we analyzed mirna expression profiles of crc tumors against normal colorectal mucosa samples, using raw data from e-mtab- and e-geod- (affymetrix microarrays), and gse and e-mtab- (agilent microarrays) datasets obtained from gene expression omnibus and arrayexpress. raw samples were normalized (different platforms separately) using quartile normalization in brb-array-tools. differential expression of mirnas was identified using cut-off values of p ≤ . , fold change ≥ . and stringent false discovery rates. mirtarbase and mirwalk . databases were explored to identify validated targets. we found thirty (including mir- and mir- ) and thirteen (mir- , mir- , mir- , etc.) mirnas commonly upregulated and downregulated respectively, in both affymetrix and agilent microarray results. predicted targets of these mirnas frequently belong to pathways related to cancer like b-catenin, phosphoinositol- kinase, and transforming growth factor-b, to name few. moreover, the target genes were significantly enriched in clusters related to cell cycle, cell differentiation and regulation of apoptosis. these promising results will further be compared with differentially expressed gene profiles from a cohort of turkish crc patients. hence the integrated study will refine the panel of diagnostic and prognostic crc markers. hsa-mir-x modulates motility and invasion in triple breast cancer cell line s. noyan , h. g€ urdal , b. g€ ur dedeoglu biotechnology institute, ankara university, ankara, turkey, department of pharmacology, ankara university, ankara, turkey breast cancer is a heterogeneous disease and expression levels of certain receptors have demonstrated subtypes which characterize clinically distinct breast tumors. a triple-negative phenotype lacks expression of er, her and pr and is known as basallike carcinoma. micrornas are a class of small non-coding rnas that participate in the gene expression in many biological processes. e-cadherin is an important mediator of adhesion in epithelial tissues, and loss of e-cadherin can play a critical role in tumor invasive behavior. another key player of cell integrity pip ( , , ) triphosphate is generated at the leading edge of the cell and leads to cell polarization. pip is generated by hydrolysis of pip ( , ) bisphosphate, which is synthesized by pip k . any dysregulation in these molecules may support the invasive behavior of the cells. the aim of this study is to find out the role of mirna precursor (hsa-mir-x) in invasion and motility in triple negative breast cancer cells. in this study a triple-negative breast cancer cell line bt- was transfected with hsa-mir-x or scrambled control sirna. to check its role in motility and invasion, wound healing and invasion assays were performed respectively. cell invasion was monitored over a period of h by xcelligence real-time cell analyzer using a double-plate and measuring impedance-based signals. additionally emt markers were analyzed by qrt-pcr to explain the molecular mechanisms beneath motility and invasion. we observed that cell motility and cell invasion diminished after transfection of bt- cells with mimic for hsa-mir-x. furthermore, qrt-pcr experiments indicated that transfection of hsa-mir-x decreased the expression level of pip k c while increasing the e-cadherin expression level. wound healing and invasion assays together with qrt-pcr results support the role of hsa-mir-x in cell motility and invasion. this process might be explained via e-cadherin mediated met or gsk- -beta related inhibition of invasion. expression level of five micrornas as diagnostic markers in glioblastoma situated in the main brain lobes, but can also be found in other brain regions. while microrna (mirna) as non-coding rnas, play a crucial function in the post-transcriptional regulation of gene expression by mrna degradation or translational repression. in the present study, we aimed to investigate the contribution of gene expression of the five mirnas and to unravel their role in brain tumor cell lines, the mirnas to the risk of gbm tumor. the five gbm cell lines (crl- , crl- , crl- , crl- and htb- ) were evaluated with non-malignant (normal) brain cell line (hcn- ) . determinations of expression level of five mirnas (mir- , mir- , mir- , mir- , and mir- ) were evaluated by monitoring quantitative rt-pcr (qrt-pcr) technique. the expression levels of four mirnas (mir- , mir- , mir- , and mir- ) were significantly decreased while the expression level of mir- was increased in gbm cell lines according to hcn- cell line. consequently, these five mirnas can potentially be used as biomarkers for gbm tumor; further studies are mandatory to a better understand and confirm our preliminary findings. background: noncoding rna are known to be crucial molecules with diverse regulatory roles in neural oncology and neurodegenerative disease. the recent study suggested that lncrna anril play role in the development of neuroblastoma and alzheimer disease via binding disease-specific micrornas. material and methods: we used lncrnadisease, hmdd v . , mir disease to predict lncrna-and mir-associated disease in our study. in addition, we utilize tardetscan to search lncrna-mirna interaction. results: disruptions of lncrna anril expression (also named as cdkn b-as, locus cdkn a/b (ink /arf), chromosome p ) have been associated with the development of neuroblastoma and alzheimer disease. here, we predicted interactions between noncoding transcripts encoded by locus cdkn a/b and their molecular partners -microrna. anril can act as decoy while containing sequences that mimic mirna target sites to titer these mirs away from their primary targets thereby act as molecular sponge. using targetscan . , we predicted target sites for hsa-mir- -p/ -p/ -p/ -p/ -p/ -p and hsa-mir- - p/ in anril utr. then, we used hmdd v . and mir disease databases to define if any of these mirs participate in alzheimer disease and neuroblastoma. according to both databases, mir- is implicated to alzheimer disease and mir- to neuroblastoma. as soon as anril participate in the development of both abovementioned disorders and can have microrna sponge activity, it could potentially positively regulate mir- and mir- targets by competing with them for micro-rna binding sites thus restoring the expression of target genes. in our further research we plan to experimentally validate predicted microrna sites in anril utr. conclusions: we predicted sites for mir- and mir- in utr of anril lncrna that could uncover its possible sponge activity in the development of neuroblastoma and alzheimer disease. aim: matrine excracted from saphora flavescens root and demonsrated that indicates pro-apoptotic and anti-proliferative effect in many types of cancer. acute lymphoblastic leukemia (all) is an acute form of leukemia, or cancer of the white blood cells which characterized by the overproduction and accumulation of lymphoblasts. mirnas play important roles in deregulated cell death mechanisms. we aimed to investigate the effects of critical mirnas during the development of matrine resistance on all cell line ccrf-cem. material-method: ccrf-cem cells were treated with different ( . - mg/ml) concentrations for h and cell viability measurements were carried out with xcelligence device to determine the cytotoxic effects of matrine. mirnas were extracted from treated and untreated ccrf-cem cells using the mirna isolation kit. cdna was synthesised using allin-one first strand cdna synthesis kit. expressions of selected mirnas were analysed with miprofiletm custom mirna qpcr array using the applied biosystem fast real-time pcr system. results: according to the cytotoxicity assay, it was determined that 'treatment with increasing concentrations of matrine, decreased the viability of the ccrf-cem cell line. expression levels of different mirnas were studied for indicated passages in two replicates. our results showed that hsa-mir- b- p (- , fold, p = . ), hsamir- - p (- , fold, p = . ), hsa-mir- a- p (- , fold p = . ), hsa-mir- a- p (- , fold, p = . ), hsa-mir- - p (- , fold, p = . ), hsamir- b- p (- , fold, p = . ), hsa-mir- b- p (- , fold, p = . ), hsamir- b- p (- , fold, p = . ), hsa-mir- - p (- , fold, p = . ), hsamir- a- p (- , fold, p = . ) expression were decreased during the development of matrine resistance. conclusion: these data suggested that especially hsa-mir- b- p plays a critical role in the matrine response. ericd (e f -regulated inhibitor of cell death) is a newly found lncrna. it is located at q . . it has two exons and its transcript size is bp. ericd is regulated by e f (transcription factor ) and modulates the cellular response to dna damage. arid a is a family member of the at rich interaction domain (arid) dna-binding proteins that participate in diverse biological processes like development, cell cycle control, chromatin remodeling and epigenetic regulation. both, ericd and arid a have just opposite roles in apoptosis in case of dna damage indicating a probability of reciprocal interaction between each other. till now, there is no work related to the interaction between lncrna and arid a in cancers. herein we try to find a probable interactive role between these in cancers. in this study, different cancer cell lines, osteoblast cell line and different types of normal human tissues rnas were selected for expression analysis of ericd and arid a. after rna isolation, cdna was converted from their rnas. expression profile analysis of ericd and arid a in different cancer cell lines and normal tissues was done using imagej program for semiquantitative and (-ddct) method for quantitative rt-pcr. among used cancer cell lines, ericd was highly expressed and arid a had lower expression in u- os (osteosarcoma), a- (glioblastoma) and a (lung cancer). at the same time, ericd expression was lower and arid a had high expression in hfob . (osteoblast cell line) and normal tissues like brain and lung . both ericd and arid a are cell cycle regulated and are commonly regulated by e f. they have just opposite roles in apoptosis during dna damage. these two genes have a probability of reciprocal interaction between each other in cancer. our results indicate that both ericd and arid a might have opposite roles in lung cancer, glioblastoma and osteosarcoma. ericd and arid a might act as cancer promoting and tumor suppressor genes respectively in these cancers. the importance of mirna expressions in infertilty implantation process is controlled with endometrium, factors secreted by the embryos and in accordance with these factors embryo and/or endometrium via receptors on. more than human microrna (mirnas) that are small noncoding rnas were shown to play an important role in intracelluler cycle regulation in both normal and pathological conditions. in this study we aim to identify mirnas and controlling molecules expressions in different time period of endometrium in fertile and infertile cases. the endometrial samples were taken from fertile and infertile patients in proliferation and early secretion periods. the samples are fixed and stained either with hematoxylen-eosin for morphological analysis or with immunohistochemistry for distributions of anti-dicer, anti-drosha, anti-eif a and anti-eif c. mir- - p, mir- a, mir- b, mir- - p, mir- , mir- a*, mir- , mir- a, mir- a, mir- b, mir- a/b/c were analyzed with qrt-pcr. while dicer immunoreactivity was detected weakly only proliferation phase of fertile group, this immunoreactivity were detected strongly in both proliferation and early secretory phases of infertile group. drosha immunoreactivitiy was also weakly detected in the proliferation phase of fertile group, it was moderately detected in both proliferation and early secretory phases of infertile group. eif a immunoreactivitiy was similar in each groups but there were a few differences between fertile and infertile group. eif c immunoreactivitiy was negative in all groups. mir- , mir- a* and mir- a were highly expressed in proliferation phase of fertile group, mir- a and mir- b were highly expressed in early secretion phase of infertile group. in conclusion, dicer and drosha immunoreactivities and different expression of mirna's were detected in all groups. implantation problems may be reason for different mirna expression which controlling with dicer and drosha in the infertile endometrium in both proliferation and early secretory phases. wheat is an important agricultural crop with an over . million metric tons harvesting capacity annually. drought and salinity are environmental stress factors that affect yield and quality of wheat, dramatically. there are different defense mechanisms against these stress conditions in plants. altering gene expression profiles by micrornas at post-transcriptional level is one of the most conserved mechanisms among plants. micrornas are an extensive class of noncoding rnas, approximately nucleotide length which regulates the expression of genes by binding to the -untranslated regions of specific mrnas. micrornas implicated under salt and drought stress have widely been reported in numerous plant species and wheat genomes in the last years; however, studies on einkorn wheat (triticum monococcum spp. monococcum) are not yet available. the goal of this study is identification of conserved micrornas from einkorn wheat using next generation sequencing technology and bioinformatic analysis. in this study, small rna molecules were extracted from pooled plant samples grown under normal, drought and salinity conditions. sequencing analysis revealed unique small rna sequences obtained from raw reads. after bioinformatic analysis based on comparative genomics approaches, we identified putative mature microrna sequences belonging to distinct microrna families. since chromosomal sequence data is not available for triticum monococcum spp. monococcum, we used available sequences from triticum urartu, a close relative, as template to extract precursor microrna sequences. of precursor sequences showing % homology to triticum urartu genome were analyzed for secondary structure prediction using mfold software. data provided in this study is critical to investigate transcriptional regulation of genes involved in stress metabolism in einkorn wheat. the role of vim-as , a natural antisense transcript, in cancer coding or non-coding transcript. in this regard, vim-as is nats located antisense to vimentin gene. in the present study, we aimed to determine tissue and cell line distribution of vim-as . materials and method: for the tissue expressions analysis, human total rna master panel ii (containing different human tissue samples) was used. total number cancer cell lines and normal cell lines included in the study. for the expression analysis rt-pcr and qpcr methods were used. results: as a result, expression levels of vim-as were found to be tissue specific. particularly, while vim-as was highly expressed in lung and thyroid gland tissues, its expression was not observed brain, stomach and adrenal gland tissues. also, vim-as was also found to be differentially expressed in cancer cell lines. vim-as expression was found to be lost in cal , pc , and hct and highly diminished a cancer cells. also, it is found to be highly expressed in bcpap, panc and beas b cells. discussion: results of the current study suggest that vim-as may have significant role in the regulation of vim gene in thyroid gland tissues, as it is highly expressed in both thyroid gland tissues and bcpap thyroid cancer cells. moreover, vim-as and vim axis can be involved in the formation of lung tumors because vim-as was highly expressed in normal lung tissues and beas b cells and expressed very low levels in a lung cancer cells. lung cancer is the leading cause of cancer related deaths in the world and approximately % patients with lung cancer ultimately die from metastatic disease. metastasis is the most dangerous step of cancer. in our recently published work showed that akt/nf-kb pathway is continuously active and induces cellular invasion and pten suppresses cellular invasion via inhibition of akt/nf-kb pathway. in this study we aimed to show nf-kb mediated induction of mirna expression can responsible for inducing nsclc invasion. we used chromatin immunoprecipitation (chip) assay kit for detection of tnf-a induced nf-kb mediated mirnas. therefore, h and pc cells treated by tnf-a ( ng/ml) for chip assay. chromatin regions, reading with chip-seq, were analyzed using bioinformatics tools. we also performed additional bioinformatics search to find nf-kb related mirnas which potentially take a role in nsclc invasion. we investigated the effects of mirna which determined at the bioinformatics analysis results on invasion using invasion chamber method. we found mirnas which potentially induced by nf-kb and related with nsclc invasion. our invasion results indicate that mir- a- p, mir- as- p, mir- , mir- , mir- - p, mir- q mimics can induce cellular invasion on h , mir- v, mir- h- p, mir- - p, mir- a- p, mir- as- p, mir- mimics can induce cellular invasion on pc . we also verified our results by qrt-pcr, because we want to sure that mirnas which can induce invasion, can also transcriptionally regulated by nf-kb or not. we found that mir- q, mir- a- p, mir- as- p, mir- , mir- in h , mir- - p, mir- a- p, mir- as- p, mir- in pc can induce cellular invasion by nf-kb. as a conclusion, our investigation indicate that nf-kb can induce nsclc invasion via mir- a- p, mir- as- p and mir- . (this study is supported by tub _ itak grand number s ). to understand of the molecular mechanisms of cellular invasion is very important for fight against cancer mechanisms and first step of invasion is emt. cells change phenotypical and genotypical in emt progress. in this study, we focussed on the explore molecular mechanism of tnf-alpha induced cellular invasion of nsclc. we use western blot, qrt pcr and mirna transfect methods for this purpose. we find that tnf-alfa treatment reduce the expression of pten and induce e cadherin expression in a cells. when we inhibit nf-kb activity by p targeted sirna tnf-alpha can not reduce pten expression means that tnf-alpha inhibits pten expression through on nf-kb. because tnf/nf-kb pathway change the transcriptional level of mir- as and pten untranslated region has recognition site for mir- as. therefore; we transfected a cells by mir- as. mir- as transfection leads to inhibition of pten expression. our results indicate that tnf-alpha mediated activation of nf-kb can inhibit pten expression on induction of emt through on mir- as. (this study is supported by tubitak grand nummber s ). introduction: the corpus luteum (cl) is an ephemeral tissue whose regulated secretion of progesterone is essential for maintenance and/or timely termination of pregnancy in rodents. our previous finding that cl of pregnant rats does not possess fas/ fasl system suggests that this tissue may undergo autophagic, but not apoptotic, cell death during regression. we here investigated the presence of autophagic system in cl and its any implications in rodent pregnancy and parturition. materials and methods: lc (-i and -ii) expression in cl was estimated by western blot analysis in comparison with progesterone secretion and luteal mass throughout pregnancy. lc was also tested by immunocytochemistry. functional implication of autophagy in this tissue was examined by local treatment with bafilomycin a (autophagy and v-atpase inhibitor, . pg/ . ml/ovary) on day of pregnancy. reproductive, biochemical, and morphological outcomes were evaluated. results: while the expression of cytosol-associated lc -i was not significantly altered throughout pregnancy, that of autophagosome-associated lc -ii increased significantly from day , showed a peak on day , and decreased on day (day of normal parturition). lc -ii / i ratio had positive correlations with steroidogenic activity and cell size. immunoreactive lc was found to be present in the cytosol of steroidogenic cells and showed marked aggregation in cells on day . in vivo treatment with bafilomycin a resulted in unaltered delivery, but in significant reductions in steroidogenic cell size and neutrophil infiltration compared to vehicle-treated control groups. discussion and conclusion: the ratio of lc -ii / i in cl was markedly up-regulated in the late phase of pregnancy. manifestation of this autophagy parameter was temporally matched with further structural and functional activation of cl. autophagy may contribute to activation, but not regression, of rodent cl and thus their female reproduction. apoptotic and necrotic effects of low dose bisphenol a in shsy y neuroblastoma cells b. ayazg€ ok, t. t€ uyl€ u k€ uc ߀ ukkilinc ß faculty of pharmacy, hacettepe university, ankara, turkey bisphenol a (bpa) is a commonly used chemical in industry to make plastics. 'low-dose' term has been expressed for the first time in studies with bpa in . the value of low dose bpa was received as < lm. in this study, matrix metalloproteinases (mmps) together with their tissue inhibitors (timps), involved in tissue remodeling after i- therapy, have been examined in patients ( m/ f) with ptc and ( m/ f) with ptc+ht. peripheral blood samples were collected just before and, subsequently, at days after i- administration ( . gbq). ptc+ht patients had positive titers of anti-thyroglobulin autoantibodies (tgab). the serum levels of tgab, mmp- , mmp- , timp- and timp- were measured by elisa. there were no significant changes in serum concentrations of mmp- , timp- and mmp- /timp- ratio after i- in the two groups. in ptc patients, i- administration resulted in an increase with % in timp- level (p = . ) and a reduction with % in mmp- /timp- ratio (p = . ). in ptc+ht patients it has been observed an increase with % in tgab level (p = . ), % in mmp- /timp- ratio (p = . ) and unchanged timp- serum concentration. tgab titers were positively correlated with mmp- /timp- ratio (r = . , p < . ). our data suggest that radioiodine therapy for ptc patients, but not for ptc+ht, modulates the balance of mmp- /timp- for anti-invasion and anti-migration by augmenting timp- . in criminal cases, the determination of the time of death of the bodies step in the analysis of events is making a big contribution. today, forensic and molecular methods utilized time of death rather than provide clear information offers potential death time interval. principally, 'time of death' is a term that should be avoided. in forensic science, the postmortem 'interval' is the term to be considered. nowadays, there is no precise molecular method that can be used alone in the determination of pmi. aim of this study is to analyze the usability of ecm components, adamts , and and mmp , and to determine pmi. for this purpose, with iliopsoas muscle tissues provided by ethical board of the ankara institute of forensic medicine, cases have been included in this study, divided into groups according to their pmis: ' - h', ' - h' and ' - h'. from these tissues, western blotting technique is used to analyse the expression of adamts , and and mmp , and . it is determined that when pmi increases; adamts- and amounts decrease. on the other hand adamts- amounts are examined to increased related to the interval., especially on the ' - h' dataset. additionally, considering metalloprotease levels, mmp- and amounts decrease as pmi increases. unlike mmp- and ; mmp- levels increase proportional to the interval, especially on the ' - h' dataset. these results are the first data on pmi determination from iliopsoas muscle tissue. in this study, it is suggested that adamts- and mmp- , proteases responsible for ecm degradation, can be used to determine pmi as markers. here we present the first observations of postmortem variation of mmp and adamts activities in skeletal muscle. in recently, popular mmps and adamts s pathways of the relationship between time-dependent changes to investigate the post mortem time interval determination to shed light on the future. the role of functional polymorphisms of matrix metalloproteinases and in spontaneous abortion samples capillaries, which are responsible for maintenance of implantation and placental nutrition, have major effects on mechanisms underlying abortion. matrix metalloproteinases (mmps) function in various cellular pathways. they play a role in patholohical conditions, metastasis; as well as normal physiological functions like tissue and bone regeneration, physiologic function of uterus, ovulation, embryogenesis and embryo implantation. mmp and mmp (gelatinases) have key roles at organisation of extracellular matrix and affect endometrial implantation. previous studies have shown that mmp - c>t and - c>t polymorphisms cause loss of gene function, and mmp - c>t polymorphism causes a decrease in gene expression, and also gene expression levels are lower in abortion specimens, compared to control specimens. the goal of this study was to investigate the potential effects of functional mmp - c>t and - c>t polymorphisms, and mmp - c>t polymorphism on etiology of abortion. restriction fragment length polymorphism (rflp) method was used to analyze the polymorphisms those evaluated in the study. study group consisted of samples collected from spontaneous abortion specimens, and control group consisted of peripheral blood blood samples collected from healthy subjects. the risk of abortion was . -fold higher in patients with heterozygous - c>t polymorphism (p = . ). combined genotype analysis showed that the risk of abortion was . -fold higher for patients with normal - c>t polymorphism, and heterozygous - c>t polymorphism (p = . ). functional polymorphisms of mmp and mmp may have a role in etiology of abortion. p- . . - changes in the specific extracellular matrix proteins and expression of adamts proteinases and effects of hypoxia in the adriamycin-induced renal fibrosis model renal fibrosis is a common cause of renal dysfunction with chronic kidney diseases. this process is characterized by excessive production of extracellular matrix (ecm) or inhibition of ecm degradation. adamts proteinases, which are widely presented in mammals, have very critical roles in ecm remodeling. we aimed to study the role of adamts proteinases in the pathogenesis of renal fibrosis and the effets of hypoxia by studying adamts expressions in rat kidney after adriamycin (adr) administration. adr was administered intravenously in consequtive two doses ( . and mg/kg) to the rats. in addition to control and adr groups, another rats were assigned into three groups as sham, min and min ischemia-reperfusion. after months following the first dose, the expression of adamtss were determined in the renal tissues using western blot analysis. additionally, renal nephropathy and fibrosis were assessed pathological and immuno-histochemical staining methods. in the adr group rats developed renal dysfuntion and tissue damage in favor of renal fibrosis pathologically. it is observed that occurred remarkable changes in the expression of adamtss. it is showed that hypoxia and hypoxia time enhanced tubulointerstitial fibrosis in the rat kidney tissues. expression differences were absorved also in the hypoxia groups, and especially the expression of adamts- and - genes were showed an increase in various rates. the restricted and different expression pattern of adamts protein profiles in the adr-induced renal fibrosis suggest that adamts family members are related with development and progression of fibrosis. moreover, our findings raise the possibility that the hypoxia promotes renal fibrogenesis. the monitoring of adamts proteinases might contribute to the early diagnosis of renal fibrosis and chronic kidney disease. adams (a disintegrin and metalloproteas) are transmembrane proteins that contain a pro-domain, a metalloprotease, a disintegrin, a cysteine-rich, an epidermal-growth factor like and a transmembrane domain, as well as a c-terminal cytoplasmic tail. they are involved in cell adhesion and they have protease activities. previous studies showed that some adam proteins act in a highly diverse set of biological processes, including fertilization, neurogenesis, myogenesis, embryonic tgf-a release and the inflammatory response. although there are more researches about adam proteins, still the function of all adam proteins remain unclear. we aimed to investigate the potential link of infertilty with adam , - , and - . in this study twenty four patients were included. the patients were classified as normozoospermia (ns; n = ), oligozoospermia (os; n = ), azoospermia (as; n = ) groups. adam , - and - protein levels in infertility indviduals were analysed by western blot. adam protein level was . fold lower in the os and as groups than in the ns group. adam protein level was . fold higher in the as group than in the ns group. adam protein level was fold lower in the as group accourding to ns group. we observed no change between protein level of adam and adam of os and ns groups . in conclusion, adam proteins may have a potential role in male infertility. our study is a preliminary and first study on this issue. keywords: adam, infertility. the role of tissue metalloproteinase inhibitors thymus chemokine and thrombospondin- on prognosis of crimean-congo hemorrhagic fever s. bakir, m. bakir, s. ersan, a. engin cumhuriyet university, sivas, turkey crimean-congo hemorrhagic fever (cchf) is a disease which is caused by an arbovirus carried by ticks and characterized by the sudden onset of high fever, severe headache, dizziness, back and abdominal pain. cchf pathogenesis is still not resolved today to fully open. therefore, in this study, to determine the level of tck- , timp- and tsp serum samples obtained from cchf patients and the control group is intended to be examined for the pathogenesis and prognosis of the disease. the study sample was created patients with diagnosis of cchf. healthy volunteers were chosen control group matched for gender and similar to in terms of age. tsp, tpc- and timp- levels of patients and a control group were analyzed using the human elisa kits. serum timp- tck- and tsp levels in cchf patients were measured significantly higher than the in the control group. cchf pathogenesis of today still have not provided fully open. therefore, it reveals the importance of this work. in our study, presence of high timp- , tck- and tsp levels indicate important direction for pathogenesis and prognosis of cchf disease. p- . . - activation of calpain and protein kinase ca promotes a constitutive expression and release of matrix metalloproteinase in peripheral blood mononuclear cells from cystic fibrosis patients matrix metalloproteinase (mmp ) is physiologically involved in remodeling the extracellular matrix components but its abnormal release has been observed in several human pathologies, including cystic fibrosis. we have studied if the alteration in intracellular ca + homeostasis, observed in peripheral blood mononuclear cells (pbmcs), isolated from cystic fibrosis (cf) patients homozygous for deletion of phenylalanine in gene of cystic fibrosis transmembrane conductance regulator (f del-cftr), could be involved in the abnormal presence of mmp in the extracellular fluids of cf patients. pbmcs were isolated from healthy donors and cf patients homozygous for f del-cftr. mmp levels were evaluated following h of cell incubation. our investigations show that all cf pbmcs analyzed constitutively express and release high levels of mmp ; conversely, in pbmcs from healthy donors, expression and secretion of mmp are undetectable but both events can be evoked, after h of cell culture, by a possible paracrine stimulation. we have demonstrated that in cf and h-cultured control pbmcs mmp secretion is prevented by chelation of intracellular ca + and mediated by the concomitant activation of calpain and protein kinase ca (pkca) and also that mmp expression is mediated by the sequential activation of pkc and extracellular signal-regulated protein kinases and (erk / ). moreover, the rescue of active f del-cftr reduces the extent of mmp secretion, correlating the channel defect to the [ca + ] i dysregulation of cf pbmcs. our results indicate that the high level of intracellular ca + concentration in cf pbmcs, promoting the aberrant activation of both calpain and pkca, induces a constitutive release of mmp . these data characterize new alterations in mononuclear leukocytes of cf patients that may be of primary importance in the progression of the disease and indicate that pbmcs may contribute to the accumulation of mmp in fluids of cf patients. p- . . - aebp /aclp is upregulated in differentiation, injury repair and fibrotic degeneration of skeletal muscle c. € ozdemir , , u. akpulat , i. onbasilar , c ß . kocaefe department of medical biology, faculty of medicine, hacettepe university, ankara, turkey, department of stem cell, institute of health, hacettepe university, ankara, turkey, laboratory animal breeding and research unit, faculty of medicine, hacettepe university, ankara, turkey aebp /aclp is an ambiguous gene with several attributed functions and cellular events, adipogenic differentiation, cell adhesion, pattern development and fibrosis are the well-understood. aebp is the short isoform that acts as a transcriptional repressor by targeting the ap promoter and aclp, which is the long isoform that harbors a leader sequence that directs the peptide to the extracellular compartment. the latter is known to be associated with development of the connective tissue, injury repair and fibrosis in certain pathological conditions. aebp /aclp displays a moderate expression in skeletal muscle where the role is not known. we have investigated the spatial and temporal expression of aebp /aclp in defined models of skeletal muscle differentiation, injury repair and fibrosis. aebp /aclp expression is present in steady state dividing myoblasts. this basal expression is upregulated folds upon the induction of differentiation in c c cells. considering that differentiation and post-natal injury repair share several common aspects, we also investigated the expression of aebp /aclp in acute injury-repair model. in the course of cardiotoxin induced injury, aebp /aclp expression peaks up to folds in the th day of regeneration. this time point concomitantly corresponds to tissue remodelling. since aebp /aclp is also known to be associated with fibrotic events in chronic pathological conditions, we also have investigated its expression in tenotomy induced skeletal muscle degeneration which mimics endomysial and perimysial fibrosis. aebp /aclp expression is upregulated up to folds in early time-point samples. these results depict a novel role for aebp /aclp in extracellular remodeling of the skeletal muscle during injury repair as well as fibrotic degeneration. the source of this expression might come from fibroadipogenic precursers which reside in endomisial area of muscle. our current efforts are focused on presenting of this endomysial expression. the mprbp gene from b. pumilus - encoding a novel secreted metalloproteinase was identified. based on the primary structure the enzyme has been classified as metzincin metalloproteinase that combines the features of two families: astacin and adamalysin. representatives of the adamalysin family previously have not been described for bacilli. the aim of the work was to elucidate the mechanisms of the gene expression regulation of a new bacillus pumilus - extracellular metalloendopeptidase. promoter region analysis revealed the presence of potential binding sites for transcription factors spo a (sporulation) and degu (biodegradation). study of mprbp expression in strain defective in regulatory proteins degs and degu shows that the productivity of metalloproteinase biosynthesis decline in average % compared with the strain with a complete degs-degu system. we also studied mprbp expression in strains with a mutation in the gene degu, leading to stabilization of degu~p protein. it is known, that this mutation leads to a multiple increase in the gene expression level, positively regulated by degs-degu system. our data shows a -fold increase in metalloproteinase productivity in the recombinant strain. thus, deg-system participates in control of the proteinase synthesis but not only in the regulation of mprbp gene expression. the mprbp expression in the strain deficient in regulatory protein spo a remained at the level with expression in the strain with the complete spo a. a similar pattern we observed in the study of mprbp gene expression in strains defective in other spore-specific regulatory proteins (spo b, spo f, spo k, spo j, sigf, sigh, sigk). these data indicate that mprbp gene expression is free of spo-regulatory proteins. on this basis, we concluded that the expression of metalloproteinase gene is not correlated with the sporulation. p- . . - paricalcitol attenuate activity and expression of matrix metalloproteinases in a rat model of renal ischemia-reperfusion injury matrix metalloproteinases (mmps) are endopeptidases involved in the degradation of extracellular matrix. they have been postulated to have a role in the pathogenesis of ischemia-reperfusion injury (iri). in the present study, we investigated the effect of paricalcitol, a synthetic vitamin d analog, on mmps in renal iri. wistar albino rats were divided into three groups: sham operated, ischemia-reperfusion, and paricalcitol-pretreated. iri model was induced by bilateral clamping of renal arteries for min followed by h of reperfusion. the analysis of serum creatinine levels and activities/expressions of mmp- and - were performed after h of iri. the effects of paricalcitol on activities and expressions of mmp- and mmp- levels were investigated by gelatin zymography and immunohistochemistry, respectively. the pathological examinations were performed to score tubular damage by light microscopy. creatinine levels increased significantly in the iri group. rats in the paricalcitolpretreated group showed significant decrease in expressions and activities of mmp- and mmp- during iri. moreover, pathological examinations displayed significantly lower score of tubular damage in paricalcitol-pretreated group. in conclusion, paricalcitol attenuated iri by downregulating the expressions and activities of mmp- and - . p- . . - the changes of matrix metalloproteinase , activity and hyaluronic acid level in rat's heart and serum under cadmium influence o. fomenko , o. shaulska , y. kot , g. ushakova , a. shevtsova dnipropetrovsk medical academy, dnipropetrovsk, ukraine, kharkiv national university, kharkiv, ukraine, dnipropetrovsk national university, dnipropetrovsk, ukraine the changes in the molecular mechanisms of the extracellular matrix degradation under toxic factors are not well known. the main goal of work was the investigation of the mmp and mmp activity and hyaluronic acid level in the heart and blood serum under cadmium influence at different doses. the wister rats divided to groups were used for the experiment. cdcl x . h o in doses . lg/kg and lg/kg was given to rats intragastrically in drinking water during days. the rats were decapitated under isoflurane anesthesia according to ethical rules; the heart was quickly removed. the relative activity [in arbitrary units (au)] of pro-and active forms of mmp and mmp , total protein (tp) and hyaluronic acid levels were calculated. it was shown that low doses of exogenous cadmium ( . lg/ kg) lead to reduced activity of pro-and active forms of mmp in myocardium ( . ae . au/mgtp and . ae . au/mgtp compare to the . ae . au/mgtp and . ae . au/mgtp in the control rats accordingly) and in serum ( . ae . au/mgtp and . ae . au/mgtp compare to the . ae . au/mgtp and . ae . au/mgtp in the control rats accordingly), but pro-mmp activity in heart was increased ( . ae . au/mgtp compare to the . ae . au/mgtp in the control rats); level of ha was decreased in both tissues ( . ae . lg/ml and . ae . lg/ml compare to the . ae . lg/ml and . ae . lg/ml in the control rats accordingly). high doses of cadmium ( lg/kg) caused a reliable increase of both gelatinase activity in the myocardium: mmp increased from . ae . au/mgtp to . ae . au/mgtp, prommp to . ae . au/mgtp, mmp to . ae . au/mgtp. ha level was increased in serum ( . ae . lg/ml) and decreased in heart ( . ae . lg/ml). the results indicate the dose-dependent and tissue-specific effect of cadmium on mmp-depended protein degradation and level of hyaluronic acid. a disintegrin-like and metalloproteinase domain with thrompospondin- repeats (adamts) are a large family of proteoglycanase that show proteolytic activity towards proteoglycans like aggrecan, brevican, neurocan, and versican. interleukin- (il- ) is an il- cytokine family member that uniquely plays a role as a cytokine and nuclear factor. it is released by necrotic epithelial cells and activated innate immune cells as an alarming danger signal. adamts and il- implicated in brain cancer pathogenesis. we aimed to seek the amount of adamts in u proteolytic enzymes are able to speed up wound healing by removal of the necrotic tissues and fibrin. several investigations have reported that proteases damage also the microbial biofilms formed by opportunistic bacteria including staphylococci on surfaces of chronic and acute dermal wounds. therefore, proteases are seemingly perspective enzymes for biofilm eradication by hydrolysis of both matrix proteins and adhesins, proteins providing cells attachment onto solid surface and other bacteria, as well as by the cleavage of signalling peptides of intercellular communication of gram-positive bacteria. here we report that ficin, a plant protease, efficiently degrades the structural components of biofilm matrix formed by s. aureus and s. epidermidis at concentrations of lg/ml while trypsin and chimotrypsin are used as - mg/ml solution. the spatial structure of the biofilm was analyzed by atomic force microscopy. after ficin treatment, the biofilm structure became porous, with reduced viscosity. the congo red staining of the treated biofilms confirmed the hydrolysis of the protein component of the matrix. moreover, the biofilm treatment with ficin increased the antimicrobial efficiency of ciprofloxacin against biofilm-embedded cells of s. aureus and s. epidermidis. while h antibiotic treatment did not lead to the increase of dead cells of neither s. aureus nor s. epidermidis embedded into the biofilm matrix, in the presence of ficin the fraction of viable cells decreased significantly. accordingly, soluble ficin appears beneficial for outer wound treatment biofilm eradication and reduces the reinfection risk. the wound-healing activity of ficin requires further investigations. this work was supported by the russian science foundation (project no - - ). resveratrol (resv) is an antioxidant that belongs to the group of plant compounds, called polyphenols. resv is defined as an antimicrobial substance that is produced by several plants (red grape skin, peanuts and berries) to protect them from rough environments like excessive ultraviolet light, infections and climate changes. as an antioxidant, this polyphenol protects the body against cardio-vascular and cancer diseases. besides, resv has anti-inflammatory, neuro-protective, anti-diabetic and other pharmacological effects. although the positive pleiotropic effects of this polyphenol are well documented, there is a huge need to understand its influence on the biophysical properties of lipid bilayer. in the present work, the interaction of resv with membranes composed of palmitoyl-docosahexaenoyl phosphatidylcholine (pdpc) or palmitoyl-oleoyl phosphatidylcholine (popc), sphingomyelin (sm) and cholesterol (ch) was investigated by means of fluorescence spectroscopy. generalized polarization of the fluorescent probe laurdan (gp) as a function of temperature was used to probe the changes in the fluidity of lipid bilayer induced by different resv concentration. the obtained results showed decreased lipid ordering from to lmol resv and opposite effect from to lmol in pdpc/sm/ch mixtures as compared to the control without resv. the interaction of resv with popc/sm/ch mixtures caused only an increase in the lipid ordering as a function of resv amount. popc and pdpc have the same head group but different fatty acid chains at sn- . since resv changes the physicochemical properties of lipid bilayer by different ways one might suggest that the interaction of polyphenol with the membrane depends on the level of fatty acid unsaturation. this specific effect of resv on lipid organization could be related to its unique properties to prevent the cell from oxidative stress. neurodegeneration is the umbrella term for the deseases including progressive loss of structure or function up to death of neurons. beta-amyliod peptide is proteolytic fragment of the amyloid protein. the spontaneously formation of selective, voltage-dependent, ion-permeable channels in the lipid bilayers was reported as one of amyliod peptide toxicity mechanisms. the aim of our study was the investigation of the influence of the flavonoids (phloretin, phlorizin, quercetin and genistein) on the membrane activity of amyliod peptides. virtually solvent-free bilayer lipid membranes were prepared from mixtures of phospholipids in . m kcl (ph . ) using monolayer-opposition technique. using spectrofluorimetry we estimated prepared from phospholipids by extrusion the liposomal membrane permeability for calcein. we found that the addition of phloretin into membrane bathing solution led to an signicant increase in the channel forming activity of fragments - of amyloid peptide, fragment - of [gly ]-amyloid peptide and - of human prion protein. addition of other flavonoids did not cause any changes in the steady-state amyloid-induced current. it was found that the effect was caused by electrostatic interaction with the peptide. we found that time course of amyloid induced leakage calcein from liposome's is characterized by two components: the fast one is related to sorption of b-amyloid peptide on the membrane and the slow one is related to the oligomerization of the peptides on the surface of the lipid bilayer. addition of the phloretin simultaneously with b-amyloid peptide to the suspension of liposomes caused significant reduction in time parameters characterizing fast and slow components. from this results we can proposed that phloretin compensates the positive charge of the b-amyloid peptides and leads to the changes in their oligomerization status. the study was supported in part by rfs ( - - ) and sp- . . . ferritin nanocarriers: a focus on a metal-based drug encapsulated inside the protein cavity s. ciambellotti , c. bernacchioni , f. scaletti , p. turano cerm (magnetic resonance centre), florence, italy, department of biochemical sciences, university of florence, florence, italy, chemistry department 'ugo schiff', florence, italy ferritin is one of the main player involved in the iron metabolism. the biological role of ferritin is the storage of iron atoms inside the cavity preventing the uncontrolled accumulation of toxic species inside cells. ferritins are polymers constituted by subunits that self-assemble giving rise to an almost spherical nanocage. in vertebrates, ferritins are formed by two distinct subunits, the heavy chain (h), with oxidoreductase activity, and the light chain (l) without catalytic activity. ferritins are promising nanocarriers for the delivery of contrast agents for diagnosis and of drugs for therapeutic purpose. their endogenous origin and the possibility to stabilize and protect the enclosed cargo inside the cavity, make ferritin a biocompatible vehicle. moreover, there are specific receptors on cells that recognize and incorporate ferritin by endocytosis, prospecting a kind of targeted-delivery. following the increasing interest in nanotechnology, we studied the interaction between different isoforms of ferritin with an antimetastatic drug, called nami-a, which is the first ruthenium derived anti-cancer drug to have entered clinical evaluation. this molecule is a metal-based prodrug that can release the metal ion ligands. here, we describe nami-a hydrolysis in the presence of recombinant homopolymers of ferritin followed spectrophotometrically. thanks to characteristic time dependent changes of spectral profile in the uv-visible region, we could detect differences in the hydrolysis process. the formation of a ru-adduct with hferritin was established by uv-visible and circular dichroism spectroscopies, as well as by kinetics measurements that showed inhibition of the ferroxidase activity of h-ferritin. crystallization trials are in progress to identify the binding site of ru by solving the x-ray structure of the complex. finally, we planned to test the cytotoxicity of ferritins pre-incubated with nami-a, using different cancer cell lines. a. cort , t. ozben , a. sansone , s. barata-vallejo , c. chatgilialoglu , c. ferreri sanko university, gaziantep, turkey, akdeniz university, antalya, turkey, cnr, bologna, italy, universidad de buenos aires, buenos aires, argentina, national center for scientific research 'demokritos', athens, greece liposomes as biomimetic models of cell membranes were used for examining some novel aspects of drug-metal induced reactivity with unsaturated lipids under oxidative conditions. the chemical basis of cis to trans transformation was ascertained by liposome experiments, using bleomycin-iron complexes in the presence of thiol as a reducing agent that by incubation at °c gave rise to the thiyl radical-catalysed double bond isomerisation of membrane phospholipids. the effect of oxygen and reagent concentrations on the reaction outcome was studied. as a chemical biology model for antitumoral strategies, liposomes highlight the role of cell membranes, which are not spectators but important targets of the drug effect, with synergic roles for chemotherapeutic effects. indeed, fatty acid recruitment and membrane formation are attracting a lot of interest in cancer, and in this context the loss of the natural cis geometry and the oxidationinduced lipid remodelling are worthy of deeper studies in antitumoral strategies. furthermore, the interaction between drugs and lipids can be suggestive of novel aspects of chemical reactivity for liposome carriers when circulating in vivo. gpr is a g-protein coupled receptor (gpcr), expressed in cells of brain, heart and kidney. it is related to the leukotriene and purinergic subfamilies of the rhodopsin-like class a gpcrs. gpr plays controversial role in the brain and spinal cord cells recovery after injuries. it is assumed that gpr is one of the cell death regulators immediately following an injury but at later stages it also takes part in tissue regeneration. there are also data implying some role of gpr in glucose homeostasis. drugs targeting gpr may help with treatments of multiple sclerosis and ischemia. the damage of rat's brain in artificially induced ischemia disease decreased after gpr inhibition. in addition, gpr takes part in myelin sheath formation, the lack of which is known to be the reason of multiple sclerosis. to better understand functional role of gpr and enable design of more efficient ligands we initiated structural studies of this receptor. to improve receptor stability and facilitate crystallization we created a series of chimeric constructs using different fusion partnerssmall soluble proteins inserted into the native amino acid sequence. preliminary experiments were carried out to evaluate the influence of different ligands on the receptor stability and cell surface expression in insect sf cells. this work was supported by russian federal target sterols are significant for the structural and dynamical features of cell membranes. among them, cholesterol is the major sterol in mammalian cell membranes whereas stigmasterol is the predominant sterol in plant membranes. stigmasterol varies structurally from cholesterol in having both an ethyl group at carbon and an additional trans double bond between carbons and . dimyristoylphosphatidylcholine (dmpc) is a widely studied synthetic lipid, which has a neutral (zwitterionic) pc headgroup and two symmetrical -carbon fatty acyl chains. the studies on the interactions of cholesterol and stigmasterol with dmpc membranes at molecular level are very limited. in the present study, a calorimetric comparison of the effects of the animal sterol cholesterol and the plant sterol stigmasterol on zwitterionic dimyristoylphosphatidylcholine (dmpc) multilamellar vesicles (mlvs) was investigated for the first time by using differential scanning calorimetry (dsc). our dsc studies indicate that with the inclusion of increasing cholesterol and stigmasterol concentrations from to mol% into pure dmpc mlvs, the pretransition disappears, the main phase transition shifts to lower temperatures and then disappears at cholesterol and stigmasterol concentration above mol%. the main phase transition enthalpy (dh) is progressively reduced whereas full width at half maximum (dt ½ ) gradually increases with increasing cholesterol and stigmasterol concentrations. moreover, the main phase transition peak consists of overlapping sharp and broad components, indicating the hydrocarbon chain melting of sterol-poor and sterol-rich dmpc domains, respectively. in conclusion, this study shows clearly that both cholesterol and stigmasterol interact effectively with dmpc membranes and cause changes in their structural and functional properties. p- . . - trh receptor mobility in the plasma membrane is affected by its interaction with its cognate signaling molecules and by cholesterol depletion r. moravcova, b. melkes, j. novotny department of physiology, faculty of science, charles university in prague, prague, czech republic g protein-coupled receptors (gpcrs) play a fundamental role in transferring information from extracellular environment to the cell interior. some gpcrs are supposed to form signaling complexes with their cognate g proteins and possibly other accessory proteins, which may facilitate the activation of g proteins and thus accelerate signal transmission. here we investigated the role of some components of thyrotropin-releasing hormone (trh) receptor signaling in hek cells stably expressing yfp-tagged trh receptor using fluorescence recovery after photobleaching (frap). we observed significant changes in values of the diffusion coefficients if expression of b -arrestin or gb subunit were suppressed by sirna. results of our frap experiments indicated significant difference between control and trh-treated cells as the diffusion coefficient markedly decreased after agonist stimulation. on the other hand, the same decline of the diffusion coefficient value was found after silencing with sirna and subsequent treatment with trh for most of the screened proteins. treatment of cells with À m trh led to fast internalization of trh receptor, which was revealed by real-time confocal microscopy. it is known that cholesterol is an essential component of the cell membranes and it exerts modulatory effects on the functioning of various membrane proteins. disruption of plasma membrane integrity by cholesterol depletion using b-cyclodextrin significantly reduced the apparent diffusion coefficient values. interestingly, addition of trh to cells treated with b-cyclodextrin did not further reduced trh receptor mobility. it can be concluded that stimulation with agonist and/or sirna silencing of some components of the trh receptor signaling cascade significantly affects the mobility of trh receptor in the plasma membrane. p- . . - l-opioid receptor mobility in the plasma membrane is diversely affected by biased ligands b. melkes, l. hejnova, j. novotny opioid receptors belong to the large family of g protein-coupled receptors (gpcrs), which are currently considered among the most important targets for pharmacological manipulations. during the past few years, a great deal of attention has been devoted to biased agonism. this phenomenon reflects the ability of different ligands to selectively affect the functioning of some gpcrs so they can display marked differences in their efficacies for g protein-or b-arrestin-mediated signaling. here we decided to investigate the effect of different agonists of the l-opioid receptor (l-or) on the lateral mobility of this receptor in the plasma membrane of hek cells which were stably transfected with l-or tagged with yellow fluorescent protein (l-or-yfp). it has been found previously that damgo stimulates g-protein-dependent signaling, endomorphine stimulates arrestin-dependent signaling and morphine does not show any significant bias towards these two signaling pathways. in our experiments, we used the fluorescence recovery after photobleaching (frap) method to estimate the diffusion coefficients of l-or-yfp in the resting state and after addition of the above mentioned specific agonists. we observed that addition of damgo increased the value of the diffusion coefficient and addition of endomorphin decreased the value of diffusion coefficient of l-or-yfp. addition of morphine or the l-or antagonist naloxone did not change the value of the diffusion coefficient compared to the resting state. these results indicate that different biased agonists of l-or may differently affect the mobility of this receptor in the plasma membrane. these findings provide new insights into the dynamics of l-or in the plasma membrane and contribute to better understanding of the mechanism of biased agonism at gpcrs, which is of central importance for receptor homeostasis and fine regulation of receptor activity. color tuning and adding potassium selectivity to a light-driven sodium pump k. kovalev , , v. polovinkin , , , v. shevchenko , , v. gordeliy , , moscow institute of physics and technology, dolgoprudniy, russia, research centre j€ ulich, j€ ulich, germany, institut de biologie structurale, universit e grenoble alpes, cnrs, and cea, grenoble, france recently a light-driven sodium pump has been discovered, characterized and tested as an inhibitory optogenetic tool. sodium pumping rhodopsin from dokdonia eikasta kr has an absorption maximum at nm at ph . and to create more redshifted variants we analyzed available structures of the kr (pdb codes: xtl, xtn) and did the rational mutagenesis of residues in the retinal proximity region (i.e. m , g and s ). the mutants of kr under investigation were: m a, g v, m a/g v, s a, s f, s g, s l, s m, s n, s t, s v, s y. the protein mutants were expressed in escherichia coli c strain, expression was induced by the addition of mm isopropyl b-d- -thiogalactopyranoside. the cells were then washed trice with unbuffered mm nacl or kcl solution. finally, the ph changes in cell suspensions (od = . ) were monitored. ph changes upon the addition of lm of protonophore carbonylcyanide m-chlorophenylhydrazone were also measured. the following mutants completely abolished the protein function and were not used for further characterization: s f, s l, s m, s n, s v. the remaining mutants have shown sodium pumping activity and s a mutant has gained an additional potassium pumping activity. all functionally active mutants were purified using ni-affinity chromatography and the absorption spectra were collected for them at ph . ( mm na/na-pi, mm nacl). m a mutant absorption maximum is blue-shifted to nm. g v and m a/g vblue-shift to nm. s a, a potassium pumping variant,red-shift to nm. s g, s yred-shift to nm. s tno change in absorption maximum position. based on structural analysis of kr we discovered another potassium pumping variant and provided the variants with absorption maximum blue-shift up to nm and red-shift up to nm. human endothelin receptors belong to the g-protein coupled receptors (gpcrs) superfamily. this class is pharmacologically important, with more than % drugs targeting it. the human endothelin system, which includes endothelin receptors types a and b (etb and eta), plays a highly important role in the blood pressure regulation. endothelium cells produce peptides, known as endothelins - , which activate endothelin receptors and launch cascades of reactions that lead to vasoconstriction or vasodilatation depending on the receptor subtype and the tissue. additionally, endothelin receptors take part in such processes as transmission of nerve impulses, development of neural crest, and regulation of acid-base-salt balance in kidneys. in order to stabilize etb receptor for crystallization trials we introduced a compact soluble protein, apocytochrome b ril (bril), is the third extracellular loop of the receptor. bril is known to be an effective crystallization driver for gpcrs. the engineered protein was expressed using baculovirus system in sf insect cells, purified and subject to variety of pre-crystallization assays. localization of the overexpressed protein in insect cells was visualized via the confocal microscopy. thermal stability of the protein in the presence and absence of ligands was measured by the thermal shift assay. finally, the mobility of the receptor in lipidic cubic phase (lcp) at many different conditions was probed by the lcp-frap (fluorescence recovery after photobleaching) assay. these tests showed that the obtained protein is thermally stable, functionally active and diffuses well in lcp at certain conditions, making it a suitable candidate for proceeding to in meso crystallization trials. this work was supported by the russian science foundation (project no. - - ). mitochondrial oxidative phosphorylation is the key metabolic pathway for the production of atp. mitochondrial respiratory chain (rc) defects are some of the most commonly diagnosed inborn errors of metabolism with a diverse spectrum of clinical phenotypes. the aim of the study is to evaluate the rc enzyme activities and histopathological findings in muscle biopsies of patients with suspected mitochondrial disease. muscle biopsy samples were collected from pediatric patients. the samples were homogenized in seth buffer using a glass/glass homogenizer. the activities of citrate synthase (cs) and rc enzymes (complex i, ii-iii, and iv) were measured in tissue homogenates by kinetic spectrophotometric assays by schimadzu uv spectrophotometer (uv- ). non-collagen protein was determined by the modified lowry assay. activities of complex (c) i, ii-iii and iv (cox) were normalized by cs. histopathological investigations included h&e, modified gomori trichrome, periodic acid schiff, oil-red-o, nadh, sdh, cox and atpase stains. deficiency of rc complexes was detected in biopsies ( %). c iv deficiency was most common ( %), followed by c i ( %) and c ii-iii ( %). multiple complex deficiency was present in % and isolated deficiency was present in % of the biopsies ( % c i, % c ii-iii, % c iv). cs activity was elevated in % of the biopsies. decreased c i/cs, c ii-iii/cs and c iv/cs ratio was observed in %, % and %, respectively. comparing with histological data, biochemical analysis revealed additional findings in % of biopsies. complex iv deficiency, either isolated or accompanied by other complex deficiencies, is most common in our cohort. rc analysis may reveal additional findings to histopathological results and careful clinical investigation with correlation of clinical, biochemical and histopathological data is mandatory for the challenging diagnosis of mitochondrial disorders in childhood. investigation of adipocytokines, activity of glut and na + /k + -atpase in rats fed glucose, fructose, starch-based sugars objective: all over the world, shows a significant increase in obesity and diabetes. intake of foods that contain fructose, glucose and starch-based sugar is a potential risk for metabolic syndrome. obesity and diabetes are important effects of high fructose corn syrup (hfcs). we aimed to research, activity of na + /k + -atpase in addition to glucose transporter (glut) , resistin, adiponectin and other biochemical markers in rats fed glucose, fructose and starch-based sugars. materials and methods: study was performed on rats and groups were included in the study. rats were fed with chows that were given either normal diet for control group ( % carbohydrate, % protein and % fat), high fructose ( % carbohydrate ( % fructose and % starch), % protein and % fat), or high sucrose ( % carbohydrate ( % sucrose and % starch), % protein and % fat). rats were fed with chows for weeks. in this process, the weight of the rats were followed. at the end of the experiment, blood is taken in all groups. level of hba c, glucose, resistin and adiponectin were studied. glut and na + /k + -atpase activity were studied in the liver tissue. results: a significant increase in adiponectin levels were determined in rats fed both hfcs and sucrose (p < . ). a significant decrease in level of na + /k + -atpase activity were determined in rats fed both hfcs and sucrose (p < . ). there was no significant differance level of hba c, glucose, resistin and glut in rats fed sucrose or hfcs (p > . ). conclusions: fructose-rich diet has an effect on changes in the atpase activity and is a major risk factor for obesity. keywords: adiponectin, fructose, glucose, high-fructose corn syrup, na + /k + -atpase, resistin. p- . . - nucleic acid-biomembrane lipid selfassemblies: from primordial soup to novel genome organization model and cellular nonviral nanotherapies f. k. demirsoy , n. eruygur , e. s€ uleymanoglu biotechnology central laboratory, biotechnology institute, ankara university, ankara, turkey, department of pharmacognosy, faculty of pharmacy, cumhuriyet university, sivas, turkey, department of pharmaceutical chemistry, faculty of pharmacy, gazi university, ankara, turkey turkey nucleic acid-cell membrane complexes has attracted research interest as models in gene regulation, cell cycle and division, as biosensors designs, as well as in molecular evolution. zwitterionic phospholipids, complexed with polyribonucleotides by divalent metal cations (mg +) are considered as genosome vehicles. their formations are studied by spectroscopic, thermodynamic, interfacial and microscopic approaches to build thermodynamic and kinetic models of their structural transitions. dna forms a mg +-driven ternary complexes with neutral liposomes both at the airwater interfaces and at vesicle surfaces. the described self-assemblies form relevant models for nuclear pore complexes and their further implications in gene expression and functions. such membrane contacts could be considered also in prokaryotic nucleoids important in bacterial segregation, whereas in eukaryotes these complexes can be regarded as focal points for transcription-translationtranslocation processes. the effects of ozone/oxygen mixture on citrate synthase and mitochondrial complex activities of striated muscle tissue of healthy mice we investigated the effects of ozone/oxygen mixture and oxygen on citrate synthase (cs) and succinate dehydrogenase (sdh) activities of striated muscle tissue of healthy mice. thirty-six mice were included the study. firstly muscle samples were taken from all mice's left thigh muscle in under anesthesia (group ). secondly mice were randomly divided in four groups as: group : oxygen was given once at days for days, group : ozone/oxygen was given once at days for days, group : oxygen was given once at days for days, group : ozone/oxygen was given once at days for days. ozone/oxygen mixture and oxygen were given at a dose of mg/ kg groups ( ) ( ) ( ) ( ) . after treatment animals were sacrificed, and muscle samples were taken and stored in À °c for until the analyses. muscle tissues were homogenized in . m tris-hci and . m kci. cs and sdh activities were measured with spectrophotometer. cs and sdh activities were expressed as lmol/min/g tissue. cs and sdh activity results were given as mean ae sd. cs activity has been found in group ( . ae . ), group ( . ae . ), group ( . ae . ), group ( . ae . ) and group ( . ae . ). sdh activity has been found in group ( . ae . ), group ( . ae . ), group ( . ae . ), group ( . ae . ) and group ( . ae . ). there was no statistically significant difference among all groups in terms of cs (p > . ) and sdh activities (p > . ). there was no difference between all groups in terms of inflammation, muscle fiber size, regeneration or necrosis. vascular structures, connective tissues, lipid and glycogen content of fibers were normal. cytochrome oxidase activity was also normal. ratio of ragged blue fibers of all groups were less than . %, so they were scored as . there was no difference among groups for ragged red fiber content. we have not found a significant effect of ozone/oxygen mixture and oxygen on cs and sdh activities of striated muscle tissue of healthy mice. lipidic cubic phases (lcps) consist of bicontinuous lipid bilayers and water channels. lpcs are widely used for membrane proteins crystallization and further determination of their spatial structures by means of x-ray crystallography. this approach was successfully used for studying g-protein coupled receptors structures. usually crystallization initiates by adding the precipitants (buffers with high salt concentrations). here we propose to use photo-switchable analogs of -monoolein to change lattice parameter of lpc. we synthetized a number of novel diazo-analogs of -monoolein. their structures were confirmed by nmr-spectroscopy and mass-spectrometry. being incorporated in phospholipid vesicles or detergent micelles they subjected to trans-to cis-isomerization under the light exposure at nm. also we characterized the lcp's structures and properties by small-angle x-ray scattering on the rigaku instrument. one of the synthetized compounds, -( -{-[ -(octyloxy) phenyl] diazenyl} phenoxy) propane- , -diol ( % mol), was incorporated into the -monoolein cubic phase. according to small-angle x-ray scattering data the structure of the monoolein cubic-pn m phase with lattice parameter . angstrem was not affected by insertion of this photo-switchable monoolein's analog. after the light exposure at nm we observed trans-cis-isomerization. in the same time the cubic-pn m phase was not changed but the lattice parameter reduced to . angstrem. this effect on monoolein lpc is similar to the addition of a precipitant to initiate protein crystallization process. the spontaneous return to the initial lattice parameter was completed after days in dark. thus, we demonstrated the possible controlling of the monoolein cubic phase lattice parameters by adding the photo-switchable diazo-derivatives of monoglyceride analogs, which can be used for crystallization of membrane proteins. evaluation of certain protein and phosphoprotein expression levels by using western blot technique in head and neck squamous cell carcinoma a. kalayci yigin , t. cora cerrahpasa faculty of medicine, istanbul university, istanbul, turkey, faculty of medicine, selcuk university, konya, turkey introduction: head and neck squamous cell carcinoma (hnscc) is a primer tumor type in head and neck cancers, characterized by aggressiveness, early recurrence and metastasis. while alcohol and smoking play an important role at pathogenesis of disease, deregulation of some signaling pathways, genes and protein levels related to these pathways are considered as important at contribution of development of hnscc. materials and methods: in this study, protein and phosphoprotein expression levels of the frequently phosphorylated sites (egfr, pegfr, igf-ir, pigf-ir, pdgfrb, ppgdfrb, pten, ppten, akt and pakt) were investigated by using a western blot to confirm the expression of mrna in the context of protein levels at normal-tumor tissues of hnscc and sccl-mt that is a hnscc tumor cell line and hek- that is a normal cell line. results: as a result of western blot analysis egfr, pdgfrb and igf- r were detected as highly overexpressed cell surface receptors in tumor tissues of hnscc. discussion and conclusion: the findings of this study revealed the overexpression of other cell surface receptors as well as egfr in hnscc. in conclution, potential pathways were identified by determining the cell surface receptors overexpressed in hnscc, these data support each other and may be important in pathogenesis of hnscc. introduction: the investigation of final products of lipid peroxidation is considered as the main mechanism involved in development of pathogenesis, diagnostics and prognosis of various parasitic illnesses. materials and methods: the concentration of lp-ap in the blood was determined in the study group considered of women ( %), and men ( %). results: before antiparasitic treatment, women infected with g. intestinalis showed a statistically significant . times increase of gpx activity levels; and . times ada level increase compared to the control group. after the treatment, the cat activity showed a sharp increase, whereas the ada activity decreased by . times, compared to the average level before the treatment. the results of the blood samples of the infected men with giardiasis, show the statistically significant increase in the level of all the studied parameters of lipid peroxidation, except the total primary production (tpp). the exception was the mda level, remaining significantly increased, in contrast to the control group and to the condition after antiparasitic treatment. in infected men, the level of cat activity was more than . times higher than that noted in control group. after treatment the levels of ada activity and gpx returned to the values of the control group, while the level of cat activity remained elevated. conclusion: an accumulation of primary and secondary metabolites in the course of giardiasis seems to confirm its involvement in the induction of oxidative-antioxidative homeostasis. antiparasitic treatment in giardiasis leads to normalization of the ap parameters studied in women and men, except the mda content in the blood of men. therefore, additional antioxidant treatment is advised for the antiparasitic therapy of men. in vitro effects of ethanol on rat brain synaptosome and dose-dependent antioxidative role of boric acid ethanol is a psychoactive drug that is very large and used frequently today. it has suppressive effects brain's comminication pathway. depending on its acute or chronic use and the dose, ethanol increase membrane fluidity and it causes oxidative stress. this study deals with the in vitro effects of ethanol toxicity ( mm) and potential protective effect of different doses of boric acid (ba) ( , and mm) on rat brain synaptosomes. with this aim, five male spraque dawley rats are killed by decapitation under anesthesia. after the frontal cortexes of the rats are taken out, each of them is divided into four pieces. these pieces were used as a sample in five groups (control, ethanol, ethanol+ mm ba, ethanol+ mm ba, ethanol+ mm ba) which include six samples. the synaptosomal fractions are prepared by the homogenization of the frontal cortex pieces and centrifugation for each samples. as markers of ethanol-induced oxidative stress in the synaptosome of the rats, malondialdehyde (mda), nitric oxide (no) and catalase (cat) levels were measured. mda levels in the ethahol group were a quantity increased compared with those in the control group but it unchanged significantly as statistically (p < . ). however the mda level in the ethanol+ boric acid ( mm) group was shown to be significantly decreased compared with that in the ethanol group (p < . ). the cat activity of the ethanol group was significantly higher than that in the control group and cat activity of the ba ( mm, mm) groups were close compared with control groups (p < . ). no levels in ethanol groups were decreased but unchanged compared with control groups as statistically. neverthless, no levels in ethanol+ boric acid ( mm) groups were increased (p < . ). these results demonstrate that ethanol ( mm) is capable of triggering damage to rat brain synaptosome and ba could be influential in antioxidant mechanisms against oxidative stress resulting from ethanol exposure. acute myeloid leukemia (aml) is the most common form of acute leukemia in adults and its incidence increases with age. carbonic anhydrases (cas) are zinc-containing enzymes. these enzymes catalyze a very simple physiological reaction, the inter conversion between carbon dioxide and the bicarbonate ion, and are thus involved in crucial physiological processes connected with respiration and transport of co /bicarbonate between metabolizing tissues and lungs, ph and co homeostasis, electrolyte secretion in a variety of tissues/organs, and biosynthetic reactions and many other physiologic or pathologic processes including reproductive tract. investigation of autoantibodies in aml patients have been popular research area in recent years. the aim of the current study was to investigate carbonic anhydrase i and ii (ca i and ii) autoantibodies in the serum of subjects with aml based on the information and considerations of autoimmune relation of acute myeloid leukemia. anti-ca i and ii antibody levels were investigated by enzyme-linked immunosorbent assay method (elisa) in serum samples of thirty patients with aml and thirty healthy peers. anti-ca i and ii antibody titers of aml group were significantly higher compared with the control group (p = . ), (p = . ), respectively. we found significant positive correlation between anti-ca i antibody and anti-ca ii antibody titers in patients with aml (r = . , p = . ). we found significant positive correlation between anti-ca i antibody and anti-ca ii antibody titers in women and the men (r = . , p = . ), (r = . , p = . ), respectively. at an anti-ca i cut-off point of . absu, sensitivity was % and specificity %. at an anti-ca ii cut-off point of . absu, sensitivity was % and specificity %. the ca i and ca ii autoantibody levels in patients with aml were found higher compared to control group and the results suggest that ca i and ca ii autoantibodies may be involved in the pathogenesis of aml. aim: behc ßet's disease (bd) is a systemic autoimmune disease. recurrent oral and genital mucosal ulcers, uveitis, and skin lesions are characteristic findings for bd. platelet-lymphocyte ratio reflects a novel marker for romatological diseases. the aim of this study was to investigate the platelet/lymphocyte ratio in behc ßet's disease. methods: whole blood samples were collected from healthy control and patients with behc ßet's disease. the mean age for controls and patients were ae . and ae , respectively (p = . ). patients with chronic disease and inflammatory disorders were excluded. thrombocyte and lymphocyte counts were analyzed with abbott cell dyne heamotolgy analyzer. statistical analysis was performed with ibm spss v . results: platelet counts were higher but not statistically significant in patients with behc ßet's disease compared to control group ( ae vs. ae ) (p = . ). lymphocyte counts were lower in patients with behc ßet's disease compared to control group ( . ae . vs. . ae . ) (p = . ). platelet/lymphocyte ratio was higher but not statistically elevated in patients with behc ßet's disease compared to control group ( ae vs. ae ) (p = . ) conclusions: platelet/lymphocyte ratio (nlr) and mean platelet volume (mpv) as inflammatory markers recently became popular because of their simplicity, cost effectivity and their advantages to predict clinical prognosis of specific diseases. according to this study's results, platelet/lymphocyte ratio must be analyzed in vast scale patient populations to identify the disease. objectives: systemic lupus erythematosus (sle) is a chronic relapsing autoimmune disease characterized by production of autoantibodies against a series of nuclear antigens and by chronic inflammation. in recent years, neutrophil-lymphocyte ratio (nlr) was determined to be a good indicator of inflammatory status. nlr can be easily calculated from a whole blood count. introduction: neuroblastoma, an embryonal malignancy, is the most common extracranial solid tumor of childhood. untreated neuroblastoma tumors and cell lines are reported to have reduced hla class i expression, rendering them potentially susceptible to natural killer cell killing due to lack of engagement of hla class i-specific inhibitory killer cell immunoglobulin-like receptors (kirs). the aim of this study was to investigate whether kir genes could influence the risk of neuroblastoma and prognosis of the patients. materials and methods: study group consisted of neuroblastoma patients ( male, female, median age: months) followed at the pediatric oncology clinic of c ß ukurova university medical faculty. control group consisted of healthy children. patients had stage , , or s disease, patients had stage disease. different kir genes were analysed by sequence specific oligonucleotide probe (ssop) analyses. statistical analysis were done using fisher's exact test. results: compared to the control group, neuroblastoma patients had lower expression of activating kir gene, kir ds (p = . ), and higher expression of inhibitory kir gene dl (p = . ). additionally kir ds genes were more common in patients with early stages (stage , , or s) (p = . ) and kir dl genes were more common in patients with stage (p = . ). furthermore, there were no statistically significant differences between the rate of aa and bx genotypes and their centromeric/ telomeric regions of patients and controls. discussion: kir dl gene can have a triggering effect in neuroblastoma pathogenesis; whereas kir ds can have a protective role. investigating nk cell infiltration and kir receptors in neuroblastoma tissue samples will give more insight to the pathogenesis p- . . - neuroprotective and immunomodulatory effects of urtica urens s. arslan , g. terzioglu , b. kabalay , a. r. tufekci , a. sen , i. demirtas department of biology, faculty of arts and sciences, pamukkale university, denizli, turkey, deparment of chemistry, faculty of arts and sciences, c ß ankiri karatekin university, c ß ankiri, turkey urtica urens (small stinging nettle) has been used for medical purposes in turkey as an alternative therapy. it has been used in the treatment of inflammation that is early, non-specific immune reaction to tissue damage or pathogen invasion, plays an important role in the initiation of neurodegenerative disorders such as multiple sclerosis. however, there are limited studies that investigate anti-inflammatory activity of urtica. therefore, aim of this study is to find out theanti-inflammatory effect of chloroform extract in caco- cell line. for this purpose, firstly, chloroform extract of urtica leaves was prepared. chemical composition of extract was determined by lc-ms. the effect of chloroform extract on selected pro-inflammatory and inflammatory proteins such as tumor necrosis factor-a (tnfa), nuclear factor kappa b (nf-jb), c-x-c motif chemokine (cxcl ), and (cxcl ) were determined. whole genome transcriptome analysis was performed by using human ht- v beadchip. extract treatment caused % and % increases in protein and mrna levels of nf-jb, respectively. on the other hand, tnf-a protein and mrna levels decreased significantly ( % and %, respectively). similarly, cxcl and cxcl mrna levels decreased % and %. transcriptome analysis showed that probes were significantly changed (p < . ). pathway analysis revealed that the extract altered a group of genes involved in immune response, calcium ion homeostasis and transport, potassium channel complex, g-protein coupled receptor protein signalling pathway, etc. it is well established that calcium is very critical for brain cell death and formation of many brain disease including multiple sclerosis. these observations suggests that urtica maybe used in neurodegenerative diseases. in order to further test this hypothesis experimental autoimmune encephalomyelitis experimentsand activity guided fractionations have been still continuing. this work is supported by tubitak t . p- . . - linear low molecular weight a- , -glucan from bifidobacterium bifidum bim b- d is implicated in pathogenesis of celiac disease the bifidobacteria are recognized as human commensals and widely used as probiotics. earlier, we have found (kiseleva et al., benef. microbes, , ( ) : - ) that bifidobacterium bifidum bim b- d contains low molecular mass ( - kda) a- , glucans (g anti-tpo and g anti-tg ) that interact selectively with human autoantibodies to thyroid peroxidase (anti-tpo) and thyroglobulin (anti-tg), recognized markers of autoimmune thyroid disease (atd). the aim of the study was isolation and identification of b. bifidum bim b- d biopolymers (bps) interacting selectively with autoantibodies to tissue transglutaminase (anti-ttg) and antibodies to gliadins (anti-gl), recognized markers of celiac disease (cd). we used affinity chromatography with anti-gl, size exclusion chromatography, h and c nmr spectroscopy, elisa with immobilized bps, tissue transglutaminase (ttg) and gliadins (gl) as positive controls. the bp isolated by affinity chromatography with anti-gl (as more available marker of cd) and size exclusion chromatography was identified by two-dimensional nmr spectroscopy as - kda linear a- , -glucan identical to g anti-tpo and g anti-tg . the functional activity of the bp named g anti-gl , viz., ability to interact selectively with anti-ttg and/or anti-gl was proven by elisa with (i) serum samples of cd patients containing either both anti-ttg and anti-gl without anti-tpo and anti-tg or anti-gl without anti-ttg, anti-tpo and anti-tg vs. serum samples of healthy donors without four types of antibodies and (ii) pure anti-gl vs. pure total igg (without anti-ttg, anti-gl, anti-tpo, anti-tg). since (i) serum samples of cd patients do not contain anti-ttg without anti-gl and (ii) pure anti-gl isolated by affinity chromatography with gliadins (gl) cross reacts with tissue transglutaminase (ttg), additional studies with pure anti-ttg are necessary to find out which of the two antibodies, anti-ttg and anti-gl, bind g anti-gl . in conclusion, we proved that b. bifidum bim b- d cells contain linear low molecular mass a- , -glucan, g anti-gl , that interacts selectively with anti-ttg and/or anti-gl. since g anti-gl is identical to earlier found g anti-tpo and g anti-tg , we hypothesize that the a- , -glucan is implicated in pathogenesis of both autoimmune diseases, cd and atd. influences of elevated serum ferritin levels on insulin resistance and non-insulin-dependent diabetes mellitus (niddm) have predicted either because of increased body iron stores or influenced by several inflammatory diseases. low serum hydroxyvitamin d is known to perturb cellular function in many tissues, including the endocrine pancreas, which are involved in obesity and niddm. we planned to investigate the association between hydroxyvitamin d with hematologic parameteres and iron status in obesity vs. diabetic patients. study groups consist of control, non-diabetic obese, obese-diabetic and lean-diabetic groups. serum triglycerides, total cholesterol, ldl-c, hdl-c, fasting glucose, hba c, uric acid, creatinine, ggt, -hydroxyvitamin d, insulin, crp, esr, total blood count and iron status. apart from the three parameters, there were no significant difference (p > . ) between groups. serum ferritin and mchc levels were significantly higher in lean-diabetic patients (p < . ). on the other hand, rdw are determined to be significantly lower (p < . ) in the non-diabetic obese group. no difference was detected in -hydroxyvitamin d levels between the control and the study groups (p > . ). non-diabetic obese patients had significantly (p < . ) higher levels of tg and lower levels of hdl compared to obese-diabetics. insulin levels were higher in nondiabetic obese and obese-diabetics than lean-diabetics (p < . ). this study provides evidence that lean diabetic patients show higher ferritin and mchc levels than obese patients. the increase in serum ferritin and mchc levels is related with altered iron metabolism at cellular level. at late mitosis, the mother cell divides, leaving two daughter cells connected by a thin intercellular bridge (icb). during abscission of the icb, the ingression of the cleavage furrow is formed, and the central spindle microtubules are compacted into the structure known as midbody (mb). the mb is situated within the icb, with the abscission usually occurring at one side of the mb. as a result, only one daughter cell inherits the post-mitotic mb. these mbs can then either accumulate in the cytoplasm or be degraded. recent studies have identified mbs as novel signaling platforms regulating stem cell fate and proliferation. indeed, stem cells as well as cancer cells were shown to accumulate post-mitotic mbs, resulting in reprogramming of the cell fate and conversion to highly-proliferative, stem cell-like phenotypes. it has been proposed that regulated macroautophagy may be playing a key role in mediating pots-mitotic mb degradation. therefore, the experimental approach involved studying the dynamics and function of a protein known as fyco , which associates with postmitotic mbs and may regulate their degradation. in this study we identified fyco as a protein, which associates with post-mitotic mbs and may regulate their degradation. interestingly, fyco is also known to be present on autophagosomes, and overexpression of fyco can induce the formation of enlarged lc -containing autophagocytic structures. here we demonstrate that fyco knock-down leads to defects in autophagic mb degradation, and that fyco functions by targeting endocytic membranes to the autophagic phagophore during early stages of mb degradation. additionally, we showed that fyco depletion leads to increased proliferation and cell growth in soft agar. based on all these data, we hypothesize that fyco mediates selective mbs degradation via endosome-dependent extension of the phagophore around the post-mitotic mbs, and that mbs may be the regulators of cancer proliferation and progression. p- . . - proliferative effect of hypericine on human skin fibroblast cells and identification of the mechanism of action in molecular level to drawbacks associated with efficiency and viral genome integration. in order to improve reprogramming efficiency and compensate for viral transduction, new chemicals have been explored through ipsc research. the aim of this study was to investigate the proliferative effect of hypericine on human skin fibroblast cells (sf) in-vitro, and to identify the mechanism of action in molecular level. the proliferation was measured using the clonogenic and dimethylthiazol diphenyltetrazolium bromide (mtt) assays. real-time quantitative polymerase chain reaction (qrt-pcr) was performed to detect the mrna levels of cyclins (d and b ) and cell cycle controller genes (p and p ). sf cells were treated with different doses ( nm- lm) of hypericine for h and h. a significant cell proliferation was observed in moderate concentrations ( . - lm; % -% ), but at high concentrations ( - lm) cytotoxic effects emerged in sf cells (ic = . m, r = . ). qrt-pcr results revealed that the most proliferative dose of hypericine ( lm) stimulates cyclin d . the anti-proliferative activity of hypericine was accompanied by inhibition of cyclin b mrna, whereas it induced expression of p and p genes, and thus apoptosis was observed by dna laddering at the same dose ( lm). overall results suggested that hypericine can compensate for viral transduction and improve reprogramming efficiency of ipscs by enforcing them in g phase. hence we report that hypericine can be a good candidate component for cocktails produced to trigger ipsc proliferation. glioblastoma (gbm) is the deadliest brain tumor. the mean survival time of gbm patients is approximately months, increasing to months after treatment with temozolomide, which is the gold standard chemotherapy. the resistance of gbm to chemotherapy seems to be associated with the blood-brain barrier (bbb) that limits the delivery of chemotherapeutics, and the presence of a population of cells that expresses stem cell-like properties, which are known to be chemo-and radioresistant, the glioblastoma stem cells (gscs). the difficulties imposed by these two factors could be reduced by the use of a targeted drugdelivery liposome-based strategy that allows bbb passage and reduces the side effects of chemotherapeutics. the present study evaluated the ability of the f peptide-targeted ph-sensitive lipid-based nanoparticle containing doxorubicin (dxr) to target gscs and non-gscs. we evaluated the expression of cell-surface nucleolin by flow cytometry, as well as of stem cell-like markers, in two gbm cell lines. we also determined the ability of gbm cell lines to specifically uptake the f peptide-targeted ph-sensitive lipid-based nanoparticles, by flow cytometry, and correlated it with the expression of stem cell-like markers. moreover, to ascertain the impact of intracellular delivery of chemotherapeutic drugs into gbm cell lines, cytotoxicity was further assessed by the mtt assay. our results showed that the f peptide-targeted ph-sensitive lipid-based nanoparticles successfully targeted glioblastoma cells and particularly gscs. in addition, the results also provided evidence of the nucleolin overexpression-dependency of this strategy, emphasizing the need to adapt the therapeutic strategy to the individual patient. this study showed that f -targeted ph-sensitive liposomes may constitute an appropriate strategy to overcome the chemoresistance associated with glioblastoma cells. p- . . - leukemic cell plasticiy as a resistance mechanism towards tyrosine kinase inhibitors chronic myelogenous leukemia (cml) is a hematopoietic stem cell disease characterized by the t( ; )(q ;q ) translocation, which encodes the chimeric tyrosine kinase onco-protein, bcr-abl. the tyrosine kinase inhibitor (tki) imatinib is the first-line treatment for patients with cml. unfortunately drug resistance is one of the main problems observed. while secondary resistance is associated with bcr-abl kinase domain mutations, oncogene amplification and mechanisms interfering with intra-cellular drug concentrations; primary resistance mechanisms haven't been elucidated. we generated high dose imatinib-resistant k subclones (k -ir) by clonal selection to study primary resistance mechanisms in vitro. drug resistance was shown by caspase and annexin v/pi assays. we also showed cellular uptake and function of imatinib with western blot technics. k -ir cells are not only resistant to imatinib but also to nd, rd generation tyrosine kinase inhibitors. we demonstrated that k -ir cells have a highly adherent character, proliferate slowly and are resistant to drug-induced senescence. microarray analysis revealed that k -ir cells differentially express tissue/organ developement and differentiation genes at high levels. we showed that k -ir cells forms intact tumor spheroids in d cell culture conditions which is a marker of tumor initiating potential. cell surface maker analyses and protein analyses of k -ir cell population, points towards an epithelial-mesenchymal plastic cell capable of adopting different morphologies. we hypotizied that imatinib and other tyrosine kinase inhibitors may cause the gain of phenotypic plasticity potential in leukemic cells, by interfering with signalling pathways; which in itself may lead to therapy resistance. hypoxia has multiple effects on cancer cells, which are critically involved in tumor progression. hypoxia leads to changes in tumor cell metabolism and can promote cancer cell survival, invasion and metastasis by its critically important role on maintenance of cancer stem cell (csc) phenotype. in this research, human cd + cscs isolated from human osteosarcoma cell line saos- using macs magnetic separation technique were characterized, and their stemness properties under hypoxic ( % o ) and normoxic ( % o ) conditions were compared in two and three dimensional culture conditions. two different d culture techniques (nanofibrous bacterial cellulose scaffolds and scaffold free microtissues) were used to evaluate effects of hypoxia on csc behavior, and the results were compared with the cell behavior in classical d culture systems. the morphologies of cells were examined by scanning electron microscopy (sem); rt-pcr and immunocytochemistry staining were used to examine the cancer stem cell phenotype maintenance under hypoxic and normoxic conditions. it is shown that hypoxia supports the expression of stemness markers such as oct / , nanog and sox compared to normoxic conditions in d cultures. although similar effects of hypoxia were observed in d cultured cscs, the expression levels of stem cell phenotypeindicative markers were significantly lower on d compared to d culture systems. this study is seen as an introduction to develop a more relevant d hypoxic cancer stem cell based tumor model to study csc behavior and tumor genesis in vitro for testing of novel cancer stem cell therapeutics and to understand signal transduction in cancer stem cells. prostate cancer (pca) is the second most frequent cause of cancer-specific mortality in the world. cancer stem cells (cscs) are a subpopulation of cells that involved in drug resistance, metastasis and recurrence of cancers. the efficacy of natural flavanone apigenin on cell survival, apoptosis and migration of cscs were evaluated. cd + cscs were isolated from human pca pc cells using a magnetic-activated cell sorting system. pc and cscs were treated with different concentrations of apigenin, docetaxel and combinations of the two agents for h. apigenin dose dependently inhibited cscs and pc cell viability, and this was accompanied with a significant increase of the cell cycle inhibitors p and p (kip ). the flavonoid significantly induced apoptosis via an extrinsic caspase-dependent pathway by upregulating the mrna expressions of caspases- , - and tnfa, but failed to regulate the intrinsic pathway as determined by the bax, cytochrome c and apaf- in cscs. in contrast to cscs, apigenin induced intrinsic apoptosis pathway as evidenced by the induction of bax, cytochrome c and caspase- while caspase- , tnf-a and bcl- levels remained unchanged in pc cells. the ability of apigenin to inhibit the proliferation of cscs through apoptosis was confirmed by tali image-based cytometer. the flavanone strongly suppressed the migration rate of cscs compared to untreated cells. significant downregulation of mmp- and - exhibits the ability of apigenin treatment to suppress invasion. the expressions of pi k/akt and nf-kb p / p were significantly decreased after h apigenin treatment. taken together, these data demonstrated that flavonoid apigenin is an invaluable chemopreventive compound that inhibits proliferation, invasion and the stemness properties of cscs. this study was funded by the scientific and technological research council of turkey (tubitak, grant no. s ). (pi k), are frequently found in patients with severe early-onset segmental overgrowth. whilst differences in timing and location of the founder mutation are likely to explain part of the observed disease heterogeneity, it is less clear whether and how quantitative differences in the strength and timing of pi k activity contribute to phenotypic variability. our aim is to characterise pik ca mutant-specific signalling as well as to explore the effects of varying the strength and/or temporal pattern of pi k activation on downstream output specificity in the cell. we are currently employing crispr/cas mediated gene editing in human induced pluripotent stem cells to generate isogenic disease models of three such activating pik ca mutations. these cells will be used for signalome profiling by reverse-phase protein arrays (rppa) to compare and contrast mutant-dependent alterations to candidate signalling networks. in parallel, ongoing efforts focus on developing an endogenously expressed optogenetic p a, allowing precise spatiotemporal control over pi k signaling to unravel the extent to which pi kdependent phenotypes are determined by strength of activation and/or dynamic encoding. ultimately, the outcome of this research will yield novel insight into fundamental aspects of pi k signalling and potentially aid the development of targeted therapies for human diseases of pi k hyperactivation. e. gov, n. kaya, k. y. arga cancer stem cells (csc) have been proposed to be the cancer initiating cells. because of their highly tumorigenic and drug resistant properties, cscs offer significant potential for developing novel anticancer drugs and therapeutic strategies. in the present study we analysed eight gene expression datasets for breast, ovarian, lung cancer and glioblastoma by comparing gene expression levels between stem cells and tumor cells and integrating them with genome scale biological networks. consequently, mutual molecular signatures (i.e: differential expressed genes, transcription factor, mirna) and biological characteristics were determined via integrative analyses, which might be feasible to uncover the mutual biological mechanism insights behind the cscs. it was identified twenty mutual differential expressed genes in four cancer types; jun and klf as transcription factors, egfr and cdk as receptors come into prominence as mutual signatures. molecules and pathways that were related to mapk, wnt, p signaling and pathways in cancer were the common indicators in csc types. our results provided similarities in gene expression profiles of various cscs and gave clues about the seed of tumorigenesis. this study proposed signatures and pathways that could be considered as effective therapeutic approaches in further experimental and clinical applications to eliminate subpopulation of csc. colorectal cancer (crc) is one of the leading causes of mortality worldwide. metastasis is associated with the presence of circulating tumor cells (ctcs) in the peripheral blood of cancer patients. ctc cut-off values have been shown to predict for poorer overall survival in metastatic breast (≥ ), prostate (≥ ), and colorectal (≥ ) cancer based on assessment of . ml of blood. in our study, ctcs were detected in blood samples of colorectal cancer patients, using with our modified convenient method for the strategies of ctc enrichment and detection. . ml peripheral blood samples were firstly collected and peripheral blood mononuclear cells (pbmcs) were isolated from the fresh blood samples by ficoll gradient separation. next, the leukocytes in pbmcs were removed by magnetic microbeads conjugated with cd for a negative selection. finally, the retained cells were labeled with anti-epithelial cell adhesion molecule (anti-epcam), cytokeratins (ck , ck ) and the leukocyte-specific marker as anti-cd . all samples were analyzed by bd facs aria iii flow cytometry. in total, patients and healthy people were included in this study. the results showed that ctcs were not detected in the blood samples of healhty volunteers, but - ctcs were detected with ck , , , -based gating strategy in the blood samples of colorectal cancer patients. it is accepted that the cut off value is ctcs for colorectal cancer and ctc is negative if it is below this value or ctc is considered as a positive, if it is equal to or above this value, which might be an indication for poor prognosis. thus ctc's detection may serve a representative surrogate tumor biomarker for real-time monitoring of disease status and tailoring personalized therapy. cells were grown in culture flasks in a humidified incubator at °c with % co and were used at the proliferation and confluent stages. cultured cells were exposed to the pemf and prfe. the proliferations of the cells are measured by mtt assay for the effect of emf on the cancer cells. on the other hand the wound healing was investigated by closure of the wound by the cell proliferation with cell morphology using inverted microscope images. the proliferation decreased significantly by the effect of pemf on the semi confluent mcf- and mda-mb- cells. this effect was observed more prominent on mcf- . considering prfe therapy this effect is much more pronounced especially for mda-mb- comparing with pemf. the phase contrast observations of these results were consistent with mtt analyses. similarly, this effect was seen less for pemf but the proliferation was more suppressed with prfe on the wound models. it was considered that the emf applications could be effective in cancer cells, but this effect has not been studied how it occurs in invasive cancers. in our cell culture study, the appropriate emf applications were found to be effective though the inhibition of proliferation of cancer cells even in invasive cancer but with lower effect. this means that emf applications may support the existing treatment methods of cancer patients and even people who suffer from invasive cancer. metastasis is the one of the most known causes of death in patients diagnosed with cancer. circulating tumor cells (ctcs) are shed from primary tumors and circulating in the bloodstream, and thought to play a key role in metastasis. a hypothesis that ctcs may contribute to metastasis was first introduced in the mid th century by thomas ashworth, an austrilian pathologist. in today's research, identification and molecular characterization of ctcs are thought to be a novel target for treatment of cancer and a key factor to understand the metastatic process. existing methods of ctc capture based on the cell search system, flow cytometers, laser scanning cytometers instruments, fiber-optic array scanning technology (fast), isolation by size of epithelial tumor cells (iset), and definition fluorescence scanning microscopy. ctcs are increasingly considered as a 'liquid biopsy' and when liquid biopsy is compared to tumor tissue biopsy, liquid biopsy for ctcs detection can be carried out routinely in patients due to accessibility and ease of blood collection. also, primary tumor sampling may not reflect the actual metastatic conditions, ctcs are thought to be a novel tumor biomarker for real-time monitoring of disease status and tailoring personalized therapy. with futher works, ctcs may be used as liquid biopsies and it might provide better understanding metastatic process, new approaches in cancer diagnostics and treatment. mesenchymal stem cells (mscs) are distributed all over the organism as a source of tissue formation and regeneration. glucose is vital for the proliferation and differentiation of mscs. glucose uptake is mediated by specific glucose transporters of two families, the na-coupled glucose transporters (sglt) and glucose transporter facilitators (glut). the presence and function of glut proteins in human placental amnion derived mscs (hamscs) is unknown. we aimed to investigate the presence of glut , glut , glut proteins and genes in hamscs isolated from term placentas. mscs were isolated from human term placenta amniotic membrane, the characterization of cells were provided by flow cytometry. mscs were used to assess their chondrogenic, osteogenic and adipogenic differentiation potential. the expression of glut , glut and glut proteins was detected in hamscs by immunofluorescence. glut , glut , glut protein and gene expression in these cells were investigated by western blot and real-time pcr, respectively. flow cytometry analysis results of isolated cells showed that they were positive for cd , cd , cd , cd (mesenchymal stem cell markers) and hematopoietic markers cd , cd b, cd , cd and hla-dr were negative. the presence of glut , glut , glut proteins and genes were identified in hamscs. in this study, for the first time in literature, glut , glut and glut gene and protein presence was determined in hamscs. therefore, gluts could mediate glucose transport in human amniotic membrane mscs. proliferation and differentiation of mscs in vitro are still not optimized. further studies are required to clarify the complex mechanisms regulating the relationship between glucose and mesenchymal stem cells. disclosure of this relationship may provide a better understanding of glucose-related pathologies such as diabetes. tumors have hierarchically organized heterogeneous cell populations and a small subpopulation of cells, termed cancer stem cells (cscs), is responsible for tumor initiation, maintenance as well as drug resistance. therefore, killing the cscs along with the other cancer cells is gaining an importance. in the present study, it was aimed to evaluate the cytotoxic and apoptotic activity of a novel platin (pt) (ii) complex [pt(hepy) cl ] on mammospheres obtained from mcf- human breast cancer line. elevated expression of stemness markers were determined by western blotting. cytotoxicity was assessed using the atp viability assay. effect of the pt (ii) complex on the formation and development of mammospheres was analyzed with sphere formation (sfa) assay. apoptosis was determined via cytofluorimetric analysis (caspase / activity, annexin-v-fitc and bcl- activity) as well as gene expression analysis. cytotoxicity was confirmed with the atp viability assay after the treatment with zvad-fmk (an apoptosis inhibitor) and necrostatin (a necroptosis inhibitor). in addition, alterations in mitochondrial membrane potential were evaluated by jc- staining. mammospheres exhibited increased oct- and sox (stemness markers) expressions compared to parental mcf- cells. cytotoxicity by pt (ii) complex was evident in a dose-dependent fashion ( . - lm) . pt (ii) complex significantly prevented mammosphere formation and disrupted mammosphere structure in a dose-dependent manner. pt (ii)-induced apoptosis was determined based on the presence of caspase / activity, annexin-v-fitc positivity and bcl- inactivation. apoptosis was also confirmed with increased tnfrsf a and hrk gene expressions. in addition to apoptosis, necroptosis was also present as evidenced with increased mlkl expression. mitochondrial membrane was depolarized. in conclusion, the pt (ii) complex seems to be a powerful apoptosis-inducing compound on cancer stem cells, thereby warrants further in vivo experiments. cancer is a disease which arises from destruction of growth and proliferation mechanisms in cells and is the second leading cause of death worldwide [ ] . in the development of primary cancers, the head and neck cancer is accounting for approximately . new cases annually around the world [ ] . laryngeal cancer is a type of head and neck cancer in which malignant cells arise from the mucosal tissues of the larynx [ ] . cancer might spread from primary tumor by getting into the lymph and blood vessel system and forms secondary tumor. greater than % of deaths in cancer patients are attributed to metastasis [ ] . circulating tumor cells (ctc's) provide an opportunity to understand the metastatic process of cancer patients. identification and molecular characterization of ctc's in the peripheral blood of cancer patients is a promising research area in the field of biomarker development and novel treatment targeting in today's cancer research [ ] . the detection of ctc methods include cell search system, flow cytometry, high-definition fluorescence scanning microscopy, fiber-optic array scanning technology, isolation by size of epithelial tumor cells, and laser scanning cytometers [ ] . in our study, . ml of peripheral blood samples were collected from larynx cancer patients and healthy volunteers and the samples were analyzed by bd facs aria iii flow cytometry via biomarkers epcam, ck , ck for positive selection and cd for negative selection [ ] . according to the results of our study; ctcs were detected in larynx cancer patients by our newly modified method whereas there was no ctc's detection in the samples of controls. thus, this study may provide us monitoring of the treatment process of larynx cancer and this method might be used as diagnostic, prognostic, and predictive biomarkers in cancer therapy as a liquid biopsy. prostate cancer is the second most common cancer and the fifth leading cause of death from cancer in men . circulating tumor cells (ctcs) present in the peripheral circulation of cancer patients with different solid malignancies including prostate cancer and have a potential as a liquid biopsy to monitor disease progression and response to therapies at cell and molecular level . one of the general methods in ctc detection is flow cytometry . radical prostatectomy is the most frequently applied procedure in the surgical management of localized prostate cancer. in this surgical operation, the surgeon removes the entire prostate gland with the seminal vesicles. a radical prostatectomy procedure can be done using the da vinci robotic system (intuitive surgical, sunnyvale, ca, usa) . robotic surgery has been suggested to have fewer complications, lower risk of infections and shorter recovery period following robotic radical prostatectomy , . in this study, our aim was to detect ctcs before and after robotic radical prostatectomy in clinical localized prostate cancer patients. the ctc detection study was performed with our modified method in which . ml of peripheral blood samples were collected from each prostate cancer patient and healthy individual; the samples, using with biomarkers epcam, ck , ck for positive selection and cd for negative selection, were analyzed by bd facs aria iii flow cytometry . according to our results, we detected ctcs in the peripheral blood samples of prostate cancer patients before robotic radical prostatectomy. however, following this surgical procedure no ctc or decreased number of ctss was detected. our study might contribute to understand disease progression after robotic radical prostatectomy in clinically localized prostate cancer patients that warrants further research. keywords: circulating tumor cells, prostate cancer, flow cytometry, robotic radical prostatectomy. p- . . - determination of effect cytotoxic, apoptotic, caspace- activity and mrna expression levels of apoptototic related genes of vulpinic acid on breast cancer cell lines n. kilic ß, s. aras, d. cansaran-duman ankara university, ankara, turkey breast cancer is the most common cancer types in women. several drugs used to treat breast cancer patients are developing resistance to the treatment for this reason success rate falls. therefore the discovery of alternative therapeutic agent and molecular detection of anticarcinogen effect because of treatment for cancer patients may be a source of hope for the contributions. in this study, different concentrations ( . , . , . , . , , , lm) vulpinic acid (va) lichen seconder metabolite was determined to cytotoxic, apoptotic effect and caspase- activity in breast cancer cells (mda-mb- , mcf , bt- , sk-br ) and normal cell (mcf a). in addition to the quantitative real-time pcr (qrt-pcr) using apoptose specific primers (tp- , bcl- , bax, birc- , gapdh, caspase- , caspase- , caspase- , caspase- ) and sybr green dye were performed to determine expression patterns of transcript level in cancer cell lines, using gapdh as a reference gene. the antiproliferative characterization of va effects identification of the gene set at molecular level and we determination role of va on apoptotic pathway. according to our study, va is demonstrated significantly (p < . ) effect cytotoxic, apoptotic, caspase- activity. beside this, dose dependent expression patterns decreased apoptose spesific genes (except of bcl- ) mrna levels from six to eleven fold change more than untreated va cell lines. va will be used as candidate molecule for effective treatment on breast cancer in the future. glycosylation largely determines the variety and functions of proteins. paucimannose, a mannosidic n-glycoepitope has long been thought to be specific for plants and invertebrates. recently, it has also been detected in mammalsin physiological conditions (stem cells) and in pathophysiological conditions (inflammation and cancer). in glioblastoma cells, paucimannose also seems to play a role in cell proliferation. glioblastoma is the most frequent brain tumor in adults with poor prognosis due to a lack of suitable treatments. we hypothesize that paucimannose could be a promising new biomarker as it is otherwise rarely found in mammals. therefore, paucimannose levels were investigated in different glioblastoma cell lines differing in their proliferation rate and tumorigenicity. the highest paucimannose levels were detected in low proliferating, nontumorigenic cells. furthermore, we found that modulation of paucimannose function by application of a specific antibody regulated cell proliferation and the capability of cells to form colonies in soft agar. these data support a functional role of paucimannosidic epitopes in tumorigenic processes. glioblastoma multiforme (gbm) is the most lethal type of malignant brain tumors. recently, gbm stem cells (gscs) have been studied in great deal and accepted that they have a legitimate role in tumor formation, development, chemo-resistance and recurrence. in this study, it is aimed to investigate new therapeutic targets within apoptosis related molecules to select and eliminate cd + gscs effectively. ten primary gbm cells were isolated from gbm tissue samples and they were cultured among with the gbm cell lines (u , u , u and t ). cd + and cd À cells were seperated by macs method via anti-cd (ac ) antibody from cultured cells and cell lines. rna isolation from cd + and (À) cells, cdna synthesis was performed. finally, by performing pcr array, mrna expression levels of genes were detected. proper results were collected and analysed statistically. according to the results of pcr array; it has been found that cd + cells express approximately fold tnfrsf and fold tnfsf when they are compared with control cells. tnfsf binds to cd that is expressed on the surface of tcells. cd does not have a death domain, instead it has a cytoplasmic tail which binds to trafs. trafs act as adaptor molecules that are related with jnk and nf-jb signalling pathways. tnfrsf (dr ) is a death receptor which are known for transmitting the pro-apoptotic signals from outside to the inside of the cell. it negatively regulates t-cell activation and the release of few cytokines. as a conclusion, tnfsf and tnfrsf both are found on immune system cells, mostly on t-cells, which may mean that gbm stem cells act as a immune system cells to avoid the elimination by the immune system. to conclude, acting as an immune system cell and promoting survival via tnfsf and tnfrsf , these molecules may be essential markers to target cd + gbm stem cells. the effect of docetaxel on p , sin a and mdm gene expression in mcf- breast cell line docetaxel is a cytotoxin effective in treating breast cancer. it stabilizes microtubules and causes catastrophic cell cycle arrest in g /m. it also initiate signaling through cell death pathways that result in programmed cell death. in this study, it was aimed to investigate apoptotic and cytotoxic effects of docetaxel has on the mcf- breast cancer cells line. in this study, mcf- breast cell line was applied different doses docetaxel ( nm, nm, lm, lm, lm) as h and h. mtt analysis was performed to the mcf- breast cancer line in control group and groups of docetaxel. afterwards, evaluation of apoptosis by tunel and levels of p , sin a and mdm gene expression by real-time pcr were determined in an order. it was observed cell variable was significant lower in docetaxel groups compared to control group (p < . ) in h as mtt analysis. the lowest cell viabilty was determinated in group applied lm docetaxel. while the lowest positive cell density was determinated in control group, it was observed apoptotic cell density gradually increased with increasing docetaxel concentration in groups treated docetaxel (p < . ). the highest p , si a and mdm expressions were apperared in nm docetaxel group compared to control group. human alpha-fetoprotein (afp) and afp receptor binding domain (afprbd) are able to bind and internalize effectively by wide range of human tumor cells and tissues. as other vector molecules afprbd has insufficient quantity of chemical groups which can be conjugated with drugs or diagnostic agents. conjugation of vector molecules with macromolecular polymer carriers like dendrimers aims to solve this problem. our study describes influence of afprbd-dendrimer-doxorubicin conjugate surface charge on intracellular trafficking routes and toxicity. the amineterminated (g ) and acetyl-terminated (g ) nd generation pamam dendrimers carrying doxorubicin (dox) were used to synthesize conjugates with afprbd. unmodified by afprbd g and g dendrimer derivates labeled with dox were absorbed by the cells at °c with different efficiency. g -dox derivate characterized much slower internalization rate than nonacetylated g -dox. only g -dox shown partial colocalization with lysosomal marker lamp after h of incubation. internalization of afprbd-g -dox and afprbd-g -dox did not show significant difference. at the same time, both conjugates contained afprbd wyкy almost fully associated with lamp already after min of incubation. cytotoxicity results revealed that ic levels of g -dox and afprbd-g -dox coincided and demonstrated a bit higher activity against sensitive to dox skov and resistant skvlb cells than afprbd-g -dox conjugate after h of incubation. at the same time, after h of incubation afprbd-g -dox and afprbd-g -dox were much more than g -dox and g -dox. we may conclude that there is significant difference in ways of dendrimers internalization by tumor cells depending on nature of surface chemical groups. on the other hand, chemical modification of dendrimer conjugated with does not afprbd influence dramatically on the protein trafficking and resulting cytotoxic effect. russian scientific foundation supported this study (no. - - . ) , a key enzyme in glycolysis, catalyzes conversion of phosphoenolpyruvate (pep) into pyruvate with regeneration of adenosine triphosphate (atp). the key regulator of the metabolic alterations found in tumor cells is the glycolytic isoenzyme pyruvate kinase type m that is generally expressed in all proliferating cells and overexpressed in all tumor cells investigated to date. during carcinogenesis a shift in the pyruvate kinase isoenzyme equipment always takes place, such that the tissue-specific isoenzymes disappear, and m -pk is expressed. breast carcinoma, the third most common cancer worldwide, accounts for the highest morbidity and mortality. breast cancer tissue analysis confirmed the upregulation of m -pk in breast cancer, and high m -pk levels were associated with poor prognosis of breast cancer patients. materials and methods: poly hema (mac) nanoploymers were immobilized by binding covalently with sulphur atoms on the gold electrod's surface. pyruvate immobilization was actualysed with cross linking reagent glutaraldehyde. biosensor was developed by preparing pottasiumferrociyanide, selected as a mediator. results: cyclic voltammograms have been carried out at between~ . and . v potentials vs. ag/agci. m -pk activty was detected by using differential pulse method at between . and À . v potentials by observing the differentiations in the current values. in the optimization studies, some parameters such as optimum ph, temperature, concentration of glutaraldehyde and p-hema-mac, were investigated. discussion and conclusion: the method developed for the measurement of the tumor m -pk activity by using biosensor. we found that more advantageous in comparison to other methods reported in the literature so far; it was determined that the method is sensitive, economic, practical and less time-consuming. piruvat kinase tumor m -pk activity determination at low concentrations is possible with this method. p- . . - tie /tek: a potential biomarker for targeting glioblastoma stem cells role in angiogenesis, endothelial cell survival, proliferation, migration and adhesion. therefore, tie /tek could be a potential target for therapeutic strategies directed against glioblastoma stem cells and their microenvironment. in this study, we investigated the gene expression levels of tie /tek in both cd + gscs and cd À gbm cells. gbm primary cells were freshly isolated from glioblastoma tissue samples and cultured in dmem supplemented with % fetal calf serum and % penicillin-streptomycin at °c in % co -humidified incubator. we isolated cd + and cd À cells from gbm primary cells using macs system. following rna isolation from healthy brain tissues, cd À and cd + cells, cdna synthesis was performed. finally, according to microarray protocol, cell surface marker panel array was applied. expression levels were analyzed using the delta delta ct method. statistical analysis was performed using spss software for windows version . . tie /tek gene expression was determined as . fold higher in cd + gscs than normal brain tissue (p < . ). morever it was determined . fold higher compared to normal brain tissue in cd À (p < . ). according to our results tie /tek expression was higher in gscs, indicating that tie / tek may be a potential marker for targeting cancer stem cells in gbm. this research has been supported by the scientific and technological research council of turkey (no: s ). adenosine inhibited the breast cancer stemlike cell population through erk / pathway s. m. jafari, m. aghaie cancer stem cells (cscs) are immortal tumor-initiating cells that can self-renew and drive tumorigenesis in various cancers, including breast cancer and others solid cancers. in a study indicated that extracellular atp reduces tumor sphere growth and cancer stem cell population. but at present, there are no reports available in literature on the effect of adenosine on breast cancer stem cells. in this study we evaluated the effect of adenosine inhibition and its mechanism of action in breast cancer stem cells isolated from breast cancer cell lines. our result showed that adenosine significant reduces breast cancer stem cell population. reduction of erk / protein levels was also observed after treatment cancer cells with adenosine. in conclusion, our results indicate that adenosine decreases the breast cancer stem-like cell population through erk / pathway. taxanes are commonly used for the treatment of many cancers as chemotherapeutic drugs that resistance to these agents has become a major clinical obstacle. taxane based chemotherapy drugs such as paclitaxel, docetaxel and cabazitaxel bind microtubules and inhibit to microtubule polymerization appear to stimulate programmed cell death. taxane-resistance to cancer has not been clearly in progression and development of drug resistance. multiple mechanisms are involved in the drug efflux proteins as multidrug resistance protein, differences in amino acid sequences among the b-tubulin isotypes. we investigated taxane resistance with different doses of paclitaxel, docetaxel and cabazitaxel in prostate cancer stem cells. we compared the expression level of apoptotic proteins, and its functional role in resistance mechanisms in cd + /cd + prostate cancer cell lines. taxane drugs were categorized as concentration-dependent or time-dependent. cabazitaxel caused a time-dependent and dose-dependent reduction in cell viability in all tested cell lines. resistance activity was consistently higher in docetaxel in prostate cancer cells compared with the other drugs. there are many different response of clonogenic formation cd + /cd + cells with resistance to docetaxel, paclitaxel and cabazitaxel in prostate cancer stem cells. the innate of prostate cancer resistances are important characterization steps and critically limits treatment outcomes therefore novel drugs must be focus on antiresistance and molecular based combinations. mesenchymal stem cells (mscs) are self-renewing cells with ability to differentiate into organized, functional network of cells. mscs isolated from various tissues including adipose tissues, bone marrow, umbilical cord, placenta and pancreas have different differentiation and proliferation potential. good knowledge of the metabolism and proliferation mechanisms of stem cells is required for stem cell therapies. glucose is an important molecule in the culture of stem cells. glucose concentration affects the differentiation and proliferation potential of stem cells. the aim of the study was to investigate the proliferation status by identifying the proliferating cell nuclear antigen (pcna) expression under normoglycemic and hyperglycemic conditions in mscs. mscs were isolated from human term placenta amniotic membrane. characterization of the isolated cells was performed using flow cytometry. chondrogenic, osteogenic and adipogenic differentiation potential of these cells were investigated. characterized cells were cultured in normoglycemic and hyperglycemic conditions for and h and the expression of pcna protein expression in these cells were investigated by western blot. flow cytometry analysis showed that isolated cells were positive with mesenchymal stem cell markers cd , cd , cd , cd and negative with hematopoietic markers cd , cd b, cd , cd and hla-dr. western blot result of pcna protein expression statistically significantly increased in human amniotic membrane mscs under hyperglycemic conditions for and h culture. the glucose content of stem cell medium is important because glucose is an effective molecule of the proliferation of stem cells. proliferation of mscs in vitro are still not optimized. when the relationship between glucose and stem cells be understood, it will provide a better understanding for the glucose-related pathologies such as diabetes during pregnancy. prostate cancer (pca) is the second most common type of cancer among men in the world. it is revealed that some gene, protein and metabolite sets control the pca, however the whole metabolomics changes are not completely understood yet. pca is common among older men, and this is an important health problem in developed countries. sarcosine is the n-methyl derivative of the glycine amino acid. glycine n-methyl transferase produces sarcosine from glycine. besides, it is metabolized to glycine by sarcosine dehydrogenase. in , high level of sarcosine in urine was associated with pca by sreekumar et al. they identified sarcosine as a pca biomarker that was significantly increased in urine during prostate cancer progression to metastasis. following this study, several studies have been published indicating sarcosine as a pca biomarker. in our study, a preliminary biosensor system was fabricated for determination of sarcosine in urine by using sarcosine oxidase. sarcosine oxidase was immobilized on au electrode surface using gelatin as an immobilization matrix. glutaraldehyde was used as a cross-linking agent to avoid the loss of the enzymegelatin mixture. optimization and characterization studies were carried out. sarcosine concentrations were detected carefully with the developed biosensor system. the fabricated preliminary biosensor is a promising system that can allow lower detection limits after surface modifications. activation of the epithelial-mesenchymal transition (emt) program in tumor cells is associated with invasiveness and stemness. recent studies implicate emt-inducing molecules in reprogramming energy metabolism. the -phosphofructo- -kinase/fructose- , -bisphosphatase- (pfkfb ) regulates glycolysis by producing fructose , -bisphosphate (f , bp). given that pfkfb is induced by several established emt-inducers in tumor cells, e.g. hif- a and ras, we hypothesized that pfkfb may be involved in regulation of the emt in tumor cells. silencing of pfkfb in pancreatic adenocarcinoma cell lines panc and s vp was achieved using specific sirna molecules. mrna and protein expressions of the cdh gene (encoding e-cadherin, an established epithelial marker), as well as zeb and snai genes, by real-time quantitative (q)-pcr and western blot, respectively. immunfluorescence analysis was performed to visualize e-cadherin protein expression on plasma membrane. in order to test the effect of pfkfb on the invasive ability of the cells, a matrigel invasion assay was performed. ectopic expression of zeb was achived by transfecting cells with a plasmid carrying zeb cdna. cells that were depleted of pfkfb exhibited markedly increased cdh mrna and e-cadherin protein expressions and reduced snai and zeb mrna expressions. immunfluorescence analysis confirmed the upregulation of the e-cadherin protein on plasma membrane. silencing of pfkfb caused approximately % reduction in matrigel invasion, compared to non-targeting sirna. inhibition of the matrigel invasion caused by pfkfb depletion does not appear to be associated with reduced zeb expression, as ectopic expression of zeb did not reverse the effect of pfkfb silencing on invasion. taken together, these data suggest that pfkfb may be required for the maintenance of the mesenchymal phenotype and associated traits in pancreatic adenocarcinoma cell lines. introduction: leukemias are neoplasms that arise from hematopoietic cells initially proliferate in the bone marrow, and then disseminated in the peripheral blood, spleen, lymph nodes and eventually to other tissues. lymphomas occur primarily in the lymph nodes, but can be extended in peripheral blood and bone marrow infiltrate. aim: to determine the values of haematological parameters the control and test groups. to determine the prevalence of types of chronic leukemia in relation to the experimental group. compare haematological parameters in relation to the type of chronic leukemia. materials and methods: a prospective-retrospective study included subjects who were made laboratory hematology in oj clinical chemistry and biochemistry ukcs. blood tests conducted on the hematology analyzer siemens advia hematology system and abbott cell dyn and microscopic analysis of the peripheral blood smear. results and discussion: according to the age of respondents test group was established mild form of anemia, a red blood cell count is totaled . ae . x , which is signifycantly lower compared to the control group. the average number of leukocytes was significantly higher in subjects studied groups and amounted to . x , with a maximum value of x . in the peripheral blood of patients with chronic leucosis has established a significantly higher number of cells compared to the control group (p = . ), while the number of monocytes was a significantly smaller. in the group of patients with chronic leukosis largest number had chronic lymphocytic leukemia ( %), and chronic myeloid leukemia had % of respondents. conclusion: subjects with cll were statistically older than patients with cml, and as regards the gender structure, men have dominated in cll and cml in women. white bloodline was found that the number of leukocytes in both forms of chronic leukemia high above the reference value. p- . . - effect of enzymatic and non-enzymatic isolation methods of endometrial stem cells on their cell proliferative potential and mesenchymal stem cell characteristics human endometrial stem cells (hescs) are responsible for the monthly renewal of the basal layer of the human endometrium by facilitating stromal and vascular regeneration. in this study, hescs were isolated with three different isolation methods including non-enzymatic and enzymatic digestion using trypsin and collagenase type . the effect of these three isolation methods on the acquisition of mesenchymal stem cells (msc) and on hesc proliferative potential was evaluated through flow cytometric analysis of cd surface markers and wst- tetrazolium salt assay. our findings indicate that hescs isolated with these three methods have statistically similar cell proliferation rate at h time point. however, at h time point, hescs isolated with the non-enzymatic and collagenase type method displayed a higher expansion in cell number when compared to the hescs isolated with trypsin. the late passage of hescs isolated with non-enzymatic and trypsin methods showed the highest proliferation rate in comparison to the hescs obtained via collagenase type isolation method at h, h and h. the three isolation methods for the early passages of hescs had a resemblance in their msc profile with no significant difference. on the other hand, late passage hescs isolated using trypsin non-enzymatic method showed a higher cd and lower cd profile. moreover, late passage of hescs isolated with non-enzymatic method displayed a significant reduction in their cell surface cd , cd , and cd surface expression levels. only hescs isolated with collagenase type did not present a significant shift in their mesenchymal cd marker profile from early to late passages, taken together results from this study suggest that the longterm maintenance of mesenchymal markers can only be achieved in cell isolation with collagenase type , while non-enzymatic method is more suitable to obtain higher msc cell yield for immediate use. hepatocellular carcinoma (hcc) abundantly arises on the viral and/or chemical-induced cirrhosis in liver. cirrhosis is defined as one of the premalignant stage hcc in which microenvironmental changes occurred such as uncontrolled production of collagen type i and activation of hepatocyte growth factor (hgf)/c-met signaling. it has been shown that epcam+/cd + subpopulation of cells isolated from hcc tissue can initiate tumor at very low concentration in xenograft model and behaves as hepatic cancer stem cells. however, the molecular mechanisms supporting hepatic stem cell activation are not well understood and knowledge about the role of hgf/c-met pathway in this process is not clear. in this study, we aimed to define effect of collagen type i and hgf induction on the cell behaviours of epcam+/ cd . epcam+/cd + cells were sorted by magnetic separation from huh- cells. then proliferation and invasion of cells were analyzed under the hgf induction as well as branching morphogenesis in vitro. after hgf stimulation, phosphorylation level of c-met increased in epcam+/cd + subpopulation. moreover, presence of collagen type i enhanced significantly effect of hgf stimulation in the invasion of epcam+/cd + cells. we also have showed that hgf stimulation increased branching tubulogenesis capacity of epcam+/cd + subpopulation while it did not effect proliferation of cells. these effects of hgf reverted by c-met inhibitor, su , in vitro. all these findings showed that hgf and collagen type i regulates aggressive phenotype as microenvironmental changes via induction of invasiveness of epcam+/cd + subpopulation of huh- . in conclusion, we showed that hgf/c-met signaling causes to get more metastatic phenotype based on invasion and tubulogenesis in epcam+/cd + hepatic cancer stem cells in hcc and it might be possible to use c-met inhibitors to target hepatic cancer stem cells during hepatocarcinogenesis. endometriosis is defined by the migration of endometrial mesenchymal stem cells (emscs) into the peritoneal cavity or other site of body rather than uterus in a retrograde fashion. its previously known intracellular crosslinking enzyme called tissue transglutaminase (tg ) was shown to play important roles in the extracellular matrix (ecm) modelling, fibrosis, cell adhesion and migration. we have hypothesized that tg might be expressed in emscs and take part in the formation of endometriosis. the difference in the proliferation capacity of emsc isolated from endometrial tissue with/without endometriosis was determined using wst- assay and tg activity and expression levels were analysed by btc assay and rt-pcr. the biosynthesis and activity for mmp- and - were investigated with zymography and rt-pcr, respectively. although tg activity was found to be % less in emscs isolated from endometriotic tissue, these cells showed times higher tg protein expression than those isolated from the control tissue without endometriosis. emscs from endometriotic tissue have . times higher tg and . fold higher itgb mrna levels when compared to the cells of healthy group. similar results were observed in sdc- gene expression with a . fold increase. endometriotic emscs demonstrated an average of . -fold increase in the mmp- activity while a onefold increase was evident in mmp- activity when compared to the healthy emscs. emscs from patient group possessed a higher proliferative ability in comparison to that of healthy subjects within h. the fact that emscs from the control tissue showed lower tg protein levels with a high enzyme activity suggested that tg might be important in the development of endometriosis not only by destabilizing ecm but also enhancing the cell migration. in this context, the upregulation of tg along with itgb and sdc was evident in emscs of endometriosis which was possibly associated with the increase in the activity of mmp- and - . recent studies have indicated that pluripotent stem cells and some stromal stem cells such as mesenchymal stem cells (msc) are metabolically different from their differentiated counterparts. in this study, the cellular mechanisms controlling metabolic changes in stem cells was investigated using wharton jelly mesenchymal/stromal stem cells (wj-mssc). wj-msscs were isolated by the explant method and cultured in dmem-f with % fbs. endothelial differentiation was induced by the addition of vegf, egf, insulin and hydrocortisone for days. neuronal differentiation was achieved by using commercial neuronal differentiation medium (millipore) for days. in parallel experiments, cellular metabolic activity such as lactate production was measured. the msc characterization was performed by flow cytometry using antibodies against cd , cd , cd and cd (bd human msc analysis kit). the differentiation process was followed by measuring the expression of cd , cd for endothelial and gfap, neu and tyrozine hydroxylase proteins for neuronal cells by immunofluorescence. for gene expression, nanog, cd and gapdh genes were analyzed by rt-pcr. differentiation stimuli to endothelial or neuronal cells resulted in a significant decrease in msc marker proteins. expression of stem cell markers other than cd were decreased to - %. differentiation induced the expression of cd , cd for endothelial and gfap and neu proteins for neuronal cells. in vitro lactate production was decreased following differentiation in both lineages. neuronal differentiation increased glucose consumption by~ % and the extracellular calcium concentration of these cells was significantly lower than synchronous undifferentiated cells. glycolytic activity is decreased during in vitro differentiation of wj-msscs. metabolic reprogramming and glucose uptake of cells may be an early indicator of the differentiation process in wj-msscs, supporting the view on their metabolic plasticity. store-operated ca + entry (soce) activated by depletion of intracellular ca + stores has been shown to control intracellular ca + homeostasis in many physiological and pathological events. stromal interactive protein, stim , as endoplasmic reticulum (er) ca + sensor and orai protein as pore-forming subunit of soc channels play crucial roles in the activation of soce channels. stim and orai were reported to have pathophysiological roles especially in hepatocellular carcinoma (hcc). anticancer chemotherapy frequently falls back because of these tumor-initiating subpopulations, tentatively called 'cancer stem cells'. the purpose of this study was to investigate the roles of stim and orai on soce in differentiation of huh- hccs expressing epcam and cd surface adhesion molecules (epcam + cd + ). epcam + cd + subpopulations in huh- cells were separated via flow cytometry and transfected with stim and orai- over-expressing (oe) plasmids. expression levels were confirmed by rt-pcr. changes in intracellular ca + concentration were monitored via dual wavelength spectrofluorimeter in fura -loaded cells. in epcam + cd + cells, er ca + release increased without any change in soce compared to that of epcam À cd À cells. similar results were observed in stim -oe epcam + cd + cells. on the other hand, increase in orai has no effect on either parameter. cancer is globally one of the most death causes. recently, huge improvements occurred in the cancer diagnosis and treatment due to advanced technology, however recurrence occurs almost - % of patients and their survival times decreases. in this study, we aimed to investigate of relationship between the cancer stem cells which are strongly associated with chemotherapy and radiotherapy resistance and recurrence with the non-classical mhc i antigens which have immunosuppressive properties. for this purpose, we immunohistochemically evaluated the expression patterns of cd , cd , nanog, oct / , hla-g and hla-e in the advanced stage colorectal, gastric and breast cancer and also non malign biopsy samples. we detected that the cancer stem cell markers cd , cd , nanog and oct / significantly increased in the advanced stage cancer tissues. however, the immunosuppressive hla-g and hla-e expressions increased only in the colorectal and gastric tumor tissue. in addition to the presence of cancer stem cell like cells in the tumor tissues, increased expressions of hla-g and hla-e may indicate an immune evasive adaptation of tumor cells. according to our findings, the hla-g and hla-e may be potential therapy targets to elimination of cancer stem cells of colorectal and gastric cancers. however, more detailed studies are needed to support our findings and also to determinate of clinical values of these markers. endocannabinoids increase sdf- release from human mesenchymal stem cells s. k€ ose , f. aerts kaya , d. uc ßkan c ß etinkaya , p. korkusuz stem cell research and application center, hacettepe university, ankara, turkey, department of histology and embryology, hacettepe university, ankara, turkey lipid-structured endocannabinoids are endogenous morphine ligands and present widespread receptor-mediated effects at physiological and pathological levels on the nervous system as well as many other systems. these effects are partially realized through mechanisms affecting cell growth, differentiation, apoptosis and migration at the molecular level. the hematopoietic progenitor cells (hpcs) and mesenchymal stem cells (mscs) form a distinct niche in bone marrow where they interact with each other in harmony. the stromal cell-derived factor (sdf- /cxcl ) is a chemotactic factor in bone marrow and is released from mscs and their receptor cxcr is found in hpcs. with these rationale in mind, we asked if hpcs and msc interaction mediates sdf- release via endocannabinoidal system. bone marrow mscs obtained from healthy donors and passage mscs were induced with ng/ml lipopolysaccaride (lps) for h. antagonists for cb (am ) and cb (am ) receptors were added to cultures for days. after incubation with antagonists msc culture supernatants collected and processed with human sdf- beta in elisa medium. analyses demonstrated direct decreasing effect of endocannabinoid receptor antagonists on sdf- beta release from bone marrow mscs. in conclusion, endocannabinoidal system regulates sdf- release on mscs and directly act on hpcs mobilization in bone marrow microenvironment (niche). this may have a clinical implication on therapeutic mobilization strategies for hscs in hematology clinical applications. implantation is invasion of the embryo into the endometrium and occurs in three stages apposition, adhesion and invasion, via the complex cellular and molecular mechanisms. during these stages, both of maternal endometrium and embryo should be appropriate for the implantation which is the beginning of pregnancy. receptivity of uterine consists in the existence of growth factors such as tgfbeta- , igfr , vegf. it is indicated that damages of factors relesead from endometrium and blastocyst prevent implantation. recently, stem cells can be obtained from many sources to use for therapeutic purposes and mesenchymal stem cells derived from bone marrow are the most studied. in our study, it was aimed to investigate molecules play a role in blastocyst implantation after bone marrow derived mesenchymal stem cell application into the rat endometriyum. female rats were divided into three groups which were saline (sf, n: ), media (m, n: ), stem cell in media (m+bmsc, n: ). after vaginal smear technique, female rats in estrous cylcle were injected into the uterine and periton ll saline, ll culture media and cell/ ll culture media. the pregnant female rats on the day were sacrified and uterine samples removed and were stained with heamatoxylin-eosin histochemically and anti-tgfbeta- , anti-igfr , anti-vegf and anti-pcna immunohistochemically and obseved under light microscope. h-score results were determined using one-way anova test statistically. it was found that intraperitoneal administration of stem cells with media, was increased tgfbeta- , igfr , vegf and pcna parameters when compared with the intrauterine administration of stem cells. in this study, it was revealed that distribution of molecules play role in implantation were changed due to stem cell application. it is supposed that stem cell treatments can be cured the molecules caused infertility. many unconventional biochemical factors remain to be investigated for their potential effects on stem cells. among others, endogenous gasotransmitter h s, generated from l-cysteine and organosulfur-compounds (oscs) metabolisms, plays very important roles in the central nervous, respiratory and cardiovascular system. slow-releasing h s donors are viewed as powerful tools for basic studies and innovative pharmaco-therapeutic agents for cardiovascular and neurodegenerative diseases. exogenous h s administration is able to promptly scavenge ros, activate myocardial k atp channels and increase pro-cell survival signaling, very likely activating erk and phosphatidylinositol -kinase (pi k)/akt pathways. the effects of h s-releasing agents on the growth of stem cells are not yet widely investigated. therefore, stem cell therapy combined with h s may have great clinical relevance in cell-based therapy for regenerative medicine. the effects of slow-releasing h s agents on the in vitro cell growth and differentiation of human lin À sca + cardiac progenitor cells (hcpc) were here studied. in particular, the effects of h s-releasing agents, such as na s, gyy and water-soluble gsh-garlic conjugates (gsgaws), on the cell viability and differentiation of hcpc were here investigated by colorimetric assay, immune-fluorescence microscopy and western-blotting analysis. the treatment with slow-releasing h s donors increased the cell proliferation in a concentration dependent manner respect to the control. moreover, the treatment with gsgaws led to an up-regulation of the expression of proteins involved in the cell adhesion and differentiation processes. these preliminary results highlight on the effects of this gasotransmitter on the stem/progenitor cells and on the possibility to develop functional d-systems for cardiac tissue repair, that take into account the relevant biological role of h s in the cardiovascular system. p- . . - investigation of the protective effect of boric acid and omega- fatty acid in model of acute myocardial infarction changes in myocardial rats ischemic heart disease being the most common cause of the mortality and morbidity in worldwide commonly results from the occlusion or narrowing of the coronary arteries by atheromatous plaque and thus is named as coronary artery disease. male sprague dawley rats were used in the present study. rats were divided into groups with rats in each: control, mi, mi+boric acid, mi+omega- and mi+boric acid+omega- groups. control rats were treated with ml/day saline, boric acid-treated rats received mg/kg/day boric acid and omega- -treated rats received mg/kg/day for days by oral gavage. for the experimental mi model, mg/kg izoproterenol-hcl (iso) was administered subcutaneously two times with a -h interval in the last days of the boric acid and/or omega- treatments. twelve hours after the second dose of iso, general anesthesia was induced. under general anesthesia and spontaneous respiration, ecg recordings were obtained by using a computerized data recording and analysis system (mp , biopar) and d-ii recordings were used in the analysis. compared to the control group, serum ck-mb, bnp and tnf-a levels were higher in mi group (p < . , p < . and p < . respectively). in the heart tissue homogenate, biochemically measured calpain activation and mda were increased (p < . and p < . , respectively) and pon levels were decreased (p < . ). according to the ecg recordings, st wave and heart rate were found to be decreased (p < . and p < . , respectively). on the other hand, all above mentioned parameters were found to be improved in rats treated with boric acid and/or omega- after induction of mi. moreover, histological analysis including light microscopy and tem revealed a significant histological improvement in rats treated with boric acid and/or omega- after induction of mi. results of the present study suggest that omega- and/or boric acid treatment significantly decreases the cellular damage in mi. this is study is aimed at measuring the level of serum heart-type fatty acid binding protein (h-fabp) in patients presenting with diabetic ketoacidosis (dka) and diabetic ketosis (dk) and to determine its role in identifying early period cardiac ischemia by comparing this level with the level of a control group at a comparable age this study was planned to be a prospective study and it included patients diagnosed with dka, patients diagnosed with dk and voluntary pediatric and adolescent healthy control subjects. the h-fabp, creatine kinase-mb (ck-mb) and troponin-i levels were studied in patients with dka and dk as well as in the control group at the time of presentation. for dka patients, their h-fabp values were measured once again after acidosis correction and compared with the values they had at the time of presentation there were no differences among groups in terms of sex, age, height and weight. no statistically significant differences were found among groups with respect to troponin-i values ( . ae . , . ae . . ae . ; p = . ). no statistically significant differences were found among groups with respect to ck-mb values ( . ae . , . ae . , . ae . ; p = . ). the h-fabp values of dka patients at the time of presentation were found to be statistically significantly higher than those of dk patients and control group ( . ae . ; . ae . . ae . ; p = . ). the h-fabp value of the dka group at the time of presentation was found to be statistically significantly higher than the value at hour after acidosis correction ( . ae . ; . ae . ; p = . ) the fact that h-fabp levels were found to be high in pediatric patients diagnosed with dka at the time of presentation suggested that myocardial ischemia had been triggered. in diabetic patients, every ketoacidosis attack may lead to cardiac ischemia, thereby accelerating progress to necrosis. in conclusion, we would like to propose h-fabp as a potential marker for indicating myocardial ischemia. p- . . - genome-wide analysis of hypoxic stress response in human cardiomyocytes stress in human cardiomyocytes on a genome-wide scale remains poorly understood. this study aimed to identify the gene expression patterns of adaptive response of the human cardiomyocytes (hcm) to hypoxic stress. in vitro experimental models of hypoxia mimicking in-vivo coronary ischemia, are useful tools to identify molecular pathways involved in myocardial ischemia. in the current study, we cultured ac -hcms in dmem/f with %fbs. to simulate hypoxia model, cardiomyocytes were plated in hypoxia chamber ( %o , %co , %n ) for , , , h and the control group was incubated in normal conditions ( %co , %o ). cell viability was determined using mttassay. annexin-v assay was used to monitor apoptosis. gene expression profiling was analysed with affymetrix-hg-u -plus- arrays. following bioinformatic and statistical analyses differentially expressed genes (deg) were classified according to gene ontology using david and kegg pathway analysis tools. according to mtt, annexin-v and hif gene expression results, hypoxia time was determined as h. we identified genes ( down-regulated and up-regulated) (p < . , fold change ≥ . ) were differentially expressed in hypoxic-ac vs. ac . degs were mainly clustered in cell proliferation, regulation of cell death, cell adhesion and response to stress. furthermore, transcriptome analyses revealed that 'metabolic, cytokinecytokine receptor interaction, hif- signaling, tgf-beta, cell cycle and apoptosis' pathways were involved in the hypoxic stress response of human cardiomyocytes. this study provides molecular information regarding gene expression reprogramming of human myocardial hypoxia. the pathways identified in this study may pave the road for translational medicine. this study was supported by tub _ itak project number s . autologous ips cells after reprogrammed into endothelial progenitor cells (epcs) may offer several advantages in the treatment of cardiovascular disorders because of their cardiogenic and vasculogenic differentiation potential. to reach that purpose, we differentiated and characterized mouse ips cells into flk + , a well-recognized epc marker. further maturation of epc was characterized by the expression of cd and cd markers. purified ips cells were differentiated into flk + cells with the use of differentiation medium on type iv collagen-coated dishes in the absence of lif. we then analyzed flk gene expression and protein levels with qrt-pcr, western blot and immunocytochemical methods on days . to . . flk + cells isolated with macs system and then recultured these cells in differentiation medium with vegf to induce epc cells. following induction, cd and cd gene expression and protein levels were analyzed with genomic and proteomic methods. after isolating these cells and aggregate overnight, we cultured cells in three-dimensional condition in collagen type i and used differentiated medium including vegf and egf. we found that flk expressing cell number reached to a peak level ( %) on day . followed by a progressive decline subsequently. in the second step, cd and cd positive cells were generated and enriched during day of induction. we showed optimal time for harvesting flk + cells is day . of initial differentiation. following isolation of flk + progenitor cells they were further matured into functional epcs by vegf within days of induction. additionally for evaluation of angiogenic potantial differentiated cells, we monitored epcs behavior along vascular formation in d culture. our work demonstrates that epcs could be successfully derived from ips cells and these cells have vascular formation and angiogenic potential in d culture. epc drived ips cells play important role in the treatment of cardiovascular disease. p- . . - electrophysiological, biochemical and genotoxic effects of luna experience on heart tissue in rat model pesticides are widely used for the control of agricultural, industrial and domestic pests. however, the uncontrolled use of pesticides has diverse effects on ecological system and public health. fungicides are one of the pesticide type used to kill fungi or fungal spores. in this study, the effect of different doses of luna experience, a fungicide, on the cardiac electrophysiology and genotoxicity in rats were investigated. among five groups ( mg, mg, mg, control and positive control for comet assay) treatment groups received by gavage doses of luna experience for days. electrical activity of heart were recorded using electrophysiological recording techniques. tissue activities of paraoxanase (pon) and arylesterase (are) and level of malondialdehyde (mda) were measured using biochemical methods. comet assay was performed on heart tissue. we calculated genetic damage index (gdi) and damaged cell percent (dcp) from comet assay. it was observed that there is a significant decrease in heart rate in all treated groups as compared with control group (p < . ). amplitude of p wave and qrs complex did not change (p > . ). in all treated groups, statistically significant differences were found for values of pon, are, mda, gdi and dcp when compared to control group (p < . ). according to our results, exposure to different doses luna experience have a probable hazard potential for the cardiac system. the macrocyclic cage complexes iron (ii) clathrochelates are of the interest due to their bioactivity; they are able to inhibit t- rna polymerase, possess toxicity to leukemia cells hl- and suppress amyloid fibril formation. their binding to serum albumins was reported; the extreme binding affinity to albumins is observed for the compounds bearing carboxy groups. upon this interaction, clathrochelates quench protein intrinsic fluorescence and gain optical activity inducing circular dichroism (cd) signal in - nm region. here we examine the effect of spatial arrangement (isomery of substituents) of clathrochelates on their binding to globular proteins. we study bis-substituted clathrochelates bearing two same or different isomers (ortho-/meta-/para-) of carboxyphenylsulfid groups. their interaction with bovine (bsa) and human serum albumins, b-lactoglobulin and lysozyme are explored by cd and protein fluorescence quenching method. the binding of compounds to albumins evoked the cd bands of the same shape, but their intensities vary up to times depending on substituents isomery. in the presence of b-lactoglobulin, the intensities, shape, and positions of the induced cdbands differ for the compounds with different isomer groups. the cd bands induced by the lysozyme in the case of di-para substituted clathrochelate are shifted relatively to the bands of other isomeric compounds. the pronounced quenching of protein fluorescence by clathrochelates was observed only in the case of bsa, its intensity depends on the geometry of substituents ( - times). the different spatial arrangement (isomery) of carboxyphenylsulfid substituents in clathrochelates causes the distinctions in both their cd-signal induced by interaction with proteins and their effect on the protein fluorescence. the geometry of ribbed substituents is important for their binding to biomolecules (particularly proteins) and is suggested to determine the structure of the formed guest-host complex. d bioprinting is a new technology that revolutionized the field of tissue engineering and regenerative medicine, allowing reconstruction of living tissue and organs preferably using the patient's own cells. using a d printer we can design biological structures by controlling exact deposition of cells, growth factors and extracellular molecules in a spatially-controlled manner. the aim of this study was to evaluate the differentiation of human amniotic fluid stem cells (afsc) into endothelial progenitor cells using a bioinkÒ hydrogel photopolymerized in a d network resembling vascular tissue. characterization of afsc was performed by flow cytometry, followed by sorting of the cd + stem cell subpopulation. cd + stem cells were stained with cell tracker red cmtpx and then mixed with bioinkÒ hydrogel. printing was done using a lm diameter needle, under bar pressure, and mm/min speed. the network models with define distance apart were printed and analyzed by fluorescent microscopy. mtt test was used to evaluate the viability of the cd + stem cells. our results showed that afsc remained viable as shown by mtt assay. the fluorescent microscopy images confirm the viability biochemical test showing that the cd + cells viability is maintained after days of cultured in bioinkÒ hydrogel. furthermore, histological section of hydrogel showed that cells have a relatively uniform distribution forming network interactions between cells. flow cytometry assay showed that cd + cells expressed endothelial markers such as cd , cd , cd , cd and vegfr . in conclusion d printers are useful tools for creating three-dimensional scaffolds that mimics the cell microenvironment where different types of cells could proliferate, differentiate and crosslink with each other forming tissue-like structures. this study aims to reveal the biocompatibility, biodistribution and immunomodulatory impact on the production of inflammatory citokines of magnetite (fe o ) nanoparticles functionalized with natural compounds with proved antimicrobial and immunomodulatory effects. co-precipitation synthesized fe o were functionalized with plant-derived compounds: eucalyptol, carvone, limonene and b-pinene. characterization was done by ir, sem and hr tem, while in vitro biocompatibility was tested using endothelial human cells (fluorescence microscopy and proliferation assay). in vivo biodistribution was tested in a balbc mouse model at and days post-intraperitoneal injection, followed by experimental organ removal. tissue sections obtained from vital organs were stained with hematoxylin-eosin. production of inflammatory cytokines was assessed by elisa. results demonstrated that, at concentrations of lg/ml, all prepared nanosystems have a good biocompatibility in vitro and in vivo, allowing the development of cultured cells and also not affecting any visible behavior and organ morphology of the mice. microscopy evaluation of the organs sections revealed that nanoparticles are not present in vital organs such as brain, heart, kidney and liver, but aggregates were visible in the lungs and spleen. at days post-injection no visible aggregated were found in the lungs, few dark-brown nanoparticles clusters being visible in the red pulp of spleen. elisa results revealed that fe o functionalized with carvone and limonene significantly stimulated the production of il- , il- and il- , while reducing the production of tnfa. other nanosystems din not impact significantly on the cytokine production. functional fe o nanoparticles are efficient drug delivery shuttles, able to stabilize pharmacological compounds, such as plant-derived bioactives, and their biocompatibility, specific biodistribution and limited immunomodulatory effects recommend their use in pharmacological formulations. p- . . - new approach for cell imaging with fluorescent carbon nanoparticles m. dekaliuk, k. pyrshev, o. demchenko palladin institute of biochemistry, kiev, ukraine in the nanotechnology field, much interest was focused on the new carbon nanomaterials for cell imaging. recently discovered inorganic carbon nanoparticles ('c-dots') due to their excellent fluorescence characteristics and biocompatibility have ample opportunities for their use in imaging and functional transformations in living cells. their distinctive features, such as high brightness, small sizes, high biocompatibility, small negative charge on the surface and very easy methods of their preparation present a good alternative to other nanoscale materials. the focus of our research was to determine the possibility of using c-dots as the easily available probes for apoptotic cells detection. the carbon nanoparticles were prepared from alanine, citric acid, urea, etc by hydrothermal treatment at c. the studies were performed with adherent epithelial vero and hela cell lines (atcc). with these tools we demonstrate that both native and apoptotic cells can be easily visualized. the cdots uptake occurs probably by endocytosis, which allows for much larger their number to accumulate in apoptotic cells. using the different methods of sample preparation, they show the ability for labeling various structural compartments of the cell. for living cells there are the intracellular vesicles and lysosomes. in contrast, in fixed cells the nucleus is labeled preferentially. the fact that apoptotic cells accumulate strongly increased amount of cdots can be efficiently used in flow cytometry for characterizing the cell populations regarding the relative amount of apoptotic cells in different experimental conditions. the application of such cheap and easily accessible nanoparticles provides more opportunities to simplify the popular methods of cell labeling and detection. previously, our studies showed the possibility of using these nanoscale fluorophores for super resolution method sofi. a new electrochemical microbial biosensor for the fast detecting of dopamine and epinephrine based on candida tropicalis immobilized in a carbon paste electrode (cpe) modified with single wall carbon nanotube (swcnt) was described in this paper. the immobilized cells were used as a source of polyphenol oxidase (ppo) to develop voltammetric epinephrine and dopamine biosensor. voltammetric determination of phenolic compounds like epinephrine and dopamine is a simple technique available. direct oxidation of phenols can be used, but the oxidation potentials of this compounds are similar and they can not be detected distinctively. another possibility is the use of biosensors based on the polyphenol oxidase (tyrosinase) enzyme that oxidises the phenolic compounds into their corresponding quinones. by this way phenolic compounds that epinephrine and dopamine that used in this study were detected at the different potential. the effect of varying the amounts of swcnt and microorganism on the response to epinephrine was investigated to find the optimum composition of the sensor. the effects of ph and temperature were also examined. increases in biosensor responses were linearly related to dopamine concentrations between . and . mm and epinephrine concentrations between . and . mm. limits of detection of the biosensor for dopamine and epinephrine were calculated to be . and . mm, respectively. finally, proposed systems were applied to epinephrine and dopamine analysis in pharmaceutical drugs. objective: it has started a long time ago to search for a material that can replace blood. this material does not require special storage conditions, independently of the recipient's blood group and can be applied to all individual. milk, casein derivatives, starch, saline and ringer were used for this aim in the past. the determination of toxic effect of natural hemoglobin (hb) on human, researchers have focused on development modified blood. in this work, the development of an artificial biomaterial alternative of blood for using as preoperative and operative aims was aimed. material and methods: in our study, ultrapure hb molecules are immobilized on triethanolamine coated magnetic nanoparticles using various techniques. prepared nanoparticles were characterized by ft-ir, ctem, xrd and cyclic voltammetry (cv). the cytotoxic effects of artificial blood were tried on mtt cell proliferation. results: the characteristic peaks of hemoglobin were obtained from ft-ir spectra differently from support. particles size is concluded by using debye-scherrer equation as > nm from xrd spectra. sem and ctem images supported xrd result. cv results showed that hb molecule has À . v cathodic potential against ag / agcl standard electrode. significant differences were not observed in the mtt results (p < . ). conclusion: the nanoparticles were obtained in accordance with the intended desired method. it is determined that the hemoglobin molecules give the same potential with natural blood even after weeks of immobilization and carrying oxygen as natural blood. there are statistical differences between results of mtt tests due to used concentration. but, it is considered that decantation advantage of the artificial blood minimized cytotoxic effects. proteoglycans are among the most abundant molecules of the inter-cellular structure and they are present in extracellular matrices of connective tissues. these glycosylated proteins contain one or more (gag) chains that are covalently attached to the core protein and their hydrodynamic function is mainly due to the physicochemical characteristics of this gag component which provides hydration and swelling pressure to the tissue. gag levels excreted via urine are used as a marker to monitor different diseases (chronic renal disease, renal fibrosis, glomerular filtration abnormalities, bladder stones, breast and lung cancers, hypertension and diabetes, etc.) besides the well known mucopolysaccharidoses. however, their detection by using chromatographic methods is hard, because of the high polarity of negative charges and different functional groups such as acetyl sulfates that generate microheterogenity. in this study, we developed molecularly imprinted chromatographic hplc columns for specific heparan sulfate (hsa), chondroitin sulfate (cs) and dermatan sulfate (ds) detection in urine. positively charged acrylamide monomers were first polymerized by precipitation polymerization, to produce polymers which will show specific recognition for gag's via electrostatic interactions and hydrogen bond formation. these gag selective polymers were then filled in the steel hplc columns and columns eluents were chemically degraded. degradation products of gag's were examined offline column coupled with tandem mass spectrometry. the results showed that our imprinted columns separated gag's specifically and sensitively. thus, urine gag's can be specifically determined by using a gag specific molecularly imprinted column. in this study internal standart weren't used because the matrix effect was lower than % for each urine samples. %cv of ds, cs and hsa was calculated as; supported lipid bilayers (slb) were started to be used for cell culture studies to focus on cell adhesion, cell signaling etc. testing the stability of slbs is essential to utilize them as cell culture platforms. in this study, the stability of phosphatidylcholine (pc) lipid bilayers on glass was investigated under milli-q water, phosphate buffer saline (pbs) and dulbecco's modified eagle medium culture (dme) medium supplemented with/without serum. the stability was also checked by enriching slb with different lipids. pc-liposomes were prepared by hydrating the dried thin lipid film with pbs and then by extruding the suspension through a polycarbonate membrane. a negatively charged phospholipid, phosphatidylserine (ps, %); a positively charged phospholipid, dotap ( %) and cholesterol ( %) were also used for liposome preparation. liposomes were fluorescently labelled and series of slb imaging were taken for a week. in all experiments in milli-q water and pbs, the stability was conserved for days. pc bilayers in medium supplemented with serum showed hole formations on the second day and their number and size increased rapidly in time. when the bilayers were prepared in medium without serum, disruption was lowered but not completely removed as a result of other factors in medium. cholesterol providing an increased rigidity to the membrane caused higher stability. positively charged bilayer structures also showed increased stability. this can be explained by decreased mobility of bilayer as a result of electrostatic interaction between positively charged molecules and negatively charged glass surfaces. decreased mobility decreases the interactions within the medium. lastly, negatively charged bilayers did not show high stability. strong repulsive forces between the negatively charged surface and bilayer probably prevented the integrity of the bilayer and increased the deformation. in recent years the use of biopolymers has gained priority in tissue engineering and biotechnology, both as dressing material and for enhancing treatment efficiency. there is a demand for new biopolymers designed with protease inhibitors and antimicrobials. ll- is an important antimicrobial peptide in human skin and exhibits a broad spectrum of antimicrobial activity against bacteria, fungi, and viral pathogens. using lignin which is an abundant carbohydrate polymer in nature and a polyacrylic acid, we prepared a polymer film by plastifying caprolactone and polyacyrlic acid. films were actified to immobilize ll- . the structure was elucidated in terms of its functional groups by fourier transform infrared spectroscopy (ftir), and the morphology of the film was characterized by scanning electron microscopy (sem) before and after the immobilization process. the amount of ll- immobilized was determined by elisa method. . % of ll- peptide was successfully immobilized onto the films. antimicrobial activity was determined in the film samples by quantitative antimicrobial activity method. according to the results, ll- immobilized film samples were effective on test organisms; gram-positive staphylococcus aureus and gram-negative escherichia coli. in bio-compatibility assays, the ability to support tissue cell integration was detected by using t mouse fibroblasts. samples were examined under transverse microscope, non-immobilized sample showed a huge cellular death, whereas ll- immobilized film had identical cellular growth with the control group. this dual functional film with enhanced antibacterial properties and increased tissue cell compatibility may be used to design new materials for various types of biological applications. p- . . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in vitro modulation of the cross-talk between macrophages and osteoblasts by titania nanotube-modified ti surfaces p. neacsu, a. mazare, p. schmuki, a. cimpean bone remodeling is a dynamic process that maintains a fine balance between bone formation and resorption, and is highly influenced by the inflammatory state of the local microenvironment. therefore, a proper modulation in the cellular interactions and cytokine expression is a promising approach to achieve enhanced bone healing. as the biomaterials surface has a major impact on cellular behavior, the goal of the current study was to investigate the influence of tio nanotube-modified ti surfaces (ti/tio ) on the cross-talk between raw . macrophages (mf) and mc t -e preosteoblasts (ob) in mono-and co-culture systems in comparison with flat ti (cpti). raw . and mc t -e cells were seeded on the test surfaces and grown in standard culture conditions for various periods of time. for co-culture studies, the cells were cultivated using a transwell system. inflammatory mediators released by raw . cells were measured using elisa technique, while the ob capacity to produce calcified bone matrix was evaluated by alizarin red staining. in co-cultures, lps-stimulated tnf-a, il- and mcp- release was significantly increased at h, while after days only il- exhibited higher amounts when compared with mf cultures alone. moreover, the secretion of these mediators by cells exposed to ti/tio was diminished, especially in lps evoked conditions. also, alizarin red staining demonstrated the presence of calcium deposits when ob were co-cultured with mf for h and days, whereas the presence of the mf for weeks significantly inhibited mineralization. on ti/tio surface elevated calcified matrix was observed, as compared with cpti. this study reveals that the overall effect of inflammation suppression induced by ti/tio may contribute to the enhanced mineralization. also, chronic inflammation may inhibit or delay the regeneration process. therefore, an adequate modulation of mf and ob interactions is vital for the biomaterials success in stimulating bone regeneration. p- . . - synthesis and characterization of the branched magnetic polymer for drug delivery systems t. tarhan , , b. tural , s. tural mardin artuklu university, mardin, turkey, dicle university, diyarbakir, turkey magnetic nanoparticles (mnp) have gained a lot of attention in biomedical and industrial applications due to their biocompatibility, easy of surface modification and magnetic properties. magnetic nanoparticles can be utilized in versatile ways, very similar to those of nanoparticles in general. however, the magnetic properties of these particles add a new dimension where they can be manipulated upon application of an external magnetic field. this property opens up new applications where drugs that are attached to a magnetic particle to be targeted in the body using a magnetic field. often, targeting is achieved by attaching a molecule that recognizes another molecule that is specific to the desired target area. in recent years, the development of the systems in which drug is delivered magnetically to the target is drawing considerable attention since it is a current issue. it is possible to eliminate the most of the problems caused by high doses of chemotherapy by using the magnetic drug delivery systems. therefore, it is important to design delivery systems with high drug loading capacity. it is necessary to increase the number of reactive groups on the surface of nanoparticles in order to increase drug loading capacity. in this study, we synthesized a novel magnetic surface for drug delivery systems. magnetic dextran-nta (md-nta) was synthesized by using magnetic o-carboxymethyl dextran (ocmd) and nana-bis (carboxymethyl) -l-lysine hydrate (nta) in order to increase the number of reactive carboxyl groups on the surface of biocompatible and biodegradable magnetic dextran. magnetic material (md-nta) which was prepared and characterized by the analysis of transmission electron microscopy (tem), scanning electron microscope (sem), vibrating sample magnetometer (vsm), fourier transform infrared spectroscopy (ftir) and x-ray photoelectron spectroscopy (xps). there are three subtypes of the tgf-b protein that has been reported to be involved in tissue repair process; scar tissue formation has been reported on tissues that has been affected by tgf-b and due to high collagen synthesis. on the other hand the other isoform tgf-b , suppresses the dense collagen production caused by tgf-b and prevents the scar formation. to be able to use these growth factors local or iv route, new drug transport systems are needed to protect the bioactivity during the treatment and controlled release. for this purpose poly(lactic-co-glycolic) acid polymer which is widely used in controlled release systems was chosen as the matrix material. aim of the project was to design, formulate, prepare and optimize tgf-b loaded plga nanoparticular and/or plga polymeric film drug delivery systems and to test their effect on cell proliferation. tgf-b loaded nanoparticles was prepared with emulsion-solvent evaporation method; whereas polymeric film systems was prepared with film castingsolvent evaporation method. following the preparation tgf-b loaded drug delivery systems was characterized. quantification and in vitro release of the growth factor tgf-b was studied with elisa. hepg cell line was used on mtt cell proliferation assay for both tgf-b loaded nanoparticles and films on a time course study. nanoparticles and films were prepared and loading efficiency of the nanoparticles were found to be . %. particle size, zeta index and polydispersity index for this formulation were determined as . ae . nm, . mw and . , respectively. thickness of the prepared films were ae . nm. additionaly prepared nanoparticles and films were found non-toxic. tgf-b nanoparticles and films which were prepared in this study are planned to be used as an effective treatment strategy for wound healing after injury. this project was supported by grand s from the scientific and technological research council of turkey (tubitak). polyvinylpyrrolidone (pvp) is a biodegradable material and natural polymeric biomaterial in such studies. ganoderma lucidum is a natural material containing triterpenes, polysaccharides, adenosine, polypeptides, and amino acids. these constituents have been shown to exhibit anti-cancer properties, enhance and regulate immunity, resist oxidation and ageing, and promote metabolism and cell proliferation. composites of polyvinylpyrrolidone (pvp) have been prepared by solution intercalation method using ganoderma lucidum at different loading amounts. the characterization of pvp/ ganoderma lucidum composites was made by x-ray diffraction (xrd) and scanning electron microscopy (sem); the interactions between ganoderma lucidum and pvp was determined by ftir-atr; the thermal stability was determined by simultaneous tg/dta. hemocompatibility of the prepared composite samples were investigated by a -well plate spectrophotometer. in addition, contact angles and antimicrobial activity of biomaterials were also determined. ftir-atr confirms interactions formed between ganoderma lucidum and pvp. xrd and sem results give evidence that ganoderma lucidum was well dispersed and homogenously in the pvp matrix. thermogravimetric analysis indicated that introduction of clay to the polymer network resulted in an increase in thermal stability. the results of in vitro hemocompatibility test were showed that pvp/ ganoderma lucidum composites are used as biomaterial. the development of synthetic materials, textured polymers and metals and their increasing use in medicine make research of biomaterials' hemocompatibility very relevant. composite material is a multi-phase system consisted of matrix material and reinforcing material. matrix material is a continuous phase and reinforcing material is a dispersed phase. the main two bioactive components of ganoderma lucidum can be broadly grouped into triterpenes and polysaccharides. despite triterpenes and polysaccharides being widely known as the major active ingredients at anti-cancer effect. this study describes the synthesis and characterisation of biocomposites of different molecular weight of peg (polyethylene glycol) as matrix with ganoderma lucidum as a filling material at different loading (% , % . , % wt). the composites have been prepared by solution intercalation method using ground and sieved ganoderma lucidum at micron scale. the characterization of composites was made by x-ray diffraction (xrd), scanning electron microscopy (sem) and fourier transform infrared attenuated total reflectance (ftir-atr) also in this study the hemocompatibility and antibactarial properties of composite investigated. when xrd and ftir-atr results discussed, all of the composites using the different loading amunt of ganoderma lucidum (% , % . and % wt) were shown a homogen distribution in the matrix (peg). and an interaction have occured between matrix and filling material. the sem photos have confirmed these results. peg and composites have been detected as hemocompatible. these results showed that they can be used as biomaterials. p- . . - evaluation of the genotoxic potential of some nanocomposites by comet assay b. yilmaz , s. dogan , s. celikler kasimogullari department of molecular biology and genetics, balikesir university, balikesir, turkey, department of biology, uludag university, bursa, turkey due to its similar nature to the bone, nanohydroxyapatite is a biocompatible particle and poly(methyl methacrylate) (pmma) is a polymer that has been used in dentistry and orthopedic applications for years. in this study, genotoxic potential of pmma/nanohydroxyapatite nanocomposite films composed of polymers having different molecular weights and nanohydroxyapatite fillers in different concentrations ( , . and %) were investigated by comet assay which is a kind of gel electrophoresis that can be used to measure dna damage in individual cells. if the dna is damaged we expect broken ends to migrate apart from the head. at the end of the assay performed after incubation with lymphocytes of healthy humans, we measured the dna damage index (ddi) and percentage of damaged cells (pdc). in addition, to prove the morphological properties of the nanocomposites scanning electron microscope was used and an interaction between the matrix and nanoparticles with a homogeneous dispersion was observed. protein adsorption on stimuli-responsive mixed pdmaema/peo polymer brushes a. bratek-skicki , , c. dupont-gillain universit e catholique de louvain, louvain-la-neuve, belgium, j. haber institute of catalysis and surface chemistry, polish academy of sciences, krakow, poland smart polymer brushes are made of macromolecules that are sensitive to stimuli from the external environment, including ph, ionic strength, temperature, etc. when stimuli-responsive polymer brushes are introduced onto material surfaces, their properties can be adjusted by tuning the environmental stimuli. these brushes can find promising applications across many areas of research, including surface science, nanotechnology, and biotechnology. in our work, the adsorption of human serum albumin (hsa, molecular weight of . kda, isoelectric point ip at ph . ) and lysozyme (lys, molecular weight of . kda, ip~ ) was studied on polymer brushes composed of poly(ethylene oxide) (peo) and poly ( -(dimethylamine) ethyl methacrylate) (pdmaema). peo is a protein-repellent polymer and pdmaema is a polyelectrolyte bearing a variable density of positive charges depending on ph. a gold substrate was modified by these thiolated polymers according to the 'grafting to' method. the obtained polymer brushes were characterized by xray photoelectron spectroscopy, static contact angle measurements and atomic force microscopy. polymer brush formation and protein adsorption were monitored by quartz crystal microbalance. surface characterization of the mixed brushes revealed the presence of both polymers at the surface. conformational changes of pdmaema/peo brushes were experimentally evidenced, and the results indicated that the brushes collapse at ph . (pdmaema is neutral in such conditions) and were swollen at ph . (pdmaema is positively charged). protein adsorption was performed at different ph values ( . - . ) and salt concentrations ( . - . m). it was shown that pdmaema has a high affinity to hsa at ph above its isoelectric point. however, the adsorption of positively charged lysozyme in a wide range of ph was not observed. these results indicate that pdmaema/peo brushes are promising candidates for selective adsorption from a mixture of proteins. clay-polymer nanocomposites (cpn) developed in recent years as a new type of inorganic-organic hybrid materials that were conceived for medical uses such as tissue engineering or drug delivery [ ] , [ ] . the understanding of the structure and physico-chemical properties of cpn is a first step in the investigation of biomaterials, but their potential in this respect is determined by their interaction with living tissue components. in this study, pure kaolinite was intercalated with dimethyl sulfoxide (dmso) and then intercalated kaolinite was modified pyridine, -amino pyridine and , -diamino pyridine to expand the interlayer basal spacing. modified kaolinite samples as filler and poly(vinyl chloride) (pvc) polymer as matrix were used in the nanocomposite synthesis. nanocomposites of pvc have been prepared by solvent blending method using thf as a solvent. the material characterizations were carried out by xrd, afm, ftir-atr, dta/tg and dsc. the xrd results reveal the formation of intercalation/exfoliation of modified kaolinite in the pvc matrix. ftir and afm results confirm the presence of nanomaterial in kaolinite/pvc nanocomposites. tga data show that the modified kaolinit/pvc nanocomposites have significant enhanced thermal stability. the glass transition temperature (tg) of pvc nanocomposites is higher than that of pure pvc. in addition, the antimicrobial activity of clay-polymer composites were also determined. introduction: polyhydroxyalkanoates (phas) are biocompatible and biodegradable materials obtained from microorganisms. they are produced in the cytoplasm of several bacteria as energy reserve. the physical properties of poly( -hydroxybutyrate) (phb), which is from the group of phas, make it a competitive source to petrochemical plastics. phb has potential in order to be used in a variety of application fields such as packaging industry, printing materials, agriculture and food industry. furthermore, phb meets expectations for tissue engineering applications, since it is biocompatible, biodegradable, non-toxic and has good mechanical properties. although its many advantages, blending approach could be needed in order to fulfill all expectations of a material. due to its flexibility, polycaprolactone (pcl) is a promising candidate to be blended with phb. the aim of this study is to construct a scaffold by using phb produced by extreme alkaliphilic b. marmarensis gmbe t (dsm ) and commercial pcl as components and investigate its properties. materials and methods: electrospinning method was used in order to construct scaffolds from blend polymer solution containing phb from b. marmarensis and commercial pcl. results: nanofiber structures were observed on scanning electron microscope (sem) images and fourier transform infrared resonance (ftir) analyses have shown characteristic peaks for both phb and pcl. discussion and conclusion: phb could be blended with other polymers in order to enrich its properties. in addition, nanofiber structure of electrospun phb-pcl blend makes it a rewarding material as scaffold for several tissue engineering applications. q fever is a zoonotic disease that is encountered widely around the world, the most common acute form of q fever shows the following symptoms; a sudden fever, shivering, lassitude, headache, anorexia. because this disease does not show specific symptoms its diagnosis is possible with laboratory tests. current diagnostic kits lack effectiveness; this is why the main goal of our studies is to come up with a new diagnostic kit that does not have disadvantages that current diagnostic kits show. with this goal, nine mile i strain (rsa ), s serologic virulent phase i, were obtained from slovak science academy, virology institute for rickettsia reference and research from who co-operation centre. these cells were purified and lipopolysaccharide (lps) isolation from coxiella burnetii was performed. the polymeric carrier, poly (n-vinyl- -pyrrolidone-co-acrylic acid) [p(vp-co-aa)] was synthesized and characterized. physical complexes of obtained lps and p(vp-co-aa) with varying ratios. ternary complexes of lps-cu + -p(vp-co-aa) were also synthesized with copper metal mediation. structure and interaction of lipopolysaccharide-p(vp-co-aa) complexes were investigated with zeta-sizer device using zeta potential analysis and ftir spectrophotometry according to the ratios of components, reaction environment conditions and chemical structure of the polymer. the best complex ratio according to analysis results will be used in the future studies for obtaining monoclonal antibodies which will be an important step for obtaining more effective and stable diagnostic kits that can be used for q fever. this in this study; new types of water soluble polymer-biomolecule conjugates were synthesized using covalent bonding techniques between polymers and co-polymers (varying monomers of polyacrylic acid and acrylic acid) with peptides. different compositions of polymers, varying ratios of biomolecule/polymer and different molecular weight of polymer has yielded new types of bioconjugates. conjugation mechanism, composition and structure were investigated with various physicochemical methods (uv, ftir, hplc, gpc, etc.). the peptide used in this study was the antigenic peptide epitope of sheep-goat pox disease (eakssiakhfslwksyadadiknsenk). whether this peptide series was bound to polymers or whether it was bound to polymer-protein carrier; peptide-specific immunogens that were capable of producing antibodies were synthesised. it is thought that using polymer-peptide bioconjugates that contain just peptide will yield a higher peptide-specific immunogenicity compared to traditional adjuvants. in vitro and in vivo investigations of bioconjugates effectivity is planned to be done in the future studies. p- . . - bioinert fluorinated ethylene-propylene copolymer modified for keratinocyte adhesion surface properties are crucial when adhesion of a cell to a polymeric material is required for a biomedical application. one of the methods for polymer surface tailoring is argon plasma treatment. this simple and reproducible method alters the surface properties such as roughness and wettability without affecting the bulk properties of the material. for the modification of the bioinert fluorinated ethylene-propylene (fep), related to teflonÒ, we employed argon plasma treatment with the powers of and w for - s. the human keratinocytes of the hacat cell line served as a model cell line for biocompatibility testing. we studied adhesion, proliferation and morphology of the cells on modified fep matrices as well as controls (pristine fep and standard polystyrene tissue culture dish) by means of fluorescence microscopy. further morphological details were acquired by scanning electron microscopy. furthermore, fluorescence microscopy with immunochemical labelling was used to determine the size and distribution of focal adhesions in cells grown on the modified matrices. the overall effect of the matrices on metabolic activity of cultured hacat cells was also evaluated using the wst- reagent. the ar plasma treatment of fep matrices improved significantly cell adhesion and proliferation and promoted spreading of the hacat cells compared to the pristine fep, on which cells were not able to spread properly. also, increased metabolic activity rates for cells cultured on modified matrices were found in comparison to the pristine fep. altogether, we found that ar plasma treatment improved the surface properties of fep to such extent, that it allows cultivation of adherent cells on its surface. we therefore propose that ar plasma treatment is a useful method for fep surface modification. p- . . - graphene oxide enriched biomaterials display potential for tissue engineering applications tissue engineering (te) requires more efficient systems that favor local tissue regeneration with minimum cytotoxicity. materials based on natural compounds ensure biocompatibility and have better effects for regeneration. graphene oxide (go) has been shown to enhance cell adhesion and to improve the rate of cell differentiation. in this context, the aim of this study was to evaluate if the addition of different concentrations ( . - wt.%) of graphene oxide (go) improves the properties of cellulose acetate (ca) materials for biocompatibility and cell differentiation, in the prospective of using these films for te applications. go-containing ca films were tested for cytocompatibility by quantitative and fluorescence microscopy assays, and compared to the ca control. cell cytoskeleton architecture in contact with biomaterials was revealed by confocal microscopy. furthermore, bioconstructs were exposed to in vitro osteogenic and adipogenic induction and monitored for days. histological stainings were performed to validate differentiation. osteogenic and adipogenic markers gene expressions were assessed via qpcr. ca/go wt.% revealed best biocompatibility among all tested scaffolds. adhesion proved to be dependent on the percentage of go in material's composition. cells cultivated on ca/ go wt.% expressed adipogenic and osteogenic markers earlier than cells cultivated on materials with lower go content. differentiation markers displayed an increasing profile of gene expression from to days post induction, with higher levels registered for materials with high go content as compared to films with low go content and to the control. go added to ca materials positively influenced cell survival, proliferation and cell differentiation. ca/go films represent potential candidates for te applications. the design of appropriate scaffolds remains one of the most important challenges for te. current idea is that the cell-scaffold interaction could drive cell differentiation and be linked to gene expression and protein organization. therefore, their quality is essential and should favour cell attachment, growth, migration, in situ vascularization and release of biochemical and physical factors able to address the cell fate. moreover, for an ideal scaffolding material an adequate and interconnected porosity is relevant for facilitating cell spreading and colonization of the inner layers. a combination of optimal mechanical and biochemical properties were here utilized to design a d composite hydrogel scaffold ( d-chs) in order to favour cell-scaffold interactions and promote a functional differentiation of human lin À sca + cardiac progenitor cells (hcpc). the biocompatible peg-diacrylate (pegda) was used to prepare hybrid protein-pegda hydrogels with embedded albumin-microspheres (ms) as protein component. ms were able to modulate the mechanical and biological behavior of the scaffold acting as air-reservoir, porogen agents and potential carriers of biomolecules. an increase of the hcpc viability in the ms-concentration dependent manner was observed. moreover, the microarchitecture of the d scaffold also plays a key role in the stability and functionality of cellularcomposite systems. therefore, pegda-honeycomb structures were fabricated using microstereolithography process and the hcpc viability and adhesion to the microstructures were assessed. d-chss were synthesized embedding honeycombstructures into ms-pegda hydrogel and the effects on cell proliferation, cell-cell interactions and cellular alignment were investigated. these results could be of relevant interest for expanding the knowledge on cell-scaffold interaction processes and to promote the development and the application of d-chs for tissue regeneration using the emerging bioprinting technologies p- . . - gene expressions of mesenchymal stem cells after osteogenic induction on ceraform bone substitute a. kilic s€ uloglu, e. karacaoglu, h. akel, c ß . karaaslan hacettepe university, ankara, turkey ceraformÒ, is a synthetic calcium phosphate ceramic with the chemical composition of hydroxyapatite % and tricalcium phosphate %, with - % pore volume and - lm pore diameter. in this study adipose tissue derived mesenchymal stem cells were differentiated into osteoblast cells and loaded on cer-aformÒ. in order to improve cell adherence, ceraformÒ was covered with fibronectin. the cells were cultivated for -day period by osteogenic induction medium. days , , , and were selected as specific intervals for incubations. total rna was isolated and cdna was synthesized. differences in the expression of runt-related transcription factor (runx ), bone morphogenetic protein- (bmp- ), and osteocalcin (ocn) were determined by qpcr. the peptidylprolyl isomerase a (ppia) gene was used as an internal control. according to the qpcr results, ocn gene expression was observed on the day th, continued to increase in day . bmp- gene expression was increased in , , day compared to day. on the other hand, runx gene expression was increased only on days and . these findings pointed out that the osteogenic induction was successfully activated on fn coated bone material. therefore, these results can be used in bone injury treatment and related disorders. p- . . - on the in vitro cytotoxicity of graphene oxide nanomaterials v. grumezescu , i. negut , f. sima , e. axente , l. e. sima national institute for lasers, plasma and radiation physics, magurele, romania, institute of biochemistry, romanian academy, bucharest, romania during the last decade, graphene and its derivates have proven unique physicochemical properties, several applications being continuously developed. among them, electronic, catalytic, mechanical, optical, and magnetic properties have attracted huge interests. however, the merging of graphene and graphene oxide (go) with biotechnology is still in its infancy, many challenges remaining unexplored. potential applications are related to biosensors, drug delivery or gene therapy and cells imaging. in order to use gos as drug release matrices for cancer cells targeting, it is necessary to ensure that these molecules do not affect normal cells within tissues. it was shown that the cytotoxicity of graphene nanomaterials is highly dependent on surface functionalization. studies suggest that pristine and reduced go with fewer surface functional groups tend to be more toxic than go. in striking contrast, it has been reported that functionalized graphenes, can significantly reduce the cytotoxicity even at relatively high concentrations. in this study, we report on the comparison between go and protein functionalized go when submitted to in vitro cytotoxicity tests. bovine serum albumin (bsa) was used for the noncovalent go surface conjugation. three case-studies were investigated: aqueous nano-colloids consisting of serial dilutions of both go and go-bsa conjugates, dropcasted thin films and laser-assembled thin films on glass substrates. safe concentration windows were identified by live/dead staining and mts assays for different human melanoma cell lines, while melanocytes and human dermal fibroblasts were used as normality controls. the predominant melanoma subtype is represented by cells bearing braf (v e) activating mutation. with a view to target this specific melanoma subpopulation, we embedded braf inhibitors into go laser-deposited scaffolds and tested their anti-tumoral effect. our results evidence the high potential of these nanomaterials for biomedical applications. osteoporosis is a skeletal disorder associated with low bone mass and increase in bone fragility due to increased osteoclastic activity. binding of rank ligand to its receptor on osteoclast precursor cells results in the osteoclast differentiation. sirna is a dsrna, used to inhibit the translation of the target gene. the aim of the study is to develop an injectable sirna-delivery system targeted to the bone for osteoporosis treatment. pei (polyethyleneimine) and rank complex was loaded into poly(lactic acid-co-glycolic acid) (plga) nanocapsules which are bound to hydroxyapatite (hap)-specific elastin-like protein (elp) for targeting to bone tissue. plga nanocapsules were prepared by w/o/w double emulsion technique. affinity of elp to hap was determined by ftir. elp was coated on the nanocapsules by using the transition temperature of elp. elp on plga nanocapsules were crosslinked by genipin and binding of elp on plga nanocapsules were studied by xps and tem. the optimum ratio of n (pei) to p (sirna) in the complexes to be loaded into plga nanocapsules were studied by etbr staining and zeta potential measurements with varying n/p ratios and finally pei-dnaoligo encapsulation efficiency of the capsules was determined by picogreen reagent. xps results of elp treated plga (elp-plga) nanoparticles indicated the presence of nitrogen atom ( . %) in the sample which appeared as a fuzzy halo in tem micrographs. n/p ratios up to show negatively charged particles. when n/p was , the zeta potential of complex was neutralized which also resulted in larger particles compared to the others. zeta potential moved to positive values when n/p was higher than . the migration of polyplexes with different n/p ratios ( - ) was analyzed by gel electrophoresis. dnaoligo complexes show the same patterns of complexation wih that of sirna and thus were used in the encapsulation efficiency studies instead of sirna. the encapsulation efficiency of pei-dnaoligo in plga nanocapsules was %. tuesday september : - : aging p- . . - novel benzenesulfonamides exhibit low toxicity on zebrafish embryonic development and selectively inhibit carbonic anhydrase ix with nanomolar affinity in xenopus oocytes introduction: the toxic effects of two recently discovered inhibitors (vd - and vd - - ) that selectively and with extraordinary strong, picomolar affinity bind to human carbonic anhydrase (ca) ix, an anticancer target, were investigated on zebrafish embryonic development and in xenopus laevis oocytes. zebrafish has emerged as a promising animal model to evaluate the toxicity of the drug candidates. xenopus oocytes do not natively possess any ca activity and thus became a convenient in vivo model system to study the ph effects and the selectivity of synthetic ca inhibitors. materials and methods: morphological changes in zebrafish treated with the compounds were studied by light-field microscopy and histological analysis. ca activity in xenopus oocytes was monitored by measuring ph in the cytosol and at the outer membrane surface and confirmed by mass spectrometry of lysed oocytes. the toxicity studies showed lc values to be lm for vd - , lm for vd - - and lm for ethoxzolamide (eza), a non-selective ca inhibitor commonly used in clinic. the zebrafish exposed to lc doses of vd - and vd - - showed fewer phenotypic abnormalities and less morphological changes compared to the zebrafish treated with the corresponding dose of eza. vd - - exhibited - nm ic for both intracellularly and extracellularly expressed ca ix in xenopus oocytes while exhibiting strong selectivity over ca ii, ca iv and ca xii. discussion: interestingly, the compounds exhibited -fold lower toxicity, induced fewer side effects in zebrafish than eza and the amount of vd - - needed to cause complete inhibition of ca ix enzymatic activity in xenopus oocytes was -fold lower than eza. conclusions: vd compounds did not lead to deleterious effects on the zebrafish embryonic development and reached the ic of nm for ca ix in xenopus oocytes. the compounds could be further developed as anticancer drugs. cacybp/sip is present in various cells and tissues, both normal and pathological. in normal tissues, e.g. stomach or colon, cacybp/sip is weakly or barely detected whereas in gastric or colon cancer this protein is expressed at a high level. there are also data indicating that the level of cacybp/sip expression correlates with tumor metastatic potency and multidrug resistance. taking into consideration data that suggest association of cacybp/sip with many vital cellular processes, in this work we decided to investigate the possible mechanism involved in regulation of cacybp/sip gene expression, mainly by transcription factors and, on the other hand, the influence of cacybp/sip on the expression of other genes. we have shown that nfat (nuclear factor of activated t cells) influences the cacybp/sip gene expression and that overexpression of cacybp/sip has an effect on the level of ap- and on the activity of nfat and ap- transcription factors. by analyzing the cacybp/sip gene promoter sequence we also found potential binding sites for transcription factors from the stat family, which are involved in interferon signaling. microarray data indicate that indeed overexpression of cacybp/sip affects levels of the stat proteins as well as of some interferons and interleukins. based on functional analysis we have found many genes the products of which are involved in immune response. to analyze in more detail the influence of an altered level of cacybp/sip on interferon signaling pathways as well as on factors involved in expression of interleukins, including nfkappab, we plan to apply methods such as luciferase assay, real-time pcr or immunocytochemistry. one of the pathological hallmarks of alzheimer's disease (ad) is the neuritic plaques occurred as a result of the extracellular accumulation of aß peptides formed from amyloid precursor protein (app) via the ß-amyloidogenic pathway. aß is more prone to aggregation to form plaques and more toxic to neurons than aß . in addition to change in app metabolism, the decline in levels of neurotransmitter acetylcholine and cholinergic dysfunction are also observed in ad. thus, current strategies for ad treatment focus on compounds with inhibitory effect on cholinesterases as well as preventive effect on aß aggregation. in our earlier studies, toluidine blue o (tbo), a phenothiazine dye, was shown to be a highly effective inhibitor of cholinesterases with k i values in nm range. we also found that intracellular app and aß levels are reduced in human neuroblastoma cells after treatment with tbo. additionally, an earlier study revealed that tbo has a selective inhibitory effect on tau aggregation, the other pathological characteristic of ad. the aim of this study was to investigate whether tbo may effectively lower the level of extracellular aß / in an ad-like cellular model. chinese hamster ovary cells that express human wild type app and presenilin , namely ps , were treated with a dose range of tbo ( - lm) or vehicle control for h. after treatment, aß / levels in cell culture media were assayed by separate sandwich-based elisas and normalized to total protein levels, determined by bca protein assay. besides, biocompatibility of tbo was evaluated in the ps cells using cell viability assay for flow cytometry. strikingly, all dose ranges of tbo inhibited both aß and aß secreted into the cell culture media. significant reduction for both aß species was evident at lm (p < . ), lm (p < . ), and lm (p < . ) of tbo vs. vehicle control. in conclusion, these results support the idea that tbo may be used as a therapeutic in ad. monitoring the changes of key molecules participating in the osmo-regulatory response of nucleus pulposus intervertebral disc cells during stress-induced senescence e. mavrogonatou, d. kletsas ncsr 'demokritos', athens, greece introduction: intervertebral disc cells are faced with a harsh extracellular milieu characterized by hyperosmotic conditions, nutrient and oxygen deficiency because of the absence of vascularization and oxidative stress due to the accumulation of their metabolism's by-products. we have previously shown that high osmolality is anti-proliferative for disc cells through the activation of the g and g cell cycle checkpoints by p and p mapk, respectively. in addition, we have shown the participation of nine solute transporters, with the a subunit of na + /k + -atpase being central in this response. here we assessed the changes in the expression of these key osmo-regulatory molecules during in vitro stress-induced senescence. materials and methods: changes in cell cycle progression were assessed using flow cytometry; overall transcriptional alterations were assessed by whole-genome arrays; differences in expression at the mrna and protein level were revealed by quantitative rt-pcr and western blotting, respectively; knocking-down of selected proteins was performed by sirna. results: high osmolality led to the differential expression of > genes, including nine genes encoding transporters. p mapk and p were demonstrated to differently participate in the regulation of the aforementioned transporters, while knocking-down of three selected transporters had a distinct outcome on the overall cellular response towards hyperosmotic stress. these molecules were found to show differences in their expression in senescent cells. discussion: given that the presence of senescent cells has been demonstrated in the intervertebral disc in vivo and could most probably attributed to the prevailing stressful conditions, here we showed differences in the expression profile of known key molecules for osmo-adaptation during senescence. conclusion: understanding disc cells' physiology is of outmost importance when designing cell-based therapies for disc degenerative disorders. p- . . - smad specific e ubiquitin protein ligase (smurf ) and its potential effects on inhibitory transmission in aging adams , , , interdisciplinary program in neuroscience, bilkent university, ankara, turkey, national nanotechnology research center (unam), bilkent university, ankara, turkey, department of molecular biology and genetics, bilkent university, ankara, turkey, molecular biology and genetics zebrafish facility, bilkent university, ankara, turkey, department of psychology, bilkent university, ankara, turkey smad specific e ubiquitin protein ligase (smurf ) is part of the tgf-b signaling pathway associated with cellular proliferation, differentiation, genomic stability and senescence. moreover, smurf , via its downstream partners, may regulate inhibitory synaptic transmission. our research group previously found that the smurf transcript is significantly higher in old zebrafish brains. thus, smurf may alter inhibitory synaptic transmission in aged animals. the focus of this study was to examine age-related changes in smurf protein levels and related key inhibitory synaptic proteins; gephyrin (gep), a scaffolding protein for gaba receptors, and gaba a , an ionotropic gaba receptor subtype. additionally, the levels of those proteins were studied in a mutant zebrafish line, which lacks acetylcholinesterase (ache) and is suggested to be a delayed aging model. whole brain tissues were isolated from young, middle-aged and old male and female zebrafish brains (ab/wildtype strain), as well as from old male and female ache mutant zebrafish (ache sb /+ ). animals were maintained and raised in standard conditions. the extracted brain tissue was homogenized in ripa buffer and subjected to western blot analysis to determine differences in the relative protein expression levels. our preliminary data indicated that smurf and gep levels remain stable in the aging brain (p = . , p = . ), and in the ache mutants gep levels are increased compared to the wildtype controls (p = . ). further analysis of the relationships between smurf and gaba a levels and brain aging is ongoing. we predicted that alterations in smurf levels would parallel changes in key synaptic inhibitory proteins during the aging process, which was the case for the gep levels. while smurf may regulate inhibitory synaptic transmission, the exact roles of those synaptic proteins in the context of normal and delayed brain aging are not known well-understood and the subject of continuing study. in recent years, express the hypothesis that aged individuals are vulnerable to infectious and other inflammatory agents and they become more prone to develop majority of severe age pathologies, including cardiovascular and oncology diseases, neurodegenerative diseases, type diabetes mellitus and inflammatory diseases, etc. one of the central components of immune response is the family of toll like receptors (tlr). there are several opinions that single nucleotide polymorphisms (snp) leading to a loss of function of the respective tlrs can be associated with age and increase the risk of age related diseases, especially cardiovascular diseases (cvd). however, many available studies focusing on tlr snps and cvd are with conflicting results. the aim of this study was to assess the potential interaction between genetic variants of tlr and tlr and ischemic heart disease (ihd) in kazakhstan population over years old. we evaluated patients with ihd and healthy subjects aged years and over (ethnical kazakhs and russians living in republic of kazakhstan). polymorphic loci of the genes tlr rs and tlr rs were genotyped by pcr with subsequent restriction analysis. our results indicated that the genotype and allele frequencies of tlr (arg gln) and tlr (asp gly) were not significantly different between the groups (p ≥ . ). statistical analysis didn't elicit any association between studied gene polymorphisms and predisposition to ihd in individuals over years old (p ≥ . ). for these polymorphisms, age, fasting blood sugar and serum lipid levels were not also significantly different among different genotypes in the ihd and control groups. in conclusion, the data shows that there is no interaction between tlr and tlr and ischemic heart disease (ihd) in kazakhstan population over years old. we plan to include other types of polymorphisms in tlr and tlr genes and increase the volume of patient cohort in our future studies. p- . . - evaluation of prognosis with total oxidant/ antioxidant status and some oxidative stress parameters in patients with acute ischemic stroke stroke is the third most common cause of death after coronary heart disease and cancer. strokes are classified into two groups according to their pathology: ischemic stroke and hemorrhagic stroke. ischemic strokes make up % and hemorrhagic strokes % of all strokes. during ischemic stroke, oxidative stress has been shown to play a major role in the occurrence and progression, formed oxidants also affect cell membranes and genetic material such asdna, rna, and various enzymatic events, and they lead to cell damage. some studies have shown oxidant-antioxidant status but have not shown the relationship with prognosis. this study has investigated the relationship between prognosis and total oxidant/antioxidant status and biochemical parameters in patients with acute ischemic stroke patients, with acute ischemic stroke and healthy controls we reenrolled in the study. blood samples were taken within st and th days, and after rd months in the patient group for analysing serum total oxidant status (tos), antioxidant status (tas), catalase, arylesterase, and thiol. prognosis was evaluated with national institutes of health stroke scale (nihss) and-modifiedrankinscale (mrs) scores. there was no significantly difference between groups by means of serum tas, tos and catalase levels. but arylesterase (p: . ) and thiol (p: . ) levels were significantly higher in first h blood samplingthancontrolgroup. statistically significant negative correlation was observed between the rd month values of tos and nihss score (r = . , p = . ). but there was no correlation between mrs scores and serum tas, tos, catalase, thiol and arylesterase. similarly, our findings suggested some serum oxidant levels were increased in acute ischemic stroke patients and total oxidant status might be used in evaluation of prognosis but larger studies are needed. p- . . - amylin and preptin regulate glucose homeostasis in infertile women with polycystic ovary syndrome and poor responders undergoing ivf/icsi disrupted glucose homeostasis leads not only metabolic disturbance such as polycystic ovary syndrome (pcos), but also influences oocyte growing. this study was designed to evaluate follicular fluid (ff) and serum levels of glucoregulatory hormones, amylin and preptin, in infertile women with pcos and poor responders undergoing ivf/icsi. human follicular and serum were obtained from infertile women with pcos and poor responder participants undergoing controlled ovarian stimulation (cos) with gonadotropin-releasing hormone antagonist protocol for ivf/icsi treatment. ff and serum amylin and preptin levels were measured by elisa. it was found that ff and serum amylin and preptin were lower in infertile women with pcos when compared with poor responder participants. ff amylin and preptin concentrations were lower than that of the serum amylin and preptin concentrations. decreased follicular fluid amylin and preptin levels suggest that amylin and preptin may have a physiological role in follicular maturation via controlling local glucose homeostasis. despite high serum levels of amylin and preptin in pcos their low concentration within the follicle may be main culprit of defective folliculogenesis seen in pcos subjects. similar to insulin resistance in pcos subjects existence of amylin and preptin resistance support the critical role of both peptides in follicular maturation in pcos. keywords: follicular fluid; amylin; preptin; polycystic ovary syndrome; infertility. the transcription initiation on p promoter of xp bacteriophage in presence of p protein, a modulator of rna-polymerase activity a. shadrin g.k. skryabin institute of biochemistry and physiology of microorganisms, ras pushchino, russia many bacteriophages are able to manage the transcription system of their bacterial host for their own needs. for example, bacteriophage xp , in the early stages of infection of xanthomonas oryzae inhibits transcriptional activity of bacterial rna-polymerase on majority of promoters via p protein, except of bacteriophage p promoter responsible for expression of the bacteriophage 'middle' class genes. the focus of this work is to study the mechanism of action of p protein in the transcription initiation and identification of the role of the individual elements of p promoter of xp bacteriophage, enabling x. oryzae rna-polymerase escapes inhibition by p protein. we have designed a set of promoter probes representing the combination of sequences of p -resistant p promoter and p sensitive t n promoter. using fret-based assay it was shown that the truncated probes corresponding to promoter dna downstream À position, relative to the transcription initiation start site, did not lead to dissociation of the sigma-factor. longer probes, containing À promoter element, induce dissociation sigma-factor. the in vitro transcription experiments show that the deletion of region , a sigma-factor domain responsible for interaction with À promoter element during the transcription initiation, is not critical for inhibition of rna-polymerase by p protein. promoter probe with up-element of p promoter had affinity to x. oryzae rna-polymerase a several times higher than a probe containing the consensus up-element for e. coli rna-polymerase . summing up the results, it seems like the transcription initiation on p promoter of bacteriophage xp can escape inhibition by p protein through a high affinity interaction between the up-element and c-terminal domains of the alpha subunit of rna-polymerase x. oryzae. p- . . - distribution of soluble form of glial fibrillar acidic protein in the different areas of gerbils brain during development and aging y. kovalchuk, g. ushakova oles honchar dniepropetrovsk national university, dniepropetrovsk, ukraine astrocytes are the most abundant cell type within the cns and play an important role in cns homeostasis and function. glial fibrillary acidic protein (gfap) forms the main astrocytic intermediate filament (if). the overall level gfap in different parts of the brain uneven and depends on the number of astrocyte cells. gfap is very sensitive to any kind of neurodegenerative diseases and aging. during aging, a glial reaction is observed in the human brain, as well as in rat and mouse brains. the aim of our study was to investigate the quantitative astrocytes-specific protein gfap in different areas of the gerbils brain at the first stages of postnatal development and aging. for the study gerbils brains were used and divided into groups (n = ): : newborn animals ( day), - : , and days respectively, : animals aged years. the animals were decapitated under mild anesthesia (thiopental), with isolated brain three divisions: the cerebellum, thalamus and hippocampus, which are then used to produce cytosolic protein fractions. the level of gfap in the obtained fractions were determined according to the method of competitive elisa. newborn gerbils found no significant content of soluble form of glial fibrillar acidic protein in all investigated parts of the brain, and a sharp increase of amount within days (in cerebellumamounted to . ae . lg/ mg tissue; to - days increased to . ae . lg/ mg tissue, and began to grow again in older individuals aged years). unlike the cerebellum, the level of sgfap in hippocampus and thalamus reached the maximum at days p.d. ( . - . lg/ mg tissue), and unchanged for days. these results revealed that the most intensive development of astrocytes in the cerebellum to p.d. of gerbils, and in the thalamus and hippocampus are formed within the first month of life. the plastid-nucleus located protein whiry acts as an upstream regulator of leaf senescence binding to the promoter of senescence associated genes (sags) like senescence marker gene hvs . in order to investigate the impact of whirly on drought stress-induced senescence, transgenic barley plants with a knockdown of whirly (hvwhy kd) were grown under untreated and drought stress conditions. the leaf senescence evolution was monitored by physiological parameters and gene expression studies of senescence and drought stress related genes. to reveal the epigenetic indexing at hvs at onset of drought-induced senescence in wild type (wt) and hvwhy kd lines, stress-responsive loading with histone modifications at gene regions of hvs ( regions in the promoter, one region around translation start site and regions located in the gene body) was analysed by chip and quantified by rtq-pcr. in barley, drought treatment caused acceleration of leaf senescence in wildtype (wt) plants, whereas why kd lines showed a staygreen phenotype. expression of senescence-associated and drought stress responsive genes expression was delayed in hvwhy kd indicating that whirly protein acts as an upstream regulator of drought stress-induced senescence. the chip results showed that drought treatment is causing in wt a significant increase in the levels of h k ac all over the analyzed gene regions, correlating with a massive induction of hvs expression, while drought stress caused no substantial increase of h k ac in why kd plants. the results suggest that drought induced expression of hvs is under epigenetic control, and furthermore that why is involved in this epigenetic control level. oncolytic viral therapy is based on the capabilities of selective lysis of tumor cells and is a prospective trend in cancer disease treatment. in vitro experiments showed that plant rhabdoviruses does not have any direct cytotoxic effect upon sarcoma cells, causes induction of apoptosis in these cells and does not pose any threat to somatic cells of warm-blooded animals, which makes it possible to use this virus for therapy of malignant neoplasms. buckwheat burn virus (bbv), the prototypic member of the family rhabdoviridae, contains surface glycoprotein and which is lectin-active. its carbohydrate branch can aid adhesion of lymphocytes to tumor cells. the present study has addressed the effect of bbv on cancer cell viability. all studies were carried out after week of inoculated with erlich cancernome ( cells/animal, i. p.) in months male balb/c mice treated at once with or without plant extract with bbv ( mg/kg, i. p.). by fluorescent microscopy and using two due staining by acredine orange and propidium iodide it was found that in the rd day of administration of bbv lead to increasing of necrotic and apoptotic cells on % and % respectively versus to untreated group. at the same time the viability of investigated cells was impaired too and according to flow cytometry analysis using propidium iodide the amount of dead cells was elevated by fivefold ( . % versus . % in untreated group). also as was shown in previously reports bbv decreased activity of macrophages in the early stages after injection and it may have a positive effect when using this drug in tumor therapy. when using this drug appears to slow down the possibility of a sharp activation of macrophages, and as a consequence of the development of cytotoxic effect will be prolonged. key words: rhabdoviruses, buckwheat burn virus, cancer, cell viability. plants are considered as one of most promising sources for new antimicrobials, based on the evidence of their use in folk medicine to treat various infectious diseases since ancient times. despite relatively small area size, armenia has large diversity of flora with many endemic species. the main goal of this study was the screening of various parts of herbs (widely being used in armenian folk medicine) for their antimicrobial activities in order to select most prospective plants for further comprehensive studies. plant crude extracts were obtained with maceration technique using five solvents: water, methanol, chloroform, acetone and hexane. agar well diffusion assay was used to evaluate antimicrobial properties of plant crude extracts at lg/ml concentration against escherichia coli vkpm-m , pseudomonas aeruginosa grp , bacillus subtilis wt-a , salmonella typhimurium mdc and staphylococcus aureus mdc , candida albicans wt- and candida guilliermondii hp- . statistical analysis was done using graphpad prism . . crude extracts of all tested plant materials expressed antimicrobial activity against at least one test strain. most of the tested extracts inhibited growth of both gram-negative and gram-positive bacteria. in contrast, only some plant materials exhibited inhibitory activity against yeast strains. according to obtained data sanguisorba officinalis, rumex confertus, hypericum alpestre, lilium armenum and agrimonia eupatoria possessed the highest and broadest antimicrobial activity. moreover, the results showed that acetone was the most effective solvent for solubilizing antimicrobial compounds from plant materials followed by methanol, chloroform, hexane and water. the results demonstrated high antimicrobial activity of medicinal plants used in armenian traditional medicine. five plant species were selected for further comprehensive studies. besides, acetone was proposed as efficient solvent in antimicrobial screening protocols. p- . . - effects of aluminum stress on photosystem-i apoprotein a gene (psab) transcription level in lichen xanthoria parietina (l.) th. fr. unal € ozakc ßa ege university, izmir, turkey in this study the effects of shortrerm aluminium (al) toxicity on the lichen xanthoria parietina (l.) th.fr. were investigated at physiological and transcriptional level. lichen thalli were treated with alcl in different doses ( . , . , and mm). lipid peroxidation and chlorophyll integrity were determined by spectrophotometer. expression level of psab gene was also investigated. chlorophyll a content was significantly (p ˂ . ) decreased after hours treatment with mm and mm of al, while chlorophyll b content was increased significantly due to treatment with increased concentration of aluminum. also treatment with . and . mm al for hours increased the gene expression level of psab by . % and . % respectively. our results indicated that aluminum treatment has decreased the chlorophyll biosynthesis and increased the lipid peroxidation depending on time and concentration. this study also demonstrates that the psi can be readily photo-inhibited by aluminum stress. in conclusion, mm al exposure for hours could damage the electron transport in photosystem i. p- . . - nigella sativa reduces paracetamol-induced nephrotoxicity and oxidative stress in rats: biochemical evaluation background: nigella sativa l. (ranunculaceae) (ns) is traditionally used to treat many conditions such as inflammation. this study evaluates the effects of ns seeds ethanol extract in paracetamol-induced acute nephrotoxicity in rats. material method: forty-eight female wistar albino rats were divided into eight groups: i = sham; ii = sham + mg/kg ns; iii = sham + mg/kg (n-acetyl cysteine) nac; iv = g/ kg paracetamol; v = g/kg paracetamol + mg/kg nac; vi, vii and viii = g/kg paracetamol + , and mg/kg ns, respectively. paracetamol administration (oral) was carried out h after ns and nac administrations (oral), and all animals were sacrificed h later. result: urea and creatinine levels were determined in serum, while glutathione, malondialdehyde levels and superoxide dismutase activity were determined in the kidney tissues. there were significant increases in the serum levels of urea and creatinine in the paracetamol-administered group. serum levels of urea and creatinine were decreased in all groups administered ns with paracetamol. ns administration dramatically restored sod, gsh, and mda levels in the kidneys. conclusion: the results suggest ns has a significant nephroprotective activity on paracetamol-induced nephrotoxicity. it may be suggested that the antiinflammatory and antioxidant effects of ns ethanolic extract originated from different compounds of its black seeds. p- . . - the study of problems of preservation of the birches e. shadenova , , e. zhumabekov , m. sembekov , m. burchaeva institute of general genetic and cytology, almaty, laboratory of genetics and reproduction of forest culture, institute of general genetics and cytology, almaty, kazakhstan nature of deciduous trees have a whole range of various medicinal properties. instead of synthetic hormone substitutes, you can use medicinal infusions and decoctions of natural phytohormones are widely used in both folk and professional medicine. one of these plants is birch, its young leaves and buds. however, they also must be used with caution because overdose of these compounds is very dangerous, not only can you not get the desired effect, but also face the opposite of his action. in our research to mass replication of plants (different types of birches (betula ajanensis, yarmolenko, jacguemontii, maximowiczii, ulmifolia, middendorffii, kelleriana, tianschanica)) we use nutritional medium excluding the application of phyto promoters in order to prevent mutation. the object of research serve as the old, the sick, being on the verge of extinction, mature trees as explant meristema. since from the moment of calling experience and most cultivation occurs at nutritional medium without hormones. as a result of molecular analysis we get without virus, genetically identical plants. molecular certification of different types of birches of interest, both in terms of organizing, and in terms of selection and genetic improvement of valuable forms, identification of lines selected from natural populations and clones obtained in vitro. relationship between clones and installed parent form by comparing profiles amplific pcr products using issr-marking. according to the results of carried out works really recovered clones obtained from one source tree, indicating the potential for certification of clones studied forms of birches pcr. a study performed in the framework of the state grant project "conservation of breeding valuable species of birches". p- . . - fractionated triterpenoid glycosides from sea cucumber inhibit invasion and metastasis in human cancer cells sea cucumbers are slow-motioned invertebrates. holothuria polii delle chiaje, is widely distributed sea cucumber in _ izmir coastline (turkey). it secretes saponins i.e. triterpenoid glycosides (ttg) as secondary metabolites. the aim of this study is to evaluate anti-invasive and anti-migrative effects of fractionated ttgs obtained from h. polii on ht- , t and upci-scc- cancer cell lines. the semi-purified ttgs was extracted from h. polii collected from coast of _ izmir-dikili. the four different fractions (fraction a-d) were collected by using hplc (high-performance liquid chromatography) and characterizated with maldi-ms/ ms. the fractions obtained from h. polii extract include holothurin a ( . m/z) and -dehydroechinoside a, scabraside a or fuscocinerosides b/c isomer ( . m/z). anti-invasive and anti-migrative effects of the fractions on the cancer cell lines were detected with xcelligence rtca dp system. the results showed that fraction a-d inhibited migration and invasion of human cancer cell lines at th and th hours compared to control group. this study shows that holothurin a, dehydroechinoside a, scabraside a or fuscocinerosides b/c isomer could be evaluated as promising anti-cancer agents for human cancers. acknowledgement: the authors acknowledged the scientific and technological research council of turkey (t € ub _ itak) for financial support ( z ). p- . . - alternative splicing regulation of sr proteins in response to environmental stress in chinese cabbage serine/arginine-rich protein (sr protein) family, which acts as rna-binding protein, plays a major role in post-transcriptional regulation of pre-mrna, such as alternative splicing (as). these proteins cause pleiotropic effect by regulating as of pre-mrna in a tissue and developmental stage-specific and stress-responsive manner in arabidopsis. here, we identified genes encoding sr proteins in chinese cabbage (brassica rapa chiifu- ) from brassica database and analyzed their phylogenetic relationship. b. rapa has types of sr protein that are classified into common (sr, rsz and sc) and plant specific (scl, rs z, rs and sr-like) subfamily similar with arabidopsis. interestingly, the as pattern of most sr genes changed at the late stage ( and days after germination). to verify the correlation between sr genes and environmental stress, we screened the as pattern of sr genes to various abiotic stress using rt-pcr and a microarray analysis. in particular, the expression level and the as pattern of bra and bra were affected significantly by heat stress. these results suggest that the as regulation by sr protein correlates with adaptation mechanism to the environmental stress in chinese cabbage. p- . . - characterization of recombinant prolyl oligopeptidase from myxococcus xanthus and potential use in gluten hydrolysis e. k. kocaazorbaz, f. zihnioglu faculty of science, biochemistry department, ege university, izmir, turkey a recombinant prolyl oligopeptidase from myxococcus xanthus was purified with a specific activity of u mg(- ) by using nickel-metal-chelate affinity chromatography and gel permeation chromatography. the recombinant enzyme had a monomeric molecular weight of kda. its isoelectric point, determined by two dimension polyacryl-amide gel electrophoresis, was close to . . the optimum ph and temperature was estimated as . and °c, respectively. the purified enzyme was stable from ph . - . and able to thermal stability up to °c. the k(m) and v(max) values were . mm and . micromol/ min per mg. the enzyme exhibited hydrolytic activity for suc-gly-ala-pna, suc-gly-pro-pna, z-gly-pro-pna, igf- , substance p, whereas no activity for h-gly-pro-pna, h-val-ala-pna, h-arg-pro-pna, h-ala-pro-pna, glu-ala-pna, pro-pna, leu-pna. its proteolytic activity was inhibited by activesite inhibitors of serine protease, z-pro-prolinal pmsf, and metal ions, cd + and hg +. the potential use of the enzyme was tested by the hydrolysis of the wheat gluten. the resulting gluten hydrolysate were characterized by means of their antioxidant, antibacterial, trypsin inhibition and prolyl oligopeptidase inhibition activities. keywords: serine protease, prolyl oligopeptidase, bioactive peptides, , , -trinitrobenzene sulfonic acid. proteomic analysis is probably the best approach to analyze seed germination. however, it is difficult to analyze complex samples and there are many obstacles that must be faced in order to achieve a reasonable proteome coverage. for example, the barley (hordeum vulgare) genome was fully sequenced in , but the uniprot database contains less than reviewed sequences, which is approximately -fold less than for arabidopsis thaliana. here, to improve the barley proteome coverage, we employed several fractionation methods including polyethylene glycol precipitation, strong cation exchange chromatography, off-gel separation, sds-page and acetonitrile elution gradient. proteomic analyses were performed using an lc-ms-based analyses and an uhr q-tof mass spectrometer. the candidate peptides were targeted via selected reaction monitoring (srm) and triplestage quadrupole (tsq) mass spectrometer. in total, proteins were identified, which represents a three-to four-fold increase compared with the standard shotgun analysis of the same sample. out of these, were only accessible by one of the techniques and, besides, the detection limits were not similar. we hypothesized that an srm-based targeted analysis will allow detection and quantitation of most of these proteins, even without the application of proteome fractionation. we can conclude that all peptides from the library with ms/ms spectra of the total intensity above , are easily detectable in the total protein extracts. p- . . - transcriptome sequencing based identification of alternative oxidase genes in white waterlily, nymphaea alba alternative oxidases (aoxs) are the terminal oxidases in the respiratory electron transport chain of plants. they reduce molecular oxygen to water with low proton translocation across the inner mitochondrial membrane. in plants, aoxs increase local tissue temperature to release volatile compounds thereby attracting pollinator insects and regulation of mitochondrial retrograde signaling pathway. regulation of retrograde signaling pathway is currently under investigation to improve cultivation studies in many plants. water lilies are aquatic ornamental and economically valuable plants classified under nymphaea family. nymphaea alba, white water-lily, has a special focus since its applications in landscaping of parks and gardens, farming as vegetable and medical applications. however, cultivation of n. alba is a challenging process. we hypothesized that by controlling alternative oxidases, success rate can be increased for n. alba cultivation. to identify alternative oxidase encoding genes in n. alba, we performed transcriptome analysis. by using transcriptome analysis data, aox gene sequences, subcellular localization of aox proteins and structural modelling of aox proteins were predicted. in transcripts, database search with trinotate tool revealed transcripts with aox domains characterized in known alternative oxidases. blast analysis of these sequences with known aox proteins revealed three distinct aox genes (nalba-aox , nalba-aox and nalba-aox ). after subcellular localization analysis of three identified aox proteins by using targetp server tool, nalba-aox , nalba-aox are predicted as mitochondrial while nalba-aox is localized in chloroplasts. template based structural modelling results showed that all identifed proteins are statistically similar to known structure models of corresponding aoxs. most environmental contaminants have toxic and mutagenic effects on living organisms as a result of the activation of free radical formation and inhibition of reparation activity. it is becoming relevant to search for protectors of natural origin from the effects of xenobiotics. many biologically active substances (bas) of inartificial origin are found to be antioxidants and can increase the body's resistance to the toxic and mutagenic effects of a wide range of pollutants. the aim of the study was to investigate the antioxidant and antimutagenic properties of bas from medicinal plants limonium gmelinii (plumbaginaceae) and inula britannica (compositae). the antioxidant potential of plant extracts was determined by the activity of superoxide dismutase (sod), catalase, and the content of malonic dialdehyde. mutagenic and anti-mutagenic properties of the extracts were determined in the test by counting chromosomal aberrations in root meristem of barley seeds. barley seeds were treated with an aqueous solution of unsymmetrical dimethyl hydrazine (udmh), which is highly toxic i class hazardous material, well known pro-oxidant. the results showed that udmh enhanced the process of lipid peroxidation and decreased the mitotic activity. treatment of barley seeds with extracts from i. britannica and l. gmelinii and their germination in the presence of stress factors stimulated antioxidant defenses in the primary roots of barley seeds. increase of the activity of sod and catalase, and reduction of peroxidation level of lipids were observed. cytogenetic study showed no mutagenic activity in plant extracts. when effects of plant extracts and udmh were combined there was a significant reduction in the frequency of structural mutations, induced by the toxicant. conclusion about the presence of the antioxidant and antimutagenic activity in the studied plant extracts is made. the work done within the framework of the mes project (no. gr rk ). p- . . - comparative analysis of cytokinin dehydrogenase inhibition and trans-zeatin treatment in arabidopsis seedlings j. nov ak , v. koukalov a , z. medvedov a , c. martin , j. hradilov a , l. sp ıchal , b. brzobohat y mendel university in brno, brno, palack y university in olomouc and centre of the region han a, olomouc, czech republic cytokinins are plant hormones regulating many processes during plant life ranging from germination to senescence. manipulation of cytokinin levels and their impact on plant vitality, production and ability to defend against stresses is in great interest of agriculture. in this work we focused on comparison of inhibitor of the cytokinin degradation incyde ( -chloro- -( -methoxyphenyl)aminopurine) and exogenous application of trans-zeatin on arabidopsis thaliana seedlings. transcripts of genes regulating cytokinin metabolism were analysed by rt-qpcr analysis. classical cytokinin root essay revealed that incyde effect is comparable to that of trans-zeatin in a similar concentration-dependent manner. besides a negative effect on the primary root length, both substances induce flavonoid accumulation and an increase in the root hairs formation. histochemical staining of transgenic plants expressing glucuronidase (gus) under cytokinin-responsive promoter of arr gene revealed increased gus activity in cotyledons following incyde treatment suggesting diverse localization of cytokinin modulation upon trans-zeatin and incyde treatment, respectively. possible molecular differences originating in different cytokinin population and distribution following trans-zeatin or incyde treatments were monitored on the level of gene expression and via an lc-ms proteome analysis in roots and shoots of -day-old plantlets. rt-qpcr analysis revealed an alteration in cytokinin metabolism that could explain observed differences on the proteome level between incyde and trans-zeatin treated seedlings. pharmacologically inhibited cytokinin degradation could be very efficient tool for modulation of cytokinin levels. interestingly, the application of incyde and trans-zeatin shows a contrasting spatial and temporal pattern on molecular levels. incyde represents potent growth regulator with interesting properties useful for agriculture. p- . . - the expression yield of prokaryotic alphaamylase is significantly magnified by molecular cloning techniques randomly hydrolyzing glycosidic bond alpha-amylase has been traditionally employed in bread and similar industries. in that regard, increasing the overall expression level of the enzyme is a crucial concern in biotechnology. to reach the goal, appropriate alpha-amylase producing species and expression vector were carefully selected. therefore, genome of bacillus subtilis was extracted and amplified by polymerase chain reaction (pcr) using specifically designed primers. subsequently, the extracted gene was inserted in expression vector pht and transferred to e. coli as intermediate host followed by bacillus subtilis host replacement. the recombinant vector was expressed in bacillus subtilis and the expression was evaluated by agarose gel electrophoresis. relative purification of the recombinant enzyme was performed by kda filtration to remove impurities. to identify the biochemical characteristics, starch was used as specific substrate to measure enzyme activity and the enzyme was exposed to various ph and temperatures. the extra-cellular expression of alpha-amylase enzyme was successfully elevated by folds in comparison to the native enzyme. the optimum temperature and ph for the enzyme was carefully determined as °c and , respectively. the enzyme was stable at °c, but thermal stability was dramatically decreased at higher temperatures up to °c. kinetic parameters were also measured; vmax was . u/ml min and km was . mg/ml. it is concluded that the elevated expression extent of recombinant alpha-amylase together with appropriate qualifications could make the clone a good choice for various industrial applications. flax seedlings of cultivars tmp , lira and lines g- / _o, g- / _k were treated for and hours with lm alcl solution or distilled water (control). twelve small rna libraries were constructed and sequenced using illumina gaiix. to identify known mirnas, obtained sequences were aligned with mirnas from mirbase (http://www.mirbase.org/). fold change value was calculated to identify up-and down-regulated mirnas under al stress. in total, about million raw reads were obtained and conserved mirnas from families were identified. significant expression alterations in flax plants under al treatment were shown for mir and mir . expression level of mir was varied in similar way in resistant and susceptible to al genotypes: mir was up-regulated after hours of alcl exposure and down-regulated after hours. mir expression was increased after hours of alcl exposure and decreased after hours in susceptible to al flax genotypes (lira, g- / _o), while in resistant genotypes (tmp , g- / _k) mir level was decreased after both and hours of al treatment. in other plant species, mir and mir were identified as al-responsive. mir targets mrna of tcp (teosinte branched/cycloidea/pcf) transcription factors, which control plant growth. mir targets mrna of tas protein, which regulates lateral root growth via degradation of arfs (auxin response factors). in flax, the involvement of mir and mir in response to al stress was shown for the first time. moreover, we revealed diverse expression alterations of mir in susceptible and resistant to al genotypes. this work was financially supported by grant - - from the russian science foundation. p- . . - association genetics of phenylalanine ammonia lyase (pal) and cinnamyl alcohol dehydrogenase (cad) enzymes involved in lignin biosynthesis of european black poplar (populus nigra) b. taskiran, z. kaya middle east technical university, ankara, turkey populus nigra l. are considered as one of the most economically significant forest trees with respect to production of wood, biomass, and other wood-based products. while wood quality and biomass are directly associated with high cellulose content, lignin emerges as an undesirable polymer for both pulp and biofuel manufacturing industries. the aim of the study is by choosing the superior and eliminating the inferior clones to make a contribution to woody feedstock development and to improve wood quality of populus nigra. to estimate association genetics of pal and cad enzymes which have important functions in lignin biosynthesis, the important germplasms of populus nigra has been sampled from year old poplar trees ( clones x replicates x ramets) which were grown in behic ßbey plantation clone bank in ankara. additionally, five commercially registered clones and six foreign clones were included to the study to make comparison. the average mean values of cellulose, lignin and glucose content were calculated as . ae . lg/ml, ae . lg/ml, and ae . lg/ml, respectively. even though for pal and cad enzymes, data gathering process have been still resuming, particular clones have been separated from all in terms of pal and cad activities as expected. key words: populus, poplar, lignin, pal, cad, genetic variation, feedstock p- . . - proteomic analysis of the molecular mechanisms of the response of plant seeds to pre-sowing treatment by stressors seed treatment with non-ionizing low-level radiation (nr), such as cold plasma (cp) or electromagnetic field (ef), is a modern eco-agricultural technology for stimulation of plant germination and performance. the molecular determinants of seed response to these treatments are not established and no genomic studies of plant seed response to nr have been reported. we studied the effects of pre-sowing seed treatment, using vacuum ( min), radio-frequency ef ( - min) and cp ( - min), on germination and growth of non-oilseed helianthus annuus. to gain an insight into the molecular mechanisms underlying effect of nr on sunflower seed germination and dormancy, we estimated changes induced in the balance of plant hormones and differential protein expression. the results of the germination tests and estimation of seedling morphology showed that response develops in time and is stronger when sowing is performed in days in comparison to days after seed treatment. the d dige analysis revealed differentially expressed proteoforms in kernels of seeds treated with cp or ef. proteins involved in biological processes of seed maturation, response to stress, response to abscisic acid stimulus, processes of organonitrogen compound metabolism and glucose catabolism were identified. while expression patterns for majority of the proteins were highly specific to cp and ef treated seed kernels, accumulation of several proteoforms of seed storage proteins (ssp), including vincilin-like, miraculin-like protein and albumin- were common for both experimental groups. this suggested that response to nr treatment could be at least partially associated to function of ssps in response to oxidative stress that protects proteins required for seed germination and seedling formation. variation of abundance of distinct proteoforms of helianthinin, vicilin-like and s globulin-like ssps suggested that post-translational modifications are involved in regulation of the function of ssps. p- . . - suppression of lipopolysaccharide-induced inflammatory responses in raw . macrophages by tuber extract of cyclamen l. turkey is a prominent centre of plant diversity, being the meeting point of three main floristic zones. geophytes which have underground storage organs such as, tubers, bulbs and rhizomes. cyclamen l. is a tuberous geophyte traditionally used by some people for treating whooping cough, headaches or sinusitis, and confirmed to have antioxidant, analgesic and anti-inflammatory properties by several reports. a prolonged inflammatory response is often associated with chronic diseases such as cancer, arthritis and autoimmune disorders. recently, plant based products are used as an alternative and complementary treatment of these diseases. in this respect, the present study was aimed to determine the effects of three cyclamen tuber extracts on lps-induced inflammatory responses of murine raw . macrophages. firstly, c. cilicium (endemic), c. pseudibericum (endemic) and c. graecum subsp. anatolicum were collected from different localities of turkey. the tubers of plants were air-dried and grounded to fine powder and then extracted with ethanol. cell viability assay was performed to evaluate the nontoxic concentration in cell line by mtt assay. several measurements were performed including tnf-a, no and il- concentration assay by elisa after treatment compared to non treated cells to determine the anti-inflammatory activity. also, tnf-a and inos mrna levels were evaluated by quantitative rt-pcr. the cytotoxic activity which is considered safe on raw. . cell were found as . - lg/ml. studied cyclamen taxa inhibited tnf-a and il- release on lps stimulated-raw. . in a concentration-dependent manner. among the three cyclamen tuber extracts evaluated, the highest nitrite-associated no inhibitory activity was obtained from c. pseudibericum compared to other two cyclamen l. taxa. collectively, these results suggest that cyclamen tuber extracts possess anti-inflammatory properties. p- . . - in vitro hypoglycemic activity of ziziphus jujuba recent reports have indicated that continuous treatment with nutritional jujuba (ziziphus jujuba miller) fruit extracts in diabetic rats improved glucose utilization and produced a significant decrease in the blood glucose. in the present study, hypoglycemic activity of z. jujuba was investigated using various in vitro techniques. the hypoglycemic effect of z. jujuba in phosphate buffered saline which grown in balıkesir was studied by measuring glucose adsorption, glucose diffusion and glucose uptake by yeast cells. the glucose content in the solution measured by spectrophotometrically with commercially kits. the adsorption capacity of the z. jujuba was found to be directly proportional to the molar concentration of glucose. the glucose binding capacity of extract increased in higher glucose concentratrations. there was significant differences were observed between the adsorption capacities of z. jujuba and control samples (p < . ). the rate of glucose diffusion was directly proportional to the time. diffusion rate was significantly lower in the solution containing z. jujuba compared to control (p < . ). the extract demonstrated significant inhibitory effects on movement of glucose into external solution across dialysis membrane compared to control. the rate of glucose transport across cell membrane in yeast cells was observed to be inversely proportional to the molar glucose concentration. z. jujuba inhibited glucose transport across the yeast cells. the results showed that z. jujuba reduced glucose levels at least by three mechanisms. first by increasing glucose adsorption capacity during postprandial hyperglycemia; second by retarding glucose diffusion rate and third, at the cellular level by inhibiting glucose transport across the cell membrane. all of these decreased the absorption of glucose in the intestinal cells and the concentration of postprandial serum glucose. p- . . - cucurbitacin b increased the anticancer effect of imatinib mesylate through inhibiton of matrix metalloproteinase- expression in colorectal cancer cells f. bakar ankara university, ankara, turkey several natural products have been investigated for their anticancer effects. among these, cucurbitacin b (cub) has been reported as its inhibitory effects on cancer cell proliferation. matrix metalloproteinases (mmps) belong to endopeptidase family and they are received as potential biomarkers for several types of cancer. the aim of this study is to investigate the effect of cub in combination with imatinib mesylate (im) on mmp- mrna expression of human sw colorectal carcinoma cells. the cytotoxicity analysis was performed via mtt assay. muse cytofluorimetric analysis system was performed to evaluate apoptotic cell population. the mmp- mrna expression was determined by quantitative real-time pcr. this study was supported by scientific and technological research council of turkey grant, sbag- s . data obtained from the cell culture experiments were expressed as mean ae sd and one-way anova test was applied for multiple comparisons. cub alone significantly inhibited cell growth at lm and higher concentrations. the most potent effect was observed in cub-im combination treatment with . lm ic value. in cub-im treated group, the apoptotic effect was higher than cub and im treated groups. cub-im induced apoptosis significantly at lm concentration when compared to control and lm (p < . ). cub alone showed inhibitory effects on mmp- mrna expression at lm and higher doses significantly (p < . ). the results showed that the combination treatment of cub with imatinib synergistically inhibited human sw cell growth and induced apoptosis by increasing the anti-histone antibodybound nucleosom levels and annexin v binding. although cub could inhibit mmp- expression alone at higher treatment doses, it enhanced the inhibitory effect of im on mmp- synergistically in a dose dependent manner. in conclusion, this study suggests that cub combined with imatinib mesylate may enhance the effects of chemotherapy in patients with colorectal cancer. plants are most important parts of natural resources that alternatively referred to synthetic drugs for reasons such as being less side effects and lower costs. ziziphus jujuba miller (z. jujuba), a plant used in traditional medicine, is one of the most important ziziphus species belonging to rhamnacea family. the fruit and seeds of this plant are used different purposes such as antiinflammatory, antioxidant, immune-stimulant and wound healer. in this study, we investigated the antibacterial effects of z. jujuba. the aims of this study were to screen the antibacterial activity of z. jujuba. the extract was obtained from z. jujuba fruits pulverized with the aid of ball mill using % aqueous-ethanol solution. extracts were screened for antimicrobial activity against six different standard strains of bacteria by determining minimum inhibitory concentration (mic) according to clsi criteria. serial dilutions are made between mg/ml and . mg/ml concentration range. the lowest concentration of wells that no visible growth has been accepted as mic value. materials in the mic and lower concentrated wells were transferred to % sheep blood agar petri dishes for calculation of minimal bactericidal concentration (mbc). the lowest concentration that no colony formation has been accepted as mbc value. jujuba showed the most potent effect on strain of s. aureus atcc is gram-positive cocci (mic: mg/ml). the mic values of other gram-positive bacteria s. aureus atcc , e. faecalis atcc , l. monocytogenes f and m. smegmatis cmm were detected as , , and mg/ml respectively. mic values of gram-negative bacilli were detected as > mg/ml. consequently, z. jujuba was found to be effective on grampositive cocci bacteria (s. aureus atcc , s. aureus atcc and e. faecalis atcc ). the strongest effect was observed on s. aureus atcc strain. in contrast, extract showed less effect on gram-negative bacilli. p- . . - selective cytotoxic effect of morus rubra extract in human lung cancer cells through enhancing apoptosis and cell cycle arrest cancer is a disease that develops as a result of unlimited proliferation of abnormal cells that occurs due to loss of control over the mechanisms of normal growth and differentiation of cells. morus rubra, known as "red mulberry" belongs to family of moraceae. for many years, the fruits of morus species have been used to treat many diseases in traditional medicine. biological effects of morus species is predominantly attributed to its content of polyphenolic compounds. many studies have evaluated the cytotoxic effects of different morus species, but there is no study about cytotoxic effect of m. rubra. in this study, we aimed to evaluate the cytotoxic effect of m. rubra extract in human lung cancer cells (a ) with regard to apoptosis, cell cycle and mitochondrial membrane potential. cytotoxic effect of m. rubra extract on human lung cancer cells was determined using mtt assay. then, mechanisms of cytotoxic activity of m. rubra extract on a cells were examined in terms of cell cycle, apoptosis and mitochondrial membrane potential using flow cytometric methods. m. rubra extract exhibited selective toxicity against a cells compared to normal foreskin fibroblast cells. we determined that m. rubra extract increased cell cycle arrest at g phase, the level of apoptotic cells and decreased mitochondrial membrane potential in a cells. our results showed that m. rubra extract has pro-apoptotic and antiproliferative effect in a cells. further studies are also needed to fully mechanisms underlying this effect of m. rubra extract. p- . . - dipeptidyl peptidase iv inhibitory activity of arctium tomentosum l. a. zeytunluoglu , f. zihnioglu denizli vocational school of technical sciences, pamukkale university, denizli, department of biochemistry, faculty of science, aegean university, izmir, turkey type diabetes mellitus (t dm) is rapidly growing metabolic syndrome of multiple aetiologies causing hyperglycaemia with insulin resistance at cellular level. a novel approach in the treatment of t dm is based on preventing of rapid inactivation of the incretin hormone glucagon-like peptide- (glp- ) and glucose-dependent insulinotropic polypeptide (gip) by dipeptidyl peptidase-iv enzyme. in this study; dipeptidyl peptidase iv (dpp-iv; ec . . . ) inhibitory activity of the aqueous and methanolic extracts of arctium tomentosum leaves were successfully tested in vitro conditions. our study revealed that both aqueous and methanolic extracts obtained from test material had a significant dppiv enzyme inhibitory activity in changing ratio. the ic values were also determined by nonlinear regression curve fit using graph pad prism . with appropriately diluted of lyophilized arctium tomentosum. diprotein-a (ile-pro-ile) was used as reference inhibitor. a. tomentosum aqueous extracts showed ic . lg/ml while the standard (positive control) diprotin a displayed the ic value of . lg/ml. this study demonstrates that a. tomentosum aqueous extracts could be a good lead for further development as a new antidiabetic agent. p- . . - dna recognition determinants of arabidopsis thaliana b transcription factors g. sasnauskas, k. kauneckaite, k. lapenas, v. siksnys institute of biotechnology, vilnius university, vilnius, lithuania transcription, one of the most important cellular processes, is regulated by transcription factors (tf), proteins that often directly interact with gene promoter sequences. tf binding to dna is mediated by various dna binding domains. the b tfs constitute a large, plant-specific protein family (approx. % of all tf proteins in the flowering plants), which is characterized by the presence of one or several small (approx. amino acids) b dna binding domains. currently the b tfs are divided into four groups (lec -abi /val, arf, rav and rem). the preferred recognition sites were identified for representatives of all groups except the rem family. currently, only a single structure of a dna-bound b domain (arf , arf family) is available, thus the mechanism of site-specific dna recognition by the lec -abi /val and rav b domains remains poorly understood. based on the arf -dna structure (pdb ldx) we have built homology models of dna-bound b domains from a. thaliana abi (lec -abi /val family) and nga (rav family) transcription factors, mutated putative dna-interacting amino acid residues and characterized the dna binding ability of the purified mutants using electrophoretic mobility shift assay and a set of radiolabelled dna substrates carrying various variants of the optimal recognition site. we confirm the importance of several positively charged amino acid residues, which are conserved between the abi / nga b domains and structurally related dna-binding domains of bacterial restriction endonucleases ecorii, bfii and ngoavii; furthermore, we identify residues in the 'n-arm' and 'c-arm' loops that may be involved in specific interactions with the dna bases. our results therefore help us refine the homology models of the dna-bound b domains and in the future may help us predict the dna binding properties of currently uncharacterized b domains. p- . . - immunohistochemical analysis of inhibitory effects of origanum hypericifolium oil on dipeptidyl peptidase iv in streptozotocininduced diabetic rats p. ili , a. zeytunluoglu denizli health services vocational high school, pamukkale university, denizli, denizli vocational school of technical sciences, pamukkale university, denizli, turkey diabetes mellitus (dm) is a serious metabolic disorder with micro-and macro-vascular complications that result in a significant morbidity and mortality. glp- and gip have significant role in pancreatic beta cells and prevention of inactivation of them by dipeptidyl peptidase iv (dpp iv) inhibition is a novel approach to treatment of dm. origanum hypericifolium (lamiaceae) is an endemic turkish plant and its essential oil is mainly composed of monoterpenes including carvacrol and thymol. streptozotocin (stz) is used to induce diabetes in rats. the aim of this study is to investigate the inhibitory effects of o. hypericifolium essential oil on the dpp iv in stz-induced diabetic rats. the animals (female spraque-dawley rats) were assigned to four groups (group : control, group : stzinduced diabetic, group : o. hypericifolium injected, group : stz-induced diabetic and o. hypericifolium injected). dm was experimentally induced in groups and by a single intraperitoneal injection of stz at a dose of mg/kg body weight. in groups and , rats were intraperitoneally injected with o. hypericifolium oil at a daily dose of ml/kg body weight for consecutive days. at the end of the experimental period, all animals were sacrificed by cervical dislocation under ether anesthesia and liver and kidney tissues of each animal were rapidly excised. tissues were fixed in sainte-marie fixative. after routine histological processes, samples were embedded in paraffin, immunohistochemical staining for dpp iv was performed on sections and then they were photographed. the immunohistochemical reaction intensity differences were observed between the groups. in conclusion, the immunohistochemical distribution of dpp iv in the tissues that the test oil was applied in the diabetic rats may be important for the investigation of the inhibitory effects of oil on the enzyme. moreover, our findings suggest that o. hypericifolium oil may be used for prevention of diabetic diseases. introduction: all eukaryotic cells need microtubules for purposes of nuclear and cell division, organization of intracellular structure, and intracellular transportation, as well as ciliary and flagellar motility. microtubules are made of polymerized a/btubulin subunits. mec is important for microtubules, because it encodes the enzyme that adds acetyl groups to lysine (k ) of tubulin. k is largely conserved in a-tubulins of many eukaryotes, and acetylation is thought to stabilize microtubule structure. in algae, the effect of acetylation by mec on flagellar motility and phototaxis has not been tested previously. materials and methods: in this study, mec mutant chlamydomonas reinhardtii cells were compared to wild-type cells to see the effect on flagellar motility and phototaxis. we tested phototaxis, eyespot size and quantity under the microscopy. in addition to this, we fixed cells and examined them by immunofluorescence microscopy using antibodies to tubulin, acetylated tubulin, and photoreceptor. results: we observed that some mec mutant cells contain more than one eyespot. we detected no acetylated-tubulin (ac-tub) by immunofluorescence. the cells still phototax and have normal motility discussion and conclusion: interestingly, mec cells still have the ability to phototax and they have normal flagellar motility, even though they contain occasional additional eyespots and no ac-tub. chlorella vulgaris as a model system for screening of plant growth modulators p. volynchuk , e. marusich , r. chuprov-netochin , j. neskorodov , y. mishutkina , s. leonov life sciences center, moscow institute of physics and technology, dolgoprudny, center "bioengineering", russian academy of sciences, moscow, russia the discovery of new plant growth modulators became extremely important task as an alternative approach to overcome plants resistance to herbicides and pesticides, which leads to harmful action on plants and land rising, environmental and ecological problems. small molecules provide agricultural biotechnology with valuable tools, which help to circumvent the need for genetic engineering and offer unique benefits to modulate plant growth and development. we developed a system to explore molecular modes of action of plant growth modulators using chlorella vulgaris model. our model allows applying high content screening approach in well plate format for fast and robust effect assessment of large number of tested modulators. chlorella v. was grown in climate chamber under optimized constant temperature ( °c) and light conditions ( : hours/light:dark). modulating effect of tested compounds was estimated by spectrophotometric measurement of microalgae density at the beginning of the experiment (start point- . od) and hours later. to validate our system we used known cytokinins and auxins ( mm) as positive controls of growth stimulation. we showed that in presence of each compound the density of chlorella v. was increased in - times range, compared with only times increase in control group. eight new chemicals ( lm), which demonstrated modulation effect on nicotianatabacum l. pollen and arabidopsis thaliana models, were tested on developed chlorella v. model. positive controls showed no stimulating effect at this concentration, while tested compounds were confirmed as hits and increased the density up to %. we demonstrated that developed model system, based on chlorella v., is an effective system for primary screening of plant growth modulators. the main advantages of this system are short time of assay, simplicity of performance, possibility of automation and low cost. selected hits can be recommended as perspective candidates for future test on crop field. sunflower is under a big threat of downy mildew which is a fungal disease caused by plasmopara halstedii. the disease can cause up to an % yield loss in sunflower production. downy mildew resistance genes (r) denoted as pl has been discovered to date in sunflower. in recent years, single nucleotide polymorphism (snp) markers have become widely used in plant breeding programs. in this study snp markers have been currently developing for pl , pl , pl , pl arg genes by competitive allele specific pcr (kasp) assay which enables bi-allelic scoring of snps and insertions/deletions (indels) at specific loci. in total sequence tagged site (sts) sequences from ncbi were aligned for pl , pl , pl , pl arg genes to identify conserved regions for each gene. based on the conserved regions, specific pcr primers were designed in order to make sequencing of these genes in five crosses and their f progenies. sequence data will be used to design an allele specific primer maches the target snp and amplifies the target region with the common reverse primer provided by kasp genotyping assay. snp markers linked to pl genes which are being developed in this study, have the potential to be used in marker assisted selection (mas) for sunflower breeding programs. p- . . - investigation of the antidiabetic effects of hibiscus sabdariffa, teucrium polium and myrtus communis in hepg cells line s. altundag , pamukkale university, denizli, istanbul medeniyet university, istanbul, turkey some antidiabetic plants currently are used in alternative treatment of type ii diabetes. hibiscus sabdariffa, myrtus communis and teucirum polium plants are also known for their antidiabetic properties. hibiscus sabdariffa, myrtus communis and teucrium polium; depending on the impact on hepg - cells to investigate the possible mechanisms of type ii diabetes with researches on glucolysis and glucogenesis pathways gene expressions (pk m , glut- ,pepck). plants were obtained in dried state from reliable herbalists in denizli and mersin. plants treated with the extractor device. plants obtained aqueous extract was subjected to lyophilization process. human cancer cells have been used throughout the study. the cytotoxicity of the cells was measured by elisa plate reader . total rna was isolated using trızol Ò solution was carried out according to the instructions of the manufacturer's (thermo scientific) recommended procedures were performed, but we have to optimize our own laboratory conditions. pk m , glut- ,pepck genes were synthesized by b _ ioneer. during our study the activation of certain genes (pk m , glut- ,pepck) were examined by real time pcr. in our study hibiscus sabdariffa, mrytus communis and teucrium polium plant to extract applied hepg - cell line in the gluconeogenesis and glycolysis pathways in involved in some important genes (pepck, pk m , glut- ) analyzed the expression levels . teucrum polium plant extract is applied in hepg - cells the glycolysis pathway genes (pk m glut- ) an increased expression also genes of gluconeogenesis pathway (pepck) were not decreased. however hibiscus sabdariffa and the expression of genes involved in glycolysis and gluconeogenesis pathway mrytus communis plants were observed to have a full effect as diabetic or hypoglycemic . in this context, it is considered that the plant teucrum polium on the line hepg - cells showed antidiabetic effect. p- . . - purification of b-glucosidase from malatya apricot (prunus armeniaca l.) seeds and some of its biochemical properties h. kara , s. sinan , z. ekmekci , y. turan university of balikesir faculty of veterinary, balikesir, university of balikesir faculty of arts and sciences, balikesir, turkey introduction: b-glucosidases are one of the key enzymes in carbohydrate metabolism and located in glycosyl hydrolases (ec . . ) family. plant b-glucosidases have biotechnological significance as they are effective on glycosidic bonds of flavor and aroma precursors in plants. b-glucosidases that located in fruit seeds are important because they affect the amygdalin. aim of this study is purification and partially characterization of b-glucosidase from malatya apricot seeds. materials and methods: apricot seeds were homogenized with extraction buffer to prepare of crude extract. the enzyme protein was precipitated with % ammonium sulfate then purified by hydrophobic interaction chromatography using sepharose b-ltyrosine- -naptylamine gel. para-nitrophenyl b-d-glucopyranoside (p-npglc) was used as substrate to determine biochemical properties of the enzyme. the optimum ph was determined using buffers between ph - and thermal optima was determined using - °c temperature range. inhibitory effects was determined with mm substances. results: the enzyme was . -fold purified with yield of %. purified b-glucosidase from apricot seed was visualized about kda molecular weight on sds-page. the kinetic parameters were determined against p-npglc substrate as km and vmax values of . mm and . eu, respectively. the optimum ph and temperature were determined . and °c respectively. effects of cacl , kcl, nacl, mgcl , k so , na so , cuso , fecl , pb(ii) acetate, agno , zncl and glucose on purified enzyme activity were investigated. kcl, na so , pb(ii) acetat and cuso reduced the enzyme activity. discussion and conclusion: in this study, b-glucosidase was purified from malatya apricot seed and some of its biochemical properties were determined. because this enzyme has pharmaceutical importance hydrolyzing amygdalin. the results showed that immobilized almond b-glucosidase was used to break amygdalin and release -cn compound that effective to shrink cancer mass. p- . . - a new affinity gel for purifing polyphenol oxidase enzyme a. erg€ un , , o. arslan balikesir university, science and technology application and research center, balikesir, department of medical chemistry, faculty of science, balikesir university, balikesir, turkey polyphenol oxidase (ppo) enzyme, sometimes called as phenol oxidase, catecholase, phenolase, catechol oxidase or tyrosinase, is considered to be an o-dipenol. ppo (ec . . . ), a multifunctional copper containing metalloenzyme, is widely distributed in nature. ppo exists in many kinds of plants and fungi, such as banana, mushroom, butter lettuce, napoleon grape, potato, coffee, marula fruit, artichoke heads, longan fruit, tobacco, wheat flour. in this study, a novel affinity chromatography gel was synthesized for purifing ppo enzyme. the affinity chromatography gel was synthesized by coupling aniline as a specer arm to cnbr activeted sepharose- b. then, p-amino benzoic acid was coupled to aniline as a ligand. ppo was purified from musa sapientum var. cavendishii (banana) by using sepharose- b-aniline p-amino benzoic acid affinity chromatography gel. % . yield and . fold purification were achieved. sds-polyacrylamide gel electrophoresis of the enzyme indicates a single band with an apparent mw of kda. the v max and k m of the purified enzyme were determined , u/ml min and . mm, respectively. p- . . - phenolic content and antioxidant capacity of gamma irradiated olive leaves m. e. diken , b. kocat€ urk , s. dogan , h. tuner balikesir university, balikesir, kavram vocational school, istanbul, turkey in this study, dried in diffirent ways (such as microwave, infrared, convection heaters and under normal atmospheric conditions) olive leaves has been used as experimental material. radiation has been applied to dried olive leaves in three diffirent dosages in room temparature. the amount of radiation to be implemented to the samples have , , kgy/min. in this study, how gamma rays (radiation) effects phenolic components, total phenolic content and antioxidant capacity of dried olive leaves has been determined. the phenolic components, total phenolic content and antioxidant capacity were analysed with hplc, folin ciocalteu and dpph radical scavenging method, respectivelty. gamma rays is well known as a decontamination method for many foodstuffs and plant materials, being an environment friendly and effective technology to resolve technical problems in trade and commercialization. for this reason, nowadays it is utilized as an alternative method of sterilization. gamma rays are of ionizing radiation. when ionizing radiation interacts with matter, generally it causes a break in the molecular bonds and/or breaks the bonds between the molecules. these intermediates have unpaired electron and called free radical. gamma radiation or the radiation-induced free radicals would break or cause damage to the dna molecules of living organisms. gamma irradiation is predict to change phenolic content and antioxidant capacity in living tissues. phenolic compounds are secondary plant metabolites naturally present in fruits and vegetables. in recent years there has been a growing interest in food phenolics because of their potential health benefits mainly due to their antioxidant and free radical scavenging activity. despite the controversy about potential risks posed by genetically modified plants on human health, environment and microorganisms, cultivation area of these crops increases day by day. this increment has revealed concerns especially related to hgt. hgt studies indicated that antibiotic resistance genes in gm plants have a potential to transfer to soil microorganisms. in this study, hgt of widely used genetic elements such as regulatory sequences, from transgenic plants to bacteria was investigated. three soybean feed and four seed examples from turkish feed manufacturers' association were used for genetic analysis based on foreign gene determination. gmo analysis were conducted by camv s promoter-specific pcr in genomic dnas. in gm positive samples, genomic dnas sheared into appropriate fragment size by ultrasonication for the purpose of bacterial transformation. presence of s promotor region in fragmented dnas was proved by pcr. escherichia coli dh a strain was transformed by fragmented dna samples according to cacl method. s promotor sequence screened by using pcr in bacterial genomic dnas. as a result of gm screening, all feed and three of the seed samples were found to be transgenic. ultrasonication conditions were optimized for shearing dna's to - bp for bacterial transformation. fragmented dnas confirmed for carrying intact s promotor sequence. none of bacterial genomic dnas were found to be s-positive. according to the transformation results, absence of s promotor sequence in all tested bacterial genomic dnas, proved the dna samples belonging to gm plants can not transfer into compotent e. coli dh under laboratory conditions. for verification of this finding, transformation studies will continue with acinetobacter baylyi bd strain which is naturally competent soil bacterium for natural transformation. we believe that all of our findings will contribute to constitute transformation system which can be used as model in hgt studies. p- . . - preliminary studies on differential methylation in a and d sub-genomes of upland cotton (gossypium hirsutum l.) four species of cotton (gossypium l.) provide raw materials for the textile industry. among the four species, two have diploid genome and another two have tetraploid genome. tetraploid genome consists of a and d sub-genomes. a sub-genome belongs to asian cotton while d-sub genome belongs to american cotton. previous studies revealed that d sub-genome of gossypium species contributes to the superior yield and quality of tetraploid gossypium l. species (atdt). dna cytosine methylation of four regions of dna sequences located on a and d sub-genomes of gossypium hirsutum l. texas marker (tm- ) was investigated using bisulfite sequencing technique. among the regions studied two could not be located on subgenomes due to sequence identity match between a and d subgenomes. on the other hand two dna regions could be located on a and d sub-genomes using the blast searches. some of the dna sequences located on different sub-genomes showed polymorphic nucleotides including c/t and g/a polymorphisms. in silico analysis indicated that some alleles located on different sub-genomes of cotton have c/t and g/a polymorphisms. c/t polymorphisms between the sub-genomes could be thought as unmethylated cytosine using the bisulfite sequencing technique. this indicated that an extra attention needs to be paid in dna total cytosine methylation studies in polyploid species such as cotton using bisulfite sequencing, methylation sensitive amplification polymorphism (msap), whole-genome bisulfite sequencing (wgbs). otherwise, t in c/t polymorphism between the subgenomes could be thought as unmethylated cytosine. based on the two genomic regions we could conclude that a sub-genome may be more methylated than d sub-genome. differential methylation of genes located on different sub-genomes may provide another mechanism responsible for differential gene expression of genes located on different sub-genomes. p- . . - cleaved minisatellite locus (cml) markers for fingerprinting of cotton cultivars grown in turkey e. u. gocer, m. karaca akdeniz university, antalya, turkey after their discovery by alec jeffreys in , minisatellites have been used in genetic studies of many organisms. minisatellites, also called variable number tandem repeats (vntrs), are composed of arrays of longer repeats mostly dispersed throughout heterochromatin (centromeres and telomeres). direct amplification of minisatellite regions of dna using a single core primer is a powerful method to amplify minisatellites (damd-pcr). although the damd-pcr technique has been applied to many plant species, the level of polymorphisms in cotton (gossypium l.) is very low due to very narrow turkish cotton genetic base. the objective of this study was to improve the level of polymorphisms by cleaving minisatellite loci by restriction enzyme digestion. genomic dna samples of twenty-one turkish cultivars, pima - , tm- and ps- were extracted. twenty-one minisatellite primers were screened using the damd-pcr technique. monomorphic amplicons were digested using several restriction enzymes. three to five micro liters of amplified products were digested with various restriction enzymes. digested products of minisatellite loci were separated in % high resolution agarose gels. comparison studies of digested and undigested markers revealed that cleaved minisatellite markers showed polymorphisms in those cotton lines that could not be differentiated by microsatellite and minisatellite markers. this approach was called cleaved minisatellite locus markers (cml). the amplification reactions of minisatellites used touch-down (td) cycling conditions. the use of td offered a simple and rapid means of optimizing polymerase chain reaction (pcr), increased specificity, sensitivity, and efficiency without the need for lengthy optimizations of minisatellite primers. the cml markers were obtained at a °c annealing temperature, which is a temperature higher than those used in random amplified polymorphic dna (rapd) inter-simple sequence repeat (issr) markers. p- . . - association between cytosine methylation and tissue specific expression of microsatellites a. g. ince, m. karaca akdeniz university, antalya, turkey heritable covalent modification of dna, rna or protein without altering their primary sequences is defined epigenetics. because all biological events are influenced by epigenetics, it is one of the most important fields in science. dna methylation is one of the most important epigenetic mechanisms. dna cytosine methylation is a process by which methyl groups are added to cytosine bases of dna. microsatellites, also knows simple sequence repeats are dna sequences consisting of - nucleotide repeats. there is a large body of information regarding the relationship between microsatellite instability and abnormal gene expression, and between dna methylation and altered gene expression. however, there is limited information on cytosine methylation of microsatellites. in the present study, we investigated whether there is any association between cytosine methylation and tissue specific expression of microsatellites. genomic dna samples of various tissues and developmental stages of pepper line demre sivrisi (capsicum annuum l.) and cotton line tm- (gossypium hirsutum l.) were extracted. cdna samples were synthesized using mrna expressed in pepper tissues. cytosine methylation levels were investigated using bisulfite sequencing methods. screening studies of microsatellites revealed that some genes containing microsatellites were differentially expressed in tissues and developmental stages of pepper. microsatellite containing genes that expressed differently among tissues had also showed different methylation levels in cg, chg and chh (where h refers to a, c or t) contexts. methylation level differences between microsatellites were also observed. as far as our knowledge, it is the first report on differential expression of genes containing methylated microsatellites. p- . . - pcr-lg: an alternative way to assign the chromosome location of genes/markers in cotton a. aydin, m. karaca akdeniz university, antalya, turkey assignment of genes and dna markers on chromosomes is very important in life sciences, especially for plant breeding and medicine. there are several methods for the assignment of a gene or dna sequence to a specific location on a chromosome. for example, the most widely used technique is the assignment of fluorescently-labeled gene or dna sequences (markers) on chromosomes using the fluorescently-labeled gene (for instance, fish technique). another example is the construction of a genetic map (linkage map) which orders the targeted genes along the dna strand based on recombination frequency. sequencing is the most precise technique in which coding (gene-containing) and noncoding dna region of genes could be located on a chromosome molecule. aneuploid lines could also be used to locate genes in a specific chromosome, but maintenance of these lines is difficult. here we report the use of chromosome substitution lines to indirectly locate genes/markers on chromosomes. we used chromosome substitution lines (csls) that carry a chromosome pair or chromosome arms from gossypium barbadense l. while the rest of chromosomes belong to g. hirsutum l. a total of chls, a homozygous cotton line tm- and a double haploid line pima - were used as plant materials. twenty microsatellite primer pairs were utilized in touch-down polymerase chain reactions. we developed a method, called polymerase chain reaction to locate gene (pcr-lg), to assign genes/markers on chromosome or chromosome arm. with the use of pcr-lg approach any polymorphic genes/markers between tm- and pima - (g. hirsutum and g. barbadense) could be assigned to a chromosome or chromosome arm. results indicated that if csls were used any polymorphic markers (genes) with known primer pairs could be assigned to cotton chromosomes. although we used cotton chromosome substitution lines to validate the proposed technique, it could be applicable all the species that have chromosome substitution lines. p- . . - pecularities of genome variability of antarctic hairgrass deschampsia antarctica desv. from the maritime antarctic deschampsia antarctica desv. (poaceae) is the only grass species native to the antarctic region, adapted to harsh environmental conditions. however, reasons for its unique success remain unexplored. stressful environmental factors can influence a plant genome and cause changes in the chromosome number and morphology and increase genetic variation. therefore, the purpose of our research was to explore alterations in the d. antarctica genome both at the chromosomal and molecular levels and to investigate species genome stability using in vitro tissue cultures. plants used for the study were grown in vitro from seeds collected in the argentine islands region during - . chromosome number was determined in plant root apical meristems and specimens prepared from tissue cultures. rrna genes localization were determined using the fish technique. moleculargenetic analysis was performed using pcr with polymorphic issr-primers. new forms of chromosome polymorphism, associated with aneuploidy ( n = - ), polyploidy ( n = - ) and the occurrence of additional b-chromosomes ( n = + - b), were observed. fish analysis also confirmed that genotypes with a different chromosome numbers varied in the number of s rdna and s rdna sites. assessment of genetic variation demonstrated a low level of diversity: differences between the plants with different chromosome numbers do not exceed the level of within-population variation. cytology analysis of d. antarctica cultured tissues revealed aneuploidy (up to . %) with predominance cells with diploid and near-diploid chromosome number irrespective of plant's initial karyotype (diploid, mixoploid or polyploid). we assume that discovered intraspecies chromosomal polymorphism is a manifestation of quick genome reaction to harsh antarctic conditions. whereas the results of molecular-genetic analysis and study of cell cultures of this species suggests on the relative stability of d. antarctica genome. p- . . - angiotensin converting enzyme inhibitory activity of morchella esculenta (l.) pers a. zeytunluoglu , i. arslan biomedical equipment technology, pamukkale university, denizli, turkey, denizli, biomedical engineering, pamukkale university, denizli, denizli, turkey hypertension is a multi-aetiological, chronic pathophysiology that leads to multi-organ dysfunctions like cardiovascular diseases, strokes, and renal complications. natural extracts play an important role in traditional medicines for the treatment of hypertension and are also an essential resource for new drug discovery. mushrooms are use as therapeutics in alternative and complementary medicine as functional food because of contain a large number of biologically active components that offer health benefits and protection against many degenerative diseases. morchella esculenta is one of the most highly priced edible mushrooms worldwide. it contains a wide range of active constituents which include tocopherols, carotenoids, organic acids, polysaccarides and phenolic compounds which exhibit a wide range of medicinal and pharmacological properties including anti-microbial, anti-inflammatory, immunustimulatory, antitumor and antioxidant. in this study; the in vitro angiotensin converting enzyme-i (ace-i) inhibitory activity of m. esculenta peptides were generated by alcalase hydrolysis were studied. the kda < peptides < kda in the ultrafiltration fractions displayed highest ace inhibition ( . ae . % at lg/ml). the results indicate that m. esculenta derived peptides may have potential as functional food ingredients in the prevention and management of hypertension. p- . . - modulations of antioxidant enzymes, gsts and catalase, by salvia absconditiflora in hepg cell line d. irtem kartal , a. altay yuzuncuyil university, van, erzincan € university, erzincan, turkey oxidative stress is considered to play a important role in the pathogenesis of aging and several degenerative diseases, such as cancer. in order to cope with an excess of free radicals produced upon oxidative stress, humans have developed several mechanisms for maintain redox homeostasis. these protective mechanisms either scavenge or detoxify ros, block their production, and include enzymatic and nonenzymatic antioxidant defenses. in enzymatic defenses include glutathione s-transferases and catalase enzymes. many epidemiological studies have revealed that there is a strong correlation between consumption of polyphenol-rich foods and the prevention of certain diseases like cancer, cardiovascular diseases and aging. phenolic compounds are abundant in all plants. so, they form an integral part of the human diet. salvia species, commonly known as sage, have been used since ancient times for more than different ailments ranging from aches to epilepsy. there are around species of salvia, of which are represented in turkey including salvia absconditiflora. in this study, s. absconditiflora collected from metu campus (ankara, turkey) is extracted with methanol and water. effects of the water and methanol extracts on the mrna expressions of antioxidant enzymes gstm and catalase in hepg cells were investigated by q-rt-pcr technique. it was also monitored the effects of the extracts on the enzyme activities of gsts and catalase by spectrophotometrically. water and methanol extracts decreased gsts mrna expression in hepg cells for hours and hours incubation and methanol extract decrease catalase mrna expression for only hours incubation. on the other hand, extracts highly increased the gsts and catalase activities in both hour incubation. overall, these results indicate that s. absconditiflora and/or its components have regulatory activities on antioxidant enzymes and they may have a potential as a therapeutic agent in the treatment of cancer. p- . . - transcriptomics and proteomics approach to drought stress mechanism in wheat b. cevher keskin tubitak marmara research center genetic engineering & biotech. institute, kocaeli, turkey birsen cevher keskin, yasemin yıldızhan, oktay kulen, bayram y€ uksel, selma onarıcı, _ ismail t€ urkan, as ßkım hediye sekmen, u gur sezerman, bu gra € ozer identification of novel stress-responsive genes and their role in drought response is an important area for the improvement of the crops. drought-related genes were investigated in leaves and roots of three wheat genotypes after different drought stress treatments by rna sequencing (rna seq) technology and de novo assembly was performed before comparative transcriptome analysis. analyzing gigabases of bp paired end illumina reads from a hexaploid wheat poly(a) rna library, we identified common and new differentially expressed transcripts. selected differentially expressed genes were confirmed by qrt-pcr. we also performed root proteome analysis with nano electrospray ionization source coupled to a high-performance liquid chromatography system (nanouplcÀesiÀqtofÀms) to identify drought-related proteins. totally proteins were differentially expressed in root tissues of tolerant and non-tolerant wheat genotypes. responses of antioxidative defense system to drought stress were comparatively studied in the same wheat cultivars. similarities between protein and rna levels help increase our confidence in novel biomarkers, differences may also reveal other post-transcriptional regulatory junctures. all these analyses will allow us to get a better idea about the possible role of these genes in the drought-response mechanism. the drought-related genes that are functionally characterized could be introduced into agronomically important wheat cultivars. this work offers a resource for accelerating drought-related gene discovery and improving this important crop. p- . . - isolation and characterization of a hexose converter from olive s. altunok , e. d€ undar department of biology, university of balikesir, balikesir, department of molecular biology and genetics, college of arts and sciences, balikesir university, balikesir, turkey introduction: hexose sugars are key components of glycolysis and photosynthesis. the genes regulating their conversion into one another, is therefore, of great importance for the control of carbon metabolism. in this study, we report isolation and characterization of a cdna associated with conversion of hexoses in olive. the cdna putatively named aldolase based on bioinformatic and experimental analyses. material-methods: characterization based on nucleotide and amino acids were conducted using bioinformatic tools such as nucleotide and protein blast, bioedit, primer , finchtv, clc genomic workbench, expasy, targetp, sosui and web promoter scan. comparison of the genomic and cdna sequence of the gene and detailed bioinformatic analyses including cellular location, hydropathy analysis, amino acid-nucleotide composition and predicted d structure were also conducted using the bioinformatics tools mentioned above. temporal expression pattern of the putative aldolase were conducted using real-time pcr experiments. sds and western blot analyses were completed while biochemical analyses are ongoing. oleocanthal is an important secondary metabolite that has been reported to be useful against important human diseases including cancer. the aim of this study was to identify and characterize the key biochemical and genetic components of oleocanthal biosynthesis. to determine the biochemical components of the pathway, multiple olive cultivars along with their spatial and temporal points were determined. the expression levels of multiple candidate genes were also aimed via real-time pcr. nucleotide blast and protein blast (for comparison of the similarity of the candidate genes with that of other organisms) were conducted on ncbi web page. phylogenetic tree construction, amino acid composition analysis, nucleotide composition analysis, hydropathy analysis and translations through expasy were conducted. primer was used to design forward and reverse primers to amplify the target genes from different olive tissues at different times. analysis of the first candiate gene with bioedit program revealed that a+t ratio was more than g+c according to the nucleotide composition analysis. according to amino acid composition analysis isoleucine, lysine and leucine were more than other amino acids while kyte&doolittle hyddropathy analysis revealed that the protein was hydrophilic. abundance of hydrophobic amino acids (leucine and isolecine) along with an abundant hydrophilic amino acid (lysine) suggest the existance of hydrophobic pockets in the protein which may mean a membrane bound protein or a sitoplasmic protein with a strong hydrophobic core. the molecular weight of the protein was kda with a pi of . . the protein was found to have a signal peptide. according to the sosui gramn , intracellular localization was found to be in the inner membrane. analysis of other candidate genes contiunes. acknowledgements: this study was supported by tubitak with grant number o . key words: olive, olea europaea l., secologanin, polymorphism, allele diversity p- . . - antioxidant potentials of propolis and its bioactive components, and their effects on cyp e gene expression in ht- adenocarcinoma cell line a. altay , d. irtem kartal erzincan € university, erzincan, y€ uz€ unc€ u yil university, van, turkey propolis is a resinous mixture that is collected by honeybees from plants, and is combined with beeswax and secretions from the bee's salivary glands plus some pollen. it is a rich mixture of polyphenols, flavonoid aglycones, phenolic acids and their esters. it has been used in traditional medicine for thousands of years because of these ingredients. propolis, just like honey, has been the subject of many studies due to its antimicrobial, antifungal, antiviral and hepatoprotective activities. the cytochrome p enzymes are involved in phase i xenobiotic and drug metabolism. cyp e is present in high levels in human tumors demonstrated by qrt-pcr and immunohistochemical studies. in this study, propolis collected from datc ßa (mugla, turkey) is extracted with % ethanol. phenolic contents of the propolis were measured by lc-ms/ms. cytotoxic effects of the propolis on ht- human colon adenocarcinoma cell lines were examined via xtt colorimetric cell proliferation assay. effects of propolis extract and its main bioactive component caffeic acid on the expression of phase i detoxification enzyme cyp e in ht- cells were investigated bu using q-rt-pcr technique. ic values for dpph radicals scavenging activities of the extract was calculated as . mg/ml. tpc and tfc were determined as . mg gae/g extract and . mg qe/g extract, respectively. caffeic acid content of the extract was measured as . lg/g extract. ic values for xtt assay in hours incubation with the extract and caffeic acid were evaluated as . mg/ ml and . mg/ml, respectively. propolis extract and its main phenolic content caffeic acid significantly dicreased cyp e mrna expression with . and . fold, respectively in ht- human colorectal adenocarcinoma cells for hours incubation. overall, these results indicate that propolis and/or its components have regulatory activities on cyp e expression and they may have a potential as a therapeutic agent in the treatment of cancer. p- . . - effects of histone h lysine inhibition on gene expression profile in tobacco (nicotiana tabacum l.) differentiation is the characteristic of multicellular organism. cellular dedifferentiation underlies topical issues in biology such as reprogramming in stem cell research, regeneration and nuclear cloning, and has common features in plants and animals. the state of dedifferentiation is evidenced by changes in cell morphology, genome organization and the pattern of gene expression as well as by the capability of plant tissues to differentiate into multiple types of cells depending on the type of stimulus applied. chromatin reorganization appears to be a fundamental theme in cellular dedifferentiation and reentry into the cell cycle both in plants and animals. the chemical modifications of histone proteins which are structural units of the nucleosome, generate 'codes' for the recruitment of proteins or protein complexes that affect chromatin structure and gene expression according to 'histone code' hypothesis. methylation of histone h at lysine residue by specific methyltransferases suv h in humans and kyp/suvh in arabidopsis generates a'code' for the recruitment of hp proteins. in this study, to enhance the dedifferentiation efficiency, chaetocin which inhibits suv h has been used at the germination stage of tobacco seeds in in vitro conditions. our results showed that chaetocin induced callus formation from leaf discs of tobacco in the early stage of the inhibitor application. chaetocin can enhance reprogramming of plant cells in seed development treatment as callus induction. it is known that the formation of callus which is the non-differentiated cell community in plants, is a consequence of the changes in the gene expression profile. it has been found that epigenetic modifications play a crucial role in some of these changes. the definition of the genes related to callus formation by the inhibitation of an epigenetic modification -h k methylation-in tobacco might be used to bear on various dedifferentiation-driven cellular processes. induction of tumor cell death by the use of some phytochemicals that consumed through diet, and derived from medicinal plants opens up new horizons for cancer treatment researches. rheum ribes species, which is studied in this research, is one of the commonly used herbs in pharmacological researches. the high content of phenolic compounds in r. ribes extracts were known to be responsible for the high antioxidant and antibacterial activities. our aim in this study is to assess cytotoxic and apoptotic changes by way of implementing methanol extract of the rheum ribes (root) to the mcf- breast cancer cell line. cytotoxic effect of rheum ribes extract was evaluated by using the xtt ( , -bis( -metoksi- -nitro- -sulfofenil)- h-tetrazolyum) test. in order to determine the dose of ic , plant extracts were applied as time and dose dependent in the range of - ug. in nd hour, the ic value is determined as ug. to examine the apoptotic effects of the extract, total rnas were isolated from dose group and the control cells firstly, then cdnas were synthesized. expression profile of the target genes(caspase- , caspase- , caspase- , caspase- , bax, bcl- , fas) are determined by qpcr. according to the results, when the control group compared with the cells, it was determined that, while . and . -fold respectively increase in the gene expressions of caspase- and caspase- of dose group cells, . -fold decrease in the gene expressions of bcl- . no significant difference was observed in the other genes examined. based on the obtained data, we believe that methanol extract of the rheum ribes induces apoptosis by activating intrinsic pathway. as a result, this plant species can be a new and effective therapeutic candidate for the medical world in search of alternative anti-cancer approaches, and could shed light on the work to be done in this area. p- . . - the effect of ferulic acid and -fluorouracil combination on apoptosis in pc- human prostate cancer cells prostate cancer is quite often seen in industrialized countries and has the second most common death rate due to cancer after lung cancer in men. -fluorouracil ( -fu) is a pyrimidine analog and cell cycle-targeting drug by inhibiting dna synthesis. it has been widely used for treatment of several cancers such as gastric, colorectal, and breast cancers. phenolic compounds found in foods are potential antioxidants of harmful oxidative processes related to cancer and also important due to induction of different mechanism such as apoptosis. ferulic acid (fa; -hydroxy- -methoxycinnamic acid), a phenolic compound, is abundant in fruits and vegetables. the purpose of this study was to investigate combination effect of fa and -fu on apoptosis in pc- human prostate cancer cell line. the effects of -fu, fa, and combination of both of them on cell viability were determined by xtt method. total rna isolation was conducted using trizol reagent. expressions of important genes in apoptosis including casp , casp , casp , casp , bcl , bax, fas and cycs were investigated in four groups by qpcr. the ic doses of fa and -fu were found to be lm and lm for hours in pc- cells, respectively. in order to determine combination effect, pc- cells were treated with <ic doses ( lm fa and lm -fu). according to qpcr results, a significant increase in the expressions of bax and cycs genes and a decrease in the expression of bcl were observed in the fa group, compared with the control group cells. after the treatment with -fu, the expression of casp was significantly increased compared with the control group. furthermore, combination of fa and -fu significantly increased expression of casp , casp , fas and cycs genes. in conclusion, comparing with the single treatments, it was observed that combination of fa and -fu affected expression of different genes in apoptosis in pc- cell line. p- . . - combination of ferulic acid and gemcitabine affects expression of some apoptotic genes in pc- human prostate cancer cells prostate cancer, the second causing of cancer-related death in men, is an important cancer type due to the late age of onset, slow the progression, high incidence. gemcitabine is an effective agent in several cancer types including non-small cell lung cancer, pancreatic, bladder and breast cancer. it is known that gemcitabine is used single agent or as a part of combination treatment in prostate cancer therapy. nowadays, new treatment methods have been tested for cancer therapy including natural compounds with low toxicity. ferulic acid (fa) one of these agents, an abundant phenolic compound found in various fruit and vegetables. in this study, objective was to investigate combination effect of ferulic acid and gemcitabine on apoptosis in pc- human prostate cancer cell line. cell viability was determined by using xtt method after the treatment with gemcitabine, fa and combination of both of them. total rna was isolated with trizol reagent. expressions of casp , casp , casp , casp , bcl , bax, fas and cycs genes are important in apoptosis, were evaluated in four groups by qpcr. the ic doses of fa and gemcitabine were found to be lm and lm for hours in pc- cells, respectively. for determination of combination effect, pc- cells were treated with <ic doses ( lm fa and lm gemcitabine). when compared with the control group, qpcr results illustrated, a significant increase in the expressions of bax and cycs genes whereas a decrease in the expression of bcl gene in the fa treatment group. after the treatment with gemcitabine, the expression of casp and fas genes were significantly increased compared with the control group. furthermore, combination of fa and gemcitabine significantly increased expression of casp , casp , casp , fas and cycs genes. in conclusion, it was observed that combination of fa and gemcitabine affected different genes in apoptosis compared with the single treatments in pc- human prostate cancer cell line. pistacia lentiscus linn. is widely distributed in mediterranean europe, morocco and turkey. the resin part of its known as mastic gum and plant called as mastic tree. it has been referred to over centuries as having medicinal properties to treat a variety of diseases. the aim of the present study are to evaluate antioxidant, cytotoxic and antimicrobial activities of heptane, chloroform and methanol extracts from p. lentiscus leaves and mastic gum. the antioxidant activities of chloroform and methanol extracts were assayed with various methods, including tpc, dpph free radical and abts radical cation scavenging activity. also, cytotoxicity of extracts was evaluated and screened against human mcf- , hela, a , and ht- cancer cell lines and nih- t cells. the viability of cells in lg/ml concentration of extracts was evaluated using mtt assay. antimicrobial activity of extracts were investigated against s aureus, s epidermidis, e coli, p aeruginosa, p vulgaris, k pneumoniae, c albicans, c glabrata, c guilliermondii, c tropicalis, c parapsilosis test organims by the agar well diffusion and broth microdilution methods . according to our results, the methanol extract of p. lentiscus leaves showed the highest dpph free radical scavenging activity (ic = . ae . mg/ml) and abts radical cation scavenging activity ( . ae . mg/ml). this study also exhibited that methanol extract of p. lentiscus leaves had the highest tpc ( . ae . mg gallic acid equivalents/g extract). the hexane extract of mastic gum showed antifungal activity against all of the tested candida species ( - mm / < . - mg/ml). the methanol extracts of p. lentiscus leaves showed the highest antimicrobial activity against all of the tested bacteria except k pneumoniae strain ( - mm/> mg/ml). on the other hand, p. lentiscus showed no cytotoxicity against cancer and normal cells. the results suggested that p. lentiscus may be natural source of antioxidant and antimicrobial activities. p- . . - antibacterial activity of and chemical composition of alcoholic extract of marjoram against some human pathogens m. ahanjan, m. rahbar mazandaran university of medical sciences, sari, iran herbs enjoy a unique value and importance in sustaining healthy communities in terms of disease prevention ( ) . in this regard, marjoram is a plant of the mint family which has antibacterial properties on microorganisms ( ) . the current study aims to investigate the anti-microbial activity of the alcohol extracts (i.e., methanol or ethanol) of marjoram plants on the bacteria of staphylococcus (atcc: ), aureus e. coli (atcc: ), and salmonella enterica (atcc: ) and p. aeroginosa through utilizing disk diffusion method. also, the minimum inhibitory concentration and the minimum bactericidal concentrationwere measured through tube. the measurement of minimum inhibitory concentration and minimum bactericidal concentration of ethanol and methanol extracts on e.coli were equal with and milligrams per milliliter, subsequently. moreover, the measurement of the minimum inhibitory concentration and of the minimum inhibitory concentration of marjoram ethanol extraction on staphylococcus aurous was reported to be milligrams and milligrams per milliliter, subsequently. in addition, the amount of ethanol and methanol extracts on salmonella enteric and p. aeroginosa was equal with and milligrams per milliliter, subsequently. the results showed that marjoram alcoholic extract enjoy antibacterial properties. also, among the alcoholic extracts, the ethanol extract has demonstrated to be the most effective extract on salmonella enterica and e. coli and p. aeroginosa. p- . . - molecular analysis of serine/arginine rich sc splicing factor from olive b. bas , e. d€ undar depertmant of biology, university of balikesir, balikesir, department of molecular biology and genetics, college of arts and sciences, balikesir university, balikesir, turkey olive (olea europaea l.) is an evergreen fruit tree adapted to mediterranean climate and rich in tannins, essential oils and organic acids. serine/arginine rich splicing factors are essential in seqeunce specific splicing of pre-mrnas. in this study we report molecular characterization of an serine/arginine rich sc splicing factor (oesarsc sf) that was isolated from a cdna library constructed from olive pedicels. nucleotide blast and protein blast (for comparison of the similarity of the candidate genes from other organisms) were conducted on ncbi web page. amino acid composition analysis, nucleotide composition analysis, hydropathy analysis, open reading frame determiantion, through, molecular weight and the isoelectric points calculations were conducted using online expasy software. primer was used to design forward and reverse primers to amplify the target gene from different olive tissues at different times. analysis with bioedit program revealed that a+t ratio was more than that of g+c. oesarsc sf was a protein consisting of amino acids. as expected, amino acid composition analysis revealed that serines and arginines were more than other amino acids. kyte&doolittle hyddropathy analysis revealed that the protein was hydrophilic. the molecular weight of the protein was kda with an isoelectric point (pi) of . . the protein was found to have a signal peptide. according to the predotar analysis results, intracellular localization was found to be in the mitochondrial. the combined results suggest oesarsc sf might function as splicing factor as its homologs from the other plants. confirming this hypothesis with futher experimental characterization including biochemical function analysis continues. acknowledgements: this study was supported by tub _ itak with grant number o . keywords: olea europaea l., oesarsc sf, alternative splcing, pre-mrna splicing, bioedit, pedicel specific cdnas. p- . . - application of three-phase partitioning for the purification of peroxidase from kiwano (cucumis metuliferus) z. denli , g. arabaci kto karatay university faculty of medicine, konya, faculty of arts and sciences, sakarya university, sakarya, turkey peroxidases are enzymes able to catalyze reduction of h o and oxidize various substrates. the kiwano is an oval shaped fruit which has an orange skin with lots of tiny horns. in this study, peroxidase isolated from kiwano is purified with three-phase partitioning (tpp). kiwano fruit was homogenized and obtained crude enzyme extract. the extract was saturated with % (w/v) ammonium sulfate ((nh ) so ) and added t-butanol with the ratio of : . (v/v). the lower and interfacial layer was collected. the influence of percent saturations of (nh ) so ( , , , , %) and tbutanol ratios ( : . , : , : . , : ) to the partitioning behaviour of peroxidase were analyzed. after dialyzed, the interfacial and lower phases were measured for peroxidase activity and protein content. the protein pattern of the peroxidases was evaluated by using gel electrophoresis. peroxidase activity recovery and the purification fold of interfacial and lower phases were . , . % and . , . . therefore, other experiments were continued with interfacial phase. at constant t-butanol with the ratio of : . , the enzyme activity recovery and purification fold of interfacial phase for saturations of (nh ) so ( , , , %) were . , . , . , % and . , . , . , . . the interfacial phase was not dissolved in % (nh ) so . at constant % (nh ) so , the enzyme activity recovery and purification fold of interfacial phase for t-butanol ratio ( : . , : , : . , : ) were . , . , . , . % and . , . , . , . . finally, at optimum conditions (% (nh ) so , t-butanol : . ) after dialyzed interfacial phase, the enzyme activity recovery and the purification fold were . % and . . the results of gel electrophoresis showed that the molecular weight of enzyme was between - kda. the applications of tpp gave the maximum recovery of . % and . -fold purification. as a result, for purfication of peroxidases, tpp is a rapid, simple and economical technique. accumulating the most robust genes and proteins in elite genotypes without any harmful effect on the potential plant yield is an urgent need to enhance productivity under various stressors. among the stressors, drought is a major challenge for agricultural productivity. brachypodium distachyon, with its close relationship to agriculturally and economically important crops, is an important model plant species. although ongoing transcriptomic analyses in brachypodium distachyon available, proteomic analyses are required to obtain an integrated picture of drought response. in the current study, a comprehensive proteome analysis was conducted on brachypodium leaves under increasing levels of drought stress. to screen gradual changes upon drought stress, brachypodium leaves subjected to drought treatment for , and days were collected for each treatment day. the cellular responses were investigated through a proteomic approach involving two dimensional difference gel electrophoresis and subsequent combined tandem mass spectrometry. for the validation of transcriptional expression, the genes encoding selected proteins were examined through quantitative real-time pcr. spot detection on cye-dyed gels revealed a total of distinct spots in brachypodium protein repertoire. a total of differentially expressed proteins (deps), with at least -fold changes in abundance, were identified by mass spectrometry and classified according to their functions. the biological functions of deps included roles in photosynthesis, protein folding, antioxidant mechanism and metabolic processes, highlighting the significant degree of overlapping between metabolic alterations induced by drought stress. identified proteins in this study and understanding the molecular mechanisms of drought response and defense mechanisms in plants will contribute to the researches on development of drought tolerant crop species. p- . . - immunohistochemical and electron microscopy investigation of tmv-based chimeric virus particles carrying conserved influenza antigen in nicotiana benthamiana recently we obtained and partially characterized set of viral vectors based on tobacco mosaic virus (tmv) genome displaying conserved influenza a m e epitope from matrix m protein. purified chimeric virus particles (cvp) conferred protection of mice against lethal homologous and heterologous influenza virus challenge. we revealed significant difference in symptoms of infections caused by tmv-m e recombinant viruses containing cysteine (cys) to serine (ser) or alanine (ala) substitutions in the human consensus m e sequence. accumulation level of m e-ala recombinant coat protein was significantly higher than m e-cys/ ser (ratio : ). tmv-m e-ser infection, in contrast to ala mutant, suspended growth and development of nicotiana benthamiana. non-inoculated leaves ( d.p.i.) were fixed with ethanol and histological sections were incubated with mouse serum to m e and secondary antibodies conjugated with either hrpo or fitc. cvps of all three mutants were detected in epidermal and stomata cells as well as in sieve elements and minor veins. electron microscopy analysis of mesophyll cells revealed typical rigid helical particles. cys/ser mutants mostly accumulated within ground cytoplasm as aggregates of discrete tubules in parallel arrangement, which were not delimited by lipid membranes. we discovered huge amount of cvps in the cytoplasm and lesser amount diffused in the central vacuole. essential part of ala particles was located in the cytoplasm, but mentioned aggregates were not found and only insignificant number of virions was revealed in vacuole. unlike wild-type tmv, none of the mutants was revealed in chloroplasts. diameters of cvps were as follows: sersingle particles in cytoplasm ae . cyanidin is a natural anthocyanidin found in a variety of fruits (grapes, blackberry, blueberry, cherry and cranberry etc.) and vegetables (red cabbage, red onion). this polyphenolic compound is a flavonoid with significant antioxidant activity. cyanidin and its glycosides have vasoprotective effects and can interfere with inflammation, carcinogenesis, obesity, and diabetes. one important role of the macrophages is the release of pro-inflammatory mediators, such as nitric oxide, various cytokines, in response to activation signals, including chemical mediators, cytokines, and bacterial lipopolysaccharide (lps). in this study, we investigated the role of cyanidin chloride in inflammation. anti-inflammatory effects of cyanidin chloride were examined in lps-stimulated murine raw . macrophages. we observed the level of various inflammation markers such as nitric oxide (no), inducible no synthase (inos), cyclooxygenase- (cox- ), tumor necrosis factor-a (tnf-a) and interleukin- (il- ) under lps treatment with or without cyanidin chloride. cyanidin chloride inhibited not only no production but also the expression of cox- and inos, without any cytotoxicity. cyanidin chloride also attenuated pro-inflammatory cytokines and other inflammation-related markers such as il- in a dosedependent manner. in conclusion, cyanidin chloride may be beneficial for the prevention and treatment of anti-inflammatory diseases. p- . . - the investigation of centranthus longiflorus plant extacts effects on cell proliferation and apoptosis activity in the cell lines of mcf- breast cancer h. askin ataturk university, erzurum, turkey introduction: in the u.s., breast cancer is the second most common cancer in women after skin cancer. current treatment of cancer can be done by surgery, chemotherapy, and radiation therapy. in addition, there is widespread use of complementary and alternative medicine in developed countries. plants and plant extracts play a critical role in the research into new anticancerogenic agents. centranthus longiflorus (cl) is used in alternative medicine for sedative and antispasmodic purposes. a plant of turkish origin, centranthus longiflorus used as traditional turkish medicine have remained uninvestigated for familial hypercholesterolemia, diabetes, coronary artery disease and cancer for their in vitro biological activity despite their use for sleep disorders. in this study, growth-inhibiting and pro-apoptotic effects of hexane, ethyl acetate and ethanol extracts of cl in mcf- breast cancer cell line were investigated. material and method: aerial parts of cl were collected in erzurum province. hexane, ethyl acetate and ethanol extraction were done by soxhlet extractor. the plant extracts obtained from cl was analyzed using a gc-ms system. dose-and time-dependent cytotoxic and apoptotic effects of cl were evaluated by mtt cell proliferation kit and cell death detection elisa kit, respectively. manufecturer's protocol was followed for analyses. then, apoptotic genes; caspase , bax and p and antiapoptotic genes; bcl- and pi expression levels were determined by rt pcr. results: according to our results, cytotoxic effect on mcf- cell was only observed in and lg/ml doses of cl. however, any of the application doses showed an apoptotic effect on mcf- cells. they exhibited a necrotic effect rather than the apoptotic effect. although alterations in expression levels of these genes were determined, this alterations was statistically insignificant. discussion and conclusion: consequently, we can say that cl have a cytotoxic effect on mcf- breast cancer cell lines. p- . . - reduction of the chloroplast genome and the loss of photosynthetic pathways in the mycoheterotrophic plant monotropa hypopitys, as revealed by genome and transcriptome sequencing e. gruzdev, a. mardanov, a. beletsky, v. kadnikov, e. kochieva, n. ravin, k. skryabin institute of bioengineering, research center of biotechnology of the russian academy of sciences, moscow, russia genomes of parasitic plants represent interesting model systems to study effects of relaxed selective pressure on photosynthetic function. previous genomic studies of nonphotosynthetic plants revealed reduction of their chloroplast genomes, but the corresponding changes in their nuclear genomes are less known. here we present the data on the transcriptome and the chloroplast genome of the non-photosynthetic mycoheterotrophic plant monotropa hypopitys. the chloroplast genomes were sequenced for two specimens of m. hypopitys, collected in different regions of russia. the cpdnas are , bp (mon- kalr) and , bp (mon- volr) long and rearranged with respect to each other. both genomes contains genes encoding ribosomal proteins, infa, matk, and ribosomal rna genes. and trna genes were predicted in two cpdna. genes encoding nadh dehydrogenase, plastid rna polymerase, all genes related to photosynthetic apparatus, clpp, ycf , ycf , accd, and some genes for ribosomal proteins are missing or became pseudogenes. the reduction of gene content is associated with extensive gene order rearrangement and the lack of inverted repeats. overall, the size and gene content of m. hypopitys cpdna indicates that it is close to the end of plastid genome degradation process. in order to get insights into the changes in the nuclear genome associated with the transition to nonphotosynthetic lifestyle, we sequenced and assembled the transcriptome of m. hypopitys. as expected for holoparasites, we did not found transcripts for the nuclear genes encoding the components of photosynthetic machinery, including photosystem i and ii, cytochrome b f complex, and ribulose bisphosphate carboxylase. contrary to the holoparasitic plant phelipanche aegyptiaca, almost all genes of chlorophyll biosynthesis pathway from protoporphyrin ix were not found in the m. hypopitys transcriptome. this work was supported by the rsf grant - - and rfbr grant - - (mon- volr cpdna sequencing). introduction: beta-sitosterol is a substance found in plants. chemists call it a plant sterol ester. it is found in fruits, vegetables, nuts, and seeds. it is used to make medicine. beta-sitosterol is used for heart disease and high cholesterol. the federal food and drug administration (fda) allows manufacturers to claim that foods containing plant sterol esters such as beta-sitosterol are for reducing the risk of coronary heart disease (chd). centranthus longiflorus (cl) is used in alternative medicine for sleep disorders. a plant of turkish origin, cl used as folk medicine have remained uninvestigated for familial hypercholesterolemia, coronary artery disease and preventing colon cancer for their in vitro biological activity despite their use for sleep disorders. we investigated of the chemical constituents from dried aerial parts of centranthus longiflorus. material and method: aerial parts of cl were collected in erzurum province. hexane, ethyl acetate and ethanol extraction were done by soxhlet extractor. the plant extracts obtained from the aerial parts of cl was analyzed using a perkin-elmer gc-ms system. results: ten compounds were obtained and identified as butanoic acid, hexadecanoic acid (palmitic acid), -methyl-z-tetradecen- -ol acetate, octadecanoic acid (stearic acid), diisobutyl phthalate, -octadecenamide, octacosane, nonacosane, alfa amyrin and beta sitosterol. the latter two were obtained in all extraction (hexane, ethyl acetate and ethanol). discussion and conclusion: all of these compounds are isolated from centranthus longiflorus for the first time. these findings may shed light on the design of new drugs, the cholesterollowering effect. p- . . - role of lutein for the high light-induced inhibition of photosystem ii related reactions in thylakoid membranes of arabidopsis thaliana, wt and lut k. dobrev, d. stanoeva, m. velichkova, a. v. popova institute of biophysics and biomedical engineering, bulgarian academy of sciences, sofia, bulgaria photosynthetic reactions taking place in thylakoid membranes of higher plants are extremely sensitive towards different environmental stress conditions such as high and low temperature, high light intensity, uv radiation etc. carotenoids are intrinsic component of photosynthetic pigment-protein complexes and are involved in performing multiple important functions. their role of accessory pigments in absorbing sun light, participation in photoprotection via dissipation of excess absorbed light, deactivating of stress-induced reactive oxygen species and structural role are well documented and recognized. the role of lack of lutein in high light-induced alterations in structural organization and functional activity of the main pigment-protein complexes was evaluated using isolated thylakoid membranes of arabidopsis thaliana, wt and mutant lut , deficient in lutein, subjected to photoinhibitory treatment for different periods of time. alterations in photochemical activity of photosystem i and photosystem ii were determined by a clark-type electrode in the presence of exogenous electron donors and acceptors. activity of oxygenevolving complex and of the grana and stroma situated photosystem ii reaction centers was evaluated by determination of flash oxygen yields and initial oxygen burst under constant light without donors and acceptors. low-temperature ( k) fluorescence was applied for unraveling of light-induced alterations in energy transfer and interaction between the main pigment-protein complexes. maximal quantum efficiency of psii was registered by pulse amplitude modulated fluorescence method. results obtained are discussed in respect to the importance of lutein for the organization and sensitivity of photosynthetic apparatus towards high light intensity treatment. modern agriculture relies heavily on phosphate rock fertilizer to improve phosphorus availability in many soils, but this approach is not sustainable long-term. phytate (myo-inositol hexakisphosphate) is an organic phosphorus compound often present in many soils. however, phytate can not be utilized by most plants, and its accumulation in soil leads to substantial ecological problems. phytases are enzymes that hydrolyze phytate and release inorganic phosphate. many microorganisms such as bacteria and fungi synthesize highly diverse phytases which are suitable for plant biotechnology. generation of transgenic plants expressing phytases of bacterial origin has been proposed as one option to improve plant phosphorus nutrition. in this study, we generated and characterized transgenic arabidopsis thaliana plants expressing a modified phytase gene paphyc from pantoea sp. under strong camv s promoter. three individual transgenic a. thaliana lines expressing the bacterial phytase gene, as well as negative control plants harboring the camv s promoter alone were identified. expression of phytase in plants was verified at both transcription and translation levels. phytase-expressing plants grown on media with phytate as the sole source of phosphorus demonstrated better than wild-type growth rates, shoot dry mass, shoot phosphorus content, as well as higher phytase activity in cell-wall extracts. overall, we show that plants expressing bacterial phytase are capable of better growth on phytate as the only source of phosphorus in laboratory conditions. further research investigating the applicability of using bacterial phytase expression to improve plant growth in soil is necessary to evaluate the different routes of solving the phosphorus deficiency problem in agriculture. p- . . - the role of elevated temperature in photoinhibition and recovery of photosystem ii in thylakoid membranes from arabidopsis thaliana a. faik, m. gerganova, m. velitchkova institute of biophysics and biomedical engineering, bulgarian academy of sciences, sofia, bulgaria photosynthesis of higher plants is the principle process to transform light energy into biochemical usable energy. in nature, plants are exposed to the environment where light, temperature, uv-b radiation varied and very often their extreme values that are unfavorable for effective performance of photosynthetic reactions. plant are developed various strategies to cope with stress including radical scavenging enzyme system, accumulation of protective compounds, etc. pigment-protein complexes of photosystem i and photosystem ii and their light harvesting antenna, situated within thylakoid membranes, are involved in the primary reactions of photosynthesis -absorption of light, charge separation and electron transport. photosynthetic process is sensitive towards higher than optimal temperatures, the photosystem ii and oxygen evolving complexes being extremely sensitive to elevation of temperature. in present work pam fluorescence was applied to evaluate the effect of long term action of elevated temperature ( / °c) on the quantum yield of photosystem ii, non-photochemical quenching and rdf, the latter quantifying the photosynthetic process. in addition, the activity of oxygen evolving complex was determined polarographically in the presence of exogenous electron acceptor , -benzoquinone. sds-page electrophoresis and western blot were applied to determine the damage of d -reaction center protein of photosystem ii. alterations of mutual organization within photosystem ii complex and its antenna and of energy interaction between them were followed by analysis of k steady state chlorophyll fluorescence spectra. the simultaneous application of high temperature and high light intensity resulted in a well pronounced reduction of non-photochemical quenching that restore to the initial values after recovery for days at optimal conditions. d was also restored while quantum efficiency of photosystem ii did not recuperate to initial values. p- . . - reorganization of the main pigment-protein complexes in thylakoid membranes from tomato (solanum lycopersicum) during long term exposure to elevated temperature the changes of earth climate resulted in unfavorable environment for plants. depending on the duration of influence of stress factors, the response of plants includes short and long term acclimation. the population, structure and organization of pigmentprotein complexes within thylakoid membranes are dynamic and flexible, thus providing for the acclimation of the photosynthetic apparatus to the changed environment. the main pigment-protein complexes, involved in energy transduction, are photosystem i, photosystem ii and light harvesting complexes. they are separated in grana and stroma regions of thylakoid membranes but it is well established that they can rearrange as a result of alterations of light intensity, temperature increase and decrease in order to balance the perception and utilization of excitation energy. in present work the effect of long term action of elevated temperature on organization and stoichiometry of main pigmentprotein complexes in the thylakoid membranes from tomato plants (solanum lycopersicum cv. m ) was investigated. three weeks old tomato grown at optimal conditions ( / °c day/ night temperature and light intensity lmol/m /s) plants were exposed for and days to elevated temperature at / °c. by means of blue-native electrophoresis the effect elevated temperature on the populations of psii (dimmer and monomers) and lhcii (monomers and trimers) was estimated and compared with the same parameters for control plants. the ability of plants to recover from this treatment was checked after days under optimal conditions. the changes of content of chlorophylls and carotenoids were determined at every stage of treatment. based on the results obtained it can be concluded that one of the mechanisms for regulating the energy balance and maintenance of efficient photosynthetic process involves a change in the organization and stoichiometry of the photosystem ii and oligomer state of light harvesting complex ii. aim of the study, was to evaluate the anti-tumor effects of silymarin, curcumin and propolis on leptin-induced mcf- cells. mcf- cells were incubated various concentrations leptin (physiological, obesity and pharmacologically doses; respectively , and ng/ml) . then different doses of silymarin ( , , , lm), curcumin ( , , , lm) and propolis ( . , . , . , . mg/ml) were added. after , , and hours incubation periods different area images were taken digital camera. then using dye release reagent we determined the intensity of apoptosis via colorimetric determination by elisa reader. absorbance was directly proportional the number of apoptotic cells (biocolor cell-apo percentageapoptosisassay). also, we examined the effect of these natural products on proliferation rate of leptin-induced mcf- cells for , , and hours (biovision cell proliferation kit) all experiments were carried out different days, at least times. all of three compounds were stimulate the apoptosis at all time points and all different doses of leptin. the differences was statistically significant at the level of p < . between and hours. it was found that there were not seen much cells at and hours time points. we thought that most of the cells were gone necrosis instead of apoptosis. the best effective doses on apoptosis of propolis was . mg/ml, silymarin and curcumin were lm. also, we evaluated the effects of on proliferation rate the mcf- cells, we found that only propolis was effective of inhibiting proliferation at all doses of leptin induced mcf- cells in hour. we hope this study will be a guide for the further studies in anti-cancer agent development field and show that the natural origin substances cause cancer cells apoptosis and provide targeted treatment for cancer therapy. p- . . - investigation of some lichen-derived substances' cosmetic potential for skin protection against ultraviolet b due to the depletion of the stratospheric ozone layer and chronic exposure, the occurrence of various skin diseases have been increased in recent decades. thence, people and cosmetic companies have progressively given more importance natural sunscreen products for the protection from harmful sun rays, especially ultraviolet b rays. we, therefore, isolated some lichen-derived substances; -hydroxyphysodic acid and protolichesterinic acid from hypogymnia tubulosa and cetraria aculeate, respectively. chemical characterization and identification of the isolated lichen substances were accomplished by using ftir, h-nmr and melting point analyses. the theoretical uv-vis spectra and d conformations of the isolated compounds were determined by using the gaussian software with hf theory at the b lyp/ - g level. the dark toxicities and ultraviolet b protection capacities of the substances were lighted up as previously described [ , ] on hacat human keratinocyte cell line by using mtt cell viability and ldh cellular membrane degradation assays. the obtained results from the assays showed that protolichesterinic acid has a more dark toxic activity on keratinocyte cells than hydroxyphysodic acid, and the toxic activities were found sufficient as much as % at the highest doses of the substances; lm. however, it was observed that the cytotoxicity of the substances were reduced at the rate of approximately % by the irradiation. consequently, we think that the substances block the ultraviolet b rays but their cytotoxic feature is an important limitation to their usage in cosmetic industry. references [ ] varol, m., t€ urk, a., candan, m., tay, t., koparal, a. t. ( ) photoprotective activity of vulpinic and gyrophoric acids towards ultraviolet b-induced damage in human keratinocytes, phytotheraphy research : - . [ ] varol, m., tay, t., candan, m., t€ urk, a., koparal, a. t. ( ) a great effort and financial supports have been consumed to explore and design novel sun protection factors due to the unhindered increase of malignant and non-malignant skin diseases caused by the chronic exposure and depletion of the stratospheric ozone layer. the testing of naturally produced compounds seems to be the best and inexpensive way to search for potentially photoprotective substances. on the other hand, as photo-resistant species, lichens are still poorly exploited. norstictic acid was, therefore, isolated from the acetone extract of pleurosticta acetabulum. ftir, h-nmr and melting point analyses were performed to identify the chemical features of norstictic acid. gaussian software with hf theory at the b lyp/ - g level was also performed to determine the theoretical uv-vis spectrum and d conformation of the isolated compound. the dark cytotoxicity and ultraviolet b-protection capacity of norstictic acid were comparatively tested as previously described [ , ] by using mtt cell viability and ldh cellular membrane degradation assays. as a result of the experiments, it is observed that norstictic acid has a dark-cytotoxicity as less as % at the highest dose of the substance; lm. however, ultraviolet b-induced damage on human keratinocytes was blocked by the lower concentrations of norstictic acid as , and -lm, and % of cells were protected according to the control experiments of irradiated cells. consequently, we think that norstictic acid might be employed as a sun protection factor at the low concentrations, and further studies should be performed. years, researchers have focused on the lichen acids because of their biological activities. it is also suggested that lichens can be used as anticancer agents. vulpinic acid, an important lichen seconder metabolite, has antimicrobial activity and strong antimutagenic, anticancer and antioxidant capacity. nanotechnology has the potential to offer solutions to current obstacles in cancer therapies, because of its unique size ( - nm) and large surfaceto-volume ratios. so, in this study we aimed to determine the cytotoxic and proliferative effects of vulpinic acid and magnetic nanoparticles loaded with vulpinic acid (fe there are four species of wild rice known around the world. zizania aquatica l., zizania palustris l. and zizania texana hitche are found in north america, whereas zizania latifolia (griseb) turcz) is native to east asia. cwr mainly grows in the areas along the yangzi river and the huai river in china without any cultivation and domestication. cwr was an ancient grain that has been used in chinese herbal medicine to treat a variety of ailments associated with nutrition, including gastrointestinal disorders and diabetes. our previous studies have demonstrated that consuming chinese wild rice can significantly improve blood lipid profiles and ameliorate high-fat/cholesterol diet-induced insulin resistance. however, compared to the well studied common dietary white rice, active composition and the associated proteomic information of chinese wild rice have yet to be investigated. in this study, we compared and analysed the different proteins between chinese wild rice and white rice by proteomics method. our study provides insights and experimental evidence for further exploration of this ancient medical food in disease prevention and therapy. the homology between cwr and n is %, but significant differences also exist between the two. we gained new insight by analyzing the biological function of the high reliability (credibility score or higher, p < . ) peptide mass fingerprint of cwr -de electrophoresis revealed differences in protein composition between cwr and n . information obtained from the pmf indicates that glutelin precursor, caffeoyl coenzyme a (coa) omethyltransferase and putative bithoraxoid-like protein can provide gene evidences for its biological function. p- . . - mir and growth-regulating factors interaction during maize leaf growth under low-temperature stress g. aktug, f. aydinoglu gebze technical university, kocaeli, turkey microrna (mirna) genes are a class of non-coding small rnas about nucleotide-long which are revealed as regulators of plant growth and stress responses. the mirna mir targets and regulates growth-regulating factors (grfs) which are plant specific transcription factors family and this regulation machinery is conserved among plant species. plant growth is a result of cell division and expansion which took place as spatial gradient zones throughout maize leaf which are meristem, elongation and mature zones. cells proliferate in meristem, migrate to elongation zone and finally reach to mature zone to get its final size. it has been shown that mir affects cell division by regulating grfs and changes leaf size which are determined by cell number and cell size of leaf. this study aims to investigate the role of mir and grfs interaction during maize leaf growth under low-temperature stress. maize seedlings were grown under low-night temperature for stress treatment to generate growth retardation and control conditions as well to make comparative analysis. length of the third and fourth leaves of seedlings was measured every day and leaf elongation rate was calculated to observe stress effects on the leaves. growth zones of fourth leaves were harvested during steady-state growth phase for determining expression level of mir s and their target by q-rt-pcr. we mined mir genes sharing sequence similarity and grf targets. the expression analyses of mir s and grf are proceeding for different growth zones. in conclusion, this is the first study investigating the regulation network between mir s and grf in different developmental stages of maize leaf under low-temperature stress. oeigpd cdna was isolated from a cdna library we constructed from olive pedicels. homology searches for nucleotide, amino acids and alternative open reading frames were conducted utilizing blastn, blastp, and blastx, respectively. nucleotide sequences of homologous genes from other plants were aligned using bioedit and the number of snps were detected. the alignment was then used to generate a phylogenetic tree using mega program. another alignment with amino acid sequences of the homologues proteins was also generated to construct a phylogenetic tree displaying oeigpd's position among other plants. various aspects of oeigpd including amino acid composition, hydropathy analysis, isoelectric point (pi) and three dimentional structure of the protein were determined using online software at expasy. multiple primer pairs to amplify the full length open reading frame of the gene, to clone the gene into the expressing vector plate , and to detect expression through real-time pcr were designed using primer . amino acid composition analysis revealed that oeigpd contained serine, arginine and isoleucine predominantly while hydropathy analysis suggested it was an hydrophilic protein. isoelectric point (pi) of the protein was calculated as . . the molecular weight of the protein was calculated as kda. analyses continue to determine the polymorphism of oeigpd among olive cultivars, and biochemical function of the gene in olive. p- . . - cytotoxic effect of fractionated triterpenoid glycosides from holothuria polii in human cancer cells sea cucumbers are the members of class holothuroidea and they have more than described living species all around the world. sea cucumbers secrete special secondary metabolites from their body walls and they are called triterpene glycosides (tggs). in this study, cytotoxic activity of fractionated ttgs from h. polii on different cancer cell lines were carried out. h. polii delle chiaje, samples were collected from dikili-_ izmir. the semipurified extracts were fractioned by using hplc. four different fractions (fraction a-d) were obtained. in order to characterize the fractions, maldi-tof/ms was used. the cytotoxic activity of the fraction a-d were tested on ht- , t and upci-scc- cell lines by using xcelligence rtca sp system. the cells were treated with three different concentrations of the fractions for hours. the cell index data were compared with the control group. ic values of the fractions for three cell lines were calculated. according to the results, the fractions have holothurin a ( . m/z), -dehydroechinoside a, scabraside a or fuscocinerosides b/c isomer ( . m/z). the fraction d was the most effective on all cell lines with ic value of . ae . mg/l, . ae . mg/l and . ae . mg/l for ht- , upci-scc- and t , respectively. in conclusion, sea cucumber ttgs are promising agents for colon adenocarcinoma, oral squamous cell carcinoma and colorectal carcinoma (metastatic) treatment. p- . . - effect of horse-chestnut (aesculus hippocastanum) seed extract on matrix metalloproteinases during diabetic wound healing impaired wound-healing in diabetics is a major public health problem. the expression and activation of matrix metalloproteinases (mmps) are also impaired in diabetic wounds according to previous studies. their main function is to degrade the various components of the extracellular matrix. also, they participate physiological processes such as inflammation, angiogenesis, tissue remodeling. horse-chestnut seeds (hc) are rich in saponins and flavonoids. it has been shown that hc has antiinflammatory, antioedema, vessel protective, and free radical scavenging properties. the aim of this study is to determine with molecular signs on cutaneous wound healing effects of the ethanol ( %) extract of hc (hce) seed in rats by excision wound model. this study was conducted on diabetic wistar albino rats, which were injected by a single dose ( mg/kg i.p.) streptozotocin. diabetic treatment rats were applied topically % (w/w) ointment with hce and control rats were applied topically simple ointment, once a day during the experimental period. the gene expression levels of mmp- , mmp- by qpcr and levels of nitric oxide (no), hydroxyproline and malondialdehyde in wound tissue investigated at the end of rd, th, and th days. wound closure was also measured. the hydroxyproline and no levels were significantly increased in the hce treated group versus control after the rd and th days. the malondialdehyde levels were significantly lower in the treatment group. mmp gene (associated with collagen processing and reepithelialization) expression levels in hce treated rats were increased in the th day while it was reduced in th day. mmp gene (associated with inflammation and gelatinase) expression levels in hce treated rats were decreased in th, and th days compared to the control. these findings indicate that hce accelerated the cutaneous wound healing process in diabetic rats via mmp and mmp regulation. p- . . - isolation and molecular molecular characterization of vps /vam from olive b. celikkaya, e. dundar molecular biology and genetic at balikesir university, balikesir, turkey vps /vam promotes aggregating and fusing of endosomes and lysosomes. it is a component of a protein complex that is found in vacuole membranes. this gene has been studied from various organisms including humans, drosophila, arabidopsis and rice. no studies on olive vps /vam , however, have been reported. the aim of this study is to report information of olive vps /vam including expression pattern and biochemical characterization. vps /vam was isolated from a cdna library we constructed from fruited olive leaves in july. to determine the putative name of the cdna, blast analyses were conducted for nucleotide, open reading frame and amino acid sequence comparisons. bioedit program was used to determine the nucleotide and amino acid composition along with its molecular weight and isoelectric point (pi). hydropathy analysis was conducted using kyte and doolittle program. phylogenetic analysis was done using mega . cellular localization of the product was predicted using sosui gramn. the three dimentional structure of the protein was calculated using i-tasser and compared to previously known structures using cn d. the blast and bioedit analyses revealed vps /vam had base pairs coding amino acids with a molecular weight of . kda, and pi of . . the at/gc ratio was very high ( . ) comparing to its homologs from other plants suggesting to expect significant differences of this gene's function from the others. amino acid composition analysis revealed high rates of serine, leusine and isoleucine indicating a hydrophobic property of the protein. the hydrophobic feature was confirmed by kyte and doolittle analysis while the cellular location was revealed to be extracellular. the hydrophobic nature despite extracellular location suggests it is a membrane associated protein which was confirmed by transmembrane domain analysis. as expected no signal peptide was detected. the d structure of the protein was similar to its previously reported homologs. p- . . - isolation and characterization of the ribosomal l protein from olive s. cinarli, e. dundar department of molecular biology and genetics, balikesir university, balikesir, turkey despite as a ribosomal protein, l is known as the inhibitor of the cellular aging gene and it has been reported to have roles in apoptosis. the ribosomal l protein is larger than the lsu of ribosome and contains domains as -layered alpha/beta domain and -layered alpha/beta domain. in ribosomes, it functions in translocation and orientation of trnas. although the ribosomal l (rl ) gene has been studied in many plants, reports on olive rl (oerl ) are very rare. this study presents molecular characterization of rl gene from olive. oerl was isolated from a cdna library we constructed from unfruited olive leaves in july. homology analyses were conducted using blast programs. nucleotide and amino acid compositions, molecular weight, isoelectric point (pi) and at/gc ratio were determined using bioedit and expasy programs. cellular location of the l protein was determined using sosui-gramn program. signal peptide detection, transmembrane domain detection, three dimensional ( d) structure analysis, and phylogenetic analysis were conducted using signalp . , thhmm, i-tasser/cn d and mega , respectively. oel was found to have an open reading frame of base pairs coding amino acids that constitutes a molecular weight of . kda and a high pi of . . lysine, leucine and valine had higher rates. the hydrophilic nature suggested by kyte and doolittle analysis despite high rates of leucine and valine suggests an amphipathic nature of the protein that can bind to both hydrophilic and hydrophobic proteins and / or function in both media. a . at/gc rate is significant comparing to that of its homologs from other plants. sitoplasmic location predicted by sosui-grann is in agreement with the hypothesis suggesting an amphyphatic nature for oerl . likewise, no signal peptide was detected and it was predicted to have at least one transmembrane domain. further characterization of oerl with respect to expression pattern and biochemical function continues. p- . . - isolation and characterization of an olive splicing factor b subunit m. nurcin, e. dundar department of molecular biology and genetics, balikesir university, balikesir, turkey splicing factor b subunit (sf b ) functions in the regulation of translation and gene expression. sf b forms u small nuclear ribonucleoprotein complex (u snrnp). splicing factors a and b binds pre-mrna at the site of the intron branching point. this binding joins u snrnp to pre-mrna. although sf b from various plants have been widely studied, no studies on olive sf b (oesf b ) have been reported. this study reports information on various aspects of oesf b . oesf b was obtained from a cdna library we constructed from fruited olive leaves in december. it was putatively identified as a splicing factor using blastn, blastp and blastx. to determine wheter oesfb was a sitoplasmic protein, sosui gramn was used. tmhmm was used to detect any transmembrane domains while signal peptide analysis was conducted by signalp. i-tasser and cn d were used to generate the calculated d structure and to compare it with experimentally generated models, respectively. nucleotide and amino acid compositions along with the calculated molecular weight and isoelectric point (pi) were analyzed using bioedit and online expasy software. the phylogenetic trees revealed genetic relationship of olive among other plants based on oesfb . the orf contained nucleotides coding amino acids that produce a . kda peptide with a pi of . . alanine, valine and leucine were found at high ratios suggesting a hydrophobicity which was also predicted by kyte and doolittle analysis. the at rich property of oesf b is not unusual comparing to most plant genes. cellular localization of the gene was suggested to be in mitochondria with no signal peptide indicating oesf b could be synthesizing in mitochondria. the predicted d structure of oesf b was similar to experimentally produced structures while some hydrophobic pockets were predicted. further characterization of the gene with respect to temporal and spatial expression pattern and biochemical function continues. p- . . - kafirin profile of turkish originated sorghum populations r. temizg€ ul, s. yilmaz, m. kaplan, t. akar department of biology, faculty of science, erciyes university, kayseri, turkey sorghum bicolor l. is the fifth important crop in the world with its high photosynthetic activity and resistance to unfavourable conditions as high temperature, drought, salt, and ph changes. sorghum has attracted great interest due to its intensive usage both as human and animal nutrition, and contribution to resistance against many diseases. some proteins of sorghum exerts reducing effect on nutrient digestion through making connetions with other proteins and/or carbohydrates. kafirin proteins have the highest proportion in grain with a range of - %. they are grouped into a ( - kda), b ( kda), c ( kda) and d ( kda) subunits depending on molecular weight, solubility and structure. in the current study, kafirin proteins from turkey originated sorghum populations were acquired through sequential extraction; first, non-prolamines were removed through application of % naci concentration, and second, kafirins were obtained using tertiary butanol ( %) and reducing agents. sds-page was conducted for seperating and visualising the subunits of kafirins. the a, b, c, and d subunits of populations were respectively estimated as , , , and %. of the total proteins, % was identified as a, % b, % c, % d, and % non-prolamines. non-prolamin group of proteins were visualised as different bands ranging from . to kda. c and b group of proteins were only viewed when treated with reducing agents as -me and dtt suggesting that they are connected with complex cross-links. however, a group of proteins visualized without using these agents due to not having intra molecular disulphide bridges and inter molecular cross-links. non prolamins, except for . , . , . , . and . kda, were able visualised in the presence of reducing agents. transcriptomic analysis of the genes encoding analysed proteins needs to be elucidated for better understanding of the genetic diversity and biochemical characteristics of sorghum. p- . . - untargeted metabolomic profiling of romanian and uk tomatoes varieties by high performance liquid chromatography coupled with mass spectrometry c. socaciu , university of agricultural sciences and veterinary medicine, cluj-napoca, center for applied biotechnology ccd-biodiatech at proplanta ltd, cluj-napoca, romania tomato flesh is a rich source of many phytochemicals of high nutritional value, including a large variety of carotenoid derivatives with health promoting properties. metabolomics became the most adequate technology for an accurate chemotaxonomic classification and discriminations between different varieties, based on untargeted profiling or targeted, quantitative analysis. different varieties of tomatoes (b-carotene-rich, lycopene-rich, ketocarotenoid-rich) cultivated in romania and uk were comparatively studied using enriched fractions obtained by a preliminary fractionation of the whole pulp homogenate. two methods were applied for carotenoid extraction: a mixture of hexane/ethanol ( ) and chloroform/methanol ( ) . the dried extracts were dissolved in ethyl acetate and analyzed by uv-vis spectrometry and hplc-esi(+)qtof-ms (bruker gmbh). the base-peak chromatograms were processed by specific biostatistics software (data analysis and profile analysis) and the molecular identification were determined by comparison with the data base lipidomics gateway (www.lipidmaps.org). the content of carotenoids were significantly higher using extraction ( ) , ranging from . to . mg/ g. the major carotenoid derivatives, were represented by lycopene, hidroxy-lycopene, all-trans or cis-beta-carotene, echinenone, all-trans retinyl palmitate, but also sterols, phospholipids, di/tri glycerides and ceramides. the romanian varieties were more rich in polar carotenoids and lipids, in general, while the uk tomatoes proved to be enriched in non-polar derivatives, especially esterified carotenoids, keto-carotenoids and glycerides. new molecules were identified, as good discriminatory markers of each tomato variety. acknowledgements. this work was supported by a grant of the romanian national authority for scientific research and innovation, cccdi -uefiscdi, project nr. / , pncdi . glycogen is a multi-branched polysaccharide that serves as the main form of glucose storage in the body, where the main reserves are in the liver and muscle. it has been observed that glycogen metabolism is altered in many tumor types, and that glycogen content is inversely correlated with proliferation rate. in addition, it has recently been described that when glycogen accumulation is forced in glioblastoma u cells in hypoxia, senescence is induced and tumor growth is inhibited in vivo. our laboratory has various animal models with different parts of the glycogen metabolism pathway affected. most notably, we have two animal models lacking glycogen: muscle glycogen synthase (gys ko) and liver glycogen synthase (gys ko) knockout animals. we isolated mouse embryonic fibroblasts (mefs) from gys ko to perform replicative senescence assays. in addition, we induced hepatocellular carcinomas in gys ko animals via n-nitrosodiethylamine (den) injections in order to track tumorigenesis in animals lacking hepatic glycogen. lastly, we performed partial hepatectomies (phx), which involves the resection of two thirds of the liver, on gys kos to evaluate the effect of the lack of glycogen on hepatocyte proliferation. interestingly, we have observed that glycogen levels are increased in human and mouse fibroblasts under replicative senescence, and that mefs depleted of glycogen bypass senescence and immortalize faster than wts. we have also demonstrated that senescence pathways are down regulated in mefs lacking glycogen. furthermore, gys kos treated with den show higher tumor burden and mortality than controls. we also evaluated the effect of glycogen on hepatocyte proliferation after phx. gys ko mice present faster proliferation and liver regeneration rates, when compared to wt counterparts. collectively, our preliminary data suggest that glycogen metabolism plays a crucial role in the regulation of cell cycle in both physiological and pathological states. it is established that pineal is involved in circadian regulation of testosterone secretion from leydig cells. however, the precise routes of this regulatory involvement are still unknown. as cgmp has been also regarded as modulator of steroidogenesis we sought to study the effects of pineal removal on the circadian pattern of cgmp variations and expression of the genes that encode elements of no-cgmp signaling pathway in adult rat leydig cells. the analysis was performed on testicular leydig cells obtained from pinealectomised and shame pinealectomized rats, in six time point during hours. the pinealectomy was confirmed by serum melatonin eia measurement. the androgen levels were measured by ria; cgmp by eia and gene expression was quantified by rq-pcr. all results were analyzed by cosinor method. data revealed circadian transcriptional pattern of nos , nos (genes encoded no producers) and pde a (gene for cgmp remover) in leydig cells from adult rats. pinealectomy significantly increased expression of nos which lost rhythm and increased and delayed amplitude of nos expression. further, pinealectomy initiated cyclic transcription of gucy b and noncyclic transcription of gucy a (genes encoded cgmp producers) and increased mesor and amplitude of pde transcription. the transcription of prkg , the main effector in this signaling pathway was not affected with pineal abolition. additionally, pinealectomy did not influence the circadian transcription profile of coxi or other investigated genes (coxi , nrf , nrf a, pgc a) related to mitochondrial function and biogenesis. finally pinealectomy reversed phase of circadian cgmp oscillation in leydig cells, increased amplitude and slightly advanced peak of serum testosterone oscillation. results suggested pineal influence on circadian rhythm of no-cgmp signaling in leydig cells. further studies based on these data are needed to better understand the relationship between pineal and circadian rhythm of testosterone production. influenza is a contagious respiratory infection caused by a variety of influenza viruses. neuraminidase inhibitors is a new class of antiviral drugs that inhibit influenza viruses. the most popular antiviral agents is oseltamivir, having a commercial name of tamiflu, within anti-influenza antivirals. as well as tamiflu is a member of neuraminidase inhibitor group drug. therefore, this study was performed to determine the effect of tamiflu on cultured human peripheral blood lymphocytes. material and methods: for examining the presence of the indirect mutagenic effect of oseltamivir in iver s fraction mix was used. cells were treated with . , and lg/ml oseltamivir, the tamiflu capsule ingradient, for or hours in the absence or presence of an exogenous metabolic activation system. the test chemical did not demonstrate any genotoxic effect dose-dependently but it showed a weak cytotoxicity on cells in this study. on the other hand, some concentrations of tamiflu induced sce and also decreased significantly the proliferation index (p ˂ . ) in the absence of s mix. result: tamiflu did not induce significant increases of ca or micronucleated cells in vitro in cultured peripheral blood lymphocytes under the treatment conditions used but week sce induction was observed. on the other hand, the weak cytotoxic effects observed disappeared in the cultures treated in presence of the s mix. discuss and conclusion: tamiflu weakly induced sce at the highest concentration with/without added s mix in cultured human peripheral lympocytes. it could be assumed to be a sce inducer. sces can be increased by several agents that attack dna. tamiflu decreased the proliferation index and nuclear division index at some concentrations thus interferring it as being weakly cytotoxic, though this effect disappeared in the presence of s mix applications. this finding is important for showing the inefficiency of tamiflu metabolites on the cell cycle. introduction: chronic renal failure as a result of the progression of diabetic nephropathy is the main cause of mortality in patients with type diabetes. chronic hemodialysis is a life-saving therapy for patients with strong renal disorders. the main goal of hemodialysis is toxins removal from the patient. the monitoring of hemodialysis is the best way for biomedical evaluation of correctness and efficiency of this clinical treatment. according to the published data, the markers of development of diabetes complicated with renal failure are increased levels of glucose, urea and creatinine in the patient blood. today colorimetric and spectrometric methods are most commonly used for determination of the above metabolites in biological samples. however, these methods are complex in application, have low selectivity, and require pretreatment of samples. materials and methods: we propose for levels of glucose, urea and creatinine detection the potentiometric multibiosensor based on ph-sensitive field-effect transistors and immobilized enzymes developed in our laboratory. results: we developed a potentiometric multibiosensor and studied its main analytical characteristics. linear dynamic ranges of determination of substrates were following: . - mm of glucose, . - mm of urea, and . - mm of creatinine. it was shown that the potentiometric multibiosensor had good reproducibility, and its bioselective elements were working independently from each other, because test of substrates cross-selectivity was negative. discussion and conclusion: very sensitive, fast and selective multibiosensor for simultaneous measurement of three metabolites in a single cycle based on ph-sensitive field-effect transistors and immobilized enzymes is developed. the developed potentiometric multibiosensor was verified by quantitative analysis of glucose, urea and creatinine in blood serum of patients with diabetic nephropathy. p- . . - ph-dependent interaction of asymmetrically charged peptides with a protein nanopore over the past two decades, the ability to use natural or artificial nanopores to probe at uni-molecular level the structural and kinetic features of various bio-molecules (peptides, dna, rna) was successfully achieved. the operating principles of the nanopore-based single-molecule technique are simple: the single macromolecule capture, entry and subsequent translocations through a free-standing, voltage-biased nanopore, depend upon the physico-chemical and topological features of the analyte. the concentration, identity volume and charge of the analyte are then deduced from the analysis of the stochastic current blockade events caused by the trafficked analyte across the nanopore. herein, we used the a-hemolysin (a-hl) nanopore and set up an experimental model providing efficient control of a-hl-peptide interactions, in the presence of a ph gradient across the nanopore. for this, we engineered a amino acids long peptide containing a neutral asparagines-containing sequence, flanked by oppositely charged aminoacid patches at the n-(glutamic acids) and c-termini (arginines), whose length was set as to span a single a-hl protein. when the ph of the solution in contact to the a-hl's b-barrel opening is changed from neutral to acidic values, the electrostatic interactions between the protein's mouth and either the n-or c-terminus end of the peptide occurs, and this influences strongly the dynamics of a peptide translocating the nanopore. we further proved that during the same experiment, peptide entry into the nanopore can be set to occur with either n-or c-terminus end head on, by simply changing the sign of the transmembrane potential across the nanopore. nanopores are emerging as a powerful and broadly applicable tool in biophysics, which allows one to study the features of charged macromolecules under confinement. a few noteworthy examples are: determining the electrophoretic mobility, effective charge and diffusion coefficients of charged molecules; exploring the folding and unfolding of peptides and proteins; analyzing biopolymers trafficking, protein transport, dna translocation, rna and dna sensing and sequencing. herein, we employ single molecule analysis techniques using a wild-type ahemolysin (a-hl) protein nanopore to study the capture and translocation behavior of a short cationic peptide ( amino acids in length) at an extremely low ph value. our experiments revealed that an effective absorbing field is created by the electroosmotic flow, against the electrophoretic force, which enables the peptide capture inside the nanopore. furthermore, our findings show that the trajectory of a single peptide can be experimentally visualized and the main steps determined: the peptide capture, reversible translocation across the pore's vestibule and lumen regions, and the peptide release from the nanopore. also, the kinetic analysis of the main steps observed allowed us to describe the free energy profile of the peptide interactions with the protein nanopore. the presented work provides evidence for the ability of controlling the dynamics of a single-peptide, its capture and passage inside a a-hl nanopore, that underlie the processes naturally occurring in cells, thus proving a powerful approach for probing single molecule biophysics phenomena, in general. changes in the physical conditions of the cancer microenvironment driven by elevated tissue growth and angiogenesis, may introduce exposure of laminar fluid flow, which effect the key factors of cancer, such as progression, immune-escaping and metastasis. conventional experimental models fail to mimic the physical cues on tumor microenvironment. microfluidic culture techniques allow precise control of fluids, simultaneous manipulation and analysis of cultured cancer cells. here, we present a platform that can be used for the investigation of the role of flow mediated mechanical stimuli on cancer cells. microfluidic cell culture platform was fabricated using polymethyl methacrylate and double-sided adhesive films with mm dimensions. ovary adenocarcinoma cells (efo- and onco-dg- ) were used for the optimization of the platform. to understand the fluid and gas distribution patterns, specific modeling was performed. dynamic microfluidic cell culture and static conventional cell culture conditions were compared for the differences of cancer cell phenotype, such as proliferation, viability, epithelial-mesenchymal transition. we confirmed that, the proliferation and viability of cancer cells are increasing under dynamic fluid flow. the proliferation rate of ovary adenocarcinoma cells was correlated with the increase of fluid flow rate. immunocytochemical analysis showed that fluid flow causes decrease in e-cadherin expression, and increase in n-cadherin and vimentin expressions, which indicate mesenchymal phenotype of cancer cells. our results showed that, cancer cells present different characteristics due to fluid flow of tumor microenvironment. to understand the role of physical dynamics by using microfluidic culture techniques, is a key to elucidate the mechanisms underlying disease progression, and may lead to new diagnostics and therapeutic approaches. (this study was funded by turkish scientific and technical research council (tubitak- s ). high-sensitive detection of low-affinity antibodies by immuno-pcr with supramolecular olygonucleotide-streptavidin complex detection of low affinity antibodies in blood sera and cell surface outwashes is important both in the study of molecules that bind to cellular receptors (circulating tumor cell masking antibody, for example) and medicine (diagnosis of allergy). low affinity igm and ige antibodies can not sometimes be determined by conventional methods. we using supramolecular oligonucleotide-streptavidin complex formed from single-stranded synthetic oligonucleotide ( n) contains biotin on '-and '-ends, and sterptavidin in molar ratio : . this complex represents a structure with equivalent electrophoretic mobility of bp dna and preferred "valency" of streptavidin is . this universal immuno-pcr approach make it possible to increase a signal by using several oligonucleotides per one antibody. after the method optimization we achieved - times highter sensitivity than elisa. to reduce the matrix effect we used - fold dilutions of sera samples. this approach achieved a significant advantage, because it allows working with small-volume samples (need only mkl of serum sample). antibodies to the disaccharide galb - glcnac (le c ) are typical of the natural antibodies. the igm anti-le c antibodies are found in almost healthy people without the epitope specificity variation. we have shown that the concentration of igm anti-le c antibodies was higher (p ≤ . ) for health donor sera (n = ; . ae . pg/ml) compared with sera from patients with breast cancer (n = ; . ae . pg/ml). sensitivity of igm anti-le c antibodies detection was pg/sample ( mkl) ie . molecules. thus for the immuno-pcr detection of antibodies the - tumor cells are sufficient. such amount of cells seems to be a realistic one for detection of antibodies masking circulating tumor cells. this study was supported by a grant from russian science foundation (# - - ) and by russian federation president scholarships donated to d. yu. riazantsev (# sp . . bacterial pathogen detection and identification is of crucial importance for disease diagnosis, bacterial contamination surveys and water quality assessment. we propose herein a novel method for bacterial detection based on the interaction of single gram-negative bacterial cells (i.e.: escherichia coli and pseudomonas aeruginosa) with an ahemolysin (a-hl) protein nanopore embedded in a reconstituted lipid bilayer, at neutral ph. as a consequence of an applied voltage, the negatively charged bacteria suspended in saline buffer solution are electrophoretically driven towards the pore opening, inducing reversible blockages in the ionic current through a-hl. experiments were also performed in the presence of an antimicrobial peptide, cma , as well as in acidic environment. statistical analysis of the frequency and duration of blockage events allowed us to discriminate between the two types of bacteria. the frequency of interactions was higher for escherichia coli with respect to pseudomonas aeruginosa. adsorption of cma peptides on the membrane of bacteria increased the frequency of interactions with the pore, contrary to the expected effect induced by lowering the net surface charge of the cells. in experiments performed at ph = , the frequency of blockage events was found to be two orders of magnitude higher, with longer interaction life-times. the net negative charge ( uncompensated aspartate residues) localized at the entrance of the pore contributes an additional electrostatic repulsion interaction between negatively charged bacterial cells and a-hl. thus, adsorption of cationic peptides at the interface will reduce this repulsive interaction. the same effect was recorded at ph = , when the aspartate residues are partially protonated, confirming our understanding of the previously observed results. this method could be further developed and integrated with other techniques, making nanopore-based systems a fast and reliable bacterial detection and identification tool. this study was performed to analyze the effects of tunicamycin (tm) and taurohyodeoxycholic acid (tudca) on thle- cells. cells were treated with tm to induce endoplasmic reticulum (er) stress and tudca was administered as an er stress inhibitor. cytotoxicity was evaluated at different times of exposure by incubating cells with increasing concentrations of either tudca, tm or both. thle cells were cultured in fibronectin, bovine collagen i and bovine serum albumin coated plates. cell lines were grown in begm media supplemented with epidermal growth factor, phosphoethanolamine, fetal bovine serum, u of penicillinstreptomycin and maintained in a humidified incubator at °c and a % co atmosphere. cell viability was measured using the colorimetric -( , -dimethylthiazol- -yl)- , -diphenyltetrazolium bromide (mtt) assay kit. cells were grown to confluence in well plates and incubated with ll/ml dmso, - lg/ml tm, . - mm tudca, or lg/ml tm + . - mm tudca for - hours. control cells were prepared in plates containing only medium. at the end of the incubation period, mtt was added to each well and incubation was carried out for hours at °c. formazan production was expressed as a percentage of the values obtained from control cells. at all hours of incubation neither dmso or mm tudca was cytotoxic. at and hours incubations mm tudca and lg/ml tm + mm tudca were significantly cytotoxic compared to control, dmso and mm tudca groups. treatment of cells with . mm tudca hours before administrating ug/ml tm significantly decreased the cytotoxic effect of tm. we conclude that tudca may show cytotoxic effects at mm concentration when treated with tm. therefore . mm of tudca, administered hours before tm treatment should be applied to protect against er stress. acknowledgement: this study was supported by a grant from the scientific and technological research council of turkey (tubitak; s ). recent studies reveals that history of preeclampsia is an independent risk factor for cardiac events and stroke. lipoprotein-associated phospholipase a (lp-pla ) is a vascular inflammatory marker associated with cardiovascular diseases (cvd). we hypothesize that vascular inflammation (lp-pla mass, activity, index) related genetic variations (pla g ) increase the risk for developing future cardiovascular disease in women with pe. a group of preeclamptic patients and normal pregnant women were recruited from university of istanbul, cerrahpasa medical school, department of gynecology and obstetrics included into the study. the control group was matched for maternal and gestational age at time point of sampling. preeclamptic patients were starified into two groups; early-onset and late-onset according to the gestational weeks. enzyme-linked immunosorbent assay procedure was used to determine the serum lp-pla mass level. lp-pla activity were determined by kinetic method. plag snp genotyping performed by using the sequenom massarray iplex. the rs tt genotype had a higher lp-pla index (p = . ) for early onset preeclampsia, cc genotype had a higher lp-pla mass and lp-pla index for late onset preeclampsia. no difference were found for control. the rs gg genotype had higher lp-pla mass and index for late onset preeclampsia (p = . , p = . respectively). stepwise logistic regression analysis performed to identify cardiovascular disease related variables that independently and significantly contributed to the presence of alleles of rs and rs snps in early, late onset preeclampsia and control group. only lp-pla mass was independently and significantly associated with both snps in early onset preeclampsia. the association between lp-pla mass, index and rs , rs snps might be useful genetic markers to adress future cvd risk in patients with preeclampsia. introduction: b-thalassemia is one of the most monogenic autosomal recessive disorder characterized by defective production of the b-chain of hemoglobin. definition of the b-globin genotype is necessary for genetic counselling in the carriers, and for predicting prognosis and management options in the patients with thalassemia. dna-based diagnosis of b-thalassemias routinely relies on polymerase chain reaction (pcr) and gel electrophoresis. the aim of this study is to develop a new procedure, a dna-based piezoelectric biosensor, for the detection of b-thalassemia ivsi- mutation, the most common b-thalassemia mutation in turkey. materials and methods: b-globin gene of genomic dna isolated from whole blood, was amplified by pcr. bioactive layer was constituted by binding -hidroxymetacrilate metacriloamidoscystein (hema-mac) nanoploymers on the gold electrode's surface. single oligonucleotide probes specific for ivsi- mutation of b-thalassemia were attached to the nanopolymer via reactive cross-linker glutaraldehyde. the measurements were executed by piezoelectric resonance frequency which is caused by binding of pcr products in media with single oligonucleotide probe on the electrode surface. the results were confirmed by the conventional molecular method as arms. results: the piezoelectric resonance frequencies obtained by hybridization of the pcr products on bioactive layer were found ae , ae , and ae hz for the samples of normal b-globin, heterozygote, and homozygote of ivsi- mutation, respectively. discuss and conclusion: the developed biosensor serves as a specific result to ivsi- mutation. it could accurately discriminate between normal and ivsi- mutation samples. because of low costs, fast results, specificity and high detection/information effectiveness as compared with conventional methods, we can be offered this techique as an alternative to conventional molecular methods. the increasing use of nano-sized materials in the last several years has compelled the scientific community to investigate the potential hazards of these unique and useful materials. one of the most widely used nanoparticles is titanium dioxide. the objective of the research is to investigate the alterations in molecular and cellular responses in culture of primary lymphocytes to tio nps. human lymphocytes isolated from heparinized blood of healthy individuals were exposed to tio nanoparticles. viability, ros generation, the changes in the expression of genes encoding proinflammatory mediators tnf-a, il- b and il- and dna damage were assessed. human lymphocytes were incubated with nanoparticles of different concentrations and viability was determined in and hours after treatment, respectively. cell viability was decreased by a treatment with nanoparticles in both a time-and concentration-dependent manners. the ability of tio to induce ros formation in lymphocytes was evaluated using dcf fluorescence as a reporter of oxidant production. the fluorescence intensity of oxidized dcf was increased in cells treated with nps. this means that ros generation occurred in response to the treatment with tio . to investigate the expression level of mrna related to the inflammation responses in human lymphocytes real-time pcr was performed. the expression of il- b, il- and tnf-a genes were increased by the exposure to nanoparticles of , and lg/ml for - hours. tio nanoparticles were shown to induce the dose-dependent fragmentation of dna strands. much evidence of hazardous health effects of nps has been reported. in this study, viability was reduced under the exposure to tio . oxidative stress was elevated by the treatment with tio nps. oxidative stress can also trigger inflammation signals. induced by exposure to nanoparticles they may cause the translocation to the nucleus of transcription factors, which regulate proinflammatory genes, such as tnf-a, il- b, il- . background: endothelial cells (ec) represent one of the primary targets of the major pro-inflammatory cytokinetumor necrosis factor (tnf). development of the new approaches for the treatment of acute and chronic inflammatory conditions, including the strategies aimed to tnf neutralization, requires the usage of the adequate cellular models closely resembling the properties of the endothelium. the endothelium-derived ea.hy cell line expresses several inflammation and neoangiogenesis markers in response to activation factors however their expression can differ from the patterns demonstrated by primary ec. the aim of the current study was to compare the expression of the known endothelial cellular markers including receptor of vascular endothelial growth factor- (vegfr ) and a v b -integrin on d and d cultures (spheroids) of ea.hy . methods: the ea.hy cell line was used with permission from dr. edgell. the cells were cultivated in the presence of tnf ( ng/ml) or vegf a ( ng/ml) for hours. mrna was isolated using rneasy kit from qiagen and reverse-transcribed with revertaid kit (fermentas). rt-pcr was performed with specific primers. expression of vegfr and a v b -integrin was visualized by confocal microscopy using specific monoclonal antibodies and previously developed fluorescent hybrid proteins. results: the expression of a v b -integrin and vegfr- increased on the d culture compared to d according to confocal microscopy and rt-pcr. the aforecited methods revealed elevated expression of a v b -integrin in the d culture of the ea.hy cell line activated with tnf. also increased expression of vegfr in the d culture activated with vegf a. then by confocal microscopy, we analyzed our fluorescent hybrid proteins that bind a v b -integrin and vegfr on the surface of d and d cultures as well as antibodies with fluorescent label. conclusions: d cultures of the ea.hy cell line represent a promising model for the inflammation studies. tumor necrosis factor (tnf) is a trimeric cytokine associated with the inflammatory response to tissue injury and found to possess a key role in rheumatoid arthritis pathogenesis. spd is a highly toxic recently discovered tnf inhibitor that promotes trimer dissociation and lead to the inactivation of the protein. according to the traditional anti-tnf treatment of ra, we aim at extracellular inhibition of this pro inflammatory cytokine as an effective therapy. the project plan comprises design, synthesis and validation of candidate inhibitors (measurement of dissociation constant and aqueous solubility). because of the elevated percentage of insoluble compounds a solubility enhancement protocol has been developed. the experimental procedure was the following:: a. drug design. identification of novel drug compounds are based on two approaches: i) structure based drug design using the d structure of tnf and ii) design of more potent and less toxic spd analogues. b. drug synthesis. a series of spd analogues were in house synthesized while novel candidates discovered by in silico approaches were commercially available. the purity of the majority of the compounds exceeded %. c. solubility measurement and enhancement. samples were incubated under specific conditions that can enhance aqueous solubility and solubility measurement with a direct uv method pursued. d. measurement of the dissociation constant. a fluorescence binding assay was used in order to evaluate the inhibitory activity of the compounds. from our results it can be concluded that dmso, peg and b-cyclodextrin can be used for solubility enhancement without interfering with fluorescence assay. however peg -in contrast to dmso-is not suitable for isothermic titration calorimetry measurements. dissolution procedure also plays a crucial role in the levels of solubility reached. finally, it has been shown that some of the studied spd derivatives have better dissociation constants than spd . the effect of exercises on serum bmp- levels of knee osteoarthritis cytokines. more complicated approaches are expected to focus on molecular proteins as bone morphogenetic proteins (bmps) of the transforming growth factor (tgf)-beta superfamily. bmps associated with many cellular functions, such as proliferation, differentiation, and apoptosis. bmp- is significantly important for the endochondral bone formation. inflamation can induced serum bmp levels in oa patients. the aim of this study is to evaluate the clinical findings of oa patients after the isokinetic exercise together with the serum levels of bmp- to sustain the molecular approaches for treatments. a total of patients were included in this study. the groups are formed as follows: group , oa patients before the exercise; group , oa patients after the exercise; group , oa patients before the isokinetic exercise; group , oa patients after the isokinetic exercise clinical and biochemical findings were evaluated before and after weeks of the exercise programme. self reported severity of pain was measured using the mm visual analog scale (vas), womac scores were calculated and isokinetic knee muscle strength testing was measured using cybex dynamometer that a standardized protocol previously described was applied in a subject-specific range of motion. serum bmp- levels of all patients were studied by elisa method. results represented a better vas and womac scores for all exercise groups after treatment. the serum bmp- levels were significantly decreased in group compared to group ( . ae . ; . ae . respectively, p < . ) and in group compared to group ( . ae . ; . ae . respectively, p < . ). there is not any statistically differences between group and group (p > . ). as a conclusion, the decreased serum levels of bmp- may be suggested as a biochemical marker for oa patients during exercise programmes. p- . . - tnf-a blokade efficiently reduced severe intestinal damage in necrotizing enterocolitis c. tayman, s. aydemir, i. yakut, u. serkant, a. c ß iftc ßi g€ olbasi devlet hospital, ankara, turkey objectives: to ascertain the beneficial effects of infliximab an inhibitor of tumor necrosis factor alpha (tnf-a) on the development of nec in an experimental nec rat model. material and methods: thirty newborn sprague-dawley rats were randomly divided into three groups as nec, nec+ infliximab, and control. nec was induced by enteral formula feeding, exposure to hypoxia-hyperoxia and cold stress. pups in the nec+ infliximab group were administered infliximab at a dose of mg/kg daily by intraperitoneal route from the first day until the end of the study. all pups were sacrificed on the th day. proximal colon and ileum were excised for histopathologic, immunohistochemical (tunel and caspase- ), and biochemical evaluation, including, total antioxidant status (tas), total oxidant status (tos), malonaldehyde (mda), and myeloperoxdase (mpo) and tnf-a activities. results: we observed better clinical sickness scores, weight gain, and survival rate in the nec+ infliximab group compared to the nec group (p < . ). histopathological and apoptosis examination (tunel and immunohistochemical evaluation for caspase- ) revealed lower damage in the nec+ infliximab group compared to the damage in the nec group (p < . ). tissue mda, mpo, tnf-a levels, and tos were significantly decreased in the nec+infliximab group, whereas tas was significantly increased in the nec + infliximab group (p < . ). conclusion: tnf-a blockade with infliximab efficiently reduced the intestinal injury and preserve the intestinal tissues from severe intestinal damage by its complex mechanisms on nec. therefore, it may be an alternative option for the treatment of nec.keywords: tnf-a; infliximab; necrotizing enterocolitis; newborn; protection; rat; treatment p- . . - short-term diabetes causes cardiovascular inflammation: anti-inflammatory effect of resveratrol introduction: diabetes is a metabolic dysfunction and has been associated with various disorders including inflammation, cardiomyopathy and coronary artery disease. inflammation is a protective mechanism elicited by the host in response to infection, injury, and tissue damage. the aim of this study was to investigate the effect of intraperitoneally resveratrol administration on cardiac and vascular function in diabetic rats. materials and methods: diabetes was induced in sprague-dawley rats by using injection of streptozotocin ( mg/kg, i.p.). rats were divided into group i: control, ii: control/ mg/kg resveratrol; iii: diabetic/vehicle; and iv: diabetic/ mg/kg resveratrol. histopathological examinations with masson's trichrome and verhoeff-van gieson staining were carried out to reveal cardiac and vascular tissue damage and inflammation. in addition to plasma glucose and cardiac & vascular mda levels were measured by standard enzymatic kits while tnf-a, il- b, il- (mbl) were analyzed by elisa kit. results: final body weight decreased in all groups compared to control. in the diabetic rats, plasma glucose and vascular mda levels were enhanced while cardiac mda was unchanged compared to control. vascular tnf-a, il- b and mbl and cardiac mbl were increased in the diabetic groups compared to control. discussion and conclusion: it has been found that resveratrol has greatly normalized altered parameters. taken together, resveratrol partly improved cardiac and vascular inflammation induced by diabetes. this may be due to the healing activity of resveratrol on pro-inflammatory markers. p- . . - cytokine network is critical in growth hormone-induced resistance mechanism against curcumin which modulates jak/stat/ socs pathway in mda-mb- and mcf- breast cancer cells m. c ß elik, a. c ß oker g€ urkan, e. damla arisan, p. obakan yerlikaya, n. palavan unsal t.c. istanbul k€ ult€ ur university, istanbul, turkey curcumin (diferuloylmethane), a polyphenolic compound that triggers apoptotic cell death in various cancer cells such as prostate, colon, melanoma and breast cancer. a pituitary-derived hormone, growth hormone (gh) play role in elongation and differentiation of ductal epithelia into the breast terminal and buds. in this study, our aim is to determine the role of inflammation in curcumin induced apoptotic cell death via acting on jak/stat/socs pathway in wt and gh+ mda-mb- and mcf- breast cancer cell lines. according to mtt cell viability assay curcumin triggers cell viability loss in time and dose dependent manner in mda-mb- wt and mda-mb- gh+ breast cancer cell lines, respectively. selected concentrations of curcumin as lm (for mcf- ) and lm (for mda-mb- ) decreased cell proliferation and induced apoptosis through causing jak dephoshorylation, stat , , dimerization and acting on socs proteins expression in each cell lines. in addition, activated jak/stat/socs pathway, via forced gh expression has been suppressed following curcumin treatment for hours. lm curcumin-induced apoptotic cell death via dephosphorylating jak at tyr / residues and decreased phospho-stat , level in both breast cancer cell lines. although curcumin dephosphorylated stat in both mda-mb- and mcf- wt cells, no significant effect has been observed in mda-mb- gh+ and mcf- gh+ cell lines. in consequence, although forced gh expression induced cell proliferation in mcf- and mda-mb- breast cancer cells, curcumin overcame gh-mediated resistance mechanism via acting on jak/ stat/socs signaling, which is related to pparg-induced inflammation. acknowledgment breast cancer is one of the highest cancer type among women worldwide. various enviromental and genetic factors such as age, gender, family history, metabolic diseases and gene mutations are involved in the breast cancer pathogenesis. growth hormone (gh), a pituitary derived hormone, has essential role on postnatal growth and development. it is also established that signalling route of gh and its receptor (ghr) activity is increased in different cancer types. curcumin, a nutraceutical deriatives from rhizomes of turmeric (curcuma longa), has potential therapeutic activity against cancer cells, including breast cancer. curcumin inhibits proliferation of cancer cells such as prostate, colon, melanoma, cervical and breast cancer via induction of apoptosis and inflammation. stat , a major downstream target of gh/ghr signalling, is related to survival, proliferation and differentiation. in this study, our aim was to investigate curcumin-induced apoptotic cell death in gh overexpressed mda-mb- breast cancer cells via jak-stat/socs signalling and inflammatory response profile. according to mtt cell viability assay, curcumin decreased cell viability in time and dose dependent manner in wt and gh+ mda-mb- breast cancer cell lines. we found that lm curcumin-decreased in apoptotic cell death through inactivity at jak which led to dimerization of stat , stat , stat . concomitantly, curcumin affected stat regulating socs proteins in mda-mb- breast cancer cell line. in addition, we demonstrated that lm curcumin induced pparg expression and altered inflammatory cytokine signalling cascade. consequently, although gh overexpression led to agressive profile in mda-mb- breast cancer cells, curcumin overcame this resistance. inflammation is involved in many systemic disturbances, including osteoarthicular or skin diseases, coordinating the signaling network that contributes to tissue injuries. the aim of our study is to reveal pro-inflammatory messengers at the cutaneous barrier (keratinocytes, fibroblasts, endothelial cells), simulating the dermal impact of active principles, especially polyphenols and flavones from vegetal sources: salvia officinalis, asculum hippocastanum and calendula officinalis. we focused on il and il cytokines as main mediators of inflammation progression, correlated in keratinocytes with il a as skin irritation indicator and vegf as pro-angiogenic factor, as well as in endothelial cells with icam- and vcam- adhesion molecules expression. in order to in vitro mimic the inflammatory conditions, we used targeted stimuli for each type of cells: for fibroblasts and endothelial cells -tnfa, a systemic stimulus, single or combined with pma that activates protein kinase c and up regulates nadph oxidase, which lead to superoxide anion production; for keratinocytescontrolled uv-a and uv-b radiation, simulating the solar damages or potential uv interactions with active principles in light exposed skin. the main analysis technique was flow cytometry: beads bases assay for soluble factors and fluorescent antibodies staining. our results prove the different involvement of polyphenols and flavones in the anti-inflammatory mechanisms, depending of the vegetal source: active principles from salvia officinalis induce a strong inhibition of il and il in tnfa stimulated keratinocytes, fibroblasts and endothelial cells, reduce the icam- over-expression but have no effects on irradiated keratinocytes; biocomplexes from asculum hippocastanum inhibit only il release in stimulated fibroblasts, but protect keratinocytes from uv-a and uv-b radiation; compounds from calendula officinalis are active on il signaling in fibroblasts and counteracts only uv-b inflammation. ischemia and/or reperfusion injury is one of the most common causes of acute renal failure. ischemia-reperfusion associated with thrombolytic therapy, organ transplantation, coronary angioplasty, aortic cross-clamping, or cardiopulmonary bypass results in local and systemic inflammation. within the endothelium, ischemia produces expression of proinflammatory gene products (e.g. cytokines) and bioactive agents (e.g., endothelin), while preventing other "protective" gene products (e.g., thrombomodulin) and bioactive agents (e.g. nitric oxide). therefore, ischemia induces a proinflammatory state that increases tissue vulnerability to further injury on reperfusion. this experimental study was designed to investigate the protective effect of salvia l. extracts on kidneys from i/r injury. salvia lamiaceae have been used for treatment of some illnesses in turkish folk medicine. forty spraque dawley rats were divided into groups (n = ). right nephrectomy was performed to all groups. group i: control group; group ii: i/r group; group iii: i/r + mg/kg salvia l.group; group iv: i/r + mg/kg salvia l. group; group v: i/r + mg/kg rosmarinic acid. group. salvia l. and rosmarinic acid for days was given single dose as a gavage. minutes ischemia, minutes reperfusion were applied to groups except control. intracardiac blood samples were taken, high sensitive crp (hscrp), tumor necrosis factor-a (tnf-a), interleukin (il)- and interleukin ib (il- b) levels were detected. serum hscrp levels were also determined in our clinical laboratory using routine standard methods. serum tnf-a, il- and il-ib levels were evaluated using an enzyme-linked immunosorbent assay technique. mean values were evaluated by statistical analysis. serum hscrp, tnf-a, il- , and il- b concentrations were significantly increased after renal i/r as compared to the control group. our treatment group mg/kg salvia l. and mg/kg rosmarinic acid especially mg/kg of salvia l. were found to show a protective effect against renal structure and function. we concluded that salvia l. extracts could be beneficial in the treatment of renal ischemic injury. but mg/kg salvia l. extract were more effective than mg/kg salvia l. extract and used as synthetic mg/kg rosmarinic acid. acne vulgaris is a common chronic inflammatory skin disease of unknown etiology. excess levels of secretory phospholipase a (spla ) contributes to inflammatory diseases and studies indicate that lipoprotein lipase (lpl) has differential effects on several inflammatory pathways. the aim of the present study was to assess serum activity of spla , lpl and evaluate changes in circulating protein levels of angiopoietin-like protein (angptl ), angptl , cyclooxygenase (cox) and prostaglandin e (pge ). serum from control subjects and acne vulgaris patients with moderate and severe disease was evaluated for levels of spla , cox, pge , lpl, angptl and angptl . disease activity was determined according to the national health service (nhs) lambeth and southwark clinical commissioning group guidelines for the management of acne. lipid profile, routine biochemical and hormone parameters were assayed by standard kit methods using autoanalyzers (beckman coulter au clinical chemistry and unicel dxi immunoassay systems). serum levels of spla and lpl were significantly increased in acne vulgaris patients compared to age and gender matched controls. no significant differences were found for cox, pge , angptl and angptl levels between acne vulgaris patients and controls. the results of this study reveal the presence of a proinflammatory state in acne vulgaris as shown by significantly increased serum spla activity. increased lpl activity in serum of acne vulgaris can be protective in patients through its anti-dyslipidemic actions. to our best knowledge, this is the first study investigating spla , lpl, angptl and angptl levels in acne vulgaris. future studies are aimed to understand the regulation of spla and lpl expression in acne vulgaris patients. acknowledgement: this study was supported by a grant from the scientific and technological research council of turkey (tubitak; # s ). p- . . - -ohdg and hogg levels are as an oxidative dna damage markers in acne vulgaris treated with isotretinoin h. ecevit, m. izmirli, b. gogebakan, e. rifaioglu, d. sonmez, b. bulbul sen, t. sen, h. m. okuyan mustafa kemal university, hatay, turkey acne vulgaris is a skin disease that characterized by comedones, papules, pustules, nodules and cysts at face, back and body skin. isotretinoin is one of the treatment agents in acne vulgaris. about weeks after drug treatment, the amount of sebum which is produced by sebaceous gland reduces keratinization disorder and the number of propionibacterium acnes normalizes. however, isotretinoin is known that has a wide range of side effects. in recent studies, isotretinoin treatment has been shown to increase the oxidative stress. -hydroxy- -deoxyguanosine ( -ohdg), an important indicator of oxidative dna damage, hydroxyl ion is bound at the th carbon of guanine. this structure is repaired through a base excision repair mechanism and the human -oxoguanine dna glycosylase (hogg ) plays a key role in this processes. in this study we aimed to evaluate the dna damage and it's repair in acne vulgaris before and after months of isotretinoin treatment by measuring -ohdg and hogg levels. the current study includes acne vulgaris patients who are diagnosed in mustafa kemal university, department of dermatology. -ohdg and hogg levels were measured by enzymelinked immunosorbent assay (elisa) method for before and after months of isotretinoin treatment. the commercial elisa kits (cloud-clone corp; usa and cell biolabs; usa) were used for the assessment of hogg and -ohdg, respectively.both -ohdg (p as a conclusion, isotretinoin increases dna damage and high serum -ohdg and hogg levels as a result of isotretinoin treatment may effect on the amount of reactive oxygen species. the pineal gland is a circumventricular organ which serves as a major neuroendocrine gland in the brain. its primary function is the production of melatonin which is controlled by signals from the suprachiasmatic nucleus. melatonin codes the length of the night and it is well recognized for its anti-inflammatory effects. lipopolysaccharide (lps) is the essential component in the outer surface membrane of gram-negative bacteria and act as a strong stimulator of natural and innate immunity in all eukaryotic species. furthermore, lps reduces melatonin synthesis and induces the expression of the serine protease inhibitor (spi- ) in the stat -mediated manner in pinealocytes. however, the precise function of stat in the cell signaling in the pineal gland is not yet known. here we investigated the effect of inhibition of stat on lps-induced changes in melatonin levels, expression of arylalkylamine n-acetyltransferase (aa-nat) and spi- in the pineal gland. experiments were performed in vitro using organotypic and primary cultures prepared from the rat pineal glands. levels of melatonin and spi- were determined from tissue homogenate by enzyme-linked immunosorbent assay (elisa). the pinealocytes were used to carry out sirna stat transfection. the successful transfection and subsequent decline in stat expression levels were proved by sodium dodecyl sulphate-polyacrylamide gel electrophoresis (sds-page). the changes in synthesis of aa-nat and spi- were studied by rt-pcr. in conclusion, lipopolysaccharide can affect the immunomodulators secreted by the pineal gland. the clarification of the effect of inhibition of stat on those immunomodulators is important from the clinical point of view because inhibitors of stat are nowadays used as tumour suppressors. silica nanoparticles have a great potential for a variety of industrial, diagnostic and therapeutic applications. in this study, we have evaluated the in vitro effects of amorphous silica nanoparticles ( nm) using human lung mrc- fibroblast as model. cells were exposed to . lg/ml silica nanoparticles for , and hours. the cytotoxic and inflammatory response, and matrix metalloproteinase expression were examined. the pro-inflammatory cytokine il- b, il- , il- , tumor necrosis factor (tnf-a), matrix metalloproteinases (mmp- , mmp- , mmp- ) and tissue inhibitor of metalloproteinase- (timp- ) were analyzed by western blot method. cytotoxicity was evaluated by lactate dehydrogenase (ldh) released into the culture medium by damaged cells. the level of ldh activity was increased after exposure to silica nanoparticles, in a time-dependent manner compared to control. the protein expression of il- , il- , il- and tnf-a as well as of mmp- and timp- , was up-regulated whereas those of mmp- , mmp- was down-regulated after and hours respectively. in conclusion, our data indicate that amorphous silica nanoparticles generate a cytotoxic and inflammatory response, as well as an imbalance in extracellular matrix due to the differential regulation of mmps and tissue inhibitor of metalloproteinase- in mrc-cells after and hours. p- . . - association of fto gene variant (rs ) with markers of t dm and obesity in population from bosnia and herzegovina and kosovo fto (fat mass and obesity-associated gene), recently discovered in a genome-wide association study for type diabetes (t d) encodes a -oxoglutarate-dependent nucleic acid demethylase and is mainly expressed in the hypothalamus. this gene may play important role in the management of energy homeostasis, nucleic acid demethylation, and regulation of body fat masse by lipolysis. the aim of this study was to analyze the association of this single nucleotide polymorphisms (snps) with clinical and biochemical parameters of obesity, t d, prediabetes and at the level of healthy population from bosnia and herzegovina (bh). the study included patients with t d and prediabetes and healthy controls both sexes, aged from up to years. patients were recruited at the clinical centre university of sarajevo, university hospital of clinical centre in banja luka, general hospital in te sanj and health centre in prizren. genotyping of analyzed polymorphism was performed by rt-pcr method in cooperation with the department of clinical chemistry, faculty of pharmacy, university of ljubljana (ljubljana, slovenia) and university hospital of charles university (hradec kralove, czech republic). our results did not show significant differences in genotype frequencies of the analyzed polymorphisms between patients with t d, pre-diabetes and healthy population also, results of logistic regression analyses did not show significant association of risk a allele of fto gene polymorphism -rs with increased risk of t d (or = . , % ci . - . , p = . ). a allele was significantly associated with higher values of hba c, insulin, homa ir index, diastolic blood pressure and higher levels of inflammatory markers (fibrinogen and leukocytes). interestingly, a tendency of association of a allele with higher values of obesity markers (bmi, waist and hip circumference) was noted. further studies are needed on a larger population in order to confirm these results. the water extract of capparis ovata (cowe) has been shown to be used as an alternative medicine for the treatment of multiple sclerosis (ms). cowe was further fractionated and studied for additional anti-neuroinflammatory effects in sh-sy y cells. for this purpose, the dichloromethane sub-fraction of the cowe extract was tested for its anti-inflammatory effects on selected anti-inflammatory genes believed to be important in ms pathophysiology using sh-sy y cells. cell viability was assessed using lactate dehydrogenase (ldh) activity in the media conditioned by the crystal violet cell staining. in these cells, levels of the tumor necrosis factor-a (tnfa), nuclear factor kappa-lightchain-enhancer of activated b cells (nf-jb ), glial fibrillary acidic protein (gfap), c-x-c motif chemokine and (cxcl , cxcl ), matrix metalloproteinase (mmp ), chemokine (c-c) motif (ccl ) and tyrosine-protein phosphatase non-receptor type (ptpn ) were determined by quantitative reverse transcriptase-pcr assay (qrt-pcr). we have found out that the dichloromethane sub-fraction of cowe effectively inhibited the expression of all of the genes given above in sh-sy y cells. thus, phytochemicals present in the dichloromethane sub-fraction of the cowe extract could be beneficial in preventing/treating neurodegenerative diseases in which neuroinflammation is part of the pathophysiology. studies are underway to identify the individual compound(s) in this subextract of the cowe extract contributing to these effects. this work is supported by tubitak s and pamukkale university paubap fbe . p- . . - apigenin and luteoline were identified as active anti-inflammatory constitutents of lavandula stoeachas by bioassay guided fractionation h. ipek , s. savranoglu , a. r. t€ ufekc ßi , f. g€ ul , i. demirtas , t. boyunegmez t€ umer graduate program of bioengineering, institute of natural and applied sciences, c ß anakkale onsekiz mart university, c ß anakkale, graduate program of biology, institute of natural and applied sciences, c ß anakkale onsekiz mart university, c ß anakkale, department of chemistry, faculty of sciences, c ß ankiri karatekin university, c ß ankiri, department of molecular biology and genetics, faculty of arts and sciences, c ß anakkale onsekiz mart university, c ß anakkale, turkey introduction: lavandula stoechas, in the genus of lavender, has distinct therapeutic uses among anatolian people. rather than worldwide use of its essential oil in aromatherapy, specifically the aqeous portion as decoction has been traditionally used in anatolia against the components of metabolic syndrome, all of which share a state of chronic inflammation as an underlying cause. the anti-inflammatory constiutents of l. stoechas were isolated using a bioassay guided fractionation in lipopolysaccharide (lps) inflammed raw . macrophages. materials and methods: an aqeous extract was partitioned into ethyl acetate (eae) and n-butanol fractions. the eae, determined as bioactive extract was seperated into subfractions by column chromatography. e was identified as active subfraction subjected to sephadex column to get pure compounds which were then applied to nmr, ir, and uv analyses for structure determination. in raw . cells, the effects of extracts/fractions/subfractions/compounds on lps induced no production was determined by using griess method. the potential inhibitory effects of each compound on lps induced inos expression were determined by qpcr and western blot. results: p-coumaric acid, apigenin and luteoline were found in the e , and the first two compounds appeared to be primarily responsible for the anti-inflammatory activity. apigenin and luteoline at lm decreased no production and %-ic : and lm-by inhibiting inos gene expression and % as well as protein expression and %, respectively (p < . ). conclusion: this is the first time that luteoline and apigenin have been found in eae of l. stoechas, and the anti-inflammatory properties of the eae can be attributed, at least in part, to the presence of these two compounds. we are on the way to gain further insight for the action mechanism of these two active principles as anti-inflammatory agent. tubitak (project id: t ) support this work. the role of tip in the inflammation process immun response generates the first line of host defense during inflammation and plays an important role inducing pro-inflammatory response by generating early response against pathogens. il- (interleukin ) is one of the pro-inflamatory cytokines and its expression increases during the infection to activate the jak/ stat pathway. jak/stat pathway is regulated by hamp (hepcidin antimicrobial peptide). our previous study, we reported that hamp gene expression was decreased in liver-specific tip conditional knockout mice, so we thought that tip may have a direct or indirect role on inflammation mechanism. tip (tat interacting protein, kda) is a member of the myst enzyme family of histone acetyltransferases (hats) and plays an important role in multiple function including cellular signaling, dna repair, cell cycle and apoptosis. in this study, the quantitative gene and protein expression of il- were investigated by using taqman real time pcr, western blot and immunohistochemistry analysis in control group, lpsinduced inflammation group and liver-specific tip conditional knockout group mouse liver. according to our preliminary results, the gene and protein expression of il- was increased in lps-induced inflammation group (p < . , p < . ) and liver-specific tip conditional knockout group mouse liver (p < . , p < . ). our initial data suggest that tip may be essential for the inflammation process. this work was funded by grants from the scientific and technological research council of turkey (tubi-tak) (grant number: z ). although intracellular reactive oxygen species (ros) level is necessary to maintain cellular homeostasis, elevated intracellular ros level with the impact of unfavorable environmental conditions leads to oxidative stress that may cause damage to dna, proteins and lipids. in case of inflammation, organism seeks to provide cellular homeostatis by increasing ros levels via antioxidant molecules and enzymes. therefore, it was thought that there can be a direct or indirect relation between inflammation and oxidative stress. in this study, inflammation was performed by intraperitoneal injection of lipopolysaccharide (lps). the gene expression and activity of antioxidant enzyme including superoxide dismutase (sod), catalase (cat), glutathione peroxidase (gpx), glutathione s-transferase (gst), glutathione reductase (gr) and glucose -phosphate dehydrogenase (g pd). additionally, any change of reduced glutathione (gsh), oxidized glutathione (gssg), malondialdehid (mda), and hydrogen peroxide (h o ) level are accepted as an indication for the accumulation of ros, the relative levels of them were also studied. to show our inflammation model was performed in mouse kidney with lps treatment or not, the expression of interleukin (il ), which is accepted as a inflammation marker, was investigated by real time pcr. the expression of il was significantly increased in lps treated group. while the level of mda and h o was elevated in lps treated group, gssg was decreased. no changes was seen for gsh level. the correlation was observed between enzymatic and molecular levels. while the gen expression and the enzyme activity of sod, cat, gst, gr, and g pd were decreased, gpx was increased with inflammation. in conclusion, increasing ros level was observed in the inflammation process and, the antioxidant system was affected at the molecular and protein level. this work was funded by grants from the scientific and technological research council of turkey (tubitak) (grant number: z ). the aim of our study is to evaluate effect of vitamin d levels on hemogram parameters including neutrophil %, lymphocyte %, neutrophil % / lymphocyte % ratio (nlr) and mean platelet volume (mpv) in behcet's patients. fifty eight patients with diagnosis of behcet that applied to selcuk university faculty of medicine department of dermatology are recruited to the study. clinical and laboratory characteristics of the patients were obtained from hospital automation. t test was used to examine the differences between the parameters. p < . was taken to be statistically significant. there was a statistically significant difference between vitamin d values and age (p = . ) whereas difference was not significant between vitamin d and neutrophil %, lymphocyte %, nlr, mpv values. according to the literature, there are a lot of studies that show the relationship between vitamin d and hemogram parameters. however, contrary to the previous studies, we were unable to find any significant relationship between vitamin d and these hemogram parameters. these results serve the idea that the effects of vitamin d on the hematopoietic system should be further investigated experimentally and clinically. crimean-congo hemorrhagic fever is a tick-borne disease caused by the arbovirus and characterized by a sudden onset of high fever, severe headache, dizziness, back and abdominal pains. the exact pathogenesis of cchf has not been clarified yet. the aim of this study, clinical cases of cchf in cu, se and zn is to examine the relationship between the concentration of trace elements. the study sample consisted of patients which have been diagnosed with cchf. matched for gender, healthy volunteers were similar to the control group according to age. the patients and control groups, serum cu, zn and se levels were analyzed using atomic absorption spectrophotometer. cchf patients in the group, cu zn and se serum levels were significantly lower compared with the control group. in our study, the cofactor of the antioxidant enzyme cu, zn and se elements were lower. this shows us in cchf disease, a decrease in antioxidant enzyme activity, and suggest that they contribute to the immune system's degradation. p- . . - inhibitors of mdm ubiquitin ligase as prospective modulators of autoimmunity e. bulatov, a. valiullina, r. sayarova, a. rizvanov kazan federal university, kazan, russia ubiquitin-proteasome system is seen as a pool of promising protein targets for therapeutic impact in many human diseases. mdm is an e ubiquitin ligase widely studied due to its wellknown role in cancerit negatively regulates p oncosuppressor that mediates apoptosis in tumour cells. inhibitors of p / mdm interaction have long been known as potential anticancer therapeutics. however, recent advances in the field suggest that both mdm and p might be playing a substantial role in autoimmune processes. we used a small molecule p /mdm inhibitor nutlin- a to test the effect of p activation on peripheral blood mononuclear cells (pbmcs) from both healthy volunteers and patients diagnosed with multiple sclerosis. in our study we employed a variety of molecular biology methods, such as immunoblotting, real-time pcr, mts cell proliferation assay, fluorescence flow cytometry and confocal microscopy. we demonstrated that disruption of p /mdm interaction by nutlin- a alters the p levels and also affects the lymphocyte subpopulations within pbmcs. our findings suggest that p /mdm interaction inhibitors can potentially be used as prospective modulators of immune response in autoimmune diseases such as multiple sclerosis, systemic lupus erythematosus and other. the study was funded by rfbr research grant - - mol_a_dk. can ykl- be an inflammatory biomarker in vitamin d deficiency? object: the tumor necrosis factor (tnf) was found to be cytotoxic to tumor cells and to induce tumor regression in mice. except for one member, all receptors to the tnf superfamily bind tnf-related ligands and act mostly on inflammatory system. there are currently tnf superfamily ligands. tnf superfamily ligands share several common features. tnf ligands are generally type ii transmembrane proteins whose extracellular domains are be divided by enzyme to create cytokines. the tnf superfamily currently consists of receptors. tnf family receptors are type i or type iii transmembrane proteins that contain multiple extracellular domains. in this study, we investigated to presence, differences and effects of tnf superfamily and receptors genes in human and mice by using bioinformatics techniques. methods: the nucleotide and amino acid sequence of each protein in human and mice was determined using t-blast-n for homologous sequences. homologous sequences of human tnf family genes found an automated procedure by using psi-blast. the secondary structure of and three-dimensional of the protein were analyzed by psipred and ffas server. netcglyc . and netphos . program were used for post-translocation modifications. the web apoptosis database was also used for the lists of domains, proteins containing these domains and their associated homologs. results and conclusion: humans tnf ligands have genes encoding proteins that contain a conserved carboxy-terminal domain. this family of proteins is highly conserved between humans and mice. humans contain genes encoding tnffamily receptors. sequence data from the ncbi databases demonstrated the presence of mouse tnf-family receptors with orthologs in humans and one additional receptor found only in mice. the differences and similarities in the tnfs genes in humans and mice will provide information for understanding the utility and limitations of the mouse models of disease and comparing of immunology outcomes. the development of left ventricular remodeling after acute myocardial infarction is a predictor of shock. the genetic influence on cardiac remodeling, and shock in the early period after acute myocardial infarction are unclear. the aim of the present study was to investigate the relationship between angiotensin converting enzyme (ace) gene polymorphism and modified shock index (msi) in the early period in patients with acute anterior myocardial infarction. overall patients with a first acute ami were included in this study. dna was isolated from peripheral leukocytes. the id status was determined by pcr. based on the polymorphisms of the ace gene, they were classified into groups: deletion/deletion (dd) genotype (group , n = ), insertion/deletion (id), insertion/insertion (ii) genotypes (group , n = ). blood pressure and pulse measurements were performed in all patients within minutes admitted to coronary care unit. msi was defined as heart rate (hr) divided by mean arterial pressure (map). echocardiographic examinations were performed in accordance with the recommendations of the american echocardiography committee. one-way analysis of variance (anova) and chi-square analyses were used to compare differences among subjects with different genotypes. the study was approved by the local ethics committee, and each patient gave a written consent. there were no significant differences among clinical parameters of patients. msi was significantly higher in patients who have ace dd genotype than in patients who have ace id / ii genotypes ( . ae . and, . ae . , p < . ). presentation time hypotension or developing hypotension during admission was reported to be an important predictor of intensive care unit admission besides other vital sign measurements. our results suggested that, ace gene i/d polymorphisms d allele may affect modified shock index in patients with a first acute anterior mi. glucocorticoids (gcs) are widely used in medicine, despite their side effects, e.g. osteoporosis. however, precise molecular mechanisms of gc action, especially on bone marrow (bm) cells, remain controversial. given the osteoprotective role of vitamin d , the aim of our study was to examine prednisolone-induced changes in the rank (receptor activator of nuclear factor kappa-b)/rankl (rank ligand)/opg (osteoprotegerin) pathway of rat bm depending on the state of vitamin d endocrine system. female wistar rats received prednisolone ( mg/kg b.w.) with and without iu of d (for days). the levels of rank, rankl, opg, a-hydroxylase (cyp b ) in bm were determined by western blotting. vitamin d receptor (vdr) and rankl mrnas were measured by quantitative rt-pcr. ohd content in the serum was assayed by elisa. rankand vdr-positive bm cells were quantified using flow cytometry and visualized by confocal microscopy. prednisolone induced a marked increase in rankl and rank levels, while opg level was shown to decrease. this reflects disturbances in cytokine-mediated regulation of bm progenitor cell function. data from flow cytometry indicated a significant growth in the number of rank-positive cells (hematopoietic osteoclast precursors) compared to control. these changes were accompanied by a decrease in the levels of vdr and cyp b , which is responsible for , (oh) d synthesis, in bm and ohd content in serum. co-localization of vdr and rank in mono-and multinuclear bm cells was observed, indicating a close relation between vitamin d and rank/ rankl/opg pathway. vitamin d co-administration prevented prednisolone-induced changes in bm cells through restoration of vitamin d bioavailability and vdr signaling that resulted in a reduction of the osteoclast progenitor pool in bm. thus, prednisolone-induced imbalance in rank/rankl/ opg system components is associated with impairments of vitamin d endocrine system in bm and can be ameliorated by vitamin d treatment. p- . . - heat shock pathway in response to different stress factors the heat shock response is an emergency pathway of the cell, which mediates repair and protection from cellular stress and therefore guarantees the survival of the cell. this stress can range from heat or hypoxia to chemicals and heavy metals. it is highly conserved in all eukaryotic cells and plays an important role during atypical conditions. due to its high complexity, the pathway is not yet completely understood. most important, after activation of the pathway, is the refolding of proteins or, in case of severe misfolding, the depletion of proteins to maintain proteostasis. heat shock factor encoded by the hsf gene is known as the main switch point in heat shock regulation. after activation it trimerizes and binds to heat shock elements in target gene promoters. one of these promoters is the hspa a promoter (hsp promoter). the promoter was analyzed by dismantling it to its functional parts. especially three elements, the heat shock elements, were in the focus of this work. in first place parts of the promoter were multimerized and combined with different reporters, like luciferase, by cloning. also mutations in the natural promoter were designed by cloning. the focus now is on the heat shock elements, where hsf can bind as a trimer. the idea is that these different elements have various effects on different stressors like heat, chemicals (geldanamycine as hsp inhibitor, mg as proteasome inhibitor) or heavy metals (cadmium, arsenic, zinc) . this was tested on cells transiently transfected with those promoter variants. for promising variants stable cell lines were created. in these stable cell lines further experiments on mrna level can be conducted. in the last months experiments with the crispr/cas system were started. furthermore, experiments on transcriptional (qpcr) and translational (dual-luciferase assay) levels were done as well. in the end we hope to get a clear picture on the regulation of the hspa a promoter by different stress factors. invasive cancer cells form membrane protrusions, invadopodia, that facilitate cell invasion and metastasis. key players invadopodia include the adaptor proteins tks and tks , the actin regulators cortactin, wip and n-wasp, the kinase src and others. in spite that in the last two decades significant advances in our knowledge of the structure and development of invadopodia have been made, detailed mechanisms they are functioning is not yet available. we have identified a series of new tks binding partners including adaptor proteins itsn , itsn , crk and grb , kinase src, amph , bin , plcg and also another member of the tks family -tks . it may indicate the possible role of tks in transport and sorting of cell vesicles. current data are supported by interaction with the proteins of amph and bin , as their main functions are membrane trafficking and remodeling. adaptor proteins crk, grb and itsns are important for the actin cytoskeleton rearrangements, endocytosis and signal transduction. moreover, we have identified and characterized new tks isoform -tks -beta. we suggested that an active state of tks is regulated via intramolecular interactions between its proline-rich motifs and own sh -domains. we have shown the interaction between itsns and other prominent component of invadopodia wip. data from immunofluorescent analysis revealed co-localization of itsn and wip at the sites of invadopodia formation and in clathrin-coated pits. we have also demonstrated that the key protein itsn and wip and n-wasp can form a complex in cells. together, these findings provide insights into the molecular mechanisms of invadopodia formation and identify itsns as scaffold proteins involved in this process. we have shown the interaction between itsns and other verprolin family members cr and wire which play an important role in the reorganization of the actin cytoskeleton. we have demonstrated that cr and wire interact with sh domains of itsns in complex with actin. p- . . - correlation between proteomic and phenazine profile of pseudomonas sp. phenazines are widely known compounds with huge variativity of biological activities which are produced by pseudomonas sp. and some other bacteria species. the results of our work shows the correlation between the changes of proteomic profile of pseudomonas aeruginosa caused by a mutagenesis and the secondary metabolism of antibiotics (phenazine) profile. different strains of pseudomonas aeruginosa were obtained using mutagenesis, after that bacterial cells were destroyed by ultrasound. protein-containing fractions were isolated using methanol-chloroform method as well as phenazines compounds were extracted from culture media using liquid phase extraction. obtained proteome was analysed by shotgun-proteomics technique. as the result of the liquid phase extraction phenazine compounds were mainly extracted to the organic phase. this phase was evaporated and re-dissolved in % methanol. after sample preparation obtained solutions were analyzed by hplc-agilent with quadrupole tof mass-detector. results of the analysis were compared with the library of known phenazine compounds mass-spectras generated by cfm-id online resource. obtained phenazine profiles were compared with each other and correlation with the changes in proteome was analyzed. received results promote better understanding of mechanisms of phenazine production. this data opens possibilities for targeted changes in the methabolic pathway in order to obtain phenazine compound with required biological activity. insulators are genomic elements which block enhancer-promoter interaction and prevent spreading of heterochromatin. cp protein is an integral component of most known drosophila insulators, it interacts directly with ctcf and pita dna-binding insulator proteins using dimeric btb-domain, but function of cp within insulators still remains to be elucidated. recently we described an interaction between cp btb-domain and cterminal domain of ctcf insulator dna-binding protein, subsequent deletion analysis allowed us to isolate aa fragment within ctcf c-terminal domain sufficient for interaction with cp btb, but deletions of flanking regions also lead to the loss of interaction with cp in vivo. at the same time crosslinking experiments suggest that a dimer of btb interacts with one molecule of ctcf, presuming that it could recognize two peptide fragments within ctcf c-terminal domain. we solved crystal structure of btb-domain from cp insulator protein at . a resolution. overall structure is similar to other btb-domains. cp btb-domain has peptide-binding groove similar to that previously found in bcl btb domain. inspection of btb-domain surface revealed several possible binding sites for polypeptide fragments from ctcf protein. based on these observations a set of point mutations within peptide-binding groove of btb-domain has been designed and we tested ctcf-interaction abilities of these mutants using gst pull-down assay and yeast two-hybrid assay. the most significant impact was found with alanine-substitutions of hydrophobic residues whereas substitutions of hydrophilic amino acids were less effective. therefore our results support that cp btb-domain recognizes ctcf protein using peptide-binding groove. this study was supported by the russian science foundation (project № - - ). p- . . - comparative study of the fatty acid composition of lipids in the raw meat samples obtained from hybrid sheep one of the most important tasks in the animal biology and husbandry is to clarify the role of animal genetic diversity in providing nutrients to the diversity of animal products. the objective of our work was to study the chemical compositions of raw meat samples obtained from domestic (group i -purebred romanov sheep) and hybrid sheep (group ii -f hybrids of romanov sheep with . % of argali blood). the significant changes in fatty acid composition of the lipid fraction from the fat and muscle tissue of the hybrid sheep as compared to the control were found. the content of saturated fatty acids (sfas) in the fat samples of the hybrid animals was by . % lower ( . ae . %, p < . ), but polyunsaturated (pufas) or monounsaturated fatty acids (mufas) contents were by . % and . % higher ( . ae . and . ae . (p < . ), respectively) as compared to purebred romanov sheep. the most pronounced changes were found for palmitic acid (decreased from . % to . %) and for oleic, linoleic, arachidonic acids (increased from . %, . %, . % to . %, . %, . %, respectively). the last two acids together with the linolenic acids belong to the so-called essential acids and very important for the animal metabolism. a similar trend was observed on the composition of the lipid fraction of muscle tissue. sfas, pufas and mufas content in muscle tissue of hybrid sheep was . ae . , . ae . and . ae . %, that was . % lower (p < . ), and . % and . % higher (p < . ) compared to purebred romanov sheep. these results emphasized the difference of the pufas/sfas ratios in fat and muscle tissues, respectively) and characterized the biological value of the lipid fraction of fat and muscle tissue. the obtained data gave evidence of the positive changes in the fatty acid compositions of the lipid fractions for the hybrid animals as compared to the purebred sheep. supported by the russian scientific foundation, no. - - . foodborne illnesses resulting from the consumption of agricultural commodities contaminated with enteric pathogens are an increasing problem around the world. while various possibilities of produce contamination with pathogens exist, the global warming combined with a widespread use of animal manure in agriculture will likely contribute to an increased number of such outbreaks. thus, phages isolated from different agroecosystems may prove to be useful in detection/biocontrol of enterobacteria in produce. during the investigation of the impact of global warming on the diversity and co-evolutionary dynamics between microorganisms and viruses in lithuanian agroecosystems, a novel enterobacteria phage vb_ecos_nbd (nbd ) was isolated from agricultural soil using e. coli novablue for phage propagation. nbd genomic dna was isolated from cscl-purified phage particles, and was subjected to illumina dna sequencing. nbd is a virulent siphovirus that has a low-temperature plating profile (fails to form plaques at a temperature > °c). the genome of nbd is $ kb long, and has a total of probable protein-encoding genes as well as gene for trna ser . the genome analysis revealed that nbd orfs encode unique proteins that have no reliable identity to database entries. among the orfs that encode proteins with matches to those in other sequenced genomes, are similar to proteins from phages that infect different members of enterobacteriaceae, while nbd orfs are most similar to those from bacteria. based on the similarity to biologically defined proteins, nbd orfs were given a putative functional annotation, including genes coding for morphogenesis-related proteins, as well as associated with dna replication, recombination, and repair. phylogenetic analysis revealed that enterobacteria phage nbd is distantly related to phages belonging to the subfamily tunavirinae. this research was funded by a grant (no. sit- / ) from the research council of lithuania. p- . . - the antibiotic novobiocin affects the composition of the escherichia coli proteome n. e. arenas , j. williamson , v. schw€ ammle , s. douthwaite universidad de cundinamarca, cundinamarca, colombia, university of southern denmark, odense, denmark novobiocin (nov) is an aminocoumarin which competitively inhibits the atp binding site in the gyrase-b subunit of prokaryotic topoisomerase ii. nov remains a therapeutic choice for treating infections with bacterial pathogens that are resistant to more commonly used drugs. the aim of this study is assess the proteomic response of e. coli strain upon nov treatment. minimum inhibitory concentrations of nov were measured by standard assays. three different e. coli strains (as , as -rlma::aph and b) were grown aerobically in nutrient rich lb media at °c during one hour. the whole cell proteome (five biological replicates in each sample,) was assessed by lc-ms by using tmt labelling protocol. raw files were imported to proteome discoverer (thermo fisher scientific) and searched together with mascot against the uniprot e. coli reference proteome. mics for nov were determined to be > -fold higher the wild-type b-strain of e. coli than for the hypersusceptible as strains ( lg/ml). whole genome comparison of the b and as strains were characterized by an increase in proteasome components ( proteins), chaperones ( ), error-prone dna polymerase components ( ), ribosomal hibernation factors ( ), heat shock response ( ), electron transport coupled proton transport ( ), pentose phosphate pathway ( ), flagellar assembly ( ), oxidative phosphorylation ( ) and tca cycle ( ). whereas ribosomal proteins ( ), aminoacyl-trna synthetases ( ), rnases ( ), abc transporters ( ), mismatch repair ( ) and sec secretion pathway ( ) were significantly down-regulated upon nov treatment. the three e. coli strains respond similarly upon nov treatment and their proteomes showed upregulation of heat shock response with changes in the components of translation and transcription, the proteasome and atp biosynthesis. the changes observed can be used to define the processes that are required for antibiotic tolerance and survival of e. coli against aminocoumarin antibiotics. postnatal growth is under control of pituitary derived hormone, growth hormone (gh) that triggers bone, fat tissue growth and development via acting on protein, carbohydrate and fat metabolism. gh functions on postnatal development by jak /stat signaling following gh:gh receptor (ghr) dimerization. isolated growth hormone deficiency (ighd) is a medical condition of insufficient production of growth hormone (gh) that is caused by mutations on gh-n gene in different ethnic origin children. various mutations within gh has been determined in different populations so far, and glutamic acid to glycine (e g), asparagine to aspartic acid (n d), threonine to alanin (t- a) missense mutations, alanine to serine (a s) substitution, tryptophan to stop codon (w- x), gaaa insertion in intron of gh-n gene and both intron (+ c) and deletion of . amino acid of gh protein phenylalanine (f del) mutations were detected in turkish ighd children. the potential role of these mutations on cell growth, proliferation, emt via acting on gh signaling pathway has not been observed yet. all these mutations were performed on wild type gh-n gene inserted pc . vector by site-direct mutagenesis and stable cell line of each gh gene mutations were generated by neomycin selection. although w- x, e g, f del, a s and n d mutations suppresses gh signaling via acting on either jak dephosphorylation or stat downregulation, t- a, gaaa insertion and deletion of + c mutations have no significant effect on gh signaling. in addition, each mutation lead different growth suppression effect and colony formation potential and intracellular polyamine levels and odc expression profiles were essential role in emt potential of hek cell lines. as a result, w- x, e g, f del, a s and n d mutations prevented gh signaling and cell growth and differentiation via polyamine metabolism. pulmonary embolism (pe) is a common cardiovascular emergency and affects a large number of patients. acute pe-induced oxidative stress can lead to the accumulation of specific nitroproteins that may play a role in disease progression. the impact of nitration of a single tyrosine residue often has broad implications on the activity of biologically critical proteins, which has become increasingly related to pathological conditions. in this study, we used a proteomic approach to analyze nitrated serum proteins in patients diagnosed with acute pe and healthy controls. nitrotyrosine (no tyr)-containing proteins were immunoprecipitated from serum with a no tyr affinity sorbent. precipitated proteins were separated by sds-page and visualized by coomassie blue staining and western blotting with mouse monoclonal anti-no tyr antibody. among the numerous immunoreactive bands observed in disease patients, the kda protein band was in-gel digested and analyzed by maldi-tof mass spectrometry (ms). mass fingerprint data sets obtained from the peptide fragment ions matched human collagen alpha- (iii) chain (co a _hu-man) with mascot algorithm analysis giving a score of (p < . ). collagen alpha- (iii) chain is a fibrillar collagen that is found in extensible connective tissues such as skin, lung, and the vascular system. altered metabolism of collagen and its excessive deposition in the matrix of the connective tissue is a hallmark of chronic interstitial lung diseases. collagen can be measured in serum and bronchoalveolar lavage fluid from patients with numerous chronic interstitial lung diseases. given these considerations, future studies are aimed understand the relevance of no tyr modifications in co a relating to changes in protein structure and function. recent studies have shown that the genes involved in dislipidemia represent potential loci to be associated with diabetes as a disease. recent genome wide association (gwa) studies have associated rs in gckr gene and rs in galnt gene with parameters of t d and diabetic dyslipidemia. in this study, the association of these single nucleotide polymorphisms (snps) with t d and dyslipidemia was tested in the population from bosnia and herzegovina (bh). our study involved patients with t d and healthy subjects. biochemical and anthropometric parameters were measured in all participants. after dna extraction, sequenom iplex platform was used for the analysis of galnt polymorphism (rs ), while polymorphism in gckr (rs ) gene was analyzed by using real time pcr. our results demonstrated significant association of gckr rs variant with waist circumference (p = . ) and fasting glucose levels (p = . ) in the control group. no such association was demonstrated for rs galnt gene. in the group of diabetic patients, significant association of gckr rs variant with levels of bilirubin (p = . ) and rs galnt variant with hba c (p = . ) and triglyceride levels (p = . ) was also demonstrated. our results suggest an association of variations of gckr and galnt genes with specific markers of t d and dyslipidemia. further studies would be needed in order to confirm these genetic effects in other ethnic groups as well. osteoporosis is the most common metabolic bone disorder affecting the normal bone turnover with low bone mineral density (bmd) and risk of fragility fractures. polymorphisms at the sp binding site of the collagen type a (col a ) gene is associated with low bmd. we examined the distribution of col a gene polymorphism in young osteoporotic women and in control group in turkish population. patients had low bmd with t score ≤ . sd and controls was healthy women ( - years). mean age ( . ae . ) and ( . ae . ) respectively. the bmd, as g/cm , was measured in the hip and the lumbar spine (l -l ) with (dexa). dna was isolated from blood. col a gene was analysed with genomica clinical array system. the x test was used to compare allele and genotype frequences between patients and controls. mean of t score in patients was À . ae . . mean bmd (as g/cm ) was . ae . , and ( . ae . ) genotype distribution were ( %) ss, (% )ss, (% )ss for patients, and ( )ss, ( )ss, ( )ss for control . patients had (% )s allele, ( %) s allele, controls had ( %)s allele, ( %)s allele. when genotypes and bmd were compared in patients, there was no significant correlation between osteoporosis and genotypes. the allelic distribution was not significant between patients and controls p > . . genotypic distribution in patients were significantly different. patients had a higher frequency of the ss(% ) than controls (ss % ) p < . . this study shows that high prevalences of the ss genotype at the col a locus, in osteoporosis . _ it is possible that the presence of the s allele causes variation col a and col a mrna's producing abnormal collagene protein. since collagen protein is major protein of bone, it is to be expected that a defect in this protein will produce bone fragility. col a gene should be detected early to initiate preventative therapy for bone health. the biological activity of nigella sativa seeds is mainly attributed to its essential oil component which is pre-dominantly ( - %) thymoquinone (tq). therapeutic effect of tq was exhibited in many diseases including inflammation, cancer, sepsis, atherosclerosis and diabetes. tq has been reported to exhibit antiproliferative effects on cell lines derived from breast, colon, ovary, larynx, lung, myeloblastic leukemia, and osteosarcoma and inhibited hormone refractory prostate cancer. tq induces apoptosis in tumor cells by suppressing nf-jb, akt activation, and extracellular signal-regulated kinase signaling pathways and also inhibits tumor angiogenesis. the aim of this study was to evaluate the anti tumor effects of tq on hepatoma cells. these antitumor assays include cell viability assay, clonogenic assay, scratch assay and molecular expression studies of death related genes. cells were treated with different concentration of tq in hep b for cell proliferation by mtt and clonogenic assay. in addition, the metastatic character of tq was investigated by scratch assay in hep b at - and hours. the effect of tq was also evaluated at mrna level by real-time-pcr. tq was treated on the hep b cells in three different concentration, namely - and . lm. tq showed the cell cytotoxicity in concentration and time dependent manner. the scratch assay revealed no healing in the scratched area due to the decreased cell viability. maximum permissible dose was lm. proapoptotic genes, bax and bad, and autophagy genes, beclin- and lc , were upregulated in hep b cells after hours treatment in contrast, antiapoptotic gene, bcl- , expression level was decreased for hep b cells after hours. p- . . - association of irs genetic variation with type diabetes and insulin resistance in patients from bosnia and herzegovina insulin receptor substrate- (irs ) encodes the irs protein, a substrate for the insulin receptor tyrosine kinase and has a critical role in insulin-stimulated signaling pathways. previous studies showed that irs single nucleotide polymorphisms (snps) were associated with type diabetes mellitus (t d). this is the first study performed in a population from bosnia and herzegovina (bh) in which we examined the association of rs (g>a), rs (t>c) and rs (a>t) with t d risk and related traits. our study involved t d patients and healthy subjects. biochemical parameters, including but not limited to insulin, homa-ir, hba c, glucose, and lipoprotein levels, were measured in all participants. genotyping analysis was performed by mass array sequenom iplex platform in cooperation with lund university diabetes centre, malmo, sweden. statistical analysis was done by spss . our results demonstrated a significant difference in frequency of rs (p < . ) and rs (p = . ) snps between t d patients and control subjects. interestingly, here we showed a significant association of irs rs risk t allele with increased insulin levels (p < . ) and homa-ir (p < . ) in t d patients. similarly, rs variant was also associated with the same markers of insulin resistance in diabetic patients, i.e. insulin levels (p = . ) and homa-ir (p = . ). no such association was demonstrated for rs . however, this irs variant was associated with changes in lipoprotein levels, where risk c allele increased vldl (p = . ) and decreased hdl levels. our results suggest that irs variants are associated with t d susceptibility in bh population, thus confirming similar findings in other population cohorts. furthermore, the associations of these variants with markers of insulin resistance and dyslipidemic metabolic changes point to their role as potential t d biomarkers. the adra a gene encodes alpha- a adrenergic receptor which mediates adrenergic suppression of insulin. a genetic variant in adra a was recently associated with defective b-cell function. the objective of this study was to analyze association of two adra a polymorphisms (rs a>g and rs g>t) with type diabetes (t d) and its related traits. in this study we have included t d patients and healthy subjects from bosnia and herzegovina (bh). biochemical parameters, including but not limited to insulin, homa-ir, hba c, glucose, and lipoprotein levels, were measured in all participants. genotyping analysis was performed by mass array sequenom iplex platform in cooperation with lund university diabetes centre, malmo, sweden. statistical analysis was performed by ibm spss statistics software. our data showed that frequencies of both, rs and rs , variants were not significantly different between t d and control subjects. however, rs risk a allele appear to increase insulin levels (p = . ) and homa-ir index (p = . ). furthermore, this variant also seems to affect vldl levels (p = . ) and waist circumference (p = . ) in diabetic patients. the genotype analysis of rs variant demonstrated that risk g allele decreased hdl (p = . ) and increased ldl levels (p = . ), as well as affected the waist circumference (p = . ) in diabetic patients. interestingly, haplotype analysis demonstrated the association of rs a / rs g with higher homa-ir index. here we demonstrated that although both, rs and rs , adra a polymorphisms were not associated with t d risk in our cohort, they were associated with markers of dyslipidemic perturbations and insulin resistance in diabetic patients. further studies in larger cohorts are needed in order to explore these possible interactions and confirm our findings. smad-interacting protein (sip ), also known as zeb is a member of zeb family transcription factors and was shown to regulate epithelial-to-mesenchymal transition, cell cycle, cellular senescence and cancer stemness. bipartite zing finger motifs at amino and carboxyl termini of the sip mediate its binding to ebox sequences in the genome. however, there are only limited data about sip target genes. by using a home-made anti-sip monoclonal antibody, clone e , we conducted chip-seq in three hepatocellular carcinoma cell lines, namely snu , plc/prf/ and sk-hep- and found receptor tyrosine kinase-like orphan receptor (ror ) as one of the targets. sip dnabinding consensus motif cacctg was found at + kb, + kb and + kb from ror transcription start site. chip experiments validated sip binding to all consensus motifs in the ror gene region. interestingly, the strongest enrichment was at + kb suggesting that long-range interactions play an important role in the regulation of ror by sip . sip knockdown by shrna in high-sip expressing snu cells resulted in the repression of ror expression. ror is expressed in embryogenesis and fetal life, and is absent within most of adult normal tissues. however, overexpression of ror was observed in many human cancers, from hematological malignancies to solid epithelial tumors. ror -positive cancer cells have enhanced proliferation, invasion and metastasis capacities, show resistance to apoptotic stimuli and display cancer stem cell characteristics. therefore, sip and ror act in similar pathophysiological processes. our finding that ror is regulated by sip at least in hepatocellular carcinoma cells adds another level of complexity to the molecular mechanisms of proliferation, invasion and stemness of cancer cells. hepatocellular carcinoma (hcc) is the most prevalent primary liver cancer and is one of the leading causes of cancer related deaths. smad interacting protein (sip ), a member of the zeb family of emt inducers, is involved in cellular proliferation, senescence, invasion and metastasis in human tumors. however, genes regulated by sip in hcc are yet to be identified. we conducted a chip-seq study in high-sip expressing hcc cell line snu by using a home-made anti-sip antibody, clone e . among annotated genes, we selected six for further studies because of its increased expression in multiple cancers and its association with poor prognosis. sip dna-binding motif cacctg was found at - kb from transcription start site of six gene. chip qpcr experiment validated sip binding to this region with , fold enrichment. compared to healthy liver, six transcripts were upregulated in of hcc cell lines included in this study. knockdown of sip by shrna in snu cells caused upregulation of six . immunohistochemistry studies in hcc tissue arrays showed increased expression of six in tumors and inverse association with sip expression in a tumor grade dependent manner. therefore, our results strongly suggest an inverse correlation of sip and six in hcc bone mineral density (bmd) and bone turnover are under genetic control and variations in the vitamin d receptor (vdr) are related to bmd. bmd is known to be affected by -hydroxy vitamin d ( (oh)d) and intact parathyroid hormon (ipth) levels. we aimed to determine correlation blood levels of vitamin d (vitd), ipth, and vdr gene effect in healthy turkish women. the subjects were healthy women in age - years. the bmd was measured as a t score in the lumbar spine (l -l ) with dexa. all subjects had normal t score between (- . to . ) sd. vitd was measured by lc- -at shimadzu. ipth was measured by chemiluminescence method, dna was isolated from blood. the fok i (vdrf-foki) and bsmi (vdrb-bsmi) polymorphisms of vdr gene was analysed with genomica clinical array system. the mean vitd level was ( . ae . ) lg/l, mean plasma ipth level was ( . ae . ) pg/ml. pearson correlation test showed no relation of vit d with bmd. there was moderately negative correlation between ipth and bmd (r = À . ). genotype distribution and allele frequency of subjects were as follows: ( %) ff), ( %) ff, ( %) ff genotype in vdrf -fok gene, ( %) bb, ( %) bb, ( %) bb in vdrb-bsmi gene. allele frequencies were f: %, f: %; b: %, b: %. when fok and bsmi were combined, %(ff-bb) and % (ff-bb) were found as the most frequent genotypes. bsmi frequency was in hardy weinberg equilibrium (p > . ). but foki was not (p = ). it was found that vit d, ipth levels and bmd were in normal levels in all carriers of ff genotype and in combined (ff-bb) type carrying healthy women ( %). the association vdr genotype and bmd may be different in various ethnic and geographical groups. therefore it is worthwhile to assess vdr polymorphism among turkish population. these type of distribution studies of vdr in healthy and in osteoporotic women may enlighten to earlier diagnosis and treatment planning. p- . . - determination of hb a c values in beta thalassemia f. g€ uzelg€ ul , g. s. seydel , a. e. yalin , e. s€ onmez , k. aksoy c ß ukurova university, adana, nigde university, nigde, mersin university, mersin, turkey introduction: hemoglobinopathies are most commonly seen hereditary blood diseases worldwide. our aim was to compare the hba c values measured on cation-exchange high performance liquid chromatography (hplc) in beta thalassemia cases. materials and methods: we collected ml of whole blood k edta containing tubes from forty-nine cases. arms, rflp and dna sequence analysis methodologies were carried out for determination of beta thalassemia mutations. hb a c values were measured using the agilent hplc system. results: forty-nine diabetic and non-diabetic patients were diagnosed with beta thalassemias: twenty-one ivs - /ivs - , one ivs - /ivs - , one ivs - /ivs - , two ivs - /ivs - , two ivs - /ivs - , one fsc /fsc , one fsc /fsc , two - /- , two cd /cd , one cd - /cd - , one cd - /cd - , two cd /cd -g/ cd /cd -g, two ivs - / ivs - , one ivs - / ivs - , one ivs - /fsc , one ivs - /cd , one ivs - /cd , one ivs - /cd - , one ivs - /ivs - , one ivs - / ivs - , one ivs - / ivs - , one ivs - /cd and one fsc /cd . cases were classified as diabetic ( ), prediabetic ( ) and non-diabetic ( ) introduction: members of aurora kinase family aurora a, b and c are conservative kinases of cell cycle which are encoded by genes aura, aurb and aurc respectively. overexpression of aura and aurb was found in human cancers, especially in prostate cancer. moreover, there is the evidence that aurb interacts with one of the major oncogenic kinases -braf. little is known about implication of aurc in cancer, but it was demonstrated, that it can overlap aurb function and shares its location. we studied expression of genes of these kinases in urine of prostate cancer patients aiming to evaluate their involvement in this disease and their potential as tumor markers. materials and methods: urine samples from patients with prostate cancer were gathered after prostate massage before surgical invasion. we used urine samples from healthy men as control. we obtained cells from each urine sample by centrifugation and isolated rna using standard approach with phenol and guanidine thiocyanate. cdna was synthesized and taken to qpcr reactions. data was statistically analysed. results: expression of all studied genes was detected in urine of patients with prostate cancer and of healthy men. expression of aurb and aurc in cancer samples each was higher than expression of aura. the cumulative expression aurb and aurc was higher than expression of aura in samples from . we observed positive correlation between expression of aurc and braf (rs = . , p = . ). discussion and conclusion: previous investigation showed, that for normal prostate tissue % of aurora family expression was presented by aura. we suppose that presence of aurb and aurc cumulative overexpression means presence of cell cycle deviations in prostate tissue of these patients and might be further studied as prognostic marker. in this study we first showed the correlation between aurc and other carcinogenic kinase braf expression, which opens the perspective for investigation of role of aurc in carcinogenesis. bacillus marmarensis sp. nov. is an extreme obligate alkaliphile isolated from mushroom compost near marmara region of turkey. it can survive at extreme ph values up to . . based on its genome sequence, metabolic pathways for proteases, amylases, cellulases, lipase, n-butanol and a biodegradable plastic poly-b-hydroxybutyrate were annotated. in addition to being a potential extracellular hydrolase producer, its ability to survive in the high ph range of . to . makes it an attractive microorganism for different industrial applications. in the current study, the adaptation strategy of b. marmarensis sp. nov. to alkaline conditions was investigated using proteomic tools. the organism was grown at two different ph values, . and ph . . for extraction of whole cell proteins, cells were disrupted with mp bio fast prep device. protein extracts were treated with protease inhibitors and a nuclease mix. salts were removed using a cleanup kit. obtained proteins were separated based of their isoelectric points in the first dimension and then based on their molecular weights in the second dimension. proteins maps of cells grown at these two extreme ph values showed significant differences in protein expression for alkaline adaptation. p- . . - biochemical and proteomic analyses of normal human astrocytes and glioblastoma exposed to dichloroacetate treatment f. c. atilgan, h. cimen yeditepe university, istanbul, turkey glioblastoma (gbm) is an aggressive malignant tumor composed of astrocytes in brain tissue. gbm cells utilize glycolysis rather than oxidative phosphorylation to support rapid growth rate which is called warburg effect. dichloroacetate (dca) is an antiglycolytic agent that inhibits pyruvate dehydrogenase kinase (pdk) activity and induces apoptosis via normalizing the mitochondrial activity. this study aimed to demonstrate the metabolic alterations between the normal human astrocytes (nha) and gbm cell lines which are exposed to dca, and to identify the differentially expressed proteins by ms-based proteomic analyses. nha cell line, u mg and u as gbm human cell lines were examined through analyzing the alterations in the glycolysis metabolism upon dca treatment by measuring the variations in the pyruvate levels, lactate dehydrogenase a, pdk . mts was performed to investigate the effect of dca treatment on cell viability. immunoblotting of pgc -a, oxphos complexes, and mitotracker green staining was employed to reveal the mitochondrial differences between normal and the cancer cells, and upon dca treatment of these cells. proteomic analyses were utilized for the identification of candidate proteins depending on the acetylation status. in this study, compared to nha, the pyruvate and ldha levels were elevated and pdk levels in u mg were reduced by %. due to mts results, ≤ mm dca treatment showed significant decrease in gbm cells compared to nha cells. immunoblotting and mitotracker green staining results showed increase in mitochondrial mass. elevation in the pyruvate and ldha levels and reduction in pdk level in u mg and u cells indicates glycolysis dependent metabolic switch in energy metabolism. proteomic analyses demonstrate that most of the differentially expressed proteins comprised of metabolic enzymes. this study provides novel information about metabolic alterations existing between nha and gbm, which can inspire further studies for therapeutic applications. kidney stone is a complex disease resulting from environmental as well as hereditary factors and principally composes of approximately % calcium oxalate (caox) crystals, which are formed through a multi-step process. vitamin d receptor (vdr) gene encodes the nuclear hormone receptor for vitamin d ; downstream targets of this gene are chiefly contributed in mineral metabolism though the receptor regulates a variety of other metabolic pathways. calcium sensing receptor casr plays an important role in sustaining mineral ion homeostasis. the aim of this study is to profile the expression level of vdr and calcium sensing receptor (casr) genes and to unravel their role in rat kidney stone induced by ethylene glycol, in order to explain the underlying molecular mechanisms. total rna were extracted from paired sample before and after ethylene glycol treated of rats. the mrna expression level of vdr and casr gene were measured employing quantitative rt-pcr (qrt-pcr). the mrna expression levels of both genes were significantly down-regulated according to before treated. in conclusion, our data suggest reduced mrna expression in vdr and casr genes might be a risk factor for kidney stone formation. further studies are necessary to verify these findings in different ethnic groups. p- . . - apj receptor a c gene polymorphism in turkish patients with coronary artery disease against different models of expected frequencies/counts to understand the evolutionary dynamics of saars in proteins. we obtained from ensembl the assemblies of genomes/proteomes of human and nonhuman primates (chimpanzee, gorilla, and rhesus monkey), rodents (mouse and rat), and birds (chicken and zebrafinch). the expected probabilities for the occurrence of saars based on their nucleotide frequencies in coding regions and amino acid frequencies in individual protein sequences or across the whole proteome were compared with the observed repeat occurrences. we found that with all three methods and in all eight species the correlation between observed and expected repeat counts decreased above a saar length threshold. the percentage of saar proteins for each amino acid also exhibited variability among species when both the repeat length and counts were taken into account. however, clustering based on saar characteristics generally reflected the known phylogenetic relationships between species. our comprehensive bioinformatics analyses reveal that saars show amino acid-specific occurrence patterns with respect to species as well as saar length. tissue proteins play important roles in biological metabolic processes. the qualitative and quantitative analysis of tissue proteins facilitates the understanding of molecular mechanisms that differentiate between physiologic and pathologic states. health and research institutions routinely prepare formalin-fixed paraffinembedded (ffpe) tissue blocks for histopathology. proteomics on ffpe tissue still requires standardization of tissue solubilization processes to overcome variability in protein extraction results. our aim is to compare the proteomic studies of fresh frozen and ffpe rat renal tissues. fresh frozen and ffpe preparations from renal tissues were included in this study. an adult rat was sacrificed and the dissected kidneys were divided two equal section. one immediately frozen in phosphate buffer, and the other tissue specimen not thicker than mm to allow rapid penetration of the fixative put in % buffered formalin for hours. the fresh frozen tissue was dissolved and homogenised in the cold phosphate buffer solution containing protease inhibitors. paraffin blocks were performed from formalin fixed tissue specimens. we have extracted the protein from the ffpe tissues using our previously verified method. we have utilized electrophoresis three times to compare protein yield, number, intracellular and intercellular of homogenised samples obtained from ffpe and fresh frozen kidney samples. the number of proteins identified from fresh frozen kidney tissue has generally been shown to be increased compared with ffpe tissue. decrease of the qualitative results in electrophoretic bands was found similar in all replicative studies. ffpe tissues undergo extensive cross linking between protein/ dna/rna molecules during formalin fixation, which creates inter-molecular crosslinks. on the other hand, ffpe tissues represent a valuable resource to carry out retrospective studies aimed to biomarker discovery in kidney cancer as well as other kidney diseases. background: development of atrial fibrillation (af) during the course of chronic primary mitral regurgitation (mr) is common and represents complex molecular mechanisms. however, the gene expression profile of human atrial fibrillation (af) in the setting of chronic primary mr remains uncharacterized. in the current study, we aimed to compare the gene expression profiles of patients with severe degenerative mr in sinus rhythm (sr) and af. methods: left and right atrial tissue samples were obtained from patients with chronic primary severe mr in permanent af (n = ) and sinus rhythm (n = ). we performed a novel micro-dissection technique for thin sections of atrial tissue samples and immediately fresh froze intra-operatively. transcriptomes of left and right atrial appendages of degenerative mitral regurgitation patients with sr versus af were compared by microarray analysis on affymetrix hgu- plus platform. bioinformatics, data mining and pathway analyses were conducted on partek gs and webgestalt. genome-wide gene expression profiles were compared between af and sr groups among . transcripts representing . well-characterized human genes. differentially regulated genes were evaluated according to fold change (fc ≥ . ) with a p-value ≤ . . results: most remarkable pathways altered in af atrial tissues compared to sr group, were extracellular matrix-receptor interaction; mapk, adipocytokine, and calcium signaling; apoptosis and cardiac muscle contraction pathways. conclusions: this is the first human study of comparative transcriptomics in left and right atrial tissues of patients with af versus sr associated with severe degenerative mr. the main findings of this multidisciplinary translational research provide novel candidate targets for the treatment and prevention of af. in order to acquire iron under iron-limiting growth conditions, bacteria employ specific mechanisms such as production and secretion of siderophores. siderophores are low molecular metalchelating compounds that contribute not only to iron scavenging, but also participate in other important processes including oxidative stress response and cell signaling. serratia marcescens, gramnegative bacterium, could be found in various environments, including wastewater, plant rhizosphere and hospital setting where s. marcescens can cause serious life-threatening infections. in this study, we performed a detailed characterization of the siderophores of the clinically important pigment-free s. marcescens strain sr - and environmental pigment-producing s. marcescens strain sm . bioinformatic analysis of these genomes by antismash software revealed the presence of several clusters involved in non-ribosomal peptides synthesis (nrps). we found four nrps clusters in genome of s. marcescens sm . cluster has a low level of identity to enterobactin gene cluster typical for bacteria producing catechol-like siderophores. second cluster has only % of identity to xantholipin biosynthetic gene cluster. clusters and of nrps genes of s. marcescens sm did not show any homology to known nrps clusters. in contrast, the genome of s. marcescens sr - contains only one genetic cluster of nrps genes. this cluster does not have similarity to any of the known bacterial nrps genes. thus, genetic analysis of two isolates of s. marcescens allowed us to identify nrps genetic clusters and showed that the repertoire of these genes is different between strains. we hypothesized that the strain isolated from environment has competitive advantage over clinical isolate due to genetic diversity of siderophores. on the other side, clinical isolate has specific genetic cluster of siderophores which may promote s. marcescens growth and adaptation to the extreme niches present in medical facilities. p- . . - the first glance on the genome's structure and activity in hibernator edible dormouse hibernation is a unique adaptive way of survival in extreme environmental conditions where mammals decrease their metabolic rate and demonstrate physical inactivity for prolonged periods of time (up to - months). remarkably, some hibernating animals have a long average lifespan and the ability to avoid muscle atrophy caused by disuse or immobilization. to identify main molecular pathways behind the protective musculoskeletal adaptation and genome structure in hibernator edible dormouse (glis glis), whole-genome analysis of mrna expression in muscles (m. soleus and m. edl) and lumbar spinal cord samples was conducted. three groups of the dormice: ) active animals ) hibernated animals and ) animals immobilized for weeks in laboratory, were examined. rna libraries have been sequenced using hiseq illumina platform. coupled with genome dna sequencing provided x coverage of the estimated genome, we have assembled de novo transcriptome of the dormice. differentially expressed genes in response to immobilization and hibernation were determined. transcriptional program of these phenotypes was similar. pathways enriched by differentially expressed genes were identified. gene expression of the key muscle proteins and muscle atrophy markers was analyzed. muscle-specific e -ubiquitin ligases murf and mafbx revealed no changes in mrna expression. our study represents the first attempt to elucidate changes in transcription profiles of skeletal muscles and spinal cord during hibernation and hypokinesia in edible dormice. in corroboration to the gene expression data, they demonstrated minimal morphological evidence for muscle disuse atrophy during physical inactivity. edible dormice, thus, can be considered as a novel model organisms in investigation of the genetic mechanisms of hibernation and prevention of muscle atrophy. the work is performed according to the russian government program of competitive growth of kfu and supported by rfbr jsps_a no. - - . in response to diverse environmental cues bacteria form complex structured communities called biofilms. the metabolic pathways activated by these cues are remarkably different depending on the species studied. however, they all lead to the formation of an extracellular matrix that holds the cells together. non-pathogenic gram-positive spore-forming soil b. subtilis strain is recognized as a model system for the study of biofilms. to discover the pathways regulating biofilm formation in b. subtilis, we studied the natural isolate of b. subtilis strain , and constructed the recombinant strains with knocked out genes of following regulatory proteins: abrb (global transcriptional regulator), degu (two-component response regulator of signal transduction system degs-degu), ccpa (regulator of carbon catabolism) and spooa (regulator of sporulation). in the minimal medium broth b. subtilis wild-type strain forms biofilm with its maximum on th hour of culture growth. ph-optimum for biofilms formation by the wild-type strain is in the range of . - . . the temperature optimum is in the range from °c to °c. this corresponds to the natural conditions of the b. subtilis habitat in rhizosphere. the level of biofilm formation by regulatory mutant strains with deleted abrb, degu, ccpa, spooa genes is on average % lower than by the wild-type strain. this indicates that global regulatory system controlls biofilm formation process. statistically significant differences in the levels of biofilm formation between regulatory mutants haven't been identified. ph and temperature optima of mutant strains are the same as for the wildtype strain - , - and °c - °c respectively. the crataegus genus which is a member of rosaceae family, has approximately species worldwide and species in turkey. all plant species in this genus have the common name "hawthorn". crataegus microphylla (c. microphylla) c. koch which is characterised by having erect sepals in fruit and smaller leaves in comparison with the other species, is one of the wild edible fruits in turkey. crataegus species have been used as food and also in folk medicine for the treatment of various diseases. for this purpose, the potential biological properties of crataegus microphylla were aimed to reveal by the preliminary work. in this study, prevention of oxidative dna damage using supercoiled pbr plasmid dna, acetylcholinesterase, tyrosinase, a-glucosidase inhibition and antioxidant effects: , diphenyl- -picrylhydrazyl radical scavenging effect, phosphomolibdenum-reducing antioxidant power, ferric-reducing antioxidant power with total phenolic and total flavonoid contents of the c. microphylla leaves, stem barks and fruits that extracted with ethanol, methanol and water were investigated. the experiments of oxidative dna damage studies and antioxidant activities of c. microphylla extracts showed that methanol and ethanol extracts possessed a strong ability to prevent dna damage and significantly antioxidant activities. methanol extracts of stem barks from c. microphylla exhibited the highest acetylcholinesterase and tyrosinase activities ( . ae . % and . ae . %, respectively), at lg/ml. in addition, ethanol extract of leaves from c. microphylla inhibited the a-glucosidase activity significantly when compared to acarbose. this study explained significant antioxidant, enzyme inhibitory, hypoglycemic, and neuroprotective activities of methanolic or ethanolic extracts prepared with stem bark and leaf from c. microphylla and also strong ability to prevent dna damage that corresponded to antioxidant potential of methanol extracts of leaf and stem bark. the yarrowia lipolytica species (yl) is nonconventional yeast widely used for recombinant protein expression due to its system of post-translation protein modification, which is the most similar to that of higher eukaryotes. yl appears the promising producer of recombinant proteins with much more complicated molecules compared to those of prokaryotic producers. however, an important feature for a producer strain of recombinant proteins is the genes, the expression of which undertakes under controlled conditions, and consequently, search of new effective inducible promoters in the yl genome is of great interest. proteome analysis of the yl cells grown at different ph values ( . , . , . ) showed that under alkaline conditions the amount of mitochondrial porine vdac (voltage dependent anion channel), one of the most abundant protein of the mitochondrial outer membrane, increased significantly. vdac is supposed to let reactive oxygen species out of mitochondria protecting the cell against oxidative stress. therefore, the por gene expression, encoding vdac should increase in the stress conditions. the promoter of the por gene was used to construct some new expression systems based on yl w . a new genetic construct bearing a reporter bgalactosidase gene under control of the por promoter. b-galactosidase activity was assayed in the cells grown in various ph conditions and exposed to exogenous oxidants such as hydrogen peroxide, menadione, and methyl viologen. it was shown, that in h o and methyl viologen treated cells b-galactosidase activity increased . - . -fold reaching its maximum in the cells, grown at ph of . . thus, we demonstrated high inducibility of the por promoter, which is essential for effective action of the expression system based on it and potency of application for transformed lines of producers. acknowledgments: supported by the russian foundation for basic research (grant no - - mol_a). aspergillus nidulans is able to detoxify and catabolize the toxic proline analogue, lazetidine- -carboxylic acid in nature, azc serves as a plant protectant against infections and consumption. we have obtained evidence that azc is not only non-toxic for the model ascomycete aspergillus nidulans, but it can be utilized as a poor nitrogen source. in order to elucidate the molecular mechanism underlying azc detoxification, we have constructed and studied a. nidulans strains deleted in the cognate genes involved in azc detoxification in pseudomonas and saccharomyces cerevisiae. these genes, found by in silico analysis, encode a putative hydrolase, acha, and an azc acetyltransferase, ngn , respectively. gene deletion was accomplished through double crossover. a cassette containing the~ bp ' and ' flanking sequences of each gene, with the afpyrg gene as a selection marker, was contructed. crossing the achad and the ngn d strains isolated the achad ngn d double mutant strain. rt-pcr was used for gene expression analysis in the wild type strain, area-loss of function and crea-derepressed mutant strains. our results clearly show that azc can be used as a poor nitrogen source by a. nidulans. this utilization requires a) acha, a putative azc hydrolase, and b) a fully active gaba catabolic pathway, as lack of either amdr or gata abolishes azc utilization. most importantly, the double mutant, achad ngn d, shows azc toxicity, suggesting that ngn is a true orthologue of mpr , able to detoxify azc, a phenotype that can be observed only in the absence of acha. as a final point, ngn was shown to be induced by the presence of azc and and to be under nitro the spatial genome organization plays a great role in the maintenance of the nuclear architecture and regulation of all processes occurring in the nucleus. this system is controlled by a set of special proteins having an architectural function. however, the mechanisms of their action remain unknown. among these proteins are, in particular, zad-domain-containing proteins. zinc finger-associated domain (zad) is a ubiquitous motif of c h zinc finger proteins of drosophila. genes that encode zad proteins are specific for and expanded in the genomes of insects. only a few zad-encoding genes have known functions, and the role of zad is being discussed. up to date there was only one known crystal structure of zad-domain from drosophila transcription factor grauzone (grauzad). here, we present for the first time the crystal structure of the zad-domain of serendipity-d transcriptional activator of the egg-polarity gene bicoid. zad-domain was cloned, overexpressed in e. coli, purified and the structure was solved at . a by mad technique. detailed analysis of the structure proved that the protein exists in dimeric form and revealed unique spatial organization of the protein, different from those for grauzad. this work is supported in part by russian ministry of education and science grant ( . . . ). mycoplasma gallisepticum is a convenient model object for studying the regulation of transcription because it has a reduced genome, lack of cell wall and many metabolic pathways and also easy to culture and non-pathogenic to humans. due to the nature of the genomic organization and the loss of many of the known regulators, the effect of disrupting the function of some proteins may be a useful tool for studying the regulation of transcription. the gene expression study was performed on agilent onecolor microarray with custom design and random-t polymerase primer for cdna synthesis. microarray represents probes for orf including genes and ncrna. in this work, we have investigated the effect of changes in the level of gene expression of m. gallisepticum for two different types of conditions: a genetic knock-out mutants and the cell response to treatment with sub-lethal concentrations of antibiotics. we characterized transcription of m. gallisepticum when the cell responses to dysfunction of proteins with metabolic potential, possible regulators of expression, in violation of permeability of membrane by cccp, inhibition of ribosomal synthesis by tetracycline, dna gyrase by novobiocin and atp synthase by oligomycin. the data obtained allow to characterize the transcriptional response under different conditions and to identify groups of genes that change expression together. major transcriptional changes were observed in the response of cells under cccp treatment due to uncoupling of the proton gradient and further reducing the membrane potential, as well as under novobiocin treatment due to changing the topology of dna. global problem of oil pollution forces scientists to search for a new safe remediation technologies constantly. careful attention is paid to bacteria, some of which possess additional biotechnologically valuable properties, such as utilization of hydrocarbons and production of biofurfactants. in this regard, we carried out proteogenomic characterization of tsukamurella tyrosinosolvens strain ps , which was isolated from chemical sludge and capable for alkane degradation and biosurfactant production. whole genome of the strain was sequenced on the miseq (illumina) platform, assembled and annotated. proteome on mineral medium with glucose, sucrose and hexadecane as a sole carbon and energy source was studied. shotgun proteomics approach was performed on hybrid chromatography-mass spectrometry machine (maxis impact). alkane oxidation genes (alkane- -monooxygenase, rubredoxin and rubredoxin-reductase) under genome sequence, as well as two pathways of trehalose synthesis and genes for mycolic acids production were found. emulsification activity of cell-free culture liquid was about four times higher on hexadecane in comparison with sugars. proteomic profile was different at various culture conditions. all glycolysis genes, beginning with glucose- -phosphate isomerase to pyruvate kinase, were found on the media with sugar. the medium with hexadecane helped to reveal enzymes involved in the beta-oxidation of fatty acids, for example , -dienoyl-coa reductase, -ketoacyl-coa thiolase and enzymes of the initial mycolic acid synthesis pathways. thus we have established that the strain t. tyrosinosolvens ps utilizes sugar by glycolysis. also, the bacterium is capable for alkane oxidation followed by beta-oxidation of fatty acids. based on the proteogenomic data, we assume that the bacterium is able to synthesize trehalose lipids, namely, trehalose mycolates. obtained results could be useful to create conditions for increased biosurfactants production. gestational diabetes mellitus (gdm) is a glucose intolerance firstly diagnosed during pregnancy. in this study, we aimed to investigate the association between serum adiponectin, resistin levels and insulin resistance in gestational diabetic patients. a total of patients; healthy pregnant women (control group) and pregnant women diagnosed with gdm (gdm group) were included in this study. serum adiponectin, resistin, glucose, insulin, hba c levels and lipid parameters were measured. insulin resistance index homa-ir values were calculated. in this study, serum glucose, insulin, hba c levels and homa-ir were significantly higher in gdm group compared to the control group (p = . , p = . , p = . , p = . , respectively). serum adiponectin levels were significantly lower (p < . ); whereas serum resistin levels were significantly higher (p = . ) in gdm group than in the control group. it can be concluded that resistin contributes to the formation of insulin resistance, adiponectin plays an important role in the regulation of this resistance and they also have effects on gdm pathophysiology. hematological cancers including acute myeloblastic leukemia (aml) and acute lymphoblastic leukemia (all) in terms of incidence and mortality, are the second most important cancer type in turkey. numerous studies show that cancer patients respond differently to treatment thus supporting the idea of personalized therapy need for individuals. renin angiotensin system (ras) have key roles in aml and all progression and it has been shown by many studies suggests that these system's genes might be good biomarkers for aml and all personalized therapy. we aimed to identify ras gene based homogeneous subgroups of acute leukemia and determine the most effective chemotherapoetic agent for each subgroup. after validation and verification of the results, more effective drugs can be recommended for the use in clinics for chemotherapy of aml and all. results of our preliminary studies showed that we are able to identify subgroups of aml and all as well as correlating each existing subgroup with fda approved drugs. considering the long and highly cost process of developing new drugs for cancer treatment makes the present study all the more valuable. in addition, there is a serious need for change in aml and all therapy since there is no highly effective chemotherapy protocol available for their treatment. welcome trust sanger (wts) and cancer cell line encyclopedia (ccle) databases will be used to determine subgroups of aml and all based on ras genes or whole genome expression using standard deviation and hierarchical clustering analysis. the most effective drugs for each subgroup will be identified using pearson's r correlation analysis with drug sensitivity data (ic , ic , amax, aare, etc.) available in same databases. further validation tests will be performed by in vitro validation using aml and all cell lines: drug sensitivity profiles will be determined and gene expression will be shown by q-rt-pcr. p- . . - functional polymorphisms of ephx in a turkish population h. pinarbasi, i. sari cumhuriyet university, sivas, turkey soluble epoxide hydrolase (seh; ec . . . ) is encoded by ephx and catalyses the degradation of endogenous fatty acid epoxides generated by cyp epoxygenases. these fatty acid epoxides such as epoxyeicosatrienoic acids (eets) have been shown to posses vasodilator, anti-inflammatory, anti-platelet, anti-hypertensive, anti-apoptotic, anti-thrombotic and natriuretic effects. it has been reported that eet levels are associated with hypertension, stroke and cardiovascular diseases. individual differences in the ephx gene that affect the seh activity may alter the circulating levels of eets. k r and r q polymorphisms have been known to cause increased and decreased seh activity, respectively. therefore we aimed to determine the genotype frequencies of these two polymorphisms in a turkish population. k r and r q polymorphisms were determined by the real time pcr using double-dye hydrolysis probes or pcr-rflp method. the observed genotype frequencies for k r polymorphism were . % wild type (aa) and . % polymorphic genotype (ag+gg) and for r q polymorphism . % wild type and . % polymorphic genotype (ga+aa). the genotype distributions for both polymorphisms were in hardy-weinberg equilibrium. pregnancy is one of manifestations for thrombophilia factors, which in its turn leads to various complications of its course. one of the markers of hereditary thrombophilia is mutations in the folate cycle mtr, mtrr and mthfr genes. insufficient intake of folate during pregnancy disrupts the functioning of the genome, leading to miscarriage, violation of embryogenesis and various fetal malformations. however, results of studies on the role of hereditary thrombophilia in the occurrence of complications during pregnancy are rather contradictory. aim of this study was to determine the frequency of alleles and polymorphic variants of folate cycle genes mtr a g, mtrr a g and mthfr c t in women of kazakh ethnic group with pregnancy complications. we used real-time pcr. blood samples for dna isolation were obtained from pregnant women. the main group consisted of women (n = ) which had a history of two or more pregnancy complications in the form of pre-eclampsia, eclampsia, missed abortion, miscarriage, and etc. control group consisted of women (n = ) with two or more normal pregnancy outcomes, and had no complications during pregnancy in history. average age of women in experimental group was . ae . years compared with control of the age . ae . . the analysis of the frequency distribution of alleles of genes in experimental group of women with complications of pregnancy revealed no significant differences relative to the control group. analysis of the distribution of polymorphic variants of folate cycle genes showed significant difference between the study and control groups in the occurrence frequency of heterozygotes for the mutant allele g in the gene mtrr a g (or = . , ci % = . - . ; v = . , p < , ). no significant differences in alleles between homozygous wild-type and homozygous mutant alleles were observed. this work was funded by the mes kazakhstan (gr rk project number). p- . . - a study on the association between rs polymorphism in connective tissue growth factor gene and pseudoexfoliation syndrome pseudoexfoliation syndrome (pes) is a disorder of the extracellular matrix characterized by the production and progressive accumulation of an abnormal fibrillary material in many ocular tissues. pes prevalence is . % above the age in turkey. since pes is characterized by excessive synthesis of elastic microfibrillar components throughout the body, growth factors can have important roles in the pathophysiology of pes. human connective tissue growth factor (ctgf) is a protein expressed in a variety of tissues, including the anterior chamber of the eye. ctgf coding gene has several genetic polymorphisms. rs g/c single nucleotide polymorphism (snp) is found at position À , in promoter region. the presence of a c allele for rs is critical for transcriptional suppression of the ctgf gene which would reduce ctgf production. aim of this study was to investigate if there is any association between pes and rs polymorphism of the ctgf gene. study population consisted of patients with pes and controls. blood samples were collected by g€ ulhane military medical academy, department of ophthalmology, ankara, turkey. genotypes were assigned by pcr followed by restriction fragment length polymorphism analysis. genomic dnas were isolated from whole blood samples using manual dna isolation. the frequency of ctgf rs polymorphic allele g was . in patients, and . in controls ( . , p = . ). distribution of genotypes was gg: . %, gc: . % and cc: . % among patients, while gg: %, gc: . % and cc: . % (or = . , p = . ) in controls. statistical analysis showed that there is no significant relationship between ctgf rs snp and pes. these are the preliminary findings of a research project which is the first study analyzing the relationship between ctgf rs snp and pes. this work did not point out a role for ctgf rs in the risk for pes. a significant relationship might be found when the study population is enlarged. p- . . - evaluation of rs single nucleotide polymorphism of clusterin gene in pseuodoexfoliation syndrome risk pseuodoexfoliation syndrome (pes), an age-related systemic disorder, is characterized by production and accumulation of abnormal fibrillar extracellular material in anterior structures of the eye. clusterin (clu) is a multifunctional glycoprotein produced and secreted by almost all cell types and is found in all body fluids and in accumulated pes material. under cellular stress conditions, clu provides inhibition of stress-induced precipitation and aggregation of misfolded proteins. clu expression level in pes patients is unexpectedly low and this could be due to single nucleotide polymorphisms (snp) on the gene coding for clu. rs c/t polymorphism has been found to be associated with alzheimer's disease and pathophysiology of alzheimer and pes are similar. this study aimed to determine whether rs snp of clu gene have a role in the development of pes. study population consisted of patients with pes and controls. blood samples were obtained from g€ ulhane military medical academy, department of ophthalmology, ankara, turkey. genomic dnas were isolated from whole blood of subjects using manual dna isolation. genotypes were assigned by pcr followed by restriction fragment length polymorphism analysis. t allele frequency of pes patients was . and that of controls was . ( . , p = . ). the distribution of genotypes was cc: . %, tc: . % and tt: . % among patients while cc: . %, tc: . % and tt: . % ( . , p = . ) in controls. there was no statistically significant difference between pes patients and controls in terms of tt genotype and t allele frequency. these are the preliminary findings of a research project which is the first study analyzing the relationship between clu rs snp and pes in turkish population. this work did not point out a relation for polymorphic genotype in the risk for pes. however, a relationship between clu rs polymorphism and pes can be found when we enlarge the study population. the tumor suppressor tp is the most frequently mutated gene in head neck squamous cell carcinoma cancer and represents a known transcription factor and tumor suppressor gene that regulates different microrna and target genes. the aim of our work is to construct the transcriptional and post-transcriptional network regulated by tp and to evaluate the difference at mrna and protein expression levels of the tp target genes in hpv negative head and neck squamous cell carcinoma (hnscc) patients with distinct tp mutation states and to elucidate the molecular mechanism that underlie the poor prognosis of tp mutation. to show the tp mutation landscape and its prognostic relevance for survival, we used cbioportal for cancer genomic analysis. we downloaded mutational profiles of hpv negative hnscc patients. employing different databases we constructed the tp regulatory network. and then, to evaluate the effect on mrna, protein and microrna regulated by tp we used the mrna and protein expression profiles of patients from tcga. our results show that hotspot, truncating and missense mutations have statistical significance in the univariate analysis. the tp regulatory network show the involvement of important target involved in the progression of hnscc and the deregulation of protein expression of an important key epigenetic modifier ezh was significantly associated with tp mutational state. ezh is a member of the polycomb group protein enhancer zeste homolog which is known to be directly repressed by tp and indirectly by the activation of mir- a and mir- b. we found a significant up-regulation of ezh that depend from tp mutation. it is important to understand the difference in mrna and protein expression of tp regulatory network that could depend from its mutational state. this finding suggest that ezh might be a potential therapeutic target for hnscc. p- . . - next generation sequencing based approach for monitoring of minimal residual disease in acute lymphoblastic leukemia minimal residual disease (mrd) monitoring is widely used to evaluate efficiency of chemotherapy and to choose a strategy for further treatment in acute lymphoblastic leukemia (all). the most commonly used approaches for mrd detection are based on flow cytometry and qpcr. these methods have several important limitations including insufficient sensitivity, complicated experimental setup and false positivity. the newly developed next generation sequencing (ngs) approaches could overcome the existing limitations in mrd monitoring. here we describe a new mrd monitoring approach based on targeted deep sequencing of malignant rearrangements. first, we identified bcr/tcr rearrangements specific for the leukemic clones in initial bone marrow samples of all patients. for this, we used sanger sequencing of the products of multiplex pcr, performed with bcr/tcr specific primers combined according to the optimal frequency distribution of v/j-genes in healthy donors. second, we analyzed concentration of malignant clone rearrangements, identified at the first step, in dna samples obtained from bone marrow after days of treatment. for this purpose, we performed ngs of libraries for each identified leukemic rearrangement. four libraries were amplicons of bcr or tcr gene rearrangements generated using characteristic v and j segment specific primer combination. six additional libraries were amplicons of the same primer combination from the same dna sample which contained initial leukemic dna spike-in (in concentrations corresponding to per , and , cells) for a calibration curve generation. using this approach, we analyzed all clone specific rearrangements for three patients and calculated concentration of the leukemic clones by using the calibration curve. for one patient we didn't find any leukemic cells and for two patients we found leukemic cell per , analyzed cells. znf is considered as a transcriptional target for p and plays an important role in the homologous recombination, mitosis, centrosome dynamics. as was shown by gwas some snps in znf have strong association with the risk of breast cancer (bc). however, it was unclear whether the same snps are associated with risk of bc in kazakhstan. therefore two polymorphisms (rs , rs ) of znf were investigated in kazakh population in this study. the present case-control study was carried out with participation of kazakh females with bc and cancer-free donors. additionally, subtypes of bc, stratified by estrogen receptor (er+/À), progesterone receptor (pr+/À) and human epidermal growth factor receptor (her +/À) status were estimated. pearson p-value, odds ratio, % confidence interval tests were applied to data analysis. significant differences were found in allele frequency and genotype distribution at rs locus in znf between the patients and control groups (p = . for allele; p = . for genotype). moreover, significant association with bc was revealed for rs after dividing patients according to er+/ À, pr+/À and her +/À status of the tumor. the g allele was associated with er+ (p = . , or = . , %ci: . - . ), pr+ (p = . , or = . , %ci: . - . ) and gg genotype with her -bc carriers (p = . , or = . , %ci: . - . ). also, g allele can be considered as a risk factors in er+/ pr+/her -luminal type of tumor (p = . , or = . , % ci: . - . ). our findings correlate with the data of several gwas where the association of the rs polymorphism with higher mammographic density and the risk of breast cancer have been shown. the obtained results allow us to consider g allele and gg genotype of rs as a marker of bc risk with predictive value, restricted to er, pr and her status of the tumor in the kazakh population. breast cancer (bc) is the most common cancer among women in most of countries. alternative variants of low-penetrance genes such as fgfr (rs ), tox (rs ), map k (rs ), lsp (rs ) are shown to have high frequency in north america, south-east asia, australia, europe populations and a multiplicative effect on the development of bc. in this study was investigated assosiasion between alleles/genotypes combinations of these genes with increase/decrease of bc risk. the case-control study included bc patients and healthy women from kazakh and russian populations. genotyping was performed by pcr-rflp methods. combined effect of allele and genotype variations in four different genes on bc risk was assessed by apsampler algorithm. the fisher exact test, odds ratio (or) with % confidence intervals ( % ci) were applied to data analysis. according to obtained results combinations of allele c of tox rs and a of map k rs (p = . , or = . ), also allele c of tox rs and c of lsp rs (p = . , or = . ) associated with increased bc risk in the russian population. consequently, combinations with c allele of tox rs contribute significantly to bc risk with p-value = . , or = . . on the contrary, tt genotype of tox rs with p = . , or = . and its combination with allele t of lsp rs with p = . , or = . determine a bc risk reduction in russian population. in addition, a risk combination of allele c of lsp rs and a of map k rs was found in kazakh population (p = . , or = . ). studies have shown that a genetic predisposition to bc can be determined by the cumulative effect of individual alleles and genotypes and possible epistatic interactions of studied genes. obtained combinations of alleles and genotypes can be considered as complex genetic markers of bc and may be used as predictive. cancer that is caused by excessive proliferation of cells and reduced apoptosis is a pathological condition. currently, studies that are comitted with breast cancer are great important early detection and diagnosis of breast cancer. after the discovery of cisplatin as chemoterapy drug, new transition metal based complexes have been developed for treatment of cancer. in this study, anti-cancer activity of azo-azomethide ligand and its mononuclear metal complexes is studied on human cancer cell lines (mcf- ) and mouse fibroblast (l ) cell lines. cells were studied four different concentrations ( , ; ; ; lm). xtt ( , -bis-( -methoxy- -nitro- -sulfophenyl)- h-tetrazolium- -carboxanilide) protocol was applied after and hours. in our study % fetal bovine serum (fbs), % l-glutamine, iu/ml penicillin and mg/ml streptomycin in dmem (low glucose) were used. cancer cell lines in dmem medium is produced in % humidity and % co incubator at °c. anti-cancer activity of synthesized complexes were determined on mcf- and l . in the biological activity studies, synthesized compounds showed higher anticancer activity than positive control ( -fu). finally, our new synthesized complexes can be suggested that potent ajan for anti-tumuour for breast cancer drugs. large interindividual differences in response to chemotherapy present an important issue in cancer treatment. malignant mesothelioma (mm) is an aggressive tumor with poor prognosis, treated mostly with gemcitabine/cisplatin (gem/cis) or pemetrexed/cisplatin (pmx/cis) chemotherapy. as both clinical characteristics and genetic variability may affect treatment outcome, our aim was to construct and validate clinical-pharmacogenetic prediction models of treatment outcome in mm for both chemotherapy regimens and to develop an algorithm for genotype-based treatment recommendations. clinical-pharmacogenetic models were built on gem/cistreated and pmx/cis-treated mm patients. pharmacogenetic scores were assigned by rounding the regression coefficients. gem/cis model was validated on independent mm patients. model predicting outcome of gem/cis chemotherapy included crp level, histological type, performance status, rrm rs , ercc rs , ercc rs , and xrcc rs . values ranged between and . ; cutoff value of . had sensitivity of . and specificity of . . patients with higher score had shorter progression-free and overall survival (p < . ). in the validation group, positive predictive value was . and negative predictive value was . . model predicting outcome of pmx/cis chemotherapy included crp level, mthfd rs , and abcc rs with scores ranging between and . . cutoff value of . had sensitivity of . and specificity of . . patients with higher score had lower probability of good response and shorter progression-free survival (p < . ). clinical-pharmacogenetic models could enable stratification of mm patients based on their probability of response to gem/cis or pmx/cis and improve treatment outcome. this approach could be used for translation of pharmacogenetic testing to clinical practice as it would facilitate the selection of the best treatment option for each patient. p- . . - evaluation of anti-diabetic potential of circiliol and circilineol using caco cell line diabetes mellitus is a metabolic disorder, and many people are suffering from this disease in the worldwide. oral hypoglycemic agents such as sulfonylureas and biguanides are currently used for the treatment. however, studies searching for a more effective anti-diabetic agents are being carried out continıously. based on that we aim to investigate the potential anti-diabetic effects of circilineol and circiliol isolated from teucrium alyssifolium extract, using in vitro cell culture models. for this purpose, the anti-diabetic actions were investigated by applying model caco (colorectal adenocarcinoma) cell line. we determined the level of ag (alpha-glucosidase), sglt (sodium-glucose transporter- ) and glut - and glucose transport. neither ag activity nor sglt activity was increased with either circiliol or circilineol treatment in caco cells compared to positive control. similarly, neither the activity nor the expression level of glut *- was increased in caco cell line with either circiliol or circilineol treatment relative to control. in conclusion, these results strongly suggest that circiliol and circilineol do not possess any anti-diabetic potentials.supported by tubitak z and paubap fbe the purpose of this study was to characterize and assess the impact of a novel magnetite (fe o ) nanosystem functionalized with the natural origin compound eugenol (e) on the pseudomonas aeruginosa virulence, biofilm formation and qs signaling in order to advance research aimed to find alternative and personalized therapeutic approaches for severe infections produced by this opportunistic pathogen. fe o nanoparticles were obtained by a co-precipitation method and functionalized with analytical purity e. functionalized nanoparticles (fe o @e) were characterized by ir, sem, tga and hr tem. one laboratory and p. aeruginosa clinical isolates were utilized in the study. growth and biofilm formation were assessed by an adapted microdilution method followed by absorbance reads and viable count analysis in dynamics ( , , and hours of treatment). soluble virulence factors production was assessed by enzyme activity evaluation of bacteria grown on specific media. the expression of qs core genes was analyzed by qrt-pcr and a luminescence assay. results demonstrated that the average size of the obtained nanosystem ranges - nm, particles are relatively homogenous and have a low tendency to form aggregates. subinhibitory concentrations of fe o @e limited biofilms formation in a time and strain dependent manner, and significantly inhibited the production of toxin pore forming enzymes (haemolysins and lipases) in most strains. the expression of lasi and lasr genes was three fold downregulated, while the expression of pqsr was upregulated in planktonic cultures suggesting that pqs signaling may be involved in virulence modulation after nanoparticle stimulation. the modulation of bacterial virulence and molecular signaling by functional nanoparticles utilized in subinhibitory amounts offer valuable perspectives to develop personalized antimicrobial approaches based on molecular communication control that clearly modulate pathogenicity and progression of the infectious process. p- . . - specimen processing and handling for plasma ammonia measurement b. sarac ßligil , , s. abus ßo glu , f. aky€ urek , b. € ozt€ urk selc ßuk medical school, konya, biochemistry department, selcuk university faculty of medicine, konya, turkey objectives: ammonia requires special processing and handling conditions due to its' unstability. in this study, our aim to investigate a preanalytical factor (delayed analyze) affecting plasma ammonia measurement. design and methods: blood samples were obtained from healthy volunteers. for determining different handling and storage conditions, the following protocols were applied: first protocol (a) transportation on ice and separation (centrifugation at °c) within minutes of collection and analyze immediately. second protocol (b) transportation on ice and separation (centrifugation at °c) within minutes and analyse refrigerated - °c hours (a , b ) and hours (a , b ). all plasma ammonia levels was analyzed enzimatic glutamate dehiydrogenase methods by abbott architect c clinical chemistry analyzer. results: there were statistically alterations in all protocols compared to first protocol. prolonged centrifugation time for plasma ammonia lead to have higher results ( . versus . lg/dl, p < . ). in all protocols including a , a , b , b also cause an elevation in plasma ammonia results ( . , . , . and . ; p = . , p < . , p < . , p < . , respectively). conclusions: ammonia concentration in the blood sample increases over time due to high concentrations in cells as erythrocyte or platelets (three fold). blood samples collected for ammonia determination should be stored on ice, and measured immediately. the wnt/b-catenin signaling pathway has been considered to be a factor in the development and progression of colorectal cancer. many studies have demonstrated that the presence of mutations or polymorphisms in ctnnb (gene encoding b-catenin; mostly mutations in exon ) can lead to aberrant activation of wnt/bcatenin signaling at the onset of various types of malignancies, including colorectal cancer. the aim of our study was to assess ctnnb alteration in the patients with colorectal cancer and compared their tumor and normal tissues. a total of paraffin-embedded colorectal tumor specimens were obtained from department of pathology in cerrahpasa medical faculty. also a total paraffin-embedded normal tissue was used from same cases as a control group. ten-micrometer-thick tissue sections were placed on a glass slide and stained with he. then the tissue sections were dehydrated in graded ethanol solutions and dried without a cover glass. dna was extracted from the tissues with ll of extraction buffer at °c over night. the tubes were boiled for min to inactivate the proteinase k. ctnnb exon was amplified by pcr. sscp is used to observe any difference between the groups. genomic dna was isolated as described above. ll of each pcr products mixed with ll denaturating buffer and were denatured by heating at °c for minutes in, and then were rapidly cooled on ice. the denatured pcr samples are run on % acrylamide/ bis gel in . tbe buffer for . hours at v at room temperature with water cooling system. the gel was stained with silver staining method. migration and adhesion involve continuous modulation of cell motility, beta-catenin play major roles. beta-catenin gene alterations frequency range between and % in colorectal cancer according to the different published studies. in our study no significant differences were found in the ctnnb exon between the tumor group and normal groups. p- . . - theranostic approach in agressive recurrent meningiomafirst experience in turkey m. o. demirkol , b. uc ßar koc ß university, istanbul, american hospital, istanbul, turkey meningiomas arise from the meningothelial cells of the arachnoid membranes of the leptomeninx, which are attached to the inner layer of the dura mater. meningiomas can be classified into three grades (i-iii): grade i meningiomas which are benign, exhibit slow growth; grade ii (atypical) and grade iii (anaplastic) meningiomas, which have a much more aggressive clinical behaviour. meningiomas express non-steroid hormones, including somatostatin. in the brain, somatostatin-a cyclic tetradecapeptide neuropeptide-is believed to act as a neurotransmitter and neuromodulator. somatostatin performs its physiological functions by binding to specific receptors (sstri-sstrv). sstr exhibit high affinity for octreotate (tate). tate is a polar, watersoluble peptide that does not penetrate the intact bbb (brain-blood barrier). pet and scintigraphic imagings can only demonstrate somatostatin receptor positive intracranial lesions if the bbb is disrupted. in this aim, dotatate (dota-dphe , tyr -octreotate, tate) has been labelled with the positron emitter ga and the beta and gama emitter lu. in this case, we conducted a study to evaluate peptide receptor radionuclide therapy (prrt) planning based on pet/ct imaging of meningioma in the department of nuclear medicine and molecular imaging at the amerikan hospital. [ ga] dota -tyr -oc-pet/ct has been established as the imaging modality of choice for the diagnosis and management of patient with skull-base malign meningioma (rapid progress -to mm. from mm. in d.-after fifth operation). due to its high sstr selectivity, [ lu]-tate showed significantly lower uptake/dose delivered to normal tissues, gatate-pet represents the imaging strategy of choice for an accurate assessment of sstr expression levels. although some studies have not shown a clear advantage over pet/ct, there is some evidence that it will have an advantage in selected body sites such as the head and neck, liver, and the pelvis. p- . . - cardiovascular diseases can be treated by using 'tetr-odd-vp ' and 'hre' hypoxia inducible systems a. celik , t. kaya , s. cigdem , m. g€ und€ uz department of medical genetic, turgut ozal university, ankara, faculty of medicine, turgut ozal university, ankara, turkey ischemia is an insufficient supply of blood to a tissue or organ, usually due to a blocked artery by a blood clot. up to now, the number one cause of death worldwide is caused by ischemia and related conditions such as heart attack or stroke. hif- a is a transcription activator that functions as a master regulator of oxygen homeostasis. hif- a protein levels increase under hypoxic conditions as a result of decreased o -dependent prolyl-hydroxylation, ubiqutination and degradation. we aimed to break up clots in blood vessels and to prevent damage caused by ischemia by using hypoxia inducible systems. we added oxygen dependent degredation domain (odd) of hif a between and in front of tetr dna binding domain and vp transactivation domain, so that tetr-odd-vp or odd-tetr-vp could activate transcription of tissue plasminogen activator (tpa) controlled by tetracycline response element (tre), in a hif a independent manner. in addition, we also designed tissue plasminogen activator (tpa) under control of hypoxia response element (hre) of hif a target genes. western blotting and immunofluorescence assay results showed the expression and nuclear localization of tetr-odd-vp and odd-tetr-vp constructs under hypoxic conditions, but not normoxic. in addition, using fluorometric reporter systems and tpa enzymatic assay we proved functionality of these constructs under hypoxic conditions. final apporoach to our project is predicting kinetic enzymatic activity of tpa during break up blood clots by using matlab. the results of the present investigation showed, the developed hypoxia responsible systems that can be engineered into endothelial cells to prevent ischemia related cardiovascular diseases. p- . . - osteogenic potential assessment of some original scaffolds with magnetic properties new advances in bone tissue engineering demand the development of materials that can not only replace bone, but also regenerate the damaged tissue based on external or even internal stimulus. magnetic materials inside bone scaffolds are known to be a promoting factor for bone healing especially when the therapy is accompanied by application of external magnetic stimulation. based on a recent report, the presence of iron oxide in hydroxyapatite can improve the radio opacity and osteoblast proliferation. in this view, this study focuses on the development of silk fibroin-magnetite biocomposites for potential uses in bone tissue bioenegineering. such novel composites possess good mechanical properties, biocompatibility and biomineralization potential by in vitro tests and could become smart arhiectures, able to stimulate bone regeneration. a new culture model was developed by exposing a d cell/ scaffold bioconstruct to a continuous magnetic field during weeks of osteogenic induction. in this view, mc t -e murine osteoblastes progenitor cells were seeded inside the novel silk fibroin-magnetite biocomposites and subjected to osteogenesys in a magnetic field during days. osteogenic specific markers were evaluated every week in the presence and absence of the field. our results showed that the osteogenic marker's expression started earlier when mc t -e cells were exposed to the magnetic field. consequently, in our experimental model, the magnetic field had a benefic effect on the osteogenic differentiation process as mc t -e cells differentiated more efficiently in its presence. these results suggest that the bone healing process could be improved in the presence of a magnetic field. nevertheless, further in vivo studies on animal model should be employed for validation. p- . . - impact of physical activity performed on different times of day on cardiac and skeletal muscle damage in trained and untrained male subjects s. algul, m. kara, o. ozcelik y€ uz€ unc€ u yil university, van, turkey introduction: physical activity elevates creatine kinase (ck) and creatine kinase myocardial band (ck-mb) levels which have been considered to be an indirect marker of skeletal and cardiac muscles damage. purpose: impact of physical activity performed on different times of day on serum levels of ck and ck-mb were investigated in trained and untrained male subjects. materials and methods: trained (n = , . ae . yr, . ae . kg) and untrained (n = , . ae . yr, . ae . kg) subjects performed three soccer matches ( min) in field ( m versus m) in morning (m), afternoon (a) and at night (n) on separate days. the study protocol was approved by the local ethics committee. venous blood samples were taken at onset and at end of match. serum ck and ck-mb levels are measured using autoanalyser. data are expressed as mean ae s.e., compared by wilcoxon-signed rank and mann-whitney u-tests. p < . was accepted as statistically significant. results: ck and ck-mb levels increased in three matches in both groups (p < . ). importantly, there were significant increases in ck-mb levels in a and n exercises compared to m exercise (p < . ) in trained ( . ae . u/l versus . ae . u/l, % (m) . ae . u/l versus ae . u/l, % (a) . ae . u/l versus . ae . u/l, % (n) and also untrained groups ( . ae . u/l versus . ae . u/l, % (m), . ae . u/l versus . ae . u/l, % (a) . ae . u/l versus . ae . u/l, % (n). discussion: increased metabolic stress or muscle damage during physical exercise elevate serum ck and ck-mb levels. however, higher percentage of increase in ck-mb levels in a and n exercise may reflects additional increases in cardiac muscle stress despite the similar skeletal muscle stress as indicated by ck levels. conclusion: considering the observation of higher percentage increase in ck-mb levels in untrained and also trained subjects, the caution should be taken while performing an exercise in a and n time especially in subjects who has cardiac weakness. p- . . - regional assessment of hematological and discrimination indices of complete blood count for beta-thalassemia screening beta-thalassemia is one of the most common genetic abnormality causing health problems worldwide. blood count and film of beta thalassemia trait and iron deficiency anemia have similar features. therefore, several simple screening indices have been developed for differentiating between these diseases. it was to asaimed to assess the hematological parameters and discrimination indices in patients with betathalassemia trait who admitted to our hospital. the parameters of complete blood count (cbc) in subjects ( males and females) diagnosed by mutational analysis (pcr, gene amplification, dna sequencing) between and , were retrospectively screened and the thalassemia status of patients was assessed in terms of discrimination indices (eng-land&fraser (ef), green&king (gk), mentzer (m), ricerca (r), shine&lal (s-l), srivastava (s), ehsani and sirdah). the percentages of being above the cut off value were detected by ef . %, gk . %, m . %, r . %, s-l . %, s . %, ehsani . % and sirdah . %. the percentages of falsely negatives for the indices of ricerca and shine&lal were lower than others. morever, when the first three common mutations of our study were considered, out of , out of and out of patients were up to the cut off values in terms of e&f, g&k, m, s, ehsani and sirdah indices for ivs-i- (g>a), ivsii- (g>a) and heterozygous codon deletion (-aa), respectively. the molecular diagnosis and prenatal detection for families at risk is important because of the difficulties of treatment in this disease. however, the use of discrimination indices may be valuable for distinguishing of thalassemia trait from iron defiency anemia when the equipment of molecular diagnosis are limited. in our study, ricerca and shine&lal had lower falsely negative results than others. nevertheless, further studies to detect diagnostic perfomance of discriminant indices should be conducted. p- . . - novel therapeutic agents in the development of effective drug combinations to treat glioma s. avdieiev , l. gera , r. hodges institute of molecular biology and genetics, kyiv, ukraine, university of colorado, aurora, co, united states glial tumors are driven by multiple molecular aberrations that cannot be controlled by a single targeted agent. so, it is possible to expect that the combined multitarget anti-cancer therapy aimed simultaneously at different elements of tumor formation mechanisms will be more effective and will promote the extension of patients' life. to find out which drug combinations will enable the development of therapeutic regimens with improved effectiveness and decreased toxicity, the cytotoxic effects of several bradykinin antagonists (ba) were analyzed for different glioblastoma (gb) cell lines. among all the ba under investigation, bkm- appeared to be the most effective, with ic values of lm and . lm in rat glioma c and human glioblastoma u cell lines, respectively. bkm- suppressed erk / and akt phosphorylation in u cells. temozolomide (tmz), the firstline anti-gliomic drug used in clinics, has only a temporary positive effect and severe side effects in gb patients. we showed that the combination of bkm- and tmz led to significant potentiation of tmz cytotoxicity at sub-therapeutic concentrations. recombinant proteins with cytotoxic properties are promising agents for complex therapeutic applications. we revealed that the glioma-associated protein chi l inhibited the viability of u cells more effectively than tmz. furthermore, the combination of chi l and bkm- resulted in an additive cytotoxic effect. chi l -mediated decrease of cell viability was associated with a g /s transition arrest. chi l provoked the dramatic reduction of prb phosphorylation and a significant decrease of cyclin d expression, as well as a substantial increase in p level. in addition to the accumulation of p , we observed the upregulation of cdk inhibitor p . therefore, g /s arrest in chi l -treated cells could be realized via activation of prb, downregulation of cyclin d, and activation of p . harmful hereditary mutations in brca and brca are one of the most important risk factors of breast cancer. the aim of this study is to determine the mutations which are associated with breast cancer in people which is diagnosed breast cancer and/or have breast cancer-diagnosed family members by sanger sequencing and thus provide predictive and prognostic utility. our ongoing study is present the genetic variations in brca and brca genes in breast cancer-diagnosed patients, that one of them is male, and person yet healthy whose brca was sequenced by sanger sequencing. the data were analyzed by using seqscape software . and detected variations were compared with literature. in brca , we determined different benign genetic variations and variation with unknown significance and variation which has not in literature. in brca gene of patient and healthy person, benign variations, variations with unknown significance, variations which has not in literature and mutation were determined. this mutation is c. - delgtca and is located in occr. c. - a>c variation in brca gene, was determined in only male patient.c. t>a variation in exon of brca , was observed in only the youngest patient who has no family member with breast cancer and healthy person. while this variation takes place in literature as variation with 'uncertain clinical significance', an in silico program mutation taster speculated as 'disease causing' for this variation. also, almost all of variations with 'unknown significance' literature knowledge were determined in only one and different cases. this situation increases the possibility of being pathogenic of this variations. the our findings until now can contribute to variations with uncertain clinical significance in the literature. also the variations that have not in the literature but we suggest the possible relation with breast cancer as an estimate may be added to literature by expanding the study. p- . . - inhibition of the recombinant human butyrylcholinesterase with paraoxon and coumarin analog of soman organophosphorus compounds (op) represent a class of extremely toxic chemicals that are used as warfare agents. uncontrolled utilization of op is highly dangerous due to their high potential to be efficient poisons in terrorist attacks. current therapy of op poisoning include intravenous administration of atropine and acetylcholine reactivators however, it does not completely eliminate brain damage effects. alternative experimental therapy against op poisoning is utilization of bioscavengers that irreversibly react with op and rapidly inactivate them. recombinant human butyrylcholinesterase (rhbche) is one of the most promising candidates as bioscavenger due to its pharmacokinetic characteristics and broad spectrum of op neutralizing activity. here we investigated in vitro inhibition of rhbche with two model oppesticide paraoxon (pox) and coumarin analog of soman (gd c ). both op lead to rapid and irreversible inactivation of rhbche that was monitored using ellman assay and fluorescence measurements. bimolecular inhibition rate constants dramatically differ between pox and gd c that could be explained by steric hindrance in soman analog. the next steps forward creation of catalytic bioscavengers based on rhbche should be done based on mechanisms of op-rhbche interactions. this work was performed in frame of grant rfme-fi x . non-hodgkin lymphomas (nhls) represent a heterogeneous group of malignancies that arise from the lymphoid system. at the present time exist a lot of drugs for the nhls therapy, but mostly all of them are unsafe and there is no consensus regarding the best treatment protocol. to increase the efficacy and safety of therapeutic b-lymphocyte depletion in lymphomas and leukemia's it would be preferable to induce the death of pathological b cells without affecting normal b cells to prevent side effects. similar to other types of cancer, nhls arise by a multistep accumulation of genetic aberrations that induce a selective growth advantage of the malignant clone. all b-cells of organism have a unique cell surface markerantigen b-cell receptor (bcr). we generate novel approach for personalized non-hodgkin lymphomas therapy based on peptide specific to malignant cells surface receptor. for this purpose we designed new lentiviral peptide library screening technique based on fluorescent reporter cells system. herein aa peptide library was used for screening of nhl's malignant receptor agonist. patients' lymph nodes biopsy samples mrna was used as a source of malignant bcr nucleotide sequence. variable domain of the lymphoma bcr was used for chimeric receptor generation, where bcr vh/vl part responsible for agonist recognition and bottom part of receptor was retranslate signal to the reporter gene. in this embodiment of the method, very large numbers of candidate aa peptides expressing lentivirus and eukaryotic reporter cells are packaged together in a format where each is capable of replication, thereby forging a direct link between genotype and phenotype. after four rounds of screening we discover peptides specifically interacted with malignant bcr's. selected peptide ligands were fused with chimeric antigen receptor for expression on t-cells. modified tcells selectively eliminate nhl's malignant cells ex vivo. this work was supported by grant rfmefi x . introduction: pesticides are used to prevent damage of unwanted insects, rodents, plant, moss and other pests. excessive use of pesticides may cause adverse effects in animals and humans. chlorpyrifosethylene (cpe) is an organophosphate pesticide, used in many agricultural products such as figs, cherries, olives worldwide; caused acute poisoning and chronically oxidative stress. rosadamascena mill (rosaceae) is a rose, used for production of rosewater (rw) and rose oil worldwide. rosaceae products are consumed in food and cosmetic industries. materials and methods: in this study, we investigated that cpe and rw effects on kidney tissues of rats. this study was included adult male rats, divided into groups. each group included rats. i.group: control (regular feed), ii.group: cpe ( . mg/kg/day), iii.group: rw ( mg/kg/day) and iv.group: cpe ( . mg/kg/day) + rw ( mg/kg/day). following days, kidneys were taken after sacrificed. analyzes were performed that malondialdehyde (mda), nitric oxide (no) as oxidant; superoxide dismutase (sod), glutathione reductase (gr) as antioxidant parameters. results: as compared with control, mda and no levels in cpe were a significant increase was determined (p conclusion: cpe is shown that significant increase on oxidant parameters, but significant decrease on antioxidant parameters. rw occurs opposite situation. similarly results of cpe, rw + cpe increased oxidant parameters, but decreased antioxidant parameters. these changes are lower than only cpe. these results showed that positive effects both rw and rw + cpe increasing on antioxidant parameters, also decreasing on oxidant parameters. we provide the comparative analysis of the reduced glutathione (gsh), reactive oxygen species (ros), a-tocopherol levels, an intracellular labile zn + pool and esterase activity of red blood cells of patients with diagnosed components of the metabolic syndrome (ms)arterial hypertension and diabetes mellitus type ii (ah + dm + ). as the comparison groups were selected patients with one diagnosed component of msarterial hypertension (ah + dm À ) or without any diagnosed component of ms (ah -dm -). patients of all investigated groups were at the hospital treatment with a diagnosis coronary heart disease (chd) ii degree. human blood was obtained from normal donors and patients with chd ii stage. cytosolic esterase activity was assessed using calcein-am test. ros level was evaluated using cm-h dcf-da. gsh level was estimated using lowry method. an intracellular labile zn + pool was assessed using fluozin- -am. investigations were performed on the specord m , hplc system lc- prominence (shimadzu) and facscantoii (bd). a significant decrease of the intracellular level of labile zn + in erythrocytes of patients with ah + dm + compare with ah + dm À and ah À dm À was shown. this fact confirms our assumption concerning the important role of zinc homeostasis in the etiopathogenesis of diabetes mellitus type ii. a direct relationship between the intracellular zn + level modification and erythrocytes esterase activity of patients with chd ii degree was observed. moreover, in ah + dm + group of patients this relation was more marked. the unidirectional alteration in the erythrocytes redox state (gsh and a-tocopherol levels reduction, ros formation activation) was revealed at the whole of investigated chd patients groups (ah + dm + , ah + dm À , ah À dm À ). however, the pathological erythrocytes response on in vitro action of the different antioxidants (n-acetylcysteine, ascorbic acid, a-tocopherol, quercetin) had a diverse character that can be a significant test under antioxidant therapy prescription. it is known that long-term social isolation and the disorder of natural circadian rhythm is considered an important stress factors, which cause a variety of metabolic and mental disorders. it should be noted that the impact of the stresses takes up a larger area, according to, review of the action of their mechanism is one of the topical issues of modern science. it is estimated that as a result of stress the metabolic processes change in the organizm. because of this, we've studied the functionality of the antioxidant system in laboratory rat heart muscle cells and blood under psycho-emotional stress. it was found that quantitative changes of nitric oxide (no) was initiated the process of lpo, which caused oxidative stress in the cells and decreased antioxidant enzymes activity, such as catalase,sod, gpx and gr. the results suggested that psycho-emotional stress was accompanied by oxidative stress, causing a reduction in the intensity of energy metabolism in cardiac muscle cells, which was further strengthened by the fact that the activity of the enzymes involved in atp synthesis in mitochondria was reduced. also, we've studied exogenous creatine positive and negative affects on energy metabolism and blood lipid spectrum. based on this, we proposed that psychological stress is one of the factors contributing to the development of various cardiac diseases. the importance of free radical lipid transformations, which differ from the peroxidation processes, was pointed out for the first time in our laboratory studies. we have found that ros can induce free radical destruction processes of sphingolipids with c-c-bond cleavage [lipids, , : - ; lipid insights, , - ] . in case of acylated sphingolipids, they can undergo decomposition with c-c-bond cleavage upon direct uv irradiation [photochem. photobiol., , : - ] . it was of interest to establish the possibility of photosensitized decomposition reactions of not acylated sphingolipids, which do not absorb an ultraviolet. in this work we studied photosensitized reactions of sphingosines containing a free amino group, and low molecular compounds, which simulate their structure, such as aminoalcohols (serinol). as photosensitizers, the salts of transition metals, hydrogen peroxide, and acetone were used. oxygen was removed by bubbling with argon to reduce the probability of side reactions during photolysis of sphingolipids, such as oxidation processes (including oxygen reactions with alkyl radicals). we have shown that the action of uv-radiation on aminoalcohols and sphingosines in aqueous solutions in the presence of photosensitizers induces their destruction with c-c bond rupture. the main carbonyl product of sphingosines free radical destruction was an unsaturated aldehyde - -hexadecanal. it was found, that -hexadecenal possesses a wide spectrum of biological activity: it promotes reorganization of the cell cytoskeleton and modifies the redox state of the cells [febs journal (suppl. ), abstracts: mem. biol. s , lipid signaling & dynamics, p. .] . the results of this study can expand the frontier of research regarding free radical lipid damage, which could contribute to a better understanding of the origins of diseases associated with the activation of free radical processes in living organisms. structural basis for the - - proteindependent inhibition of apoptosis signalregulating kinase protein kinase ask (apoptosis signal-regulating kinase ) is a member of the mitogen-activated protein kinase kinase kinase (map k) family that plays a crucial role in immune and stress responses. the activity of ask is regulated through homo-oligomerization and interaction with other proteins including the - - protein which binds to the phosphorylated motif located at the c-terminus of the kinase domain of ask and suppresses its catalytic activity through unknown mechanism. under stress conditions, ask is dephosphorylated at ser and the - - protein dissociates. this dissociation is then one of the factors that lead to the activation of ask . we performed low-resolution structural analysis of the kinase domain of ask (ask -cd) bound to - - using chemical cross-linking, analytical ultracentrifugation and small angle x-ray scattering. the low-resolution structural analysis shows that ask -cd binds to the - - protein in two to two stoichiometry through a small binding interface involving surface of - - outside its central channel and several regions from the c-lobe of ask -cd. the complex is dynamic and conformationally heterogeneous. phosphorus nmr and time-resolved fluorescence measurements, together with low-resolution structural analysis, indicate that binding of ask -cd to - - modulates conformation of ask 's activation segment. these results suggest that the - - binding suppresses the catalytic activity of ask through direct structural modulation of its activation segment. our study provides new insight into the interaction between the kinase domain of ask and - - and offers a plausible structural explanation for the - - protein-dependent inhibition of ask kinase activity. introduction: thymoquinone ( -methyl- -isopropyl- , -benzoquinone, tq) exerts a great antitumor activity against different types of cancer cells. a growing body of evidence indicates that reactive oxygen species (ros) generation followed by modulation of the akt and mapk pathways is a general mechanisms underlying the tq antitumor action. however, the data of tq effects on the mapk pathway are conflicting. to date, the activation or inhibition of the mapk protein family seems to depend on the cell type and on the tq concentration used. in order to elucidate the antitumor potential of tq against gliomas and the underlying molecular mechanism, tq influence on c rat glioma cells functioning was studied. results: it has been shown that the cultivation of c cells with tq in concentrations of - lm during hours strongly inhibits cell proliferation and induces cell death with id of lm. at the same time, tq induces ros generation and intracellular gsh depletion in a dose-dependent manner, that is followed by the mitochondrial potential decrease. interestingly, ros production has only cytoplasmic, but not mitochondrial origin in cells challenged with tq at the concentrations up to lm. two-electron reduction of tq by dt-diaphorase attenuates tq anticancer efficiency whereby inhibition of dt-diaphorase by dicumarol increases tq-induced c cell death by %. we analyzed mapk pathways involvement in c cells growth inhibition at tq treatment. it has been shown that inhibition of the erk pathway by pd and jnk pathway by sp does not influence on tq-induced effects. on the contrary, the specific phosphoinositide- -kinase (pi k) inhibitor (ly ) abrogates tq-induced growth arrest. conclusion: antitumor effects of thymoquinone on c glioma cells is a result of ros generation and intracellular gsh depletion, that is followed by mitochondria disfunction, and growth arrest via pi k pathway. assessment of oxidative stress and antioxidant defense activity parameters in patients with hiv-infection is of great importance, especially for hiv-positive women of reproductive age planning to have children. data of women of reproductive age with hiv-infection analyzed: patients with hiv-monoinfection (n = ) and patients with co-infection (hiv and hepatitis b and / or c) (n = ). as a control we used the data of healthy women (n = ). serum and hemolysate used as material for the study. lpo-aod products were determined by spectrophotometric and fluorometric methods. average value of initial lpo products -diene conjugates was significantly increased in the group with hiv-co-infected compared to control ( . times; p = . ) and group with hivmonoinfection ( . -fold; p = . ). the level of secondary products -ketodienes and conjugated trienes increased in patients of both groups compared to control ( . times (p = . ) and . -fold (p < . ), respectively). at the same time isolated double bonds and tba-active products content showed no significant changes (p > , ). total antioxidant activity parameter decreased . fold (p = . ) in the group with hiv-monoinfection compared to control. decrease in activity of the primary antioxidant enzyme -superoxide dismutase (p = . , compared to the control and p = . , compared with the group with hiv-monoinfection) and the level of a-tocopherol ( . -fold to control and . fold to hiv-monoinfection) was detected in the group with hiv-coinfection. . -fold higher content of retinol in hiv-coinfection group (compared to the control) revealed. in women with hiv-coinfection the oxidative stress was significantly higher than in women with hiv-monoinfection. suggested to include antioxidant supplements in the complex pathogenetic therapy in women with hiv-coinfection (hiv and hepatitis b and / or c), which will contribute to women's ability to bear children. p- . . - acute different doses of malathion induce cholinesterase inhibition, glucogenic enzymes and histopathological change in rat liver malathion, which is an organophosphorus compound, is a widely used pesticide all over the world. despite its benefits, malathion has many toxic effects on many tissues including liver. we designed to evaluate the acute different doses of malathion on cholinesterase (che) inhibition, gluconeogenic enzymes and histopathological change of rat liver. for this purpose groups were formed. rats in group served as control group animals which were only given corn oil. group , group and group were administered , , mg/kg of malathion, respectively, dissolved in corn oil by oral gavage. the rats were sacrificed after hours following administration and the livers of rats were removed. the liver che, alanine aminotransferase (alt), aspartate aminotransferase (ast) and lactate dehydrogenase (ldh) were studied using autoanalyzer. histopathological investigation was performed using microscope. the liver che activities of group , group and group were inhibition percentage of %, %, and % respectively, comparison of group 's che activity. the liver alt, ast and ldh increased in group and group compare to group and group (p < . ). we also observed that there was vacuolar and hydropic degeneration in liver of group . according to our result, acute administrations of malathion result in hepatotoxic effects with increasing doses. background and aims: an imbalance between free radicals and antioxidants is closely linked to the onset of an acute myocardial infarction (ami). the aim of this study was to investigate the antioxidant status and the lipid peroxidation in patients admitted to hospital immediately after ami. methods: the study population comprised patients with ami and healthy subjects. patients that had an acute myocardial infarction (ami) less than hours since onset were selected for this study. antioxidant status was assessed by lactonase activity of paraoxonase (pon dhc), trolox equivalent antioxidant capacity (teac) and plasma uric acid level. malondialdehyde was used as marker of lipid peroxidation. results: compare with the control group, the levels of mda and pon dhc were significantly higher in group with ami (p < . , respectively p < . ). elevated levels of mda (p < . ) were found in patients with ami compare with the control subjects. ami patients had also statistically significant reduced levels of teac (p < . ) comparative with healthy subjects. no statistically significance was found for plasma uric acid level in subjects from our study. conclusion: a high lipid peroxidation correlated with a decreased teac activity suggest an exacerbated oxidative stress in subjects admitted to hospital immediately after an ami. p- . . - dealing with copper toxicity: new insights into copper detoxification in yeast copper (cu), an essential metal, is a double-edged sword, as its essential nature is counterbalanced by the toxic effect that it can exert on cells when not properly controlled. as such, organisms have evolved defence mechanisms against cu toxicity, and in the yeast saccharomyces cerevisiae, the transcription factor ace orchestrates several of those mechanisms, by activating cu-detoxification genes. in s. cerevisiae iron (fe) uptake is partially dependent on cu, as the membrane multicopper-oxidase fet , which is part of the high-affinity iron uptake system, requires cu as a cofactor. aft , the low iron-sensing transcription factor in yeast, is known to regulate the expression of fet gene. however, we found that a strain lacking fet is more sensitive to cu surplus conditions than a strain carrying the aft gene disrupted. this finding suggests that under such conditions another regulator came into play and controls fet gene expression. we next evaluated whether ace could be the alternative regulator of fet under cu excess. to test this hypothesis we first constructed the double mutant aft ace and assayed its fitness under cu surplus. as expected, the double mutant is much more sensitive to cu than the single aft or ace mutants. we next monitored the expression of fet gene in cells lacking ace , using yeast-one hybrid and qrt-pcr approaches. our data clearly indicates that fet expression is dependent on ace when cu is overly abundant. altogether our data unveil a novel mechanism of cu detoxification relying on the activation of fet by ace in an aft independent way. experiments to understand the consequences of this regulation in terms of cu detoxification are currently being undertaken. in joint degeneracy, reactive oxygen species manifest their toxicity both through intrinsic reactivity and the inflammatory process activation, leading to cartilage dysfunctions, injuries of matrix proteins and cytokines stimulation. the study is focused on the identification of oxidative balance modulation (enzymes and oxygen free radicals) by a bioactive extract obtained from small sea fish. the cellular support was represented by the chondrocyte line chon- derived from human long bones (atcc Ò crl- tm ), that assure the reproducibility of a standardised biological system. the oxidative stress was induced through stimulation with il b, a cytokine-factor that promotes the protein catabolism and also with tnfa, the initiator of pro-inflammatory activation, combined with pma, the activator of protein-kinase c, triggering of oxygen reactive species generating cascades. the antioxidant effect was compared with known antioxidants: vitamin c, x fatty acid, n-acetyl -cysteine. the acellular antioxidant/antiradical screening was done using two complementary techniques for total antioxidant status evaluation and completed by measuring cellular catalase (cat) and superoxidedismutase (sod) activity, correlated with intracellular hydrogen-peroxide and superoxide anion monitoring through flow cytometry. the antioxidant properties of the bioactive extract proved in acellular systems are confirmed at cellular level by the involvement of the product in the enzymatic cascade cat -sod, potentiating the catalytic action of the enzymes, and by the decline of both intracellular reactive oxygen species (the hydrogen peroxide decrease with %, the superoxide anion is reduced with % compared with the stimulated control). the demonstrated antioxidant synergy assures a complete cellular protection induced by the small sea fish extract in human condrocytes. introduction: alzheimer's disease (ad) is a progressive neurodegenerative disorder characterized by memory loss, cognitive impairment. oxidative stress is a contributory factor in ad pathogenesis. glutathione (gsh) is the main antioxidant cellular defence. the ratio of gsh/gssg shows the redox status of gsh, and plays important role in maintaining intracellular redox homeostasis. the current study was carried out to determine oxidative dna damage and ratio of gsh/gssg which plays an important role in protection of target molecules from oxidation in the patients with ad. methods: the study subjects were consisted of patients with ad (n = ) and age matched control group (n = ) who were treated and followed in the cerrahpasa medical faculty hospital, department of neurology and department of internal medicine/ geriatrics. dna strand breaks and h o -induced dna damage were determined in lymphocyte dna with comet assay. the gsh and gssg levels in the erythrocyte lysates were measured by using a commercial spectrophotometric kit. the ratio of gsh/gssg were calculated. statistical analysis was performed with spss software package. results: dna strand breaks and h o -induced dna damage were found to be higher (p = . for all), the ratio of gsh/gssg was found to be lower (p = . ) in the ad group than control group. there was no significant difference between male and female for dna strand breaks and h o -induced dna damage in the ad group, but ratio of gsh/gssg were higher in male when compared with female (p = . ). no significant difference was found between the men of ad group and men of the control group for gsh/gssg ratio whereas women of the ad have a lower gsh/gssg ration than those in the women of the control group (p = . ). conclusion: increased systemic oxidative dna damage and dna susceptibility to oxidation may be resulted from diminished gsh/gssg ratio in ad patients. this finding shows the importance of antioxidant support in ad management. p- . . - validation of a liquid chromatography-tandem mass spectrometry method for the measurement of lipid peroxidation product iso-prostaglandin f a in urine m. kant , m. akıs ß , h. _ is ßlekel , department of medical biochemistry, school of medicine, dokuz eylul university, izmir, department of molecular medicine, school of medicine, dokuz eylul university, izmir turkey -iso-prostaglandin f a ( -iso-pgf a ) is a reliable indicator of lipid peroxidation resulting from oxidative lipid damage and is postulated as a gold standard biomarker for the evaluation of oxidative stress. the aim of this study was to validate non-invasive and highly accurate stable isotope dilution-multiple reaction monitoring liquid chromatography-tandem mass spectrometry (sid-mrm lc-ms/ms) method for identification and quantification of -iso-pgf a . twenty four hour urine samples were collected from healthy volunteers at medical school of dokuz eylul university for analytical performance studies. lc-ms/ms analyses were performed on conventional hplc coupled to a triple quadrupole ion trap mass spectrometer equipped with a turboionspray tm source. analyst software version . were used for data analyses. mrm transitions used were m/z? / for -iso-pgf a and m/z? / for -iso-pgf a-d . analytical performance of the method was evaluated by linearity, selectivity, sensitivity, precision and accuracy studies using pure standards and samples extracted from urine of healthy volunteers. the linear calibration range for -iso-pgf a was determined as ng/ml by using standards ranging from . - ng/ml. analytical sensitivity of the method was determined by lod with s/n of and loq with s/n of . lod and loq for iso-pgf a were . À and À ng/ml, respectively. the assay stability and reproducibility were assessed by the precision and accuracy of intra-and interday measurements (n = ). the intra-and interday cvs for -iso-pgf a were . % and . %, respectively. sid-mrm lc-ms/ms method for absolute quantification of -iso-pgf a was optimized and validated in our laboratory and therefore this highly accurate method can successfully be applied to clinical patient samples. p- . . - synergistic anticancer effects of sulforaphane and cisplatin through the induction of apoptosis and autophagy following oxidative stress in malignant mesothelioma cells malignant mesothelioma is characterized by poor responsiveness to current chemotherapeutic drugs, usually owing to high resistance to apoptosis. here, we investigated chemosensitizing effects of phytochemical resveratrol, in combination with cisplatin, on malignant meothelioma cells. cell viability was evaluated using mtt assay. cell apoptosis was detected with dapi staining, caspase / activity assay and flow cytometry. cell cycle distributions, ros levels and mitochondrial membrane potential were determined using flow cytometry. the expression of cell cycle-, apoptosis-, and autophage-related proteins was measured with western blotting. the combination treatment of cisplatin and resveratrol (cis/res) synergistically induced apoptosis, as evidenced by typical cell morphological changes, the appearance of a sub-g /g peak, an increase in the annexin v(+) cells and the cleavage of caspase- and parp. cis/res increased ros production and depolarization of mitochondrial membrane potential with an increase in the bax/bcl- ratio. these changes were attenuated by pre-treatment with n-acetylcysteine, suggesting that cis/res induced apoptosis through oxidative mitochondrial damage. compared with msto- h cells, cis/res was less efficient in killing h- cells. h- cells exhibited an enhanced autophagy to cis/res, as observed by an increase in viable cells exhibiting intense lysotracker red staining and up-regulation of beclin- and lc a. inhibition of autophagy by bafilomycin a rendered cells more sensitive to cis/res-induced cytotoxicity and this was associated with induction of apoptosis. these data indicate that the increased resistance of h- cells to cis/res is closely related to the activation of self-defensive autophagy, and provide the rationale for targeting the autophagy regulation in the treatment of malignant meothelioma. stress oxidative induced by chemotherapy with cyclophosphamide (cp) causes vulnerability in sperm and decline of fertility. this study was aimed to evaluate the role of ethyl pyruvate (ep) in the amelioration of fertility and growth of primitive embryo in animals that received cp. adult male mice ( - weeks) were randomly divided into groups: control group received normal saline ( . ml/day, ip), cp group received cp ( mg/kg/week,¬ ip), the cp+ep group received ep ( mg/kg/day, ip) along with cp, were treated for days. mice from each group were arranged for evaluation of sperm quality and in vitro fertilization (ivf) too. afterward, the separated oocytes from ovulation stimulated mice were conducted to evaluation of ivf and embryo development. the results revealed that cp caused notable decrease in percentage of fertilization in cp group, but administration of ep along with cp caused an increase in the percentage of fertilization in comparison to cp group. the percentage of the two cell zygotes in cp+ep group, and the percentage of blastocysts in control and cp+ep groups were higher than that in cp group (p < . ). results showed that the total number of arrested embryos in control and cp+ep groups was decreased in comparison to cp group (p < . ). the percentage of arrested embryos type i, ii, and iii in cp+ep group was decreased in comparison to cp group, but that decrease was significant only in types i and ii (p < . ). the average motility, viability, nucleus maturity and sperm morphology were decreased significantly in cp group in comparison with control and ep groups, whereas ep caused significant increase of these parameters (p < . ). also, the percentage of dna damage was increased significantly in cp group in comparison with control and ep groups (p < . ). the results of this study indicated that the ethyl pyruvate was able to suppress free radicals and enhance the ivf and quality of sperm in cp treated animals. malathion, which is a member of organophosphate chemical family, is used to control pests and is a widely used pesticide all over the world. however it is also known to be highly toxic on many tissues including pancreas. to test this we set groups to administer a single dose of malathion dissolved in corn oil via oral gavage at the doses of mg/kg (group ), mg/kg (group ) and mg/kg (group ). only plain corn oil was given to control group (group ). the rats were sacrificed hours after administration of the chemical and the pancreases of rats were removed. in an attempt to evaluate the dose dependent response, we measured amylase and lipase activities, insulin, malondialdehyde (mda), total oxidant status (tos) levels in rat pancreases. all of the parameters were measured spectrophotometrically. we found that pancreas insulin levels significantly increased in group compare to group , besides the insulin levels of group and group were significantly higher than group (p < . ). pancreas amylase and lipase activities significantly decreased in group and group compare to group and group (p < . ). however, there was no significant change in pancreas mda and tos levels (p > . ). according to correlation analysis, when pancreas amylase levels declined, lipase levels were decreased simultaneously and there was a strong positive correlation between them (p < . ). in addition, when the comparison was evaluated as a binary, while pancreas amylase and lipase levels diminished, pancreas insulin levels increased and a strong negative correlation between them was found (p < . ). according to our result, acute administrations of malathion leads to alterations of insulin, amylase, and lipase levels with a dose dependent manner, while it does not to change oxidant status. the aim of this study is to evaluate the potential toxic effects of mancozeb on the stress biomarkers such as catalase (cat) activity, malondialdehyde (mda) level and protein levels in the brain tissue of zebrafish (danio rerio). mancozeb, is a synthetic fungicide contaminating aquatic environments as a potential toxic pollutants, was investigated in the present study for acute toxicity. zebrafish groups (m-low and m-high) were exposed to different doses of mancozeb ( mg l- and . mg l- ) for hours except the control group. catalase (cat) activity, malondialdehyde (mda) level and total protein levels were determined by spectrophotometer. the results showed that cat activity and mda levels were decreased in all experiment groups. protein levels were increased in experiment groups when compared to the control group. in conclusion, the changes in the cat activity and mda levels were time and as well as mancozeb dose-dependent. furthermore, the biochemical parameters of mancozeb exposure on zebrafish, showed that mancozeb has significant effect on the zebrafish and/or aquatic organisims. paracetamol (para), which is antipyretic and analgesic, is widely used around the world. paracetamol can be recommended for moderate or mild pains especially in pregnancy as an analgesic. it is known that, paracetamol can cause hepatotoxicity or nephrotoxicity. we were aimed that in this study to show potential hepatoprotective and nephroprotective effect of betaine against long term paracetamol using at therapeutic doses. it has been prepared groups, control, para and para+-betain groups. paracetamol and betaine were administered by gavage to pregnant rats, from first day to the last day of pregnancy (aprox. day). ml physiological saline (% . nacl solutions), mg/kg/day paracetamol, mg/kg/day paracetamol and mg/kg/day betain was given by orally to control, para and para+betain groups respectively. the day of the birth, newborn rats anesthetized by ether and after decapitated. newborn rat's liver and kidney tissues used for biochemical analysis [malondialdehyde (mda), reduced glutathione (gsh), nitric oxide (no) and paraoxonase-arylesterase (pon-are)] and rat's liver and kidney tissues used for histological studies. we showed that, mda and no levels was significantly increased, while pon activities decreased. on the other hand gsh levels and are activities was decreased but these decline wasn't significant in the liver and kidney para group. these biochemical results showed hepatotoxicity and nephrotoxicity in neonates which can be formed in long term maternal paracetamol using at therapeutic doses. also our histological findings was support these biochemical results. we used betaine against potential hepatotoxic and nephrotoxic effect of long term maternal paracetamol using at therapeutic doses for neonates. betaine has antioxidant properties and also used as a methyl donor for transsulfuration reactions in the cell. biochemical and histological examinations showed that betaine protected the tissue injury relatively. p- . . - lipid rafts are involved in modulation of ca + responses induced by glutoxim and molixan in macrophages pharmacological analogues of oxidized glutathione (gssg) disulfide-containing drugs glutoxim Ò (gssg disodium salt with dmetal nanoaddition, «pharma-vam», st. petersburg) and molixan Ò (complex of glutoxim with inosine nucleoside) have found clinical application as a wide range immunomodulators and hemostimulators. however, the cellular and molecular mechanisms of these drugs action are still unclear. previously we showed for the first time that glutoxim and molixan cause biphasic intracellular ca + concentration ([ca + ] i ) increase due to ca + mobilization from thapsigargin-sensitive ca + stores and subsequent store-dependent ca + entry in rat peritoneal macrophages. it is known that key proteins involved in ca + signaling are localized in discrete plasma membrane lipid rafts domains. lipid rafts are cholesterol and sphingolipids enriched microdomains that function as unique signal transduction platforms. thus, the aim of the present work was to elucidate the possible involvement of lipid rafts in glutoxim and molixan effects on [ca + ] i in macrophages. [ca + ] i measurements were performed with fura- am microfluorimetry. to examine the involvement of lipid rafts in the effect of gssg-based drugs on [ca + ] i we used methyl-bcyclodextrin (mbcd), widely used to remove cholesterol from membranes, thus disrupting the lipid raft domains. we have shown for the first time that macrophage preincubation with mm mbcd for hours before molixan addition causes significant inhibition of both ca + mobilization (on average, by . ae . %) and subsequent ca + entry (on average, by . ae . %), induced by molixan. similar results were obtained in experiments with glutoxim. thus, we have demonstrated for the first time that mbcd significantly decreases both phases of glutoxim-or molixan-induced ca + responses in macrophages. the results suggest that intact rafts are required to initiate complex signaling cascade activated by glutoxim or molixan and leading to [ca + ] i increase in macrophages. plant-derived natural substances (phytochemicals) with potent pro-apoptotic activity towards cancer cells in vitro are considered as promising nutraceuticals in anticancer therapy. nevertheless, due to their relatively low bioavailability, administration of high doses of nutraceuticals that are not achievable in vivo seems to exert potentially negligible physiological effects in clinical trials. thus, there is a need for revealing novel cytophysiological effects of low doses of phytochemicals towards cancer cells. in the present study, we have considered thirty one nutraceuticals and selected four phytochemicals acting at low micromolar range ( to lm) against phenotypically different mcf- , mda-mb- and sk-br- breast cancer cells, namely diosmin, sulforaphane, ursolic acid and betulinic acid. nutraceuticals inhibited cell proliferation and caused changes in the cell cycle that was accompanied by elevated levels of p , p , p and/or p . apoptosis (annexin v staining, multicaspase and mitopotential assays) was observed exclusively when nutraceuticals were used at the concentration of lm, whereas at the concentration of lm, stress-induced premature senescence was noticed (sa-b-gal activity). nutraceuticals diminished the levels of glut- and selected glycolytic enzymes. nutraceuticals promoted oxidative and nitrosative stress as judged by increased production of total reactive oxygen species, total and mitochondrial superoxide, nitric oxide and protein carbonylation. nutraceuticals also stimulated dna single and double strand breaks that was accompanied by atm phosphorylation and to a lesser extent by histone h ax phosphorylation and bp foci formation. taken together, several responses to nutraceutical treatment were observed in breast cancer cells that may reflect the heterogeneous nature of cancer cell populations. this study was supported by grant from the national science center, / /d/nz / . nucleolus is thought to be a stress sensor and oxidative and ribotoxic stimuli may cause the inhibition of rrna synthesis by the inactivation of transcription factor tif-ia/rrn that is accompanied by the relocation of nucleolar proteins and p -based cell cycle arrest and/or apoptosis. as nutraceutical-mediated modulation of nucleolar activity may be considered an attractive anticancer strategy, in the present study, we have investigated the effects of three selected nutraceuticals, namely sulforaphane, ursolic acid and betulinic acid on nucleolus state in three breast cancer cell lines (mcf- , mda-mb- and sk-br- ). we found that low dose nutraceutical treatment resulted in p -mediated inhibition of cell proliferation, a decrease in rrna synthesis, shifts in lamin a/c and b pools, changes in the nucleolar protein levels and their carbonylation, and changes in nucleolus size and number. breast cancer cells differed in erk activity that resulted in different patterns of erk activation/inhibition, phosphorylation status of s and autophagy induction upon nutraceutical stimulation. nutraceuticals also affected dna methylation parameters, namely the levels of dnmt , dnmt a and dnmt b that resulted in both global dna hypo-and hypermethylation. taken together, after nutraceutical treatment, nucleolus-centered cellular response was revealed in breast cancer cells of different phenotypic characteristic that may be considered a potential target of anticancer therapy. this study was supported by grant from the national science center, / /d/nz / . p- . . - rate of apoptosis in human macrophages infected with leishmania tropica promastigotes infection of the cells with parasites or exposing cells to heat stress induces a cellular stress. in the present study human macrophages are infected with leishmania tropica promastigotes and exposed to heat stress. the measurement of cytoplasmic histone-associated dna-fragments was carried out using elisa technique. visualization of apoptotic cells was performed by the terminal deoxynucleotidyl transferase dutp nick end labeling staining method (tunel). degree of oxidative stress on cell is evaluated by measuring nitric oxide (no), malondialdehyde (mda), reducte glutathion (gsh) levels and superoxide dismutase (sod) activities. results of the elisa technique showed that infection of macrophages with promastigotes induced apoptosis rate significantly (p < . ), heat stress however decreased the rate of apoptosis in infected macrophages remarkably (p < . ). high levels of apoptosis rate in infected macrophages and drastic decdrease in apoptosis in heat subjected macrophages infected with promastigotes are confirmed by visualisation of apoptotic cells using tunel method. levels of glutathion (gsh) in infected macrophages decreased significantly (p < . ), while malondialdehyde (mda) levels increased notably (p < . ). however, no statistical significant alterations were detected in the nitric oxide (no) values and superoxide dismutase (sod) activities. results of the present study indicates that infection of human macrophages with leishmania tropica induces a cellular stress response, characterized by decreased values of gsh and increased levels of mda. increased rate of apoptosis in infected macrophages may be due to the increased cellular stress caused by leishmania tropica amastigotes. decreased rate of apoptosis measured in heat exposed macrophages infected with promastigotes indicates an extention in life span of macrophages. measurements of the parameters characterizing the redox and inflammatory processes in blood are essential for diagnosis and prognosis of type diabetes mellitus (t dm), but also for monitoring the effectiveness of medical treatments. along with other biochemical effects, hormonal imbalance leads to modified transport function of erythrocytes due to changes in enzyme systems involved in upholding of cellular homeostasis through a rapid degradation of altered proteins, being the second line of defense against the free radicals, which degrade and eliminate the damaged molecules. some of these enzymes are hemoglobin peroxidase (pa) and esterase (ea). the aim of this research study was to identify new parameters with a potential role of biochemical markers in t dm like hemoglobin peroxidase and esterase activity from erythrocyte. our data showed that pathological processes involved in t dm imply an increased enzymatic activity of pa ( . %), which correlates with increased levels of ea ( . %) and glycated hemoglobin (hba c) ( . %), compared with control group. the variables hba c, pa and ea are correlated: the identified pearson correlation coefficients r = . and r = . respectively, have an associated probability of p < . and p < . a value that indicates a strong positive correlation between the dependent variables pa and ea and independent variable hba c. based on these results we concluded that together with glycosylated hemoglobin assay, all the studied parameters can be successfully used as extra test for diabetes associated with oxidative stress and disorders in erythrocyte functions or blood rheology. the radioprotective effects of propolis and caffeic acid phenethyl ester on radiationinduced oxidative/nitrosative stress in brain tissue s. taysi , e. demir , k. cinar gaziantep university, school of medicine, gaziantep, haran university, sanliurfa, department of neurosurgery, medical school, gaziantep, turkey head and neck cancer patients treated with radiotherapy suffer severe side effects during and following their treatment. efforts to decrease toxicity of irradiation to normal tissue, organs and cells have led to searching for cytoprotective agent. investigations for effective and non-toxic compounds with radioprotective capability led to increasing interest in antioxidant such as propolis and caffeic acid phenethyl ester (cape). the aim of this study was to evaluate the antioxidant and radioprotective effects of propolis and cape on radiation-induced oxidative/nitrosative stress in the brain tissue. fourty sprague-dawley rats were randomly divided into five groups. group (irradiation (ir) + propolis) received total cranium irradiation and propolis was given orally through an orogastric tube daily. group (ir+cape) received total cranium irradiation plus cape, was dissolved in dimethyl sulfoxide (dmso) just before giving to the rats, intraperitoneally (ip) every day. group (ir) received gy of gamma irradiation as a single dose to total cranium plus ml saline daily. group received daily plain dmso. group received daily plain saline. at the end of the day time period, xanthine oxidase (xo), nitric oxide synthase (nos) activities, nitric oxide (no•) and peroxynitrite (onoo -) levels were significantly higher in ir group compared to all other groups. in conclusion, the results suggest the radioprotective ability of propolis and cape involving prevention of radiation-induced oxidative/ nitrosative damage. p- . . - role of leptin and adiponectin in obesityassociated oxidative stress e. becer , a. c ß irakoglu near east university, nicosia, cyprus, istanbul university, istanbul, turkey objective: increased oxidative stress is one of the major characteristics of obesity and obesity-related complications. adipokines also induce the production of reactive oxygen species and generating oxidative stress in physiological and pathological conditions of obesity. the aim of this study was to determine the association of leptin and adiponectin levels with body mass index, lipid parameters and oxidative stress biomarkers in obesity. methods: the study included obese and non-obese subjects. plasma leptin and adiponectin levels (ng/ml) were measured using commercially available enzyme-linked immunosorbent assay kits. serum lipid, superoxide dismutase, malondialdehyde and antropometric parameters were measured. results: obese and non-obese subjects did not differ in age, while plasma glucose, total cholesterol, triglycerides, ldl cholesterol and leptin levels were significantly higher and mean hdl cholesterol and adiponectin levels were significantly lower in obese than non-obese subjects. the plasma leptin (p < . ) and adiponectin (p = . ) levels were significantly correlated with bmi in both obese and non-obese subjects. in obese subjects, leptin levels were significantly correlated with superoxide dismutase (p < . ) and malondialdehyde (p < . ). strikingly, adiponectin was significantly correlated with superoxide dismutase (p = . ) and malondialdehyde (p = . ) levels in obese group. conclusion: our results suggest that leptin and adiponectin levels are associated with defective antioxidant status and increased lipid peroxidation which may have implications in the development of obesity related health problems. clinical trials of biologically active plant substances show a significant preventive effect in cancer, cardiovascular diseases and peptic ulcer disease in the form of both nutritional supplements and therapeutic intervention. anthocyanins contained in dark berries show great antioxidant potential, with the most important including a reduction in oxidative degradation of lipids or tyrosine oxidation by peroxynitrite. our previous studies of the antioxidant properties of extracts from vaccinium corymbosum, aronia melanocarpa and sambucus nigra, however, indicated that their activities largely depend on the method of extraction. while quantitative determination of anthocyanins pointed to a disproportionately larger content of anthocyanins in isolates from lyophylized berries, their scavenging activities against hydroxyl radicals was surprisingly the lowest. inflammatory processes, vascular damage, atherosclerosis and others are caused by oxidativenitrosative stress, so we tested their efficiency to scavenge no degradation products. we found that only purified extracts of lyophilized berries showed the most significant effects against no degradation products, with efficacy of around %. an extract from aronia showed greater than % efficiency, and a net ethanol extract from all the berries showed a % effect. cleaned ethanol extracts showed the lowest effects, while aronia initiated production at a concentration of mg/l. conversely, all acetone extracts consistently initiated no degradation products. these findings are in complete contrast to their determined action against reactive oxygen species. in summary, it follows that a particularly adjusted lyophilized extract of the berries could be responsible for the increased biological activity of no and the observed biological and pharmacological activities of anthocyanins in circulatory disorders. the study was supported by grant vega / / and / / . p- . . - attenuation of dysfunction, oxidative stress and apoptosis by resveratrol in benzo(a)pyrene exposed ins -e / pancreatic beta cell line s. c ß elik, b. baysal faculty of medicine, afyon kocatepe university, afyonkarahisar, turkey diabetes is one of the most important problems in the world. this disease is a very important health problem due to affects many different organs and systems. it has been well established that, environmental pollutants had deleterious effects on glucose metabolism, and caused insulin resistance and type diabetes. with this investigation, it was aimed to investigate the effects of benzo(a)pyrene on pancreatic beta cells and treatment affects of resveratrol. in this study, rat ins- e beta cell line was used. after reaching the appropriate number of cells culture operations by cell culture, benzo(a)pyrene ( lm, hours) application have been made after resveratrol ( lm, hours) application. after incubations oxidative stress, insulin secretion (in cell and in medium), cell proliferation and apoptosis were analysed in cells by biochemical and molecular techniques. b(a)p application resulted in no increase and resveratrol also increased this level of no. resveratrol increased the tas levels decrased by b(a)p, and tos levels were also increased by resveratrol interestingly. osi levels determined with tas and tos levels, has no significant change between groups. gsh levels were decreased by b(a)p while resveratrol increased its' level to control level. mrna expression levels of beta cell functions related genes ins- , ins- and sirt- were increased by resveratrol treatment. insulin levels in cell and in medium were increased after resveratrol treatment. mrna expression level of foxo- gene was increased while pdx- was decreased by resveratrol treatmeant. b(a)p suppressed the mrna expression of p gene, but resveratrol increased. the effects of b(a)p on pancreatic beta cells and the protective effects of resveratrol on this cells were investigated in vitro with this research firstly. the results obtained from this research showed that oxidative changes, functional impairment and carcinogenetic effects of b(a) p in pancreatic beta cells could be blocked by resveratrol. the protective effect of vitamin e (alphatocopherol) on ischemia-reperfusion injury in rat liver ischemia-reperfusion (i/r) process is usually used during transplantation and resection of the liver but liver dysfunction and cellular death due to lack of oxygen in tissues, changes in the balance of oxidant/antioxidant in favor of oxidants, and inflammatory response are inevitable during this process. in the present study, it was aimed to investigate whether vitamin e(alpha-tocopherol), an antioxidant agent, has a protective effect against liver ischemia reperfusion injury in rats by using morphometric methods. for this purpose, adult sprague-dawley male rats were divided into groups as; control, ischemia / reperfusion (i/r), and vitamin e+ischemia/reperfusion (evit +i/r). in experimental groups, the total hepatic ischemia was applied for minutes followed by a hour of reperfusion. in the treatment group, days before ischemia mg / kg dose of vitamin e was administered intraperitoneally once a day. after the termination of the reperfusion, the rats were perfused by cardiac way and liver tissues were dissected. following volume and weight calculations, the livers were subjected to the standard histological preparation methods and embedded in paraffin. serial sections at lm thickness were obtained from these blocks, stained with hematoxylineosin, and analyzed with morphometric methods. in light microscopic examinations of the i/r group, irregularity in lobules, dilatation in central veins and sinusoids, extensive areas of necrosis and pycnotic nuclei were seen in hepatocytes. the volume density of sinusoids to liver parenchyma was estimated as % in the control group, whereas it was % in the i/r group. this value was decreased to % in the evit + i/ r group. however, no significant difference was found among the groups in the lobule area calculated by the point counting method. these results show that intraperitoneal vitamin e administration for days prior to ischemia partially inhibits damage caused by ischemia-reperfusion injury in the liver. the leaves, fruit and bark of annona muricata, a member of the annonaceae family, are commonly used in the traditional medicine of tropical and subtropical regions. in recent years, many studies have shown their anti-cancer, anti-convulsant, antiarthritic, anti-parasitic, anti-malarial, and anti-diabetic activities. it should be noted that these characteristics have been described using different types of extracts from different parts of the plant. our studies have focused on the systematic characterization of activities most easily accessible from an aqueous extract of leaves, with hitherto documented antihypertensive and hepatoprotective effects. we found that the extract shows almost % efficiency against hydroxyl radicals. with increasing concentrations, the effectiveness weakened, reaching a second peak ( %) at a concentration of mg/l. the scavenging activity against no degradation products maintained a continuously increasing trend with a maximum at a concentration of mg/l. surprisingly, the extract initiated peroxynitrite production in a similar trend, except at mg/l, where it scavenged peroxynitrites with relatively high efficiency, up to %. these findings are consistent with the elevated levels of reduced glutathione detected after incubation of liver mitochondria with extract to a maximum concentration of mg/l, with subsequent sharp decline. the activity of glutathione s-transferase was decreased, although not significantly. this indicates a reduction of metabolic processes of compounds, allowing their action over a longer period of time. in a live system, even antihypertensive effects can be observed. however, a significant outflow of gsh to create the gsh adducts of active substances, and particularly s-nitrosoglutathione from increased production of peroxynitrites, can cause liver toxicity. the study was supported by grant vega / / and / / . the role of polyamine metabolism in curcumin induced apoptosis via reactive oxygene species (ros) generation in growth hormone (gh) overexpressed t d breast cancer cells r. genc ß, a. coker gurkan, e. d. arisan, p. obakan yerlikaya, n. palavan unsal, n. palavan unsal t.c istanbul k€ ult€ ur € universitesi, istanbul, turkey autocrine growth hormone (gh) signaling triggers cell proliferation, growth, metastasis and drug resistance in cancer cells. polyamines (pas) play an essential role in cell cycle, proliferation, growth and carcinogenesis of various cancer types such as prostate, colon and breast cancer. odc (ornithine decarboxylase) is the key enzyme in the pa biosynthetic pathway that is under control of antizyme (az) and antizyme inhibitor (azi) activity. pa catabolic enzymes polyamine oxidase (pao) and spermine/spermidine acetyle transferase (ssat) by-products triggers reactive oxygene species (ros) generation and apoptotic cell death. curcumin decreased cell viability in dose and time dependent manner in t d wt and gh+ cells. although forced gh expression induced cell proliferation, lm curcumin inhibited cell invasion. curcumin ( lm) induced apoptosis by acting on intrinsic and extrinsic pathway in both cell lines. moreover, curcumin supressed odc, azi expression in wt and gh+ t d cancer cells. although curcumin decreased az expression in t d wt cancer cell, increased az expression was determined in t d gh cancer cell. pao and ssat expressions were upregulated in t d gh+ cells. concomitantly, putrescine levels were increased in t d gh+ cancer cell compared to wt cells and curcumin depleted spermidine and spermine levels in wt and gh + t d cells. curcumin induced-apoptotic cell death via ros generation and co-treatment of n-acetyl cysteine (nac) overcame curcumin effect. conclusion, forced gh expression triggers cell proliferation and growth via acting on polyamine metabolism and curcumin-triggered ros generation was prevented by nac treatment in t d wt and gh+ breast cancer cells. acknowledgment: this study was supported by tubitak research project (project no: z ). the radio-protective effects of propolis and nigella sativa oil on oxidative/nitrosative stress in liver tissue of rats exposed to total head irradiation s. taysi our purpose is to investigate propolis and nigella sativa oil (nso) for their antioxidant effects on the liver tissue of rats exposed to ionizing radiation. a total of sprague-dawley rats were divided into five groups to test the radioprotective effectiveness of of propolis and nso administered by orogastric tube. appropriate control group was also studied. biochemical parameters in liver tissue of rats were determined by spectrophotometer. xanthine oxidase (xo), nitric oxide synthase (nos), superoxide dismutase (sod) activities, nitric oxide (no•) and malondialdehyde (mda) levels were higher in ir group while glutathione-s-transferase (gst), glutathione peroxidase (gsh-px) level in the ir group were lower in this group when compared to the other groups. gst activity in ir plus propolis group was statistically higher than in all other groups. propolis and nso clearly protect liver tissue from radiationinduced oxidative stress. the effects of royal jelly on the antioxidant parameters in the breast tissues of the rats with breast carcinoma treated with paclitaxel or not effects of royal jelly on the breast tissue antioxidant parameters in rats with breast carcinoma treated with paclitaxel or not. - weeks old female sprague-dawley rats (n = ) included in current study were divided into groups: control group (n = ) with healthy rats; breast cancer group (n = ); breast cancer group (n = ) treated with mg/kg paclitaxel injection (once a week for weeks); breast cancer group (n = ) treated with mg/kg royal jelly (by oral gavage for days); and finally breast cancer group (n = ) treated mg/kg royal jelly in addition to mg/kg paclitaxel injection. rats with breast carcinoma was obtained at th days after a single dose injection of mg/kg n-methyl-n-nitrosourea (mnu). all cancer groups were followed by days with treatment of paclitaxel and/or royal jelly. the antioxidant parameters in rat breast tissues, superoxide dismutase (sod) and catalase (cat) activities were determined by spectrophotometric colorimetric methods and glutathione (gsh) by high performance liquid chromatography (hplc). all the antioxidant parameters decreased in breast cancer group without any treatment (p < . ). but, statistically non significant increases were observed by paclitaxel and royal jelly treatment (p > . ). this study indicated that royal jelly supplementation can not be sufficient to increase the antioxidant parameters in breast cancer. we are going to continue to identify the effects of royal jelly on breast cancer detail. the effects of n-acetylcysteine on microsomal and serum paraoxonase activities at high fat diet induced obese rats obesity is a chronic disease that develops from the interaction between genotype and environmental factors and increase in the accumulation of body fat. it is related with glucose and lipid metabolism disorders, cardiovascular diseases and increased oxidative stress. paraoxanase (pon ) is an enzyme which plays a protective role in oxidative stress, inflammation and liver diseases. it has been suggested that pon has protective effects against high fat diet induced obesity and obesity related disorders. n-asetylcysteine (nac) is a potent antioxidant due to its ability to stimulate glutathione synthesis. the aim of this study was to evaluate the microsomal and serum pon enzyme activities (paraoxonase, arylesterase and lactonase) at high fat diet induced obese rats in the presence of nac. this study consisted of control, obese and nac-supplemented obese ( g/l nac) groups. eighteen sprague-dawley rats were randomized into three groups (n = ). control rats were fed by standart food and obese and nac groups were fed by high fat diet. the microsomal and serum paraoxonase, arylesterase and lactonase activities were determined by colorimetric methods. serum paraoxonase, arylesterase and lactonase activities decreased in obese and nac groups when compared to control groups. on the other hand microsomal paraoxonase, arylesterase and lactonase activities increased in nac group when compared to control and obese groups. however there was no statistically significant difference between the groups. it has been concluded that the microsomal and serum paraoxonase enzyme activities did not change at high fat diet induced obese rats in the presence of n-asetylcysteine. reactive oxygen species, playing an active role in the early and late course of acute pancreatitis, lead to dysfunction of cell membrane and releasing of lysosomal enzymes, and thereby to the injury in pancreatic cells. gallic acid, found in vegetables such as green tea, is an active component which has antioxidant, antiinflammatory, antiviral, anticancer activities. the aim of this study was to investigate the effects of gallic acid in experimental acute necrotizing pancreatitis (anp) model in rats. eighteen male sprague-dawley rats were divided into three groups ( rats in each group). group : sham + saline; group : anp induced by intraductal glycodeoxycholic acid and intravenous cerulein; and group : anp + gallic acid ( mg/kg/day, intraperitoneal). at the end of th hours, pancreas histopathology was examined. the levels of serum amylase as a diagnostic marker of pancreatitis, interleukin- (il- ), total antioxidant status (tas), nitrite + nitrate, total thiols as antioxidant marker and thiobarbituric acid reactive substances (tbars) to measure malondialdehyde (lipid peroxidation product) were determined by spectrophotometric methods. serum amylase, il- , plasma tbars levels were significantly higher but total thiols levels were lower than sham group in anp group without treatment (p < . ). however; tas and nitrite + nitrate levels did not show any significant difference (p > . ). on the other hand, while serum amylase, il- and tbars levels were lower, total thiols levels higher in gallic acid treatment group than in the untreated anp group, but statistically insignificant (p > . ). in conclusion, gallic acid treatment is beneficial but not sufficient to treat the acute necrotizing pancreatitis in rats. p- . . - evaluation of oxidant/antioxidant system parameters, il- and il- levels in amniotic fluid of pregnancies with down sydrome b. _ imge erg€ uder , s. bahsi , t. bahsi , v. topc ßu , a. bakir ankara universty faculty of medicinel, ankara, zekai tahir burak research and training, hospital genetic center, ankara, turkey introduction and aim: down sydrome (ds) can be diagnosed at high-risk of down syndrome pregnancies by invasive prenatal testing. in this study we aimed to demonstrate antioxidant/oxidant system markers, il and il levels in amniotic fluid samples of pregnancies affected by ds. materials and methods: for this purpose we collected amniotic fluid samples from pregnancies affected by down sydrome and normal healthy pregnancies who applied to zekai tahir burak research and training hospital genetic center and were proceeded with amniocenthesis. in the amniotic fluid samples; malondialdehyde (mda), superoxide dismutase (sod), glutathion peroksidase (gsh-px) xhantine oksidase (xo), catalase (cat), adenozine deaminase (ada), nitric oxide (no), nitric oxide senthase (nos) enzymatic activities were evaluated by spectrophotometric methods, il and il levels are evaluated by elisa. for statistical analysis student's t-test and spearman corralation analusis are used. results: it was found that sod levels are significantly elevated in study group compared to control group (p < . ). besides this, in study group, cat and il- levels are found singnificantly lower than control group (p < . ). we couldn't find any significant difference between two groups in terms of mda, gsh-px, xo, no, nos, ada ve il- levels (p > . ). discussion and conclusion: there is an important decrease in inflammation compared to normal pregnancie in the amniotic fluid of pregnancies having ds. based on these results, sod enzyme may be used as a marker for prenatal diagnosis of ds. for this purpose these experiments should be tried on larger sample groups. the aim of our work was to compare prooxidant and antioxidant properties of linalool, which is the oxygenated monoterpene compound reported to be a major volatile component of the essential oil of several aromatic species, in hep g cells. cytotoxicity of linalool was assayed by celltiter-blue Ò cell viability assay. malondialdehyde levels result in membrane damage in hep g cells were assayed by using fluorometric method. hep g cells were incubated with linalool at , and hours. the viability of hep g cells decreased in a manner dependent upon concentration and incubation time. the ic values were calculated . lg/ml ( hours), . lg/ml ( hours) and . lg/ml ( hours). but, cell viability of hep g cells increased when the cells preincubated with linalool at lower concentrations (˂ic ) against h o cytotoxicity. membrane-damaging effects of linalool were increased with accelerating concentrations. on the other hand, membrane damaging effect of h o was decreased when the cells preincubated with linalool before h o incubation. oxygenated monoterpene linalool had both prooxidant and antioxidant properties showing membrane damaging and protective effects on hep g cells depend on concentration. postprandial lipemia is primarily characterized by increasing triglyceride levels after the lipid rich meal. postprandial lipemia may cause oxidative stress by increasing free radical production and increasing oxidative stress could be responsible for the development of many diseases. plasma oxidant-antioxidant status was evaluated in healthy individuals with postprandial hypertriglyceridemia generated by performing oral triglyceride tolerence test (ottt). the study group included subjects ( female and male). ferric reducing ability of plasma (frap), total thiol and thiobarbituric acid reactive substances (tbars) levels were determined by colorimetric methods at fasting and nd, th and th hours following ottt. the levels of frap and thiol were significantly higher in males than females (p = . and . , respectively). thiol levels decreased significantly in both gender at postprandial nd, th and th hours as compared with fasting condition (p = . ). while tbars levels increased at postprandial nd hour, that was only significant for male individuals (p = . ). it has been concluded that postprandial lipemia may change oxidant-antioxidant balance in favor of oxidants and gender is an important criteria while assessing the oxidant-antioxidant status in postprandial lipemia p- . . - ischemia modified albumin and c-reactive protein levels in prediabetes prediabetes is a state of abnormal glucose homeostasis characterized by the presence of impaired fasting glucose, impaired glucose tolerance, or both. the aim of this study was assess serum ischemia modified albumin (ima) in prediabetes and determine its correlation with other risk factors for chronic complications such as inflammation and hyperglycemia. glucose, insulin, total cholesterol, hdl cholesterol, triglycerides, albumin, c-reactive protein (crp) and ima were measured in patients with prediabetes and controls. prediabetes patients had higher levels of ima and crp in comparison with control subjects but there was no significant difference between groups for ima. significant positive correlation was observed between crp and fasting glucose, insulin. there was no significant correlation between ima levels and the parameters tested. we have shown higher level of crp in prediabetes. these results support the hypothesis that chronic inflammation may be involved in development of hyperglycaemia. p- . . - the effects of s _ io nanoparticles of rat uterine smooth muscle specially used in textile field sio nanoparticles on uterus smooth muscle was aimed to be researched. in this study wistar albino female rats were used. rats were separated in groups as control, dose ( lg/ml), dose ( lg/ml) and dose ( lg/ml). nanoparticle's size was chosen as nm. preparations of four groups were evaluated for biochemical and histological examinations. all isolated uterine smooth muscle stripts except the controls were treated with sio for two hours. in biochemical examinations in order to evaluate oxidative stress level of malondialdehit (mda), activity of superoxide dysmutase (sod) and glutathione peroxidase (gsh-px) were measured. in histological examinations via electron microscope ultrastructure of uterus was examined as well as apoptotic cells detected with immunofluorescent labeling method. intergroups differences were defined by statistical analysis. while mda level increased depending on the dosage, sod level was decreased depending on the dosage. gsh-px rate was decreased for each dosage with respect to control. however, no significant difference is detected between groups. in electron microscopic examination no changes were observed in uterus ultrastructure with compare to control. however, in immunofluorescent labeling it was detected that apoptosis increased in dosage groups with compare to control group. as a result, it was thought that application of sio nanoparticles, in nm size and in , and lg/ml dosages caused of oxidative stress and apoptosis. this results suggested that sio has toxic effects on uterine smooth muscle. uterine myomas are the most common benign pelvic tumors arising from myometrium. they are rarely associated with mortality but responsible for significant morbidity and have adverse effects on quality of life especially in reproductive age women. reactive oxygen species and superoxide dismutases, as well as sex steroids play important roles in the reproductive physiology processes. in addition, oxidative stress and impaired antioxidant defense system have been linked to pathophysiology of various diseases including malignant gynecological disorders. clinical investigations indicate that women with myoma may have increased risk of developing malignant tumors particularly sarcomas. the present study aimed to investigate the possible role of oxidant and antioxidant status in myomas. blood and urine samples of myoma patients were collected. activities of erythrocyte antioxidant enzymes [copper-zinc superoxide dismutase (cuzn-sod), catalase (cat), glutathione peroxidase (gpx )] and levels of lipid peroxidation biomarkers [plasma malondialdehyde (mda) and urine -epi-prostaglandin f a ( -epi-pgf a)] were determined. the results were compared with those of controls. the groups were matched in terms of age, body mass index, smoking habit, coexisting chronic diseases, menopausal status and sex steroid hormone levels. all antioxidant enzyme activities were higher ( % for cuzn-sod, p = . ; % for cat, p . ) and the levels of lipid peroxidation biomarkers were lower (% for mda, p = . and % for -epi-pgf a, p > . ) in myoma patients compared to controls. correlation analyses showed a significant negative correlation between erythrocyte cuznsod activity and plasma mda levels (r = - . , p = . ). the decreased lipid peroxidation may be the consequence of elevated antioxidant enzyme activities and the data suggests a protective role of activated antioxidants especially cuznsod and cat in patients with myoma. p- . . - investigation of ischemia-modified albumin levels in patient with acute limb ischemia introduction: acute limb ischemia commonly occurs as a result of embolus caused by cardiac origin and which may end up with limb loss or even death if left untreated. thrombosis are usually seen where the arteries give branches and tendency to atherosclerosis is more serious at these sites. involvement of several arteries in either embolus or in situ thrombosis limits the adequacy of collateral circulation. restriction of blood flow due to arterial stenosis or occlusion often leads patients to complain of muscle pain on walking. any further reduction in blood flow causes ischemic pain at rest, which affects the foot. early recognition may prevent limb loss or death. ischemia can alter the capacity of the amino terminus of the albumin to bind free metal atoms such as cobalt, copper and nickel. this new, chemically changed albumin is called ischemia modified albumin (ima). ima is a sensitive marker of myocardial ischemia, skeletal muscle ischemia, pulmonary embolism, mesenteric ischemia and stroke. therefore, in this study it was aimed to investigate the ima level in acute limb ischemia. materials and methods: in this study, patients with acute limb ischemia (li group; mean age years) and healthy individuals (control group; mean age years) were included. ima levels were detected in control and li group by elisa (organo teknika, avusturya) using ima el _ isa kit. results: ima values were compared with nonparametric methods mann whitney u test, and significantly decreased ima level was statistically significantly different between li group and control group (p < . ). conclusion: there is a significant increase in serum ima in limb ischemia, so that alterations also might be clinically useful in the diagnosis of limb ischemia, but should be supported with further studies. object: polycystic ovary syndrome (pcos) is a multifaceted disorder with a pathogenetic pathway that is not fully understood yet. apart from hormonal derangements, insulin signaling defects and adipose tissue dysfunction, oxidative stress, defined as an imbalance derived from excessive formation of oxidants in the presence of limited antioxidants defenses, has been actively implicated in the etiology of the syndrome. the aim of this study was to determine of serum myeloperoxidase activity (mpo), paraoxonase activity (pon ) and arylesterase activity (are) in patients with pcos. material and methods: the study was carried out on women consisted of patients with pcos and healthy ones as control. serum pon activities were measured spectrophotometrically using diethyl-p-nitrophenylphosphate as substrate. phenylacetate was used as substrate for are measurement, and are activity was determined by measuring absorbance of the resulting phenol at nm. molar absorptivity coefficients were used in the calculation of pon and are activities as nmol phenol/ml serum/min. result: the mpo and are activities were significantly lower in the patient groups when compared with the control group ( . ae . - . ae . u/ml p < . , . ae . - . ae . u/ml p < . , recpectively). the pon activities are higher in the patient group ( . ae . u/ml) compared to the control group ( . ae . u/ml) are found, but are not statistically significant. conclusion: lower serum mpo and are activities might contribute to the increased susceptibility for the development of diseases risk in women with pcos. because free oxygen radicals are thought to contribute to the complication of many chronic diseases, the pcos may be related to oxidative stress. subclinical hypothyroidism, defined as an elevated serum thyroid stimulating hormone level associated with serum thyroid hormone concentrations within the reference range. free radicalmediated oxidative stress has been implicated in the pathogenesis of thyroid disorders. the ischemia-modified albumin (ima) has been proposed as a marker of protein oxidative damage, which has been found to reflect hypoxic stress. this study aimed to investigate the influence of subclinical hypothyroidism on serum ima levels. thirty-one subclinical hypothyroidism patients and control subjects were enrolled in the study. albumin, ima were measured and ima/albumin ratio was calculated. to determine the ima levels the measurement method based on albumin cobalt binding assay was used. serum ima levels of patients with subclinical hypothyroidism were . ae . absu, ima levels of control subjects were . ae . absu. ima levels were significantly higher in patients with subclinical hypothyroidism patients than in control subjects (p < . ). when ima values were normalized for albumin concentrations, the ima/albumin ratio was also significantly elevated in patient group compared to control group (p < . ). ima levels are increased in patients with thyroid dysfunction. elevated levels of ima can be a clinically useful marker of protein oxidative damage in subclinical hypothyroidism. p- . . - the effects on endothelial dysfunction of quercetin in streptozocin-induced diabetic rats excessively produced in pathologic conditions. ultimately, imbalance between oxidants and antioxidants results with oxidative stress (os). in this study, we investigated some os parameters in standard ( % protein, % ( % sucrose) carbohydrate, % lipid) and sucrose ( % protein, % ( % sucrose) carbohydrate, % lipid) diet fed bdnf heterozygous mice liver tissues. the male c bl strain wild type (+/+) and bdnf heterozygous (+/À) mice ( weeks) were obtained. the animals were fed ad libitum by special standard and sucrose diets. twenty four mice were divided into four groups and each group consist six mice. all mice were fed for weeks. first group involved in c bl wild type mice and fed by standard diet. second group contained c bl bdnf heterozygous mice and fed by standard diet. third group consisted c bl wild type mice and fed by sucrose diet. fourth group involved in c bl heterozygous mice and fed by sucrose diet. in first group, mda levels, sod and cat activities were higher than other groups. in second group, cat activities were lower than other groups. but, we could not find any statistically significant differences between all groups about mda, sod, cat levels in bdnf heterozygous mice liver tissues. in conclusion, standard and sucrose diet feeding may not affect mda, sod and cat levels in bdnf heterozygous mice liver tissues. brain-derived neurotrophic factor (bdnf) is member of neurotrophin family which plays critical roles in the development, differention, survival, maintenance of the central and peripheral nervous systems. bdnf also contributes to food intake and body weight control. bdnf heterozygous mice display increased body weight and mild hyperphagia. expression of bdnf is not limited to the brain, it also express some peripheral tissues like adipose tissue, liver, kidney, skeletal muscle, heart. even though roles of bdnf are well known relatively in central nervous systems, effects of this protein is not clear in peripheral tissues. as mentioned before, it is expressed in organs involved in energy, lipid and glucose homeostasis, including the liver, adipose and muscle tissues, but its role there remains unclear. in this study, we aimed to investigate role of bdnf on liver oxidative stress parameters in heterozygous mice model fed fat diet induced obese mice. in this study, we used c bl/ mice inbred strain wild type and bdnf heterozygous (+/À) mice. animals were divided to two groups: wild type (n = ) and bdnf heterozygote mice (n = ). the animals were fed ad libitum by high-fat diet during month. weight gain was recorded every th days. in liver tissues were measured malondialdehyde (mda), superoxide dismutase (sod) and catalase (cat) by spectrophotometric methods. liver mda levels decreased in obese bdnf heterozygous mice compared to obese wild type group and statistically significant difference between groups. bdnf heterozygous mice cat activities were higher than the other group and this difference was statistically significant. there was no statistically significant difference between the groups in terms of sod activities. it has been concluded that the mda levels and sod enzymes activities changed at high-fat diet induced obese bdnf heterozygous mice compared to wild type mice liver tissues. p- . . - disturbances of microelements profile in serum of overweight/obese adult females with acute and persistent pro-inflammatory chlamydia pneumoniae infection p- . . - determination of reactive oxygen species induced dna damage using modified cupric reducing antioxidant capacity (cuprac) colorimetric method s. uzunboy, s. demirci c ß ekic ß, r. apak department of chemistry, istanbul university, faculty of engineering, istanbul, turkey reactive oxygen species (ros) term is a common name of a group of species. hydroxyl radical and singlet oxygen can be taken into account as ros samples. ros may be formed as a result of endogenous or exogenous reasons. although ros have some beneficial functions, they should be balanced by antioxidants (aox). excessive amounts of ros can attack biological macromolecules including dna. dna damage is usually related with mutagenic and carcinogenic changes. that's why determination of dna damage is so important and there are a great many studies in literature comprising different techniques. one of the most common of them is the 'comet assay'. but application of the method and interpretation of the results is not easy. investigation of certain dna damage products is also very common. these methods usually need expensive instrumentation such as using tandem mass spectrometry. on the other hand, depicting total dna damage on a certain product may cause misinterpretations. in the presented study, dna was decomposed by hydroxyl radicals produced by fenton method. in the study while dna is not cuprac reactive the oxidation products can react with the cuprac reagent. the effect of aox was also investigated. for this purpose, selected aox compounds were added to the reaction medium. because of their radical scavenging effect, the cuprac absorbance decreased in the presence of aox. in the presence and absence of aox, absorbance differences were calculated. the calibration graphs between final concentration and absorbance differences were drawn for each aox. gallic acid was determined as the most effective one among the tested aox samples. for statistical comparison with the presented study, tbars was used as reference method. direct use of dna as a probe material to determine oxidative damage may be an advantage to understand dna hazard in biological systems. the proposed method can be applied in all laboratories having a spectrometer as a cost-effective and simple procedure. p- . . - effects of alpha- antagonists on oxidative system of rat heart tissue benign prostate hyperplasia is a progressive process occurring in the stromal and epithelial components of the prostate. alpha- receptor blocking agents are used for relaxation of the smooth muscles in the prostatic stroma. our aim was to investigate the effects of alpha- antagonists on oxidative system of rat heart tissue. male wistar albino rats were divided into groups randomly. ) tamsulosin ( mg/kd/day), ) terazosin ( mg/kg/day), ) doksazosin ( mg/kg/day), ) alfuzosin ( mg/kg/day), ) control. all drugs were administered every other day single doze via oral. rats were sacrificed after days. heart tissue was taken for biochemical analysis. malondialdehyde (mda), nitric oxide (no), protein carbonyl (pc) levels and superoxide dismutase (sod), glutathione peroxidase (gsh-px) enzyme activities were determined in supernatant samples. there was not an significant difference between terazosin, doxazosin, alfuzosin, tamsulosin groups in means of sod, mda and gsh-px levels. no levels were significantly different between tamsulosin group and the control group (p = . ). in addition, tamsulosin group and terazosin group were also significantly different (p = . ). according to these results we can say that tamsulosin group had higher no levels than control and terazosin group. tamsulosin's enhancer effect on no levels leads to relaxation of the heart muscle and vascular relaxation, and so fewer side effects than other alpha antagonists. the effect of rat liver tissue radical metabolism and the protective role of hippophae rhamnoides l. on cold and immobilization stress model cold and immobilization stress is a widely used model for study the changes that occur on oxidant-antioxidant balance. hippophae rhamnoides l. (seabuckthorn; sbt) a unique and valuable plant has recently gained worldwide attention, mainly for its medicinal and nutritional potential. this study was aimed to investigate the protective role of sbt which is a natural herbal product with high antioxidant content on oxidative and nitrosative stress induced by cold and immobilization stress in rats. wistar albino rats were divided into groups randomly. control (i.p. physiological saline), sbt (i.p. mg/kg/ hours sbt), stress (i.p. physiological saline; hours cold + immobilization stress) and sbt + stress (i.p. mg/kg/ hours sbt; hours cold + immobilization stress) groups were formed. nitrotyrosine levels were determined by elisa whereas total antioxidant capacity, total thiol, total glutathione, nitrite-nitrate levels and superoxide dismutase and glutathione peroxidase activities were measured by colorimetric methods. sbt + stress group nitrite-nitrat (p = . ), total glutathione (p = . ) levels and glutathione peroxidase activities (p = . ) were found to be significantly higher whereas superoxide dismutase activity was found to be lower (p = . ) when compared to stress group. there was no significant differences between stress group total thiol and total antioxidant capacity levels compared with stress + sbt group. stress + sbt group oxidative and nitrosative stress marker -nitrotyrosine level was found to be significantly higher when compared with control group (p = . ) whereas there was no significant differences between stress and stress + sbt groups. all this data show that sbt has antioxidant properties on cold and immobilization induced oxidative and nitrosative stress in rat liver tissue. obesity is a major health problem with growing incidence and accompanying complications. its relation with diminished cognitive functions was reported. this study aims to evaluate the effects of obesity induced oxidative stress and metabolic alterations on the cognitive functions of children and adults. children and adolescents with obesity (age: - ); and age and gender matched healthy subjects were enrolled. all subjects completed the battery tests of cnsvs via computer. the scores were compared by using commercial software (ibm spss statistics ). biochemical parameters, malondialdehyde (mda) and protein carbonyl (pc) levels were estimated. mda and pc levels were significantly higher in subjects with obesity ( . ae . lmol/l; . ae . nmol/ml) than the controls ( . ae . lmol/l; . ae . nmol/ml) (< . ). there was statistically significant difference between study and control groups on all cognitive performance domains. significant correlation was detected between mda, pc levels and the cognition indexes. children with obesity should be evaluated for the cognitive functions, together with the metabolic follow-up. obesity induced oxidative stress may be the reason of the diminished cognition in children as well as the changes in the lipid profile and inflammation, but we need larger study groups to lighten these complex process. p- . . - relative contribution of nitric oxide synthase (nos) isoforms to oxidative/nitrosative stress in the cerebral cortex of rat with acute liver failure (alf) acute liver failure (alf) is associated with deregulation of nmda/cgmp/no signaling and oxidative/nitrosative stress in the brain. however, the relative roles of the different nos isoforms and the mechanisms underlying alterations in their activities during alf are not fully clear. here we investigated gene and protein expression of nos isoforms, nos activity, enos uncoupling and total no production in cerebral cortex of rats with thioacetamide (taa)-induced alf. sprague dawley rats ( - g) received three i.p. injections of taa ( mg/kg) at hours intervals. the brain cortex expression nos isoforms (enos/inos/nnos) was measured by real-time pcr and western blot, nos activity was tested by monitoring the conversion of radiolabeled arginine to citrulline. reactive oxygen species (ros) were quantified in the presence of nos substrate l-arginine, using the carboxy-h dcfda probe. no was measured with the griess procedure. the enos expression was decreased, whereas the enos dimmer/monomer ratio and nnos/inos expression were elevated in taa treated rats. while the total nos activity was decreased, the inos activity was elevated and no concentration tended to increase. ros production was elevated by taa. unspecific nos inhibitors l-name and l-nna attenuated ros production in both control and taa rats, but with higher efficiency in the latter case. ca + chelation had almost the same effect as pharmacological nos inhibition suggesting that ca + -independent inos activity is not the main source of ros. incubation with high dose of tetrahydrobiopterin (bh ) with which is critical for enos dimerization and subsequent no production also reduced ros production indicating the enos uncoupling phenomenon in taa cortex. the study points to enos downregulation due to lowered protein expression and uncoupling as a novel mechanism contributing to enhanced superoxide o anion formation, and confirms the role of inos/nnos in enhancing no synthesis in alf-affected brain. introduction: diabetes mellitus (dm) is an endocrine disorder of world which is characterized by altered blood glucose levels and related complications including hepatic injury. myrtus communis l. (mc) is widely used by diabetic patients in the folk medicine of turkey as well as they are used worlwide. it is known that of leaves, oil and fruit of myrtus communis l. (mc) have therapeutic effects on diabetes mellitus (dm). this study was aimed to analyze the possible antidiabetic and hepatoprotective effects of mc berries in streptozotocin (stz) induced diabetic rats. materials and methods: a total of thirty rats composed of six groups as each included five rats were used. mg/kg stz was injected once to animals to induce dm. after stz injection, rats were exposed to three different ethanol extracts of mc berries ( , and mg/kg) by oral gavage during days. alanine aminotransferase (alt) and aspartate aminotransferase (ast) levels were determined in serum and glutathione (gsh), malondialdehyde (mda) levels and superoxide dismutase (sod) activity were determined in liver tissue. results: mc administration provided significant reducement in the altered serum glucose, ast and alt levels in all diabetic groups. mc extract showed significant antioxidant activity by altering sod activity and gsh level and reducing mda levels in diabetic rats compared to controls (p < . ). serum ast and alt levels were reduced by mc administration in all diabetic groups. mc administration provided significance increment in sod activity and gsh level, and significant reduction in mda levels compared to controls (p < . ). the maximum hypoglycemic and antioxidant effects were observed at mg/kg dose of mc. background: human serum paraoxonase (pon ) is a calcium dependent esterase that hydrolyzes organophosphates and also arylesters such as phenyl acetate. pon prevents ldl oxidation by hydrolyzing lipid peroxides. pon is inhibited by various chelating agents, heavy metal ions, and sulfhydryl reagents. in our study we investigated the effect of calcium on ldl oxidation of purified pon q r isoenzymes. methods: pon q r isoenzymes were partially purified from human serum. both allozymic forms were treated by preincubation with mm edta for minutes. ldl oxidation was induced by copper ions. formation of thiobarbituric acid-reacting substances (tbars) was used as a measure of lipid peroxidation. homocysteine thiolactonase (htlase activity) and arylesterase activities were measured spectrophotometrically by using homocysteine thiolactone and phenylacetate as the substrates. results: addition of mm edta to partially purified hdl-pon q r isoenzymes inhibited % of htlase and arylesterase activities. inactivation of pon for arylesterase/htlase activity by the addition of edta did not reduce the abilities of both allozymic forms in protecting ldl from oxidation. conclusion: ca + -dependent inhibition of pon q r arylesterase/htlase by using the metal chelator edta, did not alter pon 's ability to inhibit ldl oxidation. pon 's ability to protect ldl from oxidation may not require calcium. p- . . - evaluation of cholinesterase inhibitory effect, anti-radical and anti-lipid peroxidation activities of mentha pulegium i. hamad , college of applied medical sciences, aljouf university, aljouf, saudi arabia, faculty of medicine, bahri university, khartoum, sudan introduction: many studies indicated that intake of dietary and medicinal plants is effective in preventing or suppressing many diseases, therefore, there is a growing interest in plant'sbioactive compounds. mentha pulegium, is widely used in gulf countries in herbal teas or as additives in commercial spice mixtures for many foods to offer aroma and flavor. the aim of this study is to investigate the in vitro radical activity, the total phenol and flavonoid content, anti-lipid peroxidation and the cholinesterase inhibitory effects of mentha pulegium methanol extract. methods: the acetylcholinesterase and butyrylcholinesterase inhibitory potentials of extracts, were evaluated by colorimetric assay. the in vitro antioxidant activity was measured by dpph assay, the total phenols content was measured by folin-ciocalteau assay, the flavonoids content by the alcl colorimetric method, and the protective effect of menthe mentha pulegium extracts against lipid peroxidation was evaluated using a liposome oxidation system. results: the methanol extract showed a scavenging activity nearly equivalent to vitamin c which is attributed to its high phenolic and flavonoid contents. the extract possessed protective effect against lipid peroxidation in a dose dependent manner. the methanol extract shows very little anticholinesterase activity as compared to the standard compound, physostigmine. conclusion: results presented here indicate that mentha pulegiumpossess strong antioxidant activity and protective effects and they can therefore be used as a natural additive in food, cosmetic and pharmaceutical industries. type diabetes mellitus is a long term metabolic disorder that is characterized by hyperglycemia and insulin resistance. because of the hyperglycemia and free radicals, diabetes can cause cellular instability. micronuclei is a sensitive indicator of genetic damage and a marker of dna damage. micronuclei is also a morphological marker of chromosomal instability. in this study, we aimed to evaluate the frequencies of micronuclei in papanicolaou stained buccal cells of type diabetic patients. a total of type diabetic patients and healthy individuals were involved into our study. buccal smear samples that belong to these individuals were stained by using papanicolaou method for cytologic examination and the stained slides were evaluated by light microscopy (olympus bx- ). cells with micronuclei in each papanicolaou stained buccal smear sample were counted under light microscopy. the frequency of micronucleated epithelial cells were seen as significantly higher in type diabetic patients than the control group (p < . ). one of the boron compounds is sodium perborate tetrahydrate (nabo . h o), which the most widely used solid peroxygen compounds. it is used in safety bleach formulations, detergents and tooth powders. as known these products are commonly used in daily life. however, the actions on blood antioxidant defenses of sodium tetraborate against reactive oxygen species are not identified yet. it is reported that oxidative stress caused by ros damages. in this study, we searched enzyme activities of superoxide dismutase (sod), catalase (cat), glutathione-s-transferase (gst), glutathione reductase (gr), glutathione peroxidase (gsh-px) and glucose- -phosphate dehydrogenase (g pd) also the effect sodium perborate tetra hydrate on activities of these enzymes from human erythrocyte under in vitro conditions. according to our findings sodium perborate tetrahydrate caused significant (p < . ) increasing in the cat activity from red blood cell. the other antioxidant enzyme activities (sod, gst, gr, gsh-px and g pd) did not show any changing by influence of sodium perborate tetrahydrate. metabolism of obese individuals could be exposed to risk of chronic low-grade pro-inflammatory effect and oxidative stress. some inflammatory and oxidative markers have been studied recently. plasma total antioxidant status (tas) and total oxidant status (tos) parameters can be non-invasive markers of diseases such as fatty liver disease, laparoscopic procedures (pneumoperitoneum), accompanying inflammatory condition like urinary tract infection, diabetic neuropathy, chronic hepatitis. the study groups have been comprised of two groups with normal to over-weight children. tas and tos levels were detected and the oxidative stress index (osi) was computed as a marker of the grade of oxidative stress. the over-weight group displayed higher levels of fasting glucose, insulin resistance, the body mass index. also, we know that insulin resistance leads to increased lipolysis and free fatty acid output. higher tos as well as crp is related to the group, also lower tas than other group is shown. crp levels in plasma were positively correlated with insulin and glucose levels. in addition, there was a significant relationship between osi and insulin resistance in the over-weight group. tas and tos are together more accurate sings of oxidative and antioxidative status of people. as well as a raise over weight-related subclinical inflammation and a fall antioxidant capacity is significant even in children. this condition may eventually develop the risk of long-term vascular damage. the effects of hydrogen peroxide pretreatment on antioxidant enzyme activities in calli tissues of two eggplant genotypes under salinity o. yasarkan , e. aky€ uz , g. baysal furtana , s. s. ellialtioglu , r. tipirdamaz nezahat g€ okyigit botanic garden, istanbul, department of biology, faculty of sciences, gazi university, ankara, department of horticulture, faculty of agriculture, ankara university, ankara, department of biology, faculty of sciences, hacettepe university, ankara, turkey the effects of hydrogen peroxide (h o ) pre-treatment on catalase (cat) and superoxide dismutase (sod) were investigated and lipid peroxidation measured as malondialdehyde (mda) content of the calli from salt-sensitive (artvin) and salt-tolerant (mardin) eggplant genotypes under salinity stress. the seeds from each genotypes were germinated on ms medium for weeks and hypocotyl tissues from these plantlets were used as explants for calli induction on ms medium including mg/l , -d and . mg/l kinetin. as for the pre-treatment, the subcultured calli tissues were transplanted on the mediums containing and lm h o for hours and then transplanted on the mediums including mm nacl for hours. antioxidant enzyme analysis and mda measurement was carried out for the control, nacl-only, h o -only and h o pre-treated tissues. pre-treatment with h o decreased the deleterious effects of salt stress on mda contents. in comparison with salt stressed groups, h o pre-treatment with or without nacl reduced mda content especially in artvin. comparing two genotypes, a decrease was observed on sod activity in artvin genotype and an increase in mardin genotype by comparison of salt stressed groups. higher increase on sod activity was observed in lm h o + nacl groups on each genotypes. comparing two genotypes, a decrease was observed on sod activity in artvin genotype and an increase in mardin genotype by comparison of salt stressed groups. higher increase on sod activity was observed in lm h o + nacl groups on each genotypes. the result showed pre-treatment of lm h o induced acclimation of the plants to salinity. in addition, lm h o pre-treatment, as a stress signal, could trigger the activation of antioxidant enzymes in calli and in this way alleviated the oxidative damage in calli growth under salinity. the investigation of effects of ghrelin and cannabinoid cb receptor agonist and antagonist on oxidant and antioxidant mechanisms on brain tissues of penicillininduced epileptic rats the aim of this study is to investigate the individual effects of ghrelin and cannabinoid type (cb ) receptor agonist acea, the antagonist am- and the interaction of these two different systems on oxidant and antioxidant systems in the brain, cerebellum and brain stem tissues of penicillin-induced epileptic rats. in this study male wistar albino rats were used weighing - g. each group was consisted of rats. study groups: : control, :penicilin( iu), :penicillin( iu) + ghrelin( lg), :penicillin( iu) + am- ( . lg), :penicilin ( iu) + acea( . lg), :penicillin( iu) + am- ( . lg) + ghrelin ( lg), :penicillin( iu) + acea( . lg) + ghrelin( lg). than the levels of mda, gpx and sod are measured in plasma and tissue samples of these rats. penicillin was found to be induced lipid peroxidation in the brain, cerebellum and brain stem tissues in our study. ghrelin and acea, which both have anticonvulsant effects, were shown to be effective in reversing the oxidative damage caused by penicillin and proconvulsant am was found to further increase the oxidative stress caused by penicillin in these tissues. ghrelin also was found to suppress the oxidative stress caused by am in the cerebellum tissue but it did not contribute to antioxidant effects produced by acea. since the role of oxidative stress in epilepsy has been established, it may be suggested that ghrelin and acea may have anticonvulsant effects via their antioxidant features. the discovery of inhibitors for enzymes that metabolize endogenous ghrelin and cannabinoids through new studies may contribute to the improvement of seizure resistance in epilepsy. accelerated atherosclerosis in patients with ankylosing spondylitis (as) give rise to increased cardiovascular morbidity and mortality. endothelial dysfunction could be the initial process in the development of atherosclerosis. human endothelial cell-specific molecule- (endocan) is a novel human endothelial cell-specific molecule. therefore, we assessed serum endocan levels and carotid intimamedia thickness (cimt) as a surrogate marker of atherosclerosis in patients with as. a total of patients with a diagnosis of as according to newyork ctriteria and control subjects were included in our study. serum endocan, interleukin- (il- ), tumor necrozis factor-a (tnf-a), c reactive protein (crp) and cimt were measured in all participants. serum endocan, il- , tnf-a levels were measured with elisa. the other parameters were done by routine biochemical methods. as patients exhibited increased serum endocan levels and cimt compared to matched controls (p < . ). whereas, serum il- , tnf-a were similar between grous. in patient with as, there were no significant differences between active and inactive patients by means of il- , tnf-a, endocan and cimt. in as group, cimt correlated with disease duration and age (r = . , p = . ; r = . , p = . ). we could not find any significant correlation between serum endocan levels and parameters studied. our study shows increased cimt in as patients without traditional risk factors such as increased bmi, lipid profile compared to controls. although we found increased circulating endocan levels in patients with as, the other factors could affect increased atherosclerosis in this population because of lack of correlation between endocan and cimt. probable biomarkers could be related to increased cimt in patients with as should be investigated in larger study groups. keywords: ankylosing spondylitis, atherosclerosis, carotid intima media thickness, endocan p- . . - investigation of pentose phosphate pathway and oxidative stress in erthrocyte infected babesia ovis a. bildik, t. karagenc ß, p. a. ulutas, n. aysul, h. aksit adnan menderes university, aydin, turkey introduction: babesia infections occur in cattle, sheep, goat, horse, dog, cat pig and rodents. in this study, the effects of babesia ovis living and present in the erythrocytes to glucose metabolism was researched. at the same time, biochemical parameters were also associated with parasitemia. materials and methods: babesia ovis (israel) cell culture was provided from dr. abel martin gonz alez oliva (portugal). culture passaged or hours according to parasitemia state ( - %). biochemical analyses were performed in erythrocyte culture in which parasitemia between % and %. cell counts and hemoglobin concentration of erythrocytes culture suspension were measured at cell counter instrument and than it was washed times with physiological saline, erythrocyte suspensions were stored at- oc analysis. gssg (oxidize glutathione), gsh (reducte glutathione), nadph, glukoz p dehydrogenaz, gshpx (glutathione peroxidase), gshrx (glutathione reductase) were determined by commercial kits. all experiments were done in duplicate, the results were calculated by the number of erythrocytes. results: parasitemia was positively correlated with gsh, nadph and gshrx (p < . ). a correlation between other biochemical parameters was not observed. discussion: the pentose phosphate pathway in erythrocytes has an important role such as to provide pentose sugar required for the synthesis of nucleic acid, to reduce glutathione, to produce nadph and to protect from methemoglobin accumulation. in studie sthat naturally infected erythrocytes with babesia parasites, it was seen to be caused to oxidative stress, however gsh results in these investigation were obtained differently . conclusion: according to the results of this study that performed in vitro, it can be suggest that their glutathione metabolism and pentose phosphate pathway of parasites may active.key words: babesiosis, gsh, gssg, nadph, g pdh, gshpx, gshrx p- . . - in vitro protective effect of betaine on peroxidative injury caused by ethanol and aspirin exposure on rat brain synaptosomes i. sogut , g. kanbak istanbul bilim university vocational school of health services, istanbul, eskisehir osmangazi university medical school department of biochemistry, eskisehir, turkey aspirin intake of specific daily doses are advised by doctors to postmenapausal women and men above years of age to prevent heart attack and even cancer in recent times. in this study, the aim is to investigate the in vitro cytototoxic effects of different doses of ethanol ( mm, mm ve mm) alone and together with lg/ml aspirin, and possible protective role of mm betaine on rat brain synaptosomes. male sprague dawley rat forebrains were divided into equal pieces and pooled to form study groups. synaptosomal fractions extracted from pooled rat brains were incubated with different doses of ethanol, aspirin and betaine, and malondialdehyde (mda) levels, an important indicator of cellular damage, were measured. a significant increase (p < . ) was observed in mda level of mm ethanol group compared to control group. different doses of ethanol ( mm, mm ve mm) + aspirin exposure significantly increased (p < . ) mda levels compared to controls, whereas betaine administration significantly decreased (p < . ) lipid peroxidation caused by ethanol + aspirin treatment. we conclude that ethanol and ethanol + aspirin administration increases lipid peroxidation in rat brain synaptosomes while betaine helps prevent this peroxidative membrane injury.keywords: aspirin, betaine, ethanol, malondialdehyde (mda) p- . . - analyses of mitochondrial biogenesis in hepatocellular carcinoma treated with berberine f. aygenli, h. c ß imen yeditepe proteomics and mass spectrometry group (yediprot), genetics and bioengineering, yeditepe university, istanbul, turkey objective: berberine (bbr) has been demonstrated to have anticancer activities against various cancer types, particularly hepatoma. in this project, we aimed to reveal the effect of bbr treatment on mitochondrial biogenesis through sirtuins and hif- a in hepatocellular carcinoma cell line, hep b under hypoxia. method: hep b cells were subjected to normoxia ( % o ) and hypoxia ( % o ) in the presence or absence of bbr treatment. the amount of bbr was optimized via cell viability (mts) assay under normoxia. then, immunoblotting experiments were performed to identify the effect of bbr on hif- a, pgc- a, and sirtuins involved in mitochondrial stress. the variation in the oxphos complexes and the level of reactive oxygen species (ros) were also measured to investigate the effect of bbr on mitochondrial energy stress state. results: here, we present that cell viability was significantly decreased at lm. bbr treatment has shown significant reduction in hif- a and sirt which responsible for up-regulation of glycolysis. also, succinate dehydrogenase (cii) and cytochrome c oxidoreductase (ciii) of the oxphos complexes were downregulated without any change in nadh dehydrogenase (ci) or atp synthase (cv). bbr significantly abolished to oxidative stress under hypoxia, which was demonstrated as a reduction in the level of reactive oxygen species by decreasing on sirt expression. bbr induces the overexpression of sirt and its deacetylated-pgc- a, which might be an indicator of being a potent protective agent against hypoxia by normalizing mitochondrial function and inducing mitophagy in impaired mitochondria caused by deficiency of glycolysis and oxphos. conclusion: detailed information about the communication between hif- a and sirtuins and their relation to mitochondrial energy production was provided with the alteration of their activity by bbr treatment. it is highly expected that bbr and its derivatives might become important during the development of supplemental therapies. introduction: reactive oxygen species are involved in a variety of biological phenomena, such as carcinogenesis, inflammation and aging. among the targets of ros, dna appears most important in tumor biology since it is firmly established that cancer is a genetic disease. ros induce several kinds of dna damage, including strand breakage and dna-protein cross-linkage. fruit of zizyphus jujuba, a traditional chinese herb widely consumed in asian countries, has been reported to possess several vital biological activities. this study intends to evaluate their antioxidant activity on glioblastoma cells. materials methods: cell survival was quantified by colorimetric mtt assay. human gliblastoma cells were pretreated with lm h o after minutes lm ziziphus jujuba essential oil was added to the cells for three hours. then, the cell homogenates were taken and glutathione, total oxidant and total antioxidant capacity and nitric oxide levels were estimated using spectrophotometric methods. results: ziziphus jujuba treated cells could prevent intracellular glutathione from being depleted following an exposure of h o . also our data suggest that ziziphus jujuba is effective in preventing h o induced oxidative stress and nitric oxide levels. discussion: some research showed that h o was over produced in the pathological process of acute and chronic neuronal toxicity, the toxicity effect of b-amyloid on the cultured neuron and neuronal cell line was mediated by h o . the traditional medicine recommend several medicinal plants for providing relief from various inflammatory diseases. many research has been reported that the essential oil from seeds of helping to prevent the oxidative stress and neuronal diseases in brain. introduction: toxicity by oxygen radicals has been recommended as a major cause of cancer, heart disease, and aging. oxygen radicals and other oxidants appear to be toxic in large part because they start the chain reaction of lipid peroxidation. most of the analytical techniques for peroxide determination are generally time consuming and not very suitable for routine or on line analysis. we aimed to design a new biosensor for rapid determining of oxidant agent hydrogen peroxide. materials and methods: all reagents were of analytical grade unless stated otherwise, and were purchased from sigma aldrich. firstly, the -hidroxymetacrilate metacriloamidoscystein nanoploymers were immobilized by binding covalently with sulphur atoms on the gold electrod's surface. free nh groups of catalase enzyme make schiff bases between nanopolymer's carbonyl groups, then immobilization was actualysed with cross linking reagent glutaraldehyde. we developed a biosensor system preparing ferrociyanide, selected as a mediator, in the buffer solution. results: polyhemamac nanopolymer and catalase complex were immobilized by glutaraldehite to construct a hydrogen peroxide biosensor. the responses of the biosensor are therefore proportional to the oxidation peaks of the complex at + . v potential. the cyclic voltammograms obtained from the experiments showed that, pottasiumferrociyanide mediator complex positively affected the biosensor responses for hydrogen peroxide determination. discussion and conclusion: as a result of this study, the method developed by the catalase enzyme electrode was found to be more advantageous in comparison to other methods reported in the literature so far; it was determined that the method is sensitive, economic, practical and less time-consuming. since biosensor technology provides economical, practical, specific and sensitive results for the determination of hydrogen peroxide, it was improved very efficiently. p- . . - impact of amoxicillin, gentamicin and cefazolin sodium antibiotics on antioxidant gene expression and enzymatic activities in mouse liver p. g€ uller , h. budak , m. sisecioglu , m. c ß iftci department of chemistry, faculty of science, atat€ urk university, erzurum, department of molecular biology and genetics, faculty of science, atat€ urk university, erzurum, department of chemistry, faculty of arts and sciences, bing€ ol university, bing€ ol, turkey reactive oxygen species (ros) are highly reactive molecules, which are produced by living organisms as a natural byproduct of the normal metabolism and environmental factors. living organisms have the antioxidant defence systems to block harmful effects of ros. the imbalance between oxidants and antioxidants is termed oxidative stress. the antioxidant defence mechanisms are divided into two groups as enzymatic and nonenzymatic defences. enzymatic defence mechanisms consist of enzymes like superoxide dismutase (sod), catalase (cat), glutathione peroxidase (gpx), glucose- -phosphate dehydrogenase (g pd) and glutathione s-transferase (gst). the present study was designed to determine the effects of gentamicin, amoxicillin and cefazolin sodium antibiotics on the hepatic antioxidant system and to determine any possible correlation between enzymatic and molecular levels. for this reason, effects of these antibiotics on the transcription of the antioxidant system has been investigated by real time pcr, and then the enzyme activity of these enzymes have been measured in whole liver homogenate obtained from control group and the drug administered groups mice. our results demonstrate that administering antibiotics led to crucial inhibition of all antioxidant enzyme activity. while significant transcriptional activation for sod and cat was seen in the gentamicin treated group, the transcription of gst and g pd was decreased. however transcriptional activation was seen for sod and cat in amoxicillin administered group, the transcription of gst was decreased as compared with the control group. in the cefazolin sodium treated group, while cat and gst transcription were elevated significantly, the expression of sod and g pd were decreased. in conclusion, gentamicin, amoxicillin and cefazolin sodium affect the hepatic antioxidant system at the molecular and protein level. this work was supported by scientific research project of ataturk university of turkey (grant no: / ). p- . . - protective effects of curcumin supplementation on oxidant/antioxidant system changes created by organic phosphorus pesticide poisoning organic phosphorus pesticides (opp), widely used in agriculture or as insecticides in home, cause adverse health effects. chlorpyrifos is one of the most commonly used opp. we aimed to investigate the possible protective effects of curcumin (cur) supplementation, the principal curcuminoid of turmeric, on poisoning symptoms and oxidant/antioxidant system changes caused by chlorpyrifos. adult sprague-dawley rats were used. cur ( , and mg/kg) were administered orally for days. on the sixth day, chlorpyrifos ( mg/kg, s.c.) was administered. twenty four hours after chlorpyrifos administration, body weights, locomotor activities and body temperatures of rats were measured. following the measurements, rats were decapitated and the blood, brain and liver tissue samples were taken and prepared for the biochemical and histopathological measurements. chlorpyrifos administration increased the malondialdehyde (mda) levels but decreased catalase (cat), superoxide dismutase (sod), glutathione reductase (grx) concentrations and reduced/oxidized glutathione (gsh/gssg) ratio in the blood samples, brain and liver tissues compared with the control group (p < . - . ). the concentration of advanced oxidation protein products (aopp) were increased only in the brain tissue after chlorpyrifos administration (p < . ). cur administration reduced all of these changes (p < . - . ). similarly, cur at the doses of mg/kg reduced the decreases in body weight, body temperature and locomotor activity with chlorpyrifos (p < . ). additionally, the histopathological damage scores induced by chlorpyrifos (p < . - . ) were decreased by the administration of cur (p < . - . ). our findings suggest that cur supplementation can ameliorate the poisoning effects of chlorpyrifos via supporting the antioxidant mechanisms and cur could be used for protective purposes against oxidative stress and tissue damage caused by chlorpyrifos. the effect of ogtt applied for screening in pregnancy on adenosine deaminase and xanthine oxidase activity in normal and prediabetic pregnant women z. c. ozmen, k. deveci, i. benli department of biochemistry, gaziosmanpasa university medical faculty, tokat, turkey objective: it was reported that the activities of adenosine deaminase (ada) were different in normal pregnant women and pregnant women with gestational diabetes mellitus (gdm). it was also stated that the activity of xanthine oxidase (xo) was increased in pregnant women with gdm. the objective of this study was to evaluate if glucose have effects on oxidative stress in prediabetic women by affecting ada and ox after g ogtt which was applied in pregnant women for screening. methods: the serum specimens of pregnant women who applied to the outpatient clinic of the obstetrics and gynecology department and had g ogtt, were used in this study. ada and xo activities were analyzed in the serum specimens taken from the normal (n = ) and prediabetic pregnant women (n = ) in the th and th minutes of ogtt. ada and xo activities were measured with the spectrophotometric method and the u/l enzyme activity was calculated. findings: there was no significant difference between the th and th minutes regarding the ada activities in the normal and prediabetic pregnant woman groups. however, we observed a significant difference between th and th minutes regarding the xo enzyme activity in normal pregnant women (p = . ). in normal pregnant women, the median xo enzyme activity in the th minute was . ( . - . ) u/l and it was . ( . - . ) u/l in the th minute. nevertheless, there was no correlation between the xo activity and glucose level. as to the prediabetic pregnant women, there was no significant difference between the xo enzyme activities in th and th minutes. the results of our study showed that the xo activity increased as a response to ogtt in the normal pregnant women compared with the prediabetic pregnant women. this finding made us think that the oxidative stress caused by ogtt did not affect the xo response in prediabetic pregnant women and that there would be some adaptive mechanisms against the chronic exposure to high level glucose. rainbow trout (oncorhynchus mykiss) aquaculture continuously increases in turkey. the objective of the present study is to increase the productivity in fish farming of rainbow trout just via intervention in physical cases without the effects of any chemicals and investigate whether this conditions cause oxidative stress. in this experiment eight tanks were used and rainbow trout larvae were placed in each tank and these tanks were illuminated with light in different wavelengths; natural sunlight, and incandescent long-wave (red light), medium-wave (green light) and shortwave (blue light) led lights. the experiment took days. biochemical changes in rainbow trout exposed to light in different wavelengths (red, green, blue) were analysed via the variations in gr, gst, g pd, gpx, sod and cat enzyme activities, which are significant for enzymatic antioxidant defence system and in ache activity, which plays an important role on central nervous system. maximum activity change in liver tissue was observed for gst and g pd enzymes in fish grown under green light and for sod enzyme in fish grown under blue light. in gill tissue, sod and g pd activities were affected the most, and in brain tissue, these were gst and sod activities. it was observed that the average weight of the fish increased . times under red and blue lights and . times under green light. the highest weight increase was observed under green light, however, antioxidant enzyme activities increased in the liver and gills and decreased in the brain tissue under this light condition. in conclusion, it was observed that productivity was . times under red light when compared with control group and it was determined that the fish grown under red light can tolerate oxidative stress more than other wavelength. p- . . - effect of nigella sativa on biliary obstructioninduced oxidative stress and apoptosis in rats human safety concerns, since that these agents may not only cause acute toxicity via inhibition of acetylcholinesterase but they can also induce delayed toxicity in the nervous system. a key interest to the current work is the potential correlation between gene expression and cytoskeletal protein changes in differentiating neural cells exposed to sub-lethal neurite outgrowth inhibitory concentrations of specific ops, which was addressed by analysing the underlying changes in the levels of cytoskeletal gene expression and protein levels. to assess the molecular effects of op exposure, phenyl saligenin phosphate (psp), chlorpyrifos (cpf) and its metabolite chlorpyrifos oxon (cpfo) were applied at the point of induction of differentiation of rat c glioma and mouse n a neuroblastoma cells and incubated for hours. at sub-lethal concentrations ( , , lm) all three ops used in this study were able to inhibit the development of neurites with no significant effect on cell viability, as determined by neurite outgrowth and mtt reduction assays. to understand the possible effects of ops on cytoskeletal gene expression, primers for genes encoding glial fibrillary acidic protein (gfap), biii tubulin, growth associated protein (gap ) and neurofilament heavy chain (nefh) were optimized for qpcr analysis and the levels of the corresponding proteins were detected by western blot analysis. exposure to ops caused in most cases a reduction in the levels of cytoskeletal proteins, and the results from qrt-pcr analysis also indicated reductions in the gene expression of gfap in c cells, and of nefh and biii tubulin in n a cells, in a dose dependent manner. thus, the observed changes in protein levels are at least partly due to altered gene expression. curcumin is extracted from a perennial herbaceous plant known as curcuma longa. in recent years, considerable interest has been focused on curcumin due to its use to treat a wide variety of disorders without any side effects. earlier studies have shown that curcumin has anti-apoptotic, anti-inflammatory, antiproliferative, antiangiogenic, anticancer and antiplatelet activities. the goal of the present study was to investigate the effects of curcumin on peroxy radical-induced oxidative changes in human platelets. healthy volunteers were enrolled in the study. none of the study participants were on anticoagulation therapy. citrated venous blood samples were centrifuged at g for minute to obtain platelet-rich plasma (prp). the platelet pellet was washed and suspended with tris-nacl buffer. then, platelets were incubated with h o absence and presence of curcumin ( - lg/ ml) for hours at °c. to determine the preventive effects of curcumin on the oxidative stress and apoptosis induced by peroxy radicals in human platelets were determined by measuring levels of of lipid peroxidation, total antioxidant capacity, caspase , and activities, and mitochondrial membrane potential. additionally, we also studied the effects curcumin on platelet aggregation induced by adp. pre-treatment of platelets with curcumin caused a marked reduction in oxidative stress, activation and apoptotic markers in a dose-dependent manner. on the other hand, pre-treatment of platelets with increasing doses of curcumin resulted in inhibition of platelet aggregation induced by adp. in the light of our findings, we suggest that curcumin may have a therapeutic potential to prevent platelet activation related disorders. people have been using mushrooms in the treatment of diseases as well as food, for centuries. most of the edible and inedible mushroom species were used in important medical studies and their effects were begun to be used in the treatment of diseases. this study focuses on the hepatoprotective effects of tricholoma anatolicum, which is endemic specie in turkey, against oxidative stress based on hydrogen peroxide (h o ) on hepg liver cancer cell line. t. anatolicum used in this study was extracted with the help of ultrasonication and fraction methods. then the cytostatic effects of extracts on hepg cells were explored and their hepatoprotective effects were determined. moreover, various concentrations of aqueous extract (ehta) of t. anatolicum were determined by hepg cells's - - hours effect analysis on their cellular morphology, xtt and real-time cell analysis in of xcelligence device. ehta extract's cell pathway (apoptosis and necrosis) effects on hepg cells were determined with flow cytometry method with the help of annexin v-apc and aad fluorescent dye. finally, the phenolic compounds found in ehta extracts were determined with the help of hplc methods. according to xtt cytotoxicity analysis, the ehta extract values were determined as follows: hours ic > lg/ml, hours ic . furthermore, according to the real-time cell analysis made with xcelligence, ehta extracts were found to be; hours ic = . lg/ml, hours ic = . lg/ml, hours ic = . lg/ml. increasing concentrations of ehta extracts were determined to direct hepg cells to apoptosis. moreover, considering the hplc analysis -according to the reference point of mg in g sample-within ehta extracts, catechins and vanillic acid peaked. the final results revealed that t. anatolicum's effect on hepg was cytostatic at low doses, and cytotoxic at high doses. p- . . - relationship between serum ceruloplasmin levels and coronary blood flow background: there is growing evidence that oxidative stres plays an important role in the development of the slow coronary flow (scf) phenomenon. ceruloplasmin (cp) is a copper containing metalloenyzme which has antioxidant functionthrough its ferroxidese activity and is associated with cardiovascular diseases. we aimed to investigate the relationship between scf and serum cp level. methods: patients who underwent elective coronary angiography and had no significant epicardial coronary disease were included in the study. patients who had thrombolysis in myocardial infarction frame counts (tfcs) above the normal cutoffs were considered to have scf and those within normal limits were considered to have normal coronary flow (ncf). a total of patients ( subject as scf and subjects as ncf) were analyzed. ml blood samples were taken from the groups to study ceruloplasmin activity. serum ceruloplasmin levels were determined spectrophotometrically. results: the serum cp levels were statistically lower in scf group than in the ncf group ( ae versus ae ng/ml, p = . ). also there was a significant correlation between serum cp levels and tfcs (r = À . , p = . ). conclusion: the findings of this study suggests that patients with scf had lower serum cp levels correlated with tfcs. we concluded that reduced serum cp levels might represent a biochemical marker of scf. introduction: sleeve gastrectomy (sg) has been used for the surgical treatment of morbid obesity, as a first step or definitive treatment. alterations of thyroid hormones in gastrointestinal surgery were previously studied. the aim of the present study was to determine the effects of triiodothyronine (t ) supplementation on oxidative stress parameters in anastomotic tissue level. materials and methods: twenty-four male wistar albino rats were divided into control (n ), and experimental (n ) groups. rats were underwent a sg, with a hand-sewn suture. experimental group rats received a single dose of t ( mg/ g) in postoperative day. rats were sacrificed on postoperative day . serum thyroid stimulating hormone (tsh), free t (ft ), and free thyroxine (ft ) were analysed using elisa. each tissue was homogenized in ice-cold pbs (ph: . ) and centrifuged at rpm for minutes ( °c) to avoid contamination with cellular debris. the supernatants were used to measure total oxidant status (tos), total antioxidant status (tas), nitric oxide (no) and malondialdehyde (mda) levels. all tissue parameters were analysed by spectrophotometric methods. oxidative stress index (osi) values were calculated. results: rats given t hormone had not decline in ft levels compared with the control groups. a significant decrease in ft levels was found in t given rats on postoperative day . whereas tissue tos levels did not alter by thyroid hormone treatment, tas levels significantly decreased. osi values were not statistically different in tissues. tissue no levels were also similar in both groups. mda levels increased in t given rats compared with the control group. discussion and conclusion: this study showed that anastomosis after sleeve gastrectomy is associated with decreased ft level. although tos levels and osi values were similar in both groups, t supplementation induced lipid peroxidation by increasing tissue mda levels that might deplete tissue antioxidant level. reactive oxygen species (ros) are reactive chemical molecules, which are produced by living organisms as a natural byproduct of the normal metabolism and environmental factors. although intracellular ros level is essential molecules for the signal transduction pathways, elevated intracellular level of ros leads to oxidative stress that causes damage to dna, proteins and lipids. therefore, excessive ros levels have to be eliminated by antioxidant defence systems. tip (tat interacting protein, kda) is a histone acetyltransferases (hats) that catalyses multiple functions in metabolism such as dna repair, apoptosis, etc. we thought that if tip has a role in signal transduction and apoptosis, it might have direct or indirect relationship with the antioxidant system. the present study was designed to determine the impact of tip gene on the hepatic antioxidant enzymes including superoxide dismutase (sod), catalase (cat), glutathione peroxidase (gpx), and glutathione reductase (gr) both gene and protein level. for this reason, quantitative gene expression analysis on the antioxidant system has been investigated by real time pcr, quantitative protein expression has been investigated by western blot analysis, and then the activity of these enzymes have been measured in whole liver homogenate collected from control and liver-specific tip conditional knockout mice. additionally, since any change of reduced glutathione (gsh), oxidized glutathione (gssg), malondialdehid (mda), and hydrogen peroxide (h o ) level in the cell might be an indication for the accumulation of ros, the relative levels of them were also studied. our data showed that the absence of tip affects the antioxidan system both gene and protein level. in conclusion, our initial data suggest that tip may be essential for the (ros) homeostasis and redox regulation. curcumin is a major chemical component produced from the rhizome of the plant curcuma longa. lt has been demonstrated that curcumin has an antioxidant, anti-inflammatory, and antiproliferative effects and, protects tissues against ischemia/reperfusion (i/ r) injury. i/r has detrimental effects on transplanted organs including uteri. the major consequence of l/r injury is oxidative stress leading to the generation of ros. uterine transplantation (ut) has been gaining popularity around the worid in the past few years. the aim of our study was to examine the antiapoptotic effects of curcumin on uterine l/r injury. the rats were randomized into three groups of seven rats each, group i consisted of rats that did not receive any treatment, group ll exposed to . hour of lschemia and hour of reperfusion, group iii of rats that received intraperitonealy curcumin ( mg/kg) . hour before the induction of i/r. then, the rat uterine tissue levels of mda, tac, and activities of caspase , and were measured. furthermore, the apoptotic index was determined immunohistochemically by the tunel method using light microscopy. biochemical analysis results showed that curcumin decreased the mda and caspase- and ieveis, and increased the uterine tissue levels of tac but, caspase activity did not changed by curcumin suggesting that curcumin induces apoptosis via intrinsic apoptotic pathway. on the other hand, an high apoptotic index was observed in i/r group ( . ae . %) and decreased after treatment with curcumin ( . ae . %). in conclusion, we demonstrated the protective effect of curcumin on apoptosis immediately after reperfusion induction in uteri and we can say that curcumin could improve ir injury and decrease apoptotic index. we propose that curcumin may be a novel approach for improvement of uteri i/r injury. glutathione and the related enzymes belong to the defence system of the tissues against chemical and oxidative stress. these enzymes especially glutathione s-transferase are often overexpressed in tumor cells and are regarded as a contributor to their drug resistance and are thought to play an important role in cancer progression. the purpose of this study is to evaluate the protective effects of chlorophylline as an antioxidant molecule which has inhibitory effects on gst p - on chemically-induced breast cancer model. in our previous work, we had observed that this molecule led to proliferation in breast cancer cells. in this study, n-methyl-n-nitrosourea (mnu) used for inducing carcinogenesis in eighteen, -day-old female sprague-dawley rats. chlorophylline and mnu solutions were injected intraperitoneally when the rats were , , and days old. their weight and tumor diameters were measured throughout the months study period. at the end of the study, all animals were sacrificed and determined both glutathione levels and related enzymes activities (gluathione s transferase, glutathione reductase and glutathione peroxidase) in tumor and tissues such as liver, kidney, heart and spleen were studied and analyzed. as a result, in breast cancer model, glutathione and related enzyme activities were protected by chlorophylline treatment whereas mnu made them decreased compared to the control group. in conclusion, chlorophylline with antioxidant features decreased the toxic effect of mnu by regeneration of glutathione and enhancement of its related enzyme activities. the use of antioxidant molecules, because of proliferative effects and defence-oriented behaviours, should be discussed in cancer therapy. p- . . - effect of overexpression of bacillus catalase on lactococcus lactis nisin production z. girgin ersoy, s. tunca gedik gebze technical university, kocaeli, turkey nisin, has been used commercially (e ) in food preservation for approximately years. it's the only bacteriocin which is approved by world health organization as a food additive. the fundamental problem that limits nisin usage in food preservation is low product yield by producer strains. because of high commercial potential of nisin, studies about increasing the production efficiency of nisin is kept in the forefront in recent years. since nisin biosynthesis and bacterial growth are occuring in parallel to each other, conditions that promote growth are also expected to encourage nisin production. it is known that, when supplied with exogenous heme, lactococcus lactis cells can respire under aerobic conditions and produce higher energy which in turn cause higher biomass. however, aerobic conditions also cause oxidative stress since catalase enzyme, which detoxify hydrogen peroxide, is absent in l. lactis. in this study, to complete the missing component of the defence mechanism of l. lactis, catalase (kate) gene of aerobic bacterium bacillus subtilis was overexpressed in facultative anaerobe l. lactis cells. for this, kate gene of b. subtilis was amplified by polymerase chain reaction (pcr). plasmid constructions were established in e. coli by using an e. coli-l. lactis shuttle vector and then the recombinant plasmid was transferred to l. lactis cells by electroporation. the presence of catalase activity in the recombinant strain grown on the solid medium was first detected by dropping hydrogen peroxide directly on the cells, then with enzyme assays. fermentation studies are going on to determine nisin production of the recombinant strain. to the best of our knowledge, this study presents the first preliminary results that shows the effect of overexpression of catalase gene on nisin production. cancer is among the leading causes of morbidity and mortality worldwide. chemotherapy is one of the major cancer treatment strategies. remarkably, natural products have garnered increased attention in the chemotherapy drug discovery field because they are biologically friendly and have high therapeutic effects. humic acid (ha) is a natural product which is forming during decomposition of organic matter in humus. in recent years, there are some resarches on the medical use of humic acid. the present study investigated anticancer effects of ha in several human cancer cell lines. ha was purchased from sigma-aldrich. in this study, we used several human cancer cell lines: the human breast cancer cell line, mcf- , colon cancer cell line, ht- , lung adenocarcinoma cell line, a , and servical cancer cell line, hela. the cells were maintained in dmem medium supplemented with % heatinactivated fbs and % penicillin/streptomycin. cells were grown in petri dishes in a humidified atmosphere containing at •c. five different concentrations ( ug/ml, ug/ml, ug/ ml, ug/ml, ug/ml) were prepared using a stock solution of ha. the cell proliferation and migration was measured. on the other hand, the apoptotic mechanisms induced by ha in cancer cells were investigated using "apoptosis antibody array kit". the effects of ha on cancer cell lines were evaluated over hours. according to our results, ha induced a decrease in ht- , a and hela cell numbers in a dose-dependent and time-dependent manner. contrary to this, ha induced proliferation of mcf- cells in dose dependent manner. ha inhibited cell migration in a dose dependent manner except mcf- cell line. it was also determined apoptotic pathways in cancer cells induced by ha. it was concluded that ha has an inhibitory effect on certain some cancers. since the effect of ha on tumor progression is unknown, further studies are needed to clarify the rol of ha on cancer activity. p- . . - chronic immobilization stress in rats: fluoxetine and amisulpride protects against chronic immobilization stress-induced biochemical alterations in the present study, the effects of amisulpride and fluoxetine on serum total sialic acid (tsa) and lipid bound sialic acid (lsa) levels was investigated in the rats exposed to chronic immobilization stress. the study was administered using male wistar albino rats weighing - g. rats were divided into five groups (n = / group). group i comprised the control group, group ii was exposed with saline + immobilization stress ( minutes daily immobilization stress for days and . ml saline was administered perorally minutes before immobilization), group iii was exposed amisulpride ( mg/kg/day) + immobilization stress, group iv was exposed fluoxetine ( mg/kg/day) + immobilization stress and v. group was exposed amisulpride ( mg/kg/ day) + fluoxetine ( mg/kg/day) + immobilization stress. statistical analysis showed that the saline + stress, amisulpride + stress and amisulpride + fluoxetine + stress groups was significantly higher than the control group with regards to tsa levels (p < . ). whereas, the fluoxetine group was significantly lower than the group regarding tsa levels (p < . ). on the other hand, saline group was significantly higher than the control group with regards to lsa level (p < . ). whereas, no significant differences in lsa levels were observed in the amisulpride, fluoxetine and amisulpride + fluoxetine groups, as compared to the control group (p > . ). the present study demonstrated beneficial effect of fluoxetine and amisulpride on the concentration levels of lsa and tsa in stress. p- . . - protective effect of borax and boric acid on total sialic acid and lipid-bound sialic acid levels against -methylcholanthrene and benzo(a)pyrene induced oxidative stress in rats s. ekin , g. oto, f. g€ ok, y. karakus, d. yildiz y€ uz€ unc€ u yil university, van, turkey the present study was performed to investigate total sialic acid (tsa) and lipid bound sialic acid (lsa) levels as possible in vivo chemoprotective effect of borax (bx) and boric acid (ba) again-st -methylcholanthrene ( -mc) and benzo(a)pyrene (b(a)p) induced oxidative stress in rats. the rats were divided into nine groups of six rats each. group i: control, untreated animals were given % . nacl, group ii: the b(a)p were administered mg/kg via ip. four times. group iii: the -mc-treated animals were administered mg/kg via ip. four times, group iv: ba was given mg/l/day with water. group v: bx was given mg/l/day with water. group vi: b(a)p mg/kg via ip four times + ba mg/l/day dosage with water. group vii: -mc mg/kg via ip four times + ba mg/l/day with water. group viii: b(a)p mg/kg via ip four times + bx mg/l/ day dosage with water. group ix: -mc mg/kg via ip four times + bx mg/l/day with water. the experimental period was continued for days. statistical analysis showed that the -mc + ba group was significantly higher than the control group with regards to tsa and lsa levels p < . , p < . ,p p- . . - effects of aluminum exposure on trace elements in rat tissues b. ozturk kurt, s. ozdemir department of biophysics, cerrahpasa medical faculty, istanbul university, istanbul, turkey aluminum (al) is the most abundant metal and the third most abundant element in the earth's crust. people are constantly exposed to al which is found in most rocks, soils, waters, air and foods, due to a result of an increase in industrialization and improving technology practices. the study was designed to examine the possible effects of aluminum exposure in different durations on trace elements in rat tissues. twenty-four healthy male wistar rats weighed - g were randomly divided into three groups: control group (gc) received only drinking water, short-term group (gs) and long-term group (gl). the study groups were orally exposed to mg/kg body weight alcl in drinking water for and weeks, respectively. at the end of the treatment period, rats were sacrificed and the kidney, liver, brain and cerebellum tissues were removed to analyse the levels of al, ar, b, ni, si, cr, cu, fe, mg, mn, se, cu and zn by icp-oes. the statistically significant increase were determined in cerebellum al, cu, as, b and cr levels in gl according to the gc. while as levels were statistically increased, ni levels were decreased in gl in the kidney and liver. while cu, mg and cr levels were higher, se and b levels were lower in the gs than gc in the brain. there were no significant difference in si and mn levels. as a result of our study, it may be concluded that al accumulation may lead to changes in tissue trace element levels. tacal, o., tacal, Ö., take, g., takic, m.m., taldykbayev, z., talim, b., tamashevski, a., tamer, f., tamer, l., , , taneva, s., taniyan, g., , tanrisev, m., tanriverdi, e.c., tanriverdi, k., tarhan, m., tarhan, t., tartar, s., tas, a., , taskin, a., taskin, t., taskiran, e., taskiran, b., taskoparan, b., taspinar, r., , tastan, Ö., tatli, Ö., tauraite, d., tay, t., tayman, c., taysi, s., , teker, h.t., tekes, s., tekin neijman, s., tekin, m.h., , tekin, g., , tekin, m., tekin, n., tekin, g., telci, d., , telefoncu, a., temel, h.e., , , temelie, m., temizgül, r., temlyakova, e., teplova, v., terashima, r., tercan avci, s., terekhov, s., tereshenko, o., terzi gulel, g., terzi, e., , terzi, e., terzioglu, g., terzioglu, o., testoni, g., tetik vardarli, a., tevdoradze, t., tevzadze, l., tezcan, Ö., tezcanli kaymaz, b., thielens, n., thomaidou, d., thomas, a., thornton, j.d., ticea, a.c., tikhonova, a., tileva, m., , timofeev, v., , timofeev, v., timofeeva, e., tipirdamaz, r., tiryaki, m., , tok, m., tokay, e., toker, a., , tokgun, o., toksoy Öner, e., tokyol, Ç., toman, r., tomasi, a., tombul, n., , tooke, c., topaloglu, h., topbas, m., topcu, b., topcu, c., topcu, g., , , topçu, v., topcu, c., topçuoglu, c., , topel, h., , toprak, b., toprak, m.s., torac, e., tosner, z., tosun, m., , toy, h., toymentseva, a., tozkoparan, b., trabulus, d.c., trantirek, l., trantirkova, s., trchounian, a., , trizna, e., , troshagina, d., tro t, m., truncaite, l., , tsakalidou, e., tsarkov, d., tsarkova, m., , tsigara, e.g., tsigara, m.g., tsverava, l., tsvetkova, e., tsyba, l., tsyganov, d., tsymbal, d., tüfekçi, a.r., , tufekci, a.r., tufenkci, h., tuglu, m.i., , tuglu, i., tuli, a., , , , tuli, a., tulubas, f., tunali, g., tunca gedik, s., , tunca gedik, s., tunçdemir, m., tuncel, h., tuncel, h., tunçer, s., tuncer, e., , tuncer, z.s., tuncer, b., tuncer, e., tuncez akyurek, f., tunçez akyürek, f., tuner, h., tüney kizilkaya, i., tural, b., tural, s., turan, i., turan, m., , turan, v., turan, y., turan, c., turano, p., , türel, s., , turhan, t., , turhan, y., , turk, s., turkan, a., türkcan kayhan, c., turkekul, k., türkel, s., turkeri, o.n., turkeri, n., turkkan, b., turkmen, s., türkmen, n., turkon, h., tutar, y., tüten, a., tutkun, e., , tüylü küçükkilinç, t., tuz, m.u., twardovska, m., tyapkina, o., tzartos, s., photoprotective activity of vulpinic and gyrophoric acids towards ultraviolet b-induced damage in human keratinocytes evaluation of the sunscreen lichen substances usnic acid and atranorin pleiotropic anticancer activity of selected nutraceuticals against mcf- bucharest, national institute for marine research and development "grigore-antipa uk in some adult and elderly populations the acute and/or persistent infection with the common intracellular respiratory pathogen chlamydia pneumoniae (chl) may be associated with increased risk of developing obesity or cardiovascular disorders. thus, microelements modifying oxidative stress status were determined by icp-ms/ms in the hno diluted serum samples collected from chl-positive adult females (n = ) living in urbanized area in poland. chl infection was confirmed by igg+ antibody elisa and real-time pcr assay. all females were classified under their body-mass index values to the normal-weight (nw), over-weight (ow) and obese group (ob) although there are many drugs currently used in the treatment of peptic ulcer, such a drug providing radical treatment without side effects is not available. since oxidative stress is involved in peptic ulceration, this study was designed to investigate antiulcerogenic and antioxidant effects of hippophae rhamnoides l. ether extract on indomethacine-induced stomach ulcer in rats. materials and methods: thirty-five sprague dawley male rats (weights ranging - g) were randomly divided into groups, as each composed of rats. after hippophae rhamnoides l. leaf ether extracts of mg/kg, mg/kg and mg/kg doses and mg/kg doses of famotidin orally administered, mg/kg doses of indomethacine were orally applied to rats in order to make ulcer. on the sixth hour of indomethacin administration all rats were sacrificed using thiopental ( mg/kg). the stomachs were removed, and ulcer areas were evaluated macroscopically. superoxide dismutase activity (sod), glutathione (gsh) and malondialdehyde (mda) levels in stomach tissues of rats were determined by elisa method with respective kits conclusions: we can conclude that the ether extract of hippophae rhamnoides l. leaves reduces free radical formation and has antiulcerogenic effects on stomach tissue control group; hours torsion/ hours detorsion group (t/d); all other groups were saturated for four days egcg, cape and egcg+cape ( lml/kg). sections were taken from bouine's-fixed and paraffin-embedded testicular tissue blocks and stained with h&e. immunohistochemistry was applied for the detection of pi k, akt and mtorc. intensities were evaluated as mild ( ), moderate ( ) or strong ( ). serum ohdg, plasma mda levels were analyzed using elisa method. results were analyzed by anova statistical test. testis samples in control group exhibited normal histological morphology. disorganization and separation of seminiferous tubule cells and accompanying interstitial edema and vessel dilation were while mda level decreased significantly in cape+egcg group, ohdg level showed significant increase in cape group. in conclusion, cape and egcg exerted protective effects on tt. effects may be achieved through pi k/ akt/mtorc pathway involved in cell proliferation, angiogenesis, apoptosis. prophylactic use of egcg prior to tt surgery improved testicular morphology, therefore could prevent destructive effects of tt lmol/l), c ( . ae . lmol/l)), respectively. conclusions: this study is important for konya region, mitochondrial fatty acid b-oxidation disorders studies subject areas. this study is the first study to assess acylcarnitine levels of patients living in our region. we believe that our results will be useful for future studies. key words: acylcarnitine, mass spectrometry, dried blood spot p- . . - binding of fas and cu(ii) ions to hsa changes its cys thiol group antioxidant capacity and carbonylation pattern with methylglyoxal binding of cu(ii) ion ( . mol/mol hsa) led to increase of k' value if fish oil extract was present, but for other fas k' value decreased. the content of free hsacys -sh decreased for % after cu(ii) ion binding, and during hours incubation at °c, it was further decreased for % (stearic acid, mixfas) and % (myristic, fish oil extract, oleic acid). carbonylation of fa-hsa-cu(ii) complexes with mg ( mol/ mol hsa), lead to decrease in cys -sh content depending on fa present: %- % for myristic and stearic acid, % for oleic acid and mixfas and % for fish oil extract. carbonylation of fa-hsa-cu complexes could contribute to further enhancement of oxidative and carbonyl stress in diabetes as well as other diseases pirto ek p- . . - anti-proliferative and inducing apoptosis of the hydro alcholic achelia. wilhelmsii extract on human breast adenocarcinoma cell lines mcf- and mda-mb- background: vitamin d deficiency is associated with several conditions and/or diseases like inflammation, atherosclerosis, cardiovascular disease and mortality. several studies showed that lower vitamin d levels were associated with high serum levels of inflammatory biomarkers. ykl- is a glycoprotein, secreted by macrophages, neutrophils and different cell types. it is also associated with inflammation and pathological tissue remodeling. in this study, we aimed to evaluate relationship between the vitamin d deficiency and ykl- levels. methods: our study group includes subjects with vitamin d deficiency (group ) and age and sex-matched healthy subjects with normal serum levels of vitamin d (group ). plasma (oh) vitamin d levels were measured with liquid chromatography-tandem mass spectrometry (lc-ms/ms) method. plasma ykl- analysis was performed by elisa. serum hs-crp levels were measured with nephelometric method. results: plasma vitamin d levels below ng/ml were accepted as vitamin d deficiency. although we could not find any significant differences by means of serum hs-crp levels between groups (p > . ), plasma ykl- levels were significantly higher in group than group (p < . ). conclusions: in literature, vitamin d deficiency is associated with inflammation. in our study, we found similar hs-crp levels between groups and higher ykl- levels in group . vitamin d deficiency may be related to increased ykl- levels in terms of causing chronic inflammation.keywords: vitamin d deficiency, ykl- , inflammation. evaluation and comparison of tnf-family ligands and receptors genes in mice and humans by bioinformatics techniques stance called plaque builds up inside the coronary arteries. apelin is a novel endogenous peptide with inotropic and vasodilatory properties and is the ligand for the angiotensin receptor-like (apj) receptor. we aimed to determine genotype and allele frequencies of apj receptor a c gene polymorphism in turkish patients with cad and healthy controls by rflp-pcr. this study was performed on unrelated cad patients and healthy controls. we obtained aa, ac and cc genotype frequencies in cad patients as . %, . % and . %, respectively. in the control group, frequencies of genotypes were found as . % for aa, . % for ac and . % for cc. we did not observe difference in apj receptor a c polymorphism between cad patients and healthy controls (v = . ; df = ; p = . ). the a allele was encountered in % ( ) of the cad and . % ( ) of the controls. the c allele was seen in % ( ) of the cad and . % ( ) of the controls. allele frequencies were not significantly different between groups (v = . ; df = ; p = . ). the frequencies of apj receptor a c genotype were not significantly different between control and patients. individuals with cc genotypes had significantly higher weight, systolic and diastolic blood pressure levels and systolic blood pressure than other genotypes, p ≤ . . in addition, hdl-c level was found decreased, but this reduction was not statistically significant. contrarily, the low levels of weight, sbp, dbp and tc were statistically significant in the subjects with aa genotype in cad. in conclusion, cc genotype carriers may have more risk than other genotypes in the development of hypertension in cad. we suggest that this polymorphism may not be a marker of cad, but it may cause useful in function of the apelin/apj system and may be a genetic predisposing factor for diagnostic processes and can be helpfull in finding new treatment strategies. p- . . - comparative genomics/proteomics analyses of single amino acid repeat containing proteins across different vertebrate taxa a. g. keskus, o. konu department of molecular biology and genetics, bilkent university, ankara, turkeyconsecutive runs of single amino acids lead to overrepresentation of certain physicochemical properties in protein sequences. researchers also demonstrated a link between single amino acid repeat (saar) containing proteins and neurodegenerative diseases as well as biological functions. moreover, saar frequencies were shown to vary across species based on selected orthologous proteomes and/or proteins. hence, analysis of whole proteomes across multiple vertebrate taxa may provide additional species-and sequence-specific trends for saars. in addition, there is a need for testing the observed saar occurrencesthe aim of this study is to evaluate the effect of quercetin (q) on liver injury secondary to cerulein induced-acute pancreatitis (ap). for this reason, rats were randomly divided into four groups ( rats for each group) control group received physiological saline, four time and dimethyl sulfoxide, two time, at hours intervals, intraperitoneally (i.p.). cerulein group received cerulein ( lg/ kg-rat weight, in physiological saline), four times, and dimethyl sulfoxide ( %), two times, at hour intervals, i.p. quercetin pretreatment (q+cer) group received quercetin ( mg/kg-rat weight, in dimethyl sulfoxide) one time, one hour before cerulein treatment and physiological saline, one time, six hour after cerulein treatment. quercetin post-treatment (cer+q) group received dimethyl sulfoxide, one time, one hour before cerulein treatment and quercetin, one time, six hour after cerulein treatment. cerulein treatment increased significantly vascular congestion in hepatic cells. quercetin treatment also decreased significantly vascular congestion. the liver mda and carbonyl levels in cerulein group were significantly higher than the control group (p < . , p < . , respectively). the mda and carbonyl levels in q+cer group decreased significantly compared to the cer group (p < . ). the mda, carbonyl, mpo levels in cer+q group were significantly lower than the cer group (p < . ). the gssg/gsh ratio of q+cer and cer+q groups were significantly lower than the cer group (p < . , p < . , respectively). the sod activity in cer group was significantly lower than the control group, but the sod activity in q+cer and cer+q groups was significantly higher than the cer group (p < . ).this study shows that quercetin treatment was reduced the severity of liver injury secondary to cerulein induced-ap as reflected by changes in the parameters of hepatic oxidant and antioxidant. p- . . - identification of water extract of propolis components by using different columns in gas chromatography-mass spectrometry propolis is a natural material obtained by honey bees from various plants. protective effect of propolis against damages of free radicals is due to different compounds within propolis. the aim of this study is to identify qualitatively and quantitatively the chemical composition of water extract of propolis (wep) provided by erzurum region using rtx- and rtx- ms column of gas chromatography-mass spectrometry (gc-ms) and to compare with two columns.in this study, wep of mg/ml was prepared, cleared by membrane filter of . lm and freezed at À °c. then, it was lyophilized up to dry form and derivatized to apply for gaseous form. mg of dry extract was reacted with ll pyridin + ll bis-trimethylsilyl trifluoroacetamide (bstfa) mixture including % trimethylchlorosilane (tmcs) and incubated for minutes at °c. all analyses were performed with shimadzu gcms-qp ultra by using a flame ionisation detector (fid). rtx- and rtx- ms capillary columns and helium for carrier gas at a flow time of ml/minute were used. injection was applied on split mode at °c. derivatized propolis sample was injected as ll, initial column temperature was adjusted as °c, then increased to °c with increments of °c. total analysis time was determined as minutes. relative percent amount of separated compounds was calculated from total ion chromatogram with computerised integrator. all components were defined by using nist and wiley libraries.peaks obtained from rtx- column were much more than those of rtx- ms. on the other hand, analyses performing with both two columns have similar carbohydrate, aromatic acid and other acid contents.consequently chemical constituents of wep were determined qualitatively and quantitatively with gc-ms. it was concluded that rtx- column among both columns differentiating for polarities may produce more compounds in the propolis analysis. introduction: aquatic environment can be mostly contaminated by mixtures of metals. biochemical parameters have gain importance to characterize the effects of metals on aquatic organisms. glutathione s-transferase (gst) and its substrate glutathione (gsh) are important parameters of antioxidant defense system of fish metabolism due to their vital role in xenobiotic conjugation. objective: the goal of the current study to evaluate the changes in gst and gsh levels in response to cd, zn and cd+zn effects after and exposure days. materials and methods: fish were obtained from cukurova university fish culturing pools (turkey). fish were exposed to . lg/ml of cd (cdcl .h o) and zn (zncl ), and their mixture, for , and days. at the end of the exposure period, liver tissues were dissected and homogenized in a phosphate buffer (ph . ). homogenates were centrifuged at , g ( min, + °c). supernatants were stored at À °c until the analysis. one-way anova was used to compare data (mean ae se) followed by duncan's test (p < . ). results: gst and gsh changes were recorded as decreases after all metal exposures at day . although day exposure was found as less effective, combined effects caused significant decreases in gst and gsh levels. also longer exposure durations were appeared to be more effective in that situation. conclusions: significant decreases in gst and gsh levels could be occurred due to increased reactive oxygen species caused by metals particularly their combined effects. metal type, their single and combined effects and also exposure duration should be also taken into account when considering the antioxidant system response. gst and gsh might be considered as sensitive biomarker in toxicity assessment of metal mixtures.financial support: this study was supported by a grant from c ß ukurova university (turkey).background/aims: the activation of lectin-like oxidized low density lipoprotein receptor- (lox- ) on endothelial cells leads to intracellular oxidative stress and inflammation and a feed-forward cycle of injury in diabetes, since both oxidized low density lipoprotein (oxldls) and glucose increase lox- expression. quercetin (qr) is part of a subclass of flavonoids called flavonols. polyphenolic compounds affect the development of atherosclerosis not only through antioxidant properties but also by modulation of serum lipids, thereby influencing the immune and inflammatory processes associated with the development of atherogenic diseases. we investigated the effects of dietary qr on endothelial dysfunction mediated by oxidized low density lipoprotein (oxldl)/lectin-like oxidized low density lipoprotein receptor- (lox- ) in animal model of type diabetes mellitus. methods: we compared groups of male adult wistar albino rats: a control group, an untreated diabetic group, diabetic groups treated with qr, and qr group. diabetes was induced by a single injection of stz ( mg/kg). animals were kept in standard condition. in day after inducing diabetic, serum was collected for biochemical parameters. glucose, lipid profiles, microalbuminuria, oxldl and lox- levels were determined. results: serum triglyceride, ldl, vldl levels in diabetic control group (without treatment) was significantly higher than control group (normoglycemic untreated group). supplementation with quercetin decreased serum total cholesterol and increased hdl-cholesterol compared with the control group. serum oxldl and lox- levels in diabetic control group (without treatment) were significantly higher than control group (normoglycemic untreated group). conclusions: consumption of quercetin reduced oxldl and lox- levels. thus, quercetin could be effective in improving hyperglycemia, dyslipidemia, and endothelial damage in type diabetes. p- . . - investigation of some oxidative stress parameters in bdnf heterozygous mice liver tissue a. bodur , i. ince , i. abidin , a. alver objectives: the aim of this study was to evaluate the possible protective effects of nigella sativa (ns) against cholestatic oxidative stress and liver damage in the common bile duct ligated rats. methods: a total of male wistar albino rats were divided into three groups:sham control, bile duct ligation (bdl) and bdl+received ns; each group contain animals. the rats in ns treated groups were given ns ( . ml/kg) once a day orally for weeks starting days prior to bdl operation. results: the changes demonstrating the bile duct proliferation and fibrosis in expanded portal tracts include the extension of proliferated bile ducts into lobules, mononuclear cells, and neutrophil infiltration into the widened portal areas were observed in bdl group. treatment of bdl with ns attenuated alterations in liver histology. the alpha smooth muscle actin (a-sma), transforming growth factor beta (tgf-b ) and the activity of tunel in the bdl were observed to be reduced with the ns treatment. bdl significantly increased the tissue hydroxyproline (hp) content, malondialdehyde (mda) levels, and decreased the antioxidant enzyme (superoxide dismutase (sod) and glutathione peroxidase (gpx)) activities. ns treatment significantly decreased the elevated tissue hp content and mda levels and prevented the inhibition of sod and gpx enzymes in the tissues. conclusion: the data indicate that ns attenuates bdl-induced cholestatic liver injury, bile duct proliferation, fibrosis, apoptosis and oxidative stress. the hepatoprotective effect of ns is associated with antioxidative potential. organophosphorous compounds (ops) are used widely as pesticides for agricultural purposes, as oil additives or as flame retardants. however, due to their widespread use, there are major introduction: in this study, the antiulcerogenic effect of a water extract (cawe) obtained from a spices sample, cinnamomum aromaticum, was investigated using indomethacin-induced ulcer models in rats. materials and methods: experimental groups consisted of six rats. antiulcerogenic activities of , , and mg/kg body wt. doses of the cawe were determined by comparing the negative (treated only with indomethacin) and positive (famotidine) control groups. results and discussion: although all doses of the cawe showed significant antiulcerogenic activity as compared to negative control groups, the highest activity was observed with mg/kg body wt. doses ( %). the cawe showed similarly antioxidant activity when compared with trolox and ascorbic acids used as positive antioxidants. in addition, the activities of catalase (cat) and myeloperoxidase (mpo) enzymes were determined in the stomach tissues of rats and compared with those of the negative and positive control groups to expose the effects of these enzymes on antiulcerogenic activity. the enzymatic activities of cat and mpo and lipid peroxidation (lpo) level in indomethacin-administrated tissues were increased significantly by indomethacin in comparison to control groups. these enzymes and lpo level were decreased, however, by the cawe. in contrast to lpo level, cat and mpo activities, glutathione (gsh) level was decreased by indomethacin and increased by all doses of cawe and famotidine. the present results indicate that the cawe has a protective effect in indomethacin-induced ulcers, which can be attributed to its antioxidant potential. introduction: thiol groups (-sh) are important anti-oxidants and essential molecules protecting organism against the harmful effects of oxidative stress. the aim of our study is to evalute thiol-disulphide homeostasis with a novel and automated method in patients with prostate cancer (pc) before and after radical prostatectomy (rp). material and methods: patients with prostate cancer and healty control subjects were enrolled into the study. plasma samples were collected from patients before rp and months after the rp operation. thiol-disulphide homeostasis was determined with a recently developed novel method. prostate specific antigen, albumin, total thiol, native thiol, disulphide and total antioxidant status (tas) were evaulated and compared between the groups. results: native thiol levels were . ae . lmol/l in the control group, . ae . lmol/l in the patients before rp, and . ae . lmol/l in patients after rp. native thiol, total thiol and tas levels were significantly higher in the control group than the patients before rp (p values < . ). native thiol, total thiol and tas levels were higher months after rp compared to before rp in patients, but these changes were not significant statictically (p values . , . and . respectively). discussion and conclusion: our study demonstrated that antioxidant defense mechanism was weakened as indicated by the decreased thiol levels in the patients with pc. increased oxidative stress in prostate cancer patients may cause metabolic disturbance and have a role in the pathogenesis of prostate cancer. p- . . - is there any relation between g oral glucose challenge test and serum total oxidant-antioxidant status in pregnant woman? the purpose of this study was to test the hypothesis that any degree of antepartum screening for gestational diabetes mellitus with oral g glucose challenge test (gct) should be associated with oxidant-antioxidant status.in this prospectif study, oral glucose challenge test was applied to pregnant women aged - years and at - weeks of gestation. plasma glucose concentrations were measured initial, hour and in addition to test hours after ingestion of g glucose. at the same time serum insulin, cortisol, total antioxidant status (tas), total oxidant status (tos) levels were measured and the oxidative stress index (osi) was calculated.ten pregnant women (forty percent) had a positive glucose challenge test (gct). a positive moderate relation with initial and hour serum total antioxidant status (tas) levels (r = . ) and the oxidative stress index (osi) (r = . ) was found. there was a positive weak correlation with initial and hours total oxidant status (tos) levels (r = . ) but statistically significance difference was not found (p > . ).in this study after ingestion of g glucose serum total antioxidant status (tas), serum oxidant status levels (tos) and serum oxidative stress index (osi) levels were higher than the initial levels.the results of this study suggest that antepartum screening for gestational diabetes mellitus with g oral glucose challenge test (gct) weakly associated with oxidant-antioxidant status and to confirm this results the longer follow-up studies with more participants are necessary.wheat (triticum ssp.), cultivated for centuries in the middle-east, central asia, europe, and north-africa, is one leading staple crops around the world, and its marginally grown ancestor einkorn (triticum monococcum ssp. monococcum), possesses rich gene resources for wheat improvement and have bioactive compounds reducing and preventing chronic diseases such as diabetes, cancer, alzheimer, and cardio vascular diseases, beside their nutritional properties. however, as more attention has been given to wheat cultivars with strong gluten, protein content, starch composition, and resistance to biotic and abiotic stresses in bread wheat and yellow-colored pasta product in durum wheat health compounds such as fibers, phytochemicals, and bioactives have been underestimated so far. the aim of this study was, then, to examine the total phenolics and flavonoids, quantify their phenolic acids, a-tocopherol by high performance liquid chromatography (hplc), and their , -diphenyl- -picrylhydrazyl (dpph) scavenging activity of bread (triticum aestivum l.), durum (triticum turgidum ssp. durum desf.) wheat cultivars and einkorn (triticum monococcum ssp. monococcum) wheat populations collected from different provinces (bolu and kastamonu) of turkey. ferulic acid ( . - . -lg/g), p-coumaric ( . - . -lg/g), and total phenolic content (ranged . - . -lmol gae/g) of einkorn populations were significantly higher than bread and durum wheat cultivars. results suggested the possibility of production of einkorn wheat populations, and hopefully cultivars rich in particular health beneficial component(s) may provide benefit to the consumers. in addition, higher phenolic content of einkorn may offer novel wheat genetic resources for the improvement of new wheat cultivars and the development of wheat-based functional foods. oxidative damage due to ischemia and acute kidney injury (aki) after coronary artery bypass graft (cabg) surgery are the leading complication during this process. in the kidney, ischemia/ reperfusion injury contributes to aki that is a clinical syndrome with rapid kidney dysfunction and high mortality rates. some animal and clinical studies have demonstrated an increase in serum and urinary neutrophil gelatinase-associated lipocalin (ngal) expression after renal ischemic injury.in this study, our aim was to investigate the relationship betwwen ngal and oxidative stress parameters due to ischemia caused by total perfusion time (tpt) in patients who have undergone on-pump cabg. materials and methods: the study was conducted in patients who received on-pump cabg at university of istanbul, cerrahpasa medical faculty, department of cardiovascular surgery. blood samples were collected prior to surgery and after hours following the termination of cardiac pulmonary bypass (cpb) . following centrifugation, serum samples were separeted and stored at - c until analysis. serum ngal, ima (ischemia modified alb€ umin), pco (protein carbonyl), nt (nitrotyrosine), lpd (lipid peroxide) levels were determined by elisa procedure. results and discussion: serum ngal, pco, nt levels in after hours following cpb were significantly higher than the before surgery (p < . , p < . , p serum ngal levels in after hours following cpb was found to have positive correlation with ima, pco, nt, and lpo levels (r = . , p < . ; r = . , p < . ; r = . , p < . ; r = . , p < . respectively). ngal levels were positively correlated with total perfusion time after cbp (r = . , p < . ).the results of our study show that, increased ngal levels hours after cpb were positively correlated with oxidative stress parameters and total perfusion time. investigation of the effects of thymoquinone against indomethacine induced gastric damage in rats introduction: incidence and high cost of acute stomach mucosa damages make this issue a very interesting issue for study. for this reason, it is aimed to investigate the effects of different dosage of thymoquinone (tq) against indomethacine induced gastric damage in rats. material and method: in our study, six groups of wistrar male rats were used. groups are named as healthy, ind control, famotidine ( mg/kg) and three different doses of tq ( . , and mg/kg). while any treatment or drug administration will done on healthy group, model was generated to other groups by giving fam or tq with tap water via oral gavage. min later, mg/kg ind administrated to each rat. animals were sacrified about hour later and stomach samples of each groups were collected for macroscopic study and gsh levels measurements. results: lower doses of tq is more effective and all tq groups exhibit reduced ulcer region with respect to the ind control group. gsh level of ind control group is lower than healthy group. the gsh level of tq, especially in lower doses, and fam groups statistically exhibit an increase in gsh level. conclusion: it is observed that ind induced gastric damage cause ulcer and increase in free radical. it is determined that lower doses of tq ( . , and mg/kg) is also exhibit a protective effect on ind induced model. it is tought that quinone in tq structure have a strong redox feature and this feature clean up the free radicals caused by ind, it reduces the oxidative stress and protect the stomach from ulcer. anzer honey is the most famous honey in turkey with many endemic species flowers. the anzer plateau is located rize province of eastern black sea region. in this study, antioxidant and anti-hyaluronidase and anti-urease activities were investigated of the plateau bee pollen. the antioxidant capacity was determined by total phenolic content (tpc), total flavonoids contents (tfc), ferric reducing antioxidant power (frap) and , diphenyl- -picrylhydrazyl (dpph) radical scavenging activity. atherosclerosis is the leading cause of mortality worldwide, and as a chronic inflammatory disease, caused by a complex interplay between inflammatory and oxidative events.quercetin, a plant derived flavonoid and a well-known antioxidant, has shown great promises with regards to its protective effects against oxidative stress.however due to its physicochemical properties, the optimum pharmacokinetic behavior is a challenging issue.herein, we aimed to fabricate quercetin loaded solid lipid nanoparticle (quer-sln) to improve the bioavailability and therapeutics efficiency. furthermore the in-vitro capacity of quer-sln for ameliorating tnf-a induced oxidative stress in human endothelial vein cell (huvec) was evaluated. quer-slns were prepared by simple hot homogenizing method and characterized by means of drug loading (dl), encapsulation efficiency (ee), cytotoxicity, size, zeta potential and morphology. antioxidant activity of plain quercetin and quer-slns were then investigated using intracellular reactive oxygen species (ros) detection method (dcfh-da assay) by facs flowcytometryin conclusion, the results here showed superior control of oxidative stress by quercetin nanosystem as compared to plain quercetin. precirol based slns as a biocompatible/biodegradable lipid, may provide a novel drug delivery system for quercetin with improved beneficiary impact in atherosclerosis. objective: zinc is known as an antioxidant essential trace element. we aimed to evaluate the dose-dependent effects of zinc on the oxidant-antioxidant system in liver, kidney and brain tissues of rats and the histological alterations in the absence of oxidative stress (os). material and methods: thirty-nine female weighing about gr wistar albino rats were divided into four experimental groups as ad libitum (al) diet (control), al diet + mg/kg zn sulfate (low dose; group ), al diet + mg/kg zn sulfate (middle dose; group ) and al diet + mg/kg zn sulfate (high dose; group ). zn sulfate solutions were administered . ml/day orally for days and in day rats were sacrificed and tissues were excised for detecting malondialdehyde (mda), advanced oxidation protein products (aopp), superoxide dismutase (sod), glutathione peroxidase (gsh-px), glutathione reductase (gr), and glutathione-s-transferase (gst) activities. histological evaluation was also performed to confirm the effects of zinc. results: in liver tissues aopp levels decreased in all groups receiving zinc as compared to the control group. liver mda levels were increased in group and ; sod and gsh-px levels were both increased while gst levels were decreased in all groups compared to control. gr levels were increased only in group . in kidney; aopp level was decreased only in group and sod level was only decreased in group as compared to control while gr levels were increased in all doses of zinc. in brain; aopp, gsh-px and gr levels were decreased in all groups receiving zinc as compared to control group. sod activity in brain tissues was increased by the administration of middle dose of zinc (group ). gst level was decreased in only group conclusions: the biochemical and histological findings of this study suggest that zinc has various effects on liver, kidney and brain tissues in the absence of os.key words: zinc, liver, kidney, brain introduction: this study aimed to investigate the effect of diabetes mellitus (dm) on oxidative stress and antioxidant capacity in humour aqueous (ha) and venous serum using total antioxidant capacity (tac) and total oxidative stress (tos) levels in serum and ha in cataract patients. materials and methods: in this study patients were divided into two groups. group was composed of patients with type dm and cataract and group was composed of patients with cataracts who are not accompanied by dm and cataract patients who are not accompanied by systemic diseases. each group consisted of patients, totally patients were included in the study. the ha which was collected from the eyes at the beginning of the cataract surgery and venous blood serum collected from the same patients were analyzed. in both groups, ha and serum tac and tos levels were measured with elisa. results: : serum tac levels in the dm group were significantly lower than in the control group (p < . ). tos serum levels in dm group was statistically higher than the control group (p < . ). differences between tac and tos levels were not statistically significant when compared the two groups' ha results (p > . ). group , divided into two subgroups according to their hba c levels, there was no statistically significant difference between the subgroups when hba c levels were compared with the relationship between serum and ha's tac and tos levels (p > . ). there was not an association between the gender, age and the levels of tac-tos in both groups (p > . ). discussion and conclusion: presences of dm is the only risk factor for increase of oxidative stress and decrease of anti-oxidant capacity in patients without a systemic complication of dm and diabetic retinopathy. in our study, diabetic patients without retinopathy showed similar ha tos and tac levels to healthy individuals, this finding indicates that blood-aqueous barrier is protected in these patients. the effect of ferulic acid against testicular ischemia/reperfusion injury in rats u. sac ßik , g. erbil , z. c ß avdar , c. ural department of histology and embriyology, school of medicine, dokuz eyl€ ul university, izmir, department of molecular medicine, health science of institute, dokuz eyl€ ul university, izmir, turkeytestis torsion is one of the urologic emergencies occurring frequently in neonatal and adolescent period. testis is sensitive to ischemia/reperfusion (i/r) injury and, therefore, ischemia and consecutive reperfusion cause an enhanced formation of reactive oxygen species (ros) that result in testicular cell damage and apoptosis. ferulic acid, known as an antioxsidant, is a phenolic acid found in seeds and leaves of the plants. we aimed to investigate potential protective effect of ferulic acid against testis i/r injury.thirty five wistar rats were randomly divided into groups; control, ethyl alcohol, ischemia, i/r, i/r-ferulic acid groups. animals were exposed to hours of ischemia followed by hours of reperfusion. ferulic acid was administered ( mg/ kg) before reperfusion intravenously. testicular cell damage was examined by h-e staining and pas. tunnel, active caspase- , inos and mpo were evaluated by immunostaining. malondialdehyde (mda), glutathione (gsh) levels, glutathione peroxidase (gpx) and superoxide dismutase (sod) activities were assessed by biochemical methods.histological evaluation showed that ferulic acid pretreatment reduced significantly testicular cell damage and decreased tun-nel, caspase positive cells; inos and also mpo expression. in addition, ferulic acid administration decreased significantly the mda levels increased by i/r. morever, ferulic acid increased significantly the sod activity levels, which was decreased by i/r. there were no statistically significant differences in the levels of gsh and gpx activity in all groups.the present results suggest that ferulic acid is a potentially beneficial agent in protecting testicular i/r. background: in heart failure (hf), angiotensin antagonists (aa), beta-blockers (bb), spironolactone, diuretics and acetylsalicylic acid are often used. top pharmaceutical groups reduce mortality. on the increased oxidative stress (os) in patients with hf, it is known to have beneficial effects of certain groups of drugs. however, the net effect of these drugs in os is unknown. the aim of this study was to investigate the effects of drugs used in hf on os. materials and methods: patients were included in the study. all of the patients had systolic heart failure and all of them were under treatment. drugs used by the patients were recorded. the levels of total antioxidant status (tos), total oxidant status (tas), the enzymatic activity of ceruloplasmin, paraoxonase- and arylestherase were measured according to erel's method. serum total thiol levels were measured with sh modified hu method and the lipid hydroperoxide levels were measured with the ferrous ion oxidation xylenol orange assay. the percentage tos / tas was determined as osi. results: in patients treated with acetylsalicylic acid (asa), spironolactone, beta blocker and furosemide, there were increased tos, decreased tas and osi (p < . ). in patients treated with angiotensin blockers, increased tas and looh, and decreased sh were found (p < . ). in patients treated with nitrates and ccb, tos and osi were found decreased. correlation analysis showed that increased tas correlated with the use of angiotensin blockers, asa, furosemide and beta blocker positively; and with the tos and osi level correlated with the use of spironolactone, asa spironolactone and furosemide (p < . ). conclusion: current medical agents that are being used in hf are effective in reducing os in hf patients. one of the effective mechanisms to reduce the mortality of some of these drugs may decrease os.key words: heart failure, drug use, oxidative stress p- . . - across adjacent ring formed titanium phthalocyanine-mediated photodynamic therapy alters and degrades filamentous actin cytoskeleton and internal membranes photodynamic therapy (pdt) is widely accepted as a promising and minimally invasive treatment strategy due to its applicability on a wide range of cancer diseases. this clinically approved treatment method relies on the dramatic production of singlet oxygen and reactive oxygen species (ros) in target tissue to evoke apoptotic cell death [ ] . we, therefore, focused on the intracellular ros accumulation, internal membrane degradation, filamentous actin cytoskeleton alteration and nucleus morphology changes induced by pdt-mediated across adjacent ring formed titanium phthalocyanine which was previously synthesized bis(ethane- , p-phenol- , -p-phenoxy) phthalocyaninatotitanium (iv).characterization of the synthesized metallophthalocyanine was accomplished by using uv-vis, ir, h-nmr and maldi-tofmass spectroscopies. the dark and pdt-mediated activities of bare and phosphonolipids (max. %) charged titanium phthalocyanine ( . , . , . , and lm) were determined on a human lung carcinoma and hacat human keratinocyte cell lines by using intracellular ros assay, dioc( ), tritc-phalloidin and dapi staining protocols. waltmann pdt l was used as the non-toxic light source at j/cm fluence and mw/ cm fluence rate. the experiments showed that pdt-mediated titanium phthalocyanine leads to significant and concentration dependent reactive oxygen species accumulation. moreover, internal membrane degradation, apoptotic bodies on nucleus and filamentous actin cytoskeleton alteration were observed. consequently, the activity mechanism of pdt-mediated titanium phthalocyanine seems to be in a tight relationship with ros accumulation-mediated internal membrane degradation, filamentous actin cytoskeleton alteration and apoptotic pathways activation. introduction: retinal vein occlusion (rvo) is a common retinal vascular disorder that can affect visual acuity and cause blindness in elder population. sulphur containing aminoacids such as cysteine (cys), cysteinylglycine, glutathione, homocysteine and c-glutamylcysteine are reported to be associated with the pathogenesis of rvo. thiols are organosulfur compounds that are formed of a carbon-bonded sulfhydryl group. sulphur containing aminoacids slightly contribute the composition of plasma thiol pool. thiols can undergo oxidation reaction via oxidants and form disulphide bonds our purpose is to research the relationship between a novel oxidative stress marker serum dynamic thioldisulphide homeostasis and retinal vein occlusion. materials and methods: rvo patients and controls were included in the study. native thiol, total thiol, disulphide levels are measured in the serum samples of rvo and control group by using an automated method described by erel et al. also disulphide/native thiol and disulphide/total thiol ratios were calculated. results: there were no significant difference between the rvo and control group in native thiol, total thiol, disulphide disulphide/native thiol and disulphide/total thiol ratios.(p > . for all) conclusion: our study is the first report evaluating the dynamic thiol-disulphide homeostasis in rvo patients by a newly developed method by erel et al. further large sample sized studies investigating the levels of sulphur containing aminoacids may additionally be planned to verify this study. purpose: the purpose of this study was to evaluate markers of systemic oxidative stress and antioxidant capacity in subjects with severity of osas. methods: a total of osa patients were included in the study ( controls, with mild, with moderate, and with severe osa). patients were grouped according to apnea-hypopnea index (ahi) as mild, moderate and severe osa. patients with ahi< served as control group. known risk factors for oxidative stress, such as age, sex, obesity, smoking, hypelipidemia, and hypertension, were investigated as possible confounding factors. plasma arylesterase, total oxidative stress (tos), total antioxidant capacity (tac), total thiol, catalase (cat) levels were measured for all patients. results: the mean age was . ae . years and . % ( / ) of the study population was female. plasma arylesterase, tos, tac, total thiol, and cat plasma values were not different between mild, moderate, severe osa groups and controls (p > . ). catalase levels were significantly lower in women patients with severe osa compared to healthy women controls (p < . ). there was a negative correlation between ahi and serum total thiol levels (r = À . , p < . ) in severe osa groups. conclusionthe present prospective study provides evidence that osa might be associated with decreased antioxidant burden possibly via catalase way. results: the sera -ohdg, mda and il- were significantly higher in diabetic group than control group (p < . ). although there was a notable positive correlation between mda and -ohdg, there was no a relationship between -ohdg or mda with il- . discussion: in agreement with previous studies our data illustrated that high levels of oxidative stress is associated with increased production of oxidized lipids and nucleobases in diabetic patients compared to control group. also enhanced proinflammatory cytokine, il- , induced inflammmation in these patients.conclusion: oxidative stress and inflammation play pivotal roles in the development of diabetes and can cause major complications in dm. so we suggest that early detection of these measurable indicatores can help to diagnosis the severity or presence of some complication in diabet. the effect of quercetin on erythrocyte glucose- -phosphate dehydrogenase enzyme activity in ethanol treated rats in this study, we aimed to evaluate the effects of ethanol on erythrocyte (g- -p-d) enzyme activity and the effects of quercetin on erythrocyte g- -p-d activity in the recovery of the effects of ethanol.rats were randomly divided into four groups. the control group (n = ) received physiological saline. the quercetin group (n = ) received quercetin ( mg/kg/ day) via i.g. route the alcohol group (n = ) received ethanol ( % v/v, ml/day) via i.g. route. the alcohol + quercetin group (n = ) received ml of ethanol ( % v/v) hours after quercetin treatment ( mg/ kg/day). experimental procedures were peformed for days. erythrocyte g- -p-d activity was found to be higher in the quercetin group than those in the alcohol group (p < . ). in the alcohol group, the erythrocyte g- -p-d activity was found to be significantly decreased than those in the control group (p < . ). statistically significant differences were observed in erythrocyte g- -p-d activity between the alcohol group and the alcohol + quercetin group (p < . ).as a conclusion, our results demonstrate that ethanol decreased erythrocyte g pd activity and quercetin was found to be beneficial in the prevention of toxic effect raised by ethanol.key words: erythrocyte, ethanol, g pd, oxidative stress, quercetin p- . . - effects of the sulphasalazine to the cerebral hypoxia reperfusion injury in rat background: cerebral ischemia/ reperfusion (i/r) injury is still a difficult process to treat and rehabilitate today. this study was designed to investigate beneficial effects of sulfasalazine in cerebral i/r injury in rat. methods: except control group (n = ), wistar albino rats were divided into four groups for acute and chronic stage investigation of i/r injury, and temporary aneurysm clips were attempted to both internal carotid arteries for duration of minutes. four hours later, except control, sham-a, sham-c groups, mg/kg once a day sulfasalazine was administered to animals, orally. animals were sacrified and then necrotic neuronal cells of hippocampal ca , ca , and ca region, and cortical necrotic neurons, perivascular edema, pyknotic neuronal cells, irregularities of intercellular organization (iio) were counted and scaled histopathologically. tissue il- b, il- , malonyldialdehyde (mda), myeloperoxidation (mpo), no, and tnf-a levels were measured by using elisa, too. results: sulfasalazine could reduce perivascular edema, iio, cortical and hippocampal neuronal cell death in both stages. it could decreased mda in acute stage, but not reduce il- b, il- , mpo, no, and tnfa levels. it could increased il- b levels in chronic stage but not affect to il- , mpo, mda, no, tnf-a levels.conclusion: sulfasalazine could improve histopathological architecture of hypoxic tissue in both stages of i/r injury. it could inhibit lipid peroxidation cascades in acute stage but not affect to tissue mpo, no, il- , and tnf-a levels in any stage in rat. these results suggested that therapeutic mechanisms of sulfasalazine should be investigated by using more specific laboratory methods in future studies.key words: antiinflamatory, cerebral hypoxia reperfusion injury, sulfasalazine, stroke. camel and horse milk xanthine oxidase (xo) was found to catalyze the reduction of nitrate and nitrite to nitric oxide (no) under aerobic condition. to date, mammalian nitrate reductase (nar) and nitrite reductase (nir) have not been identified. no, a gas, is found to control a seemingly, limitless range of functions in animals.one assay was used to determine nar and nir activities of milk xo: ( ) nitrite formation from nitrate by nar, and ( ) nitrite utilization by nir. nitrite concentrations were determined by using sulfanylamide and n-( -naphtyl)-ethylenediamine, which form red color measured at nm.these activities of the milk xo require nadh as a physiological electron donor. high xo, nar and nir activities are detected only after heat treatment ( °c, min) of the fresh milk in the presence of molybdate. in both camel and horse milk nar activity of xo was almost two times higher than its nir activity. it is well known that xo can be reversibly converted from the dehydrogenase form to the oxidase through the oxidation of sulfhydryl groups. cysteine and, to a lesser extent, glutathione increased nir activity of milk xo but not its nar activity. the mechanism of this increase of nir activity remains unclear and is currently under study. substitution of tungsten for molybdenum under above conditions gave no detectable nar and nir activity of milk xo. the molybdenum site-directed inhibitor, tungsten inhibited in a dose-dependent manner. therefore, nitrate and nitrite are clear to interact with mo center of xo.camel and horse milk are traditional drinks in central asia and kazakhstan. therefore, it is very important that xo provide a mechanism for generation of no in camel and horse milk where nitric oxide synthase, no producing enzyme, does not exist. p- . . - the influence of phytomedicine on metabolic processes of white rats undergone to ionized radiation the study of peroxide lipids oxidation (plo) process is used as one of stability parameters of organism's changes and as a key mechanism for understanding of adaptation reactions and of pathogenesis of different diseases. it's determined by high biological activity of products which are formed in the plo reactions, in this relation lipids with high contents of fat acids play important role. to investigate the influence of phytomedicine eminium regelii on the metabolic processes (peroxide lipids oxidation) of white rats' organism in conditions of ionized radiation.the animals were exposed to ionizing radiation (gamma-radiation co) on the radiotherapeutic equipment teragam in a dose of gy and received phytomedicine eminium regelii in a dose of . mg/kg orally within days following the ionizing radiation exposure. gamma-rays caused the increase of lipid peroxidation (lpo) primary (dc) and secondary products' (mda) concentrations in spleen, liver, thymus and adrenal glands.treatment by phytomedicine resulted in contents of dc decreased in times in spleen, in times in thymus, in times in adrenal glands, in liver in times, in lymph nodes of small intestine it in times. mda decreased in liver up to and times, in spleen in . times, in thymus in times, in liver in times, in adrenal glands in time, no changes in lymph nodes of small intestine.the effect of phytomedicine treatment of organisms exposed to sublethal dozes of gamma-radiation results in the lpo primary and secondary products concentrations decrease in spleen, liver, thymus and adrenal glands. p- . . - evaluation of serum levels of ischemia modified albumin (ima) in bipolar disorder patients k. € unal , c. topc ßuoglu , m. cingi clinic of biochemistry, ankara polatli duatepe public hospital, ankara, clinic of biochemistry, ankara numune training and research hospital, ankara, clinic of psychiatry, ankara numune training and research hospital, ankara, turkey introduction: bipolar disorder is one of the most debilitating psychiatric disorders characterized by disruptive episodes of mania/hypomania and depression. considering the complex role of biological and environmental factors in the etiology of affective disorders; recent studies have focused on oxidative stress, which may damage nerve cell components and take part in pathophysiology. aim of our study is to contribute these data about oxidative stress in bipolar disorder, by detecting ischemia modified albumin (ima) levels of bipolar disorder patients in remission and also by comparing these results with healthy controls. methods: study population consisted of patients meeting the diagnostic and statistical manual of mental disorders, fifth edition (dsm- ) criteria for bipolar disorder i. healthy subjects were included as control group (hc). serum ischemia modified albumin (ima) levels of all participants were determined. results: statistical analysis on serum ischemia modified albumin (ima) levels did not show any significant difference between bipolar disorder patients in remission and healthy controls.conclusion: studies on oxidative stress in bipolar disorder have reached controversial results up till now. in this study, no statistically significant difference was detected between oxidative parameters of bipolar disorder patients in remission and healthy controls. in order to evaluate oxidative stress in bipolar disorder comprehensively, further studies are needed. keywords: bipolar disorder, ischemia modified albumin (ima), oxidative stress p- . . - xanthine oxidase and adenosine deaminase activity in patients with familial mediterranean fever (fmf) objective: fmf is an autosomal recessive dissease which is characterized by recurrent fever and inflammation of serous membranes. in this study we measured serum adenosine deaminase (ada) and xanthine oxidase (xo) levels in fmf cases. method: serum ada levels were measured with a sensitive colorimetric method described by giusti and xo levels were analysed by the method of worthington in fmf patients and healthy controls. results: there was a significant difference in xo and ada levels between controls and cases. ada and xo levels were higher in patents with fmf. humic acid (ha) is a natural product which is forming during decomposition of organic matter in humus. in recent years, there are some resarches on the medical use of ha. the present study was undertaken in order to evaluate the anticancer properties of the ha using a prostate cancer and osteosarcome cell lines pc- , sjsa as an in vitro model system.ha was purchased from sigma-aldrich. the cells were maintained in dmem medium supplemented with % heat-inactivated fbs and % penicillin/streptomycin. cells were grown in petri dishes in a humidified atmosphere containing at •c. five different concentrations ( ug/ml, ug/ml, ug/ml, ug/ ml, ug/ml) were prepared using a stock solution of ha. we measured cell proliferation and migration to understand of progression effects of ha in pc- and sjsa cell lines in vitro.according to our results, ha treatment caused cytotoxicity and induced cell death in vitro in pc- cells with an ic value of . lg/ml. contrary to this, ha induced proliferation of sjsa cells in dose dependent manner. ha demonstrated the highest proliferatif activity against sjsa cells with an ic value of > lg/ml. on the other hand, cell migration was reduced in pc- cell line and interestingly, migration was accelerated in sjsa cell line.our study may provide new insights into the regulatory effect of ha in cancer, but further studies are needed to clarify the role of ha in cancer pathogenesis. the febs journal (suppl. ) ( ) key: cord- - qib authors: nan title: the th annual meeting of the european society for blood and marrow transplantation: physicians – poster session date: - - journal: bone marrow transplant doi: . /s - - - sha: doc_id: cord_uid: qib nan background: allogeneic hematopoietic stem cell transplantation is routinely offered to patients with high-risk or advanced all in the hopes of improving outcomes. use of truly non-myeloablative (nma) conditioning reduces toxicity in other contexts but outcome data for all patients after nma transplants is lacking. we report the outcomes of patients with all transplanted using a nma conditioning without t cell depletion. methods: first transplant patients between october and june were reviewed. these were consecutive patients until then only those considered unfit for fmc conditioning as per the ukall protocol. all patients were conditioned with fludarabine mg/m /day for days and cyclophosphamide g/m /day for days. short course mtx and ciclosporin were used for gvhd prophylaxis. standard supportive care was employed. thirty-one patients with a median age of ( - ) met the criteria for this case review. had b-all and were philadelphia chromosome positive. patients ( %) had high risk disease by standard diagnostic criteria. ( %) were in first complete remission (cr ). matched sibling donors were used in instances with the remaining being fully matched unrelated donors. % of patients had a hct-ci score of , % a score of or with patients having a score of or higher. median cd dose was . x /kg ( . - . ) with a median cd dose of . x / kg ( . - . ) results: trm was low at % at year and % at and years respectively. no factors included in a univariate analysis (which included age, diagnosis, disease status, hct-ci, donor type, cmv risk and cell dose) significantly impacted trm. the incidence of classical acute (a) gvhd grade - and - was % and % by day and % and % by day if late onset agvhd is included. out of eligible patients developed chronic gvhd of any stage. relapse incidence was low ( % at years in all patients, % in cr patients) and was not impacted by any pre-transplant factors including positive mrd post phase induction (present in patients). notably, in univariate analysis relapse was significantly lower in patients who developed chronic gvhd. background: allogeneic stem cell transplantation (allosct) is the treatment of choice for many patients (pts) suffering from acute myeloid leukemia (aml). the graft vs. leukemia effect (gvl), applied by immunocompetent cells of donor origin, is the most important effector mechanism for the eradication of leukemia, the presentation of leukemic or allospecific antigens by malignant blasts is regarded as a crucial trigger for an effective allogeneic immune response. conversely, insufficient stimulatory capacity by the leukemic blasts is thought to be a relevant escape mechanism from cellular immunotherapy (allosct or donor-lymphocyte infusion (dli)). the purpose was to test, whether the ability of malignant blasts to differentiate in vitro towards dendritic cells of leukemic origin (dc leu ) is associated with response to allosct or outcome after immunotherapy (second allosct or dli) for post-transplant relapse in aml. methods: leukemic blasts were isolated from peripheral blood (pb) or bone marrow (bm) samples of aml patients before allosct (n= ) or at relapse after allosct (n= ). a panel of different assays was used to generate dc leu in vitro ( of them containing gm-csf). finally, in vitro results were correlated with clinical characteristics and outcome of patients treated with donor lymphocyte infusion and/or allosct. results: dc leu could be generated in vitro from all samples. when correlating proportions of dc-subtypes generated ex vivo with clinical data, significantly higher mean proportions of dc leu in the dc-fraction were found in responders vs. non-responders to immunotherapy ( . % vs . %,p= . , range: %- %). vice versa, the chance for response to immunotherapy was significantly higher, if a dc leu /dc ratio of >= % could be reached in vivo (p= . ). those patientswere characterized by a longer time to relapse (p= . ) and by a higher probability for leukemia-free survival (p= . ). similarly, generation of higher amounts (> %, p= . ) of dc leu in the mnc-fraction, and generation of more mature dc (> % cd +, p= . using the best gm-csf containing assay) were associated with a longer time to relapse in the respective patients. moreover, overall survival was improved, if > % dc leu /dc could be generated with the best gm-csf containing assay (p= . ). conclusions: in vitro generation of dc/dc leu from leukemic blasts obtained in active stages of aml before allosct or at relapse post transplant were associated with clinical outcome. this observation supports a role of antigen presentation by leukemic cells for an allogeneic immune response in aml. disclosure: nothing to declare background: the role of autologous hematopoetic cell transplantation (hct) in the treatment of aml is not clear. trials in the past have shown that autologous hct consolidation lowers the risk of relapse, however the magnitude of this effect is limited . autologous hct is advocated in patients with aml with lower genetic risk in cr .many of these patients will eventually relapse and will undergo reinduction followed by allogeneic hct in cr . methods: the aims of this study is to analyze outcome of allogeneic hct performed in cr comparing patients with prior consolidation by autologous hct vs. patients with chemotherapy consolidation. primary outcome is non relapse mortality (nrm) of allogeneic hct in cr in patients with, or without prior autologous hct in cr . secondary outcomes include leukemia free survival (lfs), relapse rate (ri), graft versus host disease free relapse free survival (grfs), overall survival (os), and treatment related toxicities. results: adult patients reigstered with the alwp of the ebmt with de novo aml were included, receiving a first allogeneic hct in cr , in cr , in - or without (n= ) prior autologous hct. patient and transplant characteristics are shown in the table. patient groups were not entirely comparable, patients with prior autologous hct were younger, had less often a favorable cytogenetic profile, had more commonly donors other than matched siblings and more often received reduced intensity conditioning (ric) as compared to mac conditioning. univariate outcomes are shown in the table with slightly higher nrm risks in patients with prior autologous hct consolidation. in multivariate analysis nrm risks in patients with prior autologous hct were . ( . - . ), p= . after adjustment for patient age, cytogenetic risk category, year of transplant, donor type, conditioning intensity, sex matching, time from diagnosis to relapse and time from relapse to allogeneic hct as compared to patients with chemotherapy consolidation. similarly, risks of events in lfs and grfs were higher with prior autologous hct, . ( . - . ), p= . and . ( . - . ) p= . , respectively, risk of death was also higher . ( . - . ) p= . but this was not statistically significant. conclusions: we may conclude that some of the advantages of potentially higher anti-leukemic activity of high dose chemotherapy and autologous hct when given to patients with aml in cr (as was shown in a randomized trial by vellenga e et al with lower relapse and higher lfs by approximately % but no significant differences in overall survival) may be lost by higher toxicity of allogeneic hct in cr in case of subsequent relapse. background: although relapse is a major cause of mortality in patients receiving allogeneic hematopoietic cell transplantation (hct) for acute leukemia, limited and conflicting data exist on extramedullary relapse (emr). we aimed to describe the incidence, risk factors, outcomes and prognosis in relapsed hct recipients. methods: we retrospectively reviewed charts of consecutive allogeneic hct recipients transplanted in our center with the indication of acute leukemia ( / - / ). we recorded: age, gender, disease, previous extramedullary involvement, phase at transplant, type of transplant, donor, conditioning, graft-versus-host-disease (gvhd), infections, treatment-related mortality and relapse mortality. in patients with extramedullary relapses, additional data on clinical manifestations, imaging, cerebrospinal fluid testing, histopathology and management were additionally documented. incidence of isolated emr (iemr) and bone marrow relapse (bmr) was calculated using cumulative incidence (ci) analysis, with each and treatment-related mortality considered a competing risk. results: among allohct recipients followed for . ( . - . ) years, ( %) patients presented with emr. the majority of emrs involved the central nervous system (cns, %). isolated emr was observed in patients at . ( . - . ) months. -year cumulative incidence (ci) of . % for iemr was associated only with pre-transplant advanced disease phase (p< . ). bmr was observed in patients at ( . - months), with a -year ci of . %. in the multivariate analysis, bmr ci was independently associated with fungal infections (p< . ), pre-transplant disease phase (p< . ) and lines of treatment (p= . ). -year trm of our whole cohort was . %. the majority of iemr and bmr ( % and %, respectively) patients received systemic treatment combined with local radiation for iemr ( %) and donor lymphocyte infusions (dlis, % and % respectively) when feasible. extensive chronic gvhd was recorded in % of iemr and % of bmr patients. outcomes were poor in iemr, with -year overall survival (os) of . %. favorable os in iemr was associated only with sibling donors (p= . ) and not with other factors, such as treatment with dlis or presence of chronic gvhd. similarly poor outcomes ( year os of . %) were observed in bmr. favorable os was independently associated only with the diagnosis of aml (p= . ) and absence of bacterial infections (p= . ). in the whole cohort, both iemr and bmr were independent unfavorable predictors of os (p< . ) along with extensive chronic gvhd (p= . ). conclusions: in a large population with long-term follow-up, incidence of iemr was relatively high, developed at the late post-transplant period and associated only with disease phase at transplant. furthermore, iemr and bmr conferred similarly poor outcomes despite systemic treatment or extensive chronic gvhd. these independent predictors of survival highlight the unmet clinical need of novel approaches either as maintenance or treatment to reduce extramedullary or systemic relapse post allohct for acute leukemia. disclosure: no competing financial interest. impact of t-cell depletion on outcome in patients undergoing allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia background: after a diagnosis of acute myeloid leukemia (aml) the majority of patients (pts) who achieve complete remission (cr) eventually relapse, with only approximately % of pts maintaining cr for years or longer. late relapses (after years in cr) occur rarely ( - %) in pts receiving hsct in cr and late effects are followed up by routine surveillance as well as preventative measures. the purpose of this study was to investigate long-term outcomes in pts with diagnosis of aml undergoing hsct at our institution in cr . methods: a standardized follow-up of hsct-survivors is applied at our center. we analyzed adult pts with aml in cr consecutively transplanted between january and december at our institution. a written consent was given for the use of medical records for research. a landmark analysis was adopted for patients in cr at -y after hsct (ltcr -long-term cr). results: ltcr was achieved after hsct in / patients (male , female ) transplanted in cr . the median follow-up was years and the median age at transplant years (r - ). the selected donor was a family haploidentical relative in cases, an hla identical relative in , a match unrelated donor in and a cordblood in . in this cohort of ltcr, the -year overall survival was % ( % ci - ). cumulative incidence of relapseevaluated in competing risk with transplant related mortality (trm) -and trm -evaluated in competing risk with relapse -were respectively % ( % ci - ) and % for the cr cohort. the event-free-survival (efs) was % ( % ci - ). the causes of death were relapse ( / pts), second cancer ( / pts) and sepsis ( / pts). the -year incidence of dyslipidemia -defined as cholesterol >/= mg/dl, and/or ldl >/= mg/dl, and/or triglycerides >/= mg/dl or need for specific treatment -was %. the -year incidence of osteopenia / osteoporosisdefined as t-score lower than - and greater than - . and t-score lower than . respectively -was %. the -year incidence of second cancer was %: nonmelanoma skin cancer, lung carcinoma, cervical intraepithelial neoplasm, thyroid cancer, gastric cancer and colon cancer. the -year incidence of chronic moderate-severe gvhd was % ( % ci - ), with the latest diagnosis performed on day . of note, / pts are still on active treatment at last follow-up. conclusions: relapse incidence is low for patient that reached ltcr: patients in cr at transplant can obtain excellent os and efs once reached the target of ltcr. a proactive long-term follow-up and strategy of counseling are essential to keep at best quality the survival advantage offered by hsct in patients with aml in cr . disclosure: chiara bonini has research contract with intellia therapeutics. the other authors declare that they have no conflicts of interest. background: relapse, graft-versus-host disease (gvhd) and gvhd-associated mortality are major obstacles to success of transplantation from unrelated (mud) donors in children with acute leukemia (al). negative depletion of αβ t cells and cd + b lymphocytes, conserves the mature donor-derived natural killer cells and γδ t cells in the graft, may improve gvhd control, immune reconstitution and prevent the relapse. we present a retrospect analyses of a cohort of pts with al in cr transplanted from mud with depletion. methods: a total of children with acute leukemia ( aml, all, female, male, median age , y) underwent allo hsct from matched unrelated donor between june and july . all pts were in complete remission (cr = , cr = , cr> = ). all pts, except one, received treosulfan-based conditioning. either melphalan (n= ) or thiophosphamide (n= ) or etoposide (n= ) were added as a second agent. fludarabine was used in all pts. two types of gvhd prophylaxis were used: type (n= ): hatg mg/kg and post-hsct tacro/mtx (n= ) or without prophylaxis (n= ); type (n= ): thymoglobulin(ratg) mg/kg, rituximab mg/ m with either bortezomib on days + , + (n= ) or tacro/ mtx (n= ) . aβ t cell depletion with clinimacs was used in all cases. the median dose of cd + cells was x / kg, aβ t cells - x /kg. median time of follow-up for survivors was , years (range, , - , ) . results: primary engraftment was achieved in % pts., the median time to neutrophil and platelet recovery was and days, respectively. all evaluable pts achieved sustained complete donor chimerism by day + . early ( day) mortality was , % ( pt -bacterial sepsis, pt -adv fulminant hepatitis), -years overall ptrm at years was , % ( %ci: - ). six late trm events were due to: viral infection in pts (cmv= , adv+cmv= ), bacterial sepsis in pts and pts had bacterial and viral infection, all late deaths were associated with cgvhd and prolonged corticosteroid therapy. ci of acute gvhd grades ii-iv was % ( % ci: - ), acute gvhd grades iii-iv , % ( % ci : , - , ) . ci of cgvhd was %( %ci: - ). regimen was more effective in prevention of agvhd ii-iv in comparison with regimen : % ( % ci: , - ) vs , %, respectively, p= , . all events with acute gvhd grades iii-iv had pts with regimen . ratg was also effective in prevention of cgvhd: ci at years after hsct was , % vs. %, respectively, p= , . cumulative incidence of relapse was % ( %ci: - ) without difference between ratg and hatg. event-free survival (efs) (event=death or relapse) at years was % ( %ci: - ), overall survival %( % ci: - ), there were no difference between age and diagnosis. conclusions: we confirm that the depletion of tcrαβ +/cd + t lymphocytes from the graft ensures high engraftment rate. transplant-related mortality is caused by infections, mostly associated with cases of chronic gvhd. gvhd prophylaxis including ratg/rituximab/ bortezomib improves gvhd control in recipients of tcrαβ+/cd +depleted grafts in comparison to hatg/ tacro/mtx apparently without loss of anti-leukemic activity. disclosure results: at baseline, r/r all with emd and lbl were diagnosed in and ino patients and and sc patients. median (range) age of the ino and sc patients was . ( - ) and . ( - ) years, with / ( . %) and / ( . %) males, respectively. the rate of cr/cri was significantly higher in the ino group ( / [ . %] , % confidence interval [ci] : . - . ) compared with sc ( / [ . %], % ci: . - . ; p= . ) (table) . allogeneic hematopoietic stem cell transplantation was carried out in / ( . %) ino and / ( . %) sc patients prior to any post-study induction therapy. the pfs hazard ratio [hr] was . ( . % ci: . - . ; p= . ), with median pfs of . ( % ci: . - . ) months among ino and . ( % ci: . - . ) months in sc patients. the os hr was . ( . % ci: . - . ; p= . ), with median os of . ( % ci: . - . ) months in ino versus . ( % ci: . - . ) months in sc patients (figure) . all patients had adverse events (aes). serious aes occurred in / ( . %) ino and / ( . %) sc patients; ( . %) ino and sc patients had grade ae. one ( / , . %) patient in the ino group died from veno occlusive disease. conclusions: among r/r all patients with emd and lbl, improvement in remission rates, transplant rates, and progression free survival was shown in the ino group versus the sc group. although patient numbers were small and limited the ability for a robust comparison, these results support the use of ino in patients in this difficult to treat population with r/r all and emd or lbl. background: bcr-abl-targeted tyrosine kinase inhibitors (tki) revolutionized the outcome of patients inflicted with ph+ b-all. moreover, addition of tki may be relevant strategy for ph-like all patients. methods: we hypothesized that overcoming the bm microenvironment-mediated protection of all cells from tki-mediated apoptosis may further enhance the responsiveness to tki therapy. results: in vitro treatment of bcr-abl-positive all cell lines nalm and nalm ) with dasatinib resulted in significant dose-dependent cell growth inhibition, with ic of - nm (p< . ). furthermore, dasatinib exhibited significant growth suppression of bcr-abl -negative all cells (nalm and reh), with ic of nm and nm, respectively. however, when cocultured with bone marrow stromal cells (bmscs), dasatinib-mediated effect was abrogated in both ph-and ph+ all cells. furthermore, dasatinib treatment promoted significant upregulation of chemokine receptor cxcr , on both mrna and cell surface levels. elevated cxcr expression was accompanied by increased responsiveness of all cells to cxcl stimulation, resulting in strong and sustained phosphorylation of erk / and akt and increased adhesion capacity to bmscs. therefore, dasatinib-induced upregulation of cxcr promotes stroma-mediated survival advantage of all cells upon tki therapy. next, in order to overcome the cxcr -mediated stromal protection, we choose to combine dasatinib with the histone deacetylase inhibitor panobinostat, for its known ability to deplete cxcr in aml cells. single-agent treatment with panobinostat demonstrated significant inhibition of ph-and ph+ all cell growth at low nanomolar concentrations (p< . ). importantly, combination of panobinostat with dasatinib synergized (ci< . ), effectively overcoming the protection provided by bmscs and inducing the apoptosis of ph-and ph+ all cells, as demonstrated by phosphatidylserine externalization, mitochondrial depolarization and dna fragmentation. furthermore, combining panobinostat with dasatinib significantly reduced cxcr surface levels in ph-and ph+ all cells. accordingly, cxcl mediated responses, including erk / and akt activation and adhesion to bmscs were significantly reduced upon combined panobinostat/dasatinib treatment. these data indicate that panobinostat effectively suppresses both basal and dasatinib-induced cxcr expression and function in all cells overcoming stroma-mediated resistance to dasatinib. to determine the molecular mechanism, we performed gene and protein expression analysis. panobinostat, alone or in combination with dasatinib, significantly down-regulated the protein levels of calcineurin, a serine-threonine protein phosphatase previously implicated in t-all and b-all pathogenesis, as well as of nfatc , a critical effector of the calcineurin signaling cascade, and nfatc -regulated target genes. it was previously found that calcineurin signaling positively regulates cxcr expression in t lymphocytes. additionally, cyclosporin a (csa) decreased both basal and dasatinib-induced cxcr surface levels in all cells, overcoming the protection of the bmscs which result in potentiation of the cytotoxic effect of dasatininb and panobinostat. combining csa with panobinostat resulted in deeper suppression of nfatc -regulated target genes. we thus link the effect of panobinostat with calcineurin-dependent downregulation of cxcr , blocking the ability of the leukemic cells to respond to cxcl mediated stromal support. conclusions: taken together, our results identify calcineurin signaling pathway as a novel target of panobinostat in all cells and indicate that hdac inhibition with panobinostat may be effective strategy for facilitating the anti-leukemic activity of tki therapy. disclosure: nothing to disclose background: the treatment of relapsed/refractory acute lymphoblastic leukemia (rr-all) remains a clinical challenge with a generally dismal prognosis. allo-sct using a sequential conditioning ("flamsa"-like regimen) has shown promising results in relapsed/refractory aml, but little is known about the efficacy of this procedure in rr-all. methods: we identified adult patients ( % females; median age: y; range, - ) with all in primary refractory phase ( %) or in relapse ( %), allografted between and from a matched sibling ( %), matched unrelated ( %) or haploidentical donor ( %) at ebmt participating centers. almost half ( %) of the patients had t-all and % had a positive philadelphia chromosome. six patients ( %) underwent a previous autotransplant. karnofsky score was above in % of patients. conditioning was myeloablative (mac) with high dose tbi in % of patients, reduced intensity (ric) including low dose tbi in %, or with chemotherapy alone in %. in vivo t cell depletion was performed in cases ( %). most patients ( %) and about half of the donors ( %) were cmv positive. % of patients were males who received a graft from a female donor. the median follow-up was (range, - ) months. results: overall, patients ( %) failed to engraft, ( %) died within days after allo-sct without relapse, and ( %) could achieve complete remission. at day , the cumulative incidences of grade ii-iv and grade iii-iv acute gvhd were % and %, respectively. the year cumulative incidences of chronic and extensive chronic gvhd were % and %, respectively. the -year relapse incidence (ri) and non-relapse mortality (nrm) were % and %, respectively. the -year leukemia free survival (lfs), overall survival (os) and gvhd relapsefree survival (grfs) were %, % and %, respectively. in a multivariable cox analysis, karnofosky score below negatively affected ri, lfs, os and grfs. also, conditioning with chemotherapy alone, compared to tbibased conditioning, negatively affected relapse rates (hr= . ; p= . ), lfs (hr= . ; p= . ) and os (hr= . ; p= . ). conclusions: allo-sct using a sequential conditioning regimen is proposed by different teams in rr-all, and could be an option, especially when considering a tbibased regimen. however, the overall -year lfs of % suggests that these patients still face extremely dismal outcomes, highlighting that other therapies (e.g. bite antibodies, inotuzumab, car t cells) need to be combined prior and/or after allo-sct in order to further improve outcome. disclosure: no conflict of interest, no funding received chemotherapy courses, only pts were not treated: pts for the worsening of the general status and the other for invasive fungal infection. results: forty-three pts ( %) were in complete remission (cr) and negative minimal residual disease (mrd) at the time of hsct; pts were in active disease ( %), and ( %) showed a morphological cr with positive mrd. pts ( %) developed chronic graft versus-host disease (cgvhd) as followed: pts ( %) mild, pts ( %) moderate, and only sever grade respectfully. only patient developed cgvhd after dli. the overall leukemia free survival (lfs) time was months, the absence of cgvhd (hazard ratio -hr: , ; p = , ) and the pre-hsct disease status (hr , ; p = , ) were the most important factors on lfs. all pts treated with chemo-based regimens died due to progression or infective complications. patient of aza/dli group is still alive with a extramedullary relapse; pts treated with bl/dli are in cr. os was better for the dli group compared to the chemotherapy group ( vs months respectfully; p < , ). conclusions: dli after allo-hsct has exhibited definite anti-leukemic effects in post-transplant patients. bl and aza were reported to increase dli's graft vs-leukemia (gvl) effect. although cgvhd could be the most important protective factor against the relapse but it remains the main cause of morbidity. maximising the gvl effect without putting the patient at risk of gvhd still represents an unmet need. our data show that the combination of either bl or aza with dli infusion is safe and might represent an improvement in disease control in the early phase of relapse. disclosure: nothing to declare p increased detection of (leukemiaspecific) adaptive and innate immune-reactive cells under treatment of amldiseased rats and one therapy-refractory aml-patient with blastmodulating, clinically approved response modifiers (pg-e ,kit-k) or +pge (kit-m),patent ) convert myeloid blasts into dendritic cells of leukemic origin (dc leu ). after stimulation with dc leu , antileukemic tcells can be generated ex vivo. the compounds are approved for clinical use and are therefore attractive tools for immunotherapy in myeloid leukemia. methods: dc/dcleu-culture from rats'/patients' wholeblood (wb) with kits, mixed lymphocyte culture (mlc) of tcells with kit-treated blood, functional blast-cytotoxicity and leukemia-specificity assays (csa/elispot/degranulation/intracellular cytokine-assays). in addition flowcytometric evaluations of cellular and (leukemia-specific) lymphocyte compositions were performed from rats'/pts' blood in the course of the disease. results: ) aml-diseased rats: each rats were treated with "i", "k" or "m" or were untreated (controls). a significant increase of dcleu could be detected in spleen/pb in kit-(esp. m) treated compared to untreated animals without induction of blasts' proliferation (ki positivity): a significant reduction of blasts was seen with "m" (p= . / . in spleen/pb) and "i", but not "k". successful treatment correlated with an increase of cd l+tcells, most likely representing tmem-cells, (p= . ) and a reduction of cd +treg (p= . ). ) therapy-refractory aml-patients (during the course of decitabine/ld-aractreatment): kit-m was shown to ex vivo generate dcleu, activate immunereactive cells and mediate leukemia-specific/antileukemic response. activated or leukemia-specific lymphocytes were monitored in low proportions in active stages of the disease as well as of two patients during the further course of persisting disease. one of these patients ( yo male), was offered an individual systemic salvage-treatment (kit-m, applied as continuous infusions) for refractory leukemia. after approval from the local ethical commitee,extensive information of the patient about the experimental nature of the treatment and obtaining his written informed consent. clinically the treatment was well tolerated and the patient improved clinically. neutrophils in wbc increased from % to %, thrombocytes reached g/l after days. after weeks of treatment, the patient was discharged in good clinical conditions. days later, progression of aml was seen with high blast counts in pb and bm. the patient developed severe sepsis and died few days later. immune monitoring showed (other than before treatment and in the patients without kit-m-treatment) a continuous increase of proliferating and non-naïve tcells, nk, cikand nkt-, th cells, bmem-cells and dc in pb. the production of ifnƔ producing t-, cik and nkt-cells was demonstrated, suggesting an in vivo production/activation of (potentially leukemia-specific) cells. immune stimulatory effects decreased after discontinuation of therapy. conclusions: treatment of wb as well as leukemically diseased organisms with blast-modulating kits (especially gm-csf and pge ) was well tolerated and induced clinical and immunological improvement (adaptive and innate immune system), whereas low counts of (leukemiaspecific) activated immune-reactive cells were found in non-kit-treated organisms. disclosure: nothing to declare p long-term outcomes after allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia with non-myeloablative and myeloablative conditioning: a single-center cohort study of consecutive patients lars klingen gjaerde, niels smedegaard andersen , lone smidstrup friis , brian thomas kornblit , søren lykke petersen , ida schjødt , henrik sengeløv rigshospitalet, copenhagen, denmark background: since , we have at our institution used a non-myeloablative (nma) conditioning regimen for older (> years) or significantly comorbid younger patients undergoing allogeneic hematopoietic stem cell transplantation (allo-hsct) for acute myeloid leukemia (aml). we aimed to compare the long-term outcomes of nma conditioned patients with myeloablative (ma) conditioned patients. methods: we studied nma and ma conditioned adult (> years) consecutive patients receiving their first allo-hsct for aml from to at rigshospitalet. nma conditioning consisted mainly of gy total body irradiation (tbi) and fludarabine mg/m ( % of cases). ma conditioning consisted mainly of cyclophosphamide mg/ kg and either gy tbi ( % of cases) or busulfan . mg/ kg ( % of cases), or fludarabine mg/m and treosulfan mg/m ( % of cases). five percent and % of nma and ma conditioned patients, respectively, received anti-thymocyte globulin. patients were followed until death or end-of-followup on october st , . cumulative incidences with % confidence intervals (ci) of acute graft-versus-host disease (agvhd) grade ii-iv, chronic graft-versus-host disease (cgvhd), relapse and non-relapse mortality (nrm) were calculated and compared between nma and ma conditioned patients using gray's test with death as a competing risk (or relapse when comparing nrm). overall survival (os) was estimated by the kaplan-meier method. results: nma and ma conditioned patients were comparable when regarding sex ( % and % female, respectively) and donor (matched related donor in % and %, respectively), but differed, as expected by indication, with regards to age (median of versus years, respectively) and karnofsky score (< in % and %, respectively). nma conditioned patients had generally a lower aml stage at transplant ( st complete remission in % versus % of ma conditioned patients) and a lower aml cytogenetic risk (adverse risk in % versus % of ma conditioned patients). patients were followed for a total of person-years (median follow-up in surviving patients was . years). agvhd grade ii-iv occurred less frequently in nma conditioned patients ( % [ci: %- %] versus % [ci: %- %] in ma conditioned patients, p < . ), while cgvhd occurred in similar rates ( % [ci: %- %] in nma conditioned patients and % [ci: %- %] in ma conditioned patients, p = . ). there was a trend towards a higher relapse rate in nma conditioned patients ( % [ci: %- %] versus % [ci: %- %] in ma conditioned patients, p = . ), and nma conditioned patients had, however not with statistical significance, lower nrm ( % [ci: %- %] versus % in ma conditioned patients, p = . ). os ( figure) was comparable, with -year os rates of % (ci: %- %) in nma conditioned patients and % (ci: %- %) in ma conditioned patients. conclusions: patients with aml undergoing allo-hsct with nma conditioning at our institution were older and frailer than ma conditioned patients, but their overall survival after transplantation was comparable. this might be explained by a generally lower aml stage and cytogenetic risk at transplant in nma conditioned patients. jedlickova , saskia güller , rosa toenges , juliane steinmann , hans martin , hubert serve , gesine bug background: allogeneic hsct is urgently indicated in patients with aml in first complete hematologic remission (chr) after intensive chemotherapy with increasing or recurrent minimal residual disease (mrd). these patients are at high risk of hematologic relapse (hr) during preparation of their transplant and hsct with active aml was found associated with poor outcome. azacitidine has recently been shown to substantially delay or even prevent hr in > % of patients (relaza trial, platzbecker et al., lancet oncology ) . we here present the outcome of a small cohort of consecutive patients with mrd-positive aml who received low dose cytarabine (ldarac) as bridging therapy prior to hsct. methods: mrd was assessed by quantitative polymerase chain reaction (qpcr) using mutated npm (n= ), runx -runx t (n= ), cbfb-myh (n= ) or kmt a-ptd (n= ). mrd negativity was defined as ratio of oncogene to control gene (abl ) ≤ , % while increased or recurrent mrd required a ratio > % (shayegi et al., blood ) . primary endpoint of our retrospective analysis was progression to hr (≥ % bone marrow blasts or extramedullary disease); secondary endpoints were achievement of molecular remission prior to hsct, neutropenia g according to ctcae, thrombocytopenia g , anemia ≥g , admission to hospital, os and rfs. os and rfs were calculated from the first dose of ldarac. ldarac was self-administered subcutaneously by the patients at home at a flat dose of mg bid over days and repeated after weeks if necessary. results: between / and / , nine patients (median age , range, - years) with low (n= ), intermediate (n= ) or high-risk cytogenetics (n= ) according to eln criteria were treated in continuous chr for increasing (n= ) or recurrent mrd (n= ) starting at a median of (range, - ) days after the last consolidation therapy, i.e., duration of chr was > months in all pts. patients received one (n= ), two (n= ) or three cycles (n= ) of ldarac prior to hsct. in three patients, neutropenia g occurred and one patient needed platelet transfusion. all patients were managed in the outpatient setting. in eight out of nine patients ( %), hr was successfully prevented and patients ( %) even became mrd negative prior to hsct. one patient (runx -runx t positive aml) progressed to hr after one cycle of ldarac and received salvage therapy with high-dose arac and mitoxantrone (ham) prior to hsct. all patients proceeded to hsct from a matched related (n= ), unrelated (n= ) or haploidentical donor (n= ) and are still alive (median follow-up of days). conditioning regimens included fludarabine (flu)/melphalan (mel)/tbi (n= ), flu/mel (n= ), flu/tbi (n= ), flu/busulfan (bu) (n= ) and thiotepa/bu /flu (n= ). after hsct, only the ldarac-refractory patient relapsed, resulting in a probability of rfs of % at years. conclusions: our data suggest that a bridging therapy with up to three cycles of ldarac prior to hsct is feasible and was associated with favorable outcomes in patients with npm -mutated or core binding factor aml and molecular relapse > months after achieving a first chr. the treatment has low costs, can be administered on an outpatient basis and is very well tolerated. clinical background: allogenic hematopoietic stem cell transplant (hsct) is the only curative treatment for all the patients with aml. high risk disease qualifies for upfront hsct irrespective of the presence of matched sibling donor (msd). in the absence of msd, haploidentical stem cell transplant is easier option with success rates as high as msd in a high volume transplant centre. we present our experience from a single centre. methods: we analyzed retrospective data of aml patients who have undergone hsct at our centre between january- and august- . for msd transplant we used fludarabine + busulfan or fludarabine + melphalan conditioning regimen, in matched unrelated donor transplant (mud) regime used was fludarabine + busulfan + atg. we followed john hopkins's protocol for haploidentical hsct. cyclosporine + methotrexate was used as gvhd prophylaxis in msd and unrelated donor group and cyclophosphamide + tacrolimus + mycophenolate was used for haploidentical post-transplant. day survival, overall survival (os), incidence of gvhd and cmv reactivation was computed. results: a total of aml patients underwent hsct during the study period, the basic and clinical characteristics of the study patients are presented in table . conditioning regime did not have significant impact on os. survival at day was %. the os function and relapse free survival (rfs) function did not significantly differ between msd and haploidentical transplantation ( . % vs . %; p= . ) and ( . % vs . %; p= . ) (graph ). disease status at latest follow up showed that % were in remission and % had relapsed. overall one year survival and five year survival in the entire cohort was % and % respectively. the average cost of msd transplant at our centre is inr , , (€ - ), haploidentical transplant is inr , , (€ - ) and mud transplant is inr , , (€ , + for stem cell procurement). conclusions: our study showed comparable outcomes in msd and haploidentical transplant with respect to day survival, os, and rate of gvhd. in a developing country like india where patients are not covered under state health insurance, the additional cost of procurement of stem cells in a mud transplant would add to the financial burden to the patients. haploidentical transplant is a feasible option in case of non-availability of msd, due to ease of donor availability and strong motivation from the family donor to donate the stem cells. background: allogeneic stem cell transplantation (allo-hsct) is not indicated as consolidation of first complete remission (cr ) in favorable-risk acute myeloid leukemia (aml) bearing mutations in nucleophosmin (npm ) in the absence of flt internal tandem duplication (flt -itd). nevertheless, a substantial proportion of patients eventually proceed to allo-hsct beyond cr or for chemoresistant minimal residual disease (mrd) while in cr , which might compromise transplantation outcomes. the study aimed at examining the characteristics and results of allo-hsct in aml cases with mutated npm and wild-type flt (npm mut/flt wt), with special focus on molecular monitoring of mrd following transplantation. methods: from / until / , patients (women/men, / ) underwent allo-hsct for npm mut/ flt wt aml. at transplant, median age of patients was . years (range, - ) , and disease phase was cr (n= ), cr (n= ), or primary refractory (n= ). among the patients who were transplanted in cr and had available molecular mrd assessments, had detectable mutant npm transcripts by real-time quantitative pcr (rq-rcr). also, patients fulfilled criteria of molecular relapse (increasing levels of npm -mutated transcripts in two successive bone marrow samples), with mutant npm load of - , transcripts/ , abl transcripts). the conditioning regimen was myeloablative in the majority of cases (n= ) or reduced-intensity (n= ). the type of donor varied, namely hla-identical sibling (n= ), matched unrelated (n= ), haploidentical relative (n= ), or double umbilical cord blood (n= ). results: engraftment was achieved in all cases, with a median time to absolute neutrophil count > /ul of days (range, - ) . among the patients with posttransplant monitoring of mrd by rq-pcr, exhibited a stable molecular remission whereas a rising level of npm mutated transcripts was observed in cases due to either hematologic (n= ) or molecular (n= ) relapse of disease. the cumulative incidences (cin) of hematologic relapse and non-relapse mortality (nrm) were . % and % at months, respectively. no events of relapse or nrm were encountered beyond months from allo-hsct. out of patients with hematologic relapse post transplant, died of disease whereas one achieved a stable complete remission after withdrawal of immunosuppression. at a median follow-up time of months (range, - ), / patients continue to be alive in cr. the estimated disease-free background: cpx- (vyxeos®) is an advanced liposomal encapsulation of cytarabine/daunorubicin at a synergistic : molar ratio. cpx- is approved by the us fda and ema for the treatment of adults with newly diagnosed, therapy-related aml or aml with myelodysplasia-related changes. methods: safety data were pooled from studies of cpx- in adults aged - years with newly diagnosed or relapsed/refractory aml. cpx- induction consisted of units/m (cytarabine mg/m + daunorubicin mg/m ) on days , , and (second induction: days and ) . cpx- consolidation consisted of or units/m (varying by study) on days and . cpx- was evaluated against standard-of-care controls. results: baseline characteristics were generally balanced between cpx- (n= ) and controls (n= ); the majority of patients were aged ≥ years ( %; %) and had secondary aml ( %; %). controls included + (n= ) and salvage therapy with mitoxantrone/etoposide/ cytarabine (n= ), idarubicin/cytarabine (n= ), other cytarabine-based chemotherapy (n= ), and mitoxantrone/ etoposide (n= ). the treatment-emergent adverse event (teae) profile of cpx- units/m was comparable to induction controls, but associated with a greater proportion of patients with teaes, grade ≥ teaes, and serious teaes during consolidation (table) . therefore, the cpx- consolidation dose was reduced to units/m in latter studies; this dose demonstrated an improved teae profile similar to consolidation controls. the most frequent system organ class was gastrointestinal disorders for both cpx- and controls; a lower incidence was reported for cpx- ( %) versus controls ( %), with this difference driven by the lower incidence of diarrhea for cpx- ( %) versus controls ( %). the most frequently reported grade ≥ teaes were febrile neutropenia (cpx- : %; controls: %), pneumonia ( %; %), hypoxia ( %; %), and bacteremia ( %; %). early mortality rates, both overall and by treatment period, appeared lower with cpx- versus controls at day and day ( table) ; the majority of early deaths were attributable to teaes. conclusions: across the studies comprising the cpx- clinical development program, cpx- demonstrated a safety profile comparable to conventional chemotherapy in adults with newly diagnosed or relapsed/refractory aml. background: haploidentical hematopoietic stem cell transplantation (hsct) with post-transplantation cyclophosphamide (pgcy) marked improved clinical outcome. recent studies comparing allogeneic hsct using unrelated donors versus haplo donors in patients with acute leukemia have suggested equivalent outcomes. the depletion of tcells with pgcy was subsequently applied for unrelated hsct setting for patients with unrelated donor. methods: we performed a retrospective study on patients with acute leukemia in order to compare the outcome after hla haploidentical (n= ) and unrelated hsct (n= ) with pgcy. the main characteristics of patients were similar in both groups. baseline disease were: aml ( %) and all ( %) for haplo group and aml ( %) and all ( %) for unrelated group. disease state at time of haplo and unrelated-hsct were following: and patients in cr ( % and %) and and non cr ( % and %). for aml recipients mainly received thiotepa, busulfan and fludarabine and for all recipients received tbi and etoposide conditioning. all patients who received pbsc graft were treated with rabbit antithymocyte globulin (atg) on days - and - . results: at the time of analysis, the os and dfs did not differ between the haplo and unrelated groups ( % vs %, and % vs %). incidence of severe (grade [ ] [ ] acute gvhd was the same in two groups ( % versus %). recipients of haplo-hsct transplant were statistical significance less likely to experience disease relapse ( % vs %) and chronic gvhd ( % vs , %). however, gvhd free relapse free survival (grfs) rate was slightly higher after haplo-hsct ( % vs %). addition, cumulative incidence of trm rate was higher after haplo-hsct ( % vs %).for haplo and unrelated groups who underwent hsct in cr , the os were % and % versus % and % for those in non cr . for aml, the os was same in two groups (haplo % versus unrelated %). however patients with all, the os was higher in haplo group compared with unrelated group ( % versus %). the impact of pretransplant disease state have a more powerfull effect on survival in the haplo-hsct setting (for aml cr % versus non cr % and for all cr % versus non cr %). viral reactivations were significant concern in both groups. conclusions: our retrospective analysis suggests largerly similar os and dfs with haplo versus unrelated transplants with pgcy for acute leukemia. our data indicate that haplo-hsct results in a lower incidence relapse and of chronic gvhd and higher grfs compared with unrelated hsct. in addtion, the pretransplant disease state have the important effect on the outcomes in both groups. allo-pbsc with atg can be used safely and effective as graft source in haplo-hsct with acceptable post-transplant outcomes and replaced bm in this settings. more statistical data for transplant related characteristics will be provided at the presentation.we emphasize that use the same pgcy gvhd prophylaxis for all types of allogeneic transplant. based on our results, we recommend haplo-hsct with pgcy against unrelated transplant for patients with acute leukemia. disclosure: disclosure of conflict of interest: none. excellent efficacy and tolerability of inotuzumab ozogamicin in b-cell all relapsed after allo-hsct background: donor lymphocyte infusion (dli) could be used prophylactically to reduce relapse after allogeneic hematopoietic stem cell transplantation for very high-risk leukemia/lymphoma without effective targeted therapy. to compare the safety and efficacy of prophylactic dli for prevention of relapse after allogeneic peripheral blood stem cell transplantation from haploidentical donors (hid-sct) and matched-sibling donors (msd-sct) in patients with very high-risk acute myeloid leukemia (aml), we performed a retrospective, observational cohort study enrolled in hid-sct and msd-sct recipients. methods: the very high-risk features were defined as: (i) in the non-remission (nr) state prior to transplantation, including primary induction failure, relapse untreated or refractory to reinduction chemotherapy, or untreated aml evolution from mds; (ii) achieving complete remission with ≥ cycles of induction of chemotherapy; (iii) carrying tp , dnmt a, tet or flt -itd gene mutation. the scheduled time of the prophylactic dli was + - days after transplantation for msd-sct recipients and + - days for hid-sct recipients. the g-csfmobilized peripheral blood stem cells were infused to the recipient at a dose of × cd + cells/kg. csa was given at mg/kg b.i.d from day - to day + (hid-sct) or to day + (msd-sct), and then tapered at % per month to be discontinued on day + - (hid-sct) or on day + - (msd-sct) unless graft-versus-host disease (gvhd) developed. if the patients received dli before day + (hid-sct) or day + (msd-sct), csa was given weeks after dli in hid group and weeks in msd group at a though concentration of - ng/ml for dliassociated gvhd prophylaxis, and then tapered and discontinued within weeks unless gvhd developed. if gvhd occurred before the scheduled time of prophylactic dli, it would be delayed for weeks when gvhd was well controlled. results: prophylactic dli was administered at a median of ( - ) days for hid-sct recipients and ( - ) days for msd-sct recipients (p= . ), and both groups displayed similar baseline characteristics except for donor's gender distribution (table ) . grade - acute graft-versushost disease (gvhd) at -day post-dli was higher in hid-sct group than that in msd-sct group ( . % vs. . %, p= . ). grade - acute gvhd ( . % vs. . %), -year chronic gvhd ( . % vs. . %) and severe chronic gvhd ( . % vs. . %) were similar between two groups (p> . ). one-year non-relapse mortality was higher in hid-sct group than that in msd-sct group with marginal significance ( . % vs. . %, p= . ). one-year relapse rate was similar between hid-sct group and msd-sct group ( . % vs. . %, p> . ). estimated -year overall survival (os, . % vs. . %) and relapsefree survival (rfs, . % vs. . %) rates were both similar between hid-sct group and msd-sct group (p> . ). in multivariate analyses, non-remission status prior to transplant, poor-risk gene mutations and donor's age ≥ years predicted a higher risk of relapse after dli. nonremission status prior to transplant predicted inferior os and rfs. patient's age ≥ years also predicted an inferior os. conclusions: prophylactic dli after hid-sct demonstrated similar tolerance and efficacy for reducing relapse compared to that after msd-sct for very high-risk aml. disclosure: the authors declare no conflict of interest. prognostic impact of pre-transplant tim levels on transplant outcome in acute leukemia patients background: t cell immunoglobulin and mucin domaincontaining protein- (tim ), a negative regulator of t cells, is expressed on a variety of tumors including hematological malignancies like acute myeloid leukemia (aml) and some lymphoma types in which it was shown to be associated with an adverse prognosis. the aim of this study is to identify the prognostic impact of pre-transplant tim levels on early and late transplant related complications as well as post-transplant relapse and survival methods: a total of hematopoietic stem cell transplantation (hsct) recipients with an initial diagnosis of acute leukemia [median age: ( - ) years; male/ female: / ] were included in the study. aml was the initial diagnosis in patients ( . %), acute lymphoblastic leukemia (all) in patients ( . %), mixed phenotype acute leukemia in patients ( . %) and blastic plasmacytoid dendritic cell neoplasm in patient ( . %). soluble tim- levels in pre-transplant serum samples were measured with enzyme linked immunosorbent assay (elisa). results: median pre-transplant tim level was . ( . - . ) pg/ml in the whole cohort. pre-transplant tim levels were significantly higher in aml patients when compared to all [ . ( . - . ) vs . ( . - . ); p= . ]. tim levels were significantly lower in patients with abnormal cytogenetics when compared to normal karyotype (p= . ). cytogenetic abnormalities, including mainly a complex karyotype or chromosome abnormalities, were more frequent in patients with low tim levels (p= . ). pre-transplant tim levels were significantly higher in patients who developed post-transplant viral hemorrhagic cystitis (p= . ). a positive correlation was demonstrated between tim levels and acute graft versus host disease (gvhd) grade (p= . ; r= . ). at a median follow-up of . ( . - . ) months, overall survival (os) was found to be better in low-tim group when compared to high-tim group, without statistical significance (% . vs % . ; p> . ) ( figure ). probability of os was relatively better in both aml ( . % vs . %; p> . ) and all patients ( . % vs %; p> . ) representing low pretransplant tim levels in the subgroup analysis conclusions: in this study, elevated levels of pretransplant tim levels in aml patients were compatible with the previous reports which had underlined an increased tim expression on aml stem cells. the possible association of tim expression with cytogenetic features should be confirmed with further studies as there is no adequate data except its relationship with flt -itd mutational status. tim- is also expressed on exhausted t cells in patients with viral infections, including human immunodeficiency virus, hepatitis b and hepatitis c virus. it plays an essential role in the regulation of antiviral and antitumor immune responses which may be an explanation for the increased frequency of hemorrhagic cystitis in patients with higher tim- levels. the adverse prognostic impact of tim on gvhd and os was confirmed without statistical significance which may be related to small sample size. as tim has a wide spectrum of action in the tumor microenvironment including stimulatory and inhibitory activities, further clues are required to define the exact role of this molecule in the clinical course of allogeneic hsct in order to develop targeted therapeutic strategies clinical trial registry: n/a disclosure: nothing to declare p homozygous hla-c is associated with increased risk of relapse after hla-matched transplantation in recipients with acute lymphoid leukemia: a japanese national registry study background: after hematopoietic stem cell transplantation (hsct), the role of natural killer (nk) cells which express killer-cells immunoglobulin-like receptors (kirs) and recognize hla-class ligands is important. kir dl recognizes not hla-c asp (c ), but hla-c lys (c ) and has polymorphism based on the th amino acid of the transmembrane domain. low frequency of c and high frequency of strong kir dl are characteristics observed in japanese. by using large transplant database, we reported that homozygous hla-c (c /c ) recipients displayed lower relapse rates than did c /c recipients after hla-matched hsct for acute myeloid leukemia (aml; hr = . , p = . ) or chronic myeloid leukemia (cml; hr = . , p = . ). this effect seemed to be independent of acute graft-versus-host disease (agvhd) or cytomegalovirus reactivation occurrence (arima n et al bbmt ) . methods: relapse rates of japanese recipients who first underwent hla-matched hsct between and for the treatment of acute lymphoid leukemia (all) were compared between c /c pairs and c /c pairs, using data from japanese data center for hematopoietic cell transplantation and adjusting for transplant characteristics. cord blood transplantation was excluded. multivariable competing risk regression analyses were performed to evaluate relapses and relapse-free survival (rfs) was estimated using kaplan-meier method. results: after recipients who did not achieve remission or experienced graft failure and recipients not-expressing c were excluded, resting recipients aged - years (median, . years) were analyzed. the median follow-up period for survivors was . years. there were recipients expressing c /c and recipients expressing c /c , respectively. after hla-matched hsct, c /c recipients had higher relapse rates than c / c recipients (hr = . , p = . ), resulting in worse rfs among c /c recipients (hr = . , p = . ). the frequent relapse in c /c recipients than in c /c was noticeable among recipients with agvhd (hr = . , p = . ), those without cytomegalovirus reactivation (hr = . , p = . ), and those with ph-negative all (hr = . , p = . ). conclusions: kir dl -positive nk cells may promote graft-versus-leukemia (gvl) in c /c recipients with aml or cml but suppress gvl in c /c recipients with all. one interpretation is that transplant-activated nk cells impair antigen-presenting cells or deprive cytotoxic tlymphocytes of their gvl effects on all cells. this hypothesis may be explained by the fact that agvhd was necessary for the recessive relapse in c /c recipients with all. furthermore, ph-positive all cells sometimes mimic aml cells in terms of their frequent myeloid antigen expression and might be directly targeted by nk cells. it would be necessary to further clarify in vitro the character of nk cell-affecting in the transplant immunity against residual leukemia cells. disclosure: authors have nothing to declare. hematopoietic stem cell transplantation with sequential conditioning for children with relapsed/refractory acute leukemia nao yoshida , kazuki matsumoto , daiki yamashita , yiqing zhu , daichi sajiki , ryo maemura , hirotoshi sakaguchi , asahito hama children's medical center, japanese red cross nagoya first hospital, nagoya, japan background: patients with acute leukemia who fail to achieve complete remission show a dismal prognosis even with allogeneic hematopoietic stem cell transplantation (hsct). this study evaluated whether sequential conditioning approach that is cytoreductive chemotherapy applied shortly prior to the main conditioning followed by hsct can improve prognosis in such high-risk patients. methods: we retrospectively analyzed the outcomes of children (median , range - years old) with primary refractory (n = ) or refractory relapsed (n = ) acute leukemia (aml n = , all n = ) who received hsct in our department between and . the stem cell source was related peripheral blood (pb) in patients, related bone marrow in , unrelated bone marrow in , or unrelated cord blood in . the grafts were hla serologically matched (n = ) or mismatched (n = ) with the recipient. in total, patients received the sequential conditioning approach. as cytoreductive chemotherapy, fludarabine/cytarabine/idarubicin/g-csf (flag-ida) was used in patients, mitoxantrone or daunorubicin/cytarabin in , or other regimens in , and of them were combined with gemtuzumab ozogamicin. without waiting for hematological recovery, the patients promptly underwent hsct; therefore, the median interval between cytoreductive chemotherapy and main conditioning was days. the main conditioning regimens were total body irradiation-based myeloablative (n = ), busulfan-based myeloablative (n = ), or reduced intensity (n = ). results: in children with relapsed/refractory acute leukemia, the -year overall survival (os), leukemia-free survival (lfs), cumulative incidence of relapse (ri), and transplantation-related mortality (trm) were %, %, %, and %, respectively. in multivariate analysis, the use of sequential conditioning was identified as the most favorable factor for lfs (hazard ratio [hr] . ; p = . ), although there were no differences in the outcomes according to the types of cytoreductive chemotherapy or the main conditioning regimen. hla-matched donor (hr . ; p = . ) and pb blasts-negative at the beginning of conditioning (hr . ; p = . ) were also independently associated with better lfs. with sequential conditioning, leukemia burden prior to the hsct was significantly reduced; pb blasts became undetectable at the beginning of conditioning in % patients given the approach, while in % patients without the approach (p = . ). notably, the outcomes in the patients without pb blasts at the beginning of conditioning who received sequential conditioning were promising; the -year os and lfs reached % and % and the -year ri and trm were % and %, respectively. conclusions: our study reveals that hsct with sequential conditioning can be an effective and tolerable treatment option for children with relapsed/refractory acute leukemia. the treatment strategies that focus on the reduction of leukemia burden immediately prior to hsct may contribute to the induction of long-term remissions in patients with high-risk acute leukemia. disclosure: this research was funded by japanese red cross, nagoya st. hospital research grant nfrch - . use of blinatumomab to achieve remission and consolidation with haploidentical transplant with cyclophosphamide post for the treatment of children with refractory acute lymphoblastic leukemia (all) background: most of patients with all in relapse or refractory to conventional treatment have only % possibilities to achieve long term remission. this report refers to the therapeutic efficacy and adverse events from the blinatumomab to achieve molecular remission in patients with pre-b cd + which lead to haploidentical with cyclophosphamide post transplant as a consolidation. methods: a pilot study was conducted in children with refractory all preb-cd +. as a strategy to achieved remission blinatumomab was used at a dose μg/m for continous infusion of hours, increasing the dose to μg/m during days, patients with a mrd of < . log, after cycles received an haploidentical bone marrow transplant as a consolidation, the conditioning regimen was with total body irradiation scheme at cgy/day/ days, cyclophosphamide and etoposide. receiving prophylaxis for gvhd with cyclophosphamide. results: a total of patients were included, seven of them achieved complete remission after cycles of blinatumomab, one with partial remission (table ) , these seven patients, six received an haploidentic transplant achieving graft in of the transplanted patients. one patient had a bone marrow relapse in the first months of the follow-up and patients are free of disease with a follow-up to months (figure ). as a acute complication the patients presented cytokine release syndrome, during the infusion of blinatumumab patients presented tachycardia (table ) and the patients presented agvhd after hsct ( grade i-ii and i grade iv). conclusions: allogeneic bone marrow transplant constitutes a treatment option on those patients that relapse or become refractory to treatment, one of the major problem is basically to identify a hla-identical donor, the alternative is an haploidentical donor. the most important factor to get these results is the disease status before transplant. the use of blinatumomab has proven to be effective in achieving remission in relapse acute linfoblastic leukemia pre-b cd + or refractory to treatment. characteristics nº % male % median age at diagnosis, (range), years . ( - ) status of disease o + relapse % refractory to primary or salvage therapy % complete remission after blinatumomab % partial remission after blinatumomab % active disease % [[p table] . table n° . demographic characteristics of patients undergoing blinatumomab (n= )] disclosure: a. olaya-vargas, r. rivera-luna, y. melchor-vidal, h. salazar-rosales, g. lopez-hernandez, n. ramirez-uribe. we wish to confirm that there are no known conflicts of interest associated with this abstact, the only financial support was provided by mexican associations that helping children wiht cancer in a few patients. sequential high-dose chemotherapy reinduction followed by myeloablative allogeneic transplant for active acute myeloid leukemias methods: at our center, relapsed/refractory aml patients were transplanted during chemo-induced neutropenia after high-dose salvage chemotherapy. median age at transplant was years (range - ). patients suffered from de novo (n= / , %) or secondary aml (n= / , %). genetic risk stratification was reported using stardardized groups proposed by the european leukemia net (eln) in . favorable, intermediate i and ii and adverse risk category at diagnosis was observed in / ( %), / ( %), / patients ( %) respectively. all patients had active disease at the time of sequential therapy and median marrow blast count was % (range - %). patients received a high-dose cytarabine based (mec in / , %) regimen as salvage therapy. donors were haploidentical relatives for / ( %) patients, identical siblings and matched-unrelated for / patients ( %) and / ( %), respectively. a myeloablative conditioning was used to further implement anti-leukemic effects. conditioning, thiotepa-busulfan-fludarabine in % patients, was started at a median of days (range [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] after the last day of chemotherapy. bone marrow and peripheral blood stem cells were used as graft source in / ( %) and / ( %) patients. graft-versus-host disease (gvhd) prophylaxis and supportive care were administered accordingly to each hsct platform. results: all patients engrafted. median day of neutrophil recovery was day + (range - ). median follow-up of survivors was months (range - ). non relapse mortality and relapse incidences (nrm, ri) were % and % at year and % and % at years, respectively. overall cumulative incidences of acute and chronic gvhd were % and % at day + and + . one and year overall survival (os) were % and %, while and year event-free survival (efs) were % and %. significant better os and efs were observed in patients with favorable-intermediate i-ii versus adverse risk score ( - years os % and % vs % and % p= . ; - years efs % and % vs % and % p= . ). adverse risk had a significant impact on os (hr . , p= . ) and efs (hr . , p= . ) by univariate analysis and on ri (sdhr . , p= . ) by fine and gray test. conclusions: though small the patient cohort, our findings suggest that sequential therapy with a myeloablative hsct is feasible in treating relapsed/refractory aml. transplant-related toxicity was low ( %) and relapse was the major treatment-failure. however, even with this approach, patients with adverse cytogenetic features have a very dismal prognosis. for these patients, the use of new drugs before hsct and/or maintenance therapy after transplant is highly encouraged to improve outcomes. disclosure: alessandro busca: honoraria from gilead sciences, merck, pfizer pharmaceuticals and jazz background: in spite of satisfactory results of overall survival (os) after allohsct in st and nd cr aml, relapse free survival (rfs) and graft-versus-host-disease free/relapse free survival (grfs) require further improvement. the detection of mrd is one of the factors which influence on the outcome of allohsct in aml is unclear but identification is important to improve risk-adapted relapse prophylactic treatment after allohsct. aim. to evaluate outcomes of allohcst in st and nd cr pediatric aml depending on the level of mrd status before myeloablative (mac) or reduced intensity conditioning regimens (ric). methods: the data of children with aml in st and nd cr underwent allohsct between and were analyzed. median age at the moment of allohcst was years old ( - ). mrd negative status had ( %) patients, ( %) were mrd positive by flow cytometry. mac based on busulfan ( mg/b.w.) received ( %) patients, on treosulfan - ( %) patients. ric based on melphalan received ( %) patients, based on busulfan ( mg/b.w.) - ( %) patients. patients received prophylaxis of agvhd by atg ( %) or ptcy - ( %) patients plus csa - ( %) or tacrolimus ± sirolimus - ( %) patients that depended on source of transplant (related, unrelated or haplo donor) . results: at the median follow up years in the cohort of mrd positive patients os is % vs % in mrd negative (p> , ). rfs is % vs % accordingly (p= , ). graft-versus-host-disease free/relapse free survival (grfs) in mrd positive patients is % vs % in mrd negative (p> , ). os, rfs, grfs in mrd positive patients after mac is %, %, % vs %, %, % after ric accordingly (p> , ). os, rfs, grfs in mrd negative patients after mac is %, %, % vs %, %, % after ric accordingly (p> , ). os, rfs in mrd negative patients with/without ptcy is %, % vs %, % (p> , ); grfs is % vs % accordingly (p= , ). os, rfs, grfs in mrd positive patients with/without ptcy is %, %, % vs %, %, % (p> , ). conclusions: mrd status does not statistically significant affect on os that can be related to different approaches to the treatment of relapse after allohsct. mrd positive status statistically significant decreases rfs that underline the necessity of posttransplant therapy improvement. ric vs mac in all patients in first and second remission do not show statistically significant impact on os, rfs, grfs. ptcy significantly improves grfs in mrd negative patients. disclosure: none of the authors has anything to disclose. background: with increasing overall-survival (os) of lymphoma patients, higher incidences of therapy-related clonal bone marrow diseases, such as acute myeloid leukemia (aml) and myelodysplastic syndrome (mds) are occuring. generally, the outcome is considered poor. allogeneic hematopoietic stem cell transplantation (allo hsct) often remains the only potentially curative treatment option. nonetheless, there is only little data available concerning this patient group. methods: we retrospectively collected data from patients with therapy-related aml (taml) and mds (tmds) after treatment for hodgkin's lymphoma (hl; n= and n= ) or non-hodgkin's lymphoma (nhl; n= and n= ), who received an allo hsct between and . median follow-up of surviving patients was . years (range . months- . years). background: the prognosis of relapsed/refractory acute leukemia (r/r al) is poor and the treatment is challenging. in this setting, allogeneic stem cell transplantation (allo-sct) constitutes the only curative option although the high relapse rate and non-relapse mortality (nrm). the sequential conditioning regimen followed by allo-sct has been used for persistent disease and aims to improve disease control by intensified chemotherapy, thus conceding more time for the presumed graft-versus-leukemia effect to occur. methods: the clinical outcome of r/r al with the sequential conditioning regimen combining a chemotherapy rescue followed by ric allo-sct in our center is described. patients who underwent a sequential allo-sct from to are included. the primary endpoint was progression free survival (pfs) and overall survival (os) that were estimated by the kaplan-meier method. secondary endpoints were non-relapse mortality (nrm). background: recommendations of the european leukemia net (eln) for favorable-risk genetics (frg) acute myeloid leukemia (aml) favor consolidation over transplantation, although reviews suggest advantage of autologous stem cell transplant (asct) in event free survival. our objective was to compare the progression free survival (pfs) and overall survival (os) of normal karyotype npm mutated without flt itd or allelic ratio < . (npm +) aml patients treated with consolidation chemotherapy alone (cc), asct or allogeneic stem cell transplant (allosct). methods: retrospective review of npm + frg-aml patients, treated in one institution ( to ) with the following induction regimens: cytarabine (ara-c) and vp- with daunorubicin (ade) or mitoxantrone (mice). consolidation regimens were ara-c with daunorubicin (ac-d), idarubicin, vp- and ara-c (mini-ice) or highdose ara-c (hidac). in asct, conditioning regimens were bucy or bvac and in allosct were bucy or flubu. pfs and os were calculated from the start of the last consolidation or stem cell infusion. results: a total of patients were evaluated, with a median age of years (y) ( - y), % female, % with ecog performance status (ps) - and % with ageadjusted charlson comorbidity index (aacii) ≥ at diagnosis. patients were treated with cc in % (n= ), asct in % (n= ) and allosct in % (n= ) of cases. there were no differences between groups for age, aacii, ps, leucocytes at diagnosis or extra-medullary disease. flt -itd was more frequent in allosct group ( %) than cc ( %) or asct ( %; p= . ). at induction, ade was used in % and mice in % of patients, with a complete remission (cr) rate of %. there were no differences between groups for induction regimen or cr. in cc group, consolidation regimens were cycle ( %) and cycles ac-d ( %) and cycles mini-ice ( %). asct patients received consolidation with - cycles ac-d ( %) and cycle mini-ice ( %), while allosct patients received - cycles ac-d ( %), cycles hidac ( %) and no consolidation in %. [[p image] . figure . pfs at y in cc, asct and allosct groups.] median follow-up was months, pfs at y was % and os at y was %. pfs at y for asct group was superior then cc and allosct groups ( %, % and %, respectively; figure ), although not statistically significant. os at y was statistically similar between groups, although inferior in allosct comparing to cc and asct ( %, % and %, respectively). conclusions: in this historical cohort review, although there was no advantage in os for asct in npm + frg aml, our data suggests that there might be a pfs improvement in asct over cc, which needs to be further addressed in prospective studies. disclosure: nothing to declare background: acute myeloid leukemia is a hematological malignant disease that motivates the persistent struggle in the scientific world to provide effective cure that can establish acceptable survival rates in this group of patients. autologous stem cell transplantation with myeloablative conditioning is still a powerful weapon that can be used against this entity methods: we have evaluated retrospectively patients with aml where autologous stem cell transplantation was performed in the period from till . our group consisted of patients; male patients ( . %), female patients ( . %). median age at diagnosis was years ( - ). the average period from time of diagnosis to autologous sct was . months. results: in the majority of our group, we used myeloablative conditioning regimen with busulphan-cyclophosphamide, patients ( . %), in patients ( . %) we have added melphalan to bu-cy conditioning, in ( . %) patients we used beam conditioning and in the rest, patients ( . %) we used bam conditioning regimen. as auto graft we used peripheral blood stem cells (pbsc) in patients ( . %), and in patients ( . %) we used bone marrow. the main mobilising regimen for pbsc was g-csf + etoposide and it was performed in patients ( . %), and in the remaining patients ( . %) mobilising of pbsc was performed only with g-csf. the mean number od apheresis procedures done in our group was . , and the mean number of collected mononuclear cells was . x /kg tt. the mean time to engraftment was . days ( - ). the transplant related mortality (trm) was . %. the year overall survival of our patients was . patients. the main reason for death was relapse of the primary disease( %). patients ( %)were treated with salvage chemotherapy regimen (flag-ida) because with the standard induction regimen + there was absence of adequate therapeutic response, or predominantly no complete remission was achieved. all patients were transplanted in complete remission conclusions: autologous stem cell transplantation could be an acceptable therapeutic solution for patients with aml as a consolidation therapy, where neither suitable compatible donor is available nor allogeneic stem cell transplantation could not be performed from various reasons depending on the bone marrow transplant unit disclosure: nothing to declare p prophylaxis dli alone may not prevent relapse of flt -itd positive aml after allogeneic hct background: one of the most potent prognostic factors affecting outcomes in aml is the presence of cytogenetic and molecular markers which can guide the selection of post-remission therapies. recently, favorable outcomes of npm wt /flt -itd neg /non-cebpa dm group after allogeneic hematopoietic cell transplantation (allo-hct) have been reported, that is similar to those of favorable risk by the eln risk classification. however, the role of allo-hct compared to consolidation chemotherapy has not yet been elucidated. methods: the data of patients who were diagnosed with aml and received intensive induction therapy from march to july were included in the current study. to address the time dependence of the allo-hct, the simon and makuch method was used in the graphical representation and the mantel-byar test and andersen and gill methods for identifying risk factors for long-term survival. results: median age of the patients were years (range - ), and patients ( %) were male. npm mutation was detected in patients ( %), and flt -itd were none, low, and high ratio in patients ( %), ( %), and ( %), respectively. the eln risk classification divided the patients into favorable, intermediate, and adverse risk group in patients ( %), ( %), and ( %), respectively. npn and flt -itd both negative group included patients ( %). allo-hct was performed in patients ( %). overall, complete response (cr) after induction therapy achieved in patients ( %), and patients ( %) were primary refractory disease. cr rates did not differ between npm wt /flt -itd negative group (n= / , . %) and other intermediate risk group (n= / , . %; p= . ) . with median follow-up duration of . months (range . - . months), one-year os rate were %, . ± . %, . ± . % in favorable, intermediate, and adverse risk group (p < . ). among intermediate risk group, os rate of npm wt /flt -itd negative group was similar to other intermediate risk (p= . ). allo-hct was performed in patients of npm wt /flt -itd negative group. one-year os rates did not differ between npm wt /flt -itd negative and other for allogenic hematopoietic stem cell transplant (allo-hsct), as a strategy to prolong survival. methods: data from aml pts over years, who underwent ric allo-hsct in our institution between september and september , was retrospectively collected from clinical files to evaluate the overall survival (os) up to november . we calculated the os using kaplan-meyer curves. results: we identified pts, median age y.o. ( - ) and median htc-i score . the median follow-up was months. one patient (pt) had cml blast crisis and was on first major molecular remission. of the remaining aml pts, were in st complete remission (cr), in nd cr and with progressive disease (pd); the other pts could be classified as mds according to who diagnostic criteria and were in cr . donors (d) were: matched unrelated (mud), mismatched unrelated (mmud - / ), matched siblings and haploidentical. thirteen pts were infused with peripheral blood hsc and with bone marrow. conditionings were: flubcnumel in unrelated donor (ud) pts and siblings, flumel in ud pt and sibling, flubu in ud pts and flutbi gy in sibling and in the haploidentical. graft versus host disease (gvhd) prophylaxis was tacrolimus (tac) + mmf in ud pts and sibling, tac + mtx in ud pts and cyclosporine (cya) + mmf in ud pt and siblings. all mmud pts had atg. ptcy was done in the haploidentical setting with tac + mmf. the median time to neutrophil and platelet engraftment for the whole cohort was and days, respectively. one pt with secondary engraftment failure required re-infusion of selected cd + cells. ten pts presented with mild acute skin gvhd. eleven pts had chronic gvhd, classified as severe; required systemic therapy, of those beyond year. the median time on immunosuppressants was days. at years the os was . %. there were deaths: disease-related ( relapses at and months and pd at d+ ), infection complications ( septic shock) and to secondary neoplasia. other relevant complications were hypoxemic pneumonia in pts, urinary sepsis, cmv and ebv reactivation respectively in and pts; pulmonary and renal toxicity either in pts. at end of follow-up, pts were in remission, without negative measurable residual disease (mrd), the other mrd negative pt died of septic shock and severe intestinal gvhd. conclusions: in this small cohort, chronic gvhd and infectious complications were major causes of morbidity but there were no treatment related deaths before d+ . pts maintaining or achieving mrd negativity after transplant had better survival. although with only pts, these results suggest that allo-hsct is feasible as consolidation strategy in selected aml pts over years. [[p image] . overall survival] disclosure: nothing to declare. background: hematopoietic stem cell transplantation (hsct) is the only curative option for fanconi anaemia (fa); an inherited disorder characterized by congenital anomalies, progressive bone marrow failure (bmf) and a predisposition to develop malignancies. methods: we retrospectively analysed the data of consecutive patients that underwent hsct at this centre from till june . the data was analysed for variables affecting the outcome in terms of overall survival (os). results: median age at diagnosis was years ( - years). median age at transplant was . years ( - yrs). all patients at transplant were in aplastic phase. male to female ratio was . : . twenty-four ( . %) patients had congenital anomalies along with bmf while were phenotypically normal. twenty-three ( . %) patients were / hla matched with siblings, with parents and with cousins. eleven ( . %) patients had gender mismatch transplant. three patients had major and had minor abo mismatch. background: paroxysmal nocturnal hemoglobinuria (pnh) is a rare clonal non-neoplastic hematopoietic stem cell disease whose incidence is . - . cases/million of individuals worldwide. disease characteristics and natural history have been mostly analyzed by multicenter, retrospective studies, with the limit of heterogeneous approaches. herein we report the incidence of severe complications and outcome in a real life setting scenario of pnh patients consecutively diagnosed and managed at our pnh referral center between january and june . methods: patients received a homogeneous diagnostic and treatment approach according to the period of observation (availability of diagnostic tests and eculizumab). all patients treated with eculizumab received vaccination with conjugated anti-meningococcus acwyserotypes and, since , conjugated anti-meningococcus b-serotype. in the event of any complication, patients could refer to dedicated hematology emergency rooms (er) hours daily. the occurrence of renal failure and pulmonary hypertension was specifically evaluated. the renal function was studied according to the cockcroft-gault formula and the lung function was prospectively monitored by daytime-on exertion, nocturnal pulsoximetric profiles and complete spirometric tests, with dlco measurement. results: overall, pnh patients, median age years (range - ), were analyzed. at diagnosis, patients had classic pnh, aplastic pnh and an intermediate form. the cumulative incidences (ci) of thrombosis, and clonal hematologic neoplasm were %, and %, respectively. ci of pancytopenia in the patients with classic pnh was %. one patient showed a spontaneous disappearance of the pnh clone. since , eculizumab was administered in patients. after eculizumab treatment % and % of patients reached hemoglobin level > g/dl and > < g/ dl without transfusion, respectively, while % were nonresponsive. during eculizumab treatment no thrombotic event was observed while two severe infectious episodes (respiratory tract and urinary tract infection) were observed in only one of the patients. extravascular hemolysis was demonstrated in % of patients. no patient showed a significant reduction of the renal function.out of patients prospectively monitored for lung function no pathological alteration in any diurnal or nocturnal pulseoximetric test was observed. no patient showed obstructive or restrictive ventilatory deficiency, nor reduced dlco values. -years overall survival (os) was % ( patients who died for non-pnh related reasons were censored at the last follow-up).a better os, even if not statistically significant,was associated to the absence of thrombotic events ( %vs %), and the period of diagnosis ( % in - , % in - , % in - ) . conclusions: our study reports a better os and lower rate of severe complications in pnh compared to previous experiences. although renal failure and lung hypertension have been reported by other groups, we did not observe these complications along a prolonged follow-up. we can assume that the availability of a dedicated er service enabled an early diagnosis and prompt treatment in case of hemoglobinuria crises (reducing the risk or organ damage) or other complications. the use of eculizumab, together with improved supportive approaches, presumably accounts for the trend towards a better survival witnessed over the last decade in the management of pnh patients. disclosure: nothing to declare haploidentical and unrelated allogeneic stem cell transplantation in aplastic anemia:single center experience zafer gulbas , elif birtas atesoglu , meral sengezer , İmran dora , cigdem eren , suat celik , demet cekdemir background: aplastic anemia is a syndrome of bone marrow failure characterized by peripheral pancytopenia and marrow hypoplasia. allogeneic stem cell transplantation from hlamatched sibling is performed in the firstline setting in young aplastic anemia patients and in elderly patients who are refractory to immunosuppressive treatment. but if the patient does not have a hla-matched sibling, allogeneic stem cell transplantation is performed from unrelated and haploidentical donors. in this study, we analyzaed and compared the results of aplastic anemia patients who had undergone allogeneic stem cell transplantation either from matched unrelated or haploidentical donors. methods: we collected and analyzed data of aplastic anemia patients who had undergone allogeneic stem cell transplantation from matched unrelated or haploidentical donor between and . results: there were patients who had received allogeneic stem cell transplantation from unrelated donors and there were patients who had undergone haploidentical transplantation. but in patients who had undergone haploidentical transplantation, engraftment failure had occurred and they were transplanted from different haploidentical donors fort he second time. so a total of unrelated and haploidentical transplants were performed. the median age of patients who had undergone unrelated transplantation was ( - ) and the median age of patients who had undergone unrelated transplantation was ( - ) . the results of the haploidentical and unrelated transplantations are shown in table . the neutrophil and platelet engraftment times were significantly longer in haploidentical transplantations (p= , and p= , , respectively). however, vod, gvhd and day mortality rates were not different in the groups. similarly overall survival (os) of the patients who had undergone haploidentical or unrelated transplantation were not significantly different (p= , ) ( figure ) . conclusions: although the number of patients are low in this study, we can conclude that urelated and haploidentical transplantation in aplastic anemia have comparable toxicity and efficacy. background: autologous stem cells transplantation (ahsct) is an effective treatment for very aggressive autoimmune diseases such as multiple sclerosis (ms). however, toxicity remains the major concern to a wide application of this approach. post transplant viral reactivations may induce severe complications and a rigorous monitoring of peripheral blood viral load for a prompt and effective therapy is required. a higher rate of ebv and cmv reactivation has been observed in patients affected by ms and conditioned with beam plus atg compared with a controlled group of lymphoma patients without atg in the conditioning regimen [ ] . we report here the policy of our center about both monitoring and treatment of such side effect. methods: a series of consecutive patients with ms, transplanted between and is included in this analysis. all patients were mobilized with cyclophosphamide g/sqm + g-csf and conditioned with beam plus rabbit atg (thymoglobulin©, . mg/kg). monitoring of cmv/ebv dna on whole blood by quantitative pcr was performed after the engraftment, weekly for at least one month, then at longer intervals. pre-emptive treatment with valgancyclovir was started in case of cmv viral load ³ x ^ copies/ml. in case of ebv assay between x ^ and x ^ copies/ml further determinations were performed and rituximab-based treatment was started if the viral copies exceeded x copies. patients received treatment in case of symptomatic disease for any value of the pcr of both viruses or ebv titer ³ x ^ copies/ml. results: detectable dna for cmv was observed in / ( , %) patients at a median time from transplant of days (range - ) and / ( %) required pre-emptive treatment. all patients promptly responded to treatment within weeks. ebv viral load was detectable in / patients ( , %) at a median time of days (range - ). one patient out of started the treatment on first determination for high viral load (> x ^ /ml); nine presented an ebv viral load over x ^ copies/ml, three of them were treated thereafter for the persistent increase of the viral load (> /ml). six patients spontaneously recovered the ebv reactivation. previous treatments were not predictive of any higher risk of viral reactivation. no impact on engraftment related to the reactivation was observed. conclusions: this policy shows that, despite a high rate of cmv and ebv reactivation, no grade iii-iv adverse events were observed, suggesting the key role of viral monitoring in these patients and the efficacy of the preemptive treatment. ebv reactivation at low titers should be monitored to identify those cases that could achieve a spontaneous resolution and avoid the induction of further immunosuppression by rituximab. these data confirm that patients diagnosed with ad undergoing autologous hsct need a more intense pattern of care than hematological patients. background: autoimmune diseases are chronic serious conditions that are often refractory to standard therapies. since , autologous haematopoietic stem cell transplantation (hsct) has been a very promising alternative that has shown satisfactory long-term results. the aim of this study is to evaluate immune reconstitution and mortality following hsct in patients with autoimmune disease. methods: a retrospective study was conducted on patients with diagnosis of autoimmune diseases that underwent autologous hsct between july and january at a tertiary referral center in colombia, south america. descriptive statistics were used to analyze patient's demographic and clinic characteristics. results: seven patients were included, with a mean age of years (range - ). five patients were female ( %). the indications for hsct were systemic sclerosis (n= ) , multiple sclerosis (n= ), and myasthenia gravis (n= ). the conditioning regimen administered in patients with systemic sclerosis was cyclophosphamide + human anti-t lymphocyte immunoglobulin, beam (carmustine, etoposide, cytarabine (ara-c), and melphalan) + human anti-t lymphocyte immunoglobulin in patients with multiple sclerosis, and cyclophosphamide + human anti-t lymphocyte immunoglobulin in myasthenia gravis. median time to myeloid engraftment (neutrophils> . × /l) was days post-transplantation, and platelet engraftment, defined as > , platelets/mm untransfused, was days post-hsct. median time of hospitalization was days (range - ); longer in-patient management was due to infectious complications. infectious complications included bacteremia caused by e. coli and pneumocystis pneumonia that resulted in septic shock and acute respiratory failure, respectively. evaluating t-cell immune reconstitution, none of the patients had reached normal cd + cell value after one year of hsct follow-up. four patients ( . %) reached normal cd + cells value at months post-hsct. regarding bcell immune reconstitution, . % of the patients ( / ) had reached both igg and iga normal levels at one-month post-hsct, and four patients ( . %) had achieved normal igm background: multiple sclerosis(ms) is an inflammatory disease caused by autoimmune reactivity of t cells against myelin. there is accumulating evidence of the efficacy of highdose chemotherapy followed by autologous haematopoietic stem cell transplantation(ahsct) in ms patients who failed response to standard immunotherapy, despite a variability in eligibility criteria, conditioning regimens and outcome. methods: we retrospectively reviewed ms patients submitted to ahsct in our centre ( ) ( ) ( ) ( ) ( ) . patient eligibility criteria were active relapsing remitting(rrms) or secondary-progressive ms (spms), with prior failure to treatment with disease-modifying therapies and evidence of disease activity (clinical relapse or new active lesions in magnetic resonance [mr] ). mobilization of cd +cells to peripheral blood was performed with granulocyte colony-stimulating factor(g-csf μg/kg/day) and conditioning regimen according to beam protocol. the severity of ms disability was classified according to the expanded disability-status scale (edss) and ahsct toxicity was evaluated by ctcaev . . results: seven ms patients had undergone ahsct ( female/ male), with a median age at ahsct of . years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . median age at ms diagnosis was . years( - ) and median time from diagnosis until ahsct was . years ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . four patients ( . %) had spms and ( . %) had rrms, with ( . %) having mr active lesions. pre-ahsct relapse rate per year was ( ) ( ) ( ) ( ) . median baseline edss was . ( . - . ). median number of previous dmts was ( ) ( ) ( ) ( ) ( ) ( ) ( ) . all patients had been treated with corticosteroids and copaxone, ( . %) received rituximab, ( . %) natalizumab, ( . %) alemtuzumab, ( . %) fampridine and ( . %) fingolimod. all patients collected enough cd + cells in a single apheresis session. median number of cd + cells infused was . ± . x ^ /kg, for a mean dmso volume of . ± . ml. median inpatient stay during ahsct was days( - ). all patients developed febrile neutropenia, one was admitted to intensive care unit due to sepsis. one patient developed an anaphylactic reaction to transfusion and another a self-limited encephalopathy. two ( . %) patients had grade≥ oral mucositis, and all had gastrointestinal toxicity (grade - ). median time until neutrophils> /μl was ( - ) days, to platelets> , /μl was days( - ), and to engraftment was days ( ) ( ) ( ) . patients were transfused with a median of ( - ) unit for erythrocytes and ( - ) for platelets. there was no treatment-related mortality and no long term side effects have been observed so far. for a median post-ahsct follow-up of . months, no patient developed new lesions in mr, but ( . %) experienced symptoms consistent with a clinical relapse, at a median time of . ( - ) months, effectively rescued with corticosteroids. the absence of evidence of disease activity at -months was . %. although there was no variation concerning edss punctuation, ( . %) patients self-reported significant benefits, especially concerning limb strength and sphincter continence improving. conclusions: our real life results claim a stabilization effect of ms patients with highly active/progressive disease after ahsct, with no significant toxicity. the failure in reporting benefits in edss punctuation is probably due to a small sample size and short follow-up. more studies are needed to establish the best patient selection criteria and define the ideal time to include these patients in transplantation programs, as well as to evaluate its long term outcome. disclosure: nothing to declare. elena poponina , elena butina , anna yovdiy , galina zaytseva , natalia minaeva , igor paramonov background: reactivation of epstein-barr virus (ebv) represents a potentially life-threatening condition in approximately % of patients after allogeneic stem cell transplantation, with no specific treatment available. methods: we have previously developed a manufacturing protocol for the expansion of cytomegalovirus (cmv) and ebv-specific t cells by stimulation of g-csfmobilized stem cell grafts with defined peptide pools (gary, ) . this advanced therapeutic medicinal product is currently investigated in an ongoing phase i/iia trial (eudract number: - - ) . however, the expansion of virus-specific t cells relies on a pre-existing virusspecific memory compartment in the stem cell donor. in virus-seronegative donors, no expansion can be achieved. we therefore aim to identify ebv peptide-specific t cell receptors (tcrs) that can be translated into off-the-shelf cell products for the treatment and prophylaxis of ebv infection and ebv-associated malignancies. leftover cells from five allogeneic stem cell grafts were expanded in vitro in the presence of hla-b * -restricted peptides (hpvgeadyfey from ebna , eplpqgql-tay from bzlf ) associated with latent and lytic ebv infection. after expansion, single ebv-specific t cells were facs sorted using peptide-mhc (pmhc) tetramers, and individual tcr αand β-chain pairs were determined with single cell sequencing (han , penter . to confirm peptide specificity, dominant tcr pairs were transfected into a murine αβreporter t hybridoma cell line with nfat-driven gfp expression (siewert, ) . functional tcrαβ candidates were transduced into human peripheral background: lymphoid and myeloid acute leukemia are the most frequent cause of cancer related death in children. interactions between nkg d receptor, expressed in cytotoxic immune cells, and its ligands (nkg dl), that are upregulated in many types of tumor cells including leukemic blasts, are important for anti-tumor immune surveillance. nevertheless, tumor cells may develop immune scape strategies like ligand shedding, which reduces nkg dl expression and may cause nkg d receptor downregulation. engineering t lymphocytes with nkg d car may overcome immune evasion and become an effective therapeutic strategy. methods: cd ra -t cells were obtained by depletion of non-mobilized apheresis with cd ra magnetic beads using clinimacs. nkg d-car t cells were generated by lentiviral (nkg d- bb-cd z) transduction of cd ra -t cells with moi= . the expression of nkg d ligands was analyzed in peripheral blood or bone marrow samples from a total of leukemia patients (aml= , b-all= and t-all= ), at different status of the disease (diagnosis, remission, relapse/refractory), and in different leukemia cell lines by qpcr and flow cytometry. cytotoxicity of nkg d-car t cells against leukemia cells was evaluated by performing conventional- hours europium-tda assays. soluble nkg dl (snkg dl) concentration was measured in the sera of leukemia patients by elisa. to evaluate the effect of snkg dl on nkg d-car t cells, those were cultured in the presence or absence of different concentrations of snkg dl for days. one week later, cell proliferation and car downregulation were measured by flow cytometry using cell trace violet and nkg d labeling, respectively. the production of ifn-g and tnf-a was measured in the supernatants by elisa. the effect on cytotoxicity was evaluated in a hoursdegranulation assay by co-culturing snkg dl pretreated nkg d-car t cells against k cell line. results: nkg d ligands were expressed in leukemia cell lines and leukemic blasts. nkg dl expression changed with disease status with a trend to decrease at diagnosis and relapse/refractory compared to remission. nkg d-car t cells were cytotoxic against / leukemia cell lines with a percentage of specific lysis over %. myeloid and t-all cell lines were more susceptible to nkg d-car t cells (specific lysis ranging from - %) compared to b-all cell lines ( - %). physiological concentrations of snkg dl caused an increase in nkg d-car expression. however, supra-physiological levels of snkg dl decreased nkg d-car expression up to times and increased cell proliferation up to times. cd + subpopulation was more affected by downregulation, while proliferation had more impact on cd + subset. the effects of snkg dl were dose-dependent and attenuated by il- . conclusions: nkg d-car t cells are cytotoxic against leukemia cells, specially aml and t-all, and thus could be a novel therapeutic approach for non-b leukemia, or those b-all that relapse with undetectable cd after cd -car treatment. nkg d-car expression may be downregulated only by supra-physiological levels of snkg dl, although antitumor activity is not affected. il- softens the negative effects of snkg dl inducing nkg d expression, cell proliferation and cytokines production. the changes observed in nkg dl surface expression at the different stages of the disease could be related to ligands release and immune escape. disclosure: nothing to declare denis-claude roy , , ines adassi , , céline leboeuf , , vibhuti p. dave , hôpital maisonneuve-rosemont research center, montréal, canada, university of montréal, montréal, canada background: for patients with high-risk leukaemia, allogeneic haematopoietic stem cell transplantation is the only curative treatment. the presence of alloreactive t cells in the donor graft, however, leads to a high probability of developing graft-versus-host disease (gvhd) . t-cell depletion minimises the presence of gvhd-causing alloreactive cells, but often results in an increased incidence of infections and disease relapse. photodepletion treatment (pdt) can specifically deplete activated alloreactive t cells while conserving resting t cells. pdt-treated cells have been utilised after t-cell-depleted haploidentical transplant to help reduce infection and relapse. the efficacy and safety of such pdt-treated cells is currently under clinical investigation in a phase iii trial (hatcy, nct ; kiadis pharma). here the reactivity of pdt-treated donor t cells was assessed toward tumour-associated and viral antigenic peptides derived from wilm's tumour protein (wt p), preferentially expressed antigen in melanoma (pramep), and from cytomegalovirus and epstein-barr virus (cmv/ ebvp). methods: healthy donor (hla-a* ) peripheral blood mononuclear cells (pbmcs) were co-cultured with irradiated pbmcs from another mismatched donor ( : ) in a -day mixed lymphocyte reaction. th , a photoactive rhodamine derivative, was added and cells were exposed to visible light to deplete the th -containing activated alloreactive cells. elimination of alloreactive cells post-pdt was assessed using cd and hla-dr as activation markers. an ex vivo expansion protocol was exploited to evaluate the impact of pdt on reactivity to tumour and viral antigenic peptides. post-pdt t cells were co-cultured with irradiated autologous monocyte-derived dendritic cells ( : ) pulsed with wt p, pramep or cmv/ebvp. antigen-specific t cells were re-stimulated on days and with wt p-or pramep-pulsed autologous pbmcs or with cmv/ebvp added directly to the culture. mhctetramer staining was performed on days and ; ifn-γ elispot was conducted on day . [[p image] . functional wt -specific and viralspecific t cells can be expanded post-pdt] results: pdt resulted in a drastic decrease of cd and/ or hla-dr activation marker-expressing cd + and cd + t cells. pdt-treated cells showed a significant increase in background: acute lymphoblastic leukemia (all) is the most common childhood cancer and relapsed or refractory all is still difficult to treat. engineered t cells equipped with a synthetic chimeric antigen receptor (car) targeting cd have demonstrated remarkable efficacy to treat all. however natural killer (nk) cells are known for their target-independent cytotoxic potential without induction of cytokine release syndrome (crs) or graft-versus-hostdisease (gvhd), car-nk cells can overcome the persisting problem in the therapy with car t cells. as the use of viral vector generated car nk cells is limited by theire genotoxicity, cost and regulatory demands, we are developing an innovative protocol using non-viral sleeping beauty (sb) transposition of third party nk cells as a source to produce 'off the shelf' car-engineered cell products. methods: nk cells are isolated from peripheral blood mononuclear cells (pbmcs) using cd selection kits. they are successfully expanded ex vivo with il- cytokine stimulation under feeder-cell free conditions. after few days of expansion nk cells are electroporated using pmaxgfp. transfection efficiency and percent of living cells after electroporation is analyzed by flow cytometry. transposition based nucleofection using an sb x mrna and a minicircles (mc) dna vector is performed at different time points after nk cell isolation. the transient mc-venus longtime expansion and the viability after sb x based nucleofection is measured over two weeks. furthermore, α-retroviral (α-rv) cd -car transduction of nk cells with different viral amounts (moi) is conducted and the cytotoxicity of the engineered cd -car-nk cells against the cd positiv cell line supb is addressed. results: for an α-rv cd -car transduction of maximal x nk cells we could show transduction efficiency of , % for moi . the α-rv cd -car modified nk cells had a high killing activity against cd positiv supb cells (e:t ration : , %) compared to cd negativ k cell lines (e:t ration : , %) and the non-transduced nk cells (e:t ratio : , %). in first experiments with pmaxgfp vector based nucleofection, we could show an increasing efficiency of , % h post electroporation with a only slightly decreas of living cells ( , %) comparing to the non-electroporated nk cell viability. using sb x mrna with mc-venus dna we electrotransfected x nk cells after fews days of cultivation and we reached , % of transfected nk cells h post electroporation and a transient expression of mc-venus positive nk cells up to , % efficiency with an increasing rate of live cells over days after electroporation. conclusions: the sleeping beauty based nucleofection of nk cells is a very promising non-viral method to generate more easy, safer and higher amounts of genetically modified third party nk cells for therapy of all and has also a broad range of clinical applications. disclosure: winfried s. wels is an inventor on a patent describing chimeric antigen receptors with an optimized hinge region. axel schambach is an inventor on a patent describing alpharetroviral sin vectors. michael hudecek and zoltan ivics are inventors on patents related to sleeping beaut gene transfer technology. the remaining authors have nothing to disclose. background: mature immune cells from the stem cell graft are essential for the graft-versus-tumor (gvt) effect to eliminate residual malignant cells after hematopoietic stem cell transplantation (hsct), but donor cells are also involved in complications such as graft-versus-host disease (gvhd). methods: we performed a prospective study of the detailed graft composition in recipients of peripheral blood stem cells (pbsc) or bone marrow (bm) in order to identify correlations to clinical outcomes, table . grafts were characterized with concentrations of t cells and nk cells together with a multi-color flow cytometry panel with staining for tcrαβ, tcrγδ, vδ , vδ , cd , cd , cd , hla-dr, cd , cd ro, cd ra, cd , cd , cd and cd for detailed immune phenotyping. cell contents in stem cell grafts were analyzed both as fractions of cd positive lymphocytes and as absolute concentrations converted to transplanted cells/ kg. fractions were evaluated in patients receiving both bm and pbsc (n= ), while concentrations (cells/kg) were only analyzed in patients transplanted with pbsc (n= ). table] . table ] [[p image] . figure ] results: we found, that patients transplanted with graft nk cell doses above the median of x /kg and fractions of nk cells out of lymphocytes above the median of . % had significantly increased relapse-free-survival compared to patients transplanted with grafts containing nk cell doses below these values, figure ; results stayed significant in multivariate analyses. relapse incidence was significantly lower in uni-and multivariate analyses in patients receiving grafts with high nk cell fractions compared with low fractions, p= . , with -year relapse rates of % versus % in patients transplanted with high versus low fractions of nk cells, p= . . peripheral blood concentrations of nk cells obtained from samples from pbsc donors before g-csf mobilization were significantly correlated to graft concentrations-and fractions of nk cells.. analyses of graft contents of nkt cells showed that the incidence of grade ii-iv acute gvhd were significantly lower in patients background: extracorporeal photopheresis (ecp) is an immunomodulatory treatment that has shown efficacy in steroid refractory acute gvhd, but the mechanism of action is only partially understood. there is no clear relationship between the ecp-treated mononuclear cells (mnc) or lymphocyte numbers and response to ecp. the objective of the study was to analyse the relationship between the infused subpopulation cellularity and response. methods: patients from different centers with a total of ecp procedures were retrospectively analized. ecp procedures were performed from january- to june- . all ecp procedures were performed with the off-line system. the response was defined as responder (complete and partial response) and non-responder. infused cell numbers for lymphocytes, monocytes and mononuclear cells (lym+mon, mnc) were calculated. for analytic purposes, the median number of cells infused per procedure until response (or until the median number of procedures until response for non-responding patients) and the cumulative number of cells infused until response (or until the median in non-responders) were calculated for all the subgroups. same procedures were performed with the number cells infused until day of ecp. finally, the response and survival impact of infusing a number of cells above or below the median and in different tertiles was assessed until the median number of procedures needed to achieve a response. [[p image] . results: the median number of procedures until response was . we observed a trend towards a higher median number of monocytes per procedure and cumulative infused monocytes in responding patients (median number infused . vs . x /kg p= . , cumulative infused median number . vs x /kg p= . ) that was lost in the day of treatment. there was also a trend toward higher median infused mnc until response for responders ( vs x /kg p= . ). we observed no differences in the number of lymphocytes infused, but patients who received a number of lymphocytes per procedure over the first tertile ( x /kg) presented higher response rates ( % vs %, p= . ). none of the other analysed parameters showed a significant impact in overall survival. conclusions: patients with acute gvhd who responded to ecp received higher numbers of monocytes and mnc in the early phase of the treatment (a median of the first processes). also the patients who received higher numbers of lymphocytes in the first procedures achieved a higher response rate. these findings suggest the possibility that higher number of treated and infused cells could influence the response to ecp, but specifically designed prospective studies are need to asses this possibility. disclosure: nothing to declare background: the field of kidney transplantation has made enormous progress over the last decades towards being a standard treatment for patients with end-stage renal disease. however, administration of immunosuppressive drugs is still one of the major limitations of long-term allograft survival. therefore, strategies for induction of donorspecific tolerance are highly desirable. to this aim, a clinical phase i study with donor-derived modulated immune cells (mics) was conducted. methods: donor-derived mics were manufactured under gmp conditions. potency of mics was tested by different in vitro bio-assays. mics were administered to patients with an escalation from . x mics/kg on day - (n= , group a), to . x mics/kg on day - (n= , group b) or on day - (n= , group c) before kidney transplantation accompanied by standard immunosuppressive medication post-transplantation. frequency of adverse events (ae) was assessed from day until day post-transplant. dynamic changes of various lymphocyte subsets in patients after mic therapy were detected by multicolor flow cytometry. donor-specific immunosuppression was assessed by measuring anti-donor antibodies and mixed lymphocyte reaction (mlr) against donor and thirdparty cells. results: in all kidney transplant recipients, we observed a median serum creatinine of . mg/dl at day which remained stable until day (median creatinine of . mg/ dl) without significant proteinuria. none of patients experienced rejection episode. aes were observed while three aes being severe. most importantly, none of them was associated with mics transfusion. besides two infectious complications, no post-transplant positive cross match results against the donor or titers of de novo donorspecific antibodies were recorded. notably, immunosuppressive therapy could be reduced without signs of rejection in group c. after infusion, we observed a dramatic increase of cd + b cells up to a median of cells/μl until day , followed by a reduction to cells/μl on day in group c. notably, regulatory b cells significantly increased from a median of % on day to % on day . in parallel, the plasma il- /tnf-α ratio increased from a median of . before cell therapy to . on day . after mic cell therapy recipient lymphocytes showed no or only minimal reactivity against irradiated donor pbmcs in vitro, while reactivity against rd -party-donor pbmcs was not impaired. moreover, in vitro mics product demonstrated their immunomodulatory potency by inducing tolerogenic dendritic cells (tdcs) characterized by low expression of costimulatory (cd , cd ) and maturation (cd ) as well as high expression of inhibitory marker cd . functionally, tdcs could inhibit not only the release of ifn-γ but also the proliferation of cmv specific cd + t cells. moreover, mic-induced tdcs showed the capacity to inhibit donor-specific allo-reactive cd + and cd + t cell proliferation. conclusions: mic cell therapy modulates the immune system of kidney transplant recipients by increasing the ratio of regulatory b cells and facilitates the reduction of conventional immunosuppressive therapy without allograft injury or rejection episodes. therefore, mic cell therapy represents a promising strategy in transplantation medicine. we currently prepare a phase ii trial with mic cell therapy. disclosure: nothing to declare p genome editing of graft-derived t cells for post- background: immunotherapy using car t cells has shown promising results to fight cancer. however, car-t cell production requires specialized infrastructure and operators, which implies high cost and centralized production. automated production of car-t cells in clinimacs prodigy device allows clinical-grade manufacturing of car t cells. methods: million cd ramemory t cells from healthy donors were cultured in texmacs supplemented with iu/ml il- . at day cells were activated with t cell transact for h. at day one, activated cd ramemory t cells were transduced with nkg d-cd tm- bb-cd z lentiviral vector at moi = . then, nkg d-car t cells were expanded for - days. nkg d-car t cell products were next harvested, counted and analyzed for viability, nkg d-car expression and anti-tumor cytotoxicity. different quality tests including sterility, vector copy number, genetic stability, quantification of viral particles in the supernatant, myc/tert expression and endotoxin detection were performed. spare cells were cryopreserved either in autologous plasma and % dmso, m % albumin and %dmso or hypothermosol. after months, cryopreserved nkg d-car t cell products were analyzed for viability, nkg d-car expression and cytotoxicity. results: nkg d-car memory t cells expanded up to ± million with , ± % nkg d-car expression and ± % viability. harvested car t cells showed ± % of specific lysis against jurkat cells and ± % against mii osteosarcoma cell line. no microbiological contamination was observed in final car t cells products. vector copy number was ≤ in all validations except for one. cgh and karyotype showed no genetic alterations. free viral particles were undetectable in the supernatants. no overexpression of myc/tert was found except for one validation. endotoxins were ≤ . eu/ml. all cryopreserved nkg d-car t cell products kept nkg d-car expression one year after freezing. however, viability and cytotoxicity was best preserved using autologous plasma %dmso. conclusions: automated production of large-scale clinical-grade nkg d-car t cells using clinimacs prodigy is feasible and reproducible, allowing a decentralized protocol to generate car t cells for clinical use. background: immune reconstitution (ir) is essential to control severe infections after hematopoietic stem cell transplantation (hsct). reconstitution of adaptive immunity may take up to years to recover t-lymphocytes (lt). delay in early lt recovery increases the risk of relapse, viral infections and transplant related mortality. adoptive transfer of selected t cell subset with low alloreactivity potential is emerging as a strategy to improve ir. methods: depletion of cd ra+ naive t cells, preserving cd ro+ memory t cells could provide functional lymphocytes to protect against infection and leukemia relapse with low risk of graft versus host disease (gvhd). we present our experience with high-dose donor cd ro + memory t cell as donor lymphocyte infusions (dli) to assess safety and outcome. a total of dli of cd ro+ after hsct was performed in cases of cmv/ebv reactivation ( %), mixed chimerism ( %), persistent lymphopenia ( , %), graft rejection ( , %) , relapse ( %) or to boost ir ( %). dli product was obtained performing a cd ra depletion on donor leukapheresis product using the clinimacs® device. results: twenty-two pediatric patients, median age years (range - ), with malignant (n= ) and nonmalignant diseases ( ), received cd ra+ (n= ), tcr alpha/beta (n= ) depleted grafts from haploidentical and cd ra+ depleted grafts from match unrelated (n= ) and match related (n= ) donors. at a median of days (range - ) after transplantation, patients received a total of dli of cd ro+ cells, median (range - ), containing a median of . x /kg (range . x - x /kg), cd +cd ro+ . x /kg (range . x - . x /kg) and cd ra+ cells x /kg (range - . x /kg). all infusions were well-tolerated and did not develop or worsen gvhd. a total of / episodes of cmv/ebv viral reactivations decreased viral load, / cleared viral load and / showed a clinical improvement. a total of / patients with persistent lymphopenia there was a slightly increase in total lymphocyte count, but not to normal levels. prophylactic dli of cd ro+ to boost ir increased lymphocyte count in of cases. none of the dli administered in cases of mixed chimerism, graft failure or relapse were effective in reverting those situations. conclusions: our preliminary data suggest that infusions of high dose cd ro+ memory t cells are a safe adoptive immunotherapy strategy. efficacy has been observed in patients with lymphopenia and cmv/ebv reactivation, with no positive results in patients with mixed chimerism, graft failure and relapse. however, to determine the real efficacy of this strategy, prospective studies are required. disclosure: nothing to declare. background: increasing clinical trials have confirmed that chimeric antigen receptor t cells (car-t) targeting cd antigen (car-t- ) is a promising effective approach for the treatment of relapsed/refractory(r/r) b-cell lineage malignancies. considering cd is frequently expressed in large part of t( ; ) acute myeloid leukemia (aml) cells, we suppose that car-t- may be used as an approach to rescuing r/r t( ; ) aml patients. methods: both patients received lymphodepletion chemotherapy with decitabine mg/m × d, fludarabine mg/m × d and cyclophosphamide mg/m × d (dac +fc). two days after chemotherapy, autologous/allogeneic cart- cells provided by the unicar-therapy biomedicine technology co.(shanghai, china) at a total dose of - × cells per kilogram(kg) were infused dose escalation within to days. the research protocol was approved by the institutional review boards of the first affiliated hospital of soochow university and both patients gave written informed consent. results: both cases responded well with transient and reversible toxicities. case presented with grade cytokine release syndrome (crs), manifested by intermittent fever and chill from day after car-t- infusion for half months associated with neutropenia. car-t cells expansion were observed in blood without obvious increase of cytokines. after infusion, case achieved and maintained molecular complete remission (cr) for more than months. case presented with grade crs manifested by continuous high fever, hypotension and grade liver disfunction from day after car-t- cell infusion for week. obvious cytokines releasing (peak il- serum concentration . pg/ml, peak crp serum concentration pg/ml) were detected which were associated with car-t- cell expansion in blood and no severe off-tumor effect was observed. after infusion, case achieved hematological cr and cytogenetic cr and got months disease free survival. conclusions: our report implicates that car-t- is a safe and promising approach to managing r/r t( ; )aml with cd expression, and may provide a salvage treatment approach for all aml patients with cd expression and benefit a certain population with aml besides b-linage malignancies. clinical trial registry: na disclosure: nothing to declare. this work was supported by research grants from the national key r&d program of china ( yfc ), national natural science foundation of china ( , , , ) background: chimeric antigen receptor engineered t (car-t) cells have emerged as a powerful cellular therapy to treat malignant disease, which is currently revolutionizing field of cancer immunotherapy. a cryopreservation step postmanufacture is not only a logistical necessity for large scale cell manufacturing processes but also a mandatory request by regulatory authorities. in case relapse after st car-t cell transplantation, a second application, maybe at a higher dose constitutes a therapeutical option. however, data concerning clinical grade car-t cell stability and functionality after months of cryopreservation have not been released by companies so far. to investigate the effect of cryopreservation on car-t cells, we performed this study. methods: different batches of cd car-t cells were manufactured according to gmp requirements at our institution. final car-t products were frozen at concentrations of x cells/ml (high batch) and x cells/ml (low batch) by a controlled freezing process with the biofreeze bv device and stored in liquid nitrogen tanks below - °c until release. quality control tests for sterility, endotoxin and mycoplasma were performed for each batch according to european pharmacopoeia and united states pharmacopoeia guidelines. stability of cd car-t cells in terms of viability, recovery, transduction efficiency and functional capacity were determined by microscopy, multi-parametric flow cytometry as well as chromium- release tests following our sops. results: all the results of quality controls fully met the requirements of the regulatory authorities. stability results were highly robust and reproducible over time for all our gmp car-t batches. duration of cryopreservation (up to days) had no negative influence on cell viability, recovery of viable cd car-t cells and transduction efficiency. however, the cell concentration for cryopreservation has a significant impact on the post-thawing viability (low batches vs. high batches: . ± . vs. . ± . , p < . ) and recovery (low batches vs. high batches: . ± . vs. . ± . , p < . ) of cryopreserved cd car-t cells, but not the transduction efficiency. moreover, we observed four transient side-effects of cryopreservation on the amount of cytokines released by car-t cells, the cytokine release on a per-cell basis, the multifunctionality of car-t cells and the killing capacity. of note, functional capacity of cryopreserved car-t cells after overnight resting was comparable or even enhanced for inf-γ and tnf-α release by cd + and cd + cd car-t cells when compared to fresh car-t cells. the multi-functionality of car-t cells could be preserved. furthermore, the killing capacity of cryopreserved cd car-t cells after overnight resting could reach the level of non-cryopreserved/fresh car-t cells. conclusions: cryopreservation up to days has no harmful effect on transduction efficiency and functionalities of car-t cells. however, the cell number per milliliter freezing medium matters. dose over x cells/ml should be avoided. for the conduction of in vitro bio-assays to determine the function of car-t cells, an overnight resting process could mimic the situation after clinical application and eliminate the transient side-effects of cryopreservation to fully regain the functional potency of car-t cells. disclosure: nothing to declare background: dc and specific t-cells are important mediators of ctl-responses. we could already show that allogeneic donor-or autologous t-cells obtained from amlpatients can be stimulated by dc leu , resulting in a very efficient lysis of naive blasts. methods: chemokine-release (cxcl , - , - , ccl , - , and il- ) was analysed by cytometric bead array in serum of aml/mds-pts as well as in supernatants from different dc-generating-methods and correlated with pts' clinical course, dc-and t-cell-interactions as well as specific t-cell-reactions. the lytic activity of dcleu/blast -stimulated t-cells in mlc against naive blasts was quantified in a cytotoxicity assay. results: minimal differences in median chemokine-levels in pts' serum subdivided in subtypes were seen, but higher release of cxcl , - , - and lower release of ccl and - tendentially correlated with more favourable subtypes (< years of age, < % blasts in pb). in persisting disease, a higher serum-release of ccl and at relapse a significantly higher ccl -release were found compared to first diagnosis -pointing to a change of 'disease activity' on a chemokine level. whereas chemokine-levels in dc-culture supernatants compared to serum were variable, clear correlations with lateron (after stimulating t-cells with dcleu in mlc) improved antileukemic t-cell activity were seen: higher values of all chemokines in dc-culture supernatants always correlated with improved t-cells' antileukemic activity (compared to stimulation with blast-containing mnc as control) -whereas with respect to the corresponding serum values higher release of cxcl , - , and - but lower values of ccl and - correlated with higher probabilities to improve antileukemic activity of dcleu-stimulated (vs. blaststimulated) t-cells. predictive significant cut-off-values could be evaluated separating the groups compared. moreover, correlations with lateron achieved response to immunotherapy and occurrence of gvhd were seen: higher serum values of cxcl , - , - and ccl and lower values of ccl correlated with achieved response to immunotherapy. predictive cut-off-values could be evaluated separating the groups compared in 'responders' and 'non-responders'. higher levels of ccl and - but lower levels of cxcl , - , - correlated with occurrence of gvhd. conclusions: we conclude, that in aml-pts' serum higher values of cxcl , - , - and lower values of ccl and in part of ccl correlate with more favorable subtypes and improved antitumor'-reactive function. since in dcculture supernatants higher values of all chemokines correlated with improved antileukemic t-cell reactivity we conclude a change of functionality of ccl and - from an 'inflammatory' or 'tumor-promoting' to an 'antitumor'reactive function. this knowledge can contribute to develop immune-modifying strategies that promote antileukemic adaptive immune-responses. disclosure: nothing to declare background: allogeneic hematopoietic cell transplantation (allo-hct) is a curative treatment option for patients suffering from hematologic malignancies. infusion of donor lymphocytes (dlis) can induce sustained remission in case of minimal residual disease or relapse through potent graftversus-leukemia (gvl) effects, although graft-versus-host disease (gvhd) represents a common dose-limiting toxicity. as invariant natural killer t (inkt) cells are known to prevent gvhd while promoting beneficial anti-tumor effects, we investigated the role of inkt cells for successful dlis. methods: we analyzed dli samples by flow cytometry. inkt cells were identified by staining with pbs -loaded cd d tetramers. culture-expanded and purified dli-inkts were then tested against tumor cell lines and primary leukemia cells in an ex vivo tumor control model. tumor cell viability after coincubation with dli-inkts was measured by flow cytometry using -aad. results: inkt cells represent . % (range . - . %) of donor lymphocytes and can be expanded fold following a two-week protocol with a preferential expansion of cd + inkt cells. tumor cell lines such as jurkat were efficiently lysed after coincubation with dli-inkts. cd a as a marker of degranulation was significantly upregulated on dli-inkts after stimulation by jurkat. in addition, increased concentrations of tnfα, ifn-γ, sfasl and perforin were measured after coincubation of dli-inkts with jurkat. we observed that tumor cell lysis correlated with the expression of the mhc-i-like molecule cd d. consequently, adding a cd d antibody to the coculture abrogated the dli-inktmediated kill of tumor cells. dli-inkts also efficiently lysed primary leukemia cells such as aml blasts: expression of cd d on these aml blasts significantly correlated with dli-inkt-mediated tumor cell lysis (r = . , p= . ). conclusions: ex vivo expansion of dli-inkts and subsequent dli enrichment is an immunotherapeutic approach that could improve leukemia control and thus, prevent relapse after allo-hct without exacerbating gvhd. disclosure: nothing to declare. generation of antigen-specific cytotoxic t lymphocytes targeting wt using activated b cells sun ok yun , kyung won baek , hee young shin , hyoung jin kang seoul national university, seoul, korea, republic of background: the wilms tumor antigen (wt ) is highly expressed in many malignancies including leukemia and targeting wt as a tumor associated antigen (taa) in cancer immunotherapy is attractive. in this study, we generated wt -specific cytotoxic t lymphocytes to confirm if activated b cells can act as a cancer antigen presenting cell and induce ctls. methods: for the induction of ctls against wt , activated b cells were used as an antigen presenting cells. b cells were isolated from pbmcs of normal healthy donors and activated with α-galactosylceramide (α-galcer) and nucleofected with wt -coding plasmid dna. activated b cells were the cultured with pbmcs for days in vitro and harvested for assay. results: cells expanded about times after days of culture. we examined characteristic of wt -specific ctls by their surface markers. wt -specific ctls had more than % cd + marker, and ratio of cd to cd was . - . . we also examined nkt cell markers to see if nkt cells were activated by il- , a cytokine used in the induction of ctls, and the portion of nkt cells was about %. the ctls showed a decrease in naïve cell (cd l+cd ra +) and an increase in effector memory (cd l+cd ra-) and central memory (cd l-cd ra-) compared with non-stimulated pbmcs. subsequently, the ifn-γ elispot (enzyme-linked immunospot) assay was performed to confirm the response of the induced wt -specific ctls to the wt antigen. when wt -specific ctls encounters a target that does not have a wt antigen, it did not produce ifn-γ, but when it encounters a target cells loaded wt antigen, it responded to secrete ifn-γ. killing assays were also performed to determine the immunogenicity of induced ctls. the induced wt ctls was found to be killing more than % when the e:t ratio was : when the autologous pbmc met the target with wt pepmix. in addition, we found that wt ctls has killing activity when it encounters leukemia cell lines that express wt and matched hla-a* . conclusions: in this study, we can induce antigenspecific ctls that specifically react to wt using activated b cells as antigen-presenting cells. these observations confirmed that b cells activated by α-galcer can act as a taa presenting cell to induce taa specific ctls as viral antigen, such as pp and ie , and consequently wt specific ctls could be induced. moreover, ctls induced activated b cells had ability to recognize and kill the target cells expressing wt correctly. our results demonstrate that these in vitro expanded wt -specific ctls using activated b cells can be a promising candidate for adoptive immunotherapy against cancer. disclosure: nothing to declare judith böhringer , michael schumm , christiane braun , marina schmidt , patrick schlegel , christian seitz , murat aktas , georg rauser , sandra karitzky , peter lang , rupert handgretinger university children's hospital tübingen, tübingen, germany, miltenyi biotec gmbh, bergisch gladbach, germany background: t cells with chimeric antigen receptors (cars) on their surface facilitate to target specific surface expressed antigens. research and clinical trials with cd -car t cells show impressive remission induction rates and increased survival in heavily pretreated patients. therefore, car t cells are introduced as new potent cellular therapeutics in the clinical routine. in order to establish the manufacture of cd -car t cells, validation runs with the fully automated clinimacs prodigy t cell transduction process have been performed using the miltenyi anti-cd -car lentiviral vector. methods: unmobilized leukaphereses from donors ( x healthy, x all) were used for the clinimacs prodigy t cell transduction process. leukocytes undergo a cd + / cd + t cell enrichment via magnetic beads, followed by stimulation with macs ® gmp t cell transact™, transduction with an anti-cd -car lentiviral vector, expansion with il and il , and final formulation to the cellular product. during and after the manufacture, facs analyses were performed as well as cytotoxicity assays after cd -car t cell production. results: total volumes of leukaphereses were between and ml with . - . x total mononuclear cells. after enrichment x cd + / cd + t cells were transduced with anti-cd -car lentiviral vector and were further expanded. cells were harvested on day . the final cell counts of the cellular products were . , . and . x mononuclear cells from two healthy volunteers and the all-patient, respectively. the transduction efficiency of the cd -car t cells was . %, . % and . % among viable cd + cells. the final count of car t cells was therefore . , . and . x cells. the final products exerted excellent cytolytic activity against cd + bcp-all cell line nalm- . importantly, cd -car t cells generated from the all patient demonstrated complete eradication of autologous blasts at . to e:t ratio after hours incubation. conclusions: the clinimacs prodigy t cell transduction process has been shown to run a fully-automated manufacturing process over days without any deviations in a clean room environment on a single device. the user interaction was reduced to activities at only days to set up the system and provide fresh medium and reagents. the transduction process yielded a high number of t cells with a high frequency of cd -car t transduced cells. the results were comparable for both unmobilized leukaphereses from healthy donors and showed expected slightly lower results in the patient. finally, these results demonstrate that the clinimacs prodigy t cell transduction process is well suited to provide the clinical mb-cart . r/r cd + bcm study with appropriate investigational medical products. disclosure background: allogeneic hematopoietic stem cell transplantation (allohct) is an effective strategy in the long term control of several hematologic diseases, however, patients could experience complications, as graft versus host disease (gvhd) and disease relapse. recently, the introduction of post-transplant cyclophosphamide (ptcy) allowed to significantly reduce gvhd, but disease relapse remains an important issue. donor-lymphocyte infusion (dli) is an established adoptive cell therapy for disease relapse after allohsct, but, in order to be efficient and safe, patients have to be off immunosuppression treatments and gvdh-free. here we report our data about efficacy and safety of dli infusion as treatment for disease relapse in patients who received peripheral blood stem cell transplantation (allopbsct) from hla-matched unrelated/related plus ptcy as gvdh prophylaxis in our clinical trial (nct ). methods: we collected data from patients, treated with ptcy ( mg/kg/die, days + + ), mofetil mycophenolate (mmf) and tacrolimus (t) as gvhd prophylaxis after allo-pbsct, who received dli infusions. they were treated between january and october . we report data about overall response rate (orr), disease control rate (dcr), and dli-related mortality and morbidity. diagnosis were as follow: had multiple myeloma, had acute myeloid leukemia, had acute lymphoblastic leukemia and had lymphomas. all patients but one, who had chimerism loss, received dli because of disease relapse. results: median time between transplant and dli was (range - ) months. median number of dli infusions was (range - ). patients ( %) received cyclophosphamide mg/m preparative regimen the day before the cryopreserved dli infusions, while in the other cases dli were associated with lenalidomide, ponatinib and -azacitidine. the overall response rate (orr) was %, while disease control rate (dcr) was achieved in %. the patient who received dli because of loss of chimerism converted it in full donor after infusions. after dli treatment the incidence of acute gvhd grade i-iii was %, while was % for grade ii-iii and patients were started on short course of systemic immunosuppression treatments . none of these patients died because of dli adverse events. estimated -year overall survival was % with a limited follow-up length ( months). conclusions: the infusion of non-manipulated lymphocytes from allogeneic donors is a valuable and safe strategy of treatment for patients relapsing after allopbsct with ptcy. ptcy showed high efficacy in gvhd prevention, allowing early discontinuation of immunosuppression drugs. because of this, we can reach the goal to transform transplant in a platform where we could add early dli infusions as a new strategy for disease control. clinical trial registry: nct disclosure: nothing to declare p extracorporeal photopheresis in the treatment of refractory chronic gvhd: analysis of mononuclear cell infusion gillen oarbeascoa , maria luisa lozano , , , luisa maria guerra , cristina amunarriz , nuria revilla , , , pastora iniesta , , , cynthia acosta fleitas , jose luis arroyo , eva martinez revuelta , andrea galego , dolores hernandez-maraver , mi kwon , , aurora viejo , jose maria garcia gala , concepcion andon saavedra , jose luis diez-martin , , background: extracorporeal photopheresis (ecp) is an immunomodulatory treatment that has shown efficacy in steroid refractory chronic gvhd, but the mechanism of action is only partially understood. in some studies, a correlation has been suggested between treated mononuclear cells (mnc) or lymphocytes and response to ecp. the objective of the study was to analyze the relationship between the infused cellularity and response in chronic gvhd. methods: patients from different centers with a total of ecp procedures were retrospectively analyzed. ecp procedures were performed from january- to june- . all ecp procedures were performed with the off-line system. the response was defined as responder (complete and partial response) and non-responder. infused cell numbers for lymphocytes, monocytes and mononuclear cells (lym+mon, mnc) were calculated. for analytic purposes, the median number of cells infused per procedure until response (or until the median number of procedures until response for non-responding patients) and the cumulative number of cells infused until response (or until the median in non-responders) were calculated for all the subgroups. same procedures were performed with the number cells infused until day of ecp. finally, the response and survival impact of infusing a number of cells over or below the median and in different tertiles (t , t and t ) was assessed until the median number of procedures needed to achieve a response. results: the median number of procedures until response was . we observed no differences in the median number of lymphocytes, monocytes or mncs infused until response or until day between responding and non-responding patients. there were no differences in response if patients received lymphocytes or monocytes above or below the median number. nevertheless, patients that received a total absolute number of mncs above the median ( x cells) showed a trend towards a higher response rate ( % vs %, p= . ). the patients that received a cumulative number of lymphocytes in the first ecp procedures above the median showed improved overall survival (os) ( y os % vs %, p= . ). patients that received a number of monocytes above the median showed a trend towards better survival (p= . ), that was significant when the number of monocytes infused surpassed the first tertile ( y os % for t , % for t , % for t , p= . ). finally, the patients that received a cumulative number of mncs above the first tertile also showed improved survival ( y os % for t , % for t , % for t , p= . ). conclusions: there were no differences in the infused cellularity between responding and non-responding patients with chronic gvhd. at the same time, we found that except for a trend toward better response with higher mncs infused, there was no relationship between lymphocytes and monocytes with the response rate as other previous studies have suggested. however, even if there is no relationship with the response rate, the patients receiving the highest numbers of lymphocytes, monocytes and mncs in the cohort showed an improved survival, suggesting that larger quantities of cells could exhibit a protective effect. nevertheless, prospective studies that address this relationship are needed. disclosure: nothing to declare comparative analysis of the cytotoxic potential of cytokine-induced killer and natural killer cells for neuroblastoma therapy annekathrin heinze , beatrice grebe , eva mudry , jochen früh , bushra rais , claudia cappel , sabine hünecke , eva rettinger , thomas klingebiel , peter bader , evelyn ullrich , university hospital frankfurt, frankfurt, germany, german cancer consortium (dktk) partner site:, frankfurt, germany background: neuroblastoma (nb) is the most common solid extracranial tumor in childhood. despite therapeutic progress, prognosis for high-risk nb is poor and innovative therapies are of medical need. therefore, we investigated the cytotoxic potential of interleukin (il)-activated natural killer (nk) cells compared to activated cytokine-induced killer (cik) cells against different human nb cell lines in vitro. methods: nk cells were isolated from peripheral blood mononuclear cells (pbmcs) using cd enrichment or cd /cd depletion kits. they were successfully expanded ex vivo with different cytokine combinations such as il- , il- , il- and/or il- under feeder-cell free conditions. in contrast, cik cells were generated from pbmcs by ex vivo stimulation with interferon-γ, il- , okt- and il- . a comparative analysis of expansion rate, purity, phenotype and cytotoxic activity against different nb cell lines following different culturing protocols was performed. results: cd enriched nk cells showed a median expansion rate of . -fold after to days in culture with a final frequency up to . % nk cells and a median frequency of . % cd + cd -t cells. in contrast, the starting cell product after cd /cd depletion consisted of a median frequency of . % nk cells that expanded significantly faster with . -fold and also reached up to . % purity without any relevant t cell contamination. cik cells expanded with a median rate of . -fold and contained . % nk, . % t and . % nk-like t cells. interestingly, nk cells, particularly after cd /cd , showed a significantly higher median cytotoxic capacity against nb cells depletion ( . % for cd enrichment, . % for cd /cd depletion) compared to cik cells that induced . % killing of nb cells with e:t ratio : in a hours' co-incubation assay. interestingly, prolonging the ex vivo stimulation after cd /cd depletion to days enhanced the median expansion rate to . -fold with a slightly reduced cytotoxic potential ( . % for days' ex vivo expansion, . % for days' ex vivo expansion, comparison of the same donors). the addition of an il boost prior harvesting increased the expansion rate to median . -fold (compared to . -fold for the same donors) with an improved cytotoxicity of . % (compared to . %) . fortunately, all nk cell products showed a high viability and no relevant t or b cell contamination (median < . %). interestingly, further optimization of the culturing procedure with use of another cell culture medium led to an improved median . -fold (compared to . -fold) nk cell expansion rate in days, also resulting in comparable cytotoxicity of . %. conclusions: nk and cik cell products may offer an innovative immune therapeutic option for patients with high-risk nb after allogenic stem cell transplantation. our study revealed that nk cells have a significantly higher cytotoxic potential to combat nb. interestingly, the use of il- expanded and il- activated nk cells developed from a cd / depleted apheresis product is highly promising as additional immunotherapy in combination with haploidentical stem cell transplantation of children with nb. disclosure: nothing to declare. quantitative determination of donor allo-reactive t-cells in haploidentical donor-recipient pairs by enzymelinked immunospot (elispot) and mixed lymphocyte culture (mlc) assays background: t-cell alloreactivity is responsible not only for graft versus host disease and morbidity, associated with hematopoietic stem cell transplantation (hsct) but also for graft-versus-leukemia (gvl) activity. in this regard, monitoring and quantitation of alloreactive t-cells (allo-t) may potentially provide valuable information for individualized clinical management of transplant recipients. the aim of this study was the optimization of allo-Т detection and comparison of the elispot and mlc assays. methods: allo-t were determined in haploidentical donor-recipient pairs before hsct. donor mononuclear cells (mnc) served as effector cells (ec) . patient cd depleted mnc were used as stimulatory cells (sc).the ratio ec:sc were : and : . the frequency of allo-t in donor peripheral blood was tested in elispot assay and mlc. elispot provides the detection and quantitation of activated t-cells on the basis of cytokine secreted by each cell. the co-incubation time was h for ifn-gamma and h for il- detection. in mcl assay donor mnc were labeled with cfse and allo-t, proliferating in response to stimulation with alloantigens, were determined by flow cytometry on day . results: the median number of ifn-gamma producing allo-t per donor mnc was , ( - ; ec:sc ratio - : ) and , ( - ; ec:sc ratio - : ). the median frequency of allo-t was , % ( , - , ; ec:sc ratio - : ) and , % ( , - , ; ec:sc ratio - : ) among lymphocytes. il- -producing allo-t were less frequent in donor mnc in comparison with ifngamma-producing allo-t. the median number per mnc was , ( , - ; ec:sc ratio - : ) and , ( - ; ec:sc ratio - : ). the median frequency of il- -allo-t was , % ( , - , ; ec:sc ratio - : ) and , % ( - , ; ec:sc ratio - : ) among lymphocytes. the ec:sc ratio : is enough for stimulation of il- producing by mnc in elispot assay, but for optimal stimulation of ifn-gamma producing cells ec:sc ratio : is preferable. this suggests that allo-t are predominantly ifn-gamma producing cells. alloreactive proliferating t-clones were detected in mlc in of donor-recipient pairs on day of cocultivation. median percentage of proliferating t-clones were , % ( , - , ; ec:sc ratio - : ) and , % ( , - , ; ec:sc ratio - : ) among lymphocytes. however, mlc assay only permit a qualitative analysis that confirmed the presence of alloreactive t-clones, giving no information on their frequency within the culture. results of elispot and mcl assay directly correlated. conclusions: allo-t were detected in , % of assayed haploidentical donor-recipient pairs by elispot and only in , % by mlc. this difference in detection is due to the fact that elispot allows to detect single cytokine secreting cell whereas mlc can reveal proliferating аllo-t clones. the analysis of allo-t in haploidentical donor-recipient pairs may provide rationale to manipulate the allo-immune response and to exploit the powerful ability of allo-t to control hematologic malignancies. disclosure: nothing to declare allogeneic mesenchymal stromal cell as rescue therapy in an infant with life-threatening respiratory syndrome due to a filamin a mutation background: cell-based therapy has gained attention in the respiratory system diseases and encouraging results are reported following mesenchymal stromal cells (mscs) administration. due to their capacity to produce and secrete a variety of paracrine factors and bioactive macromolecules, mscs became a key player in lung tissue injuries and function, reducing fibrosis, promoting the normal development of alveoli and pulmonary vessels. for the first time we used the msc infusions as rescue therapy in a pediatric patient with flna gene mutation and life-threatening respiratory syndrome. methods: a child with a new pathogenic variant of the flna gene c. _ del; (p.val alafster ) at the age of months, due to the serious and irreversible chronic respiratory failure and dismal prognosis, was treated with intravenous infusions of allogeneic bone marrow (bm)-mscs at the dose of × mscs/kg body weight. bm-mscs were produced at "cell factory", fondazione irccs policlinico s. matteo, pavia,isolated and expanded ex vivo from healthy donor bm, following a previously reported protocol. premedication with antistaminic drug, min before every infusion to avoid any potential reaction was performed. the evolution of the respiratory condition was detected. peripheral blood were collected before each msc treatment for treg and th monitoring. treg, defined as cd + cd neg cd + cells expressing the forkhead box p (foxp ) transcription factor, and th , defined as cd + cells expressing intracellular il- , evaluation was performed by flow cytometry (facscanto; bd biosciences, san diego, ca) as previously reported, following standard procedures. results: no acute adverse events related to mscs infusion was recorded. during follow-up, patient maintained a good general condition and showed a regular growth. no systemic or respiratory infections occurred. after the second infusion, the child experienced a progressive improvement of his clinical respiratory condition, with a good adaptation to mechanical ventilation, in the absence of episodes of respiratory exacerbations. the baby maintains adequate volumes of exchange with substantial reduction of the inspiratory support. a reduction of trigger sensitivity was also obtained. thorax ct scan showed a recovery of the basal parenchyma bilaterally and the improvement of the anatomical-functional alignment and aerial penetration. after the first msc administration, an enrichment of treg and th percentage in peripheral blood, was observed. while, after the second msc infusion a significant increase in treg/th ratio was noted. conclusions: this report suggest that msc serial infusions are a promising therapy in aiding the respiratory failure, even in a pediatric patient with flna mutation. intravenous administrations of allogeneic mscs are feasible and safe without toxicity. our results suggest that to mitigate lung injury, mscs may act as regulators of treg and th balance. further investigations are upcoming to establish the useful of this therapeutic proposal in interstitial lung diseases in children. disclosure: nothig to declare p feasibility of il- stimulated donor nk cells manufacturing for early infusion in patients with high risk acute myeloid leukemia undergoing haploidentical transplantation background: nk cells provide a potent antitumor effect in the setting of manipulated haploidentical hematopoietic stem cell transplant (haplo-hsct). we propose a novel strategy to enhance the antitumor effect of allogeneic transplant through the infusion of nk cells stimulated with il- exvivo in adult high-risk acute myeloid leukemia (aml) patients undergoing unmanipulated haplo-hsct. the objective of this study was to provide efficiency and productivity data obtained in the manufactured cellular products infused. methods: selection criteria included patients with highrisk aml undergoing unmanipulated haplo-hsct. lymphoapheresis of the haploidentical donor was performed using spectra optia (terumo® bct) on days + and + after transplant. from the obtained product a double immunomagnetic cellular selection with clinimacs system (miltenyi biotec®) was performed in two steps: cd + depletion followed by positive cd + selection. the obtained an enriched cellular product of cd -cd + nk cells was incubated with il- ( ng/ml) between and hours at ºc and % co in gmp conditions. quality and microbiological controls were performed at the end of each manufacturing step. dxh cellular counters (beckman coulter®) and multiparametric flow cytometry were used for lymphocyte subpopulations and viability analysis (navios cytometer; beckman coulter®, conjugated monoclonal antibodies; miltenyi biotec®). the final product was infused intravenously to the patient on days + and + if manufacturing conditions were met (range of . - x nk/kg, purity ≥ %, viability≥ % and < x cd + cells/kg). if not, it was discarded. nk cell activation in the product was measured by the expression of cd and cd . results: between november and april , patients were included in this ongoing trial. two products were manufactured for of the patients, and only one for the first patient, due to transplant complications between first and second infusion. one product did not meet minimum viability criteria and was discarded. in the infused final products mean and sem of nk cell purity, recovery and viability were . %± . , . %± and . %± . , respectively. log cd + depletion ranged between - . and - . . median infused doses of nk cells and cd + cells per kg were . x ( . x - . x ) and ( - ). complete manufacturing data of all procedures are shown in table background: cytokine-induced killer (cik) cells are a promising immunotherapeutic approach to combat relapse following allogeneic hematopoietic stem cell transplantation (hsct) for acute leukemia or myelodysplastic syndrome. to show safety and efficacy, a multicenter clinical study with pediatric and adult patients including up to eight cik cell applications with escalating doses is ongoing. methods: we favor single large scale cik cell generation with the aim to apply fresh cik cells and cryopreserve ready-for-use doses according to the study protocol in contrast to recurrent manufacturing. therefore cryopreserved cik cells were tested against freshly generated cik cells to approve equivalence. furthermore, an alternative medium supplement for cik cell culturing was investigated to avoid supply bottlenecks in ab-serum. results: fresh frozen plasma (ffp), platelet lysate (pl) and ab-serum in cik cell culture showed median expansion rates of -fold, whereas cultivation without medium additive resulted in significantly lower proliferation (p< . ). cik cell composition including t cells, nk like t cells and a minor part of nk cells was not significantly influenced by changing the medium additive. moreover, neither cytotoxicity against thp- cells nor cd expression on nk like t cells were significantly influenced by the different medium additives. for cik cell generation either ficollized peripheral blood (pb) or unstimulated leukapheresis (lp) products were utilized. with regard to repeated manufacturing within the clinical study, also cryopreserved lp and pbsc as starting material came into the focus of interest. comparing cik cell expansion rates, no significant differences for the entire cik cells and the subgroup of t cells were detected between the four starting materials. cryopreservation of cik cells had no significant effect on cik cell composition, cytotoxicity and cd expression on nk like t cells. a small, albeit not significant effect of cryopreservation on viability was detected, which was . % before and . % after freezing and thawing. conclusions: the challenge was an efficient time-, personal-and cost saving production of cik cells within the clinical study. introducing ffp enabled cik cell manufacturing for an increased patient cohort by avoiding supply bottlenecks in ab-serum. furthermore, cryopreservation allows the storage of ready-for-use cik cell doses fulfilling the demands of the clinical study. clinical trial registry: eudract number - - disclosure: nothing to declare. automated generation of cd ra depleted donor lymphocyte infusion (dli) with the clinimacs prodigy® cd ra system , methods: the current clinimacs cd ra system was developed for graft engineering. up to x e magnetically labeled cd ra+ cells from leukapheresis products can be depleted from up to x e white blood cells (wbc). we developed a new clinimacs prodigy® process in order to ease the procedure for routine-use, to reduce the specifications according to reported cell numbers for dli applications, and to enable the use of peripheral blood products with high amounts of red blood cells (rbc). the new system was tested by performance runs. an new fluorescent flow analysis protocol was developed. results: the resulting clinimacs prodigy pb- ra system is an automated procedure with integrated labeling and washing steps. the new application software pb- ra depletion enables to deplete up to . x e cd ra + cells from up to x e total wbc from peripheral blood products. a major difference of this process is the rbc removal option based on an integrated camera for cell pellet detection. the final cell product is provided in physiologic saline. verification runs with peripheral blood products (n= in total, n= with whole blood, n= with leukapheresis products) resulted in a mean depletion of . log (range . - . ) for cd ra + t cells in the cd ra depleted product. viability of the target products was always above %, and mean wbc recovery was %. the mean process time was h min (range h to h min) without including the manual steps, i.e. tubing set installation and downstream analysis of blood products by flow cytometry. this data were in line with preceding evaluation runs (n= ), and results obtained in cooperation with an external beta test site. the performance results were furthermore in line with results obtained on clinimacs plus instrument runs. for quality control of cd ra depleted products we developed a flow cytometric analysis strategy for fast, accurate, and convenient analysis of even rare counts of remaining unwanted cells. it allows to determine naïve t cells at two different levels of subset staining. the minimum requirement for the flow cytometric analysis includes colors to define viable cd +cd ra+ cells. for further evaluation of the naïve t cell subsets additional colors are used to define viable cd +cd ro-cd -cd l+cd + cells. conclusions: the automated clinimacs prodigy pb- ra system process is capable to deplete cd ra+ cells efficiently from peripheral blood products within hours. the new process is a fast, convenient, and regulatory compliant method for the preparation of ready-to-use cd ra-depleted cell products for clinical applications. the submission to an european notified body for ce certification is an important next step. myeloablative conditioning regimen was preferred for patients out of . gvhd prophylaxis regimens are csa +mtx: (% ), csa+mmf: (% ), csa only: (% ). atg was given patients. despite been given gvhd prophylaxis (% , ) patients out of transplanted patients had gvhd features. of patients, had experienced steroid resistant gvhd after transplantation, including (% ) grade and (% ) grade . ecp treatment was started mean days after diagnosis of steroid resistant gvhd and (% ) patients had complete response while (% ) patients had partial and (% ) patients had no response to ecp treatment on day . sixteen out of patients had also received mesenchymal stem cell therapy as salvage therapy. only one patient had experienced hypocalcemic tetany, a complication of ecp procedure. thirteen patients had died and were directly related with steroid resistant gvhd. other conditions like relapse of primary disease or pres syndrome also played role in death. conclusions: extracorporeal photopheresis is a reliable and effective second line treatment modality in steroid resistant gvhd. starting ecp sessions as soon as gvhd symptoms occur increases its effectivity. mesenchymal stem cell administration with ecp for (% ) patients limits our study to reach o conclusion for efficacy of ecp itself. need for hemodialysis catheters, the prolonged sessions while adequate flow is not possible and catheter related infections are the lmitations for feasibility of ecp. disclosure: nothing to declare donor lymphocyte infusion administrations after allogeneic stem cell transplantations in pediatrics: a single center experience background: loss of chimerism is one of the major problems after allogeneic stem cell transplantation(sct). donor-lymphocyte infusions(dli) are used as a treatment after taper or stopping immunosuppression. in this study, dli experience in patients with loss of chimerism after sct due to various benign and malign hematological diseases was presented. methods: between july -august , twenty patients, detected chimerism loss and received dli after sct were evaluated retrospectively. patients received myeloablative or reduced intensity conditioning, atg, cyclosporine a and methotrexate for gvhd prophylaxis. chimerism analyses were performed with short tandem repeat(str) method from peripheral blood. results below % were considered as mixed chimeric and below % were nonchimeric. when patients considered as mixed chimeric, immunosuppression therapy was ceased immediately and treated with dli. donor lymphocyte infusions were performed at two-week intervals with chimerism follow-up. student t, mann whitney u, ki kare tests and kaplan-meier analysis were used. results: between - ages (median ), female, male patients were evaluated. the initial diagnoses were thalassemia major( ), aplastic anemia ( ),all( ), aml ( ) . dli initiation time was . +- . days after sct, total number of dli administrations were . +- . . dose of dli was x - . x /kg (mean . x /kg). nine patients' chimerism out of , fell below % at first month after transplant; patients were nonchimeric, of them were complet chimeric and were mixed chimeric. eleven patients´chimerism were below % between - months after sct, patients were nonchimeric and were mixed chimeric. early mixed chimerism was found relevant with graft rejections (p= . ). patients were followed up for - days. eight patients' chimerism increased after dli infusion and continued to decrease in patients. after dli, acute gvhd has been seen in both group.the group with decreased chimerism after dli, dose was mean x ± x /kg while the group with increased chimerism had dli dose mean x ± x /kg. although the difference was not statistically significant, numerical value revealed significantly different. eventually patients out of were mixed chimeric, patients were complete chimeric and were none. in thalassemic patients, patients with thalassemia-trait donor were mixed chimeric, in patients whose donors were normal, of them were complete chimeric and one of them was nonchimeric.the difference was significant (p= . ). the cd infusion doses revealed mean . ± . x /kg in mixed chimeric patients, . ± . x /kg in complete chimeric patients and . ± . x /kg in the patients with loss of chimerism. cd amount was seen high as numerical value in complete chimerics but no statistical significance was found. overall survival was %, disease-free survival was %. conclusions: we evaluated the efficacy of dl for patients with mixed chimerism in our patient group. we concluded that chimerism loss in patients with early decreased chimerism is similar to those in literature in spite if dli practices. dose and application frequency were greater in patients with increased chimerism. the small number and the heterogeneity of the patients limited our study. in this regard, studies with larger series and homogeneous groups are acquired. disclosure: nothing to declare phase i clinical trial of repeated administrations of bone-marrow derived mesenchymal stem cells in steroid-refractory chronic graft-versus-host disease patients nayoun kim , young-woo jeon , jae-deog jang , keon-il im , nak-gyun chung , young-sun nam , yunejin song , jun-seok lee , seok-goo cho (cghvd) is the most common long-term complication of allogenic hematopoietic stem cell transplantation which is associated with poor quality of life and increased risk of morbidity and mortality. currently, there is no standardized treatment available for patients who do not respond to steroids. as an alternative to immunosuppressive drugs, mesenchymal stem cells (mscs) have been used to treat and prevent steroidrefractory acute gvhd patients. these studies and reports have also provided a basis for using mscs in steroid refractory cgvhd patients. methods: to evaluate the safety and efficacy of repeatedinfusions of mscs, we enrolled ten severe steroid-refractory cgvhds patients. steroid refractory was defined as either no response to steroids lasting at least weeks or progression of disease during treatment or tapering lasting at least weeks. patients were intravenously administered with mscs produced from third-party bone marrow donors at a -week interval for a total of four doses. each dose contained x cells per kg body weight and all four doses consisted of mscs from the same donor and same passage. results: we enrolled ten patients ( female/ male, with a median age of . (range - ). median of cgvhd affected organs was (range - ) including the skin (n= ), eyes (n= ), oral cavity (n= ), lung (n= ), liver (n= ) and joints (n= ). all ten patients received their planned four doses of mscs, administering a total of infusions. median time from initial cgvhd diagnosis to first msc treatment was days (range - ). msc infusions were well tolerated with no immediate or delayed toxicities. after weeks of the first msc infusion, all ten patients showed partial response showing alleviation in clinical symptoms and increased quality of life. organ responses were seen in skin (n= ), eyes (n= ), oral cavity (n= ), liver (n= ), and joint(n= ). however, one patient died of progressive gvhd and one patient relapsed from primary disease. conclusions: repeated infusions of mscs was feasible and safe and may be an effective salvage therapy in patients with steroid-refractory cgvhd. further large-scale clinical studies with long-term follow up is needed in the future to determine the role of mscs in cgvhd. background: the majority of pregnant polish women ( %) have heard of cord blood banking. however, most doctors do not have sufficient knowledge about the possibility of using cord blood in order to respond to their potential concerns. only . % of healthcare professionals were aware that cord blood could be used to treat haematological diseases. in order to make doctors aware of this issue and provide patients with the information they expect, we would like to present data on the use of cord blood stored in our blood bank for haematological and nonhaematological therapies. methods: the table presented below has been created using data from the general database of the polish stem cell bank, warsaw, poland. no data regarding umbilical cord blood data have been excluded. all patients were planned to be assessed on day , day , on discharge, days after transplantation and , , , , and years after transplantation, but in some cases, patients were lost from follow-up due to a persistent lack of reports from transplantation centres. results: in cases, the therapeutic use of cb was transplantation (replacement of patients' own tissue); in cases it was administration (infusion without destruction of patients' own tissue). thirty-three were administered as standard therapy and as experimental therapy. conclusions: the survey study cited above, indicated low awareness of cord blood use among healthcare professionals. on the other hand, one study indicated that the expectations placed in cord blood banking may be unreasonable. as a private cord blood bank, we support recommendations which underline the importance of patient education. in poland, cord blood has been approved as standard therapy in approx. diseases; most of them are rare, but polish law allows the use of cord blood for the siblings, parents and grandparents of a donor. additionally, active and planned clinical trials throughout the world evaluate the therapeutic efficacy of cord blood in such areas as haematology, neurology, cardiology, diabetology, congenital paediatric disorders, ophthalmology, dermatology, gastroenterology, hiv infection, and the quality of life during aging. therefore, further indications may be expected in the future. background: cytokine release syndrome (crs) has been identified as a clinically significant, on target, off tumour side effect of the chimeric antigen receptor (car) t-cell therapies. it is clinically increased in interkeukin and elevations in other cytokines, lactate dehydrogenase (ldh), c-reactive protein (crp), and ferritin. these side effects can include fever, fatigue, headache, encephalopathy, hypertension, tachycardia, coagulopathy, nausea, capillary leak and multi organ dysfunction. crs symptoms can appear as early as one day after infusion and can resolve quickly or last for weeks. it´s severity to be related to the disease burden prior to car t-cell therapy. methods: the bristol oncology and haematology centre will be providing car t-cell therapy to patients in early . on collating from the leading consultant on the ward and fellow nursing team members it was apparent that an effective way at managing patients post car t-cell therapy side effects is to provide an educational and informative poster depicting a flow chart that will aid the practitioner to recognise and effectively treat/manage a patient with crs symptoms. results: none as of yet as this is a prospective tool ready for our first patient in early conclusions: through continuing reading and study days prior to the ward receiving its first car t-cell patient it is increasingly important that the entire multi disciplinary team recognise crs and understand the importance of early detection, careful monitoring and early intervention. background: allogeneic stem cell transplantation (allosct) is the only curative procedure for primary and secondary myelofibrosis (pmf, smf). elderly people are mainly affected, limiting the feasibility of intensive myeloablative chemotherapy regimens. the introduction of reduced-intensity conditioning (ric) made allosct feasible and effective for old patients. nevertheless, the incidence of pmf and smf is not negligible in young patients, theoretically able to tolerate also high-intensity therapy. very few data are available about the efficacy of ric-allosct in the particular setting of young-aged mf patients. methods: this study includes myelofibrosis young patients (age < y) who received allosct between and at the university hospital hamburg/germany. four patients were previously splenectomized. patients mostly fall into intermediate risk groups according to dipss. four patients belonged to the high-risk triple-negative category (jak /calr/mpl-). asxl -mut was tested in patients (pos: ). in % graft source was pbsc, patients received bmsc. only % of patients had a / hla-matched sibling, the others were transplanted from fully-matched ( %) or partially-matched ( %) unrelated donor. all transplants were conditioned according the ebmt protocol with busulfan ( mg/kg po or mg/kg iv), fludarabine ( mg/m ), atlg (grafalon® neovii, germany) administered in days at a dose of mg/kg die for mud, mg/kg die for mrd transplants, followed by cylosporina, and mycophenolate in the first days. results: engraftment rate was %, median neutrophil engraftment time days. platelet engraftment was reached by patients ( %, median days). four patients ( %) developed poor graft function, successfully treated with cd + selected pbsc-boost. after a median follow up of . years, estimated y-pfs and os were % and % respectively. dipss-risk and donor hla-matching resulted the only significant impacting factors on os. neither cytogenetic nor molecular abnormalities were significantly related to os. twenty-five patients ( %) experienced agvhd grade > . c-gvhd was observed in patients ( %), mostly ( %) beginning in the first days after transplantation. cumulative incidence of trm was % at year, with a plateau after the first year ( y trm = %). trm was observed only in patients with maximal grade ( ) of marrow fibrosis. furthermore, trm never occurred in previously splenectomized patients (p= . ), but no significant impact from splenectomy on os was observed (p= . ). after transplant, patients ( %) relapsed: died without any treatment because of infection, received dli ( durable cr), patients ( after dli) underwent a second allosct, with long-term survival in cases. conclusions: ric followed by allogeneic sct is a curative treatment approach for younger patients with myelofibrosis with a low nrm. the most important outcome-determining factor is donor hla-matching. interestingly, marrow high grade fibrosis showed to significantly impact trm. biological markers such as asxl mutation and cytogenetics, largely known as highly predictive for poor prognosis in the disease natural course, did not show any impact on survival, suggesting that patients harboring these abnormalities could get the greatest benefit from allosct. further data collection, and a prospective randomized trial are needed to confirm our conclusion. disclosure: nothing to declare p abstract already published. splenectomy as a risk factor for relapse after allogeneic hematopoietic stem cell transplantation in patients with myelofibrosis -retrospective cohort study background: splenectomy is a common procedure in patients (pts) with myelofibrosis (mf) performed to achieve improvement in blood cell counts and reduce b-symptoms. however, it has also been shown that splenectomy may adversely predispose to leukemic transformation in this setting. aim: to evaluate in a single-center retrospective analysis the long-term impact of pre-or post-transplant splenectomy on transplant outcome regarding overall survival and relapse risk. methods: this retrospective analysis comprises the data of pts ( male and female) with primary (n= ) or secondary (n= ) mf after allo-hsct from hla-matched sibling (n= ) or unrelated (n= ) donors in our center between and . the median age was years (range, to years). a myeloablative conditioning regimen was performed in pts, while pts where treated with a reduced intensity conditioning. peripheral blood stem cells (n= ) or bone marrow (n= ) with a median of . x cd + cells/kg bodyweight (bw) (range, . to ) were transplanted. splenectomy was performed in of pts: pts were splenectomized prior to and pts after allo-hsct. relapse was diagnosed in ( %) of pts. the median duration to relapse after transplantion was months (range, - months). results: the median duration of follow-up of this cohort was months (range, - months), the -year overall survival (os) was %. pts died, including pts who relapsed and pts who died of treatment related causes. the observed probability of relapse was significantly higher in splenectomized pts than in non-splenectomized pts: % versus % (relative risk (rr) . , % ci, . - . , p= . ). at years, the os was % in nonsplenectomised and % in splenectomised pts (p= . ) (fig. ) . the relapse rate in splenectomised pts was independent of pre-( of pts, %) or post-transplant ( of pts, %) treatment (rr . , % ci, p= . ) . conclusions: on the basis of our cohort, we could assert that pre-and post-allo-hsct splenectomy was equally and significantly associated with an increased relapse ratio in patients with mf, which also tends to negatively affect overall survival. [[p image] . figure : the overall survival after allo-hsct in patients with myelofibrosis.] background: b-cell prolymphocytic leukemia (b-pll) is a very rare lymphoproliferative disorder. although allogeneic stem cell transplantation (allosct) could be a curative option, patients often do not qualify for this consolidation treatment due to an aggressive course of disease. in this case study, we report on three patients who failed ibrutinib therapy but achieved complete remission and even mrd negativity after treatment with the chimeric cd -antibody rituximab, enabling them to undergo allosct. methods: clinical data and follow-up data were collected by chart review. results: all three patients (pt# : male, years; pt# : female, years; pt# : female, years) were referred with b-pll harboring highly complex aberrant karyotypes, including p abnormalities in pt# and pt# . a tp mutation could be detected in pt# and pt# . all three patients had symptomatic disease with rapidly increasing hyperleukocytosis and massive splenomegaly. two of them were treatment-naive and one relapsed after chemoimmunotherapy. all patients were put on ibrutinib mg. despite initial response to treatment, two patients developed progressive disease after (pt# ) and months (pt# ) on ibrutinib, whereas pt# remained in partial remission with persisting leukocytosis, precluding consolidating allosct as originally intended. in pt# , ibrutinib was replaced by venetoclax, but without response. in order to control rapid lymphoproliferation, rituximab was added to venetoclax. grade infusion reaction / tumor lysis syndrome (tls) (fever, tachycardia and hypotonia requiring intravenous vasopressors) followed each rituximab administration despite fractionating rituximab to small doses. however, continuation of rituximab ( mg/d over d) led to complete and durable clearance of hyperleukocytosis (from /nl to mrd negativity) despite venetoclax cessation. a similar pattern was observed in pt# , who received rituximab while showing rapidly increasing leukocytosis upon ibrutinib. again, complete clearance of b-pll cells in the peripheral blood (from /nl to mrd negativity) occurred after initial grade tls despite only modest cd expression on tumor cells in this patient. also, pt# achieved profound b-pll cell depletion (from /nl to a mrd rate of . %) upon addition of rituximab to ibrutinib (without tls in this case). subsequently, all three patients were able to undergo allosct after conditioning with fludarabine and total body irradiation with gy. pt# received stem cells from a hla-ident sibling donor, whereas pt# and pt# had unrelated donors (hla-ident and hla-matched respectively). with follow-up times of and months post-transplant, pt# and pt# are currently in ongoing mrd-negative remission. pt# developed an acute graft-versus-host disease (gvhd) of the liver (grade ), nevertheless the clinical course was well controlled by immunosuppression. in pt# a chronic gvhd of the skin occurred. pt# , who achieved mrd negativity after allosct, developed acute and chronic steroidrefractory gvhd of the skin and gastrointestinal tract. nine months post-transplant, gvhd deteriorated and after further complications the patient died of pneumonia months post-transplant. conclusions: supplementary treatment with rituximab can induce deep remissions in patients with ibrutinibresistant, genetically poor-risk b-pll, thereby enabling them to undergo successful consolidation with allosct. a high risk of life-threatening infusion reactions / tls associated with the addition of rituximab has to be taken into account. background: there is little experience on the use of the newer targeted therapies in cll patients relapsed after allogeneic stem cell transplantation (allo-sct). against this background, we evaluate the safety and efficacy of the bcr inhibitors (bcri), ibrutinib and idelalisib, administered after allo-sct for the purpose of treating the cll relapse. methods: data from cll pts who relapsed after sct, and were subsequently treated with ibrutinib (n= ), idelalisib (n= ) or both (n= ),were retrospectively collected in collaboration with the spanish group of cll (gellc) and the spanish group of stem cell transplantation (geth). results: transplant characteristics are summarized in table . eight patients received the bcri as the first salvage treatment after sct relapse, whereas patients had received ≥ prior lines of treatment. at the time of the onset of the bcri, patients had rai stage and patients had a lymph node size ≥ cm. del p was present in patients and del q and complex karyotype in patients, respectively. tp gene mutation was detected in patients (all with del p ). median time from sct to bcri therapy was . months, being shorter in patients treated with ibrutinib (n= , median months) than in those treated with idealisib (n= , median months). median time on ibrutinib and on idelalisib was . months ( . - . ) and months ( . - . ), respectively. the best overall response rate (orr) obtained with ibrutinib was % ( cr, pr, pr+l) whereas it was of % for patients receiving idelalisib ( cr, pr+l). among the patients treated with ibrutinib, ( . %) presented an adverse event (ae), being diarrhea (n= ), asthenia (n= ) and infections (n= ) the most frequent. hypertension was seen in patient and none patient developed atrial fibrillation. five patients stopped ibrutinib treatment, due to toxicity (n= ) or progression (n= ). after ibrutinib discontinuation, patients were newly treated with idelalisib (n= ) or venetoclax (n= ). all patients treated with idelalisib developed at least one ae, being diarrhea (n= ), pneumonitis (n= ) and neutropenia (n= ) the most common. four patients discontinued idelalisib because progression (n= ) or toxicity (n= ). venetoclax was given after idelalisib in patients. although acute and/or chronic gvhd before bcri was documented in ( . %) and ( . %) patients, respectively, only one patient (treated with idelalisib) reactivated a mild chronic gvhd. none patient received infusion lymphocyte from donor after bcri and one patient underwent a second sct. with a median follow-up of . months ( . - . ) after the onset of the bcri treatment, patients had died, all of them due to cll progression ( richter´s transformation), whereas patients remained in response ( cr, pr). the overall survival probability of the whole series at months was . % ± . %. conclusions: in our study, ibrutinib and idelalisib, administered in cll patients relapsed after sct did not increase the risk of gvhd reactivation but they show high incidence of adverse events. nevertheless, bcri offers a possibility of disease control in these patients with poor prognosis. further studies are needed to confirm these data. background: prior to the introduction of tyrosine kinase inhibitors (tki), median survival of chronic phase chronic myeloid leukemia (cp-cml) patients was approximately months and the standard treatment with interferon-alpha resulted in complete cytogenetic responses in about % of the patients. autologous stem cell transplantation (auto-sct) was first attempted for patients in transformation in order to restore a second cp and was introduced secondarily in cp to try to prolong the response. the main rational for autografting in cp resides on the reduction of the tumor burden and the number of leukemic cells at risk of developing blastic transformation. nevertheless, auto-sct alone was not able to maintain a long-term remission. nowadays, tkis represent the state-of-the-art therapy for cml and the concept of auto-sct has only little interest while long-term follow-up and outcome in this setting are currently unknown. the aim of our study is to evaluate at a first time the longterm outcome of cml patients who received auto-sct in chronic phase, and to evaluate at a second time in a subgroup analysis, the outcome of those who received tki after having been auto-transplanted, mainly for disease progression/loss of response and/or to enhance disease response. methods: we found a total of patients who received auto-sct for cp-cml in europe between years and , ( %) were males, median age at auto-sct was years (range: - ), the median time between diagnosis and auto-sct was months, stem cells source was peripheral blood in % of patients, most frequent conditioning regimen was busulfan mg/kg/day days + day of melphalan mg/m² one day prior to the cells reinfusion. information about receiving tki post auto-sct was available only for patients, first tki was imatinib for ( %) patients, dasatinib for ( %), nilotinib for ( %) and ponatinib for one ( %) patient. results: after a median follow-up of . years (range: - ) from time of auto-sct for the whole population, the probability of overall survival (os) at years was % ( % ci: - ); there was ( %) patients who relapsed after a median time of months after auto-sct. there was a total of patients transplanted before the tki era and survived until the availability of tkis. when we performed a landmark analysis evaluating the outcome of patients who received auto-sct, survived until the tki era and received tki (n= ), the years os probability of these patients from tki treatment was % ( % ci: - ). additional data requests will be sent to centers querying about prognosis, molecular responses, treatment and disease details. conclusions: we demonstrate here with these preliminary results that the introduction of tki has improved survival of cml patients. in addition, patients who received auto-sct, survived until the tki era and also received tki, had encouraging rates of long-term survival. an extensive analysis will be performed when additional data will be available and the study will be updated with more results. disclosure: nothing to declare a year single center transplant experience in chronic myeloid leukemia background: allogeneic hematopoietic stem cell transplantation (hsct) has been considered for decades the only curative approach for patients with chronic myeloid leukemia (cml). in the tyrosine kinase inhibitors (tkis) era, hsct for cml has been reserved only to patients not achieving a cytogenetic remission or showing progressive disease after multiple tki treatment lines. however, a progressive improvement in the long-term survival has been obtained in the overall hsct population. the present study aimed at evaluating whether in cml patients transplanted at our center over a long time period -from to -the outcome improved over time. methods: consecutive patients who underwent a transplant between and were compared to patients who received the transplant between and . overall survival (os), leukemia-free survival (lfs) and graft-leukemia-free survival (glfs) were estimated using the kaplan-meier method and the log-rank test was used to compare risk factors categories. results: of the patients [median age years (range - )], ( . %) were in st or nd chronic phase, ( . %) in accelerated phase and six ( . %) in blast crisis. matched related donors and alternative donors (matched unrelated donors, cord blood or mismatched related donors) were used in and cases, respectively. as stem cell source, bone marrow was used in patients, peripheral blood in and umbilical cord blood in . tbibased conditioning regimens were used in patients, while in the other cases irradiation-free conditioning regimens were used. both in univariate and multivariate analysis, irradiationfree conditioning regimens (hr . ; %ci . - . , p=. ) and transplants performed in st chronic phase (accelerate phase hr . ; %ci . - . , p=. - nd chronic phase hr . ; %ci . - . , p=. -blast crisis hr . ; %ci . - . , p< . ) were associated with a better os. patients transplanted before had a worse os (hr . ; %ci . - . , p < . ) and dfs (hr . ; %ci . - . , p=. ). a trend for a worse glfs was observed in univariate analysis (hr . ; %ci . - . , p= . ), in the first period of observation. conclusions: our single center experience confirms that higher os, dfs and glfs are observed in cml patients allografted in more recent years. improvement of conditioning regimens, use of tbi-free conditioning regimens and supportive therapy, have presumably contributed to these results, together with the more recent strategy of close monitoring of minimal residual disease, and prompt use of tki or donor lymphocyte infusion in case of relapse. hsct is nowadays a safer therapeutic procedure in cml patients that should be considered timely in tki-resistant patients to avoid progression into a more advanced disease phase. disclosure: the authors declare no conflict of interest. reduced-intensity transplantation (rit) in patients with high-risk or advanced chronic lymphocytic leukemia in last years: improvement of transplant outcomessingle centre experience . hct-ci ≥ was in % of pts. source of stem cells was peripheral blood in % and bone marrow in % of pts. the median of infused cd + cells was , x ^ / kg. the conditioning regimen consisted of fludarabine and melphalan (+atg in unrelated donor). gvhd prophylaxis were cyclosporine and methotrexate. results: all pts engrafted. none of pts in cr before rit progressed at day + after rit and among pts beyond cr before rit all of them achieved at least pr at day + after rit. pts ( %) developed acute gvhd ( pts grade iii-iv) and among evaluable pts ( %) of them developed chronic gvhd ( mild, moderate, severe). with median follow-up months (range - months) pts ( %) are alive in cr. pts ( %) relapsed or progressed , and months after rit and of them died. last relapsed patient achieved next cr after ibrutinib. pts ( %) died due to nrm. nrm till day + after rit was %. the estimated probabilities of -years cgrfs, pfs and os are %, % and %. conclusions: in spite of relatively small number of evaluated pts and retrospective type of analysis our data show that rit in pts with high-risk or advanced cll has achieved promising results ( -and -years pfs and os % and % resp. and %) in recent years and these results are better than outcomes of our historical patient cohort from period - ( -and -years pfs % and % resp. os % and %, p= . ) or ebmt published data of pts transplanted for cll in period - ( and -years pfs % and % resp. os % and %). current results of transplantation should be taken into account in our future decision-making process on indications for transplantation in pts with high-risk cll, of course also in the context of new or updated results of targeted cll treatment and its complications. disclosure methods: retrospective data and treatment outcomes were collected from the singapore childhood cancer registry (sccr). most children with cancer in singapore receive therapy at one of the two public paediatric cancer centers (kkh or nuh). a total of thirty two cases were diagnosed with cml and received treatment in either of these centers over a twenty year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . results: the age at diagnosis of the thirty two children ranged from to years (median . years). six patients in the pre-tki era were treated with an upfront hsct. the remainder twenty six patients were initially started on a tki. of these / ( %) had a hsct at a median period of . months from diagnosis (range - months). the reason for hsct in ten out of the twelve children was due to high risk features i.e. accelerated/blastic phase/ no ccr/no cmr. the remaining two patients had a hsct due to parent and patient preference for attempt at upfront cure rather than the use of life-long and expensive tki therapy. non-compliance to tki therapy was a major finding in our teenage cohort. eleven of the eighteen transplants used a matched sibling donor. three patients had cord blood as their stem cell source. one patient had a single antigen mismatched related donor and three patients had a mismatched unrelated donor for their hsct. all patients except one had myeloablative conditioning with busulfan and cyclophosphamide. atg was added according to physician preference. one patient had cy/tbi conditioning because of pre-transplant lymphoid blast crisis. anti gvhd medications included cyclosporine/ methotrexate or tacrolimus and methylprednisolone in the cord transplant patients. six of the eighteen ( %) patients who had a hsct died. four died due to treatment related mortality ( infections, acute gvhd and pulmonary fibrosis). one patient died due to an early relapse and one had a late relapse related mortality. for the pre-tki era, hsct related and year os was % and % respectively. post-tki era and year os was %. for the entire cohort, the year os was %. conclusions: the post-tki era transplant outcomes from our two centers is comparable to leading centers in the world. outcomes for patients with mismatched unrelated donors was poor in our cohort. we recommend a haploidentical related donor transplant or an unrelated cord blood stem cell source for patients when a matched sibling or unrelated donor is not available. clinical trial registry: na disclosure: we have nothing to disclose. fludarabine, busulfan, and thiotepa may be a promising conditioning regimen for myelofibrosis patients undergoing allogeneic stem cell transplantation background: allogeneic stem-cell transplantation (sct) is a curative therapy for patients with myelofibrosis. however, recurrent disease and non-relapse mortality (nrm) are frequent causes of treatment failure. the optimal conditioning regimen for sct in this disease has not been defined. methods: we retrospectively analyzed transplantation outcomes of all adult patients given sct for myelofibrosis between and at a single large academic medical center. patients (n= ) were treated with several conditioning regimens that were grouped according to conditioning intensity. myeloablative conditioning (mac) included busulfan . mg/kg and cyclophosphamide mg/kg (bucy, n= ), fludarabine and busulfan . mg/kg (flu/ bu , n= ) and fludarabine and treosulfan - g/m (flu/ treo, n= ). reduced-intensity conditioning included fludarabine and busulfan . - . mg/kg (flu/bu , n= ). more recently we adopted the tbf regimen including fludarabine, busulfan . - . mg/kg and thiotepa - mg/ m (n= ). all patients were also given anti-thymocyte globulin during conditioning, irrespective of donor source. results: the median age was years (interquartile range [iqr] - ). the majority of patients had documented splenomegaly ( %) and were not previously exposed to ruxolitinib ( %). donor type was an hla-matched sibling ( %), / ( %) or / ( %) matched unrelated donor. the dipps+ score distribution was intermediate- ( %), intermediate- ( %), or high (n= %). the median followup was . years since the success of tyrosine kinase inhibitors (tkis), transplant-related mortality is considered too high to justify allogeneic hematopoietic stem cell transplantation (allohsct) as first-line treatment for chronic myeloid leukemia (cml) patients in chronic phase (cp). allohsct is currently considered for patients failing to at least tkis or with disease in advanced phase. nevertheless, the optimal timing for transplant referral is still not well defined. methods: we performed a retrospective analysis on consecutive patients with cml in cp receiving first transplants from an hla-identical sibling donor with partially t-cell depleted grafts from to at our center. partial t-cell depletion (ptd) consisted of in vitro alemtuzumab incubation of a part of the graft for infusion at day while the rest, containing x cd + cells/kg was given as a t-cell add-back at day . donor lymphocyte infusions (dlis) were provided, in the absence of gvhd, in case of disease relapse or mixed chimerism. molecular monitoring was performed by -month bcr-abl rt-qpcr testing in peripheral blood during at least a -year period after hsct. thereafter, -month testing schedule was maintained where possible, or followed by a -month one. kaplan-meier method was employed to determine the probability of overall survival (os) and leukemia free survival (lfs) since allohsct. results: median age at hsct was years (range, - ). all patients were in first cp but one who was in second cp. twelve patients were tki-naïve at hsct ( hsct ( - , patients had presented suboptimal response or/ and intolerance to imatinib ( - period) , while the last seven patients had presented suboptimal response or/ and intolerance to imatinib, dasatinib and nilotinib ( - period) . the time interval from diagnosis to transplant was < months in / ( %) patients. ( %) patients had an ebmt risk score of - , while ( %) patients of - . the conditioning regimen was myeloablative for all but one patients. the stem cell source was pbsc for patients and bone marrow for one. all patients engrafted. patients presented molecular relapse and one patient hematological relapse with a median interval from transplant to relapse of months (range, - ) . patients received dlis ( for relapse and for mixed chimerism), while patients in relapse also received tki. without prior administration of dli, ( %) patients presented grade ii agvhd and patients moderate cgvhd. after dli, agvhd occurred in and cgvhd in patients. one patient died of disease progression years after hsct and one of myocardial infarction years after hsct. with a median follow-up of . years (range . - . ), -year os and lfs were %. at the time of the analysis / patients were alive and in major molecular response. conclusions: these results of excellent long-term survival and no transplant-related mortality suggest that ptcd improves the outcome of cp-cml patients transplanted from an identical sibling donor and they can be useful for deciding risk-adapted strategies. we believe that ptcd could allow earlier transplant referral of patients failing tkis and having an identical sibling donor. disclosure: nothing to declare single tertiary centre experience in allogeneic haematopoietic stem cell transplantation (allo-hsct) for primary and secondary myelofibrosis (mf) the only curative option for fit patients is allo-hsct. novel therapy is emerging but current recommendation is that eligible patients with life expectancy less than years should be considered for allografting. methods: we retrospectively looked at the clinical features and outcomes of all allo-hsct for mf performed in our centre since . results: patients ( male, female) aged between - years old (median age ) with intermediate- or high-risk mf as per the international prognostic scoring system (ipss) or dynamic ipps (dipps) were transplanted in our centre since . of them ( %) were diagnosed with pmf and the remaining % with secondary mf; post-et and post-pv mf. / of our patient group received a sibling allograft and / a matched unrelated donor allograft ( % received a / human leukocyte antigen (hla)-matched transplant, % a / hlamatched and % a / hla-matched graft). all patients received a reduced intensity conditioning (ric); / patients with fludarabine/ melphalan/ campath (fmc), / fludarabine/ busulphan/ atg (fbatg) and fludarabine/ ara-c/ campath (flag/ campath); all received peripheral blood as source of hsc. engraftment occurred between day - , with a median of d+ . one late graft rejection occurred. all patients were alive at d+ . patients are currently alive; overall survival (os) is %. transplant related mortality (trm) was . % at year, % at years. patient died of graft versus host disease (gvhd) and patients of septicaemia leading to multiorgan failure. acute gvhd grade ii skin occurred in patients, grade iii and above in patients. patients have limited chronic gvhd. / patients received donor lymphocyte infusion (dli) for mixed chimerism (one of which had nd graft failure). out of these patients developed acute grade gvhd and died. response rate: / alive patients i.e . % exhibit no fibrosis in trephine biopsies, / alive patients had residual fibrosis but % donor chimerism, / alive patients had residual fibrosis with mixed donor chimerism, other patient non-assessable. conclusions: allo-hsct remains the only potentially curable option for myelofibrosis. in our centre which serves . million population, with new cases per year, patients were transplanted since . our data suggest that close collaboration between mpn-treating haematologists and transplant physicians is required so that all suitable patients have a transplant assessment early in their disease course. novel molecular prognostic systems are likely to identify those best placed to benefit in future but this series currently supports allo-hsct survival and cure. (range, - ) . dynamic international prognostic scoring system (dipss) score at the time of hct was intermediate- or high risk in patients ( %), intermedate- in patient. molecular evaluation was available in out of : jak v f mutation was detectable in patients, mpl-w k in patient, carl in patient. patients were "triple negative" for driver mutations. cytogenetics information was available for out of ; among which patients had complex karyotype, trisomy and trisomy . patients underwent splenectomy before hct. ruxolitinib was administered in patients before hct. ( %) patients received stem cells from an hla identical sibling, ( %) from a matched unrelated donor and ( %) from an haploidentical sibling. graft source was bone marrow in patients ( %) and peripheral blood in ( %). conditioning was myeloablative in patients ( %), reduced intensity in ( %). all patients engrafted. acute graft versus host disease was absent in patients ( %), grade i-ii in ( %), grade iii-iv in ( %). in evaluable patients chronic graft versus host disease was limited in ( %), extensive in ( %) and absent in ( %). transplantrelated mortality at days was %. main causes of death were: acute gvhd in patients, chronic gvhd in , pancreatitis in , pulmonary aspergillosis in . relapse occurred in patients and was the main cause of death in of them. notably, patients experienced late relapse after . and . years after hct. both of them are living while receiving ruxolitinib therapy. after a median follow up of days (range, - ), out of patients are alive. of them ( %) are disease-free and are living. the kaplan-meyer overall survival and disease-free survival at years was % and %, respectively. conclusions: our experience confirms that hct is a valid option to achieve cure in one third of mf patients. two patients experienced very late (> years) recurrence of mf. the rarity of this condition limits the amount of data and cases available for evaluation and study. life-long follow-up of all mf transplanted patients is warranted to better understand this rare event. disclosure: nothing to declare methods: А -years old female was diagnosed with jak v f-positive pmf, xx, ipss low risk, dipssplus intermediate - risk, subacute budd-chiari syndrome and portal vein thrombosis four years before allohsct. to reduce the splenomegaly and constitutional symptoms we performed pre-transplant ruxolitinib therapy mg daily. after three months of therapy the patient achieved clinical improvement (eln criteria). contrast-enhanced computer tomography and magnetic resonance imaging showed enlarged intrahepatic collateral vessels and signs of portal vein thrombosis with cavernous transformation and multiple dilated collateral veins. gastroscopy documented enlarged esophageal veins. allogeneic stem cell transplantation was performed from / -hla matched unrelated donor with peripheral stem cells ( . x Сd + cells/kg). conditioning regimen consisted of fludarabine ( mg/ m ), busulfan ( mg/kg p.o.). post-transplant cyclophosphamide was administered at mg/kg at day + , + , and ruxolitinib mg was used from d+ till d+ as graft versus host disease prophylaxis. results: starting d+ the patient experienced eight episodes of ebv some of them with severe blood loss. to treat the bleeding episodes blackmore tube was placed six times with temporary effect. to place blackmore tube the patient was two times intubated and required mechanical ventilation. at d+ leukocyte and neutrophil engraftment, full donor chimerism and molecular remission were achieved. platelet engraftment was documented only at d + and poor graft function was present due to cytomegalovirus reactivation (d+ ) and parvovirus b reactivation (d+ ). evb was stopped at d+ only after two esophageal veins ligations, and two procedures of gastric veins sclerotherapy. soon (d+ ) the patient achieved complete platelet recovery (more than x /l) and became red blood cells transfusion independent. at day + complete remission was confirmed by splenomegaly resolution, regression of bone marrow fibrosis, full donor chimerism, jak v f-negative molecular status. cbc showed hb g/l, platelets x /l, leucocytes , x /l. ultrasound examination after transplant documented portal vein thrombosis recanalization. at day + she developed mild (nih) chronic graft versus host disease with eyes and mouth involvement, which was managed with topical steroids. at d+ after transplant the patient is alive in complete remission and has no recurrent bleedings. conclusions: splanchnic vein thrombosis can significantly complicate the course of allohsct in pmf. easy access to surgical, intensive care unit and endoscopic teams is required to make allohsct more feasible in this group of patients. disclosure all patients received treosulfan-based mac regimens, treosulfan(total dose, - gms/m ) was given in combination with different conditioning drugs. the most commonly used regimen was treosulfan, fludarabine ( mgs/m ) and thiotepa( mgs/kg) referred to as ftt that was used in %(n= ). serotherapy was given in % of patients(n= ), as either alemtuzumab or antithymocyte globulin in %(n= ) and %(n= ), respectively. post-transplant graft-versus-host disease (gvhd) prophylaxis was given in all patients, based mostly on ciclosporin. patients( %) received the transplant from identicalrelated donors, patients( %) received the transplant from matched-unrelated donors, and two patients( %) had haploidentical transplants. % of the patients(n= ) were fully hla-matched. all stem cell sources were used as bone marrow in %(n= ), peripheral blood stem cells in %(n= ), and umbilical cord blood in %(n= ). this treosulfan-based conditioning was given as the st transplant in %(n= ), and as the nd transplant after the failure of a first procedure in %(n= ). two patients received treosulfan-based conditioned transplant twice. results: neutrophil engraftment and platelet engraftment occurred at a median of days and days respectively. chimerism was full donor in %(n= ), high donor in %(n= ), and mixed donor in %(n= ). gvhd developed in % of patients(n= ), with acute gvhd grade i/ii and grade iii/iv developed in %(n= ) and %(n= ), respectively. chronic gvhd grade i/ii and grade iii/iv developed in %(n= ) and %(n= ), respectively. all chronic gvhd were mild, limited, non-extensive, and resolved completely. none of our patients had persistent gvhd necessitating long-term systemic immunosuppression. mild vod occurred in %(n= ), and severe vod occurred in %(n= ). one of them died but was believed to be related to the underlying disease (wolman syndrome). viral reactivation occurred in % of patients(n= ), with cmv, ebv, and adenovirus reactivation was found in %, %, and %, respectively. five patients had invasive adenoviraemia that contributed to death in two of them. primary graft failure happened in two patients( %) due to adenoviraemia. seven patients( %) had secondary graft failure with autologous reconstitution. graft failure was significantly lower (p . ) in the ftt group than other conditioning groups. at a median follow-up of months (range, two- months), eleven patients( . %) died, with overall survival of . %, and event-free survival of . %. five patients died due to complications related to their original disease, while six patients died due to transplant-related causes (transplant-related mortality . %). immune reconstitution in alive patients was achieved at a median of eight months. this time was significantly longer (p . ) in ftt group. conclusions: this study demonstrates that treosulfan is a safe and effective conditioning drug that can achieve engraftment, with low rates of graft failure, transplantrelated mortality and morbidity, even if it is used twice in the same patient. disclosure: nothing to declare background: high-dose chemotherapy (hdc) followed by autologous stem cell transplantation (asct) is the treatment of choice for the patients with relapsed or high risk nhl. although the high-dose conditioning regimens commonly used in patients with non-hodgkin lymphoma (nhl) are beam (bcnu, etoposide, cytarabine, and melphalan), beac (bcnu, etoposide, cytarabine, and cyclophosphamide), survival of patients with nhl received above high-dose chemotherapy followed by asct was still unsatisfactory. methods: we prospectively evaluated the efficacy and toxicity of busulfan, etoposide, cytarabine and melphalan (bueam) including iv busulfan instead of bcnu of standard beam as a conditioning for asct in patients with nhl. the high-dose chemotherapy consisted of bu ( . mg/kg i.v. q.d. from day - to day - ), e ( mg/m i.v. b.i.d. on day - and day - ) a ( g/m i.v. q.d. on day - and day - ) and m ( mg/m i.v. q.d. on day - ) at centers in korea. results: two hundred five patients were enrolled onto the study. main subgroup was diffuse large b cell lymphoma (n= , . %), t cell lymphomas (n= , . %), and nk/t cell lymphoma (n= , . %). upfront asct was performed in patients ( . %), and salvage asct in patients ( . %). the disease status of the patients before hdt/asct consisted of patients ( . %) with complete response and patients ( . %) with partial response. treatment related toxicities included nausea in patients ( . %), diarrhea in patients ( . %), anorexia in patients ( . %) and stomatitis in patients ( . %), which were grade i or ii in the majority of cases. the common grade iii toxicities were stomatitis ( . %), diarrhea ( . %), and anorexia ( . %). there were no vod, and transplant-related mortality occurred in patients ( . %), due to infection. one hundred fifty three patients ( . %) achieved a complete response and patients ( . %) after asct, while patients ( . %) showed progressive disease. at a median follow-up duration of . months, the estimated -year overall survival and progression free survival for all patients was . % and . %, respectively. conclusions: the conditioning regimen of bueam for asct was well tolerated and seemed to be effective in patients with relapsed or high risk nhl. disclosure: none of declare background: allogeneic hematopoietic cell transplantation (hct) is potentially curative for high risk acute myeloid leukemia (aml) and myelodysplastic syndrome (mds), however both gvhd and disease relapse remain major challenges. we recently introduced a combination of posttransplant cyclophosphamide (ptcy) and atg ( . mg/kg) as graft-versus-host disease (gvhd) prophylaxis. the purpose of our study was to compare outcomes between ptcy/ atg and other gvhd prophylaxis regimens for high risk aml and mds. methods: we retrospectively investigated outcomes of patients that underwent allogeneic hct between january and july for high risk aml (n= , %) and mds (n= , %). gvhd prophylaxis regimens were compared for overall survival (os), cumulative incidence of relapse (cir) and non-relapse mortality (nrm) in univariate and multivariable analysis. high risk aml was defined as secondary aml, therapy related aml, high risk cytogenetics (eln criteria) in cr , good/ intermediate cytogenetic risk aml in cr and primary induction failure; high risk mds was defined as high/very high risk wpss score. results: median age of patients was years (range - years). donors were matched related in ( %) patients, matched unrelated in ( %) patients and haploidentical in ( %) patients. graft source was peripheral blood stem cells in patients ( %). myeloablative conditioning was used in patients ( %), reduced intensity regimens in ( %) patients. ptcy combined with atg was used in ( %) patients, other gvhd prophylaxis regimens were used in ( %) patients. both donor and recipient were cmv negative in ( %) patients. median follow-up of survivors was months (range - months). univariate analysis demonstrated os of the entire cohort at years was % ( %ci - %), cir at years was % ( %ci - %) and nrm at years was % ( %ci - %). concerning gvhd prophylaxis regimen, -year os for ptcy/atg versus others was % ( %ci - %) versus % ( %ci - %) (p= . , figure) , -year cir for ptcy/atg versus other was % ( %ci - %) versus % ( %ci - %) (p= . ) and -year nrm for ptcy versus other was % ( %ci - %) versus % ( %ci - %) (p= . ). grade ii-iv acute gvhd was seen in % of ptcy/atg patients versus % using other regimens (p< . ). chronic gvhd was observed in % of ptcy/atg patients versus % using other regimens (p= . ). multivariable analysis for os confirmed that the gvhd prophylaxis regimen has no influence (p= . ), while the predominant predictor of survival was age at hct (hr . , %ci . - . , p= . ). for cir, the ptcy/atg combination had no influence compared to other gvhd prophylaxis regimens (p= . ), while ric conditioning was the predominant predictor of relapse (hr . for ric, % p= . ) . for nrm, the atg with ptcy combination demonstrated no significant difference (p= . ), while age at hct was the predominant predictor (hr= . , %ci . - . , p= . ). conclusions: the ptcy/atg combination for gvhd prophylaxis has demonstrated on multivariable analysis similar os, cir and nrm with other previously used regimens at our center. a decrease in atg dose may potentially decrease the relapse rate while retaining the advantage of decreased gvhd. [ background: the combination of fludarabine with myeloablative doses of busulfan (fb ) represents a standard of care conditioning regimen before allogeneic transplantation in patients with myeloid malignancies (giralt, s.: the lancet oncology ). fb has potent antileukemic activity and is associated with low transplantrelated mortality and acute gvhd. however, early after transplantation (days - ), a proportion of patients may not convert to a full donor haemopoietic chimerism, particularly if anti-t lymphocyte globulin (atg) is used as gvhd prophylaxis (rambaldi a, et al.: the lancet oncology ) methods: we retrospective analyzed patients who underwent an allogeneic stem cell transplantation after fb conditioning regimen at our hospital, from november to august . the median age was years (range - ) and diagnoses were aml %, mds % cml % mfi %). the disease status at transplantation was: cr in %, cr in % and active disease in % of patients. the stem cell source was represented by pbsc in more than % of cases and anti-t lymphocyte globulin (atg) was part of the conditioning regimen in more than % of cases at a dose of mg/kg. the donor was a hla identical sibling ( %), a matched unrelated ( %) or mismatched (one allele or one antigen mismatched) unrelated, %. hematopoietic chimerism was molecularly evaluated by variable number of tandem repeats (vntr) on bone marrow (bm) mononuclear cells or peripheral blood (pb) t lymphocytes, purified by immunomagnetic positive selection (miltenyi, biotec). the analysis was performed at day , , , and after transplantation results: after , and days from transplantation, the proportion of patients with a full bm chimerism was %, % and %, respectively. at the same time points, the pb t cell chimerism was %, % and %. before day , patients required the infusion of dli to treat a pending or overt hematologic relapse and patients to convert the lymphoid chimerism from mixed (median %, range - ), to complete (successfully in cases). after day , additional patients required dli to treat disease relapse or progression and patients to improve the chimeric status or the immune reconstitution. at years, the overall survival is %, with a relapse and non-relapse mortality of % and %, respectively ( figure ). by uni and multivariable analysis, aml diagnosis and a mixed bm chimerism before day were associated with relapse and overall survival while age > was the only factor significantly associated with nrm. a mixed pb t-lymphoid chimerism before day does not adversely impact on non-relapse mortality, cumulative incidence of relapse, leukemia-free and overall survival. conclusions: after fb and atg, a progressive increase of pb lymphoid donor chimerism develops gradually after transplantation, in most of cases without the need of dli. early mixed lymphoid chimerism does not compromise the main long-term clinical outcomes and may at least partially explain the low non-relapse mortality. an incomplete bm chimerism within the first months strongly correlates with early disease progression or relapse. background: busulfan (bu) is widely used as a component of myeloablative conditioning regimen before hematopoietic stem cell transplantation (hsct) in children. bu has a narrow cumulative exposure window. the relation of bu exposure with toxicity is well established, but the link between the exposure and efs is not clear due to conflicting reports especially in pediatric patients. obtaining the ratio of bu to its metabolite i.e. metabolic ratio (mr) may serve as an indicator of bu gsh conjugating capacity of an individual, thus cumulative exposure of bu for a particular day that could be used along with auc as a marker to predict efs. the present investigation is aimed at evaluating the utility of bu mr to predict efs in children undergoing allogeneic hsct. methods: two different cohorts with children receiving bu in four times daily (qid, n= ) and once daily doses (qd, n= ) at st. justine's hospital, montreal were studied. bu and su levels were measured on day of the conditioning regimen at the end of infusion (dose in qid or dose in qd dosing). efs was defined from the time of transplant until death, relapse, or rejection, whichever occurred first. a receiver-operator characteristic curve (roc) for bu mrs measured was plotted to show the trade-off in sensitivity vs. -specificity rates for efs, as the cut-off of the test was shifted from low to high. cutoff values were defined based on the youden´s j statistic (i.e. sensitivity+specificty- ). results: twenty-two males and females aged from . to . years (mean±sd: . ± . ) from bu qid cohort had the mean mr of . (sd: . ). a cut off value of . in mr was chosen in roc analysis in this cohort, with better sensitivity ( %) and specificity ( %) for efs prediction (p= . , auc= . ( % ci= . - . ). in qd cohort nine females, and four males aged between . and . years ( . ± . ) had the mean mr of . (sd: . ). in roc analysis, a cut off value of . was chosen with better sensitivity ( %) and specificity ( %) for efs prediction (p= . ; auc= . ). conclusions background: treosulfan is an alkylating agent increasingly used prior to hematopoietic stem cell transplantation (hsct). the main objective of this study was to develop a population pharmacokinetic model of treosulfan in pediatric hsct recipients and to explore the effect of different covariates on treosulfan pharmacokinetics (pk). also, a limited sampling model (lsm) was developed. methods: in this multicentre study, patients, receiving a dose of , or g/m treosulfan a day, administered during consecutive days, were enrolled. a population pharmacokinetic model was developed using nonlinear mixed effect modelling (nonmem version . . , using psn toolkit . . and piraña version . . as modelling environment). demographic factors, as well as laboratory parameters, were included as covariates. results: treosulfan pk was best described by a twocompartment model. a bodyweight-based allometric model improved the model more than a model incorporating body surface area (bsa). clearance (cl) and intercompartmental clearance parameters were . l/h/ . kg ( %ci . - . ) and . l/h ( %ci . - . ). typical volumes of distribution of the central and peripheral compartments were . l/ . kg ( %ci . - . ) and . l ( %ci . - . ). a model-based dosing table based on bodyweight is created to achieve a target exposure of mg*hr/l (table ) , which was the median exposure of our population. estimated glomerular filtration rate (egfr) was shown to be the only parameter that significantly reduced interpatient variability in cl from . % to . %. a limited sampling model with samples (taken at . , and hours after start of infusion) accurately estimated pharmacokinetic parameters of treosulfan. conclusions: to the best of our knowledge, this is the largest cohort of pediatric patients treated with treosulfan used for a population pharmacokinetic study. we developed a two-compartment model with weight and egfr as covariates influencing treosulfan pk. recently we showed a relationship between treosulfan exposure and early toxicity. patients with an exposure > mg*hr/l have an increased risk of developing grade or higher mucositis and skin toxicity. another study in pediatric patients with thalassemia major reported an association between treosulfan clearance (< . l/h/m ) and poor overall survival. our model, together with the limited sampling strategy, can be used to adjust the dose, prior to or during treosulfan administration. ongoing studies conducted in different disease settings will determine if treosulfan exposure can influence patient outcome. subsequently, the optimal target exposure can then be established. background: autologous stem cell transplant (asct) is an effective treatment method for non-hodgkin lymphoma (nhl). until recently, carmustine, etoposide, cytarabine and melphalan (beam) was the most commonly used conditioning regimen. despite acceptable efficacy with beam, carmustine is associated with major pulmonary toxicity. for this reason, the aim of this study was to investigate the safety and efficacy of beb conditioning regimen for asct in nhl. methods: we conducted a prospective, multicenter, phase ii study for beb conditioning regimen for asct in nhl patients. a total of patients were enrolled from centers. they underwent asct with beb conditioning regimen (busulfan . mg/kg for days, etoposide mg/ m for days, bendamustine mg/m for days) between and . [[p image] . two year progression-free survival and overall survival.] results: the median age was years (range - ) and patients ( . %) were men. the most common type was diffuse large b cell lymphoma (n= , . %) and more than half of patients (n= , . %) were classified as ipi score or . eight patients ( . %) had a history of relapse and patients ( . %) received more than lines of chemotherapy before asct. most patients (n= , . %) were complete remission (cr) state at asct. a median number of . x /kg cd cells were infused (range . - . ). all patients engrafted after a median time of days (range - ). twelve patients ( . %) experienced neutropenic fever and patients ( . %) had grade toxicities during asct. however, no one had a documented infection, veno-occlusive disease, or treatment-related death. three months cr rate was . %. during a median follow-up period of . month, patients ( . %) exhibited relapse or progression, while patient ( . %) died of the disease. the estimated -year pfs and os rate were . % and . %, respectively ( figure ). conclusions: the beb conditioning regimens for asct is a feasible with tolerable toxicity in patients with nhl. disclosure: nothing to declare long-term report of total marrow or total lymphoid imrt in advanced leukemia, myeloma and lymphoma background: during the last three decades, total body irradiation (tbi) continues to play an important role in the conditioning regimens for patients undergoing stem-cell transplant (sct) for a wide variety of advanced hematological malignancies. however, tbi showed boundaries in dose limits for toxicity in allogenic and moreover in autologous stem cell transplantation. currently, the choice of conditioning regimen is based on the use of the least-toxic regimen to achieve the optimal therapeutic result. this report aims to assess the feasibility of a conditioning strategy based on high dose chemotherapy and whole-body radiotherapy focused on selective extensive tumor burden irradiation, both in allogeneic and autologous stem cell transplantation. methods: since december , sixty-two patients (pts) have been irradiated by helical tomotherapy (ht) to extensive target before allogeneic or autologous transplantation. selected total marrow irradiation (tmi) schedules were planned to treat patients with high risk acute leukemia (all or aml) or multiple myeloma (mm) as a part of conditioning regimen. total lymphoid irradiation (tli) was planned for patients with refractory or relapsed (r/r) hodgkin (hd) or non-hodgkin lymphomas (nhl). results: tmi and tli allowed delivering therapeutic dose over extensive selected targets with wide reduction of toxicity to all the organs at risk (oars). the higher radiation doses rate to the oars is reduced from % to %. allogenic conditioning regimen was tli ( gy x fx) than fludarabine + endoxan for patients with hd ( pts). tmi ( gy x fx) + fludarabine + melphalan for patients with mm ( pts). tmi ( gy x fx) + thiotepa + fludarabine + busulfan for advanced lam patients ( pts). tmi as the boost ( - gy) after conventional tbi was ( gy in bi-fractionated doses) by cyclophosphamide ( pts). autologous preparation to sct consisted of tli ( gyx fx) followed by high-dose bendamustine and melphalan for patients older than years and conventional feam (fotemustine, etoposide, cytarabine, and melphalan) for younger patients, in hd e nhl ( pts). while tmi ( gy x fx) plus melphalan was delivered for autologous sct in mm and lam ( pts). no unexpected acute toxicity was found. in the allogenic setting, all the patients' engraftment was achieved in all patients. no acute graft versus host disease increasing was detected. within the autologous setting, only % developed grade / mucositis. none experienced grade / extra-hematological toxicity. outcomes of the specific disease will be reported. conclusions: the current report describes the clinical feasibility of using ht to deliver tmi or tli in the setting of autologous transplantation or during allogenic stem cell conditioning regimen, to allow all patients (old, fragile or with high tumor burden) to achieve an ablative regimen before sct. to our knowledge, this single institution experience describes data from one of the largest cohort of patients treated in europe since the development of this irradiation techniques. disclosure induction therapy in both groups of patients was based in polychemotherapy without the use of new drugs. case matching was performed according to age, clinical stage at diagnosis, and response to induction therapy. conditioning regimen consisted of iv bu at a dose of . mg/ kg once a day on days - to - followed by mel at a dose of - mg/m on day - in the bumel group versus mel in the control group. maintenance therapy after transplant consisted of interferon and steroids in the majority of patients. results: the cut-off date for this update was june , . after a median follow-up of and months in the bumel and mel groups respectively, patients had relapsed in the bumel group and patients in the control group. median pfs was ( % ci, . - . ) months in the bumel and ( % ci, . - . ) months in the mel group (p = . ) ( figure ). in this update, patients in the bumel group are in maintained response and of them are in continuous cr (two with negative status for minimal residual disease) between and years after transplantation. ten-year os was not significantly different between both groups, being ( % ci - ) months in the bumel and ( % ci - ) months in the control group.transplant-related mortality was similar in both groups of patients ( % in the bumel and % in the mel group). regarding toxicity, bumel was associated with a higher incidence of mucositis and liver toxicity than the melphalan-only approach but no patient in our series developed sinusoidal occlusive syndrome and the hepatic toxicity observed was only grade i/ii. finally, no long-term side effects have been reported among bumel recipients. conclusions: this long-term follow-up analysis confirms that a therapeutic strategy including bumel as conditioning regimen beforeasct in patients with newly diagnosed mm is highly active and safe in these patients. [[p image] . figure . progression free survival in the bumel (____) and control group (…… frequency of acute gvhd grade iii-iv [cc: %; ct: %; tt: %, p= . ], and transplant-related mortality was higher in tt-carriers (cc: %; ct: %; tt: %, p= . cc&ct vs tt) . ta-tma, cmv infection/reactivation and cgvhd were also not different according to donor genotypes. fungal infections occurred more frequently as causes of death in carriers (cc: . % vs. ct: . % vs tt: . %, p= . ). conclusions: our results suggest that donor tgfb - c>t may exert an adverse influence on the outcome of myeloablative conditioning. our finding might be explained by the combination therapy of calcineurin and mtor inhibition in gvhd prophylaxis in myeloablative conditioning. disclosure: nothing to declare. treosulfan-based reduced intensity conditioning in hla-haploidentical transplantation using ptcy as gvhd prophylaxis in high-risk mds /aml of the elderly background: standard conditioning regimens prior to allogeneic hematopoietic stem cell transplantation (allo-hsct) are often associated with a considerable risk of severe adverse events, especially in elderly patients suffering from high-risk (hr) mds/aml. previous clinical studies have demonstrated feasibility of treosulfan-based reduced-intensity conditioning (ric) by stable engraftment, low non-relapse mortality (nrm), and favorable survival in elderly patients undergoing hla-matched related or unrelated allo-hsct (beelen et al, ash # ). however, data for treosulfan-based conditioning in the t-cell-replete hlahaploidentical (haplo-hsct) setting in high-risk aml/mds patients are rare. here we report on the outcome of eleven patients treated with a treosulfan-based conditioning undergoing haplo-hsct using exclusively post-transplantation cyclophosphamide (ptcy) as gvhd prophylaxis. methods: eleven patients with high-risk (hr) aml (n= )/mds (n= ) who underwent haplo-hsct using treosulfan for reduced intensity conditioning (ric) and ptcy as gvhd prophylaxis were retrospectively analyzed with respect to outcome and toxicity. all patients were > years old and transplanted between january and february at our institution. the majority of the patients ( / ) suffered from active disease at time of treatment initiation, only two patients presented in cr. all but one received sequential conditioning with cytoreductive chemotherapy using flamsa applied shortly prior to treosulfan-based ric ( g/m over days). a bone marrow graft was used in / patients. post-grafting immunosuppression consisted of cyclophosphamide, tacrolimus and mmf. national cancer institute common terminology criteria for adverse events version . were used for nonhematologic toxicity assessment starting from sequential therapy initiation or conditioning until day + . results: median age of the entire cohort was years (range: - ). the hct-ci was ≥ in eight pts (median hct-ci= , range: - ). no graft rejection occurred. neutrophil and platelet engraftment were achieved in % and % of the patients at a median of ( - ) and . ( - ) days, respectively. acute gvhd grade ii-iv occurred in % of the patients, exclusively involving the skin. no one developed severe (°iii-iv) acute gvhd. no patient died prior to haplo-hsct. severe nonhematologic regimen-related toxicities (°iii-iv) occurred in / patients, predominately affecting the gastrointestinal tract. no patient suffered from ≥two iii-iv°toxicities. all patients developed fever during treatment course, four with positive blood cultures. cmv reactivated in / patients at risk. no ebv reactivation or ptld occurred. six patients had clinical and radiological signs of pneumonia (probable invasive aspergillosis) without detection of aspergillus/antigen in the bronchoalveolar lavage. ci of nrm at day + was %. four patients relapsed within the first year after haplo-hsct, with two of them dying due to relapse. at last follow-up (dec ) / patients were alive. with a median follow-up of months ( - ) estimated -year os and dfs were % and %, respectively. conclusions: treosulfan-based unmanipulated hlahaploidentical allo-grafting using ptcy as gvhd prophylaxis in hr mds and aml patients aged over years is safe and well tolerated resulting in stable engraftment and a favorable toxicity profile. our preliminary data further show promising outcome with low nrm, no severe acute gvhd and favorable survival offering an attractive alternative in ric for haplo-hsct of the elderly. disclosure: nothing to declare comparison of outcomes of total body irradiation (tbi) vs non-tbi conditioning regimens in acute lymphoblastic leukemia for allogeneic transplantation background: in adult patients diagnosed acute lymphoblastic leukemia (all) long-term results are poor with intensive chemotherapy. allogeneic stem stem cell transplantation is the potential treatment that provides cure for these patients. myeloablative preparation regimens include total body irradiation (tbİ)+ cyclophosphamide(cy) and busulfan + cyclophosphamide.in adult all patients wbi/cy widely used, but the toxicity rate is higher. the aim of this study is to compare the result and effect of the tbi/cy and busulfan/cy regimens in allogenic bone marrow transplantation in all patients. methods: between - there were all patients who underwent transplantation using myeloablative preparation regimen with or without addition tbi in the adult bone marrow transplantation units of medipol medical faculty, istanbul university istanbul medical faculty, sisli florence nightingale hospital, atakent acıbadem hospital adult bone marrow units . we analyzed overall survival (os), progression free survival (pfs), veno occlusive disease, acute and chronic graft versus disease development rates in these patients. results: demographic characteristics of patients summarized in table - there was no significant difference between groups in donor age, gender, stem cell source. it was observed that the relapse rate was not statistically significant in both group.there was no statistically significant difference between the patients who underwent myeloablative regimen and myeloablative regimen with tbi in relaps,death, os, pfs. (figure- ) [[p image] . figure ] in terms of transplant complications there was also no respectable difference in development of vod and acute and chronic graft versus disease but vod was more common in the group that did not use tbi (p: . ) ( conclusions: although there are contradictory data in the literature, in our multicentre study, it was revealed that the addition of tbi in the myeloablative preparation regimen compared with myeloablative preparation regimen alone did not have a positive or negative effect on overall survival.we think that if we can prepare a good vod prophylaxis approches, we can give up tbi in future. disclosure (n= ) . for gvhd prophylaxis, cyclosporine a was given either alone (n= ), with mmf (n= ) or with methotrexate (n= ). the graft source was bone marrow (bm) in most cases (n= ), pbsc in seven cases, matched sibling cord +bm in two cases and one matched related cord. twentyfive of the donors were family donors and ten were unrelated. twenty-nine of the donors were / hla matched, six were / mismatched and one haploidentical. four patients had engraftment failure and required a second transplant, two of them were re-transplanted with cyclophosphamide and tbi, one with fludarabine, busulfan and campath, and one with no conditioning. thirty of the patients are alive ( %). four patients died of transplant complications and one died of metastatic squamous cell carcinoma. eight survivors are mixed chimeras ( %- % donor) and are all doing well, none of them developed any gvhd. nine patients developed acute gvhd, four of them with grade - . seven of these patients later developed chronic gvhd, two of them have extensive disease. conclusions: our results show a high survival rate of %, with a low rate of engraftment failure and reasonable rates of gvhd. only one of our patients died of late effects of hsct for fa. mixed chimerism does not seem to present a problem. we conclude that reduced intensity fludarabine based conditioning regimens are a good treatment option for patients with fanconi anemia undergoing hsct. disclosure: nothing to declare total marrow irradiation + bendamustine as reducedtoxicity myeloablative conditioning prior to allohsct for younger patients with multiple myeloma background: the prognosis of patients with multiple myeloma (mm) has improved markedly over the last two decades. despite that, allohsct remains the only treatment option with curative potential. however, its use is limited due to high incidence of non-relapse mortality (nrm) after myeloablative conditioning while insufficient efficacy of reduced-intensity regimens. we developed a new protocol characterized by reduced toxicity while preserved myeloablative potential, based on the use of total marrow irradiation (tmi) in combination with bendamustine. the aim of this study was to evaluate its safety and efficacy in a singlecenter experience. methods: between years - , mm patients below years old were offered tandem auto-allohsct as part of first-line therapy. the decision was based on individual patient preferences after detailed description of potential risks. autohsct was preceded by melphalan mg/m iv. the conditioning prior to allohsct consisted of tmi performed using helical tomotherapy at the dose of gy/d on days - , - , - (total gy) and bendamustine - mg/m /d iv. on days - , - (total - mg/m ). the immunosuppressive therapy consisted of cyclosporine + methotrexate +/-atg. peripheral blood was used as a source of stem cells. results: the analysis included patients (women - , men - ). the median follow-up was ( - ) months. the median age at allohsct was ( - ) years. the disease stage before allohsct was as follows: cr- , vgpr- , pr- . patients were treated with hsct from either hlamatched siblings (n= ) or unrelated donors (n= ). the interval between autohsct and allohsct was ( - ) months. all patients engrafted after allohsct with median time of neutrophil and platelet recovery of and days, respectively. one patient ( %) experienced grade acute gvhd, while there were no cases of grade - acute gvhd. the incidence of mild, moderate and severe chronic gvhd was %, % and %, respectively. the rate of grade non-hematological toxicities was %. one patient died of late bacterial infection. the incidence of trm was %. grade adverse events were not reported. disease status months after allohsct was: cr- , vgpr- , pr- . the probability of os and pfs after months was % (+/- %) and % (+/- %), respectively. the incidence of progression and trm was % and %, respectively. conclusions: allohsct using tmi gy + bendamustine conditioning protocol is characterized by good tolerance and low risk of gvhd. it may be used for younger patients with mm as part of tandem auto-allohsct strategy. encouraging results reported in this study should be confirmed in prospective clinical trials. disclosure: nothing to declare p comparison between two reduced intensity conditioning regimens in patients with a myeloid malignancy: a single center experience comparing fb with flumel background: hematopoietic stem cell transplantation (hsct) remains the only curative option for high-risk myeloid neoplasms. the optimal reduced-intensity conditioning (ric) is still debated. methods: a single-center retrospective analysis was conducted at our institution to compare two different ric regimens in adult patients transplanted for myeloid malignancy from to . a total of patients were analysed, of them treated with busulfan-based (fludarabine mg/m , busulfan . mg/kg, fb ) and with melphalan-based conditioning regimen (fludarabine mg/m ,melphalan mg/m , flumel). antithymocyte globulin (atg) was administered in all patients while no one received tbi. partial in vitro t-cell depletion was performed using alemtuzumab for low risk patients. results: the two groups were well balanced with a median age of and years in the fb and flumel group, respectively, and a median follow up of months. the most frequent indication for transplant in both groups was aml ( . and . % for fb group and flumel group, respectively) and the stem cell source was peripheral blood in . and . % of patients. more patients in the first group had near to significant worst karnosfky status (< ) at transplant compared to second ( . vs %, p= . ) and more patients received a t-partial depleted graft ( . vs . %, p= . ). the neutrophil engraftment was significantly shorter after flumel ( vs days, p < . ). the -year overall survival (os) and disease-free survival (dfs) were of . and . %, respectively, after fb and . and . % after flumel, respectively, and were not significantly different (p=. for os and . for dfs), with a karnofsky >= being the only factor significantly associated in univariate analysis with better os and dfs (p=. for both). the cumulative incidence (ci) of grade to acute graft-versus-host disease (agvhd) was . % after fb and . % after flumel (p< . ) and was associated in multivariate analysis with both t depletion and ric type (p< . and . , respectively). the ci of chronic gvhd at years was . % in fb and . % in flumel group (p=. ) . the ci of non-relapse mortality at years was . % after fb and . % after flumel (p=. ). the ci of relapse at years was . % for the first and . % for the second group (p< . ) and was associated with conditioning regimen in multivariate analysis (p=. ). no difference in -years gvhd-free/ relapse-free survival (grfs) was observed between the two group ( . % for fb and . % for flumel, p=. ). conclusions: when comparing two ric regimens for myeloid neoplasms, we observed a higher incidence of agvhd after flumel whereas no statistical difference was noted for the cgvhd occurrence. while the toxicity appears to be higher after flumel, this result is counterbalanced by a higher proportion of relapse after fb , accounting for no difference in os, dfs and grfs between the two groups. these findings could be partially explained by a larger proportion of patients receiving a partial t-depletion after fb ric, but a larger trial is needed to clarify this issue. disclosure: nothing to declare. once-daily vs -times daily intravenous busilvex in conditioning regimen before allogeneic stem cell transplantation for patients with myeloid malignancies: safety and efficacy background: busilvex (bu) is part of standard conditioning regimen before allogeneic stem cell transplantation (asct) for patients with myeloid malignancies and usually administered as an intravenous (iv) infusion -times daily. this study aimed to compare the saftey and efficacy of this schedule to a once-daily iv bu. we conducted a retrospective study in adult patients (≥ years) with myeloid malignancies who received asct from hla-identical sibling donors between january and june following iv bu-based preparative regimens. graft-versus host disease (gvhd) prophylaxis consited of cyclosporine and short course of methotrexate. intravenous bu was administered -times daily ( . mg/kg every hours x to doses) or oncedaily in a -hour infusion ( . mg/kg x to days) since june . results: ninty-nine patients were enrolled ( men and women). median age was years (range, - y). the median time from diagnosis to asct was months (range, days - years). diagnosis were acute myeloid leukemia (n= , %), chronic myeloid leukemia (n= , %), myelodysplasic syndrome (n= , %), primitive myelofibrosis (n= , %) and chronic myelomonocytic leukemia (n= , %). thirty-seven ( . %) patients had ebmt-score ≥ . sixty-five ( . %) patients were transplanted in cr , ( %) beyond cr and ( . %) had active disease. conditioning regimens consisted of bu/cyclophosphamide in patients ( . %), bu/fludarabine in patients ( . %). four-times daily bu was given to patients ( . %, groupe ) and once-daily bu to patients ( . %, groupe ). stem cell source were bm in patients ( . %) and pbsc in patients ( . %). globally, patients characteristics were well balanced between the two groups. the rates of severe complications were similar between the two groups with no statistically significant differences except oral mucositis (table ). non-relapse mortality (nrm) was comparable in the two groups ( % and % in groups and , respectively, p= . ). the relapse rate was % and %, respectively (p= . ). after a median follow-up of years (range, days - years), the os was not significantly different between groups and : % vs % (p= . ). however, the rfs was significantly better in the groupe : % vs % (p= . ). conclusions: once-daily iv bu regimen seems to be an efficient and safe alternative to the -times daily protocol. however, results should be interpreted with caution because the historical comparison and lack of bu pharmacokinetics studies. disclosure background: standard therapy of the most patients with juvenile myelomonocytic leukemia (jmml) is allogeneic hematopoietic stem cell transplantation (ahsct). the choice of optimal conditioning regimen for patients with jmml is crucial as well as long-term observation. we aimed to estimate the long-term follow-up and survival rates of patients with jmml after ahsct with the help of busulfan or treosulfan-based conditioning regimens. methods: thirty eight patients with jmml underwent ahsct in - . we compared equal groups of patients received busulfan (n= ) and treosulfan-based (n= ) conditioning regimen. m:f= : . median of age at hsct was . ( . - ). donor type: hla-related / - % (n= ), hla-related / - . % (n= ), hlaunrelated / - . % (n= ), hla-unrelated / - . % (n= ), and haploidentical - . % (n= ). stem cell source: bm - . % (n= ), pbsc - . % (n= ), ucb - , % (n= ), and ucb+bm - . % (n= ) . disease status on hsct: cr - . % (n= ), refractory - . % (n= ). results: median follow-up . months ( - months) . the estimated -year overall survival (os) probability in patients received busulfan-based conditioning was , ± , % in comparison with , ± , % in patients with treosulfan-based regimen (р= , ). event-free survival (efs) was , ± , % in group with busulfan-based regimen and , ± , % in patients with treosulfanbased conditioning (р= , ). background: post-transplant relapse remains the leading cause of treatment failure in high risk (hr) acute myeloid leukemia (aml), myelodysplastic syndrome (mds), myeloproliferative neoplasia (mpns) receiving allogeneic hematopoietic cell transplantation (allo-hct), especially for patients with relapsed or refractory aml. recently, a sequential transplant approach, as developed by the munich group, comprising of intensive cytoreductive chemotherapy flamsa (fludarabine/amsacrine/cytarabine) to decrease leukemia cell burden shortly prior to conditioning regimen, has been successfully used for high-risk (hr) aml/mds with promising results. methods: we studied patients (median age years, range - ) with hr aml (n= ), as defined by refractory, relapsed disease, secondary leukemia, or high/ very risk disease risk index risk, and hr mds (n= ) according to ipss-r, undergoing allo-hct using the sequential transplant approach in institutions between january and october . the sequential transplant approach combined a cytoreductive chemotherapy, which consisted of either flamsa (n= ), flag +/-ida (fludarabine/cytarabine/granulocyte colony stimulating factor /idarubicin) (n= ), or clo-arac (clofarabine/cytarabine) (n= ), followed by reduced (ric) (n= ) or myeloablative (mac) (n= ) conditioning regimen. all patients received peripheral blood stem cell from matched related donors (n= ) matched unrelated donors (n= ), or mismatched unrelated donors (n= ). post-grafting immunosuppression consisted of calcineurin inhibitor and mycophenolate mofetil in all patients. thymoglobulin was added for gvhd prophylaxis for unrelated donor transplant. results: the median time to neutrophil > /μl was days (range, - ) . with a median follow-up of . months (range, . to . months), the kaplan-meier estimate of leukemia-free (lfs) and overall survival (os) at years were % ( % ci, - ), % ( % ci, - ), respectively. patients receiving flag or clo-arac based sequential regimen showed a trend towards more favourable overall survival (os) as compared to patients given flamsa ( year os: % vs %; p= . ). at years, the cumulative incidences of relapse and non-relapse mortality (nrm) were % ( % ci, - %) and % ( % ci, - %), respectively. in multivariate analysis, the type of sequential conditioning regimen did not show any significant impact on lfs, os, nrm or relapse. conclusions: sequential transplant conditioning with flamsa, flag or clo-arac followed by allo-hct is an effective strategy in overcoming the dismal prognosis of hr aml and mds, and enabling long-term disease free survival. more studies on effective strategies such as posttransplant maintenance therapy of prophylactic donor lymphocyte infusion, are needed to further eliminate the risk of relapse, without increasing risk of treatment related toxicity. disclosure: nothing to declare optimization of the blood sampling procedure for busulfan therapeutic drug monitoring (tdm) to optimize our sampling scheme ( minutes, , , , , , and hours after the end of a -hour infusion), we reduced the number of blood samples collected, reducing nursing and laboratory staff time and increasing patient convenience. this study aims to show the performance of a simplified sampling protocol which includes the first samples from the original protocol. methods: individual pk parameters were retrospectively estimated using samples (simplified protocol) and were compared with those obtained after samples (original protocol). individual pk parameter values for a one compartment model were estimated using a maximum likelihood estimation modelling algorithm (adapt . ) and the statistical analysis of the results was performed (statgraphics centurion xv). results based on the approved dosage recommendations, mean (sd) initial dose was . ( . ) mg. after tdm, mean (sd) calculated dose at day for the remaining days (to achieve the defined target cumulative auc) was , ( , ) mg obtained from the original protocol. according to the simplified protocol the result would be , ( , ) mg. the median and the mean variation of the calculated dose were % and % ( - %) between protocols. a strong relationship between the cl of the day - obtained from the original protocol and the simplified protocol is observed (r = . ). this high correlation is also observed for patients with busulfan t / > h (r = . ), a population were the reduction of sampling could be more problematic. anova test for the log cl with the factors: patient, day of busulfan and type of sampling protocol was performed. sampling protocol was determined as non-statistically significant (p = . ). conclusions: results suggest that both protocols are equivalent concerning to the busulfan cl estimation and calculated auc. variation between protocols regarding the calculated dose at day for the remaining days to achieve the defined target cumulative auc is considered acceptable. we verified a strong relationship between busulfan cl obtained from both protocols and sampling protocol doesn't influence cl statistically. a reduced sampling collection of determinations until h after the end of the infusion is shown to be sufficient for the tdm of busulfan, so this was implemented in our centre in line with published data. disclosure: nothing to declare p impact of anti-thymocyte globulin doses in unrelated hematopoietic stem cell transplantation for patients with myeloid neoplasm background: anti-thymocyte globulin (atg) is widely used for the prophylaxis of graft-versus-host disease (gvhd) in hematopoietic stem cell transplantation (hsct). however, there is still controversy regarding the optimal dose of atg. therefore, we analyzed the impact of atg doses in unrelated hsct for patients with myeloid neoplasm. methods: this was a retrospective multi-center study that assessed the impact of atg doses on clinical outcomes in patients with acute myeloid leukemia (aml) or myelodysplastic syndrome (mds) undergoing an unrelated hsct. the patients who received peripheral blood stem cells (pbsc) transplantation after conditioning regimens containing i.v. busulfan (bu), fludarabine and rabbit atg between and were included in this study. results: a total of patents, median age years, with aml (n= ) or mds (n= ) were included in our analyses. patients ( %) received a myeloablative regimen (i.v. bu> . mg/kg). high-atg (atg mg/kg), intermediate-atg (atg . - mg/kg) and low-atg (atg mg/kg) were given in , and patients, respectively. after a median follow-up of months, the cumulative incidence of extensive chronic gvhd was . % in the high-atg group, . % in the intermediate-atg group and . % in the low-atg group (p= . ). conclusions: our study shows that the incidence of extensive chronic gvhd was similar regardless of the doses of atg after transplantation of pbsc from unrelated donor for patients with aml or mds. however, the rate of relapsefree survival and the rate of a composite end point chronic gvhd-free and relapse-free survival were significantly higher in the intermediate dose ( methods: we retrospectively retrieved data from the electronic medical records for consecutive patients aged and older, who underwent an asct for lymphoma over the last years at our institution. results: forty four patients ≥ years old underwent asct between aug and aug . twenty eight of them received a reduced-dose conditioning (median %, range %- % dose reduction). the dose was reduced for % of patients ≥ years old and for % of patients aged - . the outcomes of the following three groups of patients were compared: a) age ≥ ; without dose reduction, b) age - ; with dose reduction and c) age ≥ ; with dose reduction (table ). only one patient aged received full-dose conditioning. there was no significant difference between the groups in the number of previous chemotherapy cycles (median , range - ). however, significantly more patients at the age of - were in complete remission (cr) pre-transplant in both full and reduced-dose conditioning groups (a and b). no significant intergroup differences were observed in the occurrence of complications (mucositis and infections), day transplantrelated mortality (trm) or engraftment day. similarly, no significant differences were found either in the -year progression-free survival (pfs), which was %, % and %, or -year non-relapse mortality (nrm), which was %, % and %, respectively for groups a, b and c. the -year overall survival (os) tended to be higher in group b ( %), compared to groups a ( %) and c ( %). conclusions: beam/beac conditioning dose reduction was not found to adversely affect -year pfs and os rates. despite the fact that / of the patients in the age group ≥ underwent asct in partial remission and had dose reduction, theier achieved trm, pfs and os rates were similar to those of patients aged - . beam/beac conditioning at a %dose may be a suitable option for patients in their seventh decade requiring asct. this strategy should be further evaluated in prospective clinical trials. background: the transplant related mortality in autologous transplants for lymphoma and multiple myeloma, reported worldwide ranges from - %. from - , the trm at our center for these two diseases was approximately %. we introduced changes in mobilization schedule, conditioning regimens and drug dosages to determine whether these changes affected the transplant related mortality and overall survival. methods: from april -december , we used beam (bcnu: mg/m on day - ; etoposide mg/ m on days - to - , cytarabine mg/m on days - to - and melphalan mg/m on day - as conditioning chemotherapy for patients admitted in transplant unit for autologous transplants in hodgkin's and non-hodgkin's lymphoma. in patients with multiple myeloma high dose melphalan ( mg/m ) was used. the mobilization protocol consisted of cyclophosphamide . gm/m followed by gcsf μgm/kg twice daily till stem cell collection was completed. from january , we changed the beam protocol to bendaeam with dose modifications that included: bendamustine mg/m on days - and - , cytarabine mg/m on days - to - , etoposide mg/m on days - to - and melphalan mg/m on day - . for multiple myeloma melphalan was reduced to mg/m . we used only gcsf for mobilization of stem cells, which was continued till stem cell harvest was complete. response to treatment was evaluated by comparing trm and overall survival for two time periods: - and from till date. results: from april till december , n= autologous transplants were performed. the male:female ratio was . : . fifty seven patients underwent transplant for lymphomas, n= for multiple myeloma and n= for other diagnosis. median age was ± . ( - years). the mean mnc was . × ± . /kg. engraftment was achieved in % of patients. the transplant related mortality was . % and overall survival was % (follow up: months). since january till march we have performed n= autologous transplants of which n= were males. fifteen transplants were performed for lymphomas (nhl: , hd: ) and n= for multiple myeloma. median age was ± ( - years). the mean mononuclear cell count was . x /kg and the mean cd count was . x /kg. engraftment was achieved in all patients. the transplant related mortality was % and the overall survival was % (follow up months). conclusions: we were able to reduce the autologous transplant related mortality to % by decreasing dosages of conditioning chemotherapy and changing the mobilization protocol. long follow-up is needed to determine late mortality and late relapse in comparison to standard chemotherapy dosages disclosure: nothing to declare risk and benefit of thiotepa based conditioning followed by autologous stem cell transplantation in high risk lymphomas years ( - ) . stage (ann-arbor) at diagnosis of hd/dlbcl/pcnsl: stage ie n= / / ( / / %), stage ii n= / / ( / / %), stage iii n= / / ( / / %), stage iv n= / / ( / / %). median time from diagnosis to asct hd/dlbcl/pcnsl: / / month ( - ). induction treatment in hd patients was abvd, in most dlbcl patients r-chop and in pcnsl patients high dose methotrexate and cytosin arabinoside. tumor status at asct hd/dlbcl/pcnsl: complete metabolic remission (cmr) n= / / ( / / %) and from pcnsl patient's n= ( %) were in first complete remission (cr ). type of stem cell graft was periferial blood stem cell in all case. conditioning: thiotepa ( mg/ m on days - to - , busulphan , mg/kg on days - to - and cyclophosphamide mg/kg on days - to - plus rituximab mg/m on day - in dlbcl and pcnsl. median follow up from asct days . tumor stage at asct was defined with computer tomography with positron emission tomography (pet-ct). results: median time of engraftment was days ( - ). thiotepa caused toxicoderma appeared at ( %) patients. cytomegalovirus (cmv) reactivation was seen in ( %) cases with low dna content ( , , copies/ml) and responded completely to oral valgancyclovir therapy. transplantation related mortality hd/dlbcl/pcnsl n= / / ( / / %), in cases bacterial sepsis and one systemic mycoses and one pulmonary fibrosis. incidence of long-lasting grade iii-iv thrombocytopenia and anaemia: n= ( , %) and n= ( %), median time of duration from transplantation days ( - ) and days ( background: this study evaluated the efficacy and toxicity of intravenous busulfan and thiotepa as a conditioning regimen for autologous stem cell transplantation (asct) in patients with multiple myeloma (mm). methods: we retrospectively analyzed the data of patients with mm who received the intravenous busulfan and thiotepa conditioning for asct between november and april in korea. results: the median time to transplant was . months, and patients ( . %) underwent asct within months of the diagnosis. the overall response rate after asct was . %, including . % with complete response, . % with very good partial response, and . % with partial response. the most common severe non-hematologic toxicity (grade - ) was infection ( . %). three patients ( . %) developed venous-occlusive disease. one patient ( . %) died due to severe pneumonia after asct. after a median follow-up of . months, the median progression-free survival (pfs) and overall survival (os) were not reached. conclusions: in conclusion, a conditioning regimen of intravenous busulfan and thiotepa was effective and tolerable. clinical trial registry: not applicable disclosure: the authors have declared no conflicts of interest. myeloablative haploidentical bone marrow transplantation with post-transplant cyclophosphamide in paediatric patients with haematological malignancies santanu sen , sameer tulpule background: haploidentical transplants have been shown to be safe and effective in treating haematological malignancies in the paediatric population. we have previously reported on our experience of using reduced intensity conditioning with post transplant cyclophosphamide in haploidentical patients. we herein report our experience of using a tbi based myeloablative conditioning to treat our first patients with haematological malignancies. methods: patients were enrolled in the study, with relapsed acute lymphoblastic leukemia (all) and with relapsed/resistant acute myeloid leukemia (aml). all aml patients had genetic markers of high risk disease and all all patients had very early relapses (either on therapy or within months of stopping therapy). all patients were conditioned with an identical protocol using tbi-based myeloablative preparative regimen (fludarabine mg/m /d × d and tbi cgy bid on d − to − [total dose cgy]) followed by an infusion of unmanipulated peripheral blood stem cells from a haploidentical family donor. postgraft immunosuppression consisted of cyclophosphamide mg/kg/day on days and , mycophenolate mofetil through day , and tacrolimus through day . results: median time of neutrophil and platelet engraftment was and days, respectively. all patients achieved sustained complete donor chimerism by day + . acute gvhd, grades ii-iv and iii-iv, was seen in % and %, respectively. disease progression occurred in patients: & months after transplant and there was one death due to severe fungal infection. estimated twoyear survival and relapse were % and %, respectively. patients had severe bk viremia and cmv reactivation occurred in patients. all patients were successfully managed with appropriate supportive and antiviral therapy. conclusions: we report good outcome with a myeloablative conditioning in haploidentical transplants with excellent engraftment and hopefully a longer life expectancy. with small number of patients, it is difficult to state whether using a myeloablative conditioning would lead to better long term outcomes in this cohort of patients with very haematological malignancies, but we certainly showed that it is possible to achieve excellent early results. disclosure: nothing to declare fludarabine in combination with melphalan and atg can be the best conditioning for hematopoietic stem cell transplant of children with hemophagocytic lymphohistiocytosis methods: in this prospective study, we analyzed the outcome of two pediatric patients with hlh who had received hsct, using reduced-intensity conditioning (ric) regimen. they received the same ric regimen based on the use of fludarabine ( mg/m /day for days) in combination with melphalan ( mg/m /day for days) and horse antithymocyte globulin (atg mg/kg/d for days). cyclosporine and methotrexate were used as graft-vs.-host disease (gvhd) prophylaxis. results: a months boy with primary hlh (fhl ) was transplanted from his mother and a years girl with secondary hlh was transplanted from her brother. both of donors were hla match with their recipients. they were received x /kg and x /kg cd + cells from the harvested peripheral blood stem cells, respectively. they achieved full neutrophil and platelet recovery. the time to neutrophil recovery was and days, respectively. full chimerism was achieved for both of them. in addition, they was developed grade and of acute gvhd, respectively. gvhd was completely controlled with prednisolone. they are alive and in complete remission without any significant complications after and months, respectively. conclusions: it appears that fludarabine in combination with melphalan and atg may be the best conditioning regimen for hematopoietic stem cell transplant of children with hlh. due to a few number cases of this study, a study with sufficient sample size is required. disclosure background: hematopoietic cell transplant (hct) recipients often report depression and impaired quality of life (qol) before transplant. mixed evidence suggests depression may be a risk factor for greater mortality and worse qol. inconsistent findings may be due to the fact that previous studies have not evaluated antidepressant use. the aim of the study was to compare pre-transplant patientreported physical functioning and post-transplant overall survival (os) between four groups of hct recipients: ) non-depressed/taking antidepressant (treated depression), ) depressed/taking antidepressant (undertreated depression), ) depressed/not taking an antidepressant (untreated depression), and ) not depressed/not taking an antidepressant (control). it was hypothesized that physical functioning and os would be worse among patients with untreated and undertreated depression relative to those with treated depression and controls. methods: this retrospective case-control study included patients completing depression (phq- ) and quality of life (sf- ) questionnaires at pre-transplant. analyses were conducted separately for allogeneic and autologous recipients. results: participants (n= , ) were % men, mean age years ( - ), % allogeneic recipients. regarding depression and antidepressant use, ( %) allogeneic patients were characterized as having treated depression, ( %) as untreated depression, ( %) as undertreated depression, and ( %) as controls. hierarchical linear regression models indicated that after adjusting for significant univariate factors (performance status, disease status, and regimen intensity), allogeneic patients with treated depression (b=- . , % ci=- . , - . ) reported better physical functioning than patients with undertreated depression (b=- . , % ci=- . , - . ) and untreated depression ) but worse physical functioning than controls (p values < . ). cox regression models indicated depression/antidepressant usage was not associated with os among allogeneic patients (p values> . ).among autologous patients, ( . %) were characterized as having treated depression, ( . %) as untreated depression, ( . %) as undertreated depression, and ( . %) as controls. hierarchical linear regression models indicated that after controlling for significant univariate factors (gender, performance status, diagnosis, and disease status), autologous patients with treated depression (b=- . , % ci=- . , - . ) reported better physical functioning than patients with undertreated depression (b=- . , % ci=- . , - . ) and untreated depression (b=- . , % ci= . , - . ), but worse physical functioning than controls (p values < . ). cox regression models showed depression/antidepressant usage was associated with os (p values < . ), with patients with treated depression demonstrating significantly worse os than other groups (p= . ), but this association was no longer significant in multivariate analyses controlling for diagnosis and disease status (p= . ). conclusions: patients with untreated or undertreated depression pre-transplant may benefit from depression screening and treatment to improve physical functioning. disclosure: hslj: consultant for redhill biopharma and janssen scientific affairs p eltrombopag (epag) induces a high percentage of responses in patients with post allo-hsct poor graft function (pgf) and no active gvhd lourdes aguirre , aitziber lizardi , pilar bachiller , brigida esteban , carmen gonzález , nagore argoitia , maría araiz , aranzazu aguirre , anunciación urquía , carlos vallejo background: persistent cytopenia is a life-threating complication after hsct. several causes can lead to this situation (viruses, gvhd, drugs, etc) . a specific entity is the one called "poor graft function (pgf)", which is diagnosed in pts with ≥ cytopenias after day + , in the presence of donor chimerism and the absence of gvhd or relapse. pgf is more frequent after alternative allo-hscts, such a haplo-identical, mismatched, or ucb. several therapeutic approaches for pgf, with poor results, have been tested. recently, epag has been shown to improve platelet counts in the post-allo-hsct setting. in this study, we analysed the efficacy of epag in pts with post-transplant persistent cytopenias. methods: the population analyzed includes all pts who underwent allo-hsct from june through may in our unit. median age was years ( - ). were male ( . %) and female ( . %). baseline diseases were: aml, lpd, all, mds, mpd, mm, and bmf. donor was unrelated in ( . %) and was family in ( . %) (including haplo-identical). conditioning was ric in ( . %) and intensive in ( . %). sc source was pb in ( . %) and bm in ( . %). median followup was months ( - ). epag was initiated at some point during the first -month post-hsct period in pts ( . % of the series) due to thrombocytopenia (< /mcl) plus, at least, one other cytopenia. patients characteristics shown in table . epag was started at mg/day and escalated each weeks to , and mg/day if platelet count was < /mcl. global response was considered when, after epag, the patient needed no transfusions and reached the three of the following: platelets > /mcl, hgb > g/dl, and anc > /mcl. epag was tapered off in responders and discontinued if no response was reached after weeks. results: at epag initiation, all the pts had thrombocytopenia (< /mcl), had anemia (hgb < g/dl), and had neutropenia (anc < /mcl). counts pre and post and response to epag are shown in table . among the responders, all but one (who relapsed from thrombocytopenia and died from bleeding) were alive at analysis close ( . %). among the non-responders, three pts had gvhd-associated cytopenias, and finally died from infectious complications; the other patient relapsed from her aml, reached a new cr after treatment, and is alive and well months afterwards. epag was tapered off and discontinued in / pts who responded; / responders are still on epag. epag was discontinued in the / pts who did not respond. rest of treatment details shown in table . conclusions: ) epag worked striking well in subjects with pgf, an otherwise a life-threatening situation for patients. ) epag induced impressive responses in platelets, but strong bilinear and trilinear responses were also seen. ) epag did not improve gvhd-associated cytopenias. ) to confirm these innovative and transcendent results, we have just initiated a multicenter prospective study on the role of epag for treatment of post-hsct pgf. * five out of the six urdt were mismatched ** the donor was a woman in the six cases: three sisters and three daughters background: hepatic vod/sos with multi-organ dysfunction (mod; typically, renal or pulmonary) may be associated with > % mortality. defibrotide is approved for treating severe hepatic vod/sos post-hsct in patients aged > month in the eu, and for hepatic vod/sos with renal or pulmonary dysfunction post-hsct in the us. this analysis provides an overview of the safety results from studies of patients with vod/sos, with or without mod, who received defibrotide mg/kg/day. methods: safety data were pooled from patients with vod/sos post-hsct treated with defibrotide in a phase trial (n= ) and a phase , randomized dose-finding trial (n= receiving mg/kg/day). safety data for historical controls (hc) from the phase study (n= ) also are provided. reported separately, due to differences in patient population and data monitoring protocol, are aes from the expanded-access program (t-ind) in patients with vod/ sos with and without mod (n= post-hsct). vod/ sos was diagnosed by baltimore criteria/biopsy for the phase / studies; diagnosis by baltimore or modified seattle criteria was permitted in the t-ind. results: median patient age at hsct for the phase / studies was . years, . years for the hc, and . years for the t-ind. in the phase / studies defibrotide-treated group (n= ), ( . %) experienced aes; most common (> %) were hypotension ( . %), diarrhea ( . %), and multi-organ failure ( . %). treatment-related aes were at least possibly related to defibrotide (table) . any hemorrhage (an ae of special interest) occurred in patients ( . %); most commonly epistaxis ( . %), gastrointestinal and pulmonary alveolar hemorrhage and hematuria ( . % each), and conjunctival hemorrhage ( . %). all hc experienced an ae; most common (> %) were hypotension ( . %), tachycardia ( . %), diarrhea ( . %), nausea ( . %), and pyrexia, agitation, and petechiae ( . % each). any hemorrhage occurred in patients ( . %): most common (> %) were petechiae ( . %); hematuria, epistaxis, and pulmonary alveolar hemorrhage ( . % each); and lip hemorrhage ( . %). in the t-ind (n= ), / patients with mod ( . %) and / patients without mod ( . %) had an ae; other than vod/sos and mod, most commonly (> % in either subgroup) hypotension ( . % and . %, respectively). traes occurred in patients ( . %) ( table) . any treatment-emergent hemorrhage occurred in patients with mod ( . %) and patients without mod ( . %); most commonly (> % in either subgroup) pulmonary hemorrhage ( . % and . %, respectively) and gastrointestinal hemorrhage ( . % and . %, respectively). conclusions: the incidence and type of aes were as expected in these critically ill patients. of the pooled patients, % had aes; . % had a hemorrhage. all hcs had an ae, with . % having a hemorrhage. in the t-ind, patients with mod had higher rates of aes. support: jazz pharmaceuticals event, n(%) phase / studies (n= ) disclosure: paul g. richardson has served on advisory committees and as a consultant, and has received research funding from jazz pharmaceuticals. angela r. smith and leslie lehmann have nothing to disclose. nancy a. kernan received grants from gentium during the conduct of the study, and her research was supported by the national cancer institute of the national institutes of health under award number p ca ; the content is solely the responsibility of the author and does not necessarily represent the official views of the national institutes of health. she has a research grant from jazz pharmaceuticals. robert ryan and william tappe are employees of jazz pharmaceuticals and hold stock and/or stock options in jazz pharmaceuticals plc. stephan a. grupp has served on a steering committee and as a consultant to jazz pharmaceuticals. defibrotide for treatment of adults with hepatic vod/ sos with or without multiorgan failure after hematopoietic cell transplantation: results of a systematic review/meta-analysis background: although hematopoietic cell transplantation (hct), autologous or allogeneic, is potentially curable in various hematologic malignancies, the procedure is associated with serious and potentially life-threatening complications, among them veno-occlusive disease/sinusoidal obstructive syndrome (vod/sos) of the liver. several studies, prospective or retrospective, have reported outcomes of defibrotide, when used as prophylaxis or treatment, in a mixed population of adult and pediatric patients. in this systematic review/meta-analysis, we analyze outcomes of defibrotide when specifically used for treatment of adult patients with hepatic vod/sos with or without multiorgan failure. methods: a comprehensive search of large databases (medline/pubmed, cochrane and embase) on november , identified publications. analysis was restricted only to adult patients (defined as median age older than years) who received defibrotide for treatment of vod/sos and were reported in prospective or retrospective (which included ≥ patients) studies published in full manuscript form. there were no limitations based on language. data were extracted in relation to benefits [complete remission (cr) rate and overall survival (os)] and harms (hemorrhage, any site or organ-specific). a total of studies (prospective= ; retrospective= ) with patients met inclusion criteria. results: the median year of publication of prospective studies was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) and for retrospective ones ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the prescribed starting dose of defibrotide varied among studies ranging from . mg/kg/day to mg/kg/day, mostly for a -day course. the pooled cr rate was % ( %ci= - %) for prospective and % ( %ci= - %) for retrospective studies. the pooled day + os rates were % ( %ci= - %) and % ( % ci= - %) for prospective and retrospective studies, respectively. the pooled rates of hemorrhage (any site) were % ( %ci= - %) for prospective and % ( % ci= - %) for retrospective studies. when analyzing organ-specific hemorrhage, prospective studies (n= patients) reported pooled rates of pulmonary alveolar (pa) hemorrhage of % ( %ci= - %) and of % ( %ci= - %) for gastrointestinal (gi) hemorrhage. only one retrospective study (n= patients) reported an incidence of pa hemorrhage of % ( %ci= - %) and a different study (n= patients) reported an incidence of gi hemorrhage of % ( %ci= - %). none of the studies reported cerebral hemorrhage as a complication of defibrotide therapy. conclusions: this systematic review/meta-analysis confirms the efficacy of defibrotide for treatment of vod/sos with or without multiorgan failure, yielding cr rates of - % and day + os rates of - %. the purportedly higher pooled cr and os rates observed with retrospective (vs. prospective) studies are likely due to assignment-bias inherent to observational studies. moreover, although the pooled hemorrhage (any site) rates of - % is considered proportionally significant, the pooled rates of pa and gi hemorrhage were ≤ %, in prospective studies. clinical trial registry: not applicable disclosure: m.a.k-d: consultancy for pharmacyclics m.m: received lectures honoraria and research support from jazz pharma efficacy and safety of defibrotide in the treatment of hepatic veno-occlusive disease/sinusoidal obstruction syndrome following hematopoietic stem cell transplantation: interim results from the defifrance study background: hepatic veno-occlusive disease/sinusoidal obstruction syndrome (vod/sos) is a potentially lifethreatening complication of conditioning for hematopoietic stem cell transplant (hsct) but may occur after nontransplant chemotherapy alone. vod/sos with multi-organ dysfunction (mod) may be associated with > % mortality with supportive care alone. diagnosis of vod/sos was traditionally based on baltimore or modified seattle criteria; however, the ebmt recently published separate diagnostic criteria for adults and children. defibrotide is approved for treating severe hepatic vod/sos post-hsct in patients aged > month in the eu, and for hepatic vod/sos with renal or pulmonary dysfunction post-hsct in the usa. the goal of the defifrance study, requested by the french health authorities, is to collect real-world data on safety and efficacy in a broader patient population in france, including all indications. this is the first interim analysis of the largest current evaluation of defibrotide for the treatment of vod/sos in europe. methods: defifrance is an observational, multicenter, post-marketing study that includes any patient treated with defibrotide from hsct centers in france. this interim analysis is based on all patients treated with defibrotide, including those with severe and very severe post-hsct vod/sos. vod/sos was diagnosed using traditional criteria. day+ survival, complete remission (cr; total serum bilirubin < mg/dl and resolution of mod), and safety profile are reported. results: a total of patients treated with defibrotide were included retrospectively and prospectively between july and october from table] disclosure: mohamad mohty: has received honoraria and research funding from jazz pharmaceuticals, delphine lebon: nothing to disclose, ann berceanu: none, charlotte jubert: has received funding from jazz pharmaceuticals, ibrahim yakoub-agha: has received honoraria from jazz pharmaceuticals, stéphane girault: none, marie detrait: has received research funding from jazz pharmaceuticals, cécile pochon: none, fanny rialland: none, virginie gandemer: none, jean-hugues dalle: has received honoraria from jazz pharmaceuticals, régis peffault de latour: has received research grant / honoraria / board from pfizer, novartis, alexion; research grant amgen; and honoraria from jazz pharmaceuticals, david michonneau: has received honoraria from jazz pharmaceuticals, myriam labopin: has received honoraria from jazz pharmaceuticals, floriane delaval: employee of jazz pharmaceuticals and holds stock and/or stock options in jazz pharmaceuticals plc, gerard michel: none, anne sirvent: none, laurence clement: none anne-lise menard: none, anne huynh: has received honoraria from jazz pharmaceuticals, virginie bouvatier: employee of jazz pharmaceuticals and holds stock and/or stock options in jazz pharmaceuticals plc, raj hanvesakul: employee of jazz pharmaceuticals and holds stock and/ or stock options in jazz pharmaceuticals plc, zakaria medeghri: employee of jazz pharmaceuticals and holds stock and/or stock options in jazz pharmaceuticals plc p incidence and predictors of severe cardiotoxicity in patients with severe aplastic anemia after haploidentical hematopoietic stem cell transplantation zheng-li xu , lan-ping xu , yuan-yuan zhang , yi-fei cheng , xiao-dong mo , feng-rong wang , yu-hong chen , wei han , chen-hua yan , yu-qian sun , ting-ting han , yu wang , xiao-hui zhang , xiao-jun huang peking university institute of hematology, peking university people's hospital, beijing, china background: severe cardiotoxicity after hematopoietic stem cell transplantation (hsct) is a rare but fatal complication. the aim of this study was to evaluate the frequency of severe cardiac complications and to assess the ability of various factors to predict these complications in patients with aplastic anemia after haploidentical transplantation., this is the first study evaluating the values of both clinical and imaging factors in the prediction of severe cardiotoxicity among saa patients after haploidentical transplantation. methods: a retrospective study was conducted in consecutive aplastic anemia patients who received haploidentical transplantation from to . all patients received a unified regimen including busulfan, cyclophosphamide (ctx) and antithymocyte globulin at our single center. results: a total of ( . %) patients developed grade iii or iv cardiac toxicity. patients with cardiotoxicity had significantly poorer overall survival (os) than those without cardiotoxicity ( . % vs. . %, p< . ). our multivariable model identified four independent adverse predictors of severe cardiotoxicity, including pre-transplant ecog score (≥ ), abnormal st-t wave on -lead electrocardiogram (ecg), hyperlipemia and recalculated ctx dose (≥ . g/m /d). a predictive risk model was refined as low risk ( - factor), intermediate risk ( factors) and high risk ( - factors) . the respective incidences of severe cardiotoxicity were . %, . %, and . % in the high-, intermediate-and low-risk groups (p< . ). the corresponding os rates were . %, . %, and . % in the three groups (p< . ) at the last follow-up. conclusions: patients with high risk scores had the poorest outcomes and should be monitored closely. a reduced intensity conditioning might be recommended for these patients. disclosure: there are no conflicts of interest to declare. background: allogeneic stem-cell transplantation (allo-sct) is associated with significant transplant-related mortality (trm). acute renal failure (arf) is a frequent complication and usually presents early after the procedure, compromising its feasibility. the aim of this study is to analyse the incidence of arf, its risk factors and its potential impact on trm after allo-sct. methods: patients were included ( males [ %]; median age years, range - ) treated with allo-sct consecutively between january and april in a single institution. patient characteristics are detailed in table . median follow-up was . years (range, . - . ). renal function was evaluated using creatinine and data was collected pre-transplant (baseline) and at the point when arf was developed after allo-sct. arf was evaluated using akin criteria, being akin- an increase . -to . -fold from baseline, akin- an increase . -to . -fold and akin- an increase ≥ -fold. chronic renal disease was evaluated one year after the date of arf using kdigo criteria. results: cumulative incidence of arf at year was % (akin- , %; akin- , %; akin- , %). in the multivariate analysis, arf (akin- / ) was associated with: non-use of antithymocyte globulin in conditioning chemotherapy, p= . (hr . , . to . ) and development of severe agvhd, p= . (hr= . , to . ). in patients with arf akin- , the most important variables in the multivariate analysis were: use of methotrexate (mtx) plus cyclosporine vs mycophenolate mofetil plus cyclosporine as gvhd prophylaxis, p= . (hr= . , . to . ); myeloablative conditioning vs reduced intensity, p= . (hr= . , to . ) and use of total irradiation therapy in conditioning, p= . (hr= . , . to . ). trm at year increased significantly according to akin: akin- , %; akin , %; akin , %; p= , ; hr= . . overall survival at years according to akin was: akin , %, akin , % and akin , %; p= , (figure ). the incidence of chronic renal disease at year after allo-sct according to arf was: no arf ( %), akin- ( %), akin- ( %) and akin- ( %); p= . . conclusions: arf is a frequent complication during the first year after allo-sct and is associated with several factors. arf akin- was associated with more intensive strategies received during conditioning, meanwhile akin- / were related to development of gvhd. there is an association of arf (akin- , or ) with development of chronic renal disease. background: the introduction of cellular therapies such as car-t and modalities of gvhd-prophylaxis with posttransplant/cyclophosphamide (ptcy) that increase the number of admission days have boosted the pressure of available beds in the bm-units. in this sense, our centre started an at-home allogeneic stem cell transplantation (allo-sct) program to follow aplasia from the d+ until independent ambulatory patient. to evaluate the feasibility and safety of allosct, we compared two groups: allohsct/athome (ah-group) vs. allohsct/in-patient (ip-group). methods: we included patients receiving allosct (january -november ) in a single centre: patients, ah-group and , ip-group. all patients received conditioning at the hospital. gvhd-prophylaxis consisted in tacrolimus (tk) plus mycophenolate (mpm) or methotrexate, or ptcy (d+ , d+ ) plus tk (d+ ). all patients received prophylaxis with levofloxacin, fluconazole and acyclovir. besides that, ah-group patients received prophylaxis with ceftriaxone g/ h iv or ertapenem g/ h iv, and aspergillus-prophylaxis with inhaled liposomal amphotericin-b or posaconazole during neutropenia. patients of ah-group since d+ or d+ (in ptcyprophylaxis) received a nurse visit at-home once daily. the visits by the physician were performed at the hospital and only during complication events. first-line therapy of neutropenic fever was meropenem g/ h in both groups, using a portable infusion pump in ah-group. in this group, the absence of focal infection or signs of severe sepsis allowed returning home after the initiation of antibiotics. the platelets support was performed at-home and the red blood support at hospital. results: the median (range) age (years) of the series was . the median follow-up of the series has been not achieved. the source of the sct was peripheral blood in all cases. we didn't find statistical differences between two groups (ah vs ip) in terms of age, diagnosis, type of donor, intensity of conditioning, gvhd-prophylaxis, toxicity (mucositis, acute renal injury, neutropenia and thrombocytopenia), agvhd, aspergilosis and trm. interestingly, a significant reduction of neutropenic fever was observed resulting the lower use of meropenem in the ah-group than ip-group. the admission median days were similar in the both groups and it represented - days the reduction in the total economic cost of the ah-group. the whole analysis of the results are detailed in table: in-patient group, conclusions: in our experience, at home allosct, including ptcy-gvhd prophylaxis, is a feasible and safe procedure reflected in similar trm and aspergillosis incidence. at-home allo-sct is associated with a significant lower risk of neutropenic fever than in-patient group, as well as a very low readmission rate. disclosure: gonzalo gutiérrez-garcía: honoraria from gilead. grant from jazz pharmaceutical and janssen. laura rosiñol: honoraria from takeda, janssen, amgen and celgene. the others author do not have any disclosures to declare. background: renal complications in sickle cell disease (scd) include episodes of acute kidney injury (aki), progressive chronic kidney disease (ckd) and hyperfiltration, defined by abnormally high glomerular filtration rates (gfrs). hematopoietic stem cell transplant (hsct) from an hla identical sibling donor is a well-established curative treatment for scd, but traditional myeloablative conditioning (mac) regimens pose risks of kidney injury due to intensive use of chemotherapeutic agents, infectious risks, and use of calcineurin inhibitors (cnis). aki and subsequent fluid overload (fo) are common in pediatric hsct with reported aki incidence of %- % (kyung-nam koh et. al., ). we report renal outcomes in pediatric patients with scd who received hsct following a non-myeloablative conditioning (nma) regimen without cni exposure. methods: retrospective chart review describing renal outcomes in pediatric patients ( years of age or younger) with scd (hbss) who underwent nma hsct in alberta, canada from july to february . the nma regimen is illustrated in figure . reported renal outcomes: ) measured gfr (dtpa) pre-hsct, ) aki (kdigo definition) post-hsct by reviewing all serum creatinine levels from pre-hsct to one month post-hsct, ) %fo calculated: (max post hsct weight -baseline weight)/ baseline weight x for the two first weeks post-hsct, and ) estimated gfr (egfr) using the pediatric schwartz formula at last follow-up post-hsct, ckd defined as egfr < ml/min/ . m , mildly reduced gfr: - ml/min/ . m , and hyperfiltration: gfr ≥ ml/ min/ . m . [[p image] . results: eighteen patients ( % male, - years old at transplant) were included. most common pre-morbid events: vaso-occlusive crisis (n= ), acute chest syndrome (n= ), splenic sequestration (n= ), and cholelithiasis (n= ). median follow-up time: months (range: - months). all patients engrafted successfully with no acute or chronic gvhd. baseline measured gfrs were all > ml/min/ . m (range: - ) with mildly reduced gfr and hyperfiltration seen in one ( . %) and ( . %) patients respectively. at baseline (pre-hsct), the only aki event was one transplant related aki secondary to delayed hemolytic reaction after exchange transfusion in preparation for transplant. post-hsct, there were no aki events. additionally, no substantial %fo post-hsct was observed. average %fo week one post-hsct: + . % (range: - . % -+ . %) and week two post-hsct: + . % (range: - . % -+ . %). post-hsct egfr remained > ml/min/ . m at last follow-up in all patients. hyperfiltration was present in ( . %) of the patients. conclusions: this is the first study describing stable kidney function in children with scd after the present nma hsct regimen with alemtuzumab/ cgy total body irradiation (tbi) with prolonged post-hsct sirolimus. no episodes of aki or significant fluid overload were observed during the first month post-hsct, and no patient developed ckd during follow-up. further prospective studies are needed to confirm our findings and to determine if stable renal function persists during longer-term followup. disclosure: nothing to declare. lung microbiota in patients with idiopathic pneumonia syndrome (ips) after hct background: idiopathic pneumonia syndrome (ips) is a non-infectious pulmonary complication after hematopoietic cell transplantation (hct) and the etiology remains unknown. recent studies have reported that various diseases are associated with changes of microbiota. the aim of this study was to evaluate the lung microbiota in hct recipients with ips and identify microorganisms potentially associated with ips. methods: frozen bronchoalveolar lavage (bal) samples from hct recipients with ips (n= ) and research bal samples from asymptomatic hct recipients as controls (n= ) were retrospectively analyzed. all samples were negative for common viruses by quantitative pcr. sequencing libraries were made with ng of input dna per sample (nextera xt, illumina). samples were pooled and sequenced by hiseq to obtain -bp paired end data. sequence data analysis and read classification were performed with sunbeam and the quality control and read classification were performed using komplexity and kraken, which classifies bacterial, archeal, and viral genomes. we used sequence data of bronchoscope prewashes from a separate cohort as controls for environmental sources (n= ). bray-curtiss dissimilarity among samples was calculated using the vegan r packages. permanova and a two-sided wilcoxon rank sum test were used to compare between the study groups. results: bal samples started at a median of x raw read pairs per sample and reduced to x reads assignable to microbial taxa following quality control. the bacterial phyla proteobacteria and firmicutes were most abundant followed by bacteroidetes and actinobacteria in both bal and bronchoscope prewash samples. separation of bal and prewash microbiota using bray-curtiss dissimilarity plots showed that bal samples were distinguished by sequences assigned to staphylococcus, acidovorax, and bradyrhizobium species, while prewash samples were distinguished mostly by pseudomonas and elizabethkingia species, consistent with environmental sources (figure) . within bal samples, staphylococcus species were the main drivers of separation between ips cases and the controls (p= . , permanova, figure) . consistent with this, a linear discriminant analysis to identify taxa best distinguishing cases and controls identified staphylococcus, especially s. epidermidis, in ips cases with lactobacillus and streptococcus species in controls. we then compared relative abundances of s. epidermidis between all study groups. ips case samples were significantly enriched in s. epidermidis compared to control (p< . , two-sided wilcoxon rank sum test) and prewash samples (p< . ). viruses were classified by category as human pathogens, non-human pathogens, and bacteriophages. torque teno viruses (ttv) was the most commonly detected virus among viruses that replicate on human cells, and there was a trend towards higher abundance in ips case samples than controls. conclusions: lung microbial sequences in hct recipients predominantly consisted of proteobacteria and firmicutes, and had considerable overlap with environmental background. patients with ips had significantly more staphylococcus sequences detected than asymptomatic hct patients. these results suggest that patients with acute lung injury post-hct show distinct patterns of lung microbiota, although heterogeneity of sample collection and processing cannot be excluded and no singular organism was uniquely associated with ips. a prospective study is required to confirm these findings and define the clinical significance of differences in abundance patterns. disclosure: nothing to declare p abstract withdrawn. romiplostim for the treatment of thrombocytopenia after allogeneic stem cell transplantation background: thrombocytopenia is a common complication after allogeneic stem cell transplantation (allo-hct). with variable possible causes, such as drug side effects, infections, poor graft function, graft vs host disease (gvhd) and immune mediated. the purpose of this study was to evaluate the efficacy of romiplostim, a thrombopoietin receptor agonist, in patients with prolonged thrombocytopenia with no obvious cause after allogeneic transplantation. methods: retrospective analysis of allo-hct patients who received romiplostim at a single bmt unit between november and november . romiplostim was given because of prolonged (> weeks) thrombocytopenia (< , μl) that couldn't be explained by obvious causes such as administration of drugs (antibiotics/antivirals), infection or gvhd. all patients were in complete remission and had complete chimerism. response to romiplostim treatment was considered transfusion independence or plt> . /μl. results: in total, patients (median years, - ) received romiplostim. patients ( male, females) had aml ( pts), all ( ), mds ( ) or hodgkin ( ), received a myeloblative (busiphex-based: , tbi-based: ) or ric ( ) conditioning and were transplanted from a sibling ( ), vud ( ) or haploidentical ( ) donor with pbsc ( ) or bm ( ) . all patients revealed primary neutrophil (median days, range - ) and > . /μl platelet ( days, - ) engraftment. romiplostim was started at median day + (range - ) with a median dose μg/kg ( ) ( ) ( ) ( ) ( ) . the median platelet count before commencement of treatment with romiplostim was . /μl (range . - . ) and them ( %) were transfusion-dependent. in total / ( %) patients responded to romiplostim treatment. eight out of the ( %) transfusion dependent patients responded to the administration of romiplostim. six out of the patients ( %) who were transfusion independent at romiplostin initiation (plt median . /μl, range . - . ) responded. the median duration of treatment was days ( - ) and the median follow up from the commencement of romiplostim was days ( - ). three out of ( %) patients experienced relapse of thrombocytopenia after discontinuation of romiplostim and re-initiation of romiplostim was commenced in all of them, of which responded and didn't. the administration of romiplostim was done on an external basis and was well tolerated by the patients. two patients experienced gvhd during romiplostim treatment (both patients transplanted from / unrelated donor, and days after initiation treatment with romiplostim). / patients interrupted romiplostim due to disease relapse. / patients receiving romiplostim are alive in complete remission and died ( due to relapse, and due to trm). conclusions: we present high response rates to romiplostim in patients with prolonged thrombocytopenia after allogeneic transplantation. in this retrospective study there were no side effects from the administration of romiplostim. however, the administration of romiplostim after allo-hct should be controlled in prospective trials. disclosure we report a single-center analysis of adult patients (median age years, range - , m/f / ), receiving tpo agonists for isolated severe thrombocytopenia (n= ) and spgf (n= ) after allo-hsct. primary diagnoses were aml ( ), all ( ), mds ( ), pmf ( ), mds/mpn ( ), saa ( ), cml ( ), nhl ( ) . severe pgf was defined as cytopenia in ≥ lineages (platelet < × /l, anc < . × /l, hemoglobin < g/l any time after sustained engraftment), full or stable mixed donor chimerism > % and no signs of relapse. median dose of romiplostim was (range, - ) mcg/kg weekly, eltrombopag - (range, - ) mg/day. overall response (or) included cr (platelet ≥ × /l, anc ≥ . × /l, and hemoglobin ≥ g/l) and pr (platelet > × /l, anc ≥ , × /l, hemoglobin > g/l). results: median time from pgf diagnosis to treatment with tpo agonists was days ( - ), median treatment duration was weeks ( - ). tpo agonists were well tolerated with no cases of grade iii-iv toxicity. tpo agonists were combined with rituximab (n= ), rituximab and dli (n= ) and hsc boost (n= ) in ( %) patients. a total of ( %) patients met criteria of response (cr: n= , %; pr: n= , %). combination therapy showed no difference in or compared to tpo agonists alone. or was not depended on the tpo agonist used nor the time to therapy initiation. median increase in anc in responders was . × /l ( . - . ), in platelet count - × /l ( - ). a total of patients died due to relapse (n= ), gvhd iii-iv grade (n= ) and infection (n= ). two-year os from the start of tpo agonist therapy was % ( % ci, - ) with a significant difference between responders and non-responders: % ( % ci, - ) vs. % ( % ci, - ) (p= , ). conclusions: this study showed promising results of tpo agonists for management of spgf. further studies are warranted to specify optimal timing and dosing regimen, predictors of response. [[p image] . two-year os in responders and nonresponders to tpo agonist therapy] disclosure: there are conflicts of interest to disclose p cytomegalovirus reactivation kinetics and peak titers as novel predictors of survival and relapse after allogeneic cell transplantation for hematologic malignancies saskia leserer , evren bayraktar , nikolaos tsachakis-mück , michael koldehoff , lara kasperidus , esteban arrieta-bolanos , mirko trilling , katharina fleischhauer , dietrich w. beelen , amin t. turki university hospital essen, essen, germany, background: after allogeneic hematopoietic cell transplantation (hct), human cytomegalovirus (cmv) reactivation associates with non-relapse mortality (nrm) but also with reduced relapse in patients with leukemia, as shown by numerous studies that evaluated cmv reactivation as a qualitative yes/no parameter in the first months posttransplant. we hypothesized that longitudinal quantitative assessment of cmv reactivation kinetics and virus loads might improve patient-specific clinical outcome associations. methods: this retrospective study included patients with hct for hematologic malignancies treated between / and / at university hospital essen, germany. cmv titers were monitored weekly by quantitative pcr (qpcr); cmv reactivation was defined by a cutoff of > genome copies per ml. patients were included for analysis, if at least measurements were available during the first days after hct. in total, , samples were analyzed. subgroup analyses were performed according to the time of cmv reactivation (before/after + d) or the cmv viremia titer (> , , , - , and - , copies/ml). results: cmv reactivation was detected in (median age years; range - years) out of patients. baseline characteristics (age, gender, underlying disease, transplant) of patients without cmv reactivation were comparable. cmv reactivation kinetics followed a gaussian normal distribution with a median first reactivation at + d and peak titers at + d. all except patient reactivated before d, % before + d. overall survival (os) of the cmv reactivation group as a whole did not significantly differ from the non-reactivation group ( vs. months). however, in subgroup analyses os was significantly reduced in patients with very early (< + d) compared to later reactivation ( vs. months, p= . ). moreover and importantly, os was significantly reduced in patients with cmv reactivation at high titers of > , copies/ml compared to those with lower titers (( vs. months) p< . ).cox regression analyses confirmed significantly reduced os for patients with cmv reactivation > , copies/ml and < day + as compared to the other cohorts (hr . , %ci . - . , p< . and hr . , % ci . - . , p= . ) respectively). the nrm was consistently higher (hr . ; %ci, . - . , p< . ) for patients with cmv copies > , /ml. the risk of hematologic relapse was exclusively reduced in patients with a peak cmv viremia between , and , copies/ml (hr . , % ci . - . ; p= . ) as compared to patients without cmv reactivation. for other levels of cmv reactivation this effect was not observed. conclusions: our data showed that cmv reactivations before + d or with high titers of > , copies/ml associated with significantly reduced os, while cmv reactivations at intermediate titers between , and , copies/ml had a positive impact on relapse incidence. these findings underline the complexity of cmv reactivations after hct outcome, and support longitudinal evaluation of cmv titers and individualized quantitative kinetics models for risk assessment after hct to distinguish the advantageous from the detrimental aspects of cmv reactivation. disclosure: att has received lecture fees from jazz pharmaceuticals and travel subsidies from neovii biotech outside the submitted work. the other authors declare no competing financial interests within the submitted work. association of serum ferritin levels before start of conditioning with mortality after allosct -a prospective, non-interventional study of the ebmt transplant complication working party background: elevated serum ferritin levels occur due to iron overload or during inflammation and macrophage activation. a correlation of high serum ferritin levels with increased mortality after allosct has been suggested by several retrospective analyses as well as by two smaller prospective studies. methods: this international multicentric study aimed to study the association of ferritin serum levels before start of conditioning with allosct outcome. patients with acute leukemia, lymphoma or mds receiving a matched sibling allosct for the first time were considered for inclusion, regardless of conditioning. data were prospectively collected between / and / . a comparison of outcomes between patients with high and low ferritin level was performed using univariate analysis and multivariate analysis using cause-specific cox model. variables included in the multivariate analyses were age, sex mismatch, diagnosis, disease status, karnofsky score, number of cd cells given, intensity of conditioning, type of gvhd prophylaxis, atg use, time from diagnosis to transplant, year of transplant and cmv status. results: twenty centers from european countries reported data on allosct recipients. patient characteristics are given in table . the ferritin cut off point was determined at μg/l (median of measured ferritin levels). overall survival of allosct recipients with ferritin levels above cut off measured before start of conditioning was significantly shorter ( figure a , univariate hr= . ci= . - . p= . ; multivariate hr= . , ci= . - . , p= . ). progression-free survival was also shorter ( figure b , univariate hr= . ci= . - . p= . ; multivariate hr= . , ci= . - . , p< . ). excess mortality in the high ferritin group was due to both higher relapse incidence (univariate hr= . ci= - . p= . ; multivariate hr= . , ci= . - . , p= . ) and increased non-relapse mortality (univariate hr= . ci= . - . p= . ; multivariate hr= . , ci= . - . , p= . ). non-relapse mortality was driven by significantly higher infection-related mortality in the high ferritin group (univariate hr= . ci= . - . p = . ; multivariate hr = . , ci = . - . p = . ). acute and chronic gvhd incidence or severity were not associated to serum ferritin levels. conclusions: ferritin levels before start of conditioning can serve as routine laboratory biomarker to predict mortality after allosct. disclosure: the authors declare no confict of interest related to this study p prediction of reduced lung function and acute gvhd by surfactant protein d in allogeneic stem cell transplantation transplantation (hsct) and may progress to bronchiolitis obliterans that has a high mortality rate. surfactant protein d (sp-d) is an innate defense molecule involved in immune regulation at the epithelial surfaces, particularly in the lungs, and elevated levels have been associated with exacerbation of chronic obstructive pulmonary disease (copd). the aim of this study was to investigate, whether sp-d plasma levels and variants in the gene encoding sp-d may predict the development of reduced lung function after allogenic hsct. methods: we performed a population-based, singlecenter study of children (aged - years) treated with allogeneic hsct. the study consisted of ) a prospective study of serial plasma sp-d levels and rs genotypes in patients during the first months after hsct, and ) a retrospective study of rs genotypes within the sp-d gene in patients transplanted between - . pulmonary function tests were performed regularly as part of the clinical monitoring. results: at the day of graft infusion (day ) sp-d levels were reduced compared to levels before start of treatment with conditioning chemotherapy, defined as baseline ( ng/ml (quartiles - ) at day vs ng/ml ( - ) at baseline, p< . ). from day + sp-d levels increased and remained increased during the whole study period ( ng/ml ( - ) at baseline vs ng/ml ( - ) at months, p< . ). acute gvhd (agvhd) occurred in patients, of those patients with grade - . high sp-d levels at day + were associated with the development of agvhd ( ng/ml ( - ) vs ng/ml ( - ), p< . ) ( fig. ). the c/c genotype was associated with generally low sp-d levels and low fev /fvc at all time intervals compared to the other genotypes, significantly - months post-hsct (p= . ). there was no overall correlation between sp-d levels and lung function, but stratifying for genotype, high baseline sp-d levels were predictive for reduced fev /fvc at - months in cc and tt homozygous individuals. conclusions: patients with a genotype causing low capacity for sp-d production are at increased risk of developing pulmonary impairment after hsct. in addition, our data lend support to other studies indicating that spd production may increase during inflammatory pulmonary disease, acting as a reactive, protective mechanism. further research is warranted to define the role of sp-d levels and genotypes as a prognostic tool for lung function and agvhd. [[p image] . background: allogeneic hematopoietic cell transplantation (allohct) means a long period of restricted mobility and a range of therapy related side effects on muscle function. in this context patients demonstrated a huge decline of physical capacity and muscle mass in particular, accompanied with a decrease of quality of life (qol). resistance training could maintain muscle mass but is limited by patientsb lood values (platelet-count) and well-being. whole body vibration (wbv) was shown to maintain muscle mass during bed rest and has less impact on blood pressure than conventional resistance exercises. furthermore it was also shown to be feasible in patients during high dose chemotherapy. therefore the aim of our study was to examine the effects of wbv during allohct on patients physical and functional performance as well as qol. methods: patients receiving allohct were randomly allocated to either a wbv exercise group (ig) or an active control group (cg) doing stretching and mobilization. both groups exercised during the whole time of hospitalization for times per week and underwent pre-, post-and followup-assessment. physical capacity was determined by maximum oxygen consumption (vo peak ) and maximum power (p max ) during cardiorespiratory exercise test and by maximum strength of the knee extensors and flexors (ex max , flex max ) during isokinetic strength test. functional performance was assessed by jumping height during counter movement jump (cmj) and time of chair rising test (crt) as well as power output during both tests. qol was assessed by questionnaires of the eortc. results: during allohsct vo peak and p max decreased in both groups but till follow-up an increase is seen in the ig (p= . ; p= . ). at day + /follow-up a vo peak group difference is seen (p= . ). ex max (p= . ) and flex max (p= . ) were only reduced in the cg during hospitalization. jumping height and power output decreased in the cg during hospitalization (p= . , p= . ) and a difference between groups were seen in changes of jumping height from pre-to follow-up-assessment (p= . ): increase in the ig and decrease in the cg. the ig showed a decrease in time from baseline to follow-up (p= . ) in the crt and an increase of power output (p= . ). qol decreased only in the cg during hospitalization (p= . ) while during follow-up qol increased in both groups (ig: p= . ; cg: p= . ). in the cg physical functioning decreased during intervention (p= . ) whereas an increase was seen in the ig from pre-to follow-upassessment (p= . ). body image was significant worse in the cg compared to the ig at hospital discharge (p= . ) as well as at follow-up measurement (p= . ) where it got worse over time (p= . ). conclusions: wbv was shown to maintain maximum strength, jumping performance and qol during allohct. although cardiorespiratory fitness could not be maintained by wbv during hospitalization, it seems in the follow up period till day + that recovery of the cardiorespiratory system is enhanced by wbv carried out during allohst. nevertheless reasons for this changes in recovery have to be analyzed in further studies as well as treatment effects of wbv compared to conventional resistance training. disclosure: supported by a grant of the faculty of medicine and comprehensive cancer center freiburg respiratory virus infection within year after of allo-sct is the significant risk factor of obstructive ventilatory disturbance kosei kageyama , michiho ebihara , mitsuhiro yuasa , daisuke kaji , aya nishida , shinsuke takagi , hisashi yamamoto , go yamamoto , yuki asano-mori , naoyuki uchida , atsushi wake , akiko yoneyama , shigeyoshi makino , shuichi taniguchi toranomon hospital, hematology, tokyo, japan, background: obstructive ventilatory disturbance (ovd) is one of the major life-threading complication at the chronic phase of allogeneic stem cell transplantation (allo-sct). bronchiolitis obliterans has been the most established etiology as a part of chronic graft-versus-host disease and major cause of late non-relapse mortality of allo-sct. but other etiologies impact on respiratory function after allo-sct and risk factor of ovd have not been well understood. methods: to address these issues, we retrospectively reviewed the medical record of consecutive patients who first allo-sct at toranomon hospital between and . to detect ovd, forced expiratory volume in second (fev . ) showed less than % of predicted in spirometry test was defined as positive. in the recipients who showed fev . less than % in pre-transplant test, more than % reduction of fev . was regarded as positive. nasopharyngeal swab of those who had upper respiratory tract symptoms were tested for the presence of respiratory viral antigens (adv, piv, and rsv). patients with ecog performance status of , had active infection at transplant were excluded from this analysis. the cases of early death or relapse before days post-transplant, and the cases of graft failure were also excluded. results: the median age was years (range, - ). underlying diseases were aml in , mds/mpd in , cml in , all in , atl in , hl in , nhl in , and others in . five hundred twenty-nine ( %) were not in remission at the time of transplant. five hundred eightythree patients ( %) were conditioned with myeloablative regimens, whereas patients received reduced-intensity regimens. donor sources consisted of related peripheral blood /bone marrow (bm) (n= ), unrelated bm ( ) forty-six developed ovd on median of ( - ) days post-transplant. cumulative incidence of ovd was . % in total population. in recipients those who could spirometry, overall survival at years was . % in patients who developed ovd and was comparable with those who did not develop it ( . %, p= . ). in univariate analysis, disease status (cr/aa or noncr), recipient age (age< or ≥ ), prior autologous stem cell transplantation (yes or no), intensity of conditioning regimen (mac or ric), tbi dose (< gy or ≥ gy), busulfan dose (< . mg/kg or ≥ . mg/kg), donor source (cord blood or non-cord) had no impact on the incidence of ovd. patients who developed respiratory virus infection showed significantly higher incidence of ovd compared to those who did not developed it ( . % vs . %, p< . ). in multivariate analysis, respiratory virus infection was the only significant risk factor for the development of ovd (hr= . , % ci . - . , p< . ). conclusions: respiratory virus infection within year after allo-sct is the significant risk factor of ovd. disclosure: nothing to declare. background: metabolic syndrome (mets) is related to increased risk of cardiovascular disease and type- diabetes (dm- ) and usually seen in overweight individuals in the general population. we investigated mets and clinical risk factors two decades after hsct. methods: all male survivors treated with myeloablative allo-hsct during childhood (< years) between - in denmark were invited to a follow-up study. mets was defined as the presence of at least three ncep atp iii criteria: fasting plasma triglyceride (tg) ≥ . mmol/l, high density lipoprotein (hdl) < . mmol/l or medical treatment of hyperlipidemia; fasting plasma glucose (fpg) ≥ . mmol/l; abdominal circumference (ac) > cm; bp ≥ mmhg (systolic) / ≥ mmhg (diastolic) or medical treatment for hypertension. patients with overt dm- were included into the mets group. furthermore, patients were examined for chronic graft-versus-host disease (cgvhd) by the nih-criteria at the time of follow-up and high sensitivity c-reactive protein (hscrp) was measured. the prevalence of mets was compared to a nordic reference group (hildrum et al. ) . results: we included out of eligible males (participation rate %) aged - years, median years. median (range) follow-up was ( - ) years. of these males, % had a malignant diagnosis and % were treated with tbi-based conditioning. donors were matched siblings (n= ), matched relatives (n= ) or matched unrelated donors (n= ). mets was more prevalent ( %) in the young adult survivors compared to the prevalence reported for - year-olds in the nordic reference ( %). instead the prevalence was comparable to that reported for the - year-olds ( %). of the components of mets, elevated tg ( %), hypertension ( %), and decreased hdl ( %) were frequent, while fpg was elevated in %. importantly, only % of those with mets had increased ac and mean bmi ( . kg/m ) of the hsct survivors was within normal range in contrast to features of mets observed in the background population. having mets was significantly associated with tbi (rr = . , %ci ( . - . ), p= . ) as was the following single components of mets (mean in tbi group vs. mean in non-tbi group): elevated tg ( . mmol/l vs. . mmol/ l, p= . ), lower hdl ( . mmol/l vs. . mmol/l, p= . ) and higher diastolic bp ( mmhg vs. mmhg, p= . ). mets was only demonstrated in one patient who received non-tbi based conditioning. sixteen of patients had cgvhd of which nine were moderate to severe cases, but cgvhd was not associated with mets. however, low-grade inflammation measured by hscrp was related to increased ac (rho= . , p= . ) and tg (rho= . , p= . ). conclusions: our results indicate that male long-term survivors of allo-hsct during childhood have a high risk of mets at an earlier age than the general population. the presence of mets despite normal bmi in several patients suggests unconventional etiologies like the effect of tbi and low-grade inflammation. disclosure: nothing to declare. results: this survey was completed by transplant directors ( %), transplant consultants ( %), nonconsultant grade physicians ( %), hsct clinical nurses specialists (cns) ( %) and other ( %) from centres in countries. % of the centres are adult-only, % paediatric-only and % treat adult and paediatric patients (mixed centres). % are located higher than degrees latitude (northern countries) and % lower than this latitude (southern countries). at the time of the survey % were members of the european union (eu). measurement of serum vd is routinely performed in % of the centres prior and in % after allogeneic hsct. the main clinical indications are known osteopaenia/osteoporosis ( %), previous fracture ( %), treatment with steroids ( %), premature menopause ( %) and established menopause ( %). monitoring occurs every months ( %), every months ( %), once a year ( %) or at other time-points ( %). in this regard, seasonality is not taken into account in the majority of the centres ( %). local and national/international guidelines (nice) are only followed by % and % of the centres, respectively. the most common cut-off value of serum vd for commencing on replacement is nmol/l ( %). northern countries tend to use values of ≥ nmol/l whereas southern countries ≤ nmol/l. % do not use cut-off values. following hsct, % of centres prescribe vd supplements to maintain calcium metabolism and bone health ( %), enhance immune reconstitution post-hsct ( %), gvhd prevention ( %), enhance immune-suppression to treat gvhd ( %), treat depression/fatigue ( %) and reduce relapse risk %. a "loading" dose is administrated in % ( % adult, % mixed and % paediatric), with a mean duration of weeks . the median daily loading dose is , iu ( - , ). the median "maintenance" daily dose is iu ( - , ). there are not remarkable differences between adult and paediatric centres or northern and southern countries. vd replacement is prescribed by transplant physicians ( %), family physicians ( %), endocrinologists ( %), cns ( %), others ( %) and in % of the centres, patients are advised to buy it over-the-counter. vd is prescribed combined with calcium carbonate in % and alone in % of the centres. it is eventually discontinued by % of the centres when therapeutical levels of vd are reached ( %), dexa scan returns to normal ( %) and symptomatic improvement ( %). conclusions: this survey has demonstrated discrepancies in monitoring and replacement of vd across ebmt allogeneic hsct programmes. although awareness has arisen over the last decade, there is still lack of evidence about the optimal levels of vd required for immunemodulation post-hsct. this survey emphasises the need for specific guidelines to harmonise the current management of vd deficiency in adult and paediatric hsct setting. disclosure background: the use of unmanipulated haploidentical sct (haplo-sct) with post-transplant cyclophosphamide (pt-cy) as gvhd prophylaxis has widely extended. primary and secondary graft failure are relatively uncommon complications. however, poor graft function (pgf) after haplo-sct with pt-cy has not been described thoroughly. the objective of this study is to describe characteristics, treatments and outcomes of patients with pgf after haplo-sct with pt-cy. methods: we retrospectively analyzed haplo-sct with pt-cy consecutively performed between and in our centre. pgf was defined as either occurring after initial engraftment: persistent neutropenia (anc < /ul) with the need of at least doses of g-csf and/or thrombocytopenia (platelets < . /ul) with platelet transfusion dependence, with complete donor chimerism and without concurrent severe gvhd or disease relapse. results: nineteen patients were excluded from the analysis due to early mortality (death before day + ), primary graft failure (absence of neutrophil engraftment by day + , with mixed chimerism) or secondary graft failure (development of severe cytopenias and mixed chimerism after initial achievement of neutrophil engraftment). thirty one patients ( , %) were diagnosed with pgf. main characteristics of these patients are summarized in table . twenty six patients ( %) presented with neutropenia and were treated with g-csf, while patients ( %) only developed severe thrombocytopenia without neutropenia, and were treated only with platelet transfusion. twenty four patients ( , %) had at least cmv reactivation, patients ( %) had or more cmv reactivations and patients ( %) received valganciclovir for cmv reactivation treatment. although most patients achieved adequate peripheral blood counts (pbc) with initial salvage therapy, patients ( %) had persistent cytopenias in spite of g-csf, platelet transfusion, cmv reactivation resolution and myelotoxic drugs withdrawal. four of them were treated with a boost of cd + selected peripheral blood donor cells at a median of days after . median cd + cells infused was , x /kg. these patients achieved adequate pbc after salvage therapy and two developed gvhd. the other patients were treated with increasing doses of thrombopoietin (tpo) receptor agonist (tra) eltrombopag. one patient started treatment days after hsct with mg daily and increased dose to mg daily, with complete recovery of pbc months after initiating tra. the second patient started treatment days after hsct with mg daily and increased dose to mg daily, with complete recovery of pbc months after initiating tra. twenty one patients ( %) with pgf diagnosis had long term survival. conclusions: poor graft function is a frequent complication after haplo-sct with cy-post. cmv reactivation and myelotoxic drugs could be the most relevant factors associated with development of this entity. although most patients recover pbc without specific therapies beyond g-csf and platelets transfusion, there is a small group of patients with persistent cytopenias. boost of cd + selected cells is effective in reverting this condition, with gvhd as main complication of this procedure. use of tra seems to be an interesting option for these patients, although more experience is needed to draw definitive conclusions. disclosure: nothing to declare. were also frequently observed. the high risk patients for anxiety (hads-a score ≥ ) and depression (hads-d score ≥ ) was found in . % and . %, respectively. . % of patients was in high distress status (nccn dt score ≥ ). we found that younger age (< years) was significantly associated with poor quality of life score (fact-bmt) (p= . ) and high risk of fatigue (p= . ), anxiety (hads-a) (p= . ), and depression (hads-d) (p= . ). female sex was significantly related to lower physical well-being score and higher distress score (p= . and p= . , respectively). acute lymphoblast leukemia (all) survivors after allo-hct showed significantly worse quality of life score (fact-bmt) (p= . ) and higher depression score (hads-d) (p= . ) compared to those with other disease. chronic graft versus host disease (gvhd) and continuous immunosuppressant usage also have significant adverse impact on lower fact-bmt score (p= . and p= . , respectively) and higher hads-d score (p= . and p= . , respectively). but there was no significant difference in fact bmt, hads-a, hads-d, nccn dt according to donor type, conditioning intensity, anti-thymocyte globulin use, acute gvhd. smoking and alcohol drinking was continued in . % and . % of allo-hct survivors. . % of survivors did not exercise regularly. regular health screening tests have been done only in patients ( . %). conclusions: allo-hct survivors over years following allo-hct still have many physical and psychological symptoms. younger patients (< years), female, all, chronic gvhd, and sustained use of immunosuppressant were significant risk factors for poor quality of life and anxiety. we need to build more active survivorship care plan after allo-hct especially for those patients. disclosure: all authors have nothing to declare. evaluation of the new ebmt criteria for the diagnosis of vod/sos in consecutive transplant patients using an electronic patient record analysis system asha aggarwal , nicola gray , oliver lomas , katalin balassa , nadjoua maouche , robert danby , , andy peniket , grant vallance background: veno-occlusive disease (vod), or sinusoidal obstruction syndrome (sos), is a recognised complication of haematopoietic stem cell transplantation. hepatic vasculature endothelial cells are damaged by conditioning chemotherapy, leading to venous occlusion and centrilobar necrosis. the ebmt criteria for diagnosis of vod are bilirubin >= with two of painful hepatomegaly, > % weight gain and ascites. vod is often under-diagnosed, and as a result, treatment may be delayed. integrated electronic patient record (epr) systems are now widely used, and provide an opportunity to retrospectively audit practice to identify patients in whom vod may have been un-diagnosed or in whom treatment was delayed. in addition these systems have potential for alerting clinicians to the potential diagnosis of vod. methods: we have developed software to analyse the data downloaded from epr to identify patients in whom vod was a possible diagnosis according to the new ebmt criteria. in order to identify patients who may have had vod we first screened for patients with a bilirubin of >= mmol/l (which is an absolute requirement for the clinical diagnosis of vod) within the first days of transplantation. epr data was then used to assess whether patients had > % weight gain. radiology reports were reviewed for patients who had bilirubin >= mmol/l to ascertain if they revealed ascites or painful hepatomegaly. results: patients underwent transplant procedures (january st to july st ). of all transplant patients ( . %) were found to have a bilirubin of >= mmol/l. of ( . %) autograft patients and of ( . %) allograft patients had an elevated bilirubin at this level. these patients were assessed for evidence of % weight gain. this was the case in patients overall- % of autograft patients, . % of allograft patients. seven patients ( autograft and allograft) had radiological evidence of ascites. two patients had a recording of painful hepatomegaly (both post allograft). overall our analysis identified patients ( . % overall) fulfilling the ebmt diagnostic criteria for classic early vod all of whom received defibrotide. all patients had received allogeneic transplants. we failed to identify any cases of late onset vod or any undiagnosed patients over this period. conclusions: this analysis enabled us to efficiently perform a complete audit of our practice to identify patients with vod. we would recommend using electronic patient records to retrospectively audit practice in this way. the tool that we have created for this analysis will be made freely available for public use and the details will be presented at the ebmt meeting. we now plan to extend the function of our epr system to provide alerts to clinicians when vod is a possible diagnosis and may lead to more rapid treatment of these patients. our data suggests that elevation of bilirubin and weight gain of > % will be the most frequently occurring criteria on which to base these alerts. disclosure: g.vallance has performed consultancy work for jazz pharmaceuticals. endothelial activation and stress index in predicting outcome of allogeneic stem cell transplantation-a retrospective cohort analysis zinaida peric , tomislav taborsak , nadira durakovic , lana desnica , alen ostojic , ranka serventi-seiwerth , radovan vrhovac university hospital centre zagreb, zagreb, croatia background: endothelial dysfunction is a common pathophysiology of major complications after allo-sct, such as graft-versus-host disease, veno-occlusive disease, thrombotic microangiopathy and sepsis. endothelial activation and stress index (easix) is a simple score comprised of standard laboratory parameters (creatinine, ldh and thrombocytes) developed as a potential tool to predict allo-sct mortality by luft and colleagues. a recent validation of easix included three retrospective cohorts and showed that easix taken before start of conditioning can be used as an independent predictor of survival after allo-sct. methods: the aim of our study was to retrospectively evaluate pre-transplant easix in our cohort of consecutive patients who underwent allo-sct in the university hospital centre zagreb between and . with the use of a cut-off used in the validation cohorts, we compared two groups of patients for overall survival (os) and transplantrelated mortality (trm). group comparisons were done using the log-rank test or gray test for competing risks outcomes. a multivariate analysis evaluated the association of os with relevant variables by using a cox's proportionalhazard regression model. results: our study group included patients and comprised males ( %) and females ( %, with a median age of years (range, to years) at the time of transplantation. the most frequent malignancies in our population were acute leukemia ( patients, %) and myelodysplastic/myeloproliferative neoplasm ( patients; %). the donor was an identical sibling for patients ( %), matched unrelated donor for patients ( %) and haploidentical for patients ( %). patients ( %) received a myeloablative conditioning regimen while patients ( %) received a reduced-intensity conditioning regimen. with a median follow-up of months (range, - ) for the whole study group, the os at months was %, ( %ci - ) in the group of patients with low easix score and % ( % ci - ) in the group of patients with high easix score (p= . ). this difference was mainly attributed to higher trm in the group with high easix score ( %, %ci - at months) compared to the group with low easix score ( %, %ci - at months) (p= . ). in the multivariate analysis which included easix, patients' age, intensity of conditioning, diagnosis (lymphoid vs myeloid), status of the disease at transplant and type of the donor, worse os was independently associated only with older age of patients (hr . ; % ci, . - . , p= . ) and high easix score (hr . ; % ci, . - . , p= . ). conclusions: our retrospective data support previous data and suggest that easix could potentially serve as a valid tool for prediction of allo-sct outcomes. as a simple biomarker panel, easix could easily be implemented in clinical decision making in the field of allo-sct. these retrospective data need validation in a prospective study which is currently being conducted. clinical background: veno-occlusive disease (vod) is a potentially devastating complication that can occur after hematopoietic stem cell transplant (hsct) and in severe cases can lead to multi-organ failure. (mohty ) defibrotide has been proven to be effective to prevent and treat vod, and it is critical that clinicians are aware of how to diagnose and treat this serious complication of hsct. this study was conducted to determine if an online, simulation-based continuing medical education (cme) intervention could improve performance of hematologists/oncologists (hem/ onc) and advanced practice providers (nurse practitioners and physician assistants, apps) in the diagnosis and treatment of patients with vod. ( methods: a cme certified virtual patient simulation (vps) was made available via a website dedicated to continuous professional development. the vps consisted of cases presented in a platform that allows clinicians to assess the patients and make diagnostic and therapeutic decisions supported by an extensive database of diagnostic and treatment possibilities, matching the scope and depth of actual practice. clinical decisions were analyzed using a sophisticated decision engine, and tailored clinical guidance (cg) employing up-to-date evidence-based and faculty recommendations was provided after each decision. one case was about vod and the other case was about acute myeloid leukemia (aml). decisions were collected post-cg and compared with each user's baseline (pre-cg) decisions using a -tailed paired t-test to determine p-values (p < . indicates significance). data were collected between / / and / / . results: at the time of assessment, hem/oncs and apps had fulfilled the participation criteria for completing the vod case simulation. conclusions: this study demonstrates that vps that immersed and engaged clinicians in an authentic and practical learning experience improved evidence-based clinical decisions related to the management of vod. this vps increased the percentage of clinicians who utilized standardized criteria to diagnose vod and who ordered defibrotide and iv fluids for vod management. however, further education is needed to increase the competence and performance of clinicians, particularly apps, in these areas in order to positively impact patients. disclosure: nothing to declare. a nationwide retrospective study of hematopoietic stem cell transplantation in solid organ transplant recipients: on behalf of jshct, transplant complications working group background: the outcome of hematopoietic stem cell transplantation (hsct) in solid organ transplant remain unclear. to address this issue, we conducted a retrospective survey of the japan society for hematopoietic stem cell transplantation centers. methods: to address this issue, we conducted a nationwide retrospective survey of the japan society for hematopoietic stem cell transplantation (jshct) centers. a first questionnaire was emailed to jshct centers requesting information on cases of hsct in sot recipient. patients' data about sot were collected by sending a second questionnaire to the centers with the patient. based on these reports, patients' data about hsct was identified in the japan transplant outcomes registry database by the transplant registry unified management program (trump), confirmed in . results: of the jshct centers, responded to the survey ( . %). of the responding centers reported a total of patients who had undergone sot from living donor, and subsequent hsct. they consist of three autologous hsct (auto-hsct) and allogeneic hsct (allo-hsct). in auto-hsct, all patients had received liver transplant for hapatoblastoma. they achieved neutrophil engraftment at days after hsct, and two of three patients were alive at one year after hsct. in allo-hsct (n= ), seven patients had received liver transplants, and nine patients had received kidney transplants. five patients received hsct from unrelated donor, and patients received hsct from related donor; two donors were identical in sot. their stem cell sources were seven peripheral blood stem cell, six bone marrow, and three cord blood. all but one patients achieved neutrophil engraftment at days after hsct. five-year overall survival ( yos) was . %. while yos in patients with bone marrow failure (n= ) was %, that in patients with malignant disease (n= ) was . %; all but one patients with malignant disease received allo-hsct in non-remission. seven of nine kidney-transplant recipients experienced dialysis, and three patients experienced renal rejection after hsct. on the contrary, no liver-transplant recipient experienced hepatic rejection. conclusions: in sot recipients, the outcome of allo-hsct for malignant disease was poor, partly due to disease status before allo-hsct. severe renal complications were common in kidney-transplant recipients, suggesting renal care with caution during and after allo-hsct. disclosure: this work was supported in part by the practical research project for allergic diseases and immunology (research technology of medical transplantation) from japan agency for medical research and development, amed. high incidence but low mortality of ebv related ptld after t-cell replete allo-peripheral blood hct with aggressive monitoring and without pre-emptive rituximab background: the aim of the study is to report the incidence and outcome of post-transplant lymphoproliferative disorder (ptld) in the setting of allogeneic peripheral blood hematopoietic stem cell transplantation (allo-hsct) combining post-transplant cyclophosphamide (ptcy) and anti-thymocyte globulin (atg) as graft versus host disease (gvhd) prophylaxis. methods: between october and may , adult patients diagnosed with hematological malignancies underwent a first t-cell replete allo-hsct in our center. all patients received a reduced intensity conditioning regimen with fludarabine, busulfan, and cgy of total body irradiation, combined with rabbit-atg, ptcy and cyclosporine (csa). ebv titres were monitored weekly by quantitative pcr in plasma samples. the cut-off value for test positivity was > copies of ebv dna/ml of plasma. last follow up was november . median follow up for patients known to be alive was months (range - ). results: patient information is summarized in table . ebv reactivation was documented in ( %) patients. median time to ebv reactivation and the diagnosis of presumed/proven (p/p)-ptld were ( - ) days and ( - ) days [ ( - ) months], respectively. median time between first ebv reactivation to p/p-ptld was ( - ) days. seventeen ( %) of the patients developed p/p-ptld. median age was years . two ( %) received mrd, ( %) / mud, ( %) / mud, and ( %) haploidentical donor grafts. twelve ( %) were on therapeutic cyclosporine at diagnosis. pre-emptive therapy was not given to any case and only probable or proven ptld were given rituximab. treatment was based on reduction of the immunosuppression in patients and with the addition of weekly rituximab mg/ m in cases. fifteen ( %) achieved complete clinical responses with pcr negativity. two ( %) patients died secondary to ptld. conclusions: atg based conditioning is associated with increased viral reactivations. frequent ebv monitoring and pre-emptive treatment may lead to rapid disease control. further research is required to optimize monitoring and management strategies in allo-hsct recipients. disclosure: nothing to declare p acoustically enriched extracellular vesicles as potential markers for allogeneic hematopoietic stem cell transplantation complications hooi-ching lim , robert palmason , stig lenhoff , thomas laurell , stefan scheding , background: extracellular vesicles (evs) contain a number of condition-specific proteins, dna and rna types and might therefore be used for the early detection of posttransplant complications. however, traditional ev isolation (ultracentrifugation) is time consuming and requires large sample volumes thus making it difficult to perform longitudinal studies on larger patient cohorts. we therefore investigated whether recently-developed acoustic trapping could be applied to isolate evs from patient plasma for biomarker development. methods: plasma samples were collected from consecutive patients before and up to months after allogeneic hematopoietic stem cell transplantation. patients (age: - years) with high-risk or refractory/relapsed diseases were transplanted with mobilized pbsc from related (n= ) and unrelated donors (n= ) after standard conditioning. gvhd prophylaxis was cyclosporine and methotrexate. plasma samples were frozen and thawed for ev enrichment using a novel acoustofluidic-based technology (acoustic trapping). acoustic trapping uses ultrasound as a local λ/ acoustic standing wave produced by a piezoelectric transducer over a capillary. first, μm polystyrene beads are captured which serve as seeding particles. after washing, target particles (evs) are then captured ("trapped") in the acoustic field. a semi-automatic trapping device (acoutrap) was used to isolate evs from diluted plasma ( : in pbs). the number of evs and size distribution were analyzed by nanoparticle tracking analysis. mirna analysis was performed by qpcr.evs were enriched in duplicate from μl and μl of diluted plasma for nanoparticle tracking analysis and qpcr analysis, respectively. results: evs were successfully isolated from all plasma samples. a total of plasma samples were processed. numbers of trapped evs ranged from . x - . x before conditioning to . x - . x per μl diluted plasma after transplantation. the maximum change in ev numbers in individual patients compared to pretransplantation values ranged from -fold to -fold. most patients showed slight increases in ev size after transplantation. eight of the patients showed signs of infection and received i.v. antibiotics. increased levels of evs (> -fold) were recorded in three patients during these episodes. furthermore, increased ev numbers were observed in a patient who required i.v. antiviral therapy for cmv reactivation. acute grade i gvhd was observed in five patients of which two had increased ev numbers (> -fold). one patient developed grade iv gvhd which was accompanied by a -fold increase in ev numbers. interestingly, progressively increasing ev numbers preceded the detection of early relapse in a pre-b all patient by three weeks. rna isolation from trapped evs yielded sufficient material for mirna profiling. here, first mirna profiling data demonstrated that mirnas were detected in ev samples (mir- a, - a, - c, - and - a) , and that acoustically enriched evs were not affected by hemolysis in contrast to the corresponding whole plasma samples (dcq of mir- a and mir- a). conclusions: acoustic trapping allows for efficient and rapid enrichment of evs from small volume plasma samples. trapped ev samples contain sufficient amounts of mirna for downstream analysis and are thus promising candidates for biomarker development in transplantation. disclosure: laurell and scheding are founders and board members of acousort ab, a lund-based biotech sme that develops particle and cell sorting methods based on ultrasound. the incidence, risk factors and outcomes of primary poor graft function after allogeneic hematopoietic stem cell transplantation fei gao , , jimin shi , , yi luo , , yamin tan , , xiaoyu lai , , jian yu , , he huang , , yanmin zhao , background: allogeneic hematopoietic stem cell transplantation (allo-hsct) is a curative therapy for both hematologic malignancy and many other blood disease. while, primary poor graft function (pgf) is still a severe complication following hsct which lead to poor prognosis. up to now, the incidence and risk factors of pgf have not been totally revealed. methods: from january to december , a total of patients who received allo-hsct in our center were analyzed retrospectively. there were males ( . %) and females ( . %) with a median age of . years ( - years) . pgf was defined as persistent neutropenia (≤ . × /l), thrombocytopenia (platelets≤ × /l), and/ or hemoglobin≤ g/l after engraftment with hypocellular bone marrow and full donor chimerism, without concurrent graft-versus-host disease or disease relapse. incidence was calculated from all patients. of the total patients, nineteen ( . %) developed primary pgf. a : ratio of nested case control study using the good graft function (ggf) subjects transplanted in the same year with the same sex and age of ± years was carried out. results: data was analyzed by univariate and multivariate logistic regression, and univariate analysis identified disease species, the time from diagnosis to transplantation, disease states, myelofibrosis, splenomegaly, serum ferritin (sf) level, cmv infection, mononuclear and cd + cells in graft as potential risk factors (p < . ) for pgf. multivariate analysis identified elements as the independent risk factors (p < . ), including cd + cells < × / background: transplant survivors affected by cgvhd usually take one or more immunosuppressants, as well as prophylactic antimicrobials; use of multiple medication classes concurrently poses a risk for drug-drug interactions or amplified side-effects. the use of medications other than cgvhd-direct immunosuppressive therapies has not been well-characterized. this study aims to evaluate patterns of opioid analgesic use in a cohort of patients severely affected by cgvhd. methods: patients (n= ) with cgvhd were consecutively enrolled in a cross-sectional natural history study (nct ) from / - / at the nih. participants underwent a comprehensive evaluation including a detailed history and physical examination (including current medications), multidisciplinary evaluations, and laboratory and diagnostic testing. for this analysis, respondents were classified as receiving or not receiving an opioid analgesic. following the initial screening by univariate methods (n= ), multivariable logistic regression analysis (mlr) was used to identify a set of factors which could jointly impact opioid use. for mlr data were divided into a training (n= patients) and a validation set (n= ). results: study participants´median age was . years ( - ), % were female, % had severe cgvhd per nih scoring criteria, and % were currently receiving high or moderate levels of systemic immunosuppression. approximately one third ( %) were taking opioid analgesics (oa). based on the univariate screening results (p< = . ), a set of parameters was evaluated by univariate logistic regression in the -patient training set, and the following parameters retained their significance and were included in the mlr model: nih average score per organ, total lss, patient impression of severity, nih cgvhd severity, presence of skin erythema, karnofsky performance score (kps,) clinician's therapeutic intent, nih joint score, and with the presence of several cgvhd symptoms including rashes, mouth sores, avoidance of food, vomiting, weight loss, joint and muscle aches, joint limitation, energy loss, need for naps, fevers, anxiety. multivariable logistic regression identified kps < % as predictive of oa use, or . , % ci . - . . in the training set . % of pts using opioids were correctly identified, . % of those not taking opioids were identified, an overall fraction of correctly identified pts was . % ( % ci . - . %), while in the testing set, . % of those using opioids were correctly identified, and . % of those not taking opioids were correctly identified, with overall . % ( % ci: . - . %) classification accuracy. conclusions: this study showed the burden of oa in this cgvhd cohort. lower kps was significantly associated with oa use, as well as self-reported symptoms and a more severe cgvhd disease, which could be of interest in the development of non-pharmaceutical interventions in this patient population. additional, prospective studies are needed to explore the indications for and effectiveness of oa in this population of survivors. disclosure: no conflict of interest to declare. rcts that tested an internet-based program and patientcentered survivorship care plans for hct survivors. patient and caregiver input is essential to inform the design and features for the mobile app platform so that it is usable and engaging for those it targets. methods: using a qualitative research design, we conducted telephone focus groups of adult patients and caregivers in the united states. adult (age > years at the time of study entry) hct recipients had to be at least oneyear post-hct to participate. participants had to be able to communicate in english, and could have received a hct for any diagnosis, and from any donor source or stem cell type. those who had multiple transplants were included. participants were asked to review printed and online visual presentations of the mobile app before the focus groups so they were prepared to discuss their responses to the materials during the call. focus groups were conducted to saturation, when no new qualitative content was offered. results: three focus groups were conducted with total participants ( patients, two caregivers/patient advocates). all patients received an allogeneic hct; average time since hct was years (range: - years).the majority of participants were female ( . %). participants had differing perspectives on the usefulness of the app to track follow-up appointments, lab values, and other health care plans. there was high interest in having the app tailored to meet specific needs of patients, including tracking information over time (e.g. test results, medications), and having health information available specific to their needs. to minimize duplication of information and data entry, participants recommended syncing the app with their calendars and online patient portals they already use. reasons provided for not using the app included perception that the materials repeated information already received, side effects such as graft-versus-host disease that restricted vision or motor skills, and lack of comfort with apps for some older participants. conclusions: many health technology and mobile apps are being created to improve patients' health and survivorship care. in this study, hct survivors and caregivers identified a variety of features that they would want in an app or website, in particular, features tailored to individual needs. health technologies provide an opportunity to improve survivorship care, but patients and caregivers should be engaged in the process of developing these tools to assure the technology fits their needs and will be used. given the effort required to maintain these technologies, they require testing for health benefits in rigorous clinical trials. clinical background: thanks to allogeneic stem cell transplantation (allo-hsct) patients suffering from hematologic malignancies have seen an increase in there life duration expectancy, but they are many side effets including decreasing in physical performance and in quality of life. the intensity of physical performance decrease is variable between patients, and today we did not know why. the aim of our study was first to characterize the physical performance of subjects less than year following allo-hsct by the use of a cardiopulmonary exercise testing (cpet), and then to determine the predictive factors of exercise performance. methods: we did a retrospective analysis from patients who had an allo-hsct at hematology department of toulouse-oncopole and cpet from / to / . the cpet was performed using a cycle ergometer with o and co analyzer breath by breath, (masterscreen cpx carefusion, san diego, usa), a continuous -lead electrocardiogram, and a blood pressure monitoring. the protocol included a -min rest period, a -min warm-up of w pedaling followed by a w/min incremental phase, up to exhaustion, then a -min active recovery of w pedaling, then a -min passive recovery. three exercise markers were analysed: the peak of oxygen uptake (peak vo ), the ve/vco slope and the first ventilatory threshold (vt ). data relative to conditioning regimen, short-term complications, impairment at cpet day, and physical activity since allo-hsct were gathered. results: after allo-hsct, nearly over patients reported fatigue, a half reported dyspnea, and over or more reported pain, muscular, neurological or psychological impairment. more than % of patients suffer from moderate or severe physical intolerance, particularly when myeloablative conditioning regimen was used. only % of patients followed rehabilitation sessions supervised by a physiotherapist, and non-supervised physical activity has been performed by % of patients. despite normal lung function tests and echocardiography findings in most patients, % had exercise intolerance (ei), % exercise deconditioning, and % had abnormal ventilatory efficiency. patients with moderate and severe impaired exercise capacity were significantly younger at diagnosis and at allo-hsct, such as patients with severe deconditioning conclusions: based on a retrospective study, we reported for the first time complete results from cpet and detailed clinical evaluation concerning deficiency and disability following first year after allo-hsct. these results confirm that exercise impairment is very frequent with more than a half of patients suffering from alterations of one or more of the three performance markers, despite being active. disclosure: nothing to declare demyelinating disorders: a paradigm of immunity disorders after hematopoietic stem cell transplantation background: neurologic complications are a major problem in patients who undergone hematopoietic stem cell transplantation (hsct). given the higher survival of transplanted patients, the burden of neurological complications is increasing in the last years. a significant reduction in overall survival was demonstrated in patients who developed neurological complication after hsct, irrespectively of the hematopoietic stem cell (hsc) source. neurologic disorders in transplanting setting comprise a wide variety of ethiologies including demyelinating disease, which are caused by immune and non-immune mechanisms. here, we analyzed the clinical presentation and the underlie ethiologies of patients developing hsct-related demyelinating disorders in order to give diagnostic and prognostic clues useful to manage these severe but treatable complications in the transplant setting. methods: a total of patients of our department which developed neurological complications after hsct were consecutively collected and ( %) of them, namely those having a diagnosis of a demyelinating disorder, were grouped and described according to the ethiologies of their neurological disorder. results: in / ( %) patients, an immune-mediated process was found, while / ( %) were diagnosed as having an infective etiology and / ( %) were supposed to have a demyelinating disorder caused by toxic exposition. a definitive etiologic diagnosis was not formulated in the remaining / ( %) patients. when patients who developed an immune-mediated demyelinating disorder ( / ) were compared to those in which a clear immune pathogenic mechanism was not detected ( / ), a higher incidence of acute graft-versus-host disease (agvhd) was detected in the former than in the latter ( % vs %). moreover, comparison of these two groups revealed that those with no evidence of immune-mediated process have a slight higher prevalence of t-cell depleted hsct thanthose with an immune-mediated demyelinating disorder ( % vs %). finally, a lymphoproliferative disorder pre-existing the hsct was detected in / ( %) patients with immune-mediated demyelinating disorder but only in / ( %) of those without evidence of immune-mediated processes. conclusions: demyelinating disorders may be responsible of near % of neurologic complications in the posttransplant setting and, among them, an immune-mediated process is likely to be involved in more than % of cases. our results suggest that the immune mechanism that underliesthe agvhd may also be involved in developing demyelinating disease in transplanted patients. it also may be possible that the lymphoproliferative disorder preexisting the hsct is a risk factor able to increase the risk to develop an immune-mediated demyelinating disorder in the post-transplanting setting. using a t-cell depleted hsct can increase the risk of immune-mediated disorders in at least a small fraction of transplanted patients. despite our results should be validated on a larger cohort of patients, we can speculate on the possible connections between the wide range of complex and still poorly defined immunity disorders which can influence the prognosis and course of transplanted patients. disclosure background: injury to the mucosal barrier and subsequent development of oral mucositis (om) is among the most common toxicities of allogeneic stem cell transplantation (sct). despite the high prevalence of om and its debilitating nature, prospective studies evaluating determinants of om are scarce. we therefore prospectively evaluated the occurrence of om following sct. risk factors for om and its implications short and long-term outcomes were assessed. methods: om was prospectively evaluated on a weekly basis in patients undergoing allogeneic hsct. the grade of om was determined based on the national cancer institute common toxicity criteria for adverse events (ctcae) scale (v. . ). severe om was defined as grade ii to iv. conditioning regimens were evaluated individually and according to intensity; myeloablative (mac), reduced intensity (ric) or reduced toxicity (rtc). the latter category included only patients receiving fludarabine and treosulfan at dose of - g/m (flu/treo). risk factors for the development of severe om were initially identified by a univariate analysis and then analyzed in a multivariate logistic regression model. association of om with peritransplant infectious complications, iv morphine consumption, hospitalization length, neutrophil engraftment, acute and chronic graft-versus-host disease (gvhd), non-relapse mortality (nrm) and overall survival were assessed in a univariate analysis. competing events were considered in analyzing engraftment, gvhd, and nrm. results: patients who underwent an allogeneic sct between and were included. median follow-up was days. leading indications for transplantation were acute myeloid leukemia ( %), lymphoma ( %), and myelodysplastic syndrome ( %). the majority of patients received an allograft from a matched sibling or unrelated donor ( %) and methotrexate gvhd prophylaxis ( %). the median time to om onset was (interquartile range [iqr] - ) days. prevalence of grade ii-iv om was %. the median duration om was [ - ] days, and iv morphine was administrated for a median of [ - ] days for patients with grades iii-iv om ( %). in a univariate analysis a younger age (p= . ), lower bmi (p= . ), recent smoking history (p= . ), recent antibiotics exposure (p= . ), mac (p< . ), and use of methotrexate (p= . ) were associated with an increased risk for grade ii-iv om. in a multivariable model the risk for grade ii-iv om was lower with rtc (i.e., flu/treo) vs. mac (odds ratio [or] . ; p< . ) and rtc vs ric (or . ; p= . ), mycophenolate mofetil vs. methotrexate (or . ; p= . ) and recent smoking (or . ; p= . ). compared to lower grades, grade ii-iv om was associated with a longer hospitalization duration (median days vs. days; p= . ), delayed neutrophil engraftment (median vs. days; p=- . ), and more gastrointestinal related infections ( % vs. %; p= . ). grade ii-iv om was not associated with increased risk of bloodstream infections, acute or chronic gvhd, non-relapse mortality, and increased mortality. conclusions: oral mucositis is prevalent among allogeneic-sct recipients. importantly, fludarabine-treosulfan, which is considered a myeloablative is associated with a markedly reduced risk for om. consequences of om include prolongation of hospitalization, delay in neutrophil engraftment, and a tendency for gastrointestinal infections, but does not increase the risk for gvhd and mortality. disclosure: nothing to declare background: the advent of recent diagnostic techniques for the assessment of iron overload (t *-mri) and their systematic use as screening tools in the setting of secondary hemochromatosis have led to an increased awareness that focal nodular hyperplasia (fnh) represents a possible incidental finding after hematopoietic stem cell transplantation (hsct). methods: clinical and radiological features of patients undergoing hsct in a single pediatric institution have been retrospectively reviewed for fnh. in order to provide an estimate of the prevalence of fnh after hsct, we analysed all the t *-mri scans performed during the last years in our centre and recorded the number of patients with fnh (group a). in addition, data about patients incidentally diagnosed with fnh at abdominal imaging performed for different clinical indications have been collected (group b). results: eight out of ( %) transplanted patients who underwent at least one t *-mri scan from september to september were incidentally diagnosed with fnh. group b included subjects with fnh incidentally found at ultrasound or non-t * mri scans performed before . overall, transplanted patients ( males, %), transplanted for al ( cases) or bone marrow failure ( cases) at a median age of . ± . years, were diagnosed with fnh between . and . years after hsct, namely . ± . years in group a and . ± . years in group b. a variable degree of iron overload was demonstrated in all patient (lic: - ± microg/g; baseline serum ferritin: - ng/ml). the potential risk factors for fnh are reported in table . in / patients, the radiological finding was pathognomonic; in / the diagnosis of fnh was confirmed histologically, while / subjects were labelled as "fnhlike", although a potential diagnosis of hepatic adenoma could not be ruled out. in / patients, fnh presented with an isolated lesion, while / had to more than hepatic nodules at diagnosis. the size of nodules at diagnosis ranged from to mm. in unenhanced mri scans, lesions were predominantly hyperintense on both t -and t weighted sequences. in dynamic studies with contrast medium, all lesions strongly enhanced during the arterial phase, with a variable degree of wash-out in the late venous scans. hepatic function tests were normal in all the enrolled patients at diagnosis of fnh. among the / patients for whom at least a follow-up scan was available, presented a complete regression, a reduction and an increase in the size and/or number of lesions, while in patients the nodules remained substantially unchanged after a mean radiological follow-up of . ± . years. no malignant transformations were observed. conclusions: fnh represents a relatively frequent incidental finding after hsct. although a malignant transformation is rare, given the demonstrated variable evolution of the hepatic nodules, a radiological follow-up is highly recommended. disclosure: nothing to disclose. incidence and risk factors for hepatic sinusoidal obstruction syndrome after allogeneic transplantation: retrospective multicenter study of turkish hematology research and education group (threg), updated data methods: ten centers from turkey were enrolled in the study. we retrospectively evaluated the medical records of patients who were treated with allo-sct between january and december . a baltimore criterion was used for assessment of hsos. four hundred twenty six ( . %) of patients who were treated with prophylaxis with defibrotide alone or one or more of the n-acetylcysteine, diuretics and heparin used defibrotide ( - mg/kg/day). results: the study included patients ( males/ females) with median age of ( - ) years. the demographic and clinical characteristics of patients were summarized in table seventy-three ( . %) of patients with hsos were treated with defibrotide after diagnosis. the median time of starting defibrotide in these patients was . ( - ) days. thirty-seven ( %) of patients with hsos recovered completely and forty-nine ( %) of them died as a result of multi organ failure. the incidence of hsos-related mortality in allo-hsct cohort was found to be . %. in univariate analysis, statistically significant associations were not found between hsos incidence and age/sex of recipient, type of conditioning regimen, stem cell source and type of gvhd prophylaxis. on the other hand donor type, engraftment status and prophylaxis for hsos were significantly associated with hsos development. hsos prophylaxis was significantly decreased hsos-associated mortality (p= . ). conclusions: hsos still remains a serious lifethreatening complication of allo-sct. although the incidence is low, hsos is associated with increased -day non-relapse mortality. hsos prophylaxis especially with defibrotide, seems to reduce hsos associated mortality in high risk patients. disclosure: nothing to declare prophylaxis with defibrotide in adults at very high risk of veno-occlusive disease: results in patients background: hepatic sinusoidal obstruction syndrome/ veno-occlusive disease (sos/vod) is a life threatening complication that can occur after hematopoietic stem cell transplantation (hsct). severe sos/vod rapidly evolves in multiple organ dysfunction syndrome (mods), associated with a mortality rate exceding %. precocity of defibrotide (df) treatment is the leading factor for efficacy. prophylactic use of df is recommended in children, but its value has not been validated in the adult population, although factors for individual risk assessment for vod are debated. we here present a real-world experience of df prophylaxis in adult patients at very high risk of sos/vod receiving allogeneic hsct. methods: from to we treated with prophylactic defibrotide and ursodeoxycholic acid (udca) patients, median age years (range - ). nine patients received allogeneic hsct for acute lymphoblastic leukemia ( b-all and t-all), one patient for severe aplastic anemia, one patient for primary myelofibrosis. they were all at high risk for sos/vod because of previous hepatotoxicity ( patients), previous hsct ( patients), double alkylating agent ( patients) or previous treatment with inotuzomab ozogamicin (io; patients). of the patients treated with io, received cycles of io, and received cycle, with the last io dose administered a median . days before hsct (range - d). defibrotide was administered in daily doses for a total dose of mg/ kg per day and udca at the dose of mg twice per day, starting from day - prior transplant. all patients received treosulfan-fludarabine based conditioning. in patients thiotepa was added to the conditioning and in patients a low dose gy tbi. gvhd prophylaxis included posttransplant cyclophosphamide, rapamycin and mycophenolate in all patients, except one patient with aplastic anemia receiving atg, rapamycin and mycophenolate. donor source was pbsc in all cases. seven patients received family haploidentical (mmrd) transplant, patient a mrd transplant and patients a mud transplant. results: the median duration of defibrotide therapy was days (range - days). documented non-severe gastrointestinal bleeding occurred in patients requiring defibrotide temporarily discontinuation, no other significant bleedings were experienced. four patients developed grade ii-iv acute gvhd and no transplant-associated thrombotic microangiopathy were diagnosed. overall, sos/vod occurred in / cases within days after hsct (days , and ) and no late-onset sos/vod were diagnosed. sos/vod was very severe, causing mods and death in all cases. all patients were characterized by a common pattern of very high risk factors for sos/vod by prior hsct and salvage treatment for b-all with cycles of io close to hsct. furthermore, they all received a fully myeloablative conditioning regimen with treosulfan and thiotepa and a mmrd transplant. conclusions: defibrotide prophylaxis was safe and well tolerated with no severe related complications. sos/vod occurred despite continuous df prophylaxis in / patients treated with inotuzomab ozogamicin close before undergoing nd transplant. to reduce the incidence of severe vod, pre allo-hsct treatment with inotuzomab ozogamicin should prompt avoidance of other cumulative risk factors for vod, such as use of double alkylating agents. disclosure background: busulfan is the backbone of many preparative regimens administered to children undergoing allogeneic and autologous hematopoietic stem cell transplantation (hsct). among its many long-term adverse effects, busulfan can cause various degrees of pulmonary injury. although well described in adults, there are few large series exploring pulmonary toxicity of busulfan in children. we describe long-term pulmonary follow-up in a large group of children treated at a single center who had received high-dose busulfan and examine the relationship of systemic drug exposure and lung function over time. methods: all surviving children who had received highdose busulfan between - in the context of hsct at the schneider children´s medical center, were referred for serial pulmonary function monitoring (including spirometry, plethysmography and diffusing capacity for carbon monoxide [dlco] . pre-transplant testing was available for children who were old enough to perform the procedure. spirometry results were adjusted according to the revised global lung initiative formulas for age, gender, and height. pulmonary injury was defined as a z score below - . for spirometry, or < % of predicted for the other parameters. busulfan levels were monitored following the second drug dose. all patients received busulfan in four daily doses. area under the curve (auc) calculations were performed by bayesian calculations. results: between - , patients aged - years were diagnosed with malignant or non-malignant diseases and treated with high-dose busulfan. of shortterm survivors, had at least one post-transplant pulmonary function evaluation. the mean age at treatment with busulfan was . years (range, . - years). of these children, children had undergone autologous transplantation and children had an allogeneic transplant. of these patients eventually relapsed and died. children had one or more pulmonary risk factors before hsct -chest or upper abdomen radiation ( ), chest wall tumors or lung metastasis ( ), chest surgery ( ), prior administration of pulmonary-toxic drug ( ) or asthma ( ). during follow-up (up to years, median . years), fev and fvc spirometry tests both decreased significantly (p= . and . , respectively), while the decrease in dlco was not statistically significant. % of patients had abnormal pulmonary function tests and seven children had symptomatic disease which in two may have been manifestations of gvhd. interestingly, no correlation was found between busulfan auc, busulfan peak levels, the number of busulfan doses administered, the type of transplantation (autologous vs. allogeneic) or primary disease to pulmonary injury. even after censoring of children with pre-transplant pulmonary risk factors we noted a decrease of fev and fvc. conclusions: as in adults, pulmonary injury is observed in children treated with high-dose busulfan prior to hsct. no correlation was observed between busulfan auc and pulmonary injury. follow-up of children who receive this drug should include regular pulmonary monitoring, referral to a pulmonologist when subclinical pulmonary compromise is found, and counseling regarding measures that might prevent or ameliorate pulmonary damage. continued follow-up of this cohort of patients should inform our pretransplant patient information sessions, and the future use of busulfan in children. disclosure: nothing to declare background: transplant-associated thrombotic microangiopathy (ta-tma) is a specific complication of allogeneic hematopoietic stem cell transplantation (hsct). post-hsct tma has been attributed to the vascular endothelial damage caused by high-dose chemotherapy, calcineurin inhibitors (cnis), graft-versus-host disease (gvhd), infections. there is a little evidence published regarding the efficacy and factors influencing the outcome of withdrawal of cnis. methods: the analysis comprised a total of patients, with diagnosed hematologic malignancy (aml ( ), all ( ), mds ( ), hodgkin lymphoma ( ), cml ( ) and neuroblastoma ( ) received allo-sct, from a matched related, unrelated or haploidentical donor between and . patients were diagnosed with ta-tma based on cho criteria. the median age of patients was ( adults, children). gvhd prophylaxis was performed with tacrolimus (tac) in , cyclosporine a(csa) in , combination tacrolimus+sirolimus (sir) in . patients received atg and ptcy. withdrawal of cnis was accompanied by administration of systemic steroids ( patients) or substitution with sir after reaching levels of csa< ng/ml or tac < ng/ml in . the target concentration of sir was - ng/ml. in pediatric patients who received combination tac+sir, the tac was discontinued in one step while sir continued. median time to development tma was , days after allo-sct (range - ). median follow-up of surviving patients was days. the primary outcome was overall survival (os) up to years after development of ta-tma. results: the following significant predictors of -year os were identified: tac replacement with sir (p< , ), ptcy in prophylaxis (p< , ), acute gvhd (agvhd) grade - (p= , ), previous sepsis (p= , ), level of ldh in debut (p= , ), combination sir+tac in prophylaxis (p= , ), major ab -mismatch (p= , ), severity of cns symptoms (p< , ). there was no significant difference in os according to patients' age, sex, "salvage" disease status at transplantation, previous vod, viral (hhv , , , cmv, ebv) reactivations, count of cd + cells transfused, ldh level, shizocytes and creatinine in the debut of ta-tma. in the multivariate analysis replacement of cnis with sir (hr . , %ci . - . , p= . ) and baseline ldh level (hr . , %hr . - . , p= . ) were associated with survival differences. the cut off for ldh was xunl. agvhd grade - (hr . , p= , ) and use of ptcy (hr . , p= . ) were not significant in the multivariate analysis (figure ). ta-tma cases after ptcy were significantly less frequently associated with clinically significant agvhd ( % vs %, p< , ). the survival was higher after ptcy ( % vs %), but not significant due to sample size and other ta-tma factors. leading causes of death were: gvhd progression ( %), bacterial infection ( %), tma ( %) and other ( %) . conclusions: replacing tac by sir is an effective therapeutic strategy in a group of patients with debut of ta-tma at least after ptcy, where it is less likely to be associated with agvhd. there is a significant overlap of populations with ptcy prophylaxis and substitution with sir, thus the study is not powered to provide guidance for patients on conventional prophylaxis with ta-tma. [[p image] . disclosure: none of the authors has anything to disclose. donor-recipient ab mismatch effect on the allogeneic hematopoietic stem cell transplantation outcome: a single-center retrospective study background: because transmission of major histocompatibility complex and blood group system genes is independent from each other, approximately - % of all allogeneic hematopoietic stem cell transplantations (allo-hsct) are realized crosswise the ab -blood group boundary. however, due to the widespread expression of ab antigens on a variety of human tissues other than erythrocytes, ab incompatibility may have an impact on the outcome of allogeneic hsct that goes beyond the wellknown immune-hematological complications such as immediate hemolysis due to the presence of isoagglutinins and delayed hemolysis due to passenger b lymphocytes. here we aimed to assess the donor-recipient ab mismatch effect on the allo-hsct outcome, comprising non-relapse mortality (nrm), overall and relapse-free survival, posttransplant prc transfusion requirement, as well as relapse rate, incidence of graft-failure and acute gvhd. methods: clinical and laboratory data from consecutive patients undergoing allogeneic hsct between / and / at the fondazione irccs ca' granda maggiore policlinico hospital in milan, italy, were retrospectively collected. kaplan meier estimates were used for the analysis of survival outcomes while nrm, relapse and acute gvhd cumulative incidences were investigated by competing risk analysis. results: the patient series included ab -match, major ab -mismatch, minor ab -mismatched and bidirectionally ab -mismatch transplants. indication for allo-hsct were mainly aml/mds ( pts), all ( pts) and t-nhl/ctcl ( pts). mean overall survival for groups of patients undergoing ab -identical, major ab mismatch and minor ab mismatch hsct were months ( % ci [ ; ]), months ( % ci [ ; ) and months ( % ci [ ; ]), respectively. nrm in the three groups were significantly different, with point estimates of %, % and % at years, respectively, whereas no significant differences were observed for relapse rate and graft failure incidence. although not statistically different, incidence of acute grade iii-iv gvhd was twice as high in patients transplanted from minor ab mismatched donors than in the ab identical group ( % vs %). following transplantation, prc transfusion requirement was significantly higher in the major ab mismatch then in the ab -match transplanted patients (median vs , p= . ), with a marginal positive correlation between the anti-donor a/b igg titers measured prior hsct and the total number of prc transfused during the first year following transplantation. we observed only one case of prca occurring in a year-old + woman who was transplanted from a -yearold male a+ hla-identical sibling using peripheral blood as the stem cell source following a myeloablative conditioning for aml in first complete remission. anti-a igg isoagglutinin titers prior to transplantation were : . during the first year post transplantation, the patient required a total of prc transfusions, with gradual resolution occurring only after introduction of danazole treatment. conclusions: in our patient cohort, both major and minor ab mismatch associated to a significantly higher nrm. major ab mismatch associated to a higher prc transfusion requirement. a more frequently occurring severe acute gvhd was also suggested in minor ab -mismatch transplants. altogether, our results suggest that allo-hsct outcome may be significantly affected by ab blood group mismatch. disclosure: nothing to declare background: at-tma is a severe endothelial injury complication and it may involve the intestinal vasculature. intestinal tma could be fatal and missdiagnosed. clinical and pathological criteria to differentiate from intestinal gvhd are needed. the aim of this study was to analyze the incidence and histological characteristics of intestinal tma in patients diagnosed of systemic tma. methods: we analyzed the incidence of tma in patients who underwent allo-hsct in our institution between january -august . tma diagnosis was based on ho criteria. we do a pathological review in biopsies from out of patients in whom an endoscopy have been performed days before and days after the diagnosis of tma for suspicious of gvhd. review was performed by a pathologist expert in gvhd, who examined the biopsies in search of hystopathological features of gvhd, tma or viral infection. diagnosis of gastrointestinal gvhd was stablished according to mcdonald and sales criteria, while intestinal tma diagnosis was stablished by warren et al criteria. results: out of patients ( , %) were diagnosed of tma. transplant characteristics and tma data of patients with systemic tma are shown in image. out of patients with tma ( %) had been diagnosed with prior/ simultaneous acute gvhd, of them grade iii-iv, and % with gastrointestinal gvhd. intestinal tma have been reported only in out of patients ( %) at diagnosis, whereas when review based on warren criteria was performed, in patients ( %) the pathologist found at least of the criteria of endothelial damage and % of the patients or more warren criteria were founded. the most frequent features were endothelial cell swelling (n= , %) and perivascular mucosal hemorrhage (n= , %). review hystological features of biopsies are shown in table of the image. regarding gvhd, it was found in patients ( %) at diagnosis and in ( %) at pathological review. with a median follow-up of months ( - ) patients of the with systemic tma ( %) are dead. of the deaths ( %) were related to tma ( tma, tma +gvhd, and tma+infection). patients with or more warren criteria in pathological review had poor outcome compared with patients less than criteria ( % alive vs % at months, p= . ). conclusions: intestinal tma is a life-threatening underdiagnosed entity. only patients of patients were diagnosed of intestinal tma. we found that most of our patients had endothelial damage in the gastrointestinal biopsy pathological reviews. gvhd histological criteria were present in most of the patients, mainly histological grade i-ii. prognosis of these patients is poor and pathologist effords in diagnosed the entity is guarranted. disclosure: nothing to disclosure p strategies to reduce neutropenic fever and hospital readmission in multiple myeloma patients managed at home after autologous stem cell transplantation background: neutropenic fever (nf) is the most frequent cause of readmission in the outpatient autologous stem cell transplantation (asct) programs. in our at home model for multiple myeloma patients, we added primary prophylaxis with ceftriaxone, decreasing the incidence of fever during aplasia phase from % to . %. the aim of this study was to analyze the addition of two strategies to reduce the non-infectious nf: withdrawal of g-csf and the addition of primary prophylaxis for engraftment syndrome with corticosteroids after asct. methods: between january and august myeloma patients were managed at-home since day + of asct. all were conditioned with mel . all patients received prophylaxis with quinolone, fluconazole, aerolized pentamidine, low-dose acyclovir (hvs+), and ceftriaxone (since day + ). the patients were classified into groups: group a (n= ; g-csf since day + without corticosteroid), group b (n= ; no g-csf and no corticosteroid), group c (n= ; no g-csf with prednisone . mg/kg/day since day + until granulocyte recovery). first-line therapy at home of nf was piperacillin-tazobactam . g/ h i.v. using a portable intermittent infusion pump. fever was an indication of immediate medical consultation and those patients presenting signs of focal infection or severe sepsis were admitted. other indications for readmission were: willingness of the patient or caregiver, uncontrolled nausea, vomiting or diarrhoea, and mucositis requiring total parenteral nutrition or i.v. morphics. results: the main characteristics of the patients and outcomes are shown in table . there were no differences between groups regarding age, gender, immunological subtype, response before asct, hct-ci, and cd cell dose infused. there were more patients with advanced disease (iss iii) in group c compared to group a ( . % vs. . %; p= . ). the duration of neutropenia was longer in those groups that did not receive g-csf (a: days, b: days, c: days; p< . ). comparing group a with group c, we observed that the incidence of nf and the readmissions rates were lower in group c (nf: . % vs. . %; p= . ; relative risk reduction: . , and number needed to treat . ; readmissions: . % vs. . %; p= . , respectively). the -day cumulative incidence of nf were . % in group a, . % in group b, and . % in group c; p= . . the non-administration of g-csf with the addition of prophylactic corticosteroid did not modify the incidence and grade of mucositis, the first day and duration of fever, nor the number of bacterial infections documented. in the multivariate analysis, this combination (no g-csf with corticosteroid) maintained its protective effect for the development of nf and hospital readmission (or . ; p= . and or . ; p= . , respectively). conclusions: the non-use of g-csf and the addition of prophylactic corticosteroid in mm patients managed at home after asct minimize the incidence of non-infectious fever and optimize hospital resources by reducing hospital readmissions. disclosure: nothing to declare. background: antibody titers to vaccine-preventable diseases decline during the - years after allogeneic hematopoietic stem cell transplantation (hsct) if the recipient is not revaccinated. it is therefore considered best practice to try to offer hsct recipients the same level of protection against all vaccine preventable diseases as the general population. few data in the literature are available concerning vaccine-related problems in hsct recipients. we performed a farmacovigilance evaluation in a cohort of allotransplanted patients followed in our clinic during a year period. methods: from october to november we administered a list of recommended vaccines to hsct recipients attending our routine out patient clinic who fulfilled the following criteria: cd t cells> /μl, cd b cells> /μl, anti-cd antibody infusion> months, ivig therapy> months, no active and severe graft-versus-host-disease (gvhd), no chemotherapy or biological therapeutic agents on going. vaccines suggested were influenza, pneumococcal conjugate (pcv ), polio (inactivated polio vaccine), diphteria, tetanus, acellular pertussis, hepatitis b, hepatitis a, haemophilus influenzae type b, meningococcal quadrivalent (mcv ), human papillomavirus, meningococcal b, measles-mumps-rubella (mmr), varicella. live vaccines (mmr and varicella) were not recommended before years after hsct and in patients with chronic gvhd. all the patients were asked to take the list to the local health facilities in order to have the vaccines injected and a vaccination table arranged with the doses already received and those to receive. we checked the vaccination tables at each visit and monitored potential side effects and gvhd status at , , and months after the first vaccine injection. results: twenty-nine out of patients were evaluable (table ), without gvhd and with chronic gvhd ( mild, moderate, severe). median time after hsct was months ( - ). median number of vaccines received was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . as regards patients without chronic gvhd, out of experienced fever after vaccine injections; out of developed transient mild reduction of platelet count; patient reported headache and otalgia after vaccine injection, while another one transient joint pain; out of patients presented signs of mouth chronic gvhd (score nih) and transaminase increase (grade according to world health organization toxicity scale) months after the first vaccine dose, so that cyclosporine dose had to be augmented. as regards patients with chronic gvhd, out of experienced fever after vaccine injections; patients with mild chronic gvhd of the mouth presented hepatic flare two and three months after the first vaccine dose, respectively. in both cases a new increase of cyclosporin and methylprednisolone doses determined progressive normalization of liver enzymes. conclusions: these data show that vaccines were globally well tolerated in hsct recipients, even when they suffered from chronic gvhd. however, close monitoring is warranted in order to better evaluate possible vaccine side effects in this setting of patients. background: allogeneic hsct improves survival for aml patients over the age of years of age when compared to chemotherapy alone. the haematopoietic stem cell transplantation comorbidity index (hct-ci) and ebmt score predict for non-relapse mortality and overall survival, yet little is known about whether qol is preserved in this patient group and whether hct-ci and other performance scores pre-bmt correlate with qol post allo-hsct. methods: we conducted a retrospective analysis of patients years and older who underwent ric allo-hsct at the university hospital of wales, cardiff between september and december (n= ). hct-ci, karnofsky performance score (kps) and ebmt scores were calculated prior to transplant and qol measured using the fact bmt (version ) questionnaire, which was completed at , and months post transplant. patients were grouped at the -, -and -month time points for each of the different performance indices, allowing group comparison against compound sub scores using the mann-whitney u test. results: patients were included in this study, with median age years (range - ). patient characteristics, including conditioning, donor type, pre-transplant hct-ci and kps scores are summarised in table . the year and year overall survival (os) for the patient cohort was . % and . % respectively. hct-ci of ≥ vs was significantly associated with poorer bmt-related qol domains at months (p= . ) and general qol domains at months (p= . ) post-transplant. while ebmt score showed no correlation with qol parameters, patients with kps of vs ≤ showed significant differences in both general (p= . ) and bmt-related qol (p= . ) at months and in all qol domains at months (symptomrelated qol p= . , general qol p= . , bmt-related qol p= . ). importantly neither the hct-ci nor the kps pre-transplant predicted for qol at months post transplant. conclusions: patient selection is key to ensuring maximum benefit from allo-hsct both in terms of overall survival but also with regards to qol and survivorship. we note that while patients with hct-ci ³ or kps ≤ had significantly poorer qol at months post allo-hsct, qol was recovered by months post transplant, with this significant difference no longer seen. our data shows that in selected aml patients over the age of years with good performance status and low comorbidity index, a favourable outcome can be achieved with good qol maintained throughout the post transplant period. background: advances in allosct technology, supportive care, and use of reduced intensity conditioning regimens for older patients have led to significant improvements in longterm survival after transplant. the survivors have an elevated probability of late morbidity and mortality, including abnormalities in phosphocalcic metabolism and bone disease. rapid and progressive bone loss occurs within the first - months after transplant, and this is followed by a slow process of recovery, with bone loss persisting for to months. bone fractures can worsen the quality of life of allosct survivors, but the real burden of the disease is unknown. the objective of the study is to ascertain the prevalence of bone pathology and vertebral fractures early after transplant in our center. methods: this is a retrospective and observational study. forty-nine patients ( male/ female, median age y, range - ) that underwent allosct were included in the study in the period of to months after transplant (may -december ). pre-and post-transplant risk factors associated with bone disease were recorded: age > years, female sex, menopause, hormone replacement therapy, previous treatment with steroids, previous fractures, weight < kg, bmi < - , low physical activity, low calcium intake, smoking, alcohol intake, and history of femoral fractures in parents. in all patients laboratory data (including serum calcium, -hydroxyvitamin d, and pth), lumbar and femoral bmd (dxa), and spinal x-ray were also evaluated. a vertebral fracture was defined as a reduction of > % in the anterior, middle or posterior high of the vertebral body. results: we identified vertebral fractures in ( %) patients. five patients had fractures prior to transplantation, and patients presented "de novo" vertebral fractures following transplantation; therefore, the prevalence of "de novo" postransplant fractures was / ( %). most ( %) of these fractures were asymptomatic at the time of diagnosis. most patients ( %) with vertebral fractures had > pre-sct risk factors (median risk factors pre-sct , range - ), the most frequent being low calcium intake, steroid exposure, presence of previous fractures, and menopause. those patients with fractures and less than risk factors pre-tph, added new risk factors after transplant, mainly steroid treatment. forty-four patients ( %) had vitamin d insufficiency (< ng/ml), ( %) had osteopenia and ( %) had osteoporosis. vitamin d insufficiency and bone disease were more frequent in women than in men ( % vs. % for vitamin d, % vs. % for osteopenia, % vs. % for osteoporosis, and % vs. % for vertebral fractures, respectively). conclusions: the prevalence of post-transplant bone disease and vertebral fractures in our series is high. most fractures appearing "de novo" after allosct were asymptomatic and were diagnosed by x-ray. patients who presented vertebral fractures frequently had more than risk factors identified pre-sct. patients undergoing allosct should have their bone health assessed early in their treatment and, if indicated, should start preventative therapy to avoid bone loss and fractures. other measures such as physical exercise, vitamin d and calcium supplementation, and dxa and spinal x-ray at baseline and following transplantation are also highly recommended. disclosure: maría suárez-lledó received a grant from dkms-spain foundation. other authors have nothing to declare the use of g-csf in selected patients after autologous stem cell transplantation is associated with low incidence of engraftment syndrome background: the use of g-csf after autologous stem cell transplantation (asct) accelerates neutrophil recovery, however it has been related to an increased risk of engraftment syndrome (es) development in some studies. for this reason, we do not routinely prescribe g-csf after asct and we only use it in patients with significant complications (enterocolitis, severe sepsis, atrial fibrillation) after stem cell infusion. the main objective of this study is to evaluate the incidence of es in patients who receive asct for monoclonal gammopathies (mg), non-hodgkin lymphoma (nhl) and hodgkin lymphoma (hl) and receive g-csf only if needed. as secondary objectives we evaluate differences in the engraftment day as well as the length of inpatient stay. methods: we retrospectively analyzed patients with mg or lymphoma, who underwent asct conditioned with high dose melphalan ( - mg/m ) or beam, respectively, between and in our center. specific clinical features for es according to spitzer and maiolino criteria were evaluated between days before and days after the engraftment. statistical analysis was performed with spss v. . . results: thirty-one patients with mg and patients with lymphoma were analyzed. median age at transplant was . years ( . - . ) and patients ( . %) were male. median prior lines of treatment in patients with gm or lymphoma were ( - ) and ( - ), respectively. table shows patients´characteristics. mobilization with g-csf ± plerixafor was performed in patients ( %) and chemotherapy + g-csf ± plerixafor in patients ( %). median cd x /kg cells infused was . ( . - . ). eleven patients ( . %) received g-csf, due to infection ( enterocolitis, listeriosis, acute hepatitis, septic shock) and because of atrial fibrillation or fibrilloflutter. median time from sct to first day of g-csf was days ( - ) and median time on g-csf treatment was days ( - ). patients who received g-csf showed a short time to neutrophil engraftment (≥ . x /l), days vs. days, p< . but longer duration of hospitalization, days vs. days, p = . . non-relapse mortality at day + , + and + was %. es was diagnosed in ( . %) patients, amyloidosis, multiple myeloma and plasmablastic lymphoma. there was not statistical difference in the incidence of es between patients who received g-csf ( . %) and patients who did not ( . %), p= . . analyzed by disease, es appeared in of patients who received g-csf in the lymphoma group ( . %) but none of the patients with mg that received g-csf developed it. we did not find statistical differences between patients who developed es and those who did not in age ( years vs. years, p= . ), length of hospitalization ( days vs. days, p= . ) and the number of cd x /kg cells infused ( . vs. . , p= . ) . conclusions: the use of g-csf in selected patients is associated with low incidence of es. our study confirms that the use of g-csf accelerates neutrophil recovery but it is unclear if it can increase the incidence of es, especially in patients with lymphoma. [[p image] . background: graft failure is one of the top- problems of allo-hsct (after gvhd and relapse). the problem of graft failure becomes more significant due to increasing number of allo-hsct with ric conditioning regimen from haploidentical and hla-mismatched unrelated donors. role of t cells in graft failure is well known. here we report an impact of t-memory cell subsets count before antithymocyte globulin (atg) administration on primary graft failure after allo-hsct. methods: sixteen patients with acute leukemia transplanted in national research center for hematology were included on this prospective study. all patients received horse atg at dose mg/kg/day from day - to - before allo-hsct as gvhd prophylaxis and were balanced by other factors that could affect engraftment. detailed patients characteristics are listed in table . peripheral blood samples were collected on day - before allo-hsct (before atg injection) in edta-tubes. flow cytometry analysis was performed on bd facs canto ii (becton dickinson, usa) to define t-memory subsets: t-naive and t-stem cell memory (tnv+scm) -cd r -ccr +cd +; t-central memory (tcm) -cd r +ccr +cd +; t-transitional memory (ttm) -cd r +ccr -cd +; t-effector memory (tem) -cd r +ccr -cd -; t-terminal effector (tte) -cd r -ccr -cd -, among cd + and cd + t-cells . sysmex xe- was used to calculate absolute count of different t-cell subsets. mann-whitney u test was used for nonparametric data analysis between two groups. fisher's exact test was used for x tables. p-value less than . was considered statistically significant. results: an influence of t-memory cell subsets count before atg administration on primary graft failure is shown in figure . according to our data high absolute number of cd +ttm and cd +tte is associated with primary graft failure. conclusions: based on these findings high absolute number of cd +ttm and cd +tte could be one of the prognostic factors of primary graft failure after allo-hsct. optimizing atg dose due to recipient absolute t-memory cell subsets count before atg administering may prevent graft failure and improve posttransplant results. background: upper gastrointestinal graft-versus-host disease (gi gvhd) has been an increasingly recognised entity following allogeneic stem cell transplantation (sct). budesonide, widely used in inflammatory bowel conditions, has also been found beneficial in gi gvhd. the major benefit of budesonide is attributable to its poor absorption and extensive first-pass metabolism via cytochrome p (cyp) a , which translates to less systemic steroid-related effects. however, transplant patients are often exposed to multiple drugs, among which some agents act as cyp a inhibitors and therefore can increase budesonide bioavailability and might lead to systemic toxicity. azole antifungal drugs are probably the most common concomitantly used cyp a inhibitors in transplant recipients. methods: we reviewed allogeneic sct records for patients treated with oral budesonide for gi gvhd at our transplant centre between and retrospectively. the aim of the work was to assess the development of adrenal suppression with or without clinical features of iatrogenic cushing`s syndrome. the standard dose of budesonide was mg three times a day. patients receiving prednisolone or other glucocorticosteroids and those with no available serum cortisol level measurements were excluded. results: our analyses identified four allogeneic sct patients in whom adrenal suppression was diagnosed with undetectable serum cortisol levels during oral budesonide treatment. of these patients two developed iatrogenic cushing`s syndrome and both patients were treated with cyp a inhibitors concomitantly: . clarithromycin and fluconazole; . clarithomycin and voriconazole. the development was rapid (within and weeks). symptoms included morphological features such as moon face, high blood pressure, weight gain, peripheral oedema and proximal myopathy. symptoms resolved gradually following cessation of azole antifungal agents and on gradual weaning of budesonide. conclusions: although single agent budesonide treatment given for gi gvhd is rarely associated with systemic side effects, patients on azole antifungal drugs and macrolide antibiotics are at higher risk of systemic toxicity due to drug interactions. patients who are allergic to penicillin and receive macrolide-based prophylaxis can be especially vulnerable. to our knowledge the number of cases reported in literature about systemic effects of oral budesonide in transplant recipients is less than . our observation supports previous reports on the potential of oral budesonide to induce systemic effects. we therefore advise careful monitoring of patients treated with budesonide in combination with cyp a inhibitors, including antimicrobial agents routinely used in sct. disclosure: none implemented strategies to overcome barriers in the establishment of a consolidated hematopoietic stem cell transplantation program in a developing country background: the national institute of medical sciences and nutrition "salvador zubiran" is a national health institute located in mexico city. although mexico is considered an upper-middle income country, more than % of the population lives in poverty without health care coverage and patients within this social stratum are referred to our institution. the first hematopoietic stem cell transplantation (hsct) in mexico was performed at our institution in . from this year until , hsct were sporadically performed (n= ), showing a poor overall survival (os) and high non-relapse mortality (nrm). these outcomes resulted from an unstructured hsct program, limitedresources, patient low socioeconomic status, and paucity of population-adapted procedures. in , according to these results, a decision to establish a hsct program was made. therefore, in order to set up a successful hsct program, implementation of financial and medical strategies were necessary. the objectives of this study were to describe the barriers and implemented strategies for the establishment of a hsct program in mexico along with the outcomes of patients undergoing this procedure throughout the reorganization of the program. methods: this study is a health services research. barriers were detected based on the results of the hsct program from - (not shown). table shows the financial, medical, and research strategies that were implemented for each barrier. results: from november to november , hsct have been performed in patients at our institution. most hsct were autologous (n= , %). forty one patients underwent hsct. from the patients, most were males (n= , %) and the median age was . years (range, - ). the most frequent underlying diseases for auto-hsct were lymphomas (n= , %), non-seminomatous germ cell tumors (n= , %), and multiple myeloma (n= , %). acute leukemias (n= , %), aplastic anemia (n= , %), and myelodysplastic syndromes (n= , %) were the most frequent diagnosis for patients undergoing allo-hsct; and acute leukemia was the most frequent diagnosis for patients undergoing haploidentical hsct (n= , %). acute and chronic gvhd were present in % (grades i-ii %) and % (limited %), respectively. for allo-hsct, , day, and -year nrm was . %, %, and %, respectively; and -day nrm in auto-hsct was . %; year os was % and % for auto and allo-hsct, respectively. conclusions: future perspectives of the hsct program include the acquisition of funds for unrelated donors; to improve outcomes of patients undergoing haploidentical hsct, and to increase the number of in-patient rooms. we conclude that despite paucity of resources and other limitations, the implementation of financial, medical, and research strategies have shown that barriers can be effectively overcome in a developing country in order to establish a consolidated and nationally renowned hsct program, providing good outcomes for patients. disclosure: none of the authors have any conflict of interest to disclose. the effect of protective buffering on daily stress and relationship quality in dyads following hematopoietic stem cell transplantation: results from daily process methodology malgorzata sobczyk-kruszelnicka , aleksandra kroemeke , zuzanna kwissa-gajewska , sebastian giebel background: cancer-related support communication (e.g., protective buffering) may impact the risk for psychological and relationship distress in patients following hematopoietic stem cell transplantation (hsct) and their caregivers. previous studies have revealed that protective buffering (i.e., hiding one's concerns and denying one's worries) has mixed effects: is beneficial (for "protected" person), costly (especially for the person using it), or unrelated to dyadic wellbeing. there has been, however, little evidence linking dyadic protective buffering with distress using daily process methodology. we assessed ( ) the relationship between daily protective buffering, and same-and next-day stress and relationship quality in patient-caregiver dyads following hsct and ( ) whether similarity or complementarity in protective buffering between dyads is adaptive. methods: two hundred patients (after first autologous or allogeneic hsct) and their caregivers (spouse or another relative) independently completed measures of daily protective buffering, daily relationship quality, and daily stress for consecutive evenings after patients´hospital discharge. actor-partner-interdependence model (i.e., both partners' and caregivers' reports regarding support communication and distress were studied) was used to test study hypotheses. results: for both patients and caregivers, multilevel structural equation modeling showed a significant positive relationship between daily protective buffering and sameday relationship quality. association of protective buffering with same-day stress level was negative. in next-day analyses, patient-reported protective buffering was related to patient's higher relationship quality, whereas caregiverreported protective buffering increased patient's daily stress. complementarity in protective buffering was related to higher immediate same-day relationship quality for both patients and caregivers, while benefits from similarity have delayed effects, although only in patients. conclusions: contrary to previous studies, protective buffering rather has a beneficial effect in dyads following hsct. protection of the partner and relationship against revealing negative emotions and powerlessness was not related to costs in both parties. the findings suggest that the effect of daily protective buffering in dyads following hsct depends on support timing (same-or next-day effect) and differs for both parties. patients seem to benefit the most from the similarity in protective buffering, while caregivers from complementarity. the "fit" between patient and caregiver in support communication ought to be taken into consideration in the practical approach. disclosure: nothing to declare. virus reactivation and low dose of cd + cell were associatied with secondary poor graft function within the first days after allogeneic stem cell transplantation yuqian sun , xiao-jun huang background: secondary poof graft function (spgf) was defined as the secondary cytopenia after initial engraftment of hsct. it was shown to be associated with poor prognosis, however there are very few reports on the incidence, risk factors and outcomes of spgf. methods: patients who received transplantation from peking university people's hospitial during january, to december, were retrospectively reviewed if they fulfilled the following conditions: ( ) diagnosed with acute leukemia or myelodysplastic syndrome; ( ) received allo-sct from either matched sibling donor (msd) or haploidentical related donor (hid). pgf was defined as persistent neutropenia (≤ . × /l), thrombocytopenia (platelets ≤ × /l), and/or hemoglobin ≤ g/l for at least consecutive days, transfusion-dependence, associated with hypoplastic-aplastic bone marrow (bm), and complete donor chimerism without concurrent graftversus-host disease (gvhd) or disease relapse. primary pgf was defined as the failure to achieve initial engraftment by days after transplantation, while secondary pgf was defined as the fulfillment of the criteria after initial engraftment hsct. results: during january, to december, , patients who received transplantation from peking university people's hospitial were retrospectively reviewed. among the patients who achieved initial engraftment, patients developed spgf. the cumulative incidence of spgf on day was . %. the median time of secondary pgf was . ( - ) days after transplantation. low (< median) cd + cell dose (p= . , hr . ( %ci, . - . )), ebv reactivation (p= . , hr . ( %ci, . - . )) and cmv reactivation (p= . , hr . ( %ci, . - . )) were identified as independent risk factors with spgf. there is no significant difference of pgf incidence in msd group and hid patients (p= . ). the overall survival of patients with spgf at year after transplantation was significantly poor than patients with ggf ( . % versus . %, p< . ). conclusions: in conclusion, spgf develop in . % patients after allo-sct, especially in patients with cmv, ebv reactivation or infused with low dose of cd + cell. the prognosis of spgf is still poor due to lack of standard treatment. disclosure: there is no conflict of interet thiotepa with treosulfan and busulfan based conditioning are significantly more gonadotoxic than treosulfan previous studies suggest that busulfan results in long-term gonadal toxicity. no previous studies have compared gonadal toxicity outcomes after treatment with busulfan with treosulfan, a newer agent with similar marrow toxicity to busulfan but with reduced non-marrow toxcitiy. our aim was to determine whether there are differences in pubertal and fertility outcomes in paediatric patients treated with treosulfan compared with busulfan. methods: inclusion criteria were patients who had received either busulfan or treosulfan or treosulfan with thiotepa, only one hct and were aged years and above in august . eligible patients were reviewed in clinic as part of their routine follow-up, thus research ethical approval was not required. follice stimulating hormone, luteinising hormone, oestradiol, and pubertal history were noted. ovarian reserve was estimated in female patients by measuring serum anti-mullerian hormone (amh). male patients had serum testosterone measured and were also offered semen analysis. results: thirty-five patients met the inclusion criteria, of which twenty-five wanted to be reviewed ( %); seventeen females and eight males. mean age at hct was years, mean age at review was years and mean years since hct was years. female patients treated with busulfan or treosulfan with thiotepa (n= ) had minimal amh and none of these patients were having regular periods. females treated with treosulfan (n= ) had normal amh and regular periods without needing hormone replacement. only four male patients opted for a semen analysis and all had significantly reduced sperm counts. conclusions: our results suggest that females treated with treosulfan have minimal (if any) reduction in ovarian reserve compared to other conditioning regimens which casue significant compromise. although this was a small study, and thus not suitable for statistical analysis, the clinical findings are marked. future studies should further investigate optimal doses of treosulfan that could be used to achieve bone marrow engraftment and limit long-term effects on fertility. disclosure background: autologous and allogenic hematopoietic stem cell transplantation (hsct) are potentially curative treatments for hematological malignancies. patients with related complications may need admission to the intensive care unit (icu) for specific therapy and organ support. mortality risk factors, supportive care and principal causes of admission in icu are described in our cohort of patients (pts). methods: we retrospectively studied pts, male, with a median age of , years (range: - ) who underwent allo-hsct in our center between july and october . two hundred and twenty-seven( , %) pts received autologous hsct (auto-hct) and ( , %) allogenic hsct (allo-hsct); from unrelated donor, from identical sibling, and the remainder, mismatched related donor . twenty-three ( , %) out of pts were admitted in the icu in the transplant procedure admission. results: fifteen ( , %) out of pts were male with a median age of years (range: - ). patients' baseline diseases were: multiple myeloma ( , %), non-hodgkin´s lymphoma ( , %), hodgkin´s lymphoma ( , %), acute lymphoblastic leukemia ( , %), myelodisplasic syndrome ( , %), solid tumor ( , ) and acute myeloblastic leukemia ( , %). fifteen ( , %) pts received auto-hsct, ( , %) allo-hsct from unrelated donor, ( , %) allo-hsct from identical sibling, and the remainder haploidentical hsct ( ) ( , %). so, , % of auto-hsct pts and % of allo-hsct were admitted in the icu. the median stay in the icu was days (range: - ) and reasons for admission were: respiratory insufficiency ( , %), septic shock ( , %), renal insufficiency ( , %) and multi-organic failure ( , %). twenty-one ( . %) pts required respiratory support with: nasal cannula or oxygen mask (c/m) ( %), non-invasive mechanical ventilation (nimv) ( , %) and invasive mechanical ventilation (imv) ( , %). fourteen ( %) pts needed inotropic agents for shock treatment. finally, ( , %) pts required substitutive renal therapy with hemodialysis or haemofiltration (hd/hf). eleven ( , %) out of pts died, ( , %) were male with a median age of years (range: - ). ten of them ( , %) needed imv and were treated with inotropic agents. all patients who required hd/hf (n= ) died. imv and treatment with inotropic agents were associated with icu mortality (or , ; p= , , or ; p= , ; respectively). conclusions: in our series of pts, , % needed admission in the icu, presenting a mortality rate of % approximately. there were no differences in the prevalence of icu admission regarding hsct donor. main reason for admission was respiratory failure with imv requirement in , % of pts. imv and treatment with inotropic agents were associated with icu mortality. an early identification of pts at risk of icu admission could have a beneficial impact on survival improvement disclosure: nothing to declare is there any association between thrombotic risk factors and veno-oclusive disease in childhood allogeneic hematopoietic stem cell transplantation? background: veno-oclusive disease (vod) is a major complication of hematopoietic stem cell transplantation (hsct). in some studies levels of fibrinolytic factors especially plasminogen activator inhibitor- (pai- ) level were found associated with vod. however, little is known about the relationship between thrombophilia risk factors and vod. in this study we aimed to investigate association of major thrombophilic gene mutations on vod in pediatric hsct patients. methods: we reviewed retrospectively patients with vod who underwent hsct between - in ankara pediatrics and pediatric hematology-oncology training and education hospital, bone marrow transplantation unit, turkey. fifty-one patients who did not develop vod and transplanted during the study period were accepted as control group. we evaluated plasma homocysteine and lipoprotein a level, protein s and c activity and antigen levels and factor v g a mutation, prothrombin g a mutation, methylenetetrahydrofolatereductase (mthfr) c t and a c mutations, plasminogen activator inhibitor- - g/ g polymorphism before hsct. we also evaluated the patients' hospital files and noted the demographic values and complications of hsct. statistical investigations were done with spss statistics . for windows and p< . has been accepted as significant. results: there was no difference between control and vod groups as regard to age, sex, diagnosis, donor type, conditioning regimen, hsc source, and hla typing . there was no difference between the groups according to homocysteine, lipoprotein a, protein s and c activity and antigen levels. we did not find any relation between the genetic variations of thrombophilia and vod (table ). in vod group there were patients ( . %) with acute graft versus host disease (agvhd) and in control group there were ( . %) patients with agvhd (p= . ). febrile episodes were more frequent in vod group compared to the controls (respectively; n= , . % vs. n= , . %, p= . ). -year overall survival was % . in vod group and % in control group (p= . ). disease free survival was also different between vod and control groups (respectively; . % vs. . %, p= . ). conclusions: in literature there are recent studies showing higher pai- levels in patients with vod. however, in our study we did not find any relationship between congenital thrombophilia factors and vod. new studies with larger sample groups is necessary to better evaluate the association of congenital thrombophilia factors and vod. disclosure: nothing to declare p different strategies of chemotherapy-induced nausea and vomiting (cinv) prevention in hematological patients receiving an autologous hematopoietic stem cell transplantation: a single center experience ilaria cutini , riccardo boncompagni , chiara nozzoli , antonella gozzini , stefano guidi , chiara innocenti , massimo di gioia , lorenzo tofani , riccardo saccardi background: despite the improvements of pharmacological control, cinv still represents a major problem in patient undergoing hematopoietic stem cell transplantation (hsct). we present here a comparison of two pharmacological strategies for preventing cinv in multiple myeloma (mm), hodgkin (hl), and non-hodgkin lymphoma (nhl) patients who received an autologous hsct in our institution. methods: from january to july , we retrospectively analyzed consecutive patients, median age years ( - yo) , diagnosed with mm, hl, and nhl, who underwent an autologous hsct following a melphalan mg/sqm and beam/feam condition regimens, respectively. the first patients received cinv prophylaxis with palonosetron i.v and dexamethasone mg die (regimen a), whilst the following were administered with fosaprepitant iv, ondansetron iv and dexamethasone mg die (regimen b) both cinv prophylaxis was administered the day of melphalan infusion (day - form transplant). emesis breakthroughs were treated with alizapride and metoclopramide. nausea and vomiting were assessed through the ctcae . score system. categorical variables were compared with pearson chi-square test. results: the overall incidence of nausea was %, ( % grade , % grade , and % grade , respectively). in regimen a was shown to be %, ( % grade , % grade , and % grade , respectively) while in regimen b was % ( % grade , % grade , and % grade , respectively). pearson chi-square test did not show any differences between the groups (p= . ). the overall observed vomit was % ( % grade , % grade , and % grade ). in regimen a it was ( % ( % grade % grade , and % grade ), and % in regimen b ( % grade and % grade ). conditioning regimens didn't' have any significant impact on either nausea or vomit. patientsyounger then median ( yrs), were reported to have higher incidence of both nausea, (p= . ) not related to cinv treatment, and vomit ( % vs %, p= . ). in multivariate analysis the overall incidence of nausea is related to age (younger patients have higher probability to develop nausea (or , ; p= , ) whilst the higher incidence of vomit is related to: regimen a (or . ; p< , ), previously reported nausea (or , ; p< , ), and no smoking habits (or , ; p= , ). conclusions: both regimens are equally effective for nausea control however regimen b evidenced a better vomiting control. this finding is particularly relevant when the center policies include an early discharge program, therefore improving both patient's quality of life and procedure cost-effectiveness. clinical background: patients who underwent an allogeneic hematopoietic cell transplantation (hct) are challenged by medical, psychological and social complications. support groups might help hct-survivors to cope with these challenges. however, the existing literature about post-hct support groups is scarce. moreover, data on professionallyfacilitated support groups do not exist. the aim of this project was ( ) to establish a professionally-facilitated support group and ( ) to assess the discussed topics. methods: from / until / all patients who received an allogeneic hct at the adult stem cell transplantation program of the university clinic mannheim were invited to participate in a professionally-facilitated support group. additionally, spouses and life partners were invited. a theologian who is also a physician served as facilitator. he had no further function within the transplant team. the format of the group was unstructured without any rules regarding regular attendance. the facilitator did not provide topics or a curriculum. during the first year the group met every days followed by a monthly schedule. from the fifth until the th meeting the attendance and the discussed topics were minuted by the facilitator. the content of the minutes was analysed by a combination of an inductive and a deductive approach. all participants provided their informed consent for the study. results: altogether patients (female: n= ; male: n= ) and spouses/life partners (female: n= ; male: n= ) participated. patients ( %) and spouses ( %) attended more than one meeting. among those who participated in ≥ meetings the median time of participation was months. the median count of participations was eight. % of the participants attended the meetings longer than one year, % longer than three years. there was no sex difference with respect to the frequency and the duration of participation. however, the frequency of participation decreased significantly the longer a participant was attending the meetings. during group meetings the facilitator recorded thematically different contributions to the discussions divided in distinct topics. these topics were grouped into main categories [(a) medical topics, (b) private life and environment, (c) human relationships, (d) physical and mental condition and (e) the support group itself] and eight further categories [( ) compliance, ( ) economic issues, ( ) religion, ( ) sexuality, ( ) death and dying, ( ) support and coping, ( ) objectives and needs and ( ) not otherwise specified issues] which could not be grouped in one of the main categories. the most frequent issues were medical topics ( %), human relationships ( %), physical and mental condition ( %), private life and environment ( %), financial issues ( %), the support group itself ( %), support and coping ( %) and objectives and needs ( %). noteworthy, death and dying ( . %) were rare topics and sexuality was never mentioned. conclusions: to our knowledge, this is the first prospective and systematic analysis of a professionallyfacilitated support group for hct-survivors. these data might help to establish support groups and to identify psychosocial needs of patients and targets for specific support. disclosure: nothing to declare background: endothelial damage is associated with inflammatory complications that appear early after hsct, such as sinusoidal obstruction syndrome or acute gvhd. engraftment syndrome (es) is an inflammatory condition diagnosed by maiolino clinical score. potentially, es can exhibit high morbidity and mortality, especially after autologous-hsct in multiple myeloma (mm) patients since the introduction of new drugs such proteasome inhibitors and immunomodulatory drugs (imids). the objective of the present study was to evaluate if es is associated with endothelial dysfunction in patients with mm who underwent auto-hsct. methods: we included six patients with mm who received induction treatment including new drugs and consolidated their response with an autologous-hsct. we analysed comparatively the effect of incubating endothelial cells in vitro with serum samples from patients with es vs. no es. serum samples were collected before (pre), and after , , and days from the transplant. an additional sample was collected at the es onset and at the discharge day (no es group). endothelial cells (hmec) in culture were exposed to media containing % of serum from each patient for h. cell growth was controlled morphologically. expression of the adhesion receptor icam- on the cell surface was analysed by immunofluorescence, and activation of the inflammation related p- mapk signalling pathway was evaluated by sds-page and western blot. results: exposure of hmec monolayers to sera from patients who developed es (onset day, n= ) resulted in an increased icam- expression on the cell surface, higher that the observed with sera from patients who did not develop es (discharge day, n= ) ( . % of labelled area vs. . %, respectively). in addition, in experiments with sera from patients not developing es, icam- expression on cells exposed to sera from day + was reduced with respect to the observed with sera from day + , probably due to the corticosteroid used as a prophylaxis in our centre. this reduction was not observed in es patients. regarding phosphorylation of p- , it was significantly higher in cells exposed to sera from es patients than in response to sera from patients who did not develop es. conclusions: the increase in the expression of the adhesion receptor icam- on the surface and the intracellular activation of p mapk in endothelial cells exposed to sera from patients developing es indicates the existence of endothelial activation in association with es. interestingly, the prophylaxis of es with corticosteroid seems to be less effective in patients who developed es than in patients who did not develop this complication. these results need to be validated in a higher number of patients and modifications in additional markers of endothelial dysfunction should be investigated. disclosure: gonzalo gutiérrez-garcía: honoraria from gilead. grant from jazz pharmaceutical the other authors do not have any disclosure to comment. p association between uric acid levels before and after allogeneic haematopoetic stem cell transplant and transplant outcomes: a single centre experience background: uric acid (ua) is a known endogenous danger signal which activates the nod-like receptor protein (nlrp) inflasome.ua is released from injured cells during conditioning in allogeneic stem cell transplantation (hsct). a pre-clinical study has demonstrated that nlrp inflasome-mediated il- production regulates graft-versushost disease (gvhd). the ua role in inflammation and gvhd is unclear. there are discordant reports in the literature about a potential protective role of ua on gvhd after a hsct. methods: we performed a retrospective study to assess the association between serum ua levels pre-and post- table] . table ] results: the characteristics of the patients are shown in table . median age was years (range - ), and patients ( %) were male. twenty-seven patients ( %) received low doses atg as part of gvhd prophylaxis. allopurinol was from the day before start of conditioning therapy until day . the median levels of ua were , mg/ dl before conditioning, , mg/dl at day , , mg/dl at day + and , mg/dl at day + . there was no impact between the ua levels and os at any time of the hsct. ua levels at day + were associated with a higher ci relapse at years ( % [ % ci, - %] for ua level > , mg/dl, and % [ % ci, %- %] for ua level ≤ , mg/dl [p= , ]). there was a trend for a higher ci of grade ii-iv agvhd for the subgroup of patients not treated with atg with ua < , mg/dl ( % vs %; p= , ) on day - and a higher nrm with ua < , on day ( % vs %; p= , ). conclusions: in our study the ua levels showed no impact on os, and only a tendency for ci of grades ii-iv agvhd grades ii-iv and nrm for the subgroup of patients not treated with atg. surprisingly, high levels of ua at day + of hsct were associated with a significant higher incidence of relapse. disclosure: dkms foundation, pi / (instituto carlos iii) and sgr (grc), generalitat de catalunya. background: veno-occlusive disease (vod) is an early, uncommon but serious complication of stem cell transplantation (sct) that is associated with high morbidity and mortality. defibrotide is the only licensed treatment for vod, and time to start of treatment (tst) affects outcomes. minor differences exist between the seattle, baltimore and classical ebmt ( ) criteria, which may trigger different start points for treatment. late onset vod (> days) is less recognised and we hypothesize, may have worse outcomes with longer time to diagnosis, and more limited treatment options across different healthcare systems. methods: electronic patient records from sept. -oct. at king´s bmt centre and pharmacy databases were reviewed, timepoint to clinical and bio-chemical manifestation of vod, diagnosis, tst, survival and longterm outcomes were analysed. results: of the patients( . %) who underwent an allogeneic sct, developed vod, including paediatric cases. none of the autologous sct patients developed vod. the paediatric and autologous sct patients were not analysed any further. adult patients (male= ; . %) developed vod at a median age of years(range - ), of whom developed < days and patients had late-onset vod as per ebmt criteria(range - days). cases classed as severe and as moderate vod. patients received defibrotide at diagnosis, patients within days, patients between - days, and patients received treatment after days. overall mortality for this cohort was %( / ). / ( . %) of patients with early onset vod and / ( . %) patients with late-onset vod died. of the deaths, died of liver failure and a further patients had vod as a likely contributing factor in their deaths. patient died with subarachnoid haemorrhage and with relapsed disease. patients that received defibrotide after days, / patients( . %) died, as compared to / ( %) for treatments between - days, / ( . %) for treatments within days. the lone surviving patient who received treatment after days has severe chronic liver disease and it's complications. of the patients who fit seattle criteria for early-onset vod, only fit the baltimore or ebmt criteria for classical vod. of these patients met the baltimore criteria later than the seattle criteria were met(range = - days). conclusions: vod carries high morbidity and mortality, and beyond the known risk factors and with the caveat of limited numbers in this study, we strongly suspect this is further increased when time to definitive treatment with defibrotide is delayed, particularly beyond days. nearly a quarter of cases with vod are late-onset as per classical ebmt criteria. however contrary to our hypothesis, their overall outcomes and mortality do not appear worse, with time to treatment again emerging as a strong predictive factor. conditioning treatment related factors, which play a stronger role in endothelial dysfunction in the hepato-portal circulation, may not be as much at play, perhaps for late-onset disease. uniformity in the use of diagnostic criteria, and high degree of vigilance, even beyond days, leading to early treatments may improve outcomes in vod. disclosure: nothing to declare background: hsct-associated thrombotic microangiopathy (ta-tma) affects - % of patients receiving an allogenic sct, with a high mortality up to - % in severe cases. endothelial injury mediated by complement activation has been atribuited a major role in the pathogenesis, and blockade of c with eculizumab offers promising results. methods: we present our experience with pediatric cases of ta-tma treated with eculizumab. the diagnosis of ta-tma was stablished attending to jodele et al criteria. clinical data were collected retrospectively from medical records. results: all cases were diagnosed between august and april , with a median age of years ( . - ) at time of diagnosis. primary disease was acute leukemia in cases ( all and aml), severe aplastic anemia in , and primary immunodeficiency in . they received their first sct in all cases, from mud and from mmrd (cd ra+ depleted haploidentical grafts), with mac regimen in cases, and ric in cases. of them received calcineurin inhibitors (cyclosporine) as gvhd prophylaxis. all patients developed agvhd (grade or higher in cases). and patients presented viral reactivation. hypertension was present in cases at tma diagnosis, requiring or more antihypertensive drugs in of them. all patients had renal injury consisting of less-than-normal glomerular filtration rate (median of ( - )) and proteinuria, with urine protein-to-creatinine ratio higher tan mg/mg in cases (data not available in patients). serum haptoglobin was decreased in just cases at diagnosis, and schistocytes were detected in patients. cutaneos signs were present in all cases, digestive symptoms in , neurological affection in , and notoriously all of them developed polyserositis. c and c were normal in all cases, with sc b higher than ng/ml in patients and lower in (data not available in cases). all patients received defibrotide as treatment, and cases received also rituximab, associated to therapeutical plasma exchange in . all of them received eculizumab, as first line in cases (median of days between diagnosis and eculizumab start). treatment was correctly monitorized with ch levels in cases (not available quick enough in other ). median number of doses needed in induction therapy was , and median interval between doses was days. patients required reduced interval and higher doses to maintain ch supressed. patients did not respond, and died because of tma. patients had hematological response, with chronic renal injury in of them and resolution of acute renal failure in case. nevertheless patient responding to eculizumab died because of tma related complications, and because of an invasive fungal infection. patients are alive, with a median follow up of months from treatment start. conclusions: our experience supports promising results of eculizumab based treatment for ta-tma, highlighting the importance of an early treatment and a careful therapy monitoring by ch supression. prospective studies are needed to achieve a better knowledge of this pathology and its treatment. disclosure: nothing to declare background: approximately - % of allogeneic hematopoietic stem cell transplant (allo-hsct) are made with some sort of abo blood group system incompatibility. an hsct abo donor-recipient incompatibility implies risks of complications during the process of infusion as acute hemolytic anemia (ah), delayed graft and other later complications due to the presence of isohemaglutinins (pure red cell aplasia or passenger lymphocyte syndrome). also, abo incompatibility could impact on graft versus host disease (gvhd) incidence, and could be associated with not relapse mortality (nrm) and overall survival (os). there are not concluded evidence about the abo incompatibility impact, so the aim of this study was to identify complications and response associated with abo incompatibility in patients undergoing allogeneic hematopoietic stem cell transplantation. methods: a retrospective study was performed on patients who receive an allo-hsct between january and august . two groups were performed according to the presences or not of abo incompatibility. demographic and clinical information was collected from physical and electronic medical records, and information was analyzed in spss v results: sixty-eight patients were enrolled in the study, % male, the median age was years ( - ) with the following diagnoses: acute lymphoblastic leukemia %, acute myeloblastic leukemia . %, granulocytic chronic leukemia . %, myelodysplastic syndrome . %, dendritic cell neoplasm . %, aplastic anemia . %. ninety-one percent of the patients received a transplant from an identical hla donor and . % received a haploidentical transplant. fifty-two patients ( %) were abocompatibility (g ) and patients ( %) had aboincompatibility (g ). none patient with aboincompatibility received a haploidentical transplant. the contrast between groups didn't show differences in fever, infections, bacterial isolation, presence and degree of acute or chronic gvhd and relapse of the disease. graft failure was %(g ) vs %(g ) (p= . ), intermediate risk cmv serostatus %(g ) vs (g ) (p= . ). the most relevant characteristics and complications are described in table . contrast analysis between g vs g showed that within the whole group there were deaths ( % vs % respectively) (p= . ), the overall survival -year was % vs % (p= . ) with a median of vs months respectively; mortality associated with relapse was % vs % respectively, and mortality related with transplantation was % vs % respectively. conclusions: abo incompatibility did not show association with complications related with the infusion, but there was a higher tendency of graft failure in the abo incompatibility group. it has no statistical significance, but it is important to expand its study. disclosure: none declared methods: retrospective data for nhl patients who underwent asct between and was analysed. patients were identified using the swbmt database and data on mets was collected using paper and electronic hospital records. forty-eight patients were excluded due to loss of follow-up, inaccessible/incomplete records, or death. cause of death was not determined. the ncep-atpiii definition of mets was used. this requires ≥ of criteria to be met. a bmi of ≥ kg/m and hba c of ≥ mmol/l were used to replace central obesity and impaired fasting glucose, respectively. other criteria include triglycerides (tgs) ≥ . mmol/l or treatment, high density lipoprotein cholesterol (hdl-c) < . mmol/l (male), < . mmol/l (female) or treatment and blood pressure > mmhg systolic or > mmhg diastolic, or treatment. results: the prevalence of mets in the cohort was % (n= ). eighty-two percent of patients (n= ) met one or more criterion for mets. twenty-seven percent (n= ) fulfilled only one criterion, % (n= ) fulfilled two criteria, % (n= ) three criteria, % (n= ) four criteria, and % (n= ) five criteria. the greatest prevalence of mets was in the + age group, accounting for out of ( %) patients with mets. overall prevalence decreased with declining age ( table ). the number of patients aged < years was too small to make any judgement on risk. raised triglycerides was the criterion most frequently met ( / patients), followed by hypertension ( ), raised bmi ( ), low hdl-c ( ) and an increased hba c ( ). conclusions: the prevalence of mets in our cohort ( %) was higher than the estimated worldwide prevalence of %, with the majority in the + age category. this is in keeping with other post-transplant studies, which show an increase in prevalence of mets after transplantation. moreover, the overall prevalence of mets was greater in the older population, which could be associated with the cumulative effect of ageing on the decline of normal metabolic homeostatic mechanisms. background: acute renal failure (arf) is a frequent complication in the early post-allogeneic hematopoietic stem cell transplant (allohsct) period with either myeloablative (ma) or non-myeloablative (nma) conditioning regimens. the aim of this study was to compare the incidence of arf in both types of hsct and to evaluate its impact on overall survival (os) and non-relapse mortality (nrm). methods: all allosct performed in one center between and were included in this study. allohsct from cord blood and from haploidentical donors were excluded. the renal function and the incidence of the main complications after allosct from day to day + were evaluated. arf was defined according to kdigo (kidney disease improving global outcomes) classification; the relative increase of serum creatinine levels was considered a marker of kidney damage. results: seventy-seven patients received a ma allohsct and a nma allohsct. recipients of nma allohsct had a higher median age ( years [range: - ] vs. years , p< . ), higher frequency of arterial hypertension ( % vs. %, p< . ) and showed most frequently active disease at allosct ( % vs. %, p= . ). in both groups the most frequent graft-versushost disease (gvhd) prophylaxis regimen was cyclosporine a and methotrexate. the median follow-up time was . years for the nma group and . years for the ma group. patients from the ma group had higher incidence of grade - mucositis ( % vs. %, p< . ) and acute gvhd of any grade ( % vs. %, p= . ) than patients from the nma allohsct. the incidence of arf was similar in both groups ( % in nma and % in ma). in the nma group arterial hypertension (hr . , p= . ), obesity (hr . , p< . ) and prior pneumonia (hr . , < . ) were predisposing factors for arf by multivariate analysis, whereas any factor was identified in the ma group. arf had no impact on -year os in both groups ( % vs. % p= . for the nma group and % vs. % p= . for the ma group). however, worse os were observed in patients with grade - arf in the nma group ( % vs. %, p= . ) and in patients with grade arf in the ma group ( % vs. %, p= . ). in turn, arf had no influence on nrm in the ma group but was associated with a trend for higher nrm in the nma group ( % vs. %, p= . ). conclusions: arf is a frequent complication in patients receiving allohsct irrespective of the intensity of the conditioning regimen. moderate and severe arf had negative impact on os. disclosure: supported by grants from: asociación española contra el cáncer, aecc (gc biga), instituto carlos iii (pi / fi), -sgr (grc), cerca program from generalitat de catalunya, and "la caixa" foundation. treatment and risk factors of hepatic veno-occlusive disease after pediatric hematopoietic stem cell transplantation: a single-center experience barbaros sahin karagün , ilgen sasmaz , ali bülent antmen background: defibrotide emerged as a promising treatment option for hepatic veno-occlusive disease, a significant cause of mortality in recipients of hsct. as vod diagnosis is quite difficult even with the recently introduced ebmt criteria, studies which report treatment outcomes and response to prophylaxis are required. our aim was to evaluate the efficacy of defibrotide prophylaxis in hsct recipients at our center. methods: a total of transplants in patients from january to july were included in this study. all patients had factors that increased the risk of vod and all received mg/kg/day prophylaxis. patients' coagulation, renal and liver function test were monitored daily and all clinical findings and complaints were recorded. diagnoses were made via the ebmt vod criteria and patients who developed vod received treatment with increased df dose ( mg/kg/day) and supportive interventions. after complete remission of vod findings, patients were returned to the prophylaxis dose. close follow-up of patients was performed until days. results: in total, patients developed vod ( . %), none of the cases were severe ( mild, moderate). median age was . years and the most common clinical findings were weight increase, hepatomegaly, right upper quadrant pain and ascites development. in those with vod, treatment with mg/kg/day df was initiated and average duration of treatment with this dosage was . ( - ) days. no adverse events were reported in any of the patients. conclusions: our findings are consistent with previous studies on this topic, and we believe that the use of df as a prophylactic agent for vod is beneficial for pediatric patients with risk factors. disclosure: the authors report no conflicts of interest in this work. background: several factors might influence outcome of allo-hsct. analysis of the impact of donor-receptor blood group-incompatibility have been performed in different series not always showing the same results. as a consequence, its clinical impact remains controversial. minormismatch is characterized by the ability of donor b lymphocytes to produce anti-recipient antibodies. in majormismatch cases, antibodies against donor antigens are present in the recipient. methods: pts underwent allo-hsct between may and august in our center. median age was years (range: - ). pts were male ( . %) and female ( . %). baseline diseases were: aml, lpd, mds, all, mpd, mm, and bmf. donor was unrelated in , and related in cases (including haplo-identical). donor-recipient abo compatibility was as follows: ( . %) majormismatched (including bidirectional), and ( . %) nonmajor-mismatched (including minormismatched and matched). donor-recipient rh compatibility was as follows: ( . %) major-mismatched, and ( . %) nonmajor-mismatched (including minor-mismatched and matched). the impact of donor-recipient abo and rh compatibility on transfusion needs (prbc and platelet concentrates) and survival by day + was analyzed. results: for the global series the median number transfusions by day + was: ( - ) prbc and ( - ) platelets concentrates. day + overall mortality was . %. rh-incompatible and nonmajor abo incompatible cases showed no different results. however, major abomismatched cases needed more prbc transfusions (median: ; range: - ) and more platelet transfusions (median: ; range: - ), and had higher day + mortality ( . %) (p < . ) (see table) . conclusions: our analysis showed: ) donor-recipient rh-incompatibility, as well as minor aboincompatibility had no impact on prbc and platelet concentrates transfusion needs nor on -day mortality; ) contrarily, donor-recipient major abo-incompatibility had a significant adverse impact on prbc and platelet concentrates transfusion needs and -day mortality. ) donor-recipient rh-incompatibility and minor aboincompatibility.might be considered of marginal importance at the time to choose a potential donor. ) donorrecipient major abo-incompatibility should probably be a factor to be considered, along with other features, to choose the best donor background: survivors of haematopoietic stem cell transplantation (hsct) are at significant risk of developing treatment-related complications, including cardiovascular risk factors such as arterial hypertension, that could eventually lead to cardiovascular disease. the aim of this study is to evaluate the incidence and risk factors of hypertension following hsct in a colombian population. methods: a retrospective cohort study was conducted to assess the incidence and risk factors of hypertension in consecutive adult hsct recipients who underwent transplantation between and at a tertiary referral center in colombia, south america. blood pressure data, from two different measures, were collected at time points: day of mobilization for autologous hsct and day before infusion for allogeneic transplantation, day , and months , , and post-transplantation. hypertension was defined as having a systolic blood pressure >= mmhg and/or a diastolic blood pressure >= mmhg. patients with history of arterial hypertension were excluded. results: one hundred and seventy-five patients were included, with a mean age of years (range - ). ninety-one patients ( %) were male. one hundred and sixteen patients ( . %) underwent autologous hsct and ( . %) allogeneic hsct. the most common indication for hsct was acute leukemia ( . %), followed by non-hodgkin lymphoma ( . %) and multiple myeloma ( . %). twelve patients ( . %) had medical history of type diabetes mellitus (dm), ( . %) dyslipidemia, ( . %) alcohol consumption, and ( . %) tobacco smoking. only two of the patients with history of tobacco smoking were active smokers at time of transplantation. twenty-four patients ( . %) had developed hypertension by the end of the first year post-hsct follow-up. two patients ( . %) had systolic and diastolic, ( %) had only systolic, and ( . %) had only diastolic hypertension. only one patient was hypertensive at more than two time points. the incidences of hypertension at each time point were . % on day post-hsct, . % at first month, . % at three months, . % at months, and . % at one-year post-transplantation. allogeneic hsct (p< . ), therapy with calcineurin inhibitors (p< . ), pre-hsct fasting glucose levels (p< . ), acute gvhd (p< . ), chronic gvhd (p< . ), and media of diastolic blood pressure (p< . ) were significantly associated with the development of arterial hypertension. however, age, history of type dm, history of tobacco consumption, volume of infusion, prophylactic treatment for gvhd with mycophenolate, chronic gvhd, serum creatinine level on day of hsct, and being overweight or obese at time of transplantation were not significantly associated with the development of hypertension. conclusions: arterial hypertension is a fairly common complication in hsct recipients. similar to findings reported in previous studies, association between allogeneic stem cell transplantation, therapy with calcineurin inhibitors, and acute and chronic gvhd, and post-hsct hypertension was found in the present cohort. further studies are needed to assess the link between hsct and developing long-term cardiovascular complications. disclosure: nothing to declare tramadol-based pain management of oral and esophageal mucositis in pediatric hsct recipients background: mucositis is one of the most common early hsct complications seen in about % transplant recipients with % of patients developing gr iii-iv mucositis. mucositis is characterized by painful gastrointestinal mucosa lesions impairing the solid and liquid foods intake and increased risk of infections, bleeding, and intestinal paresis. thus, it greatly decreases the quality of life of a transplant recipient. according to who recommendations, the moderate pain control in pediatric patient is based on the use of low-dose morphine. however, there are some factors such as genetic polymorphisms causing variable morphine pharmacokinetics in children, side effects, and social factors (caregivers' general unwillingness to use narcotic analgesics), which cause the need for alternative pain relief options in pediatric practice. tramadol, which has both opioid and non-opioid mechanisms of action, may be a feasible option in mild to moderate pain. it may be delivered via patient-controlled analgesia (pca), although there is no consensus on its optimal parameters in pediatric practice. methods: a total of pediatric patients with a median age of (range to ) years receiving an autologous or allogeneic hsct in our clinic as part of the treatment regimen for solid tumor (n= ), leukemia (n= ), acquired aplastic anemia (n= ) or inherited condition (n= ) were included. conditioning regimens were myeloablative (mac) in and reduced-intensity (ric) in patients. all patients had oral and/or esophageal mucositis accompanied by moderate pain. the pain severity was assessed using the scales corresponding to patient's age and varied from to points. the pain control was based on intravenous tramadol administration using patientcontrolled analgesia (pca) approach. the following pca parameters were used: loading dose of . mg / kg (not exceeding mg), basal infusion rate of . mg / kg (not exceeding . mg), a bolus of . mg / kg (not exceeding . mg), lockout interval of min. the maximal daily dose was mg/kg/day. the pain control was considered adequate if a patient was satisfied or the basic and breakthrough pain score values were not higher than and, accordingly. in case of inadequate pain control nsaids were added. non-responders were switched to morphine. all patients were divided into groups based on conditioning regimen intensity. results: as a whole, % of patients did not require pain control measures escalation. the tramadol pain control rate was slightly higher for ric (n= , %) compared to mac (n= , %) recipients. in most cases the inadequate pain control was due to progressive mucosal lesions. the pca regimen used was characterized by very few complications. drowsiness was observed in ( %) of patients, in all cases the patients also had anemia. there was only ( %) patients with severe nausea requiring switching to morphine. conclusions: tramadol is an effective pain control option in transplant recipients with mild to moderate pain due to oral and esophageal mucositis without progressive mucosal lesions. the pca allows achieving a very low complication rate. therefore, this option may be considered for both mac and ric recipients. disclosure: no immune reconstitution of lymphocyte subsets after allogenic stem cell transplant (sct) and vaccination background: infectious diseases are a major cause of morbidity and mortality after allogenic stem cell transplant (sct). vaccines constitute an effective strategy to prevent infections but the optimal timing to start vaccinating is not well stablished. in order to individualize the early vaccination schedule, we studied the lymphocyte subsets involved in generating enough response to produce protective serological levels. methods: we studied retrospectively patients that had undergone allogenic sct at our hospital. patient distribution -age range: - years-old; diagnosis: acute leukaemia/myelodysplastic syndrome/ chronic myeloid leukemia ( patients), lymphoma ( patients). analytic parameters: tcd +, tcd +, nk, total b and functional b lymphocyte subsets (naïve igd+cd -, memory igd+cd + and igd-cd +, and effectors cd ++cd ++). immunoglobulin levels (igg, iga, igm) and specific igg for pneumococcus, tetanus, hbv, chickenpox, measles, rubella and mumps. clinical parameters were collected from medical records. results: we distributed patients in two groups, based on the timing of lymphocyte analyses: -less than months since sct ( patients) no patient showed complete immune reconstitution, although had enough t and functional b lymphocytes to generate response to vaccination. in these patients, vaccination for pneumococcus was completed and they generated sufficient protection antibody levels, despite being under immunosuppressive treatment. -more than months since sct ( patients) before the beginning of vaccination, we collected specific antibodies of patients. we compared the serological status before and after sct and observed that protection against tetanus was the most frequently preserved ( patients) and hbv the least frequent ( patients). other than one patient treated with alemtuzumab, all patients in this group had minimum absolute count of tcd + (> cells/microl), tcd + (> cells/microl), nk (> cells/microl) and b cells (> cells/microl). we also observed presence of b effector and b memory cells, with predominance of igd-cd + memory cells. immunoglobulin levels were within the normal range. in this group, we registered vaccination in patients. all of them were vaccinated against flu, and against pneumococcus and hbv. the rest of vaccines administered were heterogeneous in type and timing. patients were under immunosuppressive treatment at the time of vaccination and were able to generate enough specific antibodies for pneumococcus. conclusions: immune reconstitution was not completed months after sct, although minimal immunological reconstitution was observed tcd + and no-switching memory b lymphocytes were the last ones to reach minimum normal values according to patient age. some patients maintain serological protection after allogenic sct. immunoglobulin levels were normal, suggesting no need for immunoglobulin administration to prevent infections. flu, pneumococcus and hbv vaccines were the most frequently administered. pneumococcus vaccination generated a much larger serological response than hbv. this seroconversion occurred in patients under immunosuppressive treatment. the analysis of lymphocyte t, nk, b total and b functional subsets could be useful when programming an early vaccination schedule after sct. completion of the vaccination schedule was heterogeneous despite giving specific indications. therefore a more rigorous supervision of the process may be required. background: the significant advances that have been achieved in the allogeneic transplantation (allohct) field, have resulted in better post-transplant outcome and therefore complications other than the graft vs. host disease (gvhd) or disease recurrence become increasingly important. the post transplant metabolic syndrome (pt-ms), which caused by several factors (i.e. immunosuppressive agents, chemo-radiotherapy, anti-viral, and biologic therapies) is a well known post transplant complication in pediatric allografted long-term survivors however, only few studies have evaluated the prevalence of the pt-ms in adults. in this retrospective study, we sought to evaluate the incidence, the risk factors and the impact of the pt-ms on the allosct outcome. methods: since , patients ( males and females) with adequate clinical and laboratory data and a minimum follow-up of months were included in the study. their median age was . ( - ) years and after a myeloablative (n= ) or a reduced intensity (n= ) regimen they received either mobilized peripheral blood stem cells (n= ) or marrow graft (n= ), originated from full-matched siblings (n= ) or haploidentical donors (n= ). calcineurin inhibitors plus either short-term methotrexate or mycophenolate mofetil were given as gvhd prophylaxis. the diagnosis of pt-ms was based on the ncep-atpiii criteria; for patients with unknown data for abdominal circumference the body mass index (bmi) ≥ kg/m was consider as a criterion for pt-ms diagnosis. the independent t-test, logistic regression analysis and logrank tests were used for the statistical analysis. results: twenty ( . %) patients ( males, females) assessed to have pt-ms within the first months following the allograft. seventeen diagnosed after the st trimester post allosct and additional patients after nd trimester. sixteen out of patients had elevated glucose and bmi> kg/m , / elevated triglycerides levels, / low hdl levels and / hypertension. four ( %) had already known history of ms before allosct (for patients no data were available for ms diagnosis before allosct). interestingly, for / ( %) patients who had diagnosed with pt-ms either in the st or in the nd trimester the syndrome was reversible and did not fulfill the criteria for pt-ms beyond months post allosct. patients' gender, age, bmi, the type of conditioning regimen and gvhd co-existence evaluated as potential predisposing factors for pt-ms diagnosis. in univariate and multivariate analysis only the: bmi> kg/m and age> years were detected as significant risk factors (p< . ). the pt-ms did not affected negatively the survival or the nrm incidence post allosct conclusions: in our study, in agreement with other publications, we demonstrated that the pt-ms is not an uncommon complication post in the early post transplant period however, for a significant number of patients the syndrome was a reversible. for patients with high risk features (bmi> kg/m , age> years, known history of diabetes-mellitus, dyslipidemia, hypertension) apart of close monitoring, specific diet and encouragement for adequate exercise might help to reduce the incidence and the severity of pt-ms. nevertheless, prospective and well design trials are warranted to determine the accurate incidence, severity and the impact of pt-ms on the allosct outcome. disclosure: no conflict ofinterest experience of a single center in the humanization of the hospitalization process: technology and team training impact on the qol of the patient and family maria claudia moreira , marcia rejane , marcia garnica , andrea ribeiro , paulo cesar dias , ilza fellows background: hematopoietic stem cell transplantation (hsct) is one of the most aggressive therapeutic modalities of internal medicine, making it a highly stressful experience for the patient and his family. the duration of hospitalization can be prolonged by several intercurrences, frequently generating anxiety in the patient and their caregiver, which may lead to confinement and reactive depression. interventions in the hospital environment, in addition to the continuous training of the multidisciplinary team, can have a positive impact in this process with improvement in the process of discharge and quality of life of the patient and his / her family. methods: the objective of this research was to evaluate the impact of a reformulation in the unit, completed in may , which modified the facilities with availability of hermetic balconies in each room, with a view of an internal garden. there was also the addition of a screen in the corridor of the floor with images -technology known as videoowall, interconnected to motion sensors (kinects) that allow interaction between patients and families, besides facilitating physiotherapy and physical exercise. there was re-training of the multidisciplinary team with emphasis on the practice of humanization. the methodology consisted in the application of questionnaires of satisfaction to patients and their families during the period of hospitalization in a bone marrow transplant unit in the third quarter of . the items evaluated ranged from the quality of the information provided by the medical team and nursing, to the cordiality and agility with which the patient and his patient were treated by the global team. the results were compared with a similar period of the same unit in the previous year and with the indices collected simultaneously in another unit of the same hospital (cardio-intensive). results: overall and segmental satisfaction scores in the various items surveyed were higher when compared to the previous period of the same unit and were also higher in those obtained in a high complexity unit of the same hospital, composed of patients submitted to mental and psychological stress similar to onco-hematologicos.a reports of "free speech" were also obtained anonymously, in order to guarantee the authenticity and free expression of the subjects analyzed. conclusions: the results obtained allowed the validation of the technical and professional team initiatives, bringing indicators that will allow better monitoring and support of these patients and their relatives in this difficult time of treatment. they served as an initial tool in the continuous process of humanization and stimulated the multidisciplinary team to continuously improve this process. disclosure background: pure red cell anemia (prca) is a rare complication of abo-incopatible hematopoetic stem cell transplantation characterized by anemia, reticulocytopenia and absence of erythroid precursors in patient's bone marrow. most patients with prca resolve spontaneously within months, however a small number of patients requires continued red blood cell (rbc) transfusions. the treatment of this complication is difficult and not standardized. different approaches has been used such as rituximab, donor lymphocytes, plasma exchange with different outcome. recently, a remarkable response to treatment with bortezomib has been described in a case of prca. methods: we reviewed patients who received an allogeneic hematopoetic stem cell transplant (hct) between januar and august at our institution. sixty eight patients received a major abo-mismached hct. prca was defined as a completely absence of erythroid precursors on day + bone marrow puncture, with absence of donor red cells and the recipient requiring rbc transfusion. results: only one patient developed prca ( . %). a years old male received a myeloablative hla-matched abomismatched sibling donor transplant (brother, years) for acute myeloid leukemia (aml), with t( ; ) cr ,mrd positive (runx -runx t ). the donor was blood type a rh positive and the patient rh positive. the patient had no complication after transplant. the day + bone marrow puncture has shown only few erythroid precursors and day + puncture and biopsy no erythroid precursors, he had transfusion dependent anemia requiring a rbc transfusion every two weeks and retukulocytopenia. parvo virus and cytomegalovirus were negative. due to very high ferritin level (> . u/l) and increased luiver enzymes without signs of gvhd, the treatment with deferasirox has been started. the patient has achived cr , mrd negative, and has evidence of complete chimerism. high titers of anti-a and anti-b issohemagglutinin was present.we started the treatment with rituximab mg/m weekly, weeks, however without response. the pathogenesis of the prca is thought to be due to the recipients plasma cells, bortezomib, a proteasome inhibitor inducing apoptosis of plasma cells has been given s. c. , mg/m two times weekly, for two weeks. the patient responded to the treatment two weeks later with increase in hb, which was , g/dl and increase in retikulocyte number. the patient has continued to be well at the last control. conclusions: prca aplasia is a rare but serious complication after abo-incompatible hct. bortezomib is an effective treatment for this complication if mediated by residual host isohemeagglutinins after hct and should be recommended as standard of care. clinical methods: this work is retrospective, observational, cross-sectional and analytical. it included all patients who received hsct at stem cell transplantation unit (utmo, by its spanish acronym) at solca-guayaquil, between the years - .we use the kaplan-meier method to analyze the survival rate between the autologous and allogeneic transplant. the information collected for this study was obtained from the database of the solcay institute and the review of the files of the patients included. results: at least, patients have been undergoing to hsct between - years. according to the type of hsct, . % received an autologous transplant and . % received an allogeneic transplant, from which . % were from a related donor. the main source of transplant was peripheral blood in . %, followed by % obtained from umbilical cord blood and . % by bone marrow aspiration. the most frequently reported pathologies were acute lymphoblastic leukemia (all) ( %), multiple myeloma (mm) ( %) and acute myeloid leukemia (aml) ( . %). the overall survival was % (ic: %). the . % of patients that were undergoing to autologous transplant have survive, meanwhile the patients that were undergoing allogeneic transplant only the . % have survived (p< . ). the highest death rate occurred during the first year after hsct, and decreased considerably after that period. the main cause of mortality related to transplant (mrt) was the graft-versus-host disease (gvhd) ( %); however, the main cause of mortality in the study population (n= ) was relapse in . % of the patients, presented more frequently in all. conclusions: the results showed that % of patients undergoing to hsct have survived. a high rate of deceased patients in this study, have died in the first year before the transplant ( . %%), due to relapse. the main cause of deceased in the study is not related to hsct, and was the relapse in % of patients, in compare the gvhd was the main cause of mrt ( %). we consider that hsct is a technique that is still under development in ecuador, but despite the short time it has been taking and the institutional and medical limitations present in the health field, has presented excellent results comparable to studies conducted in developed countries. [ background: pigmented epithelioid melanocytoma (pem, early known as 'Аnimal type' melanoma) is a rare tumor with unpredictable clinical behavior and metastatic potential. pem generally has favorable prognosis. involvement of regional lymph nodes is not rare. extranodal and distant nodal metastases are extremely rare. we report about patient with fanconi anemia (fa) and pem with developed distant metastases in the early term after allogeneic hematopoietic stem cell transplantation (hsct). methods: -years old boy with fa was hospitalized for hsct. the blue-black painless nodulus х mm was noted on the left cheek. this lesion was observed from early childhood and during life only slightly increased in size. there were no distant and regional metastases on computerized tomography (ct) and scintigraphy with m tc. the nodulus and regional lymph nodes were radically removed before hsct. the resection margin was within the normal tissue. microscopically the derma and subcutaneous fat were infiltrated with epithelioid and spindle cells with total expression of s , melana, mhb , cyclind . ki- expression level was - %. histological structure was specific for pem. hsct with tcrαβ+/cd + graft depletion from match unrelated donor was performed. the conditioning regimen included total lymphoid irradiation gy, fludarabin mg/ m , cyclophosphamide mg/kg, rabbit atg mg/kg and rituximab mg/m . results: at + day after hsct was detected the tumor on the left cheek and parotid region with a histological structure identical to the primary lesion. on ct in s segment of the left lung was detected focus x mm with a cavity. invasive aspergillosis was suspected and empirical antifungal treatment was started. but in days the lung lesion increased in size to x x mm and penetrated in the bronchus. after bronchoscopy with biopsy, pem metastasis was histologically confirmed. moreover, the tumor on the face continued to grow. therapy with cobimetinib and vemurafenib was not effective and patient died from progression of pem on + day after hsct. conclusions: pem was early described as indolent tumor with rare distant metastasis and favorable prognosis. we suspect that pem may acquire an aggressive course in the absence of immunological control, especially in high immunocompromised patients after hsct. disclosure: nothing to declare p abstract withdrawn lidia gartcheva , antoaneta mihova , penka ganeva , margarita guenova , branimir spassov background: the main objective of the study is to assess the dynamics of quantitative and qualitative changes in the parameters of the b cell population and the production of immunoglobulins in patients after autologous transplantation of hematopoietic stem cells in the course of recovery of the immune system. methods: patients with hematological neoplasms undergoing autologous transplantation were included in the study: women and men, with an average age of years. patients were diagnosed with lymphoma (n = ), multiple myeloma (n= ), leukemia (n = ) and solid tumors (n = ). at the time of transplantation, patients were in complete clinical remission or at least with very good partial response, patients were in partial remission and patients -with progression. all patients were evaluated in nine time points through examinations by clinical-laboratory, flow cytometric and immunochemical methods. results: the percentage of cd (+) b cells reached the minimum values one month after transplantation then began to increase in the second month reaching a plateau around the mean values in the period - months after transplantation. the absolute number remained low during the entire period of observation. the amounts of igg and igm serum immunoglobulins gradually increased within the reference range throughout the entire period, while the iga level varied around the lower reference range. conclusions: implementation of an adequate humoral immune response is hampered by the reduction of circulating b cells, suppressed proliferative potential and functional deficits. restoration of b-cell function occurs over a period of months to years after autologous transplantation. clinical trial registry: no clinical trials disclosure: nothing to declare justyna background: allogeneic hematopoietic stem cells transplantation (allo-hsct) is a life-saving and well established therapy for wide range of diseases. however, it is still uncommon treatment for infants less than months of age. the data about indications and outcome of allo-hsct in the youngest group of patients is sparse. the primary objective of this study was to assess the incidence, indications, post-hsct complications and general outcome of allo-hsct among infants not older than months. latter sequelae of hsct such as physical and cognitive development were secondary aim of this study. methods: we retrospectively analyzed data of patients who underwent allo-hsct before year of age in department of pediatric hematology, oncology and bone marrow transplantation in wrocław during years - . clinical and epidemiological features as well as indications for transplantation, early and late complications and general outcome were assessed. results: infants who underwent hsct in our department comprise . % of all patients undergoing hsct in analyzed period of time. thirty-one ( . %) patients received stem cells from matched unrelated donor (mud), ( . %) from mismatched (haploidentical) related donor (mmrd) and ( . %) from a sibling donor (msd). non-malignant disorders were indication for transplant in ( . %) patients and malignant diseases in ( . %) . acute graft versus host disease (agvhd) occurred in ( %) infants, chronic graft versus host disease (cgvhd) in ( %). majority of graft rejections were seen in infants transplanted from mmrd ( . %), whereas the rest ( . %) was associated with mud. median follow-up in study cohort was days, days for alive patients (range days- . yrs) and days for those deceased (range days- days). overall survival (os) in study cohort was . and transplant related mortality (trm) was . . in children with malignancy ( . %) patients died comparing to ( . %) patients in non-malignant group respectively. main cause of death in analyzed group of infants was infection ( %). conclusions: . allo-hsct is rarely performed in children less than months of age. . majority of those patients receive stem cells due to non-malignant disorder. . among youngest hsct recipients, haploidentical transplant are more common than in general pediatric transplant population. . graft rejection is a significant problem in infants transplanted from mmrd. disclosure: nothing to declare unusual non-infectious lung complication after allogeneic haematopoietic stem cell transplantation claudia lucia sossa melo , , manuel rosales , francisco fernando naranjo junoy , , sara inés jiménez , , luis antonio salazar , , angela maría peña , , maría angélica chacón manosalva , maria luna-gonzález , claudia marcela chalela , manuel ardila-báez jirovecii infections, viral infections or nocardia. we describe the case of a patient with acute lymphoblastic leukemia (all) diagnosis with pap associated to a hsct and pulmonary pneumocystis. methods: a -year-old colombian female patient diagnosed with b-precursor all of high-risk in january , positive philadelphia chromosome, positive bcr / abl in february , infiltration to the central nervous system (cns), . % of lymphoblasts, and karyotype without legible metaphases. refractory to induction according to the pethema protocol (vincristine, daunorubicin, prednisone, l-asparaginase) with presence of . % blasts at the end of the induction. re-induction was performed with the flag-ida protocol (idarubicin, fludarabine, cytarabine) achieving complete remission, obtaining minimum residual disease (mrd) < . . dasatinib was initiated by bcr / abl expression and cns involvement at the time of diagnosis. an allogeneic hsct was performed, from a male brother donor, with low intensity conditioning tt buflu and prophylaxis of graft-versus-host disease (gvhd) with tacrolimus and sirolimus. patient showed early posttransplant complications, given the reactivation of cytomegalovirus and hemorrhagic cystitis grade i due to adenovirus. late complications such us gvhd at the cutaneous level and subsequent hepatic and gastrointestinal involvement were seen too, for which immunosuppressive therapy was administered with high doses of systemic corticosteroid. results: patient was hospitalized on day + posttransplantation due to febrile neutropenia and respiratory symptoms, with normal chest ct, and ct of paranasal sinuses with acute pansinusitis, for which she received meropenem gr intravenously every hours plus vancomycin gr intravenously every hours during days with symptom resolution. she remained hospitalized for cytopenias with normal bone marrow and % chimerism. on day + posttransplant she presented fever and leukocytosis, with acute respiratory failure with chest ct that showed bilateral alveolar occupation, "crazy-paving" pattern and frosted glass (see image), so diagnostic fibro-bronchoscopy was performed, reporting postoperatively for pneumocystis jirovecii. she received days of trimethoprim-sulfamethoxazole, with a torpid evolution requiring mechanical ventilation and tracheostomy, persisting with hypoxemia. the report of cultures for fungi, mycobacteria, and respiratory panel of filmarray were negative. a pathology report was obtained with % neutrophils, as well as pas staining with acellular pink material and elevated serum ldh, with a diagnosis of secondary pap. the patient continued with poor general condition, refractory hypoxemia, high ventilatory parameters and hemodynamic instability, due to which she was not able to be a candidate for treatment with total pulmonary lavage; leading to multi-organ failure and later death. [[p image] . high resolution chest ct. sample opacification in frosted glass (a) and pattern ''crazypaving'' (b)] conclusions: the importance of considering the diagnosis of pap as a noninfectious pulmonary complication in patients with allogenic hsct despite its low incidence is recognized. disclosure: nothing to declare methods: once the project was approved by the clinical trials and ethics committee, pairs of blood samples were drawn ( from picc line and from venepuncture) from voluntary allo-hsct recipients who were receiving continuous infusion tacrolimus from february through august . the pts had inserted a double-lumen polyurethane picc. tacrolimus was always administered through the red line, and the blood draw always performed through the purple line. all of the patients signed the informed consent. were male and women. median age was years ( - ). of the venepunctures were carried out in the arm where the picc was set, and the other from the contralateral arm. a limited group of nurses performed the extractions of the samples. results: as shown in the table, tacrolimus trough levels determined in blood from venepuncture were similar to those in blood drawn through the picc (median: . vs . ng/ml). when comparing one by one in the individual patients, the differences were not significant, and changed the dosing prescription in no cases. conclusions: in our experience, there are not significant differences in tacrolimus levels draw from the picc line, compared with a peripheral site. so, in our opinion, if the line for tacrolimus infusion is properly identified and the one used for the sample draw is the alternative one, venepunctures to obtain sample from peripheral sites are not justified for tacrolimus levels measurements. background: patients undergoing a hsct may require icu admission due to transplant-related toxicities. the aim of this study was to analyse a single centre experience with hsct patients requiring icu admission and the factors affecting outcome. methods: we included all adult patients (age >= ) who had an allogeneic or autologous hsct during (d between - - to - - ) at st. george's hospital. data was retrospectively collected from patients' notes. icu outcome and -day survival were analysed. for those patients who were admitted to icu more than once, outcome was analysed from their last icu admission. results: allograft patients were included. were male, with a median age years (range - years). were female, with median age years (range - years). diagnosis n (%) includes all ( %), aml ( %), acml ( %), cmml ( %), hl ( %), mds ( %), mds/mpn ( %), fl ( %), scd ( %). sixteen ( %) patients received their first transplant, ( %) received second transplant. eight ( %) patients had sibling donor, patients ( %) had unrelated donor. sixteen ( %) patients had / matched donor, ( %) patients had / matched donor, ( %) patients had / matched donor. nineteen ( %) received reduced intensity conditioning (ric), one ( %) received myeloablative (ma) conditioning. majority of ric allo-hsct patients were conditioned with fludarabine, mephalan, campath (fmc). a small number were conditioned with busulfan, fludarabine and atg. the ma allo-hsct patient was conditioned with tbi, cyclophosphamide. gvhd prophylaxis was ciclosporin alone starting on day - with a target level of - ug/l for all ric and ciclosporin and methotrexate for the ma patients. two ( %) allograft patients were admitted to icu on three occasions. both patients were male, and years old. one had mmud allograft for mds/mpn. the other had nd mud allograft for relapsed aml. the reasons for icu admission include sepsis, cardiac arrest and respiratory failure. the median duration of icu admission was days (range - ). there were deaths within days of transplant. one patient died on day + during his second icu admission with multi organ failure (mof). one patient died after icu discharge on day + with relapsed disease, bronchopneumonia with disseminated fungal infection. icu mortality rate was %, and -day mortality rate was %. nineteen autologous patients were included (median age (range - years)), ( %) were myeloma patients who were conditioned with melphalan, ( %) were lymphoma patients who were conditioned with beam. the icu admission was %. the -day mortality rate was %. conclusions: our centre's icu admission rate, icu mortality rate, cause of icu admission in allo-hsct patients and autologous patients is comparable to literature reports. autologous transplant is safe with no deaths and icu admissions despite an older age. the mortality rate for allo-hsct patients requiring icu admission remain high. all patients were appropriately referred to icu and there was no one who was denied icu admission. this analysis is being extended to preceding years. disclosure: nothing to declare liposomal doxorubicin for the treatment of iatrogenic kaposi sarcoma following hematopoietic stem cell transplantation background: iatrogenic kaposi's sarcoma (iks) represent a rare complication after hematopoietic stem cell transplantation (hsct), related to hhv- infection in hivnegative immunocompromised patients (pts). methods: we describe a case of iks occurred after an allogeneic hsct and we provide a review of the literature using pub med. results: a -year-old man, hiv-negative, received full hla-matched related hsct after a reduced intensity conditioning regimen for relapsed aml. gvhd prophylaxis was based on atg (fresenius mg/kg), cyclosporine (cya) and methotrexate. no severe complication occurred in the first days after transplant. shortly after cya withdrawal, he developed grade i acute gvhd. gvhd resolved after restarting cya. at fifth month after transplant, the patient developed several red and purple angiomatous plaque and nodules involving the skin of both lower limbs, right arm and the nose (figure ). skin biopsy revealed multiple localizations of iks and positive hhv- viremia was detected in the peripheral blood. a visceral involvement was excluded. patient was treated with cya tapering and nine courses of liposomal doxorubicin mg/m every days, obtaining a negativity of hhv- viremia and partial response of the skin lesions. at last follow up, at months after transplant, the patient was in complete remission (cr) for aml, cya-free without signs of gvhd recurrence and with his single stable residual iks lesion on his left limb, currently waiting for local radiotherapy. we found additional iks published cases after hsct. most of post-hsct iks were secondary to an allogeneic-hsct ( out of , . %) and occurred in adult ( , %) and male ( , %) pts. median age at the time of iks diagnosis was . years (range - ). thirteen pts ( . %) had mediterranean origin. the most frequent underlying disease was aml ( . %). gvhd prophylaxis was primary based on calcineurin inhibitor. half of the pts developed gvhd and were treated with steroid and other immune suppressive drugs. median time between the hsct and the occurrence of iks was . months (range . cutaneous iks was the prevalent form of manifestation, however visceral involvement was reported in pts ( . %). in four cases ( . %) an hhv- associated bm failure was report. immune suppression drugs tapering ( . %) and chemotherapy ( . %) were the most frequent actions taken after the diagnosis of iks. in most cases, liposomal doxorubicin was used as chemotherapy. cr rate was high, . %, whereas progression disease occurred in out pts ( . %), all of which had visceral involvement. in pts ( . %), iks was the cause of death. conclusions: withdrawn of immune suppression drugs and anthracycline based chemotherapy can represent a feasible treatment option for pts with iks after hsct. clinical background: acquired haemophilia a (aha) is an autoimmune disease caused by the spontaneous production of neutralizing immunoglobulin g (igg) autoantibodies (inhibitors) targeting endogenous fviii. treatment of these inhibitors presents additional challenges in a hematopoietic stem cell transplantation (hsct) recipient, because preservation of the graft that restores a normal hematopoiesis is critical. here we describe the management of a case of aha in an acute myeloid leukemia patient following hsct. methods: the clinical, laboratory and molecular aspects of a -year-old italian male who developed aha after allogenic bone marrow transplantation were collected and presented in order to show how we diagnose and manage this severe but rare complication within the special setting of hsct. results: a -years-old man with a flt- itd, npm- , runx -runx t and cbfb-myh negative, not differentiated, chromosomally normal acute myeloid leukemia (aml) in third complete remission (cr) was submitted to a hematopoietic stem cell transplantation (hsct) from his haploidentical son. the conditioning regimen consisted of oncothiotepa, busulfan and fludarabine and was followed by the infusion of a t-cell depleted bone marrow graft. gvhd prophylaxis consisted of cyclosporine a (csa) and mycophenolate mophetyl (mmf). neutrophil engraftment occurred on day + . recipient's autoimmunity was negative. at months post-transplantation the patient received an antipneumococcal vaccination. fifteen days post-vaccination the patient was admitted to our in-patient ward due to general malaise, diffuse muscle and joint pains, cutaneous bleedings, oedemas, hyperchromic urines and constipation. physical examination revealed diffuse ecchymosis, swelling of deep muscles with a progressive functional disability due to hematomas and hemorrhagic suffusions of the tongue frenulum. and anti-factor viii inhibitors . bu/ml (high titers > bu/ml). thus, a diagnosis of acquired autoimmune haemophilia a was made and treatment with feiba combined with prednisone was started. patient's clinical conditions dramatically improved as he referred an improvement of movements and the resolution of joint and muscle pains despite the persistence of deep hematomas just after one day of treatment that had determined an increase of fviii:c value to . % and an improvement of aptt to . seconds. on the following medical checks physical examination showed the progressive disappearance of deep muscle hematomas, and normal values of fviii:c. conclusions: aha is a rare but severe complication following hsct and it could appear years afterengraftment. a prompt diagnosis and an early treatment with feiba and corticosteroid are necessary to avoid life-threatening sequelae. the inclusion of the coagulation panel in the laboratory exams performed during the follow-up is advisable in order to early detect this life-threatening complication. disclosure: nothing to declare background: splanchnic thrombosis is an uncommon complication of myelofibrosis and a controindication to proceed to hematopoietic stem cell transplantation (hsct) due to the risk of additional vascular and endothelial complications. we present a patient with myelofibrosis (mf) that proceeded to hsct from an unrelated donor, despite splanchnic thrombosis unresolved after heparin treatment and unable to proceed to surgical treatment due to severe thrombocytemia. methods: a -year woman with mf secondary to essential thrombocythemia, with intermediate- score according dynamic international prognostic staging system (dipss) and with extreme splenomegaly (maximum diameter cm), refractory to ruxolitinib, showed an extensive thrombosis of the portal and splenic veins, unresolved after -week heparin therapy, at the time of availability of an hla ( / ) and abo matched unrelated donor. she received a conditioning regimen including fludarabine and thiotepa and a gvhd prophylaxis with atg thymoglobuline, cyclosporine and methotrexate, followed by the reinfusion of . x /kg cd + pbsc. at the time of transplant we were aware of an high risk of developing sos, on the basis of the older age of the recipient, the unrelated donor, the advanced stage of myelofibrosis and the ferritin serum level of . ng/mg. results: on day + after hsct sos complicated the aplasia phase, characterized by jaundice, ascites, weight gain, progressive increase in creatinine and bilirubin serum levels. an ultrasound of abdomen confirmed an unchanged thrombosis extension and the development of ascites. on day + the patient was categorized as very severe sos stage, according to ebmt severity criteria, because of doubling of bilirubin serum level in hours and a % increase in comparison with her baseline weight. therefore, defibrotide was promptly started in association with diuretic therapy. the treatment was continued for weeks and allowed gradual restoration of the water balance and normalization of bilirubin serum level. at the last follow-up, months after hsct, the patient shows the persistence of a non-transfusion dependent anemia, platelets . x ^ /ul, palpable spleen cm below the rib, > % allogeneic chimerism in the granulocytic compartment and % in the t lymphocyte compartment. splanchnic thrombosis is partially recanalized and replaced by collateral circles with cavernous aspects. the patient is on treatment with fondaparinux and has shown neither significant infectious episodes or acute or chronic gvhd. conclusions: we conclude that defibrotide treatment allowed to perform a successfull allogeneic transplant in a patient with mf associated with an overt picture of splanchnic thrombosis. background: hematopoietic stem cell transplantation (hsct) is associated with an increased incidence of secondary malignancies including skin cancer. squamous cell carcinoma (scc) is the most common type in patients who are receiving immunosuppressive therapy and chronic graft-versus-host disease (cgvhd) appears to be an important risk factor for its development. recent studies describe voriconazole exposure as an independent factor that may contribute to this increased risk as well. in our best knowledge, no cases of scc have been reported in pediatric allogeneic hsct to date. methods: we present a case report of a year-old boy who developed a scc with high-risk features six years after undergoing hematopopoietic stem cell transplant. results: a year-old boy with acute lymphoblastic leukemia (all) underwent a matched unrelated bone marrow transplant years ago. he developed grade iv agvhd followed by extensive cgvhd with generalized scleroderma. he required intensive and continued immunosuppressive therapy and was on prolonged antifungal prophylaxis with voriconazole. in march , he developed scc involving left temporal region that was completely excised. two months later, more lesions in scalp and nose were noted and intralesion treatment with methotrexate was started. however, an unfavorable evolution was noted and he was put on systemic treatment including cisplatin and cetuximab receiving the whole scheme from january to march and continuing only with cetuximab, ten doses in total, until may, for unaceptable and severe tubulopathy that required admission at the hospital in several ocassions. he achieved a very good partial response but progression was noted shortly in follow up. at this point, non curative therapeutic options were found and he was put on intralesion methotrexate and photodynamic theraphy in a weekly basis with palliative intention. unfortunately, tumor growth was fast and patient passed away in august , fifteen months after squamous cell carcinoma diagnosis, due to tumoral progression. conclusions: ) scc is a rare, non-previously described, secondary malignancy in children undergoing hsct. ) high-risk features scc constitutes an aggresive disease with a median overall survival below year. ) cgvhd appears to be an important risk factor for its development. ) voriconazole induced-photosensitivity might have played a role. ) cisplatin based regimens +/-cetuximab are a therapeutic option in disseminated and/or high risk cases. as outcomes are unsatisfactory in these cases, alternative therapeutic options need to be explored. disclosure background: pregnancy is a rare event after allogeneic stem cell transplantation (sct) for acute leukemia. here we report, to the best of our knowledge, for the first time on a successful pregnancy after treosulfan-based conditioning. methods: a -year old woman was diagnosed with acute myeloid leukemia (aml) secondary to chronic myelomonocytic leukemia in july . ovarian preservation was performed by leuprolide acetate depot injection prior to cytostatic chemotherapy. of note, no cryopreservation of oocytes or ovarian tissue was conducted. she received two cycles of chemotherapy consisting of idarubicine ( mg/m² on day - ) and cytarabine ( mg/m² b.i.d. on days , , and ). due to secondary origin of aml sct was performed in first complete remission of aml after conditioning with treosulfan ( g/ m² days - ) and fludarabine ( mg/m² days - ). she received . × cd -positive cells per kilogram body weight from a hla-matched unrelated donor. results: follow-up bone marrow aspirates showed continuous complete remission of aml. seven months after sct she became pregnant, but decided for induced abortion. in january , months after hsct she became pregnant again and desired the child. medical examinations were performed monthly on an outpatient basis in stringent cooperation with the maternity clinic. the course of pregnancy was unremarkable, although she was hospitalized due to premature labor in the th week of pregnancy. however, gynecological examination showed no clinical significant findings, so that section was planned and she could be discharged again. in the th week of pregnancy she gave birth to a healthy girl ( cm, g) by cesarean section. peripartum she developed hypoethesia of the left body half. neurological examination showed no abnormalities and she recovered immediately. there were no other postpartum complications. breastfeeding was established but additional food was necessary for a sufficient nutrition of the child. conclusions: this case of successful pregnancy following sct demonstrates that fertility can recover after treosulfan-based conditioning. however, detailed studies of ovarian function and fertility are necessary to gain more insight into the risk of premature ovarian failure. disclosure: nothing to declare. experimental stem cell transplantation p cd -cart therapy before allo-hsct in children and adolescents patients who diagnosed r/r b-all with e a-pbx background: b-all with e a-pbx in children and adolescents is described with favourable prognosis. but there are more than % patients with e a-pbx diagnosed as relapsed or refractory. the results of allo-hsct in children and adolescents with this group leukemia in our center was analyzed in order to understand the therapeutic effect of cd -cart on the patients. methods: retrospective analysis, from june st, to july , , all children and adolescents diagnosed relapse or refractory b-all with e a-pbx who received allo-hsct, total cases. all patients was divided into two groups depending on whether or not accepted cd -cart before allo-hsct. according to fcm-mrd and e a-pbx level before allo-hsct, os lfs and cumulative recurrence rate were analyzed. r . . was used as statistical analysis software. results conclusions: . for r/r b-all with e a-pbx in children and adolescents, fcm-mrd pre-transplant hasn't obvious effect on the outcome of allo-hsct, while the level of e a-pbx has obvious effect. the out come of e a-pbx negative group was obviously better than positive group. . cd -cart can obviously improve the os and lfs, it is mainly because of cd -cart can makes more patients fusion to zero. . for r/r b-all with e a-pbx in children and adolescents, if chemotherapy can't make the fusion to zero. it is suggested to accept cd -cart therapy to make the fusion zero. it can improve the outcome of os and lfs. disclosure background: currently, hematopoietic stem cell transplantation (hsct) represents the only curative treatment for numerous hematopoietic malignancies like leukemias, immune deficiencies or metabolic diseases. cd serves a quality marker for stem cell grafts, which is not solely expressed on stem cells but also on a variety of progenitors. the role and the impact of these subpopulations remains unknown. we made use of our genetic barcode system to analyze the influence and contribution during reconstitution on a clonal level. methods: fluorescence activated cell sorting (facs) was used to sort hematopoietic stem and progenitor populations, namely hscs, mpps, cmps and clps, which were lentivirally transduced with our previously established bc barcoding system. after mixing the marked cells with bone marrow support, lethally irradiated recipient animals were and transplanted and monitored over weeks. we focused on bone marrow, blood, spleen and thymus, on chosen endpoints ( w, w, w, w) and samples were used to analyze the contribution of the subpopulations during the reconstitution process based on fluorescent protein (fp) expression. to investigate the clonal contribution in different organs, we performed next generation sequencing (ngs) and frequencies of unique barcodes in a sample were analyzed by bioinformatical approaches. results: a maximum of % of cells expressed the encoded fps, which were mostly derived from the hscs and mpps. cmp-derived cells were only detected week after transplantation in the myeloid compartment. cells derived from the clps were not detected at any time point. we analyzed the barcode content of the differently marked cells after next-generation-sequencing. in accordance with the facs data, the majority of the clones during the weeks of observation are derived from hscs and mpps. cmp-derived clones were only contributing during the first weeks and clp-derived clones are barely detectable. we did not observe any major differences with regard to age of donor or recipient, despite the total number of clones is higher in the group, which received the "aged" graft, independently from the transduced cell population. conclusions: here we show the suitability of our highly complex multi-color barcode system to study the clonal contribution of hscs and three progenitor populations after hsct. our results will contribute to a better understanding how these different populations interact to support the establishment of a new hematopoietic system. emphasized by the variability in data of graft and recipient age, this comprehensive analysis gives rise to an impression to the necessity of personalized graft composition, by which treatment success could be influenced. disclosure: nothing to declare survival and fate of adipose derived mesenchymal stem cells in a rat brain injury model background: mesenchymal stem cells have been identified as promising candidates in the treatment of central nervous system (cns) injury through neurotrophic support and immunomodulation. adipose tissue is an attractive source of mesenchymal stromal/stem cells (ascs) for regenerative therapeutic applications because they can be harvested from autologous donors with minimally invasive methods, can be rapidly expanded ex vivo, show low immunogenicity if allogeneic, and can be used in autologous or heterologous settings. the present study examines the fate and effects of intracerebroventricularly (icv) transplanted ascs in a traumatic brain injury (tbi) model. methods: ascs were isolated from inguinal fat pad of adult wistar rats under sterile conditions and cultured according to standard procedures. ascs at passage ( x cells) were seeded and transfected with sleeping beauty transposase and pt venus-neo r plasmids. selection with g antibiotic resulted in the generation of a homogeneous asc population which expressed fluorescent venus protein for several passages, phenotypic characterization showed that these cells were . % double positive for cd and cd stem cell markers, verifying their mesenchymal origin. tbi was induced by stereotactic surgery under deep anaesthesia and subsequently icv transplantation of venus+ ascs was performed on adult wistar rats. normal ascs-transplanted and tbi-saline transplanted rats were used as controls. the proliferation, migration, survival and fate of transplanted ascs and their effect on injury restoration were examined six weeks post transplantation (pt). results: six weeks pt ascs expressed the fluorescence venus protein and therefore were identified in brain parenchyma. their presence into brain was also confirmed by masson trichrome staining, which revealed their collagen depositions. ascs were found in lesser numbers compared to those transplanted and exhibited no proliferative activity. ascs were found scattered distributed in brain as individual cells, and there were no aggregates of ascs or mass formation into lateral ventricles. extensive migration of ascs was mainly performed through white matter tracks in the corpus callosum and fimbria of hippocampus. six weeks pt ascs retained the characteristics of mesenchymal cells and did not differentiate into cells of neural lineage. ascs exhibited limited long-term survival, which is restricted in perivascular areas probably contributing to vascular formation. homing of ascs into peri-injured area was detected in half of the animals and achieved through the corpus callosum, as revealed by the collagen depositions, in this white matter track. transplanted ascs reduced the area of tbi cavity and did not enhance the astroglial scarring in peri-injured area. in tbi +ascs transplanted animals, the cortical injury site, showed a significantly smaller volume and lower % tissue loss compared to that of tbi+vehicle animals ( . ± . mm and . ± . % respectively, versus . ± . mm and . ± . %, p= . and p= . respectively). conclusions: considering the effects of ascs on inflammation and regeneration, we suggest that their transplantation after brain injury may promote host brain repair mechanisms. ascs transplantation may be beneficial in tbi, however some of its effects need careful and indepth evaluation. disclosure: nothing to declare xie-na cao , yuan kong , zhong-shi lyu , , qi wen , min-min shi , , qian-yu sun , yu-hong chen , yu wang , lan-ping xu , xiao-hui zhang , xiao-jun huang , background: poor graft function (pgf) remains a serious complication after allogeneic hematopoietic stem cell transplantation (allo-hsct). our previous work reported that abnormal bone marrow (bm) endothelial cells (ecs) were involved in the pathogenesis of pgf patients after allo-hsct (bbmt ; bmt ; blood ), but the explicit mechanism requires further clarification. autophagy is a self-degradative process responsible for the elimination of cytosolic components including proteins and damaged organelles. recent findings demonstrated that stimulation of autophagy could reduce oxidative status and angiogenic potential in ecsafter high-glucose exposure, from diabetic patients.however, little is known regarding the autophagy of bm ecs in pgf patients. therefore, the current study was performed to evaluate whether autophagy in bm ecs play a role in the pathogenesis of pgf. moreover, to investigate the effects of autophagic regulation on ecs and thereby regulating hematopoietic stem cell (hscs). methods: in the prospective case-control study, the autophagy levels were compared in bm ecs from pgf patients, and their matched good graft function (ggf) patients.the expression levels of autophagy-related markers (lc , beclin , and p ), and intracellular autophagosomes were detected by immunohistochemical staining, flow cytometry, western blot and transmission electron microscopy. subsequently, rapamycin (the autophagy activators) or hydroxychloroquine (hcq, the autophagy inhibitor) were administrated tothe -day cultivated bm ecs and human umbilical vein endothelial cells (huvecs), respectively.the autophagic vacuoleswere detected by monodansylcadaverine (mdc) staining assay. the bm ecsand huvecs were evaluated by cell counting, dii-ac-ldl and fitc-lectin-uea- double staining, migration, cell proliferation, and levels of reactive oxygen species (ros). to explore whether autophagy would affect the ability of bm ecs to support hscs in vitro, bm cd + cells from healthy donors were co-cultured with cultivated bm ecs and huvecs. colony-forming unit (cfu) and the apoptosis of co-cultured hscs were analyzed. results: the defective autophagy in bm ecs, characterized by decreased intracellular autophagosomes and autophagic vacuoles, decreased expression of lc -ii and beclin , and high level of p , were observed in pgf patients compared with ggf patients. moreover, the coculture of bm cd + cells with bm ecs showed significant deficient cfu plating efficiency, and increased apoptosis of cd + cells in pgf patients. in vitro upregulation of autophagy by rapamycin quantitatively and functionally improved bm ecsand huvecs, which manifested as more dii-ac-ldl and fitc-lectin-uea- double stained cells, increased capacities of migration, lower levels of ros and apoptosis via regulating beclin pathway, whereas inhibition of autophagy by hcq aggravated the huvecs and bm ecs from pgf patients. furthermore, in vitro upregulation of autophagy by rapamycin significant improved cfu plating efficiency, and decreased apoptosis in bm hscs co-cultured with huvecs and bm ecs from pgf patients. conclusions: these findings suggest that defective autophagy in bm ecs may be involved in the pathogenesis of pgf. the effect of rapamycin in pgfpatients is potentially mediated by improving the dysfunctional bm ecsto support hscs. therefore, it would be of value to investigate whether upregulating of cytoprotective autophagy of bm ecs may ameliorate pgf, thereby providing a novel clinical intervention for pgf in the future. clinical background: heparanase (hpse) in an endoβ-glucuronidase that specifically cleaves the saccaride chains of heparan sulphate proteoglycans (hs), leading to a loss of integrity of the extracellular matrix and to release of hs-bound cytokines, chemokines, angiogenic and growth factors. hpse gene is polymorphic and includes approximately snps. the combination of two snps, rs and rs , are involved in the regulation of hpse expression with an inverse correlation between mrna expression and protein levels: gg-cc, gg-ct, gg-tt, ga-cc (low group) expressed high hpse concentration; ga-ct and ga-tt (median group) expressed intermediate hpse levels; aa-tt and aa-ct expressed low hpse concentration (high group). we studied hpse snps in the allogeneic stem cell transplantation (hsct) setting to evaluate a possible association with post-hsct outcomes. methods: we enrolled patients submitted to hsct in our department since to . for each couple recipient-donor, rs snp was genotyped using restriction fragment lenght polymorphism assay, whereas for rs snp an allele-specific polimerase chain reaction was applied. hpse genotype distribution was compared in different groups according to post-hsct outcome: graft-versus-host disease (gvhd), transplantrelated mortality (trm), overall survival (os), infectious complication and disease-free survival (dfs). statistical analysis was performed using ncss . results: distribution of rs snp was as follows: gg . %, ga . % and aa . % among recipients and . %, . % and . % among donors, respectively. hardy-weinberg equilibrium (hwe) was respected. distribution of rs snp was as follows: cc . %, ct . % and tt . % among recipients and . %, % and . % among donors, respectively. rs snp distribution did not respect the hwe. an association was found between recipient rs snp and the cumulative incidence of agvhd among patients submitted to a reduced intensity conditioning (ric): . % for tt genotype and % for ct or cc genotype (p= . ). on the other hand, an association was identified between donor rs /rs snps combination and the cumulative incidence of agvhd: . % for low group donor, % for median group donor and . % for high group donor (p= . ). conversely, aa genotype for donor rs resulted independent risk factor for cgvhd de novo development (p= . , od . ) together to donor-recipient sex mismatch (female donor to male recipient vs. others: p= . , od . ) . considering cmv reactivation rate after hsct, an association was observed according to recipient rs snp: % for cc genotype, . % for ct genotype and . % for tt genotype (p= . ). multivariate analysis confirmed recipient rs snp as independent risk factor for cmv reactivation after hsct (p= . , od . ) together with recipient cmv serostatus at transplant (positive vs. negative: p< . , od . ). conclusions: hpse role was widely studied in the setting of inflammation, autoimmune diseases, hematological disease and tumor. however, it still remains debated the inducing or protective activity of hpse in the setting of gvhd. obviously, our results need to be confirmed in a validation cohort. clinical trial registry: na disclosure: nothing to declare novel protocol for autologous hsct in patients with high risk of complications: ambulatory chemomobilization and transplantation of fresh hematopoietic stem cells with backup storage background: autologous hematopoietic stem cell transplantation (ahsct) is standard of treatment in many patients with high risk of complications: dialysed patients, patients with heart and kidney amyloidosis or patients with systemic sclerosis. we introduced recently a novel protocol for ahsct: combination of ambulatory mobilization with very low doses of ara-c and g-csf connected with direct ahsct with fresh cells. this protocol allowed us to reduce the transplant risk in various patient groups traditionally connected with high risk of complications. in this work we summarize the experience in such high risk patients. methods: the prospectively collected database of patients after ahsct was searched for patients who underwent ahsct after chemomobilization with ara-c and transplantation with fresh cells and who fulfilled at least one study inclusion criteria: a) dependence on dialysis b) amyloidosis c) systemic sclerosis d) disqualification from transplantation at other centre due to the high risk of complications. there were together patients selected for this analysis - with amyloidosis ( with ≥ organs involved), dialysed, with systemic sclerosis, unfit at other centre. the database included prospectively recorded serious adverse events during the mobilization and transplantation. results: there were transplantations performed in this group of patients. mortality was % at days. all patients underwent successful ambulatory mobilization. all patients received mephalan conditioning with single infusion with median dose of mg/m (min , max ). mean engraftment was . days for white blood cells and . days for plt over g/l. the rate of complications was low with cases of neutropenic fewer, single bacterial culture with staphylococcus epidermidis without clinical signs of infection, median mucositis grade of . and without patients on parenteral nutrition. the median time of hospitalization was days (min , max ). conclusions: we present here novel protocol of transplantation combining chemomobilization and ahsct with fresh cells with excellent safety profile among most severely ill patients allowing for safe and efficient transplants. with this protocol we were able to overcome multiple risk factors and perform full intensity transplantation in very fragile patients. disclosure: nothing to declare single umbilical cord blood transplantation provides durable disease remission of advanced hematological malignancies in elderly patients background: although allogeneic hematopoietic stem cell transplantation (allo hsct) is potentially curative therapy in a variety of hematological malignancies, little has been reported of the outcome for elderly patients who are not in remission at transplantation. but it has been pointed out that recipient age alone can not be regarded as contraindication for allo hsct in the literature recently, supported by suitable donor, conditioning regimens and appropriate management of complications. we conducted a retrospective study of elderly patients who had advanced hematologic malignancies to elucidate the outcome of single umbilical cord blood transplantation (sucbt) in toranomon hospital kajigaya, japan. methods: we retrospectively investigated the outcomes of patients aged over who underwent their first ucbt from june to december in our medical center. results: diseases included acute myelogenous leukemia (n= ), myelodysplastic syndrome (n= ), adult t-cell leukemia/lymphoma (n= ), myelofibrosis (n= ) and chronic lymphocytic leukemia (n= ). the median age at transplantation was years (range, - ) and follow-up for survivor post transplantation was day (range, - ). all patients were not in complete remission (cr) at the time of transplantation. reduced intensity conditioning (ric) regimens were used in patients. all patients received tacrolimus and mycophenolate mofetil as graftversus-host disease (gvhd) prophylaxis. all cases except early death achieved neutrophil recovery at median days (range, - ). at year, overall survival (os) rate and disease free survival (dfs) were , % ( % confidence interval (ci), . - . ). we performed univariate analysis to identify the factor that influenced os at year, but no statistical significance was demonstrated at the age of transplantation (aged to vs. ≧ , . % ( % ci, . - . ) vs. . % ( % ci, . - . ), p= . ). the cumulative incidence of non-relapse mortality (nrm) at days was . % ( % ci, . - . %) and relapse at year was . % ( % ci, . - . %). only two patients developed acute gvhd(ii-iv) and one developed severe gvhd at days after transplantation. the main causes of death was infection (n= ), including sepsis (n= ) and viral encephalitis (n= ), followed by idiopathic pneumonia syndrome (n= ) and thrombotic microangiopathy (n= ) during the early phase of transplantation. in contrast, no patients died of recurrence. conclusions: although our report consisted relapsed/ refractory disease of elderly patients at the time of sucbt, durable remission and lower incidence of gvhd could be noteworthy compared with previous reports. further strategies to reduce the rate of nrm and longer duration of follow up would be warranted. disclosure background: pearson syndrome and kearns-sayre syndrome are metabolic disorders caused by a de-novo deletion in the mitochondrial dna (mtdna). allogeneic stem cell transplantation has shown to improve metabolic function in distal organs in several metabolic disorders, but bears significant morbidity and mortality, especially for patients with mitochondrial disorders. novel gene therapies may correct diseases rising from genomic dna mutations, but targeting the mitochondrial dna is complex. mitochondria are able to transfer into cells and between cells, as seen in preclinical models of mitochondrial and other metabolic disorders. here, we introduce a novel concept of mitochondrial augmentation therapy (mat) of autologous cd + cells in children with mitochondrial deletion syndromes. methods: patients were treated under a compassionateuse program, approved by the sheba medical center irb and the israeli ministry of health. briefly, mobilization was performed using gcsf alone (n= ) or in addition to plerixafor (n= ) . cd + cells were isolated via miltenyi clinimacs system and co-cultured with maternal mitochondria, drawn from peripheral blood and confirmed nondeleted, for hours, and re-infused to the patient without any conditioning. patients were followed for clinical and metabolic parameters. results: all four patients presented with different deletions in mitochondrial dna, and different baseline characteristics, and were treated at the age of . , , and years. despite normal cbc, significant bone marrow hypocellularity was seen in evaluated patients ( %, % and % cellularity at age , and ), which correlated with low colony forming unit capacity of patients and low yield of cd + mobilization in the leukapheresis product. patients received on average x enriched cells/kg (range, . - . ), and the median enrichment of cd + cells was % (range, - %). no infusion reactions occurred, and the only severe adverse events of this cellular therapy were leukapheresis-related anemia, hypokalemia, hypocalcemia and alkalosis, all resolved promptly with proper supplementation. follow-up duration is variable, ranging - months. we were able to show improvement in mitochondrial heteroplasmy (proportion of deleted mtdna of total mitochondrial dna) and in normal mtdna content, starting - months from cell therapy, which correlated with improved atp production in peripheral blood derived mononuclear cells. clinically, patients showed improvement in aerobic function and endurance (measured by the half-bruce protocol, sit-to-stand test and -minute walk test), muscle strength (hand-held dynamometry), and in quality of life, measured by the international pediatric metabolic disability scale. no metabolic crises occurred following cell infusion. conclusions: patients with deletion in mtdna have metabolic dysfunction, including poor bone marrow cellularity and function. hematopoietic stem cells in patients with mtdna deletions can be enriched with normal mitochondria, via mat, as first shown in our patients. this novel process is safe and results in increase in the normal mtdna in peripheral blood of patients, and in improved metabolic and clinical function. clinical trial registry: clinicaltrials.gov nct disclosure: moria blumkin, noa sher and natalie yivgi ohana -minovia therapeutics, employment p high cytotoxic efficiency of alpharetrovirally engineered cd -specific chimeric antigen receptor natural killer cells for treatment of acute lymphoblastic leukemia stephan müller , tobias bexte , annekathrin heinze , franziska schenk , axel schambach , winfried s. wels , , ute modlich , evelyn ullrich , background: autologous chimeric antigen receptormodified (car) t cells with specificity for cd showed potent antitumor efficacy in clinical trials regarding relapsed and refractory acute lymphoblastic leukemia (all). natural killer (nk) cells are cytotoxic lymphocytes that are capable to kill their targets in a non-specific manner and additionally do not cause gvhd. therefore, using cd -car-nk cells exhibits several advantages, such as safety in clinical use, possible allogenic settings and the potential to also attack heterologous leukemia cells which lost cd . previous approaches used cd -car-nk cells pre-stimulated by feeder cells, bearing potential risks. thus, we focused on the optimization of generating cd -car-nk cells by viral transduction under feeder-cell free conditions. methods: human nk cells were isolated from healthy donor peripheral blood mononuclear cells via cd negative selection. after a feeder-cell free expansion phase with interleukin , transductions were performed with an egfp or a cd -car encoding vector at different multiplicities of infection (moi). to optimize gene modification different transduction enhancers (retronectin and vectofusin- ) and viral vector systems (lentiviral and alpharetroviral) were compared. finally, generated cd -car-nk cells were tested in their ability to kill cd positive and cd -negative cell lines. results: nk cells transduced with a lentiviral egfp encoding vector or a lentiviral cd -car vector using retronectin and vectofusin- showed similar transduction efficiencies for both transduction enhancers (egfp: retronectin moi : . %; vectofusin- moi : . %; cd -car: retronectin moi : . %, moi : . %; vectofusin- moi : . %, moi : . %). the generated cd -car-nk cells showed increased cytotoxic capacity against cd -positive cells compared to nontransduced (nt) nk cells ( . % vs. . %, effector to target (e:t) ratio : ). both nk cell populations were equally efficient in killing cd -negative cells ( . % vs. . %). alpharetroviral transduction of nk cells with an egfp encoding vector showed higher transduction rates with vectofusin- than with retronectin (retronectin moi : . %, moi : . %; vectofusin- moi : . %, moi : . %). further using vectofusin- , similar transduction efficiencies could be achieved with an alpharetroviral cd -car encoding vector (moi : . %, moi : . %, moi : . %), outperforming the efficiencies of lentivirally generated cd -car-nk cells in the same experiments (moi : . %, moi : . %, moi : . %). additionally, alpharetroviral cd -car-nk cells showed a higher cell killing activity against cd -positive cells than lentiviral cd -car-nk cells or nt-nk cells ( . % vs. . % vs. %, e:t ratio : ). interestingly, similar killing activities were achieved with an e:t ratio of . : ( . % vs. . % vs. . %) and alpharetroviral cd -car-nk cells remained a stable cytotoxicity level at lower cell concentrations down to an e:t ratio of . : . all three nk cell populations were equally efficient in killing cd negative cells ( . % vs. . % vs. . %, e:t ratio : ). conclusions: cd -car-nk cells can be successfully generated under feeder-cell free conditions using different transduction enhancers and viral vector systems. these data suggest the usage of vectofusin- in combination with alpharetroviral vectors to genetically modify nk cells to achieve sufficient amounts of transduced cells. these cd -car-nk cells mediate high cytotoxicity and therefore may offer a new therapeutic option in the treatment of all. disclosure: axel schambach is an inventor on a patent describing alpharetroviral sin vectors. winfried s. wels is an inventor on a patent describing chimeric antigen receptors with an optimized hinge region. the remaining authors have nothing to disclose. graft-versus-host diseaseclinical walter spindelböck , bianca huber-krassnitzer , barbara uhl , gregor gorkiewicz , hildegard greinix , christoph högenauer , peter neumeister background: steroid-refractory acute gastrointestinal (gi) graft-versus-host disease (agvhd) is a severe complication of allogeneic hematopoietic stem cell transplantation (allo-hsct) associated with a high mortality rate. loss of intestinal bacterial diversity is thought to be associated with severity of gi-agvhd and an impaired intestinal microbiota with reduced diversity is an independent predictor of mortality. methods: the fecal microbiota transplantation (fmt) procedures were performed according to a protocol approved by the local ethical committee ( - ex / ) after obtaining informed consent. donors were healthy adult subjects screened for potential infections by serologic and microbiologic tests according to local standards. donor stool was diluted with saline and homogenized to a volume of~ ml fecal solution for instillation into the terminal ileum and caecum via colonoscope. microbiota sequencing analysis of s rdna was performed before fmts and afterwards at predefined timepoints. results: we report the outcome of nine patients refractory to - lines of immunosuppressive therapies with lower gi-stage iii (n= ) or iv (n= ) agvhd following repetitive fmts from a single donor. all patients had received an allo-hsct for mds (n= ) , aml (n= ), pmf (n= ) and mm (n= ) following a reduced intensity (n= ) or mac (n= ) conditioning regimen using pbsc as stem cell source. after an onset of lower gi agvhd between - days after allo-hsct, nine patients refractory to several lines of immunosuppressive therapies received - fmts ( patients were treated with more than fmts, in patients fmt was only administered once or twice) mostly in weekly intervals. five patients achieved a clinical complete response with resolved diarrhea and no gastrointestinal complaints, and four of these could be discharged without gvhd symptoms. two patients (pr, nc) were discontinued after or fmts in pr or nc due to concomitant infections (metapneumoviral pneumonia, cmv gastroenteritis), the other non-responders succumbed to gvhdrelated infectious complications. the establishment of donors' microbiota with the emergence of new taxa, an increase in bacterial richness/diversity, and the disappearance of the "enterococcus signature" were associated with disease control and response to fmt. except the possible transmission of adenovirus by fmt in one patient, no other immediate procedure-related infections or other side effects were observed. conclusions: restoration of dysbiosis by fmt might represent a promising novel therapeutic approach for a subset of patients with refractory lower gi-agvhd. vigorous donor screening for infectious disease is mandatory. clinical background: migration of allo-activated donor effector tcells from lymphoid tissues to target organs is an important step in acute graft versus host disease (gvhd). the sphingosine- -phosphate- (s p ) receptor plays a crucial role in lymphocyte trafficking. data from animal models suggest that pharmacological modulation of the s p receptor reduces gvhd and improves mortality. we investigated this mode of action by using the secondgeneration s p modulator krp for the prophylaxis of gvhd in a pilot clinical trial in patients undergoing allogeneic hsct. methods: a multi-centric, phase b, prospective, open label, two-part study was conducted to evaluate the safety, tolerability and pharmacokinetics of krp in patients undergoing allogeneic hsct for hematological malignancies. primary endpoint was safety. initial efficacy was explored based on the incidence of gvhd, mortality and relapse. part was a single arm open label study to investigate the safety of mg/day krp added to standard of care gvhd prophylaxis (csa/mtx) in patients. part was a randomized two-arm open label study to compare the safety, efficacy and pk of mg/day of krp in combination with tacrolimus/mtx to mg/day of krp in combination with csa/mtx in patients. in both parts, treatment with krp was initiated days before hsct and continued for an additional days. patients were followed up for up to years. results: patients were included in the study. of patients completed the -day treatment with krp at the assigned doses. median duration of follow-up was days (range to days). krp was safe and well tolerated. serious adverse events (saes) suspected to be related to krp were observed. macular edema (n= ) and peripheral edema (n= ) as s p related adverse events occurred and resolved without sequelae. of note, the incidence of macular edema in hsct recipients is unknown. neutrophil engraftment was confirmed in all patients with a median of days (range to days). of patients presented with grade iii or iv acute gvhd (on days , , , and ) . no gvhd or infection related death occurred during the first days. -day survival was %, with no death occurring during krp treatment. death occurred on study day due to lymphoma relapse. a second death occurred on study day due to liver gvhd. four patients died in the follow-up period due to gastrointestinal gvhd (day ), aspiration pneumonia (day ) and relapse (day and day ). the kaplan-meier estimate of overall survival at year was . . when comparing the data from the two dose groups ( and mg krp ), no major differences in safety, engraftment, gvhd rate or mortality were observed. conclusions: this clinical trial was the first to test s p modulation in this population. our data suggest that krp had no negative impact on engraftment and overall, was safe, and well tolerated. based on exploratory data, when comparing to matched historical mortality data, krp may have favorable effects on overall survival ( figure ). background: uric acid is a danger signal contributing to inflammation. relevance to allosct has been demonstrated in preclinical models: the depletion of uric acid led to improved survival and reduced gvhd (j exp med. sep ; ( ): - ). results of a clinical pilot trial suggested that peri-transplant uric acid depletion reduce acute gvhd incidence (bbmt may; ( ): - ). methods: this international multicentric study aimed to study the association of uric acid serum levels before start of conditioning with allosct outcome. patients with acute leukemia, lymphoma or mds receiving a matched sibling allosct for the first time were considered for inclusion, regardless of conditionning. data were prospectively collected between / and / . a comparison of outcomes between patients with high and low uric acid level was performed using univariate analysis and multivariate analysis using cause-specific cox model. variables included in the multivariate analyses were age, sex mismatch, diagnosis, disease status, karnofsky score, number of cd cells given, intensity of conditioning, type of gvhd prophylaxis, atg use, time from diagnosis to transplant, year of transplant and cmv status. results: twenty centers from european countries reported data on allosct recipients. patient characteristics are given in table . the uric acid cut off point was determined at . mg/dl (median of measured uric acid levels). overall survival (os) and progression free survival (pfs) of allosct recipients with uric acid levels above cut off measured before start of conditioning were significantly shorter ( figure a , os univariate hr= . ci= . - . p< . ; multivariate hr= . , ci= . - . , p< . ) ( figure b , pfs univariate hr= ci= . - . p= . ; multivariate hr= . , ci= . - , p= . ). nonrelapse mortality was significantly increased in allosct recipients with high uric acid levels prior to start of conditioning (univariate hr= ci= . - . p= . ; multivariate hr= . , ci= . - . , p= . ). in addition, there was a non-significant trend towards higher acute gvhd incidence (gvhd grades ii-iv univariate hr= . ci= . - . p= . ; multivariate hr= . ci= - . , p= . ) in allosct recipients with uric acid levels above cut off before transplantation. finally, the incidence of relapse after allosct was moderately increased in the cohort with higher uric acid levels (univariate hr= . ci= - . p= . ; multivariate hr= . , ci= . - . , p= . ). conclusions: high uric acid levels before start of conditioning correlate with high mortality after allosct. our results can serve as rationale for clinical trials on depletion of uric acid during allosct. results: we found significant correlation between donors' ctla- + a>g polymorphism and hsct outcome. genotype aa was present in donors, ag in donors and donors was homozygous for g allele. recipients who received graft from g allele carrier donors showed significantly increased cumulative incidence of relapse (at months aa: . %, ag: . % and gg: . %; p= . ). on contrary, the frequency of the acute gvhd grades iii-iv and cytomegalovirus (cmv) reactivation/disease decreased according to the presence of the g allele in the donor ctla- genotype [agvhd: aa: %, ag: %, gg: %; p= . ; cmv: aa: %, ag: %, gg: %; p= . ]. cumulative incidence of agvhd was also markedly decreased among patients with g allele carrier donors (at days aa: . %, ag: . %, gg: . %; p= . ). donor genotype similarly influenced hsct outcome in mud donor and mac conditioning subgroups. overall survival (os) was not different in patient subgroups according to donor genotypes [os at months: aa: . ± . %, ag: . ± . %, gg: . ± . %; p= . ]. we did not find any correlation between recipients' ctla- + a>g polymorphism and hsct outcome. conclusions: several ctla- snps have previously been described to be associated with relapse rate, incidence of agvhd and os, but results are often contradictory in the publications. in our study, ctla- + a>g polymorphism of hsct donors influenced risk of relapse, agvhd, cmv and cause of death, but not overall survival. the genotyping of ctla- + a>g polymorphism in donors may help in the risk assessment process and the choice of personalised therapy. disclosure: nothing to declare. background: although steroids remain first-line therapy for the treatment of acute graft versus host disease (agvhd), response rates in patients with grade iii-iv disease are poor, with no apparent improvement in survival over the past years. we performed a prospective, multicenter trial to assess the efficacy and safety of the combination of ruxolitinib and etanercept as a novel approach to treat grades iii-iv sr-agvhd . methods: forty malignant hematologic disease patients with grades iii-iv sr-agvhd after allo-sct from three centers in east china were enrolled from january to june . ruxolitinib was initiated at a dose of - mg bid for months, and then tapered gradually for another one month. etanercept was administrated at mg biw for - weeks. results: the median age of patients was (range - ) years. at day after the combination treatment, the overall response rate (orr) was % including crs ( %) and prs ( %). the median time to the optimal response was (range - ) days. the incidences of cr per organ were . %, . %, and % for skin, liver, and gut, respectively. the agvhd relapse rate was analyzed for the patients who had achieved cr or pr and survived beyond days. relapses in agvhd occurred in . % ( / ) of responsive patients. the patients who received ruxolitinib within days after agvhd onset have a significant higher cr rate that those with delayed ruxolitinib therapy ( . % vs. . %, p= . ). and the patients without gut infections have a significant higher cr rate than infected cohort ( . % vs. . %, p= . ). by logistic regression analysis, the time from agvhd to ruxolitinib (rr= . , p= . ) and gut infection (rr= . , p= . ) were independent predictors for incomplete response. thirteen patients ( / , . %) suffered from at least infectious episode after the start of the combination therapy, and pulmonary infectious diseases was a frequent complication ( / , . %). iii-iv cytopenia and cmvreactivation were observed in % and . % of patients. the -year overall survival (os) after initiation of the combination therapy were . %. the -year nrm and relapse incidence was . % and . %, respectively. patients with complete response on day had significantly higher os probability than non-cr patients ( -year os: . % vs . %, p= . ). compared with the historical cohort of basiliximab and etanercept for sr-agvhd in our center (n= ), no significant difference was found on the baseline. although the orr in patients treated with ruxolitinib and etanercept is identical with the historical cohort, ruxolitinib group achieved rapider remissions in liver agvhd and gut agvhd than the historical cohort (gut agvhd: days vs. days, p= . ; liver agvhd: days vs. days, p= . ), thus, with regard to hospital stay after agvhd onset, the ruxolitinib cohort stayed shorter (median: days vs. days, p= . ) than basiliximab cohort. conclusions: combined treatment with ruxolitinib and etanercept resulted in a rapid cr to visceral agvhd and meanwhile reserve graft anti-leukemia (gvl) effect as the relapse rate of primary disease is relatively lower. the various infection complications associated with ruxolitinib merit more attention. disclosure: nothing to declare background: graft-versus-host disease (gvhd) remains one of the main life-threatening complications after allo-hsct, especially in patients with non-malignant diseases. the standard gvhd prophylaxis strategy is mostly based on the use of calcineurin inhibitors alone or in combination with other immunosuppressive (is) post-transplant cyclophosphamide (ptcy) is effective gvhd prophylaxis optiont for adult patients (pts), but has limited data in children. methods: the study aim was to evaluate ptcy as gvhd prophylaxis in pediatric pts with inherited disorders undergoing allo-hsct. pts, the most of them are pediatric age (median age - y.o., range month - y.o.) with different types inherited disorders (β-thalassemia - , bone marrow failure syndromes - , storage diseases - , primary immunodeficiencydisorders - ) were inrolled in retrospective study. donor type was: matched/mismatched unrelated (mud/mmud) - , matched related donor (mrd)- , haploidentical (haplo) - . conditioning regimen was: myeloablative (mac) - , reduce-intensity (ric) - . graft sourse was: bone marrow (bm) - , peripheral blood stem cells (pbsc) - , combintions bm +pbsc/bm+cord blood - . ptcy mg/kg days + , + based gvhd prophylaxis recived pts., standart gvhd prophylaxis based on calcineurin inhibitors - pts. results: cumulative incidence (ci) of agvhd was %. grade - , - agvhd were % and % respectively. ptcy based gvhd prophylaxis reduced ci of agvhd ( % vs %, p= , ). another reduce ci of agvhd factors were mac ( % vs % in ric pts group, p= , ), mrd ( % vs % in haplo group vs % in mud/mmud group, p= , ), bm as a transplant source ( % vs % in pbsc group, p= , ). in a multivariate analysis mac (hr , %ci , - ,, p= , ), time from diagnosis to allo-hsct less then month (hr , %ci , - , , p= , ) were predictive for reducing ci agvhd. for agvhd - st. significant factor increase ci was female donor both in univariate ( % vs %, p= , ) and multivariate analysis (hr , %ci , - , , p= , ). years overall survival (os) was %. improving os factors were: transplant age younger then y.o. ( % vs %, p= , ), time from diagnosis to allo-hsct less then month ( % vs %, p= , ), engraftment ( % vs %, p= , ). in a multivariate analysis only transplant age younger then y.o. (hr , %ci , ( ) ( ) ( ) ( ) ( ) p= , ) and engraftment (hr , %ci , - , , p= , ) were predictive for os. conclusions: ptcy-based gvhd prophylaxis can be effective options for reduce risk of acute gvhd. using unrelated donors, bone marrow as transplant source and mac can reduce ci of gvhd. performing allo-hscr earlier from diagnos and in earlier age can improve os patients with inherited disorders background: diarrhea is a frequent complication after allo-sct. at onset it is often difficult to differentiate gi gvhd from other causes of enterocolitis. recently, non-invasive tests, such as fecal calprotectin (fc), have been validated as markers of gut inflammation in patients with inflammatory bowel disease, but only a few studies have been published regarding its use as a diagnostic marker in gi gvhd. methods: our aim in this study was to explore the levels of fc in allo-sct recipients with new-onset diarrhea. so far we have included allo-sct recipients who developed acute diarrhea ≥ stage - at a median of days (range: - ) post allo-sct. stool samples were analyzed as soon as possible after the onset of diarrhea. fc levels were determined in addition to an extensive microbiological panel for infectious enterocolitis (including norovirus pcr and c. difficile associated diarrhea). endoscopies for histologic analysis were performed according to the treating physicians' discretion (n= ). results: patients characteristics are summarized in table . median follow-up for survivors was days (range: - ). twenty-eight patients ( %) were diagnosed of gi-gvhd. the additional causes of diarrhea were: drug-related enterotoxicity (n= ), viral enteritis (n= ), food intolerance (n= ), c.jejuni-enteritis (n= ), and non-specific causes (n= ). the concentration of fc was higher in patients with gi gvhd vs. other causes of diarrhea ( μg/g +/- vs. μg/g +/- , p= . ). patients who did not develop severe enterocolitis had normal to slightly raised calprotectin at the onset of diarrhea [< - in out of ( %) cases], including % ( / ) of patients with enterotoxic drug-related diarrhea. among the patients with gi-gvhd, ( . %) were later found to be steroid-resistant. as shown in figure , we found a significant association between high fc (≥ μg/g) and severe-refractory gvhd (hr . , p= . ). of note, high values of fc were also found in patients with severe infectious enteritis (norovirus, adenovirus and c.jejuni infections), with baseline fc> μg/g, respectively. overall survival was % (ic %: - ) at months. hypoalbuminemia and thrombocytopenia were the only variables linked to -yr os in univariate analysis, regardless of the cause of enterocolitis. conclusions: in the absence of standarized (and expensive) biomarker panels for analyzing and predicting gvhd onset and outcomes, the fc test may be an useful tool in the allo-sct setting. our initial results show that fc is helpful in predicting mild causes of diarrhea and to identify patients with a high probability of developing severe (and potentially steroid-refractory) gi gvhd, although high levels are also found in severe infectious enteritis. background: there is an urgent need for effective therapy for severe acute gvhd. results of gvhd therapies beyond months are rarely reported. we here report a median follow-up of years. we introduced mesenchymal stromal cells as therapy for severe acute gvhd, with a dramatic response in some, but not all patients. the placenta protects the fetus from the mothers haploidentical immune system during pregnancy. we found that maternal stromal cells from the fetal membrane, so called decidua stromal cells (dscs) were more immunosuppressive than other sources of stromal cells. methods: we treated patients, median years of age (range . - ) for severe acute gvhd. all had biopsy proven gastro-intestinal gvhd. all were steroid refractory, after > days or with progression and after > days. we used an improved protocol where dscs were thawed and infused in a buffer with % albumin. dscs were given at a median dose of . ( . - . ) x cells/kg and ( - ) doses, given one week apart. viability of frozen and thawed dscs was % ( - ) and cell passage was ( - ). results: complete resolution of gvhd was seen in patients and had a partial response. the cumulative incidence of chronic gvhd was %. six had mild, moderate and one severe nih overall gvhd severity scoring. nine patients died, from relapse, acute gvhd and septicemia, zygomycetes infection, liver insufficiency, cerebral hemorrhage, multiorgan failure and chronic gvhd with obstructive bronchiolitis. four years transplant related mortalliy was . % and overall survival was %. survival was not significantly worse (p= . ) than % for all patients undergoing allogeneic hematopoietic cell transplantation during the same period - . conclusions: to conclude, dscs seems to be a promising therapy for severe acute gvhd. randomized trials are under way. disclosure: nothing to declare p anti-apoptotic protein bcl- is upregulated in graftversus-host disease stem cell transplantation (allo-hsct) with - % developing either acute or chronic gvhd. recently, bcl- inhibitor venetoclax was approved for treatment of chronic lymphocytic leukemia. induction of apoptosis and depletion of lymphocyte subpopulations e.g. follicular b-cells or cd + and cd + t-cells led to further exploration in autoimmune disease. methods: to establish expression levels of genes in the bcl- pathway, low-input rna sequencing was performed on t cells isolated from non-inflamed skin and peripheral blood of hsct recipients at different time points before until year after transplantation. furthermore, we analyzed blood, lung, gut and skin samples of patients post allo-hsct with and without previously untreated acute or chronic gvhd by rt-pcr, flow cytometry and tissue immunofluorescence. [[p image] . bcl- is up-regulated in t and b lymphocytes of acute and chronic gvhd lesions.] results: rna-sequencing revealed that t cells upregulated bcl- upon conditioning treatment (day ) and cells of patients who later developed gvhd failed to downregulate bcl- after transplantation (day+ , day+ ). bcl- protein levels were elevated in overall leukocytes and pathogenic cell subsets including monocytes, cd + t lymphocytes and nkt cells showed significantly higher expression of bcl- in peripheral blood of gvhd patients as compared to healthy controls. these results could be recapitulated in tissue samples, where disease-promoting lymphocytes (t, b, nk, nkt) were numerically expanded and expressed bcl- in acute and chronic gvhd skin lesions. notably, non-pathogenic cell types such as keratinocytes did not exhibit increased bcl- expression compared to control samples from hsct recipients and healthy donors. while bcl- rna expression did not depend on type of conditioning (mac vs. ric) or gvhd grade, it correlated to disease severity and was significantly elevated in biopsies of patients with steroidrefractory gvhd. conclusions: we could show exclusive upregulation of bcl- in gvhd-mediating cell types in peripheral blood and tissue samples affected by gvhd, correlating to gvhd severity and response to first-line therapy. thus, bcl- inhibition may present a novel and urgently needed targeted therapy in treatment of steroid-refractory acute and chronic gvhd. disclosure: supported by a docmed fellowship od the austrain academy of sciences background: graft-versus-host disease (gvhd) represents a major contributor to morbidity and mortality in recipients of allogeneic hematopoietic cell transplants (hct). several therapeutic strategies exist for gvhd prophylaxis and include post-transplant cyclophosphamide (ptcy) and antithymocyte globulin (atg). while several groups have described the use of ptcy in younger patients, there is a paucity of data about the efficacy of ptcy in older individuals, particularly when combined with atg. we investigated the combined effect of ptcy with atg on transplant outcomes in older patients at princess margaret cancer centre, toronto, canada. methods: this retrospective study included all patients age ≥ who underwent allogeneic hct for any indication at our centre between december and july . overall survival (os) was calculated using kaplan-meier analysis and multivariable cox proportional hazards regression. cumulative incidence of relapse (cir) and non-relapse mortality (nrm) were calculated using competing risk regression (fine and gray method). incidences of acute (agvhd) and chronic (cgvhd) were compared using the fisher's exact test. results: of patients, ( %) were male. median age was (range - ) and median follow-up among survivors was months (range - ). acute myeloid leukaemia (aml) was the most common indication for hct ( patients, %), followed by myelodysplastic syndrome ( patients, %) and myelofibrosis ( patients, %). eightyfour ( %) patients had a matched unrelated donor, ( %) had a matched related donor and ( %) had a haploidentical donor. one hundred twenty-five ( %) patients received reduced intensity conditioning. sixty-two ( %) patients received ptcy combined with atg ( . mg/kg) while ( %) received other forms of gvhd prophylaxis. os at years was % ( % confidence interval (ci) - ) in the entire cohort. patients who received ptcy with atg had a superior -year os compared with other gvhd prophylaxis regimens ( figure a ): % ( % ci - ) vs. % ( % ci - ), respectively (hr= . , % ci . - . , p= . ). the -year nrm for the entire cohort was % ( % ci, - ). patients who received ptcy with atg had a lower -year nrm compared to those who did not ( figure b ): % ( % ci - ) vs. % ( % ci - ), respectively (hr= . , % ci . - . , p= . ). the -year cir in the whole group was % ( % ci - ). use of ptcy with atg was associated with a modest increase in cir at two years ( figure c ): % ( % ci - ) vs. % ( % - ), respectively (hr= . , % ci . - . , p= . ). there was a trend toward lower incidence of grade ii-iv agvhd among patients who received ptcy with atg compared to those who did not: % vs. % (p= . ). the incidence of grade ii-iv cgvhd was lower in individuals who received ptcy with atg compared to those who did not: % vs. % (p= . ). conclusions: in older hct recipients, use of ptcy combined with atg is associated with improved os, lower nrm, decreased risk of both agvhd and cgvhd and a modest increase in relapse risk. therefore the ptcy with atg combination represents an effective strategy for gvhd prophylaxis in older allogeneic hct recipients. disclosure: the authors have no conflict of interest to declare. outcome of severe graft versus host disease in pediatric patients with nonmalignant diseases after allogeneic bone marrow transplantation. a single center experience irina zaidman , sigal grisariu , batia avni , ehud even-or , bella shadur , adeeb nasereddin , polina stepensky background: hematopoietic stem cell transplantation (hsct) remained the only curative option for many nonmalignant diseases in pediatric patients. survival after hsct has improved the last few years due to significant advancement in human leukocyte antigens (hla) typing techniques, less toxic conditioning regimens and better supportive care and resulted to % survival and cure in some non malignant diseases. graft-versus-host disease (gvhd) remains a major complication of hsct and leading cause of morbidity and mortality. prognosis of patients with high grade gvhd is dismal and survival rate varies between % to % in pediatric patients. methods: the retrospective study included patients with non malignant diseases who underwent allogeneic hsct at hadassah medical center from to . the collected data included patient´s clinical data and transplant characteristics. the study was approved by the institutional helsinki committee. results: children with nonmalignant diseases underwent allogeneic bone marrow transplantations in hadassah university hospital during ten years period. fifty seven patients ( %) developed agvhd grade - , twenty five of them ( . %) grade - . median age was . (range . - . ), most patients were males ( males, females). patients underwent bmt from fully matched family members, children were transplanted from matched unrelated donors and from mismatched donors. twenty one of patients with severe gvhd ( %) survived. four patients ( %) died from severe gvhd and complications of immunosuppressive treatment. of deceased patients were transplanted from mismatched donor, in of cases the age of donor was advanced, of patients developed severe gvhd and died after second hsct. all patients were refractory to different treatment modalities. three of patients died in and one in , it was no death from severe gvhd in patients that were transplanted and developed high grade gvhd after . conclusions: the results of this study show a high survival rate of % in pediatric patients with non malignant diseases and severe gvhd. significant risk factors for mortality in our group included mismatched donor, advanced age of donor and second transplant. trend to better survival was observed after . additional multicentral studies analyzed the outcomes of agvhd in pediatric patients with nonmalignant diseases are urgently required. background: chronic graft-versus-host disease (cgvhd) is a serious late complication after allogeneic hematopoietic stem cell transplantation (allohsct) with heterogeneous presentation and still poorly understood pathophysiology including inflammation and endothelial dysfunction. factor viii (fviii) and von willebrand factor (vwf) are coagulation factors but also known indicators of endothelial dysfunction and inflammation in different settings, and therefore could serve as interesting candidate biomarkers of cgvhd. methods: since patients after allohsct were assessed by the multidisciplinary cgvhd team at the university hospital center zagreb, croatia, using established nih cgvhd-related measurements. an extensive history, physical and laboratory evaluations were performed, including fviii, vwf:ag and vwf:ac analysis. descriptive statistic and non-parametric analyses were performed. variables that showed significant univariate correlations were used in multivariate logistic regression (mlr) to identify the most predictive for fviii, vwf:ag and vwf:ac in cgvhd patients. results: cgvhd patients and controls (subjects after allohsct without cgvhd) were analysed. median age of cgvhd patients was ( - ) years, % females, . % underwent allohsct for hematologic malignancies, . % had myeloablative conditioning and . % matched related donor. median time from hsct to study was . days and from cgvhd diagnosis to study days. there were no demographic neither transplant related significant differences between cgvhd patients and controls beside stem cell source (peripheral blood . % vs . %, p= . ) and history of acute gvhd ( . % vs . %, p< . ). majority of patients had moderate ( . %) or severe ( . %) nih global cgvhd score, . % active cgvhd by clinician´s impression. median number of organs involved by cgvhd was ( - ), and the most frequently involved organs were mouth, skin and eyes ( . % each). cgvhd patients compared to controls had higher fviii levels (median ( - )% vs ( - )%, p= . , reference range - %) and higher vwf:ag (median . ( . - )% vs . ( . - )%, p= . , reference range - %), while vwf: ac showed a trend toward higher levels among patients (median . ( - )% vs ( . - )%, p= . , reference range - %). patients had higher ggt (p= . ), lower anticardiolipin igg (p= . ) and igm (p= . ), and lower albumin (p= . ) than controls, without differences between other laboratory parameters. univariate analysis showed that among cgvhd patients higher fviii was associated with worse karnofsky score (ks) (p= . ) and performance score (ps) (p= . ), higher leukocytes (p= . ), cholesterol (p= . ), triglycerides, ast, alt, ggt, ldh, and lower albumin. higher vwf:ag and vwf:ac in cgvhd patients were associated with worse ks and ps (p< . ), with more active cgvhd (p< . ), worse nih cgvhd liver (p= . ; p= . ) and nih cgvhd mouth (p= . ; p= . ), higher total nih score (p= . ; p= . ), higher number organs involved (p= . ; p= . ), higher esr, monocytes, ddimers, ast, alt, ggt, ldh, triglycerides, β- -microglobulin, ferritin, total proteins, iga and lower albumin. mlr analysis showed leukocytes (p= . ) and cholesterol (p= . ) as the strongest predictor of fviii (r = . %; p< . ), while strongest predictor of vwf: ac was number of organs involved by cgvhd (r = . %; p= . ). conclusions: results of this study detected high fviii and vwf levels in cgvhd patients with possible reflections to cgvhd manifestations, what needs to be further confirmed in larger longitudinal studies. disclosure: this work was supported, in part, by the unity through knowledge fund project entitled "clinical and biological factors determining severity and activity of chronic graft-versus-host disease after allogeneic hematopoietic stem cell transplantation", and also, in part, by the croatian science foundation project entitled "new biomarkers for chronic graft-versus-host disease". antonela samardzic -work financed by the croatian science fondations`"young researchers`career development project -training of doctoral students" background: thrombotic microangiopathy (tma) is a severe complication of allogeneic hematopoietic cell transplantation (hct) with multisystem involvement. a few recent reports have recognized evidence of tma in the intestinal vasculature (intestinal tma/itma) of patients with graft-versus-host disease (gvhd) with or without tma. we aimed to identify patients with itma and describe histological, clinical and prognostic features. methods: we prospectively evaluated available endoscopic samples (stomach and/or colon) from consecutive adult hct recipients for previously described histopathologic signs of itma (january -september ). systemic tma was diagnosed according to the international working group criteria. we compared findings among clinical groups: gvhd/systemic tma, gvhd/no systemic tma and no gvhd/no tma. results: we studied patients, classified as gvhd/ systemic tma, gvhd/no systemic tma and no gvhd/no tma. baseline transplant characteristics (age, donor, hla matching, conditioning) did not differ significantly among groups. histological features of itma, including loss of glands, total denudation of mucosa, apoptosis and detachment of endothelial cells, intraluminal fibrin, intraluminal microthrombi and mucosal hemorrhage were found in patients. previously described features of intraluminal schistocytes were not observed in our patients. interestingly, loss of glands, total denudation of mucosa, apoptosis and detachment of endothelial cells were also found in patients with gvhd and no itma, suggesting that these features are not pathognomonic of itma. among itma patients, two patients were classified in the clinical group of acute gvhd/systemic tma, while the other patients had clinical and histopathological features of itma and severe grade iii-iv steroid-refractory acute gvhd ( patients) or extensive chronic gvhd ( patient) but no evidence of systemic tma. in the majority of patients ( / ), itma occurred during the early posttransplant period at . ( . - ) months. clinical features (gastrointestinal bleeding, diarrhea, pain, nausea) presented no differences between patients with or without itma. prognosis was poor for patients with itma who suffered from a significantly higher mortality rate of % compared to the rest patient population (p= . ). with a median follow-up of . ( . - . ) months, year overall survival probability (os) was . for itma, % for gvhd and % for systemic tma. unfavorable predictive factors for os were itma (p= . ), hla mismatched donors (p= . ) and gastro-intestinal bleeding (p= . ). conclusions: intestinal tma has emerged as a novel distinct entity in patients with gvhd and/or systemic tma. distinct histological features may be useful in differential diagnosis of these severe hct complications. mortality rates higher than those of systemic tma highlight the need of proper recognition of itma that needs to be further studied in terms of diagnostic and therapeutic potential. disclosure: e.g. was supported by the european hematology association clinical research grant. the remaining authors declare no competing financial interest. the beneficial effects of thrombomodulin gene polymorphisms after hematopoietic stem cell transplantation background: chronic graft-versus-host disease (cgvhd) remains the major cause of late morbidity and mortality after allogeneic blood and marrow transplantation. treatment options for cgvhd, particularly its sclerotic forms remain limited. active hedgehog (hh) signaling was shown as a therapeutic target in both mouse and human cgvhd, with limited efficacy and significant toxicities described in a published clinical trial (defilipp, ). methods: adult patients with steroid refractory sclerodermatous cgvhd, defined as requiring > . mg/kg/day of prednisone dose equivalent (pde), or need for second-or third-line therapy beyond corticosteroids and calcineurin inhibitors or sirolimus were eligible for this open label study of vismodegib, a first generation hh pathway inhibitor. primary endpoint was failure free survival, defined as absence of non-relapse mortality, no recurrent malignancy, steroid dose at months =< . mg/kg/day of pde, and no addition of new systemic treatment. vismodegib was administered orally for - months, with dose reductions at development of toxicities. peripheral blood mononuclear cells were isolated from samples collected at treatment initiation and every three months thereafter. the immune profile of circulating b cells was analyzed by flow cytometry and t helper polarization by qrt-pcr of sortpurified cd + t cells. results: at the time of interim analysis, patients were evaluated. patients completed months of treatment and five patients completed months of treatment. therapy was discontinued in patients prior to months due to treatment-related (n= ) and unrelated (n= ) side effects. most patients experienced grade toxicities (muscle cramps and dysgeusia), with only a single grade toxicity (weight loss). patients who completed months of therapy demonstrated partial response, and overall, the primary endpoint was reached in % ( / ) of patients. in patients who discontinued vismodegib, cgvhd worsened acutely after discontinuation. correlative analysis of immune cellular subsets in peripheral blood in paired samples (pre-treatment and month of therapy) documented modulation of b cell subsets pathogenic in cgvhd (pregerminal center and plasmablast-like b cells) and diminished t helper polarization in cd t cells. conclusions: overall, use of vismodegib was associated with potential clinical efficacy in sclerodermatous cgvhd with possible mechanistic evidence arising in correlative studies. while side effects were common, further studies of hh inhibition in cgvhd are warranted. future studies should employ adjusted dosing regimens, along with supportive care interventions to offset side effects, and testing of novel hh inhibitors with enhanced safety profiles. clinical background: graft-versus-host disease (gvhd) results from recognition of host antigens by donor t cells following allogeneic hematopoietic stem cell transplantation (sct). we tested the hypothesis that somatic neomutations occurring after sct from donor and/or recipient dna may trigger gvhd. methods: we longitudinally analyzed both constitutive and somatic mutations by whole exome sequencing (wes) in patients who received sct from a sex-matched hlaidentical sibling for npm mutated acute myeloid leukemia (pt# ) and jak v f mutated primary myelofibrosis (pt# ). both patients were initially refractory to alloreactivity, i.e. not displaying any signs of gvhd, even after several donor lymphocyte infusions. acute gut gvhd finally occurred after a further dli preceded by a lymphodepleting chemotherapy. in pt# , gvhd correlated with a graft-versus-tumor effect. wes was performed on dna from recipient saliva and donor pbmcs (germline samples) and from sequential post-sct pbmcs samples on a hiseq illumina with x bp paired-end reads at a mean depth of coverage of - x. germline and somatic mutations were determined using in-house bioinformatic pipelines (named ewok from the curie institute and smaug from the henri mondor hospital), using briefly gatk as variant caller for germline samples, and a combination of variant callers for matched normaltumor pairs. we adjusted parameters to detect somatic mutations at a minimal variant allelic frequency (vaf) of % compared to recipient and donor germline for all variations (minimal coverage = x for germline and x for tumor sample). results: wes allowed detecting somatic driver mutations explaining aml and pmf for both patients in the initial timepoint and all these driver mutations disappeared at the following timepoints. as expected, the somatic variant rate was x higher in pt# with aml than in pt# with pmf at each timepoint, except for the final gvhd timepoint. indeed, at this final point, the somatic variant rate dramatically decreased by % as compared to previous timepoints. by subtracting variants detected pre-and post-sct from those identified at the ultimate time-point of gvhd occurrence, we created sets of and variants respectively for each patient (keeping only variants with at least reads of mutated dna). these variants can be classified in categories: (i) those with only with a slight increase at time of gvhd, i.e. ≤ -fold compared to highest previous vaf (lrrc , or u , or g , alpp, frg , frg b and lilrb genes), and (ii) those with a significant increase at that time, i.e. > -fold compared to highest previous vaf (phf , smpd , ercc and krtap - genes). none of the variants or genes involved was common between the patients. ontology classification of mutated genes showed the implication of some of them in cell death, regulation of map kinase activity, mrna splicing and immune system process, making them good candidates for further studies. identification of variants appearing pre-gvh and turning off at time of gvhd is ongoing to unveil putative neoantigens that could trigger the alloreactive response. conclusions: using a comprehensive, pre-and post-sct, wes of donor/recipient pairs, we identified several neomutations from donor and/or recipient dna correlating with gvh/gvt effect development. disclosure results: a total of patients experienced cgvhd, and mild, moderate, and severe cgvhd were observed in , , and patients, respectively. the -year cumulative incidence of total cgvhd was . % ( % ci, . - . %), and the -year cumulative incidence of moderate to severe and severe cgvhd was . % ( % ci, . - . %) and . % ( % ci, . - . %), respectively. the patients who had loci mismatched had a higher -year cumulative incidence of total cgvhd ( . % vs. . %, p= . ) and moderate to severe cgvhd ( . % vs. . %, p= . ) compared to those of the patients who had - loci mismatched. the patients who had maternal donors had a higher -year cumulative incidence of moderate to severe cgvhd ( . % vs. . %, p= . ) compared to that of the patients who had other donors. the patients who had grade iii to iv acute graft-versus-host (agvhd) had a higher -year cumulative incidence of total cgvhd ( . % vs. . %, p< . ) and moderate to severe cgvhd ( . % vs. . %, p< . ) compared to those of the patients without agvhd. in multivariate analysis, grade iii to iv agvhd was the only independent risk factor for total cgvhd (hr= . , %ci, . - . ; p< . ) and moderate to severe cgvhd (hr= . , %ci, . - . ; p< . ). in the model excluding agvhd, maternal donor was the risk factor for moderate to severe cgvhd (hr= . , %ci, . - . ; p= . ). conclusions: we observe that severe agvhd was the most important risk factors for cgvhd after haplo-hsct, and further interventions should be considered in these patients to prevent severe cgvhd. disclosure: none of the authors have any potential financial conflict of interest related to this manuscript. background: extracorporeal photopheresis (ecp) has been successfully used for the treatment of graft-versus-host disease (gvhd). ecp therapy might restore the balance between effector and regulatory cells which is severely impaired in gvhd. nk cells are the first lymphocyte subset to be reconstituted after allogeneic hematopoietic stem cell transplantation (allo-hsct). as an important innate immune cell population, nk cells can temporally bridge the transient period of t-cell deficiency post allo-hsct, by protection from opportunistic infections and prevention of leukemic relapse by graft-versus-leukemia (gvl) effect. nk cells not only preserve homeostasis through targeted killing of allo-reactive t cells and thereby control gvhd but also enhance inflammation by secretion of tnf-α and ifn-γ and thereby promote gvhd. therefore, we investigated here the role of nk cells in gvhd patients under ecp therapy. methods: thirty four patients with steroid-refractory/ resistant agvhd ≥ ii°and moderate to severe cgvhd received ecp therapy which performed according to the guidelines. glucksberg and nih criteria were used for clinical staging of agvhd and cgvhd under ecp therapy, respectively. the comprehensive phenotypical analysis of nk cells was evaluated by multicolor flow cytometry. nk activity in terms of killing function, cytokine release capacity and proliferation function was monitored by chromium- release assay, intracellular cytokine staining and cfse staining, respectively. results: five different nk cell subsets were defined based on cd and cd expression. cd bri nk cells displayed an immature and activation profile with high expression of cd l and nkg d. agvhd patients had a higher frequency of cd bri nk cells when compared with hds and cgvhd patients, who were characterized by significant increase of the cd dim cd + and cd -cd + nk cell subsets with high expression of differentiation markers cd b and cd . of note, cd bri cd -nk cells could serve as a novel predictive biomarker for the response of agvhd patients to ecp treatment. in responding agvhd patients, an increase of cd bri nk cells was observed already during the early ecp treatment phase, suggesting immune reconstitution. after priming of the progenitors, ecp could differentiate immature cd bri nk cells into mature cd dim nk cells with reduction of cd l on cd bri nk cells. moreover, cd dim nk cells could further be matured through upregulation of cd expression by ecp. notably, ecp therapy could shift the nk cells from a cytotoxic to a regulatory phenotype within the cd bri nk cells. in spite the immunomodulatory effect of ecp on nk cells, nk activity could be kept intact under ecp therapy. the killing activity of nk cells was stable as confirmed by a cr release assay. ecp therapy had no negative effect on the quantity and quality of cytokine release by nk cells upon k stimulation. especially, the polyfunctionality of nk cells was not altered significantly by the ecp therapy. conclusions: nk cells play an important role in gvhd and could serve as a predictive cell population for the clinical response to ecp therapy. in the current study, ecp influenced the differentiation, maturation and education of nk cells ameliorating gvhd without comprising the antiviral immune defense and gvl effect. disclosure: the authors declare no competing financial interests, except the following: therakos mallinckrodt gave a financial support to as and ms for the documentation of the clinical course and for the analysis of immune cells of the patients, pw has honoraria and membership on advisory boards for sanofi-aventis. abstract withdrawn. cyclosporine levels > µg/l on day post-transplant was associated with significantly reduced acute graftversus-host disease following allogeneic hematopoietic stem cell transplantation monica bianchi , dominik heim , claudia lengerke , martina kleber , dimitrios tsakiris , jakob passweg , alexandar tzankov , michael medinger background: acute graft-versus-host disease (agvhd) remains a major complication of allogeneic hematopoietic stem cell transplantation (allo-hsct). affected patients, especially with steroid-refractory agvhd, have a very poor prognosis. prophylaxis with cyclosporine a (csa) is the backbone of gvhd prevention in most conditioning regimens. methods: in a retrospective analysis of patients treated with allo-hsct, we correlated csa levels at the day of transplantation (day ) and day + with the incidence of acute and chronic gvhd. we postulate that higher target csa levels > μg/l will result in a lower incidence rate especially of agvhd after allo-hsct. results: we assessed patients with either aml n= , lymphoma/myeloma n= , mds/mpn n= , all n= , cll n= , cml n= , or bone marrow failure n= . in patients with clinically relevant agvhd grade ≥ , mean csa levels was lower on day and day + ( ± μg/l; and ± μg/l; respectively) compared to patients without agvhd ( ± μg/l; and ± μg/l; respectively; day : p= . ; day + : p= . x - ). in patients with csa level < μg/l, the incidence of agvhd was significantly more frequent compared to patients with csa levels > μg/l [( / ; %) versus / ( %); p= . x - ]. in patients with cgvhd, there was no significant difference between csa levels < μg/l ( / ) compared to csa levels > μg/l ( / ; p= . ). the optimal csa cut-off level for the prevention (i.e. roughly % incidence reduction) of agvhd was > μg/l at day and > μg/l at day + ( figure ) in a competing risk analysis, time to agvhd grade ≥ (using death of other causes as competing risk) was associated with csa levels > μg/l on day and on day , unrelated donors, myeloablative conditioning (mac), and for the diagnosis lymphoma/myeloma. conclusions: our data support close monitoring with active adjustments of csa dosing to maintain therapeutic csa levels above μg/l in the first days of allo-hcst to reduce agvhd. disclosure: noting to declare. liposomal cyclosporine a for inhalation (l-csa-i) to treat bronchiolitis obliterans syndrome: novel formulation with therapeutic potential for patients with bos following allo-hsct noreen roth henig , emilie hofstetter , dominik kappeler , gerhard boerner background: bronchiolitis obliterans syndrome (bos) is a rapidly progressive lung disease caused by t-cell mediated inflammation that leads to blockage of bronchioles, leading to respiratory failure and death shortly after diagnosis. approximately % to % of patients who undergo allogeneic hematopoietic stem cell transplant (allo-hsct) will develop bos, with - % developing bos as a respiratory form chronic graft-vs-host disease (cgvhd) in addition to other signs of cgvhd. mean time to bos diagnosis ranges from to days post-transplant. the histopathology of bos after allo-hsct and lung transplantation is identical. early studies of l-csa-i for the prevention of bos in lung transplant recipients demonstrated therapeutic benefit. l-csa-i is a novel, liposomal formulation of cyclosporine administered via a pari investigational eflow â nebulizer which delivers a potent immunosuppressant to the site of disease. pharmacokinetics and tolerability of l-csa-i is presented. methods: retrospective review of two clinical studies of l-csa-i (isotonic, mg/ml) for bos associated with lung transplantation. both studies had a control arm and results reported here are for patients who received l-csa-i. subjects received mg (single lung transplant) and mg (double lung transplant) bid via inhalation. blood samples for pharmacokinetic analysis of cyclosporine a concentrations were collected before inhalation, immediately after inhalation, and thereafter in intervals of , , min and , , and hours. local and general tolerability of l-csa-i was investigated. results: between the two studies, subjects received either or mg bid of l-csa-i. pharmacokinetic models predict a constant drug level in the lung. maximum serum cyclosporine a concentration after inhalation was . ± . ng/ml. trough levels for up to -years of daily administration was - ng/ml with no evidence of accumulation following repeated exposure. tolerability data was assessed from patient-month exposure to l-csa-i. reported symptoms were: pharyngeal soreness %; cough %; dyspnoea %; and wheezing %. no subject discontinued due to intolerability. inhalation time is on average - min. conclusions: l-csa-i provides high and constant concentrations to the airways of the lungs and the site of bos. l-csa-i is well tolerated in lung transplant patients. use of l-csa-i instead of augmentation of systemic csa reduces the total drug exposure. a multicentre phase safety and exploratory efficacy trial for the treatment of bos in allo-hsct recipients is underway. disclosure background: there are a number of biomarkers that predict non-relapse mortality (nrm), graft-versus-host disease (gvhd) and relapse incidence (ri) after conventional gvhd prophylaxis based on calcineurin inhibitors with or without antithymocyte globulin. currently there is limited data whether the conventional predictive biomarkers work with posttransplantation cyclophosphamide (ptcy) prophylaxis. methods: prospective single-center study in - enrolled adult patients with acute leukemia in cr ( % with all, % with aml). received matched related bone marrow (bm) graft with single-agent ptcy and received unrelated peripheral blood stem cell graft (pbsc) with ptcy, tacrolimus and mmf. the grafts were studied by flow cytometry (facs aria ii, antibodies by miltenyi biotec). the following populations were analyzed: cd , cd , cd , cd cd , nkt, inkt, treg, double-positive t-cells, double-negative t-cells, tcralpha/beta, tcr v memory cells. the crypreserved plasma from were analysed by elisa (commercial kits by ebioscience and critical diagnostics) for vegf a soluble tnf receptor (stnfr), il- , il- , soluble il- receptor, st , il- and stnfr. the above mentioned biomarkers were tested in logistic regression with roc analysis, assays with auc> . were selected for analysis in fyne-gray regression with competing risks. cut off levels were determined for significant parameters. results: median follow-up was months (range - ). in the whole group overall survival (os) was %, eventfree survival (efs) %, grade ii-iv acute gvhd %, moderate and severe (m&s) chronic gvhd %, nrm %, mortality in patients with gvhd %, ri %. there was no difference between bm/related and pbsc/unrelated grafts in the incidence of gvhd, nrm and ri (p> . ). the only significant predictor of acute gvhd were low levels of il- level on day+ (p= . , % vs % with the cut off pg/ml). m&s chronic gvhd was predicted only by the high percentage of inkt cells in the graft (p= . , % vs % with the cut off . %). there was a correlation between il- levels and number of nk cells in the graft (p= . ). nrm was related to infectious complications, nonetheless high levels of vegf a on day (p= . , % vs % with the cut off ng/ml), st on day+ (p= . , % vs % % with the cut off ng/ml) and low percentage of cd +cd -cells in the graft (p= . , % vs % with the cut off . %). the identified biomarkers of nrm had no association with the pre-transplant crp and ferritin levels (p> . ). the only significant parameter for ri was the level of cd cells in the graft (p= . ). none of the identified biomarkers significantly predicted overall survival (p> . ). conclusions: in the related and unrelated grafts with ptcy the study of biomarkers has low clinical utility due to very low gvhd-related mortality. however st and vegf a can predict infection-related mortality. also the study verified previous observations that high level of il- is associated with reduced gvhd incidence after ptcy and identified the importance of nk and inkt cells in the induction of tolerance with ptcy. references background: hematopoietic cell transplantation (hct) is the only curative approach for many hematological malignancies but life-threatening toxicities, such as graft-versushost disease (gvhd) and infections, still limit its fullpotential impact on the disease. strategies for keeping allohsct more effective and safe are needed in order to reduce morbidity while improving its immunological effect to control disease relapse. post-transplant cyclophosphamide (ptcy) has been demonstrated to improve acute gvhd (agvhd) and chronic gvhd (cgvhd) control in allogeneic bone-marrow hct from identical and haploidentical donor. the use of ptcy, after peripheral blood stem cell transplantation (allopbsct) from hla-matched unrelated/related donors, has been investigated by our group in a clinical trial (nct ) and preliminary results were published last year. here we report updated efficacy and safety data about the expanded cohort of patients treated with ptcy followed by tacrolimus and mycophenolate mofetil (t/mmf). methods: we analysed data about consecutive patients with high-risk hematologic malignancies received allopbsct from hla-matched unrelated/related donors between march and august . gvhd prophylaxis was ptcy mg/kg (days + + ), tacrolimus from day + and mmf from day + to day + . primary objectives were cumulative incidence of agvhd and cgvhd. secondary objectives were event-free survival (efs), cgvhd-efs, overall survival (os) and non-relapse mortality (nrm). results: patients median age at transplant was (range - ) years. ( %) patients were transplanted in first complete response (cr), ( %) patients in second/third cr, the others in disease control. a median dose of . (range - ) x ^ cd /kg was infused. primary graft failure was observed in one patient. all patients were off mmf on day + , the median day of tacrolimus discontinuation was (range - ). eight out of ( %) patients developed agvhd, ( %) of them were grade ii-iii; median day of onset was day (range . no grade iv was observed. no cases of late-onset agvhd were reported. cumulative incidence of cgvhd was % ( / ), median day of onset was (range - ). systemic treatments were required, but all patients were able to discontinue immunosuppression (is). with a median follow-up of (range - ) months, efs was %, cgvhd-efs was % and os was %. non-relapse mortality (nrm) was % ( / ): patients died because of multidrug resistant bacteria septicemia. nowadays patients are alive with no evidence of disease, being continuously off is and completely reintegrated in their normal daily life activities. conclusions: the updated reported results confirm, in a larger cohort of patients with a longer follow-up, that ptcy after pbsc-hct is highly active in agvhd and cgvhd prevention with extremely limited nrm. this strategy, not only allowed earlier discontinuation of immunosuppression, but also reduced the overall time of exposure to is for most of the patients. all these features might contribute, in the future, to transform hct into a safe immunologic platform that may be combined with advanced form of cellular therapies (car-tcells), aiming to increase safely the graftversus-tumor effect. clinical methods: pediatric patients ( - years) with nmd undergoing unrelated hct were eligible for this single center, phase i trial. following reduced intensity conditioning, abatacept ( mg/kg iv on days - , + , + , + ) was added to standard gvhd prophylaxis (cyclosporine, mycophenolate mofetil [mmf]). patients were followed for years for standard hct outcomes. [[p image] . figure results: since june , patients have been enrolled and transplanted (table , excluding # ). donor source was bone marrow in all. with median follow-up of . years, of patients survive without disease. initial engraftment was successful in , at a median of and days, for neutrophils and platelets respectively. one patient ( ) had secondary graft rejection in the setting of viral reactivation (cmv/ebv), with successful engraftment following a nd unrelated hct. in engrafted patients, myeloid (cd ) chimerism was % at all timepoints; t-lymphoid (cd ) chimerism was mixed but reached >/= % (figure ). one patient ( ) with saa had primary graft rejection in the setting of inadequate tnc dose ( . x /kg) and died from marrow aplasia/infection despite nd hct. a second death from wilms' tumor occurred months post successful hct, in a patient ( ) with dba and constitutional chromosome abnormality. except patient , all patients received doses of abatacept, which was well tolerated, with all severe adverse events expected for a hct population. cmv and ebv reactivation occurred in patients each, with resolution using standard anti-viral therapy. one patient ( ) was diagnosed with ebv-driven post-transplant lymphoproliferative disease, which responded to rituximab and immune suppression withdrawal. no patients developed severe acute (grade iii-iv) or chronic gvhd (table ) , and no patients required systemic immune suppression at > year. conclusions: these preliminary data suggest that abatacept can be safely added to cyclosporine and mmf gvhd prophylaxis in pediatric patients with bone marrow failure undergoing unrelated donor hct, with encouraging rates of gvhd despite half of patients having a mismatched ( / ) donor. given the higher risk of graft rejection in this non-malignant cohort, rejection (in addition to gvhd) will be a primary focus in our subsequent multi-center, phase trial. clinical trial registry: clinicaltrials. gvhd and may to have be separated from from toxicity to infectious complications in the early phase after allohsct. methods: from our files we identified patients which had upper gastrointestinal tract endoscopy after allohsct in with biopsies were taken from the esophagus, stomach and duodenum simultaneously. of these patients were excluded because of infection, reflux disease or drug toxity and the remaining patients were included in our study. we evaluated the routine stained esophageal biopsies, applied a grading scheme and compared the histological findings with those within the stomach and duodenum, the endoscopic findings and the clinical course. results: in of biopsy samples of the esophagus, we identified histological features of acute gvhd, ranging from vacuolar degeneration (grade ) and single-cell apoptosis (grade ) to the formation of clefts (grade ) and mucosa denudation in advanced cases (grade ), resembling epithelial lesions in acute gvhd of the skin. these findings correlated with gvhd involving the stomach and duodenum and the clinical manifestations of gvhd in other organs. endoscopically patients with gvhd revealed signs of inflammation, ranging from erythema to ulceration in the more advanced cases, sometimes reminiscent of reflux or infection. clinically these patients had abdominal discomfort ranging from inappetence to nausea, accompanied by emesis or diarrhea and weight loss. conclusions: we have shown that acute esophageal gvhd occurs after allohsct and is correlated with acute gvhd in stomach and duodenum. it could be diagnosed and graded histologically. the endoscopic findings are signs of inflammation. our results may help to establish the histological diagnosis of acute gvhd using endoscopic biopsies from the esophagus and to explain the alterations observed in the esophageal mucosa in patients after allohsct. [ background: intestinal acute graft versus host disease (agvhd) is a major thread after allogenic hematological stem cell transplantation (allohsct), with a high mortality in patients which were refractory to steroid treatment in particular. recent papers point to a correlation of histological grading of intestinal gvhd and prognosis in patient after allohsct. however a comparison with clinical scores has not been performed so far. methods: in this analysis, retrospective data from patients who underwent endoscopy due to clinical signs of agvhd (day + to + after allohsct) were evaluated. of each patient least biopsies from different sites of the colon which were taken simultaneously. of each biopsy series the maximum histological grad of agvhd according to the lerner scheme was obtained and compared with the glucksberg stage of the lower gastro intestinal tract (gslgi) and the overall glucksberg grade (ogg). these three grades were compared for non-relaps related mortality using the log-rank test and for sensitivity to steroid treatment applying the receiver operating characteristic for the patients who received steroid treatment. for these patients the non-relaps related mortality for responder and non-responder were calculated using also log-rank test. results: the histological grade strongly correlated with the survival (p= . ). a statistical significant correlation was also found for the gslgi (p= . ), whereas the ogg revealed no significant correlation (p= . ). non-relaps related mortality was mainly related to infection or sepsis (in / patients who died). -eighty-one of the patients received steroid therapy. the sensitivity to the steroid therapy correlated with each of the three scores (p< . ) but was the strongest for gslgi (area under the curve (auc) . ), compared to ogg (auc . ) and the histological score (auc . ). the survival of the patients, which were sensitive to steroid treatment was significantly better than those of steroid refractory patients (p= . ). conclusions: we found that histological and clinical grading in patients after allohsct with intestinal gvhd was correlated with survival and respond to steroid treatment. histological scoring may predict survival more precisely than ogg and gslgi but did not add substantial information to the prediction of treatment response. [ emerging evidences suggest that regulatory b cells (bregs) play essential roles in inflammation, autoimmune diseases and tumors. few data exist about the role of bregs in the contest of hematopoietic allogeneic stem cell transplantation (hsct). some authors have observed that bregs from patients with chronic graft-versus-host disease (cgvhd) were less frequent and less likely to produce il- than bregs as compared to healthy donors or patients without cgvhd. these findings suggest that bregs may be involved in cgvhd pathogenesis. the purpose of our study was to evaluate a possible role of b cell subsets on gvhd occurrence. methods: lymphocyte subset enumeration was performed by aquios cl flow cytometer (beckman coulter), a quantitative automated analyzer that performs two diagnostic panels: tetra- cd -fitc/cd -rd / cd -ecd/cd -pc and tetra- cd -fitc/cd +cd -rd /cd -ecd/cd -pc . b cell subsets (memory, mature and transitional b cells) on peripheral blood samples were analyzed by aquios designer software, a tool for the creation of user-defined applications. panel- cd -fitc/cd -pe/cd -ecd/cd -pc /cd -pc and panel- cd -fitc/cd -pe/cd -ecd/cd -pc / cd -pc were specifically designed by beckman coulter for our center. the flow cytometric analysis was performed as follows: in donors and patients at basal level; on graft products and in patients at days + , + , + , + after hsct. statistical significance was assessed with prism software (graphpad) by mann withney test. p < . was considered statistically significant. results: actually we enrolled patients submitted to hsct in our center from november . a preliminary statistical analysis was performed on patients. stem cells source was peripheral blood (pb) in cases and bone marrow (bm) in the others . the conditioning regimen was myeloablative in patients and ric in patients. agvhd was diagnosed in patients ( %). no associations were found between b cell subsets in donors and patients at baseline and the occurrence of agvhd. however we found a higher median percentage of transitional b cells in graft products in patients without agvhd ( . %, . - . ) compared to patients with agvhd ( . %, . - . ) (p= . , fig a) . in addition, patients without agvhd showed a lower median percentage of memory b cells ( . %, range . - ) in graft product as compared to patients with agvhd ( . %, range . - . ) (p = . , fig. b ). finally in the subgroup of patients receiving pb as stem cell source we observed a higher percentage of cd + lymphocytes in graft product in patients with agvhd ( %; range - ) compared to patients without agvhd ( %; range - ) (p= . ). in the monitoring of b cells reconstitution we observed that cd + events did not appear before day + after hsct and these were b transitional immature events predominantly. conclusions: our data suggest a possible protective link between transitional b cells and agvhd development. these results data need to be confirmed in a larger cohort of patients. moreover, it will be interesting to evaluate the relationship between transitional b cells at day + and the occurrence of cgvhd. clinical background: agvhd is a major complication of allogeneic hematopoietic stem cell transplant (hsct) and a risk factor for post-hsct mortality. the objective of this analysis is to describe patients with agvhd who had a suboptimal response to corticosteroids. methods: patients who developed ibmtr severity index ii-iv agvhd after first hsct between / / to / / were included in an ongoing chart review at centers in the united states. patients who had ever participated in a gvhd prophylaxis trial or used jak inhibitors were excluded from the study. suboptimal response to corticosteroids was defined as use of additional systemic anti-gvhd therapy, inability to taper high-dose steroids (≥ mg/ kg) by ≥ %, or tapered corticosteroids by ≥ % but not to < mg/day. results: the analysis included patients with suboptimal response to corticosteroids. mean age was years; % were male. median time from transplant to agvhd diagnosis was days. at the time of maximum agvhd grade, % of patients were grade ii and % were grade iii-iv; % had lower gi involvement, and % had ≥ organs involved. from time of diagnosis to maximum agvhd grade, % of patients had new organ involvement or an increase in agvhd grade. median time from diagnosis to maximum grade was . days, and was . days for patients with lower gi involvement. systemic corticosteroids were initiated on the day of diagnosis for % of patients. average starting daily dose was mg ( . mg/kg) for prednisone and mg ( . mg/kg) for methylprednisolone. steroid dose was increased for % of patients during follow-up; % were unable to taper below mg/day. among patients who received additional systemic anti-gvhd therapy (n= ), % increased their corticosteroid dose before initiation of additional anti-gvhd therapy. median time from initiation of corticosteroids to additional therapy was . days. frequently used therapies were mycophenyalate mofetil ( %), atg ( %), extracorporeal photophoresis ( %), tocilizumab ( %), etanercept ( %), and sirolimus ( %). agvhd recurred in % of patients and was managed by increasing corticosteroid dose in % of patients. % had any infection within first days post-hsct. forty patients ( %) required hospital readmission(s); % had ≥ readmissions within days post-hsct, with a mean inpatient lengthof-stay of days. relapse of underlying malignancy was reported for ( %) patients. two-thirds ( %, n= ) patients died at a median of (interquartile range (iqr): - ) days from agvhd diagnosis; a higher proportion ( %) of patients with maximum grade iii-iv agvhd died at a median of (iqr: . - . ) days; majority ( %) of patients with lower gi agvhd died at a median of . (iqr: - ) days. conclusions: a majority of patients with agvhd who had suboptimal response to systemic corticosteroids had severe and rapidly progressing disease and resulted in a high mortality rate ( %); progression was more rapid and mortality increased for patients with lower gi involvement. most patients required readmission to the hospital with extended length-of-stay. an urgent need exists for effective and tolerable therapies that quickly resolve life-threatening agvhd in early stages of disease. disclosure results: median time to onset of bo from allohct was . months (range . - . ). previous acute gvhd in . % (n = ) [grades iii-iv . % (n = )]. in . % (n = ) cgvhd had exclusive lung involvement, while the other patients ( %) had other organs affected. at diagnosis of bo, . % (n = ) were under immunosuppressive treatment. . % (n= ) of patients with bo received ecp as second-line treatment. median duration of treatment was months ( . - . ) and time to response . months ( . - . ). median of sessions was ( - ). evaluation of response was based on the evolution of fev measurement: . % (n = ) complete response; % (n = ) partial response and % (n = ) stable disease. one patient did not get any response and another was not evaluable. . % of patients (n = ) could reduce immunosuppression, and in one case it was completely discontinued. there is a trend for early separation between survival curves in favor of ecp ( figure ). one patient had sepsis secondary to central venous catheter infection as complication related to ecp. conclusions: ecp has emerged as a promising treatment for bo after allohct. in our experience, ecp was effective to stabilize or improve the disease in many patients and allowed to taper esteroids with minimal associated complications. however, prospective studies and longer follow-up are needed to support these findings. disclosure: nothing to declare background: the key role of il- signaling in acute graft vs. host disease (agvhd) and cytokine release syndrome (crs) has evoked growing use of tocilizumab, an anti-il receptor (il -r) antibody, in these settings. apart from regulation of t-and b-cell differentiation, immune cells migration to inflammatory sites and t-cell recruitment, il- complex with il -r through gp upregulates production of fibrinogen (fg) and other acute phase proteins, including c-reactive protein (crp). methods: we retrospectively analyzed data of patients treated with tocilizumab ( mg/kg) due to steroid-refractory (sr) agvhd and patients because of crs. median age was and years, respectively. seven patients were transplanted from unrelated donors (mud/mmud) and from sibling donors. eight patients received myeloablative and reduced intensity conditioning regimen. analyzed data included concentrations of fg, crp, an incidence of infections at tocilizumab administration and in weeks following the infusion. results: stage ii agvhd was diagnosed in patient, stage iii in , and stage iv in patients. involvement of the gastrointestinal tract (gi) was observed in % of cases. the median fg concentration before tocilizumab administration was . g/l (range, . - ) and crp mg/dl (range, - ) and % of patients had an active infection. after infusion of the antibody, we observed a decline of fg and crp levels. the median level of fg was . g/l (range, . - . ) - days after the tocilizumab infusion with no severe bleeding complications. a median crp value was . mg/dl (range, . - ) despite confirmed infectious complications. three weeks after infusion of tocilizumab fg raised to the normal range in % of patients (fig ) . five patients with sr agvhd achieved a complete response, and had a partial response after tocilizumab therapy. [[p image] . fibrinogen levels in gvhd patients following tocilizumab infusion.] a group treated with tocilizumab due to crs had higher initial levels of fg . g/l (range, . - . ) and crp mg/ dl (range, - ) before administration of the drug. reduced fg and crp levels from a baseline value were also observed in this group. however, concentrations were higher than in gvhd patients: fg . g/l (range . - . ) and crp . mg/dl (range . - ). in all patients, a differential diagnosis of disseminated intravascular coagulation was excluded. conclusions: . fibrinogen declines after tocilizumab therapy due to its cytokine-regulated production in the liver. coagulation monitoring should be performed during the first weeks after administration of the antibody to avoid serious bleeding complications. . crp concentrations remain low despite the presence of active infections following infusion of tocilizumab. crp fails as a marker of infection during weeks following the therapy. . tocilizumab is an effective therapy in patients with agvhd, especially with the gi involvement. disclosure: nothing to declare vanishing bile ducts after allogenic hsct: is it really gvhd? antonio grasso , lorenzo d'antiga , aurelio sonzogni , massimo gregori , alessandra maestro , roberto simeone , natalia maximova background: evaluation of liver gvhd was historically based by elevation of bilirubin levels and by reduction and degeneration of small bile ducts on histological samples of post-transplant liver biopsy. however, there is a lack of studies that compared histological finding of ductopenia between post-autologous hsct and post-allogenic hsct. studying severity of ductopenia following allogenic hsct, we aimed to demonstrate lack of correlation between ductopenia and clinical signs of liver gvhd. methods: we retrospectively collected a series of allogeneic hsct performed from to in the institute burlo garofolo. all patients undergo percutaneous liver biopsy in most cases at three months, one year and three or more years after hsct. indications for biopsy were alteration noted at weekly follow-up assessments of at least one clinical or laboratory marker of liver impairment or cholestasis. ductopenia was defined by number of portal tracts with no interlobular bile duct divided by the total number (severe if the ratio was less than . ). clinical gvhd was defined by nih consensus criteria results: our population involved % males and % females with oncological ( %) and non-oncological underlying disease ( %). clinical signs of liver gvhd were present in % of the patients (n= ), % with contextual intestinal involvement, % with cutaneous and intestinal involvement. patients underwent biopsy at a mean time of +/- days after hsct, patients underwent a biopsy at months after hsct and patients after three or more years from hsct. results of biopsies are showed in table . no difference in incidence of ductopenia were found between liver gvhd group and no gvhd. table] . table : incidence of ductopenia - months, months and or more years after hsct in total population, gvhd group and no-gvhd group] the group that not received chemotherapy prior the hsct had an overall incidence of ductopenia of % (severe ductopenia of %) statistically significative in comparison with the oncological underlying disease group ( % of ductopenia and % of severe ductopenia). furthermore, a little sub-group of patients extrapolated from our population received liver biopsy before hsct for diagnostic assessments: of the with an oncological underlying disease % already showed ductopenia, while no signs of ductopenia were found in the others with a nononcological disease. conclusions: there is no correlation between incidence of gvhd and histologically finding of ductopenia on liver biopsy. ductopenia may be caused in the first place by chemotherapy treatment received before hsct and myeloablative conditioning for hsct and it's not related with gvhd. this hypothesis is strengthened by the subgroup analysis of pre-hsct biopsy. background: second and third line therapies for steroid refractory acute graft versus host disease (agvhd) after allogeneic stem cell transplantation (asct) are still lacking. ruxolitinib, a selective januskinase / inhibitor could show high efficacy in agvhd, as well as extracorporeal photopheresis (ecp). here we report a single center experience of combining both therapeutic approaches in severe steroid refractory agvhd with additional analysis of immune status of these patients to elucidate direct effects of this treatment on immune response. methods: from june to february , patients ( . % male, . % female, median age: . years, r: - ) with steroid refractory agvhd of lower gi-tract after asct were treated with ruxolitinib and extracorporeal photopheresis as third, fourth or fifth line therapy. some patients showed additional agvhd of skin (n= ), liver (n= ) or upper gi-tract (n= ). all patients had an overall grade iii ( %) or iv agvhd ( %). steroid refractoriness was defined as no improvement in days or aggravation after days of steroid treatment.median start of ruxolitinib or ecp was day . after asct (r: - ). medianduration of ruxolitinib therapy was . days (r: - ) with a median start dosage of mg per day ( x mg; r: - mg). all patients started with ecp treatments per week with an individual reduction of treatment frequency. median number of ecp treatments was . (r: - ) with a median frequency of ecp therapy once a week (r: . - . ). cytomegalovirus (cmv) status of all patients and immune status of ten patients (lymphocyte count with cd + t helper lymphocyte and regulatory t cell count) were collected previously, after four weeks of starting combined treatment and four weeks after stopping the treatment. results: one-year estimated overall survival (os) of all patients was % with a median estimated os of days. patients died because of relapse of underlying disease, one of severe therapy refractory agvhd of lower gi tract and due to infection complications in agvhd refractory setting. overall response was . % (complete remission rate: . %, partial remission rate: . %). . % (n= ) of the patients had cytopenia ctc i-iii during the treatment, no grade iv cytopenia was reported. cmv reactivation during ruxolitinib occured in . % of cases (n= ). tapering of steroids could be performed rapidly with a medium reduction time of . days for reducing to half of the dosage.remarkably, regulatory t cells significantly increased during combined ruxolitinib/ecp treatment compared to regulatory t cell count before treatment (p= . ) and after stopping treatment, regulatory t cell count decreased again (p= . , see figure) . significant changes in whole lymphocyte count or in cd + t helper cell count were not observed. conclusions: treatment of severe steroid refractory agvhd with ruxolitinib plus ecp could show a high complete remission rate of . % with an one year os of %. detecting increased regulatory t cell count during the treatment underlines its direct effects on immune response and encourages to pursue this promising therapeutic approach. [ background: due to increased immunosuppression infections remain the main cause of death followed by higher risk of relapse in patients treated for acute graft versus host disease (agvhd) after allogeneic stem cell transplant (sct). here we report a single-centre experience with extracorporeal photopheresis (ecp) for acute gvhd that was introduced in order to reduce steroid treatment. comparison of overall survival (os) for patients on ecp and patients that received standard first line therapy for agvhd was performed. methods: we retrospectively analysed patients ( %) with acute gvhd grade ii-iv treated from january to october out of total allogeneic sct in that period. all patients received calcineurin inhibitors or sirolimus while receiving steroid treatment for agvhd. twenty-five patients ( %) received ecp with steroid lowering intent. we defined response as ( ) reduction of steroid dose for at least % from baseline while not adding another immunosuppresive agent and ( ) not repeating second steroid treatment if the ecp was started after lowering of steroids to prevent agvhd flare. we checked separately patient responsive and refractory/dependent to steroids. on average patients received ecp procedure once weekly. results: tapering of immunosuppressive therapy as defined was successful in ( %) out of patients in ecp group. in a group of patients without ecp ( %) patients had steroid refractory or steroid dependent agvhd compared to ( %) patients in ecp group. four ( %) patients with steroid refractory or dependent agvhd showed improvement in ecp group compared to only one ( , %) in non ecp group. twenty ( %) patients died due to infectious complication and ( %) due to relapse in non ecp cohort. in ecp cohort ( %) patients died due to infection and ( %) due to relapse. median os was months in non ecp group (r., - ) compared to months (r., - ) in ecp group and os of % at years in non ecp compared to % in ecp cohort was observed. patients with agvhd treated with ecp and faster steroid tapering had longer os compared to patients without ecp (p= , ). conclusions: ecp enables successful tapering or withdrawal of steroid therapy in many patients, even in those who are steroid refractory or steroid dependent. reduction of immunosuppression leads to reduced incidence of infection and relapse which translates into a better overall survival. background: the curative potential of allogenic stem cell transplantation is hampered by graft-versus-host disease (gvhd). pre-clinical study showed an efficacity of jak / inhibitor, ruxolitinib, in treatment of steroidrefractory gvhd. methods: we reported in this monocentric retrospective study, ruxolitinib response and follow up of cases of chronic gvhd (cgvhd) not improved with standard immunosuppressive therapy. complete organ response (cr) was defined as the resolution of clinical manifestations of cgvhd in a specific organ. very good response partial (vgpr) was defined as an improvement of clinical manifestations of cgvhd with more than % decrease of corticosteroid, while a partial response (pr) was associated with less than % decrease of corticosteroid. treatment failure was defined by the absence of improvement of cgvhd, deterioration of cgvhd in any organ by at least one stage, the development of cgvhd manifestations in a previously unaffected organ, and the use of any additional agents to control the disease. results: median age at transplant was years (range, - ). % of patients presented an acute myeloid leukemia. donor type was sibling (n= ), unrelated (n= ) or haploidentical (n= ).two patients benefited a cord blood transplant. patients received either myeloablative ( %) or reduced intensity ( %) conditioning regimens. stem cell source was peripheral blood for % of patients. patients presented mild (n= ), moderate (n= ) or severe (n= ) cgvhd according to nih score. median number of regimens prior to ruxolitinib was (range, - ), among those corticosteroids (n= ). median follow-up after ruxolitinib was months (range, - ). overall responses rate (orr) at month was % with % cr, % vgpr and % pr ( figure ). % of patients failed at month after introduction of ruxolitinib. the rate of cr increased with time : % at months (n= ), % at months (n= ) and % at months (n= ). but vgpr rate was rather stable at months ( %), at months ( %) and at months ( %) vs % at month. among the patients under steroids, ( %) patients discontinued steroids. the -months overall survival (os) and diseasefree survival (dfs) after ruxolitinib was % ( %- %, % ci) and % ( %- %, % ci), respectively. severe cytopenia (grade and ) was observed in patients. after introduction of ruxolitinib, patients presented bacterial infections, patients presented an invasive pulmonary aspergillosis and patient developped a pneumocystis. cytomegalovirus reactivation requiring preemptive treatment was observed in patients. no toxicities required withdrawal of ruxolitinib. [[p image] . figure and partial response to mesenchymal stem cells (msc), as second-line therapy, varies from % to % in acute gvhd patients. we report our experience using mscs to treat refractory agvhd. methods: the study was a retrospective single center study. all data were collected from patients' files. twenty patients were enrolled (age ranging from months to years) between april and april . results: five of these patients received reduced intensity conditioning and patients received myeloablative regimens before hsct. one haploidentical, autologous, cord blood, mud, msd transplantations were performed. the patients were eligible if they developed grades ii-iv agvhd. all patients were treated with standard first-line treatment with corticosteroids and at least one second-line therapy. the definition of steroid resistant agvhd considered as either no response to steroid treatment lasting at least days or progression during treatment of at least one grade within the first hours. prophylactic treatment with calcineurin inhibitors continued at therapeutic dose level. totally, doses of mscs were infused. the median dose of msc was . × cells per kg body weight. the median duration between the diagnosis of agvhd and initiation of mscs therapy was days (range: - ). the received msc doses ranged from one to seven. none of our patients had severe side-effects during infusions of mscs. overall, complete response (ocr) was obtained in patients, partial response in patients and no response (nr) was documented in patients. in our study group, the complete response rates in liver, gastrointestinal, skin agvhd were %, %, % respectively. four patients ( %) died in days after using mscs from complications of agvhd. eleven of patients ( %) were still alive with a median follow-up of days (range: - days) after first mscs infusion. one year estimated probability of overall survival for patients achieving ocr and partial remission/no remission in th day of mscs were . % and %, respectively. conclusions: in conclusion, mscs appears to be a safe and effective treatment option for pediatric patients with steroid refractory agvhd. disclosure: nothing to declare effect of extracorporeal photopheresis on production of serum elafin in chronic graft versus host disease arun alfred , charlotte burton , kathryn goddard , nichloas matthews background: extracorporeal photopheresis (ecp) is a second line therapy for steroid refractory, dependent or intolerant chronic gvhd (cgvhd). in order to guide ecp there is an unmet need for predictive and diagnostic biomarkers. elafin is a serine-protease inhibitor primarily produced by epithelial cells, particularly keratinocytes in inflammatory skin diseases and plasma and epidermal elafin have been identified as biomarkers of skin gvhd ( , ) . since skin cgvhd is noted for a particularly high response rate to ecp, we conducted a study to investigate whether ecp affects the production of elafin. methods: serum samples were collected from cgvhd patients ( male / female; age range: - ) and age-matched healthy controls ( male / female) before ecp and at month intervals up to year. patients had gvhd affecting skin ( / ), mucosal membranes ( / ), liver ( / ), joints ( / ), gut ( / ), eye ( / ), genital ( / ), and respiratory involvement ( / ). serum elafin was assessed by elisa (r&d systems). data were analysed using graphpad prism . statistical tests performed include -tailed mann-whitney, pearson's correlation test, and -way anova with repeat measures, as appropriate. results: chronic gvhd patients presenting for ecp had significantly elevated serum levels of elafin (p= . ; median of ng/ml, iqr - ng/ml) compared to healthy controls (median of ng/ml, iqr . - ng/ml).while % of patients had skin involvement, only % had elafin levels above the iqr of healthy controls. where disease scores were available (n= ) there were no significant correlations with modified rodnans (r= . ) or nih bsa scores (r= . ).sub-analysis was performed by grouping cgvhd patients according to quartiles of serum elafin at pre-ecp baseline. retrospective analysis of patients after months of ecp (n= ) revealed that those with serum elafin levels in the upper quartile (elafin hi ) pre-ecp (min-max: - ng/ml), showed a significant reduction after months of therapy (p< . ; mean +/-sd : ng/ml +/- ng/ml vs ng/ml +/- ng/ml, respectively), which was sustained up to months of ecp (p< . ; mean +/-sd: ng/ ml +/- ng/ml). in contrast, patients with elafin levels below the upper quartile (elafin lo ) showed no significant change (mean +/-sd: ng/ml +/- ng/ml vs ng/ml +/- ng/ml, respectively). of note, pre-ecp patients with elafin below the median received significantly more corticosteroid (cs) than those above, (p< . ; mean +-sd: +/- mg/d vs +/- mg/d, respectively), which was significantly reduced after months of ecp (p< . ; to +/- mg/d), while cs dose was not significantly changed in elafin hi patients until months (p< . ; mean +/-sd: mg/d +/- mg/d vs mg/d +/- . mg/d, respectively). conclusions: consistent with recent data, we found that serum elafin is significantly elevated in a subset of cgvhd patients compared to healthy controls, but did not correlate with skin disease scores. ecp administration was associated with a reduction in serum elafin in the elafin hi subset. further, elafin lo and elafin hi patients tolerated different rates of ecp-mediated tapering of cs immunosuppression suggests pre-ecp elafin measurements may have predictive value. references : background: allogenic hematopoietic stem cell transplantation (hsct) is a potential curative treatment for many malignant and no malignant hematologic diseases, primary immunodeficiencies and some metabolic and deposit diseases in children. graft versus host disease (gvhd) is a major cause of morbidity and a leading cause of non-relapse mortality. corticosteroids are the standard first-line systemic treatment for both acute and chronic gvhd, whereas no second line option for corticosteroid-refractory patients is standardised. ruxolitinib is a potent inhibitor of jak / showing significant responses in refractory gvhd patients in recent reports. methods: we present two centres experience with ruxolitinib for gvhd treatment in pediatric patients. the study was conducted in two spanish pediatric hsct centres, hospital vall d'hebron (barcelona) and hospital universitario la paz (madrid). all patients receiving ruxolitinib since the drug was available were included for retrospective analysis. results: between march and december pediatric patients with acute or chronic gvhd with refractoriness to corticosteroids were treated with ruxolitinib, in different episodes (one patient received it in different moments, and one patient received it in ). patient's sex at birth was female in and male in cases. median age at hsct was , years ( , - , ). primary disease was malignant in patients and non malignant in . median time of gvhd diagnosis was , days ( - ). all gvhd episodes were treated with corticosteroids as first line, with maximum doses between - mg/kg/day (the main dose used was mg/kg/day, / episodes). patients received a median number of , ( - ) previous lines of treatment including steroids before starting ruxolinib; they were extracorporeal photopheresis ( / episodes), sirolimus ( / ), mesenchymal cells ( / ) ruxolitinib initiation was indicated for acute gut refractory/steroid dependant gvhd in episodes and chronic multisystemic in episodes. other indications were chronic lung ( / episodes), chronic skin ( / ) and acute skin gvhd ( / ) . median post-hsct time of ruxolitinib start was days. doses ranged between , - mg/ h depending on age, weight, and tolerance (hematologic and liver toxicities). average duration of treatment was days ( - ). complete response (cr) rate was , %, global partial response (pr) , %, and no response (nr) % (progression in one patient and recent treatment start in other patient). mean time to maximum response was weeks. treatment stop cause was cr in cases, infection in , liver toxicity in . no severe side effects directly related to ruxolitinib treatment were described. conclusions: ruxolitinib has been recently introduced as second line strategy for rescuing corticosteroid-refractory gvhd in pediatric patients. while results of randomized trials are lacking, we present our experience (two centres). the main indications for starting treatment were acute gut and chronic multisystemic gvhd. most patients achieved some grade of response (partial or complete), allowing stopping or tapering corticosteroids. toxicity profile appears to be acceptable. disclosure: nothing to declare. stability of tacrolimus concentration early after allogeneic hematopoietic stem cell transplantation reduces the risk of acute gvhd background: tacrolimus is used as an immunosuppressive drug after allogeneic hematopoietic stem cell transplantation (allo-hsct). it is well known that early concentration level of tacrolimus is correlated with the risk of acute graft versus host disease (agvhd), however, whether range of standard derivation (sd) of early tacrolimus concentration after allo-hsct also affect to the risk of agvhd still remains unknown. here, we investigate the correlation between the range of sd of early tacrolimus concentration after donor hematopoietic cells engraftment and the development of agvhd. methods: we retrospectively assessed patients who underwent allo-hsct in our hospital from - . all patients received standard gvhd prophylaxis by continuous intravenous (iv) tac with starting dose of . mg/ kg/day from day before allo-hsct (day - ) and iv methotrexate on day , , at dose of mg/m , mg/m , mg/m , respectively. tac dosage was adjusted to target the serum concentration of - ng/ml until at least day and then tapered. to evaluate the sd of weekly tacrolimus concentration, the range of sd of tacrolimus concentration at day - (week- ), day - (week- ), day - (week- ) and day - (week- ) were calculated. the difference of the range of sd between the groups that develop or did not develop agvhd was compared by using mann-whitney u test. multivariate analysis was performed by using multiple logistic regression analysis. patients had given written consent allowing the use of medical records for research, in accordance with the declaration of helsinki, and the institutional review board approved the study. results: there were males and females and the median age was years (range, to years). the risks of disease were low-standard in and high in pts. the number of donors were in hla-identical sibling, in hla-mismatched related donor, in hla-matched unrelated donor and in hla-mismatched unrelated donor. thirty-seven patients developed agvhd (grade i-ii; , gradeiii-iv; patients). as a result, the wide range of sd at week- significantly increased the risk of agvhd (agvhd-group; . ± . ng/ml, agvhd+ group; . ± . ng/ml, p= . ). multivariate analysis demonstrated that narrow range of sd of tacrolimus concentration at week- reduce the risk of agvhd (or= . ; % ci: . - . ; p= . ). there were no correlation between gender, age, disease status, hla with the development of agvhd. conclusions: the range of sd at week- , an engraftment phase of donor hematopoietic cells, was significantly correlated with the development of agvhd. fine tuning of early tacrolimus concentration with narrow range of sd reduces the risk of agvhd, resulting in improvement of the overall survival after allo-hsct. disclosure: nothing to declair p ruxolitinib treatment for steroid-refractory graftversus-host disease han-seung park , je-hwan lee , jung-hee lee , eun-ji choi , miee seol , young-shin lee , young-ah kang , mijin jeon , kyoo-hyung lee background: steroid-refractory graft versus-host disease (gvhd) is one of the most lethal complications after allogeneic hematopoietic cell transplantation. recent studies have shown that ruxolitinib, a janus kinase / inhibitor, is effective in patients suffering from gvhd. here, we report a retrospective result of ruxolitinib treatment for steroid-refractory gvhd. methods: all patients had received cyclosporine and a short course of methotrexate as gvhd prophylaxis. antithymocyte globulin was added for unrelated or mismatched familial donor hct. ruxolitinib mg twice daily was added to immunosuppressive treatment in patients with steroid-refractory gvhd. results: a total of patients with gvhd (acute, , including patients with donor lymphocyte infusion [dli]related; and chronic, ) were included in the analysis. all patients had grade / acute gvhd or severe chronic gvhd at the time of ruxolitinib treatment. six ( . %) of patients with acute gvhd responded to ruxolitinib, including with complete response (cr). the median time to response was . days (range, - ) . nineteen patients received ruxolitinib for severe chronic gvhd, with the median of involved organs (range - ). fourteen patients ( . %) showed response to ruxolitinib, including crs. the median time to response was days (range, - ). five responders discontinued ruxolitinib and patients are still on the agent. after a median follow-up duration of . months, died ( from relapse of disease, from infection). the -year survival probability was . %. eleven of responders discontinued ruxolitinib. gvhd relapsed in of patients at , , and days after ruxolitinib discontinuation. thrombocytopenia ( / , grade / ; ) was the most common adverse event of ruxolitinib. during treatment, with grade / infectious adverse events occurred; pneumonias, brain abscess, and liver abscess. conclusions: ruxolitinib treatment seems to be effective for the treatment of steroid-refractory gvhd including long-standing chronic gvhd. the agent was well tolerated and relatively safe. disclosure: nothing to declare. il -receptor antibody tocilizumab as salvage therapy in the treatment of severe chronic gvhd after stem cell transplantation: a retrospective analysis background: severe chronic graft-versus-host disease (cgvhd) remains the most relevant factor affecting survival and long-term quality of life after allogeneic hematopoietic stem cell transplantation (hct). besides corticosteroids there is no established therapy for cgvhd and many of the used immunosuppressive agents may lead to significant toxicity incl. infectious complications. tocilizumab (an il -receptor antibody) has shown efficacy in acute gvhd and cgvhd. we retrospectively analyzed the efficacy and safety of patients having received tocilizumab for treatment of advanced cgvhd at our center between the years and . methods: patients with severe steroid refractory cgvhd and a median age of years (range: - yrs) having received at least two prior lines of therapy for cgvhd (range: - regimens) were treated with tocilizumab for at least one cycle (q w, dosage: mg/kg iv, maximum: mg) with a median number of cycles (range: . nih consensus criteria grading for cgvhd and the immunosuppressive regimen were noted at the time of the first tocilizumab administration and after , and months of therapy. all patients received additional concomitant immunosuppressive agents already given at least weeks without response before start of tocilizumab. no new immunosuppression (is) was added in parallel to tocilizumab and response assessment was stopped at start of any additional new is. all patients had received peripheral stem cell allografts. gvhd prophylaxis consisted of a calcineurin inhibitor in combination with methotrexate or mycophenolate and in case of unrelated donors atg was added. / patients had quiescent onset of cgvhd, one patient developed de novo cgvhd. the median number of days between hct and onset of cgvhd was ( - ). the median number of days between hct and initiation of tocilizumab therapy was ( - ) days. at cgvhd onset, / patients had mild cgvhd and / patients had moderate cgvhd. the thrombocyte count was < /nl in / patients. organs involved at initiation of tocilizumab therapy were skin ( %, all grade ), eyes ( %), mouth ( %), fascia ( %), lungs ( %) and genitals ( %). / patients are still receiving tocilizumab at the time of analysis. results: as tocilizumab was given fairly recently in most patients, -and -month follow-up was only reached in / patients ( %). at three-month follow-up after initiation of tocilizumab therapy, / patients ( %) showed partial remission, / patients stable disease ( %), and / patients progressive disease ( %) of cgvhd. maximal response was partial remission ( %), stable disease ( %) and progressive disease ( %). patients required subsequent new immunosuppressive treatment. one patient has not yet reached -month follow-up. during tocilizumab therapy none of the patients suffered recurrence of underlying malignancy. two patients developed significant respiratory infection and one patient developed soft tissue infection, all requiring antibiotic treatment and pausing of tocilizumab administration, hospital admission was not required. the os and rfs was % with median follow up of . months (range - months). conclusions: tocilizumab appears to be a promising treatment option in advanced cgvhd but further evaluation within a phase ii trial is required. disclosure: nothing to declare background: allogeneic hematopoietic stem cell transplantation (hsct) is for many patients suffering from aml the only curative treatment option. one major complication is graft versus host disease (gvhd), caused by donor immune cells attacking healthy tissue. regulatory t cells (treg) have been getting huge attention during the past years because of their important role in maintaining immune balance. here we collected peripheral blood samples from patients at different time points after hsct to investigate immune-reconstitution of treg as predictive marker for the development of gvhd. methods: we collected blood samples from patients in the course of allogeneic hsct prospectively once a week from d+ up to d+ . all patients received conditioning regimen with fludarabine and melphalan, combined with alemtuzumab for t cell depletion. patients developed acute gvhd in the later course. after isolation of pbmc`s we performed facs multicolor staining of t cell and nk cells. treg were identified as cd + cd + cd ++ foxp + , nk cells were characterized as cd neg cd + cd + and divided in nk cell subpopulation due to their expression of cd dim or cd high . results: . cd neg t cells: all patients developing acute gvhd in the later course showed significant elevated levels of cd + cd neg t cells, especially cd neg treg at d+ . . cd neg treg / cd + cd + t cells: one patient not developing acute gvhd showed lots of cd neg treg but missed cd + cd + effector t cells. we recently showed that cd + cd neg effector t cells are of impaired effector function. these data suggest that cd neg treg are only of relevance combined with functional cd + cd + effector t cells in the development of agvhd. . t cell marker: patients without agvhd showed elevated expression of garp on treg. garp was significantly higher expressed on cd + treg, indicating a better suppressive capacity of cd + treg. this was detected throughout from d+ until d+ . tigit and ilt showed a heterogeneous expression profile without significant differences between the two groups. . nk cells: we detected a higher ratio of cd ++ /cd dim nk-cell population in patients without. we could also show that tigit is mainly expressed on cd dim nk cells. conclusions: we and others showed reconstitution of cd neg t cell subsets after alemtuzumab mediated t cell depletion -our data on effector t cells showed an impaired effector function for cd neg cd and cd t cells. recently we presented data on impaired suppressive capacity of cd neg treg and the association with acute gvhd retrospectively (wölfinger ebmt , ash ). here we provide prospective data on patients after the use of alemtuzumab in the context of hsct: our preliminary data suggest that the total amount of cd neg-treg and the ratio of cd neg treg to cd + cd + treg on d+ after allogenic hsct could predict agvhd. this data may be a basis for immune monitoring of patients at d+ to evaluate their risk for agvhd and could lead to the use of prophylactic treg dli in the context of alemtuzumab mediated t cell depletion. disclosure: medac -travel support, novartis -consultancy fee, pfizer -consultancy fee, shireconsultancy fee background: multiple factors such as disease activity and severity, therapy and/or dietary habits can cause changes in nutritional status independently or by interacting with each other. presence of malnutrition or significant weight loss in chronic gvhd (cgvhd) patients was reported in literature up to %. the aim of this cross-sectional study was to identify factors that affect nutritional status in cgvhd patients. methods: nutritional status in patients with cgvhd treated at the university hospital center zagreb, croatia from to was assessed. anthropometric measurements (height, body weight (bw), body mass index (bmi)) and clinical validated tool patient-generated subjective global assessment (pg-sga) (where patients were categorized as well-nourished (pg-sga a), moderately malnourished (pg-sga b) or severely malnourished (pg-sga c)) were used. all patients were evaluated according to nih criteria for cgvhd diagnosis. descriptive and correlation analysis were preformed. results: in total, adult cgvhd patients were included in the study, women ( . %), median age ( - ) years, with mild cgvhd in ( . %), moderate in ( . %) and severe in ( . %) patients. according to the pg-sga rating ( . %) patients had pg-sga a, ( . %) pg-sga b and ( . %) had pg-sga c, giving a total malnutrition or risk of malnutrition prevalence of . %. the mean bmi was . ± . kg/m with correlation to pg-sga rating (r= . , p= . ). malnutrition according to the bmi (defined as bmi< kg/m ) was found in patients ( . %). bw changes ( % or more in months) were significant in patients ( . %). according to the pg-sga assessment tool, oral symptoms reported by patient ( . %) and decreased appetite reported by patients ( . %) were associated with oral cgvhd nih score (r= . , p= . ; r= . , p= . ) but not with bw or bmi. gastrointestinal (gi) symptoms assessed with sga, were generally mild with no correlation to gi cgvhd nih score. no significant association was found between nutritional status and other nih cgvhd scores. corticosteroid therapy present in ( . %) correlated with pg-sga rating (r= . , p= . ) but not with bw, bmi or appetite changes. in patients ( . %) with altered pg-sga rating, bmi, appetite and body weight changes, dietary counseling and oral nutritional supplementation were initiated. conclusions: oral symptoms, decreased appetite and corticosteroid therapy in our cgvhd patients were associated with altered nutritional status according to the pg-sga, but not with bmi. therefore, pg-sga might be a more sensitive tool in assessment of changes of the nutritional status and detection of patients at risk of malnutrition than bmi since it includes different factors like physical examination, presence of gi symptoms and corticosteroid therapy in its scoring system. nutritional counseling and support are important in cgvhd patients especially in presence of oral symptoms. disclosure: nothing to declare. background: sclerotic skin changes are common features in chronic graft versus host disease (cgvhd). one of the most challenging aspects in the diagnosis and management of sclerodermoid cgvhd (scgvhd) is the differentiation between reversible symptoms related to active cgvhd and nonreversible symptoms related to residual permanent damage such as long-standing fibrosis. although several candidate biomarkers of cgvhd inflammatory activity have been proposed, none of them are currently validated. therefore, there is a need for the development of more quantifiable and reproducible measurements tools to guide clinical decisions. we report our experience evaluating the usefulness of high-frequency ultrasonography (hfus) plus doppler ultrasound (doppler-us) and serum fibrosis biomarkers to determine the inflammatory activity of scgvhd. methods: we report patients with scgvhd. hfus plus doppler-us were performed at diagnosis of scgvhd and at different time-points after treatment initiation. serum hyaluronic acid and pro-colagen-iii were measured as fibrosis biomarkers simultaneously with hfus and doppler-us. nih cgvhd consensus conference diagnosis criteria, scoring system, and response criteria were used to assess global and organ-specific cgvhd, and to measure overall response to therapy. abnormal ultrasound findings were defined as the presence of ≥ of the following: hypoechogenic dermis, dermo-epidermal junction effacement, hypoechogenicity of septa and/or hyperechogenicity of lobules in hypodermis, hypoechogenic fascia, or myositis, for hfus; and, vessels thicker than mm in dermis and/or hypodermis, systolic pressure > cm/sec, and index of vascular resistance > . , for doppler-us. inflammatory activity was classified as mild, moderate and severe according to the severity of doppler-us findings. results: hfsu showed abnormal findings in all patients at diagnosis with no changes except in two patients along the treatment follow-up. inflammatory activity by doppler-us was observed in / patients at diagnosis ( mild, moderate, severe). four patients responded to treatment ( complete responses, cr, and partial responses, pr), one presented clinical improvement less than pr, and one, progressive disease. all patients with clinical response had also a p-rom improvement or normalization. all patients achieving a response showed normalization (n= ) or improvement (n= ) of doppler-us findings. the patient with clinical improvement less than pr and the patient with progressive disease showed persistence of inflammatory doppler-us findings. most patients had normal or light increase of pro-collagen levels at diagnosis and no significant changes were observed during follow-up. levels of hyaluronic acid tended to be very high in patients with progressive scgvhd (patients and ) and tended to decrease or normalize in those who responded to therapy (patients , , and ). conclusions: in this exploratory study, hfsu was a reliable method for evaluating sclerotic skin changes in scgvhd. doppler-us showed a good correlation with disease activity and response to treatment. serum hyaluronic acid levels might be a biomarker of disease activity that deserves further investigation. hfsu plus doppler-us is a useful, non-invasive, repeatable device in monitoring patients suffering from scgvhd. according to our results, doppler-us may be a more sensitive parameter than hfsu in assessment inflammatory activity of scgvhd. disclosure: maría suárez-lledó received a grant from dkms-spain foundation. other authors have nothing to declare post-transplant cyclophosphamide versus antithymocyte-globulin in hla-matched unrelated and haploidentical transplantation for hematologic malignancies background: post-transplant cyclophosphamide(ptcy) and antithymocyte-globulin(atg) are the most commonly used regimens for the prophylaxis of graft-versus host disease(gvhd). we compared these two regimens in hlamatched unrelated (mud) and haploidentical transplantation for hematologic malignancies. methods: we retrospectively analyzed the consecutive adult patients with hematologic malignancies who received mud and haploidentical transplantation at chungnam national university hospital between january and january . patients who received second transplantation and had refractory disease were excluded. results: this study included patients with median age of (range, - ) years: ( . %) patients received mud transplant ( and patients in ptcy and atg group, respectively), and ( . %) patients received haploidentical transplant ( and patients in ptcy and atg group). graft source was peripheral blood stem cell in all patients. median follow-up duration was . months (range, . - . ). in mud transplant, the estimated -months survival rate were . % in ptcy vs. . % in atg (p= . ), the -months relapse rate were . % in ptcy vs. . % in atg (p= . ), the cumulative incidence of grade to acute gvhd were . % in ptcy vs. . % in atg (p= . ), and the estimated -month extensive chronic gvhd rate were . % in ptcy vs. . % in atg (p= . ). in haploidentical transplant, the estimated -months survival rate were . % in ptcy vs. . % in atg (p= . ), the -months relapse rate were . % in ptcy vs. . % in atg (p= . ), the cumulative incidence of grade to acute gvhd rate were . % in ptcy vs. . % in atg (p= . ), and the estimated month extensive chronic gvhd rate were . % in ptcy vs. . % in atg (p= . ). patients receiving ptcy had significantly longer neutrophil engraftment time than those receiving atg in haploidentical transplant [median(range); . ( . - . ) days vs. . ( . - . ) days, p= . ]. conclusions: ptcy might be a good option for the prophylaxis of gvhd in hla-matched unrelated transplant as well as haplo-identical transplant. disclosure: nothing to declare early fam therapy for post allo-hsct bronchiolitis obliterans syndrome background: bronchiolitis obliterans syndrome (bos) is a potential major complication after allogeneic hematopoietic stem cell transplantation (hsct). attributed to an allo-immune reaction against the small airways, bo is considered a pulmonary manifestation of chronic gvhd. reported incidence of bos ranges from to %, and bos-attributed mortality as high as %- %. a few years ago, a new therapeutic approach with fluticasone, azithromycin, and montelukast (fam) was described (norman bc, et al. bmt ) . our aim was to analyze the outcomes of pts who developed bos and were precociously treated with the fam scheme. methods: all the allo-hsct performed in our center from january and july were included in the analysis. baseline diseases were: aml, lpd, mds, all, mpd, mm, and bmf. day + and day + overall mortality were , % and , %, respectively. rest of characteristics of the series are shown in table. fam therapy was systematically started when any patient was first diagnosed with bo. results: eleven patients ( , %) were diagnosed with bos. at diagnosis of bos, the pts exhibited a fev % of predicted (median fev : %; range; - %) and/or a decline > % from pre-hsct . at day + , pts had already the syndrome. two of them died before the end of the first year: one due to invasive zygomycosis (cns plus pulmonary) and the other to baseline disease progression. at day + , more pts had bos. two more pts with bos died at and months post-hsct due to baseline disease progression. at the close of the analysis, of the pts were alive. so, with a median follow-up of months (range: - ), mortality and bos-attributable mortality of the pts with the complication were , % and , %, respectively. conclusions: ) bos is an infrequent but very severe complication of allo-hsct; ) bos seems to be less frequent in pts with prophylactic pre-transplant ratg or post-transplant cyclophosphamide, as well as in pts undergoing transplantation with bm (compared to pbsc). ) early diagnosis and therapy are critical to minimize the bos-attributable mortality. disclosure background: donor lymphocyte infusion (dli) is an established treatment for patients with hematological malignancies relapsed after allogeneic hematopoietic stem cell transplantation (hsct). however, it is associated with an increased risk of graft-versus-host disease (gvhd) and modest anti-tumor activity. compared to the infusion of nonmobilized lymphocytes, granulocyte colony-stimulating factor (g-csf)-primed dli might induce a stronger anti-tumor effect and reduce the risk of infusion-induced gvhd. due to the limited experience of g-csf primed dli in patients relapsed after haploidentical hsct, we conducted a retrospective study of all patients at our hospital who received dli for the relapsed hematological diseases following related hla-matched or hla-haploidentical hsct. methods: the institutional research board approved the study. we identified patients with hematological malignancies receiving dli following related allo-hsct at national taiwan university hospital between and aug. the infusate was obtained from the cryopreserved specimen, which had been collected and stored at multiple aliquots at the same time as the initial haploidentical peripheral stem cell graft. patients received dli for either hematological relapse, preemptive or prophylactic treatment. univariate and multivariate analysis was performed using cox proportional hazard regression model. results: for the patients following related hlamatched and the patients following hla-haploidentical hsct received and doses of dli, respectively. in comparison, the median cd + cell dosage of haplo-dli is significantly lower (p = . ) than that of dli from sibling donors, with median cell dosage . × /kg (range, . - × /kg) and . × /kg (range, . - . × /kg), respectively. the median time to dli from initial sibling hsct and haplo-hsct was days (range, - days) and days (range, - days), respectively. overall, ( %) of the patients following sibling hsct developed grade - acute gvhd after dli, whereas ( %) of the patients receiving haplo-hsct developed grade - acute gvhd after dli (p= . ). importantly, for patients receiving dli with cd + cell dosage less than × /kg, there is no difference in the risk of developing grade - acute gvhd between patients receiving dli from sibling or haplo donors ( figure a) . interestingly, for patients receiving dli with cd + cell dosage more than or equal to × /kg, ( %) of the patients following haplo-hsct developed grade - acute gvhd after dli, significantly more than ( %) of the patients following sibling hsct developed grade - acute gvhd after dli ( figure b) . the cumulative incidence of grade - acute gvhd at day after haplo-hsct and sibling hsct were % ( % ci: . - . ) and . % ( % ci: . - . ), respectively ( figure b , p = . ). [[p image] . conclusions: our study shows that the administration of g-csf mobilized dli is feasible after haploidentical hsct for relapsed hematological malignancies. however, dli with cd + cell dosage more than or equal to × /kg in patients receiving haplo-hsct is associated with significantly higher risk of developing acute gvhd than dli from the sibling donors. disclosure: the authors declare no competing financial interests. background: the fresenius phelix is a uva irradiation device used to photoactivate mnc collected on the amicus. the system is closed, utilizing a special mnc kit and modified instrument software. the preliminary results of a phase i safety trial involving three patients ( treatments) with chronic graft vs. host disease are presented. methods: reasons for transplantation for the patients ages , and years were: acute myelogenous leukemia, myelodysplastic syndrome, and myelodysplastic syndrome with pnh. stem cell source was peripheral blood with a / match for all. each developed chronic skin gvhd. inclusion criteria included wbc and plt counts > and x /l, gfr > ml/min/bsa, and ast - unit/l. exclusion criteria included active gi bleeding, nyha cardiac disease greater than grade iii, and the presence of light-sensitive diseases. amicus software . and phelix software . were used. settings included: ml/min max draw rate, ml fixed cycle volume, . mg/kg/min citrate infusion rate, and : acd-a ratio. venous access was peripheral or subcutaneous port. target uva dose was . j/cm and -methoxypsoralen dose was . ml. results: the following mean + sd procedure results were obtained: , + ml whole blood with acd-a drawn, + ml acd-a used, + ml saline used, + minutes procedure time, and , + ml total blood volume. minor alarms (n= ) on the amicus and no alarms on the phelix were encountered. all -day aerobic and anaerobic cultures were negative and mean endotoxin levels were . + . eu/ml. mean pre/post cbc and plasma hemoglobin levels were: . / . wbc, . / . neutrophils, . / . basophils, . / . eosinophils, . / . lymphocytes, . / . monocytes, / platelets x /l, / % hct, . / . g/dl hgb, and . / . mg/dl plasma hemoglobin. plasma hemoglobin delta in the product was . + . grams and the subject was - . + . grams. collected product hct. mean . + . %. yields are in the table. adverse events included one each: acute respiratory failure, respiratory failure, muscular weakness, musculoskeletal discomfort, and peripheral swelling. three of four events occurred in one patient two weeks after the study procedure. none of the adverse events were considered related to the procedure or investigational product. the patient who experienced acute respiratory failure was removed from the study because of death due to pneumonia, felt to be unrelated to the procedure. conclusions: results indicate the new closed photopheresis system is capable of collecting sufficient mnc and irradiating the cells producing high lymphocyte apoptosis, with minimal alarms and adverse reactions. ( . %)). ( . %) of the patients also had acute gvhd of the skin or liver. patients ( . %) could be treated and controlled with methyl-prednislone monotherapy, patients had steroid refractory gvhd of whom patients ( . %) could be salvaged with additional drugs (infliximab: ; tacrolimus: ); patients ( . %) had refractory acute gut gvhd and could not be salvaged despite more than three lines of therapy. at the time of reporting, patients ( . %) of the are alive. patients died due to transplant related mortality, while patients developed relapsed disease. on binary logistic regression analysis, no baseline clinical or treatment related predictor (disease indication, disease status at transplant, transplant type, graft source, type of conditioning) could be identified for developing acute gvhd of the gastrointestinal system. conclusions: acute gvhd of the gastro-intestinal system is a significant cause for morbidity in allo-hct patients at our centre. further studies are warranted in our cohort, and a prospective analysis of gut microbiome analysis, faecal multi-drug resistance organism surveillance, conditioning related toxicity and antibiotic usage is ongoing. clinical trial registry: not applicable disclosure: the authors declare no potential conflicts of interest benefits and precautions of ruxolitinib in steroidrefractory acute gvhd background: corticosteroids are the standard first-line treatment option for patients with acute graft-versus host disease (gvhd), but approximately half of patients become refractory to steroids and require second-line treatment. ruxolitinib has the potential to treat gvhd in steroidrefractory (sr) patients based on retrospective clinical data. the ongoing prospective trials are currently enrolling patients to evaluate the therapeutic potential of ruxolitinib for gvhd. methods: we analyzed retrospectively clinical experience with ruxolitinib in patients (n= ) with grade ~ steroid-refractory acute gvhd patients compared with the control group not receiving ruxolitinib. in addition, immune status was evaluated about weeks~ weeks after the administration of ruxolitinib using flow-cytometry. ruxolitinib was used as a third option for sr gvhd, combined with previously used immunosuppressive drugs. and steroids were gradually decreased according to the symptoms and discontinued. patients received ruxolitinib mg twice daily (bid), with increase to mg bid if hematologic parameters are stable and no treatmentrelated toxicities. results: fifteen patients all were assessable for response. seven patients achieved a complete response, had a partial response, and had no response at weeks after the first ruxolitinib dose. overall response rate was %. three were treatment failures. most adverse effects were manageable, except infectious complications. infectious complications were occurred in about % patients (n = ), resulting in two deaths. common cause of infectious events included cytomegalovirus (n = ), herpes-zoster (n= ), epstein-barr virus (n= ), fungal infection (n = ), pneumocystis jiroveci (n = ), bacterial infections (n = ), and pneumonia of unknown origin (n = ). t cell counts tended to decreased in the group with ruxolitinib compared with the control group, especially cd cell counts. conclusions: ruxolitinib is effective in controlling sr gvhd and can lead to clinical benefits. however, we need to be aware of the infectious complications because ruxolitinib may lead to increased risk of opportunistic infections or reactivation of latent infections. in addition, common infectious complications are presumed to involve t cell dysfunction. clinical background: graft versus host disease (gvhd), being one of most common life-threatening complication post hsct, contributes significantly to morbidity and mortality. when affecting gastrointestinal tract (gi) it is the major cause of death in early period post hsct. due to widespread tissue involvement in most patients diagnosed with gi gvhd, surgical treatment is rarely considered. methods: among allo-hsct performed in department of pediatric hematology, oncology and bone marrow transplantation in wroclaw, poland during years - , ( , %) cases were diagnosed with gi gvhd. in this study we present cases ( %) which were referred to and benefit from surgical approach. results: . male, years old underwent hsct from matched unrelated donor (mud) due to chronic myelogenous leukemia (cml) and subsequent molecular relapse succesfully treated with donor lymphocyte infusion, followed by agvhd (skin and gut involvement, grade iv). extensive immunosuppression (steroids, mycofenolate mofetile, atg, okt ) resulted in significant resolution of agvhd symptoms. however aggravating severe abdominal pain and lack of gut movement suggesting bowel obstruction. due to presence of acute abdomen patient was immediately directed for laparotomy. resection of constricted bowel segment followed by subsequent laparotomies for secondary obstruction provided complete resolution of abdominal symptoms. after years of follow-up patient is alive and well. . eleven years old male was diagnosed with skin and gut grade iv agvhd on day + post mud-hsct performed due to acute myelogenous leukemia (aml). he received pronlonged immunosuppressive treatment including steroids, antibodies, msc and ecp which led to resolving of skin leasions and diarhoea. nevertheless patient was suffering from severe paroxysmal abdominal pain and incidentally vomiting. ct enterography showed partial small bowel constriction. after numerous surgical consultations, eventually on day+ patient underwent laparotomy with constricted bowel resection. histopatological examination of resected tissue revealed moderate gvhd. immunosuppersion was tapered to low dose of steroids with ecp. for now, years post hsct patient is alive, rarely experiencing mild abdominal cramps . fourteen years old female developed severe abdominal pain and high volume diarhoea on day + post mud-hsct performed for severe anaplastic anemia (saa). despite extensive immunosuppression (steroids, anti-tnf, anti-il antibodies) patient condition did not improved. through consistent stomach pain, suspected subileus confirmed by ct enterography, laparotomy was performed (day+ ). resection of inflamated and obstructed bowel was made. microscopic evaluation confirmed prior gvhd diagnosis therefore immunosuppression including csa and tapered doses of steroids was continued. complete resolution of abdominal symptoms was almost immediately achieved post-surgery, however months after recurrent abdominal cramps were observed and are now well controlled by pain killers. conclusions: commonly gi gvhd is diffused inflammatory process. however in some cases it may be localized and may lead to partial bowel constriction. in case of severe and prolonged stomach pain, despite of partial resolving of other gvhd symptoms, ileus should be considered. ct enterography may be useful for diagnosis confirmation. in those patients, surgical intervention may improve quality of life or even be a salvage approach. disclosure: nothing to disclose is there any impact of the uric acid levels during the preand early post-graft infusion period, on the gvhd occurence and allotransplant outcome? . ( . - . ) years, who underwent allogeneic stem cell transplantation (allosct) from full-matched sibling donors for acute leukemia (n= ), very severe aplastic anemia/pnh (n= ), lymphoma (n= ), myelodysplastic/ myeloproliferative syndrome (n= ) . thirty-two patients were in remission at the time of allosct (cr : , cr : , beyond cr : ). for a better and more accurate assessment of the ua levels on the agvhd incidence, unlike to the other published studies which evaluated the ua levels only at day , we evaluated the ua levels in different time points during the the peri-transplant period (at the conditioning regimen initiation, and at days , + and + ). because the majority of our patients developed agvhd within the - days post-transplant, we did not incorporated in the study the of ua levels beyond the + day. we also investigated the effect of the ua on survival and the non-relapse mortality (nrm). the vast majority of patients received allopurinol from the st day of conditioning regimen till day - . the independent t-test, kaplan-meir method and logrank test were used in the statistical analysis. results: the median ua levels were . , . , . and . mg/dl at days - , , + and + respectively. for the statistical analysis purposes, we grouped our patients as low-ua if they had values < mg/dl or high-ua if they had > mg/dl. this threshold was chosen based on the ua values from all the collected samples (n= ). finally / ( %) patients developed agvhd; ( %) were assessed as gr ≥ii, while ( %) as gr iii-iv. the incidence of the agvhd gr ≥ii was similar (ranged from - %) in both groups of patients (low-ua and high-ua) and for all the estimated time points (days - , , + , + ). we noticed a better -years overall survival for patients with low-ua ( % vs. %) however without any statistical significance. ten patients succumbed to nrm causes; / deaths attributed to gvhd complications. the nrm was assessed higher in the high-ua group ( % vs. %) but also this difference was not statistically significant. conclusions: though our study bears the limitations of the small number of patients and the retrospective origin, at least to our knowledge is the first which evaluates the impact of ua levels at different time points in the peritransplant period, on the agvhd incidence. in our study the ua levels did not influence the incidence or the severity of agvhd. the higher nrm rates for patients with ua> . mg/dl merits further evaluation. definitely, the role of ua on the allosct outcome will be clarified through well designed prospective trials. disclosure results: five male patients ( %) had genital cgvhd manifestations presented by urethral stricture in / patients and phimosis requiring surgical treatment in one patient. all five patients had simultaneously cutaneous, oral, and/or ocular cgvhd manifestations. the first patient underwent urethroplasty of bulbomembranous part of urethra with termino-terminal anastomosis and urethroplasty of penile part of urethra with buccal mucosa autograft -bmg (dorsal onlay) that resulted in significant improvement of symptoms and normal miction afterwards. biopsy of the urethra showed mononuclear infiltration in lamina propria consistent with cgvhd. biopsy of the buccal mucosa was done prior to surgery and was negative for cgvhd involvement. the second patient underwent urethrotomy due to circular strictures, but symptoms reappeared again and he is now candidate for bmg. in two patients urethral dilatation was done, and the fifth patient presented with phimosis requiring circumcision, resulted in significant improvement of symptoms. conclusions: male genital cgvhd is an underrecognized and under-reported manifestation. patients after allo-hsct need to be actively asked about their genital symptoms and sexual function, especially if they are diagnosed with other mucocutaneous or ocular cgvhd. multidisciplinary approach, early recognition and frequent follow-up is necessary for timely start of treatment. new methods, such as bmg for cgvhd patients with urethral stricture seem promising and should be further investigated. disclosure: nothing to declare. p abstract withdrawn. heracles: a phase ii single-arm prospective study to assess the efficacy of fecal microbiota transfer in the treatment of steroid refractory gastro-intestinal agvhd post allo-hsct background: steroid-refractory acute graft-versus-host disease (sr-agvhd) is associated with an % mortality rate and reduced quality of life (qol). so far, there is no approved standard of care for agvhd second-line treatment. there is an urgent need to identify effective therapy for sr-agvhd to improve patients' outcomes. fecal microbiota transfer (fmt) might be beneficial to substantially improve the prognosis. higher gut microbial diversity is strongly associated with increased survival in gvhd patients. recent studies reported promising results of sr-agvhd patients treated with fmt. further evaluation to confirm the efficacy and safety of fmt for agvhd is warranted. the ongoing phase study (heracles) investigates the efficacy of allogeneic fmt in the treatment of patients with sr-agvhd. heracles was launched after the odyssee study showed promising results in the reconstruction of gut microbiota diversity after induction chemotherapy with fmt in acute myeloid leukemia patients. we expect that fmt-based biotherapeutic drugs could be effective treatments to contain sr-agvhd, and thereby reduce the risk of life-threatening complications after allogeneic hsct. methods: heracles is a single-arm, multicenter prospective trial in european countries. patients aged ≥ years-old, who underwent allogeneic hematopoietic stem cell transplantation (allo-hsct) and developed a first episode of stage or agvhd with gut predominance resistant to a first-line steroid therapy are eligible for inclusion. main exclusion criteria comprise the use of other second-line gvhd therapy, patients with grade iv hyperacute gvhd, late onset agvhd, and overlap chronic gvhd and agvhd after donor lymphocyte infusion. patients receive a first maat enema within days after sr diagnosis (v ) and additional ones week apart (v / v ) from each other. maat is a highly-diverse, microbiome-rich enema formulation obtained from pooled, rigorously screened faeces from healthy donors, manufactured with a standardized process using the signature maat microbiome restoration biotherapeutic (mmrb) platform. at inclusion (v ), before each dosing (v , ), and days post inclusion (v ), patients' faeces and blood are collected. safety monitoring will be performed with corresponding blood analyses. exploratory measures on faeces include characterization of gut microbiota composition and evolution, impact of maat on metabolism, and gut inflammation. immune system phenotyping will be performed by flow cytometry on peripheral blood mononuclear cells, and by elisa assay on plasma. patients' qol will be assessed using a standard, eq- d- l questionnaire. the primary objective is to assess the efficacy of maat by evaluating complete response (cr, according to modified glucksberg criteria) and very good partial response (vgpr, defined by martin et al., bbmt, ) days post-inclusion (primary follow-up). secondary objectives include fmt safety assessment and evaluation of fmt impact on several endpoints, such as overall, relapsefree or gvhd-free survival and chronic gvhd evaluation, as well as multi-drug resistant bacteria carriage. patients will be followed-up until year after inclusion. overall, patients are planned to be enrolled and treated, to assess overall response rates and maat 's safety profile. results background: anti-programmed cell death protein (pd ) monoclonal antibodies can be used as "bridge to" a subsequent allogeneic hematopoietic stem cell transplantation (hsct) in patients with relapsed/refractory hodgkin´s lymphoma (hl). this strategy has been reported to be effective, but a frequent onset of steroid-refractory graft versus host disease (gvhd) was also reported. we report clinical cases of patients affected by hl undergoing allogeneic hsct after having been treated with nivolumab. methods: the patients of , and years respectively had advanced hl and had relapsed after a previous autologous ( ) or allogeneic ( ) hsct. they underwent a rescue therapy with , , nivolumab cycles respectively, depending on the time of partial response achievement and the availability of a donor. two patients received a thiotepa-fludarabinecyclophosphamide conditioning, atg-based prophylaxis and pb cells from unrelated donors. the third patient received bm cells from an haploidentical donor using the "baltimora" nonmieloablative platform. results: at a follow-up of , , months after hsct, respectively, all patients achieved and maintained a complete remission by pet-ct scans. all the patients developed acute gvhd on day + , + and + , respectively. patient progressed to grade iv acute gvhd with hepatic and intestinal involvement unresponsive to first line mg/kg steroid therapy and second line etanercept plus extracorporeal photopheresis (ecp). third line therapy with ruxolitinib partially controlled the gvhd. gvhd onset in patients and was preceeded by a prolonged fever without microbiological findings. patient developed hepatic grade ii gvhd with high transaminase levels, initially responsive to steroid therapy, then it progressed to gut requiring second line therapy with etanercept. patient progressed to severe chronic gvhd with skin involvement and resulted unresponsive to steroids and ecp and it was partially controlled by ruxolitinib. immune reconstitution was delayed in all patients: at months post transplantation cd levels were /μl, / μl and /μl and cd levels were /μl, /μl and / μl respectively. only patient , that underwent haploidentical transplant and received post-trasplant cyclophosphamide (pt-cy), is off of immunosuppressive treatment at months after hsct, without evidence of gvhd and no history of infections. out of the patients receiving pbsc from unrelated donors and atg prophylaxis, patient developed a disseminated fusariosis on day + and died of cns fusarium localization year after hsct, despite targeted antifungal therapy. patient had pulmonary aspergillosis, sepsis by multidrug resistant psuedomonas aeruginosa and otomastoiditis: at + months after hsct, he is on ruxolitinib treatment with skin clinical partial response. conclusions: this case series confirms that nivolumab as "bridge to transplant" is effective in appropriately selected patients. however, risk of acute gvhd and delayed immune reconstitution may require a careful consideration at the moment of planning the transplant. a possible advantage of pt-cy gvhd platform and haploidentical donors should be addressed in larger studies. background: acute graft-versus-host disease (agvhd) is the most important complication after an allogeneic hematopoietic stem cell transplant (hsct). no standard secondline treatment has been established for the corticosteroid refractory agvhd. the anti-tnfα agents are a good option of treatment for these patients, especially when lower gi tract is involved. methods: from april to july we reviewed the outcome of patients with steroid-refractory (sr) agvhd treated with etanercept as at least, second line treatment. etanercept dose was mg twice a week for the first weeks, followed by weekly doses. results: median age was years (range - years), and patients ( %) were male. fourteen patients ( %) had a non-advanced disease status at hstc. eleven patients ( %) received a myeloablative conditioning, and the stem cell source was peripheral blood in patients ( %). sixteen patients ( %) were / hla matched. the characteristics of the patients, their agvhd stage previous to rescue treatment with etanercept and their outcome are shown in table . seventeen patients ( %) had a classic agvhd while had a late-onset agvhd. etanercept was given as a nd , rd and th line in ( %), ( %) and ( %) patients respectively. the median doses of etanercept administered were (range - ), and just patients ( %) completed the doses planned treatment, of whom were alive at , and months from the onset of rescue treatment. complications during etanercept treatment were: infection (n= [ %]: gram negative bacilli [n= ]), grade - neutropenia (n= ) and grade - thrombocytopenia (n= ). etanercept was indicated as a rescue treatment due to: progression after days of agvhd treatment (n= ), no response after days of treatment (n= ), no complete remission after days of treatment (n= ) and relapse due to decrease corticosteroid doses (n= ). at the end of treatment patient achieved a complete response and patients a partial response, all of them are alive. these patients received etanercept as a nd (n= ) and th line (n= ) treatment, all of them had lower gi agvhd without any other organ significantly involved. causes of death were: agvhd with or without infection in patients ( %) and leukemia relapse in patient. conclusions: although if etanercept is an option for treatment of sr agvhd in some patients, their prognostic remains poor and more effective alternative strategies are needed. a prompt initiation of etanercept as a rescue treatment for sr agvhd is crucial to improve the prognosis. ( ) ( ) background: although both cyclosporine (csa) and tacrolimus are calcineurin inhibitors, csa is more widely used in pediatric hematopoetic stem cell transplantation (hsct) as a prophylactic drug for acute graft versus host disease (agvhd). there are some clinical experience but very few data about the clinical efficacy of conversion to tacrolimus. here, we present our single center data on this arguable topic. methods: this study involves the data of pediatric hsct patients in medical park göztepe hospital between - . all patients had prophylactic csa therapy and for various reasons csa was converted to tacrolimus therapy. most of the patients had this conversion due to agvhd. as steroid is the first line therapy for agvhd, conversion to tacrolimus is done concurrently at the start of steroid therapy (within hours after the start of steroid). and also, patients who had any other immunosupressive therapy for agvhd are excluded. response is defined as resolution of symptoms within days after conversion. results: mean age of the study population is months ( - months), male/female ratio is , ( / ), donor types are mud patients ( %), mfd patients ( %), haplo patients ( %) and mean conversion time is days ( - days) . the rationales for conversion are agvhd for patients, unproper csa plasma levels for patients, allergic reaction for patients, nephrotoxicity for patients, hepatotoxicity for patients, severe headache for patients, high arterial blood pressure for patients and one each for refractory vomiting, autoimmune thyroiditis and visual disturbance. the subgroup analysis of agvhd patients reveals that mean conversion time for agvhd is days ( - days) and there are only responders whose agvhd resolve completely (% ) after conversion. all of the patients had proper tacrolimus levels after conversion due to unproper csa levels and also patients in allegic reaction, severe headache, visiual disturbance and refractory vomiting group responded to conversion completely but only one of the patients in nephrotoxicity group responded and also of the patients in hepatoxicity group responded. the only one patient suffered from autoimmune thyroiditis did not respond to conversion. conclusions: in this study, it is obvious that there are response to conversion for some specific adverse effects of csa and tacrolimus is a good alternative for the patients who have unproper csa levels. conversely, the high percentage (% ) of non-responders shows that it is not feasible to make a conversion to tacrolimus for acute gvhd. disclosure: nothing to declare background: capillary leak syndrome is caused by the dysfunction of the vascular endothelial cells,and is characterized by weight gain,generalized edemas,unresponsive to diuretic treatment,and hypotension.it usually develops in the first days post hsct.and it is of great difficuty to distinguish from other complications which are occured post the allo-hsct. to diagnose this complication at the early stage,it is very difficulty. methods: a -year-old man was admitted to ningbo first hospital for its abnormal in the peripheral blood .he was diagnosed with aml-m by the classical morphology and immunophenotype.cytogenetic evaluation showed a normal , xy( ).the patient achieved cr with induction therapy including idarubicin, cytarabine and etoposide. after consolidation therapy,an allo-hsct from hla identical related dornor( -year-old male, donorrecipient matched by high resolution hla typing at hlaa, -b, -c, drb , and dqb , / matches) was performed.the recipient received conditioning with busulfan, mg/kg/day injection for days; cyclophosphamide, mg/kg/day injection for days; cytarabine, g/m /day injection for day; semustine, mg/m /day orally for day; donor peripheral blood stem cells (pbsc:mnc: . × /l, cd +: . × /l) were mobilized, pheresed and administered to the recipient. gvhd prophylaxis consisted of traditional cyclosporine, short-course methotrexate ( mg/ m at day + , mg/m at days + , + , and + ) and cyclosporin a injection mg/kg qer day was mot reduced untill the hematopoietic reconstitute sucessfully . on day + , complete donor chimerism was acheieved. the csa was gradually reduced and tapered.on day + ,the patients was manifested with increasing in the time and volume of the faeces, he was diagnosed with ii°gvhd (gut).the standarded does of immunosuppressive drug including methylprednisolone and cyclosporin a was administrated. the immunosuppressive drug was gradually reduced when the gvhd was controlled.on day+ ,the patient felt distress and the distress was not related to with the exercise,the temperature was normal,and he did not gain weight.there was no edema in the body.laboratory test including routine blood test,c-reactive protein,procalcitonin,blood gas analysis,cmvdna,ebvdna was normal. the ct scan shows that the pleural is filled up with water, and could not be enlarged promptly, there is pericardial effusion in the body.pulmonary function test shows that reduced function in ventilation and diffusion fuction.the laboratory test of the pleural effusion was normal,the blast cell was not detected in the pleural effusion,the cd + cell count was below the dectable level,the next generation sequencing for minimal residual disease shows that there was no gene mutation .thus, post capillary leak syndrome was considered .sirolimus was adopted and taken the place of cyclosporin a,immunoglobulin was adminstrated to reduce the edema. results: taking together comprehensively,the effusion in the pleural and cardiac was absorbed well. conclusions: occurance of capillary leak syndrome is rare,there is limited data about capillary leak syndrome. comprehensively,the mechanism of cls has not been totally identified.and there is no standard treatment to treat the complication.at present,the cls of this patient was absorbed well by administrating sirolimus,closely followup is needed. disclosure: nothing to declare graft-versus-host diseasepreclinical and animal models p short-term krp and posttransplant cyclophosphamide for graft-versus-host disease prophylaxis emi yokoyama , daigo hashimoto , takahide ara , eko hayase , takanori teshima hokkaido university faculty of medicine, hematology, sapporo, japan background: post-transplant high-dose cyclophosphamide (ptcy) in combination with other immunosuppressants such as calcineurin-inhibitors (cis) has been increasingly used as gvhd prophylaxis after hla-haploidentical or matched hematopoietic stem cell transplantation (hsct). however,cis could hamper reconstitution of regulatory t cells (tregs) and tolerance induction after hsct, facilitating us to develop novel ci-free/ptcy-based gvhd prophylaxis. in the current study, we developed a novel gvhd prophylaxis in which ptcy was combined with short-term administration of krp , a selective agonist of sphingosine- -phosphate receptor type (s pr ), using murine models of mhc haploidentical bone marrow transplantation (bmt). methods: b d f (h- b/d ) recipients were lethally irradiated and transplanted with bone marrow cells and splenocytes from allogeneic b (h- b ) donors. cy at a dose of mg/kg was intraperitoneally injected into the recipients on day + , and krp at a dose of . mg/kg was orally administrated daily from day to day + after bmt. donor t cells in the target organs and secondary lymphoid organs were evaluated by flow cytometric analysis. plasma levels of tnf-α were determined using cytometric beads array. to evaluate graft-versus-leukemia (gvl) effects, recipient mice were intravenously injected with luciferase-transduced p cells (p -luc) on day , and in vivo bioluminescence imagingwas conducted weekly after bmt. results: severe gvhd was developed in allogeneic recipients and all mice died by day after bmt.ptcy alone at a dose of mg/kg significantly ameliorated gvhd and % of ptcy-treated allogeneic recipients survived. oral administration of krp alone enhanced contraction of donor t cells in the lymph nodes and also ameliorated gvhd as has been previously shown with multi-s pr agonist, fingolimod. next, we tested if shortterm krp on days to + added to ptcy enhances anti-gvhd effects of ptcy. we found that survivals of ptcy+krp group were significantly prolonged compared to those of ptcy-alone group ( figure a) . plasma levels of tnf-a, clinical gvhd scores ( figure b) , and donor t-cell infiltration into the target organs such as the gut and skin were also significantly reduced in ptcy +krp group compared to ptcy-alone group (figure c and d) . unlike cis, addition of krp to ptcy promoted treg reconstitution after bmt. finally, bioluminescence imaging demonstrated that proliferation of p -luc injected on day was significantly delayed in ptcy +krp -treated allogeneic recipients compared to control mice transplanted only with t-cell depleted bone marrow cells, suggesting that significant gvl effects persisted in ptcy+krp -treated recipients. conclusions: a combination of short-term krp and ptcy is a promising novel calcineurin-free gvhd prophylaxis in mhc-haploidentical sct. we recently showed that donor inkt cells can be expanded ex vivo and that they are able to prevent activation and proliferation of alloreactive donor t cells while promoting efficient graft-versus-leukemia effects (schmid et al. ). however, the underlying mechanisms how human inkt cells induce immune tolerance after allogeneic hct are not fully understood. methods: monocyte-derived dendritic cells (dcs) were cultured in a mixed lymphocyte reaction with mhcmismatched t cells and culture-expanded inkt cells. tcell activation and proliferation was analyzed by multiparametric flow cytometry and released cytokines were measured via multiplex analysis. transwell assays and imaging flow cytometry were performed to elucidate cellcell interactions. bead-controlled flow cytometry-based cytotoxicity assays were used to evaluate dc apoptosis. apoptotic dcs were then purified by fluorescence-activated cell sorting to investigate their tolerogenic potential to prime regulatory t cells (tregs). results: the addition of inkt cells to mixed lymphocyte reactions resulted in a significantly reduced activation and proliferation of mhc-mismatched t cells. transwell assays and imaging flow cytometry revealed a cell contactdependent mechanism between inkt cells and dcs leading to apoptosis with increasing dna fragmentation of dcs over time. interestingly, various fluorescence-activated single cell sorted inkt-cell subsets were all able to induce apoptosis of host dcs. multiplex analysis revealed that dcs triggered inkt-cell release of cytotoxic factors like perforin, granzyme b and granulysin. blocking the inktcell receptor engagement with a cd d antibody prevented inkt-cell degranulation as well as the subsequent induction of host dc apoptosis. inhibition of cytotoxic factors also abrogated apoptosis of dcs. in turn, sorted apoptotic dcs induced tolerogenic dcs characterized by a high expression of pd-l in mixed lymphocyte reactions. such tolerogenic dcs promoted the expansion of cd + cd + foxp + tregs and prevented activation and proliferation of mhcmismatched t cells. conclusions: we propose a novel mechanism how culture-expanded human inkt cells prevent gvhd after allogeneic hct. host dc apoptosis through donor inkt cells induces a tolerogenic immunoenvironment characterized by pd-l high dcs and expanding donor tregs inhibiting activation and expansion of alloreactive donor t cells. our findings pave the avenue for clinical translation of adoptively transferred culture-expanded inkt cells in humans. disclosure: nothing to declare results: vip-ko mice transplanted with allogeneic tcd bm alone had increased graft rejection with lower levels of donor chimerism and % day survival compared with % survival of wt recipients. transplanting tcd bm plus × e donor t cells from b .br or balb/c donors in vip kio mice led to > % donor chimerism and significantly increased gvhd-mortality compared with wt recipients, with % vs % survival in the b .br-->b model (p< . ), and % vs % survival in the balb/c-->b model (p< . ). donor-derived t cells in vip-ko recipients had significantly higher th and th polarization, with higher rorγt in both cd + (p< . ) and cd + (p< . ) t cells, and higher frequencies of ifn-γ (p< . ), tnf-α (p< . ), and il (p< . ) in cd + and cd + t cells compared to wt recipients. b .br-->b second allogeneic transplantation of radiation chimeras caused lethal gvhd mortality in vip-ko-->vip-ko and wt-->vip-ko mice, but not in wt-->wt or vip-ko-->wt b mice, demonstrating the protective effect of vip was due to synthesis by non-hematopoietic recipient cells. immunofluorescent imaging of allo-bmt recipients showed marked up-regulation of vip in lungs post-transplant and high vip production within neurons innervating the lungs. finally, we demonstrated that short-term administration of vip ( mcg/day) from day to day prevented gvhdmortality in vip-ko recipients transplanted with b .br-->b mhc donor bm & t cells. conclusions: the absence of vip in recipient cells led to increased graft rejection in the absence of donor t cells and increased lethal gvhd when donor t cells were transplanted, indicating vip induced post-transplant regulates allo-reactivity of host graft-rejecting lymphocytes and donor gvhd-causing t cells. the protective effect of parenteral vip administration suggests vip-mimetics represent a novel approach to prevent and treat gvhd. these data also suggest a mechanism of action for the mitigation of gvhd by alpha- anti-trypsin (aat) whereby aat inhibits the proteolytic inactivation of endogenous vip. disclosure: dr. waller reports personal fees and other support from cambium medical technologies, grants from celldex, personal fees from kalytera, grants and personal fees from novartis, grants and non-financial support from pharmacyclics, and equity ownership in cerus corporation and chimerix outside the submitted work. in addition, dr. waller has intellectual property related to vip signaling that has been licensed to cambium oncology in which he holds equity. low-density neutrophils expansion is associated with acute graft versus host disease in allogeneic hematopoietic stem cell transplant patients background: low-density neutrophils (ldns) are distinguished from normal-density neutrophils (ndns) by their anomalous sedimentation within the mononuclear cell fraction after density gradient centrifugation of peripheral blood (pb). by analysing ldns and ndns from g-csfstimulated donors or lymphoma patients, we have previously demonstrated that, depending on physiopathological conditions, immature cd b + cd -ldns can promote t cell survival and ifn-γ production, while mature cd b + cd + ldns can exert immunosuppressive proprieties. aim of this study was to establish the frequency of cd b + cd and/or cd b + cd + ldns in pb of allogeneic hematopoietic stem cell transplant (hsct) patients throughout immune reconstitution, and verify their potential correlation with acute graft versus host disease (agvhd). methods: patients undergoing hsct in our institution between december and june were prospectively enrolled in the study upon informed consent and after institutional board approval. criteria of inclusion were age ≥ years and absence of rheumatologic or viral diseases. pb samples were collected at day + , + , + , + and + after hsct and any time within day + in case of gvhd, before first-line therapy. eight healthy donors (hds) were enrolled as control. mononuclear, polymorphonuclear, and whole blood cells were analysed by flow cytometry after cd vioblue, cd apc-cy , cd b pe-cy , cd pe, cd b fitc staining. cd b + ldns were expressed as percentage of cd + pb mononuclear cells (pbmcs) or cd + whole blood cells and were further characterized based on cd expression. cd b + ndns, expressed as percentage of cd + whole blood cells, were also analysed for cd staining. results: patients (m/f / , median age ) were enrolled in the study. patients received hsct from hlaidentical ( ) or haploidentical ( ) related and from hlaidentical unrelated ( ) donors. after a median time of ( - ) days, patients developed grade ii-iv agvhd. no patients were receiving g-csf at agvhd onset. the scheduled assessments were interrupted in agvhd patients at the beginning of first-line treatment and in patients relapsed of their primary malignancy. no patients developed de novo late-acute or chronic gvhd. starting from day + the frequency of ldns within cd + pbmcs was higher in all patients as compared to hds. the patients that did not develop agvhd showed a decreasing frequency of cd b + cd -ldns, with a progressive increase of cd b + cd + ldns, from day + to + . interestingly, patients with agvhd showed a significantly higher frequency of cd b + cd -ldns as compared to patients without agvhd throughout the same time lapse (i.e. from day + to + ) ( . vs . , p= . ). consistently, patients with agvhd had a significantly lower frequency of cd b + cd + ldns ( . vs . , p= . ). the frequency of mature cd b + cd + ndns was normal in all patients since day + . conclusions: ldns are more represented in hsct patients than in hds, with a significant expansion of the cd b + cd subpopulation (with a parallel decrease of the cd b + cd + subpopulation) in patients with agvhd as compared to those without agvhd. according to the previously demonstrated t cell activating function of cd b + cd -ldns, it is tempting to speculate that the expansion of this subpopulation may contribute to agvhd development. disclosure: nothing to declare background: acute graft-versus-host disease (agvhd) is a major complication after allogeneic hematopoietic stem cell transplantation (allo-hsct) which has negative impact on the morbidity and mortality of the patients. accumulating evidences suggest that abnormalities of foxp + regulatory t (treg) cells contributed to the pathogenesis of gvhd, but the underlying molecular mechanisms still remain largely unknown. methods: in this study, we enrolled all the patients treated with allogeneic hsct at the institute of hematology, chinese academy of medical sciences between and ,as well as age-matched healthy adults as control samples. the ratio of tregs in pb and bm of healthy controls (hcs) and patients with and without agvhd was determined by flow cytometry. the transcription profile between tregs from patients with or without acute gvhd was measured,the pathway enrichment analyses were performed by the kyoto encyclopedia of genes and genomes (kegg) pathway database and geneset enrichment analysis (gsea).the expression of lkb at transcript levels and protein levels was measured by realtime pcr and analyzed by the nanopro tm system. a series of functional assays in vitro were performed to assess the function and stability of tregs from patients with and without agvhd.meanwhile, to assume the affect of lkb on gvhd outcome, we established a murine transplant model,which recipient balb/c animals were transplanted with the same amount of mixture made by bm, cd +cd -tcon cells from c bl/ and cd + foxp yfp+ tregs from either foxp crelkb f/f or foxp cre mice. results: in this study, we demonstrated that bm had decreased frequencies of tregs, accompanied with a reversed lower ratio of tregs frequencies between bm and pb in agvhd patients. meanwhile, the number and function of tregs in bone marrow also affected hematopoietic reconstitution. futhermore,to elucidate these mechanisms which regulate tregs homeostasis, we examined the role of lkb on tregs in patients with agvhd and in agvhd murine model. studies demonstrated that lkb deficient tregs lost foxp expression and weaken suppressor function during agvhd. transcriptional profiling and pathway analysis revealed that nf-kb signaling activation and the impairment of a wide spectrum of immunosuppressive genes in agvhd tregs. further mice experiments suggested that cns methylation might lead to the instability of tregs in agvhd group. transplantation with marrow grafts from foxp crelkb f/fmice exacerbates gvhd lethality. conclusions: these studies indicate that lkb is a critical homeostatic regulator for tregs during agvhd. targeting of lkb therefore represents a novel therapeutic strategy that promote immune tolerance to mitigates the severity of agvhd. disclosure: national program on key basic research project ( program) role of aryl hydrocarbon receptor in intestine after allogeneic hsct in mice won-sik lee , soung-min lee , sj-kil seo inje university, busan paik hospital, hemato-oncology, busan, korea, republic of background: aryl hydrocarbon receptor (ahr) is a ligandactivated transcription factor that is activated by various small molecules from the diet, microorganisms, host metabolism, and xenobiotic toxic chemicals. the function of ahr has been demonstrated as a crucial regulator in intestinal homeostasis. here, we investigated the regulatory role of ahr in intestine of recipients after allogeneic hematopoietic cell transplantation in mice. methods: wild-type (wt) b (h- b ), ido -/-(h- b ) and ahr -/-(h- b ) mice were lethally irradiated and transplanted with x tcd-bm plus x t cells from balb/c donor mice. ahr activation in colon tissue of recipients was determined by the ahr target genes cyp a and cyp b expression using real-time pcr. the recipient mice were monitored every other day for survival and clinical score. histopathology and pathogenic effector cytokine levels in colon tissue were analyzed for evaluating ahr function. results: we observed that cyp a was constitutively expressed in the colon tissue of naïve recipient mice. although the expression levels were increased by tbi conditioning, the additive up-regulation of its levels with donor t cell alloreactivity was not observed. in contrast, cyp b expression was markedly induced in the colon tissue by donor t cell alloreactivity. we further observed that the cyp b expression was significantly decreased in the colon of ido-/-recipients with donor t cell alloreactivity, but cyp a was not changed. ido-/-and ahr-/recipient mice showed higher histopathological score for intestinal gvhd and increasing pathogenic cytokine levels in the colon compared with wt mice. conclusions: our results demonstrate that ahr-induced target gene profiles might be differently induced in intestine by ligand dependent manner after hsct, which affect intestinal gvhd. disclosure: nothing to declare. abstract already published. abstract withdrawn. in vitro platelet activation evaluation in allogeneic hematopoetic stem cell transplanted patients in response to haemostatic stimulation and cytomegalovirus stimulation (gvhd), complication of which one of the risk factor is cmv reactivation. the resultant inflammatory platelet response during the high-risk period of gvhd after allogeneic hsct remains unknown. our study aimed to characterize spontaneous platelet activation during the d and d months after allogeneic hsct, and in response to haemostatic stimulation and cmv stimulation. methods: we compared a group of healthy volunteers to a group of allogeneic hsct patients followed between the th and the th days after hsct. platelet activation was determined by the platelet surface expression of cd p and cd using flow cytometer after stimulation by an haemostatic agent, thrombin-receptor activating peptid (trap) and after stimulation by cmv glycoprotein b. the inflammatory response was determined by the detection of immune mediators, rantes, cd ps, pf , cd l and ccl , using the elisa technique in the stimulated platelet supernatants. results: no platelet activation or molecules release were observed after stimulation by cmv glycoprotein b in both groups. rantes and cd ps baseline levels are spontaneously higher in allogeneic hsc patients than in healthy volunteers. platelets from allogeneic hsct patients can be activated after haemostatic stimulation and release cd ps and rantes. in this situation, platelets release more cd ps, rantes and pf than platelets from healthy volunteers. conclusions: although no platelet activation was detected in response to cmv glycoprotein b stimulation, our study revealed a chronic platelet activation condition during the d and d months after allogeneic hsct with an haemostatic inducible hyper-responsiveness. this leads to the release of molecules with immune-modulating properties involved in the pathophysiology of gvhd. as we move further away from the hsct, that phenomenon seems to gradually weaken. clinical trial registry: nct , fipalloc https://clinicaltrials.gov/ct /show/nct disclosure: nothing to declare p efficient process and characteristics of umbilical cordderived mesenchymal stromal cells as a feasible source for anti-inflammatory therapy background: recently, umbilical cord (uc) has become attracted source of mesenchymal stromal cells (msc), because of abundant sources and ease of collection of fetal origin without invasive process for the donor and low immunogenicity with immunosuppressive ability and tissue repair potency. objectives of this study were to explorer the efficient and safe products and to evaluate the antiinflammatory potency of uc-mscs for the application of acute graft versus host disease (gvhd). methods: informed consent was obtained from mothers planning to have cesarean sections. uc tissue was cut and once cryopreserved. the safety assessment including infections and baby's health and development were done after months of birth, and performed small-scale quality test of the frozen uc. then we initiated to isolate master uc-mscs from frozen-thawed uc by an improved explant method, which was passed for quality test. the master uc-mscs were cryopreserved once and thawed and expanded until p . product cells were cryopreserved in original serum-free cryoprotectant dba-d solution. mixed lymphocyte reaction (mlr) assay co-cultured with uc-mscs was carried out using responder mononuclear cells (mnc) stained with cfse, and proliferation and cytokine secretion were analyzed by flowcytometry. results: uc-msc cultured showed significantly higher proliferation ability compared with those from bone marrow-derived mscs, and positive for cd , cd , cd , and negative for cd , hla-dr. cd , and cd were negative even in the high concentration of ifn-γ, while bm-mscs became positive for hla-dr. pd-l was constitutively expressed in uc-msc, while pd-l was induced by the addition of ifn-γ. in mlr, responder t cell proliferation triggered by allogeneic dendritic cells was inhibited efficiently by rd party derived uc-mscs, in which was induced ido, pge , hgf, and tgf-β analyzed by rt-pcr, and inhibited ifn-γ and tnf-α in the supernatant by cytokine beads array. uc-mscs migrated toward the tnf-α treated mnc and increased regulatory t cells incidence in peripheral mononuclear cells by the coculture. conclusions: these results demonstrated that cryopreserved uc are feasible and efficient source of mscs and frozen-thawed uc-mscs have high anti-inflammatory background: a new protocol is under development on the amicus separator that enables the device to perform ecp procedures. the amicus separator is used with a photoactivation device, disposable kit and -mop to provide ecp therapy in a closed system. the objective of this study was to evaluate the safety and performance of the investigational amicus ecp system in healthy human subjects. methods: an irb-approved written informed consent was obtained from subjects ( male, female). the amicus ecp system processed either , or ml whole blood (n ≥ per arm) using double-needle access and acd-a anticoagulation at a : wb:ac ratio. after mnc collection was completed, the subject was disconnected from the device. -mop ( . ml, μg/ml) was injected directly into the collected mnc product and saline (approximately ml total), which was photoactivated with - j/cm uva light. post photoactivation, the amicus separator reinfused the treated mncs into a transfer pack. subject laboratory and safety parameters were evaluated; in vitro evaluations were performed on subject whole blood, collected mncs, treated mncs, and reinfused cells. lymphocyte and monocyte analysis were performed on samples purified using density gradient separation and cultured for up to days post treatment. results: in procedures, median (range) wb processed was . ( - ) ml using . ( - ) ml of acd-a. procedure time was . ( - ) minutes, including photoactivation. no adverse events were reported. subjects' vital signs and hematology values were unremarkable and within expected values. the wbc count of the collected mncs was . ( . - . ) x /μl, comprised of . ( . - . ) % lymphocytes, . ( . - . ) % monocytes and . ( . - . ) % granulocytes and platelet count was . ( - ) background: transfusion of white blood cells (wbc) causes a number of transfusion reactions and complications, for example transfusion-associated graft versus host disease (tagvht), which still does not have effective treatment and is a fatal complication of transfusions. the only effective method of preventing tagvht is irradiation of blood components with ionizing radiation (x-ray or gamma radiation). but the use of ionizing radiation sources has a number of technical and material difficulties. the emergence of pathogen reduction technologies (prt) in blood components targeted by nucleic acids has opened the possibility of using these technologies as an alternative to irradiating of blood components. several prt demonstrated effective inactivation of wbc in platelet concentrates and blood plasma. so, determination of the influence of prt based on the combined effect of riboflavin (rf) and ultraviolet (uv) on the viability and proliferating potential of lymphocytes in whole blood is important. methods: samples of whole blood were obtained in healthy volunteers. each sample was divided into three unequal parts: untreated control, gamma irradiated, and treated by rf and uv prt (mirasol, terumo bct inc.). mononuclear cells (mnc) were cfse stained, viability and proliferating activity were tested at intervals of hours for consecutive days by flow cytometry. statistical analysis was performed with xlstat . . levels of significance were calculated by mann-whitney test, expressed as p-values (p< , ). results: the median viability of mnc after application of both methods of treatment was over , % on day and decreased to day -median percentage of viable mnc were , % (control group), , % (after gamma irradiation) and , % (rf/uv prt). the median of spontaneous proliferative activity on day of untreated and gamma irradiated mnc did not differ ( , % and , % respectively, p< , ). phytohemaglutenin (pha) induced proliferation on day in gamma-irradiated samples was significantly lower in comparison with control group ( , % and , % respectively, p< , ). in samples treated with rf/uv, spontaneous and stimulated proliferating cells was not detected. median percentage of proliferating mnc was less than , %. the use of this prt on whole blood, as well as gamma irradiation, significantly reduces the viability of lymphocytes during storage for days. conclusions: inactivation of wbc using rf/uv prt is a useful and very necessary bonus for a number of reasons. in one procedure two effects are achieved: infectious and immunological safety. the use of prt on whole blood gives the potential for obtaining pathogen-reduced and immunological safety components of blood, which reduces their material cost and staff loading. the use of rf/uv system does not have such complex security requirements and difficulties in servicing as the use of sources of ionizing radiation. the results demonstrate a promising potential for using this technology as an alternative to irradiation disclosure: nothing to declare p influence of patients´serum after allogeneic stem cell transplantation on t cell proliferation and treg function background: acute or chronic graft versus host disease (a/ cgvhd) is one of the major complications after allogeneic hematopoietic stem cell transplantation (ahsct). application of regulatory t cells (treg) as "immunosuppressive dli" to prevent or treat gvhd is investigated in clinical trials. here we ask the question, if there could be clinical conditions (e.g. cytokines or drug effects) limiting the efficacy of this approach. to face this problem we tested the influence of patients´serum on t cell proliferation and treg function. methods: lymphocytes from healthy donors were incubated with t cell medium ( % aim v + % serum + il /okt ) containing serum from healthy donors or serum derived from patients after ahsct with or without gvhd (n= ). next we evaluated the suppressive function of treg by performing treg suppression assays, also comparing serum from patients suffering from gvhd versus serum obtained from healthy donors (n= ). proliferation of cfse stained t cells was measured after days. to test the effect of immunosuppressive drugs on treg we performed treg suppression assays after incubation of treg with corticosteroids or tacrolimus or the combination of both drugs. results: serum of patients with acute or chronic gvhd had a negative effect on t cell proliferation. to avoid bias tests were performed with samples from patients without or only with low levels of immunosuppressive drugs. incubation with serum of patients without gvhd or with serum of healthy individuals showed no differences in t cell proliferation. treg from healthy donors showed a stronger antiproliferative capacity when incubated with serum derived from patients with gvhd. treg previously incubated with immunosuppressive drugs showed no decreased suppressive capacity. conclusions: components of serum from gvhd patients seem to have an antiproliferative effect on t lymphocytes itself. this fact might influence the clinical course of gvhd, but should not be a limiting factor for therapeutic application of treg dli. even the systemic treatment with immunosuppressive drugs e.g. corticosteroids or calcineurin-inhibitors should not diminish the treg application. in a next step we will analyze serum components responsible for this immunosuppressive effect with multi cytokine assays and proteomic analysis. the aim of our project is to develop new strategies to avoid gvhd and to optimize clinical settings for treg dli. disclosure background: hypercalcaemia can be very severe following stem cell transplant (sct) in some osteopetrosis patients. denosumab is a fully human monoclonal antibody that binds the cytokine rankl (receptor activator of nfκb ligand), an essential factor initiating bone turnover. rankl inhibition blocks osteoclast maturation, function and survival, thus reducing bone resorption. we describe the effective management of hypercalcaemia in a patient with rank mutation osteopetrosis who received a haploidentical sct. methods: our patient was diagnosed with osteopetrosis at year of age with a defect in the tnfrsf a gene which codes for rank and received a maternal haploidentical sct aged years. the patients calcium levels were monitored regularly post sct. denosumab was administered for hypercalcaemia as per laboratory reports or clinical symptoms. the drug was diluted with water for injection to make mg/ml solution to facilitate subcutaneous administration. results: significant hypercalcaemia emerged on day + with a level of mmol/l and treated with hyper-hydration and diuretics. this was ineffective in reducing the hypercalcaemia; therefore denosumab was initiated on day + post-transplant. initial dosing was determined using the only available paediatric case report at . mg/kg. a repeated larger dose of . mg/kg was given days later due to an inadequate response (calcium decreased from . mmol/l to . mmol/l). the calcium decreased to . mmol/l after this dose. four weeks later a third dose was required at . mg/kg as the calcium level had increased to . mmol/l. the dose was further increased to . mg/kg for another four doses and then further increased to . mg/kg for another doses and repeated every weeks. normalisation, but not excessive drop in calcium was achieved with these larger doses. over the month follow up post-transplant there were three admissions lasting less than hours for symptoms of hypercalcaemia. these were managed with denosumab administration and hyper-hydration. the remaining doses were given in an outpatient setting. conclusions: denosumab can be safely used as a first line agent in treating post stem cell transplant hypercalcemia in patients with osteopetrosis. a dose of . mg/kg is required as an initial starting dose in order to control hypercalcemia. this is a new higher dose than previously suggested by the original report. denosumab can be effective even after dilution and safely given in children weighing less than kg. disclosure: nothing to declare methods: the clinical, laboratory and molecular aspects of this italian male patient who developed such a complication were collected and presented in order to discuss the origin, clinical outcome and management of this very rare post-transplant event. results: a -years-old man affected by a high-risk chromosomally abnormal, ph -, mll-pro-b (egil b-i) all relapsed during maintenance treatment, nonresponsive to re-induction chemotherapy, in second complete remission (ii cr) after blinatumumab treatment received a female cb transplant. according to sorror's and ebmt scores he was considered a high-risk transplant. the patient and the cb unit were sex-mismatched, shared the same blood groups and were both cmv+/ebv+. he received a tbf conditioning regimen that was followed by the infusion of . x /kg cd + cb cells. gvhd prophylaxis consisted of rabbit atg, cyclosporine a (csa) and mycophenolate mophetyl (mmf). neutrophil engraftment occurred on day + , whereas platelets were never > . /μl. on day + a cm bulged area became apparent on the left parietal region of the skull. an echotomography showed that the lesion adhered to the bone without infiltrating it and lacked blood vessels and suggested that it may be either a site of disease relapse or an area of infection. at the same time a bone marrow (bm) aspiration showed morphological cr confirmed by immune-phenotypic studies and x-y fish a complete chimera. since the patient was still febrile no biopsy was performed, but on day + the axial diameter of the lesion that on a ct scan showed the same appearance revealed by the previous echo-tomography increased to cm. thus, the lesion was surgically removed and histological examination showed cd +, cd +/-, cd +/-, cd /lca+/-, cd -, cd -, cd -, cd -, and s -neoplastic cells whose phenotype suggested a granulocytic sarcoma rather than a histiocytic sarcoma. immuno-chemistry confirmed this suggestion by showing a nuclear npm positivity. fish studies demonstrated that these neoplastic cells were of recipient's origin. a novel bm aspiration showed cr confirmed by immune-phenotypic studies and fish revealed a complete chimera. since the patient was still pancytopenic due to anti-cmv treatment, radiotherapy with gy in nine fractions were given and the lesion completely resolved. conclusions: a granulocytic sarcoma of recipient's origin occurring three months after a cb transplant is a very rare and unusual event. in order to explain such a complication we suggest that granulocytic sarcoma cells were dormant but already present at the time of pro-b all diagnosis and survived not only the initial all treatment but also the cb transplant conditioning regimen. we can't exclude that immune-suppressive treatments given early post-transplant might have promoted the outgrowth of these neoplastic cell population. disclosure: nothing to declare haemoglobinopathy and inborn errors of metabolism p abstract already published. addition of fludarabine on to anti-thymocyte globulin, busulfan and cyclophosphamide conditioning improves outcomes in low-risk matched-related bone marrow transplantation in children with severe thalassaemia flu-atg-bucy. atg dose was mg/kg in all patients except patients with splenomegaly > cm from costal margin and/or sex-mismatched/maternal donor in whom atg was increased to mg/kg. all patients were younger than years and had no hepatomegaly (liver ≤ cm from costal margin) at bmt. results: actuarial overall survival (os) in the atg-bucy and flu-atg-bucy groups is % and %, thalassemia-free survival (tfs) % and %, gvhdfree and thalassaemia-free survival (gtfs) at a median follow up of . and . months was . % and . % months respectively, which is a significantly improved outcome by log-rank statistics (p= . ) in the flu-atg-bucy group. there was no significant difference between the groups in pre-transplant characteristics and posttransplant complications except for the following: median cell dose more in nd group with total nucleated cell dose of . vs . x cell/kg with p< . ; csa taper started later in the new protocol ( day vs. p= . ); median age at bmt ( . vs. . years, p= . ); number of pre-bmt transfusions (p= . ) and ferritin at bmt ( . vs. . ng/ml, p= . ) were higher in the second group; day and chimerisms were also significantly higher in new protocol (p= . and . respectively). there was a trend towards increased incidence of veno-occulsive disease (vod) and posterior reversible encephalopathy syndrome (pres) on the second group but this difference did not reach statistical significance. conclusions: adding fludarabine and targeted dose increase of atg in the standard bucy context seems to significantly improve outcomes of thalassaemia transplants without contributing to excessive gvhd or infectious complications. this protocol can be easily administered in low resource setting without major additional costs. clinical is an acquired clonal disorder of the hemopoietic stem cells for which the only curative treatment is allogeneic hematopoietic stem cell transplantation. however, there are still few reports on the outcomes of allogeneic hematopoietic stem cell transplantation (allo-hsct) in patients with pnh compared to paroxysmal nocturnal hemoglobinuria-aplastic anemia (pnh-aa) syndrome. our study aimed to compare the outcomes of allo-hsct for pnh with pnh-aa syndrome. methods: the clinical data of pnh patients received allo-hsct (pnh = , pnh-aa = ) in our center from july to june were analyzed retrospectively to compare the outcomes of pnh group with pnh-aa group. the clinical data including male patients and female patients, the median age was years (range - ). all patients had received various treatments before transplantation such as steroids, androgens, cyclosporine (csa), antithymocyte globulin, and growth factors. the median interval from pnh diagnosis to hsct was months (range - ). the conditioning regimen was modified bu/cybased regimen in haploidentical donors and unrelated donors, csa, mycophenolate mofetil (mmf) and shortterm methotrexate (mtx) were administered for graftversus host disease (gvhd) prophylaxis. patients with matched sibling donors were treated with the flu/cybased regimen and csa were administered for gvhd prophylaxis. results: there were no differences of baseline between the groups (p> . ) except gender and haploidentical donors. the median values of absolute nucleated cell counts were . ( . - . ) × /kg in the pnh group and . ( . - . ) × /kg in the pnh-aa group (p = . ). the median doses of cd + cells infused were . ( . - . )× /kg and . ( . - . )× /kg (p = . ), respectively. all patients attained complete engraftment, no patient occurred graft failure. the median time for myeloid engraftment were (range, - ) days in the pnh group and (range, - ) days in the pnh-aa group (p = . ). the median time for platelet engraftment were (range, - ) days and (range, - ) days (p = . ), respectively. with a median follow-up of ( - ) months in the pnh group and ( - ) months in the pnh-aa group (p = . ). in pnh and pnh-aa groups the incidences of grade i-iv acute graft-versus-host disease (agvhd) were . % and . % (p = . ), grade ii-iv agvhd were . % and . % (p = . ); chronic gvhd were . % and . % (p = . ), moderatesevere chronic gvhd were . % and . % (p = . ). in haplo-hsct and msd groups the incidences of infection were . % ( / ) and . % ( / ) (p = . ). no patient occurred early death and relapse. -year estimated overall survival (os) of pnh and pnh-aa groups were . % ± . % and . % ± . % (p = . ), gvhd-free and failure-free survival (gffs) were . % ± . %、 . % ± . % (p = . ). conclusions: the preliminary results indicated that allo-hsct is a feasible choice for pnh with favorable outcomes, time for myeloid and platelet engraftment in pnh group were faster than pnh-aa group. there were no differences in os and gffs between pnh group and pnh-aa group. disclosure: no disclosure pattern of calcineurin inhibitor-associated neurotoxicity in sickle cell disease patients receiving a stem cell transplantation background: allogeneic hsct with a msd represents currently the only curative option for sickle cell disease (scd), limited by a donor availability < %. neurotoxicity (nt) contributes significantly to hsct-associated morbidity and mortality. calcineurin-inhibitor (cni) associated nt ranges from . %- . % (severe nt %- %). the elevated incidence of nt in scd (around %) might be triggered by the systemic vasculopathy of scd, with the brain being the primary target. although both cyclosporine a (csa) and tacrolimus (fk ) have a proinflammatory effect, it is more pronounced in csa. infusion modalities also might impact ( . % after bolus injections versus . % after continuous infusion). methods: in a pilot study, we compared t-cell depleted haploidentical hsct (t-haplo hsct) with msd hsct in patients (pts) with advanced stage scd, using almost identical conditioning regimens. pts ( - years; yrs) with homozygous scd or hbs /+ ß-thal were treated between and . nine pts received a msd bone marrow graft, pts received t-haplo-hsct ( second t-haplo due to graft rejection). immunosuppression consisted of either csa ( msd, t-haplo) or fk ( msd, , in combination with mycophenolate mofetil (mmf). fk was administered as a -hours continuous infusion, csa as -hours bolus injections; both target level adjusted (csa: - ng/ml; fk : - ng/ ml). duration of immunosuppression was > months in thaplo-sct and < months in msd, depending on chimerism. results: cni-related nt was observed in . %, severe nt (pres, visual disturbance, aphasia) in . %. nt was more prevalent in msd (n= , . %) than in t-haplo (n= , . %). the incidence of nt was identical under csa ( / ; . %) and fk ( / ; . %), however the majority of severe nt (all pres) occurred with csa. complete recovery of nt was achieved in all pts either spontaneously or after switching to fk /everolimus or withdrawal of fk . moreover, . % of pts with nt were > yrs, and . % > yrs, suggesting an increased risk with age. only . % of pts with pre-existing cerebrovascular disease experienced post-hsct nt. of note, . % of pts with severe nt also developed mild acute gvhd. the overall (os) and disease-free survival (dfs) with a median follow-up of months in t-haplo-hsct and months in msd hsct was % vs. %, respectively. conclusions: our data confirm an elevated nt risk in scd pts following allo-hsct. importantly, the incidence of nt seems to be related to age ( % of pts with nt were > yrs), donor source (msd . % vs. t-haplo . %) and type of cni inhibitor where almost all severe nt ( . %, particularly all pres) was observed under csa. continuous infusion of fk vs. bolus injections of csa might have levelled concentration peaks. the nt observed with csa could be the consequence of predominantly csarelated vascular toxicity inflicting pre-damaged vessels in scd. the mechanism of action could be related to other systemic endotheliopathies such as vod, tam and agvhd, which was observed in . % of pts with severe nt, compared to an overall agvhd rate of %. disclosure: nothing to declare background: matched-related bone marrow transplantation (bmt) may cure over % of low-riskchildren with severe thalassemia (st) defined as a thalassemia syndrome with inability to keep a spontaneous hemoglobin > g/dl. it is well known that patient status at the time of transplant is critical in predicting transplant outcome. liver size > cm is an established adverse prognostic factor in terms of transplant-related mortality and, in our own experience,a spleen size > cm from costal marginis associated with increase rejection rates (blood vol. no. suppl ) . optimising liver and spleen size prior to transplant is likely to improve transplant outcomes. methods: we retrospectively reviewed the effectiveness of our strategy to reduce liver and spleen size pre-transplant using hydroxyurea, super-transfusion and intensive iron chelation. we considered liver size < cm and spleen size less than cm below costal margins as good risk features. liver biopsies were not performed thus pesaro risk classification could not be assigned. all transplant candidates were started on hydroxyurea for a minimum of months and pre-transfusion haemoglobin was maintained > gm/dl while on hydroxyurea. if the child had hepatospenomegaly at enrollmentand no improvement in liver and spleen size after an adequate trial of hydroxyurea (minimum of months of treatment achieving maximum dose of mg/kg day or tolerable haematological toxicity, i.e. neutrophil count between and /μl and/or platelet count between . and . /μl) patients were given a trial of supertransfusion maintaining haemoglobin above g/dl) for a minimum of months prior to declaring the patient as having failed downstaging. results: out of transplants across collaborating centers in india, patients had no hepatosplenomegaly at enrolment and hence were not actively downstaged. twelve patients were excluded due to inadequate information on their records. all of the remaining patients with enlarged liver and/or spleen were downstaged to low-risk features. all patients received adequate hydroxyurea trial among which seven ( %) patients required super transfusion in addition to maximal hydroxyurea. out of the patients ( %) were successfully down-staged with the above strategy and proceeded to transplant as low-risk patients. among the remaining ( %) patients had liver > cm and one had a spleen > cm only. there was significant improvement in liver and spleen size from the time of enrollment to transplant (p value . and . respectively by wilcoxon test for paired samples -two tailed) with median duration of downstaging of months (range - months). there was no significant difference in overall survival (os) and disease-free survival (dfs) by log rank test between the downstaged group and those who did not have hepatosplenomegaly at enrollment (p value . . respectively). conclusions: in the majority of children with thalassaemia and high transplant risk features liver and spleen size can be reduced pre-transplant using hydroxyurea and supertransfusions thereby decreasing transplant risk. disclosure: nothing to declare p abstract already published. abstract withdrawn. longitudinal analysis of the effect of hematopoietic cell transplantation on ocular disease in children with mucopolysaccharidosis i shows ongoing disease progression background: corneal clouding is seen in nearly all patients with mucopolysaccharidosis- (mps- ) causing visual impairment. hematopoietic cell transplantation (hct) is able to stabilize disease in many organs including the brain. however, residual disease in peripheral tissues is often described. therefore, the aim of this study was to determine the long-term effect of hct on ocular disease in mps- patients. methods: corneal clouding (grade - ) and visual acuity (decimal scale) were prospectively collected from all consecutive mps- patients treated with hct between and at the umc utrecht. the primary outcomes of interest, the effect of time on corneal clouding and visual acuity, were analyzed using a linear mixed model. the correlation between corneal clouding and visual acuity was analyzed with pearson's rho. other parameters studied were clinical phenotype, age at time of transplantation and hematological enzyme level after transplantation. other outcomes of interest analyzed included intra-ocular pressure, refraction, and macula and lens abnormalities. [[p image] . results: successfully engrafted mps- patients were included ( % with > % chimerism and normal enzyme levels after hct). corneal clouding stabilized during the first years after hct, but increased rapidly beyond three years (figure ). other predictors for increased corneal clouding were age at time of transplantation ( . , %ci . : . ; p= . ) and clinical phenotype (- . , %ci - . :- . ; p= . ). visual acuity also worsened significantly over time (- . , %ci - . :- . ; p= . ). corneal clouding was strongly negatively correlated with visual acuity (ρ - . , p = . e- ). conclusions: after initial stabilization, ongoing ocular disease is seen in mps- patients despite successful hct. this hallmarks the shortcomings of current standard therapies. new therapies that overcome the weak spots of current therapies are necessary to improve the late outcomes of these patients. clinical trial registry: n.a. disclosure: b.t.a.v.d.b. was supported by a research grant from the sylvia toth charity foundation, the hague, the netherlands, while working on this study. the sponsors of this study are public or nonprofit organizations that support science in general. they had no role in gathering, analyzing, or interpreting the data. all authors would like to thank all parents and patients for participating in this study. all authors state they have no competitive (financial) interests in this study. background: paroxysmal nocturnal hemoglobinuria (pnh) is an acquired clonal disorder of the hemopoietic stem cells for which the only curative treatment is allogeneic hematopoietic stem cell transplantation. haploidentical donor hematopoietic stem cell transplantation (haplo-hsct) is now increasingly applied as a curative therapy for patients with hematologic diseases. however, there are still few reports on the use of haplo-hsct for the treatment of pnh. our study aimed to compare the outcomes of haplo-hsct with matched-sibling donor transplantation (msd-hsct) for pnh. methods: the clinical data of pnh patients received hsct (haplo-hsct = , msd-hsct = ) in our center from july to may were analyzed retrospectively to compare the outcomes of haplo-hsct group with msd-hsct group. the clinical data including male patients and female patients, classical pnh and pnh-aa syndrome, the median age was years (range - ). all patients had received various treatments before transplantation such as steroids, androgens, cyclosporine (csa), antithymocyte globulin, and growth factors. the median interval from pnh diagnosis to sct was months (range - ). the conditioning regimen was modified bucybased regimen in haplo-hsct group, csa, mycophenolate mofetil (mmf) and short-term methotrexate (mtx) were administered for graft-versus host disease (gvhd) prophylaxis. patients with msd-hsct were treated with the flucy-based regimen and csa were administered for gvhd prophylaxis. results: there were no differences of gender, age, patients of pnh-aa and median time from diagnosis to transplantation between the groups (på . ). the median values of absolute nucleated cell counts were . ( . - . ) × /kg in the haplo-hsct group and . ( . - . ) × /kg in the msd-hsct group (p = . ). the median doses of cd + cells infused were . ( . - . ) × /kg and . ( . - . ) × /kg (p = . ), respectively. all patients attained complete engraftment, no patient occurred graft failure. the median time for myeloid engraftment were (range, - ) days in the haplo-hsct group and (range, - ) days in the msd-hsct group (p = . ). the median time for platelet engraftment were (range, - ) days and (range, - ) days (p = . ), respectively. with a median followup of ( - ) months in the haplo-hsct group and ( - ) months in the msd-hsct group (p = . ). in haplo-hsct and msd-hsct groups the incidences of grade i-iv acute graft-versus-host disease (agvhd) were . % and . % (p = . ), grade ii-iv agvhd were . %、 . % (p = . ). chronic gvhd were . % and . % (p = . ), moderate-severe chronic gvhd were . % and . % (p = . ). in haplo-hsct and msd groups the incidences of infection were . % ( / ) and . % ( / ) (p = . ). no patient occurred early death and relapse. -year estimated overall survival (os) of haplo-hsct and msd-hsct groups were . % ± . % and . % ± . % (p = . ), gvhd-free and failure-free survival (gffs) were . % ± . % and . % ± . % (p = . ). conclusions: the preliminary results indicated that haplo-hsct is a feasible choice for pnh with favorable outcomes, haplo-hsct and msd-hsct had similar therapeutic efficacy. disclosure: no disclosure p pres in bmt for thalassemia major in india: lower incidence and limited impact background: posterior reversible encephalopathy syndrome (pres) is a relatively common complication seen after blood or marrow transplantation (bmt) for hemoglobinopathies with a reported frequency of - %. pres has also been associated with poorer survival rates. severe hemoglobinopathies are one of the most frequent indications for bmt in the developing world, particularly in india. given the risk of rejection in multiply transfused patients and the need to minimize gvhd risk, immunosuppression post-bmt for these non-malignant conditions can be particularly intense and prolonged. we sought to measure the incidence and impact of pres in developing countries. methods: we analysed successive transplants for thalassemia using protocol (atg-bucy+csa/mmf or csa/mtx) maintaining cyclosporine a (csa) blood levels - ng/ml for patients and protocol (flu-atg-bucy+csa/mtx) maintaining higher csa levels post, i.e. - ng/ml for patients from fully matched donors with g-csf-primed bone marrow. for patients this was the second transplant from a different matched related donor. pres was confirmed with brain ct/mri for all patients. results: all recipients who had pres had sibling donors, males and females. age median . (iqr . - years). the frequency of pres was . %; disease free survival for patients who had pres was %. pres resolved completely in all. csa was switched to mmf in patients who had received mtx and were on csa only at the time of pres occurrence, while csa was stopped but mmf continued in patients taking csa/mmf combination and csa was continued for patient. three patients with pres had grade acute gvhd, had grade gvhd and none developed chronic gvhd. csa levels at the time of pres were a median of ng/ml (iqr: to ) with patient having ng/ml. three patients had pres while they were thrombocytopenic. hypertension stage was observed in four patients, stage in one patient, one patient was not hypertensive and in one patient blood pressure values were not available. two patients were on methylprednisolone and . mg/kg/day and one was on dexamethasone mg/m /day. one patient was started on csa again after the pres episode and within weeks had another one while on csa (level ng(ml), methylprednisolone . mg/kg/day and ruxolitinib for gvhd. protocol had statistically significant improvement in disease free survival from % to % (p< . ) with probability of occurrence of pres increasing from . % to . % (p = . , see figure ), yet had a benign course in all patients. conclusions: not stopping immunosuppression may have been the key factor which could explain why we have better outcomes with pres than what is reported. intensifying immunosuppression pre-bmt did lead to more pres, albeit not significantly, and yet it was quite manageable. even with addition of fludarabine our pres incidence is lower than previously reported. [[p image] . background: sickle-cell diseases (scd) are a group of genetic hemoglobin disorders marked by brain vasculopathy. allogeneic hematopoietic stem cell transplantation (hsct) is a curative option able to stop vascular disease progression. diffusion-tensor imaging (dti) is a magnetic resonance imaging (mri) technique sensitive to the brownian motion of water molecules and cellular environment. this microscopic quantitative technique is able to detect white matter (wm) alterations before a conventional mri. the aim of this study was to use dti to evaluate axonal damage and structural connectivity in the brain of patients with scd submitted to hla-identical sibling allogeneic hsct. methods: sixteen scd patients with no extensive vasculopathy detected by conventional mri ( male, age range: - years) and age-matched healthy controls ( male, age range: - years) participated in this prospective study. mri acquisitions were performed in a t scanner two times for patients (before and - years after hsct) and at a single moment for controls. from dti acquisitions, fractional anisotropy (fa), mean (md), radial (rd) and axial diffusibility (ad) were calculated in the wm of the whole brain. structural connectivity was also analyzed, based on graph theory, obtaining efficiency, length path and clustering coefficients of the brain network. an anova test was applied to analyze fa differences among controls and patients, before and after hsct. a paired two-tailed t-test was used to determine statistical significance of changes in the fa, diffusivity mean values and network parameters before and after hsct. results: mean fa was lower in patients before hsct than controls (p = , ) and increased after hsct being not statistically different when compared to controls (controls = , ; patients before hsct = , ; patients after hsct = , ; post hoc dunnett's test -error , ; anova test). when patients were compared before and after hsct, md and rd decrease after hsct (p = , and , , respectively). on the other hand, fa increased (p = , ). after hsct, efficiency was higher (p = , ) and path length index was lower (p= , ) than at study entry (table ) . conclusions: this study indicates that, before hsct, patients with scd present axonal damage not detectable by conventional mri, when compared to healthy controls. we also suggest that hsct is able to promote axonal recovery and reorganization. partial diffusivity recovery could be associate to a still unidentified mechanism of myelin regeneration. in the future, longer follow up and comparisons with other forms of treatment are required. background: bmt is a well-established treatment modality for haemoglobinopathies, limited by the availability of related donors. unrelated transplantation has historically shown variable outcomes driven by gvhd and toxicity, and usually restricted to / matches, but the impact of reduced toxicity conditioning regimens is yet to be known. methods: from to twenty-five consecutive unrelated bone marrow transplants were conditioned with fludarabine mg/m , treosulfan g/m , thiotepa mg/ kg and atg (thymoglobulin) . mg/kg if the source of stem cells was marrow (n = ) or ptcy if pbsc (n = ). endogenous haemopoiesis was suppressed pretransplantation for a minimum of weeks. gvhd prophylaxis was provided with ciclosporin/sirolimus and mmf. thirteen patients were transplanted for b thalassaemia major, one of a thalassaemia major and sickle cell disease. the median age was years ( - ). ten patients were / matched ( thalassemia and sickle) and patients had a / match ( thalassaemia and sickle). the median cell dose was . x tnc/kg (range . - . ) and . x cd +/kg (range . - . ). the median survival was . months ( . - . ). patients with thalassaemia were pesaro class i or ii (pesaro class iii patients were intensively chelated pretransplantation to return to class i or ii). patients with sickle cell disease were transplanted for stroke or recurrent vaso-oclusive crises and/or acute chest syndrome not responding to hydroxycarbamide. results: all patients engrafted and achieved evidence of donor haemopoiesis on day + and achieved transfusionindependence and donor haematological values, but subsequently one / patient with thalassaemia suffered secondary graft failure on day + after macrophage activation syndrome. median neutrophil engraftment was days (range to ) and days ( - ) for / and / patients respectively. patient with sickle cell disease had the platelet count maintained > x /l at all times. the median platelet engraftment > x /l was days (range to ) and days (range to ) / and / patients respectively. there were three deaths, all in the / matched group: two with thalassaemia (day + due to idiopathic pneumonia syndrome and day + due to mas) and one with scd (day + due to ips). there were different trends of complications seen by degree of matching that did not segregate otherwise by disease. conclusions: in conclusion, unrelated bmt for haemoglobinopathies with reduced toxicity regimens is feasible. whilst gvhd caused significant morbidity during the transplant period, other alloreactive/endothelial complications (vod, macrophage activation syndrome, idiopathic pneumonia syndrome) were only seen in the / transplants. disease-free survival, dependent on transplantrelated mortality, and lack of long-term toxicity, including chronic gvhd, are determined by the degree of matching. / matched transplants have excellent long-term outcomes with no chronic gvhd > months and can be considered for patients without a related donor; whereas / transplant have significant toxicity and mortality, warranting a haploidentical approach. disclosure: no conflict. long-term safety and efficacy of lentiglobin gene therapy in patients with transfusion-dependent β-thalassemia following completion of the phase / northstar study patients with transfusion-dependent β-thalassemia (tdt) may benefit from gene therapy involving β-globin gene addition to hematopoietic stem cells (hscs) enabling production of functional hemoglobin (hb). lentiglobin gene therapy contains autologous cd + hscs transduced ex vivo with the bb lentiviral vector encoding β-globin with a t q substitution under transcriptional control of the encoding β-globin locus control region. the safety and efficacy of lentiglobin was evaluated in adults and adolescents with tdt in the -year phase / northstar study (hgb- ; nct ). methods: patients with tdt (≥ ml/kg/year of red blood cells [rbcs] or ≥ rbc transfusions/year) received g-csf and plerixafor for hsc mobilization. to generate drug product (dp), cd + hscs were transduced with the bb lentiviral vector. patients underwent single-agent, myeloablative busulfan conditioning, were infused with the dp, and were followed for safety and efficacy. results: eighteen patients have been treated in the completed northstar study. as of september , patients had a median follow-up of . (min -max: . - . ) months. the median age at consent was (min -max: - ) years including patients ≥ years old. patients received a median cell dose of . (min -max: . - . ) cd + cells x /kg with a median dp vector copy number (vcn) of . (min -max: . - . ) vector copies/ diploid genome. the median liver iron content (lic) at baseline was . (min -max: . - . ) mg fe/g dw. outcomes by age and baseline iron status will be presented. the median time to neutrophil and platelet engraftment was . (min -max: - ) and . (min -max: - ) days, respectively. four patients had platelet engraftment ≥ day and four patients had platelet counts of ≤ x /l at month . none of these patients had ≥ grade bleeding events post-lentiglobin infusion. transfusion independence (ti, defined as weighted average hb ≥ g/dl without rbc transfusions for ≥ months) was achieved in / patients with non-β /β genotypes and / patients with β /β genotypes. in patients who achieved ti, total hb at last visit was . - . g/dl. lic increased from baseline in patients who achieved ti by a median of . % and . % at month and then decreased from baseline by a median of . % and . % at month and , respectively. non-hematologic grade ≥ adverse events post-infusion in ≥ patients included stomatitis, febrile neutropenia, pharyngeal inflammation, and irregular menstruation. there was no transplant-related mortality, vector-mediated replication competent lentivirus, or clonal dominance. two patients experienced grade serious veno-occlusive liver disease (table ) . events resolved following treatment with defibrotide and were attributed to myeloablative conditioning. conclusions: in the northstar study, % of patients with tdt and non-β /β genotypes and % of patients with β / β genotypes achieved transfusion independence. the safety profile of lentiglobin remains consistent with myeloablative busulfan conditioning. longer time to platelet engraftment was observed in some patients, but no graft failure was reported. clinical background: sickle cell disease (scd) is an inherited hemoglobin disorder associated with high morbidity and mortality. currently, allogeneic hematopoietic stem cell transplantation (hsct) is the only curative therapy for scd. transplant outcomes with thiotepa, treosulfan and fludarabine (ttf) preparative regimen are encouraging but this regimen has not been directly compared to other preparative regimens in scd. we therefore planned to compare the event free probability for death, rejection and high grade acute graft versus host disease (agvhd) between ttf and busulfan and fludarabine (bf) regimens. methods: in this retrospectively cohort study, we included all patients with scd who received allogeneic hsct at our center or who were transplanted in other centers and referred to ours for follow up before day . patients were transplanted between july and december . we used kaplan-meier curve to estimate the event free probability for death, rejection and high grade agvhd (grades - ). cox regression was used to assess the impact of the preparative regimen on these outcomes. results: a total of patients were included with a median age of years (interquartile range [iqr]: - ) and a median hemoglobin of g/dl (iqr: - ). sixtytwo percent were males. the proportion of patients who had splenectomy, stroke and acute chest syndrome was %, % and % respectively. all patients received peripherally collected hematopoietic stem cells from a matched sibling donor with a median stem cell dose of x /kg (iqr: . - . ). most patients, %, received cyclosporine or tacrolimus based agvhd prophylaxis. most patients received ttf ( %) or bf ( %) preparative regimens. all patients in the bf group received atg. the median follow-up time was months (range: - ). four patients died during the follow-up period with an os of % ( % confidence interval [ci]: %- %) at years. the os was not different (hr . , p = . ) between the ttf ( %) and the bf ( %) regimens. the probability of high grade agvhd free survival at day was % ( % ci: - ) for all patients. this probability was % in the ttf group and % in the bf group and the difference was not statistically significant (hr . , p = . ). the rejection free survival at months was % ( % ci: - ) for all patients. no patients in the ttf group rejected while the rejection free survival at months for the bf group was %. this was not statistically significant (p = . ). conclusions: in patients with scd undergoing allogeneic hsct from a matched sibling donor, the ttf preparative regimen is not associated with improved os, rejection free or high grade free agvhd survival when compared to the bf preparative regimen. larger studies are needed to confirm these findings. disclosure: nothing to declare. novel strategy for haploidentical hematopoietic stem cell transplant in sickle cell disease methods: consecutive patients suffering from scd who underwent hhsct between jan till date were enrolled in the study. all underwent autologous backup (target dose> x /kg) followed by pre-transplant immune suppression (ptis) cycles at weekly intervals using fludarabine @ mg/m /day(d -d ) + cyclophosphami-de@ mg/m /day(d ) + dexamethasone@ mg/m / day(d -d ) along with hypertransfusion (target hb - gm/dl), hydroxyurea ( mg/kg/day) and azathioprine ( mg/kg/day) from day - . the graft was mobilized using gcsf@ mcg/kg/day(d -d ) + plerixafor@ . mg/kg s/ c on d - hours before the pbsch. conditioning included thiotepa mg/kg in two divided doses (d- ), fludarabine mg/m (d- to d- ), cyclophosphamide . mg/kg (d- , d- ), tbi gy with thymic shielding (d- ), ratg (genzyme thymoglobulin . mg/kg (d- to d- ). gvhd prophylaxis included ptcy mg/kg/day on d and , sirolimus (target levels - ng/ml) (till - months post hsct) and mmf (till d ) starting from d . results: the median age of patient's was years (range - years). before transplantation all patients had repeated episodes of one or other complication warranting a transplant, non-responsive to hydroxyurea. six had maternal donors, paternal and sibling. median age of the donor was years (range - years). all were dsa negative with a cutoff mfi of > iu. all patients received x /kg cd cells irrespective of harvested dose which ranged from ( . - . x /kg). median cd dose was . x /kg (range . - . x /kg). all patients engrafted with median time to neutrophil engraftment days (range - days) and median time to platelet engraftment days (range - days). median duration of hospital stay was days (range - days). one patient had cytokine release syndrome needing tocilizumab. five had engraftment syndrome treated with short course of steroids. two had cmv reactivation needing treatment with ganciclovir/valganciclovir. acute gvhd grade ii was seen in one patient. till date of analysis none had features compatible with chronic gvhd. of the patients, are alive without sickle cell disease with lansky/ karnofsky scores of . at median follow up of days (range - ) the probabilities of survival, sca-free survival, and transplant-related mortality after transplant were . %, . %, and . %, respectively. one patient died due to mdr klebsiella sepsis after being discharged initially while he was receiving iv ganciclovir on day care basis. he had full donor chimerism. none of the patient had primary or secondary graft failure. conclusions: pre-transplant immune suppression and upfront use of plerixafor for graft mobilization decreases the risk of graft failure and graft versus host disease leading to overall better survival in hhsct for sickle cell disease. disclosure: none. combined haematopoietic stem cell transplant and enzyme replacement therapy in wolman disease: outcomes and challenges jane kinsella , denise bonney , helen campbell , robert wynn , simon jones background: infantile lysosomal acid lipase deficiencymore commonly known as wolman disease -is an autosomal recessive lysosomal storage disease, characterised by storage of cholesterol esters in the liver, spleen and gastrointestinal tract. these children present under the age of months and traditionally had a poor prognosis, with almost all being dead by the age of months. bone marrow transplant has been used to correct disease manifestations, but limited by high procedure-related mortality with the significant co-morbidities. the survival has changed over the past few years due to pharmacological enzyme replacement therapy but still presents challenges for these patients and their clinicians. in these children haematopoietic stem cell transplant we have offered bmt with enzyme replacement therapy, in certain specific circumstances. methods: four children with wolman disease being treated with enzyme replacement therapy, limited by alloantibody, or poor venous access, received treosulfan-based, myeloablative conditioning with serotherapy followed by a matched haematopoietic stem cell transplant: two family donors, one sibling donor and one unrelated donor. results: three of the four children survived transplant. they have continued to receive enzyme replacement therapy but at reduced dose and frequency with improved tolerability. they have continues to grow and develop. growth and gastrointestinal histology is improved for children having received transplant compared to those receiving enzyme replacement alone. monitoring of peripheral blood chimerism has shown a disease-associated engraftment defect, with mixed chimerism in the surviving patient. conclusions: haemopoietic stem cell transplant is a suitable treatment option in children with wolman disease in whom receiving enzyme replacement therapy is not possible because of venous access, sensitisation or cost reasons. it improves their tolerability of the enzyme treatment and allows for a reduction in enzyme dose and frequency. however, the results of engraftment are not as good as expected for a transplant with myeloablative conditioning and a matched donor. an engraftment defect has been observed in lysosomal acid lipase deficient animal models. a further understanding of this poor engraftment in children with wolman disease is required as to determine whether the risks of transplant is beneficial in these patients and for the consideration of future treatment options including gene therapy. background: thalassemia major is the most common transfusion dependent hemolytic anemia in the world. the absent or reduced production of the β-chain of hemoglobin causes severe ineffective erythropoiesis, massive erythroid hyperplasia in the bone marrow and extramedullary hematopoesis occurs. patients require regular transfusion therapy lifelong. currently, the only proven curative treatment of thalassemia is allogeneic stem cell transplantation (sct). methods: we evaluated the immune reconstitution results of patients at year after hematopoetic stem cell transplantation at our pediatric bone marrow transplantation center between january and december . all patients were not receiving any immunosuppressive treatment at least for months and they have normal lymphocyte counts, immunoglobulin levels and transfusion independent. lymphocyte subtypes and chimerism percentages and the relationship with the donor type were evaluated at year of transplantation. results: ages of transplantation was ranged between - years (median: years). seven ( %) of them was male. matched unrelated donor type was chosen in patients while others ( patients) were transplanted from family matched donor (matched sibling: patients, matched family: patients). all patients received myeloablative conditioning regimen containing busulfan/treosulfan, cyclophosphamide, thiotepa and fludarabine. follow up time was between - months (mean: ± months). in patients, whole bone marrow product was used while peripheral stem cell harvest in remaining patients. cd levels were found low in only patients, in normal patients mean was % ± %. cd levels were severely low in patients while cd in only patient. cd levels were increased in total patients in as compensatory. cd /cd ratios were very low in all patients (range: . - . ). b cells (cd +) were low in patients while immunoglobulin levels were normal. chimerism values between - % (mean: ± %). donor and product types did not differ in cd + lymphocyte reconstitution at year (p= . , p= respectively). all patients were alive and well at year after transplantation. conclusions: after year of transplantation, although patients are in well condition regarding to infection frequency and transfussion dependency, it was seen that their lymphocyte subtypes reconstitution could not be achieved enough as in normal children. we can conclude that low cd + cell levels were an expected finding in almost all patients. so, these patients may have a tendency to suffer serious bacterial and viral infections, and close follow up be required in terms of infections as long as cd levels continue to be low. immunoglobulin replacement therapy did not required even in patients with low b cell levels. disclosure: nothing to declare p phase international, multicentre trial to assess haploidentical aß t-cell depleted stem cell transplantation in patients with sickle cell disease with no available sibling donor background: sickle cell disease (scd) is an inherited disorder with an estimate of , affected newborns per year worldwide. allogeneic hematopoietic stem cell transplantation (hsct) with a matched sibling donor (msd) is currently the curative standard of care for scd patients (pts). however, msd availability is < %. a t-cell depleted haploidentical hsct (t-haplo-hsct) from a relative, mostly a parent, expands the donor availability while exhibiting low gvhd rates and thus could offer cure to the remaining % of scd patients. in a pilot study, comparing t-haplo-hsct with msd hsct in advanced stage scd, using almost identical transplant regimens for both. the overall (os) and disease-free survival (dfs) was % vs. %, respectively. methods: these results led to the design of a clinical trial to assess tcd-haplo-hsct prospectively which aims to demonstrate that a hsct from a haploidentical relative is not inferior to a msd hsct with regard to major outcome parameter. this phase , prospective, stratified, open-label study is targeting enrollment of patients aged - years with homozygous hbs disease or heterozygous hbsc or hbs /+ ß-thal suffering from severe or moderate scd related complications. inclusion criteria are clinically significant scd related complications such as stroke, silent crisis, pathological angio-mri, transcranial doppler (tcd) velocity > cm/s, or more episodes of acute chest syndrome (acs) in a lifetime, chronic transfusion dependency, transfusion-refractory allo-immunization and others. pts fulfilling inclusion criteria will be stratified according to donor availability. pts with a msd will receive a bone marrow graft, pts requiring an alternative donor will be transplanted with an aß/cd depleted graft from a haploidentical family donor. the conditioning regimen for both groups will be identical with the exception that antithymoglobulin (atg-neovii ® ) is given upfront in thaplo-hsct versus day - to - in msd. chemotherapy consists of thiotepa, fludarabine and treosulfan. posttransplant immunosuppression will consist of mofetil mycophenolate and tacrolimus for a duration > months in t-haplo-hsct and < months in msd, depending on chimerism. (eudract number: - - ) results: primary efficacy endpoint: event free survival (efs). event is defined as incidence of acute gvhd, grade iii -iv, chronic gvhd, rejection (graft failure) or death (for any reason). key secondary endpoint(s) are os, dfs, graft failure, hematological and immunological reconstitution, quality of life (qol) assessment and fertility. the primary null hypothesis is: efs of scd patients treated with t-haplo-hsct is non-relevantly inferior to efs in the msd arm. conclusions: results will help to determine if an a/ß depleted t-haplo-hsct can be considered equivalent to msd hsct with regard to dfs, adverse events and safety, in order to offer this form of cure to the majority of patients with scd. disclosure: nothing to declare hit three birds with one stone: successful stem cell transplantation from one family donor to three siblings methods: in august , three thalassemic siblings were admitted to hospital for stem cell transplantation from a full match donor, their years old sister. the patients' general health conditions and specific health issues due to thalassemia were checked extensively. it was decided to perform first transplant to older sister whom the disease and transplant complications are expected more intense due to prolonged transfusion and chelation therapy. the oldest daughter of family, healthy, was planned to accompany her sisters in transplantation unit so parents can take care the others and organize this period for whole family. results: the years old sibling was first admitted to bone marrow transplantation unit in july . the conditioning regimen was busulfan, fludarabine, cyclophosphamide and thiotepa with antithymocyteglobulin(atg) and defibrotide prophylaxis was given. the healthy donor was admitted to hospital and received g-csf for continuous days before harvesting. stem cells were collected peripherally on day and viable cd + cells were /ul. patient received , x e /kg stem cell and the other cell products were divided into parts according to other recipients´weight. no infusion problems were recorded in stem cell transfusion. gvhd prophylaxis was given with cyclosporin and methotrexate. severe sinusoidal obstruction syndrome was observed and successfully managed with supportive therapy. neutrophils were engrafted + . day, and platelets were on day . full blood chimerism results were % in day , % in day and % in day consecutively. after months from first transplant the years old sister was admitted to hospital on october . same conditioning with defibrotide prophylaxis and gvhd prophylaxis were given and , x e /kg peripherally derived and previously frost stem cell was infused without any complications. mild sinusoidal obstruction syndrome was observed and managed with supportive therapy successfully. neutrophils were engrafted + . day, and platelets were on day . full blood chimerism results were % in day , % in day and % in day consecutively. the third transplant was performed on january with the same conditioning and prophylaxis regimen. although defibrotide was used mild sos was observed and treated with supportive therapy with success. neutrophils were engrafted + . day, and platelets were on day . full blood chimerism results were % in day , % in day and % in day consecutively. conclusions: the patients are being followed for over a year after first transplat, neither adverse nor gvhd symptoms were observed. we presented this case for being a unique example for match family donor transplant and the first successful example from one donor to three recipients. disclosure: nothing to declare results: our female patient admitted for anemia at rd month of birth and was transfused every - months from th months to . years of age. since investigations directed towards hemoglobinopathies or membrane defects like hereditary spherocytosis were unremarkable, she was not transfused for years after the age of . -years because hemoglobin level was constant over g/dl. her bm examination showed erythroid hyperplasia and feature of dyserythropoiesis with a few binucleated erythroblasts. it was decided to follow-up the patient with a diagnosis of cda ii. after the age of -years, the need for transfusion started again for every to months which led the parents of our patient to request for bone marrow transplantation, however, the diagnosis was not definite, and because of the insufficient data for the transplantations for cda ii patients, it was decided to go on to follow-up. nevertheless, after years, the frequency of transfusion gradually increased to every - weeks, and bone marrow transplantation was brought into question again. at that time, genetic examination was started and sec b gene was analyzed by direct sequencing. hsct decision from her hla / matched brother, carrying sec b mutation in heterozygous state, was taken. in the preparation regimen, busulfan (bu) at a myeloablative weight adjusted dose ( days), mg/kg cyclophosphamide (cy) ( days), and mg/kg antithymocyte globulin (atg fresenius) were used. graftversus-host disease (gvhd) prophylaxis was with cyclosporin a started on day - and short-term methotrexate on day + ,+ and + . she was transplanted with bm with a dose of total nucleated cells= . x /kg and cd = x / kg. neutrophile and platelet engraftment were achieved at + and + , respectively. indeed, grade hemorrhagic cystitis due to bk virus and a moderate veno-occlusive disease prolonged platelet transfusion days which concealed the exact engraftment day of platelet. the patient was discharged on day with no more need for any transfusion and followed up as a complete chimeric with no type of gvhd since then. now, she is years old, under regular surveillance at our transplant centre without any symptoms. conclusions: hsct data in cda ii patients is still insufficient, however based on data from tm patients with similar treatment approaches in td cda ii patients, it is seen that the hsct is reliable and effective. disclosure: nothing to declare hematopoietic stem cells background: the prognosis after frontline therapy in b-all patients have improved due to monoclonal antibodies (cd , cd , cd ) and approximately % of patients achieve complete remission. in relapsed and refractory (r/ r) b-all and also in mrd + outcomes are relatively poor. disease-free survival (dfs) in this cohort is - %. in this cohort allo-hsct is indicated and complete remission before transplantation is crucial for prognosis. conventional chemotherapy is associated with high failure rate and significant toxicity. immunotherapy with monoclonal antibodies and car-t are more promising approaches. the aim was to evaluate the efficacy (frequency of responses, os, dfs) and toxicity, especially neurotoxicity and cytokinerelease syndrome, of a bispecific monoclonal antibody blinatumomab in patients both children and adults with persistence of minimal residual disease (mrd + ) or r/r b-all as a bridge to allo-hsct. methods: this study included patients with high risk b-all blinatumomab treated in - , among them pts ( %) with t( ; ), ( %) with t( ; ), with mll ( %), pts ( %) who were refractory to previous chemotherapy, ( %) after allo-hsct from deferent type of donors. median age was y.o. (range m- y.o), children - y.o. ( %) and adults > y.o. ( %). r/r all had pts ( %), mrd + - pts ( %), median days of follow up were ( - ). blinatumomab was applied as -day cycles followed by a -day off-period before the start of the following cycle. majority pts received one cycle (n= , %). in r/r all group dose was of mcg/d during the first days and afterwards mcg/d. patients with weight less than kg received mcg/m /d and mkg/m /d accordingly. in mrd group dose was mcg/m /d. results: the frequency of responses to blinatumomab was higher in mrd + pts in comparison r/r all pts ( % vs % p= . ). in mrd + pts cr mrdwas achieved in pts ( . %), pts ( . %) were mrd+ after blinatumomab. two-year os in this group was %. twenty pts ( %) received allo-hsct. in rr all pts cr mrdwas achieved in pts ( %), pts ( %) were mrd+ after blinatumomab, pts ( %) had no hematological response . two-year os in r/r all was %. fifteen pts ( %) received allo-hsct. os in cr mrdpatients who received allo-hsct was not significantly different in comparison with patients who received blinatumomab as a monotherapy ( % vs %, p= . ). no significant differences in dfs were observed at two years in cr mrdpts depending status of the disease before therapy-mrd vs r/r ( % vs %). of the reported adverse events, febrile fever was the most common pts ( %), neutropenia ( %), thrombocytopenia ( %), infection ( %), neurotoxicity ( %), cytokine-release syndrome ( %). all complications were reversible. conclusions: blinatumomab is effective option in patients with high risk b-all especially in the group with mrd persistence after previous chemotherapy and facilitates effective bridging to hsct. blinatumomab therapy is generally well tolerated. disclosure here we address the transcriptional regulation of differentiated cells from human embryonic stem cells (escs) using self-assembling peptide hydrogel without stromal cells, and compare with embryoid body (eb) culture system. methods: esc differentiation was induced in eb culture system or three-dimensional ( d) hydrogel culture system. the engraftment potential of differentiated cells was evaluated by flow cytometry. cd + cells from mobilized peripheral mononuclear blood cells (mpbmcs) or differentiated from escs at different times (day , day , day ) were purified by fluorescent-activated cell sorting. sorted cells were captured on medium-sized microfluidic chips using the fluidigm c single cell auto prep system. sequencing was performed by hiseq x ten. results: self-assembling peptide hydrogel formed a d scaffold for cell culture, the pore diameter of which ranged from to nm. compared to eb culture system, escs in d culture system differentiated more potently. the differentiated cells from d system were short-term engrafted in the nog mice, and myeloid cells, b cells and t cells could all be detected in peripheral blood after transplantation. however, the engraftment was not obtained in differentiated cells from eb culture system. we obtained and analyzed escs, cd + cells from eb culture system, cd + cells from d culture system, and cd + cells from mpbmcs. the cells were divided into cluters ( figure a ). in both differentiation systems, the cd + cells from day were more heterogeneous than cd + cells from day and day ( figure b) . however, cd + cells from mpbmcs were more homogeneous, probably because the differentiated cd + cells contained several cell lineages, including hematopoietic cells, endothelial cells and mesenchymal cells. there is transcriptional overlap between individual cd + cells from eb and d culture systems. however, we found that cluster , which is composed mainly of cd + cells from d at day and day , expressed similar level of several hematopoietic regulator as hsc, such as tal , lmo , erg ( figure c ). the cluster , which is almost the cd + cells from d at day , also expressed the highest gata among the clusters from differentiated cells ( figure c) . conclusions: our study demonstrates that d hydrogel culture system facilitates hematopoietic specification of escs. disclosure: nothing to declare higher cd + cell dose increases overall survival in the setting of dual t-lymphocyte suppression with atg and ptcy in matched related and unrelated donor allosct background: there is no consensus on the cd + donor cell numbers required for optimal outcomes in allogeneic stem cell transplant (allosct). there is controversy on the benefits or harm in higher cell dose for allosct. this study aims to evaluate the impact of cd + cell dose in allosct patients receiving reduced intensity conditioning (ric) combined with anti-thymoglobulin (atg) and posttransplant cyclophosphamide (ptcy) using related (mrd) and / and / matched unrelated donors (mud). methods: this is a single-centre retrospective analysis of adult patients who received allosct for hematologic malignancies between october and may . all received ric using fludarabine ( mg/m /day: day - to - ), busulfan ( . kg/m /day: day - and - ) and total body irradiation ( cgy: day - ). all patients also received rabbit-atg ( . mg/kg: day - to - ), ptcy ( mg/kg/day: day + ,+ ) and cyclosporine (from day + ). unmanipulated peripheral blood stem cells were infused on day . analyses were done using thresholds: ( ) an arbitrary cd + cell dose of x /kg (as this was our target dose) and ( ) cell dose according to quartiles (< . , . - . , . - . and ≥ . x /kg). results: median cd + cell dose was . x /kg. median follow up was months (range - ). median neutrophil engraftment was (range - ) days and platelet engraftment was (range - ) days. a cell dose greater than x /kg was associated with an increased overall survival (os) at year ( . %; % ci, . - . vs . %; % ci . - . ; p= . , figure ). the higher dose was also associated with shorter platelet engraftment time (p= . , figure ). there was no significant difference in neutrophil engraftment, nonrelapse mortality (nrm), relapse free survival (rfs), grade ii-iv acute graft versus host disease (agvhd) and moderate to severe chronic graft versus host disease (cgvhd), (table ) . analyses using quartile cell dose thresholds showed a trend towards decreased os with a cell dose of < . x ^ /kg, however this was not statistically significant ( figure ). higher cd + cell doses were associated with shorter platelet engraftment time (p= . , figure ). there was no significant difference in neutrophil engraftment, nrm, rfs, agvhd and cgvhd (table ) . conclusions: cd + cell dose greater than x /kg significantly increases overall survival in the setting of ric and dual t-lymphocyte suppression with atg and ptcy in mrd and mud allohsct. further studies in a larger number of patients and longer follow up are recommended to validate these findings. disclosure methods: fifty two adult patients were included. median cd + cells requested for infusion were x ^ /kg. all patients received the same ric regimen including fludarabine ( mg/m /day day - to - ), busulfan ( . kg/m /day day - and - ), and total body irradiation ( cgy) (day - ) combined with rabbit-atg ( . mg/kg: day - to - ), ptcy ( mg/kg/day: day + ,+ ), and cyclosporine. unmanipulated peripheral blood stem cells were infused. last followup was november . median follow-up was months (range - ). median cell dose count infused was . cd +/kg. we arbitrarily divided the cohort in two groups with cd + dose of > x ^ cd /kg as cut-off point. results: findings are summarized in figure . the infusion of more than x ^ cd /kg dose had a significant worse impact on overall survival (os) (p= . ), relapse-free survival (rfs) (p= . ) and cumulative incidence of acute gvhd (p= . ). chronic gvhd could not be compared between the two cohorts due to the different median follow-up. conclusions: the infusion of a cd + cell dose count higher than x ^ cells/kg had a significant adverse impact in overall survival and grade ii-iv acute gvhd in the setting of ric and dual t-lymphocyte suppression with atg and ptcy for haplohsct. disclosure: nothing to declare p long-term thymic activity and immune-reconstitution after haplo-identical allografting with post-transplant cyclophosphamide background: the use of post-transplant cyclophosphamide (ptcy) has expanded the application of t repleted haploidentical stem cell transplantation (haplo-hsct). in this setting, to investigate thymus role in longterm clinical outcomes, evaluation of immune reconstitution kinetics was performed. methods: twenty-nine patients (median age ) were enrolled. blood samples were collected before conditioning and at , , , , , months after haplo-hsct. analyses of cd and cd t-cell subsets by flow-cytometry were correlated by generalized linear models with real-time pcr (rt-pcr) quantification of signal joint t-cell receptor excision dna circles (sjtrecs), specific marker of naive t-cells thymopoiesis. a) naive; b) central; c) memory; and d) revertant cd and cd t-cells were defined as follows: a) cd ra+cd l+; b) cd ro +cd l+; c) cd ro+cd -; and d) cd ra+/ ro +, respectively. sjtrecs rt.pcr was performed on genomic dna ( ng) extracted from sorted cd and cd t-cells. results: a gradual increase in absolute numbers of all cd and cd t cell subsets and of sjtrecs copies from the first month up to years post-transplant was observed ( figure ) . however, at years, cd and cd t-cell levels and sjtrecs levels were lower than those observed in healthy donors. sjtrecs kinetics was associated with the increase in cd naive t-cells (overall, p < . ). this correlation suggests that most of cd naive t-cells derives from thymic re-education of donor precursor stem cells, whereas cd naive t-cells undergo peripheral expansion after thymic production. furthermore, an increase in cd revertant memory t-cells was also significantly correlated with sjtrecs kinetic (p , ). central and effector memory t-cells showed a faster thymic-independent expansion in both cd and cd tcells. interestingly, sjtrecs levels and thymic dependent immune-reconstitution were higher in a cohort of patients undergoing hsct from hla identical donors (manuscript in preparation). clinical outcomes and thymic function were correlated starting at months after hsct. lower thymic output was significantly associated by multivariate analysis with low pre-transplant trecs values (p , and p < , in cd and cd , respectively), moderate-severe chronic graft-versus-host disease (gvhd; p < , in cd ), and age (≥ years, p , in cd ). conclusions: the thymus, despite age-dependent involution, substantially contributes to t-cell reconstitution after haplo-hsct. chronic gvhd and older age were significantly correlated with reduced thymic function. overall, lower production of sjtrecs after haplo-hsct as compared after hla identical sibling hsct may partly be due to a higher degree of "mismatching" of mhc molecules during thymic re-education. [[p image] . figure ] background: the use of allogenic hematopoietic stem cell transplantation (hsct) in the treatment of adolescents and young adults (aya) with philadelphia negative all is decreasing with the adoption of pediatric inspired protocols to treat this age group and the incorporation of minimal residual disease assessment in the routine care of all patients. previously, its use was defined mainly by disease risk features at presentation. methods: a study on aya (age - years), who underwent allogenic hsct at our institute for philadelphia negative all, between february and december . all the studied patients received calgb based adult chemotherapy protocol for induction, and underwent a matched related donor (mrd) transplant with cy/tbi conditioning and mtx/csa as gvhd prophylaxis. the patients were eligible for allogeneic hsct, if they have a mrd plus one or more of the following risk factors: ( ) age ˃ years, ( ) high presenting wbc count (> for b-all, > for t-all), ( ) high risk immuno-phenotyping (pro-b, pro-t, early t, and mature t), ( ) bulky splenomegaly or bulky lymphadenopathy, ( ) high risk cytogenetics ( ; , ; , low hypodiploidy/near triploidy, complex), ( ) cns involvement, ( ) relapsed or refractory disease at d of induction. in this study, we investigated the impact of those different risk factors on the long term outcome of allogeneic hsct. results: the median os of our studied patients was not reached at . years, with a median dfs of . years (figure ). in a univariate analysis, relapsed or refractory disease prior to transplant was the only independent risk factor for os and dfs (p-value= . , and . respectively) (figure ). in addition, patients who had or more risk factors ( , . %) prior to transplant had a significantly lower long term outcome compared to patients, who had one ( , . %) or two risk factors ( , . %) with a median os of months, and a median dfs of only months (p-value= . , and . respectively) ( figure ) . conclusions: our results show that the long term outcomes of hsct in aya with philadelphia negative all treated on an adult type chemotherapy regimen, were significantly better in patients who showed a good response to initial therapy and a limited poor prognostic factors at presentation, with worsening of dfs as the number of poor prognostic features increase. we can conclude that, using this risk score can be helpful in predicting the outcome of allogenic hsct in aya with philadelphia negative all treated with adult type chemotherapy protocol. disclosure: no conflict of interest a prospective single center survey on donor-specific anti-hla antibodies and desensitization strategy in patients undergoing an allogeneic stem cell transplant background: in the setting of hematopoietic stem cell transplantation (hsct), considering the risk of poor engraftment or graft failure (gf), the detection of antibodies (ab) directed against donor specific hla loci (dsa) represents a contraindication to proceed with the same donor, suggesting the search of other donors. in many cases, there is not sufficient time to search for alternative donors and it is necessary to plan an immunosuppressive strategy to decrease the dsa level, thus reducing the risk of gf. to date, there is no consensus on desensitization standards to manage dsas in hsct. the aim of this study was to determine the incidence of anti-hla ab and dsas in hematologic patients candidate to an allogeneic hsct, and the efficacy of our desensitization protocol. here, we present an update of the results obtained with our strategy. methods: between august and september , we prospectively screened for dsa consecutive patients candidates to an allogeneic hsct. anti-hla ab research was carried out using the luminex bead assay (lifecode screen and lsa i/ii-immucor). the results were expressed as mean fluorescence intensity (mfi); mfi > was considered positive. in case of a mismatched related donor, a flow cytometric crossmatch test (fcxm) was performed. if the patient had dsas and only one available donor, a desensitization strategy was employed, scheduled with rituximab on day - , single-volume plasmapheresis procedures (pp), usually on day - and - , intravenous immunoglobulins on day - , infusion of hla selected platelets for dsa absorption in case of persistent antibodies directed against class i hla antigens. the aim of this schedule was to avoid interferences with chemotherapy and anti-t-cell globulins, infused during condition regimen results: since august , patients have been prospectively screened. thirty-three patients ( . %) showed anti-hla ab and of them ( . %) had dsas: were treated with the desensitization strategy, applied according to the mfi score and the fcxm result, and all of them obtained an engraftment; in cases, an alternative donor was selected and in case the research for an alternative donor is still underway. dsa detection was performed every days after hsct for the first month and , and days following hsct. neither a dsa rebound nor other complications were observed during the follow-up. conclusions: our prospective analysis underlines the high frequency of anti-hla antibodies detection in hematologic patients, confirming the necessity to routinely evaluate the presence of dsas before an allogeneic mismatched hsct. our desensitization schedules based on the combination of pp, rituximab, ivig and platelet absorption proved successful in reducing dsas. we confirm the necessity of a prospective multicenter collaboration to better define the role of dsas against each hla locus and the critical mfi cut-off level associated with a higher risk of gf. transplant and transfusion specialists should joint to define a consensus for a standard desensitization strategy. disclosure the most frequent technique used for counterbalance partial incompatible hsct is cd + selection that is associated with sustained engraftment and effective reduction of t cells that minimizes gvhd. on the other hand, this approach could delay immune reconstitution and increase risk of viral and fungal infection. in mud setting the use of pbsc is the procedure that most centers have recently adopted. this implies the infusion of a relevant higher number of t cells to times more as compared with bone marrow (bm). since in our centre most part of our patients are primary immunodeficiencies, we applied a procedure to minimize the risk of severe gvhd infusing a controlled number of cd positive cells. methods: we report data about paediatric patients who received mud hsct ( patient received hsct) between and in the bmt unit of the children's hospital of brescia. patients received conditioning, according to the european group for bone marrow transplantation (ebmt) and the european society for immunodeficiencies (esid) guidelines. cd + selection has been realized by a milteny column with an ideal addback of cd positive cells of x /kg. stem cell source was bm in cases and pbsc in cases. results: median patients age at transplant was years (range . months- years). the mean number of infused cells were: x /kg cd + and x /kg cd + in bm product, while x /kg cd + and x /kg cd + in pbsc. mean time for engraftment was day post-hsct. as concerns acute gvhd overall incidence . % ( / ) of the children presented this complication, but only % ( / ) presented gvhd grade iii and none gvhd grade iv, while chronic gvhd presented in . % ( limited, extensive/ ). while acute gvhd incidence and severity weren't significantly different between bm recipients and pbsc recipients, the cases of chronic gvhd were prevalently in the latters. no major infections presented in the post-transplant period and immunological reconstitution both cellular and humoral was completed by months. overall survival at years is % ( / ). the results obtained show how it is possible control severity of gvhd if an addback of a controlled number of cd + lymphocytes. acute gvhd wasn't severe and only few children presented with limited chronic gvhd. the method allows to graft primary immunodeficiencies patients even with pbsc without infusing too many t cells. in fact, especially in very young children, the number could be excessive and risky. nevertheless in case of an oncohaematological patient, gvl effect is preserved. disclosure background: dc is a rare genetic disorder that results from a defective telomere length maintenance and is characterized by mucocutaneous features, bone marrow failure (bmf) and a high predisposition to cancer and pulmonary fibrosis. bmf remains the major cause of mortality and the hsct is the only definitive treatment to restore hematopoiesis but is limited by a high incidence of treatmentrelated mortality. methods: a retrospective analysis of patients (pts) with dc who underwent hsct at the bone marrow transplantation unit in the clinical hospital of federal university of paraná, brazil, between july- and november- . results: boys and girls, with a median age of y ( - y) received a hsct from a mds (n= ), mud (n= ) or mmrd (haploidentical, n= ). pts received bone marrow (bm) and pt received a cord blood unit (cbu). the median of tnc infused was , x /kg (range , - , x /kg) and in the cbu was , x / kg. two pts received a myeloablative preparatory regimen with busulfan (bu) mg/kg + cyclophosphamide (cy) mg/kg or fludarabine (flu) mg/m + antithymocyte globulin (atg). the remaining pts received a ric regimen with cy mg/kg (n= ), flu mg/m + cy mg/kg + atg mg/kg (n= ), and flu mg/m + cy + tbi rads (n= , haplo). graft versus host disease (gvhd) prophylaxis consisted of cyclosporin (csa) and methotrexate or steroids (cbu) and post-transplant cy + csa + mycophenolate mofetil in the haploidentical transplants. of evaluable pts engrafted with a median time to neutrophil recovery of days (range: - days). one patient experienced primary graft failure (haplo) while second graft failure occurred in other pts. all these pts went a second hsct and survived. acute gvhd grade ii-iv occurred in of pts at risk. moderate to severe chronic gvhd occurred in pts with cases occurring in pts who had previously presented acute gvhd. overall survival (os) was , % at a median follow-up of y. the y os was slightly better in msd transplants compared to the others ( , % x , % p= , ). causes of early death include adenovirus sepsis (n= ), toxicity to preparatory regimen and sepsis (n= ), primary graft failure (n= ). pts remain alive between - y after hsct with a median fu of y. among them only pt has developed organ involvement by the underlying disease: hepatopulmonary syndrome (hps). pts died due to pulmonary fibrosis (n= ), liver fibrosis(n= ), gi bleeding(n= ), hps (n= ); cgvhd and sepsis(n= ), infection (n= ), and pts were lost to fu. conclusions: early mortality from bmf can be reduced by hsct, but late outcomes remain a consequence of the underlying disease. long term fu is essential in order to detect late complications related to the hsct procedure or the underlying disease. disclosure: nothing to declare single intra-bone cord-blood transplantation with a treosulfan-based regimen, atg-free and sirolimusbased gvhd prophylaxis: fast hematopoietic engraftment and immune-reconstitution in patients background: cord blood transplants (cbt) require less stringent hla-matching, compared to peripheral blood stem cell or bone marrow. however, cbt has been associated with delayed engraftment and immune reconstitution, especially if in vivo t-cell depletion, such as antithymoglobulin (atg), is used. methods: from to , patients with high-risk diseases received intra-bone infusion of unwashed single cb unit with an atg-free gvhd prophylaxis; were in active disease at cbt and had received prior allogeneic stem cell transplantation. median age was y [range (r) . conditioning regimen was myeloablative, with treosulfan and fludarabine in all, intensified with melphalan in or with gy tbi in . hla matches was / , / , / in , and cases, respectively. gvhd prophylaxis included sirolimus and mycophenolic acid (mmf). results: after thawing, median cd + cells was . x /kg [r . - . ], median cd + cells . x /kg [r . - . ], and median cd + cells . x /kg [r . - . ]. of the evaluable patients all engrafted with a sustained full donor chimerism at day . median time to neutrophils ( / , anc> /μl for consecutive days) and platelet engraftment ( / immune-reconstitution of cbt patients (tables a-b ) was compared with two cohorts of patients transplanted at our center from any adult donor with ( ) or without ( patients, including post-transplant cyclophosphamide cohort) atg in association with sirolimus and mmf. profiles of immune-reconstitution at day - - showed a better cd + recovery at any time-point in both cbt and no-atg versus atg cohort, with no statistic significant difference in the first cohorts. moreover, cd +/cd + ratio at any time point was better in the cbt cohort vs the no-atg cohort. b cell recovery was faster in the cbt cohort; immunoglobulin recovery was superimposable across different platforms. focusing on late events (> days from cbt), / pts experienced ebv reactivation, median time days [ - ] treated with rituximab, and experienced late hhv and cmv reactivation, both solved at last visit. sirolimus was withdrawn after a median of days [r - ]. only patient developed severe chronic gvhd, solved at last visit. overall, after a median follow-up of days [r - ], pts are alive and well. conclusions: our data confirm that intra-bone cbt without in-vivo t-cell depletion is associated with fast hematopoietic engraftment and immune-reconstitution, with very low rate of chronic gvhd and late infective events. background: a promising improvement of hematopoietic stem cell transplantation (hsct) may lie in the transplantation of high numbers of pluripotent stem cells to minimize the time span between transplantation and immunological reconstitution. hence, an ex vivo platform is needed that supports hsc proliferation before application and, at the same time, the maintenance of pluripotency by diminishing hsc differentiation into lineage-specific progenitor cells. methods: to artificially model the natural hsc niche in vitro, we used d bone marrow (bm)-like scaffolds made of polydimethylsiloxane (pdms). these structures are based on a human long bone cross section as a representative of the bm. human cryoconserved hscs were cultured in distinct cultivation systems for days under different conditions. cell counting and facs analyses at day were conducted. for characterization of the cultivated hscs, we used antibodies against cd alone or in combination with antibodies against cd , cd , cd ra and cd f. results: for optimization of culture conditions for human hscs, a commercially available medium was supplemented with a panel of cytokines and valproic acid. we found a significant increase in the number of cd + hscs by simultaneously increasing their vitality using the d system compared with conventional d culturing. a further improvement was achieved by introducing a silicon oxidecovering of the d pdms structures, suggesting that hydrophilic surface properties offer superior attachment for semi-adherent hscs. for a more precise characterization of the cultivated hscs, we introduced a panel of facs markers reflecting the immaturity of the amplified hsc. surprisingly, with increasing immaturity of the cultivated hsc, non-covered d pdms revealed to be best suited for amplification: cell number of vital immature hscs was increased after cultivation on non-covered d pdms compared with silicon oxide-covered d pdms and the d system. conclusions: by establishing a d scaffold according to the human bm, we found a platform mimicking the natural niche of human hsc which is suitable to amplify human hscs in vitro and support their vitality, pluripotency and ability for self-renewal. [[p image] . with the introduction of sion covering of d pdms structures the maintenance of cd + hscs could be further improved. despite the better conservation of cd + hscs by using silicon oxide-covered d pdms, we found that immature human hscs obviously prefer more hydrophobic conditions found on non-covered d pdms. disclosure: nothing to declare. abstract already published. improvements in neutrophil engraftment following changes in freezing method background: in the setting of autologous haematopoietic progenitor cell (hpc) transplants for haematological disorders, peripheral blood stem cells are routinely collected via apheresis and cryopreserved. leicester royal infirmary had been using a controlled rate freezer (crf) to cryopreserve cellular therapy products up until . in a literature review of cryopreservation techniques was undertaken, since the crf required replacement. this review found consistent evidence that cryopreservation using minus o c is comparable to crf, and engraftment times should not be negatively affected by changing to a more simplified method of freezing. there would also be cost saving benefits from switching from a crf to minus o c freezers. methods: as a result two minus o c freezers were purchased following the acceptance of a preparation process dosier (ppd) which was prepared for the human tissue authority. validation was carried out, and from january stem cell laboratory at the lri switched from the crf method to minus o c for cryopreservation of cellular therapy products. briefly, cells are frozen using % dmso (wak-chemie) in g/l human albumin solution (grifols) in cyrobags (origen biomedical, inc). the cells are transferred on cold packs to the minus o c freezer. cells are packaged in between stainless steel heattransfer plates. the plates are placed within a bubble wrap bag, and are placed in a rack within the minus o c freezer, which allows air to circulate freely around each bag. in one plate a el-usb-tc thermocouple data logger (thermosense) is inserted between the bag and stainless steel plate, to record the freezing profile. this data is downloaded after each run. after an overnight freeze at minus o c, the cells are subsequently removed from the bubble wrap and plates, and are transferred to minus o c freezers the following morning. results: a total of patients have had autologous stem cells frozen using this method so far this year. in addition to engraftment data for neutrophils, post-freeze trypan blue viabilities were also compared to the previous year. during a total of patients, who had all their cells cryopreserved, underwent collections. the post freeze median viability was % ( - %). a total of median neutrophil engraftment was . days, with a median cd dose infused of . x /kg. during so far, patients have undergone collections. median viability is . % ( - %). subsequent median neutrophil engraftment is days, with a median cd dose infused of . x /kg. conclusions: ongoing savings of approximately £ per annum have been made by changing our procedure. the benefit of changing to a simplified method of freezing has also resulted in a reduction in staff working overtime. more importantly, this simplified cryopreservation method has resulted in an improvement in neutrophil engraftment times since changing the cryopreservation technique from the previous method using crf to mechanical freezing using a minus o c freezer. disclosure: nothing to declare low doses of granulocytes in the apheresis product predict a better outcome of autologous hematopoietic stem cell transplantation in multiple myeloma patients background: high-dose chemotherapy with autologous stem-cell transplantation (asct) remains the standard consolidation therapy for multiple myeloma (mm). peripheral blood stem cell collection may be contaminated with large quantities of granulocytes and its consequences on the outcome of asct are still unclear. on the other hand, the effect of performing apheresis with high levels of monoclonal component (mc) on outcome is unknown. the objective of this study was to analyze the effect of total nucleated cells (tnc) and granulocytes count (considered as contaminating components of apheresis products) as well as the influence of mc in the apheresis product on outcome of asct in mm. methods: eighty-two patients diagnosed with mm were mobilized with filgrastim μg/kg/day (plus plerixafor if insufficient mobilization of cd + cells on day ). apheresis collection was performed with cmnc program by spectra optia cell separator. cd + count was carried out according to ishage protocol (target: ≥ x e cd +/kg). subsequent cryopreservation were performed according to the local protocol. results: the medians (range) of collected cd +, tnc and granulocytes were . x /kg ( . - . ), . x / kg ( . - . ) and . x /kg ( . - . ), respectively. the medians (range) of infused cd +, tnc and granulocytes were . x /kg ( . - . ), . x /kg ( . - . ) and . x /kg ( . - . ), respectively. a successful collection after first line therapy was performed in % of patients. treatment for mm was continued after carrying out apheresis in % of patients, as per protocol. a significant reduction of mc was observed prior to asct, indicating a further improvement in responses after apheresis (p= . ). an optimal response (cr or vgpr) at the time of apheresis was achieved in % of patients and a suboptimal response (partial or minimal response) was observed in the remaining %. undergoing apheresis in optimal response did not result in lower number of tnc or granulocytes in the harvest. the subtype of mc did not influence on the number of tnc and granulocytes in the product of apheresis. no differences in collected tnc and granulocytes were observed when plerixafor was used as mobilizing agent. the type of chemotherapy given prior the apheresis did not have influence on the characteristics of the apheresis product. a significant improvement in overall survival (os) probability ( %ci) was observed when low tnc (< . x figure a ). lower incidence of relapse (p= . ) ( figure b ) and non-relapse mortality (p= . ) was observed in patients who received low granulocyte count in the graft. no significant correlation was observed between the time of engraftment and the number of tnc or granulocytes infused. similarly, no increase in the frequency of the engraftment syndrome was observed when higher number of tnc or granulocytes were infused. conclusions: in our series, low doses of granulocytes in the product of apheresis predicted a better outcome of asct in mm patients. the amount of mc at the time of apheresis did not have influence in the characteristics of the harvest. efforts for avoiding contamination in grafts are important for its impact on outcome of asct in mm patients. disclosure: dkms foundation, pi / (instituto carlos iii) and sgr (grc), generalitat de catalunya. background: our initial experience (from to years) with hematopoietic stem cell transplantation (hsct) from mud with tcrαβ+/cd + graft depletion in patients with cgd showed high rate of secondary graft dysfunction, the incident of graft rejection was %. to improve the outcome, we hypothesized that the use of plerixafor and g-csf as additional agents in conditioning regimen would offers advantages and better outcomes. this trial was registered at www.clinicaltrials.gov (nct ) methods: between april and september , patients with cgd underwent allogeneic hscts from mached unrelated donors with tcrαβ + / cd + graft. the conditioning regimen included -treosulfan g / m , fludarabine mg / m , thiotepa mg / kg, g-csf mcg / kg and plerixafor mcg / kg. all patients received rabbit atg -timoglobulin® ("genzyme europe b.v.", the netherlands) mg/kg for serotherapy. in all cases, tcrab +/cd + graft depletion was used with the immunemagnetic method (miltenyi biotec, bergisch gladbach, germany) according to the manufacturer's instructions. stem cell source was g-csf mobilized peripheral blood stem cells in all cases. posttransplant gvhd prophylaxis was not performed. minimal follow up was days after hsct. results: neutrophil and platelet engraftment occurred at - days post-hsct in all patients. patients had full donor chimerism in whole blood and in cases we observed predominantly donor mixed chimerism at last follow up. all patients had full donor chimerism in cd + compartment and mixed chimerism in cd + lineage, but it stable without any sign of graft dysfunction. acute gvhd is verified in of cases and was limited to skin grade . all patients are alive for periods from to months post-hsct with good graft function without severe clinical problems. conclusions: we presented first experience of g-csf and plerixafor addition to conditioning regimen before hsct with tcrαβ+/cd + graft depletion in cgd patients . we suppose, the preliminary results are encouraging, as the frequency of primary and secondary graft dysfunction in patients from this group is not observed today, there are no significant toxic complications, as well as clinically severe manifestations of gvhd. currently, the recruitment of patients is continuing, and estimation of the rates of immune reconstitution and a more detail analyses will be evaluated later. background: introduction -it is believed that aboincompatibility is of minor importance in allogeneic stem cell transplantation (allo-sct) and that the clinical outcome is equivalent to abo-compatible sct. therefore, we performed a single center retrospective study to characterize the impact of abo-incompatibility on the outcome of haploidentical stem cell transplantation (haplo-sct). methods: this analysis included consecutive patients who underwent haplo-sct for various hematological malignancies at our center between october and may . we used our institutional database to evaluate details and characteristics of patients and transplant outcomes. results: demographic features of the patients and donors have been summarized in table . all of the patients had advanced hematological disease with a high risk of relapse ( patients with acute leukemia). out of patients, early transplant-related mortality was seen in this cohort of patients. the remaining patients were followed in and months. donor type abo group switch was observed in a median of days ( - days) after transplant. we were not able to show any statistical difference in terms of blood group switch between minor and major abo incompatible transplant. the median red blood cell (rbc) transfusions in the first days for the abo compatible and incompatible transplants were median units (range, - ) and median units (range, - ) (p= . ). no statistical difference was also encountered for the rbc transfusion need for stem cell source, peripheral blood vs bone marrow. a total of patients were followed up for reticulocyte engraftment. the median time for reticulocyte engraftment was days (range, - ) for all patients. reticulocyte engraftment was tended to be faster in minor abo-mismatched group (p= . ) than major or abo-compatible ones. nineteen patients achieved independence from rbc support after a median time of days (range, - days) in abocompatible patients, days (range, - days) in minor abo-incompatibilityand days (range, - days) in major abo-incompatibilitygroup, respectively (p> . ). the engraftman kinetics due to major and minor aboincompatibilitytransplants were presented in table- . pure red cell aplasia was not developed in our cohort. conclusions: the present single center study provides new evidence for the importance of the abo system for erythrocyte recovery in haploidentic stem cell transplantation. it's important to note that, randomize prospective and larger studies are warranted. disclosure: nothing to declare low dose of anti-t lymphocyte globulin protects against severe forms of graft versus host disease in patients undergoing allogenic stem cell transplantation background: graft versus host disease (gvhd) is the most important complication after allogeneic stem cell transplantation (allosct). optimal dose of different anti-tlymphocyte globulin (atg) formulations in this setting has not been established yet. the aim of this study was to analyze the impact of a low dose of atg-fresenius (atg-f) in allosct outcomes. methods: we analyzed adult patients who received an allosct for hematologic malignancies from october to march . the gvhd prophylaxis included a total dose of mg/kg ( mg/kg on day - , - and - ) of atg-f for patients who received a graft from peripheral blood, an unrelated donor; with a mismatch, and/or were older than years; associated to a calcineurin inhibitor and mycophenolate mofetil/short course-methotrexate. statistical analysis was performed using spss v. and r software. results: median age was years ( - ) and . % of patients were males. seventy-four percent of patients underwent myeloablative conditioning. the stem cell source was peripheral blood in patients ( . %), % were from unrelated donors ( % mismatched). seventeen ( . %) patients had high risk cmv status (d-/r+) (see image b). engraftment was observed in patients ( . %). primary graft failure occurred in patients ( myelofibrosis, aml). twenty ( . %) out of evaluable patients developed grade - acute gvhd. the cumulative incidence of severe agvhd and moderatesevere chronic gvhd were . % ( % ci, . - . %) and . % ( % ci . - . %), only ( . %) patients developed severe cgvhd. twenty-nine patients ( . %) discontinued immunosuppression before the first year of transplant. the median duration of immunosuppression for patients with moderate-severe cgvhd was days ( - ). at years non-relapse mortality (nrm) was . % ( % ci, . - . %). thirty-nine ( %) patients developed relevant infectious complications. two ( %) patients died within the first days due to gram negative blood stream infection. eleven ( . %) had at least two episodes of cytomegalovirus (cmv) reactivation between day and . three ( %) patients developed cmv gastrointestinal disease, ( %) had probable invasive fungal infection and ( . %), post-transplant lymphoproliferative disorder associated to epstein barr virus. with a median follow up of months for alive patients , the gvhd and relapse free survival (grfs) at one year, overall survival (os) and progression free survival (pfs) at two years were . % ( % ci, . - . %), % ( % ci, . - . %) and % ( % ci, . - . %), respectively. the relapse incidence at two years was . % ( % ci . - . %). complete remission at transplant was associated with better long term survival ( % at years, p < . ). hla disparity did not affect os (see image a). conclusions: the use of low doses of atg-f is protective against severe forms of acute and chronic gvhd in a cohort with high prevalence of unrelated donors and a high median age. this strategy showed good results in grfs, os and pfs in a population at high risk for developing gvhd or relapse. disclosure: nothing to declare performance parameters of a ngs-product for chimerism monitoring -applicable in patients after hematopoietic stem cell transplantation methods: for this purpose, samples from patients with mixed chimerism (mc) with increasing amounts of recipient dna were analyzed and compared using realtime pcr of insertions/deletions (indels), fragment analysis of short-tandem repeats (str) and ngs of indels. results: whereas real-time pcr displayed excellent sensitivity down to , % mc, but poor precision above %, fragment analysis exhibited good precision with limited sensitivity (> , %). in contrast, ngs chimerism demonstrated good sensitivity, with a limit of detection (lod) of , % mc, and precision throughout the whole spectrum of patient/donor mixed chimerism. the ngs chimerism product (devyser chimerism) exhibited at least three (average eight) and at least two (average ) informative genetic markers (indels), suitable for monitoring mixed chimerism of patients with their corresponding matched unrelated ( ) or related ( ) donor samples. in order to establish the performance of the separate techniques for determination of mixed chimerism on retrospective patient samples, a cohort of patient monitoring samples ( - weeks post-hsct) with low (< %), intermediate or high mixed chimerism (> %) were included and analyzed. dna from all monitoring samples was extracted from sorted cell fractions. the results show that although all evaluated techniques are suitable for monitoring patient/donor chimerism after allogeneic hematopoietic stem cell transplantation (hsct), only the ngs chimerism product exhibits high sensitivity (lod , %) and a broad dynamic range (detection range , - %) with good precision and accuracy throughout the whole spectrum of mixed chimerism (% patient/donor). in addition, the ngs chimerism product employ non-population dependent highly informative genetic markers providing stable resolution power and thus suitable for monitoring mixed chimerism. disclosure: dan hauzenberger is medical adviser at devyser ab and shareholder in devyser holding gender distribution: male - % (n= ), female - % (n= ). age median - , years old ( months - ). stem cell source: bone marrow - % (n= ), peripheral blood stem cells - % (n= ). patients ( %) received / matched unrelated donors hematopoetic stem cells transplantation and patients ( %) - / matched unrelated donors hematopoetic stem cells transplantation. differences in the antigen blood system: single group % (n= ), minor % (n= ), major % (n= ), mixed % (n= ). age of donor: - years old - % (n= ), - - % (n= ), - - % (n= ), and more % (n= ). gender differences in donor/recipient: male/female % (n= ), female/male % (n= ), one sex % (n= ). we also took into account the impact of gender difference and cytomegalovirus serostatus in the donor/recipient pair. results: in / group the estimated probability of overall -years survive was % and in the / group -years survive was %. the increase in donor age of years reduces the -years survive by - % (p= , ), however, the -years survive from donors over years old was %. we have found no difference between -years survive in transplants from donors that are compatible/ incompatible with the antigen blood system, cytomegalovirus serostatus, or the gender differences in donor/ recipient. in the study of donor-related factors, we found the negative impact of an human leucincompatibility ( / ) on the incidence of chronic gvhd - % (p = . ). the combination of cytomegalovirus positive serostatus of the donor and the negative status of the recipient increases the risk of primary graft rejection up to %, in comparison with others (p = . ). conclusions: our study showed the role of genetic matching on the hla system between the patient and the unrelated donor, and the donors age value. / transplants have better outcome and lower incidence of severe a. gvhd and ch. gvhd. younger donor increases -years survive, but there is a significant increase in -years survive if the donor is over years old. disclosure: nothing to declare allogeneic stem cell transplantation in chronic myelomonocytic leukemia. a single center experience nine patients ( %) relapsed with a median of , months ( - ) with different strategies at this point: in all cases we modulated immunosuppression, in cases as the unique strategy, in cases with donor lymphocyte infusion (dli), in cases we employed hypometilating agents (hma) and in cases with intensive chemotherapy, reaching cr only in two patients, one of them after dli and the other one after hma and consolidation with a second asct. eleven patients ( %) died being the relapse the main cause ( %). transplant related mortality (trm) at + were % and global trm were %. in the last follow-up, patients ( %) are still alive, ( %) in cr and ( %) in relapse situation. with a median follow-up of months ( - ), the event free survival (efs) were months ( - ) and the overall survival (os) were months ( - ). we observed advantage in terms of os in those patients that reach cr at + post asct and in those who develop chronic gvchd (p= . and p= . respectively) conclusions: asct is still the only curative option despite the high relapse rates. to reach cr at + post asct and the development of chronic gvhd seems that they confer advantage in terms of os. the importance of knowing the molecular profile of the entities that we consider for asct. disclosure this study documents a first experience of a cell processing lab seeking to integrate process automation technology to wash and volume reduce products which can account for the initial material source volume variability, product characteristics, and number of bags. methods: here we report the pre-clinical assessment of the lab's initial work with the lovo cell processing system for a product experience over days with machine. this study used products intended for destruction. the workflow used parallel and sequential processing schedule. after water-bath thawing, bags were sampled, weighed to determine volume, and subsequently connected to lovo or pooled into a transfer pack and then connected to lovo. the bags were then diluted : at ml/min with lovo at + - c using % hydroxyethylstarch / . (voluven, fresenius kabi) and processed using a cycle procedure. after processing the bags were weighed for volume, sampled, and stored in a - c refrigerator in their lovo final product bags. samples were assessed from t= to t= hours. results: cd + viability and absolute counts were determined using flow cytometry. processing duration and solution volume consumed was determined by the lovo's sensors and confirmed by the operator. data is presented as a percentage relative to the post-thaw values. note, the values presented are not total process yields. the results focus on the lovo processing step. conclusions: the operators easily integrated into the software to drive the machine. the machine demonstrated it's flexibility with a wide-range of volumes, cell-inputs, and number of bags. the lovo produced products which meet our specifications in a quick and reliable manner. further work on this platform will be performed to validate and qualify this system for production use. properties. the aim of this study was to evaluate prospectively the efficacy of a fbm protocol for the prevention of om in patients undergoing a hsct. methods: all patients consecutively who underwent a hsct at our center from x onwards received five weekly fbm sessions with a bidiodic laser (lumix ®, prodent, italy), which simultaneously emitted at nm and nm with a power of mw and energy of j per point. the procedure started the day before the beginning of the conditioning regimen up to the tenth day post-transplant. the laser was applied in a defocused mode on each of the mucosal surfaces ( areas). at each session, the morphine dose, the om level (according to the who scale) and pain through a numerical rating scale (nrs) were recorded. results: consecutive patients ( male/ female) submitted to a hsct were analyzed. the median age was years (range - ). eighteen patients had acute leukemia, myelodysplastic syndromes, lymphoproliferative diseases. the median number of treatment lines before hsct was (range - ). at transplant, patients had advanced disease. the myeloablative conditioning regimen mac (thyotepa, busulphan, fludarabine) was employed in patients; the same conditioning, with a reduced dose of busulphan (ric), was infused in patients. seven patients ( %) had no evidence of om. the incidence of grade ii-iv om was % in the group of patients receiving mac and the median duration days (range - ); grade om was observed, for day, in patient. in the ric group the incidence of om was %, the median duration days (range - ); no patient had evidence of grade iv om. in the whole population, the maximum nrs value was . morphine administration was required in patients, due to the occurrence of non-oral complications. conclusions: in our experience, prophylaxis with fbm to prevent or reduce om was safe and effective, compared to results of previous experiences reported in the literature, which used no prevention against this complication that negatively affects the quality of life of transplanted patients. further studies on a large series of are necessary to confirm our results. disclosure: nothing to declare background: cytogenetic abnormalities are an essential part of prognostic systems in myeloid malignancies before hematopoietic stem cell transplantation (hsct), however, their role in posttransplantation prognosis is unknown. the aim of this study was to assess the prognostic impact of genetic risk stratification of aml and mds patients on posttransplantation course, which could be an additional tool in making decisions regarding preemptive therapy. methods: a retrospective analysis covering patients treated with allo-hsct between and . cytogenetic studies included karyotyping (c-and gbanding) and fluorescence in situ hybridization (fish). the number of analyzed cells exceeded european cytogenetics association guidelines (for each fish at least interphase nuclei were analyzed). cytogenetic risk group in aml was assessed based on the eln criteria. patients with mds were stratified into three groups; favorable (good and very good prognostic score), intermediate, and adverse (poor and very poor) prognostic score according to ipss-r . interestingly, the poorest survival was in patients with monosomy of chromosome , which was present in patients of whom succumbed to refractory disease, while all patients who had deletion of long arm of chromosome (del q)-are alive at the time of writing of this report after a median follow-up of months ( - ). relapse was diagnosed in patients ( %), including; ( %) with adverse, ( %) with intermediate and ( %) with favorable cytogenetic risk. among patients with a complex karyotype and/or cytogenetic evolution prior hct: patients ( %)relapsed, including ( %)-who died. follow-up cytogenetic studies in relapse after transplantation were performed for patients; of them ( %) had clonal evolutions of the original karyotype with additional abnormalities-( % died) and ( %) had new aberrations in cells without primary changes (all died). in patients ( %) ( unfavorable, intermediate group) cytogenetic relapse was diagnosed by fish analysis and they were treated with azacitidine (+/-dli) achieving cr (n= , %), stabilization-(n-= , %), transient response (n= ), while deceased). conclusions: cytogenetic studies in patients after transplantation may facilitate assessment of mortality. karyotype may undergo cytogenetic evolution after allo-hsct. patients with monosomy of chromosome seem to have a particularly poor prognosis. transplanted patients are vulnerable to new cytogenetic alterations. disclosure: nothing to declare methods: the primary end-points were the rate of complete response (cr), defined as no emesis and no nausea without rescue medications, for both acute (cr- ) and delayed (cr - ) cinv and rate of post-transplant complications until discharge. we prospectively analyzed patients undergoing autologous ( %) and allogeneic ( %) stem cell transplantation and receiving cinv prophylaxis with nepa and dexamethasone (schedules shown in fig. ). in our series, patients ( %) were female. patients median age was years ( - ). the most frequent diagnosis were myeloma ( %) and lymphoma ( %), while % of patients were diagnosed with aml or mds. myeloma patients received one day hd-ct with melphalan ( % mel / % mel ). lymphoma patients were conditioned with feam ( , %) or tt_flu_edx ( , %) hd-ct. busulfan-based mds-ct regimen was offered to aml/mds patients. results: the incidence of cr- and cr - observed was % ( / ) and , % ( / ), respectively. more than grade nausea and vomiting (according to ctae- ), was reported in % ( / ) and % ( / ) of patients, respectively. female sex was associated with an increased risk of acute (hr , ; p , % ci . - . ) but not delayed (hr , ; p , % ci - . ) cinv. similar rate of cr and cr - was observed in one-day hd-ct ( % and %) compared to mds-ct ( % and , %) group (pns). median lenght of stay was days ( - ). no case of cardiotoxicity and no exitus was observed. the incidence of febrile neutropenia was % ( % fuo; % sepsis; % pneumonia). only one patient experienced an agvhd on day + . neutrophil (> /mcl) and platelet (> /mcl) recovery occurred in median on day ( - ) and on day ( - ) respectively. conclusions: nepa seems to be safe and effective in preventing acute and delayed cinv in patients receiving both one day hd-ct and mds-ct as conditioning regimen for hsct. more studies are needed to define the better -ht ra and nk- ra combination and the better schedule in transplant setting. disclosure: "nothing to declare background: vod and ta-tma represent two early endothelial complications occurring after allogeneic stem cell transplantation (sct) sharing many pre-transplant risk factors. the aim of our study is to evaluate the impact of donor graft composition, engraftment kinetics and infections on the development of these endothelial complications (ec). methods: we retrospectively reviewed consecutive sct recipients at our institu-tion between january and june . the median age was years (range - ). acute leukemia was diagnosed in patients ( %). complete remission was documented in % of patients at transplant. donor source was from hla mismatched donor in % and from unrelated donor in % of the patients. hbv positive patients were % of the sample. conditioning regimen was busulfan based in % of patients. ursodeoxycholic acid and unfractionated heparin were given to all patients as vod prophylaxis. cyclosporine was used as gvhd prophylaxis. lymphocytic subpopulation analysis (cd +, cd +, cd + and cd +/cd +) and cd + cells count on the donor graft were performed using bd facs cantoll. all patients had routine monitoring for ebv and cmv pcr, hemolysis tests, creatinine and electrolyte panels, proteinuria, complete blood count, blood pressure and schistocytes by direct examination until day + . the fisher's exact test was used to compare categorical variables, while continuous variables were analyzed with anova test. diagnosis of vod and ta-tma were carried out by using ebmt and cho criteria respectively. results: the incidence of very severe vod and tma was % ( / ) and , % ( / ) respectively. cmv reactivations with viral load over . cv/ ml was % and % in patients with and without ec, respectively (p , ; hr , p , %ci , - , ). the median day to neutrophils (ns) engraftment ( /ml and /ml) was vs and , vs in vod/tma group vs control group (p , and , , respectively). more rapid neutrophils engraftment (ns > /ml and ns> /ml within days) was related to a higher risk of ec with a hr of , (p , ; %ci , - , ) and , (p , ; % ci , - , ). patients with ec received a donor graft with a higher median numbers (x e /kg) of cd + and cd + (p> , ) and a lower numbers (x e /kg) of nk cells (p> , ). patients who received a cd + cells count > x e /kg and nk cells count < , x e /kg presented a relative risk of ec of , (p , ; % ci , - , ) and , (p , ; % ci , - , ), respectively. there were no differences with respect to the other analyzed variables between patients who developed vod/tma compared with those who did not. (pic_ ) conclusions: cmv viremia, early neutrophils engraftment and donor nk and cd + cells infused are associated with the risk of vod and tma. very few studies evaluated the link between these variables and the risk of developing such two complications. it could be interesting to investigate these relationships on larger series. clinical trial registry: not applicable disclosure: nothing to declare p when the last hope turns out to be just as good as best: haplosct following tbf conditioning, pt cyclophosphamide and tacrolimus as gvhd prophylaxis background: hematopoietic stem cell transplantation is an effective therapy for a variety of severe hematological diseases. in last decades, haploidentical sct (haplosct) followed by ptcy as gvhd prophylaxis has been reported as a valid alternative for patients who lack an hla matched donor. we therefore analysed outcomes with this. methods: patients without hla-matched donor received a haplosct between / and / . thiotepa mg/kg ( days), fludarabine mg/m ( days) and oral busulfan mg/kg/ h ( days,with pkd dose adjustments) was used as conditioning regiment; in patients > years busulfan administration was limited to two days. gvhd prophylaxis consisted of cyclophosphamide mg/kg on day + and + , and tacrolimus as a continuous iv infusion from day + . all patients received pbsc as the stem cell source. outcomes analysed were overall survival (os), progression free survival (pfs); cumulative incidences (ci) of gvhd, relapse and non-relapsed mortality (nrm). results: median ages was (range - ). % male and % female. diagnoses were: aml ( %), mds ( %), all ( %), hl and nhl ( %), and mm ( %). % (n ) were transplanted in early disease status, while most cases ( %) were in advanced status, including, second/third cr ( %, n ), one ( %) in aplasia without progressive disease and % (n ) had active/progression disease, % (n ) had stable disease; four cases were second alosct. thus, % of patients had a high or very high rdri and % had intermediate. ebmt score was ≤ was in % of patients (n ) . the donor was as son/ daughter in %, % a sibling and % a patient's mother. median time to neutrophil ( . x e /l) and platelet (> x e /l) recoveries were + and + days, respectively (g-csf was not used). only one patient had a primary graft failure attributed to anti-hla donor specific antibodies. median follow up in survivor is months (range - ). overall survival is ± . % (at months) and ± % (at months). pfs is ± % and ± % respectively. the cumulative incidence of relapse was % and %, respectively, while nrm is % at months. day + , grade - acute gvhd were %, while mild/ moderate and severe chronic gvhd were % and % respectively. ebmt ≤ and first alosct were the only variables to clearly impact -months os in univariate analysis. a combined covariate of ebmt ≤ -no prior alosct vs other patients showed a month os ± % vs ± % (p . ), pfs ± % vs ± % (p . ) and nrm % vs % (p . ) but without impact on relapse % vs % (p . ). conclusions: haplosct with an age-adapted tbf conditioning regimen, pbsc and ptcy followed by tacrolimus, led to very encouraging results, mainly in patients with a low ebmt score and as a first alosct. although formerly considered as a last alosct strategy, we now agree that the time has come to compare this strategy with hla mud (and even elderly sibling donors) in ongoing prospective randomized multinational trials. disclosure: nothing to disclosure background: autologous hematopoietic stem cell transplantation (autosct) for acute myeloid leukaemia (aml) is increasing becoming a viable option for an increasing number of patients due to limited availability of matched sibling or unrelated donor for allogeneic hematopoietic stem cell transplantation (allosct). we examined the relevant long-term outcomes in our local patient cohort. methods: we retrospectively reviewed the data for all autosct done for aml in our centre over a -years period between st january until st dec from our electronic record. patients with acute promyelocytic leukaemia (apml) were excluded from this analysis. patients were further stratified based on the number of high risk features present; not achieving complete remission (cr) following induction chemotherapy, high presenting total white cell count (wbc > x /ml, adverse cytogenetics (example: complex cytogenetics) and adverse molecular mutations (example: flt -itd & mll gene arrangement). outcome data including mortality (overall survival (os) and non-relapse mortality (nrm)) and morbidity (leukaemia free survival (lfs)) were recorded and analysed. results: a total of patients were identified. median age at diagnosis is -years old. the cohort comprised of males and females. the overall median os and median lfs is . years and . years respectively. the nrm is . % ( / ). there was no difference in the median os and median lfs for the patients achieving cr following induction chemotherapy and those not in cr following induction chemotherapy; . years versus . years (log-rank, p= . ) and . years versus . years (log-rank, p= . ) respectively. the median os were statistically significant for patients with zero versus one and two and more high risk features present; . years versus . years versus . years (log-rank, p= . ) respectively. however, the median lfs were not statistically significant for these three patient cohorts; . years versus . years versus . years (log-rank, p= . ) respectively. conclusions: in our patient cohort, autosct appeared to be a feasible option for patents with aml without matched sibling or unrelated donor available. disclosure: none to declare methods: between - , thalassemic patientsunderwent hisct. the median age of patients was ( - )years with male preponderance (n= , . %). across the gender and abo mismatch transplants were done in . % and % of patients. stem cell source was bone marrow in ( %) while peripheral blood in ( %) of patients. mean stem cell dose was . ± . x cells / kg and mean volume of product was ± . ml. preparative regimen included anti-thymocyte globulin, busulfan, fludarabine and cyclophosphamide.graft versus host disease (gvhd) prophylaxis comprised of posttransplant cyclophosphamide on day + & + followed by tacrolimus and mycophenolate mofetil. patients were observed for hematopoietic recovery (neutrophil and platelet engraftment) and transplant related mortality including acute and chronic gvhd for skin, gut, liverand lungs, primary and secondary graft failure and infectious complications. results: nine( . %) of sixteenpatients were engrafted with full donor chimerism. twelve ( %) patients belonged to pesaro class i and ( %) toclass ii patients. median time to neutrophil and plateletengraftment were ( - ) and ( - )days respectively. average number of packed red cell and platelet transfusions were . ± . and . ± . respectively.primary graft failure was observed in ( %) and secondary graft failure was observed in ( %) patients. two patients received a second dose of stem cells and they engrafted at and days of infusion respectively. of patients with primary graft failure died, one with sepsis (day + ) and the other because of intracranial bleeding (day + ).acute gvhdof gut and skin (grade ii-iii) was observed in patients each, within first days post-transplant. none of the patients had grade iv gvhd. cytomegalovirus reactivation occurred in % of patients, all of them received pre-emptive therapy with intravenous ganciclovir. none of them developed cmv disease. invasive fungal infection was not observed in any of the patient. culture proven bacterialinfection was documented in % of patients requiring intravenous antibiotics during first days post-transplant.overall survival and relapse free survival were . % and . % over a median follow-up of ( - ) days. conclusions: haploidentical transplant is a suitable modality for thalassemic patients lacking a full matched donor in pakistan. in view of our results, we suggest that thalassemia patients should be offered hisctas an option for cure. clinical background: gemtuzumab ozogamicin (go) is an anti-cd monoclonal antibody with significant activity in de novo and relapsed/refractory (r/r) acute myeloid leukemia (aml). a relevant side effect consists of hepatotoxicity and especially sinusoidal obstruction syndrome (sos). the objective of this study was to analyze tolerability of go during the induction and reinduction therapy in patients with aml, and its possible impact on subsequent hematopoietic stem cell transplantation (hsct). methods: from to , patients who had received go in three hospitals were collected and their medical records were retrospectively reviewed. results: fourteen patients diagnosed with de novo aml received go ( mg/m ) on day + in combination with standard chemotherapy (idarubicin and cytarabine, x schedule) as induction therapy. hyperbilirubinemia (bilirubin > . unl) was detected in patients and increase of aspartate aminotransferase (ast) (> . unl) in . twelve patients achieved complete remission (cr) and one was refractory ( not evaluated). in the r/r setting, patients diagnosed with aml (n= ), biphenotypic acute leukemia (n= ) and acute promyelocytic leukemia (n= ) received go as rd or subsequent rescue therapy either as monotherapy (n= ) or in combination with cytotoxic chemotherapy (n= ). prior hsct was performed in patients (autologous [n= ], allogeneic [n= ] ). rescue therapy was indicated for refractoriness (n= ), relapse (n= ), partial response (n= ) or absence of donor (n= ). four patients received doses of go ( mg/m ) and patients, one dose. hyperbilirubinemia (> . unl) was observed in patient and increase in ast (> . unl) in patients. seven patients achieved cr, was refractory, obtained partial response and died early during induction). thirteen patients received subsequent hsct (autologous [n= ], allogeneic [n= ]) after go therapy ( in the de novo aml and in the r/r group). the reasons for not performing hsct in the remaining patients were: low cytogenetic risk (n= ), active chronic graft versus host disease (gvhd) in previous hsct (n= ), early death during treatment (n= ), relapse (n= ), severe complications in rescue treatments (n= ), and unknown (n= ). the conditioning regimen was myeloablative (n= ), non-myeloablative (n= ) and sequential (n= ), and the donors were matched sibling (n= ) or unrelated (n= ) . cyclosporine, methotrexate and thymoglobulin were administered as gvhd prophylaxis in patients and cyclosporine, mycophenolate and thymoglobulin in . hyperbilirubinemia was observed in patients belonging to the de novo aml group. death after hsct occurred in patients due to infection (n= ), relapse (n= ), gvhd (n= ) and traffic accident (n= ). three patients are currently alive in remission. no sos was observed in any patient. conclusions: in both de novo and r/r aml the administration of low dose go is feasible and does not have impact on subsequent hsct outcome. although some degree of hepatotoxicity was observed, no cases of sos were observed, either before or after hsct. disclosure: supported by grants from: asociación española contra el cáncer, aecc (gc biga), instituto carlos iii (pi / fi), -sgr (grc), cerca program from generalitat de catalunya, and "la caixa" foundation. outcome of allogeneic hematopoietic stem cell transplantation in patients with benign hematological disorders saqib ansari , tahir shamsi , uzma zaidi , saima siddiqui , tasneem farzana background: allogeneic hematopoietic stem cell transplantation is a potentially curative treatment modality for hematological disorders. we evaluated the outcome of patients suffering from benign hematological disorders, including aplastic anemia, fanconi's anemia and thalassemia after matched related allogeneic transplantation. methods: all patients having hematological disorders including aplastic anemia (aa), beta thalassemia (btm), fanconi's anemia (fa) and severe combined immune deficiency disorder (scid) with hla identical related donors who underwent allogeneic transplantation were included. donors were given g-csf at a dose of μg/ kg/day daily for four days prior to harvest. the conditioning regimens for thalassemia included cyclophosphamide (cy) + busulfan (bu) in ( %), bu + cy + thiotepa in ( %) and bu + cy + antithymocyte globulin (atg) in ( %). conditioning regimens for aplastic anemia included, fludarabine (flu) + cy in ( %), flu + atg in ( %) and cy in ( %), cy+ atg in ( %) patients. for fanconi's anemia flu + atg in ( %), flu in ( %), cy + atg in ( %) and flu+ cy + atg in ( %). flu + atg in ( %) and cy given in ( %) and no conditioning regimen was offered to ( %) patients with scid. results: a total of allogeneic transplants were performed for benign hematological disorders including aa (n= ), btm (n= ), fa (n= ) and scid (n= ) from to july . median age was . years (range . - ). across the gender and abo blood group transplants were ( . %) and ( %). the median time to neutrophil and platelet recovery was days (range: - ) and (range: - ). primary and secondary graft failure was observed in ( . %) and ( . %). overall survival in aplastic anemia ( / , %), beta thalassemia ( / , %),fanconi's anemia ( / , %) and severe combined immune deficiency disorder ( / , %). eighty four patients expired ( . %) among them patients expired within days post transplant main cause of deaths included sepsis ( %), multi organ failure ( %) and gut gvhd ( %) conclusions: in developing world scenario where non malignant disorders are leading cause of morbidity and mortality. bone marrow transplantation has been successfully implemented with better long term diseases free survival and quality of life. clinical background: hematopoietic cell transplantation (hct) remains the only curative therapy for many diseases, yet transplant survivors carry an unusually high burden of morbidities, primarily because of exposure to intense chemotherapy, radiation and /or gvhd. this study aimed to evaluate the burden of chronic diseases at the end of life after allogeneic-hct and to identify the disability-adjusted life years (daly). methods: the pubmed, medline, and ovid databases were queried utilizing specific mesh terminology (post, allo stem cell, hematopoietic, bone marrow, transplantation).we collected data on the impact of the hct on the variables affecting survivor's health in all aspects .the rates of late complications were compared to the risks in the general population (united states). results: a total of studies fulfilled the selection criteria totaling to patients (table ) . median os at -year mark varied widely between studies from % to %. majority of the patients at -year mark were found to have new comorbidities thereby indicating a huge burden of late effects at the end of life, though exact dalys could not be calculated due to incomplete data. hct survivors were found to have higher risk of premature arterial disease (pad) at . % compared to the general population, however gvhd or the addition of tbi to the conditioning regimen were not found to be significantly associated with pad. regarding the risk of new cancers, the cumulative incidence of their development at and years was . , and . , respectively. increased risks compared with the general population were seen for some solid cancer including cancers of the lip: p= . , tonsils: p= . , oropharynx: p< . , bone: p< . , soft tissue: p< . , and vulva: p= . . with respect to mental health, depression was prevalent in ( . %) survivors, in whom ( . %) were still on antidepressants at the last follow-up. cognitive impairment and other psychiatric disorders were found in ( . %) and ( . %) survivors, respectively. the most common cause of nrm in the first years was gvhd. however, after years, the leading cause of death in those conditioned with mac regimen was secondary cancer, but in the ric group, new cancers and gvhd contributed equally. conclusions: hct survivors remain at risk of significant complications which lead to premature death and their burden of comorbidities at the end of life is significantly more than that of general population. background: late onset hemorrhagic cystitis (hc) is a common complication of hematopoietic stem cell transplantation (hsct) frequently associated with reactivation of bk virus (bk-hc).there is no consensus as to the best therapy for bk-hc, and many different treatments have been reported. hyper baric oxygen therapy (hbot) is used as primary or adjuvant therapy in diverse clinical situations involving hypoxic injury to tissues and has been explored as a useful tool in treating bk -hc. we report our experience with hbot in combination with non-invasive supportive care in children and adolescents suffering from bk-hc following allogeneic hsct. methods: the computerized database of schneider children´s medical center of israel was reviewed for all patients aged to years who underwent hsct between january and june and developed bk-hc. hbot therapy consisted of hours sessions at atmospheres, with patients breathing oxygen by mask. parents accompanied patients during the treatment. results: fourteen patients with a variety of underlying diseases received (hbot) for treatment of bk-hc following hsct. the initial treatment for children with bk-hc at our center prior to included continuous bladder irrigation and intravesicular instillation of various medications. beginning in , we adopted a non-invasive strategy that included the administration of oral anticholinergics (oxybutinin), systemic pain management, hyperhydration and the administration of weekly cidofovir with probenecid. hbot was administered to patients who failed the above regimen. with this protocol, the average time of starting hbot dropped from (prior to ) to . days. the median onset of hc was days post hsct. all patients were receiving immunosuppressive treatment at the onset of bk-hc. all patients suffered from macrohematuria with blood clots (grade iii cystitis), ( . %) experienced severe dysuria and ( . %) urgency. bk viruria was present in all patients, and concurrent bk viremia was detected in % of those who were tested. patients reported symptomatic improvement at a mean of . days following the initiation of hbot. no patient experienced serious adverse effects due to hbot, but two patients required insertion of tympanic ventilation tubes. eleven of our patients ( . %) experienced complete remission of bk-hc following hbot, with an overall response rate of . % ( / patients).eight of our patients ( . %) eventually succumbed due to either hsct complications or disease relapse. conclusions: hyperbaric oxygen therapy is a safe, effective, non-invasive and well tolerated treatment modality for bk -hc and should be considered for first line therapy for this complication of hsct. clinical background: every year, almost one thousand cases of hematological malignancies in pediatric population are reported in peru. allogeneic hematopoietic stem cell transplantation (allo-hsct) is an alternative strategy in many of these cases. only between - % of the pediatric population that requires a hsct has a compatible human leukocyte antigen (hla) donor. the remaining % have to access international donor registries, extending the awaiting time and conditioning the progress of the disease. allo-hsct has the potential to help children with several hematological disorders with non-compatible hla donor. hla genotypically identical sibling donors are the best option when pursuing an hsct. nevertheless, patients' alternative sources of stem cells could be obtained from an haploidentical donor like one of their parents. the haploidentical transplantation program with macs was implemented in peru in to reduce the risk of graft-versus-host disease (gvhd), support the immune system reconstitution and to expand pool of donors. it allows patients to access a treatment that is efficient and safe, as shown in the depletion of positive tcrα/β+ and b cells procedures for allo-hsct. methods: the mobilized leukapheresis products (n= ) of haploidentical healthy donor was washed to remove platelets and preparations were performed according to miltenyi's clinimacs® manual for tcrα/β+ and cd + cell depletion. analysis of the initial leukapheresis product and tcrα/β + and cd + depleted graft (target and non-target product) was performed using flow cytometer. cells were analyzed for cd +, cd +, -aad, cd +, tcrα/β+, tcrγ/δ +, cd + and cd + with fluorochrome-labeled antibodies from miltenyi biotec using a novocyte cytometer. the results obtained with the ex vivo t-cell depleted allo-hsct procedures show an overall survival (os) over % with an ic % at the end of the first year with low incidence of gvhd. macs of tcrα/β+ and cd + cells are effective (logp . and logp . , respectively) obtaining minimum levels of depleted lymphocytes within clinical established parameters for diverse pathologies. in addition, tcrα/β+ and cd + cell depletion does not significantly affect hematopoietic stem cell populations such as cd + and cd + cells or tcrγ/δ+ cell population. cd + and tcr γ/δ cells are highly recovered ( . % and . , respectively), which contributes with a better engraftment after allo-hsct. conclusions: peruvian results oscillated within european ranges with an os over %. our data suggests that the macs method is an efficient, effective and safe strategy for haploidentical hsct which has a remarkable cost-benefit ratio and makes it viable in countries of the latin american region with peruvian socio-economic characteristics. evaluation of genoresistance for viral reactivation treatment has been implemented as a strategy to improve os. better results are achieved in patients after allo-hsct with the validation of these tests in peru. preliminary pharmacoeconomic evaluations allow us to establish magnetic activated cell sorting (macs) as a promissory strategy compared to other alternatives for haploidentical hsct. it is necessary to increase the number of procedures in order to confirm efficacy and safety of macs in a larger population. disclosure: all authors have no conflicts of interest. abstract already published. micro-costing study of hematopoietic stem cell transplantation in two hospital institutions from southern of brazil background: hematopoietic stem cell transplantation (hsct) is a potentially curative treatment indicated for patients with onco-hematological, hereditary and immunological diseases. considering the increase of patients indicated to the hsct and the lack of knowledge about the costs resulting from this treatment, is important to identify and detail the resources consumed in each phase of hsct and provide knowledge to the public health brazilian system. we aimed measure the total cost of related hsct, based on micro-costing study of patients assisted in two hospitals in the south region of brazil. methods: hsct costs were estimated using the timedriven activity based costing method (tdabc), which measured cost of services / products based on actual consumption of resources. we collected data from medical records of patients submitted to allogeneic hsct in from public and private (philanthropic) hospitals. we interviewed professionals involved in the tcth activities, we performed chrono-analysis and, we consulted financial and administrative systems reports of hospitals. in order to compare costs according to clinical complications observed in patients, we grouped into two ranges of complexity: low/ medium and high. the study was divided into stages: hsct processes mapping; costs measurement; and analysis of results. finally, the costs were compared: by activity, by resource and by hospital. this study was financed by psid-uhs, by an agreement signed between ministry of health and moinhos de vento hospital, through adjustment term number: / , and approved by research ethics committees. results: from the hsct processes mapping, the following steps were defined: (i) hospitalization; (ii) conditioning; (iii) transplantation; (iv) period of aplasia; (v) engraftment; (vi) observation; (vii) pre-and medical discharge. seven patients were classified in low / medium complexity level, with hospitalization median time of days and an median cost of usd , . , whereas the other five patients, classified as high complexity, presented median time of days and median cost of usd , . . the hsct costs evaluation identified that steps ii and iv presented greatest cost in high complexity patients. lower complexity patients presented, in steps ii and iv, median costs of usd , . while in higher complexity usd , . . in addition, median costs of materials and drugs were usd , . and usd , . in lower and higher complexity patients. conclusions: tdabc method allowed the identification of the moment when patients consume the most resources. of all the hsct stages, periods of conditioning and aplasia presented higher costs, representing . % of the total hospitalization value. in these stages, higher complexity patients presented three times higher the median cost. the resources that had the greatest impact were medicines and medical materials, costing times more than lower complexity patients. conclusion: this study allowed a detailed identification of the hsct costs in patients with different complexity ranges in two hospitals from southern brazil. therefore, the identification of service demand regarding the clinical complexity, allows the generation of important information for the management of the best care in the health service. disclosure background: immunodeficiency due to lrba deficiency is characterized by hypogammaglobulinemia and autoimmunity. hemolytic anemia, lymphadenopathy, autoimmune hepatitis and, above all, autoimmune enteropathy are the fundamental characteristics of these patients together with the history of recurrent invasive infections.the therapy includes immunosuppressants, endovenous immunoglobulins. bone marrow transplantation is the final therapy of these patients, especially in the most serious cases and in recent years, also on the light of increasingly targeted conditioning regimes, it is associated with ever better prognosis. methods: we present the case of caterina, an -year-old patient with lrba deficiency, diagnosed at years of age for a history of hypogammaglobulinemia, recurring invasive, bacterial and fungal infections and a picture of autoimmunity represented by ahia, myelitis (c -c ), autoimmune hepatitis and enteropathy in treatment with abatacept and sirolimus. it also presents leptin deficiency lipodystrophy.she presented to our observation for ostemielitis in multiple outbreaks (tibia, femur and left knee) secondary to sepsis from mrsa. broad spectrum antibiotic therapy and curettage surgery were performed during hospitalization.after months of broad-spectrum antibiotic therapy (daptomycin, rifampicin, ceftaroline, cotrimoxazole, levofloxacin, dalbavancin) there was resolution of the infections.because of the seriousness of the disease it is therefore decided to subject catherine to hematopoietic stem cell transplantation. results: therefore were performed bone marrow transplant from mud after conditioning at reduced intensity, delayed in days, with treosulfan, fludarabine and thiotepa. prophylaxis for gvhd was performed with atg ( mg / kg / day), sirolimus (already practiced for enteropathy) and mmf. because of the hepatic picture, we also performed prophylaxis for vod with defibrotide for days. transplantation was performed by peripheral stem cells with x ^ cd / kg and x ^ cd / kg.the patient had always presented good general conditions with engrafment of the pmn to the d + and the plt to the d + . the chimerism at d + was % donor both on pmn and on pbl. prophylaxis for gvhd was changed on d + by replacing the sirolimus with tacrolimus for the appearance of grade i cutaneous gvhd . conclusions: we have successfully performed bone marrow transplantation in patients with lrba deficiency. the new antibiotic molecules, used to induce infectious remission, the new low-intensity regimens, the prevention of the most fearful complications (vod) have been the key to success in such complicated case. the high number of cd cells infused with a controlled number of cd were the key then of rapid engraftment with minimal gvhd readily controlled by the immunosuppressant. disclosure background: in the absence of hla-matched related donor, allogeneic stem cell transplantation from haploidentical donors are potential alternatives for patients with hematological malignencies with an indication to allogeneic stem cell transplantation. herein, we retrospectively assessed the outcome of haplo-sct for patients with refractory hematological malignancies. methods: this analysis included consecutive patients who underwent haplo-sct for various hematological malignancies at our center between october and may . we used our institutional database to evaluate details and characteristics of patients and transplant outcomes. results: demographic features of the patients and donors have been summarized in table . all of the patients had advanced disease with a high risk of relapse. the majority of patients underwent haplo-sct from their parents. out of patients, early transplant-related mortality was seen in this cohort of patients. four patients treated with second haplo-sct and recovered hematopoiesis after second transplant. the remaining patients were followed in a median of months. donor type abo group switch was observed in a median of days ( - days) after transplant. the median time for engraftment was days (range, - ) for all patients. after the first transplant, patients developed acute gvhd ( . %) with patients having grade ii-iii acute gvhd. five ( . %) had chronic gvhd, none of them with extensive manifestation. the prepative regimen was relatively well tolerated with limited regimen-related toxicity. cmv reactivation occurred in patients ( . %) during the follow-up of the study. eight patients ( . %) relapsed after a median of days post transplant (range, - days). cr was achieved in ( %) patients after haplo-sct. mean estimated -year os and pfs are . %± . % and . %± . %, respectively. conclusions: given the growing data on the similarity of outcomes after hla-matched and haploidentical sct, further studies are required to determine whether factors may be more important for donor selection than hlamatching. clinical trial registry: -disclosure: nothing to declare outcome of allogeneic stem cell transplantation for hodgkin and non-hodgkin lymphoma: single center experince from turkey ayşe uysal , hale bülbül , nur akad soyer , mahmut tobu , murat tombuloglu , guray saydam , filiz vural background: allogeneic sct (allosct) is generally optionally treatment choice for young and fit patients with relapsed/refractory lymphoma who were heavily pre-treated and after the failure of autologous stem cell transplantation (asct). relapse after asct is associated with a poor prognosis and allosct is a potentially curative therapy for lymphomas which have relapsed after asct. methods: in this study, we evaluated patients with hl and nhl who had treated with allo-hsct between november and december in ege university adult hematology transplantation unit. results: patients, disease and transplant characteristics were illustrated in table. histologic subtype of nhl was evaluated as t cell lymphoma (n= ; , %), mantle cell (n= ; , %), diffuse large b-cell lymphoma (n= ; , %) and b-cell lymphoma, unclassifiable, with features intermediate between dlbcl and classical hodgkin lymphoma (n= ; , %). all histologic subtype of hl was determined as nodular sclerosing. the median number of prior treatments before allo-hsct was (range, - ). twelve ( , %) patients had refractory disease, ( , %) patients were in complete remission and ( , %) patients were in partial remission before allo-hsct. the median time from diagnosis to allosct was (range, - ) months. peripheral stem cell was used for stem cell source in all of them. total body irritation plus fludarabine plus cyclophosphamide and busulfan plus cyclophosphamide were preferred most frequently for conditioning as non-myeloablative and myeloablative, respectively. neutrophil engraftment was occurred median of (range, - ) days. graft versus host disease (gvhd) prophylaxis was applied all of them and cyclosporine plus methotrexate was preferred most frequently (n= ; , %). gvhd was occurred in , % of them ( , % acute gvhd, , % chronic gvhd and , % both). veno-occlusive disease (vod) was occurred in ( , %) patients. transplant related death was observed in ( , %) patients. overall survival (os) and disease-free-survival (dfs) were evaluated as median (range, - ) and (range, - ) months, respectively. analyze of os and dfs was illustrated in figure. six patients are alive without disease. after a rapid tapering of immunosuopressive therapy was underwent a therapy with ponatinibat dose of mg/die results: afther a month of therapy we observed a rapid decrease in minimal residual disease on molecular assessment with an mmr of p -bcr-abl/abl non detectable confirmed by bone marrow revaluations at days + , + nd + after the salvage therapy. the patient has not had experienced of graft-versus-host disease, ponatinib treatment was well tolerated and considered safe with easily manageable side. conclusions: maybe in the era of tyrosine kinase inhibitors (tkis), philadelphia chromosome positive acute lymphoblastic leukemia (ph+ all) it could benefit from a combined treatment between transpalnt and tkis however more studies are needed to confirm these hypotheses. disclosure: nothing to declare immunodeficiency diseases and macrophage background: although a number of patients with hiv infection and hematological disease have successfully undergone allogeneic hsct together with combination anti-retroviral therapy (cart), short and long-term outcomes remain not well known. we report the largest spanish experience of hiv-infected adult patients with high-risk hematological malignancies with allogeneic hsct. methods: we retrospectively reviewed hiv-positive patients who received allogeneic hsct between and in spanish centers within geth (grupo español de trasplante hematopoyético y terapia celular). results: baseline and transplant characteristics of patients are shown in table . median age was years and % of the patients were men. the most frequent underlying malignancies were non-hodgkin lymphoma ( , %) and aml ( , %). in half of the patients an hlaidentical sibling was the donor; and in the other half, an alternative donor was used. peripheral blood was used as graft source in % of the transplants. at the time of hsct, all patients had been receiving suppressive cart for a median of years and only of them showed detectable plasma hiv rna, one of them because of poor adherence to cart together with the accumulation of multiple resistance mutations; and the other patient had detectable hiv rna at low levels (< copies/ml). all patients received cart throughout the transplant procedure, being temporally stopped in two patients due to significant mucositis. after a median follow-up of months ( - ), -year overall survival (os) and event-free survival (efs) were %. nrm was % at months and relapse was % at months. grade ii-iv agvhd rate was %, and moderate/severe cgvhd rate was % at months. a significant proportion of patients ( %) showed infectious complications with viral infections as the most frequent cause. two patients had invasive aspergillosis and one patient presented disseminated tuberculosis. causes of death included infections ( %), relapse ( %) and toxicity ( %). among the patients who died due to infections, had severe chronic gvhd and were under immunosuppressive therapy. two patients showed severe toxicity related to drug interaction with anti-retroviral therapy. all survivors except one showed undetectable hiv load at last follow-up after hsct. conclusions: allogeneic hsct is an effective therapy for high-risk hematological malignancies in patients with hiv infection, providing long-term disease free survival together to long-term hiv suppression with cart. however, drug interactions with anti-retroviral agents, occurrence of gvhd, and frequent infectious complications account for a complex procedure in this population. selected hiv-infected patients with hematological malignancies should be considered for allo-hsct when indicated, in experienced centers, with a multidisciplinary care. disclosure background: primary immunodeficiencies (pid) are rare diseases often associated with genetic defects in the immune system, predisposing individuals to recurrent infections and increased risk of allergy, autoimmunity and malignancy. allogeneic haematopoietic stem cell transplantation (hsct) has been successfully used as a curative therapy for most severe forms of pid. because pid is a genetic disease, < % of these children will have a healthy, human leukocyte antigen (hla) matched sibling donor available, and umbilical cord blood grafts from unrelated donors are a suitable alternative cell source. we report the results of umbilical cord blood transplantation (ucbt) performed in patients with pid between and at children's hospital of fudan university in china. methods: patients included chronic granulomatous disease (cgd, n= ), severe combined immunodeficiency (scid, n= ), interleukin- receptor-a deficiency (il- rad, n= ), wiskott-aldrich syndrome (was, n= ), leukocyte adhesion deficiency (lad, n= ), severe congenital neutropaenia (scn, n= ) and other immunodeficiencies (n= ). all patients were assessed by clinical immunologist to confirm clinical phenotype and genetic diagnosis. median age of patients was months (range, to months), and median body weight was . kg (range, . to kg). all patients received a ≤ / hla alleles-mismatched cord blood unit, were hla fully matched, were / matched, were / matched and were / matched. median nucleated cells of the cord blood were . x /kg (range, . to . x /kg), and median cd + cells were . x /kg (range, . to . x /kg). results: median follow-up time was months (range, to months), the overall survival rate at year for all patients was . %, and was . %, . % and % for cgd, scid and il- rad, respectively. patients died, most deaths ( / , . %) occurred in + days after transplantation, the main cause of death was infection ( / , . %). / ( . %) patients engrafted, median time of neutrophil engraftment was days (range, to d), and median time of platelet engraftment was days (range, to d). the cumulative incidence of grade - acute gvhd was . %, and that of chronic gvhd was . %. conclusions: unrelated ucbt should be considered for pid patients without an hla -matched sibling donor. effective control of infection before and after transplantation is important for improving survival. disclosure background: dedicator of cytokinesis (dock ) deficiency causes a combined immune deficiency characterised by recurrent bacterial infections, susceptibility to viral infection, eczema, food allergies, vasculitis and increased risk of malignancy. due to the high morbidity and mortality of the disease hsct has been increasingly offered to patients as a potentially curative therapy . methods: we retrospectively reviewed the outcomes of hsct for patients with dock deficiency at great north children's hospital newcastle upon tyne between and ( in published reference). results: ten patients with dock deficiency were treated with hsct (median age . y range . - . y). median duration of follow up was . years (range . - . y). there were a range of donor sources ( msd, mud and tcr ab/cd + depleted haploidentical), conditioning regimens ( treo-flu, treo-flu-thiotepa) and serotherapy ( alemtuzumab, atg+rituximab, none). one patient who received a cd + tcr alpha beta/cd + depleted haploidentical transplant received add back t-cells with caspacide molecular safety switch (bellicum pharmaceuticals). skin only agvhd occurred in / patients ( x stage , x stage ). no patients had cgvhd. overall survival was % ( / ). survival was comparable regardless of donor source. all deaths occurred within months of transplant. the patients who died had significant burden of disease pre-transplant: patient had chronic liver failure secondary to cryptosporidial sclerosing cholangitis, had a cirrhotic liver secondary to cryptosporidium, cerebral vasculitis, an axillary aneurysm and aortic vasculitis requiring grafting of an ascending aortic aneurysm, was pn dependent for failure to thrive with a history of cryptosporidium infection and had candida in a bal pre-transplant. causes of death in these patients were: respiratory failure (n= ), progressive encephalopathy (n= ), multi-organ failure with septic shock and encephalopathy (n= ) and multiorgan failure and septic shock after treatment for tma (n= ). two of these patients had reactivation of cryptosporidium prior to their death. pretransplant cryptosporidium was associated with mortality (graph ). one patient who survived had suffered from stroke pretransplant. one suffered from a basilar artery aneurysm years post-transplant at yo. at the time of latest follow up donor chimerism was % in / survivors and high level mixed in the other( % cd , % cd and % cd ). conclusions: this single centre study of hsct for patients is consistent with literature indicating that hsct is a potentially curative therapy for patients with dock deficiency. the increased morbidity associated with cryptosporidial infection is likely to be a consequence of overall disease burden rather than an infection specific effect. this does however highlight the improved outcomes of transplant prior to development of multiple comorbidities and suggests that hsct should be considered early. it is unclear whether the late occurrence of vascular complications after transplant were caused by a manifestation of disease which is not corrected by transplant or a result of vascular injury sustained pre-transplant. reference methods: referred infants underwent testing for: immune phenotype (ab, gd, naïve and memory t cell, b cell and nk cell numbers); functional activity of t and nk cells; maternal engraftment; adenosine deaminase (ada) and purine nucleoside phosphorylase (pnp) enzyme activity; and genetic testing. those with a confirmed diagnosis of scid underwent either allogeneic hematopoietic stem cell transplant (hct) or (if eligible) gene therapy (gt). infants identified as having ada deficiency as the etiology of their scid received enzyme replacement therapy prior to proceeding to definitive therapy. results: twenty-three ( %) infants were confirmed to have scid. three ( %) of these infants had a family history of scid but would not have been identified without nbs. in addition, one infant, born prematurely at weeks, was diagnosed as having pnp deficiency only after developing infections. this infant was identified by nbs but repeat testing at weeks gestation was normal likely due to support of transient t cell production from exogenous enzyme provided by red cell transfusion. twelve infants with confirmed low trecs had a non-scid diagnosis: with transient lymphopenia of infancy who normalized trec, immune phenotype and function, with prenatal exposure to -mecaptopurine ( -mp), genetically confirmed with digeorge syndrome, and with prolonged lymphopenia. of the three with prolonged lymphopenia, two had recurrent infections: one ultimately diagnosed with ataxia telangiectasia and one with absent trec but near normal number of t cells, normal pha but no specific antigen responses, and absent b cells who will be undergoing transplant in the near future. the third continues with absent trec, short telomeres, low numbers of a/b t cells, presence of g/d t cells, vaccine responses and freedom from infection with no identified genetic etiology. in summary, % of the patients referred to msk with confirmed abnormal nbs for scid have a non-scid diagnosis. there is no uniform collection of data for these infants and the threshold trigger for repeat testing varies from state to state, so the incidence of significant non-scid disorders identified will also likely vary from state to state. although our institution specific experience is biased, as most infants had confirmation of a low number of trec prior to referral, the significant number of disorders in the non-scid cohort emphasizes the importance of full evaluations and follow-up for these infants. disclosure: none of these relate to the work being presented. susan prockop -research funding mesoblast and atara biotherapeutics. nancy kernan -research funding jaz pharmaceuticals. richard o´reilly research funding and royalties atara biotherapeutics. kevin curran consulting juno pharmaceuticals, novartis. j.j. boelens avrobio, magenta, chimerix and bluebird bio background: post-transplant autoimmune cytopenia (aic) is challenging and associated with substantial morbidity and mortality. we aimed to study the cumulative incidence (ci) of post-hct autoimmune cytopenia (aic) and its predictors in a cohort of children with primary immunodeficiency (pid). methods: in this retrospective study, we included children with pid who underwent their first hsct with fludarabine(f)-treosulfan(t)±thiotepa(thio) at great north children's hospital from - . main outcomes of interest were the ci of aic and its predictors. fine-and-grey regression models were used to analyse predictors of aic, considering death as a competing event. variables included were age at transplant (< . years vs > . years), gender, diagnosis (scid vs immune-dysregulatory disorders vs other pids), pre-transplant aic, pre-and posttransplant respiratory virus, donor (mfd vs mud vs mmfd/mmud vs haploidentical donor), abo incompatibility, conditioning (ft vs ftthio), serotherapy (none vs alemtuzumab . - . mg/kg vs alemtuzumab . - . mg/kg vs atg), stem cell source (marrow vs pbsc vs cord vs exvivo t depleted pbsc), infused stem cell doses (tnc, cd and cd ), agvhd (none vs any agvhd), cgvhd (none vs any cgvhd), viral infections (cmv/adenovirus/ ebv/hhv viraemia), chimerism (full vs mixed chimerism (wb < %) within first year post-hct). impact of thymopoiesis using naïve t cell recovery was studied. results: median age at transplant was . years (range, . - . years). primary diagnoses were scid ( %), immune-dysregulatory disorders ( %) and other pids ( %). donors were mfd ( %), mud ( %), mmfd/ mmud ( %) and haploidentical parents ( %). stem cell sources were marrow ( %), unmanipulated pbsc ( %), ex-vivo t-depleted pbsc ( %) and cb ( %). % received additional thiotepa and % had csa/mmf as gvhd prophylaxis. median duration of follow-up of survivors was . years (range . to . years). -year os for the entire cohort was %. -month and -year ci of aic were % and %. of developed aic, ( %) had aiha, ( %) had aiha±itp and ( %) had aiha ±itp±ain. median onset of aic was . months post-hct (range . - . months). patients were treated with a median of treatment modalities (range, - ). one ( %) had steroid, ( %) had steroid+high-dose-ivig, ( %) had steroid+high-dose-ivig+rituximab, ( %) had steroid +high-dose-ivig+sirolimus and ( %) had steroid +high-dose-ivig+rituximab+sirolimus. the median time to resolution in ( %) who achieved remission after first aic was . months (range . - . months). had one relapse and had two relapses. died after development of aic ( aspergillus pneumonia; multi-organ failure). of ( %) surviving patients after aic, had on-going aiha at median of follow-up . years post-hct (range . - . years). on univariate completing-risk analysis, age at transplant > . years (p= . ) and pre-transplant aic (p= . ) were associated with higher incidence of aic (figure a -ic). on fine-and-grey models, only age at transplant (hr . , %ci . - . , p= . ) was independently associated with aic. of with complete immune reconstitution data, naïve t cells > cells/ml at months post-hct was associated lower incidence of aic (hr . , %ci . - . , p= . ) (figure d) conclusions: younger age and thymopoiesis were associated lower incidence of aic in children with pid after hct clinical background: human heme-oxygenase- (ho- ) deficiency has been reported to present with tetrad of anemia, nephritis, inflammation and asplenia and is fatal if not treated. its an auto-inflammatory disorder. macrophages/ monocytes express ho- and are engaged in recycling of red cells. human ho- deficiency results in intravascular hemolysis and severe damage to the endothelial system, kidneys, and other organs. transplantation of either healthy wild type macrophages or new macrophages produced by sct from healthy donor has been proven to be curative for ho- deficiency in mice. in , we had reported first successful allogeneic sct for human ho- deficiency. here we report second successful non-myeloablative msd hsct for a child with ho- deficiency. methods: a -yr-old-girl presented with complaints of fever, anemia and severe hypertension. in the past, at the age of years she was admitted for high fever for month and needed blood transfusion for the first time for severe anemia and had high platelets and high ferritin. she was treated as macrophage activation syndrome with prednisolone alone and later cyclosporine was added. she had short stature, abnormal facies but normal development. hemoglobin g/dl, urine for haemoglobin was positive, platelets , /ul, ferritin mcg/l and urine albumin + and urine rbc - /hpf. ultrasound and ct scan abdomen showed asplenia. a diagnosis of ho- deficiency was suspected. mutation analysis showed homozygous missense mutations in exon (r x) on chromosome q , which would result in the absence of the functional ho- protein. both parents were carriers of this mutation. we managed her over next -years with prednisolone, hydroxyurea and mycophenolate mofetil (mmf). however she remained steroid dependent. hla-typing confirmed her healthy unaffected -year-old brother to be a fully matched donor. at the age of years she was taken up for msd sct after taking informed consent. she weighed just kg. we conditioned her with alemtuzumab- . mg/kg, fludarabine- mg/m , cyclophospamide- mg/kg and total body irradiation gray. we infused million/kg peripheral blood stem cells from her brother. graft-vs.-host disease (gvhd) prophylaxis consisted of tacrolimus & mmf. results: she tolerated procedure very well. her entire hospital stay was uneventful and lowest platelet count recorded was , /ul. her neutrophils engrafted on day + and she was discharged on day+ . his urine albumin was nil by day+ . she had no gvhd. her chimerism on day+ showed % donor cells, on day+ was % and on day+ was % donor. now he is day+ post-sct and doing well. she has no evidence of hemolysis, proteinuria, hypertension, fever. she has normal ferritin and platelets. she has gained cm height and kg weight in last months. she had no viral reactivation and her immune recovery at months post sct is good. conclusions: non-myeoablative allogeneic msd sct is a curative treatment option for human ho- deficiency. disclosure: nil two decades of excellent transplant survival in children with chronic granulomatous disease: a report from a supraregional immunology transplant centre in europe background: haematopoietic stem cell transplantation (hsct) confers life-long curative therapy for chronic granulomatous disease (cgd). the ability of donor-derived neutrophils to replace recipient's defective neutrophils makes hsct a superior therapy compared to conventional standard of care using antimicrobial therapy. methods: we examined the outcome of children with cgd who received a first hsct at great north children's hospital from to . outcomes included overall survival (os), event-free survival (es), toxicity endpoints, autoimmune disease, long-term survival and graft function. cox proportional-hazard models were used to analyse predictors of os and es. variables included for predictor analysis were age at transplant, donor, stem cell source, stem cell doses and conditioning. results: = children were included in this analysis. median age of transplant was . years (range, . - . years). ( %) had x-linked and ( %) autosomal recessive cgd. twenty ( %) had matched family donor, ( %) had unrelated donor and ( %) had parental haploidentical donor. prior to , various conditioning regimens were used, with ( %) patients undergoing conditioning with pharmacokinetic guided intravenous (iv) busulfan (bu) and iv cyclophosphamide with or without serotherapy. from , the conditioning regimen was switched to flu-treosulfan-alemtuzumab with gvhd prophylaxis using ciclosporin (csa) and mycophenolate mofetil (mmf) for family and unrelated donors (n= , %). flu-treosulfan-thiotepa-atg-rituximab was used for cd tcr alpha-beta cd depleted haploidentical grafts (n= , %). ten ( %) patients had grade ii-iv acute gvhd while had ( %) had grade iii-iv acute gvhd. none had chronic gvhd. the -year os for the entire cohort was % ( % ci, - %) (figure ). analysis by age at transplant revealed a -year os of % for children transplanted at < = years of age and % ( %ci, - %) for the children > years of age (p< . ) (figure ) . the os was comparable between match family donor ( %, % ci, - %) and unrelated donor transplant ( %, - %) ( figure ). all four haploidentical transplants were successful. the -year es for the entire cohort was % ( % ci - %). none of the variables was associated with es. all seven patients with slipping chimerism received a successful second transplant. the five deaths were all due to transplantrelated complications ( multi-organ failures; pulmonary haemorrhage; graft iv acute gvhd; post-transplant lymphoproliferative disease). the median age at transplant of deceased patients was . years (range . to years). the -year and -year cumulative incidence of autoimmune diseases were % and % respectively. three ( %) had immune cytopenia while ( %) had autoimmune endocrinopathy ( thyroid dysfunction; type diabetes mellitus). the median age of long-term survivors was years (range, to years) with the median duration of follow-up of . years (range, . to . years). there was no late death in the entire cohort. the median donor myeloid chimerism was % (range to %) conclusions: despite the limitations of a single centre study, our findings confirm that hsct is a safe and longlasting curative therapy for children with cgd disclosure: none non -medical challenges in the diagnosis and transplantation of patients with primary immune deficiency: an experience from a tertiary care center in india sagar bhattad , stalin ramprakash , raghuram cp , chetan ginigeri , fulvio porta , background: primary immune deficiencies (pid) are increasingly being recognized in several parts of india. despite being diagnosed, many patients fail to receive optimal care due to financial and social constraints. methods: case records of patients diagnosed and treated (including hematopoietic stem cell transplants) for pid diseases during feb -nov at aster cmi hospital, bangalore, india were analysed. factors leading to deferred or suboptimal care were assessed in detail. results: patients with various pids were diagnosed during the study period (details in table). of them warranted a hematopoietic stem cell transplant (hsct) as definitive curative treatment. a total of children received hsct. of them died while of them are alive and well. children ( with severe combined immune deficiency) died before a hsct could be carried out. of them were critically ill at presentation, while were stable but deferred further treatment citing financial and social constraints. children needing transplant continue to remain on follow-up and have not been transplanted to date ( of them have significant financial constraints, families are not convinced about the need for transplant and of them are being prepared for transplant). table: (scid -severe combined immune deficiency, vodi-veno-occlusive disease with immunodeficiency, cgd -chronic granulomatous disease, hlh -hemophagolymphohistiocytosis, was -wiskott aldrich syndrome, xlt -x linked thrombocytopenia, lad-leukocyte adhesion deficiency, msmd -mendelian susceptibility to mycobacterial disease, xla -x linked agammaglobulinemia, cvid -common variable immune deficiency, apeced -autoimmune polyendocrinopathy candidiasis ectodermal dystrophy, cmcc -chronic mucocutaneous candidiasis, at -ataxia telangiectasia). conclusions: we present our experience from a developing country and discuss non-medical factors leading to suboptimal care in children with pid. only % children warranting hsct could be transplanted in our cohort. among those where hsct is potentially curative % of children died before hsct could be offered. transplants in developing countries pose unique challenges due to the absence of government funding and/or universal insurance coverage. in addition to delay in diagnosis and critical state of patients at admission, financial and social factors significantly contributed to poor outcome. disclosure: none the outcome of hematopoietic stem cell transplantation (hsct) in pediatric patients with hemophagocytic lymphohistiocytosis (hlh) in korea methods: the korea histiocytosis working party retrospectively collected nation-wide data from the patients diagnosed with hlh and underwent allogeneic hsct between and . the clinical characteristics and treatment outcomes of the patients were analyzed. results: a total of patients were enrolled. there were patients with fhl ( fhl , fhl , and fhl ), infection associated hlh, and secondary hlh of unknown cause. all the patients were treated with hlh- protocol, and patients achieved complete response (cr) after treatment for weeks, while did not. the main reasons for receiving transplantation were fhl in , reactivation in , and refractory disease in . the conditioning regimens were busulfan-based in patients, fludarabine-based in , treosulfan-based in , and busulfan/fludarabine-based in . stem cell sources used for hsct were from peripheral blood in patient, cord blood in , and bone marrow in . the donor types of hsct were unrelated donor in patients and related in ( matched sibling donor, haploidentical donor, partially matched donor). the causes of death of patients were disease reactivation/ progression in , acute gvhd with/without vod in , and graft failure in . five year overall survival rates were . %, respectively. the disease status at the time of hsct was cr in patients, and non-cr in . the -year survival rate of patients who received hsct in cr was % and % for patients transplanted while in non-cr status (p= . ). patients who received hsct using peripheral blood stem cells had a better -year survival rate of % compared to % of patients who received cord blood stem cells, significantly. the presence of neurologic symptoms, disease status after intial week therapy, conditioning regimen, and cd positive cell count did not have statistically significant impact on survival. conclusions: hsct improved the survival of patients who had familial, or relapsed, or refractory hlh in the korean nation-wide hlh registry. these results are similar to other reports in the literature. the disease status at the time of hsct and the stem cell source of the transplant were the important prognostic factors that affected the survivals of the hlh patients who underwent hsct. clinical trial registry: no registry number. disclosure: to the best of our knowledge, the named authors have no conflict of interest, financial or otherwise p hematopoietic cell transplantation with reduced intensity conditioning regimen using fludarabine/ busulfan and fludarabine/melphalan for primary immunodeficiency diseases background: primary immunodeficiency disease (pid) is congenital disorders of innate or acquired immune system. hematopoietic cell transplantation (hct) was a treatment option for pids with life-threatening infections or immune dysregulations. reduced intensity conditioning (ric) was increasingly used to prevent complications in hct, but optimized regimens have not been established. we performed hct for pids with ric using fludarabine and busulfan (flubu) or melphalan (flumel) according to the guidelines of european society for immunodeficiencies (esid) / european society for blood and marrow transplantation (ebmt), and assessed the efficacy and safety of these ric. methods: from april to december , pid patients underwent ric-hct using flubu or flumel in tmdu were analyzed retrospectively. the auc of bu was set to mg*hour/l for severe combined immunodeficiency disease (scid) and mg*hour/l for non-scid. overall survival (os) was analyzed. results: the median age at hct was . ( . - ) years old ( male and female patients). flubu was used for patients ( scid, combined immunodeficiency disease (cid), ectodermal dysplasia (eda), and severe congenital neutropenia (scn)) and flumel was used for patients ( scid, cid, xiap deficiency, and eda). anti-thymocyte globulin was used in patients of flubu group and patients of flumel group. cord blood in and bone marrow in was used for donor sources. matched donor was used for and patients in flubu and flumel groups ( . % and . %), respectively. median follow up period was . years. two years-os of all patients, flubu group patients and flumel group patients was . %, . % and . %, respectively. neutrophil engraftment was . %, . % and . % (all patients, flubu group and flumel group). in scid, all patients in flubu group achieved engraftment and survived. seven out of in flumel group achieved engraftment, but patient had secondary graft failure and patients died. in non-scid, out of in flubu group achieved engraftment, but patients had secondary graft failure. all non-scid patients in flumel group were engrafted and survived. two and patients in flubu group and flumel group suffered from severe acute graft-versus-host disease (grade iii-iv). ten patients had hemophagocytic lymphohistiocytosis (hlh). viral reactivation or infection was observed in patients, and resolved in all but one patient. conclusions: the ric-hct using flubu or flumel was advantagous for neutrophil engraftment, and flubu for scid and flumel for cid with immune dysregulation may be an effective opinion. flubu regimen needs to be improved for secondary graft failure in non-scid. prevention of hlh after transplantation using dexamethasone palmitate will be considered. disclosure: nothing to declare. survival after hematopoietic stem cell transplantation with tcrαβ/cd graft depletion in older children with primary immunodeficiencies background: tcrαβ/cd depletion is a graft engineering method that proved valuable in increasing the survival rate after hematopoietic stem cell transplantation (hsct) in patients with primary immunodeficiencies (pid). decreased survival rate in older patients with pid was previously reported after transplantations with nonmanipulated grafts. methods: patients with various pid (excluding classic scid) who received allogenic hsct with tcrαβ/ cd graft depletion from to september in our center were analyzed. the median age at hsct was , years (range , - , ). patients were divided into age groups: - years - patients, - years - , - years - . patients received hsct from matched unrelated, -haploidentical donors, -siblings. conditioning regimens with - alkylating agents and antithymocyte globulin were used in all patients. patient received short courses of various posttransplant immunosuppressants. median follow up after hsct is , years (range , - , years). results: overall survival (os) in patients was , ( % ci , - , ). we observed similar os in the younger age groups: , ( % ci , - , ) in - years and , ( % ci , - , ) in - years of age. seven of patients in older group ( - years of age) died, the os was only , ( % ci , - , ), p= , . all patients from older age group who died had combined pid: -wiscott-aldrich syndrome, -undefined pid, -il rg deficiency, -dclre c deficiency, -nijmegen breakage syndrome (nbs), -kabuki syndrome, -icf syndrome. the median time of death after hsct was , years (range , - , ). six of those had transplant-related mortality (trm). five patients had hsct-associated viral infections: -cmv pneumonias, -adv infections ( -fulminant hepatitis, -multiorgan). interestingly, of them had prolonged history of disseminated viral infections (adv), with the reduction of viral load in blood and other fluids and tissues upon treatment. one patient with kabuki syndrome after hsct developed hhv associated kaposi sarcoma, was successfully treated. eventually all patients with reduction of viral infection and sarcoma symptoms developed multiorgan failure with some clinical and laboratory evidences of endothelium cell damage syndrome. one patient with nbs died of high grade lymphoma progression. conclusions: hsct with tcrαβ/cd depletion demonstrates high survival rate in patients with various pid. in our group patients' age older than years predisposes to decreased posttransplant survival. patients with combined pid are at higher risks of posttransplant mortality. we conclude that at least in some of our patients with prolonged history of viral infections after hsct the cause of death could be multiorgan failure due to endothelium cell damage syndrome resulting from persistent inflammation and drug toxicity effects. disclosure background: chronic granulomatous disease (cgd) is a primary immunodeficiency (pid) caused by a mutation in of the subunits of the nicotinamide dinucleotide phosphate (nadph) oxidase, which leads to a reduction in the microbicidal activity of phagocytic cell. starting at an early age, cgd patients suffer from severe recurrent infections, as well as inflammatory events. allogeneic hematopoietic stem cell transplantation (hsct) is a curative option for cgd in patients with insufficient benefit from supportive care and prophylactic antibiotics. we reported a series of patients with cgd who underwent unrelated umbilical cord blood transplantation (ucbt) at our center. methods: in this retrospective study, we observed a series of consecutive ucbt performed at our center in children with cgd between and .median age at transplantation was months (range, to months), median body weight was kg (range, to kg). / patients received a myeloablative conditioning regimen consisting of busulfan, fludarabine, cytarabine, cyclophosphamide and g-csf, / patients received another myeloablative conditioning regimen consisting of busulfan, fludarabine, cyclophosphamide and atg. prophylaxis for graft-versus-host disease (gvhd) was tacrolimus. results: engraftment occurred in / ( . %) patients. / ( . %) patients occurred graft failure, all of them received a myeloablative conditioning regimen without atg. median time to neutrophil and platelet engraftment were (rang, - ) and . (rang, - ) days. / ( . %) patients developed acute gvhd, with / ( . %) episodes of grade iii-iv agvhd. chronic gvhd occurred in / patients ( . %). at a median follow-up of months (rang, to months), the overall survival rate was . %, and event-free survival rate was . %. conclusions: unrelated ucbt should be considered as potential curative methods in children with cgd. cgd patients who used myeloablative conditioning regimen with atg shows better graft and survival. disclosure: nothing to declare background: invasive fungal infections (ifi) remain a major cause of treatment-related morbidity and mortality in aml patients. although not uncommon, the presentation of unusually severe clinical features might be indicative for an underlying immunodeficiency. caspase-associated recruitment domain (card ) is recognized to have a crucial role in effective antifungal response, leading to th and th differentiation and to the initiation of the inflammatory cytokine cascade. particularly interferon-gamma (ifng) increases macrophage activity. patients with homozygous card mutations are known to have a significantly increased susceptibility to life-threatening systemic candidiasis. however, some sequence variants may lead to increased ifi-susceptibility even in heterozygosity, e.g. under immunosuppression. ifn-γ has been described as an additive treatment option because of its immune stimulating effect on the leukocyte immune response in a situation of immunological "blindness". methods: here, we report the case of an -year old male with aml m with a severe systemic candida tropicalis infection, unresponsive to triple-antimycotic regimen, leading to multi-organ failure. he was discovered to bear a heterozygous card mutation, and ifn-γ immunotherapy leaded to complete response of all disseminated infections. results: the patient developed septic fever immediately after the first chemotherapy cycle. unexpectedly, candida tropicalis was confirmed in the blood culture within hours. liposomal amphotericin b (ambisome ® ) was started immediately, however candida rapidly disseminated to lungs, liver, spleen, kidneys and cns despite extended antimycotic therapy with caspofungin, voriconazole and fluconazole. the patient was splenectomized due to massive infiltration ( figure ). genetic testing for mycosis predisposition revealed a heterozygous mutation in the card gene, inherited from the father (c. a>t(p.glu val)). ifn-γ treatment was started ( μg subcutaneously, times per week), leading to an almost complete response of disseminated infections. due to the severe infection, chemotherapy had to be interrupted after one course. however, bone marrow remained in complete remission for almost one year. the patient experienced altogether two relapses requiring an unrelated allogeneic and a haploidentical hsct. under combined ifn-γ and ambisome/ fluconazole prophylaxis no further mycosis was observed despite extensive and prolonged immunosuppression. conclusions: ifi in aml patients are common, however an unusual presentation in presumably immune competent individuals should raise the suspicion for immunodeficiencies. in our case, an unexpected early candida-sepsis was completely unresponsive to an adequate multi-agent treatment. while ifn-γ is used in adults as an immune stimulatory cytokine, little data are available for children. to our knowledge, this is the first case of successful ifn-γ treatment of a pediatric aml patient with disseminated candida sepsis, bearing a card mutation. given the elevated mortality risk for ifi, and the apparently safe and well-tolerated application of ifn-γ, an adjuvant immunotherapy might be considered. further studies are needed to define the indication and duration of this kind of adjunctive immunotherapy. moreover, considering the wide heterogeneity of genetic mutations involved in ifi-susceptibility, genome-wide expression profiling might be useful for pediatric cancer patients, as the identification of specific immune pathways might help to identify individual ifisusceptibility in order to improve the outcome of those high-risk patients. [[p image] . background: chronic granulomatous disease (cgd) is curable by allogeneic hematopoetic stem cell transplant (hsct). recent reports of haploidentical donor hsct with with post transplant cyclophosphamide (ptcy) from family donors in pediatric primary immune deficiencies have shown encouraging results. however, it has not been reported in cgd. here we describe successful haploidentical hsct in a child with cgd with myeloablative conditioning and ptcy. a year-old, male child diagnosed with cgd showed oxidative activity . % by dihydrorhodamine (dhr) test. he had no matched related or unrelated donor available so underwent haploidentical hsct after taking informed consent of the parents in may . donor was his / hla matched healthy elder sister (oxidative activity % by dhr). he has had multiple admissions for recurrent pneumonia prior to hsct. the conditioning was with rituximab mg/m iv on day - , thiotepa mg/ kg/dose intravenous (iv) for day (day- ), busulfan . mg/kg/dose daily iv for days (day - to - ) and fludarabine mg/m /dose daily iv for days (day - to - ) and rabbit anti-thymoglubulin (thymoglobulin) . mg/ kg/dose daily for days (day- to - ). peripheral blood stem cells ( million/kg cd + cells) were harvested from his sister and transfused to the patient on day . graft vs. host disease (gvhd) prophylaxis was with ptcy mg/ kg on day+ & , intravenous cyclosporine from day- (targeting levels - ng/ml) and mmf from day+ . results: his neutrophils engrafted on day+ and platelets on day+ . chimerism on day+ , and months was fully donor. he developed no acute or chronic gvhd. at months his lymphocyte counts showed cd - /ul, cd - /ul, cd - /ul and cd / - /ul. his had no viral reactivation. he is disease free and gvhd free on day+ post hsct and is on tapering doses of cyclosporine. his dhr test showed oxidative activity of % on day + . background: primary immune deficiencies (pid) are a functional disorder of inheritance immune system that increase predisposition to infectious disease in number and severity. the incidence is : , birth live; its immunological dysregulation may increase the predisposition of autoimmune diseases and malignancy, the latter being more frequent ( - %). at present, the only curative treatment is hematopoietic stem cells transplant (hsct). methods: we describe all patients transplanted with primary immune deficiencies at instituto nacional de pediatria. the conditioning regimen depended on the type donor and pathology: myeloablative ( . %), reduced intensity ( . %) and non myeloablative ( . %) without modification statistically significantly in overall survival. results: a total of patients were included from to january/ . severe combined immunodeficiency (scid) is the pathology most frequently transplanted ( figure ) . seventy three percent have molecular diagnosis, and . % have cases of family pid. the most used sources were umbilical cord blood (ucb) with . % and peripheral blood ( . %), however the trend of the source of obtaining it has been modified a few years ago (figure ) . the median graft was days for ucb, days for bone marrow (bm) and days for peripheral blood (pb) (figure ) the main complications are infectious (bacterial . % and viral . %) and non-infectious as pre-graft syndrome ( . %). conclusions: the overall survival was . % survival according to pathology was: % chediak higashi syndrome, % scid, . % griselli syndrome, . % hyper igm syndrome, % was, % cgd, % hemophagocytic lymphohistiocytosis. disclosure: ramírez-uribe rosa maria nideshda, salazar-rosales haydeé, olaya-vargas alberto, lópez-hernández gerardo, del campo-martínez maria de los Àngeles we wish to confirm that there are no known conflicts of interest associated with this abstact, the only financial support was provided by mexican associations that helping children wiht cancer in a few patients. long-term outcome following hematopoietic stem cell transplantation of wiskott-aldrich syndrome in a single institute mamoru honda , , yukayo terashita , minako sugiyama , yuko cho , akihiro iguchi background: wiskott-aldrich syndrome (was) is an xlinked disorder of hematopoietic cells, characterized by thrombocytopenia with small platelets, eczema, and immunodeficiency. hematopoietic stem cell transplantation (hsct) is the only curative treatment, and it is recommended to be performed as soon as was is diagnosed. myeloablative conditioning before hsct is recommended because there is a high risk of development of autoimmune disease in patients with mixed chimera after hsct. however, there are few reports about late complications such as pubertal development and eruption of teeth in patients with was receiving hsct. thus, we evaluated late complications in patients with was receiving hsct at hokkaido university hospital. methods: we reviewed medical records of male patients with was who received hsct between and . results: mean age at hsct was . (range, . - . ) years, and median follow-up time after hsct was . (range . - . ) years. conditioning regimen in all patients comprised busulfan at mg/kg for days and cyclophosphamide at mg/kg for days or mg/kg for days. additionally, anti-thymocyte globulin at . mg/kg/day for - days was administered in patients. engraftment, normal platelet count, and complete chimera were confirmed in all patients. no patients showed complications such as severe chronic graft-versus-host disease, autoimmune disease, short stature (≤ - . sd) and second malignancy. however, high ige level was observed in patients. pubertal development has been confirmed in patients. lack of complete eruption of permanent teeth has been observed in patients who received hsct at age of < years. conclusions: although this was a small-cohort study in a single institute, complete chimera has been achieved in all patients who received hsct with busulfan-based myeloablative conditioning. however, late complications such as male infertility and incomplete eruption of permanent teeth remain major problems. disclosure: nothing to declare methods: we performed unrelated umbilical cord blood transplantation (ucbt) in consecutive children with lad-i. median age of children was months (range, to months), and median body weight was kg (range, to . kg). all patients received myeloablative conditioning regimen consisting of busulfan, fludarabine and cytarabine. prophylaxis for graft-versus-host disease (gvhd) was tacrolimus. all patients received a ≤ hla alleles-mismatched cord unit, was hla fully matched, were / matched, was / matched. median nucleated cells of the cord blood were . x /kg (range, . to . x /kg), and median cd + cells were . x / kg (range, . to . x /kg). results: all patients engrafted, median time of neutrophil engraftment was days (range, to d), and median time of platelet engraftment was days (range, to d). median follow-up time was months (range, to months), all patients were alive with continuous completely donor engraftment, and achieved complete clinical remissions. / patients developed grade ii/iii acute graft-versus-host disease (gvhd), and / patients developed chronic gvhd with skin. conclusions: it is the first successful unrelated ubct for lad-i children in china. our data shows ucbt provided excellent outcome for patients with lad-i. disclosure: nothing to declare p excellent outcome using 'nktm' enriched hematopoietic stem cell transplants for patients with inborn errors of immunity results: majority of patients in the cohorts had significant infective co-morbidities at the time of hsct with patients in the later cohort entering hsct earlier. patients in the later cohort were sicker at hsct. final engraftment occurred in all except patient who received a hla mis-matched cord blood hsct. graft failures occurred in patients ( in earlier and in later cohort); of these patients received unmanipulated hscts from hla mis-matched unrelated donors ( cb, bm). second hsct were with same donors in and different donors in patients. no grade ii to iv acute gvhd or extensive gvhd occurred. one patient (cbt) died of infections/ non-engraftment. all patients in the later cohort compared to of patients in earlier cohort are alive, engrafted and cured. performance status were % in all alive patients. of the patients in the later cohort, ( hla mis-matched related and hla matched related donors) received 'nktm' enriched hsct. in the hla mis-matched 'nktm' enriched hscts, patients received high cd +, cd +cd ro+ and nk cell doses, with median of . (range, . - . ), . (range, . - . ) and . (range, - ) x /kg, respectively. no invasive infections occurred in these patients and immune reconstitution in t, b, nk compartments were complete at year after hsct with cd > by months and tcrαb > by year after hsct. background: viral infections contribute to significant morbidity and mortality after allogeneic hematopoietic cell transplantation (allo-hsct), increasing both the human and the financial cost. antiviral agents are often ineffective or/ and associated with toxicity. methods: in view of t-cell anti-viral immunotherapy in greece, we evaluated the actual cost of conventional pharmacotherapy for cmv, ebv and bkv reactivations after allo-hsct, by calculating the costs of (i) the antiviral agents, (ii) the treatment (excluding transfusions) of antiviral drug primary toxicity (e.g. graft failure, cytopenias, renal or hepatic dysfunction) and secondary toxicity (e.g. leukopenia-associated bacterial infections), iii) the treatment (excluding transfusions, ie for bk cystitis) of infectionrelated complications, iv) the transfusions due to treatmentrelated toxicity (ie cytopenias) or infection-related complications (ie, bk cystitis), v) the inpatient or outpatient daily care. notwithstanding that blood and its products, as a common natural good, are provided free in our country, the costs related to blood and platelet collection, processing, storage, laboratory testing and infusions were included in our model. results: the treatment cost of cmv, ebv and bkv reactivations/infections for the first six months post allo-hsct was evaluated in / patients who reactivated viruses and were transplanted between / - / from matched related ( / ), matched unrelated ( / ), mismatched unrelated ( / ), haploidentical ( / ) and mismatched related donors ( / ). we detected cmv, ebv and bkv infections/reactivations in , and patients respectively, with a mean of ± . infection per patient from all three viruses ( - /patient). of note, / patients experienced reactivations from more than one virus, requiring repeated treatments with antiviral agents and/or rituximab. the cost of antiviral agents for all cmv, ebv and bkv reactivations/infections was , €, , € and , € respectively ( , €, , € and , €/patient, respectively). the treatment cost of toxicity related to antiviral drugs and infection-related complications was , € ( , €/patient) excluding transfusions and , € ( , €/patient) including transfusions. in particular, the cost of transfusions for bkv hemorrhagic cystitis reached , €/patient. repeated ( - ) and/or prolonged (Δm d, range - d) hospitalizations were needed, up to a total of and days of inpatient hospitalization and short-term outpatient treatment, respectively. hospitalizations further increased the cost of inpatient and outpatient post-transplant care by , € and , € respectively ( , € and €/patient, respectively), onthe basis of a, rather underestimating the true cost, fixed, unified hospitalization fee ( €/day and €/day). conclusions: overall, in a six-month study period, the treatment of cmv, ebv and bkv infections substantially increased the cost of post-transplant care by , € ( , €/patient). the actual cost is undoubtedly higher as the hospitalization fee for transplant recipients is largely underestimated in greece. considering not only the hematopoietic but also the solid organ transplant recipients, the financial burden of antiviral treatment for national economies is enormous. given that antiviral pharmacotherapy is often associated with suboptimal efficacy, toxicity, development of drug resistance, reactivation recurrences and repeated hospitalizations, it is expected that a one-time treatment with multi-virus-specific t cells, able to expand in vivo and provide a long-lasting protection without significant toxicity, will serve as a powerful and costeffective treatment over conventional pharmacotherapy. disclosure: nothing to declare methods: this is a single-centre retrospective analysis of consecutive patients who underwent tcd allo-hscts for myeloid malignancies between january -june . ebv-dna was monitored frequently on whole blood samples with standardised quantitative real-time pcr. serum protein electrophoresis was routinely tested with immunoglobulin subclasses identified by immunofixation electrophoresis. histological confirmation of ptld was based on standard who diagnostic criteria ('proven'), while those without biopsy were classed as 'probable' based on clinical & radiological criteria as defined by ecil- guidelines. results: majority of patients had aml(n- / ) and mds(n- / ) with a median age of years(range . median follow up of survivors was months(range - ). majority of patients(n- / ; %) developed ebv-r with a median time of days[inter quartile range(iqr) - days] &higher cumulative incidence with atg(n- ) versus alemtuzumab(n- )(p< . ). figure- a shows schematic representation of ebv and ptld events (cumulative incidence of . %( %ci- . %- . %) at months). significantly higher peak ebv dna viral load(evl) were noted in patients with ptld(p-< . ). development of post-hsct mg was observed in %(n- / ). roc curve identified peak blood evl> , copies/ml significantly correlated with risk of developing ptld (sensitivity- . %,specificity- . %;auc- . ,p< . ). based on these estimates, subgroup of patients with no ebv-r(n- / ), peak evl < , (< k)copies/ ml(n- / ) & > , (> k)copies/ml(n- / ) were categorised in groups along patients with/without mg accordingly (groups - ;figure- b). patients with ebv-r had significantly better os [ -year os of % vs %(no ebv-r);log-rank p< . ],with this survival benefit mainly driven by subgroup of patients with lower evl(< k)(p< . ). ptld patients had trend towards inferior -year os( % vs %;p- . ). patients with mg had a significantly better os irrespective of degree of evl (group - ,p< . ).we report a 'sweet spot' of low evl & presence of mg in these patients, with a clear survival advantage compared to those with no ebv-r and/or no mprotein (group- -year os % vs % in group- ; hr- . ; %ci: . - . ;p< . ;figure b). overall cumulative incidence of relapse (cir) was %( %ci: - ) and non-relapse-mortality(nrm) of %( %ci: . - ) at years. multivariate analysis(mva) revealed absence of m-protein,high evl (> k copies/ml) or no ebv-r and absence of any gvhd as significant factors for high cir. similarly, high evl or no ebv-r, absence of m-protein and itu admission were significant predictors of high nrm. conclusions: this study adds to our understanding of role of ebv viraemia & associated mg in tcd-hscts while highlighting its significant impact on risk of ptld, os, nrm & cir. low ebv burden and development of mg is protective with significantly better survival outcomes and we recommend pre-emptive approach of using rituximab for ebv-r /ptld is best employed at higher ebv burden (e.g. > k copies/ml dna) in high risk patients and be prospectively evaluated in future studies. clinical trial registry: n/a disclosure: nothing to declare p impact of early candidemia on the long-term outcome of allogeneic hematopoietic stem cell transplant in non leukemic patients: an outcome analysis on behalf of idwp background: to assess the incidence of, and risk factors for, candida infection in the first days post-allogeneic hematopoietic stem cell transplantation (hsct) and the impact on long-term survival. methods: outcome analysis of , patients, % male, median age years (range - ), with diagnosis of hemoglobinopathies in ( . %), bone marrow failure in ( . %), lymphoma in ( . %) and myelodysplastic/myeloproliferative disesases in ( . %) patients who underwent hsct from to : with candidemia by day + , and , without candidemia. the incidence of -day candidemia was estimated by using the cumulative incidence method. the univariate and multivariate risk factor analysis for -day candidemia was performed with the cause-specific cox regression model. the occurrence of candidemia was analyzed as a timedependent covariate. the overall survival and non-relapse mortality after day + were assessed in a land-mark setting, this analysis was restricted to patients surviving to day + post transplant. [[p image] . figure a - b] results: the incidence of candidemia by day + was . % ( % c.i. . - . ) ( / , ) and occurred at a median of days post-hsct (range - - ). considering the candidemia within -day from hsct as a time dependent covariate, a higher -day non-relapsemortality (nrm) (hr . ( . - . ), p < . ), and a lower -day overall-survival (os) (hr . , % ci . - . ), p< . ) were obtained from the cox model for patients with candidemia. factors significantly associated with candidemia occurrence in the multivariate analysis were: gender female, increased age at hsct, bone marrow failure, lymphoma or myelodysplastic/myeloproliferative diagnosis, bone marrow or cord blood stem cell source, t-cell depletion, less recent year of hsct. among patients alive at day + , the -year nrm and os with and without candidemia were . % vs. . %, p < . , and . % vs. . %, p< . , respectively, after a median follow-up of . years ( % ci . - . ) (figure ). in multivariate analysis, the occurrence of a candidemia episode within day + was an independent risk factor for higher nrm, hr . ( . - . ), p= . , and lower os, hr . ( . - . ), p= . . conclusions: despite the general improvements in prophylaxis and treatment, the occurrence of early post-hsct candidemia had a negative impact on transplant outcome as showed previously in leukemic patients. abstract already published. carbapenem-resistant enterobacteriaceae colonizationimportance in the risk of cre bacteremia and mortality in stem cell transplant (hsct) and acute leukemia patients marcia garnica , , marco a f bellizze , priscila g a de jesus , rafaela r c gomes , filipe m akamine , alan j marçal , luzinete co rangel , andreia assis , marcia rejane valentim , angelo maiolino background: spread of infections due to carbapenemresistant enterobacteriaceae (cre) is a worldwide phenomenon and has been associated with high mortality and clinical complications. gut translocation is the most important portal of entry of bacteria during neutropenia, and cre gut colonization is a possible risk factor for bacteremia during neutropenia. goals: in the present study, we describe the frequencies of cre colonization and analyzed its relationship with development of cre bacteremia and mortality in two different scenarios: stem cell transplant patients (hsct) and leukemia patients. methods: prospective cohorts of hsct (from to ) and leukemia patients (from to ). hsct patients were analyzed from conditioning until discharge (pre-engraphment phase) and leukemia patients from first induction chemotherapy until last intensification. if an hsct was performed in leukemia patient the patient was censored in leukemia cohort and included in hsct cohort. all patients had rectal swabs performed weekly during hospitalization for the identification of cre colonization. patients with at least one positive swab (cre colonization group) were compared to patients with no documentation of colonization (controls). the outcomes analyzed were bacteremia due to cre, and overall mortality. results: there were hsct performed during the study ( [ %] autologous and [ %] allogeneic). multiple myeloma and non-hodgkin lymphoma were the most frequent baseline diseases (n= ; %, and n = ; %), respectively. cre colonization was documented in % (n= ), and it was more frequent among allogeneic hsct and leukemia patients (p< . for both). cre colonized patients had longer hospitalization ( vs. days, p< , ), higher frequency of cre bacteremia ( % vs. . %; p= . ), and mortality ( % vs. . %, p< , ) compared to non-colonized hsct. negative and positive predicted values for cre bacteremia were % and %, respectively. thirty-one patients were analyzed in leukemia cohort, accounting to hospitalizations (median hospitalizations per patient, ranging from to ). the median age was years, and % aml vs. % all. cre colonization was documented in eight ( %), with a median time from leukemia diagnosis and colonization of days ( - days). cre bacteremia was documented only in colonized patients ( % vs. zero; p= , ). all eight colonized patients were submitted to other cycles of chemotherapy after colonization, in one of them cre bacteremia relapsed. conclusions: a routine surveillance of cre colonization showed colonization frequencies from % to % in hsct and leukemia patients respectively and was effective to stratify cre bacteremia risk as the predictive negative value was over %. colonization had association with cre bacteremia and overall mortality. efforts to minimize risks for colonization and mortality are necessary. the information of surveillance can be a tool to improve adequacy in empirical febrile neutropenia therapy in hsct and leukemia patients. disclosure: nothing to declare background: the incidence of hepatitis b virus infection is high to . % in asian population, so there is more and more attention to the risk of hepatitis b virus(hbv) reactivation in the hepatitis b core antibody positive patients during chemotherapy, anti-cd monoclonal antibody, hsct, or other intense immunosuppressive drug therapy (isdt). hepatitis b core antibody is associated with a significant risk of hbv reactivation in patients undergoing hsct. however, there are remain uncertain that the effect of anti-hbsag antibodies in hepatitis b virus reactivation among the hepatitis b core antibody positive patients undergo hsct. we aim to investigate the role of the anti-hbs and the necessity of anti virus in hepatitis b surface antigen(hbsag) negative, hepatitis b core antibody positive patients during hsct. methods: we enrolled hematological malignant patients received hsct in our center from to . we classified hbsag negative and undetectable hbv dna patients into groups as anti-hbc(-)anti-hbs(-) (n= ), anti-hbc(-)anti-hbs(+) (n= ), anti-hbc(+) anti-hbs(-) (n= ), and anti-hbc(+)anti-hbs(+) (n= ). results: hbv reactivation was identified in patients ( . %) after hsct. there was a significant difference in hbv reactivation rate in anti-hbc(+)anti-hbs(-) ( . %) vs anti-hbc(+)anti-hbs(+) ( . %) (p= . ) and anti-hbc (+)anti-hbs(-) ( . %) vs anti-hbc(-)anti-hbs(-) ( . %) (p= . ), anti-hbc(+)anti-hbs(-) ( . %) vs anti-hbc(-) anti-hbs(+) ( . %) (p= . ), but not among anti-hbc(+) anti-hbs(+) ( . %) and anti-hbc(-)anti-hbs(-) ( %) and anti-hbc(-)anti-hbs(+) ( . %). whereas there were no difference according to the donor viral profile(p= . ). the median time of hbv reactivation in hbsag negative patients accepted hsct was ( - ) days after hsct. all of the patients with hbv reactivation have been controlled with nucleos(t)ide analogues drugs, and of them achieved reverse seroconversion which detect persistent anti-hbsag antibodies in their bodies. conclusions: the anti-hbsag antibodies negative and anti-hbc positive patients have the highest risk of hbv reactivation after hsct in resolved hbv patients. the anti-hbsag antibodies play a protective role in resolved hbv patients receiving hsct. we recommend not prophylactic anti hepatitis b virus in hbsag negativity and anti-hbsag antibodies positive patients following hematopoietic stem cell transplantation. disclosure: nothing to declare methods: allo-hscts performed between and for acquired bone marrow failure ( . %) or hemoglobinopathies ( . %), with bm±cb ( . %) or pb±cb+bm ( . %) as a stem cell source were included in this retrospective registry megafile idwp ebmt study. results: demographics: the median age of recipient was . years (range: . - ), and . % were children. . % recipients and . % donors were ebv-seropositive. . % had hsct from a matched family donor, . % from a mismatched family donor, and . % from an unrelated donor. t-cell depletion was performed in vivo in . %, and ex vivo in . % patients. conditioning regimen was myeloablative in . %, ric in . %. median follow-up was . years ( % c.i. . - . ). transplant out-comes: ebv-seropositive recipients in comparison to ebv-seronegative recipients had lower os ( . % vs . %, p= . ), and higher nrm ( . % vs . %, p= . ). no other significant differences were found for: ri, rfs, and acute or chronic gvhd with respect to ebv pretransplant serostatus donor and/or recipient. multi-variate analysis: ebv serostatus as a risk factor did not reach significance, while a trend towards higher risk of development of cgvhd (hr= . ; %ci . - . ; p= . ) and better survival (hr= . ; %ci . - . ; p= . ) in allo-hsct from ebv-seropositive donors. allo-hsct in ebv-seropositive recipients had a trend towards lower risk of development of cgvhd (hr= . ; %ci . - . ; p= . ). when subgroups (r-/d-, r-/ d+, r+/d-, r+/d+ ebv serology) were analyzed, the ebv serostatus had no significant impact on os, rfs, ri, trm and development of acute or chronic gvhd. conclusions: allo-hsct from ebv-seropositive vs ebv-seronegative donors are at % higher risk of chronic gvhd in patients with non-malignant hematological disorders undergoing allo-hsct, however this difference is non-significant in multivariate analysis. disclosure: nothing to declare. results: twenty-eight ( %) pts ( male, female) were tested positive (group ) for subtype a (n= , %), b (n= , %) or a (h n ) (n= , %) while ( %) pts ( male, female) were negative (group ). vaccination rate in group ( %) was significantly lower compared to group ( %, p= . ). the median time after transplantation ( vs days), t-cell counts ( vs / μl), bcell counts ( vs / μl), igg-level ( , vs , g/ l), proportion of immunosuppressed pts ( % vs %), male/ female ratio was not significantly different between groups and . within group influenza subtypes were similarly distributed in vaccinated and not vaccinated pts (a % vs %, b % vs %, a (h n ) % vs %). pts. with subtype b infection had higher levels of t-( vs / μl) and b-cells ( vs / μl) and a longer follow up from sct ( vs days) compared to subtype a / a (h n ) infection but differences were not significant. conclusions: influenza could be proven in one third of all tested pts. dominance of b and a (h n ) pdm e subtype occurrence corresponded to the flu epidemic dissemination in the german population. the most important protective factor for outpatient sct recipients was influenza vaccination. disclosure: nothing to declare background: cmv infection is one of the most frequent complications after haplo. some risk factors are well known but the best strategy (prophylactic or preemptive treatment) to mitigate this complication is not still well defined. the primary endpoint in our study is to describe incidence and risk factors to develop cmv infection or disease in haplo. as secondary objective we analyzed efficacytoxicity of treatment and cmv related mortality. methods: we analyzed patients who underwent haplo in our center between may and may . all of them received ptcy (d+ and d+ ), tacrolimus and mycophenolate as graft versus host disease prophylaxis. a preemptive therapy based on viral load was applied. treatment was started when > ui/ml of cmv were detected in one determination or > ui/ml in two consecutive determinations. cmv analyses were made in plasma using cobas pcr technique® and positive viral load cut-off point was ui/ml. the cmv viremia was determined weekly until d+ and then every two weeks until immune reconstitution. results: the cmv infection and disease incidence at d + was . % ( episodes) and . % ( episodes), respectively. cmv disease was digestive (n= ), pulmonar (n= ), neurologic (n= ) and disseminated (n= ). the median time to first cmv infection was . days ( - ). thirty-six patients had at least one episode of cmv infection: of them ( . %) had one episode, ( . %) had two episodes and ( . %) had or more episodes, respectively. only pre-transplantation cmv status was significantly associated with cmv infection (p< . ). risk factors are shown in image . the median viral load in first cmv infection and disease was ui/ml ( - ) and ui/ml ( - ), respectively (p= . ).the median counts of cd lymphocytes at d+ in cmv infection and disease were /mm and /mm , respectively (p= . ). preemptive therapy for the first episodes of cmv infections (n= ) was valganciclovir ( , %), ganciclovir ( . %) or foscarnet ( . %), reaching a complete viral load clearance in %, with a median time to response of . days ( - ) and a median treatment duration of days ( - ). grade iii-iv toxicity (mainly hematologic) was observed in . % (n= ), % (n= ) and . % (n= ), respectively. three patients had an ul mutation, one of them with clinical and microbiological resistance to the mentioned drugs. three patients ( %) had a graft failure secondary to cmv infections. five patients ( . %) died as consequence of cmv infection: before d+ secondary to cmv disease ( pulmonar, disseminated) and after d+ due to graft failure and infectious complications. with a median follow up of . months, overall survival at months for patients who had cmv infection was . % compared to . % for those who had no infection (p= . ). conclusions: a high incidence of cmv infection in haplo with ptcy was shown in our series and it contributed to mortality in . % of patients. only cmv status (d-/r+ and d+/r+) was significantly associated with higher risk of infection. identification of high risk patients and new prophylactic and treatment strategies may improve these results. disclosure: nothing to declare. methods: consecutive patients admitted at the sct unit between january- to november- were reviewed. only first admission was analysed. screening consisted of rectal and perineal swap on admission and weekly until discharge. in case of detection of mdro, patients were isolated and infection control strategies were applied. results: patients were analysed, median age years ( - ). % were male (n= ). median duration of hospitalization was days( - ). swabs were performed, with a median of swaps/patient ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . patient characteristics are shown in table . patients ( %) spiked fever in a median of days after admission . % (n= ) had previous documented mdro colonization. median neutrophil engraftment was days ( %ci - ), in % patients (n= ) of patients had a positive screen: in ( %) patients at baseline and in ( %) patients were detected for the first time beyond baseline screen. cumulative incidence of colonization at days was . % ( %ci . - . ), at days % ( %ci . - . ), and at days . % ( . - . %) (figure ). mdro identified were: with extended-spectrum beta-lactamases producing e. coli (esbl-ec), multidrug-resistant pseudomonas aeruginosa (mr-ps), vancomycin resistant enterococci (vre) and patient with carbapenemaseproducing (cp) citrobacter freundii. / colonized patients developed mdro infection ( %): patients mr-ps, site of infection was urinary tract infection (uti), urethritis, genital ulcer. two patients were treated with ceftolozane/ tazobactam, with meropenem+amikacin; patients esbl-ec both uti treated with meropenem; patient cpcitrobacter freundii uti treated with ceftazidime/avibactam. in % patients ( / ) antibiotic treatment at febrile episode was guided by positive screening. no mdro related icu admission or mortality was observed. in % patients (n= ) background: hepatitis e virus (hev) can cause chronic infection and liver cirrhosis in immunocompromised individuals. there is limited data on hev infections in patients undergoing allogeneic hematopoietic stem cell transplantation (hsct). the aim of this study was to investigate the frequency and clinical importance of hev in a swedish cohort of hsct recipients. methods: we analyzed serum samples from hsct patients ( adults and children), collected months after hsct. hev igg and igm were detected by elisa (dia.pro®), hev rna by reverse transcriptase pcr, and quantification of hev rna was performed by digital pcr. in all patients, who were positive for hev-rna and/or serology at months, also samples collected at the time of hsct from both the patients and their donors were analyzed. in the hev rna positive patients, additional samples were analyzed to determine the duration of viremia. three hev rna negative controls were selected for each case of hev infection, matched for age, diagnosis, conditioning regimen and donor type. results: hev rna was detected in / ( . %) patients. in three of the patients hev rna was positive during a period of - months, and two of these patients were infected already at the time of hsct. in five patients hev-rna was positive, at a low level, only at months. / ( . %) patients had detectable hev igg and/or igm, whereof eight patients were hev rna negative. in / ( %) patients with hev infection (hev rna positive) alanine aminotransferase (alt) was > upper limit of normal (uln), in / ( . %) patients > . uln, and in / ( . %) patients alt was normal, at months after hsct. bilirubin was elevated > . uln in / ( . %) patients, and > uln in no patient at months after hsct. two patients died with ongoing signs of hepatitis and hev rna detected in blood. one of them developed acute liver failure, at the time interpreted as drug toxicity, and died of multi-organ failure. the other patient died of unrelated causes. the remaining six patients had cleared the infection at - (median . ) months after hsct. active gvhd was present at months after hsct in / ( . %) patients with hev infection, involving the liver in of these patients. corticosteroid treatment was ongoing in / ( %) patients; the mean dose during the preceding days was > . mg/kg in / ( . %) patient, . - . mg/ kg in / ( . %) patients, and < . mg/kg in / ( %) patients. hev infection correlated to elevated alt > . uln, or . p= . ) and > uln, p= . ) at months, but not at months, after hsct, compared to hev rna negative controls. conclusions: hev infection was detected in . % of patients tested at months after hsct and was correlated to abnormal alt. spontaneous clearance was common but one patient died in acute liver failure, where hev may have contributed. hev infection is a differential diagnosis in patients with elevated alt months after hsct. disclosure: nothing to declare monitoring of t-cell responses to viral-coded antigens in pediatric patients receiving tcrαβ-depleted haplo-hsct followed by bpx- cell administration background: αβ t-cell-depleted haplo-hsct is an effective option for children with hematological disorders in need of an allograft. however, recovery of adaptive immunity is impaired in these patients. thus, in order to accelerate immune reconstitution, we developed a novel approach based on post-transplant infusion of a titrated number of donor t cells, transduced with the suicide gene inducible-caspase- , ic (bpx- cells, sponsor bellicum pharmaceuticals®; nct ). we previously reported on immune recovery of children transplanted at our institution, showing that bpx- cells infused after αβ t-cell-depleted haplo-hsct expand in-vivo and persist over time, contributing to fasten adaptive immunity recovery (merli, ash ). here, we report the results of lymphoproliferation assay to viral-encoded antigens to assess tcell function in patients transplanted with this approach. methods: we evaluated children, male and female. median age at transplant was . years (range . [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . patients had either malignant ( children) and nonmalignant ( ) disorders. no patient was given any posttransplant graft-versus-host disease prophylaxis. nine children were enrolled in the phase i portion of the trial consisting of cohorts receiving escalating doses of bpx- cells. the remaining patients (phase ii portion) received the recommended dose of x bpx- cells/kg identified in phase i. bpx- cells were infused at a median of days post-hsct (range - ). antigendriven activation of peripheral mononuclear cells was evaluated by lymphoproliferation assay with h-thymidine pulsing at d+ and harvesting at d+ . stimuli included pha or cmv, ebv and adv whole viral lysate. results are given as stimulation indexes (si, cpm stimulated sample/cpm unstimulated control). thresholds for positive response were arbitrarily set at si> for viral-encoded antigens and at si> for mitogenic stimulation with pha. fractions of responders are indicated in the figure. results: patients were analyzed from d+ to d+ post-hsct. pha responders (a) increased to %, while cmv (b), ebv (c) and adv (d) responders were %, % and % at years after haplo-hsct. responses to ebv and adv antigens were slightly delayed but improved over time. responses to pha and to cmv (e,f) were analyzed in the cmv-reactivating and cmv-non reactivating groups (cmv-yes/cmv-no). significant differences in pha response were observed at d+ and d+ . moreover, increased cmv responses were observed in cmvreactivators at d+ , d+ and d+ , with approximately % of responders at d+ , as opposed to cmvnon reactivators which comprised % responders. neither primary disease, age nor tbi during the conditioning regimen influenced proliferative capacity of the two subgroups (not shown). conclusions: we showed a rapid recovery over time of t-cell function after αβ t-cell-depleted haplo-hsct followed by bpx- cells administration. when patients were grouped according to cmv reactivation (previously demonstrated as a strong driver of immune reconstitution), a significant difference in the number of responders among the patients experiencing viral reactivation was observed using the cmv lysate only but not the immunodominant pp protein (not shown), suggesting that other viral antigens account for increased t-cell responses. results of t-cell function after bpx administration complements the phenotypic data we already reported. clinical trial registry: nct disclosure: nothing to declare. background: cytomegalovirus (cmv) is associated with significant morbidity and mortality in allogeneic hematopoietic cell transplantation (allo-hct) patients (pts). cumulative incidence of cmv infection in high-risk patients such as cd -selected or haploidentical hct have been reported as high as . - . % and - %, respectively. letermovir (ltv) was approved in / for prophylaxis (ppx) in cmv-seropositive recipients (r+) of allo-hct. since / , ltv ppx was implemented at our center for both primary and secondary ppx. we report our real-world experience. methods: adult cmv r+ allo-hct pts who initiated ltv as primary and/or secondary prophylaxis were identified between / / and / / . cord blood transplants were excluded. the primary outcome was the incidence of clinically significant cmv infection (cmv viremia requiring preemptive treatment or cmv disease). pts were followed through / . results: pts initiated ltv. . % pts were at high risk for cmv reactivation and disease (primarily ex vivo t-cell depleted hct [n = ; %] or haploidentical t-replete hct [n = ; . %]). the most common indication for hct was acute myeloid leukemia (n = ; . %) and the majority of patients received myeloablative conditioning (n = ; . %). pts ( . %) received ltv as primary ppx after hct, with a median day of ltv initiation of d+ (range d+ ─d+ ). at ltv initiation, pts had an undetectable cmv dna, and had cmv < iu/ml. clinically significant cmv infection requiring preemptive treatment occurred in of pts ( . %). one patient was treated with valganciclovir (vgv) for persistent cmv < iu/ml and received ltv as secondary ppx. a nd patient developed persistently detectable cmv (< iu/ ml) and breakthrough cmv viremia with a mutation in ul at site c yltv successfully treated with vgv. the median duration of primary ltv ppx was days ( - ), with primary ppx continuing beyond weeks post hct in pts. the median additional follow-up in patients who discontinued ltv was days ( - ), without clinically significant cmv infection to date. an additional pts ( pts overall; . %) received ltv as secondary ppx after cmv pre-emptive therapy. the median duration of secondary ltv ppx was days ( - ), with no reactivation. ltv was not discontinued due to toxicity or intolerance in any patient. cmv outcomes are summarized in figure . all-cause mortality for the pts over the observational period was . %. conclusions: primary ltv ppx significantly reduced cmv reactivation, and high-risk patients may benefit from extended prophylaxis. in patients who received preemptive therapy for cmv, use of secondary ppx showed no recurrent cmv reactivation. ltv is well tolerated. additional studies are needed to determine optimal ppx duration and to clarify role of secondary cmv ppx in high-risk allo-hct. the future standard of care will likely include extended primary ppx and secondary ppx and result in decreased morbidity and mortality associated with cmv. disclosure: andrew lin -nothing to declare, molly a. maloy -nothing to declare, valkal bhatt -nothing to declare, lauren derespiris -nothing to declare, meagan griffin -nothing to declare carmen lau -nothing to declare, anthony j. proli -nothing to declare, juliet barker -angiocrine bioscience , letermovir primary prophylaxis (pp) has been shown to reduce clinically significant cmv infection with a favorable safety profile. letermovir pp will improve the outcome of seropositive patients. however, patients who did not benefit from pp and experienced > cmv episode (infection or disease) after hct may be candidate to secondary prophylaxis (sp). indeed half of them will have > recurrent episode after pre-emptive treatment (pet). letermovir is available since november as part of the french early access program for pp and sp. we report the outcome of patients who benefited from letermovir sp in the context of this program. methods: letermovir is granted, in a restrictive manner, by the french drug agency (ansm) on a case-by-case basis for prophylaxis of cmv episode, in cmv-seropositive adult allogeneic hct recipients. sp patients should have a negative baseline cmv pcr, have already experienced > cmv episode, in the context of a potentially harmful pet according to physicians. planned letermovir daily dose was mg in case of concomitant cyclosporine and mg otherwise. all patients were routinely screened by blood or plasma cmv pcr. results: between november -july , patients received letermovir in the early access program, for pp, and for sp. among the sp patients, had previous cmv disease (gut: ; cns: ). mean age was ± years, m/f ratio was / . the sp cohort included one cord blood and haplo-identical hct. main diagnoses were acute leukemia ( %) and myelodysplastic syndrome ( %). the conditioning regimen was myeloablative in % and included atg in %. based on available data ( missing data, md), previous gvhd was present in ( %) patients, and active at letermovir initiation in ( %). thirty two ( %) patients were planned to receive immunosuppressants. donor's cmv serology was negative in / ( %) ( md). at baseline, cmv pcr was detectable in / patients. letermovir was initiated a median of days (iqr: - ) after transplant for a mean duration of ± days. only one ( %) patient developed cmv breakthrough. the median follow-up from letermovir initiation was days. among the patients exposed to letermovir prophylaxis, two patients permanently discontinued because of letermovir-related adverse events (acute gvhd and nephropathy for one, loss of appetite, pruritus, diarrhoea and weight loss for the other); two deaths occurred with no causal relationship to letermovir. data were consistent with the known safety profile of letermovir. conclusions: letermovir is or will be soonly available in most european countries for cmv prophylaxis in hct recipients. pending its routine use, letermovir used as sp was well tolerated and effective, with only / patients developing a breakthrough infection. in this high-risk population for cmv recurrence, letermovir may provide a safe bridge between pet and specific immune reconstitution, pending tapering or discontinuation of immunosuppressants. whether sp may improve survival deserves further studies. disclosure: thierry allavoine is a former employee of msd france, nathalie benard and amir guidoum are employees of msd france, marion masure is an employee of icta pm, sophie alain and catherine cordonnier have participated in advisory boards and have been members of the speaker bureau of msd. ibrahim yacoub-agha has received honoraria from msd, other authors: nothing to declare p real-world data on letermovir prophylaxis for cytomegalovirus reactivation after allogeneic hematopoietic cell transplantation: a single center experience patrick derigs , maria-luisa schubert , paul schnitzler , carsten müller-tidow , peter dreger , michael schmitt heidelberg university hospital, heidelberg, germany, background: reactivation of cytomegalovirus (cmv) still contributes substantially to morbidity and mortality after allogeneic hematopoietic cell transplantation (allohct). recently, letermovir became available as the first drug approved in europe for prophylaxis of cmv reactivation in seropositive patients who have undergone allohct. letermovir is neither myelo-nor nephrotoxic, and significantly reduced the incidence of cmv reactivation in a pivotal phase iii trial (nejm ; : ) . therefore we adopted letermovir prophylaxis according to the label as standard policy in our institution: in seropositive recipients letermovir was initiated after engraftment and continued until day + or cmv reactivation. the aim of the present study was to investigate if the favorable trial results could be reproduced under real-world conditions. methods: the study cohort consisted of the first seropositive patients who received letermovir prophylaxis at our institution (between march and august ). these were compared with a control cohort transplanted between august and march before the advent of letermovir. study and control cohorts were matched for cmv donor/recipient sero-status, underlying disease and donor type source of stem cells and application of atg. cmv viremia was monitored by a quantitative pcr twice a week during the inpatient period and weekly thereafter. patients reactivating cmv prior to engraftment were not considered as event in both groups. results: no major side effects of letermovir intake were observed. with altogether reactivation events, the cumulative rate of cmv reactivation on day + was % ( %ci - %) in the letermovir cohort and thus significantly lower than in the control group ( events, % ( %ci - %); hr . ( . - . ); p= . ). the median time to reactivation was days for the control group and not reached for the letermovir group. the cumulative number of days on valganciclovir before d + was d for the letermovir patients vs d for the control patients. there were no hospitalizations for foscavir administration in the letermovir group compared to hospitalizations in the control group. there were deaths before d + in the letermovir group (one pd, one nrm) and deaths in the control group (all pd). conclusions: this observational study confirms the safety and efficacy of letermovir for the prophylaxis of cmv reactivation in seropositive patients after allohct in a real-world setting. our results are in good concordance with the phase iii trial. although letermovir appeared to reduce the need for therapeutic valganciclovir and foscavir tremendously, larger samples with longer follow-up are needed to assess the impact of letermovir prophylaxis on non-relapse and overall mortality as well as on resource consumption. background: cmv viremia occurs in %- % of cmv r + hct recipients. pet use has reduced the risk of cmv end-organ disease (eod) and associated mortality; however, pet use may lead to substantial antiviral use and healthcare resource utilization. limited real-world data are available on the outcomes of pet. therefore, we aimed to examine cmv outcomes (eod, resistance), cmv-related mortality by day (d) and healthcare resource utilization between pet and no-pet groups among cmv r+ recipients undergoing first hct. methods: we conducted a retrospective cohort study of adults, cmv r+ recipients of first peripheral blood or marrow allograft at mskcc identified from march through december . data was extracted from electronic medical records and hct databases. cmv+ recipients were monitored weekly by quantitative pcr assay starting on d through d post hct. use of antiviral therapy for cmv viremia defined pet. high cmv risk (hr) comprised t-cell depleted (tcd) hct by cd +-selection regardless of donor hla match or conventional hct from mismatched or haploidentical donors; low risk (lr) included conventional hct from matched related donors. cmv eod was scored by standard criteria. cmv resistance mutations were confirmed by sequencing (viracor-eurofins). length of stay (los) for hct admissions and readmissions were identified through d . stratified analyses were performed to examine outcomes by pet use and cmv risk. background: in a phase iii randomized, double-blind, placebo-controlled study of cmv-seropositive post-hsct recipients, letermovir prophylaxis significantly reduced the incidence of clinically significant cmv infection through week . the objective of this research was to assess the impact of cmv prophylaxis on rates of rehospitalization in adult cmv seropositive allogeneic hsct recipients from the letermovir phase clinical trial. methods: rehospitalization was recorded as an exploratory endpoint in the clinical trial at end of treatment (week ), time of primary endpoint (week ) and through an extended follow-up period (week ). cmv-related rehospitalization was assessed in the trial. prespecified analyses describe the observed rates of rehospitalization for the letermovir and placebo groups at the specified times. fine-gray cumulative incidence function(cif) regression models were used to explore the rate of all-cause, and cmv-related rehospitalization accounting for the competing risk of mortality. a multiple linear regression model was used to describe the cumulative length of stay (los) for all-cause rehospitalizations that occurred through week (excluding time of initial transplant stay). results: observed rates of all-cause rehospitalization were lower for the letermovir group compared to placebo at end of treatment ( . %vs. conclusions: letermovir was shown to significantly reduce the rate of clinically significant cmv infection in a placebo-controlled randomized clinical trial. these analyses suggest that there is also a reduction in the rate and cumulative days of rehospitalization. this trial was not sufficiently powered to detect differences in this exploratory endpoint. nonetheless, these data provide valuable insights into the economic burden of cmv. real world data and findings from future clinical trials are needed to better understand the nature of the association between cmv and rehospitalizations. clinical methods: all consecutive patients with hematologic disorders who received hsct at our center between january and august were included. among the evaluable patients, received levofloxacin as antibacterial prophylaxis (group a) while did not receive any fq prophylaxis (group b). baseline characteristics were similar in the two groups, except for the number of patients with advanced disease ( % in group a and % in group b, p , ). median duration of neutropenia was days (range - ) in group a and days (range - ) in group b. a positive rectal swab for carbapenem-resistant enterobacteriaceae (cre) was detected in patients in group a and patients in group b. results: overall, bsi was detected in patients ( , %), ( , %) in group a and ( , %) in group b (p= , ). the median onset of bsi was days post transplant (range - ), without significant differences between the two groups. in univariate analysis, fq prophylaxis (or , ; % ic , - , ) and bone marrow stem cell source (or , ; % ic , - , ) were significant factors associated with the risk of bsi. gramnegative bacteria accounted for , % (n= ) of bsi in group a and , % (n= ) in group b, and gram-positive bacteria for , % (n= ) of bsi in group a versus , % (n= ) in group b, without statistically significant differences (p = , ). polymicrobic bsi were , % (n= ) in group a and , % (n= ) in group b. mdrgram negative bsi were detected in patients ( %) in group a and in patients ( , %) in group b (overall, cre, esbl producing enterobacteriaceae and mdr-pseudomonas). death attributable to bsi occurred in of patients ( , %); of these patients did not receive fq prophylaxis, but of them had both a pre transplant kpc colonization and active disease at transplant. neither antibacterial prophylaxis (p = , ) nor bsi (p = , ) had a significant impact on overall survival (os). conclusions: the preliminary data of our study show that fq prophylaxis is associated with a reduced incidence of bsi, in particular gram-negative infections, with no impact on os. the limitations of our study may be the different group sizes and the retrospective nauture of the study. whether antibacterial prophylaxis should be avoided in the pre-engraftment period in still a matter of debate and needs to be evaluated in larger prospective studies. disclosure: nothing to disclose. gillen oarbeascoa , nieves dorado , , laura solan , , rebeca bailen , , pascual balsalobre , , carolina martinez-laperche , , ismael buño , , javier anguita , , jose luis diez-martin , , , mi kwon , hospital general universitario gregorio marañón, hematology, madrid, spain, instituto de investigación sanitaria gregorio marañón, madrid, spain, universidad complutense de madrid, madrid, spain background: incidence and outcome of invasive fungal infection (ifi) are not well characterized in the setting of peripheral blood, non-manipulated haploidentical stem cell transplantation with postransplant cyclophosphamide (haplosct). the aim of the study was to analyze incidence and risk factors of ifi in patients who underwent haplosct at our institution. methods: consecutive patients who underwent peripheral blood haplosct with postransplant cyclophosphamide between and at our centre were reviewed. ifi was classified according to eortc definitions. proven and probable ifi were included. results: patients´characteristics are shown in table . primary antifungal prophylaxis was performed with micafungin from day - until oral intake, followed by posaconazole until day + . patients on steroid treatment for gvhd received prophylaxis with micafungin or posaconazole. % of patients obtained neutrophil engraftment. twenty-two episodes of ifi were observed in patients: proven and probable, with a cumulative incidence of ifi of % at days. most commonly isolated organism was aspergillus spp (n= ), followed by candida spp (n= : c. kruseii and c. parapsilosis), and fusarium spp (n= ). isolated cases of inonotus spp, mucor spp and trichosporon ashii were observed. pulmonary involvement was the most frequent clinical presentation (n= ), followed by fungemia (n= : candidemia, trichosporon ashii) and skin-pulmonary involvement (n= ). among patients with lung involvement, showed probable ifi: with elevated serum galactomannan and positive galactomannan in bronchoalveolar lavage (bal). there were patients without galactomannan, one with a positive bal culture for penicillum spp and the other with an aspergillus spp. median time to ifi diagnosis was days. thirteen cases were diagnosed in the pre-engraftment period, after engraftment and cases after day + . among patients with late ifi, median time to development was days. all of them were associated with gvhd ( grade iii-iv acute gvhd and moderate/severe chronic gvhd). ifi outcome was favorable in out of the ifi. treatment was liposomal amphotericin b in cases, voriconazole in and combined treatment (amphotericin b and azole) in . there were ifi related deaths, with a cumulative incidence of ifi related death of . %. prior transplant (or . , p< . ), particularly allohsct was associated to ifi development (or . , p< . ). patients with previous allohsct presented ifi mainly from molds: aspergillus, fusarium, inonotus, trichosporon and mucor. there were also candidemia episodes. no other factors were significantly associated to ifi occurrence. conclusions: in our experience, cumulative incidence of ifi in the setting of haplosct with posttransplant cyclophosphamide was similar than observed in previous studies in allosct. having received a previous sct, especially allosct, was the most significant factor related to ifi development. this high risk population should be closely monitored and could benefit from prophylaxis with azoles. disclosure: nothing to declare. methods: rsv infection was diagnosed in nasal wash (nw) or bronchoalveolar fluid (bal) by dfa (millipore, usa) or pcr (seeplex, seegene, kor). urti and lrti were defined according to ecil- guidelines. death from all causes was assessed within days after rsv infection and was attributed to rsv if the patient had persistent or progressive rsv infection with respiratory failure at the time of death. neutropenia and lymphocytopenia were defined as an absolute neutrophil count (anc) < /ul and absolute lymphocyte count (alc) < /ul, respectively. results: median number of confirmed rsv infections per year was , ranging from to . an outbreak of rsv was detected in , possibly due to a lack of compliance with contact precautions in the unit. median patients' age was years and time to rsv infection was day (- to ). twenty-three patients (pts) had received an autologous transplantation ( . %) and were allogeneic hsct recipients ( , %). median time to engraftment was days, ranging from to days. at rsv diagnosis, pts presented with urti ( . %) and with lrti ( . ) . surprisingly, around % of the auto hsct recipients had rsv pneumonia at diagnosis. variables significantly associated with lrti at diagnosis were mud hsct (no/ yes, or . ; ci . - . ); anc < /ul (or . ; ci . - . ); alc < /ul (or . ; ci . - . ); and recent or pre-engraftment hsct (no/yes, or . ci . - . ). among the pts with urti at diagnosis, progressed to lrti ( . %). forty-four of the pts died ( . %) and mortality rate was significantly higher in pts with lrti in comparison with pts with urti ( . % versus . %, p= . ). death was attributed to rsv in of the pts who died ( %). conclusions: autologous hsct recipients are also at risk of lrti caused by rsv. risk of rsv lrti is higher in mud hsct, infection acquired pre-engraftment or early after hsct, and low neutrophil and lymphocyte counts. continued education is necessary to sustain compliance to contact precautions in hsct units. disclosure background: measles is a life-threatening infection after allogeneic hct. due to the decreased coverage of vaccination in many countries, the disease reappears, increasing the risk of outbreaks worldwide. allogeneic hct recipients have been shown to be seropositive for measles in roughly - % of the cases years after transplant. however, these data were obtained before the 's from hct populations mainly conditioned with myeloablative (ma) regimens. our aim was to assess measles immunity before considering vaccination in a cohort of hct survivors including patients conditioned with reduced intensity (ric) or non-ma regimens. methods: allogeneic hct adult recipients who had not been vaccinated for measles since hct were routinely screened for measles immunity. measles igg titers were determined with a chemiluminescence immunoassay (liaison measles igg kit, liaison xl analyser, diasorin, italy). patients were considered to be seropositive if the igg titer was > . ua/ml. risk factors for seropositivity were analyzed. qualitative variables were described as numbers (%) and compared using the chi- test or fisher exact test as appropriate. quantitative variables were described as median or mean (range) and compared using the kruskall-wallis test. ors were estimated separately for factor yielding a p-value < . in the univariate analysis using logistic regression models. results: eighty-six patients, transplanted . to years (mean: , years) ago, were included. the mean age was years (range: - ), the sex ratio m/f: , . the underlying diseases were acute leukemia: ( %), myelodysplastic syndrome: ( %), lymphoproliferative diseases: ( . %), myeloproliferative neoplasms: ( %) and non-malignant diseases : ( . %). the hct was performed from an hla-identical donor in , an unrelated donor in , and a cord-blood in . conditioning regimen were ma in ( %), ric in ( %) and non-ma in ( %) patients no patient had experienced measles or had received measles vaccination since transplant. fifty-seven of the ( %) patients were seropositive for measles. measles seropositivity was not associated with conditioning regimen, patient age at transplant, patient age at time of assessment, donor age at transplant, lymphocyte count or gammaglobulin levels, or type of transplant (hlaid. vs others) measles vaccination before transplant or previous measles before transplant. the only parameters significantly associated to seropositivity were absence of previous gvhd (any type or severity, p= , or , [ , - , ]), and absence of previous extensive chronic gvhd (or , [ , ] p , ). conclusions: sixty-seven percent of allogeneic hct are seropositive for measles at a median of years after hct before vaccination. the only risk factor strongly associated with seronegativity is extensive chronic gvhd. in patients background: cytomegalovirus (cmv) reactivation is a frequent complication after hematopoietic stem cell transplantation (hsct). extracellular vesicles (evs) have emerged as a promising new category of biological biomarkers in different scenarios, including inflammation, tissue damage, cancer and viral infections. we recently reported on the potential use of serum evs as biomarkers of agvhd (lia g. et al. leukemia ( ) , ) . here, we investigated the potential correlation of cmv reactivation with plasma evs in post-transplant cyclophosphamide (ptcy) haploidentical-hsct (haplo-hsct). methods: plasma samples were collected after mononuclear cell separation at given time-points (pre-transplant, on day , , , , , , , , , and after haplo-hsct) and evs were extracted by a protamine-based precipitation method and their concentration and dimension were characterized by nano-tracking particle analysis (nanosight). after extraction, evs were analyzed by flowcytometry (guava easycyte flow cytometer) with a panel of antibodies (cd , cd , cd , krt , cd a, cd , cd , cd , cd , cd , cd , cd , cd , and cd a). results: thirty-two patients with hematological malignancies underwent haplo-hsct between and . cmv reactivation was observed in / ( , %) and occurred at a median of (range: - ) days after transplant. preliminary analysis ( / patients) showed that cd a fluorescence (platelet-derived growth factor receptor-α or pdgfr-α), cd fluorescence (ki- antigen) and cd fluorescence (ve-cadherin) were associated with an increased risk of cmv reactivation (or . p= . ; or . p= . ; or . p= . ), whereas cd (platelet endothelial cell adhesion molecule, pecam- ) concentration level was associated with a decreased risk of cmv reactivation (or . , p= . ). all these biomarkers showed a signal change before cmv reactivation (an increase with cd a, cd and cd , a reduction with cd ). (figure ). conclusions: we observed a potential association of evs membrane proteins with cmv reactivation: cd a, cd , cd and cd . these proteins are crucial for endothelium and immune cells interaction. cmv can infect different cell types including endothelial cells (bentz gl. pnas ( ) ). moreover, cd a (pdgfr-α) has been shown to function as an entry receptor for cmv expressing gh/gl/go complex (wu y. et al. plos pathog ( ) ). we plan to implement our analysis characterizing evs contents (mirnas) and will be applied to investigate other viral reactivations (e.g. epstein barr virus and human herpes virus ). [[p image] . methods: to explore the value of cmv dna extracted from gi tissue for the diagnosis of cmv gastroenteritis, we retrospectively evaluated patients, aged - (median . years) who received allo-hct from sibling( ), matched unrelated( ) or haploidentical donors( ), after receiving myeloablative ( ) or reduced intensity conditioning( ). they all underwent endoscopy for gastrointestinal symptoms between - . cmv dna from tissue samples and parallel blood samples were measured by q-pcr. positive cmv dna on the tissue was considered cmv gi infection.cmv gi disease was proven with the identification of cmv inclusion bodies or positive immunehistochemical staining using anti-cmv antibodies. results: overall, endoscopic tests were performed ( gastro-, colonoscopies) at a median of days (iqr: ) post transplantation. symptoms included nausea, vomiting, diarrhea, abdominal pain and weight loss. cmv dna was positive in / tissue samples: median copies/ml, range: - x ^ . only half patients ( / ) had concurrent cmv viremia (plasma viral load> c/ml). cmv gi infection was not correlated to the type of transplant, acute or chronic gvhd. gi cmv disease was documented by biopsy in patients. cmv dna of the tissue, but not the plasma viral load, was a predictor of biopsy positivity (or: . , %ci: . - . , p= . ). thirty-six out of cmv dna positive patients received specific treatment for at least days. symptoms resolved in / patients ( %) and the gi viral load was not a significant factor to predict cure. gi gvhd was diagnosed in / patients, among which %( / ) with cmv dna positivity. median os was days ( %ci: - ) for patients with cmv infection, similar to those without (median os: , %ci: - days, p=ns). we studied separately endoscopies of the upper ( / ) or lower gi tract ( / ) . there was no significant relationship between cmv gastritis proven by biopsy and cmv dna levels in gastric tissue. however, the viral load of the colon was a predictor of cmv enteritis (or: . , %ci: . - , p= . ). the auroc of the q-pcr was . ( %ci: . to ), the sensitivity was . % and the specificity was . % with a cutoff value of copies/ml dna. conclusions: pathognomonic findings in the biopsy remain the gold standard for the diagnosis, especially for the upper gi tract. however, when the lower gi tract is involved, quantification of cmv viral load in the tissue may be a valuable tool to support the diagnosis. positivity of cmv dna of the gi tissue, in linearity to the cmv viremia, may guide to preemptive treatment for prevention of cmv disease . disclosure: nothing to declare background: clostridium difficile infection (cdi) is caused by cd overgrowth in antibiotic-disturbed intestinal microbiota. antibiotics targeting unselectively beneficial for t-regulatory cell formation strains of clostridiales may increase pro-inflammatory processes in the guts promoting or augmenting the development of graft vs. host disease (gvhd). the efficacy of cdi treatment has impact on the persistence of inflammation which might influence the alloreactive reactions. methods: we retrospectively and, from , prospectively analyzed the data from transplant centers concerning cdi occurrence, treatment efficacy, and gvhd development. the study included patients with hematological malignancies who underwent allogeneic hematopoietic cell transplantation (allohct) between - . results: median time to cdi was days post-allohct with detection of both toxins a and b in % of cases. disturbance of intestinal microbiome was confirmed by a % rate of colonization with multidrug-resistant bacteria (mdrb). the cdi symptoms resolved with the negative toxins after the first line treatment in . % of patients. the median time to remission and therapy duration was and days, respectively. fifteen therapeutic failures were observed after treatment with metronidazole ( ), vancomycin ( ) and a combination therapy ( ) . eleven patients responded to second line treatment. thirty-seven ( %) patients died due to infections ( ), relapses ( ) and gvhd/infections ( ). we noted recurrent cdi in cases. eight patients died with active cdi. we observed occurrence or exacerbation of gvhd in ( %) patients following cdi, including cases with gut involvement (gi-gvhd). treatment with metronidazole and failure of the first line therapy increased the development or escalation of gi-gvhd (p= . and p< . , respectively). the duration of cdi exceeding days also had impact on the gi-gvhd incidence (p= . ). conclusions: . patients colonized with mdrb are at high risk of cdi. . high mortality due to infections and/or gvhd in patients with cdi. . due to lower efficacy and harmful immunomodulatory impact, metronidazole should not be the first line treatment in cdi post-hct. . emphasis must be put on fast cdi resolution to interrupt a vicious circle of the intestinal inflammatory processes. disclosure: nothing to declare establishing optimal preemptive cytomegalovirus therapy threshold post allogeneic hct in a patient population with high prevalence of seropositive status background: preemptive therapy (pet) for cytomegalovirus (cmv) reactivation post allogeneic hematopoietic stem cell transplantation (hct) was shown to decrease the incidence of cmv disease. however, the optimal pet threshold is unknown and there are significant toxicities associated with anti-cmv therapy. at our institution, we initiate pet at cmv dna titer above copies/ml ( iu/ml). our aim was to examine the efficacy of this approach including the incidence of spontaneous clearance in a population with high prevalence of cmv seropositive status. methods: after due irb approval, patients that underwent allogeneic hct were identified and records retrospectively extracted.cmv reactivation was defined as the first detectable viral titer post hct from plasma samples whereas clearance of viremia as the first date of two negative pcr values obtained at least week apart. cmv monitoring was initiated post hct performed at least weekly during the first days and every - weeks thereafter. a high sensitivity assay abbott realtime cmv was used with detection threshold of copies/ml ( . iu/ml). analysis was computed using jmp v. . . results: a. baseline characteristics: a total of patients were identified and included with a median follow up of . ( . - . ) months. median age was ( - ) years and % were male. indication for hct was for a malignant disorder in % of cases. the majority had a matched related donor ( %) and cmv igg was positive in both donor and recipient in % of cases. myeloablative conditioning was given to ( %) and ( %) received tbi. in vivo t-cell depletion was given to ( %); atg in ( %) and alemtuzumab in ( %). b. cmv reactivation and pet: a total of ( %) patients had a positive cmv pcr with median days to reactivation post hct of ; ( %) patients had peak cmv titer < copies/ml (low titer) whereas the remaining ( %) had a peak titer ≥ copies/ml (high titer). patients with high titer were more likely to be older (p = . ), have malignant disease (p = . ), haploidentical or unrelated donor (p < . ) and higher incidence of agvhd grade ii-iv (p = . ) as shown in the table. median peak titers for the low and high groups were vs. , respectively (p < . ). ( %) patients with low titers cleared spontaneously with median time to clearance of days ( - ), ( %) received anti cmv therapy and the remaining died with active viremia (range - copies /ml) with active disease. one patient in the high titer group developed cmv disease. -year os and ci-nrm was . % vs. . % (p = . ) and % vs. . % (p = . ) in the low and high titer groups, respectively. conclusions: cmv reactivation was high in this cohort however of low titer viremia in over %. a pet threshold of copies/ml ( iu/ml) appears desirable as it was associated with spontaneous clearance in almost all patients while minimizing treatment related toxicity. validation of these observations is warranted. background: the risk of pneumocystis pneumonia often warrants antifungal prophylaxis for recipients of blood and marrow or solid organ transplantation. however, complications such as myelosuppression, nephrotoxicity, and intolerance with the existing standard, trimethoprim/sulfamethoxazole (tmp/smx), may hinder or interrupt prophylaxis. rezafungin (rzf) is a novel echinocandin in development for prevention of invasive fungal disease caused by candida, aspergillus, and pneumocystis species in blood and marrow transplant patients. rzf has a favorable safety and tolerability profile and a low risk of drug-drug interactions. furthermore, the stability and pharmacokinetics of rzf allow for once-weekly dosing and broad distribution to the lung and other target organs. rzf was shown to prevent in vitro pneumocystis biofilm formation and to reduce the viability of mature biofilms. a previous prophylactic study was conducted using a broader range of rzf doses. in the current study, the efficacy of rzf was evaluated to better understand the minimum doses necessary to prevent pneumocystis growth in a mouse model. methods: c h/hen mice were immunosuppressed (dexamethasone mg/l in acidified drinking water) and then infected intranasally with p. murina ( x / μl). given the slow growth of p. murina, test agents were administered at the same time mice were inoculated to test for prophylactic efficacy. mice received intraperitoneal injections of either vehicle (control/steroid [c/s]), tmp/ smx / mg/kg/ x/week (wk), caspofungin mg/kg once daily, or rzf mg/kg or . mg/kg once daily, x, or x/wk. after a -week dosing period, mice were sacrificed and lung homogenates were processed for analysis to quantify the nuclei (trophic) and asci (cyst) forms of pneumocystis. prophylaxis efficacy was based on reduction of organism burden compared with c/s. nuclei and asci counts were log transformed and analyzed by anova; individual groups were compared by the student-newman-keuls t test. survival rates were compared using graphpad prism v . results: all mice in the rzf groups had significantly reduced nuclei and asci burdens compared with the c/s group, and all but the lowest doses of rzf ( . mg/kg x or x/wk) worked as well as tmp/smx at reducing nuclei levels. similarly, all rzf groups except for the . mg/kg x/wk group showed reductions in asci levels comparable to that of tmp/smx. the survival rates were not statistically different between treatment groups. conclusions: rzf demonstrated potent in vivo efficacy for prophylaxis against pneumocystis in an in vivo mouse infection model at dose regimens much lower than the human equivalent phase regimen. these data support the development of rzf for the prevention of invasive fungal infections including pneumocystis pneumonia. disclosure: melanie t. cushion: research funding (cidara therapeutics) taylor sandison: employee, stockholder (cidara therapeutics) alan ashbaugh: nothing to declare. yuhua ru , , ziling zhu , , yang xu , , suning chen , , xiaowen tang background: immunocompromising period following allogeneic hematopoietic stem cell transplantation (allo-hsct) may allow opportunistic pathogens to thrive and result in fatal complications. epstein-barr virus (ebv) infects more than % of chinese population, and its reactivation after hsct is one of the major concerns due to the increased risk of ebv diseases and post-transplant lymphoproliferative disease. with the development of infection prophylaxis and supportive care after hsct, demographic data on ebv reactivation post-hsct needs to be updated. methods: we retrospectively analyzed the data of patients who received allo-hsct between july and july in the first affiliated hospital of soochow university. quantitative pcr (q-pcr) was used to monitor ebv-dna load in peripheral blood dynamically. ganciclovir (pre-hsct) followed by acyclovir was given as viral prophylaxis. the treatment protocol for ebv reactivation consisted of tapering of immunosuppressive agents, antiviral agents (including ganciclovir and sodium phosphonatel), and rituximab for persistent positive patients. results: totally cases from most of the provinces in china were enrolled (characterized in table ), among whom ebv reactivation developed in recipients. most reactivation events ( . %) occurred in the first year post-hsct, with a peak of . incidence rates per personyears at the second month. besides, more episodes of lateonset reactivation occurred in patients receiving grafts from haploidientical donors ( figure a ) . multivariate analyses revealed that the major impactors of ebv reactivation included atg as gvhd prophylaxis (p< . ), hlamismatched donor (p= . ) and the appearance of chornic gvhd (p= . ). cumulative incidence of ebv reactivation was low ( . %) among patients with no major risk factors, but increased to . %, . % or . % with , , and major risk factors, respectively ( figure b) . there was no statistical difference of overall survival between people with or without ebv reactivation (p= . ). conclusions: we concluded that there are similar ebv reactivation impactors in chinese population compared to literatures, including atg use, hla-mismatched donor and the appearance of chronic gvhd. additionally, incidences of ebv reactivation increased significantly with the accumulation of risk factors. however, ebv reactivation had no impact on overall survival in current virus management protocol. disclosure: nothing to declare background: several studies have shown loss of diversity of the gut microbiome in association with significant gut injury following hematopoietic stem cell transplantation (hsct). prolonged broad spectrum antibiotic use further promotes loss of microbiome diversity and increases the risk of intestinal colonization by multi-drug-resistant (mdr) bacteria. aims of this study were to prospectively evaluate the overall changes in gut microbiome composition after hsct and differences in patients colonized by mdr bacteria and treated with carbapenems. methods: we performed a prospective observational study evaluating the gut microbiota of hematological patients undergoing hsct, from admission (t ) through day + (t ). fecal microbiota was assessed by s amplicon-based sequencing. clinical, and microbiological data as well as fecal samples were collected every th day from admission. results: one-hundred fecal samples were analyzed. overall, we found a progressive decrease of bacterial richness from t to t , with a significant reduction of blautia, ruminococcus and dorea species, which are strictly associated with the production of short chain fatty acids (sca) (fig. ) . moreover, in the % (no. ) of patients who were colonized by esbl bacteria, we observed a significant reduction of clostridium spp and bifidobacterium species. as for antibiotic therapies, carbapenems were used as second line treatment of febrile neutropenia in % (no ) of cases, usually associated with aminoglycosides. in patients treated with meropenem, a strong decline of blautia and ruminococcus species was observed. this finding suggests a correlation between carbapenem regimens and increase of pro-inflammatory bacterial strains in the gut. conclusions: our data support the hypothesis that loss of intestinal commensals that produce short-chain fatty acids may increase dysbiosis. moreover, for the first time we report significant and progressive alterations in the composition of blautia, ruminococcus and bifidobacterium species in patients treated with meropenem and colonized by esbl bacteria, respectively. our findings offer potential modifiable targets to reduce risk of colonization by mdr bacteria and to promote a carbapenem-sparing approach in the hsct setting. clinical background: cmv is associated with significant morbidity after allogeneic hematopoietic stem cell transplantation. strategies to prevent cmv-related complications include universal prophylaxis and preemptive therapy, more widely spread. antivirals used for cmv reactivation (cmv-r) produces major toxicities and costs. rate and characterization of cmv-r after haploidentical transplantation with post-transplant cyclophosphamide (haplo pt-cy) is scarce. our goal was to analyze cmv-r rate after haplo pt-cy, outcome, complications associated to therapy, and to identify risk factors. methods: one hundred haplo pt-cy transplants using peripheral blood as stem cell source performed between and in our center have been retrospectively reviewed. gvhd prophylaxis consisted of pt-cy mg/ kg/day on days + and + , mmf and csa from day + for all cases. cmv pcr was performed in a biweekly basis during admission for transplant and treatment, and weekly thereafter. cmv-r was considered with any cmv dna level by pcr assay above copies/ml. prior four consecutive negative weekly pcrs were needed to consider a new reactivation episode. preemptive strategy was applied in all cases. data collected in relation to cmv-r included: cmv serostatus of donor/recipient (d/r), number of cmv reactivations, length of each reactivation, antiviral treatment used, need for admission to receive treatment and adverse events related to cmv reactivation and/or antiviral treatment. results: patients characteristics are summarized in table . among patients, of them with positive cmv serology, episodes of cmv-r were detected. seventysix patients ( %) had at least one cmv-r in a median of days after transplant. none of them had cmv disease or die as a consequence of cmv-r. median duration was days ( - ). valganciclovir or ganciclovir was used in episodes ( %). foscarnet was used in episodes ( %). six of the episodes occurred after initial discharge, and required re-admission for treatment, with a median length of hospitalization of days ( - ). cytopenias requiring transfusion or g-csf support occurred in episodes ( %) treated with ganciclovir or valganciclovir. three of them needed further cd + cells booster for graft rescue. mild acute renal failure and genital ulcers were found in ( %) and ( , %) events treated with foscarnet, respectively. no cases of severe renal failure were observed. serological status different than negative/negative (n/n) (p . ) and older age ( vs years, p . ) were significantly associated with cmv-r. no relationship was observed with gender, disease, donor relationship, conditioning, gvhd or cells infused. more than reactivations were more frequent among patients with grade ii-iv acute gvhd (agvhd) and moderate-severe chronic gvhd (cgvhd). conclusions: in our experience, rate of cmv-r after unmanipulated haplo pt-cy, using pbsc as stem cell source, is considerably high. a significant proportion of patients presented complications associated with cmv-r and its treatment. cmv serological status other than n/n and older age are associated with high risk of cmv-r. patients with grade ii-iv agvhd are at higher risk of multiple reactivations. this population could be benefited from primary prophylaxis, in order to decrease treatment´s complications, re-admissions and costs. disclosure: nothing to declare. impact of infectious events occurring during the first hundred days after hsct for hematological malignancy: a monocentric retrospective study over a five-year period marie-pierre ledoux , célestine simand , , karin bilger , annegret laplace , bruno lioure background: patients undergoing hematopoietic stem cells transplantation (hsct) for hematological malignancy often present with infectious events in the early stages of the procedure, some of which having a documented impact on the outcome of the graft. for instance, cytomegalovirus (cmv) has been shown by some authors to have a protecting effect against relapse, whose features remain to be elucidated. we conducted a retrospective monocentric study regarding the outcome in terms of graft versus host (gvhd), relapse and survival of consecutive patients over a period of years, whether they presented or not with an infectious event by day among the following: cmv viremia, epstein-barr virus (ebv) viremia, human herpes virus (hhv ) viremia, bk virus (bkv) viruria, bacterial bloodstream infection (bsi) or invasive fungal infection. results: a high proportion of cmv seropositive recipients underwent a viral reactivation of cmv by day of the hsct: % if the donor is seronegative and % if the donor is seropositive. we observed that cmv wasn't associated with a lower relapse rate in our cohort, and data weren't sufficient to conclude firmly, but showed a trend towards a worse acute gvhd (hazard ratio hr . , pvalue . ). no significant correlation was found for ebv viremia. occurring in % of our patients and mostly with an early timing, hhv strongly correlated with worse acute gvhd (hr . , p-value < . ) but its impact on survival was not significant. bkv ( % of our patients) and bsi ( % of our patients) both correlated with poorer outcome in terms of overall survival (logrank < . and . respectively) although not significantly associated with relapse or acute gvhd. fungal infections were too rare events to draw any conclusion. conclusions: thus, contrary to many studies, we found no protection against relapse induced by cmv, although the trend for worse acute gvhd was obvious. the mechanisms behind this discordance could include early treatment, but remain to be studied. whether hhv is a cause rather than a consequence of acute gvhd or its treatment is debated, but the correlation is strong and the sequence of events suggests hhv might act as a trigger for gvhd. the association between bkv viruria and a higher mortality is in contrast with previous observations, and the lack for association with gvhd and relapse could suggest bkv is a surrogate for poor immune recovery and therefore other causes of non-relapse mortality. in addition to the direct lethal risk of bacteriemia, bsi also are a promoter of late non-relapse mortality through indirect toxicity. through the expansion of immune effectors they promote, one could assume that infectious events play a role in gvhd and gvl, and therefore have an interference with relapse. however, the association between each infectious event and outcome remains to be clarified to guide our prophylactic and therapeutic choices by a better understanding of the bright and dark sides of infectious events. disclosure background: rezafungin (rzf) is a novel echinocandin in phase development for treatment of candidaemia and invasive candidiasis and for antifungal prophylaxis against invasive fungal diseases caused by candida, aspergillus, and pneumocystis in blood and marrow transplant patients. rzf is differentiated by stable, prolonged pharmacokinetics (pk) that allow for once-weekly dosing and a pk-pharmacodynamic (pd) profile correlating with efficacy. clinical in vivo evaluations of drug interaction potential were performed proactively to assess the risk of drug-drug interactions (ddis) with respect to the phase dose of mg once weekly and known pk exposure in healthy individuals. methods: this open-label study of healthy inpatients assessed ddis between rzf (as perpetrator) and drugs known to have interactions with cyp enzymes and transporters (probe drugs): repaglinide (cyp c ), metformin (oct/mate), rosuvastatin (bcrp/oatp), pitavastatin (oatp), caffeine (cyp a ), efavirenz (cyp b ), midazolam (cyp a ), and digoxin (p-gp), as well as tacrolimus, a drug likely to be coadministered with rzf. an initial dose of rzf mg was administered on the first dosing day, to approximate a steady state plasma concentration of multiple once-weekly -mg doses, followed by once-weekly -mg doses on days and . probe drug cocktails containing ≥ drugs were administered, once before and once after rzf administration, on a schedule designed to allow for washout between doses and to limit interactions with other probe and test drugs. samples were analysed to determine respective drug concentrations in plasma (except for tacrolimus which was in whole blood) to characterize the pk profile of each analyte. area under curve (auc) and maximum concentration (c max ) were calculated from the plasma/blood concentration-time profiles by noncompartmental analysis. ln-transformed pk parameters were statistically analysed using an analysis of variance model. the ratio of geometric least squared means between each substrate drug when administered with and without rzf and corresponding % confidence intervals (cis) were calculated for lntransformed c max and auc. results: when rzf was given concomitantly with the probe drugs, six of nine substrates (metformin, pitavastatin, caffeine, efavirenz, midazolam, and digoxin) statistically demonstrated the absence of drug-drug interaction, as their % ci were all included within the default - % noeffect boundary. three substrates had the upper (repaglinide and rosuvastatin) or lower (tacrolimus) bounds of their ci falling just outside of this range (figure ), and these changes are considered unlikely to be clinically significant. conclusions: no meaningful pk interactions were observed between rzf and drugs known to have ddis and/or likely to be coadministered with rzf. these findings provide evidence that no dose adjustment is expected when rzf is co-administered with these commonly used drugs, which stand in contrast with the ddi complications widely associated with azole antifungals. disclosure: voon ong: employee, stockholder (cidara therapeutics), michael boily: employee (altasciences), hong wong: employee (altasciences), taylor sandison: employee, stockholder (cidara therapeutics), shawn flanagan: employee, stockholder (cidara therapeutics) abstract withdrawn. background: cytomegalovirus (cmv) continues to cause morbidity following allogeneic hematopoietic stem cell transplantation (hsct). letermovir is a newly approved drug for cmv prophylaxis in cmv-seropositive allogeneic hsct recipients. however, there is a paucity of data for its efficacy in patients receiving in-vivo t-cell depletion (tcd). at weill cornell medical center, we perform in-vivo tcd with alemtuzumab for related and hla-identical unrelated transplants, and anti-thymocyte globulin for umbilical cord blood transplant supported by third party accessory cells (haplo-cord transplant).although these drugs reduce the frequency of graft-versus-host-disease (gvhd), they significantly delay t-cell immune reconstitution post hsct, and may cause higher rates of cmv reactivation. our historical rate of cmv reactivation in cmv seropositive recipients receiving high dose valacyclovir prophylaxis is approximately %. therefore, we implemented letermovir for cmv prophylaxis in february . the primary aim of this study is to determine the incidence of cmv infection (defined as cmv viremia warranting treatment or development of end-organ disease) in tcd cmv seropositive allogeneic hsct patients who received letermovir prophylaxis. methods: this is a single center, retrospective cohort study to determine the incidence of cmv infection in adult, cmv-seropositive recipients receiving letermovir prophylaxis after in vivo tcd hsct with atg or alemtuzumab for gvhd prophylaxis. all included subjects were at least days post-transplant. results: allogeneic hsct transplant recipients met inclusion criteria. median age was years, iqr [ , ] and % were male. eight ( %) had a matched related donor, six ( %) had a matched unrelated donor, and ( %) were haplo-cord transplants. their underlying malignancy and conditioning regimens are summarized in table . ( %) received atg and ( %) received alemtuzumab for gvhd prophylaxis. median follow up time for survivors is days, iqr [ , ] . the incidence of cmv infection in the first days post-transplant was % as only one patient reactivated with detectable cmv viremia. this same patient developed cmv pneumonitis with documented ul resistance, and was successfully treated with ganciclovir. the incidence of cmv infection within the first days post-transplant was % ( / patients) . six patients ( %) developed acute gvhd in the first days, and one ( %) had relapse of their malignancy. five patients ( %) died within days post-transplant, but none of these deaths were cmv related. background: infectious complications caused by endogenous adenovirus (adv) are common and associated with morbidity and mortality rates in patients after hematopoietic stem cell transplantation (hsct). adv infections occur in about % to % of hsct recipients, with significantly higher rates in pediatric patients. a better understanding of adenoviral-specific t-cells (advt) response in donors can serve as a basis to develop more effective strategies for antiviral therapy. methods: frequencies of cytomegalovirus (cmv)-and adv-specific t cells were determined by enzyme-linked immunospot (elispot) assays with adv hexon and cmvpp respectively in health donors. we used x of mononuclear cells (mnc) per well in elispot assays. all donors were divided into groups according to the number of spots per well (spw) as follows: high responders (hr) (≥ spots; n= ), low responders (lr) (> and < spots; n= ), nonresponders (nr) (≤ spots; n= ). the average spot area of adv-and cmv-specific lymphocytes was calculated by immunospot® multiplate autocount™. cd ra+ and cd ro+ t-cells were generated by immunomagnetic negative selection. hla typing for class i and ii was performed by sequence specific oligonucleotides technology. statistical analysis was performed using graphpad prism v . software. levels of significance were calculated by mann-whitney rank-sum test, expressed as p-values (p< . ). results: the median frequency per well of advts were in hr group, in lr group, in nr group. the median spw of cmv-specific t cells in donors mnc were and didn´t differ between groups. antiviral activity may depend not only on the amount of advt but also on their ability to produce ifnγ. the average spot area for advt did not differ between hr, lr and nr groups and were , , , and , mm respectively. the median of the average spot area for anti-cmv t-lymphocytes was equal to , mm . thus, the frequency of advt was lower than cmv-specific t-cells, but advt have the ability to produce more ifnγ per cell (p< . ). in order to evaluate the distribution of the advt between naive and memory t cell compartments, we evaluated response to adv in preselected cd ra+ and cd ro+ fractions of t-cells in a group of donors. the median frequency of advt in unfractionated mnc was ; the median frequency of advt in cd ra and cd ro fractions were and , respectively. the amounts of cd ra and cd ro tcells were normalized to their amounts in mnc. we evaluated the impact of hla-alleles on the anti-adv response of t-cells in different groups and found association: hla-a* with hr group (p-value= , ; rr= , ; % ci: , to , ) and hla-a* with lr group ; rr= , ; % ci: , to , ) . conclusions: in this study the frequency of donors with advt is , % which corresponds to the reported frequency of adv-seropositive people ( %) in population of russia. advt are exclusively cd ro-positive cells. the analysis of advt in potential hsct donors will allow to determine more accurately the amounts and functional activity of specific antiviral t-lymphocytes administered to patient and optimize antiviral therapy. disclosure: nothing to declare p abstract withdrawn. chemotaxis and exhaustion of γδ t cells in the allografts are associated with cmv reactivation after hematopoietic transplantation background: cytomegalovirus (cmv) reactivation and its related diseases remain the most common and serious complications in patients who underwentallogeneic hematopoietic stem cell transplantation (allohsct). we previously reported that the incidences of total and refractory cmv reactivation reached approximately % and % after haploidentical hsct. while majority of studies in the literatures focused on the adaptive cd + αβ t cellsand nk cells in anti-cmv immunity, increasing evidences highlighted the important role of γδt cells in this context. a progressive and prolonged expansion of vδ + t cells in response to cmv reactivation was observed after allohsct. the effect of vδ + t cells associated with cmv clearance has been reported in vitro and in vivo. in contrast to the reconstituted γδt cells post transplantation, whether the phenotypes of γδt subsets in allografts correlate to cmv reactivation in hsct recipients have not been documented. methods: the proportions and phenotypes of γδ t cells were detected inallografts those were unmanipulated g-csf-mobilized bone marrow (bm) and peripheral blood (pb) harvests from donors for haplohsct. bm grafts were collected by aspiration on the fourth day of g-csf treatment (filgrastim, μg/kg/day), and pb grafts were obtained on the fifth day by leukapheresis. immunophenotyping for γδ t-cell subpopulations, including the expression of cd , cd , cd , tcrγδ, tcrvδ , tcrvδ , hla-dr, nkg d, cxcr , ccr , pd , ki , ifnγ, tnfα, and il- , was performed using flow cytometry. for detection of the intracellular cytokines, bm and pb grafts were pre-stimulated with x cell stimulation cocktail ( x, ebioscience). cmv dna in the peripheral blood of recipients was routinely monitored by quantitative pcr. the association of γδ t-cell contents in allografts with cmv reactivation in haplohsct recipients was analyzed using the mann-whitney u test and spearman test. all calculations were performed using spss . statistical software. results: we found that the proportions of total γδ t cells, and vδ and vδ subsets in both bm and pb grafts for cmv+ and cmv-recipients were comparable. neither the expression of hla-dr nor nkg d in the allografts were significantly different in correlation to cmv reactivation after hsct. the productions of intracellular cytokines of γδ t subsets did not varied in bm and pb grafts for cmv+ and cmv-recipients. interestingly, the proportions of cxcr +vδ and ccr +vδ cells in bm grafts for cmv + recipients were significantly higher than those for cmvrecipients (p = . and . , respectively). meanwhile, pma-stimulated ki +vδ cells in bm grafts for cmv+ recipients were less than those for cmv-recipients (p = . ). in parallel, the concentration of pd +vδ cells in pb grafts for cmv+ recipients were significantly higher than those for cmv-recipients (p = . ). conclusions: this study is the first to connect the chemotaxis and exhaustion of γδ t cells in grafts to the risk of cmv infection after allogeneic hsct. future studies should explore how the expressions of chemokines and exhaustion marker on the effector γδ t cells in allografts facilitate cmv replication and/or dissemination in the setting of hematopoietic transplantation. disclosure: all authors do not have conflicts of interest. this study is supported by the national natural science foundation of china (grants no. and no. ) results: incidence of ic was , %: allo-hsct - % (n= ), auto-hsct - , % (n= ). the etiology: c. parapsilosis %, c. albicans %, c. krusei %, candida tropicalis %, candida dubliniensis %. the most frequent underlying diseases was acute leukemia - % (n= ). the median age was y.o. [ month - years] . the median day of onset of ic after allo-hsct was , auto-hsct - [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . febrile fever was the main clinical symptom; septic syndrome develops in % cases. antifungal therapy was with echinocandins - %, lipid ampho b - %, azoles (fluconazole, voriconazole) - %, without therapy (the early mortality) - %. overall survival (os) at days from diagnosis of invasive candidiasis was %. the central venous catheter (cvc) removal was the only factor significantly improved os ( % vs %, p= , ). conclusions: incidence of invasive candidiasis in children after hematopoietic stem cell transplantation was . %. the main etiology agent was c. parapsilosis. invasive candidiasis infections most often affect leukemia patients, developed later after allo-hsct than auto-hsct. overall survival at days from the diagnosis was %. removing of cvc improved overall survival in children with invasive candida infections after hsct. disclosure: nothing to declare background: graft versus host disease (gvhd) and virusassociated enteropathy in allogeneic hematopoietic stem cell transplantation (allo-hsct) may cause severe quantitative and qualitative composition changes of intestinal microbiota, leading to the development of small intestinal bacterial overgrowth (sibo) on the background of immunodeficiency, which can have a negative impact on treatment effectiveness. the gold standard for diagnosis and the main criterion for sibo is the detection in the jejunum aspirate > /ml bacteria and/or the appearance of colonlike microbiota in small intestine. it is also acceptable to use an alternative non-invasive technique -hydrogen breath test, which could be especially important in patients with severe mucositis, grade iii-iv and thrombocytopenia grade iv. sibo diagnosis in the setting of the gastrointestinal tract damage and dysfunction in patients treated with allo-hsct is insufficiently studied. methods: the study included patients with acute myeloid leukemia (n= ), acute lymphoblastic leukemia (n= ), myelodysplastic syndrome (n= ), non-hodgkin´s lymphoma (n= ), hurler syndrome (n= ), who underwent allo-hsct from an unrelated (n= ) and haploidentical donor (n= ) , and which were complicated by enteropathy development. in cases, the enteropathy reason was a combination of intestinal gvhd and viral colitis (hhv- ), in cases -viral colitis (hhv- ). all patients had esophagogastroduodenoscopy with species aspiration from descending part of the duodenum and feces collection, with further bacteria pcr identification. hydrogen breath test was performed also in which patients were treated with oral lactose g/kg with subsequent hydrogen assessment after and minutes. the study was performed in the period from to days after allo-hsct. results: according to feces analysis data, colon microbiota composition significantly differed from the reference values. at the same time total bacterial mass of the duodenum was less in comparison with colon microbiota: e+ ( e+ / e+ ) and e+ ( e+ / e+ ), respectively (p< . ). quantitative composition of the duodenal microbiota was comparable to that of colon: lactobacillus spp. e+ ( e+ / e+ ) > . e+ ( e+ / e+ ), (p= . ); bifidobacterium spp. e+ ( e+ / e+ ) < . e+ ( e+ / e+ ), (p= . ); escherichia coli e+ ( e+ / e+ ) > e+ ( e+ / e+ ), (p= . ); bacteroides fragilis group e+ ( e+ / e+ ) > e+ ( e+ / e + ), (p= . ); faecalibacterium prausnitzii e+ ( e+ / e+ ) < . e+ ( e+ / e+ ), (p= . ), indicating the presence of sibo. in this case, the hydrogen breath test was completely uninformative: basal values - . ( . / . ) ppm, hydrogen concentration in minutes - . ( . / . ) ppm, in minutes - . ( . / . ) ppm, which is less than in healthy volunteers. conclusions: quantitative composition of the duodenal and colon microbiota is similar in the case of intestinal gvhd and/or virus-associated enteropathy in allo-hsct patients, which may be of diagnostic value for sibo confirmation. the hydrogen breath test is an uninformative method for sibo identification in patients after allo-hsct. disclosure: nothing to declare johannes schulte , patrick hundsdörfer , sebastian voigt background: adenovirus (adv) infections or reactivations frequently occur in the pediatric hematopoietic stem cell transplant (sct) setting and these infections contribute to increased morbidity and mortality. the nucleotide analog cidofovir might be effective in reducing adv load, however, nephrotoxicity is a considerable side effect. the new antiviral compound brincidofovir (bcv, cmx- ), a lipid-conjugate nucleotide analog with broad-spectrum antiviral activity in vitro, has been reported to be effective in cases where cidofovir treatment was unsuccessful. methods: data of eight pediatric patients undergoing sct for malignant and nonmalignant indications were analyzed. all patients were weekly monitored for adv viremia by pcr. in case two consecutive positive adv pcr results indicating a viral copy number > /ml were documented, patients received a weekly dose of cidofovir. if no reduction of adv load was seen within two weeks after the commencement of treatment or side effects demanded cidofovir discontinuation, bcv was obtained through an emergency expanded access programme. results: eight pediatric patients developed adv viremia with maximum viral loads ranging between and copies/ml. six patients had c type adv and two patients had non c type adv infections. five patients had viral co-infections: two had an additional cmv infection, one had an epstein-barr virus (ebv) and herpes simplex virus co-infection, one patient had an ebv co-infection and one patient had a bk virus co-infection. all eight patients initially received cidofovir, however, a substantial decrease in adv load could not be observed in any patient after a two-week administration course. except in one patient who had extensive intestinal graft-versus host disease (gvhd), adv infection was cleared in all patients within three weeks after the beginning of bcv treatment. in addition, all coinfections were cleared. no nephrotoxicity or other side effects were observed. conclusions: bcv was effective in all but one patient. oral bcv might not be effective in advanced upper gut gvhd, especially when applied via a gastric tube, yet this was observed in only one patient. eventually, without nephrotoxic side effects, bcv could be an useful alternative to cidofovir. disclosure: nothing to declare. background: the use of post-transplant high-dose cyclophosphamide (ptcy) has overcome the need for extensive depletion of t lymphocytes from haploidentical donor grafts, which traditionally resulted in severe and prolonged immunosuppression. however, reconstitution of cellular immunity may be delayed even after t cell replete haploidentical stem cell transplantation (haplo-sct) with ptcy. the study of the incidence and severity of viral reactivation is therefore relevant to the outcomes of haplo-sct with ptcy. methods: our study enrolled patients (women/men, / ), who underwent t cell replete haplo-sct from / to / and achieved hematopoietic engraftment. median age at transplant was . years (range, - ) . the underlying disease was aml (n= ), all (n= ), mds (n= ), myelofibrosis (n= ), cml (n= ), or cll (n= ). the conditioning regimen was myeloablative (n= ), reduced-intensity (n= ) or non-myeloablative (n= ). peripheral blood was the graft source in the majority of cases (n= ) and bone marrow in the remaining (n= ). recipient/donor cytomegalovirus (cmv) serostatus was -/-(n= ), -/+ (n= ), +/-(n= ), or +/+ (n= ). the combination of tacrolimus and mycophenolate mofetil was administered in addition to ptcy for prevention of graftversus-host disease. cmv, epstein-barr virus (ebv), and human herpesvirus- (hhv- ) reactivation was monitored by real-time quantitative pcr (rq-pcr) in blood twice weekly post haplo-sct. bk virus (bkv) reactivation was assessed by rq-pcr in urine and/or blood specimens in cases with symptoms suggestive of bkv-associated hemorrhagic cystitis (hc). results: with a median follow-up time of months (range, , the cumulative incidences (cin) of relapse and non-relapse mortality (nrm) were . % ( % ci, . - . %) and . % ( % ci, . - . %) at years, respectively. median disease-free (dfs) and overall survival (os) were . % ( % ci, . - . %) and . % ( % ci, . - . %) at years, respectively. the cin of cmv reactivation/infection (> copies/ml) reached . % ( % ci, . - . %) at months. cmv infection developed in out of patients who were at risk, whereas recurrent cmv reactivation was observed in patients with a median number of episodes (range, - ) per patient. the median total duration of antiviral therapy for cmv infection was days (range, - ) . cmv disease (pneumonia) was documented in patients. the cin of ebv reactivation (> , copies/ml) was . % ( % ci, . - . %) at months. no case of ebv-related post-transplant lymphoproliferative disorder was observed, however preemptive therapy with rituximab was required in patients with rapidly increasing ebv viral load. hhv- reactivation (> , copies/ml) was observed in patients (cin, . % at months; % ci, . - . %), with none of them requiring specific therapy. bkv-related hc occurred at a cin of . % ( % ci, . - . %) at months. cystoscopy for bladder hemostasis was required in / and nephrostomy in / patients with hc. conclusions: despite preservation of non-alloreactive memory t cells, haplo-sct with ptcy is associated with substantial rates of viral reactivation (especially cmv and bkv) resulting in the need for prolonged antiviral therapy and considerable morbidity as well. therefore, strategies to prevent viral reactivation and disease are still warranted in haploidentical stem cell transplantation. disclosure: nothing to declare. background: adenovirus(adv) infections are a wellrecognised cause of morbidity and mortality in children and adults receiving an allogenic stem cell transplant(hsct).the reported incidence of adv infection is higher( %- %) in paediatric hsct than in adults( - %),but we currently lack accurate data of adv infection burden among adults.cidofovir has been extensively used as a pre-emptive anti-adenoviral therapy and is current standard of care.we present our single centre experience of adv incidence and outcomes with pre-emptive approach in adult patients receiving t-cell depleted(tcd) hscts for myeloid disorders. methods: this is a single-centre retrospective analysis of consecutive hsct patients for myeloid disorders including aml, mds, mpn & aplastic anaemia between january -june using atg or alemtuzumab based tcd.adv screening was performed in all patients with standardised real time quantitative pcr on weekly basis during standard risk period. figure a - b] results: baseline characteristics (table ) of patients were similar across both cohorts with or without adv infection. overall . %(n- / ) patients were positive for adv dna on atleast one of the sanctuary sites(upper respiratory airway,blood,faeces,urine) and %(n- / ) of these experienced disseminated infection(defined by adv in ≥ sanctuary sites or rising adv dna copies in blood), while developed typical adenoviral disease (pulmonary). among patients with disseminated infection,majority had adv in gastro-intestinal( %), . % in genitourinary and % as both sanctuary site of infection,in addition to blood viraemia( % of all cases).cumulative incidence of adv infection was . %( %ci: . - . %) at months with median time of days(iqr: - days) to detect adv-dna post hsct.overall survival(os) at years for whole cohort was %( %ci: - ;median os- months) with no statistical difference between patients with disseminated adv infection vs those with none(log rank; p- . ; fig- a ). overall cumulative incidence of non-relapse mortality (nrm) was %( %ci: - %) and relapse(cir) was . %( %ci: - %) at years,but no statistical difference noted between patients with disseminated adv infection & those with none(nrm:p- . ;cir: p- . ;gray test).pre-emptive therapy with cidofovir ( mg/kg weekly iv infusion for weeks and fortnightly thereafter until infection free) was required in %( / ) of symptomatic adv infection patients and %( / ) with disseminated infections.one patient required brincidofovir therapy for refractory disease,but one patient died due to severe sepsis, before adv specific therapy could be given.remaining patients were monitored and all self-recovered on cessation of immunosuppression.all patients treated with cidofovir developed renal impairment(defined by atleast > % increase in baseline creatinine),however majority( %) recovered their renal function near their baseline (fig- b) . conclusions: adv infection remains a significant cause of morbidity in adult hsct patients, however pre-emptive management with cidofovir has improved os and nrm despite use of tcd conditioning.renal toxicity remains common with cidofovir but with use of intermediate doses, majority do recover their renal functions. clinical trial registry: n/a disclosure: nothing to declare background: publications on invasive fungal disease (ifd) in lymphoma patients are limited especially after allo-hsct. there are no data on outcome of allo-hsct in lymphoma patients with prior ifd. this study focuses on epidemiology of ifd before and after allo-hsct in children and adults with hodgkin's lymphoma (hl). methods: single center prospective study included patients with classical r/r hl who received allo-hsct from to . the median age was ( - ) y.o., children (< yo) - %. allo-hsct from mud was performed in , % (n= ), mrd - , % (n= ), mmud - , % (n= ), haplo - , % (n= ), with ric ( %) and predominantly ptcy-based gvhd prophylaxis ( %). primary antifungal prophylaxis was fluconazole in %, secondary -voriconazole ( %). eortc/msg criteria for diagnosis and bronchoscopy before allo-hsct in pts with ct-scan lung lesions were used. "active ifd" means ifd diagnosed just before hsct. median follow-up time was months . results: incidence of ifd before allo-hsct was , % (n= ). ifd prior to hsct were invasive aspergillosis (ia) with lungs involvement. antifungal therapy before allo-hsct was used in , % pts with median duration - months. complete response to antifungal therapy was in , % pts, partial response or stabilization - , %, and , % pts had an "active ifd". after allo-hsct all pts received voriconazole as an antifungal therapy or secondary prophylaxis. cumulative incidence of relapse or progression of ia after allo-hsct was , % with the median day after hsct, which were successfully treated with voriconazole in post hsct period. incidence of ifd after allo-hsct for naïve patients was , % (n= / ). etiology of ifd after allo-hsct was ia - %, invasive candidiasis (ic) - %, mucormycosis - % and % combined ifd caused by aspergillus fumigatus + rhizopus stolonifer. the median day of onset of ifd after allo-hsct was day+ and was associated with post-hsct relapse of hl (p= , ). the main site of infection were lungs ( %), the main clinical symptom -febrile fever ( %). antifungal therapy was used in all patients: voriconazole - %, micafungin - %, posaconazole - %, lipid amphotericin b - % and combination lipid amphotericin b with caspofungin - %. overall survival (os) at weeks from the diagnosis of ifd after allo-hsct was %. the -year os in children and adult with hl after allo-hsct was , %. development of ifd after allo-hsct do not decrease the -year os rate ( , % vs %, p= , ). the impact of prior ifd on -year os in allo-hsct recipients was not statistically significant in all group ( , % vs , %, p= , ) , and separately in children and adults. conclusions: incidence of ifd in children and adults with hodgkin's lymphoma before allo-hsct was , %. incidence of ifd after allo-hsct in patients with hodgkin's lymphoma was , %. the major etiology agents as before as after allo-hsct were aspergillus spp. ifd was a late complication after allo-hsct and associated with post-hsct relapse. despite the high incidence ifd before or after allo-hsct didn't influence the outcome in children and adults with hodgkin lymphoma. disclosure: nothing to declare our community has high cmv positive serostatus, which is a known risk for cmv infection or reactivation. we conducted a study to explore the incidence and outcome of cmv infection among post-hsct children. methods: medical records of pediatric patients (age ≤ years) undergoing single allogeneic hsct from january to december , at king faisal specialist hospital and research centre, riyadh, saudi arabia, were reviewed. all patients with active cmv infection or disease before and during transplant were excluded. a total of patients were included in the study; were female. median age at hsct was years. recipient cmv serostatus was positive in patients before hsct, and donors were cmvpositive. the recipient-donor (r/d) serology was . % r +/d+, . % r+/d-, . % r-/d+, and . % r-/d-. indication for hsct was immune disorders . %, hemoglobinopathies . %, bone marrow failure . %, malignant disorders . %, histiocytic . %, and metabolic disorders . %. source of stem cells was bone marrow in , cord blood in and peripheral blood stem cell in cases. donor was matched related among , unrelated matched/mismatched in , haploidentical , and related with -antigen mismatch in . total body irradiation (tbi) based conditioning was used for patients, while atg was used in patients. results: out of a total of patients, patients developed cmv infection post-hsct ( . %). incidence in female recipients was high ( . % versus . %, p-value . ). both recipient and donor cmv serology positive ( . %) developed cmv infection (p-value < . ). however, no cmv infection in both recipient and donor negative group (r-/d-). the incidence of cmv infection post-hsct was high in patients received tbi based conditioning ( out of , . %, p-value . ), and in haploidentical transplant with . % (p-value . ). source of stem cells, myeloablative versus nonmyeloablative conditioning, atg use in conditioning and agvhd, did not exhibit significant association with cmv infection. in multivariable setting, when adjusted for primary indication for transplant, donor hla type, tbi based conditioning and recipient and donor cmv serology at transplant, haploidentical donor (odds ratio: . , p-value: . ) and donor-recipient cmv sero-positivity (odds ratio: . , p-value: . ) were found to be significant risk factors. cmv infection resolution rate was . % ( ). with a median follow-up time of . ± . months from infusion, five-year overall survival of cmv infected group was lower ( . ± . ) as compared to non-cmv infected ( . ± . , p-value: . ). conclusions: incidence of cmv infection post-hsct in our center is comparable to other centers. our data suggest that donor-recipient cmv positive serostatus, haploidentical donor, and use of tbi based conditioning necessitate close attention and surveillance. background: toxoplasmosis is a rare and underestimated complication following allogeneic stem cell transplantation (allo-sct) with an often fatal course. this is in part due to limited diagnostics relying mainly on imaging and detection of parasite dna by pcr. we present here eleven cases of toxoplasma disease following allo-sct. methods: we retrospectively analyzed consecutive adult patients who received an allo-sct in our bone marrow transplant unit between july and july . eleven ( %) of these patients were diagnosed of toxoplasma disease. the main characteristics of the patients are shown in table . all patients, except two cord blood, have received peripheral blood stem cells. fludarabine-based conditioning regimes were used in all patients. only the two cord blood patients received thymoglobulin in the conditioning. graft-versus-host disease (gvhd) prophylaxis consisted on tacrolimus plus mycophenolate mofetil in ( %) patients and post-transplant cyclophosphamide followed by tacrolimus in ( %). before the allo-sct was performed the igg/igm toxoplasma serology of the recipient and donor. we reviewed the absolute lymphocyte count (alc) and cd + lymphocyte count within four weeks prior to the diagnosis of toxoplasmosis, and if the patients took effective primary prophylaxis for this parasite. toxoplasma disease was defined as the presence of toxoplasma infection plus clinical, radiological or pathological evidence. toxoplasma disease was considered the main cause of death when no other major life-threatening infection or other potential fatal complication occurred immediately before death. results: median (range) age (years) of the eleven patients diagnosed with toxoplasma disease was ( - ). for pancytopenia, no patient received trimethoprimsufmethoxazole (tmp-smz) but pentamidine for pneumocystis jirovecii-pneumonia (pcp) prophylaxis in cases and atovaquone in one. toxoplasma serology pretransplant was positive (igg+/igm-) in ten of the eleven patients. all donors were seronegative (igg-/igm-) except two. toxoplasmosis was diagnosed a median (range) of days ( - ) post allo-stc. the clinical presentations were as cerebral-encephalitis (n= ), chorioretinitis (n= ), pneumonitis (n= ) and disseminated toxoplasmosis (n= ). one case, patient and donor seronegative pre-transplant, was presented as a primary infection in form of chorioretinitis. all three patients with chorioretinitis were diagnosed after day + of allo-sct. at the time of toxoplasma disease, of ( %) of patients had an alc < cells/μl and all of them with immunosuppressive therapy and corticosteroids for acute or chronic gvhd. we had cd + lymphocyte count only in four patients and in three of them was < cells/μl. eight of the eleven ( %) patients died, with a median (range) of days ( - ) since diagnosis of toxoplasmosis, and in of them the toxoplasma disease was the main cause of death. conclusions: in our series, the incidence of toxoplasma disease after allo-sct is low and is related to high mortality, in accordance with what has been reported by other groups. positive pre-transplant serology and gvhd and its treatment were factors strongly related with toxoplasmosis. we encourage the use of tmp-smz instead of pentamidine for pcp-pneumonia prophylaxis in patients seropositive for toxoplasma gondii pre-transplant. clinical trial registry: data about its epidemiology in children are scarce. we retrospectively analyzed the incidence, the severity and the risk factors that contribute to the manifestation of this complication in a pediatric population. methods: during a -year period (january -june ) we performed in our center allogeneic transplantations, for malignant hematological diseases and for non-malignant. the majority of our patients received myeloablative conditioning regimens. diagnostic criteria of hemorrhagic cystitis were the detection of the virus with pcr in urine samples and/or in blood samples, in combination with hematuria and lower urinary tract symptoms (dysuria, urinary frequency, urgency, suprapubic pain) that couldn't be attributed to any other reason. we defined the hemorrhagic cystitis as severe when one of the following factors was present: formation of clots and continuous bladder irrigation, obstructive uropathy with creatinine elevation or need for urological intervention. results: a total of patients with median age , years ( , - ) were studied. children ( %, % ci, , - , ) manifested bk virus associated hemorrhagic cystitis with median age , years ( , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ) . onset of cystitis occurred at a median time of days (day +-day + ) after transplantation. in children cystitis was severe. the median duration of symptoms was days ( - ). the median time of hospitalization for children with severe cystitis was days ( - ) whereas for those who didn't manifest cystitis was ( - ) . in of the patients we examined the presence of the virus not only in urine but also in blood samples. in of them the test was positive and almost half of them ( ) manifested severe cystitis. the risk factors that were examined were age, administration of antithymocyte globulin, type of disease, graft source, type of donor and the presence of acute graft versus host disease (agvhd). in multivariable analysis, independent risk factors for the manifestation of hemorrhagic cystitis were age > years old (hr: , , % ci, , - , p< , ), transplantation for malignant disease (hr: , , % ci, , - , , p= , ) and the presence of agvhd (hr: , , % ci, , - , , p< , ). the overall survival of children with hemorrhagic cystitis was , % vs , % of those who didn't manifest this complication, but in multivariable analysis for survival cystitis wasn't a statistically significant risk factor. conclusions: according to our results, stem cell transplantation in children > years old who suffer from a malignant disease and the presence of agvhd consist independent risk factors for the manifestation of bk virus associated hemorrhagic cystitis. the identification of the risk factors of this serious complication will contribute to better management of transplanted patients. further research through prospective trials can contribute to the better understanding of the pathophysiology of hemorrhagic cystitis and to the establishment of appropriate diagnostic and therapeutic guidelines. disclosure: nothing to declare p impact of natural killer cell reconstitution on outcomes in patients with early cytomegalovirus reactivation after allogeneic hematopoietic stem cell transplantation background: cytomegalovirus (cmv) reactivation influences survival after allogeneic hematopoietic stem cell transplantation (sct) and induces natural killer (nk) cell expansion. we evaluated nk cell reconstitution and clinical outcomes following early cmv reactivation after sct. methods: lymphocyte subsets were measured by flow cytometry on day in patients with hematologic malignancies undergoing sct between january and december at kanagawa cancer center, excluding patients with graft failure or death within days. cmv reactivation was defined as initiation of preemptive cmv therapy following pp antigenemia surveillance. results: the subjects were males and females with a median age of years (range: - years). the median follow-up period for survivors was . years (range: . - . years). there were patients with acute myeloid leukemia, with acute lymphoblastic leukemia, with myelodysplastic syndromes, and with other diseases. at transplantation, patients were standard risk and were high risk. myeloablative conditioning and reduced-intensity conditioning were employed in and patients, respectively. bone marrow transplantation, peripheral blood stem cell transplantation, and cord blood transplantation was performed in , , and patients, respectively. cmv reactivation occurred in patients ( %) at a median of days (range: - days) after sct. grade ii-iv acute gvhd and chronic gvhd affected patients ( %) and patients ( %), respectively. among all patients, -year overall survival (os), cumulative nonrelapse mortality (nrm), and cumulative relapse (cir) rates were %, %, and %, respectively. in patients without cmv reactivation (cmvr-) versus patients with cmv reactivation (cmvr+), -year os, nrm, and cir were % vs. % (p < . ), % vs. % (p = . ), and % vs. % (p = . ), respectively. among all patients, the median level of cd -cd + cells, cd +cd cells, and cd +cd + cells on day was /μl (range: - /μl), /μl ( - /μl), and /μl ( - /μl), respectively. nk cell subsets showed no significant differences between cmvr-and cmvr+ patients. when patients were divided into low and high groups at the median level of each nk cell subset, cmvr+ patients with high cd -cd +, cd +cd -, or cd +cd + cells showed significantly better -year os than those with low cells ( % vs. %, p < . ; % vs. %, p < . ; % vs. %, p = . , respectively). high cd -cd + cells were significantly associated with lower nrm ( % vs. %, p = . ), while high cd +cd -cells were significantly associated with lower cir ( % vs. %, p = . ). multivariate analysis confirmed these nk cell subsets as prognostic factors in cmvr+ patients. conclusions: nk cell reconstitution may contribute to improved transplantation outcomes in subgroups of cmvr + patients. disclosure: nothing to declare background: rezafungin (rzf) is a novel echinocandin in development for prevention of invasive fungal infections caused by candida, aspergillus, and pneumocystis spp. in patients at high risk of infection. rzf has demonstrated in vivo prophylaxis efficacy and low risk of drug-drug interactions. furthermore, the stability and pk profile of rzf allow for once-weekly dosing. rzf is also in development for treatment of candidemia and invasive candidiasis using a dosing regimen of rzf mg followed by mg once-weekly, which achieved > % target attainment against candida. while lower doses might be useful to prevent candida and pneumocystis, invasive aspergillosis is a different challenge. we evaluated rzf dosing for prophylaxis against aspergillus fumigatus in blood and marrow transplant (bmt) patients using pk/pd simulations of the treatment dosing regimen. methods: a previous population pk model was refined using data from phase and phase trials of iv rzf (nonmem vers . ). stepwise forward selection (α = . ) and backward elimination (α = . ) were used to assess for relationships between interindividual pk variability and covariates, such as age, sex, bsa, albumin, liver and renal function markers, and infection status. the final model was validated by comparing model-based predictions to observed data. the model and demographic data from bmt recipients at stanford medical center were used for monte carlo simulation (n= , ) of expected rzf concentrationtime profiles in bmt patients receiving iv rzf mg on week followed by mg weekly x . of the patients included in the demographic dataset, were female (mean values at baseline: age, years [ - years]; weight, . kg [ - kg] ). the median (range) bsa in the demographic dataset was . m ( . - . ), and albumin was . g/dl ( . - . g/dl) . free-drug concentration-time profiles were evaluated ( . % human protein-binding) relative to the a. fumigatus minimal effective concentration required to inhibit % of isolates tested (mec ; jmi - sentry international surveillance data). results: the population pk model was a linear, compartment model with zero order iv input. albumin, sex, infection status, and body surface area were statistically significant predictors of interindividual variability; clinical significance of these factors was not determined. the model provided precise, unbiased fits to the observed data (r = . observed vs individual-predicted concentrations). rzf plasma free-drug concentrations at weeks , , and were above the a. fumigatus mec ( . mg/l) for the entire dosing interval in . %, . %, and . % of simulated patients, respectively, and in ≥ . % for all weeks based on the mec ( . mg/l). conclusions: these data modelled from bmt patients support the rzf dosing regimen of mg iv followed by mg once-weekly for prophylaxis against a. fumigatus. current antifungal prophylaxis may be limited by toxicity, ddis, or patient factors such as mucositis. the pk of rzf and its spectrum, safety, tolerability, and lack of ddis may address current unmet needs in ifi prophylaxis for bmt and other immunocompromised patients. disclosure: janice brown: research funding, cidara therapeutics, elizabeth lakota: research funding, cidara therapeutics, shawn flanagan: employment, cidara therapeutics, taylor sandison: employment, cidara therapeutics, voon ong: employment, cidara therapeutics, christopher rubino: research funding, cidara therapeutics p is fungal prophylaxis necessary in non myeloablative peripheral blood stem cell allogeneic transplantation in the pre-engrafment period? julien vaidie , jean-baptiste woillard , stéphane girault , marie-laure dardé , arnaud jaccard , daniel ajzenberg , bernard bouteille , pascal turlure background: non myeloablative peripheral blood stem cell transplantation (pbsc), by limiting toxicity, can be proposed to elderly patients or patients with comorbidities. however, fungal infections remain a key issue that can negatively impact outcome, and increase duration and cost of hospitalization. systematic fungal prophylaxis have demonstrated benefits in outcome in the context of myeloablative conditioning but are not currently in reduced intensity conditioning allograft with pbsc. fluconazole prophylaxis is currently recommended in this situation (ecil). methods: primary objective of this retrospective study was to evaluate fungal infection incidence after allograft procedure in patients who received a non myeloablative allograft with pbsc in limoges university hospital between june and june . patients received fludarabine mg/m /day between d- and d- before allograft and busulfan . mg/kg/day at d- and d- . gvh prophylaxis consisted in rabbit anti-lymphocyte serum at the dose of . mg/kg at d- and d- , and ciclosporin at the beginning dose of mg/kg per os twice a day. mycophenolate mofetil was adding for patients with hla-matched or mismatched unrelated donors. patients did not systematically receive antifungal prophylaxis during the neutropenic pre-engraftment period. when patients had fever during more than hours, an empirical fungal treatment (caspofungine) was added to empirical antibiotics. as soon as neutropenic recovered and in the case of apyrexia without microbiologic documentation, antimicrobial treatments were stopped while in the case of microbiologic documentation, treatments were adjusted to germ in term of dosing and time of administration following recommendations. however, some patients received antifungal azole prophylaxis during the neutropenic pre-engraftment period in case of history of previous invasive aspergillosis (ia), or a nasal colonization by aspergillus. in post-engraftment period, posaconasole prophylaxis was administered for patients with systemic corticotherapy for acute graft-versus-host disease. results: patients were evaluated (median [min-max] age of [ - ] years). % of patients received an hlaidentical related donor, % an hla-matched related donor and % an hla-mismatched unrelated donor. the five years overall survival and survival without relapse or gvhd were % ic [ %- %] and % respectively ic [ %- %]. the median time for neutrophil recovery was days. patients did not receive prophylaxis and only patients received systematic fungal azole prophylaxis in the pre-engraftment period. two patients received an empirical treatment by caspofungine. only ifi was documented during the neutropenic period : candida krusei in blood culture. in the post engraftment period, patients with acute gvhd treated by corticotherapy received an antifungal prophylaxis by posaconazole and only patient had a probable ia at day despite prophylaxis by posaconasole. conclusions: except for patients with previous history of ifi, our results provide additional arguments against systematic fungal prophylaxis after reduced intensity conditioning with pbsc allogenic transplantation in the pre-engraftment period with a very low incidence of invasive fungal infections. in post-engrafment period, posaconazole prophylaxis is required for patient with gvhd treated by corticotherapy. disclosure methods: a simple, rapid and sensitive method using hplc with a diode-array detector (dad) was developed and validated for the quantification of letermovir in human serum using sorafenib as internal standard. after pretreating serum samples by liquid-liquid extraction with tert-butyl methyl ether, separation was achieved on a x-terra rp- column (dimension x . mm, μm) at c using gradient elution with a mobile phase of mm ammonium bicarbonate ph . (mobile phase solvent-a) and acetonitrile: mm ammonium bicarbonate ph . (mobile phase solvent-b). samples were eluted at a flow rate of . ml / min throughout the -minute run. uv wavelength mode was used, detection was at nm. results: the calibration curve was linear (r > . ) in a concentration range of - ng / ml for letermovir. the hplc assay established for letermovir determination showed a high rate of accuracy and precision with an intraday variability of - . to % (accuracy) and . to . % (precision) and an interday variability of - . to . % (accuracy) and . to . % (precision), respectively. letermovir serum concentrations of patients ( male / female, mean age . years) were determined in daily clinical practice. the mean concentration was ng / ml (median ng / ml, standard deviation ng / ml, range - ng / ml). conclusions: the newly developed hplc method is useful for the determination of letermovir concentrations. patient samples analyzed in a routine clinical setting demonstrated considerable interindividual variability. all measured concentrations were above the ec of letermovir. monitoring the concentration of letermovir could help to prevent over-or underexposure, especially in patients with polypharmacy which is frequent in allogeneic hematopoietic stem cell transplant recipients. disclosure background: the use of preemptive strategy (pet) has lowered the incidence of cmv disease in allo-sct to - %. nonetheless the use of this strategy implies that more than % of seropositive patients will replicate cmv. several studies have shown that cmv replication is detrimental for patient survival although the viral load related to this bad outcome variates among studies. objective: to analyse thel impact of cmv replication in overall survival (os) in allo-hct patients. methods: to analyse the impact of cmv replication in os we perform a unicentric, retrospective study on consecutive first allo-hsct patients transplanted between jan- and oct- with a median follow-up of days ( - ). all patients were monitored post-hct with real time pcr cobas-taqman® /cobas ® (rtpcr) in plasma. the cut-off for inception of pet was iu/ml. cmv mutations (ul /ul gene), were studied in plasma samples by sanger sequencing, median cmv viral load iu/ml ( - ). results: patients ( ): women/men ( %/ %), median age was years (range - ). identical allogeneic scts ( %), haploidentical scts ( %). donors were related in cases ( %) and ( %) unrelated. progenitors source was % peripheral blood and % bone marrow. cmv status was (d+/r+) in %(n= ), (d+/r-) in %(n= ), (d-/r+) in % (n= ) and (d-/r-) in % (n= ), unknown cases. positive pcrs were detected in patients: one episode in ( %); episodes in ( %) and to episodes in patients ( %). fifty-five patients ( %) received preemptive therapy. fourteen episodes ( %) were refractory/ probable refractory cmv infections (according to the criteria of chemaly r. cid ). a resistant mutation (ul gene) was detected in one patient with refractory infection patients that developed cmv infection had an inferior non-significant os at years ( , % vs , % log-rank p , ). those patients that received pet for cmv had a significant inferior os compared with those that replicate cmv but didn't receive preemptive therapy ( , % vs %, log rank p= . ). os of patients that received pet was inferior compared with those without pet (with or without infection) ( , % vs , %, logrank p , ). no difference in survival was found for those patients treated pre-emptively that were refractory vs no refractory ( % vs , %, log-rank p , ). conclusions: patients that received preemptive therapy had a significant inferior overall survival compared with those that didn´t replicate and those that replicate cmv but didn't receive preemptive therapy. this reinforce the relevance of prophylactic strategies for cmv with drugs with good safety profile like letermovir that in a randomised trial proved to decrease the need for preemptive therapy. disclosure: rafael, de la camara: has received grants from astellas, gilead, janssen, merck, novartis and pfizer clinical evaluation of stenotrophomonas maltophilia infection in allogeneic hematopoietic stem cell transplant recipients -retrospective single-center data analysis negative bacillus that causes severe infections associated with high morbidity and mortality in immunocompromised patients. the aim of our study was to determine incidence, characteristics and outcome of s. maltophilia infection in patients (pts) who underwent allogeneic hematopoietic stem cell transplantations (allo-hsct) in institute of hematology and transfusion medicine between october and november . methods: we retrospectively evaluated incidence, clinical features and outcome of s. maltophilia infections in consecutive patients with median age- years (range - ), who underwent allo-hsct from unrelated donors - ( . %), matched sibling donors - ( . %) and haploidentical donors - ( . %) in our center. s. maltophilia was detected by culture-based microbiological tests. invasive infection was defined by isolation s. maltophilia from cultures in the presence of both clinical symptoms and signs of infection -blood stream infection (bsi), pneumonia with or without pulmonary haemorrhage. the only colonization status was defined as s. maltophilia culture-positive samples in the absence of infection symptoms. in vitro susceptibility tests to antibiotics were performed. results: pts ( . %) with median age- years (range - ) with s.maltophilia culture positive samples were identified. ( . %) underwent allo-hsct from unrelated donors, -from matched sibling donor and -from haploidentical donor. among them bsi developed in pts ( . %), pneumonia in pts ( %) -with fulminant and fatal pulmonary hemorrhage in pts ( . %). all patients with pneumonia demonstrated bsi. positive sputum cultures were detected in pts, in pts hemoptysis was observed. the rest of isolated strains were identified as colonization (throat -in pts, stool -in pts). all patients with invasive s. maltophilia infection before pathogen identification demonstrated persistent fever despite of the use of broadspectrum antibiotics (carbapenems, glycopeptides, aminoglycosides, colistin), prophylactic antifungals and antivirals. all of them received fluoroquinolone (ciprofloxacin) as a standard antibacterial prophylaxis before neutropenic fever occurred. all patients ( %) with bsi, pneumonia and pulmonary hemorrhage died before engraftment (anc - . g/l) - of them during - hours from the onset of a positive blood culture for s. maltophilia. the c-reactive protein (crp) concentration before identification of s. maltophilia invasive infection was > x- x upper normal limits (unl). susceptibility to antibiotics of isolated strains from blood and sputum was respectively: % and % for ceftazidime, % and % for trimethoprim-sulfamethoxazole, % and % for levofloxacin; while % and % strains were resistant to ciprofloxacin. -year overal survival (os) and -y os for this group was . % and . % respectively compared with . % and . % for group without s. maltophilia infection. conclusions: s. maltophilia invasive infections are associated with high morbidity and mortality in allo-hsct recipients especially in the period from conditioning therapy to engraftment. an exposure to broad-spectrum antibiotics in the treatment of neutropenic fever or confirmed bacteremia of other etiology is one of risk factors of breakthrough s. maltophilia infections. empiric therapy against s. maltophilia in selected patients in risk of such infection before pathogen identification may be lifesaving procedure. disclosure: nothing to declare. role of cmv reactivation following allogeneic stem cell transplantation in preventing relapses in patients with acute myeloid leukemia background: cytomegalovirus(cmv) reactivation is common in patients undergoing allogeneic stem cell transplantation. it has been shown recently that cmv reactivation is associated with reduced risks of relapse in patients undergoing allogeneic stem cell transplantation for aml. however the analysis of cibmtr data did not show any effect of cmv reactivation on relapse. with this background we conducted an analysis of patients suffering from aml who are undergoing allo-sct for their long term disease free survival with respect to cmv reactivation. methods: after obtaining permission from hospital medical records committee, we retrospectively analysed data from electronic medical records of patients undergoing allo-sct for aml at our center between january to august . patients who underwent matched sibling, matched unrelated and partially matched allo sct were included. all patients underwent cmv monitoring with weekly pcr starting from the time of engraftment till d+ following allo sct. value of ≥ copies/mcl was considered as cut off for initiation of treatment in matched sibling donor transplant but in unrelated donor or partially matched donor transplants, ≥ copies/mcl was used as cut off for initiation of pre emptive therapy. results: total of patients were included in study. median age was . ± . years ( - yrs). ( . %), ( . %) and ( . %) patients underwent matched sibling, haplo (partially matched) and mud transplantation respectively. median follow up was months( - months). (table ) acute gvhd (grade - ) was observed in ( . %) of patients. cmv reactivation occurred in ( . %) of patients. overall survival at last follow up was . % ( / patients). ( . %) patients relapsed during follow up. relapse free survival at at last follow up was . %. ( . %) of patients who had cmv reactivation didń t relapse, whereas ( %) of patients who didn´t have cmv reactivation relapsed which was statistically strongly significant p < . . (figure ) similar results were seen in recently published paper from japanese society for hematopoietic cell transplantation (jshct) transplantation-related complication working group. conclusions: . cmv reactivation following allo sct had beneficial effect on preventing relapse in patients with aml. . probable immune activation resulting due to cmv reactivation may result in better graft versus leukemia effect preventing subsequent relapses. [ background: human herpesvirus (hhv- ) causes lifethreating central nervous system disorders such as encephalitis after allogeneic hematopoietic stem cell transplantation (hsct). recent studies showed that cd , a member of the tumor necrosis factor receptor superfamily, has been implicated as a specific receptor of hhv- b, and that its expression levels in cd -positive t cells after hsct could be related to the reactivation of hhv- . real-time quantitative polymerase chain reaction analysis (qpcr) is the most commonly used method for detecting and evaluating hhv- reactivation after hsct, but more sensitive detection method is required. we recently developed a new monitoring method for hhv- reactivation using digital pcr (dpcr) which provides high sensitivity of detecting hhv- dna in clinical samples. in this prospective study, we evaluated the relationship between hhv- reactivation monitored by dpcr and expression of cd on cd + t cells before and after allogeneic hsct. methods: thirty-four patients who underwent allogeneic hsct for hematological diseases at keio university hospital (tokyo, japan) between january and march were consecutively enrolled into this study. peripheral blood samples of the patients were obtained before the conditioning (pre), the day of transplant (day ), and weekly during the first month after transplantation (days , , , and ) . hhv- viral load in plasma was quantitatively measured by dpcr. the primers and a probe of dpcr for hhv- b were selected from immediate-early (ie- ) protein transactivator region (u ). we evaluated the relationship between hhv- reactivation and the serial expression rates of cd in cd + t cells (cd /cd ratio) measured by flow cytometry before and after hsct. results: median age of the patients was . years. onethird of patients received cord blood as a stem cell source. hhv- reactivation was detected in patients ( %) with dpcr. a comparison of cd /cd ratio between the patients with and without hhv- reactivation after hsct revealed that cd /cd ratio was significantly higher in patients with hhv- reactivation than those without before conditioning ( in contrast, there was no such significant difference after transplant (days to ) . in multivariate analysis, higher cd /cd ratio before conditioning (odds ratio (or) = . , % confidence interval (ci): . - . , p = . ) and stem cell source from human leukocyte antigen mismatched donor (including all cord blood transplantation cases) (or = . , %ci: . - . , p = . ) remained to be significantly associated with the incidence of hhv- reactivation. conclusions: higher cd expression rate in cd + t cells before hsct was associated with higher risk of hhv- reactivation, which could be a promising marker for predicting hhv- reactivation after allogeneic hsct. careful observation and monitoring may be needed in cd highly expressed patients. it is a subject of further research to clarify the role of cd + cd + t cell in hhv- reactivation. disclosure: nothing to declare. methods: criteria for the administration of ici (vistide) were grade iii-iv (clinically significant hematuria with clots) bk-related hemorrhagic cystitis after allo-hct which showed no improvement after symptomatic therapy with hyperhydration and bladder irrigation. cidofovir was diluted in ml of normal saline and installed via a foley catheter which was blocked for hour. not knowing the level of absorption of the drug we decided to give probenecid prophylaxis in all patients. ici was repeated weekly according to severity of symptoms. urine and plasma bkv viral loads were quantified by rq-pcr results: six patients (median years, - ) received ici after allo-hct. patients had haematological malignancies (aml , all , mds ), received busilfex-based myeloablative conditioning and a graft (pbsc , bm ) from a / hla-matched ( pts), / ( pt) or haploidentical ( pt) donor. median time for the onset of bkv-hc after allo-hct were . days (range - ). all patients were under standard cyclosporine prophylaxis and none of the patients had any signs of acute gvhd at the time of onset of hc. the median pcr-bkv viral load at the onset of bkv-hc in urine and plasma were . x (range . x - x ) and . (range - ), respectively. the median maximum pcr-bkv viral load in urine and plasma were . x (range . x - x ) and . (range - . ), respectively. five patients had impaired renal function (median egfr ml/min, range - ) at first ici which was probably multifactorial. the median dose of intravesical cidofovir was mg/kg (range . - mg/kg) and a median number of . instillations (range - ) were given. in / cases symptoms of cystitis improved dramatically and hematuria resolved. virological response (at least log reduction) was observed in all cases. two patients experienced relapse of hemorrhagic cystitis and were retreated with ici which resulted in resolution of the symptoms and the hematuria. no deterioration of renal function of other systemic adverse effects were observed. after a median follow up of . days after transplantation (range - ), / patients are alive without cystitis symptomatology and died ( due to relapse and due to trm). conclusions: in this retrospective study we propose that local therapy of bkv-hc with ici is safe and has high clinical and virological response rates. the administration of ici after allo-hct should be controlled in prospective randomized trials. disclosure: nothing to declare background: since cmv-preemptive therapy approach was implemented, cmv disease frequency is very low. however, cmv reactivation and the need of using nephrotoxic plus/less myelotoxic drugs is very frequent. in addition to the toxicity of the medications to avoid cmv disease, other potential adverse effects of cmv have been mentioned in medical literature. in this study, we wanted to estimate how recipient/donor serologic status influences the outcome of allo-hsct in our most recent series of patients. methods: the population analyzed for this report is the all patients who underwent allo-hsct during the -year period from october september in our unit. median age at transplant was years (range: - ). one hundred and thirty were male ( %) and were female ( %). baseline diseases were: aml, lpd, all, mds, mpd, mm, and bmf. donor was unrelated in transplants ( , %) and was family in ( , %) (including haplo-identical). conditioning regimen was ric in procedures ( %) and intensive in ( %). stem cell source was pb in ( , %) and bm in cases ( , %). median follow-up was months (range: - ). patient's and donor's cmv igg were positive in ( , %) and ( , %), respectively. recipient/donor serology was +/-(risk group ) in ( , %), +/+ (risk group ) in ( , %) , -/+ (risk group ) in ( , %) y -/-(risk group ) in ( , %). results: two pts underwent a second transplant before day + due to graft failure. overall mortalities (om) at days + and + of the rest of the series ( pts) are shown in table. the highest risk group (recipient cmv + / donor cmv -) exhibited more than double om at day + and more than four times om at day + , when compared with pts at lowest risk (recipient cmv -). those striking differences were mainly due to nrm. om for risk group ii (recipient cmv + / donor cmv +) was intermediate. conclusions: in our studied population, mainly adult patients, the combination of cmv-seropositive patient with a cmv-seronegative donor had a very clear adverse impact on hsct outcome. as a result, we considered that the election of a cmv-positive donor for a cmv-positive patient continues to be strongly advisable, whenever is possible. on the other hand, once letermovir has proved to be efficient and well-tolerated and has been licensed for prophylaxis of cmv in high risk recipients, this approach appears to be very attractive to try to avoid the adverse impact of recipient cmv-seropositivity, particularly when finally chosen donor is cmv negative. disclosure: nothing to declare an active surveillance and an early and individualized management is critical to avoid mortality from respiratory viral infections in allo-hsct recipients background: respiratory viral infections (rvis) are frequent among the general population. in transplant recipients, rvis are known to cause an important morbidity and potential mortality. for this reason and several others, as the need of preventing other pts from contagious or avoiding misdiagnosis with other infections processes, a high index of suspicion of vris is necessary. during the last few years, we have implemented an active and systematic surveillance policy orientedto early detection and management of rvis in the hsct recipients. methods: the population analyzed for this report is the patients who underwent allo-hsct from january through march in our unit. median age at transplant was years (range: - ). one hundred and four were male ( . %) and were female ( , %). baseline diseases were: aml, lpd, all, mds, mpd, mm, and bmf. donor was unrelated in transplants ( . %) and was family in ( . %) (including haplo-identical). conditioning regimen was reduced in procedures ( %) and intensive in ( %).stem cell source was pb in ( . %) and bm in pts ( . %).median follow-up was months (range: - ); at the close of the analysis, majority of the series ( . %) had a follow-up superior to one year from hsct. a throat swab(ts) was taken from every patient with any, even minor, respiratory symptoms. the respiratorysamples were tested whith a complete pcr panel of human respiratory viruses: rhinovirus (rv), influenza a and b virus (iv-a, iv-b), parainfluenza virus (pivs - ), respiratory syncytial virus (rsv), metapneumovirus (mpv), coronavirus (cov), adenovirus (adv), and bocavirus (bov). results: day + overall mortality of the series was , %. day + overall mortality was , % ( , % nonrelapse mortality -nrm-, and , % progression/relapse mortality). causes of nrm reflected in table . no patients died due to rvis. from st july through th june (a -month period), ts samples were obtained from pts ( , %).the median number of samples/patient was (range: - ).a total of ( - ) rvis episodes were diagnosed in pts ( , %).the median presentation of the first rvi was at the day + ( - ) post-hsct. the viral distribution was: rv ( . %), iv ( . %), piv ( . %), rsv ( . %), mpv ( . %), cov ( . %), adv ( . %), and bov ( . %).there were mixed (two or more viruses) rvi episodes. the temporary distribution of vri episodes is shown in figure . conclusions: ) symptomatic infections due to respiratory viruses are very frequent among the allo-hsct recipients. ) a high level of suspicion, as well as an early and systematic screening and management policy, are critical to avoid potential attributable mortality and the nosocomial spread of rvis among the transplant recipients. ) in our series, rhinovirus, parainfluenza and adenovirus might be detected at any moment of the year; the rest of the viruses showed a clear seasonal pattern (november to april). [[p image] . background: trimethoprim-sulfamethoxazole (tmp-smx) is the most suitable drug for prophylaxis against pneumocystis pneumonia and infections with toxoplasma after allogeneic haematopoietic stem cell transplantation (allo-hsct). allergic reactions or hypersensitivities, mainly exanthemas, occur in about - % of the patients, usually resulting in the use of alternative prophylactic drugs (e.g. pentamidine or atovaquone). it has been hypothesised that allergies might be cured with allo-hsct. methods: we conducted a retrospective chart review of patients with tmp-smx re-exposition after allo-hsct from december to september . follow-up is current as of december . results: six patients (f/m: / , median age: years, range: - years) with a history of tmp-smx hypersensitivity prior to allo-hsct were re-exposed to tmp-smx after engraftment of a matched related (mrd, n= ) or matched unrelated (mud, n= ) donor. median time to re-exposition was . (range: - ) days after allo-hsct with one oral dose of tmp-smx. in four patients, tmp-smx was tolerated without any signs of hypersensitivity reactions and has been continued for a median of days (range - ) until last followup. one patient (mud, re-exposition at d+ ) experienced pruritus and erythema some hours after tablet intake. another patient (mud, re-exposition at d+ ) developed an exanthema one day after re-exposition which was later diagnosed as a cutaneous gvhd. conclusions: re-exposition of tmp-smx in patients with prior hypersensitivity is feasible after allo-hsct. after successful re-exposition, patients can be treated with the best-studied drug for prophylaxis of infections with pneumocystis and toxoplasma. disclosure: nothing to declare brincidofovir for adenoviremia in paediatric hsct for primary immune deficiency background: reactivation of adenovirus is a severe complication of hsct associated with significant morbidity and mortality, particularly for children with primary immune deficiency (pid). the only drug currently licensed to treat adenovirus infection is cidofovir. brincidofovir is a lipidlinked derivative of cidofovir which has been shown to be a safe and effective alternative treatment to cidofovir. there is limited data describing the use of brincidofovir in patients undergoing hsct for primary immune deficiency. we reviewed all patients who received brincidofovir after undergoing hsct for primary immune deficiencies between and at the great north children's hospital, newcastle upon tyne, uk. results: of patients transplanted for pid, developed significant adenoviraemia ( %). all were treated with cidofovir initially but were switched to brincidofovir because of a failure to respond or because of renal toxicity. of these, resolved their adenoviraemia within days of commencing treatment (figure ). donor sources were tcr alpha/beta/cd depleted haplo-identical (n= ), tcr alpha/beta/cd depleted mmud (n= ) and / mud (n= ). patients were conditioned with treosulphan/fludarabine/thiotepa/atg/ rituximab (n= ), treosulphan/fludarabine/atg/rituximab (n= ) or treosulphan/fludarabine/alemtuzumab/ gcsf/plerixafor (n= ). occurrence of agvhd and treatment of agvhd are outlined in table . patient died + days post-transplant of multi-organ failure, severe thrombotic microangiopathy and sepsis. although patient initially responded to brincidofovir, reactivation occurred after cessation of treatment; severe diarrhoea precluded the reintroduction of brincidofovir and the adenoviraemia persisted with poor immune reconstitution. treatment with addback t cells was attempted however the patient died days post-transplant after a cerebral haemorrhage. patient had long-standing chronic diarrhoea which was thought not severe enough to warrant cessation of brincidofovir treatment. conclusions: the complete resolution of adenoviraemia in / patients who had previously failed to respond to prior therapy with cidofovir suggests that brincidofovir may be an effective treatment option for adenoviral reactivation post-hsct for pid. however, resolution of adenoviraemia is influenced by many other factors, including the adequacy of immune reconstitution, the degree of induced immune suppression and the presence of comorbidities such as gvhd. due to the small sample size it was difficult to assess the relative importance of these factors in this cohort. brincidofovir was well tolerated however its effectiveness may have been limited by poor gastrointestinal function in one patient (patient ) and could not be used after a viral reactivation in another for the same reason. further studies of the use of brincidofovir in this specific cohort are needed to clarify the role and effectiveness of this treatment. background: there is a high prevalence of cmv seropositivity in algerian population. because of high morbidity and mortality in pts who underwent allo sct with cmv reactivation, effective surveillance and timely treatment using anti-viral therapy s required. the risk of cmv reactivation depends on the type of stem cell source, immunosuppression (is) and serological status of the donor/ recipient pair. methods: over a months period (from / / to / / ), pts underwent allo-hsct for malignant or non-malignant hematology diseases of which pts are evaluated for this study. cmv reactivation was observed in pts ( . %) (aml: pts, all: pts, cml: pts, multiple myeloma: pt, nhl skin: pt, primary myelofibrosis: pt, aplastic anemia: pts, fanconi anemia: pts, β-thalassemia: pt), with a median age of years ( - ), sex ratio (m/f) of . . allo-hsct done with sibling donors: pts, haplo-identical donors: pts and pheno-identical donor: pt. all pts were treated by chemotherapy alone with myéloablative conditioning (mac) in pts and reduced intensity (ric) in pts. all pts received peripheral blood stem cells with an average rate of cd + cells: , . /kg ( . - . ). additional bone marrow graft was used in pts that received a haploidentical graft without pt-cy. gvh prophylaxis associated cyclosporine (csa) and methotrexate (sibling and phenoidentical); csa-mtx-mmf or csa-mtx-cyclophosphamid (haplo-identical). before transplantation, donor/recipient pair is at high risk reactivation in pts ( . %). detection of cmv reactivation done by antigenaemia pp or by quantitative pcr weekly for the first months and during an is treatment for acute or chronic gvhd. pre-emptive therapy is initiated by ganciclovir as soon as positivity of antigenaemia or increased viral load in pcr. results: a first reactivation occurred on average day ( - ) in pts ( . %) of which pts under corticotherapy for acute gvhd ( pts), thrombotic micro-angiopathy ( pt) and renal failure ( pts) or due to a reinforced is for haplo-identical transplantation ( pts). one pt with chronic gvhd presented a late reactivation months after transplant. twenty pts presented a nd reactivation on average day ( - ) and pts a rd reactivation on average day ( - ). pre-emptive treatment is introduced in the first episode by a viral dna polymerase inhibitor (ganciclovir: pts; valganciclovir: pts, foscarnet: pt). the negativity of antigenaemia is observed on average at days of treatment ( ) ( ) ( ) ( ) ( ) . second line treatment was required in pts ( %) due to resistance ( pts), severe cytopenia ( pt) or renal failure ( pt). the onset of severe cytopenia imposed a dose reduction ( pts) or a therapeutic stop ( pts) before days. two pts received additional maintenance treatment for negativation delay. three pts ( . %) died from cmv infections resistant to antiviral treatment (pneumonia: , colitis: ). conclusions: cmv infection is a serious complication after allo-hsct. in the absence of vaccination, the systematic monitoring for cmv reactivation is strongly recommended for the establishment of a rapid and effective preemptive treatment. disclosure: nothing to declare p abstract withdrawn. results: in transplanted group, episodes of bkv reactivation occurred in patients ( %). in cases only urine colonization (c) found before hsct. in this group in patients ( %) virus was transmitted from urine to the blood (b) . dysuria and/or hc were observed in / ( %) patients . all of them ( %) had urine and serum involvement. in cases bkv replication was found after hsct ( -cases detected in urine, cases-bothserum and urine). dysuric syndromes and/or hc were found in / of cases ( %)-all in patients with serum and urine involvement. urinary tract was always first location of the virus. there was no case of isolated serum reactivation. the incidence of bk infection was higher in patients older than > yrs (p< . ), transplanted from family donor (msd) (p< . ). mud recipients had more often both serum and urine reactivation (p< . ) than isolated urine involvement. sex, day of neutrophil recovery, conditioning regimen, or use of total body irradiation were not significant risk factors for bkv infection, or hc . six patients were treated with cidofovir (range - doses) with good response. there was no death due to evident bkv infection. conclusions: bkv reactivation remains one of the most frequent infectious complication in children undergoing allogeneic hsct. most of patients experienced mild infection and age < years was the positive prognostic factor influencing its incidence. bkv monitoring and prompt treatment of hc resulted in excellent outcome. we observed surprisingly high rate of new bkv replication after hsct. disclosure: nothing to declare background: high-dose chemotherapy (hd-ct) and auto pbsct have been the standard therapy for multiple myeloma (mm) for more than two decades, despite a wide range of new therapeutic options. recurrent/refractory malignant lymphomas and recurrent/metastatic germ cell tumors (gct) also benefit from this intensive therapy. in comparison to allogeneic transplantation, this treatment is known for lower complication rates, e.g. infections. however previous studies have schown that treatment related toxicity may not be underestimated and depending on the conditioning regimen used. methods: we retrospectively analyzed patients ( cases) who underwent hd-ct plus auto pbsct between and in a single-center study. to anlyze the incidence of infections depending on the conditioning regimen, we formed the following categories based on the agiho: no infections, neutropenic fever, sepsis and severe sepsis. results: the median age in this analysis was years; . % were male. the most frequent diagnosis was mm ( . %) receiving high dose melphalan (mel), followed by malignant lymphoma ( . %) receiving beam (bcnu, etoposide cytarabine, melphalan) and relapsed/metastatic germ cell tumours (gct) ( . %) receiving high dose carboplatin/etoposide (ce). % of all patients developed severe sepsis, patients had to be ventilated and patients died. sepsis was documented in . % of all cases ( cases). the majority of patients ( . %, cases) developed neutropenic fever and . % ( cases) didn´t have any infection complications. the beam conditioning regimen showed the highest tendency to result in a septic course ( . %), followed by ce ( . %) and mel ( . %). the most commonly documented pathogen in blood cultures was s. epidermidis ( . %), followed by e. coli ( . %) and s. mitis ( . %). only in one blood culture we detected a multi-resistant pathogen ( mrgn e. coli). p. aeruginosa was detected in blood cultures ( . %), l. monocytogenes in ( . %) and s. aureus in ( %). . % of all patients developed diarrhea, only in . % of these cases we could detect c. difficile. the conditioning regimen shows no significant effect on the incidence of c. difficile. the mean neutropenic period was . days in malignant lymphoma patients, followed by . in mm patients and . days in gct patients. the hospital discharge, calculated from the day of transplantation, was significantly different: for malignant lymphoma the mean was . days, for mm . days and for gct . days. conclusions: our data correspond to former published results by many groups. the beam regimen shows the highest infectious complication rate followed by ce and mel. the duration of neutropenia and hospital stay depends on the conditioning regimen. the type of infectious complication doesn't effect the progression free-and overall survival in our analysis. disclosure: nothing to declare. impact of donor and recipient cytomegalovirus serostatus on outcomes of unrelated allogeneic haematopoietic stem cell transplantation background: cytomegalovirus (cmv) is an important cause of morbidity and mortality in allogeneic haematopoietic stem cell transplant (hsct) patients. the aim of our study is to evaluate the outcomes of our cmv seropositive recipients who received grafts from seropositive unrelated donors (d+r+) compared with grafts from seronegative unrelated donors (d-r+). methods: this is a retrospective single center study on a series of cmv seropositive recipients who underwent hsct from unrelated donors between febuary to july . a total of patients were analyzed. their clinical course and laboratory results were reviewed for evidence of cmv reactivation and/or cmv disease. we defined cmv infection as detection of cmv reactivation or primary infection by antigenaemia or polymerase chain reaction (pcr) assays, but was not accompanied by signs and/or symptoms suggestive of a systemic disease. cmv disease occurred when cmv was isolated from any site in association with organspecific signs and/or symptoms. monitoring for cmv infection commenced upon engraftment (approximately day + ). peripheral blood samples were sent twice a week for cmv antigenaemia or cmv quantitative pcr. the duration of twice weekly monitoring was at least about days. longer monitoring was performed in patients who experienced cmv infection after hsct. results: all patients received graft-versus-host-disease (gvhd) prophylaxis using anti-thymocyte globulin (atg) at . mg/kg in addition to cyclosporin or tacrolimus. among the entire cohort of patients, ( %) had cmv infection, including ( . %) out of patients from the d-r+ group and ( %) out of patients from the d+r + group. patients ( . %) from the d-r+ group and patients ( . %) from the d+r+ group had ≧ cmv reactivation above the threshold for preemptive therapy respectively; p= . . patients developed cmv disease, ( . %) from the d-r+ group and ( . %) from the d +r+ group. cmv resistance to both foscarnet and ganciclovir was detected in patients ( . %) from the d-r+ group but none from the d+r+ group. patients died due to cmv disease, both were from d-r+ group. year overall survival (os) were % versus % for d-r+ group and d+r+ group respectively; p= . . median survival was not reached at years. year non-relapse mortality (nrm) were % for d-r+ group and % for d +r+ group respectively; p= . . conclusions: the incidence of recurrent cmv infection was higher in the d-r+ group compared to the d+r+ group. there were no statistically significant differences between the groups in terms of os and nrm. however, there was a trend towards higher nrm in the d-r+ group compared to d+r+ group. our findings suggest that for matched unrelated hsct, it may still be important to select a seropositive donor for a seropositive recipient. disclosure: none background: it´s known that some patients submitted to allogeneic stem cell transplantation (asct) could present a greater susceptibility to infection even when they are in long term complete remission or potentially cured. this fact is related to the dynamic of immunological recovery that is variable in every single patients and it is dependent from many factors: the haematological disease, the conditioning regimen, the age of patient and donor, the number of stem cell and lymphocytes infused, the anti-gvhd prophylaxis, the use of anti-thimoglobulins and others. in clinical practise we can observe patients who are potentially cured, who tapered and stopped the immunosuppressive treatment months or years ago and who are suddenly graved from opportunistic infections. the largest part of these infections is represented from varicella-zoster virus (vzv) cutaneous eruption. methods: in this report we retrospectively analysed a monocentric cohort of patients submitted to asct for haematological malignancies from a median time of months. all of them were free of disease. they stopped the immuno-suppressive treatment in a median time of days after asct (range: - ) and did not present later chronic gvhd needing treatment neither other moderate or severe chronic post transplant complications nor other diseases. prophylactic treatment with anti viral agents (acyclovir or valacyclovir) has been conducted simultaneously to immuno-suppressive treatment and for a period ranging between to months after its suspension. in this cohort of patients we considered the incidence of vzv eruption occurred after the suspension of the immunosuppressive treatment, and we analysed the immunological recovery in terms of lymphocytes sub-population after , , and months from asct. results: of these patients considered, developed at least one vzv manifestation. all the vzv presentation were cutaneous, we did not observe neurological, ophthalmic or visceral presentation. all the vzv manifestation occurred in patients who ended the anti-viral prophylaxis. median time of presentation was days after asct (range: - ) the remaining patients did not present vzv manifestation nor other kind of opportunistic infection despite the absence of anti-viral prophylaxis. the analysis of lymphocyte sub-population after - - and months did not show a significant difference in b, t, t , t and nk lymphocytes in the different post transplant period. conclusions: vzv reactivation seems not to be correlated with the number of the different lymphocyte subpopulations in the post transplant period. actually it is not possible to distinguish patients more suitable of vzv reactivation on the basis of lymphocyte sub-populations analysis, so anti-viral prophylaxis should be prolonged for a medium period after suspension of immuno-suppressive drugs. in absence of anti viral prophylaxis a careful clinical surveillance should be performed in order to treat early eventual vzv manifestations. disclosure background: infection and disease cytomegalovirus (cmv) are common problems in patients undergoing hematopoietic stem cell transplantation (hsct). cmv infection has a high overall seroprevalence, therefore, during the first days post-hsct, it is important to prevent reactivation of cmv. the international clinical recommendation is the use of ganciclovir as prophylaxis in hsct patients; however, the cost of this treatment is not accessible for our population. in this respect it has been used as an alternative valganciclovir because of its lower cost and oral administration. our study´s aim was to assess the response and safety of valganciclovir in comparison with ganciclovir to prevent viremia and cytomegalovirus disease in patients undergoing allogeneic hsct methods: a retrospective study was performed on patients who receive an hsct-allo between january and august . participants were enrolled in two groups according to prophylaxis treatment: (a) ganciclovir mg/k once daily and (b) valganciclovir mg twice daily for days pretransplant, at day + ; viremia was measured by pcr. demographic and clinical information was collected from medical records and furthermore analyzed in spss v . results: sixty-eight patients were enrolled in the study, % male, the median age was years ( - ) with the following diagnoses: acute lymphoblastic leukemia %, acute myeloblastic leukemia . %, granulocytic chronic leukemia . %, myelodysplastic syndrome . %, dendritic cell neoplasia . %, and aplastic anemia . %. ninety-one percet of the patients received a transplant from an identical hla donor and . % received a haploidentical transplant. thirty-four patients received ganciclovir (g ) and thirtyfour valganciclovir (g ). median age was vs years (p= . ), intermediate risk cmv % vs (p= . ), associated bacterial infections was %vs % (p= . ), and fungal infections % vs % respectively (p= . ). the reactivation by cmv was presented in % vs % respectively (p= . ). there were no significant differences in fever, bacterial isolation, dysfunction or graft failure, presence and degree of acute or chronic gvhd and relapse of the disease. the most relevant characteristics and complications are described in table . within the whole group there were deaths, % in the ganciclovir group and % in valganciclovir group (p= . ), overall survival -year was % vs % (p= . ) respectively; in both groups % was associated with relapse and % associated with transplantation. conclusions: ganciclovir and valganciclovir were effective in preventing the reactivation of cmv, the only statistically significant difference was that the presentation of the disease appeared earlier in the valganciclovir group. no difference in toxicity between the groups was identified. disclosure: none declared background: invasive pulmonary aspergillosis (ipa) is a severe and serious complication that occurs in the immediate post-transplant period due to severe neutropenia or late usually following prolonged corticosteroid therapy during treatment of graft-versus-host disease (gvhd). the objective of this study is to analyze the epidemiological, diagnostic and evolutionary characteristics of this major complication over a period of years. methods: from january to december , patients (pts) received an allogeneic hematopoietic stem cell transplantation (allo hsct) for malignant and nonmalignant haematological diseases. during the transplant procedure, anti-infectious prophylaxis consisted of pts isolation, digestive decontamination, fluconazole and aciclovir. secondary prophylaxis done for pts with prior history aspergillosis. during the follow-up, a standard chest x-ray is performed systematically at each control or in case of clinical signs a thoracic ct scan is requested from suspicion. the diagnosis of ipa is made according to the criteria of the eortc-msg based on the predisposing criteria of the host and clinico-radiological criteria (possible infection). galactomannan antigen and histopathology criteria are not common practice. results: a total of ipa episodes ( %) were identified in pts (aml: , aa: , all , cml , mm ) of median age ( - ) , sex ratio: . . all of them had transplantation from a family donor (geno-identical: , haplo-identical: ) with conditioning by chemotherapy alone and a graft of csp ( pts) and peripheral stem cells-bone marrow ( pts). all pts had at least one predisposing risk factor: antecedent of aspergillosis ( pts), prolonged neutropenia> d ( pts), acute gvhd ( pts), chronic gvhd ( pts), prolonged corticosteroid therapy ≥ , mg /kg/day exceeding days ( pts). the diagnosis of api was possible on average at j ( - ) after appearance of clinical signs (in all cases) and evocative radiological in cases (in cases, the standard chest x-ray was normal). at the time of thoracic ct scan, pts ( %) had characteristic signs: halo sign ( pts), crescent sign ( pt) and cavity ( pts). other minor radiological signs are found in the other pts. empirical first-line antifungal therapy was started as monotherapy in pts (voriconazole: , caspofungin: pts) or in combination in pts. a secondline treatment was required in pts for failure after an average duration of days . three pts presented a second episode after an average delay of months ( ) ( ) ( ) ( ) with a favorable evolution of resumption of thetreatment. fourteen pts ( %) are alive with complete resolution after a median treatment time of months ( - ). twelve pts ( %) died rapidly on average days after diagnosis (ipa , relapse of his disease: ) conclusions: ipa occurring after an allograft of allo-hsct is a severe complication with high mortality. it is essential, in each case, to identify the pts with risk factors, perform a thoracic ct-scan, send serum serology for apergillus galactomannan antigenand start specific treatment as soon as possible while waiting to be able to reinforce the diagnosis by direct examination or sputum or brochoalveolar lavage with aspiration. disclosure: nothing to declare background: cmv (cytomegalovirus) has a prevalence varying between - %. its pathogenicity is relatively low in the general population, usually resulting in a selflimiting viral illness. in an immunosuppressed host, infection can lead to life threatening illness. disseminated cmv infection can manifest in a number of organs and is diagnosed using internationally accepted criteria. in the post solid organ and stem cell transplant (sct) setting, it is postulated that it is viral reactivation, rather than primary reinfection that leads to cmv viraemia. prevention of reactivation requires the presence of a competent immune system, mediated by t-cells. this accounts for the increased incidence in intensive and t-cell depleting sct conditioning regimens. despite improved outcomes following the introduction of cmv monitoring by pcr and pre-emptive treatments (current uk guidance), cmv pneumonitis still carries a high mortality. the use of cmv specific immunoglobulins (cmvig) for the treatment of this complication is generally not recommended post chemotherapy or sct in haematological cancers due to lack of evidence. however, cmvigs are widely used in the setting of cmv reactivation post solid organ transplants. we report the use of cmvig in patients with suspected cmv pneumonitis at a single uk centre. the aims of this retrospective study were to establish safety and review efficacy in this highly immunocompromised group of patients. methods: data was collected retrospectively on the use of cmvig in patients with haematological cancers post sct or chemotherapy alone between and at manchester royal infirmary, uk. all patients included had cmv positive pcr in blood (and or from bronchoscopy), as well as high resolution ct imaging evidence of cmv infection. the data was sourced from pharmacy database and crossreferenced with a departmental list. for each patient identified, case notes and prescriptions were sourced. data collected included patient baseline characteristics, timing of treatment, number of doses of cmvig and outcome. results: eight patients received cmvig for suspected cmv pneumonitis. seven patients were post sct and one patient was severely immunosuppressed with chemotherapy alone. median age was years (range - ). the cmvig regimen used was ml/kg of cytotect ® on days , , and , followed by ml/kg every four days until resolution of symptoms. there were no infusion related reactions observed. patients received a median of doses of cmvig. four out of patients responded to the treatment and showed full recovery but only are alive and well to date. conclusions: this study shows that the use of cmvig is safe in the post-sct setting of acutely unwell patients with multi-organ failure. despite limitations of retrospective studies, there appears to be benefit for the use of cmvig in our patient population, with % of patients showing a full recovery from that episode. allogeneic sct plays a confounding role in the outcome of patients although the numbers in our study are small. there is clearly a need for better treatments of cmv pneumonitis. cmvig is a promising treatment but further studies are needed to identify the optimal dosing regimen and provide evidence of efficacy. disclosure: biotest-honaria p abstract withdrawn. background: the risk of fungal infection related to allogeneic transplantation is a well-known cause of morbidity and mortality. the main agents implicated are yeast during the neutropenic period and filamentous fungi after this period. methods: we decided to evaluate the effectiveness of a prophylactic regimen containing fluconazole since day - . after discharge fluconazole was kept until day or or switched to posaconazole in high-risk patients. patients with gvhd under steroids were kept under prophylaxis.the group of high risk patients was defined by one of the following variables: -non related donors -atg, campath or fludarabine in the conditioning -presence of gvhd with need of steroids above . mg/kg we have analyzed the patients submitted to allobmt during and . all patients were first admitted to an isolation room with hepa filters.patients under secondary prophylaxis were excluded. breakthrough fungal infections during the first year and toxicity leading to discontinuation was evaluated. results: sixty six patients were included with transplants. male/female ratio was / . the age range was . - yo with a median of . malignant ( ) and nonmalignant ( )diagnosis were included. donor type was related ( ) haploidentical ( ) and non-related ( ). the conditioning regimen includes atg in , campath in and fludarabine in . fourteen patients were treated after discharge with fluconazole and with posaconazole. three patients fluconazole were switched to micafungin for hepatic toxicity, two cases to amphotericin due to persistent fever and in one case to caspofungin for a proven fungal infection (candida parapsilosis in blood stream in day + ). after discharge and during the first year of follow-up a single case of possible fungal infection was diagnosed, in a patient with gvhd with a lung nodule. conclusions: during the neutropenic period after transplantation the main risk of fungal infection is associated with candidiasis. the greatest risk of aspergillosis occurs later and have a significant relation with gvhd. except for candida parapsilosis the main source of yeasts are the gi tract. the main source of aspergillus are aerosolized particles retained by hepa filters. in patients without a previous episode of fungal infection the main risk of filamentous fungi occurs only after discharge. we conclude that fluconazole alone or followed by posaconazole in high risk patients is a feasible and effective regimen for primary prophylaxis, in allogeneic transplantation. disclosure background: bk virus-associated hemorrhagic cystitis (bkv-hc) has emerged as a serious infection after hematopoietic stem cell transplantation (hsct). it is characterized by painful hematuria due to hemorrhagic inflammation of the urinary bladder mucosa, this causes significant morbidity, prolonged hospital care with extensive nursing requirements and increases in healthcare costs. the purpose of this study is to determine the incidence, risk factors, and duration of treatment in our center. methods: we performed a retrospective review of hsct patients at luis calvo mackenna children´s hospital in santiago, chile diagnosed with bkv-hc, from st january to th november . we investigated the incidence, risk factors and duration of treatment of bkv-hc in paediatric patients undergoing hsct over a months period. bkv-hc was defined as bk virus (bkv) detection in urine by pcr testing in association with clinical symptoms and hematuria grade or higher. sixty-seven patients were trasplanted during this period. results: eleven patients were diagnosed with bkv-hc at our institution, only one with bk viremia. the cumulative incidence of bkv-hc in our series was %. all of them were treated with cidofovir. the median age at diagnosis was years old (range: - y.o.). the median time from hsct to hemorrhagic cystitis (hc) was days (range: - days), the median length of treatment was weeks (range: - ). all patients received myeloablative conditioning regimens and used cyclophosphamide ( %); ten ( %) were unrelated cord blood transplant recipients and nine ( %) used antithymocyte globulin. a concomitant viral reactivation (cmv/vh ) was demonstrated in six ( %) patients. no patient died due to bkv-hc or its complications, but in the follow up three patients died, one in relapse and two of other post transplant´s complications. conclusions: bkv-hc is the result of a complex interaction between patient characteristics, donor type and conditioning regimen intensity. these patients experienced significant morbidity and prolonged treatment. in our cohort bkv-hc of all patients but one were transplanted with an unrelated umbilical cord blood unit, all of them received myeloablative conditioning regimen with cyclophosphamide and most of them received anti-thymocyte globulin. we also observed frequently co-existence of viral infections from herpes family as cmv and vh . the main limitations of this work are its retrospective nature and it´s from a single center. more studies are necessary to better understand the epidemiology and risk factor associated with bkv-hc and the morbidities associated with its treatment. disclosure: nothing to declare how we manage hhv- reactivation in the posttransplant setting oscar borsani , anna amelia colombo , daniela caldera , paolo bernasconi university of pavia, san matteo hospital, pavia, italy background: hhv- encephalitis is a life-threatening complication in the post-transplant setting and it develops in about % of patients receiving traditional hsct. several risk factors were described. a differential diagnosis between hhv- encephalitis and other neurological complications is extremely important but often not-easy to achieve because of the highly heterogeneous clinical and radiological features and complexity of interpretation, especially in transplanted patients. here we described vignettes that represent and highlight distinct problems in the diagnosis and management of transplanted patients with suspected hhv- reactivation. methods: we collected the clinical, laboratory and radiological (electroencephalogram, brain mri and brain ct) data of transplanted patients who developed a neurological syndrome suspected for hhv- reactivation. hhv- was detected on serum and csf using rt-qpcr. results: ) a -years-old patient developed a diffuse erythema and subsequent encephalitic syndrome following hsct. the brain mri revealed clear signs of limbic encephalitic and searching for hhv- on serum and csf revealed . copies/ml and . copies/ml respectively. an antiviral therapy was started but no clinical benefit was achieved. ) a -years-old patient developed a typical neurological syndrome without brain mri findings of encephalitis and with no evidence of skin involvement. the lumbar puncture and csf analysis showed a total of . hhv- dna copies/ml. antiviral therapy with ganciclovir and foscarnet was promptly started with clinical improvement and a drastically reduction of hhv- dna on both csf and serum. a new brain mri revealed an acute limbic encephalitis. ) a slight neurological syndrome consisting of confusion and amnesia developed in a -years-old-patient. brain mri findings were compatible with a wernicke syndrome, but no improvement of neurologic symptoms were obtained with thiamine supplementation. csf analysis did not revealed hhv- dna, which was detected at low copies number on serum analysis. a second brain mri was conclusive for limbic encephalitis, so an antiviral therapy with foscavir was started and radiological but not clinical improvement was noted. the patient died after few days. ) in the last case we present a -years-old patient who developed a clinical picture of encephalopathy (i.e. amnesia, ataxia, drowsiness, weakness, depression) with rapid progression to coma after seventy-eight days from hsct. a brain mri showed a slight contrast enhancement in parietal-occipital regions. during the recovery phase from conditioning-induced cytopenia, an increasing in serum hhv- dna was detected. searching for hhv- dna on donor's follicles showed a chromosomally integrated hhv- (cihhv- ). cyclosporin a (csa) was interrupted and neurological improvement was observed in the following hours: a diagnosis of pres was made. conclusions: hhv- encephalitis should be suspected in transplanted patients with a clinical syndrome of encephalopathy. pcr detection of hhv- dna in csf associated with either typical brain mri abnormalities or a clinical diagnosis of nonspecific encephalopathy must lead to the urgent initiation of systemic antiviral treatment. if an increase of both serum hhv- dna and wbc is detected, a cihhv- should be confirmed. pres is an important differential diagnosis in transplanted patients which developed an encephalitic syndrome. disclosure: nothing to declare background: cytomegalovirus (cmv) infection is a major cause of morbidity and mortality after hematopoietic stem cell transplantation (hsct). it causes end-organ disease, multi-organ dysfunction syndrome, graft failure, increased susceptibility to infections and gvhd. greatest risk of cmv infection in a seropositive host is the reactivation of latent virus. methods: a prospective descriptive study performed at armed forces bone marrow transplant centre, rawalpindi, pakistan from dec to sep . hundred consecutive patients who underwent hsct were followed with weekly cmv dna quantitative pcr from engraftment till day for cmv reactivation. patients in whom cmv pcr showed more than copies/ml were treated with antiviral therapy. factors associated with cmv reactivation, outcome of antiviral therapy and effect of cmv on transplant outcome is studied. results: out of cases, were hla matched siblings, were matched family donors and were haploidentical transplants there were males and females. mean age was . ± . years. fourty-two transplants were done in thalassemia, in aplasia, in leukemias and in other hematological disorders and immune deficiencies. ninety-eight recipients and all the donors were cmv seropositive before hsct. cmv reactivation was seen in patients and of them had cmv viral load more than copies/ml and patients had cmv viral load less than copies/ml. nineteen patients had no cmv reactivation. mean time to reactivation since transplant was ± days. valganciclovir was given in patients due to ease of administration and six patients were treated with ganciclovir during their hospital stay. only one patient had resistant disease. mean time to clear viremia was ± . days. the patients having viral load less than copies/ml, subsequently cleared cmv without any treatment. antiviral agents; ganciclovir and valganciclovir were equally effective for treating cmv infection with % efficacy, however, more adverse effects were seen with ganciclovir. myelosuppression i-iii was seen in % patients treated with valganciclovir and in % treated with valganciclovir. renal impairment i-ii was seen in % of valganciclovir and % of ganciclovir treated patients. steroid administration was strongly associated with cmv reactivation (p = . ). no statistically significant association was found with the use of atg, gvhd, underlying disease, abo or gender mismatch. os was . % and . % in with and without cmv reactivation (p= . ) and dfs was . % and . % in with and without cmv reactivation (p= . ) conclusions: cmv reactivation was seen in % of the transplant recipients, this is higher compared to the western world due to high cmv seropositivity is this region. steroids administration in post-transplant period significantly increase the risk of cmv reactivation. preemptive therapy with valganciclovir effectively treats cmv reactivation with acceptable side effects. viral threshold for treatment should be decided considering the regional endemicity. cmv adversely affects the transplant outcome in terms of dfs and os. disclosure: no conflict of interest. acute nephritis requiring nephrectomy caused by adenovirus (hadv) and human polyomavirus bk (bkpyv) following allogeneic hematopoietic stem-cell transplantation in a patient with ph+ all background: adenovirus infection represents an important cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (allo-hsct), with no established therapy. although different organs may be affected by disseminated hadv infections, kidney involvement has been rarely reported. co-infection of hadv and bkpyv are common complication in patients undergoing allo-hsct, but recent studies demonstrate that bkpyv may facilitate the replication of hadv and lead to elevated viremia with increased virulence and serious clinical consequences. here we report a case of an adult patient who required a monolateral nephrectomy due to hadv pyelonephritis as an early complication of allo-hsct for philadelphia-positive acute lymphoblastic leukemia (ph+ all). methods: in september , an ethiopian gentleman was diagnosed with ph+ all at the age of years. he was treated with polychemotherapy in association with the tyrosin kinase inhibitor imatinib mesylate achieving a complete remission (cr). one year later, due to disease relapse with cns involvement, he was started on vincristine and dexamethasone plus imatinib treatment and in april he was referred to our bmt center from ethiopia. upon confirmation of the p ph+ b-all diagnosis, therapy with the scr/abl dual inhibitor dasatinib associated to intrathecal chemotherapy was started and a salvage treatment with inotuzumab ozogamicin followed by an allogeneic hsct from a hla-identical brother was planned. having achieved a documented molecular cr disease status, in june the patient underwent allo-hsct following the fludarabine-melphalan reduced-intensity conditioning regimen. graft-versus-host prophylaxis included anti-thymocyte globulin, cyclosporine and mycophenolate mofetil results: on day + post-transplantation the patient developed macro-hematuria due to hemorrhagic cystitis and a ct scan unveiled a left pyelonephritis with marked kidney enlargement. kidney microbial investigations were all negative. at the same time, hadv viremia with very high copy number (> cp/ml) was documented and also elevated bkpyv (> cp/ml) viruria and viremia ( cp/ml). the genotyping of hadv evidenced serotype b mainly involved in infections of the urinary tract. treatment with cidofovir was immediately started; nonetheless, due to rapid clinical worsening despite maximal antibiotic therapy, on day + a left nephrectomy was performed, which led to a subsequent progressive resolution of the clinical symptoms and negativization of hadv and bkpyv viremia and viruria. pcr real time performed on the kidney tissue unveiled very high concentration of hadv copy number. conclusions: acute pyelonephritis due to disseminated hadv infection may represent a possible cause of severe complication following allo-hsct. monitoring of hadv copy number is helpful to evaluate infection severity and response to treatment. co-infection of hadv and bkpyv in immunocompromised patients should be always considered likely to worsen clinical course and outcome. disclosure: nothing to declare background: infection is a major cause of morbidity and mortality in patients (pts) receiving an allo-hsct. its severity is related primarily to the depth and duration of neutropenia. febrile neutropenia (fn) is defined as a neutrophil count below cells/mm and a fever ≥ . °c at a single measurement or≥ °c times at one hour intervals. the objective of our study is to analyze the epidemiological, clinical, biological characteristics of febrile episodes (fe) occurred in pts who benefited an allo-csh over a period of years. methods: from january to december , allo-hsct were performed in pts including sibling-hla identical, haplo-identical and phenoidentical for essentially acute leukemia ( pts, %), acquired and congenital aplasia ( pts, %). the median age is years ( - ) and sex-ratio (m/f): . . prophylaxis consisted on isolation sterile room with laminar flow, digestive decontamination, fluconazole and aciclovir. nine pts ( . %) were infected at the time of hospitalization (cellulitis , pneumoniae , bacterial angina , veinitis , bronchial pneumonia , furuncle cutaneous ) requiring treatment with antibiotics. conditioning regimen is myeloablative in all pts. anti-thymocyte globulin is used in pts ( . %). peripheral blood stem cells (pbsc) are used in pts ( %) with an average level of cd + cells: , . /kg ( . - . ) , bone marrow (bm) in pts with a mean level of nucleated cells: . x /kg ( . - . ) and the association of pbsc-bm in pts (haplo-identical). at each fe, are practiced: chest x-ray, procalcitonin test, blood culture, microbiological study of urine and stool (if diarrhea). results: all pts showed aplasia with an average duration of days ( - ), neutrophil engraftment was observed at day ( - ). one hundred and twenty-nine pts ( . %) presented fe with an average of . per pt. eleven pts ( %) had fe or more. forty nine ( , %) fe are clinically documented (digestive: , skin: , pulmonary: , urinary: , oto-rhino-laryngology: ). the blood cultures are made at fe, fe are microbiologically documented ( %): gram-positive bacteremia in % (mainly coagulase negative staphylococci) and gramnegative bacilli in % of cases. procalcitonin test performed during fe: normal ( cases), probable infection ( cases), probable sepsis ( cases), severe sepsis ( cases) and septic shock (one case). empirical double antibiotic therapy is initiated in pts without waiting for the results of the microbiological study. this association was sufficient in pts ( %). the transition to a second line was needed in pts ( . %) and third line in pts ( %). antifungal is added in cases ( %). eight pts benefited from g-csf. the evolution is favorable in fe ( . %), apyrexia obtained after an average of . days . three pts died ( %) by severe sepsis on a durable aplasia, of which had a cellulitis before the conditioning. conclusions: fe increase morbidity and mortality in allo-hsct so prophylactic measures are essential. empirical antibiotics treatment has to be instituted very quickly in the absence of documentation. disclosure: nothing to declare p abstract withdrawn. atsushi satake , masaaki hotta , ryo saito , akiko konishi , hideaki yoshimura , takahisa nakanishi , shinya fujita , tomoki ito , kazuyoshi ishii , shosaku nomura kansai medical university, osaka, japan background: cytomegalovirus (cmv) infection remains a common complication after allogeneic hematopoietic stem cell transplantation (ahsct), which results in increased morbidity and mortality. letermovir is a novel anti cmv drug that inhibits the cmv-terminase complex. the purpose of this retrospective study is to elucidate the efficacy and safety of cmv prophylaxis with letermovir early after ahsct in clinical practice. methods: we retrospectively analyzed the incidence of cmv infection, cmv disease, preemptive therapy, adverse events through week after ahsct, the rates of engraftment and overall survival. all patients underwent ahsct in our institution for hematopoietic malignancies between may and nov . data collected in this study included patient's characteristics such as age, sex, disease status, donor source and cmv disease risk. cmv infection was evaluated by cmv antigenemia. this study was approved by the research ethics committee of the faculty of medicine, kansai medical university. results: thirteen patients (male , female ) underwent ahsct and received cmv prophylaxis with letermovir. the median age was years (range, - years). overall, of patients ( . %) were considered to be at high risk for cmv, including patients ( . %) with haploidentical donors, and ( . %)with mismatched, unrelated donors. all patients began letermovir from day after ahsct, and achieved engraftment (median , - days). no patient developed cmv disease and required preemptive therapy. one patient died of treatment-related mortality, and patients died of acute gvhd. although one patient discontinued letermovir before day after ahsct because letermovir was suspected to be a cause of persistent nausea, severe adverse events were not observed. conclusions: it is still unknown whether cmv prophylaxis with letermovir improves os and reduces trm; however, our data suggests that cmv infection is considerably inhibited by administration of letermovir early after ahsct. clinical trial registry: not applicable. disclosure: the authors declare noconflicts of interest for this study. background: cytomegalovirus (cmv) is cause of increased morbidity and mortality after transplantation of hematopoietic cells. the pathogenesis of cmv disease or infection is complex with multiple interactions with the immune system, mainly in acute and chronic graft-versus-host disease (gvhd). the aim of this study is to analyze the risk factors for the reactivation of cmv in patients undergoing allogeneic hematopoietic cell transplantation (hct). methods: prospective descriptive study of the risk factors for the reactivation of cmv in the described population. univariate and multivariate analysis of the predisposing factors were performed: donor graft, treatment with corticosteroids, use of antithymoglobin, serologic status, conditioning regimen and the presence of gvhd. results: during the period between august until january , patients were evaluated. . % (n: ) had reactivation of cmv. average reactivation was days post transplant. both (recipient and the donor) had positive cmv igg in . %. in the univariate analysis, the reactivation of cmv was associated with haploidentical transplantation (p: < . ), with the use of corticosteroids (p: < . ) and gvhd (p: < . ). in the multivariate analysis, the haploidentical transplant maintained its statistical significance in comparison with the related allogeneic transplant (p: . , or: . ; ic %: . - . ) as well as the use of corticosteroids (p: . , or: . ; ic %: . - . ). % of patients receiving corticosteroid treatment had grade ii / iii gvhd. the serologicac status, myeloablative conditioning regimen and the use of atg showed no statistically significant association. conclusions: in patients undergoing allogeneic transplantation, were found as risk factor to reactivation, those who received haploidentic transplantation and treatment with corticosteroids. another risk factor that showed greater reactivation was the presence of gvhd. disclosure: nothing to declare methods: a y/o male was referred for allogeneic transplant following cycles of induction therapy for aml with complex karyotype and axsl mutation having achieved complete remission following the first cycle of chemotherapy. his first induction cycle was complicated by a perianal myeloid sarcoma which became infected and required surgical drainage and formation of a defunctioning colostomy. results: following allogeneic transplants, the first complicated by secondary graft failure and the second by primary graft failure he presented with two skin lesions, with a third lesion adjacent to his stoma developing shortly after admission. all lesions were erythematous with central necrosis and progressed rapidly in size over hours. biopsy of the skin and para-stomal lesions revealed fungal mycelia, with culture subsequently identifying rhizopus oryzae. initial treatment was with liposomal amphotericin b mg/kg/day followed by dose escalation to mg/kg/day due to the development of new skin lesions. the patient had been taking posaconazole (tablet) prophylaxis since his first allogeneic transplant and peripheral blood drug levels checked at the time of admission were therapeutic confirming that this was a breakthrough fungal infection. consequently posaconazole was stopped and isavuconazole added to the treatment regimen. surgical assessment was undertaken but surgery was deferred on the basis of high risk due to the extent of the infection and the patient´s profound pancytopenia. the organism was tested for in vitro susceptibilitiy and found to be resistant to posaconazole (mic > mg/l), with borderline resistance to isavuconazole (mic mg/l) and sensitive to amphotericin b (mic . mg/l) (phe mycology reference laboratory, england). isavuconazole was therefore stopped and the patient was managed with liposomal amphotericin b along with daily granulocyte infusions. he underwent a third allogeneic transplant using a different unrelated donor and stable engraftment was achieved. post transplant there was initially an increase in the size of the para-stomal lesion, but no new skin lesions developed. following engraftment he underwent resection of the stomal lesion, with primary closure and re-siting of his stoma. amphotericin b was replaced by isavuconazole prophylaxis on discharge and he continues to make an excellent recovery. conclusions: whilst aspergillus species remain the most common cause of invasive fungal infections in allogeneic transplant patients, other species including the mucorales are seen, and generally associated with poorer outcomes. whilst there are standardised methodologies for susceptibility testing, fungi specific cut offs based on clinical outcomes are only available for a limited number of species/ antifungal agents. in this case, susceptibility testing demonstrated resistance to posaconazole which was consistent with the clinical presentation of invasive infection despite therapeutic levels of posaconazole. it is also worth noting that an estimated % of r. oryzae isolates in the uk are resistant to posaconazole. treatment with high dose amphotericin b resulted in improvement in small skin lesions with stabilisation of the larger stomal lesion until count recovery allowed surgical resection. background: total depletion of innate and adaptive immune cell populations occurs after intensive chemotherapy and hematopoietic stem cell transplantation (hsct). both t and b lymphocyte pools are restored slower that myelomonocytic populations. hsct patients are at high risk for bacterial and viral infections at early terms (< days) post-transplant. the reconstitution of the immune system depends on the time required for stem cell recruitment, differentiation, expansion, maturation and release into the bloodstream. restoration terms for myeloid cells after hsct are usually defined as the st day with neutrophil count of ≥ . x ^ /l with mean recovery terms of to days. high occurrence of cytomegalovirus (cmv) in hsct patients mostly result from reactivation of a latent virus acquired in early childhood. however, delayed immune reconstitution and subsequent infections such as cmv, adenovirus (adv) or herpes (hhv- ) diseases are not unusual and still constitute a major cause of death in peru. methods: peruvian pediatric patients (n= ) diagnosed with aplastic anemia, mds, aml or all underwent a haploidentical hsct performed with the clinimacs device. patients treated were separated in two groups. the group of patients who received viral prophylaxis (ganciclovir) was compared to the group that did not receive any prophylaxis treatment. viral reactivation was confirmed by pcr test twice a week and clinical signs within days after hsct. results: in the group that didn´t received prophylactic treatment, engraftment occurred close to day post haplo-hsct and none of the patients developed gvhd (graft versus host disease). nevertheless, incidences of cmv, hhv- and bkv infections before day post haplo-hsct were still high. an overall survival (os) over % with an ic % was reached at the end of the first year. on the other hand, the group of patients that received prophylaxis with ganciclovir did not developed gvhd and reached the engraftment close to day with a very low viremia incidence after the first month post haplo-hsct. all viral reactivations were caused by cmv and the os was over % with an ic % at the end of the first year. previous prophylaxis to both the donor and the receptor with ganciclovir ( mg/kg) every hours before and during the conditioning regimen has allowed a better control of viral reactivation. conclusions: the attempts to improve immune function and reduce nonrelapse mortality from infectious complications without increasing gvhd have focused on a partial t cell depleted graft, such as t cell depletion (tcr α/β). this graft retains a large numbers of effector cells, such as tcr γ/δ and natural killer cells. however, delayed immune reconstitution and subsequent infections are a big issue. a novel partial t cell depletion strategy such as depleted naïve t cells (cd ra+ t cells) could enhance the recovery of immune function after haplo-hsct because donor pathogen memory t cells from the donor are retained. it is necessary to increase the studies and the database to set the scheme of previous prophylaxis to the recipient to contain the viral reactivation and to help a rapid immune reconstitution. disclosure: no conflict of interest is declared information was recovered from the medical records. results: thirty-four patients were included, of them with the following diagnoses: acute leukemia ( ), granulocytic chronic leukemia ( ), dendritic cell neoplasia ( ), aplastic anemia ( ). % of the patients received a transplant from an identical hla donor and % received a haploidentical transplant. mean age's patients was years ( - ). prophylaxis with posaconazole was performed on % of the patients with identical hla and % on haploidentical group; the rest of the patients received fluconazole. the posaconazole group presented: fever %, mucositis gi-ii %, gastrointestinal toxicity gi-ii % (p= . ), hepatic toxicity %, kidney toxicity %, oral candidiasis %. during this period none of the patients presented invasive fungal infection in any group. there were deceases, one on each group and none related to a fungal infection. the overall survival was of the % versus % on the posaconazole group and the fluconazole group respectively. conclusions: the prophylaxis with posaconazole and fluconazole is effective on the prevention of invasive fungal infection on the first days. the toxicity was similar on both groups. posaconazole can be effective on the prevention of the haploidentical type. is necessary to continue following the patients with infection risk on a long-term period associated with the chronic gvhd. disclosure: none declared lymphoma these results open the question whether allo-sct should still be offered to these patients. methods: we aimed to define the role of allo-sct in refractory or relapsing after two lines de novo or transformed dlbcl patients, and its comparison with zuma- car-t cells trial (neelapu et al nejm ). we analyse long-term allo-sct results in de novo (n= ) or transformed dlbcl (n= ) out of the allo-sct performed in our institution between october to october . results: patients and transplant characteristics are summarized in table . complete response (cr) at days was , % and % of them remain in cr at months. with a median follow-up of months, -year progression-free survival (pfs) was % and -year overall survival (os) %, with a -year transplant-related mortality of %. refractoriness at the time of the transplant was associated with a poorer prognosis, with only out of refractory patients being long term survivors (figure ). similar results were reported for zuma- trial, with a best response of % cr retained in % of them at months. with a median follow-up of months, -months pfs was % and -months os %. patients characteristics did not differ in our series and zuma- , except that all the patients in zuma- were refractory prior to therapy (table ) . conclusions: although very few patients with de novo or transformed dlbcl are offering an allo-sct ( % of all allo-sct), this is a curative option in chemosensitive patients and with more mature data and longer follow-up than with car-t therapy; for these reasons, it should still be offer to these poor prognosis patients. moreover, almost all patients have now available donor, better graft-versus-host disease prophylaxis will decrease trm and morbidity, and new therapies will make more patients in sensitive disease before allo-sct. therefore, allo-sct and car-t cells are strategies to be discussed in every young patient with available donor. disclosure: honoraria as advisor or speaker from gilead ( methods: consecutive patients transplanted for hgbl (excluding burkitts lymphoma) between - in the ebmt database were included. data collected included age, sex, pathology subtype (hgbl (including subtypes), tfl, dhl), disease status at sct, conditioning (ma vs beam cam vs flu-mel-cam/atg), engraftment, day outcome, trm, os and pfs and eligibility for emea licensed indication of car-t therapy. results: fifty patients ( m, f) with a median age of at diagnosis and at sct were included. the subtypes included hgbl (n= ), tfl (n= ) and dhl (n= ). indications for sct were: primary refractory (n= ), relapse < months after primary treatment (n= ), previous autologous-sct (n= ) and dhl (n= ). the median lines of therapy was (range to ). conditioning used was cytbi n= , bu/cy n= , etop/tbi n= , flubucy n= , beamcam n= , fmc/t, n= . all patients engrafted with neutrophil > . /l at median days and platelets > /l at median days. the day mortality was % (progressive disease %, nrm %) with a year os of % and mortality due to progressive disease % and nrm %. disease subtype influenced outcome with an os for primary refractory hgbl, relapsed hgbl, tfl and dhl respectively of %, %, % and %. patients were eligible for a licensed car-t product. conclusions: the outcome of these high risk hgbl patients have an acceptable os of %, with relapsed disease being the commonest cause of mortality. patients with dhl have a particularly good outcome in this series; recent evidence indicates that some of these patients with a non-immunoglobulin gene associated myc translocation could be managed more conservatively (ash sehn). the outcomes achieved with allogeneic-sct in this series will provide a baseline for outcome assessment with a cart program. disclosure: nothing to declare background: immune checkpoint inhibitors (ici) allow to achieve a durable remission in patients with resistant or refractory (r/r) classical hodgkin lymphoma. however, the information about optimal duration of therapy and the prognosis of the patients after ici cessation is limited (manson, blood ). therefore, the optimal role of hematopoietic sct (hsct) in this patient group is not defined. our aim was to determine remission duration in patients who discontinued ici monotherapy after achieving complete remission (cr). methods: this analysis included patients ( male/ female) aged to (median years) with r/r classical hodgkin lymphoma who were treated with nivolumab ( mg/kg every days) and achieved cr. response was assessed by positron-emission tomography/computed tomography (pet/ct) using lyric criteria every month. after nivolumab therapy had been stopped the patients received no other treatment and disease was assessed every months by pet/ct. median follow-up after therapy discontinuation was ( - ) months. results: at the moment of therapy initiation ( %) patients had stage disease, ( %) patients had progressive disease (pd), ( %) patients had stable disease, ( %) patients had partial remission and ( %)complete remission; ( %) patients had b-symptoms and ecog score > . the median number of previous therapy lines was ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . before nivolumab initiation high dose chemotherapy with autologous sct was performed in patients ( %) and ( %) received brentuximab vedotin. the median number of nivolumab cycles was ( - ). cr was achieved after median of ( - ) cycles. the median duration of therapy after achievement of cr was ( - ) months. at the time of analysis, all patients were alive, ( %) out of patients relapsed after therapy discontinuation. the median progression-free survival (pfs) for the total group was not achieved. among patients with relapse, the median time before pd was ( - ) months. after relapse all patients were retreated with nivolumab monotherapy or with chemotherapy combination. one patient achieved complete remission; -partial remission; -indeterminate response type . other patients are continuing the therapy and their response has not yet been evaluated. conclusions: while complete response was maintained in some patients at median follow up of months after nivolumab therapy cessation, the pfs plateau was not reached. we report that patients with relapse after nivolumab discontinuation sustained sensitivity to nivolumab and achieved a response during retreatment with nivolumab monotherapy or with chemotherapy combination. in patients with unsatisfactory response to nivolumab retreatment, hsct option should be considered. disclosure: nothing to declare high dose chemotherapy with autologous stem cell transplantation in primary central nervous system lymphoma: data from the japan society for hematopoietic cell transplantation (jshct) registry center hospital, tokyo, japan, national cancer institute, bethesda, md, united states, okayama university hospital, okayama, japan, kanazawa medical university, uchinada, japan, kyoto university, kyoto, japan, aomori prefectural central hospital, aomori, japan, yamagata unversity school of medicine, yamagata, japan, tenri hospital, tenri, japan, hiroshima university, hiroshima, japan, japanese data center for hematopoietic cell transplantation, nagoya, japan, nagoya university graduate school of medicine, nagoya, japan, shimane university hospital, izumo, japan background: high-dose chemotherapy (hdt) with autologous stem cell transplantation (asct) has been shown to improve prognosis of patients with central nervous system (cns) lymphoma. whereas the common regimen of hdt for pcnsl in the europe and the us is thiotepa-based regimen, e.g. bcnu-thiotepa, tbc (thiotepa-busulfan-cyclophosphamide), thiotepa-based regimen was only available before discontinuation of thiotepa in in japan. we report the results of asct for pcnsl from the japan society for hematopoietic cell transplantation (jshct) registry. methods: data from the jshct registry were retrospectively analyzed. patients with pcnsl who received first hdt/asct between and were evaluated. distribution differences of clinical characteristics between groups were analyzed with fisher´s exact or mann-whitney u tests. overall survival (os) and progression free survival (pfs) were calculated using kaplan-meier method. two-group analysis of the cumulative incidence of relapse was conducted using the grey test. factors were analyzed in univariable analysis, and all factors with p≤. were retained in the multivariable model. all p values were sided, and values were regarded statistically significant if p< . . results: median age was months (range - ) with patients over years of age; males and females. ecog-performance status (ps) at diagnosis was better (ps - ) in patients and poor (ps - ) in patients. serum lactate dehydrogenase (ldh) levels at diagnosis were elevated in patients. karnofsky ps and cerebrospinal fluid (csf) protein concentration at diagnosis were not collected in the registry. patients were in complete remission (cr), patients were in partial response (pr), and patients were stable disease (sd) or progressive disease (pd) at the time of hdt/asct. after hdt/asct, additional patients achieved cr. with median follow-up period of months, the -year os and pfs were . % and . %, respectively. the was no significant difference in os and pfs between upfront and salvage hdt/asct. since thiotepa, a key agent in hdt/asct for pcnsl, has been unavailable after the discontinuation in japan, the hdt regimens used were not uniform. thiotepa-containing hdt was received by out of patients before , but by out of patients after . thiotepa-containing hdt showed improved pfs (p=. ), lower relapse (p=. ) and a trend toward a survival benefit. in the multivariate analysis, non-complete remission at hdt/asct was an independent predictor for os (hr= . , %ci: . - . , p=. ) and thiotepacontaining hdt remained significant for pfs (hr= . , %ci: . - . , p=. ). [[p image] . os(a),pfs(b) in all patients (n= ) and cumulative incidence of relapse in cr patients (c; n= )] conclusions: our results confirm the activity of thiotepacontaining regimen for hdt/asct in pcnsl patients. currently a pharmaceutical company re-develops thiotepa for new approval of hdt/asct in pediatric solid cancer and adult lymphoma in japan (japiccti- ). further evaluation with the thiotepa by prospective clinical trials is warranted. disclosure background: t-cell non-hodgkin lymphomas (t-nhl) are rare diseases and they are associated with worse prognosis when compared to their b-cell counterparts. allogeneic stem cell transplantation (allo-sct) may have a curative potential for these patients due to the graft versus lymphoma effect. however, data is limited on the efficacy of allo-sct for these diseases. methods: we identified patients ( % females; median age: y; range, - ) with t-nhl that underwent allo-sct at university hospital eppendorf between and . twenty-one patients (underwent allo-sct from a matched sibling donor (msd) and ( %) from a matched unrelated donor (mud). sixteen patients had ptcl ( %), n= ( %) anaplastic large-cell lymphoma (alcl), n= ( %) angioimmunoblastic large cell lymphoma, n= ( %) adult t-cell leukemia/lymphoma, n= ( %) hepatosplenic gamma/delta t-cell lymphoma, n= ( %) enteropathy associated t-cell lymphoma, n= ( %) tcell-prolymphocytic leukemia, and n= ( %) each extranodal t/nk-cell lymphoma, cutaneous t-cell lymphoma as underlying diagnosis. the median ann arbour stage at diagnosis was (range, - ). ten patients ( %) had bone marrow involvement at diagnosis. all patients were heavily pretreated, ( %) patients relapsed post autologous stem cell transplant (apsct) and one patient post allo-sct. fifteen patients ( %) were transplanted in complete remission (cr) ( in st cr, in nd cr), n= ( %) in partial remission (pr), and n= ( %) with advanced disease. most of the patients received myeloablative conditioning ( %). thirty-eight ( %) patients received total body irradiation based regimens and ( %) received chemotherapy based regimens. twenty patients ( %) received anti-t-lymphocyte globulin (atlg neovii), and most patients ( %) received g-csf mobilized peripheral stem cells. results: overall, patients ( %) had neutrophil engraftment (median days: ; range, - ) . at day , the cumulative incidences of grade ii-iv and grade iii-iv acute gvhd were % and %, respectively. after a median follow up of months (range, - ) the cumulative incidences of chronic gvhd was % distributed evenly between limited and extensive. twenty nine patients ( %) achieved cr after allo-sct. median overall survival (os) and disease free (pfs) survival were months and months respectively. the year os and pfs were % and % respectively. fourteen ( %; % ci [ . - . ]) deaths were due to non relapse mortality (nrm) and patients ( %; % ci [ . - . ]) died due to disease progression. patients with a male donor had improved os compared to those with a female donor ( year os male %, female %; p= . ). patient gender, disease subtype, bone marrow involvement, type of allo-sct, donor, patient cmv status, abo incompatibility, disease stage at diagnosis, previous transplant, disease status at transplant, conditioning regimen, atg and stem cell source had no effect on os, pfs, nrm, and post transplant complications. conclusions: acknowledging the retrospective nature, our study shows that allo-sct induces high rates of complete remission, and may have a curative potential even in diseases relapsing post asct. however our findings need to be confirmed in larger prospective studies. disclosure: no funding, no conflict of interest p abstract already published. at-home autologous stem cell transplantation in lymphoma patients: clinical impact of non-g-csf administration post-transplant background: severe neutropenia remains the main cause of morbidity and mortality after autologous stem cell transplantation (asct). g-csf administration after asct is a common practice, performed to reduce the duration of neutropenia and its complications. in a previous work in patients with multiple myeloma managed at home after asct, we did not observe a deleterious clinical impact in those patients that did not receive g-csf post-transplant (martinez-cibrian n. et al, bmt ) . despite the fact that lymphoma patients receive a more intensive conditioning regimen that multiple myeloma patients, we hypothesized that the use of g-csf in lymphoma patients managed at home during the aplasia phase of asct does not provide a significant clinical benefit. methods: lymphoma patients were managed at-home since day + of asct. between february and july , patients received at-home g-csf μg/kg per day since day + until their anc reached x /l (g-csf group) and, since august , patients did not receive g-csf (non-g-csf group). all patients were conditioned with beam and received prophylaxis with a quinolone, fluconazole, aerosolized pentamidine and low-dose acyclovir (hvs+). in all cases we added primary prophylaxis with piperacillin-tazobactam . g/ h i.v., using a portable intermittent infusion pump (iip), from an absolute neutrophil count (anc) < . x /l until the first day of fever or until attaining an anc of x /l. first-line therapy at home of neutropenic fever (nf) was refrigerated meropenem g/ h i.v using a portable iip. fever was an indication of immediate visit to the hospital, and those patients presenting with focal infection or signs of severe sepsis were admitted. other indications for readmission were: willingness of the patient or caregiver; uncontrolled nausea, vomiting or diarrhea and mucositis requiring total parenteral nutrition or i.v. morphics. results: the main characteristics of the patients are shown in table . there were no differences between groups with respect to gender, diagnosis, stage of disease, comorbidity index (hct-ci), source of stem cells (peripheral blood) and cd + cell dose infused. the median (range) age (years) was ( - ) in g-csf group and in non-g-csf group (p= . ). duration of neutropenia less than . x /l was significantly longer in non-g-csf group, with a median of days (range - ), compared with (range - ) in g-csf group (p < . ). severe neutropenia, less than . x /l, was also longer in the non-g-csf group ( days ( - ) vs. ( - ); p= . ). no differences were observed in the time to platelet engraftment. g-csf post-transplant avoidance did not influence the incidence of neutropenic fever, the first day and duration of fever, the incidence and severity of oral mucositis, bacterial infections documented and number of readmissions. the median duration of the whole procedure at-home was day shorter in the g-csf group ( vs. days; p= . ). conclusions: the policy of not administering g-csf post-asct in our home-based program for lymphoma patients, that include intensive bacterial prophylaxis, did not have a deleterious impact on the main results reviewed, which suggests that elimination of its use can be achieved. disclosure the aim of this study was to analyze the spanish experience with patients diagnosed of nhl who received haplosct with pt-cy. methods: sixty patients who received haplosct with pt-cy in spanish centers from to were analyzed. patients were followed-up until . gvhd prophylaxis consisted in cyclophosphamide mg/kg/d on days + and + , and mmf and a calcineurin inhibitor from day + . results: patients' characteristics are summarized on table . median age of patients was , % male, and diagnosed from t cell lymphoma ( %). most of them didn´t achieve complete response prior to transplant ( %), but only % with active disease. up to % of patients had received previous transplant, from which % was an allogeneic transplantation. source of stem cells was mainly peripheral blood ( %), and reduced intensity conditioning was the preferred ( %) regimen. donors were % siblings ( ), % offspring ( ), and % parents ( ). median neutrophil and platelet engraftment was ( - ) and ( - ) days, respectively. acute gvhd grade ii-iv rate was %, with only patients developing grade iii-iv ( %). chronic gvhd rate was %, and only in ( %) was extensive. median follow-up was months. the -year overall survival and event free survival was % and %, respectively. the -year cumulative incidence of relapse was % and -year cumulative incidence of nrm was %. conclusions: relapsed/refractory nhl are aggressive entities with a fatal course in a short period of time. haplosct with pt-cy permit a new treatment option among these patients, with acceptable outcomes. more studies are needed with a larger cohort of patients and longer follow-up to confirm these results. disclosure: nothing to disclose. higher suv at pre-transplant and day posttransplant pet scan both independently predict inferior survival in patients with diffuse large b cell lymphoma background: autologous stem cell transplant (auto-hct) can cure some patients with relapsed diffuse large b-cell lymphoma (dlbcl) but relapse occurs in about % of patients. while our center and others utilize routine surveillance imaging post-transplant, the utility in this setting is unclear. imaging is costly and exposes patients to radiation. novel interventions are now available for patients relapsing after auto-hct making early disease recognition crucial to intervene prior to clinical progression. hence, we studied impact of post-auto-hct surveillance ( )f-fdg-pet ct at day on transplant outcomes. methods: we analyzed a cohort of consecutive auto-hct recipients with relapsed/refractory dlbcl who then underwent pre-transplant pet/ct and surveillance pet ct at day (interquartile range (iqr): - days) post-hct at the university of minnesota medical center. univariate analysis was performed to analyze pet parameters including deauville score (d), standardized uptake values (suv), total lesion glycolysis (tlg) and total metabolic tumor volume (tmtv) as predictors of relapse and survival after auto-hct. in addition, we assessed outcomes of patients with clinically versus radiographically detected relapsed dlbcl after auto-hct. other pre-hct factors analyzed included age, gender, conditioning regimen, performance status, consolidation radiation therapy, tmtv, suv, tlg. results: five-year cumulative incidence of relapse after auto-hct was % ( %ci to ) and overall survival (os) was % ( % ci to ). twelve ( %) relapsed prior to day . d-score for patients with d pet/ct were d ( %), d ( %), d ( %), d ( %), d ( %) with median survival in years for d , d , d and d of . , . , . , and . , respectively. mean suv varied from . (d ) to . (d ). suv was predictive of relapse and os. risk of relapse increased with doubling of suv; -fold higher suv increased hr by . ( %ci . - . ; p= . ). mortality increased with doubling of suv in both pre-hct ( -fold increase in suv associated with hr . [ % ci . to . ]; p= . ) as well as post-hct pet (hr . [ % ci . to . ]; p= ) irrespective of the bulk of tumor. in addition, risk of death was times higher in d patients relative to d (hr . [ % ci = . to . ]; p≤ . ). patients with d (n= ) had higher tmtv ( cm ) compared to d (n= , tmtv . cm ). the hazard ratio for death following relapse was -fold higher (hr . [ % ci . to . ]; p= . ) if relapse was detected clinically versus only radiographically over a median follow-up time period of . years. other pretransplant patient and disease characteristics did not significantly influenced the outcomes. conclusions: in patients with r/r dlbcl undergoing auto-hct, surveillance pet/ct at day identified patients with poor survival~ year. higher suv in both pre-transplant as well as post-hct pet was predictive of increased mortality. these patients may benefit from novel treatments. [ there are concerns about the risks of nivolumab treatment before and after allo-hsct, due to the risk of heavy gvhd, thus the place of immune checkpoints inhibitors is not yet defined. this report include analysis of our center experience of nivolumab treatment in patients with r/r hl before and after allohsct. methods: we retrospectively evaluated the results of allohsct in patients with r/r chl who had undergone transplant from to . the analysis included patients received the flube conditioning and ptcy gvhd prophylaxis. in group a patients (n= ) received bridge therapy with nivоlumab and in group b patients (n= ) received bridge therapy with brentuximab vedotin or chemotherapy-based bridges. time from the last nivolumab administration to allohsct was at least months. results: at the time of analysis, median follow-up was ( - ) months for group a, and ( - ) months for group b. there was no difference in two-year os (p= , ) with significantly better efs (p= , ) for group a versus group b: % and % vs , % and % respectively. relapse incidence was % for group a versus , % in group b (p= , ). cumulative incidence of non-relapse mortality at years was , % and , % in group a and group b, respectively (p= , ). there was no difference in grade ii-iv ( % vs %, p= . ) and grade iii-iv ( % vs %, p= . ) agvhd, as well as extensive chronic gvhd ( % vs %, p= , ) in groups a and b, respectively. ten patients with relapse after allohsct were treated with different doses ( , - mg/kg) of nivolumab in cic center. at the median follow up of mo ( , - ) all patients remain alive. the objective response to therapy was assessed in patients noted in all patients ( %), disregard the dose of the nivolumab: cr in %, and pr in %. the response was lost in four patients, which required nivolumab retreatment. none of the patients developed gvhd after nivolumab administration. in this analysis, there was also no correlation between dose of nivolumab and incidence and severity of adverse events. conclusions: allohsct in combination with immune checkpoints inhibitors is a good option for patients with r/r chl. consideration for immune-mediated toxicities and the potential for increased graft-versus-host disease remain important. early data suggest that nivolumab may be an efficient therapy in patients with r/r chl relapse after allo-hsct. further research needed. disclosure: the authors declare no conflicts of interest. background: transformation to diffuse large b-cell lymphoma (dlbcl) is considered to be one of the most unfavourable events of lymphoma natural history with poorer outcome as compared to de novo dlbcl (alonso-Álvarez et al, bjh ). in patients suitable for salvage therapy, hematopoietic stem-cell transplantation (sct) could be an option, although its role is not well stablished. we analyse indication and outcome after transplant in transformed dlbcl at a single reference transplant unit. methods: out of total of transplants performed at our unit between and - autologous and allogeneic- were dlbcl transformed from an indolent nhl. of them, received an autologous sct (asct) and an allogeneic sct (allo-sct). results: median age was years old (range - ) and (range - ) for patients receiving asct and allo-sct, respectively. all asct received beam as a conditioning regimen and most of the patients in the allo-sct group received a fludarabine/melphalan combination ( %). gvhd prophylaxis consisted on tacrolimus/sirolimus combination in % and calcioneurin plus methotrexate in %. regarding transplant disease status, ( %) of the asct patients were transplanted in complete response (cr). in the allo-sct group, ( %) patients had received three or more treatment lines before transplant and patients ( %) had received a previous asct, being ( %) in cr, in partial response (pr) and in progressive disease. transplant related mortality (trm) was . % in the asct and % in the allo-sct group. overall survival (os) and progression-free-survival (pfs) at months were % (os), % (pfs) for patients receiving asct and % (os) and % (pfs) for allo-sct. with a median follow up of months for patients receiving an asct, ( %) remain in cr. in the allo-sct group median follow up is months for the whole group and months for alive patients; patients are alive and disease free and have died, due to trm ( %). regarding progression, ( %) have progressed after autologous transplant and after allo-sct. conclusions: indication for hematopoietic sct in transformed dlbcl is stablished in few patients. only % of the patients in our transplant unit receive a transplant due to transformed lymphoma, corresponding to a . % of autologous activity and . % of allogeneic activity. according to our results transplant should be considered a curative option. most of our patients were transplanted in cr, so new agents trying to reach best response before transplant should be considered. [[p image] . eva konirova , antonin vitek , marta krejci , edgar faber , katerina steinerova , david belada , jan novak , juraj duras , petr sedlacek , veronika valkova , andrea janikova , ludek raida , pavel jindra , pavel zak , tomas kozak , marie trnkova , michal karas , marek trneny management. however, differences in patient's characteristics as well as frequency of hsct indication in different lymphoma subtypes have been observed in the last decade. the aim of this study was retrospective analysis of hsct for lymphomas in czech republic. methods: data of adult patients transplanted between years - were retrospectively analyzed using ebmt database. results: between and , autologous hsct (asct) were performed in patients ( men, %) with different lymphoma subtypes. the median age was years (range - ). out of these, ( %) were patients with non-hodgkin lymphoma (nhl), ( %) with hodgkin lymphoma (hl). the nhl group comprised of diffuse large b-cell lymphoma (dlbcl, %), follicular lymphoma (fl, %), mantle cell lymphoma (mcl, %) and t-nhl ( %). the frequency of asct in lymphomas increased from to and has been constant since ( - transplants per year). differences in frequency of asct were observed among lymphoma subtypes -decreasing numbers of dlbcl and fl and increasing numbers of t-nhl and mcl, with asct as part of the induction therapy. between and a total of allogeneic hsct (allosct) were performed in patients ( men, %). median age was years (range - ). out of these ( %) were patients with nhl, ( %) hl. the most common nhl subtypes were fl ( %), mcl ( %), t-nhl ( %) and dlbcl ( %). in the last years the number of allosct for lymphoma is fluctuating around per year. the median age at asct was significantly higher in the years - vs - [ . ( . - . ) vs. . ( . - . ), p < . , fig ] , while the increase at allosct [ . ( . - . ) vs . ( . - . )] did not reach statistical significance (p= . ). with median follow up for allosct, y probability os for patient transplanted in the later period - was in relapsed dlbcl . %, in fl . %, in hl . % and in mcl . %, y os for asct as part of first line therapy in the same period was in mcl . % and in t-nhl . %. os was significantly better in all patients who underwent asct in the years - vs - ( .% vs. . %, p < . ) and there was a trend towards better os in patients after allosct (with . % vs . %, p= . ) (fig ) . conclusions: hsct remains important treatment modality for lymphomas in the era of targeted antibody and molecular therapy and we can transplant older patients due to better supportive treatment. acknowledgment: progress q - uk from the czech ministry of education youth and sports disclosure: nothing to declare background: disease chemosensitivity to salvage treatment has been proven to be a major predictive factor for a favorable outcome after autologous stem cell transplantation (asct) for patients with refractory lymphomas. therefore the importance of effective and safe salvageregimens is indisputable. methods: we retrospectively compared the outcomes in terms of safety and efficacy, in (hl: , nhl: ) patients, with a median age of . ( - ) years, who received as st salvage either dicep [cyclophoshamide ( mg/m ), etoposide ( mg/m ), cisplatin ( mg/ m ), days - , (n= )] or the widely used regimen eshap (n= ). rituximab was additionally given to all cd- positive lymphoma patients. the statistical analysis based on the independent t-test, kaplan meir method and logrank test. results: the reason for salvage treatment was primary induction failure (pif, n= ), early relapse (< months post induction-remission therapy n= ) and late relapsed disease (n= ). more specifically, / patients ( %) in the dicep-group, and / patients ( %) in the eshapgroup were assessed with pif or early relapsed disease, however this difference was not statistically significant. both regimens were well tolerated and no major organ toxicities were noticed. eleven patients ( %) from the dicep-group, while only ( %) from the eshap-group developed febrile infections. all patients were successfully managed with the appropriate treatment and only one, from the eshap-group, required for short period admission to the intensive care unit. after cycle of dicep and cycles of eshap the disease response was re-assessed by pet/ct scan. the overall response rate (> % tumor reduction) was significantly superior for the dicep-regimen, reaching % ( / patients) vs. % ( / patients) for eshapregimen (p= , ). eleven patients ( %) from the dicep-group and ( %) from the eshap-group achieved complete metabolic remission according to pet/ ct criteria (p=ns). the median hospitalization period was ( - ) days for the dicep-group compared to ( - ) days for the eshap-group. however, for the eshapgroup, an additional median of ( - ) hospitalization days were required, since of the non-responders patients received a nd salvage before asct. the mobilization and stem cell collection was successful for both groups, though significant higher number of cd + cells were collected in the dicep-group ( . x /kg vs. . x /kg, p= , ). all but two patients (due to refractory disease) underwent asct. noticeably, the median period from st salvage treatment to asct was significantly shorter for the dicepgroup ( vs. days, p= , ), apparently because non-responders patients from eshap-group treated with a nd salvage. the -years overall and progression free survival were similar for dicep-and eshap-groups ( % vs. % and % vs % respectively). two heavily pretreated patients from the eshap-group developed secondary myelodysplastic syndrome post asct conclusions: in our series of patients both regimens proved to be safe. interestingly, despite the fact that more patients in dicep-group had poor risk disease the dicepregiment was significantly more effective, resulting thus in an earlier asct, less exposure to chemotherapeutic agents, that might led in less long-term toxicity. nevertheless, prospective trials with large series of patients are needed to define the role of dicep in the salvage treatment setting. disclosure: no conflict of interest background: although autologous hematopoietic stem cell transplantation (auto-hsct) is one of the best curative strategies for patients with chemosensitive t-cell lymphoma, major limitation remains a tumor contaminated graft-related relapse or residual disease after chemotherapy. several purging methods were introduced in auto-hsct for these limitations, however there are few studies of ex vivo purging of the autograft in lymphomas, especially t-cell lymphoma. therefore, we retrospectively analyzed consecutive t-cell lymphoma patients receiving auto-hsct with/without ex vivo purging. methods: among them, patients underwent autograft manipulation with ex vivo purging by cd + cells selection using a clinimacs device. results: with median follow-up duration of months (range, - months), -year overall survival (os; . % vs. . %, p= . ) and -year progression-free survival (pfs; . % vs. . %, p= . ) in a purged and unpurged group, respectively. transplant-related mortality was observed in both groups ( patients of a purged group and patient of an unpurged group). neutrophil ( vs. days, p= . ) and platelet ( vs. days, p= . ) recovery were similar in both group and there was no engraftment failure. on subgroup analysis according to upfront and salvage auto-hsct, while survival outcomes were improved by stem cell purging in the upfront auto-hsct (os with p= . and pfs with p= . ), there were no different survival outcomes in salvage auto-hsct. the unmanageable late-infectious complications were few in both groups except for predominantly cytomegalovirus reactivation in a purged group ( vs. patient). conclusions: although cohort was a small number, ex vivo graft-purging method was feasible and safe in t-cell lymphomas. and this purging strategy observed the more favorable survival outcomes in the upfront auto-hsct than salvage setting. therefore, further randomized studies are needed to determine the firm efficacy of cd + purification with the large number of patients in auto-hsct for t cell-lymphomas. disclosure: nothing to declare nivolumab-based regimens in relapsed or refractory non hodgkin lymphomas: the role of hematopoietic stem cells transplantation methods: we analyzed data of patients with r/r nhl, among them n with diffuse large b-cell lymphoma (dlbcl), n with primary mediastinal b-cell lymphoma (pmbcl), n with gray zone lymphoma (gzl) and n with gamma-delta peripheral t-cell lymphoma (ptcl), who received nivolumab-based regimens. the median age was years (range, - years). most of the patients n ( %) had a primary chemoresistant disease, the rest patients n ( %) had a relapse. the median of lines of prior therapy was lines (range, - lines). all sixteen patients with dlbcl and pmbcl received - cycles of nivolumab in combination with bendamustine, gemcitabine and rituximab (begern). the patient with gzl received cycles of nivolumab in combination with brentuximab vedotin and epoch. and the patient with ptcl received cycles of nivolumab monotherapy. results: at median follow up months ( - ) objective response (or) after nivolumab-based regimens was noted in n ( %) patients, complete response (cr) and partial response (pr) in n ( %) and n ( %) patients, respectively. cr observed in n patients with dlbcl, n with pmbcl, n with gzl, n with ptcl. and pr observed in patient with dlbcl. two responding patients with dlbcl underwent auto-hsct. and four responding patients (n dlbcl, n pmbcl, n gzl, n ptcl) received allogeneic hematopoietic stem cells transplantation (allo-hsct). the median duration of response for all n patients with or was (range: - +) months. among n patients who achieved or without hsct, only n remain in cr. two patients who received auto-hsct had a relapse. one patient with dlbcl improved the response after allo-hsct from pr to cr, and all four patients with allo-hsct remain in cr. the probabilities of -year os and pfs rates were % and %, respectively. conclusions: nivolumab-based regimens can lead to an objective response in % patients with r/r nhl. however, the durability of response to therapy is not long. nivolumab-based regimens can be used as bridge to allo-hsct disclosure: there are no conflicts of interest to disclose background: patients with aggressive non-hodgkin lymphoma (nhl) who relapse after autologous stem cell transplantation have a dismal outcome and could benefit from radiotherapy, allogeneic stem cell transplantation or experimental treatments. systemic inflammatory parameters at diagnosis have demonstrated to be useful to predict lymphoma evolution. methods: we conducted a retrospective review of patients with aggressive nhl who underwent autologous stem cell transplantation (astc) to evaluate the relationship between ldh, β -microglobulin, inflammatory parameters (lymphocyte (alc) and monocyte count (amc), ferritin or c-reactive protein) and imaging techniques before and on day + post-astc and progression free survival (pfs), as well as the role of residual disease directed radiotherapy (rt). results: one hundred and sixty patients with aggressive nhl received asct as consolidation treatment in our center between and . the most common diagnosis was diffuse large b-cell lymphoma (dlbcl). one hundred and nine patients received upfront asct for high risk dlbcl (defined as age-adjusted ipi - )(n= ) or for having received two or more lines to obtain first complete remission (n= ), for t-cell lymphoma (n= ) and for mantle cell lymphoma (n= ). the rest was performed in relapsed lymphomas. forty-seven patients ( %) relapsed and pfs was months. pretransplant response was evaluated with ct scan in patients ( of this with partial remission (ct-pr) and patients were evaluated with fdgpet/ct ( were pretransplant positive (pet ); of these, patients maintained positivity at day after astc (pet ). pfs in patients with ct-pr was months, in pet positive ones months and in pet positive ones months. univariate analysis showed pet positivity as the most accurate predictor of relapse (hr , , p= , ) followed by amc at day + (hr , , p= , ), albumin at day + (hr , , p= , ), ldh at day + (hr , , p< , ) and pretransplant alc/amc ratio (hr , p= , ). multivariate analysis only demonstrated an association with pet positivity (hr , ) p< and ldh in day + (hr , ) p= , with pfs. five and ten years overall survival were % and % in pet negative patients vs and % in pet positive ones (p< , ). eight out of patients with pet positivity did not relapse. salvage radiation therapy was used in patients with positive residual mass and of them did not relapse. two patients relapsed: one patient had residual mass and another had remote affectation from primary site and could be considered as progression before day + . conclusions: post asct fdgpet/ ct is superior to conventional ct in predicting outcome in aggressive lymphoma after astc. pre and post asct systemic inflammatory parameters didn't help to improve the relapse risk prediction. addition of consolidative rt after astc has demonstrated improvement in pfs in patients with pet positivity. it would be neccesary to develop randomized trials to assess the role of rt in residual disease in advanced aggressive nhl with insufficient response to systemic treatment with pet response evaluation. disclosure: nothing to declare long term outcome of patients with lymphoid malignancy who underwent high dose chemotherapy followed autologous hematopoietic cell transplantation at a single institution over years joanna romejko-jarosinska , ewa paszkiewicz-kozik , lukasz targonski , lidia popławska , jan walewski background: high dose chemotherapy (hdt) and autologous hematopoietic cell transplantation (auto-hct) is a standard of care for relapsed/refractory lymphoma patients (pts) or it is used as a consolidation for myeloma and high risk lymphoma patients in first line treatment. we retrospectively evaluated long-term outcome including late effects and risk factors in patients with lymphoid malignancy who underwent auto-hct. methods: we collected data from consecutive patients with hodgkin lymphoma (hl) (n= ), aggressive b lymphoma (dlbcl) (n= ), myeloma (n= ), indolent lymphoma (n= ), mantle cell lymphoma (n= ) and peripheral t cell lymphoma (n= ) who underwent auto-hct at our institution between and . at transplant median (range) age was ( - ) years, clinical stage iii/iv was found in of lymphoma pts, complete remission, partial remission and stable/ progressive disease occurred in ( %), ( %), ( %) pts, respectively. beam regimen was used in pts ( %), mel in pts ( %) and other myeloablative regimens in pts ( %). results %) ], respectively. partial remission or stable disease at transplant, clinical stage iii or iv, and age more than , were identified as risk factors associated with inferior os and pfs in univariate and multivariate analysis. histopathologic diagnosis was not a risk factor for os and pfs (p=ns). the outcome of patients who underwent auto-hct between - was inferior to the outcome of patients treated in - or - . - year os was %, %, %(p< . ) and year pfs was %, %, % (p< . ), respectively. we recorded ( %) cases of second primary cancer ( solid tumors and hematologic cancers). acute cardiotoxicity occurred in patients from to years after transplant, and required heart transplant in patients. patients ( %) died. the main causes of death were progressive disease in pts ( %), second primary malignancy in pts ( . %) treatment related mortality was . % ( pts), and mortality within days was ( , %). [[p image] . pfs and os in patients underwent hdt and auto-hct - , - , - conclusions: more than % of patients who underwent hdt and auto-hct had long term survival without progressive disease. older age, non-complete remission at transplant, advanced stage are associated with poor outcome. patients recently transplanted had a better outcome than patients transplanted before . disclosure: nothing to declare outcomes after haploidentical and matched related hsct in lymphoma do not differ significantly: a single center study nadira durakovic , , zinaida perić , , lana desnica , ranka serventi-seiwerth , sandra bašić kinda , ivo radman-livaja , alen ostojić , ante vulić , dražen pulanić , , pavle rončević , zorana grubić , igor aurer , , radovan vrhovac , university of zagreb, school of medicine, internal medicine, zagreb, croatia, uhc zagreb, zagreb, croatia background: allogeneic hsct still offers patients with relapsed/refractory lymphoma the best chance of long-term survival. in most such patients timing of hsct is crucial, therefore a related donor is preferred. we analyzed acute and chronic gvhd incidence, relapse and overall survival, but also time to immunosuppression (is) discontinuation and hematopoietic recovery comparing transplantation using haploidentical (haplo) and matched related donors (mrd) in single center in this indication. methods: in the time period between / and / at uhc zagreb, croatia, mrd and haplo transplantations in lymphoma were done, for hodgkin and for nhl. all patients transplanted from haploidentical donors received ptcy. data were computed using the r package. the probability of gvhd was calculated using the cumulative incidence method and subgroups were compared using the gray test. results: median age was ( - ) years; ( - ) in haplo and ( - ) in mrd group. four patients were in pr and in cr in haplo group, while in mrd group patients were in cr and in pr. in haplo group patients ( %) received bone marrow (bm) and only ( %) peripheral blood stem cells (pbsc). in mrd group all patients received pbsc. all patients in haplo group received nma ("baltimore") conditioning with ptcy while in mrd group patients ( %) received flu-bu atg, and only one received flutbi as conditioning protocol. in haplo group % patients were previously treated with autologus transplantation, % in mrd group. there was no significant difference in time to is discontinuation, and days in haplo and mrd group, respectively. patients after haplo recovered slower, recovering anc after . days ( % ci, . - . ) and . ( % ci, . - ) (p= . ) and recovering platelets after . days ( % ci, . - . ) and . ( % ci, . - . ) (p< . ) in haplo and mrd group. with a median follow up of days, overall survival was % ( % ci, - ) in haplo and % ( % ci, - ) in mrd group. trm was % in haplo and % in mrd group. cumulative incidence of agvhd ii-iv was % ( % ci, - ) and % ( % ci, in haplo and mrd group, respectively (p= . ). cumulative incidence of cgvhd requiring treatment was % ( % ci, and mrd % ( % ci, - ) in haplo and mrd group, respectively (p= . ). all cases of cgvhd developed after dli. cumulative incidence of relapse was % ( % ci, - ) and % ( % ci, - ) for haplo and mrd group, respectively (p= . ). conclusions: we found no significant difference in overall survival, relapse incidence, agvhd and cgvhd incidence between these two groups. hematopoietic recovery was slower after haploidentical transplantation, but it did not influence trm as it was higher after mrd. even though limited in number, this data contribute to the growing body of evidence that use of haploidentical donors, particularly in lymphoma setting, is as worthy as using matched related donors and should be at least second choice in donor selection, and in older patients (with older donors) probably the first one. disclosure: nothing to declare. adjuvant involved field radiotherapy post autologous stem cell transplantation for refractory/relapsed lymphomas results in favorable outcome with low toxicity: a single center experience background: involved field radiotherapy (ifrt) to previous bulky or localized residual disease, is a widely used treatment approach to minimize the risk of relapse post autologous stem cell transplantation (asct). however, the proper time for irradiation treatment remains controversial. adjuvant ifrt (adj-ifrt) in pre-asct period could cause undesirable toxicity which might delays or even cancel the asct resulting in increased risk of relapse, or could affect the marrow environmental and marrow niche resulting thus in impaired engraftment. on the other hand, the ajd-iftr in the early post-asct period, upon marrow recovery, offers a potential advantage by delivering irradiation after sufficient disease response, without affecting the engraftment. in this retrospective study we evaluated the safety and efficacy of the ifrt as adjuvant treatment in patients who had previously treated with asct for relapsed or refractory lymphomas. methods: twenty-three patients (hodgkin= , non-hodgkin= ), aged of ( - ) years, underwent asct, for primary refractory (n= ) or relapsed (n= ) disease. patients who had bulky disease at the time of relapse or those with residual mass post salvage treatment, were considered as candidates for adj-ifrt, early (within - months) after documentation of autologous stem cells engraftment. all patients proceeded to asct with chemosensitive disease after a median of lines of salvage therapy. at the time of asct patients ( %) had residual disease while ( %) evaluated to be in complete remission. the preparative regimens were: single-agent melphalan (n= ), busulfan-etoposide-melphalan (n= ), beam (n= ) and bendamustin-etoposide-cytarabine-melphalan (n= ). filgrastim was given till neutrophills recovery, while prophylaxis against bacteria, fungus, viruses and pcp were administered till the completion of adj-ifrt. results: all patients engrafted promptly and successfully. no patient experienced any severe toxicity or active infection before adj-iftr. though our plan was to proceed with adj-ifrt within months post asct, finally it was delivered after a median of . ( - ) months; the median radiation dose was ( - ) gy. ten patients received radiotherapy in the mediastinum, in the abdomen/pelvis/ inguinal area in the neck, and in the left leg. the adj-ifrt was well tolerated. no patient experienced toxicity grade > and none required hospitalization. currently, after a median follow-up of ( - ) years, / patients are alive and well; the -years overall and progression free survival rates are % and % respectively. four patients died; due to relapsed disease and heavily pretreated patients due to secondary myelodyspalstic syndrome conclusions: in our study, the adj-ifrt in the early post transplant period demonstrated a safe and well-tolerated profile. taking into consideration the poor risk status of our patients (residual disease post salvage regimen or bulky disease at the time of relapse), the promising overall and progression free survival rates suggested that adj-ifrt post asct is also an effective approach. well designed trials are needed to clarify the role and the appropriate time of radiotherapy in the asct setting disclosure: no conflict of interest adverse prognostic impact of pre-transplant neutrophil/ lymphocyte ratio in lymphoproliferative disorders background: brentuximabvedotin(bv) is a chimeric anti cd igg antibody, conjugated to synthetic antitubulinmomomethylauristatin. bv is approved for the treatment of classical hodgkin lymphoma (hl) in relapse either after autologous stem cell transplantation (asct) or after two lines of combination chemotherapy in transplant ineligible patients. the aethera trial revealed increased pfs when bv is used as maintenance therapy for cycles in high risk patients after asct. however, this schedule is associated with a high cost and significant toxicity particularly in term of peripheral neuropathy. our primary objective is to assess the efficacy of cycles brentuximab as consolidation therapy after asct for relapsed/refractory (r/r) hl. secondary objectives include side effects, progression free survival (pfs), and overall survival (os). methods: this is a retrospective single center analysis approved by the irb of the american university of beirut medical center. we included in this study consecutive patients with r/r hl who underwent asct between and , and received bv consolidation post-asct. results: we identified consecutive adult patients with r/r hl treated with bv . mg/kg iv every weeks as consolidation therapy after asct. the indications for bv consolidation was primary refractory disease in patients ( %), early relapse in patients ( %) (after a median time of months; range, - ) andextranodalinvolvement in one patient ( %). the median number of lines of therapy pre-asct was (range, - ). the median time to bv initiation post-asct was days (range, - ). patients received a median of cycles (range, - ) of bv post-asct. after a median follow up of months (range, - ), five ( %) patients relapsed after asct. the median time to relapse was months (range, - ). median pfs and os were not reached. we did not observe any significant toxicities during or after therapy. conclusions: cycles of bv consolidation after asct seem to be safe and effective in preventing relapse, however our findings need to be confirmed with larger prospective studies. chemotherapy or who progress after autohsct is poor. despite introduction of novel agents like brentuximab vedotin (bv) or nivolumab, allohsct appears the most effective treatment option with curative potential. the goal of this study was to evaluate efficacy of allohsct for hl, including patients pre-treated with novel agents. methods: between years - , patients (including males) with hl were treated with allohsct in msc institute of oncology in gliwice, poland. median age was ( - ) years. median lines of preceding chemotherapy was ( - ); ( %) patients had been pre-treated with autohsct, ( %) with radiotherapy, ( %) with bv, ( %) -with nivolumab. disease status at allohsct was as follows: cr- , pr- , nr- . patients were treated with hsct from either hla-matched sibling donor (msd, n= ), unrelated donor (urd, n= ) or haploidentical donor (n= ). conditioning was myeloablative in ( %) cases. peripheral blood was used as a source of stem cells. results: all but one patient engrafted with median time of neutrophil recovery of ( - ) days. the incidence of grade - and grade - acute gvhd was % and %, respectively, while the incidence of chronic gvhd was %. the probabilities of os and pfs at years were % (+/- %) and % (+/- %), respectively. the incidences of progression and transplant-related mortality were % and %, respectively. the y pfs rates were % for msd, % for urd and % for haploidentical donors. in a univariate analysis pfs was affected by recipient gender (female - %, male - %, p= . ) and disease status at allohsct (cr - %, pr - %, nr - %, p= . ). in a multivariate model the disease status other than cr was the only factor associated with increased risk of treatment failure (reverse pfs) -hr= . , %ci . - . , p= . . neither donor type nor conditioning affected long-term outcome. conclusions: results of allohsct for patients with relapsed/refractory hl are determined by disease status at transplantation. efforts should be done to reduce tumour burden before transplantation, optimally to achieve cr. disclosure: nothing to declare background: brentuximab vedotin (bv), nivolumab and pembrolizumab have been assigned to chemorefractory hodgkin lymphoma treatment. impact of these agents on disease-free-survival after autologous stem cell transplantation (asct) remains under investigation. aim of the study is to compare bv-and nivolumab-treated patients with a control group. methods: clinical characteristics and outcomes of chemo refractory hodgkin lymphoma patients who underwent asct during - . results: a total of patients ( men; women, median age years old, - ) were treated with bv: pre-transplant, post-transplant and pre-and posttransplant. pre-transplant bv patients had primary refractory disease or early relapse in the majority ( %). post-transplant treatment occurred in the context of relapsed/refractory disease in patients; ( %) had an allogeneic stem cell transplant. among them, had additional chemotherapy and nivolumab, gaining a complete metabolic response. in the rest of patients, change of treatment due to eventual bv failure occurred. bv was administered as a maintenance treatment in patients. in six of them bv had already been administered pre-transplant as well. out of maintenance treatment patients, relapsed and subsequently received nivolumab. two patients died due to prior chemotherapy complications, whereas are currently on nivolumab treatment. pet-based response was available in patients, having a complete metabolic response (cmr) and a partial metabolic response. stable disease was achieved by ctbased response in the rest patients. no major toxicities were observed. one patient presented with grade asymptomatic hypothyroidism and one with grade anemia attributed to non-inflammatory upper gastrointestinal blood loss. in total, patients received anti-pd treatment, all post bv failure. with a median follow-up of . ( . - . ) months, -year overall survival (os) was . % in patients treated only with bv compared to . % in patients treated with additional anti-pd treatment (p= . , figure) . median os for patients treated only with bv was . months, whereas median os has not been reached for patients that received anti-pd treatment. conclusions: bv pre or post-transplant and anti-pd treatment post-transplant after bv failure have outstanding results in chemo refractory lymphoma patients. treatment sequence in allogeneic transplantation eligible patients remains to be further studied. disclosure: nothing to declare background: allogeneic hematopoietic cell transplantation (allo-hct) with reduced-intensity conditioning (ric) has been used in heavily pretreated lymphoma patients with the promise of decreased treatment-related mortality. despite improvements in outcomes of patients with lymphoid neoplasms, several new agents emerge as potential therapies. therefore, we aimed to describe our long-term experience in patients with hodgkin (hl), non-hodgkin lymphomas (nhl) and chronic lymphocytic leukemia (cll) post allo-hct. methods: in this retrospective study, we enrolled consecutive patients who underwent allo-hct for lymphoid neoplasms in our institution ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . results: in total, patients (male:female= : ) aged ( - ) years, underwent allo-hct for hl (n= ), nhl (n= ) and cll (n= ). the majority of patients were diagnosed at stage iv ( %); % had bone marrow involvement and % had undergone autologous hct. most patients were heavily pretreated (median lines= , range - ), of them had received more than treatment lines and at the time of transplantation only had complete response, while had partial response and were refractory. according to disease-risk index (dri), patients were stratified at low (n= , . %), intermediate (n= , . %), high (n= , . %) or very high (n= , . %) category. among patients with hodgkin lymphoma, brentuximab vedotin was administrated in and of them were effectively bridged to allo-hct. all patients received ric, mainly fludarabine ( mg/ m )-cyclophosphamide ( g/ m ) in cll and nhl and thiotepa ( mg/kg)-fludarabine ( mg/m )-cyclophosphamide ( mg/kg) in hl from matched sibling (n= ), matched (n= ) or mismatched unrelated (n= ) donors. graft-versus-host disease (gvhd) prophylaxis consisted of cyclosporine or tacrolimus and mycophenolate mofetil or short-term methotrexate and additional low-dose antithymocyte globulin ( mg/kg) in unrelated donors. peripheral blood was the main cell source ( / ) and median number of cd + cells infused was . x /kg ( . - . ) . two patients succumbed to advanced underlying disease before engraftment; while the other engrafted successfully. median time until neutrophil and platelet engraftment was and days respectively. eighteen patients ( . %) developed acute gvhd (grade iii-iv, n= ), steroid sensitive in ( . %) and relapsed. one-year cumulative incidence (ci) of extensive chronic gvhd was . %, and patients required more than one additional line of immunosuppression (range - ). ten patients presented cmv reactivation successfully treated with antiviral medication and patient died from hsv encephalitis. with a median follow of years ( - years), -year os was . %, -year non-relapse mortality ci . % and year dfs %. there was no difference in survival according to original disease ( -year os for nhl= . %, hl= . %, cll= %%, p= . ). multivariate analysis revealed high and very high dri as the single predicting factor of os (hr . , ci . - . , p= . ), when assessing impact of disease, dri, prior treatment lines, gender and bone marrow infiltration at diagnosis. conclusions: our data suggest that ric allo-hct provides encouraging survival rates, potentially offering the chance of cure, with acceptable long-term mortality in selected high-risk patients with lymphoid neoplasms. dri that is mainly associated with disease stage at transplant independently affects survival. therefore, continued efforts are necessary for clinical application of novel agents aiming to lower disease stage pre-transplant. disclosure: nothing to declare results: six pts were identified, with a median age of years at diagnosis: five with hl nodular sclerosis and with lymphocyte depletion. the median number of therapeutic lines prior to allo-hsct was [ - ]; four pts were previously treated with brentuximaband two pts had been submitted to high dose chemotherapy with autologous bone marrow support. at the time of allo-hsct, pts had progressive disease (dp), was in partial response and in complete response (cr). five allo-hsct were performed with a related donor, of wich were haploidentical ( parents, sibling and descendant) and with an unrelated donor ( / ). prophylaxis for gvhd was performed with tacrolimus and mycophenolate mofetil (with post-transplant cyclophosphamide in haploidentical allo-hsct). on day + evaluations, pts had a cr and patient (pt) had dp. the median time to relapse after allo-hsct was of months. at the time of initiation of nivolumab, pts were under steroid therapy for disease control, without other immunosuppressive therapy. the median time between allo-hsct and the beginning of nivolumab was months. the initial dose was mg / kg (associated with corticosteroid therapy), escalated up to mg/kg biweekly, according to patient's tolerance. after the start of nivolumab, patients, with previous gvhd manifestations, presented a worsening of the cutaneous gvhd, which required an escalation of immunosuppressive therapy. as toxicity, pt had a grade pneumonitis, pt had a grade encephalitis/hypophysitis, pt had a grade pancreatitis, pts had headache (grade and ), pts had a grade - cutaneous reation. with a median follow-up of months since nivolumab treatment, the overall response rate was %: pt obtained cr and pts partial remission. nevertheless, there were deaths after the onset of nivolumab: pt at monts with dp and another one due to acute myocardial infarction at months. at the time of analysis, pts maintained response under nivolumab treatment (median cycles ) and pt had therapy suspended because of toxicity. conclusions: these results demonstrate the high probability of achieving response with nivolumab treatment in patients with rr-hl relapsing after allo-hsct, but adverse events of grade were frequent in this small group, and the treatment toxicity was significant. disclosure: nothing to declare background: intravascular large b-cell lymphoma (ivlbcl) is a rare form of large b-cell lymphoma with pathological findings of intravascular proliferation and/or sinusoidal involvement of lymphoma cells. according to their geographic distribution, ivlbcl could be dichotomized into asian and western variants. compared with the western variant, where skin involvement was common, the asian variant was reported to involve more frequently the liver, spleen and bone marrow, and hemophagocytic lymphohistiocytosis is more common in asian variant. diagnosis of ivlbl is still difficult because of the lack of overt lymphadenopathy and peripheral blood involvement. thus, timely diagnosis and immediate treatment remain as a challenge to improve outcomes for patients with the asian variant. therefore, we analyzed the clinical features and treatment outcomes of patients with the asian variant of ivlbcl. methods: we analyzed patients who were diagnosed with ivlbcl between and . all patients were treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (r-chop). results: forty-six patients were diagnosed with ivlbcl, and their median age at diagnosis was years (range: - years). male patients predominated (n= , %), and b symptoms were present in patients ( %). hepatomegaly and/or splenomegaly were observed in patients ( %), whereas lymphadenopathy was less common (n = , %). bone marrow and liver were the most commonly involved extranodal organs ( %, and %, respectively) and were the most common sites of biopsy for diagnosis in this study. all patients received r-chop as a first-line treatment after diagnosis with a median number of six cycles (range one to eight). at the end of treatment, patients achieved a complete response (cr), whereas eight patients showed progression. six patients died after the first or second cycle of r-chop, and the causes of death were treatment-related adverse events including cytopenia, infectious complications, and pulmonary hemorrhage. upfront asct was done for two patients including one patient with cns involvement at diagnosis, and these patients were still alive at the time of analysis without evidence of relapse. on the other hand, the outcome of six patients undergoing salvage asct after relapse was poor; thus, only one patient was alive. likewise, patients with disease progression at the end of treatment with r-chop showed dismal prognoses even after salvage chemotherapy except for one. at a median follow-up of . months ( % confidence interval, ci . - . ), the median overall survival was . months ( % ci . - . ). the treatment outcome of patients with the asian variant of ivlbcl is still not satisfactory. although upfront autologous stem cell transplantation might be effective for selected patients at high-risk of relapse, its role is still not clear, either. thus, further study should be warranted to develop more effective strategies for diagnosis and treatment. clinical trial registry: not applicable disclosure: nothing to disclare background: peripheral t-cell lymphomas (ptcls) are about % of non-hodgkin´s lymphomas usually with an aggressive clinical course and unfavorable prognosis.given their heterogeneity, consensus on the best first-line treatment and the role of autologous/allogeneic (asct/allosct) stem cell transplantation as consolidation is controversial. methods: we evaluated the overall survival (os), progression-free survival (pfs) and toxicities of a cohort of patients with ptcls submitted to asct/allosct intensification at our institution between january and july . os was calculated from the date of diagnosis until death. pfs was measured from transplant until relapse, progressive disease or last follow-up. os and pfs rates were estimated using the kaplan-meier method and compared with the log-rank test. results: twenty-six patients were identified, female ( %), median age was years (range: to ). ninetytwo percent of patients presented with advanced-stage disease at diagnosis (ann arbor stage iii or iv), % with b symptoms. according to the who classification, histologic ptcl subtypes included angioimmunoblastic tcell lymphoma (n = ); ptcl not otherwise specified (n = ); anaplastic large cell lymphoma, alk-negative (n = ); anaplastic large cell lymphoma, alk-positive (n = ); nodal peripheral t-cell lymphoma with tfh phenotype (n = ). extranodal nk/t-cell lymphoma, nasal type and primary cutaneous subtypes were excluded. the ageadjusted ipi (aaipi) was low/intermediate low in patients ( %) and intermediate high/high in patients ( %). twenty-seven transplants were performed ( asct, allosct); were consolidation in st response ( asct and allosct) with in complete remission (cr) and in partial remission (pr). nine transplants were performed as consolidation of nd response ( asct and allosct) with in cr and pr. in patient allosct was performed after asct, due to early relapse (< months). beam regimen was used in asct as conditioning and flumel in allosct. all patients engrafted, the median time to leukocyte recovery > , /μl was days (range, to ). four of the pts ( %), submitted to allosct had chronic graft versus host disease which was the most relevant complication of this analysis. considering the whole cohort, the median follow-up was . months (range, to ). the estimated -year os and pfs were % and %, respectively. seven patients relapsed ( early) all after asct, there were no relapses after allosct, however, the results were not statistically significant between the allosct and asct groups; the -year os rates were % and % (p = , ) and the year pfs rates were % and % (p = , ) respectively. for the all patients treatment-related mortality (trm) was , %; patients died, with progressive disease (asct) and for hepatic toxicity (allosct) before d+ . conclusions: the results of this retrospective study, taking into account the adverse risk profile of the population, suggest that autologous/allogeneic stem cell transplantation as an effective and safe option for the consolidation of patients with ptcls. these results need to be validated in prospective studies, including a larger number of patients. disclosure background: autologous stem cell transplantation is used as consolidation therapy in relapsed lymphoma patients. however, outcome of lymphoma patients relapsing after autologous stem cell transplantation is poor and allogeneic stem cell transplantation which can be curative is used in the transplant eligible patients in this setting. besides, allogeneic stem cell transplantation can be an option before autologous stem cell transplantation in some high risk patients. in this study, we aimed to compare the survival rates of lymphoma patients older than years of age and patients aged - who had undergone allogeneic transplantation in our center. methods: we collected the data of lymphoma patients older than years of age who had undergone allogeneic transplantation in our center and analyzed the results by grouping them into , namely the ones between - years of age and the ones over years of age. [[p image] . figure results: there were patients over the age of who had undergone allogeneic stem cell trasplantation with the diagnosis of lmphoma between and . of these patients were over years of age. patients had non-hodgkin lymphoma and patients had hodgkin lymphoma. the characteristics of the patients are summarized in table . patients' comorbidity indexes were calculated with augmented hct-ci which includes patients' pretransplant ferritin, albümin and thrombocyte counts as a variable. no difference could be found between groups regarding neutrophil and platelet engraftment times and comorbidity indexes. however, acute graft versus rate and documented bacterial infection rate during the hospitalization period were higher in the - years age group (p= , ). day mortality rate and non-relapse mortality rate were not different between groups. more importantly, progression free survival(pfs) and overall survival(os) of patients in the - years age group and over years of age group were not different (p= , ) (figure ) conclusions: in the present study, although the number of patients is low, we showed that lymphoma patients over years of age have similar outcomes and transplant related toxicity as the patients between to years of age. pfs and os were very close in this study. we think that this may be due to low relapse rate in the patients and high mortality rate in relapsing patients. in conclusion, allogeneic stem cell transplantation which has a curative potential may be employed in transplant eligible elderly lymphoma patients disclosure: nothing to declare background: follicular lymphoma (fl) histologic transformation consist on the development of an aggressive lymphoma, usually a diffuse large b cell lymphoma (dlbcl). histological transformation has been considered to have poor prognosis. in pre-rituximab era median os ranged between and years, however, in recent series of patients treated with chemotherapy plus rituximab, the outcome of transformed fl has improved, especially in those that receive autologous stem cell transplantation (asct), who reach -year os up to % in some series. methods: we have retrospectively studied consecutive patients undergoing asct for transformed fl between and in a tertiary center in the basque country, spain. patients were considered to have a transformed fl if they were diagnosed of a dlbcl and they have previous history of fl or histological evidence of a fl in another location. these patients were compared to a retrospective cohort of dlbcl patients with high ipi or stage that received asct in first remission according to our institution strategy. pfs and os were calculated from the time of the asct. in the case of transformed fl, both relapses of the aggressive or indolent lymphoma were considered. survival analysis was performed with kaplan-meyer estimator results: a total of transformed fl and dlbcl patients were studied, with a median follow up of . and . months respectively. patient characteristics are described in table . -year pfs was % in transformed fl and % in dlbcl, and -year os was % and %, respectively (picture ). there were no significant differences in pfs or os between this two groups (p = . ). in both groups all relapses occurred in the first three years after asct. among the patients with transformed fl relapses were observed. five of them ( %) were aggressive relapses, while only one patient presented relapse as an indolent lymphoma (fl histological grade a with an aggressive clinical course). [[p image] . image : transformed fl and dlbcl pfs after asct] conclusions: in our experience, asct in transformed fl offers good results, similar to those in dlbcl. fl presents a natural course akin to that of dlbcl, with relapses occurring early and survival reaching a plateau. this data suggests that some patients with transformed fl can be cured after asct. disclosure: nothing to declare. safety and efficacy of intensive preconditioning regimen containing cladribine in autologous peripheral blood stem cell transplantation of refractory and relapsed young highly invasive lymphoma background: autologous peripheral blood stem cell transplantation (apbsct) is one of the main treatments for patients with non-hodgkin's lymphoma (nhl). effective and safe conditioning regimens can improve the cure rate of nhl. beam is the most common pretreatment scheme, but for refractory and relapsed young highly invasive lymphoma, especially for dual-expression dlbcl, pretreatment needs to be strengthened. studies have shown that the cladribine (clad)+gemcitabine (gem)+busulfan (bu) combination provides synergistic cytotoxicity in lymphoma cell lines.we evaluated the the safety and short-term efficacy of intensive preconditioning regimen containing cladribine (clad+gem+bu) for refractory and relapsed young highly invasive lymphoma undergoing apbsct. methods: ten patients with nhl received apbsct. ca)ctx+ ara-c) therapy followed by g-csf was used for pbsc mobilization. sevenr patients received conditioning regimens of beam(beam group): bcnu mg/ m ·d - × d (- d), vp mg/m · q h× d (- d-- d), ara-c mg/m ·q h× d (- d-- d), mel mg/m ·d - × d (- d). three patients received intensive preconditioning regimen containing cladribine (clgb group): clad mg/m ·d - × d (- d-- d), gem mg/m ·d - × d (- d, - d), bu . mg/kg q h× d (- d-- d). follow-up date expires on december , . results: the age of patients in clgb group was , and years, respectively. two patients were diagnosed as diffuse large b-cell lymphoma with double expression and one was diffuse large b-cell lymphoma with two recurrences. the patients of beam group were all high-risk, relapsed and refractory nhl.all patients were successfully engrafted after infusing apbsc. the average lowest leukocyte in clgb group and beam group were ( . ± . ) × /l vs ( . ± . )× /l, respectively. the average lowest leukocyte in clgb group was lower than that in beam group. the average time to anc < . × /l in clgb group and beam group were . d ± . d vs . d± . d. the average time to anc≥ . × /l in clgb group and beam group were . d± . d vs . d± . d; the average time to plt≥ × /l of clgb group was not different to that of beam group ( . d± . d vs . d± . d) the average time of neutropenia wasn't significantly different in two groups ( . d± . d vs . d± . d). the adverse reactions of gastrointestinal tract and oral mucosa were close in tow groups.vod, hemorrhagic cystitis, pretreatment-related interstitial pneumonia, liver and kidney dysfunction were not happened in tow groups. the rate of infectious fever was close in two groups ( / vs / ). the median followup period in beam group was ( ~ ) months. in the beam group, a patient died days after transplantation, because he was diagnosed with recurrent nkt cell lymphoma and intracranial infection caused by severe sinus infection. another case of beam group was diagnosed as double-expressed dlbcl, which relapsed months after transplantation. the remaining patients in ebmt group survived disease-free. the follow-up time of patients in clgb group were months, months and months respectively. all patients survived without disease.however, the follow-up time is short and needs long-term follow-up. conclusions: the treatment of intensive preconditioning regimen containing cladribine (clgb) for refractory and relapsed young highly invasive lymphoma undergoing apbsct is safe. the time of hematopoietic reconstruction is short, and the adverse effects is tolerable for patients with refractory and relapsed young highly invasive lymphoma. the current short-term outcome is good, but the long-term effect need a longer time to follow-up. disclosure: this work was supported by national nature sciences found of china ( ). there is no disclosure of conflict of interest.the all authors name: xiang-li chen, yu-zhu zang, wen-hui zhang, yin zhang, zhong-wen liu, ping-chong lei, jing yang, yu-qing chen, kai sun. background: small part of children with hodgkin disease (hd) demonstrate initial resistance to the standard and even "salvage" chemotherapy and need innovative drugs for the treatment. methods: a -year girl was diagnosed with classical hd (nodular sclerosis)corresponding to stage ii e b (fever > °c) in april .after two cycles of oepa (vincristine, etoposide, prednisone and doxorubicin) and next two cycles copp (cyclophosphamide, vincristine, prednisone and procarbazine) the patient again had progressive disease. as the patient achieved a partial response (pr) after "salvage"therapy with two cycles of igev (ifosfamide, gemcitabine, vinorelbine, and prednisone), she received auto-sct in february (patient status before auto-sct was pr). we used ccnu-containing conditioning regimen cem: lomustine (ccnu) mg/m + etoposide mg/m + melphalan mg/m . at day + after auto-sct, the patient again demonstrated progression of the disease: pet/ct-examination showed mediastinal tumor mass enlargement with increased left lung nodule simultaneously to short metabolic activity. patient was under observation. at day + the disease had relapsed and progressed -examination by pet/ct demonstrated multifocal progressive disease with multiple pulmonary lesions and increased metabolism in comparison with the previous pet/ct scan. in july-october , the patient had salvage chemotherapy with a combination of brentuximab vedotin (bv) (bv dhap (dexamethasone, cytarabine, cisplatin) + bv (without chemotherapy due to suspected invasive mycosis) + bv dhap), however, only partial pet-positive remission was achieved. because of many times relapsed and progressed disease pembrolizumab therapy was started in october : mg / kg every three weeks four cycles totally. toxic effects and serious complications during and after therapy by pembrolizumab were not observed. in february , after pembrolizumab # , the patient showed complete metabolic remission of the disease by control pet-ct. in april , the patient received haplo-sct with post-transplant hd-cyclophosphamide. we used conditioning modes with reduced toxicity (fludarabin mg/m + treosulfan g/m ), high doses of cy ( mg / kg) on days + and + . tacrolimus and mycophenolate mofetil started on day + . mmf was terminated on day , tacrolimus -on day . patient did not have acute and chronic gvhd. results: at the moment the patient is alive and still in pet-negative cr with duration more than mo. conclusions: pembrolizumab has demonstrated high activity against resistant hd even after post-auto-sct progression with good tolerability for the sick child. disclosure: nothing to declare p high dose chemotherapy followed by autolougous peripheral blood stem cell transplantation (asct) in diffuse large b cell lymphoma (dlbcl) median age is , years ( to ) and sex ratio (m/f) . ; ann arbor stage iii-iv: pts. before hdt induction chemotherapy (chop, c h opa) was instituted and associated with rituximab in pts ( , %), pts ( , %) received more than treatment lines and pts ( , %) received complementary radiotherapy. transplant disease status before hdt was complete remission (cr) in pts, partial remission in pts (rp) and disease progression in pts. the delay from diagnosis to hdt is , months ( - ). the hdt protocols used are: tutshka : pts, tutshka+vp : pts, bam (busulfan +cytarabine+melphalan) : pts et beam : pts. all pts received, after thawing, mobilized pbsc obtained by g-csf mobilization ( μg/kg/d, days) alone and froze in liquid nitrogen. the median rate cd + cells infused is , x /kg ( . - . ) . the median follow-up at / / is months . results: the median time to graft (pnc > . x /l) was days ( - ). ten early deaths were observed including infection (trm: , %) and in disease progression at months. after months of hdt pts are assessable including pts in cr ( , %) and pts in pr ( , %). relapse was observed in pts ( . %) and it was earlier relapse in a period of months in pts ( %). deaths were among / pts ( %). persistent cr was achieved in / pts ( , %) including / ( , %) mlcl and / ( , %) others dlbcl. the overall survival (os) and event free survival (efs) at years are respectively % and %. the os and efs are better in patients who received rituximab in initial therapy : os ( % vs %; p< , ) et efs ( % vs %; p< , ). herein, we present one patient with refractory mcl, who were insensitive to chemotherapy and then experienced a dramatic improvement with ibrutinib mono-therapy but later developed ibrutinib resistance,ultimately resulting in the deterioration of disease and death. methods: we give the patient several examinations including ultrasound, bone marrow biopsy, lymph node biopsy, exome sequencing, sanger sequencing, and so on. for the treatment of lymphoma, the patient received chemotherapy, including course of chop(cyclophosphamide . g day , doxorubicin mg day ,vinorelbine mg day , and dexamethasone mg from day to ) and course of r-dhap (rituximab mg day , cytarabine g q day , cisplatin mg day ,dexamethasone mg from day to )in succession.because of the failure to control disease progression, ibrutinib mg qd was used until the patient died. results: the -year-old man initially referred to our hospital for complaints of abdominal pain and distention over months. ultrasound showed splenomegaly and multiple enlarged retroperitoneal lymph nodes.excisional biopsy conducted on the right neck lymph node revealed the presence of malignant cells.immunohistochemically, the neoplastic cells were positive for bcl , bcl ,cd , cd , cd a, cd , ki- ( %), sox , cd (fdc) and cyclin d and negative for cd , cd and cd ; fluorescence in situ hybridization(fish) showed igh/ ccnd ,t( ; ) %.thus a diagnosis of mcl was confirmed. course of therapeutic chemotherapy were applied to the patient but he did not respond well.he suffered recurrent fever, thrombocytopenia, left abdominal pain, splenomegaly and multiple enlarged lymph nodes. then he received ibrutinib mono-therapy, and experienced a dramatic improvement as his body temperature was controlled, his hemogram became normal and his spleen and lymph node tapered.after about months response of ibrutinib, the disease deteriorated rapidly and he died very soon. exome sequencing from the patient peripheral blood at this time detected one missense mutation in exon of tp at nucleotide g>a, resulting in an argnine to histidine change at amino acid (p.arg his). but sanger sequencing of the patient bone marrow ffpe sample at the time of original diagnosis did not detect this mutation. conclusions: thus, our study reported a tp r h mutation mcl patient who developed ibrutinib resistance and progressed aggresively, which may open new insight for future effort for alternative therapeutic strategies in ibrutinib-refractory mcl. disclosure: nothing to declare. minimal residual disease, tolerance, chimerism and immune reconstitution peripheral blood samples were obtained for routine analysis at several time points after hsct. all available blood samples between . and years were used in the analysis. to assess changes in the cd +b and cd +cd +memory b cell counts over time while accounting for the correlation between the repeated measurements of each patient, we used linear mixed-effects models. wilcoxon rank test, kruskal-wallis test and linear regression were used for univariate analysis. results: at one year after hsct, univariate analysis showed that patients transplanted with a cb graft compared to bm and pbsc had a significantly higher absolute number of b cells (median bm= , median cb= , median pbsc= cells/μl, p= . e- ) and memory b cells (median bm= , median cb= , median pbsc= cells/μl, . recipients with age under years had significantly higher absolute numbers of b (median= , median= cells/μl, p= . e- ) and memory b cells (median= , median= cells/μl, p= . e- ) than above years. increase in donor age was associated with a decreasing effect on b cell (r = . , p= . e- ) and memory b cell (r = . , p= . e- ) reconstitution as determined in regression analysis. following univariate analysis, we analysed these factors in a mixed effects model to assess the relation with differences in b cell or memory b cell numbers . - years after hsct. in our analysis we found significant decreasing b cell and memory b cell numbers with increasing donor age corrected for recipient age and source (both p< . ). increasing recipient age also showed a significant decrease in b cell and memory b cell numbers (both p< . ) but there was no significant influence of donor source ( figure ) . conclusions: b cell and memory b cell numbers after hsct are influenced by donor and recipient age but not by donor source. older donors and recipients show a decrease in b cells and memory b cells numbers . - years after hsct. [[p image] . figure . b cell development and donor age. green shows cb, red bm, blue pbsc at mean donor age.] copenhagen university hospital rigshospitalet, copenhagen, denmark, leiden university medical center, leiden, netherlands background: the outcome of allogeneic hsct is challenged by a delayed and long-lasting imbalanced t-cell reconstitution increasing the risk of acute gvhd, infections and disease progression. although the role of differentially and functionally distinct t-cell subsets in the development of complications has been addressed, little is known about the factors controlling their recovery. in this study, we investigated the impact of immuneregulating and homeostatic cytokines on the reconstitution of functionally distinct t-cell subsets and associated clinical outcomes. methods: we included children undergoing allogeneic hsct for all (n= ) or aml (n= ) with a median age of . years (range: . - . ). donors were either mrd (n= ), mud (n= ) or mmud (n= ). bm (n= ) or pb (n= ) were used as stem cell source. conditioning regimens were based on tbi (n= ) or highdose chemotherapy alone (n= ) and included atg in patients. thirty age-matched healthy children were included as controls. cytokines (il- , il- , il- , scf, il- , il- and tnfα) and active atg in plasma were longitudinally measured from before conditioning until months after hsct (n= ) along with an extended phenotyping of t-cell maturation and differentiation by flow cytometry (n= ). results: the homeostatic cytokines il- and il- increased from pre-conditioning to peak - weeks post-hsct and gradually declined thereafter. il- levels were shortly elevated, while il- and scf remained relatively stable, and il- and tnf-α levels were below threshold of detection at all time points. the early rise of il- and il- was strongly associated with the degree of t-cell depletion by atg, while il- also correlated with markers of systemic inflammation. il- and il- levels were significantly higher in children treated with atg (p< . ) and correlated with both longer exposure to atg (p< . ) and increased levels of active atg (day + : il- : r= . , p< . ; il- : r= . , p< . ), indicating that high levels of these cytokines reflected more pronounced t-cell depletion during lymphopenia. higher circulating levels of il- and il- were associated with a slow recovery of cd +, cd + and cd + t-cell counts at day + and + post-hsct (p< . ), while the remaining cytokines did not correlate with immune reconstitution. looking into t-cell subpopulations, increased levels of il- and il- during the first month post-transplant were associated with lower numbers of naïve t cells and correlated with an increased proportion of cd + and cd + effector memory cells ( figure) . no differential effect of cytokines on polarization of cd + t cells into th , th , th cells or treg cells was found. in atg-treated patients, il- and il- levels at day + were significantly lower in patients developing acute gvhd grade ii-iv (p= . and p= . , respectively). in the total cohort, increased il- levels were associated with a reactivation of ebv (p= . ). conclusions: these findings suggest that quantification of il- and il- can be indicative for the degree of t-cell depletion during the first weeks after hsct and predictive of complications. overall, these results indicate that the lymphopenia-induced elevation of il- and il- is a major driver of the initial expansion of donor t-cells. background: mathematical kinetic models were adopted to study immune cell reconstitution after allogeneic hematopoietic stem cell transplantation (allo-hsct). the associations between acute graft-versus-host disease (agvhd), relapse and the immune cell reconstitution kinetic models were explored. methods: from june , to may , , sixty-five patients with hematological malignancies after allo-hsct were recruited. peripheral blood was collected on + day, + day, + day and in + month, + month, + month, + month, + month, + month, + month. lymphocyte subsets were determined by flow cytometry, including in total t lymphocytes (cd + ), helper t cells (cd + cd + ), cytotoxic t cells (cd + cd + ), cd /cd ratio, nature killer (nk) cells (cd -cd + ), nkt cells (cd + cd + ), b lymphocyte (cd + ), naive t cells (cd + hla-dr + ), static t cells (cd + hla-dr -), and regulatory t cells (cd + cd high foxp + ). mathematical kinetic models were calculated for immune cell reconstitution with spss. results: after allo-hsct, a logarithmic curve model was observed for cd + t cells. cubic curve models were observed for cd + cd + t cells, cd + cd high+ foxp + t cell, cd + hla-dr -t cells, cd + cd + nkt cells, cd + b cells. cd + cd + t cells, cd + hla-dr + t cells, and cd -cd + nk cells showed s type curve models. considering t cells were the major mediators for agvhd and graft-versusleukemia effect after allo-hsct. with established immune cell kinetic models, we found that different curve models were observed between patients with and without agvhd after allo-hsct. although the kinetic models were almost the same for leukemia-free and relapsed patients in the first months after allo-hsct, significantly different kinetic curves could be observed thereafter. conclusions: the immune cell reconstitution showed different mathematical curve models after allo-hsct. kinetic reconstitution model of certain immune cell was associated with agvhd and relapse. hence, mathematical kinetic models of immune cell reconstitution may be potential indictor for predicting agvhd and relapse after allo-hsct. disclosure: nothing to declare lineage specific chimerism analysis in pediatric patients following allogeneic hematopoietic cell transplantation (hct background: the outcome of allogeneic hct is dependent on several variables that include patient age, disease and stage, cytoreduction, graft, graft manipulation, and graft versus host disease (gvhd) prophylaxis. one aspect of hct that remains poorly defined and studied is the donor/ host (d/h) chimerism post hct. since , we followed patients with d/h lineage specific chimerism post hct. analyses were performed by short tandem repeat (str) polymorphism analysis at the american red cross blood services (philadelphia, pa). studies were performed on blood total leukocytes, myeloid/neutrophil cells, t-cells, bcells, and nk-cells. methods: in this retrospective study, the charts of consecutive patients who underwent allogeneic hct between january to june on the pediatric bone marrow transplant service at mskcc were retrospectively reviewed. lineage specific donor chimerism post hct was studied including d/h chimerism trend, and factors with potential impact on chimerism including: age, disease, graft source, and t-cell depletion (tcd). preliminary analyzes performed on this cohort included wilcoxon rank test and cox proportional hazard analyses. results: patients were selected based on the number of analyses. the median age was . years. patients had hematologic malignancies (n= ) or non-malignant hematologic diseases (n= ), or immune disorders (n= ). cytoreduction included tbi-(n= ), or chemotherapybased regiments (n= ). patients were recipients of t-cell depleted marrow or peripheral blood grafts (n= ), unmodified marrow or peripheral blood grafts (n= ) or cord blood grafts (n= ). full donor chimerism of myeloid cells, b-cells and nkcells, but not t-cells occurred early post-transplant. there was no difference in the percentage of total donor leukocytes at months vs. months post hsct (n= ), while the median of donor t-cell chimerism was % at months and % at months post hsct (p< . , n= ). figure shows the impact of different factors including: (a) the use of tbi-or chemotherapy-based regimens, (b) age (< or > years), and (c) type of graft (t-cell depleted vs unmodified vs cord blood). donor total leukocytes chimerism was significantly lower at months as compared to months for patients < years of age (p= . ). for most grafts, full donor chimerism of t-cells occurred early, while for t-cell depleted transplants, it took up to one year to complete. cord blood grafts were associated with high t-cell donor chimerism throughout the post-transplant period. there was a significant difference in the % donor t-cells at and months post hct when comparing t-cell depleted and unmodified grafts (p= . ). conclusions: this preliminary analysis of lineage specific chimerism post-transplant showed that donor tcells may take one year to fully recover post-transplant, mostly following t-cell depleted grafts, without intervention. cord blood grafts were associated with high donor chimerism throughout the post-transplant period. lastly, factors associated with loss of donor chimerism posttransplant were younger age and non-malignant disorders. more in-depth analyses are being performed including the relation of chimerism and hct outcome. disclosure: eileen nicoletti -employee rocket pharmaceuticals, susan prockop -investigator atara biotherapeutics -research funding, susan prockop -mesoblast -research funding, nancy kernan -gentium -support; jazz pharmaceuticals -support, richard o´reilly -atara biotherapeutics -royalty, consultancy and research, jaap jan boelens -bluebird bio -consultancy, avrobio -consultancy; jaap jan boelens -chimerix -consultancy; magenta -consultancy background: the success of hematopoietic stem cell transplantation (hsct) lies with the ability of the engrafted immune system to remove residual leukemia cells via a graft-versus-leukemia effect. despite this, relapse remains the major cause of mortality among patients receiving hsct. one of the immune evasion mechanisms of leukemic cells to escape from donor t cell recognition in haplo-hsct is the genomic loss of the patient specific hla. it has been described in - % of acute myeloid leukemia (aml) and myelodysplastic syndrome (mds) relapses after haplo-hsct. the aim of this study was to analyze hla loss in a large cohort of patients who relapsed after t-cell replete haploidentical transplantation with posttransplant cyclophosphamide. methods: from december to september , patients with hematological malignancies who received a haplo-hsct were recruited. among them, patients presented a relapse after haplo-hsct. hla typing was performed by real-time pcr using hla-kmr kit (gendx, netherlands).nine patients were excluded from the analysis because the kit employed did not include the recipientspecific hla. thus, a total of relapse cases were analyzed. the analysis of chimerism was carried out using short tandem repeat pcr amplification (ampflstr sgm plus, thermo fisher, usa) with a sensitivity of %. results: genomic loss of the patient hla occurred in / patients ( %) ( table ) . these patients presented different hematological neoplasms. interestingly, patients presented lymphoid neoplasm ( acute lymphoblastic leukemia (all-t), dentritic cell leukemia (dcl) and hodking´s lymphoma (hl)). hla loss relapses occurred later than classical relapses ( vs. days). regarding the treatment received (table ) , four patients were studied retrospectively. three of them were treated with donor lymphocyte infusions (dlis) + chemotherapy or other drugs at the time of the relapse. the other patient did not receive any treatment. in the end, all patients died from disease progression. prospectively, we detected hla loss at relapse in other two patients. at the moment of relapse, the first case received brentuximab + haplo-hsct from alternative donor and the other case received daratumumab + haplo-hsct (pending). both patients are alive, the first one in complete remission (cr) and the second one in partial remission (pr). conclusions: the frequency of hla loss at relapse is similar in our cohort to what is described in the literature. hla loss has been identified in patients with lymphoid neoplasms, while this mechanism has not been previously described in such diseases. the analysis of this immune evasion mechanism should be implemented in the routine screening of patients transplanted from haploidentical donors in order to design effective rescue strategies. these treatments should not be based on dlis or second transplantation with the same donor, instead, alternative donors should be used. background: an adequate immune reconstitution (ir) is crucial to reduce transplant toxicity, relapse rate and mortality after allogeneic stem cell transplantation (allohsct). the aim of this, single center retrospective study was to investigate the correlation between the recovery of different lymphocyte subpopulations with the main transplant outcomes, including overall survival (os), disease free survival (dfs) and non-relapse mortality (nrm). methods: we analyzed the ir of adult patients (aml n= , all n= , mds n= , nhl n= , hd n= , cll n= , cml n= , mm, n= , mpn n= ) who underwent (allohsct) between january and march . median age at transplant was years (range . - . ) with male/female ratio of %. donors were hlaidentical siblings (n= , %), family haploidentical (n= , %), matched unrelated ( , %), mismatched unrelated (n= , %) and cord blood units (n= , %). the stem cell source was the bone marrow (bm) in patients ( %), the cord blood in ( %) and g-csf mobilized peripheral blood in ( %). the conditioning regimen was myeloablative in ( %) transplant, reduced intensity in ( %) and immunosuppressive in ( %). gvhd prophylaxis was based on calcineurin inhibitors in combination with methotrexate or mofetil mycophenolate. antilymphocytes immunoglobulins was used in patients ( %) (anti thymocytes globulin, atg sanofi-genzyme in or anti t-lymphocyte globulin, atlg -neovii biotech, in ). the peripheral blood lymphocyte subsets (cd +, cd +cd +, cd +cd +, cd + (b cells) and cd +cd + (nk) were analyzed by flow cytometry at , , , , and months after hsct. post-transplant engraftment was molecularly determined by vntr analysis. results: as detailed in table the proportion of full donor chimerism analyzed in the peripheral blood t lymphocytes improved progressively after transplantation and the same pattern was observed when the chimeric status was measured in bone marrow mononuclear cells. to favor the achievement of a full donor chimerism, dli were performed in patients starting at the median of days after transplant (range: - ). with a median follow-up observation of months (range - ), the one year os and nrm was % and %, respectively. at months after allohsct, the achievement of values higher than , and /μl for cd +, cd + and nk cells, respectively was significantly associated to a better os (figure ), dfs (p = . ), and to a lower nrm (p< . for cd + and cd +, p= . for nk). a better lymphoid reconstitution was observed after the use of either a sibling or a haplo donor than a matched unrelated or cord blood donors. the use of atg was significantly associated with a delayed cd + recovery but with a faster nk cells reconstitution. conclusions: at six months after allohsct, recovery of cd + and nk cells predicts survival. monitoring of immune recovery may help to guide pre and post-transplant treatment strategies. days infections and disease control. several groups have demonstrated the independent prognostic value of different lymphocyte subpopulations in hsct outcomes. posttransplant cyclophosphamide (pt-cy) effectively prevents gvhd after hla-haploidentical hematopoietic stem cell transplantation (haplo). the use of pt-cy in hla matched related (mrd) or unrelated (mud) donors hsct, although less explored, has also been introduced. the aim of this study was to compare the early immune reconstitution after allogeneic hsct from haploidentical and hla-matched donors using pt-cy. methods: one hundred and sixty-four hsct performed in our center were analyzed: haplo performed between and and hsct from hla-identical donors ( consecutive mrd sct performed with pt-cy between and and mud sct with pt-cy between and ). pt-cy was administered at mg/kg/d in days + and + postransplant, followed by mmf mg/kg/ d and a calcineurin inhibitor (ciclosporina a or tacrolimus) from day + ahead. we retrospectively compared early immune reconstitution at day + and day + among these three populations. early ir was assessed through the analysis of lymphocyte subpopulations including total t lymphocytes cd +, cd + and cd +subpopulations, nk cd -cd + cells, cd + bright immature subpopulation and total b cd + lymphocytes.. lymphocytes subpopulations were determined by multiparametric flow cytometry (fc and navios, beckman coulter®). results: all patients, but mud and haplo, received pb as stem cell source. patients received prior transplant in haplo group. patient´s characteristics are shown in table . patients who received hsct from mrd showed the fastest ir, with statistically significant differences compared to haplo in almost all lymphocyte populations at day + (cd +, cd +, cd + and nk cells), and also in cd +, cd + and b lymphocytes at day + . comparison between haplo and mud hsct showed better ir among haplo, demonstrated by higher counts in cd +,cd +, cd + and nk cell counts at day + . no differences were seen at day + . (figure ). percentage of immature cd bright nk cells was higher in mud hsct at + , with no differences between haplo and mrd hsct. conclusions: in our cohort of patients with pt-cy based gvhd prophylaxis regimen, those who received hsct from mrd showed the earliest immune reconstitution compared to haplo and mud at day + and + . haplo showed better ir compared to mud at day + . nk maturation at day + was a little better among haplo and mrd hsct recipients than mud hsct patients. in our experience, using mostly pbsc as graft source, type of donor influenced early ir in pt-cy based hsct, background: cell-free dna (cfdna) isolated from plasma or serum has received increasing interest for diagnostic applications. however, the reported clinical usefulness of cfdna in patients undergoing allogeneic cell transplantation (hsct) is scarce. methods: the chimeric status both in peripheral blood and in cfdna obtained from plasma was investigated in patients undergoing hsct. dna and rna were isolated from plasma within four hours of blood draw. patients were evaluated for chimerism at day + , + and + post-transplant. a panel of seven microsatellites was amplified by pcr for chimerism detection and pcr products were analysed by capillary electrophoresis. for further cfdna characterization the micro rna (mirna) c was analysed using digital pcr. mutations frequently used for minimal residual disease assessment such as flt -itd, npm and jak were also investigated in cfdna. results: the mean cfdna concentration in transplanted patients was ng/ml, while in healthy donors used as control group (n= ) was ng/ml. the mean cfdna concentration difference between both groups reached statistical significance (p= . ). when analysing cfdna from transplanted patients and in the control group we could not detect dna fragments larger than bp and the size range of the analysed fragments was between and bp. in out of patients a mixture of donor and recipient cfdna (mc) was detected. with the exception of three patients relapsing after transplant in which mc was detected both in peripheral blood and plasma in the rest of the patients (n= ) mc was detected only in plasma. the mean percentage of recipient cfdna in the plasma samples was % (range: - %). all the patients with acute gvhd (agvhd) (grade: i-iv) (n= ) showed mc in plasma at least in one of the time-point tested. no significant difference was found in the mean recipient cfdna percentage in patients with agvhd grade i-ii when compared with grade iii-iv. meanwhile in the group of patients with chronic gvhd (n= ) mc in plasma was detected in patients. in those patients with clinical improvement of agvhd (n= ) a decrease in the percentage of recipient cfdna was observed during treatment. in patients without improvement or even agvhd worsening (n= ) stable or increasing recipient cfdna percentage was detected. since recipient cfdna can be detected in patients without transplant-related complications we analysed the mirna c expression in all patients with recipient cfdna. a significant difference was found in the mirna c expression in patients with agvhd (mean mirna c: . mirna c copies/ u copies) when compared with patients without gvhd (mean mirna c: . mirna copies/ u copies). in those patients with extramedullary aml relapse (n= ) frequent mutations (flt -itd, npm ) were only detected in the cfdna fraction. conclusions: longitudinal analysis of cfdna represents a useful complementary tool in particular for those patients with clinical complications after hsct. disclosure: nothing to declare comparison of the impact of atg/pt-cy-based and tcr αβ-depletion as gvhd prophylaxis regimens on the recovery of memory t-cell compartment background: over recent years haploidentical and hlamismatched donors have been increasingly adopted as a valid donor source. modern graft-versus-host disease (gvhd) prophylaxis regimens such as drug-based (antithymocyte globulin (atg), post-transplant cyclophosphamide (pt-cy)) or graft-manipulated (tcr αβ-depletion) demonstrate effective prevention of gvhd. here we report our data about an influence of different gvhd prophylaxis regimens after allo-hsct with pbsc as a graft source on cd + memory t-cells recovery. methods: our study comprised leukemia patients who underwent allo-hsct with pbsc as a graft source in national research center for hematology, moscow, russia. detailed patients characteristics are presented in table . peripheral blood samples were collected on day + , + and + after allo-hsct. flow cytometry analysis was performed on bd facs canto ii (becton dickinson, usa) to define t-memory subsets: t-naive and t-stem cell memory (tnv+tscm) -cd +cd r -ccr +cd +; t-central memory (tcm) -cd +cd r +ccr +cd +; t-transitional memory (ttm) -cd +cd r +ccr -cd +; t-effector memory (tem) -cd +cd r +ccr -cd -; t-terminal effector (tte) -cd +cd r -ccr -cd -. sysmex xe- was used to calculate absolute count of different t-memory cell subsets. mann-whitney u test was used for nonparametric data analysis. a p-value less than . was considered as significant. results: results of mann-whitney u test (calculated pvalues) to compare absolute number of t-memory cell subsets in terms of different gvhd prophylaxis regimens are presented in figure . during all follow-up period the number of tnv+scm and tcm remains significantly reduced after atg+pt-cy or tcr αβ-depletion compared to atg-based immunosuppressive regimen. on day + we observe no difference in the number of tnv+scm and tcm cells after atg+pt-cy or tcr αβ-depletion. terminally differentiated cd + cells (ttm, tem, tte) count is significantly lowered in tcr αβ-depletion patients group in comparison to atg+pt-cy. nevertheless recovery of tnv+scm and tcm after pt-cy is faster than after tcr αβ-depletion. conclusions: according to our data the mechanism of pt-cy is seems to be more selective compared to tcr αβ-depletion due to its transient impact just on tnv+scm and tcm without affecting on the effector pool. through this it may lead to delayed reconstitution of adaptive immunity after tcr αβ-depletion compared to using pt-cy. clinical relevance of the quantitative characteristics of immune recovery in the context of different approaches to gvhd prevention remains to be established. background: immune effector cells, belonging to either innate or acquired immunity, play a key role on preventing disease relapse after allogeneic haematopoietic stem cell transplantation (hsct). most of known immune effector are cd + cd + t-cells and cd -cd + natural killer lymphocytes, while cd + cd + cells act as modulatory and regulatory cells. the early post-hsct ratio between these cellular subsets may be an indicator of graft vs-tumor (gvt) effect. methods: we retrospectively revised the immune recovery of allogeneic hsct performed at our institution from to , analysed on peripheral blood by multiparametric flow cytometry lymphocyte subpopulations panel. diagnosis were acute leukemias ( %), chronic myeloproliferative neoplasms ( %), lymphomas ( %), myelodysplastic syndromes ( %), multiple myeloma ( %) and severe aplastic anemia ( %). we established early time-points of evaluation, and days from the graft infusion, to analyse the differences in disease free survival (dfs) and overall survival (os) between patients according to the cd + cd + x cd -cd + / cd + cd + ratio. results: median ratio at + days was of , . at this time point, patients who showed the ratio higher than the median had both a better dfs (median dfs time not reached vs months; p = , ) ( figure ) and os (median os time not reached vs months; p = , ). likewise, ratio at + showed an advantage on dfs (p = , ), and not on os (p = , ). other factors possibly affecting both dfs and os were analysed in univariate analysis, such as the use of antithymocyte globulin (atg), conditioning regimen intensity, graft source, hla-matching and disease status at hsct, the latter being the only variable with a significantly detrimental impact on both os and dfs. disease status was confirmed an independent valriable associated with both dfs and os as well as + ratio both on dfs (hazard ratio [hr] - , ; p = , ) and os (hr , ; p = , ). conclusions: our data show that cd + cd + x cd -cd + / cd + cd + ratio assessed at + is and independent predictor of transplant outcome, possibly representing a row indicator of anti-leukemic immune surveillance. the integration of this index with other known outcome predictors may help in improving the management of post-transplant phase. [[p image] . figure background: allogeneic stem cell transplantation (alo-hsct) is a curative treatment but it is associated with lifethreatening complications. most deaths are due to relapse, graft versus host disease (gvhd) and infection. the pattern and quality of the immune reconstitution (ir) after transplantation may affect these outcomes. however, there are limited data on the association of the quality of the ir and either the development of gvhd and survival. methods: eighty-five patients who received a non t-cell depleted alo-hsct in our center from to were prospectively studied. most patients received hla-identical grafts. total cd + and cd + t cells, ccr +cd + and ccr +cd + (which include both naïve and central memory t cells) and naïve ccr +cd l+ t lymphocytes were quantified by flow cytometry. data were collected at days + , + , + , + and + after alo-hsct. the association between ir and the gvhd was studied through an anova. for the multivariate analysis, a logistic regression was performed including those confusing clinical variables that were significant in the univariate analysis (p≤ . ). the study of overall survival (os) versus ir was performed with a cox regression model. results: total cd + t lymphocytes reached normal numbers within the first two months. median t cd + count was cells/ul after one month, which is within the normal range. conversely, it took nearly one year to get normal counts of cd + t cells ( cells/ul). the only two clinical parameters conditioning a worse recovery of the cd + t cells were the previous alosensitization of the donor and the sex, being female donor and male recipient the worst combination for the ir. no parameters influenced the quality of the reconstitution of cd + t cells. of note, the age or the hla status did not influence the quality of the ir. when the patients were divided into gvhd and no gvhd, we found no differences in the recovery of either the proportion or absolute count of every t cell subpopulation, including total t cells as well as naïve/central memory t cells, both cd + and cd +. finally, a multivariant analysis confirmed that the absolute counts of cd +ccr + t cells at day + as well as the absolute counts of both cd +ccr + t cells and naïve cd +ccr +cd l+ at day + were associated with better os. conclusions: in conclusion, neither the development of gvhd nor other relevant parameters seem to play a determinant role in the quality of the ir. to our knowledge this is the first study which demonstrate a clear association between the recovery of naïve cd + t cells measured by flow cytometry and the os. disclosure: nothing to declare p abstract already published. azacitidine (aza) for prophylaxis or pre-emptive therapy for myeloid neoplasms after allogeneic stem cell transplantation whom were treated prophylactically and preemptively. median age was years [range, - ] and all patients had a diagnosis of aml or high-risk mds. prophylactic treatment consisted of aza mg/m for days in cycles of days. in the pre-emptive setting, patients received mg/m for days per cycle and patients mg/m for days per cycle. a median of cycles [range, [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] was administered in the prophylactic group and of cycles [range, - ] in the pre-emptive group. ten patients also received at least one dli after the third aza cycle: patients in the prophylactic group and patients in the pre-emptive one. results: during follow-up, patients had significant delays in treatment plan due to transitory mild complications. however, % of patients (n= ) presented infectious complications requiring hospitalisation and % of patients (n= in the prophylaxis group and in the pre-emptive group) presented some form of gvhd. in patients who developed gvhd, had to discontinue treatment (all in the prophylaxis group); also patients discontinued treatment due to disease progression. the overall drop-out rate was . % (n= ). survival was analysed from initiation of treatment with aza and median follow-up was months. one-year efs was % in the prophylaxis group, with only one patient relapsing and no deaths. in the pre-emptive group, the -year efs was % and the median efs was months; -year os was % and median os was months. conclusions: we conclude that post-transplant aza treatment is a well-tolerated therapy, but the incidence of side effects remains discordant in the literature. results in the prophylaxis group are excellent, but patients with positive minimal residual disease treated pre-emptively had a lower outcome with only stabilisation of the disease. randomised prospective trials are needed to define patients who would benefit the most from this treatment and at what timing, dosage and duration of treatment. disclosure: nothing to declare. abstract already published. results: all subjects experienced hematopoietic engraftment at a median of days (range - ) and demonstrated full donor myeloid chimerism. m-mdsc and pmn-mdsc recovery peaked at a median of days posttransplant. the median peak absolute m-mdsc count was , cell/ml (range , - , /ml) representing a range of . % to . % of pbmcs. the pmn-mdsc peak was more robust, with a median absolute peak of , cells/ml (range , - , /ml) representing a median of . % of pbmcs (range . - . %) . of note, the one patient who developed severe, life-threatening gvhd had the lowest absolute and relative pmn-mdsc recovery ( , cells/ml and . % of total pbmcs). recovery of m-and pmn-mdscs occurred at a similar tempo and magnitude in two recipients of standard gvhd prophylaxis (tacrolimus/methotrexate). however, while mdscs isolated from ptcy recipients exhibited clear t-cell suppressive capacity, those from the comparison patients did not (see figure) . conclusions: mdscs recover rapidly and robustly after allohct using ptcy as gvhd prophylaxis, and may play a role in mitigating gvhd risk by mediating t-cell suppression. this may be a mechanism by which ptcy results in donor-recipient tolerance. background: high dose chemotherapy followed by autologous stem cell transplantation (asct) offers a cure in the upfront and relapsed setting in both hodgkin (hl) and non-hodgkin lymphoma (nhl). asct also remains standard of care in previously untreated multiple myeloma (mm) patients after induction therapy, if eligible. the availability of new cellular or other immune therapies that can be used after asct underscores the potential importance of monitoring immune reconstitution after asct. methods: immune reconstitution panels (irp) were evaluated retrospectively in all lymphoma and mm patients over a -year span ( - ) whom underwent asct at our institution. patients were included if they had a pre-asct measured within days of asct and two other irp at any of the following timepoints ( ) day - , ( ) day - , and ( ) at -year post-asct. patients in the lymphoma cohort had their irp excluded if they had additional treatment within the first year post-asct (other than maintenance rituximab). mononuclear cells from peripheral blood were analyzed by flow cytometry for assessment of lymphocyte phenotype and numbers. absolute values were compared using the mann-whitney u test. results: the data on patients were available for analysis ( mm, nhl, hl) . all lymphoma patients were conditioned with beam. all mm patients were conditioned with a standard high dose melphalan regimen. the median pre-asct absolute cd counts in the lymphoma cohort were significantly lower than the mm cohort at cells/μl vs cells/μl, respectively (p= . ). however, the mm cohort exhibited a greater percent reduction in cd cells on day at . % vs . %, respectively which continued through day at . % vs . %, respectively. this led to nonsignificant changes in absolute cd count by day at cells/μl vs cells/μl, respectively (p= . ) (figure ). the median absolute cd count pre-asct for mm and lymphoma cohorts were cells/μl and cells/μl, respectively (p= . ). similarly, a greater percent reduction in cd cells led to comparable absolute counts on day at cells/μl vs cells/μl, respectively (p= . ). the failure of post-asct cd reconstitution to pre-asct levels was driven by lack of cd + cell recovery, namely cd +cd ra+ cells with a median of cells/μl and cells/μl in the mm and lymphoma cohorts, respectively at day (figures and ). this led to markedly diminished cd :cd ratios through day (figure ). [[p image] . conclusions: impaired t-cell reconstitution in both lymphoma and mm continues through -year post-asct. as shown, a larger percent reduction in median cd and cd counts through day was appreciated in mm compared to lymphoma leading to the nonsignificant differences in the post-asct absolute counts despite significantly higher pre-asct counts in the mm cohort. impaired recovery of cd t-cells may increase the risk of opportunistic infections, decrease the response to vaccination and lead to ineffective anti-tumor response. further prospective and larger retrospective studies like this should continue in the modern-era as they may help predict responses to further interventions requiring a robust t-cell repertoire for maximal efficacy such as car-t cell and bite therapies. disclosure: nothing to declare p peri-transplant detection of measurable residual disease by multicolor flow cytometry is highly predictive for relapse in acute myeloid leukemia patients background: presence of measurable residual disease (mrd) prior to allo-sct has been shown to be predictive for survival in patients in hematological cr of aml. in this study we analyzed the impact of mrd in such patients measured by -color multiparameter flow cytometry (mfc) prior to and on day + post-transplant. methods: the bone marrow samples immediately prior to allo-sct and on day + post-transplant were retrospectively analyzed. mrd evaluation was carried out with antibodies against: ( ) results: a number of aml patients (male, n= ) with median age of years ( - ) in hematological cr prior to allo-sct were enrolled in the study. we observed lower survival in patients with mrd by mfc pre-transplant ( y os: % ( - %) vs. % ( - %), p= . ) due to increased relapse incidence ( % ( - %) vs. % ( - %), p= . ). in multivariate analysis, mrd pos prior to allo-sct has strong significant impact on os (hr . ( . - ) , p= . ). of patients, a sample both before and on day + after transplantation was available in patients. of those patients, ( %) were mrd negative prior to transplant and on day + (mrd neg/neg ); ( %) patients were mrd positive prior to transplant and negative at day + (mrd pos/neg ); and ( %) patients were mrd positive at both timepoints (mrd pos/pos ). dfs and os for these three groups were as follow: y dfs: mrd neg/neg : % ( - %), mrd pos/neg : % ( - %); mrd pos/pos : % ( - %, p= . ); y os: mrd neg/neg : %; mrd pos/neg : % ( - %); mrd pos/pos : % ( - %, p< . ). upon multivariate analysis, the mrd status prior to transplant and on day + showed strong significant impact on dfs (hr . ( . - . ), p= . ) and os ), p= . ). we did not observe any significant impact of other factors included in the multivariate analysis (patient's age, patient's sex, and recipient/ donor sex constellation). conclusions: mrd positivity prior to allotransplant and at day + by mfc is highly predictive for survival after allo-sct. disclosure: nothing to declaire background: immune reconstitution is a critical factor for risk assessment of life threatening infections and long-term survival in patients undergoing allogeneic cell transplantation (hsct). methods: immune cell subsets (cd , cd , cd , cd , cd +cd -) were quantified by flow cytometry. trec and krec were quantified simultaneously using droplet digital pcr (dpcr). a total of patients were evaluated. mean age at transplant was years (range: - years) samples were obtained before hsct and at day , and after hsct. results: absolute numbers of cd and cd cells remained below pre-transplant levels until day , increasing further and eventually reaching pre-transplant levels one year after hsct. absolute counts of cd and cd +cd -cells remained below pre-transplant levels beyond one year after hsct. cd cells were characterized by fast reconstitution kinetics, reaching pre-transplant levels already at day . b cells correlated with krec levels at all time-points tested, whereas t cells correlated with trec levels only one year after transplantation. when we compared cell subsets, trec, krec levels and the reconstitution kinetics thereof between patients with reduced intensity conditioning (n= ) or full conditioning (n= ) no significant differences were observed. patients with pre-transplant trec levels above the mean ( trec copies/ml blood) showed higher trec levels and a faster t-cell reconstitution after hsct suggesting that tcell reconstitution can be predicted by analysing thymic functionality before transplantation. indeed, in patients with a pre-transplant trec above trec copies/ml blood, the positive predictive value for an efficient t-cell reconstitution was . (p= . ). we analysed the recovery kinetics of the cell subsets, trec and krec levels in patients with and without transplant-related complications. patients with either acute graft-versus-host disease or severe infections showed a slower trec reconstitution when compared with patients without complications. conclusions: our data suggest that the analysis of immune cell subsets together with trec and krec quantification can be used to evaluate the immune reconstitution process after hsct. pre-transplant trec levels allow t-cell reconstitution efficiency prediction after hsct. disclosure: nothing to declare background: falling donor / mixed chimerism after allogeneic haematopoetic stem cell transplant (sct) is associated with an increased risk of relapse and the potential for graft rejection. donor lymphocyte infusions (dli) are often administered in patients with mixed chimerism to achieve full donor chimerism but there is little data on long term outcomes for dli given for persistent mixed chimerism. methods: a retrospective analysis of all patients administered dli for mixed chimerism between to january was performed. all patients were transplanted at the university hospital of wales within the south wales blood and marrow transplant (swbmt) programme. patients were identified by the swbmt database and additional outcome data gathered by review of patients' medical records. results: patients were treated with donor lymphocyte infusions between and january . thirty one patients treated for relapse (with or without mixed chimerism) were excluded as was a further patient with a mismatched donor. the rest were / match. twenty six patients received a total of donor lymphocyte infusions for mixed chimerism alone. the median age was years (range: - ) with % women. fourteen ( %) of the patients had sibling donor transplants and twelve ( %) from matched unrelated donors. indications for transplant were: for aml or saml (n= ), myelofibrosis (n= ), mds (n= ), hodgkin lymphoma (n= ), non-hodgkin lymphoma (n= ) and all (n= ). escalating doses of donor cd + t cells were administered commencing at × /kg to × /kg then increased at half log increments according to chimerism results until full donor chimerism was achieved. the median number of doses administered was (range - ). the median interval was days (range - ). the median dose was × / kg (range × - × ). seventeen patients ( %) achieved full donor chimerism and remained so until most recent follow up (median months, range - ). one patient continued to receive dli after the study period and later reverted to full donor. two patients had ongoing mixed chimerism with no evidence of relapse. two patients relapsed; one of whom later achieved remission. there were six cases of gvhd; acute gvhd (grade ii n= , grade iii n= ) and cases of chronic extensive gvhd. one patient had gvhd features consistent with overlap syndrome. a total of five patients died, four due to infection (one in a patient with gvhd) and one due to cardiac toxicity from previous treatment (confirmed on post-mortem). conclusions: the results of our single centre study help reinforce the evidence for dli in establishing full donor chimerism when mixed chimerism is detected in the absence of relapse. incremental dli dosing is an effective strategy and associated with a low relapse rate. caution should still be given to the risk of gvhd following dli, however the risk appears to be low in this study. larger prospective studies are ongoing to address the optimal dosing strategy for dli post-transplant. disclosure: nothing to declare hypomethylating agents for the treatment of relapsed acute myeloid leukemia after allogeneic blood stem cell transplantation: a single center experience mariarita sciume , giorgia saporiti , elena tagliaferri , nicola fracchiolla , federica grifoni , giorgia levati , luca baldini , francesco onida the post-transplant period with well-balanced profile of good efficacy and moderate toxicity. we retrospectively evaluated the safety and efficacy of hma +/-dli in a reallife cohort of aml patients relapsing after allo-sct. methods: data from all patients with aml who underwent allo-sct at our institution in the last years and subsequently received hma as a salvage treatment for disease recurrence or preemptively for loss of complete donor chimerism were collected. results: eleven patients with a median age of years (range - ) were identified; median time between allo-sct and time to hma therapy was months (range - ). according to eln genetic risk stratification, patients were classified in the favorable group, in the intermediate-i, in the intermediate-ii and in the adverse one. six patients were treated with aza, whereas the remaining patients with dac. the cycles were repeated every days. ten patients ( %) started hma for morphological aml relapse, while one patient received aza as a sequential treatment after dli administered for loss of complete donor chimerism. median number of cycles was (range - ). treatment strategy included combination with dli in patients ( in the dac cohort, in the aza cohort), while in one case of flt -itd + aml sorafenib was also associated to dac and dli. no grade / toxicities and no acute gvhd occurred. a clinically significant response was observed in four patients ( %), all receiving at least cycles of hma therapy; in particular, a complete remission (cr) was achieved in / patients treated for morphological relapse, including the one who received the dac/dli/sorafenib combination and one (favorable eln risk) who received aza alone (not eligible for dli due to a concomitant lateonset cutaneous grade gvhd). of interest, the latter patient also displayed a resolution of the cutaneous gvhd. full donor chimerism recovery with no gvhd was observed in the patient who received aza for the progressive donor chimerism loss not responding to dli alone. with a median follow-up of months (range - ), the median os from hma treatment in responding patients was months (range - ); at the time of data collection responses were maintained in all four patients. seven patients had died, six from aml progression and one for severe intestinal gvhd occurring after failure of dli+aza and a following salvage induction chemotherapy treatment. conclusions: although arising from a limited number of patients, our real-life experience of treatment with hmas +/-dli in aml patients relapsing after allo-sct showed a general very good safety profile and promising antileukemic activity, altogether suggesting a facilitation of the graftversus-leukemia effect (gvl) associated to a possible suppression of the gvh reaction. disclosure: nothing to declare conclusions: in this study, cd -positive cell count and igg value had recovered about months after sct. in our institute, we have achieved a low incidence of infection by education and medication for patients until recovery of cd -positive cell count and igg. however, we found a higher incidence of infection after recovery of cd -positive cell count and igg. at - months after sct, administration of prophylactic medications such as sulfamethoxazole-trimethoprim were terminated and social comeback such as return to school or work were achieved in most patients. it is possible that the high incidence of community-acquired infection was associated with their comeback. thus, we should consider additional prevention of infection for patients in this period and further evaluation of immunological markers is needed. disclosure: no potential conflicts of interest were disclosed. effect of minimal residual disease before transplantation on the outcome of haplo-identical hematopoietic stem cell transplantation for high-risk acute lymphoblastic leukemia yehui tan , sujun gao , xiaoliang liu , long su , wei han , yu liu , yangzhi zhao background: to analyze the effect of haploid hematopoietic stem cell transplantation (hid-hsct) on high-risk acute lymphoblastic leukemia (all), and to explore the effect of minimal residual disease (mrd) before transplant on the prognosis. methods: a retrospective analysis was made on high risk all patients accepted hid-hsct in our hospital from january to january . the clinical features, stem cell implantation, complications, survival and recurrence were compared between pre-transplant mrd + and mrdpatients. results: all the patients got successfully implanted. the overall survival (os) was . %, the disease free survival (dfs) was . %, the incidence of acute graft versus host disease (agvhd) was . %, including . % ii~iv degree agvhd and . % iii~iv degree agvhd. there was no significant difference in stem cell implantation, gvhd, cytomegalovirus and hemorrhagic cystitis between mrd + and mrdpatients. dfs and os in mrd + patients were significantly lower than those in mrd -patients, and the cumulative rr rate increased significantly, there was no significant difference in cumulative trm. conclusions: hid-hsct was an effective method to treat high risk all, but mrd + patients had high recurrence rate and poor prognosis. strategy adjustment should be considered to reduce tumor residual and the transplantation strategy should be optimized for these kind of high risk patients, so as to improve survival rate. disclosure: nothing to declare background: lymphocytes are responsible for the cellular and humoral immunity and, consequently, its recovery after allo-hsct might be linked with the survival after the procedure. the aim of this study was to analyze this hypothesis in our series of patients. methods: all the allo-hsct performed in our center from january through july were included in the analysis. median age was years (range: - ). pts were male ( , %) and were female ( , %). baseline diseases were: aml, lpd, mds, all, mpd, mm, and bmf. donor was unrelated in ( , %), and was family in cases ( , %) (including haplo-identical). stem cell source was pb in ( , %) and bm in pts ( , %). conditioning regimen was reduced in procedures ( , %) and intensive in ( , %) (including just one non-myeloablative). overall mortalities at days + and + (the latter in patients with follow-up superior to year) were , % and , %, respectively. median follow-up was months (range: - ). evolution of absolute lymphocyte counts (alc) and subpopulations at pre-hsct and during the first year after allo-hsct were analyzed. results: as shown in table , alc and cd + lymphocytes decreased after conditioning therapy, and recovered progressively during the post-hsct period. at day + , majority of patients had > alc/mcl, clearly improved compared to admission values. cd + lymphocytes at day + was still very low, but at day + around half of the series had - /mcl. we found a strong link between alc, cd + lymphocytes, and cd + lymphocytes at days + and day + with overall survival at day + of the series (table ) . conclusions: in our series, immunity recovery was a late event for majority of patients undergoing allo-hsct. in addition, in our experience, the precocity and quality of the alc, cd +, and cd + cells recovery was clearly linked with long-term survival. background: the reconstitution of t and natural killer (nk) cells after hematopoietic stem cell transplantation (hsct) strongly influences the outcome of hsct including viral infection and graft versus-host disease (gvhd). the purpose of this study was to investigate the clinical efficacy of immune reconstitution including t and nk cells after hsct in children. methods: we reviewed the records of patients who undergoing allogeneic hsct in department of pediatrics, pusan national university children's hospital, from january to july . the counts of t lymphocyte subsets and nk cells was monitored in peripheral blood by flow cytometric technique during , , , and months post-hsct. blood samples for cytomegalovirus (cmv) and epstein-barr virus (ebv) monitoring were tested by real-time pcr assay. results: for total of patients, the mean age was . years (range, months- years), of the patients were boys and was girl. out of a total patients without pre-hsct cmv viremia or cmv infection, ( . %) recipients experienced cmv infection. the number of cd + t cells in and months post-hsct was significantly higher in patients with cmv reactivation compared to patients without (median . /μl vs. . /μl, p= . , and . /μl vs. . /μl, p= . ) . in ( %) recipients presented acute gvhd, the number of cd + t cells in and months post-hsct was significantly lower in patients with acute gvhd compared to patients without (median . /μl vs. . /μl, p= . , and . /μl vs. . /μl, p= . ) . the number of nk cells in months post-hsct was significantly lower in patients with cmv reactivation and acute gvhd compared to patients without ( . /μl vs. . /μl, p= . , and . /μl vs. . /μl, p= . , respectively) . in multivariable analysis, acute gvhd was shown to be the decisive factor influencing total t cells (p= . ) and cmv reactivation was independently associated with cd + t cells (p= . ). the cd + t cells counts were associated with prior hsct history and acute gvhd (p= . and p= . ), and the cd + t cells counts were also significantly associated with donor type (p= . ). conclusions: overall, our study documents that immune reconstitution of cd + , cd + t cells and nk cells is strongly associated with cmv reactivation and acute gvhd. additionally, we show that acute gvhd is influenced by lack of sufficient numbers of nk cells as well as cd + t cells early after sct. cd + t cells, on the other hand, significantly increase after cmv-reactivation and most likely play an important role in reactivation. disclosure: nothing to declare background: curative effect of allogeneic hematopoietic stem cell transplantation (allo-hsct) depends on the alloreactive t-cell immune response toward residual malignant cells -graft-versus-leukemia reaction. however, alloreactive population has not been phenotypically defined. recent studies suggest that alloreactive t cells express both costimulatory and inhibitory receptors simultaneously. exhaustion caused by the inhibitory signaling dampens tcell functionality, which could lead to the disease relapse. here we aimed to investigate the expression of costimulatory and inhibitory receptors on antigen-experienced t cells after transplantation, to isolate subpopulation specific for allo-hsct patients and analyze their t-cell receptor (tcr) repertoire. methods: expression of coinhibitory and costimulatory molecules on pbmcs patients at various time points after allo-hsct was analyzed for expression of: cd , cd , cd , cd ra, ccr , cd , cd , cd , klrg , tigit, pd , cd and ox by flow cytometry and compared to healthy donors. cd +cd +cd -cd +cd +pd +tigit+ fraction and cd + cd + control fractions were separated on facs aria ii cell sorter. double barcoded cdna libraries of tcr beta-chains for both fractions were prepared and analyzed by sequencing on illumina platform. sequencing results were processed by migec, mixcr and vdjtools software. enriched clones were identified by fisher's exact test (p> - ). results: we did not find any significant differences between patients after allo-hsct and healthy donors in single marker's expression, but, when considering coexpression of co-stimulatory and inhibitory molecules on t cells we found that cd +cd +cd -cd +cd +pd +tigit+ subpopulation was significantly increased in allo-hsct patients. moreover it increased with the time since the transplantation (fig. ). this population was isolated by cell sorting and alongside with total cd + fraction subjected to tcr beta-chain repertoire sequencing. the population contained clones significantly enriched compared with cd + fraction representing potentially alloreactive cells. this hypothesis is further supported by the notion that the level of expression of cd and cd co-stimulatory molecules is lower in the group of patients who subsequently relapsed, compared with the patients with complete remission, while the expression of inhibitory receptors was high in both groups. conclusions: according to our data patients after allo-hsct have a phenotypically distinct t-cell population characterized by simultaneous expression of costimulatory and inhibitory markers. this population contains specifically enriched clones, which may be specific for alloantigens. further functional assays are needed to confirm the alloreactive potential of this subpopulation. besides low expression of costimulatory molecules combined with high expression of inhibitory receptors on antigen-experienced t-cells of patients after allo-hsct might be associated with a disease relapse. fondazione mbbm, monza, italy, ospedale san gerardo, laboratorio stefano verri, monza, italy background: poor graft function (pgf) is a severe complication after hsct, with a high risk of morbidity and mortality, mainly due to infections. donor cd + scb seems to offer high chances of haematological recovery, not jeopardized by gvhd. however, pediatric reports remain scarce. methods: out of patients undergoing transplantation in our pediatric unit from to have been retrospectively evaluated for at least line persistent cytopenia (hb< . g/dl, plt< /mmc, n< / mmc) and/or transfusion-dependency beyond months after hsct in the presence of full donor chimerism. bone marrow cellularity was evaluated through biopsy as further indicator of pgf. ( / ) to donate or medical decision ( / ). bone marrow cellularity was < % in % of the patients who underwent scb for which the histology was available ( cases), and % in those who have not been treated ( / ). at days after scb / ( %) patients had hematological response, which was complete in % and partial in % of the patients. only patient had no response. the infusion was always well tolerated with no adverse events, and no worsening of gvhd. haematological recovery occurred spontaneously at days after bone marrow biopsy in a significantly lower proportion of patients ( / , %, p< . ) within the non-scb group. in two cases platelets engraftment was significantly delayed, up to one year after bone marrow biopsy and in one case thrombocytopenia persists and the patient is still receiving thrombopoietin agonists and red blood cells transfusions at months after bone marrow biopsy. conclusions: a stem cell boost matched the goal to yield count recovery in our cohort. viral infections and gvhd may be possible risk factors for pgf.bilinear or trilinear cytopenia with transfusion dependency and bom cellularity < % and full donor chimerism are good indications for scb, that can provide a significantly earlier hematological reconstitution, without risks of gvhd. due to the proved early efficacy and safety of cd + stem cell infusion, we suggest that this procedure should be taken in consideration in children with severe bone marrow hypoplasia and persistent cytopenia after hsct. disclosure background: as allogeneic hematopoietic stem cell transplantation (hsct) is sometimes performed despite erythrocyte's antigens incompatibility and mismatch, it is essential to carefully track patients' genotypes after it. methods: for the study we used erythrocytes (n= ) and dna (n= ) from patients undergoing abo-or rhesus-mismatch hsct and their donors. we used posttransplant no transfused patients on the periods according transplant protocol by hemagglutination methods in plate and tube using monoclonal antibodies to abo and rhesus antigens (hematolog, russia). we extracted dna with dna kit (bag, germany) and conducted pcr-ssp with kits abo-type, rh-type (bag, germany). chimerism was assessed by the str-pcr analysis with cordis plus multiplex kit for amplification of polymorphic strmarkers and amelogenin loci. the fragment analysis was performed on a genetic analyzer. informative loci were chosen by comparison of pretransplant patient's and donor's dna. the percentage of donor chimerism was calculated using standard formula. precise rhce and abo genotypes were determined by direct sanger sequencing. we revealed patients with unexpected erythrocyte abo, rhesus phenotypes and genotypes after hsct on + ( patients) and + days (all patients). chimerism analyses on str showed in a.e.kh. and g.l.v. patients % of donor's dna and less than % of recipient's one. b.n.a. patient was relapsed and chimerism analysis revealed % of recipient's dna and % of donor's one. using serological methods and pcr-ssp we revealed genotypes abo * a b ; rhd+; rhce * ccee in patient a. e.kh. before hsct, abo * a o ; rhd+; rhce * ccee in her donor, and abo * a a ; rhd+; rhce * ccee on + d after hsct. genotype a a was no recipient's neither donor's origin. direct sequencing did not prove this genotype, but revealed donor's one.on + d serological methods and pcr-ssp also revealed donor's genotype in this patient. patient b.n.a. had genotypes abo * o /o ; rhd+; rhce * c w cee before hsct, her donor -abo * b o ; rhd +; rhce * ccee. on + d this patient relapsed, but rhesus genotype has been detected as rhd+; rhce * c wcee (lack e gene). direct sequencing revealed gene rhce*ee. abo genotype was recipient's origin -o o . in patient g.l.v. using serological and pcr-ssp methods we determined genotypes abo * o /o ; rhd +; rhce * ccee genotype before hsct, and abo * a / o ; rhd+; rhce * ccee genotype in her hsc donor. on + d patient had unexpected genotype abo * o /o (a lack of a antigen); rhce * ccee (a lack of e antigen). in order to explain unexpected patient's genotypes after hsct we sequenced her rhce and abo genes and found donor's genotype ccee; a o that was in agreement with results of str analysis. to resolve discrepancies between serological, pcr-ssp and sequencing analysis data we sequenced patient's rhce cdna and observed only ce allele. at present time the molecular basis of selective inactivation one of the two rhce alleles is not clear. on + d patient had donor's genotype. conclusions: what kind of mechanisms led to discrepancies between results obtained by different laboratory methods are still not clear. an interesting case of expression of only one rhce allele in patient g.l.v. allows us to suggest involvement of some epigenetic mechanisms like dna methylation or histone modification in this process. clinical background: in relapsed patients with acute b -lymphoblastic leukemia (all-b) who achieved complete remission (cr) after re-induction therapy, minimal residual disease (mrd; ≥ - all-b cells/ul) is often detected. according to available data, such condition varies from % to even % of cases, as assessed by pcr or flow cytometry (fc), while the presence of mrd is the most important risk factor for all recurrence. in this abstract, we describe our experience with bridging therapy using blinatumomab infusion after re-induction regimens and before the planned allogeneic stem cell transplantation (allo-sct). the procedure was performed in three young men suffering from relapsed ph (-) all-b at the age of , and years. in the first case ( yo), relapse with previous mrd accounting for . % occurred months after cr mrd neg . in the next patient ( yo) the second relapse with central nervous system (cns) involvement occurred months after allo-sct performed in cr ( months after cr , mrd neg ), while in the third patient ( yo), recurrence with cns and testis involvement occurred years after cr (mrd neg ). all patients underwent chemotherapy (flam, hypercvad and dnr/vcr/pegasp/dexa regimens respectively) followed by one cycle of blinatumomab (at a dose of mcg/d on days - , followed by mcg/d on days - in a continuous infusion) and allo-sct (using eto/cy/tbi/atg/ conditioning regimen for ist and iiird patient and bucy for iind patient; using matched unrelated donor (mud, ist and iiird patient) or matched related donor (iind patient)). mrd status was assessed after each cycle of blinatumomab by fc. results: all patients achieved cr mrd pos after reinduction therapy followed by clearance of mrd after blinatumomab course (tab. ). the second patient, due to positive mrd months after allo-sct received donor lymphocyte infusions additionally. during the administration of blinatumomab, no adverse events (aes) were observed in grade or . one patient developed cytokine release syndrome in grade . the progression free survival, time to positive mrd and follow up are presented in tab . conclusions: the use of blinatumomab as a bridging therapy between re-induction regimens and allo-sct in patients with all-b and mrd pos appears to be safe and leads to the clearance of mrd which may be crucial in os and pfs prolongation after following allo-sct. future studies on larger groups of patients are necessary to confirm this thesis. background: haploidentical hematopoietic stem cell transplantation (hsct) is considered an alternative treatment for hematologic malignancies in patients who do not have an hla-identical sibling donor [ ] . since infections and disease relapse resulting from delayed immune reconstitution (ir) are the most common causes of mortality among patients undergoing haploidentical-hsct [ ], timely ir is essential in the recovery and survival of these patients. the aim of this study is to describe the evolution of ir after haploidentical-hsct and to estimate survival rates in patients with delayed vs. adequate reconstitution in a single center in colombia, south america. methods: a retrospective cohort study was conducted on consecutive adult haploidentical-hsct recipients at a tertiary referral center. cd +cells, cd +cells, cd +cells, and immunoglobulins levels were monitored before hsct, at first month, and then every three months for the first two years post-transplantation. descriptive statistics were used to analyze patient's clinical characteristics. the kaplan-meier method was used to assess overall survival (os) and relapse-free survival (rfs) rates. results: twenty-six patients were included ( % were male), with a median age of . years (range - ). the most common indication for haploidentical hsct was acute lymphoblastic leukemia (n= , . %), followed by non-hodgkin lymphoma (n= , . %) and myelodysplastic syndrome (n= , . %). all patients received gvhd prophylaxis therapy with cyclophosphamide, tacrolimus, and mycophenolate mofetil. fifteen patients ( . %) presented cytomegalovirus reactivation ( / at risk), patients ( . %) epstein-barr virus reactivation, and patients ( . %) developed adenovirus infection. median time to neutrophil engraftment (neutrophils> . × /l) was days (range - ) for the patients recipients of peripheral blood progenitor cells (pbpcs) and days (range - ) for the three remaining bone marrow recipients. platelet engraftment, defined as > , platelets/ mm background: daratumumab is a human monoclonal antibody directed against the glycoprotein cd that is overexpressed on the surface of plasma cells in multiple myeloma patients. it is approved as second line therapy either as single agent therapy or in combination with lenalidomide or bortezomib for the treatment of patients with relapsed/refractory multiple myeloma. despite the curative potential of an allo-sct, the high relapse rate remains a clinical problem. data addressing the choice of an optimal salvage therapy regime for these heavily pre-treated patients is missing. methods: from april till november a total of patients (male, n= ) with the median age of years ( - ) received daratumumab as a salvage therapy for relapse of multiple myeloma after allo-sct at the university of hamburg. prior to allo-sct all but one patient had received an autograft, patients even ≥ autografts and patients also a . allograft. the median number of salvage lines post-transplant and prior to first daratumumab infusion was ( - ). these salvage regimens included cyclophosphamide, etoposide, bortezomib, lenalidomide, pomalidomide and carfilzomib. daratumumab was started at a median of months ( - ) after relapse/ progress and initiated as single agent therapy in all patients. concomitantly, patients received either an immunomodulatory drug (lenalidomid, n= ; pomalidomid, n= ) or a proteasome inhibitor (bortezomib, n= ) during a later course of daratumumab infusions. combination therapy was initiated when a slow rise of paraprotein and/or free light chains or no response to monotherapy was observed (median at the th infusion). results: the median number of infusions was . twenty adverse reactions were observed in of ( %) patients: dyspnea (n= ), bronchospasm (n= ) shivering (n= ) , cough (n= ), musculoskeletal pain (n= ), acute coronary syndrome (n= ), skin rush (n= ), facial edema (n= ), pressure on eyes (n= ). all adverse reactions appeared during the first infusion and were mostly mild or moderate (ctc - , n= ). tolerance of the following infusions improved and in none of the cases therapy had to be stopped due to adverse events. three patients developed late onset infections (pneumonia, n= ; urinary tract infection, n= ) followed by temporarily therapy interruption. with a median follow-up of months after the first administration of patients remain alive . %). one patient died due to progress of myeloma and another died due to severe infection/sepsis. of patients responded ( %; pr, n= ; vgpr, n= ; cr, n= ) to the therapy with daratumumab. the responses (decrease of paraprotein and/or free light chains ≥ %) occurred at a median of days ( - ) after the first administration and lasted for . months ( . - . ). conclusions: daratumumab shows an encouraging efficacy and acceptable toxicity profile in patients with relapsed/refractory myeloma after allo-sct. further studies are needed to investigate the role of the combination therapy with immunomodulatory drugs or proteasome inhibitors in this setting. disclosure: nothing to declare p clonal plasma cell detection by high sensitive flow cytometry in aphaeresis product is poor prognostic and not increased by use of plerixafor alone background: in an earlier from our center we have demonstrated that residual clonal plasma cells (cpc) decrease both overall survival (os) and disease free survival (dfs) (ash ).plerixafor is a selective antagonist of cxc chemokine receptor (cxcr ) and able to mobilize human peripheral blood stem cell (pbscs) by acting synergistically with g-csf.the purpose of this study was to evaluate the safety and efficacy of plerixafor in myeloma patients who were proven poor mobilizers and specifically to assess the flow cytometric measurement of residual clonal plasma cells in the apheresis products. methods: patients with a diagnosis of mm who underwent auto hsct at our center between january -november were retrospectively analyzed.out of patients, patients received plerixafor as mobilization regimen due to poor mobilization with g-csf.pbsc grafts were tested for the presence of clonal pcs (cpc) and the number of normal pcs (npc) by multi-parameter flow cytometry (fcm).the acquisition of the cells was performed using the navios flow cytometer beckmancoulter) .upon the daily checks of the instrument, x cells for each sample were acquired and the collected data was analyzed using the kaluza software (beckmancoulter,usa). results: patient demographics are shown in table .the majority of patients were male and median age was years in the plerixafor group.the median interval from time of diagnosis to mobilization and follow-up from mobilization were . months and . months in plerixafor group, respectively. cpc contamination in the pbsc grafts was detectable in and patients with counts ranging between - . x - and - . x - in g-csf alone and g-csf+plerixafor groups, respectively (p= . ).there were no significant differences in the proportion of the patients with graft contamination between subtypes of mm in both groups. one hundred (gcsf/plerixafor; / ) patients had pre-asct pet-ct imaging done with (gcsf/plerixafor; / ) have active lesion at the time of mobilization. statistically significant association could not be demonstrated between the disease < cr status at mobilization and the number of apc in the apheresis product in both groups (p> . ).twelve of patients from plerixafor treatment arm proceeded to transplantation within median . months.the best overall response to induction treatment is shown in table .thirtyfour patients from the g-csf alone arm and patients from the g-csf+plerixafor arm died during the follow-up (p= . ).disease progression was seen in patients from g-csf alone group and patients from g-csf+plerixafor group of the study(p= . ).estimated mean os was better among patients w/o apc contamination in plerixafor group, respectively ( . ± . mos vs . mos; p= . ). conclusions: our results on and few plerixafor used patients show that clonal plasma cells are detectable by multiparametric flow more frequently when patients are poor mobilizers and require plerixafor.the clonal pc contamination can be attributed to the myeloma biology as manifested by higher number of lines induction regimens and pet positivity among the plerixafor-required patients. the overall and disease survival was impaired by residual clonal pcs in the graft but not by plerixafor per se. neither was the content of clonal pcs differed from others.thus the cxcr shared by hsc and myeloma cells do not cause a myeloma mobilization. clinical trial registry: -disclosure: nothing to declare prognostic factors for overall survival after allogeneic hematopoietic cell transplantation in multiple myeloma patients all factors with significant influence on pts survival were included multivariate analysis (cox regression model) but only re-admission in the first days demonstrated impact on os (hr , ; p= , ) . conclusions: we analyzed risk factors for survival in mm pts who received allo-hct. our study identified disease-related risk factors like iss and transplantationrelated factors such as hct-ci and pam, hospital readmission, days of hospitalization and cmv reactivation that were associated with worse long-term survival. in our series, the most frequent death and re-admission cause was infection, so focusing the efforts in reduction of infection could have a beneficial impact on improvement of survival in mm undergoing allo-hct. [[p image] . figure ] disclosure: there is no disclosure. novel protocol for autologous hsct in multiple myeloma: ambulatory chemomobilization and transplantation of fresh hematopoietic stem cells with backup storage background: autologous hematopoietic stem cell transplantation (ahsct) after melphalan conditioning is still a part of standard treatment of multiple myeloma patients. traditional transplantation of frozen stem cells poses additional risk for the patients connected with dmso and central venous catheter. the transplantation of fresh cells is an option -however, most mobilization protocols are either low-efficient (g-csf), expensive (g-csf + plerixafor) or toxic (standard dose chemomobilization) to directly proceed to transplantation in this fragile group of patients. we describe here the novel combination of ambulatory mobilization with very low doses of ara-c and g-csf connected with direct ahsct with fresh cells. methods: the prospectively collected database of patients after ahsct was searched for patients who underwent ahsct after chemomobilization with ara-c and transplantation with fresh cells (fc) and compared with control group of consecutive patients transplanted with standard protocol (sp) (transplantation with frozen cells) between july and october . protocol of ambulatory mobilization was: mg/m² of arac on days + and + and g-csf at the dose μg/kg/day from day + and escalated to μg/kg/day split into two doses + to + , apheresis started on day + (or later) and finished when at least . x e cd + positive cells were collected. the collected cells were split in three equal parts: ) for use as fresh transplant ) frozen for possible nd transplant ) frozen as backup. results: there were transplantations with fresh cells and transplantations with frozen cells compared. both groups had same mobilization protocol -ambulatory low dose ara-c. the median age and number of transplanted cells was similar in both groups ( vs , p= . ; . vs . cd +/kg, p= . conclusions: we present novel approach that allows direct ahsct after chemo mobilization in all patients who are treated with melphalan. we show that it is not only feasible to do ahsct directly after chemomobilization but also the results may favour this approach when compared with current standard. disclosure: nothing to declare background: high dose chemotherapy followed by autologous hematopoietic cell transplantation (hsct) is considered, since the nineties, the standard of care for patients aged less than - years old with newly diagnosed multiple myeloma (mm). however, the optimal induction treatment prior to hsct to reduce the tumor burden has changed during the last few years. improved regimens have shown to be able to increase the quality of the pre-hsct response, which might subsequently impact on the post-hsct response, which has been proved to be associated with a longer pfs. we recently changed the induction therapy for pts candidates to hsct. in this analysis, we aimed to check if newer regimens impacted on pretransplant responses, and how auto-hsct changed the pre-hsct status. methods: all the auto-hsct for mm patients performed in our center from january through august were included in the analysis. median age was years (range: - ). pts were male and were female. durie-salmon stage was distributed as follows: i ( . %), ii ( . %) and iii ( %); % had creatinine > mg/dl. iss was: ( %), ( . %), and ( . %). type of monoclonal component was: igg ( . %), light chains ( . %), iga ( . %) , and non-secretory ( . %). . % had bence jones proteinuria. conditioning regimen was melphalan mg/m in ( . %), melphalan - mg/m in ( . %), and other in ( . %). results: pre-transplant therapy was: vcd in (mostly in - ), vtd/vrd/krd in (mostly in - ), and others in cases. status of the disease at transplant was: cr/vgpr in , pr in , and sd in . distribution of pretransplant response based on the type of induction is shown in table . peri-transplant mortality was %. day + mortality was . % ( pts), due to progressive disease. as shown in table , all patients ( / ) who obtained cr pre-hsct, maintained the response at day + post-hsct. among the patients in vgpr at hsct, ( . %) became into cr, and ( . %) maintained the response. the cr rate at post-hsct increased % compared to pre-hsct ( versus pts). altogether, after hsct pts ( . %) improved and ( . %) maintained the pre-hsct response. during the last period of time, pts started on post-hsct maintenance/consolidation, mainly with lenalidomide. conclusions: ) with the new chemotherapeutic schemes, . % of patients underwent hsct in cr or vgpr; ) majority of pts ( . %) consolidated or improved the pre-hsct response; ) cr increased substantially ( . times) after transplant; ) optimized induction regimens, along with auto-hsct followed by the recently licensed use of maintenance therapy with lenalidomide, might result in a better pfs of patients with mm. background: autologous stem cell transplantation (asct) is commonly used in treatment of patients over years with multiple myeloma (mm), however the safety and efficacy of this procedure is debatable. methods: we conducted a retrospective review of mm patients who underwent asct from to at our institution. the purpose of this retrospective study was to compare the -day mortality, time to engraftment, and incidence of grade - toxicities in elderly mm patients with younger patients taking into account comorbidity information. other secondary end points measured were overall survival (os) and progression-free survival (pfs). results: a total of patients were analysed and categorized by age as young patients ( to y; n= ) or elderly ( to y; n= ). the compared groups did not differ in terms of gender, ecog, hct-specific comorbidity index (hct-ci), and disease status at asct. melphalan in a dose of mg/m was used as preparative regimen in % of younger patients, and in % of the elderly (p= . ). the remaining patients received mg/m of melphalan or lower dose (range, - mg/m ) due to hct-ci > or age, on the physician discretion. in the whole study group there were no transplant related deaths within the first days of asct. stratifying by age, there was no statistically significant difference concerning febrile neutropenia (fn) incidence, which was observed in % of younger patients, and % of elderly. in contrast, fn was observed more frequently in patients with hct-ci > ( % vs %, p= . ). grade - infections were more frequent in older patients ( % vs %, p= . ), but no difference was found in grade - infections incidence rate such as pneumonia, uroinfections and neutropenic enterocolitis ( % vs %, p= . ), nor grade - and - noninfectious toxicities ( % vs %, p= . , and % vs %, p= . , respectively) . the median time to granulocyte engraftment was days (range, - days) in elderly and was comparable with younger patients. the time to platelet recovery was also similar. after the median follow-up of months for survivors, os at months was % in both groups. pfs at moths was % for younger patients, and % for elderly (p= . ).however, the association between pfs and the dose of melphalan used in conditioning was observed. pfs probability at months for patients conditioned with the dose of mg/m , mg/m and mg/m was %, % and %, respectively (p= . ). conclusions: our data show that asct in transplant eligible mm patients ≥ years of age is safe and provides similar outcomes as seen in younger patients. disclosure: nothing to declare is mobilization with chemotherapy effect response in the multiple myeloma? background: high dose melphalan therapy with autologous stem cell support is a standart approach in symptomatic multiple myeloma patients. response rates increased with the novel anti myeloma agents and the use of chemotherapy for stem cell mobilization should be questioned. the purpose of this study is to determine the effect of cyclophosphamide used during stem cell collection on disease response and transplantation results. methods: we retrospectively collect data from myeloma patients who underwent autologous stem cell transplantation (asct) in ankara university medicine faculty, blood and bone marrow transplantation unit between january and november . patients who received cyclophosphamide protocol for stem cell mobilization were included in the study. disease response were determined according to international myeloma study group (imwg) criteria before and after the cyclophosphamide. transplant responses and their effects on survival were also indicated. results: after the diagnosis of mm, patients (male/ female: / ; median age: years (between - years)) with median follow-up of . months (between , - , months) underwent asct at a mean of , ± , months.. forty-one patients were evaluated before and after cyclophosphamide (table ). in % of the patients, the disease response was not altered by cyclophosphamide therapy, and % of the patients improved their response status. post-transplant response rates of patients who underwent stem cell mobilization with cyclophosphamide are also shown in table- . the mean survival of the patients was , ± , months. when patients were grouped according to changes in response status before and after cyclophosphamide; there was no statistical difference between mean calculated survival (improved response, disease progression and stable disease; , ± , months, , ± , months and , ± , months respectively, p= . ) (figure- ) . the rates of -year and -year overall survival (os) of the patients with no response to cyclophosphamide treatment were as follows; , %± , % and , %± , % respectively. thirteen patients who were followed up median months after transplantation died at an average of , ± , months; of these deaths were caused by the infection after transplantation. conclusions: in our study, it was observed that the use of cyclophosphamide for cd + stem cell mobilization did not change the disease response rates by %. the posttransplant survival rates of mm patients who had progressive disease after cyclophosphamide use were lower. however, these results warranted confirmed by randomized controlled trials. clinical trial registry: -disclosure: nothing to declare results of a single center experience: an attempt to augment conditioning regimen in first autologous stem cell transplantation treatment of multiple myeloma (mm) continues to evolve in the era of novel agents. the addition of bortezomib to highdose melphalan (bor-hdm) has been reported by several groups, and it has been outcome and toxicity profile is comparable to high dose melphalan (hdm) alone. the aim of this retrospective study was to evaluate the outcome of the bor-hdm conditioning regimen on overall response for patients with mm undergoing first single asct at our institution. methods: this retrospective single center study reviewed consecutive myeloma patients who had received the first asct either with bor-hdm (n= , m/f= / ) or single agent hdm (n= , m/f= / ) conditioning regimen. in the single agent hdm conditioning regimen, melphalan was administered intravenously at a total dose of mg/m on day - and - and stem cells were infused on day . in the bor-hdm group, melphalan mg/m was administered on day - . bortezomib was administered intravenously at a dose of mg/m on day's - , - , + , and + as described in a phase study by intergroupe francophone du myeĺome (ifm). results: all consecutive patients who underwent single asct from january to march using bor-hdm as conditioning or hdm were evaluated. conditioning regimen was hdm in patients and bor-hdm in patients. median age was significantly lower in bor-hdm conditioned asct compared to hdm group ( years vs years, p= ). there was no significant difference for mm subtype, iss stage at diagnosis, prior treatment line among hdm vs bor-hdm cohorts (p> . ). after a median of cycles of induction chemotherapy, patients in the bor-hd exhibited ≥vgpr of . % (n= ) compared to . % (n= ) in the hdm group (p= p> . ). pre-asct immune response (if (-)) was reported in . % of patients treated with hdm, higher than that seen in the bor-hdm group ( . %) (p= . ). nine ( . %) patients achieved post-asct immune response (if (-)) ≥vgpr compared to ( . %) in the hdm group. at the time of this analysis, ten patients in the bor-hdm group and in the hdm group had already died, respectively (p> . ). a total of ( . %) patients in the bor-hdm group and ( . %) patients in hdm group had already progressed (p> . ). estimated mean os and pfs was shorter for group treated with bor-hdm; . ± . mos and . ± . mos vs. . ± . mos and . ± . mos, respectively (p> . ) (figure- ) . we could not demonstrate the impact of pre or post transplant ≥vgpr immune response on survival and disease free survival. there was no engraftment failure observed on either treatment group and no worsening peripheral neuropathy was developed in the bortezomib arm. conclusions: this single center experience on a small patient pool was able to repeat the prospective randomized study results of ifm. further studies are warranted to explore this regimen, especially when induction treatment with novel agents are employed, with special emphasis on the high-risk myeloma patients where response rates are good but sustainability remains an issue. disclosure: nothing to disclosure the efficacy and safety of bortezomib plus busulfan/ melphalan as conditioning regimen in multiple myeloma undergoing autologous stem cell transplantation: phase / study background: bortezomib have a powerful antimyeloma activity and was regarded as backbone of therapy in the past decade but its safety and efficacy as a part of busulfan/ melphalan conditioning regimen of autologous stem cell transplantation is yet to be shown. methods: a phase / trial to explore the safety and activity of a bortezomib on days - , - , and + added to a conditioning regimen with busulfan and melphalan (bumel, . mg/kg/day and busulfan during day - and - , mg/ m /day of melphalan on the day - ), in multiple myeloma (mm) patients who received autologous stem cell transplantation following bortezomib-based induction chemotherapy. in phase , escalating doses ( . , . , and . mg/m ) of bortezomib with bumel were administered in each group with three patients. with determined maximum tolerated dose of bortzomib at a . mg/m /day, cohort with patients were analyzed for phase . results: in phase , no dose limiting toxicity was observed at a . mg/m /day of bortezomib. in phase , overall responses at months was shown as % of very good partial response (vgpr) or better and % of complete response (cr), whereas post-transplant overall best response included % of vgpr or better, and % of cr, respectively. with median follow-up duration of . months, median progression-free survival (pfs) was . months. the probabilities of years-pfs and overall survival (os) were . % and not estimable, respectively. especially, high-risk cytogenetics were associated adverse survival outcome compared to standard-risk cytogenetics, respectively (pfs, . vs. . months, p= . ; os, . vs. . months, p= . ) . with median days and days for neutrophil and platelet engraftments, any graft failure or delayed engraft was not observed. the common grade or severe non-hematological adverse events included neutropenic fever ( . %) and stomatitis ( . %). except three cases with transplant-related mortality due to sepsis, other adverse events were manageable. conclusions: these results demonstrate that bortezomib is safe and can be a part of conditioning regimen in combination with bumel, for patients with transplanteligible multiple myeloma. clinical background: allogeneic stem-cell transplantation (allo-sct) is one of treatment option for patients with multiple myeloma (mm) refractory to novel agents. the reports on allo-sct for mm are limited and it is an important issue to argue appropriate conditioning regimens and stem-cell sources, and patient population who will benefit from allo-sct. methods: we retrospectively analyzed consecutive patients who received allo-sct for relapsed and refractory multiple myeloma (rrmm) between oct and july at japanese red cross medical center. characteristics of patients, progression-free survival (pfs), and overall survival (os) were analyzed. results: median age at allo-sct was (range - ). twelve patients were male and were female. myeloma type were igg: , iga: , igd: , and bence-jones: . stem-cell sources were peripheral blood from hlamatched related donor (rpbsct): , bone mallow from hla-matched unrelated donor (mud): , bone marrow from hla-mismatched donor (mmud): , and cord blood (cb): . twenty-three of patients received flu/mel-base, one patient received bu/mel-based, and one patient received etoposide/cyclophosphamide-based conditioning regimens. twenty-two patients who transplanted after received gy of total body irradiation (tbi). responses before allo-sct were cr: , vgpr: , pr: , sd: . five-year pfs was % ( %ci: - ) and -year os was % ( %ci: - ). ten patients died during observation period and causes of death were primary disease: and treatment-related mortality: . patients with vgpr or better before allo-sct showed significantly better pfs (p= . ) and os (p= . ) as compared with others. female recipients showed significantly better pfs (p= . ) and os (p= . ) as compared with male recipients. recipients of mmud showed significantly better pfs (p= . ). among patients surviving, patients received treatments including maintenance therapy. conclusions: the reason for better pfs and os in female recipients is unknown. it is interesting that recipients of mmud showed better pfs, suggesting graft-versusmyeloma effects. allo-sct can be an effective treatment option if patients and stem-cell sources are appropriately selected. disclosure: authors declare that there are no conflicts of interest. second autologous hematopoietic stem cell tranpslant versus chemoimmunotherapy in relapsed multiple myeloma after first transplantation: single center data background: combination therapy, mostly triple, followed by autologous hematopoietic stem cell transplantation (auto-hct) is widely accepted as the first-line standard therapy for multiple myeloma (mm). despite the availability of agents such as new immunomodulatory drugs (imids), proteasome inhibitors (pis), histone-deacetylase inhibitors and antibodies, it is still possible to achieve longer and deeper responses, however, multiple myeloma is still not cured and relapse is inevitable. the availability of these novel agents has increased questions for determining optimal treatment of patients with relapse after the first auto-hct. methods: we retrospectively analyzed patients who relapsed according to international myeloma working group (imwg) criteria after st auto-hct. first group [salvage chemotherapy(ct)] (n= ) was treated with only chemoimmunotherapy because of early relapse or refractory first auto-sct (within months), ineligible to second transplantation because of co-morbidity, unwillingness to transplant. second group (n= ) (salvage transplantion) was treated with second auto-hct as a salvage therapy. consolidation and long term maintenance treatments were used in both groups. results: there was no difference in sex and age between salvage ct and auto-sct groups [female/male: vs / vs ; ]. the best response after salvage auto-sct was complete remission (cr) in , %, partial remission (pr) in , % patients, while cr in %, pr in , % patients treated with salvage ct. progression free survival (pfs) were significantly better in second transplant group (pfs; % on the first year; , % on the second year after transplant vs % on the first year; % on the second year after the salvage therapy in chemotherapy patients)[p: , ]. overall survival (os) in salvage auto-sct group was longer than salvage ct ( , % . %), although it did not reach a statistical significance (p> . ). time to achieving the best response after salvage auto-sct and salvage ct was ( - ) month versus , ( - ) months [p: , ]. grade or nonhematological toxicities were similar (auto-sct %, salvage ct %) in both groups. conclusions: salvage auto-hct may provides longer progression free survival with similar toxicity profile according to chemoimmunotherapy especially in patients with sensitive to first auto-sct. it is suggested that earlier and better responses, long-term progression free survival can be achieved with salvage auto-sct. we believe that there will be statistical significance in os such as pfs by increasing the number of patients. the authors believe that large scale randomized clinical trials are needed for optimal treatment of relapsing multiple myeloma after first auto-sct. disclosure: nothing to declare background: one of the conditions for successful transplantation of autologous hematopoietic stem cells (auto-hsct) in patients with multiple myeloma (mm) is the timely recovery of hematopoiesis, which is associated with the quantitative and qualitative characteristics of the graft. one of the key indicators is the content of cd + cells in the autograft, which depends on many factors. some of them are due to previous treatment, others are directly related to the patient: age, stage of the disease, features of the hematopoietic stem cells (hsc) microenvironment. the aim of the study was to assess the influence of the immune response genes on the autograft cellularity in patients with mm. methods: А retrospective analysis of the genotyping results was performed. evaluation of loci in genes immune response and harvesting of autologous hsc in patients with mm has been made. hematopoietic stem cell mobilization regimen included cyclophosphamide g/m with granulocyte colony-stimulating factor. genotyping of the immune response genes polymorphic regions was carried out by the polymerase chain reaction with allelespecific primers. the number of cd + cells was counted on a -color facs canto ii flow cytometer. results: according to the results of the autologous transplant harvesting, two groups of patients were identified. first included patients with an autograft cellularity of more than × /kg body weight. the second group consisted of patients examined with the number of cd + cells in the autograft ≤ × /kg of the patient's body weight. comparing the identified haplotypes of the immune response genes with the cellularity of the transplantation material, it was found that the presence of the mutant allele in the homo-and heterozygous haplotypes of the il β gene (t- c) increased the chances of harvesting cellular material with a higher content of cd + cells in times (χ = . , p= . ), and the carriage of the wild type allele in the homo-and heterozygous state of the tlr (arg gln) gene is more than in times (χ = . , p= . ). currently, it has been shown that single nucleotide or amino acid substitutions in genes can lead to changes in the expression pattern of their final products: increased secretion of interleukin β (il- β) or changes in the spatial configuration and functionality of the receptors (tlr ). thus, in the presence of mutations in the il β gene, the enhanced synthesis of il- β influences on fibroblasts, immunocompetent, endothelial, epithelial and other cells, by activating hemopoiesis. in turn, the mutational status of the arg gln locus located within the tir domain of the tlr receptor in the cytosol, determines the spatial configuration of the tlr acting as a co-stimulatory receptor of cd + cells, which ensure the engraftment of the graft. conclusions: identified haplotypical features of the il β and tlr genes in patients with mm may act as predictors of the response effectiveness to mobilization of hscs in their carriers, which may contribute to the mobilization regimen optimization and will contribute to harvesting the optimal cellularity of an autologous graft. clinical trial registry: none. disclosure: authors declare no conflict of interest. differentiating diffuse from focal pattern on computed tomography: added values of a radiomics approach background: focal pattern in multiple myeloma (mm) seems to be related to poorer survival and differentiation from diffuse to focal pattern on computed tomography (ct) has inter-reader variability. therefore the purpose of this study is to assess if a radiomic approach could help radiologists in differentiating diffuse from focal patterns. methods: we retrospectively reviewed imaging data of patients with mm between january and september of whom ( men and women; mean age . ± . ) with ct, pet-ct or mri available before bone marrow transplant. two general radiologist evaluated in consensus only ct images to define a focal (at least one lytic lesion > mm in diameter) or a diffuse (lesions < mm, not osteoporosis) pattern. radiomic analysis on ct thinslice images was then applied with regions of interest (rois) done by one researcher not expert in medical imaging or mm blindly to the condition of the patients. the reference standard to differentiate diffuse from focal pattern was done by radiological evaluation of two expert musculosketal radiologists blinded to the clinical data reviewing ct, mri and pet-ct images. n= radiomics features were extracted and evaluated with an open source software. mann-whitney u test for unpaired data with bootstraps samples was used to compare radiomics features of diffuse and focal patterns and then feature reduction was done to avoid over-fitting. receiver operator characteristic (roc) analysis with area under the curve was done to compare radiologists and radiomics evaluation against reference standard. reading time to perform radiomic analysis was also estimated. results: the pathological group included: diffuse and focal patterns. after feature reduction, features were different (p< . ) in the diffuse and focal patterns (n= / features were shape-based: majoraxislength and sphericity; n= / were gray level run length matrix (glrlm)). mg/kg). a number of eleven patients did not receive any additional immunosuppression except of post-cy. results: after a median follow up of . months (range . - . ) patients were alive. the -year probabilities of pfs and os were % ( - %) and % ( - %).the cumulative incidences (cis) of relapse and nrm at years were % ( - %) and % ( - %), respectively. lower serum albumin level at transplantation (≤ g/dl) was associated with increased relapses (hr . ( . - . ), p= . ) and nrm (hr . ( - ), p= . ) and resulted in poorer pfs ), p= . ) and os ), p= . ). mmud and haploidentical donors were associated with poorer nrm (hr . ( . - . ), p= . ), and resulted in decreased pfs ), p= . ). the high-risk cytogenetic at diagnosis showed no impact on survival. the cis of acute (grade ii-iv) at day + and chronic gvhd at years were % ( - %) and % ( - %), respectively. absence of immunosuppressive medication beside post-cy was associated with poorer os ), p= . ). conclusions: the conditioning with bu, tt and post-cy leads to a favorable pfs and os due to low incidences of relapse and nrm for patients with multiple myeloma relapsing after autografting. disclosure: nothing to declare methods: between january and may , we included patients with mm who underwent asct and received bortezomib/lenalidomide/dexamethasone (vrd) consolidation and maintenance therapy, mainly lenalidomide(r) mg/day for days every days. results: the median age at transplant was years ( - ). forty-six ( %) of patients received r maintenance, patients received vrd maintenance for higher risk features. median duration of r maintenance was months . r dose was changed for toxicity (grade i-ii) in ( %) patients. twenty-nine ( %) patients relapsed: ( %) patients were shifted to different treatment protocols (treatment change). patients ( %) were kept on the same r maintenance (observation group) and ( %) patients had increased lenalidomide dose with dexamethasone (r/ d group). patients ( %) of the last groups required change of treatment later. the median follow up was months . median tnt was months ( - ). at years, the estimated pfs and os were % and . % respectively. the median os and pfs (from change of therapy) were and months for patients in the observation group, versus and months in the r/d group, and and months with treatment change, respectively. no statistically significant difference was noted. conclusions: our small monocentric study is limited by its retrospective design and small sample size. however, it suggests that increasing lenalidomide dose as well as adding dexamethasone in selected patients can postpone change to different lines of treatment without affecting survival. disclosure: nothing to declare can the drugs used before autologous hematopoietic stem cell transplantation have impact on cmv reactivation that results in decreased os in myeloma patients after asct? more intensive treatment regimens, such as proteasome inhibitors (pi) and/or immunomodulatory (imid) agents. we performed a retrospective, single center study to evaluate the incidence, risk factors, and outcomes of cmv infection in patients with mm who underwent asct with a high-dose melphalan-based regimen. methods: this study involved a retrospective review of all patients with who underwent asct between january and november at our stem cell transplantation center. a total of consecutive adult patients with a diagnosis of mm (median age at diagnosis: , range: - ) underwent asct following induction treatment with novel agents (pis and/or imids). all patients received antiviral prophylaxis with acyclovir mg/day (n= ) or valaganciclovir mg/day (n= ). results: baseline patient characteristics, according to induction treatment, are summarized in table- . one hundred-five of the patients ( . %) were cmv iggpositive before asct. overall, . % (n= ) of cmvseropositive patients developed at least one episode of cmv viremia (cmv dna > copies/ml) after a median months (range; - mos) follow-up. persistent cmv viremia (detectable cmv dna load in more than sequential plasma specimens) occurred in . % ( of ) of the seropositive asct recipients and all of them were preventive treated with ganciclovir (n= ) or valganciclovir (n= ). the time from stem cell infusion to the development of cmv viremia ranged from days to days. none of the patients with untreated viremia developed identifiable cmv sequelae. no case of primary infection in seronegative patients at transplant was observed. adding to that none of the patients developed cmv disease post asct. if we analyzed the subgroups of patients according to induction therapy (pi-based, imids, pi+imid), the incidence of post-asct cmv reactivation was higher but not statistically significant, in patients who received only pi vs pi+imid ( ( . %) vs ( . %); p= . ). in univariate analysis, we could not demonstrate the importance of induction therapy with novel agents the occurrence of a post-asct cmv reactivation requiring antiviral treatment. however, statistically significant association found between the disease < vgpr status at asct and cmv reactivation ( . % vs. . %; p= . ). after a median follow-up . months (range; - . months), there was no significant impact on pfs, however there was significant decrease in estimated mean os who had cmv reactivation when compared to those without cmv reactivation ( . ± . vs. . ± . ; p= . ) (figure- ) . conclusions: cmv establishes lifelong latency within host cells and in the setting of impaired cellular immunity; cmv may reactivate from latency, disseminate, and directly cause life-threatening disease. our data suggests that mm patients treated with pi-based induction regimens and immunological response < vgpr at time of asct seem to have higher risk of developing symptomatic cmv reactivation. however, further studies on a large number of patients are warranted to clarify these findings. clinical background: high-dose therapy followed by autologous stem cell transplantation (asct) has been shown to prolong survival in patients with multiple myeloma (mm) in randomized trials. however, these trials only include patients aged < years. data regarding safety and outcomes in this patient population is lacking. methods: the aim of this study was to compare safety profile and outcomes in mm patients younger and older than years-old who underwent asct in our unit from july to october . patient's demographics, clinical characteristics, transplant related variables and probability of admission to the intensive care unit (icu) were analyzed. patients aged < and ≥ years-old would be called m and m , respectively, from now on. sorror index was used to estimate risk of mortality in the two cohorts. results: a hundred and eleven patients with mm underwent asct in the study period. median age was . years-old (range - ) and . % were male. thirtythree ( , %) patients were ≥ years. the probability of having a high risk comorbidity index was similar in both groups (m , vsm , %). the median cells obtained in the apheresis procedure was . x ( , - . ) in m compared to . x ( . - - ) in m . there were no differences in median admission lenght between the cohorts (m : days vs m : days). median days for neutrophil recovery above was days in both groups with a wider range in m ( - ) compared to m ( - ) . no differences were found in platelet recovery above . (m days vs m days). median packed red blood cells and platelets transfusions were ( - ) and ( - ), respectively, in m . in m cohort, they were ( - ) and ( - ), respectively. the incidence of grade - mucositis in m and m was . % and . %, respectively. there were no statistically significant differences in terms of using morphine for pain control between the two cohorts (m , , % vsm , , %). none patient requiered total parenteral nutrition (tpn) in group m and only one in group m . the incidence of icu admission was . times higher in patients aged ≥ than in patients < years-old , % vs , %), but differences were not statistically significant (p = . ). there were no deaths during the transplant procedure in any of the cohorts conclusions: ) in our series, high-dose therapy followed by autologous hematopoietic cell transplantation in mm patients aged ≥ was feasible. ) transplant procedure in older patients was as safe as in patients < years-old. ) no differences were found in terms of graft, transfusion support, transplant related complications and length of admission. ) age should not be a limiting factor in considering the modality of asct in this patient population disclosure: nothing to declare the correlation between the kinetics of peripheral blood counts and the response to treatment after high-dose melphalan with stem cell support in multiple myeloma patients background: the long-term survival of mm patients has dramatically increased in the last years, particularly for younger patients. this is attributable in part to the introduction and development of high dose chemotherapy with melphalan with stem cell support (hdm-asct). currently, frontline asct is still considered the standard of care for all eligible patients. many prognostic factors pre and post transplantation have been identified, e.g.: age, comorbidities, cytogenitcs, response to treatment and disease status prior to and post transplantation. to our knowledge there is no data correlating between kinetics of counts response to melphalan and prognosis. our aim was to assess the prognostic significance of the neutrophil and platelets decaying counts after high dose melphalan. methods -we retrospectively analyzed our cohort of multiple myeloma patients who underwent hdm-asct at the hadassah medical center bone marrow transplant department, between the years - . the kinetics of neutrophil and platelet decay during the first two weeks after melphalan administration was fitted using linear and exponential mathematical models. methods: we retrospectively analyzed our cohort of multiple myeloma patients who underwent hdm-asct at the hadassah medical center bone marrow transplant department, between the years - . the kinetics of neutrophil and platelet decay during the first two weeks after melphalan administration was fitted using linear and exponential mathematical models. results: factors associated with prolonged os in univariate analysis were: iss stage (p= . ), ≤ lines of treatment prior to asct(p< . ), favorable cytogenetics(p= . ), response to treatment (pr or better, p= . ) and rapid linear neutrophil decay (p = . ). in multivariate analysis, only ≤ lines of treatment before hdm-asct and rapid linear neutrophils count decay remained statistically significant for os prolongation. no predictive threshold value of the neutrophil decay incline was found. improved pfs was associated with ≤ lines of treatment prior to asct, and the response status after hdm-asct (p= . , p= . ). additionally, toxicity evaluation showed prolonged neutropenia to be associated with inferior os (hr = . , p= . ) and rapid exponential decay of neutrophil counts to correlate with higher incidence of mucositis (p = . ). fast platelet decay was associated with delayed platelet engraftment (p< . ) conclusions: we have shown that rapid linear decay in neutrophil counts predicts better os without a significant benefit in pfs in mm patients undergoing hdm-asct. this discrepancy might reflect the problematic estimation in a retrospective analysis of pfs. rapid decrease in neutrophils and platelet counts was associated with more toxicity: higher mucositis rate and delayed engraftment, respectively. therefore a rapid decay of blood counts after hdm-asct appears to be an in-vivo phamacodynamic marker of higher efficacy and toxicity of melphalan. disclosure: nothing to declare p do we need to freeze hematopoietic cells for autotransplants in patients with myeloma conditioned with melphalan? daniel garcia belmonte , beatriz aguado bueno , miguel herrero coderch , rafael de la camara background: multiple myeloma (mm) is the most frequent indication of auto-hsct, representing % of all auto-hsct in (passweg jr. bmt ; : - ) . nearly all are performed with peripheral blood progenitor cells (pbpc), and melphalan mg/m is considered the gold standard conditioning regimen. the standard procedure consists in obtaining progenitors, cryopreserved with dimethyl sulfoxide (dmso) and stored and subsequently thawed and re-infused in the patient on day . the procedure of cryopreservation is expensive and has some inherent toxicities (dmso) and loss of cells during the procedure. several groups have used non-cryopreserved progenitors showing some benefits compared with cryopreserved transplants, mainly a faster engraftment and a shorter length of hospitalization. objective: to compare noncryopreserved vs cryopreserved auto-hsct in mm methods: we perform an unicentric, retrospective study on consecutive first auto-hsct mm patients transplanted with pbpc between nov- and oct- , and conditioned with high dose melphalan ( mg/m ). the median follow-up was days (range: - ). patients received non-cryopreserved and cryopreserved auto-hsct. patients characteristics, without differences between non-cryopreserved vs cryopreserved: women/men ( / ); median age was years (range - ); in the majority auto-hsct was done as consolidation after first line therapy ( %); year of transplant ≤ ( %), ≥ ( %). the number of infused cd cells were not different: median . x /kg (range . - . ) in noncryopreserved patients and . x /kg (range . - ) in cryopreserved patients. results: we didn´t observe significant differences in the day of engraftment between non-cryopreserved vs cryopreserved although always was a little bit faster in the noncryopreserved group with a tendency to faster platelet engraftment (> /mm ): > platelets/mm (median day: vs . , p . ), > platelets/mm (median: vs days, p . ); > neutrophils/mm (median: vs . days, p . ). the media of days of hospitalization was shorter in non-cryopreserved patients ( vs days) although not statistically significant (p . ). transplantrelated mortality at day + was % in both groups. overall survival at years was not different: . % in in non-cryopreserved vs . % in cryopreserved patients (kaplan-meier, log-rank p . ). the accumulative incidence of relapse at the median follow up ( days) was similar: . % in non-cryopreserved vs . % in cryopreserved patients. conclusions: in our short experience, auto-hsct with non-cryopreserved pbpc in myeloma patients conditioned with high dose melphalan obtain similar results to those performed with classical cryopreserved pbpc and might has a faster platelet engraftment and shorter length of hospitalization. if no advantages are associated with cryopreservation, the simplicity of using fresh product is appealing. disclosure: nothing to declare p abstract withdrawn. . results: a early death is observed in one pt (group ) and pts(group ). the median delay of aplasia is days ( - ) and days ( - ) respectively. in group , among the evaluable pts, / ( %) are in cr, pts in pr and refractory. in group , cr: / ( %), pr: and refractory. a relapse is observed in pts/ ( , %) in group and pts/ ( %) in group with a frequency of % and % respectively in the first months. at months: pts/ ( %) in group and pts/ ( %) in group are dead. at months: pts ( %) and pts ( %). at months: pts ( , %) and pts ( , %). the overall survival (os) of the group and group pts were % and % at months; . % and . % at months; % and , % at months respectively (without significant difference). the event free survival (efs) of group and pts were % and , % at months, % and % at months and % and % at months respectively (without significant difference). conclusions: these protocols with equivalent toxicity allow obtaining of long-term equivalent results on the response rate early transplant, on the rate of relapse and on the overall survival. these results are identical to those of fermand ( ) . disclosure: nothing to declare background: dimethylsulfoxide (dmso) is a major intracellular cryoprotectant, used for cryopreservation of stem cells. it is toxic to both cells and patients at temperatures above o c. reduction of this effect is achieved by either washing of cells after thawing or by reduction of dmso during freezing and storage. the latter requires addition of extracellular cryoprotectants to the freezing media. we assessed the effect of low dmso concentration and different hematocrits of the frozen cells on cell viability and hematologic recovery in patients, transplanted for multiple myeloma. methods: cells were non-programmed frozen and stored at - o c in a cryoprotectant solution achieving final concentrations of % dmso, . % of hydroxyethyl starch (hes, weight average molecular weight da) and % of human serum albumin. the cell concentration in the frozen product for the first patients ( transplantations) varied between x and x cells/ml. in an attempt to reduce the amount of dmso infused, for the rest of the patients (n= ; transplantations) we further decreased the volume of the freezing suspension by removal of the entire plasma. the average age of the transplanted patients was ( - ). the cells were bedside thawed at o c water bath. the average cell dose was , x /kg ( , - , x /kg). results: viability of the stem cells following thawing assessed by trypan blue exclusion was , % . the hematocrit of the frozen cells had no effect on cell viability ( , %(low) vs , %(high)). the major complaints, if any, during stem cell infusion were coughing and an increase in nausea and vomiting induced by the prior conditioning. the average time for hematological recovery was , days (between and ) for the neutrophils, and , (between and ) days for the platelets. there was no significant difference in viability and hematologic recovery ( , and , vs , and , ) between patients receiving cells frozen with low or high hematocrit. conclusions: dimethylsulfoxide, despite its cryoprotective properties, is toxic for stem cells at temperatures above zero c and induces many side effects (cardiac, neurologic, respiratory, etc.) in the patients. to reduce those side effects we use lower dmso concentration, high hematocrit resulting in lower volume of the frozen cell suspension, thus reducing the final quantity of dmso to be infused to the patients. this does not affect the cell viability or the hematologic recovery of patients after transplantation. our easily performed method for unprogrammed freezing of stem cells with final dmso concentration % at - o c is safe, well tolerated, and provides cryopreservation, which allows high viability and stable cell engraftment, while reducing the undesired side effects of dmso. disclosure: nothing to disclose the conditioning regimen consisted of melphalan for most of the patients. the average age at the time of transplantation was years ( - ). patients were transplanted with an average cell dose of , x /kg ( , - , x /kg) for the first transplantation and , x /kg ( , - , x /kg) for the second one (every patient received the same cell dose as for the first) with average cell viability , % ( - %), with little difference between first and second transplantation. results: the average time for hematological recovery was , (between and ) days for the neutrophils, and . (between and ) days for the platelets. we found no correlation between the cell dose and the hematological recovery. there was no difference in the hematopoietic recovery between the first and the second transplantation in the patients, who underwent tandem or two transplantations. conclusions: recovery time is considered by some to be a function of the effective stem cell number. we did not find such correlation, probably because in the analyzed group all the patients, except four of them, received a dose greater than x /kg cell, which is accepted as a safe dose for autologous stem cell transplantation. disclosure: nothing to disclose p plerixafor-mobilized patients have a high risk of noninfectious fever during engraftment after autologous peripheral blood stem cell transplantation background: plerixafor enables rapid and efficient mobilization of hematopoietic stem cells. however, its impact on adverse clinical events after autologous peripheral blood stem cell transplantation (pbsct) is not fully understood. fever is one of the major complications in the preengraftment phase of pbsct. in this research, we focused on non-infectious fever around the time of bone marrow recovery and investigated whether plerixafor as mobilization therapy plays a role in engraftment fever. methods: we reviewed autologous pbscts for treatment of multiple myeloma at the japanese red cross medical center between - . non-infectious fever was defined as temperature ≥ °c with onset between two days prior to and two days after engraftment without clinical or microbiological documentation of infection. results: patients were mobilized by cyclophosphamide and filgrastim in . % (n = ) and filgrastim and plerixafor in . % (n = ). the median number of transfused cd + cells were . × /kg and . × / kg, respectively (p= . ). patients transfused with plerixafor-mobilized grafts had a higher risk of noninfectious fever ( . % vs . %, p< . ). cd + cell number or cyclophosphamide pretreatment had no relationship to non-infectious fever. the recovery of lymphocytes was more rapid in plerixafor-mobilized patients (p= . ). however, the number of lymphocytes was not associated with non-infectious fever. conclusions: combination of filgrastim and plerixafor as mobilization therapy resulted in an increased risk of noninfectious fever during engraftment comparing to mobilization with cyclophosphamide and filgrastim. while the mechanism remains unclear and requires further studies, plerixafor-mobilized grafts may result in an unintended increase in engraftment fever. clinicians should be aware of this possibility if patients are transplanted with those grafts. disclosure: ks received honorarium outside the submitted work from janssen, novartis, celgene, ono pharmaceuticals, takeda, fujimoto pharmaceuticals and srl. ti received honorarium outside the submitted work from janssen, celgene, ono pharmaceuticals and takeda. we assessed the efficacy of a new conditioning regimen consisted of decitabine (dec), busulfan (bu), cyclophosphamide (cy), fludarabine (flud) and cytarabine (ara-c) for allo-hsct in patients with mds and mds/ mpn. fifty patients were enrolled, including with mds and with cmml. patients received dec mg/m /day on days - to - , combining bu/cy/ flu/ ara-c modified preparative regimen. results: at a median follow-up of ( - ) days, the overall survival (os) was %, disease-free survival (dfs) was %, and relapse incidence was %. the incidence of severe acute (grade iii/iv) graft-versus-host disease (gvhd) was %, and that of (predominantly mild) chronic gvhd was %. os at years was % for mds patients with high risk, % for mds patients with very high risk, respectively. the survival was delightful in patients with poor-risk mutations, such as tp and asxl , ( %) and with three or more gene mutations ( %). among the total patients with poor-risk mutations in our research, only one patient ( %) with tp relapsed and one ( %) with asxl and tet died. result of continuous observation after transplantation, the percentage of nk cells in the peripheral blood of all patients who had received dec/flu/bu/cy/ara-c conditioning increased at day , which may essentially contribute to disease control post-transplantation. conclusions: in summary, the addition of a -day schedule of decitabine to a flu/bu/cy/ara-c conditioning regimen has proven feasible, with a low level of toxicity and promising early disease control especially in patients with high risk mds. disclosure: there are no conflicts of interest. the sfgm-tc mds score at day is associated with post-transplant outcomes in patients with myelodysplastic syndrome who underwent cd + selected allogeneic stem cell transplant conclusions: in patients with mds undergoing tcd-hct, the sfgm-tc score at day is significantly associated with survival. the lower incidence of acute gvhd in recipients of cd -selected transplants and the use of myeloablative condition regimens, with lower relapse, may explain the difference with the original finding that the sfgm-tc was predictive at day in unmodified grafts. disclosure the most frequent grade , toxicities were thromobocytopenia and neutropenia. infections developed in patients ( . %), neutropenic fever in ( . %). five patients ( . %) either developed or experienced exacerbation of acute graft versus host disease (gvhd), nonechronic gvhd. conclusions: azacitidine use is associated with only modest activity in patients who relapse after allo-hsct. however, in patients who respond to treatment it may allow for a durable disease control. disclosure: the authors declare no competing conflicts of interest background: somatic mutations in mds patients are closely related with clinical phenotypes and prognosis in mds patients. but whether mutations are prognostic for outcomes after allogeneic hematopoietic stem-cell transplantation (allo-hsct) remains to be elaborated. methods: targeted mutational analysis were performed on samples obtained before transplantation from patients underwent hsct. we analyzed the relationship of mutations and clinical outcomes. results: all patients carried more than one somatic mutations, most frequently in kmt d( . %), arid b ( . %), ccdc ( . %), pclo( . %), asxl / ( . %), srcap( . %), u af ( . %), dnah ( . %), ush a( . %) and tet ( . %). tp mutations were associated with higher ipss-r risk, complex karyotype and monosomal karyotype. dnah were more frequent in pediatric patients. in univariable analyses, tp mutations were related with decreased disease-free survival (p= . ); dnah mutations were related with increased disease-free survival (dfs) (p= . ). in multivariable analysis including ipss-r stratification, gvhd, hct-ci and candidate genes, dnah mutations were independently associated with better dfs(p= . ). conclusions: dnah mutations is independently associated with better outcomes in mds patients treated with allo-hsct while tp may predict unfavorable outcomes. accounting for these somatic mutations may help better selection of candidates for allo-hsct among mds patients. disclosure background: there is a controversy among experts if and how patients with mds and saml should receive cytoreductive therapy before transplant. while aiming to reduce disease burden in order to lower the risk of relapse after transplant cytoreductive therapy is associated with several drawbacks. besides a considerable risk for toxicity and mortality preventing patients to proceed to transplant cytoreductive therapy may also favour the selection of resistant clones which may be difficult to treat at relapse. methods: to address this hypothesis we retrospectively analysed the response and survival following salvage therapy in patients with mds and saml who had relapsed in median . months ( to months) after allo-sct according to their pre-transplant strategy (upfront transplantation n= %; induction chemotherapy [ctx] n= %; hypomethylating agents [hma] n= %). results: the majority of these patients received salvage therapy with hma (n= , %; aza n= , dac n= ) mostly in combination with dli, while the remaining received other salvage treatments (intensive chemotherapy n= , dli alone n= , nd transplant n= , bsc n= , miscellaneous n= , missing information n= ). when focussing on those patients treated with hma and dli it became apparent that a significantly higher proportion of patients in the upfront group ( %) achieved cr after salvage therapy in comparison to pre-treated patients ( % cr, p= . ; ctx group % cr; hma group % cr). accordingly, overall survival (os) calculated from the time of relapse was significantly longer in patients in the upfront group than in the group of pre-treated patients ( -year os % vs. %, p= . ). conclusions: overall, these findings imply that pretransplant therapy may favour the iatrogenic selection of resistant clones, which poorly respond to salvage therapy with hma and dli in case of relapse after allo-sct. furthermore, the results support the concept that an upfront transplant strategy is a promising alternative for patients with mds and saml that can be augmented by salvage therapy with hma and dli. disclosure: ts and gk received travel support, lecture fees and research funding from celgene gmbh conclusions: in our country, this procedure has shown to be feasible and we hope to improve it, with better infection control and by acquiring more experience related to the management of these patients. background: extramedullar relapse of mds is a rare complication after allogeneic stem cell transplantation. we present the case of a -year-old woman who was admitted into hospital because of insecure walking. paresis of both legs, hypaesthesia of the inner thighs, increased effort at urinating, reduced sphincter tonus, central paresis of the right arm and discreet paresis of the right facial nerve were documented at neurological exam. mri showed a large tumour of the dorsal thorax that immured the adjacent ribs and spine, affected the processus transversus of t - and invaded the spinal canal. the patient had undergone ric allogeneic stem cell transplantation five years ago for mds-eb with complex aberrant karyotype. following an uneventful course and no signs of gvhd, she had been off immunosuppression since , years. at the time of the admission the patient had slightly lowered wbc ( , gpt/l) and plt ( gpt/l) and clearly increased ldh ( u/l). methods: histology of a ct-based biopsy of the paravertebral tumour showed an infiltration of the muscles by blastous cells that were cd -, cd -, pax -positive, tdt and cd a were questionably positive. provisonal diagnosis therefore was lymphoblastic lymphoma, pox tested negative. the bone marrow was hypocellular with increased numbers of mature lymphocytes, but no definite signs of malignancy. cerebrospinal fluid revealed cells/μl with % blasts. immunotype was cd , cd , cd , cd , hla-dr positive, pox and lymphatic markers were negative. because of this we finally suspected meningeosis leucaemica. we completed the diagnostic workup with genetical and chimaerism tests and compared the result to the patients' mds before allogeneic stem cell transplantation. [[p image] . mri scan of the large thoracic tumour] results: cerebrospinal fluid (csf) cells consisted of % recipient cells, whereas peripheral blood cells were % donor. high risk mds at transplant displayed a complex caryotype including trisomy and tetrasomy , now % of the cells in csf showed trisomy and % tetrasomy . chimerism and fish of the solid tumour could not be performed, coexpression of myeloid markers within the tumour is pending. conclusions: in conclusion the patient has meningeosis as a result of exclusively extramedullary relapse of myeloid blasts originating from the initial high risk mds with blast excess and complex aberrant caryotype. the evolution of a trisomy clone to tetrasomy clone in relapse is linked to extramedullar manifestations. whether the solid tumour represents myeloid sarcoma with coexpression of lymphoid markers, extramedullary relapse of mds with lymphoid differentiation or, less likely, a separate lymphobastic lymphoma, is not yet clear. disclosure background: adoptive t cell therapy with genetically engineered t cells is a potent innovative immunotherapeutic approach for cancer treatment. unfortunately, the use of t cells redirected against tumor antigens, is severely limited by ) the difficulty in identifying appropriate cell surface antigens, that could be targeted by car t cells and ) the paucity of tumor-specific t cell receptors (tcrs) against shared, oncogenic antigens. methods: focusing on wilms´tumor (wt ), a tumorassociated antigen overexpressed by acute myeloid leukemia and several solid tumors, we designed and implemented an innovative protocol for the rapid isolation of wt -specific t cells and for the generation and characterization of a library of wt -specific tcrs displaying different human leukocyte antigen (hla) restrictions, to be exploited by tcr gene transfer and tcr gene editing. to this aim, we repetitively stimulated t cells with autologous antigen-presenting cells, including immortalized b cells, pulsed with overlapping peptides spanning the entire wt protein. t cell recognition was assessed by flow cytometry in terms of cd a expression and ifnγ production. recognized peptides were mapped by a deconvoluting grid and t cell clonotypes were longitudinally tracked by tcrαβ sequencing. results: we successfully expanded tumor-specific t cells from consecutive healthy donors, in an average of rounds of in vitro stimulations. the ability of wt specific t cells to recognize naturally processed epitopes and their on-target specificity was demonstrated upon coculture with antigen-expressing targets including primary leukemic blasts. tracking of the tcrαβ repertoire during culture led to the identification of clonotypes that recognize several tumor-associated peptides and are restricted by more than hla alleles, including hla-a* : . tcrs were then expressed via genome editing. briefly, simultaneous editing of endogenous tcr α and β chain genes was achieved using crispr/cas technology (efficiency > %), followed by transduction of t cells with lentiviral vectors encoding wt -specific tcrs (efficiency > % of cd + t cells). phenotypic characterization of edited t lymphocytes showed a major enrichment of cells harboring t stem cell memory properties. functional validation of the edited t cells is currently ongoing. preliminary results of a hours coculture experiment show that tcr edited t cells kill fresh wt + leukemic blasts, harvested from hla-matched patients, with an efficiency up to % at an effector to target ratio of to , while no killing of controls is observed. conclusions: we set up a protocol enabling consistent and efficient hunting for tumor-specific tcrs with no need for labor intensive t cell cloning. tcr genes can be easily and rapidly used to redirect t cell specificity against cancer cells by tcr gene editing. disclosure: chiara bonini: research funding from intellia therapeutics p car t cell therapy targeting relapsed or refractory cd + lymphoid disease with third-generation vector rv-sfg.cd .cd . - bbzeta maria-luisa schubert , anita schmitt , leopold sellner , , brigitte neuber , angela hückelhoven-krauss , kunz alexander , lei wang , gern ulrike , birgit michels , susanne hofmann , carsten mueller-tidow , , dreger peter , , michael schmitt , background: t cells genetically engineered to express chimeric antigen receptors (carts) directed against cd have demonstrated significant efficacy in patients with iymphoid malignancies including relapsed or refractory (r/r) b-lineage acute lymphoblastic leukemia (all) or r/r b-cell non-hodgkin's lymphoma (nhl). access to cart treatment for patients in europe has been limited so far given that the vast majority of cart trials have been performed in the united states and the p. r. of china. here we present the preliminary results of the first investigator-initiated trial (iit) cart trial in germany. hd-car- (eudract no. - - ; nct ) is a phase i/ii trial with in-house cart manufacturing which was initiated in september at the university hospital heidelberg. methods: adult as well as pediatric patients with r/r all and patients with chronic lymphocytic leukemia (cll) or nhl including diffuse large b-cell lymphoma (dlbcl), follicular lymphoma (fl) or mantle cell lymphoma (mcl) are treated with autologous t lymphocytes transduced with a third-generation car retroviral vector (rv-sfg.cd .cd . - bbzeta) targeting cd . the main purpose of hd-car- is to evaluate safety and feasibility of escalating third-generation car t cell doses ( - × transduced cells/m ) after lymphodepletion with fludarabine and cyclophosphamide. patients are monitored for cytokine release syndrome (crs), car-t-cell related encephalopathy syndrome (cres) and/or other toxicities. in vivo function, survival and anti-tumor efficacy of carts are assessed. results: to date, three patients (cll, dlbcl and mcl, respectively) have been enrolled and subjected to leukapheresis. high numbers of transduced carts were harvested on day of culture ( - x carts). transduction efficiency ranged between and %. cart products were sterile and free from mycoplasms and endotoxins. no production failure occurred and all patients received the cart product. no signs of crs or cres > grade have been observed. assessments of clinical responses are pending and will be presented at the conference along with updated technical results. conclusions: for hd-car- , gmp-conform leukapheresis as well as cart manufacturing was effective. administration, patient monitoring and follow-up were performed in-house providing independency from transport or production sites outside the university hospital heidelberg, altogether suggesting that academic cart iits are feasible in germany. clinical background: the prognosis of adult patients (pts) with relapsed/refractory (r/r) precursor b-acute lymphoblastic leukemia (all) is dismal, including with allogeneic hematopoietic stem cell transplantation (allo-hsct). blinatumomab, a bispecific cd -directed cd t-cell engager and inotuzumab ozogamycin (io), a cd -directed antibody-drug conjugate revolutionized the field, improving their outcomes. anti-cd chimeric antigen receptor t (cart) cell therapy has led to further progress and improved outcome (jacoby e; am j hematol, ). nowadays, patients with r/r b-all can be offered both therapies, but there are limited data on the safety and efficacy of cart -cell therapy post antibody treatment. we detailed our single center experience in this regard. methods: this report is a part of a single center, phase b/ study on therapy of b-cell malignancies with locally produced cart-cells (nct ). the approach uses autologous t cells with car construct that is composed of an anti-cd single-chain fv, cd co-stimulatory and cd -zeta intracellular domains. cd expression on the blasts was documented prior treatment in all pts by flow cytometry. all pts received x /kg cart-cells after lymphodepletion with fludarabin and cyclophosphamide. results: six pts ( males and females) with r/r b-all were enrolled, including one with ph-positive b-all. the median age was years ( - ). median number of prior therapy was ( ) ( ) ( ) . five pts had prior allo-hsct. four pts were given antibodies as the last therapy prior to cart cells. two pts received blinatumomab resulting in pr in one of them. two additional pts received io ( after failing blinatumomab) achieving mrdpositive cr. cytokine release syndrome occurred in all pts and was severe in only one patient who required tocilizumab treatment. this patient was also the only patient who experienced neurotoxicity (grade ), and was treated with dexamethasone. this patient eventually died days post infusion of cart cells due to severe pseudomembranous colitis, toxic megacolon and sepsis. all pts had prolonged neutropenia for a median of days ( - ) after the infusion of cart cells. at day after infusion of cart-cells the cr for the entire cohort was %: three pts with mrd-negative and one with mrd-positive response. among the four pts who received antibodies prior the cart-cells, one patient had mrd-positive and two pts had mrd-negative response. the patient with ph positive b-all had progressive disease during the treatment. two pts were referred to second allo-hsct from other donors. one patient with mrd-negative response relapsed after the second transplant and was treated by salvage therapy. the second patient with mrdnegative response demonstrated prolonged remission ( months) even without second transplantation. with a median follow-up of months ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) the median progression-free and overall survival for the entire cohort were . and months, respectively. conclusions: autologous anti-cd car t-cell therapy after debulking treatment with antibodies, including blinatumomab and/or io, is feasible and results in high response rates in pts with r/r b-all. patients may respond to anti-cd car t-cell therapy even after failure to their last salvage therapy with blinatumomab, which demonstrates similar mechanism of action. clinical background: genetically engineered t cells expressing a chimeric antigen receptor (car-t) targeting specific antigens present on acute lymphoblastic leukemia (all) blasts have generated promising results in children and adults with relapsed and refractory disease. the below report provides an insight of lineage switch occuring as a result of intense immunological selection after car-t cell therapy, even with a tumor clone that has no potential for this switch. methods: an eight year old caucasian male with precursor b (pb) cell lymphocytic leukemia was treated with cd directed car-t cell therapy in third remission, and after relapse after previous bone marrow transplantation (bmt) . he was diagnosed with t( ; ) pb cell all at years of age and treated with bfm protocol. he relapsed months after completion of maintenance therapy, and had a / mmud bone marrow transplant after etoposide, tbi and alemtuzumab conditioning therapy. he had cutaneous acute and chronic gvhd but months post-transplant, he relapsed again with pb cell all, with the same cytogenetic and immunophenotypic disease characteristics.. he was treated with lymphodepleting chemotherapy with fludarabine, cyclophosphamide and alemtuzumab followed by infusion of cd directed car t cells. he developed cytokine release syndrome of grade severity manifested as persistent fever, associated with car t cell expansion in the blood. after car-t infusion,there was no detectable b cell all clone in the marrow by pcr and the cytogenetics were negative for t( : ) translocation. months after the car t cell therapy, he was found to have a mrd positive disease which was monitored closely. results: we document clonal evolution from cd negative, mrd positive disease to aml, with the same ig rearrangement (the same clonal disease) but with complete myeloid phenotype mpo, cd , cd positive disease. there was cytogenetic evolution of the underlying clone but the original t( ; ) was retained within the evolved karyotype. sadly, our patient developed fludarabineneurotoxcity during an attempt to induce aml remission, and further curative-intent chemotherapy was not possible. conclusions: there are two case reports of mll rearranged b-all acquiring a clonally related myeloid phenotype associated with cd -negative escape after cd directed car t cell therapy,so far. but, this is the first post car-t cell therapy transformation of all to aml with etv -runx mutation, which is not recognised to have such lineage-switch potential. unlike mll, etv -runx translocation in the pathogenesis of acute myeloid leukemia is not been reported in the literature. the theory behind such transformation is an intense immunological selection of the tumor, driving it to myeloid differentiation with additional clonal cytogenetic events. disclosure: nothing to declare p ivac-all- : interim analysis of a phase i/ii clinical study on personalized peptide vaccination based on patient-individual tumor-specific variants in relapsed pediatric acute lymphoblastic leukemia armin rabsteyn , , christopher mohr , olaf witt , , roland meisel , , cristiane chen-santel , tobias feuchtinger , , christopher schroeder , jakob matthes , background: acute lymphoblastic leukemia (all) is the most common pediatric malignancy. standard chemotherapy is a successful treatment in % of patients, only about % develop a relapse, however these patients have a dismal prognosis. prevention of relapse after firstline chemotherapy or stem cell transplantation (sct) is therefore an urgent clinical need. we established a platform for the design of patient-individual peptide vaccination cocktails by combination of whole exome sequencing of tumor and normal tissue with in silico epitope prediction algorithms for individual patient hla types. we started clinical translation of this approach by starting a phase i/ii clinical trial in (nct ). besides feasibility and toxicity assessments, we aim to assess the capability of the peptide vaccination to induce neoantigen-specific t cell responses in high-risk all patients to target residual tumor cells and prevent leukemic relapses. methods: key inclusion criteria are: pediatric patients with all who suffered from second relapse after standard therapy or first relapse after sct. hematological remission has to be reached prior to vaccination. nonsynonymous mutations are identified by whole exome and transcriptome sequencing of patient leukemic blasts and healthy reference tissue. hla binding peptides harboring the altered amino acids are subsequently predicted in silico by algorithms syfpeithi, netmhc and netmhcpan for the patients' individual hla type. vaccine cocktails consisting of - individual peptides are produced and formulated under gmp conditions. the vaccination schedule is vaccinations over weeks using gm-csf and imiquimod as adjuvants. response to the vaccination is monitored by detection of t cells recognizing the vaccinated peptides occurring over time in peripheral blood of patients by prestimulation and intracellular cytokine staining. results: until now, patients were recruited, for of those, whole exome sequencing was performed to identify all-specific snvs using a comparative bioinformatics pipeline. we found an average of . mutations per patient on dna level. based on these data, an average of hla binders derived from neoantigens could be predicted per patient. an average expression of . % of mutations was assessed by rna sequencing. in all cases validated mutations could be identified and cocktail design was feasible. until now, patients received vaccinations. the vaccine was generally well tolerated and no or only mild side effects were observed. immune monitoring was performed for patients until now. in the first patient, we observed a transient cd + response against one vaccinated mhc class ii ligand and a sustained cd + response against the included wildtype control peptide derived from the antigen survivin. in the second patient, immune monitoring was performed for the first vaccination timepoints, a t cell response was not measurable at this timepoint of vaccination. conclusions: whole exome sequencing of pediatric all patients is feasible and yields small amounts of expressed, tumor-specific mutations. these few mutations are sufficient to predict hla-binding peptides that can be used to formulate individualized peptide vaccine cocktails. we currently conduct a clinical phase i/ii trial in a small cohort of high-risk all patients to assess safety, toxicity and immunogenicity. clinical background: chimeric antigen receptor t cells (cart) are considered as gene therapy medicinal products (gtmp) and genetically modified organisms (gmo). hence, carts manufacturing for clinical application is strictly regulated. appropriate methods assessing car transgene copy number (cn) in a cart product and definition of the frequency of carts in treated cart patient are mandatory. although quantitative real-time pcr-based (qpcr) analysis has been used for this purpose, no standardized procedure to minimize systematic errors and enable comparability has been established yet. here, we report on a single copy genebased (scg) duplex (dp) pcr (scg-dp-pcr) for the determination of the vector copy number (vcn) in cart products as well as patient samples following cart administration. scg-dp-pcr was validated and compared to the broadly used absolute copy number qpcr (acn) approach within the framework of a clinical trial treating patients with good manufacturing practice (gmp)-grade carts (hd-car- ). methods: for conventional acn, primers and probe targeting the car vector rv-sfg.cd .cd . - bbzeta were designed. standard curves were established via serial dilutions of the sfg.car plasmid. amplification of the standard curve as well as target genomic dna for vcndetermination was performed as singleplex (sp) pcr (sp-car) (method a). on the same qpcr plate, duplex (dp) qpcr reactions were carried out. additionally to the components comprised within method a, the experimental setup contained haploid human genomes as well as primers and probe targeting ribonuclease (rnase) p as human scg. the amplifications for the sfg.car plasmid (dp-car) and the rnasep gene (dp-rnasep) were performed simultaneously (scg-dp-pcr; method b). scg-dp-pcr was performed for standard curves and target samples. target-sample dna was extracted from carts prepared from leukapheresis products of three healthy donors (hd). results: for method validation, efficiency and linearity (correlation coefficient) of the qpcr reactions of method a (sp-car) and method b (dp-car, dp-rnasep) were assessed by linear regression of the pcr signal to the reference standard curve. overall, standard curves were only considered valid if a correlation coefficient (r ) of above . and efficiencies of % ± % were achieved. vcns applying method a and b to the same target sample were compared. sp-car pcr reaction displayed efficiency of . ± . %; . % ± . % and . ± . % efficiencies were achieved for dp-car and dp-rnase pcr reaction, respectively (table ) . applying scg-dp-pcr using formula for relative cn assessment ( -Δct (dp-car -dp-rnasep) ) on hd samples resulted in an average of . ± . increased cn when compared to method a (table ) . conclusions: in terms of efficiency and linearity by linear regression qpcr reactions were comparable. validation of scg-dp-pcr was achieved and represents an exact and less error-prone method to fulfil regulatory safety release criteria of cart products. besides of accurately assessing vcn of transduced cells, scg-dp-pcr is also a highly robust method to follow-up carts in treated patients. applying this approach, no standard curve is needed, hence significantly economizing required material as well as time. disclosure: nothing to declare background: t-cells' antileukemic responses in aml-pts need to be improved. dc leu effectively activate t-cells against leukemic blasts, resulting in blast-lysis ex-vivo. factors influencing these activities are not known. methods: we generated dc/dc leu from aml-blastcontaining mononuclear cells (n= ) using standard methods (mcm-mimic/ca-ionophore/picibanil/ifn-α, "mnc-methods") and from blast-containing heparinized whole blood (n= ) using modulatory kits (various combinations of - clinically approved response-modifiers, "wb-kits", patent ) and correlated statistically (t-/u-test, pearsons correlation, # means significant) proportions of dc-/t-cell-subtypes/cytokine-profiles with t-cells' antileukemic cytotoxicity (ctx), achieved after mixed lymphocyte culture (mlc) with/without mncmethod-("t*dc mnc "/"t*bla mnc ") or wb-kit-treated cultures ("t*dc wb "/t*bla wb "). ctx was given as proportions of cases with achieved or "improved" blast-lysis compared to control and as frequencies of viable blasts (bla via ) after effector-cell-influence. pooled data and data obtained with single methods in different cohorts are given. results: . generation of dc/dc leu : with a) mncmethods: Ø ± % dc and Ø ± % dc leu and b) wb-kits: Ø ± % dc and Ø ± % dc leu without induction of blasts' proliferation. t-cell-proliferation increased (vs uncultured t-cells) after mlc with a) mnc-methods: Ø ± % vs Ø ± % and b) wb-kits: Ø ± % vs Ø ± %. . antileukemic reactivity (t-effector-cell-cytotoxicity after mlc): pooling all data: a) mnc-methods ("t*dc mnc " vs "t*bla mnc "): we found a ) blast-cytotoxicity in Ø %(vs %) of cases with Ø %(vs %) bla via , a ) blast-cytotoxicity was improved (vs control) in % with Ø decrease of bla via of %; b) wb-kits ("t*dc wb " vs "t*bla wb "): we found b ) blastcytotoxicity in Ø %(vs %) of cases with Ø %(vs %) bla via , b ) blast-cytotoxicity was improved (vs control) in % of cases with Ø decrease of bla via of %. in general, these results could be confirmed with single methods: best mnc-methods were picibanil and mcm-mimic, best wbkits were kits containing gm-csf+picibanil or prostaglandins. . correlations: pooling all data: cases with "improved" lysis (vs "not improved" lysis) were characterized by a) mnc-methods: increased proportions of mature dc/cells (Ø ± % vs Ø ± %), dc leu /cells (Ø ± % vs Ø ± %) and proliferating t-cells (Ø ± % vs Ø ± %), b) wb-methods: dc/cells (r= . # ), dc leu /cells (r= . # ), dc leu /bla (Ø ± % vs Ø ± %), dc leu /dc (Ø ± % vs Ø ± %), cd + t-cells (Ø ± % vs Ø ± %), ifn-γ (r= . #) , mcp- ( ± vs ± pg/ml). conclusions: blasts are regularly converted to dc leu in the presence of mnc-methods and wb-kits (simulating the in vivo microenvironment). t-cells' coculture with dc/ dc leu after mlc induces and improves antileukemic t-cell activation compared to controls. blast-cytotoxicity correlates with proportions of dc/dc leu -and t-cell subtypes and released cytokines. these data support a role of antigen presentation by leukemic cells (dc leu ) for the stimulation of an immune response in aml in vitro and possibly in vivo. disclosure: nothing to declare evaluation year after the launch of the motion comic immuno-t, explaining patients and their caregivers how immunotherapy strategies work background: one year ago, the first version of immuno-t, a motion comic explaining to patients and caregivers how immunotherapy strategies work, was released. people were informed on and inspired to use the application during (inter)national meetings and events for the general public. meanwhile, the motion comic was further refined and adapted into a second version, based on the evaluations we've collected on the first version. adaptations included a multi-language tool (currently languages), increased user friendliness, and a new supporting musical score. also, a website was launched from which the second version could be downloaded on tablet or smartphone (both android and apple) and a new online evaluation form could be filled in. in months, people have evaluated the motion comic online, and these results are presented here, as well as our future plans within the immuno-t program. methods: through an online questionnaire, participants from belgium (n= ) and the netherlands (n= ) have evaluated the dutch version, and belgian participants evaluated the french version of the motion comic. results: the total group (n= ) consisted of patients (n= ) and their families (n= ), general public (n= ), students (n= ), health care professionals (n= ), researchers (n= ) and kindergarten teachers (n= ). participants' age ranged from to years, with an even distribution amongst the different generations. the majority of the evaluators ( , %, n= ) thought the motion comic is a good way to explain immunotherapy to patients. individuals ( , %) felt mainly interested after watching immuno-t, and a total of participants ( , %) felt hopeful or motivated. focussing on the patient group (n= ), all of the responders think the immuno-t motion comic is a good tool to use in a patient-doctor consultation. patients ( , %) felt hopeful and/or motivated after watching the whole motion comic, while of them ( %) felt combative and ( , %) felt gripped and intrigued. as for the new musical score, participants ( , %) think the music is suitable for the app, while evaluators ( , %) think the new music is not or not at all fitted to support the motion comic. conclusions: the detailed evaluations allow us to further improve immuno-t, and aid us in the development of other motion comics we plan to release under the cancer-t in motion umbrella. with the current version of immuno-t, a single-center pilot study is being set up, to test the efficacy and usability of immuno-t, based on qualitative research during the experience of the tool, and using validated questionnaires. with this study we want to evaluate the impact of immuno-t on patient empowerment, and the decision making process. the study protocol will be presented at ebmt. disclosure: the development of immuno-t was partly financially supported by celyad, calgene, novartis, roche, amgen, bms, but these companies did not by any means influence the contents and development of the motion comic. a therapeutic strategy to trespass the blood brain barrier for adoptive nk cell therapy in glioblastoma multiforme induced rat: a preclinical study background: glioblastoma multiforme (gbm) is among the most common and aggressive primary brain tumors with very poor prognosis. according to the central brain tumor registry of the united states, central nervous system (cns) tumors in pediatric patients (ages between - years old) are the second most common malignancies after blood-born malignancies, and the first amongst solid tumors, and known the most common cause of cancer-related deaths. although hematopoietic stem cell transplantation has been exploited to treat many kinds of malignancies, currently its success rate in gbm is limited. therefore, the gbm treatment paradigm needs shifting towards more effective treatments such as immune cell therapy. natural killer (nk) cells have been recognized as potential anti-cancer effector cells, as they can recognize and target tumor cells. since a small percentage of blood cells are differentiated as nk cells, the number of this group of cells is hardly enough to fight tumors, and so their multiplication and activation would be a potential effective cancer treatment. methods: this preclinical study was focused on setting up an optimal protocol for expansion and activation of naïve nk cells and assessing their efficacy towards induced gbm in rat models. ex-vivo expanded and interlukin- (il- )and heat shock protein- (hsp- )-treated nk cells have been exploited. after in vitro study and confirming the efficacy of treated cells through cytotoxicity assays, we induced gbm in male wistar rats (weighted - gr) using c tumor cells injection in rat brain through stereotactic surgery. the tumor formation was proven by mri imaging. following tumor establishment, we analyzed the effect of single injection of il- -and hsp- -treated nk cells compared with single injection of non-treated nk cells in two groups of rats. results: systemic intravenous delivery of il- -and hsp- -treated nk cells through tail's vein resulted in tumor shrinkage in different time intervals and complete remission in the first group of gbm-induced rat models, whereas in the other group of gbm rats receiving untreated nk cells, the tumor progressed. therapeutic efficacy of the treated nk cells was ascertained compared with non-treated nk cells considering tumor shrinkage observed in mri and survival rates between the two model groups. conclusions: the amelioration of tumor which has been confirmed by mri, proved the migration of activated nk cells through blood brain barrier and homing to cns, and finally targeting gbm tumor cells. our data suggest that nk-cells treated with il /hsp may be a promising immune cell-based therapeutic approach towards treating the fatal gbm. disclosure: nothing to declare p abstract withdrawn. long term sorafenib response for extramedullary flt + aml relapse after allogeneic stem cell transplantation since june , sorafenib dose has been tapered to mg/day, due to mild skin and gi toxicity. after years of treatment, she maintains cr at medullary and extramedulary levels, with no evidence of a disease that had escaped the mechanisms of action of chemo, hsct and dli. conclusions: in our patient, treatment with sorafenib has provided long-term control of this refractory extramedullary disease, even at adjusted doses. further studies are needed to confirm the efficacy of flt inhibitors in the control of relapses after allo-hsct, extramedullary disease and its potential role as maintenance agent. disclosure: nothing to declare background: although chemotherapeutic(ct) agents that used in the treatment of acute lymphoblastic leukemia (all) increase survival, the results are still weak. longterm survival with ct's in relapse all cases is difficult and the prognosis is very weak. inotuzumab ozogamicin is an anti-cd monoclonal antibody and it has the potential to reduce the overall toxicity of intensive regimens for all, as well as to possibly increase the number of patients who may achieve a state of minimal residual disease. methods: -year-old male patient was diagnosed with b-cell all in december .after the hoelzer kt protocol was started, maintenance treatment was continued. in the fifth month of treatment,flag ct protocol was started cause of recurrence was seen on % blast detection in peripheral blood smear. in august , inotuzumab ozogamicin treatment was started and six cures were completed because the patient was not in remission. in september , he had gone haploidentical bone marrow transplantation from his sibling donor( / )with defibrotid prophylaxis for veno-occlusive disease(vod)s. he engrafted succesfully and chimerizm was . % in th days of transplantation. he is th day of transplantation and in a remission. results: bone marrow transplantation cannot be performed since the complete response cannot be achieved in patients with relapse and resistant b-all.in these patients, new therapies targeting malignant lymphoblasts are needed. inotuzumab ozogamicinis a monoclonal antibody drug conjugate that targets cd antigen on malignant lymphoblasts.in many studies, it has been shown that inotuzumab ozogamycin is effective and reliable anti-tumor activity in adults with recurrent and resistant cd positive all. however, monoclonal antibody drug conjugates have been shown to be associated with vod's.for this purpose, we used defibrotid to protect our patient from vod. conclusions: treatment with combination ct regimens in b-all is suboptimal and long-term survival is achieved in only - % of patients.targeted molecular therapy and new regimens are needed in relapse and resistant patients.at this point, inotuzumab ozogamycin is an anti-cd- monoclonal antibody, as in our case, it provides remission in recurrent and resistant b-all patients and allows patients to complete their treatment with an allogeneic transplant from a fully compatible donor. disclosure: nothing to declare background: mesenchymal stem cells (mscs) are an attractive consideration for therapeutic cures of many difficult diseases on the cellular-level. due to the trophic effects of the cytokines and chemokines that they produce, mscs have shown multiple beneficial properties in the field of oncology. in this study, we will be investigating the effect of mscs derived from human bone marrow (bm), adipose tissue (at), and umbilical cord derived mscs (uc-mscs) on ovarian cancer. to differentiate the mscs, we performed a comparative analysis between the various sources for proliferative capacity, surface antigen expression, differentiation ability, tumor marker and paracrine activity, and their influence on ovarian cancer cell proliferation. methods: measurements of ovarian tumor marker proteins were computed by elisa. proliferative effects, immunomodulatory effects, and apoptosis of the mscs were measured by the culture and counting of colony formations. flow cytometry (fcm) was used to measure the variation of the immunophenotyping and cytokine secretions in co-culture, as well as gene expression. results: cells noticeably proliferated without any modifications to their immunophenotype during the third subculture. the colony-forming unit fibroblast (cfu-f) test showed a proliferation of the mscs along with healthy cells and cancer cell lines with no changes in their phenotype. the supernatant of mscs showed an increase in cellular death of the ovcar in ovarian cancer cell lines. a reduction in the level of ca- ( - %; p= . ) with ovcar in co-culture, and a decline of ldh ( - %; p= . ) and beta-hcg ( - %; p= . ) were observed in co-culture in caov , skov and igrov cell lines. a decrease in cd of the cancer cell lines in co-culture with the msc supernatant showed a reduction of the cancer tumorigenicity and aggressiveness, while the rate of the cd and cd asserted their stem state. msc supernatant decreased cell proliferation and mmp- , mmp- , and ca- mrna expression, while increasing timp , , and . this suggests that mscs have a role in cell death and inhibition of ovarian cancer cell proliferation. an increase of anti-inflammatory il- and il- cytokines, and a decrease in growth factor gm-csf along with their proinflammatory inf-a, tnf-a, il- , and il- a cytokines were also noted. conclusions: the gene and cytokine activity indicate a potential therapeutic anti-inflammatory and antiproliferative role of mscs on ovarian cancer despite their sources. the reduction of ca- , ldh, and beta-hcg in co-culture, along with the decrease in cd and amplified cellular apoptosis demonstrate the beneficial effects of stem cells in ovarian cancer cell lines. disclosure background: hematopoietic stem cell transplant (hsct) is the only cure in sickle cell disease (scd) so far. because of the risk of toxicity, its indication in france is restricted to severe patients with match sibling donor. this study compares the incidence of severe acute toxicity after hsct, between children aged less than years and teenagers aged to years old, treated for scd. methods: all patients suffering from scd, aged less than years at transplant, who received hsct in chu robert debré and necker, between / / and / / , were included. severe acute toxicity, defined by onset of severe acute gvhd, organ toxicity or infection, was compared between the two groups of age. results: patients ( children and teenagers) were included. all patients received a myeloablative conditioning regimen. bone marrow from a sibling donor was the main stem cell source (n= ; %). neither death nor rejection was observed with a median follow-up of . months (range, . the incidence of grade iii-iv acute gvhd was . % and was similar between the two groups; no risk factor was identified in univariate analysis. teenagers had more frequently acute skin toxicity ( . % vs %, p= . ). in univariate analysis, patients presenting severe organ toxicity were significantly older than others ( . vs . years old, p= . ). teenagers were more frequently treated for bacterial ( . % vs . %, p= . ) or bk virus ( . % vs . %, p= . ) infections. in univariate analysis, patients who developed infection were also significantly older at time of transplant (respectively . vs . years old, p= . ). no severe sinusoidal obstruction syndrome was observed. regarding long-term toxicity, patients presented an extensive chronic gvhd, they were both aged less than years old. no cut-off of age could have been defined. conclusions: this study confirms the excellent results of hsct in scd, with a -year event-free survival and overall survival of %. an older age at transplant seems to be associated with more frequent severe acute toxicity. these results are consistent with previous studies and suggest that hsct should be performed as soon as possible, without any defined "best age". prospective studies are needed, in order to define the place of each therapeutic in scd, with the aim of reducing treatment-related toxicity and developing alternative strategies for patients without match sibling donor. disclosure: nothing to declare p new insights into risk factors for transplant-associated thrombotic microangiopathy (ta-tma) in paediatric hsct (n= ) was associated with ta-tma in % vs . % vs . % respectively (p= . ). the presence of comorbidities at d (n= ) was significantly associated with an increased risk of ta-tma . % vs . % in absence of co-morbidity (n= ); p= . . use of csa/tac-based gvhd prophylaxis was associated with less ta-tma with an incidence of % vs % if these agents were not included (p= . ). in univariate analysis ta-tma was significantly higher among patients with agvhd grade ii-iv ( / ; . %) vs grade -i ( / ; . %) (p= . ). pres was recorded among cases and % of them developed ta-tma. two out of the patients with ta-tma had pathological gene mutations in their complement pathway. on multivariate analysis the presence of active comorbidity was a risk factor for ta-tma (or: . ; % ci: . - . ; p= . ) while the use of csa/tac-based gvhd prophylaxis did not increase the risk for ta-tma (or: . ; ci: . - . ; p= . ). in the presence of comorbidities the use of defibrotide as prophylaxis or therapy for vod (n= ) was associated with a drop in the incidence of ta-tma from % ( / ) in absence of defibrotide to % ( / ). -year overall survival was significantly lower among ta-tma cases ( %) in comparison to . % in absence of ta-tma (p= . ) (figure ). conclusions: active co-morbidity is a significant risk factor for ta-tma. use of defibrotide prophylaxis in patients with co-morbidities at the time of hsct might offer protection against ta-tma. surprisingly the use of csa/tac based gvhd prophylaxis is not a risk factor for ta-tma probably through limiting the development of high grades agvhd. the association between pres and ta-tma suggests a common pathway of endothelial damage background: gonadal impairment is a severe late effect of myeloablative conditioning regimes with significant impact on quality of life of cancer survivors. the aim of this study was to analyze gonadal function after busulfan (bu) or treosulfan (treo) containing regimens with regard to pubertal stage. methods: this was a retrospective, multicenter study involving patients treated in pediatric ebmt centers between - . patients receiving myeloablative doses of bu or treo as part of hsct conditioning were eligible for inclusion. analysis was conducted in two groups according to pubertal status at time of hsct. results: patients (pts) were treated in pediatric ebmt with bu or treo before allogeneic hsct. the median age at transplant was . years (range - ); / ( %) were males (m), / ( %) were females (f). / ( %) pts were pre-pubertal at hsct (f= ;m= ) and / ( %) were post pubertal (f= ;m= ). / ( %) patients received bu (f= ;m= ), / ( %) were pre-pubertal. / ( %)(f= ;m= ) received treo, / ( %) were pre-pubertal ( figure ). females who received treo in pre-pubertal stage (n= / ) reached more often spontaneous puberty ( % vs %; p= . ) compared to pre-pubertal bu group (n= / ) and occurrence of menarche was higher in treo group (p< . ) hormonal replacement therapy was given in / ( %) females transplanted in pre-pubertal stage and in / ( %) of those transplanted in post-pubertal stage. / ( %) males were pubertal at last follow-up and of them ( %) performed sperm analysis ( oligo-azoospermic, unknown). three pregnancies were reported in the population group, all received bu. regarding the evaluation of hormonal levels in pubertal patients at time of hormonal dosage (median . yrs) ( bu and treo), males treated with treo had significant lower lh levels (p = . ) compared to bu group. females treated with treo had significant lower levels of lh and fsh (p= . and p= . respectively). conclusions: gonadal damage related to treo was significantly lower compared to bu. we observed that: females transplanted during pre-pubertal period had spontaneous puberty more frequently after treo compared to bu and that hypogonadism hypergonadotropic was more frequent after bu than treo. these results must be further confirmed on a larger population. background: viral infections significantly contribute to both morbidity and mortality in patients undergoing hematopoietic stem cell transplantation. traditional antiviral therapy is associated with lack of efficacy, potential toxicity, prolonged hospitalization and increased patient costs. viral specific t cells can be manufactured from donor blood to treat viral infections post-transplant, and are associated with increased clinical efficacy and low toxicity. we postulated that direct costs of vst therapy are lower compared to traditional anti-viral medications methods: vsts were manufactured according to local protocols and fda requirements. total drug cost (as per institutional charges per drug) was calculated for patients who required treatment for viral infections post-hsct. manufacturing costs of vsts are fixed per fda requirements. patients who were treated with investigational antiviral medications (including brincidofovir) were excluded from analysis. patients treated with vsts +/anti-viral medications over a year period were compared to patients treated only using traditional anti-viral medications, including cidofovir, ganciclovir, valganciclovir, foscarnet and rituximab. results: demographics are shown in table . there were no major differences between the two groups treated. the number of anti-viral medications used in the vst group was lower compared to the anti-viral treatment group. median cost of vst treatment was significantly lower compared to those threated with traditional anti-viral therapy ($ , vs $ , , p-value= . ) . conclusions: treatment with vsts post-hsct for viral infections was lower in cost compared to anti-viral medical therapy. it is likely that overall costs are further reduced with vsts due to reduced inpatient hospital time, less monitoring of labs associated with anti-viral medication side-effects and reduced ancillary costs including nursing and pharmacy. more studies are needed to examine these indirect costs further. background: dock deficiency is an autosomal recessive primary immunodeficiency (pid) disease caused by loss-offunction mutations in the dock gene ( ) . patients with dock deficiency present with multiple abnormalities of the immune system, including defective t cell function and impaired production of antigen-specific antibodies. these lead to persistent viral infections of the skin, mucocutaneous candidiasis, recurrent sinopulmonary infections, atopic dermatitis, and other allergic disease, malignancies, and sometimes autoimmunity ( ). hematopoietic stem cell transplantation (hsct) is currently the only curative treatment option available ( ) . methods: we retrospectively evaluated our patients who underwent allogeneic hematopoietic stem cell transplantation due to dock deficiency in ege university pediatric stem cell transplantation unit between and . results: we identified patients transplanted at a median age of . years (range: - . years). of patients; (% ) received hsct from matched sibling, (% ) from unrelated donors and patient from haploidentical donor. we used busulfan-based myeloablative conditioning regimen to patients (% ), reduced toxicity myeloablative regimen with treosulfan to patients (% . ) and nonmyeloablative regimen to patients (% . ). eight of the recipients received bone marrow, of the patients received peripheral blood stem cells, of the recipients received cord blood as stem cell source. fifteen of patients (% ) had achieved engraftment and median follow-up of patients was months ( - ). grade iii-iv acute graft versus host disease (gvhd) occurred in % of patients and chronic graft versus host disease was seen % of patients. one patient received cord blood from unrelated donor did not engraft and died from septic shock. four patients died from transplant related toxicity. our patient's survival was % ; / patients alive. conclusions: hsct is the only curative treatment option for dock deficiency. in particular, patients with high comorbidity scores have a high risk of toxicity and toxic death. therefore, reduced toxicity conditioning regimens should be used for these patients. references : background: eltrombopag, a low-molecular-weight synthetic nonpeptide thrombopoietin receptor agonist (tpo-r), is a second-generation tpo. it is an oral thrombopoietin mimetic licensed in chronic immune thrombocytopenic purpura that induces platelet maturation and release by binding to c-mpl receptors on megakaryocytes. in a recent study; for patients with refractory saa, eltrombopag induced a response (at weeks) in at least one hematologic lineage in % patients and % no longer required platelet transfusions. and also % patients became rbc transfusion independent and % had a neutrophil response. trilineage responses were seen in % of patients; although surprising, this might indicate stimulation of c-mpl receptors on remaining stem cells. delayed recovery from thrombocytopenia is common after stem cell transplantation. in a study including adult patients, eltrombopag was used to enhance platelet recovery for post-hsct thrombocytopenia. it is well tolerated and efficacious offering transfusion independence. methods: in our retrospective study, eltrombopag ( mg/day) was started in pediatric patients (age ranging from to years with a median age . years) for posthematopoietic stem cell transplantation (hsct) thrombocytopenia. all patients fulfilled the following criteria: ( ) undergone hematopoietic stem cell transplantation (hsct), ( ) had improved total leucocyte counts after leucocyte engraftment, ( ) had prolonged thrombocytopenia (< . ) needing platelet transfusion. results: four of the patients have received ric while patients ma conditioning regimens before hsct. two haploidentic, autologous, mud, msd transplantations were performed. et ( mg/day) was started in patients who had thrombocytopenia despite neutrophil engraftment on the + th day of hsct a reduction in platelet transfusions and a platelet count of more than , were the primary endpoints. before et treatment, bone marrow biopsy was checked in / patients, / patients had decreased number of megacocyocytes. none of the patients had active bleeding at the start of eltrombopag but they were all at high risk of bleeding. according to the platelet monitoring, patients had a dose increase starting from the second week. the number of patients in need of platelet transfusions was at the end of the first month; and only at the end of the nd month. all patients had a thrombocyte count of more than . in the third month. in patients, et was discontinued after - months. no dose limiting toxicities have been observed. conclusions: as a conclusion, et was found highly effective for posthsct thrombocytopenia, with no drug related adverse effects. there was a gradual increase in platelet count, and none of the patients had any complication due to thrombocytopenia. disclosure background: isavuconazole (isa) is a new triazole approved for ifi treatment in the adult population. advantages are activity against both moulds and yeasts spp, excellent bioavailability after oral administration without relevant food or gastric ph effect, a water-soluble prodrug developed to facilitate intravenous administration without nephrotoxic excipients such as β-cyclodextrin, potentially poor drug-drug interactions. isa does not currently appear to require tdm. isa safety and efficacy have not been yet established in children and, in particular, no data are available in the pediatric hsct setting. methods: italian association pediatric hematology oncology (aieop) multicentric analysis of a cohort of allogeneic hsct pediatric patients who received isa as ifi treatment or prophylaxis. due to the lack of recommended dosing in pediatric patients and a clear target isa plasma trough-level range, the therapeutic monitoring (tdm) of isa concentrations was applied by a validated liquid chromatography-tandem mass spectrometry (hlpc-ms/ ms) assay technique. isa trough plasma concentrations (c ) and hours after drug intake (c h) were measured. results: a total of allo-hsct recipients were included, (m/f / ); median age: , years, range - , median body-weight , kg (range - ). isa was used as ifi treatment in cases and as prophylaxis in patients. donors were haploidentical in patients, matched-sibling in , allogenic-unrelated in cases. according to eortc criteria, ifi was proven in patients ( penicilum, mucor, aspergillus fumigatus), probable in and possible in patients. lungs were the main localization ( cases), associated with cns involvement in cases and paranasal sinuses in ; patient had possible hepatic candidiasis. all patients, but one, received isa as rescue treatment for previous therapeutic failure ( ambisome, voriconazole, combination therapy, posaconazole). seven patients received only iv isa, received only oral isa whereas patients received both iv and oral isa. patients under kg body weight received half isa dose ( mg tid loading dose on days and , mg/die manteinance). the others received adult schedule; only patients received loading dose. isa was administered for a median of days (range: - ). in patients isa was administered in combination with caspofungin. tdm was applied to patients including patient with severe vod and with renal failure secondary to ta-tma. the median isa concentrations were . ( . - . ) mg/l and . ( . - . ) mg/l for c and c h, respectively. ifi complete remission was achieved in cases, partial remission in ; treatment failure was experienced by patients. in cases fungal lesions remained stable. ctae grade ii-iii toxicity was observed during treatment in patients, with increased transaminase and/or creatinine levels which resolved after temporary isa withdrawal. no drug-drug interactions were observed in patients receiving csa as gvhd prophylaxis and no modification of csa daily dose was needed. conclusions: isavuconazole use may be considered in the pediatric population, even in the hsct setting, for its safety, efficacy, tolerability, no drug-drug interaction. of course these data deserve further evaluation. disclosure: nothing to declare p new treosulfan-based conditioning regimens including epigenetic agents in patients with very high-risk neuroblastoma background: the pts aged mos. or older with disseminated nb involving bone and bone marrow constitute a group of pts with very poor prognosis. although the majority of them are responsive to intensive conventional chemotherapy, most eventually relapse with efs at years of < %. at the beginning of the year we came up with a protocol for this very unfavorable group including epigenetic therapy ( -azacitidine) in the phases of consolidation. methods: seven pts with a median age of ( , - ) years completed the protocol and received hdct with autologous sct as a consolidation. hdct included two different epigenetic agent containing regimes according to tumor response to the induction therapy assessed by i-mibg and mri (ct-scan). three pts revealing large active residual tumor assessed by i-mibg scan or multiple active bone metastases received a conditioning regimen (regimen a) including i-mibg therapy at a dose . - . mbe/kg on d- , treosulfan mg/m /d, on d- ,- and - (total mg/m ), melphalan mg/m /d, on d- ,- (total mg/m ), -azacitidine mg/m /d on d- to d- (total mg/m ). four pts with cr or vgpr received a «split» conditioning regimen (regimen b) including treosulfan mg/m /d, on d and - , and on d- and d- (total mg/m ), melphalan mg/m /d, on d- and - (total mg/m ), and -azacitidine mg/m /d, on d - to d - and on d- to -d- (total mg/m ). a median number of . ( . - ) cd +/kg was infused on d . results: the median recovery times to wbc> . x /l and to an unsupported plt> x /l were ( - ) and ( - ) days, respectively. all pts experienced grade hematological as well as infectious toxicity assessed by nci-ctc score. there were episodes of severe organ toxicity of grade occurring in pts. in cases we observed a severe mucositis, in cases gi toxicity and episode of the erythema multiforme occurred. one pt revealed a lifethreatening episode of hypotension of grade . no transplant-related death occurred. the median number of transfused rbc and plt doses was ( - ) and ( - ), respectively. all pts are alive and well without signs of disease progression in complete hematological recovery with a limited follow-up of . ( - ) mos. from day of hdct. conclusions: although it is rather early to evaluate the efficacy of the epigenetic agent's inclusion in the induction and/or consolidation phases of a very high-risk nb treatment, we can assume that, first, the hdct combining mibg i and/or high dose of treosulfan with epigenetic agent such a -azacitidine was feasible and had an acceptable toxicity. second, the "split" modality of the treosulfan use in conditioning regimen would permit to increase the total dose of the alkylating agent with no inacceptable toxicity. disclosure: nothing to declare pre-and-post magnetic resonance imaging of hips and knees for detecting osteonecrosis in children undergoing hematopoietic cell transplantation: in whom is it necessary? ali y suliman , sue c kaste , ying li , dinesh keerthi , guolian kang , brandon m triplett , ashok srinivasan between april and august at the university medical center hamburg-eppendorf, germany, were included. total and active ratg plasma levels were analyzed by elisa and flow cytometry, respectively. primary endpoint of the study was exposure to ratg. secondary endpoints included transplant-related mortality, incidence of acute and chronic gvhd, immune reconstitution, chimerism, rejection and viral infections. patients were monitored at least days post transplantation. statistical analyses were performed using ibm spss statistics software, or graphpad prism software. results: median total grafalon™ and thymoglobuline™ peak plasma levels were . μg/ml and . μg/ml, respectively; median active grafalon™ and thymoglobu-line™ peak plasma levels (appl) were . μg/ml and . μg/ml, respectively. active thymoglobuline™ plasma levels showed highly variable pharmacokinetics compared to grafalon™. neither grafalon™ nor thymoglobuline™ exposure correlated with lymphocyte count prior to transplantation, cell count in the graft (wbc, mnc, t cells), age, body weight or body surface area (bsa). this is indicative for a saturation effect in both groups. to correlate high or low ratg exposure with clinical outcome parameters, we built two groups within each patient cohort by median appl. the incidence of gvhd was not dependent on high or low ratg exposure. until day post hsct, viral infections or reactivations (ebv, cmv, adv, hhv , bkv) occurred in the patients. interestingly, adv infections affected only children with high ratg exposure. the median time to leukocyte engraftment was not significantly longer in the high ratg groups compared to the low ratg groups ( to days for grafalon™, and to days for thymoglobuline™). there was a decreased and/or delayed recovery of cd + , cd + and cd + t cell reconstitution, but not of b cells and nk cells in the high thymoglobuline™ exposure group compared to the low thymoglobuline™ exposure group. overall survival was not statistically significant with % in the grafalon™ and . % in the thymoglobuline™ group without influence of ratg exposure. conclusions: high and low exposure to grafalon™ or thymoglobuline™ did not result in significant differences in outcome parameters as incidence of survival, agvhd, cgvhd, rejection, or mixed chimerism in this limited cohort. delayed and decreased immune reconstitution in the high ratg exposure groups did not translate into different clinical outcome parameters. adv infections only occurred in the high ratg exposure group. grafalon™ and thymoglobuline™ showed distinct pharmacological and immunological differences in children and larger cohorts are needed to detect clinically significant differences and adjust dosing regimens individually. disclosure: nothing to declare background: the optimal conditioning regimen for allogeneic hematopoietic cell transplantation (allohct) in children with myeloid malignancies remains undefined, particularly when reduced-intensity conditioning (ric) regimens are utilized. methods: we performed a retrospective review of children undergoing allohct for acute myeloid leukemia (aml) and myelodysplasia-related aml (mdr-aml) over a year period ( - ) at our institution, comparing the outcomes of those who received either a busulfan (bu)-or melphalan/thiotepa (mel/thio)-based conditioning regimen. results: a total of patients were analyzed. twentyone received fludarabine/melphalan/thiotepa and received myeloablative busulfan-based conditioning, either in combination with cyclophosphamide (n= ) or fludarabine (n= ). atg was used in patients depending on donor. recipients of mel/thio were selected for ric regimens due to pre-transplant comorbidities (cardiac dysfunction, n= , requiring peri-transplant milrinone), transplant during chemotherapy-induced aplasia (n= ), underlying diagnosis of treatment-related aml (t-aml) and significant pre-allohct chemotherapy exposure (n= ). proportions of patients with de novo aml (mel/ thio, %; bu, %) and mdr-aml ( % and %) were similar between groups; however, recipients of mel/thio were more likely to have t-aml ( % vs %). cytogenetic and molecular risk factors were similar between groups. the majority of patients were transplanted in cr (mel/thio, % vs bu, %) or cr ( % vs %). more recipients of bu conditioning ( % vs %) were mrd-negative at the time of allohct; both groups had comparable proportions of patients with ≥m marrow (~ %). donor types and stem cell sources were similar between groups, except unrelated umbilical cord blood which was more common in bu recipients ( % vs %). there were no graft failures in mel/thio recipients, compared to % (n= ) in those receiving bu-based regimens. engraftment kinetics and immune reconstitution were similar. overall acute and chronic gvhd incidence was higher in recipients of mel/ thio compared to bu ( % vs %, and % vs %, respectively), but rates of grade iii-iv acute or extensive chronic gvhd were comparable. vod requiring treatment was diagnosed in ( %) recipients of bu conditioning and no mel/thio recipients. median duration of follow-up was months (range - ) in the mel/thio group, and months (range - ) in the bu group. transplantrelated mortality (trm) was similar in both groups ( patient), occurring before day . relapse incidence was comparable (mel/thio, % vs bu, %); however, relapse occurred at a later time in mel/thio recipients (median d + vs d+ ). overall survival at and years was superior in mel/thio recipients ( % vs %, and % vs %, respectively). conclusions: in our single institution experience, use of a melphalan/thiotepa-based ric regimen was associated with similar outcomes compared to full-intensity bu-based conditioning, despite higher risk patient and disease characteristics. the majority of recipients of mel/thio conditioning had significant pre-transplant comorbidities, which did not translate into higher trm. while mel/thio recipients had less optimal leukemia control at the time of transplant and high-risk leukemia features (e.g. t-aml), relapse was similar between groups, occurring later in mel/ thio recipients, which may have contributed to better overall survival. disclosure: nothing to disclose methods: pubertal development and biological gonadal parameters were assessed in a retrospective monocentric cohort of pre-pubertal patients who underwent hsct after myeloablative conditioning with total body irradiation (tbi) or busulfan between and . results: seventy-four patients ( girls and boys) were included. no spontaneous pubertal development was found in % of girls and % of boys (p < . ) and delayed puberty or no spontaneous pubertal development was found in % of girls and % of boys (p= . ). hormone replacement therapy was used in % of girls and % of boys (p < . ). in univariate analysis, tbi conditioning (p= . ), female sex (p < . ), acute gvhd (p= . ), extensive chronic gvhd (p= . ), steroid treatment > months (p= . ), and malignant diseases (p= . ) were associated with no spontaneous pubertal development, whereas tbi conditioning (p= . ) and extensive chronic gvhd (p= . ) were associated with delayed puberty. in multivariate analysis, factors independently associated with no spontaneous puberty onset were female sex (p= . ) and age > years (p= . ). factors independently associated with delayed puberty were extensive chronic gvhd (p= . ) and age > years (p= . ). tbi was not an independent risk factor for pubertal complications. conclusions: this study confirms the toxicity of myeloablative conditioning on pubertal development and the role of older age and female sex in increased pubertal issues, and suggests a possible role of gvhd in delayed puberty. disclosure: nothing to declare p abstract already published. neutrophil elastase activity may serve as a marker for neutrophil extracellular traps formation following stem cell transplantation ronit elhasid , sivan berger-achituv , hila rosenfeld-keidar , szilvia baron tel aviv sourasky medical center -tel aviv university, tel aviv, israel background: post-transplant infections rise dramatically in patients with quantitative or qualitative neutrophil defects and constitute a major source of morbidity and mortality following hematopoietic stem cell transplantation (hsct). neutrophils protect the host from microorganisms via multiple processes including phagocytosis and formation of neutrophil extracellular traps (nets). although reactive oxygen species (ros) production seems to be essential for nets formation, the key enzymes of the process are neutrophil elastase (ne) and myeloperoxidase (mpo). methods: ne and mpo activity as well as nets formation were investigated following hsct in patients at week to and after neutrophil engraftment. neutrophils were isolated using easysep direct human neutrophil isolation kit (stemcell technologies inc.) by immunomagnetic negative selection. enzymatic activity of ne and mpo were measured using colorimetric assays. nets formation of phorbol -myristate -acetate (pma)activated neutrophils was investigated by confocal fluorescence microscopy. all results were compared to those of healthy volunteers. statistical significance was calculated using one way-anova with bonferroni post hoc test. results: patients (median age of . years [range - years]) were investigated, following allogeneic hsct ( acute lymphoblastic leukemia, acute myeloblastic leukemia, epidermolysis bullosa, rhabdomyosarcoma) and following autologous hsct ( ewing sarcoma, desmoplastic small round cell tumor). all patients experienced fever and neutropenia. at engraftment, average ne activity was significantly decreased compared to the average value of healthy individuals. ne activity improved week by week in patients, reached the lower reference range at weeks following transplantation (fig. a) and continued to increase. the enzymatic activity of mpo was comparable to the average value of healthy individuals (fig. b) and showed no significant difference between the distinct time points. at neutrophil engraftment, nets formation was absent and comparable to those of non-activated neutrophils (fig. c) . although nets formation increased week by week, it did not reach the average of normal controls during the monitored time period. also linear correlation between ne activity and nets formation (r = . ) was demonstrated. conclusions: impaired ne activity following hsct corresponds to decreased nets formation and could serve as a marker for netosis. strategies to accelerate the recovery of ne function post transplantation might improve nets formation and thereby induce better infection control. a) the average of ne activity (n= ) during weeks following hsct. reference range was measured and calculated from measurements of healthy volunteers using. b) the average of mpo activity (n= ) during weeks following hsct. reference ranges were measured and calculated from measurements of healthy volunteers using the quartile method. c) the average of netosis activity after nm pma activation for h (n= background: to have a better understanding of incidence, treatment, outcome and risk factors of immune cytopenia in children after allogeneic hsct. methods: between january and september , pediatric allogeneic hsct have been performed in patients at the ghent university hospital (ghent, belgium). autoimmune hemolytic anemia was defined by a positive direct agglutinin test (dat). dat was performed at moment of engraftment and in case of hemolysis or unexplained anemia. platelets antibodies were evaluated in case of no otherwise explained thrombocytopenia. results: the cumulative incidence of post allo sct autoimmune cytopenia is . % ( / ). in cases there were positive antibodies against red blood cells, and one patient against had antibodies against platelets. of these cases, only ( . %) were clinically relevant and needed treatment. the median observation period post sct for the whole cohort was months ( - ) . the clinically significant immune cytopenia started at a median time of day+ and day + in the group without symptoms. the patient who presented the autoimmune thrombopenia developed antibodies against anti-gpiib/iiia, this was resolved after days, the treatment consisted intravenous immunoglobulins (ivig). two of the patients with autoimmune hemolytic anemia had igg mediated antibodies, and had complementmediated dat. these patients were treated with ivig, steroids, rapamune and rituximab. one patient has still dat positive after months, but clinical stable. the other two are also dat positive and have some hemolysis, but the follow up is much shorter ( months). treosulfan-contained conditioning regimens were more frequently used in patients with significant immune cytopenia. conclusions: immune cytopenia is an infrequent complication after allogeneic hsct. however, its treatment can be challenging, and the hemolysis can persist for years. the association of rapamune and rituximab was adequate to treat this problem in our patients. background: approaches to the management of refractory and relapsed classical hodgkin´s lymphoma (r-r chl) are changing and become more effective. the role of anti-cd targeted immunochemotherapy with brentuximab vedotin (bv) has been extensively investigated in adults with r-r chl and is only to be elucidated in children. the study included children and adolescents with r-r chl that were sucessfully treated with bv-based therapy prior to hematopoetic stem cell transplantation (hsct). median age of patients was years ( - ), main histological variant -nodular sclerosis ( %, n= ), advanced stage at diagnosis - % (n= ). most were heavily pre-treated (median number of previous therapies - ) and progression after autologous hsct was documented in ( %). refractory disease was diagnosed in ( %) and relapsed in ( %). among relapsed patients ( %) were with multiple episodes, ( . %) -early and ( . %) -late relapse. treatment regimens consisted of bv in monotherapy . mg/kg triweekly (n= ) or combination of bv . mg/kg on day with bendamustine - mg/ m on days and of -week cycles (n= ) or combination of bv . mg/kg on day with dhap (n= ). median number of bv infusions was . ( - ). all selected patients achieved complete (n= , %) or partial remission (n= , %) prior to hsct. consolidation with autologous hsct was performed in ( %) and with allogeneic hsct -in ( %). primary end points were overall (os) and progression free survival (pfs). response to bv was not assessed in the study as only responders to the bv-based treatment were included. results: with median follow-up of days ( - ) os and pfs for all patients are % and %, respectively. pfs after autologous hsct and allogeneic hsct are % and %, respectively (p= . ) at present moment ( %) patients are alive and are in remission. three patients died ( %): disease progression (n= ), postransplant idiopathic pneumonia syndrome (n= ) and posttransplant pneumonia (n= ). bv was generally well tolerated with only mild polyneuropathy in patients ( %) as the main reversable documented adverse event. conclusions: in prognostically unfavourable heavily pretreated children and adolescents with r-r chl achievement of response to bv-based therapy prior to hsct is assosiated with promising rates of os and pfs. disclosure provides a treatment by restoring thymidine phosphorylase function and improving disease manifestations. here we report the outcomes of affected siblings who underwent transplantation using an unaffected sibling donor to highlight important experiences in the transplant of such a rare condition. methods: four siblings of consanguineous pakistani descent aged , , and years underwent myeloablative hsct using fully hla-matched ( / ) peripheral blood stem cells harvested in a single apheresis from an unaffected year old sibling. the oldest sibling, a year old male, first presented in having emigrated from pakistan with a history of growth failure and abnormal movements. biochemical, nerve conduction and imaging studies confirmed a diagnosis of mngie. testing on three other siblings identified similar biochemical abnormalities, though the youngest children had minimal clinical manifestations of the disease. based on the progressive nature of the disease and the availability of a fully matched donor, a decision was made to pursue transplant for all affected siblings. results: due to the severity of their disease, the oldest siblings were transplanted first using a myeloablative conditioning regime of fludarabine, thiotepa and treosulfan with alemtuzumab. neutrophil engraftment occurred on day + for both, with % donor chimerism achieved. there were no significant transplant related complications. the post-transplant course of the year old sibling was complicated by a major stroke-like event characterised by dramatic imaging changes and requiring ventilation, though no cause was identified and the patient's neurologic deficits have since resolved. gastrointestinal symptoms have persisted and both remain tpn dependent, though symptomatically have shown gradual improvement. following the neurologic complications in their older sibling, the younger siblings were conditioned with auc-targeted busulfan and fludarabine plus alemtuzumab. neutrophil engraftment occurred on day + , with full donor chimerism achieved. progression to enteral feeding has been much more rapid, with nutrition now fully enteral for both. there were no significant transplant related complications. conclusions: stem cell transplantation represents the only curative option for mngie. due to its rarity and relative infancy as a condition, little is known of the expected course following transplant or the best approach to transplantation itself. despite previous challenges with graft failure in mngie recipients, we were able to gain rapid and sustained donor engraftment using different myeloablative conditioning regimes with minimal transplant-related morbidity and no mortality. in keeping with previous reports, resolution of established gastrointestinal symptoms has been slow, though the siblings transplanted earlier in their disease course have shown more rapid improvement supporting the role of early recognition and access to transplant. it is essential moving forward that specialised transplantation centres collaborate so as to guide clinicians in the management of such a challenging condition. disclosure: there are no conflicts of interest to disclose. g pc congenital neutropenia -biology of inflammatory colitis associated with gcsf use, and disease response to allogeneic transplant, a report of cases background: an autosomal recessive disease, glucose- phosphatase catalytic subunit (g pc ) deficiency is a relatively recently identified cause of chronic severe neutropenia. there can be a spectrum to the disease and patients may also present with non-haematological features including prominent chest veins, cardiac, endocrine or urogenital abnormalities. we describe in our patient cohort a response to gcsf but an inflammatory, incapacitating, biopsyproven colitis associated with that g-csf response. we have transplanted children with such colitis, and describe a similar colitis with intestinal failure in a fourth. methods: we investigate the biology of the neutropenic colitis, and demonstrate necrosis of the stimulated neutrophils. in vitro studies demonstrated that unstimulated neutrophils from patients with g pc d exhibited significantly increased production of il , reactive oxygen species (ros) and neutrophil extracellular traps (nets) alongside significantly higher expression of cd b, cd b and cd . in contrast, neutrophils from patients with g pc d produced significantly less ros, mmp- , neutrophil elastase and nets upon stimulation. neutrophils from patients with g pc d also exhibited significantly accelerated apoptosis and secondary necrosis which was exaggerated upon stimulation with live escherichia coli bacteria but could only be partially rescued with supplemental exogenous glucose. results: patients have undergone hsct for g pc neutropenic enterocolitis ( unrelated donor and msd) after fludarabine treosulfan and thiotepa conditioning therapy. alemtuzumab was given as as serotherapy. all patients are alive and well, immune suppression has been discotniuned and there is no gvhd with normal organ function, and resolution of colitis. we describe a th patient with no good donor who has continuing intestinal failure with g-csf use. conclusions: we describe the aetiology of intestinal inflammation and failure with an extensive study of neutrophil biology in this metabolic neutropenia. we describe a novel indication for hsct in this "g-csfresponsive neutropenia". disclosure: nothing to declare p does body mass index (bmi) pose a risk to outcome for pediatric non-infantile patients undergoing hematopoietic cell transplantation (hsct)? mona al-saleh , khawar siddiqui , amal al-seraihy , abdullah al-jefri , ali al-ahmari , hawazen al-saedi , awatif al-anazi , mouhab ayas , ibrahim al-ghemlas with no evidence of toxicity. as benefits of stoss therapy in hsct remain unknown, and safety has yet to have been studied extensively in the pediatric population, we hypothesize that stoss therapy is an effective and safe method to reach and attain sufficient levels of vd in pediatric patients undergoing hsct. methods: this is an ongoing prospective, randomized clinical control trial at phoenix children's hospital that commenced december st , . following consent, subjects are randomized to the intervention (stoss) or control arm prior to hsct. stoss therapy consists of a single oral dose of vd (ranging , iu - , iu), given based on baseline -hydroxyvitamin d [ (oh)d] level and age, followed by standard weekly supplementation. subjects enrolled on the control arm receive standard of care based on endocrine society guidelines of weekly vd supplementation. data collection includes demographics, (oh)d levels at baseline, day + , and day + , vd toxicity (hyperphosphatemia, hyperkalemia and renal calculi), as well comorbidities were collected. at each time point and for each trial arm, the mean (oh)d level and changes from baseline were computed with corresponding % confidence intervals (cis) to indicate variability. results: presently, subjects have completed baseline assessment, with day + and day + follow-up completed for and of these, respectively. at baseline, the mean ( % ci) (oh)d was . ng/dl ( . , . ) among stoss patients and . ng/dl ( . results: total hrqol scores of transplanted patients were significantly improved compared to those on supportive care and also compared to healthy siblings (p < . and . respectively), the same was true for physical (p < . and . respectively) and emotional functioning (p < . and . respectively). social and school functioning of transplanted children were not different from healthy siblings (p . and . respectively) while were very significantly improved compared to children with st on supportive care (p < . in both cases). conclusions: bmt in a lower-middle income setting may be even more impactful compared to high-income regions. our analysis clearly indicates normalization of hrqol in all major areas of children transplanted for st. a possible resilience effect was noted for physical and emotional scores which were improved compared to healthy sibling controls. we could not however quantify the effect of longer-term issues like fertility impairment after bmt which may eventually adversely impact hrqol, particularly in the indian culture. disclosure: none allogeneic hematopoietic stem cell transplantation in ataxia telangiectasia patients without malignancy background: ataxia telangiectasia (a-t) is a primary immunodeficiency with mutations in atm-gene. besides a slowly progressive neurodegenerative course, a-t leads to increased susceptibility to malignancies which affects % of patient (median: . years) with a high mortality mainly due tocomplications of conventional radio-chemotherapy. the incidence of cancer correlates with the extent of immunodeficiency. patients often develop severe progressive granulomatous skin disease with evidence of vaccine-strain rubella-virus in the lesions. prolonged survival, neurologic improvement and malignancy prevention was observed in atm-deficient mice after treatment by syngeneic hsct. nevertheless, pre-emptive hsct is not routinely performed in a-t patients due to concerns about neurodegeneration and toxicity. methods: we present three a-t patients with severe immunodeficiency phenotype, undergoing successful hsct as an individual treatment strategy intending to restore immunodeficiency for long-term malignancyprevention (patient- ) and to treat progressive skin/joint granulomas (patients- and - ). results: patient- underwent a reduced intensity conditioning (ric) regimen at years of age including fludarabine ( mg/m ), cyclophosphamide ( mg/kg), and atg-fresenius ( mg/kg/d) which was tolerated well. hematopoietic engraftment occurred by day + . there was an expansion of naïve and memory cd + t-cells and cd + cells. while initially a mixed donor chimerism in patient's pbmcs ( - % donor) was observed, patient's tcells (cd + ) reached over % of donor origin over time. at last follow-up ( years) he is well, without signs of gvhd and organ toxicity, off immunosuppression with normal levels of atm-protein; his granulomas resolved. patient- is a year-old male who was transplanted from his hla-identical sibling, conditioned with fludarabine ( mg/m²), cyclophosphamide ( mg/kg), and atg-fresenius ( mg/kg). hematopoietic engraftment was observed by day + . t-cell reconstitution started by day + with > μl cd + t-cells. his mixed chimerism rapidly turned to donor origin ( % donor cd +) over time. there was no acute toxicity, however, he developed lumbosacral pain episodes with evidence of urine bk-virus with spontaneous remission. an intermittent metapneumovirus associated pulmonary hypertension was observed with pericardial effusion. treatment included sildenafil and oxygen. at last follow-up ( months) patient is well without immunosuppression. patient- suffered from recurrent chest infections, failure to thrive and progressive and debilitating rubella positive progressive granulomas of the skin. she received allohsct from an hla-identical family donor at years of age. conditioning included busulfan ( . mg/kg), fludarabine ( mg/m²), cyclophosphamide ( mg/kg), and alemtuzumab ( x mg/m², x mg/m²). hsct was complicated by intermittent acute renal failure, cmv reactivation and tma. hematopoietic recovery was observed by day + . t-cell chimerism increased rapidly over time (> % donor). at last follow-up ( months) patient is well, off immunosuppression and ivig. her skin granuloma resolved with scarring residues. conclusions: pre-emptive allohsct is feasible in a-t when reduced intensity conditioning is used and can correct the immunodeficiency. it might be a treatment option for some a-t patients at high risk of hematological malignancy and severe granulomatous skin disease. to what extent the restored immune system and the increase of atm-protein in these patients could prevent the development of other malignancies needs to be evaluated further. disclosure: nothing to disclose p abstract withdrawn. hematopoietic stem cell transplantation in diamond blackfan anemia: brazilian experience background: diamond-blackfan anemia (dba) is a rare inherited red cell aplasia caused by an intrinsic defect of erythropoietic progenitors. the main therapeutic approach is based on repeated red blood cell transfusions and/or corticosteroid therapy. hematopoietic stem cell transplantation (hsct), a potentially curative treatment for dba, is indicated for patients that do not respond to first-line therapy. methods: the aim of our retrospective study is to report the outcomes of brazilian dba patients transplanted between and in bmt centers. the median age of the patients was ys (range - ) and % were male. seventeen patients ( %) were transplanted with matched related donors (mrd) and thirteen ( %) from matched and mismatched unrelated donors (mud/mmud). in the mrd group all patients received bone marrow as hsc source, while in the mud/mmud, eight patients received bone marrow and five received cord blood. all patients with incompatibilities (mismatched) were ucb ( / ). nineteen recipients were conditioned with busulfan plus cyclophosphamide, while the remaining received fludarabine and busulfan, which has been the preferred regimen in brazil in the recent years. after transplant, most (n= ) of the mrd and mud recipients received cyclosporine and short course methotrexate as graft versus host disease (gvhd) prophylaxis. results: twenty-two out of the patients were alive and disease-free at a median follow-up of months (range to months). the -year overall survival (os) was % (ci - %) (fig ) . similar results have been demonstrated in studies from europe and from the united states. when analyzed according to donor type, os was % (ci - %) and % (ci - %) in mrd and mud/mmud respectively (fig ) . three out of the patients who were transplanted with ucb died. these results are in agreement with those of previously published data showing worse results in unrelated ucb transplants. twenty-nine out of the patients engrafted successfully. in of the evaluated patients, the median time to neutrophil engraftment was days (range - ). one patient experienced an early death from hemorrhagic shock on day , before neutrophil recovery, and another two patients experienced primary graft failure. post-transplant chimerism was available for patients. sixteen had complete chimera (> % chimerism), while patients presented with mixed chimerism. acute gvhd was observed in patients ( %), of which classified as grade iv. five patients developed chronic gvhd, considered severe in three of them. eight patients died at a mean of days (range - days) after hsct and the main causes of death were infections and hemorrhagic disorders. conclusions: hsct is a potentially curative treatment option for dba. in the present study, we report the outcomes of patients with dba transplanted in brazil with a os of %, with better results in mrd compared to mud, as expected. despite the small numbers, we observed lower survival after mud/mmud ucb transplantation. since dba is a rare disease, international collaborative studies are essential to better understand the benefits of the hsct in the treatment of these patients. disclosure: nothing to declare p treatment of the obliterant bronchiolitis in pediatric allogeneic recipients: two periods compared results: in group , the therapies administered for bo included prolonged treatment with steroids in all patients, anti-tnf in , azatioprine in ; while in the group , all patients received ima, montelukast and azitromicin, and received i.v. mpd. the median duration of imatinib therapy was years ( . - . years). after a median follow-up of . years (range . - . yrs), / patients of group ( %) died with bo in progress for transplant-related causes. while in the group , / ( %) died in presence of worsening bo. the estimated os at year after hsct was % ( % ci; - ) in group and % ( % ci, - ) in group (p= . ) (figure ), while the os after year decreased at % ( % ci; - ) in the group while remained stable in the group . conclusions: this experience shows a relevant improving in prognosis of children with bo with the use of this protocol including ima, since the significant improving of survival obtained, confirming as reported in adult populations. disclosure results: we presented patients with pres, age ranging from months to years with a average of . years. there were ten patients with thalassemia major, two patient with acute lymphoblastic leukemia, three patients with sickle cell disease and one patient with myelodysplastic syndrome, one patient with immune deficiency, two patients with acute miyeloid leukemia, one patient with aplastic anemia. ten patients were males, ten were female. all patients were treated with csa or tacrolimus and metilprednisolone for the prophylasix of gvhd. pres occurred at a median of days (range - ). clinical findings at onset of leukoencephalopathy were hypertension, headache, seizures, visual disturbance, and altered mental function. eighteen patients alive with normal neurological status. mri showed abnormalities in all patients including patchy bilateral cortical and subcortical lesions, especially in parieto-occipital lobes. conclusions: bmt is associated with several neurological complications that may be underlying diseases, bmt procedure, and severe immunosupression. pres is an uncommon but serious complication after bmt. we report cases of pres who received allogeneic bmt for thalassemia major to emphasize the importance of early recognition and institution of appropriate management of pres during bmt. disclosure: nothing to declare p continuous complete molecular remission using three different monoclonal antibodies followed by allogeneic bone marrow transplantation in an infant with chemotherapy-refractory acute lymphoblastic leukemia bernd gruhn , susan wittig , thomas ernst , jana ernst university of jena, jena, germany, background: a -week-old infant was diagnosed with very immature acute lymphoblastic leukemia (all) with myeloid markers in a foreign university hospital. at the end of induction therapy according to the current lal/shop protocol % leukemic cells were detectable in the bone marrow. treatment was changed to fludarabine, cytarabine and granulocyte colony-stimulating factor (flag) in combination with liposomal doxorubicin. after this re-induction still % leukemic cells were detected in bone marrow, so the bispecific t-cell engager antibody blinatumomab was given. due to an increasing portion of leukemic cells during the continuous infusion, antibody therapy was stopped and a cycle of clofarabine, cyclophosphamide and etoposide was administered. unfortunately, still % leukemic cells were detectable afterwards. because of chemotherapy-refractory leukemia a palliative oral treatment with mercaptopurine was started. however, the parents did not accept the palliative situation and searched for alternative therapeutic options in other university hospitals in europe. after plenty of refusals the infant was admitted to our hospital five months after diagnosis. methods: for molecular characterization genomic dna was isolated from leukemic cells. a mll-mllt /af rearrangement as a consequence of the translocation t( ; ) (p ;q ) was detected and used as a marker for minimal residual disease. for further molecular characterization targeted deep next-generation sequencing was performed for a panel of leukemia-associated genes. interestingly, no mutation was found. to allow precise immunophenotyping of the leukemic cells treatment with mercaptopurine was stopped. results: as in the first immunophenotyping the cd antigen was found, we administered the anti-cd monoclonal antibody gemtuzumab ozogamicin twice within two weeks. because of the detection of cd + leukemic cells after infusion of gemtuzumab ozogamicin, the anti-cd antibody daratumumab was given alternating twice within two weeks. unfortunately afterwards, leukemic cells reappeared being negative for cd und cd , but positive for cd . therefore, we administered the third antibody, the anti-cd monoclonal antibody inotuzumab ozogamicin, whereupon our patient developed a tumor lysis syndrome and a severe bone marrow aplasia. shortly after, allogeneic bone marrow transplantation from an unrelated donor using a special conditioning regimen consisting of thymoglobulin, busulfan, fludarabine and clofarabine was conducted. clofarabine was added because an additional antileukemic effect especially in infant all with mll rearrangement was described. after transplantation the patient suffered from a severe hepatic sinusoidal obstruction syndrome with massive ascites, renal and pulmonary dysfunction, but finally the patient recovered completely. the first bone marrow examination days after transplantation revealed a donor chimerism of % and a complete molecular remission using the mll-mllt /af rearrangement as marker for minimal residual disease. in all follow-up bone marrow samples we observed a complete donor chimerism and a complete molecular remission. currently, eight months after transplantation the patient is in a very good physical condition with normal development according to the age. background: paediatric chronic graft versus host disease (cgvhd) is a debilitating condition associated with substantial morbidity and mortality. to date, there are no approved therapies for paediatric patients with cgvhd, and current treatments often lack sufficient efficacy or lead to severe/life-threatening toxicities that limit their effectiveness. ibrutinib, a first-in-class, once-daily inhibitor of bruton's tyrosine kinase (btk), is approved in the us for the treatment of adult patients with cgvhd after failure of ≥ lines of systemic therapy. this phase / study will evaluate the use of ibrutinib in paediatric patients with moderate or severe cgvhd. methods: this open-label, multicenter, international phase / study (pcyc- ) includes patients with moderate or severe cgvhd as defined by the nih consensus development project criteria. it is divided into two parts: part a will determine the recommended paediatric equivalent dose (rped) of ibrutinib in patients aged ≥ to < years, and part b aims to evaluate the safety and efficacy of ibrutinib in patients age ≥ to < years. for part a, patients with cgvhd aged ≥ to < years who have failed ≥ lines of systemic therapy will receive once daily oral ibrutinib at a starting dose of mg/m to be escalated up to mg/m after days, if no grade ≥ toxicities occur, until the rped is determined. for part b, patients aged ≥ to < years with cgvhd who have failed ≥ lines of systemic therapy or have newly diagnosed cgvhd will receive once daily ibrutinib ( mg) until one of the following criteria is met: treatment is no longer required; new systemic treatment for cgvhd is initiated; progression of cgvhd; recurrence of underlying disease; or unacceptable toxicity. patients with newly diagnosed cgvhd will receive ibrutinib in addition to daily corticosteroids ( . - mg/kg prednisone). patients < years of age may be enrolled in part b and treated at the rped after it is determined in part a. key exclusion criteria include uncontrolled active systemic infection or active infection requiring systemic treatment; progressive underlying malignant disease or any post-transplant lymphoproliferative disease; or active hepatitis c/hepatitis b virus. patients must have adequate renal, hepatic, and hematologic function to be enrolled. the primary endpoint of part a is the rped of ibrutinib, as based on pharmacokinetic (pk) data; secondary endpoints include safety and pharmacodynamics (btk occupancy). the primary endpoints of part b are pk and safety of ibrutinib in paediatric patients with cgvhd. secondary endpoints for part b include response rate at weeks as defined by the nih consensus development project criteria; duration of response; overall survival; and late effects on growth, development, and immune reconstitution. results: this global study is currently enrolling. conclusions: this phase / study will explore the use of ibrutinib in paediatric patients with cgvhd to potentially meet the high unmet need for proven effective therapies for this population. disclosure enzyme replacement therapy (ert) is the treatment of choice in non-neuropathic hunter syndrome, but as the recombinant enzyme does not cross the blood brain barrier and neuropathic hunter syndrome is left untreated. hematopoietic stem cell transplantation (hsct) is the standard of care in patients with severe mucopolysaccharidosis (mps) type i (mpsih, hurler syndrome) as early transplantation halts cognitive decline in these patients and significantly improves survival. only few case studies have been published on the potential benefit of hsct in mps ii and mostly used busulfan-based conditioning regimens. in one comparative non-randomised multicenter study, hsct might to be superior compared to ert. here, we present our experience in hsct in three children with hunter syndrome using a treosulfan-based conditioning regimen. methods: a retrospective chart review was carried out in patients, who underwent hsct for hunter syndrome. the conditioning chemotherapy regimen included fludarabine, treosulfan, thiotepa and atg. all patients received bone marrow of either related and or matched unrelated donors. gvhd prophylaxis was performed with csa and methotrexat. results: three patients with hunter syndrome were transplanted in our department in . the age was six months, two years and four years, respectively. bone marrow donors were related in one patient and matched unrelated in two patients. the conditioning therapy was generally well tolerated. major complications were fever of unknown origin with need for antibiotic therapy and a mucositis. one patient developed a cmv reactivation. all patients engrafted successfully and recovered well from the hsct. there was no case of acute or chronic gvhd. in all three patients are alive. donor chimerism is complete in one patient; two patients have a mixed donor chimerism. after application of donor lymphocyte infusions in one patient, donor chimerism is stable at a low level of %. the donor chimerism of the other patient still slowly declines to currently %. after stem cell transplantation, two patients did not show further progression of the disease and even achieved psycho-motor improvements. interestingly, one of these patients is the one with the low donor chimerism of %. one patient suffers from a further progression of the underlying disease with psycho-motoric agitation, aggressive behavior and loss of speech, that occurred within the first year following hsct, but neurocognition stabilized thereafter. conclusions: we found a beneficial effect of hsct on the neuropsychological outcome or at least stabilization of neurocognitive function in our patients with a follow-up of eight years. despite low toxicity of the conditioning regimen, increased donor chimerism may further improve the neurological outcome. disclosure: nothing to declare. tandem sct in pediatric solid tumors, other than brain tumors, has no advantage in terms of efs over single procedure-single center experience , germ-cell tumour (gct), ewing sarcoma (es), nefroblastoma. patients were divided into groups according to the number of procedures: st group-single sct procedure, nd group-multiple procedures. regimens used for stem cell mobilisation were: topo-cy for nbl and epi-tax for gct, followed by g-csf±plerixafor. conditioning regimens: bu-mel and thiotepa-cy for pts with nbl, thio-tax and ice for pts with gct. patients received antibiotic, antiviral and antifungal prophylaxis, parenteral nutrition and supportive treatment. patients received consolidation treatment, followed up monthly in the first year, then yearly. patients were evaluated for residual disease by imaging tests. parents signed informed consent forms. results: we performed sct procedures to patients: . % nbl, . % es, . % gct and . % nefroblastoma. for this study only patients with nbl and gct were considered. in st group were % of pts, % in nd group. patients were diagnosed, staged and treated according to international protocols. sex ratio was f/ m. age distribution was - y % ( pts), - y % ( pts), > y % ( pts). peripheral stem cell (pbsc) mobilisation was more difficult in patients with multiple courses of chemotherapy±radiotherapy. we found no difference in the period of engraftment following a nd or rd procedure. hospitalization and supportive measures increased in nd and rd procedures ( to days). patients with multiple courses of chemotherapy and multiple hospitalizations had increased infectious risk and during the nd or rd procedures developed various infectious complications.incidence of severe oral mucositis after the first hsct was %, after tandem hsct was %. nbl patients : st group- / patients alive and efs, / receives anti g treatment; nd group- / patients-alive, / patients-not reached timepoint for mibg scan; / patients-mibg negative at first, relapsed after mo; / patient deceased due to pulmonary toxicity. gct patients: st group- / patients alive and ef, / high values in afp levels and receives metronomic therapy, / patients deceased due to progressive disease, but only had sct. only / patient had one procedure and died due to progressive disease. conclusions: in our study, tandem hsct in children with solid tumours lead to an increase in survival rates, at least in the first months after sct. most patients ( %) had progressive or relapsed/refractory disease when referred to our department. multiple procedures require a higher number of cd cells, very hard to achieve in patients with multiple courses of chemo± radiotherapy. new approaches have to be considered in these diseases, especially in high risk group. disclosure: nothing to declare background: antimicrobial prophylaxis for prolonged neutropenia occurred during the pre-engraftment period is a common practice in allogeneic hsct recipients. data on its effectiveness are few and generally from cases series and not from randomized clinical trials, especially in children. methods: all clinical records of allo-hsct performed from january st to november th at hsct-unit of istituto g.gaslini, genoa-italy, were retrospectively reviewed. collected data were underlying diseases, type of donor, antibiotic prophylaxis administration and type, development of fever and pathogen isolated from blood culture, if any, during pre-engraftment neutropenia. antibiotic prophylaxis, usually starting together with the conditioning regimen, was categorized in "standard" (with amoxicillin/clavulanate or ampicillin/sulbactam) or "tailored" (when based on previous bacterial isolations or colonizations). results: allo-hscts were performed in pediatric patients ( % males) with a median age at hsct of years (iqr: - ; range: - ). hscts were performed from alternative donor (ad) in % patients, from relative donor (rd) in %, and from haploidentical donor in %. table shows the pre-engraftment febrile neutropenia episodes according to type of antibiotic prophylaxis. ( %) hscts received standard prophylaxis, while ( %) the tailored one; only in ( %) did not receive any prophylaxis. fever occurred in ( %) of episodes in patients receiving standard prophylaxis, in ( %) of those treated with tailored prophylaxis and ( %) in the group without prophylaxis; only % of patients who received prophylaxis did not develop fever.in % of patients, the febrile episodes were diagnosed as bloodstream infections: staphylococcus aureus in %; cons in %; enterococcus spp in %; enterobacteriaceae in %; pseudomonas aeruginosa in %; other non-fermenting gram negatives in % and fungi in %. conclusions: the occurrence of fever in patients who received antibiotic prophylaxis suggested that it could not be effective in prevention of fever related to neutropenia after allo-hsct. the personalization of prophylaxis could be a possible path to follow these patients. disclosure methods: a total of patients with leukemia or neuroblastoma were included in the study. patients' mothers signed an informed consent for participation in the study. six of study participants were boys and girls, all aged to years. the control group consisted of healthy preschool children ( groups of children aged to years), boys and girls. results: in most of games the role of a doctor was played by a child. only one child declined to impersonate both a patient and a doctor. younger children mostly agreed to have for a "patient" a toy (proposed by psychologist or one of child's own), child's mother or a medical psychologist. the game lasted for - minutes. most patients preferred using real medical consumables and instruments (syringes, adhesive tape, winged infusion sets or, more rarely, pills). most often a syringe or an adhesive tape was chosen. as known from their mothers, among medical manipulations most unpleasant for children are injections and changing implanted catheter dressing. also, most healthy preschool children preferred using real medical instruments over toy ones. group more often used a syringe, a winged infusion set, adhesive tape, gauze or pills. group most often chose syringe or gauze. among medical instruments both groups more often chose a phonendoscope or thermometer.one patient refused to cause pain to a "toy patient". other children sympathized with a "toy patient", stroke injection or dressing location sites or used soothing terms ("wait a little", "it's going to be all right"), wished prompt recovery and hugged their "patients". one child was angry over his "patient" wishing him to "get hurt too". first preschool group children were mostly scolding a toy "patient" for "being guilty of getting sick". second group children were mostly compassionate, encouraged a "toy patient" telling that "all the procedures are needed to get healthy". from children's schoolmasters we know that all first group children received vaccination about a week before a test. children from second group had no injections. overall attitude towards toy "patients" was more mild in the second group. conclusions: . during a play children mostly use the medical devices which cause them most discomfort and/or pain. . manipulating the items children illustrate their own impression of medical procedures, which are most unpleasant. . children may express their negative emotions directed towards medical manipulations via their play actions, these negative reactions may be suppressed in different ways by parents or medical staff. . the intensity of child's own traumatic experience and an attitude of nearby adults may influence the child's attitude towards other patients. . the mother's wish for a child to tolerate all medical procedures with ease exceeds real capabilities of a small child. disclosure: nothing to declare. allogeneic stem cell transplantation in patients with mucopolysaccharidosis type iiia (sanfilippo): a case series methods: allogeneic sct was performed at the ages of , and years, respectively. all three patients received intrathecal enzyme replacement therapy within a clinical trial setting prior to hsct. the conditioning regimen consisted of treosulfan, fludarabine, thiotepa and thymoglobuline. gvhd-prophylaxis was carried out with csa and mtx in two patients and csa and mmf in one patient. stem cell source was bone marrow in two patients and peripheral blood stem cells in one patient. results: the conditioning regimen was well tolerated and all three patients successfully engrafted. two of three patients had an uncomplicated course without occurrence of acute or chronic graft-versus-host-disease (gvhd). at last follow-up and months after hsct, both patients are in good condition and show constant progress of psychomotor development. the third patient experienced severe steroid refractory acute gvhd of intestines (stage ) and skin (stage ), which resolved under intensive immunosuppression with cyclosporine, mycophenolate and ruxolitinib. around day after hsct, this patient showed clinical and biochemical signs of transplant-associated microangiopathy (tma) with cerebral seizures and acute renal failure. the cerebral mri showed progressive cerebral atrophy and leukoencephalopathy, also consistent with a progress of the mps iiia. at last follow-up months after hsct, this patient had recovered from tma and was in a stable clinical condition. conclusions: in consideration of the small case number and the short follow-up period in our cohort, allogeneic hsct might be considered as a salvage therapy for patients with mps iiia if other therapeutic options are unavailable for children with this otherwise unfavourable prognosis. however, the early psychoneurological course after transplant seems promising compared to the literature and hsct could become a treatment option for this rare disease. disclosure: nothing to declare methods: for the identification of underlying molecular mechanisms leading to the increased sensibility of rms cells, the activation status of different nf-kb signaling pathways were analyzed using western blot analysis and quantitative real time pcr (qpcr). further, flow cytometry was used to analyze the surface expression of death receptors on either sm treated or untreated rms cells. the overall effect on cell death induction was measured by pi/hoechst staining using a fluorescent microscope. results: treatment with sm led to the suspected degradation of iaps. followed by the activation of both the canonical nf-κb signaling pathway, indicated by the phosphorylation of iκbα and p , and the non-canonical nf-κb signaling pathway, as indicated by the accumulation of nik and the degradation of p to p . determination of selected target gene transcription revealed an upregulation of the inhibitor iκbα, nik, p , il- and at later time points the death receptors trail-r and trail-r . analysis of gene transcription also led to the finding of neither up-nor downregulation of ciap and p . to evaluate the involvement of trail-r and trail-r in the sm induced sensitization towards nk cell-mediated killing, surface expression of both death receptors was analyzed. treatment with sm led not only to an induced transcription of trail-r and trail-r , but also to an increased surface presentation of trail-r . subsequent ligation of trail-r by either wt-trail or a specific agonistic antibody (etr- ) resulted in a significant increase in cell death induction. the aforementioned analysis of gene transcription hints towards a bimodal feedback mechanism regulating both, the canonical and non-canonical nf-κb signaling pathway. on the one side, the canonical pathway is negatively regulated by the induced transcription of the inhibitor iκbα. on the other side, the induced transcription of nik, p and relb points towards a positive feedback loop of the non-canonical pathway. one mechanism of the increased rms cell sensitivity might be the induced transcription and surface presentation of the death receptor trail-r . the involvement of trail receptors is further validated by the cytotoxicity data, illustrating a sm mediated sensitization towards a trail induced cell death induction. this mode of cell death fits to the previous research, were trail transcription could be induced in nk cells by sm treatment. the graphical abstract shows the transcriptional upregulation of target genes leading to a putative bimodal nf-kb regulation and increased surface presentation of trail-r by treatment with smac mimetics. aim: to investigate the outcome of ucb transplantation in pediatric patients with malignant and non malignant diseases methods: data from patients underwent first allogeneic bone marrow transplantation with ucb from / until / were retrospectively analyzed. eighteen had malignant disease (md), of whom in complete hematologic response, and non malignant disease (nmd) (scid , chronic granulomatous disease , severe aplastic anemia , s.kostmann , osteopetrosis , wiskott-aldrich , amegakaryocytic thrombocytopenia ). the majority of the patients were male, for md and nmd, as well (m: /f: , m: /f: , respectively), of median age . years (range . - . years) and . years (range . - . years), respectively results: all patients but one, received ucb unit. hla compatibility in antigen/allele level was at least / and only in patients with md was / . conditioning regimens were myeloablative and tbi gy was given in / . gvhd prophylaxis consisted of cyclosporine and atg was given in all patients pre-transplantation. median value of nucleated cells for md was . χ /kg (range - . χ / kg) and for nmd was . χ /kg (range - . χ /kg). neutrophil and platelet engraftment was achieved in / and / patients with md respectively, in a median time of days (range - ) και days (range - ). in patients with nmd, neutrophil and platelet engraftment was achieved in / and / with median day of engraftment days (range - ) και days (range respectively. acute gvhd grade ΙΙ-Ιv presented in / patients with md and / with nmd, although none had cgvhd. the incidence of viral infections was cases in patients with md and cases in patients with nmd. disease relapse occured in / patients with md. after a median time of years follow up, overall survival (os) and event free survival (efs) for children with md were % and . % respectively, while for nmd, os and efs were %.treatment related mortality at d+ was % for md and % for nmd. among patients with md, are still alive, while the rest died from relapse (n: ), viral infections (n: ), septicemia (n: ) and agvhd(n: ). among patients with nmd, are alive, while the rest died from viral infections (n: ), septicemia (n: ) and multiple organ failure (n= ). the median time of hospitalization for patients with md was days (range - ), whilst for nmd was days (range - ). conclusions: transplantation of unrelated ucb in our unit was combined with high trm in children with nmd and higher probability of relapse for md. disclosure: nothing to declare p serum levels of -s cysteinyldopa is associated with stem cell transplantation related complications yukayo terashita , mamoru honda , minako sugiyama , yuko cho , akihiro iguchi hokkaido university hospital, pediatrics, sapporo, japan background: diffuse hyperpigmentation is common in patients who received chemotherapy or stem cell transplantation (sct). however, there are few reports of the relationship between skin reaction such as pigmentation and the other complications. pigmentation of the skin is thought to be the result of melanin stagnating in the dermic layer due to increased synthesis of melanin and destruction of the basement membrane due to inflammation induced chemoradiotherapy. melanin pigments are classified into two types: brown to black eumelanin and yellow to reddishbrown pheomelanin. -s cysteinyldopa ( scd) is precursors of pheomelanin, and its serum level has been used specific biochemical marker for malignant melanoma. here, we examined serially scd during the course of sct to determine association with sct related complications, because visual evaluation of skin color is difficult, and there have been no reports about scd as sct related biomarker. methods: we prospectively analyzed ( males, females) patients who received sct between may and march in hokkaido university hospital. the median age at transplantation of the patients was . years (range, - ). indication for sct were acute myelogenous leukemia in patients, acute lymphoblastic leukemia in patients, and other disease in patients; juvenile myelomonocytic leukemia( ), malignant solid tumor( ), immunodeficiency( ), anaplastic anemia( ), and diamond blackfan anemia ( ) . patients received allogeneic sct and received autologous sct. myeloablative conditioning (mac) was used for patients and reduced intensity conditioning (ric) was used for patients. sera were obtained from patients before conditioning therapy, on day , + , + , + , + and + . all blood samples were centrifuged at , rpm for min, and stored at - ˚c until used. we also examined sct related complications such as graft-versus-host disease (gvhd), viral infection, and pre-engraft syndrome (pes). statistical analyses were completed using the mann-whitney u test for unpaired samples, and kruskal-wallis test for three samples. each test was performed with a % level of significance. results: the average value of scd reached two peaks, day ( . nmol/l) and day ( . nmol/l), regardless of stem cell source and intensity of conditioning. in all patients, we found that the level of scd on day was associated with viral reactivation (p= . ), scd on day was associated with pes (p= . ), and scd on day was associated with malignant disease (p= . ). similarly, in patient who received allogeneic sct (n= ), the level of scd on day was associated with viral reactivation (p= . ), scd on day was was associated with pes (p= . ), scd on day was associated with malignant disease (p= . ). in addition, the level of scd on day was associated with gvhd of skin (p= . ), the peak level of scd was associated with acute gvhd (p= . ). conclusions: we found that scd can be a biomarker for sct-related complications such as aute gvhd. it is presumed that the production of pheomelanin could be induced by inflammatory procedure in sct. disclosure: nothing to declare p hsct in children with bone marrow failure: outcomes from a single singapore centre prasad iyer , michaela seng , vijayakumari k , ah moy tan , mei yoke chan , rajat bhattacharyya kk women's and children's hospital, paediatric haematology-oncology, singapore, singapore background: children presenting with pancytopenia often present a challenge to the paediatric haematologist. the underlying diagnosis can be hard to establish as many of the inherited bone marrow failure syndromes (ibmfs) can present with protean manifestations. the large majority of patients with bone marrow failure are often diagnosed with idiopathic severe aplastic anaemia (saa) despite extensive testing. we report our experience of hsct in patients treated with primary and acquired bone marrow failure. methods: we reviewed case notes of all the children who underwent hsct for bone marrow failure in our centre. results: a total of fifteen patients underwent eighteen stem cell transplants in our centre between and . three patients were diagnosed with fanconi anaemia, one with hoyeraal-hreidarsson syndrome, one with paroxysmal nocturnal haemoglobinuria and the remaining ten children had idiopathic saa. eight children had matched sibling donor transplant, had a matched related donor, had a matched unrelated donor, had umbilical cord blood transplants and the remainder were haploidentical transplants. four of the haploidentical transplants were t-cell depleted and one was t-cell replete. one child with fanconi anaemia had primary graft rejection with cord blood transplant and was successfully rescued with a haploidentical transplant. one child with saa had primary graft rejection twice (t-cell depleted graft) and then was rescued with an alternate haploidentical donor with a t-cell replete graft. of the two patients who died, one had a fatal fungal infection ten months after transplant, and the other died due to a severe influenza pneumonitis three and a half years after bmt. conclusions: haematopoietic stem cell transplant outcomes from our centre are comparable to leading centres in the world. the understanding of underlying conditions that present with bone marrow failure has improved our approach and the way we treat bone marrow failure syndromes. clinical trial registry: not applicable. disclosure: nothing to declare. methods: a retrospective study was performed in children treated with hsct who received pos or flu during early neutropenic period until engraftment from january to december at siriraj hospital in thailand. the efficacy, safety and tolerability of pos were compared to flu. results: there were hsct recipients (allo-hsct . %, auto-hsct . %) with mean age of . + . years. most of the patients were thalassemia ( . %) followed by hematologic malignancy ( . %) and solid tumor ( . %). seventeen and cases received pos and flu, respectively. all of patients in pos group were allo-hsct whereas . % in flu group were allo-hsct. in pos group, cases were diagnosed with suspected ifi and cases were probable ifi with total cases ( . %). in flu group, cases were diagnosed with suspected ifi and cases were probable ifi with total cases ( . %) which compared groups were not statistically significant (p= . ). no possible and proven ifi in both groups. in flu group patients received empirical antifungal treatment more than pos group but no statistical significance ( . % vs. . %, p= . ). both groups had similar rate of elevated liver function test (p= . ). no early discontinuation of antifungal prophylaxis for intolerance was found in both groups. only . % of patients achieved pos target trough level of . mg/l after days of treatment with started dose mg/kg three times a day. conclusions: pos and flu are comparably effective, safety and tolerability in ifi prophylaxis in neutropenic children treated with hsct. defining dose recommendation of pos in this setting requires larger studies. disclosure background: severe congenital neutropenia (scn) is typically characterized by anc of < /μl, maturation arrest of bone marrow myeloid precursors at the promyelocyte-myelocyte stage, and susceptibility to lethal pyogenic bacterial and fungal infections. scn is a rare group of disorders resulting from intrinsic defects in myeloid cell proliferation and maturation caused by mutations in several genes; elane, hax , gfi , was, and g pc are among the most common ones. almost % of patients are refractory to g-csf, and the only definitive curative approach for such patients is allogeneic hsct. the current absolute indications for hsct is failure to respond to g-csf treatment, or the development of mds/leukemia in patients with scn. here, we present the result of children with scn who received allogeneic hsct . methods: we retrospectively assessed allogeneic hsct in children with severe congenital neutropenia. all patients received busulphan (bu) based myeloablative conditioning regimen. busulphan was used according to weight adjusted dose. in addition, all patients received fludarabine mg/m in five days or cyclophosphamide mg/kg in days and atg mg/kg in days. cyclosporin-a and mtx were used for graft versus host disease (gvhd) prophylaxis. donor chimerism was evaluated in either bone marrow or peripheral blood on days + , + and + . results: the median transplantation age of the patients was months (range - months). six of them are male. two of the donors were matched siblings and were unrelated two of which were ag ag mismatched. stem cell source was bone marrow in patients, peripheral blood in and cord blood in patients. all patients engrafted. the median time of neutrophil and platelet engratment to was ( - ) days and ( - ) days, respectively. graft rejection was experienced in patients, one of them had received unrelated cord blood. all patients are alive, eight of which are with full donor chimerism (between - %) without any complication (no infection, no gvhd) with a median months (range - months) follow up. probability of disease free and overall survival were found % and %, respectively. conclusions: we concluded that hsct is a useful treatment for scn patients, especially those who are unresponsive to gcsf treatment and at high risk for leukemic transformation. however, a larger number of scn patients and longer follow-up are necessary to identify appropriate conditioning regimens and long-term prognosis. disclosure: nothing to declare background: prolonged thrombocytopenia (pt) or secondary failure of platelet recovery (sfpr) are a lifethreatening complications that occurs in - % and - % respectively of the patients following allogeneic hematopoietic stem cell transplantation (allo-hsct). management strategies, including the use of growth factors, cd +-selected stem cell boost, mesenchymal stem cell (msc) transfusion, and second allo-hsct, are not effective or possible for all patients. eltrombopag, is an oral non-peptide thrombopoietin receptor agonist, that leads to signal transduction and results in promoting the proliferation and differentiation of megakaryocytes. some recently studies show that also can promote haematopoiesis along all three lineages. methods: we described our experience in paediatric patients with poor graft function or secondary failure of platelet recovery after allogeneic stem cell transplantation treated with eltrombopag. results: patients characteristics are detailed in table . all the patients received and allo-hst. the median dose of cd + cells infusion was . x e /kg ( . - . ). neutrophils engraftment occurred in + day ( - d) and platelets in + day ( - d). all the patients had an hypoplastic bone marrow with complete chimerism. the median duration from transplantation to spcf diagnosis was months ( . - m) . one of the patients received a stem cell boost prior to eltrombopag, without response. the time onset from spgf/sfpr diagnosis to initiating eltrombopag was days ( - d). eltrombopag was started at a dose of mg/kg/d, requiring an increase dose in all cases. the median dose was mg/d ( - mg). the overall response rate was % ( / ). two patients achieved complete response (cr), as defined by platelet ≥ × /l. both patients already got neutrophil ≥ . × /l without g-csf. the time from eltrombopag initiation to achieving cr was ( - d) days. the treatment was given for a median of days ( - ). it was discontinued after and days respectively in the two responder patients. both patients maintain stable blood counts after discontinuing the treatment. the non-responders patients had to stop the treatment because of other reasons not related to eltrombopag. patient had to be rescued with a cd + cells boost with a good response. two patients that were in treatment with voriconazole for a fungal infection developed hyperbilirubinemia. there were no grade - toxicities related to eltrombopag. conclusions: in our experience, according to recently published studies, eltrombopag is a safe and efficacy drug in the treatment of secondary failure of platelet recovery post-hsct. it may be used successfully in children. sometimes higher doses may be considered if no response is achieved. further prospective trials are needed to increase the level of evidence and to identify predictors of response. disclosure: nothing to declare very slow clearance of busulfan in a child with infant leukemia background: busulfan is a drug with a high interindividual variability between dose and exposition. therefore, it is recommended to perform therapeutic drug monitoring (tdm) in the context of myeloablative conditioning, especially in children. methods: we report on a -month old boy ( . kg, cm) of caucasian decent born to non-consanguine parents with mll-rearranged prob-lymphoblastic leukemia. diagnosis was established one month after birth from peripheral blood and csf tap showed cns involvement. primary chemotherapy was commenced according to the interfant- protocol. however, mrd remained positive two months under treatment, leading to an indication for allogeneic stem cell transplantation. in the interfant- protocol, we opted for a conditioning regimen comprised of fludarabine ( . mg/kg for days), busulfan and thiotepa ( x mg/kg). in our institution, busulfan is applied once daily with a target auc of - h*mg/l in this very high risk situation. according to body weight, busulfan was given with . mg/ kg as a three-hour infusion on the first day. busulfan concentrations in plasma were measured with gas chromatography-mass spectrometry (gc-ms) and auc was calculated using bayesian curve fitting. results: exact busulfan quantification was not possible after the first dose due to technical reasons. as the levels were estimated to be very high, we decided to reduce the second dose of busulfan by %. this resulted in a very high auc of h*mg/l for the second dose, so that busulfan was discontinued after two days, because it was calculated that the patient already received busulfan with a cumulative auc of h*mg/ml. trough levels after the first and second dose were and μg/l, respectively. the patient showed a very slow clearance of . l/h/sqm, while the volume of distribution was in the usual range ( . l/kg). bilirubin and liver transaminases were in the normal range at the time of conditioning, while albumin and quick were decreased on day + after transplantation the patient developed clinical und biochemical signs of venoocclusive disease (vod). vod symptoms completely resolved under therapy with defibrotide. leukocyte engraftment was established on day + . unfortunately, the patients suffered from an early relapse of the leukemia from day + . attempts to induce a second remission with blinatumomab failed. the patient is currently under palliative chemotherapy. conclusions: busulfan tdm is very important especially in infants receiving myeloablative doses of busulfan to prevent under-or over-exposure. there is evidence that high busulfan trough levels contribute to the development of vod, but anti-leukemic activity of busulfan and cns permeability make it a valuable drug for very high risk patients in childhood leukemia. larger patient cohorts are needed to assess the exposure dependent risks of toxicity versus relapse in infants and toddlers. disclosure: nothing to declare blood (ucb) obtained at delivery from three children who received a diagnosis of cerebral palsy. methods: immunophenotyping of the ucb leukocyte fraction was performed using multicolor flow cytometry. the procedure was performed according to the protocol by shatorje and colleagues ( ) . briefly, the ucb samples were labeled with specific antibodies and incubated in the dark for minutes. afterwards, the samples were treated with ml of bd facs lysing solution for minutes to preserve the leukocyte fraction only. the cells were washed using pbs (roche) and then centrifuged twice ( rpm, °c, minutes). the results were analyzed using the facsdiva software (becton dickinson). results: we found an increased white blood cell (wbc) count, lymphocyte count, and cd :cd ratio in all ucb samples. one patient had a low nk cell count and percentage, and another had a low b-cell count and percentage. one sample displayed high t (cd +) and th cell (cd +) counts, but with percentages within the limits of the reference values. conclusions: we detected elevated wbc and lymphocyte counts in all ucb samples, despite a lack of intrauterine infection symptoms. many authors have described the pathogenesis of hypoxic-ischemic encephalopathy. briefly, after an acute hypoxia-ischemia insult, activated resting microglia show macrophage-like activity. this leads to a break-down of the blood-brain barrier, infiltration by peripheral leukocytes, and brain exposure, which further exacerbates inflammation. the role of systemic inflammation is being evaluated in the animal model. it is known that systemic inflammation plays a role in traumatic brain injury (tbi) and is an independent risk factor for poor outcome in isolated tbi patients. on the other hand, m -phenotype microglia inhibit inflammation and protect neurons from secondary damage and death. however, anti-inflammatory mechanisms in neonates are immature and expose them to extremely intensive inflammation. therefore, anti-inflammatory agents, including stem cells, may be beneficial in these patients. disclosure: three of four authors are employees of the polish stem cell bank, warsaw, poland reference: background: under the hypothesis that early natural killer cell infusion (nki) following haploidentical stem cell transplantation (haplo-sct) will reduce relapse in the early post-transplant period, we conducted a pilot study to evaluate the safety and feasibility of nki following haplo-sct in children with recurrent neuroblastoma who failed previous tandem high-dose chemotherapy and autologous sct. methods: we used the high-dose i-metaiodo benzylguanidine and cyclophosphamide/fludarabine/antithymocyte globulin regimen for conditioning and infused × /kg of ex-vivo expanded nk cells derived from a haploidentical parent donor on days , , and posttransplant. results: seven children received a total of nkis, and nki-related acute toxicities were fever (n = ) followed by chills (n = ) and hypertension (n = ); all toxicities were tolerable. grade ≥ii acute gvhd and chronic gvhd developed in two and five patients, respectively. higher amount of nk cell population were detected in peripheral blood until days post-transplant compared with reference cohort. cytomegalovirus and bk virus reactivation occurred in all patients and epstein-barr virus in six patients. six patients died of relapse/progression (n = ) or treatment-related mortality (n = ), and one patient remained alive. conclusions: nki following haplo-sct was relatively safe and feasible in patients with recurrent neuroblastoma. further studies to enhance the graft-versus-tumor effect without increasing gvhd are needed. disclosure: nothing to declare regenerative medicine p repeated administration of g-csf using stem cell mobilization protocol could induce improvement of cognitive functions of children with cerebral palsy: phase ii randomized placebo-controlled study background: we performed phase ii randomized placebocontrolled clinical study to reveal the safety and feasibility of repeated granulocyte colony-stimulating factor (g-csf) administration for improvement of cognitive functions of children with cerebral palsy. methods: forty-four children with non-severe type of cerebral palsy were enrolled, and their age were - years old. g-csf ( μg/kg) was administered for days subcutaneously every months during months. we compared their cognitive functions with the magnetic resonance imaging (mri) findings and the following tools between before and months after treatment; zoo location and picture memory as working memory index (wmi) in wechsler preschool and primary scale of intelligence (wpssi), receptive and expressive vocabulary test (revt), and visual motor integration (vmi)/visual perception (vp) test. mobilized stem cell count and cytokine levels were measured before (d+ ) and after (d+ ) g-csf administration for days every months. results: no significant findings in demography was noticed between g-csf (g-) and placebo (p-) groups. no serious adverse events were observed during the whole study period. the non-severe adverse events such as urticaria (n= ), itching sense (n= ), bone pain (n= ), headache (n= ), fever (n= ), and stomatitis (n= ) were tolerable. the parents felt the clinical improvements of cognition in cases of g-group and cases of p-group (p= . ), of language in cases of g-group and cases of p-group (p= . ). in zoo location test, we can not find out the significant score (expressed as age equivalent) differences between g-and p-groups. however, in picture memory test, there were significant improvement of age equivalent of months ( . ± . → . ± . ) during months of study period in g-group compared to months in p-group (p= . ). in revt, there were significant improvement of months of age equivalent in expressive tests of g-group ( . ± . → . ± . , p= . ) compared to months in p-group. no significant findings were noted in receptive test. vmi test showed the increasing tendency of months of age equivalent in g-group ( . ± . → . ± . , p= . ) compared to p-group. the increment of cd + cell counts in peripheral blood were significant in ggroup compared to p-group. the changed levels of interleukin (il)- , il- , vascular endothelial growth factor (vegf) as well as g-csf were noted in g-group. we also observed the correlation of cognitive function tests and white matter connectoms of several networks using functionally-defined white matter atlases. conclusions: the repeated administration of g-csf using stem cell mobilization protocol is safe and feasible to improve the language and cognitive functions in children with cerebral palsy. further studies for cellular and paracrine effect of g-csf and/or mobilized peripheral blood stem cells would be needed. background: while high-dose chemotherapy (hdct) with autologous hematopoietic stem cell transplantation (auto-hsct) is an integral part of multimodal therapy for highrisk neuroblastoma (hr nb), there are still subgroups, in which the results are extremely poor. for these patients allografting (allo-hsct) may offer some hope. methods: we summarize the experience of consecutive hr nb patients receiving therapy in our pediatric transplant department in - . the median age was years ( months to years). a total of auto-hscts and allo-hscts were performed. all auto-hsct recipients were characterized by one or several high-risk features: age of more than months at disease (onset n= ), primary disseminated disease (n= ), unfavorable biologic variant (n= ), poor st -line therapy response (n= ) or systemic relapse (n= ). most patients (n= ) received bu-mel hdct (in younger patients oral busulfan was replaced by busilvex), in primary resistant cases a d/ d regimen was used. a total of patients with st (n= ) or nd (n= ) chemosensitive relapse, resistant relapse (n= ) or poor mobilizers with locally advanced resistant tumor (n= ) received allo-hsct from haploidentical donor with fludarabine-based ric. in cases the transplant was modified via immunomagnetic positive or negative selection, patients received post-transplant cyclophosphamide (post-cy)-based gvhd prophylaxis. gvhd prophylaxis also consisted of calceneurin inhibitors and sirolimus. thirteen of allo-hsct recipients received posttransplant immunoadoptive (n= ) or targeted (n= ) therapy. results: the -year os and efs in auto-hsct recipients was % and %, accordingly. all but one patient engrafted with a median time of ( - ) days. bu-mel regimen was characterized by acceptable toxicity with most common toxicities being oral mucositis and infectious complications. the vod/sos incidence was only %. four patients dies due to infection (n= ), cns hemorrhage (n= ), and secondary leukemia (n= ). according to multivariate analysis the most important prognostic factors were response to st line therapy and post auto-hsct mibg scan results. the prognosis in initially resistant patients with good response to nd or rd -line therapy was still very poor (all patients relapsed with the median efs of months). all patients receiving a second auto-hsct after relapse died due to disease progression. with a median follow up of ( - ) months allo-hsct recipients are alive, of them with no signs of disease progression. all long-term responders received post-transplant therapy. one patient died due to transplant complications, other deaths were caused by disease progression. there was no obvious difference between outcomes in post-cy based and transplant modification-based transplantations. agvhd more often developed in modified transplant recipients ( patients vs in post-cy group, of these cases gr iii-iv), patients in post-cy group had grade iii-iv hemorrhagic cystitis. the median time to engraftment was longer for ptcm group compared to transplant modification group (d + vs. d+ , accordingly). conclusions: while single hsct with auto-hsct is a golden standard in hr nb patients, the relapse rate is still high and the prognosis in relapsed/refractory patients is dismal. the allografting has some limited effectiveness in these cases and post-transplant therapy has a potential for further improvement. disclosure: nothing to declare p abstract already published. veno-occlusive liver disease (vod) is frequent but well treatable with early defibrotide administration in children with neuroblastoma receiving high-dose busulfan and melphalan background: using high-dose intravenous busulfan and melphalan (bumel) prior to autologous stem cell transplantation (sct) in children with high-risk neuroblastoma, seems to decrease toxicity of the myeloablative regimen, except for vod. in this multicenter retrospective study we aimed to assess the outcome of bumel-associated vod with early defibrotide treatment intervention. methods: we retrospectively analyzed children with high-risk neuroblastoma who underwent autologous sct with i.v. bumel regimen in slovakia and prague, czech republic in the period / - / . busulfan was administered in q hour schedule, with therapeutic drug level monitoring in % of patients. all vod patients except one were treated with defibrotide starting at a standard dose of mg/kg/day, given in doses per day. patient was treated with supportive therapy only. ursodeoxycholic acid was used as prophylaxis in all patients. vod was established using the modified seattle clinical criteria (corbacioglu, lancet ). results: the incidence of vod was % ( / ) in patients treated with intravenous busulfan and melphalan. there was no significant difference in busulfan total dose/kg between patients with ( . mg/kg (sd= , )) and without ( . mg/kg (sd= , )) vod manifestation. vod developed at a median of days after sct (range - days). anicteric forms of vod were documented, although % patients with vod ( / ) presented with increased bilirubin. % patients with vod ( / ) developed ascites but only patients ( %) required ascites drainage. no vod patient received renal replacement therapy and only one needed mechanical ventilation. importantly, we successfully treated vod in all patients. relapse or progression of neuroblastoma was the cause of death in vod patients ( %) who died. conclusions: despite targeting busulfan levels to decrease toxicity of the regimen, vod is common (we observed vod incidence exactly in the range of the siopen hr nbl- multicenter study (ladenstein, ) ). early recognition and early treatment with defibrotide seems to be effective in vod associated with bumel regimen -none of our patients died due to vod. disclosure: nothing to declare results of high-dose chemotherapy (hdct) with autologous hematopoietic stem cell transplantation (auto-hsct) in the treatment of ewing sarcoma family tumors (esft) background: while current dose-intense treatment protocols allow achieving - % survival in localized esft patients, the long-term survival in high-risk cases is still unsatisfactory. although there is a considerable body of data on high-dose consolidation the real effectiveness and optimal indications for this option are still not completely clarified. therefore, a large prospective cohort analysis may still yield useful data. methods: the whole cohort includes consecutive highrisk esft patients with median age of (range - ) years receiving hdct with auto-hsct in to after obtaining st (n= ) or nd (n= ) cr, pr (n= ), or stable disease (n= ). the high-risk features included lung (n= ), bone (n= ) or bone marrow (n= ) involvement, inadequate local control in primary axial tumors (n= ), large lesions volume or poor treatment response (n= ), and chemosensitive relapse (n= ). most patients had several risk factors. disseminated disease patients were also evaluated according to prognostic score by r.ladenstein et al. highdose busulfan-melphalan followed by autologous stem-cell transplantation (hdt/sct) was used. results: the median observation time was (range - ) months. the -year overall (os) and event-free (efs) survival were % and %, accordingly. most important outcome predictors were inadequate local control in chemoresistant cases, a primary tumor volume more than ml, more than one bone metastatic site, bone marrow involvement and additional lung metastases. according to prognostic risk score in disseminated disease esft patients identified three groups with -year os rates of % for score ≤ ( patients), % for score to ( patients), and % for score ≥ ( patients), (p< . ). conclusions: while bu-mel hdct with auto-hsct may still be a feasible option with acceptable toxicity for chemosensitive patients with inadequate local control and some primarily disseminated cases it is ineffective in primary resistant or very high-risk metastatic patients. disclosure: nothing to declare efficacy of tandem high-dose chemotherapy with autologous hematopoietic stem cell transplantation in the treatment of infant embryonal brain tumors day + (range, - ), after the second auto-hsct was day + (range, - ). two-year overall survival (os) was % and disease free survival (dfs) was %. dfs was significantly better among patients with mb ( %) and pnet ( %) in compared to children with etmr ( %), pb ( %) and atrt ( %), (p= , ). dfs in patients who received tandem auto-hsct was % in compare to infants who received only one auto-hsct ( %), (p= , ). complications grade (according to common toxicity criteria ) were observed in % of cases. conclusions: employment of tandem hdct with auto-hsct in primary infant embryonal brain tumors may be a feasible option for patients after induction treatment. both conditioning regimens had acceptable toxicity. all patients who had tandem hdct with auto-hsct had better os ( %) in compare with single hdct ( %). patients with mb and pnet had better prognosis with os % and %, respectively, in compare with other embryonal tumors. disclosure: nothing to declare background: metastatic extra ocular retinoblastoma is carrying a poor prognosis. therapeutic intensification with high-dose, marrow-ablative chemotherapy and autologous hsct has been explored, but its role is not yet clear. this study aimed to evaluate the survival outcome of patients with extraocular retinoblastoma post autologous stem cell transplant, treated at single center methods: this is a retrospective study included all patients with metastatic extraocular retinoblastoma (stages a and b) that underwent autologous hsct at the children cancer hospital egypt (cche) from november to july , the treatment protocol was adopted from cog protocol (aret ) as all patients received cycles induction chemotherapy followed by consolidation myloablative conditioning, cem (vp . mg/m x , melphalan: mg/m x , carboplatin: mg/m x ) and stem cell rescue. patients data including initial disease characteristics, transplant data, and survival outcomes were collected and analyzed results: a total of cases were included with median age of . years, and male to female ratio . . nine patients ( %) were initially presented by extra ocular disease, while patients were presented by intra ocular disease and progressed to metastatic disease. according to cog staging of extra ocular disease, patients had stage a, and were stage b ( of them had trilateral disease). after induction therapy, ( %) showed complete response and ( %) had ≥ partial response. with average cd count of x / kg, the median time to anc and platelet engraftment were days and days respectively, and there was no transplant related mortality. post-transplant radiotherapy was given only to patients. with median duration of follow up of months, the overall and event free survival rates of whole patients were . % and . % respectively conclusions: high dose chemotherapy and stem cell transplantation is a promising potential curative option for patients with metastatic extra ocular only two primary gf ( . %) occurred, both without dsa. patients developed a primary pgf ( %). -years os, years pfs and -year nrm were analyzed according to the presence of dsa in comparison with negative population. no statistically difference was found. no impact of the presence of dsa on the risk of developing gf and pgf was revealed. major outcomes of transplant was analyzed separately in patients with pgf and good graft function (ggf). -years os, -years pfs and year-nrm in ggf and primary pgf populations were % vs % (p< . ); % vs % (p< . ), % vs % (p= . ), respectively. conclusions: the presence of low level of dsa in the absence of desensitization doesn't correlate with the risk of developing gf and pgf. patients who experienced a pgf had worse outcomes in comparison with patients with ggf. disclosure: nothing to declare. the impact of hla-dpb mismatch in t-cell replete unrelated donor allogeneic stem cell transplantation background: high resolution matching of donor-recipient hla improves outcome in allogeneic stem cell transplants. matching for hla-a, -b, -c, -drb and -dq is mandatory in our transplant centre, to identify / or / matched unrelated donors. high resolution matching for dpb has been added over the last - years. however, the role of dpb matching is not yet clearly defined. methods: in this study, we retrospectively analyzed the impact of hla-dpb matching on the outcome of t-cell replete allogeneic hematopoietic stem cell transplants with cya/mtx-and without atg as gvhd prophylaxis in patients with hematological malignancies at oslo university hospital between and . patients with an unrelated donor fully matched ( / ) at hla-a, -b, -c, -drb and -dqb loci were included. further, patientrecipient pairs were also fully matched on dpb ( / ); had permissive and had non-permissive mimatches of one or two dpb alleles. the three groups were comparable with respect to diagnosis, gender, age, cytomegalovirus serostatus and conditioning regimen. results: cumulative incidence of relapse at years were significantly higher in the dpb matched pairs compared with the permissive and non-permissive mimatched ones, at % vs % and % (p< . ) respectively. relpase free survival and overall survival were superior in the nonpermissive and permissive dbp mismatched groups vs the fully matched, at % and % vs % (p= . ) and % and % vs % (p= . ) respectively. no difference in frequency of acute gvhd grade ii-iv between the three groups were found; dp match %, permissive mismatch % and non-permissive mismatched % (p= . ). neither was there a difference seen in gvhd grade iii-iv; % vs % vs %, respectively. finally, there were similar outcomes between the three groups regarding chronic gvhd and trm. in corrected multivariate analysis, only dp matching had significant influence on mortality and survival. conclusions: our results show a favorable relapse free and overall survival following a mud allotransplant with a dpb permissive or non-permissive mismatched donor compared to a fully dpb matched. this is likely due to an increased gvl-effect in dpb mismatched groups without the counterbalance of increased acute gvhd and trm. disclosure: nothing to declare p a haploidentical may be a better choice than a female genoidentical donor to transplant a patient with high risk acute myelogenous leukemia in first remission norbert gorin , myriam labopin , didier blaise , goda choi , gerard socie , jean henri bourhis , fabio ciceri , emmanuelle polge , arnon nagler , mohamad mohty china, the first affiliated hospital of soochow university, hematology, suzhou, china background: despite the incidence of leukemia increases with age, currently the geriatric population is poorly represented in the standards of care concerning that older adults undergoing hematopoietic cell transplant (hct) may experience higher transplant-related mortality (trm). previous studies have demonstrated that donor age is vital for older patients by affecting trm and survival. accordingly a relevant question is whether outcomes can be improved with a younger hla-haploidentical offspring donor rather than an older hla-matched sibling (msd). in our previous multi-center report under atg+g-csf based protocol for haplo hct, offspring donor is correlated with lower trm and higher leukemia free survival (lfs) as compared with older msd in subgroup analysis for recipients > years although it did not reach statistical significance. on the contrary, in a recent report from ebmt and cibmtr under ptcy modality for haplo hct, among patients aged to years, despite lower chronic graft-versus-host-disease (gvhd), graft failure, trm, and overall mortality were higher after transplant from offspring compared with an msd although there were differences in transplant platforms between the groups. methods: we extended our multi-center dataset and a matched pair analysis was performed. outcomes of acute leukemia patients (>= years) transplanted in cr / cr who received hct from offspring (n= ) or msd (n= ) between jan, and june, present in the multi-center database were analyzed. because the patient population was small, a : ratio matched pair analysis was implemented with the following matching factors: underlying disease (acute myeloid leukemia, acute lymphoblastic leukemia), disease status (cr /cr ), age and sex of patients, year of transplant, blood group incompatibilities, and sex of donor. results: we were able to match offspring with msd patients. the two matched groups were comparable in baseline characteristics except for donor age due to the family relationship. all patients achieved myeloid recovery with a median time of d and d for msd cohort and offspring group (p= . ). the d platelet recovery rate was % in both groups. the cumulative incidence of grade ii-iv acute gvhd in msd cohort was significantly lower than in offspring group ( % vs %, p= . ) while the incidence of chronic gvhd in msd cohort was significantly higher than in offspring group ( % vs %, p= . ). the -year trm ( % vs %, p= . ) were significantly lower in offspring-hct compared with in msd-hct and relapse incidence was comparable ( % vs %, p= . ). as a result, the -year overall survival ( % vs %, p= . ) and lfs ( % vs %, p= . ) ( figure ) were significantly higher in offspring-hct compared with in msd-hct. in a multivariate analysis, msd-hct remained a significant factor for decreased overall survival (hr . ( . - . ), p= . ) by increased trm ), p= . ) in comparison with offspring-hct. conclusions: these data favor a young offspring over an older msd in patients > years. the current analyses confirm non-hla donor characteristics, rather than hla disparity, predominantly influence survival in older acute leukemia patients. validation of these findings requires a prospective trial wherein the transplant platforms can be closely matched. [[p image] . figure . lfs in offspring-hct compared with in msd-hct ( % vs %, p= . )] disclosure: nothing to declare. impact of sibling donor-recipient sex combinations on rejection after hla-matched bone marrow transplantation for severe thalassemia cure children foundation, florence, italy, sankalp india foundation, bangalore, india, people tree hospitals, bangalore, india, south east asia institute for thalassemia, jaipur, india, pakistan institute of medical sciences, islamabad, pakistan, central asiri hospital, colombo, sri lanka, nawaloka hospital, colombo, sri lanka, kokilaben dhirubhani ambani hospital, mumbai, india background: severe thalassemia (st), i.e. a thalassemia syndrome with inability to keep spontaneous hemoglobin > g/dl, is a common indication for bone marrow transplantation (bmt) in children in the middle east and south east asia. sex mismatch has been associated with increased risk of solid organ rejection but is not generally considered an important transplant-associated risk factor in the context of fully matched sibling bmt for st. methods: a total of consecutive sibling bone marrow transplants carried out between january and april after conditioning with busulfan ( mg/kg oral, not adjusted to serum levels) and cyclophosphamide ( mg/kg) ( patients) in addition to either thiotepa ( mg/kg) ( patients), or anti-thymocyte globulin (genzyme mg/ kg or fresenius mg/kg on days - to - ) ( patients) and fludarabine mg/m ( patients) were analysed. all cases received cyclosporine and methotrexate or mycophenolate mofetil as gvhd/rejection prophylaxis. in the thiotepa group methylprednisolone at . mg/kg/day was also used during the first days after bmt (lucarelli protocol i). bone marrow was the source of hematopoietic stem cells in all cases, in the atg group it was g-csfprimed ( μg/kg/dose twice daily for to days prior to harvest). all patients were considered low risk based on liver size < cm from costal margin and age less than years (median . years, range . to . ), all sibling pairs where hla-compatible. results: [[p image] . sibling donor-recipient sex combinations.] the lowest rejection rate ( %) was observed in the sister to sister (s s) group of cases, followed by brother to brother (b b) group of cases with %. in the sister to brother (s b) group of cases, rejection rate was %, and % in the brother to sister (b s) group of cases. on univariate analysis the only significant difference at the p . level by log rank test was b s vs. s s groups (rejection proportions of % and % respectively). interestingly, all patients with rejection and persistent pancytopenia were female recipients of male grafts. conclusions: even though several preparative regimens were employed over an -year period, our data suggests that sex mismatch among compatible siblings should be considered as a relevant variable related to bmt decisionmaking. we also recommend to consider autologous back up hematopoietic stem cell collection and storage in sibling sex mismatched transplants, particularly in brother to sister bmts. same-sex fully matched related bmt for severe thalassemia might be the best scenario in which reducedintensity preparation strategies aiming at maximizing fertility preservation might be explored. disclosure: nothing to declare. outcomes of t-cell replete hematopoietic cell transplantation from mismatched related or unrelated donors using high dose post-transplant cyclophosphamide based gvhd prophylaxis background: high dose post-transplant cyclophosphamide (ptcy) based gvhd prophylaxis overcomes immunological barriers in hla mismatched donor transplantation. ptcy has been adopted in many centers as de facto standard for hct from haploidentical donors (haplo hct). it's use in mismatched unrelated donor transplant (mmud hct) is less well established. methods: we analyzed retrospectively outcomes of contemporary cohorts of patients who underwent haplo hct or mmud hct using ptcy + cyclosporine (csa) and mycophenolate mofetil (mmf) at our center. we compared these outcomes with outcomes of cohorts of patients who underwent hct from matched unrelated donors (mud) using atg based gvhd prophylaxis or matched sibling donor (msd) with csa and mmf. patients and donors were considered matched if they background: hla-alloantibodies are a major risk factor for engraftment failure in allogeneic hematopoietic stem cell transplantation (hsct). particularly, complement fixing, donor specific antibodies were shown to be associated with early engraftment failure. prospective antibody-screening, although not currently required for donor search, could permit early identification of high risk patients for positive crossmatch. aim of this study is to set the basis for future applicability of antibody-screening-based definition of acceptable mismatches in donor selection, by creating a large prospective antibody-screening database of patients due to receive an hla-mismatched allogeneic hsct. methods: patients (n= ) diagnosed with mds/mps, nhl, mm, cll, cml, anaemia (aplastic anemia, hemoglobinopathies, pnh) and hl were prospectively screened for hla-antibodies whenever initial donor search indicated that no completely matched donor would be available. screening was performed with an elisa class i +ii screening assay. all positive screening cases were tested for antigen-specific antibody identification with luminex sab, and acceptable mismatches were defined. the results were subsequently considered in donor search and selection. we now report the frequencies of alloimmunization observed in these patients. results: the highest rate of alloimmunization was observed in patients from the anaemia disease group (overall . %) followed by those from the mds/mpn group (overall . %). the lowest immunization rates were observed in cll (overall . %) and hl ( . %) patients. alloimmunization rates for hla-class i antigens (p< . ) were significantly higher compared to hla-class ii antigens. overall hla-class i immunization rates ranged from . % to . %. hla-class ii immunization rates ranged from . % to . % (table ) . conclusions: our findings suggest that patients with high transfusion burden like anaemia and mds/mpn patients have the highest risk of hla-alloimmunization with . % and . % anti-hla prevalence rates, respectively. analysis of follow-up data, will enable us to confirm whether prospective definition and consideration of acceptable mismatches in donor selection may lead to similar engraftment failure rates between immunized and non-immunized patients undergoing hlamismatched hsct. background: mothers displaying a persistent fetal microchimerism (fm) proved to be the most suitable donor in t cell-depleted haploidentical stem cell transplantation (hhsct) in children. we presumed that fetal cells leave an imprint in the mothers' immune system which positively affects recognition and elimination of malignant cells in the child by maternal effector cells. distinct killer cell immunoglobulin-like receptors (kir)/hla constellations are not only associated with reduced relapse rates after hsct in children, but also supposedly influence the establishment of an fm. methods: after approval by the local irb and obtaining informed consent, we initiated a protocol to elucidate the factors that influence the establishment, persistence and effect of fm. we established a digital droplet pcr (ddpcr) protocol to determine the fetal microchimerism. for differentiation between maternal and fetal cells, biallelic short insertion/deletion polymorphisms were used. kir and hla-c genotyping was performed by ssp-pcr. parental nk cell alloreactivity against the respective leukemic blasts and kir phenotyping were analyzed by flow cytometry. results: we analyzed parents, whose children were treated for hematological diseases at the university medical center hamburg-eppendorf. a fetal microchimerism was detected in % of the mothers. the amount of fetal cells varies between individuals ( x - - x - ). we observed a positive correlation between a persisting fm and hla-c homo-and heterozygous mothers along with a maternal cen a/b and cen b/b genotype. additionally, fm positive mothers showed a higher surface expression of the hla-c respective receptors kir dl /s . the percentage of alloreactive maternal nk cells against fetal cells was higher compared to paternal nk cells; while alloreactivity of fm positive maternal nk cells was similar to nk cells from fm negative mothers. conclusions: persistence of fm was more frequent in mothers carrying at least one hla-c allele and a centromeric b/x motif. phenotypically, fm positive mothers had higher expression of kir dl /s indicating a role of these receptors on the persistence of an fm. in vitro, maternal nk cells showed a higher alloreactivity compared to paternal nk cells. there was no difference in alloreactivity whether the mothers were fm positive or negative, suggesting other mechanisms are responsible for the superior outcome in transplantation from fm positive mothers. disclosure: nothing to declare background: although there have been significant improvements with conventional therapies in beta thalassemia major, hematopoietic stem cell transplantation is only curative therapy. related donors are preferred to diminish transplant risks. in lack of identical related donor, identical unrelated donors are second best choice. in this study, thalassemia major patients transplanted from unrelated donors (mud) were compared with thalassemic patients transplanted from relative donor (mrd) retrospectively. methods: patients who were transplanted between june and december in bahçelievler medical park hospital pediatric bone marrow transplantation unit were evaluated retrospectively. all patients were classified according to pesaro risk classification. thirty four of received busulfan, fludarabine, cyclophosphamide, thioteopa for conditioning, patients received myeloablative preparation regimen with treosulfan, fludarabine, thiotepa, cyclophosphamide. all patients were given atg, cyclosporine and methoteraxate for gvhd prophylaxis. the patients were compared in terms of acute complications in first days, engraftment, chimerism, acute and chronic gvhd after transplantation. results were evaluated with ibm spss statistics (ibm spss) program. results: a total of patients, ( . %) male and ( . %) female, aged between and years (median years) were evaluated. patients were evaluated in two groups as "mud" (n = ) and "mrd" (n = ) groups. there was no difference between groups about given stem cells (mud , ± , x /kg and mrd , ± , x / kg). neither significant difference between different pesaro risk groups in terms of developing acute and chronic gvhd and nor decreased chimerism were detected. neutrophil engraftment time ( , days) in mrd group was significantly longer than mud group ( , days) (p = . ) but no difference between platelet engraftments were observed. gvhd ratio was . % in mud donor group and . % in mrd group and no statistically significant difference was found(p> . ). the incidence of engraftment loss in mud group was . % and . % in the mrd group, and there was no statistically significant difference (p> . ). the rate of decreased chimerism was found to be significantly higher in the mrd group ( %) than in the mud group ( . %) (p: . ; p< . ). the survival rate was . % in the mud group and . % in the mrd group. the disease-free survival rate was . % in the mud group and % in the mrd group. the disease-free survival of mud group was significantly higher than mrd group (p: . ). conclusions: in our study, transplant related complications and success of transplantation with both mud and mrds were found to be similar. it is promising for mud transplantations to found lower decreased chimerism and similar os and dfss. based on these results, it was concluded that hsct from non-family donors, especially for patients incompatible with chelation therapy and had organ damage, transplantation from unrelated identical donors can be a good choice. although the results of our study seem promising, larger patient groups and prospective clinical trials are required. disclosure: nothing to declare background: use of g-csf stimulation of bone marrow (bm) donors is beneficial in many aspects; it can enhance tnc yield, but also have an immunomodulatory effect on donor t cell function, particularly invariant natural killer t (inkt) cells expansion as well as apcs. we analyzed outcomes of consecutive patients receiving bone marrow from hla-haploidentical donors that were stimulated with g-csf prior to harvest. methods: in the time period between / and / , patients received bone marrow from donors stimulated with ug/kg bw of g-csf on days - , - and day of bm collection. four patients ( %) received myeloablative (bucy) conditioning, one ( %) received tec ric conditioning while ( %) received nma ("baltimore") conditioning. all patients received posttransplantation cyclophosphamide (ptcy) on days + and + , tacrolimus and mmf were started on day + . for patients donors were fathers, mothers, siblings and children. results: median age was years ( - ), there were female and male patients. twelve patients had aml, hodgkin lymphoma, all, mds, nhl and cml. median number of infused tnc in graft was . x /kg bw ( . - . ) and cd + cells . x /kg bw ( - . ) . after median follow up of days (range - ), overall survival was %, with median survival of months. engraftment was established in ( %) patients, ( %) had primary rejection and patients ( %) died in sepsis prior to engraftment. of patients that engrafted, further ( %) patients had secondary rejection, two of them were transplanted again from a haploidentical donor, both using pbsc as a source of graft. median time to neutrophil recovery (anc> ) was days ( - ), while median time to platelet recovery (plt> x /l) was days ( - ) in evaluable patients. cumulative incidence of agvhd ii-iv was . % ( % ci, - );of note is that of patients that developed agvhd only one had grade iii, while remaining patients had grade ii. cumulative incidence of cgvhd requiring treatment was . % ( % ci, [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . cumulative incidence of relapse was . % ( % ci, - ) and trm was . % ( % ci, - ). conclusions: the use of g-csf mobilized bm graft in the hla-haploidentical setting with ptcy has proven to be useful to us, not only in terms of tnc yield which was more than satisfactory and contributed to adequate hematological recovery, but also in the excellent control of both acute and chronic gvhd, with most patients developing agvhd of grade ii and only one grade iii (actually developed only after dli given for decreasing chimerism). comparative studies are of course warranted to prove benefit, but this data contributes to the growing body of evidence that indeed donor stem cell stimulation with g-csf has potentially powerful immunomodulatory effect. disclosure: nothing to disclose p other-relative donors as a reliable bank for allogeneic hsct in countries with culturally accepted cousin-cousin marriages: a two-year report from a pediatric center in iran background: although the optimal donors for patients undergoing allogeneic hematopoietic stem cell transplantation (allo-hsct) are fully-matched siblings, the cousincousin (consanguineous) marriages in some countries have extended the chance to find a matched donor for the hsctrecipient. in this study, an outcome analysis of transplanted patients receiving stem cells from their relatives other than siblings (other-relatives or non-sibling donors) is provided. methods: in this retrospective cross-sectional study, a two-year report of patients who received allo-hsct from their other-relative donors during september to september at the department of stem cell transplantation of children's medical center in tehran, iran is presented. the patients were followed up until st december . results: during this time period, patients underwent hsct (both autologous and allogeneic) at this center, of which cases received allo-hsct. out of allo-hsct recipients, the donors of stem cells for cases ( . %) were their other-relatives. the median (range) age at hsct was ( - ) years and the majority of patients were boys ( / , . %). according to disease class, the patients were most commonly involved with non-malignant hematologic diseases ( / patients, . %) (figure) . the source of hscs for most patients ( cases, . %) was peripheral blood and for only patients the source was bone marrow. the donors for patients were fully matched and only one patient received the hscs from a one-locus mismatched donor. hsct was successful in patients with most of them achieving full chimerism ( patients, . %) followed by those developing mixed chimerism ( patients, . %) and only one patient ( %) experienced graft failure. post-hsct complications included cmv infection in patients ( . %), other infections in ( . %), hemorrhagic cystitis in ( . %) and pres in ( . %). acute gvhd occurred in patients ( . %) and chronic gvhd in ( . %). death occurred in cases and of them were transplant-related, while was due to disease relapse and due to graft failure. the median of overall survival was ( - ) days. conclusions: the likelihood of receiving hscs from an hla-matched other-relative donor in one-thirds of children undergoing allo-hsct, with comparable outcomes to sibling and unrelated donors (as evidenced in this study compared with other studies), introduces family bank as a reliable source for pediatric allo-hsct in countries with culturally accepted cousin-cousin marriages. hence, for transplant physicians, parental consanguinity would be an indication of an extended search for a potential matched donor among the patient's family. [[p image] . distribution of patients according to disease and disease class] disclosure: nothing to declare. abstract already published. update on the hla frequency distribution of the portuguese bone marrow donor registry eduardo espada , dário ligeiro , hélder trindade , joão forjaz de lacerda frequency distribution varied throughout the country, allowing for analyses of molecular variance and generation of relatively geographically accurate graphical representations of genetic distances between regions and districts. conclusions: with the most recent hla analysis of the portuguese bone marrow donor registry we were able to extrapolate high-resolution haplotype frequencies from the most common low-resolution hla-a/-b/-drb haplotypes (corresponding to % of the estimated haplotypes at that level), which will lead to an optimization of its use, hopefully limiting the time between donor search and allogeneic hematopoietic stem cell transplant. disclosure: nothing to declare. abstract already published. abstract already published. unmanipulated haploidentical donor transplantation compared to identical sibling donor had better antileukemia effect for refractory/relapsed acute myeloid leukemia in not remission status background: patients diagnosed with saa with no sibling donors and who are refractory to immunosupression are candidates to hematopoietic stem cell transplant using alternative donors. haploidentical donor transplants has been reported using cyclophosphamide (cy) post stem cell infusion as immunephrophylaxis. the present study has the objective of evaluating overall survival and engraftment rates after haploidentical stem cell transplant for saa in a reference center. methods: saa adult patients (≥ yo) received hsct from haploidentical donors from de january/ to august/ . median age was y ( - ); donor was the father in six, mother in five and a brother in four cases. stem cell source was marrow in cases ( %). conditioning: patients ( %) received cy mg/kg, fludarabine mg/m² e tbi cgy. the remaining received the same drugs but radiotherapy dose varied from - cgy, all them received immunephrophylaxis with post transplant cy mg/kg, cyclosporine and mmf. median of infused cells (tcn) was , x /kg ( , - , ). results: eight patients engrafted ( %). among seven graft failures four received a second haploidentical transplant and one received an unrelated donor transplant as salvage regimen. two patients were successfully rescued after the second haplo and the others died from infectious complications. three years overall survival was %. death causes included: five infections and two lung hemorrhage. median survival was days ( - ). no patient had acute graft-versus-host-disease (gvhd) and one patient had mild c-gvhd. conclusions: haploidentical transplant was feasible as therapy for saa refractory to immunessupression with an overall survival of % in this cohort. graft failure however is still a problem to be addressed in this setting. disclosure: no disclosure stem cell mobilization, collection and engineering p abstract already published. key performance and quality indicators for a successful bone marrow collection marco sampaio , , ana salselas , fátima amado , filipa bordalo , sérgio lopes , catarina pinho , susana roncon and one from ecc (staphylococcus spp.)presented positive microbiological results. conclusions: bm collection is a challenging strategy because it is a one-time procedure and manually operatordependent technique; simultaneously it is more difficult to control the final cellular content of the bm, which is a risk for donor volume depletion. bm collection is feasible even with donor and recipient weight difference. poorer performance may be found when higher tnc are requested. we respond efficaciously when the request is between and * tnc but we fail to accomplish higher tnc values. we must emphasise that icc tnc demanded was generally lower than ecc. deciding the appropriate tnc for each patient remains a dare and an art. disclosure: nothing to declare. impact of adding plerixafor to mobilization protocol in the immune reconstitution of vδt cells after autologous hematopoietic stem cell transplantation efrat luttwak , , yael chava cohen , , odelia amit , , irit avivi , , svetlana trestman , , esti rom , , rinat eshel , , ram ron , tel aviv medical center, tel aviv, israel, sackler faculty of medicine, tel aviv university, tel aviv, israel background: multiple myeloma has remained an incurable disease even in the era of novel therapies. front line treatment typically comprises of induction chemotherapy with - cycles of a bortezomib-based regimen, stem cell mobilization, and harvesting of peripheral blood stem cells (pbsc) by apharesis, followed by high dose melphalan with hct. while brotezomib-based induction regimens have demonstrated no adverse impact on hematopoietic cell harvest number and quality, no study analyzed the impact of timing of the last brotezomib dose prior to collection. in this study we aimed to determine the effect of the timing of the last dose of brotezomib before hematopoietic cell collection and the collection yield. methods: this was a single center historical prospective study, including all sequential newly diagnosed patients with myeloma between and that were given a bortezomib-based induction therapy (≤ cycles) followed by pbsc collection. we excluded patients who either received st line vtd-pace or lenalidomide-containing regimens. peripheral blood cd + cells were measured on the day of collection. patients with cd + levels of > cells/ microliter started collection on the same day, while those with lower levels were given plerixafor. we performed regression analyses to analyze the impact of a variety of precollection factors, including days from last bortezomib therapy on the collection yield. results: we identified patients who fulfilled the inclusion criteria, table. median time from last dose of brotezomib to first leukapheresis was (range, - ) days. a statistically significant correlation was found between the days from last dose of brotezomib and both the first collection day-cd + cells/kg (r= . , p< . ), and the total collected cd + cells/kg(r= . , p= . ), figure. the optimal cutoff point as indicated by the roc curve was . days according to collection success with sensitivity of % and specificity of %, youden´s index . . in multivariate analysis included other factors affecting collection yield (age, gender, status of disease at collection, and prior radiation) -timing of last dose of brotizomib remained significantly associated with the total collected cd + cells/kg (p= . ). increasing age, female gender, and prior radiation were associated with lower collection yield (p= . , . , . , respectively). based on this, we developed a model to predict the total collected cd pos cells = . + . (timing in days of last dose of brotezomib) - . (age) - . (if female) - . (≥pr) - . (if prior radation). conclusions: timing of last dose of brotezomib is an important factor for predicting a successful collection. a washout period of days is associated with a better collection yield. these results should be further validated in a prospective study. age (median, range) ( - ) gender -male (%) ( ) prior radiation treatment (%) ( ) disease status at collection (%) ≥pr - ( disclosure: nothing to declare p mobilization with plerixafor in "poor mobilizer" related and unrelated donors of hpc-a in case of failed mobilization with g-csf background: in the allogeneic hpc transplantation, both from related and unrelated donors, the most commonly used source is peripheral blood after mobilization with g-csf. it is however known that about % of donors are "poor mobilizers"; the rescue strategies are: a third apheretic collection; bone marrow donation. methods: in - in italy a procedure to be adopted in case of failed mobilization of peripheral blood stem cells has been defined and shared between ibmdr, cnt (transplant national center) and cns (blood national center) and the scientific societies simti, sidem and gitmo, using plerixafor, a selective reversible antagonist of the cxcr receptor with its binder (the stromal derived factor sdf- ), in combination with standard g-csf dose. moreover since , in accordance with this protocol, the competent authority (aifa) has extended the registration of plerixafor (law no. / ), also for the mobilization in "poor mobilizer" healthy donors. finally, in the protocol was extended to "poor mobilizer" family donors, making management equivalent in related and unrelated donors. at the time of the donor´s informed consent for the donation of hpc, the hypothesis of the lack of mobilization or inadequate collection was illustrated and the possible actions proposed as "back-up donation" were anticipated. failed mobilization of cse has been defined as the presence of one of the two criteria: a number of cd + circulating on peripheral blood lower than /μl on the th day of stimulation ( d), or the collection of cd + < . x /kg weight of the recipient at first apheresis. in these cases, a single dose of plerixafor is administered subcutaneously by health professionals under medical supervision, . mg/kg of body weight, - hours before the start of apheresis. in case of use plerixafor due to failed mobilization of hpc-a or collection of an inappropriate number of cd +, the notification is made by the collection center to ibmdr (for both family and non-family donors), and to the recipient transplant center : both donor and recipient express their consent; finally once the collection is completed, the collection center informs ibmdr, which in turn notifies cnt/cns/simti/sidem/gitmo. any adverse reactions/events are notified in real time, based on the sop specifications and current regulations. results: since the introduction of the national protocol, donors ( unrelated donors and related donors) were treated, presenting at least one of the two inclusion criteria (cd < /μl at d or cd < x e /kg after first collection)after use of plerixafor in all donors, the required dose of cd was obtained to ensure successful transplantation, with a sufficient increase in the cd + cells. no side effects or adverse reactions related to the administration of plerixafor occurred. conclusions: in cases of failed mobilization in the related and unrelated donor, the use of plerixafor according to the methods described in the shared protocol between ibmdr, cns, cnt, simti, sidem, gitmo, proved to be safe and effective. this protocol emphasizes the great value of the sharing of procedures between the register, institutions and scientific societies, ensuring the supervision of the process and the protection of the donor and recipient. disclosure: nothing to declare background: autologous stem cells transplantation (asct) is an effective treatment option for young patients with multiple myeloma (mm). a minority of patients may still experience untoward toxicity due to delayed engraftment. thus, the current policy in many centers is aimed to increase the target dose of collected cd + cells up to an "optimal" level of x /kg per procedure. therefore, an ideal mobilization, aimed to collect to cd + cells/kg in one apheresis, should achieve a number of circulating cd + cells > /mcl (very good mobilizers). plerixafor may help to maximize the cd + collection but its use is limited by high cost. we carried out a retrospective analysis aimed to predict the quality of mobilization and develop an algorithm to optimize both timing of collection and use of plerixafor. methods: we retrospectively collected data from mobilization procedure performed in our center between and for mm. all received the same mobilization protocol with cyclophosphamide (range - gr/sqm) and g-csf mcg/kg from + . cd + cell count was started when white blood cells (wbc) count exceeded x /l. patients were excluded from this analysis if ) showed a cd + count > /mcl (target achieved at first day count) and/or ) cd + count on second day was missing and/or ) plerixafor was administered on first day according to previous policies. sixty-eight patients were evaluable for the study. univariate and multivariate logistic regression analysis to study ccd + kinetics and assess predictors impact on mobilization was carried out. ratio cd +/wbc in first day count, gender, disease category and time from mobilization chemotherapy were also included results: among the patients included in the analysis, the threshold of cd +/mcl cells on the second day was reached by ( , %) of patients (groupa) whilst the remaining ( , %) failed the target (groupb). median (range) wbc x /l and cd + /mcl counts in group a and b were , ( - , ) and , ( , - , ), , ( ) ( ) ( ) ( ) ( ) ( ) ) and , ( , - , ) respectively, with a statistically significant differences among group (mann-whitney p= , and p= , respectively). only cd + /wbc ratio and cd + /mcl on first day count had an impact on kinetics and optimal mobilization. logistic regression model highlight cd +/mcl (or= , ; % ci: , - , ) on first count as an independent predictor of second day optimal mobilizer, with auc of . % ( , ) in roc analysis. two cd + thresholds were then calculated: < , /mcl (ppv , ; npv , ) that identified poor mobilizer, and ≥ , /mcl (ppv , ; npv , ) that exclude probability to fail on second day. for those with a cd + count between , - , the cd +/wbc ratio (or= , , % ci: , - , ) was a predictor of optimal mobilization (auc , ; , - , ); cut-off value was , (sensibility , ; specificity , ) conclusions: assessment of circulating wbc, cd + and their ratio at wbc recovery in a chemo-based mobilization is a valid tool to manage the collection strategy and the on-demand use of plerixafor. we have developed an algorithm aimed to the use of plerixafor to both rescue poor mobilizers and boost cd + count in intermediate mobilizers. background: successful autologous stem cell transplantation (asct) requires the infusion of a sufficient number of hematopoietic stem cells (hscs). peripheral blood (pb) is the most commonly used source of hscs, therefore, it is important to optimize methods used to mobilize the hscs. the most clinically used chemotherapeutic agents for effective mobilization are cyclophosphamide and etoposide. recent published studies suggest that etoposide has a better mobilization effect than cyclophosphamide even at lower doses, but it is not clear why this difference occurs. in this study, we tried to determine whether there is a difference in the mechanism of mobilization between cyclophosphamide and etoposide. methods: first, in order to confirm the clinical data for efficacy and toxicity of mobilization, we retrospectively analyzed the data of patients who were diagnosed with lymphoma and performed mobilization using cyclophosphamide or etoposide from january to december . second, mesenchymal stem cells (msc) were primarily cultured from the healthy controls, then treated cyclophosphamide or etoposide at a concentration of % inhibition of cell growth, and cytokine analysis was performed to identify cytokines known to be associated with mobilization. third, mobilization mouse model using cyclophosphamide or etoposide was generated, total blood was collected at the time of hscs collection, and cytokine and network analysis (using ingenuity pathway analysis) was performed. results: the mobilization yields for cyclophosphamide or etoposide were analyzed. etoposide miblized a significantly higher median number of cd +cells than cyclophosphamide. the rate of successful or adequate mobilization was also significanctly higher for etoposide in univariate and multivariate analysis (table ). in the analysis of toxicity during mobilization, the incidence of neutropenic fever was higher in the cyclophosphamide group (p = . ). during mobilization, cyclophosphamide maintained lower wbc counts than etoposide and showed a large increase in wbc counts at the start of collection ( figure ). the cumulative dose of cyclophosphamide or etoposide in patients who underwent autologous stem cell transplantation did not affect leukocyte (anc> /microl or platelet (plt > k/microl) engraftment. in msc treated with etoposide at a concentration of % inhibition of cell growth, il- , which is a cytokine that promotes hematopoietic stem cell mobilization, were shown a statistically significant increase (figure ). in the mouse model of mobilization (figure ), the levels of kc, one of the il- homologues in mice, had significantly increased in the etoposide-treated group compared with the levels in the cyclophosphamide-treated group. the levels of other il- homologues, mip- and lix, also showed increases in the etoposide-treated group compared with those in the cyclophosphamide-treated group; these differences, however, were not statistically significant (figure ). network analysis based on in vivo cytokine results identified that etoposide could promote mobilization in association with matrix metalloproteinase as compared to cyclophosphamide ( figure ) . conclusions: etoposide has a higher mobilization efficacy when compared to cyclophosphamide, which could due to the different mechanisms of mobilization through the elevation of il and the activation of matrix metalloproteinase associated therewith. background: high-dose chemotherapy followed by autologous blood stem cell transplantation (asct) is a standard therapy for wide range of hematologic and solid malignancies. although various methods have been introduced to improve the peripheral blood stem cell (pbsc) mobilization, autologous stem cell collection (ascc) is not successful in every patient. furthermore, even if the ascc is complete, not all of them lead to asct. we evaluated the result of ascc and actual use of pbsc grafts in current practical setting. methods: we retrospectively reviewed the all consecutive ascc procedures performed at the department of oncology in asan medical center, seoul, korea, between january and october . the targeted number of background: fanconi anemia (fa) is a rare inherited genetic bone marrow (bm) failure syndrome. while abnormal bm cells production occurs very early in life, the usual age of diagnosis is - years old. gene therapy (gt) might be an alternative to hematopoietic stem cells (hsc) transplantation, but harvest a large number of autologous hsc remains a challenge. we started a mobilization assay, fancomob, to evaluate the safety and the efficacy of fa patients' mobilization with granulocyte-colony stimulating factor (g-csf) and plerixafor. this study is part of the fa's european gt project "eurofancolen". methods: four patients with fanca mutations following the inclusion criteria were selected before pancytopenia. to note, fa was diagnosed before clinical manifestation through family screening. they received subcutaneous injection of g-csf ( μg/kg twice a day) from d- and plerixafor ( . mg/kg/day) from d- . the collection protocol targeted x e /kg of cd + cells, based on a predicted future weight in years. cd + cells and white blood cells (wbc) blood count were monitored tightly along the mobilization. patients with more than cd +/μl or between and cd /μl with a clustered aspect detected by flow cytometry after plerixafor injection underwent apheresis. cd + cells were immunoselected from the collection with clinimacs purification system (miltenyi) and cryopreserved for further gt manipulation. results: the mobilization target was not achieved for the first two included patients (fa years old and fa years old). the minimum value of cd +/μl required wasn't obtained for fa and the flow cytometry cd + aspect was not clustered for fa . cd + cells were mobilized quickly but transitionally after plerixafor injection for the last two patients, fa and fa , and years old respectively. both patients underwent apheresis procedures. no cd + cell rebound was observed after the apheresis was stopped.collection target was not achieved after four days of collection for fa . it was obtained the first day for fa (figure ). back-up for hsc transplantation could not be cryopreserved because of the limited number of cd + cells collected in patients fa and fa . no short-term adverse events were observed. following cd + immunoselection, cd + cell purity and recovery were poor but in the normal range described in the literature for fanconi patients ( - %)( table i) . one month after the collection hemograms were unchanged. conclusions: our clinical study offer new data showing that mobilization of fa patients with g-csf and plerixafor is safe and more efficient for younger patients, especially before clinical manifestations of bm failure. further efforts are required to establish an effective technic to purify the cd + cells after harvesting. basal cd + cell and platelets count are a strong predictor for mobilized peripheral blood stem cells on the th day of g-csf treatment in donors cryopreserved pbscs. this was associated with considerable efforts for the patients and caused additional treatment costs. on the one hand, having the therapeutic option of an autologous transplantation in the future may represent a clinically relevant advantage. however, a huge number of stem cell products are kept in storage for many years without ever been used for transplantation. our study provides cause for a careful reevaluation of the current clinical practice, which may help to focus more precisely on patients who actually benefit from a cryostored autologous stem cell graft. [[p image] . fig. : absolute numbers and relative distribution of stem cell grafts] disclosure: the authors confirm that there are no potential conflicts of interest to disclose, except the following: katharina kriegsmann: research funding from bms, celgene, and sanofi. patrick wuchter: membership in advisory boards for sanofi-aventis. reduction of dimethylsulfoxide (dmso) concentration from % to % in criopreservation of stem cells. influence on the kinetics of engraftment and tolerance to infusion patricia lopez-pereira , beatriz aguado , elena sola , carmen cámara , isabel vicuña , lorena vega , adrian alegre hospital universitario de la princesa, madrid, spain background: dmso is the cryoprotectant most used in the cryopreservation of stem cells. it is associated with adverse effects during the infusion of the product, its toxicity being proportional to the volume infused. the most common concentration used has been %, although recent publications report that reducing it to % leads to lower rate of side effects without impact on the product or the graft. we retrospectively analyzed patients recipients of autologous peripheral blood stem cell transplantation (hct) in our hospital from january to september . they are divided into two groups according to the concentration of dmso used in the freezing ( % until september or % since october ). the baseline characteristics of the patients, the infused product and the graft are shown in table . the cd count was performed by flow cytometry. all freezings were performed with a biological freezer for programmed controlled rate cryopreservation and stored in ultrafreezers at - ºc. results: both population groups are homogeneous. the t-test was used for statistical analysis. regarding the cd + variable, no statistically significant differences were observed (p = . ). neither for the variables leukocyte recovery and platelet recovery (p = . , p = . respectively). the difference in the variable viability is . units (ci %: [ . - . ]) and is statistically significant (p = . ) in favor of dmso %. regarding adverse effects, % (n = ) of the serious adverse reactions occurred in the % dmso group (hypotension and seizures). the mild and moderate ones were similar in both groups, most were mild nausea, vomiting and flushing. overall, no statistically significant differences were observed due to the low rate of adverse effects found. patients starting with until october , total of patients attempted collection of autologous pbscs, and poor mobilizers recieved plerixafor during first mobilization cycle. in total, patients required repeated mobilization cycles ( , %) of which were from the plerixafor group. in total patients recieved pleriksafor; females and males, median age ( - ) with following diagnoses: nhl, mh, multiple myeloma, neuroblastoma, nephroblastoma, sarcoma ewing and seminoma. of repeated mobilizations with plerixafor, patients ( , %) still failed to collect adequate transplant. in this period we had altogether unsuccessful mobilizations ( , % in repeated cycles, , % in total). this group of patients consisted of male and female patients, median age ( - ), diagnosis of nhl and failure to collect after leukapheresis procedures each. median number of leukapheresis needed for adequate collection was with preemtive plerixafor use, and in repeated mobilizations. conclusions: our expirience shows that preemtive use of plerixafor in poor mobilizers is efficient and has enhached success of the pbsc collections. due to drug high cost each institution needs to develop its own algorythm in management of poor mobilizers. the factors contributing to plerixafor mobilization failure still need to be elucidated. disclosure: nothing to declare. platelets recovered from mobilized leukapheresis units obtained from hla-haploidentical donors fulfill the criteria of a conventional hemocomponent and can be used for transfusion background: central venous catheter (cvc) related complications may lead to high morbidity and mortality. unlike cvc, peripheral cannulation offers a quick and inexpensive method for safe and non-traumatic vascular access (va) thus its utilization is strongly recommended whenever possible. the ultrasound (us) guidance for acquiring peripheral va is a useful tool for reduction or elimination of the need of using cvc for stem cells collection. we have made an attempt to introduce us method in our apheresis unit having no previous experience with us devices. the aim of the study was to measure the decrease of cvc insertions after introducing us and evaluate the quality of va by comparing average flow rate and confirming that the desired blood volume could be processed. methods: the theoretical education involved a free elearning course in peripheral ultrasound-guided va (pugva, usabcd, aarhus, denmark). subsequently, the personnel have implemented knowledge in practical training on gelatine and silicone phantoms and healthy volunteers. the practical activities also included a fiveday course in an apheresis centre with us-guided cannulation experience. the details concerning va were recorded, including va site, cannula size, average inlet flow rate, number of inlet pressure alarms reported by the apheresis device. the procedure details where traditional approach was applied i.e. palpable cannulation and cvcs have been collected. similarly, the necessary data for procedures where veins were assessed with ultrasound prior to apheresis were recorded. results: before introducing ultrasonography, stem cell collections have been performed in patients. of all these procedures, were accomplished with cvc ( %) and with peripheral va ( %). median cubital vein was the vessel of choice. out of the peripheral va procedures, ( %) were problematic, with or more inlet pressure alarms during every procedure. after the training stage, collection procedures were performed in patients. after introducing us we have observed a significant reduction of the number of cvc insertion required for successful apheresis from % to % (p= . ; chi-square test with fisher's exact). thirty one procedures were completed with peripheral va ( %). ultrasound device enabled cannulation not only the superficial veins but also for the deeper veins. cannulation sites included upper arm cephalic vein ( %), median cubital vein ( %), upper arm basilic vein ( %), median antebrachial vein ( %). out of the collections, were considered problematic ( %). no difference in an average flow rate was observed between procedures performed peripherally with and without ultrasound usage (p= . ; u mann-whitney test). conclusions: despite no previous experience in us guidance, we have successfully managed to introduce the new method in our apheresis unit. within months, we have reduced cvc usage threefold and as the personnel is gaining more experience, we suppose that the cvc usage may be reduced to episodic cases. despite slightly higher number of pressure alarms, all procedures with ultrasound guidance were completed as planned. ultrasound guidance is the most important tool for significant increase in peripheral va usage and may become the only option for patients with difficult va. disclosure: nothing to declare. abstract already published. donor blood management in healthy bone marrow donors: a retrospective single institution analysis background: over the last two decades mobilized peripheral blood stem cells (pbsc) have been established as the main source of stem cells because of improved engraftment and no necessity for hospitalization for the donors. nevertheless, due to the introduction of promising new transplant regimens, especially in the haploidentical transplantation setting bone marrow (bm) donations are regaining importance. although for both donation methods severe side effects are rarely described, bm collection is associated with considerable blood loss and hence symptoms of acute blood loss are commonly observed. therefore autologous blood are collected routinely in some institutions before donation. since the collected bone marrow amount depends on the target dose, the wbc yield in the product influences the required bone marrow volume. therefore we sought to investigate the relationship between collection volume, rbc volume removal, drop in hb and indications for blood transfusion. furthermore, we assessed wbc and cd +yields in relationship to various donor parameters and to product volume, in order to find prediction tools for collection volumes. methods: allogeneic bone marrow harvests from adult donors were performed at our institution and retrospectively analyzed. complete blood counts, serum iron and ferritin were assessed at work-up and weeks after donation. the bone marrow product quality including wbc, hematocrit (hct) and cd + cells were assessed by automatic hemocytometry and single-platform flow cytometry with ishage gating. results: besides local pain most of the side effects were related to blood loss. none of the donors received blood transfusions. the mean reduction of hemoglobin levels was . g/dl with a minimum hemoglobin level of . g/dl and a persistent anemia according to who criteria after weeks in . % and pathologically low ferritin levels in %. no donor presented symptoms with indication for blood transfusion. the median wbc concentration of the bm product was . /nl ( - % percentile: . - . / nl) the cd +cell concentration . /μl ( - % percentile: . - . /μl). in the linear regression analysis leukocyte counts of the donor before donation correlated significantly with wbc concentration in the product. thus in order to collect with % certainty the mio wbc which are a typical per-kg dose for an allogeneic recipient, . ml of bone marrow must be collected. collection volume did not systematically affect wbc or cd + cell concentration. conclusions: achieving high wbc yields in the bone marrow product allowed for collection of relatively modest bm volumes, thus protecting donors from excessive blood loss. acute adverse events were acceptable. optimization of perioperative management in healthy bone marrow donors may be achieved by good collection technique and reevaluation of wbc yields of each institution to calculate required bone marrow amount. the collection of autologous blood is not indicated. furthermore stringent pre-and postoperative hemoglobin management is predicted to limit adverse effects. disclosure: nothing to declare. donor-recipient weight ratio predicts successful stem cell mobilization on day four of gcsf mobilization results: in group median age of donor was years (range to years). in group median age of donor was years (range to years). table] . table ] elaborates other parameters analyzed between the two groups. one patient in group developed grade ii acute gvhd whereas patients in group developed acute gvhd grade ii-iv. at the last follow up no ( / ) patient in group has any symptoms of chronic gvhd whereas ( / ) patients in group have features of chronic gvhd (one extensive, one limited). conclusions: our observation suggests that upfront use of plerixafor in combination with gcsf modifies the graft favorably decreasing the risk of graft failure and graft versus host disease both acute and chronic. it also helps the donor by decreasing the total volume processed, amount of acd exposure and the duration of harvest. disclosure: none. impact of vitamin d levels on peripheral stem cell mobilization in autologous hematopoietic stem cell transplant recipients ferda can , zeynep arzu yegin , zubeyde nur ozkurt , orhun akdogan , lale aydın kaynar and total product cd + cell count [ . ( . - ) vs . ( . - . ); p= . ] were significantly higher in patients receiving chemotherapy+g-csf than g-csf only. the study group was divided into two groups based on peripheral cd (cut-off level: x /kg) as well as product cd levels (cut-off level: x /kg). vitamin d levels were found to be similar among these groups (p> . ). total product cd + cell count was found to be relatively lower in patients with vitamin d levels below μg/l [ . ( . - ) vs . ( . - . ); p= , ]. (figure ) conclusions: based on its effect on stem cells in in vitro studies, it may be considered that vitamin d may have a favourable impact on stem cell mobilization. statistically insignificant but relatively lower total product cd + cell count in patients who had lower vitamin d levels, which may indicate a role for vitamin d in stem cell mobilization, needs to be confirmed with larger studies. considering the high prevalence of vitamin d deficiency in the general population, the possible role of vitamin d in hematopoietic stem cell mobilization deserves further consideration. disclosure: nothing to declare background: one of the factors, affecting efficiency of autologous hematopoietic stem cell transplantation (autohsct) in hodgkin lymphoma (hl) patients is early recovery of graft, depending on cd + cell count and conditions of cell product cryopreservation and storage. it is well known, that dimethylsulfoxide (dmso), used for cryopreservation, can be cardiotoxic and cause diverse gastrointestinal, pulmonary, kidney, liver side effects and acute hemolysis. lethal for animals dose - mg/kg leads to life threatening arrhythmias and respiratory arrest. in order to improve dmso toxicity different ways of alternative cryoconservation modes are studied -lower dmso concentration ( % vs %), temperature - ˚c instead of ultra-low and washing of cell product. aim of the study is to evaluate the influence of dmso washing on hematopoietic recovery after autohsct. methods: retrospective analysis of hematopoietic recovery of relapse/refractory hl patients after autohsct was performed. mobilization regimen included second line chemotherapy for hl (dhap, begev, igev, ice) with consecutive g-csf administration. cd + cells were assessed, using -colour flow cytometer facs canto ii while cell collection, thawing and washing. cells with % dmso were stored at - ˚and washed in cases of transplantation with human albumin-dextran (reopolyglukin) and centrifugation. statistical data processing was performed by the χ method -pearson criterion; p -the level of significance of differences. results: patient groups had no difference in age, disease stage, gender, time from treatment start to autohsct and cd + cell count (p> , ). time to wbc recovery > х /л was - (median , ) days vs - (median , ) days, time to platelet> х /л recovery was - (median , ) days vs - (median , ) days in groups without and with cell washing respectively (p= , ). no difference in blood component consumption was observed (p= , ). in out of ( %) patients during cell reinfusion without washing nausea, vomiting, arterial hypertension was observed, no reactions were detected after cell washing (p = , ). conclusions: washing autologous mononuclear cells from cryopreservant dmso does not lead to low hematopoietic recovery rate after autohsct and can avoid toxicity, thus making autohsct more safe. disclosure: authors declare no conflict of interests. quality assesment of hematopoietic stem cells autografts after cryostorage, harvested using plerixafor background: the introduction of high-dose chemotherapy followed by transplantation of autologous hemopoietic stem cells (hscs) into the treatment program for multiple myeloma (mm) has significantly increased the frequency of achieving complete remissions and overall survival in patients. to obtain a sufficient amount of hscs, hematopoiesis is stimulated with granulocyte-macrophage factors (gm-csf) both in mono mode and after the administration of cytostatics followed by cytapheresis sessions (alone or after the cytostatics followed by cytapheresis sessions) . cryopreservation protocols are used to preserve cells in a viable state, followed by long-term storage of transplants in liquid nitrogen. however, in some patients it is not possible to obtain the necessary amount of hscs. the inclusion of plerixafor in standard mobilization schemes allows you to prepare the sufficient quantity of hscs in most patients with mm. methods: the study included samples of autografts from patients with mm from to (median . ± . ). hscs mobilization was performed on the background of unstable blood formation after high doses of cyclophosphamide g/m with the subsequent administration of g-csf at a dose of - μg / kg ( samples from patients) and with the addition of plerixaphor at a dose of . μg / kg ( samples from patients). immunophenotype viability of hscs in autotransplants after cryopreservation were determined by flow cytometry using the ishage protocol on a flow cytometer (facs cantoii, becton dickinson) by expressing surface markers of antibodies against cd , cd , cd , cd and staining with aminoactinomycin ( -aad). the colony-forming activity of hscs (cfu-cfu-mix, cfu-gm, cfu-g, cfu-m) was evaluated in methylcellulose (methocult h , stemcell technologies, canada) for x transplanted cells for days. results: the viability of hscs in autografts (cd + / cd + / add-) after cryopreservation in both groups was ± . %. in the group of samples using plerixaphor, a higher content of primitive hemopoiesis precursors (primitive cells) (cd + cd + cd -) was detected compared with the control group ( . ± . % and . ± %, respectively). the cfu count (cfu-cfu-mix, cfu-gm, cfu-g, cfu-m) in the plerixafor group was ± . per x explanted cells, in the control group - ± . ( figure a-d) . conclusions: the use of plerixafor against the background of standard protocols for the mobilization of hscs allows to obtain high-quality graft with a higher content of primitive cells and proliferative activity. disclosure: no conflict of interest. nothing to declare. comparison of effectiveness of plerixafor plus g-csf in poor and very poor-movilizers: efficacy of the combination of plerixafor and g-csf in poor-movilizer background: healthy donors ocassionally show a poor response to mobilization agents. plerixafor+g-csf can be a salvage strategy in poor mobilizers. some series describe the use of plerixafor to collect greater doses of cd + cells in hematopoietic stem cell transplantation (hsct) with tcell depletion. plerixafor use in the mobilization protocol could help collecting higher cd + dose in indirect t-cell depletion (cd + selection) for ex-vivo manipulated haploidentical transplantation, with less number of apheresis and a rapid engraftment. methods: data of fourteen healthy peripheral-blood donors was retrospectively collected. they received days mcg/kg/day g-csf and , mg/kg/day plerixafor on º day as mobilization treatment. fourteen pediatric patients (median age years, range - ) diagnosed with malignant and no malignant hematological diseases received haploidentical hsct with cd + selection and cd ra+ depletion between february and july . results: one leukoapheresis procedure was performed in all cases. median processed volume was liters (range - ). median of cd + cells obtained was , x /kg (range , - , ) . after positive selection, > x /kg cd + cells were infused in all cases (figure ). neutrophil engraftment was achieved after a median of days (range - ). few donors presented only plerixafor mild secondary effects. conclusions: our experience showed that a mobilization protocol using g-csf and standard dose of plerixafor (compasive use) is a safe strategy that allows collecting great cd + dose in one apheresis procedure. this could be useful for haploidentical transplantation with ex-vivo t depletion, especially if there´s a weight disproportion between donor and patient. background: mesenchymal stem cells (mscs) are selfrenewing multipotent progenitor cells with wide differentiation potential. their ease of isolation and expansion in vitro as well as their unique regenerative therapeutic properties suggest the use of msc as an approach for treating several disorders. extra-embryonic tissues as placenta have been proposed as potential sources of mscs due to the absence of ethical problems neither risks for the patients. furthermore, only protocols using fresh placental tissue have been described so far. a protocol for isolating mscs from delayed-manipulated tissue was designed and tested in order to optimize the use of placental mscs (mscs-p) in an advanced therapies context. methods: full term placentas (n= ) were obtained from healthy mothers in hospital universitario central de asturias (spain). informed consent was obtained from each mother prior to delivery. after dissection of gr decidual tissue it was washing with saline (b. braun, germany) and cut into small pieces. these biopsies were conserved hours in dmem media with % antibiotic solution x (gibco, usausa) until processing. the day after, tissue was mechanically minced and then enzimatically digested with a combination of ui/ml dnase i (sigma aldrich, usa) and . % tripsin-edta solution (w/v) (biochrom, germany) at ºc for hour. then, the mixture was filtered with μm cell strainer (bd bioscience, usa) and centrifuge at xg for minutes. finally, cells were resuspended in ml of dmem media suplemented with % fbs and antibiotic, seeded in -cm flask and incubated in forma stericult co incubator (thermo fisher scientific, usa) at ºc, %co . culture-expanded mscs cells were phenotipically characterized by flow cytometry (facs aria iiu, bd) with antibodies against cd , cd , cd , cd , cd , cd , cd , cd , hla-dr cd and cd using mesenchymal cell kit (immunostep, spain). afterwards, these cells were differentiated to adipogenic, osteogenic and chondrogenic lineages using stemmacs adipodiff media, stemmacs osteodiff media and nh chondrodiff medium (miltenyi biotec, germany) respectively. after three weeks of differentiation cells were fixed in % paraformaldehide (merck, usa) and analyzed. adipogenic, osteogenic and chondrogenic differentiation was visualized after staining with oil red o, alkaline phosphatase and hematoxilin-eosin (sigma-aldrich, usa). results: mscs-p isolated cells were characterized according to the isct criteria for mesenchymal stem cells. they were positive for cd , cd , cd , cd and cd and negative for cd , cd , cd and hla-dr, indicative of a typical msc phenotype ( figure ). all the markers showed a high percentage of expression between . and . %, meaning that msc population obtained with the designed method was very homogenous. similarly, staining for the three studied lineages was positive ( figure ). conclusions: the described protocol allows us to obtain mscs from decidual placental tissue stored and processed hours after the biopsy extraction using a unique enzymatic digestion. this circumstance permits to take advantage of placentas that are discarded after delivery giving us the option to obtain mesenchymal cells that could be used in clinical trials. disclosure: nothing to declare outcomes of umbilical cord transplant in high risk relapsed or refractory acute myeloid leukaemia background: high-risk relapsed/refractory acute myeloid leukaemia (aml) is a fatal disease. allogeneic haematopoietic stem cell transplantation represents the only chance of cure. as the transplant relies on the graft-versusleukaemia (gvl) effect, and if different donors exert different gvl effects, then choosing the right donor assumes great importance. in manchester, a large bmt centre in the north of england, our practice in such aml has been to choose unrelated cord blood (ucbt), without serotherapy in the conditioning therapy, as our preferred donor cell source. methods: we report the results of unrelated ucbt in patients (five boys and ten girls) with high-risk aml, defined as relapsed or refractory disease. thirteen patients ( %) received this as a st transplant, two patients ( %) received this as a nd transplant for relapsed aml post matched unrelated donor transplant, and one ( %) received ucbt twice, once in cr and once in cr . nine patients ( %) had mismatched ucbt, and the rest were fully matched at class-i (hla-a, -b, and-c) and class-ii (hla-drb ). conditioning was given as treosulfan, fludarabine and thiotepa in half of the patients (n = ), other treosulfanbased regimens were used in two patients ( %), and busulfan-based regimens were used in six patients ( %). no serotherapy was given. results: the median age at transplant was years (range, months - years). neutrophil and platelet engraftment were achieved in and patients at a median of and days, respectively. patients ( %) had engraftment syndrome. all engrafted patients achieved % donor chimerism, except one patient who had mixed lymphoid chimerism initially, that was corrected spontaneously to % at three months after transplant. acute gvhd grade i-ii developed in six patients ( %), and grade iii-iv developed in three patients ( %). all cases resolved, except two patients where acute gvhd evolved into chronic gvhd (one with grade i skin gvhd which fully resolved, and one with grade iii gvhd gut colitis who was parenteral nutrition dependent till death). two more patients developed chronic grade i skin gvhd and resolved (chronic gvhd developed in % in total). three patients ( %) developed veno-occlusive disease (vod), that completely resolved with defibrotide treatment and necessitated ascitic drainage in one of them. viral reactivations occurred in five patients ( %) and were successfully treated. at a median follow-up of months (range, seven months -four years), eight patients ( %) died at a median of (range, to days), with a transplantrelated mortality of % and relapse-related mortality of %. five patients ( %) relapsed post-ucbt; four died and one had a successful second ucbt (event-free survival was %). immune reconstitution in alive patients was achieved at a median of eight months. conclusions: very high-risk patients treated with ucbt with good overall survival and event-free survival, similar to aml treatment rate with low-risk disease. disclosure: nothing to declare in haploidentical transplants is the incidence of acute and chronic gvhd strictly related to the stem cell source? results: the odds ratio was . with a % confidence interval of . - . (p= . ). conclusions: the risk of infection of the uc is not related to the microbiological status of the ucb. a possible explanation for this is the presence of antibiotics in the medium used for uc, but not ucb, transport. this means that cryopreservation of ucs from which contaminated cord blood has been obtained is justified. comparison of turkish stem cell coordination center (turkok) with istanbul university bone marrow bank (tris); a single center experience in match unrelated donors azize mergen , selime aydoğdu , başak aksoy , yunus emre savcı , gürcan dikme , funda Çipe , ceyhun bozkurt , tunç fışgın older patients are increasingly being transplanted, thanks to improvement in allogeneic hematopoietic stem cell transplantation (allo-hsct) techniques. increasing donor age is associated with greater risk for mortality and graftversus-host disease (gvhd). since sibling donors are of similar age to recipients, we hypothesized that, in older patients, a young matched unrelated donor (mud) would be comparable to an hla-matched sibling donor (msd). methods: we retrospectively compared outcomes of allo-hsct from msd (n= ) and / hla mud (n= ) in patients aged ≥ years with hematological malignancies transplanted between - . all patients received reduced-intensity conditioning and graft source was peripheral blood. the primary outcome was overall survival. msds served as the reference category and were compared to muds split into three age groups (≤ [n= ], - [n= ], > [n= ] years) using univariable analyses and multivariable cox regression models adjusted for patient, disease, and transplantation features. results: the median age of hsct recipients was years and was similar across groups. median donor age for msd was years and , , and for the mud age groups ≤ , - , and > years. acute leukemia was the leading transplant indication ( %) followed by myelodysplastic syndrome, myeloproliferative neoplasms and indolent non-hodgkin lymphoma. disease risk distribution was similar across donor groups (low [ %], intermediate [ %] , and high [ %] in the complete population; p= . ). time from diagnosis to hsct was longer with mud compared to msd and increased with an older age of mud. in a univariate analysis, overall survival was % (msd), % (mud≤ ), % (mud - ), and % (mud≥ , p= . ). corresponding non-relapse mortality (nrm) cumulative incidence was %, %., %, and . % (p< . ) (figure) . gvhd-relapse-free (grfs) was %, %, %, and % (p= . ). in a multivariable cox model, young mud (≤ ) had a similar risk for mortality compared to msd (hr . , p= . ), while a monotonic increase in risk was observed with an older donor age (mud - y: hr . ,p= . ; mud≥ y: hr . , p= . ) (table) . findings were confirmed in a propensity score analysis, matched for key covariates. nrm and grade - acute gvhd were consistently higher with mud, with the greatest risk associated with older muds. the hazard for grfs was higher with mud aged or higher compared to msd; risk was not higher with younger mud. conclusions: in older patients receiving reduced intensity conditioning, msd remain the optimal choice. however, when not available, young mud provide comparable results. disclosure: nothing to declare background: there is growing evidence that community acquired respiratory virus (carv) increase the risk of pulmonary invasive fungal disease (ifd) in recipients of allogeneic hematopoietic stem cell transplantation (allo-hsct). to date, there is a lack of knowledge regarding the rate of ifd, risk factors (rfs) as well as the most critical period for the development of a later ifd after carv infections in allo-hsct recipients. methods: in this prospective observational study, we retrospectively analyzed the effect of carv on the development of a later ifd in a consecutive cohort of allo-hsct adult recipients who developed carv infectious episodes from december to december . respiratory virus in upper and/or lower respiratory tract specimens were tested using multiplex pcr panel assays. results: overall, out of allo-hsct recipients ( %) developed ifd within months after a carv episode at median of days (range - days) from the day of carv detection. all the ifds involved the lungs and in cases ( %) the diagnostic was ia accomplishing criteria of probable (n= ) or proven (n= ). of note, out of ifd ( %) occurred within the first year after transplantation. the overall rate of ifd after carv episodes was % whereas this rate was higher in recipients developing carv during the first year of transplant ( %). ifd was diagnosed in out of with carv lower respiratory tract disease (lrtd) episodes ( %) compared to out of carv upper respiratory tract disease (urtd) ( %) (p= . ). twenty-three out of carv episodes involving the lrtd during the first year after transplant ( %) developed ifd. we did not found differences in ifd rates according to the type of carv identified. multivariate analysis identified rfs for ifd: the use of atg as a part of conditioning [odds ratio (or) . , % confidence interval (c.i.) . - . , p= . ], carv lrtd (or . , % c.i. . - , p= . ), carv infection during the first year of transplant (or . , p natural killer cell alloreactive haploidentical stem cell transplantation for multiple myeloma patients catharina elssen , lotte wieten , peter von dem borne , ellen meijer , gerard bos maastricht university medical center, maastricht, netherlands, leiden university medical center, leiden, netherlands, amsterdam university medical center, location vumc, cancer center, amsterdam, netherlands background: in the past years many new drugs for multiple myeloma (mm) have been developed and are responsible for a increase in survival. notwithstanding such progress, mm remains incurable. results from allogeneic stem cell transplantation (sct), including haploidentical transplantation, in mm has shown clinical results. however, these responses are only observed in a minority of patients. we hypothesize that this observation might be due to differences in natural killer (nk) cell alloreacitvity, since we have shown in in vivo and in vitro models that mismatched alloreactive nk cells hold the capacity to kill mm cells. the aim of this prospective phase study is to evaluate if kir-ligand mismatched haploindentical bone marrow transplantation (bmt) with post-transplant cyclophosphamide will improve progression free survival (pfs) in poor risk mm patients. methods: poor risk mm patients, aged < years were enrolled if they were responsive to their last line of therapy. poor risk was defined as, high-risk cytogenetics, or relapse within a year after autologous sct, or treated with three or more previous lines of therapy. a prerequisite of enrolment was the possibility of an nk cell mismatch and availability of a mismatched family donor. patients were excluded if donor-specific hla-antibodies were present. patients received a haploidentical bmt with a non-myeloablative conditioning regimen and post-transplant cyclophosphamide. primary endpoint is pfs at , years. secondary endpoints are engraftment, bone marrow reconstitution, nk cell reconstitution and repertoire, graft versus host disease (gvhd), infections and non-relapse mortality (nrm) at , years. results: in total poor risk patients were included in the study of which could be evaluated for the primary end point. graft failure and disease progression before transplant rendered the remaining two patients not evaluable. at this interim analysis patients have already reached the , years of follow up, relapsed within , years and died due to treatment related infections, without showing progression of disease ( % nrm). average time of progression is days ( - days). two of the remaining patients at follow up, still show responsive disease (days en ). the average time to neutrophil reconstitution is days ( - days). all evaluated patients ( / ) show nk cell reconstitution with a mature phenotype in the bone marrow and peripheral blood by day . three patients developed acute gvhd ( %) of which / grade i-ii agvhd and / patient showed a grade iv agvhd. treatment related mortality was / ( %), which was in all cases due to infectious disease. conclusions: our interim analysis of mismatched haploidentical bmt in mm showed that the treatment is feasible and forms a possible platform for immunotherapeutic strategies. the majority of patients showed an early disease progression. we predefined that with a pfs of % at , years we would qualify this treatment option successful. with only two patients still in remission this goal will not be achieved and we hypothesize that the late nk cell reconstitution (day ) is responsible for the lack of response. clinical background: mscs are known to have immune modulatory capacity and may be effective in the treatment of patients with acute gvhd. however clinical studies yielded inconclusive results which was in part due to the great heterogeneity of the msc used. the off-the-shelf msc preparation "msc-ffm", generated by a proprietary pooling process, selection by plastic-adherence, expansion for an aggregate four weeks followed by cryopreservation until use, is available in germany through a national marketing authorization. "msc-ffm" is indicated in steroidrefractory agvhd, dosed at - x /kg bw i.v. in four doses one week apart. methods: we report seven consecutive pediatric patients (median age . y), who received "msc-ffm" from unrelated hla disparate donors between december and november in our institution. we gave msc infusions to patients with steroid-refractory grades iii-iv agvhd and one patient who had therapy-refractory background: regulatory t cells (treg) are known for their immunosuppressive function and have proven successful as graft-versus-host disease (gvhd) prophylaxis after allogeneic bone marrow transplantation in a number of preclinical as well as first clinical studies without compromising graft-versus leukemia (gvl) effects. in murine models of acute gvhd lymph node homing capacity via cd l (l-selectin) proved to be essential for disease prevention. yet, treg recruitment from lymph nodes to peripheral sites of ongoing gvhd also seems necessary to achieve maximum protective as well as therapeutic effects. the chemokine receptor ccr directs activated t cells to sites of inflammation, thus high ccr expression should facilitate treg homing to affected gvhd target organs. with this project we lay the foundation for future in vivo studies of treg therapy for gvhd by upregulation of ccr expression. methods: we performed systematic ex vivo analysis of ccr expression on murine naive and memory conventional (tconv) and regulatory t cells isolated from spleen, blood, bone marrow, lymph nodes, liver and lung. cells were stained for characteristic surface and intracellular markers and characterized by multiparametric flowcytometric analysis. ccr expression kinetics following stimulation were analysed in tconv and treg isolated from murine splenocytes by facs and polyclonally activated by anti-cd /cd -coated beads in the presence of exogenous il- . expression was monitored by daily flow cytometric analysis. ccr overexpression was induced by transduction of expanded treg with ccr mrna via electroporation. expression kinetics were monitored by facs, receptor function was tested in transwell migration assays using ccr ligands ccl- and ccl- . results: systematic analyses showed higher ccr expression on memory treg than on their naive counterpart in all examined organs with bone marrow samples displaying the greatest disparity. memory treg showed higher ccr expression than memory tconv in all analysed organs, except for lymph nodes where both memory populations revealed equal expression levels. stimulation of in vitro expanded treg and tconv lead to a strong increase in ccr expression with maximum levels on d and d respectively, whereas restimulation (d ) resulted in no further relevant ccr expression on treg. we performed systematic optimization of stimulation and mrna-electroporation conditions to reliably achieve highlevel short-term ccr expression. transduction of treg on d of in vitro expansion resulted in a strong ccr expression, with maximum levels h after electroporation and strong ccr expression being detectable for at least h. transwell migration assays showed enhanced migrational properties of mrna-electroporated treg towards ccr ligands. analyses performed h and h after electroporation showed persistent migration even though measured ccr surface expression had already declined significantly. conclusions: we showed that high ccr expression can be detected on memory treg in all analysed organs. since in vitro stimulation of murine treg did not reliably induce ccr expression, we established a protocol for ccr mrna-electroporation. electroporated cells showed stable short-term ccr expression and enhanced migrational properties towards ccr ligands in vitro. future studies will show whether the induction of short-term ccr expression will facilitate in vivo homing of adoptively transferred treg to sites of ongoing gvhd and thus mediate long-term inflammation suppression. disclosure: the authors have no conflict to disclose. survival and immune reconstitution of syngeneic, haploidentical and allogeneic hematopoietic stem cell transplantation in atm-deficient mice ruth pia duecker , patrick c. baer , stefan zielen , ralf schubert from allo-hsct. it´s not necessary to do chemotherapy before transplantation for patients with bone marrow blast cells more than % at the time of diagnosis. [[p image] . figure the hci-ct of patients before transplantation and occurance of grade iii-iv agvhd on overall surviv] background: . allogeneic haematopoietic stem cell transplantation (sct) offers the chance of cure for patients with transfusion-dependent thalassemia (tdt). based on the non-neoplastic nature of this condition sct approaches urgently require to prove both efficacious and safe. methods: . we report on children, adolescents and young adults (median age: years; range - years) with tdt receiving sct from an hla-matched donor (mud n= , msd n= , mfd n= ) in our center from - . all patients received the same treosulfan-based conditioning regimen (treosulfan x g/m , fludarabine x mg/m , thiotepa x mg/kg). gvhd prophylaxis was based on atg-fresenius™ ( x mg/kg, if mud or mfd as donor), csa (with taper from day + ) as well as mtx (day , , , ) in / and mmf in / patients with mtx toxicity, respectively. stem cell source was bone marrow in , peripheral blood stem cells in and cord blood in patient. prior to transplantation children received cytoreductive treatment with azathioprine, hydroxycarbamide and intensified erythrocyte transfusion. iron elimination therapy was carried out in / children with deferasirox. among the patients with available ferris-can™ analysis patients showed substantial liver iron overload (liver iron > mg/g) despite intensive chelation prior to sct. results: . all patients achieved leukocyte engraftment at median day + (range - ), however two patients required a cd -selected pbsc boost on day + and day + based on delayed platelet and/or erythrocyte engraftment. nine patients exhibited full donor chimerism in the bm at day + , the other showed mixed chimerism with < % autologous cells. on day + peripheral blood chimerism was complete in / patients with the remaining patient exhibiting stable split chimerism with % donor-derived erythrocytes and - % autologous myeloid cells. acute gvhd was observed in three patients (grade : n= , grade : n= ). however, all patients responded to immunosuppressive therapy with steroids ± ecp and re-initiation of cni (n= ). one patient suffered background: patients with relapsed or refractory acute myeloid leukaemia (aml) have a poor prognosis. allogeneic hematopoietic stem cell transplantation is the only curative option. however, allogeneic transplantation with active leukemia failed to improve significantly the longterm outcome. to improve the outcome of allo-hsct in such high-risk and refractory patients, sequential schedule of cytoreduction therapy followed by nonmyeloablative conditioning has been developed. methods: to evaluate the outcome of sequential intensified conditioning regimen followed by allogeneic hematopoietic stem cell transplantation (allo-hsct) for refractory acute myeloid leukemia (aml). results: a total of patients with primary or secondary refractory aml transplanted between june to july were included. refractoriness was defined as primary induction failure, relapse within months from induction/ consolidation chemotherapy or second relapse. median age is years ( to ). the salvage chemotherapy administered was flag-ida. two patients did not receive intensive chemotherapy because of no recovery after induction chemotherapy. seven days after the end of flag-ida, a reduced intensity conditioning consisting of fludarabine, mg/m , thiotepa, mg/kg and busulfan , mg/kg i.v. (n= ) for haploidentical donors or fludarabine plus busulfan (n= ) for hla identical sibling or unrelated donors was administered. graft-versus-host disease (gvhd) prophylaxis consisted of tacrolimus and mycophenolate mofetil. the mycophenolate was withdrawn at day + post-transplantation and tacrolimus at day + . donor lymphocytes (dli) were infused in patients without agvhd at day + post-transplantation. seventeen patients achieved complete donor chimerism, patients progressed early and patient died before engraftment. one of the patients which recovery was with persistent leukemia reached donor chimerism after immunosupression discontinuation. ten patients are alive in complete remission. median follow-up of survivors is months (range: - ). five patients died of leukemic progression, as result of gvhd and suffered intracranial hemorrhage. five patients received prophylactic dli. the incidence of acute moderate-severe gvhd and moderate-severe chronic gvhd were % (n= ) and % (n= ), respectively. the non-relapse mortality was % (n= ), mainly due to acute gvhd (n= ) . the -year cumulative incidence of relapse posttransplantation was . %. the probability of relapse was %± %. the -year os and dfs were % ± % and % ± % conclusions: the strategy of sequential chemotherapy followed by allohsct ± prophylactic dli has an acceptable toxicity profile and improves both the relapse rate and the survival for refractory aml patients. disclosure: nothing to declare background: the concept of immunological intervention to prevent relapse after hematopoietic stem cell transplantation is associated with the assessment of the chimerism status. distinguishing patient and donor hematopoiesis is usually performed by str-pcr, a powerful method developed for forensic purposes. however, this method shows restrictions with respect to detection limit, preciseness, and the possibility of automated read out. digital pcr could circumvent some of these limitations. methods: recently, validated for the bio-rad droplet digital platforms, the biotype mentype digitalquant assay was released. the assay uses indel polymorphisms on chromosomal dna to distinguish patient and donor hematopoiesis on a fret hydrolysis assay basis ("taqman assays"). thus the assay in principle is applicable on the chamber based d digital pcr system (thermo fisher). due to different reaction chemistry and physical properties of thermal transfer between the digital pcr platforms protocols are reasonably not fully compatible which would lead to lower fluorescence intensities and poor signal resolution on the solid chip based thermo fisher d platform. an adjusted pcr protocol was established and optimized using representative markers, followed by determination of tolerable and optimal amount of input dna. specificity, sensitivity and reproducibility testing with artificial mixed samples preceded the extensive verification by comparative measurement of clinical samples (n= ) and ring-trial samples (n= ). source to allogenic bm or pbsc. ucb units are immediately available for transplantation as they are frozen and banked with defined hla typing and it has an advantage for patients who need urgent transplantation. in addition, a higher degree of hla mismatch appears to be acceptable with a comparatively lower risk of acute and chronic gvhd. meanwhile, a higher incidence of engraftment failure, delayed neutrophil and platelet recovery, and posttransplant immune disorders including pre-engraftment immune reactions (pir) are major problems in unrelated ucbt. methods: in our institute, gvhd prophylaxis in ucbt was changed after march . between january and march , thirty-two patients received tacrolimus plus methylprednisolone (tac/mpsl) and between april and january , thirty-one patients received tac plus methotrexate (tac/mtx) for gvhd prophylaxis. to investigate better gvhd prophylaxis after ucbt, we compared transplant outcomes after ucbt using gvhd prophylaxis with tac/mpsl (n= ) and tac/mtx (n= ) in single-pediatric transplantation center. results: the cumulative incidence of neutrophil engraftment at day in tac/mpsl group was . % and . % in tac/mtx group (p= . ). median time of neutrophil engraftment was days earlier in tac/mtx group ( days) than tac/mpsl group ( days). according to pir, and acute gvhd, tac/mtx group showed superior outcomes; the incidence of pir (p= . ) and the cumulative incidences of acute gvhd at day ( . vs . %, p = . for grade ii-iv, . vs . %, p= . for grade iii-iv) was significantly lower in tac/mtx group than in tac/mpsl. however, the incidences of relapse (p= . ) and cytomegalovirus viremia (p= . ), and estimated overall survival (p= . ) and event-free survival (p= . ) were comparable between two groups. conclusions: our results indicated that gvhd prophylaxis with tac/mtx had favorable effects; reduced incidence of rip and acute gvhd after ucbt without any negative influences. disclosure: nothing to declare transfer of donor regulatory t-cells after atg reconditioning cures severe refractory gvhd and leads to long term persistence of regulatory t-cells in the recipient cells on a clinimacs® plus device (miltenyi biotec). the cell product contained % foxp + t-cells. the patient received , x /kg t reg on day + . subsequently intestinal gvhd decreased and finally resolved. three months after the first t reg transfer the patient got a second t reg transfer ( , x /kg) on day + due to decreasing t reg levels. thereafter t reg persisted and there was no recurrence of gvhd. the patient is well with low dose sirolimus and prednisone as the only immunosuppressants and is particularly recovering intestinal function. conclusions: this case illustrates an unusually severe acute gvhd after matched sibling sct. transfer of donorderived t reg was able to cure severe and refractory gvhd after t-cell ablation by atg. transferred t reg persisted in the recipient for a long period and did not lead to any adverse events. disclosure: no disclosures to declaim allogeneic hsct for patients with transfusion dependent anemia from matched and mismatched donors julia fekadu , andrea jarisch , jan sörensen , emilia salzmann , eva rettinger , andré willasch , shahrzad bakhtiar , thomas klingebiel , peter bader after first asct. the mean harvest for patients receiving dhap was , x cd (+) cells/kg, , x cd (+) cells/kg for cy, . x cd (+) cells/kg for igev, , x cd (+) cells/kg for ice, , x cd (+) cells/kg for choep. the patient mobilized with vtd-pace achieved , x cd (+) cells/kg after apheresis. of the patients achieved the target number of > x /kg cd + cells after apheresis, after two, and after three apheresis. the median time to apheresis was days ( - ) without significant difference between the regimens. the mean wbc count at the time of apheresis was , x /l after dhap, , x /l after cy, , x /l after igev, , x /l after ice, , x /l after choep. there was correlation between wbc and cd harvested cells (p= . ). grate - thrombocytopenia was found in patient ( dhap, ice, igev, vtd-pace). grate - anemia was registered in patients ( dhap and vtd-pace). no correlation was found between the cd + harvest and the age, number of previous lines chemotherapy, the response before mobilization, the type of the lymphoma and the clinical stage. conclusions: our results demonstrate that the chemo-g-csf protocols have comparable effectiveness with accep- background: cytomegalovirus (cmv) may cause severe complications in recipients of allogeneic haematologic stem cell transplantation (allohsct). letermovir (ltv, / mg daily without/with co-administration of cyclosporine) was recently licenced only for cmv prophylaxis in adult allohsct-recipients. paediatric data as well as data on cmv therapy are missing so far. methods: we administered letermovir mg orally once daily (with no co-administration of cyclosporine a) to paediatric patients after allohsct. edta-plasma were occasionally obtained at different time points and frozen for determination of letermovir levels using liquid chromatography/mass spectrometry (lc-ms/ms). results: for details on patients, treatment and cmv load see table . in short periods of letermovir administration, cmv blood levels became negative in both patients. considering the lacking safety data in paediatric patients, we stopped letermovir treatment in both patients, when liver parameters increased. in patient hepatopathy turned out to represent histologically proven graft versus host disease (gvhd). in patient liver parameters further increased despite withdrawal for another weeks, however, hepatopathy was only mild and self-limiting. both patients additionally received other possibly hepatotoxic substances (mycophenolate mofetil and trimethoprim/ sulfamethoxazole). letermovir plasma levels were . ng/ml ( h), . ng/ml ( h), . - . ng/ml (median . ng/ ml, n= , h) and . ng/ml ( h after administration). conclusions: during short letermovir treatment, we observed fast resolution of cmv viraemia as well as rising liver parameters in both patients. while elevated liver parameters represented gvhd in patient, a causal relationship with letermovir might be considered in the other patient. letermovir peak levels after administration of mg were within ranges reported in adults after administration of mg while trough levels were higher indicating differences in pharmacokinetics in terms of delayed clearance. inguinal lymphadenomegaly. after failure to respond to seven conventional treatment lines: methotrexate, cop (cyclophosphamide, vincristin and prednisone); gemcitabine; puva; interferon; acitretin and extracorporeal photopheresis), allogeneic hsct from an identical hla male donor was indicated. the non-myeloablative conditioning consisted of fludarabine ( mg / m ), cyclophosphamide ( mg / kg) and total body irradiation(tbi) ( cgy). prophylaxis of graft versus host disease (gvhd) was performed with cyclosporine ( mg / kg) and mycophenolate mofetil ( mg/kg). after conditioning, there was improvement of pruritus and involution of the skin. bone marrow infusion occurred on / / (d ). on d + he presented recurrence of skin lesions of fmf. donor lymphocyte infusion (dli) was performed ( x cd + cells / kg / recipient). he presented oral lichen and diarrhea respectively as manifestations of gvhd on d + and d + . as infectious intercurrence, hemorrhagic cystitis occurred by bk virus months after the first dli and he received conservative treatment and remained without systemic immunosuppression. nine months after hsct, a second dli ( x cd + cells / kg / receptor) was performed and at this time the patient is without clinical manifestations of fmf or gvhd. conclusions: the clinical response of the presented case confirms what has been reported in the literature. ctcls appear to be particularly susceptible to gvl effect, which makes hsct a potential cure for advanced ctcls in eligible patients. the timing to perform hsct in the clinical course of the disease remains a matter to be settled clinical trial registry: not applicable disclosure: no conflict of interest p abstract already published. methods: we applied next generation sequencing (pgm, ion torrent/ fischer lifetechnologies) to an unselected cohort of patients ( female, male, median age ( - ) years) who had been referred for allogeneic stem cell transplantation due to the presence of a high-risk myeloid disorder dnmt a r h ( . %) . ), cebpa ( . %; ceb-pap s ( . %) vus) kras ( . %; krasr r ( . %) vus), and kit ( . %; kitm l ( . %) . ). patients displayed a median of sequence variants (aml, mpn and cmml patients each ; mds, saa and patients with other, non-malignant hematologic diseases each sequence variants found most frequently in aml were cebpap s ( . % of all sequence variants in patients with aml, p< - , chi² test) in patients suffering cmml, dnmt ar h was particularly frequent ( . % of all sequence variants in cmml, p=. ). asxl e d ( . % of all sequence variants in other, non-malignant hematologic diseases, p=. ), idh r q ( . %, p=. ) and krasr r ( . %, p=. ) were frequent in other, non-malignant hematologic diseases. in saa, nrasg d ( % of all sequence variants in saa patients; p=. ) was frequently found, as were dnmt ak fs* ( %, p=. ), tet l w ( %, p=. ) and tet i v ( %, p=. ). conclusions: taken together, these data show that vus occur with high abundancy in this high-risk cohort of patients, and that they differ in frequency between various myeloid disorders methods: retrospective analysis of patientswho experienced either hematological relapse or progressed to aml after allo-hsct and were treated with azacitidine for this indication at hematological centers in poland. the primary end-point was overall survival (os), the secondary -response rate. results: patients, males ( . %), median age (range, - ), were enrolled. the primary indication for allo-hsct was aml median time from allo-( %ci: . - ); with -year os of . % ( %ci: . - . ). for patients stratified according to ebmt aza relapse prognostic score -year os was: prophylaxis of agvhd: with atg -atgam mg/b.w.- pts( , %), posttransplant cyclophosphomide (ptcy) mg/b.w. on d+ ;d+ - pts ( , %) conclusions: unmanipulated haplo-hsct in st - nd cr in children and adolescents with high risk al allows achieving the long-term survival in , %. the use of g-csf stimulated unmanipulated haplo-bm is associated with a satisfactory rate of engraftment. the main cause of death in our study was relapse after allo-hsct. the frequency of acute and chronic gvhd was acceptable, -years grfs rate of , % in st - nd cr represents good quality of life following unmanipulated haplo-hsct and therefore may be recommended as option for use in children and adolescents with high-risk al. disclosure: nothing to declare background: b -h (cd ) is thought to act as an immune checkpoint and regulates t and nk cell responses. it is highly overexpressed on many solid tumors while on healthy tissue protein expression is limited. this makes b -h an interesting target for cancer immunotherapy. in highrisk neuroblastoma patients, targeting disialoganglioside gd with the recently approved monoclonal antibody (mab) ch . after autologous or allogeneic sct, significantly improves survival. however, gd expression is heterogeneous and ch . causes severe adverse effects. thus, we evaluated b -h as an alternative or additional target antigen. we investigated different anti-b -h mab constructs and mab-cytokine fusions (immunocytokines) for their ability to elicit antibody-dependent cellular cytotoxicity (adcc) using expanded γ/δ t cells of healthy donors, chex lf-il was confirmed to be the most effective mab construct. interestingly, chek -il showed comparable target cell lysis -however, lysis was only transient while chex lf-il mediated permanent target cell lysis. using patient pbmcs after receiving allogeneic sct, chex lf-il and ch . mediated comparable lysis. calculated specific lysis of lan- (after hrs.; in ascending order): targets + effectors w/o mab ( %) conclusions: b -h is a suitable target antigen in case gd expression is low or absent. immunocytokines and fcoptimized mabs targeting b -h might increase the efficacy of immunotherapy in gd -negative tumors and in combinatory approaches. until now, the low-fucose immunocytokine chex lf-il seems to be the most promising anti-b great ormond street hospital, nhs foundation trust petersburg/ raisa gorbacheva memorial institute of children's oncology, hematology and transplantation, rehabilitation medicine, saint petersburg, russian federation, first i. pavlov state medical university of st. petersburg/raisa gorbacheva memorial institute of children's oncology, hematology and transplantation, bone marrow transplantation for pediatric solid tumor petersburg/raisa gorbacheva memorial institute of children's oncology, hematology and transplantation, pediatric hsct outpatients, saint petersburg, russian federation university hospital carl gustav carus james`s hospital diagnosis was aml in %, all in % and mds in % of patients. % of patients received pbsc grafts, % received unmanipulated bone marrow grafts. os at years was % in msd/mud-atg, % in haplo-ptcy, % in mmud-ptcy and % in mmud-atg groups (p= . ). in a multivariate cox model non-relapse mortality was %, %, . % and % in msd/mud-atg, haplo-ptcy, mmud-ptcy and mmud-atg groups, respectively. cumulative incidence of acute gvhd grade or was %, . %, % and % after in msd/mud-atg, haplo-ptcy cumulative incidence of chronic gvhd was % in the msd/mud-atg group uwe platzbecker , verena wais republic of china background: there are two most noteworthy strategies of haploidentical stem cell transplantations (haplo-hsct), the baltimore post-transplantation cyclophosphamide (ptcy) with or without anti-thymoglobulin (atg), and the beijing g-csf primed bone marrow (bm) plus peripheral blood stem cells (pbsc) (giac). however, the comparison of these two modalities is scarce. in this study, we aim to compare these two approaches for hematological malignancies based on the taiwan blood and marrow transplantation registry (tbmtr) with the comparable cd infusion amounts, the neutrophil engraftment time were statistically distinct among these three groups [d+ (group ) vs. d+ (group ) vs. d+ (group ), respectively as to the graft-versus-host disease (gvhd), the patients in group had more grade ii-iv but similar grade iii-iv acute gvhd compared with others (grade ii-iv: . % vs. . % vs. . %, respectively conclusions: haplo-hsct with different strategies is a feasible treatment modality for hematologic malignancies in taiwan. regarding the retrospective nature and limited patient numbers of this study republic of china background: we previously presented a low-resolution hla analysis of cedace, the voluntary portuguese bone marrow donor registry (ebmt , poster p ) and, more recently, its epidemiological characterization (ebmt , poster b ). currently, cedace is one of the largest bone marrow donor registries in the world, including nearly % of the country's population, twice the number of donors present in . the current work is an update on the most common hla haplotypes found in cedace results: of the donors in the cedace registry, . % were typed in at least loci (hla-a/-b/-drb ), . % in (including hla-cw), and . % in (including hla-dqb )the , and most common haplotypes accounted for, respectively, . %, . % and % of the haplotypes found in the entire registry. the five most common haplotypes at the low-resolution at the loci, low-resolution level, out of donors, individual genotypes were identified, leading to an hla matching probability at this level of . % hid-hsct) have a stronger anti-leukemia effect compared to identical sibling donor hsct(isd-hsct) in high-risk features .but in refractory/relapsed(r/r) aml patients who not in remission status, it is unclear whether it also augments the gvl effect antithymocyte globulin was used in haploidentical hsct. unmanipulated bone marrow and peripheral blood stem cells for all patients. cyclosporine, short-term methotrexate were employed for gvhd prophylaxis. mycophenolate mofetil included in hid-hsct. performed multivariate analysis for all patients of pretransplantation variables and developed a predictive scoring system for survival according to adverse factors. results: the total survivor median period of follow up was ( - ) months. hid -cohort had higher -year actuarial of os multivariate analysis showed isd-hsct,standard conditioning regimen and less than % proportional reduction in blast percentage pre-≥ . conclusions: haploidentical donor compared to identical sibling donor had better anti-leukemia effect in allo-hsct for r/r aml in nr status conditioning protocol was melphalan mg/m for mm and beam for nhl. the quantification and characterization of γδt cells in peripheral blood samples were performed by flow cytometry based on the expression of cd /cd /vδ /vδ /vγ /cd at , and days after ahsct. percentage (%) of γδt cells represented the proportion of these cells among all t cells. results: median age at ahsct was ( - ) years, % male. median time from diagnosis to mobilization was ( - ) months, after a median number of therapeutic lines of ( - ); pts ( . %) received radiotherapy. seventeen pts ( . %) were re-mobilized with plerixafor±g-csf ( % mm vs % nhl there was no difference in febrile neutropenia incidence (p= . ), timeto-engraftment (p= . ), time-to-neutrophils> /μl (p= . ) or erythrocyte transfusions (p= . ). however, there was more time-to-platelets> , /μl ( vs days; subpopulations did not affected pfs. conclusions: our results showed that pts mobilized with plerixafor need more collection volume (less cd +cells, higher dmso). plerixafor negatively affected platelet recovery, with similar hematologic and immune recovery for the remaining variables. its use was associated with higher %vδ +, suggesting that it induces an antineoplastic phenotype. more studies with larger samples and follow-up period are needed to evaluate plerixafor results: total ascc procedures were carried out in patients over years, once in patients, twice in patients, three times in patients, and four times in patient. non-hodgkin lymphoma (nhl) comprised . % of all cases (n = ) ), total number of chemotherapy cycles before ascc (or . , % ci . - . , p = . ), failure to achieve at least partial response before ascc (or . , % ci . - . , p = . ), total number of days receiving g-csf for mobilization (or . , % ci . - . , p = . ), and salvage use of plerixafor (or . , % ci . - . , p < . ) were found to be independent factors associated with failure of ascc. at the end of the study period, . % of successful collections (n = / ) were used for asct, . % (n= / ) were in storage awaiting transplantation hôpital necker-enfants malades melf methods: a total ahsct candidates [median age: ( - ) years; male/female: / ] were included in this study. twenty-seven patients ( . %) were diagnosed as non hodgkin's lymphoma, patients ( . %) hodgkin's lymphoma, patients ( . %) multiple myeloma, patients ( . %) acute myeloid leukemia, patients ( . %) plasmocytoma and patient ( %) testis cancer. premobilization serum -hydroxy vitamin d ( -oh d) levels were measured with immunoassay method peripheral cd + cell count background: some published data suggest a positive effect of iron chelators on the risk of post-transplant relapse, with an improvement in overall survival after allogeneic hematopoietic stem cell transplantation (hsct) conditioning regimen consisted to intravenous bu mg/m and, flu mg/m d- to d- . gvhd prophylaxis included atg . mg/kg on d- and d- , ciclosporin and methotrexate. all patients received peripheral blood stem cell transplant from an identical hla-related donor. iron chelation consisted on deferasirox (exjade ® ) - mg/kg/day, started at day , if serum ferritin level ≥ - ug/l and stopped when the level decreased below ug/l or normalized at day after transplant, / patients were evaluable (g = pts), (g = pts). patients were abo compatible ( %), had major incompatibility ( %), and % had minor incompatibility. median serum ferritin level at day , were ug/l ( - ) and ug/l ( - ) in g and g respectively with a median follow-up of months, ( - ), disease relapse incidence was higher in patients who did not received iron chelation treatment (g : . %) versus those who received oral deferasirox (g : . %) (figure ), but the difference was not statistically significant conclusions: these results deserve more investigation choep (n= ), and patient received vtd-pace μg/kg depending on the protocol. the aim was to collect at least x cd (+) cells/kg body weight. results: forty patients all patients were stage iii and iv at diagnosis. of the patients were mobilized after one line of treatment, six after two lines of treatment and five after and more lines of treatment alexandra martínez-roca , gerardo rodriguez-lobato , gonzalo gutierrez-garcia , , maria suárez-lledó background: hematopoietic stem cell transplantation (hsct) is an established procedure in lymphoma background: the role of inflammatory cascade in tumor microenvironment has been demonstrated in several studies. as a part of this issue, elevated neutrophil/lymphocyte ratio (nlr) was shown to be associated with an adverse prognosis, particularly in solid tumors. the aim of this study is to determine the impact of pre-transplant nlr on early transplant complications, as well as post-transplant relapse and survival.methods: a total of lymphoma patients [median age: ( - ) years; male/female: / ] who underwent autologous hematopoietic stem cell transplantation (hsct) were included in this retrospective study.results: the initial diagnosis was hodgkin lymphoma (hl) in ( . %), b-cell non-hodgkin lymphoma (nhl) in ( . %) and t-cell nhl in ( . %) patients. of patients who were evaluated for pretransplant disease status, patients ( . %) were in complete remission, patients ( . %) were in partial remission and ( . %) patients had refractory disease. median pre-transplant nlr was found to be . ( - ) . when the study population was divided into two subgroups as "low-" and "high-nlr", based on median nlr value, number of febrile days were found to be relatively higher in the low-nlr group (p= . ). a positive correlation was demonstrated between nlr and lactate dehydrogenase levels (r= . ; p= . ); and nlr and ferritin levels (r= . ; p= . ). at a median follow-up of ( - ) months, overall survival (os) was found to be better in the low-nlr group without statistical significance [ vs ( - ) months; p= . ]. in univariate analysis, pre-transplant nlr represented a significant impact on os (p= . ). other prognostic factors were age (p= . ), platelet engraftment (p= . ), post-transplant relapse (p= . ) and pre-transplant ferritin level (p< . ). the permanent impact of ferritin on os was confirmed in multivariate analysis (p= . ).conclusions: in this study, an adverse impact of elevated pre-transplant nlr on os was demonstrated in autologous hsct recipients with lymphoma. as a predictor of prognosis, nlr may be considered as a safe and cost-effective parameter. further studies are required in order to use this predictor in routine clinical practice.background: high cure rates in childhood diseases have been achieved by stem cell transplantation (sct). however, there is little knowledge concerning recovery of the immune system and community-acquired infection after sct. here we studied the long-term reconstitution of the immune system and incidences of community-acquired infection after sct.methods: we reviewed medical records for patients (m/f: / , median age: years (range: - years) who were treated in the department of pediatrics, hokkaido university hospital. we analyzed cd -positive cell counts, serum immunoglobulin g (igg) levels, and incidences of community-acquired infection until years after sct. indications for sct were all in patients, aml in , aa in , nb in , rms in , jmml in , nhl in , cgd in , was in , xscid in , apds in , cd ld in , and other solid tumor in patients. stem cell sources were autologous pb/bm in , allogenic bm in ( related and unrelated) and allogenic cb in patients. in this study, we excluded patients who relapsed after sct.results: the duration of cd -positive cell counts < / ml after sct was . ± . months in all patients. the durations were . ± . months in patients with hematologic malignancies, . ± . months in patients with hematologic disorders such as aplastic anemia and pid, . ± . months in patients with solid tumor, . ± . months in patients who received autologous sct, . ± . months in patients who received related bmt/ pbsct, . ± . months in patients who received unrelated bmt, and . ± . months in patients who received cbt. the durations of igg < mg/dl after sct were . ± . months in all patients, . ± . months in patients with hematologic malignancies, . ± . months in patients with hematologic disorders, . ± . months in patients with solid tumor, . ± . months in patients who received autologous sct, . ± . months in patients who received related bmt/pbsct, . ± . months in patients who received unrelated bmt, and . ± . months in patients who received cbt. there was a significantly higher incidence of community-acquired infection from months after sct. there were significant differences in the incidence of community-acquired infections between patients with cd -positive cell counts of < /ml and background: allogeneic hematopoietic cell transplantation (allo-hct) has the potential to cure subgroups of patients with multiple myeloma (mm) but its role is controversial due to high transplant-related mortality. while autologous hct is well established as consolidation after induction therapy using novel agents, allo-hct is still considered experimental due to excessive early toxicity.methods: we retrospectively studied mm patients (pts) ; ( , %) were males with a median age of years (range: - ), who underwent allo-hsct in our center between and .median time between diagnosis and allo-hct was months (range: - ).results: the international staging system (iss) was iss i ( , %), iss ii ( , %), and iss iii ( , %). twentyeight ( , %) pts received cells from unrelated donor and pts from identical siblings. stem cell source were: peripheral blood (n= ) and bone marrow (n= ). grouprisk distribution using hct-ci and pam index can be seen in figure . response was evaluated at day + : cr ( , %), vgpr ( , %), pr ( , %) and sd ( , %); response was not evaluated in pts. regarding hospitalization, ( , %) pts and ( , %) pts needed readmission in the first days and days post-allohct, respectively, and median days of hospitalization was days (range: - ). reasons for first re-admission were: infection ( , %), gvhd ( , %) and renal insufficiency ( , %). twenty-seven ( %) died and death causes were: infection ( , %), progression ( , %), secondary tumor ( , %) and the remainder, gvhd and intracranial hemorrhage. in addition, pts ( , %) suffered cytomegalovirus (cmv) reactivation.median overall survival (os) was months (range: - ). univariate analysis showed that re-admission in first days (hr , ; p= , ) , re-admission in first days (hr , ; p= , ) , cmv reactivation (hr , ; p= , ), iss (iss-i vs iss-ii and iii; hr , ; p= , ), days of hospitalization in the first days and response at + day (cr plus vgpr vs the remainder; hr , ; p= , ) were predictor factors for os. other factors like karyotype, response before allo-hct, hla-mismatch or baseline cmv serostatus, among others, do not impact on os.median os in pts with low hct-ci were months (range: - ) vs months in intermediate-high hct-ci background: allo-sct is a potentially curative therapy for patients with multiple myeloma as it provides a graftversus-myeloma effect and a myeloma-free graft. due to increased nrm and unclear os benefit the recent guidelines suggested allo-sct to be used in context of clinical trials focusing on the high-risk patients and those who relapsed early after autograft. reduced-intensity conditioning regimens may improve rate of nrm; however, optimal conditioning regimen is still to be determined. here we studied conditioning regimen with alkylating agents consisting of thiotepa (tt), busulfan (bu) and gvhd prophylaxis with post-transplant cyclophosphamide (post-cy) in high risk myeloma patients relapsing after autograft.methods: a total of patients (m, n= ) with median age of years (range - ) underwent an allo-sct (mud, n= ; mrd, n= ; mmud, n= , haploidentical, n= ) during a period from to in university of hamburg. the majority of patients had advanced disease (stage iiiab, %) and high-risk cytogenetics ( %). the median response durartion after autograft was . years (range . - . ). the conditioning included tt (cum. dosage mg/kg), bu (median cum. dosage . mg/kg i.v. or . mg/kg in elderly patients) and post-cy (cum. dosage mg/kg, day + and + ). eight patients (all of them received allografts from mmud or haploidentical donors) received additionally fludarabine (flu, cum. dosage of background: the overall incidence of active cmv infection in patients with multiple myeloma (mm) receiving background: several scoring systems have been developed to estimate outcomes in mds patients who undergo allohct. however, none of them have been specifically validated in t cell depleted grafts. the aim of this study is to investigate the prognostic ability of a recently published scoring system (sfgm-tc) in a cohort of patients with mds who underwent tcd transplants.methods: patients underwent a first tcd allohct for mds from to . the sfgm-tc score (caulier et al. curr res transl med. ) is performed at day and ranges from - , discriminating low ( ), intermediate ( ) ( ) ( ) , and high risk ( - ). additional analyses were performed at day and day . a landmark analysis was done at each time point for the day , , and analyses, respectively. background: hematopoietic stem cell transplantation (hsct) is the only curative procedure for the treatment of myelodysplastic syndrome (mds), but among several limiting factors for its accomplishment, such as the patient´s performance status, is a very relevant issue, i.e., the availability of a compatible hla donor and, when available, very often the donor´s age and comorbidities also constitute factors that hinder this medical conduct. considering this scenario, the possibility of a haploidentical transplantation (ht) has emerged as an option. in latin america, ht has been included as a treatment option since . since then, these patients have been included in the latin american registry of transplantation in myelodysplastic syndrome, making it possible to analyze the viability and results of these transplants.methods: from october to october , seventeen ( ) patients were transplanted with a haploidentical donor and included in the latin american registry. none of these patients had an identical hla ( / match) related or unrelated donor. data were obtained from the latin american registry of hsct in mds. the statistical analyses were performed using the software spss, version . and graphpad prism version . , with significance being set at p < . .results: table shows the patients and their characteristics. all donors were haploidentical. there was a predominance of reduced intensity conditioning, which was performed in patients ( . %), whereas the others received the myeloablative conditioning. cell source was peripheral blood in ( . %) and bone marrow in ( . %) of the patients. graft-versus-host disease (gvhd) prophylaxis in post-hsct was carried out with cyclophosphamide mg / kg on d+ and d+ , cyclosporin from d and mycophenolate from d+ . complete hematologic recovery was achieved in ( . %) patients. the incidence of grade ii-iv acute gvhd was . %, whereas chronic gvhd was . %. one death occurred due to graft failure and none of the patients showed autologous recovery. three other patients died. one on d+ due to a fungal infection, the second on d+ due to sinusoidal obstruction syndrome and a third on d+ due to pneumonia caused by pseudomonas. regarding overall complications, there was a predominance of mucositis ( %), overall infections ( . %) and reactivated cmv in . % of cases. of the total number of living patients, ( %) achieved complete remission and ( . %) showed disease relapse. the mean follow-up was months (ranging from to months). the lowest probability of disease-free survival at years was % ( % ci: . - . ).background: relapse is the most important cause of failure after allogeneic hematopoietic stem cell transplantation (hsct) for flt -itd-positive acute myeloid leukemia (aml). treatment with flt tyrosine kinase inhibitors (tki) constitutes a promising clinical approach to induce remission without conventional chemotherapy.methods: a year-old woman diagnosed with aml secondary to myelodisplastic syndrome (mds) with npm mutation and internal tandem duplications of the flt gene (flt -itd) in october . after achieving complete remission (cr) with conventional chemotherapy, she received a hla sibling allogenic-hsct in february , with bucy. four months later, aml relapsed only at medullary level (flt ratio: , %), treated with chemotherapy and donor lymphocytes infusions (dli). she achieved nd cr and developed limited chronic graft-versushost disease (cgvhd). nine months later (april ), she suffered the first extramedullary relapse only, breast and skin. disappearance of the lesions at all levels was achieved with chemo and radiotherapy. she always had full hematologic donor chimerism.in december , she referred atypical precordial pain irradiated to the back. cardiac mri was performed and several masses were visualized in the pericardial sac, up to cm in diameter. bm remained in cr with full donor chimerism.pericardial fluid showed massive infiltration by leukemic-flt positive cells (ratio: , %). she was not considered background: ta-tma is a severe complication that can reduce survival after hsct. risk factors have been variably reported in adults although data on children remains scarce. we aimed to identify a risk profile for development of ta-tma in children undergoing hsct.methods: we retrospectively reviewed clinical charts of children who underwent hscts between - : at great ormond street hospital (gosh) and the great north children's hospital (gnch). ta-tma was defined according to revised criteria (jodele et al. ) . risk factors were categorized into patient derived [age, gender, active co-morbidity at d of hsct (uncontrolled viral/ bacterial or fungal infection, pulmonary, cardiovascular instability, steroid therapy > . mg/kg beyond d , bcgiosis or autoimmune disease), transplant related factors (conditioning intensity, stem cell source, hla-matching, use of ciclosporin a (csa) or tacrolimus (tac), cd + dose, ex-vivo t cell depletion, use of defibrotide) and post-hsct factors (agvhd, post-hsct viral reactivation, venoocclusive disease (vod) and occurrence of posterior reversible leukoencephalopathy (pres).results: at a median of months post-hsct, ta-tma occurred among / transplants ( . %). there was no reported centre variation ( . % vs . % in gosh vs gnch; p= . ). gender, underlying disease -primary immune deficiency (pid) (n= ) vs haematological disease (n= ), use of myeloablative (n= ) vs reducedor minimal intensity conditioning (n= ), use of serotherapy or mega doses of cd ≥ x * /kg did not influence the development of ta-tma. donor type: msd/ mfd(n= ) vs mud (n= ) vs mmud/haplo-hsct background: we evaluated the outcome of haploidentical hct (hhct) using ex vivo αβ t cell-depleted (tcd) grafts after reduced-intensity conditioning (ric) containing low-dose tbi (ld-tbi) in pediatric patients with acute leukemia (al) in complete remission (cr).methods: between may and october , patients with acute leukemia ( all and aml) in cr received haploidentical hematopoietic cell transplantation (hhct) using tcrαβ-depleted graft at asan medical center children's hospital. eighteen patients received hhct between and (earlier time period) and the remaining between and (recent study period). the conditioning regimens, the dose of αβ+ t cells and gvhd prophylaxis are summarized in table. results: all patients achieved a sustained neutrophil engraftment at a median of days (range, - ) . of patients, patients ( all & aml) relapsed at a median of months (range, - ) after transplant. of the patients, patients died of disease. one patient died of disseminated tuberculosis at months after transplant, leading to the trm of % at year. as of december , of the patients survive free of disease at a median follow-up of months (range, . at a median followup of months (range, - ), efs and os at years for all patients were % and %, respectively. outcome of hhct in the recent study cohort was significantly better than that in the earlier study period (efs of % vs efs of %, p= . ). among the patients with all, the efs of patients, who received hhct in early time period after conditioning with tbi of cgy, was significantly worse than that of patients, who received in recent study period after a higher dose of tbi at cgy ( % vs %, p< . ). the efss of aml were similar between the two study groups ( % for earlier cohort vs % for recent study, p> . ).conclusions: in pediatric patients with acute leukemia in cr, our current haploidentical hct using ex vivo αβ tcd graft after ric containing ld-tbi without gvhd prophylaxis is feasible approach with a low trm. the background: anti-hla antibodies (ahab) have been recently recognized as an important risk factor for graft failure (gf), especially in hla-haploidentical stem cell transplantation (haplo-hsct). although, recently, ebmt consensus guidelines have been published [ciurea, bone marrow transplant ] , experience in pediatric t-cell depleted (tcd, another well-known risk factor for gf) haplo-hsct is lacking. in the present study, we report our experience on the use of a desensitization approach based on ebmt guidelines.methods: between june and august , all patients affected by non-malignant diseases and scheduled for a transplant from an hla-haploidentical donor after negative depletion of αβ t and b cells as previously described [li pira, biol blood marrow transplant. ], were tested for ahab with luminex® solid-phase immunoassay (one lambda, thermo fisher scientific) month before the hsct. all patients with a mfi higher than , which is considered a cutoff predicting for gf, were treated with a desensitization protocol based on the use of anti-cd rituximab ( mg/m before and immediately after the end of plasma-exchange cycle) and plasma-exchange (pe) ± infusion of irradiated buffy coat (bc) (if after pe ahab mfi was still > mfi). this latter was obtained by the non-target fraction of the αβ t-cell/b-cell-depletion procedure and consisted of * irradiated nucleated cells/kg of the recipient; this was infused - hours before the infusion of the tcd graft. pe was performed with miltenyi life tm apheresis unit (miltenyi, bergish-gladback) .results: in the study period, patients received αβ tand b-cell depleted haplo-hsct. eighteen ( %) resulted positive for ahab (mfi> ); ( %) of them had an mfi > for either anti-class i or ii ahab. these patients (see table i background: osteonecrosis (on) is a debilitating complication in survivors of allogeneic hematopoietic cell transplantation (hct). limited data is available on its course post-transplantation in children. the purpose of our study was to identify recipients of hct in whom pre-and post-magnetic resonance imaging (mri) is indicated.methods: the retrospective cohort consisted of patients who underwent first allogeneic hct from - , and prospectively underwent a total of pre-and post-transplant mri studies of the hips and knees done annually for years regardless of symptoms. surviving patients were followed for a median time of . (range . - . ) years. cases of on were compared to controls matched for age, sex, transplant type, and follow up in a : ratio for the following variables: ethnicity, underlying disease, on pre-hct, conditioning regimen, graft source, bone mineral density z-scores, body mass index, presence or absence of graft-versus-host disease, steroid use and dosage, and survival status.results: thirty ( . %) patients had mri findings confirming on post-hct. all patients with on except one were more than years of age. twenty ( %) patients were male. on pre-hct (p < . ) was the only factor associated with presence of on post-hct. epiphyseal on was seen in ( %) patients pre-hct, and ( %) post-hct. eighteen ( %) patients had involvement of more than % of articular surface, and were more likely to undergo surgery (p = . ).conclusions: the incidence of on in this large pediatric cohort was %. the only risk factor for on post-hct was pre-existing on. mri evaluation for on pre-hct is indicated in all patients. mri evaluation for on post-hct is only indicated for patients with on pre-hct and symptomatic patients. this will entail cost savings of usd , per surviving allogeneic hct patients per year. patients with more than % involvement of the articular surface need close follow up.clinical trial registry: none disclosure: none impact of rabbit anti thymocyte globulin exposure on immune reconstitution and outcome after stem cell transplantation in children background: rabbit anti thymocyte globulin (ratg) has been frequently used for many years as gvhd prophylaxis in pediatric stem cell transplantation. precise dosing regimens are crucial but remain challenging due to several pharmacological characteristics in children.methods: ratg levels were measured in pediatric patients undergoing allogeneic stem cell transplantation after obtaining approval by the local irb and informed consent by legal guardians. pediatric patients who received either thymoglobuline™ (n= ) or grafalon™ (atg-f) (n= ) as part of their conditioning regimen background: obesity among children is a growing health problem. malnutrition or being over-weight can be of prognostic impact among children who need hsct.scientific literature shows a lot of controversy in terms of effect of bmi at the time of infusion on the outcome of hsct.methods: we reviewed data of patients who underwent hsct at king faisal specialist hospital & research centre between - to correlate bmi with the outcome and complications of hsct. transplant naïve recipients with age at infusion between - years who received hsct from matched related donor or autologous hsct, were included in the dataset for analysis. a total of patients' profiles were reviewed of whom . % were boys. median age at transplant was . years. primary indication of disease was malignancy in . % followed by hemoglobinopathies . %, bone marrow failures . % and immune disorders . %. solid tumors accounted for . % among malignant disorders. myeloablative conditioning was used in . % transplants with . % regimens containing total body irradiation. majority of the patients . % underwent allogeneic transplantation using bm as the source in . % and pbsc in the remaining . % cases. donor was hla-identical sibling in %, parents in . % and others in the remaining . % patients. median tnc dose was . x ^ and cd was . x ^ per kg of the body weight at the time of infusion. age and gender specific bmi percentiles were obtained and classified according to the definition of centers for disease control and prevention (cdc); . % ( ) recipients were categorized as under-weight, . % ( ) normal, . % ( ) over-weight and remaining % ( ) as obese.results: based on chimeric studies at day- , our engraftment rate was . % ( ) out of evaluable cases. median time to neutrophil recovery was -days from infusion and -days for platelets. no statistically significant difference was found for engraftment rate on d- as it was % ( ) among . % ( ) in normal, % ( ) in under-weight and . % ( ) in the obese (p-value: . ). median time to neutrophil recovery from the infusion date was -days in over-weight patients and in the remaining three groups (p-value: . ). acute graft vs. host disease (agvhd) of any grade at day- was recorded in . % ( ). any-grade agvhd was more common in over-weight % ( ), followed by obese with . % ( ), % ( ) in under-weight and . % ( ) in normal bmi-category (p-value: . ). chronic gvhd was more frequent in over-weight ( . %, ), compared to ) background: hematopoietic stem cell transplantation (hsct) is the standard treatment for children with severe aplastic anemia (saa) who have hla-identical related donor. there is no standard conditioning regimen for children with saa secondary to non-fanconi anemia (fa) constitutional bone marrow failure syndromes such as telomeropathies. we report the outcome of a consistent reduced intensity conditioning regimen in patients with idiopathic saa or inherited bone marrow failure syndromes other than fa who underwent hla matched related hsct methods: children with saa underwent hsct using the following conditioning regimen: fludarabine mg/m , cyclophosphamide mg/m , and atg (thymoglobulin) ( mg/kg) . gvhd prophylaxis included cyclosporin and mycophenolate mofetil. donors were all matched related and bone marrow was the stem cell source. all patients had normal chromosomal fragility testresults: a total of children with saa underwent hsct, females and males. average age was . (range . - . years). all nine patients who were tested for telomere length had short telomeres. pathogenic or likely pathogenic mutations were reported in patients ( ercc l , ankrd , tinf , lztfl ). all donors had normal physical examination, normal cbc, and negative genetic testing if patient mutation is known. all patients engrafted successfully, median time to neutrophil engraftment was (range, - days) and platelet engraftment (range, - days). median infused nucleated cell dose was . (range, . - . x /kg) and cd cell dose was . (range, . - . x /kg). none of our patients had acute gvhd and one patient had mild classic chronic gvhd of the skin that was controlled with topical therapy for a short period. three patients had secondary graft failure in the first-year post transplant. first patient had pancytopenia with loss of donor chimerism and underwent successful second transplant using fludarabine, atg, and melphalan. the second patient had a nonfunctioning graft despite full donor chimerism suggesting that the related donor might be affected and had silent phenotype. the third patient had homozygous ercc l mutation and developed progressive cytopenia with myelodysplastic features few months post-transplant and subsequently underwent myeloablative matched unrelated transplant using busulfan, fludarabine, thiotepa and atg. however, the patient progressed to have acute myeloid leukemia six months post hsct. fifteen patients ( %) have normal cbc and stable donor chimerism. median follow-up duration of days (range - days). one patient with lztfl mutation developed chronic renal impairment five years post hsct.conclusions: hsct using lower dose cyclophosphamide ( mg/kg) as part of fludarabine based regimen was safe and effective in saa patients with shorter telomeres and described genetic abnormalities. optimal conditioning regimen in ercc l -associated bone marrow failure needs to be defined. larger study is needed to confirm our results.clinical trial registry: not applicable disclosure: nothing to declare late effects in patients with hemophagocytic lymphohistiocytosis treated with hematopoietic stem cell transplantation: a review of the literature background:hemophagocytic lymphohistiocytosis (hlh) is an inherited or acquired disorder of immunedysregulation. early diagnosis and immunosuppressive treatment can prevent significant organ-failure. the inherited forms, and some acquired cases can only be cured by hematopoietic stem cell transplantation (hsct). with modern transplant practices, a significant number of patients survive. the purpose of this literature review was to collect data on the frequency and type of late effects in hlh patients surviving after hsct and to examine the association with pre-existing hlh conditions (eg. involvement of the central nervous system (cns) before transplant) and with the pre-transplant conditioning regimens.methods: the medline, embase, web of science and pubmed databases were searched, by two librarians at the karolinska institutet, between may and september according to the preferred reporting items for systematic review and meta-analysis (prisma) statement. the search terms included "hlh", "fhl", "mas", multiple terms for "hsct" and late-effect conditions. inclusion criteria were publications in english that included children between january and may . authors of this review screened all the abstracts of studies against the inclusion criteria.results: only nine papers published between and , with information on late effects in hlh patients who had undergone hsct, were identified. three reports include only small numbers of hlh patients. the remaining papers contain data on long-term survivors with a median follow-up of . years. five papers address neurological sequelae with a reported incidence from - %. the highest incidence was found after a thorough neurological assessment of hlh patients compared to matched sibling controls. however, the association with cns disease before transplant and age at transplant was not clear. patients with ebvassociated hlh seem to have fewer long-term neurological problems. non-neurological late effects are described in papers only, with endocrinological problems, namely short stature, being the most frequent. one paper specifically analyzed poor growth, thyroid dysfunction and vitamin d deficiency in a cohort of patients with non-malignant disorders including hlh who had undergone hsct after a reduced intensity conditioning regimen and found significant abnormalities in all groups.conclusions: data on late effects in hlh patients is scarce and is mostly based on the retrospective evaluation of small national cohorts. the available information indicates that a significant number of patients suffers from problems which affect their daily life, but lack of information does not allow to analyze the association between pre-transplant conditions and long-term sequelae. therefore, a retrospective comprehensive analysis of patients registered in the ebmt and cibmtr registries is currently performed. it will be crucial to better define the frequency and type of late effects in a large cohort. this knowledge will aid counselling prior to hsct, provide guidance for long-term monitoring of these patients, and potentially identify specific risk factors for late effects in this rare patient population.disclosure: nothing to declare. allogeneic stem cell transplantation in patients with mucopolysaccharidosis type ii (morbus hunter)bernd hartz , nicole muschol , matthias bleeke , johanna schrum , ingo müller background: the transplantation of hematopoietic stem cells (hsct) is one of the leading methods of treatment in patients with blood system diseases, primary immunodeficiency syndromes and genetic diseases. at the same time, the quality of life in patients in the long-term after hsct significantly differs from the quality of life of healthy people of the same age. deformations in psychosexual development including problems in the gender identity formation cause social isolation of adolescents, which makes their sexual selfrealization impossible and significantly reduces the quality of their life. the purpose of our study was an assessment of the level of gender identity formation of adolescents and psychosexual development correlation to the normal adolescents of the same age.methods: in a prospective single-center study in , on the base of the department of rehabilitation medicine raisa gorbacheva memorial institute of children´s oncology, hematology and transplantation, we conducted a study of families. the respondents were: ) parents / guardians of patients accompanying them in the process of examination; ) adolescents who underwent hsct treatment and undergo planned examinations at the clinic in the posttransplant period (after d + ), (n = , of which girls and boys, age - years, from the date of hsct - years).the following methods were used to assess gender identity: specially developed questionnaires for teenagers and parents; questionnaire by sandra l. bem (sandra l. bem, ) ; projective techniques "the human picture", "the non-existent animal"; max lüscher´s color choices test.results: the traditional type of gender identity, which characterizes high masculinity among male respondents and high female gender indicators in % of cases, was not revealed. both among girls and among boys, the androgynous type prevails with a tendency toward femininity.on average, adolescents see themselves as a bit more courageous than their mothers, with rare exceptions, regardless of gender. this confirms the thesis that we received in a previous study that parents tend to see and encourage complacency of adolescents of both sexes, passivity instead of leadership, dedication and independence. all % of adolescents who participated in the test demonstrate a shift in the theme of aggression, % have some signs of preventing sexual self-determination, abandoning their body, gender, and age. % of patients do not communicate with their peers. in % of them, negative emotions prevail over positive ones. one third of the test participants demonstrate strong support for rest and minimizing their efforts.conclusions: the characteristics of family upbringing of adolescents who have undergone hsct often contribute significantly to limiting their social experience and lead to specific deformities of individuality, including in the sphere of gender identity. we consider advisable to introduce thematic group counseling of parents within the framework of the "patient's school" in psychological treatment support in the clinic. early diagnosis of the personal aspects of the psychosexual development of adolescents after hsct allows for timely identification of individual problems in this area and identification of general trends in the long term after hsct.disclosure: all authors -nothing to disclose. abnormalities in the morphology of the umbilical cord blood obtained at delivery from children who received a diagnosis of cerebral palsy maciej boruczkowski , izabela zdolińska-malinowska , maciej rojek , dariusz boruczkowski background: embryonal brain tumors are the most common malignancies in infants less than months of age. histologically characterized as undifferentiated small round cell tumors, all are similarly aggressive, have a tendency to disseminate throughout central nervous system and very poor prognosis. we tried to assess the effectiveness of tandem highdose chemotherapy (hdct) with autologous hematopoietic stem-cell transplantation (auto-hsct) in this patient group. methods: from to , infants under months with different primary embryonal brain tumors such as medulloblastoma (n= ), different pnet nos (n= ), pineoblastoma (n= ), atypical teratoid rhabdoid tumor (n= ), etmr (n= ) after surgical resection and induction chemotherapy were planned to receive tandem hdct with auto-hsct. nine patients were conducted only single transplantation because of the development of lifethreatening complications after the first hdct (n= ) or the emergence of early disease progression (n= ). at the moment of hdct patients were in complete remission (cr), patients were in partial remission (pr) and patient had stable disease (sd). the conditioning regimen for tandem auto-hsct were: the first hdct was carboplatin and etoposide, the second was thiotepa and cyclophosphamide, both with intraventricular methotrexate.results: the median follow-up is months (range, - ). the median time to engraftment after the first auto-hsct was background: a series of findings suggest that optimizing natural killer (nk) cell reactivity could further improve outcome after allogeneic hematopoietic cell transplantation (allohct). this could be achieved by killer cell immunoglobulin-like receptor (kir) genotype informed donor selection. an enhanced receptor-ligand model which used kir ds and kir dl donor genotype information to augment nk cell activation and minimize inhibition demonstrated improved survival in one large aml study (boudreau et al, jco ) . likewise, a second model built on the classification of centromeric and telomeric kir haplotype motifs, also predicted mortality after allohct for aml (cooley et al, blood ) . this joint ebmt and cibmtr study aimed at validating the two approaches in an independent cohort of patients with mds or secondary aml.methods: donor samples were retrieved from the collaborative biobank (dresden, germany) and mapped to patient outcome data extracted from the ebmt and cibmtr. genotyping of all kir genes by sequencing exons , , , , , and was performed by high resolution amplicon-based next generation sequencing. the impact of the classifiers on time-to-event outcomes was tested in cause-specific cox regression models adjusted for patient age, a modified disease risk index, performance status, donor age, hla-match, sex match, cmv match, conditioning intensity, type of t-cell depletion and graft type.results: clinical data from patients and corresponding donor genotype information were analyzed. the median age at allohct was . years (range, . to . years). the indication for allohct was mds for % and saml for % of patients. disease risk was low/intermediate and high/very high in % and %, respectively. donors were / matched for % of patients. myeloablative, reducedintensity and non-myeloablative conditioning regimens were used in %, %, and % of patients, respectively. peripheral blood stem cells were the predominant graft source ( % of patients). atg was administered in % and alemtuzumab in % of patients. during follow-up after allohct patients died. in univariable and multivariable analyses of the whole cohort, overall survival and the cumulative incidence of relapse of patients with kiradvantageous versus disadvantageous donors were not statistically significantly different. we could not replicate the pattern of outcomes predicted by the kir dl / conclusions: relapse incidence and overall survival after unrelated donor allohct could not be predicted using the kir dl /kir ds -receptor-ligand model and centromeric/telomeric kir-motif model in this large cohort of patients with mds or secondary aml. this points at the possibility of interactions between nk-cell mediated alloreactivity and disease type or procedural variations of allohct. available information on kir-genes, which have been sequenced but not yet analysed, will be investigated in exploratory analyses.disclosure: the authors have nothing to disclose in the absence of an alternative donor, it is recommended that patients undergo desensitization therapy, especially with high dsa levels (> , mfi). the aim of this study is to analyze the impact of dsa on risk of gf and poor graft function (pgf), and on major outcomes in a consecutive cohort of patients who were systematically screened for dsa before haplo-sct. methods: consecutive patients were candidates for unmanipulated haplo-sct with post-transplant cyclophosphamide (pt-cy) at our center from january to january and were analyzed for the presence of hla antibodies.results: patients underwent haplo-sct. hla antibodies were detected in patients, of them were dsa, while were non-dsa (ndsa). patients out of with dsa were transplanted using the same donor; underwent a desensitization program before transplant.background: a recent study from ebmt comparing matched sibling (msd) versus haploidentical donors transplantations, showed better outcome with msd in adult patients with intermediate risk aml in first remission (cr ). however, a female donor to a male recipient transplant combination is a poor prognostic factor and this study did not address the question whether in this situation, a haploidentical donor transplant might do better. the present study compared the outcomes of allografted male patients according to whether they received stem cells from a female msd or a haploidentical donor, in the intermediate and high risk cytogenetics groups (mrc classification).methods: the study included male patients with cytogenetics transplanted between january and june and reported to ebmt. received stem cells from a msd female donor and from a haploidentical donor ( male and female). the follow up was months ( - ). we studied separately intermediate and high risk patients. multivariate analysis was adjusted on factors differing significantly between the groups.results: -intermediate risk group: male patients received a female msd and a haploidentical transplant. the distribution of group characteristics was even except that in the haploidentical transplant group, donors were younger ( y versus ; p< . ), marrow was more frequently used ( % versus %, p< . ) and the interval from diagnosis to transplant was longer ( . versus . months, p< . ). by univariate analysis at two years post transplant, cumulative incidence (ci) of nrm post haplo was higher ( % versus %, p= . ) and ci of extensive chronic gvh lower ( % versus %; p= . ). lfs post msd and post haplo were % and % (p= . ), os % and % (ns), grfs ( % and %). by multivariate analyses the only significant poor risk factors were the haplo-identical transplant for nrm (hr: . ( . - - )) and the patient age for os (hr: . ( . - . ; p= . ). haploidentical transplantation resulted in less chronic gvhd (hr: . ( . - . ); p < - ), but a lower lfs (hr: . ( . - . ); p= . ). -high risk group: male patients received a female msd and a haploidentical transplant. in the haploidentical group, donors were younger ( y versus ; p< . ), marrow was more frequently used ( % versus %, p< . ) and the interval from diagnosis to transplant was longer ( . versus . months, p= . ). by multivariate analysis, haploidentical transplants were associated with a lower relapse incidence (hr: , ( . - . ; p = . ),a better lfs (hr: , ( . - . ; p = . ),os (hr: , ( . - . ; p = . ), and grfs (hr: , ( . - . ; p = . )(see figure) . the only other significant prognostic factor was patient age.conclusions: this study shows that in a male patient with intermediate risk aml, a genoidentical sister donor remains associated with a better lfs. in contrast, in a male patient with high risk aml in cr , a haploidentical donor may be a better choice than an hla genoidentical sister.disclosure: nothing to declare p abstract already published. hematopoietic transplant for older acute leukemia patients: improved survival with offspring donor in comparison with older-aged matched siblingsyu wang , sheng-ye lu , qi-fa liu , de-pei wu , xiao-jun huang background: post-transplant relapse remains the major cause of death of treatment failure. therapeutic options for relapse after first allogeneic stem cell transplant ( st hsct) include chemotherapy followed by donor lymphocyte infusion or second allo-hsct ( nd hsct) from the original donor or change to another donor. however, there is unclear outcome for different treatment approach. in this retrospective cohort study, we aim to compare the clinical outcome after different treatment strategy for relapse after first allo-hsct.methods: between jan and oct, consecutive patients receiving st hsct registered to the bmt database in national taiwan university hospital were analyzed. among them, cases had relapsed after first allo-hsct. one hundred and three patients who received no treatment after relapse or with incomplete data were excluded. their transplant data was collected following the ebmt registry data collection forms and manuals. overall survival rate and progression free survival rate were performed by the kaplan-meier method. univariate and multivariate analysis were performed using cox proportional hazard regression model.results: of the patients who experienced relapse after st hsct, total patients ( %) received chemotherapy followed by dli or nd hsct from the same donor (no change group), patient ( %) received chemotherapy followed by nd hsct from different donors (change group), and ( %) had conventional chemotherapy alone. the patients in "change group" were younger (median age vs , p = . ), and had more patients achieving complete remission (cr) prior to nd hsct ( % vs %, p = < . ) than patients in "no change group". after the nd hsct, the cr was % for "no change group" and % for "change group". the progression-free survival at -year and -year were . % and . % (fig a, p = . %), respectively, for "no change group" and . % and . %, respectively, for "change group". while the overall survival (os) at -year and -year were . % and % (fig b, p = . %), respectively, for "no change group" and . % and %, respectively, for "change group". those who achieved cr prior to nd hsct had a trend of better os than those without cr ( . % vs . % at -year; . % vs . % at year, p =. )( fig c) . there were cases survived for more than years in "change donor group" and cases survived more than years in "no change group". only one had developed relapse after nd hsct but achieved subsequent remission again.conclusions: our study shows that change donor had similar poor outcome comparing to those using the same donor after the st hsct. patients who achieved cr before nd hsct had a trend of better os than those without remission and the long-term survivors were only those who achieved cr prior to nd hsct. novel therapy for cr induction would be warrant for this poor prognostic population.disclosure: nothing to declare functional relevance of fetal microchimerism in nk cell cytotoxicity against leukemic blasts in children: a role for hla-c and kir dl /s ?background: allogeneic stem cell transplantation (allo-sct) remains the most effective curative intent therapy for patients with unfavorable risk acute leukemia. various donor options are available for the patient who lacks an hla-matched sibling donor, such as unrelated donors (urd) and hla-mismatched family (haploidentical) donors. in order to discover the exact role of transplantation type, there are many retrospective analysis, which compared these donor sources, have been reported. recent studies showed some promising results of haploidentical donor transplantation (hidt) using post-transplant cyclophosphamide in comparison with unrelated donor. the goal of this study was to compare the outcome of allo-sct from haploidentical versus matched unrelated (mud / ) or mismatched unrelated donor at a single hla-locus (mmud / ) for patients with acute leukemia in remission.methods: ninety-six adult ( - years) patients with acute leukemia in first or second remission who underwent allogeneic transplantation with a minimum days follow-up at florence nightingale hospital hematopoietic stem cell transplantation center between and were included in this study. patient characteristics and medical records of all patients were reviewed retrospectively. thirty-eight patients who received haploidentical donor transplantation were compared with patients receiving a mud / and receiving a mmud / . patients who completed minimum days post-transplantation follow-up were identified as eligible for survival analysis.results: the characteristics of the patients and transplant donors in this study are summarized in table . median age of patients was . ± years. proportion of male patients was . %, . % and . % for mud / , mmud / and hidt groups, respectively, which is significantly different (p= . ). the other baseline factors were similar, including patient age, donor age, recipient cytomegalovirus (cmv) status, donor cmv status, graft versus host disease incidence, median neutrophil and platelet engraftment times and disease status at post-transplant th day. no significant difference was identified in survival analysis among the mud / , mmud / and hidt groups, even if they were classified according to primary disease (aml vs all) and pre-transplant disease status (cr vs cr ). also, donor cmv status (cmv igg positivity or negativity) was not an important factor on survival analysis when compared between these three groups (p= . ).conclusions: in our study population, clinical outcomes of hidt patients were inferior to mud / and mmud / groups. when choosing an alternative donor for patients without an available hla-matched sibling, urgency of transplantation and host/donor features should be considered. we believe that hidt might be a feasible alternative choice in this subset of patients.disclosure: nothing to declare p g-csf primed bone marrow in hla-haploidentical transplantation using post-transplantation cyclophosphamide (ptcy) could promote tolerance and further reduce risk of gvhd nadira durakovic , , zinaida perić , , lana desnica , ranka serventi-seiwerth , mirta mikulić , brian melamed , alen ostojić , dražen pulanić , , pavle rončević , zorana grubić , radovan vrhovac , implementation, development, and coordination of unique quality management systems with evaluation audits, intrahospital and international accreditation and certification processes. quality of health care is a major focus for providers, patients, and accreditors; so, in this study, we aim to compare the quality of bm harvested at ipo-collection centre (icc) with the quality of bm received from external collection centres (ecc) during these last years.methods: this retrospective evaluation included the number of total nucleated cells (tnc) requested by the transplant centre, the tnc collected, and the results of bm microbiological analysis performed; donor age, weight and infectious disease markers (idm); patient demographics and diagnosis. bm collection technique in use at icc was validated according to jacie standards.we consider successful a collection (sc) with tnc between and % of the requested value, unsuccessful (uc) if lower than % and outstanding (oc) if over %.results: a total of bm was collected, for allogenic ( unrelated) and seven for autologous transplant; unrelated bm were received from ecc (nine from germany, seven from usa and five from portugal). patient main diagnosis were severe aplastic anaemia (n= ), acute myeloblastic leukaemia (n= ), and acute lymphoblastic leukaemia (n= ). donors idm were all negative and nonreactive.mean age (±standard deviation, sd) was (± . ) and (± . ) years for icc and ecc donors, respectively. at icc, we were asked to collect an average (±sd) of . * (± . ) tnc while ecc were asked for . * (± . ). we collected . * (± . ) and received . * (± . ) tnc. correlation between requested and collected tnc was . at icc and . for ecc.we had . % sc and . % oc meaning an accomplishment of . %. we failed to collect required tnc in . %. although % of received bm fulfil tnc requirements, bm processing lowered this value to % due to erythrocyte removal (seven patients with major abo incompatibility) and plasma reduction (two patients with abo minor incompatibility). these steps reduce final tnc available for transplant. weight difference between donor and patient had no significant impact on final tnc collection performance.sixteen bm from icc (seven staphylococcus spp., five propionibacterium acnesand fourcorynebacterium spp.) background: success of peripheral blood stem cell (pbsc) collections depends on patient biological parameters and stable apheresis device performance. peripheral blood cd + cell enumeration is the most reliable predictive factor of apheresis yield however, there are some unexpectedly poor cd + cell harvests despite successful mobilization. the aim of the study was assess total collections cd + yields and factors influencing main apheresis procedure outcomes including collection efficiency (ce).methods: of consecutive donors covering the period - - to - - were analyzed for the following parameters: pre cd count, cd yield per procedure, total cd dose collected per patient, cd collection targets requested by clinical teams. the efficiency of pbsc procedures was determined by calculating the ce and the correlation coefficient between pre cd count and yield per procedure. ce was correlated to preprocedure wbc, platelet count, pre cd count and blood volume processed. all pbsc collections were performed by optia spectra across units in uk.results: of the donors, were autologous and allogeneic. the autologous donors underwent in total procedures. the median cd target dose for these donors was x /kg. ( %) achieved the target dose with procedure and ( %) with procedures. the median pre cd count was /μl. the median cd yield per procedure was . x /kg and the median total cd dose collected per donor was . x /kg. ( . %) of autologous donors collected a total cd dose < x /kg, of those ( . %) had a pre cd count < /μl and ( %) > /μl.the allogeneic donors underwent in total procedures. the median cd target dose for these donors was x / kg. allogeneic donors ( %) achieved the target dose with procedure and ( %) with procedures. the median pre cd count was /μl. the median cd yield per procedure was . x /kg and the median of total cd dose collected per donor was . x /kg. ( . ) % of allogeneic donors collected a total cd dose < x / kg, of those ( . %) had a pre cd count < /μl and ( . %) > /μl. the median ce for autologous donors was % (range - ) and for allogeneic donors was % (range - ). the ce was negatively correlated to wbc (r= - . and - . ) and platelet count (r=- . and - . ) for auto and allogeneic donors respectively, but did not correlate to the pre cd and blood volume processed. the correlation coefficient between pre cd count and cd yield per procedure was r = . for the autologous and r = . for the allogeneic collections.conclusions: the majority of autologous and allogeneic donors achieved the target cd dose with one procedure. . % of autologous and . % allogeneic donors collected a transplantable cd dose of > x /kg. % of autologous and . % of allogeneic donors did not collect a transplantable dose despite a precd count of > /μl indicating suboptimal procedure performance. the ce was variable and was negatively correlated to the preprocedure wbc and platelet count. the ce and correlation coefficient are lower in allogeneic donors compared to autologous donors.disclosure: nothing to declare the outcome of autologous blood stem cell collection and its actual use in real world: the st century experiencekyoungmin lee , jung yong hong , dok hyun yoon , jae-lyun lee , shin kim , kyoung min lee , jung sun park , cheolwon suh background: mobilized peripheral blood stem cells (pbscs) have largely replaced bone marrow as the graft source for allogeneic stem cell transplantation. pbscs mobilization with g-csf is highly effective even on the th day in order to collect enough number of stem cells. a longitudinal, prospective, observational, single-center, cohort study on healthy donors (hds) was designed to identify predictors of cd + cells on the th day. methods: as potential predictors of mobilization, age, sex, body weight, height, blood volume as well as white blood cell count, peripheral blood (pb) mononuclear cells, platelet count, hematocrit, and hemoglobin levels were considered. two different evaluations of cd + cell counts were determined for each donor: baseline (before granulocyte colony-stimulating factor [g-csf] administration) and in pb after g-csf administration on day . a total of consecutive hds with a median age of . years were enrolled.results: the median value of cd + on day was cells/μl (iq - ). basal wbc, plt and basal cd +, are significantly higher for group with cd + on the th day over the median than below. a multivariate quartile regression analysis, adjusted by gender, age, basal cd + and basal plt, shows a, progressively steeper, relationship between baseline cd +, basal plt and cd + on the th day. the basal cd + cut-off for prevision of cd + on the th day was < = cells/μl and >= cells/μl whereas basal platelets count was < = x /l and >= x /l.conclusions: g-csf can be highly effective in hds on the th day in order to collect enough number of stem cells and we have developed a model for predicting the probability to perform pbsc collection after a short course of g-csf.disclosure: nothing to declare p pre-apheresis peripheral blood cd + cell counts highly correlates to actual stem cells collected background: prediction of stem cell yield on the basis of pre-apheresis cd + cell count and the processed blood volume is essential for the planning and executing of the apheresis process.methods: data analyzed included donor weight, complete blood count and cd + count on day of collection, total processed blood volume, cd + cell dose collected in the apheresis product and the number of aphereses performed. using the method described by pierelli et al, predicted cd + yields were calculated: predicted cd + yield x /kg = (benchmark ce x volume of blood to be processed x peripheral cd + count per μl) / (patient's weight in kg x metric conversion factor).results: in we established the method described by pierelli to predict the cd + cell yield. allogenic aphereses were performed in with this approach. mean processed volume was . liters. the mean cd + peripheral count before apheresis was /ul, the mean collected cd +count per kg bodyweight recipient was . . pearson´s correlation coefficient (r) between predicted yield using pre-apheresis cd +count and actually collected cd + cells per kg bodyweight recipient was . . the mean difference between predicted and collected cell dose was + . %.with knowledge of the predicted stem cell count, we were able to adjust apheresis procedure. in case of marginal predicted yield compared to the requested cell dose, we increased the blood volume to be processed. this proceeding led to a significant reduction of second day donations in by % compared to . in only cases we saw more than - % lower cd + doses collected than initially predicted. all donors showed mild iron deficiency with rbc microcytosis, a factor known to affect apheresis procedure.conclusions: pierellis method of calculating the stem cell yield shows a good correlation between pre-apheresis cd + count and actual collected stem cells, making planning and adjusting of the apheresis procedure more feasible and reliable. this proceeding led to significant reduction of second day donations. attention should be paid to iron deficiency anemia, leading to lower than estimated cd + dose.[ background: for more than a decade many transplant centers routinely collect and cryopreserve two or more peripheral blood stem cell (pbsc) grafts for a tandem and/ or salvage autologous blood stem cell transplantation (absct) in patients with hemato-oncological diseases. however, subsequent high-dose chemotherapy (hd-cht) and absct is in many cases not performed for a variety of reasons, specifically in patients with aml, all, mpn and burkitt lymphoma. data about the actual utilization rate of the cryostored stem cell products are lacking.methods: we retrospectively analyzed the collection, storage and disposal practices of pbsc products from a large cohort of patients who were treated at the university hospital heidelberg or at the university medical center mannheim during a -year period. disease entities included acute myeloid leukemia (aml, n= ), acute lymphoblastic leukemia (all, n= ), mpn (n= ; primary myelofibrosis [pmf], n= ; chronic myeloid leukemia [cml], n= ; secondary fibrosis/essential thrombocythemia [et], n= ; not specified, n= ) and burkitt lymphoma (n= ). patients between and were included and followed until .results: an adequate stem cell graft was defined as ≥ . x exp cd + cells /kg body weight. % of the patients were able to collect at least one stem cell graft and the median number of grafts per patient was (range - ). we could demonstrate that only % of all patients who had collected sufficient pbscs for transplant subsequently underwent an absct. among the disease entities the actual use of the stored pbsc grafts varied considerably from % to % (figure ) .conclusions: we could identify striking discrepancies between the collection/storage and actual utilization of background: biosimilars (bio) of granulocyte colony stimulating factors (gcsf) were approved several years ago on the basis of some studies that indicated similar efficacy to the already patented gcsf (neupogen®, neu) both in terms of shortening the neutropenic period after chemotherapy as well as peripheral blood stem cell mobilization in patients with lymphoma and multiple myeloma (mm) treated with autologous stem cell transplantation (auto-hct). however, all these studies are retrospective and there are still concerns about the real efficacy of bio and even more about the real benefit on final costs.methods: we have retrospectively compared the characteristics of the mobilization procedure in both patients with mm and lymphomas, and healthy donors that received either neu or bio (with no chemotherapy) in university hospitals in catalunya from december / to november . bio replaced neu in june in all institutions. primary objectives were the mobilization rate (defined as the percentage of patients that achieved ≥ x /ml cd + cells in peripheral blood on day ) and the use of plerixafor (plex) in each group as pre-emptive strategy. a multivariable analysis of risk factors influencing the use of plex and mobilization failure (defined as collection of < x /kg cd + cells) was also performed.results: we treated patients ( lymphomas and mm) and healthy donors. both groups of patients ( neu and bio) and donors ( neu and bio) were comparable regarding pre-mobilization general characteristics. there was a trend for a lower median cd + peak on day for bio patients ( vs , p value = . ). a total of patients received plex, although of them ( . %) out of strict theoretical indication, cd + cells > x /ml (range . - . ) and were removed for further analysis (n = , in the neu group and in the bio group). median number of cd + cells on day was significantly lower in the group bio who needed plex ( . vs . for neu+plex, p= ), as well as cd + cells finally harvested ( . vs . x /kg, p= . ). mobilization failure rate was higher in bio group ( vs %, p= . ). regarding no plex patients, median number of cd +cells on day was also significantly lower for bio patients ( . vs . , p= . ). risk factors for plex use were age, basal disease (lymphoma) and number of prior mobilization therapies. the use of bio was the only risk factor for mobilization failure patients receiving plex [hr . ( %ci . - . ), p= . ]. with respect to healthy donor mobilization, none of them needed plex but cases from the bio group ( %) needed more than one apheresis procedures ( and , respectively).conclusions: we found a lower efficacy of bio in the setting of stem cell mobilization of patients with only gcsf both in terms of a lower cd + cells peak on day and a lower number of cd + cells in final apheresis product. bio gcsf also seems to be less effective in healthy donors.disclosure: no conflict of interest to be declaredbackground: auto-sct is a common treatment in patients with mm or nhl. the aim of the prospective multicenter goa (graft and outcome in autologous transplantation) study was to investigate the impact of mobilization method used on the cellular composition of collected blood grafts and eventually hematological and immune recovery as well as long-term outcome post-transplant. altogether patients with mm or nhl transplanted between / and / at four university hospitals were included. the long-term goal of the study is to evaluate characteristics of optimal blood grafts in regard to post-transplant recovery and outcome. methods: altogether patients with mm undergoing first auto-sct were compared with patients with nhl. all nhl patients were mobilized with chemotherapy + g-csf, whereas % of mm patients were mobilized with g-csf only (p < . ). mobilization data, graft cellular composition including cd + cell subsets and lymphocyte subsets of the blood grafts, post-transplant hematological recovery and outcome were evaluated. the median followup time was months in mm patients and months in nhl patients.results: mm patients mobilized cd + cells better (median peak blood cd + vs. x /l, p < . ). the median number of aphereses was in both groups (p = . ). altogether % of the nhl patients received plerixafor compared to % in mm patients (p = . ). the median number of cd + cells collected was higher in mm patients ( . vs. . x /kg, p < . ).the median amount of cd + cells (with -aminoactinomycin) in the infused graft was . x /kg in mm group and . x /kg in nhl group (p = . ). the grafts contained more nk cells (median . vs. . x /kg, p = . ) and cd + cells (median . vs. . x /kg, p < . ) in mm patients. neutropenic fever tended to be more common in nhl patients ( % vs. %, p = . ) but mm patients had significantly more bloodstream infections ( % vs. %, p = . ). the median duration of hospitalization was longer in the nhl patients ( d vs. d, p < . ) and the nhl patients had significantly more often icu admissions ( % vs. %, p = . ).post-transplant neutrophil engraftment was faster in the nhl group (median d vs. d, p < . ). the median time to platelet engraftment was days in both groups. platelet count was higher in the mm group from day until year after auto-sct. there were significantly more early deaths (< d from the graft infusion) ( % vs. %, p = . ) and non-relapse deaths ( % vs. %, p = . ) in the nhl group.conclusions: mm and nhl patients differ in terms of cd + cell mobilization, graft cellular composition and post-transplant recovery as well as risk of non-relapse death. thus, the optimal graft may be different in nhl and mm patients.disclosure: the study was supported by vtr fund from north savo hospital district and study grant from sanofi. abstract already published. single-center experience in use of plerixafor for autologous stem cell mobilization: change in practice over years background: plerixafor has been proven to mobilize human periferal blood stem cells (pbscs) alone or acting synergistically with granulocyte-colony stimulating factor (g-csf). it has mainly been used for rescue mobilization after failed regimen of chemotherapy plus g-csf, but lately preemptive use in poor mobilizers has been established as cost-effective. we aim to show ten years of experience and change in practice with plerixafor use in our center.methods: we retrospectively evaluated the outcome of mobilization procedures and leukapheresis collections in our center in the period from january to october . practice from the first years, when plerixafor was mainly used as rescue agent after failed attempt, was compared to period from till present when preemptive use in poor mobilizers (defined as cd + cell counts < x /l blood) was established.results: in the period from to , total of patients underwent collection of autologous pbscs, and patients required repeated mobilization cycles ( , %). g-csf alone was used in patients and patients ( %) recieved combination g-csf with plerixafor. this cohort consisted of males and females with non-hodgkin (nhl) and hodgkin lymphoma (mh); and respectively. we noted unsuccessful mobilizations ( , % in repeated mobilization, , % in total) of which one patient was from plerixafor group ( , %).background: transplantation of hla-haploidentical hematopoietic stem cells (haplo-hsct) is an established procedure for the treatment of several different hematological diseases. one possible strategy to reduce the risk of graft-versus-host disease is represented by the selective depletion of ab t-lymphocytes (coupled with the depletion of cd + b-cells in order to reduce the risk of ptld) using the clinimacs device (miltenyi, bergish-gladback). before depletion, leukapheresis units are washed by lowspeed centrifugation, resulting in a platelet (plt) rich supernatant (prs) as a by-product generally discarded. we studied the possibility of recovering plt from prs of the haplo donor for transfusion to the recipient during the aplasia period occurring after hsct.methods: hsc donors were mobilized with g-csf (plus plerixafor in out of donors) as previously described [locatelli et al, blood ] . leukapheresis units, obtained with a spectra optia device, were washed twice (producing prs bags) at low speed to remove plt before starting the ab t-cell/b-cell depletion. the two prs were leukodepleted by filtration, centrifuged, resuspended and pooled in a total volume ranging from to ml intersol (is-plt) for overnight incubation at °c with agitation ( cycles/min). the is-plt samples were analyzed for the criteria established by the italian transfusion law. is-plt bags were examined for the following parameters: volume > ml, plt after leukodepletion > x , residual leukocytes < x , ph > . at °c at the end of the -day storage period. the sterility was tested using bd bactec culture vials. the evaluation of the residual leukocytes was performed with the bd leucocount kit. the absolute plt counts were determined using hemocytometer sysmex xn .results: prs bags from donors were processed to produce is-plt units. median resuspension volume in intersol was ml (range - ). the absolute mean value of plt counts measured at the end of the storage period was . x (range . - . x ). this value was found below the threshold fixed by italian regulation in cases ( . %). mean value of residual leukocytes was . x (range - x ); the ph value was always > . . sterility was observed in all cases. according to the work of slichter et al. conclusions: we demonstrated that plts recovered from leukapheresis bags can be accepted as a conventional hemocomponent according to the parameters fixed by italian transfusion law and thus can be administered to the haplo-hsct recipients early after transplantation. this strategy carries several advantages. indeed, apart from the obvious advantages in terms of reduced costs, is-plt can be used to desensitize the recipient by absorption of anti-hla class i antibodies, if present in the recipient. moreover, this strategy can avoid the risk of sensitizing the transplanted patients with hla alleles that differ from the donor's ones. finally, the is-plt unit is readily available. a clinical study aimed at testing the use of is-plt units in transplant recipients will be performed to confirm the clinical efficacy of the approach.disclosure: nothing to declare p ultrasound guidance as a powerful tool in increasing background: peripheral blood stem cells are generally the preferred graft source for allogeneic stem cell transplantation for malignant disease. in most centers first apheresis is performed on day after to doses of granulocyte colony stimulating factor (gcsf) up to ug/kg twice daily. the dose of gcsf and the number of apheresis procedures required contribute to symptom, travel and time burden donors are put through during the process. we hypothesized that taking donor-recipient weight differences into consideration may help reduce this burden methods: a total of healthy donors who donated peripheral blood stem cells on day of gcsf mobilization in the period between january and august at the university medical center hamburg-eppendorf were included in this quality control evaluation. the donors were divided into two cohorts. the impact of donorrecipient weight ratio on stem cell harvest was tested in the training cohort ( - ) and validated in the second cohort ( ) ( ) . for the training cohort, donors were grouped according to donor-recipient weight ratio < . vs. . - . vs. > . . for the purpose of this analysis a stem cells dose of x cd +/kg recipient weight was set for successful apheresis.results: in the training cohort including donors, ( %), ( %) and ( %) had a donor-recipient weight ratio of < . , . - . and > . respectively. the target stem cells count of x cd +/kg recipient weight was achieved in of ( %), of ( %) and of ( %) donors with donor:recipient weight ratio < . , . - . and > . respectively. the cut-off for the validation cohort was therefore set at a weight ratio of . .in der validation cohort including donors, ( %) had a weight ratio > . while ( %) had a weight ratio ≤ . . overall in this cohort target cell count of x cd +/kg recipient weight was reached in ( %) cases. this target was reached in of ( %) of donors with weight ratio ≤ . and in of ( %) donors with weight ratio > . , p = . .conclusions: a donor-recipient weight ratio of > . is seen in about % of peripheral blood stem cell donations for allogeneic stem cell transplantation. in these cases apheresis on day after doses of gcsf is reasonable. donors with lower weight ratios should preferentially donate on day after to doses of gcsf.disclosure: all authors declare no conflicts of interest background: the effect of a second mobilization and collection of peripheral blood stem cells (pbsc) on the cell yield is low, as we previously demonstrated. however, donor safety has been poorly addressed with no changes in the clinical practices.methods: second donations of unrelated and related donors performed between and were evaluated (n= ), including pbsc+pbsc (n= ), bone marrow (bm)+pbsc (n= ) and pbsc+bm (n= ). analytical parameters including leukocyte, lymphocyte, hemoglobin and ldh quantification, obtained on the pre-harvest evaluation of first and second donation, were retrospectively analyzed and compared for all donors. the portuguese bone marrow donors registry (cedace) recommends a time between donations no lesser than months. it also states that in very urgent situations like graft failure, donor should be clinical and analytical cleared and its safety ensured.in order to evaluate the impact of time between donations, donor population was divided in groups: < months, - months, > months; to determine the influence of donor age, donors were divided in groups: < and ≥ years.results: among the total of donors, were volunteer donors of cedace and were familiar. fifteen second donations were performed because of recipient graft failure and due to disease progression or relapse. at the time of second collection, median donor age was years (range - ). the median delay between both collections was days ( - ). time between donations did not seem to substantially impact the analytical donor evaluation: leukocytes, lymphocytes, hemoglobin and ldh results are kept within the reference values. however, donors with less than months between donations showed a slight decrease on leukocyte counts ( %) and hemoglobin values ( %), from the first to the second pre-harvest evaluation. donor age showed no significant influence on the analytical evaluation. nevertheless, when considering only the pbsc+pbsc donations, donors with ≥ years showed a small decrease on lymphocyte counts ( %) .conclusions: this study demonstrated that the analytical parameters, chosen based on literature, had no significant changes between first and second donation. however, particular attention should be paid when time between donations is lesser than months or donor age is ≥ years.as we concluded that no significant changes were observed in the group of - months, it is our opinion that the minimum of - months established by the registries can be shortened to months ensuring donor safety. an accurate donor risk assessment with a larger population should be accomplished in order to strengthen this recommendation.disclosure: nothing to declare. gaurav kharya , atish bakane , pratibha dhiman , anil khetrapal , vikrant bhar background: t cell replete haploidentical stem cell transplant (hhsct) is complicated mainly by increased risk of graft failure (gf) and graft versus host disease (gvhd). conventionally gcsf has been used to mobilize hematopoietic stem cells (hsc). in tcr hhsct gcsf mobilized graft with megadose of cd + cells expose the patient to higher doses of alloreactive t cells increasing the risk of gvhd. plerixafor based mobilization gives an advantage of giving high cd cell dose limiting exposure to high alloreactive t cell dose. we share our experience of gcsf + plerixafor based mobilization for tcr hhsct. methods: consecutive patients suffering from scd who underwent hhsct between jan till date along with the respective donors were enrolled in the study (group ). all underwent pre-transplant immune suppression (ptis) cycles at weekly intervals using fludarabine+cyclophosphamide+dexamethasone.the graft was mobilized using gcsf@ mcg/kg/day(d -d )+plerixafor@ . mg/kg(d ) - hours before the pbsch. gvhd prophylaxis included ptcy mg/kg/ day on d and , sirolimus and mmf starting from d . group included historical controls where graft was mobilized using gcsf@ mcg/kg/day(d -d ). various parameters pertaining to mobilization, harvest, engraftment, gf and gvhd were assessed between the two groups.background: poor mobilizers (pm) defined as those with a peripheral blood cd + count ≤ cells/μl on day+ is a significant risk factor for mobilization failure. within these, patients with < cells/μl are considered as very poor mobilizers (vpm). use of plerixafor in vpm patient is controversial. the aim of our study is to compare mobilizing and engraftment between pm and vpm who received plerixafor plus g-csf (p+g-csf).methods: in our center, mobilization with g-csf at dose of μg/kg/day was used in all pts. apheresis were scheduled on day+ . plerixafor ( . mg/kg) was added if the number of cd + cells on day + was < /ul for x cd + /kg requested (or < /ul for x cd + /kg), or if the number of cd + cells collected in the first apheresis was < % of cd + cells requested.between january and september , out of pts ( , %) received plerixafor for mobilization. we retrospectively studied pts who mobilized with p+g-csfdue to the number of cd + cells on day + was < /ul.results: twelve out of pts were pm, were females, median age , years (range: - ). patients' baseline diseases were: non-hodgkin lymphoma (nhl) ( , %), multiple myeloma (mm) and hodgkin lymphoma. median cd + cell count on day + was / ul (range: - ).there was no mobilization failure. eighteen out of pts ( %) were vpm, were females, median age , years (range: - ). patients' baseline diseases were: nhl ( , %), mm and solid tumor. median cd + cell count on day+ was , /ul (range: - ). two out of pts ( , %) were considered mobilization failure, in of them did not realized apheresis due to cd + cell count on day + was /ul. no difference was seen between both groups regarding gender, age, patients baseline disease or median cd + cells count on day + .vpm needed more apheresis sessions, / pts required sessions against / pts in pm (p=not significant (ns). we obtained enough cells to carry asct in % pts, although mean number of cd + cells obtained in vpm was lower than in pm ( , x /kg vs , x /kg, respectively) (p=ns).twenty-six pts underwent asct and mean number of cd + cells infused were , x /kg in vpm vs have been the only route used for chpc administration. the appearance of other catheters types made us to reconsider the exclusive use of the cvc for the infusion of chpc. we analyzed the use of a peripheral iv cannula (pivc) as an alternative to cvc for the infusion of chpc in patients with cardiovascular diseases.methods: medical records of patients who received an asct for hematological malignant diseases at the hospital clínic of barcelona from january to february were reviewed. of those, eight were infused through a pivc due to cardiac impairment related to previous treatments, ischemic cardiomyopathy or amyloid deposition.hpc were obtained from peripheral blood by apheresis after mobilization with g-csf using acd-a as an anticoagulant. cryopreservation was performed with autologous plasma and dmso % by mechanical means and stored in liquid nitrogen. analytical controls were performed including hematocrit, total nucleated cells, total polymorphonuclear neutrophils and platelets using the advia analyzer. the cd + / cd + population was analyzed by flow cytometry following the ishage single-platform protocol. viability of total nucleated cellularity was carried out by vital staining with acridine orange and the specific viability of the cd + population through the technique of -aminoactinomycin d. thawing was performed bag to bag by immersion in a water bath at ºc and transferred to the bedside of the patient for gravity infusion using an infusion set without filter through pivc of gauche. vital sings monitoring performed before, during and the end of the every infusion bag including: blood pressure, heart rate, oxygen saturation, body temperature and central venous pressure. other aspects assessed during the infusion were pain, cold sensation and signs of extravasation in the area of pivc insertion. after the infusion, the recovery time of the granulocyte series and platelet were evaluated.results: median volume and bags administered was ( - ) ml and ( ) ( ) ( ) . the median of total nucleated cells, total nucleated cells / ml and total cd + cells/kg was . x ( . - . ), . x ( . - . ) and . ( . - . ) respectively. vital signs were within the normal range and allowed to perform the infusion in an average of - minutes/bag. no patient required stopping the infusion due to pain in the area of peripheral catheter insertion and no extravasations were detected. all patients referred some cold sensation in the insertion vein and its path. median hematopoietic recovery was ( - ) days for neutrophils and ( - ) days for platelets, similar to the recovery experienced from patients who received chpc through cvc.conclusions: based on our data, we conclude that the administration of chpc, through pivc and by gravity is safe for the product and for the patient, being the preferred choice for patients suffering from some type of cardiovascular disease.disclosure: nothing to declare background: by selective depletion of potentially alloreactive cd ra + cells, t memory cells might be retained in the graft and could mediate pathogen specific immunity. however, cd ra expression is not restricted to naïve t cells, but also available on b cells, nk cells and cd + stem cells to some extent. methods: within this project we aim to analyze cd ra expression on stem-and nk cells by flow cytometric analysis to estimate the eventual loss of these cells during cd ra-depletion. furthermore, clinimacs depletion following a one-step approach of direct cd radepletion and a two-step approach with primary cd selection followed by cd ra-depletion of the negative fraction was investigated.results: cd ra expression on cd + stem cells was in median . %. with a median of . % cd ra expression was measurable on nearly all b cells, which obviates depletion via cd . a comparably high cd ra expression of in median . % was detected on nk cells. unfortunately, the amount of nk cells in the cd ra-depleted product was . %. clinimacs depletion following one-step approach resulted in a stem cell recovery of . %. memory t cell recovery was . % following one-step and . % applying two-step approach. depletion quality measured by log-depletion was . and . for cd ra + t cells and . and . for cd + b cells for one-and two-step approaches, respectively.conclusions: with regard to stem cell recovery, a previous cd -selection before cd ra-depletion is recommendable.background: current clinical practice of routine use of filters for infusion of autologous hematopoietic cell transplantation (ahct) at bone marrow transplant centers across north america and europe is not known. the use of "y" administration tubing without a filter could possibly increase the risk of infusion of macro-aggregates and cellular debris, which may result in increased side effects.methods: we carried out a retrospective chart review of patients (pts) at spectrum health who underwent ahct. group a (gp a) pts received ahct using a "y" administration tubing with -micron filter from / - / . these patients were compared to a control group (gp b) that received ahct without filter administration tubing from / - / .this change in clinical practice occurred due to a change in policy at our transplant center as a result of inorganic particles noticed during cryopreservation. we compared the neutrophil and platelet engraftment duration between these groups. we also studied the length of hospital stay and the effect of filter use on any immediate side effects after infusion. due to the retrospective nature of the study it was not feasible to evaluate the difference in duration of infusion between these groups results: the two groups were similar in their age, gender, primary disease distribution and median number of cd stem cells infused (table) . there was no difference in median neutrophil ( vs days) or platelet engraftment ( vs days) duration for the filter group and the nonfilter group respectively. the median length of hospital stay was also comparable ( days). there was no statistically significant difference in the immediate side effects (fever, cough, dyspnea, fluid overload, flushing, nausea, vomiting, hypertension, hypotension and anaphylaxis) or confirmed post-transplant infections (viral, bacterial, fungal) experienced by these two groups.conclusions: our results show that the routine use of filter does not prolong hospital stay, and neutrophil/ platelet engraftment duration, thereby, suggesting that viable stem cells are not affected. on the other hand, filter use failed to demonstrate any appreciable decline in the immediate side effects experienced after ahct. gp background: allo-hsct from related haplo-identical donors (haplo-hsct) with post-transplant high-dose cyclophosphamide is increasingly employed in patients who lack a matched related or unrelated donor. the current standard is to use bone marrow grafts (bm) as peripheral blood stem cell grafts (pbsc) have been associated with an increased risk of acute and chronic gvhd. thus, the aim of our study was to compare the main transplant outcomes and especially the incidence of acute and chronic gvhd in recipients of bm and pbsc grafts. methods: thirty-five unselected patients with hematologic malignancy who underwent an haploidentical transplant at our unit between and and received bm (n = ) or pbsc (n = ) grafts after the same tbf conditioning regimen were analysed in order to assess differences in transplant outcomes.our gvhd prophylaxis consisted in cyclosporine a (csa) from day - to + , a methotrexate "short course" and mycophenolate mofetil (mmf) from day + to + .results: no statistically-significant differences were observed between patients who received bm grafts and those who received pbsc grafts. at transplant fourteen patients were in first complete remission (cr), twelve in advanced cr and had active disease. according to sorror's risk, nine patients were low-risk, nine intermediate-risk and seventeen high-risk. twenty-eight cmv+ patients received the graft from twenty-three cmv+ and five cmv-donors, seven cmv-patients received the graft from five cmv+ and two cmvdonors. mean age at transplant was years (range - ), mean donor's age years (range - ) and mean follow-up . months (range . - . ). median cd + cell dose was . x /kg (range . - . ), . x /kg (range . - . ) in bm recipients and . x /kg (range . - . ) in pbsc recipients. median time to neutrophil recovery (> /μl) was days (range - ) posttransplant, days (range - ) for bm recipients and (range - ) for pbsc recipients. platelet recovery (> . /μl) occurred in all patients except one at a median of days (range - ) post-transplant, at a median of days ( - ) post-transplant for bm recipients and at a median of days (range ( - ) for pbsc recipients. seven patients never reached platelets > . /μl. three patients developed a poor graft function. acute and chronic gvhd incidence was . % and . % and the risks of acute (hazard ratio [hr], . ; p = . ) and chronic (hr, . ; p = . ) graft-versus-host disease were similar in the two patient groups. in addition, there were no differences in relapse risks post-transplant (hr, . ; p = . ); relapse-free survival was better with pbsc grafts but this difference did not reach any statistical significance. finally, no significant differences were noted in overall mortality by graft type (hr, . ; p = . ).conclusions: despite in haplo-hsct the incidence of acute and chronic gvhd is reported to be higher with pbsc than with bm our small patient series does not confirm this assumption that should be clarified by additional studies. instead, our data suggest that pbsc background: since , cord blood (cbu) has become an alternative source of stem cells for transplantation, with approximately , procedures currently performed. with a -year gs of %.objective: analyze the outcomes from all the patients transplanted with cbu in our hospital unit.methods: retrospective, longitudinal study. all patients transplanted with cbu in our hospital between and were included. we analyzed patients with ages from months to years.results: two of them received doubled cord transplantation the ratio male: female was . : . the transplanted pathologies were: bone marrow failure %, immunodeficiency %, aml %, all . %, osteopetrosis . %. ric regimens were used in patients with bone marrow failure and immunodeficiency and myeloablative conditioning regimens were used in patients with malignant hematology diseases. antithymocyte rabbit globulin (atg) based serotherapy was used. one case received cbu from a related donor (sister), the rest received unrelated cbu obtained from centro nacional de la trasfusión sanguínea. the infusion of cd + was in a range of . to of . x /kg with and average of . x / kg. compatibility was / in %, / in % and / in %. post-thawing cellularity was not measured. the hla-c was not analyzed. forty two point five percent of the patients had a successful engraftment; the average time of engraftment was days. primary graft failure was detected in . % and secondary graft failure in %, for a total success of . %. gvhd was detected in % of patients, of which % was grade i-ii and % grade iii-iv. the overall mortality was . %. causes of death were: infection % relapse %, hemorrhage % and gvhd %. the cbsct continues to be an essential alternative in our patients who required transplantation knowing that this stem cell source allows the procedure to be done with less histocompatibility requirements and it is available immediately, which facilitates the process considering the great diversity that exists within our population. however, in our experience, the cbsct has shown a higher mortality risk, which can be improved by analyzing the hla c, choosing in this way the units with better compatibility, and improving cellular dosage since this is key in success.disclosure: nothing to declare the risk of infection of the umbilical cord is not related to the microbiological status of the umbilical cord blood methods: the statistical analysis was carried out on data obtained from samples taken in poland between -jan- and -dec- . the samples were collected in hospitals by external midwifes and sent to the pbkm in accordance with the requirements of the american association of blood banks. after arrival in the laboratory, the blood samples were cultured and the ucs were assessed immediately for visual signs of infection, such as odor, altered color, or visible bloom. the status of both kinds of samples was introduced into the pbkm general database. for the purpose of this analysis, the ucs were considered as microbiologically pure if stored, destroyed after storage, or handed over to the pbkm. samples marked as infected or disqualified for unknown reasons (other than termination of the contract with the customer, viral infection of the mother, and lack of cell growth) were considered as infected. at the time of the statistical analysis, the samples of unknown ucb microbiological culture status were removed from the generated report. the data was summarized as percentages and the odds ratio was calculated. statistical significance was considered at p˂ . .background: match family donors are the preferable options in allogenic stem cell transplant. however, in the absence of donor relatives match unrelated donors have been an option. in this study, the donor screening, transplant preparation phases of turkish stem cell coordination center (turkok) and the İstanbul university bone marrow bank (tris), were compared.methods: the unrelated donor scanning data between march and november in pediatric stem cell transplantation unit of altınbas university bahcelievler medical park hospital were evaluated. unrelated transplants were performed in total. % of these transplants (n= ) were included from the donors of turkok registration system and , % of these transplants (n= ) were included by means of tris from donors outside of turkey. patients ( tris, turkok) were excluded from the study in consequence of screening update and postpone of transplantation. the statistics were carried out on a total of patients, , % of whom were in turkok (n= ) and , % were transplanted via tris (n= ). the day of application to stem cell transplantation unit, reply dates and the transplantation dates were examined for the transplant patients.results: in the current study, the average response time of turkok was found as , ± , day (median: ), the average transplant time after receiving a reply was found as , ± , (median: ) day, the average number of days from date of application to date of transplantation of patients was found as , ± , (median: ). the average response time of tris was , ± , (median: ) day, the average transplant time after receiving a reply from tris was , ± , (median: ) day, average number of days from date of application of tris to date of transplantation of patients , ± , (median: ) day.the average response time of turkok, the average transplant time after receiving a reply from turkok and the average number of days from date of application of turkok to date of transplantation of patients was shorter than tris. the difference between them was found statistically significant (p< . ).conclusions: in this study, it was determined that the transplantation processes with turkok were progressing more rapidly. the rapid progress of the process was attributed to the fact that all donor hla tissue groups in the turkok database were studied in high resolution. in international scans carried out through tris, it was thought that the examination of the donor castings coming from bone marrow banks and the time differences between the countries prolong the process. it was thought that hla tests of the registered donors in the tris database and some international bone marrow banks were studied in low resolution but not studied the all hla loci, the centers wanted high-resolution hla, and therefore the involvement of social security institutions and payment procedures were among the factors extending this process.disclosure: nothing to declare background: allogeneic hematopoietic stem cell transplantation (ahsct) is being performed for a group of hematologic diseases with a curative intent. outcomes after ahsct are influenced by the type of donor used. haploidentical transplantation is an emerging option when a fullmatched donor is unavailable. methods: we retrospectively analyzed our transplants performed between january and november , investigating outcomes and complications among haploidentical stem cell recipients.results: one hundred and nineteen patients underwent ahsct, of them ( . %) were recipient of a haploidentical stem cell and included in this study. one patient diagnosed with acute lymphoblastic leukemia (all) were performed a haploidentical ahsct for two times due to relapse. among those transplants, of them were diagnosed with acute myeloid leukemia, with all, with chronic lymphocytic leukemia, with myelodysplastic syndrome and with hodgkin lymphoma. the mean age of group was . ± . years. three patients ( aml, all) were in remission at the time of transplantation. patients were given a conditioning regimen based mostly on busulfan, fludarabin and total body irradiation with a myeloablative intent. patients were also given a various combinations of post-transplant cyclophosphamide, calcineurin inhibitors, mycophenolate mofetil and antithymocyte globulin for graft versus host disease (gvhd) prophylaxis; post-transplant cyclophosphamide administered on ( %) of those transplantations. peripheral blood was the source of stem cells in all patients. patients were infused with mean . ± . x /kg of cd + cells. hematological recovery was achieved with neutrophil engraftment at a mean of . ± . days and platelet engraftment at a mean of . ± . days. after a median month ( . - . months) follow up, the cumulative rates of grade - gvhd, relapse and non-relapse mortality were %, % (n= ) and %, respectively. one patient died due to relapse, at the end of the follow up two were still alive with remission. only one patient has died due to chronic gvhd affecting serosa and resulting with a fatal tracheoesophageal fistula. the mean overall survival was . ± . months in our study.conclusions: haploidentical transplant is a feasible option in hematologic malignancies with novel gvhd prophylaxis approaches, especially post-transplantation cyclophosphamide. however, these results need to be supported with further investigations with a larger patient group.disclosure: nothing to declare results: a total of patients between and years (median age: years). transplant was done for following disease: acute leukemia (n= , %), aplastic anemia (n= , %), lymphoma (n= , %), myelofibrosis (n= , %), myelodisplastic syndrome (n= , %), chronic myeloid leukemia (n= , %). ten donors were from turkey and fifteen donors were from different countries of europe and america. two of donors were / and the other was / hla matched. the conditioning regimen was mostly non myeloablative (n= , %) while eight patients were treated with myeloablative regimen. other than two patients who took tacrolimus and mycophenolate mofetile all of them got cyclophosphamide and methotrexate for graft versus host disease (gvhd) prophylaxis. the median time of neutrophil and platelets engrafman were days (range - ) and , days (range - ) respectively. acute gvhd was seen nearly half of the patients ( , %).overall survival was % for all patients and of patiens ( %) died within first month to months (median months). the mortality rate was more higher for the recipients who had donor source from countries other than turkey ( % vs % p= , ). transplant related mortality was the most common reason of mortality (n= / , , %) and other reasons were gvhd ( , %), infections and cirrhosis respectively.conclusions: we found the mortality rate more higher in the patients whose donors were from out of our country. however, we need to further multicentric and prospective investigations to confirm our hypothesis, it would be related with impact of ethnicity.disclosure: nothing to disclose late-breaking abstracts p targeted twice daily busulfan-based ric-conditioning for allogeneic hematopoietic stem cell transplantation in pediatric patients with chronic granulomatous disease: a -year experience with the zurich protocol matthias felber , mathias hauri-hohl , ulrike zeilhofer , federica achini , jana pachlopnik-schmid , janine reichenbach , seraina prader , tayfun güngör background: chronic granulomatous disease (cgd) needs sufficient myeloablation to avoid graft failure. for this purpose the ebmt inborn errors working party currently recommends treosulfan or busulfan-based conditioning regimens for cgd-sct. we analyzed the last years of targeted busulfan-based ric-conditioning including engraftment, gvhd rates, chimerism and late term effects in our pediatric sct center in zurich. methods: between and , n= consecutive pediatric cgd patients (median age years, range - years, n= female, n= autosomal recessive inheritance) have been transplanted. all patients received therapeutic drug monitoring of twice daily administered iv busulfan ( or hour infusions; d- to -d ) to achieve a targeted cumulative auc of - mg/l*h. fludarabine ( mg/ sqm; d- to -d ) and serotherapy (thymoglobuline . mg/ kg total, d- to d- ) or alemtuzumab ( . - . mg/kg total; d- -to d- ) were used for immunoablation. donors were matched unrelated ( / hla; n= ), mismatched unrelated ( / hla; n= ), mismatched unrelated (hla / ; n= ), matched sibling (hla / ; n= ) and haploidentical parental (hla / ; n= ). for patients with haploidentical donor post-transplant cyclophosphamide (d- and d- with mg/kg iv each) and upfront atg-grafalon ( mg/kg - to-d- ) was used. stem cell sources were bm (n= ) and pbsc (n= ). gvhdprophylaxis included iv csa (d- ; continuous infusion) and iv. mmf (d- , in - doses).results: follow-up was to months. good overall engraftment was noted, with n= secondary graft failure followed by successful retransplantation. in one patient a stem cell boost/dli was necessary due to decreasing myeloid donor chimerism during ebv reactivation, resulting in rapid myeloid donor reconstitution after intervention. low rates of gvhd were documented with n= agvhd grade iv and n= mild/limited cgvhd (nih criteria). with exception of one patient, myeloid donor chimerism at last follow-up was over %, mostly over %. overall survival was / ( %). deaths were due to gi-gvhd (n= ), autoimmune hemolytic anemia/sepsis (n= ) and thrombotic microangiopathy (n= ).conclusions: precision dosing of iv busulfan in combination with fludarabine and serotherapy results in excellent outcome of hsct for pediatric cgd-patients with good engraftment, low overall cgvhd rates and stable, mostly excellent donor chimerism. graft failure rate was as low as %. low dose alemtuzumab prevented gvhd in the majority of patients. this analysis demonstrates that targeted busulfan-based conditioning is a valid option for pediatric cgd-patients. serum alemtuzumab or atg monitoring could further improve gf and gvhd rates in the future.disclosure: the authors declare no conflict of interest. abstract already published. young hla-matched unrelated donors are comparable to matched sibling donors in elderly patients receiving reduced-intensity conditioning: an analysis on behalf of the ebmt scientific council % c.i. . - . , p= . ) and voriconazol prophylaxis during carv (or . , % c.i. . - . , p= . ). conclusions: we provide evidence that ifd after carv infection. allo-hsct recipients developing a carv lrtd during the first year after transplant may benefit from an adequate antifungal prophylaxis and a close monitoring for the development of a later ifd.disclosure: jose luis piñana has received both, advisory for preclinical/clinical research and financial support to assist to the spanish society of hematology annual meeting from msd. favorable outcome and engraftment following reducedintensity conditioned allo-hsct in children with primary haemophagocytic lymphohistiocytosis (hlh) and high-risk langerhans cell histiocytosis (lch) laura m. moser, emilia salzmann-manrique, andrea jarisch, jan sörensen, shahrzad bakhtiar, peter bader background: primary haemophagocytic lymphohistiocytosis (hlh) and high-risk langerhans cell histiocytosis (lch) represent two major entities of childhood histiocytoses, which are -although only of rare occurrence -severe in their clinical manifestations. patients present with multisystemic uncontrolled inflammation and multi-organ involvement requiring diverse courses of immunosuppressive and chemotherapy regimens. allogeneic haematopoietic stem cell transplantation (allohsct) is the only available curative option; however, the cumulative treatment toxicity and the underlying inflammatory disease often result in high organ toxicity and inflammatory complications of transplantation, such as graft versus host disease (gvhd) and/or graft failure. especially patients with unrelated donors often deal with high transplant-related mortality (trm) in the setting of conventional intensity conditioning.herein, we present the clinical course of the disease and transplant outcome of children diagnosed with primary hlh (n= ) and high-risk lch (n= ) who underwent allohsct at our centre from / to / .methods: the hlh cohort consisted of cases of familial hlh (fhlh), cases of griscelli syndrome, one xiap-deficient patient and one hlh-patient with inconclusive genetic testing. all hlh patients had developed clinical symptoms prior to transplantation and had been treated according to hlh-protocols , hlh-protocols , or median age at transplantation was months ( to months). stem cells were derived from hla-matched siblings (msd, n= ), matched unrelated donors (mud, n = ) or haploidentical donors (n= ).the majority of patients ( / ) received a ric regimen containing fludarabine, melphalan and thiotepa (n= ) and fludarabine plus cyclophosphamide (n= ). myeloablative treatment ( / ) included a treosulfan-based regimen (n= ) and busulfan-containing treatment (n= ). the entire cohort received serotherapy using either muromonab (n= ), atg-fresenius® (n= ) or alemtuzumab (n= ).results: the overall survival of the entire cohort was . % ( / ) on a median follow-up of . years ( figure a+b) .all lch patients, being treated with fludarabine, melphalan and thiotepa, survived transplantation and showed complete remission ( / ) . within the hlh cohort the overall survival was . % ( / ). fatalities (n= ) included two patients from the myeloablative group and one ric-treated patient. the cause of death were progressive disease activity during the conditioning phase, leading to multi-organ failure on day + despite immunosuppressive treatment (n= ) and complicated cerebral seizures followed by lung haemorrhage, possibly due to aspiration pneumonia with evidence of enterococcus faecium, resulting in septic multi-organ failure on day + (n= ). a third hlh patient developed a sudden cerebral edema and ensuing respiratory insufficiency on day + . whether this was caused by acute neurotoxic damage by fludarabine or a consequence of relapsed hlh could not be conclusively specified. none of our patients suffered from transplant failure or nonengraftment. there was neither severe acute gvhd (iii-iv) nor chronic gvhd observed in this cohort.conclusions: primary hlh and high-risk lch are lifethreatening medical conditions needing rapid allohsct. ric regimens are well-tolerated and sufficient for proper engraftment and disease clearance. disclosure: the authors have no conflicts of interest to disclose. abstract withdrawn. thrombocytopenia following allo-sct concomitant to stem cell boosts. steroid refractoriness was defined as: progression after three days or no response after days of steroid treatment. the median time from sct to the onset of agvhd was . d (range - d), and d (range - d) from the onset of agvhd to the first msc infusion, respectively.the majority of our patients (n= ) suffered from a malignant disease and received a graft from a matched unrelated donor (n= ), while one patient had a haploidentical donor. gvhd prophylaxis was performed in all patients except the patient with the haplo-identical graft. all patients with agvhd were treated with steroids and the patient with thrombocytopenia required regularly transfusions and romiplostin therapy. the median msc dose was . x cells/kg bw (minimum . x ; maximum x ). three patients received msc doses, two patients , one patient and another doses.results: at the time point of agvhd manifestation and msc application, two patients had cmv reactivation, one patient adenovirus infection and one patient ebvreactivation. by day , / agvhd patients responded to msc administration: with complete response and with partial response. at the last follow-up (median: . months, range , - . months), of patients were alive without acute or chronic gvhd. one patient died soon after msc treatment with no obvious response in the course of a systemic hyperinflammation syndrome. the other patient although complete responder to msc-ffm developed fatal adenovirus sepsis. this based on the profound tcell depletion induced by concomitant application of steroids. the overall survival probability at six month was . %. no acute side effects occurred after msc infusions. the previously mentioned patient suffering from thrombocytopenia did not need any further transfusions after receiving doses mscs combined with stem cell boosts while continuing romiplostin application.conclusions: our data confirm excellent tolerability and high efficacy of the licensed off-the-shelf msc preparation "msc-ffm" in pediatric steroid-refractory agvhd. in our center, current treatment algorithms have escalated "msc-ffm" to the second line, i.e. immediately after steroid refractoriness has been established. besides immunoregulatory properties, this product might facilitate hematopoietic stem cell engraftment.disclosure: novartis (consultancy: included expert testimony, speaker bureau, honoraria), medac (research funding, patents and royalties), riemser (research funding), neovii (research funding), amgen (honoraria) expression of ccr modulates migrational properties of in vitro expanded murine regulatory t cells laura m. moser , , ulrike tischler , christin riegel , julia minderjahn , rüdiger eder , jaqueline dirmeier , isabel zimmermann , evelyn röseler , petra hoffmann , , matthias edinger , background: hematopoietic stem cell transplantation (hsct) as it is carried out successfully at other genetic instability syndromes seems to be an encouraging opportunity for a curative therapy to restore immunity and prevent the development of hematologic malignancies in ataxiatelangiectasia (a-t). however, experience in the conditioning regimen is limited and no transplantation strategy for a-t patients exists, especially in an allogeneic setting. conditioning regimen and donor selection are critical factors in the clinical setting of hsct and incur substantial risks, especially in a-t. the aim of this study was ( ) to evaluate whether different approaches of hsct including allogeneic hematopoietic hsct are feasible in regard to graft versus host response (gvhd) and sufficient concerning immune reconstitution ( ) and to de-escalate the toxic effects of the conditioning regimen by reducing the dose of cyclophosphamide (cp).methods: t cells from syngeneic, allogeneic and haploidentical donor mice were used to determine gvhd induced t cell proliferation in a mixed lymphocyte reaction (mlr). atm-deficient mice were treated with cp or reduced cp in combination with fludarabine (flu) and transplanted with x cd . depleted bone marrow donor cells from /svev gfp-transfected wildtype mice (syngeneic) or from mice of the f generation of /svev wildtype mice and c bl/ mice (haploidentical), or from c bl/ mice (allogeneic). tracking of gfp-positive donor derived cells was performed using flow cytometry and atm pcr. oxidative stress and damage were detected by a rt profiler pcr array and -hydroxy- ′deoxyguanosine.results: mlr resulted in an increased proliferation of allogeneic donor t cells compared to syngeneic and haploidentical donor cells. response was lower on dendritic cells isolated from atm-deficient mice compared to wildtype controls. in vivo results showed the restoration of t cells in atm-deficient mice accompanied by a prolonged life span and through reduction of thymic tumors. however, allogeneic stem cell transplantation was accompanied with a higher mortality rate, compared to the haploidentical and syngeneic setting. decreased antioxidative capacity and a higher dna-damage were seen in cp treated atmdeficient mice.conclusions: haploidentical hsct seems to be a feasible strategy for a-t. our data provided further evidence for the high sensitivity against ros-inducing agents in a-t and this fact needs to be taken into consideration in the choice of the host-conditioning strategy.disclosure: nothing to declare this research received funding from action for a-t charity ( gou ) background: prognosis of pediatric patients and young adults suffering from refractory or high-risk soft tissue sarcomas remains poor with limited improvement over the last decades despite multimodal treatment strategies. replacing the immune system by an allogeneic hematopoietic stem cell transplantation (hsct) in refractory solid malignancies has been proposed as a potentially curative therapy due to its presumable graft versus tumor effect. based on this concept we additionally performed consecutive donor-derived lymphocyte infusions in allogeneic hsct-patients with refractory or relapsed solid malignancy to further increase anti-tumor efficacy post-transplant.methods: pediatric patients with relapsed and/or refractory cancers or with delayed responses to the respective induction therapies were offered donorderived cellular therapies after immune system replacement by an allogeneic hsct. cellular immunotherapies comprised of donor lymphocyte infusions (dli), natural killer (nk) cell or cytokine-induced killer (cik) cell infusions generated from the original stem cell donors. allogeneic nk cells were generated from unstimulated leukapheresis by a two-step purification procedure using immunomagnetic cd t cell depletion, followed by nk cell enrichment (cd +) with or without in vitro il- stimulation and expansion for - days. for cik cell generation peripheral blood mononuclear cells were isolated and activated by in vitro cytokine stimulation (inf-γ, anti-cd , il- and il- ) an expanded over - days. expanded cik cells represented a heterogeneous population of polyclonal t cells with in part shared phenotypic and functional properties of nk cells.results: between october st and january st a total of patients (eight patients with rhabdomyosarcoma, one patient with synovial sarcoma, two patients with ewing sarcoma, five patients with neuroblastoma, one patient with hepatoblastoma, and one patient with nasopharynx carcinoma) were enrolled. seven of ( %) patients in this study had achieved complete remission (cr) before hsct while another of ( %) patients had obtained at least very good partial or partial response (vgpr or pr). dli was applied in patients, nk cell treatment was offered to another patients, while cik cell therapy was given to patients. . -year probabilities of overall survival (os) and progression-free survival (pfs) were . % and . % for all patients with a median follow up of . months (range, . - . months). patients in cr at the time of immune cell therapy (it) showed estimated . -year os and pfs of . % and . %, respectively. the majority of patients relapsed and ultimately succumbed to their diseases with two of ( %) patients still being alive . and . years after it. cumulative incidence of relapse was . % at . years. t cell engraftment and immune reconstitution (ir) was improved by it, and correlated with treatment response. however, two of heavily pretreated patients ( %) died due to cumulative treatment-related mortality (trm). furthermore, acute graft-versus-host-disease (agvhd) occurred in of patients ( %) with agvhd grade i-ii observed in ( %) and agvhd grade iii seen in three ( %) patients.conclusions: altogether, the results of this study indicate that allogeneic donor-derived cellular therapy at its current state offers curative benefit in selected refractory childhood cancers but warrants further improvement. background: allogeneic stem cell transplantation (allo-sct) is the only curative treatment option for a variety of nonmalignant diseases. the success of allo-sct is strongly associated with rapid and sustained immune reconstitution (ir). we analyzed the ir in patients who received an allo-sct for nonmalignant diseases.ir was assessed on days + , + , + , + and + after allo-sct analyzing leukocytes, lymphocytes, monocytes, cd + t cells, cd + cd + t helper cells, cd + cd + cytotoxic t cells, cd -cd + natural killer (nk) cells and cd + b cells.methods: we analyzed ir-data of consecutive patients receiving allo-scts between september and november . indications of allo-sct were hereditary anemias (thalassemia, sickle cell disease, diamond blackfan anemia; ha, n= , %), inherited bone marrow failure syndrome (fanconi anemia, severe aplastic anemia, others; bmfs, n= , %), hemophagocytic lymphohistiocytosis (hlh, n= , %), immunodeficiency (id, n= , %) and metabolic disorders (n= , %). the median age at allo-sct was years (range, . - ) and at diagnosis . years (range, - . - . ).patients received st allo-sct from msd/mfd (n= , %), mud (n= , %), haploidentical mismatch family donors (n= , %) and mmud (n= , %). conditioning regimens were busulphan-based (n= , %), treosulphan-based (n= , %), flu-mel-thio (n= , %) or others (n= , %). graft sources were bm (n= , %) and pbsc (n= , %).in order to consider the age-dependency of ir we normalized each absolute cell count with its corresponding age-specific expected mean values. (huenecke et al.; eur j haematol; ) results: the ir pattern was similar between the ha and bmfs groups. the cd + t cells were recovering slightly faster in ha patients compared to the recovery of bmfs patients.monocytes and nk cells proliferate very fast. at day + half of the patients already reached their respective monocytes reference value except for id patients, who reached % of the reference value at the end of the first year.cd + cd + cytotoxic t cells recovered significantly faster in patients with hematologic diseases compared to patients with hlh (p< . ) and id (p= . ). half of the patients reached the reference value of cytotoxic t cells in the hematologic diseases group at day + . by far inferior was the ir for the hlh patients. in this group only % of the patients reached the th percentile of the healthy age-matched reference. in the id group % of all patients reached the th percentile of the age-matched reference group at day + .b cells are profoundly decreased at day + in all groups. however, the longitudinal expansion of b cells was significantly lower both in the id group and hlh group compared to the hematologic diseases group. at day + fifty percent of patients with id, hlh and hematologic diseases reached the th percentile, th percentile and the th percentile, respectively (p< . ; p= . ).conclusions: allo-sct is the only curative option for patients with nonmalignant diseases. ir is dynamic and revealed a complex diversity pattern with regard to the original disease. to investigate factors influencing ir after allo-sct is crucial to improve outcome of these patients.disclosure: nothing to declare. allogeneic hematopoietic stem cell transplantation in patients with myelodysplastic syndrome of relatively high-risk groups: curative effect analysis and optimal timing selection results: among the patients, patients were transplanted successfully. the -year overall survival (os) rate and disease-free survival (dfs) rate was . % ± . % and . %± . % respectively. the -year cumulative relapse rate (rr) and the non-relapse mortality (nrm) rate was . %± . % and . %± . % respectively. the incidence of grade ii-iv acute graft versus host disease (agvhd) was . %± . %. for the patients who survived more than days after allo-hct, the years cumulative incidence of chronic graft versus host disease (cgvhd) was . %± . %. univariate analysis showed that the hematopoietic cell transplantation comorbidity index(hct-ci) and grade iii-iv agvhd are the high risk factors for os( . ± . % vs . ± %, p= . and . ± . % vs . ± . %,p < . ). multivariate analysis demonstrated that grade iii-iv agvhd and hct-ci are independent risk factors for os(hr= . , p < . , % ci: . ~ . and hr= . ,p= . , %ci: . ~ . ). chemotherapy before transplantation did not improve os or dfs for patients with bone marrow blast cells more than % at the time of diagnosis.conclusions: allo-hsct is an effective treatment for mds patients of relatively high-risk groups. the physical condition of the patients and occurrence of agvhd are independent risk factors. for intermediate and high risk ipss-r mds patients, transplantation before the disease progressed into very high risk can achieve better prognosis, high-risk group can still benefit from rebound gvhd after cni tapering which was promptly responsive to treatment steroids, fk and ecp. aa one year after sct / patients were without gvhd and off all immunosuppression while one single patient was still on taper of immunosuppressant after rebound acute gvhd. no chronic gvhd occurred. sctrelated toxicity was common with mucositis in all patients (who grade : n= ), elevated liver enzymes (≥grade : n= ) and impaired renal function (gfr - ml/min: n= ). five patients developed neurologic symptoms (seizures n= , pres n= , pseudotumor cerebri n= ) which all resolved without sequelae. overall survival and transfusion-free survival was % with a median observation time of ( - ) years.conclusions: . treosulfan-based conditioning followed by sct from hla-matched related or unrelated donors represents a highly efficacious treatment approach for children, adolescents and young adults with tdt and exhibits an acceptable but not negligible safety profile. an individual risk-benefit assessment incorporating hazards such as secondary graft failure, gvhd and long-term toxicity including infertility and nd malignancy has to be executed in the informed consent process for every patient and his/her guardians.disclosure: "nothing to declare" p abstract already published. early iron chelation with deferasirox might prevent relapse after busulfan plus fludarabine and atg as a myeloablative conditioning for hla-identical sibling allogeneic hct in aml results: we show an excellent concordance between chimerism assessment on bio-rad and d platforms over the complete range of mixture ratios (r > , ) and proof the lower detection limit ( , %) compared to str-pcr.conclusions: our results promote the transfer of the established mentype assay to a more diverse instrument portfolio. that will allow to implement the analysis of patient and donor hematopoiesis by digital pcr methods in our lab.disclosure background: with the immense progress in therapeutic regimens in pediatric oncology and stem cell transplantation the survivor rates increased up to %. at the same time the field of reproductive medicine has achieved substantial advances to offer potential options for fertility preservation. therefore it is of great importance to implement fertility counseling and fertility preserving (fp) procedures for patients facing gonadotoxic therapy. in the report on the expert meeting of the paediatric diseases working party (pdwp) of the ebmt in counseling related to fp opportunities should be offered to each patient receiving stem cell transplantation (sct), as part of the pre-sct workup by a dedicated and trained team. yet there many medical, ethical, structural and financial issues to consider and overcome. we describe the setting up process to enable fertility counseling for all children with newly diagnosed cancer or those facing stem cell transplantation for malignant and nonmalignant diseases in our department of pediatric oncology and immunology/stem cell transplantation.methods: at our tertiary care center we assembled a multidisciplinary team involved in fertility preservation (pediatric hematology/oncology, pediatric immunology/ stem cell transplantation, reproductive medicine, andrology, psychology and pediatric surgery). we developed an internal grading system for recommendations regarding fertility preservation based on the current recommendations for fertility preservation of leading societies in this field like ebmt, gpoh and dggg. it is important to find a consensus within the team for the counseling to ensure reliable counseling. the third step is to implement structures needed for fertility counseling and performance of invasive procedures including legal aspects (amg). a detailed description of this process is given.results: after setting up structures for the counseling process we counseled oncology and stem cell transplant patients ( - years) between january and may . we analysed data of the patients including age subgroups and disease entities and the results of the counseling process. for those patients undergoing stem cell transplantation the risk of gonadotoxicity is very high, therefore even the very young children underwent fertility preserving procedures in alignment with our recommendations if they suffered from a nonmalignant disease. currently we discourage tissue preserving in malignant systemic disease due to possible contamination with malignant cells. postpubertal female patients were more likely to undergo invasive procedures such as ovarian tissue cryopreservation in the case of oncological diseases, while sperm cryopreservation was recommended in all postpubertal male patients. overall a high percentage of the patients and their family followed our recommendations.conclusions: fertility preservation should be considered as a very important part of the treatment plan for newly diagnosed children and young adults with cancer and those facing stem cell transplantation. unfortunately there is still a great need for setting up structures in institutions taking care of these patients. in addition fertility preservation sadly lacks funding by health insurance in some countries. with the presentation of our experience and data we want to facilitate incorporation of fertility counseling in other pediatric care centers to provide counseling for pediatric patients in need for fertility preservation.disclosure: no conflict of interest regulatory t-cells (t reg ) have been shown to play a role not only in autoimmune diseases and solid organ transplantation but also in gvhd. several mouse models showed a decrease of gvhd incidence after t reg administration. the few clinical trials regarding the application of t reg for the treatment of gvhd are encouraging, however the data is limited. methods: patient: a -year-old boy underwent allogeneic sct for chronic myeloid leukemia refractory to imatinib, dasatinib and nilotinib treatment from his / hla identical brother. freshly derived unmanipulated bone marrow was transplanted after conditioning with of fludarabine ( mg/m²/d, day - to - ), thiotepa ( x mg/ kg, day - ) and melphalan ( mg/m², day - ). cyclosporin a (csa) and mycophenolatmofetil (mmf) were used for gvhd prophylaxis. leukocyte regeneration (> /μl) was seen on day + , granulocyte regeneration (> /μl) on day + and thrombocyte regeneration (> . /μl) on day + . on day + after sct he developed acute intestinal gvhd that exacerbated to grade iv°(bloody diarrhea, ileus) and did neither respond to steroids, nor to different immunosuppressive drugs such as cyclosporin, tacrolimus, sirolimus, mycophenolatemofetil and ruxolitinib. extracorporal photopheresis and the administration of immunmodulatory antibodies (adalimumab and tocilizumab) did not succeed either.results: by administration of low-dose interleukin- (il- ) in vivo induction of t reg was expected but did not succeed. finally antithymocyte globuline (atg, mg/kg/ d) was administered on day + to + to eliminate the gvhd-triggering cells. hence, the gvhd declined to grade iii. finally, a decision was made to manufacture t reg from his stem cell donor. from an unstimulated leukapheresis t reg were selected by magnetic depletion of cd + t-cells and cd + b-cells followed by positive selection of cd + background: treatment of patients with transfusion dependent anemia like thalassemia major (tm), sickle cell disease (scd) and diamond-blackfan anemia (dba) has improved over the last decades. for the vast majority of patients, allogeneic hematopoietic stem cell transplantation (hsct) is the only available curative therapy. for a long time, hsct has only been performed from hla-identical sibling donors (msd) or matched family donors (mfd). however, approximately only - % of affected patients do have a matched sibling donor, therefore hsct from / (mud) and even / (mmud) matched unrelated donors has gained importance in recent years.methods: patients (age range: - years) with scd (n= ), dba (n= ) or tm (n= ), receiving hsct from a msd, mfd, mud or mmud between and were included in our analysis. patients received transplants from msd/mfd, patients from mud/ mmud. patients were identical for hla-a, b, cw, drb and dqb , patients shared only / genes. we analyzed extended haplotypes including drb , drb , drb and dpb for all patients with thalassemia. pairs showed non-permissive dpb mismatch and pair mismatch for dpb and drb .results: median time for granulocyte recovery was days in patients transplanted from msd/mfd and days in patients transplanted from mud/mmud. platelet recovery was reached after days after hsct from msd/mfd and days after hsct from mud/ mmud. / ( %) patients showed complete donor chimerism in all controls. / ( %) patients showed low level mixed chimerism up to % during follow up. patient died shortly after hsct, patient showed slowly increasing mixed chimerism and finally developed autologous recovery and one patient rejected the graft.cumulative incidence of grade ii-iv acute graft-versushost disease (agvhd) of mud/mmud was , %, whereas only cases of agvhd grade i occurred in patients transplanted from msd/mfd. as patient rejected the graft from a hla-identical parent, patient transplanted from a hla-identical grandparent developed autologous recovery after year and patient transplanted from a mud lost the graft due to hemophagocytosis, the probability of event-free survival was , % after hsct from msd/mfd and , % from mud/mmud.altogether / patients ( , %) are alive and transfusion-independent with complete donor chimerism two years after hsct; resulting in an overall survival probability of , %. in contrast, overall survival probability was % in the group of patients transplanted from msd/mfd and , % in patients transplanted from mud/ mmud after years.there were patients with thalassemia ( , %) who died from transplantation-related causes. the first patient died days after hsct from a mmud due to candida sepsis with pulseless electrical activity resulting from cardiac iron overload. the second patient died months after hsct from a mud due to graft failure.conclusions: hsct from mud and mmud is a feasible therapy option for patients with transfusion dependent anemia. nevertheless, it should be noted that iron overload can cause severe complications; therefore, measurement of liver and heart iron concentration through mri prior to hsct as well as phlebotomy after transplantation are advisable.disclosure: novartis (consultancy: included expert testimony, speaker bureau, honoraria), medac (research funding, patents and royalties), riemser (research funding), neovii (research funding), amgen (honoraria) background: the therapeutic options for patients with hodgkin´s disease who relapse after first high-dose chemotherapy with autologous stem cell ( st asct) support are limited. allogeneic stem cell transplantation in this setting is associated with a high level of transplant-dependent mortality rates in excess of - %. new agent, such as brentuximab vedotin, have been approved for the treatment of these patients, however, their efficacy to provide longterm control or cure is still unknown. a second autologous stem cell ( nd asct) has historically been considered as an option only in a small group of patients so the published experience is scarce. we report our institution´s experience with second autologous transplants in this patient population.methods: we evaluated the outcome of adult patients ( ( %) female and ( %) male), who received an nd asct between / and / . planned tandem asct were excluded. the median age at nd asct was years (range - ), ( %) patients had a karnofsky performance score ≥ %. ( %) patients were in complete remission (cr) and ( %) patients were in partial remission (pr) at day after st asct. seven ( %) relapses within months after st asct. patients received a median of ( - ) treatment lines between st asct and nd asct. only ( %) patients received brentuximab vedotin and none of the patients in our series received checkpoint inhibitors as salvage after st asct. the median interval from st asct to relapse/progression was , months (range , - , ). the median interval from relapse/progression to nd asct was , months (range , - , ). all patients received beam as the conditioning regimen for st asct, and beeam as the conditioning regimen for nd asct.results: the median time to neutrophil recovery (> . x /l) after nd asct were days (range - ). best response at day following nd asct included cr in ( %) patients and pr in ( %); ( %) had stable disease. ( %) patients received brentuximab vedotin and none of the patients received checkpoint inhibitors after nd asct. ( , %) patients are currently alive, with a median follow-up , months (range , - , ). patient died after nd asct. causes of death were hl progression. the -year overall survival was %.conclusions: the second asct in patients with a longterm response after the first asct may be the optimal therapeutic option, the effectiveness of which can be enhanced by using new drugs, such as brentuximab vedotin, at all stages of treatment.disclosure: nothing to declare effectiveness of chemo-g-csf protocols for mobilization of peripheral stem cells in patients with non-hodgkin lymphomas and hodgkin disease-single center experienceilina micheva , stela dimitrova , vladimir gerov , trifon chervenkov , liana gercheva , igor reznik background: high-dose chemotherapy and autologous stem cell transplantation (asct) play an important role in achieving long-term remission in patients with non-hodgkin lymphoma (nhl) and hodgkin disease (hd). granulocyte colony stimulating factor (g-csf) combined with high-dose chemotherapy is a frequently used mobilization approach; however, the optimal mobilization strategy has not been determined.the objective of the study was to analyze the mobilizing potential of different regimens used for the collection of peripheral stem cells in patients with relapsed or refractory (r/r) nhl and hd. methods: we retrospectively analyzed patients with r/r nhl and hd undergoing stem cell collection after chemo-mobilization in the transplant unit at the university hospital, varna. patients were mobilized after dhap letermovir is promising, even as a therapeutic agent. more paediatric data are urgently needed.disclosure: nothing to declare p development of paroxysmal nocturnal hemoglobinuria in a patient after mudallohsct due to jak v fpositive myelofibrosis-a case of successful treatment with the second transplantation from another donor agnieszka tomaszewska , barbara nasiłowska-adamska , iwona solarska , kazimierz hałaburda background: paroxysmal nocturnal hemoglobinuria (pnh) is a very rare disease associated with pig-a gene mutations in hematopoietic stem cells. there are only single case reports on evolving myeloproliferative diseases to pnh in the literature. there is no data concerning development of pnh de novo after allogeneic hematopoietic stem cell transplantation. in our report we describe a patient with recurrence of jak v -positive myelofibrosis years after matched unrelated donor allogeneic hematopoietic stem cell transplantation (mudallohsct) with simultaneous development of clinically significant pnh. a year-old-man with a history of mudal-lohsct in may due to jak v -positive myelofibrosis secondary to essential thrombocythemia was admitted to our department years later with mild anemia (hb- . g/dl) and elevated lactate dehydrogenase ( u/l). during last years he remained in complete remission of myelofibrosis with jak v mutation negativisation and % donor chimerism. suspecting disease recurrence we performed trephine biopsy confirming myelofibrosis (mf /mf ) with heterozygous jak v mutation and in flow cytometry analysis of bone marrow we identified cell membrane defect in myeloid line (loss of cd c). we decided to perform detailed diagnostic tests on pnh -multiparametric flow cytometry of peripheral blood revealed % granulocytes and % red blood cells with loss of gpi-anchored proteins -pnh clone. these results corresponded with donor chimerism -it was only % of donor dna in bone marrow and % in blood tests. molecular analysis didn't revealed any mutations in genes: calr, asxl and mpl. finally the diagnosis of myelofibrosis recurrence after mudallohsct with presence of pnh clone was established. the therapy with eculizumab was unreachable. so the second allohsct from another matched unrelated donor after fludarabinemelphalan-thymoglobuline-tbi cgy conditioning was performed on . . . we didn't observe any complications of this procedure, engraftment was slightly delayed: anc> . g/l on the day and plt> g/l on the day.results: at present, more than years after the second mudallopbsct, the patient remains in a very good condition with % of the second donor chimerism and without any features of pnh (clone is undetectable) and myelofibrosis.conclusions: presented case is the first in the literature well documented myelofibrosis recurrence after mudal-lohsct with concurrently development of clinically significant paroxysmal nocturnal hemoglobinuria. the second mudallohsct from another donor was safe and successful treatment strategy in this situation.disclosure: nothing to declare. abstract already published. cutaneous refractory t-cell lymphoma treated with allogeneic hematopoietic stem cell transplantationmarcia silva , ercole orlando , maria claudia moreira , simone lermontov , simone maradei , yung gonzaga , leonardo arcuri , renato araujo , decio lerner instituto nacional de cancer, cemo, rio de janeiro, brazilbackground: folliculotropic mycosis fungoides (fmf) is an aggressive clinical course variant of cutaneous t-cell lymphoma (ctcl) -classic mycosis fungoides (mf) , with distinct clinical and pathological characteristics, and it is less responsive to skin-directed therapies. for diseases in advanced stages, chemotherapy, autologous hematopoietic stem cell transplantation (hsct) or immunomodulator drugs may provide remissions with limited duration and the treatment remains substantially palliative , . these dismal results have induced to explore the therapeutical approach with allogeneic hematopoietic stem cell transplantation (hsct) in such patients. early studies have shown encouraging results also in patients with advanced disease, suggesting a major therapeutical role played by the graft versus lymphoma (gvl) effect , , . methods: this is a case report of the use of allogeneic hsct as a potential cure for cutaneous refractory t-cell lymphoma type folliculotropic mycosis fungoides .results: case presentation : a -year-old male patient with refractory subtype b fmf t-cell lymphoma , diagnosed in , clinically characterized by exfoliative erythroderma, widespread plaques on the trunk and limbs, solitary tumor on the right shoulder, pruritus and bilateral